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A 


DICTIONARY  OF  MEDICINE 

EXCLUDING 


GENERAL  PATHOLOGY,  GENERAL  THERAPEUTICS, 
HYGIENE,  AND  THE  DISEASES  PECULIAR 
TO  WOMEN  AND  CHILDREN 


BY  VARIOUS  WRITERS 


EDITED  BY 

RICHARD  QUAIN,  M.D.,  F.R.S. 

FEXLCW  AND  LATE  SENIOR  CENSOR  OF  THE  ROYAL  COLLEGE  OF  PHYSICIANS;  MEMBER  OF  THE  SENATE  CF 
THE  UNIVERSITY  OF  LONDON;  MEMBER  OF  THE  GENERAL  COUNCIL  OF  MEDICAL  EDUCATION 
AND  REGISTRATION;  CONSULTING  PHYSICIAN  TO  THE  HOSPITAL  FOR  CON- 
SUMPTION AND  DISEASES  OF  THE  CHEST  AT  CROMPTON,  ETC. 


TWELFTH  EDITION. 


NEW  YORK 

D.  APPLETON  AND  COMPANY 

1,  3 and  5 BOND  STEEET 

1890 


T-V~- 

' l3 


=0 


. 


. 


*5  i : -i 


PREFACE 


The  vast  number  of  facts  and  observations,  by  which  the  recent 
progress  of  scientific  and  practical  medicine  has  been  marked,  is  dif- 
fusely recorded  in  the  Transactions  of  learned  societies,  in  journals,  in 
monographs,  and  in  systematic  treatises.  With  progress  so  rapid,  and 
information  so  diffused,  it  is  extremely  difficult  alike  for  the  practitioner, 
the  teacher,  and  the  student  to  keep  pace.  It  was  the  perception  of 
this  difficulty  which  induced  the  Editor-,  when  invited  to  undertake  the 
production  of  a new  Medical  Dictionary,  to  engage  in  a task  which, 
he  was  fully  conscious,  must  be  one  of  great  labour  and  of  great 
responsibility.  He  felt,  however,  that  he  would  be  rendering  useful 
service  to  his  profession  if  he  could  bring  together  the  latest  and  most 
complete  information  in  a form  which  would  allow  of  ready  and  easy 
reference.  Accordingly,  he  invited  the  co-operation  of  certain  of  his 
colleagues  and  professional  friends,  both  in  this  country  and  abroad ; 
and  evidence  of  the  readiness  with  which  this  invitation  has  been 
accepted,  is  afforded  by  the  list  of  contributors.  Each  contributor 
volunteered  or  was  invited  to  write  on  a subject  with  which  he  was 
specially  familial-.  The  present  work,  which  is  the  result  of  these 
combined  efforts,  may  therefore  be  regarded  not  only  as  a dictionary, 
but  also  as  a treatise  on  systematic  medicine,  in  which  the  articles  on 
the  more  important  subjects  constitute  monographs  in  themselves, 
whilst  definitions  and  descriptions  of  matters  having  less  claim  to 
extended  notice  are  given  as  fully  as  is  required.  Thus  an  endeavour 
has  been  made  to  supply,  in  a clear,  condensed,  and  readily  accessible 
form,  all  the  information  that  is  at  present  available  for  the  use  of  the 
practitioner  of  medicine. 

As  indicated  on  the  title-page,  the  work  is  primarily  a dictionary 
of  Medicine,  in  which  the  several  diseases  are  fully  discussed  in 
alphabetical  order.  The  description  of  each  includes  an  account  of  its 


n 


PREFACE. 


aetiology  and  anatomical  characters ; its  symptoms,  course,  duration, 
and  terminations ; its  diagnosis,  prognosis,  and,  lastly,  its  treatment. 
General  Pathology  comprehends  articles  on  the  origin,  characters,  and 
nature  of  disease,  and  the  many  considerations  which  these  topics 
suggest.  General  Therapeutics  will  be  found  to  include  articles  on  the 
several  classes  of  remedies — medicinal  or  otherwise — which  are  avail- 
able for  the  purpose  of  treatment ; on  the  modes  of  action  of  such 
remedies ; and  on  the  methods  of  their  use.  The  articles  devoted  to 
the  subject  of  Hygiene  will  be  found  to  treat  of  the  causes  of  disease,  of 
its  prevention,  of  the  agencies  and  laws  affecting  public  health,  of  the 
means  of  preserving  the  health  of  the  individual,  of  the  construction 
and  management  of  hospitals,  and  of  the  nursing  the  sick.  Lastly, 
the  diseases  peculiar  to  Women  and  Children  are  discussed  under  their 
respective  headings,  both  in  aggregate  and  in  detail. 

It  may  be  well  to  explain  that,  although  it  has  been  found  neces- 
sary to  include  some  notice  of  diseases  which  fall  more  generally  under 
the  care  of  the  surgeon,  the  work  does  not  pretend  to  be  a dictionary 
of  Surgery ; and  also  that,  although  certain  drugs  are  enumerated  in 
discussing  subjects  of  general  therapeutics,  and  of  poisons  and  their 
actions,  there  has  been  no  intention  to  invade  the  domain  of  Materia 
Medica. 

It  is  right  to  observe  that  all  the  articles  have  been  edited  and 
revised  with  great  care,  so  as  to  ensure  a completeness  and  unity  in 
the  work,  which  it  is  not  always  possible  to  obtain  in  books  composed 
by  a number  of  writers. 

The  Editor  desires  also  to  state  that,  although  the  work  has  occu- 
pied several  years  in  preparation,  arrangements  were  made  with  the 
printers  which  have  enabled  him  to  revise  every  article  which  required 
revision,  up  to  the  time  of  going  to  press.  Further,  by  the  addition  of 
an  Appendix  it  has  been  possible  to  incorporate  the  latest  contributions 
to  medical  knowledge. 

Having  thus  set  forth  the  aims  and  objects  of  his  undertaking,  and 
how  far  they  have  been  carried  out,  the  Editor  has  the  great  satis- 
faction of  offering  his  thanks  to  his  friends  and  colleagues,  for  the 
valuable  assistance  which  he  has  received  from  them.  He  is  fully 
conscious  of  the  trouble  which  must  often  have  been  necessary  in  order 


PREFACE. 


vii 

to  condense  extended  knowledge  of  a familiar  subject  within  the 
limited  space  which  the  nature  of  this  work  could  afford. 

The  Editor  has  further  the  pleasing  duty  of  offering  his  special 
thanks  to  Dr.  Frederick  T.  Eoberts  and  to  Dr.  J.  Mitchell  Bruce, 
who  from  the  first  have  been  his  Assistant-editors  and  fellow-labourers. 
Without  the  help  which  they  have  afforded  him,  it  would  have  been 
impossible  for  him  to  have  fulfilled  the  duties  which  he  undertook. 
He  is  well  aware  of  the  time  and  labour  which  their  assistance  has 
involved  ; and  he  appreciates  most  fully  the  marked  ability  by  which  i t 
has  been  characterised. 

The  Editor  cannot  conclude  without  a reference  to  some  of  those 
who  were  his  friends  and  colleagues  when  this  work  was  commenced, 
but  who  have  since  been  taken  away  by  death.  He  would  specially 
mention  the  names  of  Edmund  Parkes,  Charles  Murchison,  G-eorge 
Callender,  Thomas  Bevill  Peacock,  John  Eose  Cormack,  Lockhart 
Clarke,  Tilbury  Fox,  Thomas  Hayden,  Harry  Leach,  Alexander 
Silver.  The  loss  of  these  eminent  men,  many  of  them  dear  and 
valued  friends,  and  all  of  them  taken  too  soon  from  their  unfinished 
labours,  is  to  him  a source  of  personal  sorrow.  The  articles  written  by 
them  for  these  pages  were  in  most  instances  their  last  contributions  to 
medical  literature,  and  will  be  valued  accordingly. 


Lostdon  : September  1832. 


* 


LIST  OF  ILLUSTRATIONS 


na. 


PAG3 


1.  OXdium  albicans  . . 


2.  Bilharzia  hcematobia,  male  and  female  . 

3.  Bilharziali  eematobia,  ovum  of,  'with 

contained  embryo  and  free  sarcode- 
granules 

4.  Cardiogram 


5.  Renal  casts — blood 


6. 

hyaline  . 

7.  , 

epithelial  . 

8. 

fatty  . . . 

9. 

granular 

10. 

enclosing  crystal 

smaller  cast ; also  cast  of  seminal  tubule 
with  spermatozoa 


11.  Filaria  sanguinis-liominis . 


12.  Side  view  of  the  left  hemisphere  of  the 

monkey,  illustrating  localisation  of 
the  cerebral  centres  .... 

13.  Side  view  of  the  left  hemisphere  of  man, 

illustrating  localisation  of  the  cerebral 
centres  


71 

107 

107 

210 

213 

213 

213 

213 

213 

213 

252 

297 

297 


14.  Cgsticercus  (tela)  celluloses,  removed  from 


the  human  eye 323 

15.  Cysticerci  in  a portion  of  measled  pork  323 

16.  Bistoma  conjunctum 401 

17.  B racunculus  medincnsis  ....  403 


18.  Filaria  sanguinis-liominis,  anterior  end  of 

the  mature  ......  512 

19.  Filaria  sanguinis-hominis,  a portion  of  the 

mature,  showing  uterine  tubules,  &c. . 512 

20.  Filaria  sanguinis-liominis,  ova  and  em- 

bryos of 513 

21.  Fungoid  filaments  and  capsules  from 

fungus  disease  of  India  . . . 522 

22.  Fatty  degeneration  of  the  heart  . . 594 

23.  Fatty  growth  in  the  substance  of  the 

heart 697 

24.  Hydatids  cf  four  weeks’  growth,  showing 

ectocyst  and  endocyst  ....  654 

25.  Group  of  Echinococci,  with  their  hook- 

crowns  inverted 654 

26  The  so-called  ‘ Echinococcus  head,’  show- 
ing hooks,  suckers,  cilia,  and  corpuscles  654 


FIG. 


27.  Micrococci,  different  forms  of  . 

28.  Red  blood-corpuscles — human  . 

29.  Scaly  epithelial  cells 

30.  Leucocytes  ; pus,  mucous,  or  white 

blood-corpuscles  . 

31.  Ciliated  epithelial  cells  . 

32.  Cotton  fibres,  showing  character- 

istic twist  .... 

33.  Milk,  showing  colostrum  corpuscles 

and  oil-globules  . 


o face 

» 

11 


34.  Particles  of  vomited  matter  . 

35.  Epithelium  from  urinary  tracts 

36.  Spermatozoa — human 

37.  Fragments  of  hair  . 

38.  Sarcina  ventriculi  . 

39.  Hooklets  of  echinococcus 

40.  From  phthisical  sputum,  showing 

elastic  fibres  of  lung-tissue  and 
leucocytes  .... 

41.  Hamlin  crystals  from  old  blood-clo 

42.  Cubes  of  chloride  of  sodium 

43.  Leucin 

44.  Tyrosin  ... 

45.  Uric  acid,  various  forms  . . 

46.  Cholesteric  plates  . . . 

47.  Cystin 

48.  Oxalate  of  lime : dumb-bells  and 

octahedra  .... 


V 


>» 

n 

n 

» 


49.  Triple  phosphate  of  ammonia  and 

magnesia  .... 

50.  Torula  cerevisia : yeast  fungus 

51.  Sputum  of  early  pneumonia, 

showing  red  blood- corpuscles 
and  leucocytes 

52.  Shreds  of  elastic  tissue  in  sputum 

cf  phthisis  .... 

53.  Oldium  albicans  ; thrush . 

54.  Fenicillium  glaucum  . . 

55.  Pulse-trace — typical 

56.  „ of  high  ten  si<  a . 


1 


PAG2 

974 

982 

982 

982 

982 

982 

982 

982 

982 

982 

982 

982 

982 

982 

982 

982 

9S2 

982 

982 

982 

982 

982 

98S 

982 

982 

982 

982 

982 

1295 

1295 


LIST  OF  ILLUSTRATIONS. 


PIG. 


PAGE 


57.  Pulse-trace — of  low  tension  . . . 1295 

58.  „ hard,  frequent,  sudden,  and 

small  pulse  . . . 1297 

59.  „ hard,  slow,  gradual,  and 

large  pulse  . . . 1297 

GO.  „ hard,  large,  gradual  pulse  . 1298 

61.  „ hard,  sudden,  large,  and 

vibratory  pulse  . . 1298 

62.  „ soft,  frequent  pulse  . . 1298 

G3.  „ soft,  frequent,  and  large 

pulse  ....  1298 

E4.  „ soft,  small,  frequent,  and 

sudden  pulse  . . . 1298 

65.  „ soft,  frequent,  and  small  pulse  1298 

66.  The  spleen  in  anthrax  ....  1303 

67.  The  spleen  in  anthrax  under  a high  power  1303 

68.  Forms  of  Bacillus  antliracis  . . . 1303 

69.  From  a cultivation  of  Bacillus  antliracis, 

after  forty- eight  hours  . . . 1304 

70.  Bacilli  from  the  fluid  exuded  from  the 

lung  in  a case  of  internal  anthrax  . 1305 

71.  Ascaris  lumbricoid.es  ; male,  with  exserted 

spicules 1379 

72.  Ascaris  mystax,  male  and  female  . . 1380 

73.  Sclerostoma  duodenale,  male  and  female  . 1398 

74.  Spliygmographic  tracing,  showing  ob- 

structed peripheral  circulation  . . 1452 

75.  Spliygmographic  tracing,  showing  easy 

and  quick  capillary  circulation  . . 1452 

76.  Sphygmographie  tracing,  showing  hyper- 

dichrotism 1452 


77.  Sphygmographie  tracing,  showing  con- 

traction of  muscular  coat  of  artery  . 1452 

78.  Sphygmographie  tracing,  showing  ri- 

gidity of  arterial  walls  . . . 1452 

79.  Sphygmographie  tracing  of  right  radial 

artery  in  aneurism  of  the  aorta  . . 1453 

80.  Sphygmographie  tracing  of  left  radial 

artery  in  aneurism  of  the  aorta  . . 1453 

81.  Sphygmographie  tracing  in  aortic  regur- 

gitation   1453 

82.  Sphygmographie  tracing  in  aortic  sten- 

osis   1453 

83.  Sphygmographie  tracing  in  njitral  regur- 

gitation ......  1454 

84.  Sphygmographie  tracing  in  mitral  sten- 

osis .......  1454 

85.  Transverse  sections  of  the  normal  spinal 

cord 1456 

86.  Transverse  sections  of  the  spinal  cord, 

showing  areas  of  descending  degene- 
ration   1461 

87.  Transverse  sections  of  the  spinal  cord, 

showing  areas  of  ascending  degene- 
ration   1461 

88.  Spirillum  Obermeieri , amengst  red  blood- 

corpuscles  ......  1508 

89.  Taenia  echinococcus  . . . . ,1585 

90  Taenia  mediocanellata,  unarmed  head  of  . 1585 

9 . Taenia  solium,  armed  head  of  . . 1585 


FIG. 

PAG  11 

92.  Taenia  mediocanellata,  proglottis  of. 

. 

1585 

93.  Taenia  solium,  proglottis  of  . , 

• 

1585 

94.  Taenia  mediocanellata,  head  and  several 
segments  of 

1586 

95.  Oxyuris  vermicularis,  female  . 

1624 

96.  Oxyuris  vermicularis,  eggs  of . 

1624 

97.  Trichina  spiralis,  male  and  female 

. 

165 

98.  Trichina,  a single  capsuled,  in  a portion 
of  human  muscle 

1657 

99.  Trichocephalus,  male  and  female 

1653 

100.  Tubercle  in  a lymphatic  gland 

1663 

101.  Fibroma  (neuroma)  . . to  face  1672 

102.  Polypus  of  nose 

99 

1672 

103.  Myxoma  . . . 

99 

1672 

104.  Ossifying  chondroma  . 

99 

1672 

105.  Enchondroma  (of  jaw)  . 

99 

1672 

106.  Enchondroma  (of  orbit) 

J> 

1672 

107.  Myeloid  of  jaw  .... 

99 

1672 

108.  Large  round-celled  sarcoma  . 

99 

1672 

109.  Small  round-celled  sarcoma  . 

99 

1672 

110.  Oval-celled  sarcoma 

99 

1672 

111.  Lymphoma 

99 

1672 

112.  Small  spindle-celled  sarcoma 

99 

1672 

113.  Alveolar  sarcoma  .... 

99 

1672 

114.  Mixed  sarcoma 

99 

1672 

115.  Melanotic  sarcoma 

99 

1672 

116.  Large  spindle-celled  sarcoma 

99 

1672 

117.  Papilloma  of  soft  palate 

99 

201 

118.  Epithelioma  of  lip 

201 

119.  Edge  of  rodent  ulcer  . 

99 

204 

120.  Simple  polypus  of  rectum 

99 

204 

121.  Columnar  epithelioma  of  intes- 
tine   

99 

204 

122.  Colloid  of  breast  .... 

99 

204 

123.  Cancer  of  liver  (scirrho-encepha- 
loid 

99 

204 

124.  Encephaloid  cancer 

„ 

204 

125.  Scirrhus  infiltrating  fat 

99 

204 

126.  Cicatrizing  cancer 

„ 

204 

127.  Scirrhus  of  mamma 

99 

204 

128.  Adenoid  of  upper  jaw  (benign)  . 

99 

204 

129.  Ulcerated  adenoid  of  parotid 
(malignant)  .... 

99 

204 

130.  Adenoid  of  breast  (common  type)  . 

99 

204 

131.  Adenoid  of  breast  (epithelial  ele- 
ment in  excess) 

99 

204 

132.  Adenoid  of  breast  (adeno-sar- 
coma) 

99 

204 

133.  Urinary  flocculi  .... 

. 

1710 

134.  Vaginal  speculum — Cusco’s  bi-valve 

• 

1777 

135.  „ Fergusson’s  . 

. 

1777 

136.  „ the  duck-bill  . 

• 

1777 

137.  Uterine  sound  .... 

. 

1778 

138.  Uterine  probes  .... 

• 

178* 

BIST  of  contributors 


ADAMS,  WILLIAM,  Surgeon  to  the  Great  Northern  Hospital, 

AITKEN,  WILLIAM,  M.D.,  F.R.S.,  Professor  of  Pathology  in  the  Army  Medical  School 
Netley. 

ALLBUTT,  T.  CLIFFORD,  M.A.,  M.D.,  F.R.S.,  Senior  Physician  to  the  Leeds  General 
Infirmary,  and  Lecturer  on  Practice  of  Physic,  Leeds  School  of  Medicine. 

ALLCHIN,  W.  H.,  M.B.,  F.R.S.E.,  Physician  to,  and  Lecturer  on  Physiology  and  Pathology 
at,  the  Westminster  Hospital ; Physician  to  the  Victoria  Hospital  for  Children. 

ANDREW,  JAMES,  M.D.,  Physician  to,  and  Joint  Lecturer  on  Physic  at,  St.  Bartholomew's 
Hospital ; Consulting  Physician  to  the  City  of  London  Hospital  for  Diseases  of  the 
Chest. 

BALFOUR,  GEORGE  W.,  M.D.,  F.R.S.E.,  Physician  to  the  Royal  Infirmary,  and  Con- 
sulting Physician  to  the  Royal  Hospital  for  Children,  Edinburgh. 

BANHAM,  G.  A.,  late  Veterinary  Assistant  at  the  Brown  Institution. 

BARNES,  ROBERT,  M.D.,  Obstetric  Physician  to,  and  Lecturer  on  Midwifery  and  Diseases 
of  Women  at,  St.  George’s  Hospital ; Consulting  Physician  to  the  Royal  Maternity 
Charity. 

BASTLAN,  H.  CHARLTON,  M.A.,  M.D.,  F.R.S.,  Physician  to,  and  Professor  of  Clinic?.! 
Medicine  at,  University  College  Hospital ; Professor  of  Pathological  Anatomy,  University 
College  ; and  Physician  to  the  National  Hospital  for  the  Paralysed  and  Epileptic. 

BAUMLER,  C.  G.  H.,  M.D.,  Professor  of  Clinical  Medicine,  and  Director  of  the  Medicai 
Clinic,  University  of  Freiburg  in  Baden. 

BECK,  MARCUS,  M.B.,  M.S.,  Assistant  Surgeon  to,  and  Assistant  Professor  of  Clinical 
Surgery  at,  University  College  Hospital. 

BEDDOE,  JOHN,  B.  A.,  M.  D.,  F.  R.  S.,  late  Physician  to  the  Bristol  Royal  Infirmary. 

BELLAMY,  EDWARD,  Surgeon  to,  and  Lecturer  on  Anatomy  at,  the  Charing  Cron; 
Hospital. 

BENNET,  J.  HENRY,  M.D  , late  Physician-Accoucheur,  Royal  Free  Hospital. 

BENNETT,  SIR  J.  RISDON,  M.D.,  LL.D.,  F.R.S.,  late  President  of  the  Royal  College 
of  Physicians ; Consulting  Physician  to  St.  Thomas’s  Hospital,  and  to  the  City  of  London 
Hospital  for  Diseases  of  the  Chest. 

BEVERIDGE,  ROBERT,  M.B.,  Physician  to,  and  Lecturer  on  Clinical  Medicine  at,  tin 
Aberdeen  Royal  Infirmary. 


BINZ.  CARL  M.D.,  Professor  of  Pharmacology  in  the  University  of  Eonn. 


LIST  OF  CONTRIBUTORS. 


BIRKETT,  JOHN,  Consulting  Surgeon  to  Guy's  Hospital. 

BISHOP,  JOHN,  M.D.,  C.M.,  Assistant  Surgeon  to  the  Royal  Infirmary,  Edinburgh. 

BLANDFORD,  G.  F.,  M.D.,  Lecturer  on  Psychological  Medicine  at  St.  George’s  Hospital. 

BOWLES,  R.  L.,  M.D.,  Physician  to  St.  Andrew’s  Convalescent  Hospital,  Folkestone. 

BRISTOWE,  J.  STER,  M.D.,  F.R.S.,  Physician  to,  and  Joint  Lecturer  on  Medicine  at,  St 
Thomas’s  Hospital. 

BROADBENT,  W.  IL,  M.D.,  Physician  to,  and  Lecturer  on  Medicine  at,  St.  Mary’s  Hos- 
pital; Consulting  Physician  to  the  London  Fever  Hospital. 

BROWN-SEQUARD,  C.  E.,  M.D.,  LL.D.,  F.R.S.,  Professor  of  Medicine,  College  de  France 

BRUCE,  J.  MITCHELL,  M.A.,  M.D.,  Physician  to,  and  Lecturer  on  Materia  Medica  and 
Therapeutics  at,  the  Charing  Cross  Hospital;  Assistant  Physician  to  the  Hospital  for 
Consumption  and  Diseases  of  the  Chest,  Brompton. 

BRUCE,  WILLIAM,  M.A.,  M.D.,  Physician  to  the  Ross  Memorial  Hospital,  Dingwall. 

BRUNTON,  T.  LAUDER,  M.D.,  D.Se.,  F.R.S.,  Assistant  Physician  to,  and  Lecturer  on 
Materia  Medica  and  Therapeutics  at,  St.  Bartholomew’s  Hospital. 

BUCHANAN,  GEORGE,  B.A.,  M.D.,  F.R.S.,  Medical  Officer,  H.M.  Local  Government 
Board;  Consulting  Physician  to  the  London  Fever  Hospital. 

BUTLIN,  H.  T.,  Assistant  Surgeon  to,  and  Demonstrator  of  Surgerv  at.  St  Bartholomew’s 
Hospital;  Surgeon  to  the  Metropolitan  Free  Hospital. 

BUZZARD,  THOMAS,  M.D.,  Physician  to  the  National  Hospital  for  the  Paralysed  and 
Epileptic. 

CADGE,  WILLIAM,  Surgeon  to  the  Norfolk  and  Norwich  Hospital. 

CALLENDER,  The  late  G.  W.,  F.R.S.,  Surgeon  to,  and  Lecturer  on  Surgery  at,  St.  Bar- 
tholomew’s Hospital. 

CANTL1E,  JAMES,  M.A.,  M.B.,  C.M.,  Senior  Assistant  Surgoon  to,  and  Demonstrator  of 
Anatomy  at,  the  Charing  Cross  Hospital. 

CARPENTER,  W.  B.,  C.B.,  M.D.,  LL.D.,  F.R.S. 

CARTER,  R.  BRUDENELL,  Ophthalmic  Surgeon  to,  and  Lecturer  on  Ophthalmic  Surgery 
at,  St.  George’s  Hospital. 

CAYLEY,  WILLIAM,  M.D.,  Physician  to,  and  Lecturer  on  Medicine  at,  the  Middlesex 
Hospital;  Physician  to  the  London  Fever  Hospital. 

CLARKE,  The  late  J.  LOCKHART,  M.D.,  F.R.S.,  Physician  to  the  Hospital  for  Diseases 
of  the  Nervous  System. 

CLARKE,  W.  FAIRLIE,  M.A.,  M.D.,  late  Assistant  Surgeon  to  the  Charing  Cross 
Hospital. 

CLOVER,  The  late  J.  T.,  Lecturer  on  Anaesthetics  at  University  College  Hospital. 

COBBOLD,  CHARLES  S.  W.,  M.B.,  Senior  Assistant  Medical  Officer,  Colney  Hatch  Asylum. 

COBBOLD,  T.  SPENCER,  M.D.,  F.R.S.,  Professor  of  Botany  and  Helminthology  at  the 
ltoyal  Veterinary  College. 

COLLIE,  ALEXANDER,  M.D.,  Medical  Officer,  Fever  Hospital,  Homerton. 


LIST  OF  CONTRIBUTORS. 


xiil 


COOPER,  ARTHUR,  M.R.C.S.,  late  House  Surgeon  to  the  Male  Lock  Hospital. 

CORMACK,  The  late  SIR  JOHN  ROSE,  KB.,  M.D.,  F.R.S.E.,  Physician  to  the  Hertford 
British  Hospital,  Paris. 

CUNNINGHAM,  D.  DOUGLAS,  M.D.,  Surgeon-Major  H.M.  Bengal  Army. 

CURLING,  T.  B.,  F.R.S.,  Consulting  Surgeon  to  the  London  Hospital. 

CURNOW,  JOHN,  M.D.,  Assistant  Physician  to  King's  College  Hospital;  Professor  of 
Anatomy  at  King’s  College ; Senior  Visiting  Physician  to  the  Seamen’s  Hospital. 

DALBY,  W.  B.,  B.A.,  M.B.,  Aural  Surgeon  to,  and  Lecturer  on  Aural  Surgery  at,  St, 
George’s  Hospital. 

DAVIDSON,  ALEXANDER,  M.A.,  M.D.,  Physician  to  the  Royal  Infirmary,  Liverpool, 
and  Lecturer  on  Pathology  at  the  Liverpool  Medical  School. 

DE  ZOUCHE,  ISAIAH,  M.D.,  Honorary  Physician  to  the  Dunedin  Hospital,  New  Zealand, 

DOWN,  J.  LANGDON,  M.D.,  Physician  to,  and  Locturer  on  Clinical  Medicine  at,  the 
London  Hospital. 

DUNCAN,  J.  MATTHEWS,  M.A.,  M.D.,  LL.D.,  F.R.S.E.,  Physician-Accoucheur  to,  and 
Lecturer  on  Midwifery  at,  St.  Bartholomew’s  Hospital. 

DURHAM,  ARTHUR  E.,  Surgeon  to,  and  Lecturer  on  Surgery  at,  Guy’s  Hospital. 

ECHEVERRIA,  M.  G.,  M.D.,  late  Physician-in- Chief  to  the  Hospital  for  Epileptics  and 
Paralytics,  and  to  the  City  Asylum  for  the  Insane,  New  York. 

EWAlRT,  JOSEPH,  M.D.,  Retired  Deputy  Surgeon-General,  H.M.  Bengal  Army;  late 
Professor  of  Medicine,  Principal,  and  Senior  Physician,  Calcutta  Medical  College. 

EWART,  WILLIAM,  B.A.,  M.D.,  Assistant  Physician  to  St.  Georgo’e  Hospital ; late  Assistant 
Physician  and  Pathologist  to  the  Hospital  for  Consumption  and  Diseases  of  the  Chest, 
Brompton. 

FARQUHARSON,  ROBERT,  M.D.,  M.P.,  late  Physician  to  the  Belgrave  Hospital  for 
Children,  and  late  Assistant  Physician  to,  and  Lecturer  on  Materia  Medica  at,  St.  Mary’s 
Hospital. 

FAYRER,  SIR  JOSEPH,  K.C.S.I.,  M.D.,  LL.D.,  F.R.S.,  Honorary  Physician  to  H.M. 
the  Queen,  and  to  H.R.H.  the  Prince  of  Wales ; President  of  the  Medical  Board,  India 
Office  ; Consulting  Physician  to  the  Charing  Cross  Hospital. 

FENWICK,  SAMUEL,  M.D.,  Physician  to,  and  late  Lecturer  on  Medicine  at,  the  London 
Hospital ; Assistant  Physician  to  the  City  of  London  Hospital  for  Diseases  of  the  Chest. 

PERRIER,  DAVID,  M.A.,  M.D.,  LL.D.,  F.R.S.,  Assistant  Physician  to  King’s  College  Hos- 
pital ; Professor  of  Forensic  Medicine  at  King’s  College ; Physician  to  the  National 
Hospital  for  the  Paralysed  and  Epileptic. 

FINNEY,  J.  M.,  B.A.,  M.D.,  Physician  to  the  City  of  Dublin  Hospital;  King’s  Professor 
of  the  Practice  of  Medicine  at  the  School  of  Physic  in  Ireland,  and  Professor  of  Clinical 
Medicine  in  Sir  Patrick  Dun's  Hospital. 

FOSTER,  BALTHAZAR  W.,  M.D.,  Physician  to  the  General  Hospital,  and  Professur 
of  the  Principles  and  Practice  of  Physic  at  Queen’s  College,  Birmingham. 

FOX,  E.  LONG,  M.D.,  Consulting  Physician  to  the  Bristol  Royal  Infirmary,  and  late 
Lecturer  on  the  Principles  and  Practice  of  Medicine  at  the  Bristol  School  of  Medicine. 

FOX,  T.  COLCOTT,  B.A.,  M.B.,  Physician  to  the  St.  George’s  and  St.  James’s  Dispensary 
Assistant  Physician  to  the  Victoria  Hospital  for  Children. 


or 


LIST  OF  CONTRIBUTORS. 


FOX,  The  late  TILBURY,  M.D.,  Physician  to  the  Skin  Department,  University  College 
Hospital. 


GALTON,  CAPTAIN  DOUGLAS,  R.E.  (retired),  C.B.,  D.C.L.,  F.R.S. 

C3ASCOYEN,  The  late  GEORGE  G.,  Surgeon  to  the  Lock  Hospital ; and  Assistant  Surgeon 
to,  and  Lecturer  on  Surgery  at,  St.  Mary’s  Hospital. 

GEE,  SAMUEL,  M.D.,  Physician  to  St.  Bartholomew’s  Hospital,  and  to  the  Hospital  for 
Sick  Children  ; Joint-Lecturer  on  Practice  of  Physic  at  St.  Bartholomew’s  Hospital. 

(JODLEE,  RICKMAN  J.,  B.A.,  M.B.,  M.S.,  Assistant  Surgeon  to  University  College  Hos- 
pital ; Demonstrator  of  Anatomy  at  University  College  ; Assistant  Surgeon  to  the  North- 
East  Hospital  for  Children. 

GODSON,  CLEMENT,  M.D.,  Consulting  Physician  to  the  City  of  London  Lying-in  Hospital ; 
Assistant  Physician-Accoucheur  to  St.  Bartholomew’s  Hospital. 

GOWERS,  W.  R.,  M.D.,  Assistant  Physician  to,  and  Assistant  Professor  of  Clinical  Medicine 
at,  University  College  Hospital ; Physician  to  the  National  Hospital  for  the  Paralysed 
and  Epileptic. 

GREEN,  T.  HENRY,  M.D.,  Physician  to,  and  Lecturer  on  Pathology  at,  the  Charing  Cross 
Hospital ; Assistant  Physician  to  tho  Hospital  for  Consumption  and  Diseases  of  the  Chest, 
Brompton. 

GREENFIELD,  W.  S.,  M.D.,  Professor  of  General  Pathology  and  Clinical  Medicine  in  the 
University  of  Edinburgh. 

GRIMSKAW,  T.  W„  M.A.,  M.D.,  Registrar-General  for  Ireland ; Consulting  Physician  to 
the  Fever  Hospital,  and  to  Steeven’s  Hospital,  Dublin. 

ILAWARD.  J.  WARRINGTON,  Surgeon  to  St.  George’s  Hospital ; late  Assistant  Surgeon 
to  the  Hospital  for  Sick  Children. 

UAYDEN,  The  late  THOMAS,  Physician  to  the  Mater  Misericordise  Hospital,  Dublin  ; 
Professor  of  Anatomy  and  Physiology,  Catholic  University,  Dublin. 

GERMAN,  G.  ERNEST,  M.B.,  Assistant  Obstetric  Physician  to  the  London  Hospital; 
Physician  to  the  Royal  Maternity  Charity. 

SICKS,  J.  BRAXTON,  M.D.,  F.R.S. , Physician-Accoucheur  to,  and  Lecturer  on  Midwifery 
and  Diseases  of  Women  and  Children  at,  Guy’s  Hospital. 

HILL,  BERKELEY,  M.B.,  Surgeon  to,  and  Professor  of  Clinical  Surgery  at,  University 
College  Hospital ; Teacher  of  Practical  Surgery  at  University  College  ; Surgeon  to  the 
Lock  Hospital. 

HOLMES,  TIMOTHY',  M.A.,  Surgeon  to,  and  Lecturer  on  Surgory  at,  St.  George's  Hospital. 

HORSLEY,  V.  A.  II.,  B.S.,  M.B.,  Assistant  to  the  Professor  of  Pathological  Anatcmy, 
University  College ; Surgical  Registrar,  University  College  Hospital. 

HOWARD,  BENJAMIN,  M.D.,  late  Professor  of  Medicine,  and  Lecturer  on  Medicine,  in 
the  University  of  New  York. 

HUTCHINSON,  JONATHAN,  F.R.S.,  Senior  Surgeon  to  the  London  Hospital,  and  to  the 
Hospital  for  Diseases  of  the  Skin  ; Consulting  Surgeon  to  the  Royal  London  Ophthalmic 
Hospital. 


LIST  OF  CONTRIBUTORS. 


xv 


IRVINE,  The  late  J.  PEARSON,  B.A.,  B.Sc.,  M.D.,  Assistant  Physiciar  to,  and  Lecturer 
on  Forensic  Medicine  at,  the  Charing  Cross  Hospital ; Physician  to  the  Victoria  Hospital 
for  Children. 

JENNER,  SIR  WILLIAM,  Bart.,  K.C.B.,  M.D.,  D.C.L.,  LL.D.,  F.R.S.,  Physician-in-Ordinary 
toH.M.  the  Queen,  and  to  H.R.H.  the  Prince  of  Wales  ; President  of  the  Royal  College 
of  Physicians  ; Consulting  Physician  to  University  College  Hospital. 

JONES,  JOSEPH,  M.D.,  President  Board  of  Health,  State  of  Louisiana,  New  Orleans. 

LATHAM,  P.  W.,  A.M.,  M.D.,  Physician  to  Addenbrooke’s  Hospital;  Downing  Professor 
of  Medicine  in  the  University  of  Cambridge. 

LEACH,  The  late  HARRY,  Medical  Officer  of  Health  for  the  Port  of  London,  and  Phy- 
sician to  the  Seamen's  Hospital,  Greenwich. 

LEGG,  J.,  WICKHAM,  M.D.,  Assistant  Physician  to,  and  Lecturer  on  Pathological  Anatom v 
at,  St.  Bartholomew’s  Hospital. 

LEWIS,  TIMOTHY,  M.D.,  Surgeon-Major,  H.M.  Army. 

LITTLE,  JAMES,  M.D.,  Physician  to  the  Adelaide  Hospital,  Dublin ; Professor  of  Practice 
of  Physic  in  the  Royal  College  of  Surgeons  in  Ireland ; Consulting  Physician  to  the 
Rotunda  Lying-in  Hospital. 

LIVEING,  ROBERT,  M. A.,  M.D.,  Physician  for  Diseases  of  the  Skin  to,  and  Lecturer  on 
Diseases  of  the  Skin  at,  the  Middlesex  Hospital. 

McCARTHY,  JEREMIAH,  M.A.,  M.B.,  Surgeon  to,  and  Lecturer  on  Physiology  at,  the 
London  Hospital. 

MAC  CORMAC,  SIR  WILLIAM,  M.A.,  M.Ch.,  Surgeon  to,  and  Lecturer  on  Surgery  at,  St. 
Thomas’s  Hospital. 

McKENDRICK,  J.  GRAY,  M.D.,  F.R.S.E.,  Professor  of  the  Institutes  of  Medicine  in  the 
University  of  Glasgow. 

MACKENZIE,  STEPHEN,  M.D.,  Physician  to,  and  Lecturer  on  the  Principles  and  Practice 
of  Medicine  at,  the  London  Hospital. 

MACLEAN,  W.  C.,  C.B.,  M.D.,  Inspector-General  of  Hospitals ; Professor  of  Military 
Medicine  in  the  Army  Medical  School,  Netley. 

MACNAMARA,  CHARLES,  Surgeon  to  the  Westminster  Hospital,  and  to  the  Westminstei 
Ophthalmic  Hospital;  Joint-Lecturer  on  Surgery  at  the  Westminster  Hospital. 

MACPHERSON,  JOHN,  M.A.,  M.D.,  Inspector-General  of  Hospitals,  H.M.  Bengal  Army 
(retired) ; Physician  to  the  Scottish  Hospital. 

MADDEN,  T.  MORE,  Obstetric  Physician  to  the  Mater  Misericordiae  Hospital,  Dublin. 

MANSON,  PATRICK,  M.D.,  Amoy. 

MEREDITH,  W.  A.,  M.B.,  C.M.,  Surgeon  to  the  Samaritan  Free  Hospital  for  Women  and 
Children. 

MERYON,  The  late  EDWARD,  M.D.,  Physician  to  the  Hospital  for  Epilepsy  and  Paralysis. 

MUIRHEAD,  CLAUD,  M.D.,  Physician  to,  and  Lecturer  on  Clinical  Medicine  at,  the 
Royal  Infirmary,  Edinburgh. 

MURCHISON,  The  late  CHARLES,  M.D.,  LL.D.,  F.R.S.,  Physician  to,  and  Special  Pro- 
fessor of  Clinical  Medicine  at,  St.  Thomas's  Hospital ; Consulting  Physician  to  the  London 
Fever  Hospital. 


LIST  OF  CONTRIBUTORS. 


MYERS,  A.  B.  R.,  Surgeon,  Coldstream  Guards. 

NETTLESHIP,  EDWARD,  Ophthalmic  Surgeon  to  St.  Thomas’s  Hospital,  and  to  the 
Hospital  for  Sick  Children ; Lecturer  on  Ophthalmic  Surgery  at  St.  Thomas’s  Hospital. 

NIGHTINGALE,  FLORENCE. 

OLIVER,  GEORGE,  M.D.,  Harrogate. 

ORD,  W.  M.,  M.D.,  Physician  to,  and  Lecturer  on  Medicine  at,  St.  Thomas's  Hospital. 

PAGET,  SIR  JAMBS,  Bart.,  D.C.L.,  LL.D.,  F.R.S.,  Sergeant-Surgeon  to  H.M.  the  Queen, 
Surgeon  to  H.R.H.  the  Prince  of  Wales;  Consulting  Surgeon  to  St.  Bartholomew’s 
Hospital. 

PARKE3,  The  late  EDMUND  A.,  M.D.,  F.R.S.,  Professor  of  Hygiene  in  the  Army  Medical 
School,  Netley. 

PAVY,  F.  W.,  M.D.,  F.R.S.,  Physician  to,  and  Lecturer  on  Medicine  at,  Guy’s  Hospital 

PAYNE,  J.  FRANK,  B.A.,  B.Sc.,  M.D.,  Senior  Assistant  Physician  to,  and  Lecturer  on 
General  Pathology  at,  St.  Thomas’s  Hospital. 

PEACOCK,  The  late  T.  BEVILL,  M.D.,  Honorary  Consulting  Physician  to  St.  Thomas’s 
Hospital ; and  Consulting  Physician  to  the  City  of  London  Hospital  for  Diseases  of  the 
Chest. 

PLAYFAIR,  W.  S„  M.D.,  Physician-Accoucheur  to  H.I.  and  R.H.  the  Duchess  of  Edinburgh  ; 
Physician  for  Diseases  of  Women  and  Children  to  King’s  College  Hospital,  and  Con- 
sulting Physician  to  the  General  Lying-in  Hospital;  Professor  of  Obstetric  Medicine 
at  King’s  College. 

POORE,  G.  VIVIAN,  M.D.,  Assistant  Physician  to  University  College  Hospital;  Professor 
of  Medical  Jurisprudence,  University  College. 

POWELL,  R.  DOUGLAS,  M.D.,  Physician  to  the  Middlesex  Hospital,  and  to  the  Hospital 
for  Consumption  and  Diseases  of  the  Chest,  Brompton. 

QUAIN,  RICHARD,  M.D.,  F.R.S.,  Consulting  Physician  to  the  Hospital  for  Consumption 
and  Diseases  of  the  Chest,  Brompton. 

RADCLIFFE,  J.  NETTEN,  Assistant  Medical  Officer,  Local  Government  Board. 

REDWOOD,  THEOPHILUS,  Ph.D.,  Professor  of  Chemistry  and  Pharmacy,  Pharmaceutical 
Society  of  Great  Britain. 

ROBERTS,  FREDERICK  T.,  M.D.,  B.Sc.,  Physician  to,  and  Professor  of  Clinical  Medi- 
cine at,  University  College  Hospital ; Professor  of  Materia  Medica  at  University  College; 
Physician  to  the  Hospital  for  Consumption  and  Diseases  of  the  Chest,  Brompton. 

ROBERTS,  WILLIAM,  B.A.,  M.D.,  F.R.S.,  Physician  to  the  Manchester  Royal  Infirmary; 
Professor  of  Clinical  Medicine,  Owens  College  School  of  Medicine. 

ROSE,  WILLIAM,  B.S.,  M.B.,  Assistant  Surgeon  to  King’s  College  Hospital ; Surgeon  to 
the  Royal  Free  Hospital. 

ROY,  C.  S.,  M.D.,  Professor  Superintendent  cf  the  Brown  Institution,  London. 

RUSSELL,  JAMES  A.,  M.A.,  M.B.,  CM.,  Inspector  of  Anatomy  for  Scotland;  Lecturer  on 
Sanitation,  Watt’s  Institution,  Edinburgh. 

SALTER,  S.  J .,  M.B.,  F.R.S.,  F.L.S.,  Late  Dental  Surgeon  to  Guy's  Hospital. 

SA.NGSTER,  ALFRED,  B.A.,  M.B.,  Physician  for  Diseases  of  the  Skin  to,  and  Lecturer  oc 
Skin  Diseases  at,  th*  Charing  Cross  Hospital. 


LIST  OF  CONTRIBUTORS. 


srvu 


8AUNDBY,  R.,  M.D.,  Assistant  Physician  to  the  General  Hospital,  Birmingham. 

SEATON,  The  late  EDWARD  C.,  M.D.,  Medical  Officer,  Local  Government  Board. 

SHAPTER,  THOMAS,  M.D.,  LL.D.,  Consulting  Physician  to  the  Devon  and  Exetei 
Hospital. 

SIBBALD,  JOHN,  M.D.,  F.R.S.E.,  Commissioner  in  Lunacy  for  Scotland. 

SILVER,  The  late  ALEXANDER,  M.A.,  M.D.,  Physician  to,  and  Lecturer  on  Physiology 
at,  the  Charing  Cross  Hospital. 

SIMON,  JOHN,  C.B.,  D.C.L.,  LL.D.,  F.R.S.,  Consulting  Surgeon  to  St.  Thomas’s  Hospital ; 
late  Medical  Officer  to  Her  Majesty’s  Privy  Council,  and  to  the  Local  Government  Board. 

SIMPSON,  ALEXANDER  R.,  M.D.,  Physician  to  the  University  Clinical  Ward  for  Diseases 
of  Women,  Royal  Infirmary,  Edinburgh  ; Professor  of  Midwifery  and  Diseases  of  Women 
and  Children  in  the  University  of  Edinburgh. 

SMITH,  EUSTACE,  M.D.,  Physician  to  H.M.  the  King  of  the  Belgians ; Physician  to  the 
City  of  London  Hospital  for  Diseases  of  the  Chest,  and  to  the  East  London  Hospital  for 
Children. 

SMITH,  W.  JOHNSON,  Surgeon  to  the  Seamen’s  Hospital,  Greenwich. 

SOUTHEY,  ROBERT,  M.D.,  Physician  to,  and  Lecturer  on  Forensic  Medicine  and  Hygiene 
at,  St.  Bartholomew’s  Hospital. 

SPARKS,  The  late  EDWARD  I.,  M.A.,  M.B.,  Physician  for  Diseases  of  the  Skin  to  the 
Charing  Cross  Hospital,  and  Physician  to  the  Royal  Infirmary  for  Women  and  Children. 

SQUIRE,  WILLIAM,  M.D.,  Physician  to  the  North  London  Hospital  for  Diseases  of  the 
Chest,  and  to  St.  George’s  Dispensary. 

STEVENSON,  THOMAS,  M.D.,  Lecturer  on  Chemistry  and  Medical  Jurisprudence  at  Guy’s 
Hospital ; Analyst  to  St.  Pancras,  &c. 

STEWART,  T.  GRAINGER,  M.D.,  F.R.S.E.,  Ordinary  Physician  to  H.M.  the  Queen  in 
Scotland ; Professor  of  Practice  of  Physic  in  the  University  of  Edinburgh. 

STREATFEILD,  J.  F.,  Surgeon  to  the  Royal  London  Ophthalmic  Hospital;  Professor 
of  Clinical  Ophthalmic  Surgery  at,  and  Ophthalmic  Surgeon  to,  University  College 
Hospital. 

THIN,  GEORGE,  M.D.,  London. 

THOMPSON,  E.  SYMES,  M.D.,  Physician  to  the  Hospital  for  Consumption  and  Diseases 
of  the  Chest,  Brompton. 

THOMPSON,  SIR  HENRY,  Surgeon  Extraordinary  to  H.M.  the  King  of  the  Belgians  ; 
Consulting  Surgeon  to  University  College  Hospital ; Emeritus  Professor  of  Clinical  Surgery 
at  University  College. 

THORNTON,  W.  PUGIN,  Surgeon  to  the  St.  Marylebone  General  Dispensary. 

THOROWGOOD,  J.  C.,  M.D.,  Physician  to  the  City  of  London  Hospital  for  Diseases  of  the 
Chest,  and  to  the  West  London  Hospital ; Lecturer  on  Materia  Medica  at  the  Middlesex 
Hospital. 

TUKE,  J.  BATTY,  M.D.,  F.R.S.E.,  formerly  Lecturer  on  Mental  Diseases  at  the  Royal 
College  of  Surgeons,  Edinburgh. 

WALKER,  T.  J.,  M.D.,  Surgeon  to  the  Peterborough  Infirmary  and  Dispensary. 


sviii 


LIST  OF  CONTRIBUTORS. 


WARD,  The  late  STEPHEN  H.,  M.D.,  Consulting  Physician  to  the  Seamen's  Hospital 
Greenwich ; and  Physician  to  the  City  of  London  Hospital  for  Diseases  of  the  Chest. 

WARDELL,  J.  R.,  M.D.,  Consulting  Physician  to  the  Tunbridge  Wells  Infirmary. 

WATERS,  A.  T.  H.,  M.D.,  Physician  to  the  Royal  Infirmary,  Liverpool  Loctarcr  on 
Principles  and  Practice  of  Medicine  at  the  Liverpool  School  of  Medicine. 

WEBER,  HERMANN,  M.D.,  Physician  to  the  German  Hospital. 

WELLS,  T.  SPENCER,  President  of  the  Royal  College  of  Surgeons  ; Surgeon  to  the  Queen’s 
Household  ; Consulting  Surgeon  to  the  Samaritan  Hospital  fcr  Women  and  Children. 

WILLIAMS,  C.  THEODORE,  M.A.,  MX.,  Physician  to  the  Hospital  fcr  Consumption  and 
Diseases  of  the  Chest,  Brompton. 

WILSON,  SIR  ERASMUS,  LL.D.,  F.R.S.,  late  President  of  the  Royal  College  of  Surgeons ; 
Professor  of  Dermatology,  Royal  College  of  Surgeons, 

WILTSHIRE,  ALFRED,  M.D.,  Physician-Accoucheur  to,  and  Joint  Lecturer  on  Obstetric 
Medicine  at,  St.  Mary’s  Hospital;  Physician  for  Diseases  of  Women  to  the  West  London 
Hospital. 

WOOD,  JOHN,  F.  R.  S.,  Surgeon  to  Bang’s  College  Hospital,  and  Professor  of  Clinical  Sur- 
gery at  King’s  College. 


A 


DICTIONARY  OR  MEDICINE, 


A 


ABDOMEN,  Diseases  of  the.  — Before 
entering  upon  the  study  of  the  particular 
diseases  -which  are  liable  to  be  met  with  in  con- 
nexion with  each  of  the  principal  regions  of  the 
body,  it  is  expedient  to  regard  them  from  a ge- 
neral point  of  view,  as  such  a course  helps  mate- 
rially in  clearing  the  way  for  their  clinical 
investigation.  This  general  survey  is  particularly 
advantageous  in  the  case  of  abdominal  diseases, 
which  are  necessarily  very  numerous  and  varied, 
both  as  regards  the  structure  affected  and  the  na- 
ture of  the  morbid  change  they  present;  they  are 
consequently  difficult  to  recognise  with  certainty 
in  many  instances,  and  are  occasionally  involved 
in  much  obscurity. 

Excluding  a few  peculiar  affections,  the  dis- 
eases of  the  abdomen  may  be  arranged  under  the 
following  groups : — 

I.  Diseases  of  the  anterior  abdominal  walls. 

II.  Diseases  of  the  peritoneum  and  its  folds. 

III.  Diseases  of  the  organs  contained  within 
the  abdominal  cavity,  namely: — 1.  Stomach  and 
Intestines;  2,  Hepatic  organs,  including  the  liver, 
gall-bladder,  and  gall-ducts ; 3,  Spleen  ; 4,  Pan- 
creas; 5,  Supra-renal  capsules  ; 6,  Urinsiry  appa- 
ratus, viz.,  the  kidneys  and  their  ducts,  and  the 
bladder ; 7,  Female  generative  organs,  including 
the  uterus  and  its  broad  ligament,  the  Fallopian 
tubes,  and  the  ovaries  ; 8,  Absorbent  glands. 

IV.  Diseases  of  the  abdominal  vessels,  espe- 
cially the  aorta  and  the  iliac  arteries. 

V.  Diseases  of  the  sympathetic  or  other  nerves 
contained  within  the  abdomen. 

VI.  Diseases  originating  in  connexion  with  the 
cellular  tissue,  such  as  inflammation  or  abscess. 

VII.  Diseases  springing  from  the  posterior 
boundary  of  the  abdomen;  from  the  pelvis  or  the 
structures  lining  it;  or  from  the  diaphragm, 
and  invading  the  abdominal  cavity. 

VIII.  Diseases  encroaching  upon  the  abdomen  ; 
from  other  parts,  especially  from  the  thorax. 

It  must  be  borne  in  mind  that  the  groups  of 
diseases  above-mentioned  may  be  presented  in  va- 
rious combinations,  two  or  more  structures  being 
not  uncommonly  implicated  at  the  same  time. 

The  special  nature  and  mode  of  origin  of  the 
diseases  thus  summarised  will  be  discussed  under 
1 


their  appropriate  headings,  but  a few  general 
observations  on  this  subject  may  prove  service- 
able. Several  of  the  abdominal  organs  are 
very  liable  to  so-called  functional  disorders, 
being  much  exposed  to  the  repeated  action  of 
various  disturbing  influences,  and  these  disorders 
often  give  rise  to  prominent  and  troublesome 
symptoms,  which  are  urgently  complained  of  by 
the  patient.  Definite  organic  diseases  are  also 
of  common  occurrence,  many  of  them  being  of  a 
very  serious  character.  Some  of  the  organs 
contained  within  the  abdomen  are  subject  to 
malposition  or  displacement,  as  well  as  to 
malformations,  these  being  either  congenital  or 
acquired  ; while  the  hollow  viscera  may  be  the 
seat  of  obstruction  or  accumulations  of  different 
kinds  ; and  each  of  these  conditions  may  become 
clinically  important. 

Abdominal  lesions  are  frequently  purely  local 
in  their  origin,  but  several  of  them  are  but 
local  manifestations  of  some  general  condition, 
being  either  associated  with  certain  acute  febrile 
diseases,  e.g.,  typhoid  fever ; or  with  some  consti- 
tutional cachexia,  such  as  cancer.  Again,  symp- 
toms connected  with  the  abdomen  may  depend 
upon  disease  in  some  remote  part  of  the  body,  oi 
some  of  its  organs  may  become  the  seat  of  morbid 
changes  as  a consequence  of  disease  in  other 
structures.  For  instance,  vomiting  is  frequently 
associated  with  cerebral  disorders ; while  affections 
of  the  heart  are  liable  to  lead  to  troublesoms 
symptoms,  as  well  as  to  serious  lesions  in  con- 
nexion with  many  of  the  abdominal  viscera 
Lastly,  a morbid  condition  of  one  organ  within 
the  abdomen  may  be  the  direct  means  of  originat- 
ing secondary  mischief  in  other  structures. 

Clinical  Investigation. — The  clinical  exami- 
nation of  cases  in  which  the  symptoms  point  to 
the  abdomen  as  the  seat  of  mischief  should 
always  be  conducted  with  particular  care  and 
thoroughness,  as  well  as  in  a systematic  manner, 
otherwise  serious  mistakes  are  liable  to  be  made. 
It  is  also  very  desirable  to  avoid  forming  any  de- 
finite conclusion  as  to  the  nature  of  the  complaint 
hastily  or  on  insufficient  data,  but  rather  to  wait 
and  observe  the  course  of  events  in  ary  doubtful 
case,  repeating  the  investigation  from  time  to 


I ABDOMEN,  DISEASES  OF  THE. 


tune,  when  any  obscurity  which,  may  exist  will 
olien  be  cleared  away.  The  past  and.  family  his- 
tory of  the  patient,  with  the  course  and  progress 
of  the  symptoms,  are  often  of  material  assistance 
in  diagnosis,  and  demand  due  attention  in  every 
instance.  The  chief  clinical  phenomena  which 
may  be  associated  with  abdominal  affections,  and 
with  reference  to  which  it  is  requisite  to  inquire, 
may  be  thus  indicated.  First,  there  are  usually 
symptoms  directly  connected  with  the  structure 
implicated,  such  as  pain  and  other  morbid  sen- 
sations, disorders  of  secretory  or  other  functions, 
or  excited  action.  Secondly,  several  of  the 
organs  mutually  affect  each  other,  either  from 
being  anatomically  or  physiologically  related,  or 
from  a morbid  condition  of  one  part  causing 
pressure  upon  or  irritation  of  some  neighbouring 
structure.  In  this  way  numerous  symptoms  are 
liable  to  arise,  sometimes  in  remote  parts,  and 
often  of  material  significance.  Thirdly,  sympa- 
thetic or  reflex  phenomena  in  connexion  with 
organs  in  other  regions  of  the  body  are  frequently 
excited  by  many  abdominal  disorders,  such  as 
palpitation  of  the  heart,  convulsions,  and  other 
nervous  disturbances.  Fourthly,  the  general 
system  often  suffers  seriously,  and  in  various 
■ways.  For  instance,  pyrexia  may  be  excited ; the 
blood  may  become  impoverished  or  impregnated 
with  noxious  materials ; or  more  or  less  general 
wasting  and  debility  may  be  induced.  Where  an 
abdominal  disease  is  but  a local  manifestation  of 
some  constitutional  condition,  it  commonly  ag- 
gravates materially  the  general  symptoms;  while 
in  connexion  with  lesions  of  certain  of  the  ab- 
dominal viscera  these  general  symptoms  consti- 
tute in  many  cases  the  most  prominent  clinical 
features.  Fifthly,  morbid  conditions  within  the 
abdomen  not  unfrequently  interfere  directly  with 
the  diaphragm  and  the  thoracic  organs ; occa- 
sionally also  they  invade  upon  the  chest,  or 
actually  make  their  way  into  this  cavity  through 
the  diaphragm.  In  rare  instances  morbid  pro- 
ducts, such  as  pus,  may  find  their  way  to  distant 
parts  of  the  body.  In  these  different  ways  a 
variety  of  symptoms  may  be.  caused,  sometimes 
of  a curious  nature  and  difficult  to  explain. 
Lastly,  abdominal  diseases  are  frequently  at- 
tended with  abnormal  physical  or  objective 
signs,  which  are  revealed  on  physical  examina- 
tion, and  these  are  of  such  importance  that  they 
demand  separate  consideration. 

Physical  Examination-.  — The  neglect  of 
submitting  patients  to  a satisfactory  physical 
examination  is  a frequent  source  of  error  in 
diagnosis  in  cases  of  abdominal  disease,  "and 
there  ought  to  be  no  hesitation  or  delay  in 
resorting  to  this  method  of  clinical  investigation 
-whenever  it  seems  called  for.  The  precise 
course  to  be  pursued  must  vary  according  to  cir- 
cumstances, butthe  following  outline  will  serve  to 
indicate  the  plan  of  procedure  ordinarily  required. 

First,  there  are  certain  modes  of  examination 
which  are  applied  to  the  abdomen  externally, 
including  Inspection-,  Palpation  or  Manipula- 
tion-, Mensuration  on  Measurement-,  Percussion-, 
and  Auscultation  ( see  Physical  Examina- 
tion). Of  these,  inspection,  palpation,  and 
porcussion  are  by  far  the  most  important,  and 
have,. in  the  large  majority  of  cases,  to  be  relied 
upon  for  the  information  required.  In  ex- 


ceptional instances  Succussion  or  shaking  the 
patient  proves  serviceable,  by  bringing  out  cer- 
Laiu  sensations  or  sounds.  In  order  to  carry 
out  these  methods  properly,  it  is  necessary  to 
expose  the  abdomen  sufficiently,  due  regard 
being  paid  to  decency  in  the  examination  of 
females  ; to  place  the  patient  in  a suitable  posi- 
tion ; and  to  see  that  the  muscles  of  the  abdo- 
minal walls  are  duly  relaxed.  The  best  posi- 
tion usually  is  for  the  patient  to  lie  on  the 
back,  in  a half-reclining  attitude,  with  .the  head 
and  shoulders  well  raised,  and  the  thighs  and 
knees  more  or  less  flexed.  This  posture  serves 
to  relax  the  abdominal  muscles,  which  may  bo 
further  aided  by  taking  off  tho  patient's  atten- 
tion by  conversation  or  in  other  ways,  as  well  as 
by  directing  him  to  breathe  deeply.  The  posi- 
tion, however,  has  often  to  he  varied  in  the 
investigation  of  particular  cases,  and  mucli 
information  is  frequently  gained  by  noticing  the 
effects  of  altering  the  posture. 

The  objective  conditions  which  may  be  revealed 
by  the  modes  of  examination  thus  far  con- 
sidered are  as  follows: — 1.  The  state  of  the 
superficial  structures.  2.  The  size  and  shape  of 
the  abdomen,  generally  and  locally,  as  indi- 
cating an  alteration  in  the  volume  of  the  ordinary 
contents  of  the  abdomen,  or  the  presence  of 
some  new  or  fresh  element,  such  as  dropsical 
fluid  or  a tumour.  3.  The  characters  of  the 
abdominal  respiratory  movements  ; and  the  pre- 
sence of  any  unusual  sensations  during  the 
act  of  breathing,  such  as  friction-fremitus.  4. 
The  sensations  experienced  on  palpation  and 
percussion  over  the  abdomen,  either  as  a whole, 
or  in  any  particular  part  of  it,  such  as  its 
mobility,  degree  of  resistance,  regularity,  con- 
sistence, &c. ; as  well  as  the  presence  of  cer- 
tain peculiar  sensations,  c.g.,  fluctuation,  r 
hydatid-fremitus.  5.  Tho  presence  and  cha- 
racters of  any  pulsation.  6.  The  occurrence  of 
abnormal  movements  within  the  abdomen,  as 
■those  of  a foetus.  7.  The  sounds  elicited,  gene- 
rally and  locally,  on  percussion.  8.  The  pre- 
sence of  certain  sounds  within  the  abdomen, 
heard  on  auscultation,  such  as  friction-sounds ; 
murmurs  connected  with  aneurism  or  due  to 
pressure  on  an  artery ; or  murmurs  and  sounds 
associated  with  the  pregnant  uterus. 

Secondly,  it  not  uncommonly  happens  that 
special  modes  of  examination  have  to  be  applied 
to  particular  organs  within  the  abdomen,  in 
order  to  arrive  at  a diagnosis  with  any  cer- 
tainty. And  here  it  may  he  remarked  that  it  is 
highly  important  in  all  cases  to  see  that  no 
accumulation  of  faeces  exists  within  the  bowels, 
and  that  the  bladder  is  properly  emptied,  other- 
wise very  serious  mistakes  are  liable  to  be  made. 
Purgatives  and  enemata  are  needed  in  order  to 
remove  any  faecal  collection.  The  urine  should 
also  be  properly  tested  in  every  instance ; and 
much  information  may  often  be  gained  in  the  in- 
vestigation of  affections  of  the  alimentary  canal, 
from  a personal  inspection  or  more  complete 
examination  of  faces  or  vomited  matters.  The 
abdominal  organs  to  which  special  modes  of 
examination  are  chiefly  applicable  are  the 
female  generative  organs,  which  are  investigated 
per  vaginam  (see Womb,  Diseases  of  i : the  bladder, 
by  means  of  the  catheter,  the  sound,  and  other 


ABDOMEN,  DISEASES  OF  THE. 
surgical  instruments  ; the  stomach,  by  the  use  of 
the  stomach-pump,  probang,  & c. ; and  the  in- 
testines, by  examining  -with  the  finger,  hand,  or 
surgical  instruments  per  rectum,  or  by  injecting 
water  or  air  through  the  anus  into  the  bowels. 
The  ordinary  modes  of  examination  already  men- 
tioned may  afford  assistance  when  employed  along 
with  some  of  the  special  methods  just  indicated. 

Thirdly,  occasionally  it  is  requisite  to  hare 
recourse  to  exceptional  modes  of  investigation, 
such  as  the  use  of  the  exploring  trochar  or  aspi- 
rator ; or  to  the  administration  of  chloroform. 
The  latter  may  afford  direct  information  in 
certain  abdominal  conditions,  and  it  may  also 
materially  assist  in  carrying  out  other  methods 
jf  exploration. 

The  abnormal  conditions  discoverable  by 
physical  examination  may  involvo  the  entire 
abdomen,  giving  rise,  for  instance,  to  general 
enlargement  or  retraction ; or  they  may  be 
limited  to  some  particular  region,  e.g.,  enlarged 
organs,  tumours,  or  abscesses.  This  part  of  the 
body  has  been  artificially  divided  by  anatomists 
nto  regions,  and  the  seat  of  any  local  morbid 
mndition  can  thus  be  defined  and  described. 
The  diseases  peculiar  to  the  several  regions  will 
l e considered  under  their  respective  headings. 

Frederick  T.  Roberts. 

ABDOMINAL  ANEURISM  includes 
aneurism  of  the  aorta,  and  of  any  of  its  branches 
within  the  abdomen. 

Aneurism  of  the  Abdominal  Aorta  is  essen- 
tially a disease  of  middle  age.  Of  fifty-nine  cases 
collected  by  Dr.  Crisp,  thirty-three  were  under 
t he  age  cf  forty.  It  is  more  common  in  the  male 
than  in  the  femalo  sex  in  the  proportion  of 
about  8:1;  and  is  usually  traceable  to  strain,  or 
to  a blow  upon  the  abdomen  or  back.  The  aneu- 
rism is  most  frequently  located  in  that  portion 
of  the  vessel  included  between  the  aortic  open- 
ing in  the  diaphragm  and  the  origin  of  the 
superior  mesenteric  artery.  In  this  situation  the 
tumour  is  deeply  seated;  liable  to  tension  from 
the  crura  of  the  diaphragm ; and  likely  to  involve 
the  great  splanchnic  nerves,  the  semilunar  gan- 
glia, and  the  solar  plexus.  Hence  the  occasional 
difficulty  of  diagnosis ; and  the  frequency  of 
boring  pain  in  the  hack  from  erosion  of  the 
vertebrae,  and  of  paroxysms  of  radiating  pain  in 
the  abdominal  viscera  from  stretching  of  the 
adjacent  nerves.  When  situated  lower  down  in 
the  course  of  the  aorta,  the  disease  is  less 
obscure,  and  the  symptoms  are  less  urgent. 
Aneurism  of  the  abdominal  aorta  is  usually  of 
tli  & false  variety;  and,  as  contrasted  with  thoracic 
aneurism,  it  is  less  often  associated  with  extensive 
atheroma  of  the  aorta,  and  with  fatty  or  other 
structural  disease  of  the  heart.  The  symptoms 
referable  to  excentric  pressure  are  also  fewer, 
and,  with  the  exception  of  pain,  are  less  urgent. 

Symptoms  and  Signs. — Of  the  symptoms, 
is  the  most  characteristic  and  the  most  urgent ; 
it  is  of  two  kinds,  which  are  not,  however,  neces- 
sarily associated.  In  its  usual  form  the  pain  of 
abdominal  aneurism  is  essentially  neuralgic;  it  is 
intermittent  and  paroxysmal, — radiating  through 
the  abdomen,  back,  pelvis,  and  base  of  the  thorax, 
and  not  unfrequently  into  either  groin  or  testicle. 
The  accession  is  sudden,  and  usually  attributable 


ABDOMINAL  ANEURISM.  3 

to  some  definite  cause  of  vascular  excitement.  The 
duration  extends  over  a period  varying  from  one 
to  three  hours,  rarely  longer;  and  the  cessation  is 
equally  abrupt,  leaving  the  patient  in  a state  of 
exhaustion,  but  quite  free  from  actual  suffering. 
The  second  kind  of  pain  referred  to  is  continuous 
and  boring ; fixed  at  a particular  point  of  the 
vertebral  column  ; aggravated  by  pressure  at  this 
point,  by  active  movement  or  stamping,  and  by 
gently  turning  the  patient  half  round  upon  his 
axis  in  the  standing  posture ; but  relieved  by 
anti-recumbency  or  leaning  forward.  Pain  so 
characterised  is  pathognomonic  of  erosion  of  the 
vertebrae.  Pressure  of  an  aneurism  may  affect 
tho  functions  of  several  organs  within  the  abdo- 
men. Thus  jaundice  may  result  from  pressure 
upon  the  hepatic  or  common  biliary  duct:  it  is, 
however,  more  frequently  due  to  an  aneurism  of 
the  hepatic  or  of  the  superior  mesenteric  artery. 
Interference  with  the  urinary  secretion,  and  the 
consequences  thereof,  from  pressure  upon  the 
renal  vessels ; dysphagia  from  pressure  upon 
the  oesophagus  ; vomiting  from  obstruction  of  the 
pylorus;  displacement  of  the  liver  forwards,  or 
of  the  heart  upwards — though  rare  symptoms 
— may  he  likewise  due  to  the  same  cause.  The 
radial  pulse  is  not  often  affected.  Symptoms  of 
constitutional  irritation  and  impaired  nutrition 
are  rarely  exhibited,  and  appear  only  at  the  ter- 
mination of  protracted  and.  painful  cases,  asso- 
sociated  with  great  suffering  and  want  of  sleep. 

The  physical  signs  are  those  discoverable  by 
palpation,  percussion,  and  auscultation.  The 
tumour  usually  projects  to  the  left  of  the  mesial 
line,  and  tends  to  descend  ; it  is  smooth  and 
elastic  ; communicating  to  the  hand  alternate 
movements  of  lifting  and  expansion  with  increas- 
ing tension,  and  of  subsidence  with  relaxation. 
Tho  pulsation  is  all  hut  invariably  single,  and 
synchronous  with  the  radial  pulse ; it  is  limited 
to  the  tumour,  and  occasionally  accompanied  by 
thrill.  Pressure  upon  the  aorta  below  the  tumour 
will  increase  the  force  of  impulse,  diminish  or 
abolish  the  thrill,  and  arrest  the  collapse.  In  a 
few  recorded  examples  the  tumour  was  hard  and 
uneven  on  the  surface,  and  non-expansile  ; and 
in  a still  smaller  number  no  pulsation  was  per- 
ceptible, the  aperture  of  communication  with  the 
u.rtery  having  been  blocked,  or  the  vessel  com- 
pressed on  the  proximal  side  by  the  growth  of 
the  aneurism  itself.  Owing  to  tho  position  of 
tho  hollow  viscera  in  front,  and  the  mass  of 
lumbar  muscles  behind,  the  evidence  from  percus- 
sion is  less  conclusive  in  regard  to  abdominal 
than  thoracic  aneurism.  If,  however,  the  ab- 
dominal muscles  he  relaxed,  and  the  stomach 
and  bowels  free  from  flatus,  absolute  dulness  to 
the  extent  of  the  tumour  may  be  detected.  A 
sound,  single  or  double,  as  distinguished  from 
murmur,  is  rarely  heard  in  front  in  connexion 
with  abdominal  aneurism ; whereas  the  existence 
of  sound  without  murmur,  and  usually  double, 
at  a point  of  the  posterior  wall  of  the  abdomen 
corresponding  to  the  tumour,  is  the  rule,  and. 
when  detected,  is  of  the  utmost  diagnostic  value. 
Murmur  in  the  recumbent  posture  is  rarely 
absent  in  front ; it  is  single,  blowing,  prolonged 
post-systolic,  and  not  transmitted  into  the  vessel 
beyond.  It  may,  however,  he  musical,  .or  it 
may  present  both  these  characters,  hut  at  dif 


ABDOMINAL  ANEURISM. 


ferent  points  of  the  tumour ; in  one  instance  it 
was  of  a buzzing  quality.  Should  the  aneu- 
rism have  taken  an  exclusively  backward  course, 
which  is  the  exception,  a single  murmur,  not 
audible  in  front,  may  be  heard  in  ihe  back.  In 
a few  recorded  cases  a double  murmur  has  been 
heard  over  the  aneurism  in  front.  In  the  erect 
posture  the  murmur  is  usually  suspended ; but 
in  a few  published  cases  it  was  audible  in  both 
the  erect  and  the  recumbent  posture,  and  in  one 
at  least  in  the  erect  posture  only.  These  peculiari- 
ties depend  upon  the  various  conditions  of  the  sac, 
its  orifice,  and  its  contents.  A small  aneurism 
engaging  the  posterior  wall  of  the  vessel  only, 
and  eroding  the  vertebrae,  may  be  latent  as  to 
physical  signs,  though  attended  with  severe 
fixed  pain  in  the  back. 

Diagnosis.- — The  diagnosis  of  abdominal  aneu- 
rism has  reference  mainly  to  its  physical  signs. 
Strong  pulsation  of  the  aorta,  simulating  that 
of  aneurism,  may  exist  in  connexion  with  hys- 
teria, uterine  or  intestinal  irritation,  dyspep- 
sia, or  copious  haemorrhage.  But  in  all  these 
cases,  irrespectively  of  the  positive  and  specific 
evidence  presented  by  each,  throbbing  exists 
throughout  the  aorta,  and  is  propagated  into  the 
main  arteries  of  the  lower  limbs,  whereas  it  is 
localised  in  aneurism  ; and  a careful  exploration 
of  the  aorta,  if  necessary  under  the  influence  of 
chloroform,  will  show  that  its  dimensions  are 
at  all  points  normal.  In  these  cases,  too, 
although  a murmur  may  he  produced  by  strong 
pressure  with  the  stethoscope,  it  does  not  exist 
when  pressure  is  withdrawn.  A cancerous  or 
other  tumour  pressing  upon  the  aorta  may  like- 
wise produce  murmur,  and  may  exhibit  pulsation 
communicated  from  the  aorta ; but  in  most  cases 
both  these  phenomena  are  promptly  arrested  by 
placing  the  body  in  the  prone  position ; the 
tumour,  in  that  position,  gravitating  from  the 
vessel.  The  fixed  local  pain  in  the  hack,  aggra- 
vated by  pressure  and  motion,  may  he  simulated 
by  spinal  rheumatism  ; and  the  paroxysmal  vis- 
ceral pain  by  biliary  colic.  The  differential 
diagnosis  must  rest  upon  the  specific  evidence 
in  each  case,  and  upon  the  absence  of  the  signs 
of  aneurism. 

Aneurism  of  the  Branches  of  the  Ab- 
dominal Aorta. — The  branches  most  liable 
to  aneurism  are  the  common  iliacs  and  their 
divisions;  the  cosliac  axis  and  its  branches; 

. the  renal  and  the  superior  mesenteric.  Aneurism 
of  the  Iliac  Arteries  belongs  to  the  domain  of  sur- 
gery, and  will  not  be  further  referred  to  here. 
Aneurism  of  the  Cceliac  Arts  and  of  its  branches  of 
division,  and  of  the  Superior  Mesenteric  Artery , 
are,  in  addition  to  the  ordinary  signs,  equally 
characterized  by  mobility ; and  the  first  two 
varieties  by  jaundice,  haematemesis,  and  melaena, 
from  pressure.  Renal  aneurism  may  cause  ob- 
struction in  the  kidney  or  renal  colic  by  pressure 
on  the  structures  in  the  hilus. 

Duration  and  Terminations. — The  duration 
of  life  in  cases  of  abdominal  aneurism  has,  in 
the  writer’s  experience,  varied  from  fifteen  days  to 
eleven  years.  Death  occurs  usually  (1)  by  rup- 
ture of  the  sac  into  ( a ) the  retro-peritoneal 
tissue  ; ( b ) the  cavity  of  the  peritoneum ; (c)  the 
left  pleura  or  lung ; (c?)  the  intestinal  canal ; (e) 
the  inferior  cava  ; (f)  the  psoas  muscle  ; (g)  the 


pelvis  of  the  kidney  ; ( h ) the  spinal  canal ; 01 
(i)  the  ureter,  biliary  passages,  or  oesophagus : 
and  in  the  order  of  relative  frequency  just  given ; 
or  (2)  by  exhaustion  or  syncope.  The  duration 
of  life  after  the  rupture  of  the  aneurism  has 
ranged  from  a few  minutes  to  several  weeks.  A 
consecutive  false  aneurism  of  the  retro-perito- 
neum is  specially  characterised  by  feeble  pulsa- 
tion of  the  tumour,  and  diminished  or  arrested  cir- 
culation in  the  femoral  artery  of  one  or  both  sides. 

Treatment. — The  Curative  treatment  of  abdo- 
minal aneurism  may  be  considered  under  three 
heads — Mechanical , Postural  and  Dietetic,  und 
Medicinal.  Mechanical  treatment  consists  in 
pressure  applied  to  the  aorta  on  the  proximal  side 
of  the  sac,  or  simultaneously  on  its  proximal  and 
distal  sides,  by  means  of  tourniquets,  so  as  com- 
pletely to  stop  the  circulation.  The  bowels  should 
be  first  well  moved  and  freed  from  flatus ; and 
during  the  continuance  of  pressure  the  patient 
should  he  kept  under  the  influence  of  chloroform 
or  ether.  Five  cases,  if  not  more,  in  which  a cure 
was  effected  by  these  means  have  been  reported. 
The  object  sought  to  he  attained  being  that  of 
effecting  rapid  coagulation  in  the  sac,  the  period 
during  which  pressure  needs  to  be  continued  in 
these  cases  varies  from  three  quarters  of  an  hour 
to  ten  hours  and  a half.  Where  space  for  the 
application  of  proximal  pressure  does  not  exist, 
distal  pressure  alone  may  he  tried.  Under  all 
circumstances,  pressure  must  he  used  with  cir- 
cumspection, as  inflammation  of  tiie  peritoneum 
or  of  tiie  bowels  may  result  from  it. 

Bellingham  introduced  the  plan  of  treatment 
by  posture  and  restricted  diet.  Under  this  plan 
perfect  repose  of  mind  and  body  is,  as  far  as 
practicable,  to  be  maintained;  the  bowels  being 
kept  moderately  free,  and  the  dietary  restric'.td 
to  10  oz.  of  solids  and  G oz.  of  liquids  daily. 
According  to  the  method  of  Mr.  Tufuell,  which 
is  based  upon  the  same  principle,  but  is  more 
rigid,  the  patient  is  strictly  confined  to  the 
horizontal  posture  for  a period  varying  from 
eight  to  thirteen  weeks,  as  determined  by  the 
effect  upon  the  aneurism,  movement  in  bed 
being  effected  with  caution  ; whilst,  by  a special 
arrangement,  the  bowels  and  the  bladder  may 
be  evacuated  without  disturbance  of  the  body. 
For  breakfast,  2 oz.  of  white  bread  and  butter, 
with  2 oz.  of  cocoa  or  milk,  are  allowed ; for 
dinner,  3 oz.  of  meat,  with  3 oz.  of  potatoes 
or  bread,  and  4 oz.  of  water  or  claret ; and  for 
supper,  2 oz.  of  bread  and  butter,  and  2 oz. 
of  milk  or  tea.  The  total  amount  in  the  twenty- 
four  hours  would  be,  solids  1 0 oz.,  liquids  S oz. 
This  system  might  be  in  some  degree  relaxed 
if  the  patient  prove  restive.  Mild  laxatives 
and  opiates  as  required  are  the  only  medicines 
used.  Ten  cases  of  the  successful  treatment  of 
aortic  aneurism  by  this  method  have  been  re- 
ported by  Mr.  Tufnell.  Abdominal  aneurism 
was  solidified  in  two  instances,  after  treatment 
extending  over  thirty-seven  and  twenty-one  days 
respectively. 

Of  tiie  various  medicinal  agents  used  with  a 
view  to  favouring  or  effecting  a deposit  of 
laminated  fibrin  in  the  sac.  acetate  of  lead, 
iodide  of  potassium,  aconite,  and  ergotin  ( hypo- 
dermically), alone  claim  attention.  Iodide  of 
potassium  maybe  given  with  advantage  in  doses 


ABDOMINAL  ANEURISM, 
of  10  to  20  grs.  thrice  daily,  with  a view  to 
reducing  vascular  tension,  and  thereby  relieving 
pain  and  promoting  deposition  in  the  sac,  whilst 
perfect  rest  in  the  recumbent  posture  and  a re- 
stricted dietary  are  observed.  The  latter  are, 
however,  the  more  important  factors  in  the 
treatment.  Dr.  G.  W.  Balfour  has  reported 
several  cases  successfully  treated  by  means  of 
iodide  of  potassium ; and  recently  an  example 
of  a similar  kind  has  been  published  by  Dr. 
Dyce  Duckworth.  Dr.  Grimshaw  has  lately 
had  an  example  of  cure  mainly  through  the  use 
of  aconite.  At  the  same  time  the  allowance  of 
liquids  must  be  reduced  to  the  lowest  possible 
standard,  whilst  excretion  is  promoted.  Alco- 
holic stimulants  may  be  given  in  small  quantity 
and  at  long  intervals,  if  the  pulse  exhibit 
debility  and  the  patient  complain  of  a sen- 
sation of  sinking  ; otherwise  they  should  be 
prohibited. 

The  Palliative  treatment  as  applied  to  Ab- 
dominal Aneurism  will  be  found  described  in 
the  article  Aorta,  Diseases  of  (Aneurism).  The 
application  of  a few  leeches,  followed  by  a 
warm  poultice,  is  very  efficacious  in  relieving 
pain.  The  hypodermic  use  of  morphia  is  still 
more  rapidly  effective.  Thomas  Hayden. 

ABDOMINAL  TYPHUS.  — A synonym 
for  Typhoid  Fever.  See  Typhoid  Fever. 

ABDOMINAL  "WALLS,  Diseases  of. 
But  little  more  will  be  needed  in  this  ar- 
ticle than  to  give  a brief  outline  of  the  nature 
of  the  affections  to  which  the  abdominal  walls 
ire  liable,  as  most  of  these  are  but  local  forms 
of  diseases  which  are  fully  described  in  other 
parts  of  this  work.  The  parietal  peritoneum  will 
be  excluded  from  consideration,  as  its  morbid 
conditions  are  treated  of  separately". 

1.  Superficial  Affections.  — a.  The  skin 
covering  the  abdomen  may  be  the  seat  of  various 
eruptions.  The  rash  of  typhoid  fever  is  chiefly 
observed  over  this  region,  b.  "When  the  abdo- 
men is  greatly  enlarged,  its  cutaneous  covering 
becomes  stretched  and  thinned,  often  presenting 
a shining  appearance  : this  may  even  give  way", 
so  that  it  exhibits  superficial  cracks  or  fissures. 
If  it  has  been  distended  for  a considerable  time 
or  on  several  occasions,  as  after  repeated  preg- 
nancies, the  skin  becomes  impaired  in  its  structure, 
and  is  often  the  seat  of  permanent  white  lines  or 
furrows — lines  aVAcantes.  In  this  connection  al- 
lusion may  be  made  to  the  umbilicus,  which,  in 
certain  forms  of  distension  of  the  abdomen,  may 
become  pouched  out,  everted,  or  actually  obliter- 
ated. c.  The  veins  of  the  skin  frequently  become 
enlarged  and  tortuous,  when  the  return  of  the 
blood  which  is  normally  conveyed  through  them 
is  in  any  way  impeded.  The  particular  vessels 
which  are  distended  will  necessarily  depend 
upon  the  seat  of  the  obstruction,  d.  The  cu- 
taneous sensibility  over  the  abdomen  is  some- 
times materially  altered.  In  certain  nervous 
diseases  it  may  become  more  or  less  impaired 
or  lost ; tut  the  most  important  deviation  is  a 
marked  increase  of  sensibility — hyperesthesia— 
which  is  occasionally  observed  in  hysterical 
females,  and  which  may  simulate  more  serious 
affections,  particularly  peritonitis,  especially  if  it 
is  accompanied  with  symptoms  of  much  depres- 


ABDOMINAL  WALLS.  6 

sion.  This  condition  is  characterised  by  ex- 
treme superficial  sensibility  or  tenderness  of  the 
abdomen,  the  slightest  touch  being  resented;  but 
if  the  patient’s  attention  can  be  taken  off, 
and  deep  pressure  be  then  made,  this  is  borne 
with  little  or  no  indication  of  distress.  The 
aspect  of  the  patient,  the  presence  of  other 
symptoms  indicative  cf  hysteria,  and  the  ab 
sence  of  pyrexia,  usually'  serve  to  distinguish 
this  affection  from  others  of  a graver  nature. 
The  surface  of  the  abdomen  may  also  be  af- 
fected with  neuralgia,  which  is  sometimes  very 
severe. 

2.  Subcutaneous  Accumulations. — a.  The 
chief  morbid  condition  coming  under  this  head  is 
oedema  or  dropsy  of  the  subcutaneous  tissue. 
This  generally  follows  anasarca  of  the  legs,  and 
may  be  associated  with  ascites.  The  fluid  tends 
to  collect  especially  in  the  lower  part  of  the  ab- 
dominal walls  and  towards  the  flanks.  The  skin 
often  presents  a white  pasty  aspect ; the  abdo- 
men maybe  more  or  less  enlarged  ; the  umbilicus 
appears  depressed  and  sunken,  if  the  cedema  ex- 
tends up  to  this  level ; the  superficial  structures 
pit  on  pressure,  and  yield  the  peculiar  sensa- 
tion of  dropsical  tissues ; and  the  percussion 
note  is  frequently  muffled,  b.  The  abdominal 
subcutaneous  tissue  is,  in  many  persons,  the  seat 
of  an  abundant  collection  of  fat,  which  may  be 
important  from  its  causing  general  enlarge- 
ment, and  simulating  or  obscuring  other  more 
serious  morbid  conditions  which  enlarge  the 
abdomen. 

3.  Affections  of  the  Muscles  and  Aponeu- 
roses.— a.  The  abdominal  walls  maybe  the  seat 
of  muscular  rheumatism,  which  is  particulaily 
likely  to  follow  undue  straining,  such  as  that 
caused  by  violent  coughing  or  vomiting.  It  is 
characterised  by  pain,  sometimes  severe,  evidently 
located  in  the  muscular  and  tendinous  structures, 
accompanied  with  much  soreness  and  tenderness. 
The  affected  parts  are  kept  as  much  at  rest  as  pos- 
sible, and  any  action  which  disturbs  them  materi- 
ally" aggravates  the  pain.  b.  As  the  result  of  violent 
strain,  the  muscular  or  aponeurotic  tissues  maybe 
more  or  less  torn  or  ruptured.  As  a consequence 
a protrusion  of  some  internal  structure  may  take 
place,  forming  a hernia,  c.  The  abdominal  mus- 
cles are  liable  to  be  the  seatef  spasmodic  con- 
tractions, cramp,  or  rigidity.  These  are  not  un- 
commonly excited  in  sympathy  with  grave  dis- 
turbance of  the  alimentary  canal,  as  in  cholera. 
In  certain  painful  internal  affections  also  some  of 
the  abdominal  muscles  are  occasionally  kept  in  a 
state  of  more  or  less  rigid  tension,  as  if  they  were 
involuntarily  contracted  in  order  to  protect  the 
diseased  parts  underneath  from  injury.  The 
spasmodic  contractions  in  tetanus  not  unfre- 
quently  cause  great  suffering  over  the  abdomen. 
d.  On  the  other  hand,  the  abdominal  muscles 
are  occasionallyparalysed,  as  the  result  of  centric 
nervous  disease.  The  movements  of  respiration 
are  then  altered  in  character ; while  the  expulsive 
acts  in  which  the  abdominal  muscles  naturally 
take  part  are  much  interfered  with. 

4.  Relaxed  Abdominal  Walls. — All  ihe 
structures  forming  the  walls  of  the  abdomen  are 
often  in  a relaxed  and  flabby  state,  yielding  to 
any  pressure  from  within,  so  that  the  abdomtx 
becomes  enlarged  and  prominent,  especially  if. 


3 ABDOMINAL  WALLS, 

as  is  frequently  the  case,  this  condition  is  as- 
sociated with  much  flatulence.  It  materially 
weakens  the  act  of  defaecation,  and  promotes 
constipation. 

5.  Inflammation  and  Abscess. — Local  inflam- 
mation may  be  set  up  in  any  of  the  abdominal 
structures,  and  this  may  terminate  in  suppura- 
tion and  the  formation  of  an  abscess.  Purulent 
accumulations  from  within,  as  in  cases  of  pelvic 
abscess,  aa  well  as  certain  abscesses  originating  in 
diseases  of  bones  or  joints,  may  likewise  extend 
among  the  tissues  of  the  abdominal  walls,  causing 
thickening  and  induration,  or  may  make  their  way 
outwards,  directly  or  through  a sinus.  Subse- 
quently permanent  sinuses  or  fistulce  may  be  left. 

6.  The  abdominal  wall  may  be  the  seat  of 
extravasation  of  blood ; and  various  kinds  of 
tumour  or  new  growth  may  form  in  its  structures. 

Frederick.  T.  Roberts. 

ABERRATION. — A divergence  or  wander- 
. ing  from  the  usual  course  or  condition  ; applied 
in  medicine  chiefly  to  certain  disorders  of  the 
mental  faculties.  See  Insanity. 

ABORTION. — The  act  of  abortion  signi- 
fies the  expulsion  of  the  contents  of  the  preg- 
nant uterus  before  the  seventh  month  of  gesta- 
tion. An  abortion  is  a designation  given  to  a 
fetus  prematurely  expelled.  See  Miscarriage. 

ABSCESS  (abscedo,  I depart).  Synon.  : Pr. 
abces  ; Ger.  Eiterbeule ; Geschwur. 

Definition. — -A  collection  of  purulent  matter, 
one  of  the  results  of  inflammation.  See  Pus 
and  Inflammation. 

Pathology. — If  the  material  which  collects  in  a 
tissue  as  the  consequence  of  inflammation  softens 
and  becomes  liquid  (suppuration),  it  does  so  either 
rapidly  or  slowly : if  the  former,  the  result  is  an 
acute  abscess ; if  the  latter,  the  abscess  is  termed 
chronic  or  cold.  If  the  material  thus  softened 
and  forming  pus,  often  mingled  with  fragments 
of  dead  tissue,  is  limited  by  condensation  of  the 
parts  around,  which  are  usually  consolidated 
by  the  products  of  inflammation,  the  abscess  is 
said  to  be  circumscribed  ; but  if  the  surrounding 
parts  in  their  turn  soften,  so  as  practically  to 
offer  no  barrier  to  the  pus,  then  the  abscess 
spreads  and  is  said  to  be  diffused.  In  an  acute 
circumscribed  abscess  the  lymph  which  collects 
around  it  as  the  result  of  inflammation  becomes 
organised  and  forms  a sae  (pyogenic  membrane) ; 
and  this,  with  the  compressed  tissue  about  it,  is 
the  wall  of  the  abscess,  consisting  therefore 
of  contents  (pus),  of  a limiting  sac,  and  of  con- 
densed tissue  around.  The  resistance  offered  to 
the  extension  of  the  suppuration  is  greatest  when 
the  parts  adjacent  are  dense  and  tough,  such  as 
bone  and  fascia ; yet,  as  the  pus  in  an  abscess  in- 
creases in  quantity,  probably  by  breaking  down 
of  the  pyogenic  layer,  sufficient  pressure  is  ex- 
erted to  cause  the  most  dense  structures  to 
yield,  and  an  abscess  will  thus  make  its  way 
even  through  osseous  tissue.  As  might  be  ex- 
pected, an  abscess  always  advances  in  the  direc- 
tion of  least  resistance,  and  this  extension  is 
spoken  of  as  its  pointing.  This  pointing  may  he 
towards  the  surface  of  the  body,  but  an  abscess 
may  direct  itself  towards  a serous  cavity,  such  as 
the  peritoneum,  or  along  a track  of  cellular  tissue, 


ABSCESS. 

as  when  pus  beneath  thedeep  cervical  fascia-  poin.s 
into  the  mediastinum.  On  the  side  at  which  th  - 
abscess  is  pointing,  its  wall,  as  the  resistance 
lessens,  projects ; and  by  ulcerative  absorption  the 
parts  covering  it  become  quickly  thinner,  until 
they  and  the  abscess-wall  give  way  and  the  pus 
escapes.  In  by  far  the  greater  number  of  cases 
this  absorption  of  tissue  before  the  pointing 
abscess  is  towards  the  surface,  aDd  it  is  by  ulcer- 
ation of  the  skin  that  the  opening  for  the  dis- 
charge of  the  matter  is  effected.  The  wall  of 
the  abscess  then  contracts,  pus  continuing  for  a 
time  to  be  discharged;  and  in  the  end,  aided bv 
the  resilience  of  the  tissues  around,  the  sac  of  tin- 
abscess  is  obliterated,  and  the  orifice  through 
which  its  contents  were  discharged  heals  by  gra- 
nulation process.  To  ensure  this  result  the  walls 
must  be  left  at  rest,  or  the  granulations  which 
cover  them  will  fail  to  unite,  and  the  obliteration 
of  the  sac  will  not  then  take  place,  as  happens 
for  example  in  the  case  of  an  abscess  situated 
between  the  moveable  rectum  on  the  one  tide  and 
the  ischium  on  the  other,  where  the  opposite 
abscess-walls  are  prevented  from  joining  by  mus- 
cular movements  on  the  side  of  the  bowel,  and 
will  only  unite  after  such  movements  have  been 
stopped  by  cutting  across  the  muscular  fibres 
which  occasion  them.  The  track  which  results 
from  such  failure  of  the  healing  of  an  abscess  is 
called  a sinus  or  fistula. 

In  a diffused  abscess  the  inflammation  of  the 
parts  around  does  not  limit  the  suppuration  by 
organisation  of  the  efiused  lymph,  but  such  lymph, 
itself  degenerating,  forms  more  pus.  and  so  the 
abscess  extends  rapidly  and  widely,  unless 
checked  by  some  barrier  of  dense  tissue.  In 
this  way  matter  often  spreads  along  tracks  of 
cellular  tissue,  as  along  the  course  of  veins, 
and  iu  the  subcutaneous  structures.  An  abscess 
when  formed  between  bone  and  periosteum,  oi 
otherwise  hindered  from  reaching  the  surface  by 
pointing,  also  tends  to  diffuse  itself  by  following 
the  course  of  least  resistance.  In  most  of 
these  cases  by  direct  pressure  upon  the  resisting 
tissue  or  by  cutting  off  the  blood  supply  (as  of 
the  skin  when  its  subcutaneous  tissue  is  infil- 
trated with  pus),  sloughing  of  the  parts  covering 
in  the  abscess  ensues,  oftentimes  to  a consider- 
able extent,  and  so  the  pus  eventually  makes 
its  way  to  the  surface.  It  is  these  abscesses, 
spreading  along  tracks  of  tissue  before  they  can 
reach  the  surface,  which  are  apt,  however,  when 
involving  certain  parts,  such  as  the  course  of 
some  of  the  lumbar  nerves,  to  burst  into  a serous 
cavity  with  fatal  consequences. 

A chronic  abscess  begins  in  some  local  inflam- 
mation without  active  symptoms,  such  as  resu.rs 
in  the  deposit  of  aplastic  lymph  and  subsequent 
ulcerative  changes,  as  caries  of  bone,  the  irrita- 
tion leading  to  suppuration.  The  formation  of 
matter  proceeds  in  a languid  manner,  so  that  it 
is  only  by  slow  degrees  that  it  collects  in  any 
considerable  quantity,  although  eventually  these 
chronic  abscesses  may  acquire  great  size.  They 
slowly  point,  and  in  their  tardy  advance  occa- 
sionally traverse  even  serous  cavities,  which  have 
been  first  obliterated  in  the  line  of  transit  by  ad- 
hesive inflammation  of  their  opposed  surfaces : ia 
this  way  an  abscess  formed  in  the  liver  (andtliii. 
holds  good  also  for  those  of  a more  acute  eliarsc. 


ABSCESS. 


ter)  may  travel  through  the  layers  of  the  perito- 
neum, and  may  point  through  the  anterior  wall 
of  the  abdomen. 

When  an  abscess  discharges,  its  contents  are 
seen  to  be  either  a thick  yellow  ( laudable ) pus,  or 
pus  stained  with  blood,  or  otherwise  coloured,  such 
as  black  or  bluish-green  ; or  the  pus  may  be  thin, 
almost  watery7,  mingled  with  flakes  of  lymph; 
it  may  he  inodorous  or  foetid,  or  irritating  to 
the  touch  (ichorous).  Abscesses  may  also  con- 
tain sloughs  of  tissue,  or  foreign  bodies,  or  masses 
of  inspissated  pus,  as  hard  occasionally  as  calculi, 
or  fragments  of  dead  bone,  or  calculi  of  various 
kinds.  Sometimes  a chronic  abscess  ceases  to 
enlarge  and  if  the  irritation  which  occasioned  it 
comes  to  an  end,  it  may  diminish  by  absorption 
of  the  fluid  part  of  its  contents,  the  solid  drying 
up  into  a shrunken  putty-like  mass.  It  may  re- 
main in  this  state  without  giving  rise  to  trouble, 
or  it  may  become  again  the  seat  of  suppuration 
by  the  formation  of  what  under  such  circum- 
stances has  been  termed  by  Sir  James  Paget  a 
residual  abscess. 

The  progress  of  any  abscess  is  largely  influ- 
enced by  the  state  of  the  general  health.  In 
persons  otherwise  robust  an  abscess  commonly 
runs  an  acute  course;  in  those  weakened  by  acute 
illness,  such  as  scarlet  fever  or  typhus,  they  form 
quickly,  but  are  slowly  recovered  from,  and 
severely  tax  by  an  exhausting  discharge  the 
powers  of  the  patient.  Persons  in  feeble  health, 
hereditary  or  acquired,  usually  suffer  from  the 
chronic  and  diffused  forms ; and  chronic  affections 
of  internal  organs,  as  of  the  liver  or  kidneys,  are 
not  unfrequently  associated  with  the  develop- 
ment of  such  abscesses. 

yEtioeogy. — The  cause  of  an  acute  abscess  may 
be  an  injury,  such  as  a blow  or  pressure,  as  often 
happens  in  persons  weakened  by  continued  fever ; 
exposure ; or  the  irritation  of  a foreign  body,  or 
that  of  a poison  introduced  from  without.  In  the 
last  case  the  abscess  is  often  diffused.  Abscess 
running  an  acute  course  may  also  he  due  to  a 
foreign  body  or  to  an  irritant  from  within,  as 
when  it  follows  necrosis  of  a portion  of  bone, 
or  the  escape  of  urine  into  the  tissues  of  the 
perineum.  It  also  arises  in  connection  with 
blood-poisoning,  as  in  various  fevers,  and  affec- 
tions distinguished  as  septic.  The  cause  of  a 
chronic  abscess  is  usually  found  in  changes  which 
go  with  deposits  of  a tuberculous  character ; or 
it  is  found  in  the  changes  which  slowly  occur 
around  an  irritating  body,  such  as  a renal  cal- 
culus ; or  chronic  inflammatory  changes  may 
culminate  in  one  of  these  collections  of  matter. 
They  may  also  form  in  parts  which  are  long 
congested  in  connection  with  obstructed  vein  cir- 
culation ( varix ) ; and  they  may  follow,  or  con- 
ditions closely  allied  may  follow,  the  occlusion  of 
a main  artery  and  the  consequent  cutting  off  of 
the  supply  of  blood  to  a particular  region. 

Symptoms. — The  symptoms  of  an  acute  abscess 
are  those  of  a local  inflammation,  with  constitu- 
tional disturbance  if  the  abscess  is  of  any  size  ; 
followed  by  a sense  of  cold  or  actual  shivering, 
with  increase  of  pain  and  swelling,  tenderness, 
and  throbbing.  The  tenderness  can  he  recog- 
nised in  the  case  of  most  abscesses  ; and,  if  pus 
is  formed  anywhere  near  the  surface,  the 
presence  of  the  fluid  is  detected  by  its  fluctua-  ' 


7 

tion.  The  severity  of  the  pain  is  much  influ- 
enced by  the  site  of  the  abscess,  as  when  the  pus 
is  held  down  and  hindered  from  pointing  bj 
dense  structures;  such  as  fascine.  Special  symp- 
toms may  also  arise  in  connection  with  the  situa- 
tion of  the  suppuration,  as  when  urgent  dyspnoea 
is  caused  by  the  pressure  on  the  larynx  of  an 
abscess  deeply  seated  at  the  base  of  the  tongue 
A diffused  abscess,  if  subcutaneous,  is  recog- 
nised by  its  rapid  spreading,  and  may  be  sus- 
pected if  other  signs  point  to  a part  as  the  site 
of  the  abscess  in  which  diffusion  is  the  rule,  as, 
for  instance,  by  the  side  of  the  rectum  in  the 
isehio-rectal  fossa. 

Of  chronic  abscess  there  is  seldom  in  its  early 
stage  any  evidence.  The  symptoms,  if  any,  are 
those  of  failing  health,  and  for  the  rest  are  marked 
by  those  of  other  changes  from  which  the  abscess 
is  an  outcome.  Thus  in  disease  of  the  hip  joint 
or  of  the  spine,  unless  an  attack  of  shivering 
chances  to  attract  attention,  an  abscess  is  not  as 
a rule  suspected  until  it  has  broken  through  its 
first  limits,  and  has  attained  considerable  size. 
It  is  not  worth  while  to  attempt  to  distinguish 
between  chronic  abscess  and  other  swellings,  such 
as  extravasated  blood  or  soft  tumours,  especially 
malignant  tumours ; for  if  a doubt  in  anj-  case 
arises,  it  can  be  at  once  solved  by  the  introduction 
of  a grooved  needle  or  of  a fine  trochar  into  the 
swelling.  The  true  pulsation  in  an  aneurism 
sufficiently  tells  its  nature,  and  is  not  easily  mis- 
taken for  the  impulse  sometimes  given  to  an 
abscess  by  an  adjacent  artery. 

Varieties. — The  chief  local  varieties  of  ab- 
scesses which  are  likely  to  he  met  with  in 
medical  practice  may  be  thus  arranged : — 
1,  Subcutaneous  or  more  deeply  seated  abscesses 
in  the  limbs,  in  connection  with  low  fevers,  ery- 
sipelas, pyaemia,  &c.  2.  Abscesses  of  local 

origin  in  the  walls  of  the  abdomen  or  chest. 

3.  Abscesses  originating  in  serous  membranes. 

4.  Certain  special  abscesses  associated  with  dis- 
eased hone,  e.g.,  psoas  and  lumbar  abscess. 

5.  Abscesses  formed  in  the  cellular  tissue  around 
organs,  e.g.,  peri-nephritic,  peri-csecal,  &c. 

6.  Abscesses  originating,  in  inflammation  of  or- 
gans, the  chief  of  which  include  hepatic,  renal, 
pyelitic,  pulmonary,  mammary,  cerebral,  splenic, 
pancreatic.  7.  Obscure  abscesses  formed  in  the 
deep  cellular  tissue,  e.g.,  retro-pharyngeal,  is- 
ehio-rectal, mediastinal.  8.  Glandular  abscesses, 
which  are  usually  chronic  and  of  a scrofulous 
nature. 

Treatment. — The  treatment  of  an  acute  ab- 
scess consists  in  rest,  soothing  local  applica- 
tions, and  the  use  of  remedies  to  allay  pain 
and  constitutional  disturbance,  if  the  latter 
exists.  As  soon  as  the  presence  of  pus  is  re- 
cognised the  abscess  must  he  opened,  if  possible 
where  the  matter  is  most  dependent;  and  as 
soon  as  its  contents  have  escaped  ail  troublesome 
symptoms  will  usually  disappear.  The  opening 
is  needed  to  relieve  pain,  and  to  prevent  in  some 
cases  diffusion,  and  sometimes  to  relieve  urgent 
distress,  as  when  dyspnoea  is  caused  by  the  pres- 
sure of  an  abscess  upon  the  air-passages.  It  is 
also  desirable  to  open  an  abscess  to  avoid  the 
considerable  scar  which  must  result  if  the  matter 
is  left  to  escape  by  ulceration  and  sloughing  of 
the  superficial  tissues.  If  it  is  important  to 


8 ABSCESS, 

avoid  the  sear  of  an  incised  -wound,  an  abscess 
may  be  punctured  in  several  places  -with,  a 
grooved  needle,  -when  the  punctures,  if  kept  open, 
will  effectually  drain  off  the  pus,  and  the  marks 
left  will  in  the  end  bo  scarcely  discernible.  In 
most  cases,  however,  it  is  necessary  to  open  an 
abscess  by  an  incision : a narrow  double-edged 
knife  should  be  used ; and  if  the  matter  is  deeply 
seated,  the  superficial  parts  only  need  be  cut,  the 
deeper  being  torn  through,  as  Mr.  Hilton  re- 
commends, by  dressing  forceps : the  risk  of 
dividing  important  structures,  as  in  the  neck, 
is  thus  avoided.  After  the  pus  has  escaped, 
the  wound  should  be  kept  open  by  means  of 
a drainage  tube  (unless  the  abscess  is  of  in- 
significant size),  which  is  conveniently  made  by 
introducing  a twisted  slip  of  thin  gutta-percha 
tissue  or  of  oiled  silk,  and  should  be  covered 
with  carbolised  oil  on  lint,  or  with  a poultice 
of  linseed  and  ferralum.  Some  surgeons  pro- 
tect the  wound  whilst  operating  by  means  of 
the  carbolic  spray  or  by  a piece  of  linen  steeped 
in  carbolic  lotion  (1  in  20),  or  take  other  anti- 
septic precautions.  Tho  drainage  tube  should 
be  withdrawn  after  the  first  day  if  the  abscess 
is  superficial,  but  if  the  pus  has  been  deeply 
seated  it  should  be  only  gradually  withdrawn, 
portions  being  cut  off  as  tho  abscess  contracts. 
If  a foreign  body  has  caused  the  formation  of 
the  abscess,  it  must  be  sought  for  and  removed 
before  the  suppuration  can  be  expected  to  cease. 
Occasionally  the  vascular  wall  of  an  abscess 
bleeds  freely,  or  a vessel  is  opened  in  the  pro- 
gress of  the  affection  : the  hsemorrhage  usually 
ceases  on  laying  the  abscess  freely  open  ; but  if 
this  does  not  suffice  it  may  be  permanently  con- 
trolled by  pressure,  and  the  cases  are  rare  in 
which  further  operative  interference  is  called  for. 
Inflammation  of  the  sac  used  not  infrequently  to 
follow  the  discharge  of  its  contents,  but  under 
the  treatment  now  employed  such  an  occurrence 
is  unknown.  During  the  healing  of  any  consi- 
derable abscess  the  general  health  should  be 
attended  to,  and  tonics  and  change  of  air  may  be 
useful  to  expedite  recovery. 

Diffused  abscesses,  whether  subcutaneous  or 
more  deeply  seated,  require  free  incisions  as 
soon  as  suppuration  is  even  suspected,  so  as  to 
avoid  the  damage  which  results  from  their 
spreading  and  from  the  sloughing  of  tissue,  as 
of  the  skin,  which  will  otherwise  occur,  especi- 
ally with  those  due  to  poison  introduced  into  the 
system  or  those  caused  by  infiltration  of  urine. 
These  abscesses  sometimes  lead  to  fatal  results. 

A chronic  abscess  may  have  its  contents  drawn 
off  by  the  aspirator ; or  it  may,  when  it  has 
come  near  the  surface,  be  opened,  drained, 
and  dressed  with  carbolised  oil  on  lint,  without 
any  risk  of  constitutional  disturbance,  but  its 
ultimate  closing  will  depend  upon  the  removal  of 
the  cause  ; if,  for  example,  it  is  due  to  disease 
of  a joint,  it  cannot  be  cured  until  the  disease 
in  which  it  has  originated  has  in  some  way 
ended. 

Sinus. — An  abscess  .after  being  opened  may 
contract  until  it  forms  a narrow  track,  sinus  or 
fistula , leading  to  the  site  of  primary  irritation. 
Such  a track  has  a dense  fibrous  wall  from  which 
muco-purulent  fluid  escapes : it  may  also  convey 
secretions,  as  from  the  liver  (hepatic  fistula)  or 


ACARUS. 

stomach  (. gastric  fistula),  or  excretion,  as  from  the 
kidneys  ; or  it  may  simply  carry  out  the  pua 
which  forms  around  some  irritant  at  the  deep 
extremity,  such  as  a foreign  body,  a portion  of 
carious  or  of  necrosed  bone.  Some  such  fistulse 
are  due  to  the  movements  of  adjacent  muscles 
preventing  union  of  the  abscess  walls.  Unless 
the  cause  of  the  sinus  can  be  removed,  as  by  ex- 
tracting necrosed  bone,  these  fistulous  tracks  are 
difficult  to  manage,  requiring  especial  treatment 
according  to  their  situation.  Other  fistula  are 
those  forming  communications  between  mucous 
canals  ( recto-vesical , vesico  - vaginal  fistula), 
and  these  need  special  treatment,  such  as 
plastic  operations  and  operations  diverting  the 
course  of  excreta  escaping  through  unnatural 
channels. 

The  tissue  about  healed  abscesses,  scar-tissue 
generally,  and  tissue  spoiled  by  inflammation, 
are  apt  on  slight  provocation  to  inflame  and 
suppurate,  and  to  those  collections  of  matter  the 
term  ‘ residual  ’ has  been  applied.  The  treat- 
ment of  such  abscesses  in  no  way  differs  from 
that  of  others,  and  they  usually  heal  in  the  or- 
dinary manner.  G.  W.  Callender. 

AB  SIN  THIS  M. — Definition. — The  condi- 
tion induced  by  the  undue  imbibition  of  ab- 
sinthe. 

From  the  mode  in  which  absinthe  is  taken, 
we  should  expect  that  the  symptoms  in- 
duced by  its  excessive  consumption  would  bo 
generally  obscured  by,  and  intermixed  with 
those  of  alcohol  (see  Alcoholism).  That  it  has 
a special  effect  on  the  organism,  and  that  this 
may  be  diagnosed  from  alcoholism,  has  been 
pointed  out  by  Motet,  Magnan,  and  other  French 
physicians  ; and  the  writer  last-mentioned  has 
clearly  exemplified  its  action  by  numerous  ex- 
periments on  dogs.  In  persistent  absinthe- 
drinkers  vertigo  and  epileptiform  convulsions  are 
marked  symptoms,  and  come  on  much  earlier 
than  when  alcohol  in  other  forms  is  habitually 
drunk.  Hallucinations  occur  also  without  auv 
other  symptom  of  delirium  tremens  ; and,  when 
tremors  coexist,  these  are  limited  more  par- 
ticularly to  the  muscles  of  tho  arms,  hands, 
and  upper  extremities.  Absinthe  acts  chiefly  on 
the  cervical  portion  of  the  spinal  cord,  and  this 
readily  explains  the  special  symptoms  arising 
from  its  regular  use.  John  Curnow. 

ABSORBENT  AGENTS. — Definition. — 

In  Surgery,  absorbents  are  substances  used  to 
absorb  fluids,  as  sponges,  charpie,  or  tow : in 
Medicine,  drugs  which  neutralize  excessive  acidity 
in  the  stomach — a synonym  for  alkalis  (see  Al- 
kalis). The  term  is  sometimes  also  made  use  of 
to  designate  remedies,  such  as  the  preparations 
of  mercury  and  iodine,  which  are  believed  to  pos- 
sess the  property  of  promoting  the  absorption  of 
morbid  products. 

ABSORBENT  VESSELS  and  GLANDS, 

Diseases  of.  S:e  Lymphatic  System,  Diseases 
of ; also  Bronchial,  and  MIesexteric  Glands, 
Diseases  of. 

ACARUS. — Acari  or  Mites  constitute  an 
order  of  the  class  Aracknida,  several  species  ol 
which  are  parasitic.  The  Acarus  scabiei  or  Sar- 
coptes  hominis,  aud  the  Acarus  foil ic u lorn m,  oi 


ACARUS. 

more  properly  the  Steatozoon  folliculorum,  are 
the  only  human  parasites  belonging  to  this 
family. 

Description.  — 1.  The  Acarus  scabiei  is  a 
small  roundish  animal,  just  visible  to  the  naked 
eye.  Examined  under  the  microscope  it  is  seen  to 
be  flattened  and  to  resemble  a tortoise  in  shape ; 
when  fully  developed  it  has  eight  legs,  and  on 
its  under  surface  are  scattered  filaments  and  short 
spines,  which  are  for  the  most  part  directed 
backwards.  The  female  is  larger  than  the  male, 
and  is  provided  with  terminal  suckers  on  the 
four  anterior  legs,  while  filaments  occupy  a similar 
position  on  the  posterior  ones  ; in  the  male,  how- 
ever, the  two  extreme  hind  legs  have  suckers 
like  those  on  its  fore  limbs.  The  young  Acarus 
has  only  six  legs,  the  two  hindmost  ones,  which 
are  distinctive  of  the  sex,  being  wanting ; it 
acquires  these  after  shedding  its  first  skin.  The 
male  Acarus  lives  near  the  surface  of  the  skin, 
while  the  female  burrows  -within  the  cuticle,  and 
deposits  from  ten  to  fifteen  eggs  in  the  cuni- 
eulus  or  burrow ; these  eggs  hatch  in  about  a fort- 
night. The  young  Acari  escape  from  the  bur- 
row, but  the  parent  does  not  leave  it,  and  dies 
when  she  has  finished  laying  eggs.  The  Acarus 
scabiei  is  the  cause  of  the  skin-affection  termed 
Scabies  or  Itch  (see  Scabies). 

2.  The  Acaros  folliculorum  is  a very  mi- 
nute parasite  commonly  found  in  the  sebaceous 
and  hair  follicles  of  the  face,  but  its  presence 
can  hardly  be  regarded  as  indicating  disease. 
In  this  animal  the  head  is  continuous  with  the 
thorax,  and  to  the  latter  are  attached  eight  very 
short  legs,  each  armed  with  three  strong  claws. 
On  each  side  of  the  head  are  short  jointed  palpi. 
The  abdomen  varies  in  length  from  twice  to 
three  or  four  times  that  of  the  thorax:  it  is 
pointed  at  its  distal  extremity.  The  presence  of 
this  parasite  in  the  follicles  of  the  skin  is  quite 
unimportant.  Robert  Liveing. 

ACCOMMODATION",  Disorders  of. — See 

Vision,  Disorders  of. 

ACEPHALOCYST  (d,  priv. ; icecpaK-) J,  a 
head  ; and  kvctis,  a bladder). — A headless  cyst  or 
hydatid. — This  term  was  formerly  much  em- 
ployed to  distinguish  the  true  hydatid  from  all 
those  bladderworms  that  are  furnished  with  a 
head  visible  to  the  naked  eye.  The  expression 
is  a misnomer  and  should  be  abandoned,  since  it 
is  only  fairly  applicable  to  such  hydatids  as  have 
failed  to  develop  the  so-called  heads  internally. 
The  Acepkalocystis  endogena  of  John  Hunter 
and  the  A.  exogena  of  Kuhl  are  merely  varieties 
of  the  true  hydatid  ( Echinococcus  veterinorum, 
or  E.  hominis).  See  Hydatids,  Echinococcus, 
and  Bladderworms.  T.  S.  Cobbold. 

ACHOLIA  (a, priv.,  andx<Au,  bile). — Absence 
or  deficiency  of  bile.  See  Bile,  Morbid  states  of. 

ACHOR. — A small  follicular  pustule  of  the 
scalp.  Willan’s  definition  is  as  follows : — ‘A  small 
acuminated  pustule  containing  a straw-coloured 
matter,  which  has  the  appearance  and  nearly  the 
consistence  of  strained  honey,  and  is  succeeded  by 
a thin  brown  or  yellowish  scab.’  Both  the  pus- 
tule and  the  scab  are  constituents  of  the  disease 
Vorrigo.  The  word  has  fallen  into  disuse,  but 
is  preserved  by  Schonlein  in  the  name  ‘Acho- 


ACIDITY.  D 

rion  ’ assigned  by  him  to  one  of  the  varieties  ol 
parasitic  cutaneous  fungi.  The  Greek  word 
a-Xap  signifies  scurf,  or  dandruff ; axvpbv  mean- 
ing chaff.  Erasmus  Wilson. 

ACHORION  (axA'p,  scurf)  is  the  name  given 
to  one  of  the  three  principal  dermophytes  or  epi- 
phytes of  the  skin.  It  is  the  constituent  of  the 
crusts  of  Favus  (Achor),  and  belongs  to  the  group 
of  fungoid  plants  denominated Oidium.  It  consists 
of  spores,  sporidia  or  tubes  filled  with  spores, 
and  empty  branched  tubes  or  mycelium. 

Achorion  was  the  first  discovered  of  the  epi- 
phytes of  the  skin,  and  in  compliment  to  one  of  its 
early  observers,  Schonlein,  has  been  named  Acho- 
rion  Schonlcinii.  It  is  supposed  to  be  the  agent 
of  contagion  in  Favus  ; it  has  also  been  found  in 
the  loose  cell-structure  beneath  the  nail  in  Ony- 
chogryphosis.  Erasmus  Wilson. 

ACHROMA  (o,  priv.,  and  xp^^t  colour). 
Absence  of  colour ; an  achromatous  or  colourless 
state  of  an  usually  coloured  tissue,  due  to  abscnco 
of  pigment.  In  reference  to  the  skin  Achroma 
is  synonymous  with  Leucoderma,  Albinism,  and 
Alphosis.  See  Pigmentary  Skin-Diseases. 

ACHROMATOPSIA  (a,  priv.  ; XP“,uai 
colour;  and  &if/,  sight). — More  or  less  complete 
inability  to  distinguish  colours  from  each  other. 
See  Vision,  Disorders  of. 

ACIDITY. — Acids  are  constantly  passing  out 
of  the  body  by  the  lungs,  the  skin,  and  the  kid- 
neys. These  acids,  if  we  except  the  small  quantity 
introduced  from  without  in  the  form  of  acid  salts 
of  certain  articles  of  food,  are  formed  within  the 
body  by  the  disintegration  and  oxidation  of  the 
tissues  and  food.  If  the  oxidation  of  organic 
substances  in  the  system  were  complete,  the  sole 
products  of  their  combustion  would  be  carbonic 
acid,  water,  and  urea;  but  as  this  oxidation  is 
never  actually  complete,  other  products,  as  lactic 
acid,  oxalic  acid,  uric  acid,  etc.,  are  formed  ; and 
the  increased  or  diminished  production  of  these 
intermediary  products  may  be  regarded  as  the 
measure  of  the  completeness  with  which  the  ox- 
idation processes  are  being  performed  in  the 
body.  The  quantity  of  acid  matter  passing 
through  the  blood  on  its  way  to  the  lungs,  the 
skin,  and  the  kidneys  is  considerable;  since  it 
has  been  shown  approximativelv,  that  a healthy 
man  of  eleven  stone  weight,  under  ordinary  cir- 
cumstances, passes  by  the  two  first  channels  an 
average  of  890  grammes  (about  28  ounces)  of 
carbonic  acid  daily,  and  that  the  acid  excreted 
by  the  kidneys  in  the  same  period  is  equiva- 
lent to  two  grammes  (about  31  grains)  of  crystal- 
lised oxalic  acid ; whilst  the  volatile  fatty  acids 
passing  off  with  the  sweat  have  not  vet  been  satis- 
factorily calculated.  It  is  evident  that  if  the  re- 
gular elimination  of  this  acid,  by  any  of  these 
channels,  be  interfered  -with,  it  will  tend  to  ac- 
cumulate in  the  system.  Acidity,  or  excess  of 
acid  in  the  body,  therefore  depends  on  two  causes ; 
— 1.  Excessive  formation,  the  result  of  incomplete 
oxidation  of  the  elements  of  the  tissues  and  the 
food.  2.  Deficient  elimination  of  acid  formed 
either  in  normal  or  abnormal  quantities.  Both 
these  causes,  however,  are  generally  found  acting 
in  conjunction.  Oxidation  is  imperfectly  per- 
formed, when  an  insufficient  quantity  of  oxygen 


10  ACIDITY. 

is  introduced  into  the  body,  owing  to  insuffi- 
ciency of  the  respiratory  act,  the  result  of 
disease  or  of  sedentary  habits ; or  when  the  blood 
is  poor  in  red  corpuscles,  the  carriers  of  oxygen, 
as  in  leucocythsemia ; or  from  functional  derange- 
ment of  some  large  gland,  as  the  liver,  where 
oxidizing  processes  are  extensively  wrought. 
Again,  the  materials  submitted  to  the  influence 
of  the  oxygen  within  the  body  may  be  so  in- 
creased, as  is  the  case  in  febrile  conditions,  or 
in  general  plethora  induced  by  over-feeding  and 
insufficient  exercise,  that  the  supply  of  oxygen 
may  prove  insufficient  for  their  complete  com- 
bustion. Defective  elimination  of  the  acids 
formed  within  the  body  is  due  either  to  dis- 
eased conditions  which  prevent,  or  to  want  of 
the  physiological  stimulus  which  excites,  the 
lungs,  skin,  and  kidneys  to  exercise  their  re- 
spective functions  properly.  It  will  bo  seen, 
therefore,  that  acidity  may  arise  in  consequence 
of  the  disturbing  influence  of  disease ; or  may 
be  acquired  or  inherited  as  the  penalty  of  trans- 
gression of  certain  laws  of  health — as  the  result 
of  unfavourable  hygienic  conditions.  In  the 
former  case,  acidity  is  only  secondary,  and  is 
generally  subordinate  to  the  disease  producing  it, 
and  has  rarely  to  be  considered  apart  from  it; 
whilst  in  the  latter  instance  acidity  is  usually  at 
first  the  only  trouble,  leading,  however,  if  dis- 
regarded to  secondary  mischiefs. 

Effects. — The  mucous  membranes  and  skin 
chiefly  suffer  in  acidity.  The  former  become 
subject  to  catarrh,  produced,  no  doubt,  by  the 
irritating  presence  of  the  acid.  Acidity  may 
thus  cause  bronchitis,  gastro -intestinal  catarrh, 
and  catarrh  of  the  genito-urinary  tract.  Some- 
times the  acid  is  poured  out  in  such  quanti- 
ties from  the  mucous  membrane  of  the  stomach 
as  to  be  ejected  from  the  mouth.  In  these  cases 
digestion  is  considerably  interfered  with  by  the 
too  acid  condition  of  the  gastric  juice.  Some- 
times, however,  this  acidity  of  the  stomach  is 
produced  by  an  opposite  condition — the  defi- 
ciency of  the  digestive  fluid,  and  consequent 
acid  fermentation  of  the  food.  Abnormal  acidity 
of  the  urine  produces  not  only  catarrh  of  the 
urinary  passages,  but  by  decomposing  the  salts 
of  uric  acid  causes  a deposit  of  insoluble  uric  acid 
in  the  passages,  thus  giving  rise  to  attacks  of 
. gravel  or  leading  to  the  formation  of  a calculus. 
Acidity  manifests  itself  in  the  skin  by  attacks 
of  erythema,  herpes,  eczema,  and  urticaria.  Rheu- 
matism, too,  may  be  considered  as  a disease 
resulting  from  the  formation  of  acid,  affecting 
chiefly  fibrous  and  serous  membrane;  no  one 
can  witness  the  enormous  quantities  of  acid 
sweat  poured  out,  and  the  highly  acid  urine, 
in  the  acute  form  of  this  disease,  without 
acknowledging  that  an  increased  formation  of 
acid  is  taking  place  somewhere  in  the  body; 
though  perhaps  unwilling  to  commit  himself  to 
accept  any  of  the  views  hitherto  advanced  as 
to  the  nature  of  the  acid. 

Estimation  of  Acid. — For  clinical  purposes 
an  estimation  of  the  acidity  of  the  urine  fur- 
nishes the  physician  with  an  approximate  clue 
as  to  the  amount  of  acid  formed  in  and  passing 
out  of  the  body.  This  is  done  by  collecting  the 
urine  for  twenty-four  hours,  placing  100  cic.  of 
this  in  a beaker,  and  then  adding  a solution 


ACIDS. 

of  sodium  hydrate,  standardised  so  that  1 c.c. 
= -01  gramme  of  crystallised  oxalic  acid,  from  a 
Mohr’s  burette,  till  the  fluid  is  neutralised  ; tho 
number  of  c.c.'s  of  the  standard  solution  required 
to  effect  this  is  to  be  multiplied  by  '01,  which 
gives  the  percentage  acidity  in  terms  of  oxalic 
acid ; to  ascertain  from  this  the  total  amount  of 
acid  in  the  twenty-four  hours’  urine  is  only  a 
matter  of  calculation.  Too  much  dependence  must 
not,  however,  be  placed  on  the  urine  as  a means  of 
estimating  excess  or  deficiency  of  acid  in  the  sys- 
tem ; it  sometimes  happens  that  in  highly  acid 
conditions  the  urine  is  alkaline.  This,  as  Dr. 
Bence  Jones  has  shown,  may  occur  when  large 
quantities  of  acid  fluid  are  poured  out  of  the 
stomach  ; and  Prout  long  ago  observed,  that  in  the 
eczema  of  gouty  persons  the  urine,  so  long  as  the 
disease  persisted,  was  either  of  low  acidity  or 
alkaline,  but  that  the  subsidence  of  the  eczema 
was  frequently  followed  by  an  over-acid  condition 
of  the  urine,  accompanied  with  renal  and  vesical 
catarrh. 

Treatment. — The  general  indications  for  the 
treatment  of  acidity  consist  in  the  promotion  of 
oxidation,  and  the  elimination  of  the  acids  formed. 
Active  habits,  which  promote  the  pulmonary  and 
cutaneous  functions,  should  be  encouraged.  The 
diet  should  he  just  sufficient  to  meet  the  physio- 
logical requirements  of  the  body ; it  should  con- 
sist chiefly  of  fish,  fowl,  game,  and  eggs  ; sac- 
charine and  farinaceous  articles  being  excluded. 
Sweet  and  cheap  wines  should  be  avoided  ; for 
those  who  cannot  afford  to  purchase  good  wine, 
pure  spirits  and  water  is  the  best  substitute. 
Carlsbad  salts  or  Friedrickshall  water  may  be 
given  if  there  is  much  abdominal  plethora,-  tho 
habit  of  taking  mercurials  as  a relief  for  this 
condition  is  to  be  deprecated.  Alkaline  medi- 
cines are  frequently  administered  with  a view  of 
neutralising  the  effects  of  acid ; their  employ- 
ment for  this  purpose  seems,  however,  question- 
able. Dr.  Parkes  has  stated  that  the  adminis- 
tration of  bicarbonate  of  potash  (a  favourite 
remedy  in  acid  diseases),  though  rendering  the 
urine  alkaline,  in  reality  increases  very  largely 
the  excretion  of  the  organic  acids.  This  is  not 
to  be  wondered  at  when  we  consider  that  the 
bicarbonate,  although  alkaline  in  reaction,  is  in 
constitution  an  acid  salt.  The  nitric  and  hydro- 
chloric acids,  given  in  moderato  doses  about  one 
hour  before  meals,  certainly  have  a powerful 
oxidising  effect,  and  diminish  the  quantity  cf 
uric  acid  excreted  in  the  urine.  In  cases  where 
the  acidity  is  manifestly  due  to  defective  oxida- 
tion consequent  on  poverty  of  blood  from  dimi- 
nution of  the  red  corpuscles,  iron  and  food  must 
be  freely  given. 

ACIDS.  — Definition.  — Substances  which 
combine  with  alkalis,  and  destroy  their  power  cf 
turning  red  litmus  paper  bluo.  Most  of  the  acids 
also  redden  blue  litmus,  and  have  a sour  taste; 
but  some,  for  example,  carbolic  acid,  possess 
neither  of  these  properties. 

Entoieuation. — Acids  may  be  divided  into 
Inorganic  or  Mineral,  and  Organic.  The  mine- 
ral acids  used  in  medicine  are  Carbonic.  Hy- 
drochloric, Nitric,  Nitrohydroeliloric,  Phos- 
phoric, Sulphuric  and  Sulphurous  acids.  The 
erg, -tale  acids  thus  employed  include  Acetic, 


ACIDS. 

Benzoic,  and  Carbolic,  Citric,  Gallic,  Hydro- 
cyanic, Lactic,  Salicylic,  Tannic,  Tartaric,  and 
Valerianic. 

Action. — The  stronger  acids — Sulphuric,  Ni- 
tric, Hydrochloric,  and  Glacial  Acetic  acids — 
destroy  animal  tissues,  and  act  as  caustics 
when  applied  to  the  surface.  When  swal- 
lowed, they  produce  the  symptoms  of  irritant 
poisoning.  ( See  Poisons.)  An  antidote  for  these 
poisons  which  is  always  at  hand  is  carbonate 
of  lime,  in  the  form  either  of  whiting  or  of 
plaster  chipped  from  the  nearest  wall.  Other 
antidotes  are  alkaline  carbonates  and  bicarbo- 
nates, milk,  oil,  and  soap.  Diluted  acids,  taken 
into  the  mouth,  increase  the  secretion  of  saliva ; 
and  hydrochloric  acid  forms  an  important  con- 
stituent of  the  gastric  juice,  without  which 
digestion  does  not  go  on.  When  absorbed  into 
the  blood,  dilute  acids  act  on  the  heart  gene- 
rally, slowing  its  pulsations  and  reducing  the 
temperature.  They  are  excreted  in  the  urine 
and  milk. 

Uses. — Nitric  acid  is  employed  as  a caustic 
application  to  piles,  to  poisoned  wounds,  and  to 
spreading  or  unhealthy  sores.  Glacial  Acetic 
acid  is  used  to  destroy  corns  or  warts.  Diluted 
Acetic  acid  or  vinegar  is  applied  as  a lotion  to 
relieve  headache ; to  allay  the  itching  of  prurigo, 
lichen,  and  psoriasis  ; to  check  perspiration ; and 
sometimes  to  hasten  the  appearance  of  exan- 
thematous eruptions.  Diluted  acids,  especially 
Citric,  Tartaric,  and  Hydrochloric,  are  adminis- 
tered in  fevers  as  refrigerants,  because  they 
relieve  the  dryness  of  the  mouth,  and  diminish 
the  thirst  by  increasing  the  secretion  of  saliva, 
ns  well  as  lower  the  temperature  and  pulse- 
rate.  Under  the  like  circumstances,  tho  organic 
acids,  Acetic,  Citric,  and  Tartaric,  when  com- 
bined with  alkaline  carbonates  in  a state  of 
effervescence  or  otherwise,  form  agents  which 
act  on  the  skin  and  kidneys.  In  febrile  con- 
ditions, amemia,  and  some  forms  of  dyspepsia,  the 
proportion  of  acid  in  the  gastric  juice  is  insuffi- 
cient for  the  proper  digestion  of  food,  and  the 
administration  of  dilute  Hydrochloric  acid,  imme- 
diately before  or  after  meals,  is  useful  both  by 
aiding  digestion  and  by  preventing  the  formation 
of  butyric  and  other  acids,  which  give  rise  to 
sour  eructations.  Nitro-hydrochloric  acid,  before 
meals,  is  likewise  beneficial  in  preventing  acidity. 
It  appears  to  have  some  action  on  the  liver,  and 
is  used  both  internally  and  externally  as  a lotion 
or  footbath  in  jaundice  and  biliousness.  It 
generally  relieves  the  frontal  headache  common 
in  young  females,  which  is  felt  just  above  the 
eyebrows,  and  not  accompanied  by  constipation. 
Dilute  acids,  especially  Aromatic  Sulphuric  acid, 
are  useful  in  checking  diarrhoea,  colliquative 
sweats,  haemorrhages,  and  mucous  discharges. 
By  lessening  the  alkalinity  of  the  urine,  they 
tend  to  prevent  the  formation  of  phosphatic  cal- 
culi, phosphoric  and  nitric  acids  being  most  fre- 
quently employed  for  this  purpose.  Care  must 
be  exercised  in  their  administration  to  nursing 
mothers,  as  they  are  excreted  in  the  milk, 
and  sometimes  cause  griping  and  diarrhoea  in 
infants  at  the  breast.  Several  acids  have  a 
special  action  of  their  own,  and  are  consi- 
dered under  their  respective  groups,  such  as 
Hydrocyanic  acid,  which  is  a sedative  ; Carbolic, 


ACNE.  1 1 

an  antiseptic ; Salicylic,  an  apyretic  ; Gallic  and 
Tannic,  astringents.  T.  Lauder  Brunton. 

ACINESIA  (a,  priv.,  and  k iv-qais,  motion). — 
A synonym  for  paralysis  of  motion,  whether 
partial  or  general.  See  Paralysis,  Motor. 

ACNE  (cucpa^a,  I bloom).  — The  ancient 
Greeks  showed  their  appreciation  of  tho  mor- 
bid states  of  the  integument  by  calling  this 
disease  cucpai,  the  JIos  cetaiis  of  their  Latin  trans- 
lators; but  in  course  of  transmission  the  p gave 
place  to  v , and  the  original  term  to  that  by 
which  the  disease  is  at  present  known. 

Definition. — An  inflammation  of  the  hair 
follicles,  or  a folliculitis  of  the  skin,  associated 
with  the  development  of  the  permanent  hair  of 
the  body  at  and  after  puberty  ; its  almost  exclu- 
sive seat  of  manifestation  being  the  face,  the 
submastoid  region  of  the  neck,  the  sternal 
region  of  the  breast,  and  the  back  and 
shoulders. 

.ZEtiology  and  Pathology. — In  its  relation 
to  other  diseases  of  the  skin,  Acne  is  nothing 
more  than  a folliculitis ; and  folliculitis,  how- 
ever engendered,  must  always  pursue  the  same 
pathological  course.  Hence  folliculitis  of  the 
face,  from  whatever  cause,  especially  if  at- 
tended with  papulation  and  suppuration  simi- 
lar to  the  acne  of  puberty,  has  likewise  been 
termed  Acne;  such  is  the  Acne  Rosacea  or  Grutta 
Rosacea  of  adult  life;  and  such  are  the  varieties 
of  folliculitis  produced  by  iodine,  bromine,  and 
tar,  which  have  been  respectively  denominated 
Iodine-,  Bromine-,  and  Tar- Acne. 

Description. — The  pathological  essentials  of 
Acne  are : — a languid  and  torpid  skin  ; a tendency 
to  accumulation  of  sebaceous  matter  within  the 
follicles  ; congestion  of  the  coats  of  the  follicles 
and  immediately  contiguous  structures  ; and  the 
ordinary  manifestations  of  inflammation,  such  as 
suppuration,  infiltration,  and  solidification.  Prom 
these,  which  are  the  ordinary  signs  of  inflamma- 
tion of  the  follicles,  we  derive  the  various  sub- 
jective designations  of  the  disease:  for  example, 
when  accumulation  of  sebaceous  matter,  showing 
as  a black  point  with  little  or  no  inflammation,  is 
the  leading  feature,  the  condition  is  termed  Acno 
punctata  ; when  congestion  and  infiltration  force 
up  the  skin  into  a conical  pimple,  Acne  coni- 
formis ; when  suppuration  is  present,  Acne  pus- 
tulosa-,  and  when  thickening  and  condensation 
display  themselves,  Acne  indurata.  The  whole 
series,  with  the  exception  of  Acne  indura'a, 
which  represents  a chronic  disposition,  may  bo 
called  indiscriminately  Acne  simplex  or  Acne 
vulgaris,  there  being  obviously  no  regular 
standard. 

Diagnosis. — Acne  is  a well-defined  eruption, 
and  not  difficult  of  diagnosis,  its  most  im- 
portant features  being: — its  limitation  to 
the  period  of  life  corresponding  to  and  soon 
after  puberty ; and  its  dependence  on  a phy- 
siological process  at  that  time  taking  place  in 
the  economy. 

Treatment. — The  treatment  of  Acne  may  be 
summed  up  in  a few  words : — Bemove  any  ex- 
citing cause  that  may  exist ; improve  the  nutri- 
tive power  of  the  individual  and  of  the  skin ; 
stimulate,  that  is,  give  tone  and  vigour  to  the 
part  locally'.  Our  best  general  remedies  are  n 


12  ACNE, 

good  hygiene,  careful  attention  to  diet  and 
habits  of  life,  ordinary  tonics,  and  especially 
arsenic.  The  most  efficient  local  application 
is  sulphur,  especially  the  compound  hypochloride 
of  sulphur  ointment,  which  consists  of  a drachm 
of  hypochloride  of  sulphur  with  ten  grains  of 
carbonate  of  potash,  to  an  ounce  of  benzoated 
lard.  Arsenic  is  best  administered  as  a com- 
bination of  Vinum  Eerri  and  Liquor  Arseni- 
calis  (uuj-iij)  three  times  daily  at  the  end  of 
meals. 

Erasmus  "Wilson. 

ACONITE,  Poisoning  by. — See  Poisons. 

ACQUIRED  DISEASES. — Diseases  origi- 
nating independently  of  hereditary  transmission. 
See  Disease,  Causes  of. 

ACEOCHOEDON- An  outgrowth  of  the 
integument  in  the  form  of  a slender  cylinder, 
which  may  be  compared  to  the  loose  end  of  a 
piece  of  string  or  cord — S.xpov  signifying  a 
point  or  end  and  x°P^^I  a string.  Such  out- 
growths are  usually  met  with  in  a feeble 
state  of  the  skin,  and  particularly  in 
elderly  persons,  their  common  seat  being  the 
neck  or  trunk.  They  are  at  first  sessile,  but 
become  elongated ; and  are  sometimes  bulbous  at 
the  extremity,  and  more  or  less  pedunculated. 
Pathologically  an  acrochordon  is  composed  of 
loose  areolar  tissue,  firmer  at  the  surface  than 
within,  and  of  a fine  artery  and  vein,  connected 
by  a capillary  loop  or  plexus,  and  sometimes  a 
little  ramified.  It  is  popularly  regarded  as  a 
wart,  and  in  medical  works  is  termed  verruca 
acrochordon,  but  it  differs  from  a wart  very  widely 
in  structure.  When  acroehordones  attain  a size 
beyond  that  of  a pea,  they  fall  into  the  category  of 
a soft  tegumentary  tumour  or  Molluscum. 

Treatment. — This  consists  in  snipping  them 
off  with  scissors,  or  touching  them  with  a strong 
solution  of  potassa  fusa  (equal  parts).  When 
numerous  and  minute,  they  admit  of  being  shri- 
velled up  and  removed  by  means  of  liquor 
plumbi,  or  a lotion  of  perehloride  of  mercury,  two 
grains  to  the  ounce.  The  latter,  by  its  stimu- 
lating property,  also  arrests  their  formation. 

Erasmus  Wilson. 

ACEODYKIA  (&xpos,  extreme,  and 
dSvvrt,  pain).  A dermatitis  affecting  the  hands 
and  feet,  particularly  the  palms  and  soles, 
accompanied  with  burning  heat,  stinging  and 
smarting  pains,  and  numbness.  The  pains  some- 
times extend  to  the  whole  system,  and  there  is 
more  or  less  disorder  of  the  digestive  and  assimi- 
lative functions.  The  redness  is  at  first  bright, 
then  deeper  tinted  and  brown,  with  considerable 
pigmentation  of  tbs  retemucosum.  Occasionally 
there  are  pimples,  pustules,  and  blisters ; the 
cuticle  desquamates,  and  is  sometimes  cast  in  a 
single  piece ; the  disease  running  on  for  several 
weeks. 

Treatment. — This  should  be  directed  to  tbe 
regulation  of  the  digestive  and  assimilative  or- 
gans, and  to  the  relief  of  local  inflammation  by 
means  of  water-dressing  followed  by  bandaging 
with  zinc  ointment.  Erasmus  Wilson. 

ACUPUNCTURE  is  an  ancient  mode  of 
treatment  for  the  relief  of  painful  affections,  now' 


ADDISON’S  DISEASE, 
but  little  used,  consisting  in  the  introduction  oi 
fine  round  needles  through  the  skin,  to  a varying 
depth.  It  is  said  to  have  been  introduced  into  this 
country  from  China  or  Japan,  about  200  years  ago. 
The  needles  used  are  about  two  inches  in  length, 
and  are  set  in  round  handles,  so  that  they  can 
be  introduced  with  a gentle  rotatory  movement. 
It  is  now  employed  solely  in  lumbago  and 
sciatica,  iu  which  affections  it  undoubtedly 
gives  relief.  The  operation  is  thus  performed. 
The  patient  beiDg  laid  upon  his  face,  tender 
spots  are  sought  for — in  lumbago  over  the 
erector  spinae,  and  in  sciatica  along  the  course  of 
the  sciatic  nerve.  The  needles  are  then  pushed 
in  vertically  for  a depth  of  from  one  and  a-half 
to  two  inches,  and  allowed  to  remain  for  from 
half  an  hour  to  two  hours.  The  number  of 
needles  employed  may  vary  from  one  to  six. 
In  sciatica  it  is  recommended,  if  possible,  to 
make  the  needle  actually  penetrate  the  nerve. 
This  is  known  by  the  patient  complaining  of 
sudden  pain  shooting  down  the  back  of  the  leg. 
The  mode  of  action  is  uncertain,  but  in  sciatica 
it  has  been  supposed  that  the  puncture  of 
the  nerve  sheath  allows  the  escape  of  fluid. 
Acupuncture  has  also  been  employed  in  painful 
neuritis  following  injury,  but  without  much 
effect.  In  a modification  invented  by  Baun- 
scheidt,  forty  punctures,  about  half-an-inch  in 
depth,  were  made  in  an  area  of  the  size  of  a 
crown  piece,  by  an  instrument  working  by  a 
spring.  Oil  of  mustard  diluted  with  olive  oil 
was  then  painted  on,  which  gave  rise  to  an 
eruption  like  herpes.  This  was  at  one  time  in 
great  repute  as  a quack  remedy  for  all  sorts  of 
diseases.  The  term  acupuncture  is  also  applied 
by  some  to  the  introduction  of  needles  into  a 
cyst,  in  order  to  allow  the  fluid  contents  to 
escape,  as  in  the  treatment  of  ganglion,  of  hy- 
drocele in  infants,  or  of  hydatid  cyst  of  the 
liver.  Puncture  of  the  skin  for  the  relief  of 
oedema  or  subcutaneous  emphysema  is  some- 
times called  by  tbe  same  name.  For  this  pur- 
pose the  ordinary  three-cornered  acupressure 
needle  is  more  convenient  then  a round  acu- 
puncture needle,  as  the  puncture  resulting  from 
it  allows  fluid  to  escape  more  readily. 

AIarcus  Beck. 

ACUTE. — This  word,  when  associated  with 
a disease,  signifies  that  such  disease  runs  a more 
or  less  rapid  course,  and  is  generally  attended 
with  severe  symptoms.  It  is  also  employed  to 
express  intensity  of  a particular  symptom,  as,  for 
example,  pain. 

ADDISON'S  DISEASE.  Synon.  : Morbus 
Addisonii ; Bronzed  Skin  Disease.  Fr.  Ma- 
ladie  d' Addison;  Ger.  Addisonsche  Krankhcit. 

Definition. — In  his  original  memoir  on  this 
subject,  Dr.  Addison  wrote — ‘ The  leading  and 
characteristic  features  of  the  morbid  state  to 
which  I would  direct  attention  are  anaemia, 
general  languor  and  debility,  remarkable  feeble- 
ness of  the  heart’s  action,  irritability  of  ti.e 
stomach,  and  a peculiar  change  of  colour  in  the 
skin  occurring  in  connection  with  a diseased 
condition  of  the  supra-renal  capsules.’ 

In  reality,  the  general  symptoms  of  the 
disease,  as  given  above,  outweigh  in  import- 
ance any  pigmentary  change  whatever ; and  it 


ADDISON’S 

is  quite  possible  for  the  disease  to  run  its 
course  without  any  unusual  deposit  of  pigment 
in  any  part  of  the  body. 

Addison’s  disease  might,  however,  be  defined 
as  ‘ a constitutional  malady  characterised  by 
great  weakness  and  anaemia,  with  deposit  of 
pigment  in  the  skin  and  some  ether  parts  of 
the  body,  and  accompanied  by  or  depending  on 
a specific  morbid  change  in  the  supra-renal 
capsules.’ 

./Etiology.  — The  constitutional  or  general 
nature  of  the  malady  must  ever  be  borne  in 
mind,  though  some  of  its  factors  are  strictly 
local ; but,  though  constitutional,  it  is  not  trans- 
missible either  (a)  by  contagion  or  infection, 
or  (b)  by  inheritance.  If,  however,  Addison’s 
disease  itself  is  never  an  inherited  malady,  it 
is  in  very  many  eases  associated  with  a highly 
hereditary  constitution,  that  of  the  tubercular 
or  scrofulous  type,  and  in  such  individuals  ac- 
cidents like  falls  or  blows,  which  would  fail  to 
make  an  impression  on  stronger  men  or  women, 
may  suffice  to  set  the  morbid  process  in  motion. 
In  not  a few  instances  the  bodies  of  the  sub- 
jects of  this  disease  have  been  found  perfectly 
healthy  apart  from  the  morbid  change  in  the 
supra-renal  capsules  characteristic  of  the  malady ; 
and,  in  a certain  number  of  Cases,  local  abscesses 
seem  to  have  been  the  starting-point  of  the 
specific  changes  in  the  capsules  themselves. 
Addison’s  disease  is,  moreover,  essentially  one 
of  early  adult  life,  the  great  majority  of  eases 
occurring  between  fifteen  and  fortjn  It  is  much 
more  frequent  in  men  than  in  women,  and  seems, 
in  a great  measure,  to  be  confined  to  the  working 
classes. 

Symptoms. — It  is  not  at  all  times  nor  in  all 
instances  an  easy  task  to  make  out  a perfect 
clinical  history  in  a case  of  Addison’s  disease. 
Tho  earlier  symptoms  are  often  so  indefinite 
and  so  insidious  that  it  may  not  he  until  the 
disease  is  fully  developed  that  the  patient  seeks 
medical  aid,  and  by  that  time  the  symptoms  are 
usually  unmistakeable.  It  is  different  when  the 
malady  apparently  originates  in  a fall  or  a blow, 
hut  even  such  a starting-point  as  this  may  only 
be  sought  for  late  in  the  history  of  the  disease. 

The  mischief  may  he  said  to  commence  in 
most  cases  with  a feeling  of  general  weakness 
and  of  being  unwell ; tho  discolouration  of  the 
skin  usually  appears  later,  but  may  be  the  first 
prominent  symptom.  In  a small  number  of 
cases  the  onset  may  be  acute,  with  loss  of 
appetite,  sickness,  headache,  pain  in  the  epi- 
gastrium, sometimes  also  vomiting  and  diar- 
rhoea. When  the  disease  has  attained  its  full 
development  the  characteristics  of  the  malady 
are  most  striking.  Then  the  downcast,  mourn- 
ful look,  the  drooping  shoulders  and  stooping 
gait,  the  arms  hanging  helplessly  by  the  sides, 
and  the  slow  and  listless  movements  of  the 
patient  are  strikingly  impressive.  If  to  this  be 
added  the  darkening  of  the  skin,  the  clear  and 
pearly  conjunctiva,  and  the  breathlessness  on 
exertion,  we  have  almost  all  that  meets  the 
eye  when  such  a patient  presents  himself.  But 
to  these,  on  enquiry,  other  important  symptoms 
are  easily  added.  The  breathlessness  will  be 
found  to  be  partly  due  to  anaemia,  partly  to 
impaired  innervation.  From  the  same  causes 


DISEASE.  13 

in  part,  but  not  entirely,  we  find  a quiet,  feeblo 
action  of  the  heart,  readily  giving  place  to  pal- 
pitation. With  these  are  usually  associated  pain 
and  tenderness  in  the  epigastrium  and  hypo- 
chondria, irritability  of  the  stomach  and  nausea 
giving  rise  to  retching,  and  frequently  obstinate 
vomiting.  Such  modifications  of  breathing  as 
sighing,  yawning,  or  hiccup,  are  frequent.  Again, 
from  the  amemia,  there  is  a strong  tendency  to 
giddiness  and  syncope,  which  last  increases  as  the 
disease  wears  on,  and,  in  many  cases,  carries  off 
the  patient  when  raising  himself,  or  being  raised 
in  bed  for  the  purpose  of  taking  food  or  perform- 
ing other  necessary  functions.  This  is  not  the 
invariable  mode  of  death,  for  nervous  sjTnptoms, 
such  as  coma  or  convulsions,  may  usher  in  the 
final  scene.  When  the  prostration  is  great,  the 
patient  may  he  for  some  time  before  death  ap- 
parently unconscious,  but  this  is  simply  due  to 
unwillingness  to  make  the  slightest  exertion, 
owing  to  his  profound  weakness. 

Throughout  the  whole  disease  the  bodily  tem- 
perature is  diminished  (97°-98°  Fh.)  rather  than 
increased,  and  this  is  often  markedly  the  case 
towards  the  close  of  the  disease,  though  then  it 
has  been  noted  as  high  as  100'8°Fh. 

From  the  above  sketch  it  is  plain  that  the 
two  most  prominent  factors  in  the  disease,  as 
presented  during  life,  are — 

1 st.  General  weakness  and  anaemia. 

2nd.  Abnormal  deposit  of  pigment  in  various 
parts  of  the  body. 

1.  To  the  former  of  these  is  to  be  referred  (a) 
the  loss  of  muscular  power,  as  evidenced  by 
diminished  muscular  energy  and  force  both  in 
the  voluntary  and  involuntary  muscles,  for  tho 
heart’s  action  is  feeble  and  imperfect,  and  the 
bowels  are  usually  confined.  (5)  At  once  a cause 
and  consequence  of  the  weakness  and  anaemia 
are  loss  of  appetite,  sickness  and  vomiting,  though 
these,  too,  depend  in  part  on  other  morbid 
changes ; whilst,  lastly  (c),  imperfect  nutrition 
of  the  nervous  system  results,  notably  of  the 
brain  itself,  whence  arise  vertigo,  numbness, 
dimness  of  sight,  deafness,  tremors,  and  the  like. 
The  pain  in  the  epigastric  and  hypochondriac 
regions  is  probably  due  to  local  causes. 

2.  The  deposit  of  pigment  is  peculiar  and 
characteristic.  It  is  not  uniform  in  disposition, 
and  varies  greatly  in  tint.  It  may  only  amount 
to  a light  brown  or  smoky  discoloration  in  cer- 
tain parts,  or  it  may  assume  the  appearance  of  a 
dark  olive-green  hue,  approaching  to  black  in 
some  situations,  especially  over  the  genitals  and 
nipples.  Elsewhere  it  is  most  abundant  on  the 
face,  where  it  often  seems  to  begin,  on  the  neck, 
the  hacks  of  the  hands,  the  folds  of  the  legs, 
and  along  either  side  of  the  linea  alba.  A 
striking  peculiarity  is  that  the  conjunctivas  are 
clear  and  pearly,  and  that  the  nails  are  never 
discoloured.  On  the  other  hand,  there  is  a great 
tendency  to  the  deposit  of  pigment  where  the  skin 
has  been  irritated  or  the  epidermis  removed, 
as  by  a mustard  poultice  or  blister ; but  the 
skin  is  always  smooth  and  supple.  In  a typical 
case  under  the  writer’s  care,  blisters  had  been 
applied  to  the  chest  for  the  uneasy  feeling  ex- 
perienced there,  and  here  the  pigmentary  tint 
was  deeper  than  in  any  other  part  of  the  body, 
save  the  genitals.  Cicatrices  affecting  the  whole 


ADDISON’S  DISEASE. 


14 

depth  of  the  skin  do  not  seem  to  be  so  pig- 
mented. The  mucous  membrane  of  the  mouth 
not  tmfrequently  becomes  the  site  of  pigmen- 
tary deposits.  These  are  not  diffuse,  but,  when 
the  lips  are  affected,  they  usually  take  the  shape 
of  smears  or  lines.  On  the  insides  of  the  cheeks 
blotches  or  irregularly-defined  spots  are  most 
common,  as  well  as  on  the  sides  and  root  of 
the  tongue.  The  latter  spots  are  commonly 
better  defined  than  are  the  others,  and  some- 
what resemble  the  small  well-marked  black 
spots  occasionally  observed  in  parts  already 
pigmented. 

The  site  of  this  pigmentary  deposit  is  m the 
growing  layer  of  the  epidermis,  the  usual  eite  of 
colour  in  all  races  of  mankind,  and  which  is 
usually  known  as  the  rete  mucosum  • but  occa- 
sionally pigmentary  granules  are  to  be  found 
deeper,  in  the  cells  of  the  true  skin. 

An  interesting  clinical  fact  has  been  brought 
out  by  Dr.  Greenhow,  which  will,  probably,  be 
noted  in  a considerable  proportion  of  cases. 
This  is  the  mode  in  which  the  disease  pro- 
gresses. Often  it  presents  periods  of  remission, 
only  to  be  followed  by  a more  marked  ad- 
vance ; but,  notwithstanding  these  remissions,  the 
progress  is  invariably  towards  a fatal  termina- 
tion. The  time  occupied  in  this  progress  varies 
much  ; it  may  be  weeks  or  months,  or  it  may  be 
years,  but  in  all  well-defined  cases  tile  result  is 
the  same. 

Pathology. — Prom  the  earliest  description  of 
the  morbid  state  known  as  Addison’s  disease, 
the  malady  has  been  associated  with  disease  of 
the  supra-renal  capsules.  At  first  it  was  sup- 
posed that  any  form  of  disease  affecting  these 
organs  must  give  rise  to  a similar  train  of 
symptoms,  and  some  of  the  investigations  car- 
ried on  with  a view  to  sustain  this  position 
Bound  absurd  enough  by  the  light  of  subsequent 
experience.  Gradually  it  has  been  made  clear 
that  only  one  kind  of  lesion  is  accompanied 
by  the  specific  symptoms  just  detailed.  Briefly, 
the  morbid  changes  are  as  follows  : — 

Normally,  the  supra-renal  capsules  consist 
of  two  parts,  a cortical  and  medullary,  differ- 
ing greatly  in  their  structure.  In  Addison’s 
disease  both  are  superseded  by  a new  structure, 
which  is  to  he  seen  in  various  stages.  In  the 
earliest  of  these  the  capsules  are  invaded  by 
a kind  of  translucent  material,  which  is  some- 
times almost  cartilaginous-  in  its  hardness,  and 
which,  when  examined  under  the  microscope, 
resolves  itself  into  a kind  of  very  finely  fibril- 
lated  or  trabecular  connective  tissue,  with  cor- 
puscles like  leucocytes  freely  congregated  in 
the  interstices  of  the  mesliwork  or  between  the 
fibres.  This  material,  when  seen  in  hulk,  is 
grey  or  greenish-grey,  afterwards  becoming  red 
on  exposure.  With  it  is  mixed  up  an  opaque 
yellow  substance,  varying  in  amount  and  appa- 
rently more  abundant  the  more  advanced  the 
disease.  In  the  earlier  stages  it  presents  the 
appearance  of  nodules  embedded  in  the  trans- 
lucent material,  hut  later  almost  the  whole  of 
this  last  may  have  disappeared,  and  the  yellow 
opaque  matter  become  converted  into  a thick 
creamy  fluid,  a putty-like  substance,  or  even  one 
or  more  cretaceous  masses.  This  opaque  mate- 
rial, then,  is  evidently,  from  its  first  appearance, 


indicative  of  fatty  degeneration,  and  closely  re- 
sembles in  every  respect  what  used  to  he  known 
as  yellow  or  crude  tubercle. 

The  exterior  of  the  capsules  presents  certain 
important  features.  The  capsules  themselves 
may  be  large  or  small,  according  to  the  stage  of 
the  disease  and  the  nature  of  their  contents,  but, 
even  when  they  are  small,  it  may  be  safely  as- 
sumed that  at  one  time  they  were  enlarged. 
In  all  cases  they  will  he  found  closely  and 
strongly  adherent  to  neighbouring  structures. 
Some  of  these  structures  are  of  great  importance : 
for  example,  the  semi-lunar  ganglia,  and  the  vast 
plexus  of  nerves  associated  therewith,  in  which 
important  changes  have  been  found.  These  pa- 
thological conditions  have  been  so  often  observed 
and  so  carefully  noted,  that  they  cannot  he 
looked  upon  as  accidental  concomitants  of  the 
diseased  process,  hut  rather  part  and  parcel  of 
it,  and,  in  all  probability,  as  giving  a clue  to 
some  of  the  most  marked  phenomena  of  the 
malady.  Broadly  it  may  be  said  that  these 
changes  consist  in  a great  thickening  of  the 
connective  tissue  surrounding  the  nerve-fibres 
and  the  ganglion-cells,  giving  rise  to  something 
like  compression  and  ultimate  destruction  of 
the  nerve  cells  and  fibres.  This  occurs  both 
in  the  cerebro-spinal  nerve  fibres  and  in  thoso 
more  intimately  connected  with  the  ganglionic 
system.  The  nerve-cells,  moreover,  are  not 
unfrequently  deeply  pigmented. 

These,  so  far  ns  is  known,  constitute  the  main 
pathological  elements  of  Addison's  disease.  It 
does  not  arise  from  mere  destruction  of  the 
supra-renal  capsules,  for  then  it  would  be  seen 
under  other  conditions,  as  when  cancer  of  a 
neighbouring  organ  extends  to  and  involves  the 
supra-renals : but  no  Addison’s  disease  follows 
this  event.  The  exact  mode  in  which  these  nerve 
lesions  give  rise  to  the  characteristic  symptoms 
of  the  disease  are,  as  yet,  matters  of  speculation, 
and  not  of  exact  science;  and  it  may  he  said 
that  our  knowledge  of  the  whole  of  this  subject 
is  yet  in  its  infancy. 

Though  these  are  the  main  facts  relating  to 
the  pathology  of  Addison’s  disease,  there  are 
still  others  of  some  importance.  Pigmentation 
has  been  sufficiently  noticed,  but  its  origin  has 
not  been  discovered.  Without  doubt  the  pig- 
ment, like  other  animal  pigments,  is  derived 
from  the  blood,  and  this  has  been  examined 
with  a view  to  discover  any  change  in  its 
composition  which  would  explain  the  darkening 
of  the  skin,  but  without  result. 

In  making  the  section  of  the  body  of  one 
who  has  been  the  subject,  of  Addison’s  disease, 
one  cannot  help  being  struck  with  the  amount 
of  subcutaneous  fat,  especially  over  the  abdo- 
men, as  contrasted  with  the  difficulties  of 
nutrition  under  which  the  patient  sufiered  ; yet 
a considerable  quantity  is  almost  always  found. 
But  more  closely  connected  with  this  malnutri- 
tion are  certain  changes  in  the  absorbent  system 
along  the  digestive  tract.  These  consist  in 
enlargement  of  the  solitary  and  agglomerated 
glands  constituting  Peyer’s  patches,  and  of  the 
mesenteric  glands ; as  well  as  of  lymphoid  de- 
posits in  the  mucous  membrane  of  the  stomach 
which  give  rise  to  little  projections,  termed  mam- 
miUations.  on  the  walls  of  that  organ,  especially 


ADDISON’S  DISEASE, 
near  the  pylorus.  Small  ecchymoses  are  also 
not  unusually  found  in  the  same  situation.  Of 
other  organs  it  may  he  noted  that  the  liver  and 
spleen  are  often  enlarged  and  hypercemic,  and 
the  heart  small  and  light. 

Diagnosis. — There  would  have  been  less  diffi- 
culty or  doubt  in  the  diagnosis  of  Addison’s 
disease,  had  it  been  dearly  enunciated  from 
the  first  that  a bronzed  skin  did  not  alone  con- 
stitute the  malady.  The  disease  rests  on  a 
threefold  basis — general  weakness , diseased  supra- 
renal capsules,  and  bronzed  skin,  the  last  being 
the  least  important  of  the  three.  There  may 
be  darkening  of  the  skin  from  a great  variety 
of  causes,  viz. : (a)  exposure,  and  attacks  of 
vermin  ( morbus  Reonum,  Greenhow ; Vaganten 
Krankkcit,  Vogt) ; ( h ) -wasting  diseases,  as 
chronic  phthisis  ; (c)  syphilis  ; ( d ) malaria ; 
(c)  liver  disease  or  jaundice  if  long-continued  ; 
&c. ; but  in  none  of  these  cases  should  there  be 
any  difficulty  if  the  preceding  dictum  is  borne 
in  mind. 

PnoGxosis. — This  is  always  unfavourable,  but 
it  is  impossible  to  assign  any  definite  period  for 
the  termination  of  the  disease,  since  it  often  pro- 
gresses irregularly,  with  periods  of  improve- 
ment followed  by  relapse. 

Treatment. — Erom  what  has  just  been  said 
it  is  plain  that  not  much  is  to  be  effected  by 
treatment  as  regards  the  cure  of  the  disease, 
but  much  may  be  done  by  careful  manage- 
ment to  retard  its  progress  aud  comfort  the 
patient.  As  soon  as  the  disease  is  discovered, 
the  sooner  the  patient  makes  up  his  mind  to 
an  invalid  life  the  better.  Rest  and  careful 
dieting  are  the  basis  of  the  treatment.  As  re- 
gards diet,  it  may  be  briefly  said  that  -what 
the  patient  can  take  best  suits  best.  As  the 
stomach  is  so  irritable,  anything  likely  to  upset 
it  should  be  avoided.  Hence,  as  a rule,  it  is 
better  to  give  concentrated  nourishment,  as 
essence  of  meat  ( not  the  extract)  or  chicken, 
or  raw  pounded  meat,  when  other  things  cannot 
be  taken.  It  is  also  important  to  bear  in  mind 
that  the  stomach  will  often  tolerate  food  cold 
or  even  frozen,  when  hot  substances  would  be 
promptly  rejected.  In  certain  stages  of  this 
malady  it  may  well  be  said  that  the  physician’s 
success  will  depend  more  on  his  knowledge  of 
the  cookery  book  than  of  the  Pharmacopoeia — 
not,  however,  that  our  pharmaceutical  gifts  are 
to  be  despised.  For  the  profound  depression 
stimulants  will  be  necessary,  but  these  may 
take  the  shape  of  ether  or  spirits  of  chloro- 
form, as  well  as  of  wine  or  brandy.  For  the 
irritable  stomach,  alkalies,  with  nux  vomica  and 
ipecacuan,  or  calumba,  are  of  great  service. 
So,  too,  in  another  way,  are  light  tonics  and 
neutral  salts  of  iron  ; but  the  stomach  should 
not  be  clogged  with  too  much  medicine.  The 
bowels  should  not  be  much  disturbed,  but, 
if  an  aperient  be  required,  a mild  one,  as  a 
small  dose  of  castor  oil,  or  the  compound 
liquorice  powder  of  the  Prussian  Pharmacopoeia 
will  suit,  if  the  stomach  does  not  rebel ; if  so, 
a wineglassful  of  Hunyadi  Janos  water  the  first 
thing  in  the  morning,  followed  by  a cup  of  warm 
milk,  may  better  agree  with  the  irritable  organ  ; 
when  there  is  diarrhoea,  a totally  different  line 
of  treatment  will  be  necessary.  But  in  all 


ADHESIOSS.  16 

things,  and  at  all  times,  the  grand  rule  is  to 
save  the  patient’s  strength,  to  add  to  it  if  pos- 
sible, and  to  resist  the  inroads  of  the  diseaso 
whatever  shape  these  may  assume. 

Alexander  Selves. 

ADENALGIA  (a5V>  a gland,  and  6\yos, 
pain). — Pain  in  a gland. 

ADENITIS.  — Inflammation  of  a gland. 
See  the  several  glands. 

ADEIfOCELE  ( oSV , a gland,  and  kt]\v, 
a tumour). — A tumour  connected  with  a gland. 

ADENODMNIA  (aSjjp,  a gland,  and  oSovti, 
pain).— Pain  in  a gland. 

ADENOID  (cl3t]v,  a gland,  and  efSor,  form). 
— Glandular : resembling  the  structure  of  a 

gland,  whether  secreting  or  lymphatic. 

ADENOMA  (ctSV,  a gland,  and  6/ubs,  like). — 
A morbid  growth,  the  structure  of  which  is  of 
glandular  nature.  See  Tumours. 

iSHESI^S.  } “Structures  are  said  to  be 

adherent  when  they  become  abnormally  united 
together,  the  morbid  formations  by  which  this 
union  is  effected  being  termed  adhesions.  These 
are  most  frequently  met  with  in  connection  -with 
serous  surfaces,  being  usually  the  result  of  an 
inflammatory  process,  but  they  may  be  observed 
in  other  structures.  The  adhesions  vary  con- 
siderably in  extent,  number,  mode  of  arrange- 
ment, firmness,  and  other  characters  ; they  may 
merely  consist  of  a few  loose,  slender,  and  deli- 
cate bands,  or  these  bands  may  be  thick  an-! 
strong,  or  the  contiguous  surfaces  may  be 
blended  and  matted  together  to  a greater  or  less 
extent,  so  that  they  cannot  be  separated  without 
tearing  or  cutting  them  asunder,  this  last  condi- 
tion constituting  agglutination.  In  structure 
adhesions  consist  mainly  of  connective  or  fibrous 
tissue,  more  or  less  perfectly  developed,  with  a 
few  new  vessels. 

Effects. — Adhesions  are  often  found  at  post- 
mortem examinations,  which  have  been  of  little 
or  no  consequence  during  life,  as,  for  instance, 
many  of  thosewhich  form  in  connection  with  the 
pleural  surfaces.  If,  however,  they  are  extensive 
and  firm,  or  if  they  occupy  certain  regions  of 
the  body,  they  may  prove  of  serious  moment. 
The  principal  evils  which  are  liable  to  result 
from  adhesions  may  be  thus  indicated : — 1 . They 
often  bind  parts  together,  and  interfere  with 
the  movements  of  important  organs,  such  as 
the  lungs,  heart,  stomach,  or  intestines  ; in  this 
way  preventing  the  due  performance  of  their 
functions.  2.  When  an  organ  is  displaced  in 
any  way.  as,  for  example,  the  heart  by  pleuritic 
effusion,  it  may  become  fixed  in  its  new  position 
by  the  formation  of  adhesions,  its  functions 
being  thus  disturbed.  3.  It  is  highly  probable 
that  agglutination  may  lead  to  hypertrophy  of  an 
organ,  e.g.,  the  heart,  by  embarrassing  its  move- 
ments, and  hence  affecting  its  action.  4.  On  the 
other  hand,  atrophy  or  degeneration  of  structure 
may  ensue,  in  consequence  of  the  adhesions  in- 
terfering with  the  due  supply  of  blood  by  pressing 
upon  the  vessels,  so  that  the  nutrition  of  the 
tissues  becomes  impaired.  In  the  young,  also, 


If.  ADHESIONS, 

the  development  of  structures  may  be  checked. 
5.  Adhesions  may  involve  important  structures, 
such  as  nerves  or  vessels,  pressing  upon  or  de- 
stroying them,  thus  giving  rise  to  symptoms  of  a 
serious  nature.  6.  Tubes  or  canals  for  the  pas- 
sage of  secretions  or  other  materials  are  some- 
times narrowed  or  obliterated  by  adhesions.  7. 
When  formed  within  the  abdominal  cavity,  espe- 
cially when  they  take  the  form  of  bands,  adhe- 
sions may  prove  highly  dangerous  by  com- 
pressing, constricting,  exerting  traction  upon,  or 
strangulating  some  portion  of  the  intestine,  in 
either  of  these  ways  leading  to  intestinal  ob- 
struction. 

It  is  frequently  difficult  or  impossible  to  deter- 
mine the  existence  of  adhesions  by  clinical  inves- 
tigation during  life  ; but  the  history  of  some  past 
illness  during  which  they  were  likely  to  be 
formed,  the  results  of  physical  examination,  espe- 
cially in  connection  with  the  heart  and  lungs, 
and  the  symptoms  present,  not  uncommonly 
enable  them  to  be  discovered. 

Frederick  T.  Eoberts. 

ADIPOCERE  ( adeps , fat,  and  cera,  wax). — 
Synon.  : Er.  Adipocire;  Gcr . Fettwachs. 

Definition. — A substance  formed  by  a spon- 
taneous change  in  the  dead  tissues  of  animals. 

Description. — As  seen  generally  in  a dried 
state  in  museums,  adipocere  somewhat  resembles 
spermaceti  in  consistence,  but  it  is  less  crystalline 
in  fracture,  and  is  of  a dull  white  or  buff  colour, 
the  surface  being  marked  by  the  outlines  of  blood- 
vessels or  other  textures.  Adipocere  in  the  earli er 
stages  of  its  formation,  or  when  formed  in  a damp 
situation,  is  soft,  and  if  rubbed  between  the  fingers 
communicates  a greasy  feeling.  The  odour  is 
peculiar  and  rather  disagreeable. 

Chemical  Composition. — Adipocere  dissolves 
in  ether,  leaving  a delicate  filamentous  web;  it 
burns  with  a blue  flame,  yielding  a white  ash.  It 
is  properly  described  as  a soap  composed  of  mar- 
garic  and  oleic  acids  in  combination  with  ammo- 
nia, the  fixed  alkalies,  and  alkaline  earths  ; the 
relative  proportion  of  the  latter  ingredients  vary- 
ing with  the  age  of  the  specimen  (the  ammonia 
disappearing),  and  with  the  composition  of  the 
fluids  in  contact  with  which  the  adipocere  had 
been  formed.  It  is  said  that  oleic  acid  predo- 
minates in  adipocere  formed  from  dead  fish. 

Microscopic  Appearances. — When  the  flesh  of 
animals  in  which  this  transformation  has  recently 
commenced  is  examined  with  the  microscope,  it  is 
found  to  be  composed  of  broken-down  or  dis- 
integrated tissues,  fatty  granules  or  particles, 
together  with  a few  acieular  scales  or  crystals. 
The  granules  may  be  seen  in  what  w'as  muscular 
tissue  to  assume  somewhat  the  arrangement  of 
the  muscular  filaments,  thus  presenting  an  ap- 
pearance resembling  an  early  stage  of  fatty 
degeneration.  In  old  and  dry  specimens  of 
adipocere  the  crystalline  scales  form  the  great 
portion  of  the  mass,  and  they  may  be  observed 
preserving  the  outlines  of  the  muscular  fibres. 

Origin. — Adipocere  has  long  been  known.  It 
is  formed  readily  from  the  flesh  of  animals  ex- 
posed to  moisture,  or  placed  in  running  water, 
in  very  dilute  nitric  acid,  or  in  alcohol  and 
water  in  the  proportion  of  1 to  6.  It  is  often 
taet  with  in  inconvenient  abundance  in  the 


ADLPOCEEE. 

specimen  jars  of  the  anatomist.  The  bodies 
of  men  and  other  animals  buried  in  peat  moss 
have  frequently  been  found  completely  converted 
into  adipocere.  Lord  Bacon  mentions  it  in  the 
Sylva  Sylvarum,  and  so  also  does  Sir  Thomas 
Brown  in  the  Hydriotaphia ; but  attention  was  es- 
pecially called  to  its  presence  when  a vast  number 
of  bodies  were  removed  (in  1786-87)  from  the 
Oimetiere  des  Innocents  at  Paris  to  the  Cata- 
combs. Fourcroy  found  many  of  these  bodies 
converted  into  what  he  named  adipocire,  a name 
since  retained.  Gibbes  (as  did  others)  suggested 
the  possibility  of  applying  adipocere  formed  from 
the  waste  flesh  of  animals  to  some  useful  pur- 
poses, but  the  tenacity  of  the  disagreeable  odour 
and  the  presence  of  other  difficulties  have  prevented 
these  suggestions  from  being  carried  out.  With  re- 
spect to  the  immediate  changes  which  give  origin 
to  adipocere  chemists  have  differed  in  opinion. 
One  class  believes  with  Gay-Lussac  and  Berzelius 
that  the  compound  results  from  the  fat  originally 
present  in  the  tissues,  and  that  the  other  compo- 
nents are  completely  destroyed  by  putrefaction. 
The  other  class,  which  includes  the  names  of 
Thomas  Thomson  and  Brande,  maintains  ‘that 
the  fatty  matter  is  an  actual  product  of  the 
decay,  and  not  merely  an  educt  or  residue.’ 
These  opinions  may,  the  present  writer  thinks, 
be  reconciled  by  the  better  knowledge  we  now 
possess  of  the  elementary  composition  of  tissues. 
We  know  that  the  combination  of  fat  and  albu- 
min constituting  one  of  the  earliest  steps  in  the 
process  of  nutrition  is  traceable  in  the  further  de- 
velopment and  formation  of  nearly  every  texture. 
When  that  combination  is  destroyed  by  a ces- 
sation of  the  process  of  life,  the  tissues  are  as  it 
were  resolved  into  their  primary  elements.  We 
may  thus  have  adipocere  derived  not  only  from 
free  fat,  but  from  the  elements  of  fat  existing  in  and 
obtained  from  the  decomposition  of  other  tissues. 
Adipocere  may  thus  be  described  as  both  an 
educt  and  a product.  This  opinion  is  confirmed 
by  the  researches  of  Bauer  and  Voit,  who  showed 
that  fatty  matter  was  derived  from  the  meta- 
morphosis of  albumin  in  starved  animals,  to 
which  phosphorus  had  been  administered.1 

The  interest  concerning  this  substance  is  not 
confined  to  the  chemist.  The  medical  jurist  lms 
studied  it  with  the  view  of  determining  the  time 
and  progress  of  its  formation,  and  of  thus  ascer- 
taining the  probable  period  at  which  death  oc- 
curred. But  hitherto  no  decided  or  satisfactory 
information  has  been  obtained,  owing  to  the 
varied  circumstances  which  influence  the  progress 
of  the  change,  in  connexion  not  only  with  the 
condition  of  the  body  itself,  bnt  also  with  the 
character  of  its  surroundings.  The  formation 
of  adipocere  has  a further  and  a special  interest 
for  the  pathologist.  It  was  the  study  of  this 
process  which  led  the  present  writer  to  point 
out  the  analogy  which  exists  between  it  and  fatty 
degeneration  in  the  living  body,  and  thus  to  es- 
tablish the  pathological  doctrine  that  fatty  dege- 
neration is  the  result  of  a retrograde  metamor- 

1 The  writer  would  desire  to  refer  here  to  the  analogy 
which  seems  to  exist  between  the  change  of  animal 
matter  into  adipocere,  and  that  which  occurs  in  vegetable 
matter  by  its  conversion  into  peat  and  coal.  This,  h js- 
ever,  is  not  the  place  in  which  to  examine  further  such 
an  analogy. 


AMPOCERE. 

phosis,  clue  to  defective  nutrition.  ( See  Medical 
and  Chirurgical  Transactions,  vol.  xxxiii.) 

Richard  Quatn,  M.D. 

ADIPOSIS. — A term  which  properly  signi- 
fies either  general  corpulency,  or  accumulation 
of  adipose  tissue  in  or  upon  an  organ.  See 
Fatty  Growth  ; and  Obesity. 


and  Siva /us, 


ADYNAMIA  \ (, 

ADYNAMIC  J *•  ’ p ’ 
power). — Terms  indicating  serious  depression  of 
the  vital  powers,  and  employed  as  synonymous 
with  the  'typhoid  condition'  The  adjective  is 
applied  to  diseases  in  which  the  phenomena 
of  this  condition  are  prominent.  See  Typhoid 
Condition. 


JEGOPHONY  (at£,  a goat,  andcpapr;,  voice). 
—A  peculiar  alteration  of  the  resonance  of  the 
voice,  as  heard  on  auscultation  of  the  chest, 
compared  to  the  bleating  of  a goat.  See  Physicai. 
Examination. 


AETIOLOGY  (atria,  cause,  and  Xiyos,  word). 
— That  branch  of  pathological  science  which 
deals  with  the  causation  of  disease.  See  Disease, 
Causes  of. 

AFFINITY. — This  term  is  the  designation 
of  a property  by  which  elementary  and  com- 
pound substances  unite  with  one  another  and 
form  new  compounds.  It  is,  therefore,  a pro- 
perty with  which  chemists  are  principally  con- 
cerned. But  the  ideas  suggested  to  the  chemist 
by  the  term  affinity  are  also,  though  less 
explicitly,  excited  in  the  mind  of  the  pathologist 
and  of  the  therapeutist  by  certain  classes  of  facts 
frequently  falling  under  their  observation.  The 
pathologist,  for  instance,  knows  that  saline  or 
earthy  matter  is  very  prone  to  accumulate  in  the 
midst  of  degenerated  tissue  in  the  walls  of  an 
artery  or  of  a cardiac  valve,  so  as  to  give  rise  to 
a patch  of  ‘ calcification  ’ ; he  knows  that  in  a 
gouty  patient  urate  of  soda  is  most  apt  to  accumu- 
late and  form  ‘chalk  stones  ’ in  the  tissues  around 
affected  joints ; he  knows  that,  however  it  may  be 
administered,  arsenic  in  poisonous  doses  tends  to 
produce  inflammation  of  the  alimentary  canal, 
that  strychnia  acts  with  preference  upon  the  ner- 
vous system,  and  that  in  ordinary  cases  of  lead- 
poisoning this  metal  interferes  especially  with 
the  nutrition  of  the  extensor  muscles  of  the  fore- 
arm. Applications  of  the  same  notion  in  the 
department  of  therapeutics  are  equally  familiar 
in  respect  to  the  action  of  many  drugs.  It 
may  be  regarded  as  an  ascertained  fact  that 
iodide  of  potassium  tends  especially  to  influence 
the  nutrition  of  the  fibrous  structures  in  the 
body,  and  that  bromide  of  potassium  has  a no  less 
certain  action  in  modifying  the  nutrition  of  the 
nervous  centres  in  many  unhealthy  states.  Again, 
there  is  a whole  class  of  substances  which  when 
taken  into  the  system  have,  whatever  their 
other  actions  may  be,  an  undoubted  effect  in 
modifying  the  functional  activity  of  the  kidney. 
We  have  in  nitrite  of  amyl  a remedy  possess- 
ing a remarkable  influence  over  the  unstriped 
muscular  fibres  of  the  arteries  and  bronchi,  or 
else  over  the  nerve-centres  by  which  they  are 
controlled.  We  have  in  woorara  an  agent  which 
acts  especially  upon  the  motor  side  of  the  ner- 

2 


AGORAPHOBIA.  17 

vous  system  ; and  we  have  in  digitalis  an  im 
portant  remedy  which,  amidst  its  other  effects, 
seems  to  have  a decided  power  of  improving  the 
nutrition  of  the  cardiac  ganglia.  The  recent 
progress  of  therapeutics  encourages  us  to  hope 
that  more  and  more  of  these  specific  effects  of 
drugs  will  be  accurately  determined,  so  that  the 
notion  implied  by  the  term  affinity  may,  after  a 
time,  have  a deeper  meaning  than  at  present 
for  the  practitioner  of  medicine.  See  Anta 
gonism.  H.  Charlton  Bastian. 

AFFUSION. — A method  of  treatment  which 
consists  in  pouring  a fluid,  usually  water,  either 
cold  or  warm,  upon  the  patient.  See  Water. 
Therapeutics  of ; and  Baths. 

AFRICA,  South.  — See  Appendix. 

AGEUSTIA  (a,  priv.,  and  7eu<m,  taste). — 
Loss  of  taste.  See  Taste,  Disorders  of. 

AGONY  (ayav,  strife  or  struggle). — Agony 
implies  bodily  pain  or  mental  suffering  so  in- 
tense that  it  cannot  be  endured,  but  excites  a 
struggle  against  it.  It  is  also  applied  to  the  final 
struggle  that  often  precedes  death.  See  Death, 
Modes  of. 

AGORAPHOBIA  (ctyopa,  a market-place, 
and tpdfios,  fear).  Synon.  : Fr.  Lapcur  dtscspaces. 
— By  these  names  a peculiar  nervous  complaint 
has  been  recognised,  characterised  by  a feeling 
of  alarm  and  terror,  accompanied  with  a group 
of  nervous  symptoms,  which  some  individuals 
experience  when  they  are  in  a certain  space. 
The  condition  may  be  developed  rapidly  or  gra- 
dually, and  the  chief  phenomena  observed  are 
as  follows : — A sudden  sensation  is  experienced, 
as  if  the  heart  were  being  grasped,  while  this 
organ  palpitates  violently ; the  face  becomes 
flushed  ; the  legs  feel  weak,  tremble,  and  seem 
as  if  they  wouldgive  way  under  the  body.  There 
may  be  sensations  of  itching,  coldness,  or  numb- 
ness ; or  profuse  sweating  may  occur.  Thereis  no 
true  vertigo  ; the  special  senses  are  unaffected ; 
and  consciousness  is  not  at  all  impaired.  A 
curious  impression  is  sometimes  experienced,  as 
if  space  were  elongating  itself  out  indefinitely. 
Persons  who  are  thus  affected  are  quite  sensible 
of  the  foolishness  of  their  fear,  but  cannot  be 
reasoned  out  of  it.  During  the  attacks  they 
feel  a strong  inclination  to  cry  out,  but  fear  to 
do  so.  They  think  that  their  dread  is  known 
to  others,  and  many  of  them  endeavour  to  con- 
ceal their  feelings,  lest  they  should  be  considered 
insane. 

The  circumstances  under  which  the  symptoms 
just  described  may  be  experienced  are  various. 
They  may  be  felt,  for  instance,  in  the  street, 
especially  if  the  shops  are  shut  ; in  public 
buildings,  such  as  churches,  concert-rooms,  cr 
theatres  ; in  omnibuses,  cabs,  or  other  convey- 
ances ; on  a bridge  ; or  in  looking  at  an  extended 
facade  or  flying  perspective.  Most  persons  who 
suffer  thus  in  the  street  feel  better  when  with 
some  one,  or  when  near  some  object,  such  as  a 
carriage,  or  even  when  carrying  an  umbrella  or 
a stick.  Occasionally,  however,  they  shun  other 
people,  especially  acquaintances. 

But  little  is  known  as  to  the  origin  and  nature 
of  agoraphobia.  The  complaint  is  not  regarded 


IS  AGORAPHOBIA. 

la  idiopathic,  but  as  sequential  to  some  other 
condition.  It  occurs  in  males  and  females,  and 
the  individuals  affected  may  be  strong  and  in 
good  bodily  health,  while  they  are  often  intel- 
ligent and  ■well-educated.  A history  of  heredi- 
tary nervous  disorder  can  be  traced  in  some 
cases,  indicated  by  the  occurrence  of  insanity 
or  epilepsy  in  members  of  the  family  ; and  the 
patients  themselves  may  present  indications  of  a 
nervous  temperament.  Their  emotions  may  be 
easily  excited ; and  they  may  be  subject  to 
nervous  symptoms,  such  as  headache,  a feeling 
of  heat  in  the  top  of  the  head,  sparks  before 
the  eyes,  occasional  faintness,  or  motor  disorders. 

Frederick.  T.  Roberts. 

AGRAPHIA.  See  Aphasia. 

AGRIA  (iypLos,  wild). — This  term  signifies 
angry  and  severe.  Willan  describes  a Lichen 
agrius,  which  is  likewise  termed  Agria  ; it  is  a 
circumscribed  inflammatory  eczema  situated  on 
the  back  of  the  hands.  The  qualities  implied 
by  agria  are  excessive  pruritus,  burning  pain, 
thickening,  fission,  and  copious  exudation. 

Erasmus  Wilson. 

AGUE. — A popular  synonym  for  Intermittent 
Fever.  See  Intermittent  Fever. 

AGUE-CAKE. — A form  of  enlargement  of 
tRe  spleen,  resulting  from  the  action  of  malaria 
on  the  system.  See  Spleen,  Diseases  of ; and 
Malaria. 

AIR,  JEtiology  of.  See  Disease,  Causes  of. 

A.IR,  Therapeutics  of. — Air  is  employed  in 
the  treatment  of  disease  in  many  ways  and 
for  many  purposes.  It  is  used,  first,  as  the 
atmosphere , a gaseous  mixture  of  definite  compo- 
sition and  with  a variable  pressure.  Secondly, 
advantage  is  taken  of  air  as  a vehicle  for  other 
substances  in  the  gaseous  or  finely  divided 
state.  And,  thirdly,  it  is  selected  as  a medium  by 
which  the  temperature  of  the  body  may  be  readily 
and  effectively  influenced.  In  the  first  of  these 
relations  only — as  pure  air — will  its  therapeutics 
require  to  be  considered  in  this  article.  The 
application  to  the  body  generally  of  air  that  has 
been  warmed,  or  warmed  and  loaded  with  mois- 
ture, will  be  found  described  in  the  article  on 
Baths  ; while  its  administration  to  the  respi- 
ratory organs,  either  in  this  form  or  as  a vehicle 
for  such  substaue.es  as  creasote,  carbolic  acid, 
alkaloids,  and  sulphurous  acid,  will  he  dis- 
cussed under  Inhalations. 

Principles. — The  dual  relation  in  which  the  air 
stands  to  the  economy — as  a definite  compound  of 
certain  gases,  and  as  an  atmosphere  with  a certain 
pressure — is  very  frequently  disturbed ; and 
this  disturbance  accounts  for  some  of  the  most 
familiar  phenomena  of  disease.  Alteration  in 
the  quality  or  quantity  of  the  respired  air, 
whether  from  the  state  of  the  atmosphere  itself 
or  from  derangement  of  the  complex  apparatus 
of  respiration  and  circulation,  is  the  cause  of 
some  of  the  most  serious  and  distressing  symp- 
toms attending  diseases  of  the  chest.  It  might 
be  predicted  by  the  physiologist  that  under  these 
circumstances  relief  would  be  afforded,  at  least 
to  symptoms,  by  suitable  alteration  of  the  com- 
position or  volume  of  the  air.  The  method  of 


AIR.  THERAPEUTICS  OF. 
treatment  thus  rationally  indicated  is  further 
readily  practicable — the  supply  of  air  is  un- 
limited ; its  composition  may  be  altered  at  plea- 
sure ; its  pressure  may  be  increased  or  dimi- 
nished ; and  such  alteration  will  alter  its  chemical 
properties.  We  find  accordingly  that,  ever  since 
the  discovery  of  the  composition  of  the  atmo- 
sphere, frequent  trials  have  been  made  of  its 
value  therapeutically.  Oxygen  was  early  recog- 
nised as  its  active  constituent,  and  came  to  be 
administered,  as  it  still  is,  in  the  form  of 
inhalation.  From  time  immemorial,  indeed, 
advantage  has  been  taken  of  the  purity  and 
certain  other  unknown  qualities  of  the  air 
for  tho  prevention  and  treatment  of  disease  ; 
and  the  character  of  the  atmosphere  is  natur- 
ally reckoned  one  of  the  most  important,  ele- 
ments of  climate  {see  Climate).  More  recently 
use  has  been  made  of  the  powerful  properties 
that  air  possesses  when  physically  change1. 
Within  the  last  few  years  a remarkable  advance 
has  been  made,  on  the  one  hand,  in  the  physio- 
logy of  respiration  and  the  relation  of  the  circula- 
tion to  tho  atmospheric  pressure,  and,  on  the 
other,  in  the  pathology  of  diseases  of  the  chest. 
Clearer  views  havo  been  reached  on  tho  signifi- 
cation of  various  symptoms,  and  especially  of 
dyspnoea  in  its  different  forms.  At  the  same 
time  observations  upon  the  effects  of  compressed 
and  rarefied  air  have  been  becoming  more  exact. 
Pursuing  the  physiological  track,  modern  tbc 
rapeutists  have  availed  themselves  of  this  know- 
ledge, and  revived  the  use  of  air  physically 
altered  in  the  treatment  of  diseases  of  the  lungs, 
heart,  and  other  parts  of  the  body.  This  ap- 
plication they  are  now  able  to  make  with  accu- 
racy, and  the  success  of  the  reformed  system  of 
aerotherapeuties  appears  to  he  unquestionable. 
Although  in  England  it  is  seldom  heard  o ( 
beyond  hydropathic  establishments,  the  system 
is  more  extensively  employed  on  the  Continent. 
Its  leading  principles  and  some  of  its  most 
important  applications  will  he  here  briefly  de- 
scribed. 

The  physiological  effects  of  compressed  or  of 
rarefied  air  will  manifestly  be  different  accor  !- 
ingasit  is  admitted  to  the  body  as  a whole,  or  only 
to  a part  of  it.  Familiar  examples  of  the  former 
condition  are  afforded  by  descent  in  the  diving- 
bell,  or  ascent  in  the  balloon  ; and  of  the  latter 
by  the  action  of  the  cupping-glass,  and  the  effect 
of  interrupted  or  frequently  repeated  respirations 
upon  the  pulse  and  system  generally.  Under 
the  first  circumstances  the  alteration  of  pressure 
is  absolute;  under  the  second  it  is  relative, 
and  capable  of  producing  most  important 
disturbances  in  the  distribution  of  the  vital 
fluids.  The  two  methods  of  application  must 
accordingly  be  separately  discussed. 

General  Aerotherapeutics. — The  effects  of 
compressed  air  on  the  body  as  a whole  have 
been  studied  in  the  air-bath , a simple  mechanical 
arrangement  in  the  form  of  an  iron  chamber, 
which  can  be  filled  with  air  at  any  pressure, 
whether  above  or  below  the  normal,  by  means 
of  steam-power.  The  principal  physiological 
effects  of  air  condensed  by  three-sevenths  of 
an  atmosphere  were  ascertained  by  von  Yivecot 
to  be: — Pallor  of  tho  skin  and  mucous  mem- 
branes ; a sensation  of  pressure  in  the  ears : 


AIR,  THERAPEUTICS  OF. 


diminished  frequency  of  respiration,  the  act  be- 
coming easier;  enlargement  of  the  lungs,  and 
increase  of  the  vital  capacity;  depression  of  the 
cardiac  force,  and  diminution  of  the  size  and 
strength  of  the  pulse  ; rise  of  temperature  ; in- 
creased vigour  of  muscular  action,  secretion,  and 
nutrition  generally  ; compression  of  the  gaseous 
contents  of  the  intestines  ; and,  perhaps,  in- 
creased absorption  of  oxygen  and  excretion  of 
carbonic  acid.  "When  the  pressure  is  excessive, 
dangerous  or  even  fatal  symptoms  may  super- 
rone.  Frequent  exposure  to  condensed  air  will 
induce  considerable  increase  of  the  vital  capacity  ; 
and  most  of  the  other  effects,  both  physical  and 
chemical,  will  tend  to  persist.  In  a word,  it  may 
probably  be  said  that  the  air-bath  acts  on  the 
system,  first,  by  increasing  the  general  me- 
chanical pressure;  and  secondly,  by  admitting 
an  increased  amount  of  oxygen.  In  employing 
the  air-bath,  the  patient  is  kept  in  it  for  a 
period  of  two  hours,  at  first  daily,  but  after 
some  weeks  less  frequently.  The  pressure,  which 
's  employed  in  different  cases  at  one-fifth  to 
one-half  of  an  atmosphere  above  the  normal, 
must  be  slowly  raised  on  admission,  and  reduced 
on  removal  of  the  patient. 

The  number  of  diseases  in  which  the  air-bath 
maybe  given  with  success  is  limited; — (1.)  In 
certain  forms  of  dyspnoea  : — thus  it  gives  great 
relief  in  spasmodic  asthma,  and  may  also  afford 
temporary  relief  in  emphysema,  but  its  prolonged 
use  appears  to  be  positively  bad,  as  it  in- 
creases the  pulmonary  distension.  (2.)  In  hy- 
percemia  and  catarrh  of  the  air-passages,  includ- 
ing pertussis.  (3.)  In  imperfect  expansion  or 
threatened  retraction  of  the  chest,  as  in  the  sub- 
jects of  phthisis  and  chronic  pleurisy.  Compressed 
air  has  also  been  extolled  in  some  forms  of  car- 
diac disease,  and  in  general  malnutrition. 

The  effects  of  rarefied  air  admitted  to  the  body 
as  a whole  do  not  demand  description  in  this 
place,  either  in  their  physiological  or  in  their 
therapeutical  aspect.  Artificially  rarefied  air  is 
never  employed  in  the  form  of  the  bath  ; and  the 
natural  supply  in  elevated  regions,  which  has 
found  so  much  favour  as  a means  of  treatment 
in  phthisis,  is  a subject  that  belongs  to  Climate 
and  Phthisis. 

Local  Aerotherapeutics. — When  it  is  de- 
sired to  bring  compressed  or  rarefied  air  into 
contact  with  the  respiratory  surface  only,  a 
different  apparatus  must  be  employed.  Several 
forms  have  been  introduced,  respecting  which  it 
will  be  sufficient  to  state  that  the  air  contained 
in  a gas-holder  is  compressed  or  rarefied  by 
simple  mechanical  means,  and  thereafter  brought 
into  relation  with  the  air-passages  by  an  arrange- 
ment of  tubes  and  valves.  There  are  four  pos- 
sible methods  of  application  : — (1)  Inspiration  of 
condensed  air ; (2)  Expiration  into  condensed 
air  ; (3)  Inspiration  of  rarefied  air  ; and  (4)  Ex- 
piration into  rarefied  air.  The  physiological 
effects  of  the  several  methods  have  been  care- 
fully investigated  by  Professor  Waldenburg,  of 
Berlin,  whose  account  we  shall  follow. 

Inspiration  cf  condensed  air.  — Inspiration  of 
air  that  has  been  condensed  by  one-sixtieth 
to  one-fortieth  of  an  atmosphere  produces 
i sensation  of  extreme  distension  of  the 
chest,  accompanied  by  an  actual  expansion 


19 

of  the  thorax  and  lungs,  and  an  increased 
admission  of  air,  so  that  inspiratory  dyspnoea,  if 
present,  is  relieved.  At  the  same  time  the  other 
thoracic  contents  are  compressed,  the  systemic 
vessels  fill,  the  arterial  pressure  rises,  and  the 
jugulars  become  distended.  The  lungs  and  heart 
will  be  comparatively  anaemic.  If  the  applica- 
tion of  condensed  air  be  frequently  repeated,  the 
vital  capacity,  the  size  of  the  chest,  and  the  re- 
spiratory force,  may  all  be  increased,  and  paitial 
relief  may  be  permanently  afforded  to  dyspnoea. 

Expiration  into  condensed  air  is  most  difficult 
of  accomplishment,  and  endsinapncea  in  inspira- 
tory time.  The  effect  on  the  circulation  does  not 
differ  essentially  from  that  just  described. 

Inspiration  of  rarefied  air.- — Inspiration  of  air 
that  has  been  rarefied  by  one  two-hundred-and- 
fortieth  to  one  one-hundred-and-twentieth — or 
even,  after  a time,  by  one-sixtieth — of  an  atmo- 
sphere, immediately  causes  the  phenomena  cf 
inspiratory  dyspnoea:  the  thoracic  viscera  are 
congested,  and  hpemoptysis  may  result,  for  tho 
effect  may  be  regarded  as  that  of  dry-cupping 
the  pulmonary  alveoli.  The  heart  at  the  same 
time  becomes  full,  and  the  jugulars  collapse. 

Expiration  into  air  that  has  been  rarefied 
by  one-sixtieth  ofan  atmosphere  is  attended  with 
a sense  of  extreme  compression  of  the  thcrax:  af 
the  same  time  there  is  actually  a partial  retrac- 
tion of  the  lungs,  an  increase  in  the  volume  cl 
expired  air,  and  a corresponding  diminution  in 
the  amount  of  residual  air  in  the  chest.  Expira- 
tory dyspncea,  if  present,  is  relieved.  While  the 
lungs  thus  diminish  in  size,  the  other  thoracic 
viscera  are  dilated — the  heart  and  the  pulmonary 
and  other  vessels  within  the  chest  being  filled  al 
the  expense  of  those  external  to  it,  both  arteries 
and  veins.  If  the  expiration  into  rarefied  air  bo 
frequently  repeated,  the  circumference  of  tho 
chest  will  be  diminished,  while  the  vital  capacity 
will  be  actually  increased,  along  with  increase  of 
the  inspiratory  and  expiratory  force. 

Applications. — The  method  of  inspiring 
condensed  air  is  obviously  indicated  in  diseases 
where  inspiratory  dyspnoea  is  an  urgent  symp- 
tom. Spasmodic  asthma,  stenosis  of  the  air- 
passages  from  anatomical  causes,  acute  and 
chronic  bronchitis,  and  atelectasis,  have  all  been 
successfully  treated  by  this  method.  In  croup, 
where  it  is  urgently  indicated,  it  is  most  difficult 
or  even  impossible  to  employ.  In  threatened 
phthisis  it  is  used  prophylaetically ; and  in  chronic 
pleurisy  it  may  prevent  or  remove  the  effects  of 
collapse  and  retraction  of  the  chest  wall.  Tho 
inhalation  of  condensed  air  should  also  be  of  use 
in  certain  forms  of  cardiac  dilatation,  especially 
that  dueto  mitral  incompetence.  Improvingas  it 
does  the  general  nutrition,  it  may  be  combined 
with  other  remedies  for  anaemia.  In  the  adminis- 
tration of  condensed  air,  a ‘ sitting  ’ should 
last  from  ten  to  thirty  minutes,  once  a 
day — seldom  twice.  — Expiration  into  con- 
densed air  is  not  used  therapeutically. — In- 
spiration of  rarefied  air  may  be  regarded  as  a 
means  of  exercising  the  inspiratory  muscles. 
Like  the  atmosphere  of  great  altitudes,  it  may 
therefore  be  employed  in  persons  with  badly  de- 
veloped chests ; and  even  in  phthisis  it  may,  by. 
increasing  the  amount  of  blood  in  tho  lungs, 
prevent  caseation  and  promote  absorption  of  th 


20  AIE,  THERAPEUTICS  OF. 
products.  In  disease  of  the  right  side  of  the 
heart,  it  would  assist  the  floyv  of  blood  from  the 
veins  into  the  lungs,  but  it  is  not  likely  to  bo 
employed  for  this  purpose. — Expiration  into 
rarefied  air  promises  to  be  the  most  successful  and 
most  extensively  employed  of  all  the  methods.  In 
it,  according  to  Waldenburg,  we  have  the  physi- 
cal antidote  for  emphysema,  and  in  his  hands  the 
majority  of  such  patients  have  been  either  cured 
or  radically  benefited.  It  has  also  afforded  great 
relief  in  some  cases  of  bronchitis,  where  it  in- 
creases expectoration. 

Other  local  applications  of  the  physical  pro- 
perties of  the  air,  as  seen  in  aspiration,  cupping, 
Junod’s  boot,  and  inflation,  are  described  else- 
where in  this  volume.  J.  Mitchell  Bruce. 

AIR  IN  CELLULAR  TISSUE.  See 

Emphysema,  Subcutaneous. 

AIR  IN  VEINS.  See  Veins,  Air  in. 

AIR-PASSAGES,  Diseases  of.  See  Re- 
spiratory Organs,  Diseases  of ; also  Larynx, 
Trachea,  and  Bronchi,  Diseases  of. 

AIX-LA-CHAPELLE,  Waters  of.  Ther- 
mal sulphur  waters.  See  Mineral  Waters. 

AIX-LES-BAINS,  Waters  of.  Hot  sul- 
phur waters.  See  Mineral  Waters. 

AKINESIA.  See  Acinesia. 

ALBINISM  ( albus , white). — Definition. — 
A state  of  whiteness  or  absence  of  colour  of  the 
integument  and  certain  other  tissues,  consequent 
on  defect  of  pigment-formation.  Tho  want  of 
colour  may  be  complete  or  incomplete ; partial 
or  universal ; congenital  or  accidental.  Partial 
albinism  may  be  limited  to  a spot  of  small 
dimensions ; or  there  may  be  many  such  spots 
of  variable  extent,  dispersed  over  the  surface  of 
the  body,  and  giving  rise  to  the  appearance 
which  is  denominated  pied  or  piebald  ; whereas 
in  universal  albinism  the  defect  of  pigment  is 
not  restricted  to  the  integument,  but  is  especially 
remarkable  in  the  iris  and  choroid  mqmbrano  of 
the  eyeball. 

General  Characters. — Persons  and  animals 
affected  with  albinism  are  called  albinoes.  It 
would  seem  more  correct  to  limit  the  term  albino 
to  those  in  whom  the  absence  or  defect  of 
pigment  is  universal,  and  demonstrable  not 
only  in  the  integument  but  likewise  in  the 
eyeball.  In  the  true  albino,  therefore,  the 
skin  is  white  and  pink  and  more  or  less 
transparent,  and  this  both  in  the  fairer  and 
in  the  darker  races  of  mankind  ; but  in  certain 
of  tho  latter,  where  the  pigmentary  function 
is  simply  defective  and  not  totally  wanting,  the 
colour  of  the  skin  may  be  grey  or  tawnv,  and 
more  or  less  variegated  and  freckled.  The  hair, 
sometimes  of  a pure  silvery  or  opaque  white,  may 
be  diversely  tinged  with  yellow  or  red;  occasion- 
ally it  is  flaxen  or  possesses  a greyish  hue  ; and 
in  some  instances  the  whole  body  is  covered 
with  a white  down.  The  iris  is  grey  or  pink  in 
accordance  with  the  density  of  its  fibrous  struc- 
ture, and  the  consequent  facility  of  penetration 
of  the  colour  of  its  vascular  layer ; or,  as  gene- 
rally happens  in  the  negro,  it  is  blue.  The  pupil 
is  contracted  and  brightly  red  from  the  absence 


ALBUMINOID  DISEASE. 

of  the  screen  of  protection  usually  afforded  to 
the  choroid  membrane  by  its  pigmentary  layer ; 
and  for  the  same  reason  the  rays  of  light  pene- 
trating the  sclerotic  and  iris  give  a brilliancy  of 
appearance  to  the  fundus  of  the  eyeball.  The 
absence  of  pigment  in  the  eyeball  is  productive 
of  several  peculiarities  of  character  in  the  albino. 
In  the  first  place  the  excess  of  luminous  rav? 
penetrating  the  coats  of  the  eyeball  interferes 
with  the  correctness  of  his  vision  ; his  retinae  are 
intolerant  of  light;  he  stoops  his  head,  or  droope 
his  eyelids,  to  shelter  his  eyes  ; he  sees  with  more 
comfort  in  the  dimness  of  evening  than  in  the 
light  of  the  sun  ; he  is  near-sighted ; and  there 
is  in  many  cases  an  oscillation  of  the  eyeballs. 

./Etiology. — Albinism  is  met  with.  amoDg  all 
races  of  mankind  and  in  every  country,  but  is 
most  common  amongst  those  who  are  subjected 
to  insalubrious  conditions  of  climate  and  hj-giene. 
For  these  reasons  it  is  not  uncommon  among  the 
natives  of  the  marshy  coast  of  Africa ; among 
negroes  who  are  transferred  to  unhealthy  districts 
in  South  America  and  the  West  Indies ; among 
the  inhabitants  of  the  western  coast  of  South 
America  and  Mexico;  in  certain  of  the  islands 
of  the  Indian  Ocean ; and  even  in  the  northern 
regions  of  Europe.  When  albinism  is  congenital, 
it  has  been  assumed  to  be  due  to  an  arrest  of  de- 
velopment ; but  when  accidental,  its  existence 
must  be  referred  to  exhaustion  of  ehromatogenous 
or  pigment-producing  function.  Arrest  of  de- 
velopment has  been  inferred  from  the  occasional 
persistence  in  albinoes  of  the  membrana  pupil- 
laris,  and  of  the  fcetal  down  of  the  skin  ; from 
the  mere  frequent  occurrence  of  the  condition  in 
females  than  in  males ; and  from  the  observa- 
tion that  albinoes  are  sometimes  misshapen  and 
feeble  intellectually  as  well  as  physically.  Oa 
the  other  hand  it  is  well  known  that  albinism  is 
often  associated  with  perfect  physical  strength 
and  remarkable  intellectual  vigour.  Among  other 
causes  to  which  it  has  been  assigned  are  hereditv, 
and  debility,  however  induced. 

Treatment.  — The  treatment  of  congenital 
albinism  must  consist  in  the  application  of  those 
agencies  which  tend  to  strengthen  and  improve 
the  general  health.  With  regard  to  the  special 
inconvenience  resulting  from  the  absence  of  pig- 
ment in  tho  eyes,  it  has  been  observed  that  the 
difficulty  felt  in  reading  is  greatly  lessened  by 
using  screens  or  goggles  made  of  some  opaque 
material,  such  as  aluminium,  each  perforated  by 
a small  opening,  admitting  only  the  rays  of  light 
from  the  object  looked  at.  The  treatment  of  acci- 
dental albinism  will  be  considered  under  Pig- 
mentary Skin-Disease.  Erasmus  Wilson. 

ALBUMINOID  DISEASE.  — Synon.  ; 

Waxy,  Lardaceous,  and  Amyloid  Degeneration. 
Fr.  Degeneration  amyJcide.  Ger.  Spcckartiye  De- 
generation (Rokitansky) ; Amyloids  Entartung 
(Virchow). 

Definition. — .1  peculiar  form  of  degeneration, 
affecting  certain  organs,  and  constituting  in  its 
effects  a distinct  and  general  disease. 

/Etiology — In  the  majority  of  cases  albu- 
minoid disease  is  preceded  by  lone-continued 
suppuration,  most  frequently  in  the  form  of 
bone-  or  joint-disease  ; or  else  of  destruction 
pulmonary  phthisis,  empyema,  pyelitis,  cystitis, 


ALBUMINOID  DISEASE. 

and  other  affections,  where  there  has  been  a con- 
stant drain  of  pus.  In  the  absence  of  obvious 
suppuration,  there  is  usually  present  an  exhaust- 
ing disease,  as  syphilis,  ague,  or  some  more 
obscure  cachexia.  These  antecedent  conditions 
must  be  regarded  as  the  cause  of  the  malady, 
and  it  is  only  in  the  rarest  instances  that  no  such 
cause  can  be  traced.  It  is  not  easy  to  recognise 
the  connection,  but  it  may  be  pointed  out  that  a 
drain  of  pus  involves  not  only  a loss  of  highly 
organised  protoplasmic  material,  but  also  ot 
potassium  salts,  which  are  contained  in  large 
proportion  in  the  solid  elements  of  pus,  and 
which  salts,  as  we  have  seen,  aro  deficient  in  tho 
affected  tissues. 

Anatomical  Characters.  — The  organs  af- 
fected are  usually  much  enlarged,  but  sometimes 
they  ultimately  decrease  in  size.  They  are  pale, 
dense,  dry,  sometimes  hard,  and  either  generally 
or  in  certain  spots  translucent.  In  an  advanced 
stage  of  the  disease  the  parts  appear  as  if  soaked 
n wax,  or  other  translucent  material.  If  iodine, 
.n  alcoholic  or  aqueous  solution,  be  applied  to  the 
affected  parts,  they  are  stained  yellow,  orange,  or 
a deep  mahogany  brown,  according  to  the  degree 
of  the  morbid  change.  If  the  portions  thus 
coloured  be  further  treated  with  dilute  sulphuric 
acid,  a purplish  black  colour  is  produced.  These 
iharacters  depend  upon  the  presence  in  the  tissue- 
elements  of  a peculiar  substance,  allied  to  the 
albuminates, and  containing,  when  approximately 
pure,  about  15  per  cent,  of  nitrogen.  It  is  so- 
luble in  alkalis,  not  digested  by  pepsine,  and  not 
readily  altered  by  putrefaction;  it  gives  with 
iodine  the  characteristic  colour  just  noted,  which 
gave  rise  to  Virchow’s  erroneous  supposition  of 
its  being  allied  to  starch,  whence  the  name — 
Amyloid.  This  albuminoid  material  being  con- 
tained in  the  tissue-elements  themselves,  and 
not  infiltrated  between  them,  is  probably  not 
poured  out  by  the  vessels  as  such,  but  results 
from  a transformation  of  the  materials  of  the 
tissues.  Chemical  analysis  of  the  affected  organs 
shows  a remarkable  change  in  their  mineral  con- 
stituents, the  potassium  and  phosphoric  acid 
being  very  greatly  diminished,  as  compared  with 
healthy  organs ; while  the  sodium  and  chlorine 
remain  normal,  or  are  proportionately  increased. 

Albuminoid  disease  affects  most  frequently  the 
liver,  spleen,  and  kidneys.  Next  in  order  of 
frequency  come  the  lymphatic  glands,  and  the 
intestinal  mucous  membrane,  especially  its  villi; 
more  rarely  the  suprarenal  bodies,  the  pancreas, 
the  urinary  mucous  membrane,  or  the  omentum 
are  involved ; and,  quite  exceptionally,  other  parts, 
such  as  the  thyroid  body,  the  generative  organs, 
the  heart,  and  the  lungs.  In  most  organs  the 
blood-vessels  and  their  appendages,  (glomeruli 
of  the  kidneys,  Malpighian  corpuscles  of  the 
spleen)  are  the  seat  of  the  morbid  change ; but  in 
some,  such  as  the  kidney,  secreting  cells  may 
also  be  affected,  and  in  the  liver  these  structures 
are  chiefly  or  solely  involved.  The  diseased  ele- 
ments are  enlarged,  translucent,  and  structureless. 

Symptoms,  Diagnosis,  and  Prognosis. — The 
general  symptoms  of  albuminoid  disease  are 
anaemia,  debility,  a cachectic  appearance,  and 
sometimes  capillary  haemorrhage.  The  local 
symptoms  are  chiefly  important  in  the  case  of 
the  liver,  spleen,  and  kidneys.  Uniform  smooth 


ALBUMINS.  21 

enlargement  of  the  liver  and  spleen,  which  can 
be  referred  to  no  other  cause,  may  be  due  to 
the  albuminoid  change.  Where  the  kidney  is 
affected,  albuminuria,  dropsy,  uraemia,  and  a 
train  of  symptoms  arise,  which,  regarded  as  a 
whole,  differ  from  those  of  other  kidney  diseases. 
The  diagnosis  is  greatly  confirmed  by  (1)  the 
simultaneous  occurrence  of  disease  in  several 
organs ; (2)  a history’  of  suppuration,  or  of 
some  cachectic  disease,  especially  sj’philis. 
The  'prognosis  is  extremely’  unfavourable,  and. 
when  the  disease  is  far  advanced,  it  is  hopeless. 

Treatment. — Though  in  advanced  cases  treat- 
ment can  avail  but  little,  there  is  reason  to  think 
that  were  the  occurrence  of  disease  anticipated, 
or  its  presence  earlier  recognised,  prevention,  or 
even  cure,  might  be  possible.  In  all  such  com- 
plaints as  chronic  joint-disease,  psoas  abscess,  sy- 
philitic disease  of  bone,  orprolonged  empyema,  the 
probability  of  this  frequently  fatal  sequela  should 
be  borne  in  mind,  and  guarded  against  by  a suit- 
able regimen.  The  diet  should  not  only  be  gene- 
rally nutritious,  but  should  include  more  especially 
abundance  of  nitrogenous  food  (albuminates),  as 
well  as  the  potassium  salts,  which  the  affected 
tissues  lack.  These  are,  indeed,  largely  contained 
in  the  juices  of  fresh  meat,  and  also  in  the  green 
parts  of  vegetables.  Among  drugs,  nutrient 
tonics,  of  which  iron  and  cod-liver  oil  are  the 
type,  must  hold  the  first  place  ; but  the  adminis- 
tration of  potassium  salts,  as  proposed  by  Dr. 
Dickinson,  is  also  indicated.  Of  these  we  should 
be  induced,  on  a priori  grounds,  to  select  those 
of  which  the  local  action  is  least  violent,  and 
which  cause  little  vascular  depression,  such  as 
the  bicarbonate,  or  the  citrate,  or  other  organic 
salts.  The  danger  of  ‘ potash  poisoning  ’ is  very 
remote.  J.  F.  Payne. 

ALBUMIN S. — Definition.  — Albumins  are 
substances  closely  resembling  egg-albumin, 
the  chief  constituent  of  white  of  egg  or  albu- 
men. To  distinguish  between  the  white  of  egg 
and  its  chief  constituent,  the  former  is  spelt 
albumen  and  the  latter  albumin.  Albumins 
constitute  a sub-division  of  the  class  of  albu- 
minous bodies,  which  includes  all  substances 
having  a general  resemblance  to  albumen. 

Enumeration.— -The  sub-class  properly  con- 
tains only  two  members,  egg-albumin  and  serum- 
albumin ; but  the  name  Bence-Jones' s albumin  has 
been  given  to  an  albuminous  body  differing  very 
considerably  in  its  properties  from  the  other 
two. 

Characters. — Egg-albumin  and  serum-albu- 
min are  semi-transparent,  yellowish,  and  struc- 
tureless when  dried.  They  are  soluble  in  water ; 
and  this  solution  is  coagulated  by  boiling.  From 
the  same  solution  they  are  precipitated  by  («) 
nitric  acid  ; (5)  salts  of  the  heavy  metals,  for 
example,  copper-sulphate  ; (c)  acetic  acid  with 
potassium-ferrocyanide  ; (d)  boiling  with  acetic 
acid  and  a neutral  salt,  for  example,  piotassium- 
sulphate ; ( e ) alcohol.  Egg-albumin  is  distin- 
guished from  serum-albumin  by  the  eoagulum 
which  it  forms  with  nitric  acid  being  insoluble 
in  excess,  while  that  of  serum-albumin  is  soluble. 
Bence-Jones’s  albumin  gives  no  precipitate  with 
excess  of  nitric  acid  unless  left  to  stand,  or  un- 
less heated  and  left  to  cool,  when  it  forms  a solid 


22  ALBUMINS, 

coagulum.  This  coagulum  redissolves  on  heat- 
ing, and  again  forms  on  cooling.  It  may  be 
separated  from  ordinary  albumin  by  adding 
nitric  acid,  boiling,  and  filtering  •when  hot.  The 
ordinary  albumin  ■will  remain  on  the  filter  while 
Bence-Jones’s  albumin  will  pass  through,  and 
will  coagulate  when  the  filtrate  cools. 

Modifications. — By  the  action  of  acids  and 
alkalis  albumin  may  be  converted  into  acid-albu- 
min and  alkali-albumin  respectively,  neither  of 
which  is  coagulated  by  boiling. 

Acid-albumin  may  be  formed  in  two  ways : — 
First,  by  dissolving  solid  albumin  in  concentrated 
nitric  or  other  mineral  acid  with  the  aid  of 
heat.  Secondly,  by  heatina:  an  aqueous  solution 
of  albumin  with  one  of  these  acids  very  much 
diluted  (1  in  500).  Although  soluble  in  very 
concentrated  or  very  dilute  acids,  acid-albumin 
is  insoluble  in  moderately  dilute  acids.  There- 
fore, when  the  solution  in  concentrated  nitric 
acid  is  diluted  with  water,  a precipitate  is 
formed,  which  redissolves  when  much  water  is 
added.  And,  conversely,  when  acid-albumin  is 
made  by  boiling  a solution  of  albumin  in  water 
with  very  dilute  nitric  acid,  the  addition  of  more 
acid  will  throw  down  a precipitate,  which  redis- 
solves if  a very  large  excess  of  the  concentrated 
acid  be  added,  and  especially  if  it  be  heated  at 
the  same  time.  On  neutralizing  a solution  of 
acid-albumin,  a precipitate  is  thrown  down, 
which  dissolves  in  excess  of  alkali. 

Alkali-albumin,  or  Alkali-albuminate  as  it  is 
also  called,  is  formed  by  dissolving  albumin  in 
caustic  potash  or  soda  ; or  by  adding  either  of 
these  to  its  aqueous  solution  and  allowing  this  to 
6tand,  or  heating  it.  This  modification  is  not 
precipitated  by  heat,  but  is  precipitated  by  neu- 
tralization; the  precipitate  dissolving  very  readily 
in  slight  excess  of  acid.  If  alkaline  phosphates 
are  present  in  the  solution,  as  they  are  in  urine, 
alkali-albumin  requires  a slight  excess  of  acid 
to  throw  it  down,  and  is  not  precipitated  by  exact 
neutralization,  as  acid-albumin  would  be  under 
similar  circumstances.  T.  Lauder  Bruntox. 

ALBUMINURIA. — Definition. — A condi- 
tion characterised  by  the  presence  of  albumin  in 
the  urine.  Otlior  albuminous  bodies,  not  albu- 
mins, may  be  present  in  hsematinuria,  hasma- 
turia,  pyuria,  and  spermatorrhoea. 

Symptoms. — Albumin  may  occur  in  the  urine 
without  any  symptoms  whatever,  but  its  con- 
tinuous loss  leads  to  anaemia  and  changes  in  the 
circulation,  which  usually  originate  the  following 
symptoms — a pallid  pasty  complexion,  dry  skin, 
and  tendency  to  oedema  of  the  cellular  tissue 
noticeable  on  the  eyelids  and  shins  ; derange- 
ment of  digestion,  flatulence,  occasional  nausea, 
and  irregularity  of  the  bowels  ; nervous  disorder 
shown  by  muscular  weakness,  languor,  lassitude, 
vague  pains  about  the  loins,  and  headache ; 
calls  to  make  water  during  the  night;  palpi- 
tation, and  frequently  accentuation  of  the  second 
sound  of  the  heart  over  the  aortic  cartilage,  and 
reduplication  of  the  first  sound  over  the  septum 
ventriculorum. 

Tests  for  Albumin. — The  two  tests  usually 
employed  to  detect  albumin  in  the  urine  are — 
first,  boiling ; and,  secondly,  the  addition  of  nitric 
acid ; both  of  which  produce  a cloud  or  precipi- 


ALBUMINUR1A. 

tate.  If  the  urine  is  turbid  the  albuminous 
cloud  may  not  be  noticed ; and  therefore  such 
urine  should  be  filtered  before  the  application 
of  either  test,  unless  the  turbidity,  being  depen- 
dent on  the  presence  of  urates,  is  removed  by 
heat. 

Method  of  employing  the  test  by  boiling. — 
With  the  object  of  saving  time  the  urine  is  often 
boiled  at  once,  but  the  results  thus  obtained  are 
liable  to  several  fallacies,  which  will  be  subse- 
quently described.  In  order  to  avoid  such  fallacies 
the  following  method  should  be  pursued : — Ascer- 
tain the  reaction  of  the  urine ; and,  if  it  be 
alkaline  or  very  strongly  acid,  add  acetic  acid  in 
the  one  case,  or  liquor  potassse  in  the  other, 
until  its  reaction  is  only  slightly  acid.  Fill  a 
test-tube  to  about  one-third  of  its  capacity  with 
the  urine,  and  hold  it  obliquely  in  the  flame  of  a 
spirit  lamp  in  such  a manner  as  to  heat  the  upper 
part  of  the  fluid  only,  until  it  boils.  If  it  be 
turbid  from  urates,  it  should  be  first  warmed 
throughout  until  it  becomes  clear,  and  then  the 
upper  part  only  should  be  boiled.  Finally,  add 
a drop  or  two  of  acetic  or  nitric  acid. 

If  albumin  be  present,  it  will  form  a cloud  or  a 
coagulum,  more  or  less  dense  according  to  its 
amount.  When  there  is  much  albumin,  its  quan- 
tity may  be  roughly  estimated  by  allowing  the 
urine  to  stand  for  a definite  number  of  hours, 
so  that  the  coagulum  may  subside,  and  then 
observing  whether  it  forms  a fourth,  a third, 
or  a half  of  the  whole  length  of  urine  in  the  test- 
tube.  A small  quantity  causes  a cloud,  but  no 
distinct  coagulum  ; and,  if  merely  a trace  be  pre- 
sent, a faint  haze  only  will  be  observed,  which  is 
best  seen  by  looking  through  the  test-tube  at  a 
dark  object.  The  advantage  of  heating  the 
upper  part  only  of  the  urine  is,  that  the  lower 
portion,  which  remains  clear,  affords  a standard 
l>y  comparison  with  which  a faint  cloud  in  tlio 
heated  part  may  be  more  readily  detected. 

Fallacies  of  the  test  by  boiling. — The  first 
fallacy  is  that  albumin  may  be  present,  and  yet 
no  cloud  or  coagulum  be  produced  on  boiling. 
This  may  occur  if  the  urine  be  alkaline  or  very 
strongly  acid,  because  alkali-albumin  or  acid- 
albumin,  which  are  soluble  in  water,  may’ 
be  formed.  It  is  to  prevent  the  formation  of 
alkali-albumin  that  acetic  or  nitric  acid  should 
be  added  to  alkaline  urine  before  boiling.  This 
addition  of  acid  also  causes  the  coagulum  to 
separate  more  readily ; and  it  should  therefore  be 
made  when  the  urine  is  neutral.  On  the  other 
hand,  urine  rarely  or  never  contains  sufficient 
acid  to  form  acid-albumin,  unless  the  patient 
has  been  taking  mineral  acids  ; and  therefore  til- 
addition  of  liquor  potassse  is  not  necessary  except 
under  these  circumstances.  The  second  fallacy 
of  the  test  by  boiling  is,  that  a cloud  resembling 
that  of  albumin  may  be  produced,  although  the 
urine  is  free  from  this  substance.  This  occurs 
when  the  acidity  of  the  urine  is  too  slight  to 
hold  the  earthy  phosphates  in  solution,  without 
the  aid  of  the  carbonic  acid  which  it  usually 
contains.  When  such  urine  is  boiled,  the  car- 
bonic acid  is  driven  off,  and  the  phosphates  are 
precipitated,  forming  a cloud  like  that  of  albumin. 
The  two  clouds  are  readily  distinguished  by  the 
addition  of  a drop  or  two  of  nitric  or  acetic 
acid,  when  if  due  to  phosphates  it  will  disappear 


ALBUMINURIA.  23 


by  solution ; but  if  caused  by  albumin  it  will 
remain.  If  an  excessive  quantity  of  nitric  acid 
be  added,  an  albuminous  cloud  may  also  clear 
up;  for  albumin  coagulated  by  heat  is  soluble 
in  strong  acid,  though  only  to  a slight  extent. 

Application  of  the  nitric-acid  test.  — Pour 
some  urine  into  a test-tube,  and  then  allow  about 
one-fourth  of  its  bulk  of  strong  colourless  nitric 
acid  to  trickle  slowly  down  the  side  of  the  tube,  so 
as  to  form  a layer  below  the  urine  without  mixing. 
Or  the  acid  may  be  put  in  the  test-tube  first, 
and  the  urine  poured  on  it.  Both  processes 
give  the  same  result.  If  albumin  be  present,  a 
haze  or  cloud  will  form  close  to  the  line  where 
the  liquids  meet. 

Fallacies  of  the  nitric-acid  test. — 1.  Albumin 
may  be  present  and  yet  escape  detection,  if  the 
nitric  acid  is  simply  poured  into  the  urine  and 
mixed  with  it,  as  is  sometimes  done.  For  if  there 
bo  too  much  or  too  little  acid,  acid-albumin 
is  formed  and  dissolved ; whereas,  if  the  liquids 
form  two  distinct  layers,  as  in  the  process  already 
described,  the  acid  gradually  mixes  with  and 
shades  off  into  the  urine,  so  .that,  at  a greater  or 
less  distance  from  the  line  where  they  join,  it  is 
certain  to  he  of  the  proper  strength  to  precipitate 
the  albumin.  2.  Albumin  may  be  supposed  to  be 
present  when  it  is  not,  from  the  formation  of  a 
cloud  by  the  precipitation  of  acid  urates  or  uric 
acid.  This  cloud  disappears  on  the  applica- 
tion of  heat : and  another  specimen  of  tho  urine 
tested  by  boiling  gives  no  cloud.  To  avoid  this 
fallacy,  it  is  common  to  employ  the  test  by 
boiling,  in  addition  to  that  by  nitric  acid. 
3.  The  third  fallacy  is  not  of  common  occur- 
rence. It  is  due  to  the  presence  of  fat  or  saponi- 
fied fats  in  the  urine.  Urine  containing  these 
when  simply  boiled  gives  no  cloud ; but  if  nitric 
acid  is  added  to  it  in  the  cold,  or  acetic  acid 
when  it  is  hot,  the  fatty  acids  are  precipitated 
and  form  a cloud  resembling  albumin.  This  is 
distinguished  by  not  being  formed  if  along  with 
dilute  acetic  acid  some  ether  is  added  to  the 
urine  before  boiling;  the  ether  retaining  the 
fatty  acids  in  solution.  If  the  precipitate  pro- 
duced by  nitric  acid  be  collected  on  a filter,  and 
treated  with  ether,  it  will  be  dissolved,  while  an 
albuminous  precipitate  will  not.  Copaiba,  which 
can  be  recognised  by  its  smell,  sometimes  causes 
an  opalescence  in  the  urine,  which  is  increased 
by  nitric  acid,  but  is  removed  by  heat. 

Additional  tests  for  albumin. — "When  urine 
contains  mucus,  which  would  render  the  presence 
of  an  albuminous  cloud  obscure,  a solution  of 
ferrocyanide  of  potassium  followed  by  acetic  acid 
should  be  added : this  will  produce  a cloud  if 
albumin  be  present,  while  it  rather  clears  up  a tur- 
bidity due  to  mucus.  A solution  of  pyrophosphate 
of  soda  also  precipitates  albumin.  If  a drop  of 
albuminous  urine  be  poured  into  a test-tube 
containing  one  or  two  drachms  of  a saturated 
solution  of  picric  acid,  a precipitate  is  formed. 
These  tests  are  sometimes  useful  in  determining 
the  presence  of  albumin  in  the  urine  in  doubtful 
cases. 

Quantitative  Estimation  of  Albumin. — There 
are  three  methods  in  common  use  for  this  pur- 
pose. The  first  is  easy  but  inexact.  It  consists 
in  boiling  the  urine  with  dilute  acetic,  acid  in  a 
test-tube,  allowing  the  coagulum  to  subside  for 


a definite  number  of  hours,  and  then  estimating 
the  proportion  it  bears  to  the  quantity  of  urine 
boiled,  for  example,  a fourth,  a third,  &c.  The 
second  is  the  most  exact,  but  is  troublesome. 
It  is  like  the  first ; but  the  urine  is  carefully 
measured  before  boiling,  and  the  amount  of 
coagulum  is  ascertained  by  collecting  it  on  a 
weighed  filter,  washing,  drying,  and  again  weigh- 
ing it.  The  third  method  is  easy  and  tolerably 
exact.  A tube  of  known  length  is  filled  with 
urine  and  placed  in  a polarizing  apparatus.  From 
the  amount  of  rotation  which  the  polarized  ra_' 
undergoes  in  passing  through  the  urine,  the 
amount  of  albumin  it  contains  may  be  calcu- 
ated.  A fourth  method  has  recently  been  re- 
commended by  Dr.  W.  Roberts.  It  consists  in 
diluting  the  urine  with  water  until  it  gives  a 
haze  on  the  addition  of  nitric  acid,  which  does 
not  become  visible  until  between  one-half  and 
three-quarters  of  a minute  after  the  acid  has 
been  added.  This  dilute  urine  contains  0'0034 
per  cent.,  or  0’01-lS  grain  of  albumin  per  fluid 
ounce  ; and  from  the  degree  of  dilution  required 
the  amount  contained  in  the  urine  may  be 
calculated. 

Pathologt. — Albuminuria  has  been  said  to 
occur  in  consequence  of  various  conditions ; c.g., 
changes  in  the  blood,  changes  in  the  circulation, 
changes  in  the  kidneys.  Thus  abstinence  from 
salt,  or  a diet  of  eggs  alone,  is  said  to  produce 
albuminuria  by  altering  the  constitution  of  tht 
blood  ; and  an  alteration  in  this  fluid  is  sup 
posed  to  be  partly  the  cause  of  the  albuminuria 
observed  in  high  fevers,  scarlatina,  diphtheria, 
and  osteo-malacia.  The  albuminuria  of  heart- 
disease  depends  on  changes  in  the  circulation, 
and  that  of  nephritis  on  alterations  in  the  kidney. 
In  order  to  distinguish  more  clearly  between  the 
different  kinds  of  albuminuria  we  may  divide 
them  into — 1st,  true  albuminuria,  in  which  serum- 
albumin  appears  in  the  urine  ; 2ndl j,  false  albu- 
minuria, in  which  some  other  albuminous  body, 
but  not  serum-albumin,  is  present.  In  true 
albuminuria  there  is  always  some  change  either 
in  the  circulation  through  the  kidney,  or  in  the 
structure  of  the  kidney  itself.  In  false  albumi- 
nuria the  albuminous  body  passes  out  through 
the  kidney,  without  there  being  any  alteration 
either  in  its  circulation  or  structure. 

The  chief  albuminous  bodies  occurring  in  false 
albuminuria  are  htemoglobin,  egg-albumin,  and 
Bence-Jones’s  albumin.  Haemoglobin  occurs  in 
the  urine  whenever  blood  is  present  in  it  ( see 
Hjematcria),  in  which  case  it  is  contained  in 
the  corpuscles  ; or  it  may  occur  free  {see  H-aaiA- 
tinuria),  the  blood-corpuscles,  while  still  circu- 
lating in  the  vessels,  having  undergone  solution. 
This  may  result  from  the  inhalation  of  arse- 
niuretted  hydrogen,  or  from  the  introduction 
of  bile-acids  or  of  a large  quantity  of  water  intc 
the  veins.  Haemoglobin  is  also  found  in  the 
urine  in  paroxysmal  hpematinuria,  but  the  cause 
of  the  solution  of  blood-corpuscles  in  this  disease 
is  unknown.  Egg-albumin  is  excreted  by  the 
kidneys,  and  appears  in  the  urine,  whenever  it  is 
injected  directly  into  the  circulation  or  under  the 
skin,  or  when  it  is  absorbed  unchanged  from  the 
stomach  or  rectum.  "When  taken  into  the  sto- 
mach it  is  usually  completely  digested  before  it 
undergoes  absorption ; but  when  taken  in  such 


«1  ALBUMINURIA. 

largo  quantities  that  the  whole  of  it  cannot  be 
digested,  part  of  it  is  absorbed  unchanged  and  is 
excreted  in  the  urine.  Thus  a diet  consisting 
exclusively  of  eggs,  especially  when  continued  for 
several  days,  produces  false  albuminuria,  and 
large  enemata  of  eggs  have  a similar  effect  in 
animals  and  probably  also  in  man.  Bence-Jones’s 
albumin  is  of  very  rare  occurrence.  It  is  found 
in  osteo-malacia.  Like  egg-albumin,  it  is  ex- 
creted by  the  kidneys  when  it  is  injected  into 
the  circulation  or  in  large  quantities  into  the 
intestine.  It  is  almost  if  not  quite  identical  with 
the  hemialbumose,  which  Kiihne  finds  to  be  one 
of  the  products  of  imperfect  digestion.  It  seems 
probable  that  those  cases  of  albuminuria  which 
appear  to  depend  on  imperfect  digestion  are  due 
to  the  passage  into  the  systemic  circulation  of 
albuminous  bodies,  which  have  not  undergone 
the  proper  transformation  in  the  alimentary 
canal  or  liver. 

In  true  albuminuria  there  must  be  some 
change,  either  in  the  circulation  or  structure  of 
the  kidney,  for  serum-albumin  differs  from  the 
other  albuminous  bodies  just  mentioned,  in  not 
being  excreted  by  the  healthy  kidney.  Some  re- 
gard the  alterations  in  circulation  which  produce 
albuminuria  as  of  two  kinds : — (a)  increased  pres- 
sure of  blood  in  the  renal  arteries  ; (b)  increased 
pressure  in  the  renal  veins.  Increased  pressure 
in  the  arteries  may  depend  either  on  general  high 
arterial  tension,  or  upon  an  increased  local  supply 
of  blood  to  the  kidney,  owing  to  dilatation  of  the 
renal  arteries,  such  as  follows  division  of  their 
vaso-motor  nerves.  Experiments  seem  to  show, 
however,  that  increased  tension  in  the  renal 
arteries  does  not  produce  albuminuria,  and  that 
the  only  change  in  circulation  which  will  cause 
it  is  increased  pressure  in  the  renal  veins.  Con- 
gestion of  the  renal  veins  may  be  produced  by 
ligature  of  the  renal  arteries,  and.  when  the 
flow  of  blood  through  the  kidney  is  temporarily 
arrested  by  ligature  of  the  artery,  the  urine 
secreted  after  the  removal  of  the  ligature  is 
albuminous.  Venous  congestion  of  the  kidney 
also  occurs  whenever  the  onward  flow  of  venous 
blood  is  obstructed,  either  by  a ligature  on  the 
renal  veins ; by  the  pressure  of  a tumour  or  of 
the  pregnant  uterus  upon  them  or  the  vena  cava  ; 
by  disease  of  the  liver  obstructing  the  vena  cava; 
or  by  disease  of  the  heart  or  lungs,  such  as  tricus- 
pid or  mitral  regurgitation,  or  chronic  bronchitis 
and  emphysema.  The  temporary  albuminuria 
sometimes  observed  after  cold  bathing  may  also 
be  due  to  venous  congestion  ; and  it  is  probable 
that  albuminuria  consequent  upon  lesions  of  the 
nervous  system  is  due  rather  to  the  changes 
which  these  produce  in  the  circulation  than  to 
any  direct  action  of  the  nerves  upon  the  tissues 
of  the  kidney  itself.  The  albuminuria  observed 
after  varnishing  the  skin  is  probably  due  to  the 
retention  of  some  substance  which  acts  as  a 
poison.  The  structural  changes  in  the  kidney 
which  cause  albuminuria  are  acute  and  chronic 
inflammation,  waxy  degeneration,  and  cirrhosis. 
See  Beight’s  Disease. 

Treatment. — In  false  albuminuria  where  hae- 
moglobin appears  in  the  urine,  the  treatment  in- 
dicated is  to  counteract  the  solution  of  blood-cor- 
puscles ; and  for  this  purpose  quinine  is  very 
ofleu  useful.  When  other  kinds  of  albumin  ap- 


ALCOHOL. 

pear  in  the  urine,  and  are  probably  due  to  im- 
perfect digestion,  the  treatment  is  to  give  some 
artificial  digestive  fluid.  Arsenic  is  aLso  useful. 
Regarding  those  cases  of  osteo-malacia  in  which 
Bence-Jones’s  albumin  occurs,  we  unfortunately 
know  very  little. 

In  true  albuminuria,  depending  on  venous 
congestion,  the  obstacle  to  free  circulation 
should  be  removed,  if  possible ; and  conges- 
tion lessened,  both  by  drawing  the  blood  from 
the  interior  to  the  surface  of  the  body,  and  by 
causing  contraction  of  the  renal  vessels.  The 
blood  may  be  drawn  from  the  interior  to  the 
surface  by  means  of  warm  baths,  hut  in  some 
cases  they  prove  injurious  rather  than  useful, 
and  the  employment  of  a wet  pack,  which  has 
a similar  effect  on  the  distribution  of  blood 
without  exciting  the  heart,  is  to  be  preferred. 
Cupping  over  the  kidneys  is  serviceable  : it  pro- 
bably acts  by  causing  reflex  contraction  of  the  renal 
•vessels  rather  than  by  actually  draining  blood 
away  from  them.  The  tone  of  the  renal  vessels 
may  he  increased  by  the  employment  of  digitalis 
(see  Diuretics)  ; and  this  drug  is  useful  even 
when  no  cardiac  disease  is  present,  although  its 
good  effects  are  still  more  marked  when  the  con- 
gestion is  dependent  on  disease  of  the  heart  . The 
constant  drain  of  albumin  from  the  body  occa- 
sions anaemia,  whicb  not  only  produces  many 
unpleasant  symptoms,  but  tends  to  cause  fatty 
degeneration  of  various  organs,  from  which  there 
is  no  reason  to  believe  that  the  kidneys  are 
exempt.  The  administration  of  iron,  therefore, 
is  the  chief  remedy  in  structural  disease  of  the 
kidneys,  and  it  is  useful  by  diminishing  or  re- 
moving the  symptoms  of  anaemia  and  the  ten- 
dency to  fatty  degeneration  consequent  thereon, 
and  also  by  increasing  the  tone  of  the  vessels, 
thus  diminishing  the  loss  of  albumin. 

T.  Lauder  Bruxtox. 

ALCOHOL.  Synon.  : Ethyl-Alcohol ; Vitiic 
Alcohol ; Spirit  of  Wine  (C  H,;6). — Alcohol  is  the 
product  of  a process  of  fermentation  induced  by 
the  action  of  a microscopic  fuDgus,  Yeast,  upon 
certain  kinds  of  sugar,  especially  grape  sugar, 
but  also  upon  that  derived  from  starch  of 
any  description,  and,  in  the  same  manner,  upon 
milk  sugar.  In  this  process  a peculiar  meta- 
morphosis takes  place,  by  which  alcohol  and  car- 
bonic acid  are  produced  in  considerable  amount, 
together  with  very  minute  quantities  of  succinic 
acid,  glycerine,  and  other  bodies. 

Alcohol  may  also  he  produced  synthetically 
from  its  elements,  carbon,  hydrogen,  and  oxygen. 

As  alcohol  is  very  volatile,  boiling  at  172° 
Fahr.  (78°  G.),  it  may  readily  be  separated  by 
distillation  from  the  water  with  which  it  is  at 
first  combined.  Other  means  must  be  resorted 
to,  however,  in  order  to  separate  the  very  ulti- 
mate particles  of  this  water,  as  a strong  attrac- 
tion exists  between  the  two  liquids. 

Alcohol,  diluted  with  about  95  per  cent,  of 
water,  and  subjected  to  the  action  of  another 
microscopic  fungus,  is  oxidised  into  aldehyd  and 
acetic  acid. 

Piiysioj.ogical  Effects.  — Applied  to  the 
skin,  alcohol  produces  a sensation  of  coolness, 
due  to  its  rapid  evaporation  ; hut,  if  the  appli- 
cation be  continued  sufficiently  long,  irritation 


ALCOHOL. 


'js  ex sited.  This  latter  effect  ensues  imme- 
diately if  alcohol  is  brought  into  contact  with 
a mucous  membrane.  Its  strong  attraction  for 
water  seems  to  be  the  chief  cause  of  this  action. 

Alcohol  is  a powerful  antiseptic,  probably  from 
the  fact  that  it  is  capable,  even  when  diluted, 
of  preventing  the  development  of  septic  germs, 
such  as  vibrios  and  bacteria,  as  well  as  of 
paralysing  the  activity  of  those  already  formed. 

There  is  scarcely  any  other  therapeutical  agent 
the  internal  action  of  which  varies  so  much  ac- 
cording to  the  dose  given.  In  small  quantity, 
and  slightly  diluted  with  water,  alcohol  promotes 
the  functional  activity  of  the  stomach,  the  heart, 
and  the  brain  ; whilst  a like  quantity,  largely 
diluted,  exerts  but  a limited  influence  upon  these 
organs : if,  however,  the  dose  of  alcohol  be  often 
repeated,  it  is  readily  assimilated ; and,  becoming 
diffused  throughout  the  system,  undergoes  com- 
bustion within  the  tissues  of  the  body,  imparts 
warmth  to  them,  and  yields  vital  force  for  the 
performance  of  their  various  functions.  Simul- 
taneously with  this  consumption  of  alcohol,  the 
.body  of  the  consumer  is  often  observed  to  gain  in 
fat — a circumstance  due  to  simple  accumulation, 
the  fat  furnished  by  the  food  remaining  unburned 
in  the  tissues,  because  the  more  combustible 
alcohol  furnishes  the  warmth  required,  leaving 
uo  necessity  for  the  adipose  hydrocarbon  to  be 
used  for  that  purpose.  A quantity  of  100  cubic 
centimetres  of  alcohol  per  diem  (about  three  and 
a-kalf  fluid  ounces) — equivalent  to  about  ono  litre 
of  Ehine  wine  of  medium  strength — is  sufficient 
to  supply  between  one-third  and  one-quarter  the 
whole  amount  of  warmth  requisite  for  the  human 
body  during  the  twenty-four  hours.  The  warmth 
so  supplied  cannot  be  measured  by  a thermometer, 
however,  any  more  than  can  that  furnished  by 
the  internal  combustion  of  other  hydrocarbons, 
such  as  the  oils  or  sugars.  The  subjective  im- 
pression of  increased  warmth  usually  experienced 
after  taking  a dose  of  any  alcoholic  liquid  is 
deceptive,  and  is  only  due  to  an  irritation  of  the 
■nerves  of  the  stomach,  and  to  the  increased  cir- 
culation of  blood  through  the  cutaneous  vessels, 
particularly  those  of  the  head. 

Doses  somewhat  larger,  but  still  sufficiently 
moderate  not  to  cause  intoxication,  act,  for  the 
most  part,  in  the  same  way  ; but,  as  an  additional 
effect,  they  produce  a distinct  decrease  of  tem- 
perature in  the  blood,  lasting  half-an-hour  or 
more.  As  far  as  the  matter  has  hitherto  been  ex- 
plained, this  latter  effect  depends  upon  a directly 
depressing  influence  exerted  by  alcohol  upon  the 
working  cells  of  the  body,  and  upon  a temporary 
paralysis  of  the  vaso-motor  nerves.  The  latter  is 
followed,  of  course,  by  dilatation  of  the  super- 
ficial vessels,  particularly  those  of  the  head,  in 
consequence  of  which  a larger  surface  of  blood 
is  exposed,  and  the  loss  of  heat  by  irradiation 
into  the  air  is  increased,  the  temperature  of  the 
circulating  fluid  being  thus  lowered  ; whilst,  the 
combustion  curried  on  by  the  cells  being  re- 
tarded, the  generation  of  heat  from  this  source 
is  diminished.  The  quantity  of  carbonic  acid 
eliminated  is  thus  diminished,  as  is  also  the 
amount  of  urea  excreted.  After  the  organism  has 
become  inured  to  the  action  of  alcohol,  these 
effects  upon  the  temperature  of  the  blood  are 
ies3  distinctly,  or  not  at  all,  marked. 


2d 

The  agreeable  excitement  at  first  caused  bv 
such  doses  of  alcohol  is  succeeded  by  a reaction, 
characterised  by  lassitude  and  drowsiness,  the 
latter  condition  usually  lasting  longer  than  the 
previous  one  of  exhilaration. 

The  symptoms  of  intoxication  produced  by 
large  doses  of  alcohol  are  sufficiently  well 
known.  "When  the  abnormal  condition  of  excite- 
ment in  the  brain  induced  by  this  stimulant 
has  been  kept  up,  almost  without  intermission, 
for  a length  of  time;  or  when  it  is  suddenly 
withdrawn  after  the  organ  has  been  long 
subjected  to  it ; the  disturbance  brought  about 
is  so  great  and  persistent  as  to  result  in  a 
complete  overthrow  of  the  reasoning  faculties, 
"and  the  condition  known  as  delirium,  tremens 
ensues.  At  the  same  time  that  this  pernicious 
influence  is  being  exerted  upon  the  cells  of  the 
brain,  fatty  accumulations  may  take  place  in 
other  organs,  particularly  in  the  liver,  heart,  and 
connective  tissues ; the  biood-vcssels  become 
diseased  ; and,  in  many  instances,  cirrhosis  of 
the  liver,  kidneys,  and  meninges  makes  its 
appearance,  as  part  of  the  general  disorder  of 
nutrition.  The  shrinking  of  connective  tissue, 
characteristic  of  this  last-mentioned  complica- 
tion, seems  to  depend  upon  the  direct  irritation 
caused  by  the  presence  of  un-oxidised  alcohol. 

Under  ordinary  circumstances,  and  after  the 
consumption  of  moderate  quantities  of  alcohol, 
only  slight  traces  of  it  are  to  be  detected  in  the 
urine,  and  none  whatever  in  the  breath.  Pure 
alcohol  imparts  no  taint  to  the  exhalations  of 
the  body;  the  ethers  and  fusel  oils,  on  tho 
other  hand,  do  so  by  reason  of  their  being 
less  readily  combustible.  It  is  very  likely  that 
alcohol  is  completely  oxidised  into  carbonic 
acid  and  water  during  the  process  of  assimila- 
tion ; at  least,  no  other  secondary  products 
resulting  from  its  disintegration  have  as  yet 
been  detected. 

Therapeutical  Applications. — There  can  be 
no  doubt  but  that  a healthy  organism,  supplied 
with  sufficient  food,  is  capable  of  performing  all 
its  regular  functions  without  requiring  any 
specially  combustible  material  for  the  generation 
of  heat  and  the  development  of  vital  force.  But 
the  case  assumes  a different  aspect  when,  in 
sickness,  it  transpires  that,  while  the  metamor- 
phosis of  tissue  goes  on  with  its  usual  activity, 
or  with  increased  energy,  as  happens  in  many 
diseases,  the  stomach,  refusing  to  accept  or  digest 
ordinary  food,  fails  to  supply  material  to  com- 
pensate for  this  waste.  Here  it  is,  then,  that  a 
material  which  can  be  most  readily  assimilated 
by  the  system,  and  which,  by  its  superior  com- 
bustibility, spares  the  sacrifice  of  animal  tissue, 
is  especially  called  for ; and  such  a material  we 
have  in  alcohol.  Small  but  oft-repeated  doses 
of  alcohol,  largely  diluted  with  water,  are  gene- 
rally well  tolerated  by  the  weakest  stomach  ; and, 
thus  given,  the  absorption  and  oxidation  of  the 
spirit  goes  on  without  difficulty  or  effort  on  the 
part  of  the  patient’s  system. 

According  to  the  experiments  of  Dr.  Frank- 
land  and  others,  the  burning  of  l’O  gramme  of 
alcohol  yields  sufficient  heat  to  raise  the  tem- 
perature of  seven  litres  of  water  1°C. ; and  the 
burning  of  DO  gramme  of  cod-liver  oil  suffice-! 
for  nine  litres.  Now,  in  taking  three  table- 


ALCOHOL. 


<2t> 

spoonfuls  of  the  oil  daily,  we  yield  about  the 
same  amount  of  warmth  to  the  body  as  is  given 
by  four  table-spoonfuls  of  absolute  alcohol — the 
quantity  contained  in  a bottle  of  light  claret  or 
hock.  The  oil,  however,  is  digested  and  oxidised 
by  the  organs  of  the  body  with  difficulty,  while, 
for  the  assimilation  of  the  alcohol,  scarcely  any 
exertion  of  the  working  cells  is  required.  Thus, 
it  can  be  demonstrated  by  calculation,  as  above- 
mentioned,  that  heat-producing  material,  suffi- 
cient to  supply  nearly  one-third  the  whole 
amount  of  warmth  required  by  the  body  within 
twenty-four  hours,  is  offered  in  a quantity  of 
100  grammes  (about  three  and  a-half  fluid 
ounces)  of  alcohol.  In  this  sense  alcohol  is  a. 
food  ; for  we  must  regard  as  food  not  only  the 
building  material,  but  all  substances  which,  by 
their  combustion  in  its  tissues,  afford  warmth 
to  the  animal  organism,  and,  by  so  doing,  con- 
tribute towards  the  production  of  vital  force,  and 
keep  up  the  powers  of  endurance.  Alcohcl, 
therefore,  diluted  with  at  least  90  per  cent,  of 
water  (in  any  convenient  form  of  beverage),  may 
be  given  with  advantage,  in  small  but  oft-re- 
peated doses,  in  most  of  the  acute  and  chronic 
diseases  where  it  is  desired  to  sustain  the 
strength  of  the  patient,  hut  where  at  the  same 
time  the  digestive  organs,  from  any  cause,  refuse 
to  tolerate  a more  substantial  form  of  nourish- 
ment, at  least  in  quantities  that  would  answer 
the  necessities  of  the  case.  In  such  cases 
it  is  certainly  not  sufficient  to  call  alcohol 
merely  a stimulant.  If  alcohol  served  here  only 
in  the  quality  of  a stimulant,  its  effect  would 
soon  pass  away,  leaving  the  patient  more  ex- 
hausted than  ever  ; for  the  human  organism  is 
so  constituted  that  it  cannot  he  driven  to  per- 
form its  functions  by  the  application  of  mea- 
sures that  simply  stimulate,  without  supplying 
some  new  force  to  take  the  place  of  that  put 
forth  by  the  organs  of  the  body  under  the  im- 
pulse of  excitemont.  To  take  a familiar  illus- 
tration, alcohol  thus  given  stimulates  no  more 
than  does  the  easily  burning  coal  which  we  put 
in  small  quantities  upon  a languid  fire,  to  pre- 
vent its  going  entirely  out. 

Medium  doses  act  powerfully  upon  the  brain 
and  heart,  and  are  therefore  serviceable  as  real 
etimulants  in  cases  where  it  is  desirable  to  excite 
the  cerebral  and  circulatory  systems  to  greater 
activity.  We  must  not  forget,  however,  that, 
while  exciting  this  increased  activity,  such  doses 
do  not  elevate  the  temperature  of  the  body  ; on 
the  contrary,  where  the  effect  can  he  measured, 
it  is  found  that  they  depress  it  a little.  By  con- 
tinuing to  exhibit  such  doses,  we  can  sometimes 
(in  erysipelas,  puerperal  peritonitis,  and  similar 
diseases)  lower  febrile  heat  by  alcohol  where  even 
quinine  proves  ineffectual.  The  consequences  of 
this  decline  of  fever-heat  are  an  immediate  re- 
storation to  consciousness,  if  delirium  or  stupor  has 
been  present ; and,  in  any  case,  a general  improve- 
ment in  the  feelings  of  the  patient.  Todd  and  his 
school,  before  the  application  of  the  thermometer, 
called  this  the  effect  of  stimulus , while  in  reality 
the  improvement  is  due  almost  entirely  to  the 
withdrawal  or  diminution  of  febrile  disturbance. 
As  fever  patients  can  tolerate  large  quantities  of 
alcohol  without  showing  any  sign  of  intoxica- 
tion. it  is  allowable,  and  sometimes  even  neces- 


sary, to  rise  in  the  scale  of  doses  beyond  the 
limits  ordinarily  prescribed. 

Of  late  years  alcohol  has  been  given  during 
the  night  to  hectic  phthisical  patients  as  a 
preventive  against  copious  and  exhausting  at- 
tacks of  sweating,  and  with  a gratifying  amount 
of  success.  Such  patients  certainly  tolerate  the 
remedy  much  better  than  has  hitherto  been 
generally  supposed.  It  need  hardly  be  said  that, 
in  cases  of  cardiac  excitement,  not  resulting  from 
fever,  alcohol  is  at  least  to  be  used  with  caution. 

Mode  of  Administration. — One  of  the  most 
important,  but  at  the  same  time  most  difficult, 
points  for  decision  is  the  exact  nature  and 
quality  of  the  alcoholic  drink  to  be  prescribed  or 
allowed  to  a patient,  who  may  require  alcohol 
in  some  form.  For  general  use,  a pure  Claret, 
Hock,  or  Mosel  wine  are  the  preparations  most 
to  he  recommended.  Cognac,  Champagne,  old 
Gin  or  Whisky,  and  the  heavier  Southern  wines, 
may  also  be  used  according  to  circumstances. 
But  whatever  drink  may  be  selected,  it  must  at 
least  be  free  from  fusel  oil  to  such  an  extent  that 
a healthy  man,  even  after  imbibing  a consider- 
able quantity,  will  not  feel  any  other  effects  than 
those  of  a pure  stimulus ; that  is  to  say,  an 
agreeable  exhilaration  of  spirits,  neither  accom- 
panied by  a sense  of  weight  in  the  head,  nor 
followed  by  that  persistent  overfilling  of  the 
cerebral  vessels  and  dulness  of  ideas  charac- 
teristic of  the  physiological  effects  of  fusel  oil. 

The  Fusel  O/ls  (so-called  from  their  oily  quali- 
ties) consist  chiefly  of  propyl,  butyl,  and  amyl 
alcohol,  of  which  the  last-named  forms  the  largest 
proportion.  In  order  to  examine  any  specimen 
of  alcohol  with  reference  to  its  purity  from 
theso  objectionable  constituents,  it  is  only  neces- 
sary to  rub  a few  drops  between  the  palms 
of  the  hands  for  half  a minute,  by  which  rapid 
evaporation  is  caused,  and  then  to  smell  the 
moist  spot  left  on  either  palm.  If  the  alcohol 
be  pure  no  odour  whatever  should  remain,  as 
ethyl  alcohol  evaporates  very  quickly;  amyl 
alcohol,  on  the  contrary,  is  much  less  volatile, 
and,  if  present  in  the  liquid,  will  not  have 
evaporated,  so  that  its  peculiar  and  unmistake- 
able  odour  will  remain  to  attest  its  presence  as 
an  impurity  in  the  specimen  examined. 

This  test  is  not  applicable  to  the  more  com- 
plicated liqueurs  and  wines,  as  these  all  contain 
certain  odoriferous  organic  principles  of  their 
own  that  might  disguise  the  smell  of  the  fusel 
oil.  The  inoffensive  quality  of  any  given  pre- 
paration, as  a wine  or  spirit,  can  only  be  relied 
upon  when  one  knows  by  experience  that  it  is 
pure ; and  then  it  should  always  be  obtained,  if 
possible,  from  the  same  source,  so  as  to  ensure 
uniform  purity. 

By  far  the  most  pernicious  of  all  the  ordinary 
drinks  in  use  is  the  spirit  obtained  from  potatoes, 
as  this  contains  the  largest  proportion  of  fusel 
oil.  Even  after  being  redistilled,  this  liquor  is  still 
tainted  with  the  poison  to  a fearful  extent  Of 
course,  wines  mixed  with  such  spirit  possess  tlio 
same  objectionable  qualities ; whilst  wines  made 
from  must  to  which  potato-sugar  has  been  added 
are  likewise  tainted,  though  to  a less  degree.  It 
can  easily  be  demonstrated  by  experiments  upon 
animals,  that  amyl  alcohol  is  the  ageDt  to  the 
presence  of  which  the  extremely  poisonous 


ALCOHOL. 

action  of  many  drinks  upon  our  nerves  and  other 
organs  is  due.  All  distilled  drinks  ma.de  from 
other  sources  than  from  grapes  contain  it  to  a 
greater  or  less  extent. 

To  facilitate  the  process  of  estimating  the 
quantity  of  any  particular  beverage  necessary  to 
1)9  administered  in  order  to  produce  a given 
effort,  a table  is  subjoined  showing  the  per- 
centage of  absolute  alcohol  contained  in  average 
specimens  of  the  different  kinds  of  wine,  beer, 
&c..  in  common  use. 

Absolute  Alcohol  contained  in — 

Kumiss  (a  fermented  liquor  made  from  whey)  is  from 
1 to  3 vol.  per  cent. 

German  Beer 1 is  from  3 to  5 vol.  per  cent. 

Hock  or  Claret  is  from  8 to  11  vol.  per  cent. 

Champagne  is  from  10  to  13  vol.  per  cent. 

Southern  Wines  (Port,  Sherry,  Madeira,  &c.)  is  from 
14  to  17  vol.  per  cent. 

Brandy  and  the  stronger  liqueurs  is  from  30  to  50  vol. 
per  cent. 

For  antipyretic  purposes  one  will  need  to  give 
an  adult  daily  not  less  than  the  equivalent  of 
fifty  cubie  centimetres  (about  two  fluid  ounces) 
of  absolute  alcohol,  in  divided  doses  within  an 
hour  or  two.  Taking  this  as  a starting-point, 
the  dose  suitable  for  each  individual  case  can 
be  estimated  accordingly. 

The  great  quantity  of  carbonic  acid  contained 
in  certain  1 sparkling  ’ wines  acts  upon  the  tem- 
perature of  a fever  patient  much  in  the  same 
favourable  manner  as  the  alcohol  itself,  and 
when  alcohol  is  to  be  taken  as  a food,  it  would 
seem  that  the  impregnation  with  carbonic  acid 
facilitates  its  absorption. 

All  that  has  been  stated  thus  far  with  regard 
to  the  use  of  alcohol  in  sickness  applies  to 
children  as  well  as  to  adults.  Of  course  no 
reasonable  person  would  accustom  healthy  chil- 
dren to  the  use  of  alcoholic  beverages ; hut,  in 
cases  of  disease,  really  good  and  pure  wine  or 
brandy  can  be  advantageously  employed,  even 
for  infants,  either  as  a stimulant , an  antipyretic, 
or  as  an  article  of  food,  according  to  circum- 
stances. 

For  external  use,  alcohol  has  been  superseded 
by  various  more  modern  agents,  of  which  car- 
bolic and  salicylic  acids  may  be  mentioned  as  the 
most  important.  In  this  connection  the  author 
cannot  omit  to  notice  one  method  of  applying 
alcohol,  suggested  by  Dr.  Richardson,  namely, 
the  treatment  of  diphtheria  affecting  the  throat, 
by  means  of  the  inhaler,  which  projects  the  al- 
cohol-spray with  considerable  force  upon  the 
infected  mucous  membrane,  causing  it  to  pene- 
trate more  deeply  than  any  other  caustic  would 
te  likely  to  do.  C.  Binz  (Bonn). 

ALCOHOLIC  INSANITY.  See  Alcohol- 
ism, and  Insanity. 

ALCOHOLISM. — Definition. — This  term 
is  applied  to  the  diverse  pathological  processes 
and  attendant  symptoms  caused  by  the  excessive 
ingestion  of  alcoholic  beverages.  These  are 
very  different  if  a large  quantity  is  consumed  at 
once  or  at  short  intervals ; or  if  smaller  quanti- 
ties are  taken  habitually:  and  hence  they  are 

1 English  beer  will  contain  a little  more,  but  the 
writer  has  made  no  personal  examination  as  to  exactly 
how  much. 


ALCOHOLISM.  27 

subdivided  into  those  due  to  (a)  acute,  and  (6) 
chronic  alcoholism.  To  the  acute  forms  of  alco- 
holic poisoning  belong  the  acute  catarrh  of  the 
alimentary  mucous  membrane,  rapid  coma,  some 
cases  of  delirium  tremens,  and  certain  special 
forms  of  acute  insanity ; whilst  to  the  chronic 
class  are  referred  the  prolonged  congestions,  the 
fatty  and  connective-tissue  degenerations  of  the 
various  organs  and  tissues,  most  cases  of  deli- 
rium tremens,  nervous  affections  of  slow  onset 
and  course,  and  the  cachexiae,  which,  in  varying 
combinations,  attend  a continuously  immoderate 
consumption  of  alcohol. 

.Etiology. — That  ordinary  vinic  or  ethyl  al- 
cohol, in  any  and  every  shape,  is  a sufficient  ex- 
citing cause  of  such  chronic  affections  is  beyond 
a doubt ; moreover,  we  find  that  the  more  con- 
centrated the  form  in  which  it  is  taken,  the 
more  surely  and  rapidly  are  they  induced,  and 
that,  although  some  beverages  give  a greater 
liability  to  certain  forms  of  disease  than  to 
others,  yet  the  ultimate  tissue-changes  produced 
by  all  are  practically  similar,  and  of  a markedly 
degenerative  character,  The  purest  alcoholic 
fluids  will  also  induce  the  acute  forms  ; but 
some  of  the  phenomena  observed  in  the  worst 
cases  of  alcoholic  poisoning  have  been  referred, 
with  some  probability,  to  admixture  with  fusel 
oil,  essential  oil  of  wormwood,  coeculus  indicus, 
and  other  substances,  more  deleterious  even  than 
ordinary  alcohol  itself.  See  Alcohol,  and 
Absinthism. 

The  predisposing  causes  of  a sudden  debauch, 
such  as  festive  gatherings,  example  of  com- 
panions, desire  of  relief  from  anxiety  and  melan- 
choly, &e.,  scarcely  require  mention.  Acute 
alcoholic  coma  is  generally  due  to  the  rapid 
consumption  of  a large  quantity,  but  occasionally 
it  is  caused  by  taking  a smaller  quantity  in 
the  presence  of  some  special  condition,  such  as 
starvation,  prolonged  exposure  to  cold,  or  de- 
bilitating disease. 

Chronic  habitual  drinking  is  undoubtedly 
hereditary  in  many  cases  ; not  that  the  ancestors 
have  necessarily  been  drunkards,  but  that  the 
family  is  of  unstable  nervous  organisation,  and 
that  the  neurotic  taint  which  shows  itself  in 
other  members  in  such  affections  as  epilepsy, 
hysteria,  insanity,  is  manifested  in  these  cases 
by  an  intense  craving  for  alcohol.  Sometimes 
a pernicious  education,  by  festering  habits  of 
indulgence  in  early  youth,  has  led  to  subsequent 
excess  ; and  the  prescribing  of  stimulants  has 
occasionally  been  productive  of  similar  harm. 
In  the  experience  of  the  writer,  the  exhibition 
of  large  doses  in  fevers  and  acute  affections  has 
never  done  this — indeed,  in  several  instances, 
a great  dislike  to  stimulants  has  been  pro- 
duced— hut  the  custom  of  recommending  small 
quantities  to  young  people  and  women  as  a 
remedy  in  hysteria,  hypochondriasis,  neuralgia, 
and  allied  disorders,  or  to  relieve  the  fatigues 
incident  to  their  daily  life,  cannot  he  too 
strongly  protested  against.  The  effect  of  occu- 
pation is  very  marked.  Brewers,  publicans,  pot- 
men, and  others  who  trade  in  alcohol  are,  as  a 
class,  very  intemperate,  and  so  frequently  are 
commercial  travellers  (Thackrah).  Sedentary 
employments,  being  moro  monotonous,  are  more 
baneful  than  out-door  occupations.  Mechanics 


ALCOHOLISM. 


28 

drink  more  freely  than  agricultural  labourers ; 
whilst  night-labourers,  cabmen,  sailors  when  on 
shore,  brewers’  draymen,  navvies,  pitmen,  and 
puddiers  consume  an  enormous  amount  of  alco- 
holic fluids.  Social  influences,  such  as  domestic 
unhappiness,  rate  of  wages,  unhealthy  dwellings, 
bad  drinking  water,  or  an  intermittent  supply, 
are  important  factors  in  the  causation  of  drunken- 
ness. Under  some  circumstances,  alcoholic  ex- 
cesses do  less  injury  than  usual,  for  example, 
in  persons  whose  employment  leads  to  copious 
sweating,  or  necessitates  abundant  exercise  in 
a keen  air  ; and  some  constitutions  resist  their 
baneful  influence  to  a remarkable  extent. 

Pathology. — A large  amount  of  ardent  spirits 
nets  on  the  nerve-centres  as  a narcotic  poison, 
and  causes  rapid  death  by  coma.  Smaller  quan- 
tities produce  intoxication,  accompanied  with  or 
followed  by  an  acute  congestion  and  catarrh  of 
the  alimentary  canal,  especially  of  the  stomach 
and  duodenum.  Habitual  dram-drinking,  by 
altering  the  chemical  composition  of  the  blood, 
and  checking  the  normal  changes  of  its  cor- 
puscles, exerts  an  injurious  influence  on  the 
nutrition  of  the  tissues.  This  is  increased  by 
the  lessened  consumption  of  food,  and  by  the 
alterations  in  the  calibre  of  the  blood-vessels, 
set  up  at  first  by  a special  action  on  their  vaso- 
motor nerves,  and  afterwards  maintained  by  de- 
generation of  their  coats,  as  well  as  frequently  of 
the  heart  itself.  Moreover,  alcohol  probably  in- 
terferes directly  with  the  nutrition  of  the  cell- 
elements  of  the  various  organs  as  it  circulates 
through  them  ; and  it  retards  the  elimination  of 
effete  materials — carbonic  acid,  uric  acid,  and  urea. 

Anatomical  Characters. — (a)  Acute  Alcohol- 
ism.— Dr.  Beaumont  thus  describes  the  appear- 
ances which  he  observed  in  the  stomach  of 
Alexis  St.  Martin,  after  an  excess  of  alcoholic 
stimulants  : — ‘ Inner  membrane  morbid  ; con- 
siderable erythema,  and  some  aphthous  patches 
on  the  exposed  surface ; secretions  vitiated.’  On 
another  occasion,  ‘ Small  drops  of  grumous 
blood  exuded  from  the  surface,  the  mucous 
covering  was  thicker  than  common,  and  the 
gastric  juices  were  mixed  with  a large  propor- 
tion of  thick  ropy  mucus  and  muco-purulent 
matter  slightly  tinged  with  blood.’  The  post- 
mortem appearances  in  a case  of  rapid  coma 
in  a patient  at  King’s  College  Hospital,  after 
taking  three  pints  of  raw  whiskey,  were  : — in- 
tense injection  of  the  vessels  of  the  pyloric  end 
of  the  stomach  and  duodenum,  with  a peculiar 
blanching  of  the  mucous  membrane  between 
them,  giving  rise  to  a vivid  scarlet  arborescent 
appearance  on  a white  ground ; two  ounces 
of  bloody  serum  in  the  pericardial  sac,  and 
about  sixteen  ounces  in  the  right  pleural  cavity 
(the  left  being  obliterated  by  old'  adhesions) ; 
double  pneumonia  of  the  lower  lobes  ; extreme 
congestion  of  the  kidneys  ; and  engorgement  of 
the  large  veins  over  the  posterior  part  of  the 
brain.  Contrary  to  the  usual  statements,  no 
alcoholic  odour  could  be  detected  in  the  brain, 
and  there  was  no  increase  of  fluid  in  the  ven- 
tricles. The  heart,  liver,  and  kidneys  were  fatty ; 
but  these  changes  were  probably  of  older  date.  In 
similar  cases  Deverjie  has  noticed  a bright  rod 
colouring  of  the  pulmonary  tissue ; whilst  Tar- 
dieu  found  pulmonary  apoplexies  in  two  cases. 


and  meningeal  haemorrhages  in  five  others. 
Death  from  acute  delirium  tremens  leaves  no 
marked  characters ; meningitis  and  coarse  brain- 
lesions  are  extremely  rare,  whilst  pneumonia  is 
much  more  common.  After  repeated  attacks,  as 
well  as  in  old  drunkards,  fatty  degeneration  of  the 
viscera,  and  various  other  chronic  changes  are 
found. 

(6)  Chronic  Alcoholism. — The  amount  of  fat 
in  the  blood  is  increased,  cr  it  becomes  more 
visible.  Chronic  congestion  and  catarrh  of  the 
stomach,  leading  to  atrophy  of  the  gland-cells 
and  an  increase  m the  submucous  connective- 
tissue,  is  very  constant,  but  chronic  ulcer  is  not 
frequent.  Tho  liver  is  at  first  enlarged  from 
congestion,  and  may  continue  so  from  a sub- 
sequent infiltration  with  fat ; but  more  frequently 
it  shrinks  owing  to  cirrhosis.  Lobar  emphysema, 
chronic  bronchitis,  and  hypostatic  pneumonia 
are  common.  The  heart  is  flabby,  dilated,  and 
presents  fatty  infiltration  or  even  degeneration  of 
its  muscular  tissue ; but  it  may  be  hypertrophied, 
probably  as  a result  of  coexistent  disease  of  the 
kidneys.  The  arteries  and  endocardium  are 
studded  with  atheromatous  deposits ; the  capil- 
laries are  congested ; and  the  veins  varicose. 
The  kidneys  exhibit  the  fatty,  or,  more  com- 
monly, the  granular  form  of  Bright's  disease.  The 
muscles  are  pale  and  flabby,  and  even  in  the  bones 
formation  of  fat  takes  place  at  the  expense  of 
the  bony  texture.  The  nervous  centres  are 
atrophied  and  tough ; the  convolutions  are 
shrunken  ; the  nerve-cells  and  nerve-fibres  are 
wasted ; and  an  increased  amount  of  serous 
fluid  exists  in  the  ventricles  and  subarachnoid 
space.  The  abnormal  adhesion  of  the  dura 
mater  to  the  cranium,  the  large  Pacchionian 
bodies,  the  opaque  arachnoid,  and  the  thickened 
pia  mater,  all  testify  to  an  exaggerated  develop- 
ment of  fibrous  tissue.  Occasionally  haemor- 
rhage into,  or  softening  of,  the  br  ain,  consequent 
on  the  diseased  state  of  its  blood-vessels,  is  met 
with.  The  increase  of  connective-tissue  is  es- 
pecially marked  in  spirit-drinkers , and  explains 
the  emaciated  appearance,  prematurely  aged 
look,  sunken  cheeks,  and  wrinkled  countenance 
which  they  generally  present.  The  beer-  and  wine- 
drinkers,  on  the  contrary,  are  loaded  with  fat.  not 
only  in  the  viscera,  but  in  the  subcutaneous  tissue 
and  the  omenta ; and  hence  these  subjects  arc 
corpulent,  with  oily  skins  and  prominent  ab- 
domens, even  when  the  face  and  extremities 
are  wasted.  Gouty  deposits  are  also  frequent. 
These  differences,  however,  are  not  nearly  so 
absolute  as  is  maintained  by  many  writers. 
The  presence  of  a variable  amount  of  dropsy, 
a congested  pharynx,  chronically-inflamed  con- 
junctivas, turgid  capillaries,  and  occasionally 
papules  of  acne  rosacea  on  the  face,  complete 
the  morbid  anatomy  of  the  confirmed  toper. 
The  autopsy  in  alcoholic  insanity  discloses  no 
specific  characters. 

Symptoms. — 1.  Acute  Intoxication. — In  this 
state  the  successive  and  varying  mental  pheno- 
mena, the  disorders  of  common  and  special  sense, 
and  of  the  motor  apparatus,  are  well  know:;. 
These  are  followed  by  uneasy  sensations  and 
tenderness  in  the  epigastrium,  vomiting  or 
retching,  headache  and  vertigo,  with  dimness 
and  occasionally  yellowness  of  vision  on  stooping 


ALCOHOLISM. 


end  rising  again.  The  tongue  is  furred,  the 
appetite  is  lost,  and  there  is  a constant  feeling 
of  thirst.  The  urine  is  copious  and  pale,  but 
afterwards  becomes  scanty  and  loaded  with 
iithates.  The  countenance  is  sallow,  and  the 
general  lassitude  and  depression  are  very 
marked. 

2.  Acute  Alcoholic  Coma. — In  slight  cases 
of  this  condition  prolonged  drowsiness  is  the  chief 
symptom : but  in  the  more  severe  forms  the 
patient  is  quite  insensible  ; the  power  of  motion 
is  in  complete  abeyance;  the  breathing  is  ster- 
torous ; the  face  is  usually  pale,  the  features  re- 
maining symmetrical;  the  pupils  are  generally 
dilated,  though  thoy  may  be  contracted  or  even 
unequal ; the  pulse  is  slow  and  laboured ; the  skin 
feels  cold  and  clammy ; and  the  temperature  is  low 
— in  one  case  it  fell  to  92°  Fahr.  There  may 
bo  albuminuria  ; and  occasionally  the  urine  and 
feces  are  passed  involuntarily. 

o.  Chronic  Alcoholism. — The  earliest  symptoms 
of  this  form  are  muscular  tremors,  especially  on 
waking;  disturbed  sleep;  noises  in  the  ears;  dull 
headache ; occasional  vertigo ; and  disorders  of 
vision.  If  there  be  also  a foul  breath,  slightly- 
jaundiced  conjunctiva,  watery  eyes,  and  dabby 
features,  with  or  without  papules  of  acne  rosacea 
around  the  nose  and  mouth,  the  combination  is  very 
characteristic.  Irritative  dyspeptic  symptoms — 
the  vomitus  matutinus  of  Hufelami — and  the 
signs  of  commencing  or  actual  cirrhosis,  of 
Bright’s  disease,  or  of  fatty  heart,  frequently  co- 
exist. As  the  affection  advances,  the  insomnia 
and  tremors  increase;  the  mental  condition  be- 
comes impaired  ; a striking  deficiency  of  will  and 
uncertainty  of  purpose  are  noticeable  ; the  gait 
becomes  ataxic  ; and  the  patient  has  a constant 
feeling  of  dread  and  anxiety. 

4.  Delirium  Tremens. — This  form  of  alco- 
holism occasionally  supervenes  on  a single  de- 
bauch, but  it  much  more  frequently  affects  the 
chronic  drinker.  It  generally  comes  on  during 
a drinking-bout,  but  this  may  have  terminated 
before  the  attack  commences.  In  some  cases 
it  is  undoubtedly  determined  by  prolonged  ab- 
stinence from  food,  mental  distress,  surgical  in- 
jury, or  the  onset  of  an  acute  disease,  along 
with  the  ingestion  of  alcohol;  but  in  others  no 
cause  but  the  last  can  be  traced.  The  first 
stage  is  indicated  by  inability  to  take  food  ; 
marked  anxiety  and  restlessness ; tremor  of  the 
voluntary  muscles ; furred  and  tremulous  tongue; 
cool  skin,  which  is  frequently  bathed  in  perspira- 
tion; cold  hands  and  feet;  and  a soft  weak  pulse. 
There  is  complete  insomnia,  or  short  periods 
of  sleep  are  interrupted  by  terrifying  dreams, 
and  the  patient’s  nights  are  tormented  with 
visions  of  horrid  insects,  reptiles,  and  other  ob- 
jects pursuing  him  and  eluding  his  attempts  to 
escape  from  them  or  to  seize  them.  Illusions 
of  hearing  are  not  uncommonly  added  ; but  the 
sense  of  smell  is  much  more  rarely  involved. 
If  there  is  no  improvement,  these  not  only  haunt 
his  nights,  but  persist  in  the  day-time ; he 
becomes  moro  incoherent,  his  mental  alienation 
increases,  and  attempts  at  suicide  are  com- 
mon. The  pupils  are  now  minutely  contracted, 
but  there  is  no  intolerance  of  light.  The  pulse 
quickens,  and  is  very  feeble  or  even  dicrotic ; 
and  the  general  symptoms  become  more  marked. 


20 

A prolonged  sleep  may  occur  in  this  stage,  and 
the  disease  thus  terminate.  If  it  continues,  the 
strength  fails : the  pulse  becomes  small,  weak, 
and  thready ; the  tremor  increases  ; the  tongue 
gets  dry  and  brown  in  the  centre  ; persistent 
coma-vigil  and  subsultus  tendinum  come  on  ; the 
patient  talks  incessantly,  and  picks  at  the  bed- 
clothes ; and  death  is  ushered  in  by  a delusive 
calm,  or  takes  place  in  a paroxysm  of  violence. 
The  writer  has  known  cases  in  which  the  attack 
of  delirium  tremens  always  began  by  several 
severe  epileptic  fits. 

5.  Alcoholic  Insanity. — The  forms  of  insanity 
caused  by  alcoholism  are  acute  mania  and  melan- 
cholia, chronic  dementia,  and  oinomania.  In  the 
first  homicidal  impulses,  and  in  the  second  strong 
suicidal  tendencies,  due  to  actual  delusions  and, 
not  to  mere  passive  terrors,  are  added  to  the 
other  signs  of  delirium  tremens.  Oinomania  is 
a peculiar  form  of  insanity,  in  which  the  patient 
breaks  out  into  paroxysms  of  alcoholic  excess, 
attended  with  violent,  strange,  or  even  indecent 
acts,  due  to  apparently  uncontrollable  impulses. 
The  attack  lasts  a few  days,  and  is  succeeded 
by  a long  interval  of  sobriety  and  chastity. 
These  patients  have  generally  some  hereditary 
taint ; and  not  unfrequently  evidences,  though 
often  slight,  of  a morbid  mental  state  may  bo 
detected  in  the  intervals,  if  very  carefully  looked 
for.  See  Insanity. 

Complications. — Most  of  these  have  been 
pointed  out,  but  chronic  drinkers  are  especially 
liable  to  pneumonia  of  a low  type,  and  to  rapid 
phthisis.  Delirium  tremens  is  very  rarely  com- 
plicated with  meningitis;  acute  alcoholic  gastric 
catarrh  may  be  followed  by  jaundice  ; and  cere- 
bral haemorrhage  may  come  on  in  a drunken  fit. 
Temporary  albuminuria  is  occasionally  caused 
by  the  ingestion  of  large  quantities  of  spirits, 
and  even  of  beer. 

Diagnosis. — The  diagnosis  of  acute  alcoholic 
gastric  catarrh,  of  insanity  from  alcohol,  and  of 
oinomania  depends  on  obtaining  a true  history. 
Acute  alcoholic  coma  can  only  be  diagnosed 
with  certainty  by  emptying  tho  stomach  and 
examining  its  contents.  Mere  odour  of  the 
breath  is  quite  fallacious ; and  the  writer  attaches 
but  little  importance  to  the  state  of  the  pupils, 
or  to  the  general  features  of  the  coma.  Convul- 
sions sometimes  usher  in  the  condition ; and 
apoplexy  may  arise  from  the  accidental  rupture 
of  a blood-vessel  whilst  a person  is  drunk. 
Opium-poisoning  can  cnly  be  satisfactorily  elimi- 
nated by  examining  the  contents  of  the  stomach. 
Urtemic  poisoning  may  be  diagnosed  by  testing 
the  urine,  though  hero  an  element  of  uncer- 
tainty is  introduced  by  the  occasional  occurrence 
of  albuminuria  in  alcoholic  cases ; the  pre- 
sence of  hypertrophy  of  tho  heart,  of  dropsy, 
of  easts  in  the  urine,  or  other  changes  typical  of 
Bright’s  disease,  must  decide  the  question.  De- 
lirium tremens  is  occasionally  separated  with 
difficulty  from  some  forms  of  insanity  not  caused 
by  drink;  but  in  these  cases  delusions,  not  mere 
terrors  or  hallucinations,  are  of  primary  im- 
portance. The  delirium  of  acute  fevers  and 
pneumonia  may  be  mistaken  for  delirium 
tremens  ; but  the  pyrexia,  history  of  the  case, 
and  physical  condition  of  the  patient  will  guide 
to  a correct  diagnosis  if  the  possibility  of  error 


i»  ALCOHOLISM, 

is  remembered.  Chronic  alcoholism  has  been 
mistaken  for  other  chronic  nervous  affections, 
such  as  locomotor  ataxy,  chronic  softening  and 
multiple  sclerosis  of  the  nerve-centres,  para- 
lysis agitans,  chronic  tremors  from  metallic 
poisons,  senile  dementia,  and  commencing  general 
paralysis.  In  all  these  maladies,  special  symp- 
toms are  present,  besides  those  common  to  them 
and  to  chronic  alcoholism. 

Prognosis. — In  the  acute  forms  of  alcoholism 
I he  prognosis  is  favourable  so  far  as  the  imme- 
diate attack  is  in  question.  In  acute  coma,  the 
patient  generally,  but  by  no  means  invariably, 
rallies  from  the  state  of  insensibility ; but  he  may 
die  from  the  supervention  of  a very  rapid  pneu- 
monia. The  prognosis  in  delirium  tremens  is 
favourable  in  young  subjects  ; but  its  gravity 
increases  •with  every  attack,  and  with  the  co- 
existence of  disease  of  the  viscera,  especially  of 
the  heart,  liver,  or  kidneys.  Patients  with 
marked  symptoms  of  fatty  heart,  or  in  whom 
pneumonia  sets  in,  but  rarely  recover.  Chronic 
alcoholism  may  be  temporarily  arrested ; but 
the  ultimate  issue  is  unfortunately  as  a rule 
only  too  certain,  for  the  habit  is  in  most  cases 
too  strong  to  be  broken  off,  or  even  to  be 
checked  for  any  lengthened  period.  Mental 
impairment,  persistent  tremors,  ataxy,  and  signs 
of  coarse  brain-lesions,  are  especially  significant 
of  a speedy  termination. 

Treatment. — The  acute  gastric  catarrh  is 
most  rapidly  subdued  by  washing  out  the 
stomach  with  copious  draughts  of  tepid  water, 
and  then  giving  a saline  purge.  All  forms  of 
alcohol  should  be  rigidly  abstained  from;  and 
the  diet  must  bo  simple,  and  taken  in  a fluid 
form  for  a day  or  two.  Passive  exercise  in  the 
open  air,  or,  if  the  patient  be  vigorous,  a brisk 
ride  on  horseback,  is  very  beneficial. 

In  cases  of  acute  coma  the  stomach  should  be 
at  once  emptied  by  means  of  the  stomach-pump. 
Cold  affusion,  followed  by  energetic  friction  and 
the  application  of  bottles  filled  with  warm  water, 
so  as  to  keep  up  the  temperature,  will  generally 
revive  the  patient.  Galvanism,  in  the  form  of 
the  interrupted  current,  may  often  be  employed 
with  advantage.  If  the  patient  be  strong,  a 
smart  purge,  or,  if  weak,  a milder  one,  will  be 
all  the  after-treatment  that  is  necessary. 

Delirium  tremens  must  be  treated  differently 
in  the  young  and  in  the  old.  In  first  attacks 
in  young  subjects,  complete  abstention  from  al- 
cohol, light  and  easily  assimilated  food  (milk  diet), 
moderate  purgation,  and  occasionally  antimony  in 
doses  of  one-eighth  of  a grain,  carefully  watched, 
have  been  most  efficacious  in  the  writer’s  hands. 
If  the  patient  has  two  or  three  restless  nights  in 
succession,  bromide  of  potassium  (thirty  grains), 
or  chloral  hydrate  (twenty  grains),  may  he  given 
at  intervals  of  four  hours,  until  sleep  is  pro- 
cured ; hut  as  the  disease  is  spontaneously 
curable,  sedatives  must  not  be  pushed.  An  ex- 
perienced attendant  should  be  always  present, 
but  no  form  of  mechanical  restraint  j s permissible. 
In  older  cases,  a mild  purge  should  begin  the 
treatment;  and  light  but  very  nourishing  food 
should  be  administered  at  short  intervals.  Milk, 
beef-tea,  raw  eggs  beaten  up  with  milk,  strong 
soups,  and  such  articles  are  to  be  given  freely ; 
when,  by  careful  management  and  good  nursing, 


ALEPPO  EVIL. 

a very  severe  attack  may  be  tided  over,  and 
natural  sleep  will  return  in  from  three  to  fivo 
days.  The  early  administration  of  sedatives  is 
to  be  deprecated,  but  should  the  restlessness 
persist,  in  spite  of  careful  and  assiduous  feed- 
ing, a full  dose  of  laudanum  (in  xxx. — xl.)  at 
bed-time  is  of  great  value.  In  the  absence  of 
albuminuria,  lung-complications,  or  any  sign 
of  failure  of  the  heart’s  action,  the  writer  prefers 
this  drug  to  other  sedatives.  If  the  opium 
alone  fail,  its  combination  with  an  alcoholic 
stimulant  (brandy,  whisky,  or  stout ) often  suc- 
ceeds. If  there  be  any  tendency  to  syncope,  or 
if  pneumonia  should  come  on,  as  well  as  in  cases 
complicated  with  shock,  as  in  surgical  injuries,  a 
free  use  of  stimulants  is  imperative.  Hypo- 
dermic injections  of  morphia,  and  large  doses 
of  digitalis,  are  recommended  by  many  autho- 
rities; but  the  writer  has  seen  great  harm  attend 
their  free  exhibition.  The  cautious  inhalation  of 
chloroform  vapour  has  occasionally  cut  short  an 
attack  by  irducing  sleep,  but  it  much  more 
frequently  fails.  Mechanical  restraint  is  seldom, 
if  ever,  necessary,  if  the  patient  be  properly 
nursed  and  attended  to.  All  methods  of  self- 
destruction  must  be  carefully  guarded  against; 
and  a padded  room,  when  available,  is  of  the 
utmost  benefit. 

The  great  desideratum  in  chronic  alcoholism  is 
to  substitute  an  easily-digested  and  nourishing 
diet  for  the  alcoholic  stimulants,  which  can  then 
be  safely  dispensed  with  altogether.  The  prac- 
titioner's judgment,  and  his  knowledge  of  the 
cuisine,  are  very  important  in  the  management 
of  these  cases.  Strong  meat-soups  and  good  speci- 
mens of  the  concentrated  preparations  of  meat 
are  of  great  value.  The  strictly  medicinal 
treatment  will  consist  in  the  administration 
of  hitter  toDies,  such  as  nux  vomica,  quinine 
in  small  doses,  calumba,  or  gentian ; with  car- 
minatives, such  as  spirit  of  chloroform,  ar- 
moraeia,  and  capsicum.  Alkalis,  effervescent 
mixtures,  and  hydrocyanic  acid  are  peculiarly 
useful  if  the  stomach  is  irritable.  The  condi- 
tion of  the  liver  and  bowels  should  be  carefully 
regulated.  Bromide  of  potassium  is  in  general 
the  best  sedative  to  employ  against  the  insomnia, 
though  chloral  hydrate  is  more  certain  ; but  tho 
latter  should  only  be  given  occasionally,  lest  the 
patient  fall  into  the  habit  of  frequently  resort- 
ing to  it.  In  long-standing  cases,  cod-liver  oil, 
arsenic  in  small  doses,  and  oxide  of  zinc  have 
all  done  good,  but  they  require  a long  and  pro- 
tracted administration.  Phosphorus  has  been  of 
no  use  whatever  in  the  cases  in  which  the 
writer  has  tried  it ; but  small  doses  of  tho 
more  easily  assimilable  preparations  of  iron 
are  occasionally  well  borne,  and  are  then  most 
useful.  The  craving  for  drink,  if  urgent,  may  be 
cheeked  by  small  doses  of  opium,  but  this  drug 
must  be  exhibited  with  extreme  caution.  Ju- 
dicious supervision,  and.  in  inveterate  cases,  a 
residence  in  a proper  asylum,  are  the  only  means 
from  which  any  permanent  benefit  can  be  ex- 
pected. The  treatment  of  insanity  induced  by 
alcoholism  will  not  differ  from  that  recommended 
in  other  forms,  except  in  an  enforced  abstinence 
from  its  cause.  John  Curnow. 


ALEPPO  EVIL.  See  Delhi  Boil. 


ALGID. 

ALGID  {algidus,  cold). — A word  implying 
extreme  coldness  of  the  body,  used  only  when  it 
urises  in  connection  with  an  internal  morbid  state, 
such  as  cholera,  or  a special  form  of  malignant 
remittent  fever. 

ALGIERS. — Warm  winter  climate.  Mean 
winter'temperature59°  F.,  liable  to  rapid  changes. 
Heavy  rains  not  infrequent.  See  Climate. 

ALIMENT. — Food  or  aliment  furnishes  the 
elements  required  for  the  growth  and  main- 
tenance of  the  organism  ; and,  through  its  action 
with  the  other  life  factor — air,  forms  the  source 
of  the  power  manifested. 

The  aliment  of  organisms  belonging  to  the  ve- 
getable class  is  derived  from  the  inorganic  king- 
dom. Under  the  influence  of  the  sun’s  rays  the 
inorganic  principles  are  applied  to  growth,  and 
constructed  into  organic  compounds.  This  con- 
stitutes the  main  operation  of  vegetable  life,  and 
in  it  we  have  the  source  of  the  aliment  of  animals, 
which  can  only  appropriate  organic  compounds, 
and  which  either  directly  or  indirectly  derive 
these  compounds  from  the  vegetable  kingdom.  As 
the  solar  force  employed  in  the  construction  of 
organic  compounds,  through  the  agency  of  the  ve- 
getable organism,  becomes  locked  up  in  the  com- 
pound formed,  such  compound  represents  matter 
combined  with  a definite  amount  of  latent  force. 
In  the  employment,  therefore,  of  organic  matter 
as  aliment  by  animals,  we  have  to  look  upon  it 
not  only  as  yielding  the  material  required  for  the 
construction  and  maintenance  of  the  body,  but  as 
containing  and  supplying  the  force  which  is 
evolved  under  various  forms  by  the  operations 
of  animal  life. 

Aliment  constituting  the  source  from  which 
the  several  elements  belonging  to  the  body  are 
derived,  it  follows  that  to  satisfy  the  require- 
ments of  life  it  must  contain  all  the  elements  that 
are  encountered.  It  is  not,  however,  with  the 
elements  in  a separate  state  that  we  have  to  deal, 
but  with  the  products  of  nature  in  which  they 
are  variously  combined. 

The  alimentary  products  as  supplied  by  na- 
ture are  resolvable  by  analysis  into  a variety  of 
definite  chemical  compounds.  These  constitute 
the  alimentary  principles.  Some  are  common 
to  both  animal  and  vegetable  food,  as  for  instance 
albumen,  caseine,  fats,  &c. ; others  are  peculiar  to 
either  the  animal  or  vegetable  kingdom.  Starch, 
for  example,  is  met  with  only  in  vegetable,  and 
gelatine  only  in  animal  products. 

With  reference  to  the  alimentary  principles,  it 
must  be  understood  that  in  no  case  do  they  exist 
in  natural  products  in  an  isolated  form,  and  no 
single  alimentary  principle  is  capable  of  sup- 
porting life.  Although,  however,  it  is  with  the 
alimentary  products  as  a whole  that  we  are  prac- 
tically concerned,  yet,  regarded  from  a scientific 
point  of  view,  a knowledge  of  these  constituent 
principles  is  required,  to  enable  us  to  assign  to 
them  their  proper  value  as  alimentary  articles ; 
and  for  the  purpose  of  systematic  consideration 
some  kind  of  classification  is  needed. 

Classification.— Prout  classified  the  consti- 
tuent principles  of  food  into  four  groups,  which 
lie  named  (1)  the  aqueous-,  (2)  the  saccharine-, 
(3)  the  oleaginous-,  and  (4)  the  albuminous. 
This  classification  is  defective,  inasmuch  as  it 


ALIMENT.  31 

omits  from  consideration  saline  matter,  which  is 
equally  as  essential  to  nutrition  as  any  other 
part  of  an  alimentary  product.  The  saccharine 
and  oleaginous  groups  also  stand  as  primary 
and  independent  divisions,  whilst  physiologically 
they  are  related,  and  may  be  conveniently  con- 
sidered under  a combined  heading. 

Liebig  proposed  a classification  based  on  phy- 
siological principles ; and,  taking  into  account 
only  the  organic  constituents  of  food,  grouped 
them  under  the  heads  of  (1)  plastic  elements  o f 
nutrition-,  and  (2)  elements  of  respiration.  Ilis 
plastic  elements  of  nutrition  comprise  the  nitro- 
genous principles  ; and  to  these  he  assigned  the 
office  of  administering  not  only  to  the  growth  and 
renovation  of  the  tissues,  but  also  to  the  produc- 
tion of  muscular  and  nervous  power.  Believing 
that  the  source  of  these  powers  issued  from  the 
oxidation  of  the  respective  tissues,  he  held  that 
the  exercise  of  muscular  and  nervous  action 
created  a corresponding  demand  for  nitrogenous 
alimentary  matter,  which  thus  became  invested 
with  an  importance  that  led  it  to  be  regarded  as 
affording  a measure  of  the  value  of  an  alimen- 
tary article.  By  recent  experimental  research 
this  view  has  been  found  to  be  untenable.  The 
nervo-muscular  organs  are  now  looked  upon  as 
holding  the  position  of  instruments,  by  whose 
agency  the  force  liberated  by  chemical  action  is 
made  to  manifest  itself  under  certain  other  forms ; 
and  what  is  wanted  for  the  purpose  is  simply 
oxidisable  organic  material,  which  may  be  de- 
rived from  non-nitrogenous  as  well  as  nitro- 
genous food.  The  dements  of  respiration  or, 
as  they  were  afterwards  more  appropriately 
styled,  the  calorifacient  principles,  represent 
the  organic  non-nitrogenous  constituents  of  foed. 
Their  destination,  according  to  Liebig,  was  heat- 
production.  It  is  now  maintained,  however,  as 
stated  above,  that  they  play  a part  in  connection 
with  nervo-muscular  action  ; and  it  may  be  also 
said  that  they  are  to  some  extent  concerned  in 
tissue-development.  From  the  considerations  set 
forth,  Liebig’s  classification  loses  the  scientific 
value  it  was  at  one  time  supposed  to  possess. 

The  following  grouping  of  the  alimentary 
principles  based  on  chemistry  furnishes  a classi- 
fication which  involves  no  theoretical  proposi- 
tion, and  is  practically  convenient : — 

Food  is  primarily  divisible  into  Inorganic  and 
Organic  principles. 

The  Inorganic  principles  consist  of  water,  and 
the  various  saline  matters  required  by  the  sys- 
tem. They  are  as  much  needed  for  the  support 
of  life  as  the  organic  portion  of  food. 

The  Organic  principles  are  sub-divisible  into 
nitrogenous  and  Non-nitrogenous  ; and  the  Non- 
nitrogenous  are  again  further  sub-divisible  into 
Hydro- carbons  and  Carbo-hydrates. 

The  Nitrogenous  principles  contribute  to  tho 
growth  and  nutrition  of  the  various  bodily 
textures,  and  furnish  the  active  agents  of  the  se- 
cretions. They  also  undergo  resolution  in  the 
system  into  urea,  which  is  excreted ; and  a com- 
plementary hydro-carbonaceous  portion,  which 
is  susceptible  of  application  to  force-production. 
They  are  thus  capable  of  administering  to  all 
the  purposes  fulfilled  by  the  organic  portion  of 
an  aliment. 

The  Hydro-carbons  or  Fats  are  applied  to  the 


32  ALIMENT, 

production  of  heat  and  other  forms  of  force, 
they  seem  also  to  be  essential  to  tissue-de- 
velopment generally,  besides  yielding  the  basis 
of  the  adipose  tissue. 

The  Carbo-hydrates  (starch,  sugar,  gum,  &c.) 
contribute  to  the  formation  of  fat,  and  are  also 
applied  indirectly  if  not  directly  to  force-produc- 
tion. 

There  are  a few  principles,  such  as  alcohol,  the 
vegetable  acids,  and  pectin  or  vegetable  jelly, 
which  do  not  strictly  fall  within  either  of  the 
preceding  groups.  Alcohol  occupies  a chemical 
position  intermediate  between  the  fats  and  carbo- 
hydrates; whilst  the  others  mentioned  are 
more  highly  oxidised  compounds  than  the  carbo- 
hydrates. 

All  alimentary  products  in  the  form  supplied 
by  nature  contain  organic  and  inorganic  prin- 
ciples, and  the  organic  principles  comprise  more 
or  less  of  the  nitrogenous  and  non-nitrogenous 
kinds ; but  the  non-nitrogenous  do  not  neces- 
sarily, and  indeed  do  not  generally,  include  both 
hydro-carbons  and  carbo-hydrates.  In  milk, 
however,  which  may  be  regarded,  from  the  posi- 
tion it  holds  in  nature,  as  furnishing  a typical 
representation  of  an  alimentary  article,  principles 
exist  belonging  to  each  of  the  groups  enumerated 
in  the  above  classification.  See  Diet. 

F.  W.  Pavy. 

ALIMENTARY  CANAL,  Diseases  of. 
See  Digestive  Organs,  Diseases  of ; and  tho 
several  organs. 

ALKALINITY. — The  reaction  of  human 
blood  is  always  alkaline;  and,  though  the  normal 
degree  of  alkalescence  has  not  yet  been  deter- 
mined, it  is  probable  that,  like  the  temperature 
of  the  body,  it  is  tolerably  constant.  In  dis- 
ease considerable  variation,  no  doubt,  occurs, 
but  still  the  blood  is  always  found  alkaline. 
Pettenkofer  and  Voit  found  the  serum  of  blood 
acid  in  a case  of  leukaemia  some  few  hours  after 
death,  but  not  during  life ; and  Dr.  Gurrod  states 
that  in  chronic  gout  the  serum  may  become  some- 
what neutralized,  but  never  acid.  F.  Hoffman 
has  also  found  that  the  blood  retains  its  alka- 
linity with  great  obstinacy ; he  fed  pigeons  for  a 
considerable  length  of  time  on  food  yielding 
only  acid  ash,  but  the  animals  suffered  from 
blood-poisoning  before  the  alkalinity  of  the 
serum  was  neutralized.  The  alkalinity  of  the 
blood  is  maintained  by  the  constant  passage  into 
it  cf  the  alkaline  salts  of  the  food,  and  of  alkaline 
carbonates  derived  from  the  oxidation  of  the 
lactic,  oxalic,  and  uric  acids  furnished  by  the 
disintegration  of  the  tissues.  The  blood  is  pro- 
bably prevented  from  becoming  too  alkaline  by 
the  withdrawal  of  its  alkaline  salts  by  the  alka- 
line secretions,  namely,  the  saliva,  the  bile,  and 
the  pancreatic  fluid ; whilst  the  acid  salts,  which, 
if  accumulated,  would  tend  to  depress  its  normal 
alkalinity,  are  removed  by  tho  acid  secretions, 
namely,  the  sweat,  the  gastric  juice,  and  the  urine, 
and  by  the  exhalation  of  carbonic  acid  from  the 
lungs.  It  has  been  shown  that  the  withdrawal  of 
acid  by  one  secretion  has  a decided  effect  on  tho 
reaction  of  other  secretions ; thus  the  saliva 
becomes  more  alkaline  during  digestion,  when 
the  stomach  is  pouring  out  the  acid  gastric 
iuioe;  and  Dr.  Bence  Jones  has  shown  that 


ALKALIS. 

during  digestion  the  acidity  of  the  urine  is 
lessened.  A similar  relationship  is  also  shown 
to  exist  between  the  elimination  of  carbonic 
acid  by  the  lungs  and  the  acidity  of  the  urine, 
the  latter  falling  as  the  former  is  increased, 
and  vice  versa.  The  importance  of  a proper 
degree  of  alkalescence  for  the  blood  is  ob- 
vious, when  we  consider  that  this  condition 
increases  the  absorption-power  of  its  serum  fc  r 
gases,  and  is  necessary  to  maintain  its  albu- 
min in  the  liquid  state,  whilst  oxidation  is 
always  more  perfectly  performed  in  alkaline 
solutions. 

ALKALIS. — Definition. — Inorganic  sub- 
stances, which  turn  syrup  of  violets  green,  and 
turmeric  brown ; and  restore  the  blue  colour  to 
litmus  which  has  been  reddened  by  acids.  They 
combine  with  acids  to  form  salts,  and  their  car- 
bonates are  soluble  in  water. 

Enumeration.— The  only  substances  which 
correspond  with  the  above  definition  are — Potash. 
Soda,  Lithia,  and  Ammonia.  The  alkaline  earths 
—Lime,  Magnesia,  Baryta,  and  Strontia,  and  the 
organic  alkaloids,  have  a similar  action  on  vege- 
table blues  and  yellows  ; but  the  carbonates  of 
the  former  group  are  almost  insoluble  in  water ; 
whilst  the  latter  contain  carbon,  and  are  there- 
fore classed  with  organic  substances. 

Properties. — Ammonia  is  distinguished  from 
the  other  alkalis  by  its  volatility.  The  non- 
volatile alkalis  are  readily  recognised  by  thoir 
spectra;  and  by  the  colour  they  impart  to  tho 
blowpipe  flame,  potash  giving  it  a violet,  soda  a 
yellow,  and  lithia  a carmine  colour.  Potash 
and  soda  are  present  as  constituents  of  the  body 
in  considerable  quantities ; ammonia  exists  to  a 
smaller  amount;  and  lithia  probably  in  traces. 
Soda  is  found  chiefly  in  the  blood,  potash  in  the 
muscles. 

Action. — When  applied  to  the  skin  dilute 
alkalis  and  their  carbonates  act  as  rubefacients. 
Pure  ammonia  is  a vesicant,  and  potash  and  soda 
have  a caustic  action.  Both  caustic  potash  and 
soda  absorb  water  from  the  tissues,  and  form  a 
corrosive  fluid,  which  destroys  the  parts  around, 
as  well  as  that  to  which  the  caustic  has  actually 
been  applied.  To  prevent  this  effect  they  are 
sometimes  mixed  with  lime,  which  absorbs  the 
wafer.  A mixture  of  potash  and  lime  forms  tho 
Vienna  Paste.  When  inhaled,  ammonia  causes 
irritation  of  the  respiratory  passages,  and  in- 
creased secretion  of  mucus.  This  irritation  ex- 
cites reflex  contraction  of  the  blood-vessels  and 
consequent  rise  of  blood-pressure.  When  swal- 
lowed in  quantity,  the  caustic  alkalis  and  their 
carbonates  produce  symptoms  of  irritant  poison- 
ing. In  the  case  of  ammonia  these  symptoms 
may  be  accompanied  by  those  of  inflammation  of 
the  air-passages,  caused  by  the  irritant  vapour. 
The  best  antidote  is  dilute  acid,  such  as  vinegar. 
In  small  quantities  and  diluted,  alkalis  increase 
the  secretion  of  gastric  juice.  After  absorption 
into  tho  blood  the}7  render  this  fluid  more  alka- 
line; whilst  potash  appears  especially  to  accele- 
rate tissue-change,  and  is  accordingly  classed 
among  the  alteratives.  When  injected  directly 
into  the  blood,  potash  acts  specially  on  the  mus- 
cles, which  it  paralyses.  Ammonia  stimulates  the 
motor  centres  in  the  brain  and  spinal  cord,  the 


ALKALIS. 

respiratory  centre  in  the  medulla  oblongata,  and 
the  accelerating  nerves  of  the  heart.  When 
injected  into  the  veins  it  therefore  causes  con- 
vulsions like  those  of  strychnia,  and  quickening 
of  the  respiration  and  pulse.  Alkalis  are  chiefly 
excreted  by  the  urine;  and  potash,  soda,  and 
iithia  lessen  its  acidity,  or  render  it  alkaline. 
Ammonia  is  partly  excreted  unchanged,  but  a 
portion  passes  out  in  the  form  of  urea;  and  it 
does  not  render  the  urine  alkaline  like  the  others. 
Potash  and  Iithia  act  as  diuretics  ; soda  to  a less 
extent ; and  ammonia  least  of  all.  The  diuretic 
action  does  not  depend  on  any  change  in  the 
blood-pressure.  Potash  and  ammonia  are  diapho- 
retic. Potash  lessens  the  tenacity  of  mucus. 

Uses. — -Dilute  solutions  of  potash  and  soda 
relieve  itching  in  skin  diseases.  Caustic  potash 
or  soda  is  used  to  destroy  warts ; to  cauterizo 
poisoned  wounds  and  ulcers;  to  open  hydatid 
cysts  in  the  liver;  and  to  establish  issues.  Am- 
monia neutralizes  the  formic  acid  which  renders 
venomous  the  stings  of  bees,  ants,  and  mosquitos, 
and  is  therefore  applied  to  relieve  the  pain  which 
they  cause.  The  intravenous  injection  of  am- 
monia has  been  recommended  as  an  antidote  in 
snake-poisoning;  but  the  value  of  the  remedy  is 
not  established.  Mixed  with  oil,  so  as  to  form  a 
liniment,  ammonia  is  used  as  a rubefacient  in  sore 
throats,  bronchitis,  rheumatic  pains,  and  neu- 
ralgia. It  is  inhaled  to  relieve  headache ; as  a 
restorative  in  syncope  and  shock,  when  it  raises 
the  blood-pressure ; and  to  facilitate  expectora- 
tion in  chronic  bronchitis.  Alkalis  administered 
after  meals  act  as  antacids,  and  relieve  heartburn. 
When  given  before  meals  they  increase  the  secre- 
tion of  gastric  juice,  quicken  digestion,  and  relieve 
w eight  at  the  epigastrium,  pain  between  the 
shoulders,  and  flatulence.  Bicarbonate  of  soda 
is  usually  given  for  this  purpose,  but  when  the 
stomach  is  very  irritable  liquor  potassse  is  pre- 
ferred, as  it  is  considered  to  have  a sedative 
action  on  the  mucous  membrane.  Alkalis  appear 
to  lessen  tho  transformation  of  glycogen  into 
sugar,  and  they  are  used  on  this  account  in  dia- 
betes. Liquor  potassae  sometimes  helps  to  reduce 
obesity.  Alkalis  are  used  in  the  treatment  of 
scrofula,  rheumatism,  gout,  and  lithiasis ; but  in 
the  two  last-mentioned  Iithia  is  considered  the 
most  valuable,  whilst  potash  is  preferred  to  soda, 
as  the  urate  of  Iithia  is  most  soluble,  and  the 
urate  of  soda  least  so.  The  salts  of  certain 
organic  acids,  such  as  the  acetate  or  citrate, 
may  be  employed  as  remote  antacids  to  render 
the  urine  alkaline,  as  they  undergo  combustion 
and  are  converted  into  carbonates  in  the  blood. 
Alkalis  are  given  to  lessen  the  acidity  of  the 
urine  in  inflammation  of  the  bladder  or  urethra, 
and  potash  is  employed  as  a diuretic  in  dropsies. 
On  account  of  its  stimulating  action  on  the 
heart  and  respiration,  ammonia  is  administered 
in  adynamic  conditions  and  in  chronic  bronchitis. 

T.  Lauder  Brunton. 

ALKALOIDS  and  other  ACTIVE 

PRINCIPLES. — Definition. — An  alkaloid  is 
a substance  formed  in  the  tissues  of  a pilant  or  of 
an  animal,  having  a definite  composition  as  re- 
gards tho  proportions  of  the  chemical  elements  of 
which  it  is  composed,  and  capable  of  combining, 
liko  an  alkali,  with  acids  to  form  salts. 

3 


ALKALOIDS.  35 

Besides  alkaloids  there  are  other  active  priD 
ciples  found  in  plants,  which  have  also  a power 
ful  influence  on  the  animal  economy  but  do 
not  possess  all  the  chemical  properties  jus' 
stated. 

Chemical  Composition  and  Relations. — 
These  are  briefly  expressed  in  the  above  defini 
tion.  Thus  morphia,  one  of  the  alkaloids  ot 
opium,  has  always  the  chemical  composition 
represented  by  the  formula  C1;H„K03,  and  it 
may  unite  with  acetic  acid  to  form  acetate  of 
morphia,  just  as  potash  may  unite  with  the  same 
acid  to  produce  acetate  of  potash.  But  tho  em- 
pirical formula  CpH^NOj  represents  only  the 
percentage  composition  of  the  substance  in  tho 
simplest  numbers,  and  does  not  express  how  the 
atoms  of  the  different  elements  are  related  to 
each  other.  For,  just  as  etliylic  alcohol,  with  the 
composition  CTPO,  is  believed  by  the  chemist, 
from  its  behaviour  towards  other  bodies,  to 
contain  a ‘ radicle,’  or  group  of  atoms,  CUP, 
having  certain  chemical  properties  resembling 
those  of  a base,  such  as  potassium,  K ; and  just 
as  this  radicle,  C2H5  may  replace  one  of  tho 
elements  of  water,  so  as  to  form  alcohol 

(C2H5  + H20  = 0 + H) ; so  chemists  have 

good  reason  for  believing  that  alkaloids  belong  to 
the  group  known  as  amines  or  amides , which  are 
really  ammonia,  Nil3,  iu  which  one  or  more  of 
the  atoms  of  hydrogen  are  replaced  by  a radicle 
or  radicles.  It  is  impossible,  however,  in  the 
present  state  of  knowledge,  to  represent  the  true 
chemical  composition  of  alkaloids,  the  exact  con- 
stitution of  the  radicles  being  still  unknown. 

It  is  obvious  that  two  or  more  alkaloids  may 
resemble  each  other  in  percentage  composition, 
and  still  be  very  different,  both  in  their  chemical 
structure  and,  necessarily,  in  their  physiological 
action.  Thus  strychnia,  C21H22N202,  quinia, 
C20H24N2O2,  and  cinchonia,  C20H2,N2O,  differ  only 
in  a few  atoms  of  carbon  or  of  oxygen,  more  or 
less ; but  they  have  different  physiological  ac- 
tions, showing  that  their  chemical  structure, 
which  is  not  indicated  in  these  formulae,  must 
also  be  different.  Tho  physiological  action  of  an 
alkaloid  may  also  be  modified  by  combining  it 
with  another  substance.  Thus,  as  was  pointed 
out  by  Crum-Brown  and  Fraser,  compounds  of 
strychnia  with  methyl,  ethyl,  and  amyl,  do  not 
present  the  well-known  physiological  action  of 
that  substance,  but  one  analogous  to  that  of 
woorara. 

Enumeration. — The  alkaloids  and  other  ac- 
tive principles  most  familiar  to  the  physician 
are Morphia,  Apomorphia,  Narceia,  Codeia, 
Thebaia,  Narcotin.  Papaverin  ; Atropia,  Hyos- 
cyamia,  Daturia ; Nicotin  ; Conia;  Physostigmia ; 
Strychnia,  Brucia  ; Quinia,  Cinchonia,  Beberia  ; 
Caffein  ; Aconitia,  Veratria  ; Digitalin  ; Curarin  ; 
Muscarin;  Santonin  ; and  Ergotin. 

Sources. — The  majority  of  alkaloids  are 
formed  by  plants.  The  function  which  they 
subserve  in  the  economy  of  the  plant  is  not 
known.  Some  plants  produce  only  one  alkaloid, 
while  in  others  two  or  more  may  be  formed. 
A few  of  the  alkaloids  have  been  produced  syn- 
thetically by  the  chemist. 

Physiological  Action.  — Alkaloids  have 
various  degrees  of  physiological  activity  when 


ALKALOIDS 


14 

introduced  into  the  animal  body.  Manyare  slow 
in  their  action,  and  a large  dose  is  required  to 
produce  any  observable  effect ; while  others  act 
more  rapidly,  and  are  so  potent  that  even  a minut  e 
dose  may  destroy  life.  Compare,  for  example, 
narcotin,  one  of  the  alkaloids  of  opium,  with 
nicotin,  the  alkaloid  of  tobacco.  Twenty  to 
thirty  grains  of  the  former  have  been  taken  by 
the  human  subject  without  producing  any  marked 
symptoms,  while  the  twentieth  part  of  a grain 
of  the  latter  may  induce  symptoms  so  severe  as 
to  threaten  death.  It  is  also  well  known  that 
alkaloids  may  have  a different  kind  of  action  on 
different  animals.  Thus  one-fourth  of  a grain  of 
atropia  will  produce  serious  symptoms  of  a com- 
plex character  in  a dog,  while  three  or  even  four 
grains  may  be  given  to  a rabbit  without  causing 
any  more  marked  effect  than  dilatation  of  the 
pupil.  In  considering  the  physiological  ac- 
tions of  these  substances  the  following  general- 
izations may,  in  the  present  state  of  science,  be 
made  tentatively: — 1.  As  a general  rule,  the 
more  complex  the  organic  molecule,  and  the 
greater  the  sum  of  the  atomic  weight,  the  more 
intense  will  be  the  action  of  the  substance.  This 
has  been  shown  in  experiments  on  the  action  of 
the  chinoline  and  pyridine  series  of  bases  by 
McKendrick  and  Dewar.  2.  Substances  which 
split  up  quickly  into  simpler  bodies,  produce 
rapid  but  transient  physiological  effects,  whereas 
substances  which  resist  decomposition  in  the 
blood  or  tissues  may  produce  no  appreciable 
results  for  a time,  but  when  they  do  begin  to 
break  up.  the  effects  are  sudden  and  violent, 
and  usually  last  fora  considerable  time.  3.  Al- 
kaloids have  frequently  a double  action  on  dif- 
ferent parts  of  a great  physiological  system,  and 
their  action  in  a particular  group  of  animals 
rill  depend  on  the  relative  degree  of  develop- 
ment of  the  parts  of  the  system  in  that  group. 
Thus  most  of  the  alkaloids  of  opium  have  such 
a double  action — a convulsive  action  resembling 
that  of  strychnia,  due  to  their  influence  on  the 
spinal  cord  or  on  the  motor  centres  in  the  brain  ; 
and  a narcotic  or  soporific  action  resembling  that 
of  anaesthetics,  due  to  their  influence  on  sensory 
centres  in  the  brain.  Hence,  in  animals  where 
the  spinal  system  predominates,  as  in  frogs, 
these  alkaloids  act  as  convulsants ; while  in  the 
higher  mammals  their  principal  action  is  ap- 
parent'y  on  the  encephalic  centres,  which  have 
now  become  largely  developed. 

Passing  to  the  consideration  of  the  action 
of  the  individual  substances,  we  cannot  do 
more  than  give,  by  way  of  example,  a brief 
resume  of  our  knowledge  regarding  a few  of  them. 

1.  Morphia — C17Hls,N03 — an  alkaloid  of 
opium.  In  the  frog  this  substance  has  an  action 
resembling  that  of  strychnia.  At  first  there  is 
a state  of  agitation,  followed  by  tetanic  spasms  : 
finally,  all  reflex  actions,  including  those  cf  the 
heart  and  of  respiration,  are  paralysed.  Pigeons 
have  been  found  to  possess  a remarkable  power 
of  withstanding  the  influence  of  this  drug — an 
ordinary-sized  bird  requiring  about  two  grains 
to  kill  it.  Babbits  become  partially  somnolent, 
show  a tendency  to  reflex  spasms,  and  tolerate  a 
large  dose — say  about  one-lialf  to  one  grain  per 
pound  weight  of  the  animal.  In  the  dog  the 
intravenous  injection  of  even  one-tenth  of  a 


grain  (for  a small  animal)  causes  agitation  fol- 
lowed by  sleep;  the  pulse  and  respiratory  move- 
ments are  slowed ; the  smaller  arteries  become 
(at  least  during  one  stage)  contracted,  so  as  to 
cause  an  augmentation  of  general  blood-pressure; 
the  pupil  is  contracted ; and,  if  the  dose  he  large, 
death  may  be  preceded  by  convulsions.  In  the 
higher  mammals  morphia  acts  chiefly  on  the 
sensory  apparatus,  both  peripheral  and  central. 

2.  Other  alkaloids  of  opium  have  also  been 
investigated. — (a.)  Nareeia,  C._,3H.„,N03,  is  a 
pure  hypnotic,  causing  profound  sleep.  Even 
in  large  doses  it  does  not  produce  convulsions. 
(b.)  Codeia,  C^H.^NOj.  has  an  action  like  that 
of  morphia,  (c.)  Thebaia,  C^H-jNOj,  causes 
tetanic  convulsions,  thus  resembling  strychnia. 
( d .)  Narcotin,  C23H.rjN 07,  is  slightly  narcotic, 
but  strongly  convulsant.  (c.)  Papaverin, 

causes  a somniferous  action  like  that 
of  narceia.  Apomorphia,  C,-H1;X02,  a deri- 
vative of  morphia,  has  none  of  the  characteristic 
actions  of  that  substance,  but  acts  chiefly  as  a vas- 
cular depressant  and  as  an  emetic.  It  is  evident, 
therefore,  that  opium,  which  may  contain  more 
or  less  of  all  of  these  substances,  must  have  an 
action  on  the  body  of  a very  complicated  cha- 
racter. 

3.  Strychnia,  C.J,II_vJK.J0.J, — the  alkaloid  of 
Strychnos  mix  vomica.  In  the  frog  very  mi- 
nute doses  cause  convulsions  of  all  "the  volun- 
tary muscles,  excited  by  peripheral  irrita- 
tion. These  convulsions  are  due  to  the  action 
of  the  poison  on  the  spinal  cord,  as  they  persist 
after  decapitation.  In  warm-blooded  animals 
the  reflex  character  of  the  convulsions  is  less 
evident ; they  have  more  of  a tonic  character, 
and  chiefly  affect  the  extensors.  The  exact 
modus  operandi  of  the  poison  on  the  cord  is  un- 
known, but  in  some  way  or  otlmr  it  heighten* 
its  reflex  sensibility.  Death  is  usually  the  result 
of  asphyxia  from  arrest  in  spasm  of  the  respira- 
tory mechanism,  but  it  may.  result  from  exhaus- 
tion. Brucia,  C23IL,6N.D4,  another  substance 
found  in  nux  vomica,  appears  to  have  an  action 
like  that  of  strychnia,  but  more  feeble. 

4.  Atropia,  C17H.,3'N03,  — the  alkaloid  of 
Atropa  belladonna.  In  the  frog  it  causes  tetanic 
reflex  spasms.  Herbivorous  animals,  as  a rule, 
have  a tolerance  of  this  poison,  so  that  its  effects 
are  best  studied  in  carnivora.  Even  in  these  the 
action  is  somewhat  uncertain.  .Respiration  may 
be  paralysed  without  general  convulsions : the 
pulse  is  quickened  by  paralysis  of  the  inhibitory 
action  of  the  pneumogastric  nerve  on  the  heart ; 
and  the  arterial  pressure  is  increased.  After  very 
large  doses  the  arterial  pressure  may  be  dimin- 
ished with  paralysis  of  all  parts  containing  in- 
voluntary muscular  fibre.  Secretion  is  dimin- 
ished. The  pupil  is  dilated  apparently  by  a 
direct  influence  of  the  poisou  on  the  centres  or 
nervous  arrangements  in  the  iris  itself,  as  the 
effect  may  be  observed  even  in  an  eye  removed 
from  the  head.  Hyoscyamia,  the  alkaloid  of 
Hyoscyamus  niger,  and  Daturia,  the  alkaloid 
of  Datura  stramonium,  have  an  action  like  that 
of  atropia. 

o.  Digitalin,  C27H,_,0,., — the  active  principle 
of  Digitalis  purpurea.  A large  dose  causes  slow- 
ing of  the  heart’s  action,  and  if  the  dose  bo  in- 
creased the  heart  will  be  arrested  in  diastole 


ALKALOIDS. 

and  will  not  respond  to  direct  excitation.  With 
medium  doses  there  is  a period  of  acceleration  of 
the  heart’s  action,  but  this  period  may  rapidly 
pass  into  that  of  slowness  just  mentioned. 
This  action  on  the  heart  has  not  yet  been 
clearly  accounted  for,  and  it  remains  to  be  de- 
cided whether  it  be  due  to  the  influence  of  the 
drug  on  the  terminations  of  the  pneumogastric,  or 
of  the  sympathetic,  or  on  the  intracardiac  ganglia 
themselves.  Coincident  with  the  action  on  the 
heart,  the  smaller  arteries  are  contracted  and 
the  arterial  tension  is  increased.  Digitalis  would 
appear  to  have  little  effect  on  involuntary  muscle, 
but  it  exerts  a potent  action  on  voluntary  muscle, 
which,  after  small  doses,  becomes  feeble  in  con- 
tractile power,  while  large  doses  may  abolish 
contractility  altogether. 

6.  Physostigmia,  C15H21N302,  — the  active 
substance  of  Physostigma  venenosum,  or  Calabar 
bean.  As  has  been  pointed  out  by  Professor 
Fraser,  this  alkaloid  has  an  action  antagonistic 
to  that  of  atropia.  Sensibility  and  conscious- 
ness remain  until  death ; the  voluntary  muscles 
are  paralysed  ; involuntary  muscles  are  said  to 
show  tetanic  contractions  ; respiration  is  at  first 
accelerated,  and  afterwards  slowed ; the  vessels 
become  alternately  dilated  and  contracted ; secre- 
tion, especially  that  from  the  lachrymal  and  sali- 
vary glands,  is  increased ; and  the  pupil  is  con- 
tracted. It  appears  to  paralyse  the  extremities 
of  the  motor  nerves,  in  this  respect  resembling 
curare. 

7.  Curare  is  a resinous  substance,  containing 
an  alkaloid,  Curarin,  of  the  composition  C,0H,jN, 
obtained  from  certain  parts  of  South  America, 
and  used  by  the  natives  of  these  regions  as  an 
arrow-poison.  It  is  probably  obtained  from  cer- 
tain plants  belonging  to  the  genera  Strychnos 
and  Paullinia.  Its  distinctive  physiological 
action  is  abolition  of  the  power  of  all  voluntary 
movement,  in  consequence  of  its  action,  as  was 
proved  by  Claude  Bernard,  upon  the  peripheral 
terminations  of  motor  nerves — the  “ terminal 
plates  ” of  muscle.  Respiratory  movements  are 
arrested  in  consequence  of  paralysis  of  the 
muscles  of  respiration,  but  the  heart  may  con- 
tinue to  beat  for  a considerable  time.  If  arti- 
ficial respiration  be  established,  the  circulation 
may  be  maintained  for  several  hours  while  the 
animal  is  completely  under  the  influence  of  the 
substance.  All  the  secretions  are  increased,  and 
the  mean  temperature  falls. 

8.  Muscarin.  the  alkaloid  of  Agaricus  mus- 
carius,  causes  arrest  of  the  heart’s  action  in  dia- 
stole, an  effect  which  may  be  removed  by  the 
influence  of  atropia,  thus  affording  an  instance 
of  physiological  antagonism.  In  warm-blooded 
animals  muscarin  slows  the  heart's  action ; the 
blood-pressure  falls ; respiration  is  first  embar- 
rassed, and  may  be  completely  arrested ; parts 
containing  involuntary  muscle  are  in  a state  of 
tetanic  spasm ; the  pupil  is  contracted  ; and  secre- 
tion is  increased. 

9.  Santonin,  C,3Hls03,  the  alkaloid  of  Arte- 
mesia  santonica,  may  cause  in  man  nausea, 
vomiting,  hallucinations,  vertigo,  and  a peculiar 
state  of  visual  sensation — the  field  of  vision 
usually  appearing  yellow,  but  sometimes  violet. 
It  is  said  that  the  stage  of  violet  rapidly  passes 
into  that  of  yellow,  and  therefore  it  is  probable 


ALTERATIVES.  30 

that  santonin  may  first  excite  the  retinal  fibres 
sensitive  to  violet  (according  to  Thomas  Young's 
theory  of  colour-perception),  and  afterwards  para 
lyse  them.  In  large  doses,  santonin  causes  loss 
of  consciousness,  tetanic  convulsions,  and  death. 

10.  Ergotin,  the  active  principle  of  Secale 
eornutum,  causes  contraction  of  the  smaller 
blood-vessels,  contractions  of  the  uterus,  and 
slowing  of  the  pulse;  and  the  animal  may  die  in 
consequence  of  arrest  of  the  action  of  the  heart. 

1 1 . Quinia,  C20H,,jN2O2,  one  of  the  alkaloids 
of  Cinchona,  in  small  doses  accelerates  the  heart’s 
action  in  the  warm-blooded  animal ; in  moderate 
doses  it  slows  it ; and  in  large  doses  it  may  ar- 
rest it,  and  cause  convulsions  and  death.  Research 
shows  that  its  action  is  essentially  upon  the  cen- 
tral nervous  system.  It  destroys  all  microscopic 
animal  organisms,  apparently  killing  vibrios, 
bacteria,  and  amoebae  ; but  it  seems  to  be  with- 
out action  on  humble  organisms  belonging  to  the 
vegetable  kingdom.  It  arrests  the  movements 
of  all  kinds  of  protoplasm,  including  those  cf 
the  colourless  corpuscles  of  the  blood.  It  arrests 
fermentive  processes  which  depend  on  the  pre- 
sence of  animal  or  vegetable  organisms,  but  it 
does  not  interfere  with  the  action  of  digestive 
fluids. 

12.  Cinchonia,  C20H24N2O,  is  said  to  have  an 
action  similar  to  quinia,  but  much  more  feeble. 
Further  research  is  needed  on  this  point. 

John  G.  McKendrick. 

ALOPECIA.  See  Baldness. 

ALPHOS  and  ALPHOIDES  (a\<pbs,  white), 
terms  signifying  white  and  white-looking,  are 
associated  with  the  whiteness  of  the  disks  of 
common  Lepra : hence  Lepra  alphos  and  Lepra 
alphoides.  See  Lepba. 

ALPHOSIS  (a\<t>bs,  white). — "Whiteness,  or 
the  process  of  turning  white.  See  Achroma. 

ALTERATIVES. — Definition. — Medicines 
which  gradually  restore  the  nutrition  of  the  body 
to  a healthy  condition,  without  producing  evacua- 
tions, or  immediately  exerting  any  very  evident 
action  upon  the  nervous  system. 

Enumeration.— The  principal  alteratives  are 
— Nitric  and  Nitro-hydrochloric  acids ; Chlo- 
rine and  Chlorides ; Iodine  and  Iodides ; 
Sulphur  and  Sulphides;  Potash  and  its  salts; 
Mercury  and  its  salts ; Phosphorus ; Hypo- 
phosphites  ; Antimony  ; Arsenic  ; Taraxacum  ; 
Sarsaparilla  ; Hemidesmus  and  Guaiacum  ; Me- 
zereon  and  Dulcamara. 

Action. — Healthy  nutrition  depends  on  the 
digestion  of  the  food,  its  assimilation  by  the 
tissues,  the  decomposition  of  the  tissues  during 
the  exercise  of  their  functions,  and  the  removal 
of  their  waste  products  being  performed  in 
a proper  manner — in  due  proportion  one  to 
another.  If  the  food  is  not  properly  digested,  as 
in  dyspepsia ; or  is  not  properly  assimilated,  as  in 
diabetes  ; if  the  tissues  break  up  too  rapidly,  as 
in  fever : or  if  the  waste  products  are  not  properly 
removed,  as  in  some  cases  of  kidney-disease, 
nutrition  suffers.  Digestion  and  excretion  may 
be  improved  by  tonics,  purgatives,  and  diuretics ; 
but  alteratives  seem  to  exert  their  action  upon 
assimilation  and  tissue-change.  The  digestion  of 
food  is  effected  by  means  of  ferments,  such  as 


86  ALTERATIVES, 

those  of  the  salivary  glands,  stomach,  pancreas, 
etc.  Some  also  of  the  changes,  such  as  the  con- 
version of  glycogen  into  sugar,  -which  the  food 
undergoes  after  absorption  in  the  liver,  and 
even  certain  so-called  vital  actions — such  as 
the  coagulation  of  the  blood — are  produced 
by  a similar  agency.  It  is  not  improbable 
that  the  histolytic  changes  in  the  tissues  are 
tdso  effected  by  ferments.  They  do  not  de- 
pend upon  oxidation,  for  although  during 
health  the  products  of  tissue-decomposition  are 
oxidised  as  fast  as  they  are  formed,  yet  under  cer- 
tain circumstances  the  tissues  are  split  up  so 
rapidly  that  the  products  which  they  yield  are 
only  partially  oxidized.  This  is  seen  in  poisoning 
by  antimony,  arsenic,  and  still  more  markedly 
by  phosphorus,  where  such  tissues  as  the  muscles 
become  decomposed,  yielding  nitrogenous  sub- 
stances, such  as  leucin,  tyrosin,  or  urea,  and  fat. 
The  former  are  excreted  in  the  urine  ; while  the 
last,  instead  of  undergoing  combustion,  accumu- 
lates in  the  place  formerly  occupied  by  the  mus- 
cular tissue,  which  is  accordingly  said  to  be  in  a 
state  of  fatty  degeneration.  It  is  possible  then, 
although  by  no  means  certain,  that  alteratives 
influence  nutrition,  either  by  modifying  the  ac- 
tivity of  ferments,  or  by  altering  the  susceptibility 
of  the  tissues  to  their  action. 

Mercurials  in  purgative  doses, taraxacum,  nitric 
and  nitro-hydrochloric  acids,  probably  act  by 
modifying  the  digestion  of  the  food  in  the  upper 
part  of  the  small  intestine,  or  by  affecting  the 
changes  which  it  undergoes  in  the  liver  after  ab- 
sorption. Potash  has  probably  an  action  on  the 
muscles.  Antimony,  arsenic,  and  phosphorus 
especially  affect  the  nervous  and  cutaneous  sys- 
tems. Mercury  has  a peculiar  power  of  breaking 
up  newly-formed  fibrinous,  and  particularly 
syphilitic  deposits.  Iodine,  iodides,  and  pro- 
bably chlorides,  act  upon  the  lymphatic  system 
and  promote  absorption. 

Uses. — Purgative  doses  of  mercurials,  taraxa- 
cum, nitric  and  nitro-hydrochloric  acid  are  useful 
in  cases  of  frontal  headache,  general  malaise,  and 
depression  of  spirits,  associated  with  symptoms 
of  so-called  biliousness,  or  with  the  appearance 
of  urates  or  of  oxalates  in  the  urine.  Potash 
and  colchicum  are  employed  in  the  treatment  of 
gout.  Phosphorus  and  arsenic  are  used  in  cases 
of  nervous  debility,  as  well  as  in  nervous  diseases, 
such  as  neuralgia  and  chorea,  in  which  antimony 
is  also  serviceable.  Arsenic  is  also  given 
in  diseases  of  the  skin ; and  antimony  in 
inflammation  of  the  mucous  membrane  of  the 
bronchi.  Mercury  in  alterative,  that  is,  in 
small  doses,  which  are  absorbed  into  the  cir- 
culation without  purging,  is  used  to  break  up 
newly-deposited  fibrinous  masses,  as  in  iritis, 
pericarditis,  etc.,  and  to  counteract  the  effect  of 
syphilitic  virus  upon  the  soft  tissues  in  the 
secondary  stage  of  this  disease.  Iodine  and 
iodides  act  on  the  lymphatic  system,  and  are 
useful  in  removing  glandular  swellings.  By 
stimulating  the  absorbent  system  they  may  also 
assist  in  the  removal  of  the  fibrinous  deposits 
and  syphilitic  growths  disintegrated  by  the  mer- 
cury. The  iodides  are  sometimes  given  in  the 
secondary,  but  are  still  more  valuable  in  the 
tertiary  stage  of  syphilis. 

T.  Lauder  Biiunton. 


AMAUROSIS. 

ALVEOLAR. — A word  used  in  pathology  aB 
descriptive  of  any  morbid  growth  which  consists 
of  small  cavities  or  spaces  {alveoli),  usually 
occupied  by  contents,  and  bounded  by  walls 
formed  of  cells  or  fibres.  Alveolar  Cancer  is 
the  most  familiar  application  of  the  term,  being  a 
synonym  for  Colloid  Cancer.  See  Cancer. 

AMAUROSIS  {a/xavpbs,  dark). — Definition. 
— This  term  cannot  be  strictly  defined.  Liter- 
ally, it  means  an  obscurity  of  vision,  a state 
of  blindness,  in  the  popular  sense  of  the  term, 
whereby  nothing  more  is  learnt  than  that  the 
patient  cannot  see  well  enough  for  practical  pur- 
poses, and  is  thereby  unfitted  for  the  usual  occu- 
pations of  life.  Besides  this,  it  is  always  tacitly 
understood  that  an  external  observation  of  the 
organ  of  vision,  during  the  life  of  the  patient, 
does  not  reveal  any  ostensible  cause  of  blindness. 
It  is  further  understood  that  th6  use  of  glasses 
is  no  remedy  in  amaurotic  cases.  It  is  rather 
the  kind,  than  the  degree,  of  blindness  that  is 
called  amaurotic ; but  it  must  be  observed  that 
lesser  degrees  of  blindness,  of  the  amaurotic 
type,  are  generally,  vaguely  and  indefinitely, 
called  amblyopic.  To  add  to  the  obscurity  of  the 
subject,  some  writers  call  some  cases  of  moderate 
blindness,  of  the  amaurotic  kind,  amaurotic 
amblyopia  ; others  speak  of  partial  or  incomplete 
amaurosis.  IV e now  estimate  any  defect  of 
vision  with  more  accuracy,  and  record  its  area  on 
a map,  and  its  degree  in  figures,  in  comparison 
with  a standard  of  ordinary  normal  vision. 

JEtiology. — The  causes  of  amaurosis  have 
been  more  recently  specifically  attributed  to 
morbid  conditions  of  the  percipient  nervous 
apparatus  of  the  eye  or  of  vision.  All  cases  are 
excluded  in  which,  in  the  present  state  of 
science,  and  using  the  ophthalmoscope,  we  can 
sec  any  morbid  condition.  But  very  few  cases 
are  now,  in  the  statistical  tables  of  tho  chief 
eye-hospitals,  included  under  the  head  amau- 
rosis. Some  few  cases  seem  likely,  at  least 
for  some  time  to  come,  to  be  called  by  this 
term  of  reproach.  The  ophthalmoscope  has 
enabled  ns  more  accurately  to  classify  a large 
majority  of  the  cases  formerly  called  amaurotic. 
Many  new  names  are  thus  introduced  to  our 
systematic  treatises  on  eyo  diseases,  whereby  we 
gain  more  definite  information,  if  only,  as  in  some 
of  them,  e.g.  ‘ white  atrophy,'  we  have  substituted 
the  name  of  a particular  ophthalmoscopic  sign 
for  an  indefinite  symptom.  At  least  we  can 
speak  more  accurately  of  the  part  that  is  or 
has  been  diseased — of  the  retina,  or  of  the  ocular 
end  of  the  optic  nerve.  And,  indeed,  before  the 
invention  of  the  ophthalmoscope,  the  ancients, 
whilst  professing  to  include  only  cases  of  disease 
of  the  percipient  nervous  apparatus  of  vision, 
included  all  kinds  of  obscure  visual  disorders. 
Mackenzie  (1854)  includes,  besides  retinitis,  etc., 
choroiditis,  and  dislocated  lenses!  Of  the  first 
named  he  says,  ‘ It  would  he  superfluous  to 
consider  these  states  separately,  because  we  are 
at  present  ignorant  of  any  diagnostic  signs  by 
which,  during  life,  the  one  can  be  discriminated 
from  the  other.’  Even  now,  whenever  the  term 
amaurosis  is  had  recourse  to,  it  expresses  more 
particularly  that  of  which  we  are  ignerant,  and  it 
may  mean  any  one  of  so  many  different  states  that 


AMAUROSIS. 

ao  anatomical  characteristics  can  be  assigned 
to  it. 

In  a large  majority  of  the  cases  commonly 
classed  as  those  of  amaurosis,  it  is  found 
ophthalmoscopically  that  there  is  ‘white  atro- 
phy ’ of  the  optic  nerves.  The  ‘ disks  ’ are 
nearly  or  quite  bloodless;  white,  not  pinky- 
white  ; and  the  nerve-fibres  going  to  the  retin®, 
being  more  or  less  wasted,  there  is  some  exca- 
vation of  the  disks,  perhaps  so  much  that  the 
lamina  cribrosa,  in  one  or  both,  is  exposed  to 
view,  while  the  retinal  vessels  are  somewhat 
diminished  in  size.  The  causes  of  this  condition 
are,  most  commonly,  intracranial  tumours  or 
other  diseases  which  induce  pressure  upon  the 
optic  nerve,  or  lead  to  an  extension  of  inflam- 
mation, followed  by  oedema  or  double  optic 
neuritis  (descending),  these  terminating  in  the 
atrophy  and  amaurosis.  The  nerve-disease  is 
often  due  to  syphilis.  But  some  cases  of  white 
atrophy  occur,  in  which  there  has  been  no  pre- 
cedent neuritis.  Of  such  ‘tobacco  amaurosis  ’ is 
an  example,  in  which,  unless  smokiDg  be  given 
up,  by  an  idiosyncrasy  of  the  patient,  he  soon 
becomes  blind.  But  nerve-atrophy  or  inflam- 
mation should  be  no  longer  called  amaurosis — 
they  have  obtained  a better  nomenclature.  The 
preceding  stages  of  the  diseases  causing  them, 
if,  as  is  rarely  the  case,  unaccompanied  by  any 
definite  ophthalmoscopic  signs,  and  yet  producing 
i considerable  amount  of  blindness,  may,  for 
vant  of  better  knowledge,  at  present  be  called 
amaurotic.  Other  such  cases  are  those  reported 
is  snow-blindness  ; or  in  which  blindness  has 
oecn  produced  by  a lightning-flash  near  the  eye ; 
a blow  on  tho  eye  without  other  mischief  re- 
sulting; disuse  of  an  eye  in  children,  as  in 
some  neglected  squint  cases  ; irritation  from  some 
branches  of  the  fifth  nerve  (dental  caries,  etc.) ; 
anmmia  after  excessive  losses  of  blood  ; suppres- 
sion of  menses ; blood-poisoning  by  tobacco,  lead, 
quinine  ; urmmia;  and  some  cases  of  cerebral 
apoplexy.  Embolism  of  the  central  artery  of  the 
retina  occurs,  but  it  is  easy  of  diagnosis  with 
the  ophthalmoscope,  and  therefore  should  not  be 
called  amaurotic.  The  writer  does  not  think  there 
are  any  cases  of  longstanding  blindness  that  show 
no  ophthalmoscopic  changes. 

Symptoms  and  Diagnosis. — There  is  one 
symptom  of  amaurotic  blindness,  affecting  both 
eyes,  which  is  noteworthy,  as  constituting,  primd 
facie,  a general  distinction  between  it  and 
the  other  cases  of  blindness  not  of  nervous 
origin : the  gait  and  general  aspect  of  the 
patient  is  peculiar — he  is  hesitating  and  hope- 
less-looking. He  no  more  tries  to  see  objects. 
He  holds  up  his  head ; the  eyes  are  open 
and  turned  upwards,  as  eyes  not  in  use  (in 
sleep)  always  are,  or  because  the  patient  has  felt 
the  heat  of  the  sun  from  overhead,  and  has  last 
enjoyed  sensation  of  light,  whence  he  knows  it  ' 
comes,  from  above.  He  feels  his  way  with  his 
feet,  and  his  hands  are  extended  before  him.  He 
does  not  look  towards  you,  or  at  anything  in 
particular.  But  amaurosis  does  not  by  any 
means  imply  a similar  state  of  vision  in  both 
eyes,  nor  that  the  blindness  is  to  be  taken  in  the 
ophthalmological  sense,  i.e.  wanting  perception 
of  light.  It  would  be  well  if  any  less  degree 
of  Imperfection  of  vision,  without  evident  cause, 


AMBLYOPIA.  87 

might  be  called  amblyopic,  but  the  two  eyes 
must  be  considered  separately.  To  diagnose  tho 
absence  or  presence  of  a power  of  perception  of 
light,  certain  important  precautions  must  be 
taken,  as  almost  all  patients  who  are  abso- 
lutely blind  will  declare,  and  probably  be- 
lieve, that  they  still  can  see  light,  i.e.  objective 
light.  The  patient  should  be  placed  opposite  to 
a bright  light,  such  as  a gas-lamp,  and  near  to  it, 
but  not  so  near  that  he  can  feel  the  heat  of  it ; 
the  light  is  then  turned  up  and  down,  and  it  is 
fully  exposed  and  obscured,  and  the  patient  is 
asked  many  times,  in  quick  succession,  if  he  sees 
light  or  not.  The  light  should  be  left  burning 
and  exposed,  or  not,  during  several  of  the  suc- 
cessive queries,  so  as  to  do  away  with  any  doubt. 
The  word  of  the  patient  untested  is  quite  inad- 
missible. Any  ether  blindness  than  this  of  abso- 
lute amaurosis,  or  originating  in  any  other 
diseases  than  those  of  the  percipient  nervous 
apparatus  of  the  eye,  is  never  so  great  as  to 
prevent  the  perception  of  light.  If  the  patient 
can  see  light  from  darkness,  test  whether  he  can 
see  shadows  of  some  small  object — of  the  hand, 
or  of  ono  finger  only,  passed  between  him  and 
tho  burning  light,  or  the  light  of  the  window 
only.  If  he  can  see  to  count  fingers,  his  blind- 
ness is  insufficient  to  indicato  what  is  called 
amaurosis.  Another  point  in  the  diagnosis  of 
amaurosis  is  that,  ophthalmoscopically,  the 
appearance  of  the  fundus  of  the  eye  is  normal, 
or  such  as,  independent  of  errors  of  refrac- 
tion, wo  find  in  other  cases  compatible  with 
standard  vision,  or  at  least  with  a fair  amount 
of  useful  vision.  This  will  allow  of  aconsiderable 
latitude,  and  will  not  include  any  slight  or  imagi- 
nary hyperremia  or  anmmia  of  the  optic  disk, 
any  physiological  excavations  of  the  same,  or 
congenital  opacities  of  the  retina,  etc.  The  pupil 
of  the  affected  eye  is,  if  the  other  be  perfectly  ex- 
cluded from  light  or  vision,  nearly  always  dilated, 
to  almost  the  greatest  extent,  though  atropine 
dilates  it  yet  more  fully,  and  it  is  fixed,  being 
insensible  to  light. 

Prognosis. — After  a due  consideration  ol 
the  cases  thus  classed  together — and  they  are 
very  unlike  in  fact,  and  often  very  obscure — wo 
may  say  generally,  that  if  the  blindness  be  of 
one  eye  only,  sudden  and  recent,  the  prognosis  is 
hopeful ; but  if  both  eyes  are  affected,  and  the 
disease,  whatever  it  may  be,  is  of  steady  progress 
and  of  long  standing,  it  is  very  serious.  Tho 
cases  of  amaurosis  are  very  rare  indeed  in  which 
vision  is  perfectly  restored ; most  of  them  end 
fatally  to  vision,  or  would  so  end  but  that  tho 
disease  is  sooner  fatal  to  life. 

Treatment. — This  must  necessarily  be  varied 
according  to  the  cause  of  the  amaurotic  condi- 
tion. For  instance,  if  there  is  intra-cranial 
disease,  treatment  directed  thereto  must  be  fol- 
lowed out ; and  should  there  be  indications  of 
syphilis,  iodide  of  potassium  and  small  doses  of 
mercury  must  be  given  for  some  time.  When 
amaurosis  depends  on  any  injurious  habit,  sueh- 
as  smoking,  this  must  be  relinquished.  Large 
doses  of  strychnine  and  iron  are  useful  in  ad- 
vanced white  atrophy.  J.  P.  Streatfeild. 

AMBLYOPIA  (ap&Xus,  blunt,’  and  Snit, 
sight). — Obscurity  of  vision.  See  Amaurosis. 


33  AMBULATORY. 

AMBULATORY  ( ambulare , to  -walk).— A 
term  applied  to  latent  typhoid  fever,  signifying 
that  the  patient  is  able  to  walk  about  during 
the  attack.  See  Typhoid  Fever. 

AMENOHBHCEA  (a,  priv.  ; /ur/v, a month; 
and  I flow). — Absence  of  the  menstrual  flow 
during  any  portion  of  the  period  of  life  when  it 
tight  to  be  present.  See  Menstruation,  Dis- 
orders of. 

AMENORRHCEAL  INSANITY.  See 

Insanity. 

AMENTIA  (a,  priv.,  and  pevos,  the  mind). 
-An  obsolete  term  for  Dementia.  See  De- 
mentia. 

AMNESIA  (a,  priv.,  and  nrijim,  memory). 
See  Aphasia. 

AMPHORIC.— A peculiar  hollow  metallic 
sound,  elicited  occasionally  by  percussion,  but 
more  commonly  heard  in  auscultation.  Am- 
phoric breath-sound  resembles  that  produced 
by  blowing  into  a large  empty  glass  or  metallic 
vessel  (amphora).  See  Physical  Examination. 

AMYGDALITIS  ( amygdala , the  tonsils). 
— A synonym  for  inflammation  of  the  tonsils. 
See  Tonsils,  Diseases  of. 

AMYLOID  DISEASE  (&pv\ov,  starch). 
- The  name  given  by  Virchow  to  Albuminoid 
Disease,  from  the  belief  that  the  material  charac- 
teristic of  this  morbid  condition  is  of  the  nature 
of  starch  or  cellulose.  See  Albuminoid  Disease. 

ANAEMIA  (a,  priv.,  and  alp  a,  blood).— 
iiYNON. : Spancemia  ; Hydrcemia ; Oligamia  ; A- 
glohulism . Fr.  Anemie.  Ger.  Anamie  ; Blutar- 
muth. 

Definition. — Deficiency  of  blood  in  quantity, 
either  general  or  local ; also,  deficiency  of  the 
most  important  constituents  of  blood,  particu- 
larly albuminous  substances  and  red  corpuscles. 

This  definition  is  purely  pathological,  and  the 
condition  thus  expressed  presents  many  varieties, 
Anaemia  in  the  widest  senso  of  the  term  including 
Oligaemia,  Oligocythaemia,  Hydraemia,  and  Spanae- 
uiia,  as  well  as  Chlorosis.  (See  Chlorosis,  Hydre- 
mia, SpANiEMiA,  Oligocythemia,  and  Blood, 
Morbid  Conditions  of.)  From  the  clinical  point  of 
view,  Anaemia  is  a condition  of  system  in  which 
impoverishment  of  the  blood,  whether  from  want 
or  from  waste,  is  associated  with  symptoms  of 
imperfect  discharge  of  the  vital  functions. 

AEtiology. — The  causes  of  anaemia  are  gene- 
rally multiple  and  complex.  First,  the  supply 
of  blood  to  the  body  may  be  insufficient,  and  that 
from  a variety  of  causes,  of  which  the  chief  are : 
— derangements  of  alimentation,  including  in- 
sufficient food,  and  morbid  states  of  the  lymphat  ic 
and  blood-glands ; such  defective  hygienic  con- 
ditions affecting  the  formation  and  nutrition  of 
the  blood  as  want  of  light,  air,  and  muscular 
exercise ; prolonged  exposure  to  the  influence  of 
certain  poisons,  as  lead,  mercury,  and  malaria ; 
and,  lastly,  interference  with  the  free  circulation 
of  the  blood  by  cardiac  or  vascular  disease, 
such  as  valvular  disease  or  dilatation  of  the  heart 
and  aneurism  of  the  aorta.  Secondly,  the  con- 
sumption of  blood  may  be  increased  by  haemor- 
rhage ; by  profuse  discharges,  such  as  suppura- 


ANAEMIA. 

tion,  catarrh,  and  albuminuria;  by  rapid  growth 
and  development ; by  frequent  pregnancy  and 
superlactation ; by  excessive  muscular  exertion  , 
and  by  the  presence  of  pyrexia, or  of  new  growths, 
which  rob  the  system  of  nutritive  material. 
In  a third  group  of  cases  of  anaemia  both  the 
supply  and  the  consumption  are  at  fault.  Thus 
derangement  of  the  organs  and  of  the  whole  process 
of  sanguification  is  frequently  associated  with 
profuse  discharges  from  various  parts  ; and  in 
malignant  diseases  and  the  ‘ chronic  constitu- 
tional diseases,’  such  as  syphilis,  tuberculosis, 
Bright’s  disease,  albuminoid  disease,  Addison’s 
disease,  and  others,  the  cause  of  the  anaemia 
is  extremely  complex.  But  the  majority  of  the 
cases  of  anaemia  that  aro  regarded  and  treated 
as  such  fall  into  the  class  to  which  the  name  of 
idiopathic  has  been  applied.  In  such  cases  the 
anaemic  condition  is  due,  not  to  any  disease  so- 
called,  but  to  disturbance  of  nutrition  generally, 
that  is  of  the  healthy  relation  between  the 
demands  of  the  system  and  the  supply  of  nu- 
trient material  This  condition  occurs  chiefly 
in  children  and  young  women,  at  the  period 
of  bodily  growth  and  of  the  development  and 
early  activity  of  the  sexual  functions ; and  when, 
as  so  frequently  and  unfortunately  happens, 
the  air,  light,  food,  occupation,  and  moral  rela- 
tions of  the  individual  are  all  more  or  less  un- 
healthy. 

Anatomical  Characters. — The  blood  suffers 
three  principal  changes  in  declared  anaemia, 
namely,  (1)  deficiency  in  amount  (Oligaemia) ; (2) 
deficiency  in  red  corpuscles  or  haemoglobin  (Oli- 
gocythsemia,  Aglobulism) ; and  (3)  deficiency  in 
albuminous  constituents  (Hypalbuminosis).  Of 
these  Oligaemia  is  the  simplest,  and  perhaps  never 
occurs  alone ; it  is  speedily  complicated  with 
Aglobulism,  which  is  a very  early  and  common,  as 
well  as  the  most  obstinate,  change  in  tbc  blood. 
Hypalbuminosis  is  the  most  advanced  and  perhaps 
the  most  serious  alteration  of  the  throi.  ( See 
Blood,  Morbid  Conditions  of.)  The  blood  is 
scanty  and  pale,  and  has  a diminished  specific 
gravity;  and  coagulates  slowly  and  loosely,  or  in 
aggravated  cases  not  at  all,  settling  into  three 
layers — consisting  respectively  of  red  corpuscles, 
white  corpuscles,  and  plasma.  The  body  pre- 
sents certain  changes  directly  due  to  the  state 
of  the  blood.  Whether  the  anaemia  be  local  or 
general,  the  corresponding  parts  are  blanched 
and  ‘ bloodless.’  The  cells  of  the  tissues  become 
atrophied  and  degenerate,  in  consequence  of,  and 
in  proportion  to,  the  interference  with  their  plastic 
and  functional  activity  respectively ; and  the 
so-called  ‘amende’  form  of  fatty  heart,  liver, 
kidneys,  and  other  organs,  is  the  result.  If  death 
occur  suddenly  from  acute  anaemia  the  heart  is 
found  empty  and  contracted. 

Pathology. — W'hcn  the  volume  of  blood  in 
the  body  has  been  reduced  by  repeated  small  hae- 
morrhages, the  phenomena  that  supervene,  while 
they  express  the  want  of  blood  as  a whole,  and 
of  its  several  constituents,  are  chiefly  referable 
tb  the  loss  of  two  of  these  constituents — the 
albuminous  substances  and  the  red  corpuscles  or 
haemoglobin — that  is,  of  the  oxidisable  and  the 
oxidising  materials.  The  pathology  of  hypalbu- 
minosis and  aglobulism  is  fully  discussed  in  the 
article  on  diseases  of  the  blood,  and  need  not  1* 


AN. 4': 

.•opeated  here.  The  same  effects  will  be  pro- 
duced by  a drain  of  the  liquid  part  only  of  the 
blood,  or  by  poverty  of  the  blood  from.  aDy  of 
the  causes  enumerated  above,  whether  of  the 
uature  of  waste  or  of  want ; inasmuch  as  loss  of 
plasma  speedily  affects  the  nutrition  of  the  red 
corpuscles.  These  phenomena  constitute  the 
symptoms  of  the  anaemic  condition  whatever  may 
be  its  cause  ; their  relative  prominence  naturally 
varying  according  to  an  immense  number  of  cir- 
cumstances. 

Symptoms. — The  subjects  ofanaemia  are  usually 
girls  and  young  women.  Their  general  appear- 
»nce,  which  is  striking,  is  one  of  pallor,  debility, 
and  variable  loss  of  feminine  fulness.  The 
visible  parts  of  the  surface  are  pallid,  often 
with  a tinge  of  dusky  brown  on  the  eyelids 
and  the  backs  of  the  hands;  the  clearness  of 
the  complexion  varies  with  the  normal  pig- 
mentation of  the  body  • the  skin  is  soft,  satiny, 
and  rather  loose.  The  mucous  surfaces  also  are 
blanched  ; the  sclerotic  is  pearly  blue.  The  loss 
of  flesh  maybe  moderate,  or  it  may  be  considerable. 
The  extremities  are  cold,  and  the  legs  and  lower 
eyelids  are  often  cedematous.  Bodily  strength 
is  reduced ; muscular  force  is  diminished,  while 
myalgia  is  common  ; an  air  of  languor  and  want  of 
vigour  pervades  the  whole  demeanour  ; and  the 
patient  is  sleepy,  dull,  and  depressed.  The  subject 
of  anaemia  generally  complains  of  weakness,  va- 
rious pains  about  the  body  and  head,  and  marked 
shortness  of  breath  on  the  least  exertion.  The 
last  symptom  is  unaccompanied  by  other  evi- 
dence of  respiratory  derangement;  in  character 
the  breathing  is  regular,  and  short  or  even  pant- 
ing. The  symptoms  referable  to  the  circulation 
consist  chiefly  of  palpitation  on  exertion;  a 
tendency  to  faint ; and  pain  or  even  distress  over 
the  cardiac  region.  The  impulse  is  variable  ; the 
first  sound  is  either  hollow  or  murmurish,  or  con- 
verted into  a murmur  at  the  base,  and  frequently 
even  over  the  whole  praecordium  ; the  diastolic 
sound  is  sharp  generally.  Over  the  manu- 
brium and  in  the  cervical  vessels  a murmur 
followed  by  a sharp  sound  is  commonly  audible, 
and  therewith  a venous  hum.  The  cervical 
vessels  may  throb ; the  radial  pulse  is  small,  soft, 
weak,  and  of  variable  but  usually  increased  fre- 
quency and  suddenness.  There  is  a tendency  to 
haemorrhages,  especially  epistaxis  ; and  petechiae 
are  occasionally  observed.  The  digestive  system 
is  markedly  affected,  as  shown  by  loss  or 
perversion  of  appetite  ; an  anaemic,  often  bare, 
but  variable  tongue ; dyspepsia,  nausea,  and  sick- 
ness after  meals  or  on  rising;  and  constipation, 
which  is  present  in  the  majority  of  cases  and  is 
frequently  prolonged  and  severe.  The  menstrual 
functions  are  almost  always  deranged ; amenor- 
rhoea  is  common  in  some  form  ; menorrhagia  is 
rare  (except  as  a cause  of  anaemia) ; dysmenor- 
rhoea  is  frequently  associated  ; and  leueorrhoea  is 
the  rule.  The  urine  is  usually  abundant  and  pale, 
but  varies  greatly.  Headache  and  other  cerebral 
symptoms  are  common.  Blood  drawn  from  the 
finger  presents  aglobulism.  (S'eeHjEMACYTOMETEB. 

The  leading  phenomena  of  acute  anaemia  are 
those  of  syncope,  or  suspended  animation  from 
failure  of  the  circulation,  and  are  described  under 
that  title. 

Course  and  Terminations. — The  course  of 


MIA.  31' 

anaemia  in  this  form  is  essentially  slow  and  pro- 
gressive, unless  it  is  checked ; the  duration  is 
perfectly  indefinite.  The  course  of  the  symp- 
tomatic form  will  naturally  vary  with  its  cause, 
idiopathic  anaemia  rarely  terminates  fatally : and, 
when  it  does  so,  the  event  may  be  referred  with 
few  exceptions  to  some  complication.  Occa- 
sionally, however,  it  proceeds  steadily  to  death 
(see  Progressive  Pernicious  An.emia,  below). 

Intercurrent  diseases  may  be  expected  to  he 
severe  in  an  anaemic  condition,  in  proportion 
to  its  degree. 

Diagnosis. — Anaemia  is  generally  recognised 
with  the  greatest  ease,  and  the  chief  question 
of  diagnosis  relates  to  its  cause.  The  first  point 
to  be  determined,  therefore,  is  whether  it  is  not 
symptomatic  of  some  more  grave  state,  such  as 
tuberculosis,  syphilis,  albuminoid  disease,  or  some 
other  of  the  many  possible  causes  of  poverty 
of  blood.  Having  settled  that  the  anaemia  if 
idiopathic,  we  must  next  exclude  two  diseases 
with  which  it  may  be  confounded,  namely, 
chlorosis  and  leukaemia.  Chlorosis,  in  which  the 
plasma  is  not  considered  to  be  altered,  and  which 
possesses  otherwise  a special  pathology,  is  ex 
pressed  by  the  yellow  tint  of  skin,  by  the  absence 
of  wasting  and  of  dropsy,  as  well  as  by  other 
features  ( see  Chlorosis.)  Leukaemia  is  recog- 
nised by  examination  of  the  blood,  spleen,  and 
lymphatic  glands.  The  starting-point  of  the 
blood-change  in  cases  of  idiopathic  anaemia,  can 
only  be  discovered  by  careful  investigation  of 
all  the  facts  of  the  case. 

Prognosis. — The  prognosis  of  anaemia  is 
favourable  as  regards  life.  In  simple  anaemia 
from  loss  of  blood,  the  patient  may  be  assured  of 
speedy  and  complete  recovery.  In  idiopathic 
anaemia,  however,  this  promise  can  be  given  only 
when  the  cause  can  be  removed  or  avoided. 
Under  favourable  circumstances  and  sound  treat- 
ment, improvement  will  begin  almost  immedi- 
ately ; and.  health  should  be  restored  after  a few 
weeks  or  months. 

Treatment.  — The  treatment  of  anaemia, 
when  it  is  symptomatic  of  some  more  grave  con- 
dition, such  as  Bright’s  disease  or  phthisis,  does 
not  require  notice  here.  When  blood  has  been 
lost  in  serious  quantity,  without  other  injury  of 
consequence,  it  will  be  naturally  restored  if  suffi- 
cient time  but  be  given  and  interference  other- 
wise avoided.  Attention  to  the  ordinary  rules  of 
health,  abundance  of  food  and  air,  and  moderate 
exercise,  will  surely,  if  slowly,  restore  the  patient, 
without  the  administration  of  a single  drug.  Even 
in  this  case,  however,  treatment  may  be  of 
great  service,  by  arresting,  if  necessary,  the  cause 
of  the  anaemia,  such  as  menorrhagia  or  epistaxis ; 
and  by  assisting  nature,  if  the  condition  should 
threaten  at  any  time  to  become  intensified  by  its 
own  effects. 

But  before  the  blood  can  be  restored  in  the 
large  and  ill-defined  group  of  cases  known  as 
idiopathic  anaemia,  the  unhealthy  influences  under 
which  the  patient  is  placed,  and  the  functional  and 
other  derangements,  which  are  usually  accountable 
for  the  imperfect  sanguification,  must  be  dis- 
covered and  corrected.  Where  the  aetiology  is 
complex,  treatment  must  be  equally  general,  and 
the  whole  system  of  life  will  have  to  be  reformed. 
On  the  other  hand,  in  the  rapidly  growing  child 


10  AN2EMIA. 

iud  youth,  and  still  more  in  girls  at  puberty,  the 
great  demand  for  nutritive  material  must  be  duly 
considered  and  every  obstacle  to  its  supply  re- 
moved. When  other  than  direct  discharges  are 
draining  the  blood  they  must  be  cheeked.  Lac- 
tation may  have  to  be  forbidden  ; and  leucorrhoea 
and  spermatorrhoea  'will  sometimes  demand  local 
treatment. 

The  removal  of  the  cause  being  thus  made  the 
first  element  in  treatment,  means  must  next  be 
adopted  for  the  restoration  of  the  blood.  But 
before  this  can  be  accomplished,  it  will  be  neces- 
sary to  bring  the  alimentary  tract  and  the  organs 
of  sanguification  into  a healthy  state.  Dyspepsia 
and  constipation  require  immediate  treatment; 
and  for  this  purpose  simple  alkaline  and  bitter 
stomachics  with  rhubarb,  and  free  purgation  by 
ordinary  means,  followed  by  a course  of  aloes 
and  iron  pill  at  night,  are  the  best.  The  food 
must  be  carefully  ordered,  so  that  it  shall  not  only 
supply  the  albuminous  elements  that  are  specially 
deficient  in  the  blood,  but  be  retained  and  ab- 
sorbed ; it  must  therefore  be  at  once  nourishing 
and  digestible,  and  be  taken  in  small  quantities 
at  frequent  intervals.  The  patient  must  not  be 
allowed  to  yield  to  the  disgust  that  she  may 
have  for  meat. 

The  process  of  sanguification  may  be  success- 
fully assisted  by  means  of  drugs.  Iron  is  the 
sovereign  remedy  for  aglobulism  ; and,  practically 
speaking,  it  speedily  becomes  a question  in  the 
treatment  of  a case  of  anaemia  in  what  form  iron 
is  to  be  given.  The  compound  iron  mixture  of 
the  pharmacopoeia  answers  more  frequently  than 
any  other ; but,  on  the  one  hand,  when  there  is 
much  constipation,  the  protosulphate  with  pur- 
gative saline  sulphates  will  be  more  suitable 
for  a time  ; and,  on  the  other  hand,  when  there 
is  a tendency  to  discharges,  the  per-salts  with 
bitters  will  better  answer  the  purpose.  The 
combinations  of  iron  with  quinia  or  strychnia, 
should  be  given  in  cases  where  less  marked 
anaemia  occurs  in  older  subjects  with  nervous 
depression  and  general  want  of  vigour.  In 
special  cases  the  ferrum  redactum,  saccharated 
carbonate,  vinum  ferri,  or  the  French  dragees  fer- 
ruginenses at  meal  timesmaybeordered.  Cod-liver 

011  may  sometimes  be  prescribed  with  success. 
Other  symptoms  must  be  treated  on  ordinary 
principles.  Uterine  complaints  demand  special 
attention  ; and  bromides,  ergot,  opium,  and  other 
sedatives  and  astringents  are  indicated  where 
excitement  and  excessive  discharge  are  present. 
While  these  dietetic  and  medicinal  measures  are 
being  carried  out,  it  is  impossible  to  insist  too 
strongly  upon  attention  to  bodily  and  mental 
hygiene.  In  a large  number  of  cases  change 
of  air  fulfils  all  the  necessary  conditions,  and  it 
is  generally  to  be  recommended.  Above  all, 
time  is  an  essential  element  in  the  cure  ; and 
rest  is  scarcely  less  so.  A frequent  charge  in 
the  form  of  the  medicinal  remedies  is  also 
advisable. 

Progressive  Pernicious  Anaemia.  — A 
peculiar  form  of  anaemia  has  long  been  known, 
but  has  lately  attracted  special  attention,  and 
is  variously  designated  as  pernicious,  malig- 
nant, idiopathic,  and  progressive,  on  account 
of  the  intensity  of  the  symptoms,  the  ob- 
scurity of  its  pathology,  and  the  frequency  with 


ANAESTHETICS. 

which  it  advances  to  a fatal  termination.  Thib 
disease  may  occur  in  both  sexes,  but  has  beenmost 
frequently  observed  in  middle-aged,  pregnant  wo- 
men ; it  presents  no  special  post-mortem  appear- 
ances ; and  it  cannot  be  referred  to  any  reasonable 
cause.  The  symptoms  are  those  of  excessive  anae 
mia,  as  described  above ; but  gastric  disturbance 
and  general  haemorrhages  are  relatively  promi- 
nent, and,  in  some  cases,  irrpgular  attacks  of 
pyrexia  occur.  The  blood  during  life  is  said  to 
differ  from  that  found  in  ordinary  anasmia,  by  con- 
taining an  unusual  amount  of  ill-shaped  red  cor- 
puscles and  granular  matter.  The  course  of  the 
disease  is  steadily  towards  death,  in  which  it  gene- 
rally terminates.  The  pathology  of  progressive 
pernicious  anaemia  is  obscure.  It  is  believed 
by  some  to  be  but  the  advanced  stage  of  or- 
dinary anaemia,  which  attracts  attention  by 
its  resistance  to  treatment,  and  its  fatal  ter- 
mination. The  appearance  of  the  blood  would 
seem  to  indicate  excessive  destruction,  rather  than 
insufficient  supply  of  the  important  elements,  as 
the  essential  cause  of  the  morbid  condition;  but 
there  is  probably  derangement  in  both  directions. 
The  prognosis  is  as  unfavourable  as  possible. 
Treatment  must  be  ordered  on  general  principles  : 
transfusion  has  been  frequently  tried,  but  with- 
out success.  J.  Mitchell  Bruce, 

ANEMIA  LYMPHATICA.-A  form  of 

Anaemia  which  is  associated  with  a peculiar  af- 
fection of  the  Lymphatic  System.  See  Hodg- 
kin's Disease. 

ANESTHESIA  (a,  priv.,  and  aurdavo/xai,  I 
feel). — Anaesthesia  literally  means  absence  or  loss 
of  sensation,  which  may  be  general  or  local. 
The  word  is,  however,  more  especially  employed 
to  signify  loss  of  tactile  sensibility,  as  distin- 
guished from  insensibility  to  pain  or  Analgesia. 
It  is  further  used  to  indicate  the  condition  in- 
duced by  the  action  of  Anwsthetics  upon  the 
system.  See  Sensation,  Disorders  of. 

ANESTHETICS. — Definition.  The  name 
given  to  a series  of  agents  which  are  employed 
for  the  prevention  of  pain,  but  more  especially 
applied  to  those  used  in  surgical  practice. 

History. — The  idea  of  annulling  pain  in  sur- 
gical operations  is  a very  old  one.  Compression 
of  the  nerves  and  blood-vessels,  and  the  inhala- 
tion of  the  vapour  of  mixtures  containing  car- 
bonic anhydride  were  practised  at  an  early  date. 
In  the  sixteenth  century  ether  was  probably  the 
active  ingredient  of  a volatilo  anaesthetic  de- 
scribed by  Porta.  The  use  of  anaesthetics  was, 
however,  but  little  understood  and  rarely  prac- 
tised. Even  the  suggestion  of  Sir  Humphry 
Davy,  that  nitrous  oxide  should  be  used  in  minor 
operations  not  attended  with  loss  of  blood,  was  of 
little  practical  value,  on  account  of  the  inefficient 
apparatus  then  available.  In  1 815  Horace  Wells 
inhaled  laughing  gas  so  successfully  that  he  may 
be  said  to  have  introduced  the  practice  ; but  he 
appears  to  have  so  often  failed  to  produce  the 
desired  effect  that  this  agent  fell  into  disuse 
on  the  introduction  of  ether  in  1816  by  Morton, 
after  some  communication  on  its  properties  from 
a chemist  named  Jackson.  In  1847  chloroform 
was  used  by  Simpson,  and  quickly  superseded 
ether  almost  all  over  Europe.  At  the  presen' 


ANESTHETICS. 


time  the  comparative  safety  of  ether  has  caused 
this  anaesthetic  again  to  be  preferred  by  many 
surgeons  in  this  country. 

Enumeration. — The  three  agents  just  men- 
tioned, namely,  nitrous  oxide,  ether,  and  chloro- 
form, are  those  chiefly  in  use,  and  they  have  each 
advantages  in  particular  cases.  Experiments  made 
vith  other  agents,  such  as  amylene,  tetrachloride 
of  carbon,  ethidenedichloride,  and  bichloride  of 
methylene,  have  not  shown  that  they  possess 
sufficient  advantages  to  counterbalance  the  defect 
of  requiring  special  management  in  their  ad- 
ministration. This  list  of  anaesthetics  might  be 
still  further  increased,  for  in  order  to  produce 
insensibility  it  is  only  necessary  to  reduce  the 
supply  of  arterialised  blood  to  the  nervous 
centres,  or  to  introduce  into  the  blood  a sub- 
stance which  deprives  it  of  its  power  of  oxygen- 
ating the  tissues. 

Modes  of  Use. — Anaesthesia  may  be  produced 
for  surgical  purposes: — 1.  by  benumbing  the 
part  to  be  operated  on  by  means  of  cold  ; 2.  by 
intercepting  its  nervous  communication;  3.  by 
arresting  the  activity  of  the  nervous  centres 
concerned  in  sensation.  Thus  anaesthetics  may 
be  local  or  general  in  their  action. 

Local  Anaesthesia  may  be  induced  by  cold. 
The  most  convenient  plan  is  to  blow  a jet  of 
anhydrous  ether  spray  upon  the  part,  as  sug- 
gested by  Dr.  Kichardson,  and  thus  to  freeze  it. 
The  surface  to  be  frozen  should  be  dry,  and  hence 
the  difficulty  of  freezing  the  gum  of  the  lower  jaw, 
on  account  of  the  saliva.  A mixture  of  equal 
parts  of  pounded  ice  and  common  salt  contained 
in  a bag  of  muslin  is  effective,  but  less  easily 
applied.  This  plan  is  adapted  for  opening  ab- 
scesses and  boils,  and  for  the  extraction  of  a few 
teeth  ; but  the  process  both  of  congelation  and 
of  thaw  is  painful.  Chloroform  applied  locally 
is  said  to  cause  numbness,  but  it  is  very  little 
used  except  inside  the  mouth,  and  then  it  owes 
its  soothing  effects  to  the  quantity  of  chloroform 
vapour  which  is  inhaled.  Compression  of  nerve 
trunks  for  inducing  anaesthesia  is  never  prac- 
tised at  the  present  day. 

General  Anaesthesia  is  at  present  rarely 
obtained  in  any  other  way  than  by  inhalation, 
although  successful  attempts  have  been  made  to 
induce  the  condition  by  subcutaneous  and  in- 
travenous injection  of  chloral  or  morphia. 

Subjects  for  Anesthetics. — We  may  say 
generally'  that  any  person  fit  for  a severe  ope- 
ration is  a fit  subject  for  an  anaesthetic,  but  no  one 
is  so  free  from  danger  that  care  in  watching  its 
effects  can  be  dispensed  with.  The  cases  requiring 
the  greatest  vigilance  are  not  the  young  and  deli- 
cate, forwhom  a small  dose  suffices,  butthestrong, 
who  inhale  deeply  and  struggle  much.  Ether  is 
probably  better  for  those  suspected  of  fatty  de- 
generation of  the  heart,  although  as  a rule  such 
cases  aro  eminently  satisfactory  under  chloro- 
form. Many  of  the  deaths  under  chloroform 
have  occurred  in  intemperate  drinkers,  and  the 
presence  of  alcohol  in  the  system  undoubtedly 
intensifies  its  effect. 

Precautions. — Before  commencing  inhalation 
file  following  particulars  should  be  attended  to. 
The  patient  must  not  have  recently  taken  a full 
meal  ; he  should  lie  comfortably,  in  a horizontal 
position  if  possible,  unless  when  gas  or  ether  is 


41 

given  for  a short  operation  ; and  the  dress  should 
not  be  tight.  When  the  administration  is  begun, 
he  should  be  encouraged  to  breathe  regularly  and 
freely.  The  pulse  as  well  as  the  respiration  must 
be  watched.  If  the  vapour  excites  either  swal- 
lowing or  coughing,  it  is  more  pungent  than  is 
requisite,  and  its  strength  should  be  diminished. 
Most  patients  are  at  first  afraid  of  breathing, 
and  some  hold  their  breath  for  half  a minute. 
The  vapour  should  not  be  removed  on  this 
account,  but  care  should  be  taken,  by  holding 
the  inhaling  apparatus  farther  off,  to  prevent 
the  vapour  becoming  too  strong  in  the  interval. 
After  volition  has  been  abolished,  any  pause  in 
the  breathing  should  be  noted,  and  more  or  less 
fresh  air  given.  Further  directions  will  be  given 
in  describing  the  anaesthetics  specially. 

Special  Anesthetics. — Protoxide  of  Nitrogen , 
Nitrous  Oxide,  or  Laughing  Gas.  This  agent  is 
now  prepared  wholesale,  and  sold  condensed  into 
a liquid  in  strong  iron  bottles.  The  gas,  whether 
supplied  thus  or  from  a gasometer,  should  be 
inhaled  from  a bag  having  such  a free  com- 
munication with  the  face  that  it  will  readily  be 
supplied  even  in  panting  respiration.  A long 
tube,  however  large,  is  objectionable,  as  the  gas 
is  less  mobile  than  common  air. 

The  special  aim  in  giving  gas  should  at  first 
be  to  exclude  air,  and  to  exchange  the  atmosphere 
within  the  air-passages  and  lungs  for  one  of  pure 
gas.  The  patient  should  not  merely  be  told  to 
breathe  slowly  and  deeply,  but  be  shown  how  to 
do  so,  about  fifteen  times  in  a minute.  The  in- 
spiration should  not  be  jerking,  and  the  expira- 
tion should  be  complete.  It  is  a special  merit 
of  laughing  gas  that  no  harm  can  come  of  inhal 
ing  too  freely  at  first.  The  gas-bag  must  be 
kept  filled  either  by  pressure  on  the  gasometer, 
or  by  turning  the  screw  tap  of  the  gas  bottle. 
This  may  be  done  by  the  hand  of  an  assistant, 
or  more  conveniently  with  the  foot  of  the  admi- 
nistrator, by  means  of  a contrivance  invented  by 
Mr.  Braine,  in  which  the  gas-bottle  is  placed  hori- 
zontally upon  rollers  and  moved  by  the  foot 
whilst  the  head  of  the  screw  is  fixed.  The 
writer’s  plan  is  to  fix  the  bottle  vertically  and 
turn  the  screw  by  pressing  the  foot  against  an 
iron  plate  with  spikes  on  its  upper  surface,  and 
a square  hole  fitting  the  tap  on  its  lower  surface. 
It  is  imperative  that  the  face-piece  or  mouth- 
piece should  fit  accurately,  and  the  air-pad  is 
almost  essential  to  effect  this  in  a great  many 
cases.  It  should  be  warmed  if  the  indiarubber 
is  stiff.  After  five  or  six  good  respirations  there 
is  no  need  of  supplying  fresh  gas  with  each  in- 
spiration. The  expiring  valve  should  be  kept 
closed,  and  the  inspiring  valve  opened.  Care  must 
always  be  taken  that  the  supply’  of  gas  is  suffi- 
cient to  replace  any  that  is  lost  by  absorption 
into  the  blood  or  by  leakage.  This  is  more  easily 
effected  if  the  gas-bag  is  made  of  thin  indiarub- 
ber, so  as  to  distend  easily  and  contract  gently 
with  the  movement  of  breathing.  It  should  be 
sufficiently  filled,  so  that  if  the  mouth-piece  does 
not  fit,  the  gas  would  escape  instead  of  air 
entering  and  becoming  mixed  with  it. 

Lividity  of  the  skin  will  not  help  us  to  know 
when  the  patient  is  fully  under  the  influence  of 
the  gas,  neither  will  insensitiveness  of  the  eyelids, 
nor  yet  the  state  of  the  pupils.  The  breathing 


Vi  AN^ESl 

should  become  stertorous  or  interrupted,  or  the 
pulse  very  feeble,  or  convulsive  twi tellings  should 
occur,  before  the  face-piece  is  removed.  A little  air 
may  be  admitted  by  raising  the  face-piece,  if  the 
operation  is  not  upon  the  face,  and  by  doing  so 
every  fourth  or  fifth  respiration  anaesthesia  may 
be  kept  up  for  several  minutes.  The  effect  of  a 
single  full  inspiration  may  he  to  bring  the  patient 
into  a state  of  excitement,  and  the  continuance 
of  the  gas  without  air  brings  on  convulsive  move- 
ments, so  that  it  is  not  well  adapted  for  any 
operation  lasting  as  much  as  five  minutes,  and 
requiring  steadiness. 

Patients  are  sometimes  so  unsteady  that  it  is 
found  to  be  almost  impossible  to  make  the 
face-piece  fit.  In  such  cases  the  best  plan  is  to 
cover  the  patient's  eyes  and  let  him  breathe  air, 
merely  preventing  him  from  rising  from  the  chair 
or  bed,  and  not  speaking  till  he  is  conscious,  and 
as  soon  as  he  becomes  so  to  recommence  the 
inhaling  as  if  nothing  had  happened.  A violent 
patient  often  becomes  perfectly  rational  in  less 
than  two  minutes. 

Sickness  and  headache  ought  not  to  result 
from  the  inhalation  of  gas,  but  if  the  use  of  it  is 
prolonged,  or  if  the  patient  is  kept  for  several 
minutes  in  a semi-conscious  state,  breathing  a 
little  air  with  the  gas,  both  these  symptoms 
may  occur.  The  recumbent  posture,  quiet,  and 
warmth  to  the  feet,  constitute  all  that  is  likely 
to  be  required  in  the  way  of  treatment. 

Ether,  Sulphuric  Ether,  Ethylic  Ether,  Vinic 
Ether,  or  Oxide  of  Ethyl,  was  first  used  for  anaes- 
thetic purposes  in  1816.  Before  its  use  was  well 
understood  in  England  chloroform  was  brought 
forward  as  a more  convenient  agent,  and  much 
less  unpleasant  to  the  patient.  Ether  is  less 
liable  to  become  dangerous  to  life,  as  it  does 
not  under  ordinary  circumstances  depress  the 
action  of  the  heart. 

If  ether  be  given  from  a towel  or  hollowsponge, 
ihe  best  kind  is  the  JEther  Purus  of  the  Pharma- 
copoeia, of  sp.gr.  '720  ; hut  the  ether  of  sp.  gr.  '735, 
which  contains  a little  water,  answers  very  well 
if  the  towel  or  napkin  is  arranged  so  as  to  form  a 
large  cone,  thus  lessening  the  access  of  fresh  air. 

'i  he  disadvantage  of  using  the  latter  kind  is  that 
the  moisture  of  the  patient’s  breath  condenses 
upon  the  surface  made  cold  by  the  evaporating 
ei.her,  and  diminishes  its  volatility.  When  pure 
ether  is  used,  a certain  amount  of  condensed 
aqueous  vapour  is  taken  up  before  it  reaches 
the  density  '735. 

In  all  inhalers  where  an  arrangement  is  made 
for  preventing  the  ether  from  becoming  too  cold, 
the  washed  ether  '735  may  be  used,  and  will  be 
found  cheaper.  Not  only  is  it  sold  at  a lower 
price,  but  it  is  much  easier  to  keep  from  escaping 
through  cork  or  stopper. 

Although  it  is  not  difficult  to  destroy  dogs  sud- 
denly with  ether,  it  is  believed  by  many  writers 
on  the  subject  that  in  man  it  can  only  prove  fatal 
by  causing  asphyxia,  and  that  the  signs  of  this 
condition  are  so  easily  seen  and  remedied  that 
practically  this  anaesthetic  is  quite  safe.  The 
writer  is  not  of  this  opinion,  believing  that  some- 
times when  narcosis  is  far  advanced,  the  glottis 
will  allow  ether  vapour  to  pass  of  sufficient 
strength  to  stop  the  heart.  Such  cases,  however,  are 
very  rare  indeed.  Ether  is  extensively  adminis- 


tered by  pouring  an  ounce  at  a time  upon  a 
very  large  cup-shaped  sponge,  which,  if  cold 
from  previous  use,  is  dipped  into  hot  water  and 
squeezed  as  dry  as  possible.  It  is  to  be  expected 
that  the  patient  will  resist  breathing  when  this  is 
held  over  his  face,  but  after  a minute’s  struggling 
he  becomes  unconscious,  and  easy  to  manage. 
Compared  with  giving  ether  timidly,  so  as  to 
let  the  patient  remain  delirious  for  several 
minutes,  this  may  be  a good  plan  ; but  there  is 
no  necessity  for  giving  the  ether  so  strongly  if 
we  diminish  the  access  of  fresh  air.  The  ad- 
ministration of  nitrous  oxide  from  which  air  is 
at  first  excluded,  and  afterwards  admitted  very 
sparingly,  has  taught  us  how  slight  the  after- 
effects are  from  the  asphyxiaso  induced.  Cones  of 
leather  or  pasteboard  lined  with  felt,  and  having 
a small  opening  at  the  apex,  are  better  than 
sponges ; but  they  should  be  larger.  They  may 
be  made  more  effective  and  economical  by  placing 
a thin  india-rubber  bag  over  the  apex  of  the  cone, 
so  that  more  of  the  expired  atmosphere  may  be 
breathed  again. 

Morgan’s  inhaler  is  very  efficient.  The  ether 
is  poured  into  a tin  chamber  as  large  as  a hat,  con- 
taining sponge.  This  is  covered  by  a sort  of 
diaphragm,  which  rises  and  falls  with  respiration 
as  the  patient  breathes  into  and  out  of  it  by  means 
of  a tube  and  face-piece.  Thero  are  no  valves. 
Anaesthesia  results  partly  from  asphyxia,  and 
partly  from  the  action  of  the  ether.  The  amount 
breathed  depends  on  its  temperature,  and  on  the 
freedom  of  respiration.  If  the  respiratory 
movements  are  slight,  as  in  young  children,  or 
in  persons  suffering  from  emphysema,  the 
amount  of  ether  supplied  is  apt  to  be  too  small. 
Ormsby’s  inhaler  is  an  improvement  upon  it. 
The  sponge  for  ether  is  contained  in  a cage  near 
the  face-piece. 

An  excellent  inhaler  for  hospital  purposes  and 
for  prolonged  operations  is  sold  by  Mr.  Hawkes- 
ley.  The  ether -vessel  is  kept  in  a water-bath. 
There  are  valves  which  allow  air  to  pass  over 
the  ether,  but  prevent  its  return,  and  the  ap- 
paratus has  an  arrangement  for  lessening  the 
odour  of  ether  in  the  room,  consisting  of  a tube 
leading  to  the  floor,  which  carries  off  the  expired 
air  and  ether. 

With  the  view  of  regulatiug  the  strength  of 
the  ether  vapour,  the  writer  has  contrived  the 
following  apparatus,  which  is  made  by  Mayer  and 
Meltzer.  It  consists  of  an  oval  india-rubber  bag 
fifteen  inches  loDg,  at  one  end  connected  with  the 
face-piece,  at  the  other  with  the  ether-vessel 
Within  the  hag  is  a flexible  tube  also  leading  from 
the  face-piece  to  the  ether  vessel.  By  turning  a 
regulator  the  patient  is  made  to  breathe  into  the 
bag  either  directly  or  indirectly  through  the  tube 
and  ether  vessel,  or  partly  one  way  and  partly  the 
other.  The  more  the  regulator  is  turned  towards 
the  letter  E,  the  more  ether  vapour  he  tikes.  By 
turning  it  back  again  the  amount  of  vapour  is 
diminished.  The  ether- vessel  contains  a reservoir 
of  water,  which  prevents  the  ether  becoming 
too  cold  from  evaporation.  It  is  filled  with 
ether  up  to  a mark  on  the  vessel.  A thermo- 
meter in  connection  shows  the  temperature  of 
the  ether.  The  vessel  should  be  just  dippec. 
into  a basin  of  warm  water  and  gently  rotated 
till  the  thermometer  reaches  from  65°  to  70°. 


ANAESTHETICS. 


When  used  this  vessel  should  be  suspended  by  a 
strap  from  the  neck  of  the  administrator. 

At  first  the  regulator  allows  the  passage  from 
the  face-piece  into  the  bag  to  remain  open,  and 
the  bag  should  be  filled  by  pressing  the  face-piece 
more  firmly  against,  the  face  during  expiration  than 
inspiration.  By  degrees  the  regulator  is  turned 
towards  letter  E,  and  thus  the  way  to  the  inner 
tube  is  opened,  and  the  air  breathed  through  it 
carries  ether  vapour  from  the  vessel  into  the  dis- 
tal end  of  the  bag.  When  the  regulator  allows 
half  the  inspired  air  to  pass  through  the  ether, 
the  vapour  is  strong  enough  to  induce  sleep  in 
two  mi-nutes,  usually  without  exciting  cough. 
As  the  act  of  swallowing  is  excited  by  a smaller 
quantity  of  ether  than  that  of  coughing,  it  should 
be  watched  for,  and  the  regulator  very  slightly 
turned  back  should  it  occur. 

This  same  apparatus  may  be  used  for  giving 
laughing-gas,  all  communication  with  the  ether- 
vessel  being  cut  off  by  turning  a stopcock, 
and  by  attaching  the  tube  leading  from  the  gas- 
bottle  to  a mount  near  the  bag. 

By  far  the  least  unpleasant  and  the  quickest 
way  of  preparing  a patient  for  a surgical  operation 
is  to  use  gas  and  ether  combined ; the  change 
from  gas  to  ether  being  made  by  turning  the 
regulator  above  described  as  soon  as  the  patient  is 
sufficiently  under  the  influence  of  gas  to  disregard 
the  flavour  of  ether.  The  supply  of  gas  should 
be  stopped  as  soon  as  the  ether  is  introduced ; but 
i ( subsequently  the  patient  is  allowed  to  become 
conscious,  the  gas  may  be  given  freely  as  at  first, 
in  order  to  make  him  sleep  again.  The  writer 
tiuds  less  sickness  and  more  rapid  recovery  from 
the  unpleasant  taste  of  ether  than  when  the  latter 
is  given  alone.  The  chief  difficulty  is  to  prevent 
the  unsteadiness  of  the  patient,  resulting  from 
the  panting  character  of  the  breathing.  To  lessen 
this  the  ether  must  be  given  as  strong  as  possible 
without  producing  initation  of  the  throat,  and 
the  operator  should  wait  until  the  influence  of 
the  ether  has  increased  to  the  production  of  deep 
stertor.  Air  being  then  admitted  with  every 
fourth  or  fifth  inspiration,  the  breathing  soon  be- 
comes as  regular  as  it  is  under  ether  when  given 
in  any  other  way. 

On  recovering  from  the  inhalation  of  ether 
patients  are  often  in  a state  of  intoxication  for  a 
period  corresponding  to  the  time  and  extent  of  l he 
etherization.  The  eyes  should  be  covered,  but  the 
mouth  and  nose  left  free ; and  the  room  should 
bo  kept  quiet,  with  a brisk  fire,  and  the  window 
more  or  less  open.  See  Appendix. 

Chloro  form  was  introduced  by  Simpson  in  1847. 
It  should  not  be  made  from  methylated  spirit, 
and,  when  a drachm  is  poured  upon  blotting 
paper,  it  should  evaporate  without  leaving  an 
unpleasant  odour.  It  is  the  most  convenient 
of  all  anaesthetics,  and  the  most  easy  to  admi- 
nister. Unfortunately,  when  given  beyond  a 
certain  strength,  it  has  a tendency  to  produce 
cardiac  syncope,  and  it  is  not  improbable  that 
6om9  persons  are  particularly  liable  to  be  so 
affected. 

Some  authorities  think  it  desirable  to  give 
alcoholic  stimulants  before  administering  chloro- 
form ; others  partially  narcotize  the  patient 
with  morphia  or  chloral.  No  doubt  these  agents 
assist  the  action  of  the  chloroform,  but  if  from  any 


4a 

accident  an  excess  of  chloroform  should  be  given, 
they  interfere  with  the  means  of  recovery,  and 
for  this  reason  are  not  to  be  recommended. 
There  is  less  objection  to  the  inhalation  of  a mix- 
ture of  chloroform  and  ether,  or  of  these  agents 
with  alcohol ; but  such  mixtures,  if  kept  for  some 
length  of  time,  alter  their  relative  proportions, 
owing  to  the  escape  of  the  more  volatile  in- 
gredients. Even  the  change  from  the  adminis 
tration  of  chloroform  to  that  of  ether,  if  made 
suddenly,  is  not  free  from  danger,  for,  wrhen  a 
person  is  partially  under  the  influence  of  chloro- 
form, the  glottis  allows  a high  percentage  ot 
ether  to  pass  ; and,  if  the  lung-circulation  be 
slow,  as  is  likely  to  be  the  case,  the  blood  may 
be  so  highly  charged  with  ether  as  to  depress 
rather  than  stimulate  the  heart. 

Chloroform,  therefore,  should  be  given  gradu- 
ally. The  object  should  be  to  keep  down  the 
proportion  of  chloroform-vapour  rather  than  to 
give  abundance  of  fresh  air.  In  preparing  for 
an  operation  requiring  perfect  stillness,  six  to 
eight  minutes  should  be  allowed  for  the  process. 
Sponges  or  lint  saturated  with  chloroform,  and 
held  close  to  the  mouth,  are  dangerous,  from  the 
possibility  of  liquid  chloroform  falling  on  the 
lips  or  into  the  mouth.  In  midwifery  practice  a 
piece  of  linen  or  blotting  paper  sprinkled  with 
chloroform  and  placed  at  the  bottom  of  a 
tumbler  is  a convenient  plan  of  administration, 
care  being  taken  to  prevent  any  liquid  chloro- 
form from  settling  at  the  bottom.  In  general 
surgery  a handkerchief  or  towel  may  be  folded 
into  a small  cone,  open  at  the  apex,  into 
which  not  more  than  a drachm  should  be 
poured  at  first,  and  fifteen  minims  at  a time 
afterwards.  A better  plan  is  to  roll  and  tie 
a piece  of  lint  into  a compress  the  size  of  a 
walnut.  A drachm  to  a drachm  and  a-half  of  chlo 
roform  should  be  poured  upon  this,  which  is  to  be 
held  about  an  inch  in  front  of  the  patient's  upper 
lip,  the  hand  and  compress  being  covered  with  a 
towel,  which  should  gradually  be  drawn  over  the 
patient's  face.  This  plan  gives  considerable  com- 
mand over  the  supply  of  chloroform,  for,  when 
the  chloroform,  having  cooled  by  evaporatiou,  is 
given  off  too  slowly,  the  vapour  can  be  increased 
by  warming  the  compress  in  the  palm  of  the 
hand.  When  it  is  becoming  dry  it  ceases  to 
feel  cold,  and  warning  is  thus  given  that  fresh 
chloroform  is  needed.  This  should  be  supplied 
half  a drachm  at  a time.  In  doing  this  the  towel 
should  still  be  left  over  the  face  of  the  patient 
in  order  to  keep  him  breathing  a slightly 
chloroformed  atmosphere.  The  movement  of 
swallowing  should  be  looked  for,  and  regarded 
as  evidence  that  the  vapour  is  stronger  than  is 
necessary.  If  any  sound  like  hiccough  indicates 
laryngeal  obstruction,  the  chloroform  and  towel 
should  be  removed,  and,  if  the  sound  continue, 
the  chin  should  be  raised  as  much  as  possible 
from  the  sternum.  Laryngeal  obstruction  arises 
from  two  main  causes,  viz.,  spasm  of  the  glottis, 
and  falling  down  of  the  epiglottis.  The  first  is 
excited  by  the  pungency  of  the  vapour,  and  also 
by  reflex  action  when  certain  nerves  are  injured, 
notably  when  a ligature  is  tightened  upon  a 
pile.  The  epiglottis  covers  the  larynx  every 
time  we  swallow,  but  the  muscles  coming  from 
the  chin  raise  it  again  directly.  In  deef> 


ANAESTHETICS. 


44 

narcosis  these  muscles  are  sluggish,  and  cannot 
act  thus  if  the  position  of  the  chin  places  them  at 
a disadvantage.  If  raising  the  chin  fail  to  open 
the  air-passage,  the  tongue  must  be  pulled 
forward.  In  doing  this  the  head  should  be 
kept  back.  Depressing  the  chin  renders  a partial 
obstruction  complete.  A laryngeal  sound  in- 
dicating obstruction  is  of  little  consequence  if 
the  pulse  is  good,  since,  although  the  breathing 
be  imperfect,  sufficient  fresh  air  continues  to  be 
breathed;  but  if  the  pulse  flags,  or  if  it  appears 
that  the  amount  of  chloroform  in  the  air-pas- 
sages is  excessive,  not  a moment  should  be  lost 
in  seizing  the  tongue  with  forceps. 

When  a patient  is  delirious  and  struggling, 
extra  care  must  be  taken  that  the  chloroform  be 
not  too  strong,  because  he  inhales  deeply,  carry- 
ing the  vapour  almost  to  the  air-cells  of  the 
lungs,  and,  when  he  next  closes  the  glottis  and 
strains,  l he  pressure  of  the  air  and  vapour  within 
the  lungs  is  increased,  and  the  chloroform  enters 
the  blood  very  quickly.  The  compress  should 
be  held  at  least  two  inches  off  the  mouth, 
although  the  towel  may  still  cover  the  face. 
Directly  any  stertorous  noise  is  heard,  a breath 
or  two  of  fresh  air  should  be  allowed,  and  no 
more  chloroform  given  till  the  pulse  beats  well 
and  the  respiration  is  free. 

Skinner’s  apparatus  -—a  capof ‘domette’  flannel 
stretched  over  a fram9 — is  a much  better  appa- 
ratus than  a towel ; but  its  virtue  is  simplicity, 
and  it  has  little  pretension  to  exactitude.  Snow’s 
apparatus  is  very  efficient,  portable,  and  econo- 
mical. The  addition  of  a water-jacket  to  equal- 
ize the  temperature  was  a great  improvement; 
but  it  should  be  provided  with  a thermo- 
meter. 

The  safest  and  least  unpleasant  mode  of  giving 
chloroform  is  by  means  of  the  apparatus  fitted 
with  a large  bag  of  air  containing  not  more 
than  thirty-three  minims  of  chloroform  in  a 
thousand  inches  of  air.  The  apparatus  is,  how- 
ever, too  complex  to  bo  generally  adopted,  and 
the  writer  hopes  shortly  to  be  able  to  introduce 
a modification  of  it  which  will  be  more  easily 
used.  The  advantage  of  more  precise  measure- 
ment of  the  strength  of  chloroform-vapour  than 
is  afforded  by  towels  or  napkins  will  appear 
when  we  consider  the  Several  circumstances 
that  alter  it  when  so  given. 

The  strength  of  vapour  given  off  from  a known 
quantity  of  chloroform  is  influenced  by : — 

1.  The  extent  of  surface  of  chloroform. 

2.  The  temperature  of  the  chloroform,  which 
is  constantly  changing. 

3.  The  temperature  of  the  air  of  the  room,  of 
the  patient's  face,  and  of  the  administrator's  hand. 

4.  The  distance  at  which  the  chloroform  is 
held  from  the  patient’s  face. 

5.  The  rapidity  of  the  current  of  air. 

6.  The  height  of  the  barometer. 

Moreover,  when  the  chloroform-mixture  is  of 

Known  strength,  its  effect  is  increased  by  high 
barometrical  pressure;  by  low  temperature  of 
the  blood  ; by  deep  or  quick  respiration,  and 
especially  by  muscular  efforts  when  the  glottis 
is  closed ; and  by  slow  movement  of  the  blood 
through  the  lungs. 

On  the  other  hand,  it  is  lessened  by  low  baro- 
metrical pressure  ; by  high  temperature  of  blood ; 


by  superficial  or  slow  respiration ; and  by  rapid 
circulation  through  the  lungs. 

Under  ordinary  circumstances  danger  from 
these  causes  is  easily  averted  with  moderate 
care,  for  they  do  not  often  concur  to  produce 
the  same  effect ; but  if  a patient,  fatigued  with 
struggling,  takes  a very  deep  breath  just  as 
fresh  chloroform  has  been  poured  upon  the 
towel,  and  then  closes  his  glottis  and  makes 
another  struggle — the  barometer  being  high  at 
the  same  time — it  is  evident  that  blood  unduly 
charged  with  chloroform  will  gain  access  into  tho 
coronary  arteries,  and  depress  the  cardiac  ganglia. 
Death  has  occurred  so  rapidly  under  these  cir- 
cumstances, that  it  has  been  thought  to  bo  tho 
result  of  shock  from  the  operation. 

Chloroform  lessens,  if  it  does  not  entirely 
prevent,  the  shock  of  an  operation,  but  it  is  to 
be  feared  that  if  chloroform  be  given  freely  for 
this  purpose,  a dangerous  amount  of  it  will  be 
administered. 

If  a severe  operation  is  about  to  be  performed, 
the  chloroform  should  bo  given  in  the  same 
gradual  manner  as  in  a slighter  one,  but  con- 
tinued to  the  point  of  fixing  tho  pupils  and  pro- 
ducing stertorous  breathing ; and,  when  the  chief 
shock  is  expected,  two  or  three  breaths  of  pure 
air  should  be  admitted,  so  that,  if  the  pulse  fail, 
there  may  not  be  an  excessive  amount  of  chloro- 
form-vapour in  the  lungs. 

Compounds  of  Chloroform. — Under  this  head 
comes  Bichloride  of  Methylene , which  contains 
a variable  quantity  of  chloroform.  Its  che- 
mical characters  and  physiological  effects  are  very 
similar  to  those  of  a mixture  of  chloroform,  ether, 
and  alcohol.  It  narcotizes  quickly',  but  not  safely ; 
and,  as  the  amount  of  chloroform  in  it  is  not 
always  uniform,  it  is  better  to  inix,  in  small 
quantities  at  a time,  one  part  of  alcohol,  two  of 
chloroform,  and  three  of  ether,  and  to  keep  the 
bottle  so  well  corked  that  the  ether  is  not  likely  to 
evaporate  and  leave  chloroform  in  excess.  The 
word  ACE  fixes  the  proportions  in  one’s  memory. 

A mixture  of  one  part  of  chloroform  with 
four  of  ether  is  convenient  for  a brief  operation, 
as  this  produces  much  less  excitement  than  ether 
alone.  On  the  whole  the  writer  objects  to 
keeping  mixtures  of  this  kind  ready-made ; and 
it  is  probable  that  the  plan  of  giving  at  the  out- 
set sufficient  chloroform  to  abolish  conscious- 
ness, and  subsequently  administering  ether,  will 
be  found  safer  than  mixing  them  together  in  the 
liquid  state. 

Ethidcnc,  8>c.  See  Appendix. 

Afte r-tiie atm ent. — Quietude  or  conversation 
of  an  encouraging  or  soothing  character  is  de- 
sirable during  the  half-minute  of  recovery  from 
gas.  The  eyes  should  be  covered,  unless  the 
view  is  tranquil  as  well  as  pleasant.  If  gas  be 
given  until  there  are  intermissions  in  tho 
breathing,  or  its  administration  continued  for 
several  minutes  with  a small  allowance  of  air. 
there  may  be  headache  and  even  vomiting : still 
no  other  treatment  than  repose  is  needed. 

After  the  inhalation  of  ether  a taste  will  re- 
main, varying  with  the  strength  of  the  vapour, 
and  the  duration  of  the  administration.  This 
may  be  got  rid  of  by  washing  out  the  mouth,  and 
gargling  with  warm  fluids ; while  tho  vapour  re- 
maining about  the  patient  and  in  the  room  may 


ANAESTHETICS. 

be  removed  by  beating  the  surface  by  means  of 
hot  bottles,  and  making  a bright  fire. 

When  the  system  has  been  long  or  pro- 
foundly under  the  influence  of  chloroform  or 
ether,  nausea  and  vomiting  are  likely  to  ensue. 
The  writer  has  not  found  any  remedies  more 
efficient  in  relieving  these  symptoms  than 
warmth,  fresh  air,  and  abstinence  from  food. 
Hot  tea  and  coffee,  taken  from  a feeder  without 
raising  the  head,  and  afterwards  beef-tea  and 
jelly,  are  sufficient  for  twenty-four  hours,  unless 
the  patient  wishes  for  something  solid.  The 
rule  then  should  be  to  give  as  little  as,  or  less 
than,  is  asked  for.  Ice  has  been  recommended, 
and,  if  it  does  nothing  else,  it  relieves  thirst, 
and  serves  to  postpone  the  necessity  for  giving 
solids  which  might  prove  hurtful. 

Treatment  of  Dangerous  Symptoms. — An- 
aesthetics in  excess  destroy  life  by  stopping  the 
action  of  the  heart,  or  the  respiration  ; generally 
both  are  affected.  When  laughing-gas  is  given  to 
animals  till  the  breathing  has  ceased,  the  heart 
continues  to  beat  long  afterwards,  and  artificial 
respiration  rapidly  restores  them.  Ether-vapour, 
given  almost  pure  through  a tracheal  tube,  will 
arrest  the  action  of  a dog’s  heart  in  sixteen  se- 
conds; but  if  administered  as  rapidly  as  possible 
with  a cloth,  without  opening  the  trachea,  the 
breathing  fails  before  the  heart,  and  the  lisema- 
dynamometer  shows  adequate  pressure  in  the 
vessels  whilst  the  breath  is  gasping,  and  for 
several  seconds  after  it  has  ceased. 

With  chloroform  the  hsemadynamometer  indi- 
cates diminished  pressure  directly  the  animal 
ceases  to  struggle,  and  the  heart  sometimes  stops 
before  the  breathing.  In  case  alarming  symptoms 
should  arise,  the  first  effort  should  bo  directed 
to  lessening  the  amount  of  tho  anaesthetic  in  the 
lungs,  by  pressing  the  trunk  with  both  hands, 
and  squeezing  out  as  much  air  as  possible  with- 
out causing  a shock.  If,  after  this  has  been 
done  two  or  three  times,  the  air  does  not  readily 
re-enter  the  chest,  tho  obstruction  is  to  be  over- 
come either  by  lifting  the  chin  or  drawing  out 
the  tongue,  and  other  artificial  movements  of 
the  chest  must  bo  carried  on.  ( See  Artificial 
Respiration.)  If  pallor  be  noticed  whilst 
breathing  is  going  on,  the  recumbent  posture 
and  elevation  of  the  feet  are  immediately  re- 
quired. (See  Resuscitation.)  Nelaton’s  plan 
of  inverting  the  body  has  often  been  followed 
by  recovery,  but,  considering  the  impediment  to 
inspiration  from  the  weight  of  the  abdominal 
viscera,  the  writer  is  of  opinion  that  the  pelvis 
should  never  be  many  inches  higher  than  the 
head.  Nitrite  of  amyl — by  reason  of  its  effect 
in  dilating  the  vessels  of  the  skin — has  been 
recommended,  but  without  careful  physiological 
inquiry,  and  upon  very  small  clinical  experience. 

Electricity  might  be  expected  to  prove  the 
best  agent  to  assist  the  action  of  a feeble  heart. 
The  writer's  experimental  observation  has  not 
been  favourable  to  its  employment;  and  cer- 
tainly artificial  respiration  should  not  be  delayed 
one  moment  in  order  to  apply  electricity. 

Insufflation  is  not  to  be  depended  on.  The 
condition  would  be  rendered  worse  by  distending 
the  stomach,  which  cannot  always  be  prevented 
by  pressing  the  larynx  against  the  spine. 

Larvngotomy  may  be  required  in  cases  where  in 


ANAPHEODISIACS.  4S 

spite  of  throwing  the  head  backward,  and  re 
moving  the  chin  away  from  the  sternum,  air  can- 
not be  made  to  enter  the  chest. 

Hot-water  injections  may  be  of  use,  but  the  o 
can  be  no  necessity  for  brandy  whilst  artificial 
breathing  is  being  carried  on.  Afterwards,  if 
swallowing  is  difficult,  brandy  may  be  added  to 
the  enema. 

Friction  of  the  limbs  in  the  direction  of  the 
heart  is  unnecessary,  provided  the  feet  are  slightly 
raised.  Where  there  has  been  great  loss  oi 
blood,  the  limbs  should  be  bandaged  firmly  from 
the  fingers  and  toes  upward,  as  in  Esmarch’s 
plan  for  saving  the  blood  of  a limb  about  to  be 
amputated.  In  warm  weather,  or  if  the  body  is 
warm,  a towel  dipped  in  cold  water  may  be  flap- 
ped against  the  chest,  but  harm  would  result 
from  cooling  the  body  generally.  Bottles  of  hot 
water  and  hot  blankets  should  be  applied  as  soon 
as  the  breathing  is  restored,  and  a brisk  fire 
should  be  kept  up,  in  order  to  favour  the  venti- 
lation cf  the  chamber.  J.  T.  Clover. 

ANALGESIA  (A  priv.,  and  iiA/yos,  pain). — 
Absence  of  sensibility  to  painful  impressions. 
See  Sensation,  Disorders  of. 

ANAPHRODISIA  (a,  priv.,  and  ’A(J>po5iT7j, 
Venus).  — Absence  of  sexual  appetite.  Some- 
times used  to  express  Impotence.  See  Sexual 
Functions,  Disorders  of. 

ANAPHEODISIACS— Definition— Me- 
dicines which  diminish  the  sexual  passion. 

Enumeration. — The  agents  employed  as  ana- 
phrodisiacs  are : — Ice,  Ccld  Baths — local  and 
general ; Bromide  of  Potassium  and  Ammonium ; 
Iodide  of  Potassium ; Conium ; Camphor ; Digi- 
talis ; Purgatives ; Nauseants  ; and  Bleeding. 

Action. — The  erection  which  occurs  in  th< 
genital  organs  during  functional  activity  is  due 
to  dilatation  of  the  arteries  in  their  erectile 
tissues,  and  is  regulated  by  a nervous  centre 
situated  in  the  lumbar  portion  of  the  spinal 
cord.  From  this  centre  vaso-inliibitory  nerves 
pass  to  these  arteries,  and  cause  them  to  dilate 
whenever  it  is  called  into  action.  It  may 
bo  excited  either  reflexly  by  stimulation  of 
the  sensory  nerves  of  the  genital  organs  and  ad- 
joining parts;  or  by  psychical  stimuli  passing  to 
it  from  the  brain.  Anaphrodisiacs  may  act  by 
lessening  the  excitability  of  the  nerves  of  the 
genital  organs,  as  the  continuous  application  of 
cold,  and  probably,  also,  bromide  of  potassium ; 
by  diminishing  the  excitability  of  the  genital  cen- 
tres in  the  spinal  cord  and  brain,  as  bromide  and 
iodide  of  potassium  and  conium ; or  by  influencing 
the  circulation,  as  digitalis.  There  are  also  ad- 
juvant measures,  of  a hygienic  and  moral  charac- 
ter, which  greatly  assist  and  may  even  replace 
anaphrodisiac  medicines,  such  as  a meagre  diet, 
especially  of  a vegetable  nature,  the  avoidance 
of  stimulants,  and  the  pursuit  of  active 
mental  and  bodily  exercise.  Everything  tend 
ing  to  stimulate  the  genital  organs,  or  to  in- 
crease the  flow  of  blood  to  them  or  to  the  lumbar 
portion  of  the  spinal  cord,  should  be  avoided,  such 
as  warm  and  heavy  clothing,  or  pads  about  the 
hips  or  loins ; and  a hard  mattress  should  be 
used  in  place  of  a feather-bed.  Everything 
likely  to  arouse  the  passions,  such  as  certain 


10  ANAPHRODISIACS. 

novels,  pictures,  theatrical  representations,  &c. 

should  also  be  shunned. 

Uses. — Anaphrodisiacs  are  employed  to  lessen 
the  sexual  passions  when  these  are  abnormally 
excited  in  satyriasis,  nymphomania,  and  allied 
conditions.  As  such  excitement  may  some- 
times depend  on  local  irritation  of  the  genitals, 
in  consequence  of  prurigo  of  the  external  organs, 
excoriations  of  the  os  uteri,  or  balanitis ; or  on 
the  presence  of  worms  in  the  rectum  or  vagina ; 
these  sources  of  excitement  should  be  locked,  for, 
and,  if  present,  should  be  subjected  to  appro- 
priate treatment.  T.  Lauder  Brunton. 

ANASARCA  (ava,  through,  and  ad.pl,  the 
flesh). — An  efi'usion  of  serous  fluid  into  the 
subcutaneous  connective  tissues,  not  limited  to  a 
particular  locality,  but  becoming  more  or  less 
diffused.  See  Dropsy. 

ANCHYLOSIS  (ayKi\os,  crooked).— 
Marked  stiffness  or  absolute  fixation  of  a joint, 
which  may  be  due  to  various  morbid  conditions 
of  the  structures  entering  into  its  formation. 
See  Joints,  Diseases  of. 

ANCHYLOSTOMA  (ayuvAos,  crooked,  and 
aviga,  a mouth). — A genus  of  nematoid  worms. 
See  Sci.erostoma. 

ANEURISM  (avevpvvw,  I dilate.)  — Defi- 
nition.— Aneurism  is  a local  dilatation  of  an 
artery,  leading  to  the  formation  of  a tumour 
which  contains  blood,  and  the  walls  of  which  are 
composed  either  of  the  tissues  of  the  vessel,  or 
those  which  form  its  sheath  or  immediately  sur- 
round it.  Therefore  every  aneurism,  properly  so 
called,  consists  of  two  parts — a sac  and  its  con- 
tents. 

Classification. — Aneurisms  are  usually  divi- 
ded, according  to  the  varying  composition  of  the 
sac,  into  the  following  varieties : — 

1.  True  aneurism,  in  which  all  the  three  coats 
of  the  artery  form  the  sac  or  a portion  of  the  sac. 
This  variety  is  rare : at  least  it  is  so  rarely  possible 
to  trace  all  tho  coats  of  the  artery  over  any  part 
of  the  sac  beyond  its  orifice,  that  some  patho- 
logists deny  the  existence  of  this  so-called  ‘ true  ’ 
form  of  aneurism,  and  most  admit  its  existence 
in  the  aorta  only  . 

2.  False  aneurism,  in  which  the  sac  is  formed 
by  one  only  of  the  coats  of  the  artery.  This  is 
almost  always  the  external  coat;  but  a sub- 
variety  has  been  proved  to  exist  as  a consequence 
of  wound  of  the  outer  part  of  the  vessel,  and  is 
believed  by  some  to  take  place  spontaneously,  in 
which  the  inner  coat,  or  the  inner  and  part  of 
the  middle  coat,  is  dilated,  pushed  through  the 
outer  coat,  and  forms  the  sac.  This  is  called 
hernial  false  aneurism. 

3.  Diffused  or  Consecutive  aneurism.  Here 
the  sac  is  formed  of  the  sheath,  cellular  tissue, 
or  other  structures  around  the  artery,  which  are 
matted  together  into  the  form  of  a membrane. 
The  name  ‘ difiused ' is  applied  to  this  form  of 
aneurism  to  express  the  fact  that  the  blood  is  at 
first  diffused  amongst  the  tissues  in  consequence 
of  the  rupture  or  division,  whether  from  injury 
or  disease,  of  all  the  coats  of  the  vessel,  either 
in  a part  or  the  whole  of  its  circumference  ; but 
it  is  not  a good  term,  since,  as  soon  as  the  aneu- 
rismalsaeis  formed,  the  blood  is  diffused  no  longer, 


ANEURISM. 

but,  on  the  contrary,  is  encysted  in  the  newly 
formed  sac.  So  that  the  other  term,  ‘ consecutive,’ 
seems  a better  one,  expressing,  as  it  does,  the 
important  fact  that  the  formation  of  such  aneu- 
risms is  always  consecutive  on  a rupture,  partial 
or  entire,  of  the  artery. 

4.  Dissecting  aneurism  is  seen  only  within 
the  trunk  of  the  body,  and  always  involving  tho 
aorta — although  it  may  spread  from  the  main 
artery  down  to  its  branches.  In  this  form  the 
internal  and  middle  coats  have  given  way,  or 
cracked ; and  the  blood  has  forced  its  way,  usually 
into  the  substance  of  the  middle  coat,  sometimes 
perhaps  between  the  middle  and  outer  coats,  dis- 
tending the  external  portion  of  the  vessel  into  a 
kind  of  aneurism. 

This  is  the  nomenclature  still  in  common  use  ; 
but  as  the  first  and  second  varieties  are  practi- 
cally indistinguishable  during  life,  and  the  first, 
though  called  the  ‘true’  form  of  aneurism,  is 
very  rare,  it  would  be  better  to  include  both 
under  the  common  name  ‘ true  ’ aneurism,  and 
apply  the  term  ‘ false  ’ to  the  third  or  ‘ consecu- 
tive ’ form. 

5.  Besides  these,  which  are  all  forms  of  pure 
arterial  aneurism,  there  are  aneurisms  in  which 
the  vein  and  artery  are  simultaneously  involved, 
and  which  are  therefore  called  Arterio-venous, 
which  will  be  afterwards  spoken  of ; and  tumours 
having  a certain  analogy  to  aneurism,  which  are 
formed  of  dilated  and  tortuous  arteries — Cirsoid 
and  Anastomotic  aneurisms. 

Other  classifications  of  great  importance  are, 
according  to  the  cause  of  the  disease,  into 
Spontaneous  and  Traumatic-,  or,  according  to  tho 
shape  of  the  tumour,  into  Fusiform  and  Sacculated. 
In  fusiform  aneurism  there  is  a dilated  tract  of 
artery,  often  of  considerable  length,  from  either 
end  of  which  springs  the  vessel  of  its  natural 
calibre.  Sacculated  aneurism  springs  like  a bud 
from  one  side  of  the  vessel,  and  the  artery  is  often 
buried  for  some  distance  in  the  wall  of  the  aneu- 
rism ; but  there  are  many  sacculated  aneurisms 
which  approach  in  shape  to  the  fusiform,  tho 
vessel  being  dilated  for  some  part  of  its  extent, 
so  that  its  two  openings  lie  at  different  parts,  and 
sometimes  on  different  aspects  of  the  sac. 

^Etiology  and  Pathology. — The  proximate 
cause  of  spontaneous  aneurism  appears  to  be 
usually  a loss  of  the  elasticity  of  the  wall  of  the 
artery,  whereby  it  loses  its  power  of  resilience 
after  having  been  dilated  by  the  force  of  the  cir- 
culation. This  loss  of  elasticity  is  commonly 
caused  by  atheroma  or  else  by  partial  calcifica- 
tion of  the  wall  of  the  artery.  In  the  latter  case 
the  blood  often  forces  its  way  through  the  entire 
arterial  wall,  and  an  aneurism  of  the  consecutive 
variety  forms,1  or  the  external  part  of  the  artery 
is  dissected  off,  and  a dissecting  aneurism  results. 
Inflammatory  softening  of  the  artery,  without  the 
presence  of  any  definite  atheromatous  deposit  is 
looked  upon  by  many  writers  of  credit,  such  as 
Wilks  and  Moxon,  as  a common  cause  of  aneu- 
rism. Such  low  inflammation  may  have  its 
origin  possibly  in  rheumatism — and,  as  a matter 
of  fact  aneurism  is  often  preceded  by  acute 
rheumatism  ; more  certainly  in  violent  strain,  or 

1 Sometimes,  however,  the  bleeding  will  go  on  without 
the  formation  of  any  aneurismal  eac,  and  lead  to  thf 
loss  of  life  or  limb. 


ANEURISM. 


in  mechanical  violence.  Anything  else  which 
weakens  the  arterial  wall,  such  as  the  exposure 
of  the  vessel  in  an  abscess,  is  looked  on  as  a 
cause  of  aneurism.  The  yielding  of  a weakened 
arterial  wall  is  doubtless  accelerated  by  irre- 
gularities of  the  circulation.  The  influence 
of  syphilis  and  of  intemperance  in  causing 
aneurism  is  widely  believed,  though  perhaps 
as  yet  neither  fact  is  absolutely  established  : the 
latter,  at  any  rate,  is  rendered  very  probable 
from  the  consideration  that  chronic  alcoholism 
tends  to  impair  the  nutrition  of  all  the  tissues, 
including  the  arteries,  and  is  accompanied  by  a 
constantly  irritable  condition  of  the  circulation. 
That  syphilis  may  cause  a fibroid  degeneration 
of  the  vessels  must  also  be  allowed  to  be  at  least 
possible,  and  that  it  does  so  is  the  opinion  of 
many  eminent  pathologists.  If  so,  the  tran- 
sition to  aneurism  is  natural,  if  not  inevitable. 
Another  proved  cause  of  aneurism  is  embolism, 
or  the  obstruction  of  a diseased  artery  by  a 
fibrinous  plug,  which  has  been  known  to  be 
followed  by  the  dilatation  of  the  artery  immedi- 
ately above  the  plug,  just  as  in  very  rare  cases 
the  ligature  of  a healthy  vessel  has  given  rise  to 
the  formation  of  aneurism  above  the  tied  part.1 
Violence  is  a very  frequent  cause  of  aneurism, 
even  in  cases  which  are  not  technically  denomi- 
nated ‘ traumatic.’  The  latter  term  is  generally 
restricted  to  cases  in  which  the  vessel  is  wounded 
by  a cut,  or  is  known  to  be  ruptured,  and  the 
aneurism  makes  its  appearance  at  once  ; and  in 
these  cases  the  aneurism  is  of  the  ‘ diffused  ’ or 
‘consecutive’  variety.  But  there  are,  no  doubt, 
many  cases  in  which  the  artery  is  partially  torn, 
and  the  walls,  being  thus  weakened,  afterwards 
slowly  yield  at  the  injured  spot.  This  fact  is 
illustrated  by  the  well-known  experiment  of 
Richerand,  designed  to  explain  the  frequency  of 
popliteal  aneurism.  The  experiment  consists  in 
hyperextension  of  the  knee  in  the  dead  subject. 
If  this  be  carried  on  forcibly  till  the  ligaments 
are  heard  to  crack,  it  will  usually  be  found  that 
the  two  inner  coats  of  the  popliteal  artery  are 
torn. 

All  these  causes  of  aneurism  act  much  more 
powerfully  in  later  life  than  in  childhood,  and 
many  are  unknown  in  early  years.  Aneurism, 
therefore,  is  very  rare  in  children.  In  cases 
where  the  arterial  system  is  extensively  affected 
with  atheroma,  a great  number  of  aneurisms 
may  be  found  in  the  same  person,  or  another 
may  form  after  the  cure  of  the  first.  To  such 
cases  the  term  ‘ aneurismal  diathesis  ’ has  been 
applied.  This  fact  shows  the  great  importance, 
in  all  cases  of  spontaneous  aneurism,  of  examin- 
ing the  whole  body  to  detect  disease  of  the  heart 
or  any  second  aneurism  which  may  exist. 

Almost  all  aneurisms  contain  more  or  less  clof, 
and  much  of  this  clot  is  usually  of  the  laminated 
variety,  consisting  almost  entirely  of  fibrine 
mixed  with  more  or  less  of  the  blood-corpuscles. 
These  laminated  coagula  adhere  very  firmly  to 
the  interior  of  the  sac  ; they  are  arranged  con- 
centrically like  the  coats  of  an  onion  ; and  usually 
lose  their  colour  in  proportion  to  their  remote- 
ness from  the  blood  which  still  circulates  through 
the  sac.  Their  deposition  depends  in  a great 

1 For  case*  of  this  nature  s«  System  of  Surgery,  2nd 
«dit  ml.  iii.  p.  422. 


47 

measure  on  the  presence  of  rough  projections 
from  the  wall  or  mouth  of  the  sac,  and  on  the 
shape  of  the  aneurism.  "When  the  latter  is 
purely  cylindrical,  much  less  coagulum,  possibly 
none,  will  be  found  in  it.  VTien  the  tumour 
stands  well  away  from  the  artery,  so  that  the 
force  of  the  circulation  is  much  broken,  the 
formation  of  coagula  is  greatly  favoured.  Tim 
deposition  of  such  firm  coagula  must  be  looked 
on  as  the  commencement  of  spontaneous  cure, 
and  at  any  rate  defends  the  patient  from  the 
risks  of  rupture,  or  of  renewed  growth  of  the 
tumour  at  the  parts  which  are  so  lined. 

Symptoms. — The  symptoms  of  arterial  aneu- 
rism are  as  follows : — There  is  a pulsating 
tumour,  which  is  situated  in  the  course  of  one  of 
the  arteries,  and  which  cannot  bo  drawn  away 
from  the  vessel.  The  pulsation  is  equable  and  ex- 
pansile, that  is,  it  not  only  causes  an  up-and-down 
movement  of  the  tumour,  for  such  a movement 
may  be  communicated  to  any  tumour  by  a large 
vessel  lying  in  contact  with  it,  but  also  expands  the 
tumour  laterally  and  in  all  other  directions.  The 
pulsation  is  in  most  cases  accompanied  by  a bruit 
or  blowing  sound,  heard  on  auscultation,  which 
can  be  tolerably  well  imitated  by  the  lipa,  and 
which  is  synchronous  with  the  pulsation.  Pres- 
sure on  the  artery  above  suspends  both  the 
pulsation  and  the  bruit.  Sometimes  it  may 
be  noticed  that  the  pulse  below  is  retarded, 
that  is,  that  it  reaches  the  finger  later  than 
in  the  corresponding  vessel  on  the  other  side. 
Besides  these,  which  are  the  main  signs  of 
aneurism,  there  are  others,  which  are  of  less 
constant  occurrence  or  of  subordinate  impor- 
tance. Thus,  on  compression  of  the  artery  above, 
the  tumour  will  empty  itself  more  or  less  com- 
pletely, and  the  greater  or  less  change  of  size 
under  these  conditions  is  a useful  test  of  the 
proportion  of  fluid  and  solid  in  the  sac.  Some- 
times pressure  on  the  artery  beyond  the  tumour 
may  cause  an  increase  in  its  size.  The  pulse 
below  the  tumour  is  often  found  to  differ  strik- 
ingly from  that  on  the  sound  side.  There  are 
many  and  various  symptoms  due  to  the  pressure 
of  the  aneurism  on  neighbouring  veins,  nerves, 
bones,  and  viscera — symptoms  which  are  of 
subordinate  importance  in  a diagnostic  point  of 
view  in  the  case  of  external  aneurism,  but  are 
often  of  the  greatest  value  in  thoracic  and 
abdominal  aneurisms.  Thus  dyspncea  and  ring- 
ing cough  from  pressure  on  the  trachea,  spasm  or 
paralysis  of  the  vocal  cords  from  pressure  on  the 
recurrent  laryngeal  nerve,  pain  in  the  back  from 
pressure  on  the  vertebrae,  or  neuralgic  pains 
from  pressure  on  the  nerves  at  the  root  of  the 
neck,  are  well-known  symptoms  of  aortic  aneu- 
rism; and,  similarly,  pain  in  the  leg  from  pres- 
sure on  the  popliteal  nerve,  and  (edema  from  com- 
pression of  the  vein  are  frequent  symptoms  of 
popliteal  aneurism. 

Diagnosis. — The  affections  which  are  usually 
confounded  with  aneurism  are  tumours  of  various 
kinds  lying  upon  arteries,  abscesses,  and  can- 
cerous tumours  which  have  large  vascular  spaces 
in  their  interior,  and  therefore  pulsate.  The 
tumours  which  receive  pulsation  from  arteries 
against  which  they  lie  are  of  various  kinds; 
cysts  and  enlarged  glands  in  the  popliteal  space, 
and  enlargements  ot  the  thyroid  body  pressing 


ANEURISM. 


48 

on  the  carotid  or  innominate  artery,  are  the  most 
familiar  examples.  The  diagnosis  is  usually 
easy.  They  have  commonly  little  or  no  bruit, 
though  in  some  cases  a dull  thud  is  produced  by 
their  pressure  on  the  artery;  they  have  not  the 
expansile  pulsation  of  aneurism ; they  present  no 
change  in  size  or  form  when  the  circulation  is 
stopped ; and  they  can  usually  be  drawn  away 
from  the  artery  sufficiently  far  to  lose  their  pul- 
sation. An  abscess  has  been  often  mistaken  for 
aneurism,  but  the  mistake  has  generally  pro- 
ceeded from  a neglect  of  auscultation.1  There 
are  a very  few  cases  in  which  aneurisms  have  lost 
their  pulsation  in  consequence  of  the  rupture  of 
the  sac,  and  in  which  no  bruit  may  be  audible,2 
and  such  tumours  can  hardly  be  diagnosed  from 
abscess  except  by  an  exploratory  puncture,  which 
under  these  circumstances  is  justifiable ; these 
cases  are,  however,  extremely  rare.  The  disease 
most  commonly  mistaken  for  aneurism  is  pul- 
sating cancer,  and  the  resemblance  has  been 
sometimes  so  striking  as  to  deceive  the  best  sur- 
geons, even  after  the  fullest  possible  investi- 
gation of  the  case.  These  pulsating  cancers 
almost  always  grow  from  the  bones  ; 3 and  the 
neighbouring  bone  can  generally  be  felt  to  be  en- 
larged, which  is  rare  in  aneurism.  They  have  not 
usually  the  well-marked  bruit  of  an  aneurism, 
nor  is  the  bruit  universal ; the  pulsation  also 
is  more  indistinct,  and  not  so  expansile  as  in 
aneurism ; and  the  growth  of  the  tumour  is 
more  rapid. 

Course  and  Terminations. — ’Aneurism  is 
generally  a fatal  disease  if  left  to  itself.  The  sac 
enlarges ; parts  of  it  give  way,  either  by  a pro- 
cess of  inflammatory  softening  or  by  rupture ; or 
it  produces  fatal  pressure  on  the  surrounding 
parts  ; or  the  whole  tumour  suppurates,  and  the 
patient  dies  of  fever,  of  pyaemia,  or  of  hiemor- 
rhage.  But  to  this  general  statement,  inde- 
pendent altogether  of  what  the  effects  of  any 
special  treatment  may  be,  there  are  numerous 
exceptions.  In  some  cases,  and  especially  in  the 
fusiform  kind  of  aneurism,  the  tumour,  after  hav- 
ing attained  a certain  size,  remains  stationary,  and 
this  stationary  condition  is  sometimes  produced 
by  a deposit  of  eoagulum  lining  the  sac,  and 
leaving  a canal  through  which  the  blood-stream 
passes,  as  through  the  normal  artery.  In  these 
cases,  however,  the  symptoms  persist,  but  there 
are  others  in  which  a complete  spontaneous  cure 
is  obtained,  and  this  may  happen  in  various  ways. 

Spontaneous  Cure. — The  first,  and  probably 
the  most  usual  method  of  spontaneous  cure  is  by 
the  gradual  diminution  of  the  circulation  through 
the  tumour,  and  the  gradual  filling  of  the  sac  by 
successive  layers  of  fibrinous  eoagulum.  The 
second  is  by  impaction  of  clot  in  the  mouth  of 
the  aneurism,  whereby  in  some  cases  possibly 
the  sac  of  the  aneurism  is  cut  off  from  the  blood- 
stream, and  its  contents  brought  to  coagulate. 
In  other  cases,  where  more  than  one  artery  opens 
out  of  the  sac,  the  impaction  of  clot  in  one  of  the 
distal  arteries  leads  to  consolidation  of  all  that 

1 See  a paper  by  the  author  in  St.  George’s  Hospital 

Reports,  vol.  vii.  pp.  17.j  et  seg. 

3 See  a case  under  the  care  of  the  writer,  reported  in  the 
same  paper,  p.  190. 

3 In  one  case  under  the  care  of  the  writer  the  disease 
was  unconnected  with  the  hones,  and  affected  the  kidney 
only. — Pathological  Transactions,  vol.  xxiv.  p.  149. 


part  of  the  tumour  through  which  the  circula- 
tion used  to  pass  into  the  obstructed  vessel,  and 
thus  a practical  cure  is  sometimes  effected,1  i.e. 
the  symptoms  are  cured  and  the  disease  arrested, 
though  the  whole  sac  is  not  consolidated.  The 
third  method  of  spontaneous  cure  is  by  inflam- 
mation of  the  tumour.  This  is  usually  accom- 
panied by  suppuration  of  the  sac  and  evacuation 
of  all  the  contents  of  the  aneurism,  the  accom- 
panying inflammation  closing  the  mouths  of  the 
arteries  which  open  out  of  it.  If  the  arteries 
are  not  so  closed,  death  from  haemorrhage  will 
occur.  It  seems  possible  that  inflammation  of 
the  sac  and  the  cellular  membrane  around  it  may 
sometimes  produce  coagulation  within  the  aneu- 
rism without  any  suppuration.  A fourth  way  in 
which  coagulation  of  an  aneurism  has  been 
known  to  be  caused  is  by  retardation  of  the 
circulation  or  impaction  of  clot,  caused  by  another 
aneurism  above;  and  there  is  an  old  idea,  which 
can  hardly  yet  be  said  to  be  exploded,  that  an 
aneurismal  sac  may  by  its  growth  compress  the 
artery,  and  so  lead  to  its  own  coagulation.  This, 
however,  it  it  ever  happens,  is  purely  excep- 
tional. 

Rupture. — The  rupture  of  an  aneurism  may 
take  place  either  through  the  skin,  in  which  ease 
the  haemorrhage  is  usually,  but  not  always,  fatal 
at  once  ;2  or  into  one  of  the  cavities  of  the  body, 
when  death  generally  occurs  immediately,  if  the 
rupture  is  into  a serous  cavity,  and  after  one  or 
two  attacks  of  haemorrhage  if  a mucous  mem- 
brane has  been  involved ; or  lastly  into  the 
cellular  tissue  of  a part.  This  event  is  marked 
by  the  cessation  of  the  pulsation ; the  sudden 
swelling,  accompanied  with  ecchymosis  if  tho 
blood  is  effused  subcutaneously;  and  the  abrupt 
fall  of  temperature  below  the  aneurism.  A 
sensation  of  pain,  or  of  ‘something  giving 
way,’  is  often  experienced.  Stethoscopic  ex- 
amination will  probably  detect  a bruit. 

Treatment— a.  Medical.— The  methods  of 
treatment  of  aneurism  are  very  numerous,  and  it 
would  be  impossible  in  a summary  of  this  kind 
to  discuss  fully  all  the  indications  for  each.  In 
the  first  place,  those  aneurisms  which  are  inacces- 
sible to  any  local  treatment,  or  in  which  local 
treatment  would  involve  great  danger,  are  treated 
medically,  that  is  by  regimen,  diet,  and  medicine, 
by  which  it  is  hoped  that  gradual  coagulation 
will  be  promoted  in  the  contents  of  the  tumour, 
and  thus  a complete  or  a partial  cure  will  be 
brought  about,  as  in  the  natural  process  above 
spoken  of.  The  method  of  Valsalva,  of  which 
the  main  features  were  starving  and  excessive 
bleeding,  and  which  therefore  produced  consider- 
able and  often  dangerous  irregularity  of  t!ie 
hearts  action,  is  now  given  up  in  favour  of  the 
opposite  plan  introduced  by  Bellingham  and 
modified  by  Mr.  Jolliffo  Tufnell,3  in  which,  by 
complete  rest  and  restricted  but  nutritious  diet, 
the  absolute  regularity  of  the  heart’s  action  is 
secured,  and  at  a rate  below  that  of  health,  both 

1 See  a case  of  innominate  aneurism  with  remarks  in 
the  Lancet,  June  15, 1872,  p.  818. 

Instances  of  successful  ligature  of  the  artcrv  above 
after  bleeding  from  ruptured  aneurism  are  on  reconi. 
See  a case  in  the  Lancet,  1851,  vol.  ii.  p.  30,  in  which  the 
femoral  artery  was  successfully  tied  after  the  bursting  of 
a femoral  aneurism  through  the  skin. 

S j he  Successful  Treatment  of  Internal  Aneurism,  2nd 
edit.  lS7o. 


ANEURISM. 


as  to  rapidity  and  force.  Mr.  Tufntll  lias  given 
some  interesting  and  conclusive  examples  of  the 
complete  cure  of  abdominal  aneurisms  thus  ac- 
complished, verified  by  dissection;  and  one,  at 
least,  in  which  an  aneurism  of  the  arch  of  the 
aorta  was  in  all  probability  entirely  consolidated, 
though  this  fact  was  not  verified  by  dissection.  At 
any  rate  the  patient  was  permanently  restored 
t i health.  In  this  method  of  treatment  drugs  are 
duly  employed  when  necessary  (as  narcotics, 
laxatives,  and  tonics  often  are)  to  ensure  the  regu- 
larity of  the  functions,  to  control  irritability,  or  to 
support  the  general  health.  The  drugs  which  have 
been  recommended  as  producing  a direct  effect 
on  aneurism  by  promoting  the  coagulation  of 
blood  in  the  sac,  such  as  acetate  of  lead  and 
iodide  of  potassium,  do  not,  in  the  writer's 
opinion,  produce  any  such  effect,  nor  in  fact  any 
specific  effect  on  the  disease  whatever.  He  has 
often  seen  a certain  amount  of  improvement  under 
the  use  of  these  drugs,  but  not,  he  thinks,  more 
than  the  regimen  and  diet  used  at  the  same  time 
would  account  for.  Other  drugs,  as  aconite  and 
digitalis,  are  recommended  in  order  to  steady 
and  reduce  the  heart’s  action,  and  the  latter 
especially  is  sometimes  a useful  adjuvant,  if 
employed  with  caution,  to  the  treatment  by 
restricted  diet  and  rest.  The  rest  is  total,  the 
patient  never  leaving  his  bed,  nor  ever  rising 
from  it,  or  changing  his  position  more  than  by 
occasionally  turning  on  his  side  ; the  bowels  are 
so  regulated  as  to  avoid  both  constipation  and 
looseness;  and  the  diet  is  restricted  to  about  10 
oz.  of  solid  food,  of  which  one  half  is  meat  or 
fish,  and  8 oz.  of  fluid  (comprising  2 or  3 oz.  of 
light  wine  if  necessary),  per  diem.  The  period 
may  be  extended  indefinitely,  so  long  as  improve- 
ment continues  ; but  in  all  cases  the  patient  and 
his  friends  should  be  prepared  for  a confinement 
of  not  less  than  three  months.  See  Abdominal 
Aneurism  ; and  Aorta,  Diseases  of  {Aneurism). 

b.  Surgical. — Most  aneurisms  which  occupy 
an  external  position,  and  are  therefore  amenable 
to  surgical  treatment,  are  curable,  when  the 
degeneration  of  the  vascular  system  is  not  too 
extensive,  by  mechanical  means.  Of  these  the 
chief  and  by  far  the  most  successful  are  either 
the  ligature  of  the  artery,  whether  in  the  sac, 
above  it,  or  in  some  special  cases  below ; or 
compression,  applied  either  to  the  artery  above 
the  aneurism,  or  to  the  tumour  itself,  or 
simultaneously  in  both  situations,  and  either 
by  the  pressure  of  an  instrument,  of  the  fingers, 
or  of  Esmarch’s  bandage.  But  as  these  methods 
of  treatment  belong  exclusively  to  the  province 
of  surgery,  it  is  thought  better  in  a work  of  this 
kind  merely  to  name  them,  and  to  refer  the  reader 
to  the  standard  works  on  surgery  for  their  de- 
scription. 

The  other  methods  of  surgical  treatment  are 
far  less  successful  than  the  above,  and  have  the 
great  drawback  of  being  addressed  exclusively  to 
the  contents  of  the  sac  ; while  in  the  treatment 
by  the  ligature  and  by  compression  the  resilient 
power  of  the  sac,  and  its  consequent  reaction 
on  the  blood  which  it  contains,  no  doubt  play  a 
creat  part  in  the  cure.  The  methods  now  to  be 
mentioned,  on  the  contrary,  as  far  as  they  act 
on  the  sac  at  all,  rather  tend  to  contuse  or  to 
inflame  it. 


Galvanopuncture. — The  first  is  galvanopunc- 
ture,  in  which  a currentof  electricity  of  low  ten- 
sion, long  continued,  is  passed  through  the  blood 
in  the  sac,  decomposing  it,  and  causing  its  coa- 
gulation. Needles  are  plunged  into  the  sac,  and 
are  then  connected  with  the  battery,  and  the 
action  is  continued  until  the  reduction  in  the 
pulsatic  n and  the  flattening  of  the  tumour  show 
that  the  blood  has  been  partly  coagulated.  Au- 
thorities differ  as  to  the  details  of  the  method. 
Some  apply  first  the  positive  and  then  the  nega- 
tive pole  to  each  needle,  others  the  negative  pole 
only,  the  positive  being  brought  in  contact  with 
the  neighbouring  skin,  while  some  on  the  con- 
trary use  the  positive  pole  only.  It.  will  be 
found  on  experiment  that  a certain  amount  of 
coagulation  takes  place  around  both  poles,  the 
clot  round  the  positive  pole  being  smaller  but 
firmer  than  that  round  the  negative.  The  ob- 
ject of  the  operation  is  to  fill  the  sac  as  much  as 
possible  with  eoagulum  which  shall  gradually 
harden,  and  shall  attract  to  itself  fresh  coagula. 
The  dangers  of  the  proceeding  are  those  of 
inflammation  of  the  sac,  or  of  the  cellular  tissue 
around  it;  of  suppuration  within  the  tumour; 
or  of  sloughing  of  the  punctures  and  haemor- 
rhage ; and  it  must  be  allowed  that  the  effects 
of  galvanopuneture  are  very  uncertain,  both  as 
to  the  amount  and  firmness  cf  the  eoagulum 
produced.  Still  there  is  satisfactory  evidence  of 
benefit  i n many  cases,  and  of  a cure  i n a few.  The 
danger  of  inflaming  or  cauterising  the  sac  or  the 
tissues  around  may  be  in  some  measure  obviated 
by  coating  the  needles  with  vulcanite,  as  recom- 
mended by  Dr.  John  Duncan  of  Edinburgh.  For  a 
very  clear  exposition  of  the  details  of  this  method, 
as  well  as  for  statements  regarding  the  success 
which  has  attended  electrolysis  hit  herto,  the  reader 
is  referred  to  a lecture  by  this  gentleman,  reported 
in  the  British  Medical  Journal,  May  20,  1S7G. 
The  writer  thinks  himself  justified  in  adding 
that  electrolysis  should  be  restricted  to  cases 
of  thoracic,  subclavian,  or  abdominal  aneurism, 
which  cannot  he  cured  by  medical  means,  and  in 
which  rupture  seems  to  be  imminent,  while  the 
situation  of  the  tumour  forbids  the  application 
of  pressure. 

Coagulating  Injections.  — Another  method  of 
producing  coagulation  of  the  blood  in  tlie  sac  is 
by  the  use  of  coagulating  injections.  Other  fluids 
have  been  employed,  but  the  only  one  in  general 
use  now  is  the  perehloride  of  iron.  The  circulation 
is  to  be  suspended  by  pressure  on  the  artery 
above,  before  the  injection  is  made  and  for  some- 
time afterwards.  The  method  is  a very  danger- 
ous one  for  large  aneurisms,  on  account  of  the 
risks  of  embolism,  sloughing,  and  inflammation, 
but  it  may  be  used  with  success  in  small  cirsoid 
and  anastomotic  aneurisms,  and  also  in  varicose 
aneurism. 

Introduction  of  foreign  bodies. — Aneurisms 
have  also  been  treated  by  the  introduction  of 
foreign  bodies  into  the  sac,  with  the  view  of  pro- 
ducing coagulation  of  the  blood  upon  the  foreign 
substance,  such  as  fine  wire,  carbolised  catgut, 
and  horsehair ; but  no  case  of  cure  has  hitherto 
been  reported. 

Manipulation. — Finally,  aneurisms  may  1 -i- 
treated  by  manipulation.  The  object  of  tins 
treatment  is  either  to  detach  a portion  of  coagu 


4 


50  ANEURISM, 

lum  from  tlie  wall  of  the  aneurism,  which  may 
1>8  carried  into  the  mouth  of  the  sac  or  the  distal 
artery,  and  so  effect  a cure  as  in  our  second 
mode  of  spontaneous  cure,  or  at  any  rate  so 
to  disturb  and  break  up  the  clot,  that  its  detached 
laminae  may  form  nuclei  for  further  coagula- 
tion. With  this  view  the  aneurismal  tumour  is 
grasped  between  the  two  hands  to  squeeze  all  the 
fluid  blood  out  of  it,  and  one  wall  rubbed  against 
the  other  till  ‘ a friction  of  surfaces  is  felt  within 
the  flattened  mass.’ 1 The  proceeding  is  obviously 
a very  dangerous  and  uncertain  one,  but  some 
indubitable  cures  have  been  thus  effected. 

Arteriovenous  Aneurisms. — A few  words 
must  be  added  with  respect  to  the  rarer  forms  of 
aneurism.  Arteriovenous  aneurisms  are  generally, 
but  not  always,  traumatic,  and  are  divided  into 
two  chief  forms : — 1 . Varicose  aneurism,  in  which 
there  is  a small  aneurismal  tumour  communicat- 
ing both  with  the  artery  and  with  a vein  which 
is  always  varicose  ; and  2.  Aneurismal  varix,  in 
which  the  opening  between  the  two  vessels  is 
direct  without  any  tumour  interposed  ; 1 he  vein 
pulsates  as  well  as  being  varicose,  and  the  tempe- 
rature of  the  limb  and  nutrition  of  the  skin 
and  hair  are  increased.  In  all  forms  of  arterio- 
venous aneurism  the  artery  after  a time  becomes 
thin  and  much  dilated.  The  signs  of  arterio- 
venous differ  from  those  of  arterial  aneurism 
mainly  in  this — that  besides  the  intermittent 
blowing  murmur  caused  by  the  arterial  current, 
there  is  a continuous  purring  or  rasping  bruit 
due  to  the  venous  current ; and  that  besides  the 
intermittent  pulsation  there  is  a continuous  thrill. 
Varicose  aneurism  may  he  cured  by  digital  pres- 
sure applied  directly  to  the  venous  orifice,  and 
indiroctly  to  the  artery  above  at  the  same  time; 
or  the  old  operation  may  be  performed,  the  clots 
being  turned  out  of  the  sac  and  the  artery  tied 
above  and  below,  the  vein,  being  of  course  laid 
open  and  secured  either  by  ligature  or  pressure  ; 
or  the  artery  may  be  tied  above  and  below  without 
opening  the  sac.  Electropuncture  and  coagulating 
injections  have  also  been  used  with  success. 
Aneurismal  varix  does  not  usually  require  or 
admit  of  surgical  treatment.  If  it  does,  the 
ligature  of  both  parts  of  the  artery  is  the  only 
measure  that  can  he  adopted,  on  the  failure  of 
compression. 

Cirsoid,  and  Anastomotic  Aneurisms. — 

Cirsoid  aneurism,  or  arterial  varix,  is  a tumour 
formed  by  the  coils  of  a single  dilated  and  elon- 
gated artery  ; - while  aneurism  by  anastomosis  is 
a tumour  formed  by  the  coils  of  numerous  di- 
lated and  elongated  arteries,  with  the  dilated 
capillaries  and  veins  which  communicate  with 
those  arteries.  It  is  often  difficult  to  distinguish 
these  two  forms  of  arterial  disease  from  each 
other.  Aneurism  by  anastomosis  frequently  origi- 
nates congenitally  as  one  of  the  forms  of  ntevus. 
The  usual  situation  of  these  tumours  is  on  the 
scalp.  They  have  often  a peculiar  continuous 
buzzing  or  rushing  murmur,  which  is  propagated 
over  the  whole  head,  and  much  disturbs  the 
patient’s  rest ; while  they  are  liable  to  ulcerate 
and  to  become  the  source  of  serious  and  even  fatal 
bsemorrhage.  Some  cases  of  spontaneous  cure 

' Sir  W.  Fergnsson,  Med.  Ctlir.  Trans.  xU  8. 

3 See  the  figure  on  p.  534,  vol.  iii.  of  the  System  of 
Surgery,  2nd  edition. 


ANGUS  A PECTORIS. 

are  on  record.  Verv  numerous  methods  of  treat- 
ment have  been  employed,  of  which  the  writer  can 
only  mention  those  which  are  most  generally  use- 
ful. When  feasible,  the  total  removal  of  the  tumour 
with  the  knife  is  certain  to  effect  a radical  cure, 
but  this  operation  is  often  too  dangerous  to  he 
attempted.  The  entire  removal  by  ligature  is 
still  more  rarely  practicable.  The  galvanic 
cautery  is  often  successful ; the  incandescent 
wire  being  drawn  through  the  mass  in  various 
directions  divides  it  into  portions,  and  obliterates 
the  vessels  by  producing  cicatrices  at  the  parts 
cauterised.  Setons  have  also  been  used  with 
success,  when  combined  with  the  ligature  of  the 
trunk-artery ; and  the  ligature  of  the  artery 
alone  has  been  said  to  he  followed  by  success, 
but  certainly  is  generally  unsuccessful.  Finally, 
coagulating  injections  and  galvanopuncture  have 
both  effected  a certain  number  of  cures. 

T.  Holmes. 

ANGEIECTASIA  [txyyriov,  a vessel,  and 
eKTams,  extension). — Extension  or  hypertrophy 
of  the  capillaries  and  minute  vessels  of  the  sur- 
faces of  the  body,  especially  the  skin ; hence 
angeiectasia  capillaris,  a term  applicable  to  several 
forms  of  vascular  naevus. 

ANGEIOLEUCITIS  (b.yyeiuv,  a vessel, 
and  \evnbs,  white). — Inflammation  of  lymphatic 
vessels.  See  Lymphatic  System,  Diseases  of. 

ANGINA  (&yx“>  I seize  by  the  throat, 
strangle,  or  choke). — Syxox.  : — Fr.  angine ; Ger. 
die  Briiune. 

The  term  angina  was  originally  applied  bj 
Latin  writers  on  Physic,  and  is  still  much  used  oo 
the  Continent,  to  indicate  a condition  in  which  dif- 
ficulty of  breathing  and  of  swallowing  exist  either 
together  or  separately,  caused  by  disease  situ- 
ated between  the  mouth  and  the  lungs,  or  between 
the  mouth  and  the  stomach.  By  a special  affix  to 
the  original  term,  significative  of  the  seat  or  the 
nature  of  the  disease,  several  varieties  of  morbid 
states  are  known  and  described,  for  example  : — 
angina  parotidca,  or  mumps  : angina  tonsiUari! , 
or  quinsy ; angina  laryngca,  or  laryngitis ; an- 
gina pectoris,  or  breast-pang ; angina  maligna,  or 
malignant  sore  throat ; angina  membranosa , or 
croup. 

These  and  numerous  other  diseases,  differing 
essentially  in  their  nature  and  pathological  rela- 
tions, and  having  nothing  in  common  but  certain 
difficulties  in  breathing  or  swallowing,  are  thus 
classed  under  the  word  angina.  Such  a classifi- 
cation is  open  to  several  objections,  and  has 
nothing  to  recommend  it.  With  the  exception, 
therefore,  of  angina s pectoris,  which  has  a special 
and  familiar  signification,  the  various  diseases 
occasionally  recognised  by  the  term  angina  will  be 
found  described  under  the  names  by  which  they 
are  generally  known  in  this  country.  See  also 
Cynanche.  R.  Quain,  M.D. 

ANGINA  PECTORIS .— Sykon. : Syncope 
Anginosa ; Angor  Pectoris  ; Suffocative  Breast- 
pang.  Fr.  Angine  de  poilrine ; Ger.  Brust- 
brdune. 

Defdtition. — An  affection  of  the  chest,  cha- 
racterised by  severe  pain,  faintness,  and  anxiety, 
occurring  in  paroxysms : connected  with  disorders 
of  the  pneumogastric  and  sympathetic  nerves  and 


ANGINA 

their  branches  ; and  frequently  associated  ■with 
organic  disease  of  the  heart. 

Descbiption. — An  attack  of  angina  pectoris 
commences  suddenly  with  pain  in  the  region  of 
the  heart,  generally  on  a level  with  the  lower  end 
of  the  sternum.  The  pain  is  severe,  and  of  a 
grasping,  crushing,  or  stabbing  character ; it 
extends  sometimes  across  the  chest,  but  more 
frequently  backwards  to  the  scapula,  and  up- 
wards to  the  left  shoulder  and  arm.  The  pain  is 
accompanied  by  a distressing  sense  of  sink- 
ing, of  faintness,  or  of  impending  death.  The 
action  of  the  heart  is  generally  irregular.  The 
pulse  at  the  wrist  corresponds ; but  in  some 
well-marked  cases  it  is  regular,  tense,  and  resist- 
ing. A fear  of  aggravating  the  pain  prevents  the 
patient  from  breathing,  though  the  respiratory 
lunetion  may  not  be  really  interfered  with.  The 
expression  is  anxious,  the  face  is  pallid,  and  the 
lips  are  more  or  less  livid.  The  whole  surface 
of  the  body  is  pale,  cold,  and  covered  with  a 
clammy  sweat.  Flatulence  is  often  present ; urine 
in  some  cases  is  passed  at  short  intervals,  and 
generally  in  abundance.  The  sense  of  faintness 
causes  the  patient  to  seek  support,  and  he  rests  on 
any  object  by  which  this  maybe  obtained.  The 
attack  having  lasted  for  a variable  time — from 
u few  minutes  to  one  or  two  hours — comes  to 
an  end,  either  by  a sudden  cessation  of  the 
more  urgent  symptoms,  or  by  their  gradual 
disappearance.  The  pallor  and  coldness  of  the 
surface  are  replaced  by  a uniform  glow — the  face 
may  even  flush,  the  pulse  becoming  soft  and  full, 
and  there  is  a general  feeling  of  relief;  a sense 
of  numbness  or  tingling  along  the  course  of  the 
nerves  derived  from  the  brachial  and  cervical 
plexuses  of  the  affected  side  occasionally  remains. 
An  attack  of  angina  pectoris  frequently  comes 
on  during  sleep ; but  it  may  be  induced  by 
emotion  or  by  physical  exertion,  especially  by 
walking  up  an  ascent,  or  by  exposure  to  cold  air 
or  wind.  An  attack  of  this  kind  may  occur  but 
once  and  end  fatally ; or  it  may  recur  after  an 
interval^f  hours,  days,  or  weeks,  and  be  thus 
continued ; or  there  may  be  an  interval  even  of 
years.  These  and  other  modifications  of  the 
disease  will  be  again  referred  to. 

Pathology. — The  nature  of  the  aggregate  of 
the  symptoms  or  phenomena  comprised  under  the 
name  angina  pectoris , cannot  be  understood  with- 
out a clear  apprehension  of  the  relations  of  the 
nerve-elements  of  the  organs  and  regions  that 
seem  to  be  involved  in  the  affection.  It  will  be 
well  briefly  to  summarise  them. 

The  nerves  chiefly  involved  are  the  pneumo- 
gastric  and  the  sympathetic,  and  their  branches, 
which  nerves,  it  should  here  be  stated,  are  con- 
nected with  each  other  at  their  origin  in  the 
medulla  oblongata,  in  their  course,  and  in  their 
distribution  to  the  ganglia  and  structures  of  the 
heart.  They  also  communicate  with  certain  of 
the  cerebral  nerves,  and  with  the  cervical  and 
brachial  plexuses,  which  supply  part  of  the  head 
and  neck,  the  arms,  the  diaphragm,  and  the 
chest-walls.  Their  connections  with  the  heart 
are  very  extensive.  This  organ  is  supplied  by 
the  cardiac  ganglia  and  the  branches  derived 
from  them,  which  are  in  relation  with,  and, 
in  fact,  constitute  part  of  the  cardiac  plexus 
formed  by  the  interlacement  of  branches  from 


PECTORIS.  61 

the  pneumogastric  and  the  sympathetic  nerves, 
The  pneumogastric  supplies  the  superior  cardiac 
nerve  and  apparently  the  inferior  cardiac  nerve 
(which,  however,  is  derived  from  the  spinal 
accessory,  and  is  merely  distributed  with  the 
pneumogastric) ; the  sympathetic  contributes 
several  branches  through  the  cervical  ganglia. 
Branches  of  both  pneumogastric  and  sympathetic 
nerves  are  distributed  to  the  respiratory  pas- 
sages, the  lungs,  stomach,  intestines,  liver,  and 
other  abdominal  viscera. 

The  connection  of  the  pneumogastric  and 
sympathetic  nerves  in  the  medulla,  to  which 
allusion  has  been  made,  occurs  at  the  cardiac 
and  vaso-motor  centres ; and  consequently  these 
nerves,  and  the  heart  (which  they  supply)  are 
thus  brought  into  relation  with  the  vaso-motor 
nerves  throughout  the  body,  and  with  all  the 
systemic  blood-vessels;  they  are  also  in  relation 
with  the  other  important  centres  in  the  neigh- 
bourhood ; and  with  the  cerebrum  itseif,  more 
especially  that  part  of  it  associated  with  the 
emotions. 

Such  being  the  distribution  and  the  relation 
of  the  nerves  connected  with  the  heart  and  sur- 
rounding parts,  we  learn,  in  reference  to  their 
functions,  that  the  movements  of  the  heart  are 
maintained  by  its  ganglia,  but  that  these  move- 
ments may  be  accelerated  by  the  action  of  the 
sympathetic,  whilst  they  are  controlled  and  may 
be  even  arrested  by  that  of  the  inferior  cardiac 
branch  from  the  pneumogastric. 

The  superior  cardiac  branch  of  the  pneumo- 
gastric has  to  do  with  the  specific  function,  of 
conveying  impressions  contripetally  from  the 
heart  to  the  medulla,  whence  these  impressions 
may  be  reflected  through  the  inferior  cardiac 
nerve  to  the  heart,  controlling  for  a time  its 
movements  ; and  also  reflected  through  the  vaso- 
motor centre  and  vaso-motor  nerves,  to  the  general 
circulation.  By  means  of  this  latter  functional 
relation,  relaxation  of  the  arteries,  especially 
those  of  the  abdomen  through  the  splanchnic 
nerves  is  accomplished,  and  the  heart  is  relieved 
of  pressure. 

With  regard  to  other  functions  of  the  cardiac 
nerves,  it  is  believed  that  such  common  sensi- 
bility as  the  heart  possesses  is  more  especially 
connected  with  the  superior  cardiac  branch  of 
the  pneumogastric.  Numerous  communications 
exist  between  this  nerve  and  the  ordinary  spinal 
nerves;  and  it  must  also  be  remembered  in 
reference  to  the  sites  of  pain  in  angina,  that 
nerves  may  be  rendered  sensitive  by  disease 
which  are  not  sensitive  in  health. 

Lastly,  it  is  to  be  noted  that  the  pnenmogas- 
tric  and  sympathetic  nerves,  as  well  as  the 
heart  and  blood-vessels,  whose  functions  they 
regulate,  possess  the  extensive  connections  above 
mentioned  with  the  abdominal  and  thoracic 
viscera,  and  thus  they  not  only  influence  but  are 
influenced  by  the  conditions  of  the  lungs,  liver, 
stomach,  kidneys,  and  other  organs. 

Keeping  in  mind  this  distribution  of  nerves 
and  their  functions,  we  can  recogniso  how  the 
movements  of  the  heart  may  be  affected,  whether 
in  the  direction  of  acceleration,  retardation,  or 
even  arrest.  We  can  further  understand  how 
painful  impressions  originating  in  the  cardiac 
nerves  may  be  propagated  so  as  to  be  referred 


ANGINA  PECTORIS. 


52 

to  the  associated  sensory  nerves  and  their 
branches;  and  how  relations  may  be  established 
with  the  raso-motor  system  and  the  circula- 
tion generally.  Thus  the  vessels  throughout 
the  body  may  be  acted  upon,  producing  cold- 
ness and  pallor  of  surface  from  the  abnormal 
filling  of  the  abdominal  at  the  expense  of  the 
superficial  vessels,  a condition  which  seems  to 
be  the  cause  of  the  diminished  arterial  ten- 
sion noticed  in  these  cases.  We  can  also  com- 
prehend how  morbid  impressions  mads  either 
on  these  nerves,  in  their  distribution  to  the 
abdominal  viscera  or  the  heart,  or  on  the 
peripheral  distribution  of  the  vaso-motor  nerves 
at  the  surface  of  the  body,  may,  passing  cen- 
tripetally,  admit  of  reflex  impressions  and  re- 
flex actions,  which  in  some  cases  may  be  pro- 
vocative of  the  symptoms  of  this  disease : also 
how  direct  impressions  made  on  the  nerves 
themselves  in  their  course,  or  at  the  vaso-motor 
centre,  or  through  the  cerebral  emotive  centres, 
may  each  give  rise  to  the  phenomena  which 
represent  the  symptoms  constituting  angina  pec- 
toris. 

Pathology  of  Uncomplicated  Angina  Pectoris. — 
That  this  disease  is  dependent  on  an  affection 
of  nerves  may  be  held  to  be  demonstrated 
by  the  paroxysmal  character  of  the  attack ; by 
its  sudden  access  and  sudden  departure ; by 
the  nature  of  the  causes  that  promote  it,  whether 
they  be  mental  emotion  or  direct  or  reflected 
irritation ; by  the  course  and  character  of  the  pain, 
and  by  the  fact  that  in  severe — even  fatal — in- 
stances of  angina,  there  is  often  an  absence  of 
any  tangible  or  evident  organic  local  disease. 

The  morbid  state  affecting  the  nerves  may  be 
situated  in  the  medulla ; or  it  may  be  in  the 
course  of  these  nerves,  or  in  their  branches  ; or 
in  the  cardiac  ganglia  themselves.  It  may 
be  the  result  of  congestion  or  inflammation 
of  the  nerve,  such  as  occurs  in  the  litliic  acid  or 
gouty  diathesis ; or  of  other  textural  changes, 
such  as  connective-tissue  growth,  involving  the 
nerve-fibres  and  ganglia.  It  may  be  produced 
by  emotions  acting  centrifugally ; or  by  irritation 
acting  centripetally,  reflected,  as  we  have  just 
said,  from  impressions  made  on  the  peripheral 
extremities  of  nerves.  Thus  acidity  of  the 
stomach  distended  by  flatus,  the  result  of  indiges- 
tion, often  gives  rise  to  symptoms  which  very 
closely  resemble,  if  they  do  not  constitute,  an 
attack  of  angina.  The  like  effect  has  been  pro- 
duced by  irritation  reflected  from  the  fifth  nerve, 
as,  for  example,  in  pivoting  teeth  ; by  such  irrita- 
tion of  the  surface  of  the  skin  as  results  from 
severe  herpes ; by  cold,  or  by  exposure  to  wind. 
But  the  most  frequent  source  of  the  symptoms 
of  angina  caused  by  reflex  action  is  to  be  found 
in  those  organic  affections  of  the  heart  which 
will  be  described  in  the  next  section. 

Whatever  the  nature  of  the  irritation  or  of 
the  exciting  cause,  the  symptoms  will,  in  some 
measure,  bear  a relation  to  the  nerves  affected. 
Thus,  if  the  sensory  branches  connected  with 
i he  spinal  nerves  suffer,  we  shall  probably  have 
pain  more  severe  and  more  diffused : whereas 
if  the  branches  more  immediately  supplying  the 
heart  are  affected,  we  shall  have  the  action  of 
that  organ  more  or  less  disturbed,  accelerated  or 
depressed.  And  so  with  the  branches  of  other 


nerves,  more  especially  of  those  connected  with 
the  vaso-motor  system,  or  wi;h  the  lungs  and 
abdominal  viscera,  modifications  of  symptoms  are 
produced  which  it  is  needless  to  describe  at 
this  point  in  detail. 

Pathology  of  Angina  Pectoris  complicated  uitr 
Organic  Disease  of  the  Heart  and  Vessels.— 
The  striking  character  of  the  symptoms  of  angina 
pectoris  has  led  pathologists  to  connect  the  heart 
with  the  disease,  and  to  investigate  its  condition 
accordingly.  Such  researches  have  established 
the  fact  already  mentioned,  that  angina  may  exist 
without  any  discoverable  disease  in  the  heart  or 
its  appendages.  On  the  other  hand,  in  the  grear 
majority  of  cases  various  forms  of  structural 
disease  of  the  heart  and  aorta  have  been  ob- 
served ; for  example  atheromatous  or  calcareous 
degeneration  in  the  coronary  arteries, in  the  valves, 
or  in  the  aorta;  dilatation  of  the  cavities  of  the 
heart,  or  of  the  aorta ; accumulation  of  fat  in  the 
cardiac  walls  ; and  lastly,  and  probably  the  most 
important  change  of  all,  fatty  degeneration  of  the 
muscular  tissue.  A knowledge  of  this  lesion  is 
of  comparatively  recent  date ; it  is  constantly 
associated  with  the  calcareous  and  atheromatous 
diseases  described  above,  and  which  alone  at- 
tracted the  notice  of  older  observers.  Nay  more, 
this  lesion  of  the  walls  of  the  heart  is  in  itself  a 
frequent  and  sufficient  cause  of  one  of  the  most 
prominent  symptoms  of  angina  pectoris — faint- 
ness. This  conditiorf  has  been  elsewhere 
described  by  the  present  writer  ( Medical  and 
Chirurgical  Society's  Transactions,  vol.  xxxiii.) 
under  the  name  of  Syncope _ Lcthalis  or  fatal- 
faintness— a designation  analogous  to  that  given 
by  Parry  to  angina  pectoris,  which  he  called 
Syncope  Anginosa. 

/Etiology. — When  treating  of  the  pathology 
of  angina  pectoris  we  have  already  discussed 
the  conditions  under  which  it  occurs.  We  have 
endeavoured  to  show  that  the  disease  consists 
in  a lesion  of  certain  nerves,  associated  with 
various  morbid  conditions.  In  seeking  to  in- 
dicate the  predisposing  causes  of  the^  condi- 
tions, we  have  to  point  out  (1)  the  existence  of 
a peculiar  state  of  the  nervous  system,  which 
may  be  described  as  an  undue  susceptibility  to 
impressions.  What  that  state  is  we  know  not. 
It  would  seem  to  be  often  hereditary-,  and  to  be 
found  in  those  temperaments  in  which  there  is 
a high  development  of  the  nervous  element, 
associated  with  certain  habits  of  life,  such  as 
sedentary  employments,  high  living,  and  so  on. 
Thus  it  is  that  this  disease  has  been  the  cause  of 
the  death  of  many  men  who,  by  their  intel- 
lectual parts,  have  left  their  mark  on  history. 
It  is  merely  necessary  to  mention,  as  instances, 
Lord  Clarendon,  John  Hunter,  Dr.  Arnold. 
(2)  The  influence  of  age  is  conspicuous  ; the 
disease  is  rare  before  puberty  ; and  the  writer's 
researches  show  that  quite  eighty  per  cent,  ot 
cases  occur  after  forty  years  of  age.  (3)  Sex 
also  displays  a marked  influence  on  the  dis- 
ease ; it  is  comparatively  rare  amongst  women, 
a statement  by  the  late  Sir  John  Forbes  show- 
ing that  out  of  49  fatal  cases,  only  2 occurred  in 
females  ; and  4 out  of  15  non-fatal  cases — facts 
entirely  corresponding  with  the  writer's  expe- 
rience. (4)  The  peculiar  diathesis  which  gives 
rise  to  neuralgia  of  various  p;irts,  and  that  i'J 


ANGINA  PECTOEIS. 


which  lithic  acid,  predominates  in  the  system, 
would  seem  to  he  in  many  cases  an  efficient 
cause  of  the  symptoms  of  angina. 

The  exciting  causes  of  angina  pectoris  are  (1) 
Those  that  affect  the  nerve- textures  themselves. 
(2)  The  condition  to  which  we  have  referred,  in 
which  organic  disease  of  the  heart  exists.  (3) 
Mental  emotion,  especially  anger  or  nervous 
shock.  (4)  Irritation  propagated  centripetally 
from  the  surface,  as  by  the  brandies  of  the 
fifth  nerve ; through  the  brachial  plexus ; 
through  the  sympathetic  and  pneumogastric 
nerves  distributed  to  the  abdominal  viscera. 
(5)  Cold  applied  to  the  surface,  and  especially 
cold  winds.  (6)  Physical  exertion,  or  any  other 
agency  by  which  the  circulation  is  quickened. 
(7)  Depressing  agents,  such  as  excessive 
tobacco-smoking,  malaria,  &c. 

Anatomical  Characters. — Beyond  the  con- 
ditions indicated  under  the  head  of  Pathology, 
there  is  little  to  be  said  on  the  morbid  anatomy 
of  angina  pectoris.  These  several  conditions, 
and  the  symptoms  of  angina  as  above  described 
have  been  found  to  exist  independently  of  each 
other.  There  must  therefore  be  something  in  the 
state  of  the  nervous  tissues  that  acts  as  the  pre- 
disposing or  exciting  cause  of  this  aggregate  of 
phenomena.  Inflammatory  changes  and  tumours, 
involving  the  vagus  or  the  cardiac  plexus,  have 
been  observed  and  described.  With  reference  to 
the  state  of  the  heart  itself,  its  cavities  have 
been  found  dilated  and  containing  blood ; or  con- 
tracted and  empty ; and  theories  have  been  founded 
thereupon,  as  to  whether  death  occurred  by  spasm 
or  by  paralysis.  It  is  more  than  probable  that 
either  one  or  the  other  of  these  conditions  may 
occur  in  angina,  and  lead  to  fatal  results,  accord- 
ing to  the  particular  nerves  controlling  the  func- 
tions of  the  hoart  which  are  affected.  See  Pnec- 
hogastric  Nerve,  Disease  of. 

Clinical  Varieties. — All  the  phenomena  of 
an  anginal  seizure  as  above  described  may  be 
more  or  less  modified.  The  attack,  though  gene- 
rally induced  by  exertion,  may  come  on  when  the 
patient  is  at  rest,  and  not  unfrequently  it  sets  in 
during  sleep.  The  pain  may  be  comparatively’ 
alight,  and  as  such  may’  recur  occasionally,  it  may 
be,  for  months  or  years.  On  the  other  hand, 
it  maybe  so  severe  as  to  mark  a first,  a single, 
and  a fatal  attack.  In  its  character  the  pain 
may  be  stabbing  or  burning;  but  it  is  more  fre- 
quently described  as  grasping,  crushing,  or  op- 
pressive. It  may  be  limited  almost  to  the  region 
of  the  heart,  or  the  lower  part  of  the  sternum  ; 
it  may  extend  all  over  the  chest  to  both  arms,  or 
spread  to  the  side  of  the  head  and  neck  and  down 
one  or  both  legs  ; and  it  may  in  some  cases 
apparently  involve  the  diaphragm.  The  action 
of  the  heart,  may  be  slow,  weak,  and  fluttering ; 
or  excited  and  bounding — constituting  palpita- 
tion ; and  it  may  be  regular  or  irregular.  The 
pulse  corresponds  with  the  heart’s  action  ; in  the 
earlystage  of  a genuine  attack  itsometimes  yields 
a sphygmographic  tracing  indicative  of  extremely 
high  tension.  The  breathing  is  sometimes  dis- 
tressing ; and  although  the  patient  can  take  a 
deep  breath  when  asked  to  do  so,  he  generally 
avoids  this  through  fear  of  aggravating  the  pain. 
There  may  be  laryngeal  spasm.  The  mental 
functions  are  generally  undisturbed ; yet  there 


53 

is  sometimes  slight  wandering  as  the  attack 
passes  off,  and  unconsciousness  is  said  to  be 
occasionally  observed.  The  sense  of  danger  of 
impending  death  is  a characteristic  symptom 
of  angina,  and  one  not  often  absent;  whilst  a 
sensation  of  gasping  or  choking  with  difficulty 
in  swallowing  is  occasionally  present.  The 
position  of  the  patient  varies ; sometimes  ho 
sits,  sometimes  he  stands,  resting  his  arms 
on  any  convenient  object  to  obtain  support  ; 
sometimes  he  sits  and  stoops,  or  leans  forward. 
As  a rule  the  attack  passes  off  as  abruptly  as 
it  commenced,  leaving  the  sufferer  free  from 
discomfort ; in  other  cases  its  disappearance  is 
more  slow.  The  varieties  in  the  symptoms  of 
angina  pectoris  are  thus  seen  to  be  remarkably 
numerous,  constituting  a form  of  disease 
which  may  be  comparatively  mild  and  of  long 
duration,  or  one  of  intense  suffering,  hastening 
to  a fatal  termination.1 

Complications. — Amongst  the  diseases  with 
which  angina  pectoris  may  be  said  to  be  asso- 
ciated, rather  than  complicated,  are  disorders 
of  the  liver  and  digestive  functions,  gout,  albu- 
minuria, diabetes,  and  certain  diseases  of  the 
nervous  system.  Indeed,  so  marked  is  the  latter 
connexion,  that  Trousseau  dwelt  on  the  relation 
between  epilepsy  and  angina — a relation  which 
seems  to  depend  on  the  susceptibility  to  nervous 
maladies  which  some  individuals  present,  rather 
than  on  any  special  identity  between  these  two 
diseases.  More  than  one  striking  example  of  the 
connexion  has  fallen  under  the  writer's  notice  ; 
he  might  mention  an  instance  recently  met  with 
in  which  this  susceptibility  was  such,  that  an 
oppressive  meal  of  indigestible  food  brought  on 
a first  and  distressing  anginal  attack,  followed  by 
others.  In  this  case  brain  disease  with  epilepsy 
was  subsequently  developed  on  the  disappearance 
of  the  angina. 

Progress,  Duration,  and  Terminations. — 
The  progress  and  duration  of  this  disease 
will  depend  wholly  upon  the  nature  of  its  cause. 
Cases  have  been  recorded  in  which  the  first 
attack  proved  fatal.  The  writer  has  seen  several ; 
in  three  of  these  cases  a post-mortem  examination 
revealed  the  fact  that  there  was  slight  partial 
hemorrhage  into  the  walls  of  the  heart,  which 
had  been  the  seat  of  fatty  degeneration,  con- 
nected with  calcification  of  the  coronary  arteries. 
The  symptoms  in  these  cases  perfectly  resembled 
those  of  the  most  severe  examples  of  angina 
pectoris.  It  is  highly  probable,  therefore,  that 

‘ A case  has  recently  come  under  the  writer’s  notice 
in  which  a gentleman  accustomed  to  pass  lithic  acid, 
and  who  for  several  years  has  had  pains  over  the  right 
side  of  the  chest  as  low  as  the  hypochondrium,  was 
seized  at  night  with  a severe  aggravation  of  these 
pains,  coldness  of  the  surface,  irregular  action  of  the 
heart,  depression,  and  other  symptoms,  which,  had  the 
attack  commenced  on  the  left  side  of  the  chest,  would 
have  been  really  called  angina  pectoris.  Similar  attacks 
recurred  at  intervals  for  some  weeks  ; they  were  easily 
brought  on  even  by  walking  on  a level  surface  for  a few 
hundred  yards.  The  most  careful  examination  failed  to 
elicit  any  evidence  of  organic  disease  in  the  organs  of 
circulation  or  respiration.  The  patient  was  recommended 
to  try  a course  of  Homburg  waters,  and  a short  residence 
in  Switzerland  ; from  which  he  returned  greatly  improved, 
and  almost  free  from  pain.  It  should  be  mentioned  that 
an  interesting  case  has  recently  been  recorded  by  Dr. 
Morison  in  which  disease  of  the  right  side  of  the  heart 
was  accompanied  by  symptoms  of  angina  affecting  th* 
corresponding  side  of  the  chest  and  arm. 


54  ANGINA  PECTORIS. 

some  of  the  cases  proving  fatal  in  a first  attack 
of  the  disease  are  rather  examplos  of  partial 
rupture  of  the  heart  than  of  what  is  usually 
called  angina.  On  the  other  hand,  cases  of 
the  disease  may  continue  with  interruptions 
for  years ; the  difference  being  entirely  due 
to  the  nature  of  the  cause  on  which  the  disease 
depends.  Thus  in  many  instances  individuals 
present  all  the  symptoms  of  marked  angina, 
accompanied  by  most  of  its  distressing  pheno- 
mena, and  by  the  anxieties  and  fears  that  they 
beget ; yet  these  cases,  having  more  a neurotic  or 
gouty  origin,  yield  to  treatment,  the  sufferers 
being  restored  to  health,  and  continuing  for 
years  to  enjoy  comparative  comfort.  On  the 
contrary,  in  the  cases  in  which  angina  is  con- 
nected with  organic  disease  of  the  heart  or  of  the 
nerves  intimately  connected  with  cardiac  action, 
the  symptoms  progress  in  frequency  and  severity; 
and  the  attacks  tend,  with  more  or  less  certainty, 
to  a fatal  termination — it  may  be  within  a few 
days  or  weeks,  or  it  may  be,  in  milder  eases, 
not  for  years. 

Diagnosis. — A typical  case  of  angina  pectoris, 
such  as  has  been  described  at  the  commencement 
of  this  article,  can  hardly  be  mistaken.  But 
when  the  several  symptoms  constituting  an  attack 
are  variously  modified,  some  being  lessened  in 
severity  and  others  exaggerated ; or  when  these 
symptoms  depend  on,  so  to  speak,  remote  and 
Removable  causes ; it  is  often  difficult  to  say  how 
far  the  disease  is  what  may  be  regarded  as  a 
passing  neuralgia,  or  an  attack  of  what  is  com- 
monly recognised  as  angina  pectoris.  So  also  it 
may  be  difficult  to  say,  in  cases  of  angina,  whether 
the  seizure  is  dependent  on  organic  lesions  which 
admit  of  no  improvement,  or  on  some  con- 
dition that  is  amenable  to  treatment.  It  is, 
therefore,  with  this,  as  with  most  other  affec- 
tions, more  difficult  to  determine  the  cause  on 
which  the  symptoms  depend,  than  to  recognise 
the  presence  of  the  disease  itself.  With  re- 
ference to  the  diagnosis  of  the  organic  dis- 
eases of  the  heart  above  alluded  to,  it  is  un- 
necessary to  repeat  here  what  will  be  found 
described  under  other  heads.  It  remains  but  to 
say  that  in  every  case  the  closest  scrutiny  must 
be  made  into  the  condition  of  the  heart  and 
great  blood-vessels,  with  a view  to  determine 
t he  presence  or  absence  of  organic  disease.  The 
investigation  must  further  extend  to  the  other 
viscera,  such  as  the  liver,  stomach,  and  the  diges  - 
tive organs  generally,  as  well  as  to  the  several 
other  sources  from  which  symptoms  of  angina  may 
be  excited  by  reflected  irritation.  Certain  symp- 
toms resulting  from  the  presence  of  other  diseases 
should  not  be  confounded  with  angina — such,  for 
example,  as  the  pain  and  dyspnoea  caused  by 
pressure  of  aneurisms  or  of  tumours  within  the 
chest  ; by  rheumatic  or  gouty  neuralgia  of  the 
chest- walls ; by  pleurodynia,  or  acute  pleurisy  ; or 
by  indigestion.  Each  and  all  of  these  conditions 
must  be  considered  by  way  of  exclusion  in  de- 
termining the  nature  and  origin  of  the  disease. 

Pkognosis. — In  anticipating  the  future  of  an 
attack  of  angina  pectoris,  one  must  be  guided 
chiefly  by  a knowledge  of  its  cause ; in  some 
respects  also  by  its  severity  ; and  by  the 
previous  history  of  the  case.  Thus,  if  we 
can  ascertain  that  tho  attack  has  been  brought 


ANGINA  PECTORIS. 

on  by  some  clearly  established  and  remov- 
able cause,  a favourable  prognosis  may  be 
fairly  entertained.  On  the  other  hand,  if  the 
history  of  the  case  tells  that  there  have  been 
several  previous  attacks,  increasing  in  severity 
and  connected  with  heart-disease,  one  can  scarcely 
avoid  being  led  to  the  conclusion  that  the  disease 
will  tend,  with  more  or  less  rapidity,  to  a fatal 
termination.  Between  these  two  classes  of  cases 
exist  a large  majority  of  the  examples  of  the 
disease  in  which  the  symptoms  of  angina,  of 
greater  or  less  severity,  depend  on  neurosis,  on 
gouty  diathesis,  or  on  other  sources  of  nerve 
disorder,  amenable  to  treatment ; and  in  which, 
therefore,  a favourable  prognosis  may  to  some 
extent  be  given.  But  in  all  cases  great  caution 
should  be  exercised  ; for  many  instances  occur  in 
which,  from  slight  and  obscure  beginnings,  severe 
and  even  fatal  examples  of  the  disease  have  been 
developed. 

Treatment. — The  treatment  of  angina  pec- 
toris must  first  have  reference  to  relief  of  the 
attack  itself;  and,  secondly,  during  the  inter- 
val to  the  removal  of  the  causes  on  which  the 
attacks  may  depend. 

During  the  attach , it  is  necessary  first,  if  pos- 
sible, to  inspire  confidence,  atid  remove  appre- 
hension. The  patient  should  be  allowed  to  retain 
tho  position  in  which  he  feels  most  comfort. 
Secondly,  if  the  exciting  cause  is  one  that  can 
be  removed,  this  should  bo  done ; for  example, 
if  the  stomach  be  full  of  undigested  food,  an 
emetic  of  mustard  might  be  given  with  ad- 
vantage ; or  if  flatulence  he  present,  peppermint, 
ether,  and  other  anti-spasmodics  will  bo  useful. 
If  cold  have  produced  the  seizure,  the  feet  and 
hands  should  he  immersed  in  hot  water,  hot 
bottles  applied  to  the  surface  of  the  body,  and 
poultices  of  linseed  or  mustard,  or  embrocations 
of  chloroform  or  laudanum,  should  be  placed  on 
the  chest.  The  administration  of  chloroform 
internally  had  better  be  avoided.  The  nitrite  of 
amyl,  as  recommended  by  Dr.  Lauder  Brunton, 
has  been  found  one  of  the  most  efficient  remedies 
employed  hitherto.  Five  or  six  minims  of  this 
drug  (preserved  in  a glass  capsule)  should  be  in- 
haled from  a handkerchief,  and,  if  necessary, 
the  inhalation  may  be  repeated.  Nitro-glyeerine 
is  useful  (yij  of  a minim  dose),  and  hypodermic 
injection  of  morphia  may  be  tried  with  advan- 
tage. In  cases  where  debility  and  exhaustion 
exist,  the  ordinary  stimulants  will  be  required; 
and  various  antispasmcdics,  such  as  ether, 
ammonia,  &c.,  may  be  given  with  more  or  less 
benefit. 

During  the  intervals. — It  is  of  course  desi- 
rable to  avoid  all  causes  likely  to  bring  on 
an  attack  of  angina,  such  as  mental  excitement, 
bodily  exertion,  exposure  to  cold,  and  the  use  of 
indigestible  food  or  heavy  meals.  The  leading 
principle  in  treatment  should,  however,  be  to 
endeavour  to  determine  and  to  remove,  if  pos- 
sible, the  cause  of  the  disease.  "Whether  it  de- 
pend on  organic  disease  of  the  heart,  whether 
on  simple  neuralgia,  whether  on  gout  or  dys- 
pepsia, whether  on  debility,  or  on  fulness  of 
habit — to  each  of  such  conditions  mustappropriate 
treatment  be  directed.  A variety  of  specific 
remedies  have  been  recommended:  such  as 

arsenic,  phosphorus,  steel,  zinc,  and  the  different 


ANGINA  PECTORIS. 

4iiti-spasmoiiies.  Galvanism,  in  the  form  of 
the  continuous  current  from  thirty  cells,  has 
proved  successful  in  some  uncomplicated  cases, 
the  positive  pole  being  placed  on  the  sternum,  and 
the  negative  on  the  lower  cervical  vertebrae.  Ex- 
cellent, however,  as  each  of  the  remedies  named 
may  be  under  special  and  suitable  circum- 
stances, the  result  of  treatment  must  entirely  de- 
pend on  the  cause  of  the  disease,  and  how  far  it 
is  within  reach  of  remedy.  Some  cases  of  ap- 
parently severe  angina  will  be  found  to  yield 
to  treatment ; whilst,  as  might  be  expected  from 
the  nature  of  the  disease,  others  unhappily  pro- 
ceed to  a fatal  termination  in  spite  of  every 
effort  directed  to  their  relief. 

R.  Quain,  M.D. 

ANIDROSIS  (a,  priv.,  and  iSpas,  sweat). 
— Absence  or  want  of  perspiration.  See  Perspi- 
ration, Disorders  of. 

ANILINE  POISON. — The  aniline  dyes, 
which  are  a modern  discovery,  present  the  most 
brilliant  hues  of  yellow,  blue,  and  red;  as  such 
they  have  been  used  for  dyeing  stockings,  gloves, 
&e.  These  articles  when  worn  are  apt  to  pro- 
duce an  intense  form  of  inflammation  and  vesi- 
cation of  the  skin,  which  is  rebellious  against 
treatment,  and  liable  to  relapse  for  many  months 
after  the  original  attack  has  subsided.  See 
Dermatitis. 

ANIMAL  POISONS.  See  Poisons. 

ANODYNES  (a,  priv.,  and  otivvr],  pain). 
— Definition. — Medicines  which  relieve  pain 
by  lessening  the  excitability  of  nerves  or  of 
nerve-centres. 

Enumeration. — Anodyne  medicines  include 
Opium  and  its  alkaloids — Morphia  and  Codeia  ; 
Bromide  of  Potassium ; Cannabis  Indica  ; Bella- 
donna and  its  alkaloid — Atropia  ; Hyoscyamus 
and  Hyoscyamin ; Stramonium;  Aconite  and 
Aconitia  ; Veratrum  and  Veratria ; Conium  and 
Conia ; Lupulus  and  Lupulin  ; Gelseminum ; 
Chloroform,  Ether,  and  their  allies ; Chloral- 
hydrate  ; Butyl-chloral-hydrate  ; and  Camphor. 

Action. — Pain  is  due  to  a violent  stimulation 
of  a sensory  nerve  being  conveyed  to  some  of  the 
encephalic  nerve-centres  (probably  the  cerebral 
hemispheres),  and  perceived  there.  The  impres- 
sion produced  on  all  sensory  nerves,  except  the 
cephalic  nerves,  is  conveyed  for  a piart  of  its  course 
to  the  head  along  the  spinal  cord.  The  primary 
impression  which  is  felt  as  pain,  is  usually  made 
upon  the  peripheral  ends  of  the  seDsory  nerves  ; 
but  it  may  also  be  made  upon  their  trunks, 
upon  the  spinal  cord,  or  possibly  upon  the  en- 
cephalic centres  directly,  without  any  affection  of 
the  nerves  themselves,  as,  for  example,  in  hysteria. 
Pain  may  therefore  be  relieved,  while  the  source 
of  irritation  still  remains,  by  lessening  the  ex- 
citability of  the  ends  of  the  sensory  nerves  which 
receive  the  painful  impression ; of  their  trunks ; of 
the  spinal  cord  along  which  the  impression  travels ; 
or  of  the  encephalic  centre  in  which  it  is  perceived. 
Opium  acts  by  lessening  the  excitability  of  the 
sensory  nerves,  the  spinal  cord,  and  the  encephalic 
ganglia  ; bromide  of  potassium  is  also  believed  to 
act  on  all  three,  although  to  a much  less  degree 
than  opium  ; belladonna  and  atropia  affect  the 
sensory  nerves,  as  probably  does  hyoscyamus; 


ANTACIDS.  56 

stramonium,  aconite  and  aconitia,  veratria,  chloral 
and  butyl-chloral,  lupulus  and  lupulin,  and 
gelseminum  probably  act  on  the  encephalic 
centres. 

Uses. — As  opium  and  morphia  act  upon  all  the 
nervous  structures  concerned  in  the  production 
of  pain,  they  may  be  used  to  relieve  pain  what  ■ 
ever  its  cause.  Cannabis  indica  and  bromide  of 
potassium  may  be  employed  under  the  same 
circumstances  as  opium,  but  they  have  very 
much  less  power.  Chloral  seems  to  relieve  pain 
only  by  inducing  sleep,  and  does  not  produce  as 
anaesthetic  effect  unless  it  is  given  in  dangerous 
doses.  Butyl-chloral  also  induces  sleep,  but  seems 
to  have  a special  sedative  action  on  the  fifth 
nerve ; so  likewise  has  gelseminum — and  henca 
both  these  agents  are  used  in  the  treatment  of 
facial  neuralgia.  As  the  action  of  belladonna  is 
exerted  chiefly  on  the  peripheral  ends  of  the  sen- 
sory nerves,  this  remedy  is  usually  applied 
directly  to  the  painful  part  in  the  form  of  plaster, 
liniment,  or  ointment.  Aconite,  veratria,  and 
opium  are  also  used  as  local  applications  in 
several  forms,  for  the  relief  of  pain.  The  various 
anodynes  may  be  administered  not  only  by  the 
mouth,  but  by  other  channels,  such  as  by  inhala- 
tion, by  enema  or  suppository,  by  hypodermic 
injection,  or  by  endermic  application. 

Several  therapeutic  measures  are  employed  as 
Anodynes,  such  as  the  application  of  Dry  cr 
Moist  Heat ; Cold ; Electricity  ; various  forms  of 
Counter-Irritation ; Acupuncture;  or  the  Ab- 


ANOEEXIA  (a,  priv.,  and  ope(is,  appe- 
tite).— Want  or  deficiency  of  appetite,  not  ac- 
companied with  disgust  for  food.  See  Appetite 
Morbid  conditions  of. 

ANOSMIA  (a, priv.,  and  bayr],  smell). — Loss 
of  the  sense  of  smell.  See  Smell,  Disorders  of. 

ANTACIDS. — Definition. — Medicines  used 
to  counteract  acidity  of  the  secretions. 

Enumeration. — The  antacids  include  Potash, 
Soda,  Lithia,  Ammonia,  Lime,  Magnesia,  and 
their  carbonates  ; as  well  as  the  salts  which  th« 
alkalis  form  with  vegetable  acids,  such  as  Ace 
tales,  Citrates*,  and  Tartrates. 

Action.—  Antacids  are  divided  into  (1)  thosr 
which  act  directly,  lessening  acidity  in  thv 
stomach ; and  (2)  those  which  act  remotely . 
diminishing  acidity  of  the  urine.  The  alkalis  and 
alkaline  earths  and  their  carbonates,  with  the 
exception  of  ammonia,  have  both  a direct  and  a 
remote  influence ; for  when  swallowed  they  act  on 
the  stomach,  and  being  absorbed  from  the  intes- 
tinal canal,  they  are  excreted  by  the  kidneys,  thus 
lessening  the  acidity  of  the  urine.  Ammonia  and 
its  carbonate  are  direct  but  not  remote  antacids  ; 
for,  although  they  neutralize  acidity  in  the 
stomach,  they  are  partly  excreted  in  the  form 
of  urea,  and  do  not  diminish  the  acidity  of  the 
urine.  The  acetates,  citrates,  and  tartrates  of 
the  alkalis  and  alkaline  earths,  on  the  other 
hand,  have  no  antacid  effect  in  the  stomach,  but 
undergo  combustion  in  the  blood,  being  converted 
into  carbonates,  in  which  form  theyars  excreted 
in  the  urine,  and  diminish  its  acidity. 

Uses. — Excessive  acidity  of  the  contents  of 
the  stomach  gives  rise  to  acid  erccviUons  and 


56  ANTACIDS, 

heartburn.  It  may  sometimes  depend  on  tko 
secretion  of  a too  acid  juice  by  the  stomach, 
but  probably  is  generally  caused  by  the  forma- 
tion of  acid,  from  the  decomposition  of  food 
when  tho  process  of  digestion  is  slow  and  im- 
perfect. Antacids  are  given  after  meals  to 
lessen  acidity  in  the  stomach,  and  afford  imme- 
diate relief  to  its  attendant  symptoms.  They 
may  prove  even  more  efficacious  by  preventing 
acidity  when  given  before  meals  ( see  Alkalis). 
If  the  action  of  the  bowels  be  regular,  soda  is 
preferable  ; but'iime  should  be  used  if  they  are 
relaxed,  and  magnesia  if  there  is  a tendency  to 
constipation.  Remote  antacids  are  given  to 
lessen  the  acidity  and  irritating  qualities  of  the 
urine  in  cystitis  and  gonorrhoea ; and  to  prevent 
the  deposition  of  uric  acid  gravel  or  calculus 
in  gouty  persons.  For  this  purpose  potash  and 
lithia  are  preferable,  as  their  urates  are  more 
soluble  than  those  of  the  other  bases. 

T.  Lauder  Bjsunton. 

ANTAGONISM.  —This  term  is  employed  to 
express  the  fact  that  the  physiological  action  of 
certain  substances  may  be  affected,  even  to  the 
extent  of  neutralisation,  by  the  presence  in  the 
body,  at  the  same  time,  of  other  substances 
having  an  action  of  an  opposite  character.  It 
is  important  to  distinguish  between  antidotal 
action  and  physiological  antagonism.  By  an 
antidote  is  meant  a substance  which  so  affects 
the  chemical  or  physical  characters  of  a poison, 
as  to  prevent  its  having  any  injurious  action  on 
living  animal  tissues.  Thus  acids  and  alkalies 
neutralise  each  other,  so  as  to  form  innocuous 
salts ; tannin  may  render  tartar-emetic  and 
many  vegetable  alkaloids  insoluble ; and  the 
hydrated  sesquioxide  of  iron  may  be  used  to 
precipitate  arsenious  acid.  In  these  cases,  the 
action  is  limited  chiefly  to  the  alimentary  canal ; 
and  the  object  of  administering  the  antidote  is 
to  form  insoluble  salts,  or  compounds  which 
will  be  physiologically  inert.  But  the  physiolo- 
gical antagonism  of  certain  substances  is  pre- 
sumed to  take  place  in  the  blood  or  in  the  tissues. 
When  such  a substance  as  strychnia,  for  example, 
is  introduced  into  the  alimentary  canal,  it.  is 
quickly  absorbed,  and  carried  by  the  blood 
throughout  the  body.  It  does  not,  so  far  as 
observation  has  discovered,  influence  all  the  tis- 
sues ; but  it  so  affects  the  spinal  cord,  and  pos- 
sibly the  brain,  as  to  give  rise  to  severe  tetanic 
convulsions,  chiefly  of  a reflex  character.  This 
cffectis,  no  doubt,  due  either  to  some  interference 
in  the  nutritional  changes  between  the  blood 
and  the  tissues  composing  the  nerve-centres  ; or 
to  some  specific  action  of  the  poison  on  the 
nerve-centres  themselves  (see  Affinity).  These 
changes,  which  are  termed  physiological,  and  on 
which  the  normal  action  of  the  nerve-centres 
depends,  are  probably  of  a molecular  or  chemical 
nature  ; and  it  is  possible  to  conceive  that  they 
may  be  modified  in  different  ways  by  different 
substances.  Thus  has  arisen  the  idea  of  phy- 
siological antagonism ; and  experiment  has 
shown  that,  within  certain  limits,  which  will  no 
doubt  vary  in  each  case,  such  an  antagonism  is 
possible.  Antagonism  maybe  either  local, affect- 
ing one  organ,  as  is  seen  in  the  opposite  effects 
u^ion  the  pupil  of  opium  or  morphia  upon  the 


ANTAGONISM. 

one  hand,  and  stramonium,  hyoscyamus,  or  bel- 
ladonna upon  the  other;  or  it  may  extend 
apparently  to  more  important  organs  or  groups 
of  organs,  as  in  the  case  of  the  antagonism 
between  strychnia  and  the  hydrate  of  chloral. 
The  most  important  investigations  upon  the 
subject  of  physiological  antagonism  are  the  fol- 
lowing ; — 

(1)  Physostigma  and  Atropia,  by  Professor 
Fraser  — an  inquiry  which  showed  that  the 
fatal  effect  of  three  and  a half  times  the  mini- 
mum fatal  dose  of  physostigma  may  be  prevented 
by  atropia.  (2)  Atropia  and  Prussic  Acid , a 
research  byPreyer  of  Jena — of  a more  doubtful 
character  as  regards  the  point  to  bo  proved,  but 
still  sufficient  to  show  that,  within  certain  limits 
not  yet  indicated,  it  is  possible  to  prevent  the 
fatal  action  of  prussic  acid  by  atropia.  (3)  Atropia 
and  Muscarin  (the  active  principle  of  Agaricus 
muscarius) : — which  were  found  by  Schmiedeberg 
and  Koppe  to  have  entirely  antagonistic  actions 
ontheganglia  of  theheart — muscarinexcitingths 
intra-cardiac  inhibitory  centres,  and  stopping  the 
heart  in  diastole,  while  atropia  has  the  contrary 
effect.  (4)  Chloral  and  Strychnia, — an  anta- 
gonism first  pointed  out  by  Oscar  Liebreich,  who 
showed  that  minute  doses  of  strychnia  might  so 
rouse  an  animal  from  the  effects  of  an  overdose 
of  chloral  as  even  to  save  its  life.  And  (5) 
Strychnia  and  Chloral — with  respect  to  which 
Hughes  Bennett  demonstrated  the  converse  of 
the  last-mentioned  observation,  namely,  that  in 
the  rabbit  a fatal  dose  of  strychnia  might  be 
so  antagonised  by  a dose  of  chloral  as  to  save 
life. 

Conclusions.  — It  has  unfortunately  to  be 
admitted  that  the  practical  results  of  the  pre- 
ceding researches  have  not  been  very  encouraging. 
In  all  of  these  investigations  it  was  quite  ap- 
parent that  the  limits  of  physiological  antagonism 
were  very  narrow.  Three  elements  affect  the 
chances  of  success  in  the  way  of  saving  life  ; — 
(1)  the  ago  and  strength  of  the  animal;  (2)  the 
amount  of  the  doses  of  the  two  active  substances 
— so  that  if  either  the  one  or  the  other  active 
substance  be  given  slightly  in  excess,  death  will 
probably  take  place  ; and  (3)  the  time  between 
the  administration  of  the  two  active  substances. 
If  the  stronger  be  introduced  first,  and  be 
allowed  to  manifest  distinctly  its  physiological 
action,  it  is  almost  impossible  to  counteract  this 
by  that  of  another  substance  ; but  if  the  two 
substances  be  introduced  simultaneously,  or 
if  the  supposed  antagonist  to  the  more  active 
substance  be  introduced  first,  the  chances  of 
success  are  much  greater.  It  is  apparent,  there- 
fore, that  the  facts  relating  to  physiological  anta- 
gonism at  present  known  in  science  do  not 
hold  out  much  hope  of  good  results  from  their 
application  in  practice  ; but  still  the  physiolo- 
gical facts  are  so  definite  as  to  indicate  a precise 
mode  of  treatment.  For  example,  no  one  ac- 
quainted with  the  investigations  mentioned 
above  would  hesitate  in  attempting  to  relievo 
the  tetanie  spasms  of  a case  of  poisoning  by 
strychnia  by  repeated  doses  of  hydrate  of 
chloral,  or  by  the  administration  of  chloroform. 
A practical  result  of  such  researches  is  that 
the  principle  of  physiological  antagonism  may 
serve  as  a guide  to  the  application  of  re 


ANTAGONISM. 

medies  in  disease.  Thus  excessive  secretion, 
say  from  mucous  membranes  or  from  sali- 
vary glands,  may  be  modified  or  arrested  by 
the  use  of  sulphate  of  atropia,  a striking  ex- 
perimental demonstration  of  -which  may  be  seen 
in  the  antagonism  between  bromal  hydrate  and 
sulphate  of  atropia  in  the  rabbit. 

John  G.  McKendrick. 

ANTEFLEXION. — A bending  forwards  of 
any  organ.  The  term  is  specially  used  in  rela- 
tion to  the  uterus,  when  this  organ  is  bent  for- 
wards at  the  line  of  junction  of  its  body  and 
cervix.  See  AVomb,  Diseases  of. 

ANTEVERSION.  — A displacement  for- 
wards of  any  organ.  The  term  is  particularly 
applied  to  a change  of  position  of  the  uterus, 
in  which  this  organ  is  bodily  displaced  in  the 
pelvic  cavity,  so  that  the  fundus  is  directed 
against  the  bladder,  and  the  cervix  towards  the 
sacrum.  See  AVomb,  Diseases  of. 

ANTHELMINTICS  (ar-rl,  against,  and 
eAfuvs,  a worm). — Definition. — Medicines  which 
kill  or  expel  intestinal  worms. 

Enumeration. — -The  principal  anthelmintics 
are : — Oil  of  Male  Fern  ; Kamala  ; Kousso  ; Oil 
of  Turpentine  ; Pomegranate  Root ; AVorm-seed 
audits  active  principle,  Santonin;  Areca  ; Mu- 
cuna ; Eue ; and  drastic  purgatives.  As  purga- 
tives only  expel  the  worms,  they  are  termed 
Vermifuges ; while  the  other  anthelmintics  which 
kill  the  worms  are  called  Vermicides. 

Action. — The  oil  of  male  fern,  kamala,  kousso, 
oil  of  turpentine,  and  bark  of  pomegranate  root, 
act  as  poisons  to  tape-worms  ; worm-seed  and 
santonin  kill  round-worms.and  also  thread-worms. 
Castor  oil,  jalap,  scammony,  and  other  purgatives 
do  not  kill  the  worms,  but  dislodge  and  expel 
them,  by  the  increased  peristaltic  action  which 
they  occasion. 

Uses. — Drastic  purgatives  may  be  used  for 
worms  of  any  sort ; areca  for  both  tape-  and  round- 
worms  ; and  the  other  agents  for  the  worms  on 
which  they  severally  act  as  poisons.  Vermicides 
are  generally  given  after  the  patient  has  fasted 
for  several  hours,  in  order  that,  the  intestines 
being  empty,  the  drugs  may  act  more  readily 
on  the  worms.  A purgative  is  usually  given 
some  hours  afterwards,  in  order  to  expel  the 
dead  worms.  As  thread-worms  chiefly  inhabit 
the  rectum,  they  are  most  effectually  killed  by 
enemata,  which  may  consist  of  a strong  infusion 
of  quassia  ; salt  and  water  ; vinegar  and  water  ; 
solution  of  sulphate,  or  of  perchloride  of  iron ; 
oil  of  turpentine  ; castor  oil ; decoction  of  aloes  ; 
or  infusion  of  senna.  As  abundance  of  mucus  in 
the  intestines  forms  a convenient  nidus  for  the 
growth  of  worms,  anything  that  diminishes  this 
tends  to  prevent  their  occurrence ; and  for  this 
purpose  preparations  of  iron  and  bitter  tonics 
are  useful.  T.  Lauder  BnuNTON. 

ANTHRAX  (Svflpaf,  a coal). — A synonym 
for  carbuncle,  and  for  malignant  pustule.  See 
Carbuncle  ; and  Pustule,  Malignant. 

ANTIDOTE  (avrl,  against,  and  SISu/xi, 
I give.) — Definition.— -An  antidote  is  any 
remedy  which,  by  its  physical  or  its  chemical 
effect  upon  a poison,  or  in  both  ways,  is  capable  of 


AN  TIPERIODICS.  57 

preventing  or  counteracting  the  physiological 
effects  of  that  substance.  (See  Antagonism.) 
Sometimes,  however,  the  term  is  used  in  a more 
comprehensive  sense,  so  as  to  include  the  gene- 
ral treatment  of  a person  affected  by  a particular 
poison.  Thus,  in  poisoning  by  opium,  the  use 
of  the  stomach-pump,  enforced  exertion,  chafing 
the  limbs,  and  artificial  respiration  may  be  in- 
cluded in  the  general  antidotal  treatment. 

Modes  of  Action,  and  Application. — Most 
antidotal  substances  form  with  the  poison  insol- 
uble or  innocuous  compounds.  Without  at- 
tempting to  give  a complete  list,  the  following 
are  examples  of  the  more  common  poisons  and 
their  respective  antidotes: — -(1)  Ar&>nious  acid: 
hydrated  peroxide  of  iron,  or  light  magnesia; 
(2)  hydrocyanic  acid:  newly  precipitated  oxide 
of  iron  with  an  alkaline  carbonate;  (3)  oxalic 
acid:  chalk,  common  whiting,  or  magnesia  sus- 
pended in  water;  (-1)  tartar  emetic:  tannin, 
catechu,  or  other  vegetable  astringents ; (5)  ace- 
tate of  lead : sulphate  of  magnesia,  or  the  phos- 
phates of  soda  and  magnesia ; (6)  caustic  potash  : 
dilute  acetic  acid,  fixed  oils,  lemon  juice  ; (7) 
corrosive  sublimate : albumen,  white  of  egg,  flour, 
or  milk ; (8)  mineral  acids : chalk,  common 

whiting,  plaster  from  the  walls  or  ceiling,  or 
carbonate  of  magnesia;  (9)  chloride  of  zinc: 
albumen,  milk,  or  carbonate  of  soda. 

Aregetable  poisons  cannot  thus  be  counter- 
acted. If  they  have  been  taken  in  the  form 
of  seeds,  leaves,  or  roots,  the  proper  course 
is  to  remove  them  from  the  stomach  or  bowels 
as  soon  as  possible  by  emetics  and  purgatives, 
and  at  the  same  time  to  sustain  the  flagging 
strength  of  the  patient  by  the  administration 
of  stimulants.  On  the  other  hand,  if  the  alka- 
loid has  been  taken,  it  is  so  soon  absorbed 
that  emetics  and  purgatives  are  of  little  avail, 
or  may  even  be  injurious.  In  these  circum- 
stances we  must  rely  on  the  administration 
of  the  physiological  antagonist  of  the  poison 
(such  as  chloral  hydrate  in  the  case  of  strychnia- 
poisoning), and  on  supporting  the  strength  of 
the  patient.  The  following  are  the  best  antidotes 
to  the  vegetable  poisons  most  frequently  met 
with: — (1)  aconite  root:  emetic  of  sulphate  of 
zinc  and  stimulants ; (2)  belladonna  leaves  or 
root : emetic  of  sulphate  of  zinc,  ammonia, 
stimulants,  and  after  some  time  an  active  pur- 
gative; (3)  digitalis : emetics,  stimulants,  and  the 
maintenance  of  the  recumbent  position ; (-1)  hyos- 
cyamus leaves : emetics  and  stimulants;  (5)  hydro- 
chlorate or  meconate  of  morphia , or  any  of  the 
preparations  of  opium:  emeticof  sulphate  of  zinc, 
external  stimulation  by  warmth,  turpentine  or 
camphor  liniments,  enforced  exertion,  artificial 
respiration,  and  small  repeated  doses  of  sulphate 
of  atropia  ; (6)  chloral-hydrate : the  same  as  for 
opium;  (7)  strychnia  or  mix  vomica:  animal 
charcoal  suspended  in  water,  repeated  large 
doses  of  chloral-hydrate,  or  chloroform.  See 
Poisons.  John  G.  M‘Kendeick. 

ANTIMONY,  Poisoning  by.  Nee  Tartar 
Emetic,  Poisoning  by. 

AN  TIPERIODICS.  — Definition. — Medi- 
cines which  prevent  or  relieve  the  paroxysms 
of  certain  diseases  which  exhibit  a periodic 
character. 


58  ANTI  PERI0DIC3. 

Enumeration. — The  chief  antiperiodics  are : 
— Cinchona-bark  and  its  alkaloids — Quinine, 
Cinchonine,  Quinidine,  and  Cinchoni dine ; Be- 
beera-bark  and  its  active  principle,  Bebeerin; 
Salicin,  Salicylic  Acid  and  its  salts  ; Eucalyptus 
globulus ; and  Arsenic. 

Action. — The  mode  of  action  of  antiperiodics 
is  at  present  unknown. 

Uses. — Cinchona,  and  still  more  quinine,  is 
almost  a specific  in  the  treatment  of  intermit- 
tent fevers,  periodic  head-aches,  neuralgias,  and 
other  affections  caused  by  malaria.  Though 
loss  certain  in  its  action  than  in  intermittent 
fevers,  quinine  is  also  the  best  remedy  in  the 
remittent  fevers  of  the  tropics,  in  which,  however, 
it  must  be  given  in  very  large  doses.  The  other 
alkaloids  of  cinchona  have  a similar  action  to 
that  of  quinine,  but  they  are  not  so  powerful. 
Bebeerin  is  only  about  one-third  as  powerful, 
and  is  by  no  means  so  certain ; and  the  same 
remark  applies  to  the  other  remedies  enumerated. 
In  some  cases  of  ague  and  other  intermittent 
affections  arsenic  proves  successful  when  qui- 
nine fails.  Emetics  and  purgatives  are  useful 
auxiliaries  to  quinine  in  the  treatment  of  ague, 
and  are  employed  alone  for  the  cure  of  this 
disease  in  some  parts  of  the  world  where  quinine 
is  not  available. 

T.  Lauder  Brunton. 

ANTIPHLOGISTIC  (dvrl,  against,  and 
fAi-yu,  I burn). — A term  for  any  method  of 
treatment  that  is  intended  to  counteract  inflam- 
mation and  its  accompanying  constitutional 
disturbance. 

ANTIPYRETICS  (avrl,  against,  and 
nvperbs,  a fever).  — Definition.  — Medicines 
which  reduce  the  temperature  in  fever. 

Enumeration. — The  principal  agents  used  as 
antipyretics  are — Cold  Baths,  Cold  Applications, 
Tee;  Diaphoretics;  Alcohol;  Chloral;  Quinine; 
Salicylic  Acid  and  its  salts ; Eucalyptol ; Essen- 
tial Oils;  Aconite;  Digitalis;  Veratria;  Pur- 
gatives; and  Venesection. 

Action. — The  temperature  of  the  body  may 
be  reduced,  either  by  increasing  the  abstraction 
of  heat,  or  by  lessening  its  production.  The 
direct  application  of  cold,  by  means  of  baths, 
affusion,  or  sponging,  or  by  enveloping  the  body 
in  sheets  wrung  out  of  cold  water,  is  the  most 
powerful  and  rapid  means  of  abstracting  heat. 
But  the  loss  of  heat  w'hich  constantly  occurs, 
even  in  health,  by  evaporation  of  the  sweat,  and 
the  radiation  and  conduction  of  heat  from  the 
skin,  may  be  increased  by  the  use  of  diapho- 
retics, such  as  salts  of  potash,  preparations  of 
antimony,  or  acetate  of  ammonia ; or  by  such 
medicines  as  dilate  the  cutaneous  vessels,  so  as 
to  allow  the  heated  blood  to  circulate  freely 
through  them,  and  to  become  cooled  by  the  ex- 
ternal media  surrounding  the  skin.  Alcohol,  in 
the  form  either  of  wine  or  spirits,  and  chloral, 
have  an  action  of  this  sort,  though  alcohol  also 
influences  the  production  of  heat.  Alcohol, 
quinine,  salicylic  acid  and  its  salts,  eucalyptol, 
and  essential  oils  lessen  the  production  of  heat 
within  the  body,  probably  by  diminishing  oxida- 
tion of  the  tissues.  (See  Alcohol.)  Aconite, 
digitalis,  and  veratria  reduce  the  temperature, 


ANTISEPTICS. 

but  their  mode  of  action  is  not  precisely  Ascer- 
tained. 

Uses. — Antipyretics  act  much  more  powerfully 
in  reducing  the  temperature  of  the  body  in  fever 
than  they  do  in  health.  They  may  he  used 
when  the  temperature  has  risen  either  from  ex- 
posure to  a high  external  temperature,  as  in 
thermal  fever ; in  consequence  of  inflammation, 
as  in  pneumonia,  or  pericarditis ; or  in  specific 
fevers,  as  acute  rheumatism,  typhus,  and  scarla- 
tina. The  most  rapid  and  powerful  antipyretic 
remedies  are  cold  baths  ; next  probably  come 
large  doses  of  salicylic  acid  and  quinine.  The 
latter  seems  to  act  very  efficiently  in  thormic 
fever  when  injected  subcutaneously. 

T.  Lattder  Brunton. 

ANTISEPTICS. — Antiputrescents  (a^Tl, 
against,  and  o-qirTiKbs,  putrefying). 

Definition.  — An  antiseptic  is  a substance 
which  prevents  or  retards  putrefaction,  that 
is,  the  decomposition  of  animal  or  vegetable 
bodies  accompanied  by  the  evolution  of  offensive 
gases.  The  putrefactive  change  occurs  only  in 
dead  matter,  and  requires  the  presence  of  water, 
heat,  and  a ferment.  That  there  is  no  putrefac- 
tion in  the  absence  of  water  is  obvious,  for  bodies, 
such  as  albumin  and  blood,  which  in  the  moist 
state  are  highly  susceptible  of  putrefaction,  may 
be  kept  for  an  indefinite  time  without  change 
if  they  he  perfectly  dry.  Heat  also  has  an  im- 
portant influence  on  putrefaction.  At  very  low 
temperatures  the  putrefactive  change  ceases, 
while  elevated  temperatures,  such  as  prevail  in 
tropical  climates,  are  favourable  to  it.  An  addi- 
tional element  besides  heat  and  moisture  is,  how- 
ever, required,  and  the  opinion  generally  accepted 
at  present  is,  that  this  consists  of  minute  vital 
organisms,  which  in  some  way  excite  putrefac- 
tive decomposition. 

Mode  of  Action. — The  substances  used  as 
antiseptics  act  either  directly  on  the  bodies  in 
which  putrefaction  is  occurring  or  might  occur, 
forming  with  them  combinations  that  are  not 
susceptible  of  the  decomposing  action  of  a fer- 
ment ; or  they  act  indirectly,  by  destroying  the 
vitality  or  otherwise  preventing  the  develop- 
ment and  propagation  of  the  organisms  of  which 
the  ferment  is  composed.  In  this  respect  anti- 
septics are  distinguished  from  disinfectants,  the 
action  of  the  latter  being  directed  only  towards 
the  excitiDg  causes  and  offensive  or  deleterious 
products  of  a class  of  changes  which  are  them- 
selves more  comprehensive  than  those  implied  by 
the  term  putrefaction. 

Enumeration. — There  are  numerous  chemical 
agents  possessing  antiseptic  properties,  the  chief 
of  these  including  Chlorine,  Sulphurous  Acid. 
Nitric  Oxide,  and  Peroxide  of  Nitrogen,  as  gases  : 
Carbolic  Acid,  Creasote,  Benzol,  Sulphites  and 
Hyposulphites,  and  the  Hypochlorites,  which 
emit  vapours  at  common  temperatures  ; Chromic, 
Boric,  Tannic,  and  Salicylic  acids,  Permanganate 
of  Potash,  Sulphoearbolates,  Chlorate  of  Potash 
Chloride  of  Zinc,  and  Charcoal,  from  which  no 
vapour  is  emitted. 

Uses. — 1.  In  therapeutic  practice  antiseptics 
are  chiefly  employed  in  the  treatment  of  surgical 
operations  and  open  wounds,  to  prevent  the  occur- 
rence of  putrefactive  decomposition.  Those  antisep- 


ANTISEPTICS. 

tics  are  best  suited  for  this  purpose  -which,  acting 
efficiently  on  the  ferment,  have  little  action,  and 
no  injurious  effect,  on  the  parts  in  which  the 
healing  process  is  going  on.  Gases,  except  in 
solution,  cannot  be  readily  used,  as  it  would  be 
necessary  to  enclose  the  substance  to  be  preserved 
in  an  air-tight  vessel  containing  the  gas.  The 
volatile  antiseptics  which  slowly  emit  a vapour 
have  been  preferred  to  those  which  emit  no 
vapour,  although  among  the  latter  salicylic  and 
boric  acids,  being  devoid  of  any  irritating  pro- 
perties when  applied  to  inflamed  surfaces,  would 
on  this  account  present  a marked  advantage. 

Carbolic  acid  has  been  used  with  success,  a 
solution  in  water  containing  one  part  of  the 
crystallised  acid  in  from  forty  to  one  hundred 
parts  of  water  being  applied  as  a lotion,  and 
also  in  the  form  of  spray,  diffused  through  the 
atmosphere  during  a surgical  operation  or  the 
dressing  of  a wound.  The  carbolic  acid  solution 
may  also  be  used  on  lint  or  cotton-wool  for 
covering  the  affected  part.  Antiseptic  gauze  for 
a similar  purpose  may  be  made  by  adding  one 
part  of  crystallised  carbolic  acid  to  five  parts  of 
common  resin  and  seven  parts  of  paraffin  melted 
together,  and  applying  the  compound  to  coarse 
muslin,  so  as  to  form  a thin  coating  of  the 
plaster  over  the  gauze,  which,  when  it  has 
hardened,  is  used  for  covering  the  parts  to 
be  protected.  Professor  Lister  has  also  re- 
commended a boric  acid  dressing  for  rodent 
ulcers,  which  is  composed  of  boric  acid  and 
white  wax,  each  one  part,  paraffin  and  almond 
oil  each  two  parts.  The  boric  acid  and  oil 
are  added  to  the  melted  wax  and  paraffin,  and 
the  whole  stirred  in  a mortar  until  it  thickens, 
then  set  aside  to  cool  and  harden,  after  which  it 
is  to  be  rubbed  in  the  mortar  until  it  acquires 
tho  consistence  of  an  ointment.  This  is  thinly 
spread  on  fine  rag  and  applied  to  the  wound. 
The  oil  separates,  and  is  absorbed  by  lint  or  rag 
placed  over  the  dressing,  while  a firm  plaster 
remains  attached  to  the  skin,  which  is  easily 
removed  when  necessary.  Salicylic  acid  may  be 
substituted  in  this  dressing  for  the  boric  acid. 
In  some  cases  salicylic  acid  is  applied  alone,  by 
merely  sprinkling  it  in  fine  powder  over  the  part 
affected.  Its  very  slight  solubility  in  water 
presents  an  obstacle  to  its  use  in  solution,  un- 
less something  be  added  to  render  it  more  solu- 
ble ; and  borax,  which  is  itself  a good  antiseptic, 
may  be  used  for  that  purpose.  One  drachm  of 
salicylic  acid,  two  drachms  of  borax,  and  half  an 
ounce  of  glycerine,  with  three  ounces  of  water, 
form,  if  aided  with  a little  heat,  a clear  solution 
which  may  be  used  as  an  antiseptic  lotion. 

2.  In  medical  practice  antiseptics  are  also  em- 
ployed, either  as  local  applications  or  as  internal 
remedies.  Those  which  are  chiefly  available 
include  creasote,  carbolic  acid,  the  snlphocarbo- 
lates,  sulphurous  acid,  the  sulphites  or  hypo- 
sulphites, chlorine  water,  permanganate  of 
potash,  borax  or  boric  acid,  chlorate  of  potash, 
charcoal,  salicylic  acid,  and  thymol.  They  are 
principally  used  for  the  prevention  and  treat- 
ment of  infectious  fevers ; and  in  low  forms  of 
ulceration  of  the  throat. 

3.  In  using  antiseptics  for  the  preservation  oi 
anatomical  specimens,  a wider  range  of  chemical 
agents  may  be  taken,  and  a selection  made  of 


ANTISEPTIC  TREATMENT.  59 

substances  that  would  be  inapplicable  in  the 
treatment  of  the  living  subject.  Arsenious  acid, 
corrosive  sublimate,  or  chloride  of  zinc  in  solution 
are  of  service  for  this  purpose,  and  chromic  acid, 
even  when  diluted  with  from  five  hundred  to 
one  thousand  parts  of  water,  possesses  the  pro- 
perty of  preserving  animal  matter  from  decom- 
position, as  also  does  a solution  of  one  part  of 
borax  in  forty  parts  of  water. 

Besides  the  more  powerful  antiseptics  noticed, 
others  of  a milder  nature,  such  as  common  salt, 
nitre,  and  sugar,  are  used  for  preserving  articles 
of  food ; while  alcohol  and  glycerine  are  employed 
for  the  preservation  of  animal  and  vegetable  sub- 
stances as  specimens.  T.  Redwood. 

ANTISEPTIC  TREATMENT  is  treat- 
ment directed  against  putrefaction,  or  rather,  as 
now  generally  understood,  against  the  develop- 
ment of  fermentative  organisms. 

1.  Ik  Suegeky,  the  employment  of  the  anti- 
septic method  is  based  upon  the  theory  which  attri- 
butes putrefaction  and  its  consequences  to  minute 
organisms  (bacteria,  &c.)  derived  from  without. 

The  treatment  yields  tho  most  satisfactory  re- 
sults when  it  is  so  employed  as  to  prevent,  rather 
than  to  attempt  to  correct  putrefaction.  To  ob- 
tain these  results  the  surgeon  must  have  unbroken 
skin  to  operate  upon,  or  the  wound  must  have 
been  so  recently  inflicted  that  there  has  not  been 
time  or  opportunity  for  the  septic  organisms 
to  get  beyond  the  reach  of  the  antiseptic  whicli 
he  employs.  Hence  there  must  always  be  a per- 
centage of  failures  in  the  treatment  of  compound 
fractures  and  large  lacerated  and  contused  wounds, 
owing  to  the  amount  of  septic  air  and  dirt  carried 
into  tho  recesses  of  the  wounds  between  the  time 
of  the  injury  and  the  commencement  of  the  treat- 
ment. In  the  event  of  putrefaction  occurring  in 
such  a case,  antiseptic  dressings  should  be  con- 
tinued, but  the  question  of  operative  interference 
must  be  determined  according  to  the  ordinary 
principles  of  surgery.  Putrid  ulcers  and  super- 
ficial wounds  may  certainly  he  rendered  aseptic 
by  suitable  means,  and  so  probably  may  cavities 
laid  open  during  excision  or  amputation  ; but 
the  attempt  to  correct  putrefaction  in  deep  sinuses, 
such  as  those  connected  with  caries  of  vertebrae, 
is  hopeless,  though  by  appropriate  dressings  the 
putrid  emanations  may  be  rendered  less  noxious 
to  the  patient  and  those  about  him. 

The  antiseptics  which  have  been  found  most 
suitable  are  carbolic  acid,  boric  acid,  chloride 
of  zinc,  and  salicylic  acid. 

Carbolic  acid  is  the  antiseptic  most  generally 
useful.  A solution  of  one  part  to  twenty  ot 
water  is  employed  to  purify  tlie  skin  of  the  parL 
to  be  operated  upon,  the  sponges,  instruments, 
&c.  A solution  of  one  part  to  forty  is  used 
for  washing  sponges  during  an  operation,  for 
the  hands  of  the  surgeon  and  assistants,  and 
for  the  changing  of  dressings.  The  volatility  of 
carbolic  acid  renders  it  invaluable  for  dressing 
hollow  wounds  and  abscesses.  It  is  the  active 
constituent  of  the  ordinary  dressing — antiseptic 
gauze,  which  is  applied  in  eight  layers,  of  size 
proportioned  to  the  expected  quantity  of  dis- 
charge, a piece  of  reliable  thin  mackintosh  cloth 
(hat  lining)  being  interposed  beneath  the  outer 
layer  of  gauze;  this  serves  to  prevent  the  dia 


SO  ANTISEPTIC 

charge  from  soaking  directly  through  the  central 
part  of  the  dressing,  thereby  washing  out  the 
stored  up  acid,  and  allowing  the  direct  access  of 
putrefactive  organisms  to  the  cavity.  Disastrous 
consequences  have  followed  from  a defect  in  the 
mackintosh.  A small  portion  of  gauze  wrung 
out  of  the  one-to-forty  carbolic  acid  solution  'e 
applied  over  the  wound  before  the  ordinary 
eight-fold  dressing,  so  as  to  prevent  possible 
mischief  from  putrefactive  organisms  accident- 
ally adherent  to  the  inner  layer  of  the  gauze, 
which  might  not  otherwise  be  destroyed,  owing 
to  the  slight  volatility,  at  the  ordinary  tempera- 
ture of  the  atmosphere,  of  the  acid  stored  in  the 
gauze.  The  gauze  is  also  useful,  on  account  of 
its  antiseptic  properties,  as  a bandage  in  retrac- 
tion of  the  soft  parts  in  stumps,  and  in  any  case 
in  which  free  discharge  is  expected. 

In  addition  to  other  measures,  there  must  be  an 
antiseptic  atmosphere  provided,  so  that  the  air 
which  gains  access  to  the  wound  or  abscess  may 
be  innocuous.  This  is  secured  by  means  of  a 
spray  of  one-to-forty  carbolic  acid  solution,  for 
the  production  of  which  Lister’s  portable  steam 
apparatus  may  be  used.  When  the  spray  is 
suspended  during  an  operation  or  the  changing 
of  a dressing,  the  wound  is  covered  with  a piece 
of  sound  calico  moistened  with  the  same  solution. 
Of  course  superficial  sores  and  wounds  require 
neither  spray  nor  guard. 

Cicatrisation  is  promoted  by  interposing 
between  the  healing  parts  and  the  antiseptic 
agent  an  impervious,  unirritating  protective 
layer,  composed  of  thin  oil-sill;;  varnished  with 
copal  and  then  coated  with  a layer  of  dextrine, 
which  allows  the  oil-silk  to  be  uniformly  wetted 
by  the  antiseptic  solution  into  which  it  is  dipped 
at  the  moment  of  application.  The  antiseptic 
dressing  proper  must  extend  a considerable  dis- 
tance beyond  the  protective  layer,  so  as  to  prevent 
the  access  of  putrefactive  organisms  beneath  it. 

Lint  soaked  in  a one-to-ten  solution  of  car- 
bolic acid  in  olive  oil  is  used  as  a dressing  for 
abscesses  near  the  anus,  and  occasionally  as  a 
stuffing  for  cavities.  A one-to-twenty  oily  solu- 
tion is  smeared  upon  urethral  instruments  to  pre- 
vent putridity  of  urine  and  its  consequent  evils.1 

Boric  acid  is  a powerful  antiseptic,  but  its 
non-volatility  prevents  its  being  used  for  the 
dressing  of  hollow  wounds  and  in  the  form  of 
spray.  It  is  bland  and  unirritating  as  compared 
with  carbolic  aeid,  and  is  therefore  particularly 
serviceable  as  a dressing  for  superficial  wounds 
and  sores.  It  is  employed  in  the  form  of  a satu- 
rated watery  solution ; as  an  ointment,  in  the 
proportion  of  one  to  six;  and  as  boric,  lint,  which 
contains  about  half  its  weight  of  the  acid. 

Chloride  of  zinc  has  the  remarkable  property 
of  producing  such  an  effect  upon  the  tissues  of  a 
recent  wound,  that  when  applied  once  as  a watery 
solution  of  about  forty  grains  to  the  ounce,  the 
cut  surface,  though  not  presenting  any  visible 
slough,  is  rendered  incapable  of  putrefaction  for 
two  or  three  days,  even  when  exposed  to  the 

* Cystitis,  thus  complicated  with  putridity  of  the  urine, 
due  to  infection  by  catheters,  may  often  be  benefited  by 
washing  out  the  bladder  with  solution  of  boric  acid. 
This  complication  of  course  never  arises  when  the  instru- 
ments have  been  carbolised  from  the  commencement  of 
the  treatment. 


TREATMENT. 

influence  of  septic  material.  The  patient  is  thus 
tided  over  the  dangerous  period  preceding  sup- 
puration, during  which  the  divided  tissues  are 
most  prone  to  inflammation  and  the  absorption 
of  septic  products.  Hence  this  agent,  though 
not  adapted  for  general  use,  is  of  the  highest 
value  when  it  is  impossible  to  exclude  septic 
organisms  in  the  after-treatment,  as,  for  ex- 
ample, after  the  removal  of  tumours  of  the  jaws, 
in  operations  about  the  anus,  and  in  ampu- 
tations or  excisions  in  parts  affected  with  putrid 
sinuses,  which  should  first  be  scraped  out  with 
the  sharp  spoon. 

Sometimes  a peculiar,  disagreeable  odour  is 
observed  on  removing  an  antiseptic  gauze  dress- 
ing which  has  been  applied  for  several  days, 
especially  to  regions  which  have  naturally  a 
powerful  odour,  as  the  axilla  or  groin  ; and  occa- 
sionally the  odorous  material  is  so  irritating  as 
to  produce  actual  eczema  around  the  wound. 
This  seems  to  depend  upon  a reaction  between 
the  discharge  or  excretion  and  some  ingredient  of 
the  gauze.  Salicylic  acid  has  the  power  of  pre- 
venting this  reaction,  or,  at  any  rate,  of  obviating 
or  remedying  its  bad  effects,  if  a little  of  the  acid 
is  smeared  upon  the  protective  or  upon  the  inner 
layer  of  gauze.  Salicylic  acid  has  been  introduced 
as  an  independent  dressing  by  Prof.  Thiersch, 
but  has  been  found  by  Prof.  Lister  to  be  inferior 
to  carbolic  acid  for  the  destruction  of  bacteria, 
though  very  efficient  in  preventing  fermentations. 
Chloral,  thymol,  and  Euculyptol  are  used  as  anti- 
septics. Mr.  Lister  recommends  gauze  containing 
oil  of  Eucalyptus  when  symptoms  of  poisoning 
follow  the  use  of  the  ordinary  gauze  dressing. 

Prepared  antiseptic  catgut  is  employed  for 
arresting  arterial  htemorrhage. 

Chassaignac’s  drainage-tubing  is  introduced  to 
prevent  tension  after  the  opening  of  an  abscess, 
or  after  the  application  of  antiseptics  to  the  raw 
surface  of  a hollow  wound. 

Carbolised  silk  sutures  are  used,  as  they  are 
not  liable  to  catch  in  the  dressings. 

2.  In  Medicine,  antiseptic  treatment  is  based 
on  the  hypothesis  that  infectious  and  contagious 
diseases  are  caused  by  the  presence  and  multipli- 
cation in  the  human  organism  of  minute  para- 
sites, termed  mierozymes,  microphytes,  micro- 
cocci, &c.  On  this  assumption,  special  remedies 
are  administered  for  the  purpose  of  destroying 
these  minute  organisms,  or  of  rendering  the 
blood  and  other  tissues  incapable  of  sustaining 
them.  The  treatment  further  aims  at  preventing 
the  spread  of  these  diseases  by  the  prophylactic 
administration  of  antiseptic  remedies  to  persons 
who  are  compelled  to  remain  in  infected  places. 

At  present  a definite  relation  would  seem  to 
have  been  made  out  between  specific  microphytes 
and  cow-pox,  sheep-pox,  splenic  fever,  and  re- 
lapsing fever  respectively ; whilst  a similar  con- 
nection has  been  so  far  supported  by  observations 
in  the  case  of  measles,  scarlatina,  diphtheria, 
enteric  fever,  and  erysipelas  ; but  much  remains 
to  be  done  before  the  true  relation  between 
microphytes  and  infectious  diseases  can  be  est  i- 
blished.  Seeing  that  antiseptic  therapeutics 
depends  on  an  unestablished  aetiology,  it  cannot, 
he  expected  to  be  in  a very  advanced  condition  ; 
accordingly  there  is  at  present  but  little  that  is 
settled  or  satisfactory  to  be  said.  The  sulphite* 


. ANTISEPTIC  treatment. 

f.r.d  hyposulphites,  introduced  by  Professor  Polli 
in  1857,  have  been  freely  givon  in  zymotic  diseases 
in  twenty-grain  doses  every  three  or  four  hours, 
end  with  apparently  good  effect. 

Carbolic  acid  is  also  said  to  have  been  success- 
fully used  in  diphtheria  and  in  intermittent  and 
eruptive  fevers,  in  doses  of  from  one  tc  five 
minims  or  more. 

The  sulphocarbnlates,  introduced  by  Dr.  San- 
som  in  1867,  have  been  used  with  success  in 
many  diseases.  They  produce  very  little  phy- 
siological effect,  and  seem  to  deserve  increased 
attention.  Dr.  Brakenridge  believed  that  he 
found  sulphocarbolate  of  soda  remarkably  bene- 
ficial in  an  epidemic  of  scarlatina  in  1875. 
Patients  under  ten  years  were  given  five  grains, 
and  those  above  that  age  twenty  grains,  every 
two  hours.  Also,  according  to  this  authority, 
the  prophylactic  effect  of  ten-grain  doses  three 
times  a day  was  very  striking. 

Thymol  and  salicylic  acid  have  also  risen  into 
favour,  owing  to  their  powerful  antiseptic  effects 
being  associated  with  comparative  physiological 
inertness. 

Sarcinous  dyspepsia  is  greatly  relieved  and 
sometimes  cured  by  Kussmaul’s  method  of  wash- 
ing out  the  stomach  with  solution  of  perman- 
ganate of  potash,  or  some  other  antiseptic. 

Reference  must  be  made  to  solution  of  per- 
manganate of  potash,  solution  of  carbolic  acid, 
glycerine  of  borax  or  a preparation  of  boric 
acid  of  the  same  strength,  sulphurous  acid,  and 
chlorate  of  potash,  as  applications  to  the  throat 
in  such  diseases  as  diphtheria  and  scarlatinal 
tonsillitis,  or  in  any  form  of  sloughy  ulceration 
of  this  part.  To  these  may  be  added  a five- 
grain  solution  of  sulphate  of  quinine. 

John  Bishop. 

ANTISPASMODICS  (avrl,  against,  and 
airdafj.a,  a spasm). — Definition.  — Medicines 
which  prevent  or  allay  spasm. 

Enumeration.— Antispasmodics  may  be  ar- 
ranged in  groups  as  follows : — Valerian,  Vale- 
rianic Acid  and  its  salts;  Musk,  Castor, 
Assafoetida,  Sumbul  and  Galbannm,  Camphor, 
Brominated  Camphor,  Oil  of  Amber  ; Ammonia 
and  its  Carbonate  ; Alcohol,  Ether,  Acetic  Ether, 
Chloroform,  Nitrite  of  Amyl ; Bromide  of  Po- 
tassium, Bromide  of  Ammonium  ; Conium,  Lobe- 
lia, Opium,  Gelseminum,  Indian  Hemp,  Bella- 
donna, Stramonium ; and  the  Essential  Oils. 
As  adjuvants  may  be  mentioned — Cold  Baths, 
moderato  Exercise,  Friction,  Heat,  and  Mois- 
ture ; and  also  Quinine,  Arsenic,  Zinc,  and  Silver. 

Action. — Certain  nerves  and  nerve-centres, 
when  excited,  produce  contraction  of  volun- 
tary or  involuntary  muscular  fibres;  other 
nerves  and  centres  arrest  movements ; and  by  the 
combined  action  of  these  two  systems  the  motions 
of  the  various  contractile  structures  in  the  body 
are  regulated,  and  subordinated  to  the  require- 
ments of  the  organism  as  a whole.  Excessive 
contraction  or  spasm  of  one  part  of  the  body 
may  therefore  arise  either  from  excessive  action 
of  the  motor,  or  deficient  action  of  the  inhibitory 
centres.  Spasm  may  affect  the  involuntary  mus- 
cular fibres  of  the  intestines — as  in  colic  ; of  the 
vessels— as  in  some  forms  of  headache,  and  in 
vaso-motor  neurcses  of  the  ulerus  and  bladder  : 


ANUS,  DISEASES  OF.  Cl 

single  voluntary  muscles,  or  groups  of  muscles — 
as  in  various  forms  of  cramp : or  the  muscular 
system  generally — as  in  tetanus,  epilepsy,  and 
hysteria.  Antispasmodics  may  act  by  lessening 
the  irritability  of  motor  centres,  as,  for  example, 
bromide  of  potassium  and  conium  ; or  by  stimu- 
lating those  portions  of  the  nervous  system  which 
restrain  and  co-ordinate  movements,  as  alcohol 
probably  does.  There  are  no  direct  experiments 
to  show  the  action  of  antispasmodics  on  the  in- 
hibitory centres  ; but  it  seems  probable  that  they 
have  such  an  action,  although  it  may  rot  be  con- 
fined to  these  parts  alone.  Thus  small  doses  of 
alcohol  and  ether,  which  stimulate  the  nervous 
system  generally,  and  usually  increase  motor 
activity,  will  restrain  and  co-ordinate  excessive 
muscular  action,  as  in  colic,  nervous  agitation, 
trembling,  and  hysteria.  It  is  at  present  im- 
possible to  localize  the  part  of  the  nervous 
system  affected  by  valerian,  assafeetida,  and 
other  drugs  of  this  class.  As  spasms  occur  when 
the  nervous  system  is  deficient  in  power,  nervine 
and  general  tonics,  such  as  quinine,  zinc,  and  iron, 
are  often  found  to  be  useful  adjuvants. 

Uses. — In  such  convulsive  diseases  as  epi- 
lepsy, laryngismus  stridulus,  and  infantile  con- 
vulsions, bromide  of  potassium  is  the  most 
powerful  antispasmodic ; in  hysteria — valerian, 
assafeetida,  and  the  bromides  ; in  chorea — arse- 
nic, conium,  copper,  and  zinc ; in  spasmodic 
asthma — lobelia  and  stramonium  ; in  spasm  of 
the  blood-vessels — nitrite  of  amyl.  In  all 
spasmodic  affections,  cold  baths  or  sponging, 
exposure  to  sunlight,  moderate  exercise,  and  a 
plain  but  nutritious  diet  should  be  employed  ; 
and  late  hours,  a close  atmosphere,  exhausting 
emotions,  or  excessive  bodily  or  mental  work 
should  be  avoided.  T.  Lauder  Brunton, 

ANURIA. — Absence  of  urination,  whether 
from  suppression  or  retention  of  urine.  See 
Micturition,  Disorders  of. 

AHUS,  Diseases  of. — The  principal  affec- 
tions of  this  part  are  Congenital  Abnormalities ; 
Epithelioma;  Irritable  Sphincter  Ani;  Irritable 
Ulcer;  Prolapsus;  Prurigo;  Tumours  and  Ex- 
crescences. 

1 . Congenital  Abnormalities  ( Atresia ) may  be 
classed  as  follows: — 1.  Imperforate  anus  without 
deficiency  of  the  rectum.  2.  Imperforate  anus,  the 
rectum  being  partially  or  wholly  deficient.  3. 
Anus  opening  into  a cul-de-sac,  the  rectum  being 
partially  deficient.  4.  Imperforate  anus  in  the 
male,  the  rectum  being  partially  deficient,  and 
communicating  with  the  urethra  or  neck  of  the 
bladder.  5.  Imperforate  anus  in  the  female,  the 
rectum  being  partially  deficient,  and  communi- 
cating with  the  vagina  or  uterus.  6.  Imperforate 
anus,  the  rectum  being  partially  deficient  and 
opening  externally  in  an  abnormal  situation  by  a 
narrow  outlet.  7.  Narrowness  of  the  anus.  These 
imperfections  can  be  remedied,  if  at  all,  only  by 
operation. 

2.  Epithelioma.— The  anus,  like  other  parts, 
where  a junction  takes  place  between  the  skin 
and  mucous  membrane,  is  liable  to  epithelioma. 
It  is  easily  recognised  by  the  ordinary  characters 
of  the  sore.  Warty  growths  and  flaps  of  skin  at 
this  part  are  subject  to  this  form  of  degenera- 
tion. The  treatment  applicable  to  this  disease 


W ANUS,  DISEASES  OF. 

is  to  destroy  or  remove  the  growth  by  caustics 
or  excision. 

3.  Irritable  Sphincter  Ani. — In  this  com- 
plaint the  anus  is  strongly  contracted  and  drawn 
in  by  the  action  of  the  sphincter.  Any  attempt  to 
examine  the  part  produces  spasm,  and  the  finger 
passed  through  it  is  tightly  grasped  as  if  girt  by 
a cord.  In  cases  of  old  standing  the  muscle  be- 
comes hypertrophied,  and  forms  a mass  encircling 
the  finger  like  a thick  unyielding  ring.  This 
state  is  the  source  of  serious  trouble  in  defecation, 
owing  to  the  expulsive  power  of  the  bowel 
being  insufficient  to  overcome  the  impediment 
caused  by  the  muscle  to  the  passage  of  the  faeces. 
Irritability  of  the  sphincter  occurs  generally 
in  hysterical  females,  and  is  relieved  by  mild 
laxatives,  the  local  application  of  an  opiate  or 
belladonna  ointment,  and  the  occasional  passage 
of  a bougie  coated  with  a sedative  ointmert. 

4.  Irritable  Ulcer. — This  is  a small  super- 
ficial sore,  situated  just  within  the  circle  of  the 
sphincter,  usually  at  the  back  part,  commonly 
known  as  fissure,  from  its  appearance  in  the  con- 
tracted state  of  the  part.  The  fseces  passing  over 
the  sore  excite  spasm  of  the  muscle,  and  cause  a 
sharp  burning  pain  which  lasts  for  two  or  three 
hours.  The  distress  often  does  not  come  on  till 
an  interval  of  ten  minutes  or  more  has  elapsed 
after  defecation.  The  pain  is  sometimes  so 
acute  that  patients  resist  an  action  of  the  bowels, 
and  allow  them  to  become  costive.  The  irri- 
table nicer  occurs  usually  in  middle  life,  and 
is  more  frequent  in  women  than  in  men.  It  sel- 
dom gets  well  under  the  influence  of  local  appli- 
cations, but  an  incision  through  the  centre  of  the 
sore  sets  the  muscle  at  rest,  and  allows  the  part 
to  heal.  The  French  surgeons  use  forcible  dila- 
tation, so  as  to  rupture  the  sphincter — a rough 
mode  of  treatment  not  to  be  commended.  When 
the  suffering  is  moderate,  a cure  may  be  at- 
tempted by  giving  a laxative  to  ensure  soft 
evacuations  ; by  enjoining  rest  in  the  recumbent 
position;  and  by  the  application  of  mercurial  oint- 
ment with  morphia,  belladonna,  or  chloroform. 

5.  Prolapsus.  See  Rectum,  Diseases  of. 

6.  Prurigo. — Itching,  though  a common  symp- 
tom in  disorders  of  the  lower  bowel,  may  occur 
as  a distinct  affection,  a neurosis  liable  to  parox- 
ysms. It  is  caused  by  worms  in  the  rectum,  and  by 
congestion  of  the  hemorrhoidal  veins.  Patients 
suffer  more  after  taking  stimulating  drinks  and 
when  heated  in  bed.  The  itching  is  extremely 
teasing  and  annoying,  especially  at  night,  keep- 
ing the  sufferer  awake  for  hours.  Friction  ag- 
gravates the  mischief,  excoriates  the  skin  at  the 
margin  of  the  anus,  and  causes  it  to  become  dry, 
harsh,  and  leathery.  As  regards  treatment, 
stimulants  and  condiments  are  to  be  avoided. 
The  bowels  should  be  regulated,  and  the  part 
should  be  washed  with  soap  and  water  after 
each  evacuation.  Every  effort  should  be  made 
to  avoid  friction.  A piece  of  cotton  wool 
soaked  in  oxide  of  zinc  lotion  should  be  kept 
applied  to  the  anus,  or  the  part  may  be 
smeared  with  some  mercurial  ointmeut,  such  as 
the  dilute  citrine,  or  one  containing  the  grey 
oxide  of  mercury.  Lotions  of  carbonate  of  "bis- 
muth aud  glycerine,  of  borax  and  morphia,  or  of 
carbolic  acid,  are  often  efficacious.  In  weak 
l*rKene  quinine  ond  arsenic  help  the  cure. 


AORTA,  DISEASES  OF. 

7.  Tumours  and  Excrescences. — Besides 
the  flaps  and  folds  of  integument  consequent  on 
external  piles,  tumours  of  a fibrous  texture  some- 
times form  in  the  sub-cutaneous  areolar  tissue, 
which  as  they  increase  become  pedunculated. 
They  are  usually  small  in  size,  lobulated,  and 
have  a firm  feel.  These  growths  may  be  easily 
and  safely  removed  by  excision.  IVarts  are 
liable  to  be  developed  around  the  anus,  and 
sometimes  grow  so  abundantly  as  to  constitute  a 
large  cauliflower-looking  excrescence.  They  then 
form  projecting  processes  of  various  sizes,  densely 
grouped  together,  with  their  summits  isolated, 
expanded,  and  elevated  on  narrow  peduncles. 
They  give  rise  to  a thin  offensive  discharge. 
They  originate  in  want  of  cleanliness.  In  some 
persons  there  is  so  strong  a disposition  to  tho 
formation  of  warts  that  it  is  difficult  to.  prevent 
their  growth.  If  few  in  number  and  small  in 
size,  they  may  be  destroyed  with  strong  escbar- 
oties.  They  usually  require,  however,  to  be 
removed  by  excision,  the  quickest  and  most 
effectual  mode  of  treatment.  Astringent  lotions 
must  afterwards  be  used  to  prevent  the  reproduc- 
tion of  the  warts.  Flattened  growths  from  the 
skin,  commonly  called  mucous  tubercles,  a secon- 
dary result  of  syphilis,  are  liable  to  occur  around 
the  anus.  They  yield  readily  to  the  local  appli- 
cation of  mercury  and  specific  general  treatment. 

T.  B.  CURLING. 

ANXIETAS. — Anxiety  or  distress,  whether 
subjectively  felt,  or  expressed  in  the  features, 
attitude,  or  general  behaviour.  The  term  is 
also  specially  associated  with  a peculiar  sensa- 
tion experienced  in  the  region  of  the  heart.  See 

PliJECORDIAX  AXXIETT. 

AOETA,  Diseases  of. — The  diseases  to  which 
the  aorta  is  liable  may  be  thus  considered ; — 
1.  Aortitis,  Acute  and  Chronic;  2.  Atheroma; 
3.  Primary  Fatty  Degeneration ; 4.  Primary 
Calcification  ; 5.  Coarctation ; 6.  Simple  Dila- 
tation ; and  7.  Aneurism. 

1.  Aortitis. — Acute  aortitis  is  exceedingly 
rare.  It  may  result  from  the  direct  irritation  of 
an  atheromatous  aorta  by  a thrombus  or  an 
embolus,  in  persons  of  gouty  diathesis ; but 
has  never  been  observed  as  an  extension  of  acut  e 
endocarditis.  The  morbid  changes  consist  in 
hypersemia,  with  thickening  and  softening  of  the 
coats  of  the  vessel,  and  deposit  of  fibrin  upon 
its  internal  surface.  The  ascending  portion  of 
the  arch  is  the  part  most  frequently  affected. 
The  symptoms  are  acute  substernal  pain  with 
oppression,  palpitation,  quick  and  feeble  pulse, 
and  elevated  temperature.  'With  these  symptoms 
may  be  associated  a harsh  systolic  murmur, 
originating  at  the  seat  of  inflammation,  and 
transmitted  to  a distant  point  of  the  aorta. 

Sub-acute  and  Chronic  Aortitis. — These  are 
the  usual  forms  of  inflammation  of  the  aorta.  The 
disease  may  be  general,  arising  from  a blocd- 
dyserasia  such  as  gout,  from  pyaemia,  or  from 
the  various  septic  agents ; but  it  is  usually 
limited  to  a definite  portion  of  the  vascular  sur- 
face, being  the  result  of  local  irritation. 

2Eiiology. — Excessive  and  continued  strain  cf 
the  vascular  walls  is,  according  to  its  degree,  the 
most  frequent  cause  of  sub-acute  and  chronic  aor- 
i titis.  Hence,  the  portion  of  the  arterial  system 


AORTA,  DISEASES  OF. 


most  directly  affected  by  the  impulse  of  the  left 
ventricle,  namely,  the  arch  of  the  aorta,  is  that  in 
which  inflammatory  irritation  is  first,  and  often 
exclusively,  exhibited.  Labour  of  any  kind  re- 
quiring great  and  repeated  muscular  effort  whilst 
the  breath  is  held,  must  necessarily  subject  the 
aorta  to  extreme  tension,  partly  through  the  ob- 
struction arising  from  the  pressure  of  the  con- 
tracted muscles  upon  the  subjacent  arteries,  and 
partly  from  the  back-pressure  of  the  distended 
veins.  Hence,  sledgers,  rammers,  ship-porters, 
&c.,  are  those  who  most  frequently  suffer  from 
the  effects  of  aortitis.  As  a necessary  result  of 
such  efforts  the  left  ventricle  soon  becomes  hy- 
pertrophied, and  the  evils  arising  from  vascular 
tension  are  thereby  proportionately  increased. 
Furthermore,  the  free  use  of  alcoholic  stimulants, 
in  which  such  labourers  habitually  indulge,  con- 
tributes to  the  same  result  by  imparting  irritant 
properties  to  the  blood.  The  British  soldier  has 
been  especially  liable  to  the  evils  above  sketched, 
owing  to  a vicious  system  of  forced  drill  with  a' 
breathing-capacity  diminished  by  faulty  con- 
struction of  his  dress  and  accoutrements.1 

Anatomical  Characters. — Sub-acute  aortitis 
occurs  in  disseminated  patches,  and  involves  all 
the  coats  of  the  vessel.  These  are  infiltrated  with 
exudation-cells  at  an  early  period;  become  soft  and 
tumid,  assuming  a bluish-white  tint;  and,  owing 
to  loss  of  normal  elasticity,  project  outwards, 
thus  causing  unevenness  or  pitting  of  the  internal 
surface.  In  the  aorta  the  inflammation  is 
usually  primary  ; but  exceptionally  it  may  be 
produced  by  the  mechanical  irritation  of  an 
embolus  derived  from  an  inflamed  focus.  In- 
flammatory softening  is  a frequent  cause  of 
aneurism  at  all  periods  of  life  ; and  in  the  young 
it  is  the  ordinary  precursor  of  that  disease. 

In  chronic  aortitis,  which  is  the  most  common 
form  of  the  disease,  the  internal  coat  is  alone  in- 
volved. The  outer  portion  of  the  intima  exhibits 
the  result  of  irritation  in  the  abundant  production 
of  new  cells.  These  cells  occupy  the  fusiform 
spaces  between  its  lamellae,  and,  gradually  distend- 
ing them,  ultimately  project  the  internal  and  un- 
affected portion  of  the  tunic  into  the  lumen  of 
the  vessel.  The  prominence  so  caused  is  com- 
paratively solid,  presents  a faint  bluish  tint,  and 
constitutes  the  condition  described  as  ‘ fibroid  or 
semi-cartilaginous  thickening.’  The  inflamma- 
tory product  is  prone  to  undergo  fatty  de- 
generation, and  the  consecutive  change  called 
atheroma. 

2.  Atheroma. — This  morbid  condition  is  most 
common  in  the  first  portion  of  the  aorta. 

Anatomical  Characters.  — Atheroma  com- 
mences with  inflammatory  overgrowth  by  multi- 
plication of  the  cells  of  the  outer  portion  of  the 
intima,  as  described  in  a preceding  paragraph. 
The  neoplasts,  from  their  situation,  readily  un- 
dergo fatty  change  and  caseation ; the  septa  of 
unaltered  tissue  intervening  between  them  soon 
lose  their  vitality  and  are  absorbed ; and  the 
disease  thus  spreads,  whilst  it  advances  through 
the  same  agency  towards  the  internal  surface 
of  the  vessel.  Examined  microscopically,  athe- 

1 Also  by  the  constrained  and  fixed  position  in  which 
the  walls  of  the  chest  are  placed  when  the  shoulders  are 
forced  backwards,  with  the  view  of  producing  the  ap- 
pearance of  an  expanded  chest. — Ed. 


63 

romatous  matter  is  found  to  consist  cf  fut 
granules,  crystals  of  cholesterine,  and  tissue- 
debris.  At  an  early  stage  collections  of  this 
matter  may  undergo  liquefaction,  and,  projecting 
into  the  vessel,  covered  only  by  a thin  layer  of 
the  unaltered  intima,  constitute  a so-called  athero- 
matous abscess.  Should  this  establish  a com- 
munication with  the  artery,  an  athcromatotis 
ulcer  will  be  the  result,  and,  consecutively,  a false 
aneurism. 

In  the  most  advanced  stage  of  atheromatous 
change  many  patches  undergo  calcification  by 
deposit  of  lime-salts  in  the  altered  cells.  The 
calcareous  lamellae  so  formed,  being  concentric 
with  the  vessel,  and  contracting  by  loss  of  their 
liquid  constituents,  may  erode  the  intima  by  their 
sharp  edges.  FTom  the  injury  thus  inflicted 
aneurism  may  arise,  or  interstitial  thrombosis, 
by  which  the  vessel  may  be  entirely  blocked  and 
gangrene  of  the  extremities  produced.  In  con 
sequence  of  the  foregoing  changes  the  vessel 
loses  its  elasticity  and  becomes  dilated;  its  in- 
ternal surface  is  mottled  with  yellow  or  fawn- 
coloured  patches  of  various  sizes,  being  also 
rough,  spiculated,  and  fissured;  and  thus  the 
condition  described  by  Virchow  under  the  name 
of  Endarteritis  Chronica  Deformans  is  established. 

The  uric-acid  and  oxalic-acicl  diatheses  favour 
these  changes,  not  only  by  stimulating  the  minute 
arteries  to  contract,  and  so  raising  the  blood-pres- 
sure in  the  larger  vessels,  but  likewise  by  fur- 
nishing material  for  cretification.  The  subjects 
of  constitutional  syphilis  are  liable  to  ‘ulcerated 
steatomatous  ’ (atheromatous)  changes  of  the 
intima. 

3.  Primary  Patty  Degeneration. — Tin  how 
has  described,  under  the  name  of  fatty  ■ erosion , a 
form  of  fatty  degeneration  of  tho  cells  of  the 
internal  coat,  unpreceded  by  inflammation,  com- 
mencing on  the  free  surface,  and  gradually  ex- 
tending outwards.  The  internal  surface  of  the 
vessel  is  marbled  with  minute  yellow  dots,  which 
are  groups  of  fatty  cells  ; these  undergo  lique- 
faction ; and  disintegration  of  the  internal  coat, 
followed  by  aneurism,  is  the  usual  result. 

4.  Primary  Calcification. — Exceptionally,  in 
the  distant  portions  of  the  aorta  the  muscular 
fibro-eells  of  the  middle  coat  are  liable  to  calcifi- 
cation, as  a remote  result  of  endarteritis.  Owing 
to  the  transverse  arrangement  of  the  calcified  cells, 
Assuring  of  the  middle  coat  under  the  pressure 
of  the  blood-current,  and  dissecting  aneurism,  are 
ordinary  results  of  this  change.  Finally,  the 
entire  middle  coat,  and  even  all  three  coats  of 
the  artery,  may  be  infiltrated  with  lime-salts 
as  a primary  change.  This  is  most  probably 
due  to  precipitation  of  these  salts  from  the 
congested  vasa  vasorum,  in  consequence  of  the 
escape  of  their  ordinary  solvent,  carbonic  acid. 

5.  Coarctation  or  Stenosis. — This  condition 
may  be  either  ccmgenital  or  acquired. 

Congenital  stenosis  of  the  aorta  is  most  fre- 
quently located  at  the  point  of  junction  of  the 
ductus  arteriosus,  and  is  of  very  limited  extent ; 
in  many  cases  presenting  the  appearance  of  a 
linear  constriction,  or  of  a perforated  diaphragm. 
In  a few  examples,  the  vessel,  at  the  seat  of 
contraction,  has  been  entirely  closed  and  con- 
verted into  a ligamentous  cord.  On  the  cardiac 
side  of  the  constriction  the  aorta  is  dilated,  and 


AORTA,  DISEASES  OF. 


64 

often  thickened  and  atheromatous,  whilst  on  the 
distal  side  it  is  reduced  in  calibre  as  far  as  the 
junction  of  the  collateral  vessels.  Congenital 
stenosis  of  the  aorta  is  compatible  with  life  of 
moderate  duration.  In  twenty-four  out  of  thirty- 
eight  cases  analysed  by  Dr.  Peacock  the  age  at- 
tained varied  from  twenty-one  to  fifty  years.  The 
diagnosis  of  the  condition  rests  mainly  on  dispro- 
portionate pulsation  of  the  arteries  arising  from 
the  aorta  on  the  cardiac,  as  contrasted  with  those  on 
the  peripheral  side  of  the  obstruction;  and  on  the 
enlargement  of  the  collateral  vessels,  namely,  the 
transverse  cervical,  internal  mammary,  and  in- 
tercostals.  The  ordinary  consequences  are  ex- 
hibited in  dilated  hypertrophy  of  the  left  ventricle, 
and  inadequacy  of  the  aortic  valves.  Death  usually 
occurs  from  progressive  debility  and  failure  of 
the  left  ventricle ; from  pulmonary  congestion  ; 
or  from  dissecting  aneurism  of  the  ascending  por- 
tion of  the  arch.  Congenital  stenosis  of  the 
entire  arch  may  result  from  imperfection  of  the 
inter-ventricular  septum  or  patency  of  the  fora- 
men ovale  allowing  the  blood  to  take  an  ex- 
ceptional course. 

In  the  acquired  form,  stenosis  of  the  aorta  at 
any  portion  of  its  course  may  result  from  in- 
flammatory thickening  or  calcareous  change  of 
the  coats  of  the  vessel,  followed  by  thrombosis  ; or 
it  may  follow  the  natural  cure  of  an  aneurism.  The 
aorta  may  be  much  reduced  in  calibre  without 
being  disproportionately  narrowed.  Such  will 
be  its  condition  in  connection  with  mitral  in- 
adequacy in  early  childhood,  should  the  patient 
survive  a few  years.  In  such  cases  the  left 
ventricle  will  have  become  dilated  and  hyper- 
trophied, and  a marked  disproportion  will  be 
observed  between  the  force  of  cardiac  and  that 
of  radial  pulsation.  This  circumstance,  taken  in 
conjunction  with  the  age  of  the  patient,  the 
existence  of  disease  at  the  mitral  orifice,  and 
hypertrophy  of  the  left  ventricle,  would  warrant 
the  positive  diagnosis  of  narrowing  of  the 
aorta. 

C.  Simple  Dilatation  of  the  aorta  consists  in 
a uniform  enlargement  of  the  vessel  or  of  a por- 
tion of  it,  from  impairment  or  loss  of  its  normal 
elasticity ; and  depends  primarily  upon  arterial 
obstruction  or  resistance  beyond  its  seat,  and 
directly  upon  consecutive  hypertrophy  of  the 
left  ventricle.  The  continued  tension,  to  which 
the  walls  of  the  aorta  are  subjected  between 
these  two  opposing  forces,  necessarily  leads  to 
progressive  impairment  of  nutrition  and  loss  of 
elasticity  in  its  middle  coat.  The  immediate 
consequence  of  this  change  is  exhibited  in  fur- 
ther hypertrophy  of  the  left  ventricle;  and  its 
remote  effects  in  still  further  impairment  of 
nutrition  and  deterioration  of  tissue  in  the  vas- 
cular tunics,  through  the  increased  tension  to 
which  they  are  now  exposed.  No  elementary 
change  of  structure  is,  however,  discoverable. 
Simple  dilatation  of  the  aorta  commences  in  the 
ascending  portion  of  the  arch,  and  to  this  it  is 
usually  limited ; but  it  occasionally  extends  into 
the  transverse  portion.  The  other  portions  of 
the  vessel  are  never  dilated,  except  in  association 
with  atheromatous  change.  The  condition  under 
notice  is  manifestly  in  close  relationship  with 
inflammatory  irritation  of  the  vessel.  It  has, 
however,  a distinct  pathological  existence,  ana- 


logous to  that  of  the  early  stage  of  vesicular  em- 
physema of  the  lung. 

No  morbid  results,  with  a single  exception,  arc 
directly  traceable  to  simple  dilatation  of  the  aorta. 
But,  should  the  dilatation  extend  into  the  trans- 
verse portion  of  the  arch,  and  eDgage  especially 
its  superior  wall,  the  primary  branches  may 
become  tortuous,  and  exhibit  abnormal  pulsation 
in  the  neck,  simulating  aneurism.  In  a note- 
worthy example  observed  by  the  writer  the 
existence  of  this  pulsation  on  both  sides  of 
the  neck,  and  the  facility  with  which  it  was 
arrested  by  forcibly  extending  the  neck  and 
shoulders,  and  so  unbending  the  vessels,  sufficed 
to  establish  the  diagnosis.  Tortuosity  of  the 
cervical  arteries,  dependent  upon  a local  dilata- 
tion of  the  aorta,  may  be  confined  to  one  side  of 
the  neck. 

Simple  dilatation  of  the  aorta  most  frequently 
occurs  in  connection  with  the  contracted  or  gran- 
ular form  of  chronic  renal  disease.  It  may, 
Jiowever,  likewise  arise  from  simple  functional 
hypertrophy  of  the  left  ventricle  dependent 
upon  habitual  vascular  excitement ; or  from  di- 
lated hypertrophy  consecutive  to  inadequacy  of 
the  aortic  valves. 

7.  Aneurism. — /Etiology  and  Pathot.ogy. — 
Aneurism  of  the  aorta  is  essenlially  a disease  of  the 
middle  period  of  life.  Of  ninety-two  cases  ob- 
served or  analysed  by  the  writer,  sixty  occurred 
between  the  ages  of  thirty  and  fifty  years  ; twelve 
over  fifty  ; and  five  under  thirty  years.  Thus, 
whilst  deterioration  of  the  arterial  coats  as 
typified  in  atheroma  is  most  common  after  the 
age'of  sixty,  one  of  its  ordinary  consequences, 
aneurism,  belongs  to  an  earlier  period  of  life. 
The  apparent  discrepancy  may  be  explained  by 
the  more  frequent  employment  of  men  under 
fifty  in  severe  labour,  and  their  greater  capacity 
for  extreme  muscular  effort  then  than  later  in 
life,  the  condition  of  the  arterial  wall  which  fa- 
vours aneurism  having  been  already  established. 
Aortic  aneurism  is  more  common  amongst  males 
than  females  in  the  proportion  of  about  8 : 1 — a 
difference  no  doubt  due  to  the  more  active  and 
laborious  habits  of  the  male  sex.  Soldiers,  me- 
chanics, and  porters  suffer  from  it  in  larger 
proportion  than  those  of  other  callings ; and  in 
most  instances  the  first  symptoms  of  aneurism 
of  the  aorta  may  be  traced  to  a great  muscular 
effort  involving  vascular  strain,  or  to  a severe 
shock  or  blow,  causing  a direct  contusion. 

Aneurism  of  the  aorta  is  always  consecutive 
to  disease  of  its  coats.  Inflammatory  softening, 
atheroma,  and  calcification  are  the  usual  ante- 
cedent conditions,  and  in  exceptional  instances 
primary  fatty  or  calcific  transformation  of  the 
internal  and  middle  coats ; whilst  a definite  over- 
strain or  a direct  contusion  of  the  vessel  is  fre- 
quently the  immediate  cause  of  the  disease. 

Anatomical  Characters. — Aortic  aneurism 
may  be  presented  under  the  following  forms, 
viz.,  (a)  true ; (b)  false  ( circumscribed , and  dif- 
fused or  consecutive ) ; (c)  dissecting  ; and  [d] 
varicose. 

a.  True  aneurism  of  the  aorta  is  rare;  it 
may  be  either  fusiform  or  saccular.  It  is  es- 
sentially transitional,  leading  to  the  false  variety 
of  the  disease ; and  differs  from  simple  dilatation 
of  the  aorta  only  by  its  sharp  limitation,  and  by 


AORTA,  DISEASES  OF. 


the  existence  of  inflammatory  products  in  its 
walls.  True  aneurism  never  contains  clots,  save 
by  incidental  thrombosis  ; and  rarely,  as  such, 
attains  dimensions  capable  of  producing  extrinsic 
symptoms  or  signs.  It  may,  however,  unlike 
simple  dilatation,  be  the  cause  of  valvular  in- 
adequacy, and  so  give  rise  to  a murmur  of 
reflux  at  the  orifice  of  the  aorta. 

h.  False  aneurism  is  either  circumscribed  or 
diffused.  Circumscribed  false  aneurism  (or,  as 
it  is  also  termed,  false  aneurism')  is  the  most 
common  form  of  the  disease  in  connection  with 
the  aorta.  It  is  necessarily  confined  to  a portion 
of  the  circumference  of  the  vessel,  the  yielding 
of  which  relieves  the  remainder  from  extra  ten- 
sion. Hence,  it  is  usually  saccular  in  general 
outline  ; but,  owing  to  unequal  resistance  at  dif- 
ferent points  of  its  surface,  it  may,  and  commonly 
does,  present  one  or  more  secondary  prominences 
The  internal  and  middle  coats  are  usually 
broken ; — the  adventitia  supplemented  by  the 
surrounding  structures  more  or  less  condensed, 
forming  the  sac. 

Disintegration  of  the  inner  coat,  already  in  a 
state  of  atheromatous  change  by  mechanical 
strain  or  vascular  tension,  is  ordinarily  the  im- 
mediate cause  of  false  aneurism.  The  irruption 
of  an  1 atheromatous  abscess  ’ may  also  give  rise 
to  it ; so  likewise  may  ulceration  of  the  intima 
from  fatty  erosion.  Rupture  of  the  coats  of 
the  vessel  by  mechanical  strain  is  usually  an- 
nounced by  definite  symptoms  of  the  utmost 
significance,  namely,  a feeling  of  something 
having  given  way  within  the  chest  or  abdomen ; 
followed  by  faintness  often  amounting  to  syncope, 
dyspncea,  palpitation,  and  occasionally  haemopty- 
sis. These  symptoms  of  shock  usually  subside 
within  a period  of  one  to  two  hours,  but  the 
patient  is  thenceforward  incapable  of  his  ac- 
customed exertion,  being  easily  put  out  of 
breath,  and  distressed  by  excitement  or  rapid 
movement,  especially  that  of  ascent ; there  is 
likewise  a fixed  pain  at  some  point  of  the  chest, 
back,  or  abdomen.  A fusiform  false  aneurism 
may  become  ‘ invaginating  ’ by  abruptly  expand- 
ing and  ensheathing  the  artery  at  its  proximal 
or  distal  side,  or  in  both  these  situations. 

Diffused  false  aneurism  (or,  as  it  is  otherwise 
called,  Diffused  aneurism,  or  Consecutive  aneurism) 
is  produced  by  escape  of  blood  from  ihe  artery, 
and  its  diffusion  to  a greater  or  less  extent 
amongst  the  surrounding  structures,  according  to 
their  previous  condition  or  anatomical  arrange- 
ment. It  may  be  the  result  of  mechanical  violence 
by  strain  or  shock  to  the  artery  in  a previously 
diseased  condition  ; or  of  progressive  disintegra- 
tion of  the  sac  of  a circumscribed  aneurism.  In 
the  latter  case  the  diffusion  of  the  extravasated 
blood  is  usually  limited  by  antecedent  adhesive 
inflammation  of  the  surrounding  parts,  where, 
as  in  the  transverse  portion  of  the  arch  of  the 
aorta,  the  position  of  the  aneurism  is  favourable 
to  that  process.  A case  of  this  description 
recently  ca mo  under  the  writer's  notice.  Under 
ordinary  circumstances  diffused  false  aneurism 
of  the  aorta  cannot  occur  within  the  pericar- 
dium, owing  to  the  isolation  of  that  portion  of 
the  vessel,  and  the  fragile  structure  of  its  serous 
investment.  Hence,  a yielding  of  the  sac  proper 
in  this  situation  is,  in  most  instances,  followed 

5 


65 

by  instant  death  from  htemorrhage  into  the  peri- 
cardium and  paralysis  of  the  heart.  In  a few 
recorded  eases,  owing  to  previous  adhesion  cf  the 
pericardium,  the  patients  survived  rupture  of  the 
sac  in  this  situation  for  several  days. 

Diffused  false  aneurism  of  the  abdominal 
aorta  is  frequently  formed  by  irruption  of 
blood  into  the  retro-peritoneal  tissue,  between 
the  layers  of  the  transverse  meso-colon  or  the 
mesentery,  or  into  the  fibrous  envelope  of  the 
psoas  muscle.  When  the  aneurism  grows  back- 
wards the  sac  is  quickly  eroded  by  pressure  against 
the  vertebra,  the  naked  and  carious  surface  of 
which  then  forms  its  posterior  boundary.  Diffu- 
sion in  such  cases  rarely  occurs  until  the  vertebra 
are  entirely  absorbed ; the  blood  may  then  escape 
into  the  spinal  canal,  causing  general  paralysis 
and  immediate  death.  Diffusion  may  also  occur 
amongst  the  muscles  and  areolar  tissue  of  theloins, 
or  behind  the  diaphragm  into  either  pleural  cavity, 
usually  the  left.  Any  portion  of  the  aorta  outs  de 
the  pericardium  may  he  the  seat  of  diffused  false 
aneurism,  but  the  transverse  portion  of  the  arch 
and  the  abdominal  aorta  are  tho  parts  most 
frequently  affected. 

Consecutive  false  aneurism,  consisting  in  a 
primary  bulging  of  all  the  coats  of  the  artery,  the 
internal  and  middle  coats  having  subset;  lentty 
given  way,  constitutes  the  ordinary  form  in 
which  false  aneurism  originates : it  therefore 
demands  no  further  notice  here. 

c.  Dissecting  aneurism  consists  in  a breach  of 
the  internal  and  middle  coats,  and  a subsequent 
detachment  of  these  from  the  external  tunic,  by 
the  force  of  the  blood-current,  to  a variable 
extent  over  the  length  and  circumference  of  the 
vessel ; or  in  a splitting  of  the  middle  coat  by  the 
same  agency.  This  form  of  aneurism  is  of  two 
kinds — that  with  a single  aperture  through  which 
the  blood  enters  theabuormal  channel  and  return* 
to  the  artery  ; and  that  which  exhibits  two  open 
ings,  one  by  which  the  blood  escapes  from,  and 
another  through  which  it  re-enters  the  vessel. 
The  former  is  tho  more  usual  variety  of  dissecting 
aneurism;  and  it  is  likewise  the  more  grave, 
because  liable  at  any  moment  to  terminate  fatally 
by  rupture  of  the  external  coat. 

Any  portion  of  the  aorta  may  he  the  seat  of 
dissecting  aneurism  ; the  asceuding  part  of  the 
arch  is  most  frequently  affected,  and  next  in  the 
order  cf  frequency  comes  the  abdominal  aorta. 
The  primary  lesion  consists  in  a transverse  rent  of 
the  internal  and  middle  coats ; when  this  is  close 
to  the  heart,  the  outer  or  the  anterior  wall  of  the 
vessel  is  its  usual  site,  and  detachment  of  the  tu- 
nics rarely  extends  beyond  the  ascending  portion 
of  the  arch,  and  seldom  engages  more  than  a limi- 
ted area  of  its  circumference.  In  this  situation, 
too,  an  aperture  of  re-entranee  is  rarely  formed, 
the  disease  usually  terminating  by  rupture  of  the 
external  coat  within  the  pericardium.  When,  on 
the  contrary,  the  second  curve  of  the  arch,  or  any 
portion  of  the  aorta  beyond  this  point,  is  the  seat 
of  primary  lesion,  separation  of  the  eoatsis  usually 
found  to  extend  along  the  remainder  of  the 
length  of  the  vessel,  and  over  the  whole  or  greater 
part  of  its  circumference,  whilst  the  blood  has 
re-entered  through  an  opening  in  one  or  both 
common  iliac  arteries. 

The  establishment  of  a second  aperture  of 


AORTA,  DISEASES  OF. 


30 

communication  -with  the  artery  is  an  attempt  at 
•'natural  cure;’  and  when  this  happens  the 
patient  may  survive  for  many  years.  Amongst 
the  eccentricities  of  dissecting  aneurism  may  be 
mentioned  detachment  of  the  laminated  clot  from 
the  walls  of  the  sac  proper,  and  subsequent  es- 
cape of  blood  by  rupture  of  the  latter ; and  sepa- 
ration of  the  mucous  from  the  muscular  coat  of 
the  oesophagus,  with  irruption  of  blood  into  the 
stomach.  Dissecting  and  ordinary  false  aneu- 
rism may  coexist,  the  former  being  usually  a 
consecutive  lesion,  and  the  immediate  cause  of 
death. 

d.  Varicose  or  Anastomosing  aneurism  consists 
in  a direct  communication  between  an  aneurism 
of  the  aorta  and  (a)  one  of  the  chambers  of  the 
heart ; ( b ) the  pulmonary  artery  or  one  of  its 
branches  ; or  ( c ) one  of  the  venae  cava;  or  innomi- 
nate veins.  This  form  of  the  diseaseis  necessarily 
consecutive,  and  usually  late  as  to  the  period  of 
its  development.  In  the  greatmajority  of  recorded 
examples  the  primary  aneurism  was  connected 
with  the  ascending  portion  of  the  arch,  and  in  a 
Iqrge  number  it  arose  from  one  of  the  sinuses 
of  Valsalva.  The  communication,  witli  few  ex- 
ceptions, is  formed  with  one  of  the  chambers  of 
the  heart,  the  pulmonary  artery,  or  the  descend- 
ing vena  cava.  Of  the  cavities  of  the  heart,  the 
right  ventricle  is  most  often  implicated ; next 
in  order  is  the  right  auricle;  then  the  left  ven- 
tricle; and  lastly  the  left  auricle.  The  pulmonary 
artery  and  the  descending  cava  have  been  fre- 
quently involved,  as  might  have  been  inferred 
from  their  close  relationship  to  the  ascending 
aorta  ; the  innominate  veins  in  fewer  instances, 
and  only  when  the  aneurism  engaged  the  upper 
portion  of  the  arch.  An  aneurism  of  the  ab- 
dominal aorta  has  communicated  with  the  in- 
ferior vena  cava  in  a few  cases.  In  the  pro- 
cess of  formation  of  a varicose  aneurism  of  the 
aorta,  the  apposed  surfaces  are  agglutinated  by 
adhesive  inflammation  ; and  the  composite  septum 
is  subsequently  eroded  by  progressive  absorption, 
or  suddenly  rent  by  the  force  of  the  arterial  cur- 
rent. The  immediate  effects  of  communication  are 
engorgement  and  increased  tension  of  the  recei  rung 
chamber  or  vessel;  diminished  blood-current  and 
vascular  tension  in  the  aorta  and  its  branches; 
and  admixture  of  arterial  with  venous  blood 
when  the  right  side  of  the  heart  or  one  of  the 
great  veins  is  the  seat  of  discharge.  The  special 
symptoms  and  signs  by  which  tho  diseaso  is 
characterised  have  direct  reference  to  these  re- 
sults. Death  has  followed  most  rapidly  in  those 
cases  in  which  the  aneurism  had  established  a 
communication  with  the  pulmonary  artery  or  the 
left  auricle. 

Effects  upon  the  Left  Ventricle. — Hypertrophy 
of  the  left  ventricle  cannot  be  regarded  as  a 
consequence  of  aneurism  of  tho  aorta.  The 
association,  when  it  exists,  is  accidental ; hyper- 
trophy depending  upon  antecedent  or  consecutive 
disease  or  inadequacy  of  the  aortic  or  the  mitral 
valves,  chronic  atheroma  of  the  aorta,  granular 
degeneration  of  the  kidneys,  or  excessive  func- 
tional activity. 

Simptoms. — The  symptoms  of  aortic  aneu- 
rism may  be  discussed  under  the  three  heads 
of  (a)  Pain;  ( b ) Excentric  Pressure;  and  (c) 

Tumour. 


Pain.— The  pain  of  aneurism  is  cf  two  kinds, 
intrinsic  and  extrinsic.  The  former  is  due  to 
subacute  inflammation  and  tension  of  the  sac, 
and  varies  with  intra-vascular  pressure.  It  is 
dull,  aching,  and  localised,  and  promptly  allevi- 
ated by  measures  which  depress  the  circulation 
or  reduce  local  tension.  Extrinsic  pain  usually 
arises  from  pressure  upon  adjacent  nerves,  and 
may  be  direct  or  reflex.  This  kind  of  pain  has 
the  characters  of  a diffused  and  aggravated 
neuralgia,  being  paroxysmal,  and  wandering  to 
a greater  or  less  extent  over  the  back,  chest, 
shoulders,  arms,  abdomen,  and  thighs.  In  the  ab- 
domen, when  due  to  pressure  upon  the  splanchnic 
nerves  or  tension  of  the  solar  plexus,  it  is  of  the 
most  excruciating  character.  The  extrinsic  pain  of 
aneurism  may  be  fixed  and  boring.  When  of  this 
character,  it  is  usually  located  in  the  back,  and 
arises  from  progressive  absorption  of  the  ver- 
tebrae. 

Excentric  Pressure. — The  parts  affected  by  the 
pressure  of  an  aneurism,  and  the  symptoms 
thereby  developed,  vary  according  to  its  situation 
and  the  direction  of  its  growth.  Parts  which 
are  exposed  to  counter-pressure,  or  are  other- 
wise fixed,  suffer  most ; whilst  those  which  are 
flexible  or  moveable  are  less  injuriously  affected. 

The  symptoms  have  reference  to  the  respective 
functions  of  the  organs  or  structures  pressed 
upon  ; whilst  their  severity  is  in  direct  proportion 
to  the  importance  of  those  functions,  and  the 
degree  of  pressure  exercised.  Structures  sub- 
jected to  the  remittent  pressure  of  an  aneurism 
are  slowly  removed  by  absorption,  but  between 
the  sac  and  the  resisting  surface  union  has  been 
previously  established  by  adhesive  inflammation. 
Hence  the  sac  itself  is  at  the  same  time  absorbed, 
and  escape  of  blood  will  inevitably  occur  where 
further  resistance  is  not  presented.  When  serous 
cavities  are  laid  open  by  this  process,  entrance  is 
effected  by  a rent ; and  if  the  cavity  be  large, 
e.g.  the  pleura  or  the  peritoneum,  death  by 
haemorrhage,  almost  instantaneous,  is  the  result; 
in  case  of  irruption  into  the  pericardium  or 
the  spinal  canal,  death  occurs  with  equal  rapidity 
from  compression  and  paralysis  of  the  contained 
organ.  Communication  with  a mucous  canal 
or  with  the  cutaneous  surface  is  effected  by  a pro- 
cess of  sloughing,  and  bleeding  occurs  by  • leak- 
age,’ in  variable  quantity  and  at  uncertain  inter- 
vals, till  the  slough  is  finally  detached,  when 
death  by  copious  haemorrhage  immediately  ensues. 
The  irruption  of  an  aneurism  into  a gland-duct, 
such  as  the  ureter  or  one  of  the  biliary  passages, 
is  fatal  by  obstruction  and  suspended  secretion, 
the  duct  and  its  tributaries  having  been  blocked 
by  eoagulum.  Communication  with  the  thoracic 
duct  proves  slowly  fatal  by  inanition  ; and  when 
an  opening  is  effected  into  a vein,  a varicose 
aneurism,  characterised  by  special  symptoms  and 
signs,  and  of  greater  or  less  gravity  according 
to  its  situation,  will  be  the  result. 

The  symptoms  of  nerve-pressure  vary  accord- 
ing to  the  nerves  affected.  Thus,  pressure  upon 
the  roots  or  branches  of  sentient  nerves  is 
attended  with  neuralgic  twinges  or  paroxysms 
referred  to  the  seat  of  their  peripheral  distribu- 
tion, and,  when  the  pressure  is  extreme,  with 
numbness  in  the  same  situation.  Irritation  of 
motor  nerves  is  indicated  by  spasm  or  paralysis 


AORTA,  DISEASES  OF.  67 


according  to  the  degree  of  pressure,  of  the 
muscles  supplied  by  them.  Irritation  of  the  cer- 
vical sympathetic,  or  of  its  cilio-motor  roots,  is 
repealed  by  dilatation  of  the  pupil  on  the  corres- 
ponding side : or,  if  the  pressure  be  such  as  to  cause 
paresis,  by  contraction  of  the  pupil  ■with,  ptosis, 
hyperaemia,  hyperaesthesia,  and  elevation  of  tem- 
perature in  the  eye  and  corresponding  side  of  the 
face.  The  effects  of  pressure  upon  the  pulmonic 
and  cardiac  plexuses  have  been  less  precisely 
determined,  owing  to  the  difficulty  of  distinguish- 
ing the  symptoms  due  to  this  cause  from  those 
which  arise  from  direct  pressure  upon  the 
trachea  or  bronchi,  the  great  vessels,  or  the 
heart,  or  from  structural  disease  of  the  heart  or 
the  coronary  arteries  : but  that  the  paroxysms  of 
bronchial  spasm  and  of  angina,  so  often -witnessed 
in  connection  with  aneurism  of  the  arch  of  the 
torta,  are  in  some  degree  dependent  upon 
pressure  on  the  pulmonary  and  cardiac  nerves,  and 
occasionally  are  due  to  it  exclusively,  the  writer 
entertains  no  doubt.  The  symptoms  arising  from 
the  pressure  of  an  aneurism  upon  the  pneumo- 
gastric  or  recurrent  nerve  of  either  side  have 
reference  to  the  larynx,  and  are  eminently 
characteristic.  They  are  of  two  kinds,  according 
to  the  degree  of  pressure  ; namely,  those  due  to 
spasm,  and  those  to  paralysis,  of  the  laryngeal 
muscles  on  one  or  both  sides.  They  are  presented 
under  the  several  forms  of  dysphonia,  aphonia, 
stridor,  metallic  cough,  and  paroxysmal  dyspncea. 
The  latter  is  frequently  of  the  most  urgent  charac- 
ter, and  sometimes  is  the  immediate  cause  of 
death. 

Adjacent  organs,  such  as  the  heart,  lungs, 
liver,  and  kidneys,  are  occasionally  displaced  by 
an  aneurism,  the  direction  being  determined  by 
that  of  the  pressure,  and  in  part  also  by  the  di- 
rection in  which  the  organ  is  moveable.  Obstruc- 
tion or  occlusion  of  adjacent  arteries,  as  indicated 
by  diminished  or  suppressed  pulsation,  may  like- 
wise result  from  the  pressure  of  an  aneurism. 
Pressure  on  a vein  is  evidenced  by  venous  stasis 
distal  to  the  seat  of  obstruction ; upon  the  pul- 
monary artery,  by  engorgement  of  the  right 
chambers  of  the  heart  and  general  venous  con- 
gestion. Obstruction  or  occlusion  of  either  bron- 
chus or  of  one  of  its  primary  branches  is  evi- 
denced by  distress  in  breathing  or  shortness  of 
breath ; and  by  diminution  or  suppression  of 
respiratory  sound  in  the  corresponding  portion 
of  the  lung.  Inasmuch  as  the  symptoms  of 
excentric  pressure  may  be  produced  by  a tumour 
of  any  kind,  they  possess,  in  regard  to  aneu- 
rism, a diagnostic  value  only  correlative  to 
other  and  more  positive  evidence  of  that  dis- 
ease. 

Tumour. — The  tumour  formed  by  an  aneurism 
of  the  aorta  is  fixed,  smooth,  and  compressible. 
It  is  alternately  tense  and  soft  in  unison  with 
cardiac  pulsation,  and  is  especially  characterised 
by  a movement  of  general  and  equal  expansion, 
synchronous  with  the  impulse  of  the  heart.  It 
is  further  distinguished  by  a remarkable  liability 
to  vary  in  the  rate  and  direction  of  its 
growth,  retrocession  at  one  point  coinciding  with 
enlargement  at  another  ; a new  set  of  symptoms 
being  at  the  same  time  developed  by  its  en- 
croachment upon  fresh  territory.  In  the  pro- 
gress of  cure  the  tumour  may  become  solid,  incom- 


pressible, and  uneven,  by  deposition  of  laminated 
fibrin  within  the  sac. 

Physical  Signs. — The  physical  signs  of  aneu- 
rism of  the  aorta  are  those  which  may  be  elicited 
by  palpation,  percussion,  and  auscultation.  They 
supply  the  most  valuable,  and,  indeed,  the  only 
positive  evidence  of  the  disease. 

Tactile  signs. — The  tactile  signs  of  aneurism, 
impulse,  fremitus,  and  remittent  tension,  are  con- 
tingent on  perceptible  tumour.  The  impulse  maj 
be  single  or  double.  It  is  most  frequently  single, 
and  is  then  always  systolic  in  rhythm,  coinciding 
approximately  with  the  impulse  of  the  heart. 
In  character  the  systolic  impulse  is  heaving 
and  expansile  ; and  it  is  diffused,  in  most  in- 
stances equally,  over  the  entire  tumour.  It  is 
due  to  sudden  expansion  of  the  sac  from  active 
influx  of  blood  during  ventricular  systole : hence, 
iu  those  portions  of  the  aorta  which  are  close 
to  the  heart,  it  is  synchronous  with  the  apex- 
pulsation  ; but  in  the  descending-thoracic  and 
abdominal  aorta  perceptibly  post-systolic  in 
time.  The  force  of  systolic  impulse  and  the 
expansion  of  the  sac  will  be  directly  as  the  con- 
tractile power  of  the  left  ventricle,  and  inversely 
as  the  deposit  of  coagulum  within  the  sac.  A 
second  and  more  feeble  impulse  of  diastolic 
rhythm  is  occasionally,  but  much  less  frequently, 
exhibited  by  an  aortic  aneurism.  This  is  the 
‘ back-stroke,’  or  ‘ impulse  of  arrest  ’ of 
authors.  It  coincides  with  the  first  period  of 
ventricular  diastole  and  the  second  sound  of 
the  heart,  and  is  due  to  asynchronism  of  re- 
action between  the  aorta  and  the  sac — that 
of  the  latter  being  notably  later,  owing  to  its 
defective  elasticity.  The  consequence  is  a sudden 
arrest  to  the  recoil  of  the  sac  by  influx  from 
the  aorta.  Diastolic  impulse  is  therefore  emi- 
nently characteristic  of  aneurism. 

Fremitus  or  thrill  is  of  more  frequent  occur- 
rence than  diastolic  impulse,  and.  when  not 
communicated  from  the  heart,  no  less  distinc- 
tive of  aneurism.  It  accompanies  the  systolic 
impulse,  and  is  due  to  the  vibration  of  a thin 
sac  from  an  eddy  in  the  current  of  influx,  pro- 
duced either  by  a spiculated  condition  of  the 
orifice,  or  by  a pendent  flake  of  fibrin. 

Percussion-sound.  — The  intrinsic  percussion- 
sound  of  aortic  aneurism  is  absolutely  dull  to 
the  extent  of  the  tumour.  Posteriorly  the 
dulness  is  not  sufficiently  distinguishable  from 
that  of  the  vertebral  column  and  muscles  to 
be  of  positive  diagnostic  value ; whilst  laterally 
and  in  front,  when  the  tumour  is  not  in  actual 
contact  with  the  walls  of  the  thorax  or  abdo- 
men, it  is  modified  or  masked  by  the  interven- 
tion of  the  lung  or  the  intestinal  canal.  Under 
any  circumstances,  dulness  per  se  cannot  afford 
positive  evidence  of  aneurism,  inasmuch  as  it 
may  be  due  to  a tumour  of  any  kind,  solid  or 
liquid,  in  the  same  situation  ; but,  the  presence 
of  a tumour  having  been  determined,  the  shift- 
ing of  percussion-dulness  from  one  point  to 
another,  or  its  cessation  where  it  had  been  pre- 
viously detected,  would  be  in  the  highest  degree 
suggestive  of  aneurism. 

Acoustic  signs. — These  are  tone  or  sound,  and 
murmur.  Sound  without  murmur  is  of  frequent 
occurrence  in  aneurisms  of  the  arch,  but  com- 
paratively rare  in  those  of  the  descending- 


38  AORTA.  DISEASES  OF. 


thoracic  and  abdominal  aorta.  It  is  usually 
double,  corresponding  in  time  to  the  sounds  of 
the  heart,  but  exaggerated,  the  second  aneu- 
rismal  sound  being  especially  intensified.  The 
first  sound  is  occasionally  ‘ splashing,’  and  both 
are  not  unfrequently  of  a ‘ booming  ’ quality, 
— characters  no  doubt  due  to  the  density, 
rigidity,  and  great  capacity  of  the  sac. 

The  murmur  of  aneurism  is  most  frequently 
single,  systolic,  and  blowing;  it  is  occasionally 
double  (systolic  and  diastolic) ; and  still  more 
rarely  single  and  diastolic.  As  to  quality,  the 
systolic  murmur  may  be  accompanied  by  a 
musical  note,  ‘cooing,’  or  shrill,  and  audible 
over  the  whole  or  only  a portion  of  the  tumour. 
Lastly,  it  may  be,  and  usually  is,  of  a ‘buzzing’ 
character  in  cases  of  varicose  aneurism.  The 
essential  cause  of  the  murmur  of  aneurism 
consists  in  friction  of  the  blood  against  the 
orifice,  and  the  production  of  an  eddy  or  a ‘ fluid 
vein  ’ within  the  sac.  A certain  force  of  ventri- 
cular contraction  is,  however,  likewise  necessary. 
Hence  the  not  unfrequent  coincidence  of  cessa- 
tion of  murmur  with  failure  of  the  left  ventricle 
for  some  time  before  death.  A strongly  con- 
tracting ventricle,  a relatively  small  orifice,  a 
capacious  sac,  and  a liquid  state  of  its  contents, 
supply  the  most  favourable  conditions  for  the 
production  of  murmur.  The  orifice  of  entrance 
need  not  be  absolutely  narrow ; a large  fusiform 
aneurism,  even  of  the  true  kind,  with  rough 
walls,  and  containing  liquid  blood,  may  yield  a 
loud  systolic  murmur,  as  the  writer  has  fre- 
quently witnessed.  A murmur  may  be  absent 
in  an  aneurism  lined  by  thick  laminae  of  fibrin 
through  which  there  is  a smooth  channel,  or  in 
a lateral  aneurism  communicating  by  a small 
orifice  with  the  vessel. 

Diagnosis. — The  positive  diagnosis  of  aneu- 
rism of  the  aorta  may  be  made  from  the  exist- 
ence of  a tumour,  forming  a second  centre  of 
pulsation  and  of  sound  ; the  pulsation  being 
systolic,  expansile,  and  equally  diffused  over  the 
tumour,  accompanied  by  thrill,  and  succeeded  by 
a minor  pulsation  of  diastolic  rhythm  ; whilst 
the  Sound,  single  or  double,  and  accompanied  or 
not  by  murmur,  is  always  sharp  and  ringing, 
and  occasionally  of  a ‘ booming  ’ quality.  The 
foregoing  signs  are  rarely  all  associated  in  the 
sam’e  ease.  Various  other  groupings  of  rational 
symptoms  and  signs  would  be  scarcely  less  con- 
clusive as  to  the  existence  of  aneurism  of  the 
aorta.  General  systolic  expansion,  thrill,  dia- 
stolic impulse,  and  exaggerated  sound,  at  a point 
more  or  less  distant  from  the  heart,  constitute 
the  most  positive  signs  of  the  disease. 

The  existence  of  aneurism  of  the  aorta  may  be 
inferred  with  greater  or  less  confidence  from 
certain  symptoms  and  signs,  according  to  their 
individual  or  correlative  value.  Even  negative 
signs,  if  associated  with  others  in  themselves 
of  minor  significance,  may  be  scarcely  less  con- 
clusive than  the  most  positive  evidence  would 
be.  Thus,  for  example,  suppressed  respiration 
with  percussion-resonance  on  the  left  side  of  the 
chest,  dyspnoea,  haemoptysis,  fixed  pain  in  the 
I Kick,  and  left  intercostal  neuralgia — the  entrance 
>f  a foreign  body  into  the  left  bronchus  and  the 
existence  of  cancer  of  the  posterior  mediastinum 
having  been  excluded — would  be  all  but  con- 


clusive as  to  the  existence  of  aneurism.  A 
foreign  body  in  the  bronchus  might  be  diag- 
nosed from  the  history  of  a misadventure  in 
swallowing,  followed  immediately  by  dyspncea, 
hsemoptysis,  and  the  special  signs  of  bronchial 
obstruction,  which,  in  nine  cases  out  of  ten, 
would  be  on  the  right  side:  whilst  the  diagnosis 
of  mediastinal  cancer  would  rest  upon  evidence 
eminently  suggestive,  namely,  the  presence  of 
cancerous  enlargements  in  the  neck  and  axilla, 
and  of  extreme  dulness  over  the  root  of  the 
lung,  without  corresponding  pulsation  or  sound. 
Finally,  aneurism  of  the  aorta  may  be,  though 
it  very  rarely  is,  strictly  latent  in  regard  to  both 
symptoms  and  signs. 

Prognosis,  Duration,  and  Terminations. — 
The  prognosis  of  aortic  aneurism  is  in  the 
highest  degree  unfavourable.  Recovery  is,  how- 
ever, under  favourable  circumstances  and  ap- 
propriate treatment,  quite  within  the  range  of 
medicine.  Numerous  examples  of  cure  of  aortic 
aneurism,  both  thoracic  and  abdominal,  have 
been  lately  recorded. 

The  duration  of  life,  in  connection  with  aneu- 
rism of  the  aorta,  has  varied,  according  to  the 
experience  of  the  writer,  from  ten  days  to  eleven 
years  ; but  it  may  be  much  longer.  The  situa- 
tion and  relations  of  the  aneurism  ; its  complica- 
tions ; the  constitution  of  the  sac,  and  the  state  of 
its  contents  ; the  previous  health  and  present 
habits  of  the  patient;  and  the  advantages  enjoyed 
in  regard  to  rest  and  treatment — will  all  ma- 
terially influence  the  prognosis,  whether  as  to 
duration  of  life  or  prospect  of  recover}-. 

Death  in  aneurism  of  the  aorta  may  result  from 
— (a)  ruptureof  the  sac;  (b)  exhaustion  from  pain, 
loss  of  sleep,  or  leakage  of  blood ; (c)  asphyxia : 
(if)  syncope;  ( e ) inanition;  or  (/)  intercurrcnt 
disease.  The  foregoing  represents  the  order  of 
relative  frequency  of  the  several  causes  men- 
tioned. Rupture  of  the  sac  is  not,  of  necessity, 
immediately  fatal.  Hemorrhage  may  be  stayed, 
and  life  thus  protracted  for  several  days,  by  ob- 
struction from  the  extravasated  blood,  itself  ar- 
rested and  coagulated  in  the  surrounding  tissues, 
or  by  its  pressure  upon  the  aorta  on  the  proximal 
side  of  the  sac.  Rupture  into  one  of  the  cham- 
bers of  the  heart,  the  pulmonary  artery,  either 
vena  cava  or  the  innominate  vein,  the  portal  vein, 
or  the  biliary  passages,  is  usually  fatal  within  a 
very  brief  period ; whilst  rupture  into  one  of  the 
serous  cavities  in  the  absence  of  previous  adhe- 
sion, into  the  trachea  or  bronchi,  or  into  the  ali- 
mentary or  the  spinal  canal,  is  instantaneouslv 
fatal. 

Treatment. — The  treatment  of  aneurism  of 
the  aorta  is  palliative  and  curative.  Pain  from 
nerve-pressure  is  most  effectually  relieved  by 
hypodermic  injections  of  morphia,  one  quarter  to 
half  a grain  in  solution,  repeated  and  increased 
in  quantity  according  to  necessity.  The  pain 
and  oppression  due  to  congestion  of  the  sac  and 
the  surrounding  structures  is  best  treated  by 
local  or  general  abstraction  of  blood,  combined 
with  the  use  of  cardiac  and  vascular  depressants, 
especially  iodide  of  potassium  (20  to  30  grains 
every  fourth  hour),  chloral  hydrate  (20  grains  \ 
andveratrum  viride  or  aconite  (5  to  10  minims  of 
the  tincture  every  thirdhour).  Mechanical  support 
by  means  of  a well-constructed  shield  is  likewise 


AORTA,  DISEASES  OF. 

useful  "when  the  tumour  projects  externally. 
Fixed  pain  in  the  back,  due  to  erosion  of  the 
vertebrae,  is  most  effectually  relieved  by  a seton 
or  issue  in  the  vicinity  of  its  seat.  The  curative 
treatment  of  aneurism  of  the  aorta  may  be  classi- 
fied under  the  heads  of — (a)  compression  of  the 
artery,  proximal  or  distal ; ( b ) distal  ligature  ; 
( c ) absolute  rest  with  regulated  diet;  and  ( d ) 
the  use  of  medicinal  agents  promotive  of  coagu- 
lation within  the  sac.  For  the  details  of  these 
several  modes  of  treatment  the  reader  is  referred 
to  the  articles  in  this  volume  respectively  entitled 
Aneurism,  Abdominal  Aneurism,  and  Thoracic 
Aneurism.  Thomas  Hayden. 

AORTIC  VALVES,  Diseases  of.  See 
Heart,  Valvular  Diseases  of. 

APEPSIA  (a,  priv.,  and  irinTcc,  I digest). — 
Indigestion.  See  Digestion,  Disorders  of. 

APERIENTS  ( aperio , I open). — Medicines 
which  produce  a gentle  action  of  the  bowels. 
See  Purgatives. 

APHAGIA  (a,  priv.,  and  <paya>,  I eat).— In- 
ability to  swallow.  See  Deglutition,  Disorders 
:f. 

APHASIA  (a,  priv.,  and  <pri/A  or  <pdaj,  I 
speak). — Synon.  : Aphemia , Alalia  ; Fr.  Aphasic. 

Description. — Aphasia  is  the  name  given  to  a 
defect  of  speech  from  cerebral  disease,  to  which 
much  attention  has  been  paid  during  the  last 
few  years.  When  it  exists  the  patient  is  found 
to  be  unable  to  utter  any  proposition,  though  his 
occasional  distinct  pronunciation  of  some  one  or 
two  words  shows  that  his  speechless  condition  is 
not  due  to  a mere  difficulty  in  the  more  mecha- 
nical act  of  articulation.  Moreover,  the  patient’s 
intelligent  manner  and  gestures  may  plainly 
show  that  he  understands  what  is  said,  and 
is  capable  of  thinking,  even  though  he  is  quite 
unable  to  give  expression  to  his  thoughts.  This 
kind  of  powerlessness  as  regards  speech  is  most 
frequently  encountered  in  persons  suffering  from 
right  hemiplegia,  though  it  is  occasionally  met 
with  in  those  who  are  paralysed  on  the  left  side, 
and  at  other  times  in  persons  who  are  not  hemi- 
plegic at  all. 

The  aphasic  condition  is  not  always,  as  it 
ought  to  be,  clearly  distinguished  from  another 
which  may  he  encountered  in  association  with 
hemiplegia  on  either  side  of  the  body,  and  to 
which  the  name  Amnesia  is  given.  The  essence 
of  this  latter  defect  lies  in  the  fact  that  the 
patient  very  frequently  substitutes  wrong  words 
or  names  in  the  place  of  those  he  wishes  to  em- 
ploy, as  when  speaking  of  his  ‘ hat,’  he  calls  it 
a ‘brush  ;’  or  when  seeking  a ‘pen,’  he  asks  for 
a ‘knife.’  In  a bad  case  of  this  kind  the  patient 
may  be  quite  unable  to  arrange  words  into  a 
sentence  capable  of  conveying  a definite  meaning, 
so  that  his  speech  is  rendered  unintelligible. 
Where  this -species  of  defect  exists  there  seems  to 
be  an  inco-ordinate  action  of  those  higher  cere- 
bral centres  whose  function  it  is  to  translate 
thought  into  the  corresponding  motor  acts  of 
speech,  so  that  we  get  hesitation  and  delay  in 
the  utterance  of  right  words,  or,  what  is  worse, 
the  substitution  occasionally  of  entirely  wrong 
words  or  even  of  a meaningless  set  of  sounds. 


APHASIA.  69 

These  amnesic  or  inco-ordinate  defects  were  not, 
at  first  recognised  as  being  distinct  in  nature 
from  those  of  an  aphasic  type,  in  which  there  is 
rather  a loss  than  a misdirection  of  power  in 
some  of  the  higher  centres,  whence  the  ineita- 
tion  to  the  motor  acts  of  speech  proceed.  The 
two  kinds  of  defects,  indeed,  not  unfrequently 
coexist  to  some  extent  in  the  same  indivi- 
dual. 

When  occurring  in  association  with  hemi- 
plegia, aphasia  varies  much  in  intensity  accord- 
ing to  the  degree  of  general  mental  impairment 
with  which  it  may  he  combined.  During  the 
first  week  or  ten  days  after  the  onset  of  such  an 
attack  the  special  defect  may  be  scarcely  recog- 
nisable, owing  to  the  masking  influence  of  the 
general  mental  impairment.  The  patient  lies, 
perhaps,  in  a restless  hut  otherwise  lethargic 
state,  taking  no  notice  of  what  is  occurring 
around  him,  and  not  allowing  his  attention  to 
be  fixed  even  for  a moment ; so  that  there  is  at 
such  a time  no  positive  ground  for  concluding 
that  he  or  she  will  subsequently  manifest 
aphasic  symptoms.  But  where  recovery  of 
general  mental  power  begins  to  show  itself,  and 
the  patient  taking  notice  of  what  is  passing 
around  him,  also  attempts  to  reply  to  simple 
questions,  the  first  signs  of  an  aphasic  condition 
may  reveal  themselves.  He  perhaps  says  ‘yes’ 
or  ‘ no’  to  all  questions  indifferently ; or  if  both 
words  are  used,  it  is  inappropriately.  Even  in 
this  stage,  however,  there  may  be  defective  power 
in  the  initiation  rather  than  in  the  execution  of 
many  much  simpler  acts  than  those  of  speech. 
Attention  to  the  nature  of  this  defective 
power  clearly  shows  that  it  is  not  occasioned  by 
paralysis  in  the  ordinary  sense  of  the  term. 
Thus  a patient  in  this  condition  may  not  bo 
able  to  protrude  his  tongue  when  simply  told  to 
do  so,  though  it  may  come  out  with  much  readi- 
ness when  a sweetmeat  is  applied  to  the  lips,  or 
even  when  he  is  shown  rather  than  told  what 
we  want  him  to  do. 

After  a time,  however,  such  a pationt  may 
regain  a considerable  amount  of  general  mental 
power,  though  he  may  he  left  more  or  less  hemi- 
plegic, and  may  also  present  the  aphasic  defect 
to  a marked  degree.  He  readily  comprehends 
everything  that  is  said  to  him,  and  can  often 
understand  what  he  reads.  But  at  other  times, 
as  was  the  case  wfith  one  of  Trousseau’s  patients, 
though  able  fully  to  understand  when  read  to, 
he  does  not  seem  to  understand  when  he  himself 
attempts  to  read.  He  can,  perhaps,  play  draughts 
or  chess  well,  and  by  means  of  gestures  and 
pantomime  can  make  his  wants  and  most  of  his 
wishes  fairly  well  understood  by  those  accus- 
tomed to  interpret  them.  Yet  he  may  only  be 
able  to  articulate  some  one  or  two  words,  or 
else  combinations  of  mere  unmeaning  sounds, 
such  as  ‘ poi,  boi,  bah,’  ‘ sapon,  sapon,’  or  some 
other  sounds  which,  doing  duty  on  all  occasions, 
constitute  his  only  form  of  speech.  On  rare 
occasions,  under  the  influence  of  strong  emo- 
tion, the  patient  may  blurt  out  some  simple 
expletive  or  short  phrase,  such  as  ‘ oh  dear ! ’ 
Sometimes  ho  can  repeat  a word  which  he  has 
just  heard  uttered,  though  at  other  times  he  has 
no  such  power,  and  may  even  be  unable  to  repeat, 
when  told  to  do  so.  one  of  t.he  stock  words  o? 


APHASIA. 


70 

sounds  to  ■which  he  is  accustomed  to  give  utter- 
ance. In  a few  cases  the  patient  has  seemed 
unable  to  understand  what  is  said,  as  though 
from  some  difficulty  in  realising  the  meaning  of 
words.  Words  may  have  to  be  uttered  very 
slowly  and  repeated  several  times  to  such  a 
patient,  and  even  then  they  may  fail  to  convey 
their  meaning.  Yet  the  language  of  gesture, 
appealing  as  it  does  to  the  sense  of  sight,  may  be 
at  once  understood. 

The  patient’s  power  of  writing  is  necessarily 
interfered  with  when  aphasia,  as  is  so  often  the 
case,  co-exists  with  right  hemiplegia.  Many 
such  patients,  however,  learn  to  write  with  the 
left  hand  to  a variable  extent,  though  others 
continue  powerless  in  this  respect.  The  varia- 
tions as  regards  the  power  of  writing  are,  in 
fact,  almost  as  marked  as  the  variations  in  power 
of  speaking,  though  these  two  classes  of  defects 
by  no  means  run  parallel  with  one  another  in 
the  same  individual.  The  writer  has  known  a 
man  who  was  quite  unable  to  express  himself  in 
spoken  words,  write  a fairly  good  letter  with 
very  few  mistakes  ; on  the  other  hand,  the  per- 
formance of  such  a patient,  without  a copy 
before  him,  may  be  limited  to  writing  his  own 
name.  At  other  times  the  patient  is  able  to 
write  only  mere  senseless  combinations  of  letters; 
or  writing  some  words  correctly,  he  makes  mis- 
takes and  substitutions  with  others — in  fact, 
shows  an  amnesic  defect  in  writing,  and  writes 
much  as  an  amnesic  patient  speaks.  Still  more 
rarely  it  is  found  that  an  aphasic  patient  is, 
though  not  from  want  of  manual  power,  unable 
to  write  even  a single  letter — in  attempting  to 
do  so  he  makes  mere  unmeaning  strokes. 

Looking  to  the  mode  in  which  these  symptoms 
most  frequently  group  themselves,  we  find  in 
one  set  of  cases  defects  of  an  aphasic  type  only, 
as  follows : — 1.  Loss  of  power,  both  of  speaking 
and  of  writing  ( Typical  Aphasia).  2.  Loss  of 
power  of  speaking,  but  power  of  writing  pre- 
served ( Aphemia ).  3.  Loss  of  power  of  writing, 

but  power  of  speaking  preserved  {Agraphia). 
At  other  times  aphasic  and  amnesic  defects  are 
combined  in  the  same  individual,  and  then  we 
may  have— 4.  Loss  of  power  of  speaking,  with  an 
amnesic  defect  in  writing,  o.  Loss  of  power  of 
writing,  with  an  amnesic  defect  in  speaking.  Or, 
lastly,  mere  amnesic  defects  alone  may  exist  in 
speech,  in  writing,  or  in  both  modes  of  expres- 
sion. 

Pathology.  — The  recent  concentration  of 
attention  upon  these  defects  of  speech  was 
started  by  the  enunciation  of  Broca’s  views  as 
to  the  dependence  of  the  aphasic  defects  upon 
lesions  in  or  about  the  third  left  frontal  con- 
volution. Subsequent  investigations  have  in 
the  main  tended  to  confirm  Broca's  view  as  to 
the  effects  of  injury  to  this  convolution,  though 
Meynert  and  others  think  that  a lesion  of  the 
convolutions  of  the  island  of  Eeil  on  the  same 
side  is  more  frequently  productive  of  aphasic 
symptoms.  But  all  pathologists  are  now  agreed 
as  to  the  fact  that  lesions  in  or  about  the  third 
left  frontal  convolution  are  much  more  prone  to 
give  rise  to  aphasic  symptoms  than  are  corre- 
sponding lesions  on  the  right  side  of  the  brain. 
It  is  commonly  believed,  however,  that  amnesia 
may  lie  induced  by  superficial  lesions  on  either 


side  of  the  brain,  and  by  legions  also  which  varj 
much  in  their  topograpnical  distribution. 

Aphasia  occasionally  supervenes,  independently 
of  paralysis  or  convulsions,  in  individuals  who 
have  been  subjected  to  great  excitement  or  pro- 
longed overwork,  when  it  may  be  due,  perhaps, 
to  mere  functional  derangements.  In  other 
cases  it  presents  itself  as  a temporary  condition, 
lasting  only  for  a few  hours  or  a few  days,  in 
a patient  who  has  just  had  an  attack  of  right- 
sided unilateral  convulsions ; or,  lastly,  as  has 
already  been  indicated,  it  occurs  in  conjunc- 
tion with  a right-sided  hemiplegia  produced 
either  by  brain-softening  or  by  cerebral  haemor- 
rhage. Cases  belonging  to  the  latter  category 
vary  very  much  amongst  themselves  as  regards 
the  degree  cf  co-existing  hemiplegia.  If  the 
third  left  convolution  alone  is  damaged  by 
softening,  the  hemiplegic  condition  may  be 
transient  and  incomplete — never,  perhaps,  affect- 
ing the  leg  appreciably.  This  condition  is 
often  induced  by  a small  haemorrhage,  or  by  a 
patch  of  softening  produced  by  an  embolism 
of  that  branch  of  the  middle  cerebral  artery 
which  supplies  the  third  frontal  convolution ; 
but  where  the  haemorrhage  is  larger,  or  where 
the  main  trunk  of  the  middle  cerebral  artery 
is  obliterated,  either  by  an  embolon  or  a 
thrombus,  the  aphasia  is  combined  with  much 
graver  and  more  persistent  paralytic  symp- 
toms. 

In  some  cases  in  which  typical  aphasia  is 
met  with,  no  actual  lesion  of  the  third  frontal 
convolution  is  discovered  after  death.  This  is 
due  to  the  fact  that  these  symptoms  may  be 
occasioned  by  a lesion  which,  whilst  not  im- 
plicating the  third  frontal  convolution  itself, 
severs  or  interferes  with  the  efferent  fibres  pro- 
ceeding from  this  convolution  to  the  corpus 
striatum,  the  next  lowest  nerve-centre  ; so  that 
a lesion  either  of  the  part  of  the  corpus 
striatum  in  relation  with  the  third  frontal  con- 
volution, or  of  the  white  matter  intervening 
between  the  two,  should  be,  and  is  found  to  be, 
as  capable  of  producing  aphasia  as  a lesion  of 
the  convolution  itself. 

The  third  left  frontal  convolution  is  not  now 
supposed,  as  Broca  put  it,  to  be  the  seat  of  any 
‘ faculty  of  language,’  though  the  anatomical  in- 
vestigations of  Meynert  and  of  Broadbent  have 
shown  that  its  relations  with  other  convolutions 
are  exceptionally  complex.  Whether  or  not 
certain  assumed  higher  centres  for  speech  are 
situated  in  this  part  of  the  brain,  it  must  at 
least  be  conceded  that  this  convolution  is  in- 
timately concerned  with  the  physical  expres- 
sion given  to  thought  in  articulate  speech  and 
in  written  language ; it  contains,  in  fact,  the 
sites  (or  nerve-centres)  from  which  the  volitional 
incitations  to  these  muscular  acts  usually  pass 
downwards  to  lower  centres. 

We  know  that  the  left  hemisphere  is  the  one 
from  which  the  volitional  incitations  proceed 
in  the  case  of  written  language,  and  it  is  pre- 
sumed that  the  same  half  of  the  brain  also  takes 
the  lead  in  the  production  of  articulate  speech. 
It  is,  therefore,  a point  of  much  interest  when  we 
find  that,  in  some  of  the  exceptional  cases  in 
which  aphasia  has  occurred  in  association  with 
lesions  on  the  right  side  of  the  brain  and  left 


APHASIA. 

hemiplegia,  the  individuals  had  been  left- 
handed  during  life.  Some  of  the  other  excep- 
tional cases,  however,  have  not  admitted  of  this 
interpretation,  so  that  further  observations  are 
required. 

Treatment. — -Where  aphasia  occurs  after  ex- 
citement or  overwork,  without  paralysis,  it  is  a 
warning  of  much  importance,  since  it  may  be 
the  precursor  of  much  graver  symptoms.  Under 
such  circumstances  the  patient  requires  an  abso- 
lute cessation  from  work  for  a time,  and  most 
careful  watching.  Stimulants  may  need  to  be  di- 
minished, and  bromide  of  potassium,  with  sumbul 
and  other  sedative  remedies,  should  be  adminis- 
tered. Where  aphasia  is  a temporary  condition 
in  association  with  right-sided  convulsions,  or 
where  it  is  lasting  and  co-exists  with  right-sided 
paralysis,  the  treatment  of  the  aphasic  condition 
becomes  merged  in  that  of  the  associated  convul- 
sive tendency  or  paralytic  condition,  since,  as  a 
rule,  an  amelioration  takes  place  in  the  patient’s 
power  of  speaking  coincidently  with  his  improve- 
ment in  other  respects.  This,  however,  is  not 
always  the  case  where  aphasia  has  co-existed 
with  a partial  hemiplegic  condition;  the  paralysis 
maybe  recovered  from,  whilst  the  aphasic  defect 
remains  more  or  less  as  it  was.  Where  this  is 
the  case,  an  attempt  should  be  made  to  teach 
the  patient  to  speak  again.  Such  efforts  have 
occasionally  been  crowned  with  success  (see 
Trans,  of  Clin.  Soc.,  vol.  iii.  p.  02),  but  much 
judgment  and  untiring  patience  have  to  be 
called  into  play  in  order  to  obtain  satisfactory 
results.  II.  Charlton  Bastian. 

APHEMIA  (a,  priv.,  and  I speak). 

See  Aphasia. 

APHONIA  (a,  priv.,  and  <pavr],  the  voice). — 
Absence  of  voice,  that  is,  of  intonated  utterance. 
Seg  Voice,  Disorders  of. 

APHRODISIACS  (’A<ppoSlTt),  Venus). — 
Definition. — Medicines  which  increase  the  sex- 
ual appetite  and  power. 

Enumeration. — The  direct  aphrodisiacs  in- 
clude—Nux  Vomica  and  Strychnia,  Phosphorus, 
Cantharides ; Urtication  and  Flagellation ; Can- 
nabis Indica,  Opium,  and  Alcohol  in  small  doses. 
Iron  and  bitter  tonics  ; meat  diet;  warm  clothing, 
especially  around  the  hips  and  loins ; and  absti- 
nence from  severe  mental  and  bodily  work  act  as 
indirect  aphrodisiacs. 

Action.— Aphrodisiacs  may  act  by  increasing 
the  excitability  of  the  nerves  passing  to  or  from 
the  genital  organs,  or  of  the  genital  centre  in 
the  spinal  cord  (see  Anaphrodislacs),  as,  for  ex- 
ample, strychnia,  nux  vomica,  and  probably 
phosphorus;  by  causing  irritation  of  the  nerves 
of  the  genital  or  urinary  organs  or  of  adjoining 
parts,  as  cantharides  and  urtication  ; or  by  sti- 
mulating the  brain,  as  Indian  hemp  or  small 
doses  of  opium.  Alcohol  in  large  doses  has  a 
double  action,  increasing  the  sexual  desire  by  sti- 
mulating the  brain,  while  lessening  the  power  of 
erection,  probably  by  weakening  the  nerves 
through  which  the  spinal  centre  acts  on  the 
genital  organs,  or  depressing  this  centro  itself. 
As  the  sexual  passion  becomes  diminished  when 
the  nervous  system  is  weakened  with  the  rest  of 
the  body,  and  increases  with  returning  strength, 


A PI1  THAI.  71 

iron  with  bitter  tonics,  and  generou„  diet  act  in- 
directly as  aphrodisiacs. 

Uses, — -When  the  sexual  functions  are  abnor- 
mally depressed,  strychnia  and  phosphorus  are 
the  most  generally  useful  of  the  direct  aph- 
rodisiacs. Cantharides,  although  sometimes 
valuable,  must  be  employed  with  caution. 

T.  Lauder  Brunton, 

APHTHA— APHTHOUS  ULCERS  (airra  , 

to  inflame). — Synon.  : Fr.  Muguetj  Ger.Fasch. 

Description. — In  some  states  of  debility  and 
deranged  digestion  the  tongue,  together  with  the 
other  parts  of  the  mouth,  becomes  studded  with 
small  flakes,  like  morsels  of  curd,  which  are 
known  as  aphtha.  Sometimes  these  flakes  extend 
and  coalesce,  so  as  to  form  large  patches  of  thick, 
soft  fur.  This  condition  is  particularly  apt  to 
manifest  itself  at  the  extremes  of  life — in  infancy' 
and  old  age — but  it  also  occurs  in  the  later  stages 
of  wasting  or  dobilitating  complaints.  The  white 
flakes  can  easily  be  detached,  but,  if  this  is  done, 
they  are  soon  reproduced.  It  is  better,  therefore, 
not  to  detach  them,  but  to  aim  at  removing  the 
conditions  which  are  essential  to  their  existence. 
If  they  are  forcibly'  detached,  they  are  apt  to  carry 
the  epithelium  along  with  them,  and  to  leave  the 
papillae  raw ; and  these  raw  spots  are  prone  to 
ulcerate.  Aphthous  ulcers  have  a very  character- 
istic appearance.  They  aro  small,  flat,  and  cir- 
cular or  oval;  generally  occurring  in  clusters, 
and,  as  it  were,  in  successive  crops.  Their  bases 
aro  soft  and  smooth,  with  a thin  yellowish  or 
greyish  slough;  their  margins  are  well-defined 
and  surrounded  by  a bright  red  areola,  without 
thickening  or  elevation.  They  are  commonly 
situated  on  the  fore  part  of  the  tongue  and  the 
lips,  where  they  are  always  accompanied  by  in- 
creased heat,  and  vivid  congestion  of  the  mucous 
membrane.  At  the  same  time  there  is  generally 


active  gastric  or  intestinal  irritation,  as  well  as 
fever  of  an  atonic  kind. 

It  was  not  till  1 842  that  the  precise  nature  cl 
these  white  patches  was  ascertained.  In  that 


72  APHTHAE. 

year  it  was  shown  by  Gruby  that  they  depend 
upon  the  presence  of  a microscopic  fungus,  to 
which  he  gave  the  name  of  aphthaphyte , or  cryp- 
togame dn  magnet.  Subsequently  this  fungus 
was  referred  by  Robin  to  the  genus  oidium,  and 
by  him  called  oidium  albicans.  It  is  found 
growing  upon  the  tongue  in  close  association 
with  the  epithelium.  It  forms  delicate,  horizontal 
filaments,  which  are  apparently  homogeneous  in 
structure,  and  from  which  short  articulated 
pedicels  take  their  rise.  The  uppermost  cells  of 
these  pedicels  become  expanded  into  oval  bodies 
which  fall  off,  germinate,  and  become  new  fila- 
ments. It  is  generally  found  growing  in  tangled 
masses,  like  minute  bunches  of  mistletoe,  mixed 
with  the  debris  of  scattered  spores,  cells  of  the 
leptothrix,  and  epithelial  scales;  but  if  separate 
filaments  are  followed  out  we  may  obtain  such 
forms  as  those  represented  in  Fig.  1. 

Many  ulcers  are  called  aphthous  which  are 
really  dyspeptic,  and  which  owe  their  origin  to 
stomatitis  and  irritation  of  the  intestinal  canal. 
The  true  aphthous  ulcer,  however,  is  always 
accompanied  by  the  growth  of  the  parasitic 
fungus  that  has  been  described  above,  and  to  such 
ulcers  the  term  ought  to  be  confined. 

The  treatment  of  this  affection  will  be  found 
described  under  Thrush,  a popular  term  which 
includes  both  aphthae  and  the  dyspeptic  ulcers 
resembling  them. 

Some  writers  speak  of  aphthous  ulceration  of 
the  vagina , by  which  is  meant  a severe  form  of 
vaginitis  attended  by  the  formation  of  small 
ulcers  resembling  the  aphthous  ulcers.  The 
oidium  albicans  is  frequently  met  with  in  the 
vaginal  secretion.  W.  Fairlie  Clarke. 

APHTHOUS. — A term  applied  to  diseases 
in  which  aphthae  are  present. 

APLASTIC  (ct,  priv.,and  irAaairw,  I mould). 
— Incapable  of  being  organized  or  of  forming 
tissues  ; generally  applied  to  inflammatory  exu- 
dation. 

APJNTEUMATOSIS  (&,  priv.,  and  iryeiga, 
respiration). — A synonym  for  Atelectasis.  See 
Atelectasis. 

APNCEA  (a,  priv.  and  irydu>,  I breathe),  lite- 
rally signifying  breathlessness,  is  used  by  some 
medical  writers  as  synonymous  with  asphyxia 
(see  Asphyxia),  the  condition  which  supervenes 
on  suspension  or  obstruction  of  the  respiratory 
function. 

By  physiologists,  and  with  more  justice,  the 
term  is  employed  to  signify  the  cessation  of 
respiratory  movements  which  is  brought  about 
by  hyperoxygenation  of  the  blood,  as  when  an 
animal  is  made  to  breathe  oxygen,  or  to  breathe 
more  rapidly  than  the  needs  of  the  economy  re- 
quire. 

APOLLIIvT APIS,  "Waters  of.— Acidulous 
alkaline  table-waters.  See  Mineral  Waters. 

APOPLEXY.  — Definition.  — The  word 
apoplexy  means-,  by  its  etymology,  a striking  from 
(curb,  from,  and  -irAp^is,  a striking),  and  was  at  first 
and  is  still  chiefly  used  to  signify  sudden  abolition 
of  consciousness  and  power  of  motion,  which,  in 
common  English,  is  also  called  a stroke.  Cere- 
bral haemorrhage  being  the  most  frequent  cause  ‘ 


APOPLEXY,  CEREBRAL. 

of  this  condition,  ‘haemorrhage  into  the  bruin' 
and  ‘apoplexy’  came  to  bo  used  as  synonymous 
expressions.  Subsequently  the  effusion  of  blood 
itself  was  spoken  of  as  the  apoplexy,  the  word 
being  used  to  designate  the  pathological  condition 
causing  the  symptoms  which  it  at  first  epitomised. 
Ultimately  it  was  applied  to  a similar  patho- 
logical state  elsewhere,  and  thus  haemorrhages 
into  the  substance  of  the  lung,  the  spleen,  or 
the  retina  were,  and  still  are  termed  respectively 
pulmonary,  splenic,  or  retinal  ‘ apoplexies.’ 

The  term  cerebral  apoplexy  is  sometimes  used 
to  particularise  haemorrhage  into  the  brain,  but 
it  is  more  commonly  employed  to  denote  an 
apoplectic  condition  depending  on  any  cerebral 
lesion,  and  in  that  sense  it  will  be  here  employed. 

W.  R.  Gowers. 

APOPLEXY,  CEREBRAL.  — SrxoN. : 

A Stroke ; Fr.  Apoplexie ; Ger.  Schlag. 

Definition. — Loss  of  consciousness,  of  sen- 
sation, and  of  voluntary  motion,  coming  on 
more  or  less  suddenly,  and  due  to  a morbid  state 
of  the  brain. 

This  condition  of  coma  is  termed  ‘apoplectic 
when  of  sudden  or  rapid  onset.  Loss  of  con- 
sciousness may  be  due  to  other  causes  acting 
directly  on  the  brain,  6uch  as  defective  or  exces- 
sive supply  or  altered  condition  of  blood;  but  it 
is  customary  to  include  among  the  forms  of 
apoplexy  only  that  sudden  loss  of  consciousness 
which  is  due  to  cerebral  congestion,  and  to  con- 
sider as  apoplectic  states  only  those  which  result 
from  distinct  toxaemia. 

^Etiology. — The  apoplectic  condition  may  be 
due  (1)  to  the  influence  upon  the  brain  of  a 
poison  circulating  in  the  blood ; (2)  to  a sudden 
cerebral  lesion,  such  as  haemorrhage  or  vascular 
obstruction;  or  (3)  to  a sudden  shock  or  other 
impression  arresting  the  cerebral  functions,  but 
causing  no  visible  alteration  in  the  brain. 

1.  The  toxaemic  states  in  which  apoplectic 
symptoms  occur  are  thoso  of  uraemia,  drunken- 
ness, and  poisoning  by  narcotics,  as  opium,  &c. 
These  are  described  elsewhere,  and  need  be  referred 
to  in  this  article  only  in  respect  to  the  diagnosis. 

2.  The  great  cause  of  apoplexy  is  a sudden  cere- 
bral lesion,  which  may  be  traumatic  or  may  occur 
without  external  injury.  Injury  may  lead  to 
apoplexy  by  simple  concussion,  by  laceration  of 
brain,  or  by  rupture  of  vessels  and  haemorrhage. 
Apoplexy,  not  due  to  injury,  may  be  caused  by 
congestion  ; by  thrombosis  or  embolism  ; but 
especially  by  haemorrhage.  The  latter  is  its  most 
common  and  most  efficient  cause.  Profound  ccma 
is  rarely  due  to  any  other  spontaneous  cerebral 
lesion.  A very  small  haemorrhage  may  cause 
apoplexy. 

3.  Lastly,  apoplectic  symptoms  may  occur  with- 
out obvious  lesion  of  the  brain.  Thecoma  which 
results  from  concussion,  that  which  succeeds  an 
epileptic  fit,  and  that  which,  in  the  absence  of 
any  recognisable  cause,  has  been  called  ‘ simple 
apoplexy,’  furnish  examples. 

Pathology. — In  all  these  eases  the  apoplexy 
is  in  relation  chiefly  to  the  extent  and  suddenness 
of  the  lesion.  Roughly  speaking,  its  occurrence 
may  he  said  to  depend  on  the  suddenness,  its 
degree  on  the  extent  of  the  cerebral  mischief. 
Butthe  occurrence  of  apoplexy  depends  sometimes 


APOPLEXY, 

in  the  size  of  the  lesion,  and  the  degree  varies  not 
only  directly  with  the  extent  of  the  mischief,  but 
with  the  extent  of  brain-tissue  which  is  exposed  in- 
directly to  the  irritative  influence  of  the  primary 
lesion.  Hence  position  of  lesion  has  an  important 
influence  in  determiningthe  apoplectic  symptoms. 
For  these  several  reasons  apoplexy  is  especially 
profound  when  the  hsemorrhage  affects  both 
hemispheres,  either  by  simultaneous  extrava- 
sation on  each  side,  or  as  the  result  of  hsemor- 
rhage into  the  lateral  ventricles. 

The  precise  condition  on  which  the  apoplexy 
is  immediately  dependent  has  been  a matter  of 
dispute.  It  was  formerly  ascribed  to  the  pres- 
sure exerted  by  the  clot  on  the  rest  of  the  brain, 
either  influencing  directly  the  cerebral  tissue,  or 
pressing  on  and  emptying  its  capillaries  (Niemey- 
er).  That  such  pressure  is  exerted  by  a large 
haemorrhage  is  unquestionable.  The  convolu- 
tions on  the  side  of  the  extravasation  are  flat- 
tened, and  the  falx  is  bulged  to  the  opposite  side 
(Hutchinson,  Jackson).  It  cannot  be  doubted 
that  the  intensity  of  the  apoplexy  in  these  cases 
is  due  in  part  to  this  cause.  But  this  will  not 
explain  the  occurrence  of  the  symptom  in  small 
haemorrhages,  by  which  no  general  pressure  is  ex- 
erted, or  not  more  than  is  at  once  relieved  by  the 
displacement  of  the  mobile  fluid  which  sur- 
rounds the  vessels.  It  will  not  explain  its  occur- 
rence in  laceration  of  the  brain,  or  the  early  loss 
of  consciousness  in  severe  hsemorrhage,  in  which, 
as  Jaccoud  insists,  it  should,  if  merely  due  to 
pressure,  be  a late  rather  than  an  early  symptom. 
There  can  be  little  doubt  from  these  considera- 
tions, and  from  the  cases  in  which  there  is  no 
recognisable  brain-lesion,  that  shock  is  an  im- 
portant element  in  the  causation  of  apoplexy. 
Thus  in  cerebral  hsemorrhage  the  apoplectic 
symptoms  are  due  in  part  to  the  influence  on  the 
rest  of  the  brain  of  the  irritation  of  the  nerve- 
elements  by  laceration.  W e can  thus  understand 
why  vascular  occlusion  causes  a slighter  degree  of 
apoplexy,  since  the  immediate  irritation  of  the 
local  ansemia  is  less  than  that  of  laceration ; and 
also  why  lesions  of  the  pons  produce  as  they  do 
such  deep  and  long-continued  coma,  since  the 
irritated  fibres  are  connected  with,  and  thus 
influence  indirectly  a large  part  of  the  cerebrum. 

Simple  Apoplexy  was  a term  given  by  Aber- 
crombie to  the  cases,  once  thought  to  be  frequent, 
in  which  apoplexy  occurs  without  recognisable 
brain-mischief  or  blood-poisoning.  Some  of 
these  cases  were  probably  instances  of  uraemic 
poisoning,  and  others  may  have  been  due,  as 
Dr.  Bastian  suggests,  to  capillary  embolism. 
But  cases  are  not  infrequent  to  which  neither  of 
these  explanations  applies,  in  which  death  occurs 
in  an  apoplectiform  attack,  all  organs  being 
found  healthy,  and  the  brain  only  exhibiting,  in 
common  with  the  other  organs,  that  passive  con- 
gestion which  results  from  an  asphj'xial  mode 
of  death.  The  nature  of  these  cases  is  still 
mysterious,  but  they  may  be  grouped  with  those 
in  which  fatal  coma  follows  an  epileptic  attack, 
and  is  apparently  duo  to  the  brain-shock  pro- 
d uced. 

Serous  Apoplexy  is  a term  applied  sometimes 
to  cases  of  fatal  apoplexy  in  which  no  lesion 
is  discoverable  except  excess  of  serum  on  the 
surface  of  the  brain.  It  is  now  understood  that 


CEREBRAL.  7-3 

such  serous  effusion  is  met  with  constantly  in 
atrophy  of  the  convolutions,  rarely  in  Bright’s 
disease,  and  under  no  other  circumstances. 
There  is  no  reason  for  associating  its  presence 
with  the  apoplectic  symptoms.  The  cases  de- 
scribed under  this  term  were  probably  instances 
of  uraemia,  or  of  ‘simple  apoplexy’  in  old  persons 
with  atrophied  brains. 

Symptoms. — The  prominent  feature  of  apoplexy 
is  loss  of  consciousness  without  obvious  failure  of 
the  heart’s  action.  The  onset  is  often  instanta- 
neous, so  that  the  sufferer  falls  to  the  ground. 
The  face  may  be  flushed  or  pale — it  is  rarely 
very  pale.  The  heart  and  arteries  beat,  often 
with  undue  force  and  lessened  frequency.  Re- 
spiration continues,  but  is  laboured  and  stertorous, 
with  flapping  cheeks.  The  limbs  are  motionless. 
In  severe  cases  no  reflex  action  can  at  first  be 
excited.  The  pupils  may  bo  dilated,  contracted, 
or  unchanged ; in  profound  coma  they  are 
usually  dilated  ; and  they  often  vary  in  size 
spontaneously,  being  sluggish  in  their  action  to 
light.  The  patient  can  usually  swallow,  although 
often  with  difficulty.  The  sphincters  permit  the 
escape  of  urine  and  faeces,  or  the  urine  may  be 
retained.  In  a case  of  moderate  severity  the 
reflex  action  soon  returns,  the  conjunctiva  become 
sensitive,  and  the  patient  can  be  roused  to  exhibit 
some  sign  of  consciousness,  shows  returning 
power  of  voluntary  motion,  opens  his  eyes  when 
spoken  to,  and  tries,  when  told  to  do  so,  to  pro- 
trude his  tongue.  On  the  other  hand,  the  apo- 
plexy may  continue  or  may  deepen  in  intensity, 
the  patient  dying  at  the  end  of  a few  hours  or  a 
few  days.  Death  rarely  occurs  in  a shorter  time 
than  two  or  three  hours.  In  very  rare  instances 
an  extensive  hsemorrhage  into  the  pons  or 
medulla  may  stop  the  respiration  and  kill  the 
patient  in  a few  minutes. 

It  is  not  often,  however,  that  there  is  this 
simple  loss  of  cerebral  function,  uniformly  dis- 
tributed, and  gradually  deepening  or  passing 
away.  Much  more  commonly  the  symptoms  of  a 
local  cerebral  lesion  are  added  to  those  of  apo- 
plexy. Frequently  such  symptoms  precede  the  loss 
of  consciousness — unilateral  weakness,  deviation 
of  the  mouth,  convulsion.  They  may  be  recog- 
nised during  the  attack:  the  limbs  on  one  side 
exhibit  more  complete  muscular  relaxation  than 
those  on  the  other ; they  fall  more  helplessly  when 
raised  ; or  there  is  unilateral  rigidity  or  clonic 
spasm,  unvaried  in  its  seat ; or  inequality  of 
pupils  is  observed,  or  rotation  of  the  head  and 
conjugate  deviation  of  the  eyes.  As  the  patient 
recovers,  these  local  symptoms  become  more  and 
more  distinct,  the  tongue  deviates  on  protrusion, 
speech  and  swallowing  are  difficult,  or  the  patient 
may  have  lost  the  use  of  language. 

In  ingravescent  apoplexy  the  commencement 
of  the  cerebral  mischief  is  marked  by  symptoms 
of  general  shock,  without  any,  or  with  merely 
transient,  loss  of  consciousness.  There  is  com- 
monly pain  in  the  head,  and  there  may  be  other 
localising  symptoms.  After  some  hours,  during 
which  the  patient  may  continue  his  occupation, 
coma  gradually  comes  on  and  deepens  into  death. 
This  form  of  apoplexy,  first  described  by  Aber- 
crombie, is  usually  due  to  a slowly  increasing 
cerebral  hsemorrhage. 

The  temperature  in  cerebral  apoplezy  is  at  first 


APOPLEXY.  CEREBRAL. 


always  lowered,  but  usually  the  fall  is  small,  and 
is  succeeded,  after  twelve  to  twenty-four  hours, 
by  a rise. 

Diagnosis. — Prom  the  unconsciousness  due  to 
cardiac  syncope,  apoplexy  is  easily  distinguished. 
In  the  former  the  heart’s  action  fails,  the  pulse 
is  weak  and  imperceptible,  the  face  is  very  pale, 
the  respiration  is  sighiDg  and  irregular,  reflex 
action  is  rarely  abolished,  and  the  sphincters  are 
seldom  relaxed. 

Promtheseveral  formsof  toxmmia  thediagnosis 
is  often  easy,  sometimes  extremely  difficult.  It 
is  easy  when,  on  the  one  hand,  the  symptoms 
of  apoplexy  are  preceded  or  accompanied  by 
those  of  a local  cerebral  lesion  ; or  when,  on  the 
other  hand,  the  direct  or  circumstantial  evidence 
of  poisoning  is  clear,  or  the  symptoms  of  toxaemia 
unmistakable.  Where  there  are  no  local  symp- 
toms, and  where  no  guiding  history  is  to  be 
obtained,  the  diagnosis  is  difficult,  but  a correct 
opinion  may  commonly  be  formed  by  an  attentive 
comparison  of  the  symptoms  present. 

There  may  be,  as  just  observed,  indirect  evi- 
dence of  toxiemia:  the  breath  may  smell  of 
opium  or  alcohol;  the  urine  may  contain  albu- 
min. But  albuminuria  or  a smell  of  spirits  may 
mislead.  Cerebral  haemorrhage  often  occurs  after 
drinking ; spirit  is  constantly  given  to  a person  in 
a fit.  A smell  of  spirit  must  therefore  only  be 
allowed  weight  in  the  absence  of  any  evidence  of 
cerebral  mischief.  So,  too,  albumin  is  always 
present  in  the  urine  in  uraemia,  but  it  is  also  very 
frequently  present  in  eases  of  cerebral  haemor- 
rhage. Alone,  this  evidence  of  Bright’s  disease 
is  of  little  value,  except  there  be  general  cedema 
and  the  patient  be  young ; then  uraemia  is  more 
probable  than  vascular  degeneration  and  cerebral 
haemorrhage.  But  with  other  symptoms  which 
indicate  uraemic  poisoning,  albuminuria  is  con- 
clusive. 

The  age  of  the  patient  should  be  considered. 
Late  life  is  in  favour  of  brain-diseaso.  The 
history  of  a fall  or  blow  on  the  head  adds  weight 
to  other  symptoms  of  cerebral  mischief. 

The  character  of  the  coma  will  sometimes 
guide.  In  uraemia,  and  commonlyin  alcoholism,  it 
is  less  profound  than  in  cerebral  mischief.  The 
patient  can  readily  be  roused.  In  apoplexy, 
in  opium-poisoning,  and  in  the  most  intense 
alcoholic  poisoning,  the  coma  may  be  profound. 
On  the  other  hand,  in  cerebral  haemorrhage  the 
patient,  as  Dr.  Hughlings  Jackson  remarks,  may 
sometimes  be  roused  to  answer  questions.  Violent 
struggling  is  strongly  in  favour  of  drink. 

The  mode  of  onset  of  the  coma  is  important. 
In  apoplexy  it  is  sudden  ; in  uraemia  slow.  The 
uraemic  patient  becomes  first  drowsy,  then  coma- 
tose. But  with  convulsions  uraemic  coma  may 
come  on  suddenly.  The  onset  of  the  coma  of 
opium-  and  alcohol-poisoning  is  also  slow.  In- 
gravescent apoplexy  is  of  deliberate  onset,  but 
a profound  degree  of  coma  is  quickly  reached. 

General  convulsions  at  the  onset  exclude  drunk- 
enness, and  usually  opium-poisoning,  while  they 
favour  uraemia.  Cerebral  mischief  sometimes 
commences  with  a convulsion,  but  the  convulsion 
is  then  commonly  unilateral,  and  one-sided 
symptoms  are  almost  always  afterwards  to  be 
recognised.  Rigidity  of  limbs  or  local  muscular 
twitching  during  the  coma  is,  if  constantin  seat, 


in  favour  of  cerebral  mischief ; if  variable  ir 
position,  it  is  in  favour  of  uraemia  (Reynolds) 
Post-epileptic  coma  is  of  course  preceded  by  a 
convulsion,  and  should  be  borne  in  mind. 

The  state  of  the  pupils  is  alone  of  little  im 
portance.  Great  contraction  occurs  in  and 
suggests  opium-poisoning,  but  it  is  present  in 
hemorrhage  into  the  pons  Yarolii.  The  pupils 
may  be  normal  or  dilated  in  uremia,  in  alcoholic 
or  opium-poisoning,  and  in  apoplexy.  Inequality 
of  pupils,  an  unilateral  symptom,  points  to 
brain-mischief.  The  retina  should  be  examined, 
since  the  presence  of  albuminuric  retinitis  points, 
in  the  absence  of  the  signs  of  a localised  cerebral 
lesion,  strongly  to  uraemia. 

Lastly,  the  temperature  should  bo  noted.  In 
uraemia  there  is  persistent  uniform  depression ; 
in  cerebral  lesions  the  initial  depression  is  suc- 
ceeded by  a rise  to  a point  above  the  normal. 

The  diagnosis  of  the  cause  of  cerebral  apoplexy 
will  be  described  more  fully  under  the  heads  of 
cerebral  congest  on,  haemorrhage,  and  softening. 
It  may  bo  here  pointed  out  that  slight  and 
transient  apoplexy,  without  local  symptoms,  with 
flushed  face,  and  coming  on  during  effort,  points 
to  cerebral  congestion  ; slight  and  transient  apo- 
plexy with  marked  local  symptoms  points  to  soften- 
ing ; early  and  profound  loss  of  consciousness  to 
cerebral  haemorrhage.  Post-epileptic  coma  may 
be  distinguished  by  the  history  of  epileptic 
attacks ; or,  if  this  be  not  forthcoming,  it  may 
be  suspected  if  symptoms  of  local  cerebral  lesion 
or  indications  of  toxaemia  are  absent,  if  the 
patient  bo  under  40,  and  exhibits  indications  of 
speedy  recovery.  ‘ Simple  apoplexy  ’ cannot  be 
diagnosed  during  life,  since  freedom  from  the 
symptoms  of  a local  lesion  does  not  afford 
ground  for  inferring  that  there  is  no  such  lesion. 

Prognosis. — The  prognosis  in  cerebral  apo- 
plexy depends  in  part  upon  the  intensity  of  the 
attack.  As  long  as  unconsciousness  is  complete, 
and  reflex  action  abolished,  the  patient  is  in  danger 
of  speedy  death.  The  longer  the  apoplectic  con- 
dition lasts  without  improvement,  the  less  pro- 
spect is  there  of  recovery.  Persistent  depression 
of  temperature,  or  a rise  of  several  degrees  above 
the  normal  after  an  initial  fall,  are  both  of  grave 
significance : such  cases  rarely  recover  ■;  Charcot, 
Bourneville). 

The  nature,  extent,  and  position  of  the  cere- 
bral lesion,  when  they  can  be  inferred,  furnish 
other  prognostic  indications.  In  haemorrhage 
the  prognosis  is  more  serious  than  in  softening. 
A sudden  occurrence  or  increase  of  apoplectic 
symptoms,  a few  hours  or  days  after  a slighter 
attack,  is  always  grave,  indicating  a fresh  ex- 
travasation. If  such  apoplectic  symptoms  become 
profound  and  uniform,  the  prognosis  is  fatal, 
rupture  into  the  ventricles  or  on  the  surface 
of  the  brain  having  probably  occurred.  If  the 
localising  symptoms  point  to  a lesion  of  the 
medulla  or  pons,  the  prognosis  is  almost  as  un- 
favourable. Early  return  of  consciousness  anil 
slight  alteration  in  temperature  are  favourable 
signs.  Previous  cerebral  disease  renders  the 
prognosis  worse.  Lastly,  the  prognosis  must  be 
influenced  unfavourably  by  any  impairment  of 
the  organic  functions  of  circulation  and  respir.v 
tion,  whether  independent  of  or  due  to  tko  cere 
bral  lesion. 


APOPLEXY,  CEREBRAL. 

Treatment. — The  treatment  of  cerebral  apo- 
plexy must  be  guided  by  the  indications  of  its 
cause.  Where  none  can  be  obtained,  it  should 
be  treated  as  cerebral  haemorrhage.  Still- 
ness is  the  most  important  condition.  The  patient 
should  be  moved  as  little  as  possible,  but  placed 
in  the  recumbent  posture  -with  the  head  slightly 
raised.  The  neck  should  be  freed  from  constriction. 
If  tho  extremi  ties  are  cold,  warmth  may  be  applied 
to  them ; and  cold  to  the  head  if  there  is  local 
heat  or  flushing.  Sinapisms  to  the  neck  and  ex- 
tremities sometimes  seem  to  hasten  the  return  of 
consciousness.  The  administration  of  stimulants 
should  be  regulated  by  the  state  of  the  heart.  In 
thrombosis  or  embolism  the  heart  should  be  kept 
up  to  the  normal  by  very  careful  administration 
of  alcohol,  ether,  or  ammonia.  In  haemorrhage 
it  may  be  allowed  to  fall  a little  below  the  nor- 
mal, but  indications  of  failing  power  should  be 
watched  for  and  counteracted.  Where  no  causal 
indication  exists,  the  latter  is  the  wiser  plan. 
Venesection  and  purgation  are  remedies  of  similar 
effect,  but  different  in  degree,  and  are  indicated 
by  high  arterial  tension  and  cephalic  conges- 
tion, shown  by  incompressibility  of  the  pulse 
and  flushing  of  the  face.  Venesection  is  useful 
where  the  heart  acts  strongly,  and  the  pulse  is 
full  as  well  as  incompressible.  Its  effect  is 
proportioned  to  the  rapidity  with  which  the 
blood  is  taken,  rather  than  to  the  quantity 
removed.  Purgatives  remove  serum  from  the 
blood,  and  lessen  the  amount  of  blood  within  the 
skull  by  causing  an  afflux  to  the  capacious  intestinal 
vessels.  The  best  purgative  is  croton  oil.  With 
a failing  heart  and  pale  surface  they  should  be 
avoided.  Diuretics  may  then  be  used  to  relieve 
the  vascular  tension.  As  the  apoplexy  clears, 
the  nature  of  the  case  becomes  evident,  and  the 
treatment  of  the  several  conditions  is  described 
elsewhere.  {See  Brain,  Haemorrhage  and  Soften- 
ing of.)  For  treatment  of  the  other  causes  of  the 
apoplectic  state,  see  Axcoholism,  Poisons,  and 
Uremia.  W.  E.  Gowers. 

APPENDIX  VEEMIPOEMIS,  Inflam- 
mation, Ulceration,  and  Perforation  of. 

Definition. — Inflammation  of  the  appendix 
vermiformis  from  lodgment  of  hardened,  fasces 
or  a foreign  body,  leading  to  ulceration,  frequently 
ending  in  perforation  of  the  coats ; to  inflamma- 
tion and  suppuration  of  adjacent  tissues  (peri- 
typhlitis) ; and  to  peritonitis,  local  or  general. 

^Etiology. — The  usual  cause  of  this  affection 
is  a foreign  body  {e.g.,  fruit-pips  or  -stones,  a 
small  bone,  shot,  pins,  &c.);  or  a faecal  concretion 
imprisoned  within  the  cavity  of  the  vermiform 
appendix.  Perforation  has  been  recorded  in  ty- 
phoid fever  and  tuberculous  disease. 

Anatomical  Characters.. — Before  perfora- 
tion takes  place  the  appendix  may  be  found 
distended  with  pus ; a foreign  body  or  concretion 
lodged  within  it ; and  the  mucous  membrane 
ulcerated.  The  concretion  or  concretions  vary 
in  size  from  a small  pea  to  a bean  ; are  usually 
brown  and  hard ; and  consist  of  layers  of  con- 
densed faeces,  secretions,  and  phosphates,  depo- 
sited around  a small  nucleus,  which  may  prove 
to  be  a seed  or  other  foreign  body,  or  a piece  of 
u tmsually  inspissated  faeces.  These  concretions 
greatly  resemble,  and  are  often  mistaken  for, 


APPENDIX  VERMIFORMIS.  76 
fruit-stones.  Ulceration  and  perforation  may  oc- 
cur at  any  part  of  the  appendix,  usually,  however, 
at  the  extremity  or  the  lower  third.  There  may 
be  a circumscribed  peritoneal  abscess ; or  the 
perforated  part  of  the  appendix  may  be  found  ad- 
herent to  the  surrounding  parts,  for  example  the 
caecum  or  the  abdominal  wall. 

Symptoms. — Pain,  generally  ill-defined,  in  the 
right  iliac  region,  may  be  the  only  symptom  to 
attract  attention,  and,  as  a rule,  it  is  not  until 
local  peritonitis  or  perityphlitis  is  set  up  that  we 
may  suspect  the  nature  of  the  disorder  ; the  ab- 
sence of  premonitory  symptoms,  of  the  character- 
istic tumour  of  typhlitis,  and  of  intestinal  ob- 
struction, excluding  inflammation  of  the  caecum. 
Often,  however,  the  course  from  the  first  is  latent, 
and  the  mischief  is  suddenly  revealed  by  perfor- 
ation into  the  peritoneum,  followed  by  general 
and  rapidly  fatal  peritonitis.  Adhesions  formed 
in  front  of  the  slowly  advancing  ulceration  may 
localise  the  consecutive  inflammation. 

The  substance  imprisoned  within  the  appendix 
may  be  dislodged  by  (a)  inflammation  and  sup- 
puration of  the  tissues  around  the  caecum  (peri- 
typhlitis, pericaecal  abscess); or  ( b ) the  appendix, 
at  the  point  of  perforation,  having  become  adhe- 
rent to  the  caecum,  a communication  is  estab- 
lished with  this  part. 

Diagnosis. — Inflammatory  affections  of  the 
caecum  and  of  the  appendix  can  rarely  be  clearly 
distinguished  from  each  other.  Inflammation  of 
the  appendix  is  apt  to  persist,  continuing  to  be 
acute  and  severe ; while  caecitis  may  be  subdued 
by  free  relief  of  the  bowels.  Caecitis  with  ulce- 
ration is  apt  to  follow  intestinal  inertia ; while 
the  alarmingly  acute  and  rapidly  fatal  symptoms 
of  inflammation  with  ulceration  and  perforation 
of  the  appendix  often  arise  during  perfect  health, 
Inflammation  of  the  cellular  tissue  surrounding 
the  caecum  (perityphlitis)  is  more  commonly  the 
result  of  ulcerative  inflammation  of  the  caecum 
than  of  the  appendix.  The  complete  investment 
of  the  appendix  by'peritoneum  contributes  to 
perforation  and  fatal  general  peritonitis. 

Prognosis.— General  peritonitis  from  sudden 
perforation  into  the  cavity  of  the  peritoneum 
is  the  great  danger,  recovery  from  which  is 
extremely  rare.  Inasmuch  as  this  may  occur  at 
any  time  during  the  course  of  ulcerative  inflam- 
mation of  the  appendix,  a guarded  opinion  should 
always  be  given  when  there  is  suspicion  of  the 
existence  of  this  affection.  Continued  uneasiness 
in  the  right  iliac  region  without  indications  of 
fecal  accumulation,  or  of  inflammation  in  or 
around  the  ctecum,  should  not  be  regarded 
lightly.  Though  this  serious  accident  is  less 
apt  to  occur  after  the  formation  of  adhesions 
around  the  advancing  ulceration,  we  must  not 
forget  that  well-marked  local  inflammation  of 
the  peritoneum,  or  of  the  cellular  tissue  around 
the  caecum,  does  not  always  prevent  it,  inas- 
much as  the  adhesion  which  may  thus  form  may 
not  be  sufficiently  strong  to  withstand  the  pres- 
sure of  pus  in  the  appendix. 

Treatment. — -The  patient  must  be  kept  at  rest 
in  bed,  hot  poultices  applied, and  an  uairritating 
fluid  diet  allowed.  Opiates,  for  the  purpose  of 
relieving  pain  and  subduing  the  peristaltic  con- 
traction of  the  intestines,  should  be  freely  and 
continuously  administered ; and  if  irritability  of 


70  APPENDIX  VERMIFORMI8. 
the  stomach  exist,  they  should  be  introduced  by 
enema  or  by  subcutaneous  injection.  Peritonitis 
or  other  complications  must  be  treated  as  they 
arise.  George  Oliver. 

APPETITE. — In  disease  th6  desire  for  food 
may  be  either  lessened  or  increased ; or  the  appe- 
tite may  be  per  verted , and  a longing  for  various 
substances  unfitted  for  or  incapable  of  digestion 
may  be  displayed. 

Loss  of  appetite  — Anorexia  accompanies 
almost  all  forms  of  acute  or  chronic  gastritis ; 
and  as  these  affections  constantly  coexist  'with 
other  diseases,  great  variety  as  regards  the  desire 
for  food  is  manifested  in  various  complaints. 
In  acute  gastritis  there  is  often  not  merely  a loss 
of  desire  for,  but  a positive  aversion  to  food, 
and  the  patient  resolutely  resists  any  attempt 
at  obliging  him  to  take  either  solid  or  liquid 
nourishment.  In  the  more  chronic  forms  of  gas- 
tritis the  distaste  for  food  may  be  only  slight ; 
in  some  cases  the  appetite  is  increased,  but  is 
quickly  satisfied  as  soon  as  a small  quantity  of 
food  is  taken.  In  chronic  ulcer  of  the  stomach 
the  appetite,  as  a rule,  remains  good,  and  the 
patient  is  only  prevented  from  indulging  it  by 
the  fear  of  the  pain  that  will  result  from  his  so 
doing.  Whenever  the  secreting  structure  of  the 
organ  is  extensively  diseased  the  appetite  fails. 
Thus,  in  atrophy  of  the  stomach  the  desire  for 
food  generally  lessens  along  with  the  diminish- 
ing strength  of  the  invalid.  In  cancer  of  the 
stomach  there  is  always  an  extensive  destruction 
of  the  glandular  structure,  and  loss  of  the  appe- 
tite is  a constant  and  prominent  symptom. 
It  must  be  remembered  that  a loss  of  appe- 
tite may  be  more  apparent  than  real,  The  phy- 
sician is  constantly  consulted  on  account  of  this 
Bymptom,  when  a little  inquiry  will  show  that 
!he  patient  is  really  digesting  as  much  as  his 
system  requires,  but  that  by  a habit  of  eating 
without  allowing  a proper  interval  between  his 
meals,  or  by  indulging  in  food  of  too  nutritious 
a nature,  or  in  an  undue  amount  of  alcoholic 
stimulants,  the  sensation  of  hunger  is  prevented. 

Increase  of  appetite — Bulimia  usually  occurs 
where  there  is  a necessity  for  an  increased  supply 
of  food.  Thus  it  is  common  after  all  febrile 
diseases,  where  the  stomach  has  been  long  inac- 
tive. Again,  in  diabetes,  where  a large  portion 
of  the  food  is  passed  off  in  the  form  of  sugar 
instead  of  being  converted  into  the  material 
required  to  keep  up  the  nutrition  of  the  body, 
there  is  an  unusually  large  appetite.  A craving 
sensation  is  a common  symptom  in  chronic  catar- 
rhal gastritis.  It  probably  arises  from  the  ir- 
ritation set  up  by  the  mucus  and  fermenting 
substances  long  retained  in  the  stomach,  and  is 
temporarily  relieved  by  eating.  The  best  treat- 
ment for  such  cases  is  to  give  alkalis  about  half 
an  hour  before  the  craving  usually  occurs,  at  the 
same  time  that  the  affection  of  the  mucous  mem- 
brane is  combated  by  appropriate  diet  and  reme- 
dies. In  some  persons  the  sensation  of  extreme 
hunger  appears  to  arise  from  an  irritable  condi- 
tion of  the  stomach,  by  which  the  food  is  passed 
into  the  duodenum  before  digestion  is  completed. 
The  sensation  is  mostly  complained  of  at  night, 
and  the  writer  has  found  it  a good  plan  to  let 
the  patient  have  some  beef-tea  or  meat  lozenges, 


ARCUS  SENILIS. 

for  example,  either  just  before  retiring  to  rest  or 
during  the  night.  In  children  a craving  for  food 
is  a frequent  symptom,  and  arises  either  from  the 
irritation  of  worms,  or  from  chronic  catarrh  of 
the  mucous  membrane  of  the  small  intestines. 

Perversion  of  appetite — Pica  is  most  common  in 
pregnant  or  hysterical  females.  Curious  articles, 
such  as  chalk,  cinders,  and  slate-pencil,  are  some- 
times swallowed.  In  the  insane  and  in  idiots 
articles  of  an  indigestible  nature  are  not  unfre- 
quently  introduced  into  the  stomach,  such  as 
string,  paper,  cocoa-nut  fibre,  &c. 

It  is  a matter  of  great  importance  that  all 
persons,  but  especially  dyspeptics,  should  ac- 
custom themselves  to  control  their  appetite. 
Whenever  a larger  amount  of  food  is  taken  than 
the  stomach  is  capable  of  digesting,  the  residue 
is  apt  to  ferment  and  thereby  to  produce  gastric 
catarrh.  This  is  more  especially  the  case  where 
the  digestive  powers  have  been  enfeebled  by 
previous  attacks  of  gastric  inflammation. 

S.  Fenwick. 

AFYRETICS.  See  Antipyretics. 

APTEEXIA  (h,  priv.,  and  irvpiaau,  I am 
feverish). — This  word  literally  means  absence 
of  fever : it  is  also  used  to  denote  the  interval 
between  paroxysms  of  intermittent  fever. 

ARACHNITIS.  — Inflammation  of  the 
arachnoid  membrane.  See  Meningitis. 

ARCACHON,  "West  coast  of  France.— 
Summer  and  autumn  resort.  Sheltered  by  pine 
woods.  Calm  in  winter.  See  Climate,  Treat- 
ment of  Disease  by. 

ARCUS  SENILIS  is  a crescentic  opacity  of 
the  cornea,  within  its  margin,  often  seen  in  old 
people.  Thearcus  is  usuallyfirst  observed  in  the 
upper  part,  and  soon  afterwards  a smaller  opaque 
crescent,  opposite  to  this,  appears  below.  In  the 
course  of  years  the  two  crescentic  marks  become 
slightly  wider  and  more  opaque,  their  points 
having  at  the  same  time  extended  much  more  con- 
siderably in  proportion,  so  that  an  annulus  or  ring 
is  formed.  It  probably  is  always  widest  and 
most  opaque  above,  and  wider  and  more  opaque 
below  than  at  the  sides.  An  arcus  is  grey  when  it 
first  appears,  but  it  may  attain  at  last  to  an 
ivory  whiteness.  It  is  especially  noteworthy 
that  arcus,  besides  being  regular  in  shape,  of  an 
evenly-graduated  degree  of  opacity,  and  well-de- 
fined at  its  inner  margin,  is  never  continuous  with 
the  opaque  sclerotic  external  to  it,  but  is  always 
separated  from  this  membrane  byTan  extremely 
narrow  line  of  demarcation  of  unaffected  corneal 
tissue,  which,  as  it  is  normally  almost  transparent 
here  at  its  margin,  is  the  more  conspicuous  by  force 
of  contrast  with  the  new  opacity.  At  the  same  time 
it  must  be  observed  that  the  well-defined  opacity 
is  most  opaque  in  the  centre  or  slightly  external 
to  the  centre  of  its  width,  at  any  part ; so  that, 
although  it  is  everywhere  well-defined,  it  is  shaded 
off  somewhat  abruptly  towards  its  outer  circum- 
ference, and  more  gradually  at  its  inner  margin. 
The  arcus  is  much  more  prone  to  increase  in  opa- 
city than  in  width.  It  rarely  attains  a width,  even 
at  the  upper  part  of  the  cornea,  of  more  than  ^-in. 
It  is  very  conspicuous  when  backed  by  a dark 
iris.  The  cornea  within  the  regular  boundaries 
of  the  arcus  senilis  remains  perfectly  transparent, 
and  vision  is  in  no  degree  impaired  by  it-  Wounds 


arcus  senilis. 

in  me  part  of  the  cornea  thus  affected  heal  well, 
and  no  surgeon  is  led  by  it  to  operate  in  any  other 
part  of  the  cornea,  rather  than  divide  the  arcus 
itself  in  the  part  in  which  the  corneal  opening  is 
made  in  almost  all  operations  on  the  eye. 

Pathology  and  ^Etiology. — Arcus  senilis  is 
essentially  a fatty  degeneration  of  the  proper 
substance  of  the  cornea.  It  is  not  fully  explained 
why  it  should  appear  just  where  it  does,  so  near 
to  the  source  of  nutrition  of  the  cornea;  the 
fatty  substitute  for  the  natural  tissues  seeming 
to  occupy  only  the  circumference,  and  first  and 
chiefly  under  the  upper  and  lower  lid,  where  also 
the  conjunctiva  and  sclerotic  overlap  the  cornea 
more  particularly — a situation  in  which  the  lids 
exercise  a certain  amount  of  pressure,  which  has 
been  regarded  by  Dr.  C.  J.  B.  Williams  as  the 
immediate  cause  of  the  degeneration. 

If  an  eye  suffers  from  chronic  deep-seated 
disease  an  arcus  will  develop  more  rapidly  ; as, 
for  example,  in  a case  of  old  recurrent  iritis  of 
one  eye  only,  in  which  there  was  a well-marked 
arcus,  while  in  the  other  there  was  hardly  a trace 
of  it.  An  anomalous  case  is  that  in  which  the 
upper  and  lower  arcus  are  opposite  as  usual,  but 
in  an  inclined  meridian.  Arcus  senilis  is  as 
capricious  in  its  appearance  as  other  senile 
changes ; it  is  no  clear  indication  of  the  age, 
certainly  not  of  the  number  of  years  of  life  of  a 
patient,  as  it  may  appear  even  in  youth,  and  may 
never  appear  even  in  extreme  old  age;  but  when 
it  occurs  before  forty  years  of  age  it  is  taken,  by 
some  life-insurance  medical  officers,  to  be  an 
indication  of  concomitant  fatty  disease  of  the 
heart  and  degeneration  of  the  arteries.  But 
fatty  heart  is  often  found  without  arcus,  and  ar- 
cus without  fatty  heart.  If,  together  with  other 
evidence  of  weakened  heart-power,  there  be  an 
arcus,  it  is  probable  that  fatty  degeneration  of 
the  heart  exists. 

Treatment. — Arcus  senilis  is  incurable,  and 
no  one  endeavours  expressly  to  cheek  its  increase, 
which,  no  doubt,  is  sometimes  possible,  as  the 
writer  is  acquainted  with  a case  in  which  the 
successful  treatment  of  Bright’s  disease  has,  for 
ten  ytars,  completely  arrested  its  advance. 

J.  F.  Streatfeild. 

ARDOR  {ardor,  heat). — A sensation  of  heat, 
burning,  or  scalding,  which  may  be  felt  along 
the  urethra  during  the  passage  of  urine  {Ardor 
Urines) ; or  in  connection  with  the  stomach 
{Ardor  Ventriculi). 

ARGYEIA  {Hpyvpos,  silver). — The  slate- 
coloured  stain  of  the  skin  produced  by  the  inter- 
nal use  of  the  salts  of  silver.  See  Pigmentary 
Affections. 

ARSENIC,  Poisoning  by. -Arsenic  is  classed 
as  a metallic  irritant  poison,  though  its  action 
is  by  no  means  limited  to  that  of  an  irritant.  It 
acts  specifically  on  the  gastro-intestinal  mucous 
membrane,  whatever  be  the  channel  bv  which 
the  poison  gains  access  to  the  system.  The  most 
usual  source  of  acute  arsenical  poisoning  is  the 
administration  of  white  arsenic  or  arsenious  acid ; 
but  the  sulphides,  various  arsenides,  and  impure 
commercial  articles,  such  as  dyes,  wall-papers, 
and  pigments,  may  be  fertile  sources  of  arsenical 
poisoning.  Poisoning  by  arsenic,  may  be  either 
acute  or  chronic. 


ARSENIC,  POISONING  BY.  77 

A.  Acute  Arsenical  Poisoning. — This  is  the 
usual  form  of  poisoning  ensuing  on  the  nefarious 
administration  of  any  preparation  of  arsenic,  but 
usually  the  oxide  {arsenious  acid)  is  employed. 

Symptoms. — The  symptoms  do  not,  as  in  the 
case  of  corrosive  poisoning,  come  on  immediately 
after  the  administration  of  the  poison.  There  is 
most  commonly  an  interval  of  half  an  heur  or  an 
hour  between  the  swallowing  of  the  agent  and 
the  onset  of  prominent  symptoms.  The  quantity 
of  the  noxious  agent,  and  its  state  as  regards 
solubility,  have  also  an  obvious  relation  to  the 
commencement  of  symptoms.  Most  commonly, 
after  a sense  of  faintness  and  depression,  intense 
burning  pain  is  felt  in  the  epigastric  region, 
accompanied  by  tenderness  on  pressure.  Nausea 
and  vomiting  quickly  supervene,  increased  by 
every  act  of  swallowing.  Unlike  what  occurs  in 
an  ordinary  bilious  attack,  with  which  arsenical 
poisoning  may  be  at  first  confounded,  the  pain 
and  sickness  are  not  relieved  by  the  act  of 
vomiting.  The  vomited  matters  are  extremely 
varied,  and  present  no  characteristic  appearances. 
At  first  they  usually  consist  of  the  ordinary  con- 
tents of  the  stomach,  but  at  a later  stage  are 
largely  charged  with  bile  which  has  regurgitated 
into  the  stomach  in  consequence  of  the  violence 
of  prolonged  emesis ; and  they  may  be  tinged 
with  blood.  Ordinarily  vomiting  is  speedily 
followed  by  violent  purging,  and  great  straining 
at  stool,  the  motions  being  often  streaked  with 
blood.  Purging  may,  however,  be  entirely  ab- 
sent. Other  prominent  symptoms  are  great 
thirst,  a feeble  irregular  pulse,  and  cold  clammy 
skin.  The  patient  as  a rule  dies  within  eighteen 
to  seventy-two  hours  in  a state  of  collapse  ; but 
tetanic  convulsions  are  not  uncommon,  and  even 
coma  and  paralysis  may  close  the  scene. 

Diagnosis. — From  an  ordinary  bilious  attack, 
induced  by  improper  diet  or  by  decomposing  food, 
arsenical  poisoning  is  diagnosed  by  the  persist- 
ence of  the  symptoms  after  the  removal  of  ths 
apparent  cause ; and  not  infrequently  by  the 
symptoms  remitting  and  again  supervening  on 
the  administration  of  food  or  drink  of  a parti- 
cular kind,  or  given  by  a particular  hand.  Prom 
choleraic  diarrhoea  it  is  distinguished  by  the 
sudden  onset  of  symptoms,  thirty  to  sixty  minutes 
after  food  or  drink  has  been  taken ; by  the  absence 
of  rice-water  stools,  or  of  lividity  of  the  skin  ; 
and  by  the  symptoms  not  yielding  to  treatment. 
Moreover,  in  poisoning  by  arsenic  there  is  usually 
greater  tenderness  over  the  epigastrium ; the 
diarrhoea  is  less  passive,  and  accompanied  with 
more  tenesmus  than  in  choleraic  diarrhoea  ; the 
stools  are  more  often  bloody' ; and  nervous 
symptoms  may  be  more  pronounced.  The  diag- 
nosis is,  however,  often  very  difficult,  except 
when  aided  by  a chemical  analysis  of  the  matters 
ejected  from  the  stomach  or  of  the  excreta 
which  should  always  be  made  in  doubtful  cases. 

Prognosis. — This  must  always  be  uncertain, 
since  it  is  rarely  possible  to  ascertain  the  quan- 
tity taken,  or  to  ensure  its  entire  evacuation 
from  the  stomach. 

Treatment. — Emetics,  diluents,  and  demul- 
cents are  the  appropriate  remedies.  The  stomach- 
pump  may  also  be  usefully  employed.  In  ad- 
ministering emetics,  tartar  emetic  should  be 
avoided,  as  it  increases  the  depression,  and  its 


!8  ARSENIC,  POISONING  BY. 
presence  complicates  a chemical  analysis.  More- 
over, tartar  emetic  frequently  contains  traces  of 
arsenic,  and,  in  the  event  of  an  analysis  being 
made,  an  unfounded  suspicion  may  be  raised. 
No  confidence  can  be  placed  in  the  so-called 
antidotes,  ferric  hydrate  and  magnesia,  except 
where  a solution  of  arsenic  has  been  taken. 

B.  Chronic  Arsenical  Poisoning.  — This 
form  of  poisoning  is  not  uncommon,  and  is, 
unlike  the  acute  form,  generally  accidental. 
The  inhalation  of  arsenical  vapours  in  factories, 
or  of  arsenical  dust,  as  from  green  and  other 
wall-papers,  and  in  the  process  of  manufacturing 
artificial  flowers,  is  a common  source  of  chronic 
arsenical  poisoning. 

Those  who  are  chiefly  exposed  to  this  form  of 
poisoning  are  persons  employed  in  the  manufac- 
ture of  pigments,  especially  green  pigments  ; 
paperhangers  and  decorators  ; artificial-flower 
manufacturers;  milliners;  persons  exposed  to 
the  fumes  of  heated  metals,  particularly  zinc 
and  brass ; manufacturers  of  dyes  ; and  leather- 
dressers.  In  the  process  of  depilating  sheep-skins, 
previous  to  the  tanning  or  the  tawing  process, 
a mixture  of  lime  and  orpiment  (sulphide  of 
arsenic)  is  used ; and  serious  ulceration  of  the 
hands,  scrotum,  nose,  and  cheeks  not  infrequently 
results.  Persons  living  in  rooms  the  walls  of 
which  are  covered  with  arsenical  paper,  especi- 
ally bright-green  papers  containing  arsenite  of 
copper,  are  liable  to  suffer  from  chronic  arseni- 
cal poisoning.  It  is  uncertain  whether  this  is 
entirely  caused  by  the  mechanical  transfer  of 
pigmentary  dust  to  the  air-passages,  or  is  partly 
due  to  volatilisation  of  the  arsenic,  probably  in 
the  form  of  arseniurctted  hydrogen.  Many  brown 
wall-papers  also  contain  arsenic,  and  arsenious 
acid  is  sometimes  added  to  the  size  ; such  papers 
have  been  known  to  produce  the  specific  symp- 
toms of  arsenical  poisoning. 

That  some  persons  can  take  arsenious  acid 
internally  with  impunity  in  relatively  large  doses 
(arsenic-eating)  is  now  a well-established  fact. 

Symptoms. — The  first  symptoms  of  chronic 
arsenical  poisoning  are  usually  loss  of  appetite, 
prsecordial  pains,  irritability  of  the  bowels,  and 
occasionally  headache.  Suffusion  of  the  eyes, 
a peculiar  and  characteristic  appearance  of 
the  conjunctiva,  often  amounting  to  actual 
conjunctivitis,  and  intolerance  of  light  are  early 
manifested.  The  muscular  power  of  the  limbs  is 
impaired  pretty  constantly,  and  actual  paralysis 
extending  upwards  from  the  lower  extremities  is 
occasionally  observed.  A characteristic  vesicular 
eruption  on  the  skin  ( eczema  arsenicale)  is  fre- 
quent, as  well  as  irritation  of  the  skin,  especially 
over  the  neck,  scalp,  hands,  and  armpits.  Males 
who  handle  arsenical  preparations  are  liable  to 
ulcerations  of  the  scrotum  and  penis,  obviously 
due  to  a mechanical  transference  of  the  poison  to 
the  genitals  when  these  are  touched.  If  the  source 
of  the  disease  be  not  removed,  progressive  emacia- 
tion, exfoliation  of  the  cuticle,  and  nervous  pros- 
tration supervene;  and  convulsions  may  precede 
the  fatal  termination.  The  effects  of  green 
arsenical  pigments  are  sometimes  manifested  by 
bleeding  from  the  nose. 

Diagnosis. — When  a patient  suffers  more  or 
less  from  the  symptoms  above  described,  and  is 
als  i known  to  be  exposed  to  any  of  the  sources 


ARTERIES,  DISEASES  OF. 

of  danger  from  arsenical  poisoning  enumerated 
under  the  setiology,  the  diagnosis  is  not  difficult. 

Treatment. — The  source  of  poisoning  should 
invariably  be  removed.  It  is  found  that  those  who 
suffer  from  working  in  arsenic  make  no  progress 
towards  recovery  until  they  are  removed  from 
contact  with  the  poison.  Wall-papers  which 
contain  arsenic,  and  are  suspected  to  be  the 
cause  of  symptoms,  should  be  taken  away. 
Quinine,  or  other  tonics,  iron,  and  attention  to 
the  digestive  organs  will  be  needed.  Removal 
to  fresh  country  air  is  often  productive  of  marked 
benefit.  Soothing  lotions  to  the  skin,  and  careful 
attention  to  eroding  ulcers,  especially  of  the  cheek, 
may  be  necessary.  Shampooing  and  warm  baths 
form  the  best  treatment  for  paralytic  lesions. 

Morbid  Appearances. — These  are  the  same 
by  whatever  channel  the  poison  has  gained 
access  to  the  system.  As  a rule  there  is  marked 
inflammation  of  the  stomach  and  duodenum, 
usually  of  the  small  and  large  intestines  also  ; 
but  not  uncommonly  the  inflammation  is  limited 
to  the  stomach,  duodenum,  and  rectum,  the 
intervening  alimentary  tract  having  escaped.  If 
the  poison  has  been  administered  in  a solid  form, 
white  patches  of  the  arsenical  compound  may  be 
foundimbeddedinthickbloody  mucus  andinflam- 
matory  exudation.  Portions  of  the  white  arsenic 
are  also  sometimes  converted  by  the  sulphuretted 
hydrogen  evolved  during  decomposition  into  the 
yellow  sulphide.  Ulceration  of  the  stomach  is 
rare,  and  perforation  almost  unknown.  An  ecchy- 
mosed  condition  of  the  heart  is  often  observed  ; 
and  fatty  degeneration  of  the  liver,  as  in  poison- 
ing by  phosphorus,  has  been  described. 

T.  Stevenson. 

ARTERIES,  Diseases  of. — It  is  important 
to  keep  in  mind  the  following  anatomical  facts 
in  studying  the  morbid  processes  to  which 
arteries  are  subject: — In  immediate  contact  with 
the  blood-stream  in  arteries  lies  the  endothelium 
— a layer  of  flattened  cells ; outside  this  is  the 
tunica  intima,  composed  of  elastic  tissue  in 
longitudinal  arrangement : together  the  endothe- 
lium and  tunica  intima  constitute  the  internal 
coat  of  the  older  writers.  Still  more  external  we 
find  the  middle  coat , made  up  of  muscular  fibre 
arranged  transversely,  in  the  larger  arteries  mixed 
with  elastic  tissue ; and,  most  external  of  all,  the 
external  coat,  consisting  of  longitudinally  fibril 
lated  connective  tissue. 

1.  Acute  Arteritis,  affecting  a very  limited 
portion  of  a vessel,  and  leading  to  ulceration, 
occasionally  occurs.  In  some  cases  this  lias 
arisen  from  the  irritation  caused  by  an  embolus, 
which,  becoming  detached  from  a cardiac  valve, 
has  blocked  a distant  artery’ ; and  Dr.  Moxon  has 
specially  drawn  attention  to  its  occurrence  in  the 
aorta,  when  the  ascending  portion  of  the  vessel  has 
been  exposed  to  the  impact  of  a hard,  freely  movi  ng 
vegetation  on  one  of  the  segments  of  the  aortic 
valve.  Dr.  Moxon  has  also  described,  under 
the  designation  inflammatory  mollif  ies,  the  occur- 
rence of  softening  and  swelling  of  the  arterial 
tunics  in  circumscribed  spots ; which  become 
flabby  and  inelastic,  and  ultimately  bulge  out- 
wards and  form  aneurisms.  He  believes  that  this 
condition  depends  on  a peculiar  general  state,  and 
is  the  great  cause  of  aneurism  in  young,  hard- 


ARTERIES,  DISEASES  OF.  79 


working  men.  Except  in  these  circumscribed 
inflammatory  lesions,  we  do  not  meet  with  any 
condition  of  the  arterial  tunics  to  which  the  de- 
signation acute  arteritis  can  be  applied.  Such  a 
change  has,  indeed,  been  described,  and  the 
writer  has  seen  the  lining  membrano  of  the 
ascending  and  transverse  portions  of  the  aorta 
of  a blight  vermilion  hue,  strongly  suggestive  of 
acute  inflammatory  change ; but  the  best  ob- 
servers are  now  agreed  in  believing  that  this 
appearance  arises  from  staining  by  haematin. 

2.  Chronic  Arteritis  has  been  described  as 
pursuing  a course  different  from  the  endarteritis 
deformans,  which  will  immediately  be  noticed  ; 
and  as  causing  thickening  of  the  coats  of  the 
vessels,  narrowing  of  their  calibre,  and  absence 
of  pulsation  during  life.  As  such,  chronic  ar- 
teritis appears  to  be  a disease  of  extreme  rarity. 
But,  on  the  other  hand,  if  it  be  considered  as 
the  first  stage  of  atheromatous  disease,  it  may 
be  said  to  be  of  frequent  occurrence. 

3.  Periarteritis  is  the  term  applied  by 
Charcot  and  Bouchard  to  the  morbid  change 
which,  in  their  opinion,  eventuates  in  cerebral 
haemorrhage.  According  to  these  physicians, 
cerebral  haemorrhage  is  not  usually  due  to 
itheromatous  decay  of  the  vessels  of  the  brain  ; 
but,  in  the  vast  majority  of  cases,  to  the  rupture 
if  miliary  aneurisms,  which  in  their  turn  have 
been  produced  by  a morbid  process  beginning  in 
the  perivascular  sheath  surrounding  the  cerebral 
vessels  ; and  which,  proceeding  from  without  in- 
wards, ultimately  involves  all  the  coats  of  the 
vessels  {see  Brain,  Haemorrhage  into). 

4.  Atheromatous  Disease,  the  Endarteritis 
deformans  of  Virchow,  is  the  arterial  disease 
which  is  most  frequently  met  with,  and  the  one 
whose  consequences  are  most  serious.  It  presents 
three  tolerably  well-defined  stages,  (n)  In  the 
first  stage  we  notice,  when  the  vessel  is  slit  open, 
greyish  patches,  by  which  the  lining  membrane  is 
irregularly  thickened ; these  patches  seem  to  lie  on 
the  surface  of  the  membrane,  but  this  appearance 
is  deceptive;  the  endothelium  lies  between  them 
and  the  blood-stream,  and  is,  at  least  at  the  begin- 
ning of  the  morbid  process,  unaffected.  The  ma- 
terial of  which  the  patches  are  formed  is  really 
situated  between  the  tunica  intima  and  tunica 
media  ; it  is  semi-cartilaginous  in  consistence,  and 
is  formed  by  an  abnormally  rapid  multiplication 
of  the  deeper  cells  of  the  tunica  intima, — the  new 
growth  pushing  up  this  tunic  with  its  super-im- 
posed endothelium,  and  so  causing  a bulging  into 
the  interior  of  the  vessel.  The  process  is  of  the 
nature  of  an  inflammatory  change ; that  is,  it  con- 
sists in  the  proliferation  of  cellular  elements,  in 
consequence  of  some  influence  which  has  excited 
them  to  unnatural  growth.  (A)  In  the  second 
stage  the  cellular  elements  of  which  the  new 
growth  is  composed  undergo  a process  of  fatty 
degeneration ; and  in  consequence  it  becomes 
yellowish  in  colour  and  pasty  in  consistence : it 
was  the  paste-like  appearance  of  the  mass  in  this 
stage  which  originally  gained  for  the  process  the 
designation  Atheroma  (atbjpi)  = meal).  It  not  un- 
frequently  happens  that  the  whole  of  the  internal 
coat  with  its  endothelium  is  involved  in  the 
softening,  and  gives  way  under  the  pressure  of 
the  blood,  leaving  an  excavation,  the  floor  of 
which  is  formed  by  the  middle  and  external 


coats  of  the  artery,  (c)  In  other  instances,  how- 
ever, the  pasty  mass,  instead  of  being  washed 
away,  becomes  the  seat  of  calcific  deposit.  This 
is  the  third  stage  in  the  process.  The  appearance 
of  a vessel  in  which  atheromatous  disease  has 
reached  this  stage  is  very  striking : plates  which 
present  to  the  naked  eye  the  appearance,  but  do 
not  show  the  minute  structure  of  bone,  are 
observed  at  intervals  in  the  walls  of  the  ves- 
sel, and  their  sharp  spicula  project  into  its 
interior ; in  the  aorta  it  is  not  uncommon  to  find 
such  plates  an  inch  long  and  half  an  inch  broad, 
and  in  the  smaller  arteries  the  calcific  matter 
sometimes  forms  a ring  round  the  vessel.  In 
the  latter  the  calcareous  particles  appear  to  be 
deposited  in  the  patch  while  it  is  still  firm,  so 
that  the  second  stage  of  the  process  is  wanting. 

Atheromatous  disease  sometimes  invades  both 
the  aorta  and  the  small  vessels,  but  the  aorta 
may  be  extensively  diseased  and  the  small 
arteries  unaffected;  or,  on  the  other  hand,  the 
cerebral,  temporal,  and  coronary  arteries  may  be 
the  seat  of  calcific  change  while  the  great  vessels 
are  healthy ; occasionally  the  disease  is  limited  tc 
afew  vessels.  Next  to  the  aorta,  the  cerebral,  coron- 
ary, and  splenic  vessels,  and  the  arteries  of  the  lower 
extremities,  are  prone  to  this  form  of  arteritis. 

Effects. — The  dangers  to  which  an  athero- 
matous state  of  vessels  exposes  the  person  in 
whom  it  exists  are  varied.  The  stream  of  blood 
is  retarded  by  the  projection  of  the  new  growth 
into  the  vessel,  and  still  more  by  the  destruction 
of  the  elasticity  of  its  coats  ; and  hence  ensues  a 
failure  in  the  nutrition  of  the  organ  which  de- 
pends for  its  supply  of  blood  on  the  diseased 
vessel ; — this  is  said  to  be  a cause  of  cerebral 
softening.  When  the  paste-like  mass  is  washed 
away  it  sometimes  happens  that  the  blood  in- 
sinuates itself  between  the  coats  of  the  vessel, 
producing  a dissecting  aneurism  ; or  the  portion 
of  the  vessel,  which  has  been  weakened  by  the 
removal  of  the  internal  coat,  yields  to  the  pressure 
of  the  current,  and  a sacculated  aneurism  is 
originated;  sometimes  the  diseased  vessel  bursts. 
Cerebral  vessels,  probably  on  account  of  the 
thinness  of  their  walls,  are  specially  liable  to 
rupture  when  they  are  the  seat  of  atheromatous 
change ; and  occasionally  a diseased  coronary 
artery  has  given  way,  filling  the  pericardium 
with  blood.  Arteries  have  been  completely 
occluded  by  the  deposition  of  fibrin  on  the 
spiculated  edges  of  calcareous  plates : this  is 
one  of  the  causes  of  senile  gangrene ; and  embolic 
plugging  of  distant  vessels  at  times  results  from 
the  detachment  of  such  fibrinous  clots,  and 
the  washing  away  of  atheromatous  debris. 
Rigidity  of  the  larger  arteries  from  atheromatous 
change  is  likewise  one  of  the  most  frequent 
causes  of  hypertrophy  of  the  left  ventricle  of 
the  heart,  on  which  increased  work  is  imposed 
iu  consequence  of  the  destruction  of  the  elasti- 
city of  the  vessels.  Anasarca  has  not,  so  far  as 
the  writer  is  aware,  been  mentioned  by  any 
author  among  the  consequences  of  diseased  ar- 
teries ; but  some  cases  which  have  come  under  his 
observation  have  led  him  to  the  conclusion  that 
persistent  anasarca,  especially  of  the  lower  ex- 
tremities in  elderly  men,  is  sometimes  mainly 
due  to  a diseased  condition  of  the  arterial  tunics. 
In  the  cases  which  he  has  observed  there  ■was 


ARTERIES,  DISEASES  OF. 


SO 

likewise  present  dilatation  with  hypertrophy 
and  commencing  fatty  change  of  the  left  ventri- 
cle, itself  a consequence  of  the  arterial  disease  ; 
but  this  seemed  insufficient  to  account  for  the 
persistent  cedema  of  the  lower  extremities. 

Etiology. — The  cause  of  endarteritis  de- 
formans is  now  generally  admitted  to  be  over- 
strain of  the  vessel.  It  was  formerly  thought  that 
syphilitic  impregnation  of  the  system  was  a power- 
ful favouring  condition ; but  this  opinion  rested 
chic-fly  on  observations  made  among  soldiers,  who, 
in  addition  to  the  syphilitic  taint,  were  subject  to 
other  influences  now  known  to  be  adequate  in 
themselves  to  develop  the  disease:  and  the  writer 
has  himself  seen  the  most  extensive  atheromatous 
disease  in  men  in  whom  there  was  no  trace  of  the 
ey^philitic  taint.  Intemperate  habits  and  gout 
appear  to  be  powerfully  predisposing  causes  ; they 
probably  render  the  blood  impure,  and  its  pas- 
sage through  the  capillary  vessels  being  thereby 
retarded,  the  tension  of  the  arterial  system  is 
increased.  Besides  violent  exertion,  which  im- 
poses a strain  on  the  entire  arterial  tree,  there  are 
other  influences  which  act  upon  certain  vessels. 
Thus  the  renal  arteries  are  kept  over-full  in  the 
cirrhotic  form  of  Bright’s  disease,  owing  to  the 
destruction  of  the  capillary  tufts,  and  hence  athe- 
roma of  these  vessels  is  almost  constantly  present 
in  that  form  of  renal  mischief.  The  writer  has 
on  two  occasions  found  extensive  calcareous 
formations  in  the  cerebral  vessels  of  persons  in 
whom  cerebral  degeneration  had  followed  ex- 
cessive anxiety  and  mental  effort.  The  pul- 
monary artery  is  very  rarely  i nvaded  by  atheroma ; 
and  only  in  cases  in  which  it  has  been  kept  in  a 
state  of  tension  by  hypertrophy  of  the  right 
ventricle  or  disease  of  the  mitral  orifice. 

Diagnosis. — The  diagnosis  of  atheromatous 
inflammation  of  the  aorta  will  be  discussed  in  a 
separate  article.  The  existence  of  the  disease  in 
the  arteries  of  particular  organs  can  only  be  a 
matter  of  reasonable  presumption  when  the  patient 
is  past  middle  life;  when  the  ascertained  causes 
of  atheroma  have  been  in  operation ; when 
symptoms  of  impaired  nutrition  of  the  organ  are 
present ; and  when  the  organ  (the  brain  or  heart) 
is  one  the  arteries  of  which  are  known  to  be 
prone  to  the  disease.  Calcification  of  the  super- 
ficial arteries  renders  these  vessels  rigid  and 
tortuous  ; the  temporals  when  so  affected  attract 
the  eye  by  their  prominence,  and  may  be  felt 
hard  and  rigid  beneath  the  finger ; the  brachial 
may  equally  be  made  the  subject  of  examination  ; 
and,  although  the  presence  or  absence  of  athero- 
matous change  in  such  superficial  vessels  does 
not  necessarily  prove  that  the  other  arteries  of  the 
body  are  in  a similar  condition,  it  renders  it  more 
than  probable  that  they  are.  Those  who  are 
not  familiar  with  the  resisting  feel  of  the  radial 
artery,  when  it  is  the  seat  of  the  change  now 
under  consideration,  are  liable  to  form  a very 
erroneous  estimate  of  the  strength  of  the  pulse  : 
this  may  convey  to  the  inexperienced  finger  an 
impression  of  a force  which  it  does  not  possess. 
The  error  also  is  sometimes  committed  of  inferring 
the  existence  of  aortic  regurgitation  in  these 
cases  in  consequence  of  the  tortuous  course  and 
visible  pulsation  of  the  superficial  vessels ; but 
they  do  not  collapse  suddenly  under  the  finger, 
as  do  the  vessels  during  the  receding  wave  in  I 


aortic  patency.  The  sphygmographic  tracing, 
moreover,  is  essentially  different:  in  atheromatous 
disease  of  the  artery  the  upstroke  is  vertical,  and 
the  summit  of  the  tracing  extended.  The 
existence  of  such  evidences  of  vascular  mischief 
affords  a fair  subject  for  consideration  to  those 
who  are  called  upon  to  form  an  opinion  as  to  the 
eligibility  of  a life  for  assurance. 

Treatment. — The  treatment  of  endarteritis 
deformans  is  mainly  preventive.  It  consists  in 
the  avoidance  of  all  those  influences  to  which 
we  have  adverted  as  causes  of  the  disease, 
namely,  indulgence  in  alcohol ; causes  originating 
a gouty  state  of  the  blood ; excessive  muscular 
efforts,  especially  in  constrained  positions  ; pos- 
tures which  involve  the  long-continued  con- 
traction of  muscles  which  surround  arteries  ; and, 
as  far  as  the  brain  and  heart  are  concerned,  all 
those  states  which  favour  overfulness  of  their 
respective  arteries : — in  the  case  of  the  brain, 
excessive  mental  application,  deficient  sleep, 
and,  the  writer  believes,  prolonged  periods  of 
sexual  excitement;  in  the  case  of  the  heart,  inter 
alia , efforts  which  involve  holding  the  breath, 
thus  leading  to  distension  of  its  right  cavities, 
and  imposing  an  obstacle  to  the  return  of  blood 
from  its  walls. 

5.  Fatty  Degeneration,  unconnected  with 
the  atheromatous  process,  is  sometimes,  though 
rarely,  found  to  affect  arteries.  Circumscribed 
opaque  and  velvety  spots  appear  on  the  surface 
of  the  intima,  and  erosion  ultimately  occurs. 
Once  this  has  taken  place,  the  muscular  coat, 
unable  to  bear  the  pressure  of  the  blood-stream, 
fissures  transversely ; and  the  blood  either  rup- 
tures the  external  coat,  or,  insinuating  itself  be- 
tween the  middle  and  external  coat,  produces  a 
dissecting  aneurism.  This  change  has  been 
found  in  the  arteries  of  persons  who  seemed 
otherwise  quite  healthy  ; it  is  ‘ a morbid  change 
which  is  simply  degenerative  from  the  first,  and 
of  whose  immediate  cause  we  know  nothing’ 
(Rindfleisch).  Fatty  degeneration  of  the  external 
coat  of  the  smallest  arteries  has  also  been  no- 
ticed : it  appears  to  be  a senile  change,  and  to 
play  a part  in  the  production  of  cardiac  and 
cerebral  degeneration. 

6.  Calcification  of  the  arterhd  tunics  also 
occurs  unconnected  with  endarteritis,  but  more 
rarely  than  fatty  degeneration.  "When  this  is 
the  case,  it  is  the  middle  coat  of  the  smaller 
vessels  that  is  the  seat  of  the  deposit,  which 
consists  of  carbonate  and  phosphate  of  lime  and 
magnesia.  The  process  is  usually  limited  to  the 
vessels  in  which  muscular  fibre  is  abundant ; 
but  these  it  may  affect  extensively,  the  super- 
ficial vessels  and  the  arteries  of  tho  brain  and 
of  the  extremities  being  the  favourite  seat : it  is 
eminently  a senile  change. 

7.  Gummatous  Disease  of  the  cerebral  arteries 
in  syphilitic  patients  has  been  described  by  Dr. 
Hughlings  Jackson,  Dr.  Wilks,  and  others.  The 
vessels  present  nodose  swellings,  and  are  thick- 
ened sometimes  to  three  times  their  normal  size 
by  gummatous  material  infiltrating  the  outer 
coat ; the  calibre  of  the  vessels  is  thereby  nar- 
rowed, the  formation  of  thrombi  favoured,  and 
cerebral  softening  produced.  ‘ A random  suc- 
cession of  nervous  symptoms,’  to  use  the  words 
of  Dr.  Jackson,  affords  strong  grounds  for  sus- 


ARTERIES,  DISEASES  OF. 

pecting  syphilitic  disease  within  the  cranium  ; 
and  the  writer  has  himself  seen  three  cases  in 
which  such  symptoms  disappeared  under  the  use 
of  perchloride  of  mercury  and  iodide  of  potassium, 
and  in  which  it  seemed  to  him  that  the  supposi- 
tion of  arterial  disease  was  much  more  probable 
than  that  of  any  other  form  of  intracranial 
syphilis. 

8.  Albuminoid  Disease,  when  it  attacks  the 
spleen  or  kidneys,  appears  first  in  the  walls  of 
tlie  small  arteries  of  these  organs,  but  is  not 
found  in  the  larger  arteries  of  the  body. 

9.  Contraction  and  final  impermeability  of 
an  artery  from  atheromatous  calcification,  from 
the  accumulation  of  fibrine  in  its  rough  inner 
surface,  from  pressure,  or  from  other  causes, 
occasionally  occurs,  leading  to  gangrene  of  the 
extremity  which  it  supplied. 

10.  Dilatation  of  arteries  is  in  the  ma- 
jority of  cases  due  to  previous  disease  of  their 
coats  ; but  sometimes  in  the  aged  the  arteries  are 
found  dilated  without  any  degeneration  of  their 
tunics  being  present, — a state  of  affairs  which 
Rindfleisch  suggests  may  depend  on  atony  of 
the  muscular  coat,  and  in  some  cases  may  pos- 
sibly be  connected  with  deficient  innervation. 

11.  Aneurism  receives  full  consideration  in 
a separate  article.  Here  it  is  merely  necessary 
to  point  out  the  ways  in  which  atheromatous 
inflammation  and  the  other  morbid  processes 
which  have  been  described  contribute  to  the  pro- 
duction of  dilatation  and  aneurism.  In  some 
cases  the  course  of  events  consists  in  the  wash- 
ing away  of  the  diseased  patch  of  the  intima  ; 
when  the  middle  coat  either  dilates,  or,  by 
separation  of  its  muscular  bundles,  undergoes 
rupture,  and  the  external  coat  yields  before  the 
pressure  of  the  blood-stream.  In  other  cases 
the  dilatation  occurs,  not  at  the  point  where 
the  endarteritis  has  invaded  the  vessel,  but 
nearer  to  the  heart.  At  the  affected  point  there 
is  narrowing  of  the  canal  of  the  vessel,  and  loss 
of  elasticity  in  its  coats ; and  as  a consequence 
we  have  slowing  of  the  circulation  and  deficiency 
in  the  supply  of  blood  beyond,  and  increased  ar- 
terial tension  on  the  proximal  side  of  the  affected 
spot.  The  effect  of  this  tension  is  more  serious 
than  would  at  first  sight  appear  ; in  health  the 
blood,  propelled  by  each  ventricular  sysf  ole,  enters 
contracted  vessels,  which,  yielding  before  it,  are 
uninjured  by  its  sudden  impact;  but  a vessel  in 
a state  of  tension  is  exposed  to  the  full  violence 
of  the  column  of  blood  discharged  by  the  heart, 
and  must  gradually  dilate  before  it. 

12.  Arterial  Disease  in  Insanity. — Accord- 
ing to  Dr.  J.  Batty  Take,  and  other  physicians 
who  have  specially  investigated  the  morbid 
changes  in  the  brains  of  the  insane,  arterial  dis- 
ease is  almost  invariably  present.  It  consists 
in  such  alterations  as  would  result  from  obstruc- 
tion in  the  ultimate  ramifications  of  the  vessels  ; 
— thickening  of  the  proper  coats  of  the  arteries, 
and  of  the  sheath  of  connective  tissue  which 
surrounds  the.  cerebral  vessels  ; the  deposition  of 
fine  molecular  matter  and  crystals  of  hEematoidin 
between  the  adventitia  and  the  sheath  ; and  ex- 
treme tortuosity  of  the  vessels. 

13.  Arterio-Capillary  Fibrosis  is  the  term 
applied  by  Sir  William  Gull  and  Dr.  Sutton  to 
the  hypertrophy  of  the  walls  of  the  small  arteries 

6 


ARTIFICIAL  RESPIRATION.  81 
found  in  the  subjects  of  the  cirrhotic  form  of 
Bright’s  disease.  It  is  admitted  by  all  observers 
of  repute  that  the  walls  of  tho  blood-vessels  of 
the  kidney  are  greatly  thickened  in  this  malady  : 
but  it  is  by  no  means  so  universally  admitted 
that  the  small  arteries  throughout  the  whole 
body  are  in  all  such  cases  similarly  hvpei'tro- 
phied.  That  they  are  hypertrophied  in  a certain 
proportion  of  the  cases  admits  of  no  doubt ; bui 
the  nature  of  the  thickening  remains  to  be  do 
cidod.  Dr.  George  Johnson,  who  early  called 
attention  to  this  condition,  considers  that  there 
is  present  an  hypertrophy  of  all  tho  tunics  of  the 
small  arteries,  especially  of  the  muscular  coat- 
a consequence  of  the  obstruction  which  impure 
blood  invariably  meets  within  the  capillaries.  Sir 
William  Gull  and  Dr.  Sutton,  on  the  other  hand, 
assert  that  the  thickening  is  due  to  a fibroid 
growth,  especially  seated  in  the  external  coat  of 
the  vessel;  and  they  believe  that  the  coexisting 
disease  of  the  kidney  is  not  the  cause  of  the 
arterial  change,  but  that  both  are  parts  of  a 
general  diseased  process.  James  Little. 

ARTERIES,  Examination  of.  See  Phy- 
sical Examination  ; and  Pulse. 

ARTHRALGIA  ( apdpov , a joint ; and  &A .70s, 
pain). — Pain  in  a joint.  Tho  term  is  more  par- 
ticularly applied  to  articular  pain  in  the  absence 
of  objective  disease. 

ARTHRITIS  (cipSpou,  a joint). — A term 
generically  used  to  signify  any  disease  whatever 
involving  a joint,  but  more  correctly  confined  to 
articular  inflammation.  It  is  also  employed  to 
designate  inflammation  of  all  the  structures 
forming  a joint,  as  distinguished  from  mere  syno- 
vitis. See  Joints,  Diseases  of. 

ARTHBODYNIA  ( ap9pou , a joint;  and 
oSvvq,  pain). — See  Arthralgia. 

ARTICULAR  RHEUMATISM.— Rheu- 
matism  affecting  joints.  See  Rheumatism. 

ARTIFICIAL  RESPIRATION,  or  the 

method  of  exciting  and  keeping  up  the  move- 
ments of  the  chest,  so  as  to  supply  air  to  the 
lungs,  is  a subject  of  tho  highest  importance, 
since  the  hopes  of  recovery  depend  on  its  due 
performance  in  many  cases  of  narcotic  poisoning, 
in  the  apparently  drowned  or  asphyxiated, 
and  in  the  collapse  of  tho  advanced  stage  of 
the  condition  induced  by  anaesthetics.  For  its 
effective  employment  it  is  essential  to  see  that  no 
foreign  body  obstructs  the  air-passages.  Children 
and  old  people  are  liable  to  swallow  large  pieces 
of  meat  or  crust,  which  become  impacted  in  the 
pharynx  or  oesophagus.  These  should,  if  pos- 
sible, be  dragged  away  with  the  finger  or  a 
spoon-handle,  but  they  may  require  the  use  of  a 
probang.  Tracheotomy  is  rarely  necessary.  A 
knife-handle  held  between  the  molar  teeth  is  a 
ready  and  useful  gag  to  keep  the  mouth  open. 

A button-hook,  in  the  absence  of  pharyngeal 
forceps,  is  sometimes  very  serviceable.  Vomited 
matter  should  be  quickly  removed  with  a sponge 
or  cloth  twisted  round  a piece  of  wood.  In 
treating  the  half-drowned  the  body  should  be 
inverted  for  a few  minutes  to  favour  the  escape 
of  water  from  the  air-passages,  but  artificial 


■>'>  ARTIFICIAL  RESPIRATION, 
breathing  should  be  commenced  even  whilst  the 
tody  is  in  this  position. 

Methods. — In  most  cases  the  best  method  of 
commencing  artificial  respiration  is  to  compress  the 
chest  and  abdomen  simultaneously,  then  remove 
pressure  so  as  to  allow  air  to  enter  the  chest,  and 
again  repeat  the  pressure  every  two  or  three 
seconds.  If  the  sound  indicates  that  air  is  passing 
into  and  out  of  the  lungs,  this  method  may  be 
continued  for  half  a minute  ; but  if  we  are  not 
sure  that  the  air  is  exchanged,  and  in  all  cases  if 
the  patient's  condition  is  not  decidedly  improved 
in  half  a minute,  we  should  resort  to : — ■ 

1 . Sylvester's  method,. — Place  the  patient  on  his 
back  on  the  floor,  with  a block  or  pillow  under 
his  shoulders,  and  raise  the  arms  upwards  above 
his  head,  by  grasping  them  above  the  elbow,  and 
pulling  firmly  and  steadily  as  long  as  there  is  any 
sound  of  air  entering  the  chest.  Some  arrangement 
is  needed  to  prevent  the  body  from  being  dragged 
towards  the  operator.  For  this  purpose  the  plan 
of  raising  the  chest  on  a high  cushion  or  box  has 
been  adopted,  but  as  a condition  of  cardiac  anaemia 
is  often  present,  this  is  objectionable.  It  is 
better  to  effect  the  object  by  placing  a book  in 
front  of  the  thighs  while  kneeling  at  the  head 
of  the  patient.  It  may  be  needful  to  draw  forth 
the  tongue,  but  generally  if  the  head  falls  back 
over  a cushion  placed  behind  the  neck,  this  is  not 
required.  An  artery  forceps,  or  a noose  of  string, 
or  a handkerchief  will  enable  an  assistant  to 
keep  the  tongue  well  forward. 

As  soon  as  the  sound  produced  by  the  entrance 
of  air  into  the  chest  ceases,  the  arms  should  be 
brought  down  a little  towards  the  front  of  the 
chest,  and  pressed  firmly  and  steadily  against  it 
for  about  one  second  after  air  is  heard  escaping. 
In  cases  of  drowning  it  is  enough  to  repeat  this 
operation  every  four  seconds,  but  in  the  collapse 
resulting  from  chloroform  or  other  anaesthetics, 
the  necessity  for  getting  the  vapour  quickly  out 
of  the  chest  justifies  a more  rapid  performance 
of  the  movements  during  the  first  five  minutes. 
After  this  time  the  movements  should  be  carried 
on  more  slowly,  but  they  should  bo  continued 
for  half  an  hour  at  least,  and  even  longer  if  the 
warmth  of  the  surface  and  diminution  of  lividity 
gives  any  reason  to  hope  that  the  heart  has  not 
entirely  ceased  to  act. 

2.  Marshall  Hall’s  ready  method  is  performed 
by  placing  the  body  on  one  side,  and  alternately 
rolling  it  on  its  face  to  compress  the  chest, 
and  on  its  back  to  allow  the  elasticity  of  the 
ribs  free  movement  to  draw  air  into  the  lungs. 
The  plan  is  not  nearly  so  effective  as  Sylvester's, 
but  if  no  assistant  is  at  hand  it  is  the  best  mode 
of  artificial  breathing  that  can  be  adopted. 

3.  Howard’s  method.  See  Resuscitation. 

4.  Moutk-to-moutk  insufflation  is  not  to  be 
depended  upon,  on  account  of  the  difficulty  both 
of  keeping  the  larynx  open,  and  also  of  prevent- 
ing the  air  going  down  the  gullet. 

Of  the  instruments  introduced  for  the  purpose 
ot  carrying  on  artificial  respiration,  mention 
should  be  made  of  those  invented  by  Dr.  Marcet 
and  Dr.  Richardson ; but  except  in  the  hands  of 
the  inventors  or  of  those  who  had  gained  much 
experiencein  theiruse  by  practising  upon  animals, 
the  writer  thinks  they  would  do  as  much  harm 
us  good.  The  objection  to  them  all  is  that  they 


ASCITES. 

interfere  with  the  prompt  imitation  of  the  move- 
ments of  respiration  just  described. 

The  administration  of  oxygen  is  indicated  in 
most  cases  of  artificial  respiration,  but  the  results 
of  its  use  have  not  been  satisfactory  hitherto. 
Now  that  the  gas  can  be  had  in  a compressed 
state,  and  can  be  given  by  means  of  the  laughing- 
gas  inhaler,  it  is  worthy  of  a further  trial;  but 
it  is  certain  that  in  all  cases  of  impending  asphyxia 
time  is  of  so  much  importance  that  anything 
which  would  delay  the  supply  of  oxygen  would 
not  be  compensated  for  by  giving  it  pure,  in- 
stead of  in  the  form  of  common  air.  Tracheo- 
tomy is  not  to  be  thought  of  in  the  first  instance 
in  any  case  in  which  air  can  be  made  to  pass, 
even  in  very  small  quantity,  through  the  trachea. 

Eor  supplemental  and  after-treatment,  see 
Resuscitation.  J.  T.  Clover. 

ASCARIDES  (aCKapls,  a kind  of  worm).- 
Tliis  term,  by  long  usage,  is  often  employed  to 
designate  the  very  common  intestinal  parasites 
popularly  known  as  Thread-worms  or  Scat-worms. 
Strictly  speaking, these  do  not  belong  to  the  genus 
Ascaris,  but  to  the  genus  Oxyuris.  The  fuller 
consideration,  therefore,  of  their  characters  and 
clinical  importance  will  bo  found  under  the 
Article  Thread-worms. 

Although  the  term  as  employed  in  the  sense 
referred  to  is  altogether  erroneous,  there  are  two 
true  species  of  the  genus  Ascaris  found  infesting 
man.  These  are,  respectively,  the  common  round- 
worm  or  Lumbricus  ( Ascaris  lumbricoides ) ; and 
the  moustached  or  margined  round-worm(AscaWs 
my stax ).  Full  particulars  respecting  the  former 
will  bo  found  under  Round-worms,  whilst  the 
consideration  of  tho  latter  need  only  occupy  a 
few  words  in  this  place. 

Since  the  discovery  and  description  of  the 
Ascaris  mystax  as  a genuine  human  parasite  by 
the  writer  in  1868,  six  instances  of  its  occurrence 
have  been  noticed  at  home  and  abroad,  and  there 
can  be  little  doubt  that  the  parasite  is  much 
more  frequent  in  man,  especially  in  children, 
than  is  commonly  supposed.  The  writer  has 
also  shown  that  this  parasite  is  identical  with 
the  Ascaris  mystax  in  the  cat,  which,  according 
to  most  helminthologists,  is  only  a variety  of 
the  Ascaris  marginata  in  the  dog.  The  males 
are  usually  from  2 to  21  inches  in  length ; the  fe- 
males sometimes  acquiring  a length  of  4 inches 
or  more. 

Treatment. — Like  its  congener,  the  falsely 
so-called  Lumbricus,  the  margined  round-worm 
readily  yields  to  treatment  by  santonine.  Two 
or  three  grains  of  this  drug,  followed  by  castor 
oil  or  a saline  purgative,  should  be  administered 
twice  or  thrice  daily  fora  few  days  in  succession. 

T.  S.  CoBBOLD. 

ASCITES  (daubs,  a leathern  sac;  a large 
belly). — Synon.  : Dropsy  of  the  peritoneum  ; 

Hydrops  peritonei  vcl  abdominis;  Hydroperi- 
toneum. Fr.  Ascite ; Ger.  Die  Bauch wasscrsuch t . 

Definition. — An  accumulation  of  fluid  within 
the  cavity  of  the  peritoneum,  more  or  less  serous 
in  character,  the  accumulation  being  of  the 
nature  of  a local  dropsy,  and  not  originating  in 
inflammation.  The  amount  of  fluid  varies  much 
in  different  cases. 

.Etiology  and  Pathology. — The  chief  mattai 


ASCITES. 


relating  to  the  causation  of  ascites  is  to  point 
out  the  morbid  conditions  by  which  it  may  be 
produced,  as  it  almost  always  follows,  and  is 
a consequence  of  certain  pre-existing  organic 
diseases,  of  which  it  becomes  a most  important 
symptom  and  pathological  phenomenon.  The 
causes  to  which  it  has  been  attributed  may  be 
discussed  according  to  the  following  arrange- 
ment:— - 

I.  Direct  mechanical  obstruction  affecting  the 
portal  circulation. 

1.  Obstruction  of  the  trunk  of  the  portal 
vein  before  it  enters  the  liver,  either  from 
external  pressure  or  internal  obstruction. 

2.  Pressure  upon  or  obliteration  of  the 
branches  of  the  vein  within  the  liver. 

3.  Pressure  upon  the  trunk  of  the  hepatic 
vein,  or  upon  the  inferior  vena  cava  after  it 
receives  this  vein. 

II.  Cardiac  or  pulmonary  diseases  obstructing 
.he  general  venous  circulation. 

III.  Disease  of  the  kidneys. 

IV.  Morbid  conditions  of  the  peritoneum. 

V.  Miscellaneous. 

I.  Any  direct  obstruction  interfering  with 
the  portal  circulation  must  necessarily  lead  to 
congestion  and  over-distension  of  its  tributaries, 
one  of  the  consequences  of  which  is  exces- 
sive transudation  of  the  fluid  portion  of  the 
blood  into  the  peritoneal  cavity,  while  absorption 
s checked.  The  ascites  is,  under  such  circum- 
stances, in  short,  merely  a localised  dropsy, 
resulting  from  mechanical  congestion.  The 
impediment  may  affect  either  the  portal  trunk 
before  it  enters  the  liver ; its  branches  in  the 
substance  of  this  organ ; or  the  hepatic  vein 
or  inferior  vena  cava  near  its  termination. 

1.  The  portal  trunk  may  be  pressed  upon  as 
it  lies  in  the  fissure,  by  prominences  from  the 
liver  itself,  enlarged  absorbent  glands  in  its 
vicinity,  a neighbouring  tumour  (as  cancer  of  the 
pancreas  or  a growth  in  the  small  omentum),  a 
hepatic  aneurism,  or  inflammatory  thickening 
resulting  from  peri-hepatitis.  The  pressure  may 
absolutely  close  up  the  vessel,  but  it  more  com- 
monly causes  a local  clot  to  form,  and  thus  its 
channel  is  blocked  up.  A thrombus  is  also  in 
exceptional  instances  produced  in  connexion 
with  a diseased  condition  of  the  portal  vein, 
such  as  inflammation  or  calcification ; obstruction 
to  the  circulation  within  the  liver ; or  feebleness 
of  the  circulation,  with  an  abnormal  tendency  to 
coagulation  of  the  blood. 

2.  Pressure  upon,  or  obliteration  of  the 
branches  of  the  portal  vein  within  the  liver,  can 
only  arise  as  a consequence  of  some  morbid 
condition  involving  the  actual  substance  of  this 
organ.  The  hepatic  disease  which  by  far  most 
commonly  leads  to  this  result,  and  which  is 
one  of  the  most  frequent  causes  of  ascites,  is 
cirrhosis.  Occasionally  it  accompanies  syphi- 
litic and  other  forms  of  contracted  and  indurated 
liver,  or  it  may  be  associated  with  infiltrated 
cancer.  The  extent  of  the  obstruction  thus  set 
up  will  necessarily  vary  with  that  of  the 
morbid  changes  in  the  organ.  Occasionally  a 
mass  within  the  liver  obstructs  a considerable 
branch  of  the  portal  vein. 

3.  Obstruction  of  the  hepatic  vein  or  inferior 
vena  cava  is  a rare  event,  but  may  arise  from 


S3 

the  pressure  of  a growth  connected  with  the 
liver  itself,  or  of  some  neighbouring  tumour. 

II.  Diseases  of  the  lungs  or  heart  which 
impede  the  general  venous  circulation  musi 
necessarily  exercise  a speedy  and  direct  in- 
fluence upon  the  hepatic  circulation,  and  may  thus 
lead  to  ascites.  Usually,  however,  in  cases  of 
this  kind  the  legs  are  the  seat  of  considerable 
anasarca  before  peritoneal  dropsy  is  observed. 
In  course  of  time  the  continued  congestion  ori- 
ginates serious  organic  changes  in  the  liver, 
its  vessels  being  more  or  less  obliterated,  and 
consequently  it  is  at  this  period  that  ascites  is 
particularly  liable  to  set  in. 

III.  Ascites  may  constitute  a part  of  the 
dropsy  which  so  often  accompanies  renal  diseases. 
It  is,  however,  of  comparatively  infrequent 
occurrence  to  any  great  extent  under  these 
circumstances,  the  amount  of  fluid  being  not 
considerable  as  a rule,  and  the  ascites  being  but 
a subsidiary  part  of  a general  dropsy. 

IV.  More  or  less  serous  effusion  into  the 
peritoneal  cavity  is  a pathological  result  of 
peritonitis  ; but,  in  accordance  with  the  defini- 
tion of  ascites  given  above,  this  does  not  come 
strictly  within  the  present  article.  In  excep- 
tional instances,  however,  true  ascites  is  observed 
as  a sequel  of  peritonitis,  in  consequence  ol 
the  morbid  conditions  which  it  leaves  behind. 
Chronic  peritonitis  may  also  occasion  a simple 
local  dropsy  ; but  this  is  particularly  liable  to  be 
set  up  in  connexion  with  morbid  formations 
in  the  peritoneum,  such  as  cancer  or  tubercle, 
of  which  the  writer  has  seen  striking  examples. 
The  immediate  causes  of  ascites  associated 
with  diseases  of  the  peritoneum  may  be  : — active 
congestion ; implication  of  the  capillaries  or 
minute  veins,  or  even  of  the  larger  veins,  lead- 
ing to  mechanical  congestion  ; obstruction  of 
the  lymphatic  orifices,  and  consequent  impaired 
absorption;  or  undue  activity  of  the  secreting 
structures. 

V.  Among  the  chief  miscellaneous  causes  to 
which  ascites  has  been  attributed  may  be  men- 
tioned exposure  to  cold  or  wet ; the  sudden  sup- 
pression of  habitual  discharges,  or  the  rapid 
cure  of  chronic  cutaneous  affections ; and  extreme 
anaemia  and  debility.  These  causes  are  supposed 
to  originate  this  symptom  either  by  inducing 
active  internal  congestion ; or  by  disturbing  the 
renal  functions ; or  in  consequence  of  the  abnormal 
state  of  the  blood  and  tissues ; butitis  very  doubt- 
ful whether  either  of  them  can  actually  of  itself 
occasion  ascites.  Fluid  may  collect  within  the 
peritoneum  as  the  result  of  the  rupture  of  a cyst 
within  the  abdomen,  especially  an  ovarian  cyst. 

It  must  be  remembered  that  ascites  may  be 
due  to  a combination  of  two  or  more  of  the 
causes  which  have  been  indicated  in  the  pre- 
ceding remarks.  For  instance,  there  may  be 
obstruction  affecting  the  portal  circulation 
within  the  liver  and  outside  this  organ  at  the 
same  time;  or  the  different  organs  maybe  in- 
volved simultaneously. 

Predisposing  causes. — Whatever  tends  to  set 
up  either  of  the  morbid  conditions  which 
originate  ascites,  may  be  regarded  as  a pre- 
disposing cause.  It  may  be  met  with  at  an> 
age,  but  is  most  common  during  middle  life 
| The  hepatic  form  is  much  more  frequent 


ASCITES. 


34 

males  than  females.  An  anaemic  condition 
of  the  Llood  and  weakness  of  the  tissues  predis- 
pose to  peritoneal  dropsy,  as  they  do  to  dropsy 
in  other  parts. 

Anatomical  Characters. — The  essential  ana- 
tomical character  of  ascites  is  the  accumulation 
of  a serous  fluid  within  the  peritoneal  sac.  Its 
amount  may  range  from  a few  ounces  to  some 
gallons.  As  regards  physical  characters,  the  fluid 
is  generally  thin,  limpid,  and  watery  in  consist- 
ence ; colourless  or  slightly  yellow ; clear  and 
transparent ; and  of  alkaline  reaction.  In  ex- 
ceptional instances,  however,  it  maybe  coloured 
by  blood  or  bile ; or  more  or  less  turbid  and 
dirty-looking ; or  of  thicker  and  somewhat 
gelatinous  consistence.  Soft  fibrinous  masses 
occasionally  float  in  the  fluid,  or  these  may  form 
spontaneously  when  it  is  allowed  to  stand. 
Very  rarely  the  reaction  is  neutral  or  acid.  The 
specific  gravity  varies  considerably.  Chemically 
the  fluid  consists  of  water  holding  in  solution  al- 
bumin and  the  usual  salts  which  are  found  in  drop- 
sical fluids ; but  their  proportion  is  very  variable, 
though  the  albumin  is  generally  in  good  quantity, 
which  is  evidenced  by  the  degree  of  coagulation 
which  takes  place  when  the  fluid  is  boiled. 
Occasionally  it  contains  fibrin,  cholesterine,  bile- 
elements,  or,  in  cases  of  renal  dropsy,  urea. 

The  effects  of  the  accumulation  upon  surround- 
ing structures  are  to  distend  and  macerate  them 
mere  or  less,  or  to  compress  them.  Of  course 
along  with  the  ascites  there  will  be  the  signs  of 
any  morbid  condition  upon  which  it  depends ; 
and  there  may  also  be  indications  of  anatomical 
changes  resulting  from  long-continued  pressure 
of  the  fluid  upon  certain  structures. 

Symptoms  and  Sions. — Ascites  usually  sets  in 
very  gradually,  being  chronic  in  its  progress,  but 
advancing  steadily.  Occasionally,  however,  the 
fluid  collects  with  considerable  rapidity.  The 
clinical  phenomena  associated  with  this  patholo- 
gical condition  differ  in  different  cases,  both  in 
their  exact  nature  and  their  degree,  according 
to  its  cause,  the  amount  of  the  fluid,  and  other 
circumstances,  but  they  may  conveniently  be 
considered  under  the  following  heads,  namely : 
— 1 . Physical  signs.  2.  Mechanical  effects  of  the 
dropsical  accumulation.  3.  General  symptoms. 

1 . Physical  Signs.— Physical  examination  con- 
stitutes a most  important  part  of  the  clinical 
investigation  of  cases  of  ascites,  and  it  will  be 
requisite  to  discuss  the  signs  in  some  detail. 

(a)  If  fluid  collects  in  the  peritoneum  in  any 
quantity,  the  abdomen  presents  more  or  less 
general  enlargement.  This  is  often  the  first 
change  which  attracts  the  patient's  attention,  and 
it  may  also  have  been  noticed  that  the  increase 
in  size  commenced  below.  The  degree  of  en- 
largement depends  upon  the  amount  of  fluid,  but 
it  may  become  extreme,  so  that  the  skin  is 
tightly  stretched  and  thin,  presenting  a smooth 
and  shining  appearance,  or  sometimes  white  lines 
are  visible,  due  to  laceration  of  its  deeper  layers. 
The  umbilicus  becomes  affected  in  a character- 
istic manner,  being  more  or  less  stretched  and 
everted,  and  finally  becoming  obliterated,  or  in 
some  cases  more  or  less  pouched  out,  and  it  may 
form  a considerable  prominence.  Should  there 
happen  to  be  a weak  portion  of  the  abdominal 
walls,  such  as  a hernial  sac,  this  will  be  unduly  pro- 


truded. The  important  characters  of  abdominal 
enlargement  due  to  uncomplicated  ascites  are 
that  it  is  of  a rounded  form,  though  tending  to 
he  more  prominent  or  to  bulge  towards  the  lower 
part  or  in  the  flanks,  according  to  the  posture 
of  the  patient;  that  it  is  quite  symmetrical  in 
shape,  when  the  patient  stands  or  lies  on  his 
back,  but  that  the  form  alters  considerably  with 
a change  of  position,  the  abdomen  becoming  then 
more  prominent  in  the  dependent  region,  in  con- 
sequence of  the  gravitation  of  the  fluid  in  this 
direction,  and  it  may  actually  he  seen  to  move 
as  the  posture  is  changed.  In  contrast  with  the 
enlarged  abdomen,  the  chest  often  looks  small 
and  depressed,  and  the  fluid  may  cause  its 
margin  to  become  everted,  or  it  may  push  for- 
wards the  xiphoid  cartilage. 

(b)  The  abdomen  feels  perfectly  smooth  and 
even  over  its  entire  surface.  It  usually  gives  a 
sensation  of  tension  of  the  walls,  without  any 
hardness  underneath.  In  some  instances  an 
obscure  feeling  of  fluctuation  is  experienced  on 
palpation  with  the  fingers. 

(c)  The  tendency  of  ascites  is  to  interfere  with 
the  abdominal  respiratory  movements , if  it  is  at  all 
considerable,  by  preventing  the  diaphragm  from 
acting  properly.  At  the  same  time  the  writer 
has  not  uncommonly  observed  that,  even  in  cases 
where  the  accumulation  of  fluid  has  been  very 
considerable,  abdominal  respiration  did  not  seein 
to  he  much  diminished. 

(i d ) Percussion  affords  some  of  the  most  im- 
portant signs  of  peritoneal  dropsy  ; and  when 
the  fluid  is  present  only  in  small  quantity,  this 
is  the  only  mode  of  examination  that  can  lead  to 
its  detection.  In  tho  first  place  marked  dulness 
is  elicited  over  the  seat  of  the  fluid ; while  a 
tympanitic  sound,  which  is  often  abnormally 
clear  and  distinct,  is  heard  over  the  intestines. 
When  there  is  but  little  fluid,  it  may  be  im- 
possible to  detect  any  abnormal  dulness  as  the 
patient  lies  in  the  recumbent  posture,  but  on 
placing  him  on  his  hands  and  knees,  the  fluid 
gravitates  towards  the  front  of  the  abdomen, 
and  dulness  may  then  he  noticed  in  the  um- 
bilical region.  In  most  cases,  however,  there  is 
no  difficulty  in  making  out  the  dulness,  and  this 
sign  is  observed  in  those  regions  towards  which 
the  fluid  naturally  gravitates.  Hence,  when 
the  patient  lies  on  his  back,  the  lower  part  and 
sides  of  the  abdomen  are  dull,  while  its  upper 
and  front  part  is  tympanitic.  As  more  and 
more  fluid  collects,  so  the  dulness  increases  in 
extent,  gathering  in,  as  it  were,  from  below  and 
from  the  sides,  until  finally  the  entire  abdomen 
may  be  dull,  except  the  umbilical  region,  which 
remains  longest  tympanitic.  The  boundary  line 
between  tho  dulness  and  tympanitic  sound  is 
usually  well-dofined.  As  the  posture  is  changed,  so 
will  the  site  of  the  dulness  vary,  the  part  which 
is  undermost  presenting  this  sign,  while  that 
which  becomes  highest  is  tympanitic  ; and  thus 
the  relative  situation  of  these  two  sounds,  as 
well  as  tho  shape  of  the  dulness,  can  be  altered 
in  a variety  of  ways.  When  the  patient  sits  up, 
the  prominence  between  the  recti  muscles  gives 
a tympanitic  sound  on  percussion.  In  exceptional 
instances  a distended  colon  gives  rise  to  a tym- 
panitic sound  along  each  side  of  the  abdomen 
even  when  there  is  abundant  fluid  present. 


ASCITES. 


Another  important  sign  brought  out  by  a kind 
of  percussion  is  the  sensation  specially  termed 
fluctuation , -which  is  the  peculiar  ware-like  move- 
ment realised  on  placing  the  fingers  of  one  hand 
over  one  side  of  the  abdomen,  and  fillipping  or 
tapping  the  opposite  side  with  the  fingers  of  the 
other  hand.  This  sensation  is  very  easily 
brought  out  if  there  is  much  fluid  present,  pro- 
vided it  is  free  to  move,  and  sometimes  the 
motion  is  actually  visible.  Change  of  posture 
will  modify  the  seat  over  which  fluctuation  can 
be  produced. 

(e)  Auscultation  yields  negative  results  in 
cases  of  ascites,  there  being  no  sound  of  any 
kind  heard  over  the  abdomen. 

( f)  In  the  large  majority  of  cases  ascites  is 
clearly  revealed  by  the  physical  signs  already 
described.  In  exceptional  instances,  however, 
when  the  diagnosis  is  obscure,  it  is  requisite  to 
resort  to  a digital  examination  through  the 
rectum , and  in  females  through  the  vagina.  The 
fluid  collects  in  the  recto-vesical  pouch,  and  on 
examination  per  rectum,  the  finger  detects  the 
sensation  of  this  fluid  through  its  anterior  wall. 
The  vagina  is  usually  felt  to  be  shortened,  while 
the  uterus  is  pushed  down  and  flexed.  In  ex- 
treme cases  of  ascites  the  posterior  wall  of  the 
vagina,  or  even  the  uterus  itself,  may  protrude 
through  the  vulva. 

(g)  Now  and  then  it  is  requisite  to  make  use 
of  the  aspirator  or  a small  trochar,  by  the  aid 
of  which  not  only  can  it  be  determined  whether 
fluid  is  present  in  the  abdominal  cavity,  but  its 
nature  can  also  be  ascertained.  This  method  of 
examination  is  further  useful  when  ascites  is 
associated  with  some  other  morbid  condition 
within  the  abdomen,  which  frequently  cannot 
be  made  out  so  long  as  the  fluid  remains  in  the 
peritoneum. 

It  must  be  borne  in  mind  that  the  ordinary 
physical  signs  of  ascites  will  be  materially  modi- 
fied or  obscured  under  certain  circumstances. 
For  example,  the  quantity  of  fluid  may  be  so 
small  that  most  careful  examination  is  required 
in  order  to  detect  its  presence;  on  the  other 
hand,  it  may  be  so  abundant  that  dulness  is 
observed  over  the  entire  abdomen,  and  fluctua- 
tion may  be  very  indistinct.  The  existence  of 
peritoneal  adhesions — for  instance,  those  which 
may  be  formed  as  the  result  of  repeated  para- 
centesis— also  renders  some  of  the  most  charac- 
teristic signs  of  ascites  very  ill-defined.  Again, 
the  association  of  peritoneal  dropsy  with  some 
other  abdominal  morbid  condition,  such  as  a new 
growth,  an  enlarged  liver  or  spleen,  or  an  ovarian 
tumour,  will  also  modify  the  signs  elicited.  The 
mesentery  may  be  abnormally  short,  or  the  in- 
testines may  be  adherent,  thus  being  prevented 
from  floating  forwards,  so  that  the  usual  relative 
positions  of  dulness  and  tympanitic  sound  are 
not  observed. 

2.  Mechanical  effects  of  the  dropsical  accumu- 
lation.— The  clinical  phenomena  resulting  from 
the  mechanical  effects  of  ascites  are  both  sub- 
jective and  objective.  The  patient  often  expe- 
riences a feeling  of  uneasiness  and  discomfort  in 
the  abdomen,  as  well  as  more  or  less  tension  and 
fulness,  if  there  is  much  fluid  present;  while 
there  may  be  a sense  of  fatigue  and  aching  about 
the  loins  or  abdominal  walls.  As  a role  no 


86 

particular  pain  is  felt,  but  colicky  pains  are 
liable  to  occur  from  time  to  time,  and  extreme 
distension  of  the  structures  constituting  the  abdo- 
minal wall  may  also  cause  painful  sensations. 
In  exceptional  instances  peritonitis  is  set  up. 
When  the  fluid  is  abundant,  the  patient  expe- 
riences its  weight  when  he  walks,  and,  during  this 
act,  he  throws  the  head  and  shoulders  back,  at  the 
same  time  keeping  the  legs  apart.  Symptoms 
connected  with  the  alimentary  canal  are  of  com- 
mon occurrence,  but  these  are  often  to  a great 
extent  due  to  the  same  cause  which  originates 
the  ascites,  though  the  fluid  must  necessarily 
tend  to  interfere  with  the  functions  of  the 
stomach  and  intestines.  The  bowels  are  usually 
constipated,  but  in  some  instances  diarrhoea 
or  dysenteric  symptoms  may  arise.  Flatu- 
lence is  very  commonly  complained  of,  even 
a small  amount  of  gaseous  accumulation  in  the 
intestines  b'feing  felt  unduly,  producing  much 
discomfort,  and  increasing  the  enlargement  of 
the  abdomen  temporarily.  Occasionally  vomit- 
ing occurs,  in  consequence  of  interference  with 
the  stomach.  When  considerable  fluid  has  re- 
mained in  the  peritoneum  for  some  time,  it 
presses  upon  the  inferior  vena  cava  and  prevents 
the  return  of  blood  through  this  vessel,  and  may 
thus  lead  to  anasarca  of  both  lower  extremities, 
with  enlargement  of  the  superficial  abdominal 
veins.  Exceptionally  the  anasarca  attracts  atten- 
tion at  an  early  period.  The  flow  of  blood 
through  the  renal  veins  may  also  be  obstructed, 
inducing  mechanical  congestion  of  the  kidneys, 
with  consequent  diminution  in  the  quantity  of 
urine  and  albuminuria.  In  rare  instances  the 
fluid  has  been  known  to  accumulate  to  such  an 
extent  as  to  rupture  some  part  of  the  abdominal 
walls. 

Ascites  also  frequently  interferes  with  the 
thoracic  organs.  The  bases  of  the  lungs  are 
more  or  less  collapsed,  and  the  breathing  becomes 
chiefly  upper-costal,  while  a sense  of  dyspnoea 
is  experienced,  especially  in  the  recumbent 
posture  and  after  taking  food,  the  breath  is 
short  on  exertion,  and  the  respirations  are  often 
hurried  and  shallow.  The  heart  is  likewise 
liable  to  be  disturbed  in  its  action,  as  evidenced 
by  palpitation,  irregularity,  or  a tendency  to 
faintness.  This  organ  may  also  be  displaced, 
so  that  its  apex-beat  is  raised  and  too  far  towards 
the  left,  and  in  rare  instances  a basic  systolic 
murmur  has  been  originated  as  a result  of  this 
displacement. 

3.  General  symptoms. — The  general  system  is 
frequently  seriously  affected  in  cases  in  which 
ascites  is  a prominent  symptom,  but  this  usually 
depends  upon  the  cause  or  causes  which  have 
originated  the  dropsy,  though  it  may  itself  in- 
duce more  or  less  debility,  wasting,  anaemia,  and 
other  general  effects.  The  loss  of  fluid  in  this 
way  has  also  been  supposed  to  lead  to  deficient 
perspiration,  and  consequent  dryness  of  the  skin; 
as  well  as  to  diminution  in  the  quantity  of  urine. 

Diagnosis. — The  first  matter  bearing  upon 
the  diagnosis  of  ascites  is  to  determine  whether 
this  morbid  condition  actually  exists.  The 
presence  of  fluid  in  the  peritoneum,  as  well  as 
its  amount,  can  only  be  positively  made  out  by 
physical  examination,  and  in  the  great  majority 
of  cases  the  signs  thus  elicited  are  quite  charac- 


ASCITES. 


*6 

teristic.  When  the  fluid  is  small  in  quantity, 
as  •well  as  under  other  circumstances  in  which 
the  physical  signs  are  obscured  or  modified,  the 
diagnosis  may  be  difficult  and  uncertain,  but  it 
may  then  be  aided  by  a knowledge  of  the  ex- 
istence of  some  disease  likely  to  give  rise  to 
ascites.  That  the  accumulation  of  fluid  is  of  a 
dropsical  nature,  and  not  due  to  acute  or  chronic 
peritonitis,  is  usually  sufficiently  obvious  from 
the  history  of  the  case,  and  the  collateral  symp- 
toms, while  the  local  signs  are  also  of  a different 
character  ( see  Peritoneum,  Inflammation  of). 
The  remaining  abdominal  enlargements  from 
which  ascites  has  to  be  most  commonly  distin- 
guished are  those  due  to  flabby  relaxation  of  the 
walls  of  the  abdomen,  combined  with  flatulence  ; 
accumulation  of  fat  in  the  subcutaneous  tissue 
and  omentum  ; abundant  subcutaneous  oedema, 
which  may  be  associated  with  and  obscure 
ascites ; an  ovarian  tumour ; or  a pregnant 
uterus.  Among  the  rarer  conditions  with  which 
ascites  is  liable  to  be  confounded  may  be  men- 
tioned colloid  disease  of  the  omentum  ; a greatly 
dilated  stomach  ; distension  of  the  uterus  with 
fluid;  great  accumulation  of  urine  in  the  blad- 
der ; a very  large  hydatid  tumour,  usually  con- 
nected with  the  liver;  extreme  cystic  enlarge- 
ment of  the  kidney  ; and  the  so-called  ‘ phantom 
tumour.’  Most  of  these  conditions  are  described 
in  other  parts  of  this  work,  and  the  limits  of  this 
article  forbid  any  discussion  of  their  several 
diagnostic  characters;  but  a consideration  of  the 
history  and  existing  symptoms  of  the  case,  com- 
bined with  the  results  of  a proper  physical  exami- 
nation, constitute  the  data  upon  which  the  diag- 
nosis is  founded.  It  roust  be  remembered  that 
ascites  may  coexist  with  other  morbid  con- 
ditions in  the  abdomen,  their  physical  signs  being 
combined.  Should  there  be  an  enlarged  organ 
or  other  solid  mass,  it  may  often  be  recognised 
by  making  sudden  firm  pressure  with  the  fingers 
over  the  abdomen,  when  the  fluid  is  pushed  aside, 
and  the  underlying  resistance  can  be  felt ; or 
paracentesis  may  be  performed,  and  further 
examination  carried  out  after  the  evacuation  of 
the  fluid. 

Another  most  important  point  in  the  diagnosis 
of  ascites  is  to  make  out  its  cause.  Por  this 
purpose  all  the  facts  bearing  upon  the  case  must 
be  taken  into  account  and  carefully  weighed, 
special  attention  being  paid  to  the  liver  and  the 
structures  in  its  vicinity,  to  the  heart,  and  to  the 
kidneys.  The  amount  of  the  ascites,  and  its 
relation  to  other  forms  of  dropsy,  afford  consider- 
able aid  in  the  diagnosis.  If  it  results  from 
cardiac  or  renal  disease,  ascites  always  follows 
dropsy  in  other  parts  of  the  body,  to  which  it  is 
also  generally  subordinate;  when  it  is  due  to 
hepatic  or  some  neighbouring  disease,  the  peri- 
toneal dropsy  appears  first,  and  is  throughout 
most  prominent.  Should  the  vena  cava  inferior 
be  obstructed  at  its  upper  part,  anasarca  of  the 
legs  will  be  observed  simultaneously  with,  or 
even  before  the  ascites. 

Prognosis. — The  prognosis  of  ascites  will 
mainly  depend  upon  its  cause ; the  amount  of 
fluid  present;  the  state  of  the  patient;  the 
condition  of  the  main  organs ; and  the  results  of 
treatment.  In  some  cases  this  symptom  is  in  it- 
Bolf  attended  with  immediate  danger,  on  account 


of  the  mechanical  effects  of  the  dropsical  accumu 
lation,  especially  upon  the  thoracic  organs,  and 
still  more  if  these  organs  are  in  a diseased  condi- 
tion. In  other  instances  it  aids  in  reducing  the 
patient,  and  in  thus  bringing  about  a fatal  ter- 
mination. When  ascites  is  due  to  local  inter- 
ference with  the  portal  circulation,  great  relief 
can  unquestionably  be  afforded  in  a considerable 
number  of  cases,  and  life  may  be  prolonged  by 
appropriate  treatment ; while,  if  the  local  causo 
is  not  such  as  in  itself  to  lead  to  a fatal  issue,  the 
ascites  may  not  infrequently  be  permanently  cured. 

Treatment. — The  principles  of  treatment  ap- 
plicable to  cases  of  ascites  are  (a),  to  attend  to  the 
condition  upon  which  the  dropsy  depends,  and 
thus  endeavour  to  get  rid  of  its  cause  ; (6)  to 
promote  the  absorption  of  the  fluid ; (c)  to  im- 
prove the  constitutional  condition  and  the  state 
of  the  blood,  if  necessary ; (d)  to  remove  the 
fluid  by  operation,  if  absorption  cannot  be  ac- 
complished ; and  ( e ) to  treat  any  symptoms  need- 
ing special  attention. 

(«)  As  an  important,  part  of  the  treatment 
directed  to  the  cause  of  ascites,  particular  atten- 
tion must  be  paid  to  those  organs  which  are 
most  commonly  accountable  for  this  symptom, 
though  unfortunately  in  a large  proportion  of 
cases  but  little  effect  can  be  produced  upon  the 
dropsy  in  this  way. 

( b ) Absorption  of  the  fluid  is  chiefly  promoted 
by  acting  freely  upon  the  bowels,  skin,  or  kidneys. 
The  class  of  remedies  indicated  will  vary  in 
different  cases,  and  must  be  adapted  to  the  state 
of  the  different  organs,  but  as  a rule  active  pur- 
gatives are  most  efficient  in  relieving  ascites, 
especially  when  due  to  local  causes,  of  which  the 
most  useful  are  compound  jalap  powder,  cream 
of  tartar,  elaterium,  calomel,  gamboge,  podo- 
phyllin,  and  croton  oil.  These  remedies  must, 
however  be  used  with  due  caution.  In  some 
instances  balsam  or  resin  of  copaiba  has 
proved  useful  in  the  treatment  of  peritoneal 
dropsy.  Assistance  may  be  derived  in  certain 
forms  of  ascites  from  acting  upon  the  skin  by 
means  of  various  diaphoretic  baths.  Digitalis 
and  squills  may  be  of  service  as  diuretics ; or 
the  application  of  poultices  of  digitalis  leaves 
over  the  abdomen  is  occasionally  attended  with 
benefit.  The  administration  of  iodide  of  potas- 
sium also  seems  to  aid  absorption  in  some  cases. 

(c)  Treatment  directed  to  the  general  condition 
of  the  patient,  and  to  the  state  of  the  blood,  is 
undoubtedly  valuable  in  many  cases  of  ascites. 
Tonics  are  often  of  decided  service,  and  prepara- 
tions of  iron  are  specially  indicated  for  im- 
proving the  quality  of  the  blood,  if  there  is  any 
tendency  to  anaemia.  Not  only  do  these  remedies 
sustain  the  patient,  but  they  may  also  have  an 
influence  in  promoting  the  process  of  absorption. 
The  diet  must  bo  adapted  to  the  circumstances 
of  the  case,  but  usually  needs  to  be  of  a nutri- 
tious character. 

( d ) In  a considerable  proportion  of  cases, 
however,  no  effect  is  produced  upon  the  dropsical 
accumulation  by  any  of  the  measures  thus  far 
considered.  Then  it  becomes  necessary  to  de- 
termine whether  it  is  desirable  to  remove  the 
fluid  by  operation.  The  fluid  may  be  taken 
away  either  by  means  of  the  aspirator,  or  by 
the  trochar  and  canula.  The  advisability  of 


ASCITES. 

having  recourse  to  this  plan  of  treatment  must 
depend  upon  circumstances.  The  ascites  is  fre- 
quently not  sufficiently  abundant  to  justify 
paracentesis,  and  when  the  condition  is  of  cardiac 
or  renal  origin,  the  operation  can  only  afford 
temporary  relief,  so  that  there  is  no  object  in 
resorting  to  it  unless  the  mechanical  effects  of 
the  accumulation  are  such  as  to  cause  trouble- 
some or  dangerous  symptoms,  and  it  had  better 
be  delayed  as  long  as  possible.  When  ascites  is 
a local  dropsy,  the  fluid  is  often  so  considerable 
in  amount  as  to  necessitate  its  removal  for  the 
mere  purpose  of  giving  relief  for  the  time.  In 
cases  of  ascites  associated  with  malignant 
disease,  for  instance,  this  is  all  that  can  be 
hoped  for,  as  the  fluid  will  certainly  collect 
again.  When,  however,  the  condition  is  due  to 
some  local  disease  which  is  not  in  itself  fatal, 
and  especially  to  cirrhosis  of  the  liver,  the  writer 
has  found  signal  benefit  result  from  the  repeated 
performance  of  paracentesis,  and  has  advocated 
this  plan  of  treatment  as  a curative  measure,  so 
far  as  the  ascites  is  concerned.  Barely  does  the 
operation  give  rise  to  any  immediate  ill-effects, 
and  it  is  frequently  found  that  remedies  will  act 
much  more  efficiently  after  the  removal  of  the 
fluid  than  they  did  previously.  In  the  writer's 
experience  paracentesis  repeated  as  often  as  the 
fluid  re-accumulated  has  ultimately  led  to  a 
complete  cure  in  several  instances;  in  others 
the  cure  was  partial,  a certain  quantity  of  fluid 
remaining  in  the  peritoneum,  limited  by  ad- 
hesions; while  in  others  still,  life  has  been 
greatly  prolonged,  and  much  comfort  afforded. 
The  repeated  accumulation  does  not  seem  to 
affect  the  system  materially  by  reason  of  the 
drain  upon  it,  and  frequently  not  at  all.  Of 
course  due  care  must  be  exercised  in  the  per- 
formance of  the  operation,  and  in  the  subsequent 
treatment.  In  a few  days  after  the  removal  of 
the  fluid,  the  application  of  a bandage  firmly 
round  the  abdomen,  so  as  to  exert  even  pressure, 
may  prove  of  service  in  aiding  the  absorption  of 
what  remains,  and  preventing  the  recurrence  of 
the  ascites  ; and  this  measure  may  also  be  useful 
when  a certain  amount  of  fluid  continues  after 
the  repeated  performance  of  paracentesis. 

(e)  The  symptoms  resulting  from  ascites  which 
are  likely  to  require  attention  are  those  con- 
nected with  the  alimentary  canal ; dyspnoea ; 
and  cardiac  disturbance,  or  a syncopal  tendency. 
These  should  be  treated  on  ordinary  principles ; 
but  it  must  be  observed  that  marked  dyspnoea, 
if  evidently  due  to  the  fluid,  is  an  indication  for 
the  immediate  performance  of  paracentesis. 

FREDERICK  T.  BoBERTS. 

ASIATIC  CHOLERA.  Sec  Cholera, 

ASPHYXIA  (a,  priv.,  and  o-<pv£is,  pulse). — 
Synon.  : Apncea ; Fr.  Asphyxie ; Ger.  Er- 
stickung. 

Definition. — The  term  Asphyxia,  though  lite- 
rally signifying  pulselessness,  is  generally  under- 
stood to  mean  the  condition  that  supervenes  on 
interruption  of  the  function  of  respiration.  The 
term  Apncea,  preferred  by  many  as  a more  exact 
one,  has  the  disadvantage  of  being  employed  by 
physiologists  in  a totally  different  sense,  viz.  the 
cessation  of  the  respiratory  movements  conse- 
quent on  artificial  hyperoxygenation  of  t he  blood. 


ASPHYXIA.  87 

There  is  therefore  no  advantage  to  be  gained 
by  substituting  the  term  apncea  for  the  well- 
understood  and  older  one,  asphyxia. 

^Etiology. — Asphyxia  may  result  from  many 
causes  which  obstruct  or  interrupt  the  respira- 
tion. They  may  be  divided  into  two  categories, 
internal  and  external. 

Internal. — These  include  paralysis  of  the  re- 
spiratory nerve-centres  by  disease  or  injury  of  the 
medulla  oblongata;  paralysis  of  the  nerves  or 
muscles  of  respiration ; a rigid  fixation  of  the 
respiratory  muscles;  collapse  or  disease  of  the 
lungs ; occlusion  of  the  air-passages  by  organic 
disease  or  spasm  of  the  glottis,  pressure  of 
tumours,  and  the  like. 

External. — To  this  group  belong  occlusion  of 
the  air-passages  by  foreign  bodies  ; pressure  on 
the  chest  not  tapable  of  being  overcome  by  tlu 
muscles  of  respiration ; closure  of,  or  external 
pressure  on,  the  air-passages,  as  in  suffocation, 
strangulation,  or  hanging.  These  are  all  case3 
of  obstruction  of  the  respiratory  movements  in 
a medium  capable  of  supporting  life.  To  these 
external  causes  are  to  be  added  those  conditions 
in  which,  though  the  respiratory  movements  arc 
free,  the  surrounding  medium  is  incapable 
of  oxygenating  the  blood,  viz.,  submersion  in  a 
liquid  medium  (drowning) ; or  being  surrounded 
by  a medium  devoid  of  oxygen,  such  as  ni- 
trogen or  hydrogen.  These  gases  have  a purely 
negative  effect ; but  many  other  gases  which  are 
classed  as  asphyxiants,  such  as  carbonic  oxide, 
sulphuretted  hydrogen,  chlorine,  chloroform  va- 
pour, etc.,  have  positive  poisonous  effects,  and 
should  therefore  be  called  by  some  special  name, 
such  as  toxic  asphyxiants,  to  distinguish  them 
from  those  which  have  no  such  properties. 

Phenomena. — When  an  animal  is  placed  in 
an  atmosphere  devoid  of  oxygen,  or  not  contain- 
ing a sufficient  quantity  of  this  gas  (under  10 
per  cent.)  to  maintain  the  respiratory  process, 
or  if  the  mechanism  of  respiration  is  simply 
obstructed,  it  begins  to  show  signs  of  agitation 
and  to  make  powerful  inspiratory  and  expiratory 
efforts,  in  which  the  accessory'  muscles  of  re- 
spiration are  all  brought  into  action ; the  arterial 
tension  increases ; and  the  superficial  vems  be- 
come distended  and  livid. 

After  a variable  period  these  dyspnceic  efforts 
pass  into  general  convulsions,  iu  which  the  mus- 
cles of  expiration  are  more  especially  in  action, 
during  which  the  sphincters  are  forced  and 
the  excretions  voided.  On  these  there  follows  a 
calm,  during  which  the  animal  lies  insensible, 
with  dilated  and  immovable  pupils,  and  with 
reflex  excitability  abolished  generally.  All 
muscular  movements  cease  except  those  of  in- 
spiration, which  are  repeated  at  intervals.  As 
death  approaches  the  respiratory  movements 
become  shallower  and  less  regular,  and  are  suc- 
ceeded by  stretching  convulsions,  during  which 
the  back  is  straightened,  the  head  is  thrown 
back,  the  mouth  gapes,  and  the  nostrils  dilate. 
The  heart  still  continues  to  beat  after  other 
movements  have  ceased.  The  heart  ultimately 
stops  in  the  state  of  diastole.  Death  is  then 
complete  and  final. 

Course  and  Termination. — The  time  neces- 
sary to  bring  about  a.  fatal  termination  varies  in 
different  aDima's,  and  in  the  same  animal  under 


ASPHYXIA. 


38 

different  conditions.  It  has  been  noted  that  the 
young  of  some  animals  resist  asphyxia  longer 
than  the  adults.  Paul  Bert  has  shown  that  these 
differences  are  all  explicable  in  accordance  with 
the  law  that  the  more  active  the  vital  combustion, 
the  greater  the  gaseous  interchange,  and  therefore 
the  more  rapidly  fatal  the  obstruction  of  the  re- 
spiratory process.  Excluding  special  considera- 
tions of  this  kind  it  may  be  stated  as  the  result 
of  the  experimentsof  the  Medical  and  Chirurgical 
Committee  on  Suspended  Animation  ( Mcd.-Chir . 
Trans,  vol.  xlv.  1862)  that  when  the  respiration 
of  a warm-blooded  animal  is  totally  obstructed, 
all  external  movements  cease  in  from  three  to  five 
minutes,  and  the  heart  stops  'within  ten  minutes. 
Certain  modifications  occur  according  to  the 
method  in  which  asphyxia  is  produced  (see 
Drowning). 

Anatomical  Characters. — The  blood  is  of  a 
dark  colour,  owing  to  complete  reduction  of  the 
hsemoglobin,  and  the  proportion  of  carbonic  acid 
is  greatly  increased.  Owing  to  the  excess  of 
carbonic  acid,  the  blood  coagulates  slowly  or 
imperfectly;  hence  it  remains  long  fluid,  or 
forms  few  and  soft  coagula.  The  venous  side 
of  the  heart,  the  great  venous  trunks,  and  the  pul- 
monary artery  are  distended  with  dark  blood ; 
while  the  left  side  varies,  being  sometimes  full, 
more  often  perhaps  either  empty  or  containing  a 
small  quantity  of  dark  blood. 

The  appearance  of  the  lungs  is  not  constant. 
These  organs  are  by  no  means  always  congested,  as 
is  very  generally  stated,  being  more  often  pale  and 
antemic.  The  posterior  and  dependent  parts  be- 
come hypostatically  congested  post  mortem.  The 
abdominal  viscera  are  usually  congested.  The 
appearance  of  the  brain  varies,  this  organ  being 
either  anaemic  or  more  or  less  congested.  Spe- 
cial signs  characterise  special  modes  of  causa- 
tion of  asphyxia. 

Pathology. — Inasmuch  as  the  cessation  of  re- 
spiration means  both  oxygen-starvation  and  accu- 
mulation of  carbonic  acid,  the  question  is  whether 
the  phenomena  of  asphyxia  depend  on  the  one  or 
the  other,  or  on  both.  Various  opinions  have  been 
entertained  on  this  subject,  but  the  experiments 
of  Rosenthal  and  Pfliiger  would  seem  to  show 
that  the  deprivation  of  oxygen  is  the  chief 
factor.  That  the  accumulation  of  carbonic  acid 
has  no  effect  at  all  cannot,  however,  be  maintained, 
for  it  is  demonstrable  that  carbonic  acid  has  a 
distinct  toxic  effect  on  living  tissues. 

The  circulation  ofnon-oxygenated  blood  through 
the  lungs  and  the  respiratory  centre  in  the  me- 
dulla oblongata  is  the  cause  of  the  powerful 
respiratory  efforts  in  the  first  stage — directly, 
by  stimulation  of  the  respiratory  nerve-centres ; 
indirectly,  by  peripheral  irritation  of  the  pul- 
monary branches  of  the  vagi.  The  respiratory 
movements  increase  in  force,  and  the  irritation 
irradiates  into  the  centres  of  other  movements 
besides  those  directly  concerned  in  respiration, 
giving  rise  to  the  expiratory  convulsions  which 
have  been  ascribed  by  some  to  excitation  of  a 
special  ‘convulsion-centre’  (Krampf centrum). 

The  respiratory  centres  ultimately  become 
paralysed,  but  subsequently  to  those  of  conscious 
activity — the  brain ; and  of  reflex  action — the 
spinal  cord. 

The  circulation  of  non- oxygenated  blood  like- 


wise causes  contraction  of  the  arterioles  from  irri- 
tation of  the  vaso-motor  centre.  Increased  resist- 
ance is  thus  offered  to  the  heart,  and  this  is  inten- 
sified by  the  convulsive  muscular  efforts.  Tho 
arterial  tension  rises.  The  resistance  to  the 
flow  through  the  capillaries  by  contraction  of  the 
minute  blood-vessels  occurs  net  only  in  the  sys- 
temic, but  also  in  the  pulmonary  circulation. 
Hence  there  is  resistance  both  to  the  arterial  and 
venous  side  of  the  heart.  The  ventricles  become 
distended,  and  the  heart’s  action  laboured.  The 
heart  becomes  enfeebled  by  the  circulation  of 
non-oxygenated  blood  in  its  walls,  the  diastolic 
intervals  become  longer,  until  the  heart  finally 
stops  in  a state  of  diastole,  with  the  right  side 
full,  while  the  left  may  have  succeeded  in  empty- 
ing itself 

Treatment.  — Resuscitation  from  pureasphyxia 
is  possible  so  long  as  the  heart  continues  to  beat. 
After  cessation  of  the  heart’s  action  treatment  is 
unavailing,  except  in  cases  of  cessation  from 
mere  over-distension,  in  which  bleeding  from  the 
external  jugular  vein  may  be  resorted  to  with 
success.  The  chief  indication  in  the  treatment 
of  asphyxia  is  to  effect  oxygenation  of  the  blood 
by  the  introduction  of  air  into  the  lungs.  If  the 
medium  by  which  the  patient  is  surrounded  is 
incapable  of  supporting  respiration,  he  must 
be  immediately  removed,  or  the  atmosphere 
changed.  If  the  air-passage  is  obstructed  by 
a foreign  body;  this  must  be  extracted ; if  this  is 
impossible,  or  if  the  obstruction  resultfrom  disease, 
tracheotomy  or  laryngotomy  must  be  resorted  to. 
Means  must  be  adopted  of  exciting  the  respiratory 
centres  or  respiratory  muscles  to  action  ; or  if 
these  are  paralysed  and  non-excitable,  the  natural 
movements  of  respiration  must  be  imitated  arti- 
ficially, or  air  introduced  by  insufflation. 

The  respiratory  centres,  if  not  absolutely  para- 
lysed, may  be  excited  reflexly  by  stimulation  of 
cutaneous  nerves,  especially  those  of  the  face  and 
thorax.  This  may  be  effected  bythe  stimulus  of 
sudden  cold,  or  better  by  alternate  dashing  of  hot 
and  cold  water  on  the  face  and  chest,  or  by  flick- 
ing the  skin  with  a towel.  These  reflex  stimuli 
are  often  of  themselves  sufficient  to  excite  respi- 
ratory movements ; if  not,  they  are  powerful 
subsidiary  aids  to  artificial  respiration.  The 
diaphragm  may  be  stimulated  to  contraction  by 
galvanisation  of  the  phrenic  nerve,  one  pole  be- 
ing placed  on  the  nerve  as  it  crosses  the  scalenus 
anticus  at  the  root  of  the  neck,  the  other  on  the 
epigastrium.  Chief  reliance,  however,  is  to  be 
placed  on  the  methods  of  artificial  respiration, 
which,  after  all,  are  the  most  simple  and  the  most 
effectual,  and  possessed  of  the  pre-eminent  ad- 
vantage of  being  always  available.  See  Aifriri 
cial  Respiration. 

Air  may  also  be  introduced  into  the  lungs  di- 
rectly by  properly  constructed  insufflation-appa- 
ratus, either  by  the  insertion  of  a tube  within 
the  larynx  (an  operation  requiring  dexterity,  but 
without  danger  if  skilfully  performed,  though 
there  is  always  risk  of  rupture  of  the  air-vesicles 
from  over-distension) ; or  more  easily  by  the  in- 
sertion of  the  tube  in  one  nostril,  the  other 
nostril  and  the  mouth  being  closed  (Richardson’s 
apparatus).  Mouth-to-mouth- insufflation  is  some- 
times of  advantage,  especially  in  infants.  Tho 
operator  must  close  the  nostrils  of  the  pnti-mt. 


ASPHYXIA. 

lud,  applying  his  mouth  directly  to  that  of  the 
patient,  inflate  the  lungs  by  his  own  expiratory 
efforts.  The  tendency  to  inflation  of  the  sto- 
trach  is  considerably  counteracted  by  backward 
pressure  ou  the  larynx.  D.  Eeeeiek. 

ASPIRATOR. — Syxon.  : Fr.  Aspirateur. — 
The  operation  of  Pneumatic  Aspiration  was  intro- 
duced into  practice  by  Dieulafoy  in  1S69.  Before 
this  period  various  instruments  had  been  used 
under  the  name  of  ‘ suction-trochars,’  but  to 
Dieulafoy  is  due  the  credit  of  fully  appreciating 
their  value. 

DeSCEIPTION  ANT)  MODE  OF  EMPLOYMENT. 

The  aspirator  consists  of  a glass  syringe,  having 
at  its  lower  end  two  openings  provided  with  stop- 
cocks. When  the  piston  is  raised  and  the  cocks 
are  closed  a vacuum  is  ereatedin  the  syringe,  which 
can  be  maintained  by  fixing  the  piston  in  the 
withdrawn  position.  An  india-rubber  tube  is 
fitted  into  each  of  the  two  openings,  and  these 
must  be  provided  with  coils  of  wire  inside  to 
prevent  them  from  collapsing.  At  the  end  of 
one  tube  is  fixed  a fine  hollow  needle.  The 
needle  should  have  only  one  opening,  at  the  point, 
and  not,  as  is  often  seen,  another  at  some  dis- 
tance from  it.  The  instrument  is  thus  used: — 
A vacuum  having  been  created  in  the  syringe 
by  raising  the  piston  whilst  both  stop-cocks  are 
closed,  the  needle  is  introduced  into  the  part  to 
be  operated  upon.  As  soon  as  the  opening  of  the 
needle  is  beneath  the  skin  the  stop-cock  leading 
to  it  must  be  opened.  The  vacuum  will  then 
extend  to  the  point  of  the  needle ; and  conse- 
quently, if  it  be  gently  pushed  onwards  the  mo- 
ment it  encounters  fluid,  this  will  jet  up  into  the 
glass  syringe,  when  its  nature  may  be  ascertained. 
This  mode  of  operating  with  what  Dieulafoy' calls 
the  ‘previous  vacuum’  is  the  essential  difference 
between  aspiration  and  suction.  In  aspiration 
it  is  impossible  to  pass  the  needle  through  a 
collection  of  fluid  without  discovering  it ; whereas 
without  the  ‘ previous  vacuum’  in  the  needle  this 
might  readily  be  done.  If  the  fluid  is  sufficient 
in  amount  to  fill  the  syringe,  the  stop-cock  lead- 
ing to  the  needle  is  to  be  closed  and  the  other 
opened,  by  which  the  fluid  may  be  discharged. 
The  vacuum  may  then  be  re-established,  and  the 
operation  repeated  as  often  as  is  necessary.  By 
opening  both  stop-cocks  at  once  and  allowing  the 
discharge  tube  to  hang  down,  the  aspirator  may 
be  converted  into  a syphon.  The  action  of  the 
instrument  may'  also  be  reversed,  and  it  may  be 
employed  for  injecting  fluids.  Other  varieties  of 
aspirator  are  in  use  besides  the  one  above  de- 
scribed. In  Weiss's  the  receiver  is  a glass  bottle, 
from  which  the  air  is  exhausted  by  means  of  a 
separate  exhausting  syTinge.  The  objection  to 
this  is  that  if  the  needle  becomes  choked,  it  can- 
not be  cleared  by  pushing  down  the  piston  and 
driving  some  of  tho  fluid  back  through  it.  Other 
kinds  of  aspirator  cannot  be  converted  into 
syphons,  and  these  are  objectionable.  Weiss’s 
has  the  advantage  of  being  less  liable  to  get  out 
of  order,  as  the  fluid  does  not  touch  the  ex- 
hausting syringe.  The  needles  employed  vary 
in  size.  Dieulafoy  recommends  that  they  should 
be  about  i and  Jj  of  an  inch  in  diameter, 

and  calls  them  Nos.  1,  2,  3,  and  4 respectively. 
Tlte  aspirator  may  also  be  applied  to  trochars, 


ASHRATOR.  89 

but  then  ♦ts  distinctive  feature  is  gone,  and  it 
becomes  but  a ‘ suction  trochar.’ 

The  following  rules  must  always  be  observed 
in  using  the  aspirator.  1st.  See  that  the  needle 
is  pervious  and  clean  and  the  syringe  in  order 
before  using  it.  It  is  advisable  to  wash  the 
needle  well  in  strong  carbolic  acid  solution.  2nd. 
The  needle  must  be  pushed  straight  on  in  one 
direction  only.  Its  course  must  never  be  altered 
while  the  point  is  under  the  skin.  If  no  fluid 
is  found,  it  may  be  withdrawn  and  reinserted. 
It  must  be  held  as  steady'  as  possible  during  the 
aspiration.  3rd.  If  the  fluid  will  not  flow  with 
the  force  of  the  vacuum,  it  is  of  no  use  squeezing 
and  pressing  the  part.  This  can  only  do  harm. 
4th.  Aspiration  must  cease  at  once  when  blood 
comes  in  any  quantity,  especially  in  abscesses. 
5th.  Keep  up  the  vacuum  during  tho  withdrawal 
of  the  needle,  lest  some  of  the  morbid  fluid  be  left 
in  its  track.  6th.  If  the  needle  becomes  choked, 
force  a little  of  the  fluid  back  through  it  in  order 
to  clear  it. 

Uses. — Aspiration  is  used  for  purposes  of 
diagnosis  and  treatment.  Dieulafoy  asserts  that 
with  the  No.  1 needle  it  is  possible  to  search  for 
fluid  without  danger,  whatever  may  be  its  seat  or 
its  nature  ; and  experience  has  proved  this  to 
be  practically  true.  In  treatment  it  has  been 
employed  in  the  following  affections : — 

Abscesses.— In  acute  abscesses  aspiration  is 
usually  of  little  value,  as  the  pus  soon  re-aceumu- 
lates.  In  chronic  abscess  connected  with  diseased 
bone  it  usually  fails;  and  often  it  is  impossible, 
from  the  amount  of  cheesy  matter  in  the  pus.  In 
chronic  abscesses  unconnected  with  bone  it  some- 
times effects  a complete  cure  after  three  or  four 
repetitions.  It  has  proved  successful  in  curing 
perinephritic  abscess  in  the  writer's  experience. 
It  is  always  well  in  chronic  abscesses  of  doubtful 
origin  to  give  this  mode  of  treatment  a trial.  It 
must  bo  remembered  in  treating  large  chronic 
abscesses  that  a dirty  needle  may  lead  to  decom- 
position of  their  contents.  Diseases  of  the  Liver. 
— Hydatid  cysts  have  been  successfully  treated  by 
aspiration.  In  many  cases  the  fluid  becomes 
purulent  after  one  or  two  aspirations,  and  in 
some  the  cyst  has  opened  externally.  Eor  pur- 
poses of  diagnosis  the  small  needles  may  always 
safely  be  thrust  into  the  liver.  Abscess  of  the 
li  ver  has  been  successfully  treated  by  th  e aspirator. 
Retention  of  Urine  may  always  be  safely  relieved 
by  using  No.  2 needle  above  the  pubes.  Ovarian 
cysts  may  be  diagnosed  and  treated  in  the  same 
way.  Hernia. — It  has  been  asserted  that  stran- 
gulated hernia  may  be,  in  the  great  majority  of 
cases,  relieved  by  the  use  of  the  aspirator.  The 
finest  needles  only  should  be  used.  They  remove 
first  the  fluid  from  the  sac,  after  which  some  gas 
may  be  obtained  from  the  strangulated  gut,  but 
fsecal  matter  rarely  fails  to  choke  the  tube.  In 
this  country  surgeons  have  not  succeeded  in 
sufficiently  emptying  the  gut  to  allow  of  its 
reduction.  Experience  has.  however,  shown  that 
if  the  needle  be  kept  steady,  any  number  of 
punctures  may  be  safely'  made  into  the  gut. 
Diseases  of  Joints. — Aspiration  is  occasionally 
useful  in  acute  synovitis.  Great  care  must  be 
taken  not  to  scratch  the  inside  of  the  joint 
with  the  needle,  as  this  has  been  known  to  lead  to 
acute  urtliritis  and  suppuration.  No.  1 or  2 needle 


30  ASPIRATOR. 


ASTHMA.  SPASMODIC. 


should  be  used.  Hydrocephalus  and  9pina  bifida 
may  be  aspirated  with,  safety  with  No.  1 needle. 
In  hydrocephalus  it  is  to  be  passed  through  the 
anterior  fontanelle.  No  case  has  hitherto  been 
cured  by  this  treatment.  In  Pleurisy  and  Ascites, 
except  for  purposes  of  diagnosis,  in  the  writer's 
opinion  the  aspirator  presents  no  advantages 
over  a trochar  properly  constructed  so  as  to 
exclude  air  (see  Paracentesis).  Pericarditis. — - 

The  operation  of  aspiration  has  frequently  been 
successfully  performed  for  pericardial  effusion. 
It  is  thus  carried  out : — A spot  is  chosen  2 to 
in.  (o  or  6 centimetres)  beyond  the  left  edge 
of  the  sternum,  in  the  4th  or  5th  interspace.  No. 
2 needle  is  then  passed  obliquely  upwards  and 
inwards,  taking  care  to  turn  on  the  vacuum  as 
soon  as  the  eye  is  covered.  The  moment  the 
fluid  jets  into  the  syringe  the  needle  must  be  held 
steadily  till  the  flow  ceases.  If  this  be  done 
there  is  no  danger  of  wounding  the  heart.  If 
there  is  any  doubt  as  to  the  existence  of  fluid, 
No.  1 needle  must  bo  employed,  with  which  the 
heart  may  be  punctured  without  great  danger. 

Marcus  Beck. 

ASTHENIA  1 , ... 

ASTHENIC/  (“.pn'Mando-eevos, strength). 

— Terms  signifying  want  of  strength.  As  applied 
to  the  entire  system,  they  indicate  considerable 
general  debility;  in  connexion  with  particular 
diseases,  they  imply  that  these  are  attended  with 
marked  weakness. 


ASTHENOPIA  (a,  priv.,  xdevos,  strength, 
and  the  eye). — Weakness  of  sight.  See 
Vision,  Disorders  of. 


ASTHMA,  SPASMODIC  {aaBfia,  from  &a, 
I blow),— Synon.  : Bronchial  Asthma.  Fr.  Asthmc ; 
6er.  Bronchial- Asthma. 

Definition. — An  affection  characterised  by 
severe  paroxysmal  dyspnoea,  recurring  at  more 
or  less  well-marked  periods,  generally  in  the 
night,  the  dyspncea  being  due  to  spasmodic  con- 
traction of  the  bronchi,  produced  by  a variety  of 
causes. 

^Etiology. — The  causes  that  induce  an  attack 
of  asthma  are  very  various,  and  may  be  roughly 
classed  according  to  their  action,  direct  or  in- 
direct, on  the  respiratory  organs.  In  the  former 
the  exciting  cause  immediately  affects  the  mucous 
membrane ; in  the  latter  it  does  so  in  a more 
circuitous  manner,  as  through  the  blood  or  the 
nervous  system  generally : — 


' Dust. 

Vegetable  irritants. 

Chemical  vapours. 

Animal  emanations. 

Climatic  influences. 

Bronchial  inflammation. 

' Through  the  ner-  f Centric, 
vous  system  . \ Excito-motor. 

Through  the  f 

blood  J syphiiM. 

| Skin  diseases. 
Heredity.  |_  Renal  diseases. 

Direct  causes. — Common  roadside  dust;  fluff 
from  woollen  clothing ; the  dust  of  mills,  threshing- 
floors,  or  bakehouses;  and  any  mechanical  parti- 
cles when  inspired,  will  produce  in  some  persons 
an  asthmatic  seizure,  dust  of  low  specific  gravity 
being  more  apt  to  have  this  effect  than  heavy 


Direct  i 


Indirect  < 


particles  like  coal,  steel  filings,  etc.,  from  which 
arise  lesions  in  the  lung  of  a more  permanent 
and  serious  character. 

The  odour  evolved  by  certain  vegetables,  such 
as  ipecacuanha ; the  pollen  of  many  grasses 
and  plants  {see  Hay-fever)  ; certain  chemical 
Vapours,  as  that  of  pitch,  sulphurous  acid,  and 
phosphorus  fumes;  the  peculiar  smell  of  some 
animals,  as  dogs,  cats,  horses,  and  hares,  may 
each  provoke  a spasm  in  individual  cases. 

A still  more  powerful  cause  is  climatic  in- 
fluence, the  action  of  which  on  different  patients 
cannot,  unfortunately,  be  reduced  within  the 
limits  of  law,  but  depends  mainly  on  the  idio- 
syncrasy of  the  individual.  Extremes  of  tempera- 
ture, or  excessive  dryness  or  dampness,  may  pro- 
duce an  asthmatic  seizure,  but  in  the  largest 
number  of  cases  one  of  two  elements  appears  as 
the  chief  factor.  One  large  class  of  sufferers 
trace  the  attack  to  dampness,  whether  of  soil  or 
of  atmosphere,  in  combination  with  either  heat 
or  cold ; another  to  closeness  of  atmosphere  and 
a want  of  proper  circulation  of  air,  such  as  is 
found  in  deep  valleys  and  thick  forests,  and  during 
thundery  weather — this  last  class  experiencing 
great  relief  when  a breeze  springs  up.  Malaria 
plays  an  important  part  occasionally  in  the  causa- 
tion of  asthma. 

Far  more  general  and  intelligible  in  its  action 
is  bronchial  inflammation,  which  is  the  cause 
in  80  per  cent,  of  asthmatic  cases.  It  frequently 
happens  that  after  whooping  cough,  measles,  or 
infantile  bronchitis  the  tendency  towards  asthma 
begins  to  appear.  These  diseases,  implicating 
as  they  do  both  bronchial  muscle  and  nerve  sup- 
plying it,  leave  their  mark  behind,  either  in  irri 
tability  of  the  mucous  membrane ; in  induration 
of  some  portion  of  the  lung,  generally  at  t.he 
root;  or  in  enlargement  of  the  bronchial  glands, 
causing  pressure  on  the  pneumogastrics,  or  on 
some  of  the  branches  of  the  pulmonary  plexuses 
{see  Bronchial  Glands,  Diseases  of ) ; and  thus  we 
often  find  that  the  diseases  which  implicate  the 
bronchial  tubes  in  childhood  lay  the  foundation 
of  asthma  in  after-life. 

Indirect  causes. — This  class  of  causes  includes 
those  acting  through  the  general  nervous  system  : 
those  acting  through  the  blood  ; as  well  as  tile 
more  or  less  structural  on9  of  heredity. 

The  centric  subdivision  embraces  attacks 
arising  from  emotion,  anger,  or  fright ; as  well  as 
the  curious  alternations  of  asthma,  neuralgia, 
angina,  and  gastralgia  due  to  some  centric  irri- 
tation in  the  medulla,  involving  the  origins  of 
the  fifth  and  eighth  pairs  of  nerves,  and  mani- 
festing itself  by  affecting  first  one  branch  and 
then  another  of  these  nerves. 

Excito-motor  causes  may  be  illustrated  by  indi- 
gestion or  costive  bowels  giving  rise  to  a paroxysm 
of  asthma.  In  the  first  case,  irritation  of  the 
medulla  is  induced  through  the  gastric  branches 
of  the  pneumogastric,  and  a motor  effect  is  re- 
flected through  the  pulmonary  branches.  These 
peptic  attacks,  as  they  are  called,  occur  more 
frequently  after  suppers  than  dinners,  probably 
because  reflex  irritability  is  always  exalted  bv 
sleep,  as  we  know  to  be  the  case  in  epilepsy 
and  the  teething  convulsions  of  childhood. 

Gout,  towards  old  age,  often  takes  the  form 
of  asthmatic  seizures,  which  alternate  with  the 


ASTHMA,  SPASMODIC. 


articular  affections.  In  like  manner  attacks  of 
the  disease  have  been  attributed  to  syphilis. 

The  connexion  between  asthma  and  various 
kinds  of  skin-disease  is  intimate ; the  sub- 
sidence of  eczema,  of  urticaria,  or  of  psoriasis, 
lias  often  been  accompanied  by  fits  of  spasmodic 
breathing,  which  have  ceased  on  the  reappearance 
of  the  eruptions.  Here,  again,  the  state  of  the 
blood  is  presumed  to  be  the  origin  of  both 
maladies,  as  in  disease  of  the  kidneys,  which  will 
ba  again  referred  to. 

Heredity  can  be  traced  in  about  40  per  cent,  of 
asthmatics,  though  the  tendency  often  does  not 
show  itself  till  late  in  life.  The  characteristic 
form  of  chest  is  often  transmitted  from  parents 
to  children  ; and  even  when  this  is  not  so,  a 
disposition  towards  spasmodic  symptoms  in 
catarrhal  attacks  is  often  seen  in  the  children 
of  some  asthmatics. 

Symptoms. — The  patient  retires  to  bed  with 
few  or  no  premonitory  symptoms,  and  sleeps 
for  some  hours,  but  is  disturbed  in  the  late'  night 
or  early  morning— two  a.m.  is  a common  time 
— by  a feeling  of  oppression  approaching  to 
suffocation,  referred  either  to  the  throat,  ster- 
num, or  epigastrium,  which  obliges  him  to  sit  up  in 
order  to  breathe.  Sometimes  the  onset  is  more  gra- 
dual ; the  patient,  having  fallen  asleep  in  spite  of 
uneasy  sensations,  begins  to  wheeze  during  sleep, 
and  is  only  aroused  when  the  dyspnoea  becomes 
severe.  The  breathing  is  accompanied  by  a hum- 
ming sound,  which  gradually  developes  into  a 
great  variety  of  discordant  noises. 

In  order  to  increase  the  capacity  of  his  chest 
to  the  utmost,  the  asthmatic  patient  sits  up  and 
fixes  his  shoulders,  either  by  placing  his  hands 
on  either  side  of  him,  or  by  supporting  his 
elbows  by  his  knees ; or  sometimes  he  stands 
leaning  over  the  back  of  a chair  or  other  support. 
In  one  or  other  of  these  positions  he  remains  im- 
movable, with  chest,  back,  shoulders,  and  head 
fixed ; unable  to  speak  or  even  to  move  his  head  ; 
the  lips  beingparted;  theface  pale,  anxious,  and,  if 
the  dyspnoea  continue,  livid;  and  the  eyes  pro- 
minent and  watery.  Every  muscle  of  respiration, 
ordinary  and  extraordinary,  is  brought  into 
requisition;  those  passing  from  the  head  to 
the  shoulders,  to  the  clavicles,  and  to  the  ribs 
become  rigid,  and,  in  place  of  moving  the  head 
and  neck,  act  the  reverse  way,  being  used  as 
fixed  points  to  raise  and  dilate  the  thorax.  The 
trapezii  and  levatores  anguli  scapulse  by  their 
contraction  elevate  the  shoulders,  in  order  that 
the  muscles  connecting  these  with  the  ribs  may 
act  as  elevators  to  the  latter.  Even  the  muscles 
of  the  back  are  pressed  into  the  service,  and 
they  almost  cease  to  support  the  back ; conse- 
quently the  patient  stoops.  At  each  inspiration 
the  sterno-cleido-mastoids  stand  out  like  cords, 
leaving  a deep  hollow  between  their  sternal  at- 
tachments; the  diaphragm  is  contracted,  and 
hence  the  stomach,  liver,  and  heart  are  some- 
what displaced.  With  all  this  display  of  mus- 
cular force,  the  chest  remains  almost  motionless, 
being  expanded  to  a variable  extent. 

In  spite  of  the  great  dyspncea,  respirations  are 
not  proportionately  frequent,  seldom  exceeding 
thirty,  and  sometimes  falling  to  nine  a minute. 
The  expiration  is  prolonged,  being  generally  two 
sr  three  times  as  long  as  the  inspiration.  The 


91 

pulse  is  usually  slow  and  feeble;  the  temperature 
rarely  exceeds  99°  Eahr.,  and  is  often  below  98° 
Fahr.  Analysis  of  the  expired  air  shows  the 
oxygen  to  bo  almost  entirely  replaced  by  carbonic 
acid,  which  may  increase  from  the  normal  to  as 
much  as  1 1 per  cent.,  the  nitrogen  varying  from 
89  to  93  per  cent.  The  arrest  of  expiration  is 
probably  the  cause  of  the  accumulated  carbonic 
acid,  but  the  total  disappearance  of  the  oxygon 
is  hardly  to  be  explai  ned,  for  that  oxidation  of 
the  tissues  does  not  pr.  iceed,  is  shown  by  the  pale 
urine  passed  after  the  fit. 

Physical  Signs. — These  reveal  less  than  might 
be  expected.  The  percussion-note  is  somewhat 
raised  over  the  whole  chest,  most  so  in  the  pos- 
terior regions,  where  a drum-like  sound  occa- 
sionally prevails  : this  hyper-resonance  is  pro- 
bably due  to  accumulation  of  air  induced  by  ob- 
structed expiration,  and  in  incipient  cases  passes 
off  with  the  attack. 

Auscultation  shows  an  entire  abolition  of  the 
normal  breath-sounds,  and  the  existence  of  dry 
sibilant  or  sonorous  rhonchi,  everywhere  varying 
in  tone  according  to  the  calibre  of  the  bronchial 
tubes  ; the  smaller  ones  giving  the  high  notes, 
and  the  larger  ones  the  deep  notes.  These 
sounds  continually  change  their  position,  spring- 
ing up  under  the  listening  ear,  and  as  quickly 
vanishing  again  to  give  place  to  profound  silence. 

Pbogbess  and  Dubation.— A paroxysm  of 
asthma,  when  once  established,  lasts  from  half 
an  hour  to  several  days,  and  generally  terminates 
with  expectoration — thin  and  transparent  if  the 
seizure  be  short ; but  abundant  and  more  or 
less  opaque  if  the  fit  be  prolonged,  or  if  the  case 
be  chronic.  The  urine  is  light-coloured  and 
plentiful ; and  flatus  is  often  expelled  from  the 
bowels.  Little  or  no  food  is  taken  during  the  at- 
tack, at  the  close  of  which  the  patient  falls  asleep. 

The  recurrence  of  the  attacks  when  once  they 
have  been  excited  is  generally  periodic,  but 
much  depends  on  the  presence  or  absence  of  the 
exciting  cause.  In  many  cases  the  patient  is 
quite  free  from  wheezing  and  dyspncea  in  the 
intervals,  and  feels  and  acts  like  other  people ; 
but  when  the  attacks  follow  each  other  closely, 
a more  or  less  wheezy  condition  remains  behind, 
and  a few  signs  of  obstructed  breathing  are 
generally  to  be  detected  in  the  interseapular 
regions. 

Complications  and  Sequelzg. — If  the  asth- 
matic attacks  become  habitual,  their  effects  are 
seen  on  the  frame  and  on  the  organs  implicated. 
The  shoulders  becom  e raised,  the  head  being  buried 
between  them ; the  muscles  of  the  back,  owing  to 
their  being  called  on  to  act  as  extraordinary 
muscles  of  respiration,  are  diverted  from  their 
use  as  erectors  of  the  spine,  which,  accordingly, 
yields  in  the  anterior  direction,  and  the  patient 
stoops.  The  frequent  occurrence  of  spasmodic 
contraction  of  the  bronchi  causes  hypertrophy  of 
their  muscular  coat ; and  this,  with  or  without  the 
congestion  of  the  mucous  membrane  accompany- 
ing it,  leads  in  time  to  thickening  of  the  tubes 
and  permanent  narrowing  of  their  calibre.  The 
more  common  result  of  asthma  is  emphysema, 
arising  from  the  difficulty  of  expiration.  The 
emphysema,  at  first  temporary,  becomes  in 
chronic  cases  permanent,  and  gives  rise  to  dis- 
placement of  the  adjoining  organs  (see  Emphv- 


ASTHMA,  SPASMODIC. 


32 

6EMA.).  Contraction  of  the  bronchia  largely 
influences  the  pul  mouary  vessels,  and  considerable 
obstruction  of  the  pulmonary  circulation  is  the 
result.  The  vessels  become  gorged,  and  some- 
times the  lungs  oedematous.  If  the  emphysema 
be  extensive,  we  may  in  time  expect  dilatation 
of  the  right  side  of  the  heart  and  marked  pro- 
minence of  the  veins  of  the  breast  and  neck,  and 
the  effects  may  be  carried  so  far  as  to  cause 
cedema  of  the  lower  extremities  with  albuminous 
urine,  as  the  writer  witnessed  in  a case  where 
the  latter  symptoms  disappeared  on  the  sub- 
sidence of  the  asthma. 

Pathology.— Patients  rarely,  if  ever,  die  of 
spasmodic  asthma,  though  death  may  ensue  from 
some  of  its  complications  and  sequel® ; and  the 
disease  being  a functional  one,  cannot  be  said 
to  have  any  morbid  anatomy.  The  onset  and 
departure  of  the  attack,  and  the  ever-changing 
physical  signs,  led  Laennec  to  think  that,  what- 
ever obstruction  in  the  bronchial  tubes  caused  the 
phenomena,mustbe  of  a spasmodic  and  transitory' 
nature.  He  therefore  concluded  that  asthma  was 
due  to  a spasm  of  the  bronchial  muscles  which 
had  been  described  by  Eeisseissen.  Laennec  also 
showed  that  an  asthmatic  sufferer  could  some- 
times, after  holding  his  breath,  actually  breathe 
naturally  for  one  or  two  respirations,  thus  clearly 
demonstrating  that  the  spasm  was  capable  of 
momentary  relaxation.  Other  theories  were 
put  forward,  and  doubt  was  thrown  on  the  exist- 
ence of  muscular  fibres  in  the  bronchi,  until 
Dr.  C.  J.  B.  Williams  proved  their  existence  by 
his  experiments  on  the  lungs  of  oxen,  dogs, 
rabbits,  and  other  animals,  when  he  caused  con- 
traction of  the  trachea  and  bronchial  tubes  by 
the  application  of  electrical,  chemical,  and  me- 
chanical stimuli.  The  muscular  coat  was 
shown  to  be  more  abundant  in  the  smaller 
tubes  than  in  the  larger,  the  former  contracting 
sufficiently  to  entirely  obliterate  their  passages. 
In  asthma,  excitation  of  the  muscle  probably 
takes  place  through  the  anterior  and  posterior 
pulmonary  plexus,  which  are  made  up  of 
branches  from  the  pneumogastrics,  recurrent 
laryngeals,  the  spinal  nerves,  and  the  ganglia 
of  the  sympathetic,  thus  giving  the  bronchial 
tubes  a very  wide  area  of  connections.  The 
branches  of  the  pulmonary  plexus  form  a net- 
work round  the  bronchial  tubes,  and  contain 
some  mmute  ganglia.  When  the  cause  is  direct, 
ns  dust  of  any  kind  or  climatic  influence,  the 
spasm  may  be  induced  by  reflex  action  through 
these  small  ganglia,  or  through  the  pulmonary 
plexus,  though  it  soon  extends  deeper  into  the 
nervous  system,  involving  the  pneumogastrics, 
and  causing  a motor  effect  on  the  thoracic  mus- 
cles through  the  upper  cervical,  phrenic,  and 
dorsal  nerves.  Where  emotion,  fright,  or 
laughter  starts  the  fit,  the  irritation  is  centric, 
and  causes  a motor  effect  on  the  pulmonary  plexus 
through  the  pneumogastrics.  W'here,  again, 
indigestion  excites  it,  the  sensation  passes 
through  the  gastric  branches  of  the  pneumo- 
gastric,  and  is  reflected  by  the  motor  filaments 
of  the  pulmonary  plexus.  Lastly,  whore  gout, 
syphilis,  skin-disease,  and  heredity  are  the  exci- 
tants, we  may  regard  the  blood  itself  aa  causing 
tlie  local  irritation.  Spasmodic  asthma  may, 
therefore,  be  considered  as  a neurosis  of  the  pul- 


monary branches  of  the  plexus  of  that  name 
similar  to  other  neuroses,  as  hemicrania  and 
sciatica,  and  giving  rise  through  the  motor 
nerves  of  the  plexus  to  spasm  of  the  bronchial 
muscle. 

Diagnosis. — Asthma  is  distinguished  from 
bronchitis  by  the  fugitive  physical  signs;  by 
the  spasmodic  character  of  the  dyspnoea;  andbv 
the  scant  expectoration.  The  breathing  in  bron- 
chitis, if  at  all  difficult,  is  hurried  ; in  asthma 
it  is  slow,  wheezy,  and  prolonged ; this  feature 
also  contrasting  strongly  with  the  gasping,  pant- 
ing dyspnoea,  generally  accompanying  pneumonia, 
pleurisy,  and  some  forms  <5f  heart-disease.  From 
croup  it  is  recognised  partly,  but  not  entirely, 
by  the  age  of  the  patient ; and  partly  by  the 
character  of  the  dyspnoea,  which  in  croup  is 
inspiratory,  whereas  in  asthma  it  is  mainly  ex- 
piratory. This  characteristic  also  distinguishes 
asthma  from  spasm  of  the  glottis  and  the  various 
forms  of  laryngeal  dyspnoea.  The  diagnosis  from 
emphysema,  which  is  so  often  mixed  up  with 
spasmodic  asthma,  is  founded  chiefly  on  the 
paroxysmal  character  and  violence  of  the  asth- 
matic dyspnoea;  and  on  the  complete  freedom  of 
the  intervals,  the  dyspnoea  of  emphysema  being 
more  or  less  permanent. 

Aneurism  of  the  aorta  and  other  mediastinal 
tumours  often  give  rise  to  symptoms  so  exactly 
simulating  spasmodic  asthma  as  to  make  the 
diagnosis  difficult,  and  this  is  to  be  accounted  for 
by  these  tumours  pressing  on  the  pneumognstric 
and  its  branches,  and  thus  inducing  an  asthmatic 
spasm.  These  cases  are,  as  a rule,  however, 
accompanied  by  a certain  amount  of  stridor 
arising  from  laryngeal  spasm,  not  present  in 
asthma,  and  this  symptom  is  often  of  great 
diagnostic  value  in  obscure  cases.  As  the 
tumour  enlarges,  it  causes  greater  pressure  on 
the  lungs,  trachea,  oesophagus,  sympathetic 
ganglia,  or  other  structures,  and  produces  shrill- 
cough,  dysphagia,  difficulty  of  inspiration,  pain 
in  the  chest,  impulse  in  the  thoracic  wall,  and 
other  noted  aneurismal  symptoms.  Moreover, 
certain  physical  signs  become  evident,  e.g.  dulness 
over  the  first  portion  of  sternum  or  to  the  right 
of  it,  or  between  the  scapula- ; tubular  sounds  and 
bronchophony  close  to  the  sternum,  or  above  one 
or  both  scapulae  ; or  some  form  of  bruit  or  mur- 
mur in  the  course  of  the  aorta.  These  and  other 
symptoms  and  signs  contrast  sufficiently  with 
those  of  spasmodic  asthma,  to  make  the  diagnosis 
from  developed  aneurism  comparatively  easy. 

In  some  cases  of  renal  disease  a form  of 
dyspnoea  appears,  which  is  occasionally  marked 
by  paroxysmal  features,  and  has  been  mistaken 
for  spasmodic  asthma.  Benal  dyspncea  differs, 
however,  as  a rule,  in  being  more  eontinuons : and 
in  having  for  its  origin  oedema  of  the  lung  rather 
than  bronchial  spasm. 

Prognosis. — The  question  of  recovery  in  cases 
of  asthma  depends  to  a certain  extent, — 

Firstly,  on  the  possibility  of  the  removal  of 
the  exciting  cause ; 

Secondly',  on  the  age  of  the  patient; 

Thirdly,  on  whether  the  attacks  increase  or 
not  in  frequency ; 

Fourthly,  on  the  condition  of  the  lungs  and 
breathing  in  the  intervals. 

If  the  patient  be  young  (say,  under  fifteen),  the 


ASTHMA,  SPASMODIC. 


;hest  -well-formed,  the  attacks  tending  to  diminish 
in  frequency  and  intensity,  and  the  lungs  free  in 
the  intervals,  a most  hopeful  prognosis  can  bo 
given.  If,  on  the  other  hand,  the  patient  be 
middle-aged,  the  attacks  increasing  in  number 
and  severity,  and  the  breath  more  or  less  short 
in  the  intervals,  we  may  conclude  that  there 
exists  a considerable  amount  of  permanent  em- 
physema, which  renders  the  prognosis  of  an  tin- 
favourable  character.  In  every  instance  the 
detection  and  removal  of  the  exciting  cause  or 
causes,  us  the  case  may  be,  exercise  a chief  in- 
fluence over  the  prognosis. 

Treatment. — The  principal  difficulty  in  the 
treatment  of  asthma  lies  in  clearly  ascertaining 
the  origin  of  the  irritation,  and  when  this  is  dis- 
covered two  great  principles  should  guide  us, 
namely,  first,  to  avoid  or  remove  the  exciting 
cause ; secondly,  to  allay  and  prevent  the 
spasm. 

Many  of  the  cases  arising  from  direct  causes, 
as  from  dust,  chemical  vapours,  &c.,  are  cured 
by  simple  avoidance  of  the  exciting  cause. 
Where  bronchial  inflammation  induces  the 
spasm,  the  inflammation  must  be  subdued  by 
salines  and  expectorants,  combined  with  some 
anti-spasmodic,  as  belladonna,  henbane,  or 
stramonium.  In  more  chronic  instances,  where 
some  thickening  of  the  walls  of  the  larger  bronchi 
and  enlargement  of  the  bronchial  glands  exist, 
iodide  of  potassium  in  doses  of  grs.  iii.  to  x., 
has  been  found  beneficial  when  persisted  in  for 
long  periods.  "Where  the  attacks  depend  on 
a morbid  state  of  blood,  as  that  associated  with 
gout,  syphilis,  renal  disease,  or  connected  with 
skin  disease,  treatment  must  be  directed  to  the 
condition  of  this  fluid,  which,  if  improved,  will 
no  longer  induce  bronchial  spasm.  Arsenic 
proves  of  signal  service  in  asthma  co-existing 
with  eczema,  psoriasis,  and  other  skin-affections. 

• Where  heredity  is  the  predisposing  cause,  the 
origin  of  the  disease  lies  generally  in  defective 
development  of  the  frame  or  of  the  lung-struc- 
ture of  the  patient:  for  such  persons  gymnastic 
exercises,  swinging  on  the  trapeze,  and  other 
means  of  expanding  the  upper  part  of  the  chest 
and  correcting  the  asthmatic  stoop  are  to  be 
employed,  combined  with  cold  sponging  and  as 
much  outdoor  life  as  possible,  with  walking  and 
riding  in  moderation.  The  tendency  to  catarrh 
is  thus  lessened,  and  the  frame  of  the  patient 
developed  and  fortified.  In  a large  number  of 
cases,  as,  for  instance,  those  arising  from  cli- 
matic influences,  we  have  to  treat  a simple  neu- 
rosis, and  to  allay  the  spasm  either  by  climatic 
or  by  medicinal  means,  of  which  the  former 
is  often  the  more  important,  and,  owing  to 
tlie  leading  part  played  by  the  idiosyncrasy 
of  the  patient,  generally  the  most  difficult. 
In  obstinate  cases  the  doctrine  of  contrasts 
appears  the  only  safe  one.  Where  the  disease  has 
been  contracted  in  a moist  climate,  a dry  one 
must  be  tried ; if  in  an  inland  district,  the  seaside 
must  be  resorted  to  ; but  for  by  far  the  majority 
of  asthmatics  the  atmosphere  of  large  towns  is 
suitable,  and  the  smokier  the  air  and  the  closer 
the  streets  the  more  good  do  the  sufferers  appear 
to  receive.  London,  Glasgow,  Birmingham,  and 
Bristol  are  all  favourable  resorts  for  cases  of 
uourotie  asthma:  and  the  points  of  difference 


93 

between  their  atmospheres  and  that  of  the 
country  consist,  (1)  in  dryness  ; (2)  in  deficiency 
of  oxygen  ; and  (3)  in  excess  of  carbonic  acid 
and  carbon:  all  of  which  peculiarities  appear  to 
exercise  a sedative  effect  on  the  neurosis.  Damp, 
whether  of  soil  or  atmosphere,  is  usually  found 
to  be  hurtful,  and  is  one  of  the  chief  exciting 
causes  of  asthma. 

Tito  medicines  most  useful  in  asthma  are  anti- 
spasmodics,  either  stimulant  or  sedative  : the 
former,  including  alcohol,  strong  coffee,  spiritus 
setheris,  and  nitrite  of  amyl,  will  prove  more 
efficacious  where  emphysema  is  present;  the  latter 
comprise  stramonium,  belladonna,  Indian  hemp, 
lobelia,  tatula,  tobacco,  opium  with  its  salts, 
and  many  other  drugs.  These  may  be  taken  in- 
ternally in  the  form  of  extracts  or  tinctures ; 
or  smoked  in  pipes  or  as  cigarettes  ; or  inhaled 
as  vapour  diffused  through  the  room  by  burning 
papers  or  pastilles  containing  them.  A popular 
and  often  reliable  remedy  is  the  vapour  arising 
from  tlie  combustion  of  nitre- paper.  In  the 
severest  attacks  the  patient  can  neither  smoke 
nor  swallow,  and  in  this  difficulty  of  in- 
troducing medicines  into  his  system  we  find  the 
hypodermic  injection  of  atropine,  morphia,  and 
chloral  proves  effectual ; but  if  emphysema  be 
present,  or  if  the  pulse  be  weak,  it  must  not  be 
attempted.  Chloroform  often  acts  like  a charm 
in  the  worst  case,  and  after  inhaling  20  to  60 
minims  the  patient  will  gain  the  sleep  which 
has  been  denied  to  him  for  hours,  or  even  days  ; 
but  the  effect  is  generally  transitory,  and  the  uso 
of  the  remedy  not  free  from  risk.  Ether  is  safer, 
but  not  so  effective.  Chloral-hydrate  in  doses 
of  15  to  20  grs.,  repeated  every  four  hours 
until  the  spasm  subsides,  has  produced  not  only 
temporary,  but  even  permanent  good  in  a large 
number  of  asthmatic  cases,  and  if  watched,  may 
be  persisted  in  for  some  time.  In  the  writer's 
hands  it  has  proved  the  most  successful  remedy. 
In  tlie  use  of  anti-spasmodics  we  must  avoid 
judging  the  effects  of  one  from  the  failure  of 
another  of  tlie  same  class ; but  in  difficult  cases 
we  must  try^  each  in  succession — for  it  often 
happens  that  the  successful  remedyis  only  arrived 
at  after  repeated  trials. 

Certain  mineral  waters,  and  especially  those 
of  Mont  Dore  and  the  Pyrenean  sulphur  springe 
of  Eaux  Bonnes,  Eaux  Chaudes  and  Cauterets, 
are  reputed  to  exercise  a beneficial  influence 
over  asthma,  but  they  have  not  been  success- 
ful in  the  writer’s  experience,  and  it  is  more 
probable  that  they  relieve  by  reducing  the 
catarrhal  symptoms  than  that  they  either  allay 
the  spasm  or  prevent  its  recurrence. 

Compressed  air  baths  at  pressures  varying 
from  Sg-  to  7 inches  of  mercury,  and  lasting  two 
hours,  have  afforded  considerable  relief.  St  • 
Air,  Therapeutics  of. 

The  dietetic  treatment  varies  in  individual 
cases,  but  as  a ride  asthmatics  should  dine  early, 
and  for  the  rest  of  the  day  limit  themselves  to 
liquid  food,  such  as  beef-tea,  soups,  and  milk, 
combined  with  such  an  amount  of  stimulant  aa 
may  he  necessary,  thus  avoiding  any  distension 
of  the  stomach  and  intestines  before  retiring  to 
rest.  The  diet  should  consist  of  brown  bread, 
toast,  and  biscuits — excess  of  starch  in  any  form 
being  studiously  avoided — a fairsupply  of  plainly 


H ASTHMA,  SPASMODIC, 
looked  meat,  fish  or  poultry,  and  a limited 
amount  of  vegetables  and  fruit,  care  being  taken 
to  select  only  the  most  digestible  of  each  class. 

C.  Theodore  Williams. 

ASTIGMATISM  — ASTIGMISM  (a, 

priv.,  and  urly/ia,  a spot  or  point). — Want  of 
symmetry  in  the  anterior  refracting  surfaces  of 
the  eyeball,  in  consequence  of  which  rays  of  light 
proceeding  from  a point  cannot  be  brought  to  a 
focus  upon  the  retina  as  a point,  but  only  as  a 
diffused  spot.  See  Vision,  Disorders  of. 

ASTRINGENTS.  — Definition.  — Medi- 
cines which  cause  the  contraction  of  tissues. 

Enumeration. — The  chief  astringents  are  Ni- 
trate of  Silver;  Sulphate  of  Copper;  Sulphate  of 
Zinc;  Acetate  of  Lead;  Perchlorideof  Iron;  Alum; 
Tannic  and  Gallic  acids,  and  vegetable  sub- 
stances containing  them,  such  as  Oak  Bark,  Galls, 
Kino,  and  Catechu;  and  Dilute  Mineral  Acids. 
Some  authors  also  include  in  this  class  of 
remedial  agents  such  articles  as  Ergot  of  Eye, 
which  contracts  the  blood-vessels  and  lessens 
haemorrhage  after  it  has  been  absorbed  into  the 
blood,  although  it  has  no  local  astringent  action. 

Action. — With  the  exception  of  gallic  acid, 
the  substances  already  mentioned  coagulate  or 
precipitate  albumin.  Dilute  mineral  acids  do 
not  coagulate  albumin,  but  precipitate  many 
albuminous  bodies  from  the  alkaline  fluids  by 
which  they  are  held  in  solution.  When  ap- 
plied to  a surface  from  which  the  epidermis 
has  been  removed,  the  other  astringents  combine 
with  the  albuminous  juices  which  moisten  this 
surface,  as  well  as  with  the  tissues  themselves, 
and  form  a pellicle  more  or  less  thick  and  dense, 
which  in  some  measure  protects  the  structures 
beneath  it  from  external  irritation,  at  the  same 
time  that  they  cause  the  structures  themselves 
to  become  smaller  and  more  dense.  On  a mucous 
membrane  they  have  a similar  action,  and  they 
lessen  its  secretion.  It  was  formerly  supposed 
that  their  action  was  partly  due  to  their  caus- 
ing the  blood-vessels  going  to  a part  of  the 
body  to  contract,  thus  lessening  the  supply  of 
fluid  to  it ; as  well  as  to  their  effect  on  the 
tissues  themselves.  But  experiment  has  shown 
that,  while  nitrate  of  silver  and  acetate  of  lead 
possess  this  power,  perchlorideof  iron  and  alum 
do  not,  and  that  tannic  and  gallic  acids  actually 
dilate  the  vessels.  The  astringent  action  of  these 
latter  drugs  must  therefore  he  exerted  upon  the 
tissues. 

Uses. — Astringents  may  be  emploj'ed  locally 
in  various  forms.  In  the  solid  form,  as  a pow- 
der, or  in  various  preparations,  such  as  lotions, 
ointments,  plasters,  glycerines,  &c.,  they  are 
applied,  especially  the  metallic  astringents, 
to  wounds  and  ulcers  for  the  purpose  of 
reducing  the  size  and  increasing  the  firmness 
of  oxuberant  granulations,  as  well  as  of  pro- 
tecting the  surface  by  forming  a pellicle  over  it. 
They  are  used  to  lessen  congestion  and  diminish 
the  secretion  of  the  various  mucous  membranes 
— as  a lotion  to  the  eye  and  mouth ; as  a gargle 
or  a spray  to  the  throat;  in  the  form  of  an 
injection  to  the  nose,  urethra,  and  vagina ; and 
as  a suppository  to  the  rectum.  Administered 
internally  several  astringents  have  a powerful 
ofiVct  in  cheeking  diarrhoea,  and  certain  of  them 


ATHETOSIS. 

may  have  a local  action  upon  the  stomach  and 
intestines. 

The  remote  action  of  such  astringents  as 
acetate  of  lead  and  gallic  acid,  when  absorbed 
into  the  blood,  in  lessening  haemorrhage,  is  made 
available  in  the  treatment  of  haemoptysis,  haema- 
temesis,  haematuria,  and  loss  of  blood  from 
other  parts  of  the  body. 

T.  Lauder  Beuntox. 

ASTURIAN  ROSE. — The  rose  or  ery- 
thema of  the  Asturias ; one  of  the  numerous 
synonyms  of  Pellagra — Mai  de  la  rosa  ; Lepra 
Asturiensis ; Elephantiasis  Asturiensis.  See 
Pellagra. 

ATAVISM  ( atavus , a grandfather)  signifies 
the  inheritance  of  a disease  or  constitutional 
peculiarity  from  a generation  antecedent  to  that 
immediately  preceding. 

ATAXIA  j ,,  , ,,  , . 

ATAXIC  J Priv-’  and  t“£is>  order).  — 

Terms  which  originally  meant  any  irregularity 
or  disorder,  but  are  now  specially  applied  to  ir- 
regularity of  associated  or  co-ordinated  muscular 
movements.  The  noun  is  frequently  used  as 
synonymous  with  the  disease  known  as  Loco- 
motor Ataxy.  See  Locomotor  Ataxy. 

ATELECTASIS  (are\i;s,  imperfect,  and 
eKTatrts,  expansion). — Absence  or  imperfection  of 
the  expansion  of  the  pulmonary  alveoli  which 
normally  takes  place  at  birth,  the  lungs  thus 
remaining  more  or  less  in  their  fcetal  condition 
See  Lungs,  Collapse  of. 

ATHEROMA.  See  Arteries,  Diseases  of. 

ATHETOSIS  (fideToy,  without  fixed  po- 
sition).— Definition. — A name  given  by  Dr. 
Hammond  of  New  York  to  a condition  in  which 
the  hand  and  foot  are  in  continual  slow  irregular 
movement,  and  cannot  be  retained  in  any  position 
in  which  they  may  be  placed. 

Description. — The  special  character  of  the 
movements  in  athetosis  is  that  they  are  slow  and 
deliberate.  They  usually  affect  the  arm  and  leg  on 
one  side  only.  Voluntary  power  is  retained,  bntis 
interfered  with  by  the  slow  spasm.  The  fingers 
areirregularlyflexedandextended:  at  onemomeDt 
they  spread  wide  apart,  the  thumb  being  over- 
stretched; thereafter  first  one,  then  another  isbent 
in  to  the  palm,  and  again  extended.  The  move- 
ment can  be  arrested  for  a moment  in  certain 
positions  by  the  will,  but  is  renewed  with  in- 
creased force.  The  foot  is  usually  inverted;  the 
toes  being  flexed  or  extended,  but  in  less  constant 
movement.  The  spasm  may  cause  pain.  The 
muscles  sometimes  become  hypertrophied.  The 
movements  in  some  cases  cease  during  sleep,  in 
others  they  do  not.  Sensation  is  often,  but  not 
always  impaired.  The  onset  of  this  condition 
is  usually  sudden,  and  in  some  cases  with  a con- 
vulsion. The  subjects  bave  been  generally  in 
middle  life. 

Athetosis  differs  from  tho  spastic  contrac- 
ture so  common  after  hemiplegia  in  children 
in  the  slowness  and  spontaneity  of  the  move- 
ments ; but  the  two  conditions  are  probably  very 
closely  allied.  It  cannot  be  regarded  as  a 
distinct  disease.  Typical  athetosis  may  suc- 
ceed hemiplegia. 

Pathology.  — It  is  probable  that,  as  Dr. 


ATHETOSIS. 

Hammond  suggests,  the  seat  of  the  mischief  in 
athetosis  is  the  corpus  striatum  or  optic  thala- 
mus. The  sudden  onset  of  the  disease,  and  the 
slight  affection  of  sensation,  render  it  pro- 
bable that  a lesion  damaging,  but  not  destroy- 
ing, a portion  of  one  of  these  nuclei,  leads  to 
a perverted  action  of  the  nerve-cells,  so  that 
abnormal  motor  impulses  are  originated,  and 
those  transmitted  from  above  disturbed — 1 irra- 
diated’ (Nothnagel).  Charcot  believes  that  all 
post-hemiplegic  chorecrd  movements  depend 
on  the  implication  of  fibres  outside  the  optic 
thalamus.  In  a case  of  simple  ataxy  after  hemi- 
plegia— an  analogous  condition, — the  writer 
has  found  a cicatricial  sclerosis  extending  across 
the  optic  thalamus,  and  probably  left  by  a 
patch  of  softening. 

Prognosis. — This  is  unfavourable,  hut  the 
slighter  cases  improve  and  may  even  approxi- 
mately recover. 

Treatment. — Nervine  tonics  and  sedatives  are 
the  remedies  chiefly  indicated.  Of  the  former 
arsenic,  and  of  the  latter  Indian  hemp,  do  most 
good  ; bromides  are  also  useful.  The  continuous 
current  is  perhaps  the  agent  which  affords  most 
distinct  relief.  In  one  well-marked  case  under  the 
writer’s  care  the  spontaneous  movements  ceased 
entirely  after  some  months’  galvanisation. 
The  positive  pole  may  be  placed  on  the  spine 
or  brachial  plexus,  the  negative  on  the  muscles 
involved.  The  action  of  the  continuous  current  is 
probably  in  part  direct,  in  part  reflex,  lessening  by 
the  peripheral  impression  the  over-action  of  the 
centre,  as  do  some  other  peripheral  Impressions. 

W.  R.  Gowers. 

ATONY*  } Prir”  and  'rivo's'  tone)-— 

Terms  implying  want  of  tone,  power,  or  vigour, 
and  associated  either  with  such  a condition  of  the 
system  generally,  or  of  particular  organs,  espe- 
cially those  which  are  contractile. 

ATRESIA  (a,  priv.,  and  rlrpri/xi,  I pierce).— 
Absence  of  a natural  opening  or  passage,  whether 
congenital  or  caused  by  disease. 

ATROPHY,  GENERAL.— Synon.  : Ma- 
rasmus. 

Definition. — Atrophy  means,  etymologically, 
simply  want  of  nourishment  (a,  priv.,  and  rpoepr), 
nourishment),  but  the  term  is  commonly  applied 
to  the  condition  resulting  from  want  of  nourish- 
ment, namely,  wasting  or  diminution  in  bulk  and 
substance,  even  though  this  may  have  bpen  pro- 
duced by  some  other  cause,  and  even  though  the 
supply  of  nutritive  material  may  have  been 
abundant.  General  atrophy  is  used  to  denote 
wasting  in  which  the  whole  body  participates. 
All  acute  diseases,  if  severe,  are  accompanied  by 
emaciation,  for  at  such  times  nutrition  is  tem- 
porarily interfered  with.  The  use  of  the  word 
‘ atrophy  ’ is,  however,  confined,  as  a rule,  to 
cases  where  the  interference  with  nutrition  has 
been  gradual,  and  the  loss  of  flesh  consequently 
slow. 

^Etiology. — Atrophy  is  common  enough  at  all 
periods  of  life.  In  infants  and  children  it  is  duo. 
in  the  majority  of  cases,  to  chronic  functional 
derangements  which  interfere  with  the  digestion 
and  elaboration  of  food.  Less  frequently  it  is  a 


ATROPHY,  GENERAL.  9o 

consequence  of  organic  disease.  In  adults  general 
atrophy  seldom  results  from  any  other  cause  than 
organic  disease,  and  functional  disorder  as  a 
cause  of  serious  wasting  is  the  exception.  In  old 
age  atrophy  is  a common  consequence  of  the 
degenerations  of  tissue  which  accompany  the 
decline  of  life.  The  interference  with  nutrition 
may,  however,  be  aggravated  by  the  presence  of 
disease. 

In  infants  under  twelve  months  old  there  are 
four  principal  causes  to  which  chronic  wasting 
can  usually  be  referred,  namely,  unsuitable  food ; 
chronic  vomiting  (gastric  catarrh) ; chronic 
diarrhcea  (intestinal  catarrh) ; and  inherited 
syphilis.  Bad  feeding,  by  setting 'up  a chronic 
catarrhal  condition  of  the  stomach  and  bowels,  is 
a frequent  cause  of  both  vomiting  and  diarrhoea, 
but  it  may  produce  atrophy  without  either  of 
these  symptoms.  AVhen  an  infant,  is  fed,  for 
instance,  with  large  quantities  of  farinaceous 
matter — a form  of  food  which  is  alike  indiges- 
tible and  innutritious — a very  small  part  only 
can  enter  as  nutriment  into  the  system.  The 
remainder  passes  down  the  alimentary  canal,  and 
is  ejected  at  rare  intervals  in  an  offensive  putty- 
like mass  or  in  hard  roundish  lumps.  The  child, 
therefore,  although  overloaded  with  food,  is  really 
under-nourished,  and  loses  flesh  as  long  as  such 
a diet  is  persisted  in.  If,  as  often  happens, 
diarrhoea  or  vomiting  be  set  u p by  the  irritation 
to  which  the  digestive  organs  are  subjected, 
wasting  is  more  rapid  and  the  danger  of  the  case 
is  increased.  Any  form  of  bad  feeding,  and  not 
only  excess  of  farinaceous  matter,  will  produce 
this  result.  Wasting,  indeed,  will  he  found  in 
every  case  where  the  food  selected  is  unfitted  for 
the  child,  and  thus  it  is  not  unfrequently  seen  in 
infants  who  are  fed  upon  milk  and  water  alone. 
The  casein  of  cow’s  milk  is  difficult  of  digestion 
by  many  infants  on  account  of  its  tendency  to 
coagulate  into  a large  firm  clot  like  a lump  of 
cheese.  In  this  respect  it  differs  from  the  curd 
of  human  milk,  which  forms  light  small  floccu- 
lent  coagula,  and  is  digested  without  difficulty. 
Special  preparation  is  therefore  generally'  re- 
quired to  render  cow’s  milk  a suitable  diet  for  a 
young  child. 

It  is  not  only,  however,  unsuitable  food  which 
is  a cause  of  atrophy  in  infants.  Catarrh  of  the 
stomach  and  bowels  may  be  present,  although 
the  feeding  is  in  all  respects  satisfactory.  In- 
fants are  excessively  sensitive  to  chills,  ami 
catarrh  of  their  delicate  digestive  organs  is 
easily  excited.  Now,  catarrh  of  a mucous  mem- 
brane is  always  accompanied  by  an  increased 
flow  of  mucus,  and  this  alkaline  secretion  in 
excess  acts  as  a ferment  and  sets  up  decom- 
position of  food.  A sub-acute  gastric  catarrh 
from  this  cause  is  not  rarely  seen  in  new-born 
infants,  who  thus  are  rendered  for  the  timo 
incapable  of  digesting  even  their  mother's  milk. 
In  such  cases  the  fault  is  usually  attributed 
to  the  milk,  which  is  said  to  be  unsuited  to  the 
child;  and  the  mother  is  compelled,  much  against, 
her  will,  to  wean  her  baby  and  feed  it  in  a 
different  way.  So  long  as  the  catarrh  continues, 
however,  no  food  appears  to  agree,  and  the  child 
often  after  a time  dies  exhausted. 

Between  one  and  three  years  atrophy  is  • com- 
monly associated  with  rickets.  In  theso  cases 


9(j  ATROPHY,  GENERAL, 

the  wasting  is  noted  chiefly  about  the  chest  and 
limbs,  for  the  belly  is  large  and  swollen  from 
flatulent  accumulation.  At  this  age  children  are 
still  liable  to  waste  from  catarrh  of  the  stomach 
and  bowels:  indeed,  rickets  is  itself  often  com- 
plicated by  such  derangements.  Cancer  of  the 
internal  organs  is  also  sometimes  found  at  this 
time  of  life,  and  is  attended  with  extreme 
emaciation. 

AJ'ter  the  age  of  three  years  caseous  enlarge- 
ment of  the  mesenteric  glands  becomes  a cause  I 
of  wasting. 

After  the  fifth  or  sixth  year  chronic  pulmonary 
phthisis  begins  to  appear.  Cases  of  heart- 
disease  as  a result  of  acute  rheumatism  are 
also  more  frequently  seen.  Diabetes,  too,  is 
sometimes  met  with.  All  these  diseases  may  pro- 
duce much  interference  with  nutrition. 

From  the  time  that  the  child  begins  to  take 
other  food  than  that  furnished  by  his  mother's 
breast,  he  is  liable  to  worms  in  the  alimentary 
canal.  The  presence  of  worms  is  frequently 
accompanied  by  loss  of  flesh,  not,  perhaps,  so 
much  on  account  of  the  parasites  themselves,  as 
on  account  of  the  derangement  of  the  digestive 
organs  which  is  associated  with  them.  Emacia- 
tion due  to  this  cause  may  sometimes  be  extreme. 

In  the  adult  atrophy  is  rarely  the  result  of 
mere  functional  derangement,  but  is  almost  in- 
variably a sign  of  serious  organic  disease.  All 
chronic  ailments  are  not,  however,  accompanied 
by  marked  wasting.  Purely  local  diseases  lead 
to  little  loss  of  flesh  unless  they  affect  some  part 
of  the  digestive  apparatus,  or  of  the  glandular 
system  which  is  concerned  in  the  elaboration 
of  nutritive  material ; or  otherwise  directly 
influence  the  processes  of  nutrition.  Thus, 
emaciation  quickly  results  from  gastric  ulcer  or 
chronic  dysentery,  but  chronic  pneumonic 
phthisis  may  produce  little  diminution  in 
weight  if  there  is  no  pyrexia,  and  if  the  case 
is  not  complicated  by  diarrhoea  or  profuse  ex- 
pectoration. The  most  marked  atrophy  is  pro- 
duced by  the  so-called  constitutional  diseases, 
such  as  cancer  and  syphilis  in  the  third  stage  ; 
by  those  which  set  up  a persistent  drain  upon 
the  system,  such  as  severe  albuminuria,  chronic 
haemorrhages,  and  long-continued  suppurations  ; 
or  by  those  which  directly  impede  the  passage 
of  nutritive  material  into  the  blood:  and  in 
the  latter  class  of  diseases,  influences  which 
act  directly  upon  the  thoracic  duct,  such  as 
obstruction  to  its  passage  from  pressure  by 
aneurism  and  other  tumours,  must  not  be  over- 
looked. There  is  a form  of  atrophy  sometimes 
seen  in  hysterical  females,  depending  upon  dis- 
ordered innervation,  in  which  the  most  extreme 
emaciation  may  be  reached.  Such  cases  are 
marked  by  a dislike  to  food  which  may  amount 
to  absolute  loathing. 

Symptoms. — The  symptoms  of  general  atrophy 
are  loss  of  flesh,  loss  of  colour,  and  loss  of  strength, 
combined  with  other  special  phenomena  arising 
from  the  particular  disorder  to  which  the  impair- 
ment of  nutrition  is  due. 

Anatomical  Chakactehs. — The  most  marked 
post-mortem  appearance  in  this  condition  is 
diminution  or  loss  of  fat,  especially  of  the  sub- 
cutaneous adipose  tissue  ; and  this  is  accom- 
panied by  wasting  of  the  tissues  and  organs 


ATROPHY,  LOCAL. 

generally.  The  histological  elements  are  reduced 
in  size  without  undergoing,  as  a rule,  actual 
numerical  diminution.  With  the  atrophy  ia 
often  associated  a certain  amount  of  fatty 
degeneration. 

Treatment. — The  treatment  of  general  atro- 
phy consists  in  removing,  if  possible,  the  impedi- 
ment to  efficient  nutrition.  In  the  case  of  a 
child  the  diet  must  be  selected  with  care.  Excess 
of  farinaceous  food  is  to  be  avoided,  and  cow's 
milk  can  be  diluted,  if  necessary,  by  admixture 
with  thin  barley  water.  Any  gastric  or  intestinal 
derangement  must  be  at  once  remedied,  plenty  of 
fresh  air  should  be  obtained,  and  perfect  cleanli- 
ness strictly  enjoined.  In  an  adult  the  disease 
which  is  the  cause  of  the  malnutrition  must  be 
sought  for  and  submitted  to  treatment.  Efforts 
should  be  made  on  the  one  hand  to  arrest  any 
drain  upon  the  system  ; and,  on  the  other  hand, 
by  a judicious  arrangement  of  the  dietary,  and 
by  attention  to  the  eliminatory  organs,  to  remove 
all  obstacles  to  the  entrance  of  nourishment. 
Even  in  cases  of  organic  and  incurable  disease 
much  benefit  may  often  be  derived  from  due 
observance  of  physiological  laws. 

Eustace  Smith. 

ATROPHY,  LOCAL. — This  condition  sig- 
nifies atrophy  of  a part  of  the  body,  which  may 
be  apparently  congenital,  or  may  be  produced 
by  various  causes  acting  during  life.  It  will  be 
convenient  to  consider  local  atrophy  according  to 
the  several  forms  which  are  met  with. 

Congenital  Atrophy  is  that  condition  in 
which  some  part  of  the  body  never  reaches  its 
full  standard  of  size.  It  is  more  correctly  den’o 
minated  arrested  growth  or  congenital  smallness. 
When  the  whole  of  one  side  of  the  body  is 
thus  affected,  a marked  and  permanent  dispro- 
portion between  the  two  sides  results.  This 
hemiatrophy  is,  in  theory,  difficult  to  distinguish 
from  hypertrophy  of  the  opposito  side,  but 
mostly  the  paralytic  or  enfeebled  state  of  the 
atrophic  side  shows  it  to  be  abnormal.  The 
limbs  are  most  strikingly  implicated,  while  the 
corresponding  side  of  the  face  and  head  is  some- 
times similarly,  sometimes  conversely  affected. 
In  many  cases  atrophy  of  the  opposite  half  of  the 
cerebrum  was  found  on  post-mortem  examina- 
tion. The  same  condition  may  be  partial — 
hemiatrophia partialis — and  it  then  chiefly  affects 
the  face,  or  some  part  of  the  territory  of  the 
fifth  cranial  nerve.  These  conditions  must  be 
ascribed  to  some  perversion  of  innervation 
occurring  during  development.  Other  congeni- 
tal atrophies,  local  but  not  /jc/m'-atrophic,  an 
more  probably  referred  to  obstruction  of  blood- 
vessels during  the  same  process.  The  defective 
development  of  the  brain  in  cretinism  has  been 
attributed  to  the  pressure  of  an  enlarged  thyroid 
upon  the  carotid  arteries. 

Physiological  Atrophies. — These  form  a 
distinct  class,  where  atrophy  of  a part  of  the 
body  takes  place  in  the  ordinary  course  of 
development.  Such  are  the  wasting  of  the  thymus 
gland  in  early  life,  of  the  niammte  and  sexual 
organs  after  middle  age.  Most  commonly 
the  atrophy  is  here  closely  connected  either  with 
the  involution  or  perhaps  the  development  of 
some  correlated  organ ; but  it  is  not  possible 


ATROPH  Y,  LOCAL. 


to  say  what  the  nature  of  this  connection  is, 
whether  one  of  nutrition  or  of  innervation. 

Acquired  Atrophies. — The  conditions  thus 
distinguished  possess  most  interest  for  the 
practical  physician.  Wasting  of  any  part  of 
the  body  during  life,  when  not  physiological, 
usually  depends  either  upon  some  interference 
with  the  blood-supply,  or  some  disturbance  of 
innervation ; but  to  these  must  be  added,  in  the 
case  of  organs  which  have  an  active  and  con- 
tinuous function,  disuse  or  over-stimulation. 
Deficient  blood-supply,  which  causes  atrophy, 
may  be  produced  by  the  obstruction  of  a nutrient 
artery,  especially  if  it  be  gradual,  since  sudden 
blocking  will  produce  more  complicated  pheno- 
mena. Constant  pressure  is  a cause  of  atrophy, 
because  it  interferes  both  with  the  blood- 
supply,  and  with  the  vital  actions  of  the  tissue- 
elements.  Intermittent  pressure,  on  the  other 
hand,  by  causing  hypertemia,  is  more  likely  to 
lead  to  hypertrophy.  Moreover,  inadequate 
renewal  of  blood,  that  is,  filling  of  the  vessels, 
even  to  excess,  with  venous  blood,  or  venous  en- 
gorgement, though  at  first  it  may  cause  enlarge- 
men’  mostly  leads  to  atrophy  in  the  end ; as  is 
seen  n the  granular  induration  of  liver  and  kid- 
neys aused  by  disease  of  the  heart  obstructing  the 
circulation.  Many  forms  of  atrophy  in  old  age  are 
clearly  dependent  upon  senile  obstruction  of  the 
arteries,  for  example,  that  of  the  skin,  spleen,  and 
kidneys.  The  instances  of  atrophy  from  disturbed 
innervation  are  less  easy  to  discriminate,  except 
where  there  is  actual  paralysis.  In  two  distinct  dis- 
eases, however,  progressive  muscular  atrophy  and 
infantile  or  essential  paralysis,  loss  of  power  in 
the  muscles  is  followed  by  a remarkable  wasting, 
far  more  rapid  than  that  which  results  from  dis- 
use alone.  Division  of  the  nerve  of  a limb  produces 
rapid  wasting  of  the  muscles  no  longer  used,  and 
this  is  accompanied  in  the  end  by  some  diminu- 
tion in  the  size  of  the  bones  and  accessory  parts. 
Local  atrophy  of  the  skin  is  sometimes  seen  in 
regions  limited  by  the  distribution  of  a nerve, 
especially  some  branch  of  the  fifth  ; and  more  ex- 
tensive atrophy  of  one  side  of  the  face  or  head, 
equally  marked  out  by  nervous  distribution,  and 
resembling  some  cases  of  congenital  atrophy,  has 
also  been,  though  very  rarely,  observed.  These 
facts  raise  the  interesting  question  whether  there 
are  ‘ trophic  nerves.’  Without  discussing  this 
question,  it  may  be  pointed  out  that  the  nerves 
which  delineate  an  atrophic  region  are  always 
motor  or  mixed  branches,  never  solely  sensory. 

Disuse  produces  atrophy  only  in  organs 
whose  functions  are  active  and  constant,  such  as 
nerves  and  muscles.  Nervous  tissue  wastes 
constantly,  and  sometimes  rapidly  when  currents 
cease  to  traverse  it.  This  is  seen  not  only  in 
the  nerves  of  paralyzed  limbs,  but  even  in  the 
nerve-centres,  where  any  interruption  of  the 
nervous  channels,  either  above  in  the  cerebrum, 
or  below  in  the  nerve-trunks,  is  followed 
by  degeneration,  ending  in  atrophy,  of  the 
whole  nervous  tract  leading  from  the  cerebral 
cortex  to  the  peripheral  termination — so  called 
secondary  degeneration  of  the  cord.  In  muscu- 
lar tissue  the  wasting  is  almost  as  constant, 
but  hysterical  paralyses  make  an  exception,  the 
helpless  limbs  preserving  their  nutrition  in  a 
surprising  manner.  In  organs  whose  functions 

7 


97 

are  intermittent  or  periodic,  disuse  does  not 
appear  necessarily  to  produce  atrophy,  as  is  seen 
in  the  ovaries,  testicles,  and  mammae. 

That  excessive  stimulation  or  over- work  may 
produce  atrophy  is  seen  in  degenerative  diseases 
of  the  nerve-centres  arising  from  undue  mental 
activity;  and  of  the  sexual  organs  from  exces- 
sive indulgence. 

Unexplained  Atrophies. — Cases  of  local 
atrophv  occur  of  which  it  is  impossible  to  give 
any  satisfactory  explanation.  Such  are  the  con- 
ditions known  as  linear  atrophy  of  the  skin  ; 
some  remarkable  cases  of  atrophy  of  bone, 
especially  of  the  skull  ( fragilitas  ossium),  and  of 
some  parts  of  the  cerebrum.  We  may  have  to 
attribute  to  changes  of  the  latter  class  just  men- 
tioned, certain  peripheral  atrophies,  without  being 
able  to  account  for  the  original  lesion. 

It  is  possible  that  deficiency  of  special  kinds 
of  food  may  lead  to  atrophy  of  special  organs — 
thus  deficiency  of  lime  may  make  the  bones  soft, 
and  deficiency  of  iron  arrest  the  development  of 
blood-corpuscles ; but  even  these  familiar  in- 
stances must  be  accepted  with  a little  reserve. 
In  the  same  way  it  is  still  doubtful  whether  any 
special  drugs,  such  as  iodine,  can  produce 
atrophy  of  special  glands. 

Pathology.- — Wasting  may  occur  simply,  or 
as  a consequence  of  change  of  substance,  or 
from  the  intrusion  of  some  new  material;  in  other 
words,  there  may  be  simple  atrophy,  atrophv 
frorn  degeneration,  or  atrophy  by  substitution. 
Tho  first  is  probably  rare ; generally  some 
change  of  substance  occurs.  The  most  frequect 
degenerative  process  is  fatty  degeneration ; the 
albuminous  substance  being  converted  into  or 
replaced  by  fat,  which,  if  afterwards  absorbed, 
leaves  a void.  Organs  thus  affected  may  be 
apparently  enlarged,  though  the  original  sub- 
stance is  wasted.  Atrophy  from  substitution  is 
seen  when  the  connective  tissue  of  an  oraan,  for 
instance,  increases,  compressing  and  destroying 
the  other  tissue-elements,  and  these  not  being 
renewed  when  the  newly-formed'connective-tissue 
is  absorbed,  the  whole  organ  is  diminishea  in  bulk. 
This  is  seen  in  all  the  changes  called  cirrhosis 
or  fibroid  degeneration,  as  in  cirrhosis  of  the 
liver  and  kidneys. 

'Treatment. — No  general  rules  can  he  laid 
down  for  treating  all  cases  of  local  atrophy.  Where 
the  blood-supply  is  deficient,  we  have  rarely  any 
means  of  supplementing  it;  where  innervation 
is  at  fault,  it  is  seldom  under  our  control.  In 
general,  harm  rather  than  good  results  from  anv 
attempt  to  attract  blood  by  artificial  irritation. 
In  the  case,  however,  of  atrophy  from  disuse  of 
the  nervo-nmscular  system,  a line  of  treatment, 
and  more  especially  of  prophylaxis,  is  very 
clearly  indicated ; that  is,  to  keep  the  muscles 
in  exercise  by  artificial  means,  particularly  by 
electricity,  or  by  the  processes  of  friction  and 
kneading,  known  as  passive  motion.  In  this  way 
so  much  of  the  atrophy  as  is  due  simply  to 
disuse  may  be  cheeked  for  the  future,  and.  even 
the  past  loss  reinstated.  We  shall,  moreover, 
never  do  harm  by  attempting  to  supply  some 
special  kind  of  food  which  appears  to  he 
deficient,  as  iron  for  the  blood  and  phosphorus  for 
the  hones  or  nervous  system. 


J.  F.  Paynu. 


38 


AUDITORY  NERVE. 

AUDITORY  NERVE,  Diseases  of.  See 
Eah,  Diseases  of ; and  Hearing,  Disorders  of. 

AURA  ( ailpa , a breeze). — A peculiar  sensa- 
tion, subjective  in  origix,  immediately  preceding 
an  epileptic  or  hysterical  convulsion,  and  named 
respectively  Aura  Epileptica  and  Aura  Hysterica. 
The  word  was  originally  adopted  because  the 
sensation  is  often  described  as  that  of  the  pas- 
sage of  cold  air  or  light  vapour  from  the  trunk 
or  extremities  to  the  head;  but  it  has  been  ex- 
tended so  as  to  include  any  phenomenon,  whether 
sensory  or  motor,  that  ushers  in  a fit  of  epilepsy 
or  of  hysteria. 

AURAL  DISEASES.  See  Ear,  Diseases  of. 

AUSCULTATION  ( ausculto , I listen).— A 
method  of  physical  examination,  which  consists 
in  listening  over  various  parts  of  the  body,  either 
by  the  direct  application  of  the  ear  ( immediate 
auscultation),  or  by  the  aid  of  special  instru- 
ments ( mediate  auscultation),  for  the  purpose  of 
studying  certain  sounds  produced  in  health  and 
disease.  See  Physical  Examination. 


BACTERIA. 

AUSCULTATORY  PERCUSSION.— A 

metho  of  physical  examination  in  which  the 
sounds  elicited  by  percussion  are  studied  by 
means  of  auscultation.  See  Physical  Examina- 
tion. 

AUSTRALIA.  See  Appendix. 

AUTOPEONIA  (ainls,  itself,  and  tpuA), 
the  voice). — A physical  sign  obtained  by  study- 
ing the  modifications  of  the  resonance  of  the 
observer's  own  voice  during  auscultation.  See 
Physical  Examination. 

AUTOPSY.  See  Necropsy. 

AZORES,  St.  Michael's. — "Warm,  very 
moist,  equable  climate.  Mean  winter  tempera- 
ture 58°  F.  Prevailing  winds  N.  and  E.  See 
Climate,  Treatment  of  Disease  by. 

AZOTURIA. — A condition  of  the  urine  in 
which  there  exists  an  absolute  and  relative  ex- 
cess of  urea,  without  accompanying  pyrexia.  See 
Urine,  Morbid  Conditions  of. 


B 


BACILLUS  (from  bacillum,  a little  staff)  is 
the  name  now  given  to  certain  filiform  Bacteria 
which  have  assumed  much  importance  of  late, 
principally  because  of  their  constant  presence  in 
the  blood  and  tissues  in  splenic  fever  and  malig- 
nant pustule.  See  Leptothrix,  auu.  Bacteria  ; 
also  Pustule,  Malignant  ; and  Bacilli  in 
Appendix. 

BACTERIA  ( fiaicTTipiov , a rod)  are  some  of 
the  lowest  known  forms  of  life.  They  most  fre- 
quently exist  as  minute  rod-like  bodies,  about 
inch  in  length,  with  a slight  median  con- 
striction. They  may  be  larger  or  smaller  than 
this,  and  may  present  minor  variations  in  form. 
They  swarm  in  all  putrefying  solutions  and  mix- 
tures of  organic  matter,  and  in  many  fermenting 
fluids  in  which  the  chemical  changes  are  not  ac- 
companied by  an  emission  of  stinking  gases.  In 
fluids  belonging  to  the  latter  category,  the  typical 
Torula  or  yeast-cell  may  be  met  with,  as  well  as 
organic  forms  strictly  intermediate  between  it 
and  the  typical  Bacterium.  From  a chemical 
point  of  view,  it  is  admitted  that  no  absolute 
line  of  demarcation  can  be  drawn  between  the 
intimately  related  processes  of  putrefaction  and 
fermentation ; whilst  from  a biological  point  of 
view  we  are  similarly  unable  to  erect  any  impass- 
able barriers  between  the  organic  forms  which 
are  found  as  part  of  the  products  of  change  in 
putrefying  and  fermenting  fluids  respectively. 
It  is  unquestionably  true  that  typical  Bacteria 
are  most  frequently  met  with  in  putrefying  fluids ; 
whilst,  on  the  other  hand,  typical  Torulae  are 
only  present  in  some  fermenting  fluids.  But 
the  rather  long  rod-like  bodies,  which  have  been 
hitherto  named  Vibriones,  and  the  still  longer 
filaments  mostly  known  as  Leptothrix  (see  Lep- 
roTHRix),  are  unquestionably  capable  of  being 
derived  from  ordinary  Bacteria  in  certain  media. 

In  the  most  highly  putrescent  fluids  Bacteria 


are  usually  found  to  he  very  small,  because, 
though  the  total  bulk  of  living  things  rapidly 
augments  in  such  fluids,  the  individual  units 
(in  consequence  of  the  frequency  with  which  a 
process  of  fission  takes  place)  do  not  increase  in 
size.  In  less  putrescent  fiuids,  however,  where  the 
chemical  changes  constituting  the  putrefactive 
process  take  place  more  slowly,  the  living  forms 
also  appear  and  grow  with  less  rapidity ; and 
owing  to  the  co-existence  of  a lower  frequency 
of  fission  or  spontaneous  division  amongst  such 
individual  living  units,  they  often  attain  a larger 
size.  They  then  appear,  according  to  their 
length,  either  as  Vibriones  or  as  Leptothrix  fila- 
ments. These  are  plain,  jointed,  or  monilated, 
according  as  partial  segmentation  is  absent,  has 
taken  place  rarely,  or  has  occurred  so  rapidly 
as  to  give  what  would  have  been  a plain  fila- 
ment the  appearance  of  a string  of  beads. 

Concerning  the  question  of  the  precise  rela- 
tion of  organisms  to  the  processes  of  putrefac- 
tion and  fermentation,  opposite  opinions  are  at 
present  held.  Believers  in  Pasteur's  germ-theory 
maintain  that  they  are  invariably  the  initiators 
of  these  chemical  processes  ; whilst  those  who 
reject  this  theory,  as  being  too  exclusive,  con- 
tend that  putrefaction  and  fermentation  may  be 
initiated  in  the  absence  of  Bacteria  and  their 
germs.  Those  holding  the  former  view  believe 
that  Bacteria  are  only  capable  of  being  derived 
from  pre-existing  organisms  of  like  kinds;  whilst 
those  who  reject  it  contend  that  particles  of 
living  matter,  which  develop  into  Bacteria, 
may  be  generated  from  the  organic  compounds 
dissolved  in  fermentable  fluids,  and  that  such 
particles  of  living  matter  are,  in  fact,  just  as 
much  products  of  the  fermentative  process  and 
of  the  fluid  in  which  it  occurs,  as  are  the  gases 
simultaneously  generated  therefrom.  According 
to  this  view,  these  lowest  living  units  bridge 
the  gap  hitherto  held  to  exist  between  living 


BACTERIA. 

and  so-called  dead  matter,  and  afford  an  illus- 
tration of  the  natural  independent  origin  of 
chemical  compounds  so  complex  and  endowed 
with  such  attributes  as  to  win  for  them  the 
name  of  ‘vital’  compounds.  (See  Proceed- 
ings of  the  Royal  Society,  No.  172,  1876,  pp. 
149-156.) 

Pasteur’s  ‘Vital  theory’  of  fermentation  is 
one  of  great  importance  both  to  chemists  and 
biologists,  and  it  also  forces  itself  upon  the 
attention  of  medical  men,  as  the  parent  of 
another  doctrine  which  has  of  late  assumed 
great  prominence  in  relation  to  the  science  of 
medicine — the  doctrine,  namely,  that  lower  or- 
ganisms allied  to  those  met  with  in  putrefying 
and  fermenting  media  are  causally  related  to  cer- 
tain morbid  processes  with  which  they  either  do, 
->r  are  said  to  coexist.  Bacteria  and  their  allies 
are  as  uniformly  coexistent  with  a few  general 
diseases  and  certain  local  morbid  processes  as 
they  are  with  putrefactions  and  fermentations, 
so  that  the  same  general  question  as  to  the 
precise  significance  of  this  coexistence  again 
presses  for  solution.  Are  the  organic  forms 
associated  with  such  morbid  processes  the  sole 
causes  or  inciters  of  these  processes  ? or  are 
they  consequences  (i.e.  concomitant  products)  of 
pathological  processes  which  have  been  initiated 
in  their  absence?  The  former  view  is  warmly 
supported  by  many  who  regard  Bacteria  and 
allied  organic  forms  as  the  contagious  elements 
of  such  communicable  diseases ; and  many  of 
these  same  pathologists,  resting  upon  analogy, 
wish  to  extend  their  theory,  so  as  to  make  it 
applicable  to  many  other  communicable  diseases 
with  which  organic  forms  have  not  as  yet  been 
shown  to  be  correlative. 

Thus,  just  ascertain  chemists  hold  that  Bac- 
teria and  allied  forms  are  the  causes  of  all 
fermentations  and  putrefactions,  so  certain 
pathologists  either  do  actually,  or  are  inclined  to 
maintain  that  Bacteria  and  allied  organisms  of 
common  or  of  special  kinds  are  the  causes  of  all 
communicable  or  contagious  diseases.  Accord- 
ing to  such  chemists  all  ferments  are  living 
organisms  ; and  according  to  such  pathologists 
all  contagia  are  allied  living  organisms. 

The  coexistence  of  organisms  is  one  which  ob- 
tains for  almost  all  fermentations,  but  only  for 
a few  of  the  communicable  diseases,  so  that  any 
argument  deducible  from  such  mere  coexistence 
in  favour  of  the  causal  relationship  of  the  or- 
ganisms, is  much  stronger  in  the  case  of  fer- 
mentations than  as  regards  diseases.  Yet,  in 
spite  of  the  almost  universal  coexistence  of 
organisms  with  fermentations,  it  is  still  necessary 
for  us  to  ask  whether  they  appear  as  causes 
or  as  ^effects  of  these  phenomena.  From 
this  it  may  be  judged  how  little  the  more 
limited  ‘facts  of  coexistence’  should  be  allowed 
to  influence  our  opinion  on  the  derivative  ques- 
tion of  the  relation  of  the  lower  organisms  to 
disease.  At  least  one  of  the  reputed  instances 
in  which  this  coexistence  of  organisms  has  been 
dwelt  upon,  as  showing  that  they  are  the  causes 
of  the  morbid  phenomena  with  which  they  are 
associated,  has  of  late  been  dissipated,  since  in 
the  case  of  the  small-pox  of  sheep  ( variola  ovina) 
the  allegod  organisms  are  now  admitted  to 
havo  no  existence — certain  appearances  pro- 


BADEN.  99 

duced  in  tne  tissues  by  preservative  media 
having  been  mistaken  for  organisms  which  have 
been  elaborately  describedand  figured.  (SeePro- 
ceedings  of the  Royal  Society,  No.  172, 1876,p.l40.) 
But  even  if  all  the  alleged  cases  of  coexistence 
of  organisms  with  morbid  processes  were  real, 
and  if  future  investigations  should  show  that 
such  facts  are  more  numerous  than  are  at  pre- 
sent imagined,  still  the  multiplication  of  this 
evidence  to  any  extent  will  never  help  us  (any 
more  than  it  has  dene  in  the  case  of  fermenta- 
tions) to  solve  the  real  question — whether  such 
morbid  processes  are  only  caused  and  propa- 
gated by  organisms,  or  whether  they  may  at 
times  como  into  existence  independently? 

The  vital  or  germ-theory  of  fermentation 
would  bo  broken  down  and  become  untenable 
whenever  it  is  shown  that  fermentation  can 
originate  independently  of  the  Bacteria  and 
their  germs  which  appear  as  part  of  the  process. 
Similarly,  the  germ-theory  of  disease  would  be 
refuted,  if  it  could  be  shown  that  some  of  the 
morbid  processes  in  question  could  originate  in 
the  absence  of  the  living  organisms  which  sub- 
sequently appear  as  part  of  the  pathological 
products.  The  latter  refutation,  however,  could 
never  be  made  directly,  since  no  living  being 
could  in  any  circumstance  whatsoever  be  proved 
—in  an  experimental  sense — to  be  beyond  the 
possible  reach  of  some  of  the  alleged  disease 
germs.  But  inasmuch  as  this  problem  is,  from 
its  very  nature,  one  which  does  not  admit  of 
experimental  proof  or  disproof  in  the  strictest 
6ense  of  the  term,  and  because  this  germ-theory 
of  disease  is  clearly  a derivative  doctrine  from 
the  germ  theory  of  fermentation,  it  must  stand 
or  fall  with  the  germ-theory  of  fermentation, 
which,  fortunately,  is  capable  of  experimental 
proof  or  disproof.  The  question  of  ‘spontaneous 
generation’  comes,  therefore,  to  be  inextricably 
mixed  up  with  the  question  of  the  truth  or 
falsity  of  the  germ-theory  of  disease,  so  that 
the  study  of  the  latter  to  the  neglect  of  the 
former  can  only  end  in  the  propagation  of 
vagueness  and  uncertainty’.  The  real  question 
is  not  as  to  the  extent  or  frequency  of  the  co- 
existence of  organisms  with  local  or  general 
diseases,  but  the  much  more  important  one  as 
to  the  nature  of  their  relation  to  such  pro- 
cesses. If  they  act  as  invariable  and  sole  causes, 
then  their  presence  is  a matter  of  the  deepest 
interest  and  importance.  If,  on  the  other 
hand,  the  organisms  are  not  causes  but  rather 
concomitant  products,  their  presence  from  a 
purely  medical  point  of  view  is  of  trifling  im- 
portance. The  study  of  their  growth  and 
development  would  in  that  case  be  important 
only  as  adding  to  our  knowledge  of  the  struc- 
tural changes  pertaining  to  the  diseases  in  ques- 
tion. See  Transactions  of  the  Pathological  Society, 
vol.  xxvi.,  and  Journal  of  the  Linncean  Society, 
vol.  xiv.  See  also  the  articles  Micrococci;  Pus- 
tule, Malignant  ; and  Zyme. 

H.  Charlton  Bastlax. 

BADEN-BADEN'  in  Germany.  Thermal 
saline  waters.  See  Mineral  AVaters. 

BADEN  in  Austria.  Thermal  sulphur 
waters.  See  Mineral  AVaters. 


100  BADEN. 

BADEN  In  Switzerland.  Thermal  sulphur 
waters.  See  Mineral  Waters. 

BADENWEILER  in  Germany.  Simple 
thermal  waters.  See  Mineral  Waters. 

BAONEBES-DE-BIGOEEE  in  France. 

Simple  thermal  and  earthy  waters.  See  Mineral 
Waters. 

BAGNERES-DE-LTTCHON  in  Prance. 

Thermal  sulphur  waters.  See  Mineral  Waters. 

BALANITIS  — BALANOPOSTHITIS 

(/3d\a,vos,  an  acorn,  and  iroaQn),  the  foreskin). — - 
Synon.:  Bastard  Clap;  Blennorrhagia  Balani; 
Inflammatory  Phimosis. 

Definition. — Inflammation  of  the  opposing 
surfaces  of  the  glans  and  prepuce  ; sometimes 
acute — even  gangrenous,  and  sometimes  chronic. 
A purely  local  affection ; frequently,  but  not 
necessarily,  of  venereal  origin. 

JEtiology. — Balanitis  is  mneh  less  common 
than  urethritis,  being  met  with  at  the  Lock  Hos- 
pital in  the  proportion  of  one  to  twenty-four  of 
the  latter.  It  may  be  either  primary;  or  con- 
secutive to  chancres,  syphilitic  eruptions,  warts, 
accumulated  smegma,  variolous  pustules,  or 
gonorrhoea.  When  primary,  the  common  pre- 
disposing co,nse  is  a long,  narrow  foreskin.  Pour- 
nier  attributes  two-thirds  of  the  cases  of  balanitis 
to  a long  prepuce  with  insufficient  cleansing; 
about  one-third  to  irritation  by  chancres  and 
gonorrhoeal  pus ; and  a very  few  to  other  causes. 

Symptoms. — The  symptoms  of  balanitis  de- 
pend on  the  intensity  and  extent  of  the  inflam- 
mation. In  the  simplest  form  there  is  heat  and 
itching  of  the  furrow,  slight  redness  of  that 
part,  with  a milky  or  yellowish  secretion.  When 
the  inflammation  is  more  severe  and  extended, 
swelling  and  pain  are  added,  the  other  sym- 
ptoms are  more  marked,  and  characteristic 
excoriations  appear.  They  are  irregular,  shal- 
low, never  extending  more  deeply  than  the 
epithelium,  but  often  coalescing  into  large 
raw  chafings.  An  abundant  yellowish-green 
matter  of  offensive  odour  bathes  the  surface. 
When  the  urine  trickles  over  these  excoriatious 
there  is  severe  smarting  pain.  If  still  further 
irritated,  the  foreskin  swells  enormously,  is 
divided  at  the  free  border  by  deep  creases,  and 
can  no  longer  be  turned  back.  Aching,  smart- 
ing, great  tenderness,  and  painful  erection,  often 
accompanied  by  constitutional  disturbance  and 
fever,  are  present. 

Complications. — The  cellular  tissue  and  the 
lymphatic  ducts  of  the  foreskin  and  sheath,  or 
thelymphatic  glands,  may  inflame  to  suppuration, 
to  ulceration,  and,  in  persons  enfeebled  by  any 
cause,  even  to  gangrene.  Sloughing  begins  on 
the  inner  surface  of  the  foreskin  at  the  upper 
part ; seldom  to  much  extent,  though  the  whole 
prepuce,  except  the  frser.mn,  maybe  lost,  and  when 
cicatrisation  sets  in  the  organ  appears  circum- 
cised. Paraphimosis  is  caused  by  imprudent 
retraction  of  a swollen  foreskin.  Warts  keep 
up  chronic  posthitis  of  the  furrow.  Adhesions, 
usually  at  the  corona  and  the  furrow,  may 
attach  the  prepuce  completely  to  the  glans. 
Thickening  and  phimosis  are  not  uncommon 
after  repeated  attacks. 

Course. — The  duration  of  balanitis  depends 


BALDNESS. 

on  the  anatomical  condition  of  the  parts.  When 
remedies  can  be  easily  applied,  it  is  not  more  than 
three  or  four  days.  With  phimosis,  the  course  is 
severe,  and  the  duration  is  indefinite  ; even  when 
limited  to  the  furrow,  posthitis  is  often  obstinate. 

Diagnosis. — This  is  easy  when  the  parts  can  be 
exposed.  Herpes  is  distinguished  from  balanitis 
by  small  grouped  round  ulcers,  limited  to  one  or 
two  points  of  the  mucous  surface,  without  general 
congestion.  Simple  chancre  has  well-defined 
undermined  edges  and  a spongy  surface.  The 
syphilitic  sore  has  the  indurated  base  and  en- 
larged lymphatic  glands.  When  there  is  phi- 
mosis, the  discharge  may  come  from  the  urethra 
or  from  a chancre.  If  from  the  urethra,  it  can 
be  usually  seen  escaping  thence,  and  there  is 
pain  along  the  penis,  with  other  signs  of 
urethritis.  A chancre  under  the  foreskin  is 
betrayed  by  a hard  and  tender  point,  and  after  a 
few  days  consecutive  sores  usually  appear  at  the 
orifice  of  the  prepuce. 

Prognosis  in  the  primary  form  is  always  good. 
If  the  complaint  is  secondary  or  symptomatic, 
gangrene  may  result. 

Treatment. — The  chief  indication  is  to  keep 
the  inflamed  surfaces  separate.  After  washing 
and  thoroughly  drying,  the  excoriations  should 
be  touched  with  a 10-grain  solution  of  nitrate  of 
silver,  and  a bit  of  dry  lint  laid  on  the  glans 
before  the  foreskin  is  drawn  forward.  If  there  is 
phimosis,  frequent  injections  of  tepid  water,  and 
twice  daily  of  a 5-grain  solution  of  nitrate  of 
silver  must  be  thrown  to  the  farthest  part  of  the 
foreskin  with  a long-nozzled  syringe.  Leeches 
to  the  groins,  and  opium  internally,  as  well  as 
in  injections,  relieve  pain.  Acupunctures  give 
vent  to  simple  oedoma,  but  tend  to  accelerate 
gangrene  with  brawny  tension  and  erysipelatous 
redness.  Incisions,  if  needed,  should  be  free  : 
one  on  each  side,  carried  quite  back  to  the  fur- 
row. The  upper  half  of  the  foreskin  can  then 
be  easily  turned  back,  and  the  subsequent  de- 
formity is  less  than  if  the  foreskin  is  divided  at 
the  dorsum.  In  paraphimosis,  before  replacing 
the  swollen  foreskin,  the  tension  should  be  re- 
lieved by  acupuncture  and  astringent  lotions,  or 
by  incisions  if  needed.  Berkeley  Hill. 

BALDNESS. — Synon.  : Alopecia. 

Description.— -Baldness  or  loss  of  hair  pre- 
sents an  extensive  range  of  variation  in  degree, 
from  moderate  thinness  of  the  hair,  such  as 
occurs  in  Dejluvium  capillomm,  to  compleie 
baldness — Alopecia  calva  or  Calcif  ies,  the  latter 
not  limited  to  the  scalp  alone,  but  involving 
eyebrows,  eyelashes,  beard,  and  every  hair  of  the 
body.  Instead,  however,  of  being  general,  bald- 
ness may  be  partial,  affecting  more  or  less  of 
the  surface  of  the  scalp  for  example,  the  summit 
and  forehead  in  men,  and  the  summit  and  occiput 
in  women.  One  remarkable  form  of  partial 
baldness  has  been  denominated  Alopecia  areata, 
or  simply  Area,  and  as  this  was  described  by 
Celsus,  it  has  likewise  been  called  Area  Cclsi. 
Area  occurs  suddenly,  and  is  a mere  falling-off 
of  the  hair  over  a space  of  circular  figure  ; there 
may  be  one  or  more  of  such  Arese,  and  sometimes 
Area  is  only  the  beginning  of  Calvities.  Area  is 
likewise  occasionally  met  with  in  the  whisker.? 
and  beard. 


BALDNESS. 

Pathology. — The  pathology  of  Alopecia  is  a 
loss  of  nutritive  power  of  the  skin,  sometimes 
progressive  and  consequent  on  advancing  age, 
as  in  general  baldness  ; and  sometimes  limited 
to  a nerve-district  of  small  extent,  as  in  Area. 
This  fact  is  very  evident  in  the  latter  form, 
inasmuch  as,  conjoined  with  the  sudden  drop- 
ping-out of  the  hair,  the  integument  is  pale  and 
thin,  poorly  nourished,  somewhat  anaesthetic,  and 
thinner  in  the  centre  than  at  the  circumference ; 
while  the  hairs  which  remain  at  the  periphery 
are  altered  in  structure,  clubbed  and  broken  off. 

IEtiology. — The  causes  of  Alopecia  are  ex- 
hausted nutritive  power  of  the  skin ; nerve 
paresis  in  the  case  of  Area;  syphilis;  and  local 
injury.  The  Alopecia  of  syphilis  follows  the  plan 
of  distribution  of  its  exanthem.  Partial  Alopecia 
may  result  from  a blow ; from  the  accidental 
tearing  out  of  a lock  of  hair ; from  the  sting  of 
a bee;  from  nervous  shock;  or  from  other 
causes. 

Treatment. — This  consists  in  the  restoration 
of  nerve-power  and  nutritive  power ; and  in 
local  stimulation.  The  best  applications  for 
the  latter  purpose  are  the  stimulating  liniments 
of  the  British  Pharmacopoeia ; e.g.  liniment  of 
ammonia,  compound  camphor  liniment,  and  the 
jniments  of  chloroform  and  mustard ; or  the 
acetum  cantharidis  properly  diluted  for  general 
Alopecia,  or  applied  with  a brush  in  its  concen- 
trated form  for  Area.  In  the  treatment  of  the 
latter,  ammonia,  turpentine,  and  the  compound 
tincture  of  iodine  are  likewise  useful ; while  for 
syphilitic  Alopecia  the  white  precipitate  ointment 
with  camphor  is  the  best  local  application,  con- 
joined with  an  anti-syphilitic  constitutional 
.reatment.  Erasmus  Wilson. 

BALHEOLOGT  (fiaKavdiov,  a bath,  and 
\iycs,  a word).  A scientific  exposition  of  all 
that  relates  to  baths  and  bathing.  See  Baths 
and  Hydrotherapeutics. 

BALNEOTHEEAPEUTICS  (fraXavdiov, 
a bath,  and  Sepaireva,  I heal).  That  department 
of  therapeutics  which  deals  with  the  application 
of  baths  in  the  treatment  of  disease.  See  Baths 
and  Hydropathy. 

BABBADOES  LEG.  A synonym  for  Ele- 
phantiasis. See  Elephantiasis. 

BABBIERS.  A synonym  for  Beriberi. 
See  Beriberi. 

BAREGES  in  Prance.  Thermal  sulphur 
waters.  See  Mineral  Waters. 

BASEDOW’S  DISEASE.  A synonym 
for  Exophthalmic  Goitre.  See  Exophthalmic 
Goitre. 

BATH  in  Somersetshire.  Simple  thermal 
and  earthy  waters.  See  Mineral  Waters. 

BATHS. — Baths  may  be  regarded  as  simple ; 
and  composite,  medicated,  or  artificial.  They  may 
be  used  in  the  form  of  liquid,  vapour,  or  air. 
We  shall  consider  them  under  these  heads  in 
the  following  description  : — - 

A.  Simple  Baths. — 1.  Simple  Liquid  Baths. 

1.  The  Cold  Bath.—Tiy  a cold  bath  is  meant 
the  immersion  of  the  body  in  water  below  the 
temperature  of  70°.  Anything  below  50°  is 
considered  a very  cold  bath.  The  first  effect  of 


BATHS.  101 

the  bath  is  a sensation  of  cold  amounting  almost 
to  shivering,  with  slight  gasping  for  breath.  If 
the  hath  is  continued  for  more  than  two  or  three 
minutes,  the  temperature  of  the  skin  is  dimi- 
nished; and  if  it  is  protracted,  the  blood  and 
the  subjacent  tissues  lose  a little  heat,  but  this 
does  not  generally  occur  till  after  quitting  the 
bath.  If  the  cold  is  intense  and  prolonged, 
there  is  a certain  degree  of  numbness  of  the 
skin  ; while  the  pulse  becomes  small,  and  may 
fall  from  ten  to  twenty  beats  in  the  minute. 
After  a short  time  (the  colder  the  water  the 
shorter),  reaction  takes  place,  bringing  redness 
to  the  skin  and  increase  of  temperature,  with 
a certain  amount  of  excitement ; but  if  the 
bath  be  continued,  the  depression  returns.  The 
immediate  action  of  the  cold  bath  is  to  cause  the 
capillaries  to  contract  and  repel  the  blood  from 
the  surface,  while  by  its  operation  on  the  peri- 
pheral extremities  of  the  nerves,  it  acts  upon  the 
central  nervous  system.  In  its  more  remote 
effects,  the  cold  bath  accelerates  the  transmutation 
of  tissues,  augmenting  the  excretion  of  carbonic 
acid  and  of  urea  from  the  system,  and,  as  a con- 
sequence, increasing  the  appetite. 

The  body  is  usually  immersed  at  once  in  cold 
water,  but  the  shock  of  this  may  be  diminished 
by  first  using  tepid  water,  and  then  gradually 
adding  cold  to  it. 

The  effect  of  a cold  bath  depends  much  on  its 
duration.  Brief  immersion,  that  is  for  three  or 
four  minutes,  makes  both  the  depressing  and  the 
exciting  action  less  ; a longer  duration,  say  of 
ten  to  fifteen  minutes,  increases  both  actions; 
but  if  the  bath  he  very  protracted,  the  continued 
abstraction  of  heat  produces  depression  only. 
The  effects  of  a cold  bath  are  less  intense,  if  the 
bather  is  able  to  keep  himself  in  motion,  and  es- 
pecially if  he  swims. 

2.  The  Warm  Bath. — A warm  bath  of  96° 
to  104°  produces  no  shock  to  the  system;  it  causes 
a moderately  increased  flow  of  the  circulating 
fluids  to  the  surface,  augmenting  the  frequency  of 
the  pulse;  and  scarcely  affects  the  respiration. 
There  is  not  the  depression  or  the  excitement  of 
a cold  bath.  It  rather  retards  the  transmutation 
of  tissues.  With  a hot  or  very  hot  bath — from 
104°  to  114°,  the  central  nervous  and  circulatory 
systems  are  more  affected.  The  frequency  of  the 
pulse  increases  greatly.  The  respiration  becomes 
anxious  and  quickened.  The  skin  is  in  a 
hypersemic  condition,  and  a free  perspiration 
breaks  out. 

3.  The  Tepid  Bath. — Tepid  baths  of  the 
temperature  of  85°  to  95°,  are  intermediate  be- 
tween cold  and  warm.  Their  effects  seem  to  be 
confined  to  the  peripheral  extremities  of  the 
nerves,  and  they  do  not  excite  the  nervous  centres 
or  the  circulatory  sj^stem.  Neither  the  pulse  nor 
the  excretions  and  secretions  are  affected.  As  no 
heat  is  confined  in  the  system  or  taken  from  it, 
there  is  no  reaction,  and  the  animal  temperature 
is  unaltered. 

It  need  scarcely  be  said  that  drying  and  rub- 
bing after  a bath  materially  assist  its  action  or 
the  skin  ; or  that,  according  to  circumstances,  it 
may  be  convenient  to  order  a whole  bath,  a hip- 
bath, or  a slipper-bath.  The  foot-bath  is  a very 
useful  and  convenient  one,  especially  when  some 
stimulant  substance  is  added  to  the  simple  water, 


102  BATHS. 


Wet  packing  and  the  various  processes  of  hydro- 
pathy, and  those  powerful  agents  hot  and  cold 
affusion,  whether  as  shower-baths  or  as  douches, 
are  described  in  the  article  on  Hydropathy. 

The  duration  of  a bath  must  depend  on  a 
variety  of  circumstances,  for  instance,  on  the  age 
and  constitution  of  the  patient,  on  the  nature  of 
his  malady,  and  on  the  temperature  of  the  bath. 
It  may  vary  from  a few  minutes  to  many  hours. 
A very  hot  or  a very  cold  bath  can  be  supported 
for  a much  shorter  time  than  a tepid  one. 

Action  and  Uses. — Cold  baths  are  indicated 
for  the  strong,  for  youth,  and  for  manhood;  warm 
baths  for  the  delicate,  for  women,  for  early 
childhood,  and  for  old  age.  Tepid  baths  are 
suitable  for  almost  all  constitutions,  sexes,  and 
ages.  Cold  baths  may  in  a general  way  be 
considered  tonic  and  bracing ; they  are  useful 
when  judiciously  employed  in  many  nervous 
affections,  as  in  chorea  and  hysteria,  and  they 
are  the  best  of  all  for  general  hygienic  purposes. 
Of  late  years  they  have  been  specially  employed 
in  the  treatment  of  fever  {see  article  Tempera- 
ture). The  great  value  of  warm  baths,  besides 
their  hygienic  employment,  as  better  detergents 
than  cold  ones,  is  in  soothing  and  reducing 
excitement;  in  relieving  spasms,  such  as  colic 
and  retention  of  urine ; in  the  convulsions  of 
children,  combined  with  the  affusion  of  cold 
water  on  the  head ; in  cases  of  gout  and  rheuma- 
tism ; and  generally  when  action  on  the  skin  is 
desired.  Where  prolonged  immersion  is  wanted, 
tepid  baths  are  indicated,  as  in  calming  many 
chronic  nervous  disturbances,  and  in  many  cuta- 
neous affections. 

As  to  contra-indications,  all  baths,  and  es- 
pecially prolonged  and  even  tepid  baths  are 
not  suited  for  the  asthenic.  Both  hot  and  cold 
baths  are  to  be  avoided  where  there  is  a weak, 
fatty  heart,  or  any  tendency  to  apoplexy.  No 
one  should  ever  enter  a cold  bath  when  ex- 
hausted, and  such  baths  are  also  contra-indicated 
when  there  is  a tendency  to  congestion  of  inter- 
nal organs.  Under  such  circumstances  a warm 
bath  is  usually  both  safer  and  more  refreshing. 
The  too  long  and  too  frequent  use  of  hot  baths 
is  debilitating. 

II.  The  Simple  Vapour-Bath. — A vapour- 
bath  is  one  in  which  the  skin  is  exposed  to  the 
action  of  hot  water  presented  in  the  form  of 
vapour.  The  vapour-bath  may  be  taken  in  a box 
with  the  head  included  or  not ; or  in  the  more 
common  form  of  the  Turkish  or  Russian  baths, 
where  a large  room  is  filled  with  vapour,  and 
where  therefore  the  vapour  is  inhaled ; or  by 
vapour  obtained  from  a small  and  suitably 
constructed  apparatus,  which  vapour  may  be 
diffused  over  the  whole  body  or  directed  to  a 
particular  part.  A very  simple  apparatus  for 
the  vapour-bath  may  be  prepared  by  placing 
under  a chair  a shallow  earthenware  or  metallic 
pan,  containing  boiling  water  to  the  depth  of  three 
or  four  inches,  and  from  which  abundant  vapour 
can  be  obtained  by  placing  in  it  one  or  two  red- 
hot  bricks.  The  patient  sitting  on  the  chair, 
surrounded  by  blankets  and  other  suitable  cover- 
ing, will  receive  the  full  benefit  of  a vapour-bath. 
Vapour-baths  produce  profuse  perspiration,  and 
act  in  cleansing  the  skin  much  as  hot-water 
baths  do,  only  more. powerfully.  Vapour  being  a 


slow  conductor,  does  not  act  so  fast  on  the  bodj 
as  water.  Vapour-baths  can  be  borne  hotter  than 
warm-water  baths,  but  their  use  cannot  be  con- 
tinued so  long,  as  vapour  interferes  with  radiation 
of  heat  from  the  body.  In  such  baths  a heat  of 
more  than  122°  is  not  borne  comfortably.  The 
vapour-bath,  though  falling  considerably  short 
in  temperature  of  the  air-bath,  raises  the  heat 
of  the  blood  somewhat  more.  The  great  virtue 
of  these  baths  is  in  their  sweat-producing  proper- 
ties. The  average  loss  of  perspiration  by  the 
use  of  a Russian  bath  has  been  set  down  at 
from  § lb.  to  3 lbs.  In  the  Russian  bath  a slight 
degree  of  stimulation  of  the  skin  is  caused  by 
switching  it  with  twigs  of  birch,  and  the  alter- 
nation of  depression  and  excitement  of  the  cold 
bath  is  obtained  by  placing  the  patient,  when  in 
a state  of  profuse  perspiration,  under  a douche  of 
cold  water. 

III.  The  Simple  Hot-Air  Bath. — There  are 
two  forms  in  which  the  hot-air  bath  is  adminis- 
tered : according  as  the  patient  does  not  or  does 
breathe  the  heated  air.  The  action  of  the  latter 
closely  resembles  that  of  a vapour-bath,  but 
differs  from  it  in  not  impeding  the  respiration, 
as  the  latter  does  by  depositing  moisture  in  the 
bronchial  tubes.  The  lungs,  instead  of  requiring 
to  heat  up  the  inspired  air,  are  subjected  to  a 
temperature  above  their  own.  Hot-air  baths 
favour  the  highest  degree  of  perspiration,  while 
the  moisture  of  vapour  baths  somewhat  retards 
it.  If  they  are  very  hot,  they  raise  the  tempe- 
rature of  the  body  by  several  degrees. 

As  the  arrangements  for  vapour-  and  hot-air 
baths  are  practically  the  same  (except  that  in  the 
latter  it  is  attempted  to  exclude  all  vapour  from 
the  calidarium  or  sudatorium,  the  hottest  room), 
the  following  description  of  an  ordinary  hot-air 
bath,  the  arrangements  of  which  are  closely 
copied  from  the  Romans,  will  answer  for  both. 

The  patient  after  unclothing  first  goes  into 
the  iepidarium,  which  has  a temperature  of  113° 
to  117°,  in  which  ho  remains  until  the  perspira- 
tion bursts  forth,  which  happens  in  from  twenty- 
five  to  forty  minutes.  He  next  proceeds  to  the 
hottest  room  or  calidarium  (in  which  the  air 
is  heated  by  hot-air  pipes  which  are  inserted 
in  the  walls),  of  a temperature  of  133°  to 
140°,  and  remains  there  until  the  perspiration 
runs  down  his  skin,  in  twelve  to  eighteen 
minutes.  An  attendant  then  rubs  off  the  per- 
spiration with  a woollen  glove,  and  kneads  all 
the  muscles  for  four  or  five  minutes.  The 
patient  next  betakes  himself  to  the  lavacrum, 
where  he  has  water  poured  over  him  of  the 
temperature  of  81°  to  86°  ; next,  the  whole  body 
is  soaped  over,  the  suds  are  rubbed  off,  and  the 
patient  goes  to  the  frigidarium,  where  he  lays 
himself  on  a couch  and  waits  till  his  skin  is 
completely  dry.  This  may  occupy  twenty-five 
to  thirty  minutes,  when  the  patient  dresses  and 
leaves  the  bath  greatly  refreshed. 

Such  is  a brief  account  of  these  baths,  the 
revived  use  of  which  is  at  present  so  general. 
The  arrangements  vary  in  detail.  For  ordinary 
purposes  it  is  easy  to  furnish  either  vapour-  or 
hot-air  baths.  A great  variety  of  apparatus 
have  been  invented  for  this  purpose,  which  re- 
solve themselves  into  this,  that  the  patient 
should  lie  in  bed  or  on  a seat,  and  have  the  bed- 


BATHS. 


slothes  or  other  covering  secured  from  contact 
with  him  by  the  employment  of  a framework 
or  cradle.  Beneath  this  hot  air  or  vapour  is 
introduced,  either  directly  or  indirectly,  from  a 
suitable  apparatus. 

The  Sand-Bath. — We  may  here  mention  baths 
of  sand,  which  are  a very  old  remedy.  Of  late 
years  establishments  for  supplying  them  have 
sprung  up  in  various  towns.  They  are  a con- 
venient way  of  applying  dry  heat  either  locally 
or  generally,  and  are  employed  in  chronic 
rheumatism.  Bags  filled  with  heated  sand  are 
useful  in  hospital  and  in  domestic  practice. 

Uses. — Both  hot-air  and  vapour-baths  are 
indicated  when  increased  action  of  the  skin  is 
desired.  They  are  used  most  for  the  cure  of 
catarrhs,  of  neuralgic  and  rheumatic  pains,  and 
sciatica.  They  have  also  been  much  employed  for 
reducing  obesity.  They  are  useful  for  general 
hygienic  purposes,  but  are  apt  to  be  given  too 
indiscriminately.  Hot-air  and  vapour-baths  are 
often  locally  applied  with  great  advantage  to  a 
hand,  or  leg,  or  arm,  iu  rheumatism  or  thickened 
joints. 

B.  Composite,  Medicated,  ok  Artificial 
Baths. — A great  variety  of  substances  have 
been  used  in  baths  at  different  periods.  We 
must  confine  ourselves  to  such  as  are  at  present 
in  use  and  appear  to  be  of  some  real  value, 
omitting  even  seme  that  are  employed,  such 
as  baths  of  iodine,  of  iodide  of  potassium,  of  iron, 
of  fermented  grapes,  and  of  rvfiey. 

I.  Composite  Liquid  Baths. 

1.  The  Sea-  Water  Bath. — The  average  amount 
of  salts  in  sea-water  may  be  set  down  at  3 
per  cent. ; this  may  therefore  be  considered  a 
suitable  strength  for  ordinary  salt  baths.  The 
quantity  commonly  used  in  London  hospitals  is 
about  9 lbs.  of  salt  to  30  gallons  of  water.  Some 
use  bay  salt,  others  Tidman’s.  Owing  to  the  high 
price  of  sea-salt  in  inland  continental  places, 
various  natural  salts,  some  of  them  containing 
a comparatively  small  amount  of  chloride  of 
sodium,  have  been  suggested  as  substitutes ; 
and  also,  for  economy’s  sake,  22  to  25  gallons 
have  been  set  down  as  a minimum  amount  of 
water  for  the  bath  of  an  adult.  The  value  of 
these  substitutes  can  only  bo  determined  by 
observing  the  degree  in  which  they  stimulate 
the  skin.  Apparently  it  does  not  matter  much 
what  particular  salt  is  employed  to  produce  the 
stimulation.  A salt-bath  can  of  course  be  in- 
creased to  any  strength  by  the  addition  of  salt, 
or  of  the  mother  lye  as  it  is  termed. 

The  chief  uses  of  salt-water  baths  are  as  tonic 
remedies,  especially  for  the  young,  when  there 
is  any  tendency  to  scrofula  or  chlorosis ; also  in 
convalescence  from  many  diseases. 

2.  Alkaline  Bathe.  — Alkaline  baths  may  be 
made  by  adding  6 ounces  of  crystallised  car- 
bonate of  soda,  or  3 ounces  of  carbonate  of  potash, 
to  25  or  30  gallons  of  water.  Alkaline  baths  are 
of  use  in  a great  variety  of  cutaneous  affections. 

3.  The  Corrosive  Sublimate  Bath. — Baths  of 
corrosive  sublimate  are  occasionally  employed. 
They  are  commonly  made  by  adding  3 drachms 
of  corrosive  sublimate  and  1 drachm  of  hydro- 
chloric acid  to  30  gallons  of  water.  They  are 
employed  in  some  skin-affections,  and  in  secon- 
dary syphilis. 


103 

4.  Sulphuret  of  Potassium  Bath. — Baths  of 
sulphuret  of  potassium  are  made  by  dissolving 
from  4 to  8 ounces  of  that  salt  in  25  to  30  gal- 
lons of  water.  A little  dilute  sulphuric  acid  is 
sometimes  added.  These  baths  have  long  been 
extensively  employed  in  the  treatment  of  cases 
of  skin-disease  in  which  the  sulphur  that  they 
contain  is  indicated. 

5.  The  Nitro-Muriatic  Acid  Bath.  — The 
nitric  or  rather  the  nitro-muriatic  acid  bath  is 
made  by  adding  nitro-muriatic  acid  to  water. 
The  ordinary  proportion  is  one  ounce  of  acid  to 
one  gallon  of  water.  The  discolouring  action  or. 
clothing  makes  a full  bath  of  this  kind  incon- 
venient for  domestic  use,  and  it  is  best  to  take 
it  in  a bathing  establishment.  For  the  ordinary 
purposes  of  a foot-bath  at  home  the  old  directions 
of  Dr.  Helenus  Scott,  who  introduced  the  use  of 
the  acid,  are  sufficient.  The  vessel  must  of  course 
be  of  wood  or  earthenware.  Dr.  Scott  added  four 
to  six  ounces  of  the  acid  to  three  gallons  of  water. 
This  made  a rather  strong  foot-bath.  The  pa- 
tient was  to  keep  his  feet  immersed  for  thirty 
minutes  : and  the  bath  was  to  be  repeated  every 
other  day  for  two  or  three  weeks.  The  axillaj, 
the  groin,  and  the  region  of  the  liver  were 
to  he  sponged  with  the  acid  solution.  The  bath 
causes  slight  tingling  of  the  skin  and  a taste  in 
the  mouth,  and  is  believed  occasionally  to  pro- 
duce salivation.  This  bath  has  been  used  very 
extensively  in  India  and  in  England  in  liver 
affections.  There  is  difference  of  opinion  as  to 
its  value  ; many  have  great  confidence  in  it. 

6.  The  Bran  Bath.—T\\6  bran  bath  is  made 
by  boiling  four  pounds  of  bran  in  one  gallon  of 
water,  straining,  and  adding  the  liquor  to  a 
quantity  of  water  sufficient  for  a bath.  Such  a 
bath  is  useful  in  allaying  the  irritability  of  the 
skin,  and  also  in  diminishing  the  stimulating 
effect  of  other  baths. 

7.  The  Fucus  Bath.  — This  is  made  by  add- 
ing a decoction  of  sea-weed,  or  the  sea-weed 
chopped  up,  to  an  ordinary  bath  ; it  will  become 
more  or  less  gelatinous  if  enough  be  added.  Such 
baths  go  popularly  by  the  name  of  Ozone  baths; 
and  they  contain  a certain  amount  of  chloride 
of  sodium  and  a minute  proportion  of  iodine. 
They  aro  useful  in  the  same  cases  as  sea-baths. 

8.  The  Mustard  Bath. — An  extremely  useful 
stimulating  bath  is  the  well-known  mustard 
hath,  which  is  made  by  adding  a handful  or  two 
of  mustard  to  the  ordinary  hot  bath.  The  pedi- 
luvium  is  its  most  useful  form. 

9.  Pine  Baths.  — Baths  of  the  balsam  of 
pine-leaves  may  be  prepared  extempore  by7 
making  decoctions  of  the  fresh  leaflets  at  certain 
seasons  ; but  the  usual  way  is  to  add  about  one 
pound  of  the  extract  which  is  prepared  from  the 
leaves,  and  is  everywhere  for  sale — at  least  in 
Germany.  The  extract  dissolves  in  the  bath, 
which  is  then  ready  for  use ; but  of  late  it  has 
been  usual  to  add  a small  amount  of  an  essence 
which  is  also  prepared  from  the  leaflets.  It 
floats  to  the  surface  of  the  water,  and  attaches 
itself  to  the  person  on  leaving  the  bath,  and  its 
aroma  is  grateful.  Of  course  the  quantify  of 
the  extract  to  be  employed  depends  on  its 
strength.  These  baths  are  at  present  largely 
employed.  They  are  slightly  stimulant,  and  are 
much  used  in  hysterical,  rheumatic,  and  gouty 


104  BATHS. 

affections,  and  also  as  an  adjunct  to  the  internal 
use  of  mineral  waters. 

10.  Baths  of  Conium,  Lavender , Spc. — Aro- 
matic or  sedative  baths  are  prepared  by  adding  a 
decoction  of  lavender,  hyssop,  or  conium  to  an 
ordinary  bath. 

It  is  scarcely  necessary  to  add  that,  as  a 
rule,  all  composite  liquid  baths  should  be  of  a 
temperature  a little  above  the  tepid ; and  that 
their  strength,  and  the  time  that  the  patient  is 
to  remain  in  them,  must  be  determined  by  the 
special  circumstances  of  the  case. 

11.  Composite  Vapour- Baths. — Vapour- 
baths  impregnated  with  fir  balsam  are  popular, 
and  are  considered  to  be  more  powerful  in  their 
operation  than  pine-baths.  The  vapour  which 
rises  in  making  the  decoction  of  pine  leaves  is 
conveyed  to  a box  in  which  the  patient  is  en- 
closed. 

Aromatic  vapour-baths  may  be  given  by 
making  the  steam  of  hot  water  pass  through 
bunches  of  fresh  aromatics  ( conium , lavender, 
&c.)  before  reaching  the  box  in  which  the  patient 
is  placed.  Such  baths  may  be  useful  in 
hysteria. 

III.  Composite  Air-Baths. 

1.  Sulphurous  Acid  Bath. — A valuable  mode 
of  applying  sulphur  in  the  form  of  a bath  is  by 
using  its  fumes — in  other  words,  sulphurous  acid. 
The  patient  is  seated  on  a cane-bottomed  chair, 
and  his  body  is  encircled  with  a cradle,  over 
which  oil-cloth  is  thrown,  the  head  remaining 
uncovered.  Sulphur  is  placed  on  a metallic 
plate,  to  the  lower  surface  of  which  the  flame  of 
a lamp  is  applied,  when  sulphurous  acid  is  dis- 
engaged. This  bath  is  less  used  in  cutaneous 
affections  than  formerly. 

2.  The  Mercurial  Vapour-Bath.— -Very  similar 

is  the  mode  of  applying  the  fumes  of  mercury. 
Under  the  chair  are  placed  a copper  bath  con- 
taining water,  and  a metallic  plate  on  which 
are  put  from  60  to  180  grains  of  the  bisulphuret 
or  of  the  grey  or  red  oxide  of  mercury.  Spirit 
lamps  are  lighted  under  the  bath  and  under  the 
plate.  The  patient  thus  experiences  the  effects 
both  of  aqueous  and  of  mercurial  vapour.  At 
the  end  of  five  or  ten  minutes  perspiration 
commences,  which  becomes  excessive  in  ten 
minutes  or  a quarter  of  an  hour.  The  lamps 
are  then  to  be  extinguished,  and  when  the 
patient  becomes  moderately  cool,  he  is  to  be 
rubbed  dry.  He  should  then  drink  some  warm 
liquid  and  remain  quiet  for  a time.  This  has 
often  been  a favourite  mode  of  treating  secondary 
syphilis  with  some  practitioners.  Calomel,  in 
quantities  of  from  20  to  30  grains,  is  adminis- 
tered in  a similar  manner,  under  the  name  of 
the  Calomel  Bath.  It  may  be  given  locally  by  a 
suitable  apparatus.  John  Macphebsox. 

BATHS,  Natural.  See  Mineral  Waters. 

BED-SORE.  See  Ulcer  and  Ulceration. 

BELL-SOUND.  A peculiar  physical  sign 
associated  with  pneumothorax.  See-  Physical 
Examination. 

BELL’S  PARALYSIS,  (Named  after  Sir 
Charles  Bell.)  A synonym  for  paralysis  of  the 
facial  nerve.  See  Facial  Paralysis. 


BERIBERI. 

BERIBERI. — Synon.  : Barbicrs;  and  nume- 
rous other  local  names. 

Definition. — A disease  characterised  by 
anaemia,  anasarca,  degeneration  of  muscular 
tissue,  effusion  into  the  serous  cavities,  debility; 
numbness,  pain,  and  paralysis  of  the  extremities, 
especially  the  lower;  prsecordial  anxiety,  pain, 
and  dyspnoea ; scanty  and  high-coloured  urine  ; 
and  in  some  cases  drowsiness  or  sleepiness. 
Beriberi  occurs  in  a chronic  and  an  acute  form ; 
in  the  latter  often  proving  rapidly  fatal  from 
exhaustion,  syncope,  or  the  formation  of  cardiac 
or  pulmonary  eoagula. 

Etymology. — The  etymology'  of  the  word  Beri- 
beri is  obscure.  Herklotts  suggests  the  Hindi 
word,  Bheree — a sheep — from  the  fancied  resem- 
blance of  the  gait  of  persons  affected  to  that 
of  sheep.  Soond-bheree  comes  from  the  words 
numbness  and  sheep.  Soond-ke-baiee  signifies 
numbness  and  rheumatism.  Bher-bheri , a Hindi 
word,  signifies  a sore,  a swelling.  Mason  Good 
says  thatBontius  introduced  the  word  Beriberia, 
and  tells  us  that  it  is  of  Oriental  origin.  Carter 
suggests  Bhari,  sailor,  from  Bahr,  the  sea  ; and 
Bkayr,  shortness  of  breath.  As  the  disease  is  seen 
among  African  and  Arab  sailors,  this  is  probable. 
Some  think  it  is  derived  from  a Cingalese  word 
meaning  weakness,  first  applied  to  a variety  oi 
conditions,  the  result  of  scorbutic,  malarious, 
rheumatic,  and  ansemic  cachexice,  on  the  Malabar 
Coast. 

Geographical  Distribution. — Beriberi  pre- 
vails endemically  in  Ceylon  ; and  in  India,  on  the 
Malabar  Coast,  and  in  the  Northern  Circars, 
between  13°  and  20°  N.  latitude,  extending  in- 
land from  forty  to  sixty  miles.  It  is  known  in 
other  parts  of  India,  probably  occasionally  all 
over  the  peninsula  ; in  Burmah  and  the  Malayan 
peninsula ; amongst  the  crews  of  ships  trading 
to  ports  in  the  Persian  Gulf,  Red  Sea,  coast  of 
Africa,  Bay  of  Bengal,  Singapore,  Siam,  and  the 
islands  of  the  Indian  Archipelago ; and  in  the 
Australian  seas.  On  the  West  Coast  and  other 
parts  of  Africa  beriberi  also  occurs,  and  is  known 
as  the  sleeping  sickness.  In  Europe  pernicious 
aneemia  is  possibly  the  same  disease.  Beriberi  is 
also  met  with  in  South  America,  and  probably 
wherever  certain  conditions  of  food,  water,  soil, 
climate,  and  mode  of  life  coexist. 

.'Etiology. — All  observation  tends  to  show 
that  beriberi  occurs  where  causes  cf  debility 
have  for  some  time  operated,  especially  in  the  cli- 
mates and  localities  previously’  mentioned,  such 
as  certain  conditions  of  soil,  air,  and  water; 
exposure  to  great  alternations  of  temperature, 
especially  when  accompanied  bv  wet,  fatigue, 
mental  and  physical  depression;  food  deficient 
in  quantity  and  quality  or  variety  : previous  ex- 
hausting diseases ; malaria,  and  other  undefined 
atmospheric  and  telluric  influences — all,  in  fact, 
that  tends  to  depress  the  vital  energies,  im- 
poverish the  blood,  and  starve  the  nerve-centres. 
The  symptoms,  it  is  said,  seldom  begin  to  appear 
within  ten  months  or  a year  after  first  exposure 
to  these  causes.  Beriberi  has  been  ascribed  by 
Ranking  to  disease  of  the  kidney,  but  there  is  no 
evidence  to  prove  that  it  is  due  to  this  cause,  or 
indeed  to  structural  changes  of  any  of  the  vis- 
cera. Morehead  refers  it  rather  to  a scorbutic 
origin,  and  in  some  respects  it  does  resemble 


BERIBERI. 

scurvy ; it  may  probably,  also,  be  a consequence 
of  the  cachexia  that  so  often  results  from  long 
residence  in  a malarious  climate,  especially  when 
that  has  been  accompanied  by  exposure,  pri- 
vation, and  excessive  exhaustion  of  the  vital 
powers.  In  such,  the  most  complete  ansemia, 
with  debility,  may  occur,  independently  of  the 
existence  of  organic  visceral  disease,  though 
naturally  they  will  be  intensified  where  such 
disease  is  present. 

Amatomical  Charactees. — Serous  fluid  is 
effused  generally  — in  the  areolar  tissue,  in  the 
lungs,  brain,  heart,  and  abdominal  viscera.  The 
cavities  are,  like  the  tissues,  soaked  with  watery 
efiusion.  The  tissties  are  soft  and  degenerate. 
Muscular  fibre  is  fatty,  especially  that  of  the 
heart,  which  is  often  enlarged  and  dilated.  The 
kidneys  are  enlarged,  anaemic,  and  softened. 

Pathology. — The  recent  discovery  by  Mr.  T. 
Lewis  in  India,  of  the  embryo  of  a nematode  worm 
in  the  blood  of  persons  suffering  from  chyluria 
(see  Chyltjeia),  lymphorrhoea,  and  elephantiasis, 
of  which  diseases  it  appears  to  be  to  some  extent 
the  cause,  suggests  inquiry  whether  a similar 
haematozoon  may  not  also  be  in  some  way  con- 
cerned in  inducing  beriberi.  Fonsagrives  and 
Leroy  de  Mericourt  describe  beriberi  as  general 
dropsy  with  a rapid  course,  no  albuminuria,  and 
weakness  and  loss  of  sensibility  in  the  lower 
limbs.  Dropsy  commences  as  anasarca,  and 
extends  to  the  serous  cavities.  Though  hepatic, 
splenic,  or  renal  complications  may  exist,  and 
intensify  the  severity  and  hasten  the  progress 
of  the  general  symptoms,  they  are  not  essen- 
tial concomitants  of  the  disease,  but  appear 
to  originate  in  a spansemic  state  of  the  blood, 
and  to  be  kept  up  by  its  progressive  imperfect 
elaboration.  The  resulting  partial  starvation  of 
the  cerebro-spinal  nerve-centres,  and  the  serous 
effusion  into  and  amongst  them,  sufficiently 
account  for  the  paralysis  which,  in  severe  cases, 
characterises  this  disease. 

Symptoms. — Beriberi  presents  itself  under  a 
chronic  and  an  acute  aspect ; rarely,  it  is  said, 
ever  occurring  in  either  form,  until  after  an  ex- 
posure of  some  months  to  the  exciting  causes. 
The  general  symptoms  may  be  said  to  be  those 
of  anaemia  and  anasarca.  (Edema  pervades  the 
limbs  and  body  generally,  accompanied  with 
numbness,  pain,  heaviness,  and  loss  of  power, 
amounting  in  some  cases  to  paralysis.  Along  with 
these  symptoms  there  occur  prsecordial  anxiety, 
dyspnoea,  irregularity  and  palpitation  of  the 
heart,  pain  at  the  ensiform  cartilage,  anaemic 
murmurs,  debility,  and  a small  quick  pulse,  which 
at  the  outset  may  be  rather  hard  and  full,  ac- 
companied by  dryness  and  heat  of  skin.  The 
appetite  is  at  first  not  impaired.  Later  there  is 
coldness  of  the  extremities ; torpor  of  the  bowels ; 
scanty,  high-coloured  urine,  of  sp.  gr.  1020  to 
1040,  bub  no  albuminuria  as  a rule.  According 
to  Horton  and  others,  excessive  drowsiness  and 
stupor  attend  some  stages  of  certain  cases  of  the 
disease ; also  pale,  flabby  tongue  and  blanched 
mucous  membranes  ; occasionally  hsemorrhage 
from  the  stomach  and  bowels ; with  petechial 
eruptions ; an  anxious  look ; a puffy,  swollen, 
and  sometimes  livid  face ; and  a peculiar 
tottering  gait.  Death  results  rapidly  in  some 
of  the  acute  cases,  with  symptoms  of  effusion 


BERIBERI.  105 

into  the  thoracic  and  abdominal  cavities,  or  with- 
in the  skull,  by  exhaustion,  syncope,  or  the  for- 
mation of  coagula,  either  in  the  systemic  or  in 
the  pulmonic  circulation.  Beriberi  frequently 
assumes  a slight  and  modified  form,  indicated 
by  anaemia,  numbness,  and  a certain  amount  of 
pain  in  the  limbs  ; an  anxious  expression ; dis- 
ordered bowels ; scanty  urine ; cold  skin  ; a low, 
feeble,  and  irregular  pulse  ; praecordiai  pain  or 
uneasiness,  with  palpitation ; nervous  depression; 
an  unsteady,  almost  tottering  gait ; and  a puffy 
face  and  neck.  Dr.  Paul  says  ; ‘ I have  met  with 
a numerous  class  of  cases  that  are  not  so  serious 
(as  the  acute)  or  so  often  fatal,  where  the  chief 
symptom  complained  of  was  burning  of  the  feet.’ 
Malcolmson  describes  this  remarkable  condition 
in  connection  with  beriberi,  to  which,  he  says,  it 
is  allied — it  is  found  to  affect  the  soles  and 
calves  of  the  legs,  the  back,  and  occasionally  the 
muscles  of  the  legs.’  It  occurs  in  recent  aud 
slight  examples  of  beriberi,  and  was  first  observed 
in  the  troops  after  the  first  Burmese  war — some- 
times in  men  who  had  not  had  beriberi ; on  the 
whole,  Malcolmson  thinks  it  is  neither  rheuma- 
tism nor  beriberi,  and  may  accompany  or  follow 
other  diseases,  as  an  indication  of  nervous  de- 
bility. 

In  the  acute  forms  of  beriberi  the  symptoms 
are  very  severe  and  often  rapid;  and  the  mor- 
tality would  indicate  it  to  be  second  only  to 
cholera  in  fatality.  The  chief  symptoms  are  : — 
Rapid  general  ansemia  and  dropsy  of  the  cavities ; 
scanty,  almost  suppressed  urine  ; constipation  ; 
weak,  irregular  pulse  ; intense  prsecordial  pain ; 
hurried,  irregular,  and  painful  breathing; 
occasional  vomiting — sometimes  of  blood ; swell- 
ing of  the  limbs,  with  numbness,  pain,  and 
paralysis,  preceded  by  a feeble,  tottering  gait ; 
all  the  symptoms  of  pleuritic  and  pericardial 
efiusion ; failing  heart ; and  death  either  from 
syncope,  or  perhaps  almost  suddenly  from  em- 
bolism— in  the  most  acute  cases  within  a few 
days.  In  this  acute  form  the  affection  is  very 
fatal,  but  in  the  milder  and  more  chronic  form 
recovery  is  frequent.  Acute  cases  often  super- 
vene in  those  who  have  suffered  from  the  milder 
disease,  or  in  those  who  are  exhausted  and  anae- 
mic from  other  causes. 

Treatment. — Attention  to  diet,  suitable 
clothing,  and  protection  against  vicissitudes  of 
temperature,  wet,  and  cold,  are  the  best  'pre- 
ventive measures.  Bad  hygiene  and  exhausting 
habits  of  life  tend  to  promote  the  development 
of  the  constitutional  condition  in  which  the 
disease  commences. 

"When  beriberi  is  established  these  precautions 
are  still  necessary,  and  attention  must  be  paid 
to  the  symptoms  as  they  occur.  Diuretics  and 
diaphoretics  relieve  the  oedema  and  dropsical 
effusions.  Tonics  and  stimulants  give  vigour 
to  the  weakened  muscular  fibre  ; while  appro- 
priate remedies  and  diet  may  improve  the  con- 
dition of  the  blood. 

Acetate  of  potash,  digitalis,  and  squill,  and 
occasionally  calomel,  are  said  to  favour  the  re- 
moval of  the  fluid.  It  is  needless  to  say  that 
the  physiological  action  of  mercury  is  to  be 
avoided.  Salines,  hot-air  baths,  diaphoretics, 
and  turpentine  may  at  various  stages  be  found 
useful.  The  object  being  to  remove  the  fluid  and 


106  BERIBERI, 

strengthen  muscular  fibre,  quinine,  iron,  and 
other  tonics  are  an  important  element  in  the 
treatment.  No  remedies,  however,  -will  be  of 
much  avail  unless  the  patient  be  placed  in 
favourable  hygienic  conditions.  Malcolmson 
speaks  highly  of  two  remedies — treak  farook, 
and  oleum  nigrum , -which  are  considered  to  be 
very  effective  in  the  treatment  of  the  disease, 
especially  in  relieving  the. dyspnoea  and  cedema, 
which  proved  very  fatal  until  these  drugs  were 
introduced.  The  composition  of  the  treak  is  appa- 
rently generally  unknown — it  seems  to  be  diuretic 
and  stimulating,  and  probably  not  aperient 
unless  combined  with  rhubarb,  in  doses  of  four 
to  fifteen  grains.  The  oleum  nigrum  is  a stimu- 
lant and  diaphoretic,  given  thrice  daily,  and 
has  been  found  by  Indian  physicians  to  be 
very  beneficial  in  some  cases  of  beriberi.  Dr. 
Aitken  says  that  turpentine  is  a useful  remedy. 
Ergotin,  iron,  and  belladonna  with  zinc  in  the 
form  of  pill,  accompanied  with  sea-bathing,  were 
useful  in  this  disease,  as  seen  at  Bahia.  Nux 
vomica  has  often  been  found  serviceable  in  cer- 
tain cases,  as  might  be  expected,  and  opium  may 
be  needed  to  allay  pain  and  irritability.  Hepatic 
and  splenic  complications  need  their  appropriate 
remedies.  Obviously  the  chief  indications  are  to 
promote  removal  of  the  oedema  ; to  regulate  the 
functions  of  the  abdominal  viscera ; to  increase  the 
action  of  the  skin  ; and  to  give  tone  and  vigour  to 
the  muscular  fibre.  By  such  measures  can  we 
alone  hope  to  deal  successfully  with  this  profound 
form  of  cachexia.  Joseph  Fayeee. 

BIARRITZ  in  Prance,  on  the  Bay  of 
Biscay.  A fashionable  sea-side  resort.  The 
climate  is  considered  to  be  bracing.  See  Climate, 
Treatment  of  Disease  by. 

BILE,  Disorders  of. — Disorders  of  the  bile 
held  a large  place  in  the  medicine  of  antiquity, 
with  the  exception  of  the  theories  of  Van  Helmont 
and  Paracelsus  ; the  latter  looking  upon  the  bile 
as  the  balsam  of  life,  and  therefore  incapablo  of 
begetting  disease ; the  former  regarding  it  as  a 
mere  excrementitial  fluid,  and  therefore  equally 
incapable  of  begetting  disease.  Disorders  of  the 
bile  have,  nevertheless,  held  their  own  quite 
into  our  time.  It  is  common  enough  to  hear 
persons  speak  of  a ‘ bilious  attack,’  or  ‘ being 
troubled  with  the  bile,’ expressions  the  survivals 
of  the  humoral  pathology.  The  liver  was  for- 
merly credited  with  most  of  the  dyspeptic  dis- 
orders of  the  stomach.  As  Sir  Thomas  Watson 
says,  it  is  an  organ  often  blamed  most  gratui- 
tously and  unjustly,  but  no  educated  or  scientific 
physician  would  now  think  of  attributing  a gas- 
tric catarrh,  or  constipation,  to  an  ‘attack  of  the 
bile,’  or  to  a ' sluggish  liver.’ 

Physicians  have  arranged  disorders  affecting 
the  bile  under  three  heads — (1)  diminished  secre- 
tion of  bile ; (2)  increased  secretion  of  bile  ; and 
(3)  secretion  of  morbid  or  altered  bile.  This  divi- 
sion may  very  well  be  accepted  as  a convenient 
basis  for  the  further  discussion  of  biliary  disor- 
ders, but  it  is  nothing  more  than  an  hypothesis. 
It  is  likely  enough  that  the  bile,  in  certain  dis- 
eases, changes  its  character  as  regards  both  its 
amount  and  constituent  parts : but  it  cannot  be 
denied  that  the  means  by  which  physicians  are 
able  to  ascertain  these  changes  can  scarcely  be 


BILHARZIA. 

said  to  exist  in  ordinary  cases.  A common  saying 
is  that  the  patient  must  be  making  plenty  of 
bile  because  the  stools  are  high  in  colour.  No 
reasoning  can  be  more  fallacious.  The  colour  of 
tho  stools  may  be  high  if  the  fseces  be  quickly 
swept  through  the  intestinal  canal,  because  thero 
has  been  no  time  for  the  bile-pigment  to  be 
absorbed  into  the  blood.  Or  the  fseces  may  be 
pale  if  they  lie  long  in  the  bowel  aDd  the  coloured 
matter  absorbed.  So  that  the  colour  of  the 
stools  is  no  sure  sign  of  the  poveityor  abun- 
dance of  the  secretion  of  bile.  In  cases  of  pale- 
coloured  faeces  purgatives  often  do  good,  not 
because  they  have  any  special  tendency  to  in- 
crease the  flow  of  bile,  but  because  they  hurry 
the  fseces  out  of  the  intestine,  and  thus  give  no 
time  for  the  absorption  of  the  bile,  which,  if  it 
lay  long  in  the  bowel,  would  be  absorbed,  carried 
to  the  liver,  and  again  excreted  into  the  gall- 
ducts — the  vicious  circle  of  Schiff. 

Nor  is  the  analysis  of  the  bile  found  after  death 
in  the  gall-bladder  of  much  value.  Frerichs 
announced  the  presence  of  albumen  in  the  bile 
in  cases  of  congestion  of  the  liver  ; but  it  is  now 
generally  thought  that  this  appearance  is  due 
solely  to  a post-mortem  transudation.  Bitter 
also  has  described  a colourless  bile  in  which  all 
the  constituents  of  bile  are  present  except  the  pig- 
ments. Most  of  his  analyses  were  made  on  bile 
taken  from  tho  gall-bladder  after  death  ; but  if 
the  cystic  duct  be  obstructed  for  any  time,  it  is 
well  known  that  the  bile  contained  in  tho  gall- 
bladder may  become  colourless  without  any  real 
secretion  of  colourless  bile  having  taken  place  in 
the  first  instance.  It  is  impossible  to  be  certain 
that  the  changes,  which  are  found  in  tho  bile 
taken  from  tho  gall-bladder  after  death,  have 
taken  place  during  life. 

The  only  source  of  what  may  be  called  know- 
ledge of  the  disorders  of  the  bile  is  observation 
of  men  or  animals  in  whom  biliary  fistulm  have 
been  formed  either  by  disease  or  by  art.  Unfor- 
tunate^, the  majority  of  such  observations  have 
been  physiological  or  pharmacological ; and  but 
few  are  recorded  of  the  changes  which  the  bile 
undergoes  in  disease.  Altogether  contradictory 
experiments  are  recorded  of  the  influence  of  the 
nerves  and  of  the  diabetic  puncture  of  the  fourth 
ventricle  upon  the  secretion  of  bile.  It  is  an 
admirable  field  for  further  research,  but  it  will 
be  seen  that  our  present  knowledge  very  closely 
approaches  to  complete  ignorance. 

It  is  disputed  still  whether  the  presence  of  bile 
in  the  stomach  puts  an  end  to  the  process  of 
digestion.  By  many  it  is  thought  that  the  bile- 
acids  throw  down  the  albumen  of  tho  food,  and 
with  the  albumen  the  pepsin.  It  is  well  known 
that  in  some  disorders  there  is  an  inverted  action 
of  the  duodenum,  and  bile  is  poured  into  the 
stomach,  as  in  long-continued  vomiting,  for 
instance ; thus  the  dispute  has  a practical  bear- 
ing. The  best  treatment  of  this  state  would 
seem  to  be  by  saline  purgatives. 

Bile  may  also  be  taken  up  into  the  blood,  and 
when  this  occurs,  jaundice  results  (sre  Jaijndicb). 

J.  Wickham  Lego. 

BILHARZIA.  — This  name  was  given  by 
the  writer  to  a genus  of  flukes  discovered  by  Dr. 
Bilharz,  of  Cairo,  in  the  portal  system  of  human 


BILHARZIA. 


BILIARY  FISTULA.  107 


blood-vessels,  and  the  worm  was  subsequently 
found  by  the  writer  in  the  portal  rein  of  a monkey. 
This  trsematode  hsematozoon  was  first  described  as 
a Distoma,  but  the  species  is  now  more  generally 
known  as  the  Bilharzia  hcematobia.  It  was  ori- 
ginally found  in  the  portal  system,  and  Bilharz, 
Griesinger.Lautner,and  others  afterwards  showed 
that  this  parasite  also  infests  the  veins  of  the 
mesentery,  bladder,  and  other  parts,  producing  a 
formidable  disease  which  is  endemic  in  Egypt,  at 
the  Cape,  at  Natal,  and  probably  in  other  parts  of 
the  African  continent,  as  well  as  in  the  Mauritius. 
The  discovery  that  the  endemic  hsematuria  of  the 
Cape  of  Good  Hope  is  occasioned  by  the  presence 
of  Bilharzia,  is  due  to  Dr.  John  Harley,  who  de- 
tected the  ova  in  the  urine  of  a patient  who  had 
previously  resided  in  Southern  Africa.  Dr.  Har- 
ley’s impression  that  he  had  to  deal  with  a new 
species  of  Bilharzia  has  not  gained  general 
acceptance,  but  he  furnished  proof  of  the  wide 
geographical  distribution  of  this  parasite,  and 
he  also  added  largely  to  our  knowledge  of  its 


ravages. 

Description. — This  parasite,  unlike  nearly  all 
the  other  known  species  of  fluke,  has  the  sexes 
separate,  the  females  being  comparatively  slen- 
der worms,  resembling  filariform  nematoids. 
During  copulation  the  female  is  lodged  in  a long 
slit-like  groove,  or  gyncecophoric  canal,  with 
which  the  abdomen  of  the  male  is  furnished. 


fid.  2.  — Bilharzia  hcema- 
tobia, male  and  female 
sexually  combined.  Mag- 
nified. After  Kiichen- 
meister. 


Fig.  3. — Ovum  of  Bil- 
harzia hcematobia 
with  contained  em- 
bryo and  free  snr- 
code-granules : x 234 
diameters.  Original. 


The  eggs,  measuring  from  yY"  to  Afa"  in  length, 
are  peculiar,  being  either  sharply  pointed  at  one 
end,  or  furnished  with  a projecting  spine,  placed 
at  a little  distance  from  the  hinder  pole.  This 
spine  gives  a point  of  resistance  to  the  egg 
during  the  struggles  of  the  embryo  to  effect  its 
escape.  Those  who  are  interested  in  the  organi- 
zation of  the  ciliated  embryos,  and  in  the  re- 
markable behaviour  of  the  larvse  during  their 
earliest  stages  of  growth,  will  find  the  subject 
fully  discussed  in  the  writer's  paper  ‘On  the 
development  of  B.  hcematobia,’  together  with 
remarks  on  the  ova  of  another  urinary  parasite, 
occurring  in  a case  of  haematuria  from  Natal, 
Brit.  Med.  Joum.,  1872. 

Treatment. — The  writer  has  pointed  to  the 
danger  of  treating  cases  of  Bilharzia  as  if  they 
were  comparable  to  ordinary  helminthiases.  It  is 
neither  desirable  to  employ  active  drugs  for  the 


expulsion  of  the  parasite  and  its  eggs  from  the 
bladder,  nor  is  it  prudent  to  attempt  the  employ- 
ment of  vermicides  with  the  view  of  destroying 
the  worms.  As  in  Trichinosis,  so  in  the  Bilhar- 
zia disease,  it  is  essential  to  support  the  sys- 
tem. Thus  tonics,  cold  bathing,  aud  a highly 
nourishing  diet,  combined  with  the  bicarbonate  of 
potash  and  infusion  of  buchu,  constitute  our  best 
resources  when  dealing  with  cases  of  endemic 
hsematuria.  The  pathological  facts  clearly 
show  that  in  order  to  effect  a cure  we  must 
imitate  nature  herself  as  closely  as  we  can.  IVe 
must  seek  to  erect  artificial  barriers,  and  thus 
check  the  hiemorrhage  as  much  as  possible.  For 
this  purpose  the  writer  has  found  the  astringent 
properties  of  Arctostaphylos  uva  ursi  eminently' 
serviceable ; small  quantities  of  hyoscyamus  being 
usefully  combined.  Dr.  Harley  advises  ‘a  perse- 
vering use  of  belladonna  and  henbane,’  under  the 
impression  that  treatment  with  these  drugs  ‘ will 
retard  the  development  of  the  parasite,  even  if 
they  do  not  effect  its  destruction.’  The  writer 
entirely  disagrees  in  this  view  of  the  case,  and 
he  also  objects  to  the  employment  of  medicated 
injections.  He  thinks  that  the  employment  of  diu- 
retics is  likewise  clearly'  contra-indicated.  Every- 
thing that  will  contribute  towards  allaying  the 
vesical  irritation,  is  certain  to  assist  the  natural 
process  of  cure  ; and,  in  this  view,  the  adminis- 
tration of  buchu-infusion,  the  enforcing  of  a 
liberal  diet,  and  the  taking  of  gentle  exercise, 
will  be  found  amongst  the  most  important  cura- 
tive aids.  In  bad  cases  a thorough  cure  is  not 
likely  to  be  completed  until  after  the  lapse  of 
several  years.  Prophydactically  it  is  essential 
to  remove  patients  from  the  localities  in  which 
there  is  every  reason  to  believe  they  have  con- 
tracted the  disease.  In  view,  also,  of  preventing 
infection  on  the  part  of  others,  it  is  necessary 
that  the  water  employed  for  domestic  purposes 
throughout  the  infected  districts,  be  rendered 
thoroughly  pure  by  efficient  filtration.  For  fur- 
ther particulars  the  reader  is  recommended  to 
consult  the  general  works  of  Kuchenmeister 
and  Leuckart ; the  writer’s  introductory  treatise 
on  Entozoa  (p.  197  et  scq.) ; Dr.  Harley’s  three 
separate  memoirs  (in  the  Transactions  of  the 
Royal  Med.  and  Chir.  Soc.,  1864,  &c.) ; and 
also  especially  the  recent  memoir  by  Dr.  Sonsino, 
entitled  1 Researches  concerning  Bilharzia  hcema- 
tobia in  relation  to  the  endemic  hsematuria  of 
Egypt,  with  a note  on  a nematoid  found  in 
human  blood’  {Rend,  della R.  Accad.  delle  Scienzc, 
§-c.,  1871).  See  also  Hjematozoa. 

T.  S.  CoBBOLD. 

BILIARY  CALCULUS.  See  Gall-stones. 

BILIARY  FISTULA. — There  are  tv.o 
kinds  of  biliary  fistula: — one,  in  which  a commu- 
nication exists  between  the  gall-bladder  and  the 
surface  of  the  body;  the  other,  in  which  there  is 
a communication  between  the  gall-bladder  and 
other  internal  organs.  Neither  kind  is  common, 
but  the  first  is  less  rare  than  the  other. 

In  the  first  variety  a tumour  forms,  sometimes 
in  the  place  of  the  gall-bladder,  at  other  times  near 
the  umbilicus,  in  the  linea  alba  or  to  the  left  of  this 
line,  or  in  the  groin.  The  tumour,  if  opened  spon- 
taneously' or  by  the  surgeon,  discharges  a quantity 
of  pus,  bile,  and  gall-sdones.  D’  the  cystic  duct 


103  BILIARY  FISTULA, 

be  obliterated,  no  bile  need  escape.  A suppura- 
tion of  the  gall-bladder,  caused  by  the  presence 
of  gall-stones,  is  the  common  cause  of  these 
fistulse.  The  prognosis  is  good.  The  diagnosis, 
before  the  tumour  opens,  is  very  difficult.  In  a 
case  ■which  came  under  the  writer's  notice,  it  was 
mistaken  for  an  abscess  of  the  liver. 

In  the  second  kind  of  biliary  fistula,  the  gall- 
bladder may  communicate  with  the  duodenum 
or  colon  ; with  an  abscess  of  the  liver;  with  the 
portal  or  other  abdominal  vein,  though  it  must 
be  owned  that  cases  of  this  kind  seem  somewhat 
dubious ; or  with  the  urinary  bladder,  or  at  least 
with  some  part  of  the  urinary  tract.  Gall-stones 
are  in  nearly  every  case  the  cause  of  the  fistulous 
opening.  J.  Wickham  Legg. 

BILIOUS. — This  term  is  used  with  much 
vagueness,  and  in  popular  language  is  often  em- 
ployed very  incorrectly,  though  the  idea  is  to 
associate  it  with  conditions  in  which  an  excessive 
formation  of  bile  is  supposed  to  occur.  The 
chief  uses  of  the  word  are  as  follows  : — In  the 
first  place  it  is  employed  to  designate  a peculiar 
temperament — the  bilious  temperament.  Again, 
individuals  are  often  said  to  be  bilious  when 
they  present  a sallow  or  more  or  less  yellowish 
tint  of  skin,  but  especially  if  they  are  distinctly 
jaundiced.  Bilious  vomiting  and  diarrhoea  signify 
respectively  the  discharge  of  a quantity  of  bile, 
mixed  with  vomited  matters  or  with  loose  stools. 
Certain  febrile  diseases,  attended  with  yellow- 
ness of  the  skin,  are  sometimes  designated  bilious 
fever,  and  under  like  circumstances  pneumonia 
has  been  described  as  bilious  pneumonia.  Lastly, 
one  of  the  most  frequent  applications  of  the 
term  is  to  certain  so-called  bilious  attacks  or 
biliousness,  which,  however,  are  commonly  merely 
attacks  of  acute  dyspepsia  or  migraine.  The 
most  prominent  symptoms  of  a supposed  bilious 
attack  are  anorexia,  furred  tongue,  a bitter 
taste,  sickness,  constipation,  and  headache,  with 
a feeling  of  marked  depression  and  general 
malaise.  Such  attacks  are  most  effectually  pre- 
vented by  careful  regulation  of  diet,  and  the 
avoidance  of  exposure  to  cold,  fatigue,  and  undue 
mental  exertion  or  anxiety ; when  they  come  on, 
abstinence  from  food  is  desirable,  with  rest  in 
the  recumbent  posture,  and  perfect  quiet.  Altera- 
tive aperients  and  saline  effervescents  may  be 
given,  alcoholic  stimulants  being  avoided  as  far 
as  possible.  Frederick  T.  Roberts. 

BILIOUS  TEMPERAMENT.  See  Tem- 
Eeeament. 

BITTER  ALMONDS,  Poisoning  by. 

See  Prussic  Acid,  Poisoning  by. 

BLACK  VOMIT. — Vomited  matters  may 
te  more  or  less  black  in  different  diseases,  but 
die  peculiar  black  vomit  is  that  which  occurs  in 
yellow  fever  ( see  Yellow  Fever).— The  rejected 
matters  are  acid  in  reaction,  and  a sediment 
is  deposited  of  coagulated  albumen  and  dis- 
integrated blood-corpuscles.  Ammonia  is  also 
present.  The  black  colour  of  the  vomit  has  been 
attributed  by  some  writers  to  altered  bile,  but 
there  can  be  no  doubt  that  it  is  due  to  its  ad- 
mixture with  blood  which  has  undergone  certain 
changes. 

BLADDER,  Disea  ses  of. — The  bladder  may 


BLADDER,  DISEASES  OF. 
be  the  seat  of  the  following  morbid  conditions: — 
Inflammation,  acute  or  chronic ; Abscess ; Neu- 
ralgia ; Atrophy  or  Hypertrophy ; Mechanical 
Distension,  with  chronic  engorgement  and  reten- 
tion of  urine,  commonly,  but  erroneously,  termed 
‘ Paralysis  Sacculation  ; Displacements,  such  as 
hernia  in  the  male,  or,  very  rarely,  inversion  and 
protrusion  in  the  female  ; Tumours  or  Growths, 
including  fibrous,  villous,  or  vascular  growths ; 
Tpithelioma  and  Carcinoma;  Tubercular  Dis- 
ease ; Ulceration,  either  simple  or  malignant ; and 
Vesico-vaginal  or  Vesico-intestinal  fistula.  The 
bladder  may  also  be  the  subject  of  true  paralysis, 
partial  or  complete,  as  the  result  of  injury  to  the 
brain  or  spinal  cord,  or  following  disease  of 
those  organs. 

Only  a brief  statement  respecting  the  most  im- 
portant of  this  class  of  affections  need  be  pre- 
sented here,  in  order  to  facilitate  an  acquaintance 
with  their  diagnosis,  since  the  treatment  of  almost 
all  of  them  belongs  to  the  province  of  the  surgeon, 
and  so  far  only  as  it  consists  of  medicinal  reme- 
dies will  the  subject  be  considered. 

1.  Acute  Inflammation— Acute  Cystitis- 
— The  mucous  lining  of  the  bladder  is  the  part 
affected  by  inflammation — and  although  after 
long  and  severe  attacks  some  morbid  action  oc- 
curs by  extension  to  the  muscular  coat,  or  even 
to  the  peritoneal  covering,  these  structures  are 
very  rarely  affected.  An  acute  inflammation 
of  a very  severe  kind  occurs  from  injuries; 
from  the  presence  of  instruments,  foreign  bodies, 
or  calculi ; and  from  unrelieved  retention  of 
urine.  A less  severe,  somewhat  evanescent, 
but  very  painful  form  of  cystitis  arises  from 
irritants  taken  internally,  as  cantharides.  A 
still  less  severe,  but  often  troublesome  form 
originates  by  extension  from  gonorrhoea. 

In  the  first  class  of  cases  there  are  not  only 
severe  local  symptoms  referable  to  the  bladder, 
but  the  general  system  may  be  gravely  affected. 

In  the  second  class,  of  which  cantharides- 
poisoning  is  the  type,  the  phenomena  of  very 
frequent,  painful,  and  spasmodic  attempts  to 
eject  small  quantities  of  urine  which  is  often 
bloody,  occur  within  a very  short  time  after 
absorption  of  the  poison.  A common  blister  is 
said  to  produce  the  affection  in  some  persons. 
In  two  cases — the  only  two  the  writer  has  seen 
— it  has  followed  the  application  of  a blister  to 
a surface  already  partially  denuded  of  the  scarf 
skin.  In  one  of  these  a blister  wras  applied 
to  a knee  which  had  been  frequently  painted 
with  tincture  of  iodine,  and  was  still  slightly 
sore.  In  three  hours  after  the  application  the 
patient  was  attacked  with  exceedingly  painful 
efforts  to  micturate,  which  were  at  times  intense. 
The  attack  lasted  six  hours,  gradually  diminish- 
ing in  force,  and  leaving  no  ill-effects  behind. 
In  less  than  twenty- four  hours  no  trace  of  the 
symptoms  remained. 

In  the  third  form  of  cystitis,  which  is  the  most 
common,  and  of  which  that  arising  by  extension 
from  gonorrhoea  may  be  taken  as  the  type,  the 
usual  symptoms  are  undue  frequency  of  mictu- 
rition ; a necessity  to  perform  the  act  imme- 
diately the  want  has  declared  itself,  a condition 
conveniently  expressed  by  the  single  word 
‘urgency;’  a desire  to  pass  more,  accompanied 
by  pain,  when  all  the  urine  has  been  voided ; and 


BLADDER,  DISEASES  OF. 


some  dull  aching  over  the  pubes  ; together  with 
a general  febrile  state  of  the  system,  often  very 
slight,  but  corresponding  for  the  most  part  with 
the  degree  of  local  inflammation.  The  urine 
itself  is  cloudy,  and  deposits  some  lignt  mucus 
on  standing,  but  is  not  otherwise  apparently 
altered.  Under  the  microscope  abundance  of 
epithelium  is  visible,  as  well  as  some  pus-cells, 
and  if  the  affection  is  severe,  a few  blood-cor- 
puscles are  also  present.  It  may  be  remarked 
here  that  the  presence  of  a few  pus-cells  in  ihe 
urine,  a fact  to  which  so  many  practitioners 
attribute  considerable  importance,  by  no  means 
necessarily  deserves  to  be  so  regarded.  The 
very  slightest  attack  either  of  this  or  of  the  pre- 
ceding form  of  cystitis  is  certain  to  be  attended 
by  the  formation  of  some  quantity,  however 
small,  of  fully-developed  pus-cells. 

Very  rarely  a false  membrane  may  be  produced 
on  the  surface  of  the  mucous  membrane  of  the 
bladder,  and  may  be  thrown  off  almost  entire, 
leading  to  the  belief  that  the  inner  coat  has  itself 
been  exfoliated.  In  women  this  membrane  has 
been  voided  per  urethram  in  a condition  for  ex- 
amination ; in  men  this  cannot  occur,  because 
the  urethra  is  too  small  to  admit  of  it.  Now 
and  then  examples  of  the  former  have  been 
shown  at  the  Pathological  Society  of  London  ; 
and  one  of  the  latter  may  be  seen,  discovered  by 
operation,  in  the  museum  of  the  Royal  College  of 
Surgeons  of  London. 

Treatment. — In  the  first  form  of  cystitis, 
the  removal  of  the  exciting  cause,  if  possible, 
is  the  chief  indication. 

The  treatment  of  the  second  form  should  consist 
of  very  hot  bidets  or  hip-baths,  the  former  being 
probably  preferable  as  capable  of  being  used  at 
higher  temperatures  than  the  latter  ; together 
with  large  doses  of  the  tincture  of  henbane,  say 
a drachm,  with  10  or  15  drops  of  liquor  opii 
every  two  hours  while  pain  is  severe;  20  minims 
of  liquor  potass®  may  be  given  either  simultane- 
ously or  alternately,  in  water  or  in  any  bland 
diluent. 

The  treatment  of  a well-marked  case  of  the 
third  class  consists  in  absolute  rest  in  the  recum- 
bent posture,  mild  diet,  abstinence  from  all  al- 
coholic stimuli,  gentle  laxative  action  of  the 
bowels,  and  the  administration  of  small  doses  of 
alkali.  The  writer  prefers  liquor  potass®  to  all 
others,  frequently  repeated ; and  this  may  be 
combined  with  henbane,  or,  if  micturition  is  very 
frequent  and  painful,  with  opium  or  morphia, 
or  with  chlorodyne  in  small  doses.  Hot  hip-baths 
or  bidets,  followed  by  hot  linseed-meal  poultices 
or  fomentations,  give  great  relief.  The  patient 
may  drink  freely  of  decoction  of  triticum  repens, 
linseed  tea,  barley  water,  or  similar  demulcents. 
Relief  rapidly  follows,  but  care  is  requisite  to 
avoid  relapse,  which  easily  occurs  if  exercise 
be  taken  too  soon,  if  injections  for  the  gonor- 
rhoea be  resumed  too  readily,  or  if  alcoholic 
stimulants  are  freely  taken. 

2.  Chronic  Inflammation — Chronic  Cys- 
titis.— Chronic  inflammation  of  the  bladder  is 
separated  from  the  acute  form  by  very  distinct 
characters.  It  is  mostly  the  result  of  retained  urine 
from  stricture  or  enlarged  prostate ; but  it  may 
arise  from  the  presence  of  calculi,  or  of  growths 
in  the  bladder  ; from  over-distension,  or  atony  of 


109 

its  coats  ; from  paralysis  after  injury  or  disease 
affecting  a nervous  centre;  from  disease  of  neigh- 
bouring organs ; and  sometimes  from  altered 
urine  : it  is  also  met  with  in  certain  affections  of 
the  kidney.  Sometimes  this  condition  is  marked 
by  the  presence  of  a large  quantity  of  viscous 
mucus,  often  called  ‘ catarrh  ’ ; but  more  com- 
monly this  symptom  is  absent,  and  the  urine 
contains  merely  ordinary  mucus  or  muco-pus, 
rendering  the  secretion  more  or  less  cloudy  and 
opaque.  Perhaps  there  are  some  cases  in  which 
the  inflammation  is  mainly  due  to  the  presence 
of  gout. 

SrapTOMis. — The  symptoms  of  chronic  cystitis 
are  increased  frequency  of  micturition  and  pain, 
but  the  latter  is  by  no  means  necessarily  present. 
The  urine  is  always  cloudy,  and  contains  some 
pus-cells.  There  is  often,  but  not  always,  some 
suprapubic  uneasiness.  The  general  health  does 
not  suffer  unless  the  affection  is  prolonged  or 
severe.  If  important  causes,  as  the  presence  of 
stricture,  calculus,  &c.,  occasion  the  chronic  cysti- 
tis, their  specific  symptoms  will  predominate.  It  is 
not  common  to  find  chronic  cystitis  as  an  idiopa- 
thic disease,  although  undoubtedly  it  occasionally 
is  so  ; so  that  the  writer  has  alwaj’s  regarded  it 
as  a useful  maxim,  ‘ When  chronic  cystitis  is 
declared  to  be  idiopathic,  we  may  be  sure  that 
we  have  only  not  yet  discovered  the  real  cause.’ 
As  a general  rule  we  may  be  sure  that  there  is 
inability  to  empty  the  bladder,  or  calculus,  stric- 
ture, or  organic  disease  of  some  kind  in  some 
part  of  the  urinary  tract,  when  the  group  of 
symptoms  are  present  which  we  denote  by  the 
term  ‘ chronic  cystitis.’  Respecting  the  well- 
known  glairy  mucus,  which  is  deposited  so 
abundantly  from  the  urine  in  some  cases,  in 
elderly  people  almost  invariably,  it  should  be 
said  that  it  appears  only  in  those  whose  urine 
is  abnormally  retained,  through  atony  of  the 
vesical  walls,  or  in  consequence  of  enlarged  pro- 
state, or  as  the  result  of  sacculation  of  the  blad- 
der, and  that  medicine  has  little  or  no  effect 
upon  it. 

Treatment. — The  regular  and  habitual  use  of 
the  catheter,  and  perhaps  also  injections  into  the 
bladder,  form  the  essential  mechanical  treatment 
of  chronic  cystitis  in  the  cases  just  mentioned. 
In  the  few  cases  in  which  chronic  cystitis  is  pre- 
sent, and  no  organic  cause,  such  as  those  named 
above,  can  be  discovered — and  also  as  adjuncts 
to  mechanical  treatment  when  these  causes  dc 
exist — certain  medicinal  agents  are  undoubtedly 
useful : these  are  buchu,  triticum  repens,  uva 
ursi,  alchemilla  arvensis,  pareira  brava,  and  the 
alkalis  potash  and  soda.  Buchu  is  more  useful 
in  subacute  and  recent  chronic  cystitis  than  in 
cases  already  of  long  duration.  The  patient 
should  take  not  less  than  ten  ounces  of  the  in- 
fusion daily.  After  this,  in  similar  cases,  the 
decoction  of  triticum  repens,  made  by  boiling  two 
to  four  ounces  of  the  prepared  underground  stem 
in  a pint  or  a pint  and  a half  of  water,  of  which 
six  ounces  should  be  taken  three  or  four  times 
in  the  twenty-four  hours,  is  highly  useful.  For 
more  chronic  cases,  where  the  urine  is  alkaline 
and  deposits  much  mucus,  and  perhaps  the  triple 
phosphates  also,  alchemilla,  uva  ursi,  and  pareira 
brava  may  be  very  valuable.  The  alchemilla 
is  administered  in  infusion,  one  ounce  of  the 


110  BLADDER,  DISEASES  OF. 

herb  in  one  pint  of  boiling  water,  of  which  the 
dose  is  four  to  six  ounces  three  times  daily ; 
the  others  according  to  the  directions  of  the 
pharmacopoeia.  These  may  be  taken  alone  or 
combined  with  potash,  whicn  in  moderate  quanti- 
ties diminishes  the  natural  acidity  of  the  urine 
before  it  enters  the  bladder;  the  mucous 
membrane  of  which,  although  accustomed  to 
that  condition  in  health,  is  perhaps  some- 
times, when  inflamed,  irritated  by  urine  cf 
even  the  ordinary  acidity.  Whether  this  be  so 
or  not,  there  is  no  doubt  that  alkalis  do  fre- 
quently tranquilliae  an  irritable  bladder.  They 
are  often  given  in  the  form  of  Vichy  water, 
Vais  water,  or  that  of  Evian,  all  strong  solu- 
tions of  soda ; but  on  many  grounds  the  salts  of 
potash  are  preferable.  On  the  other  hand,  the 
mineral  acids  have  been  largely  administered 
in  cases  where  the  urine  is  alkaline  ; although 
there  is  no  reason  to  believe  that  the  acid  has 
any  direct  action  through  the  kidneys,  or  that 
it  is  eliminated  by  those  organs.  Alkalinity 
of  the  urine  in  chronic  cystitis  is  almost  always 
due  to  inability  of  the  bladder  to  empty  itself,  and 
the  remedy  wanted  is  not  medicine  but  a cathe- 
ter, at  all  events  to  ascertain  whether  this  be  the 
cause  or  not.  A very  small  quantity  of  urine 
retained  in  the  bladder,  say  one  or  two  ounces, 
after  every  act  of  micturition,  suffices  in  some 
cases  to  maintain  an  alkaline  and  otherwise  un- 
healthy state  of  the  secretion:  while  it  is  equally 
true  that  some  patients  may  habitually,  aDd 
during  long  periods  of  time  do  fail  to  empty 
the  bladder,  always  leaving  behind  from  half  a 
pint  to  a pint,  without  losing  the  acidity  of  the 
urine.  Of  course  other  signs,  and  notably  great 
frequency  of  micturition,  are  present  when  such 
is  the  case. 

3.  Neuralgia. — It  is  impossible  to  deny  that 
the  bladder  may  be,  like  other  parts  of  the 
body,  subject  to  symptoms  which  are  described 
ns  neuralgia,  although  the  occurrence  is  an  ex- 
tremely rare  one.  All  the  writer  can  say  is, 
that  he  has  occasionally  met  with  cases  in  which 
he  has  not  been  able  to  account,  by  the  existence 
of  any  lesion,  for  pain  and  frequency  in  micturi- 
tion, or  for  difficulty  in  performing  that  act,  and 
where  these  symptoms  have  been  more  or  less 
periodic  in  their  appearance.  In  such  instances 
he  has  given  quinine,  and  has  occasionally 
found  great  relief  to  follow  a few  doses  ; more 
frequently  tills  has  not  been  the  case.  But  now 
and  then  the  value  of  the  drug  has  been  so 
marked  as  to  corroborate  a belief  in  the  existence 
of  vesical  neuralgia.  It  mustbe  repeated,  however, 
that  examples  of  such  phenomena  are  extremely 
rare.  The  writer  has  also  employed  arsenic 
on  the  same  ground.  It  is  invariably  necessary 
fx>  investigate  the  general  health,  as  well  as  the 
habits  and  diet  of  the  patient.  This,  porhaps, 
may  be  the  place  for  stating  that  in  all  chronic 
and  slight  deviations  from  natural  and  healthy 
function  in  the  urinary  organs,  it  is  essentially 
necessary  to  inquire  into  the  state  of  the  diges- 
tive organs,  to  correct  by  diet  and  by  medicine 
when  necessary  any  imperfect  action  on  their 
part,  if  possible.  Constipation  alone,  when 
habitual,  may  produce  considerable  irritability  of 
the  bladder,  so  also  may  the  unnecessary  use 
of  purgativos.  A geutle,  easy,  and  daily  action  of 


BLADDER,  DISEASES  OF. 
the  bowels,  a healthy  condition  of  the  primary 
digestion,  the  absence  of  flatulence  and  distension 
after  food,  should  bo  ensured  as  far  as  possible  in 
all  patients  complaining  of  frequent,  difficult,  or 
uneasy  micturition;  and  many  such  may  be  com- 
pletely cured  of  so-called  urinary  affections  by 
strict  attention  to  these  matters.  The  writer’s 
strong  convictions  relative  to  this  fact,  grounded 
on  innumerable  experiences  of  its  value  as  an  aid 
;n  practice,  led  him  nearly  twenty  years  ago  to 
ascertain  the  great  value,  for  such  patients,  of 
Friedrichshall  water,  now  so  extensively  used; 
and  more  than  ever  he  insists  on  the  use  of  a mild 
and  laxative  regimen  and  diet  in  their  manage- 
ment. 

4.  "Where  obstruction  to  the  outflow  of  urine 
exists  (stricture  of  the  urethra,  most  forms  of 
enlarged  prostate,  other  tumours,  &c.),  tho 
muscular  walls  of  the  bladder  become  the  seat  of 
Hypertrophy,  which  is  a condition  of  compen- 
sation, therefore,  and  not  of  disease  in  or  by 
itself.  But  such  changes  in  the  interlacing  mus- 
cular fibres  existing,  Sacculation  readily  occurs, 
by  protrusion  of  the  lining  membrane  between 
the  bands  so  produced.  On  the  other  hand,  most 
commonly  when  the  prostate  is  hypertrophied, 
the  bladder  becomes  gradually  distended,  its 
coats  become  expanded,  thinned  and  weakened, 
and  a certain  degree  of  Atrophy  takes  place. 
The  power  of  the  organ  to  expel  urine  is  lost  or 
diminished  ; and  micturition  being  a function  of 
simply  mechanical  nature,  the  circumstances  of 
the  case  demand  only  a mechanical  remedy,  viz. 
the  catheter.  No  medicine  can  restore  power  and 
exercise  of  function  under  these  circumstances. 
But  atrophy  and  loss  of  power  may  occur  from 
complete  or  partial  loss  of  nervous  influence  to 
the  bladder,  as  in  those  who  are  the  subjects  of 
paralytic  states  commencing  in  the  spinal  cord  or 
brain.  When  the  paralytic  state  follows  accident 
causing  injury  to  a nervous  centre,  the  nature  of 
the  case  is  obvious  enough.  But  sometimes  the 
onset  and  progress  of  chronic  disease  in  these 
organs  are  very  slow  and  insidious ; theurinary 
troubles,  as  manifested  by  slowness  or  difficulty 
in  passing  urine,  or  by  urine  clouded  through 
inability  of  the  bladder  to  empty  itself,  may  he 
the  earliest  signs  of  the  nervous  lesion.  On  the 
other  hand,  impaired  gait,  and  other  evidences  of 
central  mischief,  may  be  and  mostly  are  earlier 
phenomena,  the  derangement  in  the  urinary 
function  appearing  at  a later  stage.  For  such 
patients,  the  habitual  use  of  the  catheter  is  often 
necessary  [always  of  course  when  unable  to 
empty  the  bladder  by  the  natural  efforts]  ; while 
such  constitutional  treatment  as  is  indicated  by 
the  cerebral  or  cerebro-spinal  lesion  present  will 
comprohend  that  which  the  bladder  demands. 
It  is  therefore  unnecessary  to  allude  further  to 
that  subject  in  this  article.  The  same  remark 
also  applies  to  those  few  examples  of  Tubercular 
disease  of  the  urinary  organs,  which  is  always  a 
local  expression  of  a general  constitutional  state 
sufficiently  considered  under  its  proper  head  in 
this  work.  All  other  treatment  of  this  malady  is 
local  and  surgical. 

5.  Relative  to  Tumours,  the  varieties  of  which 
have  already  been  enumerated,  no  medical  treat- 
ment other  than  that  of  chronic  cystitis  is  to  b« 
thought  of. 


BLADDER,  DISEASES  OF. 

With  almost  all  affections  of  the  bladder, 
simple  or  malignant,  ulcerative  or  associated 
with  fistula,  cystitis  to  some  extent  and  in  some 
form  co-exists.  It  is  this  which  gives  rise  to  the 
presence  of  an  undue  quantity  of  mucus  in  the 
urino  ; it  is  often  the  source  of  pus,  sometimes  of 
blood  in  small  quantity.  Thus  in  all  the  above- 
mentioned  diseases,  some  degree  of  cystitis  ap- 
pears sooner  or  later.  Henry  Thompson. 

BLADDEB-WOEMS. — Entozoa  having 
the  character  of  cysts  or  vesicles,  and  being 
at  the  same  time  more  or  less  transparent.  This 
general  term  embraces  a variety  of  parasitic 
forms,  such  as  Echinococci , Ccenuri,  and  Cysti- 
cerci,  all  of  which  are  the  larvae  of  different 
species  of  tapeworm.  Practically,  it  is  impor- 
tant to  know  the  origin  of  every  kind  of  human 
bladder- worm,  since  the  adoption  of  appropriate 
hygienic  measures  may  prevent  infection  by  each 
of  the  various  species.  See  Echinococcus,  Cys- 
ticercus,  Hydatids,  Measle,  Taenia,  and 
Tapeworm.  T.  S.  Cobboi.d. 

BLAIN. — A blister,  as  in  the  case  of  chil- 
blain. According  to  Mason  Good,  blains  are 
‘ orbicular  elevations  of  the  cuticle,  containing 
a watery  fluid.’ 

BLEB. — A large  vesicle  or  bulla,  containing 
for  the  most  part  a serous  fluid,  as  in  pemphigus, 
erysipelas,  or  burns  and  scalds.  See  Blister. 

BLENOKB.HCEA,  BLEW  OEEHAGIA 
(f}\4vva,  phlegm,  and  [>eai,  I flow  ; f}\ ivva,  phlegm, 
and  piiyvO/i i,  I burst  out).  These  terms  are  most 
correctly  used  to  express  excessive  flow  of  mucus 
from  any  mucous  surface.  By  means  of  an  affix, 
tho  locality  or  nature  of  the  discharge  is  ex- 
pressed: e.g.,  blenorrhoea  oculi,  nasalis,urcthralis. 
More  commonly,  however,  and  less  accurately, 
bienorrhcea  is  employed  as  synonymous  wilh 
gonorrhoea  in  tho  male  or  female. 

BLEPHAB.ITIS  ((SAetpapor,  an  eyelid).  In- 
flammation cf  the  eyelids.  See  Eye  and  its 
Appendages,  Diseases  of. 

BLEPHAROSPASM  (/3Ae\ paouv,  an  eye- 
lid, and  <nrd<r/ra,  a spasm).  Spasmodic  move- 
ment or  contraction  of  the  eyelids.  See  Eye  and 
its  Appendages,  Diseases  of. 

BLINDNESS.— Loss  of  sight.  See  Amau- 
rosis, and  Vision,  Disorders  of. 

BLISTER.— Synon.:  Bleb;  Bulla;  Fr. Bulle; 
Ger.  Blase. 

Definition. — A vesicle  of  the  skin,  caused  by 
the  separation  of  the  horny  cuticle  from  the  rete 
mucosum  by  the  transudation  of  serous  lymph 
beneath  the  former. 

-Etiology. — Blisters  may  be  idiopathic,  as  in 
pemphigus;  or  symptomatic,  as  in  erysipelas. 
They  are  met  with  under  the  influence  of  any 
cause  which  depresses  the  vitality  of  tho  integu- 
ment, as  in  some  forms  of  prurigo,  in  chilblain, 
and  in  carbuncle;  in  scalds  and  burns  ; and  as  an 
effect  of  powerful  irritants,  such  as  cantharides 
or  the  aniline  salts. 

Description'. — A blister  ranges  in  size  from 
that  of  a pea  to  a turkey’s  egg ; it  is  more  or  less 
convex  according  to  the  amount  of  exudation ; 
and  conforms  in  colour  with  that  of  its  contents, 
being  sometimes  yellow  or  amber-coloured  and 
transparent,  liko  serum,  sometimes  opalescent 


BLOOD,  ABSTRACTION  OF.  Ill 
from  tho  presence  of  pus,  and  sometimes  red  or 
purple  from  admixture  with  blood.  The  fluid  of 
a blister,  generally  limpid  and  free,  is  sometimes 
held  in  the  meshes  of  a delicate  network,  result- 
ing from  the  stretching  of  the  connecting  cells  of 
the  rete  mucosum  and  horny  epidermis.  This  is 
peculiarly  the  case  in  blisters  developed  under 
the  influence  of  acute  inflammation,  and  especially 
in  Dermatitis  anilina.  Blisters  may  bo  dis- 
persed, or  aggregated,  or  even  single,  as  in  Pem- 
phigus or  Pompholyx  solitarius. 

Treatment. — Blisters  are  essentially  asthenic 
in  their  nature,  and  call  for  corroborant  therapeu- 
tical treatment.  Locally  they  should  be  punc- 
tured so  as  to  admit  of  the  gradual  escape  of 
their  contents,  and  then  dusted  over  with  some 
absorbent  powder,  such  as  oxide  of  zinc,  fuller’s 
earth,  or  cinchona.  Erasmus  Wilson. 

BLISTERING-. — A therapeutic  measure 
which  consists  in  the  artificial  production  of 
blisters  on  the  skin.  See  Counter-irritation. 

BLOOD,  Abstraction  cf. — Synon.  ; Bleed- 
ing; Blood-letting.  Fr.  La  Saignee  ; Ger.  Lor 
Adcrlass.  — Definition.  — The  withdrawal  of 
blood  from  the  body,  either  (a)  from  the  gene- 
ral circulation,  by  arteriotomy  or  phlebotomy ; 
or  (b)  localh-,  by  leeches,  scarifications,  or  wet- 
cupping. 

It  is  to  the  first  two  of  these  methods  of 
abstracting  blood  that  the  term  ‘bleeding,’ 
or  ‘ blood-letting,’  has  by  common  usage  been 
restricted. 

The  topical  abstraction  of  blood  by  means  of 
leeches,  scarifications,  and  cupping,  though  often 
valuable,  is  of  secondary  importance.  The  pre- 
sent article  will,  therefore,  chiefly  be  devoted  to 
general  bleeding. 

General  Bleeding. — This  art,  practised  for 
centuries  more  or  less  universally,  has  of  late 
years  in  this  country  fallen  into  disfavour.  Much 
discussion  has  been  raised  as  to  the  grounds  for 
so  groat  a difference.  It  has  been  attributed — 
(1)  to  the  type  of  disease  having  undergone  a 
change;  (2)  to  mere  fashion  or  caprice;  (3)  to  a 
better  knowledge  of  the  nature  of  disease,  teach- 
ing us  that  its  processes  were  of  a lowering  or 
depressing  character,  which  were  to  he  overcome, 
not  by  the  abstraction  of  blood,  hut  rather  by 
the  use  of  stimulants  and  support.  It  is  highly 
probable  that  several  causes  have  contributed 
to  the  undoubted  change  which  has  taken  place. 
The  year  1830  and  subsequent  years  were 
marked  by  the  epidemic  visitation  of  cholera  and 
of  influenza.  These  diseases  were  characterised 
by  extreme  depression.  If  antiphlogistic  measures 
were  adopted,  they  proved  failures,  and  taught  tho 
physician  that  blood-letting  was  not  the  universal 
panacea  it  was  supposed  to  be.  By  degrees  it 
ceased  to  be  practised  as  it  used  to  be.  A new 
generation  which  knew  not  the  past  has  sprung 
up  ; and,  as  in  all  reactionary  movements,  the 
practice  has  become  at  length  as  limited  as  it  for- 
merly was  universal.  It  is  almost  certain  that 
in  either  extreme  there  is  an  evil,  and  that  we 
may  have  recourse  in  certain  cases  to  abstraction 
of  blood  with  some  degree  of  that  success  which 
formerly  led  to  its  extensive  use,  if  not  its  abuse. 
It  will  ho  well  to  consider  the  subject  at  some 
little  length,  and  under  the  following  heads: — 


1 1 2 BLOOD.  ABSTRACTION  OR 


1.  The  effect  of  moderate  losses  of  blood  on 
the  healthy  economy. 

2.  The  value  of  bleeding  as  a remedy  in  dis- 
ease, together  with  the  indications  for  its  employ- 
ment in  various  affections. 

3.  The  method  of  performing  the  operations 
of  opening  an  artery — arteriotomy ; and  opening 
a vein — phlebotomy. 

1.  Effects. — We  have  first,  then,  to  con- 
sider the  effect  of  moderate  losses  of  blood  upon 
the  healthy  economy.  Upon  this  point  we  have 
abundant  evidence,  for  the  custom  of  regularly 
bleeding  healthy  people  had  reached  such  a 
point  during  the  earlier  half  of  this  century  that 
in  country  districts  it  became  a practice  for 
adults  to  be  bled  as  regularly  as  they  went  to 
market.  No  better  testimony  regarding  the  effects 
of  this  practice  could  be  adduced  than  that  of  Sir 
James  Paget,  who,  when  referring  to  these 
customary  venesections,  says : ‘ I can  regard 
those  as  a series  of  venesections  fairly  performed 
for  the  determination  of  what  is  the  influence 
of  the  removal  of  blood  up  to  the  point  of 
syncope  upon  a comparatively  healthy  person. 
I think  I can  say  surely  that  not  one  of  these 
persons  suffered  harm.’  To  this  might,  bo 
added  other  and  abundant  testimony  to  the 
harmlessness  of  venesection  on  the  healthy  eco- 
nomy. 

2.  Indications  and  Uses. — Concluding,  then, 
that  the  abstraction  of  a limited  quantity  of  blood 
has  no  deleterious  effect  upon  the  healthy  organ- 
ism, we  will  nest  set  forth  the  general  indica- 
tions for  the  use  of  bleeding  in  disease,  and 
briefly  refer  to  the  various  affections  in  which  it 
may  most  suitably  be  employed. 

Broadly  stated  it  may  be  said  that  bleeding 
is  indicated  when  there  is  evidence  of  marked 
over-distension  either  of  the  arterial  or  of  the 
venous  system.  In  either  case  the  result  will 
be  cardiac  distension — in  the  former  case  of  the 
left,  and  in  the  latter  of  the  right  chambers 
of  the  heart.  In  such  conditions  general  bleed- 
ing restores  the  lost  equilibrium  of  the  vascular 
system,  and  relieves  the  heart  and  the  other 
parts  concerned  in  the  circulation  of  the  blood. 

The  arterial  system  may  be  in  a state  of  aug- 
mented tension  from  two  causes:  (1)  contrac- 
tion of  the  arteries  (the  smaller  vessels)  them- 
selves with  a diminished  amount  of  blood  in  the 
arterial  system  ; and  (2)  engorgement  or  dis- 
tension of  the  arteries  from  spasm  of  the  arte- 
rioles: both  maybe  regarded  as  vaso-constrictive 
neuroses.  In  the  first  case  there  may  be  engorge- 
ment of  the  venous  system  and  embarrassment 
of  the  right  heart,  calling  for  abstraction  of 
blood  by  venesection ; or  visceral  fluxion,  the  skin 
being  pale : and  in  the  second,  relative  emptiness 
of  the  veins  with  overfulness  of  the  larger 
aiteries,  calling  for  blood-letting  by  arteriotomy. 

In  the  former  condition  there  would  be,  in 
bed-side  language,  a small  hard  or  wiry  pulse, 
and  in  the  latter  a full  and  hard  or  bounding 
pulse.  In  the  former  the  surface  of  the  body 
may  present  one  of  the  two  following  con- 
litions  : either  the  skin  is  injected  and,  perhaps, 
dusky,  and  this  appears  to  be  the  case  ordinarily; 
or  it  is  pale  and  cool,  the  blood  having  receded 
inwards,  chiefly  to  the  abdominal  viscera.  The 
second  condition  obtains  and  is  well  seen  in 


cases  of  uraemic  asthma,  when  the  arterial  sys- 
tem is  turgid  almost  to  bursting,  while  the 
voins  are  comparatively  empty.  ‘ Hardness  ’ of 
the  pulse  is  usually  said  to  be  an  indication  for 
bleeding,  and  in  certain  associations  it  is  so ; 
but  it  is  necessary  to  discriminate  carefully 
between  the  ‘hardness’  due  to  ‘tension’  of  the 
sound  artery  arising  from  (a)  excessive  con- 
traction (the  small,  hard,  wiry  pulse),  and  (6) 
overfulness  (the  full,  bounding  pulse)  on  the  one 
hand  ; and  that  due  to  arterial  degeneration  with 
more  or  less  hard  deposit  in  the  walls  of  the 
vessels,  on  the  other.  In  doubtful  cases  inquiry 
should  be  made  into  the  state  of  the  brachial 
artery  at  the  beud  of  the  elbow.  This  can  readily 
be  done  by  flexing  the  limb,  when,  if  calcareous 
degeneration  have  taken  place,  the  vessel  will  be 
thrown  into  serpentine  folds,  visible,  except  in 
fat  people,  to  the  eye,  and  cord-like  and  rigid  to 
the  touch.  The  temporal  artery  is  a less  safe 
guide,  but  neither  it  nor  an  arcus  senilis  should 
be  overlooked  in  this  connexion.  A visible  and 
tortuous  pulse  in  a young  person  may  indicate 
aortic  regurgitant  disease  : the  age  of  the  patient 
must  therefore  be  taken  into  consideration. 

Dilatation  of  the  arterioles  would  permit  of 
the  rapid  passage  of  arterial  blood  into  the  veins : 
under  such  circumstances,  therefore,  we  should 
expect  the  blood  issuing  from  a cut  vein  to  pre- 
sent a more  florid  appearance  than  under  ordinary 
conditions.  Bleeding  here  should  be  undertaken 
with  considerable  circumspection,  and  not  be 
pushed  very  far,  for  collapse  out  of  proportion 
to  the  amount  of  blood  abstracted  might  ensue. 
On  the  other  hand,  when  there  is  spasm  of  the 
arterioles,  and  the  abstraction  of  blood  is  deemed 
advisable,  it  would  be  well  to  resort  to  arterio- 
tomy rather  than  venesection.  The  best  guide 
here  would  be  the  sphygmograph,  but,  as  few 
persons  are  yet  accustomed  to  use  it,  the  full, 
hard,  bounding  pulse  must  be  relied  on  when 
found  i n association  with  corroborative  symptoms. 

Whatever  leads  to  over-engorgement  of  either 
side  of  the  heart  may  render  bleeding  necessary. 
If  the  left  side  of  the  heart  be  over-full,  arterio- 
tomy is  indicated ; if  the  right,  venesection. 
The  object  of  the  withdrawal  of  blood  from 
the  general  circulation  is  the  direct  relief  of 
the  overburdened  heart.  'W  hether  the  right  or 
left  chambers  be  taxed  the  immediate  effect  is 
the  same  ; they  are  over-distended,  and  cannot 
get  a grip  upon  their  swollen  currents.  It 
is  with  the  embarrassed  heart  as  with  other 
hollow  muscular  organs — the  bladder  and  uterus. 
Over-distension  paralyses  them  by  removing  the 
‘points  d’appui ’ essential  for  the  initiation  of 
muscular  contraction  ; the  energy  may  be  there, 
but  it  cannot  be  exercised.  It  is  obvious  that  the 
amount  of  blood  which  it  is  necessary  to  with- 
draw, in  order  to  free  the  embarrassed  organ, 
must  vary  considerably  in  different  cases.  But 
it  may  be  safely  laid  down  as  a rule  that  it  need 
rarely  exceed  a few  ounces.  Excess  in  this 
respect  is  the  evil  which  formerly  existed. 

On  this  subject  we  may  refer  to  the  eminently 
practical  remarks  of  Sir  Thomas  Watson,  who 
says : ‘ I hold  it,  then,  to  be  certain,  that  for  some 
special  morbid  conditions,  which  inflammation 
may  or  may  not  accompany,  general  blood-letting, 
and  especially  venesection,  is  a potent  and  life 


BLOOD,  ABSTRACTION  OF. 


preserving  remedy  ; that  there  are  many  exigen- 
cies for  which  it  is  not  only  safe  to  employ,  but 
unsafe  and  unpardonable  to  withhold  it.’ 

He  also  gives  the  following  judicious  ad- 
vice : — 

‘ Always  it  is  necessary  to  consider  the  age, 
the  sex,  the  general  temperament  and  condition 
of  the  sick  person,  when  we  are  turning  over  in 
our  minds  the  expediency  of  abstracting  blood. 
The  very  young,  the  old,  the  feeble,  the  cachectic, 
no  not  hear  well  the  loss  of  much  blood.  This 
consideration  is  not  to  deter  you  from  bleeding 
such  persons  topically  when  they  are  attacked 
by  dangerous  inflammation,  but  it  especially 
enforces,  in  regard  to  them,  the  golden  rule  that 
no  more  blood  should  he  abstracted  than  seems 
absolutely  requisite  to  control  tho  disease.’ 

The  following  are  some  of  the  affections  under 
which  blood-letting  would  seem  to  be  more  or 
less  indicated : — 

Pneumonia. — Blood-letting  in  pneumonia,  as 
in  many  other  inflammations,  is  most  useful  in 
tho  early  stages.  It  is  indicated  in  healthy 
patients  suffering  from  uncomplicated  acute 
sthenic  pneumonia,  if  they  happen  to  be  seen 
early  enough.  It  relieves  pain,  abates  fever, 
and  if  it  does  not  arrest  the  disease,  it  certainly 
appears  to  lessen  its  duration.  It  may  also  be 
called  for  when  there  is  severe  pain  and  evidence 
of  cardiac  embarrassment.  It  did  good,  and  will 
still  do  good,  in  cases  of  pneumonia,  attended 
by  embarrassment  of  the  circulation,  and  that 
in  truth  is  the  indication  for  bleeding  in  this 
disease. 

Apoplexy. — The  same  may  be  said  wdth  re- 
ference to  cerobral  apoplexy.  The  old  belief 
in  the  importance  of  ‘ letting  blood  ’ in  cases 
of  apoplexy  was,  if  possible,  stronger  than  in 
cases  of  pneumonia.  But  here  again  more  accu- 
rate clinical  and  more  extended  pathological 
knowledge  have  taught  us  to  look  upon  ‘ apoplexy  ’ 
very  differently  to  our  forefathers.  Recognising 
the  escape  of  blood  from  tho  bursting  of  a brittle 
artery  as  a common  cause  of  ‘ apoplectic  fits,’  we 
see  the  futility  of  venesection  when  the  ‘stroke’ 
or  ‘fit’  is  due  to  a lesion  of  this  kind.  Nor  will 
bleeding  unstop  an  artery  when  it  is  plugged  by 
an  embolus,  or  carry  nutriment  to  the  region 
thus  bereft  of  vital  fluid.  On  the  other  hand 
we  have  learnt  to  recognise  the  value  of 
bleeding  in  another  class  of  cases  of  so-called 
‘apoplexy’ — those  which  are  unaccompanied 
by  effusion  of  blood 'or  lesion  of  the  nervous 
tissue,  but  depend  on  rapidly  occurring  com- 
pression of  the  nervous  centres  from  sudden 
or  unequal  increase  in  the  volume  of  any  portion 
of  the  cranial  contents  ; or  in  certain  eclamptic 
cases  from  the  circulation  of  blood  poisoned  by 
uneliminated  urinary  excreta.  In  cases  of  this 
description,  when  the  right  heart  and  venous 
system  are  engorged,  phlebotomy  acts  well ; the 
stertor  will  cease,  the  purple  face  resumes  its 
natural  hue,  the  clouded  intelligence  becomes 
clear,  and  the  impending  danger  is  for  the  time 
averted.  This  has  not  cured  the  patient,  how- 
ever, it  has  only  ‘ obviated  the  tendency  to 
death:’  it  has  saved  the  patient’s  life,  though 
he  may  ultimately  die  of  the  disease  which 
afflicts  him.  Where  we  meet  with  evidence  of 
cerebral  congestion  accompanied  by  fulness  of 

8 


115 

the  veins,  a dusky  countenance,  and  a slow  full 
pulse,  bleeding  may  most  usefully  be  resorted 
to.  In  a word,  although  bleeding  will  not  re- 
move the  effused  blood  in  cases  of  cerebral 
haemorrhage,  it  may  sometimes  be  usefully  em- 
ployed to  prevent  furthor  escape,  when  the 
heart  is  acting  too  forcibly  ; but  it  is  altogether 
forbidden  when  that  organ  is  enfeebled.  The 
pulse  at  both  wrists  should  be  attentively  ex- 
amined before  bleeding,  in  cases  of  cerebral 
haemorrhage,  for  as  a rule  it  is  larger  on  the 
paralysed  than  on  the  sound  side. 

Eclampsia.  — Indiscriminate  bleeding  in 
eclamptic  seizures  would  be  a grievous  error. 
It  would  not  relieve,  but  rather  would  probably 
intensify,  convulsions  of  reflex  origin,  as  in  cer- 
tain cases  of  puerperal  convulsions.  On  the  other 
hand,  cases  of  puerperal  convulsions  accompanied 
by  great  turgesefmee  of  the  vascular  system, 
whether  venous,  (as  is  commonly  the  case)  or 
arterial,  would  be  immensely  benefited  by  the 
withdrawal  of  blood  from  the  general  current, 
either  by  venesection  or  by  artcriotomy,  accord- 
ing to  the  indication.  This  treatment  may  serve 
to  stop  the  convulsions,  and  though  that  may  be 
far  from  curing  the  disease,  it  may,  neverthe- 
less, be  of  the  utmost  value,  for  in  the  first 
place  the  fits  themselves  may  kill  by  their 
violence  or  frequent  repetition  ; whilst,  secondly, 
time  may  be  gained  for  the  employment  of  other 
measures  calculated  to  relieve  the  oppressed 
system,  as,  for  example,  purging  by  hydragogue 
cathartics,  vapour  baths,  cupping  the  loins,  &e. 
This  gain  may  be  immense ; for  bleeding  may 
avert  impending  dissolution.  Moreover,  per- 
manent good  may  ensue,  inasmuch  as  bleeding 
reduces  temperature,  and  in  the  eclampsia  of 
pregnancy  the  temperature  is  usually  high.  In 
this  it  contrasts  with  pure  uraemic  convulsions, 
in  which  there  is  lowering  of  temperature. 

Venous  Engorgement. — Engorgement  of  the 
venous  system  arising  from  chronic  disease,  e.g. 
pulmonary  emphysema  or  heart-disease,  does  not 
call  for  bleeding,  unless  the  condition  be  acutrh 
intensified  by  some  intercurrent  mischief,  such 
as  acute  bronchitis ; for,  as  the  derangement  is 
slowly  produced,  the  organs  and  structures  in- 
volved learn  to  accommodate  themselves  more  or 
less  to  the  altered  conditions.  It  is  only  when 
vascular  engorgement  suddenly  occurs  in  appa- 
rently healthy  subjects,  or,  as  stated  above,  there- 
is  acute  intensification  of  a chronic  condition, 
that  bleeding  is  required.  Thus,  in  cases  whero 
mediastinal  tumours  impede  the  return  of  blood 
from  the  head  and  upper  portion  of  the  body, 
the  condition  is  ordinarily  of  such  comparatively 
slow  production,  that  bleeding  is  seldom  urgently 
called  for:  and,  moreover,  it  would  be  of  but 
small  service,  for  the  obstruction  is  irremediable 

The  lividity  of  the  face  which  accompanies  all 
fits  should  not  be  confounded  with  the  duskiness 
due  to  engorgement  of  the  venous  system  gene- 
rally. 

TJrcemia. — In  pure  uraemia  bleeding  is  use- 
ful ; the  kidneys  being  especially  in  default.  For 
venesection  answers  a doublo  purpose,  by  not 
only  relieving  the  engorged  right  heart  and 
venous  system,  but  removing  from  the  body  a 
certain  amount  of  poisoned  blood — blood  that  is 
charged  with  urinary  excreta.  Doubtless,  it  does 


114  BLOOD.  ABSTRACTION  OF. 


good  in  both  ways,  but  the  former  is,  quoad  the 
fits,  the  more  important  because  more  imme- 
diate mode  of  its  action.  The  second  effect,  that 
of  ridding  the  body  of  damaged  blood,  is  ob- 
viously available  to  us  when  we  have  to  deal 
with  uraemia,  occurring  in  the  non-pregnant; 
and  when  coma  is  deepening,  the  heart  labouring, 
and  the  vascular  system  turgid,  no  remedy  is  so 
swift  and  sure  as  the  lancet. 

Plethora. — Blood-letting  may  be  called  for  in 
cases  of  general  plethora,  whether  sthenic  or 
asthenic.  In  the  former  condition  the  vascular 
system  generally  seems  to  be  overfull,  though 
the  excess  is  most  marked  in  the  arterial  system. 
Arteriotomy,  however,  is  seldom  called  for, 
though  it  might  at  first  sight  seem  indicated, 
since  venesection  usually  answers  every  pur- 
pose. 

In  asthenic  plethora,  on  the  other  hand,  the 
venous  system  only  is  overfilled ; the  right  side  of 
the  heart  is  distended  and  its  action  is  laboured. 
Here  venesection  is  sometimes  called  for,  but 
it  should  be  carefully  employed.  It  is  seldom 
necessary  to  withdraw  more  than  6 to  1 0 ounces 
of  blood,  and  often  a smaller  quantity  suffices. 

Peritonitis. — The  relief  obtained  by  bleeding  in 
acute  peritonitis  rendered  venesection  a famous 
remedy  in  this  affection  in  former  times.  And 
there  can  be  no  doubt  about  its  efficacy  in  relieving 
the  pain  of  peritonitis,  as  of  inflammation  of  other 
serous  membranes.  It  may  be  used  when  the 
patient  is  young  and  strong,  and  in  that  stage 
of  the  disease  which  is  accompanied  by  a small, 
hard,  and  wiry  pulse — the  pulse  of  a contracted 
artery,  of  augmented  tension  from  contraction, 
not  from  overfulness.  It  is  worse  than  useless 
in  the  later  stages  of  the  disease,  when  adynamia 
has  set  in.  But  valuable  as  bleeding  may  be  in 
ceitain  cases  of  peritonitis,  it  rarely  happens 
that  it  is  admissible,  for  in  the  great  majority  of 
cases  inflammation  of  the  peritoneum  is  second- 
ary to  other  diseases,  and  notably  to  disease  of  the 
kidneys.  Where  peritonitis  arises  after  delivery 
it  is  commonly  of  septicaemic  origin,  and  it  is 
seldom  indeed  that  bleeding  is  of  any  avail 
under  these  conditions.  So  that,  practically, 
bleeding  is  not  a remedy  which  we  can  often 
employ  in  peritonitis.  A very  high  temperature 
cannot  alone  be  held  to  be  indicative  of  its  use, 
for  it  so  happens  that  such  pyrexia  is  as  a rule 
present  only  in  septiesmic  cases.  Some  cases  of 
peritonitis,  even  fatal  ones,  run  their  course 
without  any  marked  elevation  of  temperature  : 
or  indeed  without  showing  any  definite  symp- 
toms. Probably  venesection  is  most  serviceable 
in  traumatic  peritonitis,  or  it  may  be,  when  the 
inflammation  is  localised,  though  in  that  case 
leeches  are  more  suitable. 

Pleurisy.— When  pleurisy  attacks  a young  and 
robust  patient,  and  is  accompanied  by  severe  pain, 
great  relief  follows  blood-letting.  The  blood 
should  be  taken  from  a vein,  and  plcno  rivo. 
But  when,  as  so  often  happens,  pleurisy  is, 
like  peritonitis,  secondary  to  damaged  blood-con- 
ditions— e.g.  Bright's  disease — bleeding  is  often 
inadmissible.  When,  as  in  pleuro-pneumonic 
cases,  pleurisy  complicates  pneumonia,  bleeding 
may  possibly  be  called  for,  if  there  bo  great  pain 
and  oppression  of  the  chest ; but  it  should  be  most 
circumspectly  used.  Local  blood-letting  is  much 


to  be  preferred  if  bleeding  be  thought  necessary , 
for  general  bleeding  is  usually  incompatib'e 
with  the  strength  of  the  patient. 

Urcemic  Asthma. — In  the  affection  known  as 
uraemic  asthma,  in  which  there  is  spasm  of  the 
systemic  arterioles,  with  intense  turgidity  of  the 
arterial  system  and  engorgement  of  the  left 
heart,  bleeding,  in  the  form  of  arteriotomy, 
appears  to  be  clearly  indicated. 

Spasmodic  Bronchial  Asthma. — Pure  asthrn- 
is  doubtless  often  a nervous  malady,  and  bleeding 
is  not  a remedy  which  should  ordinarily  bo 
employed  for  its  relief.  It  is  only  admissible 
when  spasm  of  the  pulmonary  vessels,  or 
obstruction  to  the  flow  of  blood  through  them 
from  bronchiole-spasm,  leads  to  rapid  engorge- 
ment of  the  right  heart  and  venous  system. 
This  is  the  exact  converse  of  uraemic  asthma  : 
but  the  effect  in  both  is  impediment  to  the 
aeration  of  the  blood.  Here  the  abstraction  of 
a few  ounces  of  blood  from  a vein  may  give 
immense  and  very  prompt  relief. 

Emphysema. — It  is  not  so,  however,  in  the 
so-called.  ‘ asthmatic  attacks,’  which  chronically 
emphysematous  people  are  so  prone  to.  Here 
venesection  may  be  imperatively  demanded  when 
an  acute  attack  of  bronchitis  has,  by  adding  tc 
the  already  difficult  passage  of  blood  through 
the  lungs,  excited  rapid  engorgement  of  the 
dilated  heart  and  previously  turgid  venous 
system. 

Puerperal  Diseases. — Formerly  bleeding  was 
much  employed  in  midwifery  practice,  and  espe- 
cially in  inflammatory  affections  after  delivery. 
We  now  recognise  that  for  the  most  part  post- 
partum affections  arise  from  septic  mischief 
and  are  of  an  adynamic  type.  It  is  but  seldom 
that  we  are  called  upon  to  bleed  in  these  cases. 
Nevertheless,  now  and  again,  venesection  mav 
be  called  for. 

Disorders  of  Menstruation. — Bleeding  is  a most 
valuable  remedy  in  certain  menstrual  disorders, 
and  especially  in  the  plethora  of  women  at  the 
change  of  life.  Many  women  sufferdistressinslv 
from  general  vascular  disturbance  at  this  period. 
The  flushings,  headaches,  giddiness,  feeling  of 
oppression  and  other  vaso-molor  phenomena 
which  they  suffer  from  in  association  witli  the 
cessation  of  the  catamenial  flow,  are  immensely 
relieved  by  an  occasional  venesection.  No  other 
measure -will  so  quickly  and  so  effectually  relieve 
these  symptoms.  Some  robust,  plethoric,  amenor- 
rhoeic  young  women  require  periodical  bleeding. 
The  writer  has  known  the  abstraction  of  a few 
ounces  of  blood  to  be  speedily  followed  by  the 
occurrence  of  the  menses,  in  cases  of  what  may 
be  called  congestive  amenorrhoea  of  many  months' 
or  even  years’  duration.  It  may  be  well  to  state 
in  this  connexion  that  in  certain  pulmonary,  intra 
cranial,  and  other  visceral  lesions,  danger  mav 
arise  from  the  augmented  arterial  tension  which 
for  a few  days  precedes  the  flow,  and  that  the 
abstraction  of  blood  may  avert  hsemorrh  ige  into 
the  damaged  organs. 

After  Operations. — Bleeding  is  less  frequently 
called  for  in  surgical  than  in  medical  practice.  It 
is  indicated  mainly  in  the  after-treatment  of  oases 
which  present  engorgement  of  the  right  lmim 
and  venous  system,  as  in  some  cases  of  ovario- 
tomy and  other  operations  involving  the 


BLOOD,  ABSTRACTION  OF. 


dominal  or  thoracic  cavities.  A turgid  venous 
system,  with  a small  hard  pulse,  and  a labouring 
heart — a condition  which  is  often  associated  with 
scantiness,  amounting  almost  to  suppression,  of 
urine — indicates  blood-letting  after  operations  of 
the  kind  above  referred  to. 

Shock. — In  certain  cases  of  shock  the  abstrac- 
tion of  a limited  amount  of  blood  may  be  required. 
This  point  will  be  found  discussed  elsewhere  ( see 
Shock). 

Fever. — That  bleeding  will  lower  the  tempera- 
ture of  fevered  patients  has  been  known  from  the 
earliest  times.  It  is,  however,  not  a remedy  to 
be  resorted  to  for  that  purpose  alone,  for,  as  the 
most  pronounced  hyperpyrexia  occurs  chiefly 
in  association  with  conditions  leading  to  great 
depression,  blood-letting  is  under  such  circum- 
stances as  useless  as  it  is  dangerous. 

Insolation. — There  are  few  disorders  in  which 
blood-letting  is  more  successful,  when  rightly 
employed,  than  in  sunstroke.  It  is  seldom 
necessary  to  take  more  than  a few  ounces  of 
blood ; and  excess  should  be  particularly  guarded 
against,  for  fear  of  subsequent  collapse.  The 
insensible  patient  with  turgid  veins,  a tight 
pulse,  and  labouring  heart,  will  gain  immense 
and  prompt  relief  from  venesection.  The  ex- 
treme pulmonary  congestion  and  over-distension 
of  the  right  heart  so  often  found  post  mortem. 
might  probably  be  prevented  by  the  timely 
abstraction  of  a little  blood  from  the  venous 
system.  Bleeding  is  not  to  bo  thought  of  in  the 
syncopal  form. 

3.  Methods  of  Bleeding. — The  following  are 
the  methods  of  performing  the  operations  of 
arteriotomy  and  phlebotomy. 

Arteriotomy. — This  operation  is  best  per- 
formed on  the  temporal  artery'.  The  vessel 
should  be  partially  cut  through  by  a simple 
transverse  incision,  and  when  a sufficient  quan- 
tity of  blood  has  been  obtained  it  may  then  be 
completely  severed,  so  that,  retraction  of  both 
ends  taking  place,  the  haemorrhage  may  be 
arrested.  A compress  of  dry  lint  should  then 
be  applied,  and  a tight  roller-bandage  applied 
over  it. 

Venesection. — The  median  basilic  vein  is  the 
one  usually  selected  for  the  operation  on  account 
of  its  being  most  readily  found.  The  brachial 
artery  lies  immediately  beneath  it,  and  care 
must  be  taken  to  avoid  wounding  the  latter 
vessel.  The  median  cephalic  vein  is  preferable, 
but  is  not  so  easily  found.  A vein  on  the  dorsum 
of  the  foot  or  other  part  of  the  body  may  be 
chosen,  but,  as  a rule,  it  is  not  desirable  to  open 
the  jugular  vein,  especially  on  account  of  the 
danger  of  the  entrance  of  air,  and  other  risks. 

The  steps  in  the  operation  on  the  arm  are  as 
follows : — First,  the  limb  is  to  be  firmly  bound 
above  the  elbow  by  a broad  tape  or  fillet.  This 
should  be  applied  with  sufficient  tightness  to 
compress,  and  prevent  the  return  of  blood  by, 
the  veins,  but  not  so  as  to  intercept  the  current 
in  the  artery,  and  extinguish  the  pulse.  An 
oblique  slit  is  to  be  made  in  the  vessel  by 
means  of  a small  lancet,  care  being  taken  not 
to  cut  too  deeply'.  The  spirting  blood  should  be 
caught  in  a vessel  and  measured. 

When  sufficient  blood  has  been  withdrawn,  the 
operator  should  firmly  place  a thumb  or  a finger 


m 

on  the  aperture,  and  then,  on  removing  compres- 
sion, place  upon  the  wound  a dossil  of  dry  lint, 
antiseptic  dressing,  styptic-colloid,  or  such-like, 
over  which  a roller-bandage  should  be  twined  a 
few  times  like  a figure  of  8,  the  cross  being  over 
the  wound. 

Local  bleeding. — The  object  of  local  bleeding 
is  the  relief  of  congested  vessels,  and  especially 
those  of  inflamed  parts.  Arteries  convey  more 
blood  to,  and  veins  convey  more  away  from,  in- 
flamed parts ; so  that  local  bleeding  may  give 
great  relief  and  initiate  resolution,  since  ab- 
sorption does  not  fully  commence  until  inflam- 
mation has  ceased. 

Methods  of  Local  Bleeding.— Blood  may 
be  abstracted  topically  by  leeches,  by  scari- 
fications, or  by  wet-cupping. 

1.  Leeching.  An  average  leech  will  abstract 
nearly  half  an  ounce  of  blood.  Leeches  are 
extremely  useful  in  a great  variety  of  affections, 
since  a pretty  definite  amount  of  blood  can  be 
withdrawn  from  the  affected  or  adjacent  parts, 
or  from  more  distant  parts,  through  intimacy 
of  the  vascular  connexion,  as  in  diseases  of  the 
eye  and  ear,  and  in  hepatic  diseases,  accom- 
panied by  obstruction  to  the  flow  of  blood 
through  the  portal  system,  when  the  application 
of  leeches  to  the  anus  is  most  valuable. 

Care  should  be  taken  not  to  apply  leeches  to 
parts  over  which  sufficient  compression  cannot 
be  made  to  control  the  bleeding,  should  any 
difficulty  arise  in  arresting  it  otherwise.  Thus, 
leeches  should  not  be  applied  over  the  trachea, 
especially  in  children,  in  whom  the  error  of 
applying  them  over  the  epistemal  notch  is  some- 
times made.  For  the  same  reason  the  fonta- 
nelles  should  be  avoided. 

The  skin  of  the  part  where  leeches  are  to 
be  applied  should  first  be  washed,  and  when 
they  do  not  bite  readily  the  part  may  be  wetted 
by  a little  milk  or  sugar  and  milk.  A slight 
prick  of  a needle,  sufficient  to  draw'  a speck  of 
blood,  will  often  cause  them  to  bite  when  re- 
fractory. 

Shoiild  the  bleeding  continue  too  long  after 
the  leeches  fall  off,  pressure  or  styptics  may  be 
applied.  If  it  is  desired  to  encourage  bleeding, 
fomentations  of  hot  water  or  linseed  poultice  are 
serviceable. 

In  applying  leeches  to  the  cervix  uteri  the 
precaution  of  closing  the  os  by  a plug  of  wool, 
should  not  be  neglected.  When  applied  within 
the  mouth  a leech-glass  should  be  used. 

2.  Scarifying. — Scarifications  consist  in  small 
cuts  of  a depth  not  exceeding  the  eighth  of 
an  inch  or  less  into  the  tissue  whence  it  is 
desired  to  take  blood.  This  mode  of  topical 
bleeding  is  mainly  applied  to  the  cervix  uteri,  to 
the  tongue  in  acute  glossitis,  and  to  the  palpebral 
conjunctiva  in  certain  kinds  of  conjunctivitis ; 
in  the  last  ease  only  slight  incisions  are  permis- 
sible. Deeper  punctures  are  made  by  some  prac- 
titioners into  the  tissue  of  the  cervix  uteri, 
but  these  are  punctures  and  not  mere  scarifi- 
cations. 

3.  Cupping. — Cupping  and  the  use  of  the  scari- 
ficator constituting  wet-cupping  is  an  important 
method  of  topical  blood-abstraction  ; and  as  a 
considerable  amount  of  blood  can  thus  be  with 
drawn,  the  general  circulation  may  thereby  bt 


110  BLOOD,  ABSTRACTION  OF. 
affected.  It  is  ordinarily  employed,  howevei, 
for  its  local  effects. 

The  method  of  its  performance  is  as  follows: — • 
Cupping-glasses  being  first  put  on  for  a brief 
time,  as  for  dry-cupping  ( see  Cupping — Dry- 
Cupping),  the  operator  applies  to  the  part 
selected  a spring  scarificator  so  adjusted  as  to 
cut  only  to  the  required  depth — about  an  eighth 
of  an  inch  or  less.  The  cupping-glasses  are  then 
re-applied,  and  the  desired  number  of  ounces 
of  blood  abstracted.  If  the  glasses  be  too  tightly 
attached  the  blood  will  not  flow  readily,  and  un- 
necessary pain  may  be  caused.  After  their  re- 
moval adhesive  plaster  or  dry  lint  and  a bandage 
should  be  applied  to  the  part. 

Cupping  over  the  loins  is  extremely  useful  in 
renal  ischsemia ; on  the  temple  or  behind  the  ears 
in  certain  cerebral  disorders ; down  the  spinal 
column  in  inflammation  of  the  spinal  cord  or 
meninges ; and  on  the  chest  in  certain  pulmonary 
affections.  Alfred  Wiltshire. 

BLOOD  - DISEASE.  — The  term  blood- 
disease  was  used  by  the  humoral  pathologists  as 
synonymous  with  dyscrasis  or  anomalous  crasis 
of  the  blood,  and  expressed  the  idea  that  the 
blood  was  the  seat  ‘ almost  without  exception’ 
of  all  general  diseases.  And,  further,  since 
purely  local  disease  was  considered  to  be  ex- 
ceptional, the  vast  majority  of  diseases  were 
referred  to  dyscrases,  and  were  classed  under 
the  head  of  blood-diseases. 

The  condition  of  the  blood  was  considered  by 
the  humoralists  to  depend  upon  the  crasis,  that 
is  the  mixture,  of  its  constituents ; and  promi- 
nent among  its  constituents  were  reckoned  the 
blastemata,  or  germinal  substances  of  the  differ- 
ent tissues,  which  exuded  through  the  capillary 
walls  in  the  process  of  nutrition.  When  the 
blood-crasis  was  disordered  or  diseased,  a dys- 
crasis was  said  to  exist,  and  dyscrases  were  held 
to  be  in  the  majority  of  cases  primary ; though 
it  was  allowed  that  local  anomalies  of  nutrition 
might  and  did  occasionally  occur,  and  give  rise 
to  secondary  dyscrases.  A blood-disease  or 
dyscrasis  being  established,  all  morbid  changes 
throughout  the  body  were  believed  to  be  but 
local  manifestations  of  the  same.  For  the  pur- 
pose, therefore,  of  a rational  classification  of 
diseases,  a previous  classification  had  to  be  made 
of  the  dyscrases.  The  principal  blood-crases 
were  said  to  be : — 

1.  The  fibrin-c rasis;  including  the  simple 
fibrin-crasis,  the  croup/ous  crasis,  and  the  tubercle- 
crasis  as  varieties.  The  local  expression  of  the 
fibrin  erases  was  inflammation  in  some  form. 

2.  The  venous  crasis,  in  which  fibrin  was 
deficient.  This  included  a vast  number  of 
special  erases,  lying  at  the  foundation  of  the 
most  diverse  diseases — e.g.,  plethora,  heart- 
disease,  acute  exanthemata,  rickets,  albuminous 
urine,  cholera,  acute  tuberculosis,  lardaceous 
disease,  cancer,  acute  convulsive  diseases,  me- 
tallic poisoning,  &c. 

3.  The  serous  crasis  ; associated  with  ansemia. 

4.  The  putrid  or  septic  crasis. 

5.  Anomalous  erases ; such  as  those  of 
syphilis,  gout,  &c. 

The  theory  of  dyscrases  may  be  said  to  have 
declined  since  the  appearance  of  Virchow’s 


BLOOD,  MORBID  CONDITIONS  OF. 
Cellular  Pathology.  Virchow  showed  that  the 
blood  is  in  every  relation  a dependent  and  not 
an  independent  fluid,  and  that  the  sources  from 
which  it  is  sustained  and  restored,  and  the  ex- 
citing causes  of  the  changes  that  it  may  suffer, 
lie  without  it  and  not  within  it.  Substances  may 
enter  the  blood  and  affect  the  corpuscles  in- 
juriously; the  blood  may  act  as  a medium  in 
conveying  to  the  organs  noxious  substances  that 
have  reached  it  from  various  sources ; or  its 
elements  may  be  imperfectly  restored.  But 
never  is  any  affection  of  the  blood  itself — any 
‘dyscrasis’ — permanent,  unless  new  influences 
arise  and  act  upon  the  blood  through  some 
channel  or  through  some  organ. 

At  the  present  time,  while  it  cannot  be  said 
that  humoralism  is  professed  by  many  patholo- 
gists, the  notion  of  blood-disease,  as  generally 
entertained  thirty  years  ago,  still  clings  to  the 
nomenclature,  and  pervades  some  of  our  patho- 
logical doctrines.  Diseases  that  affect  the  whole 
economy — syphilis,  tuberculosis,  gout, and  cancer 
— are  frequently  described  as  ‘constitutional,’ 
or  ‘ blood-diseases,’  and  that  whether  theil 
general  manifestations  are  secondary  to  local 
disease,  as  in  syphilis  and  cancer,  or  are  refer- 
able to  inheritance.  While  the  morbid  conditions 
of  the  blood  are  real  aud  numerous,  ‘ blood  - 
diseases,’  so  called,  are  but  abstractions,  and,  as 
such,  a fruitful  source  of  confusion  and  useless 
discussion.  It  is  desirable  that  the  term  blood- 
disease  should  be  abandoned,  and  that  the  ex- 
pression morbid  conditions  of  the  blood  should 
be  applied  to  the  pathological  states  of  the  vital 
fluid,  which  can  be  distinctly  demonstrated  by- 
physical,  chemical,  or  histological  examination. 

J.  Mitchell  Bruce. 

BLOOD,  Morbid  Conditions  of.  — The 
characters,  composition,  and  functions  of  the 
blood  in  health  are  sufficiently  familiar,  and  do 
not  require  to  be  described  here.  But  certain 
facts  connected  with  the  physiology  of  this  fluid 
have  a special  bearing  upon  its  pathology,  and 
must  be  briefly  considered  before  its  morbid  states 
can  be  profitably  discussed. 

A.  Physiology  op  the  Blood. — The  Bed  Cor- 
puscles of  the  blood  consist  of  two  portions — a 
colourless, sponge-like  matrix;  and  a coloured  sub- 
stance of  complex  composition,  which  occupies  the 
interstices  of  the  former  and  accurately  fills  them. 
The  matrix  is  regarded  as  possessing  chiefly 
physical  properties;  while  its  contents  constitute 
the  active  part  of  the  corpuscle,  and  consist  of 
haemoglobin.  The  source  of  the  red  corpuscles  is 
of  the  greatest  pathological  importance.  In  the 
embryo  the  blood  and  blood-vessels  are  developed 
from  the  same  elements,  and  thus  the  two  struc- 
tures in  their  physiological  aspect  are  essentially 
inseparable.  In  fully -developed  blood  the  source 
of  the  red  corpuscle  is  obscure:  but  there  can 
be  no  reasonable  doubt  that  it  originates  in 
the  colourless  corpuscle,  and  more  remotely  in 
the  lymphatic  glands,  the  spleen,  and  the 
medulla  of  bones ; and  that  light  is  of  the 
greatest  importance  in  the  f rmation  of  haemoglo- 
bin. With  respect  to  the  piroperties  and  function 
of  the  red  corpuscle,  it  is  to  be  noted  that  the 
ultimate  elements  of  haemoglobin  are  carbon, 
nitrogen,  hydrogen,  oxygen,  sulphur,  and  iron, 


BLOOD,  MORBID  CONDITIONS  OF. 


—the  lust  of  these  probably  being  the  cause 
of  its  red  colour.  Haemoglobin  is  soluble  in 
rater,  forming  a lake  liquid  from  which  fine 
crystals  may  be  obtained,  and  which  may  be 
variously  decomposed,  giving  rise  to  other  ‘ blood 
crystals.’  Most  important  of  all  its  properties, 
haemoglobin  combines  with  certain  gases  to 
form  definite  chemical  compounds ; — with  0 to 
form  oxyhaemoglobin ; with  CO  to  form  curbonic- 
oxidt-haemoglobin ; and  with  N 20  to  form  nitrous- 
oxide-haemoglobin.  These  compounds,  and  es- 
pecially the  oxyhaemoglobin,  are  exceedingly 
unstable,  being  reduced  even  under  very  feeble 
influences  to  haemoglobin  and  their  other  con- 
stituents respectively.  Alternate  oxidation  of 
haemoglobin  and  deoxidation  of  oxyhaemoglobin 
are  constantly  going  on  within  the  red  corpuscles 
of  the  circulating  blood ; and  the  two  changes, 
occurring  in  the  pulmonary  and  systemic  capil- 
laries respectively,  constitute  the  first  great  func- 
tion of  the  blood — its  oxygenating  or  respiratory 
function.  The  volume  of  oxygen  in  arterial  blood 
is  16'9  per  cent.,  and  in  venous  blood  5'9G  per 
cent.  It  must  be  clearly  understood  that  dis- 
orders connected  with  the  red  corpuscles  or 
respiratory  elements  of  the  body,  whether  in 
amount,  composition,  or  circulation,  directly 
Effect  the  oxidation-processes  only.  Besides  its 
origin  and  its  function,  there  is  a third  relation 
of  the  red  corpuscle  to  the  organism — namely  that 
of  its  products.  These  are  eliminated  by  the 
ordinary  channels ; the  salts,  which  are  chiefly 
salts  of  potash,  being  excreted  by  the  kidneys, 
and  the  coloured  material  furnishing  the  pigments 
cf  the  bile  and  urine. 

The  White  or  Colourless  Corpuscles  of  the 
blood,  also  called  Leucocytes,  are  chiefly  derived 
from  the  corpuscles  of  the  lymph,  and  the  cells  of 
the  lymphatic  glands  and  allied  organs,  which 
they  closely  resemble.  By  escaping  through  the 
walls  of  the  blood-vessels,  they  become  identical 
with  the  wandering-cells  of  tissues  and  with 
pus-corpuscles,— from  which  they  are  indistin- 
guishable except  by  locality.  Such  is  the  origin, 
and  such  are  some  of  the  functions  of  the  white 
corpuscle,  and  its  occasional  development  into 
the  red  corpuscle  has  been  already  mentioned.  It 
might,  therefore,  be  expected  that  morbid  states 
cf  the  leucocytes  would  be  associated  with  dis- 
order of  the  lymphatic  structures  and  connec- 
tive tissues,  of  the  red  corpuscles,  and  of  the 
blood-vessels,  and  this  will  presently  be  shown  to 
be  the  case.  The  proportion  of  white  corpuscles 
n the  blood  is  subject  to  physiological  increase, 
without  becoming  excessive,  as  after  meals,  dur- 
ing periods  of  growth  and  development,  and  in 
menstruation  and  pregnancy.  This  state  is 
called  Physiological  Leucocytosis  (Virchow),  and 
signifies  lymph-glandular  excitement. 

Plasma. — The  physiological  relations  of  the 
plasma  to  the  organism  are  extremely  complex ; 
and  disturbance  of  these  relations  furnishes  many 
of  the  symptoms  of  disorder  of  the  blood.  Its 
mature  function  is  essentially  one  of  nutrition — it 
supplies  the  tissues  with  oxidisable  material  for 
development,  growth,  support,  secretion,  and  the 
liberation  of  force.  The  source  of  the  plasma  is 
equally  extensive.  It  derives  its  principal  con- 
stituents from  the  alimentary  canal  through  the 
absorbent  glands  and  liver ; while  other  impor- 


117 

tant  albuminous  substances  are  being  constantly- 
supplied  from  the  tissues  generally,  through  the 
lymphatic  system.  Lastly,  the  products  of  the 
plasma,  such  as  carbonic  acid,  urea,  and  water, 
are  discharged  by  the  regular  excretory  channels. 
Thus  the  condition  of  the  plasma  is  found  to  be 
most  intimately  associated  with  that  of  the  or- 
gans and  tissues  generally,  whether  as  regards 
its  origin,  its  mature  function,  or  its  products ; 
and  it  will  therefore  be  affected  by  disorder 
or  disease  of  every  organ,  whether  alimentary, 
sanguifacient,  or  excretory,  and  of  all  the  tis- 
sues. 

Coagulation  of  the  Blood:  Fibrin. — Under 
certain  circumstances,  especially  after  removal 
from  the  body,  the  blood  coagulates,  and  fibrin 
separates  more  or  less  completely  from  the  other 
constituents.  This  change  is  now  believed  to  be 
due  to  the  action  of  three  bodies  contained  in  the 
plasma — two  fibrin-generators,  named  respec- 
tively fibrinogen  and  fibrinoplastic  substance, 
albuminous  in  nature ; and  the  third  a ferment. 
The  amount  of  fibrin  produced  varies  not  only 
with  the  amount  of  these  bodies,  but  with  the 
amount  of  salts,  with  the  degree  of  alkalinity 
and  of  heat,  and  with  other  influences ; and  these 
variations  are  subject  to  no  law  at  present 
known.  The  rapidity  of  the  process  depends 
upon  (1)  the  amount  of  ferment;  (2)  its  in- 
creased activity  by  agitation  of  the  blood 
and  by  elevation  of  temperature ; and  (3)  the 
increased  number  of  points  of  contact  (so- 
called  ‘ catalytic  ’ action)  by  the  presence  of 
red  corpuscles,  haemoglobin,  charcoal,  &c.  It 
thus  appears  that  the  expressions  ‘ amount  of 
fibrin  ’ and  ‘ rapidity  of  coagulation,’  however 
important  as  facts,  do  not  afford  any  definite 
indication  of  the  state  of  the  blood,  as  has  been 
generally  believed  hitherto.  Three  essential 
factors,  and  a large  number  of  accidental  influ- 
ences, share  in  the  process ; theymaydo  so  in  very 
various  proportions  and  degrees  ; they  do  not 
vary  together ; the  amount  of  fibrin  is  not  in 
proportion  to  any  one  of  them ; and  after  coagu- 
lation is  complete,  portions  of  all  the  factors 
probably  remain  uncombined.  The  part  played 
by  the  red  corpuscles  in  coagulation  is  a double 
one — (1)  the  corpuscles,  as  ‘points  of  contact,’ 
greatly  increase  the  rapidity  of  coagulation ; and 
(2)  they  supply  oxygen,  which  appears  to  be 
indispensable  to  the  process.  The  leucocytes 
probably  produce  the  ferment. 

B.  Pathology  of  the  Blood. — The  morbid 
states  of  the  blood  will  now  be  considered  in  the 
following  order : — 1.  Changes  in  quantity,  and 
the  effects  of  such  changes  upon  the  composition 
of  the  vital  fluid.  2.  Morbid  conditions  of  the  red 
corpuscles.  3.  Changes  in  colour.  f^Melanaemia. 

5.  Morbid  states  of  the  white  corpuscles. 

6.  The  pathology  of  the  blood-plasma  ; and  of 
the  process  of  coagulation.  7.  The  presence 
of  foreign  materials  in  the  blood,  including  poi- 
sons and  infective  substances.  8.  Organisms. 

1.  Changes  in  Quantity  of  the  Blood. — 
Alterations  in  the  total  amount  of  blood  in  the 
body  are  perhaps  never  simple,  but  always  as- 
sociated with  alterations  in  quality. 

a.  Polyheemia,  or  excess  of  blood  in  the  body 
generally,  may  be  the  result  either  of  excessive 
ingestion  of  the  elements  of  blood  ; of  the  accu 


118  BLOOD,  MORBID 

mulation  of  the  same  by  the  suppression  of 
habitual  haemorrhages  or  fluxes ; of  the  loss 
or  obsoleteness  of  a part  of  the  body,  such  as  a 
limb  or  a lung;  or  of  insufficient  exercise.  It 
cannot  be  said,  however,  that  polyhaemia  has 
ever  been  demonstrated  by  exact  investigation, 
inasmuch  as  the  total  amount  of  blood  in  the 
body  is  still  uncertain,  and  the  physiological 
limits  in  this  respect  are  very  wide.  Polyhaemia 
is  believed  to  be  present  in  'plethora,  along  with 
relative  excess  of  the  solids,  and  especially  of 
the  red  corpuscles  ( see  Plethora). 

b.  Oligemia  or  deficiency  of  the  total  amount  of 
blood  is,  on  the  contrary,  an  exceedingly  frequent 
change,  and  constitutes  the  simplest  form  of 
anemia.  It  is,  however,  probably  never  pure, 
inasmuch  as  alterations  in  quality  appear  to  be 
inseparably  associated  with  it ; and  the  terms 
hydremia  and  spanemia  have  accordingly  been 
used  as  synonymous  with  the  preceding.  The 
manner  in  which  diminution  in  quantity  gives 
rise  to  alteration  in  quality  must  be  considered 
here. 

When  haemorrhage  occurs  to  any  amount,  and 
the  whole  quantity  of  blood  in  the  vessels  is  re- 
duced, the  pressure  falls,  and  absorption  of  the 
parenchymatous  plasma  rapidly  follows;  by 
which,  along  with  vaso-motor  stimulation,  the 
physical  relations  are  restored.  If  the  loss  of 
blood  has  been  moderate,  the  only  change  in 
its  composition  may  be  considered  to  be  oligocy- 
themia, or  diminution  of  the  red  corpuscles, 
which  alone  of  all  the  constituents  of  the  blood 
cannot  be  rapidly  restored.  If  the  haemorrhage 
has  been  more  serious,  the  fluid  absorbed  into 
the  circulation  from  the  tissues,  from  the  sup- 
pressed secretions,  and  from  the  alimentary  canal, 
consists  of  water  in  ever-increasing  excess,  whioh 
carries  with  it  an  amount  of  salts  equal  to  one- 
ninth  the  loss  in  albuminous  substances.  The 
morbid  state  of  the  blood  is  now  beyond  oligoey- 
thsemia;  there  is  deficiency  of  albuminous  con- 
stituents, or  hypalbuminosis , and  the  condition 
correctly  called  anemia  is  the  result.  The  total 
quantity  of  blood  probably  remains  for  some  time 
below  the  normal.  A similar  impairment  of  the 
quantity,  and  therewith  of  the  quality  of  the 
blood,  may  be  slowly  developed  by  repeated  small 
haemorrhages,  or  by  any  cause  whatever  that 
impoverishes  the  blcod,  whether  of  the  nature 
of  waste  or  of  want.  The  condition  which  results 
closely  resembles  that  just  described  in  the  acute 
form — oligaemia  with  oligocythaemia  and  hypal- 
buminosis : the  same  is  known  clinically  as 
anemia  (pee  Anaemia). 

As  a therapeutic  measure  oligtemia  may  be 
desirable.  It  may  be  induced  either  (1)  by 
direct  abstraction  of  blood,  or  (2)  by  gradual 
impoverishment  of  the  blood,  and  reduction  of 
the  intra-vascular  pressure. 

2.  Morbid  Conditions  of  the  Red  Corpus- 
cles.— The  pathology  of  the  red  corpuscles  is 
still  imperfectly  understood.  The  following 
comprise  the  most  important  changes  connected 
with  them  so  far  as  they  are  known. 

a.  Polycythemia. — Increase  in  number  of  the 
red  corpuscles  is  never  considerable,  being 
generally  transitory  and  within  physiological 
limits;  for  example, in  the  newly-born, and  after 
meals.  It  has  already  been  mentioned  as  associated 


CONDITIONS  OF. 

with  polyhaemia  in  plethora.  In  the  algid  stage 
of  cholera  the  red  corpuscles  are  relatively  in 
excess 

b.  Oligocythemia. — Diminution  in  number  of 
the  red  corpuscles  is,  on  the  contrary,  of  very- 
frequent  occurrence,  and  of  the  greatest  patho- 
logical importance.  Microscopically  the  num- 
ber of  red  corpuscles  in  a given  visible  area  of 
blood  is  diminished  ; and  chemically  the  amount 
of  haemoglobin  in  a given  volume  of  blood  may 
fall  from  1 5 even  as  low  us  5 per  cent.  The 
principal  circumstances  under  which  oligocy- 
thaemia occurs  are — (1)  in  anaemia,  or  diminution 
in  the  amount  of  blood  as  a whole,  from  any 
cause,  whether  rapid  or  qorotraefed,  especially  as 
the  result  of  fever ; the  red  corpuscles  suffer 
ing  early,  seriously,  and  persistently,  as  com- 
pared with  the  other  constituents  : (2)  in 
leucocythaemia  — the  development  of  the  red 
corpuscles  being  interrupted:  (3)  in  hypalbumi- 
nosis, where  the  red  corpuscles  like  other  elements 
suffer  from  want  of  albuminous  material : and 
(4)  in  chlorosis.  See  ILemacttometer. 

c.  Oligochromemia. — Deficiency  of  the  re  1 cor- 
puscles in  haemoglobin  has  been  described  by  this 
name,  and  is  a morbid  condition  of  the  greatest 
possible  interest,  inasmuch  as  it  is  one  of  the 
essential  alterations  of  the  blood  in  chlorosis. 
When  the  individual  red  corpuscle  contains  less 
haemoglobin  than  normal,  it  is  said  to  present  a 
pale  appearance  to  the  eye.  A more  trustworthy 
method  of  determining  the  richness  of  the  red 
corpuscles  in  haemoglobin,  is  by  means  of  the 
haemoglobinometer  (see  TLemoglobinometer).  Or 
we  may  compare  the  amount  of  haemoglobin  in  a 
given  weight  of  blood  with  the  number  of  red  cor- 
puscles in  a given  microscopical  area.  "When  the 
former  is  small  in  proportion  to  the  latter,  the 
defect  must  lie  in  the  individual  corpuscle  ; and 
this  may  be  so  great  that  the  proportion  of  hae- 
moglobin falls,  as  in  some  cases  of  chlorosis,  to 
25  per  cent,  of  the  normal.  See  Chlorosis. 

d.  Aglobulism . — The  effects  of  the  two  con- 
ditions of  blood  just  described,  namely,  oligocy- 
thsemia  and  oligochromaemia,  may  be  discussed 
together  under  the  head  of  aglobulism,  or  defi- 
ciency of  the  blood  in  haemoglobin.  Want  of  the 
oxygenating  substance  of  the  organism  gives  rise 
to  symptoms  at  once  extremely-  various,  and  of 
the  most  serious  import.  Every  vital  process, 
whether  developmental,  plastic,  secretory,  dyna- 
mic, or  nutritive,  is  absolutely  dependent  on  a 
free  and  immediate  supply  of  oxygen.  All  of  these 
processes,  therefore,  will  suffer  in  aglobulism. 
The  respiratory  and  circulatory  movements  are 
accelerated.  The  complex  processes  of  alimen- 
tation and  secretion  are  performed  imperfectly, 
and  the  results  are  dyspepsia,  constipation, 
and  disordered  sanguification — which  intensify 
the  abnormal  blood-state.  Muscular  contraction 
is  feeble,  and  cannot  be  sustained.  Psy- 
chical force  is  weak ; and  dulness,  sleepiness, 
pains,  and  other  symptoms  indicate  imperfect 
oxidation  within  the  nervous  system.  Bodily 
growth  and  development — as  of  the  sexual  organs, 
for  example — remain  incomplete,  and  puberty  is 
deferred.  Nutrition  everywhere  suffers,  the  ma- 
terials being  insufficiently  oxidised;  and  sub- 
stances ‘intermediate’  to  albumen  on  the  one 
hand,  and  carbonic  acid,  water,  and  urea  or 


BLOOD,  MORBID 

the  other  hand,  are  formed,  especially  oils. 
Tims  the  organs  and  the  connective  tissues 
become  loaded  with  fat  and  enlarged,  instead 
of  suffering  atrophy,  as  they  do  when  the  blood- 
plasma  is  deficient.  Finally  the  excretions  are 
disturbed,  and  the  subject  of  aglobulism  presents 
derangement  of  the  colouring  matters  of  the  bile 
and  urine,  which  are  derived  from  haemoglobin. 

Histological  changes.  — Alterations  in  the 
size,  outline,  and  consistence  of  the  red  corpuscle 
have  been  frequently  recorded,  but  such  accounts 
are  incomplete,  and  no  successful  attempt  has 
yet  been  made  to  connect  any  of  these  changes 
with  morbid  processes  in  the  tissues.  In  severe 
fevers,  such  as  typhus,  and  in  somo  rapid  malig- 
nant diseases,  the  red  corpuscles  appear  pecu- 
liarly soft,  their  outline  being  less  resistant  and 
sharp,  and  the  bodios  running  together  into  ir- 
regular heaps,  instead  of  into  rouleaux  with  well- 
defined  lines  of  contact  between  the  elements.  In 
another  class  of  cases  the  corpuscles  appear  small 
and  crenated  or  like  the  ‘ thorn-apple.’  Macrocy- 
thamia  and  Microcythemia  have  also  been  de- 
scribed as  temporary  and  variable  conditions,  in 
which  the  red  corpuscles  are  abnormally  large 
and  abnormally  small  respectively.  Transitional 
cells  between  the  white  and  the  red  corpuscle  are 
unusually  numerous  in  some  cases  of  leukaemia. 

3.  Changes  in  Colour. — The  colour  of  the 
blood  is  chiefly  due  to  the  red  corpuscles,  and 
alterations  from  the  normal  in  this  direction 
will  be  best  considered  in  this  place,  although 
the  white  corpuscles  and  the  plasma  may  also 
affect  the  colour,  as  will  be  presently  shown. 

a.  The  chief  determining  cause  of  the  colour 
of  the  blood  is  the  chemical  condition  of  the 
haemoglobin.  When  this  is  united  with  oxygen,  in 
the  arteries,  the  blood  is  scarlet ; as  deoxidation 
advances,  this  colour  passes  into  a purple,  and 
finally  becomes  black  or  venous.  The  dark  colour 
is  directly  due  to  absence  of  oxygen.  The  purest 
example  of  this  change  is  seen  in  asphyxia,  where 
oxygen  is  excluded  from  the  blood  ; but  it  also 
occurs  as  the  result  of  the  action  of  certain  in- 
jurious influences  upon  the  corpuscle  itself,  such 
as  extreme  heat,  or  poisoning  by  phosphorus, 
prussic  acid,  and  other  toxic  agents.  If  the 
change  proceed  no  farther,  the  scarlet  colour  may 
still  be  restored  by  oxidation.  This  blackness  of 
the  blood  is  generally  associated  with  imperfect 
coagulation  or  even  a state  of  fluidity  (sec 
Fibrin). 

b.  Paleness  of  the  blood  is  observed  in  oligae- 
mia  and  oligocythaemia,  and  is  due  to  deficiency 
of  the  haemoglobin. 

c.  The  blood  may  be  not  only  palo,  but  present 
streaks  of  a pur  (form  character,  even  as  it  flows 
from  the  living  vessels,  as  inleucoeythsmia.  The 
same  blood  will  settle  on  standing  into  three 
layers — of  plasma  superiorly,  loosely  coagulated 
or  not;  of  white  corpuscles  in  the  middle — a pus- 
like layer ; and  of  red  corpuscles  at  the  bottom. 

d.  The  milky  appearance  of  chylous  blood  will 
he  described  under  the  head  of  Blood-Plasma, 

e.  Lake  blood.  The  remarkable  change  in  the 
blood  in  which  it  becomes  lako  or  transparent, 
is  frequently  observed  as  a further  stage  of 
that  first  described  above  ; but  it  may  occur 
under  other  circumstances  than  deoxidation,  and 
is  of  the  very  gravest  significance,  inasmuch  as 


CONDITIONS  OF.  119 

it  indicates  complete  and  hopeless  destruction  of 
the  red  corpuscles.  Lake  blood  is  no  longer 
opaque,  but  transparent ; the  haemoglobin  has 
left  the  corpuscles  and  is  dissolved  in  tbo 
plasma.  The  change  can  be  effected  experiment- 
ally by  the  addition  to  blood  of  water,  chloro- 
form, the  bile-acids,  or  other  solvents  ; and  it  is 
probable  that  somo  of  the  cases  of  rapid  death 
after  enormous  draughts  ofwater,  and  the  destruc- 
tion of  red  corpuscles  that  is  believed  to  occur 
in  jaundice,  may  be  accounted  for  in  this  way. 
But  the  most  important  cause  of  * solution’  ol 
the  red  corpuscles  is  complete  deoxidation  of  the 
haemoglobin,  which  is  followed  by  its  diffusion  in 
the  plasma.  Thus  drawn  blood  is  rendered  lake 
by  the  addition  of  sulphide  of  ammonium,  phos- 
phorus, phosphoric  acid,  or  iron-filings;  and.  the 
same  effect  is  produced  by  the  intravenous  in- 
jection of  salts  of  the  bile-acids.  This  being  so. 
it  might  be  expected  that  blood  would  assume 
the  lake  appearance  when  exposed  to  the  pro- 
longed action  of  the  causes  that  render  it  black  ; 
and  recent  observations  seem  to  indicate  that 
such  is  the  case.  In  a number  of  diseases  which 
are  attended  with  the  accumulation  of  oxidis- 
able  substances  in  the  circulation,  the  blood  has 
been  described  as  ‘fluid,’  ‘claret-’  or  ‘ cherry - 
eoloured,’  ‘ clear,’  and  ‘ staining  the  tissues,' 
-~but  apparently  without  more  exact  observa- 
tions on  the  colour  of  tho  living  plasma.  Such 
diseases  are  high  fevers,  hyperpyrexia,  insola- 
tion, and  poisoning  by  malaria,  phosphorus,  and 
perhaps  other  agents.  The  effect  of  some  of 
these  influences  is  obviously  to  produce  an  exces- 
sive amount  of  oxidisable  material  in  the  blood, 
while  the  others  may  lead  to  the  same  result  by  re- 
ducing the  oxygenating  capacity  of  the  corpuscles. 
Persons  dying  under  such  circumstances  present 
great  lividity,  from  the  black  or  venous  condition 
of  their  blood  ; death  occurs  with  symptoms 
indicative  of  want  of  oxygen,  as  if.  so  much  cf 
the  haemoglobin  had  been  diffused  through  the 
plasma ; and  post  mortem  the  vessels  are  found 
stained  with  the  solution,  the  tissues  are  soaked 
with  fluid  lake  blood,  and  decomposition  is  early 
and  rapid.  The  ‘ fluidity  ’ of,  or  absence  of  clot  in 
such  blood  will  be  presently  accounted  for  under 
Fibrin.  That  a similar  solution  or  destruction 
of  the  red  corpuscle  may  occur  in  all  cases  of 
fever,  but  in  a much  less  degree,  is  supported  by- 
several  fiicts: — (1)  the  increased  discharge  of 
potash-salts  in  fever;  (21a  similar  increase  of 
the  colouring  matter  of  the  urine;  and  (3)  the 
anaemia  that  is  found  at  the  termination  of  the 
process. 

f.  Other  alterations  in  colour  may  occur  in  the 
blood.  The  blood  is  light-red  after  poisoning  by 
carbonic  oxide  and  remains  so  after  exposure. 
It  is  chocolate-coloured  after  poisoning  by  the 
nitrites,  such  as  nitrite  of  amyl ; and  other  hues 
have  been  recorded. 

4.  Melaneemia. — In  relation  with  the  pig- 
ment-bearing element  of  the  blood  may  be 
mentioned  a morbid  condition  which  has  been 
described  under  the  name  of  melanaemia.  In  it 
there  are  found  in  the  blood  black  and  browm  pig- 
ment-particles and  flakes,  free  or  contained  in 
cells  of  various  shapes.  This  state  is  especially 
associated  with  two  others,  namely,  malaria  and 
I an  enlarged  deeply-pigmented  condition  of  the 


120 


BLOOD,  MORBID  CONDITIONS  OF. 


spleen ; and  it  is  highly  probable  that  the  pigment- 
particles  are  produced  by  the  fever,  and  find 
their  way  from  the  spleen  into  the  blood.  They 
are  thus  deposited  in  the  liver  and  other  organs, 
and  give  rise  to  symptoms  of  visceral  disturbance 
during  life,  and  to  the  peculiar  slaty  or  grey  dis- 
colouration that  is  found  post  mortem.  It  has 
been  said  that  in  melanotic  cancer  pigmented 
cells  have  been  found  in  the  living  blood. 

5.  Morbid  Conditions  of  the  White  Cor- 
puscles.— The  white  corpuscles  of  the  blood 
may  undergo  certain  morbid  changes  both  in 
uumber  and  appearance. 

a.  The  most  remarkable  of  these  is  increase  in 
numbers,  which  may  advance  to  such  a degree 
that  the  white  corpuscles  become  as  numerous  as 
the  red.  This  condition  is  known  as  leucocythcemia 
cr  leukaemia  ( see  Leucocyth;emia).  Short  of 
this,  however,  the  proportion  of  white  corpuscles 
in  the  blood  may  be  appreciably  increased,  and 
to  this  minor  condition  the  name  of  leucocytosis 
has  been  applied.  Leucocytosis,  according  to 
Virchow,  accompanies,  almost  unexceptionally, 
every  case  of  lymphatic  excitement,  such  as 
inflammation,  and  tubercular,  scrofulous,  or 
cancerous  enlargement  or  swelling  of  the  glands 
and  allied  structures — Peyer’s  glands,  the  solitary 
follicles,  the  spleen,  and  the  tonsils.  Loucoey- 
tosis  is  distinguished  from  leueocythremia  by  its 
very  moderate  degree  ; by  its  evanescent  course  ; 
by  the  absence  of  deficiency  of  the  red  corpuscles ; 
and  by  tho  accompanying  symptoms.  Leucocy- 
tosis may  be  appreciated  even  by  the  naked  eye 
in  the  clot  of  drawn  blood,  by  the  presence  of 
an  irregular  ‘lymphatic  layer’ — crust  a lym- 
phatica,  consisting  of  collections  of  white  cor- 
puscles between  the  red  clot  and  tho  huffy  coat 
which  so  frequently  occurs  along  with  it. 

b.  A diminution  in  the  number  of  white  cor- 
puscles occurs  in  chlorosis  ; and,  it  is  said,  in  ma- 
laria, especially  during  the  paroxysm  of  fever. 

c.  With  regard  to  the  structure  of  the  indivi- 
dual white  corpuscles,  the  proportion  of  uninu- 
clear or  young  cells,  and  of  multinuclear  or  aged 
cells  may  be  disturbed  both  in  leucocytosis  and 
leucocythsemia  ; while  corpuscles  may  be  found 
containing  granules  of  various  kinds,  especially 
pigment-particles,  bacteria,  micrococci,  and  other 
structures. 

6.  Morbid  Conditions  of  the  Blood-plasma. 
— (1)  Water. — The  limits  of  the  physiological 
variations  in  the  amount  of  water  in  the  blood 
are  very  wide. 

a.  Diminution  of  water  in  the  blood  is  observed 
in  various  degrees.  It  is  moderate  and  transitory 
as  the  result  of  stimulation  of  the  kidneys,  skin, 
or  bowels,  but  the  normal  proportion  is  speedily 
restored  by  absorption.  This  condition  is  found 
after  severe  purgation,  sweating,  diarrhoea,  or 
dysentery ; and  its  production  is  the  rationale  of 
several  of  the  methods  adopted  for  the  relief  of 
dropsy.  If  the  drain  of  water  continue,  or  if  the 
supply  fail,  the  anliydric  condition  of  blood  in- 
creases, so  that  the  fluid  appears  black,  thick,  and 
tarry.  Such  is  the  state  of  the  blood  in  .the  algid 
stage  of  cholera ; the  specific  gravity  of  the  serum 
rising  as  high  as  1,080,  accompanied  by  a com- 
parative excess  of  salts,  albumen,  and  urea.  The 
chief  symptoms  of  great  deficiency  of  water  in  the 
blood  are  intense  thirst ; a shrivelled  shrunken 


aspect  of  the  body  generally ; coldness  and  lividitj 
of  the  extremities  ; muscular  pains ; and  suppres- 
sion of  the  excretions — phenomena  directly  re- 
ferable to  loss  of  water,  retardation  of  the 
circulation,  and  interference  with  the  function 
of  the  red  corpuscles. 

b.  Excess. — Hydrcemia. — Reference  has  been 
already  made  under  the  head  of  oligsemia  to  the 
anaemia  or  hydraemia  that  follows  it.  Excess 
of  water  in  the  blood  is  perhaps  never  absolute, 
and  the  change  may  therefore  be  regarded  with 
equal  accuracy  and  greater  convenience  as  de- 
ficiency of  solids. 

(2)  Albuminous  Constituents. — On  reviewing 
what  has  already  been  said  under  the  head  of 
Coagulation  and  Fibrin,  the  reader  will  observe 
that  ‘ amount  of  fibrin,’  and  other  expressions  con- 
nected with  the  albuminous  constituents,  must  be 
regarded  at  present  as  comparatively  meaning- 
less, in  the  light  of  our  knowledge  of  the  process 
of  coagulation.  Inasmuch,  therefore,  as  little  value 
can  now  be  attached  to  the  analyses  of  fibrin  that 
have  been  made  in  different  diseases,  it  follows 
that  the  estimates  of  the  albuminous  substances 
left  after  coagulation — that  is,  of  the  albumins  of 
the  scrum,  must  also  be  rejected.  But  the  total 
amount  of  albumins  in  the  blood  may  be  easily 
ascertained;  and  this  is  subject  to  extensive  vari- 
ations. Tho  balance  between  the  albuminous 
substances,  which  enter  the  blood  from  the  ali- 
mentary tract  and  the  lymphatic  system,  on  the 
one  hand,  and  the  products  of  their  transforma- 
tion by  the  tissues,  on  the  other,  is  represented 
by  the  albumins  of  the  blood.  These  will  in- 
crease accordingly  when  the  supply  is  excessive, 
or  the  consumption  small ; and  will  decrease 
under  opposite  circumstances. 

a.  Hyperalbuminosis  is  the  name  given  to 
excess  of  albumins  in  the  blood.  The  amount 
has  been  found  notably  increased  when  the 
activity  of  the  tissues  is  abnormally  heightened, 
as  for  example  in  inflammatory  diseases  (acute 
rheumatism,  tonsillitis,  pneumonia,  and  pleurisy) ; 
and  when  fibrinogen,  which  is  the  product  of  this 
increased  activity,  is  poured  abundantly  into 
the  blood.  The  amount  of  albuminous  fluid  pro- 
duced in  an  inflamed  part,  whether  it  appears 
as  a catarrh,  an  infiltration,  an  exudation,  or  an 
effusion,  is  very  great,  and  may  be  enormous ; 
and,  under  favourable  circumstances,  this  and 
much  that  cannot  be  so  easily  appreciated  is 
carried  into  the  blood,  the  lymphatic  structures 
swelling  en  route.  Hyperalbuminosis  as  a result 
of  diminished  consumption  probably  does  not 
exist;  for  the  effect  of  an  insufficient  supply  of 
oxygen  to  the  albumins — (want  of  exercise  or 
over-feeding) — is  not  the  accumulation  of  these 
in  the  blood,  but  the  formation  of  ‘lower’  pro- 
ducts, such  as  uric  acid  and  its  allies,  and  tho 
deposit  of  fat.  Relative  hyperalbuminosis  is  a 
necessary  but  transient  effect  of  cholera  and 
other  severe  watery  fluxes. 

b.  Hypalbuminosis,  or  deficiency  of  albumins  in 
the  blood,  occurs  under  exactly  opposite  circum- 
stances from  the  preceding, — whether  the  in- 
gestion of  albumins  from  the  alimentary  tract 
and  the  tissues  be  comparatively  small,  or  the 
consumption  excessive.  Inanition,  therefore,  on 
the  one  hand,  and  its  multitude  of  causes,  are 
associated  with  such  poverty  of  blood ; and  so,  on 


BLOOD,  MORBID 

!he  other  hand,  are  loss  of  blood,  profuse  dis- 
charges of  albuminous  fluids,  morbid  growths, 
and  other  sources  of  waste,  as  well  as  excessive 
demands  of  growth  and  development.  The  albu- 
mins of  the  plasma  may  fall  under  these  circum- 
stances from  80  to  37  parts  in  1,000.  Such  hypal- 
buminosis  is,  however,  never  simple  : the  blood 
cannot  be  deficient  in  albuminous  substances 
and  otherwise  normal,  for,  as  we  have  already 
shown,  loss  of  albumen  is  always  followed  by 
absorption  of  water  and  salts  from  the  tissues 
in  definite  proportions,  and  anaemia  is  the  result. 
The  red  corpuscles  suffer  at  the  same  time,  for 
their  nutrition  speedily  fails  in  hypalbuminosis, 
and  aglobulism  ensues.  Hypalbuminosis  is 
thus  a serious  disease  of  the  blood.  The  re- 
lations of  these  conditions  to  each  other  and  to 
oligaemia  are  even  more  complicated  clinically 
than  they  are  pathologically:  and  in  this  rela- 
tion the  whole  of  them  are  most  conveniently 
discussed  under  the  comprehensive  head  of 
anaemia  (see  Anzsmia). 

(3)  Clot;  Fibrin.  However  uncertain  as  a 
measure  of  any  particular  constituent  in  the 
blood,  the  amount  of  clot  or  fibrin  demands  a 
brief  notice  as  a matter  of  fact. 

a.  Abundant  clot  has  been  considered  as  indicat- 
ing an  excess  of  fibrin  in  the  blood  or  hyperinosis, 
the  proportion  being  stated  to  rise  as  high  as 
l’O  instead  of  0'2  per  cent.  Acute  rheumatism, 
cellulitis,  pneumonia,  and  pleurisy  are  the  dis- 
eases in  which  hyperinosis  is  most  marked; 
but  it  also  occurs  in  pregnancy.  The  two 
principal  conditions  of  its  occurrence  appear 
to  be— (1)  Increased  activity  of  the  tissues — 
including  inflammation;  and  (2)  Free  and  abun- 
dant communication  of  these  tissues  with  the 
blood  through  the  lymphatic  system. 

b.  Deficiency , looseness , or  absence  of  clot — ‘ Fluid 
blood! — A small  loose  clot  is  frequently  observed, 
as  for  example  in  typhous  states,  or  in  chronic 
wasting  diseases  attended  with  loss  of  blood ; 
and  has  been  described  as  indicating  liypinosis 
or  deficiency  of  fibrin.  When  the  condition 
is  extreme,  the  clot  may  be  absolutely  wanting, 
as  in  certain  cases  of  anaemia:  the  blood  then 
separates  on  standing  into  three  layers  — an 
upper,  consisting  of  clear  liquid ; a middle,  puri- 
form,  of  white  corpuscles  ; and  a lower,  red,  of 
red  corpuscles.  In  another  and  larger  group  of 
cases,  non-coagulating  or  fluid  blood  is  at  the 
same  time  of  an  intensely  dark  colour  or  even 
lake,  and  is  commonly  described  as  ‘ black.’  The 
circumstances  under  which  this  condition  of  blood 
occurs,  and  the  cause  of  the  remarkable  colour 
have  been  already  noticed ; and  it  remains  to 
account  only  for  the  fluidity.  The  profound 
alteration  of  the  red  corpuscles,  the  want  of  oxy- 
gen, the  interference  with  the  production  of  the 
ferment,  and  the  changes  in  the  fibrinogen  and 
fibri noplastic  substance — one  and  all  combine 
to  prevent  coagulation. 

c.  Duffy  coat.  Another  phenomenon  connected 
with  coagulation,  from  which  erroneous  and  even 
dangerous  conclusions  have  been  drawn,  is  the 
so-called  huffy  coat.  Tho  process  of  coagulation 
is  generally  sufficiently  slow  to  allow  of  the 
gravitation  of  some  of  the  red  corpuscles  from 
the  surface  of  the  blood ; and  the  corresponding 
part  of  the  clot ’S  accordingly  paler.  When  the 


CONDITIONS  OF.  121 

pale  layer  is  unusually  large  it  is  known  as  the 
huffy  coat  or  crusta  phlogistica : it  may  l e seen 
in  the  blood  in  pregnancy,  inflammatory  fevers, 
hydraemia,  and  oligocythaemia.  When  these 
cases  are  analysed,  it  is  found  that  the  conditions 
favourable  to  the  formation  of  the  huffy  coat  are 
probably  all  more  or  less  connected  with  the  red 
corpuscles,  namely — ( 1 ) increased  specific-gravity 
of  the  red  corpuscles,  as  in  oligocythaemia  and 
hydraemia — allowing  more  rapid  sinking;  (2) 
interference  with  the  catalytic  action  of  the 
haemoglobin,  which  is  so  powerful  in  determin- 
ing the  rapidity  of  coagulation,  as  in  fevers  and 
oligocythaemia;  and  (3)  want  of  oyxgen,  corre- 
sponding to  the  amount  and  condition  of  the 
haemoglobin,  as  in  the  same  diseases.  One  and  all 
of  these  states  render  the  process  of  coagulation 
slow  compared  with  the  descent  of  the  red  cor- 
puscles ; and  the  huffy  coat  is  the  result.  It 
thus  appears  that  the  buffy  coat  is  no  indication 
whatever  of  excess  of  fibrin-generators,  or  of  the 
opposite;  and  that  it  is  found  under  the  most 
diverse  conditions  of  blood. 

(4)  Salts. — The  amount  of  positive  knowledge 
concerning  morbid  alterations  of  the  salts  of  the 
blood  is  but  small.  It  is  to  be  observed  that  the 
salts  of  tho  plasma  have  chiefly  sodium  as  their 
base,  while  potassium-salts  mostly  resido  in  the 
corpuscles. 

a.  Diminution.— In  febrile  diseases  there  is  an 
increased  discharge  of  compounds  of  both  bases, 
but  at  different  periods;  the  potassium-salts  ap- 
pearing in  excess  in  the  excretions  until  the  crisis 
is  past,  and  the  sodium-salts  during  defervescence. 
At  both  periods,  it  may  be  considered  certain 
that  the  blood  is  the  chief  source  of  the  salts  ex- 
creted; and  that  it  is  accordingly  deficient  in 
these  constituents. 

b.  Excess. — On  the  other  hand,  the  salts  of  the 
plasma  are  relatively  in  excess  in  hypalbumi- 
nosis, replacing,  in  the  proportion  already  stated, 
the  lost  albumen.  The  effect  on  the  salts  of  the 
blood  of  such  drains  as  occur  in  cholera  has  been 
variously  stated;  some  authorities  declaring  that 
it  is  an  increase,  others  a diminution. 

c.  Reaction. — The  alkalinity  of  the  blood  is 
said  to  be  diminished  in  gout,  cholera,  and  osteo- 
malachia. 

(5)  Fats. — The  normal  increase  of  fats  in  the 
plasma  thatoccurs  after  meals  may  be  exaggerated 
by  a diet  rich  in  oil,  and,  it  is  said,  in  chronic 
drunkards  and  in  persons  disposed  to  obesity. 
When  this  increase  is  so  great  that  the  serum 
presents  a milky  appearance  the  blood  has  been 
called  chylous.  A cream-like  scum  forms  on 
the  surface  of  the  serum ; and  the  milky  appear- 
ance is  found  microscopically  to  be  due  to  the 
presence  of  fine  granules  and.  oil-globules.  A 
marked  increase  of  fatty  matters  in  the  blood 
has  been  found  in  some  cases  of  chyluria.  Fat 
may  also  appear  in  the  blood  as  a foreign  body, 
by  the  escape  of  marrow  into  the  circulation  in 
fracture  of  bones — and  that  in  such  quantity  as 
to  cause  fatal  capillary  embolism. 

(6)  Carbonic  Acid,  which  exists  in  arterial 
blood  in  the  proportion  of  30  per  cent.,  and  in 
venous  blood  of  35  per  cent.,  by  volume,  may  accu- 
mulate within  the  circulation  either  by  increased 
formation  or  by  retention.  Although  associated 
with  asphyxia,  this  increase  of  carbonic  acid  la 


L 22  BLOOD,  MORBID  CONDITIONS  OR. 
probably  not  the  cause  either  of  the  symptoms 
of  that  condition,  or  of  the  dark  colour  of  the 
blood  that  accompanies  it. 

(7)  Other  Constituents. — Amongst  the  most 
important  of  the  other  constituents  of  the  blood, 
the  following  are  to  be  noticed : — 

a.  Urea , which  exists  in  normal  blood  to  the 
amount  of  1'8  parts  in  10,000,  may  increase  in 
uraemia  by  two  or  three  times.  There  is  still 
much  uncertainty,  however,  on  this  subject  ( see 
Uraemia).  Disease  of  the  urinary  organs,  which 
interferes  with  the  elimination  of  urea  and  allied 
products  from  the  blood,  is  the  usual  cause  of 
uraemia;  but  excessive  tissue-change, as  in  fever 
and  inordinate  muscular  exercise,  has  also  the 
same  effect. 

b.  Uric  acid,  found  in  normal  blood  iD  minute 
traces,  is  increased  (as  urate  of  soda)  in  all  cases 
of  gout,  and  may  amount,  according  to  Dr.  Garrod, 
even  to  0T75  parts  in  10,000.  Its  presence  is 
easily  demonstrated  by  the  thread-experiment 
(see  Gotjt).  Uric  acid  is  also  increased  in  leukae- 
mia and  chlorosis — probably  from  the  imperfect 
oxidation  associated  with  the  condition  of  the 
red  corpuscles. 

c.  Leucin,  tyrosin,  hippuric  acid,  sarcin,  and 
other  allied  complex  compounds,  have  been  fre- 
quently found  in  the  blood  in  small  quantities, 
and  the  same  may  be  said  of  oxalic  and  lactic 
acids,  and  of  acetone. 

d.  Bile. — Certain  of  the  constituents  of  the  bile 
mayoccurin  the  plasma.  Themostobviousof  these 
are  the  bile-pigments — bilirubin  and  biliverdin, 
which  either  by  direct  formation  in  the  blood  from 
the  haemoglobin,  or  more  frequently  by  absorption 
from  the  liver,  accumulate  within  the  circulation, 
and  by  their  deposit  give  rise  to  the  colour  of  the 
tissues  in  jaundice.  The  bile-acids — glycocholic 
and  taurocholic  acids — are  also  under  certain  cir- 
cumstances absorbed  into  the  blood,  where  they 
may  be  detected  with  difficulty.  They  have  a 
destructive  effect  upon  the  red  corpuscles,  and  act 
further  as  a powerful  poison  to  the  tissues;  causing 
the  excessively  severe  symptoms  that  may  occur 
in  hepatogenous  jaundice.  Cholcsterin  is  credited 
by  some  pathologists  with  being  the  cause  of  the 
same  symptoms,  and  it  has  been  found  in  the 
blood  in  increased  proportion  in  some  cases  of 
severe  jaundice. 

e.  Sugar. — The  sugar  of  the  blood  is  increased 
in  diabetes,  in  some  cases  reaching  0'3  to  0'5  per 
cent. 

7.  Extraneous  Matters  in  theBlood.. — Be- 
sides its  normal  constituents  and  their  products, 
the  blood  may  occasionally  contain  certain  matters 
entirely  foreign  to  it,  such  as  tho  numerous  poisons 
which  act  either  directly  upon  the  corpuscles,  or 
remotely  upon  the  organism.  These,  entering 
the  circulation  before  they  exert  their  specific 
effect,  are  in  many  instances  readily  discovered 
by  analysis.  Tho  acid  compounds  of  hydrogen 
with  sulphur,  phosphorus,  arsenic,  and  antimony, 
respectively,  act  as  blood-poisons  by  depriving 
the  oxyhaemoglobin  of  its  oxygen  ; while  carbonic 
oxide  and  nitrous  oxide  unite  with  the  hemo- 
globin, and  expel  the  oxygen  from  the  blood. 
It  is  a matter  of  speculation  whether  other  so- 
called  poisons,  the  nature  of  which  is  still  obscure, 
do  not  enter  the  blood  and  there  exert  their 
primary  effect.,  such  as  the  eontagium  of  acute 


BOILS. 

specific  fevers  and  other  infectious  disorders. 
Similar  infective  matters,  produced  in  the  tissues 
of  the  body  itself,  are  believed  to  be  absorbed  in 
septicaemia,  pyaemia,  and  other  allied  diseases,  and 
numerous  observations  support  the  further  be- 
lief that  the  presence  of  bacteria  is  intimately 
associated  therewith.  A somewhat  similar  in- 
fection may  occur  in  malignant  disease,  the 
juices  being  mixed  with  the  blood-plasma,  but 
in  some  instances  the  process  may  be  different, 
namely  by  means  of  cells.  We  cannot  expect  to 
detect  these  cells  in  the  blood  in  transitu.  The 
same  remark  applies  to  embola,  of  whatever 
nature,  and  to  blood-crystals. 

8.  Organisms.— -The  blood  may  contain  a 
variety  of  living  organisms,  either  foreign  or 
peculiar  to  itself ; the  latter  being  called  hama* 
tozoa.  See  Hjematozoa,  Chyiuria,  and  Re- 
lapsing Lever;  also  Bacteria,  Filaria  San- 
guinis-hominis,  Micrococci,  Spirillum,  and 
Zyme.  J.  Mitchell  Bruce. 

BLOOD,  Transfusion  of.  See  Transfusion. 

BLOOD-WORMS. — This  term  is  of  general 
application.  It  refers  to  all  kinds  of  Entozoa 
living  in  the  blood.  See  Hsmatozoa. 

BLBTE  DISEASE.  A condition  in  which  the 
most  prominent  symptom  is  a peculiar  disco- 
louration of  the  skin  and  mucous  membranes, 
due  to  the  circulation  of  dark  blood  in  the  vessels. 
See  Cyanosis  ; and  Heart,  Malformations  of. 

BOILS. — Synon.  : Furuncles  ; Fr.  Furoncle-, 
Ger.  Furunkcl. 

Definition.— Gangrenous  inflammation  of 
the  skin,  forming  small  painful  swellings,  and 
ending  by  expulsion  of  the  necrosed  centre  or 
1 core.’  The  inflammation  begins  in  the  glandu- 
lar structures,  hence  involving  not  only  the  skin, 
but  also  the  cellular  tissue  immediately  beneath. 
The  sebaceous  glands  are  most  commonly  the 
seat  of  boils,  but  occasionally  the  Meibomian 
glands  (stye),  the'  ceruminous  glands,  and  the 
sweat-glands  of  the  armpit ; or,  more  rarely  still, 
the  glands  of  the  lips,  vulva,  or  anus  are  affected. 

HStiologv.— The  predisposing  causes  of  boils 
are  : — the  male  sex  ; middle  life  ; a stout  habit 
of  body;  seasons  of  spring  and  autumn;  a diet 
too  full  of  flesh,  or  one  suddenly  changed,  such 
as  that  adopted  during  training  for  rowing,  &e. 
To  these  must  be  added  the  vitiation  of  the 
blood  during  exhausting  fevers  and  in  certain 
eases  of  saccharine  urine,  or  induced  by  inhaling 
dissecting-room  effluvia ; and  dirty  occupations, 
for  example,  chimney-sweeping  or  rag-picking. 
Lastly,  boils  are  sometimes  epidemic. 

Local  causes. — The  parts  of  the  skin  most  ex- 
posed to  dirt  or  chafing,  the  hands  and  face,  the 
neck  and  back,  the  buttocks  and  knees,  are  favour- 
ite sites  for  boils  ; but  they  may  form  on  any  part 
except  the  palms  and  soles.  Blisters,  poultices, 
and  stimulating  liniments  occasionally  causethem. 

To  these  causes  is  added  by  some  authors  the 
specific  contagion  of  a parasitic  fungoid  plant, 
the  mycelium  of  which,  by  developing  in  a gland- 
cell, thereby  causes  limited  necrosis  (the  slough) 
of  the  tissue  in  which  it  grows.  The  truth  of 
this  view  is  not  yet  clearly  established. 

Symptoms. — Boils  appear  either  singly,  in 
succession,  or  several  at  once,  forming  thee  ar, 


BOILS. 


eruption  on  the  skin.  The  solitary  boil  begins  with 
itching;  soon  a reddish  pimple  forms,  sometimes 
tipped  with  a minute  vesicle,  in  the  centre  of 
which  a hair  may  generally  be  detected.  The 
pimple  grows  larger  and  harder,  the  red  area  in- 
creases and  grows  darker,  and  pain  begins,  sting- 
ing at  first,  then  throbbing.  In  about  five  days  the 
summit  breaks,  pus  oozes  forth,  the  pain  abates, 
and  the  hardness  diminishes.  A day  or  two  later 
the  core,  a shred  of  sphacelated  cellular  tissue, 
escapes.  The  boil  then  subsides,  and  healing 
rapidly  takes  place  ; the  scar  is  depressed,  and  for 
some  time  of  a violet  colour.  Occasionally  the 
inflammation  affects  chiefly  the  cellular  tissue 
beneath  the  skin  ; the  mass  is  then  softer,  more 
round  and  clearly  circumscribed,  and  fluctuates 
like  an  abscess — this  variety  forms  in  the  arm- 
pit.  Barely,  the  central  slough  extends  rapidly 
beneath  the  surface,  and  communicates  with  the 
surface  by  several  small  apertures  ( carbuncle ). 
In  other  cases  the  swelling  is  more  diffuse ; no 
core  appears  at  the  surface,  but  a hard  very 
painful  pimple  is  formed,  which  is  long  in  sub- 
siding ( blind  boil).  The  furuncular  eruption, 
consisting  of  groups  of  small  boils,  forms  suc- 
cessive crops,  and  thus  the  disease  may  continue  a 
long  time.  Boils  are  generally  limited  to  a small 
region,  but  this  is  not  always  the  case  ; and  the 
greater  part,  even  the  whole,  of  the  body  may  be 
attacked. 

The  constitutional  disturbance  is  usually  nil 
or  slight  when  the  boil  is  due  to  local  irritation, 
though  it  may  suffice  to  render  nervous,  irritable 
persons  unfit  for  work.  When  the  boils  are 
caused  by  exhaustion,  the  general  symptoms  are 
severe  and  denote  great  depression.  Prostration, 
agitation,  stupor,  low  delirium,  dry  brown  tongue, 
sordes,  vomiting,  and  diarrhoea  set  in,  and  the 
ease  often  ends  fatally;  or  recovery  is  very  slow, 
accompanied  by  much  suppuration.  Septic  ab- 
sorption and  pyaemia  very  rarely  take  place. 

Carbuncular  Boil  of  the  Face. — There  is  a rare 
and  often  fatal  form  of  boil,  the  determining 
cause  of  which  is  unknown.  It  is  met  with  only 
on  the  head  and  neck,  notably  on  the  lip.  Mild 
and  trifling  at  first,  like  an  ordinary  boil,  it 
rapidly  extends  by  inflammation  of  the  veins  or 
lymphatics,  and  causes  poisoning  of  the  blood. 
The  earliest  sign  of  this  fatal  change  is  the  occur- 
rence of  violent  and  repeated  shivers.  The  boil 
becomes  a boggy  swelling  of  blackish  violet 
colour ; the  surrounding  tissues  become  hard 
and  brawny;  suppuration  ceases;  sloughing 
occurs  ; the  complexion  grows  earthy ; the  fea- 
tures, if  the  boil  is  on  the  face,  become  everted ; 
the  skin  round  the  eyes  in  some  cases  is  puffed 
out,  and  the  eyes  themselves  project  from  the 
sockets;  anxiety  and  laboured  gasping  breathing 
set  in ; and  a violent  constricting  pain  in  the 
head,  chest,  or  belly  is  frequently  experienced. 
Delirium  and  coma  usually  supervene,  but  some- 
times consciousness  and  terrible  suffering  re- 
main to  the  last.  The  duration  from  the  first 
shiver  to  th»  end  is  about  four  days.  The  veins 
of  the  face  first  inflame,  and  the  phlebitis  extends 
by  the  veins  of  the  orbit  to  the  sinuses  in  the 
skull,  to  the  diploe,  &e. ; hence  abscesses  form  in 
the  eyelid,  the  forehead,  the  meninges,  or  the 
brain,  and  occasionally  in  distant  viscera. 

Diagnosis.. — A boil  is  distinguished  by  the 


ins 

central  cavity  and  slough — characters  peculiar  to 
it.  The  boil  of  the  face  accompanied  with  phle- 
bitis has  been  confounded  in  this  country  with 
the  ‘ malignant  pustule  ’ of  Continental  surgeons. 
The  former  is  still  a boil  with  a central  core. 
The  ‘ pustule  maligne'  is  said  to  have  invariably 
a large  vesicle  surmounting  a brownish  eschar, 
with  a ring  of  smaller  vesicles  round  the  larger 
one, — a condition  never  met  with  in  boils. 

Phognosis. — When  due  to  local  causes,  the 
prognosis  is  always  good,  unless  the  patient  be 
exhausted  by  old  ago  or  fever;  under  such  cir- 
cumstances the  extensive  sloughing  and  suppu- 
ration often  lead  to  a fatal  issue. 

Treatment.—  General. — First  remove  predis- 
posing causes,  and  invigorate  the  patient  by 
change  of  air,  outdoor  exercise,  vapour  and 
Turkish  baths.  The  diet  should  be  moderate 
and  mixed.  Alcohol,  unless  the  patient  is  greatly 
debilitated,  should  be  given  in  very  moderate 
quantity,  and  the  form  of  fermented  liquor  most 
habitual  to  the  patient  is  best ; much  alcohol 
taken  before  the  core  has  loosened  increases  the 
pain  and  throbbing.  Occasionally  a saline 
purge  should  be  given.  Of  empirical  remedies, 
yeast  (a  tablespoonful  thrice  daily)  is  said  to  put 
an  end  to  the  repetition  of  boils.  Quinine  and 
perchloride  of  iron  are  also  used.  Quinine 
should  be  given  to  an  adult  in  five-grain  doses 
every  six  hours,  till  singing  in  the  ears  and  head- 
ache begin;  it  should  then  be  gradually  lowered 
for  three  or  four  days  to  three  or  four  grains 
per  diem,  and  then  left  off.  In  obstinate  cases 
the  waters  of  Vichy,  Bareges,  or  Harrogate  are 
believed  to  remove  the  disposition  to  boils.  In 
diabetes  omission  of  sugar-forming  food,  and  the 
free  administration  of  alkalis  are  the  most  effec- 
tual remedies.  For  the  exhausting  boil  of  the 
face,  large  doses  of  brandy,  with  quinine,  are  re- 
quired. 

Local. — When  signalled  by  itching,  a boil  may 
be  stopped  by  plucking  out  the  hair  of  the  in- 
flamed' follicle,  and  in  a long  succession  many 
boils  may  thus  be  prevented.  When  the  areola  has 
formed,  if  the  pain  be  slight  a drop  of  caustic  solu- 
tion applied  to  the  centre  will  sometimes  check 
the  progress  of  the  boil.  A better  plan  at  this  stage 
is  to  cover  the  boil  with  a galbanum  and  opium 
plaster  (Erasmus  Wilson’s)  spread  on  leather. 
Under  this  treatment  pain  at  once  ceases,  the 
inflammation  gradually  subsides,  and  the  sepa- 
ration of  the  core  proceeds  painlessly ; when 
the  boil  discharges,  a hole  should  be  cut  in  the 
centre  of  the  plaster,  for  the  escape  of  the  pro- 
ducts. When  the  pain  is  stinging,  and  the 
areola  wide,  with  restlessness  and  headache, 
warm  poultices  are  most  soothing  — those  of 
starch  cause  pustulation  less  than  linseed  meal 
poultices.  Mixing  lard  with  linseed  poultice,  or 
sprinkling  it  with  the  dilute  solution  of  acetate 
of  lead,  has  a similar  effect.  Poultices  hasten 
the  expulsion  of  the  slough,  but  should  be  dis- 
continued as  soon  as  the  hardness  changes 
to  doughiness.  If  the  slough  is  large,  the  sur- 
face may  be  dressed  with  lint  spread  with  Peru- 
vian balsam,  and  the  boil  carefully  protected  by 
means  of  pads  and  compresses. 

Incisions  are  now  much  less  employed  than 
formerly.  They  increase  rather  than  lessen  the 
loss  of  tissue  in  ordinary  boils,  and  do  not 


>24  BOILS. 

shorten  the  duration  of  the  inflammation.  They 
give  relief  to  pain,  however,  and  check  the 
spread  of  diffused  boils.  When  made,  incisions 
should  be  free,  crucial,  or  even  star-like,  and 
carried  beyond  the  boil.  In  the  rapidly  extend- 
ing boil  of  the  face  local  treatment  is  of  little 
avail ; the  free  use  of  the  actual  cautery  may 
be  beneficial  if  employed  at  an  early  period. 

Berkeley  Hill. 

BONE,  Diseases  of. — Under  this  head  are 
included : — Acute  and  Chronic  Inflammation  of 
bone  and  its  membranes,  with  the  consequences 
thereof,  such  as  Caries,  Necrosis,  and  Abscess  ; 
New  Growths  which  arise  both  within  and  upon 
the  bone  ; Malformations ; and  certain  Disorders 
of  Nutrition,  namely.  Hypertrophy  and  Atrophy. 
Bone-tissue  should  be  regarded  as  being  simi- 
lar to  other  connective  tissues,  but  some  dis- 
eases affecting  it  are  rendered  obscure,  while 
others  are  materiall}'  modified,  by  reason  of  its 
meshes  being  filled  with  lime-salts. 

1.  Inflammation. — As  a matter  of  clinical 
convenience,  it  is  usual  to  consider  separately  in- 
flammations of  the  periosteum,  of  the  bone  proper, 
and  of  the  medulla ; but  it  should  not  be  forgotten 
that  these  structures  are  throughout  continuous 
and  interdependent,  and  that  disease  is  rarely 
exclusively  confined  to  any  one  of  them — it  may 
originate  or  be  chiefly  developed  in  one,  but 
it  cannot  long  exist  without  involving  the  others 
to  a greater  or  less  degree. 

A.  Periostitis — Inflammation  of  the  invest- 
ing membrane  of  bone  ( die  Knochenhaut).  By 
periosteum  is  usually  meant  the  thin  fibrous  en- 
velope of  the  bone  in  which  the  vessels  for  the 
supply  of  blood  subdivide.  But  between  it  and 
the  bone  is  a layer  of  osteogenetic  cells  like  the 
cambium-layer  of  a growing  plant,  and  immedi- 
ately external  is  a layer  of  cellular  tissue,  con- 
tinuous with  that  of  the  adjacent  parts ; these 
are  integral  portions  of  the  periosteum,  and  take 
an  active  share  in  all  its  diseased  processes. 
Periostitis  may  be  either  acute  or  chronic. 

(a)  Acute  periostitis,  osteoperiostitis,  acute  pe- 
riosteal abscess,  or  acute  necrosis. — This  is  a for- 
midable, but  fortunately  comparatively  rare, 
disease,  at  least  in  the  adult.  It  attacks  the  long 
bones  almost  exclusively,  usually  those  of  delicate 
children  or  young  adults,  in  whom  active  bone- 
growth  is  still  going  on,  and  the  periosteum  is 
highly  vascular.  Acute  periostitis  probably  never 
occurs  without  coincident  inflammation  of  bone, 
and  it  is  by  far  the  most  common  cause  of  ne- 
crosis. It  will  be  best  to  regard  it  as  an  acute 
ostitis  and  periostitis  combined,  and  to  call  it 
osteoperiostitis,  just  as  we  call  inflammation  of 
the  bone  and  of  the  endosteum  osteomyelitis. 
The  extent  to  which  the  bone  and  the  perios- 
teum are  in  the  first  instance  respectively  in- 
volved is  always  difficult,  and  sometimes  im- 
possible, to  determine  — it  may  be  inferred 
from  the  extent  of  the  necrosis.  There  are 
two  ways  in  which  the  disease  may  begin — - 
either  in  the  fibrous  investing  sheath  of  the  bone 
and  the  cellular  laj'ers  beneath  and  superficial  to 
it,  from  whence  it  spreads  inwards  to  the  cortical 
bone-substance,  or  even  to  the  medulla;  or  in 
the  bone-tissue — the  inflammation  spreading 
outwards  to  the  periosteum.  It  is  impossible 


BONE,  DISEASES  OF. 

in  the  living  subject  to  distinguish  acute 
osteomyelitis  and  osteoperiostitis  arising  from 
idiopathic  causes.  The  disease  is  usuallv  at- 
tributed to  an  injury,  often  slight,  or  to  ex- 
posure to  extremes  of  cold  or  heat.  Frequently 
no  cause  is  assignable. 

Pathology. — Rapid  exudation  takes  place  in 
the  layers  of  the  periosteum,  and  in  the  Haversian 
spaces  and  canals  of  the  bone,  to  such  an  extent 
as  to  obstruct  the  circulation,  and  probably  to 
cause  by  pressure  the  severe  pain  complained  of 
at  the  outset.  The  exudation  beneath  the  fibrous 
layer  of  periosteum  is  copious,  and  soon  becomes 
purulent ; the  periosteum  is  detached ; the  vascular 
supply  of  the  bone  is  cut  off ; and  necrosis  results. 
The  extent  of  the  necrosis  depends  upon  the 
extent  to  which  the  periosteum  is  engaged,  while 
the  thickness  of  the  dead  bone  depends  mainly 
on  the  depth  to  which  the  inflammation  in  the 
osseous  tissue  extends.  Large  accumulations 
of  pus  are  often  rapidly  formed  in  these  cases, 
the  pus  escaping  through  openings  in  the  fibrous 
envelope  into  the  circumjacent  cellular  tissue. 
The  shafts  of  the  tibia  and  femur  are  the  part3 
most  frequently  affected  ; the  disease  occurs  more 
rarely  in  the  bones  of  the  upper  extremities  and 
other  parts  of  the  skeleton. 

Symptoms. — One  of  the  earliest  symptoms  of 
acute  periostitis  is  sudden  and  severe  pain  in 
the  affected  bone,  which  is  soon  followed  by 
intense  fever.  On  the  second  or  third  day 
deep-seated  swelling  sets  in,  somewhat  obscarc 
at  first.  After  an  interval  varying  from  five 
to  ten  days,  the  inflammatory  signs  approach 
the  surface,  the  skin  becomes  cedematous. 
pits  on  pressure,  and  finally  reddens  and 
inflames.  The  length  of  interval  depends  on 
the  thickness  of  muscles  and  soft  parts  covering 
the  affected  bone.  Other  things  being  alike  in 
respect  of  pain  and  amount  of  fever,  the  longer 
the  delay  in  the  appearance  of  external  swelling, 
the  greater  the  probability  that  the  bone  is  the 
first  and  chief  tissue  engaged,  the  inflammation 
having  reached  the  periosteum  secondarily,  while 
the  early  appearance  of  swelling  and  fluctuation 
externally  suggest  that  the  inflammation  is 
chiefly  periosteal.  Blood-poisoning,  either  sep- 
ticaemic  or  pyaemic,  is  a common  consequence  of 
acute  inflammation  of  bone  and  periosteum. 

Diagnosis. — This  disease  may  be  obscure  at 
the  commencement,  and  its  nature  overlooked ; 
it  has  often  been  mistaken  for  acute  rheumatism 
on  account  of  the  swollen  joints,  for  phleg- 
monous erysipelas,  for  acute  cellulitis,  or  for 
typhoid  fever.  The  only  malady  with  which 
acute  periostitis  need  be  confounded  is  an 
idiopathic  inflammation  of  the  deep-seated 
cellular  tissue  in  a limb.  This  disease  is  rare. 
When  we  observe  the  chain  of  symptoms  above 
described  in  a young  person,  we  mav  safely 
assume  the  presence  of  an  acute  osteoperiostitis. 
The  disease  almost  invariably  terminates  in 
suppuration  and  necrosis ; resolution  happens 
rarely,  but  necrosis  is  not  inevitable,  even  after 
suppuration.  In  a few  cases,  especially  in  young 
children,  if  the  matter  be  speedily  evacuated,  tLe 
abscess  collapses,  the  periosteum  reunites  wilh 
the  bone,  and  no  necrosis  takes  place.  This 
result  is  unfortunately  quite  exceptional. 

Prognosis. — This  must  be  founded  on  the 


BONE,  DISEASES  OF. 


latent  of  the  necrosis ; whether  blood-poison- 
ing has  taken  place ; and  whether  the  adjacent 
joints  are  implicated  in  the  disease.  Cure  cannot 
take  place  until  the  dead  hone  is  cast  off  or 
removed,  and  this  is  often  long  delayed.  The 
usefulness  of  a limb  may  be  permanently  impaired 
by  the  disease,  or  it  may  require  amputation,  or 
the  patient  may  lose  his  life  altogether.  On  the 
other  hand,  the  use  of  the  limb,  and  the  health 
of  the  patient,  may  become  completely  re- 
established. 

Treatment. — Early  and  energetic  treatment  is 
of  the  greatest  importance,  as  it  affords  the  best 
prospect  of  averting  the  disastrous  consequences  of 
acute  periostitis,  but  in  hospital  practice  the  cases 
are  rarely  seen  sufficiently  early.  In  the  first 
stage  the  limb  should  be  elevated,  and  ice  applied ; 
painting  the  limb  with  a strong  solution  of  iodine 
is  advisable.  As  soon  as  the  nature  of  the  affec- 
tion is  manifest,  incisions  down  to  the  bone,  so 
as  to  divide  the  periosteum,  are  indicated  even 
before  pus  is  formed.  They  relieve  pain  and 
tension, and, by  permitting  the  timely  escape  of  pus 
as  soon  as  it  does  form,  the  amount  of  perios- 
teal separation,  and  consequently  of  necrosis,  is 
limited.  It  is  the  more  important  to  make  an 
early  incision,  because  evidence  of  fluctuation  is 
at  first  by  no  means  clear  or  easy  to  make  out, 
and  this  should,  therefore,  be  done  in  all  cases 
of  doubt.  Antiseptic  precautions  should  always 
be  taken.  Sometimes  the  abscess-cavity  does 
not  readily  collapse,  owing  to  its  walls  being 
stiff  and  infiltrated,  and  its  contents  may  become 
putrid,  thus  greatly  increasing  the  patient’s 
risks.  If  there  be  synovial  effusion  into  a 
neighbouring  joint,  the  limb  should  be  kept  at 
rest  by  means  of  a splint  or  a fixed  bandage. 
When  the  acute  symptoms  subside,  the  abscess- 
cavity  contracts,  one  or  more  sinuses  remain,  and 
the  dead  bone  begins  to  separate  ( see  Necrosis). 

Where  the  epiphysis  is  engaged  in  the  disease 
the  case  is  more  urgent ; the  fever  runs  higher, 
the  suppuration  is  greater,  and  the  degree  of 
joint-implication  more  intense,  proceeding  in  ex- 
treme cases  to  suppurative  inflammation  and 
destruction  of  the  articulation.  The  oedema  of 
the  limb  often  indicates  a deep-seated  phlebitis, 
the  precursor  of  septic  poisoning.  Under  these 
circumstances,  amputation  of  the  limb  is  often 
the  only  resource.  It  is  imperative  to  amputate 
where  there  is  extensive  bone-destruction,  and 
the  symptoms  indicate  commencing  pyaemia  ; or 
where,  with  the  death  of  a large  portion  of  the 
shaft,  one  or  both  of  the  neighbouring  joints  has 
become  gravely  implicated,  and  great  suffering 
and  loss  of  strength  forbid  us  to  temporise.  It 
is  precisely  in  these  cases,  however,  where  the 
diaphvsis  has  become  necrosed  up  to  the  epiphy- 
sal  junction,  that  good  results  are  attainable  by 
the  immediate  extraction  of  tho  dead  hone.  The 
shaft  where  it  joins  the  epiphysis  becomes  ra- 
pidly detached  and  loose,  and  may  easily  he 
separated,  while  the  bone  can  he  divided  with  a 
chain  saw  beyond  the  limit  of  the  necrosis  in 
the  other  direction,  and  removed.  It  is  difficult, 
however,  in  the  early  stages  to  diagnose  the 
extent  of  the  necrosis.  Where  the  joints  both 
above  and  below  are  involved,  amputation  is 
usually  necessary. 

A periostitis  of  a very  acute  form,  almost 


125 

invariably  suppurating,  and  accompanied  by 
necrosis,  is  very  common  in  the  fingers,  where  it 
chiefly  affects  the  ungual  phalanges!  The  pain 
is  very  great,  hut  may  be  relieved  by  an  earlv 
and  free  incision  down  to  the  bone,  which,  never- 
theless, does  not  usually  avert  either  suppuratioi 
or  necrosis. 

( b ) Chronic  'periostitis  is  usually  due  to  some 
diathetic  cause,  but  may  result  from  injury,  or 
from  some  continuous  pressure.  It  is  most  fre- 
quent on  the  superficial  parts  of  the  skeleton,  as 
the  tibia,  clavicle,  skull,  and  ribs,  but  may  affect 
any  bone  ; and  it  is  often  observed  at  the  origin 
or  insertion  of  muscles.  When  the  disease  arises 
from  a general  cause,  such  as  syphilis,  many 
parts  of  the  skeleton  are  affected ; when  from  a 
local  cause,  usually  only  one. 

Symptoms.  — Chronic  periostitis  generally 
takes  tho  form  of  what  is  called  a node — a 
tender,  more  or  less  painful,  rounded  or  oval 
swelling ; at  first  tense  and  hard,  afterwards 
softer,  or  even  fluctuating.  The  pain  is 
much  greater  at  the  outset,  from  the  tension  of 
the  parts  involved,  and  is  general^  worse  at 
night.  Subsequently  the  swelling  becomes  in- 
dolent, and  painless,  unless  pressed  upon.  Nodes 
are  due  to  a localised  inflammation.  The  cambium- 
layer  of  the  periosteum  and  its  external  layer 
proliferate  and  become  filled  with  leucocytes, 
thus  forming  a well-marked  projection  on  the 
hone,  which  may  undergo  resolution,  suppurate, 
or  ossify,  according  to  circumstances. 

Prognosis. — In  chronic  periostitis  this  is  usu- 
ally favourable.  Under  the  influence  of  early  and 
suitable  treatment,  the  inflammatory  products 
are  completely  absorbed,  and  the  hone  resumes 
its  natural  shape.  If  the  chronic  inflammation 
of  the  periosteum  he  permitted  to  proceed  un- 
checked, a deposit  of  new  osseous  lamellae  usually 
takes  place  on  the  surface  of  the  affected  bone, 
giving  rise  to  permanent  thickenings,  or  even  to 
osteophytic  growths.  These  are  composed  of 
light  porous  bone,  with  a rough  surface.  The 
skeleton  of  a syphilitic  subject  will  often  present 
numerous  thickenings  of  this  nature.  On  making 
a section  of  the  hone,  it  is  easy  to  see  that  the 
new  hone  is  superimposed  upon  the  old,  and  is 
formed  by  the  periosteum. 

Treatment — When  due  to  a local  cause,  the 
swelling  will  often  spontaneously  subside  with 
rest  to  the  part,  hut  in  obstinate  cases  iodide  of 
potassium  internally,  and  iodine  ointment  or 
blistering  externally,  may  be  required.  If  the 
subject  be  unhealthy,  or  if  the  original  injurvbe 
considerable,  suppuration  may  take  place,  t&en 
the  treatment  will  be  that  of  an  inflammatory 
abscess.  Syphilitic  nodes,  which  are  a very 
common  expression  of  chronic  periostitis,  yield 
rapidly  to  the  influence  of  iodide  of  potassium, 
which  in  some  cases  may  usefully  be  combined 
with  a mercurial  course.  Blistering  or  friction 
externally  is  hurtful  in  such  cases.  Syphilitic 
nodes  are  not  at  first  prone  to  suppuration,  and 
even  when  they  become  soft  and  fluctuating,  and 
the  skin  reddens  over  them,  they  should  not  he 
mistaken  for  abscesses,  as  they  readily  become 
absorbed  under  suitable  treatment. 

(c)  Periostitis  after  typhoid  fever. — A peculiar 
form  of  chronic  periostitis  is  occasionally  observed 
as  a sequel  to  typhoid  fever.  It  occurs  during 


BONE,  DISEASES  OF. 


125 

convalescence,  and  without  general  symptoms.  It 
takes  the  form  of  hot,  painful,  and  tender  nodes, 
frequently  symmetrical,  and  often  placed  on  the 
Libia ; the  disease  is  also  found  on  the  ribs  and 
other  bones.  It  may  be  associated  with  necrosis, 
but  if  so  the  extent  of  the  dead  bone  is  small  in 
proportion  to  the  inflamed  area  of  periosteum. 
The  general  health  is  not  seriously  affected,  and 
the  disease  is  very  amenable  to  treatment  by 
iodide  of  potassium,  combined  with  iodide  of  iron. 

B.  Osteitis  is  an  inflammation  chiefly  affect- 
ing the  bone-substance;  this  form  may  also  be 
acute  or  chronic. 

(a)  Acute  osteitis  is  neither  clinically  nor  patho- 
logically to  be  distinguished  from  acute  osteo- 
myelitis or  endostitis  {see  Osteomyelitis). 

(b)  Chronic  osteitis  is  a disease  beginning  in  the 
bone,  in  which  the  chief  changes  from  first  to  last 
occur,  the  periosteum  being  secondarily  engaged. 
This  affection  may  result  from  injury,  or  be  ex- 
cited by  exposure  to  cold  ; but  it  often  depends 
on  constitutional  predisposition,  such  as  the 
syphilitic,  the  strumous,  the  gouty,  or  the  rheu- 
matic diathesis,  the  first  being  the  most  frequent 
cause.  It  may  occur  in  any  part  of  the  skeleton  ; 
the  chief  changes,  when  produced  by  syphilis, 
ocetir  -in  the  shafts  of  the  long  bones.  They  con- 
sist mainly  of  hypertrophy,  and  the  bone  is  ulti- 
mately increased  in  thickness,  in  length,  and 
generally  in  density : its  interior  is  often  trans- 
formed into  dense  bone-tissue,  and  the  medullary 
cavity  is  obliterated.  Another  form,  associated 
with  the  strumous  diathesis,  is  generally  seated 
iii  the  joint-ends  of  the  long  bones,  and  in  the 
spongy  bones.  It  is  prone  to  end  in  suppura- 
tion, accompanied  by  either  caries  or  necrosis. 
The  gouty  and  rheumatic  forms  are  associated 
with  evidence  of  the  presence  of  either  of  these 
diatheses. 

Pathology. — Increased  vascularity  first  takes 
place,  the  Haversian  canals  enlarge,  the  canali- 
euli  disappear,  the  cancelli  enlarge  to  con- 
tain the  inflammation-products,  and  the  earthy 
matter  diminishes ; hence  the  inflamed  bone 
softens,  and,  if  macerated  at  this  stage,  will  be 
found  comparatively  light  and  porous.  When  the 
inflammation  affects  the  superficial  laminae  of 
the  bone,  the  periosteum  becomes  thick  and 
vascular ; if  the  deeper  parts  are  involved,  simi- 
lar changes  will  occur  in  the  endosteum.  The 
porous  condition  of  the  bone  may  become 
permanent,  when  the  condition  is  called 
osteoporosis,  the  result  of  so-called  rarefying 
ostitis ; or  the  granulations  become  transformed 
into  new  bone,  and  the  cancellated  structure  is 
filled  with  osseous  deposit,  so  that  the  whole  of 
the  inflamed  area  becomes  very  dense,  and  is 
then  said  to  be  sclerosed ; or  the  inflammation- 
process  may  terminate  in  suppuration,  followed 
by  caries,  necrosis,  or  an  abscess  of  the  bone, 
which  last  may  be  either  diffused  or  circum- 
scribed. 

Symptoms. — These  are  insidious,  very  obscure 
at  the  outset,  and  may  be  mistaken  for  those 
of  chronic  rheumatism,  or  mere  periostitis.  They 
consist  chiefly  in  aching,  gnawing  pain  in  the 
affected  bone,  with  characteristic  remissions  and 
nocturnal  exacerbations.  The  bone  is  tender  on 
pressure,  and  feels  increased  in  bulk  at  first, 
from  the  infiltration  of  the  immediately  sur- 


rounding soft  tissues ; subsequently  the  bone 
itself  enlarges.  There  is  often  increase  of  heat 
in  the  limb.  The  progress  is  very  chronic,  and 
if  unchecked  by  treatment  may  give  rise  to  con- 
siderable deformity. 

Treatment. — This  should  be  directed  to  the 
cause  of  the  disease.  If  this  be  syphilis,  an 
antisyphilitic  treatment  will  be  followed  by 
good  results  ; even  in  chronic  bone-inflammation, 
not  dependent  on  syphilis,  iodide  of  potas- 
sium is  often  of  great  service.  Local  counter- 
irritation  may  also  be  employed.  Often  the 
cause  cannot  be  made  out,  and  if  iodide  of 
potassium  fail  in  producing  an  effect,  we  must 
fall  back  on  general  treatment.  In  the  early 
subacute  stage,  rest,  with  elevation  of  the  affected 
part,  is  very  desirable.  Warm  fomentations,  fol- 
lowed by  iced  compresses,  relieve  the  suffering. 
If  there  be  much  pain  and  tension,  leeches  should 
be  applied.  Puncturing  the  tissues  down  to 
the  inflamed  bone  with  a tenotomy  knife  or  fine 
bistoury,  relieves  the  tense  periosteum,  and 
allows  extravasation  beneath  it  to  escape,  so 
that  the  pain  is  promptly  abated. 

(c)  Osteitis  deformans. — A peculiar  form  of 
chronic  inflammation  cf  bone  has  been  described 
by  Sir  James  Paget  under  this  title,  from  the 
changes  it  produces,  both  in  the  form  and  density 
of  the  affected  bones.  It  is  a chronic  osteitis 
of  the  most  extreme  type.  It  begins  in  middle 
age,  and  may  continue  for  an  indefinite  time 
without  influence  upon  the  general  health, 
which  distinguishes  it  clinically  from  other 
bone-inflammations.  It  is  usually  symmetrical, 
and  affects  chiefly  the  long  bones  of  the  lower 
extremity  and  the  skull.  At  first  the  bones 
enlarge  and  soften,  from  excessive  produc- 
tion of  imperfectly-developed  structure  and  in- 
creased blood-supply,  and,  yielding  to  the  weight 
of  the  body,  become  curved  and  misshapen,  but 
the  limbs,  although  deformed,  remain  strong  and 
fitted  to  support  the  body.  In  its  early  period, 
and  sometimes  throughout  its  course,  the  disease 
is  attended  with  pains  in  the  affected  bones, 
which  vary  widely  in  severity,  and  are  not 
especially  nocturnal  or  periodic.  It  is  not  at- 
tended by  fever,  nor  associated  with  any  consti- 
tutional disease.  It  differs  from  the  chronic 
osteitis  dependent  on  simple  inflammation  of  bone 
or  that  produced  by  gout  or  syphilis,  in  affecting 
the  whole  length  of  the  bone.  Hyperostosis  and 
osteoporosis  dependent  on  these  latter  causes 
rarely  affect  the  entire  bone.  No  treatment 
appears  to  produce  any  effect  upon  this  disease. 

C.  Osteo-myelitis  is  an  inflammation  chiefly 
affecting  the  interior  structure  of  the  bone.  Like 
the  former,  it  may  be  acute  or  chronic. 

(a)  Acute  osteomyelitis  or  endostitis  is  a sup- 
purative inflammation  of  the  medulla  and  bone, 
which  very  frequently  ends  in  septic  poisoning 
and  necrosis.  It  is  nearly  always  associated  with 
bone-injury,  and  most  frequently  happens  after 
amputation,  or  gunshot  fractures,  in  which  the 
cancellated  structure  is  injured ; a severe  contu- 
sion of  the  bone,  an  injury  to  the  periosteum, 
or  exposure  to  sudden  extremes  of  heat  and  cold 
is  capable,  under  some  circumstances,  of  produc- 
ing the  disease. 

Symptoms. — The  symptoms  are  obscure,  more 
especially  if  there  be  no  opportunity  of  examining 


BONE,  DISEASES  OF.  127 


the  affected  hot  e,  as  the  changes  in  the  bone  are 
often  masked  by  inflammation  of  the  superficial 
parts.  They  usually  make  their  appearance 
from  five  to  ten  days  after  the  injury  to  the  bone. 
The  pain  may  not  be  excessive  ; there  is  fever 
and  perhaps  rigor.  If  there  be  a -wound  the 
secretion  from  it  diminishes  in  quantity’,  and  be- 
comes less  healthy;  the  medulla  protrudes  from  its 
central  cavity  ; the  parts  soon  become  surrounded 
by  putrescent  fluid ; and  the  symptoms  become 
those  of  more  or  less  intense  septiesmia.  The 
periosteum  sometimes,  but  not  always,  separates 
from  the  bone.  In  young  persons  the  disease 
is  sometimes  arrested  at  the  epiphysis  ; but  in 
the  adult  the  whole  length  of  the  bone  is  liable 
to  be  affected.  The  risk  of  septic  poisoning  is 
infinitely  greater  in  osteomyelitis  that  in  osteo- 
periostitis. Thrombosis  of  the  bone-veins  is 
especially  prone  to  happen,  and  by  the  breaking 
down  of  the  clot  septic  emboli  are  carried  into 
the  circulation,  and  deposited  in  the  liver,  lungs, 
and  elsewhere.  It  is  in  this  disease,  too,  that 
fatty  embolism  takes  place— a condition  associ- 
ated with  a very  acute  and  fatal  form  of  blood- 
poisoning.  The  prognosis  is  generally  bad.  It 
is  impossible  to  distinguish  acute  osteomyelitis 
from  acute  osteo-periostitis,  arising  from  non- 
traumatic  causes.  In  military  hospitals,  in  war 
time,  acute  osteo-myelitis  is  often  epidemic. 

Treatment. — Where  the  symptoms  lead  us  to 
suspect  osteomyelitis,  although  the  medullary 
cavity  of  the  bone  may  not  have  been  exposed, 
it  may  be  desirable  to  trephine  the  bone,  and  if 
suppuration  in  its  interior  be  discovered,  it  will 
be  necessary  to  amputate,  and  as  soon  as  the 
nature  of  the  disease  is  recognised,  this  affords 
the  best  chance  of  saving  the  patient's  life. 
The  chief  difficulty  consists  in  arriving  at  a 
correct  diagnosis  and  deciding  when  it  becomes 
necessary  to  interfere.  This  may  best  be  done 
by  observing  the  general  progress  of  the  case  ; 
and  locally  by  the  introduction  of  a probe  into 
the  medullary  cavity  when  this  is  exposed. 
If  it  reach  healthy  bleeding  medulla  near  the 
surface,  we  may  temporise,  if  the  constitutional 
symptoms  admit  of  this;  but  it  is  rare  for  the 
disease  once  commenced  to  be  limited — it  has 
an  extreme  tendency  to  become  diffused.  Ex- 
perience shows  that  nothing  short  of  amputa- 
tion at,  or  even  above,  the  next  joint  is  sufficient 
to  arrest  the  consequences  of  the  malady,  and 
this  must  be  done  before  the  systemic  poisoning 
has  become  marked.  Amputation  in  the  con- 
tinuity of  tile  affected  bone  is  worse  than  use- 
less. 

(6)  Chronic  osteomyelitis  is  an  obscure  affec- 
tion, not  to  be  distinguished,  either  clinically  or 
pathologically,  from  chronic  ostitis.  It  may  ter- 
minate in  sclerosis,  or  in  the  formation  of  an 
abscess.  See  Chronic  Osteitis. 

2.  Abscess. — This  is  a term  applied  usually 
to  a limited  suppuration  in  the  bone,  unattended 
by  necrosis.  Young  adults  are  most  prone  to 
the  disease,  or  boys  about  the  age  of  puberty ; it 
is  very  rare  in  women.  It  is  the  result  of  a 
chronic  inflammation  of  bone,  which  maybe  asso- 
ciated with  some  injury.  This  affection  is  most 
frequently  met  with  in  the  upper  or  lower  ex- 
tremities of  the  tibia,  just  external  to  the  epi- 
physal  cartilage,  less  frequently  in  the  ends  of 


the  femur,  only  occasionally  in  other  bones,  and 
very  seldom  in  the  compact  tissue  anywhere. 

Symptoms. — A circumscribed,  slightly  elevated, 
very  tender  and  painful  swelling  may’  be  dis- 
covered. This  is  due  to  a local  periostitis  with 
new  bone-deposit,  and  the  bone  itself  is  often 
half  an  inch  or  an  inch  longer  than  its  fellow, 
by  reason  of  increased  activity  of  growth  at  the 
epiphysis.  The  skin  and  superficial  parts  are  un- 
changed at  first,  or  there  maybe  but  trifling  sub- 
cutaneous cedema.  There  is  often  slight  local  in- 
crease of  temperature.  The  pain,  on  deep  pressure 
at  the  central  point,  is  often  intolerable.  It  is 
intermittent  at  first,  but  generally  worse  at  night. 
After  a time  it  becomes  continuous,  and  deprives 
the  patient  of  all  rest,  owing  to  its  severity’. 
The  abscess  may  persist  with  little  change  for 
months  or  years.  The  symptoms  generally 
resemble  those  of  osteitis,  from  which  at  the 
outset  it  is  difficult  to  distinguish  this  affection. 
When  the  abscess  tends  to  reach  the  periosteal 
surface,  the  soft  parts  become  engaged,  and 
there  will  be  slight  redness  and  oedema  of  the 
skin.  Barely  the  pus  makes  its  way  into  the 
adjacent  articulation,  in  which  it  sets  up  destruc- 
tive inflammation  ; but  usually  the  joints  are 
free  from  implication.  The  subjects  of  the 
disorder  have  often  suffered  from  antecedent 
bone-disease.  Evidence  of  this  should  be  looked 
for,  as  giving  a clue  to  the  diagnosis. 

Treatment. — Spontaneous  cure  cannot  occur 
— even  if  the  abscess  discharge  itself,  a perma- 
nent fistula  will  usually  remain.  It  is  necessary 
freely  to  lay  open  the  abscess-cavity.  A crucial 
incision  must  be  made  through  the  soft  parts, 
down  to  the  bone,  at  the  most  tender  and  pro- 
minent point,  and  a disc  of  bone  removed  by  the 
bone- trephine — an  instrument  without  a shoul- 
der, about  half-an-inch  in  diameter.  The  sudden 
loss  of  resistance  indicates  the  piercing  of  the 
abscess-cavity.  The  lay’er  of  granulation-tissue 
lining  its  interior  should  not  be  interfered  with, 
but  the  cavity  simply  washed  out.  The  pus  is 
often  foul,  and  greenish  in  colour.  The  wound 
should  be  dressed  antiseptically ; granulations 
presently  fill  it.  which  are  subsequently  trans- 
formed into  a fibrous  cicatrix.  Immediate  and 
permanent  relief  follows  the  operation.  If  the 
abscess  is  missed,  the  trephine  may  be  re-ap- 
plied, or  drill  punctures  made  in  the  most 
likely  directions  in  the  adjacent  bone,  in  order  to 
discover  the  pus.  Somet  imes  an  error  of  diagnosis 
is  committed,  and  the  symptoms  are  found  to 
arise  from  chronic  osteitis,  without  suppuration. 
The  operation,  however,  affords  relief  in  these 
cases  also.  Where  there  is  doubt,  a preliminary 
course  of  iodide  of  potassium  will  often  re- 
solve it. 

3.  Caries  is  a form  of  chronic  inflammation  of 
bone,  which  has  been  likened  to  the  process  of  ul- 
ceration in  the  soft  tissues.  It  is  generally  found 
in  the  spongy  bones,  in  any  part  of  the  skeleton, 
the  vertebrae  and  tarsus  being  the  parts  most 
commonly  affected.  There  are  two  forms  of  the 
disease — one,  simple  caries,  resembles  an  indo- 
lent ulcer  of  the  soft  parts,  is  most  common  in 
the  fat  or  short  bones,  but  is  sometimes  met 
with  in  the  compact  tissue  of  long  bones ; the 
other,  fungating  caries,  is  often  met  with  in  the 
articular  ends  of  the  long  bones,  and  usually 


BONE,  DISEASES  OF. 


128 

terminates  in  joint-disorganisation.  It  has  been 
called  subarticular  caries-,  and  is  part  of  the  dis- 
order known  as  tumor  dibus  (see  Joists,  Diseases 
of).  The  non-articular  form  of  simple  caries  often 
originates  in  a localised  periostitis,  and  is  gene- 
rally due  either  to  syphilis  or  struma — the  latter 
is  most  frequent  in  young  persons,  the  former  in 
adults. 

Pathology. — In  caries  the  bone  gradually  dis- 
integrates as  the  result  of  a chronic  inflammation 
of  its  cancellated  tissue.  The  trabeculae  become  in- 
filtrated with  leucocytes,  and  granulations  form, 
which  prove  the  source  of  purulent  discharge, 
just  as  in  a granulating  surface  of  the  soft  parts  ; 
but  the  process  is  interfered  with  and  delayed 
by  the  act  of  getting  rid  of  the  osseous  struc- 
ture, in  the  trabeculae  of  which  the  cells  remain 
shut  up  until  the  dead  bone  finally  breaks 
down,  and  comes  away  in  the  discharges,  being 
often  distinguished  in  the  form  of  gritty  par- 
ticles. Until  this  process  is  completed  the  dead 
bone  is  soaked  in  pus,  which  often  becomes 
putrid,  and  until  it  is  got  rid  of  a healthy  granu- 
lation-surface is  impossible. 

Symptoms. — Caries  is  very  chronic  in  its  pro- 
gress, and  often  causes  extensive  loss  of  bone, 
destruction  of  a joint,  or  loss  of  a limb.  It  is 
almost  always  associated  with  an  impaired  con- 
dition of  general  health  : the  adjacent  soft  parts 
are  involved  in  the  inflammation  ; abscesses  form 
in  them,  generally  connected  with  the  diseased 
bone ; these  burst  or  are  opened,  and  sinuses  lined 
with  gelatiniform  granulations,  and  discharging 
a thin  pus,  persist  for  an  indefinite  time.  On 
examination  with  the  probe  the  surface  of  the 
bone  is  felt  bare,  rough,  and  much  softened; 
and  outside  the  area  of  carious  bone  periosteal 
deposits  of  newly-formed  osseous  tissue  are  often 
found.  The  diagnosis  and  prognosis  depend  upon 
the  age,  constitutional  condition,  and  history 
of  the  patient,  as  much  as  on  the  local  signs. 

Treatment, — This  must  be  directed  to  relieve 
the  constitutional  taint,  as  well  as  the  local 
disease.  Merely  to  excise  or  destroy  the  diseased 
portion  of  bone  is  not  sufficient  to  cure  the 
patient.  Local  means  prove  efficient  only  when 
the  general  condition  has  been  sufficiently  ame- 
liorated, especially  in  the  unhealthy  chronie  in- 
flammation of  bone  frequently  called  strumous. 
Good  air,  good  food,  and  tonics  are,  therefore, 
of  great  importance.  If  syphilis  be  present,  an 
anti-syphilitic  treatment  must  be  pursued.  The 
principle  by  which  the  local  moans  act  is  to 
facilitate  the  formation  of  a healthy  granulating 
surface — to  transform,  in  fact,  an  indolent  into  a 
healing  ulcer.  The  disintegration  of  the  dead 
and  diseased  trabeculae  must  be  assisted.  For 
this  purpose  the  application  of  strong  sulphuric 
acid  diluted  by  two  or  three  parts  of  water,  or 
some  other  mineral  acid,  often  piroves  useful. 
Partial  gouging  out  of  the  diseased  bone  seldom 
succeeds,  because  of  the  injury  done  by  the  in- 
strument to  the  adjacent  bone,  weakened  as  it  is 
by  inflammatory  changes,  and  therefore  prone  to 
set  up  fresh  disease.  The  complete  evidemcnt 
of  the  bone,  leaving  nothing  but  its  thin  outer 
shell,  is  more  successful ; but  when  the  disease 
begins  to  invade  adjacent  joints,  as  in  the  tarsus, 
excision  of  the  entire  bone  is  best ; or  when 
several  bones  are  involved,  amputation  becomes 


necessary.  In  children  operations  of  this  kind  art 
not  so  often  required;  general  treatment  usually 
proves  sufficient.  In  the  early  stages  the  actual 
cautery,  applied  over  the  most  painful  spot,  is  a 
valuable  counter-irritant.  It  is  undesirable  to 
make  early  incisions  into  strumous  abscesses  in 
connection  with  diseased  bone.  It  is  better  to 
empty  them  by  a small  trochar,  and  to  preserve 
the  diseased  area  as  long  as  possible  from  atmo- 
spheric influence.  When  the  carious  action  is 
arrested,  the  cavity  fills  with  healthy  granulations, 
the  sinuses  close,  the  parts  cicatrise,  and  the  gap 
in  the  osseous  tissue  is  filled  by  fibrous,  or  some- 
times by  osseous  material. 

4.  Necrosis. — The  complete  arrest  of  nutri- 
tion in  a portion  of  bone  from  any  cause  is  fol- 
lowed by  the  death  or  necrosis  of  the  bone,  and 
by  a series  of  inflammatory  changes  in  the  ad- 
jacent parts,  which  result  in  the  complete  separa- 
tion of  the  dead  from  the  living  tissue. 

/Etiology. — Necrosis  is  most  frequently  tho 
resultof  acutebone-inflammation  or  severe  injury, 
as  after  amputation,  fracture,  or  contusion.  It  is 
especially  prone  to  happen  in  the  compact  tissue, 
but  it  also  occurs  in  the  spongy  structure,  as  the 
joint-ends  of  long  bones,  or  the  tarsus  and  car- 
pus, where  it  is  usually  associated  with  more 
chronic  forms  of  inflammation,  and  is  more 
limited.  Tho  peculiar  nature  of  the  blood-supply 
to  bone,  and  the  facility  with  which  it  may  be 
interfered  with  or  arrested  under  the  pressure 
of  inflammatory  changes,  go  far  to  explain  the 
frequency  of  necrosis  as  a result  of  bone-inflam- 
mation. Acute  suppurative  osteoperiostitis  or 
osteomyelitis  rarely  terminates  without  necrosis. 
Whether  the  dead  bone  will  be  in  the  superficial 
or  the  deep  lamellae  depends  on  the  seat  of  the  in- 
flammation, and  on  the  extent  to  which  the  perios- 
teum and  endosteum  are  respectively  implicated. 
The  long-continued  action  of  phosphorus,  a3 
observed  in  match-makers,  and  also  of  mercury, 
may  induce  necrosis.  Syphilis  is  a frequent  cause 
of  necrosis,  through  its  tendency  to  produce 
chronic  osteoperiostitis,  the  sclerosed  bone  thus 
originated  being  afterwads  prone  to  necrose.  It 
is  not  an  uncommon  sequel  during  convalescence 
from  some  eruptive  and  continued  fevers.  After 
scarlatina,  osteoperiostitis,  followed  by  necrosis, 
is  by  no  means  rare,  although  affections  of  the 
joints  are  more  common.  It  is  probable  that 
many  cases  of  necrosis  occurring  in  childhood  are 
connected  with  an  antecedent  attack  of  scarlet 
fever.  The  nasal  bones  may  necrose  as  the 
result  of  severe  coryza,  the  vertebrae  after 
pharyngitis,  or  the  petrous  portion  of  the  tem 
poral  bone  as  a consequence  of  otitis.  Arterial 
thrombosis  and  embolism  are  occasional  sequelae 
of  typhus,  and  may  produce  a local  gangrene, 
not  only  of  the  soft  parts,  but  of  bone.  This 
is,  however,  more  frequent  in  connection  with 
typhoid  fever.  In  endocarditis  the  nutrient  artery 
of  a bone  has  been  observed  to  be  obliterated 
by  an  embolus,  thus  producing  necrosis. 

Pathology  —After  the  death  of  a piortion  of 
bone,  the  living  tissue,  in  immediate  contact  with 
the  dead,  becomes  inflamed.  The  Haversian  canals 
and  canaliculi  become  distended  with  migratory 
cells  ; loops  of  capillaries  form  from  the  pre- 
existing vessels ; a granulating  surface,  in  fact, 
surrounds  the  dead  bone  in  a manner  precisely 


BONE,  DISEASES  OF. 


similar  to -what  takes  place  in  the  soft  parts  when  ! 
a slough  is  being  thrown  off.  The  periosteum 
separates  from  the  bone,  becomes  thick  and 
vascular,  while  the  osseous  surface  beneath  is 
smooth  and  white,  like  macerated  bone.  In  cases 
of  syphilitic  necrosis,  as  well  as  in  that  result- 
ing from  phosphorus,  the  surface  is  rough  from 
antecedent  periosteal  deposit.  How  the  osseous 
t rabeculse  are  dissolved  or  disintegrated  over 
the  surface  of  separation,  so  as  to  loosen  the 
dead  bone,  is  not  certain.  Probably  the  granu- 
1 ition-tissue  that  forms  from  the  living  bone 
possesses  amoeboid  properties,  and  thus  disposes 
of  some  of  the  bone-particles.  The  pus  that  is 
formed  has  a mechanical  influence,  while  accord- 
ing to  one  theory  lactic  acid  is  produced,  which 
transforms  the  insoluble  into  soluble  salts  of 
lime.  Whilo  this  loosening  process  is  going  on 
new  bone,  formed  chiefly  from  the  periosteum,  is 
being  deposited,  constantly  becoming  thicker,  and 
with  one  or  more  openings  in  it  for  the  escape 
of  pus,  called  cloaca,  so  that  eventually  the  dead 
piece  becomes  completely  invaginated,  and  is 
named,  from  its  position,  a sequestrum.  This 
sequestration  of  the  dead  bone  is  not  invariable, 
as  for  instance  in  the  spongy  bones,  the  bones  of 
the  skull,  and  the  upper  jaw,  or  where  from  any 
cause  the  periosteum  has  been  destroyed,  no 
sheath  of  new  bone  will  be  formed.  Necrosis 
very  rarely  takes  placewithout  suppuration  ; when 
this  does  happen  the  nature  of  the  case  is  very 
obscure.  Occasionally  nearly  the  whole  shaft  of 
a long  bone  has  been  found  necrosed,  and  after 
an  interval  of  months  or  even  years  no  suppu- 
ration may  have  taken  place.  Such  forms  of 
necrosis  closely  simulate  malignant  disease,  and 
often  they  cannot  be  relieved  or  even  recognised 
save  after  amputation.  A chronic  ostitis,  fol- 
lowed by  hypertrophy  and  sclerosis  of  tho  bone, 
is  the  most  common  antecedent  condition  of  this 
form  of  necrosis. 

Treatment. — The  changes  already  described, 
which  separate  the  dead  bone  from  the  living, 
do  not  cause  its  expulsion  from  the  body.  On  the 
contrary,  they  shut  it  up,  like  a kernel  within 
its  shell,  and  nothing  so  imperatively  demands 
surgical  interference  as  the  presence  of  necrosed 
bone.  It  acts  as  a foreign  body,  is  a constant 
source  of  risk  to  the  patient,  and  should  be  re- 
moved as  soon  as  practicable.  Its  presence  ex- 
cites the  periosteum  to  further  formation  of  bone, 
so  that  the  invaginating  sheath  becomes  of  great 
thickness  in  old-standiug  cases.  The  period  at 
which  an  operation  is  usually  undertaken  is  when 
the  sequestrum  has  become  loose,  and  the  time 
required  for  this  purpose  varies  with  the  extent 
and.  thickness  of  the  necrosed  bone.  In  the 
actively  growing  bones  of  tho  young  tho  process 
of  separation  is  accomplished  more  quickly  than 
in  tho  adult,  especially  when  the  sequestrum  in- 
volves the  epiphysal  junction.  Roughly  esti- 
mated, a period  of  from  three  to  six  months  might 
be  named  as  that  within  which  loosening  of  the 
eequestrum  usually  occurs.  Beyond  the  latter 
term  an  effort  to  extract  the  dead  bone  should 
not  be  delayed,  even  if  it  cannot  be  felt  to  be 
loose.  Among  other  risks  involved  in  doing  so 
may  be  that  of  amyloid  degeneration  of  the 
viscera,  principally  the  liver,  kidneys,  and  spleen, 
which  are  subject  to  this  change  as  the  conse- 
9 


12D 

I quenceof  long- continued  discharge  from  bone- 
disease.  In  order  to  remove  a sequestrum,  a 
director  should  first  be  introduced  through  a 
cloaca  as  a guide,  and  the  soft  parts  sufficiently 
divided.  An  adequately  large  opening  must  now 
be  made  in  the  encasing  sheath  of  new  bone  with 
the  chisel,  trephine,  small  saw,  or  cutting  for- 
ceps, and  the  dead  bone  extracted,  either  in  one 
or  several  pieces,  as  may  be  the  more  convenient 
The  operation  may  prove  difficult  on  account  of 
great  thickness  of  the  soft  parts  or  of  theseques- 
tral  envelope,  or  because  the  sequestrum  itself  ix 
extensive.  After  the  removal  of  the  dead  bone 
the  cavity  fills  with  granulations,  which  subse- 
quently ossify,  and  the  softpartscicatrise.  Finally 
the  sequestral  envelope  of  new  bone  is  partly 
absorbed,  partly  consolidated,  just  as  the  redun- 
dant callus  is  after  fracture,  and  the  bone  tends 
more  or  less  to  resume  its  normal  size  and  shape. 

5.  Tubercle. — An  examination  of  some  cases 
of  chronic  bone-disease  in  scrofulous  subjects 
seems  to  prove  their  connection  with  the  forma- 
tion of  tubercle  in  the  bone.  The  medullary  tissue 
in  the  joint-ends  of  the  long  bones,  and  cancel- 
lated bone  generally,  are  chiefly  affected.  The  ex- 
ternal appearances  are  those  of  fungating  caries  ; 
but  microscopical  examination  discloses  multi- 
tudes of  round  cells  like  lymph-corpuscles,  with 
protoplasmic  matter,  filling  up  the  interspaces. 
The  cells  are  found  surrounding  thesoft,  gray,  non- 
vascular  patches,  which  are  often  seen  on  section 
of  an  inflamed  cancellated  bone  instrumous  indivi- 
duals, the  central  part  of  which  maybe  the  sub- 
ject of  calcareous,  fatty,  or  suppurative  changes. 
The  bone  when  so  affected  is  never  sclerosed ; 
hence  these  are  not  simply  cases  of  chronic  inflam- 
mation. There  is,  however,  some  difference  of 
opinion  as  to  whother,  in  strictness,  .they  should 
be  called  tubercular  in  their  nature,  and  the 
inference  that  they  are  so  rests  rather  on  the 
general  condition  of  the  patient  than  on  any 
purely  local  characteristic. 

Treatment. — In  cases  of  this  kind  general  tonic 
treatment  becomes  of  the  greatest  importance. 
Rest  must  be  given  to  the  affected  part,  and  exer- 
cise to  the  body  generally,  combined  with  fresh  air 
both  day  and  night,  and  simple  nourishing  food. 
Where  the  bone  is  extensively  diseased,  it  must 
either  be  excised,  or  the  part  amputated.  The 
presence  of  the  tubercular  diathesis  does  not. 
forbid  an  operation,  the  local  source  of  irritation 
and  drain  upon  the  system  being  thus  removed, 
and  a healthy  traumatic  surface  substituted  for 
one  infiltrated  with  inflammation-products.  The 
removal  of  the  local  disorder  often  proves  a 
comfort  to  the  patient,  and  increases  his  chance 
of  regaining  health  and  strength. 

6.  New  Growths. — The  bones  are  liablo  to 
most  of  the  new  growths  forming  tumours  found 
elsewhere  in  the  body,  such  as  cancerous,  vas- 
cular, and  other  tumours.  The  most  important 
are  the  following: — 

a.  Some  tumours  are  peculiar  to  bone,  as,  for 
instance,  the  Myeloid,  so  called  from  the  many 
nucleated  corpuscles  contained  in  it,  analogous 
to  those  found,  in  foetal  marrow ; it  is  of  en- 
dosteal origin,  causing  an  expansion  of  the  bone 
in  which  it  grows.  It  is  most  common  in  tho 
maxillary  bones,  and  near  the  epiphysal  ends 
of  the  long  bones.  It  is  generally  observed  ir? 


BONE,  DISEASES  OF. 


130 

young  persona,  requires  removal,  and  extir- 
pation, if  complete,  is  not,  as  a rule,  followed  by 
a return  of  the  disease. 

b.  Periosteal  or  Fasciculated  Sarcoma, 
springing  from  the  periosteum  of  a long  bone, 
such  as  the  femur,  is  not  uncommon.  The  shaft 
of  the  bone  may  be  seen  on  section  passing 
through  the  centre  of  the  tumour.  Numerous 
bands  of  fibrous  tissue,  often  ossified,  radiate  from 
the  periosteum  through  the  growth,  like  an  out- 
spread fan.  The  best  treatment  is  amputation  of 
the  limb  at  the  joint  above,  which  does  not,  how- 
ever, ensure  against  recurrence  of  the  disease. 

c.  Exostosis. — This  is  a bony  outgrowth  de- 
veloped on  any  part  of  the  skeleton.  It  is  diffi- 
cult to  distinguish  cartilaginous  from  osseous 
outgrowths.  The  two  structures  are  often 
mixed,  and  a lumonr  originally  cartilaginous  is 
often  transformed  into  bone.  Cartilaginous  out- 
growths, called  Enchondroses  are  met  with  on 
the  costal  cartilages  of  old  persons,  also  on  the 
intervertebral  discs,  near  the  synchondroses, 
and  arise  also  from  the  articular  cartilages  iu 
rheumatic  arthritis.  Cartilaginous  tumours, 
growing  either  from  the  periosteum  or  the 
medulla,  have  tbeir  favourite  seat  upon  the 
phalanges  ; they  are  usually  multiple,  and  from 
the  deformity  and  inconvenience  they  produce 
often  demand  either  enucleation  of  the  tumour 
or,  in  extreme  cases,  amputation  of  the  finger. 
The  more  special  forms  of  exostosis  are  of  two 
kinds,  the  spongy  and  the  ivory-like.  Spongy  exos- 
tosis is  often  developed  near  the  articular  ends  of 
the  long  bones,  where  it  forms  a nodulated  out- 
growth of  cancellated  hone  of  variable  size,  en- 
crusted with  a thin  layer  of  cartilage,  and  having 
generally  a bursa  superimposed.  This  kind  of 
exostosis  is  often  connected  with  the  epiphysal 
cartilage,  and  ceases  to  grow  when  the  bone  is 
fully  developed.  This  fact,  as  well  as  the  prox- 
imity of  the  neighbouring  joint,  renders  surgical 
interference  generally  unnecessary,  and  often 
hazardous.  Another  form  of  spongy  exostosis, 
sometimes  called  osteophyte,  depends  on  a local 
excessive  periosteal  growth  of  bone.  At  first 
this  outgrowth  is  porous,  and  but  slightly  con- 
nected with  the  bone  on  which  it  is  developed. 
Afterwards  it  may  become  dense  and  hard  from 
interstitial  deposit,  or  it  may  always  remain 
spongy.  Such  exostoses  often  depend  on  some 
local  exciting  cause,  such  as  a blow ; or  they 
may  be  found  at  the  insertion  or  origin  of  a 
muscle,  as  iu  the  so-called  rider’s  bone,  at  the 
origin  of  the  adductor  longus  muscle,  or  the  exos- 
tosis frequently  found  at  the  insertion  of  the 
adductor  magnus,  or  the  1 exercise  bone  ’ of  the 
German  soldier.  They  may  he  regarded  as  morbid 
exaggerations  of  the  normal  tuberosities  of  the 
skeleton.  Ivory  exostosis,  so  called  from  its  dense, 
eburnated  character,  is  more  rare.  It  varies 
much  in  size,  and  maybe  pedunculated  or  sessile. 
Hereditary  influence  appears  to  exist  in  some 
cases,  in  others  a predisposition  to  chronic  peri- 
ostitis, but  there  may  be  no  apparent  cause.  The 
development  is  slow  and  painless. 

Treatment. — Interference  is  seldom  required 
m the  spongy  exostoses,  except  on  account  of 
pain  or  loss  of  function.  When  pedunculated 
they  can  be  broken  off  or  divided  subcutaneously ; 
and  although  they  may  reunite,  it  will  probably 


be  in  a more  convenient  and  painless  relation  to 
adjacent  parts.  Otherwise  they  should  be  ex- 
cised. 

Except  on  account  of  deformity,  or  of  pressing 
on  important  structures,  an  ivory  exostosis  need 
not  be  meddled  with.  It  can  often,  however, 
when  necessary,  he  enucleated;  and  where  only 
a partial  removal  is  possible,  the  low  vitality 
of  the  tumour  often  causes  necrosis  and  su  > 
sequent  exfoliation  of  the  remainder.  Sponta 
neous  necrosis  also  occasionally  occurs. 

d.  Osteo-aneurism.— Certain  sarcomata  and 
myeloid  tumours,  when  very  vascular, pulsate,  and 
have  been  mistaken  for  aneurism.  There  are, 
however,  undoubted  cases  of  aneurismal  tumours, 
dilating  the  hone,  which  have  been  cured  by 
ligature  of  the  main  vessel  of  the  limb.  When 
the  tumour  is  small  it  may  be  excised,  or  the 
actual  cautery  applied.  Sometimes  amputation 
is  required.  The  causes  and  pathology  of  the 
disease  are  obscure.  It  is  probably  in  some 
cases  of  a nsevoid  character. 

e.  Bone-cysts  are  tumours  distending  and 
thinning  the  bone,  and  filled  with  serum  or 
bloody  fluid.  In  some  rare  cases  they  contain 
hydatids.  The  origin  of  bone-cysts  is  obscure  ; 
some  originate  in  the  dentigerous  cavities  of 
the  maxillae,  in  which  hone-cysts  are  most  fre- 
quent, but  they  are  sometimes  found  elsewhere. 
Avery  slow,  painless  increase  in  size  takes  place. 
Tho  hone  becomes  gradually  very  thin,  and  often 
affords  on  pressure  a peculiar  and  characteristic 
parchment-like  crackling.  In  obscure  cases  an 
exploratory  puncture  should  he.  made. 

Treatment  consists  in  freely  laying  open 
the  cyst-cavity,  and  providing  for  subsequent 
drainage.  The  cavity  gradually  contracts  and 
becomes  obliterated. 

f.  Hydatids. — The  formation  of  echinococ 
cus-eysts  in  bone  is  exceedingly  rare,  compared 
with  ether  parts  of  the  body.  The  causes  arc 
unknown,  and  the  symptoms  very  obscure,  re- 
sembling those  of  an  ordinary  cyst.  A cavity  is 
formed,  usually  in  the  spongy  extremities  of  the 
long  bones,  to  contain  the  mother  cyst.  But  it 
is  also  found  iu  the  medullary  canal.  The  af- 
fection is  grave.  Serious  inflammation  often 
follows  interference  with  these  entozoa.  It  is 
sometimes  difficult  to  remove  the  whole  disease : 
and  unless  this  be  effectually  done  a relapse  will 
occur  ; while  in  such  parts  as  the  pelvis  art  is 
unavailing.  The  cavity  should,  if  possible,  be 
freely  laid  open,  and  all  the  cysts  carefully  re- 
-moved  or  destroyed.  The  actual  cautery  may 
be  sometimes  employed  with  advantage,  or  the 
surface  of  the  adjacent  bone  removed,  as  it  may 
be  invaded  by  the  cysts.  An  exploratory  punc- 
ture can  alone  resolve  the  diagnosis,  by  finding 
the  hooks  of  the  acephalocyst  iu  the  fluid. 

7.  Malformations. — These  consist  in  any 
departure  from  the  normal  type  of  the  skeleton, 
by  reason  of  excess,  deficiency,  or  irregularity, 
either  congenital  or  acquired.  It  is  not  neces- 
sary more  than  to  allude  to  the  fact,  that  tho 
skeleton  is  often  defective  in  parts  ; that  senile 
changes  occur,  especially  in  certain  hones  ; and 
that  supplementary  bones  and  processes  are  met 
with.  Various  deformities  occur  in  bones  from 
fractures,  both  intra-uterine  and  subsequent  to 
birth,  and  from  curvatures  due  to  rickets  or 


BONE,  DISEASES  OF. 
fcoftcni ng.  Treatment,  ofeurvature  consists  in  gra- 
dual s;  Heightening  by  splints  or  other  apparatus, 
or  immediate  straightening  under  chloroform, 
methods  which,  in  the  soft  growing  bones  of  the 
young,  prove  successful  in  abating  many  defor- 
mities. The  curvatures  of  adult  bones  do  not 
yield  in  this  way.  When  there  is  loss  or  impair- 
ment of  function  from  deformity,  the  bone  may 
be  safely  divided  subcutaneously  with  the  chisel 
or  saw,  and  the  limb  straightened — often  with 
admirable  results.  Forcible  fracture  is  a clumsy 
md  somewhat  dangerous  method,  as  the  force 
employed  cannot  be  regulated. 

8.  Hypertrophy  means  an  excessive  growth 
of  bone-tissue.  Apart  from  inflammation  this  is 
rare,  but  in  museums  specimens  of  excessive 
growth  are  met  with,  especially  of  the  bones  of 
:he  face  and  skull.  The  causes  are  unknown, 
and  no  treatment  appears  applicable. 

9.  Atrophy  consists  in  a diminution  of  the  size 
or  compactness  of  a bone.  It  may  be  the  result 
of  inflammatory  changes,  of  senile  degeneration, 
of  disuse  of  a limb,  or  of  an  injur}’,  such  as  a 
fracture  followed  by  non-union.  The  bone-tis- 
sue gradually  wastes  away,  the  cortical  portion 
often  becoming  a thin  parchment-like  layer  of 
bone,  filled  with  soft  medulla.  This  has  been 
called  excentric  atrophy.  The  external  appear- 
ance and  size  of  the  bone  remain  unchanged. 
Concentric  atrophy,  where  the  size  of  the  bone 
diminishes  in  all  its  dimensions,  may  occur  in 
bones  which  have  been  disused  for  lengthened 
periods,  as  from  paralysis  of  a limb,  disease  of  a 
joint,  or  un-united  fractures.  Spontaneous  frac- 
tures, or  fractures  due  to  trifling  causes,  are 
very  common  under  these  circumstances.  The 
term  Fragilitas  Ossium  has  been  applied  to  this 
condition  of  bone-tissue,  which  also  frequently 
occurs  in  cases  of  cancerous  cachexia. 

10.  Softening. — This  change  occurs  in  Rickets 

and  Mollities  Ossium.  See  Rickets;  and  Moxxi- 
ties  Ossrcir.  Wuium  MacCormac. 

BOHBOETGMI  (fSop&opvfa,  I grumble). — 
Rumbling  sounds  produced  in  the  abdomen  by  the 
movements  of  gas  within  the  bowels  or  stomach. 

BORDIGHEB.A  in  Italy,  on  the  Riviera. 
A suitable  winter  residence  for  patients  suffering 
from  some  forms  of  chest-disease.  The  climate 
is  warm  and  dry.  See  Cxtmate,  Treatment  of 
Disease  by. 

BOTEEIOCEPHALTJS  (060ptov,  a pit, 
and  KeipaX^],  the  head). — A genus  of  cestode 
entozoa,  characterised  by  the  possession  of  two 
pits  or  depressions,  one  on  either  side  of  the 
head,  in  place  of  the  four  sucking  disks  usually 
present  in  tapeworms.  The  reproductive  open- 
ings, instead  of  being  placed  along  the  margin 
of  the  so-called  joints  or  segments  of  the 
body,  occur  at  the  ventral  surface  along  the 
mesial  line.  Three  species  of  Bothriocephalus 
are  known  to  infest  the  human  body.  These  are 
the  broad  tapeworm  ( B . latus),  the  Greenland 
tapeworm  ( B . cordatus ),  and  the  crested  tape- 
worm [B.  cristatus)  recently  described  by  Da- 
vaine.  From  a clinical  point  of  view  little  need 
be  said  concerning  them.  The  broad  tapeworm 
is  rarely  seen  out  of  Europe,  and  then  only,  it 
would  seem,  in  persons  who  have  travelled  on 
the  Continent.  It  is  most  common  in  Switzer- 


BRAIDISM.  lot 

land  and  nor:h-western  Russia;  but  cases  alsi. 
occur  in  Poland,  Sweden,  Holland,  Belgium,  the 
south-western  provinces  of  France,  and  some- 
times in  Ireland.  In  reference  to  treatment, 
the  parasite  readily  yields  to  the  remedies  em- 
ployed in  ordinary  cases  of  tapeworm.  In  English 
practice  we  have  generally  resorted  to  male  fern, 
but  Dr.  Arthur  Reared  has  found  kamela  equally 
efficacious.  See  Tape-worm:  ; and  T.isu. 

T.  S.  Cobboxd. 

BOTS. — A term  employed  to  designate  the 
larval  of  certain  dipterous  insects  called  gadflies. 
They  more  rarely  infest  man  than  animals.  See 
(Estrtjs. 

BOULIMIA.  See  Bulimia. 

BOUEBONNE-LES-BAINS  in  France. 

Common  salt  waters.  See  Minerax  Waters. 

BOTTRBOT7LE,  LA,  in  France.  Thermal  al- 
kaline and  arsenical  waters.  S&Hieerax  Waters. 

BOUEHEMOUTH  in  Hampshire.  Re- 
garded as  a suitable  winter  residence  for  patients 
suffering  from  certain  forms  of  chest-disease. 
The  climate  is  mild  and  slightly  humid.  See 
Climate,  Treatment  of  Disease  by. 

BOWELS,  Diseases  of.  See  Intestxves, 
Diseases  of. 

BBAIDISM. — Synojt.  : Hypnotism. — Braid 
ism  is  the  name  which,  after  its  inventor,  James 
Braid,  has  been  applied  to  a therapeutic  method 
destined  to  utilise  the  undoubted  powers  cl 
mind  over  body  for  the  cure  of  various  diseases. 
In  essence  it  consists  of  a species  of  Mesmerism, 
the  patient  being  reduced  to  a partial  or  com- 
plete trance-like  condition,  by  being  made  to  look 
fixedly  for  a few  seconds  at  a bright  object  held 
by  the  operator  at  ‘ about  eight  to  fifteen  inches 
above  the  eyes,  at  such  a distance  above  the  fore- 
head as  may  be  necessary  to  produce  the  greatest 
possible  strain  upon  the  eyes  and  eyelids,  and 
enable  the  patient  to  maintain  a steady  fixed 
stare  at  the  object.’  The  patient  must  be  made 
to  understand  that  he  is  to  keep  his  eyes 
steadily  fixed  on  this  object,  and  his  mind 
riveted  upon  the  image  of  it.  After  so  short  a 
time  as  ten  or  fifteen  seconds  some  patients  may 
be  intensely  affected,  and  if  so,  it  will  he  found,  on 
gently  elevating  the  arms  and  legs,  that  the 
patient  has  a disposition  to  retain  them  in  the 
situation  in  which  they  have  been  placed.  ‘ 11 
this  is  not  the  case,’  Mr.  Braid  writes,  ‘ in  a soft 
tone  of  voice  desire  him  to  retain  the  limbs  in 
the  extended  position,  and  thus  the  pulse  will 
speedily  become  greatly  accelerated,  and  his 
limbs  in  process  of  time  will  become  quite  rigid 
and  involuntarily  fixed.’  By  slightly  prolonging 
this  process  a condition  of  profound  ‘nervous 
sleep  ’ may  be  induced,  in  which  operations  may 
he  performed  as  easily  and  in  as  painless  a 
manner  as  if  the  patient  had  been  under  the 
influence  of  chloroform.  All  this  has  been 
abundantly  proved  by  Esdaile  and  others  who 
performed  numerous  operations  upon  Hindoos, 
with  absence  of  all  pain,  whilst  they  were  in  the 
hypnotic  state.  In  his  attempts  to  cure  morl  id 
conditions,  however,  Braid  only  rarely  pro- 
ceeded so  far  as  to  induce  actual  unconscious 
ness.  Whilst  in  a scmi-cataleptic  condition  the 
patient's  attention  is  strongly  directed  to  the 


132  BRAIDISM. 

Biorbid  part,  and  some  rery  marvellous  instances 
of  relief  are  recorded  by  him,  said  to  have  been 
effected  under  the  influence  of  this  faculty  only, 
without  the  aid  of  imagination,  since  some  of 
the  patients  operated  upon  were  quite  incredu- 
lous as  to  any  good  being  likely  to  result.  In 
a recent  work  on  ‘ The  Influence  of  the  Body 
upon  the  Mind,’  Dr.  Daniel  II.  Tuke  remarks : 

‘ Braidism  possesses  this  great  advantage,  that 
while  the  Imagination,  Faith  or  Expectation 
of  the  patient  may  be  beneficially  appealed 
to,  this  is  not  essential;  the  mere  concentra- 
tion of  the  attention  having  a remarkable 
influence,  when  skilfully  directed,  in  exciting 
the  action  of  some  parts,  and  lowering  that  of 
others.  The  short  period  of  time  required,  also, 
compares  favourably  with  that  consumed  in 
some  other  forms  of  mental  therapeutics.  . . . 
The  great  principle  which  appears  to  be  involved 
in  all  is  the  remarkable  influence  which  the 
mind  exerts  upon  any  organ  or  tissue  to  which 
the  Attention  is  directed,  to  the  exclusion  of 
other  ideas,  the  mind  gradually  passing  into  a 
State  in  which,  at  the  desire  of  the  operator, 
portions  of  the  nervous  system  can  be  exalted  in ' 
a remarkable  degree,  and  others  proportionately 
depressed  ; and  thus  the  vascularity,  innervation, 
and  function  of  an  organ  or  tissue  can  be 
regulated  and  modified  according  to  the  locality 
and  nature  of  the  disorder.’  Braidism  certainly 
deserves  more  attention  than  it  has  received, 
though  it  is  a method  very  difficult  of  adoption 
in  ordinary  practice,  and  which,  however  legiti- 
mate may  be  its  foundations,  would,  unless  the 
greatest  care  and  vigilance  were  exercised,  be 
apt  to  descend  perilously  near  to  the  level  of 
quackery.  Still,  if  only  half  the  results  which 
have  been  attributed  to  Braidism  would  follow 
the  systematic  adoption  of  this  method  for  the 
alleviation  of  many  diseases,  it  is  one  which 
should  commend  itself  to  the  earnest  attention  of 
future  enquirers  who  may  be  able  to  place  the 
practice  upon  a broader  and  firmer  foundation 
than  that  on  which  it  now  rests.  See  Mesmerism. 

H.  Charlton  Bastian. 

BEAIN,  Diseases  of. — General  Obser- 
vations.— The  range  of  unnatural  phenomena 
which  manifest  themselves  as  the  result  of  dis- 
turbed actions  of  the  brain,  whether  from  func- 
tional perturbations  or  structural  disease,  is  wide 
and  varied.  This  result  is  due  to  the  fact  that  the 
brain,  though  spoken  of  as  a single  organ,  is  really 
a congeries  of  many  distinct  but  functionally  re- 
lated parts  ; and  further  to  the  fact  that  this  con- 
geries of  parts  is  continuous  with  the  spinal  cord 
and  intimately  related  to  a scattered  network 
of  ganglia — entering  into  the  formation  of  the 
nervous  sj'stem  of  organic  life ; whilst  these 
several  centres  within  and  without  the  cranium 
are  brought  into  connexion,  through  the  interven- 
tion of  nerves,  with  all  other  structures  in  the 
body,  whether  entering  intothecompositionof  the 
organs  of  relation,  or  into  That  of  the  visceral 
system. 

The  action  of  particular  parts  of  the  brain 
may  be  stimulated,  depressed,  or  suppressed,  and 
either  of  such  altered  modes  of  activity  may 
entail  a stimulation,  depression,  or  suppression 
in  the  functions  of  one,  two,  or  more  distant 
parts  of  the  nervous  system.  The  first  class  of 


BRAIN,  DISEASES  OF. 
effects  are  spoken  of  as  direct , and  tho  second 
as  indirect  symptoms.  It  is  often  extremely 
difficult,  if  not  impossible,  for  us  to  say  which  of 
the  symptoms  presented  by  a patient  suffering 
from  organic  disease  of  the  brain  should  bs 
ranged  under  the  one  head  and  which  under  the 
other.  Our  ability  to  make  such  distinctions  is 
at  present  hindered  by  our  still  incomplete  know- 
ledge concerning  the  anatomical  details  of  the 
brain,  the  proper  functions  of  its  several  parts, 
and  tho  precise  modes  in  which  they  co-operate 
with  each  other. 

The  effects  of  a shock,  whether  produced 
by  injury  or  disease,  falling  on  such  an  extensive 
assemblage  of  sensitive  and  mutually  related 
organs  are,  as  may  be  well  imagined,  subject 
to  much  variation ; and  as  a matter  of  fact  it 
happens  that  in  different  cases  of  structural 
brain  disease,  the  symptoms  produced  are  de- 
pendent upon  three  factors,  viz.,  the  situation, 
the  extent , and  the  suddenness  of  the  lesion. 
Except  in  so  far  as  the  nature  of  the  lesion 
tends  to  entail  variations  in  one  or  other  of 
the  above-mentioned  respects,  it  is  not  of  much 
significance  from  a clinical  point  of  view  ( i.e . 
it  does  not  lead  to  much  difference  in  the 
sets  of  symptoms  produced)  whether  we  have 
to  do  with  a case  of  haemorrhage  into,  or  with 
a case  of  softening  of  the  brain.  Thus  the 
‘locality’  and  extent  of  the  lesion  in  the  case  of 
a local  disease  of  the  brain  has  always  to  be 
enquired  into  as  a problem  altogether  apart 
from  that  as  to  the  more  or  less  distinct  nature 
of  the  pathological  change  in  tho  part  affected. 
In  other  words,  the  problem  of  diagnosis  in  brain 
disease  is  twofold ; it  must  have  reference  to 
the  region  affected  (Regional  Diagnosis)  and  tn 
the  pathological  cause  (Pathological  Diagnosis). 
The  causes  interfering  with  the  progress  of  our 
knowledge  in  the  former  direction  are  both 
numerous  and  baffling,  so  that,  as  yet,  compara- 
tively little  progress  has  been  made. 

Symptoms. — The  most  frequent  effects  or 
symptoms  of  functional  or  structural  brain-dis- 
ease may  be  thus  classified : — 

1.  Perverted  Sensation  and  Perception. 
— The  special  senses  of  smell,  sight,  hearing, 
touch  (fifth  nerve),  or  taste  may  be  interfered 
with  by  diseases  of  their  respective  nerves  or 
primary  ganglia  within  the  cranium.  Owing 
to  the  decussation  of  the  optic  nerves,  disease  of 
the  optic  tract  gives  rise  (most  frequently)  to 
an  affection  of  the  sight  of  the  opposite  eye. 
The  sense  of  taste  pertains  to  different  nerves. 
Thus  the  glosso-pharvngeal  has  to  do  with  this 
special  sensation  in  the  back  part  of  the 
tongue,  the  palate  and  fauces ; whilst  the  taste- 
nerves  for  the  front  part  of  the  tongue,  though 
they  pass  from  these  parts  with  the  lingual 
branch  of  the.  fifth,  seem  to  leave  it  by  the 
chorda  tympani  and  then  proceed  to  the  brain 
with  the  facial  or  the  fifth  nerve.  Disease  of 
the  intracranial  portion  of  the  fifth  nerve  may 
not  affect  the  sense  of  taste,  though  it  impairs 
the  common  sensibility  of  the  tongue. 

Disease  of  the  primary  ganglia  of  these  nerves, 
whether  they  are  separate  (first  and  fifth)  or 
lodged  in  the  brain-substance  at  its  point  of 
connection  with  the  nerve,  will  produce  decided 
impairment  of  the  several  special  senses.  But 


BRAIN,  DISEASES  OF. 


disease  of  portions  of  the  brain  above  these 
regions  on  one  side  only,  even  though  very 
extensive,  often  exists  -without  disturbing  the 
exercise  of  the  special  senses  on  either  side. 
There  may,  however,  be  Illusions,  Hallucinations, 
or  Delusions  in  connection  with  either  of  these 
senses  in  many  functional  and  structural  diseases 
of  the  brain,  where  the  morbid  condition  is  situa- 
ted in  parts  higher  up  than  the  primary  ganglia, 
or  where  there  is  a functional  exaltation  of  the 
ganglia  themselves.  This  latter  functional  ex- 
altation seems  sometimes  to  be  favoured  by 
morbid  states  of  some  of  the  viscera — especially 
of  the  stomach,  or  of  the  uterus  and  ovaries. 

Disease  in  the  brain  may  also  impair  the  com- 
mon sensibility  of  the  body,  and  in  some  of  the 
most  marked  cases,  this  impairment  is  strictly 
limited  to  ono  lateral  half  of  the  body  (Hemi- 
anaesthesia).  It  may  be  very  marked  and  last 
for  a long  time ; or  it  maybe  slighter  and  present 
only  for  a few  days.  There  are  several  modes  of 
impressibility  comprised  under  the  term  ‘ com- 
mon sensibility.’  The  principal  varieties  are 
tactile  impressions,  impressions  produced  by 
differences  of  pressure  and  of  temperature,  im- 
pressions yielding  pain,  and  lastly  those  of  the 
so-called  ‘ muscular  sense.’  There  is,  moreover, 
a general  sensibility  pertaining  to  the  muscles 
and  joint-textures,  and  the  last  may  be  pro- 
foundly impaired  in  some  eases.  The  writer  be- 
lieves that  what  there  is  of  conscious  impression 
pertaining  to  that  endowment  known  as  the 
‘ muscular  sense,’  is  compounded  of  the  ordinary 
sense  of  touch  and  pressure  pertaining  to  the 
skin,  plus  sensations  in  joints  and  muscles  ac- 
cruing from  the  contraction  of  the  latter. 

Besides  diminutions  of  sensibility,  we  often 
have  to  do  with  disagreeable  sensations  of  numb- 
ness tingling,  or  actual  neuralgic  pains  in  parts. 
The  two  former  may  be  widely  distributed, 
though  neuralgia  from  brain-disease  is  princi- 
pally limited  to  the  territory  of  the  fifth  nerves. 

2.  Perverted  Emotion  and  Ideation. — 
These  manifestations  vary,  from  the  mere  in- 
ireased  tendency  to  emotional  displays  seen  in 
a hysterical  person  or  in  persons  suffering  from 
hemiplegia,  to  those  more  complex  aberrations 
met  with  in  the  various  forms  of  delirium  and 
insanity  (see  Insanity). 

3.  Perversions  of  Consciousness. — Under 
this  head  may  be  included  the  comparatively 
rare  states  known  as  somnambulism,  ecstasy, 
and  catalepsy ; as  well  as  the  exceedingly  common 
conditions  of  drowsiness,  stupor,  and  coma.  The 
former  may  be  said  in  almost  all  cases  to  be 
associated  with  functional  rather  than  with 
structural  disease  of  the  brain ; at  least,  this  is 
most  in  accordance  with  our  present  knowledge. 
Drowsiness,  stupor,  and  coma  are,  however, 
amongst  the  commonest  results  of  organic  dis- 
ease of  the  brain  ( see  Consciousness,  Disorders 
of),  though  they  are  also  common  conditions  in 
blood-poisoning — whether  arising  from  fevers, 
uraemia,  or  from  poisonous  doses  of  opium  or 
of  other  narcotic  or  narcotico-irritant  poisons. 

■f.  Perversions  of  Motility. — These  mani- 
fest themselves  in  many  forms,  which,  however 
distinct  they  may  appear  to  be,  are,  neverthe- 
less, closely  linked  to  one  another. 

Tremors  may  be  general  or  local,  and  in  the 


133 

latter  case  they  may  be  most  marked  in  the 
tongue  and  facial  muscles — principally  those 
about  the  corners  of  the  mouth  or  the  orbicularis 
palpebrarum.  General  tremors  may  arise  from 
debility,  over-exertion,  nervousness  ; or  they 
may  be  due  to  alcoholic  or  mercurial  poison- 
ing, or  to  degenerative  disease  about  the  pons 
and  medulla,  as  in  Paralysis  Agitans. 

Twitchings  may  be  characteristic  of  a highly 
nervous  habit  of  body,  and  are  especially  fre- 
quent in  some  epileptics  in  the  intervals  between 
their  fits,  either  in  some  of  the  facial  muscles  or 
in  those  of  the  neck  or  limbs.  They  may  also 
occur  in  acute  febrile  affections,  in  which  the 
functions  of  the  cerebrum  are  involved,  as  shown 
by  coexisting  delirium,  &c.,  and  also  in  the 
course  of  many  organic  diseases  of  the  brain. 
In  chorea  the  irregular  movements  of  different 
parts  of  the  body  are  often  of  this  nature  ; they 
may  affect  both  sides  of  the  body,  or  only  one 
(hemichorea). 

Spasms  of  a continuous  or  ‘tonic’  character  are 
encountered  in  various  diseases  of  the  nervous 
system,  such  as  laryngismus  stridulus,  trismus, 
hydrophobia,  tetanus,  hysteria,  and  some  forms 
of  hemiplegia  and  paraplegia.  Such  tonic 
spasms  produce  muscular  rigidity,  which  has  to 
be  distinguished  from  that  due  to  chronic  changes 
apt  to  occur  in  paralysed  limbs. 

Clonic  Spasms  or  Convulsions  maybe  either 
unilateral  or  general,  and  may  be  induced  by 
the  most  varied  causes.  "When  well-marked 
they  are  mostly  attended  by  loss  of  conscious- 
ness, as  in  epilepsy  and  the  majority  of  epilepti- 
form attacks. 

Co-ordinated,  Spasms,  or  movements  of  a strug- 
gling type,  are  met  with  in  many  epileptiform 
and  hysterical  paroxysms.  Spasms  of  this  type 
may  be  also  limited  to  particular  groups  of 
muscles,  as  in  the  conjugated  deviation  of  the 
eyes  and  neck  occurring  in  hemiplegia,  in  wry- 
neck, in  writer’s  cramp,  and  other  allied  affections. 

Paralysis  may  be  local  and  limited  in  seat  to 
some  of  the  ocular  muscles,  the  muscles  of  mas- 
tication, the  facial  muscles,  those  of  the  tongue, 
or  to  parts  supplied  by  the  spinal  accessory  and 
pneumogastric  nerve,  in  those  cases  in  which 
there  is  merely  an  implication  of  the  intra- 
cranial portion  of  one  or  more  of  the  motor- 
cranial  nerves  ; or  it  may  take  an  incomplete  or 
a complete  hemiplegic  type,  with  lesions  limited 
to  one  half  of  the  encephalon ; or  it  may  be 
general,  and  involve  both  sides  of  the  body, 
if  a large  lesion  exists  in  the  pons  Varolii,  or 
if  the  functions  of  both  cerebral  hemispheres 
or  their  peduncles  are  gravely  interfered  with. 
In  some  of  these  cases,  and  especially  with 
right-sided  paralysis,  various  difficulties  exist 
in  giving  expression  to  thoughts  by  means  of 
speech  or  writing  • (see  Aphasia).  Deficient 
action  of  the  will  (without  obvious  structural 
change  of  the  cerebrum)  may  cause  paralysis  in 
hysteria  and  allied  states. 

Defective  Co-ordination  of  muscular  acts  is  met 
with,  as  in  stammering  and  in  some  hemiplegic 
defects  of  speech ; also  in  the  body  generally  in 
some  cases  of  cerebellar  disease,  producing  a 
peculiar  and  unsteady  gait  (titubation)  closely 
resembling  that  which  may  be  met  with  in 
alcoholic  intoxication.  Similar  motor  distil: l> 


BRAIN,  DISEASES  OF. 


134 

ances  may  bo  induced  by  vertigo  of  'well-marked 
extent.  Vomiting,  again,  is  a reflex  motor  act  due 
to  impaired  co-ordination,  which  occurs  in  many 
forms  of  brain-disease.  More  rarely  the  sphinc- 
ter ani  and  the  sphincter  vesicse  become  relaxed, 
or  the  bladder  may  be  paralysed.  But  incon- 
tinence of  faeces  or  of  urine,  or  inability  to 
void  the  urine,  are  comparatively  rarely  met 
with  as  a result  of  brain-disease,  except  in  the 
comatose  state,  or  in  patients  who  are  more  or 
less  demented. 

5.  Nutritive  or  Trophic  Changes. — With 
lesions  in  the  motor  tract  of  the  brain  in  or 
below  the  corpus  striatum  a band  of  degenera- 
tion is  produced,  occupying  part  of  the  crus 
cerebri,  the  pons,  and  the  medulla  on  the  same 
side,  and  (below  the  decussation  of  the  pyramids) 
the  opposite  lateral  column  of  the  spinal  cord. 
This  is  one  of  the  most  important  of  the  trophic 
changes  occasioned  by  brain-disease,  because  the 
degeneration  in  the  lateral  column  of  the  cord 
is  apt  to  spread  to  the  contiguous  grey  matter, 
and  thus  to  give  rise  to  some  of  tho  trophic 
changes  prone  to  ensue  in  paralysed  limbs. 

Trophic  changes  in  other  organs  occasioned  by 
some  severe  lesions  in  the  brain  appear  as  low 
inflammations  and  congestions  of  the  lungs,  or 
as  haemorrhages  into  these  organs ; also  as 
haemorrhages  beneath  the  pleura  or  endocardium, 
or  even  into  the  substance  of  the  suprarenal 
capsules  or  kidneys. 

Again,  we  may  have  acute  sloughing  of  the 
integument  in  the  gluteal  region  on  the  para- 
lysed side,  dropsy  of  paralysed  limbs,  inflamma- 
tions of  joints  and  of  the  main  nerves  of 
paralysed  limbs,  and,  though  more  rarely, 
marked  atrophy  of  paralysed  muscles.  Retard- 
ation or  arrest  of  growth  is  also  apt  to  occur 
in  paralysed  limbs,  when  we  have  to  do  with 
infants  or  young  children,  suffering  from  severe 
organic  brain-disease. 

Blanching  of  the  hair,  or  altered  pigmentation 
of  the  skin,  also  occurs  not  unfrequently  in  con- 
nection with  brain-disease  or  violent  mental 
emotions  ; whilst  in  the  insane  the  nutrition  of 
tho  bones  and  of  the  pinna  of  the  ear  is  apt  to 
be  interfered  with. 

6.  Perverted  Visceral  Actions. — Exalted 
activity  of  the  uterus,  bladder,  intestine,  stomach, 
or  heart,  may  bo  occasioned  by  functional  brain- 
disturbance  more  especially;  whilst  tho  same 
brain-conditions  may  give  riso  to  depressed  or 
exalted  activity  of  the  liver  or  kidneys.  With 
other  functionally  disturbed  or  emotional  brain- 
states  there  may  be  a lowered  functional  activity' 
of  the  salivary  glands,  of  the  heart,  of  the  respira- 
tory organs,  of  the  organs  of  deglutition,  of  the 
organs  of  digestion,  or  of  the  sexual  organs. 
These  are  only  to  be  taken  as  mere  indications 
of  the  kinds  of  modification  that  may  be  pro- 
duced in  visceral  activity  by  brain-disease.  Much 
doubtless  remains  to  be  learned  in  this  direction. 

It  seems  fitting  here  also  to  mention  those 
contractions  and  dilatations  of  vessels  which  are 
apt  vo  take  place  in  different  parts  of  the  surface 
of  the  body,  or  in  internal  organs,  from  stimu- 
lation or  contraction  of  vaso-motor  nerves,  oc- 
casioned either  by  direct  or  indirect  influence 
exerted  upon  the  principal  vaso-motor  centres  in 
the  region  of  the  pons  Varolii.  These  contrac- 


tions or  dilatations  produce  correlated  alterations 
in  the  temperature,  sensibility,  and  functional 
activity  of  the  parts  or  organs  affected.  The 
temperaturo  of  paralysed  parts,  as  well  as  the 
general  body  temperature,  in  the  apoplectic  state 
is  subject  to  great  variations,  and  these  are  new 
beginning  to  be  studied  more  attentively.  They 
are  capable  of  yielding  diagnostic  indications  of 
great  value. 

Remarks. — Some  general  remarks  on  tho 
subject  of  structural  and  functional  diseases  of 
the  nervous  system,  showing  how  intimately 
these  two  classes  of  disease  are  related  to  one 
another,  will  be  found  in  the  article  Nervous 
System.  Most  of  what  is  said  there  is  applic- 
able to  diseases  of  the  brain  in  particular ; here, 
however,  it  is  necessary  to  call  attention  to  cer- 
tain points  specially  related  to  brain-disease. 

When  paralysis  occurs  from  brain-disease  affect- 
ing one  cerebral  hemisphere,  in  the  great  majority 
of  cases  it  is  situated  on  the  opposite  side  of  the 
body,  owing  to  the  fact  that  the  fibres  conveying 
the  volitional  impulses  to  the  muscles  decussate 
in  the  medulla  oblongata.  It  is  true  that  many 
cases  are  on  record  in  which  the  paralysis 
either  lias,  or  has  been  said  to  have  existed  on 
the  same  side  as  the  brain-lesion.  A certain 
number  of  these  cases  are  probably  due  to  errors 
either  in  the  clinical  or  in  the  post-mortem 
records  of  the  case.  Others,  however,  still 
remain  unexplained.  The  characters  of  the 
various  forms  of  paralysis  due  to  brain-disease 
are  briefly  set  forth  in  the  article  on  Paralysis. 

Lesions  of  the  left  hemisphere  much  more  fre- 
quently than  those  of  the  right,  are  associated 
■with  aphasie  defects  of  speech ; whilst,  accord- 
ing to  Brown-S4quard,  lesions  of  the  right  hemi- 
sphere are  more  frequently  and  rapidly  fatal 
than  otherwise  similar  lesions  of  the  left  hemi- 
sphere. They  are  also  more  apt  to  be  associated 
with  acute  sloughs  of  the  skin  on  the  paralysed 
side.  Convulsions  at  the  onset,  and  subsequent 
tonic  spasms  of  the  paralysed  limbs,  are  also  said 
to  be  more  frequently  associated  with  left-  than 
with  right-sided  paralysis. 

Congenital  atrophy  of  one  hemisphere,  or 
atrophy  occurring  in  early  infancy,  is  mostly 
associated  with  an  arrest  of  growth  and  develop- 
ment in  the  limbs  on  the  opposite  or  paralysed 
side  of  the  body. 

Very  little  is  positively  known  concerning  the 
diseases  of  tho  cerebellum.  Of  its  functional 
affections  we  may  be  said  to  know  absolutely 
nothing.  That  is,  of  the  various  functional  dis- 
eases of  tho  nervous  system  with  whose  clinical 
characters  we  are  familiar  we  are  unable  to  name 
even  one  which  we  can  positively  say  is  a func- 
tional disease  of  the  cerebellum.  Whatever  tho 
precise  mode  of  activity  of  the  cerebellum  may 
be,  there  is  a general  consensus  of  opinion  that  it 
is  principally,  if  not  exclusively,  concerned  with 
motility,  and  that  it  has  more  especially  to  do 
with  the  higher  co-ordination  of  muscular  acts. 
Atrophy  of  one  hemisphere  of  the  cerebrum  is 
followed  by  atrophy  of  the  opposite  half  of  the 
cerebellum,  so  that  there  is  a strong  presumption 
that  the  functional  relationship  of  either  half 
is  with  muscles  on  the  same  side  of  the  body. 
Clinically  we  know  that  disease  of  the  cerebel- 
lum is  not  unfrequently  associated  with  innr. 


UK  AIN,  DISEASES  OE. 
or  less  marked  paralysis  on  the  opposite  side  of 
the  body ; but  this  effect  is  now  generally 
attributed  to  the  pressure  which  structural  dis- 
eases of  the  cerebellum  are  apt  to  occasion  on 
the  pons  and  medulla  of  the  same  side. 

^Etiology. — The  principal  modes  of  causa- 
tion of  diseases  of  the  brain  may  be  thus  sum- 
marised : — 

1.  Defective  Nutrition  operates  by  modifjdng 
the  proper  constitution  of  nerve-tissues  as  well 
as  the  constitution  of  the  blood,  and  thereby  in- 
terfering with  the  normal  functional  relations  of 
the  several  parts  of  the  brain.  Anaemia,  chlorosis, 
syphilis,  ague,  and  all  lowered  states  of  health, 
howsoever  induced,  and  w'hether  acquired  or  in- 
herited, become  predisposing  or  actual  causes 
of  brain-disease.  To  these  states,  favourable 
to  the  manifestation  of  brain-disease,  should  be 
added  the  various  acute  specific  diseases,  uraemia, 
metallic  poisoning,  poisoning  by  the  narcotic  and 
narcotico-irritant  poisons  generally,  and  also  by 
the  occasional  qualities  of  certain  articles  of  food, 
such  as  mackerel,  mussels,  mushrooms,  &c. 

2.  Emotional  Shocks  cause  cerebral  disorder, 
especially  in  children,  or  prolonged  overwork  in 
those  who  are  older — particularly  when  com- 
bined with  worry  and  anxiety,  with  sexual  ex- 
cesses, or  with  protracted  lactation.  Beligious 
excitement,  again,  not  unfrequently  leads  to  in- 
sanity. 

3.  Physiological  Crises,  such  as  the  period  of 
the  first  dentition,  the  period  of  puberty,  preg- 
nancy, and  the  climacteric  period,  all  favour  the 
manifestations  of  various  nervous  diseases. 

4.  Visceral  Diseases  or  surface-irritations 
(especially  in  children  or  in  persons  having  a very 
sensitive  and  mobile  nervous  system)  may  give 
rise  to  varied  nervous  diseases.  Thus  we  may 
havo  convulsions  or  delirium  in  children  from 
the  presenco  of  worms  or  other  irritants  in  the 
intestines,  or  convulsions  in  adults  during  the 
passage  of  a renal  calculus.  Again  we  may  have 
the  phenomena  classed  as  hysteria,  or  we  may 
have  nymphomania,  in  consequence  of  certain 
states  of  the  sexual  organs.  Cases  of  paralysis 
are  said  also  to  have  a reflex  origin  occasionally, 
though  this  must  be  a very  rare  event.  With 
much  greater  frequency  we  find  surface-irrita- 
tions of  various  kinds  leading,  as  in  Dr.  Brown- 
Sequard’s  guinea-pigs,  to  epileptiform  attacks. 

5.  Structural  lesions  of  the  brain  itself  give 
rise  to  a ver}'  large  proportion  of  its  diseases. 
The  various  kinds  of  change  will  be  found  enu- 
merated under  another  heading  {see  Nervous 
System).  Haemorrhage  and  softening  are  tho 
most  common  and,  therefore,  the  most  im- 
portant of  these  morbid  conditions. 

6.  Brain-disease  may  be  determined  by  the 
action  of  Heat  {insolatio),  especially  when  com- 
bined with  fatigue  and  deficient  aeration  of  blood. 
A somewhat  similar  brain-affection,  however,  is 
occasionally  developed  in  the  course  of  rheu- 
matic fever  or  in  that  of  one  of  the  specific  fevers, 
in  which  the  body-temperature  rapidly  rises  to  a 
lethal  extent  (109°-111°  F.). 

7.  Concttssions  (whether  from  blows  or  falls) 
may  give  rise  to  brain-disease,  even  where  no 
traumatic  injuries  or  lacerations  of  the  brain 
are  produced. 

Treatment. — The  treatment  of  brain-disense 


BBAIN,  ABSCE.'  S OF.  l;sn 

will  be  discussed  under  the  articles  Nervous 
System,  Paralysis,  Convulsions,  and  those  on 
the  several  special  diseases  which  will  now  be 
described  in  alphabetical  order. 

H.  Charlton  Bastian. 

BBAIN,  Abscess  of. — This  term  is  applic- 
able whenever  a circumscribed  collection  of  pus 
is  formed  in  any  part  of  the  cerebral  mass. 

.ZEtiology  and  Pathology. — Amongst  the 
most  frequent  causes  of  cerebral  abscess  are  severe 
injuries  to  thoBskull,  disease  of  the  temporal  bone 
in  connection  with  the  ear,  ligature  or  obstruc 
tion  of  a main  artery,  and  pyaemia.  Under  th«. 
three  first-named  conditions  the  abscess  is  usually 
solitary,  but  from  pyaemia  multiple  abscesses 
often  result.  For  practical  purposes  we  may  per- 
haps conveniently  discard  the  latter — since  the 
symptoms  will  usually  be  those  of  general  ence- 
phalitis— and  confine  ourselves  to  those  cases  in 
which  single  large-sized  collections  of  pus  are  met 
with.  With  this  limitation,  abscess  in  the  brain 
is  by  no  means  of  frequent  occurrence. 

The  best  marked,  and  also  the  more  common 
examples  of  largo  brain-abscess  are  met  with  in 
connexion  with  compound  fractures  of  the  skull, 
and  by  far  the  most  definite  symptom  which  de- 
notes them  is  the  formation  of  a fungus  cerebri. 
Unless  in  a compound  fracture  the  brain  be 
directly  injured  and  the  dura  mater  torn,  it  is 
very  rare  indeed  for  any  suppuration  in  its  sub- 
stance to  occur.  It  is  not  to  be  denied,  however, 
that  now  and  then,  after  severe  concussion  or 
laceration  without  external  wound,  abscess  may 
follow.  In  such  cases  we  may  conjecture  that, 
usually  some  slight  laceration  or  extravasation 
occurred  in  the  first  instance,  which  constituted  a 
focus  for  the  inflammation.  Abscess  after  simple 
concussion  without  lesion  is  probably  a most 
rare  event. 

In  the  article  Brain,  Inflammation  of,  wr 
shall  have  to  define  Encephalitis  as  a diffuse 
change  of  a large  part  of  the  cerebral  mass,  per- 
haps of  a whole  hemisphere,  attended  by  the 
infiltration  of  cells  and  fluid.  It  is  obvious  that 
the  term  abscess  in  the  brain  is  applicable  tc 
one  of  the  results  of  encephalitis,  but  it  seems 
clinically  probable  that  the  two  classes  of  eases 
are  for  the  most  part  distinct,  and  that  diffuse 
encephalitis  has  but  little  tendency  to  result  in 
abscess,  and  that  abscess  is  rarely  preceded  by  a 
stage  of  encephalitis.  Both  are  usually  tho  con- 
sequences of  local  injury  to  the  brain,  or  of  ex- 
tension from  local  disease  of  its  coverings  ; but 
whilst  encephalitis  probably  resembles  the  ery- 
sipelatous type  of  inflammatory  action,  in  loca- 
lised abscess  this  tendency  is  not  present. 
Having  distinguished  brain-abscess  from  ence- 
phalitis, we  must  next  say  a word  as  to  the  risk 
of  confusing  it  with  intra-cranial  but  extra- 
cerebral  collections  of  pus.  Encysted  collections 
of  matter  may  be  met  with  either  between  the 
dura  mater  and  bone ; or  within  the  arachnoid 
cavity;  and  perhaps  it  ought  to  be  added,  though 
with  some  hesitation,  beneath  the  arachnoid,  in 
the  pia  mater.  Not  unfrequently  inflammation 
of  the  membranes  precedes  and  attends  the  for- 
mation of  an  intra-cerebral  abscess,  and  in  these 
cases  the  symptoms  will  be  mixed.  In  dealing 
with  published  cases  it  is  also  necessary  to  be 
on  our  guard  as  to  certain  errors  which  have  crept 


136  BRAIN,  ABSCESS  OF. 

in — cases  of  meningeal  abscess  being  spoken  of 
as  brain-abscess.  Mr.  Prescott  Hewett  has  ex- 
pressed his  opinion  that  the  celebrated  case  of 
De  la  PeyroniAs  was  an  example  only  of  extra- 
eerebral  abscess.  It  is  absolutely  necessary  to 
make  these  restrictions  if  we  would  judge  cor- 
rectly as  to  the  symptoms  which  attend  local 
collections  of  matter  in  the  brain  and  the  usual 
terminations  of  such  cases. 

Symptoms. — The  symptoms  of  local  suppura- 
tion in  the  brain  will  vary  with  the  stage,  the  size 
of  the  collection,  its  precise  situation,  and,  above 
all,  with  the  presence  or  otherwise  of  a fistula  of 
relief.  In  many  of  the  cases  which  come  under 
surgical  care  a fistula  exists  from  a very  early 
period,  though  not  unfrequently  it  is  liable  to 
occlusion.  Under  the  latter  conditions  the  symp- 
toms of  a closed  and  an  open  cerebral  abscess  may 
be  alternately  studied  in  the  same  case.  It 
will  usually  be  observed  that  when  the  exit  is 
closed  and  the  abscess  fills,  the  patient  complains 
more  or  less  of  headache,  becomes  heavy  and 
drowsy,  experiences  twitehings  or  spasms  in  the 
opposite  side  of  the  face  and  limbs,  with  some  ten- 
dency to  hemiplegia.  Of  this  group  the  tendency 
to  spasms  is  probably  by  far  the  most  significant. 
The  headache  may  be  but  trifling,  and  the  pa- 
tient may  even  be  well  enough  to  leave  his  bed, 
when  the  occurrence  of  spasm  followed  by  pare- 
sis alone  gives  warning  of  what  is  going  on. 
The  cases  now  alluded  to  are  chiefly  those  in 
which  abscess  results  from  compound  fracture 
of  the  skull  with  laceration  of  the  brain-sub- 
stance. In  these  the  abscess  often  gives  way 
spontaneously,  and  a fistula  forms,  around  the 
orifice  of  which  a mass  of  pouting  brain-granu- 
lations, known  as  fungus  cerebri,  usually  forms. 
In  these  cases  the  canal  of  communication  may 
be  very  tortuous,  and  the  liability  to  blocking 
considerable.  Now  and  then  the  same  result 
may  be  met  with  after  syphilitic  disease  of  the 
skull  and  meninges.  The  writer  had  some  years 
ago  a man  under  his  care  in  whom  he  had  opened 
a cerebral  abscess  beneath  a hole  in  one  parietal 
bone.  The  patient  was  able  to  walk  about,  and 
ailed  but  little  so  long  as  the  fistula  was  freely 
open ; but  spasms  of  the  face,  or  even  convulsions 
of  the  limbs  (on  the  opposite  side)  always  fol- 
lowed its  occlusion.  The  softening  gradually 
extended,  and  he  at  length  died  in  consequence, 
perhaps,  of  the  impossibility  of  making  a counter- 
opening in  a depending  situation.  Unless  the 
abscess  be  in  the  anterior  lobe,  there  will  almost 
invariably  be  present  some  degree  of  hemiplegia, 
but  this  will  of  course  vary  with  the  size  of  the 
collection  and  the  extent  of  destruction  of  tissue. 
The  formation  of  an  abscess  after  injury  is  some- 
times very  insidious,  the  symptoms  being  very 
slight.  The  cases  in  which  violent  headache 
and  pain,  vomiting,  delirium,  and  dry  tongue, 
are  said  to  have  been  present  in  the  early  stages 
are,  the  writer  suspects,  usually  instances  of 
suppuration  between  the  bone  and  dura  mater. 
These  symptoms  occur  especially  when  brain- 
abscess  follows  disease  of  the  internal  ear,  and 
in  these  there  nearly  always  is  the  complication 
of  inflammation  around  the  petrous  bone.  Such 
symptoms  are  very  rarely  present  in  traumatic 
abscesses,  which  often  develop  very  quietly 
autil  they  attain  a considerable  size.  It  is  pro- 


BRAIN,  ANAEMIA  OF. 

bable  that  some  degree  of  rigor,  attended  by 
rise  of  temperature,  usually  occurs  in  the  begin- 
ning of  cerebral  abscess,  but  no  very  precise 
data  are  extant  on  these  points. 

The  contents  of  a brain-abscess  usually  con- 
sist to  some  extent  of  broken-up  cerebral  tissue, 
and  in  some  cases  there  are  but  very  few  pus- 
cells.  Especially  is  this  likely  to  occur  when 
the  so-called  abscess  follows  on  ligature  of  the 
carotid  or  occlusion  of  a cerebral  artery.  In  these 
cases,  it  is  in  the  first  instance  at  least  the 
result  of  a process  of  softening  rather  than  of 
true  suppuration. 

If  a large  abscess  be  permitted  to  develop 
without  relief,  the  symptoms  of  compression 
will  in  time  ensue  : first  spasm,  then  hemiplegia 
then  hebetude  and  coma,  preceded  possibly  by 
violent  convulsions. 

Diagnosis. — The  diagnosis  between  cerebral 
abscess  and  meningeal  abscess  is  exceedingly  diffi- 
cult, and  often  a guess  is  all  that  can  be  made 
The  almost  invariable  occurrence  of  spasm  or  con- 
vulsions in  the  former,  and  their  frequent  a n- 
sence,  with  the  greater  degree  of  pain  and  head- 
ache in  the  latter,  are  the  most  reliable  signs 
Sometimes — as,  for  instance,  when  trephining 
has  been  practised,  and  no  inflammatory  products 
are  found  between  the  bone  and  dura  mater  or 
under  the  latter — the  diagnosis  maybe  helped  by 
this  negative  knowledge.  In  such  cases,  if  hemi- 
plegia, preceded  by  spasm,  have  been  gradually 
developed,  the  surgeon  will  be  well  justified  in 
making  an  incision  or  puncture  into  the  hemi- 
sphere. Optic  neuritis  may  equally  be  present 
in  both,  and  its  presence  or  absence  will  scarcely 
help  the  diagnosis. 

Prognosis. — In  addition  to  the  danger  of 
death  by  compression,  there  is  the  risk  that  the 
abscess  may  break  into  the  ventricles  or  into  the 
subarachnoid  space.  Some  cases  are  on  record  in 
which  spontaneous  openings  into  the  nose  or  into 
the  ear  occurred,  and  profuse  discharge  followed, 
the  patient  in  the  end  recovering.  It  may  be 
doubted  whether  these  were  not  instances  of 
meningeal  abscess. 

Treatment. — It  is  needless  to  say  that  if  ab- 
scess be  diagnosed  with  any  degree  of  confidence 
a-n  opening  is  essential.  There  is  little  or  no 
room  for  medical  treatment.  For  the  prevention 
of  abscess,  in  all  cases  in  which  injuries  likely  to 
produce  it  have  occurred,  the  utmost  precautions 
should  be  enforced.  Mercury  in  small  doses,  fre- 
qently  repeated,  should  be  given  from  the  first ; 
the  injured  region  should  be  covered  with  lint 
soaked  in  a strong  spirit-of-wine  lotion,  frequently 
re-wetted  ; purgatives  should  be  administered  ; 
and  the  patient  should  be  kept  very  quiet  until 
long  after  the  healing  of  the  wound. 

Jonathan  Hutchinson. 

BRAIN,  Anaemia  of.— Definition. — A con- 
dition in  which  the  blood  contained  within  the 
capillaries  of  the  brain  is  deficient  in  quantity, 
or  defective  in  quality. 

The  blood  within  the  brain  is  contained  in 
arteries,  capillaries,  and  veins.  The  functional 
condition  of  the  brain  depends  on  the  quantity 
and  quality  of  the  blood  circulating  in  its  capil- 
laries, and  it  is  to  these  that  the  special  symptoms 
are  related.  Deficiency  in  the  quality  of  th» 


BRA  IX,  AN2EMIA  OF.  J37 


blood  supplied  to  the  brain  is  always  of  gradual 
occurrence,  andaffeets  the  whole  brain ; deficiency 
in  quantity  of  blood  may  affect  the  whole  brain 
or  part  only,  and  it  may  be  sudden  or  gradual  in 
its  production. 

Aetiology. — General  cerebral  anemia  may  be 
due  to  the  following  causes: — (1)  It  may  be  a 
part  of  systemic  amentia — defect  in  quantity  or 
quality  of  the  whole  blood,  and  due  to  causes 
which  are  considered  elsewhere.  This  is  often 
seen  in  cases  of  htemorrhage,  of  exhausting 
discharges,  or  of  defective  blood-nutrition,  as 
in  chlorosis,  (2)  The  supply  of  blood  to  the 
brain  may  be  deficient,  the  quantity  of  blood  in 
tho  body  being  normal.  This  may  be  due  to 
cardiac  weakness,  or  to  causes  acting  through 
the  nervous  system  on  the  heart,  as  in  swooning. 
In  systemic  anaemia,  the  lessened  cardiac  power 
increases  the  cerebral  deficiency.  Whatever 
lessens  the  amount  of  blood  discharged  from  the 
heart  at  each  systole,  such  as  aortic  or  mitral 
disease,  may  be  a cause  of  cerebral  anaemia. 
Pressure  on  the  vessels  conveying  the  blood  to 
the  head,  as  by  an  aortic  aneurism,  has  a similar 
effect.  Unequal  distribution  of  the  systemic 
blood  is  another  cause.  The  intestinal  vessels, 
if  dilated,  are  capable  of  containing  a large  part 
of  the  blood,  of  the  body,  and  the  effect  of  their 
engorgement  is  often  seen  after  paracentesis 
abdominis.  One  theory  of  shock  ascribes  its 
mechanism  to  vaso-motor  dilatation  of  these 
vessels,  and  consequent  anaemia  of  the  rest  of 
the  system.  The  effect  of  each  cause  is  increased 
by  the  action  of  gravitation  in  the  erect  posture. 
Some  causes  act  only  in  that  position.  (3)  The 
capacity  of  the  cerebral  vessels  may  be  diminished 
by  pressure  on  the  brain,  exerted  by  effusions 
of  fluid  (hydrocephalus),  of  blood  (in  cerebral 
and  meningeal  haemorrhage),  or  by  growths  within 
the  skull. 

Partial  cerebral  anemia  is  due  to  some  ob- 
struction to  the  passage  of  the  blood  through 
tho  vessels.  To  be  permanently  efficient  such 
obstruction  must  be  situated  beyond  the  circle  of 
Willis.  Ligature  of  one  carotid  causes  immediate 
symptoms  of  cerebral  anaemia,  but  permanent 
symptoms  are  not  frequent.  Pressure  on,  or 
disease  of  one  carotid,  for  the  same  reason  rarely 
gives  rise  to  symptoms.  Obstruction  in  certain 
arteries  of  the  brain  may  cause  local  ansemia, 
sudden  or  gradual,  temporary  or  permanent, 
according  to  its  cause.  Such  obstruction  may  be 
due  to  narrowing  of  the  calibre  of  the  vessel  by 
atheromatous  changes  in  its  wall,  or  by  spasm 
of  its  muscular  coat,  or  may  be  due  to  actual 
occlusion  by  embolism  or  thrombosis.  The 
pressure-effects  of  an  intruding  substance  within 
the  skull  (tumour,  or  clot)  act  most  intensely  in, 
and  may  influence  only  one  region  of  the  brain. 

It  is  obvious  that  of  these  causes  some  act 
suddenly,  others  gradually,  and  the  symptoms 
produced  will  differ  accordingly. 

Anatomical  Characters. — The  principal  ana- 
tomical character  of  cerebral  anaemia  is  pallor 
of  the  brain,  observable  chiefly  in  the  paler  tint 
of  the  cortical  substance,  and  the  diminished 
number  of  red  spots  in  the  white  centre.  The 
pallor  may  bo  partial  or  general.  The  mem- 
branes are  usually  pale,  but  in  some  cases  of 
partial  anaemia  they  are  hyperaemic.  Effusion 


of  serum  in  the  meshes  of  the  pia  mater  and 
between  the  convolutions,  may  be  found  in 
general  anaemia. 

Symptoms. — The  symptoms  of  this  condition 
vary  according  as  the  an®mia  is  suddenly  or 
slowly  produced,  and  as  it  is  general  or  partial. 

(1)  In  sadden  general  ansemia  of  the  brain  the 
sufferer  feels  drowsy;  the  special  senses  are 
dulled  ; noises  in  the  ears  and  vertigo  are  com- 
plained of;  the  pupils  are  at  first  contracted; 
sight  may  fail;  muscular  power  is  weakened; 
respiration  is  sighing;  the  skin  is  pale,  cold,  and 
moist ; nausea  is  common  ; and  headache  is  rare. 
If  the  anaemia  is  more  intense,  consciousness  is 
lost ; there  is  universal  paralysis ; and  general 
convulsions  may  occur,  epileptiform  in  character, 
these  being  especially  frequent  in  sudden  exten- 
sive losses  of  blood  in  strong  subjects.  The  pupils 
dilate,  and  the  coma  may  deepen  to  death.  The 
loss  of  sight  in  cases  which  recover  may  persist  as 
permanent  amaurosis. 

(2)  When  general  ansemia  of  the  brain  is 
slowly  produced,  the  state  of  the  cerebral  func- 
tions is  usually  that  of  ‘irritable  weakness.’ 
Their  action  is  imperfect  in  degree,  and  excited 
with  undue  facility.  There  is  mental  dulness 
and  drowsiness ; sometimes,  however,  insomnia 
is  troublesome.  Delirium  is  common  in  severe 
cases,  and  is  conspicuous  in  some  forms  of  im- 
perfect blood-nutrition,  as  in  the  so-called 
‘ inanition  delirium.’  Headache,  usually  general, 
is  a common  symptom.  Sensory  hypermsthesi®, 
tinnitus,  muse®  volitantes,  and  vertigo  are  fre- 
quent. Convulsions  are  rare,  but  muscular  power 
is  generally  deficient.  All  these  phenomena  are 
more  marked  in  the  erect  than  in  the  recumbent 
posture,  especially  when  the  erect  posture  is 
suddenly  assumed.  It  has  been  remarked  that 
some  an®mie  persons  can  think  well  only  when 
lying  down.  In  young  children,  after  exhausting 
discharges,  as  diarrhoea,  symptoms  referable  to 
cerebral  an®mia  are  common,  namely,  somnolence 
and  pallor,  with  depressed  fontanelle  and  con- 
tracted pupils.  The  somnolence  may  deepen  to 
coma  with  insensitive  conjunctiva,  and  the  coma 
increase  to  death.  Such  symptoms  have  been 
called  hydrocephalcid,  from  some  resemblance  to 
those  of  acute  hydrocephalus. 

(3)  Partial  cerebral  an®mia  causes,  if  complete, 
loss  of  function  in  the  affected  area ; and  if  it  be 
permanent,  as  in  obstruction  of  a vessel  beyond 
the  circle  of  "Willis,  necrosis  of  the  cerebral  tissue 
results  (see  Brain,  Softening  of).  Ifincomplete  and 
sudden,  there  is  temporary  arrest  of  function. 
Ligature  of  one  carotid,  for  instance,  causes 
transient  weakness  and  numbness  in  the  opposite 
half  of  the  body.  There  may  be  at  first  an  over- 
action of  grey  matter,  causing,  in  certain  regions, 
unilateral  convulsions.  If  slowly  developed,  as 
in  atheroma  of  arteries,  pain  and  vertigo  are 
common,  with  recurring  local  symptoms,  such  as 
numbness,  tingling,  and  weakness. 

In  all  cases  of  long-continued  cerebral  ansmia, 
permanent  damage  to  the  nutrition  of  the  brain 
may  result.  In  the  child  the  development  of  the 
brain  may  be  arrested;  in  the  adult,  loss  of 
memory  and  of  general  mental  power  indicate 
the  deterioration  of  structure. 

Pathology. — The  symptoms  are,  as  already 
stated,  dependent  mainly  on  the  defective  quantity 


1S8  BRAIN,  ANAEMIA  OF. 

and  quality  of  the  blood  circulating  in  the  brain. 
Some  influence  may  probably  be  ascribed  to  the 
diminution  in  the  blood-pressure  to  which  the 
nerve-elements  are  ordinarily  exposed  (Burrows). 
Nothnagel  has  pointed  out  that  the  symptoms 
indicate  an  early  affection  of  the  respiratory 
centre  in  the  medulla,  and  of  the  cortical  grey 
matter.  Kussmaul  and  Tenner  ascribe  the  con- 
vulsions in  acute  anaemia  to  the  irritation  of  the 
medulla ; Nothnagel,  to  that  of  the  pons  Varolii. 

Diagnosis. — The  diagnosis  is  not  difficult.  It 
rests  on  the  recognition,  in  a given  case,  of  the 
causes  of  cerebral  anaemia ; and  on  the  exclusion 
of  graver  maladies,  as  organic  cerebral  disease. 
With  the  latter,  it  should  be  remembered,  anaemia 
of  the  brain,  local  or  general,  often  co-exists. 
Some  symptoms  of  hyperaemia  of  the  brain  closely 
resemble  those  of  ansemia.  A common  patho- 
logical state  of  imperfect  blood-renewal  probably 
exists  in  both  conditions. 

Pbognosis. — The  extent  to  which  the  cause 
of  the  anaemia  is  amenable  to  treatment,  and  is  of 
transient  character,  must  influence  the  prognosis. 
As  a rule  this  is  favourable  when  there  is  no  or- 
ganic disease  of  heart,  vessels,  or  brain.  In  the 
so-called  ‘pernicious  amemia,’  the  prognosis  is,  of 
course,  unfavourable.  Hydrocephaloid  symptoms 
in  infants,  if  met  by  prompt  and  suitable  treat- 
ment, are  usually  recovered  from. 

Treatment. — The  treatment  necessarily  varies 
in  the  several  forms  of  the  affection,  but  it  is  in 
the  main  causal.  The  beneficial  effect  of  the 
recumbent  posture  in  affording  immediate  relief 
to  the  symptoms,  and  obviating  permanent 
damage  to  the  cerebral  nutrition,  must  be  always 
remembered.  In  acute  aniemia  from  loss  of 
blood,  the  head  must  be  kept  continuously  low, 
stimulants  freely  administered,  and  as  a penulti- 
mate resort  bandages  applied  to  the  limbs  from 
below  upwards  may  increase  the  proportionate 
supply  of  blood  to  the  brain.  If  this  fails  trans- 
fusion must  be  had  recourse  to.  In  chronic 
ansemia  sudden  change  of  posture  should  be 
carefully  avoided,  and  ferruginous  tonics  are 
needed.  In  spasm  of  the  cerebral  vessels,  bro- 
mides are  useful.  In  the  cerebral  ansemia  of 
syncope,  the  recumbent  posture,  stimulants  to 
the  skin,  cold  water,  faradisation,  sinapisms,  and 
ammonia  to  the  nasal  mucous  membrane,  assist 
the  recovery  of  cardiac  action  and  the  return  of 
consciousness.  In  all  cases,  carefully  regulated 
food  and  stimulants  are  needed ; beef-tea  should 
be  given  iu  small  quantities,  at  frequent  inter- 
vals. The  group  of  symptoms  called  hydrocepha- 
loid require  similar  treatment. 

W.  R.  Gowers. 

BRAIN",  Aneurism  of.  See  Brain,  Vessels 
of,  Diseases  of. 

BRAIN",  Atrophy  of. — Atrophy  of  the  brain 
may  be  congenital,  due  to  arrest  of  development 
in  very  early  fetal  life  ; or  the  constituents 
of  the  brain  may  have  been  perfectly  developed, 
and  may  subsequently  disappear  from  one  of 
several  causes.  This  morbid  state  is  regarded  as 
; primary  when  tlieere  has  been  no  pre-existing 
disease  of  the  brain  or  its  membranes ; secondary, 
either  when  there  has  been  such  pre-existing 
disease,  and  the  atrophy  has  occurred  from 
absorption  of  the  part  broken  down  by  in- 
flammation. softening,  haemorrhage,  &c. ; when 


BRAIN,  ATROPHY  OF. 
atrophy  of  some  special  cerebral  organ  follow! 
upon  destruction  of  the  particular  nerve  thal 
arises  from  it;  or  when  localised  atrophy  ha: 
taken  place  in  a very  gradual  manner  from  pres- 
sure of  a tumour,  of  ventricular  effusion,  &c 
To  take  these  forms  in  order: — 

1.  Congenital  atrophy. — This  is  usually  asso- 
ciated with  weakness  of  intellect,  even  to  the 
extent  of  idiocy : there  is  atrophy  of  the  body  op- 
posite to  the  side  of  the  cerebral  lesion,  and  this 
atrophy  involves  all  structures,  even  the  bones. 
Paralyses  of  various  intensity  supervene,  often 
with  contraction  of  the  paralysed  parts  ; there 
being  no  particular  sensitiveness  of  the  special 
senses,  possibly  because  of  the  mental  hebetude. 
Epileptic  attacks  are  common;  vitality  is  low; 
and  the  patient  easily  succumbs  to  other  diseases. 

2.  Primary  atrophy. — In  this  variety  there  is 
general  diminution  both  of  volume  and  of 
weight,  affecting  most  usually  the  cerebral 
hemispheres,  and  that  in  pretty  equal  degree. 
It  is  most  common  as  a condition  of  old  age — 
senile  marasmus,  atrophia  cerebri  senilis.  It  some- 
times in  earlier  life  follows  exhausting  diseases  ; 
and  may  also  be  caused  by  deficient  or  impure 
blood-supply  to  the  brain.  In  close  connexion 
with  this  mode  of  causation  it  is  seen  after  re- 
peated attacks  of  intoxication,  especially  after 
delirium  tremens.  In  this  last  condition  the 
cerebral  atrophy  may  be  acute  and  rapid. 

.3.  Secondary  atrophy. — This  may  be  general 
or  partial.  When  general,  the  convolutions  have 
a shrunken  appearance,  and  there  is  always  an 
increase  of  the  subarachnoid  fluid.  This  condition 
follows  various  lesions  of  the  brain,  especially  oi 
the  convex  surface,  such  as  haemorrhage  of  the 
convexity,  encephalitis,  or  more  accurately  that 
form  of  encephalitis  that  attacks  only  the  grey 
matter  or  perhaps  only  one  layer  of  the  grev 
matter,  as  in  some  mental  diseases.  When  the 
atrophy  is  partial,  there  are  found  depressions  in 
an  otherwise  normal  hemisphere,  at  which  point 
a localised  haemorrhage  or  patch  of  softening, 
inflammatory  or  depending  on  thrombosis  or 
embolism  of  vessels,  bas  been  absorbed,  leaving 
only  a cavity  of  greater  or  less  extent,  filled  with 
fluid  and  sometimes  lined  with  a thin  membrane. 
A certain  portion  also  of  the  brain  may  become 
atrophied  by  the  gradual  pressure  of  a tumour 
or  any  foreign  body.  Even  the  little  sieve-like 
depressions  seen  in  various  situations  after  con- 
stantly repeated  congestion  of  vessels  may  be 
the  result  of  atrophy  from  compression  by  the 
distended  vessels.  Functional  inactivity  and 
atrophy  of  the  optic  nerves  has  led  to  a similar 
abnormality  of  the  corpora  quadrigemina. 

Anatomical  Characters.  — The  atrophied 
brain  or  portion  of  brain  will  vary  in  appear- 
ance on  minute  examination,  according  as  the 
lesion  has  or  has  not  been  preceded  by  inflam 
mation.  When  the  atrophy  is  primary  and  due 
to  gradual  interference  with  blood-supply,  thero 
is  seen  a shrunken  condition  of  the  nerve-tissue, 
especially  of  the  calibre  of  the  nerve-tubes.  Tho 
cells  are  smaller  than  usual  and  pigmented,  the 
arteries  being  decreased  in  size  or  themselves 
diseased.  If  the  lesion  has  had  an  inflammatory 
origin,  the  process  in  order  of  sequence  is,  first, 
inflammation,  then  softening  with  fatty  degene- 
ration then  partial  absorption,  and  so  atrophy  : 


BEAIN,  ATEOPHY  OP. 

the  appearances  differing  according  to  the  stage 
of  the  lesion.  Traces  of  fatty  degeneration  of 
all  the  tissues, — vessels,  nerve-tubes,  and  cells, 
— may  be  found,  -with  the  neuroglia  either  -want- 
ing or  sclerosed. 

Dr.  Budolph  Arndt  has  lately  thrown  doubt 
on  the  possibility  of  determining  atrophy  of  the 
ganglionic  bodies  or  nerve-tubes  by  their  size. 
The  size  of  these  bodies  varies  so  greatly,  within 
the  limits  of  health,  that  he  considers  this  test  a 
very  uncertain  one.  Almost  the  only  trustworthy 
sign  of  atrophy,  in  his  opinion,  is  the  appearance 
in  the  substance  of  the  ganglionic  bodies  and  in 
the  medullary  sheath  of  nerve-bundles,  of  black 
shining  globules,  somewhat  fatty-looking.  In 
process  of  time  these  globules  increase  in  number, 
and  at  last  the  whole  of  the  bodies  appear  per- 
meated by  them.  These  globules  are  not  fatty, 
they  are  certainly  more  or  less  pigmental. 
Exactly  similar  bodies  appear  at  post-mortem 
examinations,  and  are  a sign  of  simple  decom- 
position. The  duration  of  this  condition,  irre- 
spective of  pre-existing  lesions,  is  protracted. 

Symptoms. — The  symptoms  of  atrophy  of  the 
brain  necessarily  vary  according  to  the  seat,  ex- 
tent. and  aetiology  of  the  lesion.  Primary  atrophy 
of  the  cerebral  hemispheres  and  the  first  form 
of  secondary  atrophy  will  most  usually  induce 
imbecility,  or  some  lesser  degree  of  mental  in- 
sufficiency, loss  of  memory,  slowness  of  thought, 
and  other  mental  diseases.  Headache,  giddiness, 
delirium,  and  stupor  are  seldom  met  with.  In- 
terference with  speech  is  more  common.  Affec- 
tions of  sight,  and  of  the  motor  condition  of 
the  eye,  do  not  depend  on  general  atrophy  of 
the  brain  ; they  own  a more  local  cause. 

Convulsions,  paralysis,  stiffness  of  muscles,  or 
contractions  are  often  met  with  in  connexion 
with  this  general  lesion,  as  well  as  various  irregu- 
larities of  locomotion  : but  it  must  be  remembered 
that  general  atrophy  of  brain  is  not  seldom  as- 
sociated with  atrophic  or  sclerotic  lesions  of  the 
spinal  cord,  and  even  where  this  is  not  so, 
several  of  the  morbid  phenomena,  and  particu- 
larly convulsion  and  paralysis,  may  derive  their 
origin,  not  from  the  atrophy,  but  from  the  con- 
dition pre-existent  to  the  atrophy,  such  as 
haemorrhage  of  the  convexity,  meningitis,  or 
peri-encephalitis. 

In  secondary  atrophy  of  a more  limited  extent, 
the  symptoms  are  apt  to  be  more  strictly  local- 
ised, such  as  partial  loss  of  power  in  a single 
limb,  slight  imperfections  of  speech,  or  strabis- 
mus ; but  here  again  the  positive  diagnosis  of 
atrophy  is  hindered  by  the  complication  of  pre- 
existent disease,  the  local  congestions,  haemor- 
rhages, softenings,  tumours,  or  other  conditions 
of  which  the  atrophy  is  only  the  sequence.  Still 
less  characteristic  are  the  phenomena  attending 
general  or  partial  atrophy  of  the  cerebellum,  the 
pons,  and  the  medulla  oblongata. 

Treatment.— Treatment  is  useless  as  to  the 
atrophy  of  the  brain  : it  must  be  directed  to 
supporting  the  powers  of  the  patient. 

E.  Long  Eox. 

BEAIN,  Carcinoma  of.  See  Brain,  Tu- 
mours of. 

BEAIN,  Compression  of.— The  brain  is 
cum;  rc>svd  in  the  pathological  sense  whenever  its 


BEAIN,  COMPBESSION  OF.  .30 

| structure  is  so  squeezed  that  its  functions  are  in 
any  degree  interfered  with.  This  squeezing  may 
be  effected  either  by  the  effusion  of  blood  within 
the  skull,  the  growth  of  a tumour,  the  accumula- 
tion of  pus  or  serum,  or  lastly  by  the  depression  of 
some  large  portion  of  the  bony  parietes.  The 
general  belief  that  depressed  fractures  are  fre- 
quently the  cause  of  compression  is  probably  quite 
a mistake.  In  such  cases  the  fragment  displaced 
is  rarely  of  sufficient  size  to  cause  serious  com- 
pression of  the  contents  of  the  skull,  and  thc- 
symptoms  usually  supposed  to  indicate  that  state 
are  really  due  in  most  cases  to  laceration  and 
contusion,  or  to  subsequent  inflammation.  This 
point  is  of  great  importance  in  practice,  for  upon 
its  recognition  depends  much  of  the  validity  of 
the  reasoning  by  which  the  operation  of  primary 
trephining  in  compound  fractures  is  defended  or 
condemned.  It  also  offers  a most  serious  fallacy 
as  regards  the  interpretation  of  the  symptoms 
due  to  compression. 

By  far  the  best  examples  of  uncomplicated 
compression  of  brain  are  supplied  to  us  by  the 
not  very'  infrequent  cases  in  which  a middle 
meningeal  artery  is  injured,  and  a large  blood- 
clot  is  effused  between  the  dura  mater  and  bone. 
It  is  from  observation  of  cases  of  this  kind  that 
the  assertion  is  justified,  that  a very  considerable 
intrusion  into  the  skuil  is  permitted  without 
the  production  of  any  symptoms.  No  doubt  the 
suddenness  or  otherwise  has  much  to  do  with 
the  results,  but  there  seems  good  reason  to  believe 
that,  as  a rule,  the  brain  will  easily  accommodate 
itself  to  quantities  not  exceeding  an  ounce  or 
two,  and  that  usually  so  large  a quantity  as  four 
or  five  ounces  is  required  to  cause  death.  It  is 
very  rarely  indeed  that  a depression  of  bone  in  the 
least  approaches  such  an  extent  of  intrusion  as 
this,  and  the  majority  of  such  cases  are,  as  regards 
the  amount  of  possible  squeezing,  quite  trivial. 
The  manner  in  which  the  accommodation  is 
effected  is  by  the  removal  of  the  fluid  contents 
of  the  skull,  first  the  subarachnoid  fluid,  and 
secondly'  the  blood.  Of  the  blood-vessels  the 
veins  and  venous  sinuses  are  probably  emptied 
first,  and  lastly  the  arteries  and  capillaries.  A 
brain  in  a state  of  strong  compression  is  an  ex- 
sanguine! brain.  In  this  respect,  the  brain  in 
the  last  stage  of  compression  differs  very  much 
from  that  in  cases  of  insensibility  from  con- 
cussion or  contusion.  It  by  no  means  follows 
that  because  the  brain  is  pale,  the  face  should  be 
pale  also  ; but  it  is  perhaps  usually  the  case 
that  extreme  compression  so  much  enfeebles 
the  heart’s  action  that  the  pulse  is  weak  or 
flickering,  the  respiration  shallow  and  irregular, 
and  the  skin  pale  and  cold.  That  stertorous 
breathing,  a laboured  pulse,  and  a suffused  and 
dusky  countenance,  are  (as  according  to  the  clas- 
sical description)  symptoms  of  compression,  is 
probably  for  the  majority  of  cases  a mistake. 
Such  a group  much  more  frequently  denotes 
laceration,  contusion,  or  central  extravasation. 
Nor  is  it  true  that  hemiplegia,  exceptirg  of  the 
most  transitory  kind,  is  often  due  to  compression. 
A clot  of  blood  poured  out  over  one  hemisphere 
may,  if  rapidly  effused,  produce  for  a while 
weakness  of  the  opposite  limbs,  but  the  brain 
mass  is  soft  enough  to  allow  of  considerable 
yielding,  and  in  the  course  of  a few  hours  the 


BRAIN,  COMPRESSION  OF. 


140 

efforts  of  the  displacement  will  hare  become 
general,  and  not  local.  In  a ease  recorded  by 
the  writer  in  which  a post-mortem,  some  weeks 
later,  proved  the  presence  of  a large  blood-clot, 
there  had  been  partial  hemiplegia  without  un- 
'rmsciousness  at  first,  but  on  the  next  day  all 
trace  of  it  had  disappeared,  and  it  never  re- 
turned. In  many  of  the  cases  cf  bleeding  be- 
tween the  dura  mater  and  bone,  from  the  men- 
ingeal artery,  the  haemorrhage  takes  place  on 
several  different  occasions,  with,  it  may  be,  inter- 
vals of  a day  or  two,  much  as  is  often  observed 
in  wounds  of  arteries,  such  as  the  palmar  arch. 
Thus  the  observer  is  able  to  appreciate  the 
symptoms  caused  by  different  degrees  of  com- 
pression, and  further  proof  is  afforded  that,  if 
the  intruded  quantity  be  but  moderate,  the 
brain  bears  it  without  obvious  inconvenience. 
Often  at  the  autopsy  it  is  quite  easy  to  dis- 
tinguish clots  of  very  different  dates,  and  to  feel 
sure  that  the  original  one  was  of  considerable 
size.  It  is  clear  then  that  in  speaking  of  the 
symptoms  of  compression  wo  must  allow  for 
differences  in  amount  of  the  compressing  sub- 
stance, and  also  for  differences  in  the  rapidity  or 
suddenness  of  its  application. 

When  compression  is  produced  instantaneously, 
as  by  a large  fragment  of  bone  driven  down,  the 
case  is  almost  invariably  complicated  by  con- 
tusion. If  paralysis  or  even  insensibility  be 
present,  it  is  usually  impossible  to  say  to  which 
lesion  they  are  really  due.  We  may,  however, 
hold  it  almost  certain,  from  what  we  know  of 
other  cases,  that  the  effects  in  such  would  be  a 
temporary  hemiplegia,  with  symptoms  of  shock 
if  the  depression  were  but  moderate ; and  insen- 
sibility, probably  soon  followed  by  death,  if  the 
depression  were  very  great.  The  cases  in  which 
depression  of  bone  has  alone  been  sufficient  to 
produce  long-continued  compression  with  insensi- 
bility are  possibly  somewhat  apocryphal.  It  is 
possible  that  compression  under  such  circum- 
stances might  be  attended  by  stertor  and  la- 
boured pulse,  but  it  is  possible  also  that  the  pulse 
might  be  extremely  feeble,  the  countenance  pale, 
and  inspiratory  efforts  weak  and  irregular. 

The  depression  of  bone  is  perhaps  the  only 
condition  which  can  be  supposed  capable  of 
producing  compression  suddenly.  When  blood 
is  poured  out  from  a ruptured  artery,  the  symp- 
toms come  on  rather  gradually.  The  patient 
complains  perhaps  of  headache,  and  then  be- 
comes more  or  less  confused  in  manner,  his  gait 
is  unsteady,  and  the  limbs  on  the  side  opposite 
to  the  injury  show  special  weakness.  Vomit- 
ing may  occur  and  the  weakened  limbs  may  twitch, 
and  unless,  as  is  often  the  case,  the  intracranial 
bleeding  stops,  these  symptoms  are  soon  lost  in 
a state  of  complete  insensibility,  with  pale  face, 
feeble  pulse,  and  symptoms  of  shock.  Convul- 
sions may  now  occur,  and  death  often  supervenes 
very  quickly.  In  such  a case  the  whole  course 
of  the  symptoms  may  occupy  less  than  an  hour. 
The  surgeon  ought,  of  course,  to  trephine  and 
let  out  the  blood,  and  he  must  be  prompt,  or  his 
patient  may  die  during  his  preparations.  More 
commonly  this  rapid  termination  occurs  unex- 
pectedly after  one  or  more  previous  attacks  of 
temporary  head-symptoms,  and  the  patient  may 
have  appeared  quite  well  in  the  intervals.  In 


cases  in  which  tho  symptoms  progress  without 
interruption,  their  rapidity,  no  doubt,  depends 
upon  the  size  of  the  vessel  ruptured.  Certain 
special  symptoms  will  also  depend  upon  the  pre- 
cise position  taken  up  by  the  clot  which  may 
chance  to  press  upon  special  nerve-trunks  as 
well  as  upon  the  brain-mass.  In  ordinary  cases 
the  clot  is  beneath  the  squamous  bone  and  the 
lower  part  of  the  parietal,  and  passes  downwards 
into  the  sphenoidal  fossa.  In  the  latter  region 
it  may  press  upon  the  nerves  going  to  the 
sphenoidal  fissure;  and  it  is  of  importance  for 
the  surgeon  to  know  that  dilatation  of  the  pupil 
on  the  affected  side  is  often  produced.  This 
important  symptom  is  probably  due  to  pressure 
upon  the  third  nerve. 

There  is  yet  another  class  of  compression- 
cases  in  which  that  condition  is  produced  by  the 
slow  accummulation  of  the  products  of  inflam- 
mation within  the  skull.  Much  will  depend, 
as  regards  special  symptoms,  upon  the  position 
of  the  abscess,  either  within  or  without  the  brain. 
If  in  the  substance  of  the  brain,  it  must  more  cr 
less  disorganise  its  structure,  and  thus  cause 
symptoms  due  to  laceration  as  well  as  compres- 
sion. Under  such  conditions  some  degree  of 
hemiplegia,  with,  probably,  preceding  spasms  of 
limbs,  can  scarcely  fail  to  be  present.  Now  and 
then  cases  occur  in  which  an  irregular  sinus 
leads  into  an  abscess-cavity  in  the  brain,  and 
this  sinus  being  sometimes  free  and  sometimes 
blocked,  the  surgeon  has  repeated  opportunity 
of  estimating  the  effects  of  filling  of  the  cavity. 
In  such  cases,  headache,  stupor,  unilateral  twitch- 
ing of  limbs,  partial  hemiplegia,  with,  perhaps, 
vomiting,  and,  it  may  be,  general  convulsions, 
are  the  symptoms  to  be  expected.  The  position 
of  the  abscess  as  regards  different  regions  of  the 
brain  is  also  of  much  importance,  but  its  discus- 
sion cannot  be  entered  upon  in  any  detail  here, 
and  it  obviously  concerns  rather  disorganisation 
of  structure  than  simple  compression. 

When  a large  accumulation  of  pus  takes  place 
between  the  bone  and  dura  mater,  the  symp- 
toms produced  are  much  the  same  as  those 
caused  by  blood-clot.  We  must  make,  however, 
much  allowance  for  the  fact  that  these  cases  are 
almost  always  attended  by  meningitis,  and  thus 
the  symptoms  of  compression  are  masked  by 
those  due  to  inflammation.  Chronic  abscess 
under  the  bone  without  arachnitis  may  occur 
now  and  then  in  syphilitic  and  other  disease  of 
the  skull-bones,  but  such  cases  are  very  rare. 
Such  cases  will  differ  from  those  of  haemorrhage 
in  that  the  symptoms  are  always  produced  verv 
slowly.  The  writer  once  had  the  opportunity 
of  watching  such  a ease,  in  which  the  patient 
died  of  compression,  very  gradually  produced, 
and  without  any  complication.  The  chief  symp- 
tom was  constant  wearing  headache,  which  pre- 
vented sleep.  The  man  was  pale  and  feeble, 
but  not  paralysed  in  any  part,  excepting  that 
both  eyelids  drooped.  He  was  rational,  but  spoke 
slowly,  as  if  in  a state  of  partial  stupor.  During 
the  last  two  or  three  days  of  life  he  had  convul- 
sions, and  finally,  for  twenty-four  hours,  he  was 
in  a state  of  increasing  insensibility. 

Diagnosis. — It  will  he  seen  from  what  has 
been  said  above  that  the  diagnosis  of  compression 
by  symptoms  is  exceedingly  difficult,  and  that 


BRAIN,  COMPRESSION  OP. 
the  -utmost  us6  must  in  each  ease  be  made  of  the 
history  of  the  case.  In  those  of  blood-compression 
after  injury  to  a meningeal  artery,  there  is  almost 
always  the  fact  that  the  patient  between  the 
date  of  the  injury  and  the  supervention  of  symp- 
toms had  an  interval  during  which  there  ap- 
Deared  to  be  little  or  nothing  the  matter.  This 
history  is,  if  the  symptoms  have  developed 
rapidly  and  without  the  signs  of  inflammation, 
by  itself  conclusive  for  diagnosis.  Under  such 
conditions  trephining  ought  to  be  at  once  resorted 
to,  or  possibly  it  might  be  yet  better  practice  to 
first  tie  the  carotid  artery. 

The  diagnosis  of  abscess  in  the  brain-sub- 
stance has  already  been  discussed,  and  that  of 
inflammatory  collections  from  meningitis  will 
be  examined  in  its  proper  place  (see  Meninges, 
Diseases  of). 

Treatment. — The  treatment  of  compression 
of  the  brain  is  almost  wholly  surgical,  and  con- 
sists in  the  use  of  the  trephine  and  knife  tc 
elevate  depressed  bone,  or  evacuate  collections  of 
blood  or  pus.  Jonathan  Hutchinson. 

BRAIN,  Concussion  of. — We  class  under 
the  head  ‘ Concussion  of  Brain  ’ all  symptoms 
which  result  simply  from  the  shaking,  more  or  less 
violently,  of  the  contents  of  the  skull.  It  will  he 
obvious,  however,  that  most  cases  of  severe  shake 
of  the  brain  are  likely  to  he  complicated  by  visible 
lesions.  The  skull  may  be  broken  and  the  brain 
may  he  contused,  lacerated,  or  ecchymosed.  It  is 
highly  probable,  however,  that  well-marked  and 
even  serious  symptoms  may  be  produced  by 
shaking  only,  and  without  the  existence  of  any 
lesion  discoverable  either  by  the  unaided  eye  or 
the  microscope.  We  must  further  clearly  under- 
stand that  this  element  of  concussion  ( i.e . the  re- 
sults of  shake  independent  of  lesion)  enters  into 
almost  every  case  of  injury  to  the  head.  Whatever 
be  the  other  lesions,  it  is  usually  the  fact  that  the 
brain  has  been  more  or  less  severely  shaken. 
Thus  it  may  easily  happen  in  cases  in  which 
conspicuous  lesions  are  present,  such  as  fracture 
of  the  base  or  local  contusion,  that  still  the  results 
of  the  shake  are  the  most  important.  It  might  be 
convenient  if  we  were  in  the  habit  of  speaking  of 
most  eases  of  severe  injury  to  the  head  as  Concus- 
sion plus  other  lesions,  with  the  endeavour  to 
assign  to  eaeh  added  complication  its  proper 
share  in  the  general  result.  These  explanations 
are  necessary  before  we  put  the  question — Can 
concussion  alone  cause  death  ? Although  it  is 
highly  probable  that  we  ought  to  reply  with  a 
very  confident  affirmation,  and  to  assert  that  it  is 
very  common  for  concussion  to  be  the  chief  cause 
of  the  fatal  event,  yet  it  is  very  difficult  to  prove 
it,  since  the  cases  are  extremely  rare  in  which 
severe  concussion  is  produced  without  some 
attending  lesion.  The  symptoms  caused  by  con- 
cussion of  the  brain  may  he  studied  in  very  nu- 
merous cases  of  very  various  degrees  of  severity, 
which  yet  recover  perfectly.  From  what  is 
observed  in  these,  we  may  infer  as  to  the  part 
which  concussion  takes  in  complicated  cases  many 
of  which  prove  fatal. 

The  results  of  concussion  may  be  divided  into 
three  stages  —the  first  stage  is  that  of  collapse  ; 
the  second,  that  of  reaction,  or  of  vaso-motor 
paresis,  or,  if  named  from  its  most  prominent 


BRAIN,  CONCUSSION  OF.  HI 
symptom,  the  sleepy  stage ; the  third  is  that  of 
convalescence,  or  recovery.  The  symptoms  of 
the  first  stage,  or  stage  of  coflapse,  vary  with 
the  severity  of  the  case,  hut  if  at  all  well- 
marked  consist  in  feebleness  of  pulse,  pallor  of 
skin,  coldness  of  extremities,  and  dilatation  of 
pupils.  They  may  approach  a condition  which 
threatens  immediate  death.  There  is  no  stertor, 
for  the  respiration  is  too  feebly  performed.  Al- 
though the  collapse  may  be  very  great,  the  in- 
sensibility is  rarely  quite  complete.  It  is  of  greaf 
importance  in  this  stage  to  establish  the  negative 
as  regards  all  forms  of  paralysis.  If  any  non- 
symmetrical  symptoms  are  present,  the  ease  is 
more  than  mere  concussion.  During  this  stage 
nothing  should  he  done,  except  placing  the 
patient  in  a condition  of  comfort,  and  preventing 
the  cooling  of  the  body.  Stimulants,  unless  the 
collapse  is  extreme,  should  be  avoided.  After 
the  collapse  has  lasted  some  little  time  (half-an- 
hour  to  two,  three,  or  more  hours),  it  begins  to 
pass  off.  The  patient  moans,  manifests  discom- 
fort, turns  on  his  side,  and  draws  his  knees  up. 
Very  often  at  this  period  sickness  occurs,  and  it  is 
almost  invariable  if  the  patient’s  stomach  was 
full  at  the  time  of  the  accident.  Consciousness 
is  now  usually  restored,  and,  by  rousing,  the 
patient  may  he  induced  to  speak,  and  will  tell 
his  name,  &c.  Gradually,  during  a period  of 
some  hours,  the  case  slides  on  into  the  sleepy 
stage.  The  pulse  is  now  relaxed  and  full,  the 
skin  is  warm  or  even  hot,  the  face  may  be  some- 
what flushed,  and  the  pupils  are  contracted.  The 
patient  is  overpowered  with  sleepiness,  and  can 
only  be  awakened  with  difficulty.  It  is,  however, 
always  within  possibility  to  awaken  him,  and  he 
usually  rouses  himself  to  the  calls  of  nature. 
Very  commonly  the  pulse  is  irregular,  especially 
if  the  patient  be  young.  At  this  stage  again  care 
must  be  taken  to  ascertain  whether  there  are  any 
non-symmetrical  symptoms,  any  weakness  of  a 
limb,  of  one  side  of  the  face,  or  of  any  single  eye- 
muscle.  If  the  patient  passes  his  urine  or  fjeces 
in  bed.  or  if  there  is  long-continued  retention  of 
urine,  it  is  very  probable  that  there  is  more  than 
mere  concussion — namely,  laceration  or  contu- 
sion. The  sleepy  stage  may  last  for  a day  or  for 
a week,  and  it  is  in  severe  cases  so  well-marked 
that  the  patient's  eyelids  may  be  held  open,  and 
the  pupils  examined,  without  awaking  him. 

During  this  stage  the  measures  of  treatment 
called  for  are  spare  diet,  purgation,  cold  to  the 
head,  and  quiet.  When  the  sleepy  stage  passes 
off,  the  patient  is  left  weary,  torpid,  unfit 
for  mental  effort,  and  often  with  distressing 
headache.  These  are  the  symptoms  of  the  con- 
valescent stage,  and  they  may  last  more  or  less 
for  a considerable  time.  The  patient  should  still 
be  kept  carefully  quiet,  no  stimulants  should  be 
allowed,  and  purgatives  should  occasionally  he 
used.  Some  of  the  symptoms  present  during  the 
stage  of  convalesenee  may  persist  bo  long  that 
they  may  rank  rather  as  sequelae.  Thus  there 
may  he  for  years  nervousness,  inaptitude  for 
business,  liability  to  headache,  and  peculiar  sus- 
ceptibility to  the  influence  of  stimulants.  As  a 
rule,  however,  even  after  very  severe  concussions, 
no  such  ill-results  are  left,  but  the  patient  re- 
gains after  a time  perfect  cerebral  health.  This 
remark  must,  however,  not  be  held  to  apply  to 


142  BRAIN,  CONCUSSION  OF. 
auncussion  when  received  in  railway  accidents; 
for  in  these  cases  there  is  a prospect  of  pecuniary 
compensation,  and  the  sequel*  are  often  severe, 
prolonged,  and  very  peculiar. 

Jonathan  Hutchinson. 

BRAIN,  Congestion  of.  See  Brain, 
Hypersemia  of. 

BRAIN,  Hemorrhage  into.  — Synon.  : 

Cerebral  Apoplexy ; Fr.  Hemorrhagic  cerebrate 
interstitielle ; Ger.  Hirnschiag. 

Definition. — Escape  of  blood,  by  rupture  of 
a vessel,  into  the  substance  or  cavities  of  the 
brain.  Haemorrhage  into  the  meninges  is 
separately  described. 

Cerebral  haemorrhage  is  commonly  due  to  the 
rupture  of  an  artery,  very  rarely  to  that  of  a 
vein.  Occasionally,  minute  extravasations  are 
caused  by  rupture  of  capillaries.  Haemorrhage 
from  arteries  or  veins  may  also  be  due  to  their 
laceration  by  injury. 

^Etiology. — Arterial  haemorrhage  is  usually 
due  to  the  coincidence  of  weakened  vascular  wall 
and  increased  pressure  within  the  vessel.  The 
causes  of  these  states  may  be  regarded  as  the 
conditions  predisposing  to  cerebral  haemorrhage. 
Hereditary  influence  is  sometimes  distinctly 
seen,  as  a tendency  to  vascular  degeneration,  or 
to  conditions  which,  as  renal  disease,  produce 
such  degeneration.  Similarity  of  vascular 
distribution  may  also  be  inherited,  and  may  de- 
termine the  locality  of  strain,  and,  therefore, 
first  of  degeneration,  and  ultimately  of  rupture. 
Cerebral  haemorrhage  is  most  frequent  after  fifty 
years  of  age,  but  occurs  at  any  age,  though  rare 
during  the  first  half  of  life.  It  is  nearly  twice 
as  common  in  men  as  in  women.  It  is  said  to 
be  more  frequent  in  temperate  than  in  tropical 
climates,  in  winter  than  in  summer,  and  at  high 
than  at  low  elevations.  Certain  acquired  con- 
ditions act  as  predisposing  causes.  Chronic 
Bright’s  disease  leads  to  early  and  extreme  de- 
generation of  vessels,  as  well  as  directly  to 
hypertrophy  of  the  heart  and  increased  blood- 
pressure  : hence  it  predisposes  powerfully  to 
cerebral  haemorrhage.  In  purpura  and  scurvy, 
cerebral  haemorrhage  occasionally  occurs — it  is 
said  in  consequence  of  acute  vascular  degenera- 
tion and  increased  blood-tension.  The  state  of 
vascular  repletion  known  as  plethora  was  for- 
merly thought  to  be  a frequent  cause  of  cerebral 
hfemorrhage.  It  probably  does  aid  other  causes, 
but  rarely  co-exists  with  the  most  eflieient, 
and  so  takes  a very  subordinate  position.  Chronic 
alcoholism  and  opium-eating  are  said  to  promote 
vascular  degeneration. 

The  proximate  causes  of  cerebral  haemorrhage 
are  the  weakened  state  of  the  wall  of  the  vessel, 
and  commonly  some  increase  of  blood-pressure. 
The  vessel-wall  is  weakened  by  degeneration, 
and  is  often  imperfectly  supported  in  an  atrophied 
brain.  The  increase  of  pressure  within  the  ves- 
sels may  be  permanent,  as  in  peripheral  obstruc- 
tion, with  or  without  hypertrophy  of  the  heart  ; 
or  temporary,  as  in  excited  action  of  heart,  or 
impeded  circulation  during  effort.  These  causes 
are  considered  more  fully  in  the  article  on 
Brain,  Vessels  of,  Diseases  of. 

Hfemorrhage  from  a vein  is  rare,  except  as  the 
result  of  laceration  by  direct  injury,  or  of  ulcera- 
tion invading  the  vein  secondarily.  Varicose 


BRAIN,  HAEMORRHAGE  INTO, 
veins  in  the  pia  mater  may  sometimes  rupture 
(Andral). 

Capillary  haemorrhage  is  usually  due  to  venous 
obstruction,  especially  to  thrombosis  in  a vein. 

Anatomical  Appearances. — In  intracerebral 
haemorrhage,  the  blood  is  extravasated  into  the 
substance  or  into  the  ventricles  of  the  brain — 
into  the  latter  usually  by  rupture  of  a previous 
extravasation  within  the  cerebral  substance.  Ie 
the  latter  situation  the  blood  occupies  a cavity 
formed  by  laceration  of  the  brain-tissue ; rarely, 
when  very  minute  and  ‘capillary,’  by  merely 
separating  the  fibres.  In  size  an  extravasation 
varies  from  that  of  a pea  or  even  smaller,  up 
to  that  of  the  fist.  The  blood  is  clotted,  and 
reddish-black  in  colour ; and  fragments  of 
brain-tissue  are  mingled  with  it.  The  cavity 
containing  it  is  often  very  irregular  in  shape ; 
its  walls  are  uneven,  present  projecting  shreds 
of  lacerated  brain-substance,  and  are  blood- 
stained and  softened — at  first  by  imbibition  of 
serum,  and  later  by  inflammation.  Many  small 
extravasations  are  often  seen  in  the  neighbour- 
hood of  a larger  clot.  Usually  there  is  only 
one  large  extravasation : sometimes,  however, 
there  are  two  or  three.  The  extravasated  blood 
exercises  pressure ; the  convolutions  are  flattened; 
the  falx  is  bulged  to  the  opposite  side  (Hugh- 
lings  Jackson,  Hutchinson) ; and  the  rest  of  the 
hemisphere  is  anaemic.  The  effused  blood  may 
tear  its  way  into  the  lateral  ventricle  ; it  then 
speedily  distends  both  lateral  ventricles  and  the 
third  and  fourth  ventricles,  and  escapes  by  the 
openings  at  the  lower  extremity  of  the  fourth 
ventricle,  central  and  lateral,  into  the  subarach- 
noid space.  Or  the  blood  may  escape  to  the 
surface,  infiltrate  the  pia  mater,  and  tear  its  wav 
into  the  subarachnoid  cavity,  often  by  a vcr-, 
small  opening.  It  is  rarely  that  the  artery  from 
which  the  blood  has  escaped  can  be  detected. 
Occasionally  the  extravasation  can  be  traced 
to  the  rupture  of  an  aneurism  of  some  size.  In 
other  cases  miliary  aneurisms  may  be  found  on 
many  vessels.  The  larger  arteries  ccmmonly 
present  atheromatous  changes. 

After  a time  the  extravasated  blood  under- 
goes changes.  The  clot  shrinks  and  gradually 
becomes,  first  chocolate,  then  brown,  and  ulti- 
mately a reddish-yellow  ; and  it  then  contains 
chiefly  fat-globules,  pigment  and  other  granules, 
and  hsematoidin  crystals.  The  rapidity  with 
which  it  undergoes  this  change  is  doubtful,  and 
certainly  varies.  It  is  said  that  the  distinctive 
blood-colour  has  disappeared  as  early  as  the 
twentieth  day.  Meanwhile  the  walls  of  the 
cavity  undergo  changes.  The  inflammation,  in 
rare  cases  excessive  and  purulent,  is  usually 
conservative,  and  leads  to  the  formation  of  con- 
nective tissue.  A firm  wall  is  thus  developed, 
the  inner  surface  of  which  becomes  smooth  by 
the  softening  and  removal  of  the  loose  fragments 
of  brain-substance;  by  this  means  a cyst  is 
formed.  It  is  said  that  connective  tissue  may 
extend  across  its  cavity,  and  that  in  rare  cases, 
the  fluid  being  absorbed,  the  cyst  walls  may- 
unite,  and  a cicatrix  result.  Such  cicatrices  are, 
however,  much  more  frequently  due  to  softening 
than  to  hfemorrhage.  It  is  asserted  that  a cyst 
may  be  developed  in  thirty  or  forty  days  undei 
favourable  conditions. 


BRAIN,  HAEMORRHAGE  INTO.  143 


Hsemorrhago  may  occur  in  any  part  of  the 
brain,  but  is  more  frequent  in  some  situations 
than  in  others.  The  most  frequent  seat  is  the 
corpus  striatum  and  the  region  just  outside  it: 
nearly  half  the  intra-cerebral  hemorrhages  are 
in  this  situation.  Other  primary  seats,  in  the 
order  of  frequency,  are  the  pons  and  peduncles, 
the  cerebellum,  the  cortex,  the  optic  thalamus 
(often  affected  by  an  extension  of  the  haemor- 
chagefrom  the  corpus  striatum),  the  posterior  por- 
tion, and  the  anterior  portion  of  the  hemisphere. 
The  frequent  extravasation  into  and  outside  the 
corpus  striatum,  is  explained  by  the  vascular 
supply.  ( See  Brain,  Vessels  of,  Diseases  of.) 

Traumatic  haemorrhage  occurs  into  and  from 
.1  lacerated  portion  of  brain,  and  is  most  fre- 
quently found  on  the  surface,  occupying  mainly 
the  middle  of  the  convex  portion  of  each  convo- 
lution, and  some  other  regions  much  exposed  to 
injury,  as  the  surface  of  the  teniporo-sphenoidal 
lobe,  and  the  under  surface  of  the  frontal  lobe. 
Ventricular  haemorrhage  sometimes  results  from 
traumatic  rupture  of  a small  vein  on  the  surface 
of  the  corpus  striatum  (Prescott  Hewett). 

Soft  tumours  (especially  glioma)  are  some- 
times the  seat  of  haemorrhage.  The  distinc- 
tion from  simple  hsemorrhage  (sometimes  diffi- 
cult) rests  on  their  position  being  commonly  one 
in  -which  cerebral  haemorrhage  is  rare ; and  on 
some  gelatinous-looking  tumour-substance  being 
found,  into  -which  haemorrhage  has  not  occurred, 
and  "which  has  characteristic  microscopic  features. 

Other  organs  may  be  healthy,  or  present  t lie 
changes  -which  have  been  mentioned  as  predis- 
posing causes ; the  lungs  are  usually  secondarily 
congested,  often  intensely. 

Symptoms. — -The  occurrence  of  cerebral 

haemorrhage  is  indicated  by  cerebral  symptoms 
of  two  classes,  the  one  general  and  more  or  less 
transient,  the  other  local  and  more  or  less 
permanent.  In  addition  to  these  there  are 
‘-ometimes  premonitory  symptoms ; and  commonly 
general  symptoms  manifested  by  pulse,  tempe- 
rature, &c.,  "which  are  secondary  to  the  brain- 
lesion. 

Premonitory  symptoms,  somewhat  rare,  are 
those  of  altered  cerebral  function  due  to  local 
vascular  disease,  headache,  vertiginous  feelings, 
local  weakness  or  numbness,  slight  mental 
changes,  and  slight  affection  of  spieech  {see 
Brain.  Vessels  of,  Diseases  of,  and  Brain, 
Anaemia  of).  They  are  less  frequent  than  in 
cases  of  softening,  and  more  commonly  precede 
cerebral  hsemorrhage  in  the  old  than  in  the  young 
and  middle-aged. 

The  onset  of  haemorrhage  is  usually  accom- 
panied with  apoplexy,  i.e.  loss  of  consciousness  and 
of  power  of  motion  and  of  sensation,  oA-en  with 
relaxation  of  the  sphincters  and  loss  of  reflex 
action  {see  Apoplexy,  Cerebral).  These  symp- 
toms are  profound  and  lasting  according  to  the 
size  of  the  hsemorrhage  and  its  position : being  es- 
pecially marked  in  large  and  double  effusions,  in 
intraventricular  hsemorrhage,  and  in  hsemorrhage 
into  the  pons.  In  a case  of  moderate  severity  they 
last  only  a few  hours,  and  gradually  pass  away. 
In  severer  cases  they  may  deepen  until  death 
occurs  from  failure  of  respiratory  power. 
Death  is  rarely  very  speedy,  life  being  usually 
prolonged  for  some  hours  even  in  the  most 


rapidly  fatal  cases.  In  rare  instances  of 
hsemorrhage  into  the  medulla,  and  also  in 
meniDgeal  hsemorrhage,  death  has  occurred  in 
five  minutes,  probably  in  each  case  from  the 
rapid  interference  with  the  respiratory  centre. 

The  temperature  is  at  first  lowered  one  or 
two  degrees,  the  pulse  becomes  less  frequent, 
and  the  respiration  slow.  The  Cheyne-Stokes 
respiratory  rhythm  often  precedes  death.  After 
a few  hours  the  temperature  rises  to  the  normal 
and  in  mild  cases  stops  there,  but  in  graver  cases 
it  rises  above  the  normal  two  or  three  degrees. 
In  some  very  grave  cases  the  initial  fall  or  sub- 
sequent rise  may  be  extreme  and  go  on  until 
death  occurs,  sometimes  reaching  90°  in  the  one 
case,  and  107°  or  10S°  in  the  other  (Bourneville). 

In  slight  eases  of  cerebral  hsemorrhage  there 
may  be  no  loss  of  consciousness.  Vomiting  in 
such  cases  is  not  unfrequent.  In  other  rare 
cases  of  large  hsemorrhage,  especially  between 
the  external  capsule  of  the  corpus  striatum  and 
the  island  of  Reil  (Broadbent),  the  loss  of  con- 
sciousness comes  on  gradually,  after  other 
symptoms,  as  of  shock,  for  example,  have  lasted 
for  an  hour  or  two.  These  cases  have  been 
termed  ingravescent. 

Local  symptoms,  often  permanent,  and  always 
of  longer  duration  than  the  loss  of  consciousness, 
are  present  in  all  cases  of  circumscribed  cere- 
bral hsemorrhage,  except  in  the  rare  instances 
in  which,  by  its  central  position  in  the  pons 
and  medulla,  it  causes  directly  bilateral  effects 
only,  which  are  added  to  and  intensify  the  gene- 
ral symptoms  caused  indirectly.  In  a unilateral 
cerebral  lesion,  the  direct  symptoms  are  unila- 
teral loss  of  powrer  of  voluntary  movement  and 
often  of  sensation,  accompanied  sometimes  with 
convulsion  or  rigidity.  These  local  sj'mptoms 
may  commence  a few  minutes  or  longer  before 
the  loss  of  consciousness.  They  coexist  with 
the  apoplectic  condition,  and  may  often  be 
recognised,  even  during  coma,  by  the  flaccidity 
of  the  paralysed  limbs,  which  fall  more  helplessly 
than  those  of  the  opposite  side ; by  inequality 
of  the  mouth  and  of  the  pupils  ; by  conjugate 
deviation  of  the  head  and  eyes  towards  the  side 
of  the  brain  injured ; by  convulsive  movements ; 
and,  as  the  apoplexy  clears,  by  the  detection  of 
unilateral  defect  of  sensibility.  The  coma  passing 
away,  these  signs  become  more  distinct,  and  all 
the  symptoms  of  hemiplegia  remain,  varying  in 
intensity  and  extent  according  to  the  position  of 
the  lesion.  The  apioplectic  state  may  recur  after 
its  disappearance— a grave  symptom,  usually  in- 
dicating that  a fresh  hsemorrhage  has  occurred 
in  the  same  or  the  other  side  of  the  brain,  or 
more  frequently  that  the  blood  has  escaped  into 
the  ventricles.  In  the  former  case  the  unilateral 
symptoms,  conjugate  deviation  of  the  head  and 
eyes,  &c.,'  are  increased  on  the  same,  or  trans- 
ferred to  the  opposite  side ; in  the  latter  the  uni- 
lateral symptoms  disappear,  and  general  power- 
lessness and  deep  coma  supervene,  with  stertor, 
relaxation  of  the  sphincters,  loweredtemperature, 
and  impeded  respiration.  Death  always  ensues. 

Convulsion  may  be  a conspicuous  symptom 
at  the  onset  or  subsequently.  It  is  usually 
unilateral  in  its  course  or  commencement,  be- 
ginning on  the  side  paralysed,  rarely  affecting 
only  the  non-paralysed  side.  Where  convulsion  is 


144  BKAIN.  HAEMORRHAGE  INTO. 


cot  met  with,  muscular  twitching  or  rigidity 
may  occur.  General  or  widely-spread  rigidity 
or  twitching  points  to  a bilateral  lesion;  if  with 
coma,  to  ventricular  haemorrhage. 

After  a day  or  two  symptoms  of  irritation 
about  the  cerebral  lesion  come  on,  such  as  head- 
ache, delirium,  and  rigidity  in  the  paralysed  limbs. 
During  this  period  the  temperature  rises  above 
the  normal,  and  the  pulse  becomes  quick.  On 
their  subsidence,  these  symptoms,  if  the  lesion 
is  slight,  may  be  scarcely  recognisable,  and  a 
stationary  period  ensues,  at  the  end  of  which 
recovery  of  power  over  the  paralysed  limbs 
begins.  In  slight  cases  power  maybe  recovered 
very  speedily.  Its  return  depends  upon  the 
structural  recovery  of  slightly  damaged  tissue, 
and  on  other  parts  taking  on  an  increased  func- 
tion in  compensation  for  that  which  is  destroyed. 
The  electric  irritability  of  the  muscles  exhibits 
little  change.  Sometimes,  however,  when  there 
is  great  irritation  at  the  lesion  propagated 
downwards  to  the  cord,  a marked  initial  increase 
in  irritability  may  precede  a considerable  de- 
pression, coincident  with  rapid  wasting.  Re- 
covery of  power  is  rarely  complete  except  in 
those  cases  in  which  the  area  of  damage  is  very 
small ; and  when  the  damage  is  large  and  affects 
an  important  motor  region,  there  may  be  no 
recovery,  loss  of  power  persisting,  commonly 
with  more  or  less  1 late  rigidity  ’ in  the  paralysed 
limbs.  Slight  permanent  mental  change  often  re- 
mains, and  as  the  motor  power  is  recovered,  ataxic 
and  other  disorders  of  movement  may  supervene 
in  the  limbs  which  were  paralysed,  although 
much  less  commonly  than  after  softening. 

Diagnosis. — The  diagnosis  of  cerebral  haemor- 
rhage rests  on  the  symptoms  of  a localised  cere- 
bral lesion,  occurring  suddenly.  The  conditions 
from  which  it  has  most  commonly  to  be  distin- 
guished are — congestion  of  the  brain ; softening 
of  the  brain,  embolic  and  thrombic ; and,  some- 
times, tumour.  For  the  distinction  from  it  of 
other  causes  of  apoplectic  loss  of  consciousness, 
uraemia,  post-epileptic  coma,  &c.  see  Apoplexy, 
Cerebral.  From  congestion  the  chief  dis- 
tinction of  cerebral  haemorrhage  lies  in  the 
transient  nature  of  the  loss  of  consciousness ; 
and  in  the  slightness  and  general  character  of 
the  symptoms  which  characterise  the  former. 
Congestion  generally,  haemorrhage  only  some- 
times, comes  on  during  effort : and  the  absence 
of  history  of  effort  is  in  favour  of  the  latter. 
Similarly,  the  premonitory  symptoms  which  are 
usually  present  in  congestion,  are  generally 
absent  in  lnemorrhage.  The  loss  of  motor  power, 
and  the  symptoms  of  cerebral  shock,  are  much 
greater  in  haemorrhage  than  in  congestion.  It 
must  be  remembered  that  the  two  states  fre- 
quently coexist.  From  softening  consequent  on 
embolism  cerebral  haemorrhage  has  also  to  be 
distinguished.  The  subjects  of  the  latter  are 
usually  of  an  earlier  age  than  those  of  haemor- 
rhage ; their  vessels  are  healthy,  but  they  have 
organic  heart-disease,  w'hich  is  often  grave. 
There  may  be  evidence  of  embolism  elsewhere, 
in  spleen,  kidney,  or  retina.  Loss  of  conscious- 
ness may  be  absent  in  embolism,  and  the  para- 
lysis often  comes  on  deliberately.  An  exten- 
sive capillary  embolism,  causing  deep  coma, 
cannot  be  distinguished  from  haemorrhage.  From 


softening  due  to  thrombosis  the  distinction  is 
often  difficult.  Age,  and  the  state  of  the  vessels, 
no  longer  serve  as  guides.  The  presence  of  chronic 
Bright’s  disease  is  in  favour  of  haemorrhage. 
The  occurrence  of  previous  hemiplegic  attacks 
points  to  softening.  In  the  attack,  loss  of  con- 
sciousness is  much  more  considerable,  in  pro- 
portion to  the  subsequent  paralysis,  in  haemor- 
rhage than  in  softening.  But  the  distinction  on 
this  ground  is  often  very  difficult,  since  loss  of 
consciousness  may  be  absent  in  slight  haemor- 
rhage, and  considerable  in  an  extensive  softening. 
A deliberate  onset  is  in  favour  of  softening,  and 
so  are  much  mental  change  and  early  rigidity. 
Paralysis  of  sudden  onset,  in  cases  of  tumour, 
may  bo  ascribed  to  haemorrhage,  to  which  it  is 
indeed  sometimes,  but  not  always,  due.  Usually, 
enquiry  elicits  a history  of  gradual,  long-con- 
tinued symptoms ; intense  headache  and  optic 
neuritis  are  strongly  suggestive  of  tumour. 

Haemorrhage  into  the  substance  of  the  brain 
is  distinguished  from  meningeal  hemorrhage  by 
the  pain  and  mental  excitement  being  less  con 
spicuous,  convulsion  rarer,  and  by  the  presence 
of  symptoms  of  a local  lesion.  Hamorrhagt 
into  the  ventricles,  which  resembles  meningeal 
haemorrhage  in  the  generality  of  its  symptoms,  is 
usually  distinguished  by  succeeding  the  symp- 
toms of  a circumscribed  lesion. 

Prognosis.  — During  the  attack  itself  the 
prognosis  in  haemorrhage  into  the  brain  must 
be  guided  by  the  intensity  of  the  symptoms, 
and  by  the  place  of  the  lesion,  as  far  as  that  can 
be  ascertained.  Death  is  probable  if  the  coma 
is  profound  or  long-continued,  and  if  the  early 
depression,  or  the  subsequent  rise  of  tem- 
perature and  pulse-rate  is  great.  When  the  symp- 
toms indicate  ventricular  haemorrhage,  or  haemor- 
rhage into  the  pons,  the  patient  will  certainly  die. 
Consciousness  being  recovered,  and  the  danger 
of  immediate  death  over,  the  freedom  from 
much  secondary  pyrexia,  from  lung-congestion, 
and  from  bedsores,  are  favourable  indications. 
The  chance  of  recovery  from  the  paralysis  is  es- 
timated by  evidence  of  position  of  the  lesion, 
and  by  any  indications  of  improvement.  Early 
contraction  of  the  flexors  is  unfavourable.  The 
danger  of  recurrence  is  in  proportion  to  the  ex- 
tent of  vascular  disease,  and  the  existence  of 
irremovable  causes  of  increased  arterial  tension. 
Hence  the  prognosis  is  rendered  unfavourable 
by  advanced  age,  or  chronic  renal  disease,  and 
by  the  evidence  of  general  premature  decay. 

Treatment. — During  the  attack.  Best  is  the 
most  important.  The  patient  should  remain, 
as  far  as  possible,  where  he  is  seized;  stillness 
must  be  secured : and  all  effort  is  to  be  avoided. 
The  posture  should  be  recumbent,  with  the  head 
raised.  Any  cause  of  passive  cerebral  congestion, 
such  as  a tight  collar,  must  be  looked  for  and  re- 
moved. Venesection  was  formerly  almost  always 
employed  in  such  cases — certainly  toouniversally ; 
but  it  is  now  quite  discarded — perhaps  too  abso- 
lutely. Loss  of  blood  lessens  the  force  of  the 
heart  and  vascular  tension  ; it  thus  hastens  t !><- 
cessation  of  external  bleeding.  Doubtless  it  acts 
in  the  same  way  in  internal  htemorrhage.  It  may- 
be used  with  probable  advantage  if  the  arteri.il 
tension  is  great  (that  is  if  the  pulse  is  inc  mpr-  - 
sible),  the  heart  acting  strongly,  an  : tlr  re  it 


BRAIN,  HAEMORRHAGE  INTO. 

reason  to  believe  that  the  intra-eranial  haemor- 
rhage is  increasing.  A small  quantity  of  blood 
should  be  taken  rapidly.  In  ventricular  haemor- 
rhage, venesection  is  probably  powerless  for  good. 
It  should  not  be  employed  where  there  is  any 
evidence  of  failing  heart-power.  Its  indications 
are  drawn  as  much  from  the  state  of  the  patient 
as  from  tho  feet  of  haemorrhage.  Bright’s  disease 
is  no  contra-indication. 

If  bleeding  is  not  employed,  the  objects  to  be 
aimed  at  by  other  measures  must  be  to  divert 
the  blood  as  far  as  possible  from  the  brain,  by 
relaxing  the  systemic  vessels,  while  endeavouring 
to  obtain  contraction  of  the  cerebral  vessels. 
Warmth  may  be  applied  to  the  limbs,  aided  by 
sinapisms.  Dry-cupping  to  the  surface,  and 
purgatives,  as  croton  oil,  will  divert  the.blood  to 
the  surface,  or  to  the  capacious  intestinal  vessels. 
Drugs  which  would  cause  contraction  of  the 
vessels  are  to  be  avoided,  since  their  influence 
being  on  the  smallest  vessels  and  universal,  their 
tendency  is  to  increase  arterial  tension  and 
haemorrhage.  Contraction  of  encephalic  vessels 
may  be  furthered  by  cold  to  the  head  or  sinapisms 
to  the  neck,  according  as  the  head  is  hotter  or 
colder  than  normal.  The  heart  should  be  allowed 
to  fall  a little  below  the  normal  in  force,  but 
failure  of  power  must  be  warded  off  by  stimu- 
lants given  with  great  care.  Convulsion  is  more 
effectually  checked  by  cold  than  by  bromides; 
the  latter  may  be  given  if  the  convulsion  recurs. 

After  the  attack. — During  the  stage  of  irrita- 
tion, rest  must  be  maintained,  and  all  sources  of 
annoyance  must  be  avoided.  The  bowels  should 
be  kept  gently  open  by  laxatives  or  by  injec- 
tions. Stimulants  must  be  avoided,  and  the  diet 
should  be  light.  Pain  may  be  relieved  by  cold 
to  the  head,  a blister  to  the  neck,  or  by  Indian 
hemp  or  by  bromide  of  potassium. 

During  reparation  the  diet  must  be  nutritious, 
but  carefully  regulated ; and  constipation  of 
the  towels  must  be  avoided.  Rubbing  of  the 
limbs,  and  their  gentle  exercise,  will  aid  their 
recovery,  and  after  the  symptoms  of  irritation 
have  passed,  faradisation  will  improve  muscular 
nutrition,  and  is  especially  indicated  where  rapid 
loss  of  irritability  indicates  probable  wasting. 
Nervine  tonics  are  useful ; none  more  so  than  a 
combination  of  hypophosphite  of  soda  and  tinc- 
ture of  nux  vomica.  In  anaemia  the  syrup  of 
the  phosphate  of  iron  is  good.  Warmth,  change 
of  scene,  and  cheerful  mental  surroundings  are 
useful  adjuncts,  especially  in  the  later  stages  of 
recovery.  W.  R.  Gowers. 

BRAIN",  Hypereemia  of.  — Synon.  : Con- 
gestion of  the  brain. 

Definition. — Increase  in  the  quantity  of  blood 
within  the  capillaries  of  the  brain. 

Since  neither  the  arteries  nor  the  veins  of  the 
brain-substance  can  be  over-distended  with 
blood  without  capillary  hyperaemia,  and  since 
it  is  to  capillary  hyperaemia  that  the  functional 
disturbance  of  the  brain  is  related,  this  may  be 
justly  taken  asthe  essential  pathological  element 
in  cerebral  congestion.  The  congestion  may  be 
active,  when  the  capillaries  contain,  in  conse- 
quence of  arterial  distension  or  dilatation,  oxy- 
genated blood  passing  rapidly  through  them  ; or 
it  may  be  passive,  when,  from  venous  obstruc- 
10 


BRAIN,  HYPEREMIA  OE.  146 
tion,  the  capillaries  contain  slowly-moving  blood, 
becoming,  and  in  great  part  already,  venous. 

^Etiology. — (A)  Active  congestion  of  the  brain 
may  be  general  or  partial.  Of  the  general  form 
the  remote  causes  are  as  follows : — Men  are  said 
to  be  more  liable  to  it  than  women.  Age  in- 
creases its  frequency  (but  this  is  more  true  of 
the  passive  form) ; yet  children,  from  the  sensi 
tiveness  of  their  vaso-motor  system,  occasional ,'j 
suffer  from  active  cerebral  congestion.  Heredil  j 
has  only  an  indirect  influence.  The  plethoric 
condition  is  a powerful  predisponent.  The  im- 
mediate causes  of  excessive  flow  through  the 
arteries  of  the  brain  may  be  thus  stated — (1)  In- 
crease in  the  blood-pressure — either  general,  from 
excessive  action  of  the  heart  (as  in  extreme 
hypertrophy  or  functional  overaction);  or  partial, 
from  an  obstruction  elsewhere,  throwing  an  un- 
due proportion  of  the  pressure  upon  the  cerebral 
vessels.  This  is  seen  in  contraction  of  the  aorta 
beyond  the  origin  of  the  vessels  to  the  head,  and 
in  sudden  contraction  of  a large  number  of  the 
systemic  arterioles,  as  those  of  the  surface,  in 
exposure  to  cold  and  in  ague.  (2)  Active  ar- 
terial dilatation  of  vaso-motor  origin  may  result 
from  prolonged  mental  work,  severe  moral 
emotion,  insolation,  digestive  disturbances,  or 
from  the  presence  in  the  blood  of  various  poisons, 
such  as  alcohol  and  amyl-nitrite.  In  these 
cases  the  vaso-motor  disturbance  may  precede 
and  cause,  or  may  succeed  and  result  from  the 
overaction  of  the  brain-tissue,  which  is  intensified 
by  it.  In  acute  alcoholic  poisoning  the  cerebral 
congestion  is,  as  Niemeyer  suggests,  probably 
secondary  to  the  disturbance  of  brain-tissuo  ; 
in  chronic  alcoholism  it  may  possibly  be  pri- 
mary. In  pyrexia  the  headache  and  delirium 
have  been  thought  to  be  due  to  congestion,  but 
this  is  not  certain.  (3)  Increased  atmospheric 
pressure  may  cause  congestion  of  the  brain. 
(4)  And,  lastly,  gravitation  in  the  recumbent 
posture  may  alone  cause  cerebral  hypersemia, 
or  may  powerfully  aid  other  causes  in  produc- 
ing it. 

Partial  active  congestion  of  brain-tissue  occurs 
chiefly  along  with  disease  of  the  arteries,  which 
perverts  blood-pressure ; in  organic  brain-dis- 
eases, as  tumour,  haemorrhage,  &c. ; and  after 
blows  on  the  head. 

(B)  Passive  congestion  of  the  brain,  when 
general,  is  the  result  of  impeded  return  of  blood 
from  the  head.  It  may  be  due  to  pressure  on  the 
veins  in  the  neck,  as  by  tumours  or  tight  collars  ; 
pressure  on  the  innominate  veins  by  tumours  or 
aneurism ; or  obstruction  to  the  circulation  from 
violent  respiratory  efforts,  as  cough  or  blowing 
wind-instruments.  It  may  be  caused  by  impedi- 
ments within  the  circulation,  such  as  tricuspid 
insufficiency  and  its  causes  in  the  lungs,  or  dis- 
ease on  the  left  side  of  the  heart.  The  recum- 
bent posture  assists  all  these  influences.  In 
arterial  obstruction  from  diseased  vessels,  a weak 
heart,  insufficient  to  overcome  the  obstruction, 
may  permit  venous  stasis,  but  the  capillary  con- 
dition is  one  of  anaemia. 

Partied  passive  congestion  may  occur  from 
thrombosis  in  a cerebral  vein,  or  from  pressure 
by  a growth  on  one  of  the  cerebral  sinuses. 

Anatomical  Appearances. — The  capillaries 
are  not  visible  to  the  naked  eye  even  when  over 


146 


BRAIN,  HYPER2EMIA  OF. 


distended,  but  with  the  microscope  they  are  seen 
to  be  dilated,  often  to  twice  their  normal  calibre. 
Their  distension  is  indicated  by  a deeper  tint  of 
the  grey  substance ; and  the  fullness  of  the  small 
arteries  and  veins  shows  itself  in  an  increase, 
often  very  great,  in  the  number  and  size  of  the 
'ed  points  visible  on  section  of  the  white  matter. 
In  active  congestion  the  arteries  are  said  to  be 
distinctly  larger  than  normal,  and  their  perivas- 
cular spaces  lessened  in  size ; the  minute  vessels 
of  the  meninges  are  distended.  In  passive  con- 
gestion the  veins  and  sinuses  are  gorged  with 
blood.  It  must  be  remembered,  however,  that 
such  engorgement  of  the  veins  occurs  in  all 
cases  of  death  from  interference  with  respira- 
tion, and  that  the  vessels  of  the  most  dependent 
portion  are  always  fullest.  The  state  of  the 
cerebral  veins  must  therefore  be  carefully  com- 
pared with  that  of  the  veins  of  other  organs. 
Active  congestion  may  sometimes  leave  no  visible 
traces.  After  a time  blood-pigment  collects  out- 
side the  vessels  (Bastian),  and  serous  effusion 
into  the  pia  mater  may  be  found ; and  after  long- 
continued  congestion,  the  vessels  may  be  perma- 
nently distended;  the  spaces  in  which  they  run 
are  increased  in  size.  Such  increase  is  common 
apart  from  pathological  congestion,  but  it  is  so 
great  in  some  cases  of  long-continued  congestion 
that  this  effect  cannot  (with  Mcxon)  be  altogether 
denied. 

Symptoms. — It  is  probab!  e that  many  symptoms 
have  been  erroneously  ascribed  1o  cerebral  con- 
gestion, some  because  hypersemia,  due  to  the 
mode  of  death,  was  found  'pest  mortem,  others 
because  an  assumed  congestion  was  the  readiest 
mode  of  explanation.  Moxon  lias  indeed  main- 
tained that  cerebral  hypersemia  never  causes 
symptoms  except  perhaps  in  death  from  Strangu- 
lation. It  is  doubtful  whether  our  knowledge  of 
the  conditions  of  the  cerebral  circulation  is  suf- 
ficiently exact  to  justify  this  conclusion,  which  is 
difficult  to  reconcile  with  clinical  facts. 

The  symptoms  commonly  referred  to  cerebral 
congestion  may  be  grouped  in  two  classes — those 
of  excitement,  and  those  of  depression.  Either  of 
these  may  exist  alone ; those  of  excitement  may 
precede  those  of  depression  ; or  they  may  partially 
co-exist.  They  may  he  slight  or  severe ; acute 
or  chronic.  Iu  all  cases  thoy  are  increased  by 
the  recumbent  posture  or  by  depressing  the 
head,  by  expiration,  and  bjr  effort;  and  they  are 
usually  aggravated  by  constipation,  and  by  in- 
dulgence in  alcohol. 

In  general  cerebral  hypersemia,  among  the 
symptoms  of  excitement  may  be  mentioned 
mental  irritability  ; headache — slight  or  violent, 
with  feelings  of  fulness  or  throbbing  in  the  head, 
and  vertiginous  or  other  unpleasant  sensations ; 
increased  or  perverted  functions  of  the  organs 
of  special  sense,  such  as  flashes  of  light  and 
noises  in  the  ears;  contraction  of  the  pupils; 
sleeplessness,  restlessness,  startings,  twitchings 
or  slight  actual  convulsions  ; and  mental  excite- 
ment. The  pulse  is  quick.  There  may  be 
vomiting.  The  face  varies,  participating  in  the 
congestions  of  circulatory  origin,  and  in  some  of 
vaso-motor  disturbance,  such  as  that  which  may 
occur  during  digestion.  In  other  forms  of  sup- 
posed congestion  of  vaso-motor  mechanism,  as  in 
those  which  result  from  excessive  brainwork,  the 


face  may  be  pale,  but  the  nature  of  these  case* 
is  doubtful. 

Among  symptoms  of  depressed  brain-function, 
are  dullness  of  the  special  senses ; motor  weakness ; 
mental  indifference  and  slowness;  somnolence, 
especially  after  meals  ; dilatation  of  the  pupils  ; 
and  infrequency  of  the  heart’s  action.  Conscious- 
ness may  be  lost  suddenly,  and  the  loss,  it  is  com- 
monly believed,  may  deepen  into  coma.  As  a 
rule  there  is  no  fever,  but  in  children  the  tern 
perature  may  be  raised  a degree  or  so. 

In  the  chronic  forms  of  cerebral  congestion, 
these  symptoms,  variously  grouped  and  moderate 
in  degree,  continue  for  days,  weeks,  or  months. 
Their  course  is  marked  by  great  variability. 
Durand-Fardel  has  pointed  out  that  in  these 
cases  there  is  often  much  viscid  secretion  of  the 
conjunctiva. 

In  the  more  acute  forms  of  cerebral  congestion, 
the  symptoms  of  muscular  spasm,  of  mental  dis- 
turbance, or  of  loss  of  consciousness,  may  be  so 
predominant  as  to  give  a special  character  to 
the  attack : — 

In  the  convulsive  form  pain  or  uneasiness  in 
the  head  commonly  precedes  the  muscular 
spasm.  The  latter  is  usually  slight.  Consci- 
ousness may  or  may  not  be  lost. 

The  delirious  form  is  seen  under  two  aspects — 
(1)  in  old  age,  after  emotional  excitement;  in 
this  the  wandering  is  slight,  and  often  related 
distinctly  to  the  recumbent  posture  ; (2;  a much 
more  violent  delirium,  which  is  apparently  re 
lated  to  cerebral  congestion,  and  is  seen  some- 
times after  mental  work  or  emotional  excite- 
ment, or  after  alcoholic  poisoning.  Occasionally 
death  results. 

The  apoplectic  form  is  marked  by  sudden  lose 
of  consciousness,  occurring  commonly  during 
effort.  The  unconsciousness  usually  lasts  only 
a few  minutes,  and  incomplete  general  weakness 
remains  for  a day  or  two.  In  rare  cases  the  loss 
of  consciousness  deepens  into  coma,  with  ster- 
torous breathing  and  relaxed  sphincters,  and 
death  may  occur  from  the  extension  of  the 
cerebral  depression  to  the  respiratory  centres. 
Vertiginous  sensations  sometimes  give  a cha- 
racter to  an  attack. 

In  children  congestion  of  the  brain  is  a rare 
but  occasional  cause  of  convulsion  or  delirium. 
Headache  and  contracted  pupils  make  up  a group 
of  symptoms  resembling  meningitis,  but  fever 
is  rarely  present,  and  if  it  exists  it  is  slight,  and 
the  symptoms  usually  come  on  suddenly  and  pass 
away  in  a day  or  two. 

Partial  hypersemia  leads  to  localised  symptoms 
of  excitement  or  depression.  Local  convulsion  or 
paralysis  may  result.  Headache  is  often  intense 
and  localised.  If  nothing  more  than  congestion 
is  present,  the  symptoms  usually  soon  pass  off. 

1’athoi.osy. — The  pathology  of  cerebral  con- 
gestion is  still  obscure,  since  we  know,  little  of 
the  relative  part  played  by  tho  blood-vessels 
and  the  nerve-elements  in  determining  the  symp- 
toms and  their  form.  An  excessive  supply  of 
arterial  blood  is,  in  all  organs,  attended  with 
functional  activity,  and  it  is  easy  to  under- 
stand that  active  congestion  should  result  in 
symptoms  of  excitement.  Subsequent  depres- 
sion of  function  has  been  accounted  for  by 
inferring  compression  of  brain-tissue  by  effused 


BRAIN,  HYPEREMIA  OF. 

serum.  The  reaction  of  exhaustion  may  con- 
tribute. In  passive  congestion  the  nerve-tissue 
is  imperfectly  supplied  "with  oxygenated  blood, 
and  compressed  by  distended  vessels,  and  its 
functions  are  impaired  by  the  presence  of  effete 
products.  Hence  the  predominance  of  symptoms 
of  depression  over  those  of  irritation. 

Diagnosis. — The  diagnosis  rests  on  the  dis- 
covery of  circulatory  and  other  causes  of  cerebral 
congestion  ; on  the  circumstances  of  posture, 
effort,  &c.,  under  which  the  symptoms  came  on ; 
m the  existence  of  concomitant  congestion  in 
other  parts  supplied  by  the  carotids,  as  the  face 
(by  no  means  invariable);  on  the  diffusion  of 
the  symptoms  ; on  their  speedy  disappearance  ; 
and  on  the  absence,  in  the  adult  at  any  rate,  of 
elevation  of  temperature.  The  diagnosis  of  the 
special  forms  of  cerebral  congestion  from  the 
diseases  which  they  most  resemble  is  considered 
inder  the  head  of  those  diseases. 

Prognosis. — The  prognosis  is  generally  imme- 
diately favourable,  but  from  a severe  attack 
death  may  probably  occur.  The  apoplectic  form 
is  most  dangerous,  the  convulsive  least  so.  De- 
generated weakened  vessels  render  the  imme- 
diate prognosis  less  favourable.  After  many 
attacks,  permanent  nutritive  changes  in  the 
brain  supervene. 

Treatment. — The  most  important  elements 
in  the  treatment  of  cerebral  congestion  are  pos- 
ture, removal  of  blood,  purgation,  cold  to  the 
head,  and  warm  and  stimulating  applications  to 
the  surface.  Whatever  be  the  cause,  it  is  im- 
portant to  raise  the  patient's  head,  so  that  gra- 
in tation  may  impede  the  flow  and  aid  the  return 
of  the  blood.  By  this  means  alone  insomnia 
from  hypersemia  may  often  be  prevented.  The 
removal  of  blood  is  useful  in  extreme  forms  of 
congestion,  either  active  or  passive,  especially  in 
those  forms  of  act  ive  congestion  in  which  the  face 
participates.  Venesection  or  leeching  may  be 
employed  according  to  the  severity  of  the  attack ; 
in  active  congestion  the  blood  which  is  taken 
should  be  removed  quickly.  The  relief  which  in 
such  cases  follows  an  epistaxis  illustrates  the 
value  of  this  method  of  treatment.  It  is  not 
advisable  in  those  cases  in  which,  from  overac- 
tion of  brain-tissue,  or  from  cold  to  the  surface, 
dilatation  of  the  cerebral  vessels  results,  while 
the  face  remains  pale.  In  all  forms  of  con- 
gestion, purgation  is  useful.  It  removes  from 
the  blood  some  of  its  serum,  and  it  affords  im- 
mediate relief  to  the  cerebral  circulation,  by 
causing  an  afflux  of  blood  to  the  capacious  in- 
testinal vessels.  In  plethoric  states  diuresis 
is  also  most  useful,  and  has  succeeded  where 
venesection  and  purgation  failed  (Reynolds). 
Cold  to  the  head  is  of  most  value  in  reflex  or 
secondary  dilatation  of  the  cerebral  vessels,  as 
after  mental  work,  insolation,  fatigue,  and  some 
tox£emic  states.  In  the  same  class  of  cases,  sti- 
mulation of  the  peripheral  nerves  by  sinapisms, 
blisters,  &c.,  applied  to  the  neck,  will,  by  reflex 
influence,  assist  in  obtaining  arterial  contraction. 
Hot  applications  to  the  limbs  act  in  part  in  a 
similar  manner,  in  part  by  causing  local  afflux  of 
blood  and  thus  lessening  the  tendency  to  en- 
cephalic engorgement.  They  are  most  useful  in 
active  congestion.  Alcohol  and  opium  must  be 
avoided  in  all  forms  of  active  congestion,  but 


BRAIN,  HYPERTROPHY  OF.  147 
in  passive  congestion  they  may  be  of  service. 
Bromide  of  potassium  is  useful  in  those  cases 
in  which  the  congestion  is  produced  by  vaso- 
motor mechanism,  excited  either  by  stimula- 
tion of  brain-tissue  or  of  distant  nerves.  In 
passive  corgestion  from  heart-disease  the  treat- 
ment is  that  of  the  cardiac  condition.  All  per- 
sons liable  to  congestion  of  the  brain  should 
live  regularly,  avoid  hot  rooms,  and  attend  care- 
fully  to  the  stomach  and  bowels,  relieving  the 
latter  by  frequent  moderate  purgation. 

W.  R.  Gowers. 

BRAIN,  Hypertrophy  of. — Hypertrophy  of 
brain  is  a misnomer.  True  hypertrophy  would 
consist  of  increase  in  number  or  in  size  of  the 
nerve-cells,  nerve-tubes,  connective  stroma,  and 
supplying  vessels  ; and  there  might  be  expected, 
as  a result  of  this  condition,  some  manifestation 
of  a.  higher  intellectual  development.  Such  a 
condition  is  never  found.  A so-called  hypertro- 
phied brain  is  one  that  is  larger  and  heavier 
than  normal.  On  removing  the  skull-cap,  the 
encephalon  seems  to  expand,  so  as  to  render  it 
difficult  to  affix  the  bone-covering  in  its  place  ; 
the  membranes  are  dry,  the  sulci  have  nearly 
disappeared,  and  the  whole  organ  appears  pale 
and  bloodless.  On  section  there  is  a sensation 
of  toughness,  though  less  in  degree  than  in  a 
case  of  general  sclerosis.  There  is  no  sign  of 
pressure  upon  the  orbital  plates,  such  as  is 
met  with  in  chronic  hydrocephalus.  The  lesion 
affects  only  the  cerebral  hemispheres,  espe- 
cially . on  the  convex  surface,  and  perhaps  the 
posterior  lobes  in  particular.  The  base  of  the 
brain  and  the  cerebellum  are  unaffected  except 
by  pressure. 

On  minute  examination,  the  nerve-cells  and 
nerve-fibres,  far  from  being  found  augmented  in 
number  or  in  size,  may  even  be  compressed  and 
diminished ; and  there  is  often  also  some  inter- 
ference with  the  normal  calibre  of  the  vessels. 
Gintrac,  however,  records  a case  in  which  the 
calibre  of  the  nerve-tubes  was  almost  double 
that  of  the  normal.  What  increase  there  is  affects 
the  white  matter  of  the  brain,  and  this  structure 
is  very  pale  and  of  an  elastic  consistence.  The 
real  and  sole  lesion  is  hyperplasia  of  the  connec- 
tive tissue.  It  differs  from  sclerosis  in  affecting 
the  cerebral  hemispheres  more  universally  than  is 
the  case  with  sclerosis ; and  also  that  in  sclerosis 
there  is  not  only  increase  of  the  connective  tis- 
sue, but  subsequent  retraction,  and,  as  a fre- 
quent consequence  of  this,  an  absolute  destruction 
more  or  less  of  the  nerve-elements  of  the  organ. 
When  the  disease  is  far  advanced  it  may  pos- 
sibly cause  absorption  of  the  inner  table  of  the 
skull,  and  thus  produce  a roughness  or  thinning 
of  the  bone,  or,  in  extreme  cases,  even  perforation. 
The  sinuses  are  generally  distended  with  blood. 
Hypertrophy  of  smaller  portions  of  the  brain  is 
rare  : still  various  cases  are  on  record  in  which, 
under  the  name  of  neuromata  of  the  nervous 
centres,  white  or  grey  matter  has  been  found  in 
certain  parts  of  the  brain  over  and  above  the 
normal  constituents  of  this  organ.  Hyperplasia 
of  the  pineal  gland  is  closely  allied  to  glioma. 
It  should  be  distinguished  from  encysted  dropsi 
of  that  organ. 

JEtiology. — Hypertrophy  of  the  brain  has  beer 


148  BRAIN,  HYPERTROPHY  OF. 
said  to  be  sometimes  secondary,  and  caused  by  the 
irritation  of  morbid  growths.  This,  however,  is 
rare.  It  is  generally  primary,  and  may  be  a dis- 
ease of  intra-uterine  life  ; but  it  is  generally  de- 
veloped after  birth,  especially  in  rickety  children. 
Some  forms  of  encephalocele,  -without,  hydroce- 
phalus, seem  to  be  due  to  tho  growth  of  com- 
pact masses  of  cerebral  substance  in  excess  of 
what  is  normal.  The  conditions  for  the  produc- 
tion of  this  morbid  state  are  infancy  ; bad  diet  ; 
repeated  congestion  of  the  cerebral  vessels, 
such  as  might  be  induced  by  frequent  cough ; 
and,  perhaps,  lead- poisoning. 

Symptoms. — The  symptoms  of  so-called  general 
hypertrophy  vary  according  as  the  sutures  are 
closed  or  not.  If,  from  insufficient  occlusion  of  the 
sutures,  the  head  expands  in  proportion  to  the 
increase  in  size  of  the  encephalon,  the  symptoms 
may  be  very  slight.  Children  thus  affected  show 
no  intellectual  hebetude.  In  them,  as  long  as  the 
abnormality  is  uncomplicated  with  local  inflam- 
mation of  membranes  or  with  haemorrhages, 
there  may  be  no  headache,  no  affection  of  sight, 
no  sensory  or  motor  paralysis,  and  no  convulsions. 
Convulsions,  however,  are  common  in  cases  in 
which  the  occlusion  of  the  sutures  has  prevented 
expansion  of  the  head  proportionate  to  the  in- 
ternal increase  of  tissue.  In  such  cases  also 
there  is  generally  more  or  less  motor  paralysis, 
often  some  anaesthesia  of  the  limbs,  headache, 
vomiting,  and  mental  hebetude — symptoms,  in 
fact,  either  of  marked  interference  with  the 
intra-cranial  circulation,  or  of  irritation  from 
inflammatory  complications.  The  prognosis  is 
always  bad,  but  in  rachitic  cases  the  course  may 
be  chronic. 

Treatment. — All  treatment  seems  to  be  inef- 
fective in  diminishing  cerebral  hypertrophy. 

E.  Long  Fox. 

Bit  AIN”,  Inflammation  of. — Synon.  : En- 
cephalitis.— Encephalitis  is  a term  which  ought 
perhaps  to  be  strictly  limited  to  inflammatory 
changes  in  the  brain-substance  itself,  to  the 
exclusion  of  all  forms  of  meningitis.  It  may  be 
either  diffuse  or  local,  but  for  our  present  pur- 
pose we  have  chiefly  to  do  with  the  diffuse  form. 
Local  encephalitis  will  generally  result  in  ab- 
scess ( see  Brain,  Abscess  of)  and  will  usually 
be  met  with,  if  we  put  aside  the  results  of  inju- 
ries, in  association  either  with  disease  of  the  ear, 
with  tubercular  growths,  or  with  pyaemic  deposits. 

It  may  perhaps  be  doubted  whether  the  oc- 
currence of  diffuse  inflammation  of  the  brain- 
substance  as  an  acute  disease  has  as  yet  been 
proved,  excepting  as  a result  of  wounds.  Even 
as  a traumatic  lesion,  its  special  features  have  by 
no  means  been  accurately  studied.  It  is,  how- 
ever, highly  probable  that  after  penetrating 
wounds  of  the  brain,  its  substance  may  inflame, 
just  as  the  cellular  tissue  of  a limb  may,  the 
inflammatory  processes  beginning  at  the  site  of 
the  wound  and  rapidly  spreading  through  a 
large  part  of  the  hemisphere.  It  is  probably  in 
the  perivascular  spaces  that  the  process  chiefly 
spreads,  and  it  is  in  these  that  the  microscope 
will  detect  the  most  abundant  results.  Such  a 
condition  of  diffuse  encephalitis  may  exist  with- 
out there  being  any  visible  changes  in  the  brain. 
It  may  perhaps  be  a little  softened  or  a little 


BRAIN,  LACERATION  OF. 

congested,  but  very  probably  there  is  nothing 
about  which  the  most  experienced  pathologist 
could  feel  certain  until  the  microscope  is  re- 
sorted to. 

Symptoms. — It  is  not  possible,  in  the  present 
state  of  our  knowledge,  to  speak  with  any  cer- 
tainty of  the  symptoms  of  diffuse  encephalitis. 
They  will  vary,  of  course,  with  the  region  affected; 
and  disturbance  of  function,  followed  by  more  or 
less  complete  loss,  will  be  the  most  frequent  oc- 
currences. 

Treatment. — When  the  symptoms  of  ence- 
phalitis are  once  recognised,  it  will  usually  be 
too  late  for  treatment,  and  measures  of  preven- 
tion are  those  of  chief  importance.  The  early 
use  of  mercury,  beginning  in  anticipation  of, 
rather  than  waiting  for  symptoms,  is  probably 
the  most  important ; and  next  to  it  come  cold  to 
the  head,  purgatives,  and  counter-irritation. 

Jonathan  Hutchinson. 

BRAIN,  Laceration  of. — In  the  more 
strict  sense  of  the  word,  the  brain  is  but  little 
liable  to  laceration  from  injury.  Yet,  in  connec- 
tion with  injuries,  such  as  penetrating  wounds 
of  the  skull,  fractures  with  great  depression  of 
bone,  and  even  with  violent  concussions,  the 
brain-substance  is  not  unfrequently,  to  some 
extent,  torn.  In  so  soft  a structure,  however, 
and  under  the  influence  of  modes  of  violence 
which  are  usually  rather  of  the  nature  of  blows 
than  of  anything  likely  to  cause  stretching, 
wo  rarely  meet  with  results  comparable  to 
laceration  of  any  of  the  firmer  textures  of 
the  body.  Whenever  the  brain  is  ‘lacerated’ 
it  is  also  contused,  and  the  contusion  often  ex- 
tends widely  around  the  rent,  and  is  by  far  the 
more  important  lesion.  In  tho  peripheral  parts 
of  the  brain-mass  this  is  especially  true,  and  it 
is  of  little  practical  use  to  speak  of  lacerations 
excepting  as  complications  ot'  very  severe  con- 
tusions. In  tho  central  parts,  the  crura  espe- 
cially, we  meet  now  and  then  with  a laceration 
properly  so  called,  and  it  is  not  very  infrequent 
to  find  the  trunks  of  single  nerves  torn  across. 
The  consideration  of  those  forms  of  laceration 
which  are  produced  by  the  effusion  of  blood  from 
ruptured  vessels  of  size  sufficient  to  supply  a 
stream  forcible  enough  to  break  up  the  sur- 
rounding substance,  will  be  found  in  the  arti- 
cles Apoplexy,  Cerebral  ; and  Brain,  Hemor- 
rhage into. 

In  the  case  of  injuries  to  the  head  from  falls 
or  blows  without  perforation,  certain  definite 
parts  are  prone  to  suffer  from  contusion  and 
laceration.  Usually  some  slight  evidence  of 
injury  is  found  immediately  beneath  the  part  of 
the  skull  upon  which  the  blow  was  received,  but 
by  far  the  chief  bruising  will  be  at  the  opposite 
point.  If  the  occiput  he  struck,  the  anterior  lobes 
will  be  contused  ; and  if  one  parietal  eminence, 
the  opposite  sphenoidal  lobe.  This  law,  how- 
ever, is  greatly  modified  by  the  differing  con- 
ditions under  which  different  parts  of  the  brain- 
mass  are  placed  as  regards  their  surroundings. 
In  the  posterior  half  of  the  skull  the  brain-mass 
is  bulky,  and  between  its  hinder  lobes  and  the  cere- 
bellum is  a strong  flexible  membrane,  well  calcu- 
lated to  break  vibrations  gradually,  and  thus  to 
prevent  contusion.  Nor  are  there  in  these  region! 


BRAIN,  LACEEATION  OF. 
any  strongly  marked  bony  ridges  against  which 
the  brain  might  be  dashed.  These  conditions 
are  reversed  as  regards  the  anterior  lobes  and 
the  middle  lobes,  and  the  consequence  is  that 
whilst  severe  contusions  are  often  seen  in  the 
latter,  they  are  much  more  rare  in  the  cerebel- 
lum and  posterior  two-thirds  of  the  brain- 
mass.  In  cases  of  compound  fracture,  with  tearing 
of  the  dura  mater,  and  deep  depression  of  bone, 
the  brain-substance  may,  of  course,  be  injured 
at  any  part ; but  even  in  respect  to  this  kind  of 
violence  the  hinder  regions  of  the  skull  are 
specially  protected. 

Symptoms.  — W e know  enough  of  surface-lacera- 
tions of  the  brain  in  parts  other  than  the  anterior 
and  middle  lobes,  to  be  able  to  assert  that,  unless 
the  lesion  extend  very  widely  or  deeply,  it  does  not 
reveal  itself  by  any  special  symptoms.  If  very 
extensive,  weakness  of  the  opposite  limbs  and 
side  of  the  face  is  usually  observed.  Injury  to  the 
anterior  lobes,  unless  extensive,  cannot  be  diag- 
nosed, but  it  may  be  guessed  at  in  a few  cases 
where  the  sense  of  smell  is  lost  in  one  or  both 
nostrils  ; for  it  is  very  common  for  the  olfactory 
bulbs  to  be  damaged  at  the  same  time.  If  the 
anterior  lobes  are  severely  lacerated,  the  symp- 
toms will  be  those  of  very  severe  concussion, 
with  the  difference  that  the  insensibility  is  more 
nearly  complete,  and  that  it  increases  instead  of 
diminishing  as  the  days  pass  on.  When  a sphe- 
noidal lobe  is  contused  there  is  usually,  accord- 
ding  to  the  writer’s  observation, incomplete  hemi- 
plegia of  the  opposite  side,  involving  sensation  as 
well  as  motion,  and  the  face  as  well  as  the  limbs. 
From  these  symptoms  the  patient  may,  in  the 
course  of  months,  wholly  recover.  It  is  usually 
the  apex  of  the  sphenoidal  lobe  which  is  lace- 
rated, but  if  the  lesion  extends  higher,  and  if  it 
occur  on  the  left  side,  aphasia  may  be  present. 

In  connexion  with  recent  discoveries  (Dr. 
Ilughlings  Jackson,  Dr.  Ferrier,  and  others) 
as  to  localised  functions,  no  doubt  we  shall  be 
able  before  long  to  diagnose  more  accurately  as 
to  the  precise  regions  injured.  It  would,  however, 
as  yet  be  premature  to  attempt  to  do  so. 

Treatment,  and  Prognosis. — In  the  treat- 
ment and  prognosis  of  lacerations  qnd  contu- 
sions of  the  surface  of  the  brain,  much  depends 
upon  whether  or  not  the  case  is  complicated  by 
compound  fracture  and  the  admission  of  air.  If 
air  have  been  admitted  there  is  risk  of  menin- 
gitis or  encephalitis,  denoted  in  either  case  by 
the  occurrence,  within  a few  days  of  the  injury, 
of  hemiplegia  of  the  opposite  side.  To  prevent 
this  must  be  the  object  of  treatment.  The  scalp 
should  be  shaved,  the  wound  closed  with  sutures 
as  far  as  practicable,  and  lint  wetted  in  a spirit- 
and-lead  lotion  should  be  laid  over  the  part  and 
systematically  re-wetted  every  hour.  If  the  case 
be  treated  in  hospital  it  may  be  well,  in  addition 
to  this,  to  wash  the  wound  with  the  lotion  before 
closing  it,  or  to  dress  with  Lister's  antiseptic 
precautions.  In  cases  of  laceration  without  ac- 
cess of  air  death  may  ensue  from  diffuse  softening 
around  the  part.  If  this  happens  the  case  will 
probably  end  within  a week  or  ten  days.  It  is 
probable  that  many  cases  of  fractured  base  with 
more  or  less  severe  laceration  of  brain  recover  ; 
in  some  with  permanent  paralysis,  but  in  others 
without.  It  must  be  added  that  many  of  the  cases 


BKAIN,  MALFORMATIONS  OF.  149 
in  which  death  occurs  within  a few  hours  or  a day 
or  two  after  fracture  of  the  base  are  attended  by 
laceration.  In  these  the  symptoms  are  often 
difficult  to  distinguish  from  those  of  compression. 
Profound  insensibility,  a bloated  face,  stertorous 
breathing,  and  a full  pulse,  are  often  present , 
but  they  may  be  substituted  by  pallor  and  a feeble 
pulse  in  connection  with  great  depression  of  the 
heart’s  action.  If  any  deviation  from  symmetry 
as  regards  the  paralysis  of  the  limbs  can  be 
proved,  it  is  in  favour  of  laceration  and  against 
compression,  but  the  differential  diagnosis  is  a 
matter  of  extreme  difficulty. 

Laceration  of  Cranial  Nerves. — Lacera- 
tions of  single  nerves  within  the  cranial  cavity 
are  not  by  any  means  uncommon.  This  occur- 
rence is  to  be  suspected  whenever  the  parts  sup- 
plied by  a cranial  nerve  are  completely  paralysed, 
without  accompanying  symptoms  indicative  of 
severe  lesion  of  the  brain-mass.  Cases  of  lace- 
ration of  the  brain  itself  may  be  complicated  by 
laceration  of  nerve-trunks,  and  thus  the  symptoms 
may  become  difficult  to  interpret  with  confidence. 

Of  single  cranial  nerves  the  olfactory  bulbs  are 
the  most  liable  to  suffer  from  contusion  ; and  the 
third,  fourth,  and  sixth  nerve-trunks  are  those 
most  frequently  torn  through. 

Jonathan  Hutchinson. 

BKAIN,  Malformations  of. — The  malfor- 
mations of  the  cranium  and  its  contents  may  be 
divided  into  two  series  : — A.  Those  which  are 
scarcely  compatible  with  life  ; and  B.  Those  in 
which  life  is  possible,  although  the  intellectual 
power  may  be  more  or  less  modified  from  a 
healthy  condition. 

A.  The  first  series  will  include  at  least  seven 
forms,  in  all  of  which  life  is  so  rare  that  it  is 
impossible  to  speak  of  more  than  the  pathological 
anatomy. 

1.  Diccphalia — in  which  two  heads  are  found 
upon  a single  body,  or  upon  two  bodies  pretty 
extensively  connected.  In  the  first  variety,  one 
head  may  be  attached  to  the  vault  of  the  palate 
of  the  other,  or  may  be  united  to  the  convexity 
of  the  skull.  In  the  second  variety  the  heads 
may  sometimes  spring  from  a single  neck. 
This  dieephalous  condition  is  frequently  accom- 
panied by  malformation  affecting  the  spinal 
column  and  spinal  nerves,  as  well  as  by  somo 
incompleteness  in  the  development  of  the  brain. 

2.  Monocephalia — the  union  of  two  heads  into 
one,  on  two  separate  bodies.  The  two  cranial 
cavities  are  united  into  one.  Dissection  of  the 
dura  mater  points  to  this  membrane  having 
been  formed  out  of  two,  and  in  like  manner  the 
cranial  contents  are  either  double,  or  appear  to 
be  singlo  from  the  union  of  double  organs. 

3.  Acephalia — the  complete  absence  of  head. 
An  acephalous  monster  is  usually  a twin ; and 
when  this  is  not  the  case,  it  is  associated  with 
the  morbid  condition  of  the  uterus  of  the 
mother  known  by  the  name  of  uterine  hydatids. 

4.  Paracephalia — the  head  not  entirely  want- 
ing, but  deprived  of  most  of  the  cranium  and  of 
the  face.  A monster  of  this  kind  is  generally 
a twin. 

5.  Anencephalia. — The  absolute  meaning  of 
this  term  would  be  the  absence  of  all  cranial 
contents,  but  it  is  made  to  include  certain  vario- 


BRAIN,  MALFORMATIONS  OF. 


150 

ties,  differing  according  to  the  amount  of  tho 
encephalon  developed.  The  aspect  of  tho  head, 
resembling  that  of  a frog,  the  considerable  pro- 
jection of  the  eyes,  the  flattening  of  the  forehead, 
and  the  absence  of  the  cranial  vault,  are  the  chief 
characteristics  of  this  abnormality. 

In  the  first  degree,  there  is  absence  of  cere- 
brum, cerebellum,  mesocephalo,  and  spinal  cord. 
In  cases  of  this  kind  the  cranial  vault  is  generally 
absent,  and  the  bones  at  the  base  of  the  skull 
convex  and  thickened. 

In  the  second  degree,  tho  cerebrum,  cerebel- 
lum, and  mesocephalo  are  absent,  but  a portion  of 
the  spinal  cord  is  found.  This  portion  of  cord 
is  most  usually  the  lower  part. 

In  the  third  degree,  the  spinal  cord  is  pretty 
complete,  but  there  is  still  an  absence  of  the 
cerebrum,  cerebellum,  and  mesocephale. 

A few  cases  have  been  recorded  of  the  fourth 
degree,  in  which  no  cerebrum  or  corebellum  are 
found,  but  a normal  spinal  cord,  and  a pretty 
complete  mesocephale. 

In  the  fifth  degree, the  cerebrum  alone  is  entirely 
or  almost  entirely  absent,  whilst  the  rest  of  the 
nervous  centres  are  present,  though  not  always 
in  a perfectly  complete  condition.  The  seat  of 
the  absent  cerebrum  is  often  filled  by  fluid. 

Lastly,  one  case  has  been  recorded  in  which 
the  cerebrum  was  present,  whilst  the  cerebellum, 
mesocephale,  and  spinal  cord  were  wanting. 

Anencephalia,  like  the  other  previously  men- 
tioned malformations,  is  due  to  arrest  of  develop- 
ment, such  arrest  depending  either  on  physical 
injuries  to  the  uterus  at  a very  early  period  of 
pregnancy,  or  to  some  mental  shock  experienced 
by  the  mother  during  tho  first  two  months  after 
conception.  It  differs  from  acephalia,  not  only 
by  the  partial  formation  of  the  head,  but  by  the 
presence  of  tho  heart,  and  other  thoracic  organs. 
The  ganglia  of  the  sympathetic  are  usually  well- 
developed. 

6.  Pscudcnccphalia.  In  this  malformation 
there  is  anencephalia  plus  a very  considerable 
thickening  of  tho  meninges,  which  take  the 
place  and  often  imitate  the  aspect  of  the  brain. 
Its  varieties  exactly  correspond  to  those  of anon - 
cephalia.  The  tumour  formed  by  the  develop- 
ment of  the  mombrancs  is  of  variable  size  and 
position.  It  may  be  frontal,  fronto-parietal,  or 
occipital.  The  real  seat  of  the  lesion  is  the  pia 
mater.  The  abnormality  consists  in  extreme 
hypertrophy  of  this  structure,  with  complete 
arrest  in  the  development  of  the  encephalon,  or 
of  some  portion  of  it.  Several  observers  have 
recognised  certain  vesicles  in  the  interior  of  the 
membranous  tumour,  and  these  have  been  sup- 
posed to  be  cerebral  cells  in  process  of  develop- 
ment. It  is  more  in  accordance  with  observation 
to  believe  with  G-intrac  that  they  are  connected 
with  the  development  of  the  choroid  plexus. 

7.  Cycloccphalia.  In  this  monstrosity  there 
is  an  approximation  or  actual  fusion  of  two  eyes 
in  a common  orbit.  It  is  connected  with  certain 
abnormalities  in  the  brain,  that  militate  against 
viability,  or  at  least  prolongation  of  life.  The 
brain  itself  is  generally  more  or  less  deficient, 
especially  in  its  anterior  and  central  portions, 
and  in  some  cases  the  nose  and  mouth  are  very 
ill-developed. 

B.  The  sctxnd  series  of  cases  owe  their  ab- 


normal conditions  to  injury  arising  in  the  cour.-c 
of  fcetal  life  ; and  some  forms  at  least  may  be 
due  to  lesion  occurring  at  a later  period  than  in 
the  first  series. 

8.  Atelencephalia — incompleteness  of  brain  or 
of  membranes — is  the  chief  of  these  forms.  This 
incompleteness  manifests  itself  in  seven  varieties 
according  to  the  part  of  the  encephelon  injured 
by  the  lesion. 

In  the  first  variety,  the  dura  mater  is  some- 
what deficient,  being  altogether  absent  in  certain 
situations  at  the  base  of  the  brain.  The  falx 
cerebri  may  be  wanting,  or  from  incomplete 
development  it  may  seem  perforated  with  holes  ; 
or  the  tentorium  cerebelli  may  be  absent.  There 
are  no  symptoms  which  allow  a positive  diagnosis 
of  any  of  these  lesions  during  life. 

In  the  second  variety,  there  is  general  incom- 
pleteness of  the  brain,  or  imperfection  of  several 
portions  of  it  at  one  and  tho  same  time.  Whilst 
the  cranial  vault  is  thrown  back,  and  the  lower 
jaw  is  short,  the  base  of  the  skull  is  large,  the 
cerebral  convolutions  almost  absent,  and  the 
cerebellum  large.  The  head  is  almost  always 
small,  and  it  may  presont  various  irregular 
forms.  This  coincides  with  certain  internal 
lesions,  partial  or  general  atrophy  with  conse- 
quent serous  effusion  under  the  membranes,  in- 
flammatory conditions,  or  thickening  of  the 
cranial  bones  and  of  the  meninges.  The  incom- 
pleteness of  tho  brain  varies  exceedingly,  from  a 
condition  in  which  the  whole  brain  is  atrophied, 
to  spots  of  deficiency,  such  as  the  absence  of  a 
single  convolution,  of  the  septum,  or  of  the  pineal 
gland.  The  symptoms  will  necessarily  vary  much 
according  to  the  amount  of  cerebral  incomplete- 
ness. Where  this  is  general,  affecting  in  some 
degree  all  the  convolutions,  the  intellectual 
powers,  as  in  the  microcephalous  Aztecs,  will 
be  very  slightly  developed,  and  their  language 
of  the  very  simplest  form.  With  the  brain  still 
more  imperfect,  there  is  generally  complete 
idiocy  or  a condition  closely  allied  to  it.  The 
special  senses  are  dulled,  particularly  sight  and 
hearing.  Speech  is  in  abeyance,  or  is  limited  to 
monosyllables.  There  are  various  motor  pheno- 
mena, suah  as  muscular  debility,  hemiplegia, 
paraplegia,  contraction,  convulsion,  loss  cf  power 
over  sphincters,  dysphagia,  vomiting,  or  feeble- 
ness of  respiration. 

Tho  third  variety  includes  incompleteness  of 
the  central  parts  of  the  brain.  The  corpus  cal- 
losum, the  septum,  the  fornix,  the  corpora  striata, 
and  the  cornua  ammonis  may  be  imperfectly 
developed.  The  cerebral  hemispheres  may  thus 
be  in  some  sort  fused  together,  and  the  shape 
of  the  ventricles  altered.  The  symptoms  differ 
from  those  of  the  preceding  variety,  in  that  the 
special  senses  are  seldom  involved;  and  that, 
although  complete  idiocy  may  accompany  these 
lesions,  it  is  more  usual  for  the  brain  to  be  found 
capable  of  some  slight  intelligence,  though  un- 
equal to  the  conception  of  abstract  ideas. 

In  the  fourth  variety,  the  lateral  portions  of 
the  brain  are  incomplete.  This  lesion  generally 
occupies  one  side  of  the  brain,  leaving  the  other 
hemisphere  intact.  Several  points  in  the  hemi- 
sphere may  be  affected,  or  the  whole  of  a singlo 
lobe.  Most  usually  there  is  a depression  occupy- 
ing the  seat  of  one  or  more  convolutions.  Such 


brain,  malformations  of. 

a lesion  occasionally  attacks  the  'whole  hemi- 
sphere, giving  it  the  appearance  of  a large  pouch 
filled  with  fluid.  Sometimes  also  the  neighbour- 
ing ventricle  communicates  with  it ; or  there  may 
be  much  ventricular  effusion,  with  imperfect  de- 
velopment of  the  corpus  striatum,  the  optic 
thalamus,  the  cornua  ammonis,  the  mamillary 
tubercle,  the  crus  cerebri,  and  the  optic  and 
olfactory  nerves  of  one  side.  In  a consider- 
able proportion  of  patients  so  affected,  the 
lesion  is  accompanied  by  idiocy,  and  possibly 
the  inability  to  speak  is  connected  with  this 
mental  condition.  Some  few  patients,  how- 
ever, possessed  with  some  intelligence,  have  yet 
been  unable  to  speak ; this  has  been  the  case 
even  when  the  lesion  has  existed  on  the  right 
side.  Deafness  is  rare ; feebleness  cf  sight, 
various  forms  of  strabismus,  and  nystagmus 
common.  Very  frequently  there  is  hemiplegia 
of  the  side  opposite  to  the  lesion,  and  certain 
other  affections  of  the  limbs, — emaciation,  incom- 
plete development,  contraction,  various  deformi- 
ties of  the  hands,  &e.  Sensation  even  in  the 
paralysed  limbs  is  normal ; convulsions  are  not 
uncommon. 

In  the  fifth  variety,  there  is  incompleteness  of 
the  anterior  portion  of  the  brain.  Here  both  the 
anterior  lobes  are  affected  together.  This  con- 
dition may  bo  associated  with  some  deficiency  of 
the  corpus  callosum,  fornix,  and  corpora  striata. 
Idiocy  is  not  uncommon ; mutism  is  the  rule,  but 
in  some  patients  not  idiotic  a few  words  have 
been  possible.  Other  phenomena — amaurosis, 
strabismus,  and  various  motor  abnormalities — 
have  occurred  so  irregularly  in  these  patients 
that  it  is  probable  they  were  symptoms  not  so 
much  of  this  lesion  as  of  certain  further  compli- 
rrations- 

Incompleteness  of  the  cerebellum  forms  the 
sixth  variety.  This  is  sometimes  associated 
with  a similar  condition  of  one  side  of  the  brain. 
Usually  one  lateral  lobe  only  is  affected.  Gene- 
ral hydrocephalus  is  an  occasional  complication, 
and  a collection  of  fluid  under  the  tentorium 
cerebelli  is  very  common.  The  symptoms  are 
very  negative.  In  general  terms  it  maybe  said 
that  there  is  no  loss  of  muscular  co-ordination, 
and  no  loss  of  sexual  power. 

In  the  seventh  variety,  there  is  incompleteness 
of  the  mesocephale  and  medulla  oblongata.  This 
is  not  carried  very  far.  Certain  modifications 
in  form  and  volume  are  alone  compatible  with 
the  preservation  of  life.  It  is  not  a common 
lesion,  and  has  generally  been  associated  with 
idiocy. 

9.  Congenital  hydrocephalus.  One  variety  of 
this  congenital  effusion  of  fluid  is  rare,  viz.,  when 
the  fluid  is  outside  the  dura  mater,  between  this 
membrane  and  the  pericranium,  and  the  cranial 
bones  are  found  floating  in  the  midst  of  the  fluid. 

The  second  variety  is  that  in  which  the  fluid 
lies  outside  the  brain.  The  writer  believes  that 
serous  effusion  in  this  position  is  not  the  cause 
of  the  atrophy,  flattening,  or  induration  of  the 
subjacent  cerebral  organs,  but  the  effect ; that 
where  fluid  is  found  in  this  situation  it  is  only 
the  consequence  of  some  one  of  the  lesions  al- 
ready mentioned,  notably  atrophy  of  brain  from 
whatever  cause,  and  of  atelencephalia.  This 
view  is, however,  opposed  to  that  of  some  authors. 


BRAIN,  (EDEMA  OF.  loi 

The  third  variety  is  congenital  hydrocephalus 
of  the  ventricles.  In  some  such  cases  the  in- 
crease in  the  size  of  the  head  occurs  before  birth  ; 
in  others,  not  until  after.  The  head  increases 
rapidly  in  size  in  the  first  four  weeks  after 
birth.  The  sutures  are  widely  separated,  the 
cranial  bones  very  thin,  the  integuments  of  the 
head  injected,  and  the  hair  deficient.  The  muscle* 
are  badly  developed,  locomotion  is  imperfect,  the 
intellect  is  generally  obtuse,  but  the  special 
senses  are  not  particularly  affected,  unless  it  be 
that  sight  is  deficient. 

10.  Syncncephalia  is  merely  a matter  of  patho- 
logical interest.  The  head  of  the  foetus  is  some- 
times found  adherent  to  the  membranes  or  to  the 
placenta,  as  a consequence  of  intra-uterine  inflam- 
mation. At  the  point  of  adhesion  the  place  of  the 
cranial  bone  is  taken  by  a thin  vascular  mem- 
brane. This  condition  is  sometimes  accompanied 
by,  and  indeed  perhaps  causes,  encephalocele. 

11.  Exencephalia. — Here  a large  portion  of 
the  brain  is  situated  outside  the  cavity  of  the  cra- 
nium. Practically  it  includes  all  the  other  mal- 
formations of  the  brain  that  are  yet  to  be  spoken 
of.  Thus,  if  only  a limited  portion  of  the  brain 
finds  its  way  outside  the  skull  by  an  abnormal 
opening,  the  displacement  is  known  by  the  name 
of  encephalocele,  or  hernia,  cerebri ; if  this  hernia 
coincide  with  a hydrocephalic  condition  of  the 
ventricles,  it  is  called  hydrencephalocele  ; and  if 
the  hernia  is  composed  not  of  the 'brain,  but  of 
the  membranes,  distended  with  fluid  it  may  be, 
the  lesion  is  called  meningocele  or  hyclroTneningo- 
cele.  Exencephalia  proper  may  be  subdivided 
into  frontal,  sincipital,  and  occipital,  according  to 
the  direction  taken  by  the  extruded  brain. 

In  encephalocele  only  a portion  of  the  brain 
more  or  less  limited  is  found  outside  the  skull. 
The  exit  takes  place  most  frequently  at  the  occi- 
pital, and  next  in  the  frontal  region  ; but  the 
temporal  and  parietal  regions  are  occasionally 
the  seat  of  this  lesion.  The  symptoms  may  be 
very  negative.  Encephalocele  unless  pressed 
upon  externally  is  not  often  attended  by  convul- 
sion or  paralysis,  by  intellectual  feebleness,  or  by 
difficulty  of  speech.  This  latter  symptom  is  some- 
times found.when  the  hernia  includes  the  cere- 
bellum. Neither  is  this  lesion  incompatible  with 
the  prolongation  of  life.  The  chief  diagnostic 
difficulty  is  the  possibility  of  the  tumour  being 
eephalhsematoma.  but  this  is  frequently  situated 
over  the  parietal  bones,  an  unusual  position  for 
encephalocele : and  external  pressure  of  the 
former  tumour  causes  none  of  the  cerebral  phe- 
nomena— stupor,  dilatation  of  pupils,  paralysis, 
convulsion,  so  constantly  seen  from  compression 
of  an  encephalocele.  E.  Long  Fox. 

BRAIN,  Malignant  Diseases  of.  See 
Brain,  Tumours  and  New  Growths  of. 

BRAIN,  Membranes  or  Meninges  of. — 

See  Meninges,  Diseases  of. 

BRAIN,  Morbid  Growths  of.  See  Brain, 
Tumours  and  New  Growths  of. 

BRAIN,  (Edema  of. — Definition. — In- 
filtration of  the  brain  and  pia  mater  with  serum, 

.Etiology  and  Pathology. — In  chronic  ma- 
ladies attended  with  general  oedema,  especially 
Bright’s  disease,  fluid  is  effused  around  the 


152  BRAIN,  (EDEMA  OF. 

brain,  into  the  meshes  of  the  pia  mater  and 
between  the  convolutions.  Occasionally  the 
cerebral  substance  is  infiltrated,  but  this  is 
uncommon.  The  perivascular  canals  afford  a 
ready  means  of  escape  for  effused  serum,  and  in 
Bright's  disease,  at  least,  the  substance  of  the 
brain  often  contrasts,  by  its  firmness,  'with  the 
condition  of  other  organs.  In  senile  atrophy  of 
the  brain  the  space  between  the  shrunken  con- 
volutions is  occupied  by  serum,  and  the  ven- 
tricles contain  an  excess  of  fluid.  The  brain- 
tissue  may  appear  to  contain  more  fluid  than 
usual  in  consequence  of  the  distension  by  serum 
of  the  enlarged  perivascular  canals.  In  hy- 
persemia,  especially  passive,  such  as  occurs  in 
heart-disease,  serum  is  commonly  effused  from 
the  engorged  vessels.  Such  effusion  is  also  com- 
mon in  insanity,  especially  in  acute  dementia. 
The  scrum  may  infiltrate  the  pia  mater,  distend 
the  perivascular  canals,  and  even  infiltrate  the 
brain -tissue. 

The  effusion  of  fluid  in  these  cases  is  usually 
slight.  Occasionally  it  is  more  considerable,  and 
the  cerebral  substance  may  be  enlarged,  the 
convolutions  being  flattened,  and  the  tissue 
much  lessened  in  consistence.  The  same  soften- 
ing is  seen  in  the  neighbourhood  of  effusions 
of  fluid  into  the  ventricles  ; the  brain-tissue  for 
a depth  of  some  lines  from  the  ependyma  being 
softened  to  a pulpy  consistence.  The  post- 
mortem imbibition  always  increases  the  appa- 
rent amount  of  the  oedema. 

Symptoms. — Little  is  known  of  the  symptoms 
of  (Edema  of  the  brain.  The  oedema  is  usually 
secondary  to  some  other  condition,  the  symptoms 
of  which  mask  those  of  the  oedema.  General 
oedema  seems  attended  by  slow  diminution  of  men- 
tal power  and  motor  force.  The  effusion  of  serum 
in  cases  of  congestion,  and  consequent  pressure 
on  the  nerve-olemonts,  has  been  considered  as 
the  cause  of  the  symptoms  of  depression  common 
in  that  condition.  Cases  occasionally  occur  in 
which  effusion  of  serum  into  the  ventricles  and 
the  pia  mater  is  the  only  post-mortem  condition 
to  be  found  after  an  apoplectiform  seizure,  and 
such  cases  are  often  spoken  of  as  instances  of 
scrolls  apoplexy.  In  so  far  as  the  effusion  of 
serum  is  related  to  the  apoplectic  attack,  it  is 
probably  merely  as  the  consequence  of  a 
cerebral  eongest.on  which  has  left  no  recognis- 
able post-mortem  hyperaemia. 

Treatment.  — The  treatment  of  cerebral 
cedema  is  usually  secondary  to  the  condition, 
commonly  conspicuous  enough,  which  is  its 
cause, — Bright’s  disease,  passive  cerebral  con- 
gestion, &c.  If  oedema  be  suspected  where 
no  causal  indication  for  treatment  exists,  purga- 
tives and  diuretics,  with  iron  if  there  be  debility, 
are  the  remedies  most  likely  to  be  of  service. 

The  effusion  of  fluid  into  the  ventricles  is 
described  under  Hydrocephalus. 

W.  R.  Gowers. 

BRAIN,  Sclerosis  of.  See  Spinal  Cord, 
Diseases  of. 

BRAIN,  Softening  of. — Definition. — A 
pathological  state  of  brain-tissue,  depending 
commonly  on  vascular  obstruction ; attended  by 
diminished  consistence,  usually  local ; and  indi- 
cated, during  life,  by  mental,  motor,  and  sensory 


BRAIN,  SOFTENING  OF. 

symptoms,  which  vary  according  to  the  seat  of 
the  lesion. 

.(Etiology. — Local  softening  of  the  brain, 
occurring  during  life,  is  due  to  one  of  two  causes, 
inflammation  or  vascular  obstruction.  Most 
cases  were  formerly  thought  to  be  due  to  inflam- 
mation ; but  it  is  now  known  that  very  few  are. 
The  vascular  obstruction,  which  is  the  usual 
cause  of  softening,  may  be  arterial  or,  rarely, 
capillary  ; it  may  be  due  to  a coagulum  formed 
in  situ  (thrombosis),  or  to  a plug  of  fibrin  con- 
veyed into  the  vessels  by  the  blood  (embolism). 
The  predisposing  and  exciting  causes  of  these 
conditions  will  therefore  be  those  of  softening 
of  the  brain  ( see  Brain,  Vessels  of,  Diseases 
of).  Tlie  chief  concomitant  conditions  are — 
in  thrombosis,  vascular  degeneration ; in  em- 
bolism, valvular  disease  of  the  heart : and  as 
predisposing  conditions  we  usually  find,  in  cases 
of  thrombosis,  advanced  age,  Bright's  disease, 
chronic  alcoholism,  or  syphilis ; in  cases  of 
embolism,  acute  rheumatism,  chorea,  or  scarlet 
fever.  Senile  vascular  degeneration  is  the  most 
common  cause  of  all  of  softening  of  the  brain, 
and  hence  the  disease  is  met  with  most  fre- 
quently in  the  old,  especially  in  its  recurrent  and 
chronic  form.  Embolism,  due  to  valvular  disease 
of  the  heart,  and  thrombosis  due  to  syphilitic 
disease,  are  the  most  frequent  causes  of  acute 
local  softening  in  the  young  and  middle-aged. 

Anatomical  Characters. — The  characteristic 
feature  of  cerebral  softening  is  diminished  con- 
sistence. This  may,  however,  arise  from  ante- 
mortem or  post-mortem  changes.  In  each  case 
the  diminished  consistence  depends  on  the 
breaking-up  of  the  myelin,  of  which  the  nerve- 
fibres  are  composed,  into  globules  and  granules, 
and  the  separation  of  these  by  an  increased 
quantity  of  fluid.  Thus  the  continuous  struc- 
tures of  which  the  brain  consists  are  broken 
up  into  disconnected  fragments,  and  the  con- 
sistence of  the  tissue  is  accordingly  dimin- 
ished. In  post-mortem  softening  thero  is 
nothing  more.  The  globules  of  myelin  are 
often  large,  and  the  separating  fluid  abundant. 
The  softened  tissue  has  the  tint  of  the  normal 
cerebral  substance.  The  process  is  the  result 
of  the  imbibition  of  fluid  from  some  collection 
of  serum,  in  the  ventricles  or  elsewhere,  and 
occurs  in  the  greater  degree  in  the  immediate 
vicinity  of  this.  In  ante-mortem  softening 
there  are,  in  addition,  certain  changes  in  the 
tissue-elements.  The  process  of  segmentation 
of  myelin  results  in  the  formation  of  finer 
granules.  These  are  in  part  aggregated  into 
1 granule  corpuscles,’  round  or  oval  masses  of 
globules  and  granules,  sometimes  contained 
within  a distinct  cell-wall.  Some  of  these 
bodies  may  arise  by  simple  aggregation,  many 
certainly  by  the  degeneration  and  distension 
of  connective-tissue  cells,  and  some  by  the  de- 
generation of  nerve  cells.  The  wills  of  vessels 
in  the  softened  area  also  present  fatty  degene- 
ration. The  specific  gravity  of  the  tissue  is 
diminished  (Bastian).  No  further  change  may 
exist,  and  the  area  affected  may  present  simply 
a diminution  of  consistence,  its  colour  remaining 
unchanged.  It  is  then  called  white  or  grey 
softening.  Very  frequently,  however,  in  the 
part  thus  diseased,  distension  of  capillaries  with 


BRAIN,  SOFTENING  OF.  153 


Llood  occurs,  most  considerable  in  the  periphery, 
and  blood  is  actually  effused,  chiefly  by  rupture 
of  capillaries,  in  part  perhaps  by  migration  of 
corpuscles.  In  proportion  to  the  amount  of 
blood  extravasated,  the  colour  is  changed,  and 
thus  red  softening  is  produced.  After  a time, 
the  effused  blood  degenerates,  its  tint  becomes 
altered  to  yellow  or  orange,  and  yellow  softening 
is  produced.  Ultimately,  it  is  said,  the  colour, 
if  at  first  moderate,  may  be  removed,  and  white 
softening  result. 

Red  softening  is  found  chiefly  in  the  grey  sub- 
stance, where  the  vessels  are  numerous, especially 
in  tho  cortex  and  central  ganglia.  The  tint 
varies ; the  red  colour  is  usually  punctiform,  or 
mingled  with  yellow  and  white.  If  the  extra- 
vasations are  large  and  numerous,  ‘ capillary 
apoplexy  ’ results.  The  diminution  of  consistence 
is  usually  moderate.  According  to  the  amount 
of  effusion  of  serum  and  blood  there  is  swelling, 
and  the  diseased  area  may  project  above  the  cut 
surface.  Inflammatory  changes  result  from  the 
vascular  distension,  and  in  proportion  to  these, 
increase  in  the  nuclei  of  the  neuroglia  is  found. 
From  this  cause  and  from  the  migration  of  white 
corpuscles,  pus-like  cells  appear.  The  vessels  are 
dilated,  and  may  present  a moniliform  appear- 
ance. Their  perivascular  sheaths  are  often  dis- 
tended with  blood.  Commencing  degeneration 
of  the  effused  blood  may  cause  a brown  tint. 

Yellow  softening  results  from  red  softening, 
by  degenerative  changes  in  the  blood  effused. 
It  has  a similar  seat,  being  frequently  met 
with  in  the  convolutions,  where  it  constitutes 
plaques  jaunes  of  the  French.  Its  consistence  is 
usually  slight,  its  aspect  granular.  The  colour 
depends  on  the  presence  of  minute  pigment 
granules,  diffused  colouring  matter,  and  haema- 
toidin  crystals. 

White  softening  has  the  tint  of  the  normal 
cerebral  substance.  In  consistence  it  varies  ; it 
may  be  only  a little  below  that  of  the  cerebral 
substance,  or  it  may  be  diffluent.  Its  aspect  is 
uniform,  or  white  flakes  are  scattered  through  it. 
The  limits  are  usually  gradual.  Under  the 
microscope  it  presents  the  detritus  of  nerve-ele- 
ments, a few  nuclei  from  the  connective  tissue, 
granule-corpuscles,  and,  ultimately,  corpora  amy- 
lacea.  White  softening  is  chiefly  found  in  the 
white  substance  of  the  hemispheres.  It  occa- 
sionally has  a gangrenous  odour,  and  then  may 
be  found  in  the  white  or  in  the  grey  substance, 
probably  resulting  from  the  obstruction  of  ca- 
pillaries by  septic  material. 

Ultimate  changes. — White  and  yellow  soften- 
ing may  remain  for  years  unchanged.  Sometimes 
the  changes  in  the  elements  of  the  neuroglia  and 
the  extravasated  white  corpuscles  result  in  the 
formation  of  a considerable  quantity  of  connec- 
tive tissue,  consisting  of  fine  fibre-cells  and  fibres, 
most  abundant  in  the  margins  of  the  softened 
area,  which  become  firm  and  dense,  while  trabe- 
cul®  of  connective  tissue  cross  the  cavity.  After  a 
time  the  fluid  may  be  absorbed,  the  fat  removed, 
and  a sort  of  cicatrix  result.  In  other  cases  the 
walls  alone  are  thus  altered,  the  solid  particles 
are  removed  from  the  softened  tissue,  and  a cyst 
is  formed.  The  outer  portion  of  the  cyst  or  cica- 
trix may  be  limited  by  a zone  of  dilated  blood- 
vessels. 


Seats  of  softening. — There  is  no  part  of  the 
brain  in  which  softening  has  not  been  found,  but 
its  most  frequent  seats  are  the  cortex,  the  corpus 
striatum,  and  the  optic  thalamus.  In  the  cere- 
bellum, pons  Varolii,  and  medulla  it  is  also  fre- 
quently found.  Its  occurrence,  position,  and 
characters  depend  on  the  distribution  of  the 
vessels.  The  small  arteries  of  the  corpus  stria- 
tum and  optic  thalamus  are  ‘ terminal  arteries,’ 
having  only  capillary  communication  with  other 
vessels.  The  arteries  to  the  surface  of  the  brain 
are  usually  for  the  most  part  terminal,  but  some- 
times possess  arteriole-anastomoses  with  other 
branches.  Hence  obstruction  in  the  central 
arteries  leads  invariably  to  softening.  Obstruc- 
tion in  the  superficial  arteries  also  usually  causes 
softening,  which  involves  the  grey  substance  of 
the  convolutions  and  some  of  the  subjacent 
white  centre  to  which  the  vessels  penetrate  ; but 
occasionally  the  anastomoses  of  the  superficial 
vessels  are  so  free  that  softening  does  not  result. 
An  obstruction  of  a main  trunk  (as  the  middle 
cerebral)  may  lead  to  softening  of  the  central 
region  (corpus  striatum),  while  the  convolutions 
escape  ; but  usually  both  suffer. 

Symptoms. — The  premonitory  symptoms  of 
softening  depend  upon  its  cause.  In  embolism 
other  symptoms  than  those  of  the  cardiac  trou- 
ble are  usually  absent.  Occasionally  a slight 
attack  of  loss  of  cerebral  function,  due  to  a 
slight  embolism,  may  precede  a graver  attack. 
In  softening  due  to  arterial  disease,  premonitory 
symptoms  of  local  cerebral  ansemia  are  fre- 
quently present.  There  is  defective  nutrition 
of  many  parts  of  the  brain,  revealing  itself  by 
symptoms  of  wide  range — mental  deterioration, 
numbness,  pains  in  the  limbs,  pain  in  the  head, 
or  slight  local  weakness.  These  symptoms  are  of 
especial  significance  when  associated  with  evi- 
dence of  arterial  degeneration  elsewhere;  with 
the  conditions — as  chronic  Bright's  disease,  alco- 
holism, and  senility — in  which  atheroma  of  the 
cerebral  arteries  is  common  ; or  with  constitu- 
tional syphilis. 

The  symptoms  of  actual  softening  are  those 
of  loss  of  function  in  the  damaged  portion  of  the 
brain.  The  onset  of  the  symptoms  may  bo 
sudden,  as  in  embolism,  and  sometimes  in  throm- 
brosis ; or  it  may  be  gradual,  as  occasionally 
in  thrombosis.  In  the  former  case  the  symptoms 
of  initial  shock  are  added  to  those  proper  to  the 
locality.  The  latter  are  fully  considered  in  the 
articles  on  Localisation.  Hemiplegic  symptoms 
and  mental  alteration  are  the  most  common. 
Hemiplegia  especially  occurs  in  embolism,  on  ac- 
count of  the  frequency  with  which  the  middle 
cerebral  artery  is  obstructed,  and  of  the  im- 
portant motor  regions  (corpus  striatum  and 
motor  parts  of  the  convolutions)  to  which  that 
artery  is  distributed.  From  the  distribution  of 
the  artery  to  the  lower  frontal  convolutions  and 
adjacent  region,  aphasia  is  frequently  present 
when  the  obstruction  is  on  the  left  side. 

When  the  symptoms  come  on  suddenly,  they 
often  follow  some  exertion,  or  occur  during  ex- 
haustion. If  the  area  damaged  be  extensive, 
there  is  loss  of  consciousness,  and  there  may  be 
all  the  symptoms  of  an  apoplectic  seizure.  The 
loss  of  consciousness  is  rarely  profound,  and  the 
symptoms  of  apoplexy  soon  pass  off.  In  the  most 


BRAIN,  SOFTENING  OF. 


154 

severe  cases,  however,  they  may  deepen  to  fatal 
coma.  Symptoms  of  irritation  commonly  succeed 
those  of  apoplexy  as  the  collateral  hyperaemia 
sets  in,  or  they  may  he  marked  at  the  onset. 
Convulsions,  often  unilateral,  may  occur  and  he 
repeated  for  days.  The  patient  may  pass  from 
the  apoplectic  condition  into  one  of  delirium. 
In  the  old,  delirium  may  he  the  chief  symptom 
of  the  onset.  According  as  these  symptoms  are 
chiefly  marked  at  the  onset  three  varieties  have 
been  described,  the  apoplectic,  convulsive,  or  de- 
lirious forms. 

Recovery  from  the  special  symptoms  of  the 
attack  is  often  incomplete  ; permanent  weakness 
may  remain,  as  hemiplegia,  and  mental  power  is 
weakened,  the  patient  passing  into  the  chronic 
state  about  to  be  described.  The  persistent 
hemiplegia  is  often  accompanied  by  rigidity,  or 
by  motile  spasm,  such  as,  in  its  most  marked 
form,  has  been  described  as  athetosis.  Whether 
recovery  is  complete  or  incomplete,  return  or 
relapse  is  common,  and  is  almost  invariable 
where  the  arterial  disease,  to  which  the  soften- 
ing is  due,  is  widely  spread. 

Chronic  softening  is  a term  applied  to  a group 
of  symptoms,  of  wide  range,  indicative  of  failure 
of  brain-power.  These  may  supervene  on  more 
acute  symptoms  of  softening,  or  may  be  gradual 
in  their  onset.  There  is  mental  dulness,  defec- 
tive perception,  drowsiness,  loss  of  memory 
(especially  for  recent  events),  often  slight  wan- 
dering ; emotional  manifestations  are  easily 
excited.  The  patient  complains  of  headache, 
pains  in  the  limbs,  and  feelings  of  ‘numbness,’ 
which  may  or  may  not  be  associated  with  actual 
loss  of  sensibility.  Physical  power  is  defective, 
usually  generally,  sometimes  locally.  The  more 
delicate  motor  actions  are  imperfectly  adjusted : 
articulation  becomes  confluent,  and  the  hand- 
writing indistinct  or  illegible.  These  symptoms 
may  progress  into  actual  imbecility,  or  maybe  cut 
short  by  some  more  profound  cerebral  seizure,  or 
by  some  intercurrent  pulmonary  affection,  ren- 
dered grave  by  the  deficient  muscular  respiratory 
power.  They  depend  upon  degeneration  of 
brain,  commonly  due  to  arterial  disease.  Spots 
of  softening,  often  widely  spread,  may  be  asso- 
ciated with  this  condition,  and  may  be,  indeed, 
the  cause  of  the  symptoms.  But  the  state  may 
come  on  without  auy  local  softening;  and 
atrophy  of  brain,  with  or  even  without  degene- 
rated vessels,  may  be  the  only  anatomical  con- 
dition. It  often  follows  any  grave  local  lesion- 
softening,  haemorrhage,  or  tumour  — and  then 
depends  on  a direct  prejudicial  influence  on 
the  cerebral  nutrition,  or  on  a secondary  effect 
through  the  perturbed  vascular  system. 

Diagnosis. — The  acute  form  of  softening  has 
to  be  distinguished  from  acute  congestive  apo- 
plexy and  from  cerebral  haemorrhage.  It  is 
distinguished  from  the  former  by  the  persistence 
of  the  symptoms  indicative  of  local  mischief,  and 
by  the  absence  of  evidence  of  cephalic  hyperaemia. 
From  haemorrhage  the  diagnosis  is  often  difficult. 
In  softening  from  thrombosis,  the  initial  apoplec- 
tic symptoms  may  be  absent,  or,  if  present,  are 
slight  and  brief.  They  are  more  often  preceded 
by  symptoms  of  local  cerebral  anaemia,  due  to  the 
vascular  disease,  than  is  the  onset  of  cerebral 
haemorrhage.  Improvement  occurs  earlier  than 


in  cerebral  haemorrhage.  The  temperature  rises 
soon  after  the  attack,  but  falls  in  a day  or  two  ; 
in  haemorrhage  the  rise  occurs  Liter  (Bourneville). 
There  is  more  marked  mental  change  than  in 
haemorrhage,  shown  at  first  in  excitement,  sub- 
sequently by  depression  and  deterioration  of 
power.  In  the  cases  in  which  the  onset  is 
sudden  and  the  apoplexy  profound,  a diagnosis 
from  haemorrhage  is  often  impossible.  In  soften- 
ing from  embolism  the  patient  is  usually  below 
middle  age,  heart-disease  is  present,  and  evi- 
dence of  arterial  disease  is  absent.  The  onset  of 
the  attack  is  commonly  sudden,  but  the  loss  of 
consciousness  is  less  profound  than  in  haemor- 
rhage. In  capillary  embolism,  if  extensive,  a 
distinction  from  haemorrhage  often  cannot  be 
made:  the  loss  of  consciousness  is  profound  and 
lasting. 

Softening  may  be  distinguished  from  local 
cerebral  anaemia,  which  often  precedes  it,  by  the 
definiteness  and  persistence  of  local  symptoms  ; 
but  a small  area  of  softening  may  produce  symp- 
toms identical  with  those  resulting  from  a large 
area  of  anaemia.  Softening  is  distinguished 
from  tumour  and  chronic  meningitis  by  the 
slight  pain  and  the  absence  of  optic  neuritis. 
From  simple  atrophy  of  the  brain,  chronic  soften- 
ing differs  by  its  less  uniform  course,  and  by  the 
sudden  occurrence  and  persistence  of  symptoms 
indicative  of  local  lesions. 

Prognosis. — The  immediate  and  ultimate 
prognosis  in  an  attack  of  softening  of  the  brain 
depends  on  its  severity  in  degree  and  extent,  as 
indicating  the  extent  of  the  lesion,  and  on  the 
region  of  the  brain  damaged.  Both  the  im- 
mediate and  the  ultimate  prognosis  is  much 
graver  in  damage  to  the  medulla  and  pons 
Varolii  than  when  the  corpus  striatum  or  cere- 
bral hemispheres  are  affected.  Youth  and 
general  health  favour  the  rapidity  and  the 
degree  of  recovery.  Where  actual  softening  has 
occurred,  the  damaged  tissue  probably  never 
regains  its  functional  power.  The  congested 
periphery  recovers  in  proportion  to  the  inherent 
vitality  of  the  tissues,  and  to  the  freedom  of  the 
vessels  from  disease.  The  chances  of  a recur- 
rence of  softening  in  another  situation  depend 
on  the  extent  to  which  its  causal  condition  is 
widely  spread  or  can  be  removed.  In  vascular 
degeneration  recurrence  is  almost  certain.  In 
embolic  softening  there  is  usually  organic 
valvular  disease  in  the  heart,  and  embolism  re- 
curs in  a considerable  proportion  of  the  cases, 
though  less  frequently  than  senile  thrombosis. 
The  prognosis  in  syphilitic  disease  of  the  vessels 
depends  upon  the  recognition  and  treatment  of 
the  syphilitic  influence. 

Treatment. — During  an  acute  attack  the 
patient  must  be  kept  at  perfect  rest,  with  the 
head  moderately  raised,  in  a uniform  tempera- 
ture. During  the  initial  stage  of  shock,  warmth, 
by  hot-water  bottles,  &c.,  should  be  applied  to 
the  surface,  to  equalize  the  circulation.  Tho 
bowels,  if  confined,  should  be  made  to  act  gently : 
but,  unless  the  evidences  of  encephalic  congestion 
are  early  and  conspicuous,  purgation  should  be 
avoided.  Should  stimulants  be  administered? 
It  has  been  proposed  by  stimulation  of  the  heart 
to  aid  the  establishment  of  the  collateral  circula- 
tion. But  it  must  be  remembered  that  the  imper- 


BRAIN,  SOFTENING  OF. 
feet  collateral  flow  arises  from  the  minute  sizo 
of  the  arterial  anastomoses.  The  obstruction  of 
one  vessel  always  increases  the  adjacent  pressure 
to  such  an  extent  as  to  distend  the  vessels  to 
their  utmost  strength,  and  any  further  increase 
would,  by  rupturing  them,  impede  rather  than 
further  the  objeet  in  view.  If,  therefore,  the 
heart  is  acting  feebly,  stimulate  it  by  small 
quantities  of  alcohol  to  the  normal  force,  but 
not  beyond.  If  the  diagnosis  from  haemorrhage 
be  in  any  degree  doubtful,  great  caution  should 
be  observed  in  stimulation.  After  the  stage  of 
depression  has  passed,  the  irritation  duo  to 
collateral  hypersemia,  and  indicated  by  ele- 
vation of  temperature,  may  be  relieved  by 
purgatives,  dry-cupping,  and  even,  in  some 
cases,  by  the  application  of  leeches,  though  the 
latter  are  only  necessary  when  the  evidence  of 
general  vascular  irritation  is  great.  When  con- 
vulsion is  an  early  and  recurrent  symptom, 
mustard  plasters  to  the  neck  and  extremities, 
and  bromide  of  potassium  in  large  doses,  are 
useful. 

After  the  attack  has  passed,  recovery  must  be 
aided  by  maintaining  the  general  health  in  the 
best  possible  condition.  The  secretions  should 
be  kept  free,  the  digestive  organs  in  good  order, 
the  habits  strictly  regulated,  and  nervine  tonics, 
cod-liver  oil,  hypophosphite  of  soda,  strychnine, 
quinine,  and  iron,  may  be  given  with  advantage. 
The  symptoms  of  chronic  softening,  whether 
occurring  after  an  acute  attack  or  coming  on 
gradually,  should  be  treated  in  a similar  manner. 
Great  care  should  be  taken  that  the  peripheral 
obstruction  to  the  circulation,  indicated  by  aug- 
mented arterial  tension,  (incompressibility  of 
pulse),  is  kept  at  its  minimum  by  the  avoidance 
of  excess  in  diet,  and  by  prompt  purgation  when 
any  increase  in  tension  is  observed. 

W.  R.  Gowees. 

BRAIN,  Syphilitic  Disease  of.  iSccBhain, 
Tumours  and  New  Growths  of. 

BRAIN,  Tubercle  of.  See  Brain,  Tu- 
mours and  New  Growths  of. 

BRAIN,  Tumours  and  New  Growths  of. 

— The  intimate  connection  of  the  brain  with  its 
membranes  makes  it  impossible,  except  in  the 
most  general  term's,  to  draw  any  marked  distinc- 
tion between  tumours  of  the  cerebral  substance, 
and  tumours  arising  from  its  envelopes.  A 
growth  pressing  inwards  from  a membrane  must 
impinge  upon  brain-tissue  : a growth  originating 
in  brain-tissue  must  in  many  situations  involve 
the  membranes. 

Anatomical  Chakactehs. — The  tissues  from 
which  tumours  have  their  origin  seem  to  pre- 
sent the  best  ground  for  a scientific  classification 
of  these  lesions  : and  it  is  not  devoid  of  interest 
to  mark  that  the  absolute  nerve-elements  of  the 
brain  are  never  primarily  the  source  of  a morbid 
growth. 

Cerebral  tumours,  then,  may  be  roughly  sepa- 
rated into  three  series  : — 

1.  Those  whose  centre  of  origin  is  some  one 
or  other  of  the  membranes,  external  to  the 
brain,  or  dipping  into  the  ventricles. 

2,  Those  which  spring  from  the  blood-vessels. 


BRAIN,  TUMOURS  OF.  155 

3.  Those  which  own  the  neuroglia  as  tlieii 
starting-point. 

Taking  this  subdivision,  which  is  Rindfleisch’s, 
the  tumours  which  are  placed  in  each  series  differ 
somewhat  from  his  arrangement. 

In  the  first  series  five  kinds  of  tumour  are  found, 
arising  from  the  membranes  or  from  the  froe 
surface  of  the  ventricles.  These  are  Pacchio- 
nian granulations  ; spindle-celled  sarcoma ; myx- 
oma of  the  membranes  ; psammoma ; and  lipoma. 

The  second  series  will  include,  first,  aneurisms, 
depending  upon  disease  of  one  or  more  of  the 
arterial  coats  ; and,  secondly,  such  tumours  as 
have  their  origin  in  the  sheaths  of  the  vessels, 
comprising  carcinoma  cerebri  simplex ; fungus 
of  the  dura  mater ; cholesteoma ; epithelioma 
myxomatodes  psammosum ; papilloma  of  the  pia- 
mater  and  vessels ; papilloma  myxomatodes ; 
and  tubercle. 

In  the  third  series  may  be  counted  glioma ; 
myxoma  of  the  nerve-substance;  syphilitic 
gumma  ; and  fibroma. 

Included  under  none  of  these  headings,  echi 
nococci  and  cysticerci  cellulosae  must  be  men- 
tioned, as  they  affect  the  braiD. 

Each  of  the  growths  enumerated  will  now  be 
briefly  described. 

1.  Pacchionian  granulations.  These  are  granu- 
lations of  the  arachnoid,  sometimes  met  with 
in  childhood,  very  constantly  from  middle  age 
onwards,  and  scarcely  recognised  as  morbid 
lesions.  Their  aetiology  is  unknown.  They  do  not 
give  rise  to  any  symptoms.  They  are  chiefly 
situated  along  the  superior  longitudinal  sinus, 
which  in  rare  cases  is  perforated  by  them.  They 
form  groups  of  papillae,  consisting  of  striped 
connective  tissue,  poor  in  cells,  and  proceeding 
directly  from  a thin  but  a continually  renewed 
layer  of  sub-epithelial  germinal  tissue. 

2.  Sarcoma.  This  sometimes  has  its  origin  in 
the  nervous  tissue  itself,  but  more  frequently 
arises  from  the  dura  mater,  especially  at  the  base 
of  the  skull.  From  their  situation  sarcomata  are 
especially  apt  to  interfere  with  one  or  more  of 
the  cerebral  nerves.  They  may  attain  the  size 
of  a pigeon’s,  or  even  of  a hen’s  egg. 

When  sarcoma  attacks  the  dura  mater  it  ori- 
ginates from  its  internal  side.  The  most  usual 
situation  is  the  membrane  about  the  sella  tur- 
cica and  the  pars  petrosa.  It  forms  a depres- 
sion in  the  brain,  while  the  bone  becomes  atro- 
phied behind  it.  The  growth  is  composed  of 
fusiform  cells,  with  tolerably  numerous,  and 
sometimes  dilated  vessels.  Sarcomatous  growths 
are  not  freely  developed  above  the  surface,  but 
rather  in  the  depths  of  the  tissue;  they  distend 
the  cerebral  convolutions,  form  deep  depressions’ 
on  the  surface,  and  even  penetrate  far  into  the 
brain.  They  occur  under  two  forms — hard  sar- 
coma with  compact  fibrous  fundamental  tissue 
and  small  cells,  often  called  fibrous  tumour ; and 
soft  sarcoma,  with  a loose  scanty  intercellular 
substance,  and  numerous  cells  of  comparatively 
large  size.  The  cells  are  mostly  fusiform,  but 
sometimes  round  and  multinuclear,  and  the  two 
latter  may  be  surrounded  by  the  former.  Sar- 
coma in  this  situation  is  generally  single.  It 
may  attain  the  size  of  a nut  or  even  of  an  applo  ; 
and  is  frequently  haemorrhagic. 

In  the  cerebral  tissue  itself  the  hard  sarcoma 


1*6  BRAIN.  TUMOURS  AND  NEW  GROWTHS  Of. 


attains  a great  degree  of  density:  it  is  sometimes 
fibrous,  at  other  times  cartilaginous,  of  a dense 
homogeneous  structure,  wlntish  or  bluish-white, 
with  a yellow  tinge  here  and  there,  and  with 
very  few  vessels.  It  is  distinguished  from  the 
brain  that  surrounds  it  by  a very  vascular  zone. 
It  can  be  easily  separated  from  the  parenchyma, 
and  may  thus  be  recognised  after  death  from 
simple  sclerosis  and  hard  glioma  of  the  brain. 
The  softer  form— fibro-cellular  sarcoma  — is 
generally  either  a myxo-  or  a glio-sarcoma  : but 
pure  fuso-cellular  sarcoma  is  met  with.  The 
tumour  is  a clear  grey,  almost  like  the  grey 
matter  of  the  corpus  striatum.  It  is  often 
vascular,  with  a reddish  tinge.  These  sarcomata 
are  often  almost  spherical,  and  easily  detached 
from  the  surrounding  brain-substance.  Others, 
however,  seem  to  be  continuous  with  the  neigh- 
bouring tissue,  and  to  be  little  more  than  simple 
hypertrophies  of  the  cerebral  tissue.  Especially 
is  this  the  caso  in  tumours  of  the  corpus  striatum 
and  optic  thalamus.  The  cells  of  cerebral  sarcoma 
are  frequently  the  seat  of  fatty  degeneration,  and 
the  whole  tumour  may  be  haemorrhagic.  Its 
most  frequent  situations  in  the  brain  are  the  gan- 
glia at  the  base. 

3.  Myxoma. — Myxoma  of  the  membranes  is 
rare,  and  generally  has  its  origin  from  the  con- 
vexity of  the  brain,  being  connected  with  the 
inner  surface  of  the  dura  mater.  It  is  a small 
growth,  soft,  fragile,  having  a gelatinous  as- 
pect. 

Myxomata  are  frequently  met  with  in  the  cere- 
bral hemispheres,  and  then  take  their  origin 
from  the  neuroglia.  Such  growths  are  probably 
malignant,  the  proof  of  their  malignancy  being 
that  thoy  are  often  multiple  locally ; that  they 
frequently  recur  when  removed  from  a peripheral 
nerve  ; and  that  they  not  seldom  affect  internal 
crgans.  Myxoma  probably  includes  all  that  has 
beon  called  colloid  cancer.  When  this  lesion 
affects  the  cerebral  hemispheres  it  may  be  of 
large  size.  The  mticus  is  a constituent  part  of 
the  tissue ; it  is  not  a product  of  secretion,  as  in 
mucous  cysts. 

4.  Psammoma. — Psammomata  have  been  met 
with  in  the  brain,  spinal  membranes,  spinal  cord, 
and  nerves:  they  are  not  uncommon  in  the 
choroid  plexus,  but  are  most  usually  found  in 
the  pineal  gland.  There  are  two  kinds  of  these 
growths.  In  the  first,  the  sand  occupies  the 
interior  of  the  meshes  of  the  connective  tissue 
in  very  varied  forms,  as  compact  cylinders,  as 
pear-shaped  masses,  as  spines,  or  as  globes, 
surrounded  by  connective  tissue,  and  connected 
by  it  with  the  other  parts  of  the  tumour.  In 
the  second  form,  the  sand  lies  without  cohesion 
m the  parts  and  between  them,  so  that  the 
different  grains  of  sand  may  be  easily  isolated. 
In  this  latter  form,  the  psammoma  is  composed 
most  generally  of  round  elliptical  corpuscles, 
and  sometimes  also  of  large  complex  conglomera- 
tions. These  little  tumours  have  usually  an 
internal  concentric  arrangement. 

5.  Lipoma. — This  is  a rare  form  of  tumour. 
It  may  be  connected  with  the  inner  surface  of 
the  dura  mater,  or  with  the  ependyma  of  the 
ventricles.  The  fatty  matter  is  contained  in 
cells,  and  the  cells  are  surroundedby  an  organised 
membrane.  Lipoma  is  usually  single,  seldom  mul- 


tiple; of  irregular  shape  ; and  varies  in  size  from 
a small  nut  to  a hen’s  egg.  Small  pieces  of 
earbonato  of  lime  have  been  found  in  these 
tumours. 

6.  Aneurisms. — The  larger  cerebral  aneurisms 
have  been  observed  from  early  times.  More 
recently  Liouville  has  called  special  attention  to 
the  subject  of  miliary  aneurisms,  and  has  shown 
that  they  are  common  ; that  they  are  multiple  ; 
that  they  frequently  give  way  in  the  brain  or  in 
the  pia  mater  ; and  that  they  often  co-exist  with 
aneurisms  of  the  larger  vessels  in  other  parts  of 
the  body.  Aneurism  of  the  middle  meningeal,  of 
the  internal  carotid  within  the  cavernous  sinus 
and  at  its  exit  from  it,  of  the  anterior  cerebral, 
of  the  anterior  communicating,  of  the  arteries  of 
the  corpus  callosum,  of  the  middle  cerebral,  of 
the  posterior  communicating,  of  the  vertebral,  of 
the  basilar,  of  the  posterior  cerebral,  and  of  the 
arteries  supplying  the  cerebellum,  are  all  met 
with  not  unfrequently.  The  middle  cerebral 
and  the  basilar,  however,  are  the  vessels  most 
usually  affected  with  this  lesion. 

The  minute  miliary  aneurisms  have  1 een 
observed  in  the  pia  mater,  at  the  surface  of  the 
convolutions  or  in  their  substance,  in  the  optic 
thalami,  tho  pons,  the  corpora  striata,  cerebel- 
lum, crura  cerebri,  and  medulla  oblongata ; more 
rarely  in  the  centrum  ovale.  These  miliary 
aneurisms  may  be  visible  to  the  naked  eye.  The 
smallest  are  seen  under  the  microscope  as 
ampullae  of  the  vessels,  containing  coagulated 
blood  or  granules  of  hematoidin.  The  arterial 
walls  have  generally  undergone  some  form  of 
degeneration.  The  vessel,  dilated  at  some  parts, 
is  constricted  at  others.  The  lesion  may  be  a 
consequence  of  atheroma  of  the  vessel,  but  far 
more  commonly  it  is  the  result  of  arterio-sclerosis 
of  the  inner  coat  of  the  vessels,  either  at  tho 
seat  or  in  the  immediate  neighbourhood  of  the 
aneurism.  See  Bralv,  Vessels  of,  Diseases  of. 

7.  Carcinoma  cerebri  simplex.  Cancer,  ex- 
cluding from  this  term  sarcoma  and  glioma,  may 
originate  in  the  cranial  bones,  the  dura  mater, 
the  pia  mater,  the  cerebrum,  the  cerebellum, 
the  pons,  and  the  medulla  oblongata.  The 
medulla  oblongata,  the  fornix,  and  the  corpora 
quadrigemina,  are  the  regions  least  often  affected, 
whereas  the  cerebral  hemispheres  are  the  most 
favourite  localities.  All  forms  of  cancer  are  met 
■with,  in  all  cases  having  their  origin  in  the  coats 
of  the  vessels.  Epithelial  cancer  has  been  gen- 
erally believed  to  have  its  starting  point  in  the 
peripheral  layer  of  the  arachnoid,  tho  tissue  that 
lines  the  under  surface  of  the  dura  mater.  En- 
cephaloid  cancer  is,  however,  the  most  common 
form  met  with  in  the  brain. 

8.  Fungus  of  the  dura  mater  can  scarcelv  be 
separated  from  the  preceding  form.  It  arises 
from  the  outer  surface  of  the  dura  mater,  pene- 
trates with  the  vessel  from  which  it  springs  into 
the  compact  tissue,  destroys  the  vitreous  table, 
and  spreads  out  in  the  diploe : in  its  progress  it 
may  penetrate  the  external  table  and  lift  up  tho 
integuments  of  the  cranium.  The  internal  table 
invariably  suffers  more  than  the  external. 
Sometimes  there  is  coincident  passage  of  the 
tumour  inwards,  and  the  subjacent  membranes 
become  glued  to  tho  dura  mater  and  to  the 
cerebral  substance.  There  may  result  simply 


BRAIN,  TUMOURS  AND  NEW  GROWTHS  OF. 


the  depression  of  surface  consequent  upon  pres- 
sure from  above,  but  more  commonly  cell-growth 
similar  to  that  of  the  original  tumour  takes 
place,  first  from  the  vessels  of  the  pia  mater, 
and  afterwards  from  the  vessels  of  the  cerebral 
convolutions. 

9.  Closely  allied  to  the  epithelial  cancer  that 
has  its  origin  in  the  dura  mater  is  the  cholesteoma, 
which  is  generally  situated  at  the  base  of  the  brain. 
Rindfleisch  considers  it  a squamous  epithelioma, 
whose  cellular  cylinders  are  wholly  converted 
into  a mass  of  pearly  nodules  with  a silky  lustre. 
It  is  covered  by  the  arachnoid,  and  springs  either 
from  the  vessels  of  the  pia  mater,  or  more  rarely 
from  the  perivascular  sheath  of  the  vessels  in 
the  substance  of  the  brain. 

10.  Last  of  the  cancers  is  a tumour  that  has 
been  found  in  the  third  ventricle — epithelioma 
myxomatodes  psammosum,  consisting  of  globes 
and  cylinders  of  epithelial  cells,  embedded  in  a 
very  bulky  stroma  of  mucous  tissue. 

11.  Springing  also  from  the  vessels,  two  forms 
of  papilloma  are  met  with — papilloma  of  the  pia 
mater  and  vessels  ; and  papilloma  myxomatodes. 
The  former  is  composed  of  a number  of  branch- 
ing papillae,  each  of  which  contains  a blood- 
vessel with  a small  amount  of  connective  tissue, 
and  a double  coat  of  epithelium,  of  which  the 
outer  layer  is  columnar.  In  the  latter,  which  is 
probably  a mere  variety  of  the  former,  the  struc- 
ture of  the  tumour  is  the  same,  but  the  columnar 
cells  secrete  a vast  amount  of  viscid  mucus. 

12.  Tubercle  springs  from  the  middle  tunic 
of  the  small  arteries  of  the  pia  mater,  or  of  the 
nerve-substance.  It  rarely  attacks  the  mem- 
branes in  the  form  of  tumour,  rarely  also  the 
white  matter  of  the  brain,  but  prefers  as  its 
principal  seat  the  grey  matter  of  the  convolutions 
and  of  the  deeper  parts.  Tubercle  of  the  dura 
mater  is,  however,  sometimes  met  with,  and  it 
may  induce  obliteration  of  sinuses.  The  cere- 
bellum is  a frequent  seat  of  tubercle,  which 
exists  here  in  the  form  of  superficial  granula- 
tions. The  pons  also  is  frequently  affected 
with  tubercle,  both  in  the  form  of  small  tu- 
mours of  its  substance,  and  as  polypous  tuber- 
cles of  the  fourth  ventricle.  Tubercle  is  sepa- 
rated from  the  surrounding  cerebral  substance  by 
a very  delicate  reddish  envelope. 

Tubercular  tumours  of  the  cerebral  substance 
are  often  multiple,  and  not  unfrequently  large  ; 
they  are  of  very  slow  growth ; persist  long  in 
the  caseous  state;  and  may  be  found  cretified. 
Sometimes  there  is  cerebral  softening  around 
them.  Virchow  states  that  the  increase  of  tu- 
bercles takes  place  by  apposition  or  juxta- 
position, and  that  the  apposition  takes  place 
not  by  layers  primarily  caseous,  but  by  zones 
of  new  grey  proliferation,  usually  in  the  form 
of  miliary  tubercle.  A very  delicate  layer  of 
connective  tissue  of  new  formation,  a species 
of  encysting  false  membrane,  represents  the 
mother-tissue  for  the  subsequent  generation  of 
young  tubercles. 

13.  Glioma , called  by  Billroth  granulated  sar- 
coma, or  round-celled  sarcoma,  is  practically  a 
local  hyperplasie  development  of  the  neuroglia. 
It  may  appear  in  three  forms,  either  as  a soft 
glioma,  rich  in  cells — the  most  common  kind ; as 
hard  glioma,  fibrous,  and,  if  the  vessels  are  much 


157 

developed,  telangiectasic ; or,  thirdly,  as  a rtvjxo- 
glioma,  a complex  tumour,  in  which  part  of  the 
tumour  takes  the  appearance  of  mucous  tissue. 
The  nature  of  the  tumour  is  partly  determined 
by  the  nature  of  the  tissue  from  which  it  springs ; 
thus  glioma  of  the  brain  is  generally,  but  not 
always,  soft ; glioma  of  the  ependyma  hard.  The 
soft  gliomata  are  closely  allied  to  myxomata. 
The  intercellular  substance  is  found  in  moderate 
quantity.  In  the  more  mucous  gliomata  the  net- 
work is  regular  and  large,  and  the  tissue  has 
little  cohesion.  If  the  meshes  are  larger  still, 
and  the  mucous  element  abundant,  this  variety 
passes  into  a myxoma.  If  there  be  a consider- 
able increase  of  cells,  whilst  the  trabeculae 
become  narrower,  we  get  a medullary  glioma, 
which  may  be  transformed  into  a medullary 
sarcoma  if  the  cells  continue  to  grow  and  mul- 
tiply. These  transitions  are  not  uncommon  even 
in  the  same  tumour,  especially  in  the  posterior 
lobes  of  the  brain.  If  the  vessels  are  developed 
in  great  abundance  we  get  ha;morrhages  and  a 
kind  of  fungus  hsematodes.  Hard  glioma  is 
closely  allied  to  fibroma,  with  which  indeed  it 
may  be  combined  to  form  a fibro-glioma.  In 
hard  glioma  the  fibres  are  not  arranged  in  a 
network,  but  in  parallel  lines,  like  felt.  The 
nervous  elements,  naturally  contained  in  the 
neuroglia,  are  absent  in  these  tumours.  The 
walls  of  the  vessels  are  frequently  thickened. 

The  glioma  of  the  ependyma  is  of  little  im- 
portance ; it  is  seen  as  fine  granulations  on  the 
surface  of  the  lateral  ventricles  in  chronic  hydro- 
cephalus ; on  the  floor  of  the  fourth  ventricle  it 
may  grow  to  the  size  of  a cherry.  In  the  cerebral 
substance,  gliomata  may  attain  the  size  of  a fist, 
or  even  of  a child’s  head  ; and  they  are  often 
mistaken  for  cancers  or  sarcomata  of  the  brain. 
Hard  glioma  may  be  distinguished  from  sclerosis, 
in  that  sclerosis  encloses  the  normal  nerve  ele- 
ments. In  glioma,  too,  there  is  great  prolifera- 
tion of  neuroglia  cells.  There  is  no  distinct  limit 
between  glioma  and  the  surrounding  brain-sub- 
stance, but  the  tumour  on  section  shows  greater 
vascularity,  greater  consistence,  and  a more  trans- 
parent constitution,  as  well  as  often  a bluish- whito 
appearance  compared  with  the  white  brain-mat- 
ter. The  demarcation  in  grey  matter  is  imper- 
ceptible to  the  naked  eye,  especially  if  the  glioma 
be  soft.  Soft  glioma  is  generally  single  ; hard  is 
often  multiple.  The  membranes  may  adhere,  but 
form  no  part  of  the  tumour. 

Virchow  thinks  that  glioma  is  not  malignant ; 
that  hard  glioma  has  an  inflammatory  origin  , 
and  that  the  soft  variety  is  set  up  by  local 
causes,  such  as  injury.  Gintrac,  on  the  other 
hand,  unites  gliomata  and  sarcomata  under  the 
head  of  cancers. 

Soft  glioma  is  most  frequently  situated  in  the 
posterior  lobes,  less  often  in  the  upper  and  lateral 
parts  of  the  cerebral  hemispheres.  It  maybe  con- 
genital. It  gives  rise  to  complications,  namely, 
first,  great  congestion,  causing  cerebral  compres- 
sion, irritation,  pain,  excitement,  or  apoplexy ; 
and,  secondly,  hydrocephalus  of  the  ventricles, 
which  in  protracted  cases  is  seldom  absent.  The 
latter  occurs  most  rapidly  in  glioma  of  the  optic 
thalami,  or  of  the  posterior  lobe,  compressing  the 
choroid  veins,  the  venae  Galeni,  or  the  transverse 
sinus. 


BRAIN,  TUMOURS  AND  NEW  GROWTHS  OF. 


158 

14.  Myxoma  of  the  nerve-substance. — This  is 
not  common  in  the  brain.  It  owns  the  same 
origin  as  glioma,  having  the  neuroglia  as  its 
starting  point. 

15.  Syphilitic  gumma. — Gummy  tumours  of 
the  brain  are  generaUy  found  at  the  circum- 
ference, and  especially  at  the  base  of  the  brain. 
Their  origin  is  either  from  the  membranes, 
from  tlie  vessels,  or  from  the  neuroglia  of 
tho  cerebral  substance.  They  have  infective 
properties,  or  at  any  rate  they  are  multiple, 
and  may  be  met  with  at  the  same  time  affect- 
ing the  dura  mater,  the  pia  mater,  the  brain, 
nerves,  and  cranial  bones.  They  are  often 
accompanied  by  inflammatory  phenomena,  a 
point  which  distinguishes  them  from  large 
tubercles.  Gumma  is  not  tho  usual  form  in 
which  syphilis  attacks  the  dura  mater  on  its 
external  surface.  It  may,  however,  affect 
the  arachnoid  surface  of  the  dura  mater.  In 
this  situation  the  gummata  may  vary  in  size 
from  a hemp-seed  to  a nut.  They  may  be  formd 
just  above  the  convexity  of  the  hemispheres,  or 
at  the  anterior  part  of  the  base  of  the  brain, 
especially  about  the  sella  turcica,  or  on  the  ten- 
torium cerebelli.  They  have  been  met  with  in 
the  falx  cerebri.  The  inflammatory  condition 
around  these  tumours  often  unites  them  to  the 
pia  mater,  and  the  subjacent  portion  of  brain  is 
frequently  softened,  either  by  the  inflammation, 
or  by  arterial  obliteration. 

When  the  pia  mater  is  united  to  the  dura 
mater,  gummata  very  small  in  size  may  form  in 
the  former  membrane.  The  subjacent  brain  may 
be  softened  or  sclerosed.  Much  larger  gummata, 
however,  from  the  size  of  a nut  to  that  of  a hen’s 
egg,  originate  from  the  pia  mater,  and  are  most 
usually  situated  in  the  region  between  tho  optic 
ehiasma  and  the  pons,  or  on  the  crura  cerebelli. 
On  the  convex  surface  they  are  much  smaller. 
Gummata  of  the  cerebral  substance  occur  in  situa- 
tions most  subject  to  traumatic  influences.  The 
chief  seats  are  the  cerebral  hemispheres,  the  large 
ganglia,  especially  the  optic  thalami,  and  next  in 
frequency  the  pons,  and  crura  cerebri  and  cere- 
belli. The  tumours  attain  to  a good  size,  but  are 
not  so  large  as  those  of  the  pia  mater.  They 
may  be  multiple,  but  often  exist  singly.  See 
Brain,  Vessels  of,  Diseases  of. 

16.  Fibroma.  True  fibromata,  distinct  from 
hard  gliomata  and  sarcomata,  probably  do  not 
exist  in  the  brain  or  its  membranes.  Fibromata 
are  essentially  composed  of  connective  tissue. 
Such  increase  in  this  tissue  is  sclerosis,  and  its 
arrangement  is  too  indefinite,  its  amount  too 
small,  to  be  considered  a tumour.  Rindfleisch 
is  probably  wrong  in  stating  that  there  are 
solitary  tubercles  of  the  brain  which  deserve 
rather  to  be  called  fibroid  tumours  ; although  it 
may  be  true  that  in  some  cheesy  nodules  of  the 
nervous  centres  the  growth  of  fibres  and  the 
condensation  predominate  enormously  over  the 
corpuscular  structure.  Practically,  however, 
both  enchondromata  and  osteomata  are  fibrous 
tumours.  An  enchondfoma  is  a heterologous 
tumour  not  developed  from  a pre-existing  car- 
tilage, but  produced  by  a change  in  the  type  of 
formation  by  proceeding  from  a non-cartilaginous 
matrix.  Although  osteoid  enchondromata  may  be 
malignant,  yet  true  osteomata  are  not  so.  These 


tumours  may  attack  the  cerebral  dura  mater,  and 
on  the  convexity  are  multiple.  If  the  tumour 
attack  the  falx  cerebri  it  is  solitary.  Its  start- 
ing-point is  the  internal  surface  of  the  dura 
mater.  It  is  distinguished  from  exostosis  of  bone 
by  having  a fibrous  layer  between  it  and  the 
bone.  It  may  set  up  irritative  pachymeningitis. 
Such  tumours  also  are  found  small  in  connection 
with  the  cerebral  arachnoid,  as  simple  united 
patches  or  pointed  prolongations.  Their  favourite 
seat  is  the  convex  surface  of  the  anterior  lobes. 
The  nervous  centres  are  very  rarely  the  seat  of 
these  tumours.  Their  matrix  is  formed  by  con- 
nective tissue,  not  cartilage,  the  product  of  irri- 
tation of  the  neuroglia,  and  so  a consequence  of 
circumscribed  encephalitis. 

17.  Hydatids  are  rare  within  the  skull,  but 
are  met  with  occasionally  in  all  parts  of  the  brain, 
between  the  membranes,  in  the  ventricles,  and 
lying  free  at  the  base  of  the  brain.  They  are 
more  common  in  children  than  in  adults.  The 
brain  may  suffer  from  pressure  either  in  the  way 
of  softening  from  interference  with  the  vessels, 
or  from  sclerosis. 

Cysticerci  are  also  met  with  in  various  parts 
of  the  brain  or  its  membranes.  They  may  be 
surrounded  by  connective-tissue  capsules ; or  may 
lie  free,  arranged  in  a racemose  form.  They 
may  be  single,  or  may  attack  the  same  individual 
in  several  hundred  places  at  once. 

Symptoms.- — Even  in  tumours  of  considerable 
size  all  symptoms  may  be  latent.  The  more  tol- 
erant portion  of  the  brain  will  include  the  hemi- 
spheres and  the  white  commissural  regions,  whilst 
the  mesocephale,  the  optic  thalami,  and  tho  cor- 
pora striata  are  amongst  the  least  tolerant  por- 
tions. It  is  not  unusual,  moreover,  to  meet  with 
decided  intermissions,  especially  in  the  early 
period  of  the  disease ; such  intermissions  de- 
pending on  temporary  lesions  in  the  immediate 
neighbourhood  of  the  tumour. 

Even  with  these  intermissions  the  diagnosis  of 
the  presence  or  position  of  the  cerebral  tumours 
would  be  comparatively  easy,  if  the  symptoms 
invariably  depended  upon  direct  excitation. 
Many  of  the  phenomena  pass  the  limits  of  the 
immediate  sphere  of  the  tumour,  and  are  the 
results  of  reflex  action.  Sometimes  also  the 
symptoms  due  to  direct  and  reflex  excitation 
may  coincide,  and  this  is  particularly  the  case 
in  tumours  of  the  base.  The  main  difficulties 
lie  in  the  possible  latency  of  all  symptoms  ; in 
their  intermission  ; in  the  distinction  and  com- 
bination of  direct  and  reflex  excitation  ; and  in 
the  remissions  following  physical  or  psychical 
excitement. 

Symptoms  then  may  depend  on  direct  or  reflex 
excitation,  and  consist  of  exaltation  of  functional 
activity,  such  as  contractions,  partial  or  general 
convulsions,  liypenesthesia,  and  hyperideation. 
Others  are  produced  by  secondary  lesions  in 
the  neighbourhood  of  the  tumour— congestion, 
haemorrhage,  inflammation,  &c. — and  these  may 
include  not  only  all  in  the  previous  division, 
but  temporary  or  persistent  paralysis,  fever,  and 
other  phenomena.  Then  there  may  be  symp- 
toms of  direct  compression,  definite  paralyses, 
and  gradual  enfeeblement  of  the  sensorial  and 
intellectual  faculties. 

Taking  some  of  the  more  common  conditions  in 


BRAIN.  TUMOURS  AND  NEW  GROWTHS  OF.  159 


order,  and  viewing  them  as  dependent  on  direct 
or  reflex  irritation,  the  most  frequent  certainly 
is  headache  ; and  except  a tumour  of  the  cere- 
bellum, when  the  headache  is  almost  invariably 
occipital,  there  is  no  symptom  less  useful  in 
determining  the  position  of  the  lesion.  It  is  less 
frequently  due  to  direct  excitation  than  to  reflex. 
The  pain  is  very  severe,  indeed,  more  so  than  in 
any  other  disease,  excepting,  perhaps,  meningitis : 
it  persists  through  the  whole  malady;  and  is 
increased  by  vibration  of  all  kinds,  light,  sound, 
or  movement  of  the  head.  It  may  be  confined 
to  a single  spot,  or  be  diffused  over  the  whole 
head.  Connected  with  headache  in  many  cases, 
and  often  equally  the  effects  of  radiated  influ- 
ence, are  tinnitus  aurium,  morbid  acuteness  of 
hearing,  and  painful  sensitiveness  to  sound  ; dis- 
turbances of  vision,  diplopia,  muscse  volitant.es, 
and  strabismus,  which  may  bo  transient ; formi- 
cation, and  sometimes  hypersesthesise  of  greater 
or  less  extent.  In  some  cases  there  is  an  agitated 
condition  of  the  intellectual  faculties,  and  even 
delirium.  Disturbances  of  sight  are  very  common. 
The  retinal  lesions  will  be  subsequently  de- 
scribed. It  is  a remarkable  fact,  as  bearing  upon 
reflex  phenomena,  that  the  affections  of  sight 
usually  implicate  both  eyes,  even  where  the 
tumour  has  involved  only  one  optic  nerve,  and 
is  not  situated  near  the  optic  chiasma  or  the 
corpora  quadrigemina.  Hearing  is  far  less  often 
affected  than  vision.  Generally  a slight  diminu- 
tion only  of  this  function  is  observed ; and,  in  the 
rare  cases  in  which  complete  deafness  is  met 
with,  it  is  unilateral.  Taste  and  smell  are  seldom 
interfered  with.  When  these  special  senses  are 
morbidly  affected,  the  tumour  in  the  first  case 
will  probably  be  located  in  the  posterior  portion 
of  the  base;  in  the  second  at  the  anterior  half  of 
the  base  of  the  brain. 

The  symptoms  of  compression  maybe  included 
in  the  expression  ‘lowering  of  function,’ com- 
prising apathy,  feebleness  of  memory,  want  of 
attention,  confusion,  and  a general  enfeeblement 
of  ideas.  These  conditions  are  often  accom- 
panied or  preceded  by  certain  diffused  symptoms, 
such  as  vertigo. 

Vertigo  is  the  first  symptom  in  many  cases  : 
it  is  felt  especially  when  the  patient  is  in  the 
upright  position.  It  often  produces  uncertainty 
of  gait,  even  where  the  tumour  is  not  in  the 
cerebellum.  Strange  sensations  in  the  head 
are  also  complained  of,  a feeling  of  liquid  in  the 
head,  or  of  a mobile  body;  or  the  sensation  may 
be  that  of  a solid  body  filling  the  head,  or  press- 
ing upon  some  portion  of  it. 

These  phenomena  often  coincide  with  evi- 
dences of  irritation  of  the  mesocephale,  whether 
clue  to  direct  compression  or  to  radiated  irri- 
tation of  the  medulla  oblongata.  Chief  amongst 
these  symptoms  is  vomiting.  It  is  not  accom- 
panied by  nausea  or  other  manifestations  of 
dyspepsia,  and  it  will  occur  when  the  stomach 
is  empty.  It  can  frequently  be  checked  only  by 
keeping  the  patient  in  a recumbent  position. 
Constipation  also  is  often  obstinate. 

Epileptiform  convulsion  has  an  important 
bearing  on  the  diagnosis  of  these  lesions.  Very 
frequently  convulsion  is  preceded  by  many  of  the 
phenomena  already  touched  upon,  such  as  head- 
ache or  vertigo.  Frequently,  however,  convul- 


sion precedes  all  other  morbid  phenomena,  and 
the  patient  may  be  in  perfect  health  in  the 
intervals  of  the  attacks.  G iven,  therefore,  con- 
vulsion as  the  one  factor  in  forming  an  opinion, 
it  is  necessary  to  consider  the  liability  of  the 
patient  to  convulsive  attacks  from  causes  other 
than  tumours ; to  realise  whether  the  family 
history  shows  any  suspicion  of  epilepsy;  and  to 
eliminate  from  the  case  the  possibility  of  satur- 
nine, alcoholic,  and  uraemic  poisoning.  If  this  is 
done,  and  especially  if  we  find  early  convulsion 
associated  with  headache  and  with  vomiting, 
this  symptom  will  prove  an  important  aid  in 
the  diagnosis  of  tumour. 

The  phenomena  depending  on  the  presence 
of  tumour  itself  may  be  associated  with  others 
due  to  complications,  such  as  oedema,  congestion, 
encephalitis,  or  meningitis  of  the  surrounding 
parts.  A high  temperature,  for  instance,  will 
point  to  inflammation  either  of  the  nervous  sub- 
stance or  of  the  meninges  near  the  lesion  ; and 
meningeal  inflammation  seems  to  be  accompanied 
by  the  highest  temperature.  Syphilitic  gumma, 
however,  may  coincide  with  syphilitic  meningitis 
on  some  other  portion  of  the  encephalon  not  di- 
rectly connected  with  the  immedjate  surround- 
ings of  the  tumour. 

Passing  for  the  moment  the  subject  of  definite 
paralyses  with  the  remark  that  the  sphincters 
are  seldom  affected,  even  in  cases  in  which  the 
paralysis  takes  a paraplegic  form,  it  may  be 
mentioned  that  a want  of  equilibrium  seems 
to  be  a not  unusual  evidence  of  the  presence  of 
tumour  in  the  cerebellum.  Aphasia  may  not 
only  be  due  to  the  special  localisation  of  tumour 
in  Broca’s  region  of  the  left  anterior  lobe,  but 
also  to  the  presence  of  this  lesion  in  any  part, 
of  the  track  (corpus  striatum,  optic  thalamus, 
or  crus  cerebri)  which  unites  this  portion  of 
the  hemisphere  to  the  medulla  oblongata,  the 
highway  by  which  the  centre  for  the  production 
of  articulate  speech  is  connected  with  the  co- 
ordinating centre  for  this  function.  Anaesthesia 
of  the  skin  is  seldom  met  with  as  a symptom  of 
cerebral  tumour.  When  present  it  is  found  only 
in  the  limbs  affected  with  motor  paralysis,  and 
is  scarcely  ever  complete. 

Symptoms  of  special  localities. — It  remains  to 
take  special  regions  of  the  encephalon  separately 
and  to  endeavour  to  differentiate  the  position 
of  the  tumour  by  the  symptoms  attending  its 
presence. 

Tumour  in  the  medulla  oblongata  will  be  ac- 
companied by  various  disturbances  of  sensibility, 
especially  headache,  and  sometimes  by  convul- 
sions. The  pressure  of  a tumour  is  seldom 
limited  to  the  medulla  oblongata,  and  the  symp- 
toms therefore  are  complex.  In  several  of  the 
cases  recorded  there  has  not  only  been  amaurosis 
and  deafness  of  one  side,  but  interference  with 
taste  and  smell. 

Tumour  of  th & fourth  ventricle  may  manifest 
itself  by  the  presence  of  sugar  or  of  inosite  in  the 
urine.  Tumour  here,  as  in  the  medulla  oblongata, 
frequently  destroys  life  quickly,  before  there  has 
been  time,  so  to  speak,  for  much  local  lesion  to 
be  set  up.  Vomiting  is  a frequent  symptom. 

Tumour  of  the  crura  cercbelli  and  of  the 
corpora  quadrigemina  cannot  be  diagnosed  by  any 
peculiar  symptoms.  In  one  case,  in  which  the 


100  BRAIN,  TUMOURS  AN 

corpora  quadrigemina  seemed  -wholly  transformed 
into  a tuberculous  mass,  the  sight  remained  good, 
but  there  Teas  double  ptosis. 

In  tumour  of  the  cerebellum  there  is  little 
disturbance  of  sensibility  except  occipital  head- 
ache. There  are  various  disturbances  of  motility, 
especially  convulsions  and  irregularity  of  locomo- 
tion, but  no  true  paralysis.  Amblyopia,  amau- 
rosis, and  convergent  strabismus  are  common. 
There  is  no  interference  with  the  psychical 
functions,  or  with  speech,  as  a general  rule. 
Vomiting  is  very  common.  In  76  cases  col- 
lected by  Ladame,  there  was  no  abnormality  in 
the  genital  functions,  except  in  four  instances. 

In  tumours  of  the  pons,  the  disturbances  of 
sensibility  are  general  or  partial  anaesthesia, 
and  in  some  cases  more  or  less  headache. 
Hemiplegia  of  unequal  degree  on  the  two  sides, 
and  other  forms  of  paralysis  are  observed,  but 
no  convulsion.  Various  and  manifold  disturb- 
ances of  the  special  senses ; phenomena  of  de- 
pression of  mind;  frequent  alteration  of  speech; 
and  early  disorders  in  swallowing  occur. 

Tumours  of  the  crura  cerebri  follow  the  ex- 
ample of  the  same  lesion  in  the  pons  -with 
reference  to  disturbances  of  sensibility.  Equi- 
lateral hemiplogia  opposite  to  the  lesion  is  met 
with,  and  paralysis  of  the  oeulo-motor  nerve  on 
the  same  side  as  the  tumour,  often  gradually  ex- 
tending itself  to  both  oeulo-motors. 

Tumours  of  the  pituitary  gland  are  accom- 
panied by  intense  frontal  headache ; by  no 
definite  disturbances  of  sensation  or  of  motion ; 
by  double  amblyopia  or  amaurosis,  unequally 
developed ; and  by  no  loss  of  speech. 

Tumours  of  the  middle  cavities  of  the  cranium 
seem  to  affect  mainly  the  third  and  the  fifth 
nerves,  anaesthesia  or  pains  in  the  face  and  ptosis 
being  the  prominent  symptoms,  with  some 
interference  with  the  free  action  of  the  other 
muscles  of  the  eyeball  supplied  by  the  third.  In 
one  case,  in  which  a scirrhous  tumour  of  the  left 
side  was  situated  on  the  inner  surfaco  of  the 
sphenoid  bone,  extending  laterally  to  the  internal 
auditory  meatus  and  backwards  to  the  pons,  not 
only  were  the  third  and  fifth  nerves  paralysed, 
but  colour-blindness  supervened  some  time  before 
death. 

In  tumour  of  the  corpora  striata  aud  optic 
thalami , headache  is  less  frequent  than  in  other 
regions.  Hemiplegia  and  convulsions  are  fre- 
quent, the  former  especially  so.  Hardly  any 
disturbance  of  the  special  senses  is  observed.  In- 
telligence and  speech  are  frequently  disordered. 

In  tumour  of  the  corpus  callosum,  there  is 
frequently  some  mental  aberration,  and  often 
convulsions. 

In  tumour  of  the  middle  cerebral  lobes , headache 
is  frequently  a prominent  symptom,  but  other- 
wise the  sensory  disorder  is  mainly  anaesthetic. 
Hemiplegia  is  common,  as  is  also  convulsion  of 
an  epileptiform  character.  These  convulsive 
attacks  are  not  rarely  unilateral,  and  sometimes 
affect  at  first  one  limb  only.  In  fact  the  position 
of  a tumour  towards  the  anterior  portion  of  the 
middle  lobe  may  be  determined  by  symptoms 
with  tolerable  accuracy.  Various  disturbances 
of  sight  and  of  hearing  are  met  with ; as  well  as 
various  psychical  abnormalities,  ranging  from 
mere  confusion  of  ideas  to  absolute  imbecility. 


D NEW  GROWTHS  OF. 

In  tumour  of  the  anterior  lobes  there  in 
general  headache,  seldom  of  the  frontal  region 
particularly.  No  other  sensory  disturbance 
occurs.  Sight  and  smell  are  frequently  affected, 
speech  seldom.  Hemiplegia,  convulsions,  and 
psychical  disturbance  will  occur  much  as  in 
tumours  of  the  middle  lobes. 

In  tumour  of  the  posterior  lobes,  there  is  gen- 
eral headache,  seldom  localised  in  the  occiput : 
no  other  sensory  disturbance.  Slightly  marked 
hemiplegia  occurs,  and  convulsive  attacks  are 
very  frequent.  There  is  no  disturbance  of  the 
organs  of  special  sense.  The  mental  faculties 
are  greatly  altered,  particularly  in  the  tendency 
to  depression. 

All  three  lobes  may  be  affected  with  tumour 
coincidently,  and  the  headache  is  then  very 
intense ; the  epileptiform  convulsions  exceed  the 
paralytic  phenomena ; the  organs  of  special  sense 
are  little  affected ; and  there  are  various  mental 
disturbances. 

In  tumour  of  the  convexity,  the  headache  is 
generally  limited  either  to  the  frontal  regions, 
to  one  side  of  the  head,  or  to  the  occiput.  There 
is  neither  anaesthesia,  nor  paralysis,  but  intense 
convulsions  occur.  The  special  senses  are  not 
disturbed.  The  mental  condition  is  one  of  irri 
tation,  evidenced  by  delirium  and  excitement. 

Lastly,  very  various  regions  of  the  brain  may 
be  simultaneously  the  seat  of  tumour,  and  the 
morbid  phenomena  will  be  necessarily  com- 
plex. 

Retinal  changes. — It  has  seemed  more  con- 
venient to  speak  of  retinal  changes  dependent 
on  cerebral  tumour  separate  from  the  other 
symptoms.  Great  variations  in  the  lesion  occur 
according  to  the  position  of  the  tumour;  its 
direct  interference  -with  the  optic  centres ; its 
complication  with  meningitis ; and  its  pressure 
on  the  optic  nerves  and  chiasma. 

Taking  choked  disc,  optic  neuritis,  and  atrophy 
of  the  optic  nerve  as  the  three  chief  lesions, 
cerebral  tumour  may  very  frequently  induce 
choked  disc,  by  interfering  with  the  venous  ebb 
from  the  eye;  optic  neuritis,  if  meningitis  is 
associated  with  the  tumour ; optic  atrophy,  by 
pressure  of  the  tumour  on  the  optic  nerve,  or  by 
this  pressure  of  the  tumour  or  of  hydrocephalus 
secondarily  induced  by  it  on  the  optic  centres 
or  tracts,  or  by  softening  around  the  tumour, 
such  softening  implicating  the  optic  centres,  or. 
lastly,  by  the  propagation  of  sclerosis.  Any 
tumour  situated  far  back  in  the  encephalon  may 
interfere  with  the  venous  flow  through  the  venae 
Galeni,  and  so  produce  hydrocephalus  of  the 
ventricles,  and  the  retinal  effects  of  hydro- 
cephalus. 

There  are  no  retinal  changes  from  tumour  in 
the  corpus  callosum,  nor  as  a rule  from  tumour 
in  the  optic  thalami.  Tumours  of  the  cerebral 
hemispheres  all  influence  the  optic  nerve,  if  they 
interfere  with  the  base  of  the  brain. 

Tumours  of  the  cerebellum  may  cause  pres- 
sure on  the  lateral  sinuses,  the  straight  sinus, 
the  venae  Galeni,  or  the  torcular  Herophili: 
pressure  in  any  of  these  situations  may  produce 
choked  disc.  Or  the  tumour  may  affect  the 
corpora  quadrigemina ; or  softening  around  it 
may  spread  to  these  organs,  and  atrophy  of  tha 
optic  nerve  be  the  result.  A fortiori,  tumour 


BE  AIM , TUMOURS  OF. 
of  the  corpora  quadrigemina  themselves  will 
lead  to  atrophy  of  nerve. 

Tumour  of  the  crura  cerebelli  causes  hydro- 
cephalus, and  its  effects  on  the  retina. 

In  a similar  way  tumours  springing  from  the 
bone  or  the  membranes  at  the  base  of  the  brain 
may  produce  choked  disc  or  atrophy,  according 
to  the  position  of  the  pressure,  optic  neuritis  by 
complications  with  meningitis,  or  neuro-retinitis 
by  irritation  of  the  connective  elements  of  the 
nerves.  See  Opthalmoscope  in  Medicine. 

Course. — The  clinical  course  of  cerebral  tu- 
mours is  intermittent  and  paroxysmal.  In  many 
eases,  such  as  those  of  glioma,  it  is  very  slow. 
Two  groups  of  phenomena  may  complicate  its 
ordinary  course,  namely,  those  associated  with 
meningitis  and  apoplexy. 

Special  Tumours. — Aneurismal  tumours  may 
sometimes  be  distinguished  by  the  sense  of  throb- 
bing in  the  head  ; by  the  patient  being  of  adult 
age  or  young  ; by  his  being  attacked  in  the  midst 
of  perfect  health  ; by  vomiting  being  rare,  apo- 
plexy frequent,  paralysis  of  cranial  nerves  early 
and  unilateral ; and  by  absence  of  mental  pheno- 
mena. Aneurism  situatedin  the  cavernous  sinus 
produces  exophthalmos.  See  next  article. 

The  symptoms  of  echinococci  differ  very  little 
from  those  of  other  slow  tumours : headache, 
dizziness,  vomiting,  syncope,  and  epileptiform 
attacks  are  most  frequent.  Disturbances  of  the 
motor  and  sensory  functions,  and  also  of  the 
mind  itself,  are  sometimes  met  with,  and  vary 
according  to  the  situation  of  the  lesion.  The 
prognosis  is  unfavourable ; the  diagnosis  im- 
possible, unless  echinococci  exist  at  the  same 
time  in  the  liver. 

Cysticerci  manifest  their  presence  in  the  brain 
by  epileptic  attacks,  which  augment  in  number 
and  severity ; the  health  of  the  patient  between 
the  fits  is  at  first  good,  then  apathy  and  torpor 
supervene  ; hemiplegia  is  rare,  and  never  early ; 
cranial  nerve  paralyses  are  exceptional ; the 
symptoms  are  diffuse  and  bilateral,  owing  to 
the  position  of  the  parasite  in  the  grey  con- 
volutions, and  in  many  spots  at  a time.  The 
age  of  the  patient  is  above  40.  Perhaps  there 
may  he  evidence  of  the  presence  of  cysticerci 
elsewhere. 

Syphilitic  tumours  coincide  with  actual  or 
previous  syphilis.  The  headache  attending  this 
form  of  tumour  is  generally  intensified  at  night. 

In  tubercle  of  the  brain  there  is  often  a tuber- 
culous family  history,  or  the  presence  of  tubercle 
elsewhere  in  the  body.  It  seldom  compresses 
cranial  nerves.  Its  clinical  evolution  is  often 
by  paroxysms,  and  grave  cases  are  combined 
with  tuberculous  arachnitis  and  hydrocephalus 
of  the  ventricles.  Tubercle  in  the  cortical  sub- 
stance of  the  brain  and  cerebellum  may,  how- 
ever, be  attended  by  no  special  symptoms. 

In  cancer  also  there  is  frequently  a family 
history  of  this  malady ; and  the  cancerous 
cachexia  may  be  present.  Cancer  seldom  ex- 
ists elsewhere  when  it  is  cerebral.  This  growth 
is  much  less  often  accompanied  by  symptoms 
due  to  congestion  and  haemorrhage  than  glioma 
or  sarcoma,  being  less  vascular. 

Prognosis. — The  prognosis  of  cerebral  tu- 
mour is  always  bad,  except  in  syphilitic  gumma, 
end  perhaps  aneurism. 

11 


BRAIN,  VESSELS  OF.  161 

Treatment.  — In  syphilitic  gumma  and  in 
aneurism  large  doses  of  iodide  of  potassium  may 
be  used  with  more  or  less  success.  This  remedy 
is  also  useful  in  dispersing  the  results  of  the 
meningitis  which  so  often  accompanies  tumour  of 
the  base.  Beyond  this  there  is  little  to  be  done, 
except  in  the  endeavour  to  relieve  pain  and  to 
support  the  strength  of  the  patient. 

E.  Long  Fox. 

BRAIN,  Ventricles  of,  Diseases  of.  Scv 
Ventricles  of  Brain,  Diseases  of. 

BRAIN,  Vessels  of,  Diseases  of. 

1.  Aneurism. — The  larger  arteries  of  the 
brain,  and  their  minute  branches  in  the  cerebral 
substance,  are  both  liable  to  aneurismal  dila- 
tation. 

(«)  Aneurism  of  the  larger  cerebral  arteries  is 
more  common  than  that  of  vessels  of  a similar 
size  elsewhere.  The  large  vessels  of  the  base,  or 
their  primary  branches,  may  be  affected.  The 
basilar  and  middle  cerebral  arteries  are  those 
most  frequently  diseased,  aneurisms  of  those  two 
vessels  constituting  three-fourths  of  the  cases. 
Next  in  frequency  is  the  internal  carotid.  The 
vertebral,  anterior  and  posterior  cerebrals,  an- 
terior and  posterior  communicating,  and  anterior 
cerebellar  arteries  are  occasionally,  but  less  fre- 
quently, involved.  In  one  or  two  recorded  cases 
the  aneurism  has  been  situated  in  the  interior 
of  the  pons  Varolii  or  cerebellum.  The  arteries 
of  the  two  sides  of  the  brain  are  affected  with 
equal  frequency,  with  the  exception  of  the  mid- 
dle cerebral,  which,  with  its  branches,  suffers 
twice  as  frequently  on  the  left  side  as  on  the 
right.  There  may  he  more  than  one  aneu- 
rism, situated  on  differert  arteries  or  on  different 
branches  of  the  same  artery.  The  aneurism  is 
usually  sacculated,  rarely  dissecting.  Its  size 
varies  from  that  of  a pea  to  that  of  a nut. 
but  aneurisms  of  the  anterior  or  middle  cere- 
brals have  attained  a much  larger  size.  When 
this  is  the  case  the  brain-tissue  is  pressed  upon 
and  softened. 

.(Etiology  and  Pathology. — These  aneu- 
risms are  rather  more  common  in  men  than  in 
-women.  They  occur  at  all  ages,  being  more  fre- 
quent before  the  ordinary  degenerative  period 
than  aneurisms  elsewhere.  Nearly  half  the  re- 
corded instances  have  occurred  between  ten  and 
forty  years,  and  about  one-seventli  between  ten 
and  twenty.  The  change  in  the  arterial  wall 
resembles  that  giving  rise  to  aneurism  elsewhere 
— a fibroid  degeneration,  with  loss  of  muscular 
and  elastic  tissue.  This  may  he  part  of  a widely 
spread  arterial  change,  or  more  frequently  is 
local.  When  local,  it  is  sometimes  due  to  syphi- 
litic disease  of  the  arterial  -wall,  but  still  more 
frequently  to  the  consequences  of  embolism. 
Dr.  Church  first  pointed  out  the  frequent  asso- 
ciation in  young  persons  of  cerebral  aneurism 
and  valvular  disease  of  the  heart,  and  many 
facts  have  been  published  which  support  the 
hypothesis  that  the  aneurism  in  these  cases 
may  he  the  consequence  of  incomplete 
obstruction  by  embolism.  There  is  often 
evidence  of  inflammatory  and  degenerative 
changes  (thickening,  calcification)  in  the  artoria) 


i62  BRAIN,  VESSELS 

wall  after  embolism,  especially  -when  the  plug 
comes  from  an  inflamed  endocardium.  If  the 
obstruction  is  incomplete,  the  altered  'wall  may 
yield  to  the  blood-pressure.  In  harmony  with 
this  theory  are  the  frequent  absence  of  degene- 
ration in  other  arteries,  the  frequency  with  which 
the  left  middle  cerebral  is  the  seat  of  the  aneu- 
rism, and  the  occasional  occurrence  of  several 
aneurisms  on  branches  of  the  same  arterial  trunk. 
The  efficient  agent  in  the  production  of  the 
aneurism  is  the  high  blood-pressure  in  the  cere- 
bral arteries. 

Rupture  has  occurred  in  about  three-fourths 
of  the  recorded  cases  of  cerebral  aneurism.  The 
blood  may  escape  rapidly  or  slowly,  and  the 
haemorrhage  may  take  place  into  the  subarach- 
noid space,  or  into  the  adjacent  cerebral 
substance.  In  the  former  case,  meningeal 
haemorrhage  is  the  result.  Rupture  into  the 
cerebral  substance  is  not  uncommon.  An 
aneurism  in  the  fissure  of  Sylvius  may  cause  a 
haemorrhage  into  the  substance  of  the  brain, 
bursting  into  the  lateral  ventricle;  and  an 
aneurism  on  the  posterior  cerebral  artery  may 
burst  into  the  substance  of  the  pons.  Two 
causes  may  determine  this  rupture  into  the 
substance  of  the  brain — first,  thickening  of  the 
subarachnoid  tissue  adjacent  to  the  aneurism, 
hindering  its  rupture  outwards;  secondly,  the 
gradual  escape  of  the  blood,  producing  a slow 
disintegration  of  the  brain-tissue,  and  thus 
preparing  a channel  for  the  effusion.  In  such 
^ cases  only  a small  quantity  of  blood  may  have 
trickled  into  the  ventricles  or  subarachnoid 
space.  In  rare  cases  a communication  with  a 
sinus  forms,  and  constitutes  an  arterio-venous 
aneurism.  This  has  occurred  between  an  aneur- 
ism of  the  internal  carotid  and  the  cavernous 
sinus. 

Symptoms. — Symptoms  of  the  existence  of  an 
aneurism  may  be  entirely  absent.  When  present 
they  depend  on  the  pressure  which  the  tumour 
exerts  on  neighbouring  parts.  They  vary  wddely 
according  to  its  seat,  and  they  are  rarely  by 
themselves  distinctive.  Mental  disturbance  is 
uncommon.  Headache  is  a veryuniform  symptom. 
It  is  often  intense,  sometimes  throbbing,  and 
may  be  localised,  as  in  the  occiput  in  basilar 
aneurism.  Convulsions  occur  in  some  cases,  and 
are  said  to  be  more  common  when  the  disease  is 
near  the  medulla.  Paralyses  are  frequent,  and 
depend  on  the  pressure  of  the  tumour : the  most 
common  are  those  of  the  cranial  nerves  which  lie 
adjacent  to  the  aneurism,  as  of  the  nerves  of  the 
orbit  in  aneurism  of  the  internal  carotid.  Such 
symptoms  are  suggestive  of  an  aneurism  when 
they  indicate  pressure  in  the  known  situation  of 
a vessel.  In  some  cases  a murmur  can  be  beard 
by  the  patient,  and  in  still  rarer  cases  (of  aneu- 
rism of  the  internal  carotid)  it  has  been 
audible  on  auscultation.  Aneurism  elsewhere 
may  increase  the  probability  that  an  intracranial 
aneurism  is  present,  and  so,  in  the  young,  ma}' 
valvular  disease  of  the  heart. 

Rupture  of  cerebral  aneurism  gives  rise  to 
symptoms  which  vary,  as  in  rupture  of  aneurisms 
elsewhere,  according  as  the  blood  escapes 
quickly  or  slowly.  If  quickly,  the  blood  usually 
escapes  into  the  meninges  and  causes  sudden 
apoplexy  with  general  paralysis,  rapidly  deepen- 


OF,  DISEASES  OF. 

ing  to  a fatal  issue.  If  slowly,  the  symptom* 
are  less  sudden,  and  unilateral  paralysis  or  con- 
vulsion may  occur.  This  is  especially  the  case 
when  the  blood  escapes  slowly  into  the  cerebral 
substance,  unilateral  symptoms  occurring,  and 
gradually  increasing  during  a few  hours  or  days, 
with  or  without  initial  lo«s  of  consciousness, 
but  ending  in  fatal  coma. 

Treatment.  — Little  can  be  done  in  eases 
where  intracranial  aneurism  is  suspected.  Even 
when  it  is  of  syphilitic  origin,  drugs  can  only 
partially  restore  the  damaged  and  dilated  vessel. 
Hypodermic  injection  of  ergotin  (£-grain)  has 
been  recommended  by  Langenbeck  and  advo- 
cated by  Bartholow.  Iodide  of  potassium  may 
also  be  given.  Rest  is  important.  All  causes  of 
increased  intravascular  pressure,  sucli  as  effort 
and  low  positions  of  the  head,  are  to  be  avoided. 
The  bowels  should  be  kept  regular.  In  rare  cases 
where  progressive  paralysis  of  orbital  nerves 
suggests  the  probability  of  aneurism  of  tile  in- 
ternal carotid,  and  a murmur  renders  the  diag- 
nosis certain,  ligature  of  the  common  carotid 
may  be,  and  has  been,  resorted  to  with  success. 

(b)  Minute  ‘ miliary  ’ aneurisms  occur  in  the 
small  arteries  of  the  pia  mater  and  substance  of 
the  brain  (Virchow,  Charcot  and  Bouchard). 
They  are  found  at  all  ages,  but  more  fre- 
quently in  the  old.  They  may  involve 
vessels  not  more  than  the  inch  in  diameter, 
but  are  most  common  on  vessels  a little  larger 
than  this;  the  walls  suffer  fibroid  degeneration 
of  the  outer  and  middle  coat,  commencing,  it  is 
said,  as  nuclear  proliferation.  The  muscular 
tissue  of  the  middle  coat  disappears,  and  the 
whole  wall  at  the  spot  becomes  dilated  into  a 
sacculated  aneurism,  varying  in  size  from  the 
jk  to  the  of  an  inch.  These  dilatations  have 

been  found  in  all  parts,  but  most  frequently  in 
the  optic  thalamus,  and  next  most  frequently  in 
the  pons  Varolii,  the  convolutions,  the  corpora 
striata,  the  cerebellum,  the  medulla  oblongata, 
the  cerebellar  peduncles,  and  the  centrum  ovale 
(Bouchard).  They  often  rupture  and  cause 
minute  hiemorrhage.  They  are  found  fre- 
quently in  cases  of  large  cerebral  haemorrhage  ; 
and  Charcot  and  Bouchard  believe  that  such 
haemorrhage  is  frequently  due  to  their  rupture. 
Liouville  has  pointed  out  that,  minute  aneu- 
risms of  the  retinal  arteries  sometimes  co- 
exist. 

The  rupture  of  a minute  artery  into  its  peri- 
vascular sheath  distends  it  with  blood,  causing 
what  has  been  termed  a minute  dissecting  aneu- 
rism. Such  are  frequently  met  with  in  cases  in 
which  the  vessels  are  exposed  to  extreme  pres- 
sure, as  in  death  from  aspkyxial  conditions ; or 
in  the  increased  tension  in  collateral  vessels 
when  vascular  obstruction  has  occurred. 

No  symptoms  are  known  to  be  associated  with 
the  existence  of  theso  minute  aneurisms.  The 
symptoms  cf  rupture  are  described  under 
‘ Brain,  Haemorrhage  into.’ 

2.  Degeneration,  (a)  Of  Arteries.  — The 
larger  cerebral  arteries  are  very  common 
seats  of  the  thickening  of  the  inner  coat,  called 
by  Virchow ' Endarteritis  deformans,’  and  which, 
when  fattily  degenerated,  constitutes  ‘atheroma.' 
On  the  cerebral  vessels  the  fatty  change  occurs 
quickly  and  frequently;  and  opaque  vellcv 


BRAIN.  VESSELS  OE.  DISEASES  OF. 


thickenings  are  the  result.  Only  one  or  two 
of  these  may  be  present;  or  the  change  may  in- 
volve the  whole  of  the  larger  vessels  at  the 
base  and  extend  for  a considerable  distance 
along  the  chief  cerebral  branches.  The  dis- 
tribution -of  the  degeneration  may  be  symme- 
trical. It  may  coexist  with  a similar  change 
in  arteries  elsewhere,  or  may  be  isolated.  De- 
generation of  the  cerebral  arteries  is  com- 
mon after  middle  life,  being  found  in  seven- 
tenths  of  the  subjects  examined  (Bichat).  It 
occasionally  occurs  much  earlier,  especially  in 
eases  of  chronic  Bright’s  disease.  Bright’s  dis- 
ease and  alcoholism  are  its  chief  diathetic  pre- 
lisponeuts.  The  exciting  cause  of  this  disease  is 
probably  the  strain  to  which  the  badly  supported 
cerebral  vessels  are  exposed.  It  is  not  easy  to 
explain  their  occasional  freedom  from  atheroma 
when  this  is  abundant  elsewhere.  The  degene- 
rated patches  rarely  soften  and  open  into  the 
vessel,  so  as  to  permit  the  formation  of  a dis- 
secting aneurism.  More  commonly  they  under- 
go calcification.  The  result  of  these  nodular 
degenerations  is  to  lessen  the  calibre  of  the 
vessel,  sometimes  to  close  it  altogether,  and  to 
favour  the  formation  of  a coagulum.  The  les- 
sened area  of  the  vessel  causes  local  anaemia  of 
the  brain.  If  the  vessel  becomes  occluded,  or  if 
coagulation  takes  place  in  it,  softening  occurs  in 
the  part  supplied  by  it.  Where  the  degeneration 
has  led  to  only  slight  thickening  of  the  wall,  the 
artery  may  be  dilated  at  the  spot.  The  degene- 
rated vessel  may  burst  under  the  pressure  of  the 
blood  and  haemorrhage  result.  The  minute 
arteries  of  the  cerebral  substance  undergo  simi- 
lar changes,  less  conspicuous  from  their  smaller 
size.  Fatty  degeneration  of  the  cells  lining  the 
perivascular  sheath  is  common  at  all  ages. 
Under  circumstances  similar  to  those  in  which 
the  larger  arteries  degenerate,  all  the  coats  of 
the  small  vessels  suffer.  Simple  fatty  degene- 
ration of  the  middle  coat  occurs  also  at  all  ages. 
Miliary  aneurisms  may  be  formed,  or  rupture 
occur,  as  a consequence  of  these  changes. 

Symptoms. — Atheroma  of  the  cerebral  vessels 
leads  to  the  symptoms  of  local  anaemia  of  the 
brain,  and  is  a common  cause  of  the  transient 
cerebral  symptoms  so  frequent  in  the  old. 

Treatment. — Tonics,  cardiac  stimulants,  and 
substances  which,  as  cod-liver  oil,  promote  the 
nutrition  of  the  nerve-tissue,  are  the  most  useful 
remedies. 

( b ) Of  Veins. — Degeneration  of  the  walls  of 
the  veins  is  much  less  frequently  observed  than 
degeneration  of  the  arteries,  perhaps  on  ac- 
count of  the  less  degree  of  pressure  to  which 
they  are  exposed.  Occasionally  the  veins  of  the 
pia  mater  may  be  found  varicose  in  advanced 
life,  and  in  one  case  recorded  by  Andral  rupture 
of  such  a dilated  vein  was  the  cause  of  menin- 
geal haemorrhage. 

3.  Embolism.  — Definition.  — - The  obstruc- 
tion of  arteries  or  capillaries  of  the  brain  by 
solid  particles  carried  by  the  blood-current  from 
some  other  part  of  the  vascular  system. 

■ZEtiology. — The  source  of  the  embolic  par- 
ticles is  almost  invariably  situated  between  the 
pulmonary  capillaries  and  the  obstructed  vessels, 
i.e.  in  the  pulmonary  veins,  the  left  side  of  the 
heart,  or  the  arteries.  In  arterial  embolism  it  is 


necessarily  so,  since  no  particles  large  enough  tu 
obstruct  even  a small  artery  could  pass  through 
the  capillaries  of  the  lungs.  In  almost  all  cases 
the  heart  is  the  source  of  the  plugs,  a particle  of 
fibrin  being  washed  by  the  blood  from  a deposit 
on  a diseased  valve  or  in  some  recess  (as  the 
auricular  appendix).  Endocarditis,  or  chronic 
valvular  disease,  therefore,  usually  coexists  with 
the  embolism.  Mitral  stenosis  is  an  especially 
frequent  source  of  emboli,  probably  because  the 
surface  is  commonly  much  altered,  and  the  blood- 
current  is  in  part  slow  (in  diastole,  allowing 
deposit),  and  in  part  very  rapid  (in  auricular 
systole,  detaching  loose  fibrin).  Disease  of  the 
aorta — atheroma  or  aneurism — is  the  next  most 
frequent  source,  and,  less  frequently,  disease  of 
the  carotid  or  vertebral  arteries,  and  coagulation 
in  the  pulmonary  veins,  large  or  small — the  latter 
in  some  rare  cases  of  inflammation  and  growths. 

Particles  obstructing  capillaries  may  come 
from  some  softened  atheromatous  patch  or  fibri- 
nous deposit,  from  pigmentary  formations,  or 
from  deposits  in  ulcerative  endocarditis.  In  the 
last  ease  the  obstructing  material  has  a septic 
character,  and  the  inflammation  it  causes  may 
be  suppurative. 

Anatomicat.  Characters. — Almost  any  of  the 
cerebral  arteries  may  be  obstructed,  the  internal 
carotids  and  middle  cerebrals  or  their  branches 
most  frequently,  the  anterior  cerebrals  or  the 
basilar  less  frequently,  and  the  posterior  cere- 
brals still  less  frequently.  Obstruction  of 
several  vessels  is  sometimes  found,  having 
occurred  at  the  same  or  at  different  times. 
The  cerebral  arteries  of  the  two  sides  are 
plugged  with  nearly  equal  frequency ; the 
internal  carotid  much  more  frequently  on 
the  left  side  than  on  the  right.  It  seems 
that  a large  fragment  is  influenced  in  its 
course  by  the  more  direct  path  through  the  left 
carotid,  while  smaller  fragments  find  their  way 
with  almost  equal  readiness  to  either  side.  The 
middle  cerebrals  are  very  frequently  affected, 
sometimes  on  both  sides ; and,  when  the  bilateral 
symmetry  of  the  vessels  is  great,  each  may 
be  obstructed  at  the  same  place. 

The  plug  is  usually  arrested  at  some  spot  at 
which  the  vessel  is  narrowed  by  a branch  being 
given  off.  Here  the  fragment  may  be  found, 
usually  decolorised,  and  commonly  closing  alto- 
gether the  lumen  of  the  vessel.  On  each  side  of 
this  is  a secondary  clot:  the  distal  extends  far 
into  the  contracted  branches  of  the  vessel,  the 
proximal  as  far  as  the  next  large  branch.  The 
obstruction  may  lead  to  inflammation  of  the 
wall  of  the  vessel  at  the  spot,  especially  when 
the  plug  has  been  carried  from  a place  at  which 
inflammation  is  going  on.  The  inflammation 
leads  to  change  of  texture  and  degeneration, 
fibroid  or  fatty ; the  former  may  permit  an 
aneiu'ism  to  be  formed,  the  latter  may  cause  a 
thickened  patch,  in  which  calcification  may 
occur.  The  inflammation  may  spread  to  the 
adjacent  tissue,  leading  to  induration  around  the 
spot. 

The  first  effect  of  embolism  is  to  arrest  the 
blood-supply  to  the  part  to  which  the  artery  is 
distributed.  It  is  only  when  the  obstruction  is 
beyond  the  circle  of  Willis  that  damage  to  cere- 
bral structure  (softening)  follows.  Softening 


164  BRAIN.  VESSELS  OF.  DISEASES  OF. 


occurs  more  uniformly  in  obstruction  of  the 
arteries  of  the  central  ganglia  than  in  those  of 
the  convolutions.  Capillary  embolism  also  causes 
softening,  and  when  the  obstruction  is  from  a 
septic  source,  ‘ metastatic  abscess  ’ may  result. 

For  the  symptoms,  diagnosis,  and  treatment 
of  cerebral  embolism  see  Brain,  Softening  of. 

4.  Rupture. — Rapture  of  cerebral  arteries 
is  common  and  is  the  cause  of  cerebral  haemor- 
rhage, and  rupture  of  capillaries  is  not  unfre- 
quent. Rupture  of  veins  is  extremely  rare,  ex- 
cept as  the  result  of  injury. 

(a)  Of  Arteries. — The  proximate  causes  of 
rupture  are  weakening  of  the  arterial  wall,  and 
increased  pressure  within  the  vessel.  The  con- 
ditions which  give  rise  to  these  two  factors  are  the 
remote  causes  of  rupture.  The  actual  rupture 
is  commonly  due  to  a temporary  sudden  excess 
of  intravascular  pressure. 

-^Etiology. — The  wall  of  the  vessel  is  weak- 
ened, especially  by  degenerative  disease — chronic 
periarteritis,  or  (rarely)  simple  fatty  degene- 
ration. Aneurismal  dilatation  and  thinning  may 
have  resulted  from  the  chronic  change.  In 
some  diseases  attended  with  a tendency  to  extra- 
vasation (purpura,  haemophilia,  &c.)  it  is  conjec- 
tured that  the  vascular  walls  have  undergone 
rapid  degeneration,  or  are  unusually  thin.  De- 
fective external  support,  from  atrophy  of  the 
brain,  causing  increased  size  of  the  perivascular 
canals,  was  formerly  thought  to  he  a potent  cause, 
and  is  now  perhaps  underrated.  The  mobile 
perivascular  fluid  which  surrounds  the  vessels 
must  afford  a less  efficient  support  than  cerebral 
tissue. 

When  vessels  are  much  weakened,  they  may 
rupture  when  the  extra  vascular  pressure  is  at,  or 
even  below,  the  normal ; very  commonly,  however, 
there  coexists  increased  pressure.  Loss  of 
arterial  elasticity  leads  to  a jerky  pressure. 
Arterial  degeneration,  and  still  more  constantly, 
arterial  contraction,  in  Bright’s  disease,  cause 
increased  tension  by  obstruction ; and  the 
hypertrophy  of  the  heart,  which  develops  to 
overcome  the  obstruction,  adds  materially  to  the 
pressure  within  the  arteries.  Hypertrophy  to 
overcome  an  obstacle  near  the  heart  has  pro- 
bably no  influence  in  causing  rupture  of  cerebral 
vessels. 

The  instant  cause  of  rupture  is  generally  some 
temporary  increase  of  the  blood-pressure  due  to 
effort — as  in  cough,  straining  at  stool  or  vomit- 
ing ; excited  action  of  the  heart ; suddenly  de- 
veloped heart-  or  lung-disease  obstructing  the 
circulation ; local  obstruction  to  return  of  blood  ; 
contraction  of  the  arterioles,  general  or  local;  or 
the  action  of  gravitation  in  the  recumbent  pos- 
ture. The  last  two  causes  probably  acting  to- 
gether determine  the  frequent  occurrence  of 
rupture  during  sleep. 

The  conditions  which  produce  these  proximate 
causes  are  the  remote  causes  of  rupture.  The 
most  efficient  are  those  which  determine  weaken- 
ing of  the  vascular  wall,  and  have  been  already 
spoken  of  (see  Degeneration).  Age  is  an  im- 
portant element — rupture  is  most  common  after 
fifty,  but  may  occur  from  local  vascular  disease 
at  any  age.  Hereditary  predisposition  is  seen 
in  a tendency  to  early  degeneration.  Position 
of  degeneration  is  probably  largely  influenced  by 


the  distribution  of  the  vessels ; and  the  latter 
may  be  strikingly  hereditary,  as  the  retina  some- 
times shows.  Sex  tells  probably  by  exposure  to 
the  greater  pressure  entailed  by  muscular  effort 
(men  suffer  from  rupture  twice  as  frequently  as 
women).  Alcoholism  leads  to  early  degeneration. 
But  the  most  efficient  predisponent  is  Bright's 
disease,  which  leads  to  great  intravascular  pres- 
sure, and  weakens  the  cerebral  vessels  by  causing 
degeneration.  It  is  probable  that  some  acute 
diathetic  diseases  in  which  rupture  is  common 
act  in  a similar  manner. 

Certain  of  the  cerebral  arteries  give  way  more 
frequently  than  others,  especially  the  arteries  of 
the  corpus  striatum  and  pons  Varolii.  This 
seems  due  (1)  to  their  origin  at  right  angles  from 
vessels  of  very  considerable  size  (basilar  and 
middle  cerebral),  and  their  consequent  exposure 
to  the  full  pressure  within  the  parent  trunk. 
(2)  To  their  ‘terminal’  character,  which 
precludes  collateral  relief  (Duret,  Heubner). 
One  artery,  which  very  frequently  gives 
way,  passes  from  the  middle  cerebral  through 
the  anterior  perforated  spot,  outwards  be- 
tween the  island  of  Reil  and  the  lenticular 
nucleus,  the  outer  part  of  which  it  perforates, 
and  then  passes  through  the  white  ‘ internal 
capsule,’  between  the  lenticular  and  eaudato 
nuclei,  to  ramify  in  the  anterior  part  of  the 
latter.  The  arterioles  supplying  the  con- 
volutions on  the  surface  of  the  brain  are  not  often 
ruptured,  except  from  injury.  They  are  exposed 
much  less  directly  to  the  blood-pressure,  and 
sometimes  possess  considerable  anastomoses. 

Symptoms. — The  consequence  of  rupture  of  an 
artery  is  cerebral  haemorrhage,  the  symptoms 
and  treatment  of  which  are  described  elsewhere 
(sec  Brain,  Haemorrhage  into).  In  traumatic 
laceration  of  the  brain  the  arteries  are  torn, 
and  often  cause  much  haemorrhage. 

(b)  Of  Capillaries. — The  minutest  arteries  and 
veins  and  the  capillaries  rarely  rupture,  except 
when  exposed  to  sudden  pressure  by  venous 
thrombosis,  when  the  obstruction  in  the  part 
from  which  the  vein  proceeds  may  determine 
numerous  capillary  haemorrhages  into  the  cere- 
bral substance.  In  general  venous  congestion, 
as  in  asphyxial  states,  such  haemorrhage  may 
occur;  but  a more  frequent  result  is  rupture 
of  a vessel  within  its  perivascular  sheath,  which 
thus  becomes  distended  with  blood. 

For  symptoms  see  Brain,  Haemorrhage  into. 

5.  Syphilitic  Disease.  — The  arteries  of 
the  brain  are  occasionally  diseased  in  the  later 
stages  of  syphilis.  The  large  arteries  at  the  base 
and  the  minute  arterioles  may  be  both  involved. 
The  wall  is  thickened  at  circumscribed  areas  by 
a fibro-nuclear  growth,  which  causes  a nodular 
projection  on  the  exterior,  and  diminishes  also 
the  calibre  of  the  vessel.  The  structure  of  the 
growth  resembles  that  of  syphilomata  elsewhere. 
It  is  said  by  Heubner  to  begin  by  a nuclear  pro- 
liferation between  the  inner  coat  and  the  elastic 
lamina;  and  in  some  cases  it  attains  its  chief 
development  in  this  situation,  the  elastic  lamina 
being  pushed  outwards  and  the  lumen  of  the  ves- 
sel obliterated.  The  middle  coat  may  ultimately 
disappear.  Vessels  may  form  in  the  substance 
of  the  growth,  and  its  centre  may  undergo  fatty 
degeneration.  The  disease  is  sometimes  sym- 


BRAIN,  VESSELS 

metrical  on  the  arteries  of  the  two  sides.  The 
growth  or  secondary  thrombosis  occluding  the 
vessel,  softening  may  result  in  the  area  of  brain- 
tissue  supplied  by  it.  The  softening  resembles 
in  its  occurrence  and  characters  that  which  is 
produced  by  degenerative  changes  in  the  ar- 
teries, but  is  more  varied  in  its  seat,  and  it 
affects  younger  persons.  The  diminished  elas- 
ticity of  the  diseased  wall,  when  the  thickening 
is  slight,  may  permit  the  dilatation  of  the  vessel 
into  an  aneurism.  Possibly  the  same  result  may 
follow  the  fatty  degeneration  of  the  new  tissue. 

Symptoms. — No  symptoms  are  produced  by 
the  arterial  disease  until  it  causes  local  anaemia 
cr  softening,  the  symptoms  of  which  resemble 
those  due  to  other  causes. 

Treatment. — This  is  that  of  the  later  stages 
of  syphilis.  It  must  be  remembered  that  the 
removal  of  arterial  disease  may  not  restore  the 
damaged  cerebral  tissue. 

6.  Thrombosis.  Thrombosis, — the  coagula- 
tion of  the  blood  in  situ, — may  occur  in  the  cere- 
bral arteries ; or  in  the  cerebral  veins  and  sinuses. 

(a)  In  the  Arteries. 

JEtiology. — The  causes  of  arterial  tlirom- 
oosis  are  the  following: — 

(1)  An  alteration  in  the  wall  of  the  artery,  by 
which  the  blood  comes  in  contact  with  an  abnor- 
mal surface.  The  most  common  condition  is  athe- 
roma, and  hence  arterial  thrombosis  is  most 
frequentwhen  atheroma  is  most  common — in  the 
old.  Syphilitic  disease  of  the  artery  sometimes 
leads  to  it.  Much  more  rarely  it  is  caused  by 
an  arteritis,  spontaneous,  or  the  result  of  ad- 
jacent inflammation  or  traumatic  damage. 

(2)  Retardation  of  the  blood-current.  This 
may  result  from  weakened  action  of  the  heart 
in  debilitating  diseases  (as  phthisis  and  cancer), 
and  in  extreme  fatigue.  It  may  be  part  of  the 
effect  of  a convulsive  fit ; or  it  may  be  caused 
locally  by  the  arterial  diseases  mentioned  al- 
ready, which  lead  to  narrowing  and  loss  of 
elasticity. 

(3)  An  increased  tendency  of  the  blood  to 
coagulate.  This  is  seen  in  many  diseases,  espe- 
cially in  marasmic  states  in  young  and  old  (such 
as  are  caused  by  phthisis  and  cancer),  in  acute 
rheumatism,  and  in  the  puerperal  condition.  A 
slight  cause  then  suffices  to  produce  coagulation, 
and  the  weak  heart,  so  common  in  many  of  these 
conditions,  may  cause  sufficient  retardation  of 
the  blood-current. 

(4)  Lastly,  thrombosis  in  an  artery  may  be 
secondary  to  its  complete  or  partial  obstruction 
by  an  embolus. 

Anatomical  Characters. — The  arteries  oc- 
cluded may  be  one  or  several,  and  large  or  small. 
Of  large  arteries  the  basilar,  middle  cerebral, 
and  carotid  are  those  occluded  most  commonly, 
and  with  nearly  equal  frequency.  The  vascular 
wall  may  present  any  of  the  local  causative  con- 
ditions, or  may  be  healthy.  After  a time 
thickening  from  secondary  arteritis  occurs. 
Within  this  vessel  is  a coagulum  which  usually 
fills  its  interior,  and  is  adherent  to  the  wall. 
It  may  not  fill  the  vessel,  either  because  origi- 
nally imperfect,  or  because  the  clot  has  shrunk. 
A recent  quickly-formed  coagulum  is  red,  but 
after  a time  it  becomes  pale  and  yellow.  A 
slowly-formed  coagulum  is  pale,  and  may  be 


OF,  DISEASES  OF.  x65 

laminated.  A secondary  clot  usually  forms  far 
into  the  contracted  distal  branches,  and  on  the 
proximal  side  as  far  as  the  nearest  large  branch. 
Ultimately  the  clot  may,  rarely,  soften,  the 
channel  being  sometimes  re-established.  More 
commonly  it  undergoes  calcification,  or,  with  the 
artery,  contracts  and  becomes  atrophied.  The 
brain-tissue,  in  which  the  artery  was  distributed, 
may  be  at  first  anaemic,  but  quickly  becomes 
congested.  It  ultimately  undergoes  softening — 
red,  yellow,  or  white,  according  to  the  amount 
of  vascular  distension.  If  the  collateral  circu- 
lation is  free  it  may  remain  unsoftened. 

Symptoms. — AYhere  chronic  arterial  disease 
is  the  cause  of  thrombosis,  the  symptoms  of 
local  cerebral  anaemia  may  precede  {see  Brain, 
Anaemia  of).  The  thrombosis  itself  leads  to  the 
symptoms  of  loss  of  function  in  the  part  to  which 
the  artery  passed.  The  onset  of  these  symptoms 
is  slow  or  sudden,  according  to  the  rapidity  with 
which  the  coagulum  forms ; and  their  degree 
depends  on  the  size  of  the  vessel  occluded,  its 
position,  and  its  relation  to  other  vessels  which 
may  supply  blood  to  the  area  involved.  Throm*. 
bosis  of  a small  vessel  in  the  cerebral  substance 
usually  leads  to  transient  brain-disturbance, 
headache,  vertigo,  tingling,  and  temporary  weak- 
ness in  the  limbs,  which  soon  pass  away  if  a col- 
lateral circulation  is  established ; more  slowly,  if 
softening  ensues,  by  compensatory  action  else- 
where. The  occlusion  of  a large  vessel  causes 
commonly  more  marked  symptoms.  Complete 
hemiplegia  is  frequent,  and  its  onset  may  be 
marked  by  loss  of  consciousness  {see  Brain,  Soft- 
ening of). 

Diagnosis.— Diagnosis  rests  on  a combination 
of  the  symptoms  of  local  cerebral  disease  with  the 
causal  condition — vascular  mischief  (indicated 
by  probable  age,  degeneration  elsewhere,  or 
syphilis),  and  with  conditions  leading  to  relaxa- 
tion of  the  blood-current,  or  increased  coagula- 
bility of  the  blood.  The  diagnosis  is  rendered 
more  probable  by  the  symptoms  if  slight  being 
transient,  if  severe  being  of  gradual  onset, 
and,  whether  slight  or  severe,  being  preceded 
by  the  premonitory  indications  of  local  cerebral 
ansemia. 

The  prognosis  and  treatment  of  thrombosis 
in  arteries  are  considered  under  its  consequence, 
Brain,  Softening  of. 

{h)  In  Cerebral  Veins  and  Sinuses. 

^Etiology. — Thrombosis  in  sinuses  may  be 
primary,  and  due  to  changes  in  the  constitution 
or  the  circulation  of  the  blood;  or  secondary,  and 
due  to  local  causes  inducing  coagulation  directly 
at  the  spot  affected.  The  same  conditions  of 
retarded  circulation  and  altered  blood-state 
which  permit  coagulation  in  arteries,  favour  it 
also  in  veins,  and  it  is  often  seen  in  such  condi- 
tions as  phthisis  and  cancer,  and  especially  in 
marasmic  states  in  children.  Local  retardation  of 
the  circulation  from  narrowing  of  the  sinus,  or 
compression  of  the  jugular  vein,  occasionally  as- 
sists. Local  change  causing  coagulation  is  usually 
the  extension  to  the  sinus  of  adjacent  inflam- 
mation, or  of  a clot  produced  in  a tributary 
vein  by  such  inflammation.  Caries  of  the  bones 
of  the  skull,  especially  of  the  temporal  bone,  and 
meningitis  are  common  causes.  Inflammation 
outside  the  skull,  in  the  scalp,  neck,  or  face,  has 


1G6  BRAIN,  VESSELS  OF. 

led,  by  means  of  venous  connections,  to  intra- 
cranial thrombosis.  Lastly,  injuries  of  the  skull 
involving  the  sinuses  sometimes  cause  coagulation 
in  them. 

Anatomical  Characters. — Of  primary  throm- 
bosis the  superior  longitudinal  sinus  is  the  most 
common  seat,  and  thence  the  clot  spreads  into 
the  veins  on  either  side,  and  often  also  into  the 
lateral  sinuses.  When  secondary,  the  thrombosis 
occurs  in  the  sinus  nearest  to  the  local  mischief ; 
in  disease  of  the  petrous  bone,  the  lateral  sinus 
is  usually  involved.  The  sinus  is  distended  by 
firm  clot,  commonly  (not  invariably)  adherent, 
sometimes  in  concentric  layers.  The  walls  of  the 
vessel  are  healthy  when  the  thrombosis  is  pri- 
mary or  secondary  by  extension  of  clot,  but 
thickened  and  brittle  when  invaded  directly  by 
adjacent  inflammation.  After  a timo  the  clot 
may  soften  and  break  down. 

.The  consequence  of  venous  thrombosis  is 
local  arrest  of  the  blood-current,  the  tributary 
veins  and  capillaries  becoming  enormously  disten- 
ded with  blood  and  rupturing,  and  the  cerebral 
substance  being  crammed  with  minute  capillary 
extravasations  which  often  coalesce.  The  condi- 
tion is  frequently  seen  in  the  convolutions.  Blood 
is  also  effused  into  the  meshes  of  the  pia  mater, 
and  into  the  subarachnoid  space.  Into  the  looser 
tissues  and  into  the  ventricles  serum  may  escape. 
Thrombosis  of  the  veins  of  Galen  is  one  causa 
of  ventricular  effusion.  Ultimately  the  brain- 
tissue,  the  seat  of  the  ischaemic  congestion,  un- 
dergoes softening,  first  red,  and  then  yellow  or 
white.  Occasionally  the  softening  of  the  clot 
loads  to  pyaemia. 

Stmptoms. — The  symptoms  are  at  first  those 
of  mental  excitement,  namely,  intense  headache 
and  muscular  spasm,  shown  as  contractions  in 
the  limbs,  or  as  convulsion,  often  beginning 
locally,  according  to  the  position  of  the  conges- 
tion. Those  symptoms,  after  one  or  several 
days,  are  succeeded  by  those  of  depression ; 
with  coma,  and  dilatation  of  pupils.  The  coma 
may  come  on  suddenly,  and  the  first  stage  may 
bo  little  marked.  Convulsions,  when  present, 
often  continue  till  death.  When  the  superior 
longitudinal  sinus  is  plugged,  epistaxis,  oedema 
of  the  forehead,  and  exophthalmos  have  some- 
times been  observed.  When  the  lateral  sinus  is 
obstructed,  there  may  be  painful  cedema  behind 
the  ear,  and  the  jugular  vein  on  that  side  has 
been  noticed  to  be  less  full  than  on  the  other. 

Diagnosis. — The  diagnosis  rests  on  the  oc- 
currence of  severe  cerebral  symptoms  in  as- 
sociation with  a causal  condition,  constitutional 
or  local. 

Prognosis. — This  is  always  serious,  death 
being,  in  most  cases,  speedy. 

Treatment. — The  indications  for  treatment 
are  mostly  causal.  In  primary  thrombosis  stimu- 
lants and  nutritious  diet  are  necessary,  and 
tonics  if  they  can  be  taken.  In  secondary  throm- 
bosis, occurring  in  robust  individuals,  leeching 
or  cupping  is  recommended ; purgatives  should 
be  given  ; and,  in  the  less  severe  cases,  a blister 
may  be  applied  to  the  neck,  and  the  utmost  care 
taken  to  afford  free  exit  for  pent-up  inflamma- 
tory products.  Pain  and  convulsion  are  relieved 
unost  effectually  by  cold  to  the  head. 

W.  R.  Gowers. 


BREAST,  DISEASES  OF. 

B RAIN- FEVER.  A name  popularly  ap 
plied  to  any  kind  of  febrile  state  in  which  symp- 
toms of  cerebral  excitement  are  prominent;  as 
well  as  to  cases  of  inflammatory  disease  of  the 
brain  or  its  membranes. 

BREAK-BONE  FEVER.  A synonym  for 
Dengue.  See  Dengue. 

BREAST,  Diseases  of. — This  subject  will 
be  treated  under  the  following  divisions  : — 

I.  Diseases  before  puberty,  in  both  sexes.  II. 
Diseases  about  the  age  of  the  establishment  oj 
puberty  ; and  after  that  period,  in  the  female, — 
(A),  in  the  active  state  of  the  gland ; (B),  in  the 
passive  state.  III.  Diseases  affecting  the  rudi- 
mentary organ  in  the  male.  IF.  Diseases  of  the 
nipple. 

The  diseases  of  an  organ  composed  essen- 
tially of  glandular  structures  have  here  to  he 
described.  The  mammary  gland  is  classed  with 
those  termed  racemose ; hut  it  differs  from 
every  other  organ  in  the  body  of  a similar  class, 
inasmuch  as  it  only  arrives  at  maturity  when  its 
function  is  to  be  subservient  to  the  nourishment 
of  the  offspring.  In  its  perfection  it  appears, 
normally,  only  in  the  female  sex,  and  even  then 
it  does  not  become  developed  until  the  internal 
organs  of  generation  are  capable  of  performing 
their  functions. 

Hence,  to  describe  systematically  the  diseases 
of ‘the  breast,  it  is  requisite  to  treat  of  them  not 
only  in  reference  to  sex,  but  also  in  relation  to 
the  different  periods  of  life  at  which  certain  dis- 
eases appear.  Briefly  then,  from  a histological 
point  of  view,  they  occur:  (a)  in  the  rudimentary 
state  of  the  gland ; ( b ) in  its  mature  state ; (c) 
when  it  has  become  a secreting  organ  ; (d)  during 
a state  of  degeneration. 

I.  In  the  rudimentary  period  of  the  gland 
the  tissues  composing  it  are  rarely  liable  to 
morbid  derangement.  Usually,  soon  afterbirth, 
especially  in  male  infants,  the  rudimentary 
nipple  and  the  skin  of  the  region  within  the 
zone  of  the  areola  become  slightly  elevated  and 
of  a pink  hue.  In  some  infants  a secretion, 
slightly  milk-like.,  oozes  from  the  ducts.  In  this 
state,  the  injudicious  rubbirg  practised  by  the 
attendant  excites  inflammation,  which,  if  not 
arrested  by  desistance  from  that  pernicious 
interference,  may  advance  to  suppuration. 
When  that  happens,  the  usual  local  application 
of  warmth  and  moisture  suffices  to  give  relief. 

II.  About  that  age,  in  both  sexes,  when  the 
development  of  the  generative  organs  advances 
with  greater  rapidity  to  maturity  than  in  early 
life,  the  breast-gland  enlarges,  and  may  be  painful, 
thus  causing  anxiety  to  the  individual.  Usually, 
symmetrical  development  takes  place  in  the 
female  ; but,  when  the  gland  of  one  side  takes 
precedence  of  that  on  the  other,  the  circumstance 
need  only  he  regarded  as  a departure  from  the 
ordinary  rule,  for  no  trouble  will  result,  and  in 
due  time  both  will  attain  their  normal  pro- 
portions. In  the  male,  pain  or  uneasiness  some- 
times occurs  for  a few  days  about  this  period, 
very  often  excited  by  the  pressure  of  the  dress. 
The  removal  of  this  cause  is  sufficient  to  arrest 
further  mischief. 

hi  the  female  the  development  of  the  breast 
having  reached  maturity,  the  gland  is  now  assrv. 


BREAST,  DISEASES  OF.  107 


ciated  by  sympathetic  influences  communicated 
through  nervous  stimuli -with  the  functions  of  the 
pelvic  generative  organs.  This  physiological 
fact  should  ever  he  remembered  when  investi- 
gating the  nature  of  the  morbid  affections  of  this 
organ. 

In  a clinical  point  of  view,  it  is  essential  to 
examine  the  diseases  of  the  breast  under  the 
:,vo  states  before  mentioned, namely,  (A)  whilst 
tho  gland  is  undergoing  metamorphosis  into  a 
secreting  organ,  and  during  lactation.  (B)  As  a 
mature  gland,  but  passive  as  regards  its  function. 

Glancing  at  the  various  morbid  states  of  the 
body  of  the  gland  as  a whole,  they  may  be  di- 
vided, primarily,  into  two  groups  : — the  Func- 
tional derangements ; and  the  Organic  or  histo- 
logical diseases. 

We  will  now  proceed  to  discuss  these  affections, 
as  they  are  presented  at  the  different  periods 
mentioned  above. 

A.  After  conception  the  breasts  soon  begin  to 
enlarge,  and  at  their  borders  and  surface  minute 
pisiform  indurations  may  be  felt.  Occasionally, 
but  very  rarely,  this  normal  increase  in  bulk  is 
attended  with  considerable  pain  and  irritation 
extending  throughout  the  nervous  relations  of 
the  gland.  The  pain  is  referred  to  the  back, 
neck,  inside  of  arms,  shoulders,  and  side  of 
thorax,  over,  in  fact,  the  area  of  distribution  of 
those  filaments  which  pass  off  to  the  skin  from 
the  same  dorsal  branches  of  the  spinal  nerves, 
the  intercostals  which  send  filaments  to  the 
breasts.  It  affords  a good  example  of  reflected 
irritation.  This  state  usually  occurs  after  the  first 
conception,  and  in  women  of  excitable,  nervous 
temperament.  Attention  to  ordinary  hygienic 
measures  during  the  progress  of  the  metamor- 
phosis of  the  organ  into  a secreting  gland,  with 
its  accomplishment,  affords  relief  to  the  pain. 
In  large,  lax,  pendulous  breasts,  the  separate 
lobes  of  which  each  is  composed  may  excite 
apprehension  of  the  existence  of  a tumour. 
But  tumours  composed  of  new  tissue  are  so 
extremely  rarely  developed  during  pregnancy, 
that  the  greatest  caution  must  be  exercised  in 
the  diagnosis  of  their  nature. 

Very  rarely,  no  change  whatever  in  the 
breasts  accompanies  pregnancy,  under  which, 
circumstances  there  is  an  absence  of  the  secre- 
tion of  milk  after  parturition — Agalactia. 

Inflammation  of  the  Breast. — Mastitis. 

^Etiology. — Before  lactation,  inflammation  of 
the  breasts  is  very  uncommon.  Afterwards,  on  the 
contrary,  it  is  very  frequent.  This  morbid  state 
is  often  the  result  of  carelessness  or  ignorance  on 
the  part  of  the  nurse.  The  slightest  unusual 
fulness  or  ‘knottiness’  discovered  after  the 
infant  has  been  sucking,  and  when  the  ducts 
and  their  terminal  secreting  vesicles  should  be 
empty,  requires  immediate  attention.  Conges- 
tion of  a lobule  or  lobe  with  milk  produces  the 
nodule,  and  the  cause  of  the  impediment  to  its 
escape  should  be  sought  fcr.  The  state  of  the 
nipple  is  generally  the  cause  of  the  difficulty. 
Either  the  orifice  of  a duct  may  be  obstructed 
by  epithelium,  or  a superficial  ulceration  around 
one  exists.  The  morbid  or  defective  states 
of  the  nipple  are  the  most  fruitful  causes  of  in- 
flammation and  its  results  in  the  breast.  Pro- 
phylactic measures  should  always  be  instituted 


when  thsre  is  reason  to  fear  that  a defective 
development  of  the  nipple  will  interfere  with 
the  free  flow  of  the  milk.  Even  with  some 
mothers  it  would  be  advisable  to  resign  the  duty 
of  suckling,  rather  than  subject  themselves  to 
the  almost  certain  misery  arising  from  per 
sistent  and  ineffectual  attempts  to  do  so.  In- 
flammation, generally  passing  on  to  suppuration 
and  abscess,  either  within  the  body  of  the  breast 
or  on  its  surface,  is  most  frequent  in  primipara, 
and  within  the  first  month  after  parturition. 

Symptoms. — First,  hardness  is  felt,  ‘a  knot, 
in  some  part  of  the  substance  of  the  organ  ; this 
enlarges,  and  may  attain  to  considerable  dimen- 
sions before  causing  pain  or  even  uneasiness. 
Next,  pain  is  felt  during  suckling;  this  increases 
each  time  the  infant  sucks,  and  ‘ the  draught  ’ 
is  produced.  The  integuments  then  become  pink, 
and  afterwards  red,  tense,  shining ; more  or  less  cf 
the  breast  feeling  very  inelastic,  Srm,  prominent, 
and  heavy.  Fain  is  now  often  very  severe,  a'nd 
great  constitutional  disturbance  is  excited.  In 
the  centre  of  the  redness  the  skin  becomes  of  a 
purplish  tint,  around  this  it  is  cedematous,  and 
with  the  finger,  at  the  centre  of  the  purple  zone, 
a slight  depression  and  softening  spot  can  be 
detected.  An  abscess  now  exists,  and  in  pro- 
portion to  the  quantity  of  pus  fluctuation  is 
more  or  less  marked.  At  the  purple  centre  the 
cuticle  has  probably  by  this  time  separated  from 
the  cutis,  and  a vesicle  containing  serum,  either 
yellow  or  slightly  tinged  with  blood,  indicates 
that  ulceration  of  the  cutis  is  proceeding,  and 
that  the  pus  will  soon  escape.  The  above  is  a 
brief  description  of  the  objective  signs  indica- 
ting the  morbid  processes  noticeable  in  all  cases 
of  local  inflammation  advancing  to  and  ter- 
minating in  suppuration  and  abscess.  It  is  not 
possible  to  state  with  any  degree  of  exactness 
the  period  of  time  required  for  the  accomplish- 
ment of  these  definite  changes.  It  varies  accord- 
ing to  so  many  local  and  constitutional  circum- 
stances, that  it  would  be  idle  to  attempt  to  pre- 
dict any  certain  definite  period  or  stage  for  each 
phase.  It  will  be  more  useful  to  describe  the 
treatment  by  which  the  progress  of  the  disease 
may  be  arrested  or  limited  and  its  painful  course 
mitigated. 

Treatment. — Great  attention  should  always  bo 
given  to  the  nipple  of  primiparse.  In  many  women, 
this  important  division  of  the  gland  is  very  small 
and  undeveloped,  perhaps  only  on  one  side,  so  that 
the  infant,  especially  if  not  very  strong,  has  great 
difficulty  in  obtaining  sufficient  milk  to  appease 
the  appetite,  and  its  efforts  cause  pain  in  the  part. 
This  circumstance  induces  the  mother  to  prefer 
suckling  most  with  that  breast  the  nipple  of 
which  is  perfect,  and  the  infant  soon  appreciates 
the  advantages  of  that  side.  Consequently  the 
gland-tissue  of  that  breast  having  the  imperfect 
nipple  becomes  congested.  Every  time  the  infant 
sucks  it  becomes  worse,  more  and  more  pain  and 
irritation  are  excited,  the  orifices  of  one  or  more 
of  the  ducts  in  the  nipple  become  blocked,  and 
perhaps  the  infant  refuses  to  suck  the  breast. 
But  the  gland  becomes  more  and  more  distended, 
the  nipple  deeply  buried,  until  at  last  suckling  is 
impracticable.  Probably  none  of  tnese  increas- 
ing troubles  have  been  stated  to  the  attendant 
surgeon  ; and,  when  he  is  consulted,  he  finds  the 


BREAST,  DISEASES  OE. 


168 

breast  to  be  in  the  state  above  described.  The 
perfect  development  of  the  nipple  should  be 
always  a subject  of  anxious  solicitude  on  the  part 
of  the  obstetric  practitioner.  If  that  organ  be 
imperfect,  precautions  should  be  taken  to  prevent 
the  gland  itself  from  becoming  congested,  and  if 
the  infant  cannot  draw  the  milk  sufficiently,  some 
mechanical  means  should  be  employed  to  effect 
this  object.  The  nipple  itself  should  be  care- 
fully examined.  If  its  end  be  more  than  usually 
coated  with  a white  secretion,  or  the  openings  of 
the  ducts  seem  to  be  obstructed  with  an  excess 
of  epithelium,  attempts  may  be  made  to  remove 
it.  If  minute  abrasions,  ulcers,  ‘ cracks  or  chaps,’ 
are  visible  between  the  rugae,  some  soothing  ap- 
plication should  be  used.  Erequent  ablution  with 
warm  water,  even  the  contact  of  a little  moist 
cotton  fibre  covered  with  tissue  gutta-percha, 
is  very  preferable  to  the  dry  dress  ; or,  if  there 
be  much  secretion  from  the  glands  on  the  nipple, 
after  cleansing  its  surface,  .some  dry  powder, 
such  as  carbonate  of  magnesia,  oxide  of  zinc,  or 
starch  powder  is  beneficial. 

When  actual  congestion  of  the  gland-tissue 
exists,  mechanical  means  should  be  used  to  reduce 
it.  Supporting  the  gland  with  strips  of  plaster 
and  a bandage  is  sometimes  very  useful.  W hen 
inflammation  is  excited,  local  applications  of 
warmth  and  moisture  are  indicated,  and  the  con- 
stitutional condition  of  the  sufferer  demands 
special  attention.  When  suppuration  has  taken 
place,  its  relation  to  the  adjacent  parts  and  the 
exact  site  of  the  abscess  when  formed  should  be 
carefully  examined.  Great  diversity  in  the  pro- 
gress, duration,  and  sufferings  of  the  patient 
depends  upon  the  locality  of  the  pus.  It  may  be 
situated  over  the  body  of  the  gland,  within  it, 
and  beneath  it.  When  overlying  or  superficial 
to  the  body  of  the  breast,  the  course  of  the  disease 
is  rapid,  the  pus  soon  points  and  escapes,  and  the 
wound  heals.  In  those  cases  the  constitutional 
disturbance  is  usually  trifling.  Water-dressing 
before  and  after  the  escape  of  the  pus  is  pre- 
ferable to  the  heavy  poultices  usually  employed. 
The  entire  organ  may  be  supported  with  strips 
of  adhesive  plaster  and  a bandage  during  cica- 
trisation. But  a bandage  dexterously  applied 
should  be  always  used. 

Both  the  local  and  constitutional  symptoms 
are  much  more  severe  when  inflammation  affects 
the  body  of  the  gland,  and  pus  collects  between 
its  lobes.  The  progress  of  the  disease  is  tedious, 
pointing  of  the  pus  slow,  and  the  exact  spot  at 
which  it  may  reach  the  surface  is  for  a long  time 
doubtful.  In  the  majority  of  cases  it  makes  its 
way  between  the  ducts  and  reaches  the  surface 
near  the  areola  or  within  its  area ; usually  to 
the  sternal  side  of  the  nipple,  where  the  gland 
tissue  is  thinnest.  The  surgeon  should  note  this 
fact,  for  as  soon  as  he  can  detect  a softening  of 
the  cutis,  by  ulceration,  he  may,  with  advantage, 
make  an  incision  at  that  spot,  and  thus  give 
immediate  relief  by  facilitating  the  escape  of  the 
pus.  In  these  cases  recurrent  abscesses  are  not 
uncommon,  and  therefore  the  incision  should  be 
free,  and  its  premature  closure  by  adhesion  must 
be  avoided.  All  incisions  should  he  made  in  a 
line  parallel  to  the  course  of  the  ducts,  never 
transversely  to  their  axis.  Manual  pressure  to 
hasten  the  escape  of  the  pus  is  not  admissible, 


the  natural  contractility  of  the  tissues  using 
quite  sufficient  for  the  purpose. 

When  the  abscess  forms  behind  the  breast  the 
local  appearances  are  quite  characteristic.  The 
gland  itself  seems  little  involved,  but  it  is  pushed 
prominently  forwards  and  seems  to  repose  upon  a 
cushion  of  fluid.  To  the  touch  the  elasticity  of 
the  swelling  is  very  striking,  and,  without  pro- 
ducing additional  pain,  a slight  bulging  of  the 
walls  of  the  abscess  may  sometimes  be  produced 
at  the  periphery  of  the  gland  when,  with  the 
palm  of  the  hand  and  outspread  fingers,  com- 
pression is  made  from  the  front  backwards 
against  the  thorax.  The  patient  should  bo  re- 
cumbent. The  pus  in  these  cases  often  points 
somewhere  around  the  borders  of  the  body 
of  the  gland. 

During  the  time  occupied  in  the  formation  of 
a mammary  abscess  and  its  local  treatment,  the 
constitutional  powers  of  the  patient  must  he  well 
supported,  and  the  general  health  maintained  by 
every  means. 

The  sequela  of  suppuration  in  an  organ  com- 
posed of  so  much  connective-tissue,  and  endowed 
with  its  peculiar  function,  frequently  cause  great 
trouble.  They  are  protracted  induration,  sinuses, 
and  fistulae,  through  which  last  the  milk  per- 
sistently escapes.  Induration  of  the  whole  or 
part  of  the  breast  subsides  when  lactation  ceases, 
and  the  organ  in  due  time  resumes  its  healthy 
state.  Sinuses  and  fistulae  may  require  incisions, 
hut  the  ordinary  plan  for  their  cure  should  be 
adopted  before  having  recourse  to  a treatment 
often  involving  much  subsequent  deformity. 

At  the  time  for  weaning  the  infant  inflamma- 
tion rarely  occurs.  Considerable  milk-congestion 
of  the  secreting  structure  may  sometimes 
produce  irritation  and  inconvenience,  to  he  re- 
lieved by  mechanically  drawing  the  milk  in  just 
sufficient  quantity  only  to  diminish  the  fulness. 

Galacticele. — An  accumulation  of  milk,  to 
which  the  above  term  is  given,  forms  a tumour  in 
the  connective-tissue  of  the  organ,  and  results 
from  the  Imrsting  of  a lactiferous  tube.  The 
swelling  always  appears  first  during  lactation. 
It  may  vary  in  size  from  time  to  time ; sometimes 
enlarging  rapidly  as  suckling  goes  on.  Two 
varieties  are  mot  with.  In  one  form  there  is  a 
single  swelling  near  the  nipple,  quite  superficial, 
and  quickly  recognizable  by  its  objective  signs. 
In  the  other  there  may  be  several  swellings  dis- 
tinguishable in  the  substance  of  the  gland,  as  well 
as  on  its  surface,  all  of  comparatively  small  size, 
very  firm  and  globular.  In  the  same  gland  they 
vary  very  much  in  size,  and  in  the  degree  of  resist 
ance  they  offer  to  manipulation.  The  discrimi- 
nation between  these  tumours  and  others  in  the 
breast  is  easy,  if  the  surgeon  is  able  to  ascertain 
with  exactness  that  the  swelling  appeared  some- 
what suddenly  during  suckling,  and  that  its  size 
varied  conformably  with  that  function. 

In  cases  of  long  standing,  the  contents  of  the 
cyst  become  solid  in  proportion  to  the  quantity 
of  the  fluid  constituents  of  the  milk  absorbed,  and 
the  cyst  wall  itself  is  very  often  rigid  and  6ven 
may  become  gritty. 

Treatment. — The  treatment  of  this  malady 
consists  in  cutting  into  the  cyst,  removing  it j 
contents,  and  allowing  the  wound  to  heal  b7 
granulation. 


BREAST,  DISEASES  OF. 


B.  The  diseases  affecting  the  mature  gland, 
in  its  passive  state,  from  the  age  of  puberty  to 
that  period,  of  life  when  the  catamenia  cease,  may- 
be grouped  as  follows : — the  functional  affections, 
or  those  which  are  characterised  by  changes  in 
the  secreting  portion  of  the  gland,  accompanied 
by  more  or  less  induration,  inconvenience,  and 
pain;  the  organic,  or  those  diseases  characterised 
by  some  new-growth,  formation,  or  tissue-struc- 
ture altogether  a superaddition  to  the  organ, 
and  growing  within  its  sphere  of  nutrition,  often 
resembling,  more  or  less,  gland-structure  in 
composition ; and  others  the  minute  elements  of 
which  are  nucleated  cells  of  various  shapes,  de- 
finitely and  diversely  arranged. 

In  this  state  of  the  breast  inflammation 
rarely  occurs.  Nevertheless,  both  the  acute  and 
chronic  varieties  of  that  morbid  process  ter- 
minating in  abscess  are  met  with,  and  careful 
discrimination  is  necessary  to  avoid  mistaking 
such  diseases  for  tissue-tumours,  especially  in 
patients  above  forty  years  old.  The  history  of 
the  case,  tactile  examination,  and  the  variations 
occurring  during  the  progress  of  the  affection, 
commonly  suffice  for  the  detection  of  such  cases. 
The  treatment  should  be  the  same  as  for  abscess 
in  general. 

Functional  Derangements. — The  functional 
derangements  of  the  breast  in  its  passive  state 
demand  special  attention.  They  are  charac- 
terised by  a peculiar  activity  of  its  secreting 
portion,  which  undergoes  structural  changes  of 
u specific  kind.  When  the  tissues  composing 
a mature  gland,  but  perfectly  passive,  are  ex- 
amined with  a microscope,  the  csecal  termina- 
tions of  the  ducts  are  scarcely  perceptible, 
and  little  else  than  fibre-tissue  is  seen.  Here 
and  there,  perhaps,  cseci  may  be  detected  con- 
taining minute  aggregations  of  epithelium. 
Out  when,  under  some  sympathetic  excitement, 
with  derangement  of  the  functions  of  the  pelvic 
generative  organs,  the  secreting  cells  of  the 
gland  become  active  and  are  distended  with 
epithelium,  they  induce  more  or  less  enlargement 
of  the  breast.  But  of  such  affections  there  is 
this  important  fact  to  be  noticed.  The  whole 
breast  need  not  be  necessarily  involved.  On  the 
contrary,  one  lobe  only  may  be  excited,  and 
when  this  occurs  the  existence  of  a tumour  is 
declared.  When,  after  excision,  such  enlarged 
lobes  are  carefully  examined  with  the  micro- 
scope, normal  gland-tissue  is  seen,  the  caecal 
ends  of  the  ducts  are  readily  recognised,  and 
their  immediate  association  with  the  excretory 
ducts  may  be  observed.  The  former  are  gorged 
■with  epithelium  ; and  true  gland-tissue,  less  its 
peculiar  secretion,  has  been  developed. 

Symptoms. — Associated  with  this  state  of  the 
tissues  ofthebreast,  the  patienteomplains  of  pain, 
both  locally  and  spread  over  a very  wide  area. 
To  express  as  briefly  as  possible  the  superficial 
regions  affected  and  over  which  pain  is  felt,  the 
reader  must  be  reminded  of  the  distribution  of 
the  nerve-filaments  of  the  lower  cervical  plexus, 
and  of  the  dorsal  from  which  the  second,  third, 
fourth,  and  fifth  middle  and  anterior  intercostal 
corves  pass  off  From  these,  special  filaments 
are  distributed  to  the  breast ; and  to  the  site  of 
exit  of  one  or  more  of  them  at  the  intercostal 
foramina,  the  course  of  the  pain  is  referred  by 


the  patient.  The  skin  of  the  neck,  shoulder, 
side  of  thorax,  and  inside  of  arm  receives 
filaments  from  the  same  source.  Hence  an 
explanation  of  the  widely-diffused  pain. 

It  is  of  the  first  importance  to  discriminate 
between  this  state  of  the  gland-tissue  and  sub- 
stantial new  growths,  especially  because  the 
latter  cannot  be  removed  by  natural  processes, 
whilst  the  former  most  probably  will  be.  The 
objective  signs  are  the  following ; — to  the  touch 
the  excited  gland-tissue  is  nodular,  irregular 
over  its  surface,  ranch  identified  and  mingled 
with  the  body  of  the  organ.  If  the  whole  breast 
be  large  and  relaxed,  the  tips  of  the  fingers  may 
be  insinuated  between  the  borders  of  the  indu- 
rated lobe  and  the  lobes  not  affected.  If  the 
entire  body  of  the  gland  be  morbidly  firm,  it 
feels  like  a disc-shaped  mass  lying  on  the  thorax, 
under  the  borders  of  which  the  fingers  can  be 
pressed.  Occasionally,  at  one  or  more  spots 
along  the  periphery  of  the  gland  irregular 
nodules  are  perceptible,  projecting  into  the  con- 
nective-tissue around  them.  When  one  lobe  is 
affected,  the  shape  of  the  induration  correspond- 
ing with  that  of  a lobe,  namely,  broad  at  the 
periphery  and  gradually  narrowing  towards  the 
areola,  may  be  detected.  Pain  as  a subjective 
indication  is  of  great  assistance  in  the  diagno- 
stication  of  these  cases  ; but  the  source  and 
course  of  the  pain  must  be  carefully  traced. 
Generally  manipulation  of  the  induration  pro- 
duces increased  pain ; occasionally  touching  the 
induration,  even  however  gently,  is  intolerable, 
and  persistence  in  or  repetition  of  the  act 
strongly  opposed  by  the  sufferer.  Light  pres- 
sure should  be  made  over  the  intercostal  fora- 
mina, both  the  middle  and  anterior,  when  the 
pain  excited  thereby  will  correspond  with  the 
nerve-filaments  of  the  affected  lobe.  Usually, 
pressure  along  the  upper  dorsal  spinous  processes 
excites  pain  also.  The  morbid  affections  above 
described  occur  in  single  women,  married  but 
sterile  females,  and  young  widows,  at  ages  be- 
tween twenty  years  and  forty.  More  or  less 
disturbance  of  the  catamenia  co-exists,  either 
in  relation  to  the  frequency  or  quantity  of  the 
discharge.  The  patient  complains  of  languor, 
inability  for  bodily  or  mental  exertion,  and  is 
desponding  and  often  alarmed  for  the  possible 
consequences  of  the  affection  suggested  by  sym- 
pathising friends.  She  becomes  irritable, 
restless  at  night,  loses  appetite  for  food,  as  well 
as  all  desire  for  social  enjoyments,  and  becomes 
highly  susceptible  and  emotional. 

Diagnosis. — An  exact  diagnosis  of  these  histo- 
logical changes  maybe  made  if  the  manipulator 
examines  the  organ  methodically.  He  should, 
first,  gently  grasp  the  induration  between  the 
thumb  and  fingers,  when  it  will  be  distinctly  ap- 
preciable. Afterwards,  placing  the  palmar  sur- 
face of  the  fingers  over  the  surface  of  the  breast 
and  gently  pressing  backwards  against  the  thorax, 
the  induration  cannot  be  detected.  Should  there 
still  remain  any  doubt  on  the  subject,  let  the 
patient  recline  on  her  opposite  side  on  a sofa, 
and  in  this  posture,  if  there  exists  a substantial 
new-growth,  the  integument  is  usually  elevated 
by  it. 

Treatment. — The  treatment  of  these  eases 
consists  in  attention  to  the  general  health.  Every 


BREAST,  DISEASES  OF. 


PO 

hygienic  direction  should  be  enjoined,  and  such 
medicines  administered  as  conduce  to  its  im- 
provement. Local  soothing  applications  are 
usually  futile,  and,  except  in  those  cases  of  ex- 
treme pain,  are  not  advisable,  since  it  is  desirable 
to  avoid  manipulation  of  the  part,  and  the 
frequent  recurrence  of  the  patient's  thoughts  to 
it.  Should  the  gland  be  heavy  and  pendulous, 
a suspensory  bandage,  as  thin  as  possible,  may 
be  adjusted. 

New  Formations. — We  shall  next  describe 
the  diseases  of  the  mature  gland  arising  from 
the  development  of  new  formations — either  of 
tissues  constituting  new-growths;  or  of  conditions 
causing  collections  of  fluid  of  distinct  and  specific 
kinds.  All  of  these  may  be  thus  arranged  in 
three  groups : — first,  the  fluid  tumours ; second, 
the  solid:  and,  third,  those  composed  of  both 
solid  and  fluid. 

A.  Cysts. — The  fluid  tumours,  commonly 
termed  cystic , consist  of  a membranous  sac  with 
its  contents.  Now,  calling  to  mind  the  histolo- 
gical divisions  of  the  breast,  and  dwelling  on  the 
structural  differences  between  its  parts,  the 
secreting  apparatus  and  the  excretory,  there  is 
little  difficulty  in  assigning  to  the  cysts  their 
true  histological  affinities.  Thus  there  are  cysts 
associated  with  the  secreting  apparatus  ; others 
with  the  excretory,  the  ducts ; and  some  due  to  the 
extravasation  of  the  gland's  secretion,  the  milk, 
into  the  connective  tissue.  Effusions  of  blood  also 
give  rise  to  the  development  of  cysts,  either  in- 
dependently of  other  diseases  ox  associated  with 
them.  Another  variety  of  cyst  is  produced  by 
the  development  of  entozoa,  notably  of  echino- 
coccus hominis.  An  ordinary  examination  of 
the  fluid  derived  from  these  cysts  at  once  es- 
tablishes the  fact  that  heat  and  the  admixture 
of  nitric  acid  produce  coagulation  in  that 
abstracted  from  some  of  them,  whilst  that  from 
other  cysts  remains  unaffected  by  the  treatment. 
The  cysts  are  thus  divisible  by  the  nature  of  their 
contents  into  two  distinctly  defined  groups : — 

a.  Those  containing  fluid  without  the  admix- 
ture of  any  coagulable  element. 

h.  Those  enclosing  fluid  which  does  contain 
coagulable  material.  Other  characteristics  of 
these  two  fluids  are  not  less  conspicuous. 

From  an  objective  point  of  view  all  cystic 
tumours  of  this  gland  may  be  classed  in  two 
groups,  thus  : — first,  those  associated  with  its 
ducts,  the  evidence  of  which  is  afforded  by  the 
escape  of  fluid  at  the  nipple ; and  secondly,  those 
not  connected  with  the  ducts  by  any  such  evi- 
dence. 

The  following  tabular  arrangement  will  place 
before  the  reader,  at  a glance,  all  the  varieties 
of  cysts  met  with  in  the  breast. 

I.  Cysts  associated  with  the  ducts,  communi- 
cating and  connected  with  them. 

1.  Containing  milk. 

2.  Enclosing  growths  ; with  serum,  eo- 

agulahle  and  often  tinged  with 
blood : — 

a.  Adenoid  growths. 

b.  Granulation  cell-growths. 
e.  Cancer. 

Cysts  not  connected  with  the  ducts. 

1.  Surrounding  effused  blood, 

2.  Enclosing  milk. 


3.  Simple  cysts.  Fluid  not  coagu 

4.  Entozoon  cysts.  / lable. 

5.  Investing  growths;  with  serum  co- 

agulable, tinged  with  Llood  and 

containing  cholesterine : — 

a.  Adenoid  growths. 

b.  Granulation  cell-growths. 

c.  Cancer. 

1.  We  have  described  above,  under  the  name 
galaciicele,  a tumour  observed  during  suckling 
and  composed  of  milk.  But,  occasionally,  the  sur- 
geon is  consulted  about  a swelling  which,  at  first 
sight,  would  seem  to  have  no  reference  to  that 
function.  Nevertheless  the  milk,  or  all  that 
remains  of  that  secretion,  constitutes  its  entire 
bulk.  If  exact  enquiry  be  made,  the  patient 
states  that  a tumour  has  existed,  unaccompanied 
by  pain,  from  the  period  of  the  last  weaning, 
perhaps  not  haring  been  observed  until  the  gland 
ceased  to  secrete,  and  that  its  size  slowly  di- 
minished until  a certain  period,  since  which  it 
has  remained  of  unvarying  bulk.  This  decrease 
is  due  to  the  absorption  of  the  serum  of  the  milk, 
and  the  solid  parts  remain.  The  cyst  should  bo 
incised,  the  contents  removed,  and  the  wound 
allowed  to  heal  by  granulation. 

Cysts  containing  the  solid  parts  of  the  milk 
are  sometimes  associated  with  perfectly  new 
growths  of  the  glandular  type. 

2.  True  scro-cysts,  that  is  to  say,  a collection 
of  serum  circumscribed  by  a fibrous  membrane, 
are  frequently  met  with,  and  are  most  commonly 
associated  with  adenoid,  granulation,  and  can- 
cerous growths.  They  occur  in  the  breasts  of 
middle-aged  women.  The  fluid  which  these 
cysts  contain  is  sometimes  quite  clear,  and  of  a 
yellow  tint ; at  others  it  is  tinged  with  blood- 
colouring matter,  and  is  turbid.  It  always  con- 
tains some  constituent  coagulable  by  heat  and 
the  admixture  of  nitric  acid.  These  are  the 
exudation-eysts  of  the  mammary  gland.  After 
the  fluid  has  been  removed  with  a trocar  and 
canula  the  cyst  soon  refills. 

3.  Other  cysts  containing  a fluid  like  serum, 
until  its  composition  is  carefully  examined,  are 
developed  in  the  breast,  and  are  probably  asso- 
ciated immediately  with  the  secreting  part  of  the 
gland.  For  the  sake  of  identification  the  writer 
would  designate  them  mucous  cysts.  The  con- 
tained fluid  is  not  coagulable  by  either  heat  or 
acid.  Its  colour  is  brown,  more  or  less  in- 
clining to  a greenish  hue  ; it  is  opalescent,  of 
variable  specific  gravity — about  1020,  rather 
greasy  when  rubbed  between  the  fingers,  and 
exhibits  an  alkaline  reaction.  When  sufficient 
quantity  is  collected  in  a test-tube  and  allowed 
to  cool,  in  a few  hours  the  lowermost  stratum 
of  the  fluid  becomes  clearer  than  the  upper.  The 
uppermost  always  remains  opalescent.  If  a little 
of  this  last  be  examined  with  a microscope,  oil 
globules  are  seen,  together  with  the  bodies  called 
colostrum  cells.  The  greasy  nature  of  the  fluid 
can  he  detected  by  smearing  a drop  of  it  on  a 
piece  of  glass. 

The  development  of  these  cysts  is  not  very 
common.  We  may  here  remark  that  they  seem 
to  have  escaped  the  observation  of  surgeons,  as 
no  special  notice  of  them  occurs  in  the  most 
recent  monographs.  Yet  they  are  so  distinctly 
separated  from  all  the  other  cysts  which  arc 


'BREAST.  DISEASES  OF. 


formed  in  the  breast,  in  respect  of  the  composi- 
tion of  their  fluid  contents,  their  progress,  and 
their  prognosis,  that  they  constitute  a marked, 
distinct,  and  isolated  class  We  meet  "with 
them  in  the  breasts  of  single  -women,  in  married 
but  sterile  females,  and  in  widows  between  forty 
and  fifty  years  of  age.  Usually  they  are  acci- 
dentally discovered  in  any  quarter  of  the  gland 
when  about  an  inch  in  diameter.  Their  shape 
is  globular  or  ovoid ; to  the  touch  elasticity 
is  the  main  feature,  and  if  sufficiently  large 
and  superficial,  fluctuation  may  be  detected. 
In  some  instances  the  tips  of  the  fingers  may 
be  insinuated  into  a sort  of  furrow  around 
them.  Pain  is  rarely  complained  of.  The 
treatment  consists  in  emptying  the  cyst  with  a 
trocar  and  canula.  After  this  the  fluid  does  not 
again  form.  These  cysts  usually  appear  singly 
and  in  one  breast  only,  but  the  writer  has  seen  a 
patient  in  whom  they  were  multiple  and  on  both 
sides. 

4.  Cysts  containing  blood — hczmatomata,  are 
very  rarely  formed  in  the  breast,  except  in 
association  with  some  new-growtk  from  which 
blood,  or  more  often  bloody  serum,  oozes. 

5.  True  entozoa-cysts  are  developed  in  the 
breast.  They- are  certainly  rare,  and  cannot  be 
distinguished  from  other  cysts  until  incised. 
Extirpation  by  excision  is  the  speediest  means 
of  effecting  a cure. 

B.  Solid  Tumours. — We  have  next  to  de- 
scribe the  solid  tumours.  These  are  essentially 
new  growths  of  tissue  superadded  to  the  normal 
gland.  Generally,  therefore,  a characteristic 
feature  of  the  existence  of  such  growths  is  an  in- 
creased bulk  of  the  affected  organ  ; another,  the 
firmness  or  resistance  to  pressure  with  the  fingers 
when  contrasted  with  the  group  of  tumours  be- 
fore described.  The  solid  tumours  have  long  been 
classed  in  regard  to  their  local  and  constitutional 
effects,  and  their  results  on  the  life  of  the  indi- 
vidual affected  with  them,  into  two  groups — the 
innocent  or  harmless;  and  the  malignant  or  life- 
destroying. 

1.  Adenoma. — In  the  first  class  are  placed  those 
growths  more  or  less  closely  resembling  in  their 
tissues  those  composing  the  glandular  structure 
of  the  breast.  Various  terms  have  been  assigned 
to  these  tumours,  namely,  Chronic  mammary  tu- 
mours, Pancreatic  Sarcoma,  Tumeur  adenoide, 
Corps  fibreux,  Hypertrophie  partieile,  Mammary 
glandular  tumour,  Fibroma,  Adenocele.  Their 
composition  is  chiefly  fibre-tissue,  the  cseci  or 
acini  of  secreting  structures,  with  more  or  less 
distinctly  marked  traces  of  ducts,  being  inter- 
spersed throughout  the  mass.  The  elementary 
nucleated  cells  are  those  of  the  gland  and  fibre- 
tissues. 

Adenomata  are  developed  in  the  breasts  of 
young,  unmarried  women  from  the  age  of  puberty 
upwards ; rarely  after  thirty,  but  very  commonly 
before  that  age.  They  may  be  intraglandular, 
occupying  the  substance  or  body  of  the  gland, 
and  having  the  normal  gland-tissue  investing 
them.  In  other  instances  they  seem  to  be  at- 
tached by  a kind  of  pedicle  either  to  its  surface 
or  margin.  In  every  instance  they  are  placed 
within  the  fascial  investment  of  the  organ. 
When  attached,  as  just  described,  their  remark- 
able mobility,  slight  lobulation  of  surface,  and 


firmness,  coupled  with  the  youth  of  the  patient, 
are  sufficient  indications  of  the  harmlessness 
of  their  nature.  Usually  they  occur  singly  and 
in  one  breast;  they  may  be  multiple  and  in 
both  breasts.  The  only  means  by  which  they 
can  be  removed  is  excision.  However  large  the 
tumour,  its  removal  should  be  always  attempted 
without  cutting  away  any  portion  of  the  normal 
breast.  In  most  cases  this  can  be  done,  especially 
if  the  patient  be  youthful  and  the  growth  of 
medium  size,  even  should  it  be  developed  in  the 
body  of  the  gland  aud  extend  through  it  to  the 
pectoral  muscle.  After  thirty-five  years  of  ago 
it  is  expedient  to  remove  the  breast  as  well. 
IVant  of  space  precludes  a lengthened  histo- 
logical description  of  these  growths.  It  must 
suffice  to  state  that  a section  shows  a solid,  uni- 
form surface,  divided  into  lobes  and  lobules  by 
fibrous  septa,  sometimes  slightly  broken  up  by 
fissures  or  clefts  in  which  there  appears  a little 
clear  tenacious  fluid.  The  growth  is  often  very 
succulent,  at  other  times  only  moist ; its  hue  may 
be  greyish,  yellow  or  almost  white.  Its  vas- 
cularity is  scarcely  perceptible.  The  prognosis  of 
these  cases  is  invariably  favourable.  In  many 
instances  excision  is  not  necessary,  and  the 
surgeon  must  be  guided  in  recommending  an 
operation  by  the  exigencies  of  the  case  spceially 
under  observation. 

2.  Fatty  tumour. — Lipomata  or  masses  of 
adipose  tissue  are  developed  in  the  breast,  or 
rather  in  relation  with  it,  to  speak  with  accuracy. 
They  are  characterised  by  the  usual  indications, 
and  require  no  special  mention. 

3.  Ncevus. — It  may  be  questioned  whether 
nsevus,  or  a growth  of  true  trabecular  vascular 
fibre-tissue,  is  ever  developed  in  the  substance  of 
the  breast,  that  is  to  say,  in  the  gland-tissue. 
The  integument  around  the  mammilla  may  cer- 
tainly be  so  affected  in  early  life  before  the  de- 
velopment of  the  gland,  and  a subcutaneous  naevus 
may  exist  at  the  site  of  the  future  organ ; but  to 
describe  such  a growth,  in  a girl  of  six  years  old, 
as  a recent  writer  has  done,  as  an  example  in 
which  the  whole  organ  was  like  a sponge  and  as 
large  as  half  an  orange,  must  be  regarded  as  an 
error  in  pathology. 

4.  Fibro-plastic. — Under  the  term  ‘fibro- 
plastic’ we  include  a group  of  new-growths 
composed  of  elementary  nucleated  cells  of  a fusi- 
form or  oval  shape,  disposed  in  a stroma  of  more 
or  less  fibre-tissue.  They  are  developed  in 
women  of  middle  age,  increase  rapidly,  and  after 
excision  are  liable  to  grow  again. 

5.  Colloid. — Colloid  growths  are  very  rarely 
met  with  in  the  breast.  They  appear  in  middle 
life,  and  are  not  distinguishable  from  other  solid 
tumours  until  after  excision. 

6.  Carcinoma. — Carcinoma,  commonly  called 
cancer,  is  developed  in  the  breast  in  two  distinct 
forms.  The  first,  and  most  common,  is  that 
variety  which  is  due  to  infiltration  of  the  normal 
tissues  of  the  gland  by  the  elementary  cells  of 
cancer.  It  constitutes  the  scirrhous  variety, 
the  carcinoma  fibrosum  of  the  present  day.  The 
second  is  that  kind  which  is  produced  by  the 
development  of  a mass  of  true  cancer-growth, 
and  is  termed  tuberous,  often  medullary.  Both 
varieties  are  met  with  in  women  after  forty 
years  of  age,  but  the  first  much  the  most  frs- 


172  BBEAST.  DISEASES  OF. 


quently.  Previously  to  that  age  the  disease  is 
rare ; from  forty  to  fifty  it  is  most  commonly 
seen ; and  it  becomes  relatively  less  frequent  as 
age  advances.  A larger  number  of  married 
women  are  affected  by  it  than  single,  and  prolific 
women  who  have  suckled  their  children  are  quite 
as  prone  to  the  disease  as  the  sterile  or  those 
who  have  not  suckled. 

Symptoms. — Scirrhous  cancer  commences  in 
any  region  of  the  mammary  gland,  although  most 
frequently  perhaps  in  the  axillary  segment.  A 
small,  firm  nodule  is  usually  accidentally  dis- 
covered, without  the  attention  of  the  patient 
having  been  attracted  to  it  by  pain.  Barely, 
the  whole  organ  is  simultaneously  infiltrated, 
but  most  frequently  one  lobe  only  is  affected. 
The  infiltration  is  often  central  in  the  body 
of  the  gland,  especially  when  the  organ  is 
atrophied,  and  the  reverse  occurs  when  the  ex- 
treme edge  of  a lobe  is  affected  at  its  periphery. 
The  infiltration  may  steadily  increase  until  the 
whole  breast  forms  a rigid,  solid  mass,  but  most 
frequently  the  larger  part  of  the  organ  remains 
unaffected.  The  disease  gives  rise  by  its  con- 
traction to  much  deformity  of  the  region,  to 
dimpling,  corrugation,  and  irregularities  of  the 
otherwise  rotund  integumental  surface.  The 
nipple,  just  in  proportion  to  the  effect  of  the 
growth  upon  the  ducts,  becomes  retracted  or 
drawn  towards  the  tumour.  Such  are  the  ordi- 
nary objective  signs  of  infiltrating  cancer  in  its 
early  stage.  The  progress  made  by  the  disease 
is  subject  to  very  remarkable  variations  in  differ- 
ent individuals,  and  the  stage  above  described 
may  be  long  delayed.  In  some  cases  many 
months  or  even  years  may  elapse  before  the 
growth  assumes  any  grave  importance.  Sooner 
or  later,  however,  the  integument  over  the 
growth  becomes  adherent  to  it,  infiltrated,  and 
red,  and  advances  towards  ulceration.  An  ulcer 
now  forms,  the  edges  of  which  are  everted,  ragged, 
and  attached  to  the  growth  beneath.  A hole 
extending  into  the  tumour  becomes  deeper  and 
deeper ; ichorous  discharges,  more  or  less  profuse, 
continue  without  much  pain ; and  the  patient 
becomes  at  last  worn-out,  or  succumbs  to  the 
ravages  of  a cancerous  growth  in  a vital  organ. 

The  tuberous  variety  commences  in  a small 
circumscribed,  globular  nodule  in  the  body  of 
the  gland ; grows  rapidly ; separates  the  lobes  of 
the  organ;  extends  equally  in  all  directions  ; and 
becomes  adherent  to  the  skin,  which  commonly 
sloughs  and  allows  of  a protruding,  fungating 
mass. 

In  both  varieties  the  axillary  lymphatic 
glands  sooner  or  later  become  involved  in  the 
disease,  which  may  also  spread  to  those  in  the 
neck  and  within  the  thorax. 

Treatment.— Local  applications  exert  little 
if  any  influence  on  the  growth  of  cancer,  but 
certainly  those  which  reduce  the  local  tempera- 
ture are  the  best.  The  vital  powers  of  the  patient 
should  be  supported  as  much  as  possible  by  hy- 
gienic measures,  and  especially  by  ferruginous 
tonics.  The  removal  of  the  primary  growth 
before  the  contamination  of  the  lymphatic  system 
is  of  great  importance,  but  whether  by  excision 
with  a scalpel,  or  by  means  of  escharotics,  space 
vill  not  admit  of  discussing.  The  writer  inclines 
to  the  first  method  in  the  majority  of  cases. 


C.  Mixed  Tumours. — To  the  group  of  mixed 
tumours  belong : — 1 Those  composed  of  cysts, 
intracystic  growths,  and  solid  interspe'rsed 
masses  of  new  tissue.  2.  Granulation  cysts — cysts 
with  growths  attached  to  their  walls,  the  elemen- 
tary tissues  of  which  resemble  those  of  ordinary 
granulation-growths — whence  the  term  applied 
to  them.  3.  Cysts,  so-called,  often  formed  upon 
the  surface  of  cancers,  in  consequence  of  the  slow 
exudation  of  serum  from  the  growth  itself. 

1.  Tumours  of  the  first  elass  belong  patholo- 
gically to  the  group  of  adenoid  formations,  and 
although  they  differ  so  remarkably  in  their  ex- 
ternal objective  appearances,  they  are,  when  un- 
alloyed with  other  growths,  perfectly  harmless. 
The  sero-cystic  disease  of  Brodie,  and  the  pro- 
liferous cysts  of  Paget  belong  to  this  class. 

2.  The  granulation-cystic  growths  constitute 
a class  of  themselves.  It  is  only  of  late  years  that 
attention  has  been  attracted  to  them.  They  are 
rarely  met  with,  and  when  pure  are  unattended 
by  untoward  circumstances. 

3.  To  the  third  class  belongs  a group  of  cases 
thoroughly  cancerous  in  their  nature,  and  differing 
only  from  the  ordinary  forms  of  that  disease  by 
the  accidental  formation  of  cysts.  See  Tumours. 

III.  Diseases  of  the  Male  Breast. — The 
male  has  sometimes  a well-developed  mammary 
gland,  and  the  part  is  subject  to  the  same  dis- 
eases as  the  female.  But  the  simple  enlarge- 
ment of  the  organ  is  harmless,  and  should  not 
be  interfered  with.  At  the  age  of  puberty  the 
mammary  region  often  becomes  painful,  owing  in 
part  to  the  pressure  of  the  dress  upon  the  mam- 
milla and  the  rudimentary  organ.  Inflammation 
followed  by  suppuratiou  has  been  observed  at 
this  time. 

TV.  Diseases  of  the  Hippie. — A defective 
formation  of  the  nipple  is  of  grave  importance, 
and  when  it  exists  measures  should  bo  adopted 
to  assist  its  elongation.  This  is  to  be  done  bv 
using  an  exhausting  glass,  such  as  those  em- 
ployed to  empty  the  gland  of  milk. 

Inflammation  and  its  effects  produce-  much 
suffering,  and  at  the  period  of  suckling  frequently 
excite  deep-seated  mischief.  The  small  ulcers, 
called  ‘ cracks,’  ' chaps,’  &c.,  which  form  between 
the  rugae  on  the  apex  and  sides  of  the  nipple,  may 
be  cured  with  an  application  of  water-dressing,  or 
by  powdering  the  part  with  carbonate  of  mag- 
nesia or  oxide  of  zinc,  far  more  readily  than  with 
ointments. 

Pendulous  cutaneous  growths  occur  on  the 
nipple,  and  should  be  excised. 

Cystic  follicular  tumours  are  sometimes  seen 
within  the  zone  of  the  areola.  See  Hipple,  Dis- 
eases of.  John  Birxett. 

BREATH,  The. — The  expired  air,  or  what 
is  familiarly  termed  the  breath,  is  important  both 
from  an  aetiological  and  a clinical  point  of  view, 
and  the  object  of  the  present  article  is  to  present 
a brief  summary  of  the  main  facts  relating  to 
this  subject,  with  which,  for  practical  purposes, 
it  is  necessary  to  be  acquainted. 

1.  The  mtiological  relations  of  the  breath  will 
be  more  appropriately  discussed  under  the  gene- 
ral subject  of  aetiology  (see  Disease.  Causes  of), 
but  a few  of  the  more  striking  examples  of  the 
manner  in  which  it  affects  the  health  may  b* 


BREATH,  THE.  173 


given  here.  It  is  well  known  that  the  expired 
air,  if  re-breathed  by  the  same  individual  with- 
out having  been  purified  by  a proper  admixture 
with  atmospheric  air,  will  produce  serious  effects 
upon  the  economy,  and  will  ultimately  lead  to 
death  by  asphyxia.  Again,  the  breath  of  a number 
of  persons  collected  together  in  an  ill-ventilated 
place  may  prove  injurious  tc  such  individuals  ; 
the  impure  atmosphere  thus  generated  tends  to 
lower  the  general  health,  to  retard  the  develop- 
ment of  the  young,  to  increase  the  virulence  of 
infectious  diseases,  and  to  predispose  to  pul- 
monary affections.  Indeed,  some  writers  regard 
re-breathed  air  as  one  of  the  most  prominent 
causes  of  pulmonary  phthisis.  Further,  un- 
doubtedly the  expired  air  is  a most  important 
channel  by  which  the  poison  of  different  infective 
diseases — for  example,  that  of  measles,  scarlatina, 
or  diphtheria — is  conveyed  frcm  cne  individual 
to  another.  It  has  been  affirmed  that  phthisis 
can  be  transmitted  directly  in  this  manner,  but 
adequate  proof  of  this  statement  is  entirely 
wanting. 

2.  In  a clinical  point  of  view,  the  expired  air 
may  afford  useful  information  in  diagnosis ; or 
it  may  present  characters  giving  important  indi- 
cations for  prognosis  and  treatment.  It  might 
be  requisite  in  different  cases  to  submit  the 
breath  to  a more  or  less  complete  examination, 
and  the  following  outline  will  serve  to  suggest 
the  particulars  to  which  attention  should  be 
directed  in  this  examination,  and  to  point  out 
the  practical  uses  which  it  may  serve. 

a.  The  breath  has  been  made  use  of  to  distin- 
guish between  real  and  apparent  death.  For 
this  purpose  a delicate  feather  or  a light  is  held 
before  the  mouth  or  nostrils,  and  it  is  noted 
whether  either  of  these  is  disturbed ; or  a cold 
mirror  is  placed  before  the  mouth,  when,  if 
breathing  is  going  on,  its  surface  will  be  clouded 
by  the  moisture  condensed  upon  it.  These  tests 
are,  however,  not  considered  very  reliable. 

b.  The  temperature  of  the  expired  air  may 
be  important  to  notice.  In  some  conditions 
it  becomes  exceedingly  cold,  and  this  may  he 
readily  perceptible  to  the  hand,  the  breath 
having  a chill  feel,  or  it  may  be  visible  in  con- 
sequence of  the  moisture  in  the  expired  air  being 
condensed,  even  when  the  surrounding  atmo- 
sphere is  warm.  This  phenomenon  is  observed, 
for  instance,  in  the  collapse-stage  of  cholera. 
On  the  other  hand,  the  temperature  of  the  breath 
may  he  raised  more  or  less,  as  in  febrile  diseases. 

c.  Chemical  examination  of  the  breath  may 
prove  of  service,  and  it  is  probable  that  this 
might  afford  useful  information,  if  it  were  re- 
sorted to  more  frequently  than  is  the  custom  at 
present.  In  the  first  place  this  examination  may 
be  employed  to  determine  the  proportion  of  car- 
bonic acid  present.  In  certain  affections,  as 
during  an  attack  of  asthma,  or  in  cases  of  exten- 
sive bronchitis,  the  amount  of  carbonic  acid  in  the 
expired  air  is  moro  or  less  increased ; in  others, 
such  as  in  the  collapse-stage  of  cholera,  this 
ingredient  may  be  very  deficient.  Again,  chemi- 
cal examination  of  tho  breath  may  reveal  the 
presence  of  a poison  in  the  system,  introduced 
from  without,  for  example,  hydrocyanic  acid.  It 
has  also  been  employed  to  show  the  existence  of 
deleterious  products  generated  within  the  body, 


especially  in  cases  of  renal  disease.  It  is 
affirmed  that  ammonia  may  he  detected  in  the 
breath  in  some  eases  of  this  kind,  by  holding  a 
glass  rod  dipped  in  hydrochloric  acid  before  the 
mouth,  the  ammonia  being  a product  of  the  de- 
composition of  urea. 

d.  Microscopic  examination  of  the  oxpired  air 
has  been  attempted,  but  at  present  no  results 
of  practical  value  have  been  obtained. 

c.  The  odour  of  the  breath  is  the  most  impor- 
tant character  demanding  attention  in  a prac- 
tical point  of  view.  It  is  easily  recognised,  and 
the  practitioner  should  always  he  on  the  alert 
to  notice  the  smell  of  the  breath  of  a patient,  as 
this  often  affords  material  aid  in  diagnosis,  and 
may  even  reveal  certain  morbid  conditions  which 
otherwise  are  liable  to  be  entirely  overlooked. 
Besides,  patients  not  uncommonly  seek  advice 
on  account  of  ‘ foulness  of  breath,’  as  a symptom 
for  w'hieh  they  require  special  treatment.  The 
following  summary  will  indicate  the  principal 
circumstances  under  which  this  clinical  phenome- 
non may  prove  of  service  in  diagnosis,  and  in 
the  course  of  the  remarks  it  will  be  pointed  out 
in  what  conditions  the  breath  is  particularly 
offensive.  At  the  outset  it  must  be  observed 
that  in  some  individuals  the  breath  seems  to 
have  naturally  a more  or  less  disagreeable  odour, 
which  cannot  be  referred  to  any  particular 
cause,  and  this  amounts  occasionally  to  extreme 
foulness.  In  females  this  may  only  be  noticed 
at  certain,  periods,  and  in  some  instances  it 
seems  to  pass  off  in  course  of  time.  Again,  it 
must  be  borne  in  mind  that  the  breath  is  fre- 
quently unpleasant,  either  temporarily  or  con- 
stantly, from  persons  eating  certain  articles  of 
food,  or  indulging  in  certain  habits,  such  as 
excessive  smoking,  chewing  tobacco,  &c. 

(i.)  The  odour  of  the  expired  air  maj'  aid  in  re- 
cognising poisons  in  the  system.  The  smell  of 
prussic  acid  or  laudanum,  for  instance,  may  he 
revealed  when  either  of  these  is  present  in  the 
stomach.  Alcohol,  however,  chiefiy  demands  at- 
tention in  this  relationship.  In  cases  of  acute  al- 
coholic poisoning,  the  odour  of  the  alcohol  or  of 
its  products  is  at  once  apparent ; and  in  persons 
who  are  found  in  a state  of  unconsciousness,  the 
cause  of  which  is  not  known,  the  smell  of  the 
breath  is  made  use  of  as  one  of  the  diagnostic, 
signs  of  drunkenness,  though  it  must  be  taken 
with  great  caution.  It  is  in  the  chronic  forms 
of  alcoholism  that  the  breath  gives  the  most  valu- 
able information.  In  very  marked  cases  of  chronic 
alcoholism  it  has  an  intensely  foul  odour,  which 
is  quite  characteristic;  but  it  gives  extremely 
important  indications  in  less  confirmed  case«, 
where  the  other  symptoms  of  alcoholism  are  not  so 
apparent;  and  especially  does  it  enable  us  to  de- 
tect dram-drinkers,  and  to  explain  the  symptoms 
of  which  they  so  frequently  complain.  These  per- 
sons, if  their  habits  are  inquired  into,  generally 
give  themselves  an  excellent  character  for  tem- 
perance, and  seem  entirely  to  forget  that  those 
with  whom  they  come  into  contact  are  endowed 
with  organs  of  smell.  Again,  the  breath  may 
reveal  the  presence  of  certain  metallic  poisons  in 
the  system,  of  which  mercury  is  the  most  impor- 
tant example,  hut  lead  may  also  affect  its  odour. 
The  expired  air  is  said  to  present  the  odour  of 
ammouia  in  exceptional  instances  of  uraemia. 


174  BREATH,  THE. 

due  to  the  exhalation  of  carbonate  of  ammonia 
derived  from  the  decomposition  of  urea. 

(ii.)  The  breath  has  a peculiar,  or  more  or  less 
disagreeable  odour,  in  connexion  ■with  several 
diseases.  That  which  is  associated  with  the 
febrile  condition  is  well  known.  In  various  dis- 
orders of  the  digestive  organs  the  breath  is  often 
very  offensive,  but  it  is  not  practicable  to  refer 
any  particular  odour  to  particular  diseases  of 
ei  ther  of  these  organs ; it  may,  how  ever,  be  affirmed 
that  an  unpleasant  smell  is  frequently  associated 
with  habitual  constipation.  In  cases  of  stercora- 
ceous  vomiting  the  breath  mayhavea  faecal  odour. 
In  this  relation  it  may  be  mentioned  that  in 
some  cases  of  phthisis  the  writer  has  noticed  a 
sickly  smell  of  the  breath  which  is  quite  charac- 
teristic, and  which  seems  to  depend  upon  the 
state  of  the  stomach.  In  cases  of  cerebral 
diseases  also,  the  breath  often  becomes  exceed- 
ingly offensive,  on  account  of  the  condition  of 
the  alimentary  canal.  Local  morbid  conditions 
about  the  mouth,  throat,  or  nasal  cavities  con- 
stitute a most  important  class  of  affections  which 
influence  the  odour  of  the  breath  ; in  many  cases 
it  becomes  extremely  foul,  and  may  be  quite 
peculiar  in  its  characters.  Among  these  condi- 
tions should  be  specially  mentioned  want  of  clean- 
liness of  the  mouth  and  teeth ; decayed  teeth  ; dis- 
eased hone  in  the  mouth  or  nose ; ulceration  or 
gangrene  about  the  mouth,  especially  cancrum 
oris,  and  gangrenous  ulceration  along  the  gums  ; 
suppuration,  ulceration,  or  gangrene  in  the 
throat,  either  of  local  origin,  or  associated  with 
syphilis,  scarlatina,  diphtheria,  &c. ; ulceration 
of  the  nasal  mucous  membrane,  and  chronic 
ozcena ; and  malignant  disease.  The  smell  of 
the  breath  is  of  special  value  in  drawing  atten- 
tion to  some  of  these  conditions,  for  they  may 
exist  without  giving  rise  to  any  local  symptoms 
whatever,  and  the  patient  may  be  quite  uncon- 
scious that  there  is  anything  wrong.  Several 
striking  illustrations  of  this  statement  have  come 
under  the  writer’s  observation.  Again,  certain 
conditions  of  the  respiratory  organs  are  liable 
to  affect  the  odour  of  the  expired  air,  and  may 
render  it  unbearably  fetid.  Among  these  may 
be  mentioned  sloughing  ulceration  about  the 
larynx,  pulmonary  gangrene  in  any  form,  and 
the  decomposition  of  retained  morbid  products  in 
dilated  bronchial  tubes  or  in  certain  cavities. 
Here,  again,  the  smell  of  the  expired  air  may 
reveal  what  otherwise  is  liable  to  be  entirely 
overlooked,  and  especially  when  the  patient 
coughs,  so  as  to  expel  some  of  the  retained  air 
out  of  the  lungs.  Lastly,  the  breath  may  have 
a peculiar  odour  in  some  special  diseases,  such 
as  pyaemia  and  diabetes. 

Treatment. — It  is  only  intended  here  to  offer 
a few  remarks  as  to  the  treatment  of  foulness  of 
breath.  The  first  great  indication  is,  of  course, 
to  seek  out  the  cause  of  this  symptom,  and 
endeavour  to  remove  or  remedy  this,  by  which  in 
a large  proportion  of  cases  a cure  may  be  readily 
effected.  The  habits  should  be  duly  regulated ; 
the  mouth  and  teeth  properly  cleansed  ; the  ali- 
mentary canal  maintained  in  good  order ; and 
any  special  affection  requiring  treatment  attended 
to.  When  unpleasant  breath  depends  on  the 
stomach,  it  may  often  be  improved  by  taking 
charcoal  powder  or  biscuits,  at  the  same  time  I 


BRIGHT’S  DISEASE. 

remedies  being  employed  suitable  for  the  parti- 
cular affection  present,  and  calculated  to  promote 
the  functions  of  the  alimentary  canal,  the  bowels 
being  also  kept  freely  open.  AVhen  the  bad 
smell  depends  on  local  causes,  it  may  be  dimi- 
nished by  the  use  of  antiseptic  mouth-washes 
and  gargles,  such  as  solution  of  Cond/s  fluid, 
carbolic  acid  or  creasote.  Antiseptic  inhalations 
are  indicated  when  the  respiratory  organs  are 
accountable  for  fetor  of  breath. 

Frederick  T.  Roberts. 

BREATHING,  Disorders  of.  See  Respira- 
tion, Disorders  of. 

BRIGHT’S  DISEASE. — The  term  Bright s 
Disease  is  now  universally  recognised  as  generic, 
and  as  including  at  least  three  different  dis- 
eases of  the  kidney.  Each  of  these  maladies  in- 
volves chiefly  one  of  the  individual  structural  ele- 
ments of  the  organ,  and  only  secondarily  affects 
the  others.  There  is  thus  a disease  originating  re- 
spectively in  the  uriniferous  tubules,  in  the  blood- 
vessels and  particularly  in  the  Malpighian  tufts, 
and  in  the  fibrous  stroma.  That  which  originates 
in  the  tubules  is  always  inflammatory  iii  its  cha- 
racter, although  the  inflammation  may  be  acute 
or  chronic  ; that  which  commences  in  the  vessels 
consists  in  a peculiar  degenerative  change,  the 
so-called  waxy,  lardaceous,  albuminoid,  or  amy- 
loid degeneration  ; that  which  is  proper  to  the 
stroma  is  an  extremely  chronic  process,  supposed 
by  many  to  he  inflammatory,  hut  as  it  appears 
to  others,  rather  of  an  hypertrophic  character. 
In  the  following  article  are  described : 

I.  The  inflammatory  affection,  affecting  the 
tubules,  or  the  stroma,  or  both. 

II.  The  waxy  or  amyloid  affection,  originating 
in  the  vessels. 

III.  The  cirrhotic  or  gouty  affection,  originat- 
ing in  the  fibrous  stroma. 

Definitions. — I.  Inflammatory  Bright's  dis- 
ease is  an  acute  or  chronic  affection  of  the 
kidneys ; caused  by  exposure  to  cold,  and  by 
scarlatinal  and  other  blood-poisons  ; consisting 
in  inflammation  of  the  elements,  passing  through 
various  stages  of  transformation,  viz.  inflam- 
matory enlargement,  fatty  degeneration,  and 
atrophy;  characterised  in  the  earlier  stages  by  di- 
minution of  urine,  albuminuria,  frequently  haema- 
turia,  tube-casts,  and  dropsy ; in  the  later  stages 
by  the  same  symptoms,  in  a more  or  less  marked 
degree,  with  secondary  changes  in  the  heart, 
blood-vessels,  and  other  organs  ; terminating  fre- 
quently in  recovery  in  the  early  stage,  rarely  in 
the  later,  often  in  death  by  dropsy,  uraemia,  or 
intercurrent  affections. 

II.  Waxy  Brights  disease  is  a chronic  affec- 
tion of  the  kidney,  caused  by  phthisis,  syphilis, 
caries,  suppuration,  and  other  exhausting  condi- 
tions ; consisting  in  waxy  or  amyloid  degenera- 
tion of  the  Malpighian  bodies,  small  arteries, 
and  sometimes  the  basement  membrane,  with,  in 
many  cases,  transudation  into  the  tubules ; pass- 
ing through  various  stages  of  transformation, 
viz.  simple  degeneration,  enlargement  from  trans- 
udation, and  atrophy;  characterised  by  a large 
flow  of  albuminous  urine  of  low  specific  gravity, 
andabsenceof  dropsy;  often  attended  by  evidences 
of  waxy  disease  of  other  organs,  particularly  the 
liver,  spleen,  and  intestinal  canal ; resulting  pro 


BRIGHT’S  DISEASE. 


bablyin  some  cases  in  recovery,  -usually  in  death, 
by  exhaustion,  uraemia,  or  coexisting  affections 
of  the  kidneys  and  other  organs. 

III.  Cirrhotic  Brights  disease  is  a chronic 
affection  of  the  kidney,  caused  generally  by  the 
abuse  of  alcohol,  sometimes  by  the  poison  of 
gout,  occasionally  by  plumbism,  and  by  unknown 
conditions;  consisting  in  increase  of  the  fibrous 
stroma,  with  thickening  of  the  capsule,  and  ulti- 
mate atrophy  of  the  organ  ; characterised  by  a 
very  insidious  commencement,  by  the  absence  of 
the  early  symptoms  of  either  of  the  other  forms, 
by  albuminuria,  at  first  slight,  but  possibly 
absent,  and  by  the  ultimate  appearance  of  en- 
largement of  the  heart,  polyuria,  albuminuric 
retinitis,  oedema  of  the  lungs,  andurmmia;  re- 
sulting ultimately  in  death  from  uraemia,  oedema 
of  the  lungs,  or  other  intercurrent  affections. 

IEtiology. — I.  Of  the  inflammatory  form. 
Cold  is  the  commonest  cause  in  the  adult.  It 
acts  especially  on  those  who  have  been  exposed 
to  its  influence  whilst  perspiring.  It  frequently 
contributes  towards  the  production  of  the  disease 
in  persons  otherwise  predisposed.  Various 
blood-diseases,  while  they  induce  temporary 
albuminuria  along  with  their  more  ordinary 
symptoms,  have  renal  inflammation  as  a common 
sequela.  Among  these  scarlatina  occupies  the 
first  place,  diphtheria  stands  next  in  order,  fol- 
lowed by  erysipelas,  measles,  pyaemia,  typhus, 
ague,  acute  rheumatism,  and  pneumonia.  Many 
of  these  maladies  being  most  common  in  child- 
hood, it  follows  that  in  the  earlier  years  of  life 
they  are  the  chief  causes  of  inflammatory 
Bright's  disease.  Pregnancy,  heart-disease,  gout, 
and  malaria  contribute  towards  its  production  in 
some  cases  ; and  the  undue  use  of  cantharides, 
turpentine,  or  alcohol  may  also  be  reckoned  as 
causes. 

II.  Of  the  waxy  form.  Constitutional  syphi- 
lis, phthisis,  prolonged  suppuration,  caries  or 
necrosis  of  bone,  and  other  exhausting  diseases, 
such  as  cancer  and  chronic  rheumatism,  induce 
this  degeneration.  There  is  at  present  no  satis- 
factory evidence  as  to  the  precise  connexion 
between  these  influences  and  the  morbid  pro- 
cess. 

III.  Of  the  cirrhotic  form.  The  commonest 
cause  is  the  abuse  of  alcohol,  particularly  in  the 
form  of  ardent  spirits.  After  this,  though  at  a 
long  interval,  rank  gout  and  lead-poisoning. 
Congestion  from  cardiac  disease  is  also  by  many 
authorities,  but  erroneously,  held  to  be  a cause. 
(See  Kidneys,  Congestion  of.)  As  experience 
shows  that  the  disease  is  often  met  with  in 
people  who  have  neither  indulged  in  alcohol, 
been  exposed  to  lead,  nor  suffered  from  gout, 
it  is  obvious  that  other  efficient  though  yet  un- 
discovered causes  must  exist. 

Anatomical  Chakactebs.  — I.  Of  the  inflam- 
matory form.  When  a case  of  this  kind  is  pro- 
longed, the  renal  disease  passes  through  several 
conditions,  which,  for  convenience  of  description, 
may  be  divided  into  three  stages,  (a)  Stage  of 
active  inflammation.  In  this  stage  the  kidney  is 
enlarged;  its  capsule  strips  off  readily ; its  sur- 
face appears  more  or  less  red,  sometimes  of  a 
deep  purple  colour  ; and  occasionally  extrava- 
sations of  blood  are  present  in  its  substance. 
Ox;  section  the  cortical  substance  is  found  to  be 


175 

relatively  increased  in  mlk.  Its  vessels,  as  well 
as  those  of  the  cones,  are  congested.  The  struc- 
ture appears  somewhat  coarser  than  natural, 
while  the  convoluted  tubules  often  present  a 
swollen  opaque  appearance,  and  occasionally 
contain  blood.  On  microscopic  examination  the 
congestion  of  the  vessels  becomes  very  apparent, 
and  the  tubules  are  found  to  be  dark  and 
opaque,  their  lumen  being  frequently  occluded. 
The  individual  epithelial  cells  are  granular,  and  in 
a state  of  cloudy  swelling.  In  some  cases  almost 
all  the  tubules  appear  affected,  in  others  com- 
paratively few.  The  enlargement  of  the  organ 
is  in  part  due  to  congestion,  in  part  to  exudation 
into  the  tubules.  As  the  exudation  increases 
the  congestion  becomes  less  marked,  so  that  in 
the  later  period  of  this  stage  the  kidney  appears 
paler  and  more  opaque.  Unless  recovery  or 
death  takes  place,  this  condition  passes  into  (h) 
The  second  stage , that  of  fatty  transformation. 
In  this  stage  the  organ  is  still  enlarged.  Its 
capsule  strips  off  readily ; the  surface  often 
presents  stellate  veins,  and  its  colour  is  mottled. 
At  this  time  extravasations  are  very  rarely 
observed,  but  there  are  alternating  patches 
of  yellowish  opaque  sebaceous-looking  material, 
mingled  with  more  natural  structure.  On 
section  the  cortical  substance  is  seen  to  be 
relatively  increased.  There  is  no  congestion 
of  the  vessels,  and  the  Malpighian  bodies 
are  not  prominent.  The  convoluted  tubules 
are  in  many  parts  occupied  by  the  sebum-like 
material,  and  sometimes  the  straight  tubules 
present  the  same  appearance.  On  microscopic 
examination  the  tubules  alone  are  found  affected. 
Many  of  them  present  under  low  powers  a black 
appearance,  due  to  fatty  degeneration  of  the  con- 
tents of  the  tubules.  It  is  in  the  cells  alone  that 
this  change  occurs,  and  not,  so  far  as  the  writer 
has  seen,  in  the  free  exudation  which  binds  the 
cells  together.  Many  of  the  tubules  are  completely 
blocked  up  by  this  material ; and  sometimes  in 
making  the  section  there  is  such  an  amount  of 
oil  set  free,  that  it  permeates  the  whole  struc- 
ture of  the  organ,  and  is  liable  to  produce  the 
impression  that  the  fatty  degeneration  is  uni- 
versal. This  condition  may  be  developed  within 
a week  or  two  of  the  commencement  of  the 
inflammation,  and  it  may  continue  for  years. 
During  the  whole  course  of  the  second  stage 
it  must  be  understood  that  inflammatory  action 
is  going  on,  although  much  less  acutely  than 
at  first,  and  less  widely  diffused.  The  disease 
is  sometimes  recovered  from,  and  if  the  patient 
survive  long  enough  it  passes  into  ( c ) The  third 
stage,  that  of  atrophy.  The  organ  is  then  reduced 
to  or  even  below  the  natural  size.  Its  capsule 
strips  off  with  little  difficulty,  and  without  tear- 
ing the  surface.  The  surface  is  uneven ; it 
rarely  appears  coarsely  granular,  as  in  the  cir- 
rhotic form,  but  rather  presents  a series  of  de- 
pressions, which  give  it  an  uneven  or  finely 
granular  character.  Its  colour  is  very  similar 
to  that  described  as  occurring  in  the  second 
stage,  but  there  is  less  of  the  sebaceous-looking 
material.  On  section  the  cortical  substance  is 
found  relatively  diminished.  The  Malpighian 
bodies  are  not  prominent.  The  tissue  feels  more 
dense;  and  many  of  the  tubules  are  occupied  by 
sebaceous-looking  material.  The  blood-vessels. 


BRIGHT’S  DISEASE. 


176 

and  particularly  tho  small  arteries,  are  sclerosed ; 
the  intima  and  the  adventitia  aro  frequently, 
the  middle  coat  almost  invariably,  thickened. 
The  fibrous  stroma  is  relatively  increased,  espe- 
cially towards  the  surface  of  the  organ,  and  the 
tubules  may  be  traced  in  different  stages  of 
atrophy.  On  close  inspection  that  atrophy  is 
found  to  result  not  from  pressure  of  the  fibrous 
stroma,  but  from  molecular  absorption  of  the 
contents  of  the  tubules.  Besides  the  typical  form 
of  the  inflammatory  affection  just  described, 
notice  should  be  taken  of  other  varieties,  such  as 
the  glomerulo-nephritis  of  Klebs,  in  which  the 
glomeruli  are  especially  affected.  The  ana- 
tomical changes  met  with  in  other  organs  are 
described  along  with  the  complications. 

II.  Of  the  waxy  or  amyloid  form.  This  chronic 
morbid  process  may  also,  for  convenience  of 
description,  be  dividedinto  three  stages.  Of  these 
the  first  is,  (a)  The  stage  of  degeneration  proper , 
in  which  the  organ  presents  an  almost  normal 
appearance.  The  size  is  natural ; the  capsule 
strips  off  readily ; and  the  colour  is  not  altered. 
On  section  all  appears  normal,  excepting  that  the 
Malpighian  tufts,  without  being  congested,  are 
prominent,  and  in  certain  lights  may  be  seen 
even  by  the  naked  eye  to  present  dim  translu- 
cency  characteristic  of  waxy  degeneration.  On 
applying  a little  aqueous  solution  of  iodine,  the 
Malpighian  tufts  and  the  small  arteries  assume 
a peculiar  mahogany  hue.  On  examination  with 
the  microscope,  the  stroma  and  tubules  are  found 
to  be  healthy,  the  vascular  structures  being 
alone  affected.  The  affection  is  often  first  seen 
and  is  most  distinct  in  the  middle  coat  of  the 
arteries,  the  swollen  transverse  fibres  taking 
on  the  colour,  and  producing  what  has  been 
described  as  the  ipecacuanha-root  appear- 
ance. How  long  this  condition  may  last  without 
the  tubules  becoming  affected  it  is  impossible 
at  present  to  say,  for  it  has  only  been  met  with 
in  patients  who  had  died  of  one  or  other  of  the 
causal  complications  while  the  renal  malady  was 
still  in  an  early  stage.  Sooner  or  later  it  passes, 
however  into  the  condition  most  commonly  met 
with,  (5)  the  second  stage,  that  of  degeneration 
with  secondary  changes  in  the  tubules.  In  this 
condition  the  organ  is  enlarged.  Its  capsule 
strips  off  readily,  the  surface  is  smooth  and  pale, 
presenting,  in  pure  examples,  little  or  no  mot- 
tling. On  section  the  cortical  substance  appears 
relatively  increased,  and  looks  much  paler  than 
the  cones.  The  structure  usually  is  denser  than 
natural.  The  vessels  appear  prominent,  and 
tho  Malpighian  tufts  resemble  minute  grains 
of  boiled  sago.  On  the  addition  of  iodine  the 
degenerated  parts  become  characteristically 
coloured,  and  stand  out  prominently  from  the 
tubular  tissue,  which  does  not  exhibit  the  charac- 
teristic reaction.  On  microscopic  examination 
the  vessels  are  found  altered  as  in  the  earlier 
stage,  but  the  change  is  more  advanced.  The 
stroma  is  normal,  but  many  of  the  tubules  are 
altered.  Some  are  blocked  up  by  a dimly  translu- 
cent, wax-like  material,  which  however  does  not 
assume  the  mahogany  colour  on  the  addition  of 
iodine.  The  epithelium  in  many  of  the  tubules 
presents  a finely  granular  appearance,  and  occa- 
sionally is  somewhat  fatty,  but  the  epithelium  I 
and  the  basement  membrane  very  rarely  present  1 


the  characteristic  reaction.  This  change  in  the 
tubules  is  thus  secondary  to  the  degenera- 
tion proper,  which  is  confined  to  the  vessels, 
and  these  secondary  changes  consist  in  some 
alteration  of  the  nutrition  of  the  epithelium,  with 
exudation  or  transudation  of  coagulable  material 
into  the  lumen  of  the  tubes.  This  condition  may 
last  for  years,  but  should  the  patient  live  long 
enough  it  passes  into  (c)  the  third  stage,  that  of 
atrophy.  The  organ  is  then  below  the  normal 
size ; the  capsule  strips  off  readily ; the  surface 
presents  an  uneven  granular  appearance,  and  is 
pale.  On  section  the  cortical  substance  is  found 
relatively  diminished.  Its  small  arteries  are 
prominent  and  thickened;  its  Malpighian  bodies 
are  very  conspicuous,  and  are  grouped  together 
in  consequence  of  the  atrophy  of  the  intervening 
structure.  The  stroma  is  relatively  increased, 
and  many  of  the  tubules  are  destroyed,  while  of 
those  which  remain  not  a few  present  the  cha- 
racters above  described  as  being  met  with  in  the 
second  stage.  The  organ  may,  in  extreme  cases, 
be  diminished  to  less  than  half  its  natural  size. 

III.  Of  the  cirrhotic  form.  The  course  of 
this  affection  is  even  more  chronic  than  that  of 
the  waxy  form.  It  consists  essentially  in  an 
increased  growth  of  the  fibrous  stroma,  with 
secondary  changes  in  the  tubules  and  vessels. 
In  an  early  stage  the  organ  may  be  found  of 
fully  the  natural  size.  The  capsule  strips  off 
less  readily  than  in  health.  The  surface  is 
somewhat  uneven,  and  may  present  cysts.  On 
section  the  cortical  substance  is  relatively  en- 
larged, and  this  is  due  merely  to  an  increase  of 
the  stroma,  not  to  any  chango  in  the  vessels  or 
in  the  tubules.  But  it  is  in  the  more  advanced 
stages  that  the  disease  is  commonly  seen.  Then 
the  organ  is  reduced  in  bulk,  it  may  be  slightly, 
it  may  be  to  one-fourth  of  its  normal  size.  Its 
capsule  cannot  be  peeled  off  without  tearing  the 
gland.  The  surface  is  uneven  and  granular, 
and  often  of  a reddish  colour.  On  section  the 
cortical  substance  is  found  relatively  diminished, 
its  structure  being  dense  and  fibrous.  The  small 
arteries  are  thickened  and  very  prominent,  all 
their  coats,  but  especially  the  middle,  being 
increased  in  volume.  Many  of  the  tubules  are 
atrophied,  but  the  epithelium  of  such  as  are  not 
involved  is  for  the  most  part  natural.  Cysts 
are  numerous,  and  are  found  in  connexion  with 
the  tubules,  the  Malpighian  bodies,  and  the 
cells. 

There  are  two  points  worthy  of  being  specially 
kept  in'  view  by  those  who  desire  to  attai  n to  clear 
conceptions  of  Bright’s  disease — viz.  (1)  That 
its  different  forms  are  very  frequently  combined — 
in  particular  that  the  inflammatory  affection  is 
found  associated  sometimes  with  the  waxy  dis- 
ease, sometimes  with  the  cirrhotic ; but  that  the 
descriptions  here  given  are  derived  from  pure 
examples  of  each  process ; and  (2)  that  atrophy 
results  in  all  the  forms  if  the  disease  lasts  long 
enough;  that  is,  that  a small,  uneven-surfaced 
kidney  may  result  from  either  the  inflammatory 
disease  of  the  tubules,  or  the  waxy  disease  of 
the  vessels,  as  well  as  from  the  increased  growth 
and  subsequent  contraction  of  the  fibrous  stroma 
in  the  cirrhotic  form. 

Symptoms. — 1.  Of  the  inflammatory  form. 
The  leading  clinical  features  of  this  variety,  in 


BRIGHT'S 

addition  to  the  albuminuria  -which  exists  in  all 
the  forms  of  Bright's  disease,  are  diminution 
in  the  quantity  of  urine,  and  the  presence  of 
dropsy. 

The  onset  of  the  disease  may  be  sudden  or 
gradual.  Sometimes  it  is  the  diminution  and 
alteration  of  the  urine  that  attracts  attention, 
sometimes  the  dropsy,  sometimes  the  gastric 
derangement  and  general  uneasiness  ; but  "which- 
ever symptommay  appear  first,  the  others  usually 
speedily  follo-w.  The  urine  is  generally  dimi- 
nished in  quantity,  often  somewhat  opaque,  and 
smoky  or  even  bloody.  It  contains  much  albu- 
men and  numerous  tube-casts.  The  casts  are 
granular,  being  composed  mostly  of  epithelium 
in  a state  of  cloudy  swelling ; sometimes  bloody ; 
frequently  hyaline  or  fibrinous.  The  urea  is 
diminished,  it  may  be,  to  one-half,  one-fourth,  or 
even  a less  proportion  of  the  natural  amount.  This 
leads  to  a corresponding  reduction  of  the  specific 
gravity,  unless  there  be  a compensatory  diminu- 
tionofwater,  or  increase  of  albumen.  Thedropsyis 
generally  distinct  in  the  face,  and  swelling  of  the 
eyelids  is  well  marked  in  the  morning.  Towards 
evening,  if  the  patient  be  out  of  bed,  the  legs  are 
chiefly  affect  ed.  The  scrotum  and  penis  are  often 
swollen,  and  sometimes  the  abdomen  is  also 
dropsical.  There  is  little  quickening  of  pulse  or 
elevation  of  temperature,  but  a good  deal  of  gene- 
ral uneasiness  is  experienced,  with  debility  and 
pain  in  the  loins  ; and  dyspeptic  symptoms  are 
often  present,  due  to  gastric  catarrh.  Such  is 
.the  usual  condition  at  the  commencement  of  the 
disease,  and  during  the  period  which  has  been 
already  described  as  the  first  stage.  But  some- 
times at  this  stage  a much  more  serious  condition 
is  developed — namely,  suppression  of  urine,  fol- 
lowed by  coma  or  convulsions  leading  to  a fatal 
result ; or  dropsy  may  increase  to  such  an  extent 
as  of  itself  to  cause  death.  Or,  again,  without  or 
even  with  the  mostunfavourable  symptoms,  under 
appropriate  treatment  the  kidneys  may  begin  to 
act  more  freely,  the  urine  increasing  in  amount 
and  improving  in  characters,  with  consequent 
gradual  disappearance  of  the  dropsy,  and  restora- 
tion of  health.  Or,  as  often  happens,  the  general 
condition  improves,  but  a chronic  albuminuria 
remains,  and  the  disease  passes  into  the  second 
stage.  The  urine  is  then  no  longer  bloody ; the 
quantity  is  greater,  though  still  below  the  normal ; 
the  specific  gravity  is  low ; there  is  albumen, 
along  with  tube-casts,  fatty,  hyaline,  or  mixed, 
partly  fatty  and  partly  hyaline.  The  urea  is 
below  the  normal  standard.  The  dropsy  may 
continue,  and  may  even  gradually  increase,  or  it 
may  pass  off  and  only  appear  when  the  patient 
is  fatigued,  or  when  he  has  caught  cold.  The 
general  symptoms  remain  unchanged,  except  that 
anaemia  comes  on,  and  the  patient’s  debility 
steadily  increases.  This  course  of  events  may 
pass  on  to  a fatal  result;  or  there  maybe  complete, 
or,  as  is  more  common,  merely  partial  recovery. 
In  this  condition  the  patient  may  linger  for  many 
months,  occasionally  suffering  exacerbations,  and 
he  may  succumb  to  one  of  them,  or  to  one  of  the 
numerous  complications  to  be  presently  described. 
If  the  patient  passes  into  the  third  stage,  he 
appears  prematurely  old.  His  urineisof  natural 
amount  or  even  somewhat  increased  in  quantity, 
hut  of  low  specific  gravity.  It  contains  albumen 

12 


DISEASE.  177 

and  a few  easts,  mostly  hyaline,  with  scattered 
fatty  cells  imbedded  in  them.  The  urea  is  stiii 
diminished.  There  is  dropsy  of  the  feet  and 
ankles  in  the  evenings,  and  slight  exposure 
brings  on  more  general  attacks.  The  face  is 
pale  and  pasty,  and  the  eyelids  are  often  cedema 
tous.  The  pulse  becomes  hard  and  tense  ; the 
arteries  gradually  become  thi  ckened  from  sclero 
sis  and  atheroma ; while  the  apex-beat  of  tin 
heart  passes  downwards  to  the  left  side,  cwinj 
to  hypertrophy,  particularly  of  the  left  ventricle 
In  this  condition  a fatal  result  may  be  induced 
by  an  acute  exacerbation  with  general  dropsy  ; by 
chronic,  or,  more  rarely,  acute  uraemia ; or  bv 
intercurrent  attacks  of  inflammatory  or  other 
affections  of  various  organs. 

2.  Of  the  wary  disease . The  onset  of  this 
affection  is  gradual  and  insidious.  A patient 
who  has  suffered  from  phthisis,  syphilis,  or 
other  wasting  malady  passes  an  excessive  quan- 
tity of  urine,  and  finds  himself  obliged  to  rise 
several  times  during  the  night  for  micturition. 
The  urine  is  pale,  of  low  specific  gravity, 
containing  at  first  no  albumen,  subsequently 
only  a trace,  ultimately  a considerable  amount. 
The  urea  is  little,  if  at  all,  diminished ; the  tube- 
casts  are  extremely  few,  and  mostly  hyaline. 
There  is  no  dropsy,  but  evidence  of  concomitant 
waxy  affections  of  other  organs  is  frequently 
afforded.  The  liver  is  enlarged,  its  margin  being 
easily  felt  and  sharply-defined.  The  spleen  is 
also  increased  in  size.  The  blood  is  slightly 
altered,  the  white  corpuscles  being  somewhat 
increased,  and  the  red  being  rather  flabby 
and  ill-defined.  These  conditions  gradually 
become  more  distinct,  and  the  strength  of  the 
patient  diminishes,  partly  from  the  disease  of 
the  kidneys  and  other  organs,  partly  from  th( 
wasting  diseases  which  have  induced  the  degene- 
rative changes.  A case  of  the  kind  has  been 
known  to  go  on  for  nearly  ten  years,  during 
which  time  the  urine  continued  of  the  characters 
just  described,  and  dropsy  never  appeared.  At 
length  the  vital  powers  of  the  patient  became  de- 
pressed,head  symptoms  gradually  supervened,  and 
death  ensued.  It  is  not  often  that  such  an  uncom- 
plicated case  is  met  with.  More  commonly  the 
exhausting  disease  which  led  to  the  degeneration 
causes  death  before  the  waxy  change  has  gone 
so  far.  Sometimes  also  intercurrent  complications 
induce  the  fatal  result.  Clinical,  observation 
renders  it  probable  that  the  kidneys,  as  well  as 
the  liver  and  spleen,  may  recover  from  then- 
degeneration,  in  cases  in  which  the  causal  malady 
has  been  got  rid  of. 

3.  Of  the  cirrhotic  disease.  The  onset  of  this 
affection  is  extremely  insidious,  and  it  may  exist 
for  a long  time  without  distinctly  manifesting 
itself  by  symptoms.  Its  existence  is  often  dis- 
covered only  when  dyspepsia,  uraemic  convulsions, 
or  blindness  from  retinitis  leads  the  patient  to 
consult  a medical  man.  The  earliest  symptoms 
are  occasional  slight  albuminuria,  and  frequent 
calls  to  micturition  during  the  night,  the  urine 
however  not  being  excessive,  its  specific  gravity 
being  low,  and  the  urea  somewhat  diminished. 
But  when  the  disease  has  existed  for  some 
time  the  complexion  becomes  altered ; the  eye 
assumes  a peculiar  appearance  from  cedema  of  tht 
conjunctiva  ; the  patient  is  subject  to  dyTspept.ie 


BRIGHT’S  DISEASE. 


i 78 

attacks;  the  heart  becomes  hypertrophied,  and 
the  vessels  sclerosed  and  degenerated ; while 
there  is  little  or  no  dropsy.  When  the  disease 
is  advanced,  these  changes  in  the  circulatory 
organs  are  well-marked,  and  the  cachectic  con- 
dition becomes  distinct.  The  occurrence  of 
various  complications,  such  as  severe  gastric 
catarrh,  diarrhoea,  anaemia,  dyspnoea,  bronchitis, 
oedema  of  the  lungs,  headache,  uraemia,  and  the 
characteristic  retinal  affection,  render  the  diag- 
nosis easy.  Frequently  towards  the  end  there  is 
an  increased  flowof  urine,  of  low  specific  gravity. 
This  is  in  some  cases  a very  prominent  symptom. 
The  disease  is  never  recovered  from,  and  the 
fatal  result  occurs  from  uraemia ; from  some 
inflammatory  complication,  such  as  pleurisy,  peri- 
carditis, bronchitis,  or  pneumonia ; or  from  some 
result  of  degenerative  change,  as  haemorrhage 
from  a mucous  surface  or  into  the  brain. 

Complications — (a)  Connected  with,  the 
Abdomen  and  Alimentary  System. 

Gastric  affections  are  met  with  in  all  the  forms 
of  Bright’s  disease.  Catarrh  of  the  stomach — - 
acute,  sub-acute,  and  chronic — is  common  to  them 
all,  and  is  characterised  by  an  unusual  tendency 
to  nausea  and  vomiting.  It  is  especially  frequent 
during  the  first  stage  and  in  acute  exacerbations  of 
the  inflammatory  form,  and  is  often  a chief  source 
of  suffering  during  the  most  advanced  stages.  It 
is  not  uncommon  during  the  whole  course  of  the 
waxy  form,  but  is  most  usually  met  with  in  the 
cirrhotic  variety.  So  close  indeed  is  the  relation- 
ship between  them,  that  in  the  management  of 
cases  of  cirrhosis  regard  should  constantly  be 
had  to  the  state  of  the  stomach,  and  in  no  case 
of  chronic  gastric  catarrh  should  the  physician 
neglect  .to  enquire  into  the  state  of  the  urine. 
This  affection,  when  complicating  the  early  stage 
of  the  inflammatory  form,  often  owes  its  origin 
to  the  same  cause  as  the  kidney-affection  is  due 
to.  When  complicating  the  later  stages  of  the 
inflammatory,  and  any  of  the  stages  of  the  cir- 
rhotic disease,  the  catarrh  is  probably  a result 
of  efforts  at  elimination  of  materials  retained 
in  the  blood  by  the  failure  of  the  action  of  the 
kidneys.  When  occurring  in  the  waxy  form,  it 
is  frequently  due  in  part  to  the  existence  of  waxy 
degeneration  of  the  vessels  of  the  gastric  mucous 
membrane.  In  the  waxy  disease  we  sometimes 
find  blood  mingled  with  the  vomited  matters,  just 
as  we  find  haemorrhage  occurring  in  other  organs 
when  this  degeneration  exists. 

Catarrh  of  the  intestine  also  occasionally 
occurs,  sometimes  producing  an  exhausting 
diarrhoea,  especially  in  advanced  inflammatory 
and  cirrhotic  cases ; but  it  is  along  with  the 
waxy  disease  that  intestinal  symptoms  are  most 
common.  These  are  due  to  waxy  degeneration, 
and  consequent  ulceration;  or  to  ordinary  tu- 
bercular disease  of  the  intestine.  Both  of  these 
affections  induce  diarrhoea,  but  there  is  evidence 
that  not  only  may  it  thus  occur,  hut  that  blood 
may  also  he  discharged,  although  there  be  no 
ulceration  recognisable  by  the  naked  eye. 

Hepatic  affections. — Functional  derangements 
of  the  liver  occur  in  the  course  of  all  the  forms 
of  Bright’s  disease.  The  chief  organic  changes 
are  fatty  degeneration,  waxy  degeneration,  cir- 
rhosis, and  syphilitic  affections.  The  first-named 
is  not  specially  related  to  any  of  the  forms. 


The  waxy  degeneration  and  the  syphilitic  affec- 
tions are  of  course  commonly  met  with  as 
accompaniments  of  tbe  waxy  disease ; whilst 
cirrhosis  attends  upon  the  cirrhotic  kidney. 

Ascites  is  often  seen  as  a manifestation  of 
general  dropsy  in  the  inflammatory  form  of 
Bright’s  disease ; and  sometimes  this  is  a pro- 
minent symptom  in  mixed  forms,  when  waxy 
liver  is  associated  with  a waxy  and  slightly  in- 
flammatory condition  of  the  kidneys. 

Peritonitis  is  occasionally  the  cause  of  death  in 
all  the  forms  of  Bright’s  disease.  It  may  result  from 
local  affections,  or  from  the  state  of  the  blood ; 
and  may  be  acute,  severe,  and  therefore  obvious, 
or  so  insidious  as  scarcely  to  attract  attention. 

(j3)  Complications  connected  with  the 
Blood,  or  with  the  Lymphatic-  and  Blood- 
glands. 

The  spleen  is  usually  unaffected  in  eases  of  in- 
flammatory Bright’s  disease,  except  such  as  prove 
fatal  in  the  earliest  stage,  and  in  which  the  spleen 
is  affected  in  common  with  the  kidney  In  the 
waxy  and  cirrhotic  forms  corresponding  lesion-' 
are  frequent  in  this  organ. 

The  lymphatic  glands  are  rarely  altered  ex- 
cepting in  the  waxy  form,  in  which  they  are 
sometimes  the  subject  of  the  waxy  degeneration, 
sometimes  of  tubercular  disease,  or  of  stramors 
inflammation. 

The  blood  itself  is  altered  in  its  chemical  com- 
position. In  the  inflammatory  form  its  density 
is  diminished,  the  corpuscles  and  albumen  being 
deficient,  while  the  water  is  correspondingly  in- 
creased. The  quantity  of  urea  is  above  the 
normal.  In  long-standing  cases  of  waxy  disease 
similar  changes  are  found ; and  not  unfrcquently 
there  is  a slight  numerical  increase  of  the  white 
corpuscles,  and  flabbiness  of  the  red  blood- discs 
when  the  spleen  is  affected.  In  the  cirrhotic 
form  like  alterations  also  occur. 

Hemorrhage  is  apt  to  occur  in  advanced  stages, 
especially  of  the  cirrhotic  form.  It  may  take 
place  from  the  kidneys,  or  from  the  mucous  mem- 
branes, particularly  that  of  the  nostrils.  In  the 
inflammatory  affection  hasmaturia  is  common  in 
the  early  stage ; in  the  waxy  variety  this  symp- 
tom occasionally  occurs,  but  rarely  to  a serious 
extent. 

( y ) Complications  affecting  the  Circula- 
tory system. 

Hypertrophy  of  the  heart  is  almost  always  pre- 
sent in  cases  of  advanced  cirrhotic  disease,  and 
also  in  the  advanced  stages  of  the  inflammatory 
affection.  One  may  trace  in  patients  the  gradual 
development  of  this  hypertrophy,  advancing  pari 
passu  with  the  progress  of  the  renal  affection. 
It  is  comparatively  rare  in  the  waxy  form.  Hy- 
dropcricardium  is  met  with  in  some  cases,  as  a 
manifestation  of  general  dropsy.  Pericarditis 
occurs  as  an  intercurrent  affection  in  all  the 
forms,  but  especially  the  inflammatory  and  the 
cirrhotic.  It  is  apt  to  be  overlooked,  owing  to 
the  absence  of  local  pain,  or  from  the  pain  being 
referred  to  the  abdomen.  Endocarditis  is  also 
frequently  associated  with  the  various  forms  of 
Bright’s  disease 

The  arteries  are  sclerosed  and  atheromatous 
in  the  advanced  stages  of  the  inflammatorv  and 
in  the  cirrhotic,  but  not  so  much  in  the  waxy 
disease.  In  that  affection  the  small  vessels  in 


BRIGHTS 

jther  paits  are  frequently  the  seat  of  waxy  de- 
generation. Thickening  of  the  arteries  occurs 
constantly  in  the  more  advanced  stages  of  the 
inflammatory  and  cirrhotic  diseases,  and  is  due 
in  great  part  to  hypertrophy  of  their  middle 
coat,  in  lesser  degree  to  sclerosis  of  the  tunica 
intima,  the  tunica  adventitia,  and  perhaps  the 
perivascular  lymphatic  sheath.  The  'pulse  be- 
comes tense  and  sustained  in  chronic  cases,  partly 
from  the  hypertrophy  of  the  heart,  partly  from 
ihe  cliauges'  in  the  capillaries  and  smaller  arteries. 

(S)  Complications  connected  with.  the 
Respiratory  system. 

Acute  bronchitis  is  common,  especially  in  the 
advanced  stages  of  Bright's  disease,  and  tends 
to  pass  into  the  chronic  state.  Bronchitis  may 
originate  also  as  a sub-acute  or  chronic  affection. 
(Edema  of  the  lungs  is  very  common  in  ad- 
vancol  stages,  and  frequently  occurs  as  a mani- 
festation of  general  dropsy  in  the  early,  as  well  as 
'n  the  later  stages  of  Bright's  disease.  It  may 
_-e  very  suddenly  developed  in  cirrhotic  eases, 
and  may  rapidly  prove  fatal.  Pneumonia  occurs 
sometimes  as  a cause  of  inflammatory  Bright’s 
disease,  sometimes  as  a consequence  of  exposure 
to  cold  during  the  course  of  chronic  cases. 
Phthisis  in  its  various  forms  is  found  causally 
associated  with  these  renal  affections,  frequently 
with  the  waxy,  and  more  rarely  with  the  inflam- 
matory form.  It  usually  proves  fatal  while  the 
renal  malady  is  yet  in  its  early  stage.  Hyclro- 
tkorax,  acute  or  chronic,  is  often  seen  in  dropsical 
cases.  Pleurisy  occasionally  occurs  with  all  the 
forms  of  Bright’s  disease,  and  may  be  due  to  the 
state  of  the  blood ; or,  as  seems  more  likely,  to 
increased  susceptibility  to  inflammatory  changes, 
which  results  from  the  lowered  vitality  of  the 
organism.  Dyspnoea  is  frequently  met  with  in 
the  inflammatory  and  cirrhotic  forms  of  the  dis- 
ease, and  may  he  independent  of  any  local 
lesion,  being  probably  a result  of  uraemic  poison- 
ing. CEclema  glottidis  is  apt  to  occur  in  inflam- 
matory cases,  when  even  a slight  laryngitis  has 
from  any  cause  been  brought  on. 

if)  Complications  affecting  the  Skin  and 
Subcutaneous  tissues. 

Dropsy,  in  the  form  of  anasarca,  is  almost 
constantly  present  in  the  early  stage,  and  during 
exacerbations  of  the  inflammatory  form.  It  can 
scarcely  bo  said  to  occur  in  uncomplicated  waxy 
and  cirrhotic  cases.  Eczema  is  occasionally 
troublesome  in  chronic  cases.  Erysipelas  is  met 
with  now  and  then,  always  constituting  a serious 
addition  to  the  other  malady. 

(C)  Complications  affecting  the  Urinary 
organs. 

The  chief  of  these  is  scrofulous  disease  of  the 
kidney,  and  more  rarely  of  the  bladder  and 
prostate.  They  occasionally  occur  along  with 
the  waxy  affection. 

(n)  Complications  affecting  the  Nervous 
system  and  Special  senses. 

Urcemic  blindness  may  occur,  which  is  sudden 
and  usually  temporary,  being  unaccompanied  by 
any  lesion  recognisable  by  the  ophthalmoscope. 
It  is  generally  met  with  in  advanced  cirrhotic  and 
inflammatory  cases.  Retinitis  albuminurica  is 
a peculiar  and  characteristic  inflammation  of 
the  connective  tissue  of  the  retina,  leading  to 
the  formation  of  white  patches  and  lines,  with 


DISEASE.  m 

fatty  degeneration.  With  it  are  also  frequently 
associated  minute  hjemorrhages  into  the  sub- 
stance of  the  retina.  This  occurs  by  far  the  most 
frequently  in  cirrhosis.  It  is  often  also  seen  in 
the  advanced  stages  of  the  inflammatory  form, 
and  is  rarely  recovered  from  except  in  the  case 
of  pregnant  women,  in  whom  it  seems  apt  to 
occur  as  a passing  condition. 

Ur&mia  includes  a group  of  the  most  strik- 
ing symptoms  of  Bright's  disease.  It  may  occur 
at  the  commencement  of  the  acute  inflammatory 
affection,  or  in  its  later  stages,  or  in  the  chronic 
forms.  The  condition  is,  however,  rare  in  the 
purely  waxy  disease,  but  common  in  the  cirrhotic. 
There  are  several  types  of  uraemia,  of  which  the 
most  important  are : — (a)  Sudden  acute  convul- 
sions, followed  by  coma  and  death ; ( b ) Gradually 
advancing  torpor,  passing  at  last  into  coma. 
The  clinical  features  of  these  and  minor  varie- 
ties are  described,  and  the  hypotheses  as  to  their 
origin  discussed,  in  the  article  Urjemia. 

Headache  is  frequently  complained  of  by 
patients  suffering  from  Bright's  disease.  Apo- 
plexy from  hemorrhage  into  the  substance  of  the 
brain  is  common  in  the  later  stages  of  the  in- 
flammatory and  cirrhotic  diseases.  It  is  due 
partly  to  the  degenerated  state  of  the  vessels, 
and  partly  to  the  increased  pressure  resulting 
from  cardiac  hypertrophy. 

(0)  Complications  affecting  the  Loccmo- 
tory  system. 

Of  these  the  only  ones  of  importance  are 
disease  of  bone,  which  has  been  already  referred 
to  as  a causal  complication  in  waxy  cases  ; and 
gouty  affections,  which  have  been  mentioned  in 
connexion  with  the  cirrhotic  disease. 

Diagnosis,  (a)  Of  Bright’s  Disease  from 
other  affections.  Erom  passive  congestion  of 
the  kidneys  due  to  cardiac  disease  these  maladies 
are  distinguished  by  the  general  condition  of  the 
patient ; the  absence  of  cardiac  disease,  and  of 
congestion  in  other  organs ; and  the  characters 
of  the  urine.  In  heart-affections  the  urine  is 
generally  scanty,  high-coloured,  not  of  low  speci- 
fic gravity.  It  may  contain  albumin,  and  deposits 
urates,  but  rarely  blood,  renal  epithelium  or  tube- 
casts.  Hyaline  casts  may  be  present,  but  never 
in  any  large  quantity.  The  presence  of  epithelial 
and  fatty  easts,  or  marked  diminution  of  the 
amount  of  urea  in  any  case,  proves  at  least  the 
co-existence  of  actual  inflammation  of  the  kidney. 
From  paroxysmal  hcematinuria  and  albumi- 
nuria, Bright's  diseases  are  distinguished.'  by  the 
abrupt  commencement  and  brief  duration  of 
these  maladies;  by  the  marked  nervous  symp 
toms,  with  gastric  catarrh,  and  sometimes  slight 
jaundice;  and  by  the  absence  of  dropsy.  In 
haematinuria  also  the  condition  of  the  urine  is 
very  distinctive ; the  dark-red  colour  being  due, 
not  to  blood-corpuscles,  but  to  granular  pigment, 
the  deposit  consisting  mostly  of  this  material 
and  of  hyaline  casts.  In  paroxysmal  albuminuria 
again  the  amount  ot  albumin  is  very  large,  and 
the  number  of  tube-casts  extraordinary.  Hema- 
turia, with  tendency  to  suppression  of  urine,  is 
distinguished  from  Bright’s  disease  by  the  small 
proportion  of  epithelial  tube-easts,  and  in  some 
eases  by  the  complete  absence  of  easts.  There 
may  be  a question  whether  the  case  is  one 
of  hsmaturia  or  of  commencing  acute  inflaro 


L80  BRIGHT’S 

uatoiy  Bright’s  disease;  or  again  -whether  it  is 
one  of  a chronic  affection,  cirrhotic  or  cystic,  in 
which  hemorrhage  has  come  on.  The  cases  in 
which  Bright’s  disease  simulates  haematuria 
are  generally  the  sequelse  of  scarlatina  or  diph- 
theria ; and,  therefore,  even  when  these  diseases 
hare  been  overlooked,  the  presence  of  desqua- 
mation or  of  paralysis  may  afford  a clue ; but 
the  peculiar  reddish-brown  deposit  rich  in  cells 
and  in  epithelial  tube-casts,  which  occurs  in 
Bright’s  disease,  makes  the  case  clearer  even 
when,  as  often  happens,  there  is  no  dropsy,  or 
when,  as  we  sometimes  see,  the  albumen  is  not 
coagulated  by  heat  or  by  nitric  acid.  Again, 
when  the  question  is  between  simple  haema- 
turia  and  hsematuria  with  cirrhosis  or  cystic 
disease,  the  evidence  afforded  by  the  tube-casts 
is  not  important,  but  the  hypertrophy  of  the 
heart,  the  thickening  of  the  arteries,  the  charac- 
ter of  the  pulse,  the  albuminuric  retinitis,  the 
low  specific  gravity  of  the  urine  and  the  small 
amount  of  urea  which  it  contains,  as  well  as  the 
tendency  to  haemorrhage  from  other  sources, 
afford  evidence  of  the  presence  of  the  chronic 
organic  disease. 

Slight  pyelitis,  with  or  without  renal  calculus 
or  gravel,  may  simulate  Bright’s  disease,  but 
the  history  of  pain,  the  presence  of  mucus  and 
pus-corpuscles  in  the  urine,  of  oxalate  of  lime 
or  uric  acid,  with  the  full  proportion  of  urea,  and 
the  absence  of  tube-casts,  indicate  the  nature  of 
the  case. 

f/3)  Of  the  different  forms  of  Bright’s 
disease  from  each  other.  The  discrimination 
presents  in  simple  cases  little  or  no  difficulty. 
The  points  to  be  attended  to  are  the  history  of 
the  patient ; the  amount  and  characters  of  the 
urine ; the  presence  or  absence  of  dropsy  ; and 
the  nature  of  the  complications.  The  previous 
occurrence  of  exanthematic  affections,  of  chronic 
wasting  disease,  or  of  intemperance,  gout,  or 
plumbism,  would  afford  some  obvious  indications. 
The  mode  of  origin  and  progress  of  the  malady 
is  very  important.  Thus  a case  commencing 
actually  with  dropsy  and  diminution  of  urine  is 
inflammatory  ; one  of  less  acute  character  with 
polyuria  is  waxy;  and  one  commencing  insidi- 
ously, with  no  marked  symptom  until  perhaps  con- 
vulsions or  dimness  of  vision  appeared,  would  he 
an  example  of  cirrhosis.  The  leading  symptoms 
of  the  inflammatory  variety  are  diminution  of 
urine  ; an  abundance  of  albumin  and  of  epithelial 
tube-casts,  with  diminution  of  urea ; and  mai'ked 
dropsy.  Of  the  waxy  kidney,  the  prominent  fea- 
tures are  early  and  persistent  polyuria  ; waxy 
degeneration  of  other  organs ; and  ^absence  of 
dropsy.  In  the  cirrhotic  form  the  insidious  com- 
mencement ; the  gradual  development  of  vascular 
and  cardiac  changes  ; with  in  the  later  stages, 
in  many  cases,  polyuria,  are  the  most  important 
phenomena.  Other  indications  may  he  gathered 
from  the  complications  of  each  form  of  Bright’s 
disease.  It  must  he  remembered  that  mixed 
forms  frequently  occur,  and  that  in  these  careful 
inquiry  and  patient  investigation  are  essential  to 
the  establishing  of  a correct  diagnosis. 

Prognosis. — The  prognosis,  though  always 
grave,  varies  in  the  different  forms  of  Bright's 
disease.  In  the  inflammatory  affection  it  is  least 
unfavourable,  although  this  affection  is  the  most 


DISEASE. 

immediately  dangerous.  During  its  first  stage  we 
may  always  hope  for  complete  recovery,  especi- 
ally in  cases  of  post-scarlatinal  origin.  Of  forty- 
one  successive  cases  treated  by  the  writer  in  the 
Royal  Infirmary,  Edinburgh,  twenty-two  recov- 
ered entirely,  while  twelve  died,  and  seven  passed 
into  the  second  stage.  If  this  he  the  proportion 
in  hospital  cases,  which  are  generally  sent  there 
on  account  of  their  severity,  and  are  rarely  sent 
in  the  earliest  stages  of  the  disease,  it  is  obvious 
that  the  proportion  of  recoveries  must  he  much 
larger  in  private  practice.  "When  the  disease 
reaches  the  second  stage,  the  prognosis  is  more 
grave,  complete  recovery  being  rare,  and  death 
sometimes  taking  place  from  sudden  or  gradual 
increase  of  the  symptoms,  or  from  intercurrent 
affections.  But  even  in  this  condition  complete 
recovery  may  he  brought  about,  and  in  many 
cases  the  patient  goes  on  for  long  periods,  pre 
senting  few  symptoms  to  attract  attention.  - In 
the  third  stage  the  prognosis  is  entirely  un- 
favourable, the  system  becoming  steadily  more 
deteriorated,  and  death  occurring,  either  from 
the  direct  effects  of  the  disease,  or  from  compli- 
cations. Still,  even  such  cases  often  go  on  fox 
long  periods,  if  placed  under  favourable  hygienic 
and  therapeutic  conditions. 

In  the  waxy  form  the  prognosis  must  almost 
always  he  unfavourable,  although  the  malady  is 
never  rapidly  fatal.  On  the  contrary,  its  course 
is  always  chronic,  in  some  cases  extending  ever 
five  or  even  ten  years.  The  fatal  result  is  due 
to  complications  more  frequently  than  to  the 
disease  itself.  Recovery  probably  sometimes 
takes  place,  hut  only  when  the  cause  of  the  de- 
generation is  removed,  and  the  general  sur- 
roundings of  the  patient  are  favourable.  It  is 
certain  that  the  liver  and  spleen  may  to  a large 
extent  recover  from  waxy  disease,  and  recovery 
has  been  witnessed  in  cases  which  presented  all 
the  symptoms  pointing  to  implication  of  the 
kidneys. 

In  the  cirrhotic  form  the  prognosis  is  very 
unfavourable,  hut  the  progress  of  the  disease  is 
so  slow  that  it  is  often  unadvisable  to  say  any- 
thing about  it  to  the  patient,  as  the  fatal  result 
may  be  long  deferred.  It  must,  however,  be 
kept  in  view  that  the  disease  may  he  far  ad- 
vanced before  its  existence  is  made  out. 

Among  the  symptoms  and  complications  which 
are  fitted  to  cause  special  alarm  when  they  occur 
in  connection  with  any  of  the  forms  of  Bright's 
disease,  wo  must  recognise  suppression  or  great 
diminution  of  urine,  especially  if  accompanied  by 
nervous  phenomena  or  general  dropsy ; uraemia, 
more  particularly  its  chronic  form ; and  acute 
inflammations  and  haemorrhages.  Retinitis  aibu- 
minurica  is  always  a verv  serious  symptom,  ex- 
cept when  it  occurs  in  pregnant  women. 

Treatment.  (1)  Of  the  inflammatory  form. 
The  objects  to  he  kept  in  view  are  to  arrest  the 
inflammatory  action;  to  remove  the  inflammatory 
products  from  the  kidneys ; and  to  obviate  the 
deleterious  effects  upon  the  system  generally  of 
the  accumulation  of  effete  materials.  One  remedy 
or  plan  of  treatment  may  meet  more  than  one 
of  these  indications.  The  most  useful  means  of 
subduing  the  inflammatory  action,  or  at  least 
the  congestion  which  attends  it,  are  local  blood 
letting  by  means  of  leeches  or  wet  cups ; drv- 


BRIGHT'S  DISEASE.  18! 


•npping;  and  the  application  of  hot  fomenta- 
tions, poultices,  and  counter-irritants.  Blood- 
letting is  only  serviceable  in  the  early  stage 
of  the  disease,  or  when  severe  exacerbations 
with  suppression  of  urine  occur.  Poultices  or 
hot  fomentations  are  of  use  in  the  same  circum- 
stances. Counter-irritation  is  helpful  in  the 
more  chronic  conditions.  Iodine  and  croton  oil 
inunction  are  the  best  fitted  for  its  induction, 
whilst  cantharides  must  be  avoided  on  account 
of  its  tendency  to  irritate  the  kidneys. 

The  removal  of  the  inflammatory  products 
which  block  up  the  uriniferous  tubules  is  of  tli6 
utmost  importance,  and  is  in  the  great  majority 
of  cases  best  effected  by  means  of  diuretics. 
Water  and  diluent  drinks  are  the  safest,  and 
are  sometimes  found  sufficient.  The  medicinal 
diuretics  must  be  non-irritating,  and  the  best  of 
all  is  digitalis,  which  may  be  given  safely  even 
when  the  urine  is  bloody.  It  may  be  adminis- 
tered in  the  form  of  infusion,  tincture,  or  made 
up  into  a pill.  Of  the  infusion  from  a drachm 
to  an  ounce,  of  the  tincture  from  five  to  thirty 
minims,  of  the  powder  from  half-a-grain  to  two 
grains,  should  be  given  three  times  a day.  The 
infusion  or  the  tincture  may  be  combined  with 
spirit  of  nitrous  ether,  with  acetate  of  potash,  or 
with  tincture  of  percliloride  of  iron.  Its  action  is 
often  favoured  by  the  addition  of  squill  and  car- 
bonate of  ammonia.  Sometimes  it  happens  that 
diuretics  do  not  suit  the  case,  the  urine  be- 
coming diminished  and  more  bloody  under  their 
use  ; and  in  other  cases  the  symptoms  become  so 
urgent  that  death  might  take  place  before  there 
would  be  time  for  diuretics  to  act.  In  either  of 
these  conditions  relief  must  be  obtained  by  the 
bowels  or  skin.  The  bowels  are  best  acted  upon 
by  means  of  from  twenty  grains  to  a drachm  of 
the  compound  jalap  powder,  or  one-twentieth  to 
half-a-grain  of  elaterium.  The  action  of  the 
skin  may  be  excited  by  the  use  of  acetate  of 
ammonia  or  antimony  ; but  pilocarpine,  hot  air, 
vapour-baths,  and  the  wet  pack  are  the  most 
efficient  agents.  Throughout  the  whole  course 
of  the  disease  constipation  should  be  avoided, 
and  the  action  of  the  skin  encouraged.  When 
the  disease  has  become  less  acute,  and  certainly 
when  dropsy  persists  during  the  second  stage, 
other  diuretics  are  of  the  utmost  value,  par- 
ticularly the  acid  tartrate  of  potash,  the  oil  of 
juniper,  and  the  decoction  of  broom.  Iron  must 
be  assiduously  administered,  to  make  up  for 
the  waste  of  the  materials  of  the  blood.  Gallic 
acid,  ergot,  and  belladonna  have  all  been  praised 
as  tending  to  diminish  the  discharge  of  albumin 
resulting  from  a persistent  chronic  inflammation 
of  the  tubules.  The  treatment  of  special  symp- 
toms and  complications  will  be  considered  after 
indicating  the  general  management  of  the  other 
varieties  of  Bright’s  disease. 

The  diet  during  the  earliest  stages  should  be 
easily  assimilable,  and  not  too  rich  in  nitroge- 
nous elements.  Milk  is,  as  a rule,  well  borne. 
Some  practitioners  laud  skimmed  milk  as  an 
unfailing  remedy  in  tho  disease.  It  is  a good 
diuretic,  and,  when  it  suits  the  stomach,  a good 
article  of  diet,  but  possesses  no  other  therapeu- 
tical virtue.  In  the  more  chronic  stages  the 
food  should  be  of  the  most  nourishing  kind,  and  a 
moderate  allowance  of  stimulants  may  be  needed. 


(2)  In  the  treatment  of  the  waxy  form,  the 
most  important  indication  is  to  seek  to  remove 
the  cause  of  the  degeneration,  if  still  existing.  If 
there  be  disease  of  bone  or  chronic  abscess  it 
must,  if  possible.be  cured;  constitutional  syphilis 
must  be  combated  by  appropriate  remedies. 
The  tincture  of  perchloride  of  iron,  quinine,  nux 
vomica,  and  such  combinations  as  Easton’s  syrup 
of  the  phosphates,  are  useful.  The  patient  must 
also  have  good  food,  and  should  lead  an  easy  life. 

(3)  In  the  cirrhotic  form  it  is  probable  that  no 
remedy  we  at  present  possess  can  influence  ’the 
pathological  process,  although  arsenic  and  alka- 
line remedies,  and  particularly  iodide  of  potas- 
sium, enjoy  a certain  reputation.  It  is  of  course 
the  duty  of  the  skilful  physician  to  obviate  the 
results  of  the  morbid  process.  It  is  obviously 
of  great  importance  to  avoid  the  causes  of  the 
disease.  Lead-poisoning  should  be  avoided ; the 
gouty  tendency  kept  in  check;  and  the  abuse  of 
alcohol  forbidden. 

(4)  In  the  management  of  the  combined  forms 
of  Bright’s  disease  these  plans  of  treatment  must 
be  conjoined  according  to  circumstances,  but,  on 
the  whole,  treatment  is  much  less  successful 
than  in  the  simple  cases.  In  the  combined  waxy 
and  inflammatory  affection,  for  instance,  it  is  not 
uncommon  for  dropsy  to  persist,  although  the 
diuretics  bring  the  urine  up  to  or  above  the 
natural  standard. 

(5)  With  regard  to  the  special  symptoms  and 
complications  of  Bright’s  disease,  the  sick- 
ness and  vomiting  are  best  relieved  by  counter- 
irritation  over  the  stomach  ; and  by  giving  ice, 
milk,  and  hydrocyanic  acid  internally.  These 
symptoms  are,  however,  often  very  intractable. 
Diarrhoea  must  sometimes  be  let  alone  ; at  other 
times  it  must  be  treated  by  means  of  astringents 
or  sedatives,  either  administered  by  the  mouth  or 
as  enema  or  suppository.  Ascites  must  be  treated 
as  a manifestation  of  dropsy,  and  occasionally 
the  abdomen  requires  tapping.  Peritonitis  must 
be  combated  by  hot  fomentations  and  opium, 
but  the  latter  requires  great  care  in  its  adminis- 
tration. All  through  the  disease  in  all  its  forms 
haematic  tonics  are  demanded;  iron  in  some  form 
should  be  constantly  administered.  For  haemor- 
rhages the  pernitrate  of  iron,  local  astringents, 
ergot  and  ergotine,  gallic  acid,  or  acetate  of  lead 
must  be  tried  in  various  combinations.  The 
best  results  have  followed  the  use  of  ergotine  in 
3-  to  5-grain  doses  injected  subcutaneously.  Tho 
irritating  effects  sometimes  observed  after  the 
subcutaneous  injection  of  ergotine  may  often 
be  obviated  by  boiling  the  solution,  or  by  the 
addition  of  a minute  quantity  of  salicylic  acid. 
Hydropericardium  and  pericarditis  must  be 
treated  in  the  usual  way.  The  vessels  and  the 
heart  are  not  amenable  to  treatment.  Bronchial 
catarrh  must  be  carefully  attended  to,  by  the 
avoidance  of  exposure  to  cold ; by  the  application 
of  counter-irritation  externally;  and  by  the 
internal  administration  of  expectorants,  ffidema 
of  the  lungs  must  be  treated  by  counter-irri- 
tants, and  by  remedies  fitted  to  reduce  the 
general  dropsy.  Pneumonia,  phthisis,  and  pleu- 
risy must  be  treated  on  ordinary  principles. 
Hydrothorax  may  demand  paracentesis.  General 
dropsy  is  one  of  the  most  important  compli- 
cations, and  should  be  combated  by  means  of 


182  HEIGHT’S  DISEASE, 

diuretics,  purgatives,  and  diaphoretics  ; in  many 
cases  puncture  of  the  cedematous  parts  is  de- 
manded. When  puncture  has  been  determined 
upon,  precautions  must  be  taken  to  avoid  inflam- 
mation. Eczema  and  erysipelas,  when  they 
occur,  should  be  dealt  with  according  to  the 
principles  of  the  art.  Headache  is  relieved  in 
different  cases  by  iron,  by  hot  or  cold  applica- 
tions to  the  head,  by  quinine,  or  by  inhalation 
nf  a few  drops  of  nitrite  of  amyl.  When  uraemia 
occurs  in  acute  inflammatory  conditions,  or  with 
•suppression  of  urine,  dry-cupping  or  wet-cupping 
over  the  renal  regions  should  be  tried,  along 
with  free  purgation  and  hot-air  baths  and,  es- 
pecially in  puerperal  cases,  general  blood-letting. 
Bromide  of  potassium  should  be  given  in  drachm 
doses,  and  if  convulsions  be  severe,  the  patient 
must  be  kept  under  the  influence  of  chloroform. 
In  the  more  chronic  and  gradually  advancing 
form  of  uraemia,  counter-irritation  at  the  back 
of  the  neck  and  over  the  scalp  sometimes  ap- 
pears to  be  useful.  But  treatment  is  net  so 
often  of  advantage  in  this  as  in  the  other  form. 
In  the  eye-affections,  iodide  of  potassium  enjoys 
some  reputation.  Haemorrhagic  apoplexy  de- 
mands no  special  measures  for  its  treatment. 

T.  Grainger  Stewart. 

BEOMISM. — Definition. — Bromism  is  the 
term  applied  to  the  morbid  effects  produced  by 
the  administration  of  the  salts  of  bromine  under 
certain  circumstances. 

Description.  — The  effect  of  the  salts  of 
bromine,  when  administered  in  medicinal  doses, 
is  to  reduce  nervous  activity  ; and  thus,  with  a 
certain  amount  of  anaesthetic  influence,  to  pro- 
mote rest  and  sleep.  When  such  doses  have 
been  long  continued,  or  in  certain  idiosyncrasies, 
or  when  excessive  doses  are  administered,  re- 
sults are  produced  which  constitute  a state  of 
disease,  and  to  this  condition  the  term  ‘ brom- 
ism’ is  applied.  These  results  are  manifested 
on  the  brain  and  spinal  cord ; on  the  skin ; 
on  the  mucous  membranes  and  glandular  struc- 
tures ; and  on  the  organs  of  circulation  and  respi- 
ration. 

1.  On  the  Brain  and  Spinal  Cord. — When 
the  therapeutic  action  intended  to  be  obtained 
from  the  use  of  a salt  of  bromine  is  exceeded, 
the  quiet  or  sleep  becomes  more  pronounced, 
and  there  is  more  or  less  constant  somno- 
lence; the  memory  becomes  impaired,  words 
being  forgotten  or  misplaced,  whilst  written  and 
spoken  language  is  confused,  the  tongue  is  tremu- 
lous, and  speech  is  difficult.  The  gait  becomes 
feeble  and  staggering,  with  inability  to  control 
movement,  and  somewhat  resembles  the  condi- 
tion observed  in  locomotive  ataxy.  The  special 
senses — sight,  hearing,  taste,  and  touch — are  im- 
paired : reflex  excitability  is  diminished,  and  this 
is  especially  observed  in  the  fauces,  occasionally 
to  such  an  extent  as  to  cause  difficulty  in 
swallowing.  Sexual  feelings  are  diminished  or 
altogether  suppressed.  The  general  aspect  of 
a case  of  well-marked  bromism  much  resembles 
one  of  senile  imbecility. 

2.  Oh  the  Skin. — A very  frequent  result  of 
the  internal  use  of  the  bromides  is  a follicular 
eruption  of  the  skin,  closely  resembling  acne, 
which  is  generally  situated  on  the  face,  chest, 


EROMISM. 

and  shoulders.  When  the  use  of  the  drug  is  con- 
tinued, the  acne  becomes  aggravated,  and  boiis 
appear.  A more  rare  form  of  skin-disease  simi- 
larly caused  has  been  described  by  Dr.  Cholmeley, 
Mr.  Hutchinson,  and  M.  Voisin.  This  disease 
appears  as  vesicles,  which  become  aggregated 
into  clusters  or  patches.  These  proceed  to  sup- 
puration, and  are  soon  followed  by  scabbing, 
their  base  being  slightly  raised,  hard,  sometimes 
ulcerated,  and  surrounded  by  a red  areola.  In 
a later  stage  the  eruption  presents  the  appear- 
ance of  dusky  red  stains.  It  has  been  observed 
more  especially  on  the  limbs  and  head.  Erup- 
tions having  more  or  less  the  characters  of  ery- 
thema and  of  eczema  have  also  been  described 
as  following  the  use  of  these  agents. 

3.  On  the  Mucous  Membranes  and  Glandular 
Structures. — Dryness  of  the  mouth  and  tongue 
is  often  experienced  in  bromism ; but  in  some 
cases  there  is  said  to  be  an  increased  flow  of 
saliva.  Nausea,  flatulence,  eructations  having 
a saline  taste,  heat  and  fulness  at  the  epigas- 
trium, and  occasionally  gastric  catarrh  and  diar- 
rhoea, have  been  observed  ; it  is  said  that  acute 
enteritis  and  even  a typhoid  condition  have  oc- 
curred. 

4.  On  the  Organs  of  Circulation  and  Bespira- 
tion. — The  salts  of  bromine  are  said  to  produce 
contraction  of  the  capillaries.  The  skin  may 
present  a peculiar  pallor,  and  the  extremities 
feel  cold.  The  action  of  the  heart  is  rendered 
slower  and  weaker;  and  may  even  cease  alto- 
gether, under  the  continued  operation  of  these 
drugs.  The  action  on  the  respiratory  organs 
is  similar  to  that  upon  the  heart.  It  has  been 
observed  that  bromine — recognised  by  its  pe- 
culiar odour  in  the  expired  air— is  eliminated 
from  the  respiratory  mucous  membrane.  Bron- 
chial catarrh  occurs,  and  instances  are  recorded 
in  which  pneumonia  is  said  to  have  followed  and 
proved  fatal. 

It  must  be  remembered  that,  although  it  has 
been  thought  desirable  to  discuss  separately  here 
the  effect  of  these  drugs  on  the  several  systems, 
these  effects  are  combined  in  various  degrees. 
In  some  cases  the  affection  of  the  skin  is  alone 
noticeable ; in  others,  that  of  the  nervous  sys- 
tem ; while  in  a third  class  there  is  produced  a 
combination  more  or  less  of  all  the  phenomena, 
constituting  what  may  be  called  a cachexia. 
In  such  cases  we  find  loss  of  flesh,  strength, 
colour,  and  mental  power;  paralysis  of  the 
muscles;  loss  of  reflex  and  general  sensibility 
and  of  the  functions  of  the  special  senses  ; com- 
plete apathy  and  general  prostration,  the  coun- 
tenance having  a semi-idiotic  expression  ; cold- 
ness of  the  extremities ; and  gradual  failure  of 
the  heart’s  action. 

Pathology. — The  condition  just  described  is 
but  the  extreme  effect  of  the  ordinary  physio- 
logical action  of  the  salts  of  bromine.  This 
condition  may  be  due  either  to  idiosyncrasy — 
that  is,  to  undue  susceptibility  on  the  part  of  the 
individual — or  to  the  administration  of  large 
quantities  of  the  drug,  either  in  medicinal  doses 
for  a long  period,  or  in  excessive  doses  ad- 
ministered within  a short  time.  The  individual 
susceptibility  may  depend  upon  the  want  of  ca- 
pability to  eliminate  the  drug ; on  the  general 
state  of  health ; or  on  the  presence  of  a disease 


BilOMISM. 

which  resists  its  action.  Under  these  circum- 
stances, as  well  as  in  the  presence  of  certain 
modifying  influences,  such  as  the  action  of  other 
remedial  agents  simultaneously  administered,  it 
is  difficult  to  fix  upon  the  amount  of  a bromine 
salt  capable  of  producing  morbid  symptoms  in 
any  given  individual.  The  writer  has  seen  a 
nightly  dose  of  ten  grains  of  bromide  of  potas- 
sium, continued  for  some  weeks,  produce 
marked  somnolence  during  the  day,  and  im- 
pairment of  memory;  whilst  it  has  required 
the  enormous  doses  of  200  or  300  grains 
a day,  which  scent  to  be  administered  on  the 
Continent,  to  produce  the  extreme  effects  above 
described.  The  rapidity  with  which  these  effects 
are  produced,  constituting  the  acute  and  chronic 
forms  of  bromism,  will  depend  on  the  amount 
and  frequency  of  the  dose,  and  on  the  suscepti- 
bility of  the  individual.  The  effect  of  a sudden 
considerable  increase  in  the  dose  has  been  ob- 
served by  the  -writer  in  a case  which  first 
directed  his  attention  to  the  subject  of  bromism 
in  1872.  This  case  hesawinconsultationwithMr. 
Alfred  Burton.  Half-drachm  doses  of  bromide  of 
potassium  had  been  taken  twice  a day  for  several 
-weeks,  when  by  mistake  the  quantity  of  the  drug 
was  doubled ; then,  after  three  days,  symptoms 
closely  resembling  senile  imbecility  were  rapidly 
developed. 

Diagnosis. — Recognising  the  value  of  the 
bromides,  and  the  frequency  with  which  they  are 
used,  it  is  extremely  important  that  the  peculiar 
results  which  tkeyare  capable  of  producing  should 
be  borne  in  mind  ; for  if  they  are  not  recognised 
in  time,  and  if  the  use  of  the  drugs  be  persisted 
in,  disastrous  effects  which  might  otherwise  be 
avoided  will  follow.  Without  going  into  details 
of  diagnosis,  it  will  probably  be  sufficient  to 
point  out  the  necessity  for  remembering  that  the 
symptoms  which  have  been  described  above  can 
be  produced  by  the  use  of  bromides;  and  that 
when  such  a combination  of  symptoms  does  occur 
during  their  use,  it  is  highly  probable,  in  the 
absence  of  disease  capable  of  accounting  for 
them,  that  the  symptoms  have  originated  from 
the  operation  of  those  agents. 

Treatment. — This  consists  in  stopping  the 
use  of  the  drug,  and  hastening  its  elimination  by 
promoting  the  action  of  the  kidneys  and  other 
excreting  organs.  It  is  said  that  arsenic  in 
combination  acts  as  a preventive  of  the  eruptions. 

The  above  description  refers  to  the  effects  of 
bromide  of  potassium ; but  like  effects  are  pro- 
duced by  other  salts  of  bromine,  though  to  what 
extent  by  each  has  not  yet  been  ascertained. 

R.  Quain,  M.D. 

BROMIDROSIS  (Bpafios,  a stench;  and 
I^pus,  sweat).  A term  for  fetid  perspiration.  See 
Perspiration,  Disorders  of. 

BRONCHI,  Diseases  of. —The  diseases  of 
the  bronchi  may  be  discussed  in  the  following 
order: — 1.  Acute  inflammation;  2.  Chronic  in- 
flammation ; 3.  Plastic  inflammation  ; 4.  Dilata- 
tion; o.  Narrowing  or  obstruction ; 6.  Cancer. 

1.  Acute  Inflammation. — -Acute  Bron- 
chitis.— Acute  Bronchial  Catarrh. 

Definition. — An  acute  inflammation  or  con- 
gestion, general  or  partial,  of  the  bronchial  tubes. 


BRONCHI,  DISEASES  OF.  183 

.Etiology. — The  causes  of  acute  bronchitis 
may  ho  classed  as  (a)  predisposing  and  ( h ) ex- 
citing. 

(a)  Of  the  predisposing  causes  age  is  one  of  the 
most  important.  The  disease  is  indeed  confined 
to  no  period  of  life,  but  it  is  most  frequently  me* 
with  in  the  young  and  the  old,  and  in  these  sub- 
jects it  assumes  its  most  serious  characters.  The 
imperfect  development  of  the  infant,  and  the 
diminished  vitality  of  the  aged,  seem  to  render 
them  especially  liable  to  attacks  of  bronchitis, 
and  to  make  the  disease  exceptionally  fatal  in 
them.  Sex  appears  to  have  no  influence  as  a 
predisposing  cause.  The  habits  of  life  have  an 
important  influence  in  the  causation  of  bron- 
chitis. The  practice  of  living  in  heated  rooms, 
especially  where  gas  is  largely  consumed,  and  of 
breathing  the  vitiated  atmosphere  produced  by 
the  assemblage  of  large  numbers  of  persons  in 
apartments,  is  undoubtedly  a fertile  predisposing, 
as  well  as  exciting,  cause  of  the  complaint ; so 
also  is  the  practice  of  keeping  children  too  much 
within  doors  on  the  one  hand,  or,  on  the  other, 
of  exposing  them  to  inclement  weather  when  in- 
sufficiently clad.  Temperament  can  scarcely  be 
considered  a predisposing  cause,  but  the  state  of 
the  general  health  exercises  a powerful  influence. 
A weakly  constitution,  or  one  weakened  by  over- 
work, improper  food,  &c.,  predisposes  to  bron- 
chitis; whilst  such  affections  as  Bright’s  disease, 
gout,  and  diseases  of  the  heart,  alike  favour  its 
occurrence.  Again,  certain  occupations  are  favour- 
able to  the  development  of  bronchitis.  Inde- 
pendently of  the  fact  that  living  or  working  in 
heated  and  confined  rooms  predisposes  to  the 
disease,  such  occupations  as  lead  to  the  inhalation 
of  irritating  particles,  as  those  of  steel,  cotton, 
&e..  give  rise  to  it.  The  climate  most  favourable 
to  the  production  of  bronchitis  is  probably  that 
which  is  at  the  same  time  both  cold  and  damp, 
and  where  sudden  variations  of  temperature 
occur.  The  seasons  of  the  year  in  which  it  pre- 
vails most  are  the  late  autumn,  the  winter,  and 
the  early  spring. 

(b)  Exciting  causes. — Although  undoubtedly 
cold  directly  applied  to  the  surface  of  the  body  ic 
in  a large  number  of  cases  the  exciting  cause  of 
bronchial  inflammation,  still  the  transition  from 
cold  to  heat — passing  from  a cold  atmosphere  to 
a heated  one — is  a large  factor  of  the  disease. 
There  can  he  little  doubt  that  bronchitis  is  often 
produced  directly  by  the  effects  of  heated  and 
vitiated  air  on  the  bronchial  membrane,  and  on  the 
system  at  large  ; and  that  in  the  latter  instance, 
the  affection  is  merely  a local  manifestation  of  a 
general  influence.  Bronchitis  may  also  be  caused 
by  the  direct  action  of  irritants  contained  in  the 
air — as  irritant  vapours,  minute  particles  of 
steel,  cotton,  or  ipecacuanha,  and  the  emanations 
(pollen)  from  flowering  plants.  Again,  morbid 
conditions  of  the  blood,  the  result  of  specific 
febrile  affections,  act  as  exciting  causes  of  the 
disease  ; as  do  also  the  poison  of  syphilis,  and 
the  altered  condition  of  the  blood  produced  by 
gout.  Bronchitis  is,  moreover,  a constant  ac- 
companiment of  influenza. 

Anatomical  Characters. — The  mucous  mem- 
brane is  mainly  affected  in  acute  bronchitis,  hut 
morbid  changes  may  be  produced  in  the  deeper 
structures.  The  mucous  membrane  is  red — the 


BRONCHI,  DISEASES  OF. 


.84 

redness  being  arborescent,  streaked,  or  mottled, 
Imt  not  usually  spread  uniformly  over  a largo 
^rfaee.  The  injected  condition  of  the  membrane 
does  not,  as  a rule,  extend  into  the  finer  bronchial 
tubes,  but  in  some  cases  where  there  have  been 
frequent  attacks  of  inflammation,  the  smallest 
bronchi  have  a red  appearance.  The  membrane 
is  sometimes  thickened  and  soft,  but  ulceration 
is  very  rare.  The  tubes  are  generally  found  more 
or  less  filled  with  secretion,  either  frothy  mucus, 
muco-pus,  or  even  actual  pus.  Sometimes  the 
secretion  is  very  abundant,  filling  all  the  tubes. 
Fibrinous  masses  are  occasionally  met  with, 
which  may  form  casts  of  the  tubes.  Collapse  of 
portions  of  lung-substance — lobulettes  or  whole 
lobules  of  the  lungs — is  not  unfrequently  found, 
as  are  also  patches  of  lobular  pneumonia.  The 
venous  system  and  the  right  side  of  the  heart 
are  overloaded,  and  the  blood  is  dark.  In  many 
cases  fibrinous  deposits  are  found  in  the  cavities 
and  great  vessels  of  the  heart. 

In  speaking  of  the  pathology  of  bronchitis,  it 
is  necessary  to  refer  to  the  distribution  of  the 
bronchial  blood-vessels.  The  bronchial  arteries 
when  the}'  have  fairly  entered  the  lungs  have  no 
accompanying  veins.  The  so-called  bronchial 
veins  are  some  small  vessels  which  return  the 
blood  supplied  to  the  structures  about  the  roots 
of  the  lungs.  The  blood  which  is  supplied  to  the 
bronchial  tubes,  when  they  have  commenced 
their  divisions,  passesinto  radicles  of  pulmonary 
veins,  and  is  returned  directly  to  the  left  side  of 
the  heart.  The  question  whether  there  is  a com- 
munication between  the  bronchial  arteries  and 
the  pulmonary  artery,  is  still  subjudice.  If  such 
communication  exist,  it  is  only  slight.  The  blood 
of  the  bronchial  arteries,  after  supplying  the 
mucous  membrane  and  other  structures  of  the 
tubes,  passes,  either  wholly  or  in  very  large  part, 
to  the  left  side  of  the  heart,  not  having  circulated 
through  the  aerating  portion  of  the  lungs.  The 
circumstances  of  this  anatomical  arrangement 
are  most  important  in  a practical  point  of  view. 
Anything  which  embarrasses  the  circulation  on 
the  left  side  of  the  heart — such  as  mitral  regur- 
gitation— must  necessarily  cause  a very  loaded 
condition  of  the  bronchial  vessels;  and  all  physi- 
cians are  familiar  with  the  form  of  bronchitis 
which  is  so  common  in  these  cardiac  affections. 
The  congested  mucous  membrane,  and  the  pro- 
fuse bronchial  secretion,  are  the  result  of  the 
direct  impediment  to  its  circulation  which  the 
blood  meets  with,  from  passing  at  once  into 
vessels  which  go  straight  to  the  left  side  of  the 
heart.  The  relief  often  afforded  in  this  form  of 
bronchitis  by  the  exhibition  of  digitalis,  is  ex- 
plained by  the  circumstance  above  referred  to. 

Symptoms. — The  symptoms  of  acute  bronchitis 
vary  according  as  the  larger  or  smaller  tubes  are 
affected.  The  disease  attacks,  first,  the  larger 
and  medium-sized  tubes ; and,  secondly,  the 
smaller  ones.  To  this  latter  form  of  the  affec- 
tion the  name  of  capillary  bronchitis  has  been 
given. 

1 . Acute  bronchitis  of  the  larger  tubes.  The 
attack  is  usually  ushered  in  by  symptoms  of 
catarrh,— sneezing,  lachrymation,  a sense  of  ful- 
ness about  the  nose  and  eyes,  with  frontal  head- 
ache ; the  throat  becomes  dry  and  sore,  and  then 
increased  secretion  sets  in  ; the  follicles  at  the 


back  of  the  pharynx  become  enlarged;  the  upp«r 
part  of  the  larynx  is  often  involved,  there  being 
slight  hoarseness  ; and  the  affection  gradually 
creeps  down  into  the  bronchial  tubes.  The 
disease  is  not  ushered  in  by  decided  rigors,  but 
chills  and  sometimes  shiverings  aro  experienced  ; 
the  pulse  is  not  much  affected,  but  its  frequency 
is  increased  in  some  cases  ; there  is  a general 
sense  of  malaise,  as  well  as  a want  of  energy. 
When  the  disease  has  set  in  fully  certain  local 
symptoms  are  found.  More  or  less  pain  is  felt 
behind  and  above  the  sternum;  the  sensation  is 
increased  by  a deep  inspiration ; the  pain  shoots 
at  times  over  the  chest  in  the  direction  of  the 
larger  bronchial  tubes ; and  there  is  a tickling 
or  unpleasant  irritation  felt  behind  the  sternum, 
which  gives  rise  to  cough.  Dyspnoea  is  not  a 
marked  feature  of  this  form  of  bronchitis ; it 
exists,  however,  sometimes ; and  in  the  most  severe 
cases  a sense  of  oppression,  weight,  and  tightness 
about  the  chest  is  experienced.  Cough  is  one  of 
the  earliest  and  most  prominent  symptoms  ; it 
is  at  first  dry,  and  there  is  usually  at  this  period 
some  hoarseness.  The  cough  is  paroxysmal,  and 
often  very  violent;  it  becomes  attended  with  ex- 
pectoration as  the  disease  progresses.  This  varies 
at  different  stages  of  the  affection  ; at  first  watery 
and  frothy,  and  almost  transparent,  it  becomes 
as  the  disease  progresses  more  consistent,  viscid, 
and  opaque,  passing  through  the  stages  of 
mucus  to  muco-pus  and  pus  ; it  is  sometimes 
distinctly  nummulated.  Small  streaks  of  blood 
are  occasionally  seen  mixed  with  the  sputa. 
Examined  under  the  microscope  the  sputa  are 
found  in  the  early  stages  of  the  disease  to  con- 
tain epithelial  cells  from  the  mucous  membrane; 
and,  later,  many  of  the  so-called  exudation-cor- 
puscles, molecular  and  granular  matter,  pus-cells, 
and  occasionally  blood-discs. 

In  the  milder  cases  of  this  form  cf  bronchitis 
there  is  but  little  general  disturbance ; and  even  in 
the  more  severe  cases  the  febrile  reaction  is  not 
usually  very  great.  The  pulse  rises  a little,  but 
does  not  become  very  frequent ; the  temperaturo 
rarely  becomes  high  ; there  is  in  many  cases  but 
little  interference  with  the  appetite.  A general 
feeling  of  depression,  which  in  some  cases  is  very 
marked,  is  usually  experienced. 

2.  Acute  bronchitis  of  the  smaller  tubes — Ca- 
pillary bronchitis.  This  is  a very  formidable 
disease.  It  attacks  the  finer  bronchial  tubes,  and 
probably  extends  to  their  smallest  ramifications. 
Its  symptoms  are  very  grave.  Some  of  the  worst 
cases  of  capillary  bronchitis  are  met  with  in 
connexion  with  emphysema  of  the  lungs.  It 
may  be  an  extension  of  inflammation  from  the 
larger  tubes  ; or  the  capillary  tubes  may  be 
attacked  simultaneously  with  the  larger  ones,  or 
alone.  The  early  symptoms  are  more  severe 
than  those  of  ordinary  bronchitis,  and  rigors  are 
more  common.  Dyspncea  is  marked ; it  may 
vary  from  mere  rapid  respiration  to  constant  or 
paroxysmal  orthopnoea.  The  respirations  may 
rise  to  fifty  in  a minute.  Cough  is  almost  con- 
tinuous, at  times  becoming  very  violent  and 
most  distressing.  Expectoration  is  attended 
with  difficulty.  The  sputa  soon  become  very 
abundant,  and  rapidly  assume  a purulent  charac- 
ter ; or  they  are  very  viscid  and  ropy. 

The  general  symptoms  are  very  severe.  The 


BRONCHI,  DISEASES  OF.  i«5 


fever  is  high. — the  temperature  reaching  to  103° 
Fahr.  and  upwards  ; and  the  pulse  is  frequent, 
rising  to  120  or  110.  The  temperature  rarely 
attains  the  height  which  characterises  acute 
tuberculosis  or  pneumonia.  There  are  often 
profuse  perspirations,  and  in  some  cases  excessive 
debility  is  lelt.  If  the  disease  progresses  unfa- 
vourably, symptoms  of  very  imperfect  aeration  of 
the  blood  come  on.  The  face  becomes  turgid  and 
bloated,  the  lips  and  ears  get  livid,  the  veins  are 
distended,  the  temperature  falls,  cold  clammy 
perspirations  break  out,  the  pulse  becomes  very 
small  and  rapid,  delirium  supervenes,  the  respi- 
ration is  shallow  and  catching,  and  the  patient 
dies  of  apncea,  and  from  the  presence  of  fibrinous 
clots  in  the  heart  and  great  blood-vessels. 

Physical  Signs. — The  physical  signs  of  both 
forms  of  acute  bronchitis  may  be  referred  to 
together.  Inspection  reveals  little  of  practical 
value  in  simple  bronchitis.  The  chest-form  is 
not  altered.  In  severe  cases  the  abdominal 
movements  are  in  excess.  The  costal  movements 
are  frequently  those  of  elevation  rather  than  ex- 
pansion. In  extreme  cases  the  lower  end  of  the 
sternum  and  the  connected  cartilages  sink  with 
inspiration  ; while  the  expiration-movements  are 
slow,  laboured,  and  inefficient.  If  the  hand  is  ap- 
plied to  the  chest,  rhonchal  fremitus  may  be  often 
felt,  sometimes  over  a large  area.  The  percussion- 
sound  may  be  somewhat  exaggerated  from  over- 
distension of  the  lungs,  especially  in  children  ; not 
appreciably  altered  ; or  deficient  in  resonance, 
owing  to  the  accumulation  of  secretion  at  the 
liases  of  the  lungs,  to  cedema  or  congestion 
'as  in  typhoid  fever),  or  to  pulmonary  collapse. 
In  young  children  a sound  resembling  the 
cracked-pot  sound  may  be  occasionally  pro- 
duced, variable  in  site.  The  sounds  heard,  in 
auscultation  vary  according  to  the  stage  of  the 
disease.  The  breath-sounds  are  loud  when  the 
tubes  are  free;  when  the  latter  are  plugged  by  se- 
cretion, they  often  become  feeble  or  even  totally 
suppressed,  from  closure  of  a tube  leading  to  a 
portion  of  the  lung.  The  adventitious  sounds 
of  bronchitis  include  the  various  rhonchi,  dry  or 
moist:  the  dry  rhonchi  are  heard  in  the  early 
stages  of  the  disease  for  the  most  part,  but  when 
once  secretion  has  set  in,  the  moist  rhonchi  or 
rales  are  more  or  less  extensively  heard,  depend- 
ing for  their  character  on  the  size  of  the  tubes 
which  are  the  seat  of  inflammation.  Thus  they 
are  called  mucous  when  produced  in  the  large 
tubes,  sub-mucous  and  sub-crepitant  when  pro- 
duced in  the  finer  ones;  the  latter  term  being 
used  to  characterise  the  rales  of  capillary  bron- 
chitis. When  the  large  bronchial  tubes  are  filled 
with  a secretion  which  is  not  viscid,  the  sounds 
may  have  a rattling  character.  The  various 
rhonchi  may  be  heard  over  different  parts  of  the 
lungs  at  the  same  time,  according  to  the  seat 
and  stage  of  the  bronchitis.  In  capillary  bron- 
chitis sub-crepitant  r&les,  accompanying  inspira- 
tion and  expiration,  are  abundantly  heard, 
towards  the  bases  of  both  lungs  especially.  As 
a rule  there  is  no  displacement  of  organs  in 
bronchitis,  but  the  diaphragm  is  sometimes 
depressed  from  great,  distension  of  the  lungs,  and 
the  heart  is  occasionally  displaced  towards  the 
rL  hr. 

Diagnosis. — The  diagnosis  of  acute  bronchitis, 


except  in  a few  instances,  presents  no  great  diffi- 
culty. In  the  early  stages  of  whooping-cough  it 
is  impossible  to  decide  whether  the  case  is  one 
of  simple  bronchit  is  or  not,  but  subsequently  the 
paroxysmal  character  of  the  cough  settles  the 
point.  In  some  cases  of  bronchitis  occurring  in 
children  the  breathing  may  resemble  that  of 
croup,  but  here  the  presence  of  catarrh ; the 
wheezing  nature  of  the  respiration  ; the  absence 
of  much  fever ; the  characters  of  the  sputa  ob- 
tained by  wiping  the  back  of  the  tongue,  and  its 
freedom  from  membranous  shreds  ; and  the  phy- 
sical examination  of  the  chest  indicating  the  pre- 
sence of  rhonchi,  will  be  sufficient  to  establish  a 
diagnosis.  From  laryngitis  the  discrimination  is 
not  difficult. 

Pneumonia  may  generally  be  easily  diagnosed 
from  capillary  bronchitis,  with  which  form  it  can 
perhaps  be  alone  confounded.  Capillary  bron- 
chitis is  not  ushered  in,  as  pneumonia  usually  is 
by  a well-marked  and  prolonged  rigor;  the  gene- 
ral febrile  disturbance  is  less,  and  the  temperature 
not  so  high  ; moreover  the  absence  of  dulness  on 
percussion,  and  of  increased  vocal  resonance  and 
fremitus  will  aid  in  the  differentiation.  From 
lobular  pneumonia  in  children  the  diagnosis  is 
not  always  easy.  In  this  disease  there  is  often 
no  dulness  to  be  perceived  on  percussion;  whilst, 
on  the  other  hand,  in  bronchitis  dulness  may 
exist  from  pulmonary  collapse. 

The  diagnosis  of  capillary  bronchitis  from 
acute  phthisis  often  presents  difficulties.  The 
main  points  to  be  relied  on,  independently  of  the 
family  history,  which  may  aid,  are  that  in  capil- 
lary bronchitis  the  fever  is  less  and  the  tempera- 
ture lower  ; signs  of  apncea  soon  come  on  ; and 
there  is  free  expectoration  of  muco-purulent 
matter.  In  one  form  of  acute  phthisis  there  is 
evidence  of  pneumonic  consolidation,  followed  by 
signs  of  the  formation  of  cavities.  In  the  miliary 
tubercular  form  there  are  in  many  cases  scarcely 
any  physical  signs  except  riles,  most  marked  at 
the  apices  of  the  lungs. 

Prognosis,  Duration,  Termination,  and 
Mortality. — The  prognosis  in  an  ordinary  case 
of  bronchitis  is  favourable,  but  when  the  dis- 
ease occurs  in  the  very  young  or  the  aged  the 
prognosis  should  always  be  guarded.  In  the 
milder  forms  the  affection  may  last  only  a few 
days,  or  two  or  three  weeks.  Severe  cases  are 
more  protracted.  The  disease  may  terminate 
in  perfect  recovery,  in  death,  or  by  passing 
into  the  chronic  form.  It  may  be  the  starting 
point  of  emphysema  of  the  lungs,  or  of  certain 
forms  of  phthisis.  The  mortality  is  much  in 
fluenced  (1),  by  age,  being  greatest  in  the 
very  young  and  the  very  old ; (2),  by  the  pre- 
vious state  of  health,  which,  if  lowered  by  any 
circumstances,  will  render  recovery  more  doubt- 
ful ; (3),  by  the  extent  of  the  inflammation, 
especially  when  the  disease  is  of  the  capillary 
form  ; (4),  by  the  existence  or  non-existence  of 
any  organic  disease  of  the  heart,  lungs,  or 
kidneys ; (5),  by  the  disease  being  epidemic 
or  otherwise  ; and,  lastly,  by  the  time  the  case 
has  come  under  treatment,  whether  early  or  late. 

Treatment. — In  the  treatment  of  bronchitis 
regard  must  be  had  to  the  constitutional  con- 
dition of  the  patient.  Care  must  be  taken  to 
ascertain  whether  the  disease  is  secondary  to 


186  BRONCHI,  DISEASES  OF 


some  organic  affection  ; 5r  the  result  of  me- 
chanical irritation,  of  the  presence  of  gout  or 
rheumatism  in  the  system,  or  of  influenza ; or 
whether  it  arises  idiopathically.  The  treatment 
of  the  disease  as  a primary  affection  will  be 
considered  first. 

In  an  ordinary  case  of  acute  bronchitis  it  is 
very  desirable  to  keep  the  patient  confined  to 
his  room  and,  if  the  case  is  at  all  severe,  to  his 
bed.  The  temperature  of  the  apartment  should 
bo  maintained  at  from  60°  to  65°  Fahr.  A 
higher  temperature  than  this  is  generally  not 
favourable  to  the  progress  of  the  case.  In  the 
early  stages  of  the  attack  it  is  well  to  allow 
the  air  of  the  room  to  be  more  or  loss  saturated 
with  steam.  A free  action  of  the  skin  should 
be  promoted ; and  for  this  purpose  warm 
drinks,  with  or  without  some  form  of  alcohol  or 
some  diaphoretic  medicine,  may  be  given  ; or  a 
hot-air  bath  may  be  used  in  bed.  Great  relief 
is  often  experienced  from  the  application  of  a 
large  mustard  or  mustard  and  linseed-meal 
poultice  to  the  chest ; and  it  is  well,  if  mustard 
is  applied  first,  to  apply  immediately  afterwards 
a large  hot  linseed-meal  poultice,  to  he  renewed 
every  few  hours.  This  constant  application  of 
warmth  and  moisture  to  the  chest  is  often  pro- 
ductive of  very  great  relief  to  the  symptoms. 

Cases  of  acute  bronchitis  do  not  require 
venesection,  nor  is  the  application  of  leeches 
often,  even  if  ever,  called  for.  Severe  counter- 
irritation is  moreover  to  be  prohibited.  It  is 
generally  desirable  to  act  on  the  bowels,  and  a 
mercurial,  followed  by  a saline  purgative,  will 
often  he  of  great  service.  In  the  old  and 
debilitated,  as  also  in  the  young,  all  lowering 
treatment  must,  however,  be  avoided.  In  the 
early  stages  of  the  affection,  before  secretion  has 
commenced,  and  when  the  mucous  membrane  is 
dry  and  the  cough  hard,  diaphoretics  with  ipe- 
cacuanha may  often  he  given  with  advantage; 
but  as  soon  as  secretion  is  fairly  established, 
carbonate  of  ammonia,  spirits  of  chloroform, 
ether,  cascarilla,  senega,  or  such-like  drugs  should 
be  administered.  Indeed  in  almost  every  stage 
of  bronchitis  carbonate  of  ammonia  is  one  of  the 
most  valuable  remedies  we  possess.  Care  should 
be  exercised,  especially  with  the  aged,  that 
nothing  should  he  given  which  will  so  nauseate  as 
to  prevent  food  being  taken.  In  the  exhibition 
of  medicines  to  alleviate  the  cough,  regard  must 
be  had  to  the  condition  of  the  patient  and  the 
stage  of  the  disease.  Opium  in  all  its  forms 
should  be  given  with  caution,  especially  in  the 
young  and  old.  It  no  doubt  often  succeeds  in 
checking  cough,  but  in  doing  so  it  also  checks 
expectoration,  and  causes  an  accumulation  in 
the  bronchial  tubes,  which  sometimes  becomes 
very  dangerous  to  life.  Chloral  in  small  doses 
is  often  of  great  use  for  relieving  cough,  and  it 
may  be  combined  with  oxymelof  squills.  It  has 
also  a good  effect  in  allaying  spasm  of  the 
tubes,  if  this  exist.  In  some  cases  of  bronchitis 
the  question  of  procuring  sleep  becomes  an 
important  one.  Opium  in  its  various  forms  is 
generally  inadmissible,  in  consequence  of  its 
tendency  to  increase  the  condition  of  apnoea ; 
but  chloral  may  he  given  with  safety,  and  the 
recovery  of  a patient  may  sometimes  he  dated 
from  the  sleep  which  this  agent  procures. 


In  reference  to  the  exhibition  of  alcoholic 
stimulants,  except  in  the  early  stages,  and  in 
certain  cases  dependent  on  a gouty  or  rheu- 
matic condition,  they  should  usually  be  given 
in  smaller  or  larger  quantities.  They  increase 
expectorating  power,  and  ward  off  the  ten- 
dency to  apncea.  In  the  old  they  are  especially 
called  for,  and.  together  with  carbonate  of 
ammonia,  should  form  the  main  therapeutic 
agents  to  be  relied  on.  In  the  treatment  of 
capillary  bronchitis,  ammonia  and  alcoholic 
stimulants  should  be  exhibited  from  the  com- 
mencement, and  the  quantity  must  depend  on 
the  symptoms  of  each  case.  There  is  one 
source  of  danger  in  capillary  bronchitis  which 
should  always  he  borne  in  mind,  viz.,  the  for- 
mation of  fibrinous  clots  in  the  heart  and  great 
blood-vessels.  These  deposits  become  the  proxi- 
mate cause  of  death  in  many  cases,  and  they 
are  especially  liable  to  form  when  there  is 
emphysema  of  the  lungs.  Their  presence  may 
often  be  diagnosed  during  life  from  the  respira- 
tion becoming  very  rapid,  shallow,  and  laboured : 
the  pulse  being  quick,  weak,  and  small,  although 
the  heart  may  at  the  same  time  be  felt  beating 
vigorously ; the  voice  becoming  feeble ; and 
the  mental  faculties  seriously  impaired.  After 
death  a large  portion  of  the  cavities  of  the 
heart  may  be  found  occupied  by  these  deposits, 
the  calibre  of  the  pulmonary  artery  and  aorta 
being  also  materially  diminished  by  them. 

In  many  cases  of  bronchitis,  when  the  acute 
symptoms  have  passed  off  hut  the  secretion  con- 
tinues profuse,  as  well  as  in  those  cases  called 
bronchorrhcea,  the  exhibition  of  iron  is  often 
of  great  service.  It  seems  to  give  tone  to  the 
relaxed  capillaries  qf  the  mucous  membrane,  and 
to  diminish  the  secretion.  It  may  be  given  in  com- 
bination with  carbonate  of  ammonia,  in  the 
form  of  the  ammonio-eitratc  ; cr  the  tincture  of 
the  perchloride  with  ether  or  spirits  of  chloro- 
form may  he  employed,  or  the  ethereal  tincture 
of  the  acetate  (Ph.  Ger.),  which  is  a very  valuable 
preparation  in  some  cases. 

Inhalations  are  useful  for  allaying  cough  in 
the  earlier  stages  of  the  affection,  or  for  the 
relief  of  spasm.  In  some  cases  of  severe 
bronchitis  where  apnrna  has  been  threatened, 
recovery  has  followed  the  exhibition  of  large 
doses — half  an  ounce — of  turpentine.  In  this 
dose,  however,  it  sometimes  produces  alarming 
symptoms,  and  it  is  perhaps  better  to  exhibit  it 
in  smaller  quantities  tentatively.  An  emetic  may 
be  serviceable,  especially  in  children,  if  the  tubes 
are  much  loaded.  Children  suffering  from  severe 
attacks  of  bronchitis  should  not  be  allowed  to 
sleep  long,  for  fear  of  dangerous  accumulation  in 
the  tubes,  and  care  should  be  taken  that  the 
secretions  do  not  collect  about  the  back  of  the 
mouth. 

Patients  should  not  be  kept  on  a low  diet  even 
at  the  beginning  of  an  attack,  and  as  the  disease 
progresses  the  quantity  of  food  allowed  may  be 
increased  according  to  the  appetite.  In  the 
treatment  of  gouty  bronchitis,  or  bronchitis 
associated  with-  a tendency  to  the  formation  of 
uric  acid  in  the  system,  colchicum  and  the 
alkalis  must  he  given,  and  the  general  measures 
used  which  are  applicable  to  tlio  constitutional 
condition.  If  bronchitis  depend  o»  a gouty  state. 


BRONCHI.  DISEASES  OF. 


it  will  not  yield  to  the  ordinary  treatment,  but 
when  its  cause  is  recognised  and  the  appro- 
priate remedies  are  administered,  the  symptoms 
usually  soon  begin  to  improve. 

In  the  cases  of  bronchitis  which  are  connected 
with  heart-disease,  and  especially  with  mitral 
regurgitation,  digitalis  is  often  of  great  value. 
By  steadying  the  action  of  the  heart  it  relieves 
the  overloaded  pulmonary  veins,  and  thus 
directly  diminishes  the  congestion  of  the  mucous 
membrane,  as  mentioned  in  the  paragraph  relat- 
ing to  the  pathology  of  the  disease. 

it  is  impossible  in  the  scope  of  this  article  to 
refer  specially  to  the  treatment  of  bronchitic 
attacks  arising  from  the  various  kinds  of  me- 
chanical irritation.  There  is,  however,  one 
form  of  bronchitis  which  may  be  mentioned, 
viz.,  that  connected  with  hay-fever,  arising 
either  from  the  inhalation  of  pollen,  or  caused 
by  some  peculiar  atmospheric  influence  acting 
on  a peculiar  nervous  system.  It  is  very  difficult 
of  cure.  In  the  writer’s  experience  no  remedies 
seem  to  have  any  particular  influence  over  it, 
and  it  is  usually  only  to  be  relieved  by  removing 
the  patient  from  the  exciting  cause  of  the  affec- 
tion. In  the  treatment  of  bronchitis  depending 
on  constitutional  syphilis,  the  appropriate  mea- 
sures for  that  affection  must  be  resorted  to. 

2.  Chronic  Inflammation — Chronic  Bron- 
chitis— Chronic  Bronchial  Catarrh. 

Definition. — A chronic  inflammation  or  con- 
gestion, more  or  less  extensive,  of  the  bronchial 
tubes. 

^Etiology.  — Chronic  bronchitis  very  fre- 
quently results  from  repeated  attacks  of  the  acute 
disease,  but  it  may  be  chronic  from  the  begin- 
ning. Emphysema  of  the  lungs,  dilated  bronchi, 
and  phthisis  are  causes  of  the  complaint;  as  are 
also  various  forms  of  heart-disease,  and  some 
blood-affections,  such  as  gout.  The  inhalation  of 
irritating  particles  gives  rise  to  chronic  bronchitis ; 
and  it  is  also  met  with  in  connexion  with  chronic 
alcoholism.  It  is  most  common  amongst  the  old. 

Anatomical  Chahactf.rs.  • — ■ The  bronchial 
mucous  membrane  is  discoloured,  being  of  a dull- 
red  tint,  greyish,  or  brownish.  The  discoloration 
is  for  the  most  part  partially,  but  sometimes 
evenly,  diffused.  There  is  swelling  and  increased 
firmness  of  the  mucous  membrane,  and  the  sub- 
mucous tissue  in  old-standing  cases  becomes 
infiltrated  and  indurated.  The  fibrous  and  mus- 
cular tissues  are  hypertrophied  ; the  cartilages  in 
the  larger  tubes  are  sometimes  calcareous  ; and 
there  is  generally  more  or  less  emphysema  of  the 
lungs. 

Symptoms. — The  symptoms  of  chronic  bron- 
chitis vary  greatly  in  different  cases.  They 
resemble  in  kind  those  of  the  acute  affection. 
There  is  cough,  expectoration,  pain,  soreness 
or  uneasiness  behind  the  sternum,  with  more  or 
less  dyspnoea.  The  constitutional  symptoms  may 
be  very  slight,  scarcely  any  effect  on  the  general 
health  being  apparent ; or  they  may  be  very  severe. 
Three  forms  of  chronic  bronchitis  are  recognised 
clinically  : — 1.  That  which  includes  the  ordinary 
cases  of  the  disease,  varying  much  in  severity  ; 
2.  that  characterised  by  excessive  secretion — 
bronchorrhaa  ; 3.  that  form  which  is  called  dry 
catarrh. 

1.  In  the  first  form  of  chronic  bronchitis  the 


cough  is  at  first  slight,  perhaps  only  occurring 
during  the  winter,  being  altogether  absent  in  the 
summer.  After  a time  the  attacks  become  more 
frequent,  and  at  last  the  patient  is  never  free 
from  the  affection,  which  is  aggravated  at  times. 
The  cough  in  such  eases  is  more  or  less  severe, 
but  usually  most  so  in  the  morning.  It  is  often 
paroxysmal,  and  sometimes  very  violent.  The 
expectoration,  in  some  cases  being  scanty,  viscid, 
and  difficult  to  discharge,  is  in  others,  especially 
old-standing  cases,  copious  and  easy.  The  sputa 
vary  much  both  in  appearance  and  quantity. 
They  may  be  yellowish-white  muco-purulent 
matter,  or  more  decidedly  purulent,  of  a green- 
ish-yellow or  bright  or  dark  green  colour  ; they 
are  but  little  aerated,  sometimes  not  at  all,  so 
that  they  sink  in  water  ; at  times  they  are  mira- 
mulated  and  quite  opaque.  In  some  cases  the 
expectoration  is  foetid,  constituting  the  form  of 
the  disease  denominated  ‘foetid  bronchitis,’ the 
odour  resulting  either  from  sloughs  of  minute 
portions  of  the  mucous  membrane,  or  from 
chemical  changes  taking  place  in  the  sputa. 
Occasionally  streaks  of  blood  are  met  with. 
Microscopically  the  sputa  are  found  to  consist  of 
epithelium,  pus-cells,  and  granular  matter,  witli 
at  times  blood-corpuscles. 

The  constitution  does  not  suffer  much  in  mild 
attacks,  but  when  chronic  bronchitis  is  permanent 
and  general,  the  system  at  large  sympathises 
more  or  less  severely:  the  appetite  fails,  sleep 
is  disturbed  by  the  cough,  emaciation  sets  in 
and  sometimes  becomes  marked,  but  it  does  not 
proceed  beyond  a certain  point,  unlike  that  of 
phthisis,  which  is  usually  progressive.  In  all 
cases  of  chronic  bronchitis  there  is  great  risk 
of  an  acute  attack  coming  on,  especially  amongst 
the  aged.  These  attacks  are  very  dangerous,  in 
consequence  of  the  rapid  extension  of  the  disease 
throughout  the  lungs,  and  its  asphyxiating  cha- 
racter. 

2.  The  second  class  of  cases  is  characterised 
by  excessive  secretion  from  the  bronchial  tubes 
— Bronchorrhcea.  This  form  is  often  met  with  in 
the  old  and  feeble,  and  especially  in  cases  of 
valvular  disease  of  the  heart.  The  cough  is 
paroxysmal,  and  attended  with  the  expectoration 
of  a large  quantity  of  thin  watery  glairy  fl  uid,  or 
of  thick  ropy  gluey  matter,  like  white  of  egg. 
The  quantity  expectorated  is  sometimes  very 
large.  This  form  of  bronchitis  may  cause  death 
somewhat  suddenly  by  apneea.  During  the 
paroxysms  of  cough  there  is  dyspnoea,  but  at 
other  times  it  is  absent,  except  -when  heart- 
disease  exists.  The  constitution  suffers  little, 
and  the  flux  seems  sometimes  to  be  beneficial  in 
cases  of  obstructive  cardiac  disease. 

3.  The  third  variety,  or  Catarrhe  see,  is  cha- 
racterised by  very  troublesome  cough,  oppression 
of  breathing,  tightness  of  the  chest,  and  some- 
times severe  dyspnoea.  Expectoration  is  either 
absent  or  very  scanty,  the  sputa  consisting  of 
small  masses  of  tough  viscid  semi-transparent 
mucus.  There  is  usually  no  febrile  disturbance. 
The  disease  is  met  with  in  gouty  people,  and  is 
often  associated  with  emphysema  of  the  lungs. 
Pathologically  it  seems  to  consist  in  a congested 
condition  of  the  bronchial  tubes. 

Physical  Signs. — Inspection  reveals  nothing 
abnormal  in  the  form  or  size  of  the  chest,  unlesn 


BRONCHI,  DISEASES  OE. 


188 

emphysema  of  the  lungs  is  present.  The 
expansion  in  long-standing  cases  is  usually 
deficient ; the  chest  being  raised  more  than  in 
health.  Expiration  is  often  prolonged.  Rhon- 
chal  fremitus  may  be  felt  more  or  less,  depending 
on  the  state  of  the  bronchial  tubes.  There  is 
often  increased  resonance,  from  the  presence  of 
emphysema.  The  breath-sounds  are  more  or 
less  changed ; they  are  harsh  and  loud,  and  the 
expiration  is  prolonged  in  cases  that  have  ex- 
isted for  a considerable  period.  The  rhonchi 
vary ; they  are  dry,  coarse,  moist,  or  bubbling 
according  to  the  condition  and  contents  of  the 
tubes.  Vocal  resonance  varies ; it  may  be  bron- 
chophonic,  normal,  or  deficient. 

Diagnosis. — There  is  usually  but  lit'Je  diffi- 
culty in  the  diagnosis  of  chronic  bronchitis.  The 
affection  is  most  likely  to  be  confounded  with 
phthisis,  but  the  character  and  degree  of  the 
wasting,  and  the  absence  of  increased  tempera- 
ture, of  haemoptysis,  and  of  the  physical  signs 
of  consolidation,  will  generally  enable  the  prac- 
titioner to  decide  in  favour  of  the  less  important 
disease.  The  main  difficulty  lies  in  the  diagnosis 
of  cases  where  the  bronchi  are  dilated  ; this  will 
1 e referred  to  hereafter. 

Prognosis. — Although  in  itself  not  a danger- 
ous malady,  chronic  bronchitis  becomes  so  in 
consequence  of  the  liability  which  exists  to  the 
occurrence  of  acute  symptoms  ; when  once  es- 
tablished in  middle  or  advanced  age  it  is  almost 
incurable.  The  complaint  is  further  serious  from 
its  tendency  to  produce  emphysema  and  dilatation 
of  the  bronchi.  Per  sc  it  can  scarcely  ever  be 
said  to  kill. 

Treatment. — No  case  of  chronic  bronchitis 
can  be  successfully  treated  without  due  regard 
to  the  constitutional  condition  of  the  patient. 
In  some  cases  it  is  impossible  to  cure  the 
lisease,  and  all  efforts  should  be  directed  to- 
wards preventing  its  extension  ; alleviating  the 
symptoms  to  which  it  gives  rise ; and  warding 
off  acute  attacks.  Attention  must  be  especially 
paid  to  the  state  of  the  heart  and  kidneys;  the 
duration  of  the  affection;  the  age  of  the  patient; 
the  characters  of  the  expectoration  ; the  state  of 
the  lungs,  as  to  the  existence  of  emphysema  or 
other  morbid  conditions ; and  the  presence  of 
gout  or  rheumatism.  Speaking  generally,  chronic 
oronchitis  must  be  treated  by  the  use  of  a gene- 
rous diet,  with  more  or  less  stimulants;  by  the 
exhibition  of  expectorants  and  tonics  ; and  by  the 
a voidance  of  all  depressing  measures.  The  func- 
tion of  the  liver  must  be  looked  to,  and  the 
administration  of  a few  doses  of  blue  pill  with  a 
saline  aperient  often  gives  great  relief,  and 
alters  the  character  of  the  bronchial  secretion. 
If  gout,  or  a tendency  to  the  formation  of  uric 
acid,  is  present,  eolckicnm  with  alkalis  and 
other  remedies  for  gout,  such  as  a course  of 
Friedrichshall  or  Carlsbad  waters,  will  prove  of 
great  service.  If  cardiac  disease  exist,  whether 
in  the  form  of  valvuLir  incompetence,  or  of  weak, 
flabby,  or  dilated  heart,  digitalis  combined  with 
iron  frequently  produces  marked  benefit. 

In  the  treatment  of  ordinary  cases  of  chronic 
bronchitis,  not  dependent  on  any  organic  disease 
or  constitutional  condition,  the  patient’s  general 
health  has  to  he  looked  to.  The  affection 
has  a tondency  to  lower  the  health  and  to  diminish 


strength,  and  therefore  the  various  tonics  may 
often  be  given  with  great  benefit.  Of  these  the 
most  useful  are  quinine,  the  preparations  of 
iron,  and  those  of  zinc.  Cod-liver  oil  is  also  very 
valuable  in  some  eases  where  there  is  much  wast  - 
ing. The  eases  of  bronchitis  marked  by  excessive 
secretion  are  generally  best  treated  by  tonics ; 
whilst  those  where  the  secretion  is  slight — cases  of 
‘dry  catarrh’ — being  often  associated  with  a gouty 
condition  of  the  system,  are  more  amenable  to 
the  use  of  colchicum,  the  alkalis,  iodide  of  potas- 
sium, and  mineral  waters. 

In  what  may  be  called  the  symptomatic  treat- 
ment of  the  affection,  the  various  expectorants 
are  useful — carbonate  of  ammonia,  ipecacuanha, 
squill,  cascarilla,  senega,  chloroform,  &c.,  and 
these  may  often  be  beneficially  combined  with 
some  form  of  tonic.  In  many  cases  of  chronic 
bronchitis  the  expectorating  power  is  diminished, 
and  stimulating  expectorants  are  of  great  service. 
Great  caution  must  be  exercised  in  the  adminis- 
tration of  opiates  and  other  narcotics  or  sedatives. 
When,  however,  the  mucous  membrane  is  very 
irritable,  and  when  there  is  but  little  secretion 
with  a troublesome  cough,  these  remedies  are  in- 
dicated. Opium  is  of  great  value,  and  chloral- 
hydrate  is  also  very  useful,  as  well  as,  in  some 
cases,  henbane  and  hydrocyanic  acid,  cr,  when- 
ever spasm  is  present,  stramonium,  lobelia,  the 
others,  and  cannabis  indica.  Inhalations  are 
sometimes  very  beneficial,  as  of  the  vapour  of 
warm  water,  iodine,  creasote,  and  other  sub- 
stances. The  inhalation  of  creasote  is  especially 
valuable  if  the  expectoration  is  foetid. 

Counter-irritation  is  one  of  the  most  impor- 
tant means  we  possess  of  relieving  chronic 
bronchitis.  The  irritation  should  not  be  exces 
sive,  hut  should  he  long-continued.  The  appli 
cation  of  iodine  over  a large  surface  of  the  chest, 
so  as  to  keep  up  a constant  slight  inflammation 
of  the  skin,  is  perhaps  the  best  that  can  be  used; 
but  other  irritants  may  be  tried,  such  as  sina- 
pisms, or  the  various  stimulating  liniments. 

The  general  management  of  the  patient  is 
most  important.  A mild  climate  should,  if  pos- 
sible, be  chosen  in  the  winter.  The  patient 
should  live  as  far  as  possible  in  an  atmosphere 
which  is  mild  and  dry.  Although  some  cases 
are  benefited  by  a moist  and  warm  atmosphere, 
the  majority  of  cases  of  chronic  bronchitis  do 
better  in  a drier  one.  The  skin  must  be  carefully 
looked  to,  its  action  should  he  well  maintained, 
and  warm  clothing  always  worn.  A moderate 
amount  of  some  alcoholic  stimulant  is  generally 
desirable ; and  the  food  should  be  nutritious  and 
of  easy  digestion.  Relief  will  often  he  found 
from  wearing  a respirator. 

3.  Plastic  Bronchitis. — This  is  a rare  form 
of  disease,  and  of  its  particular  causes  nothin" 
is  known.  It  is  perhaps  connected  with  some 
peculiar  diathesis.  Sir  John  Rose  Cormack  sug- 
gests thatitmaybeavarietyof diphtheria.  It mav 
occur  in  either  sex, and  atanyperiod  of  life,  but  is 
most  frequent  in  those  who  are  of  a strumous 
or  phthisical  constitution.  It  has  been  known, 
however,  to  attack  persons  of  apparently  healthy 
frame  and  in  the  enjoyment  of  robust  health. 

Anatomical  Characters.- — Plastic  bronchitis 
is  anatomically  characterised  bv  the  formation 
of  concretions  in  the  bronchial  tubes.  These 


BRONCHI,  DISEASES  OF.  i«S 


loneretions  consist  of  fibrinous  exudation  from  the 
mucous  membrane ; they  form  casts  of  the  tubes, 
and  are  expectorated.  These  casts  are  either 
solid  or  hollow,  and  on  examination  are  always 
found  to  consist  of  concentric  laminae.  They  are, 
for  the  most  part,  poured  out  into  the  finer  bron- 
chial tubes,  sometimes,  however,  into  the  larger 
ones,  but  never  into  the  trachea.  The  casts  are 
Of  a whitish  colour,  but  they  are  often  stained 
with  blood.  Microscopically  they  consist  of  an 
amorphous  or  fibrillar  material,  with  exudation- 
corpuscles,  granular  matter,  and  oil-globules. 

Symptoms. — This  disease  is  essentially  chronic, 
but  it  has  been  met  with  as  an  acute  affection  in 
children.  At  the  times  wdien  the  casts  of  the 
tubes  are  expelled  exacerbations  occur,  the 
patient  being  attacked  with  pain  and  a sense  of 
constriction  across  the  chest,  dyspnoea,  and  an 
irritating  cough.  After  a time,  varying  from 
some  hours  to  a few  days,  the  dyspnoea  becomes 
very  urgent,  and  the  cough  very  severe ; then, 
after  a paroxysm  of  coughing,  it  is  found  that 
the  patient  has  expectorated  some  solid  material, 
either  with  or  without  blood,  usually  intermixed 
with  ordinary  bronchitic  sputa.  The  dyspnoea 
and  cougli  now  subside,  to  recur  after  an  interval 
of  a few  hours  or  longer.  The  disease  may  last 
for  weeks,  months,  or  even  years,  marked  from 
time  to  time  by  severe  accessions,  and  relieved 
by  the  expulsion  of  further  concretions.  The 
matter  expelled  is  often  in  small  masses,  but  at 
times  casts  of  bronchial  tubes  with  several  rami- 
fications are  expectorated.  The  disease  may 
recur  at  intervals  for  many  years ; the  general 
health  in  such  cases  does  not  seem  to  suffer,  the 
breathing  during  the  intervals  being  unaffected. 
There  is,  in  some  instances,  an  absence  of  febrile 
symptoms  during  the  attack,  whilst  in  others  the 
fever  is  more  marked.  With  the  general  symp- 
toms are  combined  the  physical  signs.  These 
are  somewhat  poculiar.  The  bronchial  tubes 
being  obstructed,  portions  of  lung  are  deprived 
of  air  ; the  breath-sounds  are  therefore  faint  or 
absent.  There  may  be  dulness  more  or  less 
complete  on  percussion,  from  collapse  of  the  lung- 
substance,  or,  as  occurs  in  some  cases,  from 
localized  pneumonia.  Apncea  may  be  threatened 
if  a large  tube  is  blocked  up. 

Diagnosis. — The  diagnosis  of  this  affection 
turns  on  the  peculiarity  of  the  expectorated 
matters.  Doubtless  tire  disease  may  be  mis- 
taken for  ordinary  bronchitis  or  pneumonia,  but 
when  once  the  fibrinous  casts  of  the  tubes  are 
observed  in  the  sputa,  the  nature  of  the  case 
becomes  clear. 

Prognosis,  Duration,  Terminations,  and 
IvIortaxity. — The  prognosis,  if  the  disease  is 
uncomplicated,  is  favourable  ; but  there  is  great 
liability  to  recurrence.  The  complaint  may  last 
for  many  years  ; and  may  terminate  in  complete 
recovery.  A fatal  result  generally  depends  on  the 
presence  of  some  other  organic  disease,  such  as 
phthisis  or  pneumonia. 

Treatment. — But  little  can  be  advanced  as  to 
ihe  value  of  any  special  treatment  for  this  affec- 
tion. Iodide  of  potassium  is  said  to  have  been 
employed  with  success.  The  chief  object  should 
be  to  maintain  the  general  health  by  hygienic 
measures,  and  the  exhibition  of  tonics,  such  as 
iron,  Quinine,  and  cod-liver  oil,  especially  if  there 


be  any  tubercular  taint.  During  the  exacerba- 
tions the  administration  of  ammonia  and  the  use 
of  inhalants  should  be  resorted  to,  and  the 
general  principles  on  which  ordinary  bronchitis 
is  treated  should  be  carried  out. 

4.  Dilatation. — Bronchiectasis. — This  is  a 
rare  disease,  which  arises  as  a secondary  affection. 
It  is  often  associated  with  serious  pulmonary 
mischief,  and  is  at  times  difficult  of  diagnosis. 
There  are  two  forms  of  bronchiectasis,  namely 
general  or  uniform  dilatation  ; and  saccular  or 
ampullary  dilatation. 

1.  The  geyieral  or  uniform  bronchiectasis  con- 
sists in  a cylindrical  dilatation  of  one  or  more  of 
the  tubes  throughout  a considerable  portion  of 
their  extent.  The  tubes  are  evenly  widened  for 
the  most  part,  and  end  abruptly. 

2.  The  saccular  form  of  bronchiectasis  con- 
sists of  a globular  dilatation  of  a tube  at  one 
point,  or  at  several  points.  The  dilatations  vary 
in  size,  being  from  half  an  inch  to  an  inch  or 
more  in  diameter.  On  the  tracheal  side  they 
usually  communicate  with  a slightly  enlarged 
bronchial  tube,  whilst  on  the  peripheral  side  the 
continuity  of  the  tube  is  almost  or  entirely  lost 
from  narrowing  or  actual  obliteration.  Some- 
times the  cavities  communicate  with  one  another. 

The  two  forms  of  bronchiectasis  ofcen  coexist. 

The  walls  of  the  dilatations  undergo  chariges 
in  the  course  of  the  disease.  The  mucous  mem- 
brane becomes  granular,  swollen,  and  congested; 
while  at  a later  stage  it  presents  a velvety  or 
villous  appearance,  and  in  some  cases  there  is 
even  ulceration  with  superficial  necrosis.  The 
muscular  and  elastic  coats  become  atrophied,  and 
coincidently  with  this  dilatation  increases.  At 
times  the  wasting  of  these  coats  is  partial ; some 
portions  of  the  walls  retaining  their  natural 
volume,  and  forming  bands  or  ridges  elevated 
above  the  surrounding  membrane.  The  dilated 
tubes  occasionally  present  an  appearance  of 
hypertrophy ; the  walls  aro  thickened,  but  the 
thickening  depends  on  changes  which  have  taken 
place  in  the  mucous  membrane.  The  cartilages 
resist  the  destructive  metamorphoses  longer  than 
the  other  structures,  but  they  sometimes  partake 
of  them.  The  contents  of  the  tubes  may  be  either 
muco-pus,  or  pus ; and  casts  of  the  minute  bronchi 
are  met  with.  At  times  the  contents  are  very 
fcetid.  Crystals  of  margarin  are  occasionally 
found,  and  sometimes  fragments  of  pulmonary 
tissue.  It  is  said  that  the  contents  may  become 
calcareous. 

Dilatation  of  the  bronchi  may  be  unattended 
with  any  change  in  the  surrounding  lung-tissue, 
but,  generally  speaking,  condensation  of  the 
latter  takes  place,  either  as  the  result  of  pressure 
or  of  chronic  pneumonia.  In  some  instances 
the  tissue  forms  an  abscess,  in  the  centre  of 
which  the  walls  of  the  bronchus  are  found,  whilst 
in  others  the  walls  of  the  bronchi  and  the  sur- 
rounding tissue  are  destroyed  by  gangrenous 
inflammation.  It  is  generally  not  difficult  to 
distinguish  between  a phthisical  cavity  and  a 
dilated  bronchus.  The  latter  is  not  characterised 
by  the  broken  irregular  surface  which  usually 
exists  in  the  former;  its  shape  is  generally  more 
regular  ; and  it  is  usually  continuous  with  bron- 
chial tubes.  The  surrounding  lung-tissue  han 
no  tubercular  infiltration. 


190  BRONCHI,  DISEASES  OF. 


The  mechanism  of  bronchiectasis  has  occupied 
much  attention.  It  is  probable  that  the  elastic 
and  muscular  fibres  lose  their  elasticity  and  con- 
tractility as  the  result  of  chronic  inflammation, 
and  thus  yield  to  the  distending  influence  of 
coughing.  When  once  a dilatation  is  produced, 
accumulation  of  the  secretions  takes  place, 
which  tends  further  to  increase  the  dilatation. 

Symptoms. — The  symptoms  of  bronchiectasis 
are  those  of  chronic  bronchitis  aggravated  in 
some  important  respects.  The  cough  is  frequent 
and  paroxysmal.  The  expectoration  is  Tery 
abundan';,  very  purulent,  and,  when  the  disease 
has  lasted  some  time,  very  foetid.  The  breath 
also  becomes  fetid.  Haemoptysis  is  occasionally 
met  with,  even  to  a considerable  extent.  There 
is  more  wasting  than  in  ordinary  bronchitis, 
and  the  blood  is  more  imperfectly  aerated. 
Night-sweats  are  not  uncommon.  In  fact,  the 
general  symptoms  approach  those  of  phthisis. 
The  digestive  functions  are  usually  not  much 
impaired. 

Physical  Suns. — The  movement  of  expansion 
is  diminished  in  bronchiectasis,  while  that  of 
expiration  is  prolonged.  Over  the  affected  por- 
tions of  the  lung  there  may  be  slight  retraction. 
Vocal  fremitus  is  increased,  and  rhonchal  fre- 
mitus is  sometimes  well  marked.  The  percussion- 
note  is  altered.  If  a dilated  tube  is  surrounded 
by  condensed  lung-tissue,  or  is  full  of  secretion, 
there  is  dulness  on  percussion ; but  if  it  is  situated 
near  the  surface  and  empty,  some  degree  of  tu- 
bular resonance  may  exist.  Cracked-pot  sound 
may  be  at  times  elicited.  The  respiratory  sounds 
are  harsh,  or  loudly  bronchial  with  a more  or  less 
blowing  character,  and  they  may  be  distinctly 
cavernous.  Vocal  resonance  is  often  greatly 
increased.  The  pulse  becomes  rapid  in  the  later 
stages.  The  temperature  rarely  if  ever  reaches 
the  height  that  it  does  in  phthisis  with  cavities, 
and  the  daily  oscillations  are  not  so  marked. 

Diagnosis. — The  main  difficulty  as  regards 
diagnosis  is  in  the  differentiation  of  certain 
■ases  of  phthisis  with  cavities  from  bronchiec- 
tasis with  large  globular  dilatations.  The  points 
to  be  relied  on  are  that  in  the  latter  disease  the 
morbid  physical  signs  are  usually  met  with  at 
the  middle  and  lower  parts  of  the  lungs,  whilst 
in  ordinary  phthisis  they  are  found  at  the  apex  ; 
that  the  temperature  differs  in  the  two  affections 
as  mentioned  above  ; that  emaciation  and  night- 
sweats  are  not  so  marked  in  bronchiectasis  ; and 
that,  if  cases  are  watched,  there  is  usually  ob- 
served a progressive  advance  of  symptoms  in 
phthisis,  whilst  in  bronchiectasis  the  symptoms 
may  remain  stationary.  In  phthisis  signs  of 
consolidation  precede  those  of  cavities,  whilst 
they  follow  them  in  bronchiectasis.  Bronchial 
dilatations  and  tuberculous  cavities  have  been 
found  in  the  same  lung.  The  fetor  of  the  breath 
and  sputa  in  bronchiectasis  may  cause  a sus- 
picion that  gangrene  of  the  lung  is  present ; 
but  the  general  symptoms  will  usually  enable 
the  practitioner  to  differentiate  between  the  two 
affections. 

Prognosis. — Bronchial  dilatation  is  probably 
never  cured.  It  may  last  for  years. 

Treatment. — The  treatment  of  bronchiectasis 
must  be  that  of  chronic  bronchitis  with  the  use 
of  auch  measures  as  are  applicable  to  wasting 


diseases  in  general.  The  fetor  of  the  breath  is 
best  relieved  by  the  inhalation  of  creasote. 

5.  Harrowing  or  Obstruction. — Narrowing 
or  obstruction  of  the  bronchial  tubes  is  by  no 
means  uncommon,  and  may  depend  on  intrinsic 
or  extrinsic  causes.  Complete  obliteration  of  a 
tube  is  sometimes  found  in  connection  with 
bronchiectasis,  immediately  beyond  a globular 
dilatation. 

tEtiology. — The  intrinsic  causes  of  obstruc- 
tion are  a thickening  of  the  mucous  membrane 
resulting  from  bronchitis ; the  retention  of  viscid 
secretions  ; the  exudation  of  plastic  material  into 
the  interior  of  the  tubes ; and  the  deposition 
therein  of  tubercle  or  cancer. 

Amongst  the  principal  extrinsic  causes  are : 
the  pressure  of  adjacent  tuberculous  or  cancerous 
deposits ; the  contraction  of  plastic  matter  exuded 
into  the  tissues  surrounding  the  tubes  ; solid 
formations  in  the  pleura;  enlarged  bronchial 
glands ; and  aneurismal  and  other  thoracic 
rumours. 

Obstruction  is  most  frequently  met  with  in 
the  smaller  tubes,  but  the  pressure  of  thoracic 
tumours  not  unfrequently  causes  obstruction,  or 
even  obliteration  of  a main  bronchus,  which 
occasionally — as  in  the  case  of  aneurisms — 
becomes  perforated. 

Symptoms. — If  a large  bronchial  tube  becomes 
suddenly  and  greatly'  obstructed,  dyspncea  of  an 
urgent  character  sets  in,  aud  death  from  apncea 
may  speedily  result,  unless  the  obstruction  be 
removed.  When  the  obstruction  is  on  a smaller 
scale,  being  confined  to  the  smaller  tubes,  or  when 
a large  tube  suffers  only'  from  slow,  gradually 
increasing  obstruction,  the  sy'inptoms  are  by  no 
means  urgent  for  a time,  and  slight  dyspncea, 
sometimes  accompanied  by  stridor,  is  the  most- 
marked  feature. 

Physical  Signs.— Complete  obstruction  of  a 
bronchial  tube  invariably'  leads  to  collapse  of 
the  portions  of  the  lung  to  which  the  tube  is  dis- 
tributed, and  thus  an  entire  lung  may  collapse  if 
its  main  bronchus  be  obliterated.  Where  partial 
collapse  is  produced,  emphysema  of  the  neigh- 
bouring lung-tissue  commonly  follows,  and  if 
one  lung  become  collapsed,  the  opposite  lung 
becomes  enlarged  and  emphysematous.  The 
existence  of  collapsed  lung  gives  rise  to  dulness 
on  percussion  over  the  affected  part,  unless  this 
be  situated  away  from  the  chest- walls,  or  masked 
by  the  presence  of  emphysema.  Further,  ob 
struction  of  the  bronchi  causes  a weakness  or 
deficiency  of  the  respiratory  sounds,  with  a 
prolonged  expiratory'  murmur,  attended  at  times 
with  sonorous  and  sibilant  rhonchi.  Over  the 
collapsed  portion  of  the  lung,  or  over  portions  of 
the  lung  supplied  by  a tube  which  has  become 
completely  obstructed,  the  breath-sounds  are 
absent.  Deficiency  or  absence  of  vocal  vibration 
is  another  physical  sign  of  obstructed  bronchial 
tubes. 

Treatment. — The  treatment  of  obstruction  of 
the  bronchi  must  depend  on  the  nature  of  its 
cause.  The  chief  interest  of  the  affection  arises 
from  the  means  of  diagnosis  of  thoracic  tumours 
which  it  may  afford. 

6.  Cancer. — Cancer  of  the  bronchial  tubes 
occurring  independently  of  cancer  in  the  lungs, 
or  mediastina,  is  probably  never  seen  ; but  can- 


BRONCHI,  DISEASES  OF. 
cerous  matter  has  been  found  in  the  tubes : 
(1)  in  cases  where  the  lungs  have  been  infiltrated 
with  a similar  deposit;  (2)  where  a cancerous 
tumour  connected  with  the  root  of  a lung  has 
perforated  a tube ; and  (3)  in  some  cases  of  can- 
cerous disease  of  the  lung,  a tumour  of  a similar 
nature  being  fouud  connected  with  the  mucous 
membrane  of  a tube.  (4)  Cancerous  matter  has 
also  been  found  in  transitu  in  a tube,  having 
been  detached  from  a cancerous  mass. 

A.  T.  H.  "Waters. 

BRONCHIAL  GLANDS,  Diseases  of. — 

Synon.  : Fr.  Adenopathie  I'rachbo-bronchique  ; 
Ger.  Krankhdten  der  Bronchialdrusen. 

Definition. — Disease  of  those  lymphatic  glands 
which  are  situated  at  the  b ifurcation  of  the  trachea, 
between  the  right  and  left  bronchus,  or  upon  these 
tubes  and  their  primary  divisions. 

General  Description. — A short  reference  to 
the  anatomical  relation  of  these  glands  in  con- 
nexion with  their  pathological  and  clinical  history 
will  be  useful.  Taking  the  bifurcation  of  the 
trachea  as  a starting  point,  we  find  in  the  space 
between  the  right  and  left  bronchus  a group  of 
glands.  They  are  from  ten  to  fifteen  in  number, 
and  they  vary  in  size  from  that  of  a small  pea  to 
that  of  an  almond.  The  glands  towards  the  right 
bronchus  are  larger  than  those  towards  the  left. 
Glands  are  also  situated  upon  the  tubes ; they  are 
few  in  number  and  small.  The  vascular  supply  of 
the  glands,  which  is  free,  is  derived  from  the  bron- 
chial arteries,  and  the  blood  is  returned  to  the 
bronchial  veins.  Afferent  lymphatics  reach  the 
glands  from  the  lungs,  from  the  pleura,  from  the 
neck,  and  other  neiglibouringparts.  Besides  these 
groups  of  comparatively  large  glands,  numerous 
minute  lymphatic  glands  are  found  in  connection 
with  the  primary  division  of  the  bronchi,  chiefly 
at  the  back  of  these  tubes  at  their  bifurcations 
and  at  those  of  the  pulmonary  artery.  The  central 
group  of  glands  is  in  relation  in  front  with 
the  pericardium,  the  arch  of  the  aorta,  and  the 
pulmonary  artery;  behind  with  the  pulmonary 
plexus  of  nerves,  the  oesophagus,  the  aorta,  the 
vena  azygos,  &c.  The  ganglia  on  the  upper, 
anterior,  and  posterior  surfaces  of  the  right 
bronchus  are  four  or  five  in  number  and  smaller 
than  those  of  the  central  group.  Their  situation 
brings  them  into  relation  with  the  arch  of  the 
aorta,  the  innominate  and  subclavian  arteries, 
with  the  brachio-cephalic  vein,  and  with  the 
vena  azygos,  the  pneumogastric  nerve,  and  its 
recurrent  branch.  The  ganglia  on  the  left  bron- 
chus are  still  smaller  than  those  of  the  right 
side.  Their  position  gives  them  relations  with 
the  arch  of  the  aorta,  the  origin  of  the  left 
carotid  and  subclavian  arteries,  the  left  branch  of 
the  pulmonary  arteries,  with  the  large  veins, 
with  the  left  pneumogastric  nerve,  and  especially 
with  its  recurrent  branch.  Lastly  it  should  be 
stated,  as  a guide  in  clinical  examination,  that  the 
bifurcation  of  the  trachea  takes  place  in  front 
of  the  body  of  the  fifth  dorsal  vertebra,  or  between 
the  fourth  and  fifth,  and  behind  the  lower  end 
of  the  first  bone  of  the  sternum.  The  glands, 
except  when  diseased,  are  proportionately  larger 
in  children  than  in  adult  or  aged  persons.  Know- 
ing that  these  glands  in  common  with  other 
lymphatic  glands,  are  liable  to  such  diseases  as 


BRONCHLAL  GLANDS.  191 

enlargement,  abscess,  morbid  deposits,  growths, 
and  other  textural  changes,  and  bearing  in  mind, 
as  just  mentioned,  their  relations  to  surrounding 
organs,  we  can  readily  see  that  the  study  of  their 
diseased  conditions  is  important.  Not  only7  is 
their  study  important  in  reference  to  the  diseased 
glands  themselves,  but  by  reason  of  their  modify- 
ing or  masking  the  symptoms  of  disease  in  other 
organs,  as  results  of  the  pressure  which  when  en- 
larged they  cause  on  nerves,  air-passages,  blood- 
vessels, &c.  Throughout  English  and  foreign 
medical  literature  numerous  cases  will  be  found 
described,  in  which  there  existed,  more  or  less 
conspicuously,  striking  disease  of  the  bronchial 
glands,  little  notice,  however,  being  taken  of  less 
striking,  though  far  more  numerous,  examples  of 
disease.  It  is  only  within  a comparatively  recent 
time  that  the  subject  has  received  special  atten- 
tion and  been  discussed  as  a disease  per  se. 

MM.  Rilliet  and  Barthez,  in  their  well- 
known  Traite  dcs  Maladies  dcs  Enfants,  have 
described  the  disease  in  infants,  and  Dr.  "West,  in 
his  work  on  The  Diseases  of  Infancy  and  Child- 
hood, has  fully  and  clearly  described — under  the 
head  of  Bronchial  Phthisis — the  tubercular  dis- 
eases of  these  glands  in  young  subjects.  It  is, 
however,  to  M.  Noel  Gueneau  de  Mussy,  follow- 
ing up  and  widely  extending  the  investigation 
of  his  predecessors,  that  we  are  especially'  in 
debted  for  our  knowledge  of  the  effects  of  these 
lesions,  and  to  his  pupil  M.  Barety,  who  has 
published  an  exhaustive  memoir  upon  these, 
under  the  title  L’ Adenopathie  Tracheo-Bron- 
chique.  The  subject  has  attracted  the  present 
writer’s  notice  since  (or  even  before)  the  year 
1853,  and  the  notes  of  nearly  sixty  cases  which 
have  fallen  under  his  observation  will  form  the 
bases  of  some  of  the  conclusions  to  be  subse- 
quently stated  in  this  article. 

Morbid  Anatomy  and  Pathology.  — The 
bronchial  glands  participate  in  the  diseases  which 
affect  lymphatic  glands  generally,  and  which 
will  be  found  described  in  another  article.  (See 
Lymphatic  System,  Diseases  of.)  Here  it  will 
suffice  to  enumerate  the  principal  morbid  changes 
to  which  they  are  liable,  referring  briefly  to  any 
special  circumstances  in  connection  with  these 
particular  glands. 

a.  The  bronchial  glands  are  liable  to  conges- 
tion with  enlargement  as  are  glands  in  other 
situations.  Hypertrophy  will  be  the  result  of 
this  last  condition  becoming  chronic.  The  glands 
in  this  situation  become  after  childhood  almost 
invariably  studded  with  black  deposits,  the  quan- 
tity of  which  may  be  so  considerable  as  to  con- 
stitute melanoma. 

b.  These  glands  are  liable  to  acute  and 
chronic  inflammation.  Acute  inflammation  in 
this  situation,  terminating  in  abscess,  is  rare, 
but  several  cases  of  the  kind  have  been  re- 
corded. Chronic  inflammation  of  the  glands  is 
by  no  means  uncommon.  It  may  lead  to  perma- 
nent enlargement,  to  contraction  and  induration 
of  the  glandular  textures,  with  the  presence  of 
calcareous  particles,  or  to  abscess.  The  contents 
of  the  abscess  may  be  more  or  less  completely 
absorbed,  leaving  a partially  filled  sac  or  cyst, 
containing  thick  pus  or  cheesy  matter.  Bnt 
these  glands,  when  inflamed  and  enlarged, 
may  form  adhesions  with  surrounding  parts,  and 


192  BRONCHIAL  GLANDS.  DISEASES  OF. 


the  contents  of  an  abscess,  if  it  exist,  may  be 
discharged,  by  an  ulcerative  process,  into  the 
substance  of  a lung,  into  the  mediastinum,  into 
the  trachea,  or  oesophagus,  or  even  into  a blood- 
vessel. General  emphysema  has  occurred  in 
such  cases ; whilst  the  emptied  sac  has  assumed 
in  some  instances  the  character  of  a cavity  con- 
nected with  the  lungs.  When  the  matter  is  dis- 
charged into  the  air-passages,  purulent  expectora- 
tion is  the  result.  Two  or  three  examples  of  such 
eases  were  noticed  in  the  writer’s  observation, 
and  the  possibility  of  their  being  mistaken  for 
the  discharge  from  a cavity  in  the  lungs,  or  an 
empyema,  was  remarked  upon  at  the  time.  The 
abscess  may  discharge  into  the  mediastinum. 
A remarkable  instance  of  the  kind  is  recorded 
in  the  case  of  the  late  much  lamented  Dr.  Fuller. 
A chronic  abscess  of  the  bronchial  glands  had 
opened  into  the  posterior  mediastinum.  This  led 
to  pyaemia,  the  formation  of  abscesses  in  the  brain, 
and  to  the  loss  of  a valuable  life. 

c.  These  glands  are  liable  to  suffer  especially 
from  tuberculous  or  scrofulous  disease,  from  various 
forms  of  malignant  disease,  and  in  secondary  or 
tertiary  syphilis.  Of  the  latter  form  of  disease, 
some  striking  examples  have  fallen  under  the 
notice  of  the  writer,  in  which  symptoms  closely 
resembling  phthisis  existed,  but  which  yielded  to 
treatment  directed  to  the  specific  disease. 

/Etioxogy. — The  causes  which  give  rise  to 
disease  of  the  lymphatic  glands  being  discussed 
in  another  article,  reference  will  here  be  made 
only  to  the  special  cireumstanceswhich  influence 
the  particular  glands,  and  thus  it  will  be  sufficient 
morely  to  allude,  amongst  predisposing  causes , to 
hereditary  predisposition,  to  general  impairment 
of  health,  and  the  like.  With  regard  to  the  in- 
fluence of  age  and  sex,  reference  has  already  been 
made  to  the  works  of  Rilliet  andBarthez,  of  Dr. 
West,  and  of  other  authors  who  described  the  fre- 
quency of  the  disease  in  childhood.  The  writer’s 
observations  made  on  young  persons  and  adults 
show  that  of  58  cases  (of  whom  21  were  males 
and  36  females — in  one  case  the  sex  was  not  re- 
corded) 2 were  under  10  years  of  age,  9 were 
between  10  and  20  years  of  age,  18  were  between 
20  and  30,  and  26  were  over  30  years  of  age.  In 
three  cases  the  age  was  not  stated.  If  these  ob- 
servations justify  any  inference,  it  is  that  females 
are  more  liable  to  disease  of  the  bronchial  glands 
than  males,  and  that  the  disease  occurs  with 
increasing'  frequency  after  the  age  of  puberty. 
Amongst  the  exciting  causes  of  disease  in  these 
glands  we  may  leave  to  he  considered  elsewhere 
those  general  conditions  which  give  rise  to  dis- 
ease in  these  and  other  glands,  sueli  as  scrofula, 
tubercle,  malignant  disease,  &e.,  and  pass  on  to 
the  consideration  of  the  more  immediately  local 
exciting  causes.  Gold  leads  frequently  to  conges- 
tion and  enlargement  of  the  bronchial  glands. 
But  it  is  to  local  irritation  or  inflammatory  dis- 
ease in  organs  or  tissues  with  which  these  glands 
have  a connection  that  the  source  of  diseasemay 
be  frequently  traced.  As  we  find  the  submaxillary 
or  cervical  lymphatic  glands  enlarged  from  irri- 
tation or  disease  in  the  mouth  or  throat,  or  the 
axillary  glands  or  inguinal  glands  enlarged  from 
irritation  or  inflammation  about  the  hands  and 
leet,  so  we  may  find  the  bronchial  glands  en- 
larged temporarily  or  permanently  from  inflam- 


matory disease  in  parts  the  lymphatics  of  which 
pass  to  these  glands.  These  glands  have  been 
observed  to  be  enlarged  in  the  course  of  or  after 
certain  acute  specific  diseases,  such  as  scarlet 
fever,  measles,  and  typhoid  fever.  In  whooping 
cough  this  enlargement  has  been  so  frequently 
observed  by  M.  Gueneau  de  Mussy,  that  he 
believes  this  disease  to  be  an  exanthem  of  the 
bronchial  mucous  membrane,  and  that  this  local 
condition  leads  to  enlargement  of  the  glands,  which, 
again,  by  pressure  on  the  pneumogastric  and  re- 
current nerves,  gives  rise  to  some  of  the  special 
phenomena  of  the  disease,  such  as  crowing  cough, 
and  even  to  the  vomiting  so  frequently  observed 
in  this  disease.  It  is  right  to  remark  here  that 
the  late  Dr.  Hugh  Ley  speaks  interrogatively, 
in  his  work  on  Laryngismus  stridulus,  of  en 
larged  bronchial  glands  being  capable  of  pro- 
ducing a cough  like  that  of  pertussis,  and  he 
further  alludes  to  some  cases  of  whooping  cough 
in  which  the  glands  by  the  side  of  the  trachea 
were  enlarged.  He  asks,  ‘May  it  not  be  that 
an  enlargement  of  these  glands  from  a speci- 
fic animal  poison,  similar  to  that  of  the  parotid 
gland  in  mumps,  is  after  all  the  cause  of  whoop- 
ing cough?’  (Note,  p.  440.)  The  same  author 
gives  several  beautiful  illustrations  of  diseased 
bronchial  glands  pressing  upon  the  pneumogastric 
and  other  nerves.  The  black  deposit  so  often  found 
in  the  glands  is  the  result  of  the  absorption  of  car- 
bonaceous or  pigmentary  matter  from  the  lungs. 

Syjvptoms. — The  symptoms  which  have  been 
recorded  by  the  writer  as  more  or  less  character- 
istic of  the  presence  of  enlargement  of  the  bron- 
chial glands  are  as  follows : — 

1.  Cough,  which  is  noted  as  beiug  a prominent 
symptom  in  39  cases.  In  21  of  these  cases  it 
was  stated  to  have  been  the  most  troublesome  of 
the  symptoms  present.  In  6 cases  it  was  de- 
scribed as  harsh  and  laryngeal ; in  4 cases  spas- 
modic, resembling  whooping  cough.  In  other 
cases,  5 in  number,  it  was  characterised  as  short 
and  hacking,  constant,  incessant,  and  in  one  case 
the  sound  resembled  that  made  by  the  cough  of 
a sheep. 

2.  Pain  is,  in  regard  to  the  frequency  of 
its  occurrence,  the  next  symptom  recorded.  It 
was  mentioned  as  being  present  in  22  cases. 
The  seat  of  pain  was  almost  constantly  referred 
to  the  situation  of  the  fourth  and  fifth  dorsal 
vertebra  at  one  or  both  sides  of  the  spinal 
column.  The  pain  was  mentioned  in  a few  cases 
as  existing  only  in  front,  beneath  and  at  one  or 
both  sides  of  the  upper  end  of  the  sternum 
and  below  the  clavicles.  The  feeling  was  de- 
scribed in  seme  cases  (5)  as  of  distressing  tight- 
ness, and  in  one  case  as  a ‘ spasm.’  Tenderness 
on  pressure  over  the  seat  of  pain  was  very  fre- 
quently observed.  The  persistence  of  the  pain 
was  very  varied. 

3.  Difficulty  of  breathing  was  a noticeable 
symptom  in  several  cases.  In  13  it  was  recorded 
as  being  specially  so ; in  4 it  had  all  the  charac- 
ters of  spasmodic  asthma,  occurring  at  intervals 
and  especially  during  the  night. 

4.  Difficulty  of  swallowing  was  noticed  in  10 
cases  ; in  one  of  these  the  difficulty  was  remarked 
especially  in  swallowing  liquids. 

o.  Hemoptysis  was  present  in  10  cases.  The 
amount  of  blood  varied  in  theso  cases  from 


BRONCHIAL  GLANDS,  DISEASES  OF. 


marked  streaks  to  copious  expectoration,  lasting 
two  or  three  days.  No  case  was  recorded  as 
presenting  this  symptom  except  on  tolerably 
clear  proof  that  it  depended  on  bronchial  gland 
enlargement,  and  on  no  other  cause. 

(i.  Congestion  and  puffiness  of  the  face  hare 
been  mentioned  as  present  in  3 cases. 

7.  Expectoration  of  mucus , such  as  results 
from  bronchial  catarrh,  was  frequently  present. 
Expectoration  of  pus  was  present  in  3 cases. 
In  each  it  resembled  the  contents  of  an  ordi- 
nary glandular  abscess  mixed  with  air.  In  one 
of  these  the  discharge  was  intermittent.  The 
frequent  occurrence  of  cough  without  any  ex- 
pectoration was  remarked  in  many  cases.  Cal- 
careous particles  are  mentioned  also  as  having 
been  expectorated. 

8.  Loss  of  voice  (4  cases)  and  hoarseness  (2 
cases)  are  recorded  as  striking  symptoms. 

9.  Vomiting  is  mentioned  as  having  been 
present  twice. 

10.  Lastly,  the  position  assumed  with  least 
discomfort  by  the  patient  when  in  bed  was 
noticed  in  41  cases.  Of  these  23  rested  on  that 
side  on  which  the  glands  were  mentioned  as 
being  chiefly  if  not  wholly  affected.  In  15  cases 
an  opposite  condition  was  noticed.  In  2 cases 
lying  on  the  back  was  the  most  comfortable 
position.  One  patient,  unable  to  lie  down,  sat 
when  in  bed,  and  stooped  forward.  One  patient, 
a little  boy,  could  only  rest  on  his  face  and  knees. 
This  case  was  further  remarkable  in  reference 
to  the  clearness  with  which  the  disease  was 
recognised  and  the  successful  result  of  subse- 
quent treatment. 

It  might  be  mentioned  here  incidentally  that 
the  glands  of  the  right  side  were  noticed  as  beiDg 
chiefly  affected  in  28  cases,  and  of  the  left  in  22 
cases — in  4 both  sides  seemed  equally  affected, 
and  in  4 no  record  was  made.  The  general 
or  constitutional  symptoms  connected  with  the 
malady  under  notice  need  not  bo  discussed  here. 
They  are  in  nowise  peculiar,  and  will  be  found 
discussed  elsewhere.  The  symptoms  described 
above  have  special  reference  to  the  bronchial 
glands.  The  cough  and  its  peculiar  character- 
istics are,  no  doubt,  in  a great  measure  depen- 
dent on  pressure  or  on  irritation  communicated 
to  the  pneumogastric  nerves  and  theii  branches. 
So  likewise  pain  and  difficulty  of  breathing,  in  a 
great  degree,  through  direct  pressure  on  the  air- 
passages,  may  also  cause  or  aggravate  these 
symptoms.  Aphonia  especially  seems  to  have 
relation  to  the  condition  of  the  recurrent  nerves. 
In  one  of  the  cases  which  the  writer  saw  with 
Mr.  Lennox  Browne,  paralysis  of  the  left  chorda 
vocalis  existed.  The  diagnosis  of  glandular 
disease  was  clear,  a conclusion  confirmed  by  the 
results  of  treatment.  Vomiting  is  mentioned  in 
two  cases.  M.  de  Mussy  says  that  this  is  a 
more  frequent  result  when  the  left  pneumogastric 
nerve  is  pressed  upon.  He  sees  a connexion 
between  the  troublesome  vomiting  which  occurs 
in  some  cases  of  tubercular  disease  of  the  lungs 
witn  like  pressure  upon  nerves.  The  puffiness 
of  the  face  and  eyes  noticed  in  these  cases  is 
due  to  the  pressure  on  the  venous  trunks,  a con- 
dition which  also  accounts  not  only  for  haemop- 
tysis, but  for  bleeding  from  the  nose,  occasionally 
present.  Copious  and  • sometimes  persistent 

13 


1S3 

haemoptysis  has  been  traced  to  the  perforation  of 
a vessel  (ulceration  in  connexion  with  disease 
of  the  glands). 

The  Physical  Signs  noticed  in  the  58  cases 
referred  to  were:  1.  Dulness. — It  was  present  in 
47  cases.  It  was  found  between  the  margin  of 
the  scapula  and  the  spinal  column  at  one  or  both 
sides,  on  a level  with  the  fourth  and  fifth  dorsal 
vertebrae.  It  varied  in  degree,  and  was  more 
readily  manifested  when  the  muscles  of  the  back 
were  made  tense  by  folding  the  arms  across  the 
chest,  and  was  often  strikingly  distinct  when  one 
side  was  contrasted  with  the  other.  Dulness  was 
present  in  front  in  8 cases  (whether  coinciden- 
tally with  dulness  at  the  back  or  not  is  not 
clearly  stated),  beneath  the  top  of  the  sternum 
and  at  each  side  below  the  sterno-clavicular 
junction.  The  dulness  here  was  best  elicited  by 
the  patient  holding  the  head  backwards  whilst 
percussion  was  being  made. 

2.  Flattening  of  the  affected  side  in  front  was 
mentioned  in  3 cases.  Diminished  mobility  of  the 
affected  side,  independent  of  flattening,  was  re- 
corded in  4 cases.  Prominence  in  front  was  not 
recorded  in  any  ease,  though,  no  doubt,  it  occurs 
sometimes. 

3.  The  respiratory  sounds  were  variously  modi  • 
fled.  Marked  tubular  breathing  was  recorded  as 
being  present  over  the  seat  of  disease  in  14  cases 
In  10  the  expiratory  murmur  was  described  a: 
being  very  loud , various  modifications  of  the  in- 
spiratory murmur  being  found  at  the  same  time. 
Feebleness  of  the  respiratory  murmur  as  a whole 
was  noticed  in  14  cases.  In  some  this  deficiency 
extended  over  the  whole  lung;  in  others  it  ex- 
isted over  the  upper  or  lower  portion  of  a lung, 
behind  or  in  front.  The  observations  made  on 
the  voice  by  the  writer  were  few,  but  M.  de 
Mussy  and  M.  Lereboullet  speak  of  a peculiar 
and  increased  reverberation  of  both  the  voice  and 
the  cough.  Dr.  Eustace  Smith  has  described  in 
the  cases  of  children  a venous  hum,  heard  at  the 
root  of  the  neck  when  the  head  is  thrown  back, 
caused  by  the  pressure  of  tho  enlarged  glands  on 
the  venous  trunks. 

Diagnosis. — In  the  present  article  those  cases 
are  not  kept  in  view  in  which  the  bronchial 
glands  becoming  the  seat  of  constitutional  disease- 
in  association  with  other  glands  in  the  neigh- 
bourhood, constitute  large  and  manifest  tumours 
— such  will  be  found  described  under  another 
head  (see  Intrathobacic  Tumours).  Nor  has  it 
been  intended  to  give  prominent  consideration 
to  the  state  of  the  glands  when  they  enlarge  in 
acute  disease — such  as  eruptive  fevers  ; nor  in 
those  diseases — such  as  typhoid — where  the 
glands  play  a secondary  part.  The  writer  has 
been  anxious  to  describe  and  to  assist  in  recog- 
nising the  presence  of  a condition  in  which  the 
disease  of  the  bronchial  glands  constitutes  to 
some  extent  a disease  per  se,  or  gives  rise 
to  complications  which  it  is  important  to  dis- 
criminate. He  believes  the  symptoms  and  signs 
above  described  will  suffice  for  the  purpose, 
always  remembering  that  in  the  present  and 
in  all  similar  instances  it  is  necessary  to  take 
means  for  excluding  in  our  investigations  dis- 
eases which  may  produce  like  phenomena.  Thus-- 
we  may  find  cough,  pain,  tenderness  on  pressure, 
and  aphonia  in  a case  of  hysteria  without  any 


194  BRONCHIAL  GLANDS,  DISEASES  OF. 

trident  structural  disease.  On  the  other  hand 
a small  tumour,  say,  a small  aneurism,  may  pro- 
duce all  the  signs  of  pressure  which  are  above 
given  as  the  signs  of  bronchial  gland-enlarge- 
ment. It  is  the  duty  of  the  physician  to  recog- 
nise these  differences  and  distinctions,  to  trace 
them  to  their  origin,  and  thus  establish  as  far  as 
may  be  the  nature  of  the  disease  under  inves- 
tigation. 

Prognosis  will  in  this,  as  in  like  instances,  so 
entirely  depend  on  the  nature  of  the  disease,  on 
its  amount  and  its  condition,  on  its  relation  to 
and  effects  on  surrounding  organs  and  textures, 
that  each  case  must  be  regarded  independently. 
It  would  be  impossible  to  discuss  them  fully 
here— all  that  can  be  said  is  that  the  simple 
enlargements  generally  yield  to  treatment  and 
within  a reasonable  period. 

Treatment. — In  several  cases  of  morbid  gland- 
enlargement,  treatment  has  proved  very  effective. 
These  cases  would  seem  to  be  those  of  simple 
chronic  enlargement.  Many  such  cases  have 
yielded  to  the  use  of  iodide  of  iron  in  the  form 
of  pills  or  syrup,  and  to  the  external  application 
of  a solution  of  iodine,  composed  of  equal  parts 
of  the  tincture,  and  the  liniment  of  iodine,  between 
the  shoulders.  The  same  treatment  has  likewise 
proved  very  effective  in  cases  in  which  a syphilitic 
origin  for  the  disease  could  bo  traced.  Symptoms 
such  as  cough,  difficulty  of  breathing,  pain  as 
well  as  dyspnoea,  loss  of  flesh,  strength,  &c.,  will 
all  require  more  or  less  suitable  treatment. 
The  cough  and  difficulty  of  breathing  may  in 
some  cases  be  relieved  by  simple  expectorants 
or  antispasmodics.  A useful  application  when 
pain  is  a prominent  symptom,  is  an  embrocation 
composed  of  equal  parts  of  chloroform,  bella- 
donna liniment,  laudanum,  and  spirits  of  cam- 
phor. A couple  of  drachms  of  this  composition 
sprinkled  on  the  surface  of  piline  and  applied  on 
the  painful  part  for  a few  ndnutes,  often  affords 
relief.  Hypodermic  injection  of  morphia  may 
be  required  when  pain  is  very  severe.  Under 
all  circumstances  it  is  necessary  to  improve  the 
general  health  by  wholesome  diet,  pure  air,  and 
the  other  conditions  which  will  promote  good 
digestion  and  elimination  from  the  excreting 
organs.  R.  Quain,  M.D. 

BEONCHOCELE  (Pp6yXos,  the  throat, 
and  kIjAtj,  a tumour).  A synonym  for  goitre.  See 
Goitre. 

BRONCHOPHONY  (PpiyXos,  the  throat, 
and  the  voice).  The  resonance  of  the 

voice,  as  normally  heard  on  auscultation  over 
those  parts  of  the  chest  which  correspond  with 
the  main  bronchi,  and,  in  certain  mordid  condi- 
tions, beyond  these  situations.  See  Physical 
Examination. 

BRONCHO-PNEUMONIA.  A synonym 
for  catarrhal  pneumonia.  See  Pneumonia. 

BRONZED  SKIN.  A peculiar  discoloura- 
tion of  the  skin  frequently  associated  with  Addi- 
son’s disease.  Sec  Addison’s  Disease. 

BROW-AGUE.  A synonym  for  frontal 
neuralgia,  or  tic-douloureux.  See  Neuralgia  ; 
and  Tic-Douloureux. 

BRUIT.  {Bruit,  Fr.,  a noise.)  A word,  used 
to  designate  various  abnormal  sounds  heard  on 


BUBO. 

auscultation,  in  connexion  with  the  heart  or 
vascular  system.  See  Phtsical  Examination. 

BUBO  {Povffuv,  the  groin). — Syxon.  : Apa.i- 
tema  inguinis  ; dragoncelus ; Fr.  Bubon ; Ger. 
Leistenbeule. 

Definition. — An  affection  mentioned  in  the 
most  ancient  medical  writings,  but  not  properly 
distinguished  in  its  several  varieties  until  the 
present  century.  Inflammation  of  any  lymphatic 
gland,  set  up  by  irritation  of  the  surface  con- 
nected with  the  afferent  ducts  of  that  gland, 
has  been  called  bubo ; but  the  term  is  almost  ex- 
clusively confined  to  swelling  of  the  glands  of 
the  groin  consequent  on  venereal  irritation  of  the 
genitals,  and  will  be  so  emploj'ed  here. 

Varieties. — Buboes  are  divided  into: — 1. 
Simple  bubo,  known  also  as  sympathetic  bubo,  due 
to  inflammation  of  a gland  through  ordinary 
irritation  from  an  inflamed  surface.  2.  Specific 
bubo,  (a)  The  chancrous  or  virulent  bilbo,  or 
abscess  inoculated  with  the  pus  of  a chancre. 
(6)  The  syphilitic  bubo,  or  indolent  enlargement 
of  the  lymphatic  glands  accompanying  the  de- 
velopment of  the  initial  sore  of  syphilis. 

The  glands  first  affected  in  the  sympathetic 
and  in  both  kinds  of  specific  bubo  are  always 
those  in  most  direct  communication  with  the 
sore.  Further,  according  to  Ricord,  when  elia'n- 
crous  matter  has  reached  a gland  through  the 
absorbent  ducts,  it  never  passes  beyond  that 
gland  into  another  more  remote  in  the  series. 
On  the  other  hand,  the  effect  of  syphilitic  ab- 
sorption is  general,  and  affects  those  remote  from, 
as  completely  as  it  does  the  glands  nearest  to, 
the  inlet  of  the  poison. 

Buboes  occur  most  frequently  on  the  side  of 
the  body  occupied  by  the  source  of  irritation, 
still  not  rarely  on  both  sides,  and  sometimes 
only  on  the  side  opposite  to  the  position  of  the  ex- 
citing sore.  The  crossing  of  the  irritant  is  due 
to  anastomosis  or  interlacing  of  the  lymphatics 
at  the  mesial  line.  When  bubo  forms  in  both 
groins,  there  is  usually  a sore  at  the  mesial  line 
or  on  each  side.  Bubo,  including  simple  and 
virulent,  occurs  in  about  thirty  per  cent,  of 
chancres ; how  often  with  urethritis  and  other 
lesser  venereal  affections  is  not  known. 

1.  Simple  Bubo — Adenitis  {aS^v,  a gland). 

.ZEtiology.  — This  variety  may  be  caused 
by: — (a)  Mechanical  irritation  of  the  sur- 
face ; such  as  erosions  or  fissures  irritated  by 
dirt  or  by  caustic  applications.  (b)  Urethritis, 
balano-posthitis,  or  a chancre  when  acting  as  a 
simple  local  irritant.  Simple  bubo  is  also  often 
excited  by  herpes,  erysipelas,  boils,  or  other  non- 
venereal  irritants  of  the  genitals,  (c)  Lastly, 
though  nearly  all  buboes  can  be  traced  to  a lesion 
of  the  part  where  their  absorbents  arise,  there 
are  a very  few  with  which  no  lesion  is  present. 
Such  are  caused  by  excessive  sexual  intercourse 
or  excitement ; they  are  met  with  generally 
among  young  lads  and  girls.  This  form  has 
received  the  names  of  idiopathic  bubo,  bubon 
d’emblee. 

Symptoms. — There  are  two  forms  of  simple 
bubo 1.  Slight  swelling  and  tenderness  of 
one  or  several  glands,  ending  in  a few  days 
by  resolution.  This  occurs  most  frequently  in 
urethritis,  balano-posthitis,  or  simple  chafings. 


BUBO. 


In  genuine  chancre  the  next  and  more  serious 
form  is  most  frequent.  2.  Swelling,  commonly  of 
one,  seldom  of  several  glands ; brawny  thickening 
of  the  surrounding  tissues;  redness  of  the  in- 
teguments ; great  tenderness  and  pain,  espe- 
cially when  walking.  In  a few  days  this  con- 
dition terminates  either  by  abscess,  by  gradual 
subsidence  to  the  normal  state,  or  by  chronic 
induration  of  one  or  more  glands.  When  the 
bubo  suppurates,  the  matter,  instead  of  point- 
ing at  once,  may  burrow  in  various  directions 
among  the  layers  of  cellular  tissue  before  it 
breaks  through  the  skin.  The  pus  of  this  form 
'jf  bubo  is  always  the  ordinary  pus  of  inflamma- 
tion. 

Such  cases  may  terminate  by  gradual  con- 
version into  chronic  fistulas,  or  the  glands  may 
degenerate  in  scrofulous  persons  by  enlargement 
and  suppuration,  or  there  may  be  successive 
formation  of  abscesses  around  the  glands  with 
undermining  of  the  skin.  This  is  most  fre- 
quently seen  in  persons  who  have  previously 
had  constitutional  syphilis,  erysipelas,  and  other 
septic  inflammations. 

Prognosis. — This  form  of  bubo  is  seldom 
dangerous,  but  serious  where  it  terminates  in 
burrowing;  it  is  then  often  very  tedious  and  ex- 
hausting to  the  patient. 

2.  Specific  Buboes. — (n)  Virulent  bubo.  This 
is  in  reality  an  enormous  chancre,  identical  in 
all  but  size  with  the  sore  whence  it  was  inocu- 
lated. This  form  is  never  met  with  in  gonor- 
rhoea or  in  syphilis,  being  a consequence  of  the 
local  sore  onlyT.  It  may  be  generated  in  two 
ways.  1.  By  touching  the  surface  of  a simple 
open  bubo  with  chancrous  pus.  2.  By  absorp- 
tion of  chancrous  pus  along  the  lymphatic  duets 
leading  from  the  chancre  to  the  gland  most 
directly  connected  with  the  sore.  Two  patho- 
logical facts  prove  the  reality  of  this  mode  of 
origin.  First,  occasionally  small  circumscribed 
abscesses  form  in  the  course  of  the  lymphatic 
duets  before  they  reach  the  gland.  These  little 
abscesses  when  opened  present  the  peculiar  cha- 
racters of  the  chancre.  Secondly,  until  the  necros- 
ing action  has  laid  open  the  interior  of  the  lym- 
phatic gland  nearest  the  original  chancre,  the 
abscess  about  the  gland  retains  its  ordinary 
phlegmonous  character. 

The  conditions  which  assist  or  hinder  the  con- 
veyance of  chancrous  pus  along  the  lymphatic 
vessels  are  wholly  unknown. 

The  proportional  frequency  of  virulent  bubo 
to  the  number  of  chancres  is  not  known.  It  is 
far  less  frequent  than  simple  bubo.  It  is  said 
that  women  suffer  more  rarely  than  men  in  pro- 
portion. 

When  not  accidentally  inoculated,  virulent 
buboes  are  almost  wholly  confined  to  the  groin, 
and  originate  in  the  gland  which  lie3  commonly 
in  the  centre  of  the  group  over  the  great  blood- 
vessels. Occasionally  with  chancre  on  the 
fiDger,  the  epitrochlear  or  axillary  glands  de- 
velop into  virulent  bubo.  Hiibbenet  of  Kiew 
experimentally  inoculated  a soft  chancre  on  the 
cheek,  which  was  followed  by  virulent  bubo 
of  the  gland  in  front  of  the  tragus  of  the  ear. 
This  bubo  is  generally  unilateral;  rarely  are 
both  sides  of  the  body  affected  ; in  such  cases 
the  chancre  is  usually  at  the  mesial  line,  or 


195 

there  are  two  chancres.  Still  more  raroly  the 
bubo  forms  at  the  side  of  the  body  opposite  to 
that  of  the  chancre.  The  time  for  appearance 
is  generally  in  the  first  or  second  week  of  the 
existence  of  the  chancre ; but  it  may  occur  at  any 
time  while  the  chancre  is  spreading. 

Symptoms. — At  first  the  symptoms  of  specific 
bubo  are  those  of  acute  abscess  forming  rapidly 
round  a single  gland.  Thus  far  they  differ 
nowise  from  those  of  simple  bubo.  When  the 
contagious  pus  reaches  the  abscess  accidentally 
from  without,  or  from  within  the  gland  by  ulcera- 
tion or  incision  of  its  capsule,  the  simple  suppu- 
rating cavity  becomes  a spreading  ulcer,  which 
rapidly  makes  itself  widely  open  by  destruction 
of  the  integuments.  The  skin,  thin  as  tissue 
paper,  gives  way  at  several  points,  and  lets  out 
a large  amount  of  matter,  which  is  thin,  yel- 
lowish-grey or  yellowish-red,  with  shreds  of  a 
chocolate  colour  floating  in  it.  When  perforated, 
the  skin  breaks  rapidly  away  until  the  cavity  is 
widely  exposed. 

The  further  progress  varies.  In  the  least 
severe  variety  the  edges  of  the  skin  ulcerate 
irregularly  for  a short  distance,  then  thicken  and 
begin  to  granulate ; the  floor  of  the  ulcer  loses 
its  unevenness  and  rises  up  to  the  level  of  the 
skin,  and  cicatrisation  follows.  But  commonly 
a much  greater  destruction  of  tissue  is  effected. 
The  skin  is  eaten  away  into  wide  gaps ; the  floor 
burrows  under  the  skin  in  long  channels,  or 
dives  deeply  among  the  great  vessels.  In  other 
cases  serpiginous  ulceration  produces  a large 
shallow  sore.  The  contagious  condition  of  these 
buboes  often  continues  for  weeks  or  months,  so 
that  consecutive  inoculation  of  the  s.kin  is  not 
infrequent.  The  characters  of  the  fully  formed 
virulent  bubo  are  those  of  the  chancre.  The 
surface  is  greyish-brown,  dug-out,  ‘ worm-eaten ; ’ 
the  borders  at  some  parts  are  thickened,  everted, 
and  pared  away,  at  others  sharply  eroded  or 
undermined  and  curled  in.  The  matter  is  thin, 
shreddy,  plentiful,  reddish  in  colour,  and  inoeul- 
able.  Again  like  the  chancre,  the  virulent  bubo 
passes  through  periods  of  extension , stagnation, 
and  repair.  The  last  stage  is  often  long  post- 
poned by  phagedcena,  a characteristic  of  no  other 
bubo,  but  another  mark  of  kinship  to  the  chancre. 
Phagedaena  very  rarely  attacks  a bubo  if  it  at- 
tacks the  original  sore.  The  virulent  as  well  as 
the  simple  bubo  is  liable  to  erysipelas  and  in- 
flammatory sloughing. 

The  duration  of  virulent  bubo  for  the  reason 
stated  is  wholly  indefinite — in  a few  cases  end- 
ing in  a week,  in  many  lasting  for  months  or 
even  several  years. 

Phagedena. — The  form  of  the  sloughing  in  pha- 
gedsena  is  most  commonly  serpiginous.  In  this  way 
the  bubo  may  wander  over  the  abdominal  wall,  the 
hip,  thigh,  and  perineum,  healing  here  and  spread- 
ing there,  or  digging  deeply  among  the  muscles. 
Generally  proceeding  at  this  imperceptible  speed, 
the  phagedenic  action  may  suddenly  destroy  the 
tissues  with  great  rapidity  for  a time,  and  then 
pause  altogether  till  another  rapid  extension  is 
made.  In  this  manner  years  may  pass  before 
healing  is  complete. 

Diagnosis. — The  virulent  bubo  has  in  its  early 
stage  no  distinguishing  mark  from  the  simple 
acute  bubo.  After  it  has  become  inoculated  -with 


BUBO. 


196 

the  contagious  matter  it  is  distinguished  from 
every  other  affection  by  the  characters  already 
described.  The  earliest  signs  of  virulence  are 
two ; the  matter  which  escapes  when  the  bubo 
is  lanced  is  thin  and  shreddy,  and  the  edges  of 
the  cut  become  in  a day  or  two  eroded  and 
partly  covered  by  adherent  sloughs.  Subse- 
quently other  characters  develops  and  remove 
all  doubt.  Nevertheless,  in  some  cases  the  signs 
of  virulence  are  so  feebly  marked  throughout 
that  the  diagnosis  remains  uncertain.  This  diffi- 
culty may  be  increased  by  the  primary  sore 
having  healed  before  the  suppuration  of  the  bubo, 
or  by  its  being  hidden  in  some  unusual  position 
(urethra,  anus). 

Prognosis. — Thisisnotalways  grave.  Virulent 
buboes  often  reach  cicatrisation  in  a few  weeks, 
and  meanwhile  cause  no  serious  inconvenience. 
On  the  other  hand,  they  are  prone  to  inflamma- 
tion, or  to  phagedsena,  and  thus  may  permanently 
cripple  or  even  destroy  life. 

(b)  Syphilitic  Bubo  ( indolent  multiple  bubo, 
pleiade  ganglionnaire). — This  enlargement  of  the 
group  of  lymphatic  glands  in  nearest  connection 
with  the  initial  sore  is  the  constant,  or  at  least 
almost  constant,  symptom  of  early  syphilitic  in- 
fection. In  this  it  differs  much  from  the  bubo 
of  chancre  or  gonorrhcea,  in  which  affections 
the  bubo  is  more  often  wanting  than  present. 
Four  conditions  have  been  noted  to  exist  in 
patients  in  whom  the  enlargement  of  the  glands 
could  not  he  detected,  namely,  1.  Phagedsena  of 
the  sore.  2.  Obesity  ; in  such  persons  the  lym- 
phatic system  as  a rule  is  small.  3.  Second  infec- 
tion ; i.e.  a primary  sore  on  a patient  who  has  had 
constitutional  disease  before.  4.  Scantiness  of  the 
induration  of  the  primary  sore,  the  sore  itself 
being  ill-developed.  But  these  exceptions  are  most 
rare,  Fournier  gives  five  instances  only  in  265 
cases  of  hard  sore,  accompanied  by  well-marked 
general  syphilis  ; or  2 per  cent.  In  1”6  similar 
cases  noted  by  the  writer,  three  had  no  apparent 
inguinal  enlargement.  One  of  the  patients  was 
a very  fat  man,  and  in  another  the  initial  sore 
was  only  slightly  hardened. 

The  seat  of  this  bubo  is,  in  the  great  majority 
of  eases,  the  groin,  whither,  besides  the  lym- 
phatic ducts  of  the  external  genitals,  those  of 
the  anus,  perinseum,  buttocks,  and  lower  part  of 
the  abdomen  are  directed.  But  the  glands  of 
other  regions,  epitrochlear,  axillary,  sub-maxil- 
lary, buccal,  cervical,  and  nuchal  are  all  occa- 
sionally found  primarily  enlarged  when  the 
syphilitic  poison  enters  the  body  through  the 
regions  whence  their  absorbent  ducts  are  derived. 

In  the  groin  the  bubo  is  generally  double,  that 
is,  the  glands  are  enlarged  in  both  groins,  those 
on  the  side  of  the  sore  being  most  affected.  On 
the  other  hand,  only  those  on  the  same  side  as 
the  sore,  in  a few  cases,  enlarge,  and  in  rare 
examples  only  those  of  the  side  opposite  to  that 
i of  the  sore.  This  enlargement  affects  the  group 
widely,  for  when  the  deeply-placed  glands  can 
be  examined  they  are  found  to  be  similarly  en- 
larged along  the  iliac  vessels  and  lumbar  verte- 
brae. Indeed,  in  some  persons  all  the  lymphatic 
glands  of  the  body  are  temporarily  increased  in 
size. 

The  enlargement  of  the  glands  is  first  per- 
ceived about  eleven  days  after  the  induration  of 


the  sore,  though  probably  the  affection  com. 
mencesatthe  end  of  the  incubation  of  the  poison. 
In  extremely  rare  instances  enlargement  is  de- 
layed until  the  third  or  fourth  week  after  th* 
induration  of  the  sore. 

Syjiptoms. — The  distinguishing  marks  of  this 
bubo  are  swelling,  wholly  devoid  of  inflamma- 
tory character,  and  rarely  surpassing  an  almond 
or  a hazel  nut  in  size ; gristly  hardness  ; ready 
isolation  and  mobility ; insensibility  to  pressure  ; 
natural  hue  and  condition  of  the  overlying  skin  ; 
and  absence  of  fulness  of  the  cellular  tissue. 

The  gland  in  most  direct  communication 
with  the  sore  is  most  enlarged;  in  rare  excep- 
tions only  a single  gland  is  enlarged.  Copious 
enlargement  of  the  glands  does  not  always  attend 
copious  induration  of  the  sore,  nor  is  scanty  in- 
duration of  the  sore  always  accompanied  by  small 
swelling  of  the  glands,  though  commonly  this  is 
the  case.  So  also,  though  absence  of  tenderness 
is  the  rule,  the  glands  may  be  slightly  painful  if 
pressed.  Again,  though  the  glands  remain  dis- 
tinct in  most  cases,  they  have  been  known  to 
coalesce  into  a single  mass,  which  becomes  fixed 
to  the  fascia.  In  many  patients  the  dorsal 
lymphatic  vessel  of  the  penis  becomes  indurated 
sufficiently  to  he  easily  distinguished  under  the 
skin. 

This  bubo  reaches  full  development  in  one  or 
two  weeks,  and  remains  without  apparent  change 
for  several  weeks,  or  even  for  two  or  three 
months.  Then  it  begins  to  diminish  slowly,  hut 
is  generally  still  evident  in  the  fifth  or  sixth 
month  after  infection,  and  now  and  then  even 
for  years  afterwards.  In  rare  cases  the  enlarge- 
ment vanishes  in  two  or  three  weeks.  The  long 
duration  of  enlargement  renders  this  bubo  a 
valuable  sign  of  constitutional  syphilis  when  the 
primary  sore  has  disappeared.  Again,  the  con- 
spicuous enlargement  of  a group  of  glands  may 
indicate  the  place  of  entry  of  the  syphilitic 
poison  when  that  is  hidden. 

Terminations. — In  nearly  all  cases  the  glands 
revert  to  their  natural  state.  Now  and  then 
suppuration  takes  place,  not  from  the  syphilitic 
change,  but  from  ordinary  irritation,  and  then 
produces  a simple  phlegmonous  abscess.  This  is 
apt  to  occur  in  strumous  persons.  The  glands 
enlarge  still  more,  grow  soft,  and  coalesce ; 
presently  matter  forms  in  the  thickened  cellular 
tissue  around  the  glands,  and  the  further  pro- 
gress becomes  that  of  scrofula. 

Diagnosis.— This  is  generally  easily  drawn 
from  the  character  of  the  swelling,  aided  by  the 
presence  of  other  syphilitic  signs  (hard  sore, 
rash  on  the  skin,  &c.)  This  bubo  may  be  con- 
founded with  chronic  inflammatory  enlargement, 
but  in  such  cases  the  history  and  attendant 
symptoms  remove  doubt. 

PnoGNOsis. — Apart  from  its  connexion  with 
syphilis,  the  prognosis  is  good.  The  only  un- 
toward termination  is  scrofulous  degeneration. 

Treatment  of  Buboes. — 1.  The  syphilitic 
bubo  hardly  needs  treatment.  It  usually  causes 
no  trouble,  and  gets  well  independently  of  anti- 
svphilitic  remedies.  If  tenderness  or  aching 
occur,  rest  and  a few  warm  baths  are  sufficient. 
If  suppuration  take  place  the  abscess  must  be 
incised  and  poulticed.  The  scrofulous  degene- 
ration is  best  met  by  anti -scrofulous  remedies — 


BUBO.  197 


iodide  of  ammonium,  or  of  iron,  cod-liver  oil,  nu- 
tritious food,  sea-air,  and  other  tonics.  Mercury, 
jn  i -grain  doses  of  the  bichloride,  combined 
with  the  iodide  of  sodium  or  with  solution  of  per- 
chloride  of  iron,  may  be  added  to  the  treatment. 
Locally,  the  abscesses  and  sinuses  must  be 
emptied  as  fast  as  they  form,  and  cleared  by 
svringing  with  weak  astringent  lotions. 

2.  Simple  acute  bubo  arising  from  any  cause 
demands  the  same  treatment,  namely,  that  of 
acute  abscess.  In  the  early  stages,  antiphlogistics 
'rest  in  bed,  the  constant  application  of  a cream 
made  of  equal  parts  of  extract  of  belladonna 
and  glycerine,  warm  poultices,  fomentations,  and 
baths,  sometimes  even  leeches)  are  requisite. 
Caution  must  be  observed  in  applying  leeches  if 
chancre  be  present.  They  should  be  used  only 
in  the  early  stage  of  congestion,  lest  the  bites  be 
converted  by  inoculation  into  chancres.  Again, 
the  leeches  should  be  applied  at  the  circum- 
ference of  the  swelling,  so  that  they  may  be 
removed  as  far  as  possible  from  the  centre  where 
pointing  is  most  probable.  If  suppuration  arrive 
more  speedily  than  was  expected,  and  the  bubo 
prove  a virulent  one,  incision  must  be  postponed 
as  long  as  possible,  and  the  leech-bites  protected 
by  collodion,  carbolic  lotion,  iodoform,  or  other 
antiseptics. 

When  active  congestion  has  ceased,  the  sub- 
sidence of  the  glands  may  be  aided  by  pressure 
with  a pad  and  spica  bandage.  Stimulating  oint- 
ments and  plasters,  iod’ne,  and  similar  prepara- 
tions are  of  doubtful  service,  and  may  possibly 
re-kindlo  the  inflammation.  When  pus  has 
formed,  it  should  be  let  out  by  a vertical  incision 
at  once.  The  proper  drainage  of  the  cavity 
should  be  insured  by  making  the  incision  long 
(jin.  usually),  and  by  placing  a bit  of  lint  or 
drainage  tube  between  the  edges  of  the  incision 
during  the  first  twenty-four  hours.  Early  evacua- 
tion reduces  undermining  of  the  skin  to  a mini- 
mum, and  prevents  burrowing.  When  matter 
forms  at  several  points,  a small  incision  should 
be  made  at  each  fluctuating  point.  When  free 
exit  has  been  given  to  the  pus,  the  groins  should 
be  well  poulticed  for  two  days,  and  then  dressed 
with  zinc  ointment  spread  under  a compress,  the 
bandage  of  which,  slackly  applied  at  first,  may 
be  tightened  as  the  swelling  subsides. 

3.  The  chancrous  bubo,  not  being  distinguish- 
able during  the  inflammatory  swelling  and  con- 
sequent suppuration  from  ordinary  sympathetic 
bubo,  requires  the  same  treatment  — calmants 
and  an  early  single  incision.  By  early  incision 
the  cavity  of  the  abscess,  subsequently  the  ehan- 
erous  ulcer,  is  kept  as  small  as  possible ; by  a 
single  incision  the  number  of  chancres  is  re- 
stricted. Occasionally,  but  only  when  the  ab- 
scess has  already  undermined  the  skin,  more 
than  one  incision  is  necessary.  Caustics  have 
no  advantage  over  the  knife  for  opening  the 
abscess,  while  they  make  a larger  gap.  When 
the  abscess  has  been  opened  and  the  chancrous 
nature  is  suspected,  it  should  be  well  cleared 
at  the  time  by  injections  of  one  part  of  carbolic 
acid  to  eighty  of  water,  5-10  grains  to  the  ounce 
of  nitrate  of  silver,  of  tartrated  iron,  or  of  some 
other  astringent  and  disinfectant.  This  injection 
may  be  repeated  three  times  in  the  first  twenty- 
four  hours;  and  constant  drainage  maintained  by  a 


drainage-tube  anda  compress  of  Lister’s  antiseptic 
gauze  or  boracic  lint.  Should  these  precautions 
fail  to  prevent  the  conversion  of  the  abscess  into 
a chancro,  it  must  then  be  dressed  as  a chancre. 
It  must  be  sedulously  washed  by  injection  twice 
daily,  dried  by  careful  mopping  with  bits  of 
cotton-wool,  and  well  dusted  and  packed  with 
iodoform  in  powder  ; the  whole  cavity  being 
loosely  filled  with  pellets  of  cotton-wool,  and 
compressed  gently  with  a layer  of  lint  and  a 
bandage.  Should  this  fail,  as  it  sometimes  will, 
caustic  may  be  applied.  The  caustics  most  suit- 
able are  the  strongest  and  most  penetrating ; 
such  as  Vienna  paste,  acid  nitrate  of  mercury, 
Rieord's  paste  (powdered  charcoal  and  the 
strongest  oil  of  vitriol).  To  apply  the  caustic 
thoroughly  the  patient  should  be  anesthetised. 
If  the  least  part  of  the  surface  is  left  unde- 
stroyed, that  will  reinoculate  the  whole.  Com- 
plete cauterisation  is  practically  very  difficult 
to  accomplish,  hence  caustics  should  be  reserved 
for  the  cases  where  iodoform,  which  is  pain- 
less, fails.  Overlapping  bands  of  skin  should 
be  divided,  that  the  dressing  may  be  fairly  ap- 
plied. 

Phagedena. — When  the  ulceration  by  its  ob- 
stinacy or  by  its  rapidity  deserves  this  title, 
plan  after  plan  of  treatment  must  be  tried  till 
the  destruction  of  tissue  is  arrested — caustics 
being  reserved  for  the  last.  When  the  patient’s 
general  health  is  good,  the  ulceration  seldom 
fails  to  yield  to  iodoform,  applied  thoroughly  in 
the  manner  directed.  While  the  nocturnal 
gnawing  pain  continues,  the  patient  should  be 
narcotised  with  opium  or  other  narcotic.  The 
cessation  of  pain  is  a signal  that  the  eroding 
action  has  stopped.  When  iodoform  alone  is 
insufficient,  the  continuous  warm  hip-bath  sel- 
dom fails.  By  it  pain  is  at  once  arrested  and 
healing  soon  set  in  motion.  As  continual  im- 
mersion in  a bath  becomes  extremely  irksome 
in  many  cases,  the  phagedsena  may  be  arrested 
by  keeping  the  patient  in  water  for  sixteen  hours 
every  day,  and  allowing  the  night  to  be  passed 
in  bed — in  this  interval  the  wound  should  be 
carefully  packed  with  iodoform.  When  the 
phagedsena  is  stopped,  the  bath  may  be  discon- 
tinued and  iodoform  alone  used.  If  the  water- 
bath  fail  (and  such  a result  has  not  yet  happened 
during  a considerable  employment  of  this  method 
at  the  Male  Lock  Hospital),  caustics  may  then  be 
used. 

The  strength  of  the  patient,  generally  much 
exhausted,  should  be  restored  by  tonics,  good 
diet,  stimulants,  and  other  general  means. 

Abortive  treatment  of  bubo. — This  once  fa- 
vourite method  of  treating  buboes  has  fallen  into 
disuse  as  the  varieties  of  bubo  have  been  better 
understood.  The  chronically  enlarged  glands  of 
syphilis  have  little  or  no  tendency  to  suppurate, 
but  subside  spontaneously  if  let  alone.  Others 
only  suppurate  when  freely  irritated,  hence  the 
best  abortive  treatment  for  such,  is  to  guard 
against  the  increase  of  irritation,  and  assuage 
that  which  exists  by  antiphlogistics.  In  the  bubo 
virulent  by  absorption  suppuration  is  inevitable. 
Thus,  the  sympathetic  bubo  is  the  only  one  which 
can  be  acted  on  by  abortive  treatment.  To  anti- 
phlogistics may  be  added  counter-irritants,  but 
these  are  uncertain  in  their  effect.  Those  least 


198  BUBO. 

open  to  objection  are  vesicants,  and  the  form 
most  beneficial  is  ropeated  ‘ flying  ’ blisters.  By 
this  means  a series  of  small  blisters  are  produced 
round  about,  not  over  the  swelling.  Any  other 
plan  is  most  uncertain — painting  the  part  with 
tincture  of  iodine,  or  othermild  irritant,  is  simply 
waste  of  time.  To  enter  at  length  into  even  a 
narration  of  the  multitudinous  ways  in  which 
irritants,  vesicants,  and  even  caustics  have  been 
employed  would  occupy  much  space  to  little 
purpose. 

Compression  is  of  great  value  for  reducing 
indolent  enlargement,  or  for  removing  the  boggy 
condition  of  the  groin  where  several  abscesses 
have  formed,  with  more  or  less  undermining  of 
the  skin.  It  is  useless  for  the  syphilitic  bubo 
and  mischievous  for  the  virulent  bubo.  The 
simplest  and  most  effectual  method  of  applying 
compression,  is  by  a graduated  compress  of  lint 
kept  firmly  in  place  by  a spica  bandage  of  calico, 
or  of  elastic  tape.  For  abscesses,  careful  packing 
may  be  added  to  the  compress.  Each  focus  of 
pus  must  be  laid  open,  and  bridges  or  tunnels 
cut  across,  so  that  narrow  strips  of  lint  soaked 
in  liquor  plumbi  subacelatis  and  lightly  pressed 
between  the  fingers,  to  drive  out  the  dripping 
excess  of  fluid,  may  be  laid  into  the  hollows  and 
under  overhanging  borders  of  skin.  The  strips 
must  be  renewed  every  day  at  first,  and  the 
cavities  well  cleared  by  syringing  with  water. 
In  a few  days,  when  the  discharge  is  very  small, 
the  strips  may  be  left  for  three  or  four  days  un- 
changed. The  first  application  is  painful,  but 
very  soon  an  insensible  crust  is  formed  over  the 
ulcerating  surface,  and  fresh  applications  cause 
no  discomfort.  As  soon  as  healthy  granulations 
are  formed,  the  plugging  should  be  laid  aside. 

Berkeley  Hill. 

BULBAR  PARALYSIS.  A synonym  for 
glosso-laryngeal  paralysis ; derived  from  the 
pathological  relation  of  the  disease  with  the 
bulb  or  medulla  oblongata.  See  Labio-Glosso- 
Laryngeal  Paralysis. 

BULIMIA  (0ov,  a particle  signifying  excess ; 
and  \ifibs,  hunger).  Excessive  or  voracious 
appetite.  See  Appetite,  Disorders  of. 

BULL2E  (Bulla,  a bubble).  See  Bleb. 

BURSTS.  The  morbid  effects  produced  by 
the  direct  application  of  excessive  dry  heat. 
See  Heat,  Effects  of. 

BURS-33  MUCOSAS,  Diseases  of. — Bursae 
mucosae  are  spaces  in  the  connective,  tissue  lubri- 
cated with  a small  amount  of  serous  fluid,  and 
situated  at  points  exposed  to  repeated  pressure 
or  friction.  Structurally  they  are  composed  of  a 
layer  of  condensed  cellular  tissue,  fusing  exter- 
nally with  the  areolar  tissue  of  the  part,  and  lined 
internally  with  an  imperfect  layer  of  flattened 
endothelial  cells,  similar  to  those  found  in  the 
pleura  or  peritoneum.  Some  bursae,  as  that 
over  the  patella,  that  under  the  deltoid,  those 
about  the  great  trochanter,  and  many  others, 
are  constantly  present ; but  new  bursas,  equally 
perfect  in  their  structure,  may  form  at  any  part 
exposed  to  abnormal  pressure  and  friction,  as 
over  the  outer  malleolus  of  a tailor,  under  an 
old  corn,  or  over  the  head  of  the  metacarpal  bone 


BUTtSJE  MUCOSiE,  DISEASES  OF. 
of  the  great  toe  (bunion).  Like  the  great 
serous  cavities,  burs®  are  indirect  communication 
with  the  lymphatics,  and  inflammatory  products 
are  consequently  absorbed  from  them  with  great 
readiness,  often  giving  rise  locally  to  a diffuse 
inflammation  of  the  surrounding  cellular  tissue, 
closely  resembling  phlegmonous  erysipelas  in 
appearance,  and  always  accompanied  by  high 
fever. 

Bursas  are  liable  to  four  forms  of  disease: — 

1.  Acute  inflammation  and  suppuration 
— Acute  bursitis. — This  is  usually  the  result  of 
some  more  or  less  violent  mechanical  injury.  It 
may  occur  in  any  bursa,  but  is  most  common 
in  the  bursa  patellae,  those  about  the  hip  and 
over  the  olecranon,  and  in  the  small  false  bursa 
formed  beneath  an  old  corn,  or  in  a bunion.  The 
symptoms  are  those  of  acute  inflammation  gener- 
ally, but  the  redness  and  swelling  often  extend 
a remarkable  distance  up  and  down  the  limb. 
Thus,  a drop  of  pus  beneath  a corn  may  cause 
oedema  and  redness  to  the  knee.  The  febrile  dis- 
turbance is  usually  proportionately  severe. 
About  the  trochanter  the  abscess  may  assume  a 
chronic  form. 

Treatment. — Hot  fomentations,  and  the  ap- 
plication of  glycerine  and  extract  of  belladonna 
(equal  parts),  may  be  of  use.  It  is  very  impor- 
tant that  pus  should  be  let  out  early,  or  it  may 
burrow  extensively,  especially  about  the  knee. 
The  antiseptic  treatment,  as  recommended  by 
Lister,  will  be  found  especially  useful  in  the 
treatment  of  suppurating  burs®. 

2.  Chronic  Bursitis — Dropsy  of  the  bursa 
consists  simply  of  an  accumulation  of  serous  fluid 
distending  a bursa  more  or  less  tensely.  The 
wall  becomes  somewhat  thickened  and  opaque, 
but  is  otherwise  unchanged.  The  fluid  is  clear, 
straw-coloured,  and  albuminous  in  character. 
The  cause  of  the  disease  is  usually  repeated 
slight  mechanical  injury,  but  in  some  cases  it 
may  be  due  to  some  of  those  obscure  conditions 
spoken  of  as  ‘ rheumatism.’  The  symptoms  are 
merely  those  of  a collection  of  fluid  in  the  situa- 
tion of  the  bursa,  perhaps  accompanied  by  a feel- 
ing of  weakness  in  the  neighbouring  joint. 
There  is  no  pain  or  tenderness.  The  commonest 
form  of  this  disease  is  the  so-called  housemaid’s 
knee,  but  it  is  not  unfrequent  in  the  bursa  of 
the  popliteal  space. 

Treatment. — Avoidance  of  the  mechanical  in- 
jury, whatever  it  may  be.  which  has  caused  the 
disease,  is  most  important.  The  swelling  may 
be  painted  with  tincture  of  iodine  twice  a day 
for  some  weeks,  or  a series  of  small  blisters  ap- 
plied over  it.  If  this  fail,  a seton  may  be  passed 
through  and  left  in  for  a few  days.  Or  an  in- 
cision may  be  made  into  the  swelling  under  anti- 
septic precautions,  and  a small  drainage-tube 
introduced  for  a week  or  ten  days.  But  before 
either  of  these  means  is  adopted,  care  must 
be  taken  to  ascertain  that  the  bursa  does  not 
communicate  in  any  way  with  the  neighbouring 
joint.  In  the  ham  it  is  safer  never  to  operate 
in  any  case,  except  perhaps  by  means  of  the 
aspirator. 

3.  Chronic  enlargement  of  the  bursa,  with 
fibroid  thickening  of  its  walls. — This  affec- 
tion is  most  common  in  the  bursa  patell®,  but 
may  occur  in  that  situated  over  the  tuberosity  of 


BUKSjE  MUCOSiE,  DISEASES  OF. 

„he  ischium.  The  bursa  becomes  converted  into  a 
dense  fibroid  mass  of  almost  cartilaginous  hard- 
ness. On  section  it  is  found  to  be  composed  of 
concentric  layers  of  dense  fibroid  tissue.  There 
is  usually  a small  central  cavity  containing  a 
little  fluid.  The  cause  of  this  change,  as  of 
simple  dropsy,  is  repeated  mechanical  injury  of 
a slight  nature.  The  only  treatment  is  removal 
by  the  knife. 

4.  Chronic  enlargement  of  the  bursa, 
with  the  presence  in  it  of  the  so-called 
melon-seed  bodies. — In  this  form  of  disease, 


CECUM,  DISEASES  OF.  ISO 

in  addition  to  some  thickening  of  the  wall  and 
accumulation  of  fluid  in  the  bursa,  small  oval, 
flattish,  smooth  bodies  of  a white  colour  are  found 
floating  freely  in  its  interior.  These  are  similar 
in  nature  to  those  found  in  some  forms  of  ganglion 
(see  Ganglion).  This  condition  is  recognised  by 
the  peculiar  soft  crackling  feeling  perceived  on 
palpation,  combined  with  the  ordinary  symptoms 
of  an- enlarged  bursa.  Marcus  Bkcx. 

BUXTON  in  Derbyshire.  Simple  thermal 
waters.  See  Mineral  Waters. 


c 


CACHEXIA  (toa/cbs,  bad,  and  e£is,  a habit  or  i 
constitution  of  body).  Stnon.  : Fr.  Cachexie. 
Ger.  Kachcxie. 

Definition. — A chronic  state  of  ill-health 
associated  with  impoverished  or  depraved  blood, 
arising  from  mal-nutrition,  persistent  loss  of 
blood-elements,  or  the  presenceof  a morbific  agent. 

In  such  diseases  as  tabes  mesenterica,  lympha- 
denoma,  and  the  like,  the  patients  become  cachec- 
tic from  direct  depravation  of  the  blood,  in 
consequence  of  disease  of  organs  which  are  impor- 
tantly concerned  in  its  nutrition  and  elaboration. 
In  other  diseases  persistent  loss  of  blood- 
elements  arising  from  chronic  suppuration  or  from 
repeated  haemorrhages  (especially  observed  in 
some  uterine  conditions)  i nduces  a cachexia  which 
is  well  described  by  the  term  secondary  anaemia. 
Again  certain  poisons  introduced  from  without  or 
nurtured  within  the  body  may  produce  marked 
cachexia.  The  syphilitic  and  malarial  poisons 
are  good  examples  of  the  first  kind.  Of  cacbexise 
produced  by  the  presence  of  morbific  agents 
which  have  been  generated  within  the  body  we 
may  instance  those  arising  from  defective 
elimination,  as  the  uraemic  and  gouty  cachexiae 
from  defective  functional  activity  of  the  kidneys 
and  liver.  In  the  latter  connexion  it  should  be 
noted  that,  as  has  been  hinted  by  Sir  James  Paget 
in  reference  to  cancer,  the  malignant  cachexia  may 
arise  from  blood-contamination  with  the  waste 
products  yielded  by  the  morbid  growth  in  the 
process  of  its  nutrition  ; such  a growth  not  only 
abstracting  material  from  the  blood  for  its  nutri- 
tion, but  also  contributing  effete  material  to  it. 

It  must  be  further  observed  that  in  the  opinion 
of  some  of  the  best  pathologists  the  term  cachexia 
implies  much  more  than  the  secondary  anaemia 
consequent  upon  the  ravage?  of  a given  local  or 
general  disease  upon  the  system.  It  rather  signi- 
fies the  morbid  constitution  which  is  the  disease, 
and  which  may  precede  its  local  manifestation. 
Thus  we  may  have  the  cancerous  cachexia,  culmi- 
nating in  scirrhus  of  the  breast,  the  tubercular 
cachexia  in  pulmonary  tuberculosis,  and  the  like. 
It  is  thus  evident  that  with  many  observers  the 
terms  cachexia  and  constitutional  disease  have 
the  same  significance.  K.  Douglas  Powell. 


CACOPLASTIC  («a/cbr,  bad,  and  irAatro-w,  I 
mould  or  form). — A term  applied  to  products  of 
inflammation  which  are  more  or  less  incapable  of 
organisation. 

CADAVERIC  ( cadaver , a dead  body). — This 
word  signifies  ‘ belonging  to  the  dead  body ; ’ and 
it  is  applied  to  the  aspect,  colour,  odour,  aDd  other 
phenomena  resembling  those  of  death  which  are 
sometimes  observed  in  the  living  subject. 

C-33CUM,  Diseases  of. — The  structural  pecu- 
liarities and  anatomical  relations  of  the  caecum 
are  specially  favourable  to  the  occurrence  of 
the  diseases  to  which  this  part  of  the  large  in- 
testine is  most  liable,  viz.,  (1 ) accumulation  of 
the  solid  and  gaseous  contents  of  the  alimentary 
canal,  and  (2)  inflammation. 

I.  Accumulations. — Hardened  faeces,  biliary 
and  intestinal  concretions,  foreign  bodies,  stones 
of  fruit,  balls  of  worms,  lumbrici,  and  gases  re- 
sulting from  decomposition,  are  apt  to  collect  in 
the  caecum,  and  cause  varying  degrees  of  local 
disturbance.  Sometimes,  as  in  elderly  patients 
of  torpid  habit,  the  emeum  is  found  loaded  with 
faeces,  without  inducing  pain  or  other  signs  of 
inflammation.  The  right  iliac  region  may  be 
full  and  hard,  and  in  it  may  be  felt  a well- 
defined,  almost  painless,  doughy  mass  ; the  tu- 
mour is  of  the  shape  of  the  caecum.  As  a rule, 
however,  sooner  or  later  the  accumulation  leads 
to  one  or  more  of  the  following  results  : — 

(a)  Obstruction  of  the  bowels.  This  may  be 
partial,  as  in  the  various  degrees  of  constipation  ; 
or  complete.  "When  complete,  it  may  even  prove 
fatal  without  the  caecum  or  peritoneum  exhibiting 
signs  of  inflammation.  On  the  other  hand,  general 
peritonitis  supervening,  obstruction  in  the  caecum 
may  be  quickly  obscured ; still,  however,  the 
chief  pain  and  tenderness  will  be  found  in 
the  right  iliac  region.  ( b ) Pressure  on  adjacent 
nerves,  vessels,  or  other  structures,  producing 
numbness  and  oedema  of  the  right  leg,  retrac- 
tion of  the  right  testicle  and  other  symptoms. 
( c ) Inflammation  (typhlitis,  peritonitis). 

It  is  of  clinical  importance  to  bear  in  mind  that 
the  caecum,  when  overloaded  or  enlarged,  may 
occupy  an  unusual  position,  c.g.  a site  betweer 


-00  CAECUM.  DISEASES  OF. 


the  right  and  left  iliac  regions,  or  it  may  descend 
somewhat  into  the  pelvis  and  press  on  the 
urinary  bladder. 

Tympanitic  distension  of  the  csecuni  is  gener- 
ally associated  with  some  fecal  accumulation  or 
obstruction  in  the  colon  or  other  part  of  the  large 
intestine  {see  Flatulence). 

II.  Inflammation. — Synon.  : Typhlitis;  Fr. 
Typhlile  ; Ger.  Blinddarmentz  undung. 

Definition. — Inflammation  of  the  walls  of 
the  caecum,  liable  to  terminate  in  perforative 
ulceration ; in  peritonitis,  local  or  general ; or 
in  inflammation  and  suppuration  of  the  cellular 
tissue  behind  the  caecum  (perityphlitis). 

Etiology. — As  predisposing  causes  may  bo 
regarded  the  anatomical  peculiarities  of  the 
caecum,  favouring  the  accumulation  of  solids  and 
gases  liable  to  irritate ; the  causes  of  constipation 
and  retention  of  fecal  matter,  or  of  inertia  of 
the  large  intestine ; the  period  of  childhood  and 
adolescence ; and  previous  attacks  of  typliilitis. 
Exciting  causes. — Attacks  of  typhlitis  have  been 
ascribed  to  exposure  to  cold,  to  irritating  ingesta, 
unripe  fruit,  &e.  Inflammation  of  the  caecum 
may  form  part  of  an  attack  of  enterocolitis  or 
dysentery. 

Anatomical  Characters.  — Inasmuch  as 
‘ there  are  no  cases  on  record  of  acute  typhlitis 
proving  fatal,  in  which  post-mortem  examination 
did  not  show  the  existence  of  perforation  of  the 
c tecum  or  appendix,’ 1 we  invariably  find  sorious 
pathological  changes  complicating  the  appear- 
ances presented  by  simple  inflammation  of  the 
walls  of  the  caecum. 

In  all  cases  the  peritoneum  investing  the 
caecum  is  involved,  as  indicated  by  opacity 
and  injection;  and  generally  adhesions  exist 
between  folds  of  the  intestines,  in  the  vicinity 
of  the  right  iliac  fossa.  General  peritonitis  is 
usually  found  associated  with  perforation  into 
the  sac  of  the  peritoneum,  and  the  escape  into  it 
either  of  the  contents  of  the  caecum,  of  an 
abscess  in  the  cellular  tissue  behind  the  caecum, 
or  of  a circumscribed  peritoneal  abscess. 

Symptoms. — Inflammation  of  the  caecum  is 
met  with  either  as  part  of  a more  extensive 
inflammation — e.g.  enterocolitis,  dysentery;  or 
alone.  In  the  former  case  its  symptoms  are 
merged  into  those  of  the  more  general  affec- 
tion to  which  it  is  subsidiary,  while  in  the  latter 
they  are  special  and  characteristic.  Clinically, 
two  classes  of  cases  may  be  recognised : — (a)  The 
inflammation  is  of  the  catarrhal  type,  does  not 
end  in  ulceration,  pursues  a favourable  course, 
and  affects  children  more  particularly.  Pro- 
bably it  is  strictly  confined  to  the  mucous  lining 
of  the  caecum.  {/>)  The  inflammation  is  more 
severe,  is  ulcerative,  and  is  apt  to  terminate  in 
perforation  of  the  walls  of  the  caecum,  and  to 
induce  tedious  or  fatal  sequelae.  It  would  seem 
that  all  the  coats  of  the  caecum  are  rapidly 
involved.  This  form  of  typhlitis  is  generally 
observed  after  the  period  of  childhood. 

Though  typhlitis  usually  commences  somewhat 
suddenly,  most  frequently  there  is  a preliminary 
history  of  intestinal  derangement,  either  in  the 
form  of  obstinate  constipation,  or  of  catarrhal 
diarrhoea  alternating  with  constipation.  The 

• Meigs  and  Tepper,  Diseases  of  Children. 


characteristic  symptoms  are  pain,  and  a tumour 
in  the  right  iliac  fossa. 

The  pain  is  continuous,  and  is  increased  by 
pressure  and  by  movements,  such  as  those  in- 
duced by  deep  inspiration  and  coughing.  The 
right  iliac  region  becomes  exquisitely  tender  and 
tens9;  and,  to  relieve  the  muscular  tension  over 
it,  the  patient  reclines  towards  the  right  side, 
with  the  thighs  drawn  up. 

In  typhlitis  from  retention  of  feces  in  the 
caecum  (Typhlitis  stercoralis)  there  is  a well- 
defined  tumour  from  the  first,  which  may  attain 
a very  large  size  ; while  in  other  cases  there  is 
often  merely  fulness  in  the  early  stage,  and 
afterwards  a distinct  tumour.  In  all  cases  the 
tumour  is  of  the  shape  of  the  caecum,  is  sharply 
circumscribed,  the  lower  part  specially  so,  while 
the  upper  is  less  distinct,  and  may  bo  traced 
into  the  ascending  colon  if  this  part  be  also 
inflamed.  When  the  tumour  arises  from  in- 
flammatory thickening  of  the  walls  of  tho 
eeecum,  it  is  less  dull  on  percussion  than  when 
consisting  of  feces.  The  abdomen  is  enlarged. 
Fever  is  usually  slight  or  absent.  The  walls  of 
the  caecum  failing  to  contract,  there  is  obstinate 
constipation,  with  tormina  and  vomiting.  As  a 
rule,  in  children  vomiting  does  not  become  fe- 
culent. In  typhlitis  stercoralis  intestinal  ob- 
struction may  arise  from  the  accumulation  com- 
pletely blocking  the  ileo-caecal  opening;  then 
the  paroxysms  of  pain  become  very  severe,  and 
the  vomiting  urgent  and  stercoraceous.  Not 
uncommonly  inflammation,  though  commencing 
thus  in  the  csecum  with  characteristic  symptoms, 
extends  all  over  the  colon  {see  Colon,  Diseases 
of);  then  constipation  will  give  place  to  diarrhoea, 
and  tenesmus  with  muco-sanguinolent  evacuations 
will  indicate  a similar  affection  of  the  sigmoid 
flexure  and  the  rectum. 

The  attack,  having  lasted  from  two  or  three 
to  ten  or  twelve  days,  usually  subsides  by  resolu- 
tion— the  bowels  are  copiously  relieved,  the 
vomiting  ceases,  and  the  pain,  tenderness,  and 
tumour  disappear  from  the  right  iliac  region. 
Even  symptoms  of  intestinal  obstruction  which 
excite  much  anxiety  may  terminate  thus  favour- 
ably. 

Not  unfrequently,  however,  the  course  becomes 
tedious  and  dangerous.  The  accidents  most  to 
be  feared  are: — (1)  Phlegmonous  inflammation 
of  the  cellular  tissue  behind  the  caecum  ( sec 
Perityphlitis)  ; and  (2)  peritonitis.  As  a rule, 
inflammation  of  the  peritoneum  is  confined  to 
that  portion  covering  the  caecum  and  adjacent 
structures;  it  may,  however,  become  general 
from  extension  of  this  local  inflammation,  but 
more  frequently  from  the  bursting  into  it  of  tho 
contents  of  the  caecum,  or  of  an  abscess. 

Prognosis. — Inasmuch  as  typhlitis  without 
perforation  almost  invariably  ends  in  recovery, 
the  prognosis  depends  on  the  occurrence  of  in- 
flammatory complications  and  sequelae,  and  is, 
therefore,  merged  in  that  of  perityphlitis.  As  a 
rule,  perforative  ulceration  is  less  common  during 
childhood  than  after  the  tenth  or  fifteenth  year. 
If,  notwithstanding  the  relief  of  constipation  and 
the  cessation  of  vomiting,  the  signs  of  local 
inflammation  persist,  ulceration  of  the  csecum,  or 
the  earliest  stages  of  perityphlitis,  may  bo  sus- 
pected. 


CAECUM,  DISEASES  OF. 

Treatment. — The  indications  are,  (a)  to  re- 
lieve constipation  and  dislodge  accumulations 
from  the  caecum  -with  as  little  irritation  as  pos- 
sible, using  laxatives  combined  ■with  sedatives, 
e.g.  calomel,  colocynth,  confection  of  senna,  or 
saline  aperients  with  opiates,  and  large  warm 
enemata ; the  latter  are  indicated  when  aperients 
by  the  mouth  set  up  or  increase  vomiting, 
or  fail  to  relieve  the  bowels,  or  cannot  be  pre- 
scribed because  of  obstinate  vomiting.  ( h ) To 
subdue  inflammation  by  rest,  poultices,  blisters, 
and  opiates.  The  diet  throughout  should  be  fluid, 
consisting  of  beef-tea,  milk,  and  such  articles. 
All  strong  aperients  are  to  be  condemned — they 
are  apt  to  increase  the  inflammation  and  the  risk 
of  perforation,  and,  while  aggravating  the  vomit- 
ing, may  fail  to  move  the  bowels.  When  local 
inflammation  is  severe,  as  indicated  by  great  pain 
and  tenderness,  aperients  by  the  mouth  should  be 
avoided,  enemata  used,  opium  given  freely,  as  in 
peritonitis,  and  leeches  may  be  applied. 

III.  Dilatation,  Contraction,  and  Per- 
foration.— The  caecum  may  be  (1)  dilated  from 
accumulation  within  it  of  solids  and  gases,  or 
from  obstruction  in  the  colon ; (2)  contracted 
from  deposits  (cancer,  &c.),  growths  (polypi),  or 
cicatrising  of  ulcers  (tubercular,  dysenteric)  ; or 
(3)  'perforated  from  ulceration  (simple  perforat- 
ing, enteric,  tubercular,  cancerous,  dysenteric 
ulcer),  or  tearing  of  the  wall  by  over-distension. 
Perforation  may  lead  to  different  results,  accord- 
ing to  the  part  of  the  caecum  selected.  When 
in  the  anterior  surface,  which  is  completely  in- 
vested by  peritoneum,  a rapidly  fatal  peritonitis 
is  most  apt  to  follow ; while  in  the  posterior 
part,  resting  on  the  connective  tissue  of  the  iliac 
fossa,  suppuration  is  usually  the  result. 

George  Oliver. 

CALCAREOUS  DEGENERATION. — A 

form  of  degeneration  characterised  by  the  de- 
posit of  earthy  salts,  especially  of  salts  of  lime, 
in  the  tissues.  See  Degenerations. 

CALCULI  {Calx,  chalk).  — Definition. — 
The  term  calculus  is  now  applied  to  any  kind  of 
concretion  formed  in  the  ducts  or  passages  of 
glandular  organs ; though  older  writers  limited 
its  employment  to  the  designation  of  concretions 
met  with  in  the  kidneys  and  urinary  bladder. 

Varieties. — The  following  is  a concise  sum- 
mary of  the  principal  calculous  concretions  met 
with  in  the  human  body,  given  according  to  their 
alphabetical  order. 

1.  Biliary  Calculi  vary  considerably  in  size, 
number,  form,  and  composition.  In  size  they 
range  from  minute  grains  about  the  size  of  a 
pin’s  head  to  a mass  as  large  as  a hen’s  egg.  The 
smaller  they  are,  generally  the  larger  is  their 
number.  Their  form  is  veryirregular — when  soli- 
tary they  are  usually  round  or  oval,  when  nume- 
rous they  are  generally  more  or  less  irregular  in 
shape,  their  surfaces  being  flattened  and  facetted 
from  compression.  The  colour  is  usually  a 
blackish-green  or  brown,  less  frequently  yellow 
or  greyish-white.  In  consistence,  some  are  soft 
like  wax;  others  hard,  dry,  and  friable.  On 
section  they  will  he  found  to  differ  widely — some 
being  granular,  and  made  up  of  sub-morphous 
particles  without  any  apparent  nucleus ; others- 
crystalline,  the  glistening  white  crystals  (choles- 


CALCULI.  201 

terine)  radiating  from  a central  nucleus,  which 
is  frequently  found  to  consist  of  inspissated 
bile.  Biliary  calculi  consist  almost  entirely  of 
cholesterine  and  bile-pigments,  mixed  with  a 
variable  proportion  of  insoluble  organic  matter 
and  traces  of  the  earthy  phosphates.  To  separate 
the  cholesterine,  finely  powder  the  gall-stone  and 
thoroughly  exhaust  with  ether;  the  ethereal 
solution  on  evaporation  yields  amorphous  choles- 
terine. To  obtain  it  in  the  crystalline  form,  it 
must  be  redissolved  in  boiling  alcohol,  which  on 
cooling  deposits  it  in  characteristic,  glistening, 
rhombic  plates.  The  pigmentary  matters  can  be 
obtained  by  exhausting  the  residue  of  the  crushed 
gall-stone,  from  which  the  cholesterine  has  been 
removed,  successively  with  water,  alcohol,  and 
dilute  hydrochloric  acid.  The  dried  residue  is 
then  boiled  with  pure  chloroform  for  some  time, 
and  the  chloroform  extract  is  distilled  to  near 
dryness,  and  several  volumes  of  alcohol  are  added, 
which  throws  down  bilirubin.  Bilirubin  thus 
obtained  is  an  orange-red  powder  insoluble  in 
water  and  ether,  slightly  soluble  in  alcohol,  but 
very  freely  soluble  in  chloroform.  On  passing  a 
current  of  air  through  an  alkaline  solution  of 
bilirubin  the  solution  acquires  a green  colour — 
biliverdin.  According  to  Stiideler  biliverdin  is 
formed  from  bilirubin  by  the  addition  of  one 
atom  of  water  in  the  presence  of  oxygen.  A 
brown  pigment,  bilifuscine,  can  also  be  obtained 
by  acting  on  bilirubin  with  strong  sulphuric 
acid. 

2.  Intestinal  Calculi  are  rare  in  man  and 
carnivorous  animals,  but  are  not  uncommon  in 
herbivorous  animals.  They  consist  almost  en- 
tirely of  ammonia,  magnesium  phosphate,  calcium 
phosphate,  and  calcium  carbonate,  deposited 
round  a nucleus,  generally  a fragment  of  some 
undigestible  material  of  the  food,  such  as  stones 
of  truit,  husks  of  grain,  or  portions  of  bone. 
There  is  a kind  of  intestinal  calculus  occasion- 
ally met  with  among  Scottish  and  Lancashire 
people,  who  use  oatmeal  largely  as  food,  which  is 
chiefly  composed  of  the  hairs  and  fragments  of  the 
envelopes  of  the  oat,  encrusted  with  calcium 
phosphate  and  carbonate.  Magnesium  carbonate 
when  taken  habitually  and  in  bulk  is  apt  to  ac- 
cumulate in  the  bowels  and  concrete  there  ; there 
is  now  less  risk  of  that  danger  since  the  fluid 
forms  of  magnesia  have  come  into  such  general 
use. 

3.  Pancreatic  Calculi  are  the  rarest  of  all 
glandular  concretions.  When  found  they  are 
generally  numerous,  being  met  with  in  the  main 
duct,  the  accessory  duct,  and  even  in  the  smaller 
radicles.  The  size  varies  greatly,  the  largest 
that  has  come  under  the  writer’s  observation 
being  quite  one  inch  in  length.  They  are  generally 
oval  in  shape,  and  their  surface  has  frequently  a 
worm-eaten  appearance,  of  whitish  colour,  which 
when  rubbed  acquires  an  enamel-like  lustre. 
When  broken,  the  fracture  often  presents  a white, 
glistening,  porcelain  appearance.  One  calculus 
analysed  by  the  writer  gave  a percentage  com- 
position of  organic  matter  -24,  fixed  inorganic 
salts  ’76.  The  bulk  of  the  fixed  inorgauic  salts 
consisted  of  calcium  carbonate,  calcium  phosphate 
being  present  in  much  smaller  proportion. 

4.  Prostatic  Calculi  consist  essentially  of 
calcium  phosphate  and  calcium  carbonate,  though 


202  CALCULI, 

incidentally  traces  of  uric  acid,  calcium  oxalate, 
and  ammonio-magnesinm  phosphate  maybe  found. 
They  occur  in  three  forms,  namely,  (a)  small, 
rough  concretions,  from  the  size  of  a pin  to  a hazel 
nut;  (6)  irregular  masses  with  porcelainous  ap- 
pearance ; and  (c)  large  regular  concretions.  The 
quantity  of  earthy  matter  that  may  be  deposited 
in  the  prostate  gland  is  often  enormous.  When  the 
calculi  are  of  the  small  variety,  fifty  or  sixty  may 
be  present,  and  a gland  may  feel  likeabagof  nuts. 
The  museum  of  the  College  of  Surgeons  contains  a 
specimen  showing  the  enormous  size  these  con- 
cretions may  attain.  See  Prostate,  Diseases  of. 

5.  Salivary  Calculi  are  generally  rough  ex- 
ternally, irregular  in  shape,  and  are  usually  found 
near  the  orifice  of  the  duct,  which  they  obstruct. 
The  nucleus  frequently  consists  of  some  foreign 
body  which  has  accidentally  found  its  way  into  the 
duct,  as  a splinter  of  wood  ora  fragment  of  bone. 
Their  chief  component  is  calcium  carbonate,  of 
which  they  contain  more  than  any  other  kind  of 
concretion,  and  traces  of  early  phosphates. 

6.  Urinary  Calculi  vary  considerably  in  size, 
form,  colour,  and  general  appearance,  according  to 
their  composition.  The  constituents  that  form 
these  stones  are  uric  acid,  urates,  cystine,  xanthin, 
calcium  oxalate,  calcium  phosphate,  magnesium 
phosphate,  ammonio-magnesium  phosphate,  cal- 
cium carbonate,  and  also  concretions  of  blood  and 
fatty  substances  (urostealitli).  Any  of  the  above- 
named  substances,  combined  with  a varying  pro- 
portion of  organic  matter,  may  constitute  the  sole 
ingredient  ofacaleulus ; more  commonly, however, 
two  or  more  are  associated  together.  To  fully 
ascertain  the  composition  of  the  mass  of  the  cal- 
culus it  must  be  sawn  across,  and  if  made  up  of 
different  layers,  a portion  of  each  layer  must  be 
analysed.  See  Oxalic,  Phosphatic,  and  Ukic 
Acid  Calculi,  and  Urine. 

Pathology. — The  manner  in  which  these  con- 
cretions are  formed,  especially  renal  and  urinary 
calculi,  has  long  been  a matter  of  speculation 
with  physicians,  some  regarding  them  as  of 
purely  local  origin,  others  endeavouring  to 
show  that  they  are  the  result  of  some  peculiar 
diathesis,  wherein  uric  acid,  the  phosphates,  &c. 
are  formed  in  the  body  so  profusely,  and  are 
eliminated  in  such  quantities  as  to  be  precipitated 
in  the  passages.  The  researches  of  Ord  and  Carter 
hare  thrown  much  light  on  this  obscure  subject. 
They  have  shown  that  the  particles  constituting 
the  bulk  of  the  calculus  are  not  mere  accre- 
tions, formed  in  the  urinary  passages  by  a pro- 
cess of  chemical  precipitation,  in  the  presence  of 
blood,  mucus,  &c. ; but  consist  of  structures, 
designated  as  ‘ sub-morphous  ’—granules,  sphe- 
roids, laminae,  &c. — and  which  require  consider- 
able time  for  their  formation.  They  have  shown 
that  this  modification  of  form,  i.e.  the  change 
from  the  crystalline  to  the  sub-morphous  type, 
can  be  artificially  produced  by  allowing  two 
saline  solutions  to  intermix  slowly  through  a 
colloid  medium ; as  gum,  albumen,  &e. ; the 
more  slowly  the  mixture  is  effected  and  the 
denser  the  colloid,  the  more  perfect  is  the  change 
to  the  sub-morphous  condition.  On  the  other 
hand  if  the  colloid  medium  is  attenuated,  and 
the  admixt  ure  rapid,  the  crystalline  form  is  more 
or  less  retained.  The  nature  of  this  colloid 
medium  has  not  been  clearly  made  out.  The 


CAN  AKIES. 

fact  that  calculus  rarely  accompanies  Bright’s 
disease  shows  that  the  ordinary  effusion  of  blood 
or  albumin  into  the  renal  tubules  does  not 
furnish  the  necessary  medium.  Indeed  if  simple 
effusion  of  fibrin,  or  increased  secretion  of  mucus, 
furnished  the  colloid,  calculus,  instead  of  being 
comparatively  a rare  disease,  would  be  extremely 
common.  Some  authors  have  regarded  the  ‘ en- 
tangling mucus  ’ as  the  product  of  a specific 
catarrh.  Thus  Meckel  speaks  of  a stone-form- 
ing catarrh  ( steinbildendend  Katarrh) ; and  Dr. 
Owen  Bees  has  pointed  out  that  among  the 
many  evils  attendant  upon  gout  is  ‘ a tendency  of 
mucous  membranes  to  secrete  a viscid  mucus, 
which  modifies  the  ordinary  crystalline  character 
of  uric  acid,  causing  it  to  appear  in  agglutinated 
masses,  which  adhere  to  the  sides  of  the  urinary 
passages.’  In  speculations  as  to  the  origin  of 
stone,  too  little  attention  has  as  yet  been  paid 
to  the  condition  of  the  renal  cells.  These  cells 
normally  eliminate  the  urinary  constituents ; and 
it  is  not  difficult  to  imagine  that  under  certain 
conditions  of  vital  impairment  these  substances- 
may  be  retained  and  deposited,  instead  of  being 
eliminated,  the  cell  itself  furnishing  the  colloid 
medium.  The  objection  urged  against  this  view 
is  that  recent  observers  have  discovered  no 
satisfactory  signs  of  cell-structure  in  the  matrix 
of  calculi;  but  this  objection  can  hardly  be 
considered  fatal,  since  the  accretion  of  particles 
within  the  cell  would  gradually  destroy  the 
cell-structure.  Professor  Quekett,  however, 
figured  {Med.  Times,  vol.  xxiv.,  p.  552.  1851) 
crystals  of  calcium  oxalate  and  triple  phosphate 
contained  in  cells  taken  from  human  tubuli 
uriniferi ; and  though  his  observations  have  not 
teen  confirmed  by  others,  still  the  accuracy  of 
his  work  has  never  been  questioned,  and  it  may 
be  when  the  tubuli  uriniferi  of  persons  dying  of 
calculous  affections  come  to  be  more  frequently 
examined  by  pathologists,  cells  containing  cal- 
culous constituents  at  an  early  stage  of  depo- 
sition may  be  observed — that  is,  before  the  cell- 
wall  is  destroyed.  It  is  a remarkable  fact  that 
calculous  deposit  commencing  in  the  kidney 
tubules  is  rarely  met  with  in  the  convoluted 
portion  of  the  tubule,  but  invariably  occurs 
at  the  apices  of  the  mammillary  processes,  the 
extremities  of  the  ducti  papillares.  Now  less 
blood  circulates  through  this  portion  of  the 
kidney  than  through  any  other  part  of  it,  and 
moreover  in  the  ducti  papillares,  the  basement 
membrane  (tunica  propria)  disappears  and  the 
wall  consists  of  epithelium  alone.  May  not 
these  anatomical  differences  render  the  cells 
of  this  part  of  the  tubule  more  liable  to  cal- 
culous deposit— in  short,  to  undergo  calculous 
degeneration  ? 

CALIPERS. — An  instrument  employed  for 
measuring  diameters,  more  especially  in  medi- 
cine the  diameters  of  the  chest.  See  Physical 
Examination. 

CALVITIES  (calvus, bald).  Synon. : Alopecia 
calva.  A synonym  for  baldness.  See  Baldness. 

CANARIES,  The  (Teneriffe),  in  North-east 
Atlantic  Ocean.  Mean  temperature  in  winter,  64° 
to  85°.  "Warmer,  drier,  but  more  variable,  thus 
Madeira.  East  winds  from  Africa. 


CANCER. 


203 


CANCER  ( Cancer , a crab). — Definition. — 
The  word  cancer  is  without  histological  mean- 
ing. We  find  it  and  its  synonym,  carcinoma, 
used  as  long  ago  as  the  time  of  Hippocrates,  and 
the  latter  term  was  then,  as  is  the  former  at 
the  present  day  by  the  vulgar,  applied  to  any 
new  growth  of  a malignant  character.  The 
name  originated  in  the  large  ramifying  veins  and 
puckered  furrows  which  spread  from  a cicatriz- 
ing cancer  that  is  involving  the  skin.  When  the 
broad  distinction  between  the  epithelial  and  con- 
nective-tissue type  of  tumours  was  established 
by  Virchow  and  others,  it  was  decided  to  retain 
the  word  cancer  as  the  name  for  the  more  malig- 
nant or  epithelial  growths ; while  the  equally 
meaningless  but  less  formidable  word  sarcoma 
has  been  from  this  time  confined  to  those 
tumours  winch  have  connective  tissue  for  their 
type.  See  Tumours. 

In  this  sense  of  the  word  the  cancers  form  a 
class  which  is,  on  the  whole,  easily  distinguished 
by  definite  microscopical  and  clinical  characters, 
but  at  two  points,  at  least,  the  difference  from 
simpler  growths  is  almost  imperceptible.  First, 
as  a matter  of  accident,  one  sarcoma  (the  alveo- 
lar) resembles  a cancer  so  closely  in  micro- 
scopical structure,  that  it  is  impossible  to  dis- 
tinguish between  them  without  reference  to 
cliuical  facts ; and,  in  the  second  place,  as  can- 
cers are  essentially  depraved  modifications  of 
epithelial,  epidermic,  or  glandular  structure,  they 
may  be  found  to  differ  so  slightly  in  histological 
characters  from  simple  hypertrophies,  that  the 
fact  of  ultimate  malignancy  is  often  all  that  can 
decide  between,  say,  a papilloma  and  an  epithe- 
lioma, a glandular  cancer  of  the  rectum  and  a 
simple  polypus,  or  a scirrhus  of  the  breast  and 
a chronic  mammary  tumour. 

Histological  Structure.  — Histologically, 
cancers  are  distinguished  by  consisting  partly  of 
cells  of  an  obviously  epithelial  origin  and  partly 
of  connective  tissue.  The  connective-tissue 
forms  alveolar  spaces,  and  may  vary  in  structure 
from  a loose  fibro-cellular  material  to  strong  and 
old  fibrous  tissue.  The  alveolar  spaces  com- 
municate with  each  other  and  contain  the  epithe- 
lial cells.  These  vary  much  in  shape,  size, 
and  arrangement,  but  are  always  easily  separable 
from  the  surrounding  connective-tissue,  while 
thej'  are  never  separated  from  one  another  by  a 
stroma  of  any  sort. 

Clinical  Characters. — Clinically,  cancers  are 
distinguished  by  the  structures  in  which  they 
originate ; by  the  method  of  their  recurrence  and 
their  mode  of  growth ; as  well  as  by  a few  charac- 
teristics apparent  to  the  eye  and  touch. 

Seat. — As  their  nature  would  have  rendered 
almost  certain  a priori,  cancers  probably  never 
originate  except  in  connection  with  epithelial 
or  epidermic  structures — i.e.,  in  skin,  mucous 
membrane,  or  secreting  glands ; but  as  the 
epidermis  and  epithelium,  the  original  upper 
and  lower  layers  of  the  embryo,  are  widely 
diffused  throughout  the  body,  and  often  inti- 
mately associated  with  the  descendants  of  the 
cells  of  the  middle  layer,  it  is  not  surprising  that 
primary  cancers  have  been  described  as  oc- 
curring in  organs  which  have  their  origin  from 
connective-tissue  only.  Such  are  the  instances 
of  primary  cancer  of  bone  and  lymphatic  glands 


the  possibility  of  the  occurrence  of  which  may 
be  at  present  considered  undecided. 

Recurrence. — The  first  recurrence  is  almost 
without  exception  in  the  lymphatic  glands, 
which  collect  their  suppily  of  lymph  from  the 
seat  of  the  original  tumour ; when  this  has  oc- 
curred the  process  may  be  repeated  in  the  next 
proximal  lymphatic  glands,  or  numerous  distinct 
tumours  may  appear  in  different  parts  of  the 
body ; but  if  a single  growth  occur  in  another 
locality  without  previous  glandular  enlargement 
the  case  may  probably  be  looked  upon  as  a 
double  primary  development.  A soft  cancer 
may  burst  into  the  abdominal  cavity,  where 
its  small  particles  may  stick  to  various  parts  of 
the  peritoneum  and  form  the  starting  points  of 
new  growths  (disseminated  cancer  of  the  peri- 
toneum) ; it  is  probable  that  a similar  seeding 
may  take  place  into  the  lungs  when  an  ulcerated 
epithelioma  projects  into  the  trachea. 

Mode  of  growth.  — Cancers  increase  in  size 
by  infiltration  of  the  surrounding  tissues,  and 
this  gives  rise  to  the  very  important  clinical 
facts  that  they  are  not  enclosed  by  a capsule  like 
many  simpler  growths,  and  that  they  have  a 
great  tendency  to  implicate  the  skin  and  cause 
ulceration. 

Naked-eye  appearances. — The  contraction  of 
the  connective-tissue  forming  the  alveoli  in  its 
advance  towards  fibrous  tissue  gives  rise  to 
puckering  of  the  surrounding  skin  ; and  the  loose- 
ness of  the  connection  between  the  epithelial 
and  connective-tissue  elements  causes  a milky 
juice  consisting  of  the  former  to  escape  on 
scraping  a recent  section.  This  characteristic 
was  made  much  of  by  our  predecessors  before 
the  word  cancer  had  lost  its  inclusive  meaning ; 
we  knownow  that  many  rapidly  growing  sarcomas 
yield  a similar  juice,  hut  in  less  abundance  than 


cancers ; and  thus  it  has  come  to  pass  that  a 
milky  juice  is  now  more  diagnostic  of  the 
malignancy  than  of  the  genetic  origin  of  the 
growth. 

This  completes  the  list  of  the  signs  by  which 
cancers  may  be  distinguished  from  other  tu- 
mours. Tables  have  been  published  to  show  the 
relative  frequency  with  which  cancer  attacks 
different  organs  ; tbey  are  not  upon  the  whole 
trustworthy,  and  this  question  will  be  best  con- 
sidered in  discussing  the  subdivisions  of  the 
genus. 

Classification. — The  subdivisions  of  cancers 
are  as  follows  : — 

Hard  cancer  or  Scirrhus.  j „ 

Soft  cancer  or  Encephaloid.  f tandular  type 
Cylindrical  Epithelioma.  Epithelial  and 
Lobular  Epithelioma.  J Epidermic  type. 
Colloid. 

Typical  hard  and  soft  cancers  stand  obviously  at 
opposite  ends  of  one  series  which  is  built  upon 
the  type  of  a secreting  gland  : between  the  two 
are  an  infinitude  of  intermediate  stages.  The 
two  forms  of  epithelioma  are,  quite  as  evidently, 
monstrous  growths  of  skin  or  mucous  membrane. 
Colloid  is  probably  the  result  of  degeneration  of 
any  one  of  the  other  forms.  Besides  these,  other 
varieties  are  often  mentioned  which  do  not  justify 
a more  complicated  classification  ; amongst  these 
are  tumours,  which  though  of  nearly  normal 
glandular  structure  are  nevertheless  malignant, 


CANCER. 


204 

and  those  which  have  received  the  names  Me- 
lanotic, Teliangiectasic,  Ostcocanccr,  & c. 

Diagnosis. — The  diagnosis  depends  upon  the 
clinical  characters  of  the  several  groups.  That 
of  an  advanced  case  of  cancer  is  generally  easy; 
in  the  early  stages  it  is  mostly  impossible. 

Prognosis. — The  prognosis  is  always  had, 
especially  in  encephaloid  cancer,  but  least  so 
in  epithelioma ; this  suggests  the  much-debated 
question  of  the  constitutional  nature  of  the  dis- 
ease. If  in  its  origin  a cancer  be  purely  local, 
early  removal  ought  to  effect  a permanent  cure  ; 
but  if  there  be  at  tho  bottom  a constitutional 
taint.,  a reprieve  should  merely  be  granted  until 
a suitable  fresh  irritation  arise.  There  is  pro- 
bably some  truth  on  both  sides.  The  cancerous 
cachexia  is  often  spoken  of ; it  depends  chiefly, 
if  not  altogether,  on  the  weakening  effects  of 
the  discharge  after  ulceration  has  taken  place  ; 
mental  worry  may  have  some  share  in  causing 
it;  but  it  must  be  remembered  that  cancerous 
patients,  who,  before  they  are  attacked,  are  fre- 
quently amongst  the  most  robust,  often  retain 
their  health  for  a remarkably  long  time. 

Course. — The  course  of  a cancer  depends  upon 
its  seat,  and  the  symptoms  must  accordingly  be 
sought  amongst  the  articles  on  diseases  of  special 
regions.  If,  however,  life  be  not  shortened  as 
a result  of  interference  with  the  functions  of 
tho  organ  attacked,  death  is  caused  either  by 
marasmus — the  result  of  prolonged  suppuration 
and  pain,  or  by  extensive  or  repeated  haemor- 
rhages. The  rate  of  progress  is  more  slow  as 
age  advances. 

Treatment. — The  treatment  of  cancer  in  tho 
early  stages  can  only  be  undertaken  by  the 
surgeon,  and  the  reader  is  accordingly  referred 
for  information  on  this  head  to  surgical  text- 
books ; in  the  later  stages  the  physician  may 
be  called  upon  to  treat  symptoms,  but  up  to 
the  present  time  all  the  specifics  introduced 
either  by  regular  practitioners  or  by  charlatans 
have  proved  quite  inefficient,  if  not  actually 
harmful. 

We  shall  now  discuss  the  varieties  of  cancer. 

I.  Scirrhus.— Scirrhus,  as  its  name  implies,  is 
amongst  the  liardestof  tumours,  if  bony  growths 
be  excepted.  Its  hardness,  as  compared  with  soft 
cancer,  depends  upon  the  larger  proportion  which 
the  alveolar  stroma  bears  to  the  contained  cells ; 
and  this  is  probably  the  consequence  of  the  soil 
in  which  the  tumour  originates,  and  the  rapidity 
of  its  growth,  rather  than  of  any  specific 
difference  between  them. 

Scat. — The  female  breast  is  the  most  common 
seat  for  scirrhus,  but  it  also  occurs  in  the 
stomach,  uterus,  tongue,  oesophagus,  and  the 
liver  and  other  glands,  and  it  has  been  described 
as  primary  in  the  prostate,  testicle,  skin,  and 
other  structures. 

Naked-eye  appearances. — A section  through 
the  centre  of  a matured  hard  cancer  of  the 
breast  presents  to  the  naked  eye  well-marked  and 
constant  appearances,  which,  with  the  exception 
of  such  peculiarities  as  are  due  to  the  situation, 
will  serve  as  a description  of  such  a tumour 
occurring  elsewhere.  These  are  clearly  explained 
by  the  microscopical  arrangement,  and  when 
looked  at  by  the  light  which  it  affords,  fully 
account  for  all  the  clinical  characters.  The 


knife  passes  through  it  with  a creaking  noise, 
and  the  cut  surfaces  are  at  once  hollowed  in  tho 
centre.  There  is  not  a sharp  edge  to  the  growth, 
and  the  circumference  is  of  a greyish  or  pinkish 
white  tint,  projecting  a little  above  the  surround- 
ing tissues,  into  which  it  sends  small  lobular  pro- 
longations ; the  hollow  centre  is  very  hard  and 
cf  a glistening  white  colour.  Scirrhus  is  evidently 
fibrous  in  structure,  and  receives  from  all 
quarters  fibrous  bands,  which  often  pass  far  out 
into  the  fat  of  the  breast  or  the  skin,  and  some  of 
which  can  nearly  always  be  traced  to  the  prin- 
cipal milk-ducts.  Between  the  centre  and  the 
edge  is  the  greater  part  of  the  tumour,  on  tho 
whole  of  a pinkish-yellow  colour,  but  notably 
pink  and  soft  externally,  and  yellow  and  hard 
internally.  The  surface  yields  a milky  juice  on 
scraping,  and  may  show  some  of  the  following  ap- 
pearances, which  are, however,  accidental:  round 
the  circumference  little  masses  of  healthy  fat 
may  be  included,  though  this  but  rarely  happens; 
cysts  containing  grumous  grey  or  red  fluid  may 
have  formed  by  the  breaking  down  of  the  new 
growth  or  by  haemorrhage ; or  such  a htemorrhage 
may  have  resulted  in  patches  of  yellow  or  even 
black  pigmentation. 

Microscopical  appearances. — Without  discuss- 
ing the  merits  of  the  opposing  theories  as  to  the 
origin  of  cancer-cells, the  following  maybe  taken 
as  the  undoubted  microscopical  appearances  of 
scirrhus ; the  grey  outer  layer  is  made  up  of  in- 
definite smallish  round  cells,  resembling  white 
blood-corpuscles,  infiltrated  through  the  tissue 
into  which  the  growth  is  spreading,  amongst 
which  are  scattered  a few  which  have  the  ap- 
pearance of  epithelial  cells.  The  next  or  pink 
layer  represents  full  development  and  shows 
fibro-cellular  stroma,  enclosing  large  epithelioid 
cells,  and  containing  a copious  supply  of  vessels. 
In  the  third  or  yellow  layer  the  stroma  has  be- 
come fibrous  and  the  cells  are  undergoing  fatty 
degeneration ; and  in  the  inner  white  centre  the 
cells  are  replaced  by  indefinite  masses  of  granular 
debris,  and  the  stroma  consists  of  firm  and  old 
fibrous  tissue.  See  figs.  125,  12V,  and  126. 

The  relation  of  these  appearances  to  the  clini- 
cal peculiarities  of  scirrhus  is  as  follows : the 
excessive  hardness  is  explained  by  the  great 
development  of  fibrous  tissue  ; the  peculiar  in- 
definiteness of  the  edge,  and  the  tendency  to 
involve  the  skin  and  ulcerate,  by  the  manner  of 
growth;  while  the  puckering,  retraction  of  the 
nipple,  and  indirectly  (from  the  manner  in  which 
cutaneous  nerves  are  involved)  the  pricking  and 
shooting  pains,  are  due  to  the  contraction  or 
cicatrization  of  the  stroma.  To  the  latter  is  also 
due  a very  important  but  notgenerally  recognized 
diagnostic  character  of  an  early  scirrhus,  namely, 
that  long  before  the  skin  is  involved  it  is  seen 
to  be  dimpled  when  gently  moved  to  and  fro  over 
the  growth.  A scirrhus  which  has  involved  the 
skin  forms  a purplish-red,  flattened,  and  shining 
tumour,  covered  with  small  veins  and  tender  to 
the  touch ; the  ulcer  which  results  from  its  break- 
ing down  is  ragged,  with  a hard  base  and  hard 
irregular  undermined  edges,  and  a dirty  surface 
covered  by  knobby  masses  of  pseudo-granulations, 
which  have  a great  tendency  to  bleed  and  often 
slough.  As  it  is  often  removed  it  often  returns 
in  the  scar.  When  occurring  in  the  liver  it  Lj 


[To  face  page  204. 


CANCER. 


Fig.  117.  Papilloma  of  Soft  Palate. 


Fig.  120.  Simple  Polypus  of  Rectum. 


Fig.  118.  Epithelioma  of  Lip. 


Fig.  121.  Columnar  Epithelioma  of 
Intestine. 


Fig.  119.  Edge  of  Rodent  Ulcer. 


Fig.  122.  Colloid  of  Breast. 


Fig.  123.  Cancer  of  Liver  (Scirrho, 
encephaloid). 


Fig.  125.  Soirrhus,  Infiltrating  Fat. 


Fig.  124.  Encephaloid  Cancer. 


Fig.  126,  Cicatrizing  Cancer. 


Fig.  128.  Adenoid  of  Upper 
Jaw  (Benign). 


Fig.  129.  Ulcerated  Adenoid  of 
Parotid  (Malignant). 


Fig.  130.  Adenoid  of  Breast  (common, 
type). 


Fig.  131.  Adenoid  of  Breast  (epi- 
thelial element  in  excess). 


Fig.  127.  Scirrhus  of  Mamma. 


Fig.  132.  Adenoid  of  Breast 
(Adeno-sarcoma). 


Drawings  Illustrating  a Series  of  Tumours  of  the  Epithelial  Type.  All  drawn  to  the  same 

scale  ( x 87  diameters). 


CANCER. 


softer  than  elsewhere,  and  the  name  of  scirrho- 
encephaloid  is  often  given  to  it.  See  fig.  96. 

II.  Encephaloid. — Encephaloid,  medullary, 
or  soft  cancer,  so  named  from  its  usually  brain- 
like  appearance  and  consistence,  is  softer  and 
grows  more  rapidly,  and  is  more  frequently  ob- 
served in  internal  organs  than  scirrhns,  often  in- 
deed formingenormous  intra-abdominal  tumours. 

Seat. — It  has  hitherto  been  observed  as  pri- 
mary in  the  salivary  and  mammary  glands,  tes- 
ticle, ovary,  and  prostate,  the  thyroid  body,  and 
in  the  mucous  membrane  of  the  nose,  the  liver, 
and  the  stomach.  It  has  -with  some  degree  of 
looseness  been  sometimes  called  the  cancer  of 
childhood  by  those  who  consider  scirrhus  as 
almost  peculiar  to  old  age. 

Naked-eye  appearances. — To  the  naked  eye  a 
fresh  section  usually  presents  a convex  surface  ; 
it  is  whitish,  but  generally  mottled  by  coloured 
patches,  the  result  of  old  or  recent  haemorrhages, 
and  yields  very  copiously  a milky  juice  on 
scraping. 

Microscopical  appearances. — Encephaloid  can- 
cer differs  from  scirrhus  only  in  the  relative  pro- 
portions of  the  two  chief  factors.  The  cells  are 
more  numerous  and  are  contained  in  larger 
spaces  ; they  are  sometimes  small,  but  generally 
much  larger  than  in  scirrhus;  and  the  stroma  is 
delicate  and  fibro-cellular  and  very  small  in 
amount.  See  fig.  124. 

Its  method  of  extension  is  the  same  as  that 
of  other  members  of  the  class.  It  is  by  far 
the  most  malignant  form  of  cancer,  because 
of  its  rate  of  growth  and  recurrence,  and  the 
rapidity  with  which  it  causes  general  cachexia. 

Epithelioma  — Lobular  epithelioma,  epi- 
thelial cancer,  or  cancroid,  develops  in  con- 
nection with  skin  and  mucous  membrane,  and 
though  consisting  essentially  of  squamous  epi- 
thelium, may  start  from  a part  which  is  covered 
by  the  cylindrical  variety.  It  occurs  near  the 
natural  orifices  of  the  mucous  tracts  — as,  for 
example,  on  the  mouth  and  tongue,  anus,  penis, 
or  vulva  ; but  also  at  other  parts  of  the  skin  — 
as  on  the  acrotum  (chimney-sweep’s  cancer)  and 
at  the  upper  end  of  the  oesophagus.  The  his- 
tory of  a local  irritation  is  often  obtainable, 
but  more  frequently  nothing  of  the  kind  can  be 
discovered. 

Naked-eye  appearances. — The  first  appearance 
is  that  of  a pimple,  which  soon  breaks  down  in 
the  centre,  forming  a small  sore.  'When  fully 
developed  there  is  an  irregular  ulcer  with  an 
extensive  hard  and  nodular,  generally  in- 
flamed base  and  circumference;  the  edges  are 
abrupt  or  undermined,  and  the  floor  grey  or 
reddish,  very  uneven,  discharging  a foul  pus,  and 
with  a great  tendency  to  bleed.  As  a rule  there 
is  considerable  pain,  and  the  proximal  lym- 
phatic glands  are  very  generally  enlarged.  A 
section  to  the  naked  eye  shows  a number  of 
minute  cylinders  of  yellowish-white  colour,  cut 
sometimes  longitudinally,  sometimes  trans- 
versely. fusing  together  into  an  indefinite  mass 
superficially,  but  more  or  less  discrete  below, 
and  infiltrating  amongst  the  subjacent  tissues. 
On  squeezing  the  section  little  nodules  like 
sebum  appear  on  the  surface. 

Microscopical  appearances. — The  cylinders  or 
lobes  of  epithelioma  are  found  to  be  made  up  c-f 


205 

squamous  epithelium,  which  generally  exhibits 
in  parts  a crenatedmargin  (Max  Schultze’s  spine- 
cells).  A s in  the  skin,  the  deeper — that  is  the  cir- 
cumferential— layer  of  cells  in  each  lobe,  which 
are  the  youngest,  are  roundish  or  oblong,  with 
large  nuclei,  and  staining  readily;  further  in, 
the  cells  are  larger  and  flatter,  and  in  the  centre 
are  found  the  well-known  globes  or  nests.  These 
were  considered  at  one  time  as  peculiar  to 
epithelioma,  but  are  now  known  to  occur  in 
warts  and  corns ; they  consist  of  onion-like  ar- 
rangements of  epithelial  cells,  varying  much 
in  size  and  the  number  of  concentric  layers, 
and  containing  in  the  centre  sometimes  an 
amorphous  mass,  sometimes  large  and  irregular 
cells.  The  tissues  beneath  and  between  the 
lobules  are  infiltrated  with  small  cells,  and 
often  contain  in  sections  what  appear  to  be  iso- 
lated masses  of  epithelium ; these  are,  however, 
the  ends  of  divided  divergent  lobules.  Opinions 
differ  as  to  the  exact  starting-point  of  an  epithe- 
lioma, the  share  which  the  sweat-  and  other 
glands  take  in  it,  and  also  as  to  the  rationale  of 
the  formation  of  the  globes.  See  fig.  118. 

Epithelioma  seems  to  be  more  local  in  its  nature 
than  other  cancers — that  is,  a complete  and  early 
removal  has  not  unfrequeutly  given  the  patient 
a long  lease  of  life.  It  recurs,  as  a rule,  in  the 
lympathic  glands,  which  inflame  and  suppurate, 
and  in  the  scar,  and  generally  proves  fatal  from 
the  constitutional  disturbance  it  gives  rise  to. 
Later  but  more  rarely  it  may  appear  in  the  in- 
ternal viscera,  bones,  &c. 

Cylindrical  Epithelioma. — The  cylindrical 
epithelioma — badly  named  adenoid  or  glandular 
cancer — is  specially  the  cancer  of  the  alimen- 
tary mucous  membrane,  but  may  occur  in  the 
bladder  and  elsewhere. 

Naked-eye  appearances. — To  the  naked  eye 
it  forms  at  first  a prominent  tumour  in  the 
interior  of -a  viscus,  which  has  a tendency  like 
other  cancers  to  ulcerate  and  involve  surround- 
ing tissues,  so  that  the  mass  may  reach  an 
enormous  size,  and  may  even  make  its  appear- 
ance through  the  skin.  To  the  naked  eye  a 
section  is  generally  whitish  and  has  a granular 
appearance,  which  is  given  to  it  by  the  tubules  of 
which  it  is  made.  It  frequently  causes  death  by 
obstruction  of  the  bowel,  but  if  it  last  sufficiently 
long,  it  recurs  unaltered  in  the  lymphatic  glands, 
and  then  in  the  viscera  and  other  parts  of  the 
body.  It  is  not  unfrequent  to  find  recurrences 
in  the  liver  with  little  if  any  implication  of 
lymphatic  glands. 

Microscopical  appearances. — Cylindrical  epi- 
thelioma consists  essentially  of  irregular  tubules 
lined  with  columnar  epithelium  in  one  or  more 
layers,  which  are  the  much  overgrown  crypts  of 
Lieberkiibn,  and  differ  in  microscopical  structure 
from  simple  papilloma  of  the  digestive  tract  only 
in  the  greater  irregularity  of  the  cells  and  in  the 
larger  proportion  of  connective-tissue  stroma 
between  the  tubes.  See  fig.  121. 

Colloid. — Colloid,  or  alveolar  cancer,  named 
from  its  jelly-like  appearance,  has  given  rise 
to  much  discussion  in  reference  to  the  ques- 
tion whether  it  is  developed  originally  in  its 
mature  form,  or  whether  it  results  from  tho 
degeneration  of  one  of  the  classes  of  cancer 
described  above.  The  latter  view  is  that  most 


206  CANCER, 

widely  held,  though  it  must  be  allowed  that 
epithelioma  soldom  degenerates  in  this  way,  and 
also  that  the  colloid  change  usually  takes  place 
pari  passu  with  the  growth  of  the  tumour. 

Seat. — Colloid  cancer  is  found  most  frequently 
in  the  abdominal  -viscera  and  peritoneum,  but 
may  occur  elsewhere,  as  in  the  breast.  Its 
malignancy  is  great,  but  is  shown  chiefly  by 
the  rapidity  with  which  it  involves  surrounding 
tissues ; it  thus  forms  primary  tumours  of  enor- 
mous size,  but  as  a secondary  growth  is  less 
common ; it  does,  however,  occur  in  lymphatic 
glands  and  other  parts.  It  causes  death  in  most 
cases  by  interference  with  the  functions  of 
the  organs  attacked. 

Naked-eye  appearances. — Colloid  cancer  con- 
sists to  the  naked  eye  of  a mass  of  semi-trans- 
parent jelly,  varying  slightly  in  colour,  but 
mostly  pale  yellow:  this  is  intersected  by  deli- 
cate white  fibrous  bands,  forming  alveolar  spaces 
of  different  sizes,  visible  to  the  naked  eye.  The 
consistence  of  the  growth  depends  upon  the  rela/- 
tive  proportions  of  these  two  constituents. 

Microscopical  appearances. — The  bands  are 
found  to  be  actually  fibrous ; the  contained  jelly 
is  arranged  in  concentric  laminae  between  which 
are  minute  granules,  and  in  the  centre  of  which 
is  a granular  mass,  sometimes  quite  indefinite, 
but  often  showing  clearly  that  it  consists  of  the 
remains  of  altered  cells.  These  cells  are  seen 
in  the  more  recent  parts  of  the  growth  to  be  the 
subjects  of  colloid  degeneration.  The  source  of 
the  colloid  material  must  be  considered  still 
undecided;  that  some  of  it  is  formed  by  the 
cells  is  certain,  but  it  is  not  equally  clear 
whether  the  stroma  takes  any  share  in  its  depo- 
sition. See  fig.  122. 

Conclusion. — Our  knowledge  of  the  pathology 
of  new  growths  is  undergoing  a process  of  rapid 
evolution.  While,  therefore,  the  writer  has 
endeavoured  in  this  article,  and  in  that  on 
Tumours,  to  represent  the  opinions  most  widely 
accepted  at  the  present  day,  he  is  conscious  that 
in  a very  short  time  these  opinions  may  require 
considerable  modification.  R.  J.  Godlee. 

CANCRUH  ORIS  ( Cancrum , a sore; 
and  oris,  of  the  mouth).  Synon.  : Gangrenous 
Stomatitis ; Noma ; Fr.  le  Nome ; Ger.  Wasser- 
krcbs. 

Definition. — A phagedsenic  ulceration  of  the 
cheek  and  lip,  rapidly  proceeding  to  sloughing. 

^Etiology. — Cancrum  oris  is  usually  seen  in 
delicate,  ill-fed,  ill-tended  children;  and  in 
these  subjects  it  is  commonly  a sequela  to  one 
of  the  eruptive  fevers.  Formerly  it  used  some- 
times to  be  due  to  excessive  doses  of  mercury. 

Symptoms. — The  disease  commences  by  swel- 
ling and  tenderness  near  the  angle  of  the  mouth, 
and  if  at  this  stage  the  mucous  membrane  is  exa- 
mined, it  will  usually  be  found  that  there  is  some 
superficial  ulceration  on  the  inside  of  the  lip  or 
cheek — that  is,  ulcerative  stomatitis.  From  this 
slight  beginning  the  disease  rapidly  advances. 
The  soft  tissues  become  much  swollen,  brawny, 
shining,  and  red.  Presently  a livid  spot  makes 
its  appearance  in  the  centre,  and  the  surround- 
ing part  becomes  purplish  or  mottled.  If  the 
patient  can  open  his  mouth  sufficiently  to  give 
a view  of  the  gums,  they  will  be  seen  to  be 


CAPILLARIES,  DISEASES  OF. 

red,  congested,  spongy,  and  bathed  with  a profuse 
and  fretid  saliva.  The  livid  tissues  of  the  cheek 
rapidly  slough,  the  disease  perhaps  involving 
the  lip,  or  spreading  to  the  gum,  laying  bare 
the  alveolar  processes,  and  loosening  the  teeth. 
This  local  affection  is  attended  by  a high  degree 
of  pyrexia,  and  by  great  prostration. 

The  disease  is  very  fatal.  Rilliet  and  Bar- 
thez  state  that  not  more  than  one  in  twenty 
cases  recover. 

Treatment. — This  consists  in  the  application 
of  strong  nitric  acid  to  any  points  where  the 
ulceration  and  sloughing  are  spreading.  Poultices 
should  be  kept  constantly  on  the  cheek,  and  from 
time  to  time  the  sore  should  be  syringed  with  a 
disinfecting  lotion.  The  constitutional  treat- 
ment consists  in  the  administration  of  a full 
amount  of  beef-tea,  milk,  eggs,  &c.,  with  a 
moderate  allowance  of  alcoholic  stimulants,  as 
well  as  bark,  ammonia,  and  other  suitable  tonics. 
Regular  and  systematic  administration  of  food 
and  medicine  is  of  the  utmost  importance ; and 
if  the  patient  is  unable  to  swallow,  nutritious 
enemata  must  be  used  regularly. 

W.  Faiblie  Clarke. 

CANITIES  ( canus , hoary  or  greyhaired). — 
Whiteness  or  greyness  of  the  hair.  See  Hair, 
Diseases  of. 

CANNES  in  Prance,  on  the  Mediter- 
ranean coast.  A dry,  bracing,  fairly  mild  winter 
climate.  Exposed  to  N.W.  Abundant  accom- 
modation, both  near  and  at  some  distance  from 
the  sea. 

CANTHARIDES,  Poisoning  by.  See 
Appendix. 

CAPE  OP  GOOD  HOPE. — A warm, 
generally  dry  climate,  but  very  variable,  and 
liable  to  sudden  storms.  Living  dear,  and  loco- 
motion difficult. 

CAPILLARIES,  Diseases  of. — The  mor- 
bid conditions  of  the  capillaries  may  be  described 
in  the  following  order  : — 1.  Fatty  Degeneration. 
2.  Calcareous  Degeneration.  3.  Albuminoid 
Degeneration.  4.  Pigmentation.  .5.  Changes  in 
Inflammation.  6.  Dilatation.  7.  Narrowing 
and  Obliteration.  8.  Thrombosis.  S.  Embolism. 
10.  Rupture.  11.  The  New  Formation  of  Capil- 
laries. 12.  Capillaries  in  New  Growths  and 
Tubercle.  13.  Changes  in  the  Perivascular  Space 
and  Sheath.  1 4.  Teleangiectasis. 

1.  Patty  Degeneration  is  the  most  common 
disease  of  the  capillary-wall,  and  is  frequently 
associated  with  fatty  degeneration  cf  the  sur- 
rounding tissues.  The  cause  of  this  change  in 
the  protoplasm  of  the  capillary  is,  as  elsewhere, 
interference  with  nutrition,  and  especially  with 
oxidation.  It  is  accordingly  found  in  morbid 
conditions  of  the  blood ; in  interference  with  the 
blood-supply;  and  in  lesions  of  the  nervous  system. 
The  microscopical  characters  of  the  early  stages 
of  fatty  degeneration  when  it  affects  the  capilla- 
ries are  not  peculiar;  in  advanced  stages  the 
diseased  vessels  may  present  the  appearance  of 
opaque  granular  cords ; and  the  1 vmphatic  sheaths 
of  the  cerebral  capillaries  are  sometimes  found, 
under  such  circumstances,  filled  with  oil-globules 
and  fatty  cells.  A frequent  termination  of 
the  disease  is  rupture  and  haemorrhage.  Fattv 


CAPILLAKIES,  DISEASES  OF. 
degeneration  of  the  capillaries  occurs  most  fre- 
quently in  the  nervous  centres,  in  the  kidneys,  in 
certain  tumours,  and  in  the  products  of  infarction 
and  inflammation. 

2.  Calcareous  Degeneration  is  rare  in 
capillaries. 

3.  Albuminoid  Degeneration  affects  the 
Malpighian  glomeruli  in  the  early  stage  of 
albuminoid  disease  of  the  kidneys.  In  other 
parts  of  the  body  the  capillaries  are  less  subject 
to  albuminoid  change  than  the  small  arteries. 

4.  Pigmentation. — Pigment  ary  granules  may 
sometimes  be  found  in  the  walls  of  capillaries, 
but  they  more  frequently  occupy  the  perivascular 
space.  In  either  situation  pigmentation  is  the 
result  of  chronic  congestion  or  inflammation,  or 
of  haemorrhage. 

5.  Changes  in  Inflammation. — The  changes 
of  the  capillaries  of  an  inflamed  part  constitute 
an  important  factor  of  the  process  of  inflamma- 
tion. See  Inflammation. 

6.  Dilatation  of  capillaries,  which  is  one 
of  the  changes  in  inflammation  just  referred  to, 
may  become  permanent  if  the  process  be  chronic. 
Changes  in  the  nutrition  of  the  capillary-wall, 
combined  with  disturbances  of  the  circulation, 
such  as  increased  pressure,  produce  local  dilata- 
tion or  Aneurism  of  the  vessels  and  subsequent 
rupture.  This  is  one  form  of  miliary  aneurism 
as  it  occurs  in  the  brain. 

7.  Narrowing  and  Obliteration. — Narrow- 
ing of  capillaries  may  be  temporary,  as  in  in- 
flammation ; or  permanent,  from  external  pres- 
sure, or  from  interference  with  the  blood-supply. 
Harrowing  may  proceed  to  complete  obliteration. 

8.  Thrombosis  commonly  occurs  in  capil- 
laries as  a consequence  of  embolism  or  of  throm- 
liosis  in  the  associated  arteries  or  veins.  Less 
frequently  the  coagulation  of  blood  is  primary, 
and  is  due  to  one  or  more  of  the  usual  causes  of 
thrombosis,  namely,  feebleness  of  the  circulation 
and  alteration  of  the  blood. 

9.  Embolism. — The  phenomena  of  ordinary 
embolism  in  a great  measure  affect  the  capillaries 
corresponding  with  the  obstructed  artery.  But 
besides  this  change,  capillaries  are  themselves 
subject  to  embolism,  or  impaction  of  particles 
within  them.  The  products  of  inflammation  or 
degeneration,  pigment-particles,  oil  or  fat  drops 
from  the  marrow  of  fractured  bones,  organisms, 
and  various  substances  artificially  introduced 
into  the  circulation,  have  been  discovered  ob- 
structing the  capillaries  in  different  instances. 
All  the  possible  results  of  embolism  in  large 
vessels  may  follow,  according  to  circumstances ; 
and  in  the  case  of  the  cerebral  vessels  definite 
symptoms  are  believed  by  some  to  result,  such 
as  delirium  and  choreic  movements.  See 
Chorea. 

10.  Rupture. — Three  circumstances  specially 
determine  the  occurrence  of  this  lesion  of  capil- 
laries, namely,  disease  of  the  vessel-wall,  increase 
of  the  blood-pressure,  and  a ‘ terminal  ’ distri- 
bution of  the  branches  of  the  artery  that 
supplies  them.  The  most  common  diseases  of 
the  wall  are  fatty  degeneration  and  aneurism. 
The  blood-pressure  rises  within  the  capillaries  of 
any  part  in  ventricular  hypertrophy,  in  increased 
tension  of  the  arteries  of  other  parts,  and  in  ve- 
nous obstruction.  When  an  artery  is  ‘ terminal,’ 


CARBONIC  ACID.  207 

that  is,  unprovided  with  other  anastomoses 
than  through  its  capillaries,  no  lateral  relief  can 
be  afforded  in  sudden  and  excessive  rises  in 
the  force  of  the  circulation.  For  these  several 
reasons,  rupture  of  capillaries  is  most  frequent 
when  the  vessel-walls  have  been  weakened  in 
the  fatty  degeneration  of  senile  decay,  in  septic- 
aemia, inflammation,  purpura,  fever,  and  scurvy  ; 
in  chronic  Bright’s  Disease,  with  increased  blood- 
pressure  ; and  in  such  organa  as  the  corpus 
striatum,  retina,  spleen,  kidney,  villi,  and  skin. 
Disturbances  in  the  pressure  of  the  air  within  the 
chest  powerfully  influence  the  occurrence  of 
capillary-rupture  in  the  respiratory  tract.  When 
a capillary-wall  gives  way,  the  blood  is  extrava- 
sated  either  on  a free  surface,  constituting  hsemor- 
hago  ; into  the  substance  of  the  tissues  around ; 
or  along  the  lymphatic  sheath  of  the  ruptured 
vessel,  where  it  gives  rise  to  the  appearance 
that  has  been  described  as  dissecting  capillary 
aneurism. 

11.  New  Formation  of  Capillaries. — Capil- 
laries grow  or  develop  in  nearly  all  forms  of  new 
growth,  whether  inflammatory  or  otherwise. 
The  young  capillaries  are  derived  either  from 
cellular  buds  upon  previous  capillaries,  which 
become  hollowed  by  the  blood-pressure ; from 
anastomosing  exudation-cells,  or  connective- 
tissue  corpuscles ; or,  in  some  cases,  from  the 
parallel  disposition  of  exudation-cells. 

12.  Capillaries  in  New  Growths  and 
Tubercle. — The  capillary- walls  are  believed  to 
play  an  important  part  in  the  production  of 
certain  forms  of  new  growth.  See  Tomoues  and 
Tubercle. 

13.  Changes  in  the  Perivascular  Space 
and  Sheath. — The  perivascular  or  lymphatic 
sheath,  which  probably  envelopes  all  capillaries, 
is  liable  to  certain  morbid  conditions,  which  are 
chiefly  secondary  to  changes  in  the  vessel  within 
it.  Thus  the  space  may  become  filled  with  blood 
from  escape  of  the  corpuscles  by  rupture  or 
otherwise;  with  leucocytes  in  inflammation; 
with  oil-globules  and  fatty  corpuscles  in  degene- 
ration of  the  wall;  with  pigment-particles;  or 
with  serum  in  disturbances  of  the  circula- 
tion. The  calibre  of  the  perivascular  canal, 
which  varios  inversely  with  that  of  the  contained 
capillary,  may  thus  be  increased,  and  present, 
uniform  or  irregular  dilatation. 

Changes  in  the  outer  sheath,  or  wall  of  the 
lymphatic  space,  have  also  been  observed,  in- 
cluding fatty  degeneration  of  the  lining  cells  and 
hyaline  thickening. 

14.  Teleangiectasis. — At  least  one  form  of 
vascular  tumour  consists  of  a local  over-growth 
of  capillaries,  which  are  both  enlarged  and  multi- 
plied. See  Tumours.  J.  Mitchell  Bruce. 

CAPILLARY  BRONCHITIS.  — Inflam- 
mation involving  the  minute  bronchial  tubes. 
See  Bronchi,  Diseases  of. 

CARBOLIC  ACID,  Poisoning  by.  See 

Poisons. 

CARBONIC  ACID,  Poisoning  by. — The 
inhalation  of  carbonic  acid  causes  injurious  or 
fatal  results,  according  to  the  length  of  time 
and  degree  of  concentration.  Carbonic  acid 
accumulates  in  large  quantities,  almost  undiluted, 
in  pits,  cellars,  W'ells,  mines  (especially  after 


208  CARBONIC  ACID. 

explosions,  constituting  what  is  called  choke- 
damp),  volcanic  grottoes,  fermenting  vats,  lime- 
kilns, &c.  A continuous  contamination  of  the 
atmospheric  air  with  carbonic  acid  goes  on  from 
the  respiration  of  animals  and  the  combustion  of 
fuel.  The  gradual  exhaustion  of  oxygen  and 
proportionate  accumulation  of  carbonic  acid  in 
ill-ventilated  apartments  is  one  of  the  factors  of 
the  evil  results  of  bad  ventilation,  but  not  the 
only  ohe,  as  other  animal  exhalations  contribute 
largely  to  the  result. 

As  a rule  excess  of  carbonic  acid  means  cor- 
responding deficiency  of  oxygen  in  the  atmo- 
sphere, and  the  proportion  cannot  exceed  10  per 
cent,  without  rapidly  fatal  results  ensuing ; but 
much  less  than  this  causes  injurious,  and  even  the 
like  consequences  if  long  inhaled ; and  less  than 
2 per  cent,  cannot  be  breathed  for  any  length  of' 
time  with  impunity. 

If  the  amount  of  oxygen  be  not  correspond- 
ingly diminished,  carbonic  acid  if  present  in 
sufficient  quantity  in  the  atmosphere  respired  will 
still  act  fatally.  Thus  Bernard  found  that  a bird 
died  instantaneously  in  an  atmosphere  of  equal 
parts  of  oxygen  and  carbonic  acid,  and  Snow 
found  that  20  per  cent,  of  carbonic  acid  in  an 
atmosphere  containing  the  normal  proportion  of 
oxygen  soon  proved  fatal  to  small  animals,  and 
that  even  12  per  cent,  might  cause  death  after  a 
longer  interval. 

Symptoms. — Undiluted  carbonic  acid  is  not 
readily  inhaled,  as  it  tends  to  induce  spasm  of  the 
glottis,  but  immersion  in  such  an  atmosphere  is 
rapidly  fatal.  It  seems  to  act  like  a narcotic. 
The  patient  falls  down  prostrate  and  insensible, 
and  death  occurs  almost  immediately.  This 
effect  is  seen  occasionally  when  labourers  in- 
cautiously descend  an  old  well,  or  when  miners 
enter  a region  filled  with  choke-damp.  Not 
unfrequently  more  than  one  fall  victims,  as  one 
goes  to  see  what  has  happened  to  the  other  and 
meets  the  same  fate. 

When  the  carbonic  acid  is  more  diluted  the 
symptoms  are  headache,  giddiness,  and  sense  of 
oppression ; followed  by  drowsiness,  and  singing 
in  the  ears  ; and  passing  into  a condition  of 
stupor  and  insensibility,  with  stertorous  breath- 
ing and  muscular  prostration,  death  usually 
occurring  quickly  and  without  convulsions.  If 
the  excess  of  carbonic  acid  corresponds  with 
deficiency  of  oxygen,  we  have  in  addition  to  the 
essentially  narcotic  effects  of  carbonic  acid,  the 
dyspncea  and  other  symptoms  of  asphyxia  (see 
Asphyxia). 

Post-mortem  appearances.  - — These  are 
largely  those  of  asphyxia,  viz.,  a general  engorge- 
ment of  the  venous  system.  This  is  generally 
seen  in  the  brain,  more  frequently  than  in  as- 
phyxia pure  and  simple.  The  blood  is  dark  and 
fluid.  The  haemoglobin  is  completely  reduced. 
Animal  heat  is  said  to  be  retained  long  after 
death,  and  rigidity  is  well-marked  and  enduring. 

Pathoeogy.— As  has  already  been  said,  carbonic 
acid  does  not  act  merely  as  a negative  asphyxiant 
by  taking  the  place  of  oxygen,  but  has  a dis- 
tinctly toxic  narcotic  effect.  Very  frequently 
in  cases  of  poisoning  by  carbonic  acid  there  is  a 
combination  of  asphyxia,  essentially  due  to  defect 
of  oxygen,  with  the  narcotic  symptoms  due  to 
carbonic  acid. 


CARBONIC  OXIDE. 

Treatment.  — 1.  Prophylactic.  — Caution, 
should  be  exercised  in  exploring  wells,  mines, 
&c.,  where  there  is  likelihood  of  the  accumula- 
tion of  carbonic  acid.  The  introduction  of  a 
lighted  candle  is  a rough  and  ready  test  of  con- 
siderable value.  The  mere  fact  of  a candle 
continuing  to  burn  in  an  atmosphere  is  no  test 
of  its  being  respirable  with  impunity,  for  a candle 
will  burn  in  an  atmosphere  containing  10  per 
cent,  of  carbonic  acid  if  the  oxygen  is  present 
in  the  normal  amount,  and  the  presence  of  an 
amount  of  carbonic  oxide  sufficient  to  cause 
death  will  not  materially  affect  the  flame.  If 
carbonic  acid  reaches  the  proportion  of  16  per 
cent,  the  candle  will  be  extinguished,  however. 
If  a candle  is  extinguished,  then  certainly  the 
atmosphere  cannot  be  breathed,  and  therefore 
the  test  is  of  sound  practical  value.  If  car- 
bonic acid  does  exist  it  should  be  expelled  by 
creating  a draught  of  some  kind.  Thus  wells 
may  be  swept  by  some  such  contrivance  as  an 
inverted  umbrella,  and  a stream  of  air  can  be 
directed  into  enclosed  spaces. 

2.  Restorative. — Artificial  respiration  and  its 
various  accessories  are  needed  to  restore  a 
person  actually  in  a state  of  coma  from  carbonic 
acid.  This  treatment,  of  course,  is  subsequent 
to  instant  removal  from  the  impure  atmosphere. 
Pure  oxygen  should  also  be  administered  if  at 
hand.  D.  I'ereier. 

CARBONIC  OXIDE,  Poisoning  by.— 

Carbonic  oxide  is  a much  more  dangerous  agent 
than  carbonic  acid,  and  to  it  are  due  many  of  the 
effects  sometimes  ascribed  to  the  latter.  Pure 
carbonic  oxide  is  rarely  generated  out  of  the 
chemical  laboratory,  but  mixed  with  other  gases 
carbonic  oxide  is  not  uncommon.  This  is  es- 
pecially the  case  in  the  fumes  of  burning  charcoal. 
The  carbonic  acid  of  the  burning  charcoal  while 
passing  over  the  heated  embers  loses  an  atom  of 
oxygen,  or  takes  up  an  atom  of  carbon,  and  is 
converted  into  carbonic  oxide,  which  burns  with 
a bluish  flame  at  the  top.  The  toxic  action  of 
charcoal  vapours  is  essentially  dependent  on  the 
carbonic  oxide  they  contain.  Usually  charcoal 
fumes  contain  from  2 to  3 per  cent,  of  carbonic 
oxide,  to  25  of  carbonic  acid,  along  with  some 
heavy  carburetted  hydrogen.  The  vapours,  how- 
ever, are  still  as  effective  after  being  passed 
through  lime-water,  which  fixes  the  carbonic 
acid.  Poisoning  by  charcoal  vapour  is  not  an  un- 
common form  of  suicide,  more  particularly  abroad; 
and  many  cases  have  occurred  accidentally  in 
this  country,  from  sleeping  in  rooms  in  which 
there  was  no  flue  for  the  escape  of  the  fumes  of 
burning  charcoal,  or  into  which  there  has  been 
leakage  from  stove  pipes,  &c. 

Carbonic  oxide  also  exists  in  coal  gas,  and 
constitutes  its  main  danger.  It  is  likewise 
found  in  the  emanations  from  brick-kilns. 

Carbonic  oxide  is  an  extremely  active  poison. 
Letheby  found  that  ’5  per  cent,  of  carbonic  oxide 
in  the  respiratory  medium  killed  small  birds 
in  three  minutes,  and  that  2 percent,  killed  a 
guinea-pig  in  two  minutes.  ATanv  similar  experi- 
ments have  been  performed  with  similar  results. 
The  animals  soon  become  insensible,  and  die 
generally  without  exhibiting  convulsive  pheno- 
mena beyond  a few  tremors  or  flutterings. 


CARBONIC  OXIDE. 

Symptoms.— In  man  inhalation  of  carbonic 
oxide  for  a short  time,  as  Sir  H.  Davy  and  others 
have  proved  on  themselves,  causes  headache, 
pulsation  in  the  temples,  giddiness,  nausea,  and 
great  prostration,  tending  to  drowsiness  and 
insensibility,  death  being  preceded  by  a state  of 
complete  coma.  Usually  death  occurs  quietly,  but 
signs  of  vomiting  are  frequently  observed  near 
those  who  have  been  poisoned  by  charcoal  fumes. 

Post-mortem  Appearances. — The  specially 
characteristic  appearance  of  death  from  carbonic 
oxide  is  the  cherry-red  colour  of  the  blood  and 
internal  organs.  The  post-mortem  hypostasis 
exhibits  a similar  bright  red  tint.  Frequently 
in  those  poisoned  with  carbonic  oxide  the  face 
retains  a ruddy  hue.  The  red  tint  of  the  blood 
is  due  to  the  compound  which  carbonic  oxide 
forms  with  haemoglobin.  Carbonic  oxide  dis- 
places the  oxygen  and  forms  a very  stable 
compound  with  the  haemoglobin,  not  readily 
broken  up,  and  hence  the  oxygen-carrying 
power  of  the  corpuscles  is  paralysed. 

In  the  spectroscope  carbonic  oxide  blood 
exhibits  two  absorption-bands  very  similar  to 
those  of  ordinary  blood-colouring  matter  or  oxy- 
hemoglobin, but  a difference  in  the  exact  breadth 
and  position  of  the  bands  can  be  made  out  by 
means  of  the  microspectroscope  when  the  two 
are  compared  together.  Carbonic  oxide  haemo- 
globin resists  reduction  in  the  usual  manner, 
and  here  again  differs  from  normal  blood-colour- 
ing matter.  Hoppe-Seyler  gives  as  an  addi- 
tional test  the  action  of  caustic  alkalies  on  car- 
bonic oxide,  and  on  ordinary  haemoglobin.  ”\Vith 
the  latter  it  causes  a green  colour  when  mixed 
with  it  on  a porcelain  plate,  while  in  the  former 
the  colour  continues  red. 

Pathology.  — Carbonic  oxide  acts  in  the 
manner  indicated,  viz.,  by  paralysing  the  bloo  !- 
corpuscles,  as  Bernard  expresses  it,  and  rendering 
them  unable  to  take  up  oxygen.  Hence  internal 
respiration  is  prevented,  and  death  ensues  from 
asphyxia. 

Treatment. — As  carbonic  oxide  hsemoglobin 
is  a very  stable  compound,  and  offers  consider- 
able resistance  to  displacement  by  oxygen, 
though  not  absolute  as  was  at  one  time  con- 
sidered , artificial  respiration  is  not  likely  to  be 
successful  by  itself.  The  best  treatment  is  vene- 
section and  transfusion  of  fresh  blood.  This 
method  of  treatment  has  proved  successful  in 
one  or  two  instances  in  which  it  has  been 
employed.  D.  Perrier. 

CARBUNCLE.  — Synon.  : Anthrax ; Fr. 
Anthrax ; Ger.  Karhunhcl. 

Definition. — A specific  local  inflammation  of 
the  subcutaneous  areolar  tissue,  rapidly  leading 
to  sloughing  of  the  deeper  and  mere  central 
parts,  followed  by  destruction  of  the  skin  ; the 
whole  of  the  dead  tissues  finally  separating  in 
the  form  of  a slough. 

^Etiology.  — Carbuncle  is  a constitutional 
affection,  dependent  upon  conditions  of  general 
debility  or  plethora,  and  often  associated  with 
gouty  or  diabetic  tendencies.  It  is  more  com- 
monly seen  in  men  than  in  women ; is  rarely  met 
with  under  the  age  of  twenty  ; and  attacks  all 
ranks  of  life. 

Symptoms.  — The  most  usual  seat  of  car- 

14 


CABBUNCLE.  20!' 

buncle  is  the  back  of  the  trunk  or  neck,  but 
it  may  occasionally  be  found  in  other  situations. 
The  affection  usually  begins  as  a painful,  hard, 
slightly  elevated,  and  ill-defined  swelling,  which 
gradually  increases  in  extent  and  assumes  a 
dusky  red  tint.  A vesicle  containing  bloody 
serum  soon  forms  over  the  most  prominent  part, 
and  on  rupturing  discloses  several  small  apei- 
tures  in  the  subjacent  skin,  \vhieh  give  exit  to  a 
glutinous  purulent  discharge.  This  sieve-liki 
condition  of  the  undermined  integument  often 
persists  throughout  the  course  of  the  disease ; 
occasionally,  however,  owing  to  the  destruc- 
tion of  the  intervening  skin,  the  several  aper- 
tures merge  into  a single,  large,  ragged  opening, 
and  thus  expose  the  characteristic  ash-grey, 
slimy  slough,  which  separates  slowly  by  suppura- 
tion, leaving  an  irregular  cavity  with  deeply 
undermined  edges.  The  cicatrix  left  after  heal- 
ing is  usually  uneven  and  may  be  permanently 
discoloured. 

In  the  early  stage  of  the  disease,  while  the 
inflammatory  oedema  is  still  extending,  the  pa- 
tient generally  complains  of  a burning,  throbbing 
sensation  in  the  part,  which  may  become  intensely 
painful;  but  on  the  full  exposure  of  the  slough, 
the  pain  diminishes,  and  in  the  later  stages  it 
may  cease  entirely. 

When  the  carbuncle  is  large,  or  involves  a 
portion  of  the  scalp,  there  is  usually  considerable 
constitutional  disturbance  of  an  asthenic  type. 
Death  ma}r  then  occur  from  exhaustion,  which  is 
sometimes  aggravated  by  free  haemorrhage  result- 
ing from  incisions ; hut  the  most  frequent  cause 
of  a fatal  termination  is  pyaemia. 

Diagnosis. — Carbuncle  is  distinguished  from 
boil  by  tho  sizo  and  extent  of  the  swelling,  and 
by  its  tendency  to  spread  ; by  the  livid  tint  of 
the  skin,  and  the  early  formation  in  it  of  more 
than  one  aperture ; by  the  character  of  the  slough, 
by  the  severity  of  the  pain,  and  the  marked  con- 
stitutional disturbance ; and  finaUy,  by  the  fact 
that  carbuncle,  unlike  boil,  usually  occurs  singly. 

Prognosis. — This  will  depend  chiefly  upon 
the  age  of  the  patient,  and  upon  the  seat  and  ex- 
tent of  the  disease,  which  proves  most  dangerous 
to  life  when  situated  or  encroaching  on  the  scalp, 
especially  in  a person  over  fifty.  The  coexistence 
of  albuminuria  or  chronic  saccharine  diabetes  is 
always  a grave  complication. 

Treatment.  — The  constitutional  treatment 
and  the  management  of  patients  with  carbuncle 
are  best  conducted  on  general  principles.  In 
ordinary  cases  the  diet  should  be  of  good  quality 
and  sufficient  in  quantity,  with  n moderate  allow- 
ance of  stimulants,  proportionate  to  previous 
habits.  Should  the  patient’s  strength  and  the 
situation  of  the  carbuncle  allow  him  to  move 
about,  he  need  not  be  confined  to  his  room, 
and  may  even  be  allowed  exercise  in  the  opeDr 
air. 

In  the  more  severe  forms  of  the  disease,  the 
frequent  administration  of  dietetic  stimulants 
and  good  nourishment  in  an  easily  assimilable 
form  is  usually  necessary.  The  bowels,  if  they 
require  it,  should  be  cleared  out  by  some  non- 
irritating  aperient,  and  the  patient  put  on  n 
course  of  quinine  or  bark  and  the  mineral  acids. 
Opium  may  be  required  in  tho  earlier  stages  to 
relieve  the  intenso  sufferings  of  some  patients : 


no  CARBUNCLE. 

while  in  the  after-course  of  the  disease,  it  may 

be  sometimes  needed  to  procure  sleep. 

For  local  treatment  see  Boils. 

For  carbuncle  of  the  face,  an  affection  distinct 
from  the  Malignant  Pustule  described  by  Conti- 
nental surgeons,  fee  Pustule,  Malignant,  and  the 
article  on  Boils.  William  A.  Meredith. 

CARCINOMA.  See  Cancer. 

CARDIAC  DISEASES.  See  Heart, 

Diseases  of. 

CARDIALGIA  (icapSia,  the  heart,  and  aAyos, 
pain). — A synonym  for  heartburn,  originating 
in  a popular  impression  that  this  painful  sensa- 
tion, which  is  situated  in  the  epigastrium,  is  con- 
nected with  the  heart.  See  Heartburn. 

CARDIOGRAPH,  The  (ndpSia,  the  heart, 
and  7 pa<pai,  I write).  This  is  an  instrument  for 
registering  graphically  the  form  of  the  heart’s 
movements.  We  owe  the  invention  of  the  car- 
diograph to  Marey,  who  in  his  physiological 
researches  on  the  circulation  of  the  blood,  ob- 
tained by  the  following  means  the  form  of  move- 
ment of  each  cavity  of  the  heart.  He  introduced 
into  the  auricles  and  ventricles  of  a horse,  hol- 
low sounds  terminating  in  elastic  ampullae  filled 
with  air.  The  air  communicated  through  the 
sounds  and  elastic  tubes  with  terminal  ampullae, 
cr  tympana  covered  with  elastic  membrane,  on 
each  of  which  rested  a light  lever.  The  move- 
ments communicated  by  the  heart  to  the  closed 
column  of  air  were  amplified  by  the  levers  and 
recorded  by  them  on  a revolving  cylinder.  In 
this  way  tracings  of  the  forms  of  movement  of 
each  cavity,  as  well  as  of  the  exposed  apex-beat 
itself,  were  obtained,  and  an  explanation  of  the 
several  parts  of  the  complex  apex-tracing  ren- 
dered possible.  The  cardiograph  used  for  clinical 
research  is  a modification  of  the  above,  and  con- 
sists of  a hollow  cup  containing  a small  spring 
which  can  be  depressed  by  means  of  a screw  so  as 
to  rest  firmly  on  the  chest-wall  where  the  impulse 
is  felt.  The  cup  communicates  by  means  of  an  elas- 
tic tube  with  a tympanum  covered  with  elastic 
membrane  carrying  on  its  surface  a lever.  When 
applied  to  the  chest  the  cup  hermetically  seals 
the  air  column  which  transmits  as  waves  the 
motion  received  by  the  spring  to  the  lever  resting 
on  the  tympanum.  These  movements  are  re- 
corded by  the  end  of  the  lever  either  on  the  plate 
of  a sphygmograph  or  on  a revolving  cylinder. 

By  means  of  this  apparatus  a very  perfect  re- 
presentation of  th§  cardiac  movement  can  be  ob- 
tained, the  auricular  and  ventricular  elements 
traced,  and  the  duration  of  each  measured.  The 
transmission  of  the  motion  through  an  elastic 
medium  like  air  has  been  objected  to,  as  liable  to 
modify  the  tracing  by  (1)  the  production  of 
secondary  oscillations  in  the  air  column;  and  by 
(2)  gradual  change  in  the  form  of  motion  caused 
by  the  elasticity  of  the  medium.  Practically, 
however,  these  objections  are  not  valid,  as 
is  shown  by  the  fact  that  the  last  of  a series  of 
cardiac  pulsations  is  often  an  exact  reproduction 
of  the  first,  and  also  by  the  close  resemblance 
between  the  tracings  obtained  in  this  way  and 
those  registered  by  the  sphygmograph,  ora  modi- 
fication of  it,  applied  over  the  apex-beat.  A 


CARMINATIVES. 

cardiogram  collected  by  the  instrument  described 
on  a healthy  person  is  given  in  the  margin.  Two 
cardiac  revolutions  are  recorded. 
The  several  waves  may  be  inter- 
preted as  follows:  the  wave  a,  in 
the  line  of  ascent,  corresponds 
with  the  early  part  of  the  ventri- 
cular diastole.  The  wave  b cor- 
responds with  the  true  auricular 

systole ; from  b to  d the  lino 

Fig.  4.  marks  the  true  impulse  caused 
by  the  ventricular  contraction,  the  rounding  of 
the  heart,  and  its  pressure  against  the  chest- 
wall.  The  wave  c,  at  the  summit  of  the  curve, 
indicates  the  closure  of  the  auriculo-ventricular 
valves ; c does  not  always  form  the  summit 
of  the  curve,  but  occasionally  in  slower  cardiac 
contractions  forms  a wave  below  the  summit. 
The  waves  between  c and  d are  referred  to 
oscillations  produced  by  the  closure  of  the 
auriculo-ventricular  valves,  but  are  probably 
manufactured  by  the  instrument.  The  break  in 
the  line  of  descent  at  e,  marks  the  closure  of  the 
sigmoid  valves.  In  the  above  cardiogram  the 
period  of  ventricular  contraction  is  measured  by 
the  space  between  the  commencement  of  the  line 
of  ascent  after  the  wave  b,  to  the  point  d,  which 
marks  the  termination  of  the  systole.  When  the 
heart  is  hypertrophied  and  acting  vigorously  this 
termination  is  often  registered  as  a slight  eleva- 
tion of  the  trace. 

The  clinical  value  of  the  cardiograph  has  yet  to 
be  fully  established.  It  has  hitherto  been  useful 
in  showing  the  relation  of  prsesystolic  murmur 
and  thrill  to  the  ventricular  and  auricular  con- 
tractions ; in  demonstrating  modifications  of  the 
form  of  impulse  in  adherent  pericardium  ; in  re- 
cording a considerable  increase  in  the  wave  a and  a 
sudden  rising  of  the  trace  after  a,  as  signs  of  aort  ic 
insufficiency ; and  in  the  recognition  of  the  re- 
lation between  reduplication  of  the  heart-sounds 
and  respiratory  influences.  The  cardiograph  is 
also  of  great  value  in  registering  the  form  of 
movement  of  pulsating  tumours  and  aneurisms. 
In  its  application  it  is  sufficient  to  hold  the  instru- 
ment firmly  over  the  apex-beat  and  to  record  the 
pulsations  at  the  end  of  expiration,  the  breath 
being  stopped  for  a brief  interval.  Occasionally, 
when  the  influence  of  respiration  is  to  be  ob- 
served, this  precaution  is  of  course  unnecessary  ; 
but  it  mtisr  be  borne  in  mind  that  the  movement 
of  the  chest-wall  modifies  the  tracing. 

Balthazar  Foster. 

CARDITIS  (urapSia.  the  heart).  Inflamma- 
tion of  the  substance  of  the  heart.  See  Heart, 
Inflammation  of. 

CARRIES  ( caries , rottenness). — A destructive 
inflammatory  disease  of  bone,  analogous  to 
ulceration  of  soft  tissues.  See  Bone,  Skull. 
and  Spinal  Column,  Diseases  of. 

CARLSBAD,  in  Bohemia.  Thermal  alkaline 
sulphated  waters.  See  Mineral  Waters. 

CARMINATIVES  ( carmino , 1 card,  or 
cleanse). 

Definition. — Substances  that  aid  the  expul- 
sion of  flatus  from  the  stomach  and  intestines, 
and  relieve  griping. 


CARMINATIVES. 

Enumeration.^  The  principal  carminative 
remedies  are — the  Essential  Aromatic  Oils ; Chlo- 
roform : Charcoal ; Ethers ; and  Camphors  ; and 
substances  containing  them. 

Uses. — The  uses  of  carminatives  are  suffi- 
ciently indicated  in  the  preceding  definition. 
They  are  extensively  administered  in  cases  of 
flatulent  dyspepsia,  especially  when  it  is  asso- 
ciated either  with  disease  or  disorder  of  the 
heart  or  with  a nervous  or  hysterical  state  of 
the  system.  A combination  of  several  different 
carminatives  is  usually  more  successful  than  the 
exhibition  of  a single  drug.  "With  antacids 
they  are  useful  in  correcting  acidity ; and  they 
are  frequently  prescribed  with  purgatives  to 
prevent  pain. 

CARETFICATIOlSr  (caro,  flesh,  and  fio,  I 
become). — A condition  of  the  lung  iu  which  its 
tissue  resembles  flesh.  The  term  was  formerly 
applied  to  the  transformation  of  any  tissue  into 
a flesh-like  substance.  See  Lung,  Collapse  of. 

CARFH  OLE  GY  1 , , . , _ , 

)>(Kap<pos,  chatf,  and  \eyco, 

CAEPHOLOGY  J I collect).  The  move- 
ments of  the  hands  and  fingers  observed  in 
delirious  patients,  as  if  they  were  searching  for 
or  gathering  imaginary  objects.  A familiar 
illustration  of  the  act  is  ‘ picking  of  the  bed- 
clothes.’ 

CARTILAGE,  Diseases  of. — Eor  a due 
appreciation  of  the  abnormal  conditions  to  which 
cartilage  is  subject,  a brief  description  of  this 
tissue  in  its  healthy  state  is  necessary. 

The  temporary  cartilage  which  forms  the 
early  skeleton,  gradually  undergoes  conversion 
into  bone,  leaving  at  the  joint  surfaces  a thin 
layer,  the  articular  cartilage,  which  never  be- 
comes ossified,  Certain  other  portions  of  the 
skeleton  also  retain  their  cartilaginous  condition 
throughout  life ; these  are  known  as  the  perma- 
nent cartilages,  and  as  examples  the  cartilages 
of  the  ribs,  ears,  and  nose  may  be  given.  The 
extremities  of  the  long  bones,  or  epiphyses,  re- 
main separate  from  the  shaft  for  a varying  period 
after  birth,  and  so  long  as  the  bone  continues  to 
grow,  they  are  attached  to  it  by  a thin  but  impor- 
tant layer  of  cartilage,  called  the  epiphysial  car- 
tilage. There  are  yet  the  fibro-cartilages,  in 
which  the  fibrous  and  cartilaginous  elements  are 
found  in  varying  proportions,  according  as  the 
tenacity  of  the  one  or  the  elasticity  of  the  other 
material  is  required. 

Cartilage  is  altogether  destitute  of  nerves, 
and  therefore  of  sensibility ; and  it  is  equally 
devoid  of  blood-vessels,  being  nourished  by  im- 
bibition from  the  vessels  of  the  neighbouring 
parts.  All  cartilages,  except  the  articular  and 
the  fibro-cartilages,  are  covered  by  a fibrous 
membrane,  the  perichondrium,  which  is  similar 
to,  and  subserves  the  same  purpose  as  the  peri- 
osteum. When  cartilage  has  been  destroyed  it 
may  be  replaced  by  fibrous  tissue,  or  by  bone, 
but  it  is  never  reproduced. 

Under  the  microscope  a section  of  cartilage 
presents  a transparent,  structureless  matrix, 
studded  with  nucleated  cells ; these  cells  are 
flattened  and  arranged  parallel  with  the  free  sur- 
face of  the  cartilage,  whilst  more  deeply  they 
are  elongated  and  grouped  vertically.  The  nu- 


CARTIEAGE,  DISEASES  OF.  211 
trient  materials  are  absorbed  from  the  neigh- 
bouring blood-vessels,  and  transmitted  throughout 
the  cartilage  by  means  of  these  cells.  In  those 
cartilages  where  tenacityor  flexibility  are  needed, 
this  hyaline  substance  is  denser  and  more  dis- 
tinctly fibrillated  than  in  the  others. 

Summary  of  Diseases. — Cartilage  beingnoD- 
vaseular,  its  inflammation  is  of  a modified  type, 
but  it  may  undergo  degenerative  changes  as  a 
result  of  impaired  nutrition.  In  uncomplicated 
disease  of  cartilage  there  is  no  inflammatory  exu- 
dation, and  when  lymph  or  pus  is  found  in  a 
joint,  it  is  obvious  that  other  structures  have 
become  inflamed. 

1.  The  ensiform  and  costal  cartilages,  with 
those  of  the  trachea  and  larynx,  show  a great 
tendency  to  ossification,  as  the  result  of  morbid 
change  or  senile  decay ; they  are  also  liable  to 
necrosis.  The  articular  cartilages  never  ossify, 
but  large  portions  of  them  may  perish  and  be 
detached,  in  consequence  of  some  interference 
with  their  supply  of  nutriment. 

2.  The  cartilages  of  the  epiglottis,  ears,  nose, 
eyelids,  andeustachian  tube  have  little  disposition 
to  ossify,  but  they  are  liable  to  ulceration,  es- 
pecially of  the  syphilitic  variety ; in  these  cases 
the  diseased  action  commences  in  the  skin  or 
mucous  membrane,  and  spreads  to  the  cartilage 
by  contiguity. 

3.  The  cartilage  of  the  external  ear  is  often 
the  seat  of  chalk-stones  iu  gouty  persons,  and 
similar  deposits  may  also  be  found  in  the  articu- 
lar cartilages. 

4.  The  epiphysial  cartilage  may  take  on  an 
ulcerative  action,  which  leads  to  separation  of  the 
shaft  from  the  epiphysis,  a condition  which, 
whether  the  result  of  disease  or  accident,  is  of 
great  moment,  inasmuch  as  the  destruction  of 
this  layer  of  cartilage  checks  farther  growth  at 
the  end  of  the  bone. 

5.  Cartilage  is  not  primarily  attacked  by  can- 
cer, but  it  may  become  involved  by  the  spread  of 
a malignant  tumour.  The  epithelial  form  of 
cancer  not  infrequently  extends  from  the  mu- 
cous or  cutaneous  surface,  in  which  it  originated, 
to  the  subjacent  cartilage. 

6.  The  articular  cartilages  are  liable  to  cer- 
tain structural  changes  as  the  result  of  disturbed 
nutrition;  and  the  fibro-cartilages  are  also  subject 
to  the  same  abnormal  conditions. 

Ulceration,  absorption,  degeneration  of  car- 
tilage are  terms  used  to  denote  a series  of 
destructive  changes  which  take  place  in  the 
substance  of  articular  cartilage,  and  lead  to  its 
partial  or  complete  removal.  These  changes  may 
originate  in  the  cartilage  itself,  or  they  may  be 
secondary  to  disease  of  the  bone  or  synovial 
membrane : however  this  may  be,  the  morbid 
action  is  the  same,  and  consists  in  increased  cell- 
development,  with  disintegration  of  the  hyaline 
substance. 

According  to  the  observations  of  Goodsir  and 
Kedfern,  the  cartilage- cells  become  enlarged,  filled 
with  nucleated  corpuscles,  and  arranged  irregu- 
larly; the  distended  cells  then  burst,  and  set  free 
their  contents  upon  the  surface  of  or  amongst  the 
alteredhyaline  substance.  Whilst  the  cell-changes 
are  taking  place,  the  matrix  softens : in  acute 
cases  it  rapidly  disintegrates  and  is  discharged  ; 
but  when  the  disease  is  more  chronic,  it  splits  uf 


212  CARTILAGE,  DISEASES  OF. 
into  fibres,  'which  remain  attached  by  one  end  to 
the  cartilage,  and  by  the  other  project  loosely 
into  the  interior  of  the  joint,  giving  a villous 
appearance  to  the  affected  spot.  The  remains  of 
the  matrix,  and  the  granular  contents  of  the  cells 
together  form  a fibro-nucleated membrane,  which 
ultimately  is  converted  into  fibrous  tissue,  and 
constitutes  the  sole  medium  of  repair  when  a 
cure  is  effected.  When  this  membrane  is  recent 
it  has  an  indistinct  granular  appearance,  from  the 
presence  of  nuclei  amongst  the  fibres,  and  accord- 
ingto  Rainey  these  nuclei  are  often  converted  into 
fat-globules ; when  the  membrane  is  of  older 
date  it  is  distinctly  fibrous  ; and  no  doubt  the 
several  appearances  which  the  membrane  pre- 
sents under  different  circumstances  has  led  to 
the  several  terms  fibrous,  fatty,  and  granular 
degeneration  being  applied  to  this  disease,  in  the 
belief  that  they  were  really  distinct  pathological 
conditions. 

Ulceration  generally  commences  upon  the 
free  surface  of  the  cartilage,  but  it  may  begin  at 
any  part.  It  is  usually  superficial,  but  sometimes 
extends  completely  through  the  substance  of  the 
cartilage,  exposing  the  bone:  commonly  limited 
in  extent,  it  occasionally  spreads  over  the  whole 
surface;  it  is  ordinarily  confined  to  a single 
joint,  but  more  than  one  may  bo  affected.  As  a 
rule  the  disease  progresses  slowly,  but  it  may 
run  its  course  more  rapidly.  See  Joints,  Dis- 
eases of. 

7.  Hypertrophy  of  the  articular  cartilages 
has  been  described,  but,  as  in  these  cases  the  car- 
tilage was  found  swollen  and  soft,  it  is  probable 
that  they  were  examples  of  commencing  disease, 
rather  than  of  actual  increase  of  texture. 

8.  Atrophy  has  been  observed  as  the  result  of 
pressure,  and  of  the  natural  wasting  which  occurs 
in  advanced  life ; it  is  also  said  to  be  occasion- 
ally produced  in  younger  subjects  by  disease. 

Geo.  G.  Gascoyfn. 

CASEOUS  DEGENERATION-.— A form 
of  degeneration  in  which  the  products  have  the 
appearance  of  cheese.  See  Degenerations. 

CASTS.  ( Kast  — Swedish  and  Danish — a 
throw.) 

Definition. — A term  applied  to  moulds  of 
gland-tubules  and  hollow  viscera,  thrown  off  in 
certain  states  of  disease. 

Classification. — The  varieties  of  casts  met 
with  may  be  represented  according  to  the  follow- 
ing arrangement : — 

A.  — Casts  of  Gland -Tubules. 

Blood-Casts. 

Pus-Casts. 

I.  Of  the  Uriniferous  Hyaline  Casts. 

Tubules.  Granular  Casts. 

Epithelial  Casts. 

Fatty  Casts. 

II.  Of  the  Seminal  Tubules. 

III.  Of  the  Gastric  Tubules. 

IV.  Of  the  Cutaneous  Glands. 

B.  — Casts  of  Hollow  Viscera  and  Passages. 

I.  Of  the  Alimentary  Canal. 

II.  Of  the  Urinary  Bladder. 

III.  Of  the  Eemale  Genital  Passages. 

IV.  Of  the  Respiratory  Passages.  I 


CASTS. 

A. — Casts  of  Gland-Tubules. 

I.  Of  the  Uriniferous  Tubules.— Dr.  F. 
Simon  of  Berlin  is  usually  credited  with  haring 
been  the  first  to  describe  these  bodies  in  his  work 
on  Medical  Chemistry,  published  in  1812;  but 
it  appears  that  before  then  they  had  been  noticed 
and  described  by  Vogla  in  1837  and  1838,  by 
Rayer  in  1838,  and  by  Nasse  of  Marburg  in  1842. 
These  observers,  however,  do  not  seem  to  have 
entered  on  the  question  of  the  origin,  structure, 
or  significance  of  these  bodies,  and  for  years  they 
were  looked  upon  rather  as  curiosities,  and  by 
some  writers,  notably  Glup,  were  wholly  disre- 
garded. Heller,  in  1845,  appears  to  have  been 
the  first  to  refer  their  origin  to  the  coagulable 
matter  of  the  blood,  but  it  was  some  time  after 
that  date  before  their  value  in  the  diagnosis 
and  prognosis  of  renal  diseases  came  to  be  appre- 
ciated. This  result  has  been  mainly  effected 
in  this  country  by  the  labours  of  Basham,  Beale, 
Johnson,  W.  Roberts,  Dickinson,  and  Grainger 
Stewart. 

Casts  may  be  formed  in  any  part  of  the 
kidney.  They  have  been  found  in  the  convoluted 
tubules  even  up  to  the  Malpighian  capsules, 
and  also  in  the  straight  tubules.  Hot  infre- 
quently small  casts  formed  towards  the  termina- 
tions of  the  tubules  come  to  be  enclosed  in  their 
passage  onwards  within  casts  of  the  larger 
ones. 

Characters. — -The  urinary  casts  are  mostly 
cylindrical  in  shape,  frequently  somewhat  coiled 
and  bent,  and  occasionally  forked.  Their  length, 
depending  very  much  on  accidental  circumstances, 
varies  considerably.  In  sections  of  the  kidney 
they  may  be  traced  occasionally  for  some  distance 
in  the  tubules,  becoming  broken  up  into  smaller 
pieces  after  leaving  the  kidney.  In  diameter  the 
casts  range  between  ITOOOth  and  1'oOOth  of  an 
inch — the  former  being  known  as  ‘ small,’  the 
latter  as  ‘ large  ’ casts.  The  greater  number  are 
of  a ‘medium’  size  of  l'700th  of  an  inch.  The 
diameter  of  the  casts  is  in  part  determined  by 
the  calibre  of  the  tubule  in  which  they  are  first 
formed,  and  in  part  by  any  subsequent  additions 
they  may  receive  in  their  passage  outwards.  Dr. 
Beale  has  suggested  that  after  their  formation 
the  casts  may  probably  shrink.  In  tubules  that 
have  become  abnormally  dilated  or  contracted, 
casts  beyond  the  limits  above  mentioned  may  be 
found. 

The  appearance  of  renal  casts  varies  consider- 
ably, not  only  in  different  kidney-diseases,  but 
also  in  various  stages  of  the  same  affection.  In 
all  cases  the  cast  consists  of  a solid  cylinder  of  a 
transparent  or  a very  faintly  granular  substance, 
which  in  certain  cases  is  fibrillated.  "What  the 
nature  of  this  base-substance  is  is  still  uncertain, 
and  it  appears  probable  that  its  composition  is 
not  constant  in  the  different  varieties  of  casts. 
It  was  formerly  accepted  that  these  bodies  were 
produced  by  a coagulation  of  fibrin  due  to  an 
escape  of  blood-plasma  into  the  tubules,  and  hence 
they  were  known  as  ‘ exudation-cylinders  ’ — a 
term  still  often  employed.  It  is  easy  to  under- 
stand the  formation  of  casts  in  this  manner, 
and  it  is  certain  that  such  blood-casts  do  occur, 
whether  as  shreds  of  fibrin  with  abundance  of 
blood-corpuscles  in  its  meshes,  or  a6  easts  ccr. 


CASTS. 


21S 


sisting  of  little  more  than  pure  fibrin  with  its 
characteristic  fibrillated  appearance.  In  a similar 
manner  pus-casts,  so  called,  may  be  produced. 


entangling  adjacent  matter.  Due  tothis  property 
is  much  of  the  variety  they  offer ; thus,  should 
the  epithelium  of  the  tubules  be  loosened,  from 


Tig.  5.— Blood  Casts. 


Fig.  7. — Epithelial  Casts. 


In  those  forms  of  renal  disease,  however,  in 
which  casts  are  found  in  the  urine,  when  no 
haemorrhage  into  the  kidney  tubes  exists,  one  of 
the  commonest  appearances  of  these  bodies  is 
that  of  a transparent  and  faintly  granular,  tole- 
rably uniform  cylinder,  frequently  somewhat 
rounded  at  the  extremities,  and  often  overlooked 


unless  searched  for  with  care.  In  them  no  sign 
of  fibrillation  is  to  be  discerned,  and  they  do  not 
correspond  in  their  chemical  behaviour  to  fibrin. 
These  are  the  hyaline,  transparent,  or  waxy 
casts,  which  may  be  large,  small,  or  medium  in 
diameter.  What  the  substance  is  of  which 
they  are  composed  is  uncertain.  It  is  distinctly 
not  fibrin,  nor  is  it  inspissated  albumin,  as 
has  been  suggested.  In  many  cases  a consider- 
able proportion  of  mucin  has  been  obtained  from 
them.  Though  frequently  called  ‘ waxy,’  and  often 
occurring  in  the  urine  from  a waxy  and  amyloid 
kidney,  it  is  extremely  doubtful  if  they  ever 
consist  of  the  amyloid  matter  which  is  produced 
in  the  lardaceous  degeneration  of  that  organ. 

According  to  the  writer’s  view  this  cast  is 
the  result  of  a colloid  degeneration  of  the  renal 
epithelial  cells,  comparable  to  what  is  met  with 
in  other  protoplasmic  tissues.  In  consequence  of 
this  change  in  the  cells  they  lose  their  normal 
appearance,  and  form  into  homogeneous,  trans- 
parent masses,  occupying  the  now  denuded  renal 
tubules,  from  which  they  are  subsequently 
washed  out  by  the  urine  secreted  behind  them. 
Other  observers  have  regarded  them  as  being 
formed  of  a substance  secreted  by  the  renal 
epithelial  cells,  rather  than  an  actual  conver- 
sion of  the  cells  themselves.  And  Dr.  Beale  has 
* thought  it  not  improbable  that  these  casts  of 
the  uriniferous  tubes  may  really  be  composed 
of  the  material  which  in  health  forms  the  sub- 
stance of  epithelial  cells.  In  disease  this  sub- 
stance, perhaps  somewhat  altered  or  not  perfectly 
formed,  collects  in  the  tubes  and  becomes  inspis- 
sated.’ Whatever  may  be  the  true  explanation 
of  their  formation,  they  present  themselves  as 
eemi-solid  and  somewhat  viscid  cylinders,  readily 


any  cause,  the  cells  will  cohere  to  the  cast  which 
has  been  formed  in  the  lumen  of  the  tube,  and 
an  epithelial  cast  will  be  voided.  Should  the 
cells  have  undergone  fatty  degeneration  the  cast 
will  be  pervaded  with  oil-globules  of  all  sizes, 
more  or  less  escaped  from  epithelial  cells,  accord- 


ing to  the  extent  of  the  degeneration ; this 
constitutes  a fatty  cast.  Very  frequently  the 
casts  are  finely  or  coarsely  granular,  this 
appearance  being  produced  by  tho  involvement  in 


the  base-substance  of  the  cast  of  granular  mat- 
ter derived  from  broken-down  epithelial  cells  or 
blood-corpuscles,  molecular  fatty  matter,  or  very 
frequently  amorphous  urinary  salts.  In  a simi- 
lar way  casts  may  be  found  containing  crystals 


Fig.  10. — Casts  enclosing  crystals  ; and  a smaller  cast ; 
also  o l seminal  tubule  with  spermatozoa. 


of  oxalates,  triple  phosphates,  &c.  Very  slight 
proof  exists  of  any  of  the  numerous  theories 
that  have  been  offered  to  explain  their  formation. 

It  is  very  commonly  the  case  that  more  than 
one  variety  of  cast  occurs  in  the  same  urine, 
epithelial  and  hyaline,  or  granular  and  fatty, 
often  co-existing.  Corresponding  to  the  casts  in 
the  urine,  free  epithelial  cells,  blood  corpuscles,  fat 
globules,  and  salts,  amorphous  or  crystallino,  arc 


214  Cl 

always  found.  The  epithelial  cells,  whether  free 
or  on  the  cast,  are  rarely  quite  normal  in  appear- 
ance. The  pathological  changes  which  have  led 
to  their  desquamation  have  at  the  same  time 
altered  them  more  or  less.  Not  infrequently  the 
cells  of  an  epithelial  cast  present  all  the  micro- 
scopic characters  of  leucocytes,  having  been  pro- 
duced by  an  abnormal  proliferation  of  the  renal 
epithelium. 

Method  of  examination.  — Samples  of  urine 
(three  or  four  ounces)  suspected  to  contain 
casts  should  be  allowed  to  stand  at  least  three 
hours  in  perfectly  clean  conical  glasses,  and 
a few  drops  should  ba  removed  from  the  bottom 
with  a pipette,  and  covered  in  the  usual  way  on 
a glass  slide.  Nor  all  practical  purposes  a j-in. 
objective,  giviug  with  the  eye-piece  a magnify- 
ing power  of  about  350  diameters,  is  sufficient. 
The  hyaline  casts  are  often  so  transparent  as 
to  escape  any  but  the  most  careful  observation, 
and  then  a little  magenta  or  carmine  staining 
fluid,  introduced  beneath  the  cover-glass,  much 
facilitates  their  detection ; cutting  off  some  of  the 
light  used  has  a similar  effect.  As  a rule  there 
is  no  mistaking  a renal  tube-cast,  but  occasion- 
ally a transparent  or  granular  streak  may  be 
noticed,  the  nature  of  which  cannot  be  positively 
stated  ; shreds  of  mucus,  especially  when  mixed 
up  with  granular  matter,  are  the  commonest  ob- 
jects which  simulate  casts  ; their  disappearance 
on  the  application  of  a little  heat  to  the  slide  de- 
termines their  character. 

Clinical  significance. — Valuable — almost  in- 
dispensable— as  is  the  evidence  afforded  by  the 
detection  of  these  bodies  in  the  urine,  their  re- 
cognition and  comprehension  is  nevertheless  but 
one  of  the  means  to  be  employed  in  the  study 
of  renal  diseases.  Of  themselves  they  afford 
practical  information,  rarely,  if  ever,  conclusive 
when  taken  alone. 

Without  doubt  certain  renal  diseases  may 
exist,  and  may  continue  throughout  their  course 
either  to  recovery  or  death,  -without  the  occurrence 
of  casts  in  the  urine.  But  for  all  practical  pur- 
poses it  may  be  accepted  that  when  casts  do  occur, 
they  indicate  the  existence  of  a disease  of  the 
kidneys  which  is  possibly  incurable,  certainly 
serious.  Besides  the  value  of  casts  in  deter- 
mining the  existence  of  kidney-disease,  they  are 
further  most  important  aids  in  helping  to  dis- 
tinguish what  variety  or  stage  of  disease  it  may 
be,  and  also  in  making  out  the  actual  condition 
of  the  kidney,  thus  furnishing  valuable  data  on 
which  to  form  a prognosis,  and  to  suggest  a plan 
of  treatment. 

Little  is  to  be  seen,  however,  from  one  exami- 
nation. This  should  be  performed  frequently,  as 
in  that  way  alone  can  the  morbid  progress  in 
the  kidney  be  recognised. 

Prom  what  has  been  said  of  the  nature  of 
casts,  it  should  be  expected — as  is  the  case — that 
several  varieties  of  these  bodies  occur  at  the 
same  time  in  the  urine.  It  is  rare  for  any  variety 
to  exist  singly,  at  least  for  any  time.  In  such 
cases  their  significance  is  ascertained  by  careful 
study  of  coincident  circumstances,  and  especially 
by  a frequent  comparison,  in  order  to  determine 
which  variety  is  in  excess. 

The  fact  that  casts  are  very  abundant  in  any 
sample  of  urine  is  not  in  itself  of  necessity  a 


serious  sign.  Thus  in  ‘granular  kidney  ’ — one  of 
the  most  serious  of  all  renal  affections, — the  casts 
may  be,  and  usually  are  very  few,  and  require 
careful  looking  for  ; whilst  in  the  convalescence 
from  acute  nephritis  they  may  be  extremely 
numerous.  In  chronic  nephritis,  however,  the 
number  becomes  an  Important  element  in  the 
consideration. 

Blood-casts  are  diagnostic  of  haemorrhage  into 
the  tubules,  whether  that  be  due  to  intense 
arterial  hypersemia  or  to  venous  congestion — 
such  as  exists  in  acute  Bright’s  disease  from 
whatever  cause — resulting  in  escape  of  blood 
from  the  vessels. 

Pus-casts  may  indicate  the  bursting  of  a renal 
abscess  into  the  tubes,  and  coagulation  of  the 
escaped  pus.  V ery  often,  however,  the  leucocytes 
which  take'  part  in  the  formation  of  a pus- 
cast  have  another  origin,  viz.  from  the  renal 
epithelial  cells,  being  the  result  of  their  proli- 
feration in  the  inflamed  state. 

Hyaline  casts. — The  large  forms  of  this  variety 
chiefly  occur  in  chronic  nephritis,  and  are  there- 
fore usually  a grave  sign.  Produced  in  tubules 
which  have  been  denuded  of  their  epithelium, 
or  in  others  that  have  become  dilated  from  con- 
tractions in  the  intertubular  substance,  they 
indicate  an  advanced  condition  of  disease.  Ex- 
ceptions to  this  do  occur,  and  large  hyaline  casts 
may  be  found  in  acute  and  curable  cases. 

Small  hyaline  casts  are  formed  iu  both  acute 
and  chronic  forms  of  renal  disease.  They  there- 
fore become  valuable  as  means  of  diagnosis  only 
in  conjunction  with  other  signs,  such  as  the  his- 
tory of  the  case,  the  character  of  the  other 
urinary  sediments,  &c.  They  are  frequently 
seen  in  acute  nephritis,  particularly  in  the  later 
stages  of  the  disease,  and  are  then  formed  in  tubes 
which  have  not  been  stripped  of  their  epithelial 
lining.  In  simple  congestion  of  the  kidney  they 
may  be  formed,  from  a coagulation  of  the  fibrin 
of  the  effused  plasma.  When  associated  with  the 
large  variety  they  usually  indicate  a chronic  and 
advanced  stage,  being  then  found  in  tubules 
that  have  become  contracted.  These  two  varie- 
ties of  hyaline  casts  are  common  in  the  albumi- 
noid kidney,  and  similar  casts  have  been  met 
with  in  the  tubules  in  cases  of  diphtheria. 

Granular  casts. — The  significance  of  these  is 
very  variable.  As  has  been  said,  the  granular  casts 
differ  much  in  nature,  and  no  positive  diagnosis 
can  be  made  upon  them  alone.  They  may  occur 
in  conjunction  with  blood-casts  where  the  cor- 
puscles have  broken  down,  and  they  will  then 
generally  indicate  a commencing  recovery  from 
an  acute  stage.  A similar  interpretation  may 
sometimes  be  put  on  casts  whose  granulation  is 
due  to  fat  molecules  resulting  from  the  degene- 
ration of  inflammatory  products.  Large,  dark, 
and  coarsely  granular  casts  are  more  particularly 
noticed  in  ‘ granular  kidney,’  where  indeed  they 
may  be  the  only  casts  found.  In  such  circum- 
stances they  become  a very  serious  sign.  In  the 
later  stages  of  chronic  nephritis  the  epithelial 
cells  disintegrate  and  produce  granular  casts. 

Epithelial  casts. — These  are  more  especially 
met  with  in  the  earlier  stages  of  nephritis,  and 
their  significance  much  depends  on  the  character 
of  the  epithelium  cells.  They  may  be  very  abun- 
dant at  first;  later  on,  when  the  hyaline  varietv 


CASTS. 


appears  in  the  urine,  becoming  less  numerous. 
The  epithelium  cells  may  differ  hut  little  from 
the  normal  renal  epithelium,  or  they  may  be 
fatty  and  more  like  leucocytes  in  appearance. 

Fatty  casts. — Probably  no  casts  are  so  general 
in  their  occurrence  as  these.  Their  presence 
may  be  of  the  gravest  import,  or  they  may  be- 
token commencing  recovery,  and  more  than  any, 
therefore,  must  they  be  considered  in  connexion 
with  other  circumstances.  The  casts  that  are 
found  in  the  later  stages  of  acute  nephritis  dur- 
ing convalescence  are  in  part  fatty.  The  inflam- 
matory products  undergoing  this  degeneration 
are  those  thrown  off.  Hyaline  casts,  both  large 
and  small,  frequently  present  a few  oil-globules 
on  their  surface.  And  in  certain  forms  of  chronic 
nephritis  the  casts  may  appear  as  if  made  up  of 
oil-globules  only.  In  such  case  an  advanced  stage 
of  fatty  degeneration  of  the  gland  is  distinctly 
indicated,  and  the  persistence  of  fatty  casts  is 
generally  taken  to  signify  the  same ; though 
such  casts  have  been  known  to  continue  in  num- 
bers for  some  weeks,  and  to  be  followed  by 
recovery. 

Casts  in  non-albuminous  urine. — The  exist- 
ence of  renal  casts  in  such  urine  has  been 
noticed  for  some  time  past.  If  the  casts  were 
formed  from  any  of  the  elements  of  the  blood, 
their  appearance  could  not  be  explained ; but  if, 
as  has  been  said,  these  bodies  owe  their  forma- 
tion to  the  degeneration  of,  or  of  a secretion  from, 
epithelial  cells,  their  occurrence  under  such  cir- 
cumstances is  intelligible.  The  conclusion  that 
the  urine  is  non-albuminous  must  not  be  too 
readily  made ; there  may  be  so  small  an  amount 
as  to  escape  notice  with  the  ordinary  rough 
method  of  testing,  and  there  may  be  only  a tem- 
porary disappearance  of  the  albumin.  The  casts 
that  are  formed  in  non-albuminous  urine  are  of 
the  hyaline  variety. 

Those  that  are  frequently  found  in  the  urine 
of  persons  suffering  from  icterus  from  what- 
ever cause,  and  which  are  stated  by  Nothnagel 
to  be  in  direct  proportion  to  the  intensity  of 
the  jaundice,  are  said  not  to  be  associated  with 
albumin.  The  pathology  of  these  casts  is  not 
as  yet  understood. 

II.  Of  the  Seminal  Tubules. — Dr.  Beale 
has  pointed  out  the  occasional  existence  in  urine 
of  casts  containing  spsrmatozoa  (see  Fig.  10). 
The  baso-substanca  of  their  bodies  is  a viscid 
tenacious  mucus,  and  they  are  usually  much 
larger  than  the  casts  derived  from  the  uriniferous 
tubules.  They  have  not  been  found  associated 
with  inflammatory  conditions  of  the  testicle,  and 
do  not  correspond  pathologically  to  the  renal 
casts  above  described. 

III.  Of  the  Gastric  Tubules. — In  inflam- 
mation of  the  gastric  mucous  membrane,  espe- 
cially in  scarlet  fever,  a desquamation  of  the  epi- 
thelial coat  involving  the  glands  has  been 
noticed.  The  casts  of  the  follicles  have  been 
found  in  the  vomit,  and  more  abundantly  in  the 

' contents  of  the  stomachpostmortem.  Their  length 
is  variable,  and  in  width  they  raDge  from  ^th 
to  yi^th  of  an  inch.  The  base-substance  is  de- 
scribed as  fibrinous,  and  is  covered  more  or 
less  completely  by  altered  epithelial  cells  and 
granular  debris. 

IF.  Of  the  Cutaneous  Glands. — In  the  va- 


213 

rious  skin-affections  which  are  associated  with 
desquamation  of  the  cuticle,  casts  of  varying 
length,  coming  from  the  sweat- and  sebaceous 
glands,  are  thrown  off  as  part  of  the  general 
shedding  of  the  epidermis.  Such  bodies  are 
hollow  tubes,  and  bear  no  resemblance  to  the 
inflammatory  casts  in  nephritis. 

B. — Casts  op  Hoixow  Viscera  axd 
Passages. 

From  time  to  time,  more  or  less  perfect  cast3 
of  these  organs  are  met  with.  The  conditions 
which  determine  their  occurrence  are  but  im- 
perfectly understood ; they  are  in  some  case? 
associated  with  inflammation  of  the  surfaces  from 
which  they  are  thrown  off,  but  in  other  cases 
appear  to  be  independent  of  any  such  morbid 
changes. 

I.  Of  the  Alimentary  Canal. — Inflammation 
of  any  part  of  the  canal,  from  mouth  to  rectum, 
has  been  known  to  give  rise  to  the  detachment 
of  flakes  of  the  superficial  epithelium  embodied 
in  a very  viscid,  tenacious  mucus.  It  is  in  scarlet 
fever  that  this  condition  has  been  usually  seen, 
where  the  degeneration  of  the  mucous  membrane 
corresponds  to  the  skin-shedding.  Occasionally 
complete  hollow  moulds  of  portions  of  the 
intestine  are  found,  and  large  pieces  have  been 
recognised  as  coming  from  the  stomach  (Beale). 
Similar  results  may  follow  croupous  and  diph- 
theritic inflammation. 

II.  Of  the  Urinary  Bladder. — A complete 
exfoliation  of  the  mucous  membrane  of  the  blad- 
der has  been  occasionally  observed  in  puerperal 
women.  It  does  not  appear  to  be  always  the 
result  of  inflammation,  and  thotigh  the  detach- 
ment may  be  complete,  perfect  recovery  may 
follow.  In  structure  such  bodies  consist  of 
epithelial  cells  in  varying  stages  of  degeneration, 
felted  together  by  mucus  and  fine  granular 
material.  The  surface  is  frequently  thickly  coated 
with  urinary  salts.  The  conditions  giving  rise 
to  their  formation  are  quite  unknown,  though 
retention  of  urine  is  associated  with  their  occur- 
rence. 

III.  Of  the  Female  Genital  Passages. — 
Casts  of  the  uterus  and  vagina  have  been  fre- 
quently noticed.  Occasionally  they  are  thrown  off 
periodically,  and  may  then  be  accompanied  with 
much  pain  and  haemorrhage  (membranous  dysme- 
norrhcea).  Partial  casts  of  the  passages  have 
also  been  found  associated  with  diphtheria. 
These  false  membranes  may  form  complete  casts 
of  the  uterus,  leaving  only  the  orifices  of  the  in- 
ternal os  and  Fallopian  tubes,  and  appear  ^is 
shaggy  bags,  consisting  of  the  epithelial  layer  of 
the  organ.  Sometimes  -these  bodies  may  be  the 
decidua  in  an  early  stage,  but  they  have  also 
been  met  with  in  virgins. 

IY.  Of  the  Respiratory  Passages. — Casts 
of  some  portion  of  the  air-tubes  are  of  frequent 
occurrence,  associated  with  a special  form  of  in- 
flammation, known  as  croupous  or  diphtheritic. 
In  such  cases  the  epithelial  covering  of  the  mucous 
membrane  comes  to  be  replaced  by  a layer  of 
material  which  is  derived  from  the  metamor- 
phosed epithelial  cells,  with  a variable  amount  of 
coagulated  fibrin  formed  from  the  effused  blood- 
plasma.  Such  false  membrane  appear?  under 
the  micrcscope  to  be  made  up  of  interlacing 


216  CASTS. 

fibres  of  a clear  homogeneous-looking  substance, 
felted  together  in  all  directions,  and  containing 
in  the  meshes  leucocytes,  altered  epithelial  cells, 
blood-corpuscles,  and  a small  quantity  of  serum. 
The  exact  method  of  formation  of  such  a mem- 
brane is  still  a matter  of  dispute — how  far  it  de- 
pends for  its  occurrence  on  blood-fibrin,  and  how 
far  on  ‘ croupous  metamorphosis  ’ of  the  ori- 
ginal epithelial  cells,  such  as  was  described  in 
speaking  of  the  formation  of  hyaline  renal  casts. 
The  fibrous  material  of  the  membrane,  however 
formed,  strongly  resists  the  action  of  ordinary 
reagents. 

It  is  easy  to  understand  that  the  extent  to 
which  the  materials  constituting  this  membrane 
infiltrate  the  deeper  layers  of  the  mucous  mem- 
brane, must  vary  considerably;  j^et  in  the  extent 
of  infiltration  and  consequent  adherence,  very 
much  depends  the  distinction,  such  as  it  is,  be- 
tween croupous  and  diphtheritic  exudation.  In 
the  larynx  and  trachea,  the  new  material  forms 
more  or  less  complete  laj'ers,  covering  the  vocal 
cords,  dipping  into  the  ventricles,  and  even 
blocking  up  the  laryngeal  cavity  completely.  By 
the.  effusion  of  serum  beneath  the  membrane,  it 
is  loosened  and  may  bo  expectorated  in  pieces 
varying  in  size  from  mere  shreds  up  to  complete 
casts. 

When  this  inflammatory  product  originates  in 
the  bronchial  tubes,  it  forms  the  so-called  bron- 
chial polypi,  so  characteristic  of  Plastic  Bron- 
chitis. It  is  rare  for  more  than  very  limited 
areas  of  the  air-passages  to  be  so  affected,  but 
within  these  areas  perfect  casts  of  the  entire 
extent  from  trachea  to  alveoli  may  be  ob- 
tained. Expectorated  as  irregular,  rolled-up, 
and  twisted  masses,  they  are  capable  of  being 
shaken  out  in  water  into  ramifying  whitish,  or 
pinky  white,  moulds  of  the  tubes.  They  are 
either  hollow  and  membranous  or  solid,  and 
in  the  latter  case  frequently  present  indications 
of  being  made  up  of  concentric  layers.  Similar 
casts  of  the  smallest  tubes  are  found  in  the  ex- 
pectoration of  acute  croupous  pneumonia.  It 
would  seem  then  that  the  material  formed  on  the 
surface  of  the  mucous  membrane  of  the  air-pas- 
sages  throughout  their  whole  extent,  and  which 
may  form  more  or  less  perfect  casts  of  their 
passages,  is  identical  in  structure,  and  probably 
in  method  of  formation,  wherever  be  its  situation, 
whether  limited  to  tho  larynx  and  trachea 
(croup  and  diphtheria),  or  only  in  the  terminal  air- 
tubes  (acute  croupous  pneumonia),  or  throughout 
the  entire  length  (plastic  bronchitis). 

W.  H.  Allchin. 

CATALEPSY  (ieaTa\7]\pis,  a seizure). — 
Definition. — A disease  of  the  nervous  system, 
characterised  by  attacks  of  powerlessness,  com- 
monly with  loss  of  consciousness,  accompanied 
by  a peculiar  form  of  muscular  rigidity,  in 
which  the  limbs  remain  for  a time  in  the  position 
in  which  they  are  placed. 

./Etiology. — Catalepsy  may  occur  at  all  ages 
between  six  and  sixty  years,  and  in  both  sexes, 
but  it  is  incomparably  more  frequent  in  the 
female  sex  and  in  early  adult  life,  at  or  soon 
after  puberty.  It  is,  in  the  majority  of  cases, 
associated  with  distinct  evidence  of  hysteria  : and 
iu  other  eases,  in  which  no  hysterical  symptoms  | 


CATALEPSY. 

havo  preceded  it,  the  affection  may  be  traced  to 
such  exciting  causes  as  give  rise  to  the  hysterical 
paroxysm.  Nervous  exhaustion  is  the  common 
predisponent;  and  emotional  disturbance,  espe- 
cially religious  excitement,  or  sudden  alarm, 
and  blows  on  the  head  and  back,  are  frequent 
immediate  causes.  It  occasionally  occurs  in  the 
course  of  mental  affections,  especially  melan- 
cholia, and  as  an  early  symptom  of  epilepsy.  In 
an  imperfect  form  it  has  appeared  to  be  due,  in 
some  cases,  to  paludal  poisoning  or  to  other 
toxtemic  states,  as  chloroform-narcosis.  In  a 
few  cases  meningitis,  and  other  organic  cerebral 
or  spinal  diseases,  have  caused  a cataleptoid  con- 
dition : but  these  cases  are  too  rare  and  diverse 
to  allow  of  any  inference  from  them. 

Symptoms. — In  some  cases  headache,  giddi- 
ness, or  hiccough,  has  preceded  the  attack.  The 
onset  of  the  special  symptoms  is  usually  sudden, 
commonly  with  loss  of  consciousness.  The  whole 
or  part  of  the  muscular  system  passes  into  a 
state  of  rigidity.  The  limbs  remain  in  the  posi- 
tion they  occupied  at  the  onset,  as  if  petrified. 
The  muscular  rigidity  is  at  first  considerable,  and 
movement  is  resisted ; but  aftera  short  time  the 
limbs  can  be  moved,  and  then  remain  in  the 
position  in  which  they  may  be  placed.  The 
resistance  to  passive  movement  is  peculiar  : it  is 
as  if  the  limbs  were  made  of  wax,  and  hence  the 
condition  has  been  termed  flexibilitas  ccrca.  The 
rigidity  commonly  yields  slowly  to  gravitation. 
Tho  countenance  is  usually  expressionless.  The 
respiratory  movements  and  heart’s  action  are 
weakened.  Substances  placed  in  the  lack  of 
the  mouth  are  swallowed,  but  slowly.  The  state 
of  sensibility  varies ; in  profound  conditions  of 
catalepsy  it  is  lost  to  touch,  pain,  and  electricity, 
and  no  reflex  movements  can  be  induced  even 
by  touching  the  conjunctiva.  In  other  cases 
partial  sensibility  remains,  and  reflex  phenomena 
may  be  excited.  In  rare  instances  paroxysmal 
hyperiesthesia  is  present.  Consciousness  is  fre- 
quently lost,  but  may  remain,  rarely  intact, 
more  often  in  an  obscured  condition.  The  tem- 
perature is  commonly  lowered.  The  attack  may 
last  a few  minutes  or  several  hours.  Recovery 
is  gradual  or  sudden ; it  is  common  for  tho 
patient  at  first  to  be  unable  to  speak.  Some- 
times a strange  periodicity  may  be  observed  in 
the  occurrence  of  the  paroxysms.  In  the  intervals 
between  the  attacks,  headache,  giddiness,  or 
hysterical  manifestations  may  be  present,  or  the 
patient  may  feel  and  seem  perfectly  well. 

Pathology. — Concerning  the  nature  of  the 
disease  there  has  been  much  speculation,  but 
little  definite  knowledge.  It  may  probably  be 
placed  between  epilepsy  and  hysteria  in  the  scale 
of  maladies.  There  is  distinct  interference  with 
the  intellectual  processes,  and  interruption  of  the 
connection  between  the  will  and  the  motor  cen- 
tres. The  rigidity  has  been  thought  by  Rosen- 
thal to  be  reflex,  but  the  abeyance  of  other 
reflex  symptoms  makes  it  more  probable  that, 
as  Holm  suggests,  it  is  of  central  origin. 

Diagnosis. — Hany  cases  of  simple  trance  have 
been  included  under  Catalepsy,  but  it  is  better 
to  restrict  the  name  to  the  condition  in  which 
the  peculiar  rigidity  exists.  Hysteria  with 
tonic  spasm  has  also  been  erroneously  termed 
catalepsy.  The  condition  is  sometimes  simulated : 


CATALEPSY. 

m true  catalepsy  the  rigid  limb  slowly  yields 
to  the  influence  of  gravitation,  and  more  rapidly 
if  a weighty  he  attached  to  it ; in  the  feigned 
form  the  limb  and  weight  are  held  firm. 

Prognosis. — The  prognosis  is  favourable  in 
simple  catalepsy,  in  proportion  to  the  freedom 
of  the  intervals  from  affections  of  sensibility  or 
motion.  In  pronounced  hysteria  and  psychical 
affections  the  condition  is  often  obstinate,  and, 
by  interfering  with  the  due  nourishment  of  the 
system,  may  cause  grave  inanition. 

Treatment. — During  the  attack  itself  little 
can  be  done  save  an  attempt,  which  may  be  re- 
peated at  intervals,  to  rouse  consciousness  by 
external  stimulation.  The  ordinary  applications, 
ammonia  to  the  nostrils,  cold  douches,  &c.,  often 
fail.  A pinch  of  snuff  will,  however,  often  suc- 
ceed. Another  effectual  stimulant  is  Faradisa- 
tion. It  may  be  applied  to  a limb  or  to  the 
cervical  spine.  The  current  should  be  gentle  at 
first,  and  gradually  increased.  Emetics  are  also 
useful  in  cutting  short  an  attack.  Injections 
of  tartar  emetic  into  the  veins  have  been  used 
with  success  by  Calvi,  but  can  hardly  be  recom- 
mended. Subcutaneous  injection  of  apomorphia, 
ith  to  ith  of  a grain,  the  writer  has  found  an 
efficient  remedy  for  similar  paroxysmal  condi- 
tions ; with  the  onset  of  nausea,  about  five 
minutes  after  the  injection,  consciousness  is  re- 
gained, and  all  spasm  ceases.  In  the  intervals 
between  the  attacks  the  treatment  is  that  of 
hysteria.  Iron,  antispasmodics,  especially  vale- 
rian, alvetic  aperients,  and  cold  baths,  are  the  most 
effectual  measures.  Firm  moral  treatment  is  also 
indispensable.  Removal  from  home  influences  is 
often  necessary  to  effect  a cure.  W.  R.  Gowers. 

CATAMENIA,  Disorders  of.  See  Men- 
struation, Disorders  of. 

CATAPLASM  (Kara,  down,  and  TrXdcraa, 
I mould  or  smear). — A synonym  for  a poultice. 
See  Poultice. 

CATARACT  (KarapdicTris,  a waterfall). — 
Definition. — Cataract  is  an  opacity  of  the  lens 
— the  want  of  transparency  being  sufficient  to 
prevent,  at  least  in  that  part  of  the  lens  which 
is  opaque  and  to  the  extent  of  the  opacity,  the 
discrimination,  with  the  ophthalmoscopic  mirror, 
of  the  details  of  the  fundus  of  the  eye. 

./Etiology  and  Pathology. — Cataract  is  pro- 
duced in  various  ways.  Any  change  in  the  nor- 
mal relationship  of  the  lens-fibres  may  cause  such 
a degree  of  opacity  of  the  lens  as  is  understood 
by  the  term  cataractous.  This  is  usually  a senile 
change,  and  it  is  then  a sclerosis  of  the  lens. 
The  question  of  the  normal  nutrition  of  the  lens 
is  yet  unanswered.  If  there  be  a solution  of 
continuity  of  the  capsule  of  the  lens,  so  that  the 
aqueous  humour  has  access  to  the  lens  proper, 
unless  it  be  in  cases  of  minute  punctures  and 
small,  clean-cut  wounds,  which  soon  heal  and 
scar,  the  whole  lens  becomes  swollen  by  endos- 
mosis,  grey,  and  cataractous.  A symmetrical 
change  in  the  lenses,  somewhat  similar  in 
eppearance,  is  observed  in  some  eases  of  diabetes, 
and  is  occasionally  seen  in  albuminuria.  The 
lens  may  be  found  to  be  ill-developed  and 
cataractous  at  birth ; while  others,  apparently 
as  a consequence  of  ill-development,  but  not 


CATARACT.  217 

during  the  whole  period  of  growth  of  the  lens, 
are  partly  cataractous  and  partly  transparent, 
and  show  opaque  concentric  lamellae.  Besides 
this  instance,  showing  the  anatomical  configu- 
ration of  the  lens,  cataracts  not  unfrequently 
demonstrate  its  normal  trifid  division  as  trans- 
parent lines;  and  the  striae  of  striated  cataracts 
are  always  in  directions  radiating  to  or  from  the 
centre  of  the  lens,  in  the  course  of  the  fibres. 

Besides  these  scleroses,  endosmoses,  and  im- 
perfections of  the  lens  proper,  there  are  many 
opacities  appertaining  to  this  part  of  the  refrac- 
tive apparatus,  which  were  formerly,  and  are 
still  commonly  called  cataract.  Among  these 
there  are  the  capsular  cataracts,  which  do  not 
imply  any  real  opacity  of  the  capsule  of  the 
lens,  but  only  an  opacity  of  that  part  of  the  lens 
which  is  next  to  the  capsule — the  rest  remaining 
transparent — or  the  deposit  of  some  opaque  mat- 
ter upon  the  lens-capsule  externally.  Pyra- 
midal cataract  is  formed  by  the  deposit  on  the 
anterior  surface  of  the  front  of  the  lens-capsule, 
at  or  near  its  centre,  of  a patch  of  lymph,  when 
an  ulcer  has  formed  in  the  cornea,  and  perfora- 
tion has  occurred,  by  which  the  aqueous  humour 
is  evacuated,  the  anterior  chamber  obliterated, 
and  the  lens  approximated  to  the  cornea,  if  it 
is  not  brought  into  actual  contact  with  it.  When 
the  aqueous  humour  is  again  retained,  the  mass 
of  lymph  is  drawn  out  into  the  pyramidal  form, 
and  if,  in  any  case  of  pyramidal  cataract,  there 
has  been  no  perforating  ulcer  to  evacuate  the 
aqueous  humour,  it  must  be  remembered  that 
these  so-called  cataracts  only  occur  in  early  life, 
when  the  anterior  chamber  is  very  shallow. 
There  is  a large  class  of  cataracts  called  secon- 
dary, where  the  condition  is  due  to  an  earlier 
disease  of  the  eye,  and  in  which  the  latter  is  of 
course  in  the  first  place  to  be  considered.  Such 
cases  are  the  glaucomatous,  in  which,  when 
excessive  intraocular  pressure  has  existed  some 
time,  the  lens,  no  doubt  by  interference  with  its 
due  nutrition,  becomes  cataractous ; and  iridec- 
tomy for  glaucoma  is  chiefly  indicated,  whether 
or  not  the  lens  should  require  to  be  extracted 
subsequently.  Other  secondary  cataracts  are 
those  called  posterior-polar,  in  which  the  opacity 
begins  at  the  centre  of  the  back  of  the  lens  and 
is  preceded  by  some  deep-seated  disease  of  the 
fundus  of  the  eye,  which  is  of  greater  and  cer- 
tainly of  prior  importance. 

Symptoms. — A patient,  having  uncomplicated 
cataract,  complains  of  his  vision,  if  he  complains 
at  all,  for  a small  definite  opacity  is  easily  dis- 
regarded, even  if  it  be  in  or  near  the  centre  of 
the  lens  or  of  the  axis  of  vision.  If  it  occupies 
a considerable  portion  of  the  pupillary  area,  it 
can  of  course  be  no  longer  considered  small,  or 
bo  disregarded  by  the  patient.  If  the  cataract- 
ous opacity  begins  in  the  circumferential  parts  of 
the  lens,  and  only  there,  it  may,  on  the  contrary, 
make  very  considerable  progress  before  it  is 
found  out  by  the  patient.  In  the  majority  of 
the  various  cases  of  cataract,  the  patient  sees 
better  with  his  pupils  dilated— he  prefers  to  sit 
with  his  back  to  the  light,  he  holds  his  hand  over 
his  eyes,  or  he  holds  his  head  down  and  frowns 
in  order  to  see  better — he  is  cheerful,  and  is  al 
ways  trying  to  see.  In  such  cases  as  these  quacks 
have  made  profit  of  the  benefit  the  patient  has 


CATAEACT. 


218 

derived  from  each  visit,  when  a drop  of  bella- 
donna or  atropine  solution  has  been  used  for  the 
‘ cure  ’ of  the  malady. 

The  only  complication  or  ill  result  of  the  ex- 
istence of  non-traumatic  cataract  as  such,  is  in 
the  congenital  forms,  in  which  for  want  of  use 
the  retina  suffers  and  nystagmus  follows.  It  is 
therefors  imperative  that  cataract  in  infancy 
should  be  operated  on  at  an  early  age. 

Diagnosis. — The  diagnosis  of  cataract  is,  in 
most  cases,  easy  enough.  The  position  and  shape 
of  the  crystalline  lens  being  known,  an  opaque 
body  is  seen  to  exist  in  its  place,  or  in  a part  of 
it.  The  cataractous  opacity  varies  from  milky  to 
chalky  white ; striae  in  it  often  appear  glistening, 
like  newly-dissected  tendon  ; some  cataracts  are 
amber-coloured.  A drop  of  liquor  atropise  sul- 
phatis  should  be  used  to  dilate  the  pupil ; and, 
this  being  effected,  the  opacity  behind  it  cannot 
be  one  of  the  result  s of  a past  iritis,  which  would 
not  leave  the  pupil  free  to  dilate  fully  and  cir- 
cularly. The  ophthalmoscope  should  then  be 
used,  not  only  for  the  diagnosis  of  a cataract,  but 
also  for  ascertaining  the  degree  of  opacity,  and, 
if  not  too  late,  the  state  of  the  fundus  ; and  for 
determining  thus  the  probable  future  need  and 
success  of  an  operation  for  its  removal.  If,  not- 
withstanding an  evident  opacity  in  the  situation 
of  the  lens,  otherwise  seen,  all  the  details  of 
the  fundus  viewed  with  the  ophthalmoscope 
are  unobstruetedly  discernible,  it  is  not  a case  of 
true  cataract.  Senile  lenses  have,  as  a rule,  an 
evident  diffused  opacity  which  does  not  imply 
any  beginning  of  cataract  formation.  There  are 
generally  striae  in  the  cataractous  lens,  which 
converge  to  the  centre  from  the  circumference,  or 
diverge  from  the  centre  to  the  circumference,  and 
if  the  fundus  can  be  illuminated  with  the  ophthal- 
moscopic mirror,  the  opaque  parts  of  the  lens 
appear  dark,  the  reflected  light  coming  from 
behind  them ; but,  on  the  other  hand,  if  the 
ophthalmoscopic  convex  lens  be  used  to  concen- 
trate the  lamp-light  obliquely  on  the  cataract, 
the  opaque  parts  appear  light,  as  they  reflect  the 
light,  and  are  backed  by  the  fundus  which  is  not 
thus  lit  up.  Striae  on  the  posterior  surface  of 
the  lens  are  seen  to  be  concave ; and,  in  senile 
cases,  being  viewed  through  a lens  having  the 
natural  yellow  tint  of  senile  lenses,  they  also 
appear  yellowish.  Some  cataracts  begin  as  a 
haziness,  chiefly  in  the  centre,  the  so-called 
nucleus,  which  is  always  increasing;  and,  seen  by 
oblique  illumination,  there  is  in  these  cases,  on 
the  side  of  the  light,  a shadow  of  the  iris  cast  on 
the  light-reflecting  opacity,  and  the  lens-opacity 
seems  to  be  most  on  the  side  furthest  from  the 
light,  whichever  that  may  be. 

Pkognosis. — The  prognosis  of  cataract,  in  a 
medical  sense,  is  bad.  It  is  very  doubtful  if  it 
ever  can  be  at  all  arrested  in  its  progress,  not  to 
say  cured  or  even  lessened.  In  all  probability 
the  cataractous  opacity  is  scarcely  ever  di- 
minished— on  the  other  hand  it  does  not  always 
progress.  Very  many  old  persons  have  cataract- 
ous striae  in  the  marginal  part  of  their  lenses, 
which  are  of  no  inconvenience  to  them,  and  are 
only  by  chance  discovered  by  the  surgeon.  If  the 
striae  should  invade  the  pupillary  area,  vision,  in 
one  ej'O  at  least,  will  be  very  likely  still  sufficient 
for  the  requirements  of  the  patient,  and  the  in- 


terference of  the  surgeon  will  never  be  called  for. 
As  to  the  prospects  of  success  in  operating — un- 
complicated cataract,  of  course,  never  leads  to  ab- 
solute blindness— the  patient  sees  and  evidently 
observes  the  light  and  light-reflecting  objects ; 
the  field  of  vision  is  perfect ; the  pupil  is  active  ; 
the  general  health  is  good ; the  cataractous 
opacity  is  not  of  the  posterior-polar  variety,  and 
there  are  no  other  complications ; all  parts  of 
the  lens  are  more  or  less  opaque.  Immature 
cataracts  must  not  be  extracted  unless  neither 
eye  is  good  for  vision,  and  the  progress  to- 
wards maturity  is  exceedingly  tedious,  because 
the  transparent  parts  of  the  lens,  unseen,  are 
likely  to  be  left  behind  in  the  operation,  and  then 
to  set  up  inflammation.  The  dangers  from  ca- 
taract operations  are  less  in  childhood  than  in 
older  persons.  In  early  life  any  subsequent  in- 
flammation threatening  the  eye  can  be  averted 
by  timely  interference  with  a certainty  of  suc- 
cess, and  an  operation  should  therefore  be  recom- 
mended, although  the  cataract  only  affects  one 
eye.  In  old  age  if  one  eye  be  available  for 
vision,  an  operation  for  mature  cataract  in  the 
other  eye  is  not  to  be  performed  unless  the 
patient  himself  desires  it. 

Treatment. — Cataracts  have  seldom,  the 
writer  believes,  any  practical  bearing  as  regards 
medical  treatment.  In  cases  of  diabetes  and  of 
temporary  albuminuria,  in  which  a cataractous 
condition  occurred,  the  state  of  the  lens  has  been 
found  to  improve  with  the  general  health  of  the 
patient.  In  a patient  with  diabetic  cataracts 
appropriate  treatment  may  remove  the  opacity  of 
the  lenses  and  restore  vision;  and  the  writer  has 
seen  senile  cataract  advance  rapidly  when  the 
patient  has  been  in  any  way  lowered  in  general 
health,  and  then  again  advance  slowly  as  before 
when  the  health  has  been  restored. 

Besides  the  palliative  treatment  by  atropine 
drops  constantly  used  (if  vision  be  improved 
by  their  use),  the  capital  surgical  treatment  is 
the  only  one  available  for  cataract — the  opaque 
lenses  must  be  removed,  and  spectacles  of  differ- 
ent powers  must  be  worn  as  substitutes  for  the 
natural  lenses  and  power  of  accommodation. 
Exception  must  be  made  in  the  case  of  some 
lamellar  cataracts,  with  a wide  transparent  mar- 
gin, in  which  an  iridectomy  is  sufficient  for  the 
restoration  of  vision.  In  infancy  and  youth  the 
best  proceeding  is  the  needle-operation,  by  which, 
with  a fine  needle  only,  entered  through  the  cor- 
nea, the  anterior  capsule  of  the  lens,  and  the  lens 
itself  also  to  some  extent,  are  broken  up,  and, 
by  repetitions  of  the  same  operation,  the  whole  is 
exposed  to  the  action  of  the  aqueous  humour  and 
thus  gradually  absorbed,  the  posterior  lens-cap- 
sule being  left  as  a barrier  to  the  vitreous  humour 
behind  it..  It  is  very  safe  when  atropine  drops 
are  constantly  used,  and  the  ease  is  continually 
watched,  so  that,  if  too  sudden  or  too  great  a 
swelling  of  lens-matter  should  at  any  time  occur 
by  the  admission  of  the  aqueous  humour,  and 
there  be  a threatening  of  iritis  as  a consequence 
of  mechanical  pressure  on  the  iris,  the  swollen 
lens-matter  may  be  at  once  evacuated  by  the 
introduction  of  a broad  needle  through  the  cornea, 
and  then  of  a grooved  curette  or  suction-syringe, 
by  which  the  semifluid  mass,  or  a sufficient 
quantity  of  it,  may  be  got  rid  of.  In  old  age.  ana 


CATARACT. 

generally  in  adult  life,  the  cataractous  lens  to  be 
removed  should  undoubtedly  be  extracted  as  a 
whole  and  at  one  time.  The  needle  operations, 
which  in  young  persons  are  not  completed  in  any 
case  in  less  than  a few  weeks  or  months,  take  a 
longer  time  to  complete  in  proportion  to  the  age 
of  the  patient ; in  adults  the  process  is  much 
slower,  and  in  old  age  it  would  be  indefinitely 
prolonged;  more  important  still,  the  eyes  by 
age  become  less  and  less  tolerant  of  what  may  be 
called  a foreign  body,  and  more  liable  to  iritis,  while 
the  iritis  is  less  easily  subdued.  Then  again  the 
central  part  or  nucleus  of  the  lens  especially 
grows  harder  as  the  patient  becomes  older  ; and 
if  the  patient  be  too  old  for  the  safe  adoption  of 
the  minor  operation,  this  so-called  nucleus  would 
become  a much  more  likely  source  of  irritation, 
particularly  if  it  floated  freely  in  the  aqueous 
humour,  than  the  swollen  soft  lens-matter  of  the 
juvenile  lens  when  thus  operated  upon.  The  so- 
called  hard  cataracts  of  old  age  must,  without 
doubt,  be  extracted.  A section  with  a knife  is 
made,  of  somewhat  less  than  half  of  the  corneal 
circumference ; then,  as  is  usually  practised  now- 
a-days,  that  part  of  the  iris  lying  beneath  the 
corneal  section  is  excised,  for  the  easier  and  more 
safe  extrusion  of  the  hard  lens;  the  anterior  cap- 
sule of  the  lens  is  freely  lacerated ; and,  by  pres- 
sure in  the  ciliary  region  opposite  to  the  open- 
ing made,  the  lens  is  gradually  forced  out  of  its 
capsule  and  out  of  the  eye,  including  subse- 
quently all  the  softer  circumferential  cortical 
parts  of  the  cataractous  lens.  The  edges  of  the 
corneal  wound  being  rightly  in  apposition,  the 
eyelids  are  closed,  and  both  eyes  are  firmly  but 
lightly  bandaged  for  some  days,  until  at  least 
the  corneal  wound  is  healed,  so  that  the  aqueous 
humour  is  again  retained.  The  cataracts  of 
adults,  though  they  may  not  be  old  people,  in  most 
eases  should  also  be  extracted.  But  at  this  age 
cataracts  are  not  common,  except  traumatic  cata- 
racts, and  these,  and  many  other  varieties, 
cannot  be  briefly  described  in  a general  way. 

J.  F.  Streatfeild. 

CATABEH  (uara,  down,  and  f>4u >,  I flow). 
Synon.  : Coryza ; Catarrhus  (Cullen) ; Catarrhus 
Communis  (Good) ; Eheuma  ; Fr.  Catarrhe, 
Coryza  ; Ger.  Katarrh,  Schnupfen, 

Definition.  — The  term  catarrh  is  applied 
generally  to  inflammations  of  the  mucous  mem- 
branes attended  with  increased  secretion.  Thus 
authors  speak  of  catarrh  of  the  stomach,  intestines, 
bladder,  Spc.  In  the  present  article  the  term  is 
limited  to  the  inflammatory  affections  of  the  upper 
part  of  the  air-passages,  resulting  from  cold,  and 
attended  by  discharge  from  the  nostrils,  sore- 
ness of  the  throat,  hoarseness,  and  cough.  The 
term  coryza  is,  however,  more  especially  limited 
to  the  cases  in  which  there  is  copious  discharge 
from  the  nasal  passages,  while  catarrh  is  applied 
to  affections  of  the  whole  mucous  membrane,  in- 
cluding the  fauces  and  larynx. 

Symptoms. — The  attack  generally  commences, 
"hortly  after  exposure  to  cold  or  more  particu- 
larly to  cold  and  damp,  with  a feeling  of 
indisposition,  sense  of  cold  down  the  back  or 
general  chilliness,  weight  in  the  forehead, 
headache,  especially  frontal,  and  dryness  of  the 
naros  and  throat.  These  symptoms  are  succeeded 


CATARRH.  219 

by  the  discharge  from  the  nostrils  of  a thin  acrid 
fluid,  watering  of  the  eyes,  pains  in  the  face, 
soreness  of  the  throat  and  hoarseness,  with 
aching  in  all  parts  of  the  body,  and  disinclination 
to  bodily  and  mental  exertion. 

At  first  the  affection  is  often  confined  to  one 
nostril,  and  there  is  pain  in  the  corresponding 
temple,  eyebrow,  eyeball,  and  side  of  the  face, 
and  lachrymation  on  that  side,  but  it  soon  ap- 
pears in  the  other  nostril,  and  involves  both 
eyes  and  all  parts  of  the  face ; and  there  is  great 
sense  of  weight  and  pain  in  the  forehead  and 
eye-brows.  The  discharge,  also,  loses  the  thin 
character  and  becomes  mucous,  and  is  often  very 
profuse ; there  is  copious  lachrymation,  the  throat 
becomes  decidedly  sore,  the  hoarseness  is  greater, 
and  there  is  pain  in  speaking  and  sometimes 
almost  entire  loss  of  voice.  There  aro  also  tran- 
sient pains  in  the  chest,  with  a sense  of  tightness 
and  some  wheezing.  The  appetite  from  the  first 
is  impaired,  and  there  may  be  entire  distaste  for 
food,  and  sometimes  sickness  and  vomiting;  not 
unfrequently  there  is  some  sense  of  weight  in  the 
right  hypochondrium,  and  sallowness  of  the  com- 
plexion ; the  bowels  aro  usually  confined,  but 
there  may  be  diarrhoea.  The  tongue  is  generally 
white,  the  pulse  may  be  a little  quickened,  the 
skin  may  . be  dry,  the  temperature  is  raised,  and 
the  urine  is  scanty  and  somewhat  high-coloured 
and  deposits  a little  sediment.  The  pains  in  the 
head  and  face  especially  affect  the  forehead,  the 
eyebrows,  the  root  of  the  nose,  the  eye-balls, 
and  the  course  of  the  dental  and  other  nerves ; 
they  generally  increase  towards  night,  and  may 
be  so  severe  as  entirely  to  prevent  sleep.  Not 
unfrequently  there  is  more  or  less  deafness,  and 
usually  loss  of  smell  and  taste.  Herpetic  spots 
often  appear  about  the  mouth,  and  the  nostrils 
may  bocome  ulcerated  from  the  discharge  ; the 
throat  is  more  or  less  red  and  swollen,  and  often 
there  is  stiffness  and  pain  of  the  neck,  and  tender- 
ness on  pressure  over  the  larynx. 

After  these  symptoms  have  continued  for  two 
or  three  days  they  generally  gradually  subside ; 
but  the  cough  may  continue  troublesome,  and 
the  patient  be  able  to  take  very  little  food,  and 
may  still  feel  weak  for  a week  or  more.  In  per- 
sons of  delicate  constitution  also,  the  weakness  is 
often  very  persistent;  and,  if  care  be  not  taken, 
more  serious  inflammation  of  the  bronchial  mu- 
cous membrane  or  of  the  lungs  may  supervene, 
and  may  lapse  into  phthisis. 

Treatment. — In  the  slighter  forms  of  com- 
mon cold,  but  little  treatment  is  required  except 
the  use  of  the  ordinary  household  remedies : 
the  feet  may  be  placed  in  hot  water,  some  warm 
diluent  beverage  may  be  taken,  and  a light  diet 
must  be  had  recourse  to  for  a day  or  two.  In 
the  more  serious  cases  febrifuge  medicines  may 
be  given,  with  an  anodyne  to  relieve  tho  cough, 
if  troublesome,  or  to  procure  rest  at  night,  if 
the  neuralgic  pains  be  very  severe.  "When  the 
attack  has  continued  for  two  or  three  days  a 
more  stimulating  diet  may  be  giveD,  and  during 
convalescence  tonics  and  stimulants  may  be  re- 
quired. 

Dr.  Ferrier  recommends  in  catarrh  the  local 
application  to  tho  nose  of  the  following  powder 
in  the  form  of  a snuff — Hydrochiorate  of  mor- 
phia 2 grains,  subnitrate  of  bismuth  6 drachms, 


220  CATARRH. 

gum-acacia  in  powder  2 drachms.  From  one- 
quarter  to  one-half  of  this  may  be  taken  in  the 
course  of  twenty-four  hours. 

It  not  unfrequently  happens  that  in  delicate 
persons  a cold  is  very  difficult  to  get  rid  of,  and 
the  slightest  exposure  is  followed  by  an  aggrava- 
tion or  renewal  of  the  symptoms.  When  this  is 
the  caso  the  most  effectual  remedy  is  change  c f 
air,  and  the  patient  after  leaving  home  often 
rapidly  improves  and  soon  gets  well. 

Thomas  13.  Peacock. 

CATARRHAL  ( Kara , down,  and  pea,  I flow). 
— Pertaining  to  catarrh,  both  in  its  pathological 
and  in  its  clinical  signification — e.g.,  catarrhal 
products,  catarrhal  pneumonia,  catarrhal  fever, 
catarrhal  attack. 

CATHARTICS  (k adaipa,  I cleanse). — This 
word  is  sometimes  used  as  a synonym  for 
purgatives ; but  in  a more  limited  signification 
it  means  purgatives  of  moderate  activity.  See 
Purgatives. 

CAUSES  of  Disease.  See  Disease,  Causes  o£ 

CAUSTICS  (kccIw,  I burn). — Definition. — 
Substances  or  measures  which  destroy  organic 
tissues  with  which  they  may  be  brought  in  con- 
tact. 

Enumeration. — The  caustic  substances  in 
most  common  use  are  Potash,  Soda,  and  Lime  ; 
Nitric,  Hydrochloric,  Sulphuric,  and  Glacial 
Acetic  Acids  ; Red  Oxide,  Acid  Nitrate,  and  Per- 
chloride  of  Mercury ; Carbolic  Acid ; Chromic 
Acid;  Chloride  of  Zinc;  Chloride  of  Antimony ; 
and  Arsenic.  The  ordinary  caustic  measures  are 
the  galvano-cautery ; the  red-hot  iron ; and  moxse. 
See  also  Poisons. 

Uses.  — Caustics  are  chiefly  employed  to 
destroy  unhealthy,  exuberant,  or  malignant 
growths  ; to  establish  issues  for  the  purpose  of 
counter-irritation  (see  Counter-irritation)  ; 
and  to  destroy  poisons  when  introduced  into  the 
body  by  breach  of  the  external  surface. 

T.  Lauder  Brunton. 

CAUTERETS,  in  the  French  Pyrenees. 
Sulphur  Waters.  See  Mineral  Waters. 

CAVERNOUS.  — A peculiar  quality  of 
sounds  heard  on  auscultation  of  the  lungs,  indica- 
tive of  the  presence  of  a cavity.  See  Physical 
Examination. 

CAVITY,  Pulmonary. — As  the  result  of 
certain  morbid  processes  which  terminate  in  the 
destruction  of  portions  of  the  pulmonary  tissues, 
abnormal  spaces  or  excavations  are  frequently 
formed  in  the  lungs,  which  are  designated  cavi- 
ties or  vomicce.  These  are  usually  associated 
with,  and  are  by  far  most  important  in  that  large 
class  of  cases  which  are  grouped  under  the  term 
Phthisis.  They  may,  however,  originate  under 
other  conditions,  namely,  as  the  result  of  abscess 
or  gangrene  of  the  lung;  of  the  destruction  of 
morbid  growths  or  hydatid  cysts ; of  dilatation 
of  the  bronchi ; or  of  destruction  of  the  pulmo- 
nary tissue  from  without,  in  connection  with 
glandular  disease,  empysema,  and  other  lesions. 
The  most  recent  observations  on  this  subject  are 
given  in  the  article  Vomica. 

Pulmonarv  cavities  present  wide  variations  in 


CELL. 

different  cases  as  regards  their  number,  size, 
shape,  condition  of  their  walls,  amount  and 
nature  of  their  contents,  and  other  particulars. 
Usually  they  begin  to  form  in  the  upper  part  of 
one  lung,  but  subsequently  they  are  produced  in 
other  parts,  frequently  both  lungs  becoming  more 
or  less  involved,  and  any  portion  may  be  exca- 
vated ir  the  first  instance.  A cavity  frequently 
goes  through  certain  stages,  namely,  those  of 
formation  and  extension ; of  arrest ; and  of  heal- 
ing or  contraction,  which  may  terminate  in  ulti- 
mate closure  and  obliteration  of  the  vomica. 
Enlargement  of  cavities  is  effected  either  by 
progressive  implication  of  their  walls,  termi- 
nating in  their  disorganisation  and  removal ; or 
by  coalescence  of  adjacent  spaces,  the  intervening 
lung-tissue  becoming  destroyed.  During  this  pro- 
cess of  destruction  some  of  the  tissues  often  escape 
more  or  less,  especially  the  vessels,  which  may  not 
uncommonly  be  seen  traversing  the  spaces  or 
running  along  their  walls,  their  channel  being 
obliterated.  When  an  excavation  is  arrested  in 
its  progress,  it  becomes  lined  by  a smooth  mem- 
brane, and  a more  or  less  purulent  fluid  is  se- 
creted within  it.  This  cessation  of  active  mischief 
may  not  take  place  until  a whole  lobe,  or  even 
the  greater  part  of  the  lung,  is  involved,  a huge 
cavity  being  formed,  which  presents  no  tendency 
to  contract.  In  other  instances  the  progress  of 
destruction  is  stayed,  the  formation  of  purulent 
matter  is  checked  and  finally  ceases,  a fibroid 
tissue  forms,  and  the  space  undergoes  a process 
of  contraction  or  cicatrization,  which  may  end  in 
a complete  cure,  but  more  commonly  merely 
diminishes  the  size  of  the  vomica  more  or  less. 
At  a post-mortem  examination  in  cases  of  phthisis 
it  is  common  to  find  numerous  cavities  in  the 
various  conditions  and  stages  indicated  above. 
Occasionally  a vomica  gives  way  into  the  pleura, 
followed  by  pneumothorax  and  its  consequences. 

Clinically,  the  existence  of  cavities  in  the  lungs 
can  only  be  ascertained  positively  by  physical 
examination  of  the  chest,  and  as  a rule  not  only 
their  presence,  but  their  conditions  may  by  this 
means  be  determined  with  tolerable  accuracy. 
The  physical  signs  vary  considerably  in  different 
cases,  and  are  more  conveniently  described  in 
other  articles.  Sec  Phthisis  ; Physical  Examina- 
tion, and  Yomica.  Frederick  T.  Eobeets. 

CELL  (cella,  a closet  or  store-room). — The 
term  ‘ cell  ’ was  for  a long  time  applied,  in 
anatomy,  to  various  spaces  in  the  body 
large  enough  to  be  recognised  with  the  naked 
eye.  In  the  Anatomic  Generate  of  Bichat, 
for  instance,  it  was  used  exclusively  for  the  ir- 
regular spaces  in  areolar  tissue  (still  often  called 
cellular  tissue).  An  entirely  different  sense 
of  the  word  was  introduced  from  botanical 
science.  The  microscope  had  shown  that  the 
structure  of  plants  was  largely  made  up  of 
hollow  bodies,  called  bladders,  vesicles,  or  cells, 
in  which  various  substances  were  enclosed  cr 
stored  up.  Schwann  was  the  first  to  show  the 
similarity  in  structure  of  many  animal  tissues 
which  were  likewise  made  up  of  minute  parts. 
These  parts  were  assumed  to  be,  as  in  plants, 
hollow ; and  in  both  eases,  cells  were  defined 
as  composed  of  a cell-wall,  cell-contents,  and 
a smaller  included  mass  called  the  nucleus 


CELL.  221 


This  conception  of  a cell  still  holds  its  ground 
in  the  anatomy  of  plants.  It  did  so  in  animal 
histology  till  about  the  year  1861,  when  Beale, 
Briieke,  and  Max  Schultze  almost  simultaneously 
showed  that  many  so-called  cells  in  animal 
tissues  did  not  possess  the  typical  structure  of  a 
cell,  but  were  homogeneous  masses  of  a sub- 
stance resembling  the  bodies  of  many  lower 
animals,  which  substance  Schultze  distinguished 
by  the  name  of  protoplasm.  This  was  first 
shown  to  be  true  of  certain  special  cells,  such  as 
the  corpuscles  of  blood  and  lymph,  but  afterwards 
extended  more  widely,  till  now  it  is  doubtful 
whether  any  minute  elements  in  the  higher 
animals,  with  the  possible  exception  of  the 
fat-cells  when  gorged  with  fat,  and  certain 
peculiar  forms  of  cell  on  the  mucous  surfaces, 
come  under  the  old  definition  of  a cell.  When 
the  conception  was  altered,  it  would  probably 
have  been  better  to  have  introduced  a new 
name.  This,  however,  was  not  done,  and  hence 
the  word  cell  as  now  used  involves  some  incon- 
sistency. 

By  ‘ cell,’  we  now  understand  a mass  of  con- 
tractile, colloid,  living  matter  called  protoplasm, 
containing  at  some  period  or  other  a smaller 
structure  called  the  nucleus.  It  must  remain 
uncertain  whether  the  nucleus  is  or  is  not  essen- 
tial to  the  cell,  till  we  know  more  about  the 
nature  and  function  of  tho  former ; and  these 
points,  in  spite  of  the  very  numerous  researches 
on  the  nucleus  which  have  lately  appeared,  must 
be  regarded  as  still  obscure.  Sometimes  the 
superficial  portion  of  the  cell-body  may  become 
hardened  or  otherwise  altered,  so  as  to  form 
what  is  called  a ‘ cell-wall,’  but  this  is  not  to 
be  regarded  as  a separate  structure.  In  cells 
destined  for  special  purposes  the  protoplasm  be- 
comes modified.  See  Nucleus  in  Appendix. 

Protoplasm  is  a nitrogenous,  albuminous, 
colloid  substance,  having  certain  properties 
called  vital,  that  is,  the  power  of  altering  its 
form  under  the  influence  of  stimuli,  or,  apparently, 
spontaneously.  This  power  may  be  lost,  under 
the  influence  of  too  powerful  stimulation  or 
other  causes.  Protoplasm  does  not  appear  to 
exist  in  the  higher  animals  otherwise  than  in 
the  form  of  minute  masses  or  cells,  but  it  would 
be  rash  to  say  that  it  cannot  exist  in  continuous 
masses,  as  in  certain  forms  of  plants. 

Many  of  the  properties  of  cells  are  the  pro- 
perties of  protoplasm.  Those  cells  which  con- 
sist of  unmodified  or  undifferentiated  proto- 
plasm possess  contractility,  the  power  of  pro- 
truding their  substance  in  the  form  of  processes, 
of  undergoing  various  changes  of  form,  and  even 
of  locomotion.  In  these  respects  they  resemble 
very  simple  animals — amoeba,  whose  bodies  are 
composed  of  homogeneous  protoplasmic  sub- 
stance, and  these  movements  are  hence  called 
amoeboid,  or  simply  vital.  Cells  which  possess 
these  properties  may  lose  them,  or  die  from 
excessive  heat,  cold,  removal  from  the  body,  or 
other  injurious  influences.  Hence  the  amceboid 
movements  are  especially  characteristic  of  re- 
cently formed  or  young  cells.  They  are  seen  in 
the  white  cells  of  the  blood,  lymph-corpuscles, 
the  round  or  unfixed  cells  of  connective  tissue, 
the  young  cells  which  appear  in  inflamed  parts, 
fresh  pus-cells,  and  occasionally  in  the  young 


cells  of  new  growths,  but  are  absent  as  a rule 
in  cells  highly  differentiated  and  serving  some 
special  purpose,  such  as  nerve-cells,  secreting 
cells,  and  the  fixed  cells  of  connective  tissue. 
Amceboid  cells  are  sometimes  found  in  tissues  to 
the  fixed  elements  of  which  they  have  no  relation, 
.and  are  then  to  be  regarded  as  emigrant  or  mi- 
gratory cells.  They  are  very  important  in  some 
pathological  processes. 

Cell-proliferation. — Cells  increase  in  number 
by  fission,  and  perhaps,  as  some  think,  by  gem- 
mation and  by  endogenous  development.  These 
processes  collectively  are  called  cell-prolifera- 
tion, which  is  doubtless  the  source  of  many  of 
the  new  cells  found  in  pathological  states.  All 
cells  are  not  equally  capable  of  proliferation, 
which  is  chiefly  seen  in  amoeboid  cells,  and  in  all 
the  elements  of  connective  tissue.  This  tissue 
was  regarded  by  Virchow  as  the  germinal  tissue, 
from  which  all  others  originate,  but  the  balance 
of  opinion  is  now  in  favour  of  a different  view, 
namely,  that  each  kind  of  tissue,  by  prolifera- 
tion, produces  only  tissue  of  the  same  kind.  Re- 
cent researches  show  that  cell-division  takes  place 
in  two  distinct  modes,  the  direct  and  the  indirect. 
See  Nucleus.  The  mode  of  proliferation  in  epi- 
thelial cells  is  still  imperfectly  understood.  It 
was  formerly  held  by  Schwann  and  others,  that 
cells  originated  spontaneously  in  a homogeneous 
blastema ; but  proof  is  quite  wanting  of  this 
mode  of  origin,  and  it  is  in  accordance  with  all 
experience  to  believe  that  new  cells  are  always 
the  descendants  of  pre-existing  cells — a con- 
clusion summarised  by  Virchow  in  the  words 
omnis  cellula  e cclluld.  It  does  not  follow  that 
new  cells  are  always  descended  from  the  cells  of 
the  tissues  in  which  they  are  found,  since  they 
may  have  emigrated  from  the  blood-vessels. 

Shape  of  cells. — Amceboid  cells  have,  strictly 
speaking,  no  fixed  shape  ; but  in  a state  of  rest, 
and  when  dead,  they  are  nearly  spherical.  Some 
cells  of  similar  protoplasmic  composition  are 
very  irregular  in  shape,  and  contain  many  nuclei, 
namely,  mj-eloid  or  giaDt-cells.  Other  cells  have 
various  shapes,  of  which  the  commonest  is  an 
elongated  form,  with  a process  at  each  extremity, 
as  in  fibre-cells;  some,  as  nerve-cells  or  fixed 
connective-tissue  cells,  are  stellate,  with  several 
processes.  Some  cells  in  certain  new  growths, 
especially  tubercle,  also  called  giant-cells,  have 
extremely  complicated  processes. 

Wasting  and  Degeneration  of  cells. — The  ac- 
tual duration  of  life  in  cells  is  not  in  all  cases  pre- 
cisely known ; but  in  the  blood  and  in  large  collec- 
tions of  amoeboid  cells  we  always  find  some  with 
signs  of  decay  and  death,  so  that  their  life  is 
probably  measured  by  days.  Epithelial  and 
secreting  cells  have  also  a limited  duration, 
while  fixed  cells  of  connective  tissue  and  nerve 
cells  are  probably  more  permanent.  Cells  are 
also  subject  to  the  degenerations  which  affect 
tissues  generally,  especially  the  fatty,  mu- 
cous, and  colloid.  The  obvious  pathological 
changes  in  organs  are  often  due  to  the  minute 
changes  in  the  cells.  Newly-formed  cells 
are  more  subject  to  degeneration  and  decay 
than  the  original  elements ; and  this  is  espe 
cially  true  of  cells  produced  in  inflammation. 
Some  pathological  processes  consist  essentially 
in  tho  rapid  production,  followed  by  rapid 


122  CELL. 

degeneration,  of  new  jells,  for  example,  scrofu- 
lous inflammation. 

Cellular  Pathology. — This  name  is  giver,  to 
the  system  which  explains  morbid  processes 
by  reference  to  the  independent  life  of  cells, 
their  active  properties,  their  proliferation,  and 
their  degenerations,  while  it  attaches  less  im- 
portance to  derangements  of  the  circulation,  or  to 
alterations  in  the  composition  of  the  blood.  Its 
foundations  were  laid  by  Remak  and  Goodsir, 
but  it  was  first  reduced  to  a comprehensive 
system  by  Virchow,  not  only  in  his  work  thus 
named,  but  in  memoirs  published  before  and 
since.  The  cellular  pathology  explains  many 
facts  which  were  before  obscure,  and  the  impor- 
tant steps  thus  made  are  not  likely  to  be 
retraced ; but  in  several  points  modification  of 
Virchow’s  views  has  become  necessary.  As  to 
the  origin  of  new-growths,  it  is  not  now  held 
that  all  arise  or  can  arise  from  the  connective 
tissue;  and  in  inflammation  it  is  agreed  that  the 
changes  of  the  tissues,  however  well-established, 
are  only  of  subordinate  importance,  as  compared 
with  those  depending  upon  the  circulation. 

J.  E.  Payne. 

CE LLTTLI TI S . — Definition. — Cellulitis  is 
the  term  applied  to  inflammation  of  the  cellular 
or  loose  connective  tissue,  whether  the  subcuta- 
neous areolar  tissue,  or  that  interposed  between 
muscles  and  viscera,  or  surrounding  various 
organs. 

The  areolar  connective  tissue  is  so  universally 
distributed  throughout  the  body  that  it  is  neces- 
sarily concerned  in  most  inflammations — no 
matter  of  what  structure — and  in  it,  in  fact,  the 
chief  changes  generally  take  place. 

To  consider  completely  the  pathology  of  in- 
flamed connective  tissue  would  be  more  or  less 
to  review  the  whole  series  of  the  acute  diseases. 
We  must  limit  our  consideration  to  cases  in 
which  the  cellular  tissue  is  the  chief  or  only 
tissue  involved,  or  where  changes  in  other  parts 
are  secondary  to  those  primarily  affecting  the 
cellular  tissue. 

Beneath  the  skin,  over  the  whole  surface  of 
the  body,  lies  a layer  of  this  tissue,  containing 
within  its  meshes  more  or  less  adipose  matter. 
It  will  be  convenient  to  consider  the  changes 
which  occur  in  it  when  inflamed,  as  they  are  iden- 
tical with  those  in  cellular  tissue  elsewhere. 

Inflammation  of  the  subcutaneous  cellular 
tissue  may  be  diffuse  or  circumscribed.  The 
former  is  nearly  always  acute  in  type,  and  the 
latter  often,  but  not  invariably  so.  A chronic 
form  of  cellulitis  causing  thickenings  is  observed 
in  various  regions,  or  it  may  be  a sequel  to  the 
acute  disease. 

1.  Circumscribed  Cellulitis. — .ZEtiology. — 
Anj  injury  to  a part,  whether  of  the  nature  of  a 
wound  or  contusion  ; an  impacted  foreign  body ; 
or  a fragment  of  bone,  may  cause  cellulitis.  Pyte- 
mia  or  septicaemia,  any  decomposing  secretion  in 
a wound,  altered  blood,  or  infiltrated  urine  are 
prone  to  produce  marked  inflammatory  changes 
in  the  connective  tissue  in  different  parts  of  the 
body.  The  poison  introduced  in  a dissection- 
or  'post-mortem  wound  often  occasions  an 
acute  cellular  inflammation.  Frostbite,  burns, 
inflammation  of  muscles,  arteries,  veins,  or  peri-  i 


CELLULITIS. 

osteum  may  produce  inflammation  of  the  adjacent 
cellular  tissue : thus,  inflammation  of  the  kidney 
may  cause  perinephritis  ; inflammation  of  the 
uterus  may  lead  to  pelvic  cellulitis;  or  some 
mischief  in  the  greater  bowel  or  rectum  may 
produce  inflammation  and  abscess  in  the  lcose 
cellular  tissue  around  them  ( Perityphlitis ) ; the 
poison  also  of  scarlatina  causes  cellulitis  of  the 
submucous  areolar  tissue  of  the  throat;  and 
Angina  Ludovici  is  the  name  given  to  the 
cellulitis  of  the  floor  of  the  mouth  and  neck 
which  is  often  associated  with  pysemic  symptoms. 
A sympathetic  bubo  is  an  irritated  lymphatic 
gland  causing  inflammation  of  the  cellular  tissue 
around  it. 

Pathology. — Pathologically,  connective  tissue 
is  of  the  greatest  importance  in  the  organism, 
being  the  most  frequent  seat  of  inflammatory  and 
other  changes.  Areolar  tissue  mainly  consists 
of  loosely  interlaced  bundles  of  fibrous  tissue, 
with  flattened  connective-tissue  corpuscles  ad- 
herent to  them,  and  leucocytes,  or  amoeboid 
corpuscles,  in  the  intervals.  The  exact  role  played 
in  inflammation  by  the  cellular  elements  is  not 
quite  settled.  Under  ordinary  circumstances  the 
leucocytes  doubtless  proliferate,  and  the  fixed 
corpuscles  probably  do  so  also.  Even  under  the 
influence  of  a slight  irritation  the  flattened 
corpuscles  in  a few  hours  become  globular,  and 
present  many  nuclei  in  their  interior — changes 
certainly  pointing  towards  proliferation  ; while 
the  very  rapid  increase  of  cells  which  takes  place 
points  to  their  derivation  from  cells  pre-existing 
in  the  part,  although  the  immigration  of  leuco- 
cytes from  the  blood  into  the  inflamed  part  adds 
considerably  to  their  numbers.  Whether  the 
perversion  of  nutrition  which  forms  the  start- 
ing point  of  the  disease  first  induces  a local 
cell-proliferation,  or  an  immigration  of  leuco- 
cytes, or  what  proportion  these  two  processes 
bear  to  each  other,  is  difficult  to  determine. 

The  disease  consists  essentially  in  a very  active 
cell-proliferation  and  increase.  Whether  the  cel- 
lulitis be  circumscribed  or  diffuse,  similar  changes 
occur;  the  difference  between  them  being  that  in 
the  former  there  is  formed  a limiting  zone  of 
vascular  tissue  resembling  graDulation-material, 
which  is  absent  when  the  inflammation  is  diffuse. 
There  are  otherwise  no  anatomical  differences. 
When  cellular  tissue  inflames,  the  part  swells 
from  the  serofibrinous  exudation  poured  out  from 
the  distended  capillaries ; its  meshes  are  filled 
with  young  round  cells,  partly  by  proliferation  of 
the  connective-tissue  corpuscles,  in  part  by  the 
accumulation  of  wandering  leucocytes ; the  cir- 
culation is  interfered  with  by  the  pressure  of 
the  effusion,  complete  stasis  sometimes  taking 
place.  While  the  cell-increase  is  proceeding, 
the  fibrillar  intercellular  substance  gradually 
disappears,  in  part  by  necrosis,  and  in  part  by 
becoming  liquefied  ; and  the  tissue  is  finally 
transformed  into  pus.  When  this  has  happened 
the  deeper  layers  of  the  skin  disintegrate;  it 
becomes  undermined  and  gradually  thinner; 
necrosis  in  one  or  more  places  follows ; and  the 
pus  mingled  with  shreds  of  dead  cellular  tissue 
escapes,  the  latter  resembling  nothing  so  much 
as  soaked  washleather.  The  pus,  at  first  thin 
and  serous,  subsequently  becomes  laudable, 
i There  is  always  a great  tendency  to  suppi> 


CELLULITIS. 


ration,  the  vitality  of  areolar  tissue  being  very 
low ; but  resolution  sometimes  takes  place  with- 
out formation  of  pus.  The  cells  then  develop 
into  fibrous  material  and  the  ordinary  pheno- 
mena of  a cicatrix  result.  The  consequences  of 
cicatrisation  differ  greatly,  according  to  the  tissue 
or  organ  involved  and  the  extent  of  the  disease ; 
but  essentially  they  are  similar  everywhere.  A 
gradual  contraction  sots  in.  In  external  parts 
we  can  observe  atrophic  changes  taking  place, 
followed  sometimes  by  deformity  or  loss  of 
function,  while  in  the  viscera  the  condition  is 
known  as  cirrhosis.  The  special  tissue  of  an 
organ  or  of  a muscle  cannot  be  reproduced  ; it  is 
replaced  after  an  injury  by  connective-tissue 
cicatrix.  In  such  tissues  as  bone,  tendon,  and 
nerve,  however,  the  cicatrix  wdl  be  converted 
into  the  normal  tissue  of  the  part. 

Symptoms.— The  amount  of  fever  varies  with 
the  extent  of  the  disease  and  the  nature  of  the 
cause ; when  the  cellulitis  is  quite  limited  there 
may  be  little  or  none,  but  deep-seated  or  ex- 
tensive cellulitis  produces  considerable  constitu- 
tional disturbance.  Painful  swelling  of  the 
inflamed  part  will  first  be  observed;  the  skin 
soon  becomes  tense,  red,  and  (edematous,  al- 
though at  the  outset  it  is  sometimes  paler  than 
normal.  The  redness  is  gradually  lost  towards 
the  periphery  of  the  swelling,  and  is  darker,  or 
of  a bluish-red  tint  in  the  centre,  from  the  ob- 
struction to  the  exit  of  blood;  the  swelling  is 
doughy,  inelastic  to  the  touch,  and  pits  on 
pressure.  The  inflamed  region  feels  hard,  the 
induration  ceasing  by  no  well-defined  border.  If 
resolution  occur  all  these  symptoms  subsido.  A 
greater  or  less  amount  of  thickening  of  the  tissue 
may,  however,  persist — often  for  a lengthened 
period — the  parts  gradually  returning  to  their 
normal  state.  Suppuration  is,  however,  the  ride ; 
and  when  it  occurs  the  pain  and  tension  dimi- 
nish, fluctuation  is  felt, — obscure  at  first, — the 
pus  by  degrees  approaching  the  surface,  and 
escaping  spontaneously,  or  by  an  artificial  outlet 
which  may  be  provided.  AVhen  the  inflamma- 
tion is  more  deeply  placed,  especially  when  be- 
neath strong  fascise,  there  will  at  first  be  no 
perceptible  redness  or  swelling  of  tho  skin,  or 
only  a slight  pinkish  hue,  with  some  oedema,  to 
indicate  the  changes  taking  place  beneath  ; and 
fluctuation  may  bo  difficult  or  impossible  to  make 
out  long  after  pus  has  formed;  but  the  pain 
and  fever  are  more  considerable.  This  variety  of 
the  disease  may  also  terminate  in  resolution — 
especially  when  early  and  appropriate  treatment 
has  been  adopted  ; or  in  suppuration.  It  may 
also  become  chronic,  or  relapses  may  take  place 
after  temporary  amendment.  If  the  cause  of 
irritation  be  a slight  one,  but  repeatedly  re- 
newed, permanent  thickenings  or  atrophic  changes 
in  the  tissue  may  result ; or  the  circumscribed 
may  be  converted  into  diffuse  cellulitis.  A very 
intense  irritant  sometimes  induces  gangrene. 
The  same  thing  may  happen  if  a previously 
diseased  tissue  be  attacked,  as  an  anasarcous 
limb ; or  pressure,  associated  with  the  cel- 
lulitis preceding  bed-sores,  may  be  sufficient  to 
cause  it. 

2.  Diffuse  Cellulitis.  Synon.  ; Diffuse  phleg- 
mon ; Pseudo-erysipelas  ; Diphtheria  of  the  cellu- 
lar tissue.  This  is  a severe  disease  attended  by 


229 

general  symptoms  of  a marked  character,  fre- 
quently associated  with  septicaemia,  of  which  il 
may  be  both  a cause  and  an  effect. 

^Etiology. — The  most  frequent  cause  of  diffust 
cellulitis  perhaps  is  some  form  of  septic  poisoning 
In  the  extremities  tho  disease  may  originate 
from  some  trifling  cause,  especially  in  those 
whose  constitution  is  impaired  by  age,  privation, 
or  excess  ; in  the  hand  and  forearm  of  such 
persons  it  is  especially  common  after  wounds  on 
the  finger  or  an  insignificant  whitlow.  In  con- 
valescence from  acute  febrile  diseases,  espe- 
cially typhus  or  typhoid,  a local  phlegmon  is 
sometimes  transformed  into  a diffuse  cellulitis. 

Symptoms. — The  local  symptoms  of  diffuse  cel- 
lulitis resemble  those  of  the  circumscribed  form, 
but  are  more  intense,  and  accompanied  by  severe 
constitutional  disturbance. 

A sudden  chill  with  elevation  of  temperature 
often  ushers  in  the  attack ; the  rigor  may  recur  at 
intervals,  but  sweating  is  unusual,  and  vomiting 
infrequent.  In  the  affected  region  the  patient 
experiences  a sense  of  weight  and  great  disten- 
sion, with  severe  dragging  pain.  AVhen  the 
inflammation  is  deep-seated  the  redness  of  the 
skin  may  not  be  well  marked,  even  after  a con- 
siderable extent  of  tho  cellular  tissue  has 
sloughed.  This  character  is  a very  dangerous  one, 
because  it  leads  to  the  nature  of  the  affection  being 
for  a time  overlooked  and  efficient  aid  postponed. 
AVhen  the  skin  participates,  the  redness  is  darker 
in  hue,  less  sharply  defined,  and  less  easily  dis- 
persed by  the  pressure  of  the  finger  than  in  the 
cutaneous  inflammation  of  erysipelas,  while  it 
soon  becomes  cedematous.  The  affected  part 
feels  brawny,  hard,  and  swollen  throughout,  and 
extremely  tender  and  painful ; sleep  is  impos- 
sible ; any  movement  causes  great  suffering;  the 
fever  is  often  very  high ; the  secretions  are  dimi- 
nished ; and  the  appetite  is  lost.  Sweating  and 
rigor  presently  announce  the  formation  of  matter ; 
the  swelling  becomes  less  prominent  and  more 
soft ; the  skin  is  mottled,  thin,  and  yielding  in 
places ; and  the  fever  and  pain  subside.  Convales- 
cence may  take  place  on  the  evacuation  of  the  pus ; 
or  the  rigor  may  be  renewed,  the  fever  reappear 
or  continue,  and  the  patient  sink  with  symptoms 
of  blood-poisoning.  The  more  deeply  the  in- 
flammation extends  the  more  tedious  is  recovery, 
and  the  more  liable  is  the  patient  to  relapse ; or 
the  muscles,  tendons,  and  adjacent  joints  may 
become  involved  in  the  suppuration ; or  perfora- 
tion of  a dangerous  character  of  neighbouring 
cavities  or  organs  may  take  place.  Suppuration 
consequent  upon  diffuse  cellular  inflammation 
will  sometimes  extend  up  the  fore-arm  to  the 
elbow,  undermine  the  skin,  dissect  the  muscles, 
open  into  the  finger-  and  wrist-joints,  cause 
necrosis  of  tendons,  and  terminate  in  the  loss  of 
the  limb  by  amputation,  or  perhaps  in  loss  of  life 
from  septic  poisoning ; should  recovery  ensue, 
the  limb  is  permanently  crippled  from  the  mat- 
ting together  of  muscles  and  tendons,  the  immo- 
bilization of  the  joints,  and  the  adhesions  that 
take  place  between  tissues  which  should  freely 
glide  over  one  another.  Suppuration  is  the  rule, 
but  under  favourable  circumstances  and  with 
early  and  suitable  treatment  it  may  occasionally 
be  prevented.  Usually  pus  has  already  formed 
when  the  case  comes  under  observation,  and 


221  CELLULITIS. 

the  surgeon  has  only  to  use  his  bistoury  to  limit 
the  spread  of  the  disease. 

The  irregular  cavities  and  sinuses  left  after 
the  evacuation  of  the  dead  tissue  often  suppurate 
for  a long  time,  and  may  thus  induce  amyloid  de- 
generation of  the  viscera.  The  thromboses  which 
form  of  necessity  in  the  smaller  veins  implicated 
in  the  inflamed  area  may  break  down  and  lead  to 
septic  embolism  and  pyaemia.  The  risk  of  this 
complication  is  a serious  and  ever-present  one  in 
these  cases. 

Diagnosis.— Cellulitis  has  chiefly  to  be  diag- 
nosed from  erysipelas.  Erysipelas  may  involve 
the  subcutaneous  tissues,  and  cause  inflammation 
and  suppuration  of  the  connective  tissue,  but  it 
always  begins  in  the  skin,  which  is  more  exten- 
sively affected.  Inflammation  of  the  cellular 
tissue  begins  beneath  the  skin,  where  the  swell- 
ing and  effusion  first  take  place,  the  skin  becom- 
ing involved  later  and  usually  to  a less  extent, 
while  it  may  remain,  at  least  for  some  time, 
almost  entirely  free ; the  redness,  too,  is  less 
bright,  and  more  diffused,  not  presenting  the 
distinct  margins  of  erysipelas,  hut  fading  into 
the  surrounding  parts. 

In  the  later  stages  the  two  diseases  are 
scarcely  distinguishable.  At  first  it  may  be 
difficult  to  decide  whether  the  case  is  one  of 
inflammation  of  the  subcutaneous  cellular  tissue, 
of  the  perimuscular  areolar  tissue,  or  of  that  con- 
nected with  the  periosteum,  or  around  a vein. 
The  greater  the  general  swelling  of  the  limb,  the 
more  considerable  the  fever  and  the  pain,  and  the 
less  the  redness  of  the  skin,  the  more  probable 
is  it  that  the  inflammation  affects  deeply  seated 
structures. 

Prognosis. — The  prognosis  depends  on  the 
extent  of  the  disease  and  the  constitution  of  the 
patient. 

Treatment. — The  local  cause  should  he  re- 
moved, so  far  as  may  he  practicable.  If  the 
wound  he  in  a foul  condition  it  should  be 
rendered  aseptic.  Absolute  rest  to  the  inflamed 
part  is  of  great  importance.  So  long  as  sup- 
puration has  not  occurred,  resolution  is  pos- 
sible. Methodical  pressure,  once  advocated, 
cannot  usually  be  tolerated.  Blistering  is  not 
employed  in  the  acute  form,  hut  may  be  useful 
in  removing  more  chronic  changes.  Cold  applica- 
tions and  ice  abate  pain  and  inflammation,  and 
limit  the  disease,  even  if  they  do  not  prevent 
suppuration.  In  the  more  advanced  stages,  es- 
pecially when  they  tend  to  become  chronic,  they 
are  useless  or  even  dangerous,  from  their  liability 
to  cause  gangrene  in  debilitated  subjects.  Local 
blood-letting  does  not  prevent  suppuration,  and 
is  usually  contra-indicated  by  the  weak  state  of 
the  patient.  When  pus  forms,  or  its  presence 
is  suspected,  a sufficiently  free  outlet  should  be 
provided  for  it  as  soon  as  possible.  Nothing  so 
effectually  checks  the  further  spread  of  the 
disease.  The  incision  should  he  made  at  the 
most  prominent  point.  It  is  better  to  make  a 
number  of  small  incisions,  from  half  an  inch 
to  an  inch  in  length,  than  one  long  one,  which 
is  apt  to  be  followed  by  dangerous  bleeding, 
and  does  net  relieve  the  strangulated  tissues 
so  efficiently.  When  suppuration  is  only  sus- 
pected, incisions  should  nevertheless  be  practised 
without  delay,  without  waiting  for  fluctuation. 


CEREBELLUM,  LESIONS  OF. 

Pus  and  shreds  of  dead  cellular  tissue  should 
be  frequently  washed  out  of  the  wound  with 
an  irrigator.  No  force  should  Le  used  to  remove 
portions  of  dead  tissue  : any  dragging  tends  to 
rupture  the  small  blood-vessels,  and  to  destroy 
the  remaining  connexions  of  the  skin  with  the 
deeper  structures.  Antiseptic  precautions  must 
be  zealously  carried  out. 

When  a joint  becomes  involved,  or  when  the 
patient  is  thoroughly  exhausted  by  the  quantity 
of  discharge,  and  the  tissues  spoiled,  amputation 
is  often  necessary.  Excision  may  be  practised 
if  the  condition  of  the  soft  parts  admits  of  it. 

The  general  treatment  consists  in  giving 
nourishing  food  and  stimulants,  combined  with 
opiates  to  relieve  pain, and  iron,  quinine,  andother 
tonic  medicines.  William  MacCobmac. 

CEPHALALGIA  (K«pa\ri,  the  head,  and 
&\yos,  pain). — Pain  in  the  head.  See  Headache. 

CEPHALHA1MATOMA  (iceQaXh, the  head; 
ai/xa,  blood;  and  d/xbs,  like). — Definition. — 
An  effusion  of  blood  occurring  in  newly-born 
infants,  forming  a tumour  upon  the  head ; situ- 
ated beneath  the  pericranium,  upon  the  surface 
of  the  skull ; or  more  rarely  beneath  the  skull, 
between  it  and  the  dura  mater. 

Description. — This  disease  is  of  very  rare 
occurrence,  and  must  not  be  confounded  with 
the  caput  succedaneum,  which  is  an  effusion  of 
serum  external  to  the  pericranium,  and  is  of  com- 
mon occurrence.  The  blood  is  generally  extra- 
vasated  immediately  beneath  the  pericranium, 
over  one  of  the  parietal  hones,  most  frequently 
the  right,  hut  it  may  occur  over  the  frontal  or 
occipital.  Combined  with  this,  or  arising  inde- 
pendently, hut  of  extreme  rarity,  may  be  an 
effusion  beneath  the  cranium.  The  origin  of 
cephalhsematoma  has  been  attributed  to  a 
variety  of  causes,  but  is  most  probably  due  to 
the  constriction  of  the  margin  of  the  os  uteri 
during  labour.  It  is  generally  observed  some 
hours  or  a day  after  birth,  as  a circumscribed 
swelling,  slightly  tense  and  fluctuating : and  its 
peculiarity  consists  in  a bony  circle  surrounding 
and  limiting  it. 

Diagnosis.  — These  tumours  have  been  mis- 
taken for  hernia  cerebri,  but  their  situation  over 
the  bone  away  from  the  fontanelles,  the  absence 
of  pulsation,  and  the  existence  of  fluctuation  in 
cephalhasmatoma  should  prevent  confusion. 

Prognosis. — Generally  the  blood  becomes  ab- 
sorbed, but  occasionally  suppuration  occurs,  or 
the  bone  may  become  necrosed ; if  beneath  the 
skull,  serious  consequences,  including  idiocy,  may 
ensue. 

Treatment. — As  a rule,  cephalhasmatoma  is 
not  to  he  interfered  with.  If  suppuration  take 
place  the  pus  must  he  evacuated. 

Clement  Godson 

CEHATITIS.  See  Keratitis. 

CEREBELLUM,  Lesions  of. — The  cere- 
bellum is  liable  to  the  same  diseases  as  the 
brain  and  nerve-centres  generally,  such  as  hae- 
morrhage, abscess,  various  forms  of  degenera- 
tion, tumours,  &c.  The  nature  of  the  patholo- 
gical condition  is  to  he  determined  by  the 
symptoms  peculiar  to  each,  so  far  as  this  is  pos- 
sible. Its  locality  in  the  cerebellum  is  to  bo 
diagnosticated,  first,  by  certain  symptoms  which 


CEREBELLUM,  LESIONS  OF.  225 


fire  due  to  the  cerebellar  lesion  as  such,  -which 
may  be  termed  the  direct  symptoms ; and.  secondly, 
by  those  symptoms  which  depend  more  on  the 
influence  exerted  by  the  lesion  on  neighbouring 
or  subjacent  centres  and  structures.  These 
latter  may  be  termed  the  indirect  symptoms. 

It  is  by  no  means  easy  to  separate  these 
symptoms  from  each  other,  and  to  say  how  much 
is  due  to  interference  with  the  functions  of  the 
cerebellum,  and  how  much  to  interference  with 
the  functions  of  other  parts.  There  are  few 
diseases  which  have  a purely  local  organic  or 
functional  limitation.  Hence,  in  order  to  arrive 
at  the  symptoms  peculiar  to  cerebellar  lesions, 
it  is  necessary  to  exclude  all  pathological  affec- 
tions which  in  their  very  nature  affect  the  whole 
of  the  intracranial  centres,  e.g.  tumours,  menin- 
gitis, &c.  The  most  satisfactory  conclusions 
from  a pathological  point  of  view  are  to  be 
drawn  from  cases  of  atrophy  or  degeneration  of 
the  cerebellum,  and,  from  a physiological  point 
of  view,  from  the  results  of  experimental  lesions 
of  this  organ  in  the  lower  animals. 

The  evidence  from  these  two  sources  is  mu- 
tually supporting. 

Diiiect  Symptoms. — The  characteristic  symp- 
toms of  cerebellar  disease  are  disorders  of 
equilibrium,  shown,  on  attempts  at  locomotion, 
in  a reeling  or  staggering  gait  (titubation),  and 
a continual  tendency  to  stumble  or  fall  over  the 
most  trifling  obstacle,  or  on  hurried  movements. 

These  symptoms  may  be  confounded  with 
locomotor  ataxy,  but  careful  observation  will 
show  that  in  cerebellar  disorders  there  is  no 
true  ataxy  of  co-ordination.  The  movements  are 
quite  co-ordinated  with  each  other,  and  are  such 
as  would  instinctively  be  made  to  prevent  fall- 
ing, or  to  preserve  the  equilibrium  ; and  have 
none  of  the  precipitate,  irregular,  and  sprawling 
character  seen  in  ataxy.  They  are  not  specially 
intensified  on  closure  of  the  eyes,  which  is  such 
a marked  feature  in  ataxy.  Nor  are  they  accom- 
panied by  any  of  the  sensory  affections  of  ataxy, 
whether  in  the  form  of  pains  or  anaesthesia. 

There  is  no  true  motor  paralysis  in  cere- 
bellar disease  as  such,  and  the  various  volitional 
movements  of  the  limbs  can  be  carried  out  per- 
fectly well  in  the  recumbent  posture.  Sensation, 
general  and  special,  is  not  directly  affected  in 
cerebellar  disease.  Nystagmus  and  strabis- 
mus have  been  observed,  more  particularly  in 
connection  with  lesion  of  the  cerebellar  peduncles. 
Defects  of  articulation  have  been  noticed,  but  it 
is  very  doubtful  whether  they  should  be  regarded 
as  direct  symptoms. 

It  is  to  be  noticed  that  in  some  cases  of 
slowly  progressive  degeneration  of  the  cere- 
bellum, the  disorders  of  equilibrium  are  not 
observed  to  any  marked  extent,  an  occurrence  to 
be  accounted  for  in  all  probability  by  compen- 
satory action  on  the  part  of  other  centres. 

Ixdtrect  Symptoms. — Pain  in  the  head , more 
particularly  at  the  back,  though  not  constantly 
situated  there,  is  frequently  associated  with 
organic  disease  of  the  cerebellum. 

Vomiting  is  also  very  frequently  observed, 
perhaps  more  constantly  than  in  connection  with 
diseases  of  other  parts  of  the  brain.  There  is, 
however,  no  reason  to  regard  this  as  due  to 
cerebellar  disease  as  such.  It  is  probably  due 

15 


to  indirect  effects  on  the  medulla.  Asa  general 
rule,  diseases  tending  to  encroach  on  the  space 
of  theposterior  fossa  or  to  increase  the  pressure 
on  this  region,  have  a similar  effect. 

Hemiplegia  is  not  uncommon  in  connection 
with  cerebellar  disease,  and  more  particularly 
in  cases  of  tumour  or  haemorrhage  into  the 
lateral  lobe  of  the  cerebellum.  The  hemiplegia 
is  on  the  side  opposite  the  lesion.  This  does 
not  prove  that  the  hemiplegia  is  due  to  tha 
destruction  of  the  cerebellar  lobe,  or  that  the 
cerebellar  lobes  have  cross  relations  with  the 
limbs.  Experimental  physiology  and  anato- 
mical investigations  tend  to  show  that  the  cere- 
bellar lobes  are  functionally  related  to  the 
motor  tracts  on  the  same  side.  This  is  also 
borne  out  by  the  fact  that  atrophy  of  the  lateral 
lobe  of  the  cerebellum  follows  disease  and  de- 
generation of  the  opposite  cerebral  hemisphere. 
The  hemiplegia,  from  cerebellar  disease  is, 
therefore,  in  all  probability,  due  to  compression 
or  some  affection  of  the  subjacent  motor  tracts, 
which  decussate  at  the  pyramids.  The  fact  that 
it  occurs  chiefly  when  the  disease  is  limited  to 
the  lateral  lobe  is  what  might  be  expected  on 
anatomical  grounds. 

Affections  of  sensation,  common  and  special, 
have  been  observed  in  cases  of  cerebellar  dis- 
ease. Diminution  of  tactile  sensation  on  the 
opposite  side  of  the  body,  when  the  disease  is 
situated  in  the  lateral  lobe,  is  to  be  accounted 
for  in  the  same  way  as  the  motor  paralysis.  As 
regards  the  special  senses,  affections  of  sight 
have  been  most  frequently  noted.  Sight  is  cer- 
tainly not  abolished  by  destruction  of  the  cere- 
bellum in  the  lower  animals,  and  when  blindness 
occurs  in  man  in  connection  with  diseases  of 
this  organ,  it  is  either  due  to  implication  of 
the  corpora  quadrigemina,  functionally  or  or- 
ganically, or  to  secondary  degeneration  in  the 
optic  tracts,  as  the  result  of  increased  intracranial 
pressure  or  descending  optic  neuritis. 

A special  feature  of  tumours  of  the  cerebellum, 
more  especially  of  the  middle  lobe,  is  a tonic 
rigidity  of  the  muscles  of  the  back  of  the  neck, 
with  retraction  of  the  head,  associated  frequently 
with  flexion  of  the  forearms  and  extension  of  the 
lower  extremities  and  pointing  of  the  toes.  In 
these  cases  also,  psychical  affections,  more  par- 
ticularly mental  hebetude  or  stupor,  occur  as 
the  result  of  secondary  dropsy  of  the  ventricles, 
caused  by  pressure  on  the  veins  of  Galen.  Tha 
symptoms  then  become  those  of  hydrocephalus. 

Haemorrhage  into  the  middle  lobe  of  the  cere- 
bellum, in  addition  to  the  ordinary  symptoms  of 
apoplexy,  has  been  frequently  found  to  cause 
vascular  excitement  of  the  genital  organs — in 
the  male  marked  priapism.  This  symptom,  of 
which  several  cases  were  first  reported'by  Serres, 
led  this  observer  to  modify  the  view  of  Gall 
that  the  cerebellum,  as  a whole,  was  related  to 
the  sexual  instinct,  and  to  regard  the  middle 
lobe  only  as  having  any  such  function.  The 
facts,  however,  are  susceptible  of  a totall}- 
different  interpretation,  and  one  more  in  har- 
mony with  other  data  of  physiology  and  pa- 
thology. It  has  been  fottnd  experimentally  by 
Segalas  and  by  Eckhaid  that  irritation  of  the- 
posterior surface  of  the  medulla  and  pons  gives 
rise  to  vascular  excitement  of  the  generative 


220  CEREBELLUM,  LESIONS  OF 
organs,  and  hence  the  symptoms  in  cases  of 
haemorrhage  into  the  middle  lobe  are  to  be 
ascribed  to  irritation  of  this  region.  This  fact 
also  explains  the  absence  of  the  symptoms  when 
the  haemorrhage  occurs  into  the  lateral  lobes. 
There  is  absolutely  no  evidence  of  the  slight- 
est value  in  support  of  Gall’s  hypothesis.  The 
facts  of  clinical  medicine  go  a considerable  way 
in  diametrical  opposition  to  it,  if  they  are  not 
themselves  sufficient  entirely  to  overthrow  it. 

Cerebellar  Peduncles.  — Respecting  the 
effects  of  disease  of  the  restiform  tracts  or  in- 
ferior cerebellar  peduncles  we  have  no  definite 
knowledge. 

Cases,  however,  are  on  record  in  which  lesions 
have  been  found  involving  principally  either 
the  superior  or  middle  cerebellar  peduncles. 
The  symptoms,  in  the  main,  agree  with  those 
observed  by  Magendie  on  section  of  the  middle 
peduncle  in  the  lower  animals.  The  chief  effect 
of  this  lesion  was  to  cause  an  irresistible  ten- 
dency to  roll  over  towards  the  side  of  lesion. 
Together  with  this  rotatory  disturbance  of  the 
equilibrium,  a peculiar  distortion  of  the  optic 
axes  was  observed,  the  eye  on  the  side  of  lesion 
being  directed  downwards  and  inwards,  the 
other  looking  upwards  and  outwards. 

In  a case  described  by  Curschmann  ( Deutsch . 
Archiv  f.  Klin.  Med.  xii.  356),  along  with 
appearances  of  basilar  meningitis,  wnich  some- 
what complicate  the  case,  there  was  found  a 
focus  of  softening,  surrounded  by  capillary 
haemorrhages  in  the  right  superior  cerebellar 
peduncle.  The  symptoms  observed  in  this  case 
were  a rotatory  distortion  to  the  right  side,  to 
which  position  the  patient  invariably  returned 
when  resistance  to  this  movement  was  with- 
drawn. There  was  no  motor  paralysis,  nor  was 
there  any  distortion  of  the  optic  axes. 

A ease  has  been  put  on  record  by  Nonat 
( Comptcs  Bendus,  181)  of  apoplectic  extrava- 
sation into  the  right  middle  peduncle  of  the 
cerebellum  and  right  cerebellar  hemisphere. 
In  this  case  the  head  and  trunk  were  twisted 
towards  the  right  side,  and  the  ocular  symp- 
toms were  also  present,  the  eyes  being  immovable 
sa  a position  of  skew  deviation.  Other  cases 
are  on  record  in  which  the  cerebellar  peduncles 
have  been  involved  in  more  extensive  lesions ; 
but  the  symptoms,  though  not  opposed  to  those 
above  related,  are  incapable  of  differential 
analysis.  The  special  diagnostic  symptoms, 
therefore,  of  lesion  of  the  cerebellar  peduncles 
are  what  are  frequently  termed  ‘ forced  move- 
ments ’ ( Zwangsbewegungcn ),  or  distortions  of 
the  normal  axis  of  the  trunk.  The  exact  direc- 
tion of  the  distortion,  in  consequence  of  lesion 
specially  limited  to  one  or  other  peduncle  on  the 
right  or  left  side  respectively,  is  somewhat 
doubtful,  though  as  a rule  it  has  been  found  to- 
wards the  side  of  lesion.  ' Much,  however,  will 
depend  on  w hether  the  lesion  is  of  an  irritative 
or  inflammatory,  or  of  a destructive  character. 
A lesion  of  an  irritative  nature,  though  occupy- 
ing the  same  position  as  a destructive  lesion, 
would  exactly  reverse  the  direction  of  the  dis- 
tortion of  the  head  and  trunk.  D.  Ferrier. 

CEREBRAL  ABSCESS.  See  Brain,  Ab- 
bess of. 


CEREBRO-SPINAL  FEVER. 

CEREBRAL  APOPLEXY.  Afofijexv, 

Cerebral. 

CEREBRAL  ARTERIES,  Diseases  of. 

See  Brain,  Vessels  of.  Diseases  of. 

CEREBRAL  HEMORRHAGE.  See 
Brain,  Haemorrhage  into. 

CEREBRITIS. — Inflammation  of  the  brain- 
substance.  See  Brain,  Inflammation  of. 

CEREBRO-SPINAL  FEVER. — Stnon.  : 
Epidemic  Cerebro-spinal  Meningitis  ; The  Black 
Sickness  (popular,  Dublin) ; Fr.  Meningite  cerehro- 
spinale  epidemique  ; Ger.  Cerebral-typhus  ; Epi- 
demische-meningitis. 

Definition. — An  acute  epidemic  febrile  dis- 
ease, characterised  by  sudden  invasion,  with 
extreme  nervous  shock,  vomiting,  excessive  pain 
referred  to  the  back  of  the  neck  and  spine,  spas- 
modic contraction  of  muscles,  excessive  sensibi- 
lity of  the  skin,  and  frequently  delirium  ; accom- 
panied by  purpuric  eruptions,  either  circum- 
scribed, raised,  hard,  and  shotty  to  the  feel, 
or  extensive  purpuric  spots  or  patches,  fre- 
quently accompanied  by  vesicular  eruptions  usu- 
ally of  herpetic  but  sometimes  of  a pemphigoid 
character,  and  frequently  purulent  inflammation 
of  the  eyes.  Post  mortem  there  aro  found : 
inflammation  of  the  membranes  of  the  brain  and 
spinal  cord,  especially  of  the  arachnoid,  with 
deposit  of  white,  yellow  or  greenish-yellow 
lymph  upon  the  surface  of  the  arachnoid,  espe- 
cially at  the  base  of  the  brain  and  anterior 
portion  of  the  modulla  oblongata  and  spinal  cord, 
and  effusion  of  serum  into  the  ventricles  and 
sub-arachnoid  spaces. 

JEtiolog y.  — Age.  — The  d isease  usually  attacks 
those  approaching  the  age  of  puberty  or  in  earlv 
adult  life  ; it  is  seldom  met  with  after  thirty-five 
years,  and  is  very  rare  after  the  age  of  forty. 
It  is  not  unfrequent  in  young  children. 

Sex. — It  is  much  more  frequent  in  males  than 
females ; robust  males  between  the  ages  of 
fifteen  and  thirty  are  its  favourite  victims. 

Occupation. — It  seems  specially  to  attack 
young  recruits  in  the  army,  as  was  the  case  in 
the  French  epidemics.  In  Dublin  it  was  specially 
severe  among  the  recruits  of  the  Roval  Irish 
Constabulary  stationed  in  the  police  barracks  in 
the  Phcenix  Park.  There  does  not  seem  to  be 
any  other  occupation  which  predisposes  to  the 
disease.  Excessive  fatigue  seems  to  predispose 
to  the  diseaso ; it  has  arisen  after  a hard  day's 
hunting,  foot-racing,  long  walks,  dancing,  or  in 
children  exhausted  from  out-door  play. 

Season  and  Climate. — It  is  widely  distributed 
in  the  temperate  zone.  It  prevails  moro  in  cold 
than  in  hot  weather ; in  Iceland  it  has  usual lv 
prevailed  in  winter  and  early  spring. 

General  Sanitary  Conditions. — It  seems  to  be 
less  influenced  than  any  other  epidemic  affection 
by  general  sanitary  conditions. 

Communicability. — It  is  generally  believed  not 
to  be  contagious  ; a few  doubtful  cases  of  con- 
tagion have  been  recorded  ; except,  however,  in 
cases  where  it  has  appeared  as  an  epidemic 
among  recruits,  there  are  few  instances  of  more 
than  one  case  arising  in  any  particular  house  or 
circumscribed  locality. 

Epidemic  Influence. — The  disease  is  undoubt 
edly  epidemic. 


CEREBRO-SPINAL  FEVER. 


Unwholesome  Food. — It  has  been  suggested 
that  the  disease  owes  its  origin  to  tho  use  of 
breadstuff's  made  from  diseased  grain. 

Anatomical  Charactees. — Cadaveric  rigidity 
is  well  marked;  large  purpuric  patches  form 
after  death  even  in  cases  where  there  were  no 
purpuric  symptoms  during  life;  in  some  cases 
the  whole  body  has  turned  black.  On  incision 
a large  quantity  of  dark,  tarry-looking  blood 
exudes  ; the  muscles  are  darker  than  usual,  and 
in  prolonged  cases  much  weakened  and  wasted. 
There  is  increased  vascularity  of  tho  scalp  ; the 
cerebral  sinuses  are  much  distended  with  dark 
blood  ; serum  is  found  in  the  sub-arachnoid  spaces 
and  ventricles  ; all  the  membranes  of  the  brain 
may  be  moro  or  less  congested,  the  arachnoid 
being  always  extremely  vascular  and  opaque  from 
deposits  of  lymph — this  opacity  varies  from  slight 
milkiness  to  thick  and  denso  deposits.  The  most 
marked  intracranial  lesion  is  the  white-yellowish 
or  yellowish-green  ‘ fibrino-purulent  ’ deposit 
found  at  the  base  of  tho  brain.  This  deposit 
varies  somewhat  with  the  duration  of  the  disease  ; 
in  cases  which  die  early  the  deposit  is  usually 
slight,  whitish,  and  soft ; in  those  which  live  for 
a week  or  so  tho  deposit  is  yellowish  or  greenish ; 
in  prolonged  eases  tho  deposit  is  more  white 
and  pure,  tho  effused  serum  greater  in  quantity, 
and  the  vascular  fulness  less.  The  origins  of 
the  nerves  seem  to  be  buried  in  and  compressed 
by  the  deposit.  The  brain-substance  itself  is 
more  vascular  than  normal,  but  not  otherwise 
altered.  In  tho  spinal  cord  tho  lesions  are  similar 
to  those  found  in  the  brain  and  its  membranes. 
In  some  cases  purulent  infiltration  of  the  eye- 
ball and  effusion  into  the  joints  have  been  met 
with.  The  lungs,  liver,  and  spleen  have  been 
found  much  congested  in  many  cases. 

Symptoms. — The  patient  is  usually  attacked 
suddenly  when  in  apparently  vigorous  health  by 
faintness,  vomiting  of  greenish  matter,  and  in- 
tense pain  referred  especially  to  the  back  of  the 
head  and  neck ; the  extremities  become  cold ; the 
patient  becomes  insensible  and  sometimes  con- 
vulsed; the  limbs  become  rigid.  On  recovering 
from  the  collapse,  the  patient  complains  of  great 
pain  in  the  head,  back  of  neck,  and  along  the 
spine ; the  head  is  drawn  back,  so  as  to  be  almost 
at  a right  angle  with  tho  spine  ; the  whole  back 
is  sometimes  arched,  as  in  tetanus,  the  muscles 
become  rigid,  and  the  skin  excessively  sensitive  ; 
neuralgic  pains  are  also  complained  of  in  all  parts 
of  the  body.  In  most  of  the  severe  cases  erup- 
tions appear  within  the  first  twenty-four  hours  ; 
the  eruption  usually  appears  first  on  the  legs, 
and  is  frequently  confined  to  the  lower  extremi- 
ties ; the  spots  are  usually  black,  raised,  about 
a line  in  breadth,  and  feel  like  a grain  of  shot 
under  the  skin ; sometimes  these  raised  spots 
are  surrounded  by  a dark  purplish  areola ; in 
most  cases  large  purpuric  patches  of  many 
inches  in  extent  form  on  various  parts  and, 
sometimes  coalescing,  cover  the  entire  body. 
Vesicular  eruptions  are  also  common ; these 
usually  have  the  character  of  herpes  zoster, 
and  are  most  frequent  on  the  face,  neck,  and 
shoulders.  The  herpetic  eruptions  are  met  with 
»s  frequently  in  mild  as  in  severe  eases.  Pem- 
phigus sometimes  appears  in  the  advanced  stages 
of  the  disease.  When  reaction  sets  in,  the  tem- 


227 

perature  is  found  to  have  risen  to  from  100°  to 
103°  or  104°  Fahr.  In  many  cases  the  tem- 
perature never  rises,  and  the  patient  dies  in  the 
collapse ; the  respiration  becomes  of  a sighing 
character ; the  pulse  rises  to  about  120,  and  has 
a peculiar  jerking  character,  giving  a sharp  up 
stroke  to  a sphygmographic  tracing.  The  fore- 
going symptoms  are  very  variable  ; any  one,  or 
even  a considerable  number  of  them,  may  be 
absent  throughout  the  whole  course  of  the  case. 

Complications  and  Sequels.  — Complica- 
tions connected  with  the  nervous  system  are  tho 
most  common ; paralysis  of  one  or  more  limbs 
is  common,  of  a hemiplegic  character,  and 
most  frequently  attacking  the  arm ; deafness 
is  not  very  common,  but  has  been  met  with  in 
several  cases,  and  sometimes  becomes  perma- 
nent. The  eye-complications  are  among  the 
most  frequent  and  most  serious.  The  eye  is 
frequently  attacked  with  a low  form  of  inflam- 
mation, terminating  in  purulent  infiltration  of 
tho  whole  or  part  of  the  organ  ; the  cornea  is 
more  frequently  attacked  than  any  other  por- 
tion ; and  this  sometimes  giving  way,  the  whole 
contents  of  the  globe  escape,  causing  perma- 
nent loss  of  sight.  The  sight  is  also  often  per- 
manently impaired  by  iritis,  or  opacity  of  the 
cornea.  In  many  cases,  however,  the  inflamma- 
tion completely  subsides.  It  is  remarkable  that 
it  is  the  right  eyo  which  is  usually  attacked, 
seldom  that  both  eyes  are  affected,  and  scarcely 
ever  the  left  eye  alone.  Acute  inflammation  of 
the  larger  joints  is  a frequent  complication  in 
some  epidemics ; this  often  terminates  in  puru  - 
lent  effusion  into  the  joints.  Haemorrhages 
are  frequent  in  the  more  malignant  forms,  and 
are  almost  always  present  in  cases  where  the 
purpuric  blotches  are  of  large  extent:  these 
haemorrhages  have  occurred  from  the  nose, 
uterus,  bowels,  kidneys,  and  ears  in  about  the 
foregoing  order  of  frequency.  Gangrene  is  occa- 
sionally met  with,  and  the  cases  in  which  it 
occurs  are  usually  fatal.  In  some  cases  toes 
have  been  lost  and  the  patient  recovered ; the 
purpuric  patches  have  also  sloughed  without 
serious  danger  to  the  patient's  life. 

Diagnosis. — The  disease  is  liable  to  bo  con- 
founded with  typhus  fever  on  account  of  the 
petechial  rash,  but  is  distinguished  from  typhus 
by  the  rash  appearing  suddenly  without  any 
previous  mottling  of  the  skin.  The  nervous  symp- 
toms also  distinguish  it  from  typhus,  although 
in  a case  of  typhus  complicated  with  cerebro- 
spinal meningitis  the  diagnosis  is  extremely 
difficult,  and  may  be  impossible.  It  is  distin- 
guished from  purpura  hamorrhagica  by  the  in- 
tensity of  the  fever  and  the  localised  nervous 
symptoms.  The  malignant  cases  are  more  likely 
to  be  mistaken  for  malignant  scarlatina  than  for 
any  other  disease,  and  must  be  distinguished 
therefrom  by  the  rash,  sore  throat,  and  nervous 
affections.  In  some  cases  it  has  been  indistin- 
guishable from  malignant  scarlatina,  especially 
where  death  occurred  within  twenty-four  hours, 
and  both  diseases  were  epidemic  at  the  time. 

Prognosis,  Duration,  Termination,  and 
Mortality. — The  prognosis,  duration,  etc.,  of 
tha  disease  depend  much  upon  the  form  the 
affection  assumes,  and  for  convenience  we  may 
divide  the  disease  into  the  following  forms; — 


228  CEREBRO-SPINAL  FEVER. 

1st.  Cases  of  a very  mild  form,  terminating  in 
recovery;  the  duration  being  usually  from  one 
to  three  weeks. 

2nd.  Cases  of  a very  severe  form,  setting  in 
suddenly;  the  symptoms  being  very  violent  and 
well  marked,  accompanied  by  purpuric  spots 
and  blotches,  with  a tendency  to  haemorrhages, 
with  deep  collapse  and  coma ; usually  terminating 
fatally  in  from  a few  hours  to  three  days. 

3rd.  Cases  of  medium  severity,  where  all  the 
nervous  symptoms  set  in  with  less  suddenness 
than  in  the  second  class  of  cases,  purpuric 
blotches  not  being  usually  present,  and  no  hae- 
morrhages. These  usually  yield  to  treatment, 
and  terminate  in  recovery  in  from  two  to  six 
weeks. 

4th.  Cases  which  set-in  either  in  a mild  or  in 
a severe  form,  but  in  which  on  the  subsidence 
of  the  fever  the  strength  does  not  return,  con- 
valescence is  retarded  or  ceases  altogether,  and 
the  patient  falls  into  a general  atrophic  condi- 
tion, and  usually  dies  in  from  three  to  six  months 
of  marasmus. 

By  deciding  to  which  of  the  above  classes  tire 
case  belongs,  the  prognosis  will  be  to  a great 
extent  determined.  The  chief  indication  of 
danger  is  the  early  appearance  of  purpuric  and 
haemorrhagic  conditions. 

The  mortality  in  cerebro-spinal  fever  is  very 
high — probably  on  an  average  about  60  per  cent. 
In  some  of  the  American  epidemics  it  is  placed 
as  high  as  75  per  cent.  Among  the  Irish  con- 
stabulary it  roached  80  per  cent.  Like  other 
epidemic  diseases  the  mortality  is  highest  at  the 
commencement  of  the  epidemic.  It  is  most  fatal 
about  the  age  of  twenty,  and  less  so  under 
fifteen  years. 

Treatment. — The  treatment  in  the  early  stage 
must  be  directed  to  recovering  the  patient  from 
the  collapse.  This  is  best  done  by  the  application 
of  heat,  the  administration  of  small  quantities  of 
stimulants  or  stimulating  enomata,  and  the  appli- 
cation of  sinapisms  over  chest  and  back.  In  the 
next  stage  of  the  disease  attention  must  be  almost 
altogether  directed  to  allaying  the  spinal  irrita- 
tion, and  promoting  the  absorption  of  tho  effused 
matters.  The  extreme  irritation  will  be  best 
diminished  by  the  use  of  bolladonna  and  bromide 
of  potassium.  The  pain,  which  is  extreme,  will 
yield  best  to  frequent  and  considerable  doses  of 
opium  ; indeed  many  physicians  rely  altogether 
on  opium  as  the  curative  agent.  With  a view 
of  promoting  absorption  of  the  effused  matters, 
mercury  and.  iodide  of  potassium  have  been 
chiefly  relied  upon.  In  the  more  sthenic  cases 
calomel  may  be  employed  with  benefit  in  small 
and  repeated  doses.  The  disease  being  usually 
of  an  asthenic  type,  mercury  will  seldom  he  well 
borne,  and  iodide  of  potassium  should  he  pre- 
ferred. Leeches  applied  to  the  hack  of  the  neck, 
behind  the  ears,  or  to  the  temples,  produce 
great  relief  of  the  excessive  pain  in  the  head 
and  upper  part  of  tho  spine.  The  application 
of  ice  to  tho  head  and  spine  temporarily  allays 
pain,  hut  there  is  little  evidence  of  permanent 
benefit  being  derived  therefrom.  In  prolonged 
cases  blisters  applied  along  the  spine  have  been 
favourably  spoken  of.  The  local  complications 
must  he  treated  as  they  arise,  and  according 
to  general  principles  applicable  in  each  case. 


CHANCE  OF  LIFE. 

Stimulants  are  required  in  considerable  quan- 
tity in  a very  large  number  of  the  cases  which 
present  adynamic  symptoms. 

T.  W.  Grim. siiaw. 

CHALAZION  (x°-^aCa,  hail). — A small  en- 
cysted tumour  of  the  eyelids,  colourless  and 
transparent,  and  resembling  a hailstone. 

CHALK-STONES. — This  name  is  applied 
to  the  deposits  which  are  formed  in  connexion 
with  the  gouty  diathesis,  especially  in  the  joints. 
They  are  thus  denominated  from  their  appear- 
ance and  physical  characters,  in  which  they  more 
or  less  resemble  chalk ; hut  in  their  chemical 
composition  they  are  entirely  different,  consist- 
ing mainly  of  urate  of  soda.  See  Gout. 

CHALYBEATE  WATER S (chalybs,  steel ). 
— Mineral  waters  which  contain  iron.  See 
Mineral  Waters. 

CHANCRE  (Fr.  chancre). — Hard  chancre 
is  the  initial  manifestation  of  syphilis.  See 
Syphilis.  Soft  chancre,  see  Venereal  Disease. 

CHANGE  OP  LIFE. — Synon.:  Climacteric 
epoch  ; Sexual  involution  ; Fr.  Menopause.  Ger. 
Mcnstruationscnde. 

Definition. — The  time  of  life  in  a woman  when 
the  functions  of  the  uterus  and  ovaries  cease, 
menstruation  terminating,  — a period  when 
disease  of  these  organs  is  especially  prone  to 
occur,  and  when  various  constitutional  disturb- 
ances are  almost  certain  to  arise. 

Anatomical  Characters. — Great  changes  oc- 
cur in  the  sexual  organs — the  ovaries  lose  their 
smooth  outline,  and  after  a while  become  shri- 
velled up,  occasionally  only  a trace  of  them  re- 
maining; the  Fallopian  tubes  diminish  in  size, 
and  sometimes  become  obliterated ; tho  walls 
of  the  uterus  atrophy,  its  cavity  becomes  much 
smaller,  and  the  cervix  disappears  altogether. 

Symptoms.  — The  term  ‘change  of  life’  is 
used  among  women  very  widely  to  signify  every- 
thing which  affects  them  at  this  critical  time.  It 
is  so  rare  for  the  transition  from  activity  to  in- 
activity to  take  place  without  some  disturbance 
locally,  or  constitutionally,  that  women  are  apt 
to  neglect  seeking  advice  for  symptoms  which 
should  demand  careful  treatment,  believing  as 
they  do  that  it  is  natural  to  suffer  in  such  ways 
at  ‘ the  change.’  There  is  no  fixed  period-  for 
the  climacteric  epoch,  though  roughly  it  may  be 
said  to  occur  between  the  ages  of  forty-five  and 
fifty.  Certain  causes  are  apt  to  determine  the 
time — amongst  these  are  parturition  and  lacta- 
tion, febrile  attacks,  such  as  typhus  or  acute 
rheumatism,  profuse  haemorrhages,  fright,  ike. 

The  symptoms  vary  much.  In  some  women 
the  change  is  abrupt,  menstruation  ceasing  all 
at  once  after  perfect  regularity ; in  others,  and 
more  frequently,  the  change  is  prolonged,  the 
catamenia  beiug  irregular  for  many  months, 
and  varying  as  to  periodicity  and  quantity. 
Frequently,  after  a long  interval,  a profuse  flow 
with  clots  occurs,  and  this  is  very  often  attri- 
buted to  a miscarriage.  This  loss  is  frequently 
beneficial,  and  if  it  do  not  take  place,  or  relief 
he  derived  from  vicarious  discharges,  such  as 
bleedings  from  hsemorrhoids,  the  excess  of 
blood  gives  rise  to  headaches,  flushes,  vertigo 
and  a host  of  other  unpleasant  symptoms.  The 


CHANGE  OF  LIFE. 

balance  between  the  nervous  and  circulatory 
systems  is  upset ; irritability  of  temper,  hyper- 
sensitiveness  and  all  sorts  of  fancies  arise,  or  de- 
pression sometimes  amounting  to  melancholia  en- 
sues. If  germs  of  disease  exist,  the  uterus  is  espe- 
cially prone  at  such  time  to  develop  them,  so  that 
carcinoma,  fibroid  disease,  and  polypus  frequently 
present  their  first  symptoms  at  this  epoch.  The 
importance,  therefore,  of  an  early  examination 
cannot  be  too  forcibly  dwelt  on,  or  the  mischief 
of  delay  from  considering  the  abnormal  condition 
as  typical  of  ‘ the  change  of  life,’  as  a natural 
consequence,  which  will  therefore  right  itself. 
At  these  times  pruritus  of  the  vulva,  vascular 
growths  at  the  orifice  of  the  urethra,  and  cuta- 
neous eruptions  are  especially  likely  to  occur. 
There  is  a tendency  to  grow  fat,  and  become 
coarse;  frequently  hairs  appear  on  the  face.  The 
breasts  often  become  very  large  and  pendulous, 
and  this  with  the  increase  in  the  size  of  the  ab- 
domen from  flatus,  and  the  deposition  of  fat  in 
its  walls,  together  with  the  cessation  of  menstru- 
ation, not  infrequently  gives  rise  to  the  supposi- 
tion of  pregnancy.  To  this  imaginary  state  the 
term  Pseudocyesis  has  been  applied,  and  it  is 
often  almost  impossible  to  set  aside  the  opinion 
of  the  woman  regarding  her  supposed  condition. 
The  headaches,  neuralgia,  loss  of  memory  and 
nervous  symptoms  appear  to  be  due  to  disturb- 
ance in  the  ganglionic  system  of  nerves,  with 
which  the  uterus  and  ovaries  are  largely  sup- 
plied. If  insanity  arise  the  most  common  form 
't  assumes  is  hypochondriasis  or  melancholia. 

Treatment. — This  must  be  directed  to  regu- 
lating the  secretions.  Generally  constipation, 
previously  troublesome,  becomes  aggravated ; and 
portal  congestion  frequently  occurs.  Saline  pur- 
gatives are  especially  beneficial,  and  these  may 
be  judiciously  administered  in  the  form  of  mine- 
ral waters,  such  as  the  Hunyadi  Janos,  or  Fried- 
richshall.  Blue  pill  with  aloes  is  often  very 
useful.  The  headaches  and  reflex  nervous  symp- 
toms may  be  best  combated  by  the  administration 
of  bromide  of  potassium,  and  this  drug  appears 
to  act  as  a direct  sedative  to  the  sexual  organs, 
besides  diminishing  the  amount  of  blood  deter- 
mined to  them.  Occasionally,  bleeding  from  the 
arm  or  cupping  gives  great  relief.  Attention 
must  above  all  be  paid  to  the  diet.  It  should  be 
plain  and  unstimulating ; beer  and  spirits  should 
be  prohibited,  and  only  light  wines,  if  anjr,  allowed. 
Tepid  baths  are  useful.  Late  hours,  heated  rooms, 
and  excitement  of  all  kinds  should  be  avoided. 
If  local  troubles  arise,  they  must  be  treated  ac- 
cording to  their  indications ; as  a rule,  abstracting 
blood  from  the  uterus  does  harm,  but  leeches  to 
the  anus  are  sometimes  beneficial.  Ic  is  clearly 
impossible  to  map  out  any  empirical  line  of  treat- 
ment for  a condition  in  which  the  symptoms  are 
so  variable.  Clement  Godson. 

CHAPPED  NIPPLES.  See  Breast,  Dis- 
eases of ; and  Nipple,  Diseases  of. 

CHAPS. — Svnon.  ; Rhagades. — Cracks  or 
fissures  of  the  skin  occur  where  the  integu- 
ment has  become  hardened  by  infiltration,  as  in 
the  erythema  of  the  hands  and  wvists  of  cold 
weather,  in  chronic  eczema,  psoriasis  and  lepra 
vulgaris.  The  treatment  for  chaps  consists  in 


CHELOID.  22!> 

protection  from  the  atmosphere ; careful  dry- 
ing after  the  hands  have  been  washed  or  wetted  ; 
and  the  use  of  zinc  ointment  and  glycerine  soap. 
Diluted  glycerine,  vaseline,  and  cold  cream  are 
also  popular  remedies.  Erasmus  ‘Wilson. 

CHELOID  a claw).— Synon.  : Chc- 

loides,  Cheloma  ; Fr.  Dartre  de  la  graisse ; Ger. 
Keloid. 

Definition. — A tumour  of  the  skin  resulting 
from  over-growth  of  connective  tissue  within  the 
corium. 

^Etiology.  — Cheloma  may  bo  idiopathic  or 
accidental,  and  in  both  cases  it  is  referable  to 
a diathesis.  When  of  accidental  origin  it  if 
commonly  associated  with  a cicatrix,  and  is  then 
developed  in  the  midst  of  the  cicatrix-tissue. 
This  form  of  the  tumour  has  been  denominated 
cheloides  spuria  or  traumatica,  and,  as  such,  has 
been  seen  scattered  numerously  over  the  chest 
and  shoulders  as  a sequel  of  acne. 

The  cause  of  cheloma  must  be  sought  for  in 
that  vital  source  from  which  is  derived  aberra- 
tion of  nutrition  in  general.  It  is  a consequence 
of  feeble  controlling  power,  and  may  be  resident 
in  the  skin  alone,  or  be  dependent  on  a want 
of  vigour  of  the  constitution  of  the  individual. 

The  traumatic  clieloid  may  follow  a light  as 
well  as  a severe  injury  of  the  skin,  such  as 
a boil,  a blister,  - a leech-bite,  or  even  the  ir- 
ritation of  a stimulating  liniment ; it  is  some- 
times met  with  in  the  scars  of  strumous 
abscesses  or  ulcers,  but  is  most  common  in  the 
cicatrices  of  burns  or  scalds. 

Anatomical  Characters. — At  its  first  de- 
velopment cheloma  occupies  the  fibrous  portion 
of  the  corium.  As  it  increases  in  bulk  it 
pushes  the  vascular  layer  outwards  and  stretches 
the  corpus  papillare,  obliterating  the  capil- 
lary network,  more  or  less  completely.  In  its 
aggregate  form  when  it  presents  itself  as  a flat 
plate,  raised  for  a quarter  of  an  inch  above 
the  level  of  the  adjoining  skin  and  sinking  to  a 
similar  extent  into  the  corium,  it  has  the  appear- 
ance of  being  tied  down  by  strong  cords  or  roots 
at  either  end,  and  frequently  overlaps  the 
healthy  skin  along  its  borders.  In  this  state  it 
is  seen  to  be  composed  of  strong  fibrous  bands 
closely  interlaced  with  each  other  and  enveloped 
by  a smooth  transparent  pinkish  layer,  in  which 
may  be  detected  a scanty  vascular  plexus 
converging  to  venules  which  sink  between  the 
meshes  of  the  fibrous  structure. 

Around  the  circumference  of  one  of  these 
larger  flattened  tumours,  such  as  is  commonly 
met  with  on  the  sternum,  and  measuring  several 
inches  in  diameter,  there  will  generally  be 
observed  a few  scattered  knots.  These  are 
developed  in  the  fibrous  sheath  of  the  arteries  at 
a short  distance  from  the  mass,  and,  being  thus 
linked  to  the  central  growth,  are  subsequently 
drawn  into  the  focus  of  the  tumour.  And  the 
development  of  the  so-called  roots  is  explained 
by  the  propagation  of  the  proliferating  process 
by  the  coats  and  sheaths  of  the  blood-vessels 
communicating  with  the  central  tumour. 

Description.  — Cheloid  has  received  its  name 
from  its  habit  of  throwing  out  spurs  from  its 
circumference,  these  spurs  having  been  com- 
pared to  crab’s  claws.  It  originates  in  a round 


Z30  CHELOID. 

aval,  or  oblong  tubercle  or  knot  in  the  skin,  and 
this  may  be  followed  by  a second  in  its  imme- 
diate neighbourhood,  or  sometimes  by  a cluster  of 
three  or  four.  When  two  of  these  knots  are  situ- 
ated at  a short  distance  apart  they  are  apt 
to  become  connected  by  a cord  of  the  same 
structure  as  themselves,  and  to  give  rise  to  what 
has  been  called  a cylindrical , club-shaped,  or 
dumb-bell  cheioid.  When  three  or  four  knots 
are  grouped  near  together  they  are  disposed 
to  become  blended  by  growth  and  produce  an 
oval  or  square-shaped  cheioid ; and  when  the 
growth  extends  from  these  latter  into  the  sur- 
rounding integument  the  appearance  denominated 
radiciformis  is  established.  Cheloma  being  due 
to  a tendency  to  overgrowth  or  hyperplasia  of 
connective  tissue  within  the  skin,  it  may  appear 
on  several  parts  of  the  integument  at  the  same 
time,  one  of  the  most  common  seats  of  its 
development  being  the  sternum,  which  it 
generally  crosses  transversely.  It  is  often 
solitary;  is  more  commonly  composed  of  five  or 
six  tumours,  discrete  or  confluent ; but  has  been 
met  with  occasionally  to  the  number  of  fifty  or 
sixty  tubercles  or  more. 

Course  and  Prosnosis. — Cheioid  rarely  gives 
rise  to  much  inconvenience  or  attains  any  con- 
siderable magnitude,  and  when  left  to  itself 
progresses  very  slowly  or  remains  stationary  for 
a number  of  years  or  for  life ; and  we  have 
known  it  to  disappear  spontaneously.  Its  sub- 
jective symptoms  are  cf  no  great  severity,  being 
limited  to  itching,  tingling,  and  smarting,  and 
more  or  less  uneasiness  in  moving  the  limbs, 
or  from  pressure  when  sitting  or  lying  in  bed. 
It  has  no  tendency  to  desquamation  or  ulcera- 
tion. 

Treatment. — Being  dependent  on  a diathesis, 
surgical  manipulation  has  generally  proved  un- 
availing in  cheloma.  It  might  be  expected  to 
recur  in  the  cicatrix  of  a wound  made  for  its 
removal,  or  in  the  scars  of  a suture  employed  to 
hold  the  cut  edges  together,  and  such  has  proved 
to  be  the  case.  The  most  successful  treatment 
consists  in  covering  up  the  tumour  with  a mercu- 
rial or  iodine  plaster,  or  even  with  simple  em- 
plastrum  plumbi.  The  writer’s  favourite  treat- 
ment is  to  paint  it  with  a spirituous  solution  of 
soap  and  iodide  of  potassium,  and  then  cover  it 
with  an  adhesive  plaster  spread  on  washleather, 
repeating  the  application  as  often  as  the  plaster 
becomes  loosened.  We  have  seen  a multiple 
cheloma  cured  in  this  way ; aided  by  mild  doses  of 
the  perchloride  of  mercury.  The  combination  of 
warmth  and  moisture,  such  as  is  produced  by  a 
plaster,  is  an  important  element  in  the  cure.  But 
Irritants,  caustics,  and  the  knife  are  all  equally 
objectionable  and  valueless. 

Erasmus  Wilson. 

CHELTENHAM,  in  Gloucestershire. 

Common  salt  waters.  See  Mineral  Waters. 

CHEMOSIS  (x^U,  a hole). — A swollen  con- 
dition of  the  conjunctiva,  caused  by  effusion  into 
its  tissue  around  the  cornea,  which  thus  appears 
as  if  placed  in  a hole  or  hollow.  See  Eye  and 
its  Appendages,  Diseases  of. 

CHEST,  Diseases  of  the. — Following  the 
plan  adopted  in  the  general  article  on  the  Abdo- 


CHEST,  DISEASES  OF  THE. 
men,  it  is  proposed  in  the  first  place  to  give  ar 
outline  of  the  diseases  of  the  chest ; and  then  tc 
indicate  the  principal  points  bearing  on  the: . 
clinical  investigation. 

General  Summary.  — The  diseases  of  the 
thorax  and  its  contents  may  be  conveniently 
divided  into  certain  groups,  namely : — 

I.  Diseases  of  the  chest-walls,  or  extending 
inwards  from  these  walls. 

II.  Diseases  of  the  respiratory  apparatus  con- 
tained within,  the  thorax,  namely: — 1.  Pleurae. 

2.  Trachea.  3.  Main  Bronchi,  i.  Lungs. 

III.  Diseases  connected  with  the  circulatory 
system,  including : — 1.  Pericardium.  2.  Heart. 

3.  Great  vessels  within  the  chest,  both  arteries 
and  veins. 

IY.  Diseases  originating  in  the  mediastinal 
cellular  tissue. 

Y.  Diseases  of  the  absorbent  vessels  or  glands 
within  the  chest ; of  the  thoracic  duct ; and  of  the 
thymus  gland  or  its  remains. 

VI.  Diseases  of  the  oesophagus. 

VII.  Diseases  of  either  of  the  important  nerves 
traversing  the  chest. 

Yin.  Diseases  of  the  diaphragm. 

IX.  Diseases  encroaching  upon  the  chest  from 
the  abdomen  or  from  the  neck. 

The  particular  diseases  comprehended  within 
most  of  the  groups  just  enumerated  are  very 
numerous,  and  they  will  be  described  under 
their  respective  articles.  Affections  connected 
with  the  chest  constitute  a large  proportion  ot 
the  cases  which  come  under  observation  in  prac- 
tice. This  will  be  readily  understood  when  we 
remember  that  the  thorax  encloses  organs  essen- 
tial to  life,  which  are  never  at  rest,  and  which  are 
constantly  more  or  less  exposed  to  influences 
liable  to  injure  them.  They  may  be  mevefunc- 
tional  disorders,  and  to  these  the  heart  is  espe- 
cially prone ; but  serious  organic  diseases  are  also 
exceedingly  common,  and  rank  very  high  as  causes 
of  death.  Moreover,  they  may  either  come  under 
the  category  of  -local  affections,  though  even  then 
they  frequently  depend  upon  some  cause  acting 
through  the  general  system,  such  as  exposure  to 
cold  or  wet ; or  they  arise  in  the  course  of  some 
general  malady.  For  instance,  pulmonary  com- 
plications are  of  common  occurrence  in  connexion 
with  fevers  and  various  other  diseases;  the  heart 
is  implicated  in  a large  proportion  of  cases  of 
rheumatic  fever ; and  malignant  disease  is  not 
infrequently  manifested  by  a local  development 
of  cancer  in  connexion  with  certain  of  the  thoracic 
contents.  The  structures  within  the  chest  have 
an  important  mutual  influence  upon  each  other ; 
and  they  may  also  be  affected,  either  directly  or 
indirectly,  by  local  diseases  involving  other  parts 
of  the  body,  such  as  the  abdomen  or  the  central 
nervous  system. 

Clinical  Investigation. — It  may  be  confi- 
dently affirmed,  that  the  means  which  we  now 
possess  for  investigating  diseases  connected  with 
the  chest  are  so  adequate  and  precise,  that  any 
one  possessing  the  requisite  knowledge  and  skill, 
and  who  carries  out  the  clinical  examination  pro- 
perly, can,  in  the  very  large  majority  of  cases, 
arrive  at  a diagnosis  with  certainty  and  accuracy. 
At  the  same  time  it  must  be  remembered  that 
every  complaint,  referred  to  this  region,  however 
trivial  it  may  appear  to  be,  does  require  system- 


CHEST,  DISEASES  OF  THE. 
atic  and  thorough  investigation,  otherwise  very 
Bei'ious  mistakes  are  constantly  liable  to  be  made. 
Of  course,  cases  also  do  come  under  observation 
occasionally  which  are  obscure,  and  which  may 
call  for  repeated  examination  before  a correct 
diagnosis  can  be  formed;  and  exceptional  in- 
stances occur  in  which  no  satisfactory  conclusion 
can  be  arrived  at.  The  previous  general  history 
of  the  patient,  the  hereditary  history,  and  the 
account  of  the  origin  and  progress  of  the  illness, 
often  afford  signal  aid  in  the  investigation  of 
chest-affections,  and  ought  never  to  be  overlooked. 
The  symptoms  to  which  these  affections  give  rise 
are  necessarily  various.  Pain  or  other  morbid 
sensations  are  veiy  commonly  complained  of,  but 
only  in  a comparatively  few  instances  are  these 
at  all  significant,  and  they  can  never  be  posi- 
tively relied  upon  in  making  a diagnosis,  while 
they  are  often  absent  in  diseases  of  the  most 
serious  character.  The  important  organs,  namely, 
the  lungs  and  heart,  usually  present  more  or 
less  disturbance  of  their  functions  when  they 
are  affected,  but  grave  diseases  may  exist  without 
any  such  disturbance.  The  different  structures 
within  the  chest  have  a mutual  influence  upon 
each  other,  and  thus  other  symptoms  besides  those 
connected  with  the  structure  actually  diseased 
may  be  apparent.  For  instance,  the  lungs  and 
heart  are  thus  very  intimately  associated ; while 
aneurisms  or  growths  often  disturb  these  organs 
seriously,  or  interfere  with  the  air-tubes,  nerves, 
veins,  and  other  structures.  In  consequence  of 
more  or  less  interference  with  the  circulation, 
various  symptoms  in  parts  remote  from  the 
chest  are  frequently  originated ; and  distant 
organs  may  become  the  seat  of  organic  lesions 
as  the  result  of  long-continued  mechanical  conges- 
tion, a new  train  of  symptoms  being  thus  setup. 
The  general  system  may  be  in  this  manner  af- 
fected ; whilst  pyrexia,  wasting,  and  other  general 
symptoms  are  often  associated  with  cliest-diseases. 
Lastly,  morbid  conditions  within  the  thorax  may 
directly  affect  the  abdominal  organs  ; or  may 
make  their  way  through  the  diaphragm  into  the 
abdominal  cavity. 

Physical  Examination  constitutes  an  essential 
and  most  important  part  of  the  clinical  investiga- 
tion of  the  chest  and  its  contents.  Indeed,  with- 
out this  examination  no  certain  and  exact  diag- 
nosis can  ever  be  made.  This  subject  is  fully 
discussed  in  other  appropriate  articles,  and  here 
it  need  only  be  mentioned  that  the  methods  of 
examination  which  are  usually  required,  and 
which  should  in  every  case  be  practised,  are: — 
1.  Inspection.  2.  Palpation.  3.  Percussion.  4. 
Auscultation.  Other  modes  which  may  be  called 
for  include: — 5.  Measurement  (not uncommonly). 
6.  Succession.  7- The  use  of  special  instruments, 
directed  to  the  investigation  of  particular  organs, 
such  as  the  spirometer,  cardiograph,  sphygmo- 
graph,  aspirateur,  oesophageal  bougie,  &c.  See 
Physical  Examination,  arid  Diseases  of  the 
several  organs.  Frederick  T.  Eobeets. 

CHEST,  Examination  of.  See  Physical 
Examination. 

CHE  ST- WALLS,  Morbid  Conditions  of. 

—The  walls  of  the  chest  may  he  the  seat  of 
Various  morbid  conditions,  and  the  affections 


CHEST-WALLS.  231 

of  tills  portion  of  the  framework  of  the  body  de- 
mand more  attention  than  they  are  accustomed 
to  receive.  All  that  can  be  done  "within  the 
limits  of  this  article  is  to  indicate  their  nature  ; 
to  notice  briefly  such  of  them  as  are  not  de- 
scribed in  other  parts  of  this  volume ; and  to 
point  out  the  principles  of  treatment.  They  may 
be  considered  according  to  the  following  arrange- 
ment : — 

1.  Superficial  Affections. — Under  this  group 
may  be  included  morbid  conditions  of  the  skin 
and.  subcutaneous  tissues,  a.  Cutaneous  erup- 
tions are  of  common  occurrence  over  the  chest. 
Among  these  may  be  specially  mentioned  the 
eruptions  of  the  exanthemata,  herpes  zoster,  and 
chloasma,  b.  The  superficial  vessels  are  liable 
to  become  enlarged  under  certain  circumstances. 
This  enlargement  is  usually  seen  in  the  veins  over 
the  front  of  the  thorax,  which  may  be  distended 
on  both  sides,  or  only  on  one  side,  or  in  sonio 
particular  region.  The  larger  divisions  may  alone 
appear  to  be  involved  ; or  a more  or  less  exten- 
sive network  of  smaller  veins  may  he  visible,  and 
occasionally  even  the  capillaries  seem  to  he  im- 
plicated. This  condition  generally  arises  from 
some  obstruction  interfering  with  the  circulation 
through  one  or  other  of  the  principal  veins  wdiich. 
either  directly  or  indirectly,  receive  the  blood 
from  the  veins  of  the  thoracic  wall.  Thus  the 
superior  vena  cava,  or  either  innominate,  sub- 
clavian, or  axillary  may  be  implicated,  being,  for 
example,  pressed  upon  by  new  growths  or  en- 
larged glands,  the  distribution  and  extent  of  the 
venous  distension  varying  accordingly.  Occasion- 
ally one  of  the  smaller  veins  is  thus  interfered 
■with.  The  writer  has  met  with  cases  in  which 
considerable  enlargement  of  the  veins  was  visible 
over  portions  of  the  thorax,  where  the  cause  was  by 
no  means  evident,  the  patients  asserting  that  this 
condition  had  existed  ever  since  they  could  re- 
member, and  being  regarded  by  them  as  perfectly 
normal.  Probably  it  has  resulted  from  some  local 
obstruction  occurring  during  early  life.  It  must 
he  remembered  that  women  who  are  suckling 
frequently  present  great  enlargement  of  the  su- 
perficial veins  over  the  front  of  the  chest,  which 
usually  subsides  when  the  period  of  lactation  is 
at  an  end.  Again,  more  or  less  venous  and  capil- 
lary engorgement  in  this  region  may  occasionally 
be  observed  in  cases  of  cardiac  or  pulmonary 
disease,  where  the  general  circulation  is  much  im- 
peded, and  due  aeration  of  the  blood  is  interfered 
with.  Sometimes  a ring  of  enlarged  veins  and 
capillaries  is  seen  around  the  lower  part  of  the 
chest.  When  the  venous  distension  is  due  to  ob- 
struction of  the  vena  cava  superior,  the  skin  may 
present  a more  or  less  marked  cyanotic  tint,  and 
in  cases  of  general  cyanosis,  the  chest,  in  common 
with  other  parts,  has  a cyanotic  appearance. 
Occasionally  one  or  other  of  the  small  arteries 
which  supply  the  thoracic  walls  is  enlarged,  and  it 
may  attain  a considerable  size.  c.  Subcutaneous 
oedema  is  sometimes  observed  over  the  chest.  In 
most  instances  this  is  a local  condition,  being 
the  result  of  venous  obstruction  ; but  it  may  ho  a 
part  of  general  dropsy,  particularly  in  connexior 
with  renal  disease.  This  morbid  state  is  evident 
on  inspection  or  to  the  touch,  and  the  affected  part 
pits  on  pressure.  d.  The  subcutaneous  tissue 
of  the  therax  is  also  liable  to  become  the  seat  o£ 


232  CHEST-WALLS,  MORBID  CONDITIONS  OF 


so-called  emphysema,  as  the  result  of  perforation 
or  rupture  of  the  lung  and  pleura,  with  the 
consequent  escape  of  air  into  the  cellular  tissue 
tinder  the  skin,  where  it  accumulates,  and  travels 
to  a greater  or  less  extent  over  the  body.  The 
lung  may  also  give  way  into  the  mediastinum, 
the  air  which  escapes  subsequently  making  its 
way  from  this  part  into  the  subcutaneous  tissue. 
This  condition  is  generally  due  to  direct  injury, 
especially  from  fractured  ribs,  but  it  may  also 
arise,  in  exceptional  instances,  from  other  causes, 
such  as  violent  cough, powerful  expiratory  efforts, 
as  in  parturition,  pulmonary  disease — for  in- 
stance, the  giving  way  of  a cavity  in  the  lung — or 
in  connexion  with  empysema.  Subcutaneous  em- 
physema is  attended  with  evident  swelling  of  the 
part,  which  may  be  very  great,  all  the  normal  ana- 
tomical outlines  being  obliterated ; the  peculiar 
sensation  accompanying  this  condition  is  readily 
elicited  on  palpation  and  percussion ; the  percus- 
sion sound  is  tympanitic  ; and  on  auscultation  a 
superficial  crackling  sound  is  heard,  e.  As  be- 
longing to  the  superficial  affections  connected 
with  the  chest  may  be  just  mentioned  diseases  of 
the  mammary  gland  or  nipple,  which  of  course 
constitute  a most  important  class  of  diseases  in 
females  (see  Breast,  Diseases  of). 

2.  Muscular  and  Tendinous  Affections. 
— a.  The  muscles  of  the  chest  or  their  tendinous 
attachments  may  be  the  seat  of  certain  painful 
affections.  These  are  of  the  nature  of  so-called 
muscular  rheumatism  or  myalgia,  of  inflamma- 
tion, or  of  more  or  less  injury  or  strain  ; being 
induced  by  cold,  constitutional  conditions  such 
as  gout,  overwork,  straining,  violent  coughing, 
fatigue  from  prolonged  sitting,  and  other  causes. 
The  painful  condition  is  usually  localized,  but 
different  muscles  are  involved  in  different  cases, 
sometimes  those  which  are  superficial  being 
affected,  in  othors  the  deeper  muscles  including 
the  intercostals  ; or  the  complaint  may  be  confined 
to  a single  muscle.  Pleurodynia,  dorsodynia,  and 
scapulodynia  are  the  terms  applied  to  muscular 
rheumatism  affecting  the  side  of  the  chest,  the 
upper  part  of  the  back,  and  the  scapular  regions 
respectively.  As  the  result  of  severe  coughing, 
muscular  pains  are  very  common  around  the  lower 
part  of  the  chest.  The  pain  is  usually  more  or 
less  aching  in  character,  and  not  severe,  but  it 
may  be  very  intense,  especially  in  acute  cases. 
Whatever  brings  the  affected  muscles  into  play 
aggravates  the  suffering,  such  as  moving  the  arms 
or  shoulders  when  the  superficial  muscles  are 
affected,  coughing,  sneezing,  and  similar  actions. 
In  some  instances  the  pain  is  not  felt  when  the 
affected  structures  are  kept  quite  at  rest.  There 
may  be  local  tenderness  on  pressure,  or  diffused 
pressure  may  give  relief ; while  posture  often 
influences  the  sensations  experienced,  such  as 
whether  tho  patient  assumes  the  recumbent  or 
sitting  posture,  or  lies  on  one  or  other  side. 
Fatigue  generally  increases  the  pain.  Muscular 
affections  connected  with  the  chest  are  not  neces- 
sarily accompanied  with  any  other  local  symp- 
toms ; and  physical  examination  reveals  nothing, 
except  that  perhaps  the  act  of  breathing  is  volun- 
tarily restrained,  on  account  of  the  pain  thus  in- 
duced. b.  Themusclesofthechestmay  beaffected, 
on  the  one  hand,  with  spasm  or  cramp  ; on  the 
other,  with  paralysis.  The  former  is  attended 


with  more  or  less  pain,  which  may  be  very 
severe ; the  latter  is  indicated  by  loss  of  power 
in  the  muscles  involved.  These  disorders  gene- 
rally depend  on  some  lesion  of  the  central  ner- 
vous system,  but  may  result  from  local  nerve- 
disease.  In  cases  of  hemiplegia  from  cerebral 
mischief,  the  muscles  of  the  thorax  on  tho 
affected  side  are  often  temporarily  weakened, 
but  they  usually  subsequently  regain  their 
power.  When  the  upper  part  of  the  spinal  cord 
is  injured  or  diseased  at  a certain  point,  all 
the  muscles  of  the  chest  become  paralysed, 
which  is  a very  serious  matter,  as  respiration 
and  the  acts  connected  therewith  cannot  be  carried 
on,  except  by  the  diaphragm,  and  consequently 
the  blood  is  imperfectly  aerated,  secretions  accu- 
mulate in  the  lungs,  and  the  patient  dies  from 
suffocation,  c.  Atrophy  or  degeneration  may 
involve  the  thoracic  muscles.  In  cases  of  pul 
monary  phthisis  either  the  whole  of  these 
muscles  or  certain  of  them  are  not  uncommonly 
wasted  out  of  proportion  to  the  general  emacia- 
tion. These  muscles  may  also  be  more  or  less 
implicated  in  progressive  muscular  atrophy, 
and  occasionally  a single  muscle  undergoes 
marked  wasting.  The  writer  has  seen  a striking 
example  of  this  local  atrophy  in  connection  with 
the  peetoralis  major,  but  the  serratus  magnus  or 
other  muscles  may  be  implicated.  The  wasting 
is  probably  in  most  eases  due  to  disease  of  the 
nerves  supplying  the  affected  muscles.  It  is 
quite  evident  on  examination,  and  the  movements 
which  are  usually  performed  by  the  involved 
structures  cannot  be  executed  properly,  d.  On 
the  other  hand,  the  chest-muscles  may  become 
hypertrophied.  This  may  be  a natural  result  of 
training ; or  it  may  occur  in  consequence  of 
their  being  called  upon,  either  habitually  or 
at  intervals,  to  act  excessively,  as  in  cases  of 
emphysema  or  asthma.  In  exceptional  in- 
stances the  condition  known  as  pseudo-hyper- 
trophic muscular  paralysis  has  extended  up  to 
the  chest,  c.  The  thoracic  muscles  occasionally 
present  marked  irritability  under  percussion  or 
friction.  This  has  been  regarded  as  an  impor- 
tant sign  of  phthisis ; but  the  writer  has  only 
observed  it  in  a comparatively  few  instances  of 
this  disease,  and  has  found  it  equally  if  not  more 
evident  in  cases  where  the  lungs  were  perfectly 
healthy,  f.  As  the  result  of  injury  and  other 
causes,  some  portion  of  the  muscular  structures 
of  the  chest  may  be  lacerated,  ruptured,  or  per- 
forated, either  alone  or  along  with  other  struc- 
tures. This  condition  will  be  further  alluded  to 
presently. 

3.  Nervous  Affections. — a.  Neuralgia  is 
very  common  in  different  parts  of  the  chest, 
especially  in  the  side,  and  particularly  the  left 
side — intercostal  neuralgia.  The  pain  is  loca- 
lised, being  usually  referred  to  a point  where  a 
branch  of  nerve  becomes  superficial.  It  is  more 
or  less  constant,  but  subject  to  exacerbations,  in 
some  cases  being  very  severe  at  times.  It  may 
be  increased  by  deep  breathing  or  coughing,  but 
is  not,  as  a rule,  so  much  affected  by  theso  and 
similar  actions  as  are  other  painful  chest-affec- 
tions. Shooting  and  darting  sensations  often 
radiate  from  the  principal  point,  and  certain 
spots  of  tenderness — points  douloureux  — may 
be  recognised  in  many  cases  ( sec  Lntkhcostai 


CHRST-WALLS,  MORBID  CONDITIONS  OF.  233 


Neuralgia),  b.  Intercostal  neuritis  is  occasion- 
ally met  with,  and  this  affection  is  attended 
with  great  pain,  localised  and  radiating,  with 
much  tenderness,  the  suffering  being  aggravated 
by  whatever  causes  any  local  disturbance.  It 
is  probable  that  the  severe  pains  experienced 
in  some  instances  where  the  complaint  is  sup- 
posed to  be  muscular,  are  due  to  branches  of 
nerve  being  in  an  inflammatory  condition,  c. 
Some  individuals,  especially  females,  exhibit 
a remarkable  superficial  tenderness  over  the 
thorax  or  in  parts  of  this  region,  especially 
the  anterior  and  upper  portions.  The  slightest 
touch  is  resented,  and  the  most  delicate  percus- 
sion cannot  be  borne.  This  condition  may  exist 
without  any  actual  disease,  or  it  is  sometimes 
observed  in  phthisical  cases,  d.  Sensation  may 
be  more  or  less  impaired  over  the  chest,  or  in 
limited  portions,  either  in  connexion  with  central 
or  local  nervous  disease,  or  in  hysterical  and 
nervous  persons.  Various  paraesthesiee  are  also 
frequently  referred  to  this  region  by  the  class  of 
individuals  just  mentioned. 

4.  Diseases  of  the  Bones  or  Cartilages. — 
The  morbid  conditions  which  may  be  referred 
to  the  bony  and  cartilaginous  framework  of  the 
thorax  are  as  follows : — a.  There  may  be  undue 
rigidity  and  firmness  of  the  chest-walls,  owing 
to  an  excessive  deposit  of  calcareous  matter  in 
the  sternum  and  ribs,  with  ossification  or  petri- 
faction of  the  cartilages.  This  is  a normal  con- 
dition in  old  people,  being  one  of  the  degenera- 
tive changes  to  which  they  are  liable,  but  it  may 
also  occur  in  younger  individuals,  as  the  result 
of  hard  work,  or  in  connexion  with  certain 
pulmonary  diseases.  This  state  of  rigidity 
interferes  more  or  less  with  the  respiratory 
movements,  and  not  infrequently  causes  serious 
embarrassment,  b.  On  the  other  hand,  the  ribs 
and  cartilages  may  be  deficient  in  firmness, 
and  consequently  too  yielding  and  elastic. 
This  is  observed  in  children  and  young  persons 
who  are  ill-nourished,  and  it  becomes  a condition 
of  great  moment  when  any  disease  sets  in  which 
causes  obstruction  to  the  entrance  of  air  into 
the  lungs,  such  as  bronchitis.  The  chest-walls 
are  then  liable  to  fall  in  more  or  less  during  the 
act  of  inspiration,  and  may  become  permanently 
deformed,  the  pigeon-breast  and  other  abnormal 
forms  of  thorax  being  thus  originated.  In 
rickety  children  the  vicinity  of  the  junction  of 
the  ribs  with  their  cartilages  is  the  most  yield- 
ing part  of  the  chest,  where  nodular  thickenings 
may  often  be  felt,  and  in  such  subjects  this  is 
the  portion  of  the  thoracic  wall  which  is  most 
liable  to  fall  in.  c.  Acute  or  chronic  periostitis 
or  perichondritis  is  sometimes  observed  in  con- 
nexion, respectively,  with  the  sternum  or  ribs, 
or  with  the  cartilages.  The  acute  affection 
gives  rise  to  much  pain  and  tenderness,  which 
may  be  accompanied  with  superficial  redness  and 
swelling,  and  may  simulate  some  more  serious 
disease.  The  chronic  complaint  usually  assumes 
the  form  of  a node,  being  the  result  of  syphilis. 
The  writer  has  occasionally  observed  a small 
swelling  at  the  junction  of  one  of  the  ribs  with 
its  cartilage,  painless,  unaccompanied  with  red- 
ness, but  presenting  distinct  fluctuation,  d. 
The  bony  and  cartilaginous  structures  them- 
colves  may  be  the  seat  of  disease  in  some  part  of 


the  chest,  and  here  must  be  included  the  portion 
of  the  spinal  column  which  limits  this  region 
posteriorly.  Thus  there  may  be  acute  inflam- 
mation, caries,  necrosis,  or  so-called  scrofulous 
disease.  Among  the  more  important  causes 
which  are  liable  to  originate  these  conditions 
may  be  mentioned  injury,  syphilis,  scrofula, 
empyaema  opening  externally,  and  thoracic  tu- 
mours or  aneurisms  growing  outwards.  They 
may  lead  to  serious  consequences,  both  local 
and  general,  and  frequently  cause  more  or  less 
deformity  of  the  chest,  e.  Permanent  thicken- 
ing and  distortion  of  portions  of  the  ribs  are 
sometimes  observed  after  fractures  which  have 
united  improperly. 

5.  Inflammation  and  Abscess. — It  is  ex- 
pedient to  make  a separate  group  of  those  cases 
in  which  inflammation,  resulting  in  the  formation 
of  one  or  more  abscesses,  occurs  in  some  portion 
of  the  soft  structures  entering  into  the  construc- 
tion of  the  chest-walls.  This  may  be  of  local 
origin,  arising  from  injury,  bone-disease,  or  other 
causes  ; or  it  may  be  due  to  the  opening  of  an 
empyaema  into  the  tissues ; to  suppuration  ex- 
tending and  burrowing  from  the  axilla  or  other 
parts  ; or  to  pyaemia.  . If  deep-seated,  an  abscess 
may  be  difficult  to  detect  with  certainty,  but 
usually  the  signs  of  this  condition  become 
sufficiently  obvious.  Sinuses  or  fistulee  may  be 
left  as  a consequence  of  suppuration  in  the 
chest-wall,  especially  when  pus  makes  its  way 
outwards  from  within. 

6.  Tumours  and  New-Growths. — These 
morbid  conditions  also  demand  separate  notice. 
They  may  be  connected  with  any  of  the  struc- 
tures of  the  chest- walls,  and  are  of  various  kinds ; 
among  those  which  have  come  under  the  writer's 
notice  may  be  mentioned  molluscum,  fatty 
growths,  cystic  tumours,  enlarged  sebaceous 
glands,  and  infiltrated  carcinoma.  Tumours  may 
make  their  way  inwards  from  the  chest- walls, 
encroaching  upon  the  cavity  of  the  thorax  ; or, 
on  the  other  hand,  the  walls  may  be  involved  by 
growths  from  within.  It  need  scarcely  be 
mentioned  that  mammary  tumours  constitute  a 
distinct,  and  by  far  the  most  important  group 
associated  with  the  structures  covering  the  chest. 
See  Breast,  Diseases  of. 

7.  Perforations  and  Ruptures. — The  mus- 
cular structures  of  the  thoracic  wall  may  be 
more  or  less  destroyed  in  some  part  either  by 
sudden  rupture  or  gradually,  allowing  a hernial 
protrusion  of  the  lung  to  take  place  between  the 
ribs.  As  already  noticed,  empysema  may  make 
its  way  outwards  through  the  chest-wall.  Aneu- 
risms and  tumours  extending  outwards  from 
within  the  thorax  frequently  cause  serious  de- 
struction of  the  tissues,  including  the  bony  and 
cartilaginous,  as  well  as  the  soft  structures. 
This  destructive  process  is  often  attended  with 
severe  pain  and  suffering,  and  leads  to  grave 
mischief. 

8.  Variations  in  Form  and  Size.  — The 
chest  often  presents  deviations  from  the  normal 
shape  and  size,  and  these  are  so  important  that 
they  demand  separate  consideration.  See  De- 
formities of  Chest. 

Treatment. — In  many  cases  where  the  chest 
walls  are  in  a morbid  state,  they  either  do  imt 
need  any  special  treatment,  or  no  treatment  can 


231  CREST-WALLS, 

be  of  avail.  The  chief  circumstances  under 
which  the  practitioner  may  be  called  upon  to 
interfere,  and  the  measures  to  be  adopted,  may 
be  briefly  indicated  as  follows  : — - 

a.  Painful  affections  of  the  chest-walls,  de- 
pending upon  conditions  of  the  muscles  or 
nerves,  frequently  demand  local  applications  for 
their  relief.  Thus  in  different  cases  it  may 
be  requisite  to  employ  hot  fomentations,  dry 
heat,  or  cold  applications,  in  the  form  of  wet 
rags  frequently  changed,  ice,  or  evaporating  lo- 
tions; or  to  use  anodyne  applications  of  various 
kinds,  such  as  belladonna  plaster  or  liniment, 
opium  plaster  or  a liniment  containing  laudanum, 
oleate  of  morphia,  tincture  of  aconite  or  ointment 
of  aconitine,  or  veratria  ointment.  Anodynes 
may  also  sometimes  be  added  to  fomentations 
with  advantage.  Priction  is  often  of  much  ser- 
vice, and  at  the  same  time  stimulating  liniments 
may  be  employed,  such  as  one  containing  cam- 
phor, chloroform,  or  turpentine.  For  ill-defined 
muscular  pains  about  the  chest,  which  are  fre- 
quently complained  of,  free  douching  with  cold 
water  every  morning,  followed  by  friction  with 
a rough  towel,  is  often  highly  efficacious.  When 
paiu  is  localised  and  obstinate,  much  benefit  may 
be  derived  from  the  application  of  a sinapism, 
mustard-leaf,  or  even  a small  blister.  In  other 
cases  the  use  of  tile  ether-spray  is  serviceable, 
repeated  more  or  less  frequently;  or  sometimes 
much  relief  may  be  obtained  from  applying  over 
a painful  spot  a mixture  of  equal  parts  of  chloro- 
form and  belladonna  liniment.  Galvanism  is 
another  agent  which  may  be  of  the  greatest  ser- 
vice in  relieving  painful  sensations  about  the 
chest,  whether  connected  with  the  muscles  or 
nerves.  Subcutaneous  injections  of  hot  water, 
morphia,  or  atropine  may  be  demanded  in  some 
cases,  and  constitute  a most  valuable  mode  of 
treatment  if  pain  cannot  otherwise  bo  assuaged. 

In  the  treatment  of  many  painful  affections  of 
the  chest-walls  much  assistanse  may  be  derived 
from  attention  to  posture,  especially  in  connec- 
tion with  certain  occupations;  from  the  avoidance 
of  undue  fatigue,  or  of  any  violent  actions  which 
are  known  to  influence  this  part,  such  as  cough  ; 
and  from  the  adoption  of  measures  tending  to 
support  the  structures,  or  to  keep  them  in  a state 
of  rest.  The  writer  has  found  great  benefit  in 
a large  number  of  instances  from  strapping  the 
side  more  or  less  extensively,  in  the  manner 
advocated  by  him  for  the- treatment  of  pleurisy; 
and  if  there  is  any  localised  pain,  some  limited 
anodyne  application,  such  as  a piece  of  belladonna 
plaster,  may  be  placed  over  this  spot  under  the 
strapping. 

b.  In  many  affections  of  the  chest-walls,  treat- 
ment directed  to  the  general  system,  or  to  some 
special  constitutional  condition,  is  often  of  the 
greatest  service.  Thus,  in  the  painful  complaints 
already  noticed,  there  are  frequently  marked  gene- 
ral debility  and  anaemia ; and.  essential  benefit  is 
derived  from  the  administration  of  quinine,  pre- 
parations of  iron,  strychnine,  cod-liver  oil,  pre- 
parations of  phosphorus,  and  other  tonic  medi- 
cines, or  such  as  improve  nutrition.  Some  of 
these  are  also  most  useful  when  there  is  disease 
of  bone  and  its  consequences.  Again,  certain  af- 
fections of  the  thoracic  wall  may  be  associated 
with  rheumatism,  gout,  ©r  syphilis,  and  then  the 


CHICKEN-FOX. 

particular  treatment  indicated  for  each  of  thes? 
several  conditions  is  called  for. 

c.  When  disorders  of  the  muscles  of  the  chcst- 
walls  occur,  such  as  paralysis  or  spasm,  asso- 
ciated with  some  disease  of  the  central  nervous 
system,  the  treatment  must  usually  be  directed 
to  this  disease,  and  but  little  can  be  done  for  the 
local  disturbance.  In  some  instances,  however, 
electrical  or  other  modes  of  treatment  may  be 
of  some  service,  by  influencing  the  action  of  the 
muscles,  but  no  definite  rules  can  be  laid  down. 

d.  Local  inflammations  in  connection  with  the 
thoracic  walls  must  be  treated  as  in  other  parts 
of  the  body,  and  it  is  unnecessary  to  discuss  this 
subject  in  the  present  article. 

e.  Surgical  treatment  maybe  called  for  under 
certain  circumstances.  Of  course  this  will  be  the 
case  if  the  chest-walls  are  injured  in  any  way. 
Among  other  conditions  likely  to  demand  sur- 
gical interference  may  be  specially  mentioned 
subcutaneous  emphysema,  abscesses,  disease  of 
the  bones,  and  tumours. 

Frederick  T.  Roberts. 

CHEST-WALLS,  Deformities  of.  See 
Deformities  of  Ciiest. 

CHICKEN-iPOX. — Svxox. : Varicella;  Fr. 
La  Varicelle ; Ger.  Wasscrpocken. 

Definition.  — A specific  infectious  febrile 
disease,  characterised  by  the  appearance,  in  suc- 
cessive crops,  of  red  spots,  which  in  the  course  of 
about  a week  pass  through  the  stages  of  pimple, 
vesicle,  and  scab. 

2Etiology. — The  origin  of  this  disorder  is  un- 
known. It  is  certain  that  it  arises  from  con- 
tagion, and  that  childhood  is  its  predisposing 
cause.  It  occurs  in  children  at  the  breast,  and 
is  seen  with  increased  frequency  up  to  the  fourth 
year,  at  which  period  it  attains  its  maximum. 
It  is  less  often  found  between  four  and  twelve, 
and  after  twelve  it  may  ho  said  to  disappear, 
although  it  is  occasionally  seen  in  adults. 

Symptoms — The  illness  commences  without 
any,  or  with  but  slightly-marked  premonitories. 
There  is  usually,  however,  some  feeling  of  lassi- 
tude, and  the  patient  goes  to  bed  earlier  than 
usual.  Within  a few  hours  an  eruption  appears, 
usually  on  some  part  of  the  back  or  chest,  but 
there  are  many  exceptions  to  this  rule.  It  may 
commence  on  the  face,  neck,  chest,  abdomen,  or 
extremities,  or  upon  several  of  these  parts  at  the 
same  time.  The  eruption  consists  of  small, 
faintly  papular  rose-spots,  varying  in  number 
from  twenty  to  one  or  two  hundred.  These,  in 
the  course  of  eight,  t welve,  or,  at  the  most,  twenty- 
four  hours  from  their  appearance,  change  into 
vesicles,  which,  at  first  small  in  size  and  clear  as 
to  their  conients,  become  quicklj’  large ; globular, 
or  semi-ovoid  iu  form  ; translucent,  glistening, 
and  opalescent  in  appearance  ; and  surrouuded 
with  a faint  areola.  Towards  the  end  of  the. 
second  day  of  illness,  the  vesicles  attain  complete 
development,  and  about  this  time  a few  may  bo 
seen  on  the  sides  of  the  tongue,  on  the  lip-, 
cheeks,  or  palate,  and  sometimes  upion  the  mucous 
membrane  of  the  genitals.  About  the  third  dav 
a few  of  the  vesicles  may  have  a pustular  appear- 
ance, and  sometimes  a few  pustules  are  seen  : Inn. 
regarding  the  eruption  as  a whole,  pustulatiou 
forms  an  incident  rather  than  an  essential  feature 


CHICKEN-POX. 

in  its  progress.  On  the  fourth  day  the  vesicles 
begin  to  dry  up,  and  by  the  sixth  complete  scabs 
are  formed.  These  fall  off  in  a few  days,  leaving 
in  their  place  faintly  red  spots,  and  sometimes 
a few  pits.  A single  crop  of  the  eruption  may 
be  said  to  complete  itself  in  five  or  six  days ; 
and,  as  two  or  three  crops  appear  on  as  many 
successive  days,  the  illness  will  last  rather 
more  than  a week.  In  the  event,  however,  of 
there  being  four  or  five  crops,  it  may  be  pro- 
longed for  another  week,  but  this  is  unusual. 
With  the  appearance  of  the  eruption,  the  tem- 
perature rises  two,  three,  or  even  more  degrees, 
and  this  rise  recurs  with  each  successive  crop  of 
spots.  The  pulse  is  sometimes  slightly  increased 
in  frequency ; the  tongue  is  moist,  and  sometimes 
covered  with  a light  fur.  As  a rule,  however, 
there  is  but  little  constitutional  disturbance, 
although  it  is  occasionally  severe. 

Pathology. — Chicken-pox  is  due  to  the  re- 
ception of  a specific  poison,  which  after  an  incu- 
bation of  about  thirteen  days,  shows  itself  by  an 
eruption  upon  the  skin.  What  this  poison  is,  how 
it  enters  the  body,  and  what,  if  any,  changes  it 
produces  upon  the  internal  organs,  the  present 
state  of  our  knowledge  does  not  enable  us  to 
say.  It  affects  the  same  individual  once  only, 
aud  it  is  perfectly  distinct  from  modified  small- 
pox, as  the  following  considerations  will  show: — 
1.  Chicken-pox  is  characterised  by  the  rapidity 
*vith  which  it  runs  through  its  stages;  modified 
small-pox,  on  the  contrary,  is  characterised  by 
an  interruption  in  the  course  of  the  disease  at 
one  or  other  of  three  points — the  papular,  the 
vesicular,  or  the  pustular.  2.  The  chicken-pox 
eruption  attains  complete  development  by  the 
end  of  the  third  day;  in  modified  small-pox, 
should  the  eruption  attain  complete  develop- 
ment, this  will  not  occur  before  the  ninth  day, 
however  much  the  disease  may  be  modified.  3. 
In  modified  small-pox  the  premonitory  symptoms 
are  usually  well-marked,  often  quite  as  severe  as 
in  the  natural  disease,  and  these  last  forty-eight 
hours,  after  which  there  is  an  eruption  of  small 
hard  papules  on  the  forehead,  face  and  wrists,  fol- 
lowed by  a fall  of  temperature.  In  chicken-pox 
the  premonitories  are  most  often  wanting,  and 
when  present  are  slightly  marked,  and  the  erup- 
tion is  followed  by  a rise  in  the  temperature.  It 
appears,  moreover,  upon  any  part  of  the  body  in- 
discriminately, and  less  frequently  on  the  face  than 
on  other  parts;  and  within  a few  hours — at  the 
most  within  twenty-four— it  has  become  vesicular; 
whereas  in  modified  small-pox  the  vesicular  stage 
is  only  reached  forty-eight  hours  after  the  appear- 
ance of  eruption.  4.  The  vesicles  of  chicken-pox 
are  globular  or  ovoid  in  form,  without  any  central 
depression ; glistening  or  translucent  in  appear- 
ance; and  unicellular  in  structure.  They  collapse 
on  pricking,  and  attain  their  maximum  develop- 
ment in  from  twelve  to  eighteen  hours.  Modified 
and  natural  small-poxvesicles  are  flat  and  circu- 
lar in  form,  always  depressed  in  the  centre,  and 
sometimes  umbilicated,  of  an  opaque  dirty 
white  colour,  and  multicellular  in  structure. 
They  do  not  collapse  on  pricking,  and  attain 
their  maximum  development  at  the  end  of  the 
third  day  from  their  origin.  5.  Small-pox  is  an 
inoculable  affection  ; chicken-pox,  according  to 
reliable  authority,  is  not.  G.  When  cases  arise 


CHIGOE.  235 

which  all  recognise  to  be  modified  small-pox, 
they  are  always  accompanied  by  others  which 
are  more  severe  ; and  in  epidemics  these  latter 
gradually  become  more  numerous  up  to  a point 
of  maximum  intensity,  when  they  decline  and 
the  modified  forms  reappear.  In  chicken-pox 
there  is  no  such  gradual  increase  in  the  intensity 
of  illness,  and  neither  serious  nor  fatal  cases  form 
part  of  its  epidemics,  which  prevail  indepen- 
dently of  small-pox.  7.  Small-pox  and  vaccinia 
are  often  early  followed,  in  the  same  individual, 
say  within  two  or  three  years,  by  chicken-pox, 
and  vice  versa.  8.  Chicken-pox,  vaccinia,  and 
small-pox  have  been  known  to  follow  in  imme- 
diate succession  in  the  same  individual. 

Course,  Terminations,  SeqPeije. — Varicelh 
always  runs  a favourable  course,  invariably  ter- 
minates in  recovery,  and  has  no  sequeke. 

Diagnosis. — It  should  be  borne  in  mind  that 
a sure  diagnosis  cannot  bemade  in  less  than  forty- 
eight  hours.  The  appearance,  however,  of  a crop 
of  vesicles,  followed  on  the  next  day  by  a second 
crop,  points  almost  certainly  to  chicken-pox. 
Attention  to  this,  and  to  the  points  noted  under 
the  head  of  pathology,  ought  to  make  the 
diagnosis  easy. 

Prognosis. — This,  as  has  been  indicated  above, 
is  always  favourable. 

Treatment. — The  treatment  of  chicken-pox 
consists  in  confining  the  patient  to  his  room,  or 
in  the  more  marked  cases  to  his  bed,  for  one  or 
two  days;  and  in  the  administration  of  light, 
unstimulating  food.  Although  no  physician  has 
recorded  a fatal  case  of  chicken-pox,  a child 
whose  temperature  may  be  three,  four,  or  six 
degrees  above  the  normal,  should  be  watched 
with  care.  Alex.  Collie. 

CHIGOE. — Description. — The  Chigoe  is  a 
minute  parasitic  insect,  common  in  the  West 
Indies  and  northern  parts  of  South  America.  It 
is  also  popularly  known  as  the  Jigger  or  Sandflca. 
Though  formerly  regarded  as  an  acarus  or  mite, 
it  is  now  generally  recognised  as  a true  flea  be- 
longing to  the  genus  Pulex  ( P . penetrans) ; but 
several  entomologists  have  advanced  solid  reasons 
for  separating  it  from  the  ordinary  fleas.  Thus 
Westwood  terms  it  the  flesh-flea,  or  Sarcopsylla 
penetrans,  whilst  Guerin  formed  the  genus 
Dcrmatophilus  for  its  reception.  Practically, 
these  distinctions  are  of  little  moment. 

The  Chigoo  ordinarily  lives  in  dry  and  sandy 
situations,  where  it  multiplies  to  a prodigious 
extent.  It  attacks,  however,  the  feet,  chiefly 
underneath  the  nails  and  between  the  toes  ; the 
impregnated  females  burying  themselves  beneath 
the  skin.  Here  the  abdomen  of  the  parasite 
swells  to  the  size  of  a pea;  and,  unless  removed 
by  operation,  gives  rise  to  acute  local  inflamma- 
tion, terminating  in  suppuration  and  sometimes 
in  extensive  ulceration,  with  even  fatal  results 
to  the  patient.  Dogs  also  suffer  excruciating 
torment  from  the  bites  and  immigration  of  the 
Bicho  do  Cachorro,  which,  however  Pokl  and 
Kollar  regard  as  distinct  from  the  human  jigger 
( Bicho  depe).  Be  that  anew  correct  or  not,  it  would 
appear  from  the  observations  of  Kodschild  and 
Westwood  that  the  larvae  of  the  human  chigoe  aro 
hatched  in  the  open  wounds  or  ulcers,  which  some- 
times extend  inwards  so  as  to  involve  the  bones 


236  CHIGOE. 

. Ihemselves.  In  bad  cases  amputation  of  the  toes 
and  adjacent  parts  becomes  necessary.  Left  to 
themselves,  the  larvae  escape  from  their  host,  and 
probably,  after  the  manner  of  bots  and  other 
parasitic  insects,  penetrate  the  soil  for  the  pur- 
pose of  acquiring  the  pupal  stage  of  growth. 

Treatment. — As  regards  treatment,  the  in- 
dications are  simple.  The  parasite  should  bo 
removed  with  the  utmost  care.  Where  this 
has  not  been  done,  and  where,  as  a conse- 
quence, open  sores  exist,  frequent  washings  with 
tepid  water,  followed  by  the  application  of  car- 
bolic acid  lotions  (twenty  or  thirty  grains  to  the 
ounce),  or  of  ointments  (one  drachm  to  one  ounce 
of  benzoated  lard)  will  be  found  most  suitable. 
Or,  again,  the  carbolic  acid  putty,  as  sold  in 
shops,  or  the  application  of  one  part  of  the  acid 
previously  mixed  with  ten  or  twelve  parts  of 
simple  olive  oil,  will,  in  all  likelihood,  bo  suffi- 
cient to  cause  the  destruction  of  any  larva;  that 
might  remain.  In  European  practice  cases  of 
jigger  are  rarely  seen;  nevertheless  the  writer 
has  recorded  an  instance  in  which  strong  men- 
tal delusions  followed  the  torture  produced 
by  these  creatures  (Worms,  p.  141).  The  pa- 
tient, a middle-aged  married  lady,  had  suffered 
severely  during  her  residence  in  the  West  Indies. 
Although  she  had  got  rid  of  the  parasites,  she 
constantly  harpooned  her  own  feet  in  the  hope 
of  destroying  the  young  jiggers  which  she  felt 
sure  were  still  burrowing  beneath  the  skin. 
Lastly,  it  seems  almost  needless  to  say  that 
residents  and  travellers  in  Guiana,  Brazil,  and 
in  the  West  Indies  generally,  should  have  their 
feet  properly  protected.  T.  S.  Cobboij). 

CHILBLAIN. — Synon.  : Kibe ; Pernio  ; Er. 
Engelure-,  Ger.  Frostbenle. 

Definition.— -A  state  of  inflammation  of  a 
part  of  the  skin  induced  by  cold. 

.ZEtiology. — Chilblains  are  common  in  children 
and  young  persons,  and  are  more  frequent  in  girls 
than  in  boys.  They  occur  chiefly  in  those  of  a 
lymphatic  constitution,  and  may  be  considered 
as  an  indication  of  debility  and  deficient  vital 
power.  In  adult  age  they  are  rare,  and  are  only 
met  with  when  the  powers  of  the  constitution 
are  reduced.  Their  occurrence  is  influenced  more 
by  the  strength  of  the  individual  than  by  the 
degree  of  cold,  and  they  continue  in  some  persons 
throughout  the  entire  year.  Their  tendency  is  to 
cease  with  the  full  development  of  the  organism, 
and  they  reappear  occasionally  in  advanced  life. 

Description. — The  regions  of  the  body  usually 
affected  with  chilblain  are  the  feet  and  hands,  to 
which  are  sometimes  added  the  ears  and  nose.  A 
chilblain  presents  three  stages  or  degrees  of 
severity,  namely,  erythematous,  bullous,  and  gan- 
grenous ; and  it  may  be  arrested  at  the  first  or 
second  stage  by  the  withdrawal  of  the  cause.  The 
erythematous  stage  is  restricted  to  hypermmia, 
swelling,  and  severe  burning  and  itching,  the 
itching  being  increased  by  heat,  as  by  that  of  the 
fire  or  that  induced  by  exercise.  The  congested 
spot  is  circular  in  figure,  somewhat  tumid, 
brightly  red  at  first,  but  later  on  roseate  crimson, 
purple,  or  livid  in  colour.  The  second  or 
bullous  stage  exhibits  the  blain  or  blister  re- 
sulting from  effusion  of  serum  beneath  the 
cuticle;  the  permanent  colour  of  the  swelling  is 


CHLOROSIS. 

now  purple  or  livid,  and  the  contents  of  the 
blister  a limpid  serum,  generally  reddened  with 
blood ; sometimes,  indeed,  the  fluid  of  the  blister 
may  be  semi-purulent.  In  the  gangrenous  stage 
the  blister  is  broken,  the  surface  of  the  derma 
is  in  a state  of  gangrene,  and  the  gangrenous 
layer  is  subsequently  removed  as  a slough  by 
ulceration. 

Treatment. — The  treatment  of  chilblain  re- 
quires to  be  modified  to  suit  its  different  degrees. 
In  the  first,  the  indication  is  to  restore  normal 
circulation  by  gentle  friction,  and,  when  the 
part  is  severely  chilled,  it  is  usual  to  rub  it  with 
snow ; then  some  soothing  liniment  may  be 
employed ; and,  finally,  a stimulating  liniment, 
covering  the  part  afterwards  with  zinc  ointment 
and  cotton  wool,  or  shielding  it  with  lead  or 
opium  plaster  spread  on  washleather.  The  lini- 
ments most  in  favour  for  this  purpose  are  tho 
soap  liniment  with  chloroform,  the  compound 
camphor  liniment,  the  turpentine  liniment,  and 
the  linimentum  iodi.  In  the  bullous  stage  a 
similar  treatment  may  be  used  to  the  erythema- 
tous portions,  whilst  the  blister  should  bo 
snipped  and  the  broken  surface  pencilled  with 
the  compound  tincture  of  benzoin,  and  afterwards 
dressed  with  unguentum  resinte  or  an  ointment 
of  Peruvian  balsam.  In  the  third  stage  the 
erythematous  phenomena  still  require  attention, 
and  the  ulcer  should  be  dressed  with  unguentum 
resinae,  either  alone,  or  in  combination  with 
spirits  of  turpentine. 

To  obviate  constitutional  debility,  the  diet 
should  be  nutritious  and  generous,  and  recourse 
may  be  had  to  tonic  remedies,  such  as  iron  and 
quinine.  Erasmus  Wilson. 

CHILL.  — A subjective  sensation  of  cold- 
ness, accompanied  with  shivering,  and  most 
frequently  experienced  in  connexion  with  febrile 
or  inflammatory  diseases,  in  nervous  individuals, 
and  after  exposure  to  cold  and  wet.  In  popular 
language  ‘ taking  a chill  ’ is  used  as  synonymous 
with  ‘ catching  a cold.’  See  Rigor. 

CHIN-COUGH. — A synonym  for  whooping- 
cough.  See  Whooping  Cough. 

CHIRAGRA  (xel p,  the  hand,  and  &ypa,  a 
seizure). — Gout  in  the  hand.  See  Gout. 

CHLOASMA  (\\ia,  a green  herb).  — 
Synon.:  Liverspot.  hr.  Ephelide ; Ger.  Leber jkek. 

A pigmentary  discolouration  of  the  skin,  of  a 
yellowish  brown  or  liver-colour  tint,  occurring 
in  blotches,  and  due  to  constitutional  causes. 
Its  synonym,  ephclis  gravidarum,  indicates  its 
occasional  association  with  pregnancy.  See 
Pigmentary  Skin  Diseases. 

Erasmus  Wilson. 

CELOHAL,  Poisoning  by.  See  Antidote 

CHLOROFORM,  Use  of.  See  Anaesthetics. 

CHLOROSIS  (x^upbs,  green  or  sallow-). 
Synon.:  Green-sickness;  hr.  La  chlorosc ; Ger 
Chlorose  ; Bleichsucht. 

Definition. — A variety  of  amemia  occurrirg 
in  a peculiar  diathesis  or  habit  of  body,  which 
is  characterised  by  deficient  growth  of  the  cor- 
puscular elements  of  the  blood,  and  of  the  vas 
cular  system. 


CHLOROSIS. 


The  subjects  of  this  diathesis  are  said  to  be 
:hlorotic.  They  ordinarily  enjoy  good  health, 
unless  exposed  to  any  of  the  causes  of  anaemia, 
when  they  speedily  suffer  from  aglobulism ; and 
this  aglobulism  may  proceed  to  complete  anaemia. 
The  term  chlorosis  is  properly  applied  to  the 
first  and  simpler  form  of  anaemia  in  these  sub- 
jects; while  the  second  and  more  complex  con- 
dition is  designated  cldor-anxmia ; or,  more 
commonly,  anemia  (see  Anosmia). 

^Etiology. — Chlorosis  occurs  almost  without 
exception  in  young  women  about  the  time  of 
puberty,  but  is  found  occasionally  in  children 
and  married  women,  and,  very  rarely,  even  in 
men.  It  is  believed  to  be  more  common  in  the 
higher  ranks  of  life.  Beyond  these  predisposing 
causes,  however,  the  very  origin  of  the  disease 
lies  in  a peculiar  condition  of  the  blood  and 
blood-vessels,  to  be  presently  described,  which 
is  believed  to  be  congenital,  and  perhaps  heredi- 
tary. In  such  subjects,  and  under  the  preceding 
circumstances,  any  of  the  numerous  causes  of 
anaemia  may  be  sufficient  to  excite  the  appear- 
ance of  chlorotic  symptoms,  but  those  which  do 
so  most  commonly  are  sexual  development,  the 
establishment  of  menstruation  and  its  disorders, 
and  an  insufficient  supply  of  light  to  the  circu- 
lating blood. 

Anatomical  and  Chemical  Characters. — 
The  blood  in  chlorosis  presents  three  definite 
and  distinct  imperfections.  First,  the  total 
quantity  of  blood  is  below  the  normal,  though 
there  may  be  an  excess  in  relation  to  the  calibre 
of  the  vessels  (plethora  ad  vasa).  Secondly,  both 
red  and  white  corpuscles  are  deficient  in  num- 
bers, and  that  proportionately.  Thirdly,  the 
individual  red  corpuscle  contains  less  than  the 
normal  amount  of  haemoglobin,  and  this  defi- 
ciency may  be  so  great  that  the  total  amount 
of  haemoglobin  in  the  blood  is  reduced  to  one- 
fourth.  It  is  an  important  negative  fact  that 
in  pure  chlorosis  the  quality  of  the  liquor  san- 
guinis is  unchanged. 

With  this  condition  of  blood  there  are  asso- 
ciated remarkable  abnormalities  of  the  aorta 
and  arterial  system  generally.  The  most  strik- 
ing of  these  is  a hypoplasia,  or  dwarfed  condi- 
tion of  the  aorta,  represented  by  small  calibre, 
increased  elasticity,  anomalous  origin  of  the 
branches,  and  unequal  thickness  of  the  intima. 
Along  with  these  there  may  bo  found — probably 
as  a consequence  of  the  preceding — fatty  meta- 
morphosis of  the  intima,  and  enlargement  of 
the  heart,  with  traces  of  endocarditis.  The 
blood-glands  and  lymphatic  structures  are  not 
diseased.  The  condition  of  the  ovaries  and 
uterus  has  been  carefully  examined  in  chlorosis 
and  found  to  vary  extremely.  In  some  cases 
the  generative  organs  are  described  as  ‘ infantile,’ 
while  in  others  they  are  either  immoderately 
developed,  or  perfectly  normal  in  every  respect. 
Corresponding  with  the  aglobulism,  the  sub- 
cutaneous fat  is  abundant;  and  the  viscera 
present  various  degrees  of  fatty  metamorphosis. 
When  the  eardio-vascular  changes  are  marked 
and  advanced,  there  may  be  extensive  secondary 
disease  throughout  the  body. 

Symptoms. — The  symptoms  of  simple  chlorosis 
are  those  of  mild  anaemia,  with  certain  impor- 
tant differences,  which  become  fewer  and  less 


237 

marked  and  finally  disappear  as  chlorosis  ad- 
vances to  the  more  serious  disease.  The  appear- 
ance of  the  chlorotic  girl  is  peculiar,  inasmuch 
as  the  pallor  of  her  complexion  is  accompanied 
by  natural  or  even  increased  fulness,  from  the 
excess  of  subcutaneous  fat.  At  the  same  time 
the  colour  of  the  skin  is  so  remarkable  as  to 
have  given  the  name  to  the  disease,  the  general 
hue  being  decidedly  yellow.  In  blondes  the 
transparency  of  the  skin  is  increased ; in  bru- 
nettes it  is  diminished,  and  a dull  yellowish- 
grey  colour  of  skin  is  the  result,  which,  in  con- 
trast with  the  greyish-blue  of  the  eyelids,  may 
appear  of  a sickly  green. 

The  patient’s  usual  complaint  is  of  this 
alteration  of  colour,  menstrual  disorder,  de- 
bility, great  breathlessness,  cardiac  symptoms, 
and  various  pains.  The  menstrual  symptoms 
are  always  prominent,  namely  amenorrhcea  or 
menorrhagia,  and  leucorrhoea.  Breathlessness 
on  exertion  is  one  of  the  most  striking  symp- 
toms. The  cardiac  symptoms  and  the  cardiac 
and  vascular  signs  closely  resemble  those  of 
ansemia.  But  there  is  this  important  difference 
in  the  phenomena  connected  with  the  heart,  that 
in  many  cases  of  chlorosis  they  indicate  enlarge- 
ment, and  especially  hypertrophy  of  the  left 
ventricle.  The  digestive  and  nervous  systems 
are  frequently  very  seriously  deranged.  The 
urine  is  abundant,  watery,  and  pale.  There  is 
no  dropsy  in  simple,  uncomplicated  chlorosis. 
Optic  neuritis  may  occur. 

The  chlorotic  diathesis  may  be  recognized  by  the 
following  characters,  which  are  variously  asso- 
ciated in  different  cases : — Diminutive  stature ; im- 
perfect sexual  development ; a history  of  peculiar 
anaemia  in  childhood,  of  anaemia  with  menstrual 
irregularity  at  puberty,  and  of  previous  attacks 
of  symptoms  of  chlorosis ; evidence  of  cardiac 
enlargement  or  mitral  disease  in  the  absence  of 
all  the  ordinary  causes  of  these;  the  occurrence 
of  endocarditis  during  pregnancy  or  post partam; 
and  the  presence  of  any  of  the  diseases  which 
will  be  referred  to  under  the  head  of  com- 
plications. 

Course,  Duration,  and  Terminations. — 
The  commencement  of  chlorosis  is  generally  gra- 
dual, but  may  be  sudden.  Its  ordinary  course  is 
towards  confirmed  ansemia,  in  which  it  may  ter- 
minate, the  liquor  sanguinis  becoming  affected, 
and  wasting  and  cedema  being  added  to  the 
previous  symptoms,  which  are  also  aggravated. 
It  is  for  this  reason  that  pure  chlorosis  is  a rare 
disease,  while  ansemia  associated  with  the  chlo- 
rotic diathesis  is  comparatively  common. — The 
duration  of  the  disease  is  variable ; it  rarely 
declines  until  the  determining  circumstances 
have  been  removed,  and  the  patient  subjected  to 
careful  treatment.  Chlorosis  may  reappear  in 
the  subject  of  the  diathesis,  and  that  more  than 
once  ; but  the  probability  of  its  return  is  small 
after  the  age  of  25,  especially  in  the  married 
female.  Death  from  chlorosis  directly  is  exces- 
sively rare. 

Complications  and  Sequelr. — According  to 
Virchow,  serious  valvular  disease  and  cardiac 
enlargement  may  be  traced  in  some  of  the  worst 
cases  of  chlorosis  to  the  associated  vascular  con- 
dition; and  the  mitral  valve  is  peculiarly  liable 
to  be  attacked  by  endocarditis  in  rheumatic, 


23b  CHLOROSIS, 

puerperal,  or  septic  feyor.  Haemorrhages,  gastric 
ulcer,  and  exophthalmic  goitre  are  believed  to 
occur  with  comparative  frequency  in  persons  of 
the  chlorotic  diathesis. 

Pathology. — The  deficiency  of  the  blood  in 
red  and  white  corpuscles,  and  of  the  individual 
red  corpuscle  in  haemoglobin,  described  above, 
indicates  an  imperfect  production  of  the  cellular 
elements  of  the  blood,  and  imperfect  growth  of 
the  red  corpuscles.  With  this  blood-state  there 
is  undoubtedly  associated  a hypoplastic  or 
dwarfish  condition  of  the  blood-vessels.  In  the 
embryo  the  blood  and  blood-vessels  are  de- 
veloped from  the  same  elements,  the  former 
making  its  appearance  within  the  cells  which 
produce  the  latter.  It  is  highly  probable,  there- 
fore, that  the  anomaly  of  blood  and  the  anomaly 
of  vessels  are  to  be  considered  as  together  an 
expression  of  some  congenital  defect  of  the  blood- 
vascular  system,  leading  to  imperfect  growth 
both  of  blood  and  of  vessels.  Any  individual 
possessing  a blood-vascular  system  thus  an- 
omalous labours  under  a peculiar  diathesis,  or 
debility  of  the  corpuscles  and  circulatory  system, 
and  is  said  to  be  a chlorotic  subject. 

If  the  other  systems  of  the  body  are  full-sized 
(which  is  not  always  the  case)  the  dwarfish  con- 
dition of  the  arteries  of  the  chlorotic  subject, 
and  the  scanty  supply  of  haemoglobin,  will  tend 
to  fail  to  supply  the  ordinary  demands  for  blood, 
and  especially  for  oxygen  ; and  at  every  period 
of  extraordinary  demand  within  the  economy  the 
blood-vascular  system  will  be  in  danger  of  break- 
ing clown.  Exposure  to  any  of  the  causes  re- 
ferred to  above  will  be  sufficient  to  produce  the 
symptoms  of  aglobulism,  that  is,  chlorosis  ; and 
that  when  they  would  not  affect  the  blood  of  an 
ordinary  non-chlorotic  individual.  This  effect  is 
peculiarly  striking  when  the  exciting  influence  is 
one  which  is  universally  recognised  as  an  impor- 
tant factor  in  the  production  of  chlorosis,  namely 
want  of  light ; for  light  is  essential  in  the  forma- 
tion of  haemoglobin,  and  to  the  health  of  the  red 
corpuscle.  Thus  the  special  phenomena  of  un- 
complicated chlorosis  are  those  of  aglobulism  or 
deficiency  of  the  oxygenating  substance  of  the 
organism ; and  they  furnish  one  of  the  purest 
examples  in  the  whole  range  of  pathology  of  the 
effects  of  want  of  oxygen  in  the  system  {see 
Blood,  Morbid  Conditions  of).  When  chlorosis 
advances  to  anaemia,  by  the  implication  of  the 
plasma,  a new  series  of  phenomena  present 
themselves,  prominent  among  which  are  loss  of 
flesh  and  (Edema  of  the  extremities. 

The  relation  of  the  cardiac  enlargement  and 
valvular  disease  to  the  vascular  hypoplasia  is 
a purely  physical  one.  More  complex  is  the 
connexion  between  the  blood-vascular  condition 
and  that  of  the  generative  organs.  The  chlo- 
rotic diathesis,  or  actual  chlorosis,  will  mani- 
festly interfere  with  the  development  and  activity 
of  the  ovaries  and  uterus  ; whilst,  on  the  other 
hand,  disorders  of  tko  sexual  functions  are 
amongst  tho  most  frequent  exciting  causes  of 
aglobulism. 

Diagnosis. — Chlorosis  is  to  be  distinguished 
from  symptomatic  and  idiopathic  anmmia  ; and 
the  points  by  which  the  diagnosis  may  be  ac- 
complished have  been  sufficiently  indicated 
above.  Leukaemia  may  be  readily  recognised 


CHOLERA,  ASIATIC. 

by  a careful  examination  of  the  blood  and 
spleen. 

Prognosis. — The  prognosis  is  highly  favour- 
able as  regards  life ; and  a speedy  cure  may  be 
assured  in  uncomplicated  cases  subjected  to 
careful  treatment. 

Treatment.  — The  success  of  a particular 
method  of  treatment  of  simple  chlorosis  is  one 
of  the  strongest  arguments  in  favour  of  the 
correctness  of  the  preceding  view  of  the  patho- 
logy of  the  disease.  The  condition  being  one  of 
aglobulism,  the  treatment  employed  will  he  so 
far  simpler  than  that  of  anaemia,  that  the  red 
corpuscles  alone  have  to  be  restored.  While  the 
various  measures  recommended  in  the  more 
serious  blood-disorder  are  therefore  to  be  em- 
ployed, if  necessary,  it  will  generally  be  found 
that  in  chlorosis  iron  alone  will  be  sufficient  to 
effect  a cure.  The  particular  form  in  which  the 
drug  is  to  be  presented  must  be  carefully  selected 
according  to  circumstances  which  need  not  he 
repeated  in  this  article.  A free  supply  of  sun- 
light is  essential,  and  must  be  insisted  upon ; and 
physiological  rest  of  the  blood  and  of  the  organs 
of  circulation  is  equally  necessary. 

J.  Mitchell  Bruce. 

CHOLAGOG  UE1S  (x°*-b,  bile,  and  &ya,  I 
move). — Definition. — Substances  which  lessen 
the  amount  of  bile  in  the  blood. 

Enumeration. — The  principal  cholagogues 
are  Mercury  and  its  preparations — especially 
calomel  and  blue  pill ; Podophyllum  and 
Podophyllin ; Aloes ; and  Rhubarb. 

Action  and  Uses. — The  liver  has  a two- 
fold action — it  forms  bile,  which  is  poured  into 
the  duodenum ; and  it  also  excretes  the  bile 
which  has  been  reabsorbed  from  the  duodenum 
and  carried  back  to  the  liver  by  the  portal  cir- 
culation. Much  bile  thus  circulates  continually 
between  the  liver  and  duodenum,  while  part  is 
carried  down  the  intestine  with  the  feces,  and 
its  place  supplied  by  newly-formed  bile.  When 
the  quantity  circulating  in  this  way  is  too  great  to 
he  completely  excreted  by  the  liver,  it  enters  the 
general  circulation  and  produces  symptoms  of 
biliousness.  These  are  removed  by  the  so-called 
cholagogues,  which  probably  act  by  stimulating 
the  duodenum,  and  thus  carrying  the  bile  so  far 
down  the  intestine  as  to  interfere  with  re-absorp 
tion.  Amongst  the  best  cholagogues  are  the  pre- 
parations of  mercury,  which  do  not  increase  the 
secreting  power  of  the  liver,  nor  augment  tho 
quantity  of  bile  formed  by  it.  Their  utility  is 
greatly  increased  by  combination  with  a saline 
purgative,  which  stiU  further  clears  out  the  in- 
testine, and  completely  prevents  any  re-absorp- 
tion of  bile.  Other  cholagogues,  such  as  podo- 
phyllin,  rhubarb,  and  aloes,  actually  increase  the 
secretion  of  bile  by  the  liver.  At  the  same  time, 
they  probably  prevent  its  re-absorption,  in  a 
similar  way  to  mercurials  and  salines. 

T.  Lauder  Bruxtox. 

CHOLELITHIASIS  {xo\tj,  bile,  and  \l6o s, 
a stone). — The  condition  of  system  associated 
with  gall-stones.  See  Gall-Stones. 

CHOLERA,  ASIATIC. — Syxox.  : Serous 
cholera,  Spasmodic  cholera,  Malignant  cholera  ; 
Er.  Cholera  asiatique ; Ger.  asiatische  Cholera. 


CHOLERA,  ASIATIC. 


Definition. — Asiatic  cholera  is  a specific  dis- 
ease, characterized  by  violent  vomiting  and  purg- 
ing, with  rice-water  evacuations,  cramps,  prostra- 
tion, collapse,  and  other  striking  symptoms ; tend- 
ing to  run  a rapidly  fatal  course;  and  capable  of 
being  communicated  to  persons  otherwise  in  sound 
health,  through  the  dejecta  of  patients  suffering 
from  the  disease.  These  excreta  are  most  com- 
monly disseminated  among  a community,  and 
taken  into  the  system  by  means  of  drinking  water, 
or  in  fact  by  anything  swallowed  which  has  been 
contaminated  by  the  organic  matter  passed  from 
cholera  patients.  In  badly  ventilated  rooms,  th-e 
atmosphere  may  become  so  fully  charged  with  the 
exhalations  from  patients  suffering  from  cholera 
as  to  poison  persons  employed  in  nursing  the 
sick.  In  the  same  way  people  engaged  in 
carrying  the  bodies  of  those  who  have  died  from 
cholera  for  burial,  or  in  washing  their  soiled 
linen,  may  contract  the  malady.  In  a dried  con- 
dition the  organic  poison  contained  in  cholera 
excreta  may  retain  its  dangerous  properties  for  a 
long  time. 

The  disease  is  endemic  in  certain  parts  of 
British  India,  where  from  time  to  time  it  assumes 
a virulent  type,  and  is  apt  then  to  spread,  through 
the  means  above  indicated,  along  the  great  lines 
of  human  intercourse,  and  so  to  extend  over  the 
world. 

History. — Since  the  days  of  Hippocrates 
medical  practitioners  residing  in  various  parts 
of  Europe  have  described  a disease  which  they 
called  cholera.  The  nosology  of  this  affection 
was  hardly  amatter  of  doubt  with  them,  and  it  is 
only  in  modern  times  that  the  question  has  arisen 
as  to  whether  the  cholera  commonly  met  with 
among  us  is  identical  in  its  nature  with  Asiatic 
cholera.  Doubtless,  if  we  compare  isolated  cases 
we  may  find  that  the  symptoms  which  these 
affections  induce  are  very  similar ; but  those 
who  have  lived  beyond  the  endemic  area  of 
Asiatic  cholera,  and  watched  the  disease  spread 
from  India  over  Europe  and  America,  can  scarcely 
mistake  this  malignant  malady  for  simple  cholera. 
Asiatic  cholera  was  unknown  in  Europe  before 
the  year  1829-30,  although  it  has  existed  in 
India  for  many  centuries.  It  is  true  we  have 
no  accounts  of  cholera  extending  throughout 
the  whole  of  Hindustan  prior  to  the  year  1817, 
but  this  arises  from  the  circumstance  that  it 
was  only  at  the  commencement  of  the  present 
century  that  the  British  Government  began  to 
bind  the  heterogeneous  principalities  of  India 
into  union,  and  thus  render  it  possible  for  us 
to  gather  together  authentic  details  regarding 
the  disease  as  it  spreads  from  one  province  to 
another. 

AVe  cannot  here  fully  consider  the  relations 
which  unquestionably  exist  between  the  rapidity 
of  the  diffusion  of  cholera  from  the  East  over 
Europe,  and  the  increased  facilities  of  communi- 
cation that  have  lately  been  established  between 
India,  and  Persia,  and  Arabia,  also  from  Hin- 
dustan to  Russia,  and  the  shores  of  the  Medi- 
terranean. Eor  instance,  forty  years  ago  the 
passage  from  Bombay  up  the  Arabian  and 
Persian  Gulfs  could  only  be  undertaken  at  cer- 
tain seasons  of  the  year  when  the  winds  were 
favourable,  and  even  then  the  voyage  was  te- 
dious and  most  difficult  to  accomplish ; now 


239 

largo  steameis  run  every  week  from  Bombay 
to  Bassorah  and  the  intermediate  ports  along  the 
Persian  Gulf,  and  others  pass  with  equal  rapi- 
dity to  the  various  towns  bordering  the  Red  Sea. 
But  although  we  cannot  enter  farther  into  this 
subject,  we  must,  in  order  to  appreciate  the 
nature  of  cholera,  glance  at  the  chronological 
order  of  some  of  the  principal  outbursts  of  the 
disease  which  have  been  disseminated  from 
British  India  over  the  world. 

In  1817  cholera  spread  rapidly  throughout 
Bengal ; extending  during  the  following  year  over 
the  greater  part  of  Hindustan,  and  from  thence 
to  Ceylon,  Burmah,  and  China.  The  disease  was 
communicated  from  Bombay  via  the  Persian 
Gulf  in  1820-21,  and  travelled  northward,  hut 
did  not  extend  into  Europe. 

During  the  year  1826  cholera  again  hurst 
out  over  Bengal,  and  passing  through  the  Pun- 
jaub,  it  entered  Cabul  in  1828.  and  from  thence 
extended  to  Persia,  and  so  to  Russia  during  the. 
years  1829-30,  and  over  the  whole  of  Europe  and 
the  groater  p:irt  of  America. 

In  1810-41  cholera  accompanied  a British 
force  despatched  from  Calcutta  to  China : it 
broke  out  among  our  troops  on  their  voyage  to 
that  country,  and  having  spread  throughout 
the  Chinese  and  Burmese  empires,  it  passed  in 
1843-44  through  Kashgar  to  Bokhara,  and  so  to 
Cabul.  From  Afghanistan  the  disease  extended 
south  into  Scinde,  and  westward  in  1845-46 
through  Persia  to  Russia  and  Europe,  reaching 
America  in  1848. 

In  1849  cholera  was  very  fatal  over  Bengal, 
and  during  the  season  of  1851-52  it  was  comma 
nicated  through  the  Punjaub  and  Bombay  re 
spectively  to  Persia  and  .Arabia,  and  in  1853-54 
it  spread  via  Russia  and  Egypt  with  frightful 
virulence  throughout  Europe  and  America. 

During  the  years  1860-61-62  cholera  pre- 
vailed to  an  alarming  extent  throughout  Bengal 
and  the  Central  Provinces,  and  in  1864-65  in 
Bombay  and  along  the  shores  of  the  Red  fc'ea ; 
thence  it  passed  with  pilgrims  from  Mecca  to 
Egypt,  and  so  to  Europe,  and  for  the  fourth  time 
to  America. 

These  various  outbursts  of  cholera  were  usually 
remarkably  sudden  in  their  advent,  a consider- 
able number  of  people  in  the  affected  locality 
being  attacked  by  the  disease  within  a few  days 
after  it  appeared  among  them.  The  malady  almost 
invariably  died  out  from  amongst  the  inhabitants 
of  a country  under  its  influence  during  the 
cold  seasons  of  the  year,  to  re-appear  on  the 
approach  of  summer.  As  a general  rule  the 
disease  was  most  deadly  during  the  first  year  of 
the  epidemic;  it  decreased  in  violence  the  second 
season  ; and  then  gradually’  disappeared,  seldom 
prevailing  in  any  one  locality  for  more  than 
three  consecutive  years. 

.ZEtiology. — The  more  we  study  the  history 
of  Asiatic  cholera  the  better  shall  we  understand 
that  every  outburst  of  tbo  disease  which  has  oc- 
curred beyond  the  confines  of  India  might  invari- 
ably be  traced  back  through  a series  of  cases  to 
that  country ; the  disease  has  never  broken  out 
spontaneously  in  any  other  part  of  the  world — no 
amount  of  filth,  bad  food,  or  climatic  influences 
have  up  to  the  present  time  induced  a widespread 
epidemic  of  cholera.  The  inhabitants  of  couji- 


240  CHOLERA.  ASIATIC. 


trios  far  removed  from  Hindustan,  and  having 
limited  communication  with  that  empire,  such  as 
Australia,  have  not  experienced  the  disease; 
whereas  those  states  which  have  been  brought 
into  intimate  relation  with  India  have  become 
frequently  subject  to  outbreaks  of  cholera. 

Many  of  the  earliest  Anglo-Indian  authors 
declared  their  conviction  that  the  disease  was 
contagious  ; others  disputed  this  idea  ; but  all 
agreed  tliat  cholera  when  extending  over  a 
country  often  settled  on  the  inhabitants  of  low- 
lying,  ill-drained,  and  overcrowded  localities,  and 
that  it  frequently  left  unharmed  people  residing 
beyond  the  affected  area,  although  they  might 
have  been  employed  in  attending  patients  suf- 
fering from  the  disease.  It  remained  for  Dr. 
Snow,  in  1854,  to  explain  this  apparent  mystery, 
and  to  demonstrate,  as  he  did  by  means  of  the 
Broad  Street  case,  that  the  poison  which  causes 
cholera  is  contained  in  the  excrements  of 
those  suffering  from  the  disease,  and  ‘ that  if  by 
leakage,  soakage  from  cesspools  or  drains,  or 
through  reckless  casting  out  of  slops  and  wash- 
water,  any  taint,  however  small,  of  the  infective 
material  gets  access  to  wells  and  other  sources 
of  drinking  water,  it  imparts  to  enormous  volumes 
of  water  the  power  of  propagating  the  disease  ’ 
(Simon).  Cholera  patients  cannot,  in  fact,  com- 
municate the  affection  to  others,  unless  by 
means  of  the  discharges  which  they  pass.  Per- 
sons attending  them  run  no  risk  of  contracting 
the  disease  provided  they  are  protected  from 
swallowing  the  organic  poison  passed  by  the 
sick ; but  in  badly  ventilated  rooms,  this  organic 
matter  having  been  disseminated  in  consider- 
able quantities  through  the  atmosphere,  may  be 
taken  into  the  system  by  attendants,  and  so 
poison  them. 

Dr.  W.  Aitken  observes  that  the  evidence  in 
favour  of  the  communicability  of  cholera  by 
means  of  water  or  food  contaminated  with  cho- 
lera dejecta  has  since  1854  become  almost  over- 
whelming. A remarkable  instance  of  the  land 
reported  by  Mr.  N.  Radcliffe  took  place  in  East 
London  during  the  year  I860  ; and  previous  to 
this  time  the  circumstances  of  a case  came  under 
the  writer’s  notice,  in  which  a small  quantity  of  a 
fresh  rice-water  stool  passed  by  a patient  suffer- 
ing from  cholera  was  accidentally  mixed  with  some 
four  or  five  gallons  of  water,  and  the  mixture 
exposed  to  the  rays  of  the  tropical  sun  for  twelve 
hours.  Early  the  following  morning  nineteen 
people  each  swallowed  about  an  ounce  of  this 
contaminated  water — they  only  partook  of  it 
once, — but  within  thirty-six  hours  five  of  these 
nineteen  persons  were  seized  with  cholera.  In 
this  instance  the  choleraic  evacuation  did  not 
touch  the  soil ; as  it  was  passed,  so  was  it  swal- 
lowed, but  (and  this  is  most  important  to  remem- 
ber) it  had  been  largely  diluted  with  impure 
water,  and  the  mixture  had  been  exposed  to  the 
light  and  heat  of  a tropical  sun  for  twelve  hours. 

Doubtless  we  have  much  yet  to  learn  regarding 
the  nature  of  the  organic  substance  which  causes 
cholera.  Professor  Pettenkofer  holds  that  if 
this  material  after  leaving  the  human  body 
happens  to  pass  into  the  ground,  it  may 
there,  under  peculiar  conditions  of  soil,  mois- 
ture, and  heat,  undergo  definite  changes,  and 
then,  having  risen  as  a miasma  into  the  air,  may 


poison  those  who  are  predisposed  to  the  disease  ; 
the  earth,  according  to  this  theory,  seems  called 
on  to  play  the  part  in  the  rule  of  cholera  which 
has  been  assigned  in  former  times  to  solar, 
lunar,  electrical,  or  epidemic  influences.  The 
conclusions  recently  arrived  at  in  Bengal  by 
Drs.  Lewis  and  Cunningham  rather  incline  to- 
wards this  view.  The  difficulty  of  working  out 
these  problems  in  relation  to  the  infecting  ma- 
terial of  cholera  is  enhanced  by  the  fact,  that 
the  human  is  the  only  animal  which  is  incontes- 
tably subject  to  its  influence.  "We  must,  however, 
refer  our  readers  to  some  admirable  papers  by 
Dr.  E.  Parkes,  published  in  the  Army  Medical 
Department  Deports,  for  accurate  knowledge  on 
this  subject. 

Predisposing  Causes. — Persons  arriving  in  an 
infected  area  are  predisposed  to  the  disease. 
Beyond  this  fact  nothing  certain  is  known  con- 
cerning the  existence  of  predisposing  causes  of 
the  disease. 

Anatomical  Characters. — The  external  ap- 
pearances of  the  bodies  of  those  who  have  died 
of  cholera  present  the  mottled  skin,  shrunken  and 
livid  appearance  of  the  limbs,  and  other  features 
hereafter  described  as  characteristic  of  the  disease 
during  the  stage  of  collapse.  The  temperature 
of  the  body  rises  after  death,  and  it  remains 
warm  for  some  time.  Rigor  mortis  sets  in  speedily 
and  is  sometimes  accompanied  with  muscular 
contractions,  which  displace  the  limbs  of  the 
corpse. 

With  regard  to  the  internal  lesions  observed 
after  death  from  Asiatic  cholera,  the  writer's 
observations  lead  him  to  the  conclusion,  that 
almost  the  only  alterations  noticed  in  the  tissues 
are  due  to  the  physical  and  chemical  characters 
of  the  blood  having  been  changed,  consequent  on 
its  loss  of  water.  The  mucous  surface  of  the 
stomach  and  small  intestines  is  injected  and 
swollen,  and  its  epithelial  cells  contain  micro- 
cocci; this  epithelium  drops  off  the  surface 
of  the  mucous  membrane  in  large  patches  within 
an  hour  and  a half  after  death ; and  whatever 
may  be  the  nature  of  the  changes  going  on  in  the 
epithelial  coat  of  the  intestinal  canal  in  cases  of 
cholera,  there  can  be  no  doubt  as  to  its  being 
extensively  affected  in  this  disease. 

Anatomical  changes  of  a specific  nature,  es- 
pecially with  reference  to  the  amount  of  blood 
contained  in  the  right  side  of  the  heart  and  lungs, 
have  been  described  by  pathologists  as  being 
characteristic  of  Asiatic  cholera ; and  in  manv 
instances  after  death  from  this  disease,  if  the 
post-mortem  is  delayed  for  a few  hours,  the 
right  side  of  the  heart  will  be  found  full  of 
blood,  together  with  the  pulmonary  artery 
and  its  divisions ; while  the  lungs  are  collapsed 
and  bloodless.  But  the  writer  holds  that  there 
are  numerous  exceptions  to  this  state  of  the 
heart  and  lungs,  and  that  the  condition  above 
described  is  not  infrequently  due  to  post-mortem 
changes ; and  if  the  bodies  of  those  who  have 
died  of  cholera  be  examined  immediately  after 
death,  the  left  side  of  the  heart  will  be  found 
as  full  of  blood  as  the  right  side,  but  as  post- 
mortem rigidity  sets  in,  the  blood  is  forced  from 
the  left  ventricle  into  the  aorta,  and  in  fact  from 
the  large  arteries  of  the  body  into  the  capillaries 
and  veins.  Ho  has  less  hesitation  in  express- 


CHOLERA, 

ing  an  opinion  of  this  kind,  because  under 
“imilar  circumstances  he  was  misled  into  attri- 
buting an  important  place  in  the  pathology  of 
cholera  to  the  shedding  of  the  intestinal  epithe- 
lium, as  observed  after  death  : more  recent  re- 
searches have,  however,  convinced  him  that  the 
shedding  of  the  epithelial  cells,  cn  masse,  is  also 
a post-mortem  change,  which  takes  place  usually 
about  an  hour  and  a half  or  two  hours  alter 
death. 

Symptoms. — Asiatic  cholera  is  most  deadly 
at  the  commencement  of  an  epidemic,  and  then 
usually  begins  without  premonitory  symptoms. 
The  patient  feels  well  lip  to  within  a few  hours 
of  the  attack,  or,  it  may  be,  goes  to  bed  and 
sleeps  soundly  through  the  night,  and  imme- 
diately on  rising  in  the  morning  is  seized  with 
violent  purging  and  vomiting.  After  the  first 
outburst  of  the  disease,  as  a rale,  cholera 
commences  with  diarrhoea,  the  stools  being  copious 
and  watery,  followed  by  great  prostration  of 
strength,  with  a peculiar  feeling  of  exhaustion  at 
the  pit  of  the  stomach ; the  sick  person  suffers 
from  nausea,  but  seldom  from  actual  vomiting 
or  pain  at  the  outset  of  the  attack.  If  judi- 
ciously treated,  many  patients  recover  from  this, 
the  first  stage  of  cholera,  but  if  neglected  the 
tendency  of  the  disease  is  to  grow  rapidly  worse. 
The  stools  become  very  frequent,  and  resemble  in 
appearance  and  consistency  the  water  in  which 
rice  has  been  boiled : these  liquid  evacuations 
flow  away  from  the  sick  person  with  a sense 
of  relief  rather  than  otherwise  ; but  the 
patient  now  commences  to  vomit,  first  throwing 
up  the  contents  of  his  stomach,  and  subsequently 
all  the  water  he  drinks,  mixed  with  mucus  and 
disintegrated  epithelium  ; the  fluid  is  ejected  from 
his  mouth  with  considerable  force,  and  this  adds 
to  the  increasing  prostration  which  is  one  of  the 
most  urgent  and  marked  features  of  the  disease 
The  patient  complains  of  intense  thirst,  and  a 
burning  heat  at  the  pit  of  his  stomach : he  suffers 
also  excruciating  pain  from  cramps  in  the 
muscles  of  the  extremities ; he  is  terribly  restless ; 
and  his  urgent  cry  is  for  water  to  quench  his 
thirst,  and  that  some  one  might  rub  his  limbs, 
and  thus  relieve  the  muscular  spasm.  Although 
the  temperature  of  the  sick  person's  body  falls 
below  the  normal  standard,  he  complains  of  feel- 
ing hot,  and  throws  off  the  bed-clothes  in  order 
that  he  may  keep  himself  cool.  The  pulse  is 
rapid  and  very  weak,  the  respirations  are  hurried, 
and  the  patient's  voice  becomes  husky.  His  coun- 
tenance is  pinched,  and  the  integument  of  his 
body  feels  inelastic  and  doughy,  while  the  skin  of 
his  hands  and  feet  becomes  wrinkled  and  purplish 
in  colour.  The  duration  of  this,  the  second  stage 
of  cholera,  is  very  uncertain ; it  may  last  for  two 
or  three  hours  only,  or  may  continue  for  twelve  or 
fifteen  hours  ; but  so  long  as  the  pulse  can  be  felt  at 
the  wrist,  there  are  still  good  hopes  of  the  sick 
person’s  recovery.  The  weaker  the  pulse  becomes, 
the  nearer  the  patient  is  to  the  third,  or  collapse- 
stage  of  cholera,  from  which  probably  not  more 
than  thirty-five  per  cent,  recover.  This,  how- 
ever, depends  much  on  the  condition  of  the 
patient’s  heart ; it  is  quite  possible,  although 
the  cases  must  be  rare,  that  a sudden  out- 
pouring of  fluid  into  the  intestinal  canal  has 
been  oufficient  to  cause  syncope  and  death,  among 

16 


ASIATIC.  241 

persons  suffering  from  a weak  heart,  before  the 
liquid  contents  of  the  bowels  have  had  time  to  be 
rejected  either  by  the  mouth  or  anus.  In  the  third 
stage  of  the  disease  the  vomiting  and  purging  con- 
tinue, although  in  a mitigated  form;  and  the  skin 
is  covered  with  a clammy  perspiration,  especially 
if  the  cramps  are  still  severe.  We  now  cease  to 
be  able  to  feel  the  pulse  at  the  wrist,  the  lividity 
of  the  extremities  and  surface  of  the  body  in- 
creases, the  patient  cannot  speak  above  a low 
whisper,  his  breathing  is  very  rapid,  his  eye- 
balls are  deeply  sunk  in  their  sockets,  and  his 
features  are  marvellously  changed  within  a few 
hours.  The  urine  is  suppressed.  The  tempera- 
ture of  his  body  may  fall  as  low  as  94°  Fahr. 
The  patient  remains  terribly  restless,  longing  only 
for  sleep,  and  that  he  may  be  supplied  with  water. 
His  intellect  is  clear,  but  he  seldom  expresses 
any  anxiety  regarding  worldly  affairs,  although 
fully  conscious  of  the  dangerous  condition  h& 
is  in;  sleep,  and  a plentiful  supply  of  drinking 
water,  are  the  sole  desires  of  a person  passing 
through  the  collapse-stage  of  cholera.  This 
condition  seldom  lasts  for  more  than  twenty-four 
hours,  and  reaction  either  commences  within 
that  period,  or  the  patient  dies  in  collapse,  or 
passes  on  into  the  tepid  stage,  which  in  ninety- 
nine  cases  out  of  a hundred  ends  speedily  in 
death.  In  the  tepid  stage  of  the  disease  the  sick 
person's  body  feels  cold  to  the  touch,  but  the 
temperature,  as  shown  by  the  thermometer,  be- 
gins to  rise  very  rapidly,  sometimes  marking  99° 
or  100°  F.  The  purging  and  vomiting  cease,  and 
the  patient  lies  in  a semi-comatose  state,  his  eyes 
half  open,  the  ocular  conjunctiva  being  deeply 
congested,  the  cornea  hazy,  and  the  pupils  fixed  ; 
the  pulse  can  be  felt  at  the  wrist,  but  the  respira- 
tion is  very  hurried,  suppression  of  urine  con 
tinues,  the  patient’s  body  is  bathed  in  a cold 
clammy  perspiration,  the  skin  becomes  of  a 
dusky  red  hue,  and  death  too  frequently  closes 
the  scene  within  a few  hours. 

On  the  other  hand,  the  sick  person  having 
been  in  the  collapse-stage  of  cholera  some  twenty- 
four  hours  (it  maybe  a longer  or  shorter  period), 
the  temperature  of  his  body  may  begin  to  rise, 
gradually  creeping  up  to  the  normal  standard ; 
the  respiration  diminishes  in  frequency ; the 
pulse  returns  ; the  patient  can  sleep,  and  after 
some  thirty-six  hours  may  pass  a little  urine  ; in 
fact,  the  functions  of  animal  life  are  slowly  re- 
stored, and  the  sick  person  recovers  his  health. 
This  desirable  result,  however,  is  not  infre- 
quently thwarted  by  various  complications  which 
arise  during  the  stage  of  reaction.  Of  these 
complications  the  following  are  the  most  impor- 
tant : — suppression  of  urine;  gastritis  and 
enteritis  ; pulmonary  congestion  ; meningitis  ; 
sloughing  of  the  cornea  ; abscesses  over  the  body; 
the  formation  of  coagula  in  the  right  side  of  the 
heart  or  pulmonary  arteries;  haemorrhage  from 
the  bowels ; and  roseola-choleraica. 

Diagnosis. — -The  question  of  the  diagnosis  of 
Asiatic  cholera  is  discussed  in  the  article  on 
Choleraic  Riarrhcea. 

Prognosis. — The  means  of  forming  a prognosis 
in  cholera  will  he  gathered  from  the  preceding 
account  of  the  disease. , Speaking  generally,  the 
prognosis  depends  chiefly  upon  the  stage  of  the 
disease,  and  upon  the  time  of  the  epidemic! — 


212  CHOLERA, 

that  is,  according  as  the  patient  has  been  seized 
at  the  outbreak,  at  the  height,  or  towards  the 
end  of  an  epidemic. 

Treatment. — In  the  first  stage  of  Asiatic 
cholera  we  should  endeavour  to  stop  the  purging, 
and  without  doubt  opium  is  the  drug  upon  which 
we  may  with  the  greatest  confidence  rely  for 
effecting  this  purpose.  When  practising  in  the 
endemic  area  of  cholera  the  writer  was  in  the 
habit  of  carrying  about  pills  containing  one 
grain  of  opium  and  four  of  acetate  of  lead,  so 
that,  if  called  to  see  a patient  suffering  from  the 
disease  in  its  early  stage,  no  time  was  lost  in 
administering  one  of  these  pills  dissolved  in 
water.  The  next  thing  done  was  to  make  a 
large  mustard  poultice,  and  apply  it  over  the 
whole  surface  of  the  patient’s  abdomen.  The 
sick  person  was  ordered  to  remain  in  bed,  and 
to  be  allowed  nothing  in  the  shape  of  food  or 
water  ; but  he  might  suck  as  much  ice  as  he  felt 
iu  dined  for. 

If,  after  the  first  pill,  the  patient  was  again 
purged,  a second  was  given,  and  a third  (but 
not  more)  after  each  loose  motion.  It  often 
happened  that  the  first  or  second  pill,  together 
with  the  mustard  poultice,  ice,  and  rest,  was 
sufficient  to  check  the  progress  of  the  disease, 
and  the  patient  recovered.  Supposing  this  treat- 
ment not  to  succeed,  or  that  on  first  seeing  the 
patient  it  be  found  that  he  has  passed  into 
the  second  stage  of  the  disease,  we  should  still 
prescribe  the  pill,  as  above  directed,  dissolving  it 
in  water,  because  in  the  solid  form  it  might  be 
rejected  entire,  and  under  any  circumstances  it 
would  take  time  to  be  dissolved,  by  the  fluid 
contained  in  the  stomach ; the  mustard  poultice 
also  should  be  applied,  and  the  sick  person 
kept  warm  and  in  bed.  Icc  is  invaluable  in  this 
stage  of  the  disease,  and  unless  a person  has 
passed  through  an  attack  of  cholera,  it  is  impos- 
sible to  realise  the  immense  relief  it  affords  ; it 
should  be  given  in  small  lumps,  the  sick  person 
eating  and  swallowing  as  much  as  he  chooses  ; 
he  will  frequently  devour  a pound  or  two  of  ice 
in  the  course  of  an  hour,  and  he  canDot  take  too 
much  of  it.  In  the  treatment  of  cholera  there 
can  be  no  question  as  to  the  value  of  ice.  The 
patient  should  be  prohibited  from  drinking 
water  or  any  other  fluid  beyond  that  which 
he  gets  from  the  ice.  The  practitioner  must 
be  firm  on  this  point,  turning  a deaf  ear  to  the 
entreaties  of  the  sick  man  or  his  friends,  that 
he  may  bo  permitted  to  swallow  even  a small 
quantity  of  water,  for  if  they  once  break  through 
this  rule,  it  will  be  impossible  to  limit  the 
amount  of  liquid  the  patient  will  consume.  If 
this  treatment  does  not  check  the  progress  of 
the  malady,  we  may  prescribe  three  grains  of 
acetate  of  lead  and  fifteen  drops  of  diluted  acetic 
acid  in  water  every  second  hour,  and  fifteen 
drops  of  diluted  sulphuric  acid  in  water  every 
alternate  hour,  so  that  the  patient  should  take 
a draught,  first  of  one  mixture  then  of  the  other, 
every  hour.  The  writer  often  combines  five 
drops  of  spirit  of  camphor  with  each  dose  of  the 
medicine,  but  this  drug  requires  care  in  its  admi- 
nistration, and  should  seldom  be  continued  beyond 
live  or  six  doses  of  from  five  to  ten  drops  each. 
Should  the  vomiting  be  very  severe,  in  spite  of 
the  free  administration  of  ice,  a second  mustard 


, ASIATIC. 

poultice  should  be  applied  over  the  abdomen ; all 
medicine  must  then  be  omitted  for  an  hour  and  a 
half,  after  which  time  a scruple  of  calomel  may  be 
sprinkled  on  the  patient’s  tongue,  and  he  should 
be  made  to  wash  it  down  with  a little  iced  water. 
The  cramps  are  best  relieved  by  hand-friction,  and 
if  very  severe,  ease  may  from  time  to  time  be 
given  by  allowing  the  patient  to  inhale  some 
ether.  The  writer  prefers  this  practice  to  ad- 
ministering hydrate  of  chloral,  either  by  the  mouth 
or  by  subcutaneous  injection.  Hot  water  bottles 
should  be  applied  to  the  soles  of  the  patient’s  feet, 
and  also  to  his  legs  and  abdomen. 

Should  the  disease  have  reached  the  collapse- 
stage  there  is  but  little  we  can  do  for  the  patient. 
Ice  must  still  be  given,  and,  if  the  purging  is  fre- 
quent, the  sulphuric  acid  draught  (butno  opium) 
may  be  administered  every  hour ; heat  and  friction 
may  with  advantage  be  applied  to  thesurfaceof  the 
body ; and  the  patient  may  now  be  permitted  to 
drink  iced  water  in  moderation,  provided  it  does 
not  increase  the  vomiting.  According  to  the  writer’s 
experience,  wine  and  stimulants,  if  given  by  the 
mouth,  do  harm  in  this  stage  of  cholera  ; but,  if 
the  purging  has  abated,  enemas  of  warm  beef-tea 
and  brandy  may  be  administered  by  the  rectum 
every  third  hour.  When  reaction  comes  on,  we 
must  guard  against  doing  too  much — it  is  very 
rare  indeed  to  see  a patient  in  this  condition  sink 
from  exhaustion,  but  probably  many  lives  are  lost 
by  endeavours  erroneously  made,  under  the  idea 
of  keeping  up  the  patient’s  strength.  Iced  milk 
or  arrowroot  is  all  that  should  be  allowed  to  be 
given  by  the  mouth  for  some  time  after  reaction 
has  set  in  ; but  enemas  such  as  those  above-men- 
tioned, administered  per  rectum  every  five  or  six 
hours,  are  often  beneficial,  especially  if  the  stomach 
remains  irritable ; and  under  these  circumstances 
we  not  unfrequently  find  that  a small  quantity 
of  solid  food  is  easily  digested,  when  soup  and 
liqttids  are  rejected.  In  each  case,  however,  the 
dictates  of  common  sense  and  experience  must 
guide  the  medical  practitioner  in  his  treatment 
of  the  sick  persou  through  the  convalescent  stage 
of  the  disease. 

With  reference  to  the  treatment  of  suppres- 
sion of  urine  after  cholera,  we  should  get  the 
patient  to  drink  about  half  a pint  of  water  every 
second  hour,  so  as  to  add  fluid  to  his  blood.  Dry- 
cupping over  the  loins  should  be  employed ; and 
ten  drops  of  the  tincture  of  cantharides  in  water 
administered  every  hour,  until  a drachm  of  the 
drug  has  been  given.  It  need  hardly  be  remarked 
that  suppression  of  urine  after  cholera  is  a most 
dangerous  complication,  and  there  is  very  little 
that  can  be  done  to  restore  the  suspended  func 
tions  of  the  kidneys. 

Preventive  Treatment. — Among  persons  pre- 
disposed to  its  influence,  the  infecting  material 
of  Asiatic  cholera  will  manifest  its  effects  on 
the  system  within  five  days  i of  having  been 
swallowed,  but  the  poison  does  not  always 
engender  symptoms  of  virulent  cholera.  Never- 
theless, in  milder  cases  of  the  disease  the 
evacuations  passed  by  the  patient  may  contain 
the  germs  of  cholera,  and  these  evacuations  are 
therefore  capable,  under  certain  circumstances, 
of  developing  a deadly  type  of  the  malady : cod- 
sequently,  the  following  remarks  are  applicable 
to  instances  of  so-called  cholerine,  as  well  as 


CHOLERA,  ASIATIC, 

to  the  severer  forms  of  cholera.  If  the  disease 
has  appeared  within  a neighbourhood, a searching 
examination  must  be  made  into  the  condition 
and  source  of  the  local  water-supply,  not  over- 
looking that  of  the  milk,  which  is  too  often 
diluted  with  water  before  being  sold.  All  sur- 
face and  doubtful  wells  (especially  those  in  tho 
proximity  of  drains  and.  cesspools)  should  be 
immediately  closed;  and  it  is  desirable  that  the 
drinking  water  before  being  consumed  should  be 
careful  ly  filtered.  All  accumulations  of  house 
refuse  and  filth  must  be  removed;  and  dirty 
places,  both  within  and  without  uncleanly  pre- 
mises, must  be  freely  disinfected  and  cleansed. 
There  is  no  necessity  when  the  disease  is  preva- 
lent for  making  any  alteration  in  the  usual  diet; 
but  in  times  of  cholera  we  cannot  too  strongly 
insist  on  at  once  checking  any  tendency  to  diar- 
rhoea, especially  if  it  be  of  a watery  nature. 
Many  cases  of  incipient  cholera  have  been  pre- 
vented from  running  on  into  dangerous  disease, 
by  the  early  administration  of  pills  containing 
four  grains  of  acetate  of  lead  ac1  one  of  opium, 
one  pill  to  be  taken  after  each  loose  motion,  to 
the  extent  of  three  pills. 

If  called  to  treat  a case  of  Asiatic  cholera, 
care  should  be  taken  that  the  rice-water  stools, 
and  the  matters  vomited,  are  disinfected  by 
means  of  bichromate  of  potash  or  Macdougall’s 
mixture,  which  should  be  poured  over  the  bot- 
tom of  the  vessel  into  which  the  evacuations 
are  received  from  the  patient ; and  directly 
the  dejecta  are  passed  from  the  sick  person,  a 
solution  of  one  part  of  carbolic  acid  to  twenty  of 
water  should  be  sprinkled  over  them,  and  they 
must  be  immediately  taken  from  the  patient’s 
room,  and  disposed  of  as  follows  : — If  the  sewage 
of  the  locality  is  conveyed  away  by  means  of  a 
constant  water  supply,  the  disinfected  cholera 
evacuation  should  be  thrown  at  once  into  the 
sewer.  Drains  used  for  a purpose  of  this  kind 
must,  however,  be  flushed  with  a mixture  contain- 
ing about  an  ounce  of  ferro-sulphate  to  a pint  of 
water.  But  if  the  drainage  of  the  place  passes 
into  a cesspool,  the  disinfected  cholera  stools 
should  be  buried  in  a deep  hole  in  the  ground,  re- 
moved from  wells,  and.  if  possible,  from  human 
habitations ; it  is  a dangerous  practice,  however 
carefully  cholera-stools  have  been  disinfected,  to 
allow  them  to  gain  access  to  a cesspool.  The 
room  in  which  the  patient  has  been  treated  must 
be  freely  disinfected,  and  his  bedding  subse- 
quently burnt.  If  the  sick  person  should  die, 
the  corpse  is  at  once  to  be  placed  in  a coffin  con- 
taining a mixture  of  lime,  charcoal,  and  carbolic 
acid ; in  fact,  the  body  should  immediately  be 
buried  in  a mixture  of  this  kind,  and  the  coffin 
with  its  contents  committed  to  the  grave  within 
twenty-four  hours  of  the  patient’s  death. 

But  after  all,  as  Mr.  Simon  remarks,  infinitely 
the  most  important  preventive  measures  to  be 
adopted  against  cholera  are  to  provide  a pure 
supply  of  drinking  water,  good  drainage,  ventila- 
tion, and  cleanliness  ; for  these  means,  if  rightly 
enforced,  must  prevent  the  cholera  contagion, 
whether  disinfected  or  not,  from  acting  to  any 
great  extent  on  the  population. 

The  Vienna  Cholera  Conference  has  decided 
that  quarantine  is  inapplicable  to  the  circum- 
stances of  cholera ; but  this  subject,  together 


CHOLERAIC  DIARRHCEA.  243 
noth  the  duties  incumbent  on  sanitary  and  port 
authorities  with  reference  to  the  preventive 
treatment  of  the  disease,  hardly  falls  within  the 
scope  of  this  article.  0.  Macnamaea 

CHOLERAIC  DIAKRHCEA.  Synon.  : 
Simple  Cholera  ; Sporadic  Cholera  ; Fr.  Cholera 
sporadique;  Ger.  sporadische  Cholera. 

Definition. — An  acute  catarrhal  affection  of 
the  mucous  membrane  of  the  stomach  and  small 
intestines,  attended  with  vomiting  and  diarrhoea. 
The  stools  consist  of  a serous  fluid,  containing  a 
little  albumin.  The  whole  system  is  implicated 
to  a greater  or  less  extent,  through  the  rapid  loss 
of  water  from  the  body. 

^Etiology. — As  has  already  been  remarked,  it 
is  only  of  late  years  that  the  question  has  arisen 
as  to  whether  Asiatic  cholera  and  simple  cho- 
lera are  identical  diseases  ; but  it  seems  pro- 
bable that  any  obscurity  which  may  exist  on 
the  subject  occurs  from  the  impression  that 
similar  symptoms  are  necessarily  produced  from 
precisely  the  same  causes.  It  appears  reasonable, 
however,  to  believe  that,  if  the  infecting  matter 
of  Asiatic  cholera,  when  introduced  into  the  in- 
testinal canal,  induces  changes  such  as  we  have 
described,  decomposing  animal  or  vegetable 
substances,  under  certain  conditions,  may  excite 
analogous  changes  in  the  mucous  membrane 
of  the  alimentary  canal,  the  consequence  being 
that  in  both  diseases  a drain  of  serous  fluid 
takes  place  from  the  bowels,  followed  by  symp- 
toms of  cholera.  In  the  case  of  Asiatic  cholera, 
however,  we  believe  that  the  discharges  have 
the  power,  under  favouring  conditions,  of  pro- 
pagating the  disease,  whereas  the  evacuations 
in  simplo  cholera  are  in  this  respect  barren. 
Doubtless  climatic  and  meteorological  influences 
very  materially  affect  the  susceptibility  of  the 
human  subject  to  disease,  and-consequently  we 
find  that  simple  cholera,  like  the  malignant  form 
of  the  malady,  is  apt  to  prevail  as  an  epidemic  in 
moist  or  wet  seasons  of  the  year,  and  especially 
among  people  whose  bodies  are  predisposed  to 
pass  into  a diseased  condition,  from  their  having 
habitually  breathed  impure  air,  and  consumed 
unwholesome  food  and  water,  or  become  debili- 
tated from  other  causes. 

In  a hot  and  moist  climate  like  that  of  lower 
Bengal,  choleraic  diarrhoea  is  an  affection  which 
we  meet  with  at  all  seasons  of  the  year,  and  it  is 
especially  prevalent  among  infants  who  are  being 
reared  on  cow's  milk,  or  on  other  kinds  of  food 
prone  to  undergo  putrefaction.  Among  the  fish- 
eating Hindoos  the  writer  has  frequently  seen 
several  members  of  the  same  family  who  have 
been  seized  with  symptoms  of  simple  cholera, 
attributable  to  the  patients  having  partaken  of 
fish  which  was  slightly  tainted.  In  fact,  accord 
ing  to  his  experience,  there  are  few  more  cer 
tain  sources  of  this  form  of  cholera  than  fish 
which  has  gone  bad  ; and  it  is  very  evident  that 
whatever  the  deleterious  influence  may  be  which 
food  of  this  description  contains,  the  mere  fact 
of  keeping  it  in  boiling  water  for  some  time  does 
not  destroy  its  pernicious  qualities. 

It  occasionally  happens  that  cases  of  choleraic 
diarrhoea  occur  among  people  residing  in  mala- 
rious districts,  the  diarrhoea  taking  the  place 
of  the  cold  stage  of  a fit  of  ague;  patients 


244  CHOLERAIC 

under  these  circumstances  have  been  seized  with 
all  the  symptoms  of  severe  cholera,  but  they 
have,  almost  invariably,  recovered  from  the  at- 
tack. 

Symptoms. — Choleraic  diarrhoea  begins  sud- 
denly ; that  is,  the  patient,  whether  an  infant  or 
an  adult,  has  probably  up  to  the  commence- 
ment of  the  attack  been  in  good  health ; there 
are  in  fact  seldom  any  premonitory  symptoms. 
A child  may  perhaps  look  somewhat  paler  than 
usual,  and  has  a dark  ring  under  his  eyes,  but 
beyond  this  appears  to  be  perfectly  well.  Shortly 
after  taking  food,  the  infant  vomits  up  a quantity 
of  uncoagulated  milk,  the  evacuation  not  being 
curdled  like  that  from  an  overloaded  stomach, 
the  gastric  secretion  no  longer  having  the  power 
of  coagulating  the  casein  of  milk.  Soon  after 
vomiting,  or  it  may  be  before,  the  child  com- 
mences to  pass  from  the  bowels  an  acid  greenish- 
yellow  fluid,  containing  flakes  and  often  lumps  of 
undigested  food.  The  little  patient  becomes 
very  thirsty,  restless,  and  is  evidently  in  con- 
siderable pain,  crying,  and  drawing  his  legs  up 
towards  the  abdomen.  If  these  symptoms  con- 
tinue the  evacuations  become  colourless,  resem- 
bling in  appearance  the  rice-water  stools  of 
Asiatic  cholera.  The  temperature  of  the  body 
falls,  the  face  becomes  of  a dusky  hue,  the  features 
are  contracted,  and  the  eyeballs  deeply  sunk  in 
their  sockets;  the  fontanelles  are  depressed,  the 
child  is  evidently  terribly  prostrated,  his  pulse 
can  no  longer  be  felt  at  the  wrist,  and  his  crying 
passes  into  a weak  whimpering,  he  eagerly  drinks 
wator  when  offered  him;  and,  as  the  exhaustion 
increases,  convulsions  supervene,  and  the  child 
dies  within  a few  days  or  even  hours.  On  the 
other  hand,  the  symptoms  may  abate  at  any 
stage  of  the  disease,  and  the  little  patient  gra- 
dually recovers  his  health. 

In  the  adult  tjie  symptoms  induced  by  chole- 
raic diarrhoea  are  much  the  same  as  those  above 
detailed.  There  are  seldom  auy  premonitory' 
symptoms,  and  the  attack  begins  with  nausea 
and  vomiting,  together  with  a sensation  of  ex- 
haustion referrible  to  the  pit  of  the  stomach; 
the  vomiting  is  speedily  followed,  or  it  may 
be  preceded,  by  purging ; copious  watery  dis- 
charges are  thus  passed  out  of  the  body,  and  the 
larger  and  more  rapid  the  evacuations,  the  more 
they  come  to  resemble  the  serum  of  the  blood, 
which,  in  fact,  drains  into  the  intestinal  canal, 
and  passes  away  from  the  stomach  and  bowels. 
The  patient  naturally  complains  under  the  cir- 
cumstances of  intense  thirst : he  is  very  rest- 
less, and  at  the  commencement  of  the  attack 
suffers  from  colicky  pains  in  the  abdomen,  and 
subsequently  from  spasms  and  cramps  which 
often  seize  the  muscles  of  the  extremities.  The 
pulse  becomes  small  and  weak,  the  respiration 
is  hurried,  the  voice  feeble,  and  the  counte- 
nance pale  and  shrunken.  The  urine  is  scanty 
or  suppressed,  and  the  temperature  of  the  body 
falls  one  or  two  degrees  below  the  usual  standard. 
These  symiptoms,  as  a rule,  gradually  subside, 
the  purging  and  vomiting  cease,  and  the  patient 
falls  off  to  sleep,  waking  more  or  less  exhausted 
in  proportion  to  the  severity  of  the  attack,  but 
he  usually  recovers  his  health  rapidly. 

Diagnosis. — The  question  naturally  arises,  are 
here  any  means  by  which  we  can  distinguish  a 


DIARRHOEA. 

ease  of  choleraic  diarrhoea  from  one  of  Asiat’c 
cholera?  and  in  reply  it  may  be  affirmed  that  there 
is  no  characteristic  symptom  by  which  these  af- 
fections can  be  diagnosed  from  one  another. 
But,  taking  all  the  circumstances  of  any  par- 
ticular case  into  consideration,  it  is  difficult,  es- 
cept  on  paper,  to  confound  the  two  diseases  ; for 
unless  a Datient  has  recently  imbibed  the  poison 
which  produces  Asiatic  cholera,  he  cannot  be 
suffering  from  that  malady.  Should  the  sick 
person  reside  in  a neighbourhood  affected  by 
Asiatic  cholera,  we  must,  in  forming  an  opinion  ae 
to  the  nature  of  the  affection,  be  guided  by  the 
previous  history  of  the  case,  the  nature  of  the 
food  consumed,  and  so  on,  and,  above  all,  by  the 
severity  of  the  symptoms.  Choleraic  diarrhoea, 
even  in  the  tropics,  rarely  passes  on  within  a few 
hours  from  the  commencement  of  the  attack  into 
collapse,  such  as  is  commonly  seen  in  cases  of 
Asiatic  cholera ; and,  in  the  early  stages  of  the 
former  disease,  there  is  seldom  that  complete  loss 
of  voice  and  pulse  so  characteristic  of  the  malig- 
nant form  of  this  affection.  An  experienced 
medical  practitioner,  placed  at  the  bedside 
of  a person  suffering  from  Asiatic  cholera,  even 
in  its  earliest  stages,  feels  no  doubt  whatever  as 
to  the  nature  of  the  affection,  and  is  at  once  im- 
pressed with  the  grave  responsibility  of  the  charge 
which  rests  upon  him : his  anxiety  is  infinitely 
less  when  he  meets  with  an  instance  of  choleraic 
diarrhoea,  although  he  is  unable  to  lay'  down  any 
hard  and  fast  rules  by'  means  of  which  he  could 
define  the  difference  that  exists  between  the 
symptoms  present,  and  those  occurring  in  a case 
of  Asiatic  cholera. 

Prognosis. — Although  choleraic  diarrhoea  in 
its  more  severe  forms  resembles  mild  cases  of 
Asiatic  cholera,  it  is  a comparatively  harmless 
disease.  Unless  among  young  infants,  or  old  and 
sickly  people,  no  matter  bow  threatening  the 
symptoms  may  be.  however  great  the  collapse  and 
depression  of  the  patient  may  seem,  a previously 
healthy  adult  seldom  dies  of  choleraic  diarrhoea. 

Treatment. — In  cases  of  simple  cholera  occur- 
ring among  children,  theimporiantpoint  wemust 
enforce  in  our  treatment  is  that  the  affected 
organ  shall  have  rest.  In  practice,  however,  it  is 
often  difficult  to  persuade  parents  and  nurses 
that  an  infant  can  exist  uninjured  for  ten  or 
fourteen  hours  on  iced  water  ; nevertheless,  we 
must  insist  on  a plan  of  this  kind  being  carried 
out.  The  little  patient  will  eagerly  swallow  cold 
water,  either  from  a bottle  or  spoon,  and  the 
child  may  be  allowed  to  take  as  much  cold  water 
as  he  requires,  a ml  to  suck  i -e,  which  may  be 
wrapped  up  in  the  corner  of  a handkerchief 
and  put  into  his  mouth.  A poultice  made  of  equal 
parts  of  mustard  and  flour,  applied  over  the 
abdomen,  is  often  very  useful  in  this  form  of 
disease.  With  reference  to  drugs,  should  the 
treatment  above  indicated  not  relieve  the  svmp- 
toms,  or  should  the  vomiting  he  very  constant,  four 
grains  of  calomel  may  he  given,  and  repeated  if 
necessary  in  an  hour's  time  ; but  if  the  diarrhoea 
is  the  more  prominent  symptom,  calomel  is  not 
required,  but  a teaspoonful  of  castor  oil  should 
be  administered,  and  after  tlie  bowels  have 
been  cleared  out,  if  the  serous  discharge  con- 
tinues, we  should  order  astringents,  in  the  form 
of  ^ of  a grain  of  acetate  of  lead  every  hour. 


CHOLERAIC  DIAERHCEA. 
or  Jg  of  a grain  of  nitrate  of  silver,  until  the 
purging  subsides.  Tannic  acid,  in  combination 
with  dilute  sulphuric  acid  and  sugar,  is  fre- 
quently a useful  combination  to  administer  to 
children  in  cases  of  this  description.  With  re- 
ference to  opium,  much  as  the  writer  dislikes 
prescribing  it  for  infants,  it  may  be  necessary  in 
cases  of  simple  cholera,  but  it  should  hardly  be 
given  in  a mixture  to  be  administered  from  time 
to  time  by  a nurse;  opium  under  these  circum- 
stances can  only  be  admissible  when  given  by  the 
medical  attendant  himself,  in  doses  of  two  or 
three  drops  of  laudanum  in  a little  weak  brandy 
and  water,  carefully  watching  its  effects.  Jf  the 
drug  causes  the  child  to  sleep  for  a few  hours 
:t  may  act  almost  like  a charm  ; the  infant  awakes 
comparatively  well ; but  if  the  opium  has  no  such 
effect,  we  may  be  tempted  to  repeat  the  dose, 
but  can  scarcely  give  it  a third  time,  at  any  rate 
until  some  hours  have  elapsed  since  the  ad- 
ministration of  the  second  dose.  The  symptoms 
having  subsided,  the  child’s  diet  must  be  strictly 
attended  to,  a good  healthy  wet-nurse  as  a rule 
being  an  urgent  necessity  in  the  case  of  infants. 
Lime-water  may  with  advantage  be  mixed  with 
the  child's  food. 

With  reference  to  the  treatment  of  adults  suf- 
fering from  choleraic  diarrhoea,  we  must  bear  in 
mind  the  fact  that,  unless  among  old  and  debili- 
tated persons,  the  patient  will,  as  a rule,  get  well 
without  medicine.  If  therefore  called  to  pre- 
scribe for  a case  of  this  complaint,  we  may  order 
fifteen  drops  cf  laudanum,  or  a drachm  of  the 
compound  tincture  of  camphor  in  water,  to  be 
taken  (supposing  the  patient  is  very  sick)  imme- 
diately after  vomiting  ; half  the  above  dose  may 
be  given  at  the  expiration  of  one  hour,  and  again 
after  another  hour,  unless  the  symptoms  have 
in  the  meantime  subsided.  A large  mustard 
poultice  should  be  applied  over  the  abdomen, 
and  the  patient  must  be  confined  to  bed,  and 
kept  on  ice  and  iced  water ; he  should  not,  how- 
ever, be  permitted  to  swallow  too  much  liquid. 
Among  old  or  weakly  persons,  and  also  in  the 
case  of  infants,  it  is  often  very  necessary  to  ad- 
minister brandy  and  water  from  time  to  time, 
according  to  the  state  of  the  pulse.  If  the 
vomiting  is  severe,  a scruple  of  calomel  may 
be  given  to  an  adult,  or  in  the  first  instance 
the  effervescing  mixture  with  hydrocyanic  acid 
may  be  employed  to  allay  the  sickness  ; on  the 
other  hand,  should  the  serous  diarrhoea  be  ex- 
cessive, we  may  with  advantage  prescribe  four 
grains  of  the  acetate  of  lead  and  ten  drops  of 
diluted  acetic  acid  every  second  hour ; or  pills 
containing  a drop  of  creasote,  a quarter  of  a grain 
of  nitrate  of  silver,  a grain  of  camphor,  and 
two  grains  of  Dover’s  powder,  to  be  repeated 
After  each  loose  motion,  C.  Macnamara. 

CHOLERINE. — A term  applied  to  a class 
of  cases  which  occur  during  the  prevalence  of 
cholera,  in  which  the  milder  symptoms  of  the 
disease  are  present.  It  has  also  been  used  to 
designate  the  poison  on  which  cholera  is  sup- 
posed to  depend.  See  Cholera  ; and  Choleraic 
Diaerhcea. 

CHOLESTEATOMA  ( X o\b,  bile;  orlop, 
suet ; and  S/ibs,  like). — An  encysted  tumour, 
consisting  chieflyof  cholesterine.  S:e  Cysts. 


CHORDEE  24fi 

CHOLESTERINE.  See  Appendix. 

CHORDEE  (xopSfi,  a harpstring). — Defini- 
tion.— Painful  imperfect  erection  of  the  penis 
during  gonorrhoea. 

.Etiology  and  Pathology.— Chordee  is  most 
common  in  the  second  and  third  weeks,  and 
rarely  attacks  the  patient  after  the  third  week 
of  gonorrhoea.  In  exceptional  cases,  on  the  con- 
trary, chordee,  absent  in  the  acute  stage,  is 
violently  developed  after  the  inflammation  has 
become  chronic  and  very  slight.  The  bulbous 
part  of  the  urethra  is  generally  intensely  inflamed 
when  chordee  happens ; and,  further,  chordee  is 
very  uncommon  when  the  urethritis  is  limited  to 
the  anterior  or  posterior  portions  of  the  canal. 

The  mechanism,  of  chordee  is  imperfectly  un- 
derstood. Two  explanations  have  been  put 
forward : — (a)  That  the  corpus  spongiosum  sur- 
rounding the  urethra  being  affected  by  inflam- 
mation through  the  effusion  of  lymph  into  its 
substance,  proper  distension  of  its  spongy  tissue 
and  elongation  during  erection  cannot  take 
place.  Hence  it  is  drawn  tight  like  a bowstring 
by  the  arching  of  the  distended  corpora  caver- 
nosa. (i)  That  the  inflammatory  condition  of  the 
mucous  membrane  and  submucous  tissue  at  the 
bulbous  part  excites  reflex  spasm  of  the  muscles 
surrounding  that  part  of  the  corpus  spongiosum. 
This  prevents  distension  of  the  parts  com- 
pressed ; while  the  corpora  cavernosa,  being  un- 
trammelled, continue  to  expand  in  the  ordinary 
manner.  The  first  explanation  is  insufficient  to 
account  for  some  cases  where  the  inflammatory 
action  is  very  slight  and  there  is  no  evidence 
that  lymph  has  been  efiused  into  the  erectile 
tissue ; for  example,  after  a plastic  operation  on 
the  penis.  Again,  natural  erection  has  been 
known  to  take  place  very  shortly  after  the  sub- 
sidence of  gonorrhoeal  irritation,  and,  it  is  fair 
to  suppose,  before  effused  lymph  can  have  been 
absorbed.  The  second  explanation  is  unsatis- 
factory, because  spasm  of  other  muscles  of  the 
perinaeumis  often  absent.  Probably  both  methods 
may  be  active  in  producing  chordee. 

The  causes  of  chordee  are  indirect  or  direct. 
The  most  common  indirect  cause  is  urethritis  or 
urethral  congestion.  Direct  causes  are  the  reflex 
irritants  which  usually  produce  erection  during 
sleep,  such  as  stimulating  food  and  drink, 
strongly  acid  urine,  great  superficial  warmth  of 
the  body,  distended  bladder,  lascivious  dreams. 
&c. 

Symptoms. — The  organ  grows  suddenly  turgid 
and  assumes  a bowed  or  crooked  form,  causing 
acute  pain,  which  is  felt  at  the  part  and  towards 
the  perinseum.  In  severe  cases  the  strain  causes 
rupture  of  the  mucous  membrane  and  spongy 
tissue,  with  haemorrhage.  The  loss  of  blood  is 
usually  limited  to  a few  drops,  and  gives  relief 
to  the  pain.  Rarely  the  haemorrhage  is  rapid 
and  prolonged. 

Treatment. — Abstinence  from  stimulants  ox 
all  kinds  and  late  suppers;  light  clothing ; aDd 
a hard  mattress  at  night  are  the  best  means  ot 
preventing  chordee.  Micturition  at  short  in- 
tervals during  the  night  must  be  enjoined.  Of 
medicines  the  best  is  a suppository  at  bed-time 
of  one  grain  of  crude  opium  in  ten  grains  of 
cocoa  butter.  The  subcutaneous  injection  into 


246  CHORD  EE. 

the  perinaeum  of  one-sixth  grain  of  acetate  of 
morphia  is  also  an  effectual  remedy.  Both 
these  applications  should  he  followed  by  an 
aperient  saline  draught  the  next  morning.  A 
drachm  of  spirit  of  camphor  thrown  just  before 
it  is  swallowed  into  an  ounce  of  water,  and  taken 
on  lying  down  at  night  is  also  useful,  and  it  may 
be  repeated  once  if  chordee  awaken  the  patient, 
but  it  is  a very  uncertain  remedy.  More  trust- 
worthy are  twenty  or  twenty-five  grains  of 
chloral-hydrate  in  syrup  and  water  at  bed-time, 
and  repeated  in  four  or  six  hours  if  needed. 
Bathing  the  genitals  and  perinaeum  with  very  hot 
water  for  ten  minutes  before  going  to  bed  some- 
times proves  successful.  The  application  of  a 
spiral  coil  of  narrow  india-rubber  tubing  round 
the  penis  and  scrotum,  through  which  a con- 
tinuous current  of  ice-cold  water  flows,  is  also  an 
excellent  preventive. — To  disperse  an  attack  of 
chordee  the  best  remedies  are  voiding  urine  ; 
the  application  of  cold  to  the  perinaeum  by 
evaporating  lotion  or  by  ice;  and  the  upright 
posture.  Berkeley  Hill. 

CHOREA  (x»pt!a,  a dance). — Synon.:  Chorea 
Minor;  St.  Vitus’s  Dance;  Fr.  Danse  de  St.- Guy, 
la  Choree ; Ger.  Veitstanz. 

Definition. — A disease  of  the  nervous  system, 
characterised  by  a succession  of  irregular,  clonic, 
involuntary  movements  of  limited  range,  occur- 
ring in  almost.all  parts  of  the  body. 

The  distinctive  features  of  the  movements  are 
the  entire  absence  of  either  rhythm  or  method 
in  their  recurrence ; that  not  individual  muscles 
but  co-ordinated  groups  are  affected;  and  notone 
or  more  groups  only,  but  almost  all  the  muscles 
in  turn.  There  is  not  actual  loss  of  command  over 
the  muscles,  but  voluntary  movements  are  inter- 
fered with  by  superaddition  of  involuntary'  move- 
ments. As  a rule  the  movements  cease  during 
sleep. 

.Etiology. — Chorea  is  a disease  of  childhood ; 
it  is  most  common  between  the  ages  of  eight  and 
twelve,  very  rare  before  six,  and  rare  after  six- 
teen ; it  is  more  than  twice  as  frequent  in  girls 
as  in  boys,  especially  after  the  age  of  nine.  It 
occurs  more  frequently  in  families  in  which  ner- 
vous diseases  are  hereditary  than  in  others.  It 
is  more  common  in  large  towns  than  in  the 
country  ; and  far  more  frequent  among  the  poor 
than  among  those  in  comfortable  circumstances. 
Want  of  proper  food,  neglect,  ill-usage,  with  the 
weakness  and  anaemia  induced  by  these  means,  are 
very  common  antecedents.  Children  well-nour- 
ished and  with  a good  colour,  exposed  to  none  of 
these  causes,  may  however  suffer.  An  intimate 
association  between  chorea  and  rheumatism  has 
long  been  recognised.  A large  proportion  of  the 
children  suffering  from  chorea  are  found  to  have 
had  acute  or  subacute  rheumatism,  and  some  of 
the  most  terrible  cases  met  with,  especially  after 
the  age  of  puberty,  are  those  in  which  the  chorea 
comes  on  during  or  just  after  acute  rheumatism. 
Whether  traceable  to  rheumatism  or  not,  there  is 
very  frequently  found  in  chorea  a cardiac  murmur, 
usually  mitral  systolic,  sometimesaortic.  This  may 
or  may  not  disappear  after  recovery.  In  almost 
all  the  fatal  cases  of  chorea  which  have  been  exa- 
mined after  death,  endocarditis  with  fibrinous  ve- 
getations on  the  valves  has  been  present.  In  adults, 


CHOREA. 

pregnancy  divides  with  rheumatism  the  causatioi 
of  this  affection  ; recovery  generally  speedily  fol- 
lows delivery,  and  can  rarely  be  brought  about  tiL' 
this  has  taken  place.  Bad  habits,  and  disorders  o! 
menstruation,  are  also  said  to  be  capable  of  induc- 
ing chorea.  Intestinal  worms  again  have  appeared 
to  set  up  the  disease,  and  instances  are  on  record 
in  which  the  expulsion  of  worms  has  been  followed 
at  once  by  cessation  of  the  movements,  but  this 
must  be  extremely  rare.  Fright  or  some  power- 
ful emotion  is  very  frequently  assigned  as  a cause ; 
and  it  is  seldom  that  parents  are  not  prepared 
with  the  instance  required.  But,  making  allow- 
ance for  this,  and  notwithstanding  the  fact  that 
endocarditis  maybe  present  in  cases  said  to  have 
originated  in  fright,  it  does  not  seem  possible  to 
exclude  fright  as  a cause  of  chorea.  The  influ- 
ence of  imitation  is  less  certain.  The  disease  is 
said  to  be  far  less  common  in  negroes. 

Anatomical  Chaeactebs  and  Pathology. — 
The  study  of  chorea,  as  of  epilepsy  and  many 
other  affections  of  the  nervous  system,  has  been 
hampered  by  its  being  regarded  as  a morbid 
unity.  The  view  here  maintained  is  that  it  is 
a sympton  rather  than  a disease,  and  that 
the  characteristic  movements  are  in  relation 
not  with  the  nature  of  the  morbid  change  but 
with  its  seat.  The  seat  of  the  disturbance  is  tho 
corpus  striatum,  its  character  probably  different 
in  different  cases  ; but  the  anatomical  condition 
cannot  amount  to  actual  breach  of  structure,  since 
that  is  known  to  give  rise  to  hemiplegia,  while 
it  must  obviously  be  of  a kind  to  impair  the 
functional  vigour  of  the  ganglia.  Chorea,  as  the 
writer  has  said  elsewhere,  has  been  called  ‘ in- 
sanity of  the  muscles  ’ — a better  phrase  would  be 
‘ delirium  of  the  sensori-motor  ganglia.’  In  de- 
lirium there  is  loss  of  control  over  the  mental 
processes  with  rapid  succession  of  incoherent  and 
imperfect  ideas  ; in  chorea  loss  of  control  over 
the  motor  apparatus,  with  movements  excessive 
in  point  of  number  and  extent,  but  wanting  in 
vigour  and  precision. 

In  some  cases  of  chorea  nothing  abnormal 
has  been  detected  after  death,  but  usually  the 
minute  methods  of  investigation  now  pursued 
yield  positive  results.  The  largest  series  of 
examinations  published  is  contained  in  a com- 
munication to  the  Medico-Chirurgieal  Society, 
in  the  session  1875-6,  by  Dr.  Dickinson.  He 
describes  dilatations  of  the  minute  arteries  as 
existing  throughout  the  brain  and  cord,  more 
especiaUy,  however,  in  the  corpus  striatum  and 
thalamus,  with  small  haemorrhages ; and  considers 
the  disease  to  be  due  to  a widely-spread  hyper- 
aemia  of  the  nerve-centres.  He  did  not  find 
capillary  embolisms,  but  does  not  appear  to  have 
drawn  out  the  arterioles  to  look  for  them.  The 
appearances  he  describes  are  very  much  those 
producible  by  impaction  of  microscopic  particles 
of  fibrin  in  the  minute  vessels.  Capillary  em- 
bolisms have  been  found  by  Dr.  Tnckwell  and 
other  observers,  predominantly  in  the  central 
ganglia,  but  also  in  the  convolutions  and  cord, 
accompanied  by  patches  of  softening  and  minute 
haemorrhages.  In  almost  all  fatal  cases  of 
chorea  there  is  endocarditis  with  deposit  of  beads 
of  lymph  on  the  mitral  or  aortic  valves  or  both, 
whether  a murmur  has  been  audible  during  life 
or  not. 


CHOREA. 


The  post-mortem  appearances  consequently  do 
not  indicate  any  localisation  of  the  morbid 
change  in  the  central  ganglia.  But  it  is  to  be 
remembered  that  the  fatal  cases  are  those  in 
which  there  is  not  only  extreme  violence  in  the 
choreic  movements  but  usually  also  delirium  and 
other  symptoms.  There  are  in  fact  multiple 
symptoms  just  as  there  are  multiple  lesions,  and 
we  are  called  upon  to  distribute  the  symptoms 
and  assign  them  to  their  respective  sources  by 
such  knowledge  of  the  functions  of  the  different 
nerve-centres  as  physiology  affords  us.  The 
delirium  or  comparative  dementia  is  thus  attri- 
buted to  the  lesions  in  the  convolutions  ; the  loss 
of  speech  to  lesions  in  convolutions  or  in  lower 
centres,  according  to  its  character ; the  impair- 
ment of  sensation  to  lesions  in  the  thalami;  the 
chorea  to  lesions  in  the  corpora  striata.  The 
grounds  upon  which  this  last  localisation — that 
in  which  we  are  immediately  concerned — is  de- 
cided, are  as  follows.  We  excludo  the  cerebral 
hemispheres  and  cerebellum,  rather  arbitrarily 
perhaps,  since  there  is  much  to  be  said  in  favour 
of  their  contributing  to  excite  the  movement,  now 
especially  that  convolutional  motor  areas  have 
been  demonstrated  by  Hitzig  and  Terrier.  The 
important  point  to  be  made  clear,  however,  is 
that  chorea  has  not  its  seat  in  the  cord.  The 
arguments  and  evidences  against  this  are  (1) 
That  tonic  and  not  clonic  spasm  is  characteristic 
of  persistent  spinal  irritation  ; (2)  Tho  degree  of 
control  over  the  movements  retained  by  the  will; 
(3)  Their  increase  under  emotion ; (4)  Their 
cessation  during  sleep.  To  those  which  were 
originally  advanced  by  Pr.  Russell  Reynolds  may 
be  added : (o)  The  diminished  reflex  action  on 
tickling;  and  (6)  The  phenomena  of  hemichorea 
and  its  relations  with  hemiplegia.  The  evidence 
afforded  by  hemichorea  is  so  conclusive  that  other 
considerations  have  been  merely  alluded  to. 
It  cannot  be  supposed,  for  example,  that  one 
lateral  half  of  the  entire  length  of  pons,  medulla, 
and  cord  can  be  affected  without  implication  of 
the  other  half,  which  would  be  the  case  with 
hemichorea  of  spinal  origin  ; and  still  more  con- 
clusive is  the  fact  that  when  in  hemichorea  there 
is  impairment  of  sensation  it  is  on  the  same  side 
with  the  movements,  and  not,  as  in  hemiparaplegia 
(due  to  division  of  one  half  of  the  cord),  on  the 
opposite  side  to  the  motor  paralysis.  The  paral- 
lelism between  hemichorea  and  hemiplegia  is 
so  perfect  as  to  suggest  at  once  that  the  two 
affections  represent  different  conditions  of  the 
same  nerve-centres,  and  is  made  more  complete 
by  the  very  discrepancies,  as  they  may  at  first 
sight  appear,  which  have  been  considered  to  be 
objections.  In  hemiplegia  there  are  certain 
muscles  which  more  or  less  completely  escape 
paralysis  the  motores  oculorum,  orbiculares 
palpebrar.um  and  other  facial  muscles,  the  mus- 
cles of  the  neck,  chest,  back,  and  abdomen. 
In  hemichorea  the  irregular  movements  cross  the 
median  line  and  invade  the  opposite  side  in  these 
same  muscles.  This  has  been  explained  (rightly 
or  wrongly)  by  the  hypothesis  that  all  these 
muscles  acting  in  compulsory  concert  with  the 
corresponding  (or  other)  muscles  of  the  opposite 
side,  the  nerve-nuclei  of  the  bilaterally  associated 
muscles  will  be  commissurally  associated  in  the 
cord,  so  as  to  become  in  effect  a single  nucleus, 


247 

and  this  single  nucleus  for  muscles  on  each  side 
of  the  body  being  connected  with  both  corpora 
striata  is  thrown  into  action  by  the  sound  cor- 
pus striatum  when  its  fellow  of  the  opposite 
side  is  damaged,  as  in  hemiplegia,  thus  prevent- 
ing paralysis;  and,  on  the  other  hand,  is  reached 
by  the  irregular  impulses  from  the  corpus  stria- 
tum affected  in  hemichorea,  thus  causing  bila- 
teral chorea  in  the  parts  enumerated. 

In  addition  to  the  correspondence  between 
hemichorea  and  hemiplegia  ju  t described,  there 
are  transitions  from  one  to  the  other,  and  combi- 
nations of  the  two  to  be  mentioned  below,  under 
the  head  of  complications.  Hemiplegia  may  bo 
succeeded  by  hemichorea  (the  post-kimiplegic 
chorea  of  various  observers);  or  chorea  may  deepen 
into  paralysis  ; or,  as  in  a case  reported  by  the 
writer,  there  may  bo  with  chorea  of  the  limba 
on  one  side,  first  chorea,  then  paralysis  (hemi- 
plegiform),  and  then  again  chorea  of  the  same 
side  of  the  face.  The  conclusion  is  obvious,  that 
hemiplegia  and  hemichorea  in  these  cases  are 
indicative  of  different  degrees  of  damage  in  the 
same  centre.  Hemichorea  and  hemiamesthesia 
have  been  found  very  constantly  associated  with 
structural  lesions  in  the  white  fibres  just  outside 
the  posterior  extremity  of  the  thalamus,  usually- 
involving  also  the  ganglion  itself  at  this  part. 

The  well-known  embolic  theory  of  chorea 
originated  by  Kirkes,  and  improved  and  ably 
maintained  by  Dr.  Hughlings  Jackson,  at  once 
finds  its  place  here.  Capillary  embolism  is  of 
all  others  the  condition  which  might  be  expected 
to  induce  the  instability  without  abolition  of 
function  which  exists  in  chorea,  and  in  almost  all 
cases  a fertile  source  of  fibrinous  shreds  is  present, 
in  the  form  of  vegetations  on  the  valves  of  the 
heart ; the  fact  of  embolism,  again,  has  re- 
peatedly been  demonstrated.  While,  however, 
giving  to  capillary  embolism  a prominent  place 
among  the  causes  of  chorea,  it  cannot  be  con- 
sidered as  the  only  cause.  The  clinical  differ- 
ences between  ordinary  chorea  and  the  acute  and 
fatal  form  are  of  themselves  suggestive  of  a 
different  pathology ; and  the  speedy  recovery  after 
delivery  in  the  chorea  of  pregnancy,  or  (as  in  one 
or  two  cases  on  record)  after  expulsion  of  in- 
testinal worms,  is  inconsistent  with  the  existence 
of  embolism.  What  the  precise  anatomical  con- 
dition is  can  only  bo  matter  of  conjecture,  but  it 
will  be  some  form  of  innutrition,  irritability,  and 
debility,  as  Dr.  C.  B.  Radcliffe  has  abundantly 
demonstrated,  going  together.  Hypera?mia,  with 
capillary  blood-stasis,  or  capillary  thrombosis 
by  cohering  leucocytes,  has  been  suggested  as 
the  cause.  Prolonged  arterial  spasm  from  per- 
sistent reflex  irritation,  uterine  or  intestinal, 
or  the  more  brief  contraction  of  tho  cerebral 
vessels  from  fright,  may  perhaps  lower  the 
functional  vigour  of  the  ganglia  to  the  degree 
required.  A very  important  consideration  is 
the  remarkable  limitation  of  chorea  to  the  period 
of  childhood — the  period  between  infancy  and 
puberty.  This  is  a limitation,  if  not  without 
parallel,  certainly  unequalled,  and  it  points  to 
a condition  of  nerve  centres  in  childhood  which 
specially  favours  the  occurrence  of  the  disease. 
This  condition  may  be  said  with  confidence  to 
I be  the  fact  that  childhood  is  the  period  of 
I special  activity  of  the  sensori-motor  ganglia. 


CHOREA. 


248 

Symptoms. — In  a slight  case  the  patient, -usually 
x child,  may  be  perfectly  quiet  when  lying  down, 
and  for  a short  time  even  when  sitting  or  stand- 
ing, if  not  conscious  of  being  under  observation ; 
but  when  walking  or  while  under  examination 
there  will  be  various  fidgety  actions,  abrupt  flexion 
of  the  fingers,  a sudden  pronation  of  the  forearm, 
or  hitching  up  of  one  shoulder,  or  twist  of  the 
body,  or  there  is  shuffling  of  a foot  on  the  floor, 
or  again  a jerk  of  the  head  or  twitch  of  the 
mouth  or  eyes.  If  the  patient  be  told  to  do 
anything,  the  movements  will  be  multiplied  and 
exaggerated  in  the  muscles  employed.  A small 
object  will  be  picked  up  and  held,  but  the  hand 
is  brought  down  upon  it  hastily  and  after  various 
irregular  excursions.  In  a more  severe  case  the 
grimaces,  contortions,  and  jerkings  succeed  each 
other  without  intermission.  The  gait  is  now 
very  peculiar,  being  slow,  shuffling,  and  uneven  ; 
the  steps  of  irregular  length  and  unequal  time  ; 
and  the  line  of  progress  deviating.  In  the  worst 
forms  of  this  disease  every  muscle  appears  to  be 
thrown  in  turn  into  violent  contraction,  the  face 
is  distorted  this  way  and  that,  the  eyes  roll  to  and 
fro,  the  teeth  are  snapped  or  ground  together,  the 
whole  body  writhes,  and  the  limbs  are  in  unceasing 
motion.  It  is  to  be  remarked  that,  even  in  extreme 
cases,  the  movements,  violent  as  they  may  be,  are 
in  some  degree  circumscribed  ; the  arms,  for  ex- 
ample, are  not  thrown  up  over  the  head,  nor  do  the 
legs  go  to  the  full  extent  of  their  range  of  motion ; 
the  tongue  is  rarely  bitten,  though  the  lips  may 
be.  Deglutition  is  greatly  interfered  with  in 
a severe  attack,  and  the  evacuations  may  be 
discharged  involuntarily.  In  the  mildest  forms, 
the  diaphragm  and  muscles  of  the  chest  and 
abdomen  are  affected,  causing  irregularity  in 
respiration.  The  action  of  the  heart  may  also  be 
irregular,  but  this  is  probably  secondary  to  the 
respiratory  variations  in  frequency  and  depth, 
and  is  not  attributable  to  chorea  of  the  heart. 
There  is  generally  impairment  of  motor  power, 
and  frequently  diminution  of  sensation.  This  is 
most  readily  ascertained  in  hemichorea,  i.e.  chorea 
affecting  one  half  of  the  body  only,  when  the  sound 
side  can  be  employed  for  comparison ; but  in  the 
violent  forms  of  the  disease,  when  the  skin  is 
gradually  worn  through  by  incessant  friction, 
there  is  often  so  little  complaint  of  pain  that 
sensibility  must,  it  would  seem,  be  blunted.  Re- 
flex sensibility  is  also,  commonly,  dull. 

It  has  already  been  stated  that  the  movements 
cease  during  sleep ; this  is  a rule  to  which  ex- 
ceptions are  rare  though  not  unknown,  even  in 
mild  cases,  and  especially  in  hemichorea. 

Chorea  is  usually  gradual  in  access,  even  in 
the  cases  which  ultimately  become  severe  ; it  is 
very  commonly  one-sided  for  a time,  and  oc- 
casionally throughout,  when  the  name  hemi- 
chorea is  given.  It  is  not,  however,  strictly 
unilateral  in  these  cases,  as  the  movements  trans- 
gress the  median  line  and  affect  the  corresponding 
muscles  of  both  sides  of  the  body  at  those  parts 
where  these  are  bilaterally  associated,  and  where 
in  hemiplegia  there  is  immunity  from  the  para- 
lysis, as  for  instance  the  oculo-motor  muscles,  the 
muscles  of  the  neck,  chest,  and  abdomen. 

Complications. — The  foregoing  description  ap- 
plies more  or  less  to  ail  cases  of  chorea,  but  there 
are  often  additional  symptoms,  and  it  will  conduce 


to  clearness  if  these  are  considered  apart  and 
called  complications.  Mention  has  been  made 
of  impairment  of  motor  power;  at  times  this 
amounts  to  complete  paralysis,  and  the  relations 
and  combinations  of  chorea  and  paralysis,  and 
especially  of  hemichorea  and  hemiplegia,  throw 
much  light  on  the  disease.  Chorea  sometimes 
succeeds  hemiplegia  in  the  paralysed  parts ; more 
rarely  chorea  deepens  into  paralysis.  Cases  again 
occur  in  which  with  facial  hemiplegia  there  is 
chorea  of  the  limbs  of  the  same  side.  Speech  is 
very  commonly  more  or  less  affected  and  occa- 
sionally completely  lost  for  a time.  The  difficulty 
is  usually  articulatory,  chorea  of  the  muscles  of 
respiration, phonation,  and  articulation  interfering 
with  utterance  of  words  ; but  there  is  in  some 
cases  true  aphasia,  and  when  this  is  so,  there  is 
the  same  tendency  to  the  association  of  aphasia 
with  right  hemichorea  as  with  right  hemiplegia. 
The  intellect  may  suffer  in  various  degrees:  the 
face  has  often  an  idiotic  expression  in  chorea, 
usually  no  doubt  from  the  muscular  contortion 
or  atony,  but  sometimes  truly  indicative  of 
temporary  imbecility.  In  the  violent  and  fatal 
forms  of  chorea  there  is  almost  always  delirium. 
Impairment  of  sensation  is  common,  and  hemi- 
anesthesia is  almost  always  associated  with 
hemichorea. 

Duration,  Terminations,  and  Prognosis. — 
The  average  duration  of  chorea  is  about  two 
months;  if  prolonged  beyond  three  months  it 
may  be  exceedingly  chronic  and  go  on  better  and 
worse  for  one  or  two  years.  There  is  a ten- 
dency to  spontaneous  recovery,  but  on  the  other 
hand  relapses  are  common.  Chorea  is  rarely 
fatal  in  children ; when  it  is  so  the  case  is 
usually  acute  and  violent  from  a very  early 
period  of  the  attack,  and  it  is  rare  for  a case  to 
run  the  usual  course  for  a time  and  then  take  on 
a very  severe  character.  After  puberty  and  es- 
pecially when  it  supervenes  on  acute  rheumatism, 
it  is  very  dangerous,  but  less  so  when  associated 
with  menstrual  disorders  and  pregnancy  than  in 
youths  or  men. 

Diagnosis. — It  is  only  necessary  under  this 
head  to  warn  against  the  mistake  of  confounding 
with  the  movements  of  chorea  the  tremor  or 
jactitation  of  disseminated  sclerosis  of  the  nerve- 
centres,  which,  though  most  common  in  adults, 
is  not  unknown  in  childhood. 

Treatment. — In  a large  proportion  of  cases  of 
chorea,  especially  such  as  come  into  the  hospitals 
of  London,  rest  and  food,  with  perhaps  aperients, 
are  all  that  are  required  for  recovery.  But  it 
can  scarcely  be  denied  that  medicinal  treatment 
often  renders  important  services,  especially  in 
cases  of  a lingering  character.  The  causation 
and  pathological  condition  being  various,  it  is 
to  be  expected  that  the  remedies  required  will 
be  different,  and  the  attempt  should  be  made  to 
adapt  the  treatment  to  the  special  features  of 
the  case,  the  basis  of  all  being  the  endeavour  to 
improve  the  nutrition  of  the  body  generally,  and 
of  the  nervous  system,  by  good  food,  rest,  and 
warmth.  The  food  may  be  supplemented  by  cod- 
liver  oil,  and  Dr.  C.  B.  Radcliffe  attaches  im- 
portance to  the  free  administration  of  wine  or 
other  stimulants.  Any  recognised  cause  should 
be  removed,  such  as  constipation  or  worms; 
irregularities  or  suspension  of  the  catamenia 


CHOREA. 

should  receive  attention ; when  there  is  pregnancy 
it  may  perhaps  he  necessary  to  induce  premature 
labour.  When  the  chorea  is  accompanied  by  rheu- 
matoidpains  and  feverishness,  iodideof  potassium 
with  ammonia  may  have  a remarkably  good 
effect.  Iron  in  some  form  or  other  is  very  gene- 
rally useful,  but  especially  when  the  patient  is 
anaemic.  Another  remedy  is  sulphate  of  zinc, 
given  in  doses  gradually  increasing  from  one 
ur  two  grains  three  times  a day,  to  six,  eight,  or 
ten,  till  sickness  is  induced,  when  in  some  cases 
the  disease  appears  to  be  cut  short.  The  remedy 
which  in  the  writer’s  experience  has  been  found 
most  generally  useful  is  arsenic.  Trousseau 
sometimes  gave  strychnine  in  gradually  increasing 
doses  till  its  physiological  effects  manifested 
themselves.  On  the  other  hand,  conium,  recom- 
mended by  Dr.  John  Harley,  has  been  exten- 
sively employed;  the  only  reliable  preparation  is 
the  juice,  which  should  again  be  given  in  gradu- 
ally increasing  doses,  beginning  with  a drachm 
and  going  up  to  one  or  two  ounces  if  necessary, 
till  its  depressing  effect  on  the  muscles  becomes 
evident.  It  has  not,  in  the  writer’s  hands,  given 
satisfactory  results ; the  same  may  be  said  of 
the  application  of  ether-spray  along  the  spine, 
which  has  recently  been  strongly  recommended, 
except  in  acute  cases  in  which  the  freezing  of 
the  skin  here  has  in  two  cases  been  followed  at 
once  by  sleep,  and  in  a few  days  by  alleviation 
of  the  violence  of  the  chorea.  Baths,  warm  and 
cold,  especially  shower-baths,  spinal  douches, 
spinal  ice-bags,  gymnastics,  musical  gymnastics, 
i.e.  movements  timed  by  music,  have  advocates 
and  may  no  doubt  be  useful  in  suitable  cases. 

In  the  terrible  cases  of  acute  chorea  the  great 
indication  is  to  procure  rest  for  the  poor  sufferer 
and  keep  up  the  strength.  Milk,  eggs,  beef-tea 
and  other  forms  of  concentrated  fluid  nourish- 
ment, should  be  given  freely,  together  with  wine 
or  brandy.  Conium,  hyoseyamus,  bromide  of 
potassium  or  ammonium,  and  chloral,  have  been 
tried  separately  or  in  combination,  with  more  or 
less  appearance  of  success;  chloroform,  again, 
may  be  administered  ; chloral  by  the  mouth  or 
rectum,  and  hypodermic  injection  of  morphia  with 
free  administration  of  brandy  have  in  the  writer's 
judgment  appeared  to  do  much  good.  It  is  in 
these  cases  that  tartar  emetic  in  full  doses  has 
been  recommended  ; it  is  certainly  tolerated  in 
an  astonishing  degree.  Restraint  of  the  violent 
movements  is  oft-en  a great  comfort  to  the  patient ; 
the  limbs  should  be  carefully  bandaged  with 
flannel  and  bound,  the  legs  together,  the  arms  to 
the  sides,  a folded  blanket,  across  the  abdomen 
and  hips,  keeping  down  the  body.  If  half-done 
it  only  adds  to  the  suffering,  but  when  properly 
carried  out  it  gives  a feeling  of  relief  and  favours 
sleep.  W.  H.  Broadbent. 

CHOROIDITIS.  — Inflammation  of  the 
choroid.  See  Eve,  Diseases  of. 

CHROMIDROSIS  (xpwua,  colour,  and  iSpus, 
sweat),  coloured  perspiration.  See  Perspira- 
tion, Disorders  of. 

CHRONIC  (vpJpos,  time). — This  word  is 
applied  to  a disoase  when  its  progress  is  slow 
and  its  duration  prolonged.  See  Disease,  Dura- 
tion of. 

CHYLOUS  URINE. — See  Chyeuria. 


CHYLURIA.  249 

CHYLURIA  (xuA.i>r,  chyle ; and  oioov,  urine). 
— Synon.  : Galacturia ; Chylous  urine ; Er. 

Urine  iaiteuse ; Gor.  Die  Chylurie ; milchsaf- 
tiger  Harnabgang. 

Definition. — A diseased  condition,  occurring 
in  tropical  and  sub-tropical  climates,  which 
manifests  itself  by  a milky  appearance  of  the 
urine,  accompanied  usually  with  more  or  less 
distinct  traces  of  blood.  On  standing,  the  fluid 
coagulates,  so  as  to  present  the  appearance  of 
size.  A microscopic  nematoid  entozoon  ( Filaria 
sanguinis  hominis)  is  generally  found  in  the  blood 
and  urine  of  persons  affected  with  the  disease. 

General  Description. — The  affection  known 
as  chylous  or  chyloid  urine  has  long  remained 
a puzzle  to  physicians,  not  only  on  account  of 
the  very  remarkable  character  assumed  by  the 
secretion,  but  also  on  account  of  the  very  erratic 
course  which  the  disease  runs.  Scarcely  any 
two  persons  affected  with  this  malady  give  a 
similar  account  of  its  mode  of  onset,  of  the 
duration  of  the  attack,  or  of  the  symptoms  and 
seasons  of  its  occurrence.  The  writer  has  had 
the  opportunity  of  studying  from  thirty  to  forty 
cases  of  the  disease  in  Calcutta,  and  the  variety 
of  symptoms  presented,  and  the  numerous  causes, 
of  the  most  opposite  character,  to  which  the 
disease  has  been  attributed,  are  very  perplexing. 
The  histories  of  the  cases  published  by  various 
observers  present  a like  uncertainty,  and  Dr 
William  Roberts  very  aptly  describes  the  courso 
which  the  disease  runs  as  marked  by  an  irregu- 
larity and  capriciousness  which  baffles  explana- 
tion. It  would  seem  as  though  the  one  symptom 
which  may  be  looked  upon  as  constant  is  the 
condition  of  the  urine  implied  by  the  designation 
which  was  applied  to  the  disorder  by  Prout. 

This  symptom,  however,  although  very  ap- 
plicable to  the  generality  of  cases  met  with  in 
India,  does  not  appear  to  be  so  generally  ap- 
plicable to  the  disease  as  it  occurs  in  Egypt,  the 
Brazils,  and  the  West  Indies.  In  these  countries 
the  term  luematuria  is  adopted  as  being  a more 
correct  description  of  the  malady,  whereas  in 
India  the  designation  ‘ haematuria,’  though  gene- 
rally more  or  less  applicable  at  some  period  or 
other  of  the  disease,  is,  nevertheless,  not  so  ap- 
propriate in  the  great  majority  of  the  cases,  and, 
indeed,  in  some  instances  is  wholly  inappropriate, 
as  occasionally  no  marked  traces  of  red  colouring 
matter  can  be  detected  in  the  urine  from  the 
beginning  to  the  close  of  the  attack.  It  is. of 
importance  that  this  feature  in  connection  with 
the  disease  should  be  borne  in  mind,  as  it  may 
hereafter  be  found  that  what  at  present  are  gene- 
rally considered  as  merely  two  phases  of  one 
malady  may  each  have  a distinctive  .Etiology. 

History  and  Geographical  Distribution.— 
The  phase  which  chyluria  usually  presents  in 
India  is,  in  this  article,  taken  as  the  typical  one, 
and  its  history  may  be  thus  briefly  epitomised. 
To  Dr.  Vandyke  Carter  belongs  the  credit  of 
having  observed  systematically,  and  seriously 
attempted  to  clear  up  the  pathology  of  the 
disease.  His  researches,  published  in  1861-62 
tended  to  show  that  a direct  admixture  of  chyle 
and  urine  occurred — a leak  from  the  lymphatic 
tract  into  the  urinary.1  In  March  1870.  when 

1 Transactions  Med.  and  Phys.  Soc.  Bombay , vol.  vil. 
1861.  Meaico-chir.  Trans.,  vol.  xlv.,  1862. 


CHYLURIA. 


260 

examining  a specimen  of  milky  urine  passed,  by 
a man  under  the  ehargo  of  Dr.  R.  T.  Lyons  in 
Calcutta,  tne  writer  found  that  it  contained 
numerous  microscopic  nematoid  worms  ina  living 
condition.  These  were  described  and  figured  in 
a report  published  in  1870  by  the  Indian  Govern- 
ment.1 * Under  the  impression  that  no  nematoid 
parasites  had  previously  been  found  in  the  urine, 
specimens  were  forwarded  to  the  late  Dr.  Parkes, 
and  by  him  shown  to  Professor  Busk,  who  sug- 
gested that  probably  they  belonged  to  the  Filari- 
dae.  Similar  entozoa  were  detected  in  the  urine  of 
chyluria  patients  in  Calcutta  by  Dr.  W.  J.  Palmer 
and  Dr.  Charles  in  the  course  of  the  next  few 
months.  Towards  the  beginning  of  July '1872 
the  writer  found  nine  minute  nematoid  worms  in 
a state  of  great  activity  on  a slide  containing  a 
drop  of  blood  from  the  finger  of  a Hindoo.  These 
wore  identical  in  character  with  those  above  re- 
ferred to.  Unfortunately  the  man  could  not  be 
found  after  the  observation  had  been  made,  so  as 
to  be  questioned  as  to  his  past  history,  so  that  the 
pathological  conditions  which  might  have  been 
associated  with  this  the  first  recorded  instance  of 
the  existence  of  nematoid  luematozoa  in  man  must 
continue  to  remain  in  obscurity.  However,  since 
this  period  the  writer  has  traced  the  helminth 
(named  Filaria  sanguinis  hominis ) to  the  blood 
direct  in  about  fifteen,  and  to  one  or  other  of  the 
various  tissues  and  secretions  of  the  body  in 
about  thirty-five  individuals.  All  with  the  ex- 
ception of  the  persou  just  referred  to  were  known 
to  suffer  or  to  have  suffered  from  chyluria  or 
some  closely  allied  pathological  condition.3  These 
observations  have,  moreover,  been  confirmed  by 
others  in  numerous  instances. 

The  more  recent  history  of  the  variety  of  the 
disease  usually  referred  to  as  ‘ Mmat.nrie  grais- 
seuse,’  ‘ heematuria  Braziliensis,’  ‘haematuria 
Egyptica,’  is  also  associated  with  an  entozoon — 
or  rather  with  two  distinct  ktnds  of  entozoa — a 
fiuke  and  a nematode.  Tko  former  was  dis- 
covered in  1851  by  Bilharz.  His  observation 
was  followed  tip,  and  now  it  is  estimated  that 
about  a third  of  the  inhabitants  of  Brazil 
harbour  this  parasite  in  their  bodies.  In  1868 
Dr.  Otto  Wuclierer,  of  Bahia,  discovered  a 
microscopic  entozoon,  which  he  forwarded  to 
Leuckart  to  be  identified.3  The  latter  writer 
suggested  that  it  might  be  the  embryo  of  some 
round  worm,  probably  belonging  to  the  strongy- 
lidse.  Dr.  Jules  Crevaux,  a French  naval  surgeon, 
succeeded  in  confirming  Wucherer’s  observation 
by  finding  (July  27,  1870)  similar  helminths  in 
the  urine  of  a young  creole  affected  with  ‘ hema- 
turia chyleuse.’4  The  next  link  in  the  chain 
appears  to  have  been  furnished  by  Dr.  Sonsino. 
who,  in  January  1874  (having  no  knowledge  of 
previous  observations  of  a like  character),  found 
similar  parasites  in  the  blood  and  in  the  urine  of 

1 Vide  abstract  of  this  description  in  British  Medical 

Journal,  Nov.  10,  1870. 

3 ‘ On  a Hjematozoon  in  human  blood  ; its  connection 
with  Chyluria  and  other  diseases.’  Vide  Eighth  Ann.  Rep. 
of  Sanitary  Commiss.  with  Govt,  of  India,  1872  ; also  Indian 
A nn.  Med.  Science,  vol.  xvi. 

‘ On  the  Pathological  Significance  of  Nematode  Hfema- 
tosoa.*  Tenth  Report  of  Sanitary  Commiss.,  1874;  also 
Indian  Ann.  Med.  Science,  vol.  xvii. 

s Gazitta  da  Bahia , Dec.  1868. 

* Journ.  de  V Anat.  et  de  la  Physiol.  T.  xi.,  1875  ; and 
Leuekart’s  ‘ Par  as  i ten,’  Band  ii.  S.  628  et  seq. 


a Jew  lad  at  Cairo  affected  with  haematuria. 
Id  the  latter  fluid  distomata  also  were  found. 
This  observer,  however,  considers  that  these 
parasites,  though  bearing  a very  close  resem- 
blance, differ  in  some  respects  from  those  found 
in  chyluria,  and  has  accordingly  added  the  word 
Fgyptica  to  the  original  designation  for  the 
purpose  of  distinguishing  it.  It  is  possible 
that  the  microscopic  nematode  which  was  dis- 
covered by  Wucherer  in  Bahia  may  also  be 
traced  to  the  blood  eventually,  and  that  the 
slight  differences  in  the- recorded  characters  in 
the  worm  as  found  in  Egypt  and  in  the  Brazils 
from  that  found  in  India  may  he  shown  to  be 
sufficient  to  indicate  a specific  difference  in 
the  parasites,  and  thus  offer  a satisfactory 
explanation  of  the  discrepancies  observed  in 
the  character  of  the  urinary  disorder  in  the 
different  countries. 

In  Europe  the  disease  has  been  investigated  by 
several  observers.  The  cases  which  have  com* 
nnder  their  care  have  occurred  with  very  rare 
exceptions  in  persons  who  have  at  some  time  or 
other  resided  in  countries  situated  between  about 
30°  north  and  30°  south  latitude.  Of  the  four  or 
five  cases  which  have  been  recorded  as  having 
originally  occurred  in  Europe,  one  is  furnished 
by  Dr.  William  Roberts,  the  patient  never  hav- 
ing been  out  of  Lancashire  ; and  another  by  Dr. 
Beale,  in  a person  who  had  never  resided  out  of 
Norfolk.1 

Symptoms. — So  far  as  is  at  present  known, 
there  are  no  premonitory  symptoms  of  chyluria. 
Sometimes  the  only  symptom  is  the  milky 
condition  of  the  urine — a condition  which 
usually  comes  on  very  suddenly;  generally, 
hcwever,  the  patient  complains  of  uneasiness, 
scarcely  amounting  to  pain,  across  the  loins, 
along  the  ureters,  over  the  bladder,  or  along 
the  course  of  the  urethra — especially  towards 
the  ptrinseum  in  the  male.  There  is  gener- 
ally marked  debility,  with  mental  depression. 
Occasionally  chylo-serous  discharges  take  place 
from  various  parts  of  the  body — the  axilla, 
the  surface  of  the  abdomen,  the  groin,  and 
especially  from  the  scrotum,  in  that  con- 
dition of  it  which  is  known  as  Elephan- 
tiasis lymphangiectodes  (Bristowe),  Neevoid 
elephantiasis,  or  Varix  lymphatieus.  The 
disease  is  also  sometimes  observed  associ- 
ated with  true  elephantiasis  of  the  limbs 
and  scrotum.  It  occurs  at  all  ages,  from 
childhood  to  extreme  old  age,  and  in  about 
equal  proportion  among  the.  sexes — perhaps 
more  frequently  in  the  female  than  in  the 
male. 

With  regard  to  the  urine,  it  presents,  as  already 
mentioned,  a milky  appearance,  and  frequentlj 
emits  a strong  milky  or  whey-like  odour,  which  is 
made  more  evident  by  warmth.  After  standing 
a short  time  the  fluid  coagulates,  so  as  to  form 
a more  or  less  semi-solid  mass  resembling  blanc- 
mange. In  the  course  of  a few  hours  the  clot 
breaks  down,  and  tbe  urine  becomes  rapidly  de- 

1 Dr.  S.  Mackenzie  exhibited  to  the  Pat holcgical  Society 
(October  1SS1)  living  specimens  of  filaria  from  a soldier 
who  had  served  in  India.  He  noticed  the  daily  periodicity 
of  the  filaria,  which  had  previously  heen  determined  by 
Dr.  Hanson  of  Amoy,  and  further  showed  that  the  peric 
dicity  could  be  inverted  from  day  to  night  by  chaDgias 
the  habits  of  the  individual. 


CHYLURIA. 


composed.  In  some  cases  the  fluid  presents  a 
pink  colour,  from  the  admixture  of  blood,  but 
more  commonly — at  least,  in  India — the  blood, 
ivhen  present,  is  seen  forming  a shreddy  adhe- 
rent coagulum  at  the  bottom  of  the  vessel.  Not 
unfrequently  the  flow  of  urine  is  suddenly 
stopped  during  micturition  by  the  blocking  up 
temporarily  of  the  urethra  with  one  of  the  clots. 
Sometimes  in  India,  but  apparently  almost  al- 
ways in  the  West  Indies,  South  America,  and 
Egypt,  the  presence  of  blood  in  the  urine  forms, 
as  already  mentioned, ’the  most  pronounced  fea- 
ture. The  specific  gravity  varies  greatly — may 
range  in  the  same  individual  from  1007  to  over 
1020.  Shaken  up  with  ether  the  urine  loses  its 
milky  aspect ; and  when  nitric  acid  or  heat  is 
applied  a precipitate  almost  invariably  results. 
These  characters,  and  the  fact  of  the  coagu- 
lability of  the  fluid,  indicate  the  presence  of  fat, 
albumen,  and  fibrin,  all  of  which  are  to  be  con- 
sidered as  abnormal  constituents.  The  propor- 
tion, however,  in  which  they  exist  in  different 
individuals,  and  even  in  the  same  individual  at 
different  times,  varies  greatly.  Dr.  Beale’s 
analyses  show,  that  though  a specimen  of  urine 
may  contain  at  one  time  1'39  per  cent,  of  fat, 
another  specimen,  obtained  a few  hours  later, 
from  the  same  person,  may  contain  none.  In 
the  majority  of  cases  the  fatty  element  is  usually 
scanty  in  the  morning  before  meals,  and  so  are 
the  other  abnormal  elements,  unless  exercise 
have  been  taken  or  the  circulation  otherwise 
accelerated.  Under  the  latter  circumstance,  as 
Dr.  Bence-Jones  has  shown,  the  albumen  is 
increased,  without,  however,  a corresponding 
increase  of  the  fat.1  It  is  evident,  therefore,  that 
in  order  to  institute  a comparison  between  the 
character  of  the  urine  and  the  character  of  the 
various  nutritive  fluids  for  the  purpose  of  ascer- 
taining from  which  of  them  the  abnormal  con- 
stituents of  the  urine  are  derived,  the  results 
of  analyses  of  the  latter  fluids  at  different  times 
of  the  day  and  at  different  stages  of  the  disease 
should  bo  taken.  Further,  as  the  nutritive 
fluids  themselves  undergo  constant  changes  de- 
pendent on  the  quality  of  the  nourishment  sup- 
plied and  the  time  which  has  elapsed  since  par- 
taking of  it,  it  is  equally  evident  that  any  single 
analysis  would  be  insufficient.  An  attempt  has 
been  made  to  bring  together  in  the  following 
table  all  of  what  appeared  to  be  the  most  trust- 
worthy analyses  of  these  fluids  which  have  been 
published.  In  order  to  simplify  the  table,  only 
the  estimates  of  the  albuminoid  and  fatty  matters 
have  been  given,  these  being  the  most  pronounced 
of  the  more  readily  estimated  abnormal  con- 
stituents in  the  urine 


Constituents 
| selected. 

Urine 
in  chy- 
luria. 
[Mean 
of  15  an- 
alyses]. 

Blood 
in  chy- 
luria. 
[Hoppe- 
Seyler.] 

Blood 
— Nor- 
mal 
human. 
[Bec- 
querel 
and 

Rodier.] 

Chyle 
[Mean 
of  6 an- 
alyses : 
man, 
cow, 
horse, 
ass,  dog, 
cat. 

Lymph 
-human 
[Mean 
of  4 an- 
alyses]. 

Albuminoids 
Fatty  mat- 
ters. 

0-54% 

0.80% 

3-35% 

0-67% 

7-00% 
0 06% 

7-08% 

0'92% 

2-96% 

0‘56% 

1 Phil.  Trans,  of  Royal  Soc.,  cxl.,  1850,  p.  651. 


251 

A glance  at  this  table  reveals  the  fact  that  tho 
relative  proportion  of  the  albuminoids  to  the 
fatty  matters  in  chylous  urine  does  not  corre- 
spond with  the  proportion  in  which  they  are 
found  in  any  one  of  the  nutritive  fluids  of  the 
body.  In  normal  blood,  for  example,  the  fatty 
matter  is  as  1 to  116  of  the  albuminoid,  whereas 
in  the  urine  the  former  exceeds  the  latter  to 
a very  considerable  extent.  The  same  discre- 
pancy, but  to  a less  degree,  is  found  to  exist 
when  the  urine  and  chyle  are  compared — the 
quantity  of  albumen  in  the  latter  being  more 
than  seven  times  greater  than  that  of  fat.  The 
proportion  of  these  substances  in  lymph  ap- 
proaches more  closely  to  what  is  encountered  in 
the  urine — the  fat  being  to  the  albumen  as  1 to 
4 very  nearly.  The  specimen  of  chyluria-blood 
recently  analysed  by  Hoppe-Seyler1  approaches 
very  closely  to  the  average  composition  of  human 
lymph — the  fatty  matters  being  as  1 to  5 of  the 
albuminoid,  thus  differing  in  this  respert  very 
considerably  from  Dr.  Bence-Jones’  analyses  of 
similar  blood  where  the  quantity  of  fat  given  is 
that  of  normal  blood.  On  the  other  hand,  the 
urine  of  the  man  from  whom  this  blood  was  ob- 
tained yielded  a proportion  of  fat  almost  iden- 
tical with  what  Hoppe-Seyler  obtained  in  the 
urine  of  the  person  whose  blood  he  examined — 
the  figures  given  by  the  former  writer  being  0 74 
and  by  the  latter  0 72  per  cent.  The  composi- 
tion of  the  blood  in  this  affection  must  be  re- 
garded as  hitherto  unsettled.  Guibort  found 
in  a clot  of  it  almost  twice,  and  Hoppe-Seyler 
about  eleven  times  as  much  fat  as  is  found  in 
normal  blood ; on  the  other  hand,  Bayer,  Bence- 
Jones,  and  Crevaux  could  detect  no  change  in 
its  composition.  It  is  possible  that  the  discre- 
pancy in  the  results  of  these  analyses  and  macro- 
scopic examinations  of  the  blood  may  be  due  in 
part  to  the  particular  moment  when  the  blood 
was  abstracted.  According  to  M.  Claude  Ber- 
nard, ‘ Les  urines  chyleuses  resemblent  au  sang 
d’un  animal  en  digestion,  ou  plutot  a celui  des 
oies  que  l'engraisse.’ 2 

With  regard  to  the  microscopic  examination  of 
the  blood,  the  writer  has  not  observed  that  the 
corpuscles  or  serum  presented  any  abnormality 
indicative  of  the  presence  of  fatty  matter  in  any 
form — the  serum  has  seemed  as  clear  and  as  free 
from  molecular  matter  as  normal  blood.  So  far 
as  his  experience  goes,  the  only  feature  worthy 
of  special  note  in  connection  with  microscopical 
examination  of  the  blood  in  chyluria,  is  the  pre- 
sence of  the  haematozoon  already  referred  to.  In 
searching  for  it,  it  will  be  advisable  to  abstract 
by  means  of  a needle  a drop  of  blood  from  several 
fingers,  and  to  submit  each  slide  to  a thorough 
examination,  which  may  have  to  be  very  pro- 
longed, employing  for  this  purpose  a compara- 
tively low  power — §"  or  V objective — a higher 
power  being  resorted  to  when  the  entozoon  has 
been  detected.  It  must  not  be  expected  that  the 
blood  will  present  any  peculiarity  to  the  naked 
eye,  even  though  every  ounce  may  contain  thou- 
sands of  these  microscopic  worms.  The  aecom- 

1 Med.-chem.  Untersuchungen , 1871,  s.  551-56.  Abstract 
by  Dr.  Ferrier  in  Joum.  Chem . Soc..  voL  ix.,  1371 : pore 
740. 

2 Quoted  by  Crevaux,  oj>.  cit. 


CHYLURIA. 


252 

panying  wood-cut,  traced  from  a micro-photo- 
graph, accurately  represents  the  size  and  form  of 
the  parasite.  Its  average  length 
is  !jt''(  = 0-34mm.) ; its  breadth 
alhto"  ( = 0'007mm.),  or  about 
equal  to  the  diameter  of  a red 
blood-corpuscle.  It  is  enclosed 
in  a transparent  tubular  sac, 
within  which  it  can  be  seen  to 
alternately  contract  and  elon- 
gate itself.  This  sac  is  extremely 
delicate  and  translucent,  and  may 
sometimes,  when  the  worm  has 
shortened  itself  more  than  usual, 
be  seen  collapsed  and  folded  like 
a ribbon,  and  the  next  moment 
be  instantaneously  straightened 
again,  by  the  extension  of  the 
filaria  to  its  ordinary  length. 
After  death  the  worm  may  occupy 
either  the  entire  length  of  the 
tubular  sac,  or  be  so  contracted 
as  t o leave  the  tube  empty  at  one 
or  both  ends,  as  may  be  observed 
in  the  wood-cut.1  The  internal 
organs  are  not  sufficiently  differ- 
entiated to  be  recognised  with 
anything  like  certainty,  although 
when  carefully  scrutinised  from 
time  to  time  during  the  twenty- 
four  or  forty-eight  hours  that  tho 
parasites  may  continue  to  live, 
something  like  differentiation  of  an  alimentary 
canal  may  be  recognised. 

Microscopical  Characters  of  the  Urine. — 
The  filaria  may  likewise  be  detected  in  the 
urine.  One  day  it  may  be  readily  obtained  in 
the  blood  but  not  in  the  urine,  and  vice  versa ; 
but,  as  a rule,  the  parasite  will  be  found  equally 
readily  in  both  fluids.  In  making  a search  in 
the  urino,  it  is  advisable  to  pick  out  one  of  the 
coagulated  shreds  generally  found  in  it,  transfer 
it  to  the  glass  slide  by  means  of  a forceps  or 
pipette,  and  carefully  tease  the  fragment  before 
applying  the  cover-glass. 

The  other  leading  microscopical  character  of 
the  urine  is  the  minutely  molecular  matter — fat 
in  an  emulsified  condition — to  which  the  fluid 
owes  its  opaline  or  milky  aspect.  There  are  also 
numerous  white,  lymphoid  corpuscles,  together 
with  red  corpuscles,  numerous  or  the  reverse 
according  to  the  degree  of  sanguinolence  of  the 
urine.  Casts  of  the  tubular  structure  of  the  kid- 
ney— indicative  of  organic  disease  of  these  organs 
- — are  seldom  to  be  seen ; they  were  absent  in  all 
the  eases  that  have  come  under  the  writer’s  obser- 
vation. 

Anatomical  Characters. — The  post-mortem 
examinations  of  persons  who  have  died  wdiilst 
affected  with  cbyluria,  also  testify  to  the  free- 
dom of  the  kidneys  from  disease.  This  was 
the  case  in  two  autopsies  conducted  recently 

’ The  microscopic  worms  detected  by  the  writer  (in 
July  1874)  in  the  blood  of  dogs  in  India — presumably  the 
same  species  as  those  discovered  by  UK.  G-rube  and 
DoiAfond,  in  France,  about  1843 — are  not  enclosed  in  an 
envelope  of  this  kind,  although  in  every  other  way  they 
appear  to  be  identical;  and  Dr.  Sonsino  states  that  the 
bBematoeoon  found  in  Egypt  is  also  destitute  of  this  en- 
veloping tube,  as  is  likewise  the  urinary  parasite  dis- 
covered by  Wucherer. 


by  Dr.  McConnell  in  Calcu  ,ta.  The  writer  had 
the  opportunity  of  examining  the  kidneys  of 
the  first  case,  and  of  all  the  organs  of  the  body 
of  the  other  ease,  but  could  find  nothing  in 
any  of  the  organs  or  tissues  suggestive  of  being 
a cause  of  the  urinary  derangement,  except  the 
fact  that  all  the  vessels — arteries  as  well  as  veins 
—contained  the  filaria  in  their  minutest  ramifica- 
tions. It  may  be  further  mentioned  that  the 
entozoon  is  present  in  the  chylo-lymphous  dis- 
charges which  have  already  been  referred  to  as 
sometimes  accompanying  chyluria.  Of  this  tho 
writer  was  able  to  satisfy  himself  in  1872,  and 
repeatedly  on  subsequent  occasions.  In  one  of 
the  instances  the  secretion  flowed  from  the  inner 
corner  of  the  eye,  several  ounces  of  which  escaped 
daily ; the  others  were  cases  of  elephantiasis 
lymphangiectodes,  or  nse void  elephantiasis  of  the 
scrotum.  For  a summary  of  what  is  known  of 
the  latter  affection,  the  reader  is  referred  to  a 
carefully-written  paper  by  Dr.  Kenneth  McLeod.1 

^Etiology  and  Pathology.— Having  consid- 
ered in  detail  what  seem  to  he  the  leading  patho- 
logical features  of  chyluria,  a brief  reference  may 
be  made  to  the  views  which  at  present  prevail 
regarding  its  aetiology.  These  may  be  comprised 
under  three  heads; — (1)  Dr.  Vandyke  Carter 
advocates  the  view  that  a direct  communication 
exists  between  the  chyle-carrying  vessels  and  the 
urinary  tracts.  (2)  MM.  Claude  Bernard  and 
Ch.  Robin  believe  that  the  condition  of  the 
urine  is  hut  a symptom  of  piarrhsemia — fatty 
blood;  the  latter  condition  being  but  the  normal 
condition  of  the  blood  for  some  time  after  the 
partaking  of  food,  aggravated  and  made  perma- 
nent by  derangement  of  the  digestive  organs — 
notably  the  liver.  One  of  these  distinguished 
authors  (M.  Robin)  suggests,  further,  that  this 
derangement  is  probably  induced  in  the  liver 
and  elsewhere  by  the  filaria  sanguinis  hominis.2 
(3)  The  third  view  to  be  noticed  is  that  advanced 
by  Dr.  W.  Roberts.  This  view  appears  to  he  based 
mainly  cn  the  history  of  a very  remarkable  case, 
published  by  him  in  1868.  It  was  one  in  which 
a eoagulable  chylo-lymphous  discharge  escaped 
from  open  vesicles  which  had  formed  over  the 
surface  of  the  abdomen:  the  patient’s  indue  was, 
moreover,  chylous  for  two  days.  Dr.  Roberts 
suggests  that  a condition  somewhat  similar  to 
that  on  the  surface  of  the  abdomen  existed  in 
the  urinary  tract, — a sort  of  eczema — probably 
on  the  front  of  the  bladder.  Post-mortem  ex- 
amination did  not  however  confirm  this  view, 
nor  could  anything  be  detected  in  any  of  the 
organs  suggestive  of  a cause,  but  Dr.  Roberts 
infers  that  this  was  probably  due  ‘ to  t’ne  fact  that 
in  the  last  few  weeks  of  life  the  morbid  process 
had  retrograded  and  had  consequently  left  no 
appreciable  marks  on  the  surface  of  the  bladder.’ 
The  examination  of  the  skin  in  the  diseased  part 
showed  that  the  cutis  vera  and  the  subcutaneous 
tissue  were  traversed  by  short  channels  or 
lacunae  from  the  width  of  a crow-quill  to  that  of 
a hair.  A careful  study  of  this  and  other  cases 
suggested  to  Dr.  Roberts  the  view  that  one,  at 
least,  of  the  forms  of  chyluria  may  be  due  to 
hypertrophy  of  the  lymphatic  channels  and  sub- 
sequent acquisition  by  them  of  gland  properties. 

1 Indian  Medical  Gazette,  August  1874. 

* ‘Lemons  sur  les  humeurs’ ; 2nd  edit.  1S74,  p.  S4S. 


Fig.  11. 


Filaria  Sanguinis 
Hominis. 
x 300. 

(Traced  from  a 
micro-photo- 
graph.) 


CHYLURIA- 

In  the  present  state  of  our  knowledge,  how- 
ever, it  cannot  be  said  that  any  of  these  ingenious 
explanations  meet  all  the  objections  that  might 
be  raised.  For  example,  before  the  explanation 
suggested  of  the  direct  leakage  of  the  chyle  into 
the  urine  can  be  accepted  as  sufficient,  it  must  be 
shown  that  such  a leakage  is  anatomically  pos- 
sible, and,  secondly,  that  the  relative  proportion 
of  the  leading  constituents  of  the  two  fluids  agree 
more  closely  than  is  suggested  by  the  greater 
number  of  the  analyses  hitherto  published.  M. 
Robin’s  view  does  not  suggest  any  special  anato- 
mical difficulty,  but  it  remains  to  be  demon- 
strated more  conclusively  than  has  hitherto  been 
done  that  the  blood  in  man  ever  contains  a 
sufficient  quantity  of  fatty  matter  to  produce 
such  extreme  milkiness  by  admixture  with  the 
urine  as  is  observed  in  chyluria.  Dr.  Roberts’ 
theory  is  certainly  not  open  to  these  particular 
objections,  as,  given  a certain  agent  to  start  the 
formation  of  these  glandular  tissues,  there  does 
not  appear  to  be  any  special  anatomical  or  phy- 
siological difficulty  to  be  got  over ; but  the  result 
of  all  the  autopsies  as  yet  recorded  do  not  war- 
rant the  inference  of  the  existence  of  such  patho- 
logical conditions.  Futuro  observation,  howover, 
may  show  that  they  really  do  exist. 

Of  the  setiological  significance  of  the  presence 
of  the  filaria  in  the  circulation  there  can,  the 
writer  thinks,  scarcely  be  much  doubt — more 
especially  when  the  number  of  observations  re- 
corded within  the  short  period  that  has  elapsed 
since  attention  has  been  drawn  to  its  existence 
therein,  is  taken  into  consideration.  These  sug- 
gest. more  than  a fortuitous  connection;  indeed  it 
might  rather  be  said  that  ehylo-serous  effusions 
may  be  considered  as  symptomatic  of  the  para- 
sitism. Filarias  have  even  been  detected  shortly 
before  chyluria  had  manifested  itself.  Whether 
they  act  injuriously  by  giving  rise  to  rupture  of 
the  walls  of  the  delicate  channels  in  which  they 
circulate  and  thus  cause  the  escape  of  the  dif- 
ferent nutritive  fluids  into  the  urinary  tract ; or 
whether,  as  M.  Robin  suggests,  they  produce  de- 
rangements of  the  liver  and  other  organs  which 
give  rise  to  piarrhaemia  (and,  probably  hi.  Robin 
would  add,  to  rupture  of  the  capillaries,  so  as  to 
permit  of  the  escape  of  the  abnormally  fatty 
blood),  it  would  be  premature  to  express  a defi- 
nite opinion.  It  is  possible  that  both  Carter 
and  Robin  may  be  correct  to  some  extent,  for 
the  disease  presents  many  phases ; and  the 
writer  would  suggest  further,  that  it  may  also  be 
possible  that,  in  addition  to  giving  rise  to  the 
escape  of  fluid  in  a purely  mechanical  manner  by 
causing  ruptures,  local  congestions,  and  so  forth, 
the  entozoon  may  in  some  way  tend  to  the  pro- 
duction of  minute  secreting  structures  (analogous 
to  those  described  by  Roberts  as  having  been 
formed  in  the  subcutaneous  tissues)  along  the 
urinary  tract,  or  in  other  situations,  which  might 
permit  of  the  filtration  of  the  ordinary  nutritive 
fluids  of  the  body  in  a more  or  less  modified 
condition. — Analyses  tend  to  show  that  the  con- 
stituents of  these  fluids  do  not  reach  the  urine 
in  the  proportions  in  which  they  are  normally 
found  in  the  body. 

It  is  also  possible  that  chyluria  may  occasion- 
ally occur  unassociated  with  any  parasite,  but 
this  remains  to  be  demonstrated. 


CICATRIZATION  253 

Prognosis.  — Persons  have  been  known  to 
suffer  off  and  on  from  this  affection  for  from  one  to 
fifty  years.  This  would  suggest  that  the  malady 
usually  runs  a chronic  course,  which  as  a rule  it 
doubtless  does ; on  the  other  hand  patients  ap- 
parently in  fair  health  otherwise  have  been 
known  to  die  very  unexpectedly  from  no  recog- 
nised acute  disorder.  With  regard  to  the  pro- 
spect of  a cure  a very  guarded  opinion  should  be 
given,  as  the  probability  is  that  the  complaint 
will  return  again  and  again  so  long  as  life  lasts — 
even  when  the  disease  commences  at  a very  early 
age,  and  often  after  a complete  change  of  climate 
and  avocation. 

Treatment. — -This  has  proved  extremely  un- 
satisfactory in  almost  all  the  cases  recorded ; in 
fact  it  cannot  be  distinctly  stated  that  the  course 
of  the  disease  has  been  materially  modified,  much 
less  cured,  by  any  known  remedy.  Iodide  of 
potassium  has  been  tried  in  large  doses,  and  in 
some  cases  appears  to  have  been  beneficial ; in 
others  the  tincture  of  the  perchloride  of  iron  has 
seemed  to  be  more  successful.  A decoction  of 
the  bark  of  Rhizophora  racemosa  (mangrove) 
has  a reputation  in  Guiana,  just  as  a decoction  of 
the  seed  of  Nigella  sativa  (used  also  as  a condi- 
ment in  curries)  has  in  India.  The  latter  remedy 
has,  however,  been  known  to  be  powerless  in 
mitigating  the  malady  even  in  cases  where  on 
former  occasions  it  had  been  resorted  to  with 
apparent  success.  Perhaps  the  most  satisfactory 
results  which  have  been  published  are  those  which 
have  followed  the  administration  of  large  doses  of 
gallic  acid — one  or  two  drachms  a day.  See  Fila- 
ria Sanguinis-hominis.  Timothy  Lewis. 

CICATRIZATION  ( cicatrix , a scar)  is  the 
process  by  which  solutions  of  continuity  in  an 
organ  or  tissue  aro  repaired.  These  solutions  of 
continuity  may  be  duo  to  injury,  ulceration,  ex- 
travasation, or  the  effusion  of  inflammatory  pro- 
ducts. The  result  of  the  process  is  the  formation 
of  a cicatrix  or  scar. 

Pathology.  — Cicatrization,  as  it  occurs  in 
superficial  parts  in  surgical  practice,  may  be 
selected  as  affording  a typical  illustration  of 
the  process.  It  is  most  frequently  and  easily 
observed,  and  it  corresponds  to  what,  is  met  with 
in  deeper  tissues. 

Repair  may  take  place  either  with  or  without 
the  occurrence  of  granulation,  and  the  process  of 
granulation  may  or  may  not  bo  accompianied  by 
suppuration  : the  existence  both  of  granulation 
and  of  suppuration  depending  on  the  degrees  of 
abnormal  stimulation  to  which  the  injured  tissues 
are  subjected. 

In  an  incised  wound  favourably  circumstanced 
as  to  vascularity  of  tissue,  absence  of  tension,  and 
apposition  of  edges,  epidermic  continuity  may  be 
re-established  in  thirty-six  to  seventy-two  hours. 
The  lips  of  such  a wound  are  temporarily  united 
by  a thin  layer  of  lymph  and  white  corpuscles  of 
the  blood,  and  perhapis  soon  afterwards  by  cells 
proliferated  from  connective-tissue  corpuscles, 
These  cells  become  spindle-shaped,  and  are  ulti- 
mately converted  into  ordinary  connective-tissuo 
corpuscles,  whilst  offsets  from  the  neighbouring 
capillaries  re-establish  the  circulation  throughout 
the  new  tissue.  Coincidently  with  these  changes 
the  surface  becomes  covered  with  epidermic  scales. 


254  CICATRIZATION. 

The  resulting  scar  at  first  appears  as  a red  line, 
which  subsequently  becomes  white  from  the  dis- 
appearance of  many  of  its  blood-vessels. 

When  an  open  wound  heals  by  scabbing,  the 
epidermis  spreads  over  the  tissues  without  the 
intervention  of  the  process  of  granulation,  owing 
to  the  protection  afforded  them  by  the  crust  of 
blood  and  lymph  which  has  formed  upon  the 
wound. 

Recent  antiseptic  surgery  has  shown  that  even 
large  hollow  wounds  filled  with  blood-clot,  such 
as  are  caused,  say,  by  operation  for  ununited  frac- 
ture of  the  femur,  may  cicatrize  completely 
without  suppuration  or  granulation,  if  protected 
from  the  stimulation  of  the  antiseptic  used. 
In  these  cases  the  white  corpuscles  of  the  clot 
become  organized  directly  into  fibro-plastic  cells 
and  connective-tissue  corpuscles,  and  the  new 
epidermis  will  probably  be  formed  beneath  a 
thin  upper  layer  of  the  clot. 

If  a recent  wound,  too  largo  for  scabbing,  be 
simply  loft  exposed  to  the  air  or  treated  with 
water  dressing,  or  with  an  ordinary  antiseptic, 
there  will  be  a discharge  at  first  of  serum  tinged 
with  blood,  then  of  pale  serum,  and  latterly  of 
cloudy  yellowish  serum,  replaced  in  about  three 
days  by  fully-formed  pus.  By  this  time  the  wound 
will  be  studded  over  with  little  bright  red  ele- 
vations, termed  granulations,  which  ultimately 
cover  the  whole  surface.  Granulation-tissue 
consists  of  nucleated  cells,  amongst  which  pass 
vascular  loops  with  thin  walls.  After  an  inter- 
val the  edges  of  the  skin  are  seen  to  be  on  a level 
with  the  granulating  surface,  and  as  it  were 
continuous  with  it.  Perhaps  already  the  wound 
is  much  smaller,  owing  to  the  shrinking  of  the 
granulutionsas  their  cells  assume  the  spindle-cell 
type.  Then,  extending  from  the  cutaneous  mar- 
gin thore  may  be  observed  a narrow  red  line, 
brighter  than  the  rest  of  the  granulating  surface, 
owing  to  the  presence  of  a layer  of  transparent 
epidermis.  Next  day  this  zone  will  be  bluish, 
owing  to  the  growing  opacity  of  the  epidermic 
cells,  and  there  will  be  a new  red  line  of  newest 
epithelium.  A day  later  the  outer  layer  will  havo 
become  so  opaque  as  to  be  whitish,  and  the  second 
to  be  bluish;  and  there  will  again  be  a fresh 
inner  red  line,  which  will  gradually  advance  until 
the  scar  is  complete.  The  new  epidermis  quickly 
separates  into  a horny  and  a mucous  layer. 

The  healing  of  an  evacuated  abscess-cavity 
depends  partly  upon  the  contraction,  and  partly 
upon  the  coalescence  of  the  granulations  of  which 
its  pyogenic  membrane  consists. 

Many  cases  of  disease  of  joints  (caries,  &c.), 
and  the  behaviour  of  abscesses  treated  anti- 
septically  and  with  adequate  drainage,  may  be 
referred  to  as  instances  of  the  existence  of  non- 
suppurating granulations.  John  Bishop. 

CINCHONISM. — A condition  induced  by 
the  administration  of  quinine,  the  chief  active 
principle  of  cinchona.  See  Quininism. 

CIKTCXiISIS  I move). — This  word 

signifies  agitation  or  motion,  and  was  formerly 
applied  to  involuntary  winking  or  movements 
of  the  eyelids ; and  also  to  the  movements  of 
the  chest  in  dyspnoea. 

OIBCUT , A TT  O 3 , Disorders  of. — Abnor- 


CIRC UL ATION,  DISORDERS  OF. 

mal  excess  and  deficiency  of  blood  are  known 
as  Hyperemia  and  Anemia  respectively.  Each 
of  these  may  be  general  or  local. 

I.  Hypereemia. — General  hypersemia  signifies 
excess  of  blood  in  the  body,  and  is  also  called 
plethora.  Local  hyperaemia  means  excess  of 
blood  in  a part.  Such  excess  may  be  caused 
either  by  superabundant  supply,  or  by  deficient 
removal  of  blood  through  the  agency  of  the 
blood-vessels.  Dilatation  of  the  arteries,  how- 
ever produced,  causes  more  copious  afflux  of 
blood,  which  fills  the  capillaries  and  veins  in  a 
corresponding  degree,  so  that  there  is  excess  of 
blood  in  all  the  vessels  of  the  part.  This  con- 
dition is  called  arterial  or  active  hyperemia , 
active  congestion,  or  determination  of  blood,.  If. 
on  the  other  hand,  blood  is  imperfectly  removed 
by  the  veins,  these  vessels,  as  well  as  the  capil- 
laries, become  gorged,  and  the  condition  called 
venous  or  passive  hypereemia , or  venous  con- 
gestion, results.  There  cannot  be  capillary 
hypereemia,  except  as  the  result  of  one  of  these 
conditions. 

A.  Arterial  or  Active  Hypereemia. — An  excessive 
amount  of  blood  can  be  conveyed  by  the  arteries 
only  under  two  conditions  : — (1)  Enlargement  oi 
these  vessels  by  relaxation  of  their  muscular 
walls  ; (2)  Increased  pressure  within  them,  from 
obstruction  of  collateral  channels  with  which 
they  communicate,  i.e.  collateral  hyperaemia. 

(1)  Relaxation  of  the  muscular  walls  may  be 
caused  directly  by  violence  or  by  warmth,  as  is 
illustrated  in  the  redness  of  the  skin  produced 
by  a blow,  by  heat,  or  by  the  reaction  aftei 
intense  cold.  Sudden  withdrawal  of  pressure 
has  the  same  effect,  as  is  sometimes  seen  on 
evacuating  a hydrocele  or  fluid-collection  in  a 
serous  cavity.  Dry-cupping  produces  similar 
but  more  complex  results,  the  veins  being  acted 
upon  as  much  as  the  arteries.  Relaxation  of 
the  muscle-fibres  is  produced  also  indirectly 
through  the  vaso-motor  nerves.  If  these  are 
paralysed,  relaxation  of  the  fibres  occurs,  and 
the  arteries  dilate.  Experimental  section  of  the 
cervical  sympathetic  in  animals  shows  this  most 
clearly;  but  the  same  result  follows  less  con- 
stantly if  other  nerves  containing  vaso-motor 
fibres  are  divided  or  injured,  such  as  the  mixed 
nerves  of  the  limbs,  or  branches  of  the  trige- 
minus. Wounds  of  the  brachial  plexus  have  been 
found  to  cause  hypersemia  of  the  fingers  (glossi/ 
fingers  of  Paget).  When  the  section  is  com- 
plete, hypersemia  is  only  transitory,  and  is  soon 
followed  by  a return  to  the  normal  condition,  or 
even  by  undue  anaemia,  which  is  permanent.  In 
irritative  lesions,  on  the  other  hand,  such  as 
gunshot  wounds,  hypersemia  continues  as  long 
as  the  irritation.  In  such  cases  it  is  possible 
that  the  lesion  is  not.  paralytic,  but  depends 
upon  stimulation  of  the  actively-dilating  vaso- 
motor fibres  which  physiologists  have  now  shown 
to  exist  in  many  parts  of  the  body,  since  stimu- 
lation of  these  produces  the  same  result  as 
paralysis  of  the  inhibitory  fibres.  Hypersemia 
often  accompanies  neuralgia,  both  depending 
upon  some  morbid  condition  of  the  nerve.  The 
starting  point  of  the  neurosis  in  all  these  cases 
may  be,  and  often  is,  in  the  central  nervous 
system,  and  hence  chronic  diseases  of  the  spinal 
cord  or  brain  are  often  accompanied  by  general 


CIRCULATION,  DISORDERS  OF. 


paralytic  hypereemia—  that  is,  flushing,  or  by  con- 
gestion of  special  parts.  The  same  result  may 
come  from  reflex  nervous  action,  set  up  by  dis- 
turbances of  the  digestive  organs,  the  organs  of 
generation,  or  of  other  parts. 

(2)  Collateral  hyperaemia  is  a consequence  of 
the  riso  of  pressure  produced  by  the  blocking-up 
of  arterial  channels  in  the  adjoining  parts.  It 
is  usually  effected  by  the  enlargement  of  existing 
vessels,  and  the  conversion  of  small,  almost  capil- 
lary, vessels  into  pulsating  arteries.  It  occurs 
not  only  in  the  familiar  instances  of  surgical 
ligature,  and  the  sudden  blocking  of  an  artery 
by  a plug  (see  Emboxjsm)  ; but  in  the  gradual 
obstruction  which  accompan'es  atrophic  and 
sclerotic  processes.  When  the  chief  arterial 
channels  to  an  organ  become  obstructed,  its  peri- 
pheral parts  are  very  liable  to  become  hyperaemic, 
a principle  which  when  applied  to  such  cases  as 
cirrhosis  of  the  liver,  granular  kidney,  and 
sclerosis  of  the  brain,  will  be  found  fruitful  in 
practical  deductions. 

Signs  and  Results. — Tho  colour  of  parts  in 
a state  of  active  hyperaemia,  is,  during  life, 
bright  red,  the  arteries,  large  and  small,  being 
visibly  injected,  while  the  capillaries,  filled  with 
arterial  blood,  produce  a diffuse  red  colour.  In 
experimental  hyperaemia  the  blood  may  remain 
bright  red  even  in  the  veins.  The  temperature 
of  external  parts  becomes  elevated,  though  not 
above  that  of  internal  parts.  Sometimes  there 
is  obvious  pulsation  or  throbbing.  There  may 
be  swelling,  which  is  due  to  simple  enlargement 
of  the  vessels,  not  to  exudation  of  fluid,  since  this 
does  not  occur  from  arterial  hyperaemia  alone. 
The  nerves,  both  those  of  common  sensation  and 
those  of  special  sense,  are  more  excitable  than 
they  are  normally.  There  is  usually  a subjec- 
tive sensation  of  warmth,  and  there  may  be  pain 
or  itching. 

Arterial  hypertemia  may  last  for  a long  time 
without  producing  any  change  whatever  in  the 
part  affected,  but  may,  under  conditions  little 
understood,  give  rise  to  hypertrophy,  which  some- 
times, though  rarety,  results  from  section  of  the 
cervical  sympathetic.  Transitory  but  repeated 
hyperaemic  conditions  more  regularly  produce  this 
result,  as  is  seen  in  hypertrophy  from  pressure ; 
in  thickening  of  the  skull  from  excessive  exposure 
of  tho  head  to  the  sun  ; in  hypertrophy  of  the 
skin  and  its  glands  from  frequently  recurring 
hyperaemia  of  the  face  ( acne  rosacea).  This  kind 
of  hyperaemia  constantly  precedes,  but  can  hardly 
be  said  to  produce,  inflammation.  It  does,  how- 
ever, render  the  tissues  more  vulnerable,  bring- 
ing them  into  a condition  in  which  a slight  cause 
will  set  up  inflammation.  Unless  the  vessels 
are  unsound,  simple  arterial  hyperaemia  does  not 
lead  to  haemorrhage. 

B.  Passive  Hypereemia  or  Venous  Congestion. — 
This  may  be  due  to  —(1)  Feeble  circulation  ; or 
(2)  Obstruction  in  the  veins. 

(1)  Blood  may  be  imperfectly  removed  from 
a part,  owing  to  the  imperfect  action  of  the 
forces  which  normally  maintain  the  flow  of 
blood  in  the  veins.  These  are,  besides  the  action 
of  the  heart,  the  pressure  of  muscles  (combined 
with  the  arrangement  of  the  valves  in  the  veins), 
an  I the  movement  of  the  thorax  in  inspiration. 
It  these  arc  deficient,  the  venous  current  will  be 


266 

everywhere  delayed,  but  notably  in  those  parts 
where  it  has  to  overcome  the  action  of  gravity. 
In  the  erect  posture  this  will  be  the  case  in  the 
lower  limbs,  and  hence  venous  congestion  is  com- 
mon in  the  legs,  ankles,  and  feet.  In  decumbent 
patients,  for  analogous  reasons,  the  nates,  sacrum, 
shoulder-blades,  and  the  bases  of  the  lungs 
behind  become  the  seat  of  what  is  called  hypo- 
static congestion.  Very  general  obstruction,  such 
as  results  from  imperfection  of  the  heart  itself, 
may  lead  to  the  condition  called  cyanosis,  which 
is  essentially  venous  congestion,  and  to  similar 
congestion  of  the  lungs,  liver,  kidneys,  and  other 
internal  organs,  with  very  serious  results. 

(2)  Obstruction  of  the  veins  is  rarely  produced 
by  a morbid  condition  of  the  W'alls  of  these 
vessels,  but  may  result  from  coagulation  of  blood 
within  them.  Another  cause  is  external  pressure, 
such  as  that  of  tumours,  of  the  gravid  uterus,  or 
of  the  intestinal  contents,  as  in  the  case  of  the 
haemorrhoidal  veins.  Finally,  indurative  changes 
in  the  solid  viscera  lead  to  venous  obstruction, 
as  is  seen  in  cirrhosis  of  the  liver,  which  produces 
congestion  of  the  whole  portal  system. 

Signs  and  Results. — The  colour  of  parts 
in  a state  of  passive  hypertemia  is  bluish  rather 
than  red,  the  veins,  large  and  small,  being  in- 
jected with  venous  blood,  and  the  capillaries, 
in  which  the  blood  is  also  venous,  producing  a 
uniform  purple  colour:  If  the  congestion  is 
extreme,  collateral  venous  channels  are  likely  to 
be  established,  which  are  sometimes  the  only 
evident  sign  of  internal  venous  obstruction.  The 
surface  is  usually  cooler  rather  than  hotter  when 
compared  with  corresponding  parts  of  the  body  ; 
and  there  is  no  unusual  nervous  sensibility  or 
sense  of  throbbing.  Swelling  very  frequently 
occurs,  and  depends  on  actual  serous  effusion 
from  the  vessels,  so  that  the  parts  are  often 
anasarcous,  pitting  on  pressure  ; while  in  cavities 
there  is  an  accumulation  of  fluid. 

Venous  congestion  produces  more  important 
and  permanent  results  than  arterial.  In  experi- 
mental venous  obstruction,  besides  engorgement 
of  the  vessels,  two  nearly  constant  phenomena 
are  seen — copious  transudation  of  serum,  and 
migration  of  a number  of  red  blood-disks  through 
the  walls  of  the  capillaries  and  smaller  veins. 
Few  or  no  w'hite  corpuscles  emigrate,  and  the 
arterial  circulation  is  unaltered.  The  absence 
or  occurrence  of  dropsy  depends  upon  the  ade- 
quacy or  inadequacy  of  the  lymphatics  to  carry 
off  the  superfluous  serum.  In  ordinary  patho- 
logical venous  congestion  all  these  changes  are 
seen  to  some  extent ; extravasation  of  red  blood- 
disks  being  shown  by  the  pigmentation  of  parts 
in  chronic  congestion,  though  this  is  not  evident  in 
the  acute  condition.  Chronic  venous  congestion 
increases  the  hardness  and  density  of  organs, 
a change  which  may,  in  the  first  instance,  result 
from  simple  oedema,  but  in  the  end  is  due  to 
fibroid  change  (see  Degenerations).  Such 
organs  are  at  first  enlarged,  hut  ultimately 
diminish  in  size,  and  suffer  fatty  atrophy,  not 
only  through  the  general  law  of  fibroid  change, 
but  because  venous  blood  is  inadequate  to  the 
proper  nutrition  of  tissues.  These  changes  are 
seen  in  the  liver  and  kidneys  in  cases  of  obstruc- 
tive heart-disease.  External  parts,  as  the  skin 
of  the  lower  part  of  the  leg,  show  by  a tendency 


256  CIRCULATION,  DISORDERS  OF. 
to  ulceration  that  they  aro  imperfectly  nourished, 
and  are  also  liable  to  becomo  inflamed  from 
blight  causes  (varicose  eczema). 

Post-mortem  Characters. — The  appearance 
of  hypersemic  parts  after  death  is  not  neces- 
sarily the  same  as  during  life.  The  colour  of 
the  blood  does  not  enable  us  to  say  whether 
the  hypersemia  was  arterial  or  venous.  All 
blood  contained  in  the  body  after  death,  excluded 
from  the  air,  is  dark  or  venous,  but  becomes 
florid  when  exposed  to  the  air,  unless  it  have 
previously  undergone  some  post-mortem  change, 
or  some  morbid  alteration  during  life.  This 
change  may  be  watched  in  the  lungs  when  the 
chest  is  opened,  especially  in  the  case  of  chil- 
dren whose  lungs  have  little  local  colour.  The 
only  important  point  after  death  is  the  fulness  of 
the  three  lands  of  vessels.  Arteries  are  usually 
empty,  unless  diseased ; the  larger  veins  almost 
always  full.  If  the  smaller  veins  and  arteries 
are  conspicuously  and  brightly  injected,  the  part 
maybe  described  simply  as  congested;  a uniform 
colour  indicates  fulness  of  the  capillaries,  which 
may  be  confirmed  by  the  microscope.  Uncom- 
plicated arterial  hypersemia  leaves  no  trace  after 
death  ; the  appearance  of  it  is  produced  by  in- 
flammation. Simple  venous  hyperaemia  can  only 
be  recognised  as  such  after  death  by  comparison, 
that  is,  with  the  same  part  under  normal  con- 
ditions. Chronic  venous  congestion  is  indicated 
by  many  of  the  same  characters  as  during  life. 
Care  should  be  taken  not  to  mistake  for  arterial 
hyperaemia  mere  staining  with  blood-pigment 
of  the  walls  of  the  vessels ; nor  for  venous 
congestion  mere  'post-mortem  hypostasis,  or  the 
settling  down  of  the  blood,  if  fluid,  after  death. 

II.  Aneemia .-—General  anaemia  is  a morbid 
condition  in  which  there  is  a deficiency  of  blood, 
or,  more  correctly,  a deficiency  of  the  red  cor- 
puscles of  the  blood,  throughout  the  whole  body. 
It  is  also  called  oligeemia,  or  oligocytlwmia  (see 
Anjemia).  Local  anaemia,  with  which  we  are  here 
concerned,  signifies  deficiency  of  blood  in  a part. 
It  may  be  complete  or  partial.  Complete  local 
anaemia'  can  only  occur  when  the  blood-supply  of  a 
part  is  totally  cut  off  by  obstruction  of  its  arteri  es. 
The  conditions  and  consequences  of  such  obstruc- 
tion  are  discussed  elsewhere  (see  Emiolism.)  Par- 
tial anaemia  or  ischasmia  may  be  produced  by  direct 
pressure,  or  else  by  arterial  obstruction,  perma- 
nent or  transitory.  Permanent  anaemia  of  many 
parts  results  from  gradual  obstruction  of  arteries 
by  atheromatous  change,  or,  still  more  strikingly, 
by  a form  of  endarteritis  (endarteritis  obliterans) 
attributed  to  syphilis  ; or,  again,  from  deposi- 
tion of  fibrin  on  the  diseased  vascular  wall. 
Temporary  anaemia  results  from  spasmodic  con- 
traction of  the  annular  fibre-cells  in  the  muscu- 
lar coat  of  the  artery.  Such  a contraction  may 
be  produced  experimentally  by  direct  electrical 
stimulation,  or  by  stimulation  of  the  sympathetic' 
branches  distributed  to  the  vessel;  and  in  pa- 
thological conditions  we  find  such  contraction 
occurring  in  consequence  of  some  derangement 
of  tho  nerve-centres,  or  from  reflex  irritation, 
or  even,  as  it  would  seem,  idiopathically.  Neu- 
ralgia and  migraine  are  often  accompanied  or 
caused  by  spasm  of  the  arteries,  and  epilepsy 
has,  with  less  certainty,  been  attributed  to  the 
name  cause.  In  these  eases  it  is  possible,  as  is 


CIRCULATION,  ORGANS  OF. 

held  by  some  authorities,  that  anaemia  of  tbt 
nerve-tissue  is  the  cause  of  the  disturbed  inner- 
vation. Hysterical  blindness,  and  probably  other 
hysterical  affections,  may  be  explained  in  the 
same  way. 

Signs  and  Results. — An  anremie  part  is 
pale,  its  temperature  in  the  case  of  external 
parts  is  diminished,  and  there  is  weakened  or 
arrested  arterial  pulsation.  A permanent  con- 
dition of  anaemia,  even  if  only  partial,  produces 
degeneration,  ending  in  atrophy  of  the  affected 
part.  The  wasting  of  the  skin,  and  possibly  that 
of  the  kidneys  in  old  age,  is  due  to  this  cause. 
Transitory  anaemia  causes  necessarily  a cessa- 
tion of  functional  activity  in  the  part,  as  is 
obvious  in  the  nerve-centres  and  the  muscles  - 
but  does  not,  so  far  as  we  know,  produce  any 
permanent  change.  Compression  or  obstruction 
of  the  abdominal  aorta  produces  symptoms  of 
temporary  paraplegia.  J.  F.  Patne. 

CIRCULATION’,  Diseases  of  Organs  of. 

The  organs  of  circulation  comprehend  the 
heart,  the  arteries,  the  veins,  and  the  inter- 
vening capillaries.  The  diseases  affecting  each 
of  these  structures  will  be  found  described  under 
their  respective  headings.  It  has,  however,  been 
thought  desirable  to  give  in  this  place  a general 
sketch  of  the  different  ways  in  which  the  inti- 
mate relations  that  exist  between  the  parts  of  the 
circulatory  apparatus  maybe  disturbed  by  disease. 
While  tho  heart,  the  arteries,  the  veins,  and  the 
capillaries  have  each  special  diseases,  related 
to  their  differences  of  structure  and  of  function, 
the  effect  of  such  diseases  is  rarely  or  never 
purely  local.  The  other  parts  of  the  circulation 
on  either  side  of  the  lesion  and  the  regions  to 
which  the  vessels  are  distributed  suffer  more  or 
less  from  the  local  disease.  This  is  true  whether 
the  disease  be  structural  or  only  functional ; and 
whether,  in  the  latter  case,  the  nervous  system 
or  the  blood  be  the  primary  seat  of  the  disorder. 
Viewed  thus,  the  sul  jeet  will  be  best  considered 
under  three  heads  ; — 1 The  structural  changes 
of  the  several  organs  of  circulation,  and  the 
diseases  and  disorders  to  which  they  give  rise 
in  other  parts  of  the  system,  whether  general 
or  local.  2.  The  functional  disorders  of  the 
organs  of  circulation  due  to  nervous  disturbance, 
both  local  and  general.  3.  The  functional  dis- 
orders of  the  circulation  due  to  changes  in  the 
blood.  We  shall  discuss  these  divisions  in  the 
order  in  which  they  have  been  named. 

(A) — Structural  Changes  in  the  Organs  of 
Circulation. — The  heart  is  liable  to  organic 
disease  either  in  its  propelling  muscular  walls,  its 
regulating  valves,  or  its  controlling  nervous  sys- 
tem ; and  it  will  be  found  that  diseases  of  each  of 
these  parts  of  the  cardiac  apparatus  affect  respeo 
tively  its  several  functions.  Thus  disease  of  the 
walls  of  the  heart  affects  the  force  or  pressure  ; 
valvular  disease  primarily  disturbs  the  distribu- 
tion or  quantity  of  blood  in  the  several  parts  of  the 
circulation ; while  nervous  disorder  especially  in- 
terferes with  the  rate  and  regularity  of  its  move- 
ments. Diseases  of  the  arteries  interfere  with 
the  quantity  of  blood  transmitted  through  them, 
and  produce  secondary  disturbances  of  distri- 
bution or  of  pressure.  When  the  capillary  walls 
are  degenerated  or  ruptured,  or  when  their  canalr 


CIRCULATION.  DISEASES  OF  ORGANS  OF.  257 


are  Mocked  as  a result  of  embolism  or  throm- 
bosis in  arteries  or  veins,  nutrition  is  disturbed 
in  various  ways.  Lastly,  the  veins  may  be  the 
seat  of  a variety  of  lesions,  which  prevent  the 
return  of  blood,  and  lead  to  haemorrhage  cr  to 
dropsy.  We  shall  consider  the  diseases  that  have 
been  above  indicated  from  a common  point  of 
view.  viz.  their  effects  upon  the  circulation. 

1.  The  pressure  of  blood  within  the  circula- 
tion may  be  either  increased,  diminished,  or 
irregularly  distributed.  The  most  marked  in- 
stance of  increased  pressure  is  seen  in  simple 
hypertrophy  of  the  left  ventricle  without  val- 
vular disease,  especially  if  the  hypertrophy  be 
associated  with  increased  peripheral  resistance, 
as  obserred  in  chrouic  Bright's  disease.  The 
effects  of  increased  pressure  on  the  heart  are 
cardiac  enlargement  with  its  consequences,  and 
valvular  disease ; in  the  arteries , they  are  fulness, 
elongation,  thickening,  and  atheroma  with  its 
results.  The  pulse  is  strong  and  full,  and  may 
possess  the  various  characters  of  the  vessel-wall 
just  enumerated.  The  capillaries  are  over-dis- 
tended, and  may  be  ruptured,  htemorrhage  being 
the  result.  The  functions  of  the  several  organs 
are,  under  favourable  circumstances,  more  active ; 
and  the  venous  circulation  is  more  free. 

Diminished  pressure  of  the  circulation  is  more 
common,  and  is  seen  in  dilatation  with  thinning 
of  the  cardiac  walls,  in  atrophy,  in  fatty  de- 
generation, and  in  fibroid  hypertrophy  or  de- 
generation. The  effects  of  diminished  pressure 
within  the  circulation  generally  are  the  reverse 
of  those  of  increased  pressure.  The  arteries  are 
comparatively  empty  and  small,  and  the  pulse  is 
weak,  small,  and  often  irregular.  The  capil- 
laries are  insufficiently  supplied  with  blood  ; the 
visible  surfaces  are  anaemic,  or  passively  con- 
gested; and  the  various  functions  are  feebly 
discharged.  The  backward  pressure  within  the 
veins  is,  on  the  contrary,  increased;  the  blood 
tends  to  accumulate  within  them;  the  walls  are 
dilated ; the  valves  are  disorganised  ; and  passive 
congestion,  thrombosis,  dropsy,  and  chronic  in- 
flammation are  frequent  results. 

2.  The  Quantity  of  blood  distributed. — What 
has  just  been  said  coucerningthe  pressure  of  the 
blood  applies,  in  a great  measure,  to  the  quantity- 
distributed  through  the  circulatory  system.  In 
hypertrophy  of  the  heart,  a larger  amount  of 
blood  passes  through  it  in  a given  time,  and  the 
arteries  and  pulse  are  full;  while  in  atrophy 
and  dilatation  the  quantity  is  less,  and  the 
pulse  is  empty  and  contracted. 

3.  The  most  frequent  disturbance  observed 
is  irregularity  of  distribution.  This  condition 
generally  affects  the  pressure  and  quantity  to- 
gether, but  may  affect  one  more  than  the  other. 
Irregular  distribution  of  blood  and  of  pressure 
is  most  markedly  present  in  valvular  imperfec- 
tion, and  especially  in  aortic  and  mitral  regur- 
gitation. It  is  also  seen  in  obstruction  and 
other  allied  conditions  of  the  arteries,  especially 
of  the  aorta.  In  the  parts  of  the  circulation  and 
in  the  organs  situated  behind  the  seat  of  disease, 
irregularity  of  distribution  of  blood  and  of  pres- 
sure is  manifested  in  the  form  of  dilatation, 
such  as  enlargement  and  engorgement  of  the 
heart,  of  congestion  and  associated  changes  in 
die  lungs  and  abdominal  viscera,  of  hoemor- 

17 


rhage,  and  of  various  exudations  and  effusion; 
whether  as  cedema,  dropsy,  or  catarrh.  On  the 
other  hand,  the  portions  of  the  circulatory 
apparatus  beyond  the  seat  of  disease  are  under 
filled  and  undersized ; the  organs  are  deprived 
of  their  sufficient  supply  of  blood  : and  anaemia, 
with  its  further  consequences,  is  the  result. 

4.  Frequency  and  Rhythm. — Among  the  mosl 
common  forms  of  cardiac  disturbance  are  altera- 
tion of  frequency  and  irregularity  of  rhythm. 
Alteration  in  frequency  is  generally  in  the  direc- 
tion of  increase ; but  unnatural  slowing  may  also 
occur  as  a symptom  of  fatty  degeneration  and 
other  morbid  conditions.  The  essential  causes 
of  modifications  in  the  rate  of  the  heart’s  action 
are  very  complex  and  obscure,  for  the  muscular 
tissue,  the  intrinsic  nervous  apparatus,  and  the 
extra-cardiac  nerves  and  centre  in  the  medulla 
oblongata,  may,  in  different  instances,  be  all 
more  or  less  concerned.  As  a rule,  increased 
frequency  is  associated  with,  and  proportionate 
to,  weakness  of  ventricular  contraction.  Un 
natural  slowing  is  believed  to  be  generally  ner- 
vous in  its  origin ; but  it  may  sometimes  be  duo 
to  inertness  of  the  muscular  substance  from 
fatty  degeneration  of  the  walls  of  the  heart. 
The  remarks  that  have  just  been  made  respect- 
ing frequency  apply  equally-  to  disturbance  of 
rhythm  and  irregularity  of  contraction.  Fre- 
quency and  irregularity  of  pulse  in  organic 
disease  of  the  heart  are  generally  indications  of 
serious  cardiac  weakness,  and  are  often  found 
in  the  later  stages  of  heart-disease,  whether  irs 
original  seat  has  been  valvular  or  parietal. 

(B.)  Functional  Nervous  Disorders  of  thk 
Circulation. — When  the  distribution  and  func- 
tions of  the  nervous  structures  associated  with 
the  organs  of  circulation  are  considered,  the 
variety  and  complexity  of  the  disorders  of  the 
heart  and  vessels  due  to  nervous  influences  will  be 
readily  appreciated. 

Through  the  medium  of  the  nervous  system 
the  action  of  the  heart  is  affected  by  every-  sen- 
sory impression  received  by  the  brain  ; specially 
by  influences  proceeding  from  the  following 
parts : — the  respiratory  centre,  the  respiratory- 
organs,  the  blood-vessels,  the  abdominal  viscera, 
the  surface  of  the  body,  and  the  cerebrum  itself 
with  the  organs  of  sense.  Many  of  the  disturbances 
of  the  circulation  with  which  the  reader  is  fami- 
liar in  diseases  of  the  lungs  are  occasioned 
through  nervous  channels,  especially  such  respi- 
ratory diseases  as  are  attended  with  imperfect 
oxygenation  of  the  blocd.  In  the  blocd-vessels, 
the  most  marked  example  of  nervous  associa- 
tion between  them  and  the  heart  is  afforded 
by  the  relaxation  of  the  arteries  in  cardiac 
over-distension  and  embarrassment  through  the 
operation  of  the  depressor  nerve,  which,  passing 
from  tho  heart  to  the  vaso-motor  centre  in 
the  medulla,  inhibits  or  controls  the  constrict- 
ing influences  constantly  exerted  by  this  centre 
on  the  walls  of  the  vessels,  and  thus  effects 
the  relaxation  of  these  vessels  and  ‘ depresses  ’ 
the  circulation  or  lowers  the  blood-pressure. 
Cardiac  disturbance  referable  to  abdominal 
causes  is  so  familiar  that  it  needs  scarcely 
to  be  mentioned  ; and  such  disturbance,  though 
frequently-  direct,  is  more  frequently  indirect 
or  reflex  through  the  nervous  centres.  Tho 


258  CIRCULATION,  ORGANS  OF. 

condition  of  the  blood-vessels  within  the  ab- 
domen has  the  greatest  influence  on  the  heart 
find  circulation  generally,  as  may  be  seen  in  cases 
of  shock,  inj  ury,  and  inflammation  of  the  peri- 
toneum and  great  viscera.  The  swrfaee  of  the 
body,  as  the  seat  of  impressions  of  touch,  of 
temperature,  and  of  common  sensibility,  may 
prove  to  be  the  source  of  cardio- vascular  nervous 
disturbance.  It  is  through  impressions  on  the 
nerves  of  the  surface  that  the  circulation  may 
be  disturbed  until  seriously  embarrassed,  and 
even  paralysed,  as  in  shock,  exposure  to  cold, 
&c. ; or,  on  the  other  hand,  roused  to  activity, 
by  blistering,  flagellation,  douching,  &c.  Lastly, 
the  more  extreme  and  frequent,  as  well  as  the 
more  irregular  and  varied  nervous  disturbances 
of  the  circulatory  organs  are  due  to  conditions 
of  the  brain.  The  most  common  of  all  forms 
of  circulatory  disturbance  is  seen  in  emotional 
excitement,  as  palpitation,  with  vascular  throb- 
bing, and  as  in  blushing  or  in  pallor. 

The  general  phenomena  of  functional  disorders 
of  the  circulation  due  to  nervous  disturbance 
are — (1)  Alteration  in  the  force,  frequency,  and 
rhythm  ot'  the  cardiac  movements  ; and  (2)  Dis- 
turbances of  sensibility  referable  to  the  condition 
of  the  nerves,  to  distension  of  the  cavities,  and 
to  irregular  muscular  contraction.  In  certain 
cases  the  cardio-vascular  disorder  may  be  ex- 
tensive, complex,  and  serious,  and  may  involve 
the  neighbouring  nerves,  as  is  seen  in  angina 
pectoris.  The  remote  effects  of  these  attacks 
of  functional  failure  are  fully  described  else- 
where. See  Heabt,  Functional  Disorders  of. 
Other  disorders  of  a complex  character  occur, 
such  as  Graves’s  disease,  which  is  probably 
referable  to  a nervous  origin. 

(C.)  Functional  Disorders  of  tub  Circula- 
tion, DEPENDING  ON  T1IE  CONDITION  OF  THE  BlOOD. 
—The  blood  is  so  essentially  associated  with  the 
organs  of  circulation,  that  any  alteration  either 
in  its  quantity  or  in  its  composition  speedily 
manifests  itself  in  disorders  of  the  heart  or 
vessels.  Besides  the  effect  on  the  general  intra- 
vascular pressure  that  follows  directly  any 
change  in  the  blood,  there  are  two  ways  in 
which  any  morbid  state  of  this  fluid  reacts  upon 
the  circulation — namely,  first,  by  affecting  the 
nutrition  of  the  cardiac  •and  vascular  walls ; 
and,  secondly,  through  the  agency  of  the  ner- 
vous centres.  Thus,  when  the  amount  of  blood 
is  below  the  normal,  not  only  is  the  circulation 
comparatively  depressed,  but  the  myocardium  is 
ill-nourished  and  feeble,  the  tone  of  the  vessels 
is  low,  and  the  excitability  of  the  nervous  cen- 
tres, which  directly  or  indirectly  control  the 
heart,  is  greatly  increased.  The  opposite  condi- 
tion— of  plethora,  high  blood-pressure,  enlarged 
and  powerful  heart,  and  energetic  nervous 
system  cannot,  within  definite  limits,  be  con- 
sidered morbid,  but  rather  an  evidence  of  too 
robust  health.  The  most  frequent  changes  in 
the  quality  of  the  blood  are  those  which  are 
associated  with  ansemia,  as  first  described.  The 
next  most  important  group  of  cases  is  that  in 
which  the  blood  contains  some  poison,  whether 
generated  within  the  body  or  introduced  from 
without.  The  disturbances  of  the  circulation 
by  poisons  of  all  kinds  are  very  numerous  and 
complex.  When  the  poisoning  of  the  blood  is 


CIRRHOSIS. 

of  long  duration,  and  moderate  in  degree,  chronic 
disease  may  be  set  up  throughout  the  organs  of 
circulation ; and  this  is  probably  the  mode  of 
origin  of  the  cardio-vascular  disease  so  often 
found  accompanying  chronic  Bright’s  disease. 

R.  Quain,  M.D. 

CIftR.HO  SIS  (ki ppbs,  yellow). — Synon.  : Scle- 
rosis ; Fibroid  Substitution ; Fibroid  Degene- 
ration ; Chronic  Interstitial  Inflammation ; Fr. 
Cirrhose ; Ger.  Cirrhose. 

The  term  cirrhosis,  which  was  originally  in- 
vented to  describe  a particular  state  of  the  liver 
has  now  acquired  a more  extended  meaning, 
and  is  applied  to  similar  morbid  processes  affect- 
ing other  organs,  though  the  name  itself, 
derived  as  it  is  from  the  yellow  colour  of  the 
liver  in  this  disease,  ceases  to  be  properly 
applicable.  Cirrhosis  may  be  regarded  as  a 
chronic  non-suppurative  inflammation  affecting 
the  interstitial,  connective,  and  supporting 
tissues  of  the  different  organs,  and  not  those  by 
■which  the  proper  physiological  function  is  per- 
formed. The  process  begins,  after  a more  or 
less  protracted  liyperaemia,  by  the  appearance 
in  the  interstitial  tissues,  between  the  proper 
functional  elements,  of  small  lymphoid  cor- 
puscles or  leucocytes,  udiich  are  arranged  in 
lines  or  tracts  interpenetrating  the  affected 
organ.  These  corpuscles  crowd  the  tunica 
adventitia  of  the  small  vessels,  the  lymph- 
spaces,  and  the  cavities  in  which  the  connective- 
tissue  corpuscles  lie ; and  when  present  in  con- 
siderable amount  appear  to  the  naked  eye  as 
narrow  lines  of  a slightly  translucent  greyish 
material.  This  condition  was  formerly  termed 
cellular  hyperplasia  of  the  connective  tissue,  and 
the  corpuscles  themselves  were  supposed  to 
originate  from  proliferation  of  the  connectivo- 
tissuo  corpuscles.  More  recent  researches  have, 
however,  shown  that  in  inflammation  the  eonnec- 
tive-tissue  corpuscles  remain  quite  passive  and 
take  no  part  in  the  formation  of  new  cells.  The 
early  stage  of  cirrhosis  is  therefore  more 
correctly  described  as  cellular  infiltration  of  the 
connective  tissue.  The  cells  themselves  are 
white  blood-globules,  which  have  emigrated  from 
the  vessels,  and  their  descendants.  The  amount 
of  this  cellular  exudation  varies  very  much 
in  different  organs  in  the  different  forms  of  the 
disease.  In  many  cases  of  cirrhosis  of  the  liver, 
and  in  the  fibroid  induration  of  the  left  ven- 
tricle of  the  heart,  and  of  the  pylorus,  it  is  very 
considerable,  and  causes  much  increase  in  the 
bulk  of  the  affected  organ.  In  other  instances, 
as  in  some  forms  of  granular  kidney,  it  may 
be  very  small.  Many  pathologists  consequently 
regard  the  process  in  these  cases  as  essentially 
one  of  atrophy  of  the  true  physiological  tissue, 
and  the  indurated  fibrous  tissue  which  results  as 
consisting  of  the  withered  remains  of  the  vessels 
ducts,  &c.  of  the  organ. 

The  later  stages  of  the  process  consist  in  the 
conversion  of  these  tracts,  which  may  be  looked 
upon  as  closely  analogous  to  ordinary  granula- 
tion-tissue, into  fibrous  tissue.  A more  or  less 
fibrillated  intercellular  substance  appears ; the 
corpuscles  diminish  in  number;  the  remaining 
ones  become  in  part  elongated  and  oar-shaped, 
and  some  may  pass  into  true  spindle-cells,  cr 


CIRRHOSIS. 

become  stellate : in  cirrhosis  of  the  lung  tracts 
of  true  spindle-cell  tissue  are  often  met  with. 
In  the  liver,  -where  much  of  this  new  tissue  is 
often  formed,  numerous  blood-vessels  become 
developed  in  it:  they  are  devoid  of  distinct 
walls  and  consist  merely  of  channels  lined  by 
endothelium.  The  fibrous  tissue  -which  is  the 
final  result  of  the  whole  process,  closely  re- 
sembles ordinary  cicatricial  tissue  ; it  is  usually 
tough,  dense,  and  imperfectly  fibrillated,  with 
a strong  tendency  to  contract.  Sometimes, 
especially  in  the  suprarenal  capsules,  and  less 
frequently  in  the  liver,  portions  of  it  consist  of  a 
reticulated  connective  tissue. 

The  effect  of  this  series  of  changes  on  the  proper 
physiological  tissue  of  the  organ  is  to  cause  its 
atrophy.  This  is  partly  due  to  the  direct  pres- 
sure of  the  new  growth,  when  it  is  formed  in  large 
quantities,  but  chiefly  to  the  constriction  of  the 
contracting  fibrous  tissue  and  the  consequent  ob- 
literation of  the  blood-vessels ; for  even  where,  as 
in  the  liver,  new  vessels  are  developed,  the  origi- 
nal vessels  of  the  organ  become  obliterated.  The 
atrophy  of  the  proper  tissue  of  the  organs  ap- 
pears to  take  place  by  a gradual  process  of  granu- 
lar and  fatty  degeneration  followed  by  absorp- 
tion. Sometimes,  particularly  in  the  lungs  and 
suprarenal  capsules,  this  change  is  less  gradual, 
and  portions  of  the  original  tissue  together  with 
the  new  growth  lose  their  vitality  cn  masse,  pass 
at  once  into  a state  of  fatty  degeneration,  and 
ultimately  become  caseous  and  even  calcareous, 
giving  rise  to  the  formation  of  opaque  yellow 
nodules  surrounded  by  the  semi-translucent  grey 
fibrous  tracts.  In  these  cases  it  becomes  difficult 
to  draw  a strict  line  of  demarcation  between 
cirrhosis  and  true  tuberculosis,  and  the  difficulty 
is  rendered  greater  from  the  fact  that  chronic 
tuberculosis  in  itself  sets  up  the  cirrhotic 
process.  In  the  lung  the  caseous  transforma- 
tion is  no  doubt  most  commonly  caused  by  the 
filling  up  of  the  air-vesicles  with  large 
epithelioid  catarrhal  cells  coincidently  with  the 
cirrhotic  change  in  the  walls  of  the  vessels. 
These  catarrhal  cells  not  being  in  immediate 
relation  with  the  blood-vessels,  are  especially 
prone  to  caseous  change.  So,  too,  in  the  suprarenal 
capsules  the  caseous  nodules,  if  examined  early 
enough,  will  be  found  to  consist  of  the  tubular 
spaces  of  the  organ  filled  with  their  cells  in  a 
state  of  fatty  degeneration.  Ill  the  liver,  on  the 
other  hand,  the  secretory  cells,  being  in  intimate 
relation  with  the  blood-vessels,  are  not  liable 
to  this  caseous  transformation.  Again,  it 
is  impossible  to  make  a strict  demarcation  be- 
tween syphilitic  affections  of  the  viscera  and  true 
cirrhosis.  Even  the  typical  gummata  of  syphilis 
originate  in  and  are  surrounded  by  tracts  of 
cirrhotic  induration  ; and  in  other  cases  where 
true  gummata  are  not  found,  the  only  difference 
between  cirrhosis  and  syphilis  is  that  in  the 
latter  there  is  a greater  accumulation  of  the  new 
growth  at  particular  points  and  a less  general 
diffusion  of  it  through  the  organ.  Lastly,  in 
6ome  cases,  as  in  the  cirrhotic  liver  of  hereditary 
syphilis,  the  two  processes  are  identical. 

If  we  now  proceed  to  inquire  into  the  causes  of 
drrhosis,  we  find  that  it  is  generally  preceded  by 
a protracted  hyperaemia  of  the  affected  organ 
produced  by  some  chronic  irritation,  whether 


CIVIL  INCAPACITY.  25? 

functional  or  mechanical.  As  examples  of  this 
may  be  mentioned  cirrhosis  of  the  liver  which 
results  from  the  congestion  produced  by  spirit- 
drinking; sclerosis  of  the  grey  matter  of  the 
cerebral  convolutions  after  protracted  maniacal 
excitement;  ci-rrhosis  of  the  lung,  the  result  of 
prolonged  inhalation  of  irritating  dust  in  tho 
various  forms  of  grinders’  and  miners’  phthisis ; 
the  cirrhotic  thickening  of  the  pylorus  in 
chronic  catarrh  of  the  stomach  ; and  cirrhotic 
affections  of  the  lungs  and  heart  extending  to 
those  organs  in  chronic  inflammation  of  their 
serous  coverings.  A mere  passive  congestion, 
however,  if  long  continued,  may  cause  a simple 
hypertrophy  or  overgrowth  of  the  interstitial 
connective  tissue,  and  more  or  less  induration  in 
consequence.  It  does  not,  however,  appear  to 
have  the  same  tendency  to  excite  active 
proliferation  and  the  formation  of  the  contract- 
ing fibrous  tissue  characteristic  of  true 
cirrhosis.  The  exception  to  this  rule  is  that  wo 
usually  meet  with  a slight  degree  of  the 
cirrhotic  change  in  cases  of  ‘nutmeg’  atrophy  of 
the  liver  due  to  prolonged  passive  congestion  of 
the  hepatic  venous  system.  W.  Cayley. 

CIRRHOSIS  OP  LIVER,  LUNG,  &e. 

See  Livee,  Lung,  &c.,  Diseases  of. 

CIVIL  IN CAPACITY. — One  of  the  causes 
of  this  condition  is  mental  weakness  or  disease, 
and  it  is  one  of  the  duties  of  the  physician  1 o 
aid  in  determining  the  existence  and  nature  of 
such  conditions.  There  is  a kind  of  incapacity 
which  is  implied  in  the  restriction  of  a person's 
liberty  when  he  is  placed  under  care  in  an  asylum 
or  other  special  place  of  treatment.  The  neces- 
sary information  regarding  this  will  be  found  in 
the  article  Lunacy,  Laws  of.  But  the  question 
of  incapacity  is  more  directly  raised  when  it  is 
proposed  that  a person  should  be  declared  unfit 
to  exercise  his  civil  rights,  to  require  tho 
shield  of  the  law  to  prevent  his  being  imposed 
on,  and  to  obtain  special  protection  for  his  pro- 
perty. Medical  evidence  will  require  to  be  taken 
if  it  becomes  necessary  for  a Commission  of 
Lunacy  to  be  issued  by  the  Lord  Chancellor.  This 
is  a proceeding  which  ought  not  to  be  adopted 
if  it  can  properly  be  avoided.  But  it  must  be 
remembered  that  till  a person  is  found  lunatic  by 
inquisition  he  may,  though  placed  in  an  asylum 
under  regular  certificates,  exercise  his  rights  un- 
restricted in  the  disposal  of  his  property.  The 
acts  of  any  person  either  in  or  out  of  an  asylum 
may,  however,  be  declared  invalid  if  it  can  be 
shown  that  at  the  time  they  were  performed 
the  person  laboured  under  such  an  insanity  as 
rendered  him  incapable  of  performing  them 
rationally  and  without  injurious  consequences. 
On  this  principle  any  person  may  be  found  to 
have  been  incapable  of  contracting  marriage,  of 
executing  a deed,  contracting  a debt,  making  a 
will,  or  giving  credible  evidence.  The  principle, 
it  must  be  carefully  noted,  is  not  that  the  mere 
existence  of  insanity  in  the  person  performing 
them  invalidates  such  actions,  but  that  if  the 
insanity  has  materially  affected  the  character 
and  quality  of  the  actions  they  may  be  thereby 
invalidated.  This  is  one  of  the  most  importaui 
principles  that  a medical  jurist  has  to  keep  ii 
mind,  as  it  is  not  an  unfrequent  mistake  to  sup 


CIVIL  INCAPACITY. 


260 

pose  that  a person  is  necessarily  incapacitated 
for  the  performance  of  every  civil  act  the  moment 
he  can  be  proved  to  labour  under  any  condition 
to  which  the  term  insanity  may  hz  applied.  Per- 
haps the  case  in  which  the  validity  of  a civil  act 
is  most  easily  endangered  by  the  existence  of 
any  form  of  insanity  is  the  contract  of  marriage. 
This  proceeding  is  supposed  so  to  affect  the 
whole  relations  of  life  that  almost  any  form  of 
unsoundness  of  mind  may  be  sufficient  to  inter- 
fere with  that  intelligent  and  deliberate  con- 
sideration which  is  essential  to  the  giving  of 
rational  consent. 

The  different  kinds  of  mental  disease  will  be 
found  described  elsewhere  (see  Insanitv),  and 
it  is  necessary  that  the  practitioner,  when  dealing 
with  medico-legal  questions,  should  be  fully  ac- 
quainted with  them.  But  it  is  chiefly  important 
that  he  should  distinguish  the  two  following 
classes:  (1)  diseased  perversion  of  the  mental 
faculties,  and  (2)  weakness  or  enfeeblement  of 
the  mental  faculties  resulting  either  from  de- 
fective development,  disease,  or  decay.  The 
first  class  includes  all  kinds  of  insanity  which 
are  the  result  of  active  disease.  These  would  be 
the  simple  forms  of  delirium,  mania,  melan- 
cholia, and  monomania ; as  well  as  the  similar 
primary  conditions  which  are  found  in  general 
paralysis,  and  other  diseases  which  present  ma- 
niacal, melancholic,  or  monomaniacal  symptoms. 
It  is  in  this  class  that  the  special  knowledge  of 
the  physician  can  be  most  successfully  applied 
in  aiding  the  administration  of  justice.  In  order 
to  establish  the  incapacity  of  a person  said  to 
labour  under  any  of  these  forms  of  disease,  it 
must  be  necessary  that  an  experienced  physician 
should  not  only  be  able  to  detect  their  charac- 
teristic symptoms,  but  also  to  show  that  the 
performance  of  the  duties  or  the  exercise  of  the 
rights  under  consideration  -would  be  modified  or 
obstructed  by  the  existence  of  such  disease.  The 
second  class  includes  congenital  imbecility,  and 
all  the  forms  of  what  is  called  chronic  dementia — 
all  those  enfeeblements  of  mind  which  are  some- 
times the  remaining  effects  of  acute  disease,  some- 
times the  concomitants  of  chronic  disease,  and 
sometimes  only  the  mental  phase  of  senile  decay. 
Here,  again,  the  information  which  may  be  com- 
municated by  the  physician  must  be  of  great 
importance.  But  in  estimating  the  extent  to 
which  a condition  of  mere  mental  weakness  will 
disable  a person  from  the  performance  of  a cer- 
tain class  of  actions  there  is  not  so  much  special 
medical  knowledge  required  as  is  necessary  in 
the  consideration  of  active  disease. 

Marriage. — As  has  been  already  stated,  the 
mere  existence  of  any  form  of  insanity  in  one  of 
the  parties  may  render  a contract  of  marriage 
void.  In  one  case  which  terminated  in  this 
manner,  a man  who  had  been  insane  and  when 
in  that  state  had  voluntarily  contracted  marriage 
instituted  the  suit  himself. 

Civil  Contracts  may  be  held  binding  although 
made  by  lunatics.  If  the  person  with  whom  a 
contract  is  made  had  no  knowledge  that  the 
person  contracting  was  insane,  and  if  no  attempt 
was  made  to  take  undue  advantage  of  him,  the 
contract  would  be  held  good. 

Wills. — -A  person  is  considered  to  be  of  a dis- 
posing mind,  that  is,  capable  of  making  a valid 


will,  if  he  knows  the  nature  of  the  act  which  L: 
is  performing,  and  is  fully  aware  of  its  conse- 
quences. It  is. in  regard  to  the  making  of  wills 
that  the  law  has  carried  out  most  thoroughly  the 
principle  that  the  validity  of  an  act  ought  to  be 
maintained  in  cases  of  insanity  unless  at  the 
time  the  act  is  performed  the  state  of  mind  of 
the  agent  can  be  shown  to  render  him  unfit  to 
perform  that  particular  act  in  a rational  manner. 
Persons  have  made  valid  wills  while  inmates  of 
lunatic  asylums.  And  one  will  was  held  to  be 
good  though  the  testator  had  committed  suicide 
within  three  days  after  its  execution.  The  ex- 
istence of  delusion  which  has  been  regarded  by 
lawyers  as  of  such  importance  in  cases  of  al- 
leged insanity  does  not  invalidate  a will ; for  it 
has  been  declared  to  be  ‘ compatible  with  the 
retention  of  the  general  powers  of  the  faculties 
of  the  mind,’  and  to  be  ‘ insufficient  to  overthrow 
the  will  unless  it  was  calculated  to  influence  the 
testator  in  making  it.’  On  the  other  hand,  a 
will  may  be  invalidated  on  account  of  the  exist- 
ence of  mental  states  which  would  not  be  re 
garded  as  insanity  from  either  a legal  or  medical 
point  of  view.  Drowsiness  and  stupor  resulting 
from  erysipelas  or  fever,  extreme  weakness  from 
cholera,  and  failure  of  memory  in  old  age,  have 
all  been  found  sufficient  to  render  wills  void.  It 
frequently  happens  that  a medical  man  is  called 
on  to  be  witness  to  a will.  On  such  an  occasion 
it  is  his  duty  to  satisfy  himself  as  to  the  testa- 
mentary capacity  of  the  testator.  His  subse- 
quent evidence  in  regard  to  this,  will,  in  case  of 
dispute,  bg  of  almost  decisive  influence  if  he  has 
taken  proper  means  of  forming  an  opinion.  Ir. 
all  cases,  therefore,  where  there  may  be  a possi 
bilitv  of  doubt  it  is  well  to  require  the  testator 
to  show  that  without  extraneous  aid,  and  with- 
out referring  to  the  document  itself,  he  remem- 
bers and  understands  all  the  provisions  of  the 
deed. 

Evidence  of  the  Insane. — Lunacy  was,  till  a 
recent  date,  regarded  by  the  law  as  incapacita- 
ting a patient  from  giving  evidence  in  court. 
But  according  to  the  much  more  extended  sig- 
nification which  the  term  lunacy  has  received  it 
now  includes  states  of  mind  which  are  looked 
on  as  compatible  with  testimonial  capacity. 
Where  the  judge  is  satisfied  that  the  lunatic 
understands  the  obligation  of  an  oath,  and  can 
give  a rational  account  of  such  things  as  happen 
before  his  eyes,  the  evidence  may  be  admitted. 
But  the  weight  to  be  attached  to  such  evidence 
will  still  depend  on  the  extent  to  which  it  fulfils 
the  conditions  commonly  required  to  constitute 
credibility.  It  has  been  held,  however,  that  when 
a person  has  suffered  from  an  attack  of  insanity 
between  the  occurrence  of  the  transaction  and 
the  time  he  tenders  his  testimony,  his  evidence 
cannot  be  admitted. 

Management  of  Property. — Where  persons  are 
supposed  to  be  unable  from  unsoundness  of  mind 
to  undertake  the  management  of  their  own  pro- 
perty, it  may  be  necessary  that  they  should  be 
placed  under  the  protection  of  the  Court  of 
Chancery;  but  this  proceeding  is  not  usually  had 
recourse  to  unless  there  is  urgent  necessity  or  a 
strong  probability  that  the  person’s  incapacity 
will  be  permanent.  It  is  consequently  resorted 
to  chiefly  in  chronic  or  congenital  cases  where 


CIVIL  INCAPACITY. 

there  is  no  room  for  doubt  as  to  the  mental  con- 
dition of  the  individual;  and  in  cases  of  recent 
insanity  where  it  is  necessary  to  have  recourse 
to  an  asylum  for  the  protection  of  the  individual 
it  may  also  be  necessary  to  obtain  protection 
for  his  property  by  the  aid  of  the  Court  of 
Chancery.  In  giving  evidence  or  framing  a 
statement  in  such  a case  it  is  important,  if 
incapacity  is  to  be  proved,  to  show  that  the 
individual  has  been  found,  when  placed  in  cir- 
cumstances requiring  such  capacity,  unable  to 
perform  the  acts  which  the  management  of 
property  necessitates.  In  cases  of  active  in- 
sanity it  is  especially  required  to  show',  not 
merely  that  there  is  delusion  or  other  symptoms 
of  insanity,  but  that  the  insanity  is  of  such  a 
nature  as  specially  to  disable  the  person  from 
duly  performing  the  duties  which  would  be  re- 
quired of  him.  Difficulties  most  frequently  occur 
n cases  of  imbecility  and  dementia  ; but  the  ver- 
dicts in  such  cases  when  disputed  will  generally 
do  found  to  rest  rather  upon  the  impression  pro- 
duced by  evidence  of  the  actual  behaviour  of  the 
individual  than  upon  the  mere  medical  view  of 
his  mental  condition.  The  most  effectual  aid  that 
the  medical  witness  can  render  in  such  cases  is 
to  show  whether  there  are  or  are  not  such  pecu- 
liarities in  the  conduct  of  the  person  under  inquisi- 
tion as  are  known  to  be  characteristic  of  imbeciles 
or  demented  persons.  In  undisputed  cases,  where 
the  duty  of  the  medical  man  consists  merely  in 
making  an  affidavit,  there  is  no  special  difficulty 
to  be  encountered.  Brevity,  scrupulous  accurac}', 
and  attention  to  the  fact  that  such  unsoundness  of 
mind  as  involves  incompetency  to  manage  pro- 
perty must  be  established,  are  the  most  important 
requirements.  A person  found  by  the  court  to 
be  incapable  is  placed  under  the  control  of  a 
‘ committee  of  the  person,’  and  the  property  under 
t.  1 committee  of  the  estate.’  In  Scotland  an 
application  to  the  Court  of  Session  for  the  ap- 
pointment of  a Curator  bonis  takes  the  place  of 
the  English  inquisition.  The  chief  peculiarities 
of  the  Scotch  process  are  that  it  is  cheaper,  more 
easily  effected  and  more  easily  annulled,  and 
that  it  does  not  affect  the  person  of  the  lunatic. 
The  functions  of  the  curator  correspond  to  those 
of  the  committee  of  the  estate  in  the  English 
court.  The  Scotch  procedure  for  the  appoint- 
ment of  a guardian  of  the  person  was  virtually 
in  desuetude  until  the  passing  of  a recent 
statute  (31  and  32  Viet.,  cap.  100).  Under 
this  act  a brieve  for  the  cognition  of  an  al- 
leged lunatic  is  issued  from  Chancery  and  tried 
before  a judge  of  the  Court  of  Session  and  a 
special  jury.  The  procedure  is  similar  to  that  of 
jury  trials  in  other  civil  causes  in  Scotland, 
and  both  medical  and  other  evidence  must  be 
produced.  If  the  person  so  cognosced  be  found 
‘ furious,  fatuous,  or  labouring  under  such  un- 
soundness of  mind  as  to  render  him  incapable  cf 
managing  his  affairs,’  his  person  is  placed  under 
the  guardianship  of  the  nearest  male  relative 
found  competent. 

Drunkenness. — This  condition  is  not  held  to 
deprive  a man  of  civil  capacity  unless  it  has  at 
the  time  rendered  the  individual  unconscious  ot 
'.That  he  was  doing.  J.  Sibbaid. 

CLAP. — A popular  name  for  gonorrhoea. 
See  Goxorrhcea. 


CLIMATE.  261 

CLAVTTS  HYSTERICUS  (davits,  a nail).— 
An  acute  pain  often  associated  with  hysteria,  but 
occurring  also  in  other  conditions,  which  is  felt 
in  a localised  point  in  the  head,  and  is  compared 
by  the  sufferer  to  the  sensation  that  might  be 
produced  by  a nail  being  driven  into  the  part. 
See  Hysteria. 

CLIMACTERIC  (icA//ia/0Tr)p,  a step,  KAi^aCjo, 
I proceed  by  degrees,  or  step  by  step). — This 
word,  which  properly  signifies  ‘ by  degrees,’  was 
originally  employed  to  indicate  certain  epochs  or 
periods  in  the  life  of  an  individual,  which  wero 
looked  upon  as  critical,  and  at  which  the  body 
was  supposed  to  have  undergone  a complete 
change,  so  that  it  had  become  entirely  renewed 
in  its  structural  elements.  The  years  in  which 
these  epochs  terminated  were  called  climacteric 
years — anni  climacterici,  and  their  number  was 
variously  estimated.  Thus,  some  only  recognised 
three  climacterics ; the  Greek  physiologists  held 
that  there  were  five,  ending  at  the  seventh  ye»r, 
the  twenty-first  (7  x 3),  the  forty-ninth  (7  x 7), 
the  sixty-third  (7  x 9),  and  the  eighty-first  (9  x 9); 
others  made  them  multiples  of  seven  or  nine,  or 
multiples  of  seven  by  an  odd  number.  Most 
regarded  the  sixty-third  year  as  the  grand  cli- 
macteric, but  the  Greeks  recognised  two  grand 
climacterics,  terminating  respectively  at  the 
sixty-third  and  eighty-first  years,  and  this  special 
denomination  was  given  because  there  was  little, 
if  any,  prospect  of  life  being  extended  beyond 
these  periods.  At  the  present  day  the  word  cli- 
macteric has  lost  much  of  its  original  meaning, 
and  is  generally  applied  to  certain  times  of  life, 
without  any  reference  to  numbers  of  years,  at 
which  marked  physiological  or  developmental 
changes  occur,  such  as  tire  period  of  puberty,  or 
that  of  the  cessation  of  menstruation. 

A particular  climacteric  disease  has  been  de- 
scribed, which  is  said  to  occur  either  about  or 
subsequent  to  the  sixty-third  year  or  grand  cli- 
macteric, and  supposed  to  be  distinct  from  the 
natural  decay  and  degeneration  which  takes  place 
in  advanced  life,  inasmuch  as  recovery  often 
ensues.  It  is  stated  that  the  complaint  comes 
on  suddenly,  but  advances  insidiously,  the 
symptoms  being  at  first  loss  of  flesh  and 
weakness,  followed  by  loss  of  appetite  and  dys- 
peptic symptoms  with  a white  tongue,  which  are 
regarded  as  sympathetic,  sleeplessness  ordisturbed 
and  unrefreshing  sleep,  constipation,  pains  in  the 
head  and  chest,  a frequent  pulse,  swelling  of  the 
legs,  and  an  emaciated  or  bloated  appearance  of 
the  face.  The  urine  does  not  present  any  ab- 
normal characters,  and  most  of  the  viscera  seem 
to  perform  their  functions  properly.  Whether 
there  is  any  independent  disease  deserving 
this  special  denomination  seems  to  the  writer 
to  be  more  than  doubtful. 

Frederick  T.  Roberts. 

CLIMATE,  etiology  of.  See  Disease, 
Causes  of. 

CLIMATE.— Formerly  the  word  climate 
(from  the  Greek  word  K\ivoi,  I incline)  was  a term 
of  astronomical  or  mathematical  geography, 
which  implied  a portion  or  zone  of  the  earth's 
surface  comprised  between  two  lines  parallel  to 
the  equator,  and  measured  by  the  length  of  timo 
during  which  the  sun  there  appears  during  the 


CLIMATE. 


>62 

Bummer  solstice,  that  is,  l>y  the  sun's  inclination. 
The  space  between  the  equator  and  the  pole 
was  diyidod  into  half-hour  climates,  in  which  the 
length  of  each  day  increased  by  half-an-hour,  and 
also  into  monthly  climates.  This  unequal  division 
of  each  hemisphere  is  now  replaced  by  a division 
of  the  interval  between  the  equator  and  the  poles 
into  ninety  degrees,  which  constitute  what  are 
called  degrees  of  latitude,  and  the  word  climate 
has  received  a more  extended  application. 

By  climate  is  now  understood  those  conditions 
of  heat,  moisture,  atmosphere,  wind,  soil,  and 
electricity,  which  impress  certain  conditions,  uni- 
form even  when  apparently  irregular,  on  given 
portions  of  the  earth’s  surface,  and  which  modify, 
also  in  a uniform  manner,  vegetable  and  animal  life. 

Climate,  when  thus  interpreted,  is  still  princi- 
pally dependent  on  astronomical  facts,  on  the 
sun's  position  or  inclination  with  regard  to  the 
earth,  and  on  the  amount  of  heat  it  supplies  to 
different  portions  of  the  surface  of  the  latter. 
Climate  may  be  studied  generally  and  locally. 
The  division  of  the  earth’s  climates  is  necessarily 
arbitrary,  and  many  different  classifications  have 
been  proposed.  The  most  simple  is  that  which 
recognises  three  principal  kinds  of  climate,  each 
susceptible  of  subdivision,  viz. : warm  climates 
from  the  equator  to  35°  lat.,  temperate  climates 
from  35°  to  50°  or  65°  lat.,  cold  climates  from 
50°  or  55°  to  the  pole.  As  subdivisions  we  may 
recognise  equatorial,  tropical,  sub-tropical,  sub- 
polar, and  polar  climates ; and  also  insular  and 
maritime,  or  moist  climates — continental  and 
mountain,  or  dry  climates. 

1.  Warm  climates,  extending  from  the  equator 
to  35°  lat.,  that  is,  1 2 J°  beyond  the  tropics,  com- 
prise nearly  all  Africa  and  its  islands,  South  Asia, 
most  of  the  islands  of  Polynesia,  and  the  portions 
cf  North  and  South  America  comprised  between 
California  and  the  north  of  the  La  Plata  territory. 
In  the  equatorial  regions  tho  medium  temperaturo 
for  the  year  is  from  80°  to  84°  F.,  the  min.  being 
54°,  tho  max.  118°.  Near  the  equator  the  annual 
mean  temperaturo  decreases  slowdy  as  we  recedo 
from  it,  the  decrease  not  amounting  to  more  than 
2°  F.  for  the  first  1 0°  lat.  Tho  difference  of  tem- 
perature during  the  day  is  slight,  but  much 
greater  during  tho  night,  owing  to  radiation. 
The  general  variations  of  the  barometer  are 
slight,  but  the  periodical  or  diurnal  variations 
are  very  marked.  It  ascends  and  descends  regu- 
larly twice  in  the  twenty-four  hours.  It  ascends 
from  4.13  a.m.  to  9.23  a.m.,  and  descends  until 
4.8  p.m.,  ascending  again  until  10.23.  Electrical 
phenomena  are  very  decided.  The  rainfall  is 
variable,  but  40  inches  may  bo  given  as  a mean. 
It  is  generally  supposed  that  heat  is  greatest  at 
the  equator  and  diminishes  as  we  recede  from  it ; 
hut  both  observation  and  astronomical  induction 
lead  to  the  conclusion  that  not  only  tho  maximum 
of  temperature  in  warm  climates  is  attained  at  or 
near  the  tropics,  but  also  the  highest  annual 
mean.  The  countries  in  which  the  highest  degree 
of  heat  is  known  to  be  attained  are  near  the 
tropic  of  Cancer,  as,  for  instance,  tho  hanks  of 
the  Senegal,  the  Tehama  of  Arabia,  and  Mehran 
in  Beloochistan.  Moreover,  the  snow-line,  or  the 
lino  of  perpetual  snow,  is  higher  at  the  tropics 
than  at  the  equator.  In  the  Bolivian  Andes, 
near  the  tropic,  it  is  17,000  feet,  whereas  in  the 


Ecuador  Andes,  on  the  equator,  it  is  only  16,000 
feet.  These  facts  are  partly  explained  dv  the 
unequal  progress  of  the  sun  after  tho  equinox  in 
its  course  towards  the  tropic.  In  the  first  month 
it  passes  through  12°  of  latitude,  in  the  second 
month  through  8°.  At  the  end  of  the  second 
month,  therefore,  it  is  20°  from  the  equator,  and 
there  remain  only  3i°  to  he  traversed  in  the  third 
month.  Tho  sun  receding  from  the  tropic  at  the 
same  rate  at  all  places  between  20°  and  234  ° of 
latitude,  the  solar  rays  during  two  months  fall 
at  noon  either  perpendicularly  or  at  an  angle 
which  deviates  from  a right  only  by  3 at  most. 

Another  cause  which  tends  to  diminish  heat  in 
the  regions  near  the  equator  is  the  prevalence  of 
rain.  For  about  five  degrees  north  and  south 
of  the  equator,  in  the  region  of  the  equatorial 
calms,  there  are  few  consecutive  days  in  the  year 
without  rain.  The  principal  cause  both  of  the 
calms  and  of  the  rains  has  been  attributed  to  the 
meeting  in  the  upper  atmospheric  regions  of  the 
trade  winds,  north  and  south.  They  neutralise 
each  other  and  precipitate  the  vapour  they  hold 
in  solution. 

Regions  that  lie  between  5°  and  10°  of  latitude 
have  usually  two  rainy  and  two  dry  seasons. 
Tho  greater  rainy  season  occurs  when  the  sun  in 
its  passage  to  themearest  tropic  passes  over  the 
zenith,  lasting  from  three  to  four  months.  The 
lesser  rainy  season  occurs  when  tho  sun  on  its 
return  from  the  nearest  tropic  approaches  the 
parallel  of  the  place.  The  mins  then  only  last 
from  six  weeks  to  two  months,  and  are  much  less 
abundant  and  continual.  Countries  more  than 
10°  or  12°  from  the  equator  havo  only  one  rainy 
and  one  dry  season  ; the  first  begins  when  the 
sun  approaches  the  nearest  tropic,  and  ends  some 
time  after,  when  in  its  course  from  the  tropic  it 
has  passed  the  parallel  of  the  place.  It  lasis 
from  four  to  six  months.  Local  conditions  may 
modify  the  course  of  tho  dry  and  wet  seasons,  as 
is  the  case  in  India,  where  the  dry  and  rainy 
seasons  depend  principally  on  the  monsoons.  The 
amount  of  rain  that  falls  in  a short  time  within 
the  tropics  is  very  great,  much  more  so  than  in 
more  northern  regions,  hut  these  heavy  rains  do 
not  last  continuously  as  is  supposed.  Days  of 
continued  rain,  even  in  the  rainy  season,  are 
rarer  than  in  the  north.  Still,  heavy  rains  are 
apt  to  cause  great  inundations,  and  to  cover  largo 
extents  of  low  or  level  country  with  water, 
causing  swamps  and  marshes,  very  injurious  to 
health. 

In  tho  vicinity  of  the  tropics  there  is  a belt, 
extending  over  several  degrees  of  latitude,  where 
it  seldom  rains.  This  rainless  tract  is  precisely 
the  region  which  has  been  already  mentioned  aa 
that  of  greatest  heat.  These  belts  of  rainless 
regions,  extending  around  the  globe  on  each  side 
of  the  equator,  may  be  said  to  separate  the  coun- 
tries which  lie  on  each  side  of  the  equator  from 
the  temperate  zones.  Thus  in  Africa  the  rains 
cease  on  the  southern  border  of  the  desert,  of 
Sahara  at  about  16°  N.,  and  begin  again  at  28°N. 
On  the  banks  of  the  Nile  the  rain  ceases  about 
18°  or  19°,  to  begin  again  between  2S°  and  29°. 
The  Tehama,  or  low  coast  of  Arabia,  is  all  hut 
rainless.  This  rainless  tract  crosses  Asia  as  fat 
as  China,  where  there  is  no  rainless  region,  owing, 
probably,  to  the  fact,  that  all  parts  of  China  bo- 


GLIM 

tween  22'  and  30°  N.  lat.  are  traversed  by  high 
mountain  chains. 

The  influence  of  warm  climates  impresses  cer- 
tain peculiarities  on  thepeoples  who  inhabit  them. 
They  are  the  abode  of  the  Ethiopian  and  Mongo- 
lian races  of  mankind,  and  appear  to  have  im- 
pressed the  samecharacteristics.in  a minor  degree, 
on  the  Caucasian  races  that  inhabit  them  : a dark 
complexion  and  black  hair.  The  inhabitants  of 
those  countries  are  indolent  and  apathetic.  The 
functions  of  the  skin  and  liver  are  peculiarly  ac- 
tive, a circumstance  which  exposes  them  to  severe 
disease  of  these  organs.  The  digestive  functions 
are  sluggish,  and  the  nervous  system  is  alter- 
nately excite  1 and  depressed.  Eemittentand  in- 
termittent fevers,  dysentery  and  yellow  fever  are 
common.  During  the  dry  season  disease  tends 
to  assume  the  ataxic,  during  the  rainy  season 
the  adynamic  form.  Pulmonary  consumption  is 
frequently  met  with  in  the  towns,  in  contra- 
diction to  received  opinions. 

2.  Temperate  climates  may  be  said  to  occupy 
the  zones  of  the  earth’s  surface  comprised  between 
35°  and  50°  or  55°  lat.  They  comprise  south- 
ern and  central  Europe,  with  its  islands  ; the 
parts  of  Asia  which  extend  between  the  Black 
Sea  and  the  Mediterranean,  and  Japan;  the 
greater  part  of  North  America  ; a part  of  Chili 
and  La  Plata  and  Patagonia,  in  South  America. 
The  mean  temperature  may  be  stated  at  from  60° 
to  50°.  The  climates  in  which  the  mean  tem- 
perature is  from  60°  to  68°  are  often  spoken  of 
as  temperate,  but  in  reality  they  approximate 
closely  to  warm  climates.  The  four  seasons, 
winter,  spring,  summer,  and  autumn,  are  well 
marked,  but  very  variable  both  as  to  barometri- 
cal and  thermometrical  conditions.  The  mean 
temperature  in  the  central  regions  is,  for  winter 
38°,  for  spring  dl°,  for  summer  68°,  and  for 
autumn  f)3°.  The  regions  which  are  near  the 
south  and  north  limits  of  the  temperate  zones 
approximate  to  the  meteorological  characters  of 
the  warm  and  cold  climates  respectively.  The 
periods  of  the  year  when  storms,  rain,  and 
general  versatility  of  meteorological  phenomena 
are  principally  observed  correspond  with  the 
vernal  and  autumnal  equinoxes.  The  in- 
fluence of  a temperate  climate  on  the  human 
organisation  is  salutary,  extremes  of  heat  and 
cold  being  both  trying.  Thus  the  healthiest 
climates  of  the  world’s  surface  are  found  in  this 
zone.  Intense  heat,  or  even  moderate  heat  if 
persistent,  throws  a physiological  strain  on  the 
liver,  skin,  and  digestive  system,  and  renders 
mankind  prone  to  severe  and  fatal  diseases  of 
these  organs.  Intense  cold  throws  a physiological 
strain  on  the  lungs  and  kidneys,  and  exposes  them 
also  to  severe  and  fatal  disease.  The  healthiest 
temperate  climates  are  those  in  which  the  winter  is 
not  very  cold  and  the  summer  is  not  very  warm, 
and  in  which,  consequently,  there  is  no  great  or 
continued  strain  on  any  one  class  of  organs. 
The  diseases  of  temperate  regions  are  those  that 
are  the  best  known,  as  their  study  and  descrip- 
tion constitute  the  foundation  of  pathological 
science,  ancient  and  modern. 

The  climate  which,  perhaps,  the  best  deserves 
tiie  appellation  of  temperate  is  that  of  the  Medi- 
terranean basin.  The  winters  are  not  severe  on 
any  part  of  its  north  shores,  and  the  summers  are 


iATE.  263 

not  intensely  hot  on  its  south  shores;  at  least 
the  heat  falls  short  of  that  of  the  tropics.  There 
are  many  conditions  of  physical  geography  which 
conduce  to  this  result.  The  north  shores  are 
protected  from  north  winds  by  the  ranges  of  high 
mountains  of  Southern  Europe  which  skirt  them, 
and  the  south  shores  are  in  close  proximity  to 
the  hot,  rainless  tract  of  Northern  Africa — the 
desert  of  Sahara,  which  favourably  modifies  win- 
ter temperature.  Moreover,  the  Mediterranean 
is  a warm  sea,  but  few  cold  rivers  of  con 
siderable  size  flowing  into  it  from  the  north.  & 
fact  which  increases  the  temperature  on  its  shores 
and  islands. 

3.  Cold  climates  comprise  the  regions  which  ex- 
tend from  50°  or  55°  lat.  to  the  poles.  They 
may  be  subdivided  into  cold,  with  a mean  of  from 
50°  to  40°;  very  cold,  with  a mean  of  from  40° 
to  32° ; glacial,  with  a mean  below  the  freezing 
point.  In  the  austral  hemisphere  the  zone  con- 
tains but  little  known  land,  although  the  existence 
of  an  antarctic  continent  is  suspected  ; in  the 
northern  hemisphere  it  comprises,  in  Europe,  the 
north  of  Scotland,  Denmark,  Sweden,  Norway, 
'Iceland,  Finland,  Lapland,  Northern  Kussia, 
SpitzbergeD,  Nova  Zembla;  Northern  Asia,  ami 
some  of  its  large  plains  below  50°  lat.,  Siberia,  and 
Kamtschatka;  in  America,  Canada,  including  some 
regions  below  50°,  the  northern  lands  and  islands 
of  Hudson’s  and  Baffin’s  Bays,  and  Greenland. 
In  this  zone  the  decrease  of  the  mean  temperature 
is  much  more  rapid  as  we  recede  from  the  equa- 
tor, than  it  is  in  the  tropical  regions.  Thus 
from  the  equator  to  20°  lat.  the  variation  of  the 
mean  temperature  is  not  more  than  7°  or  8°, 
whereas  the  variation  between  55°  and  7o°  lat. 
amounts  to  from  22°  to  27°.  The  coldest  region 
of  the  globe  is  not,  it  would  appear,  at  or  near  the 
pole,  but  at  about  80°  lat.,  or  10J  from  the  pole, 
north  of  Behring's  Straits  : the  cold  of  the  glacial 
climates  has  been  exaggerated.  At  the  latitudes 
of  from  70°  to  78°,  the  extreme  limit  of  human 
habitation,  the  moan  annual  temperature  is  be- 
tween 19°  and  17°,  i.e.  13°  to  15°  below  the 
freezing  point.  The  extreme  of  cold  registered, 
however,  reaches  a hundred  degrees  or  more  below 
the  freezing  point.  Owing  to  astronomical  condi- 
tions there  is  great  disproportion  between  the 
length  of  the  nights  and  of  the  days  at  different 
seasons  of  the  year.  In  the  more  northern  regions, 
for  several  months  in  the  winter  the  sun  never 
appears  above  the  horizon,  and  in  the  summer  for 
several  months  the  sun  never  disappears  below 
it.  Spring,  during  which  the  extreme  cold  is 
mitigated,  lasts  but  a very  short  time,  and  is  suc- 
ceeded by  summer,  which  is  in  its  full  strength 
in  June  and  July.  Temperature  rises  rapidly 
from  35°  to  5oc  and  60°.  In  some  northern 
localities  it  rises  to  86°  or  90°.  Under  the  in- 
fluence of  the  prolonged  or  persistent  days,  and 
of  the  increased  temperature,  the  vegetation 
peculiar  to  each  locality  passes  through  all  its 
phases  with  extreme  rapidity.  Towards  the  end 
of  J uly  rain  and  fog  reappear,  and  are  followed 
by  snow  and  intense  cold,  the  highest  expression 
of  which  is  in  January  and  February.  The 
barometrical  changes  are  the  reverse  of  what 
obtains  in  the  tropics.  Above  60°  lat.  the  diur- 
nal or  periodical  changes  are  scarcely  perceptiblo, 
whereas  general  or  occasional  variations  become 


CLIMATE. 


264 

more  marked  as  we  approach  the  pole.  Electrical 
phenomena  become  less  marked,  and  above  68° 
lat.  they  are  scarcely  perceptible,  with  the  excep- 
tion of  the  aurora  borealis.  The  winds  which  pre- 
dominate are  the  N.E  andS.W.,  and  they  change 
rapidly  from  one  point  of  the  horizon  to  the 
other,  and  thus  frequently  occasion  tempests 
which  extend  over  considerable  areas.  The  quan- 
tity of  rain  that  falls  in  cold  climates  is  much  less 
than  in  the  tropical  and  temperate,  with  some 
exceptions.  Between  60°  and  90°  lat.  it  only 
amounts  to  a few  inches,  and  falls  principally  in 
the  form  of  snow.  The  influence  of  cold  climates 
is  showm  on  the  inhabitants  of  these  countries, 
w ho  vary  much  in  stature,  and  possess  a vigorous 
constitution,  a sanguineous  temperament,  great 
muscular  development,  active  digestive  func- 
tions, and  sluggish  nervous  powers.  Notwith- 
standing the  severity  of  the  climate  they  gene- 
rally succeed  in  protecting  life,  and  live  to 
old  age,  presenting  few  diseases  peculiar  to 
climatic  influences.  They  are,  however,  subject 
to  opththalmia  and  amaurosis,  owing  to  the  re- 
flexion of  light  from  the  snow'  in  the  polar 
regions,  and  to  scrofula  and  scurvy,  the  result  of  a 
poor  and  incomplete  dietary.  Agues,  and  intermit- 
tent fevers  from  marsh  influences,  are  rare,  and 
not  severe,  and  disappear  entirely' as  w'e  approach 
the  pole.  Continued  fevers  are  met  with,  but 
seldom  if  ever  epidemically. 

4.  Insular  climates  present  important  pecu- 
liarities. The  temperature  of  the  sea  is  more 
equable  than  that  of  the  land.  Owing  to  the 
action  of  currents,  and  to  the  circulation  of  its 
waters  under  the  influence  of  heat,  its  super- 
ficial temperature  is  warmer  in  winter  and  cooler 
in  summer — more  equable — than  that  of  the 
land.  It  has  thus  a tendency  to  warm  in  winter 
and  to  cool  in  summer  the  island  which  it 
surrounds.  Moreover,  there  is  constantly  w'atery 
vapour  arising  from  the  sea  which  extends  to 
island  atmospheres,  veils  the  sky  more  or  less, 
shields  their  surface  from  the  ardour  of  the  sun 
in  summer,  and  prevents  great  radiation  both  in 
summer  and  in  winter.  Thus  it  is  that  the 
climate  of  all  islands  is  more  equable  than  that 
of  continents.  This  fact  is  more  especially 
recognisable  in  the  climate  of  the  British  Isles, 
which  is  also  modified — rendered  warmer  and 
inoister,  by  the  waters  of  the  Gulf  Stream  im- 
pinging on  their  shores.  The  warm  Gulf  Stream, 
commencing  in  the  tropics,  in  the  Gulf  of  Mexico, 
passes  northwards  along  the  shores  of  North 
America,  crosses  the  Atlantic  to  the  south  of 
Newfoundland,  and  strikes  the  shores  of  the 
British  Islands,  of  Norway  up  to  Cape  North,  of 
Holland,  and  of  France ; everywhere  raising 
temperature  and  the  annual  mean. 

5.  Maritime  climates  participate  in  these  influ- 
ences ; temperature  is  more  equable,  warmer  in 
winter  and  cooler  in  summer,  on  the  shores  of  seas 
and  oceans  than  it  is  inland.  Owing  to  this  cause 
most  of  the  winter  sanitaria  have  been  chosen  in 
islands  or  on  the  coasts  of  oceans  and  seas : 
such  as  Hastings,  Ventnor,  Bournemouth,  Tor- 
quay, Funchal,  Malaga,  Cannes,  Nice,  Mentone, 
Naples,  Salerno,  and  Algiers. 

6.  Continental  climates  exhibit  conditions  the 
reverse  of  those  which  obtain  in  maritime 
climates.  The  tendency  is  to  cold  winters  and 


warm  summers,  owing  principally  to  the  absence 
of  the  equalizing  influence  on  temperature  of 
large  masses  of  water.  A very  short  distance 
from  the  sea  is  sufficient  to  establish  this  differ- 
ence. Thus  the  central  parts  of  France  are  very 
much  warmer  in  summer  and  colder  in  winter 
than  the  coasts  of  Normandy  and  Brittany.  But 
it  is  when  we  reach  the  centre  of  continents — 
Russia,  central  Asia,  central  America — that  the 
difference  is  the  most  marked. 

7-  Mountain  climates. — As  we  rise  above  the 
level  of  the  sea,  we  meet  with  two  important  me- 
teorological conditions.  The  ai  r becomes  more  and 
more  rarefied,  and  the  heat  diminishes,  indepen- 
dently of  the  more  or  less  obliquity  of  the  sun’s 
rays.  The  higher  we  rise  above  the  sea  level  the 
more  the  air  is  rarefied,  and  the  more  the  degree 
of  heat  due  to  the  solar  rays  diminishes.  IVe 
arrive  at  last,  even  at  the  tropics  or  the  equator, 
at  a height,  variable  according  to  latitude,  where 
the  sun's  heat  .is  insufficient  to  melt  the  snow. 
This  is  termed  the  snow-line.  Mountains  attract 
clouds  and  watery  vapour,  and  the  coolness  of 
their  atmosphere  causes  the  precipitation  of  the 
vapour  in  the  form  of  rain  or  snow.  Thus, 
mountains,  mountain-ranges,  and  the  glaciers 
they  contain,  are  the  principal  cause  and  origin 
of  rivers.  The  influence  of  mountain  climates, 
notwithstanding  the  clouds,  fogs,  and  rain  which 
characterise  them,  is  proverbially  a healthy  one, 
owing  to  the  purity  of  the  air,  and,  perhaps,  to 
the  sparseness  of  population.  They  have  of  late 
been  much  recommended  for  phthisis.  The  t wo 
conditions  above  mentioned,  however,  namely, 
purity  of  the  atmosphere  and  sparseness  of  human 
habitations,  are  quite  sufficient  to  account  for  the 
rarity  of  phthisis  amongst  their  inhabitants,  and 
for  the  improvement  of  the  phthisical  who  re- 
sort to  them. 

Soil  modifies  climate  considerably.  Wet  and 
marshy  soils  are  cold,  engendering  fog  and  mist. 
Sandy,  dry,  well-drained  soils  are  comparatively 
warm.  All  sandy  plains  are  warm  in  summer 
and  cold  in  winter. 

Such  are  the  features  which  characterise  the 
climates  of  the  terrestrial  globe,  generally.  Each 
locality,  however,  each  mountain,  plain,  and  val- 
ley, each  city,  village,  and  house,  has  a climate  of 
its  own,  modified  bjr  all  the  meteorological  ele- 
ments which  we  have  successively  considered.  To 
discover  what  each  climate  is,  we  must  study 
carefully  the  meteorological  conditions  and  in- 
fluences which  we  have  rapidly  surveyed  in  their 
application  to  it. 

8.  Isothermal  climates. — Owing  to  the  unequal 
influence  of  the  different  elements  that  constitute 
climate,  the  annual  mean  temperature  of  regions 
occupying  the  samelatitude  on  the  earth’s  surface 
is  very  variable.  Hence  the  above  name  has  been 
given  to  the  regions  in  which  the  annual  mean 
is  the  same.  The  study  of  a map  on  which  the 
isothermal  lines  are  marked  is  an  instructive 
illustration  of  the  facts  above  described.  Thus 
it  will  be  seen  at  a glance  that  the  limit  of  con- 
stantly frozen  ground  in  the  central  plains  of 
Asia  and  in  the  northern  plains  of  America  is 
below  54°  F.,  which  is  the  latitude  of  York  ! 

The  general  influence  of  climate. — The  vege- 
table and  animal  worlds,  including  man  himself, 
have  been  modified  in  essential  characters  b> 


CLIMATE.  265 


climatic  conditions.  The  study  of  its  influence 
on  their  vitality  and  organisation  opens  out  a 
wide  field  to  the  observer.  This  study  leads 
to  the  conclusion  that  geological  periods  of 
time  have  been  necessary  to  impress  on  ter- 
restrial life,  be  it  vegetable  or  animal,  the  cha- 
racteristics observed  now  or  formerly  in  the 
climates  of  different  regions  of  the  earth.  The 
current  of  modern  research  is  strongly  directed 
to  the  elucidation  of  the  influence  of  climate 
on  life  during  such  geological  periods.  The 
investigations  of  Darwin  and  his  followers  may 
be  named  as  the  most  remarkable  and  impor- 
tant illustration  of  this  fact.  We  may  also 
mention  the  researches  of  modern  philologists, 
which  have  proved,  by  the  study  of  languages 
and  their  roots,  that  most  of  the  nations  of 
modern  Europe  have  descended  from  the  same 
Aryan  parents  as  the  inhabitants  of  the  Indian 
peninsula.  Climate,  in  the  course  of  time,  has 
so  modified  them  as  apparently' to  produce  dif- 
ferent races.  For  such  a change  to  take  place 
geological  lapses  of  time  are  certainly  required. 
Our  earliest  records,  dating  back  several  thou- 
sand years,  show  these  races  such  as  they  are 
now,  quite  as  distinct.  In  these  days  the 
Aryan  races  of  Europe  cannot  rear  their  chil- 
dren in  the  climate  of  India,  where  their  Hindoo 
relatives  thrive  and  propagate  their  species.  In 
Palestine  and  Egypt  the  biblical  records, 
those  of  the  Pharaohs,  and  those  of  Nineveh  and 
Babylon,  show  these  regions  to  have  been  in- 
habited, several  thousand  years  ago,  by  nations 
and  tribes  presenting  precisely  the  same  race 
characteristics  as  those  that  now  inhabit  them. 
During  the  historical  period,  the  races  of  Europe 
have  in  vain  endeavoured  to  colonise  the  valley 
of  the  Nile ; but  they  have  not  been  able  to  propa- 
gate their  species,  and  have  died  away,  leaving 
the  valley  of  the  Nile  to  its  ancient  inhabitants. 
Their  children  cannot  withstand  the  heat  of 
summer.  On  the  north-eastern  shore  of  Africa 
the  Algeria  of  the  present,  history  presents  the 
same  record.  The  Eomans  and  the  Visigoths 
occupied  its  plains  for  centuries,  continually  re- 
cruiting their  colonies  from  the  mother-countries  ; 
and  yet,  except  in  the  mountains,  all  traces  of 
their  presence  has  disappeared.  They  could  not 
roar  their  children  so  as  to  occupy  the  land  of 
the  Arabs.  What  lengthened  periods  of  time 
must  have  elapsed  to  so  profoundly  modify  races 
deriving  their  origin  from  a common  parentage, 
that  they  can  no  longer  live  and  propagate  their 
species  in  the  same  climates  J 

Therapeutical  Applications. — The  therapeutical 
application  of  many  of  the  above  facts  is  contained 
in  the  facts  themselves.  Reasoning  suffices  to 
deduce  the  therapeutical  law,  and  experience 
proves  the  correctness  of  the  deduction.  A very 
brief  summary  only  can  here  be  given.  See  also 
Climate,  The  Treatment  of  Disease  by. 

Firstly,  it  is  clear  that  if  a local  climate  pro- 
duces injurious  effects  on  the  health  of  its  inhabi- 
tants, or  of  visitors,  the  latter  should  leave  it, 
and  the  regular  inhabitants,  who  cannot  leave 
it,  should  endeavour  by  every  possible  means  to 
modify  the  pernicious  climatic  influence  to  which 
they  are  exposed,  and  to  partially  escape  from 
.ts  action.  This  rule  may  be  illustrated  by  the 
influence  of  confined  mountain  valleys  in  pro- 


ducing goitre,  and  of  marshy  districts  in  pro- 
ducing intermittent  fevers.  The  principle  ap- 
plies to  all  local  climates  which  exercise  a 
pernicious  influence  of  any  kind  on  the  human 
organisation.  When  possible  the  climate  should 
be  abandoned ; if  that  is  impossible  its  pernicious 
influence  must  be  combated  by  every  possible 
hygienic  and  therapeutical  means. 

The  injurious  effects  which  extreme  climates 
exercise  on  the  human  economy — warm  climates 
on  the  abdominal  and  cerebral  organs,  cold  cli- 
mates on  the  thoracic — point  to  change  of  resi- 
dence as  an  important  therapeutical  agent,  the 
value  of  which  is  only  beginning  to  be  under- 
stood. Our  naval  and  military  surgeons  have 
done  much  to  clear  up  this  branch  of  therapeu- 
tics, as  regards  the  diseases  of  tropical  regions. 
Thus  chronic  affections  of  the  liver  and  intestines, 
incurable  in  a warm  climate,  often  become  quite 
curable  if  the  patient  is  transferred  to  a tem- 
perate region  or  to  a mountain  elevation  in  the 
tropics,  which  reproduces  a temperate  climate. 

Inversely,  persons  suffering  from  diseases  of 
the  respiratory  organs,  so  common  in  damp  tem- 
perate climates  like  those  of.  France,  England, 
and  Holland,  find  relief  by  migrating,  especially 
during  winter,  to  warmer  regions  of  the  earth’s 
surface,  where  they  escape  from  the  influences 
which  have  proved  so  detrimental  to  them. 
Thence  the  yearly  increasing  exodus  of  persons 
suffering  from  chronic  laryngitis  and  bronchitis, 
from  bronchial  asthma  and  from  phthisis,  from 
the  north  of  Europe  to  the  south. 

The  increased  facilities  of  locomotion,  by  rail 
and  by  steam,  have  thus  opened  out,  as  it  were, 
a new  and  important  brancli  of  therapeutics, 
that  of  the  application  of  climate  to  the  treat- 
ment of  disease.  J.  Hexky  Benxet. 

CLIMATE,  The  Treatment  of  Disease 

by. — Though  we  can  scarcely  say  with  accuracy 
that  change  of  climate  is  a specific  for  disease, 
yet  much  can  be  effected  by  it  in  relieving  symp- 
toms, and  in  assisting  the  reparative  powers  of 
the  organism  by  thus  improving  the  general 
health.  The  diseases  in  which  change  of  climate 
has  been  found  of  value  will  be  enumerated 
below,  with  a short  notice  of  various  climates. 
Here  we  may  notice  the  rationale  of  the  benefit 
to  be  derived  from  such  change. 

Change  of  climate,  we  must  premise,  is  only  a 
relative  term.  It  does  not  necessarily  involve 
the  idea  of  removal  to  a great  distance  from  the 
patient's  home.  A few  miles’  journey  from  the 
town  to  the  country,  from  inland  to  the  seashore, 
from  the  plain  to  the  mountain,  often  suffices 
to  produce  marked  results.  One  use  of  climate 
being  to  expose  the  organism  to  the  effects  of 
contrast,  the  element  of  distance  comes  in  most 
when  we  wish  to  make  the  contrast  greater  ; for 
instance,  in  ordering  change  from  a cold  to  a 
warm  climate  or  vice  versa. 

The  therapeutic  elements  of  most  importance  in 
any  climate  are  (1)  pure  air  free  from  dust  and 
organic  particles  ; (2)  abundance  of  sunshine, 
without  excessive  heat,  so  that  much  time  can 
be  spent  in  the  open  air ; (3)  a temperature 
without  extremes,  so  that  the  body  is  not  ex- 
posed to  the  risk  of  great  variations  of  heat  and 
cold— equability ; (4)  absence  of  violent,  very 


266  CLIMATE,  THE  TREATMENT  OF  DISEASE  BY. 


cold,  or  very  hot  winds,  at  any  rate  of  long  duration 
(in  this  is  involved  the  element  of  local  shelter). 

These  four  elements  should  be  present  in  each 
of  the  subdivisions  of  climate  which  a thera- 
peutic classification  renders  necessary,  namely 
climate  of  (a)  the  seashore ; (6)  mountains ; (e) 
inland  wooded  districts;  (d)  the  open  sea. 

The  epithets  ‘moist’  and  ‘dry,’  which  are 
applied  to  climates,  are  merely  relative,  and 
depend  on  local  peculiarities  of  rainfall,  soil, 
&e.,  as  well  as  to  some  extent  on  season ; and  the 
essential  differences  between  the  climate  of  the 
seashore,  the  woodland,  and  the  mountain  remain 
everywhere  the  same.  We  shall  say  a few  words 
about  each  of  these,  with  the  indications  for  their 
use.  The  climate  of  the  open  sea  will  be  referred 
to  in  speaking  of  sea  voyages. 

(a)  Climate  of  the  Seashore.  — The  special 
peculiarities  of  this  variety  of  climate  are  that — 
the  air  is  saturated  with  moisture,  except  when 
dry  land  winds  prevail ; it.  is  dense,  and,  as  a 
rule,  therefore,  bulk  for  bulk,  contains  more 
oxygen  than  air  of  any  higher  level ; its  density 
is  liable  to  great  and  frequent  but  regular  varia- 
tions, which  increase  the  activity  of  the  circula- 
tory and  respiratory  organs,  and  thus  favour 
their  functional  activity ; it  is  more  equable  ; and, 
lastly,  it  contains  saline  particles  in  suspension. 

According  to  Beneke,  sea  air  cools  the  body 
relatively  quicker  than  mountain  air,  and  thus 
quickens  the  processes  of  tissue-change  the  most. 
Hence  the  seaside  should  be  ordered  where  we 
wish  for  a highly  stimulating  effect,  as  in  persons 
of  scrofulous  tendency,  in  chronic  diseases  suc- 
ceeding acute  ones,  or  in  the  later  stages  of 
convalescence  from  the  latter,  in  convalescence 
from  surgical  operations,  or  in  some  surgical 
diseases  where  we  wish  to  accelerate  tissue- 
change,  without  exertion  on  the  patient’s  part. 
On  account  of  the  equability  of  the  climate,  some 
patients  who  cannot  bear  great  changes  of  tem- 
perature do  well  at  the  seaside.  Persons  suffer- 
ing from  overstrain,  mental  or  bodily,  with  a 
fair  digestive  powex-,  and  not  liable  to  nervous 
irritability,  may  also  be  sent  there. 

(b)  Mountain  Climates  are  distinguished  from 
sea-side  climates  by  the  lower  density  of  their 
atmosphere ; their  lower  and  less  equable  tem- 
perature ; by  less  humidity,  though,  owing  to 
local  winds,  mist  and  cloud  often  form  ; and  by 
relatively  lower  night-temperatures  in  clear 
weather,  owing  to  the  dryness  of  the  air,  and 
consequent  great  radiation.  They  are  cooler  also 
than  the  inland  climates  of  level  districts,  and  this 
coolness  tends  to  some  extent  to  diminish  the 
rarefaction  and  increase  the  density  of  their  air. 

The  general  action  of  mountain  air  is  to  pro- 
duce a freer  circulation  of  the  blood  and  greater 
vascularity  of  the  lungs,  owing  to  deeper  and 
more  frequent  inspirations  and  greater  ease  of 
bodily  movement.  Owing  to  the  cooling  of  the 
body  by  the  lowered  temperature  more  food  is 
required,  the  appetite  improves,  and  the  body 
becomes  better  nourished  and  gains  weight. 

The  intensity  of  the  effect  is,  roughly  speaking, 
directly  as  the  height.  The  term  ‘mountain 
climate  ’ is  applied  in  medical  parlance  to  eleva- 
tions in  Europe  of  from  1,500  to  6,000feet,  though 
in  South  America  patients  have  been  sent  as 
high  as  10,000  feet,  or  higher. 


Mountain  Climates  are  indicated  (1)  in  cases 
of  hereditary  tendency  to  phthisis  in  young 
persons  with  narrow,  shallow  chests,  and  who 
are  growing  too  fast ; also  in  young  scrofulous 
patients.  (2)  In  chronic  phthisis  and  pneumonia  ; 
remembering,  however,  that  phthisis  occurs  at  all 
elevations.  The  coolness  of  the  mountain  air  in 
the  height  of  summer  is  an  important  .element  in 
phthisical  cases,  which  always  suffer  from  great 
heat.  (3)  As  a tonic  and  restorative  in  persons 
suffering  from  over-work  in  business  or  literary 
pursuits,  and  who  have  no  real  organic  disease. 
(4)  Generally  to  complete  the  convalescence  from 
acute  diseases  of  individuals  not  past  middle 
life,  with  a fair  amount  of  muscular  power  and 
bodily  activity.  (5)  As  a prophylactic  against 
hay-fever,  cholera,  and  other  infectious  diseases, 
Mountain  climates  are  not  advisable  in  cases 
of  chronic  bronchitis,  heart-disease,  emphysema, 
Bright’s  disease,  chronic  rheumatism,  or  for 
aged  persons. 

(c)  The  Climate  of  Wooded  Districts  (elevations 
above  1,500  feet  are  not  here  referred  to)  is  peculiar 
in  the  following  points; — (1)  It  has  a temperature 
lower  than  that  of  the  surrounding  country — on 
the  average  3°  Eahr. — during  the  hours  of  day- 
light; tho  temperature  is  also  mere  equable. 
(2)  The  relative  humidity  is  higher  (9-3  percent) 
in  summer  than  in  the  less  wooded  country, 
and  hence  there  is  greater  liability  to  rain  and 
mist.  (3)  It  affords  greater  protection  and 
shelter  against  winds  than  other  climates. 

The  general  effect  of  woodland  climates,  as 
may  be  deduced  from  the  above,  is  sedative  and 
tonic.  They  may  be  advised  in  chronic  bron- 
chitis, emphysema,  heart-disease,  and  in  hypo' 
chondriasis,  hysteria,  and  other  nervous  affections 
where  tranquillity  and  subdued  light  are  of 
importance;  also  in  the  earlier  stages  of  con- 
valescence from  acute  disease  when  sea  or 
mountain  air  is  too  stimulating.  In  bronchitis 
pine  woods  shordd  be  selected,  and  in  heart- 
disease  level  walks  are  essential. 

(d)  Ocean  Climates. — Sea  Voyages  have  of 
late  years  been  much  recommended  in  the  treat- 
ment of  phthisis  in  its  early  stages,  with  a view 
to  enable  the  invalid  to  spend  much  time  in  an 
exceedingly  pure  and  fairly  equable  atmosphere, 
and  to  secure  a sufficient  amount  of  bodily  move- 
ment without  great  fatigue. 

The  main  drawbacks  to  the  sea  are  the  impos- 
sibility of  escape  from  bad  weather  and  the 
confinement  to  close,  ill-ventilated  cabins,  if 
such  occurs  ; the  absence  of  sufficient  light  and 
air  below  decks,  the  latter  being  felt  very  much 
at  night;  want  of  variety  in  the  diet  after  a 
certain  time,  and  at  all  times  (except  in  short 
cruises,  or  coasting  trips)  of  fresh  food,  milk, 
&c. ; monotony  in  society  and  occupations  ; and. 
lastly,  the  inconveniences  arising  from  crowding 
of  tho  maindeck  with  hen-coops,  sheep-pens,  &c., 
and  in  steamers  from  the  smoke  of  tho  engines, 
and  the  smell  and  vibration  of  the  machinery. 

The  routes  generally  recommended  to  invalids 
are  either  to  (1)  Australia,  90  days;  (2)  the 
Cape  of  Good  Hope,  30  days ; (3)  the  Y.  est 
Indies,  14  days;  (4)  the  United  States  or 
Canada  (in  summer),  10  days.  Short  cruises  in 
the  Mediterranean,  or  to  the  latitudes  of  the 
Canaries  and  Azores  are  suitable  for  certair 


CLIMATE,  THE  TREATMENT  OF  DISEASE  BY. 


eases  where  expense  is  no  object.  Of  routes  (3) 
and  (4)  we  may  say  that  they  are  too  short  for 
the  full  benefit  of  the  sea  to  be  obtained,  as 
improvement  does  not  generally  begin  for  a 
week  or  two  after  sea-siekness  has  subsided  and 
the  patient  can  remain  comfortably  on  deck. 
Route  (2)  does  not  allow'  him  to  get  the  bracing 
effect  of  high  South  latitudes.  Hence  where  a 
long  sea  voyage  is  indicated,  route  (1)  is 
decidedly  the  best.  England  is  quitted  in  the 
beginning  of  October,  Australia  (Sydney  or 
Melbourne),  or  New  Zealand  (Wellington),  is 
reached  early  in  January,  and  the  return  voyage 
is  begun  not  later  than  the  end  of  February. 

Patients  should  not  remain  in  the  coast-towns 
cf  Australia  in  summer  on  account  of  the  heat. 
They  should  go  to  the  table-land  of  New  South 
Wales,  or  to  Darling  Downs  in  Queensland,  or 
else  they  should  cruise  from  port  to  port,  or  run 
over  to  New  Zealand  or  Tasmania. 

In  returning,  the  route  round  Cape  Horn 
should  bo  avoided  on  account  of  the  great  risk  of 
the  climate  of  the  South  Pacific  Ocean  and  the 
chance  of  encountering  icebergs,  fogs,  and  un- 
favourable winds.  Either  the  patient  should 
come  back  round  the  Cape  of  Good  Hope  ; or  if 
his  strength  permits  he  may  cross  to  California, 
travel  overland  to  New  York  and  thence  by 
steamer;  or,  lastly,  he  may  come  by  the  Red  Sea, 
Suez  Canal,  and  Mediterranean. 

The  invalid  must  expect  about  20  wet  days 
on  the  voyage  out.  The  temperatures  met  with 
range  from  40°  to  80°  Fahr.,  the  coldest  and  most 
uncertain  weather  occurring  in  the  North  Atlantic 
and  South  Pacific  Oceans. 

Choice  of  Vessel. — The  following  considera- 
tions may  be  useful  in  deciding  between  steam 
and  sailing  vessels : — 

For  a steamer  there  is  the  greater  certainty 
in  predicting  the  length  of  the  voyage,  and  the 
calms  of  the  tropics  are  sooner  passed. 

Against  steamers,  there  is  the  nuisance  of 
steam  and  smoke  on  deck  ; much  space  is  taken 
up  by  the  engines,  stokers’  rooms,  &c.,  and  hence 
other  parts  of  the  ship  are  more  crowded ; the 
bilge  water  is  tainted  with  the  engine  grease ; 
there  is  the  wearying  grind  of  the  screw  by  day 
and  by  night;  while  more  seas  are  shipped, 
because  a steamer  can  run  against  a head-wind. 

For  sailing  vessels  there  are  the  advantages  of 
more  room,  light,  and  air  in  the  cabins,  and  the 
absence  of  the  above-mentioned  disagreeable 
conditions. 

Against  them  there  is  the  longer  and  more 
uncertain  duration  of  the  voyage,  and  the 
necessity,  of  shaping  their  course  by  the  prevail- 
ing winds. 

A word  must  be  added  as  to  the  comparative 
merits  of  wooden  and  iron  vessels.  Briefly 
stated,  iron  ships  are  cleaner,  drier,  freer  from 
smell  of  bilge  water,  and  hence  healthier  than 
wooden  ; but  on  the  other  hand  they  are  less 
equable  iu  temperature  (hotter  in  hot  and  colder 
iu  cold  latitudes),  and  less  aerated  by  natural 
ventilation  through  their  sides  than  the  latter. 
They  are  also  noisier. 

The  vessel  chosen  should  not  be  under  1,000 
tons,  and  her  age,  class  of  passengers,  the 
character,  temper,  and  standing  of  her  captain, 
es  well  as  the  size  of  her  cabins,  should  be  care- 


207 

fully  ascertained.  Of  course  it  is  a sine  qud  nen 
that  she  should  carry  a duly  qualified  surgeon. 

The  cabin  for  the  outward  voyage  to  Australia 
should  be  on  the  port  side,  so  as  to  get  the 
breeze  in  hot  weather,  and  vice  versa  in 
returning. 

The  cabin  outfit  should  include  a spring 
mattress,  with  hair  (not  wool)  mattress  over,  a 
folding  easy  chair,  chest  of  drawers,  carpet, 
curtains,  and  sponge  bath  (Faber).  Clothes  of 
various  degrees  of  thickness  are  essential,  both 
for  body  and  head,  and  a waterproof  suit  is 
necessary  for  bad  weather. 

Plenty  of  linen  must  be  taken,  as  washing  is 
difficult  on  board,  and  there  should  be  a supply 
of  preserved  milk,  meat  or  essence  of  meat, 
fruit,  and  light  wines. 

The  indications  for  a sea  voyage  are  hereditary 
tendency  to  phthisis,  or  the  presence  of  actual 
but  uncomplicated  disease  in  a very  early  stage, 
in  persons  not  past  middle  life,  with  a fair 
digestion,  absence  of  severe  pyrexia,  and  general 
health  not  much  impaired.  Patients  with  a 
tendency  to  haemoptysis  should  not  be  sent, 
nor  should  those  of  a desponding  disposition, 
who  would  thus  be  likely  to  suffer  by  the  long 
absence  from  home,  or  from  fears  of  their  per- 
sonal safety.  Of  course  a tendency  to  protracted 
sea-sickness  is  a distinct  contra-indication. 

The  invalid  should  be  careful  not  to  overtax 
his  digestion  too  much  ; he  should  take  regular 
daily  exercise  on  deck  to  the  extent  of  his 
strength,  have  some  definite  occupation  to 
beguile  the  time,  and,  if  possible,  be  accompanied 
by  a personal  friend  (Faber). 

Choice  of  a Climate — General  Hints. — It  is  a 
good  plan,  if  possible,  to  order  a patient  a 
climate  with  that  mean  temperature  and  relative 
humidity  which  he  is  known  to  tolerate  well 
(Sigmund).  The  patient’s  disposition  must  be 
considered,  and  a lively  or  a quiet  place  chosen 
according  to  his  temperament.  We  should  not 
send  a poor  man  to  a place  beyond  his  means, 
otherwise  he  has  to  grudge  himself  many  com- 
forts, and  loses  much,  if  not  all.  the  benefit  of 
the  change.  In  sending  patients  to  the  South  of 
Europe  this  rule  is  too  often  neglected. 

The  special  indications  for  the  climates  of  par- 
ticular places  can  only  be  understood  by  study- 
ing their  local  aspect.  Generally  speaking,  as 
far  as  Great  Britain  is  concerned,  the  climate  of 
the  east  coast  is  colder  and  drier  than  that  of 
the  west  and  south  coasts.  In  Ettrope  the  north 
and  west  coasts  are  moister  and  cooler  than  the 
shores  of  the  Mediterranean.  As  to  season, 
mountain  and  woodland  climates  are  almost 
exclusively  indicated  in  summer  from  May  to 
September.  Certain  parts  of  the  sea-coast  are 
adapted  for  invalids  at  all  seasons  of  the  year; 
but  as  a rule  the  northern  coasts  of  Europe 
and  the  eastern  or  south-eastern  coasts  of  Great 
Britain  are  best  suited  for  summer,  and  the 
south,  west,  and  south-western  for  winter  resi- 
dence. The  Mediterranean  coast  is  only  to  be 
recommended  from  mid-October  to  the  middle 
or  end  of  May,  and  Egypt  should  be  quitted 
not  later  than  April.  A word  may  bo  added 
as  to  the  advantages  of  wintering  in  the  South 
of  Europe.  It  is  incontestable  that  the  in- 
valid gets  a milder  winter,  a longer  autumn, 


268  CLIMATE,  TIIE  TREATMENT  OF  DISEASE  BY. 


find  an  earlier  spring.  Although  there  is  no 
place  where  some  days  of  bad  weather  do  not 
occur,  or  where  uninterrupted  calms  are  met 
with,  yet  the  number  of  rainy  days  is  fewer, 
there  is  more  sun,  little  or  no  fog,  and,  except  in 
the  neighbourhood  of  the  Pyrenees,  little  or  no 
snow  or  ice.  The  scenery  is  picturesque  and 
attractive,  and  the  invalid  is  able  to  spend  much 
time  in  the  open  air,  and  to  sit  out  of  doors  on 
many  days,  e cen  in  mid-winter.  The  drawbacks  to 
the  South  are  the  risk  of  chills,  owing  to  the  differ- 
ence between  sun  and  shade  temperatures, 
especially  at  first,  when  persons  are  unaccus- 
tomed to  the  climate,  and  fail  to  take  sufficient 
care ; the  occasional  occurrence  of  high  winds, 
especially  in  spring ; the  more  limited  accom- 
modation, owing  to  the  expense  of  rooms  and 
living;  and  the  absence  of  many  so-called  ‘ home 
comforts.’ 

Those  who  visit  the  South  must  remember 
that  the  curative  value  of  the  climate  consists  in 
its  allowing  w.xich  time  to  be  spent  in  the  open  air, 
and  in  its  milder  temperature  and  drier  air, 
which  protect  the  respiratory  organs  from  fresh 
inflammatory  attacks.  A south  room  and  warm 
clothing  of  the  texture  usually  worn  in  England 
in  autumn  are  essential,  and  a coat  or  wrap 
should  always  be  carried  out  of  doors  in  mid- 
winter to  put  on  in  passing  from  sun  to  shade. 
The  invalid  should  strictly  avoid  the  hot  atmo- 
sphere of  gaslit  salons  at  night. 

Patients  with  acute  diseases  of  the  respiratory 
organs  should  not  be  sent  to  the  South;  and  high 
fever,  excessive  weakness,  or  the  necessity  of 
remaining  in  bed,  are  also  contra-indications, 
owing  to  tho  fatigue  and  risks  of  the  journey 
and  the  need  of  home  comforts.  Cases  of  mental 
disease  with  excitement,  where  rest  and  protec- 
tion of  the  mind  and  body  is  of  primary  im- 
portance, should  not  be  sent. 

In  the  convalescence  from  acute  diseases 
occurring  in  autumn,  where  a cold  northern 
winter  would  prevent  open-air  exercise,  and 
probably  set  up  fresh  exacerbations,  southern 
winter  climates  are  of  great  value. 

In  ordering  change  of  climate  the  accommo- 
dation, food  and  water  supply,  soil  and  drainage 
of  the  locality’  chosen  should  be  carefully  con- 
sidered, especially  if  the  distance  is  a long  one. 
The  best  climate  may  be  unavailable  for  the 
invalid,  owing  to  defects  in  one  or  more  of 
these  particulars. 

Lastly,  the  patient’s  own  feelings  should  be 
carefully  consulted  before  he  is  sent  far  away 
from  home.  In  some  cases  all  the  benefits  of 
climate  are  counteracted  by  ‘ home-sickness.’ 
Odium  non  animum  mutant  qui  trans  mare  currant. 

Enumeration  of  Climates.— We  shall  now 
enumerate  various  climates  and  regions  suitable 
for  the  treatment  of  cases  that  can  be  benefited. 

1.  Of  the  Hervous  System. — In  neuralgia, 
Arcachon  (for  the  calm,  sedative,  yet  tonic 
atmosphere  of  the  pinewoods),  Cannes  (the  dis- 
tricts away  from  the  sea), 'Upper  Egypt  (Cairo, 
Luxor,  Helwan),  Hastings,  Hyeres,  the  Enga- 
dine,  the  Bernese  Oberland,  Pau,  Pisa,  Rome, 
tho  Salzkammergut  (Ischl,  Berchtesgaden). 
Some  of  the  above  climates  will  also  be  found 
suitable  to  cases  of  hemicrania  and  sciatica. 

In  hysteria,  hypochondriasis,  spinal  irritation. 


and  in  some  eases  of  protracted  chorea,  Brighton, 
Cannes,  Ischl,  Malta,  Mentone,  Montpellier, 
Morocco  (Tangiers),  Nice,  Naples,  the  Bernese 
Oberland  (Grindelwald,  Miirren).  Palermo,  Pau, 
Seville,  Spezia,  and  Valencia ; the  effect  pro- 
duced being  chiefly  due  to  diversion  of  the  atten- 
tion by  the  change  of  scene,  although  the  bracing 
influence  exerted  on  the  system  at  large  must  be 
taken  into  account. 

In  chronic  softening  of  the  brain  and  spinal 
cord,  in  paralysis  of  cerebral  origin,  and  in  some 
cases  of  locomotor  ataxy  the  South  of  France 
may  be  advantageously  ordered  in  winter,  and 
Alpine  climates  of  moderate  height  in  summer. 
As  a rule  hot  climates,  or  those  where  the  sun 
has  considerable  power,  are  contra-indicated 
where  there  is  a tendency  to  apoplexy  or 
hypersemia  of  the  brain. 

Temperate  and  bracing  climates  are,  as  a rule, 
to  be  recommended  in  nervous  diseases,  to  restore 
the  general  tone  of  the  system. 

The  immediate  neighbourhood  of  the  sea  not 
nnfrequently  causes  nervous  excitement,  neu- 
ralgia, and  sleeplessness. 

2.  Of  the  Respiratory  and  Circulatory 
Systems. — In  chronic  bronchitis,  emphysema, 
bronchial  and  spasmodic  asthma,  as  well  as  in 
chronic  pharyngeal  and  laryngeal  catarrh  and 
laryngeal  ulceration  the  following  climates  may 
be  recommended: — Algiers,  Australia,  the  Azores, 
Bordighera,  Bournemouth,  the  Canaries, the  Cape 
of  Good  Hope  (?),  Upper  Egypt,  Glengarriff, 
Hastings,  Hyeres,  Lisbon,  Madeira,  Malaga, 
Malta  (?),  Mentone,  Naples  (?),  Nervi,  Nice, 
Palermo,  Pau,  Pisa,  Queenstown,  Rome,  San 
Remo,  Torquay,  and  Ventnor. 

Change  of  climate  is  of  great  value  in  con- 
valescence from  the  acute,  and  as  a prophylactic 
and  curative  measure  in  the  chronic  forms  of 
bronchitis  ; but  we  must  remember  that  where 
there  is  copious  expectoration  a dry  climate  is 
indicated,  while  in  the  irritative  forms  with 
scanty  sputa  ( bronchitis  sicca)  a moderately 
moist  mild  climate  is  generally  suitable.  In 
emphysema  we  should  choose  a mild  and  not  too 
dry  climate,  if  possible  in  the  neighbourhood  of 
pine-woods,  such  as  Arcachon,  on  the  west  coast 
of  France.  In  spasmodic  asthma  the  choice  of 
climate  must  be  partly  a matter  of  personal 
experience. 

In  the  early  active,  and  in  the  quiescent  forms 
of  the  later  stages  of  phthisis,  as  well  as  in 
chronic  pleurisy,  and  in  convalescence  from 
pneumonia,  the  following  (chiefly  winter)  health 
resorts  and  climates  have  been  favourably  spoken 
of:— Algiers  (?),  Australia,  Bordighera, Bourne- 
mouth, Cannes,  Davos,  Upper  Egypt,  Upper  En- 
gadine  (in  summer),  South  of  France,  Hastings, 
Hyeres,  Queenstown,  Ischl  (in  summer),  Madeira, 
Malaga,  Mentone,  Natal  (?),  Nervi,  Nice  (?),  the 
Oberland  (in  summer),  Palermo,  Pau,  Pisa,  San 
Remo,  Sicily,  Spezia,  Torquay,  Glengarriff,  and 
the  Underciiff  (Isle  of  Wight). 

In  chronic  endocarditis,  pericarditis,  and  in 
heart-disease  generally,  a rather  bracing  climate, 
without  extremes  and  of  the  character  suited  to 
chronic  bronchitis,  is  usually  indicated.  Here 
both  the  tonic  effects  of  climatic  change  and  the 
prevention  of  pulmonary  complications  and  fresh 
rheumatic  attacks  must  be  taken  into  account. 


CLIMATE. 

Mountain  resorts  of  moderate  height,  well  pro- 
tected from  sudden  changes  of  temperature,  may 
be  prescribed  in  summer  (von  Dusch). 

In  the  neuroses  of  the  heart,  including  (1) 
angina  pectoris,  (2)  palpitation  associated  with 
chlorosis,  hysteria  or  hypochondriasis,  and  (3) 
exophthalmic  goitre,  bracing  climates  are  in- 
dicated. In  angina  pectoris  long  journeys 
involving  great  exertion  must  be  rigorously  for- 
bidden, as  must  also  sightseeing  or  exciting 
amusements. 

3.  Of  the  Abdominal  Organs. — In  the 
various  forms  of  chronic  dyspepsia  and  intestinal 
catarrh,  in  chronic  hepatic  disease,  in  chronic 
dysentery  (after  removal  from  a malarial  district 
or  tropical  climate),  in  diabetes,  and  in  chronic 
endometritis,  pelvic  cellulitis,  and  other  diseases 
of  the  uterus  and  its  surroundings,  the  following 
climates  may  be  selected  from : — Cannes,  The 
Engadine,  Hastings,  Hyeres,  Lisbon,  Malta, 
Mentone,  Montpellier,  Morocco,  Naples,  Nice, 
the  Nile,  the  Bernese  Oberland,  Pontresina, 
the  Pyrenees  (in  summer),  Queenstown,  the 
Falzkammergut,  Seville,  Spezia,  St.  Moritz, 
Valencia,  and  Ventnor. 

In  convalescence  from  acute  nephritis,  and  in 
all  forms  of  chronic  Bright’s-disease,  but  especi- 
ally catarrhal  nepliritis,  warm  dry  climates  are 
indicated.  Among  the  best  are  Upper  Egypt, 
the  Kiviera,  the  Cape  of  Good  Hope  (inland), 
Bombay ; and  in  England : Brighton,  Folkestone, 
and  Ventnor. 

In  renal  calculus  removal  from  particular 
districts  in  which  stone  is  known  to  be  prevalent 
may  possibly  be  of  use  in  some  cases. 

4.  Of  the  System  at  large.  — Change  of 
climate  is  here  nearly  always  indicated: — 

(1)  In  convalescence  from  typhus  and  typhoid 
fevers,  scarlet  fever  (at  the  end  of  the  desquama- 
tive stage),  measles,  diphtheria,  and  acute  rheu- 
matism ; also  in  the  third  stage  of  protracted 
hooping  cough. 

(2)  As  a prophylactic  against  all  infectious 
diseases,  and  especially  cholera,  yellow  fever, 
hay  fever,  influenza,  and  malaria;  also  against 
rheumatism  and  phthisis  by  withdrawal  from 
damp  districts,  and  goitre  and  cretinism  by 
removal  from  the  ensemble  of  conditions  to  which 
the  latter  are  due. 

(3)  In  rickets,  scrofula,  chlorosis,  general 
anaemia,  and  functional  debility.  Here,  where  a 
pure  air  and  a bracing  sunny  atmosphere  are  the 
chief  indications,  the  climates  enumerated  in  sec- 
tion 1,  page  263,  are  suitable,  as  are  also  Algiers, 
Biarritz  (in  autumn),  the  Cape  of  Good  Hope, 
Ischl,  Malaga,  Home,  Sicily,  St.  Moritz ; and  in 
Great  Britain  a number  of  inland  and  seaside 
places  (Malvern,  Scarborough,  &c.)  which  we 
have  not  space  to  mention. 

Edwa  ud  I.  Sparks. 

CLINICAL  (/cXhoj,  a bed). — This  word  lite- 
rally signifies  ‘ of  or  belonging  to  a bed  ’ ; but  it 
has  been  particularly  applied  to  the  practical 
study  and  teaching  of  disease  at  the  bedside ; 
and  has  more  recently  been  extended  to  all  that 
relates  to  the  practical  study  of  disease  in  the 
living  subject  generally. 

CLONIC  (kaSvos,  commotion) This  word 

is  applied  to  spasmodic  movements  which  are  of 


COAL  GAS,  POISONING  BY.  269 
short  duration,  and  alternate  with  periods  of 
relaxation.  See  Convulsions,  and  Spasm. 

CLOT. — A clot,  or  coagulum,  is  the  product 
of  the  formation  of  fibrin.  The  separation  or 
formation  of  fibrin  is  attributed  to  the  union, 
under  the  influence  of  a ferment,  of  the  fibrino- 
genetic  substance  or  fibrinogen  which  is  con- 
tained in  the  liquor  sanguinis,  the  juice  of  the 
flesh  and  most  of  the  serous  fluids,  with  the 
fibrinoplastic  substance  which  is  contained  in 
the  blood-globules,  the  lymph-corpuscles,  and 
the  cells  of  the  body  generally.  Coagulation  of 
the  blood  within  the  blood-vessels  is  described 
under  Thrombosis  ; the  coagulation  of  extrava- 
satecl  blood  under  Hemorrhage  and  Brain, 
Haemorrhage  into  ; and  the  coagulation  of  inflam- 
matory exudations  under  Lvixammation  and 
Exudation.  See  also  Blood,  Morbid  Conditions 
of. 

CLOTHING.  See  Disease,  Causes  of;  and 
Health,  Personal. 

COAGULUM  ( coagido , I curdle).  See  Clot. 

COAL  GAS,  Poisoning  by. — Coal  gas,  so 
largely  employed  for  illuminating  purposes,  is  a 
compound,  containing — in  addition  to  olefiant  gas 
and  analogous  hydrocarbons,  on  which  the  lumi- 
nosity principally  depends — certain  so-called 
diluents  which  burn  with  a non-luminous  flame, 
viz.,  hydrogen,  marsh  gas,  and  carbonic  oxide 
along  with  what  are  termed  impurities,  of  which 
the  chief  are  carbonic  acid,  sulphuretted  hydro- 
gen, and  bisulphide  of  carbon.  On  these  im- 
purities the  characteristic  odour  mainly  depends. 
This  odour,  which  is  perceptible  even  to  the 
extent  of  1 in  10,000,  is  a valuable  safeguard 
against  accidents  from  escape  of  gas. 

A mixture  of  coal  gas  with  the  air  inhaled 
exerts  a deleterious  effect  on  the  system,  and 
proves  fatal  when  it  reaches  a certain  percentage. 
In  addition  to  the  danger  from  inhalation,  fatal 
accidents  frequently  occur  from  the  explosive 
nature  of  the  compound  vdiich  is  formed  when 
the  gas  reaches  the  proportion  of  1 to  10  of  the 
atmosphere.  Much  less  than  this,  however  (a 
non-explosive  mixture,  therefore),  proves  fatal 
if  long  inhaled. 

It  is  difficult  to  determine  the  exact  propor- 
tion of  the  gas  present  in  atmospheres  in  which 
fatal  accidents  have  occurred,  but  we  derive  im- 
portant information  on  this  point  from  experi- 
ments on  animals.  Many  such  have  been  made. 
M.  Tourdes,  who  has  carefully  investigated  the 
subject,  finds  that  pure  gas  is  almost  instan- 
taneously fatal ; ^tli  kills  rabbits  in  five  minutes, 
and  dogs  in  twelve  minutes ; ith  kills  rabbits 
in  from  ten  to  fifteen  minutes ; ^th  still  proves 
fatal  after  a longer  period ; and  evident  signs  of 
distress  are  caused  in  rabbits  by  an  atmosphere 
containing  only  ith  of  the  gas.  Dr.  Taylor 
( Edin . Mid.  Jour.,  July,  1874)  has  estimated 
the  proportion  of  gas  existing  in  a room  in 
which  a fatal  case  occurred  at  three  per  cent. 

Sources  op  Poisoning. — Poisoning  by  coal 
gas  is  only  known  of  as  an  accident.  Occasion- 
ally suddenly  fatal  consequences  ensue  among 
workmen  from  exposure  to  a sudden  rush  of  un- 
diluted gas  from  gasometers  and  mains.  More 
commonly  slowly  fatal  cases  result  from  the  gas- 


270  COAL  GAS,  POISONING  BY. 

tap  in  a bed-room  being  left  open  carelessly, 
from  accidental  extinction  of  the  light,  or  from 
leakage  of  gas-pipes  in  a house  or  at  a dis- 
tance ; the  gas  gaining  access  to  the  house  in 
the  latter  case  through  cellars,  -walls,  and  more 
especially  by  means  of  drains  and  sewer-pipes. 

Symptoms. — Gas,  even  when  in  comparatively 
small  proportion  and  just  sufficient  tc  cause 
an  unpleasant  odour,  acts  deleteriously  if  long 
breathed,  and  gives  rise  to  headache  and  general 
depression  of  health. 

In  severe  and  fatal  cases  She  symptoms  wh-ich 
have  been  noted  are  headache;  nausea  or  vomit- 
ing ; vertigo ; and  loss  of  consciousness,  passing 
into  deep  coma  and  muscular  prostration,  which 
resembles  the  apoplectic  state,  the  individual 
lying  insensible  and  incapable  of  being  roused, 
with  livid  features,  stertorous  breathing,  and 
froth  at  the  mouth.  Death  usually  occurs  quietly, 
in  this  state  of  coma,  but  occasionally  with  con- 
vulsions. 

The  state  of  the  pupils  does  not  seem  to  be 
constant,  though  they  are  generally  dilated 
before  death. 

In  Dr.  Taylor’s  case  the  teeth  were  firmly 
clenched,  and  the  eyes  were  in  a constant  state 
of  lateral  oscillation. 

Fatal  Period. — The  fatal  period  of  poisoning 
by  coal  gas  is  extremely  variable,  and  a remittent 
character  of  the  symptoms  sometimes  gives  rise 
to  fallacious  hopes  of  recovery  in  cases  which 
ultimately  prove  fatal. 

Diagnosis.' — The  smell  of  gas  in  the  clothes, 
breath,  and  perspiration,  which  continues  for  a 
considerable  time  after  removal  from  the  in- 
fected atmosphere,  is  the  best  indication  of  the 
cause  of  the  coma. 

Anatomical  Characters. — The  smell  of  gas 
is  often  very  marked.  M.  Tourdes  has  found, 
as  the  most  constant  appearances,  a dark  colour 
of  the  blood,  which,  however,  coagulates;  a bright 
colouration  of  the  pulmonary  tissue;  froth  in  the 
air-passages;  congestion  of  the  mucous  membrane 
at  the  base  of  the  tongue  more  particularly; 
engorgement  of  the  cerebral  and  spinal  venous 
system  ; and  rose-coloured  patches  on  the  thighs. 

Mode  of  Action. — It  is  obviously  impossible 
to  differentiate  between  the  effects  of  the  various 
constituents  of  coal-gas,  but  we  have  good  reason 
for  believing  that  the  most  active  agent  is  the 
carbonic  oxide,  which  exists  in  the  proportion  of 
from  five  per  cent.  (English  gas)  to  twenty-five 
per  cent. 

The  symptoms  in  the  main  agree  with  those 
caused  by  carbonic  oxide  (see  Carbonic  Oxide, 
Poisoning  by),  and  the  effects,  therefore,  would 
be  chiefly  due  to  the  action  of  the  carbonic  oxide 
on  hcemoglobin. 

Treatment.— Instant  removal  from  the  in- 
fected atmosphere  is  the  first  thing  to  be  attended 
to.  Attempts  must  then  be  made  to  cause  oxy- 
genation of  the  blood  by  artificial  respiration  and 
excitation  of  the  respiratory  centres  by  reflex 
stimulation  of  the  face,  chest,  &e. 

Pure  oxygen  gas  may  be  administered.  As, 
however,  the  compound  which  carbonic  oxide 
makes  with  the  blood-colouring  matter  is  a very 
stable  one,  and  not  easily  broken  up  by  the  in- 
troduction of  atmospheric  air  or  oxygen,  it  not 
unfroquently  happens  that  these  measures  prove 


COLD,  EFFECTS  OF. 

of  no  avail.  In  such  cases  it  would  be  highly 
advisable  to  perform  venesection,  and  then  trans- 
fuse fresh  blood,  a plan  of  treatment  which  has 
been  found  successful  in  poisoning  by  carbonic 
oxide.  D.  Furrier. 

COARCTATION  (coarcto,  I straiten). — 
A pressing  together,  narrowing,  or  stricture  of 
any  hollow  tube,  such  as  the  aorta,  intestine,  or 
urethra. 

COLD,  A. — A popular  name  for  Catarrh.  Set 
Catarrh. 

COLD,  JEtiology  of.  See  Disease,  Causes  of. 

COLD,  Effects  of  Severe  or  Extreme. — 
The  general  effect  of  exposure  to  severe  or  ex- 
treme cold  is  to  lower,  even  to  extinction,  all 
vital  activity.  The  blood-vessels,  especially  the 
smaller  arteries  and  capillarios,  after  a brief 
period  of  congestion,  become  contracted,  the 
latter  to  such  an  extent  as  no  longer  to  permit 
the  passage  of  the  red  corpuscles;  the  normal 
condition,  composition,  and  structural  integrity 
of  the  various  tissues  are  more  or  less  impaired, 
or  altogether  destroyed ; and  those  processes  of 
chemical  and  physiological  change  which  are 
essential  to  every  manifestation  of  life,  being 
only  possible  within  certain  very  narrow  limits 
of  temperature,  are  hindered  or  absolutely  pre- 
vented. 

Effects  and  Symptoms. — The  more  special 
effects  vary  in  degree  and  kind: — lstly,  with 
the  degree  of  cold,  the  duration  of  the  exposure, 
and  the  medium  or  manner  of  application : 
2ndly,  with  the  part,  and  extent  of  surface  ex- 
posed; and,  3rdly,  with  the  general  constitu- 
tion and  physiological  condition  of  the  sufferer. 
Moderate  cold,  acting  during  a short  time,  or 
even  severe  cold  during  a still  shorter  time, 
followed  by  the  glow  of  speedy  reaction,  ex- 
ercises a tonic  and  stimulating  influence.  But 
if  the  cold  is  too  severe,  or  the  exposure  too 
long,  no  glow  of  reaction  occurs,  but  a sense  of 
depression  is  experienced,  from  which,  at  best, 
recovery  takes  place  but  slowly.  Continued  ex- 
posure to  such  degree  of  cold  as  is  yet  not 
incompatible  with  the  maintenance  of  life,  never- 
theless keeps  at  low  ebb  activity  of  nutrition  and 
function  alike.  Extreme  cold  and  long  exposure 
lead  to  congelation  and  consolidation  of  the 
various  tissues  of  the  body.  Alter  complete 
congelation  recovery  is  impossible.  Dry  cold  is 
much  less  readily  injurious  in  its  influence  than 
cold  associated  with  wet.  The  better  conductor 
of  heat  the  medium  is,  the  more  speedily  and 
completely  does  it  reduce  the  temperature  of  the 
part  with  which  it  is  in  contact.  Immersion  in 
water  cools  more  rapidly  than  exposure  to  air  of 
the  same  temperature : and  contact  with  wool, 
wood,  or  metal,  of  the  same  degree  of  coldness, 
excites  in  each  case  a different  sensation,  and 
leads  to  a different  result,  or  to  the  same  result 
with  very  different  rapidity.  Constant  renew  . 1 
of  the  medium  in  contact  hastens  the  cooling 
effect ; and  a continuous  draught  of  only  mode- 
rately cold  air  may  do  more  to  chill  than  tem- 
porary exposure  to  an  intensely  cold,  but  still 
atmosphere.  If  some  external  part,  and  a 
comparatively  small  extent  of  surface  only,  be 
acted  upon,  the  effect  may  he  simply  local,  aud 


COLD,  EFFECTS  OF  SEVERE  OR  EXTREME.  271 


the  general  disturbance  of  the  system  scarcely 
appreciable.  But  if  the  whole  body,  or  a con- 
siderable extent  of  surface,  or  any  important 
internal  organs  be  acted  upon,  a proportionately 
serious  general  effect  is  produced.  The  young 
(infants  especially)  and  the  aged  alike  ill  sustain 
exposure  to  cold,  and  are  most  liable  to  suffer, 
not  only  from  its  direct  effects,  but  also  from 
the  various  maladies  to  which  it  gives  rise.  The 
feeble,  ill-nourished,  and  broken  in  health,  especi- 
ally the  subjects  of  organic  disease,  or  of  de- 
generation due  to  habitual  intemperance,  readily 
succumb,  or  only  slowly  and  imperfectly  recover. 
Among  the  healthy  and  otherwise  vigorous,  hun- 
ger, fatigue,  sleep,  anxiety  of  mind,  fear  and 
mental  depression  of  whatever  kind,  lower — too 
often  even  to  fatal  issue — the  power  of  resistance 
to  the  deadly  influence  of  cold. 

For  local  effects  of  exposure  to  cold  sec  Chil- 
blain, F rost-mte,  and  Gangrene. 

The  General  Effects  produced  by  exposure 
to  severe  or  extreme  cold  vary  somewhat  in 
different  eases.  Temporary  exposure  produces, 
first,  a sense  of  coldness  or  chilliness,  associated 
with  paleness  and  corrugation  of  tne  skin  (the 
so-called  cutis  anserina),  then  shivering  and 
tingling  sensations,  followed  by  numbness  and 
diminution  of  muscular  activity  and  power. 
Healthy  reaction  restores  more  or  less  quickly 
the  normal  condition.  Prolonged  exposure  to 
extreme  cold  gives  rise  to  a series  of  symptoms, 
graphically  described  by  Beaupre  somewhat  as 
follows : — Reaction  has  a limit,  and  a moment 
arrives  when  the  powers  are  exhausted.  Shiver- 
ings,  puckerings,  paleness  and  coldness  of  the 
skin,  livid  spots,  muscular  flutterings,  are  symp- 
toms of  the  shock  given  to  the  vital  forces  ; syn- 
cope approaches ; the  stiff  muscles  contract 
irregularly ; the  body  bends  and  shrinks  ; the 
limbs  are  half-bent;  lassitude  and  languor  invite 
to  repose ; a feeling  of  weight  and  numbness 
retards  the  steps  ; the  knees  bend  ; the  sufferer 
sinks  down  or  falls  ; the  propensity  to  sleep  be- 
comes irresistible  ; everything  grows  strange ; 
the  senses  are  confused ; the  mind  grows  dull,  the 
ideas  incoherent,  and  the  speech  stammering  or 
raving;  respiration,  at  first  interrupted,  becomes 
slow  ; the  heart’s  action  is  feeble,  quick,  hard, 
irregular,  and  sometimes  painful,  and  the 
pulse  progressively  smaller ; the  pupils  dilate  ; 
the  brain  becomes  stupified;  and  finally  deep 
coma  indicates  the  approach  of  inevitable 
death. 

Other,  and  somewhat  different  effects  and 
symptoms,  attributable  to  differences  of  circum- 
stances and  condition,  have  been  from  time  to 
time  observed.  Distressing  and  almost  intoler- 
able thirst,  with  loss  of  appetite  for  food,  is  often 
experienced ; and  the  attempt  to  obtain  relief, 
by  sucking  snow  or  ice,  only  adds  to  the  suffering. 
Somnolence  is  by  no  means  so  constant  an  effect 
as  is  commonly  supposed— at  any  rate,  in  the 
earlier  stages,  and  iess  extreme  cases.  On  the 
other  hand,  inability  to  sleep  has  proved  a com- 
mon cause  of  suffering  and  consequent  loss  of 
strength.  The  manifestations  of  brain-disturb- 
ance due  to  exposure  to  cold,  varying  as  they  do 
from  dullness,  incoherence,  wandering  and  thick- 
ness of  speech  to  even  raving  delirium,  are 
especially  worthy  of  note,  inasmuch  as  they  re- 


semble, and  are  liable  to  be  mistaken  for,  the 
effects  of  alcoholic  intoxication. 

Death  from  the  direct  and  immediate  effects  of 
cold  is  rare  in  our  country  ; but  it  is  estimated 
that  in  the  Russian  Empire,  on  an  average,  694 
deaths  occur  annuallyfrom  this  cause.  The  length 
of  time  during  which  exposure  can  be  sustained 
varies  greatly  with  the  condition  of  the  indivi- 
dual and  with  surrounding  circumstances,  as 
well  as  with  the  degree  of  cold.  Under  ordinary 
circumstances,  an  hour’s  exposure  to  intense  cold 
often  suffices  to  determine  a fatal  result.  At  the 
same  time,  well-authenticated  cases  are  on  record, 
in  which  persons  buried,  for  days  even,  in  the 
snow,  have  nevertheless  survived  and  ultimately 
recovered  with  little  permanent  damage. 

i! lode  of  Death. — The  immediate  cause  or 
mode  of  death  from  cold  seems  in  some  cases 
to  be  principally  shock;  in  some,  syncope;  in 
others,  asphyxia ; and  in  others,  again,  coma. 
In  most  cases  it  is  probable  that  these  several 
conditions,  with  others  less  readily  specified, 
combine  to  produce  the  fatal  issue. 

Anatomical  Characters. — The  appearances 
presented  on  post-mortem  examination  are  some- 
what differently  described  and  estimated  by 
different  observers ; but  none  of  them  are  ab- 
solutely pathognomonic,  and  some  are  as  likely 
to  be  produced  by  exposure  of  the  body  after 
death  as  during  the  process  of  extinction  of  life. 
Among  the  more  noteworthy  are  the  following ; — 
strong  cadaveric  rigidity;  paleness  or  waxy  white 
ness  of  skin,  with  patches  of  more  or  less  bright 
redness  about  the  face,  neck,  and  limbs,  especi- 
ally on  exposed  or  prominent  parts  ; a contracted 
and  shrunken  condition  of  the  male  genital 
organs  ; comparative  bloodlessness  of  superficial 
and  external  parts  ; accumulation  of  blood  in 
and  about  the  thoracic  and  abdominal  viscera  ; 
great  distension  of  all  the  cavities  of  the  heart, 
with  more  or  less  clotted  and  often  bright-coloured 
blood ; the  blood  in  other  parts  also  some- 
times of  brighter  colour  than  usually  seen  on 
post-mortem  inspection ; hypercemia  and  con- 
gestion of  the  lungs  ; hyperemia  cf  the  brain, 
overfulness  of  the  sinuses,  and  excess  of  serous 
fluid  in  the  ventricles,  and  at  the  base,  in  some 
cases;  in  others,  comparative  bloodlessness  of  the 
surface  of  the  brain,  and  no  distension  of  the 
sinuses ; excessive  fullness  of  the  urinary  bladder ; 
and,  lastly,  separation  of  the  cranial  bones  along 
the  coronal  and  sagittal  sutures.  The  lines  of 
reddish  or  brownish  staining  along  the  course  of 
the  superficial  blood-vessels,  relied  on  by  some 
as  pathognomonic,  are  certainly  not  so,  inasmuch 
as  they  depend  upon  exosmosis  of  the  blood 
colouring-matter  set  free  by  disruption  of  the 
corpuscles,  which  may  be  effected  by  freezing 
after  death,  as  well  as  before. 

Treatment. — The  treatment  of  sufferers  from 
the  effects  of  cold,  consists  in  the  restoration  of 
warmth,  and  the  rekindling  of  those  processes  by 
which  the  natural  heat  of  the  body  is  maintained. 
But  this  must  be  done  gradually,  and  with  great 
care.  As  in  the  treatment  of  a frostbitten  part, 
so  in  the  treatment  of  the  body  generally— all 
sudden  or  rapid  elevation  of  temperature  must 
be  avoided.  The  sufferer,  divested  of  the  clothing 
previously  worn,  and  wrapped  in  blankets,  should 
be  placed  in  the  recumbent  position  in  a room. 


272  COLD,  EFFECTS  OF. 

the  air  of  which  is  dry,  still,  and  cold,  but 
capable  of  being  gradually  warmed.  Gentle,  but 
continuous  friction  should  be  made  over  the 
trunk  and  limbs,  care  being  taken  that  rigid  or 
frozen  parts  be  not  damaged  by  rough  manipula 
tion.  At  first,  ice  or  ice-cold  water  may  be  used ; 
afterwards  dry  rubbing  with  flannel  or  with  the 
hands  is  better ; later  still  some  stimulating  lini- 
ment may  be  employed.  Some  recommend  im- 
mersion of  the  body  in  a bath  of  cold — at  first 
ice-cold — water,  the  temperature  of  which  can  be 
gradually  raised.  This  method  would  seem  easy 
and  advantageous,  if  means  are  at  command. 
When  the  sufferer  can  swallow,  warm,  gently 
stimulating,  drinks — as  tea,  coffee,  aromatic  in- 
fusions, beef-tea,  or  soup — may  be  given,  at  first 
without,  hut  later  with  some  wine  or  spirit. 
Alcohol,  though  useless  or  injurious  if  taken  to 
fortify  against  cold,  is  useful  and  beneficial  when 
judiciously  administered  as  a restorative  after 
exposure.  In  all  cases  of  insensibility,  and  even 
apparent  death  from  cold,  every  effort  must  be 
made  to  restore  animation;  and  the  attempt  must 
be  persevered  in  for  a considerable  time  before 
being  given  up  as  hopeless.  It  is  often  difficult, 
sometimes  impossible,  to  judge  whether  life  is 
absolutely  extinct  or  not.  And  while,  on  the 
one  hand,  it  is  important  that  the  temperature 
be  not  raised  too  quickly,  lest  reaction  should  he 
too  strong  or  dangerously  irregular  ; on  the  other 
hand,  it  is  equally,  if  not  more  important,  that 
the  needful  measures  bo  adopted  without  delay, 
and  carried  out  not  too  slowly,  lest  the  chance  of 
revival  should  he  lost.  In  the  less  severe  cases, 
restoration  of  warmth  may  he  comparatively 
quickly  accomplished.  The  state  of  the  bladder 
should  always  be  examined,  and  relief  afforded,  if 
needful,  by  aid.  of  the  catheter.  Attention  to  the 
general  health  is  often  requisite  for  long  after 
recovery  from  the  more  immediate  effects  of 
exposure  has  taken  place.  Rest,  good  nourish- 
ment, and  tonics  are  indicated. 

Cold  as  a Cause  of  Disease. — As  a pre- 
disposing and  exciting  cause  of  disease,  cold 
proves,  in  this  country,  year  by  year,  more  fatal 
in  its  effects  probably  than  any  other  single 
condition  or  influence.  Any  considerable  fall 
in  the  thermometer  below  the  average  standard 
during  the  colder  months  of  the  year  is  con- 
stantly followed  by  a corresponding  rise  in  the 
death-rate,  and  an  increase  in  still  greater  pro- 
portion in  the  amount  and  extent  of  sickness 
and  suffering.  The  Deports  of  the  Registrar- 
General  clearly  prove  this,  so  far  as  the  death- 
rate  is  concerned.  A striking  instance  may  be 
quoted.  In  the  week  ending  December  19, 1863, 
in  the  London  district  1,291  deaths  were  regis- 
tered. Severe  frost  set  in,  and  in  the  week 
ending  January  9,  1861,  the  number  rose  to 
1.798.  The  week  following,  ending  January  16, 
no  fewer  than  2,427  deaths  were  registered.  This 
enormous  increase  could  be  attributed  to  no  other 
cause  than  the  effects  of  the  severe  cold  which, 
prevailed.  The  Registrar-General  also  shows 
that  after  the  age  of  from  twenty  to  forty  the 
mortality  from  cold  increases  in  something  like 
a definite  ratio  with  increasing  years. 

General  depression  of  the  vital  powers,  con- 
gestion and  functional  derangement  of  various 
internal  organs — the  lungs,  liver,  and  kidneys — 


COLD,  THERAPEUTICS  OF. 

[ catarrhal  and  other  forms  of  inflammation  of  the 
mucous  membranes,  especially  of  the  respiratory 
tract,  but  also  of  the  intestinal  canal  and  bladder, 
paralysis  from  central  or  peripheral  iesioD,  to- 
gether with  rheumatism,  chilblain,  frost-bite,  and 
gangrene,  constitute  the  list  of  maladies  most 
commonly  caused  and  fostered  by  exposure  to  the 
influence  of  cold.  Author  E.  Durham. 

COLD,  Therapeutics  of. — The  therapeutic 
uses  of  cold  are  various  and  extensive.  Cold 
may  he  applied  as  moist  cold,  by  means  of  wet 
compresses  and  cold  lotions  or  baths ; and  it  may 
also  be  used  as  dry  cold  in  the  form  of  ice  en- 
closed in  a receptacle  of  metal  or  india-rubber. 
Each  of  these  methods  has  its  special  advantages 
and  adaptations.  Furthermore,  cold  may  he 
made  use  of  by  the  mouth,  and  by  injection  into 
the  mucous  canals  of  the  body. 

General  Principles. — The  general  effect  of 
cold,  however  applied,  is  to  lower  temperature, 
to  diminish  sensibility  and  fluidity,  to  contract 
the  tissues  and  vessels,  and  so  to  reduce  the 
volume  of  parts.  The  cold  bath  and  cold  spong- 
ing alike  have  the  effect  of  lowering  the  tem- 
perature of  the  body.  The  fall  of  temperature 
sometimes  is  hut  transient,  reaction  set  ting  in  and 
heat  of  surface  returning  when  the  body  is  with- 
drawn from  thecooling  medium.  At  other  times 
the  temperature  continues  to  fall  after  the  indi- 
vidual is  removed  from  the  bath.  If  the  action 
of  the  cold  bath  be  prolonged,  then  athermometer, 
introduced  within  the  rectum,  shows  a great  de- 
pression of  temperature,  and  much  pain  is  ex 
perieneed,  similar  to  the  severe  pain  which  is 
felt  in  the  hand  and  arm  when  the  former  is 
held  for  some  time  in  water  at  a temperature  of 
41°  Fahr.,  and  which  soon  compels  the  with- 
drawal of  the  hand  from  the  vessel.  Cold  baths 
and  their  uses  are  treated  of  in  another  article, 
but  attention  may  here  be  drawn  to  the  practice 
of  cold  sponging  over  the  surface  as  an  efficacious 
means  of  lowering  preternatural  heat  and  reliev- 
ing acridity  and  dryness  of  tho  skin  during  fever. 
Reduction  of  hyperpyrexia  by  means  of  cold  is 
now  a well-established  therapeutic  method. 
Temperature  ; and  Special  Diseases. 

Methods  of  Application  and  Uses.  — 
1.  Cold  Affusion  and  Wet  Packing. — In 
the  practice  of  cold  affusion,  introduced  by 
Dr.  Currie,  in  1797,  the  patient  is  unclothed, 
seated  in  a tub,  and  four  or  five  gallons  of 
cold  water  thrown  over  him.  Thus,  Dr.  Currie 
said,  a commeneiug  fever  might  be  1 extinguished.’ 
In  cases  where  the  skin  was  burning  hot  and  dry, 
it  was  observed  that  after  the  cold  allusion,  temper- 
ature fell,  perspiration  broke  out,  aud  the  patient 
usually  dropped  into  a refreshing  sleep.  If  the 
body-heat  did  not  exceed  985°  Fahr.,  or  if  the 
patient  was  damp  and  chilly,  with  or  without 
delirium,  the  cold  affusion  was  regarded  as  danger- 
ous and  by  all  means  to  be  avoided.  In  fevers  com- 
plicated with  any  visceral  inflammation,  the  cold 
affusion  is  prejudicial.  Drs.  Strauss  and  Hirtz 
speak  most  highly  of  the  marvellous  effect  of 
cold  affusion  in  cases  of  collapse  during  fever. 
This  kind  of  collapse  appears  due  to  a paralysis 
of  the  nervous  centres  : the  heart's  action  fails, 
as  docs  also  the  respiration ; but  while  the  sur- 
face of  the  body  is  cold, the  temperature,  taken  in 


COLD,  THERAPEUTICS  OP.  273 


Che  rectum,  still  remains  abnormally  high.  The 
affusion  is  applied  by  pouring  a pitcherful  of 
water,  at  a temperature  of,  or  a little  abore 
10°  C.  (50°  Fahr.),  over  the  patient  seated  on  a 
waterproof  cloth.  The  patient,  plunged  in  stu- 
por, is  suddenly  roused  by  the  shock  ; he  draws 
a long  breath,  the  respiration  becomes  fuller ; 
the  cardiac  ataxy  ceases,  and  the  pulse,  which, 
traced  by  the  sphygmograph  during  the  collapse, 
presented  a scarcely  broken  horizontal  line,  now 
regains  its  normal  line  of  ascension;  heat  of  sur- 
face returns,  and  the  temperature  in  the  rectum 
falls.  The  action  of  the  cold  affusion,  as  thus 
applied,  is  to  excite  immediate  and  energetic 
reflex  action. 

In  many  nervous  affections,  such  as  chorea 
and  hysteria,  cold  douches,  shower  baths,  and 
affusions  are  valuable  as  restorative  and  cura- 
tive agents.  In  the  convulsions  of  robust  chil- 
dren, a stream  of  cold  water  directed  over  the  head 
from  a height  of  two  or  three  feet  often  has  a 
speedily  beneficial  effect.  Cold  affusion  has  been 
tried  in  tetanus,  but  it  has  in  some  instances 
killed  the  patient  (Elliotson). 

Other  cases  in  which  cold  affusions  are  of 
service  are  those  where  respiration  fails,  and  it  is 
necessary  to  appeal  powerfully  to  the  reflex  ex- 
citability of  the  nervous  centres.  To  resuscitate 
those  who  are  in  danger  of  death  from  a narcotic 
such  as  chloroform  or  opium,  slapping  the  patient 
severely  with  a cold  wet  towel  is  an  efficient  me- 
thod. In  sun-stroke  cold  affusion  over  the  head 
and  neck  may  be  resorted  to,  provided  the  skin 
be  not  cold  and  clammy  and  the  patient  in  a 
very  syncopal  state.  In  conditions  of  nervous 
spasm,  of  the  larynx  for  example,  cold  douches 
over  the  neck  may  prove  useful.  Cold  affusion 
to  the  feet  was  much  commended  by  Cullen  as  a 
means  of  promoting  action  of  the  bowels  in  cases 
of  obstinate  constipation.  Spasmodic  retention 
of  urine  has  been  relieved  by  cold  douche  over 
perineum  and  thighs  (Currie);  and  Mr.  Erichsen 
mentions  the  case  of  an  old  man  who  found  his 
power  of  micturition  increased  by  sitting  on  the 
cold  marble  top  of  his  commode. 

In  cases  of  extreme  debility,  with  damp,  cool 
skin,  low  muttering  delirium,  and  very  feeble 
pulse,  cold  affusions  are  dangerous. 

In  some  cases  of  fever,  where  for  any  cause 
a cold  bath  is  objectionable,  the  patient  may 
be  wrapped  in  a wet  sheet  and  then  covered 
with  a few  blankets.  The  sheet  as  it  becomes 
heated  may  be  changed  for  one  fresh  and  cold, 
or  very  cold  water  may  be  squeezed  from  a 
sponge  over  the  sheet  as  the  patient  lies  rolled 
up  in  it  on  a waterproof  cloth.  In  scarlet  fever  of 
malignant  type,  where  the  rash  does  not  readily 
appear,  this  form  of  cooling  pack  has  been  found 
most  valuable.  Drs.  Hillier  and  Gee  have  both 
added  their  testimony  to  its  utility.  In  Dr.  Gee’s 
cases  the  patient  remained  packed  in  the  wet 
sheet  for  one  hour  and  was  then  removed  to  bed. 
The  cases  best  suited  for  treatment  by  the  wet  pack 
are  those  where  the  skin  is  very  dry  and  hot,  and 
the  patient  exceedingly  restless  and  delirious. 

2.  Cold  Compresses,  Irrigations,  Lotions, 
and  Injections. — Cold  maybe  continuously  ap- 
plied with  a view  to  abating  undue  heat  of  apart 
of  the  body.  Thus  iced-water  rags  or  compresses 
may  be  placed  over  an  inflamed  throat,  or  on 
18 


the  head  in  inflammation  of  the  brain.  In  acute 
pneumoniaNiemeyer  has  commended  strongly  the 
use  of  cloths  dipped  in  cold  water,  well  wrung, 
and  then  applied  so  as  to  cover  the  chest  and  es- 
pecially the  affected  side.  These  compresses  are 
repeated  every  five  minutes.  Pain  and  dyspnoea 
are  much  relieved  ; somotimes  the  temperature 
falls  an  entire  degree  ; and  if  the  cold  appliances 
do  not  arrest  the  actual  attack  of  pneumonia, 
they  shorten  its  duration  and  promote  speedy  con- 
valescence. The  necessity  of  so  often  having 
to  change  the  compress,  and  thus  disturb  the 
patient  , is  a great  objection  to  this  mode  of  apply  - 
ing cold. 

A powerful  sedative  and  antiphlogistic  effect 
of  cold  can  be  obtained  by  irrigation ; i.c.  allow- 
ing cold  water  to  fall  drop  by  drop  on  a cloth, 
so  as  to  keep  it  continually  wet  with  fresh 
supplies  of  water.  This  may  be  done  by  sus- 
pending over  the  part  to  be  irrigated  a bottle 
of  water,  in  which  a few  pieces  of  ice  may  be 
put;  one  end  of  a skein  of  cotton,  well  wetted,  is 
then  allowed  to  hang  in  the  water,  while  the 
other  end  is  brought  over  the  side  of  the  bottle. 
This,  acting  as  a syphon,  causes  a continual  drop- 
ping upon  the  part  to  be  irrigated.  In  injuries 
of  joints,  where  it  is  of  much  consequence  to 
check  inflammation,  this  process,  which  abstracts 
heat  gradually,  and  without  disturbance  of  the 
part,  is  most  valuable.  Irrigation  of  the  shaven 
scalp  in  cases  of  meningitis  is  a very  powerful, 
cooling,  and  sedative  appliance,  requiring  care 
and  watchfulness.  A cap  of  india-rubber  over 
the  head  and  back  of  neck,  so  arranged  that  a 
current  of  cooled  water  may  flow  continuously 
through  it,  will  act  as  a general  reducer  of  tem- 
perature. Where  pounded  ice  is  applied  to  the 
head  in  a bladder,  this  should  be  suspended  by 
a string  from  the  bedstead,  so  that  the  head  of  the 
patient  may  not  have  to  sustain  the  weight  of  the 
bag  and  its  contents.  Five  ounces  of  sal  ammoniac 
and  five  ounces  of  nitre  in  a pint  of  water  will 
form  a frigorifie  mixture,  which  can  be  applied 
in  a bladder  when  ice  is  not  at  hand.  The  ice- 
bag,  and  cold  water  compresses  renewed  every 
three  minutes,  have  been  used  as  an  appliance  to 
strangulated  hernia,  and  to  prolapsed  rectum, 
to  reduce  the  volume  of  the  part  and  so  facili- 
tate reduction.  Care  must  be  taken  that  the 
cold  application  be  not  continued  so  long  as  to 
cause  gangrene.  Cold  wet  compresses  should 
not  be  applied  over  dry  bandages,  with  which 
wounded  or  broken  parts  are  secured.  Several 
cases  are  recorded  where  a hand  or  arm  has 
become  gangrenous,  in  consequence  of  having 
been  bound  up  with  dry  bandages,  and  then 
treated  with  cold  water  compresses.  The  dry 
bandages,  as  they  become  wet,  contract  tightly 
on  the  limb,  thus  stopping  circulation  and 
causing  gangrene. 

A mixture  made  of  spirit  of  wino  and  water, 
or  of  eau  de  cologne  with  water,  is  a simple 
form  of  cooling  lotion.  The  spirit  evaporates 
and  so  carries  off  heat  from  the  surface.  1 oz. 
of  rectified  spirit  to  15  of  water  makes  a good 
spirit  lotion,  and  the  addition  of  4 drachms 
of  nitrate  of  potash,  or  chloride  of  ammonium, 
will  add  to  its  cooling  and  sedative  effect.  -1 
drachms  of  the  chloride  of  ammonium  with  hal  t 
an  ounce  of  diluted  acetic  acid,  and  the  same 


!7i  COLD,  THERAPEUTICS  OF. 
quantity  of  rectified  spirit  in  15  ozs.  of  camphor 
water,  is  another  form  for  a very  serviceable 
lotion.  These  lotions,  applied  by  means  of  a 
piece  of  soft  rag  or  lint  over  the  skin,  act  as 
refrigerants,  cooling  the  head  when  it  is  hot 
or  painful ; reducing  heat  and  arterial  excite- 
ment in  tumours  or  contusions;  and  tending  in 
the  latter  to  promote  the  absorption  of  effused 
blood.  Cold  water,  and  cold  lotions  of  vinegar 
and  water,  are  familiar  means  for  trying  to  stop 
haemorrhage. 

In  cases  of  severe  uterine  haemorrhage,  injec- 
tions of  ice-cold  water  into  the  vagina,  or  into 
the  rectum,  frequently  succeed  in  checking  the 
bleeding.  In  eases  of  bleeding  internal  piles  an 
injection  of  cold  water,  after  the  action  of  the 
bowels,  braces  the  parts  and  constringes  the 
bleeding  vessels. 

3.  Dry  Cold.  Uses  of  Ice. — Heatmaybecon- 
tinuously  abstracted  from  an  inflamed  part  in  a 
safe  way,  and  without  undue  risk,  by  applying  dry 
cold  by  means  of  a waterproof  bag  of  vulcanised 
india-rubber  filled  with  ice,  snow,  or  a freezing 
mixture  made  of  equal  parts  of  salt,  nitrate  of 
potash,  and  chloride  of  ammonium.  Moisture 
from  the  air  will  condense  on  the  exterior  of  the 
cold  bag,  but  a piece  of  lint  interposed  will 
protect  the  skin  from  damp.  The  india-rubber 
is  a bad  conductor,  and  too  great  abstrac- 
tion of  heat  need  not  bo  feared.  The  walls  of 
an  animal  bladder  conduct  heat  much  better 
than  the  india-rubber,  and  it  is  necessary  to 
watch  carefully  over  the  application  of  ice-blad- 
ders, for  when  continuously  applied  they  have 
been  known  to  cause  severe  frost-bite  of  the 
part.  If,  when  cold  is  being  applied,  the  patient 
persists  in  complaining  of  severe  pain,  it  is  right 
carefully  to  examine  and  see  how  the  part  is 
affected  by  the  cold.  Professor  Esmarch,  in 
rases  of  fracture,  and  in  various  forms  of  trau- 
matic inflammation,  has  applied  ice  for  periods 
of  twenty  or  thirty  days  with  the  best  results. 
In  cases  of  commencing  disease  of  the  vertebrae 
this  surgeon  has  used  cold  water  placed  in  a tin 
vessel,  so  made  as  to  adapt  itself  to  the  part  to 
be  treated.  Minor  cases  of  bruise  with  inflam- 
mation may  be  treated  by  cold  employed  in  the 
form  of  a common  bottle  filled  with  cold  water 
and  kept  pressed  against  the  part.  After  opera- 
tions upon  the  eye,  the  extraction  of  cataract  for 
example,  a small  ice-bag  is  very  useful  in  reliev- 
ing pain  and  keeping  down  inflammation. 

Ice-bags  placed  along  the  course  of  the  spine 
have  been  found  effectual  remedies  in  many  forms 
of  nervous  disorder.  In  cases  of  epilepsy,  where 
the  circulation  is  sluggish,  the  hands  and  feet 
being  always  clammy  and  cold,  an  india-rubber 
bag  of  ice  applied  along  the  spine  has  been 
found  to  restore  warmth,  at  the  same  time 
relieving  headache  and  symptoms  of  incipient 
paralysis.  Cold  to  the  spine  is  asserted  by  Dr. 
Chapman  to  lessen  the  excito-motor  power  of 
the  cord.  In  the  severe  pain  of  an  inflamed 
ovary  or  testicle  ice  in  a bag  may  often  be 
employed  beneficially  as  an  anodyne. 

Lumps  of  ice  swallowed  are  invaluable  in 
arresting  haemorrhage  from  the  throat  and 
stomach.  In  tonsillitis  and  diphtheria  this  same 
treatment  tends  to  reduce  inflammation  and  cool 
the  throat  of  the  patient.  Obstinate  vomiting  can 


COLIC,  INTESTINAL. 

often  be  checked  by  swallowing  fragments  of 
tee. 

4.  Cold  as  an  Anaesthetic. — Dr.  James  Arnott. 
in  1849,  brought  forward  the  use  of  a freezing 
mixture  of  ice  and  salt  as  a means  of  producing 
local  anaesthesia,  by  freezing  the  part  to  which 
the  mixture  was  applied,  either  in  a hag  or  in  a 
metallic  spoon.  For  small  superficial  opera- 
tions this  method  of  anaesthesia  by  congela- 
tion answers  very  well.  The  part  becomes 
white  and  hardened  to  the  cut  of  the  surgeon's 
knife,  there  is  very  little  haemorrhage,  and  the 
wound  made  usually  heals  well  by  primary 
adhesion. 

More  recently,  Dr.  Richardson  has  indicated 
a very  convenient  way  of  inducing  local  anaes- 
thesia, by  the  volatilization  of  ether  in  the  form 
of  spray,  by  means  of  the  hand-ball  spray  atomi- 
zer. Ether  sprayed  on  the  bulb  of  a thermometer, 
held  about  an  inch  from  the  jet,  brought 
down  the  mercury  to  within  10°  Faltr.  of  zero. 
When  the  jet  was  turned  on  to  the  skin,  a 
marked  degree  of  local  anaesthesia  was  produced, 
but  not  enough  for  surgical  purposes.  By 
driving  over  the  ether  under  atmospheric  pres- 
sure, instead  of  trusting  simply  to  capillary 
action — or  to  suction,  as  in  Siegle's  apparatus — 
one  may  bring  the  thermometer  within  thirty 
seconds  to  4°  below  zero.  By  the  use  of  this 
apparatus,  at  any  season  or  temperature,  the 
surgeon  can  produce  cold  even  6°  below  zero: 
and  by  directing  the  spray  upon  a half-inch  test- 
tube  containing  water,  he  can  produce  a column 
of  ice  in  two  minutes.  For  local  anaesthesia  by 
cold,  the  ether  spray  anwers  well.  Such  opera 
tions  as  the  removal  of  small  tumours,  opening 
abscesses,  and  inserting  sutures,  may  be  pain- 
lessly performed.  J ohx  0.  Thobowgoou. 

COLIC  ( kuiXov , the  large  intestine). — Origin- 
ally colic  signified  a painful  affection  due  to  spasm 
of  the  bowel,  hut  though  still  retaining  this  ap- 
plication, it  has  now  come  to  be  further  associated 
with  other  complaints  which  are  attended  with 
severe  pain  of  a spasmodic  character,  a qualifying 
adjective  indicating  the  nature  and  seat  of  each 
particular  form.  Thus  renal  colic  is  applied  to 
the  group  of  symptoms  due  to  the  passage  of 
a stone  from  the  kidney  to  the  bladder  ; hepatic 
colic  to  those  accompanying  the  escape  of  a gall- 
stone. See  Colic,  Intestinal. 

COLIC,  INTESTINAL.  — Srxox. : Fr. 

Coliquc  ; Ger.  Die  Kolilc. 

Defixitiox. — Painful  and  irregular  contrac- 
tion of  the  muscular  fibres  of  the  intestines, 
without  fever. 

JEtiology. — Predisposing  causes. — These  in- 
clude the  nervous  (as  hysteria,  hypochondriasis), 
lymphatic,  and  bilious  temperaments ; sedentary 
occupations;  the  female  sex;  and  the  period  of 
youth  or  adult  age.  Exciting  causes. — These  may 
be  grouped  as  follows  : — 1.  Irritation  from  lodg- 
ment of  gas  due  to  fermentation  of  undigested 
food  and  decomposition  of  faeces  long  retained 
within  the  large  intestine;  from  faeces,  or  intes- 
tinal concretions,  undigested  or  partly  digested 
food,  such  as  pork,  shell-fish,  salt  meats,  unripe 
fruit  or  septic  game ; from  cold  drinks  or  ices  - 
from  excessive  or  morbid  secretions,  especially 
bile ; from  gall-stones : orfrom  worms — abundleof 


COLIC,  INTESTINAL, 
round  worms  or  coiled  up  tape-worms.  2.  Morbid 
6tates  of  the  bowel,  including  obstruction  from 
intussusception,  twisting,  strangulation,  &e. ; 
ulceration  (typhoid,  tubercular,  dysenteric) ; in- 
flammation (enteritis,  typhlitis,  &c.)  3.  Keflex 

nervous  disturbance,  due  to  anxiety,  fright,  anger, 
jr  other  emotional  disorder  ; to  disease  of  the 
ovaries  or  uterus;  to  calculus  (hepatic  or  renal); 
to  dentition  ; or  to  exposure,  especially  of  the 
feet  and  abdomen,  to  cold.  4.  Blood-poisoning,  as 
from  lead,  copper,  gout,  rheumatism. 

SniPTOMS.—  The  characteristic  or  essential 
symptom  of  intestinal  colic  is  pain  in  the  abdo- 
men, without  febrile  disturbance.  It  usually  be- 
gins, and  is  most  severe,  in  the  umbilical  region, 
then  spreads  to  other  parts,  or  to  the  whole 
abdomen,  and  is  apt  to  travel  from  one  part  to 
another.  It  is  almost  always  relieved  by  firm 
pressure  and  by  expulsion  of  flatus,  and  is  par- 
oxysmal in  character,  remitting,  or  exacerbating, 
)r  completely  subsiding  at  intervals.  The  suffer- 
ing is  usually  severe,  often  agonising,  and  to 
relieve  it  the  patient  bends  forwards,  pressing  the 
abdomen  firmly  with  his  hands  or  against  some 
lard  surface,  or  rolls  about.  As  a rule  the  ab- 
domen is  distended  by  flatus  ; in  lead-colic  it  is, 
however,  firmly  retracted  towards  the  spine,  and 
the  movements  of  the  inflated  intestines  affected 
by  spasmodic  contraction,  producing  loud  bor- 
borygmi,  may  frequently  be  seen  and  may  be 
felt  by  the  hand  applied  to  the  abdomen.  The 
muscles  of  the  abdominal  wall  and  the  bladder 
usually  participate  in  the  internal  spasm : the 
abdomen  becomes  rigid  or  knotted,  and.  the  recti 
muscles  become  contracted  into  round  balls, 
while  frequently  the  navel  is  retracted ; mictu- 
rition is  frequent  or  suppressed.  Usually  there 
is  constipation,  and  the  pain  disappears  when 
the  bowels  are  freely  relieved ; sometimes,  how- 
ever, it  persists  for  a time.  Constipation  stands 
in  a twofold  relation  to  colic,  either  as  cause 
or  effect  of  the  spasm. 

The  countenance  expresses  great  suffering, 
anxiety,  and  depression,  and  the  features  may  be 
pinched.  The  surface  of  the  body  is  cold,  es- 
pecially the  feet,  and  the  pale  skin  is  covered  by 
a cold  perspiration.  The  pulse  is  commonly  of 
normal  frequency,  or  is  infrequent  and  feeble. 

The  symptoms  vary  somewhat  with  the  cause. 
When  due  to  irritating  ingesta  the  prominent 
symptoms  are  vomiting  and  diarrhoea,  sometimes 
ending  in  catarrhal  dysentery.  In  children  the 
logs  are  drawn  up  upon  the  abdomen,  the  bowels 
are  often  at  first  confined,  and  the  evacuations 
greenish,  offensive,  and  very  acid,  afterwards 
becoming  loose. 

In  nervous  and  hypochondriacal  subjects,  and 
especially  females,  severe  pain  in  the  intestines, 
resembling  that  of  spasmodic  colic,  is  apt  to 
occur  (sec  Enteralgia).  Flatulence  plays  a 
varying  part  in  different  cases;  it  is  often  a 
prominent  symptom,  and  the  form  of  colic 
thus  characterised  has  been  termed  Colica  flatu- 
lenta. 

Vomiting  is  generally  in  proportion  to  the 
severeness  of  spasm,  and  the  degree  of  intestinal 
obstruction. 

Duration. — The  duration  of  the  attack  varies 
greatly,  from  a few  minutes  to  several  days.  The 
spasm  usually  ceases  abruptly,  leaving  a feeling  of 


COLLAPSE.  375 

soreness  in  the  abdomen,  while  there  is  enjoyable 
relief  from  suffering.  Colic,  when  violent  or 
intractable,  may  terminate  in  enteritis,  in  peri- 
tonitis, and,  especially  in  children,  in  intussuscep- 
tion. 

Diagnosis. — A pain  moving  from  place  to 
place,  relieved  by  firm  pressure  and  unattended 
by  fever,  separates  colic  from  other  affections, 
more  particularly  from  those  due  to  inflammation, 
in  which  pain  is  always  aggravated  by  pressure. 

Distension  with  spasm  of  the  stomach  may  bo 
distinguished  from  a similar  condition  of  the 
colon,  by  the  pain  occupying  a higher  position 
in  the  abdomen  (at  or  around  the  ensiform 
cartilage  instead  of — as  in  colic — the  umbilical 
or  hypochondriac  regions),  and  by  the  percus- 
sion note  elicited  being  deeper-toned  and  more 
prolonged  than  that  which  is  produced  by  a 
distended  colon ; besides  in  colic  the  spasmodic 
contraction  of  the  colon,  producing  borborygmi, 
maybe  traced  by  the  hand,  or  may  be  even  seen, 
and  there  is  tenesmus. 

It  should  be  borne  in  mind  that  enteritis  or 
peritonitis  may  follow  colic,  when  the  pulse, 
previously  unaltered,  may  become  frequent, 
hard  and  small,  or  frequent  and  soft,  and  the 
seat  of  inflammation  becomes  tender. 

Prognosis. — Colic  almost  always  ends  in  re- 
covery, preceded  by  free  evacuation  from  the 
bowels.  Unfavourable  signs  are  those  arising 
from  inflammation  or  intestinal  obstruction. 

Treatment. — In  the  first  place  the  setiologicai 
indications  should  be  met.  The  irritating  contents 
of  the  bowels  should  be  dislodged  by  purgatives 
combined  with  sedatives,  such  as  calomel  (five  or 
eight  grains)  or  rhubarb  (twenty  grains)  with 
opium  (one  grain),  followed  by  repeated  doses  of 
some  saline  aperient,  such  as  magnesi®  ve! 
potass®  sulph.,  with  tinct.  of  henbane  or  opium, 
and  spirits  of  chloroform,  until  free  action  of 
the  bowels  is  obtained. 

A suppository  containing  half  a grain  each  of  hy- 
drochlorate of  morphia  and  extract  of  belladonna, 
or  a subcutaneous  injection  of  morphia,  may 
secure  immediate  relieffrom  pain  before  aperients 
have  time  to  act.  Large  warm  enemaia  often 
relieve  quickly.  Other  suitable  measures  are — 
the  warm  bath,  friction  with  warm  oil  or 
stimulating  liniments,  hot-water  fomentations, 
steamed  flannels,  mustard  or  turpentine  stupes, 
flannel  bags  containing  hot  chamomile  flowers 
or  heated  sand,  the  stomach- warmer  filled  with 
hot  water,  large  linseed  and  mustard  poultice. 
The  diet  should  be  liquid. 

In  the  prophylactic  treatment  the  diet  should 
be  strictly  regulated,  lodgment  of  irritating  solids 
and  gases  within  the  bowels  should  be  pre- 
vented (see  Constipation  ; E.eces,  Retention  of ; 
and  Flatulence),  and  the  abdomen  and  feet 
should  be  kept  warm  by  a flannel  roller  or  belt 
and  thick  woollen  stockings.  George  Oliver. 

COLLAPSE. — Definition. — Collapse  is  a 
state  of  nervous  prostration.  When  it  is  ex- 
treme, the  vital  functions  are  in  a condition  of 
partial,  and  sometimes  nearly  complete,  abeyance. 
It  may  terminate  in  death,  or  be  followed  by 
gradual  reaction  and  complete  recovery. 

Collapse  and  shock  have  usually  been  classed 
together,  but  it  is  not  accurate  to  do  sc.  If  is 


276  COLLAPSE. 

;rue  that  the  ganglionic  centres  of  the  medulla 
oblongata  are  more  or  less  profoundly  involved 
in  both,  and  that  both  possess  many  symptoms 
in  common,  dependent  upon  the  derangement 
of  function  of  one  or  more  of  these  centres. 
Some  confusion  is  attributable  to  the  fact  that 
shock  is  a term  applied  not  only  to  a state  or 
morbid  condition,  but  to  the  cause  which  most 
frequently  produces  that  condition — a violent 
impression  or  ‘ shock  ’ to  the  nervous  centres. 
See  Shock.  Collapse  arises  from  many  different 
causes,  shock  being  one,  of  which  collapse  may 
be  regarded  as  a final  and  extreme  degree,  and 
into  which  it  often  imperceptibly  passes.  Col- 
lapse, on  the  other  hand,  may  occur  under  con- 
ditions where  there  has  been  no  antecedent 
state  of  shock.  Collapse  presupposes  previous 
nervous  exhaustion,  while  shock  may  instantly 
appear  in  a healthy  individual. 

^Etiology. — Any  severe  injury,  especially  if 
attended  by  profuse  and  sudden  haemorrhage, 
may  terminate  in  collapse,  such,  for  instance,  as 
the  rupture  of  one  of  the  abdominal  viscera,  a 
penetrating  wound  of  the  chest  or  abdomen,  or 
a wound  of  the  heart  or  of  a large  artery.  Ex- 
tensive burns  or  scalds  frequently  give  rise  to 
typical  collapse ; and  severe  and  prolonged  pain 
is  capable  of  causing  it.  Rupture  of  the  heart 
or  of  an  internal  aneurism,  if  the  patient  do  not 
immediately  die,  causes  extreme  collapse.  Cer- 
tain poisons,  as  tobacco  and  arsenic,  will  also 
produce  this  condition.  It  is.  the  terminal  stage 
of  some  diseases,  as,  for  instance,  of  Asiatic 
cholera;  severe  drastic  purgation  also,  or  pro- 
longed vomiting,  from  wnatever  cause,  may  occa- 
sion it.  The  pernicious  malarious  fevers  and 
yellow  fever  often  end  in  collapse.  In  the  acute 
yellow  atrophy  of  the  liver  symptoms  of  severe 
nervous  disturbance,  resulting  in  a species  of  col- 
lapse, sometimes  suddenly  supervene.  Pyaemia, 
septicaemia,  prolonged  narcosis,  frequently  ter- 
minate in  collapse. 

Symptoms. — The  severity  of  collapse  depends 
on  the  nature  of  the  cause- and  the  physical  and 
mental  vigour  of  the  individual.  It  may  vary  from 
a moderate  to  an  extreme  degree.  A moderate 
amount  is  seen  in  the  course  of  fever  and  some 
other  diseases,  but  this  neither  modifies  the 
progress  of  the  malady  nor  attracts  the  notice  of 
the  patient,  causing  chiefly  peripheral  coldness. 
From  this  trifling  amount  collapse  may  pass  to 
the  most  intense  form,  where  the  patient  scarcely 
differs  in  outward  semblance  from  a dead  body. 
A superficial  inspection  will  fail  to  detect  the 
existence  of  the  functions  of  respiration  and  cir- 
culation. Vitality  may  be  said  to  have  reached 
its  minimum.  In  well-marked  collapse  from  severe 
injury  or  loss  of  blood  the  pulse  at  the  wrist  may 
bo  almost  or  wholly  imperceptible,  the  heart's 
action  scarcely  audible,  very  rapid,  fluttering, 
and  irregular ; the  surface  of  the  body,  the  face 
especially,  is  deadly  pale  and  cold,  and  the 
skin  moist  with  clammy  sweat ; the  respiration 
is  very  feeble,  slow,  and  irregular,  accompanied 
by  sighing  or  gasping  inspirations  at  intervals  ; 
the  expression  and  character  of  the  face  are  lost; 
the  features  are  sunken  and  relaxed;  the  eye  is 
dull,  glassy,  staring,  or  languidly  rolling  about, 
and  the  conjunctiva  perhaps  insensible  to  the 
touch ; the  nostrils  are  dilated ; the  sensibility 


COLON,  DISEASES  OF. 
of  the  whole  body  is  diminished ; and  the  mus- 
cular debility  is  extreme.  The  patient  lies  on  his 
back,  without  a trace  of  voluntary  effort.  If  a limb 
is  lifted  it  falls  back  again  as  if  dead.  Yet  the 
consciousness  and  senses  may  be  almost  un- 
impaired ; if  roused  by  repeated  questions  the 
sufferer  will  with  visible  effort  make  a coherent 
though,  probably,  inadequate  reply. 

If  relief  be  not  given,  the  respiration  may 
become  slower  and  slower  till  each  one  appears 
the  last,  when  a sudden  sigh  shows  that  life  is 
still  present;  finally,  the  pulse  and  heart's  ac- 
tion become  more  and  more  faint,  and  death 
results  from  pure  asthenia.  A condition  closely 
resembling  traumatic  collapse  is  often  wit- 
nessed in  the  last  stage  of  cholera,  when  in 
an  extreme  degree  the  patient  almost  resembles 
a corpse  save  for  the  convulsive  motions  induced 
from  time  to  time  by  the  painful  cramps.  The 
surface  is  pale  or  bluish,  covered  with  profuse 
sweat,  but  is  at  the  same  time  cold  to  the  touch. 
The  hands  and  extremities  are  icy  cold,  the 
tongue  is  cold,  and  so  also  is  the  breath,  which 
is  gasping  and  paroxysmal ; no  pulse  can  be  felt 
at  the  wrist;  the  eyes  and  features  are  sunken  : 
the  mind  is  apathetic,  but  nevertheless  the  con- 
sciousness may  be  perfect,  and  the  patient  able 
to  respond  to  questions  with  a strong  voice. 
Severe  purging  and  tobacco-poisoning  produce 
a condition  extremely  like  that  described  as 
traumatic  collapse. 

Some  cases  of  malignant  fever  terminate  in 
collapse,  which  is  characterised  by  extreme 
anxiety,  pallor  or  lividity  of  the  face  and  surface, 
coldness  of  the  skin,  sweating,  and  a small, 
frequent,  and  irregular  pulse. 

A decrease  of  animal  heat,  especially  in  the 
external  parts,  is  characteristic  of  collapse.  The 
temperature  of  the  internal  organs  varies;  and 
there  may  be  collapse  with  high  internal  tem- 
perature. This  occurs  in  cholera,  intense  fevers, 
and  some  forms  of  septicaemia;  or  the  converse 
may  obtain,  as  is  frequently  witnessed  in  the 
collapse  of  dissolution.  Collapse  from  loss  of 
blood  differs  from  syncope,  although  the  latter 
may  be  described  as  an  acute  and  transient  form 
of  collapse.  In  syncope  the  prominent  symptom 
is  loss  of  consciousness,  which  in  collapse  may 
be  almost  or  quite  perfect. 

For  the  pathology  and  treatment  of  col- 
lapse see  Shock.  William  MacCormac. 

COLLAPSE,  Pulmonary. — A condition  in 
which  the  lung  is  simply  more  or  less  devoid 
of  air.  See  Lung,  Collapse  of. 

COLLIQUATIVE  ( colliquco , I melt). — 
A term  which  originated  in  the  belief  that  in  cer- 
tain conditions  the  solid  parts  melted  away,  and 
were  carried  off  as  liquid  discharges.  The  word 
is  now  generally  applied  to  the  copious  sweats 
and  diarrhoea  which  occur  in  certain  wasting 
diseases,  such  as  phthisis. 

COLLOID  (k6\\u,  glue,  and  e75os,  like). — 
A peculiar  morbid  product  resembling  in  its 
characters  glue  or  jelly,  and  found  associated 
with  cancer  and  other  forms  of  new-growth. 
See  Cancer  and  Degeneration. 

COLON1,  Diseases  of. — The  colon  partici- 
pates to  a varying  extent  in  the  lesions  aud 


COLON,  DISEASES  OF, 
derangements  of  dysentery,  typhoid  fever,  ente- 
ritis, peritonitis,  and  other  affections.  The  special 
disorders  to  -which  it  is  most  liable  are  inti- 
mately connected  -with  its  anatomical  and  phy- 
siological peculiarities.  The  colon  is  a distensible 
membranous  tube,  of  large  capacity,  with  chiefly 
solid  contents,  which  are  propelled  slowly  on- 
wards by  the  muscular  contractions  of  the  walls. 
The  moving  force  and  the  resistance  offered  to  it 
are  often  too  finely  balanced,  so  that  whenever 
the  energy  of  the  former  is  somewhat  reduced,  an 
accumulation  of  excretory  products  is  apt  to  be 
determined.  Hence  arise  retention  of  faeces  and 
gases,  constipation  and  consecutive  evils,  such 
as  colic,  colo-enteritis,  or  ulceration  of  the  colon. 

I.  Atony. — Definition.  — Loss  of  contrac- 
tility of  the  walls  of  the  colon,  leading  to  accu- 
mulations and  other  sequelae. 

./Etiology. — The  causes  of  torpor  or  atony 
of  the  colon  are  mainly  those  of  constipation — 
sedentariness,  indolent  and  luxurious  habits,  a 
sluggish  and  lymphatic  temperament,  old  age, 
and  general  debility  or  exhaustion,  as  after  a 
long  and  tedious  illness.  Whenever  the  wall3 
of  the  colon  are  distended  by  solid  or  gaseous 
accumulations,  the  contractile  power  is  apt  to  be 
enfeebled,  leading  to  further  retention  and  loss 
of  tone. 

Atony  of  the  colon  is  an  essential  element  in 
the  patliogeny  of  constipation  not  depending  on 
mechanical  obstruction.  Tympanitic  distension 
of  the  colon  from  paralysis  of  the  sympathetic 
nerve  occurs  in  peritonitis  and  in  fevers,  c.g. 
typhus  fever. 

Symptoms. — Torpor  of  the  colon  may  be  indi- 
cated only  by  constipation.  There  are  usually 
the  ordinary  signs  of  retention  of  flatus  or  faeces. 
In  hysteria,  and  in  inflammation  of  the  bowels 
or  peritoneum,  flatus  is  apt  to  accumulate  rapidly, 
ind  to  produce  great  distension  of  the  colon. 
Faeces  may  collect  and  form  large  tumours  in 
any  part  of  the  large  intestines,  but  especially 
in  the  caecum  and  sigmoid  flexure. 

Faecal  and  gaseous  accumulations  in  the  colon 
resulting  from  atony  may  produce  the  follow- 
ing effects,  directly  or  remotely  connected  with 
them: — 

(«.)  Local, — 1,  Colic.  2,  Inflammation  of  the 
walls  of  the  colon,  or  of  the  mucous  and  sub- 
mucous coats,  and  ulceration.  3,  Disturbances 
from  pressure:  thus  flatulent  distension,  and  large 
faecal  accumulation  encroaching  on  the  cavity 
of  the  thorax  and  impeding  the  descent  of  the 
diaphragm,  may  cause  dyspnoea  or  short  and  rapid 
respiration,  palpitation  aud  irregular  action  of 
the  heart,  with  remote  effects  arising  from  a dis- 
turbed circulation  in  the  brain,  such  as  giddiness 
and  headache;  a distended  esenrn  or  sigmoid 
flexure  pressing  on  veins  and  nerves  may  induce 
oedema,  numbness,  and  cramps  of  the  right  or 
left  lower  extremity.  4,  Retarded  digestion,  de- 
rangement of  the  stomach  and  liver,  and  intes- 
tinal obstruction. 

(A)  General. — The  absorption  of  excremen- 
titious  matter  is  said  to  lead  to  wide-spread 
general  effects,  such  as  a sallow,  earthy,  or  dirty 
complexion,  lassitude,  debility,  offensive  breath, 
loaded  urine,  &c. 

1 keatment. — Atony  of  the  colon  is  usually  a 
euronic  disorder  demanding  prolonged  treatment. 


COLON,  DISEASES  OF.  277 

The  hygienic  and  dietetic  rules  laid  down  in  the 
article  Constipation  require  in  most  cases  to  be 
supplemented  by  medicines.  The  most  satisfac- 
tory results  follow  a course  of  tonics,  combined 
with  aperients,  such  as  iron,  quinine,  strychnia, 
belladonna,  with  aloes,  colocynth,  or  rhubarb. 

The  purgative  should  be  adjusted  to  each 
case,  so  as  to  secure  no  more  and  no  less  than  a 
regular  and  efficient  evacuation  ; and  while  the 
loaded  colon  continues  to  be  thus  relieved,  the 
dose  should  be  very  gradually  reduced. 

This  tonic-aperient  course  may  be  greatly 
aided  by  local  stimulation  of  the  colon,  as  by  fric- 
tion, kneading,  electricity,  cold-water  compresses, 
or  douches.  The  abdomen  should  be  supported 
by  a belt  or  roller.  Bretonneau  and  Trousseau 
strongly  advised  a course  of  belladonna,  giving 
gr.  y of  the  extract  or  of  the  powdered  leaf  as  a 
pill  in  the  early  morning, — the  stomach  being 
empty, — then  two  such  pills  if  in  four  or  five  days 
the  bowels  do  not  respond,  and  increasing  the 
dose,  but  not  beyond  that  contained  in  four  or 
five  pills,  in  twenty-four  hours.  A teaspoonful 
of  castor  oil  may  be  given  twice  a week  to  aid 
this  course  of  treatment.  Flatulent  distension 
of  the  colon  in  the  elderly  and  in  females  at  the 
climacteric  period  is  often  greatly  relieved  by 
the  prolonged  use  of  a pill  containing  compound 
assafoetida  pill  and  nux  vomica  after  meals.  Elec- 
tricity is  sometimes  used  with  benefit. 

Tympanitic  distension  of  the  colon  in  perito- 
nitis and  in  fevers  is  best  treated  by  free  doses 
of  opium. 

II.  Inflammation. — Synon.:  Colitis,  colonitis, 
colo-enteritis ; Fr.  oolite ; Ger.  Kntzundung  des 
Schleimhautcs  des  Kolons. 

An  inflammation  with  ulceration  of  the  mucous 
membrane  and  submucous  connective  tissue  of  the 
colon,  producing  lesions  undistinguiskable  from 
those  of  dysentery,  has  been  pointed  out  by 
Copland  and.  Parkes.  Colitis  is  said  to  be  a non- 
specific local  affection,  commencing  in  the  sub- 
mucous tissue,  and  subsequently  attacking  the 
mucous  membrane  with  its  glandular  structures — 
the  primary  seat  of  dysenteric  inflammation.  As 
in  dysentery  the  inflammation  induces  gangre- 
nous destruction  and  ulceration  of  the  mucous 
membrane  and  underlying  cellular  tissue. 

A catarrhal  form  of  colitis  is  apt  to  occur  in 
measles.  1 It  often  happens  that  the  morbillous 
catarrh  of  the  intestines  exhausts  itself  by 
attacking  the  large  intestine,  producing  that 
special  form  of  colitis  characterised  by  tenesmus 
and  glairy  bloody  stools.’  1 Inflammatory  diar- 
rhoea, particularly  in  children,  often  terminates 
similarly. 

Colitis  arising  from  retained  excreta  may  in- 
volve the  entire  wall  of  a circumscribed  portion 
of  the  colon,  commonly  the  ascending  colon  and 
sigmoid  flexure,  or  may  be  confined  to  the  mucous 
and  submucous  tissues.  In  inflammation  of  the 
ccecum  (typhlitis)  the  walls  of  the  ascending 
colon  are  more  or  less  implicated.  In  fsecal 
retention  the  mucous  follicles  of  the  colon  may 
become  obstructed,  and  the  distension  resulting 
therefrom  may  lead  to  inflammation  and  ulcera- 
tion. Irritation  of  the  mucous  lining  of  the 
colon  from  the  lodgment  of  faeces  may  extend 
to  the  lymphatic  vessels  and  glands.  The  glan- 
1 Trousseau,  Clinique  Medical*, 


178  COLON,  DISEASES  OF. 
dular  enlargement  cannot,  however,  usually  bo 
recognised  during  life.  While  the  symptoms  of 
tabes  mesenterica  may  be  traced  to  enlargement 
and  obstruction  of  the  mesenteric  glands,  set  up 
by  irritation  of  the  intestinal  tract,  it  is  doubtful 
whether  such  results  can  follow  a similar  cause 
limited  to  the  colon  only. 

Treatment. — The  treatment  of  colitis  consists 
in  the  local  application  of  fomentations,  poultices, 
opium  enemata,  or  morphia  suppositories  ; and  in 
the  use  of  gentle  laxatives,  such  as  castor  oil, 
combined  with  sedatives,  such  as  opium  or  hen- 
bane. The  catarrhal  form  generally  terminates 
in  spontaneous  recovery.  Trousseau  advises  the 
use  of  albuminous  injections,  or  of  injections  con- 
taining about  half  an  ounce  of  water  and  nitrate 
of  silver — from  f to  1J  grains, — or  sulphate  of 
copper  or  sulphate  of  zinc — from  3)  to  grains. 

III.  Displacements. — The  parts  of  the  colon 
most  liable  to  displacement  are  the  transverse 
colon  and  sigmoid  flexure — the  former  may  de- 
scend as  low  as  the  pubes,  and  the  latter  may 
cccupy  any  position  between  the  left  iliac  region 
and  the  right  side  of  the  abdomen.  Usually 
the  meso-eolon  is  elongated ; there  is  adhesion 
between  the  displaced  part  and  the  new  site; 
and,  the  longitudinal  bands  being  elongated,  the 
loculi  are  obliterated.  Displacements  are  most 
apt  to  occur  in  those  who  have  long  suffered 
from  constipation,  retention  of  faeces,  chronic 
dysentery,  hernia,  or  from  encysted  or  other 
tumours.  They  may  lead  to  complete  obstruc- 
tion, and  cannot  usually  be  recognised  with  cer- 
tainty during  life. 

IV.  Diverticula. — A loculus  of  the  colon  from 

repeated  accumulation  may  become  so  distended 
as  to  form  a lateral  appendix.  Such  a diverti- 
culum when  loaded  with  faeces  may  he  felt 
through  the  abdominal  wall  as  a distinct  tumour, 
which  may  collapse  when  pressed  between  the 
fi  ngers.  George  Oliver. 

COLOUR- BLIND  NESS.  — A defect  of 
vision,  the  subject  of  which  is  unable  to  distin- 
guish certain  colours.  Sec  Vision,  Disorders  of. 

COMA  deep  sleep). — A condition  of 

profound  insensibility.  See  Consciousness,  Dis- 
orders of. 

COMA-VIGIL  ( Ku/j.a , insensibility,  and 
vigil,  wakeful). 

Definition. — A symptom,  or  set  of  symptoms, 
where  continuous  sleeplessness  is  associated  with 
partial  unconsciousness. 

Coma-vigil  occurs  towards  the  end  of  diseases 
in  which  the  nervous  system  is  involved  either 
directly  or  indirectly,  especially  where  sleep- 
lessness has  been  a sympttom  in  the  earlier  part 
of  the  disease.  Thus  it  frequently  appears  towards 
the  end  of  an  attack  of  typhus  or  of  delirium  tre- 
mens, when  these  are  about  to  terminate  fatally. 

Symptoms. — The  patient  lies  quiet  with  his 
eyes  half-closed, inattentive  to  everything  around, 
but  not  absolutely  unconscious.  If  the  eyelids 
are  touched,  they  are  closed,  and  perhaps  the 
head  is  slowly  turned  away.  The  eyes  have  a 
dull,  half-glazed  look,  and  slowly  follow  any 
moving  object  near  them.  The  pupils  are 
neither  much  dilated  nor  contracted,  and  they 


COMEDONES. 

move  under  the  influence  of  light,  but  very  slug 
gishly.  The  mouth  is  generally  somewhat  open 
and  dry,  as  are  also  the  lips.  The  power  of 
swallowing  is  much  impaired  ; if  a small  quan- 
tity of  fluid  be  put  into  the  mouth,  an  effort  is 
mad6  after  a short  time  to  swallow  it,  and  this 
effort  is  for  a time  successful;  but  after  the 
symptoms  have  been  present  for  some  time,  the 
effort  is  so  feeble  that  no  result  follows.  The 
patient  lies  mostly  on  the  back:  if  turned  on 
the  side,  he  either  remains  as  placed,  or  often 
slowly  turns  to  the  former  position  on  the  hack. 
The  limbs  are  occasionally  moved  a little,  and  ii 
the  hand  or  arm  be  raised,  a slight  resistance  is 
offered.  If  the  bladder  or  the  rectum  be  emptied, 
there  is  slight  consciousness  of  the  act,  as  if  a 
feeling  of  discomfort  preceded  it.  The  pulse  is 
quick  and  weak.  The  respiration  is  weak,  but 
otherwise  normal.  The  symptoms  continue 
unbroken  throughout,  nothing  like  natural  sleep 
occurring. 

Diagnosis.— Coma-vigil  is  distinguished  from, 
coma  by  the  presence  of  a certain  amount  of 
consciousness,  by  the  quick  pulse,  and  by  the 
absence  of  stertorous  breathing.  It  is  distin- 
guished from  concussion  of  the  brain  by  the  pupil 
not  being  contracted,  by  the  history  of  the  case, 
and  by  the  absence  of  coldness  of  the  skin,  and 
of  any  sign  of  shock. 

Prognosis, — The  prognosis  is  unfavourable; 
coma-vigil  is  almost  invariably  a fatal  symptom. 
It  may  last  from  a few  hours  to  three  or  four 
days ; from  twenty-four  to  forty-eight  hours 
being  the  most  common  duration.  It  may  deepen 
into  actual  coma;  hut  more  usually  the  symp- 
toms change  but  little,  save  that  the  pulse  be- 
comes quicker  and  weaker,  and  the  respiration 
more  feeble,  and  death  by  asthenia  then  results. 

Pathology. — As  being  little  but  a symptom, 
coma-vigil  has  strictly  speaking  no  pathology. 
It  seems  to  coincide  with  the  gradual  suspension 
through  exhaustion  of  the  functions  of  the  ner- 
vous centres ; the  cerebral  hemispheres  being 
nearly  if  not  quite  inactive,  while  the  action  of 
the  rest  of  the  centres  is  kept  up  weakly  hut 
continuously,  till  the  little  remaining  nervous 
power  is  exhausted,  when  death  ensues.  It 
differs  from  coma,  inasmuch  as  in  the  latter,  the 
medulla  oblongata  is  the  only  centre  left  active, the 
functions  of  the  rest  being  entirely  suspended.  It 
differs  from  concussion,  inasmuch  as  the  symp- 
toms attending  the  temporary  unconsciousness  of 
the  latter  are  more  those  of  irritation  than  of 
pure  suspension  of  function.  E.  Beveridge. 

COMEDONES  ( comedo , I consume). — 
Stnon.  : Grubs.  — This  is  the  name  applied 
to  the  little  cylinders  of  sebaceous  and  epi- 
thelial substance  which  are  apt  to  accumulate 
in  the  follicles  of  the  skin,  and  to  appear  on 
the  surface  as  small  round  black  spots.  When 
squeezed  out  they  have  the  appearance  of 
minut  e maggots  or  grubs  with  black  heads,  and 
thence  have  derived  their  name.  They  may 
occur  in  all  parts  of  the  body  where  sebaceous 
follicles  exist,  but  are  most  common  on  the  face, 
the  nose,  the  neck  and  shoulders,  the  breast,  and 
within  the  concha  of  the  ears,  in  the  latter  situa- 
tion often  attaining  a considerable  size.  The 
accumulation  of  this  substance  is  due  to  want  cl 


COMEDONES. 

expulsory  power  of  the  skin,  and  to  the  slight 
.impediment  which  is  afforded  by  the  aperture  of 
the  follicle  to  its  exit ; and  when  squeezed  out  it 
is  found  to  vary  in  colour,  in  figure,  and  in  den- 
sity, according  to  the  period  of  its  detention. 
When  recent,  the  comedones  are  soft  and  white, 
and  modelled  into  an  exact  cylinder  by  compres- 
sion through  the  mouth  of  the  follicle;  when 
impacted  for  a considerable  time  they  acquire 
the  yellow  tint,  the  transparency  and  hardness 
of  horn  ; and  assume  a bulbous  figure  from  the 
dilatation  of  the  follicle  below  the  constricted 
orifice  of  the  epidermis  ; and  by  their  bulk  they 
sometimes  stretch  the  hair-follicle  so  far  as  to 
obliterate  it  completely.  Besides  their  usual 
composition  of  sebaceous  substance  and  epithelial 
cells,  they  frequently  contain  lanuginous  hairs, 
end  not  rarely  the  entozoon  folliculorum  in  its 
different  phases  of  development.  When  they 
raise  the  pore  into  a minute  pimple  they  have 
a similitude  to  acne  punctata,  and  might  be  mis- 
taken for  that  affection  ; whilst  the  black  spot 
on  the  summit  of  conical  acne  is  due  to  a comedo. 

Treatment. — Comedones  are  generally  asso- 
ciated with  a weak  state  of  the  skin  as  well  as 
of  the  individual ; they  are  most  frequently  met 
with  in  young  persons  in  whom  the  powers  of 
the  constitution  are  not  yet  established,  and  will 
be  benefited  by  generous  diet  and  tonic  treat- 
ment. Locally,  soap  and  water  with  plentiful 
friction  and  ablution  will  be  fotmd  of  great 
service;  and,  as  an  astringent  to  invigorate  a 
debilitated  skin,  a lotion  of  perchloride  of  mer- 
cury, in  emulsion  of  bitter  almonds  (two  grains  to 
an  ounce)  and  spirits  of  wine. 

Erasmus  Wilson. 

COMPLICATION'  {con,  with,  and  plico, 
I fold). — It  is  difficult  to  give  a strict  definition 
of  what  ought  to  be  included  under  the  term 
complication , but  the  word  signifies  the  occur- 
rence during  the  course  of  a disease  of  some 
other  affection,  or  of  some  symptom  or  group  of 
symptoms  not  usually  observed,  by  which  its 
progress  is  therefore  complicated,  and  not  un- 
commonly more  or  less  seriously  modified. 
The  difficulty  lies  in  determining  what  should 
be  looked  upon  as  essentially  part  of  the  original 
disease,  and  what  as  a mere  accidental  occur- 
rence. For  instance,  many  regard  the  cardiac 
affections  which  so  often  arise  during  the  pro- 
gress of  acute  rheumatism  as  a part  of  the 
complaint,  others  as  complications.  The  same 
remark  applies  to  the  relationship  of  renal  dis- 
ease to  scarlatina,  as  well  as  to  numerous  other 
cases. 

Complications  arise  in  different  ways.  They 
may,  as  just  indicated,  be  considered  as  develop- 
ments of  the  original  morbid  condition,  resulting 
from  the  same  cause  and  being  more  or  less 
allied ; or  they  are  independent  and  accidental, 
of  which  an  illustration  is  to  be  found  in  the 
association  of  ague  with  scurvy  or  dysentery, 
or  in  the  co-existence  of  two  or  more  of  the 
exanthemata.  The  most  important  class  of 
complications,  however,  are  those  which  follow 
the  primary  disease  as  more  or  less  direct 
consequences.  These  may  further  be  induced 
in  various  ways.  Thus,  for  example,  in  febrile 
diseases  secondary  lesions  are  liable  to  arise  as 


CONCRETION.  276 

a result  of  changes  in  the  blood ; a mechamral 
act,  such  as  cough,  may  lead  to  complications  in 
the  course  of  phthisis  and  other  pulmonary 
affections;  cardiac  diseases  frequently  bring 
about  consecutive  changes  in  other  organs, 
by  inducing  obstruction  of  the  venous  circulation, 
or  emboli  may  originate  under  certain  conditions 
and  produce  their  usual  consequences.  It  i3  of 
great  practical  importance  to  be  acquainted 
with  the  complications  which  are  liable  to  b? 
met  with  in  the  various  diseases,  and  especially 
in  those  which  are  of  an  acute  nature,  in  order- 
that  measures  may  be  taken  to  prevent  them, 
and  that  they  may  be  recognized  and  treated  at 
the  earliest  possible  period,  if  they  should  occur 
Ebedebick  T.  Roberts. 

COMPOUND  GRANULAR  CORPUS. 
CLES.  — Formerly  these  microscopic  objects 
were  regarded  as  of  inflammatory  origin,  and  as 
affording  positive  evidence  of  the  occurrence  of 
inflammation.  Hence  they  were  termed  ‘ com- 
pound inflammation  globules  ’ (Gluge.)  Almost 
all  pathologists  now,  however,  recognize  the  fact 
that  they  are  not  products  of  an  inflammatory 
process,  but  result  either  from  the  degenera- 
tion of  pre-existing  cells,  in  which  protein  and 
fatty  granules  accumulate,  or,  perhaps,  from  the 
aggregation  of  granules  originally  distinct,  which 
are  present  in  abundance  in  degenerating  tissues. 
They  may  even  be  formed  out  of  the  cells  of 
morbid  products,  such  as  cancer.  These  com- 
pound granular  corpuscles  derive  their  name  from 
the  fact  that  they  consist  of  a large  number  of 
minute  granules  aggregated  together,  and  they 
either  present  a delicate  cell-wall,  or  this  cannot 
be  detected.  Occasionally  there  is  an  appearance 
of  a nucleus  in  the  centre. 

Frederick  T.  Roberts., 

COMPRESS. — Folds  of  lint  or  other  mate- 
rial, which  are  used  for  the  purpose  of  producing 
pressure,  or  as  a pad  by  which  hot  or  cold 
water  or  medicinal  agents  may  be  applied  tc  the 
surface.  In  the  latter  case  the  compress  may  be 
rendered  waterproof  by  being  covered  by  a piece 
of  gutta-percha  tissue  or  mackintosh-cloth.  See 
Hydropathy. 

COMPRESSIBLE. — A term  implying  com- 
paratively slight  resistance,  and  applied  specially 
to  the  pulse  when  it  yields  readily  under  the 
finger.  See  Pulse,  The. 

COMPRESSION  of  Brain.  See  Brain, 
Compression  of. 

COMPRESSION  of  Lung.  See  Lung, 

Compression  of. 

CONCRETION  (con,  together,  and  cresco,  I 
grow). — Synon.  : Calculus  ; Fr.  Concretion,  Cal- 
cul ; Ger.  Concrement. 

Definition. — An  unorganised  body,  formed 
either  in  one  of  the  natural  cavities  or  canals,  or 
in  the  substance  of  an  organ,  by  the  deposit  of 
certain  solid  constituents  of  the  fluids  of  the 
part.  In  the  widest  sense  of  the  term,  Concro- 
tions  comprehend  Calculi. 

Enumeration  and  Classification. — The  fol- 
lowing classified  list  includes  the  principal 
varieties  of  concretions ; — 

1.  In  glandular  structures',  lachrymal,  soli 


280  CONCRETION. 

vary,  pancreatic,  prostatic,  seminal,  urinary, 
hepatic,  sebaceous,  and  mammary. 

2.  In  the  circulatory  system  : cardiac,  and 
venous  ( phleboliths ). 

3.  In  closed  sacs  : peritoneal,  and  articular. 

4.  In  culs-dc-sac  : bronchial,  pulmonary,  nasal, 
tonsillar,  laryngeal,  gastric,  intestinal,  praeputial, 
uterine,  and  vaginal. 

5.  In  the  substance  of  tissues  and  new  forma- 
tions, especially  in  the  nervous  system — Cor- 
pora amylacea. 

6.  Various,  such  as  the  concretions  on  the 
teeth  known  as  tartar. 

General  Characters  and  Number. — Con- 
cretions are  generally  firm  or  even  of  stony 
hardness  ; but  they  may  be  soft  and  friable. 
Their  colour  varies  from  white  to  black  through 
shades  of  yellow  and  red.  Concretions  occur 
either  singly  or  in  groups  ; and  their  shape  and 
size,  as  well  as  the  character  of  their  surface, 
vary  considerably  with  their  number ; single  con- 
cretions being  more  frequently  rounded,  larger, 
and  less  smooth  than  multiple  specimens,  which 
often  present  facets  and  polished  surfaces. 
Many  concretions  are  composed  of  concentric 
laminae. 

Composition. — The  chief  constituents  of  con- 
cretions are  inorganic,  that  is,  mineral  salts,  in  a 
basis  of  organic  matter.  The  bulk  of  the  salts 
are  carbonate  and  phosphate  of  lime  and  mag- 
nesia, with  smaller  quantities  of  alkaline  com- 
pounds. The  organic  basis  is  composed  of 
albuminous  substances,  mucus,  cholesterin,  and 
colouring  matters. 

Mode  of  Formation. — Concretions  are  gene- 
rally derived  from  the  solid  constituents  of  vital 
fluids,  whether  physiological  or  pathological.  In 
most  instances  the  fluids  are  delayed  in  the 
natural  passages  by  some  abnormal  obstruction 
or  dilatation ; and  under  such  circumstances  a 
chronic  inflammatory  condition  of  the  walls  con- 
tributes greatly  to  the  probability  of  mineral 
deposit.  Most  frequently — as  in  the  formation  of 
the  salivary  and  biliary  concretions — the  fluid 
portions  of  the  secretion  escape  by  the  natural 
outlet  or  are  absorbed,  while  the  solid  constitu- 
ents are  deposited ; the  particles  being  either 
agglomerated  around  a nucleus,  or  deposited  in 
centripetal  layers  upon  the  surface  of  the  cavity. 
In  other  instances — intracardiac,  peritoneal,  and 
articular,  a nucleus  is  furnished  by  a portion 
of  fibrin,  blood-clot,  or  growth,  on  which  fresh 
deposits  take  place,  while  calcification  proceeds 
in  the  interior.  In  a third  series,  examples  of 
which  are  found  in  the  alimentary  canal,  the 
basis  of  the  concretion  consists  of  foreign  or 
indigestible  matter,  such  as  hair,  inspissated 
fasces,  and  masses  of  magnesia. 

Effects  and  Symptoms. — The  functions  of  a 
part  occupied  by  a concretion  are  generally  more 
or  less  impaired ; the  neighbouring  tissues  fre- 
quently atrophy ; and  inflammation  and  ulceration 
are  common  results,  ending  probably  in  the  escape 
of  the  body.  The  concretion  may  be  passed 
along  a duct,  and  this  process  is  generally 
attended  with  great  pain ; but  concretions  may 
remain  where  formed  without  causing  symptoms. 
Occasionally  they  are  spontaneously  disintegrated 
or  dissolved. 

Treatment. — The  treatment  of  concretions  will 


CONGENITAL. 

be  found  discussed  under  the  heads  of  the  diseases 
of  the  organs  where  they  respectively  occur. 

J.  Mitchell  Bruce. 

CONCUSSION  ( concutio , I shake  together). 
This  term  is  used  to  indicate  a condition  induced 
by  a more  or  less  violent  shaking  or  physical 
commotion  of  the  general  system,  or  of  somo 
particular  organ,  whereby  serious  symptoms  may 
be  induced,  but  no  definite  lesion  can  be  detected 
to  account  for  them.  The  nerve-centres  are  the 
parts  most  liable  to  be  thus  affected,  concussion 
of  the  brain  or  spinal  cord  being  of  considerable 
moment,  giving  rise  to  more  or  loss  complete 
abolition  of  their  functions,  though  this  effect 
is  usually  only  temporary.  See  Brain,  and 
Spinal  Cord,  Concussion  of.  General  con- 
cussion of  the  body  is  highly  important  at  the 
present  day,  in  connexion  with  railway  acci- 
dents, after  w'hich  persons  seem  to  be  uninjured, 
or  only  to  be  slightly  shaken,  but  subsequently 
grave  symptoms,  associated  with  the  nervous 
system,  set  in.  See  Railway  Accidents,  Results 
of.  Frederick  T.  Roberts. 

CONCUSSION  OF  BRAIN,  SPINE. 

&c.  See  Brain  ; and  Spinal  Cord,  Diseases  of. 

CONDYLOMA  (Lat). — Definition.  — Ex- 
crescences often  found  about  the  anus  and  organs 
of  generation  in  both  sexes.  The  term  has  been 
applied  to  simple  cutaneous  growths  as  well  as 
to  those  of  syphilitic  origin  ; but  since  these 
latter  are  altogether  due  to  a constitutional 
taint,  and  require  a different  treatment,  they 
will  be  described  separately  under  the  heading 
of  Mucous  Tubercles,  whilst  the  term  Condy- 
loma, will  be  restricted  to  non-specific  growths. 

Symptoms. — Condylomata  are  generally  situ- 
ated in  the  neighbourhood  of  the  anus  and 
genital  organs ; and  they  result  from  the  irritation 
produced  by  acrid  vaginal  or  rectal  discharges, 
or  by  the  natural  secretions  in  dirty  persons. 
They  consist  in  hypertrophy  of  the  tegumentary 
tissues,  and  generally'  form  smooth  pendulous 
growths,  but  they  may  be  flattened,  irregular, 
and  ulcerated  on  the  surface.  They  are  vascu- 
lar, liable  to  become  inflamed  and  painful  from 
friction,  and,  as  their  position  favours  develop- 
ment, they  may  attain  considerable  size. 

Treatment. — When  all  inflammation  has  been 
allayed,  these  excrescences  should  be  removed 
with  a pair  of  scissors ; and  to  prevent  their  re- 
currence thorough  cleanliness  must  be  practised, 
and  any  discharge  from  the  rectum  or  vagina 
stopped.  If  the  parts  he  damp  and  perspiring 
they  should  he  kept  dry,  and  frequently  dusted 
with  zinc  or  bismuth  powder,  or  bathed  with 
seme  astringent  lotion.  No  general  treatment 
is  of  the  slightest  service. 

George  G.  Gascoyen 

CONFLUENT  ( confluo , I run  together). — 
Applied  chiefly  to  a variety  of  smallpox  and  of 
other  exanthemata,  in  which  the  eruption  runs 
together  or  coalesces. 

CONGENITAL  ( con , together,  and  genitus, 
begotten). — Existing  at  birth  : a term  generally 
applied  to  diseases  or  malformations,  such  ar 
Congenital  Syphilis,  and  Congenital  Clubfoot. 


CONGESTION. 

CONGESTION  ( congero , I accumulate). — 
Overfulness  of  vessels  caused  by  accumulation  of 
their  contents:  generally  applied  to  blood-vessels. 
See  Circulation,  Disorders  of. 

CONIUM,  Poisoning  by.  See  Appendix. 

CONJUNCTIVITIS. — Inflammation  of  the 
conjunctiva.  See  Eve  and  its  Appendages,  Dis- 
eases of. 

CONSCIOUSNESS.  Disorders  of.— The 
disorders  of  consciousness  are  so  numerous  as  to 
make  it  desirable  briefly  to  consider  them  in  one 
article,  with  a view  to  their  classification  and  the 
better  comprehension  of  their  mutual  relations. 
We  shall,  therefore,  here  group  and  arrange  the 
various  morbid  conscious  states,  not  aiming  to 
produce  a strictly  scientific  classification  so  much 
as  one  which  will  be  practically  useful. 

1.  Exaltation  of. — Under  this  head  may  be 
ranged  certain  states  of  consciousness  more 
or  less  distinctly  bordering  upon  the  un- 
natural, to  be  met  with  in  persons  under  the 
influence  of  ‘ mental  excitement  ’ from  various 
causes,  as  from  sudden  good  news,  or  generally 
pleasant  surroundings ; also  from  a slight  degree 
of  poisoning  by  alcohol,  opium,  hashish,  or 
other  drugs ; or  from  an  early  stage  of  some 
forms  of  insanity,  or  of  delirium.  In  this  state 
of  mental  exaltation  the  individual’s  powers  of 
perception,  apprehension  recollection,  thought, 
emotion,  and  volition,  would  seem  to  be  all  more 
or  less  intensified,  just  as  in  that  of  hebetude 
or  dementia  they  are  diminished  and  conscious- 
ness is  proportionately  dwarfed. 

2.  Perversions  of. — Many  of  the  various 
defects  here  to  be  referred  fo  are  very  par- 
tial in  the  extent  to  which  they  implicate 
consciousness,  though  others  are  general.  In 
what  is  known  as  an  illusion  some  object  of 
sense  is  not  correctly  perceived ; or,  in  other 
words,  some  sensorial  impression  is  quite  wrongly 
interpreted,  as  when  a feverish  or  a maniacal 
patient,  looking  at  some  inanimate  object,  de- 
clares that  it  is  a cat  or  a dog  about  to  fly  at  him, 
or  hearing  even  the  slightest  noise  in  any  part 
of  his  room,  interprets  it  to  be  the  voice  of  some 
friend  or  imagined  enemy.  In  the  case  of  an 
hallucination,  however,  forms  are  declared  to  be 
seen,  or  voices  heard  (by  a patient  suffering 
from  delirium  tremens,  for  instance),  where  no 
appreciable  external  realities  could  have  started 
the  notion.  And  in  these  cases,  it  is  not  that 
the  patient  sees  or  hears  without  believing  ; 
he  implicitly  believes  that  the  visions  or 
voices  which  have  been  conjured  up  subjectively 
by  the  working  of  his  own  brain,  have  a real 
existence  in  the  outside  world.  It  is  necessary 
to  make  this  distinction  because  it  is  by  no 
means  uncommon  in  regard  to  the  olfactory 
sense  (especially  in  some  epileptics),  for  odours 
or  smells  to  be  perceived  which  the  patient  soon 
comes  to  know  are  purely  subjective  or  devoid 
of  any  external  correlative. 

Hallucinations  and  illusions,  though  occasion- 
ally existing  alone,  are  quite  commonly  asso- 
ciated with  a very  important  and  more  general 
derangement-  of  consciousness,  viz.,  delirium. 
This  is  a symptom  very  common  in  many 


CONSCIOUSNESS,  DISOKDEKS  OF.  2S1 
fevers,  in  certain  low  states  of  the  system,  after 
severe  frights,  in  inflammatory  or  other  lesions 
of  the  brain  and  its  mombranes,  as  a result 
of  somo  narcotico-irritant  poison,  or  occasion- 
ally in  a person  who  is  recovering  from  an 
epileptic  attack,  or  from  the  stupor  sequential 
to  a series  of  convulsive  attacks.  The  state 
itself  varies  much  in  intensity.  Three  fairly 
distinct  types  exist.  In  (a)  low  or  muttering 
delirium  the  patient  lies  still  and  more  or  less 
heedless  of  what  is  occurring  around;  or  if 
heeding  at  all,  the  impressions  which  he  receives 
give  rise  to  erroneous  perceptions  (illusions) 
which  are  woven  into  the  incoherent  fabric  of 
his  rambling  thought.  In  ( b ) delirium  tremens 
the  patient  is  more  restless,  tremors  of  the 
limbs  and  of  the  muscles  of  the  face  are  often 
easily  induced,  hallucinations  of  sight  and 
hearing  are  common,  and  the  character  of  the 
delirium  reveals  that  the  patient  is,  to  an  un- 
usual extent,  possessed  by  fears,  terrors,  and 
other  emotions  of  a depressing  type.  In  (c) 
wild  or  raving  delirium  we  have  to  do  with  a 
much  more  active  state.  The  patient  raves 
loudly  and  incoherently,  more  in  regard  to  his 
fleeting  dream-like  thoughts  than  in  connection 
with  external  impressions,  of  which  he  is  more 
or  less  heedless.  He  is  often  violent  in  de- 
meanour, and  difficult  to  be  restrained,  persons 
in  this  state  being  capable  of  great  and  pro- 
longed muscular  exertion.  The  bodily  activity 
accompanying  this  form  of  delirium  is,  in  fact, 
just  as  characteristic  as  the  great  intensity  of 
the  mental  processes.  It  is  met  with  occasion- 
ally in  some  fevers,  but  more  commonly  in 
meningitis  and  in  acute  mania. 

In  its  early  stages  delirium  is.  principally 
noticed  during  the  transition-period  between 
waking  and  sleeping — at  times,  that  is,  when  the 
nervous  system  most  needs  the  reinvigorating 
influence  of  sleep.  It  is  in  these  cases,  too,  that 
beef-tea  or  stimulants  may  for  a time  dispel  all 
traces  of  the  wandering  thought.  'Whilst  illu- 
sions and  hallucinations  enter  largely  into  the 
mental  activity  of  a delirious  patient,  delusions 
also  are  generally  well-marked  components. 
That  is  to  say,  the  person  becomes  for  a time 
possessed  by  an  idea,  notion,  or  fancy,  for  which 
there  is  no  real  warranty,  though  he  believes 
and  wishes  to  act  as  though  it  were  true. 

Somewhat  allied  to  delirium  in  nature,  though 
much  lower  in  intensity  as  a mental  process,  is 
that  incoherence  of  thought  which  is  met  with  in 
many  chronic  maniacs,  or  in  non-febrile  patients 
suffering  from  various  organic  brain-diseases. 
In  its  slighter  degrees  this  incoherence  displays 
itself  as  mere  ‘rambling’  talk;  the  patient 
has  not  sufficient  brain-power  to  follow  up  the 
mam  subject  of  thought,  and  is  frequently  di- 
verted into  collateral  channels.  This,  which  is 
a natural  state  with  some  persors,  may  be  dis- 
tinctly indicative  of  disease  in  others  whose 
mental  power  has  previously  been  of  a more 
vigorous  type.  At  times  tho  incoherence  is  seen 
to  be  governed  principally  by  mere  verbal  sug- 
gestion, the  patient  being  led  away  from  point 
to  point  in  new  directions,  owing  to  the  asso- 
ciations of  some  word  which  has  been  used  bo- 
coming  for  the  time  dominant.  This  state  is 
often  well  seen  in  the  sub-acute  exacerbations  ol 


282  CONSCIOUSNESS, 

chronic  mania,  though  it  may  occur  also  where 
multiple  softenings  or  indurations  of  the  brain 
exist.  At  other  times  the  incoherence  is  more 
absolute — wayward  transitions  from  subject  to 
subject,  connected  by  no  discoverable  bond,  ra- 
pidly following  one  another.  The  result  in  such 
a case  is  a mere  unmeaning  jumble  of  words, 
interspersed  here  and  there  with  brief  propo- 
sitions having  a limited  significance  of  their  own, 
though  often  wholly  unrelated  to  that  which 
precedes  or  follows. 

Hypochondriasis  is  a perverted  state  of  con- 
sciousness, having  some  resemblance  to  that  of 
illusion,  but  in  which  some  internal  or  visceral 
slate  becomes  the  starting-point  of  impressions 
(possibly  not  actually  painful)  which,  when  mag- 
nified and  perverted  as  they  are  in  the  mind  of 
the  patient,  fill  him  with  false  and  gloomy  ap- 
prehensions of  various  kinds.  This  perversion 
of  consciousness  is  more  generalised  than  that 
which  exists  in  the  case  of  illusion ; and  also 
instead  of  being  a more  or  less  temporary  defect, 
it  is  one  that  may  last  for  weeks,  months,  or 
even  years.  The  state  of  mind  of  an  hysterical 
patient  is  often  not  altogether  different  from 
that  of  the  hypochondriac. 

3.  Partial  Loss  of. — Defects  of  this  order 
arc  numerous  and  may  exist  in  great  variety. 
They  may  implicate  almost  equally  nearly  all 
the  varieties  of  conscious  mental  activity,  or 
some  more  than  others.  They  maybe  either  con- 
genital, or  acquired  during  the  life  of  the  indi- 
vidual. 

In  idiotcy  we  may  have  from  birth  defect  in 
the  power  of  concentrating  the  attention,  a de- 
fective power  of  apprehension  and  of  thinking, 
and  a defective  volition,  shown  alike  by  an  in- 
ability to  guide  or  control  thought,  and  by  a 
deficient  vigour  of  bodily  movement.  Again, 
ns  a result  of  epilepsy,  of  organic  brain- 
disease,  or  of  injuries  to  the  head,  the  patient 
may  gradually  lapse  into  such  a condition  from 
one  of  health,  so  as  to  become,  as  it  is  termed, 

‘ demented.’  Whilst  this  state  of  dementia  may 
supervene  at  any  age,  it  is  much  more  common 
as  a consequence  of  the  brain-diseases  frequent 
in  advanced  life.  There  is,  moreover,  a form 
known  as  senile  dementia , in  which  without,  any 
typical  disease,  but  as  a consequence  of  im- 
paired tissue-vitality  and  diffused  degenerative 
changes  throughout  the  nervous  system,  the 
mental  faculties  undergo  a more  marked  degra- 
dation than  is  usually  met  with  in  old  age.  This 
condition  in  its  minor  degrees  goes  by  the  name 
of  hebetude.  In  all  such  states  or  grades  of 
idiotcy  and  dementia,  we  meet  with  an  undue 
tendency  to  sleep  in  the  day-time  as  a result  of 
the  listless  and  languid  mental  condition.  This 
is  but  another  sign  of  the  general  lowering  of 
conscious  vigour. 

Here  we  must  include,  also,  a peculiar  group 
of  conditions,  having  some  alliance  to  one  ano- 
ther, and  which  are  all  characterised  by  loss  of 
consciousness  to  some  extent,  either  partial  in 
range  or  general.  They  are — reverie,  somnam- 
bulism, ecstasy,  coma-vigil,  catalepsy,  hypnotism, 
and  trance.  They  are  merely  enumerated  here, 
but  are  defined  or  described  in  their  several 
places.  In  the  latter  of  these  conditions  the  loss 
of  consciousness,  in  the  ordiuary  acceptation  of 


DISORDERS  OE. 

the  term  (viz.  loss  of  perceptive  power)  is  so 
absolute,  that  some  may  think  it  ought  rather 
to  be  included  in  the  next  section.  Loss  of  per- 
ceptive power,  however,  would  not  seem  to  be 
absolutely  synonymous  with  loss  of  conscious- 
ness. There  is  good  reason  to  believe,  for  in- 
stance, that  where  the  influence  of  chloroform 
and  other  anaesthetics  is  not  pushed  to  the  fullest 
extent,  a condition  of  anesthesia  intermediate 
between  slight  and  profound  is  produced,  in 
which,  whilst  there  is  absolutely  no  conscious- 
ness for  external  impressions,  so  that  pain  is 
altogether  unfelt,  there  is  still  a certain  amount 
of  cerebral  activity — as  evidenced  by  rambling 
and  indistinct  speech  on  subjects  altogether  apart 
from  what  the  surgeon  may  be  doing.  There 
is  mental  activity  clearly,  though  the  nature  of 
this,  as  revealed  by  the  patient's  speech,  may 
preclude  the  notion  that  pain  is  at  the  time 
being  felt.  Sensorial  consciousness  is  blotted 
out,  whilst  a kind  of  ideational  consciousness 
remains.  We  have  an  approximation  to  such  a 
condition,  also,  in  the  case  of  sleep  when  dreams 
are  rife.  But  here  sensorial  consciousness  is  not 
completely  in  abeyance.  Again,  in  certain  rare 
and  anomalous  epileptiform  attacks  we  may  find 
the  patients,  after  the  first  paroxysms,  bereft  of - 
some  senses,  though  not  of  others.  They  may 
hear  what  is  said  by  those  around  them,  though 
they  continue  for  a time  quite  unable  to  see  or 
speak. 

4.  Complete  Lossof. — In  very  profound  sleep 
(sopor),  in  that  prolonged  form  of  it  in  which 
the  person,  if  he  can  be  momentarily  roused, 
drops  off  again  immediately  (lethargy),  and  alsc 
in  profound  anesthesia,  there  is  complete  loss  of 
consciousness.  The  terms  sopor  and  lethargy 
are  now  rarely  used,  and  authors  are  not  even 
agreed  as  to  the  precise  state  which  should  be 
designated  by  the  latter  word. 

In  syncope  we  have  insensibility  resulting 
from  a cutting  off  of  the  preper  supply  of  blood 
to  the  brain  ; whilst  in  asphyxia  we  have  a like 
result  fallowing  upon  an  interference  with  re- 
spiration. 

A condition  of  narcosis  or  profound  insen- 
sibility may  result  from  opium  or  other  drugs 
and  poisons,  amongst  which  alcohol  is  to  be  in- 
cluded as  one  of  the  most  common  producers 
of  such  a state.  Or  it  may  also  be  due  to  the 
deficient  elimination  of  urinary  products  by  the 
kidneys,  when  ursemic  coma  is  produced. 

Complete  loss  of  consciousness  exists  for 
some  time  during  the  ordinary  form  of  epileptic 
fit,  or  during  an  attack  of  convulsions ; though 
in  other  epileptiform  fits,  not  imfrequently  met 
with — having  some  of  the  characters  of  hyste- 
rical convulsions — there  seems  to  he  a loss 
of  sensorial  consciousness  only  (loss  of  percep- 
tion), whilst  a certain  amount  of  ideational 
consciousness  remains.  In  apoplexy  also  thero 
may  be  for  hours  or  days  a more  or  less  pro- 
found loss  of  consciousness.  In  the  less  pro- 
found attacks,  as  well  as  after  an  epileptic  fit 
or  an  attack  of  convulsions,  the  loss  of  con- 
sciousness is  not  complete,  and  wo  have  a con- 
dition now  commonly  known  as  siupor.  This 
state  is  also  frequent  as  a result  of  concussion 
or  other  injuries  of  the  brain,  and  it  occasionally 
follows  a severe  fir.  of  hysterical  convulsions, 


CONSCIOUSNESS. 

It  may  last  for  hours,  days,  or  even  weeks  in 
some  cases.  In  it  the  patient  lies  with  his  eyes 
closed,  taking  no  heed  of  what  is  passing  around, 
though  he  may  show  obvious  signs  of  feeling 
when  touched  or  pinched,  and  may  he  capable 
of  being  momentarily  roused,  so  as  to  give  a 
short  monosyllabic  answer,  if  slightly  shaken 
or  spoken  to  in  a loud  voice.  On  these  occa- 
sions, signs  of  impatience  are  often  shown. 
Though  such  a patient  will  not  ask  for  food, 
ho  will  often  drink  freely  when  it  is  offered. 
He  will  of  his  own  accord,  when  his  bladder  is 
full,  sometimes  get  out  of  bed,  find  the  chamber- 
pot, use  it,  aud  return  to  bed  without  saying  a 
word — and  then  speedily  relapse  into  his  previous 
state  of  stupor.  When  the  insensibility  is  more 
profound,  both  urine  and  faeces  arepassed  incon- 
tinently. 

The  state  just  spoken  of  is  referred  to  in  this 
section  because  it.  is  so  intimately  allied  to  and 
connected  by  all  sorts  of  transition  conditions 
with  another,  known  as  coma,  in  which  the  loss 
of  consciousness  is  more  complete  and  absolute. 
There  are  different  degrees  of  stupor  and  there 
are  different  degrees  of  coma;  the  former  is 
commonly  spoken  of  as  slight  or  deep,  whilst 
a comatose  condition,  coma,  and  profound  coma 
(the  latter  being  what  the  older  writers  termed 
earns)  are  the  phrases  ordinarily  used  to  denote 
the  increasing  insensibility  of  the  graver  state, 
which  is  more  especially  characteristic  of  the 
apoplectic  condition.  Coma  may  result  from 
long-continued  exposure  to  cold,  from  sun-stroke, 
from  poisons  of  various  kinds,  from  erysipelas 
of  the  head  and  face,  from  inflammations  of  the 
meninges,  multiple  embolisms,  the  effects  of 
hyperpyrexia,  orfrom  cerebral  haemorrhage.  The 
most  common  cause  of  very  profound  coma  is 
cerebral  hsemorrhage  (apoplexy).  In  this  condi- 
tion the  breathing  is  often  loud  and  stertorous, 
and  consciousness  is  entirely  obliterated,  so  that 
there  is  an  utter  absence  of  reflex  movements 
when  a limb  is  pinched  or  when  the  conjunctiva 
is  touched.  The  patient  in  the  deeper  forms  of 
coma  often  cannot  be  roused  at  all,  even  for  a 
moment,  and  if  this  state  does  not  terminate  in 
one  way  or  another  before  the  expiration  of 
twenty-four  hours,  or  if  it  does  not  gradually 
pass  into  one  of  mere  rtupor,  a fatal  result  may 
be  considered  imminent, 

H.  Charlton  Bastian. 

CONSTIPATION  {con,  together,  and  stipo, 
I cram). — Definition.. — infrequent  or  incomplete 
alvme  evacuation,  leading  to  retention  of  faeces. 

.Etiology. — The  causes  of  constipation  may 
be  local — an  impediment  to  the  onward  movement 
of  the  faeces  in  the  large  intestine  or  from  the 
rectum;  or  general — pertaining  to  habits,  diet, 
and  other  conditions. 

Local. — These  include  : — (a)  Lesions  inducing 
narrowing  of  some  part  of  the  large  intestine. 
(Ij)  Collections  of  scybala,  intestinal  concretions, 
&e.  in  the  caecum,  sigmoid  flexure,  or  rectum,  (c) 
Pressure  on  the  rectum,  by  uterine  fibroid  or 
ovarian  tumours,  uterine  displacement,  the  gravid 
uterus,  or  an  enlarged  prostate,  (d)  Defaecation 
thwarted,  as  when  the  expiratory  abdominal 
muscles  are  enfeebled,  as  in  pregnancy,  especi- 
ally when  repeated  or  after  twins,  obesity,  old 


CONSTIPATION.  2SJJ 

age,  or  in  some  painful  affection  of  the  abdomen, 
such  as  rheumatism  of  the  abdominal  walls  and 
diaphragm,  chronic  dysentery,  piles,  anal  fissure. 
(e)  Peeble  contraction  of  the  intestinal  muscular 
fibres,  as  in  distension  of  the  large  intestine  or 
a portion  of  it  by  gas,  faeces,  or  lumbrici,  in- 
flammatory affections,  lead-poisoning,  senile 
atrophy,  or  in  delicate  females  with  lax  muscular 
fibre  {see  Colon,  Diseases  of).  (/)  Pain  in 
the  pelvic  viscera  and  probably  elsewhere  may 
induce  paralysis  of  the  sympathetic  nerves  sup- 
plied to  the  intestinal  walls  ; thus  may  be  ex- 
plained obstinate  constipation  in  painful  uterine 
and  ovarian  diseases,  which  caunot  be  accounted 
for  by  pressure  on  the  bowels  or  otherwise. 

General.— The  general  causes  of  constipation 
are:— (a)  Sluggishness  of  function— lymphatic 
temperament,  anosmia,  especially  with  amenor- 
rhosa  ; or  disposition  to  great  activity  of  the 
muscular  and  nervous  system.  (A)  Certain  habits, 
namely,  sedentariness ; too  great  muscular  ac- 
tivity; mental  application,  especially  when  exces- 
sive or  prolonged  ; the  continued  use  of  aperients 
or  enemata  after  the  relief  of  temporary  consti- 
pation ; habitual  disregard  of,  or  hurry  in  the 
act  of  defecation  ; prolonged  hours  of  sleep ; the 
excessive  or  even  moderate  use  of  alcohol,  tea, 
tobacco,  or  opiates,  (e)  Dietetic  errors. — Diet 
too  nutritious — leaving  little  intestinal  residue 
— or  poor  and  insufficient;  improper  feeding, 
especially  in  infants  and  children  ; the  use  of 
indigestible  substances,  such  as  cheese,  nuts,  or 
cucumber. 

Constipation  is  frequently  a prominent  symp- 
tom in  diseases  of  the  stomach  ; of  the  liver ; 
of  the  heart,  inducing  congestion  of  the  portal 
system  and  of  the  nervous  system  : as  well  as 
in  connexion  with  diabetes,  excessive  perspira- 
tion, prolonged  lactation,  and  discharges. 

The  causes  of  constipation  are  such  as  evi- 
dently induce  one  or  both  of  the  following  con- 
ditions.— 1.  Dryness  and  hardness  of  the  contents 
of  the  large  intestine  from  deficient  secretion,  oi 
too  active  absorption  of  fluid  from  the  intes- 
tinal tract.  2.  Impaired  contraction  of  the  muscu- 
lar fibres  of  the  large  intestine. 

Description. — In  constipation  the  evacuations 
are  infrequent,  solid,  deficient  in  quantity,  and 
sometimes  unusually  offensive ; they  often  consist 
of  dry,  hard,  dark  or  clay-coloured  masses  or 
scybala.  Defaecation  is  generally  difficult  or  even 
painful.  As  a rule  the  depth  of  colour,  and  the 
scybalous  character  of  the  motions,  are  in  propor- 
tion to  the  duration  of  the  lodgment  of  faeces  in 
the  large  intestine.  Infrequency  of  defaecation 
regarded  alone  is  an  untrustworthy  sign  of  consti- 
pation, or  constipation  demanding  medicinal  or 
other  treatment,  inasmuch  as  it  often  depends  on 
individual  peculiarity.  Good  health  is  consistent 
with  wide  departures  from  the  ordinary  rule — a 
daily  evacuation ; not  unfrequently  there  is  no 
relief  from  the  bowels  for  several  days  or  even  for 
a week,  and  yet  without  inconvenience,  so  long  as 
the  infrequent  defaecation  is  habitual,  or  can  be 
ascribed  to  idiosyncrasy. 

The  disturbances  of  function  usually  associ- 
ated with  constipation  may  be  local,  or  extend 
to  distant  parts. 

The  immediate  or  local  effects  are  such  as  may 
arise  from  retention  of  faeces :— signs  of  faecal 


CONSTIPATION. 


>84 

collections  in  the  caecum,  colon,  sigmoid  flexure, 
or  rectum  ; irritation  of  portions  of  the  intestine, 
indicated  by  colic,  inflammation,  ulceration,  and 
perforation  of  the  intestines ; intestinal  ob- 
struction ; pressure  of  faecal  accumulations  on 
the  intra-pelvic  vessels  and  nerves,  inducing 
menorrhagia,  uterine  catarrh,  seminal  emissions, 
haemorrhoids,  cold  feet,  neuralgia  and  numbness 
of  the  legs  (Niemeyer).  Constipation  frequently 
exerts  a pernicious  influence  on  primary  diges- 
tion, indicated  by  foul  tongue,  fcetid  breath, 
anorexia,  acidity,  flatulence,  biliary  disturbance 
— even  jaundice,  and  urine  loaded  with  lithates. 

The  remote  or  general  effects  of  constipation 
are  lassitude  of  body  and  mind ; headache, 
flushing  and  heat  of  head,  vertigo ; anaemia  and 
wasting. 

Treatment.— Constipation  depending  on  in- 
dividual peculiarity  is  rarely  relieved  perma- 
nently by  treatment.  The  bowels,  having 
acquired  from  early  life  the  habit  of  infrequent 
evacuation,  may  be  stimulated  for  a time,  and 
are  then  apt  to  become  more  sluggish  than 
before.  In  all  cases  the  habit  of  the  patient 
in  this  respect  from  childhood  should  first  be 
determined,  either  as  a warning  against  active 
or  prolonged  treatment,  which  may  prove  in- 
jurious, or  as  a guide  to  the  adjustment  of  direc- 
tions and  remedies — affording  as  it  does  a limit 
which  should  not  be  over-stepped. 

1 . JEtiological,  Dietetic , and  Hygienic  Treatment. 
— In  treating  constipation  the  causes  should  be 
met.  Local  causes — such  as  those  inducing  con- 
traction of  or  pressure  on  some  part  of  the  large 
intestine,  or  feeble  or  ineffectual  contraction  of 
the  intestinal  muscular  fibres  or  of  the  ex- 
piratory muscles,  should  first  be  eliminated. 
Habits  disposing  to  constipation  should  also  be 
corrected.  Persons  who  are  much  preoccupied  or 
careless  are  apt  either  to  disregard  the  call  to 
stool,  or  to  perform  the  act  of  defecation  hurriedly, 
incompletely,  and  at  irregular  intervals.  The 
sensibility  of  the  nerves  of  the  rectum  becomes 
blunted  by  the  constant  contact  of  feces.  Hence 
the  periodical  removal  of  collections  in  the  lower 
part  of  the  large  intestine  is  an  essential  element 
of  the  treatment.  It  is  best  when  this  can  be 
done  by  well-timed  natural  efforts.  The  pa- 
tient should  be  told  to  attempt  defecation  every 
day  after  breakfast,  and  to  persevere  in  so  doing 
even  when  the  result  is  occasionally  or  frequently 
unsuccessful.  While  straining  to  relieve  the 
bowels,  he  may  facilitate  evacuation  by  pressing 
firmly  the  fingers  in  front  and  on  each  side  of 
the  coccyx,  thus  supporting  the  levator  ani  during 
contraction.  Failing  to  obtain  relief  on  the 
second  day,  a small  cold  water  enema  should  be 
used  to  prevent  further  accumulation  of  feces 
in  the  rectum,  and  to  restore  tone  and  sensibility 
to  the  blunted  nerves.  The  enema  should  never 
be  larger  than  is  required  to  dislodge  the  motion 
from  the  pouch  of  the  rectum — nor  should  it  be 
warm  ; at  first  it  may  be  tepid,  afterwards  cold. 
When  evacuation  is  obstructed  by  the  lower  part 
of  the  fecal  mass  becoming  dry,  relief  may  be 
obtained  from  emollient  enemata  and  supposi- 
tories, such  as  infusion  of  linseed,  decoction  of 
marsh- mallow,  solution  of  white  of  eggs,  olive  oil 
lione  or  in  oatmeal  gruel,  or  glycerine  injected 
in  small  quantity  into  tha  rectum,  and  allowed 


to  remain  there  lor  some  hours ; or  by  the  use  cf 
suppositories  at  bed-time,  consisting  of  cocoa- 
butter,  soap,  or  honey  hardened  by  heat,  either 
alone  or  combined  with  a stimulant  to  excite 
the  flow  of  mucus  into  the  rectum,  or  with 
extract  of  belladonna  or  of  stramonium.  Seden- 
tary habits  should  be  broken  into.  Exercise 
on  foot  or  on  horseback  is  specially  to  be 
commended,  and  carriage  exercise  to  be  avoided. 
While  studying  or  reading  the  patient  should 
walk  about,  and  stand  rather  than  sit  at  the 
desk.  Gymnastics  and  out-of-door  games  are 
useful  when  a limited  time  only  can  be  de- 
voted to  exercise.  Excessive  and  exhausting 
exertion  should  be  avoided.  It  is  generally 
advi  sable  to  recommend  early  rising  and  cold 
bathing  in  the  morniDg.  In  different  cases 
one  or  other  of  the  following  may  be  found  ser- 
viceable : a shower-  or  sponge-bath  containing 
vinegar,  baysalt,  or  consisting  of  sea-water,  or 
a cold  sitz  bath ; douches  directed  to  the  abdo- 
men ; a cold  water  compress  applied  to  the  abdo- 
men during  the  day  or  night  or  for  three  or  four 
hours  in  the  morning  ; friction  or  kneading  in 
the  course  of  the  colon  every  morning  and  when 
at  stool ; an  abdominal  belt  (flannel  or  elastic) 
— especially  if  the  abdomen  be  pendulous.  The  in- 
terrupted current  ox  electricity  has  been  success- 
fully employed  as  a special  excitor  of  the  muscular 
fibres  of  the  intestines  or  of  the  abdominal  wall. 

Diet.  — Vegetable  should  predominate  over 
animal  food.  Greens  (cabbage,  lettuce,  &c.)  are 
useful,  as  well  as  fruits,  which  should  be  ripe, 
and  taken  on  an  empty  stomach.  Prunes  or  figs 
stewed  in  olive  oil,  or  infusion  of  senna,  prune- 
pulp,  oils  and  fats,  such  as  cod  oil  or  olive 
oil,  are  also  serviceable  when  they  do  not 
disturb  the  digestion.  Bread  made  of  bran  (or 
three  parts  flour  and  one  part  coarse  bran),  of 
corn-meal,  or  of  cracked  wheat : oatmeal  por- 
ridge ; or  wheat  ground  in  a coffee-mill,  boiled 
and  salted  and  served  like  rice,  only  less  thick, 
may  assist  in  preventing  constipation  ; if  there 
be  acidity  and  other  symptoms  of  dyspepsia, 
however,  these  indigestible  articles  of  diet  should 
be  avoided.  Tobacco-smoking  after  meals  in 
moderation  sometimes  relieves  constipation. 
Cold  water  or  carbonic  acid  water — a tumblerful 
at  bed-time,  or  preferably  on  rising  in  the  morn- 
ing, may  be  useful.  Much  must  be  left  to  indi- 
vidual experience;  sometimes  coffee,  cr  beer,  or 
cider  answers  best.  As  a rule  farinacea,  astrin 
gent  wines,  and  tea  increase  constipation. 

2.  Medicinal  Treatment. — When  dietetic  and 
hygienic  directionsfail,  they  require  to  be  assisted 
by  medicinal  agents.  The  ends  to  he  secured 
are  threefold  : — 1.  To  evacuate  feces  and  gases 
which,  d’Stending  the  large  intestine,  thwart  peri 
staltic  action.  2.  To  tone  the  walls  of  the  bowel, 
and  thus  prevent  reaccumulation  of  feces  and 
the  products  of  their  decomposition.  3.  To 
increase  the  flow  of  intestinal  mucus.  Remedies 
are  usually  variously  combined  for  these  pur- 
poses, and  should  be  carefully  adjusted  to  the 
requirements  of  each  case,  so  as  to  meet  the 
leading  indications.  Among  the  most  useful 
aperients  are  aloes  or  its  watery  extract,  rhubarb, 
colocynth,  gamboge,  and  podophyllin,  and  either 
of  these  may  fie  variously  combined  with  extract 
of  hyoscyamus  or  belladonna,  extra»t  of  gentian 


CONSTIPATION. 

extract  of  nux  vomica,  quinine,  sulphate  of  iron, 
or  ipecacuanha.  The  dose  of  the  aperient 
should  not  exceed  that  required  to  secure  gentle 
evacuation,  and  it  varies  with  individuals. 
Purging  exhausts  torpid  bowels,  and  perpetuates 
constipation.  The  bowels  should  not  he  pushed 
to  more  frequent  relief  than  has  been  habitual 
with  the  patient  from  early  life.  The  aperient, 
which  should  be  varied  in  a prolonged  course  of 
treatment,  should  be  very  gradually  dropped, 
while  the  intestinal  tonics  (belladonna,  quinine, 
nux  vomica,  iron)  are  continued.  The  duration 
of  treatment  is  prolonged  until  the  aperient  is 
almost  entirely  withdrawn.  The  remedies  should 
be  taken  immediately  or  two  or  three  hours  after 
the  principal  meal.  The  treatment  by  bella- 
donna, introduced  by  Bretonneau,  was  greatly 
prized  by  Trousseau  (see  Colon,  Diseases  of). 

In  ansemic  subjects  afirm  and  prolonged  course 
of  iron  should  be  aided  by  aloes,  nux  vomica, 
and  arsenic.  In  lisemorrhoidal  complications 
aloes  should  as  a rule  be  avoided,  and  laxative 
electuaries  should  be  prescribed ; in  some  cases, 
however,  it  tones  without  irritating  the  rectum. 
Flatulent  dyspepsia  and  tympanites  are  indica- 
tions for  the  prescription  of  nux  vomica,  which, 
however,  will  not  radically  cure  constipation. 
In  obstinate  cases  the  most  useful  remedies 
are  colocynth  — tincture  (Prussian  Pharm.)  5 
minims  or  more  on  sugar  or  in  water  throe  or  four 
times  a day,  or  10  to  20  minims  an  hour  before 
breakfast ; extract  or  compound  pill  with  small 
doses  of  croton  oil,  or  with  gamboge,  elaterium,  or 
other  combinations ; podophyllin  with  bella- 
donna (Trousseau),  ipecacuanha,  and  colocynth 
or  aloes.  A full  dose  of  opium  may  liberate 
the  bowels  after  the  failure  of  the  strongest 
purgatives,  and  constipation  depending  on  inhibi- 
tion of  the  sympathetic  nerve  from  pain,  will  be 
relieved  by  opium  with  belladonna.  Enemata, 
when  frequently  required,  should  be  small  in 
quantity,  and  at  first  tepid,  then  cold  ; for  occa- 
sional use  for  the  purpose  of  clearing  away 
faeces  loading  the  large  bowel,  they  should  be 
largo  (from  two  to  six  pints)  and  warm  (see 
PiECES,  Retention  of).  The  frequent  use  of  large 
warm  injections  is  injurious.  Purgative  waters, 
such  as  the  Friedriehshall,  Pullna,  Hunyadi,  or 
Carlsbad  waters,  given  occasionally  in  small 
doses  with  warm  water  in  the  early  morning, 
are  often  valuable  adjuvants  to  a well-organised 
course  of  treatment.  Constipation  cannot,  how- 
ever, be  cured  by  a course  of  saline  purgatives, 
and  may  be  greatly  aggravated  by  it. 

Numerous  other  drugs  have  been  recommended 
in  the  treatment  of  habitual  constipation,  among 
which  are  nitric  acid;  arsenic  with  food  in  de- 
bilitated anaemic  females,  in  the  sedentary,  or 
the  old;  tincture  of  benzoin — 20  minims  thrice 
daily ; tincture  of  colchicum — -a  few  drops  after 
each  meal ; carbonate  of  iron ; compound  liquorice 
powder  with  sulphur — a teaspoonful  at  bedtime 
in  water;  tincture  of  veratrum  viride — 3 minims 
four  or  five  times  a day ; or  ox -gall  dried,  in  pills. 

George  Oliver. 

CONSTITUTION. — Stnov.  : Diathesis, 

Habit,  Conformation  of  body  Fr.  Constitution ; 
Ger.  Leibesbeschaffenkeit. 

The  constitution  may  be  sound  or  unsound. 


CONSTITUTION.  285 

A sound  constitution  may  he  defined  as  the 
harmonious  development  and  maintenance  of 
the  tissues  and  organs  of  which  the  body  is 
made  up.  It  originates  with  the  union  of  a 
healthy  sperm  and  germ  cell,  continues  with  the 
growth  of  the  product  under  the  most  favour- 
able conditions  to  adult  life,  and  becomes  gradu- 
ally enfeebled  with  advancing  age  by  the  process 
of  natural  decay. 

The  constitution  may  be  unsound  in  con- 
sequence of  deficient  vitality.  This  deficient 
vitality  may  be  general,  as  is  sometimes  ob- 
served in  the  children  of  parents  one  or  both 
of  whom  are  in  advanced  life,  or  whose  vitality 
on  one  side  or  the  other  has  been  reduced  by 
excesses,  such  as  alcoholic  or  venereal.  Ex- 
hausted vitality  from  prolonged  disease,  c.g. 
phthisis  or  tertiary  syphilis,  affecting  either 
parent,  may  determine  the  death  of  the  offspring 
at  an  early  period  from  mere  failure  of  nutrition, 
or  may  cause  it  to  succumb  to  acute  disease  not 
not  necessarily  associated  with  any  inherited 
tendency  of  a special  kind.  The  deficient  vitality 
may  be  restricted  to  certain  tissues  or  organs,  viz., 
those  concerned  in  the  nervous,  vascular,  respi- 
ratory', or  digestive  systems.  Thus  amongst  tho 
most  strikingly  hereditary  of  diseases  are  those 
of  degeneracy,  such  as  emphysema,  structural 
heart-diseases,  atheroma  of' vessels,  certain  kidney- 
diseases,  &c.  Rightly  interpreted,  these  diseases 
are  of  the  nature  of  premature  senility',  attacking 
certain  tissues  or  organs — as  it  may  be  seen  to 
attack  the  hair  or  the  cornea  — from  some  in- 
herent defect  in  their  vitality. 

The  constitution  may,  in  the  second  place,  be 
unsound  from  some  definite  inherited  form  of 
disease.  Although  the  constitution  of  an  indi- 
vidual begins  with  his  life,  it  is  nevertheless  the 
resultant  of  the  constitutional  peculiarities  of 
many  antecedents.  This  being  so,  tendencies  to 
disease  may  date  far  back  in  the  pedigree,  to  be 
called  forth  from  time  to  time  by  favouring  cir- 
cumstances. We  need,  however,  practically  only 
go  back  a few  generations  in  inquiring  for  those 
diseases  which  are  well  recognised  as  being 
hereditary.  These  form  one  section  of  the  group 
of  constitutional  diseases. — Congenital  syphilis, 
gout,  scrophulosis,  tuberculosis,  cancer,  asthma, 
and  certain  neuroses  are  all  diseases  which  are 
apt  to  appear  at  certain  periods  of  the  life  of  the 
offspring,  in  consequence  of  some  specific  inherent 
defect  of  blood  or  tissue  derived  from  his  pro- 
genitors. 

The  constitution  may,  thirdly,  become  unsound 
at  any  period  subsequent  to  birth,  (a)  This  may  be 
due  to  the  surrounding  conditions  of  lifebeing  evil. 
Deficient  or  impure  air,  insufficient  or  improper 
food, defective  sunlight,  over-work,  intemperance, 
&c.,  may  injure  the  constitution  and  give  rise  to 
diseases  whoso  constitutional  nature  is  some- 
times strikingly  shown  in  the  tendency  of  some 
of  them  to  become  hereditary.  Rickets,  phthisis, 
and  scrofula  are  examples.  (A)  The  introduction  of 
certain  poisons  into  the  system  affects  the  consti- 
tution profoundly,  and  in  some  cases  permanently, 
after  the  more  obvious  effects  of  the  poisons  have 
passed  away.  All  the  acute  specific  zymotic  dis- 
eases, including  vaccinia,  would  come  under  this 
category.  They  render  the  organism,  for  a long 
period  or  for  life,  proof  against  subsequent 


286  CONSTITUTION. 

ittacks  of  the  same  disease.  Only  in  certain 
cases,  however,  can  the  soundness  of  the  consti- 
tution be  said  to  be  impaired  by  such  diseases, 
and  then  it  is  usually  through  the  occurrence  of 
sequelae.  E.  Douglas  Powell. 

CONSTITUTIONAL  DISEASES.  — 

These  may  be  regarded  as  diseases  generated 
from  within,  in  the  course  of  the  wear  and  tear, 
nutrition  and  waste  of  the  body,  in  consequence 
of  inherent  or  acquired  weakness  in  its  con- 
struction. 

The  applicability  of  the  term  ‘constitutional’ 
to  disease  is  sufficiently  explained  in  the  pre- 
ceding remarks  on  ‘constitution.’  The  term 
may,  however,  be  associated  with  a group  of 
so-called  ‘ general  ’ diseases,  in  opposition  to 
that  which  includes  ‘ zymotic’  or  ‘ specific’  diseases, 
which  are  generated  by  the  introduction  of  some 
definite  poison  from  without. 

In  our  present  state  of  knowledge,  however,  no 
very  rigid  lines  can  be  drawn  to  separate  local, 
general,  constitutional,  and  specific  diseases  from 
one  another.  See  Disease,  Causes  of. 

E.  Douglas  Powell. 

CONSTRICTION  ( constringo , I bind  to- 
gether).— A narrowing,  to  a limited  extent,  of  a 
canal  or  hollow  organ,  due  either  to  a textural 
change  in  its  walls,  or  to  the  pressure  of  a band 
surrounding  it. 

CONSUMPTION  {con sumo,  I waste).— This 
is  a term  for  any  wasting  disease,  but  it  is  gener- 
ally applied  to  pulmonary  phthisis.  See  Phthisis. 

CONTAGION. — The  word  contagion  is  ap- 
plied in  pathology  to  the  property  and  process 
by  which,  in  certain  sorts  of  disease,  the  affected 
body  or  part  causes  a disease  like  its  own  to 
arise  in  other  bodies  or  other  parts ; and  the 
Latin  word  contagium  is  conveniently  used  to 
denote  in  each  such  case  the  specific  material, 
shown  or  presumed,  in  which  the  infective  power 
ultimately  resides.  'See  Zyme  and  Zymosis. 

The  property  of  contagiousness  belongs  to  a 
very  large  number  of  the  diseases  which  affect 
the  human  body.  And  in  more  than  this  direct 
way  the  property  is  of  great  interest  to  mankind. 
Contagiousness  of  disease  is  a fact  not  only  for 
man,  but  apparently  for  all  living  nature  ; and 
the  influence  of  contagion  in  spreading  destruc- 
tive diseases  among  domestic  animals,  and  among 
those  parts  of  the  vegetable  kingdom  which  con- 
tribute to  the  nourishment  of  man,  is  such  as  to 
make  it  of  immense  social  importance  that  the 
laws  of  contagion  should  be  well  studied  and 
understood,  further,  just  as  contagion  in  the 
case  of  living  bodies  and  their  parts  spreads 
disease  from  one  to  another,  so,  to  an  immense 
extent,  in  the  case  of  certain  matters  which, 
though  of  organic  origin,  are  net  living,  it 
spreads  various  processes  of  decay.  The  so- 
called  ‘fermentations’  which  yield  alcohol 
and  vinegar,  as  well  as  that  in  -which  putre- 
faction consists,  are  contagious  affections  of  the 
respective  matters  in  which  they  cccur  : every 
cheesemonger  knows  that  moulds  of  different 
kinds  spread  by  inoculation,  each  in  its  own 
kind,  from  cheese  to  cheese ; and  if  the  Greek 
proverb  ‘grape  mellows  to  grape’  is  true  of  the 


CONTAGION. 

living  fruit,  the  apple-loft  gives  analogous  ex- 
periences of  contagion  among  the  fruit  which  is 
garnered. 

The  rationale  of  the  word  ‘ contagion,’  as  now 
used,  is  that  the  property  is  understood  to  attach 
itself  essentially  to  a material  contact ; not  neces- 
sarily that,  when  infection  is  spread  frem  indi- 
vidual to  indivi dual,  the  contact  of  the  individuals 
must  have  been  immediate ; but  that  in  all  casss 
there  must  have  been  such  passage  of  material 
from  the  one  to  the  other,  as  was  in  itself  at 
least  a mediate  contact  between  them.  And 
similarly,  in  those  very  instructive  illustrations 
of  the  process  of  contagion  which  are  furnished 
within  the  limits  of  a single  diseased  body  by 
the  propagations  of  disease  from  part  to  part  of 
it,  we  can  in  general  easily  see  that  infection 
advances  from  part  to  part,  either  in  proportion 
as  part  touches  part,  or  in  proportion  as  the  one 
receives  from  the  other  the  outflow  of  lymph  or 
blood  or  secretion. 

The  various  specific  matters  which  effect  con- 
tagion in  the  living  body,  the  respective  ' con- 
tagia’  of  the  given  diseases,  seem  all  to  have  in 
common  this  one  characteristic : that  in  appro- 
priate media  (among  which  must  evidently  be 
counted  any  living  bodily  texture  or  fluid  which 
they  can  infect)  they  show  themselves  capable  of 
self-multiplication ; and  it  is  in  virtue  of  this 
property  that,  although  at  the  moment  of  their 
entering  the  body  they  in  general  do  not  attract 
notice,  either  as  objects  of  sense  or  as  causes 
of  bodily  change,  they  gradually  get  to  be  re- 
cognisable in  both  of  these  respects.  Now.  the 
faculty  of  self-multiplication  is  eminently  one  of 
the  characters  which  we  call  vital ; and  when  it 
is  said  that  all  contagia  are  self-multiplying 
things,  this  is  at  leastvery  strongly  to  suggestthat 
perhaps  all  contagia  are  things  endowed  with  life. 

In  order  to  any  general  consideration  of  the 
question  thus  suggested,  contagia  may  conveni- 
ently (even  if  but  provisionally)  be  distinguished 
as  of  two  main  classes,  differing,  or  at  present 
seeming  to  differ,  from  each  other  in  their  mode 
of  action  on  the  organisms  which  they  infect : 
one  class,  namely,  that  of  Parasites;  and  the 
other  class,  that  of  the  true  or  Metabolic  Com- 
tagia.  Of  this  separation,  so  far  as  present 
knowledge  seems  to  justify  it,  the  assumed 
grounds  are:  that  each  true  Contagium,  in 
proportion  as  it  multiplies  in  the  body,  trans- 
forms, in  a way  which  is  specific  to  itself  and  is 
different  from  the  ways  of  other  contagia,  the 
bodily  material  with  which  it  has  contact;  while, 
on  the  contrary,  the  Parasite,  however  much 
it  may  grow  or  multiply  in  the  body,  produces  no 
qualitative  effects  specific  to  itself,  but  only  such 
effects  as  are  of  common  kind  to  it  and  all  other 
parasites — indications,  namely,  of  its  mechanical 
intrusiveness  in  the  parts  which  it  occupies,  and 
sometimes  of  the  drain  which  it  makes  on  its 
host's  general  nutritive  resources. 

A. — Of  Parasites,  in  relation  to  processes  of 
contagion,  little  needs  be  said  in  the  present 
article.  When  an  organism  or  part  of  it  is,  in 
greater  or  less  amount,  inhabited  by  other 
organisms,  animal  or  vegetable,  which  subsist 
on  it,  or  its  food  or  refuse,  it  of  course  may  bo 
a centre  of  infection  to  other  (if  susceptible) 
bodies  or  parts,  to  which  it  can  transmit  live 


CONTAGION.  287 


parasites  or  their  germs  or  seeds : for,  when 
this  transmission  takes  place,  growth  and  self- 
multiplication,  as  in  a colony,  are  the  natural 
results  which  hare  to  be  expected  ; and  in  pro- 
portion as  these  occur,  the  newly-infected  body 
or  part  gradually  gets  to  suffer,  like  the  old,  from 
those  particular  derangements  which  make  the 
type  of  parasitic  disease.  Some  parasitic  diseases, 
especially  some  of  those  of  the  skin,  spread 
actively  by  direct  contagion  in  ordinary  inter- 
course ; as  for  instance,  scabies  by  the  migration 
of  its  acari,  and  porrigo  (among  children)  by  the 
spores  of  its  microphyte;  and  the  spreading  of 
such  diseases  where  they  exist  may  of  course  be 
to  any  extent  facilitated  by  aggregation  of  per- 
sons and  uncleanliness  of  personal  habits.  There 
are  cases  in  which  parasitic  disease  spreads  from 
animal  to  animal  only  in  proportion  as  the 
ono  feeds  on  the  other,  and  eats  it  with  para- 
sites still  living  in  it ; or  in  proportion  as  live 
parasite-eggs  or  larvae,  discharged  from  the  body 
of  one  animal,  get  conveyed  with  food  (especi- 
ally on  raw  herbage  and  in  water)  into  the 
bowels  of  another.  Considerable  epidemics  of 
trichiniasis  in  the  human  subject  have  been 
traced,  chiefly  in  Germany,  to  infection  from  the 
pig;  in  cases  where  pork,  abounding  with  trichinae, 
has  been  eaten,  as  sausage-meat  or  otherwise,  in  a 
raw  or  imperfectly-cooked  state : and  in  Iceland 
the  very  great  sufferings  of  the  human  subject 
and  the  cattle  from  echinococcus  have  been 
traced  to  the  influence  of  the  dogs  in  spreading 
contagion  from  the  slaughter-house,  where  they 
cat  liydatidised  offal,  to  the  kitchen-gardens  and 
water-sources  and  pastures,  where  they  dis- 
charge tape-worm  eggs  from  their  bowels.  See 
Porrigo,  Scabies,  Trichina,  Hydatid,  &e. 

The  diseased  states  which  consist  in  being 
colonised  by  parasites  are  diseases  of  indefi- 
nite duration,  tending  in  some  cases  to  indefi- 
nite increase.  In  cases  where  the  disease  consists 
in  the  presence  of  swarms  of  blood-sucking  or 
otherwise  exhausting  animal  parasites,  symptoms 
of  the  blood-drain  will  of  course  gradually  arise; 
but  otherwise  the  parasite,  whether  animal  or 
vegetable,  operates  only  as  a mechanical  presence. 
Skin  and  mucous  membrane  will  be  irritated  in 
their  superficial  layers,  and  in  some  cases  more 
deeply,  by  the  animal  or  vegetable  parasites 
which  breed  on  or  in  them,  just  as  they  might  be 
by  dead  mechanical  irritants  : solid  organshaving 
cystic  entozoa  in  them  will  in  like  manner  show 
evidence  of  irritation  by  encapsulating  the  colo- 
nists; and  the  surrounding  tissue  will  of  course 
suffer  compression  and  displacement  in  proportion 
as  the  colonisation  ( e.g . in  case  of  echinococcus) 
is  compact  and  massive.  In  the  case  of  trichiniasis 
— but,  in  ourordinary  experience,  in  no  other — the 
multiplication  of  the  parasites,  the  burrowing  of 
their  young,  and  the  general  diffusion  of  these  in 
the  body,  are  processes  of  such  extreme  activity 
that,  if  the  quantity  of  contagium  taken  into  the 
stomach  has  been  large,  the  innumerable  local 
irritations  suffice  to  make  a very  acute  fever ; 
but  even  in  this  extreme  case,  the  merely  irrita- 
tive type,  though  exaggerated,  is  essentially  pre- 
served. 

As  different  sorts  of  animals  are  notoriously 
liable  to  different  sorts  of  parasites,  so,  even 
among  animals  of  one  sort,  as  for  instance  in  the 


human  kind,  the  liability  of  different  bodies  to 
receive  particular  parasite-infections,  does  not 
seem  to  be  quite  equal  for  all.  Especially,  the 
vegetable  parasites  seem  to  have  their  affinitie- 
determined  or  modified  by  the  general  state  of 
health  of  the  recipient;  and  there  are  cases  in 
which  it  looks  as  if  there  ran  in  particular  family- 
lines (perhaps  with  some  slight  chemical  idiosyn- 
crasy) a special  liability  to  particular  intestinal 
worms.  There,  however,  is  no  reason  to  believe 
that  in  regard  of  the  more  important  animal 
parasites,  as  particularly  of  trichina  and  the  taeni- 
adse,  the  susceptibility  of  individuals  to  attacks 
is  other  than  universal  and  practically  equal. 

B. — The  true  or  metabolic  contagia  (to  which 
the  rest  of  the  present  article  will  exclusively 
refer)— the  contagia  which,  in  their  respective 
and  specific  ways,  operate  transformingly  on 
the  live  bodily  material  which  they  affect,  are 
perhaps  the  most  important  of  all  the  inciden- 
tal physical  influences  which  concern  mankind. 
Whether  they  may  all,  at  some  time  hereafter, 
admit  of  being  named,  like  the  parasitic  con- 
tagia, in  terms  of  biological  classification,  is 
a question  which  needs  not  in  the  first  instance  be 
raised ; formeanwhile  the  identityof  each  separate 
true  contagium  is  settled  in  experimental  and 
clinical  observation  by  the  uniformity  of  tho 
operation  of  each  on  any  given  animal  body 
which  it  affects.  Each  of  the  diseases  propagates 
itself  in  its  own  form  in  as  exact  identity,  as  if 
it  were  a species  in  zoology  or  botany;  and  in 
each  such  repetition  of  the  disease  there  is  a 
multiplication — always  a large,  and  sometimes  an 
inconceivably  immense  multiplication,  of  material 
which  has  the  same  infective  property.  Evi- 
dences innumerable  to  that  effect  are  under  daily 
clinical  observation  in  this  climate  in  instances 
of  smallpox,  measles,  scarlatina,  whooping-cough, 
enteric  fever,  mumps,  typhus,  syphilis,  cowpox, 
diphtheria,  erysipelas,  hospital  gangrene,  puru- 
lent ophthalmia  and  gonorrhoea,  venereal  soft- 
chancre  and  phagedaena,  &c. : for,  barring  falla- 
cies, no  man  ever  sees  any  one  of  those  diseases 
produced  by  the  contagium  of  any  other  of 
them ; and  any  man  who  has  before  him  a caso 
of  any  of  them  can  see  that,  however  minute 
may  have  been  the  quantity  of  contagium  by 
which  the  disease  was  started,  the  patient's 
diseased  body  (part  or  whole)  yields  for  the  time 
an  indefinitely  large  supply  of  the  specific  agent. 
It  is  more  or  less  habitual  to  some  of  the  diseases 
that  the  infectedness  of  the  patient  is  first  made 
known  to  the  observer  by  such  general  'pyrexia 
as  tells  of  change  already  far  advanced  in  the  cir- 
culating mass  of  blood  ; and  it  is  only  after  this 
has  shown  itself,  that  other  symptoms,  adding 
themselves  to  the  fever,  complete  the  more  or  less 
complex  type  which  establishes  the  identity  of  the 
disease.  But  in  many  of  the  diseases  it  may  be 
the  case  (either  naturally  or  as  result  of  experi- 
mental infection)  that  the  first,  and  in  some  dis- 
eases the  main  or  even  the  only,  effects  of  the 
contagion  are  local  changes,  passing  where  wo  can 
from  the  first  observe  them  ; an!  the  broad  facts 
of  metabolic  infection,  as  regards  waste  of  bodily 
material  with  concurrent  increase  of  contagium, 
are,  in  many  such  cases,  among  our  most  familiar 
experiences.  Most  instructive,  too,  are  the  facta 
of  contagion  which  are  to  be  learnt  in  the  study 


CONTAGION. 


288 

of  tubercle:  the  contagium.  introducible  either  by 
tubercular  and  certain  septic  inoculations  through 
the  skin,  or  internally  by  the  infective  action  of 
the  milk  or  diseased  organs  of  tubercular  animals 
if  taken  as  food ; and  the  contagium,  when  intro- 
duced, gradually  spreading  as  it  multiplies,  and  as 
lymph  and  blood  carry  it  from  the  first  infection- 
spot  to  other  organs  which  now  will  repeat  the 
process.  And  similarly  in  cancer  (though  the 
primary  disease  is  at  present  of  unknown  origin 
and  cannot  be  created  by  experiment)  the  repeti- 
tion of  the  primary  disease  in  secondary  and  ter- 
tiary propagations  in  the  body  of  the  sufferer  is 
one  of  themoststrikingof  all  evidences  of  conta- 
gion ; because  of  the  great  number  of  structural 
types  which  pass  under  the  name  of  cancer,  and 
the  fidelity  with  which  each  of  them  is  repro- 
duced in  the  organ  to  which  the  contagion  ex- 
tends. A further  fact  of  contagion,  deserving 
notice  in  the  present  context,  is  the  local  spread 
of  certain  of  these  processes  by  continuity  of 
tissue;  as,  for  instance,  in  the  continuous  ex- 
tension of  phagedama  or  hospital-gangrene  from 
any  centre  of  first  inoculation,  or  of  tubercular 
softening  or  cancer  at  the  place  where  it  begins : 
a mode  of  extension  which  indicates  successive 
infective  actions  of  matter  on  matter  in  spheres 
of  ever-widening  circumference ; 1 and  the  like 
of  which,  but  in  rudimentary  degree,  may  be 
traced  in  the  areola  of  any  acute  inflammation. 

In  the  physiology  of  the  metabolic  contagia 
no  facts  are  more  characteristic  or  more  important 
than  those  which  show  the  eelativeness  of  par- 
ticular contagia  to  particular  receptivities  of 
body.  First,  and  in  intimate  connexion,  as  would 
seem,  with  a chemical  electiveness  of  action  which 
will  presently  be  imputed  to  contagia,  there 
is  the  preference  which  some  particular  contagia 
(however  introduced  into  the  system)  show  for 
particular  organs  of  the  body ; so  that,  by  the 
exercise  of  this  preference,  there  is  given  to  each 
of  the  diseases  its  own  set  of  clinical  and  ana- 
tomical characters.  Compare,  as  instances  in 
this  point  of  view,  the  respective  local  affini- 
ties of  smallpox,  enteric  fever,  mumps,  syphilis, 
hydrophobia,  &c. — Secondly,  it  may  be  noted 
that,  in  regard  to  some  of  the  contagia,  different 
persons,  and  particularly  persons  of  different 
family-stocks,  show  original  differences  of  sus- 
ceptibility; original,  namely,  as  distinguished 
from  others,  hereafter  to  be  mentioned,  which 
are  acquired;  so  that,  for  instance,  the  severity 
with  -which  scarlatina  or  diphtheria  will  strike 
in  particular  families  contrasts  with  a com- 
parative mildness  of  the  same  disease  in  other 
families,  or  perhaps  even  with  eases  of  ap- 
parently complete  personal  immunity  under  ex- 
posure to  the  particular  danger:  and  recent 
researches  have  seemed  to  suggest  as  possible 
that,  in  the  very  wide  differences  of  degree 
with  which  tubercular  disease  prevails  in  differ- 
ent families,  an  essential  condition  may  be,  that 
the  families  have  widely  different  degrees  of 
original  predisposition  towards  some  of  the 
septic  contagia. — Thirdly,  there  is  the  extremely 
suggestive  fact  with  regard  to  many  of  our  best- 
known  febrilising  contagia,  that  they  run  a 
* Compare  Tennyson’s 

‘ little  pitted  speck  in  garnered  fruit, 

Which,  rotting  inward,  slowly  moulders  all.’ 


course  of  definite  duration,  and  that  in  this 
course,  provided  the  patient  do  not  die,  all 
present,  perhaps  all  future,  susceptibility  to  the 
particular  contagium  is  utterly  exhausted  from 
the  patient ; so  that  re-introduction  of  the  same 
contagium  will  no  more  renew  that  patient's 
disease  than  yeast  will  excite  a new  alcoholic 
fermentation  in  any  previously  well-fermented 
bread  or  wine.  The  inference  from  this  fact  seems 
unavoidable,  that  each  such  contagium  operates 
with  a chemical  distinctiveness  of  elective  affinitv 
on  some  special  ingredient  or  ingredients  of  the 
body ; and  that  exhausting  this  particular  mate- 
rial in  febrile  process,  which  necessarily  ends 
when  the  exhaustion  is  complete,  is  the  bodily 
change  which  the  contagium  ‘specifically’  per 
forms. — Of  not  all  metabolic  contagia,  however 
can  it  be  said  that  their  operation  runs  so  definite 
and  self-completing  a course.  For,  first,  there 
are  particular  acute  infections  which,  as  a rule, 
kill ; either  (as  appears  to  be  the  case  in  splenic 
fever  when  affecting  man)  because  of  the  extreme 
magnitude  of  the  transforming  process  which  the 
contagium  sets  up,  or  else  (as  appears  to  he  the 
case  in  hydrophobia)  because  the  elective  in- 
cidence of  the  contagium  is  on  an  organ  indis- 
pensable to  life  ; so  that  in  such  cases  there  is 
in  fact  hardly  such  an  event  as  passing  alive 
through  the  whole  process  of  the  disease.  And 
secondly,  there  are  the  contagious  dyscrasies 
which  are  clearly  characterised  by  their  tendency 
to  indefinite  duration  : syphilis,  which  oftener 
than  not  relapses  in  successive  outbreaks,  and 
often  as  years  pass  invades  the  body  more  and 
more  deeply,  and  may  after  all  never  during  life 
be  ended ; and  tubercle  and  cancer,  which,  with 
almost  invariable  persistence,  will  in  general 
steadily  advance  month  by  month  to  infect  more 
and  more  of  the  body  till  the  process  eventuates 
in  death. 

The  transmission  of  various  contagious  diseases 
ix  communities  is  of  course  greatly  influenced, 
both  in  detail  and  in  aggregate,  by  such  differ- 
ences of  individual  receptivity  as  were  men 
tioned  in  the  last  section.  Notably,  as  regards 
communities  through  which  particular  acute  in- 
fections have  had  full  run,  fresh  sparks  of  the 
contagium  may  find  little  or  no  fuel  on  which  to 
act ; and  much  new  diffusion  of  the  disease  may 
not  again  be  possible,  till  immigration,  or  births, 
or  lapse  of  time  operating  in  other  ways,  shall 
have  reconstituted  a susceptible  population.  And, 
given  the  susceptible  population,  circumstances 
of  time  and  place  are  infinitely  various  (especi- 
ally as  regards  quantity  and  quickness  of  per- 
sonal or  quasi-personal  intercourse)  in  determin 
ing  how  far  this  population  shall  have  particular 
contagia  thrown  in  its  way. 

Also  there  are  conditions,  not  primarily  of 
a personal  kind,  which  operate  on  a very  large 
scale  in  determining  the  spread  of  some  of  the 
metabolic  infections  : giving  to  them  respec- 
tively at  certain  times,  in  ways  not  hitherto 
understood,  a special  increment  of  spreading- 
power,  and  in  some  instances  also  special  malig- 
nity : and  thus  enabling  them  respectively  from 
time  to  time  to  come  into  comparative  prominence 
in  national  life,  and  perhaps  at  once  or  success- 
ively in  many  different  countries,  in  the  form  of 
so-called  epidemics.  Thus,  it  is  matter  of  familiar 


CONTAGION. 


knowledge  that  the  fevers  -which  are  most 
habitual  to  this  country,  scarlatina,  measles, 
6mallpox,  enteric  fever,  are  of  nothing  like 
uniform  prevalence, — that  scarlatina, for  instance, 
will  be  three  times  as  fatal  in  one  year  as  in 
another,  and  that  smallpox  is  liable  to  even 
greater  exacerbations : and  it  is  known  that 
temporary  differences  of  this  kind  are  not  exclu- 
sively local, — that,  for  instance  (to  quote  a late 
official  report)  ‘ the  epidemic  of  smallpox  which 
began  in  England  towards  the  close  of  1870  and 
terminated  in  the  second  quarter  of  1873  was 
part  of  a general  epidemic  outbreak  of  that 
disease,  of  world-wide  diffusion,  marked  wher- 
ever it  occurred  by  an  intensity  and  malignity 
unequalled  by  any  previous  epidemic  of  the 
disease  within  living  memory.’  The  wider  the 
survey  which  wo  take  of  epidemiology,  the 
more  certain  it  becomes  to  us,  that,  outside  the 
conditions  which  are  independently  personal 
or  local,  there  are  cosmical  conditions  which 
have  to  be  considered.  Doubtless  there  are 
great  epidemiological  facts — such,  for  instance, 
as  the  first  spreading  of  smallpox  to  America,  or 
in  our  own  times  the  increasing  frequency  of 
Asiatic  cholera  in  Europe,  which  may  be  ascribed 
to  novel  conditions  of  international  intercourse: 
but  there  are  others,  equally  great,  to  which 
apparently  no  such  explanation  can  be  applied. 
For  what  reason  it  is  that  cholera  every  few  years 
has  its  definite  fit  of  extension  in  India, — or  why 
diphtheria,  which  scarcely  had  a place  in  history 
till  it  overran  Europe  in  the  16th  century,  and 
which  since  then  had  been  rarely  spoken  of, 
began  again  some  twenty-odd  years  ago  to  be 
comparatively  import antin  England, — or  why  the 
plague  of  the  Levant  has  for  the  last  two  centu- 
ries been  so  unfamiliar  to  us, — or  why  the  yellow 
fever  of  the  Mississippi  has  in  particular  years 
raged  furiously  in  parts  of  Europe, — or  why  our 
black-death  of  the  14th  century,  though  appar- 
ently still  surviving  in  India,  has  never  but  that 
once  been  in  Europe. — or  whither  has  gone  our 
sweating-sickness  of  three  centuries  ago, — or 
whence  have  come  the  modern  epidemics  of 
cerebro-spinal  meningitis : these,  and  many  like 
questions,  which  cannot  at  present  be  answered, 
seem  to  be  evidence  enough  that,  in  the  making 
of  epidemics,  contagion  and  personal  suscepti- 
bility may  be  factors  in  a partly  conditional  sense. 
Influences  which  are  called  ‘ atmospheric  ’ — the 
various  direct  and  indirect  influences  which 
attach  to  the  normal  succession  and  occasional 
abnormality  of  seasons,  in  respect  of  the  insola- 
tion of  our  planet,  and  of  the  temperature  and 
humidity  of  air  and  earth — are  in  general  far  too 
vaguely  regarded  as  elements  of  interest  in  the 
present  question,  but  are  possible  factors  which 
no  epidemiologist  should  omit  from  scientific 
consideration.  For  any  definite  knowledge  which 
exists  on  the  relation  of  particular  conditions  of 
season  to  the  prevalence  of  particular  epidemics, 
the  reader  is  referred  to  the  article  Epidemics, 
and  to  articles  on  the  respective  diseases. 

In  the  passage  of  the  metabolic  contagia  from 
person  to  person  various  agencies  may  be  in- 
strumental,— bedding  or  clothing  or  towels  which 
have  been  used  by  the  sick,  dirty  hands,  dirty 
instruments  or  other  utensils,  the  washerwoman’s 
basket,  foul  water-supply,  stinking  house-drains, 

19 


289 

contaminated  milk  or  other  food,  the  common 
atmosphere,  &e.  ; but  differences  of  that  sort 
are  only  differences  as  to  the  means  by  which 
stock  communication  is  established  with  a dis- 
eased body  as  brings  its  products  into  relation 
with  healthy  persons;  and  the  disengagement 
of  infectious  products  from  the  bodies  of  the 
sick  is  pathologically  the  one  influential  fact. 
As  regards  the  products  which  ought  to  be 
deemed  infectious,  the  specially-diseased  sur- 
faces and  organs  of  the  patient,  and  the  dis- 
charges and  exhalations  which  they  respectively 
yield,  must  always  be  regarded  with  chief  sus- 
picion; but  suspicion,  however  much  it  may 
insist  on  them,  must  never  disregard  other 
sources  of  danger.  Of  some  of  the  metabolic 
contagia  we  practically  know,  and  of  many  of 
the  others  we  may  by  analogy  feel  sure,  that, 
w-hen  a given  body  is  possessed  by  one  of  them, 
no  product  of  that  body  can  be  warranted  as 
safe  not  to  convey  the  infection.  Presumption 
against  every  part  and  product  of  the  diseased 
body  is  by  everyone  readily  admitted  where 
there  are  vehement  general  symptoms  of 
disease:  but  it  is  important  to  know  that  not 
only  in  such  febrile  states,  but  even  in  states  of 
chronic  dyscrasy,  and  even  at  times  when  the 
dyserasy  may  be  giving  no  outward  sign,  the 
infected  body  may  be  variously  infective.  Thus, 
in  regard  to  constitutional  syphilis,  it  is  certain 
that  the  mere  utero-catarrhal  discharge  of  the 
syphilitic  woman,  or  the  sperm  of  the  syphilitic 
man,  or  the  vaccine  lymph  of  the  syphilitic 
infant,  may  possibly  contain  the  syphilitic  cca- 
tagium  in  full  vigour,  even  at  moments  when  the 
patient,  who  thus  shows  himself  infective,  has 
not  on  his  own  person  any  outward  activity  of 
syphilis.  Similarly,  in  regard  to  tubercular  dis- 
ease, experiment  has  proved  beyond  question  that 
the  milk  of  animals  suffering  from  tubercle  will, 
if  taken  as  food  by  other  animals,  infect  them 
through  the  intestinal  mucous  membrane : and 
there  are  independent  reasons  for  believing  that 
the  tubercular  contagium  (like  the  syphilitic) 
will  at  times  during  the  dyscrasy  be  contained 
in  the  seminal  fluid,  and  that  men,  tubercular 
perhaps  only  in  some  degree  which  is  not  im- 
mediately important  to  themselves,  may  by  that 
secretion  convey  fatal  infection  to  women  with 
whom  they  have  conjugal  relations.'  Regarding 
many  of  the  metabolic  contagia,  conclusive  evi- 
dence exists  that,  when  they  are  in  operation 
in  pregnant  women,  the  foetus  will  in  general 
be  infected  by  them ; and  this  though  the 
diseases  (e.g.  smallpox,  cholera,  syphilis)  be  of 
the  most  different  pathological  types : but  with 
regard  to  pregnant  animals  affected  with  splenic 
fever  it  is  noticeable  that  Brauell,  in  his  ex- 
tensive researches,  found  the  blood  of  the  foetus 
not  to  be  infective. 

In  general,  each  contagium  has  its  own 
favourite  w^ay  or  ways  of  entering  the  body  ; 
and  these  preferences  are  not  only  of  speculative 
interest,  as  attaching  to  varieties  of  nature  and 
natural  habits  among  the  contagia,  but  are  of 
obvious  practical  importance  as  measures  of  the 
widely  different  degrees  in  which  the  different 
contagia  are  qualified  to  spread  in  communities. 
Thus,  inoculation  at  broken  surfaces  of  skin 
1 See  Dr.  Weber,  in  Clin.  Soc.  Trans.,  1874- 


CONTAGION. 


1 90 

t mucous  membrane  has  long  been  known  as 
the  ordinary  mode  by  which  the  infections  of 
syphilis,  hydrophobia,  splenic  fever,  cowpox,  and 
tarcy  or  glanders,  get  admission  to  the  body; 
and  our  best  knowledge  of  some  other  infec- 
tious diseases  (notably  of  tubercle)  has  been 
derived  from  inoculations  intentionally  made 
with  their  contagia  for  purposes  of  study. 
While  probably  all  infections  which  tend  to  be 
of  general  action  on  the  body  can  be  brought  into 
action  in  that  way,  and  while  some  infections 
are  not  known  to  pass  by  any  other  mode  of 
transmission,  there  are  many  infections  which 
spread  freely  from  subject  to  subject  by  atmo- 
spheric and  dietetic  communication ; and  the 
meaning  of  these  preferences  is  hitherto  not 
fully  known.  It  seems  that  some  contagia  are  so 
acted  upon  by  air  and  water,  that  they  seldom  or 
never  reach  the  body  in  an  effective  state  by  those 
common  means  of  communication, — some  hardly, 
if  at  all,  by  water,  and  some  not  by  air  except  with 
very  close  intercourse ; and  further,  that,  of  eon- 
tagia  which  reach  the  body  in  an  effective  state, 
some  require,  while  others  do  not  require,  that 
an  abnormal  breach  of  surface  shall  give  them 
special  opportunity  for  taking  hold.  In  some  of 
the  cases  where  a disease  can  be  propagated  in 
both  ways, — i.e.,  certainly  in  smallpox,  and 
apparently  also  in  bovine  pleuro-pneumonia,  tbs 
artificially-inoculated  disease  tends  to  bo  much 
milder  than  the  disease  otherwise  contracted;  but 
pathologically  it  is  difficult  to  conceive  any  essen- 
tial difference  between  those  different  modes  of 
contagion.  It  may  be  presumed  that,  in  the  modes 
which  are  not  by  true  inoculation,  acts  which 
are  comparable  to  inoculation  take  place  on 
internal  surfaces  ; that,  for  instance,  when 
particles  of  scarlatina-contagium  are  caught 
in  the  tonsils,  or  inhaled  into  the  bronchi,  or 
swallowed  into  the  stomach,  they  begin  by  pene- 
trating the  texture  of  the  mucous  membrane, 
and  by  thus  effecting  as  real  an  inoculation,  with 
regard  to  the  blood,  as  that  which  art  or  acci- 
dent provides  in  other  cases  through  the  punc- 
tured skin.  That  previous  abnormal  breach  of 
surfaco  by  artificial  puncture  or  otherwise  is  not 
necessary  to  allow  the  infection  of  mucous  sur- 
faces is  illustrated  in  ophthalmia  and  gonor- 
rhoea ; where  apparently  no  other  condition  has 
to  be  fulfilled  than  that  a particle  of  the  blen- 
orrhagie  contagiiun  shall  be  deposited  on  the 
natural  surface  of  the  mucous  membrane.  It 
deserves  notice  that,  while  a considerable  number 
of  the  worst  diseases  of  the  domestic  animals 
admit  of  being  communicated  to  man  by  artificial 
inoculation  atmospheric  communication  seems  to 
be  very  inapt,  if  not  absolutely  unable,  to  infect 
man  with  any  one  of  them  ; and  in  this  connection 
it  may  be  of  interest  to  remember  that  syphilis, 
one  of  the  most  familiar  of  human  infections, 
but  hitherto  not  traced  to  any  brute  ancestry, 
differs  from  our  other  current  infections  in  re- 
quiring inoculation  to  transmit  it. 

When  any  metabolic  contagium  enters  the 
animal  body,  it  requires  an  interval  of  time,  and 
'.n  most  cases  a considerable  interval,  before  its 
morbific  effects  can  become  manifest  even  to 
skilled  observation.  The  period  of  latency  or 
so-called  incubation  varies  greatly  in  different 
cases.  In  hydrophobia  it  is  very  rarely  less 


than  of  one  month,  is  certainly  often  of  several 
months,  and  is  said  to  be  sometimes  of  years. 
In  syphilis  the  inoculated  spot  remains  generally 
for  at  least  a fortnight,  and  may  remain  even 
as  much  as  five  weeks,  without  any  ostensible 
change  ; and  the  roseola  of  the  general  infection 
will  not  be  seen  till  some  weeks  later,  when 
generally  at  least  three  months  will  have 
elapsed  since  the  first  inoculation.  In  the  acuts 
eruptive  fevers,  when  their  contagium  is  trans- 
mitted by  air,  the  first  changes  which  ensue  cd 
infection  are  not  external,  and  we  cannot  be  sura 
what  early  internal  changes  may  take  place ; bnt 
in  smallpox,  the  fever  (which  is  the  first  overt 
sign)  does  not  attract  notice  till  about  the  twelfth 
day  after  infection,  nor  the  eruption  till  two  days 
later;  and  in  measles  the  incubation-time,  though 
perhaps  less  uniform,  seems  to  be  little  (if  any) 
shorter  than  that  of  smallpox.  The  septic  con- 
tagia and  the  contagium  of  splenic  fever  seem  to 
be  of  particularly  quick  operation  ; but  even  the 
most  virulent  septic  contagium,  when  without 
admixtures  which  tend  to  complicate  its  action, 
will  not  begin  sensibly  to  derange  the  infected 
animal  till  at  least  several  hours  after  it  has 
been  inoculated.  As  regards  the  contagia  last 
referred  to,  it  is  conceivable  that  the  self-multi- 
plication of  the  contagium  in  the  form  in  which 
it  proves  fatal  to  life  is  a process  which  goes  on 
continuously  and  uniformly  from  the  moment  of 
inoculation  to  the  moment  of  death,  and  that  the 
moment  when  signs  of  general  derangement  be- 
come manifest  is  the  moment  when  this  uniformly 
advancing  process  has  accumulated  in  the  system 
a certain  quantity  of  result : — but  it  does  not 
seem  easy  to  apply  this  explanation  to  the  dis- 
eases of  long  incubatory  period  ; and  we  can 
hardly  conjecture  what  may  be  the  latent  pro- 
cesses— for  instance,  of  smallpox,  during  tli6  first 
ten  or  more  days  after  contagium  has  been 
received. 

Itisnotyetpossibletosay,  many-universal  sense, 
with  regard  to  the  metabolic  coutagia,  what  is  the 
essential  constitution  of  ‘ contagious  matter,’  or 
what  the  intimate  nature  of  the  ‘transforming 
power  ’ which  the  particle  of  such  matter  exer- 
cises on  the  particles  which  it  infects. — As 
regards  the  question  of  the  force,  chemists, 
when  they  refer  in  general  terms  to  the  various 
acts  which  they  designate  acts  of  fermenta- 
tion, allege  that  certain  processes  of  change  in 
certain  sorts  of  organic  matter  induce  charac- 
teristic changes  in  certain  other  sorts  of  organic 
matter,  not  by  the  common  chemical  way  of 
double  decomposition  with  reciprocally  new  com- 
binations, but  (so  to  speak)  as  a mere  by-play 
or  collateral  vibration-effect  of  the  chemical 
force  which  is  in  movement ; and  though 
language  can  hardly  be  more  vague  than  this  for 
any  scientific  purpose,  it  expresses  clearly  enough 
the  conviction  of  experts  that  a certain  great 
force  in  nature  lies  beyond  their  power  even  of 
definite  nomenclature,  much  more  of  exact  iden- 
tification and  measurement.  In  that  most 
interesting,  but  most  difficult  and  hitherto 
almost  uninvestigated,  branch  of  chemical 
dynamics,  we  are  supposed  to  have  our  nearest 
clue  to  the  scientific  problems  of  the  present 
subject-matter.  It  may  be  conceded  that  ibe 
‘ contact-influences  ’ which  are  dimlv  rocoeaine  i 


CONTAGION. 


is  causing  the  fermentatory  changes  of  dead 
organic  matter  have  apparent  analogues  in 
many  of  the  morbific  influences  of  contagion  : 
for  the  changes  -which  chemists  call  ‘ fermenta- 
tory ’ are  all  catalytic  or  disintegrative  of  the 
organic  compounds  which  they  affect;  and  when 
living  protoplasm  is.  brought  by  contagion  into 
processes  of  characteristic  decay , the  analogy 
seems  sufficiently  close  to  justify  the  word 
eymotic  in  the  naming  of  the  nature  of  the  pro- 
cess. But  it  must  not  be  forgotten  that,  among 
immediate  effects  of  contagion  in  the  living  body, 
are  cases  wherein  the  process  (so  far  as  we 
can  yet  see)  is  primarily  not  catalytic  or  dis- 
ntegrative,  but,  on  the  contrary,  anaplastic  or 
ffon-structive.  Thus,  when  tubercle  gives  rise 
.o  tubercle,  whether  by  secondary  and  tertiary 
infection  in  a single  diseased  body,  or  by  infec- 
tion from  the  sick  to  the  healthy,  each  new 
tubercle  which  the  contagion  brings  into  being  is 
a growth-product  of  the  texture  which  bears  it. 
And  similarly,  when  the  innumerable  varieties 
of  cancerous  tumour  propagate  themselves  by 
contagion,  each  after  its  special  type,  in  the 
bodies  of  the  respective  sufferers,  it  is  growth, 
not  disintegration,  which  we  first  see.  It  would 
seem  that  in  those  cases  of  anaplastic  ‘ contact- 
influence  ’ something  far  beyond  the  analogy  of 
chemical  fermentations  must  be  involved ; and, 
in  view  of  some  of  them,  the  physiologist  has  to 
bethink  himself  of  the  analogy  of  that  ‘ contact- 
influence  ’ which  becomes  the  mainspring  of 
all  normal  growth  and  development,  when  the 
ovum  receives  spermatic  impregnation. — -As 
regards  the  ultimate  organic  constitution  of  the 
several  metabolic  contagia — (each  of  them  of 
course  abstracted  from  accidental  admixtures, 
and  seen  or  conceived  in  the  smallest  and 
simplest  units  of  quantity  and  quality  in  which 
its  specific  force  can  be  embodied) — modern  re- 
search seems  more  and  more  tending  to  show 
that  the  true  unit  of  each  metabolic  conta- 
gium  must  either  be,  or  must  essentially  include, 
a specific  living  organism , able  to  multiply  its 
kind.  For  with  regard  to  those  other  contagia 
( as  we  may  properly  call  them)  which  spread 
fermentatory  processes  in  common  external 
nature,  and  of  which  it  is  as  clear  as  of  the 
morbific  contagia  that  they  multiply  themselves 
in  proportion  as  they  act,  it  seems  to  be  estab- 
lished beyond  reasonable  doubt  that  the  ‘ self- 
multiplication’ of  each  of  them  as  it  acts  is  the 
infinite  multiplication  of  a specific  microphyte  ; 
and  that  this  microphyte  (acting  apparently  by 
means  of  a matter  which  it  produces  and  from 
which  it  can  be  mechanically  separated)  is  the 
essential  originator  of  the  fermentation.1  This 
being  the  case  in  regard  of  those  fermentations, 
it  seems  probable  that  the  same  is  in  substance 
true  of  the  specific  morbid  changes  which 
extrinsic  contagia  produce  in  the  materials  of 

' The  doctrine  to  which  the  words  in  parenthesis  refer 
I that  the  microphyte  is  not  itself  the  ferment,  but  the 
producer  and  evolver  of  the  ferment)  tends  to  bring 
the  case  of  these  ferments  into  parallelism  with  that  of 
the  chylopoetic  and  other  functional  ferments  which 
more  highly  organised  creatures  produce  for  the  purposes 
i f their  own  economy.  In  the  latter  case  the  distinc- 
tion between  the  ferment-yielding  live  bodies  (say  cer- 
tain gastric  cells)  and  their  not-live  product  (say  pepsin) 
is  already  familiar. 


291 

the  living  body:  probable,  namely,  that  low, 
self-multiplying  organic  forms,  specific  in  each 
case  for  the  particular  disease  which  is  in  ques- 
tion, are  essential  to  each  morbid  poison  ; that 
the  increase  of  each  contagium  as  it  acts  is  the 
characteristic  self-multiplication  of  a living  thing ; 
and  that  this  (however  obscure  may  yet  remain 
its  mode  of  operation)  is  the  essential  originator 
of  change  in  the  affected  materials  of  the  diseased 
body.  The  fact  that  low  organic  forms  of  the  sorts 
now  spoken  of  have  often,  or  generally,  been 
seen  in  the  morbid  products  and  tissues  of  per- 
sons with  zymotic  disease,  would  not  by  itself 
be  a proof,  or  nearly  a proof,  that  the  forms  are 
causative  of  the  morbid  change  : for  obviously 
they  might  be  mere  attendants  on  the  necrosis 
and  decomposition  of  bodily  material,  availing 
themselves  of  the  process  (just  as  certain  insects 
would)  to  feed  and  multiply  : and  in  many  of  tho 
cases  in  which  micrococci  have  been  seen  in 
morbid  material,  no  direct  proof  could  be  given 
that  the  meaning  of  their  presonee  was  more  than 
that.  There  are,  however,  some  cases  in  which 
this  proof  has  been  completely  established;  and 
though  such  cases  are  at  prosent  but  few,  the 
significance  of  each  of  them  in  aid  of  the  inter- 
pretation of  other  cases  is  of  the  highest  im- 
portance. The  researches  of  successive  able 
observers  in  regard  of  the  splenic  fever  of 
farm-stock,  and  those  of  Dr.  Klein  in  regard 
of  the  ‘pneumo-enteritis’  (as  he  names  it)  of 
swine,  have  shown  that  in  each  of  these  cases 
the  microphyte  which  attends  the  disease  is 
botanically  specific;  that  it  and  its  progeny 
can  be  conducted  through  a series  of  artificial 
cultivations  apart  from  the  animal  body;  and 
that  germs  thus  remotely  descended  from  a first 
contagium  will,  if  living  animals  be  inocu- 
lated with  them,  breed  in  these  animals  tho 
specific  disease.  It  is  equally  well  known  that 
the  organisms  (spirilla)  which  are  found  multi- 
plying  in  the  blood  during  the  accesses  of  relaps- 
ing fever  are  botanically  specific ; but  in  regard 
to  this  disease,  experimental  proof  has  not 
hitherto  been  given  that  the  spirilla,  if  sepa- 
rately inoculated,  will  infect  with  relapsing 
fever.  Studies  as  complete  as  those  which 
have  been  made  in  splenic  fever  and  pneumo- 
enteritis will  no  doubt  sooner  or  later  be  made 
in  regard  to  many  other  of  the  diseases,  hut 
their  progress  will  necessarily  be  slow;  partly 
because  the  objects  which  have  to  he  scrutinised, 
and  to  which  specific  characters  have  to  ho 
assigned,  are  so  extremely  minuto,  and  often  so 
similar  among  themselves,  that  none  hut  very 
skilled  and  very  patient  microscopical  observers 
are  competent  to  pronounce  on  them;  and  partly 
again  because  the  conditions  of  the  case  aresucti 
as  to  limit  very  closely  the  field  within  which 
the  essential  experimental  observations  can  he 
made.  Meanwhile,  however,  the  two  diseases, 
regarding  which  the  larger  knowledge  has  been 
obtained,  must  he  regarded  as  highly  suggestive 
in  regard  of  other  diseases  of  the  same  patholo- 
gical group,  and  particularly  as  giving  impor- 
tance to  fragments  of  evidence  (not  by  them- 
selves conclusive)  which  have  been  gathered  of 
late  years  in  studies  cf  some  of  these  other 
diseases.  Eminently  this  is  true  of  the  large 
family  of  the  septic  infections — including  on  the 


CONTAGION. 


292 

one  hand  erysipelas  and  pyaemia  -with  its  conge- 
ners, and  haring  on  the  other  hand  tuberculosis 
Intimately  associated  with  it ; and  almost  equally 
it  is  true  of  enteric  fever  and  cholera  and  diph- 
theria, and  of  the  smallpox  of  man  and  beast. 
Thus,  though  it  would  be  at  least  premature  to 
say  of  these  diseases  that  they  certainly  have  as 
their  contagia  microphytes  respectively  specific 
to  them,  it  seems  at  present  not  too  much  to 
say  that  probably  such  will  be  found  tho  case  ; 
and  if  as  much  may  not  yet  be  said  of  many  other 
diseases  which  are  due  to  metabolic  contagia,  it 
must  be  remembered  that  the  right  lines  of  study 
relating  to  contagia  in  this  point  of  view  have 
not  till  within  very  recent  times  been  opened. 

Of  the  naturae  history  of  the  contagia,  con- 
sidered independently  of  the  part  which  they 
play  in  the  living  body,  there  are  hitherto  only 
the  beginnings  of  knowledge.  The  absolutely 
first  origin  of  contagia  may  perhaps  not  be  more 
within  reach  of  scientific  research  than  the  abso- 
lutely first  origin  of  dog  or  cat ; but  their  nearer 
antecedents — the  states  out  of  which  they  come 
when  first  about  to  act  on  the  living  body, 
and  generally  the  variations  which  they  and  the 
common  ferments  exhibit  under  natural  and 
artificial  changes  of  circumstance,  are  within 
easy  reach  of  investigation  ; and  those  humbler 
studies  are  likely  to  give  very  useful  results. 
For  some  of  our  cases  we  seem  to  have  an 
instructive  analogy  in  the  facts  which  Professor 
Mosler  has  put  together  in  explanation  of  the 
blue-millt  contagium  of  dairies  : facts  showing 
that  the  omnipresent  penicillium  glaucum,  if  its 
spores  happen  to  alight  in  particular  (morbid) 
sorts  of  milk,  will  operate  distinctively  on  their 
casein  as  an  anilin-making  ferment,  rendering 
the  milk  blue  and  poisonous,  and  imparting  to 
each  drop  of  it  the  power  to  infect  with  a like 
zymosis  auy  normal  milk  to  which  it  may  be 
added.1  In  our  own  more  special  field,  patholo- 
gists have  already  learnt  that  certain  of  the 
so-called  ‘morbid  poisons’  — the  contagia  of 
erysipelas,  pyaemia  and  tuberculosis,  are  inti- 
mately related  to  the  common  ferment  or  fer- 
ments of  putrefaction ; and  that  the  most  vehe- 
ment of  these  contagia  can  be  developed  by  the 
artificial  culture  of  successive  transmissions  in 
the  living  body  from  the  comparatively  mild 
contagium  of  any  common  inflammatory  process.2 

Two  other  directions  suggest  themselves  as 
likely  to  lead  to  fields  of  useful  observation 
and  experiment.  On  the  one  hand,  in  compara- 
tive pathology , and  with  the  tracing  of  contagion 
from  animal  to  animal,  there  is  the  possibility 
that  at  last  some  lower  and  relatively  worth- 
less order  of  animals  may  be  found  the 
starting-ground  of  fatal  infections  for  higher 
orders ; and  this,  perhaps,  by  contagia  which  in 
their  former  relations  are  of  mere  inflammatory 
significance.  On  the  other  hand,  in  geographical 
pathology , and  with  the  tracing  of  contagion 
from  place  to  place,  local  centres  of  contagium- 

1 Virch.  Arch.,  vol.  43. 

* See  particularly  Professor  Sanderson’s  papers  in  suc- 
cessive yearly  volumes  of  Reports  of  the  Medical  Officer  of 
the  Privy  Council  from  1868  to  1877.  It  concerns  the 
second  fact  mentioned  in  the  text  to  remember  that  ap- 
parently every  ‘ common  inflammatory  process  ’ includes 
more  or  less  of  textural  changes  which  are  necrotic  and 
of  septic  tendency.  See  Holmes’s  System  of  Surgery,  first 
edition,  article  ‘ Inflammation.’ 


origination  may  possibly  be  f und,  in  which  th< 
contagium,  before  it  enters  the  animal  body,  will 
show  itself  an  independent  microphyte  of  the 
earth,  first  operating  on  the  animal  body  as  the 
essential  force  in  a local  malaria.  Some  of  the 
worst  pestilences  known  to  the  human  race — 
yellow  fever,  cholera,  perhaps  plague,  and  alsc 
some  of  the  diseases  of  cattle,  have  in  then 
history  facts  which  suggest  that  sort  of  interpre- 
tation : the  supposition,  namely,  that  certain 
microphytes  are  capable  of  thriving  equally 
(though  perhaps  in  different  forms)  either  with- 
out or  within  the  animal  body  ; now  fructifying 
in  soil  or  water  of  appropriate  quality,  and  now 
the  self-multiplying  contagium  of  a bodiiy 
disease.  In  regard  to  our  own  common  ague- 
poison  there  seems  every  reason  to  suspect  that 
its  relation  to  soil  is  that  of  a microphyte ; and 
though  we  know  ague  only  as  practically  a non- 
contagious  disease,  we  do  not  know  that  any 
little  transfusion  of  blood  from  sick  to  healthy 
would  not  show  it  to  be  (in  that  way)  communi- 
cable from  person  to  person. 

It  needs  hardly  be  said  that  exact  scientific 
knowledge  of  the  contagia,  and  of  their  respec- 
tive modes  of  operation,  is  of  supreme  importance 
to  the  prevention  of  disease.  With  even  such 
knowledge  of  them  as  already  exists,  diseases 
which  have  in  past  times  been  most  murderous 
of  mankind  and  the  domestic  animals  can,  if  the 
knowledge  be  duly  applied,  be  kept  compara- 
tively, or  absolutely,  in  subjection  ; and  the  fact 
that  at  the  present  time  fully  a fifth  part  of  tho 
annual  mortality  of  the  population  of  England 
is  due  to  epidemics  of  contagions  disease  is  only 
because  of  the  very  imperfect  application  hitherto 
made  of  that  knowledge.  In  the  present  article 
it  is  not  necessary  to  state  in  detail  the  practice 
which  ought  to  he  adopted  in  the  various  different 
cases  of  infectious  disease ; but  briefly  it  may  be 
said  that  one  principle  is  at  the  root  of  all  such 
practice,  whatever  the  disease  to  which  it  relates. 
This  principle,  which  of  course  becomes  more 
and  more  important  in  proportion  as  the  infec- 
tion is  dangerous,  and  as  the  persons  whom  it 
would  endanger  are  many,  is  the  principle  of 
thoroughly  effective  separation  between  the  sick 
and  the  healthy : a separation,  which,  so  far  as 
the  nature  of  the  disease  requires,  must  regard 
not  only  the  personal  presence  of  the  sick,  but 
equally  all  the  various  ways,  direct  and  indirect, 
by  which  infective  matters  from  that  presence 
may  pass  into  operation  on  others.  Especially 
as  regards  the  diseases  which  make  serious 
epidemics,  the  principle  of  isolation  is  not  carried 
into  effect  unless  due  care  be  taken  to  thoroughly 
disinfect  in  detail  allinfective  discharges  from  the 
sick,  and  all  clothing  and  bedding  and  towels  and 
like  things  which  such  discharges  may  have  im- 
bued, and  finally,  as  regards  certain  contagia,  the 
rooms  in  which  the  cases  have  been  treated ; and 
in  order  to  secure  these  objects,  it  is  essential  in 
all  grave  cases  to  make  such  nursing-arrange- 
ments and  such  arrangements  of  the  sick-room 
(whether  private  or  in  hospital)  that  no  reten- 
tion or  dissemination  of  infections  matters  wii' 
escape  notice.  It  is  likewise  essential  that  all 
who  attend  on  the  sick  should  he  careful  not  to 
carry  contagion  to  other  persons;  as  they  may 
but  too  easily  do,  particularly  in  scarlatina  and 


CONTAGION. 


in  certain  traumatic  and  puerperal  infections,  if 
they  omit  to  take  special  precautions  against  the 
danger.  See  articles  Quarantine,  Disinfection, 
and  Public  Health,  and  those  on  the  special 
diseases. 

The  social  conditions  through  17111011,  in  our 
own  country  at  the  present  time,  the  more  fatal 
infectious  diseases  are  enabled  to  acquire  epidemic 
diffusion  are  chiefly  such  as  the  following  : — that 
persons  first  sick  in  families  and  districts, 
instead  of  being  isolated  from  the  healthy,  and 
Treated  with  special  regard  to  their  powers  of 
spreading  infection,  are  often  left  to  take  their 
chance  in  all  such  respects  ; so  that,  especially 
in  poor  neighbourhoods,  where  houses  are  often 
n several  holdings,  and  where  always  there 
is  much  intermingling  of  population,  a first 
case,  if  not  at  once  removed  to  a special  estab- 
lishment, will  almost  of  necessity  give  occa- 
sion to  many  other  cases  to  follow ; — that  per- 
sons with  infectious  disease,  especially  in  cases 
of  slight  or  incipient  attack,  and  of  incomplete 
recovery,  mingle  freely  with  others  in  work-places 
and  amusement-places  of  common  resort,  and, 
if  children,  especially  in  day-schools;  and  that 
such  persons  travel  freely  with  other  persons 
from  place  to  place  in  public  conveyances  ; — that 
often,  on  occasions  when  boarding-schools  have 
infectious  disease  getting  the  ascendant  in  them, 
the  schools  are  broken  up  for  the  time,  and 
scholars,  incubating  or  perhaps  beginning  to 
show  infection,  are  sent  away  to  their  respec- 
tive, perhaps  distant,  homes; — that  keepers  of 
lodging-houses  often  receive  lodgers  into  rooms 
and  beds  which  have  recently  been  occupied 
by  persons  with  infectious  disease  and  have 
not  been  disinfected; — that  persons  in  various 
branches  of  business  relating  to  dress  (male  and 
female)  and  to  furniture,  if  they  happen  to 
have  infectious  disease,  such  as  scarlatina  or 
smallpox,  on  their  premises,  probably  often 
spread  infection  to  their  customers  by  pre- 
vious carelessness  as  to  the  articles  which  they 
send  home  to  them  ; and  that  laundries  further 
illustrate  this  sort  of  danger  by  carelessness  in 
regard  to  infected  things  which  they  receive 
to  wash; — that  purveyors  of  certain  sorts  of 
food,  if  they  happen  to  have  infectious  disease 
on  their  premises,  by  carelessness  spread  in- 
fection to  their  customers ; — that  streams  and 
wells  with  sewage  and  other  filth  escaping  into 
them  are  most  dangerous  means  of  infection, 
especially  as  regards  enteric  fever  and  cholera  ; 
and  that  great  purveyors  of  public  water-supplies, 
so  far  as  they  use  insufficient  precautions  to  ensure 
the  freedom  of  their  water  from  such  risks  of 
infectious  pollution,  represent  in  this  respect  an 
enormous  public  danger; — that  ill-conditioned 
sewers  and  house-drains,  and  cesspools  receiving 
infectious  matters,  greatly  contribute  to  dis- 
seminate contagia,  often  into  houses  in  the  same 
system  of  drainage,  and  often  by  leakage  into 
wells.  Of  the  dangers  here  enumerated,  there  is 
perhaps  none  against  which  the  law  of  England 
does  not  purport  in  some  degree  to  provide.  At 
present,  however,  they  all  are,  to  an  immense  ex- 
tent, left  in  uncontrolled  operation  ; partly  be- 
cause the  law  is  inadequate,  and  partly  because 
local  administrators  of  the  law  often  give  little 
care  to  the  matter;  but  chiefly  because  that  strong 


29& 

influence  of  national  opinion  which  controls  both 
law  and  administration  cannot  really  be  effective 
until  the  time  when  right  knowledge  of  the  sub- 
ject shall  be  generally  distributed  among  the 
people,  and  when  the  masses  whom  epidemics 
affect  shall  appreciate  their  own  groat  interest 
in  preventing  them. 

Whenever  that  time  shall  come,  probably  the 
public  good  will  be  seen  to  require,  with  regard 
to  every  serious  infectious  disease  which  is  apt 
to  become  epidemic,  that  the  principles  which 
ought  to  be  accepted  in  a really  practical  sense, 
and  to  be  embodied  in  effective  law,  are  some- 
what as  follows  : — (1)  that  each  case  of  such  dis- 
ease is  a public  danger,  against  which  the  public, 
as  represented  by  its  local  sanitary  authorities,  is 
entitled  to  be  warned  by  proper  information ; (2) 
that  every  man  who  in  his  own  person,  or  in  that- 
of  anyone  under  his  charge,  is  the  subject  of  such 
disease,  or  is  in  control  of  circumstances  relating 
to  it,  is,  in  common  duty  towards  his  neighbours, 
bound  to  take  every  care  which  he  can  against 
the  spreading  of  the  infection;  that  so  far  as  he 
would  not  of  his  own  accord  do  this  duty,  his 
neighbours  ought  to  have  ample  and  ready  means 
of  compelling  him  ; and  that  he  should  be  respon- 
sible for  giving  to  the  local  sanitary  authority 
proper  notification  of  his  case,  in  order  that  the 
authority  may,  as  far  as  needful,  satisfy  itself 
as  to  the  sufficiency  of  his  precautions  ; (3)  that 
so  far  as  he  may  from  ignorance  not  under- 
stand the  scope  of  his  precautionary  duties,  or 
may  from  poverty  or  other  circumstances  be 
unable  to  fulfil  them,  tile  common  interest  is  to 
give  him  liberally  out  of  the  common  stock  such 
guidance  and  such  effectual  help  as  may  be 
wanting;  (4)  that  so  far  as  he  is  voluntarily  in 
default  of  his  duty,  he  should  not  only  be 
punishable  by  penalty  as  for  an  act  of  nuisance, 
but  should  be  liable  to  pay  pecuniary  damages 
for  whatever  harm  ho  occasions  to  others;  (5) 
that  the  various  commercial  undertakings  which 
in  certain  contingencies  may  be  specially  instru- 
mental in  the  spreading  of  infection — water- 
companies,  dairies,  laundries,  boarding-schools, 
lodging-houses,  inns,  &c.,  should  respectively  be 
subject  to  special  rule  and  visitation  in  regard 
of  the  special  dangers  which  they  may  occasion  ; 
and  that  the  persons  in  authority  in  them  should 
be  held  to  strict  account  for  whatever  injury 
may  be  caused  through  neglect  of  rule;  (6) 
finally,  that  every  local  sanitary  authority  should 
always  have  at  command,  for  the  use  of  its  dis- 
trict, such  hospital-accommodation  for  the  sick, 
such  means  for  their  conveyance,  such  mortuary, 
such  disinfection-establishment,  and  generally 
such  planned  arrangements  and  skilled  service, 
as  may,  in  case  of  need,  suffice  for  all  probable 
requirements  of  the  district. 

Persons  who  are  imperfectly  acquainted  with 
the  scientific  and  social  facts  relating  to  the 
present  subject-matter,  or  who  have  never  seri- 
ously considered  them,  may  think  it  would  be 
over-sanguine  to  expect  any  general  recogni- 
tion of  principles  so  peremptory  as  the  above 
may  at  first  appear  to  them;  but,  if  so  think- 
ing, they  would  perhaps  have  under-estimated 
the  rapidity  with  which  knowledge  is  now 
increasing  as  to  the  common  interests  and 
mutual  duties  of  mankind  in  respect  of  danger- 


m CONTAGION, 

ous  infectious  disease.  Fourteen  years  ago,  ■when 
the  so-called  cattle-plague  or  steppe-murrain  was 
imported  afresh,  as  a long-forgotten  disease,  into 
this  country,  and  was  found  to  affect  very  large 
pecuniary  interests,  primarily  of  the  chief  land- 
owners  of  the  United  Kingdom,  and  second- 
arily of  other  classes,  an  immensely  valuable 
stimulus  was  given  to  the  education  of  the 
country,  and  especially  of  its  Legislature,  in 
regard  to  the  preventabilitv  of  the  infectious 
diseases.  And  the  remarkable  zeal  and  ability 
which  have  been  shown,  in  providing  adequate 
laws  and  admirable  administrative  arrangements 
against  the  diffusion  of  steppe-murrain  and  other 
infectious  diseases  of  Farm-Stock,  are  not  likely 
to  be  found  permanently  absent  in  relation  to  the 
interests  of  Human  Life,  when  once  the  true  bear- 
ings of  the  subject  shall  have  got  to  be  popularly 
understood.  John  Simon. 

CONTINUED  FEVERS. — Characters. 
— Under  the  name  of  Continued  Fevers  is 
included  a group  of  diseases  which  have  the 
following  characters  in  common : — 

1.  They  are  attended  with  'pyrexia,  or  a febrile 
condition  sustained  for  a more  or  less  definite 
period  of  considerable  duration,  without  inter- 
mission or  very  decided  remission,  and  not  due 
to  any  local  inflammation.  That  is,  the  fever 
is  essential , and  not  merely  symptomatic.  The 
distinguishing  feature  of  pyrexia  is  unnatural 
elevation  of  the  temperature  of  the  body,  but 
there  are  other  symptoms  scarcely  less  constant 
— increased  frequency  of  the  pulse,  thirst,  loss  of 
appetite,  furred  tongue,  headache,  chilliness,  and 
— if  the  temperature  is  high — various  manifesta- 
tions of  disturbance  of  the  nervous  system. 

2.  They  are  clearly  due  to  the  introduction 
into  the  body  of  a poison  from  without,  and  this 
poison  is  reproduced  in  the  system,  so  that 
con  tinned  fevers  are  communicable  directly  or 
indirectly  from  the  sufferer  to  others.  This 
statement  would  not  apply  to  simple  continued 
fever  so  called  ; but  simple  continued  fever, 
when  not  a mild  or  abortive  attack  of  one  or 
other  of  the  specific  fevers,  has  scarcely  any- 
thing in  common  with  them. 

3.  The  continued  fevers  rarely  affect  the  same 
individual  twice.  An  attack  is  protective  against 
subseque7it  attacks  of  the  same  fever.  This  is 
much  less  manifest  in  relapsing  than  in  typhus 
and  enteric  fever. 

4.  The  continued  fevers  have  a more  or  less 
definite  duration.  A certain  time  intervenes 
between  the  exposure  to  the  poison  and  the 
onset  of  the  disease,  which  is  called  the  period 
of  incubation  ; and  the  disease  is  divisible  into 
the  stages  of  invasion,  dominance,  and  decline. 

5.  In  two  out  of  the  three  continued  fevers 
there  is  a characteristic  cutaneous  eruption. 

Enumeration.  — The  continued  fovors  are 
typhus,  enteric,  and  relapsing  fever.  Common 
continued  fever,  or  febricula,  often  associated 
with  them  for  the  sake  of  convenience,  re- 
sembles them  only  as  consisting  in  pyrexia  not 
traceable  to  any  known  local  inflammation.  It 
does  not  conform  to  the  characteristics  enume- 
rated, and  cannot  be  brought  within  any  defini- 
tion which  applies  to  the  true  fevers. 

Diagnosis. — The  continued  fevers  have  to  be 


CONTINUED  FEVERS, 
distinguished  from  the  intermittent  and  remit- 
tent fevers  on  the  one  hand,  and  from  the  eruptive 
fevers  and  some  other  diseases  on  the  other. 

1.  From  intermittent  and  remittent  fevers  they 
are  distinguished  clinically  by  the  comparatively 
sustained  high  temperature ; but  were  this  all, 
the  continuous  character  sometimes  assumed  by 
intermittents  and  the  remittent  type  occasionally 
seen  in  enteric  fever — especially  in  children — 
would  bring  them  close  together.  The  essentia] 
distinction  is  that  indicated  under  the  second 
head,  and  is  mainly  setiological.  Both  kinds  of 
fever  are  due  to  a poison  received  from  without; 
but  while  in  continued  fevers  the  source  of  the 
poison  is  for  the,  most  part  a previous  case  of 
fever  of  the  same  kind,  and  the  poison  is  gene- 
rated anew  in  the  subject  of  the  disease,  remit- 
tents and  intermittents  are  of  malarious  origin, 
and  the  poison  is  never  reproduced  in  the  sys- 
tem, and  therefore  never  communicated  by  the 
sufferer. 

The  formation  of  the  specific  contagium  of 
continued  fevers  within  the  system  during  the 
disease  is  of  course  the  cause  of  their  spread  by 
contagion.  The  mode  of  this  spread  is  different 
for  the  different  fevers.  Typhus  and  relapsing 
fever  are  directly  contagious  in  an  eminent  de- 
gree ; the  poison  is  contained  in  the  emanations 
from  the  skin  or  lungs,  and  is  capable  of  en- 
tering the  blood  of  healthy  persons  by  being 
breathed  or  swallowed;  it  may  also  be  carried 
by  fomites.  Enteric  fever,  if  directly'  contagious 
at  all,  is  very  slightly  so  ; the  contagium  is  appa- 
rently not  given  off  in  the  breath  or  perspiration, 
but  chiefly  or  exclusively  from  the  bowels,  and 
the  disease  is  spread  mainly  by  the  contami- 
nation of  drinking  water,  or,  more  rarely,  by  sewer 
gases  or  by  the  emanations  from  typhoid  excreta, 
especially  after  long  residence  in  sewers. 

2.  The  distinctions  between  the  continued  and 
the  eruptive  fevers  remain  to  bo  pointed  out. 
They  are  of  a very  slight  character.  All  the 
characters  given  of  the  continued  fevers,  includ- 
ing the  occurrence  of  a cutaneous  eruption,  are 
common  to  them  and  the  eruptive  fevers.  The 
differences  are  as  follows : — 

a.  The  liability  to  the  eruptive  fevers  is 
almost  universal  in  the  absence  of  protection  by 
a previous  attack,  and  is  little  affected  by  the 
state  of  health  of  the  individual,  while  the  lia- 
bility to  continued  fever  is  very  variable  in  dif- 
ferent persons,  and  even  races,  and  is  greatly 
influenced  by  external  conditions.  There  is  no 
parallel  in  the  eruptive  fevers  to  the  predisposi- 
tion to  typhus  and  relapsing  fever  generated  by 
overcrowding  and  famine. 

b.  The  protective  influence  of  a previous 
attack  is  more  marked  in  the  eruptive  fevers, 
though  not  to  such  a degree  as  would  constitute 
an  important  distinction.  Instances  of  small- 
pox after  a previous  attack,  or  after  vaccination, 
and  second  attacks  of  measles  and  scarlet  fever, 
are  not  very  uncommon. 

c.  While  in  the  eruptive  fevers  the  specific 
poison  is  considered  to  be  invariably  derived 
from  a previous  case,  this  cannot  be  said  with 
the  same  confidence  with  regard  to  the  continued 
fevers.  It  is  true  that  in  by  far  the  larges: 
proportion  of  attacks  of  typhus,  enteric,  and 
relapsing  fevers  the  source  of  the  poison  can  be 


CONTINUED  FEVERS, 
traced,  and  that  as  tha  experience  and  trained 
skill  brought  to  bear  on  the  search  increase,  the 
fever  are  the  examples  in  which  it  fails ; but  it 
cannot  yet  be  said  definitely  that  these  fevers 
are  not  generated  anew  under  certain  conditions. 
The  constancy  with  which  typhus  and  relapsing 
fever  follow  in  the  track  of  overcrowding  and 
starvation  is  suggestive  of  spontaneous  origin ; 
bit  in  this  country  typhus  is  never  so  completely 
extinct  that  foci  of  infection  are  wanting,  and 
epidemics  of  relapsing  fever  may  be  imported. 
Enteric  fever,  again,  appears  from  time  to  time 
under  circumstances  which  appear  to  exclude 
the  possibility  of  the  poison  having  been  derived 
from  a previous  case,  though  in  most  instances 
of  epidemic  prevalence  of  the  disease,  there  is 
conclusive  evidence  of  specific  and  not  merely  ge- 
neral contamination  of  the  air  or  water.  It  is  not, 
however,  necessary  to  enter  upon  this  controversy 
here,  or  to  do  more  than  allude  to  the  question 
whether  or  not  their  contagia  are  of  the  nature 
of  organic  germs.  See  Contagion  ; and  Zyme. 

The  fevers  will  be  fully  described  under  their 
respective  names.  "William  II.  Broadbent. 

CONTRACTION,  Muscular  ( contraho , I 
draw  together). — A term  applied  to  the  action 
or  to  the  shortening  of  a muscle  from  any  cause, 
whether  in  health  or  in  disease.  See  Spasm. 

CONTRA-INDICATION.- Any  circum- 
stance which  forbids  the  employment  of  thera- 
peutic measures  otherwise  indicated. 

CONTRE-COUP  (Fr.),  Counter-stroke.— An 
injury  of  a part  opposite  to  and  distant  from  that 
to  which  force  is  applied,  as  by  a fall  or  direct 
blow.  Contre-coup  is  chiefly  observed  in  injuries 
of  the  skull. 

CONTUSION  ( contundo , I bruise). — A 

bruise  or  injury  of  the  soft  parts  without  breach 
of  surface. 

CONVALESCENCE  ( con  and  valcsco,  I 
grow  well.) — The  period  of  convalescence  signifies 
that  period  during  which  a patient  is  progressing 
towards  recovery,  and  is  returning  to  a state  of 
health  after  having  suffered  from  an  illness. 
When  the  health  has  been  completely  restored, 
convalescence  is  said  to  be  established,  and  the 
patient  is  regarded  as  convalescent.  The  word 
is  used  most  commonly  in  association  with  fevers, 
inflammatory  diseases,  and  other  acute  affec- 
tions. Convalescence  may  be  ushered  in  by  a 
crisis,  and  become  speedily  established ; or  it 
may  be  very  slow  and  protracted  in  its  progress, 
which  is  also  often  interrupted  by  relapses,  com- 
plications, or  sequel®.  Patients  frequently  require 
careful  watching  and  judicious  treatment  while 
becoming  convalescent,  as  they  are  apt  to  retard 
or  even  prevent  their  recovery,  and  to  lay  the 
foundation  for  permanent  disease  by  neglect  of 
due  precautions,  especially  as  regards  their  diet. 
Much  injury  is  not  uncommonly  inflicted  by 
the  injudicious  administration  of  medicines,  and 
the  employment  of  other  means  which  are  sup- 
posed to  hasten  convalescence. 

Frederick  T.  Roberts. 

CONVOLUTIONS  OE  THE  BRAIN 
and  CORTEX  CEREBRI,  Lesions  of. — 


CONVOLUTION'S  OF  THE  BRAIN.  29b 
The  pathology  of  the  cortex  cerebri  is  a subject 
which,  notwithstanding  the  extensive  literature 
relating  to  cerebral  disease,  is  still  comparatively 
in  its  infancy.  The  older  records  and  observa- 
tions made  while  the  idea  was  still  prevalent,  that 
the  convolutions  of  the  brain  had  no  definite  dis- 
positions and  relations,  and  that  the  various  part? 
of  the  hemispheres  were  functionally  equivalent, 
are  not  sufficiently  exact  to  be  made  the  basis  of 
trustworthy  clinical  and  physiological  conclu- 
sions. Recent  anatomical  investigation  into  tha 
topography  aud  homologies  of  the  cerebral  con 
volutions,  and  the  experimental  researches  of 
Hitzig,  the  writer,  and  others  in  reference  to 
the  results  of  electrical  irritation  of  the  brain, 
have  directed  greater  attention  to  accurate 
topographical  descriptions  of  the  lesions  of 
the  cortex  in  connexion  with  observed  clinical 
symptoms.  As  yet,  however,  the  reliable  patho- 
logical material  is  not  very  extensive,  though  it, 
is  every  day  accumulating,  more  particularly  by 
the  labours  of  Charcot  and  his  followers  in 
France,  and  Hughlings  Jackson  and  others  in 
this  country.  Up  to  a comparatively  recent 
date  physicians  and  physiologists  generally  held 
by  the  views  of  F’lourens,  based  on  experimental 
investigation  of  the  brains  of  the  lower  classes 
of  animals.  According  to  Flov.rens  the  hemi- 
spheres were  concerned  purely  with  intelligence — 
a faculty  one  and  indivisible  ; and  each  part  of 
the  hemisphere  possessed  the  functions  of  the 
whole,  so  that,  if  part  were  destroyed,  functional 
compensation  might  he  effected  by  the  parts 
which  remained.  These  views  seemed  satisfac- 
torily to  explain  the  cases,  not  uncommon,  in 
which,  notwithstanding  the  existence  of  exten- 
sive lesions  in  the  hemispheres,  no  symptoms 
were  observed  during  life.  The  frequent  associa- 
tion of  aphasia  with  a limited  lesion  of  the 
cortex  cerebri,  vaguely  indicated  by  Bouillaud 
and  Dax,  and  definitely  fixed  by  Broca  at  the 
posterior  extremity  of  the  third  left  frontal  con- 
volution, was  a step  towards  localisation  of 
function  in  the  brain,  which,  however,  met  with 
much  opposition  and  counter-facts.  The  clinical 
and  pathological  observations  of  Hughlings 
Jackson  in  reference  to  the  causation  of  limited 
and  unilateral  epileptiform  convulsions  were  an 
important  contribution  to  the  physiology  and 
pathology  of  the  cortex.  These  convulsions  he 
attributed  to  irritative  or  discharging  lesions  cf 
the  grey  matter  in  the  neighbourhood  of  the 
corpus  striatum  in  the  opposite  hemisphere. 

Physiological  experiment  has  demonstrated 
the  correctness  of  the  views  advanced  by  Hugh- 
lings Jackson,  and  shown  that,  not  only  can 
movements  be  excited  by  electrical  irritation  cf 
certain  regions  of  the  cortex,  but  also  that  defi- 
nite combinations  of  muscular  movements  uni- 
formly result  from  stimulation  of  certain  specia- 
lised areas  within  this  region.  The  interpretation 
of  these  facts,  now  no  longer  disputed,  has  been 
much  debated,  but  the  views  the  writer  has 
elsewhere  expressed  at  length  ( Functions  of 
the  Brain ) seem  in  accordance  with  the  most 
recent  and  careful  pathological  and  clinical 
research,  viz.  that  the  brain  is  divided  into  a 
motor  and  a sensory  region,  and  that  in  each 
there  are  definite  centres  with  definite  functions, 
and  that  the  symptoms  of  cortical  lesions  depend 


29C  CONVOLUTIONS  OF  THE  BRAIN  AND  CORTEX  CEREBRI,  LESIONS  OF. 


on  the  locality  of  the  lesion,  and  cn  •whether 
it  is  unilateral  or  bilateral. 

Physiological  experiment  is,  as  to  precision 
in  its  results,  considerably  in  advance  of  clinical 
observation,  and,  from  the  nature  of  the  two 
methods,  this  is  what  might  be  expected. 

The  investigation  of  diseases  of  the  brain  is 
surrounded  by  special  difficulties.  Though,  as 
shown  by  physiological  experiment,  the  brain  is 
capable  of  being  mapped  out  into  different 
regions  possessing  different  functions,  yet  the 
brain  acts  as  a whole,  and  it  is  not  always  easy 
to  analyse  the  facts  of  disease,  and  to  distinguish 
with  certainty  between  the  effects  directly  de- 
pendent on  the  locality  of  the  brain  and  those 
due  to  the  indirect  influence  exerted  on  the 
functions  of  neighbouring  regions  and  on  the 
brain  as  a whole.  And  when,  moreover,  we  take 
into  account  the  vague  manner  in  which  it  has 
been  the  custom  to  define  the  locality  of  the 
lesion,  it  is  not  surprising  that  so  little  has  as 
yet  been  accomplished  in  reference  to  the  locali- 
sation of  cerebral  disease. 

But,  besides  these  difficulties  there  are  others, 
of  greater  magnitude  and  less  easy  to  overcome, 
inherent  in  the  subject  itself.  For  the  brain, 
besides  being  concerned  with  certain  functions 
which  we  can  investigate  objectively,  viz.  sen- 
sation and  voluntary  motion,  is  the  organ  of 
mental  operations,  and  as  the  same  parts  have 
an  objective  and  subjective  function,  it  is  obvious 
that  cerebral  diseases  may  manifest  themselves 
mentally  as  well  as  bodily.  These  two  sides  of 
brain-function  and  their  disordered  manifesta- 
tions have  been  in  a great  measure  artificially 
separated  for  convenience  in  treatment,  and  the 
relation  between  the  physiological  and  the  psy- 
chological has  not  been  duly  recognised.  And 
yet  it  is  obvious  that  until  psychological  phe- 
nomena have  been  reduced  in  ultimate  analysis 
to  their  anatomical  and  physiological  substrata 
we  can  have  no  rational  medical  psychology,  as 
distinguished  from  empiricism  or  mere  specu- 
lation, available  as  a guide  to  the  diagnosis  and 
treatment  of  cerebral  disease  in  its  subjective 
or  mental  manifestations. 

That  the  brain  is  diseased  in  insanity,  func- 
tionally or  organically,  is  a fact  now  universally 
admitted ; but  it  is  also  true  that  the  lesions 
which  cause  objective  symptoms  in  the  domain 
of  motion  and  sensation  need  not  cause  mental 
derangement,  and  also  that  lesions  which  cause 
mental  derangement  need  not  manifest  themselves 
in  any  discoverable  disorders  of  sensation  or  mo- 
tion. In  fact,  for  purposes  of  ideation  we  have 
practically  two  brains ; for,  though  motion  and 
sensation  will  be  paralysed  on  the  opposite  side 
by  destruction  of  one  hemisphere,  yet  intelligence 
and  thought  are  possible  through  the  hemisphere 
which  remains. 

Various  forms  of  lesion  have  been  found  in 
the  brains  of  the  insane,  such  as  morbid  con- 
ditions as  to  vascularity,  degeneration  of  the 
blood-vessels,  degeneration  of  the  nerve-cells, 
neuroglia,  membranes,  &c.  ; but  no  constant 
relation  has  as  yet  been  established  between  any 
one  form  of  degeneration  and  any  one  form  of 
mental  alienation,  or  between  the  latter  and  any 
localised  lesion.  Nor  has  it  been  clearly  estab- 
lished whether  the  forms  of  degeneration  found 


in  the  brains  of  the  chronically  insane  are  the 
result  or  the  cause  of  the  mental  disorders.  An 
exception,  however,  is  to  he  made  in  favour  of 
general  paralysis  of  the  insane,  where  there 
seems  to  be  a definite  connexion  between  tho 
anatomical  lesion  and  the  symptoms  manifested 
In  this  disease  we  find  as  a constant,  if  not  the 
only  factor,  a form  of  chronic  encephalitis,  affect- 
ing chiefly  the  cortical  regions  which  physio- 
logical experiment  has  shown  to  be  the  motor 
zone  of  the  hemispheres.  This  lesion  is  asso- 
ciated with  progressive  motor  paralysis,  varied 
with  intercurrent  epileptiform  and  apoplectiform 
seizures,  and  with  mental  symptoms  characterised 
generally  by  exalted  ideas  and  delusion  as  to 
wealth,  power,  and  grandeur.  The  motor  symp- 
toms are  readily  accounted  for  by  the  locality 
and  character  of  the  cerebral  lesion,  but  the 
relation  between  this  and  the  mental  symptoms 
is  a subject  which  psychological  analysis  has  yet 
to  elucidate. 

Another  link  between  the  physiological  ami 
psychological  aspects  of  brain-function  is  fur- 
nished by  aphasia,  in  which,  with  a definite  ana- 
tomical lesion,  there  is  a definite  psychological 
defect  (see  Aphasia).  But  beyond  these  the 
relation  between  morbid  mental  manifestations 
and  morbid  conditions  of  the  brain,  and  their 
joint  relation  to  the  bodily  symptoms,  remain 
involved  in  great  obscurity. 

The  objective  symptoms  of  cortical  lesions 
depend  on  their  locality,  and  on  whether  they 
exercise  an  irritative  or  destructive  influence  on 
the  parts  they  invade.  From  the  localisation 
point  of  view  alone  the  intimate  nature  of  the  mor- 
bid process  is  unimportant,  except  in  so  far  as  its 
imitative  or  destructive  character  is  concerned. 
Lesions,  such  as  tumours,  which  from  their 
very  nature  exercise  important  indirect  effects 
on  the  encephalon  as  a whole,  apart  from  their 
effects  on  the  regions  which  they  directly  invade, 
can  rarely  be  exactly  localised,  owing  to  the 
difficulty  of  separating  the  direct  and  indirect 
symptoms  from  each  other  and  referring  each 
to  its  exact  cause.  Also  no  rigid  conclusions  as 
regards  localisation  can  be  drawn  from  morbid 
affections  of  the  hemispheres  which  extend  over 
a large  area,  such  as  the  various  forms  of  menin- 
gitis and  meningo-encephalitis.  In  all  these 
cases  the  nature  of  the  affection  must  he  diag- 
nosed from  its  own  general  and  special  cha- 
racters ; its  position  and  extent  in  the  brain 
being  arrived  at  approximately  from  a considera- 
tion of  the  effects  of  accurately  circumscribed 
lesions,  as  determined  by  careffii  clinical  and 
pathological  observation  and  physiological  ex- 
periment. 

The  brain  may  he  considered  as  divided  into 
a motor  and  a sensory  zone. 

Motor  Zone. — The  motor  zone  includes  the 
convolutions  hounding  the  fissure  of  Rolando, 
viz.  the  ascending  frontal  and  the  bases  of  the 
three  frontal  convolutions,  the  ascending  pari- 
etal and  postero-parietal  lobule,  and  the  in- 
ternal surface  of  the  same  convolutions  or  para- 
central lobule.  In  this  zone  are  differentiated 
centres  for  the  movements  of  the  limbs,  head, 
and  eyes,  the  muscles  of  expression,  and  those 
of  the  mouth  and  tongue.  The  centres  of  the 
leg  and  foot  are  situated  in  the  postero- 


CONVOLUTIONS  OF  THE  BRAIN  AND  CORTES  CEREBRI,  LESIONS  OF.  297 


parietal  lobule,  those  for  the  arm  in  the  upper 
third  of  the  ascending  frontal,  those  for  the 
hand  and  wrist  in  the  ascending  parietal,  those 
of  the  facial  muscles  in  the  middle  third  of  the 
ascending  frontal  and  base  of  the  second  frontal, 
those  for  the  mouth  and  tongue  at  the  lower 
third  of  the  ascending  frontal  at  the  base  of  the 
third  frontal,  and  for  the  platysma  at  the  lower 
extremity  of  the  ascending  parietal,  just  posterior 
to  the  mouth-centre.  The  posterior  third  of  the 
upper  frontal  convolution  and  corresponding 
part  of  the  second  frontal,  contain  the  centre  for 
the  lateral  movement  of  the  head  and  eyes. 

The  frontal  regions  in  advance  of  this  centre, 
though  anatomically  related  to  the  motor  divi- 
sion of  the  internal  capsule,  do  not  seem  directly 
connected  with  motor  manifestations  as  judged 
by  the  negative  effects  cither  of  irritation  or  ex- 
tirpation. 

Irritative  lesions  of  the  motor  zone  proper, 
such  as  may  be  induced  by  syphilitic  lesions, 
tumours,  spieula  of  bone,  depressed  fractures, 
thickening  of  the  membranes,  <fcc.,  cause  con- 
vulsions, which  may  remain  limited  to  one  limb 
or  one  group  of  muscles  without  loss  of  conscious- 
ness, or  affect  the  whole  of  the  opposite  side 
with  loss  of  consciousness,  or  become  more  or 
less  bilateral  w ith  all  the  symptoms  usually  ob- 
served in  so-called  idiopathic  epilepsy. 

If  the  convulsive  phenomena  begin  always  in 
the  same  way,  and  if  they  frequently  remain 
localised  in  one  limb  or  one  group  of  muscles, 
and  especially  if  paralytic  symptoms  manifest 
themselves,  the  exact  position  of  the  lesion  in 
the  opposite  hemisphere  may  be  accurately  diag- 
nosed. ( See  cases  by  Hughlings  Jackson,  Clini- 
cal and  Physiological  Researches  on  the  JS'erccms 
System  (reprints),  1873 ; Dr.  Dreschfeld,  Lancet , 
Feb.  24, 1877  ; Dr.  Bramwell,  Brit.  Med.  Joiern., 
Aug.  28,  1S75  ; MM.  Charcot  and  Pitres,  Revue 
Mensuelle , 1877.) 

Destructive  lesions  of  the  motor  zone  cause 
general  or  limited  paralysis  of  voluntary  motion 
in  the  opposite  side  of  the  body,  according  as 
the  lesion  affects  the  whole  of  the  motor  zone  or 
is  limited  to  special  centres  within  this  area. 
The  causes  of  destructive  lesions  of  the  cortex 
may  be  various  — haemorrhage,  laceration  by 
wounds,  &c.  One  of  the  most  common  causes 
is  embolism  or  thrombosis  of  the  arteries  sup- 
plying the  cortical  motor  area.  These  are  de- 
rived from  the  Sylvian  artery  of  the  middle 
cerebral.  The  cortical  branches  may  be  occlud- 
ed without  interfering  with  the  circulation  in 
the  corpus  striatum,  which  is  supplied  by  special 
branches,  as  shown  by  the  researches  of  Duret 
and  Heubner. 

When  the  motor  zone  is  affected  by  general 
destructive  lesion,  complete  hemiplegia  of  the 
opposite  side  results,  in  all  respects  like  that 
resulting  from  destructive  lesion  of  the  corpus 
striatum  and  anterior  portion  of  the  internal 
capsule.  In  this  form  of  paralysis  the  loss  of 
motion  is  most  marked  in  those  movements 
which  arc  most  independent,  hence  the  arm  is 
more  paralysed  than  the  leg  or  face,  and  the 
hand  more  paralysed  than  the  shoulder  move- 
ments of  the  arm.  This  has  been  accounted  for 
by  the  fact,  that  the  centres  for  bilateral  move- 
ments are  intimately  associated  in  the  lower 


ganglia  ; hence  the  stimulus  from  one  hemisphere 
can  to  a certain  extent  call  forth  the  action  of 


Fig.  12. — Side  view  of  the  Left  Hemisphere  cf  the 
Monkey.  The  areas  have  the  same  signification  as  in 
the  next  figure. 


Fig.  13. — Side  view  of  the  Left  Hemisphere  in  Man, 
with  the  areas  of  the  cerebral  convolutions.  The  effects 
of  stimulation  of  each  area,  as  ascertained  by  experi- 
ments on  the  brain  of  the  monkey,  are  subjoined. 

1.  Postero-parietal  lobule.  Advance  of  the  opposite 
hind  limb,  as  in  walking 

2,  3,  and  4.  Around  the  upper  extremity  of  the  fissure 
of  F.olando.  Complex  movements  of  the  opposite  leg 
and  arm,  and  of  the  trunk,  as  in  swimming. 

а , b.  c,  d.  Ascending  parietal  convolution.  Individ- 
ual and  combined  movements  of  the  fingers  and  wrist 
of  the  opposite  hand.  Prehensile  movements. 

5.  Posterior  extremity  of  the  superior  frontal  convolu- 
tion. Extension  forward  of  the  opposite  arm  and  hand. 

б.  Upper  part  of  ascending  frontal  convolution.  Su- 
pination and  flexion  of  the  opposite  forearm. 

7.  Median  portion  of  ascending  frontal  convolution. 
Eetraction  and  elevation  of  the  opposite  angle  of  the 
mouth. 

8.  Lower  part  of  the  ascending  frontal  convolution. 
Elevation  of  ala  nasi  and  upper  lip,  with  depression 
of  lower  lip. 

9 and  10.  Inferior  extremity  of  ascending  frontal  con- 
volution (Broca's  convolution).  Opening  of  the  mouth 
with  (9)  protrusion  and  (10)  retraction  of  the  tongue. 
Eegion  of  aphasia.  Action  bilateral. 

11.  Between  the  inferior  extremities  of  the  ascending 
frontal  and  the  ascending  parietal  convolutions.  Ee- 
traction of  the  opposite  angle  of  the  mouth ; and  the 
head  turned  slightly  to  one  side. 

12.  Posterior  portions  of  superior  and  middle  frontal 
convolutions.  Eyes  opened  widely;  pupils  dilated; 
head  and  eyes  turned  towards  opposite  side. 

13  and  13'.  Supra-marginal  lobule,  and  angular  gyrus. 
Eyes  moved  towards  the  opposite  side,  with  an  upward 
(13)  or  a downward  (13')  deviation.  The  pupils  gener- 
ally contracted.  (Centre  of  vision.) 

14.  Infra-marginal  (superior  temporo-sphenoidal)  con- 
volution. Pricking  of  opposite  ear ; head  and  eyes 
turned  to  opposite  side ; pupils  largely  dilated.  (Centre 
of  hearing.) 


298  CONVOLUTIONS  01'  THE  BRAIN  AND  CORTEX  CEREBRI.  LESIuN  uF. 


the  conjoint  motor  nuclei.  Tlie  electrical  con- 
tractility and  nutrition  of  the  muscles  is  not 
affected  by  paralysis  of  cerebral  origin.  The 
nutrition  of  the  muscles  may,  however,  suffer 
from  disuse,  and  frequently  paralyses  of  cortical 
origin  are  followed  after  a time  by  rigidity  and 
contraction,  accompanied  with  descending  secon- 
dary sclerosis  of  the  metor  tracts  of  the  crura, 
pons,  and  lateral  tracts  of  the  spinal  cord.  In 
some  cases  the  descending  degeneration  invades 
the  anterior  cornua  of  the  spinal  cord,  and 
atrophy  of  the  paralysed  muscles  ensues.  Occa- 
sionally from  limited  lesions  of  the  cortical 
motor  area  complete  hemiplegia  may  occur  on 
the  opposite  side  for  the  time  at  least.  This  is 
to  be  explained  by  the  fact  that  sudden  estab- 
lishment of  a destructive  lesion  may  cause  such 
commotion  or  perturbation  of  the  centres  in 
genei’al,  that  their  functions  are  for  the  time 
suspended.  But  in  such  cases  those  centres 
which  have  been  only  functionally  suspended  will 
again  resume  their  functions,  and  the  paralysis 
will  disappear  except  of  those  movements  the 
centres  of  which  have  become  permanently  dam- 
aged. Limited  lesions  of  the  motor  zone  cause 
paralysis  of  those  movements  the  centres  of 
which  the  lesion  invades.  The  result  is  not 
complete  hemiplegia,  but  a monoplegia  or  disso- 
ciated paralysis.  Hence,  from  a cortical  lesion 
we  may  get  a paralysis  of  the  arm,  or  of  the  arm 
and  face,  or  of  the  leg  and  arm,  or  of  tho  face 
alone,  or  of  the  lateral  movements  of  the  head 
and  eyes.  Numerous  examples  of  these  mono- 
plegise  resulting  from  limited  cortical  lesions 
have  been  collected  by  Charcot  and  Pitres  (Revue 
MensueUe,  Jan.  1877.  et  scq. ; abstract  in  Lond. 
Med.  Record , April,  1877).  The  morbid  process 
which,  while  circumscribed  at  first,  causes  a 
monoplegia,  may  advance  to  other  centres,  and 
after  a time  produce  general  hemiplegia  of  the 
opposite  side.  Hemiplegia  so  resulting  is  a 
succession  of  monoplegise,  and  is  a sure  indi- 
cation of  cortical  disease.  It  is  to  be  noted 
that  destructive  lesion  of  the  mouth-centre 
(Broca’s  region)  on  one  side  does  not  causa  para- 
lysis cf  articulation,  owing  tc  the  fact  that  each 
centre  has  a more  or  less  complete  bilateral 
influence  over  the  movements  of  the  mouth  and 
tongue.  Destructive  lesion  of  this  centre  in  the 
left  hemisphere  generally  gives  rise  to  aphasia 
without  paralysis  of  articulation  ( see  Aphasia). 
In  bilateral  lesions  there  is  both  aphasia  and 
paralysis  of  articulation  (see  Dr.  Barlow  s case, 
Brit.  Med.  Jour.  1877,  vol.  ii.  p.  103).  Limited 
cortical  motor  lesions  are  frequently  associated 
with  transitory  rigidity  of  the  opposite  side  of 
the  body ; and  if  the  lesion  is  complete,  the 
local  paralysis  or  monoplegia  will  remain  per- 
manently, and  may  ho  accompanied  by  late 
rigidity  and  descending  sclerosis  of  the  motor 
tracts,  as  has  been  shown  by  Charcot  (op.  cit.). 
These  monoplegise  frequently  alternate  with 
unilateral  convulsions,  owing  to  the  morbid  pro- 
cess occasionally  inducing  irritation  of  the  neigh- 
bouring centres. 

Destructive  lesions  of  the  frontal  and  orbital 
regions  cause  no  motor  paralysis  or  aDy  very 
evident  physiological  symptoms.  In  the  recorded 
cases  of  bilateral  lesions  symptoms  of  dementia 
to  a greater  or  less  extent  have  been  noted. 


Sensory  Zone. — From  experiments  ou  thi 
brain  of  monkeys  by  means  of  the  eomplemental 
methods  of  excitation  by  the  electric  current,  and 
destruction  of  the  grey  matter  of  the  cortex,  the 
writer  has  arrived  at  the  conclusion  that  in  the 
regions  lying  posterior  to  the  motor  zone  there 
are  differentiated  centres  of  sight,  hearing,  touch, 
smell,  and  taste.  The  sight-centre  is  situated  iu 
the  angular  gyrus,  and  embraces  also  the  occi- 
pital lobe — the  occipito-angular  region  ; the 
centre  of  hearing  is  localised  in  the  superior 
temporo-sphenoidal  convolution  ; the  tactile  cen- 
tre is  situated  in  the  hippocampal  region ; while 
the  centres  of  smell  and  taste  are  situated  to- 
gether at  the  lower  parts  of  the  temporo-sphe- 
noidal  lobe. 

Destructive  Lesions. — Unilateral  destruction 
of  these  seDsory  centres  does  not,  however, 
appear  to  permanently  abolish  sensation  on  ihe 
opposite  side  of  the  body.  It  is  only  when  the 
lesion  is  bilateral  and  in  corresponding  points 
that  the  loss  of  sensation  is  thorough  and  per- 
manent. Hence  the  fact  is  to  be  accounted  for, 
that  in  man,  as  a rule,  unilateral  destructive 
lesions  of  the  regions  indicated  are  latent,  or  not, 
so  far  as  at  present  known,  accompanied  by  any 
objective  symptoms.  Numerous  cases  of  this 
kind  are  on  record.  No  secondary  descending 
degeneration  of  the  spinal  cord  has  been  ob 
served  in  these  cases. 

Until  evidence  is  increased  from  human  pa- 
thology of  the  occurrence  of  loss  of  sensation 
from  lesion  of  the  cortex — and  this  the  writer 
holds  is  to  be  looked  for  in  bilateral  destructive 
lesions — pathologists  iu  general  reserve  their 
opinion  as  to  the  explanation  of  the  latency  of 
the  lesions  in  question. 

But  though  the  pathological  evidence  in  favour 
of  the  localisation  of  distinct  sensory  centres  is 
as  yet  comparatively  slender,  it  is  daily  increas- 
ing. Though  numerous  cases  are  on  record  of 
lesions  in  the  angular  gyri  and  occipital  lobes 
without  symptoms  as  regards  vision,  there  are 
others,  more  particularly  of  lesions  of  the 
medullary  fibres  of  this  region,  in  which  hemiopia 
towards  the  side  opposite  the  lesion  has  been 
observed.  Some  of  these  cases  may  perhaps  bo 
explained  by  direct  or  indirect  lesion  of  the  optic 
tract,  but  others  cannot  he  so  accounted  for. 
For  other  facts  bearing  on  this  question  the 
reader  is  referred  to  a paper  by  the  writer  on 
Cerebral  Amblyopia  and  Hemiopia,  Dram,  xii. 
1881. 

It  has  been  established  by  the  researches  of 
Tiirck,  Charcot,  &e.,  that  destructive  lesions  of 
the  posterior  third  of  the  internal  capsule,  ex- 
ternal to  the  optic  thalamus,  cause  hemiaD»s- 
thesia  of  the  opposite  side  of  the  body.  The 
hemiansesthesia  of  organic  origin  exhibits  the 
same  symptoms  as  are  observed  in  what  is  termed 
hysterical  hemiantesthesia.  In  this  condition 
there  is  loss  of  tactile  sensation  and  more  or  less 
complete  loss  of  sight,  hearing,  smell,  and  taste, 
on  the  side  opposite  the  lesion.  The  affection 
of  sight,  which  is  not  accompanied  by  any 
changes  in  the  eye  discoverable  by  the  ophthal- 
moscope, is  characterised  by  dysehromatopsy, 
and  a remarkable  contraction  of  the  field  of 
vision.  The  loss  of  hearing  is  very  marked,  if 
not  absolute,  and  similarly  as  regards  smell 


CONVOLUTIONS  OF  THE  BRAIN, 
and  taste.  It  is  evident  that  the  lesion  situated 
in  the  medullary  fibres  is  not  an  affection  of 
sensory  centres,  and  that  it  is  simply  a solution 
of  continuity  of  the  centripetal  paths  -which  ra- 
diate out  into  the  differentiated  sensory  centres 
of  the  cortex.  The  exact  destination  of  the 
Epeeial  sensory  paths  the  -writer  has  indicated 
above,  and  to  this  the  special  attention  of  physi- 
cians and  pathologists  should  be  directed.  The 
writer  is  likewise  of  opinion  that  the  loss  of 
smell  and  taste,  which  is  occasionally  observed 
to  result  from  a blow  on  the  occiput  or  vertex  is 
in  many  cases  due  to  injury  by  counterstroke  to 
the  centres  of  smell  and  taste,  which  are  situated 
in  such  a position  as  to  he  specially  affected  by 
violence  so  directed.  There  is  no  doubt  that  in 
some  cases  the  loss  of  taste  might  bo  accounted  for 
by  rupture  of  the  olfactory  tracts  or  nerves,  such 
as  those  in  which  taste  is  lost  only  for  flavours, 
which  are  compounds  of  smell  and  taste.  But 
there  are  others  in  which  there  has  been  clear 
loss  both  of  smell  and  taste  independently  of  each 
other ; cases  which  can  only  he  satisfactorily 
accounted  for,  in  the  writer’s  opinion,  in  the 
manner  which  he  has  indicated. 

Irritative  Lesions. — Though  the  pathological 
evidence  in  reference  to  the  localisation  of  sen- 
sory centres  is  as  yet  but  deficient,  at  least  as 
regards  paralysis  of  the  special  senses  from 
destructive  lesions  of  the  cortex,  there  is  good 
reason  for  believing  that  in  cases  of  insanity, 
accompanied  by  sensory  hallucinations,  as  also 
in  certain  cases  of  epilepsy  ushered  in  by  sub- 
jective sensations,  such  as  flashes  of  light  and 
colour,  loud  sounds,  disagreeable  tastes  and 
smells,  &c.,  the  phenomena  are  the  result  of 
some  morbid  irritation  of  the  cortical  sensory 
centres,  the  anatomical  substrata  of  ideation. 

D.  Ferrier. 

CONrVTrLSIONS.— Defdtitiok.— This  term 
is  commonly  given  to  more  or  less  general,  pur- 
poseless muscular  contractions,  occurring  simul- 
taneously and  successively  for  a variable  time.  It 
is  also,  however,  applied  at  times  to  certain  more 
localized  purposeless  contractions,  though  these 
would  he  more  appropriately  (and  are  in  the  ma- 
jority of  cases)  termed  SrASMS.  The  latter,  like 
Convulsions,  are  of  two  kinds,  foiricand  clonic. 

Classifications. — Convulsions  have  been  va- 
riously classified  by  different  authors  according 
to  the  different  points  of  view  from  which  they 
have  been  regarded.  Looking  to  their  causation, 
there  is  both  a clinical  and  a physiological  divi- 
sion into  classes.  From  the  former  standpoint 
we  have  (1)  primary  or  essential  convulsions ; (2) 
sympathetic  convulsions;  and  (3)  symptomatic 
convulsions ; whilst  from  the  physiological  point 
of  view  they  have  been  divided  into  (1)  centric 
and  (2)  excentric.  These  classifications  are  arbi- 
trary and  will  not  stand  the  test  of  a critical  ex- 
amination, though  the  first  of  them  is  to  a certain 
extent  useful.  Again,  looking  to  the  distribution 
of  the  convulsions,  or  to  the  parts  involved,  their 
classification  by  different  writers  may  he  sum- 
marized as  follows (1)  External — a,  general; 
b unilateral;  c,  partial;  (2)  Internal. 

These  various  terms  need  little  explanation, 
though  something  requires  to  he  said  in  regard 
to  them. 


CONVULSIONS.  299 

Convulsions  are  termed  primary  or  essential 
when  they  occur  either  without  assignable  cause, 
from  mental  or  moral  perturbations,  or  as  a re- 
sult of  some  local  irritation.  They  are  called  sym- 
pathetic when  the  convulsions  declare  themselves 
as  a prelude  to,  or  in  the  course  of,  any  of  the 
specific  fevers,  as  a consequence  of  acute  pul- 
monary or  renal  affections,  or  in  association  with 
disordered  states  or  structural  diseases  of  any 
of  the  organs  of  the  body  other  than  those  of  the 
nervous  system ; whilst  the  name  symptomatic 
has  been  applied  to  the  convulsions  which  occur 
as  a result  of  injury  or  structural  disease  of  the 
nervous  system  itself.  The  unilateral  convulsions 
which  affect  one  half  of  the  body  only,  as  well  as 
other  more  partial  convulsions,  are  almost  en- 
tirely confined  to  this  latter  group,  though  gene- 
ral convulsions  of  the  symptomatic  type  are 
perhaps  just  as  frequently  met  with.  The  so- 
called  internal  coiivvlsions  constitute  an  ill-de- 
fined group,  the  members  of  which  are  scarcely 
worthy  of  the  name  of  convulsions  at  all.  They 
are  rather  tonic  or  clonic  spasms  of  particular 
parts.  The  best  known  member  of  this  group 
is  laryngismus  stridulus  (see  separate  article 
thereon),  though  we  may  also  include  another 
much  less  grave,  though  often  obstinate  malady, 
viz.  a spasmodic  and  frequently  recurring  hic- 
cup. Some  would  include  angina  pectoris  also 
in  this  group. 

Convulsions,  either  tonic  or  clonic,  or  both, 
enter  into  or  form  the  semeiological  basis  of  five 
principal  diseases  having  separate  places  in  our 
nosology.  These  are  Eclampsia,  Epilepsy,  Teta- 
nus, Hydrophobia,  and  Chorea.  All  hut  the  first 
of  these  diseases  w ill  be  fully  considered  in  their 
respective  places,  so  that  Eclampsia  alone  wrould 
remain.  But  Eclampsia  and  Convulsions  are  con- 
vertible terms,  meaning  almost  absolutely  the 
same  thing.  The  former  term,  indeed,  is  useless 
except  for  the  mere  pui-pose  of  literary  precision. 
In  epilepsy  and  in  eclampsia  we  have  equally  to 
do  with  convulsions,  which  are  now  admitted  by 
almost  all  modem  writers  to  be  quite  indistin- 
guishable from  one  another.  The  former  name, 
however,  is  given  to  convulsions  which  have  a 
known  tendency  to  recur  at  variable  intervals ; 
whilst  the  latter  has  been  commonly  applied  to 
convulsions  which  are  either  solitary  or,  if  not 
exactly  so,  which  occur  as  a closely  successive 
cluster  or  group,  more  or  less  distinctly  sym- 
pathetic with  some  general  or  local  bodily  con- 
dition. Seeing  that  there  is,  in  a very  large 
number  of  cases,  almost  nothing  in  the  nature  of 
the  attack  itself  to  enable  a medical  man,  called 
to  a patient  in  convulsions  for  the  first  time,  to 
say  whether  he  has  to  do  with  an  attack  which 
will  he  repeated  or  not,  it  is  easy  to  understand 
that  eclampsia  is  a word  more  frequently  to  be 
seen  in  books  than  to  be  heard  at  the  bedside.  In 
books  we  may  read  of  eclampsia  neonatorum, 
the  eclampsia  of  parturient  women,  and  uriemic 
eclampsia;  though  the  more  common  clinical 
equivalents  are  infantile  convulsions,  puerperal 
convulsions,  and  uraemic  convulsions.  The  dis- 
tinction between  epilepsy  and  eclampsia  is,  there- 
fore, one  which  is  to  a very  great  extent  purely 
artificial. 

Convulsions  have  a frequent  though  less  con- 
stant relationship  also  with  many  other  atfeo- 


CONVULSIONS. 


300 

tions,  such  as  general  paralysis  of  the  insane, 
tubercular  meningitis,  chronic  hydrocephalus, 
hemiplegia,  and  hysteria. 

-ZEtiology.— The  causes  of  convulsions  are 
oftentimes  more  than  usually  complex,  consti- 
tuting a web  of  causal  conditions  partly  made  up 
of  («)  predisposing,  partly  ( b ) of  exciting,  and 
partly  ( c ) of  proximate  elements.  It  is  often  the 
fashion  to  pick  out  some  one  of  the  most  promi- 
nent or  easily  recognizable  of  these  factors,  and 
speak  of  it  as  ‘ the  cause’  of  the  attack.  It  must 
never  be  forgotten,  however,  that  this  so-called 
cause,  in  any  given  case,  may  be  able  to  act  as 
such  only  when  in  conjunction  with  certain  other 
more  obscure,  though  perhaps  not  less  potent, 
co-operating  conditions.  Without  the  conjoint 
influence  of  the  latter  it  might  have  been  quite 
powerless  to  produce  any  such  results.  Hence  the 
proverbial  uncertainty  in  regard  to  the  action  of 
any  of  the  more  important  factors,  or  so-called 
‘ causes,’  upon  different  individuals  whose  age, 
state  of  health,  predisposition,  or  surrounding 
conditions  are  not  similar. 

The  question  of  the  causation  of  convulsions 
resolves  itself,  however,  into  two  distinct  depart- 
ments, one  of  which  is  strictly  clinical  in  cha- 
racter, whilst  the  other  is  more  strictly  physio- 
logical. It  is  one  thing  for  the  medical  man  to 
ascertain  what  are  the  particular  individual  states, 
■conditions  of  life,  and  occurrences,  physical  or 
moral,  which  have  contributed  to  induce  an  at- 
tack of  convulsions  (to  ascertain  which  he  studies 
the  ‘predisposing’  and  ‘exciting’  causes  of  the 
disease) ; but  it  is  quite  a different  problem  when 
he  endeavours  to  unravel,  by  anatomico-physio- 
logical  data,  the  actual  mode  of  production  of  the 
convulsions.  In  this  latter  part  of  the  inquiry 
he  has  to  do  with  what  are  called  ‘ proximate  ’ 
causes,  and  is  brought  face  to  face  with  a problem 
Gtill  involved  in  great  obscurity,  and  concerning 
which  the  most  opposite  views  are  held  by  lead- 
ing pathologists  and  physiologists.  This  second 
part  of  the  problem  of  causation,  for  the  present, 
concerns  us  less  than  the  more  strictly  clinical 
side  of  the  inquiry,  and  it  will  be  only  inciden- 
tally referred  to  in  the  present  article.  It  will 
be  fully  considered  in  the  article  Epilepsy. 

Predisposing  Causes. — The  most  important  of 
theso  is  the  existence  of  an  unduly  excitable 
nervous  system — one  in  which  there  is  an  exalta- 
tion of  the  tendency  to  produce  reflex  movements 
— an  ‘undue  mobility  of  the  nervous  system,’  as 
it  is  sometimes  called.  This  is  a state  of  things 
which  is  naturally  more  marked  in  women  than 
in  men,  and  is  also  notably  prominent  in  young 
children  of  both  sexes.  It  is,  moreover,  much 
exaggerated  in  some  children  of  nervous  habit, 
who,  besides  being  unduly  emotional  or  exci- 
table, are  very  prone  to  start  or  tremble  on  the 
least  noise,  and  are  subject  to  muscular  twitch- 
ings  in  various  parts  of  the  body.  With  in- 
creasing age,  and  more  especially  in  the  male 
sex,  we  find  the  sensorial  and  emotional  nerve- 
centres  becoming  less  excitable,  owing,  in  great 
part  at  least,  to  their  more  complete  subordina- 
tion to  the  controlling  or  inhibitive  influence  of 
the  developing  cerebral  hemispheres. 

The  predisposing  groundwork  being  of  this 
nature,  how-  is  it  caused,  or  to  be  accounted  for? 
(3)  It  may  be  inherited  from  one  or  both  parents, 


or  from  grandparents,  who  may  themselves  have 
possessed  a nervous  system  of  this  type,  and 
may,  morever,  have  been  subject  to  fits  or  other 
well-marked  disease  of  the  nervous  system.  But 
though  not  inherited  in  the  strict  sense  of  the 
term  it  may  (2)  be  connate;  the  patient  may 
always  ( i.e . from  birth)  have  possessed  a nervous 
system  of  this  type,  as  an  accompaniment  of  the 
mere  low  vitality  which  is  often  seen  in  children 
born  from  parents  who  are  simply  weak  and 
debilitated,  or  in  those  whose  parents  have 
been  advanced  in  life.  (3)  At  other  times  the 
nervous  system  may  have  acquired  such  predis- 
posing characters  some  time  during  the  life  of 
the  individual  (especially  during  childhood  or 
adolescence)  owing  to  the  action  of  various  sets 
of  conditions,  some  of  the  best  established  of 
which  are  these  : — (fl)  The  cachexia  sometimes 
following  measles,  pertussis,  &c. ; ( b ) insufficient 
or  improper  food ; (e)  chronic  diarrhoea  ; ( d ) 
haemorrhages  or  exhausting  discharges. 

If  we  turn  now  to  the  various  exciting  causes 
we  find  these  so  powerfully  influenced  by  the  age 
of  the  patient,  as  to  make  it  desirable  to  consider 
them  in  reference  to  different  periods  of  life, 
which  we  may  artificially  though  conveniently 
mark  off  from  one  another. 

Infancy  (from  birth  to  end  of  2nd  year). — In 
certain  cases  convulsive  attacks  are  congenital ; 
and  here  perhaps  the  most  frequent  exciting  cause 
is  a meningeal  effusion  of  blood  which  presses 
upon  and  irritates  the  surface  of  the  brain — the 
extravasation  having  in  some  cases  been  occa- 
sioned during  parturition  where  it  has  been 
prolonged  or  unnatural.  These  congenital  attacks 
are  most  frequently  associated  either  with  more 
or  less  marked  hemiplegia,  or  with  a subsequent 
partial  or  distinct  condition  of  amentia  or 
idiotcy.  Such  unfortunate  infants  may  continue 
quite  unable  to  stand  or  even  sit  up  ; they  remain 
unable  to  speak,  and,  as  in  a case  which  I have  re- 
cently seen,  the  child  may  be  quite  blind.  Menin- 
geal or  superficial  haemorrhages  may  also  occur  in 
young  infants,  under  the  strain  of  the  mechani- 
cal congestion  produced  by  violent  fits  of  cough- 
ing in  pertussis  or  bronchitis,  and  in  some  of 
these  cases  such  effusion  may  be  followed  by- 
convulsions.  Fits  in  infancy  may  also  follow 
falls  or  blows  upon  the  head,  though  at  this  early 
age  such  occurrences  are  comparatively  rare. 

In  infancy,  again,  convulsions  may  usher  in 
or  subsequently  supervene  in  almost  any  acute 
disease,  this  being  especially'  the  case  with 
measles,  scarlet  fever,  and  other  of  the  exanthe- 
mata; in  pneumonia  or  bronchitis;  and  also  in 
tubercular  meningitis. 

But,  still  more  frequently,  convulsions  in  in- 
fancy are  excited  by  mere  peripheral  irritations, 
as  during  the  process  of  teething,  from  an  over- 
loaded stomach,  or  from  indigestible  food.  Diar- 
rhoea, worms,  &e.,  also  take  their  place  as  more 
or  less  frequent  excitants  of  convulsive  parox- 
ysms in  infants — though  worms  only  begin  to 
appear  towards  the  end  of  this  period.  But 
though  irritations  in  the  field  of  distribution  of 
the  5th  and  pneumogastric  nerves  are  especially 
potent  in  exciting  convulsions,  irritations  of  other 
parts  of  the  body-  may-  also  lead  to  similar  results, 
whether  they  are  occasioned  by-  the  injudicious 
disposition  of  pins,  by  tight  strings  wounding  or 


CONVULSIONS. 


irritating  tlie  skin  of  the  body,  or  by  any  other 
means.  The  more  distinctly  predisposing  con- 
ditions exist,  the  more  frequently  "will  any  or  all 
of  these  exciting  causes  give  rise  to  an  attack 
of  convulsions. 

Lastly,  an  infant  which  has  taken  the  breast 
of  a woman  who  has  shortly  before  been  much 
perturbed  by  violent  anger,  grief,  or  any  other 
strong  emotion,  may  thereafter,  if  predisposed, 
be  seized  with  convulsions — probably  owing  to 
the  milk  of  the  nurse  having  been  so  altered 
in  quality  as  to  have  led  to  gastric  trouble  and 
irritation  in  the  infant. 

Childhood  (from  the  2nd  to  the  13t'n  year). — 
Most  of  those  exciting  causes  which  are  influential 
during  the  last  period  continue  to  be  occasionally 
operative  in  this — especially  during  the  first  half 
of  it.  Meningeal  haemorrhages  are  now  rarer, 
though  they  may  still  occur  during  violent  par- 
oxysms of  coughing,  and  also  from  falls  or  blows 
upon  the  head.  Tho  latter  causes  of  haemorrhage 
may,  however,  act  in  producing  fits  in  other  ways, 
e.g.  by  concussion,  shock,  &c.,  and  they  now  come 
to  be  more  frequently  operative.  The  exanthe- 
mata are  still  aptto  be  preceded  or  associated  with 
convulsive  attacks;  and  irritations,  especially  from 
teething  or  irritants  (undigested  food  or  worms) 
in  the  intestinal  canal,  are  also  still  apt  to  be  fol- 
lowed by  such  a sequence. 

During  this  period  another  cause  of  consider- 
able potency  comes  into  operation  with  great 
frequency,  and  this  is  fright.  The  first  fit  either 
follows  the  fright  more  or  less  immediately,  or  it 
may  not  take  place  for  days — perhaps  for  weeks 
— after  the  sudden  emotional  disturbance.  During 
the  interval,  however,  the  health  and  mental  con- 
dition of  the  child  is  generally  obviously  dis- 
turbed. Proper  treatment  at  this  stage  may  pre- 
vent the  occurrence  of  fits.  Scrofulous  tumours 
in  the  brain  sometimes  help  to  determine  con- 
vulsions in  children. 

Adolescence  (from  the  13th  to  the  20th  year). 
— Fright  or  other  sudden  emotions,  falls  upon  or 
blows  about  the  head,  still  appear  as  frequent 
excitors  of  convulsive  attacks  which  recur  (epi- 
lepsy) at  this  period  of  life,  though  meningeal 
haemorrhages,  acute  diseases,  and  peripheral  irri- 
tations are  much  less  frequently  operative  than 
at  earlier  periods,  since  the  special  irritability  of 
the  nervous  system  characteristic  of  childhood 
decidedly  abates  as  the  cerebral  hemispheres 
develop  and  begin  to  exercise  a more  powerfully 
controlling  influence  over  the  lower  centres. 

Other  and  new  causes,  however,  come  into 
play  at  this  epoch.  The  establishment  of  puberty 
is  a kind  of  crisis  during  which,  independently  of 
all  other  causes,  convulsions  or  fits  may  be  initi- 
ated in  those  whose  nervous  systems  are  at  all 
predisposed  towards  such  an  occurrence.  This  is 
more  especially  so  in  the  case  of  the  female, 
partly  because  of  the  existence  of  a more  frequent 
predisposition  in  persons  of  this  sex,  and  partly 
because  of  extra  excitations  in  association  with 
the  establishment  of  the  catamenia — whether 
this  be  brought  about  imperfectly  or  in  a natural 
manner.  Ovarian  or  uterine  irritation,  or  irre- 
gularity of  the  functions  of  these  organs  at  any 
part  of  this  period,  may  help  to  occasion  fits 
which  may  or  may  not  take  an  hysterical  type. 
Masturbation  may  alsc  be  added  as  an  oeca- 


301 

sional  provocative  of  epilepsy  at  this  critical 
period  of  life,  though  I am  inclined  to  think  toy 
much  stress  is  often  laid  upon  this  as  a cause. 
When  operative  this  mode  of  causation  occurs 
more  frequently  with  the  male  than  with  the 
female  sex. 

Excessive  study  andmental  application,  as  well 
as  worry  or  anxiety,  must  also  undoubtodly  bo 
enumerated  amongst  the  causes  of  epilepsy  at 
this  period  of  life. 

Neither  must  we  forget  the  possible  existence 
of  Aneurysms  of  the  arteries  or  of  morbid  growths 
in  connection  with  some  portion  of  the  brain  or 
its  meninges,  either  of  which  may  actas  occasional 
excitants  of  epileptic  paroxysms.  This  cause 
also  figures  in  earlier  periods  of  life — more  es- 
pecially in  those  of  a scrofulous  type.  And  in 
some  of  such  cases  the  new-growth  may  lead 
to  the  supervention  of  chronic  hydrocephalus, 
and  thus  render  the  occurrence  of  convulsions 
even  still  more  likely. 

Early  Adult  Age  (20-40  years) — Fits  originate 
much  less  frequently  during  this  period  of  life 
than  in  adolescence  or  childhood.  They  ate, 
however,  apt  to  supervene  more  especially  when 
the  general  health  is  lowered  under  the  influence 
of  various  exciting  causes.  Grief  and  mental 
worry,  more  especially  when  combined  with  long- 
continued  bad  sleep,  and  the  labours  or  cares  of 
business,  are  then  apt  to  induce  them. 

Blows  or  falls  upon  the  head  may  still  be 
followed  by  attacks  of  this  kind,  though  perhaps 
with  less  frequency  than  in  the  earlier  periods 
of  life. 

Syphilitic  indurations  or  growths  from  the 
meninges  may  now  occur ; and  otherattacks  (often 
of  one-sided  convulsion)  may  be  determined  by 
various  pathological  changes  or  accidents  taking 
place  in  regions  of  the  braiu  where  more  severe 
lesions  would  give  rise  to  hemiplegia.  The  pri- 
mary change  in  these  cases  maybe  minute  haemor- 
rhages into  the  brain-substance,  or  minute  and 
slight  softenings  produced  by  stopping  of  small 
vessels  (embolism  or  thrombosis).  From  lesions 
of  this  kind  hemiplegia  and  epilepsy  are  often 
more  or  less  associated.  Occasionally  the  cause 
may  be  a non-syphih’tic  tumour,  occupying  the 
side  or  base  of  the  brain. 

Puerperal  convulsions  in  the  female,  and 
uraemic  convulsions  in  both  sexes,  are  most  fre- 
quently met  with  during  this  period  of  life. 
During  pregnancy  the  reflex  excitability  of  the 
nervous  system  is  often  greatly  increased,  and 
in  the  production  of  puerperal  convulsions  some 
amount  of  uraemia  also  intervenes  not  unfre- 
quently.  Intemperate  habits,  carried  to  excess, 
frequently  produce  fits,  and  so  also  may  venereal 
excesses. 

After  Middle  Age  (40  years  and  onwards). — 
The  mobility  of  the  nervous  system  gradually 
diminishes  during  this  period,  so  that  epileptic 
attacks  commence  now  with  still  less  frequency. 
There  is,  however,  one  period  (the  climacteric) 
in  the  female  sex  in  which  this  mobility  is 
temporarily  increased,  and  in  which  fits  again 
become  more  frequent,  under  the  influence  of 
apparently  slight  exciting  causes. 

Although  fits  are  only  very  rarely  liable  to  be 
induced  by  the  sequelae  of  haemorrhages  or  of 
softenings  of  the  brain,  yet  these,  events  now 


CONVULSIONS. 


302 

grow  more  common  as  age  advances,  and  are 
therefore  to  an  almost  corresponding  extent 
more  liable  to  figure  as  causes  of  epileptic  at- 
tacks. An  attack  of  haemorrhage  or  of  softening 
may  be  ushered  in  by  epileptiform  convulsions 
(especially  when  the  lesion  occurs  in  certain 
parts  of  the  brain),  and  in  some  cases  such 
attacks  may  thereafter  recur  at  irregular  inter- 
vals. Exposure  to  great  heat,  or  sunstroke,  may 
also  at  this  period,  or  earlier  in  life,  act  as  the 
exciting  cause  of  convulsions. 

Mental  overwork,  worry,  fright,  and  such-like 
influences,  are  much  less  likely  to  operate  in  per- 
sons over  40  than  in  earlier  life;  and  the  same  is 
to  be  said  of  blows  or  injuries  of  the  head,  short 
of  the  most  severe  causing  actual  lesions  of  the 
brain.  But  the  malnutrition  and  degeneration 
induced  by  intemperate  habits  may  predispose 
to  symptoms  of  this  kind;  and  so  also  may 
blood-poisoning  from  rena)  disease,  which  is  now 
not  unfrequently  present. 

Various  organic  diseases  of  the  brain,  whether 
principally  characterized  by  degenerations  with  a 
process  of  more  or  less  general  atrophy,  or  with 
localized  overgrowth  of  connective  tissue,  are 
also  not  unfrequently  productive  of  convulsions, 
either  in  persons  of  middle  or  of  advanced  age. 
A well-marked  instance  of  the  former  of  these 
associations  is  to  be  met  with  in  general  para- 
lysis of  the  insane.  Cysticerci  on  the  surface 
of  the  brain  have  also  in  some  recorded  in- 
stances been  the  cause  of  most  obstinately  re- 
curring convulsions. 

Lastly,  it  should  always  bebornein  mind  that 
convulsions  are  sometimes  the  result  of  the 
action  of  poisons  of  various  kinds  upon  persons  of 
any  age.  Occasionally  such  poisoning  may  be 
brought  about  by  articles  of  diet,  such  as  mussels 
or  fidh  in  certain  states,  or  from  poisonous  mush- 
rooms ; whilst  at  other  times  it  results  from 
some  of  the  well-known  narcotico-irritant  poisons, 
taken  either  inadvertently  or  purposely. 

Anatomical  Characters. — These  may  be  said, 
so  far  as  our  present  knowledge  goes,  to  be 
absent.  It  is  true  that  general  or  partial  con- 
gestion of  the  brain  may  frequently  be  encoun- 
tered in  those  who  die  during  an  attack  of 
convulsions.  But  this  congestion  is  to  be 
regarded  as  a result  rather  than  as  a cause  of 
the  fit.  The  convulsions  are  due  to  mere  mole- 
cular changes  in  the  brain,  inappreciable  to,  or 
at  all  events  unappreciated  as  yet  by,  the  most 
skilled  microscopists.  When  fits  occur  in  asso- 
ciation with  actual  organic  growths  or  other 
lesions  of  the  cerebral  cortex  or  elsewhere,  such 
lesions  may  form  merely  the  starting  points  for 
nervous  impressions  which  travel  downwards  so 
as  to  upset  the  equilibrium  of  certain  unstable 
or  highly'  charged  motor  centres  ; just  as  a simi- 
lar disturbance  of  nervous  equilibrium  with 
discharge  of  motor  energy  may  result  in  another 
case  from  abnormal  visceral  impressions  (in- 
duced it  may  be  by  indigestible  matters  in  the 
intestine  or  by  an  acute  disease  of  the  lungs),  or 
from  some  surface-irritation.  In  accordance 
with  this  point  of  view,  such  organic  growths  or 
other  lesions  need  receive  no  further  mention 
here.  Those  who  may  be  inclined  to  think 
otherwise,  should  bear  in  mind  the  fact  that 
convulsive  attacks  are  easy  to  be  produced  in 


animals  from  whom  the  cerebral  aemispheres 
have  been  removed. 

Symptoms. — The  varied  nature  of  the  causes 
make  it  impossible  to  say  anything  of  moderate 
compass  concerning  the  premonitory  signs  or 
symptoms  which  may  precede  an  outbreak  of 
convulsions.  These  must  necessarily  vary  im 
mensely  in  different  cases.  Some  of  the  charac- 
ters of  the  predisposing  state  hare  been  already 
alluded  to  (p.  300).  The  onset  is,  however,  often 
abrupt  and  without  any  distinct  premonitory 
symptoms. 

With  regard  to  the  actual  characters  of  the 
attack  it  will  be  sufficient  to  say  here  that  they 
also  vary  immensely  in  different  cases;  aud  as 
notwithstanding  this  great  variability  it  is  im- 
possible in  any  individual  case  to  tell,  from  the 
nature  of  a first  convulsive  fit,  whether  it  will 
form  a more  or  less  isolated  attack,  or  whether 
it  will  constitute  one  of  a subsequently'  recurring 
series,  the  reader  may,  for  this  part  of  the  sub- 
ject, be  referred  to  the  description  of  the  attacks 
given  under  Epilepsy.  All  that  is  there  said 
concerning  the  actual  phenomena  and  mechanism 
of  the  attack,  holds  good  for  occasional  convul- 
sions as  well  as  for  those  which  are  habitual. 
In  each  we  have  to  do  with  (I)  a more  or  less 
distinct  stage  of  tonic  spasms,  followed  (2)  by 
one  of  clonic  spasms,  and  (3)  succeeded  by  a 
state  of  stupor.  One  or  other  of  such  stages  is, 
however,  not  unfrequently  more  or  less  abortive. 
These  attacks  may,  at  times,  so  rapidly  follow 
one  another  as  to  be  merged  into  one  long  series 
or  status  convulsivus,  differing  in  no  respect  from 
the  analogous  status  epilepticus. 

Complications  and  Sequelae. — The  compli- 
cations are  most  various,  seeing  that  in  different 
cases  we  may  have  to  do  with  irritated  gums, 
repletion,  diarrhoea,  worms,  or  an  acute  specific 
disease ; whilst  in  other  cases  it  may  be  with 
general  debility  and  sleeplessness,  with  mental 
anxiety,  puberty,  or  the  climacteric  period. 
Again  pneumonia,  renal  disease,  pregnancy, 
ovaritis,  or  some  organic  brain-disease  may  be 
the  accompanying  condition. 

The  nature  of  the  sequelae  will  depend  princi- 
pally upon  the  frequency  of  the  attacks  and  the 
duration  of  the  period  during  which  the  patient 
has  been  subject  to  the  recurrence  of  them,  so 
that  for  this  part  of  the  subject  the  reader  may 
refer  to  the  article  Epilepsy. 

Diagnosis. — There  is  very'  little  difficulty  in 
regard  to  the  diagnosis  of  the  affection.  The 
differential  characters  of  Laryngismus  Stridulus 
are  given  elsewhere,  and  the  absence  of  any  real 
distinction  between  a fit  of  Eclampsia  and  a fit 
of  Epilepsy  has  already  been  insisted  upon. 
Neither  of  these  affections  can  be  easily  con- 
founded with  certain  forms  of  Chorea,  which 
occasionally  present  themselves  in  adults,  with 
movements  not  unlike  those  of  ordinary  con- 
vulsions. The  more  continuous  nature  of  the 
movements,  and  the  fact  that  consciousness  is 
not  impaired,  suffices  to  distinguish  all  forms  of 
Chorea.  The  spasms  of  Tetanus  and  Hydro- 
phobia are  also  easily'  distinguishable  from  an 
ordinary  attack  of  convulsions. 

The  characteristics  of  hysterical  convulsions 
will  be  pointed  out  in  the  article  on  Hysteria. 

The  real  difficulties  from  this  point  of  view 


CONVULSIONS. 


of  diagnosis  have  reference  to  the  cause  of  the 
attack.  To  arrive  at  a decision  in  regard  to  this 
is  often  very  difficult  and  occasionally  impossible, 
at  all  events  when  a patient  first  comes  under 
observation.  At  other  times,  however,  the  indi- 
cations are  so  plain  that  there  can  be  little  or  no 
difficulty.  It  is  a question  which  should  always 
be  considered  with  the  utmost  care,  since  on  the 
correctness  of  our  conclusions  in  regard  to  this 
point  the  efficacy  of  the  oarticular  line  of  treat- 
ment which  we  adopt  must  necessarily  depend. 
Nothing  is  more  to  be  deprecated  than  hasty 
jumping  at  conclusions,  from  mere  routine  and 
superficial  considerations.  The  condition  of  the 
patient  must  be  carefully  examined,  and  the 
nurse,  attendants,  or  relatives  must  b6  closely 
questioned  in  order  that  we  may  learn  as  much 
as  possible  as  to  the  previous  state  of  health  of 
the  patient,  and  more  especially  as  to  the  time' 
and  events  which  immediately  preceded  the  first 
outbreak  of  an  attack  of  convulsions.  Exami- 
nation and  enquiries  combined  may  convince  us 
that  the  convulsions  are  (1)  of  the  primary  or 
idiopathic  variety,  immediately  occasioned  per- 
haps by  fright,  anxiety,  overwork,  overmuch  or 
indigestible  food,  &c. ; or  we  may  come  to  the 
conclusion  that  the  convulsions  are  (2)  of  the 
sympathetic  order  dependent  upon  pregnancy, 
renal  disease,  the  onset  of  an  acute  specific  fever 
or  of  pneumonia,  or  due  to  the  existence  of  hooping 
cough,  scarlet  fever,  &c.  Or,  in  the  absence  of 
reasons  for  placing  them  in  either  of  these  cate- 
gories, we  may  be  forced  to  conclude  that  they 
are  (3)  symptomatic  of  some  organic  brain- 
disease,  the  nature  of  which  must  then  be 
determined  as  nearly  as  possible,  judging  from 
the  age  of  the  patient,  the  mode  of  onset,  his 
present  state  and  associated  conditions. 

In  any  case  we  may  have  to  enquire  more 
closely  as  to  hereditary  tendencies,  or  acquired 
predisposing  causes,  which  sometimes  reduce  the 
nervous  system  to  such  a degree  of  irritability 
as  to  lead  to  an  attack  of  convulsions  without 
the  aid  of  any  obvious  exciting  cause.  In  infants 
or  very  young  children  such  a condition  of  the 
nervous  system  may  display  itself  by  great  rest- 
lessness and  startings  at  night,  by  the  child’s 
sleeping  with  half-open  eyes,  by  drawing  in  of 
the  thumbs  across  the  palms,  by  twi tellings  of  the 
limbs,  of  the  angles  of  the  mouth,  or  of  the 
facial  muscles  generally.  In  older  children  and 
in  young  adults  the  signs  which  most  easily  mark 
r,  similar  below-par  condition  of  the  nervous 
system  are  twitchings  of  tho  muscles  about  the 
angle  of  the  mouth  and  of  the  tongue  (the  for- 
mer being  especially  well  seen  when  the  latter 
organ  is  tremulously  protruded  for  inspection) 
associated  with  debility,  anorexia,  partial  insom- 
nia, and  general  nervousness.  In  nervous  girls 
fits  are  induced  by  very  slight  causes  about  the 
time  when  the  catamenia  become  first  established. 
The  indications  for  treatment  must  in  fact  vary 
immensely  in  any  five  consecutive  cases  of  con- 
vulsions to  which  the  practitioner  may  be  sum- 
moned. 

Prognosis. — The  possibilities  under  this  head 
bre  at  least  six  in  number  in  regard  to  any  case 
of  convulsions: — (1)  The  patient  may  recover 
after  having  a single  fit  or  a batch  of  them  within 
a few  hours  or  days,  and  may  never  have  another 


303 

attack.  (2)  The  patient  may  recover,  and  though 
he  or  she  may  not  have  fits  habitually  thereafter, 
they  may  recur  at  prolonged  intervals,  when 
predisposing  circumstances  chance  to  be  strong 
or  are  supplemented  by  an  exciting  cause  of  un- 
usual potency.  Thus  convulsions  during  teething 
may  cease,  and  may  not  recur  till  the  constitu- 
tion has  been  lowered  by  some  illness  years  after, 
or  when  the  nervous  system  has  been  rendered 
more  irritable,  as  at  the  time  when  the  catamenia 
are  about  to  commence,  especially  if  some  slight 
fright  should  also  come  into  operation  as  an 
exciting  cause.  (3)  The  patient  may  recover, 
though  he  subsequently  continues  to  have  fits 
either  at  irregular  or  regular  intervals ; he  be- 
comes, in  short,  a confirmed  epileptic.  (l)  The 
convulsions  may  come  to  be  followed  by  tempo- 
rary delirium  or  a more  or  less  marked  maniacal 
condition,  recurring  after  all  or  some  seizures, 
(o)  The  patient  may  recover  from  the  convulsive 
attack  and  mayor  may  not  have  another  fit,  though 
he  may  remain  hemiplegic.  (6)  The  patient  may 
die  during  the  attack  or  almost  immediately 
afterwards,  (a)  from  the  effects  of  it,  or  (6)  by 
reason  of  some  organic  lesion  by  which  the  fit 
itself  has  been  determined. 

Recoveries  are  fortunately  common,  but  death, 
especially  in  infants,  is  by  no  means  uncommon. 
We  possess  no  accurate  data  to  enable  us  to 
assign  the  numerical  proportion  of  these  termi- 
nations to  one  another  and  to  the  other  above- 
mentioned  sequences. 

Treatment. — During  the  convulsion  itself, 
whether  we  have  to  do  with  an  infant  or  an 
adult,  we  must  see  that  all  clothes  are  thoroughly 
loose  about  the  neck  and  chest,  and  the  patient 
should  be  placed  in  the  supine  position  with  the 
head  slightly  raised.  Beyond  seeing  that  the 
patient  does  not  knock  or  injure  himself,  owing 
to  the  violence  of  his  movements,  these  should 
not  be  much  restrained  ; although  efforts  should 
always  be  made  to  prevent  the  tongue  being 
bitten,  by  slipping  the  most  suitable  thing  at 
hand  between  the  molar  teeth  on  one  side,  when 
the  ago  of  the  patient  or  the  character  of  the  fit 
renders  it  likely  that  this  event  might  otherwise 
occur.  Beyond  such  simple  measures  as  this, 
the  less  we  do  during  the  actual  continuance  of 
the  fit  the  better  it  will  probably  be  for  the 
patient.  We  know  of  no  rational  or  successful 
means  of  cutting  short  an  ordinary  attack  of  con- 
vulsions, and  in  the  face  of  such  an  attack  we 
should  be  cautious  lest  evil  might  be  done. 

Where  we  have  to  do  with  a succession  of 
attacks  quickly  following  one  another,  and  which 
have  already  lasted  some  time,  the  careful 
administration  of  chloroform  may  be  tried,  as  it 
is  very  serviceable  in  many  cases  when  a status 
convulsivus  occurs  in  children  or  in  adults — 
though  it  would  not  be  desirable  to  have  recourse 
to  it  in  infants.  Under  similar  circumstances, 
for  the  latter  the  warm  bath  may  be  substituted, 
and  sometimes  seems  to  do  good.  On  the 
cessation  of  the  convulsions,  or  during  the  in 
tervals,  the  treatment  to  be  adopted  to  prevent 
their  recurrence  must  necessarily  vary  immensely 
according  to  the  age  of  the  patient,  and  accord- 
ing to  the  predisposing  aud  exciting  causes  which 
appear  to  have  been  operative  in  inducing  the 
attack. 


304  CONVULSIONS. 

An  overloaded  stomach  'will  call  for  the  speedy 
administration  of  an  emetic,  and  where  indiges- 
tible food  has  already  passed  into  the  intestine 
an  enema  or  brisk  purgative  should  be  given. 
Diarrhoea  must  be  checked,  or  anthelmintics 
administered  when  worms  are  suspected.  Gums 
may  be  lanced  if  they  seem  really  to  need  it.  In 
many  of  these  cases  an  acquired  or  hereditary 
predisposition  will  have  to  be  combated  by  the 
careful  regulation  of  the  diet,  so  that  nutritious 
and  easily  digested  food  are  given  in  place  of 
their  opposites,  whilst  at  the  same  time  the  most 
suitable  nervine  tonics  and  antispasmodics  are 
administered.  For  general  usefulness  in  such 
eases  no  remedies  can  compare  with  the  bromides 
of  potassium  and  ammonium.  As  part  of  the 
specific  influence  which  they  exercise  over  nerve- 
tissue,  they  fortunately  establish  a tendency 
to  quieter  and  sounder  sleep,  of  which  such 
patients  often  stand  much  in  need.  Ten-grain 
doses  three  times  a day  should  be  given  at  the 
commencement  to  youths  or  adults,  and  after- 
wards increased  if  necessary.  Or  a larger  dose 
may  be  given  once  a day,  either  in  the  morning 
or  at  night,  according  to  the  indications  in  each 
case.  Quinine  or  belladonna  may  be  often  given 
simultaneously  with  great  advantage.  To  young 
children  or  infants,  the  dose  of  the  bromide  must, 
of  course,  vary  with  their  age.  Valerianate  of 
zinc  and  oxide  of  zinc  are  remedies  of  less 
power,  though  these  and  other  drugs  may  be 
tried  where  bromides  appear  to  fail.  This 
general  treatment  is  applicable  to  a large  pro- 
portion of  cases  also  in  which  in  debilitated  or 
‘ nervous  ’ patients  fits  have  been  brought  on  by 
fright,  worry,  or  anxiety,  or  by  no  assignable 
cause.  Fatigue  of  mind  and  body  is  always  to 
be  avoided,  and  in  those  instances  in  which  over- 
attention to  business  or  over-study  have  been  in 
part  operative  in  bringing  on  the  fits,  absolute 
rest  must  form  an  essential  part  of  the  treatment. 
In  girls  or  young  women  in  whom  fits  occur  at 
the  time  of  the  establishment  of  the  catamenia, 
or  where  they  recur  in  association  with  an  irre- 
gular menstrual  function,  the  general  health 
often  requires  our  most  careful  attention. 

Tha  convulsions  which  belong  to  the  class 
known  as  sympathetic  have  to  be  carefully  con- 
sidered in  relation  to  the  malady  of  which  they 
are  the  forerunners  or  associates.  When  con- 
vulsions precede  an  attack  of  scarlet  fever  or  of 
small-pox  they  usually  subside  of  themselves  as 
the  disease  develops.  They  are,  however,  of 
much  more  significance  when  occurring  during 
the  course  or  towards  the  close  of  one  of  these 
maladies  or  during  an  attack  of  hooping  cough 
or  of  cror^.  Our  indications  for  treatment  must 
then  be  derived  in  the  main  from  the  general 
state  oi  che  patient,  and  this  is  also  eminently  the 
case  where  we  have  to  do  with  uraemic  con- 
vulsions. 

The  treatment  oi  symptomatic  convulsions,  de- 
pendent upon  actual  organic  brain-disease,  must 
also  necessarily  be  subordinated  to  that  appro- 
priate for  the  affection  itself  upon  which  such 
symptoms  depend.  No  drug  will  be  found  more 
generally  useful,  however,  than  bromide  of  potas- 
eum  in  ten  to  fifteen-grain  doses  for  an  adult 
(administered  three  times  a day),  in  checking 
or  diminishing  the  repetition  of  convulsions  in 


CO-ORDINATION. 

these  cases.  Sometimes  the  action  of  the  bro- 
mide seems  to  be  favoured  by  combining  it  with 
moderate  doses  of  digitalis,  especially  in  those 
cases  in  which  there  is  great  general  nervous- 
ness in  association  with  a disordered  cardiac 
rhythm.  Where  sounder  slec-p  is  urgently 
necessary,  chloral,  either  alone  or  in  combination 
with  bromide  of  potassium,  should  be  given  at 
bed-time.  Tinctures  of  sumbul  or  of  henbane 
are  also  at  times  useful  adjuvants.  Where  we 
have  to  do  with  tumours  of  the  brain,  and  espe- 
cially with  syphilitic  growths  in  the  meninges, 
much  better  results  are  to  be  hoped  for  from  large 
and  increasing  doses  of  iodide  of  potassium, 
either  alone  or  in  combination  with  small  doses  of 
bichloride  of  mercury,  with  the  administration  of 
nutritious  food  and  attention  to  the  improvement 
of  the  general  health.  See  Brain  ; and  Spinai, 
' Cord,  Diseases  of.  H.  Chariton  Bastian. 

CO-ORDINATION. — This  term  is  used  in 
reference  to  muscular  movements  principally. 
Certain  parts  of  the  nervous  system  have  more 
especially  to  do  with  the  calling  into  activity, 
and  therefore  with  combining,  the  contractions 
of  different  muscles,  both  simultaneously  and  in 
succession,  in  the  precise  order  in  which  they 
occur  in  the  several  motor  acts  of  which  we  are 
capable.  The  nervous  arrangements  upon  which 
these  actions  depend  have  come  into  being,  both 
in  the  race  and  in  the  individual,  by  processes 
of  organic  growth  and  development  pari  passu 
with  the  possibility  of  executing  these  several 
movements.  It  would  be  wrong  to  expect,  there- 
fore, that  an  isolated  organ  should  exist  solely 
for  co-ordinating  muscular  movements.  The 
execution  of  the  most  habitual  of  these  must  de- 
pend, to  a large  extent,  upon  the  activity  of  the 
ordinary  motor  tracts  of  the  spinal  cord  and 
brain.  The  extent  or  precise  mode  in  which  the 
cerebellum  intervenes  in  certain  higher  forms  of 
co-ordination  is  still  involved  in  much  obscurity. 
That  it  has  some  share  in  such  functions  may 
be  regarded  as  certain,  though  it  probably  inter- 
venes far  less  than  some  would  have  us  believe, 
who  regard  the  cerebellum  as  the  organ  for  the 
co-ordination  of  muscular  movements. 

Many  nervous  affections  exist  in  which  the 
co-ordination  of  muscular  movements  is  more  or 
less  impaired.  One  of  the  most  familiar  of 
these  is  locomotor  ataxy,  a disease  dependent 
upon  a morbid  process  in  the  posterior  columns 
of  the  cord.  Sclerosis  of  the  antero-latcral  co- 
lumns of  the  cord  also  not  unfrequently  dis- 
turbs the  execution  of  muscular  movements, 
especially  those  of  the  upper  extremities.  Cho- 
rea gives  rise  to  very  similar  uncertainties  in  the 
execution  of  muscular  acts.  Spasms  of  all  kinds, 
in  short,  tend  to  interfere  with  the  harmony  of 
the  muscular  movements  in  the  course  of  which 
they  intervene.  Stammering  is  an  affection  of 
this  kind,  implicating  the  muscles  of  articulation, 
and  certain  disturbed  cardiac  actions  characte- 
rised by  disordered  rhythm  can  only  he  regarded 
as  belonging  to  the  same  category. 

The  above-mentioned  are  common  instances 
of  impaired  co-ordination  of  muscular  move- 
ments dependent  upon  structural  or  functienui 
changes  in  parts  of  the  nervous  system  other 
than  the  cerebellum.  Certain  diseases  of  this 


CO-ORDINATION. 

organ,  however,  are  known  to  give  rise  to  a dis- 
•jnct  form  of  inco-ordination.  It  is  characterised 
by  a reeling,  unsteady  gait  in  walking,  with  legs 
straggling,  and  mostly  wide  apart,  to  which  the 
term  ‘ titubation  ' is  commonly  applied.  Other 
kinds  of  inco-ordination  may  hereafter  he  proved 
to  depend  upon  diseases  of  the  cerebellum.  These 
are  still  very  imperfectly  recognised,  and  this  is 
especially  true  in  regard  to  its  merely  functional 
perturbations. 

Certain  inco-ordinations  in  speech  and  writing 
are  common.  Instances  are  to  be  found  in  that 
use.  of  wrong  words  or  misapplication  of  terms 
which  we  meet  with  in  apliasic  and  amnesic 
persons  ; also  in  the  substitution  of  wrong  words 
in  the  act  of  writing,  or  of  wrong  letters  in  the 
writing  of  words,  when  such  substitution  is  me- 
chanical and  unintentional — when  it  is  wholly 
distinct,  therefore,  from  mere  inability  to  spell. 
These  defects  are  inco-ordinations  of  a complex 
kind,  dependent  upon  the  perverted  action  of 
higher  cerebral  centres,  in  the  same  way  that 
incoherent  speech  generally  is  dependent  upon 
incoherent  thought.  There  is  reason  to  believe, 
indeod,  that  the  same  kind  of  ultimate  defective 
nervous  action  which  leads  to  inco-ordinations 
of  movements  when  certain  motor  regions  of  the 
nervous  system  are  affected,  may,  on  the  other 
hand,  give  rise  to  perverted  perceptions  ( illusions ) 
or  to  perverted  thought  (incoherence)  when  the 
disturbed  nervous  action  occurs  in  other  and  in 
higher  parts  of  the  central  nervous  system. 

H.  Charlton  Bastian. 

COPHOSIS  (Kucpbs,  deaf). — Deafness.  Sec 
Hearing,  Disorders  of. 

COPPER,  Poisoning  by.— Metallic  copper 
may  be  regarded  as  innocuous  when  swallowed, 
and  the  recent  researches  of  Hirt  show  that  those 
who  are  engaged  in  the  metallurgy  and  manu- 
facture of  copper  utensils  aro  not  specially  liable 
to  any  diseases  which  can  be  attributed  to  copper 
as  such.  It  is,  iudeed,  stated  that  workers  in 
copper  enjoy  an  immunity  from  cholera,  a conclu- 
sion which  is  based  on  very  insufficient  premisses. 
It  is  contradicted  by  the  occurrence  of  cholera 
among  coppersmiths  in  Buscau  in  1866,  and  by 
certain  other  cases  of  a like  nature  reported  by 
Hirt.  That  the  disease  is  seldom  found  among 
workers  in  copper  is  true,  but  that  the  copper 
has  anything  to  do  with  this  result  is  not  proved. 

Though  pure  copper  may  be  regarded  as  in- 
nocuous, it  is  otherwise  with  alloys  of  copper , 
more  particularly  with  the  alloys  of  copper  with 
zinc  and  tin,  known  under  the  names  of  brass 
and  bronze  respectively,  and  with  compounds  of 
copper  with  lead  or  arsenic.  In  these  the  inju- 
rious agent  would  appear  to  be  the  alloy,  and 
not  the  copper  itself.  An  affection  of  a febrile 
character,  and  known  as  ‘ brass-founder’s  ague,’ 
occasionally  occurs  on  fusing  days,  and  is  attri- 
butable to  the  zinc  fumes  which  are  generated  by 
the  melting  process. 

The  salts  of  copper , on  the  other  hand,  are 
capable  of  causing  injurious  and  fatal  results. 
The  more  important  salts,  from  a medico-legal 
point  of  view,  are  the  sulphate,  blue  vitriol,  or 
bluestone;  the  acetates  (basic  and  neutral)  con- 
stituting artificial  verdigris;  and  the  carbonate 
or  natural  verdigris.  The  manufacture  of  ver- 

20 


COPPER,  POISONING  BY.  306 
digris  is  carried  on  to  a large  extent  in  the 
south,  of  France.  Plates  of  copper  are  acted  on 
by  the  skins  of  grapes  which  are  allowed  to  un- 
dergo the  acetous  fermentation.  Those  engaged 
in  this  industry  on  the  whole  enjoy  good  health, 
and  it  is  only  rarely  that  symptoms  can  lie 
directly  traced  to  the  work  ; and  then  only  when 
through  sheer  carelessness  and  uncleanliness 
quantities  of  the  salt  have  been  ingested.  It  is 
even  said  thatdogseattherefusegrape-skinswith- 
out  appearing  to  suffer  from  poisonous  symptoms 

1.  Acute  poisoning  by  copper. — Symp 
toms. — The  salts  of  copper,  when  taken  in 
sufficient  quantity,  cause  symptoms  of  acute 
poisoning,  frequently  terminating  fatally.  Twelve 
to  fifteen  grains  of  the  acetate  have  been  suffi- 
cient to  kill  a dog  within  an  hour.  The  fatal 
dose  in  man  is  not  quite  determined;  but  doses 
above  the  usual  emetic  dose  of  the  sulphate  (ten 
to  fifteen  grains)  have  caused  serious  symptoms, 
and  death  has  resulted  within  four  hours  after 
swallowing  some  pieces  of  the  sulphate.  Half 
an  ounce  would  probably  cause  a fatal  result. 
The  symptoms  aro  essentially  those  of  irritant 
poisoning,  viz.,  styptic  or  coppery  taste,  constric- 
tion of  the  fauces,  epigastric  pain,  violent  vomit- 
ing and  purging,  followed  by  collapse  and  death, 
usually  with  tetanic  or  convulsive  symptoms. 
That  which  characterises  copper-poisoning  more 
especially,  as  compared  with  other  irritants,  is 
the  frequent  occurrence,  of  jaundice.  In  dogs 
copper  usually  causes  death  with  symptoms  of 
paralysis  of  the  hinder  extremities,  in  addition 
to  the  usual  irritant  symptoms.  It.  is  said  also 
to  have  a paralysing  action  on  the  heart. 

2.  Chronic  poisoning  by  copper. — It  is 
generally  stated  that  the  long-continued  intro- 
duction of  copper  into  the  system  in  small  doses 
gives  rise  to  a form  of  chronic  poisoning  known 
under  the  name  of  1 copper  colic.’ 

Symptoms. — The  symptoms  are  essentially 
those  of  gastro-intestinal  irritation,  with  nausea 
or  sickness  and  diarrhoea.  They  have  none  of 
the  characters  of  colic  in  the  sense  in  which  the 
term  is  usually  employed.  The  hair  and  the 
cutaneous  secretions  of  workers  in  copper  and 
brass  are  sometimes  found  of  a green  colour, 
and  a line  is  sometimes  found  at  the  margin  of 
the  gums  and  teeth,  variously  described  by 
authors, — Corrigan  calling  it  purple,  while  Clap- 
ton calls  it  green. 

Though  symptoms  of  gastro-intestinal  irrita- 
tion, as  above  described,  have  been  found  among 
workers  in  copper,  the  question  is  whether  they 
are  in  reality  due  to  the  copper,  or  merely 
symptoms  of  a not  uncommon  affection  showing 
themselves  among  copper-workers.  That  copper 
does  gain  access  into  the  system,  and  may  he 
detected  in  the  urine  during  life,  and  found  in 
the  bones  after  death,  without  the  individual 
showing  any  manifest  symptoms  during  life, 
seems  pretty  well  established.  But  though  we 
may  regard  it  as  certain  that  symptoms  of 
copper-poisoning  are  more  rarely  found  than 
those  of  lead-poisoning  among  thoso  who  have  to 
deal  with  these  metals,  yet  it  would  be  a very  un- 
warrantable conclusion,  and  contrary  to  all  that 
we  know  of  the  action  of  poisons,  to  assert  that  a 
substance  which  is  undoubtedly  poisonous  can 
be  taken  freely  into  the  system  with  impunity 


306  COPPER,  POISONING  BY. 

This  is  a point  cf  considerable  interest  in  refer- 
ence to  the  accidental  or  wilful  adulteration  of 
articles  of  food  with  copper  salts.  Many  cases 
are  on  record  of  severe  symptoms  resulting  from 
the  use  of  copper  utensils  in  cooking,  or  more 
frequently  from  the  storage  of  water  or  articles 
of  food  in  copper  vessels,  especially  if  the  food 
contains  oil — which,  on  turning  rancid,  dissolves 
the  copper — or  vegetable  acids,  or  even  large 
quantities  of  ordinary  salt. 

Copper  salts  are  also  employed  intentionally 
to  impart  a green,  fresh  colour  to  pickles  and 
preserved  vegetables,  such  as  peas.  It  is  as- 
serted that  the  quantity  of  copper  necessary  to 
produce  this  effect  is  infinitesimal,  and  that  no 
poisonous  effects  can  be  proved  to  have  resulted 
even  from  long-continued  employment  of  these 
vegetables  as  articles  of  food.  This  is  strongly 
maintained  by  M.  Galippe,  who  has  tried  them  on 
himself  and  family.  Assuming  the  impossibility 
of  proving  the  injurious  effects  of  copper-tinted 
vegetables,  the  question  comes  to  be  principally 
a social  and  economic  one,  as  to  the  propriety 
or  legality  of  adulteration  of  food  at  all,  and 
especially  with  a substance  undoubtedly  poi- 
sonous. Copper  is  said  by  some  to  be  a natural 
constituent  of  the  human  body,  but  Boutigny 
furnishes  strong  grounds  for  attributing  the 
minute  quantity  which  may  be  found  in  the 
liver  to  accidental  introduction  into  the  system 
from  cooking  utensils,  or  from  fruits  raised  on 
manure  containing  copper. 

Diagnosis. — The  greenish  or  bluish  colour  of 
the  vomited  matters,  which  turn  bright  blue  on 
the  addition  of  ammonia,  renders  the  diagnosis 
comparatively  easy. 

Treatment. — In  acute  cases  the  stomach  should 
be  evacuated  by  encouraging  vomiting,  or  by  the 
Stomach-pump.  Albumen  in  some  form,  as  milk 
or  white-of-egg,  should  be  given  in  order  to  pre- 
cipitate the  copper.  Iron  filings  may  be  given 
for  a similar  purpose. 

In  chronic  poisoning  the  cause  should  be  dis- 
covered and  removed,  or  the  individual  removed 
from  the  cause.  D.  Ferrier. 

CORN.  — - Synon.  : davits  ; Fr.  C'.ou,  cor  ; 
Ger.  Ltichdorn,  die  Hiihnerauge. 

A com  is  a thickening  of  the  epidermis,  caused 
by  undue  pressure  and  friction,  as  by  boots,  shoes, 
or  implements  of  occupation.  It  is  usually  situa- 
ted on  a prominence,  such  as  that  of  a joint, 
where  the  skin  is  subjected  to  double  pressure, 
and  is  therefore  unable  to  yield,  or  between  the 
toes.  Corns  are  most  common  on  the  feet. 

A corn  usually  begins  as  a general  and  uni- 
form thickening  of  the  epidermis,  which  is 
termed  a callosity,  ( tyloma , tylosis,  Schwielen). 
Callosities  may  occur  on  any  part  of  the  in- 
tegument. Thus  they  may  occupy  the  promi- 
nence of  a joint,  or  spread  over  the  heel  or  the 
metatarsal  cushion  of  the  foot  from  pressure  in 
walking,  or  occupy  the  metacarpal  prominences 
of  the  hand  as  in  boatmen. 

The  callosity  is  composed  of  laminated  epider- 
mis ; is  thickest  in  the  centre,  becoming  thin 
towards  the  circumference ; and  is  more  or  less 
hard  and  condensed,  smooth  and  hornlike  in  ap- 
pearance, and  yellowish  in  colour.  When  the 
irritation  which  gives  rise  to  a callosity  is  pro- 


CORONARY  ARTERIES, 
longed,  effusion  is  apt  to  take  place  beneath  u, 
and  it  is  raised  like  a blister,  the  effused  fluid 
being  sometimes  serous  and  sometimes  sero- 
purulent.  Whenever  this  happens,  the  subse- 
quent separation  of  the  horny  layer  results  in 
spontaneous  cure. 

When  the  pressure  giving  rise  to  a callosity, 
instead  of  being  diffused,  is  concentrated  on  a 
central  point,  the  epidermis  corresponding  with 
that  point  increases  in  thickness,  by  its  under 
surface,  and  forms  a conical  prominence ; further 
pressure  increases  the  length  and  breadth  of 
the  cone,  and  in  this  way  a corn  is  established. 
Continued  irritation  enlarges  the  corn  by  hyper- 
plasia of  epidermic  cells,  and  its  pressure  produces 
absorption  of  the  derma,  sometimes  extending 
to  the  bone  itself.  Not  unfrequently  effusions  of 
serum  or  blood  take  place  beneath  the  conical 
prominence,  and,  in  rare  instances,  a bursa  is 
found  between  the  corium  and  the  joint. 

At  a late  stage  of  its  growth  the  corn  lias  the 
appearance  of  a central  core — technically,  the  eye 
of  the  corn — surrounded  by  a collar  of  smooth 
epidermis  in  the  state  of  callosity.  The  core  is 
a lamellated  ovoid  mass,  corresponding  in  exter- 
nal figure  with  the  cup  by  which  it  is  produced ; 
and  consisting  in  substance  of  vertical  cup- 
shaped lamellae  closely  packed  one  within  the 
other.  In  an  old  com  the  shape  of  the  entire 
core  is  conical,  the  point  resting  on  the  sensitive 
skin,  and  the  signification  of  the  term  clou  or 
nail  applied  to  it  by  the  French  is  made  mani- 
fest. The  substance  of  the  corn  resembles  horn 
both  in  colour  and  density,  but  between  the 
toes,  where  moisture  is  generally  present,  it 
remains  white  and  soft,  like  soddened  cuticle, 
and  is  thence  named  soft-corn.  Effusion  at  its 
base  is  more  common  in  the  soft  than  in  the 
hard  corn. 

Treatment. — The  treatment  of  a corn  is  lo 
romovo  its  cause,  namely,  pressure  and  friction  : 
but  when  this  is  impracticable,  to  equalize  pres- 
sure, by  which  the  corn  will  revert  to  the  state 
of  callosity.  The  second  indication  is  best 
effected  by  some  simple  unirritating  application, 
such  as  soap-  or  lead-plaster  spread  on  wash- 
leather.  As  a preliminary  to  this  application, 
as  much  of  the  hard  epidermis  as  possible  should 
be  removed  by  soaking  and  scraping,  and  the 
core  turned  out  with  a blunt-pointed  instrument. 
The  soft  corn  may  be  removed  as  the  hard  one,  or 
by  snipping  with  scissors.  When  there  is  much 
pain  and  inflammation  about  the  corn  it  should 
be  treated  by  means  of  water-dressing.  Chronic 
corns  and  callosities  are  much  benefited  by  paint- 
ing with  iodine  liniment,  and  the  use  of  an  un- 
irritating protective  plaster. 

Erasmus  Wilson. 

CORNEITIS. — Inflammation  of  the  cornea. 
See  Eye  and  its  Appendages.  Diseases  of. 

CORNUA  (cornu,  a horn). — A synonym  for 
horns.  See  Horns. 

CORONARY  ARTERIES,  Diseases  of 

The  diseases  of  the  coronary  arteries  may  be 
classified  as  follows  : (a)  atheroma  and  calcifi- 
cation ; ( b ) aneurism : (cl  occlusion  of  the  orifice ; 
(d.)  thrombosis;  and  (e)  syphilitic  disease. 

a.  Atheroma  and  calcification  of  the  coro- 
nary arteries  are  ordinary, but  by  no  means  cod 


CORONARY  ARTERIES, 
stant  sequelae  of  similar  changes  in  the  root  of  the 
aorta.  The  disease  may  be  general,  affecting 
both  vessels  equally  or  unequally ; or  it  may  be 
limited  toone  of  them,  or  even  to  a primary  branch 
of  either ; and  may  lead  to  fatty  degeneration  or 
fibroid  change  of  the  corresponding  substance 
of  the  heart.  The  experiments  of  Mr.  Erichsen 
and  M.  Schiff  have  proved  that  the  nutrition  of 
the  heart  in  health  depends  upon  a free  coronary 
circulation,  and  pathology  has  confirmed  this  con- 
elusion.  Dr.  Quain  found  the  coronary  arteries 
diseased  or  obstructed  in  13  out  of  33  cases  of 
fatty  degeneration  of  the  heart,  and  in  one  of 
these  cases,  the  trunks  of  both  vessels  being 
healthy,  a calcified  coronary  branch  led  to  the 
only  portion  of  the  heart  exhibiting  fatty  change. 
Of  oo  cases  of  fatty  degeneration  of  the  heart 
collated  by  the  author  from  the  Transactions 
of  the  London  Pathological  Society,  21  exhi- 
bited atheromatous  or  calcific  change  of  the 
coronary  arteries.  In  10  of  these  death  oc- 
curred by  rupture  of  the  left  ventricle,  in  1 by 
rupture  of  the  right  ventricle,  and  in  2 by  rup- 
ture of  the  septum  ventriculoruin,  the  coronary 
branch  leading  to  the  seat  of  rupture  having 
been,  in  every  instance,  in  a more  advanced 
state  of  disease  than  the  other  portions  of  the 
vessel.  From  the  foregoing  statistics  it  would 
appear,  that  whilst  fatty  degeneration  of  the 
heart  may  exist  independently  of  disease  of  the 
coronary  arteries,  the  latter  condition  may  be 
regarded  as  the  immediate  cause  of  fatty  change 
in  the  heart,  in  the  proportion  of  about  38  per 
cent,  of  all  cases. 

Symptoms  and  Signs. — There  are  none  which 
are  peculiar  to  this  disease  ; those  which  exist 
being  due  to  the  consecutive  changes  in  the 
substance  of  the  heart.  The  doctrine  formerly 
held,  that  calcification  of  the  coronary  arteries 
was  the  cause  of  angina  pectoris,  is  no  longer 
tenable.  In  an  example  of  this  disease  in  its 
most  typical  form,  eventuating  in  death,  which 
recently  came  under  the  writer’s  notice,  the 
coronary  arteries  were  found,  on  examination, 
to  be  perfectly  sound. 

b.  Aneurism  of  the  coronary  arteries  is  of  rare 
occurrence.  It  is  usually  preceded  by  athero- 
matous or  calcific  changes  in  the  coats  of  the 
vessels,  and  may,  therefore,  be  regarded  as  a 
disease  of  middle  or  advanced  age.  Dr.  Gee 
has,  however,  published  an  example  of  coronary 
aneurism  in  which  the  patient  was  a boy  of  only 
seven  years. 

Symptoms  and  Signs. — There  is  no  positive 
indication  of  coronary  aneurism  during  life. 
When  the  termination  is  fatal,  as  it  usually  is. 
death  occurs  by  haemorrhage  into  the  pericardium 
from  rupture  of  the  sac. 

c.  Occlusion  of  the  orifices  of  the  coronary 
arteries  has  been  met  with  only  in  connection 
with  calcific  changes  in  the  root  of  the  aorta,  a 
partially  detached  calcareous  plate  overlying  the 
orifice  of  either  vessel  (both  are  rarely  affected), 
and  partially  or  completely  shutting  off  the  cir- 
culation. There  are  no  symptoms  distinct  from 
those  of  the  principal  disease. 

d.  Thrombosis  of  the  coronary  arteries  is  a 
frequent  result  of  disease  in  the  coats  of  these 
ressels;  and,  owingto  their  small  size,  complete 
blocking  and  arrest  of  circulation  through  them 


CORPORA  QUADRIGEMINA.  307 
| are  the  ordinary  consequences  of  this  accident. 
! The  heart-substance,  depending  upon  tho  oe- 
! eluded  vessel  for  its  vascular  supply,  quickly 
undergoes  the  atrophic  changes  of  fibroid  or  fatty 
degeneration.  Special  symptoms  are  entirely 
wanting. 

Disease  or  obstruction  of  the  coronary’  arteries, 
with  the  ordinary  consequences — fatty  degenera- 
tion of  the  heart,  and  anaemia  with  white  soften- 
ing of  the  brain — are  the  conditions  usually  found 
in  cases  of  permanently  slow  pulse. 

c.  Syphilitic  disease  of  the  coronary  arteries 
has  been  recorded  in  a fewmstanees,  but  its  identi- 
fication depended  entirely  upon  the  history  and  the 
concomitant  symptoms,  the  deposit  being  histolo- 
gically indistinguishable  from  ordinary’  atheroma. 

Thomas  Hayden. 

CORPORA  AMYLACEA  ( corpus , a body ; 
and  amylum,  starch). — These  minute  bodies,  which 
were  described  in  this  country  by  Dr.  Quain  and 
Dr.  Hughes  Bennett  in  the  2nd  and  3rd  vols.  of 
the  Transactions  of  the  Pathological  Society, 
were  thus  named  by  Virchow.  They  are  generally 
only  visible  with  the  aid  of  the  microscope, 
but  sometimes  are  large  enough  to  be  seen  by 
the  naked  eye,  and  now  and  then  attain  some 
size.  Usually  they  are  round  or  oval,  and  pre- 
sent a concentric,  laminated  arrangement,  which 
is  made  more  apparent  by’  tho  action  of  acetic 
acid.  They  often  have  a yellowish  tinge.  In  ap- 
pearance corpora  amylaeea  somewhat  resemble 
starch-granules,  and  they  are  tinged  brown  or 
bluish  by  the  action  of  iodine  upon  them.  These 
bodies  were  formerly  supposed  to  be  composed 
of  starch,  and  hence  their  name.  This  is  not 
the  case,  however,  and  their  actual  chemical  com- 
position is  not  clearly  known ; it  probably 
differs  in  different  structures.  Bodies  resembling 
corpora  amylaeea  in  appearance  and  arrangement 
have  been  found  in  various  parts,  but  they  have 
attracted  most  attention  in  connexion  with  tho 
nerve-centres,  being  particularly’  observed  when 
these  are  the  seat  of  atrophy  or  degeneration ; 
they  are  also  seen  in  the  choroid  plexus. 

Frederick  T.  Roberts. 

CORPORA  QUADRIGEMIHA, 

Lesions  of. — The  facts  of  comparative  anatomy 
and  experimental  physiology  tend  to  show  that 
the  corpora  quadrigemina  (corpora  bigemina  or 
optic  lobes  of  the  lower  vertebrates)  are  in  rela- 
tion not  only  with  vision  and  irido-motor  co 
ordination,  but  also  with  these  functions  which 
are,  to  a large  extent,  independent  of  the  cerebral 
hemispheres,  viz.,  equilibration  and  locomotor 
co-ordination. 

The  facts  of  human  pathology,  though  not 
opposed  to  these  data,  cannot  be  made  the  basis 
of  very  precise  conclusions  as  to  the  diagnostic 
indications  of  disease  of  these  ganglia,  as  it  is 
exceedingly  rare  to  find  disease  limited  to  this 
region  anatomically  or  functionally’. 

The  corpora  quadrigemina  are,  however,  not 
unfrequently  involved  in  lesions  which  invade 
neighbouring  parts,  such  as  meningitis — simple 
and  tubercular,  tumours,  especially  of  the 
pineal  gland  and  middle  lobe  of  the  cere- 
bellum, &c. ; but  disease  strictly  limited  to  the 
corpora  quadrigemina,  such  as  local  softening,  is 
extremely  rare,  and  hmmorrhage  is  unknown. 


308  CORPORA  QUADRIGEMINA. 

It  is  a fact  agreed  on  by  all  experimenters 
that  when  the  anterior  tubercles,  which  are  more 
especially  connected  with  the  optic  tracts,  are 
destroyed,  vision  is  abolished,  and  that  if  the 
lesion  is  unilateral,  the  blindness  occurs  on  the 
side  opposite  the  lesion. 

These  phenomena  in  animals  are  in  accordance 
with  what  lias  been  observed  in  man.  Dr. 
Bastian  has  recorded  a case  of  total  blindness,  in 
which  the  cause  proved  to  be  softening  limited 
to  the  anterior  tubercles  of  the  corpora  quadri- 
gemina  {Paralysis  from  Brain  Disease,  p.  115). 

It  has  been  found  experimentally  in  animals, 
and  also  in  man,  that  atrophy  of  the  opposite 
tubercle  ensues  when  the  eye  has  been  destroyed. 
Irido-motor  action  is  also  paralysed  by  destruc- 
tion of  the  corpora  quadrigemina,  a result  which, 
however,  is  stated  not  to  occur  unless  the  injury 
is  more  than  superficial  and  implicates  the  oculo- 
motor nuclei. 

Disturbances  of  equilibration  and  co-ordina- 
tion also  result  from  lesion  of  the  corpora  quad- 
rigemina. These  are  attributed  to  lesion  of  the 
subjacent  tracts,  and,  according  to  Lussana  and 
Lemoigne,  more  particularly  to  lesion  of  the 
subjacent  superior  cerebellar  peduncle.  For  his 
own  part,  the  writer  thinks  that  all  attempts  at 
differentiation  are  pure  hypotheses,  and  from  the 
nature  of  the  question  must  remain  so.  But, 
from  whatever  cause,  there  is  no  doubt  that 
the  disturbances  alluded  to  do  occur. 

Irritation  of  the  corpora  quadrigemina  on  one 
side  causes  dilatation  of  the  pupils  and  a hemi- 
opisthotonus  of  the  opposite  side,  which  becomes 
general  if  the  irritation  is  prolonged  or  bilateral, 
the  head  being  retracted  and  the  legs  extended, 
trismus  also  being  very  marked.  According  to 
Lussana  and  Lemoigne  unilateral  lesion  of  the 
corpora  quadrigemima  causes  an  incurvation  of 
the  trunk  and  gyration  to  the  side  of  lesion. 
This  would  agree  with  the  effects  of  irritation, 
being  naturally  a reversal  of  the  phenomena. 
Clinical  illustrations  of  these  facts  in  the  lower 
animals  are  difficult  to  find,  for  the  reasons 
above  mentioned ; but  a case  reported  by  Dr. 
Duffin  ( Clin.Soc.  Trans.,  vol.  ix.,  p.  1 87),  which  the 
writer  had  an  opportunity  of  seeing  and  examin- 
ing post  mortem,  is  important  in  this  relation. 
This  was  a case  of  tumour  of  the  pineal  gland, 
which,  besides  passing  forward  into  the  third 
ventricle,  pushed  underneath  the  aqueduct  of 
Sylvius,  stretching  and  causing  atrophy  of  the 
corpora  quadrigemina.  The  symptoms,  in  addi- 
tion to  those  of  cerebral  tumour,  viz.,  violent 
occipital  headache  and  double  optic  neuritis, 
were  double  vision  followed  by  loss  of  sight,  ver- 
tigo, specially  marked  when  tho  eyes  were  open, 
staggering  gait,  and  tendency  to  retraction  of 
the  head  and  rigidity  of  the  dorsal  muscles. 
The  pupils  were  large  and  sluggish.  These 
symptoms,  to  a certain  extent,  resemble  those 
caused  by  tumour  in  the  middle  lobe  of  the  cere- 
bellum, and  it  is  a question  how  far  these  latter 
may  be  due  to  mechanical  irritation  of  these 
ganglia.  But  we  may  infer  that  such  a combi- 
nation of  symptoms  as  the  above  points  to  lesion 
of  the  corpora  quadrigemina,  or  of  the  middle 
lobe  of  the  cerebellum,  though  we  cannot  be 
certain  of  absolute  limitation  of  the  lesion. 

Naturally  tho  same  secondary  affection  of  the 


CORPUS  STRIATUM,  LESIONS  OF 
functions  of  the  cerebral  hemispheres  occurs 
from  tumours  situated  in  this  region,  as  in  cases 
of  tumours  of  the  middle  cerebellar  lobe. 

Pressure  on  the  veins  of  Galen  leads  to  dropsy 
of  the  cerebral  ventricles,  and  its  consequences 
on  the  cerebral  circulation  and  functions. 

D.  Eebeieb. 

CORPULENCE  [corpus,  a body,  and  lentue, 
thick). — An  undue  accumulation  of  fat  in  the 
body.  See  Obesitt. 

CORPUSCLE  ( corpusculum , a little  body). 
— In  physiology  and  pathology  this  word  is 
generally  used  as  synonymous  with  cell.  See  Ceia. 

CORPUS  STRIATUM,  Lesions  of. — 

The  corpus  striatum  of  English  anatomy  and  pa- 
thology comprises  various  structures  which  have 
received  special  names,  viz.  : the  nucleus  caudalus, 
or  intra- ventricular  nucleus,  which  is  exposed  to 
view  by  laying  open  the  lateral  ventricle ; the 
nucleus  lenticularis,  or  extra-ventricular  nucleus, 
consisting  of  three  divisions,  and  subjacent  to 
the  convolutions  of  the  Island  of  Reil ; together 
with  part  of  the  internal  capsule,  or  peduncular 
expansion,  which  forms  part  of  the  ‘projection 
system’  between  the  cortex  and  crus  cerebri. 

This  differentiation  is  considered  necessary, 
as  it  is  believed  that  the  effects  of  lesion  of  the 
corpus  striatum  will  differ  according  to  the  part 
involved,  although  up  to  the  present  it  cannot  bo 
said  that  this  has  been  conclusively  established. 
This  is  not  to  be  wondered  at  considering  the 
excessive  rarity  of  lesions  which  have  an  exact 
anatomical  and  functional  circumscription. 

Physiological  experiment,  w-hile  thoroughly  in 
harmony  with  clinical  and  pathological  obser- 
vations respecting  the  effects  of  lesion  of  tho 
corpus  striatum,  has  not  succeeded  in  defining 
the  functions  of  its  several  parts,  if  such  differ- 
entiation exists,  with  any  degree  of  precision. 
The  statements  made  by  some  physiologists  on 
the  point,  do  not  seem  to  the  writer  to  rest  on 
any  satisfactory  basis. 

The  corpus  striatum  is  especially  liable  to 
lesion  from  embolism  or  rupture  of  its  blood- 
vessels. These  are  furnished  principally  by 
the  middle  cerebral  artery,  which  in  the  first 
part  of  its  course  sends  off  numerous  straight 
twigs,  which  sink  into  the  anterior  perforated 
space,  and  supply  thisganglion  and  the  adjacent 
part  of  the  optic  thalamus.  Owing  to  their 
position,  and  direction  as  regards  the  main  cur- 
rent, they  are  easily  ruptured  or  blocked  up. 
and  owing  to  their  being  of  the  nature  of  ‘ end 
arteries,’  and  almost  destituteofauastomoses  with 
other  cerebral  arteries,  embolism  rapidly  leads 
to  softening  of  the  regions  which  they  nourish. 

Symptoms. — The  symptoms  of  lesion  of  the 
corpus  striatum  may  be  divided  into  three 
groups  or  stages. 

First  stage. — This  includes  certain  symptoms 
which  are  more  or  less  transient,  and  depend 
chiefly  on  the  suddenness  of  the  lesion  and 
functional  disturbance  of  other  parts. 

To  the  latter  belong  the  symptoms  usually 
accompanying  an  apoplectic  seizure  (apoplexy), 
as  also  the  loss  or  diminution  of  sensation  on  the 
opposite  side  of  the  body,  which  sometimes  oc- 
curs in  consequence  of  pressure  on,  or  functional 
interference  with,  the  sensory  tracts  of  the  in- 


CORPUS  STRIATUM,  LESIONS  OF.  309 


ternal  capsule  by  effusion  into  the  corpus  stria- 
tum. The  symptoms  due  to  the  suddenness  of 
the  lesion  of  the  corpus  striatum  as  such,  are 
complete  paralysis  of  every  voluntary  movement 
on  the  opposite  side  of  the  body,  occasionally 
varied  by  convulsive  spasms  of  the  paralysed 
side,  and  conjugate  deviation  of  the  head  and 
eyes  towards  the  sound  side.  This  latter  symp- 
tom is  due  to  the  centres  for  the  head  and  eyes 
of  the  opposite  hemisphere  suddenly  losing  their 
antagonists.  The  temperature  of  the  paralysed 
side  is  as  a rule  higher  than  that  of  the  sound 
side.  The  total  paralysis  and  flaccidity  of  the 
opposite  side  of  the  body,  and  conjugate  de- 
viation of  the  head  and  eyes,  are  transient 
symptoms,  lasting  from  a few  hours  to  a day 
or  two. 

Second  stage.  — This  stage  includes  those 
symptoms  which  continue  for  a variable  period, 
after  those  depending  on  the  suddenness  and 
disturbing  effect  of  the  lesion  have  passed  off. 
They  constitute  the  common  type  of  hemiplegia 
or  paralysis  of  voluntary  motion  on  the  side 
opposite  the  lesion.  The  face,  arm,  and  leg, 
and  to  a certain  extent  the  thoracic  and  abdo- 
minal muscles  on  the  one  side  of  the  body,  are 
affected.  The  paralysis  does  not  affect  all  these 
parts  equally.  As  a general  rule  it  may  be 
stated  that  those  movements  are  most  affected 
which  are  most  independent  of  those  of  the 
opposite  side,  and  which  are  most  complex  and 
delicate. 

Hence  the  movements  of  the  hand  and  arm 
are  more  affected  than  those  of  the  face  or  leg, 
owing  to  the  fact  that  these  latter  are  more 
commonly  exercised  in  associated  or  alternating 
action  with  those  of  the  other  side.  The  facial 
paralysis  is  most  marked  in  the  lower  facial  re- 
gion. The  orbicularis  palpebrarum  is  more  or  less 
paretic,  but  never  paralysed  to  the  extent  which 
occurs  in  Bell's  or  true  facial  paralysis,  depending 
: 11  lesion  of  the  portio  dura.  The  angle  of  the 
mouth  on  the  paralysed  side  hangs  lower,  and 
che  tongue  deviates  slightly  to  the  paralysed 
side.  The  weakness  of  the  facial  muscles  is 
best  brought  out  when  the  patient  smiles  or 
tries  to  whistle.  The  face  then  becomes  drawn 
to  the  sound  side.  While  some  volitional  con- 
trol may  have  been  acquired  over  the  leg,  the 
hand  and  arm  remain  perfectly  motionless. 

In  the  process  of  recovery,  the  leg  recovers 
before  the  arm,  and  as  a rule  the  recovery  pro- 
teeds  from  the  proximal  to  the  distal  end  of 
the  limb,  the  shoulder  and  hip  movements  being 
regained  before  those  of  the  hand  or  foot.  The 
flexors  regain  their  power  before  the  extensors. 

The  sensibility  of  the  paralysed  parts  is  un- 
impaired ; the  superficial  reflexes  are  diminished, 
the  deep  (tendon)  reflexes  increased. 

The  faradic  contractility  of  the  muscles  is 
unimpaired,  occasionally  rather  increased  than 
diminished. 

The  muscles  do  not  undergo  atrophy  except 
by  disuse. 

The  temperature  of  the  paralysed  limbs,  which 
at  first  is  usually  increased,  is  generally  found 
to  be  lower  than  that  of  the  sound  side,  to  the 
extent  of  a degree,  more  or  less. 

Recovery  may  take  place  from  all  the  symp- 
toms of  this  stage,  within  a period  varying  from 


weeks  to  months,  or  the  patient  may  pass  into 
the  third  stage. 

Third,  stage. — The  special  symptoms  of  this 
stage  are  the  occurrence  of  what  is  termed  ‘ late 
rigidity’  in  the  paralysed  limbs,  a condition  of 
evil  import.  This  rigidity  shows  itself  most 
frequently  in  the  arm,  but  it  is  common  enough 
in  both  limbs.  The  rigidity  affects  the  flexors 
more  particularly,  and  causes  the  limb  to  as- 
sume a position  in  which  the  flexors  predomi- 
nate. It  is  variable  in  degree  and  at  first  is 
capable  of  being  overcome.  At  first  also,  it  is 
remittent,  tending  to  give  way  when  the  patient 
abstains  from  volitional  efforts  or  from  excite- 
ment, and  seems  almost  gone  on  waking  from 
sleep  or  when  the  patient  yawns  or  stretches 
himself. 

Gradually  it  assumes  a more  intense  form, 
and  the  limb  becomes  permanently  fixed  and 
rigid. 

After  death,  this  condition  is  found  to  coin- 
cide with  descending  sclerosis  of  the  motor 
tracts  of  the  brain  and  spinal  cord.  The  dege- 
neration proceeds  from  the  seat  of  lesion  down- 
wards through  the  crus,  pons,  pyramid  of  the 
same  side,  and  then  across  to  the  posterior  part 
of  the  lateral  column  of  the  spinal  cord  on  the 
paralysed  side.  Frequently  also,  a similar  track 
of  degeneration  is  found  on  the  inner  aspect  of 
the  anterior  column  of  the  spinal  cord,  on  the 
same  side  as  the  brain-lesion  (Charcot,  Tiirck, 
&c). 

Even  during  the  rigid  stage,  there  is,  as  a 
rule,  no  trophic  degeneration  of  the  muscles  or 
annihilation  of  faradic  contractility,  though  the 
muscles  waste  from  disuse  unless  artificially 
stimulated.  But  in  some  rare  instances  as 
Charcot  has  shown,  the  secondary'  degeneration 
invades  the  anterior  cornua  of  the  spinal  cord, 
in  which  case  amyotrophy  or  troprhic  degenera- 
tion of  the  muscles  ensues. 

There  is  no  recovery  from  this  condition. 

Variations  and  complications. — Though  gene- 
ral hemiplegia  of  the  opposite  side,  without 
affection  of  sensation,  is  the  type  of  disease  of 
the  corpus  striatum,  certain  variations  and 
complications  have  been  observed,  some  of  which 
still  require  elucidation. 

When  sensation  is  permanently  affected  along 
with  voluntary  motion,  we  have  reason  to  re- 
gard the  lesion  as  not  confined  to  the  corpus 
striatum,  but  as  implicating  also  the  posterior 
part  of  the  internal  capsule  and  the  thalamus, 
an  occurrence  by  no  means  rare.  When  the 
lesion  affects  only  the  grey  matter  of  the  nu- 
cleus caudatus,  it  is  said  that  the  hemiplegia  is 
as  a rule  comparatively  slight  and  transitory. 

Similar  affection  of  the  nucleus  lenticularis  is 
said  to  produce  more  marked  paralysis  than 
that  caused  by  affection  of  the  nucleus  caudatus, 
but  also  not  of  a permanent  kind.  When,  how- 
ever, the  lesion  causes  rupture  of  the  anterior 
two-thirds  of  the  internal  capsule,  the  hemi- 
plegia is  most  marked  and  most  enduring.  It  is 
this  lesion  only  which  gives  rise  to  secondary 
degeneration  of  the  motor  tracts  and  permanent 
rigidity. 

Cases  are  on  record  in  which  lesions  of  the 
corpus  striatum  have  given  rise,  not  to  gener.J 
hemiplegia  of  the  opposite  side,  but  to  mono 


J10  CORPUS  STRIATUM,  LESIONS  OF. 

plegia,  such  as  paralysis  of  the  face  or  of  one 
or  other  limb.  We  cannot  yet  say 'whether  tho 
lesions  in  these  cases  affected  specially  differ- 
entiated centres  or  medullary  fibres,  but  that 
such  may  be  the  case  is  not  impossible,  though 
the  subject  requires  investigation. 

Cases  are  also  on  record  of  paralysis  occur- 
ring on  the  same  side  of  the  body  as  the  lesion. 
The  real  existence  and  explanation  of  such  ex- 
ceptional occurrences  are  still  sub  judice,  and 
though  various  explanations  may  be  suggested, 
it  is  well  to  wait  for  further  instances,  carefully 
investigated  by  accurate  modern  methods,  before 
pronouncing  definitively  on  the  question. 

Treatment. — It  is  unnecessary  to  discuss  the 
treatment  of  lesions  of  the  corpus  striatum,  as 
this  is  considered  under  the  head  of  the  various 
diseases  of  the  Brain.  D.  Ferried. 

CORRELATION. — This  term  is  used  in 
medicine  almost  exclusively  in  reference  to  the 
aetiology  of  disease,  and  in  this  relation  princi- 
pally in  regard  to  the  zymotic  diseases.  The 
term  ‘correlation  of  the  physical  forces’  maybe 
taken  as  implying  that  the  several  forces  are 
capable  of  being  converted  into  or  of  giving 
place  to  one  another  ’when  they  are  permitted  to 
act  under  certain  conditions,  and  that  they  are 
all  related  to  a common  cause.  It  is  very  much 
the  same  idea  that  is  implied  by  the  term  ‘ Cor- 
relation of  the  Zymotic  Diseases,’  a subject  which 
has  recently  been  discussed  in  a separate  work 
by  A.  Wolff. 

It  is  contended  that  the  several  contagious 
diseases  of  a general  type  (the  exanthemata)  do 
not,  necessarily  and  in  all  cases,  reproduce  their 
like;  but  that  occasionally,  the  contagious  par- 
ticles thrown  off  from  the  same  sick  person  suf- 
fering from  some  one  of  the  diseases  (e.g.  scar- 
latina) may  suffice  to  engender  one  or  more 
different  kinds  of  disease,  according  to  the  mode 
in  which  this  matter  operates — that  is  according 
as  it  may  he  swallowed,  taken  into  the  system 
through  the  pulmonary  surface,  or  through  some 
other  mucous-membrane  or  skin  abrasion.  These 
diseases  arc  said  to  be  correlated,  therefore,  on 
account  of  this  assumed  relation  to  a common 
cause — a specific  contagium.  According  to  this 
notion  the  seat  of  primary  action  and  the  con- 
stitutional condition  of  the  patient  are  factors 
which  largely  influence  the  form  of  disease 
which  will  ultimately  manifest  itself  as  a result 
of  the  contact  of  any  given  contagium.  This 
view  has  at  present  scarcely  passed  beyond  the 
stage  of  an  ingenious  speculation — though  it  is 
one  which  is  by  no  means  unworthy  of  further 
attention. 

Diseases  may  be  said  to  he  correlated  also 
when  they  are  severally  related  to  the  same 
cause  acting  with  different  degrees  of  intensity. 
Thus  it  is  held  by  some  epidemiologists  that 
tlie  plague  is  only  a malignant  form  of  typhus  ; 
that  yellow  fever  is  due  to  a more  intense  form 
or  action  of  the  same  poison  as  suffices  at  other 
times  to  engender  intermittent  or  remittent 
fever ; and  that  summer  diarrhoea,  cholerine,  and 
cholera  are  also  hut  different  manifestations  of 
one  common  though  variable  cause. 

Similarly  it  is  held  by  many  surgeons  that 
ordinary  surgical  fever,  pyaemia,  and  septicaemia 


COUGH. 

are  correlated  effects.  They  maintain  that  the 
appearance  of  one  or  other  of  these  morbid 
states  after  a surgical  operation  is  dependent  in 
the  main  upon  differences  in  the  constitutional 
condition  of  their  patients,  and,  moreover,  that 
these  forms  of  disease  are  further  linked  to  one 
another  by  numerous  intermediate  states.  This 
point  of  view  has  been  both  strengthened  and 
extended  of  late,  by  some  of  the  experimental 
researches  of  Dr.  Burdon  Sanderson.  He  found 
that  tho  subcutaneous  injection  of  different  por- 
tions of  the  same  inflammatory  product,  exe- 
cuted at  the  same  time,  would  often  produce 
quite  different  effects  upon  different  animals  of 
the  same  species.  At  one  time  a typical  sep- 
ticaemia proved  rapidly  fatal,  at  another  a 
slower  pyaemic  process  was  established,  whilst 
in  a third  animal  the  still  more  chronic  process  of 
so-called  tuberculosis  was  set  up.  Here  we  get 
out  of  the  region  of  speculation  into  that  of  fact. 

The  term  correlation  is  only  applicable  to 
communicable  diseases,  otherwise  its  leading 
signification,  viz.  convertibility,  could  not  be 
fulfilled.  Hence  it  is  that  though  very  many 
diseases  may  arise  from  the  operation  upon  dif- 
ferent individuals  of  some  common  cause  (such 
as  exposure  to  cold),  the  maladies  which  may 
result  from  such  a cause  no  one  would  think  of 
speaking  of  as  correlated. 

H.  Charlton  Bastlan. 

CORROSIVE  SUBLIMATE,  Poisoning 

by.  See  Mercury,  Poisoning  by. 

CORYZA  (ic6pv£a,  a running  from  the  head). 
— A synonym  for  nasal  catarrh.  See  Catarrh. 

COUGH. — Synon.  : Tussis ; Fr.  Toux;  Ger. 
Husten. 

Description. — The  act  of  coughing  consists  in 
cne  or  more  abrupt  forcible  expirations,  accom- 
panied by  contraction  of  the  glottis.  First  a 
deep  inspiration  is  taken,  the  glottis  is  closed  for 
a moment,  and  then  it  is  opened  by  the  pressure  of 
the  air  forced  out  by  the  combined  action  of  the 
thoracic  and  abdominal  expiratory  muscles.  With 
the  air  thus  suddenly  expelled,  any  foreign 
matter  that  may  he  in  the  larynx  or  bronchi  is 
driven  into  the  pharynx  or  the  mouth. 

/Etiology. — The  immediate  cause  of  cough  is 
the  presence  of  an  irritant,  mechanical  or  sympa- 
thetic, affecting  the  surface  of  the  air-tubes  or 
the  nerves  that  supply  them,  and  it  is  the  object 
of  the  cough  to  remove  this  source  of  irritation. 

The  sensibility  of  the  respiratory  surfaces  is 
greatest  at  the  commencement — the  glottis  being 
an  ever-watchful  janitor.  It  may  he  increased 
by  congcstiou  or  inflammation,  or  by  the  continued 
act  of  coughing.  Even  the  mere  inhalation  of  eoc! 
or  dry  air  may,  in  asthma  or  bronchial  conges- 
tion, be  sufficient  to  excite  cough.  The  result 
of  the  irritation  is  to  increase  the  natural  secre- 
tion, and  to  alter  its  characters  (see  Expectora- 
tion). 

Cough  may  he  due  to  numerous  reflex  causes, 
such  as  gastric  irritation,  ear-disorder,  or 
aneurismal  or  other  pressure  on  the  vagus,  re- 
current, or  sympathetic  nerves.  The  act  may 
also  be  caused  by  a long  uvula  or  enlarged  tonsil, 
a granular  state  of  the  pharyngeal  or  laryngeal 
mucous  membraue ; polypi  or  other  foreign 


COUGH. 

bodies  in  the  larynx,  trachea,  or  even  in  the  ex- 
ternal auditory  meatus ; various  affections  of  the 
bronchial  tubes — e.g.,  undue  dryness,  hyperasmia, 
alteration  in  the  quality  or  quantity  of  the  bron- 
chial secretion,  or  inflammatory  affections;  in- 
flammation of  the  lung  or  pleura;  or  tubercle, 
cancer,  or  other  growths  in  or  near  the  lung. 

Diagnosis. — -Cough  is  not  a disease  to  be 
treated,  but  a symptom  to  be  traced  to  its 
source.  An  inspection  of  the  pharynx  and 
larynx  and  a physical  examination  of  the  chest 
will  generally  suffice  to  detect  the  cause. 

The  character  of  the  cough  is  often  quite 
pathognomonic — e.g.,  the  ‘ whoop  ’ of  whooping 
cough  ; the  ‘ bark  ’ of  hysteria ; the  catching, 
painful  cough  of  pleurisy;  the  slight  ‘ hack  ’ of 
early  phthisis,  and  the  equally  distinctive  cough 
of  advanced  phthisis  with  laryngeal  ulceration  ; 
the  loud  clanging  cough  due  to  pressure  on  the 
trachea  or  laryngeal  nerves ; the  spasmodic, 
suffocative  cough  of  asthma. 

The  ‘tightness’  or  ‘looseness’  of  cough,  indi- 
cating the  absence  or  presence  of  secretion,  is  a 
valuable  guide  in  diagnosis  and  treatment. 

The  absence  of  cough  is  no  proof  of  the  absence 
of  serious  lesion : while  the  presence  of  a few 
granulations  in  the  lung  is  often  productive  of  in- 
cessant and  uncontrollable  cough,  long-continued 
destructive  disease  may  exist  without  it. 

Treatment. — Before  prescribing  for  a cough 
it  is  of  course  essential  to  ascertain  its  cause  ; 
and  the  simplest  and  most  innocuous  remedies 
should  be  first  used.  The  routine  treatment  of 
cough  by  sedatives  is  as  injurious  as  is  their  use 
in  diarrhoea.  The  secretions  which  ought  to  be 
removed  are  thus,  in  either  case,  locked  up,  and 
the  irritation,  which  would  have  been  transient, 
becomes  established. 

If  the  tonsils  are  found  much  enlarged,  or  the 
uvula  pendulous  and  irritating  the  epiglottis, 
caustics  or  the  guillotine  will  remove  the  evil. 
If  a granular  state  of  the  pharyngeal  mem- 
brane, dependent  on  torpid  or  engorged  abdomi- 
nal viscera,  gout,  or  hepatic  obstruction,  exists, 
it  may  be  treated  by  local  astringents  and 
general  deobstruents. 

A lax  or  congested  state  of  the  laryngeal 
mombrane,  due  to  overwork  of  voice,  or  the  un- 
due direction  of  attention  to  the  vocal  apparatus 
(clergymans  sore-throat),  is  best  treated,  accord- 
ing to  the  writer’s  experience,  by  the  local  ap- 
plication of  iodine  dissolved  in  spirit  and  olive 
oil.  Undue  dryness,  simple  hyperaemia,  or  hyper- 
testhesia  of  the  respiratory  mucous  tract,  may 
often  bo  relieved  by  the  act  of  sipping  and 
slowly  swallowing  cold  water,  or  the  decoction 
of  Iceland  moss,  fruit  lozenges,  gum  arabic, 
liquorice,  or  linseed  tea.  Sucking  ice  or  in- 
haling steam  is  very  often  all  that  is  needed. 
In  the  early  stage  of  catarrhal  sore-threat, 
chlorate  of  potash  in  crystal,  or  in  the  form 
of  lozenge,  should  not  be  neglected.  The  use 
of  glycerine  of  tannin,  or  nitrate  of  silver  dis- 
solved in  glycerine  (half  a drachm  to  one  ounce) 
is  of  more  service  in  relaxed  throat  than  alum 
or  tannin  gargle  ; indeed,  the  free  use  of  well-se- 
lected lozenges  has  rendered  the  employment  of 
gargles  well-nigh  obsolete.  The  former  can  be 
constantly,  the  ladder  but  seldom  applied. 

Medicinal  trcaiment. — If  it  is  desired  to  in- 


COUNT  ER-IRE  IT  A NTS.  3 1 1 

crease  the  fluidity  of  the  secretion,  squill  or 
ipecacuanha  may  be  used,  or  better  still,  tartar 
emetic  in  small  doses,  which  is  best  given  in 
effervescence  with  ammonia  and  citric  acid.  It 
must  not  be  forgotten  that  syrups  and  nausea- 
ting expectorants  are  apt  to  do  harm  by  enfeeb- 
ling or  disturbing  digestion.  Tincture  of  aconite 
in  three-drop  doses  is  often  of  value  in  allaying 
irritable  cough,  especially  when  fever  is  present. 
Gelseminum  is  the  novel  remedy  for  the  same 
purpose.  Of  the  direct  sedatives,  morphia  is 
the  most  valuable  ; it  proves  of  service  in  very 
small  doses,  yVgr.  in  a lozenge  being  often  ade- 
quate. Conium,  with  or  without  morphia,  suits 
some  persons ; hydrocyanic  acid  still  more ; 
and  Indian  hemp  is  also  of  value.  The  bro- 
mides, in  combination  with  chloral,  have  recent  ly 
gained  great  repute  ; the  latter  should  be  given 
with  caution.  The  power  of  the  bromide  of 
ammonium  in  allaying  spasmodic  cough  is  re- 
markable. An  emetic  of  ipecacuanha,  sulphate 
of  zinc,  oi  mustard  may  be  useful  in  relieving 
cough,  by  expelling  secretion  when  this  has  ac- 
cumulated in  large  quantity.  If  cough  causes 
vomiting,  food  should  be  taken  in  small  quanti- 
ties, fluids  should  be  limited,  and  a little  capsicum 
or  spiced  brandy  ‘ stays  the  stomach.’ 

External  applications. — The  use  of  counter- 
irritants  must  not  be  neglected.  In  the  inflam- 
matory stage  of  bronchitis,  for  instance,  linseed 
and  mustard  poultices,  and  in  the  later  stages, 
iodine  or  croton  oil  are  of  great  use.  The  ap- 
plication of  a small  blister  or  vesicating  fluid  is 
a remedy  not  to  be  forgotten  in  some  cases. 

Inhalations. — Infusion  of  hops  as  an  inhalation 
is  a useful  calmative;  iodine  is  indicated  in  re- 
laxed conditions  in  strumous  subjects.  Chloro- 
form (10  to  15  minims)  mixed  with  Eau  de 
Cologne,  and  inhaled  from  a handkerchief,  is  use- 
ful in  other  cases.  By  means  of  the  spray-inhaler, 
many  non-volatile  preparations  may  be  applied  to 
the  respiratory  passages.  A solution  of  carbon- 
ate of  soda  is  very  useful  in  liquefying  tenacious 
secretion.  Tannic  acid,  alum,  perchloride  of  iron, 
and  nitrate  of  silver,  are  all  valuable.  Of  seda- 
tives, henbane,  conium,  camphor;  and  of  anti- 
septics, sulphurous  and  carbolic  acids  are  ser- 
viceable as  inhalants.  In  chronic  granular 
disease  of  the  pharyngeal  and  laryngeal  mucous 
membranes,  the  sulphurous  waters  of  Aix-la- 
Chapelle,  Aix-les-Bains,  and  St.  Saveur  in  the 
Pyrenees,  when  inhaled  in  an  atomised  state,  are 
of  distinct  service. 

Patients  may  be  thus  taught  how  to  cough : — 
Try  to  suppress  the  inclination,  until  the  secre- 
tion that  causes  the  cough  is  within  reach,  then 
take  a deep  and  deliberate  inspiration,  and  the 
accumulated  phlegm  is  removed  at  a single  effort. 
By  inhaling  steam  from  a hot  sponge  or  basin 
of  boiling  water  on  first  waking  from  sleep,  the 
inspissated  secretion,  which  is  apt  to  be  difficult 
to  move,  may  be  easily  loosened  and  expelled. 
An  ipecacuanha  lozenge  may  serve  a similar 
purpose.  E.  Symes  Thompson. 

COUNTER-INDICATION.  See  Contra- 
indication. 

COUNTER  - IRRITANTS.  — The  term 
counter-irritation  implies  any  irritation  arti- 
ficially established  with  a view  to  diminish 


COUNTER-IRRITANTS. 


8t2 

counteract  cr  remove  certain  morbid  processes 
which  may  De  going  on  in  a more  or  less  remote 
part  of  the  system.  The  substances  employed  in 
establishing  this  state  are  called  counter-irri- 
tants, and  may  be.  classified  as  follows,  according 
to  degree  of  action: — 1.  Rubefacients  ; 2.  Epi- 
spastics,  vesicants,  or  blistering  agents  ; 3.  Pus- 
tulants. 

Although  some  therapeutists  have  of  late  been 
disposed  to  question  the  value  of  counter-irri- 
tants, on  the  theoretical  ground  of  inability  to 
explain  their  mode  of  action,  yet  there  is  not 
wanting  evidence,  both  from  clinical  observation 
and  physiological  experiment,  that  irritation  in 
one  part  of  the  body  may  affect  the  functions 
and  nutrition  of  other  parts.  That  stimulation 
of  the  vessels  of  the  surface  can  influence  de- 
cidedly the  circulation  of  deeper  parts  has  been 
demonstrated  by  Dr.  Brown-S4quard : for  he 
found  that  irritation  of  the  skin  of  the  back, 
over  the  kidneys,  caused  a contraction  of  the 
arteries  supplying  those  organs.  Prom  this  ex- 
periment we  can  understand  how  a blister  may 
relieve  a sudden  internal  congestion  in  the  lungs 
or  brain,  and  how  it  may  act  in  restoring  tone 
to  dilated  and  paralysed  capillaries. 

Revulsion  and  derivation  are  both  examples  of 
counter-irritation.  In  the  first,  the  induced  mor- 
bid action  is  set  up  in  a part  remote  from  the 
primary  disease,  as  when  mustard  poultices  aye 
applied  to  the  feet  in  an  attack  of  apoplexy ; in 
the  second,  derivative  action  is  set  up  in  the 
neighbourhood  of  the  primary  malady,  as  when 
a blister  is  placed  on  the  back  of  the  neck  for  the 
relief  of  cerebral  disorder. 

Rubefacients.  — Action.  — These  remedies, 
applied  to  the  skin,  produce  local  warmth  and 
redness  from  increased  flow  of  blood  in  the 
cutaneous  vessels.  The  local  hypersemia  thus 
induced  subsides  gradually  on  ceasing  to  employ 
the  rubefacient ; but  sometimes,  when  the  action 
of  this  has  been  prolonged,  the  epidermis  may 
peel  off,  and  more  or  less  local  soreness  remain. 
Rubefacients  are  usually  quick  in  action ; their 
local  after-effects  are  trifling;  and  they  may, 
therefore,  be  applied  without  injury  over  a large 
extent  of  surface. 

Enumeration  and  Application. — Examples  of 
rubefacients  are  found  in  Ammonia /md  Ammo- 
uiaeal  Liniments  or  Embrocations;  Mustard 
Plasters  and  Liniment;  Volatile  Oil  of  Mustard  ; 
Oils  of  Turpentine  and  Cajuput ; and  Iodine. 
Hot  water  is  at  times  applied  on  a sponge  or 
flannel  to  produce  a speedy  counter-irritant  and 
derivative  effect  in  relieving  sudden  internal  con- 
gestion and  spasm,  as  in  the  early  stage  of  croup, 
laryngitis,  and  laryngismus  stridulus.  TheCata- 
plasma  Sinapis,  or  mustard  poultice,  is  a useful 
and  rapidly-acting  rubefacient  in  inflammation, 
spasm,  and  neuralgic  pain.  Dr.  Garrod  recom- 
mends a very  useful  sinapism,  made  by  mixing 
lO  minims  of  volatile  oil  of  mustard  with  1 oz. 
of  spirit  of  camphor,  and  sprinkling  this  on 
impermeable  piline.  Rigollot’s  mustard  leaves, 
and  the  Charta  Sinapis  or  mustard-paper  of  the 
Pharmacopoeia,  applied  to  the  skin,  produce  a 
-needy  rubefaction  of  the  surface.  Vinegar 
should  not  be  added  to  mustard  poultices ; but 
by  mixing  some  oil  of  turpentine  or  a little 
oowderetl  capsicum  in  a mustard  poultice,  its 


rapidity  of  action  as  a stimulant  and  rubefacient 
can 'be  greatly  increased.  Where,  on  the  other 
hand,  a gentle  stimulation  with  warmth  and 
moisture  to  the  surface  are  desired,  as  in  some 
cases  of  pneumonia,  a linseed-mcal  poultice  may 
be  used,  with  its  surface  sprinkled  lightly  over 
with  mustard-meal.  Generally  twenty  minutes 
is  as  long  as  an  ordinary  mustard  poultice  can  be 
safely  borne  on  the  skin.  In  persons  who  haTe  a 
very  delicate  skin,  a layer  or  two  of  muslin  should 
be  placed  between  the  mustard  application  and 
the  surface  of  the  body.  In  applying  mustard 
poultices  to  those  who  are  unconscious  of  pain, 
caution  is  necessary,  for  it  has  happened  that  the 
poultice  being  left  on  for  a long  time  has  pro- 
duced dangerous  ulceration  and  sloughing  of  the 
surface.  A mustard  foot-bath  is  at  times  em- 
ployed with  a view  to  a revulsive  and  counter- 
irritant  effect.  To  prepare  a mustard  bath,  two 
tablespoonfuls  or  more  of  mustard  should  be  tied 
in  a cloth,  and  agitated  well  with  cold  water;  then 
hot  water  may  be  added  to  make  the  bath.  It  is 
found  by  experiment  that  cold  water  extracts  the 
active  principle  or  volatile  oil  of  mustard  far 
better  than  very  hot  water  does. 

Uses. — Rubefacients  are  used  in  chronic  in- 
flammation and  irritation  of  the  mucous  sur- 
faces, as  in  bronchitis,  and  irritation  about  the 
air-passages.  Troublesome  cough,  in  cases  of 
phthisis,  is  often  relieved  by  applying  tincture 
of  iodine,  or  acetic  acid  and  turpentine  liniment, 
to  the  chest.  Rubefacients  are  of  service  in 
removing  lingering  irritation  about  a joint, 
their  use  also  tending  to  promote  the  absorption 
of  chronic  thickening  or  effusion  in  the  joint ; 
but  friction  with  a rubefacient  liniment  over  a 
joint  must  not  be  employed  till  all  active  in- 
flammatory action  has  entirely  ceased.  Various 
degrees  of  persistent  counter-irritation  may  be 
maintained  by  applying,  after  the  skin  has  been 
well  cleansed  with  soap  and  water,  the  Emplas- 
trum  Picis  or  Emplastrum  Calefaciens  of  the 
Pharmacopoeia.  A mustard  plaster  applied  to 
the  nape  of  the  neck  has  proved  useful  in  cases 
of  irritable  brain  with  sleeplessness.  The  same 
application  made  to  the  foot  or  great  toe  is  a 
valuable  revulsive  where  gout  attacks  more 
important  organs.  A mustard  plaster  has  the 
advantage  over  a blister  in  rapidity  of  rubefa- 
cient action;  and,  from  the  sharp  pain  caused, 
the  mustard  plaster  is  preferable  when  it  is  a 
matter  of  moment  to  rouse  one  who  is  in  a state 
of  lethargy  or  torpor  from  narcotic  poisoning  bv 
opium,  or  alcohol,  or  from  coma  in  the  course  of 
a fever.  Where  we  wish  to  exercise  a prolonged 
action  over  chronic  inflammation  in  an  organ, 
we  should  use  a blister  rather  than  a sinapism. 

Vesicants,  Epispastics,  or  Blistering 
Agents. — Action. — A blister  acts  primarily  as 
a rubefacient  and  powerful  stimulant  to  the 
cutaneous  vessels.  The  papillae  of  the  skin  be- 
come reddened  and  raised ; minute  vesicles  soon 
appear  on  these  elevations ; and  these,  gradually 
coalescing,  form  a bleb,  or  large  vesicle,  contain- 
ing an  albumino-fibrinous  fluid. 

Enumeration  and  Application. — The  agent 
most  commonly  employed  for  blistering  purposes 
is  Cantharis  or  Spanish  fly,  in  the  several  pre- 
parations to  be  found  in  the  Pharmacopoeia  ; but 
there  are  other  agents  that  have  been  used  fora 


COUNTER-IRRITANTS. 


similar  object.  Glacial  Acetic  Acid  applied  to 
the  skin  produces  intense  redness  and  pain,  with 
rapid  vesication,  but  its  action  may  extend  deeply 
as  a caustic,  and  cause  a troublesome  sore.  Liquor 
Ammonise  dropped  on  a piece  of  lint,  applied  to 
the  skin,  and  covered  with  watch-glass,  very 
soon  causes  redness  and  rapid  vesication  in  most 
persons.  This  is  a good  way  of  raising  a blister 
when  it  is  desired  to  apply  powdered  morphia 
endermically  to  relieve  severe  pain. 

The  application  of  blisters  should  not  he  made 
directly  over  an  inflamed  part.  There  is  some 
evidence  to  show  that  a strong  stimulus  applied 
very  near  an  inflamed  organ  may  increase  the 
paralytic  dilatation  of  its  capillaries,  and  so  add 
to  the  disease.  Blisters  should  not  be  applied 
where  the  skin  is  loose,  nor  over  any  prominence 
of  bone,  nor  to  the  breast  during  pregnancy. 
It  should  moreover  be  borne  in  mind  that  the 
cantharidine  of  a blister  may  be  absorbed  by  the 
skin,  and  act  on  the  kidneys,  producing  strangury 
and  bloody  urine.  This  accident  may  be  obviated 
by  sprinkling  powdered  camphor  over  the  blister 
before  placing  it  on  the  skin,  or  a thin  piece 
of  silver  paper  may  be  interposed.  In  persons 
of  feeble  vitality,  a blister  left  on  too  long 
time  has  been  known  to  induce  dangerous 
sloughing. 

When  vesication  is  specially  desired,  there  is 
no  need  to  leave  the  blister  on  for  twelve  hours 
or  more,  for  it  may  be  removed  at  the  end  of 
six  or  eight  hours,  and  a warm  linseed  poultice 
applied.  If  the  blister  be  opened,  which  is  best 
done  by  pricking  the  most  dependent  part  with 
a needle,  sweet  oil  and  cotton-wool  is  the  best 
dressing.  The  practice  of  maintaining  a blister 
as  a running  sore  or  exutoire,  by  applying  irri- 
tating ointments,  is  not  often  resorted  to  now. 
The  process  causes  great  pain  and  exhaustion 
of  the  system,  and  is  one  rather  of  depletion 
than  of  counter-irritation.  In  the  case  of  chil- 
dren, blisters  should  be  used  with  caution,  being 
kept  on  till  the  skin  is  well  reddened,  when 
they  should  be  replaced  by  a poultice.  It  is 
also  a good  plan  not  to  open  the  blister,  as  the 
effused  serum  forms  the  best  dressing  for  the 
excoriated  surface,  and  by  following  this  plan 
the  child  is  saved  much  worry  and  pain. 

Uses.— In  its  primary  action  a blister  acts  as 
a local  stimulant,  but  when  it  remains  on  long 
enough  to  produce  extensive  vesication  and  dis- 
charge of  serum,  it  acts  as  a depletive  and  de- 
pressing agent.  This  primary  and  secondary 
action  of  blisters  has  been  much  insisted  on  by 
the  late  Dr.  Graves  of  Dublin,  who  found  great 
benefit  in  cases  of  fever  with  apathy  and  pros- 
tration from  the  application  of  flying  blisters 
to  various  parts  of  the  surface.  Thus  a blister 
over  the  praeeordial  region,  kept  on  for  about  one 
hour,  and  then  removed,  was  observed  to  rouse 
and  stimulate  a flagging  heart.  In  other  cases 
the  flying  blister  might  be  placed  at  the  chest  or 
back,  or  else  behind  the  head  on  the  neck.  Care 
should  be  taken  not  to  leave  the  blister  on  long 
enough  to  cause  vesication,  and  the  size  of  the 
blister  should  be  fairly  large. 

Vesication  by  a blister  is  of  service  in  many 
brain-affections  attended  with  congestion  and 
tendency  to  serous  effusion,  such  as  in  the  chro- 
nic stages  of  hydrocephalus,  and  non- tubercular 


31$ 

meningitis.  In  hysterical  paralysis  narrow  strips 
of  blister  placed  completely  round  the  affected 
limb  have  proved  curative.  A strip  round  the 
throat  may  cure  nervous  aphonia.  A strip 
of  blister  one  inch  wide  will  sometimes  stay  the 
spread  of  erysipelas  along  a surface.  In  cases 
of  pleuritic  or  periearditic  effusion  the  repeated 
application  of  blisters  to  the  chest-wall  is  of 
manifest  advantage.  In  effusions  into  joints 
(hydrarthrosis)  blisters  aid  absorption  ; and  it 
has  seemed  to  the  writer  that  absorbent  reme 
dies,  such  as  iodide  of  potassium,  often  begi- 
to  do  good  as  soon  as  a blister  appears  to  have 
once  set  the  absorptive  process  in  action.  In  the 
joint-affections  of  acute  rheumatism,  ‘ the  blister 
treatment’  has  attracted  notice.  Armlets  and 
wristlets  of  blister-plaster  are  applied  close  to 
the  inflamed  joints  during  the  fever,  and  the 
serous  discharge  from  the  blister  is  kept  up  by 
means  of  linseed-meal  poultices. 

In  the  obstinate  acid  vomiting  of  gouty  pa- 
tients, a blister  over  the  epigastrium  often  gives 
relief.  Some  forms  of  neuralgia,  as  for  example 
pleurodynia,  may'  yield  to  a blister  over  the  seat 
of  the  pain.  At  times  obstinate  pleurodynia,  or 
mastodynia,  can  be  relieved  by  flying  blisters 
applied  in  the  vertebral  groove  on  the  affected 
side,  where  a tender  spot  can  often  be  detected  on 
pressure.  Blisters  should  be  avoided  in  cases  of 
renal  and  vesical  inflammation,  as  the  absorption 
of  the  cantharidine  may  increase  the  mischief. 

Counter-irritation  by  heat. — The  skin  can 
be  rapidly  blistered  by  applying  a hammer  or  a 
small  flat  iron  heated  in  a spirit-lamp  or  boiling 
water.  The  skin  is  tapped  for  a few  seconds 
with  the  hammer,  just  to  induce  redness  of  the 
part.  In  some  forms  of  rheumatism,  neuralgia, 
and  spinal  weakness,  this  practice  has  been  fol- 
lowed by  satisfactory'  results.  Vesication  of  tho 
skin  by  th eferrum  candens,  or  hot  iron,  has  been 
used  in  chronic  joint-disease. 

Moxas  are  used  for  the  purpose  of  causing 
severe  counter-irritation.  European  moxas  are 
made  either  with  cotton  wool  6oaked  in  solution 
of  nitrate  of  potash,  or  of  the  pith  of  the  sun- 
flower, which  naturally  contains  this  salt.  A 
wet  rag  is  placed  on  the  skin ; in  the  centre  of 
this  is  a hole  in  which  the  lighted  moxa  is  placed, 
which  gradually  burns  down  to  the  skin  and  pro- 
duces an  esShar  which  in  due  time  separates  by 
suppuration.  In  spinal  affections,  and  in  some 
forfts  of  paralysis  of  the  sensory  and  motor 
nerves,  moxas  are  said  to  have  done  good ; but 
their  application  is  very  painful,  and  now  they 
are  seldom  employed. 

Pustulants. — Action. — The  agents  belonging 
to  this  class  of  counter-irritants  produce  a pus- 
tular eruption  on  the  part  of  the  skin  to  which 
they  are  applied. 

Enumeration  and  Application. — Among  pustu- 
lants may  bo  placed  croton  oil,  tartarated  anti- 
mony, and  strong  solution  of  nitrate  of  silver. 
When  croton  oil  is  applied  to  the  skin,  it  acts  as 
an  intense  irritant,  producing  an  eruption  which 
is  at  first  papular  but  very  soon  becomes  pustu- 
lar. Tartarated  antimony  in  the  form  of  oint- 
ment, or  in  hot  aqueous  solution,  is  a powerful 
counter  irritant,  producing  pustules  which  re- 
semble those  of  variola.  When  applied  thus  it 
may,  by  becoming  absorbed,  induce  symptoms  of 


m COUNTER-IRRITANTS, 

gastro-enteritis.  It  should  not  be  applied  to  parts 
usually  uncovered,  as  the  pustules  leave  marks 
behind  them ; and  under  all  circumstances  the 
remedy,  being  a painful  one,  must  be  used  with 
caution.  Strong  solution  of  nitrate  of  silver  will 
produce  pustulation,  but  it  is  seldom  employed 
for  this  purpose. 

Issues  have  long  been  used  as  counter-ir- 
ritants. An  issue  is  formed  by  placing  on  the 
skin  a piece  of  adhesive  plaster,  in  a hole  in 
the  centre  of  which  a fragment  of  caustic  potash 
is  inserted.  The  caustic  causes  an  eschar,  and 
when  this  has  come  away  an  issue-pea  is  placed 
in  the  cavity  left  by  the  eschar;  this  pea  acts 
as  a foreign  body,  and  keeps  up  suppuration. 
One  drachm  of  pus  may  be  discharged  daily  by 
an  issue ; more  than  this  is  too  great  a drain 
on  the  system.  An  issue  requires  to  be  dressed 
daily,  and  ;when  it  has  been  long  open  and  run- 
ning it  must  not  be  healed  too  suddenly.  Issues 
over  the  spine  have  been  found  useful  in  chronic 
spinal  disease  ; and  in  some  chronic  brain-affec- 
tions, with  hypersemia  and  congestive  tendency, 
an  issue  in  the  back  of  the  neck  or  in  the  arm 
is  frequently  of  service. 

Setons. — A seton  is  made  by  passing  a nar- 
row-bladed  knife  under  a fold  of  skin  and  then 
carrying  a few  silk  threads  through  the  incision 
by  means  of  a probe  or  long  needle.  The  threads 
remaining  in  the  wound  prevent  it  from  healing, 
and  maintain  a free  purulent  discharge.  Setons 
are  used  for  the  same  purposes  as  issues,  and 
they  have  proved  useful  in  certain  intractable 
forms  of  headache — the  seton  being  inserted  in 
the  skin  of  the  neck.  Setons  have  been  used  in 
cases  of  cystic  bronchocele  with  thickened  walls ; 
in  chronic  inflammation  of  the  bladder ; in  maDy 
chronic  affections  of  the  uterus ; in  various 
chronic  skin-diseases  of  an  obstinate  character  ; 
in  chronic  inflammations  of  the  eye,  and  ulcera- 
tions of  the  cornea  ; and  in  the  early  stages  of 
pulmonary  phthisis. 

In  acute  affections  issues  and  setons  are  never 
employed,  and  they  should  not  be  placed  over 
any  part  where  there  is  much  movement,  as  a 
troublesome  sore  may  be  the  result.  It  is  neces- 
sary to  bear  in  mind  that  issues,  setons,  and 
pustulants  are,  like  blisters,  when  kept  on  long 
enough  to  induce  serous  discharge,  of  the  nature 
of  evacuants.  They  carry  off  nutrient  material 
from  the  blood,  and.  therefore  are  more  or  less 
depressing  arid  exhausting  to  the  system,  And 
their  repeated  or  protracted  employment  will 
tend  to  induce  the  irritative  fever  of  debility. 

John  C.  Thorotvgood. 

COUP  DE  SOLEIL  (Fr).— A synonym  for 
sunstroke.  Sec  Sunstroke. 

COW-POX.  See  Vaccinia. 

COXALG-IA  (coxa,  the  hip,  and  &X yos, 
pain). — Pain  in  the  hip-joint.  See  Joints,  Dis- 
eases of. 

CRACKED-METAL  or  CRACKED-POT 
SOUND  (Bruit  depot  fe!e).  A peculiar  sound 
elicited  by  percussion,  and  resembling  that 
emitted  on  striking  a broken  jar  or  a metallic 
vessel.  See  Physical  Examination. 

CRAMP. — This  name  is  applied  to  certain 
painful  varieties  of  tonic  spasm.  In  its  most  I 


CRETINISM. 

familiar  form  it  affeet3  the  calves  of  the  legs, 
coining  on  principally  at  night,  on  the  occasion 
of  some  slight  movement  of  these  parts.  The 
affected  muscles,  mostly  on  one  side,  coatract 
with  such  energy  as  to  give  rise  to  a board-like 
rigidity,  together  with  sensations  of  an  agonising 
character.  The  attack  rarely  lasts  more  than  a 
minute  or  two,  though  it  may  more  or  less 
speedily  recur.  It  is  perhaps  best  cut  short  bv  a 
vigorous  but  steady  voluntary  contraction  of  the 
opposing  extensor  muscles  of  the  foot.  'Where  it 
is  more  obstinate  than  usual,  firm  pressure  around 
the  thigh  or  upon  the  great  sciatic  nerve,  some- 
times gives  relief.  Cramp  is  often  associated  with 
some  irritation  of  the  stomach  or  of  the  intestines, 
especially  in  children  or  delicate  nervous  persons. 
In  this  way  it  is  produced  not  infrequently  when 
arsenic  in  medicinal  doses  has  been  continued  for 
some  time,  and  is  beginning  to  exert  a slightly 
poisonous  effect  upon  the  system.  In  a more 
general  form  it  often  occurs,  to  a marked  extent, 
in  cholera.  Other  forms  of  painful  spasm  are  by 
no  means  common,  if  we  except  colic.  See  also 
Spasm.  H.  Charlton  Bastian. 

CRANIO  TABES. — See  Skull,  Diseases  of. 

CREPITANT  ( crepito , I make  a noise). — 
When  applied  to  a body,  this  word  signifies  that 
it  is  capable  of  yielding  the  sensation  or  sound  of 
crepitation.  It  is  also  associated  with  a rale,  to 
indicate  a peculiar  character  which  it  possesses. 
See  Physical  Examination. 

CREPITATION  (crcpito,  I make  a noise). 
— A sensation  or  sound  of  crackling.  It  may  be 
observed  in  morbid  states  of  the  bones,  joints, 
or  subcutaneous  tissue;  but  the  term  is  more 
frequently  applied  to  a physical  sign  connected 
with  the  lungs.  See  Physical  Examination. 

CRETINISM  (crcta,  chalk).— Synox.  ; Lat. 
Cretinismus;  Fr . Cretinisme;  Ger.  Cretinismus ; 
Ital.  Cretinismo. 

Definition. — A condition  of  idiocy  arising 
from  endemic  causes,  associated  with  imperfect 
development  and  deformity  of  the  whole  body, 
varying  however  in  degree. 

This  condition  of  physical  and  mental  de- 
generacy is  not  limited  to  any  rationality.  It 
obtains  in  the  great  mountain-chains  of  Europe, 
Asia,  and  America.  In  Europe  it  is  met  with  in 
the  valleys  of  Switzerland,  Savoy,  and  Piedmont; 
and  it  abounds  in  the  neighbourhood  of  Ssilzburg, 
Styria,  and  the  Tyrol.  It  is  less  frequently  met 
with  in  the  Pyrenees  and  in  the  valleys  of  the 
Auvergne  in  France.  Even  in  England  it  has 
been  met  with  in  various  parts,  among  others 
in  the  dales  between  Lancashire  and  Yorkshire. 
Although  more  frequently  met  with  in  valleys, 
it  is  not  unknown  on  plains  which  are  subject  to 
inundations. 

Description. — The  degrees  of  cretinism  are 
numerous.  A residence  in  one  of  the  valleys 
where  this  affection  exists,  enables  one  to  trace 
the  various  steps  of  degeneracy,  commencing 
with  those  who  are  taking  part  in  the  industrial 
life  of  the  valley,  down  to  the  helpless  indivi- 
duals who  are  leading  only  a vegetative  exist- 
ence. 

The  typical  cretin  presents  a marked  physical 


CRETINISM. 

conformation.  He  is  stunted  in  growth,^  rarely 
reaching  five  feet  in  height.  His  skin  is  of  a 
tawny  yellowish  line,  thickened  and  wrinkled ; 
and  looks  as  if  too  large  for  the  body.  There  is 
also  a great  increase  of  subcutaneous  areolar 
tissue.  His  tongue,  large  and  thick,  with 
hypertrophied  papill*,  always  displays  lessened 
power  of  co-ordination ; and  often  hangs  from 
the  mouth.  The  mouth  is  partly  open,  margined 
by  thick  fissured  lips,  and  with  the  saliva  running 
over  the  chin.  The  face  is  large ; the  lower  jaw 
is  drooping,  and  its  angle  obtuse.  The  eyes  are 
often  affected  by  strabismus,  obliquely  placed,  and 
small ; and  the  lids  are  commonly  puffy.  The 
belly  is  pendulous  from  the  laxness  of  the  skin. 
The  lower  limbs  are  generally  short  and  deformed, 
and  the  gait  is  waddling.  The  head  is  deformed, 
the  forehead  retreating,  the  top  flat,  and  the  occi- 
pital region  ill-developed.  The  cranium  is  bra- 
chycephalic.  The  nose  is  broad  and  flattened. 
Puberty  is  often  delayed  to  the  twentieth  year. 
The  mammas  in  the  female  are  large  and  pendu- 
lous ; the  same  remark  applies  to  the  genitals  in 
the  male.  The  intellectual  faculties  are  imper- 
fectly developed.  The  cretin  is  often  unable  to 
speak,  and  his  hearing  is  frequently  defective. 
The  affection  is  usually  associated  with  more  or 
less  enlargement  of  the  thyroid  gland.  His 
viability  is  low.  few  living  beyond  thirty  years  of 
age.  The  sexual  functions  are  abnormal ; mastur- 
bation is  frequent;  and  the  subjects  of  cretinism 
are  often  impotent. 

JEtiology. — The  conditions  for  the  development 
of  cretinism  are  hereditary  predisposition  ; the 
action  of  deteriorating  influences  on  the  parents, 
such  as  unwholesome  dwellings  and  non-nutritious 
diet;  and  accidental  causes  operating  on  the  infant 
during  the  period  when  its  physical  and  intellec- 
tual life  are  developing.  The  last-named  causes 
are  atmospheric  and  possibly  geological  conditions, 
peculiar  to  special  localities.  Humidity  of  the  soil 
and  air  in  valleys  where  there  is  little  interchange 
of  the  atmosphere,  and  the  existence  ofinagnesian 
limestone  in  the  soil,  are  probably  the  most 
potent  factors.  Cretinism  is  not  met  with  as  an 
endemic  disease  on  elevated  plateaux,  nor  in  cold 
countries  where  sudden  changes  of  temperature 
are  uncommon.  Goitre  is  a frequent  accompani- 
ment of  cretinism,  and  would  appear  to  be  de- 
veloped under  the  same  conditions.  The  cases  of 
cretinism  met  with  in  England  present  features 
which  are  indicative  of  a scrofulous  origin. 
There  is  a condition  of  idiocy  associated  with 
arrest  of  growth  and  development  at  the  period 
of  first  dentition,  not  unfrequently  met  with  in 
England,  which  has  been  termed  Sporadic  Cre- 
tinism. Some  of  these  cases  have  been  traced 
to  alcoholism  on  the  part  of  the  progenitors, 
and  are  usually  associated  with  an  absence  or 
atrophy  of  the  thyroid  body.  There  is  reason  to 
believe  that  children  become  cretinoid  when 
taken  to  reside,  at  the  period  of  their  early 
development,  in  localities  where  the  disease  is 
markedly  endemic.  There  are  numerous,  well- 
attested  instances  of  healthy  women  living 
during  their  pregnancy  in  cretinic  districts 
bringing  forth  cretinoid  children,  who  removing 
from  such  localities,  propagate  healthy  children. 
By  far,  however,  the  greater  number  of  cretins 
arri  ve  at  their  helpless  condition  by  successive 


CRIMINAL  IRRESPONSIBILITY.  315 
steps  of  degeneracy  in  their  ancestors.  It  has 
been  thought  that  cretinism  was  due  to  pre- 
mature ossification  of  the  cranial  sutures,  es- 
pecially of  the  spheno-basilar  suture ; and  that 
this  was  caused  by  drinking  water  largely  charged 
with  lime.  It  is  impossible,  however,  to  regard 
this  premature  ossification,  when  it  does  occur, 
as  other  than  one  of  the  outcomes  of  the  malady 
and  not  its  cause.  Moreover  there  are  numer 
ous  examples  where  the  synostosis  is  deferred 
instead  of  being  premature. 

Anatomical  Characters. — Pathological  ana- 
tomy shows  that  the  bones  of  the  cranial  vault 
are  thickened  and  without  diploe.  The  basilar 
groove  is  generally  wanting.  The  foramina  for 
the  passage  of  arteries  and  nerves  are  somewhat 
smaller  than  natural.  The  occipital  fossae  are 
flatter  than  usual,  as  if  the  flattening  had  re- 
sulted from  a compression  of  the  cranium  from 
above  downwards.  Every  variety  of  deformity  of 
the  cranium  is  met  with  of  the  brachycephalic 
type.  The  brain  is  usually  small,  unsymmetrical, 
pale,  and  infiltrated  with  serum.  Premature 
synostosis  is  occasionally  met  with  at  the 
spheno-basilar  suture,  and  with  it  a rectangular 
form  of  the  base  of  the  skull ; this,  however,  can- 
not be  regarded  as  a constant  condition. 

Diagnosis. — The  diagnosis  of  cretinism  may  be 
made  in  childhood,  from  the  slowness  of  the  de- 
velopment of  the  body,  the  stupid  expression,  the 
postponement  in  the  evolution  of  the  teeth,  and  of 
the  ossification  of  the  fontanelles  and  sutures,  the 
tawny  yellow  colour  of  the  skin,  the  thick  and 
goitrous  neck,  the  slavering,  and  the  delay  of 
speech  and  of  walking. 

Treatment. — This  consists  in  removing  the 
child  as  early  as  possible  from  the  circumstances 
which  have  produced  the  disease.  He  should  bo 
taken  to  a locality  where  the  soil  is  dry  and  porous, 
and  should  have  frequent  baths  with  friction  to  the 
surface  of  the  body.  The  diet  should  be  of  the 
most  nutritious  kind — a diet  into  which  animal 
foodlargely  enters.  The  administration  of  cod-liver 
oil  and  of  the  lacto-phosphate  of  lime  and  iron 
is  indicated.  Early  education  should  be  com- 
menced as  to  habits  of  cleanliness,  followed 
by  systematic  physical  exercise  of  the  various 
muscles.  All  intellectual  advancement  must  be 
sought  for  through  the  improvement  in  every 
way  of  his  physical  condition.  The  lower  animal 
life  may  thus  be  supplemented,  if  earnest  efforts 
are  used,  by  increased  capacity  for  rational 
enjoyment,  and  a more  or  less  useful  existence. 

J.  Langdon  Down. 

CRIMINAL  IRRESPONSIBILITY.— 

Historical  Summary. — A medical  opinion  as 
to  the  condition  of  an  accused  person  is  often 
necessary  in  order  to  determine  whether  he  or 
she  can  be  held  accountable  for  criminal  acts. 
Such  an  opinion  generally  depends  on  the  pre- 
sence or  absence  of  insanity,  or  on  the  con- 
nection which  may  be  traced  between  this 
mental  condition  and  the  act  in  question.  In  the 
article  on  Legal  Insanity  it  is  explained  that  it 
is  only  within  a comparatively  recent  period 
that  insanity  has  been  admitted  as  an  excuse  for 
crime,  except  in  those  comparatively  rare  cases 
in  which,  as  Justice  Tracey  expressed  it  iu  1723, 
a person  does  not  know  what  he  is  doing,  • at 


CRIMINAL  IRRESPONSIBILITY. 


316 

more  than  an  infant,  a brute,  or  a -wild 
beast.’  See  Insanity,  Legal.  This  view  fairly 
represents  the  state  of  public  and  of  legal 
opinion  until  the  later  years  of  the  eighteenth 
century.  The  subsequent  enlightenment  of  the 
public  mind  did  not  receive  juristic  expression 
until  the  trial  of  Hadfield  in  1800,  when  Erskine 
first  enunciated  the  doctrine,  that  ‘ delusion 
where  there  is  no  frenzy  or  raving  madness 
is  the  true  character’  of  such  insanity  as  im- 
plies irresponsibility.  The  most  important  case 
in  the  history  of  this  question  was  that  of  Bel- 
lingham, who  was  executed  in  1812  for  shoot- 
ing Mr.  Spencer  Perceval.  In  this  case  Lord 
Chief  Justice  Mansfield  said,  that  if  a person 
labouring  under  mental  derangement  were  cap- 
able in  other  respects  of  distinguishing  right 
from  wrong,  ‘ he  could  not  be  excused  for  any 
act  of  atrocity  which  he  might  commit.’  ‘ It  must 
be  proved  beyond  all  doubt,’  he  added,  ‘ that  at  the 
time  he  committed  the  atrocious  act  he  did  not  con- 
sider that  murder  was  a crime  against  the  laws  of 
God  and  nature.’  The  trial  of  MacNaughton  in 
1813  for  the  murder  of  Mr.  Drummond  led  to 
the  most  authoritative  statement  of  the  law 
which  has  ever  been  obtained  in  this  country. 
MacNaughton  was  acquitted  on  Chief  Justice 
Tindal’s  direction  that  the  point  for  the  jury  to 
consider  was  whether  ‘ at  the  time  the  act  was 
committed  ’ the  accused  ‘ had  that  competent  use 
of  his  understanding  as  that  he  knew  that  he 
was  doing  by  the  very  act  itself  a wicked  and 
a wrong  thing.’  The  general  application  of  this 
doctrine  would  have  greatly  enlarged  the  area 
of  irresponsibility,  and  its  enunciation  at  that 
time  produced  considerable  surprise  and  even 
consternation.  The  matter  was  indeed  regarded 
as  so  urgent  that  the  House  of  Lords  imme- 
diately ordered  a series  of  questions  to  be  laid 
before  the  fifteen  judges  with  the  view  of  settling 
the  state  of  the  law.  In  the  answers  to  these 
questions  it  was  in  substance  laid  down,  that  to 
entitle  an  accused  party  to  acquittal  on  the 
ground  of  insanity  it  is  necessary  that  he  be  of 
diseased  mind,  and  at  the  time  he  committed  the 
act  not  conscious  of  right  or  wrong  ; or,  that  ho 
be  under  some  delusion  which  made  him  regard 
the  act  as  right.  But  this  statement  has  been 
fir  from  effecting  a final  settlement  of  the  ques- 
tion. 

Most  writers  on  medical  jurisprudence  have 
insisted  that  the  real  criterion  of  responsibility 
is  the  freedom  of  the  will,  or  the  power  of  the 
individual  to  control  his  actions.  This  has  been 
more  or  less  advocated  by  Esquirol,  Mare,  Ray, 
Pagan,  Jamieson,  Mittermaier,  and  Von  Krafft- 
Ebing.  Esquirol  dwells  strongly  on  the  impor- 
tance of  the  freedom  of  the  will.  Ray  includes 
it  in  the  comprehensive  statement  which  has 
received  the  approval  of  so  many  medical  jurists. 
‘ Liberty  of  will  and  action,’  he  says,  ‘ is  abso- 
lutely essential  to  criminal  responsibility,  unless 
the  constraint  upon  either  is  the  natural  and 
well-known  result  of  immoral  or  illegal  conduct. 
Culpability  supposes  not  only  a clear  perception 
of  the  consequences  of  criminal  acts,  but  the 
liberty  unembarrassed  by  disease  of  the  active 
powers  which  nature  has  given  us,  of  pursuing 
I hat  course  which  is  the  result  of  the  free  choice 
of  the  intellectual  faculties.’  Pagan  observes 


that  the  ‘loss  of  control  over  our  actions,  which 
insanity  implies,  is  that  which  renders  the  acts 
which  are  committed  during  its  continuance 
undeserving  of  punishment.’  Jamieson  puts  the 
question : ‘ Had  the  lunatic  at  the  time  of  com- 
mitting the  deed  a knowledge  that  it  was  cri  - 
minal,  and  such  a control  over  his  actions  as 
ought,  if  it  existed,  to  have  hindered  him  from 
committing  it.’  Dr.  Taylor  says  : ‘ The  power 
which  is  most  manifestly  deficient  in  the  insane 
is  generally  the  controlling  power  of  the  will  ’ ; 
and  he  expresses  the  opinion  that  ‘ we  have  here 
a fair  criterion  on  which  responsibility  or  irre- 
sponsibility may  be  tested.’  Dr.  Bucknill's 
view  is  substantially  the  same.  ‘ Responsibility,’ 
he  says,  ‘ depends  upon  power,  not  upon  know- 
ledge, still  less  upon  feeling.  A man  is  respon- 
sible to  do  that  which  he  can  do,  not  that  which 
he  feels  or  knows  it  right  to  do.  If  a man  is 
reduced  under  thraldom  to  passion  by  disease 
of  the  brain  he  loses  moral  freedom  and  respon- 
sibility, although  his  knowledge  of  right  and 
wrong  may  remain  intact.’  The  latest  German 
code  puts  responsibility  upon  the  same  basis. 
‘ An  act  is  not  punishable,’  according  to  it, 

‘ when  the  person  at  the  time  of  doing  it  was  in 
a state  of  unconsciousness  ; or  of  disease  of  the 
mind,  whereby  free  volition  was  prevented.’ 
Mittermaier  and  Von  Krafft-Ebing  sanction  the 
attempt  to  render  the  meaning  of  ‘ free  volition  ’ 
more  definite  by  describing  it  as  made  up  of 
libcrtas  judicii  and  libertas  consilii,  freedom  of 
judgment  and  freedom  of  choice.  Casper  some- 
what obscurely  defines  criminal  responsibility  as 
‘ the  psychological  possibility  of  the  efficacy  of 
the  penal  code.’  Mr.  Balfour  Browne,  a recent 
writer,  gives  as  the  best  definition  ‘ a knowledge 
that  certain  acts  are  permitted  by  law,  and  that 
certain  acts  are  contrary  to  law,  and,  combined 
with  this  knowledge,  the  power  to  appreciate  and 
be  moved  by  the  ordinary  motives  which  influ- 
ence the  actions  of  mankind.’  Dr.  Guy  thinks 
that  every  person  who  is  insane  must  be  regarded 
as  wholly  irresponsible,  and  that  the  law  of  Eng- 
land ought  to  be  assimilated  to  that  of  France  in 
the  declaration  that : ‘ II  n’y  a ni  crime  ni  debt 
lorsque  le  prevenu  etait  en  4tat  do  demence  au 
temps  de  Faction.’  Mr.  "Warren,  on  the  other 
hand,  suggests  that  a person  should  not  be  held 
irresponsible  unless  he  were  as  ‘ unconscious  of 
his  act  as  a baby.’  Dr.  Maudsley  and  others 
hold  that  the  determination  of  responsibility 
in  cases  where  insanity  is  alleged  depends  on 
whether  a connection  can  or  cannot  be  traced 
between  existing  disease  and  the  act. 

Insanity  has  been  pleaded  as  an  excuse  for 
acts  of  theft ; but  such  eases  are  rare,  and  never 
occur  except  where  the  social  position  of  the 
accused  adds  importance  to  the  decision.  Indeed 
it  may  almost  be  said  that  the  plea  is  never 
raised,  except  in  order  to  avoid  capital  punish- 
ment. Hence  it  is,  that  in  the  discussions  which 
have  arisen  the  question  has  been  intimately 
associated  with  the  law  of  murder  and  homicide. 
A special  inquiry  into  the  state  of  this  law  by  a 
committee  of  the  House  of  Commons1  has  conse 
quently  given  occasion  to  the  enunciation  of  im- 
portant views  as  to  the  legal  relations  of  insanity 

1 Report  of  Select  Committeeof  the  House  of  Common; 
on  the  Homicide  Law  Amendment  Bili,  July  21,  1874. 


CRIMINAL  IRRESPONSIBILITY.  317 


And  responsibility.  Evidence  was  furnished  to 
the  Committee  by  Lord  Chief  Justice  Cockburn, 
Baron  Bramwell,  Mr.  Justice  (now  Lord)  Black- 
burn, and  Sir  James  Fitz-James  Stephen.  The 
immediate  object  of  the  Committee  was  to  examine 
a bill  drawn  by  Sir  James  Stephen  for  the  codi- 
fication of  the  law  of  homicide.  In  the  clause  of 
the  bill  which  deals  with  the  relations  of  disease 
and  responsibility,  homicide  is  stated  to  be  ‘not 
criminal  if  the  person  by  whom  it  is  committed  is 
at  the  time  when  he  commits  it  prevented  by 
any  disease  affecting  his  mind — (a)  from  know- 
ing the  nature  of  the  act  done  by  him,  ( b ) from 
knowing  that  it  is  forbidden  by  law,  (c)  from 
knowing  that  it  is  morally  wrong,  or  (d)  from 
controlling  his  own  conduct.’  But  it  is  stated 
to  be  ‘criminal,  although  the  mind  of  the  person 
committing  it  is  affected  by  disease,  if  such  dis- 
ease does  not  in  fact  produce  one  of  the  effects 
aforesaid  in  reference  to  the  act  by  which  death 
is  caused,  or  if  the  inability  to  control  his  con- 
duct is  not  produced  exclusively  by  such  dis- 
ease.’ It  was,  however,  preposed  in  the  bill 
that,  ‘ if  a person  is  proved  to  have  been  labour- 
ing under  any  insane  delusion  at  the  time  when 
ho  committed  the  homicide,  it  shall  be  presumed, 
unless  the  contrary  appears  or  is  proved,  that  he 
did  not  possess  the  degree  of  knowledge  or  self- 
control  hereinbefore  specified.’  That  is  to  say, 
where  delusion  exists,  the  burden  of  proving 
moral  capacity  would  be  shifted,  the  prosecutor 
having  to  prove  its  existence,  instead  of  the  ac- 
cused having  to  prove  its  absence.  The  opinions 
elicited  during  the  enquiry  showed  that  the  law 
is  regarded  by  legal  authorities  as  being  at  pre- 
sent too  uncertain  in  its  operation,  and  as  failing 
to  recognise  some  of  the  most  important  elements 
in  the  question.  The-divergent  character  of  the 
recommendations  which  were  made  showed,  how- 
ever, that  legal  opinion  is  much  divided  not  only 
as  to  the  proper  relations  of  insanity  and  crime, 
but  also  as  to  the  essential  elements  of  respon- 
sibility. In  the  meantime,  therefore,  the  state- 
ments of  the  fifteen  j udges  after  the  MacN aughton 
case  remain  the  chief  exposition  of  the  English 
law  where  insanity  is  pleaded  in  excuse  for 
crime. 

Present  state  o f the  question. — It  is  necessary, 
in  order  to  justly  appreciate  the  present  aspect 
of  the  subject,  thus  to  trace  its  more  recent  his- 
tory, and  it  would  be  useful,  did  space  per- 
mit, to  present  an  estimate  of  the  comparative 
value  of  the  several  tests  or  criteria  which  have 
been  proposed  for  the  determination  of  cases 
in  which  insanity  has  been  alleged.  Theso 
criteria  may  be  broadly  summarised  in  the 
following  six  propositions.  According  to  one 
view  a person  should  be  held  irresponsible  for 
an  act  if  at  the  time  of  committing  it  (1)  he 
laboured  under  insanity  of  any  kind  or  degree  ; 
according  to  another,  if  (2)  he  laboured  under 
delusion ; or  (3)  if  ho  was  ignorant  of  right 
and  wrong ; or  (f)  had  not  power  to  appreciate 
and  be  moved  by  ordinary  motives  ; or  (5)  had 
lost  the  controlling  power  of  the  will ; or  (6)  if 
the  act  is  traceable  to,  or  its  nature  has 
been  determined  by  mental  disease  affecting  the 
agent.  The  last  of  these  views  is  the  only  one 
to  which  fatal  objection  may  not  be  raised  both 
on  the  theoretical  and  praitical  sides.  The 


others  are  all  too  vague  to  be  of  much  advan- 
tage ; and  they  rather  tend  to  introduce  new 
difficulties  than  to  remove  those  already  existing 
The  proposition  therefore  which  seems  to  ap- 
proach nearest  to  a solution  of  the  difficulty  is 
that  irresponsibility  must  be  admitted  whenever 
the  act  is  traceable  to,  or  its  nature  is  deter- 
mined by  mental  disease  affecting  the  agent.  It 
will  of  course  be  understood  that  under  such 
a rule  the  term  ‘ mental  disease  ’ must  be  held  to 
include  both  congenital  and  acquired  disorders  : 
arrest  of  development  being  as  much  a morbid 
condition  as  functional  or  structural  change. 
This  view  of  the  subject  may  not  be  ultimately 
accepted  in  the  precise  terms  of  the  proposition 
here  given  ; but  the  principle  on  which  it  rests 
seems  to  afford  the  only  safe  basis  upon  which 
we  can  go.  As  has  already  been  shown,  it  has 
not  hitherto  been  regarded  in  this  light  by  the 
majority  of  the  judges  ; but  there  have  been  in- 
dications of  late  years  that  judicial  views  are 
tending  in  that  direction.  The  late  Lord  Wen- 
sleydale  and  others  have  given  sanction  to  the 
principle  in  their  judicial  statements.  And  the 
present  Lord  Justice-General  of  Scotland  (Inglis) 
gave  definite  expression  to  it  in  one  case  (Brown, 
Sept.  1866).  He  told  the  jury  that  the  main 
question  was  ‘ whether" the  prisoner  was  in  such 
a state  of  insanity  at  the  time,  as  not  to  be 
responsible  for  the  act  which  he  had  committed’ ; 
and  in  order  to  constitute  such  insanity  ho  said 
that ‘it  must  be  clearly  made  out  that  at  the 
time  of  committing  the  act  the  prisoner  was 
labouring  under  mental  disease  in  the  proper 
sense  of  the  term,  and  that  that  mental  disease 
was  the  cause  of  the  act.’  In  America  the  doc- 
trine has  been  frequently  acknowledged,  but 
never  more  fully  and  tersely  than  by  Judge  Doe, 
of  New  Hampshire  (State  v.  Pike),  who  compre- 
hensively defined  tho  medical  relations  of  both 
criminal  irresponsibility  and  civil  incapacity, 
when  he  stated  that  ‘a  product  of  mental  disease 
is  neither  a contract,  a will,  nor  a crime.’  One  im- 
portant point  is  to  prevent  persons  from  being 
punished  for  actions  which  are  the  direct  outcome 
of  pathological  processes.  But  it  is  of  equal  im- 
portance to  avoid  the  adoption  of  a principle 
which  would  make  the  existence  of  slight  mental 
irregularities  incompatible  with  responsibility. 
There  does  not  appear  to  be  any  danger  of  this  in 
acting  on  the  principle  which  is  here  enuuciated. 
For  it  lies  in  the  very  naturo  of  the  cases  in  which 
the  doctrine  could  be  applied,  that  the  condition 
to  which  it  is  proposed  that  irresponsibility 
should  be  attached  must  be  one  which  is  known 
to  exhibit  itself  in  acts  of  serious  and  even 
criminal  character.  If  the  trained  observer  of 
disease  is  able  to  recognise  in  an  act — which 
is  ordinarily  followed  by  severe  punishment — a 
direct  result  or  a characteristic  feature  of  a 
morbid  process,  of  the  existence  of  which  there 
may  otherwise  be  sufficient  proof,  the  question  of 
responsibility  cannot  present  any  serious  diffi- 
culty. It  may  admit  of  doubt  whether  a person 
is  responsible  for  not  controlling  his  actions, 
cr  for  not  knowing  right  from  wrong,  or  even  ir 
some  cases  for  the  harbouring  of  a delusion. 
But  once  let  it  be  proved  that  an  act  is  the 
natural  result  of  a disease  under  which  a person 
is  known  to  labour,  and  the  question  must  be 


418  CRIMINAL  IRRESPONSIBILITY, 
practically  removed  from  the  field  of  discussion. 
Before,  however,  the  principle  can  be  accepted  as 
fully  satisfactory,  it  is  necessary  to  enquire 
whether  its  application  would  permit  insane 
persons  to  be  held  responsible  who  ought  not  to 
ue  so  considered.  In  other  words,  are  there 
states  of  insanity  in  which  a person  is  irrespon- 
sible for  acts  to  which  he  has  not  been  predis- 
posed or  impelled  by  the  insanity  ? It  is  per- 
haps impossible  to  give  such  an  answer  to  this 
question  as  would  be  both  definite  and  complete; 
but  for  practical  purposes  we  think  it  may  be 
answered  in  the  negative.  Where  the  insanity 
is  of  such  a nature  that  it  does  not  modify  the 
whole  conduct,  we  believe  it  will  be  found  in 
practice  necessary  to  admit  the  existence  of  re- 
sponsibility for  acts  where  there  is  no  demon- 
strable connection  between  them  and  the  mental 
disease.  The  insane  persons  who  on  this  prin- 
ciple might  be  held  responsible,  would  be  found 
solely  among  those  whose  irresponsibility  could 
only  be  admitted  after  very  searching  enquiry, 
and  whose  insanity  was  of  that  kind  and  degree 
which  has  often  been  declared  by  medical  writers 
to  be  consistent  with  responsibility.  It  is  not 
to  be  supposed  that  under  this  rule  difficulties 
would  cease.  It  would  often  be  hard  to  show 
in  cases  of  actual  disease  that  there  was  good 
reason  for  believing  in  its  existence,  or  that  it 
was  really  contributory  to  the  act  committed. 
This,  however,  would  not  result  from  any  defect 
in  the  principle,  but  from  that  imperfection  of 
our  knowledge  which  renders  the  perfect  appli- 
cation of  any  principle  impossible.  Let  the  task 
of  the  medical  witness  be  limited  to  the  demon- 
stration of  facts  indicative  of  disease  and  its 
consequences,  and  he  will  at  least  be  acting 
quite  within  his  special  province  andmight  expect 
that  reasonable  weight  would  be  attached  to  his 
opinion.  And  if  juries  were  instructed  that  the 
law  does  not  hold  a person  responsible  for  acts 
committed  under  the  influence  of  disease,  it  is 
scarcely  conceivable  that  anyone  would  be  found 
guilty  where  good  cause  had  been  shown  even 
for  the  reasonable  supposition  of  such  an  influ- 
ence. Whatever  may  be  the  view  ultimately 
adopted,  it  would  seem  to  be  in  every  way  de- 
sirable that  the  attention  of  the  medical  expert 
should  be  confined  to  the  elucidation  of  the 
medical  facts,  and  that  he  should  not  be  required 
to  deal  with  questions  which  are  legal  and  ab- 
stract, and  in  no  way  specially  medical.  The 
condition  known  as  diminished  responsibility  has 
not  been  alluded  to  in  this  article.  It  is  only 
indirectly  recognised  by  British  law,  and  there- 
fore, though  much  is  to  be  said  in  favour  of  its 
recognition,  it  is  unnecessary  to  deal  with  the 
subject  here.  John  Sibbabd. 

CRISIS  (Kpl<ns,  a decision,  a turn).- — Crisis 
is  a term  applied  to  the  rapid  defervescence  of 
an  acute  febrile  disease.  It  has  wandered  some- 
what from  its  original  meaning,  which  was 
‘judgment,’ — primarily  an  operation  in  the  mind 
of  tho  observer,  but  reflected  upon  the  pheno- 
mena observed.  The  converse  term,  employed  to 
designate  a gradual  subsidence  of  fever,  is  lysis. 

Crisis  formed  at  one  time  the  basis  of  an  im- 
portant medical  doctrine.  Certain  days  from 
the  onset  of  the  disease  on  which  the  crisis  com- 


CRISIS. 

monly  occurred  were  considered  to  be  propitious. 
The  seventh  day  was  especially  favourable,  while 
the  sixth  was  the  most  unfavourable ; speaking 
generally,  the  odd  numbers  or  the  multiples  of 
7 were  propitious,  and  even  numbers  and  such 
odd  numbers  as  stood  near  multiples  of  7,  such 
as  19,  were  unpropitious.  The  preparation  also 
for  a crisis  was  indicated  and  the  critical  day 
foretold  by  remissions  perceptible  some  day* 
previously.  The  whole  morbid  process  of  fever 
was  represented  as  a process  of  elaboration  by 
which  a materies  morbi  was  prepared  for  expul- 
sion, and  an  essential  feature  of  the  crisis  was  a 
critical  evacuation,  by  means  of  which  this  wa^ 
eliminated. 

The  doctrine  of  crisis  and  even  of  critical  days 
was  not  pure  imagination  or  superstition,  but 
was  founded  originally  cn  careful  observation. 
In  times  when  nothing  was  known  of  the  organic 
lesions  which  give  rise  to  fever,  and  in  countries 
where  a large  proportion  of  the  diseases  were  of 
a malarious  origin,  it  would  afford  data  for  prog- 
nosis and  conduce  to  appropriate  treatment; 
and  at  the  present  day  in  hot  climates  a crisis 
is  anxiously  looked  for  in  febrile  attacks  on  a 
given  day,  and,  as  is  well  known,  a critical  fall 
of  temperature  and  improvement  in  the  general 
symptoms  precede  in  pneumonia  improvement 
in  the  physical  signs. 

In  order  to  constitute  a true  crisis  the  defer- 
vescence should  occupy  less  than  forty-eight 
hours,  and  it  often  takes  place  in  a much  shorter 
time.  The  fall  of  temperature  should  be  accom- 
panied by  a corresponding  reduction  in  tho  fre- 
quency of  the  pulse,  and  should  coincide  with  a 
foeling  of  relief  and  a return  of  strength,  the 
skin  will  be  warm  and  soft,  the  tongue  moist,  and 
there  will  be  indications  of  reviving  appetite ; 
there  may  or  may  not  be  a critical  evacuation, 
but  the  secretions  will  become  more  natural  in 
amount  and  character. 

This  favourable  mode  of  termination  of  an 
acute  febrile  disease  is  more  common  than  is 
usually  supposed.  The  circumstances  under 
which  it  is  most  likely  to  occur  are  when  the 
attack  begins  abruptly  and  the  temperature  rises 
rapidly,  the  natural  course  of  the  disease  being 
short  and  not  attended  with  organic  lesions, 
such  as  will  of  themselves  keep  up  fever.  After 
twenty-one  days,  termination  by  crisis  is  not  to 
be  expected.  The  more  marked  the  onset,  as, 
for  example,  by  a definite  rigor,  the  more  rapid 
the  rise  of  temperature  and  the  greater  the 
height  to  which  it  reaches,  the  greater  the  pro- 
bability of  an  early  critical  termination. 

Occurrence. — The  diseases  iu  which  the  con- 
ditions favouring  a crisis  are  realised,  and  in 
which  this  mode  of  termination  is  observed, 
belong  to  various  classes. 

Among  the  specific  fevers,  eruptive  and  con 
tinned,  it  occurs  frequently  in  variola,  but  in 
severe  cases  it  is  interfered  with  by  the  febrile 
disturbance  excited  by  the  eruption.  In  measles 
it  is  very  common : in  scarlet-fever  a true  crisis 
is  seen  only  in  mild  cases,  though  the  onset  of 
this  disease  is  peculiarly  abrupt.  The  mode 
of  termination  of  typhus  is  essentially  critical, 
but  as  a rule  the  crisis  is  not  sharp.  Relapsing 
fever  affords  the  best  examples  of  crisis,  which 
is  moreover  attended  by  a critical  evacuation  ir 


CRISIS. 

the  form  of  profuse  perspiration,  the  temperature 
sometimes  falling  10°F.  in  as  many  hours,  and  the 
patient  passing  from  a state  of  extreme  suffer- 
ing and  oppression  to  almost  perfect  ease  and 
comfort.  In  enteric  fever  lysis  is  the  mode  of 
termination. 

Remittent  fevers  often  present  crises,  which 
may  be  true  and  curative,  or  false  and  illusive; 
and  the  sun-fever  and  common  continued  fever 
of  hot  climates,  and  tropical  diseases  generally, 
have  a tendency  to  fever  running  high  very 
early  and  breaking  abruptly  at  a critical  period. 

In  this  country  feverish  colds,  attacking  the 
throat  or  taking  the  form  of  influenza  or  catarrh, 
often  terminate  critically  in  three  or  four  days. 
Erysipelas  may  so  end,  but  at  a later  and  less 
definite  period.  The  sharp  febrile  attacks  which 
sometimes  occur  after  childbirth  often  exhibit  a 
very  decided  crisis.  In  'pneumonia  the  natural 
termination  is  by  a well-marked  crisis,  which 
may  take  place  as  early  as  the  fifth  day,  or  be 
deferred  to  the  ninth,  after  which  a critical  ter- 
mination is  not  to  be  expected,  and  the  sus- 
picion may  be  entertained  that  the  case  is  not 
one  of  frank  pneumonia,  the  prognosis  becoming 
grave.  As  has  been  already  stated,  the  general 
improvement  precedes  the  indications  by  phy- 
sical signs  of  resolution  in  the  inflamed  lung. 
Pleurisy  is  said  also  to  terminate  critically, 
but  it  is  not  in  the  same  definite  way  as  pneu- 
monia. 

The  critical  evacuations  which  entered  into 
the  original  notion  of  a crisis  are  really  a com- 
mon attendant.  The  most  common  is  a profuse 
warm  perspiration,  which  may  occur  whatever 
the  disease  may  be.  Occasionally  the  evacua- 
tion is  a copious  flow  of  urine,  or  it  may  take 
the  form  of  diarrhoea.  Epistaxis  or  hsemor- 
rhoidal  flux  is  a more  rare  and  doubtful  critical 
evacuation.  A common  critical  phenomenon  is 
a prolonged,  sound,  and  refreshing  sleep. 

The  question  whether  or  not  a favourable 
crisis  affects  the  odd  rather  than  the  even  days 
has  been  a frequent  subject  of  dispute,  and  it 
still  remains  undecided.  It  is  not,  however,  of 
any  importance ; but  another  point  handed  down 
with  the  doctrine  is  worthy  of  attention,  namely, 
that  indications  of  an  approaching  crisis  are 
often  given  two  or  three  days  beforehand  in 
slight  remissions  of  fever.  By  the  presence  or 
absence  of  such  remissions  at  a certain  period 
of  the  attack,  or  by  a continuous  rise  of  tem- 
perature where  a remission  might  be  expected, 
important  prognostic  information  may  be  af- 
forded and  indications  for  treatment  obtained. 

Therapeutic  Indications. — The  main  thera- 
peutic deduction  from  a study  of  crisis  as  a ter- 
mination of  acute  disease  is,  that  we  should  not 
hastily  interfere  with  the  reactions  by  which  the 
system  adjusts  itself  to  altered  conditions  or 
meets  the  incidence  of  the  causes  of  such  dis- 
ease, but  contribute  to  their  completion.  We 
do  not  assume  the  existence  of  a vis  medicatrix 
tending  invariably  to  the  restoration  of  health  ; 
but  we  must  recognise  the  power  inherent  in  a 
living  organism  to  respond  by  internal  changes 
to  external  influences,  and  to  regain  the  balance 
when  this  has  been  disturbed.  In  this  process  a 
certain  cycle  of  changes  must  be  gone  through, 
and  tl  c great  opportunity  for  treatment  of  an 


CROUP.  319 

active  kind,  should  any  be  required,  arises  when 
the  course,  direction,  and  probable  duration  of 
these  changes  are  known,  and  when  agencies 
can  bo  brought  to  bear  at  a given  moment,  which 
will  contribute  to  bring  about  the  appropriate 
critical  evacuation  or  a critical  sleepi,  through 
which  a return  to  a normal  condition  would 
naturally  be  effected. 

William  II.  Bkoabbent. 

CKITTCAL. — Having  relation  to  a crisis. 
See  Crisis. 

CROUP.  — Definition.  — Croup  is  a word 
which,  in  accordance  with  its  etymology,  origi- 
nally meant  stridulous  breathing,  a symptom, 
therefore,  of  laryngitis  stridulosa,  laryngismus 
stridulus,  oedema  of  the  glottis,  laryngo- tracheal 
diphtheria,  and  other  affections  which  perma- 
nently or  spasmodically  contract  the  chink  of  the 
glottis.  It  was  imported  from  the  Scottish  ver- 
nacular into  medical  nomenclature  by  Dr.  Francis 
Home,  of  Edinburgh,  in  1765,  when  he  published 
a tract  of  60  sparsely  printed  pages,  entitled 
An  Inquiry  into  the  Nature,  Cause,  and  Cure  of 
the  Croup.  It  has  since  drifted  into  very  strange 
and  very  different  meanings.  ‘ In  France,’  to  quote 
the  Dictionary  of  Littre  and  Robin,  ‘it  is  a term 
now  generally  reserved  for  tracheal  diphtheria : ’ 
in  Germany,  it  is  applied  to  membranous  deposits 
on  the  internal  surface  of  organs,  such  expres- 
sions as  ‘ croup  of  the  uterus  ’ and  ‘ croup  of  the 
intestine  ’ being  in  current  use  : in  Great  Britain 
it  is  used,  as  employed  by  Home,  Cheyno,  and 
their  followers,  to  designate  a disease  which 
they  believe  to  be  distinctive  and  separate,  but 
which  is  declared  by  an  increasing  number  of 
British  physicians,  the  followers  of  Bretonneau, 
to  be  a mere  literary  composite  of  diseases 
pathologically  different  from  one  another.  In  a 
general  way,  the  question — What  is  croup  ? — has 
now  been  answered.  It  is  necessary,  however, 
still  further  to  explain  the  position  which  ‘croup’ 
at  present  holds  in  the  literature  and  science  cf 
British  medicine. 

In  1826  Bretonneau  of  Tours,  by  the  publica- 
tion of  his  work  entitled  Necherches  sur  f In- 
flammation Speciale  du  Tissu  JMuqueux , en  par- 
ticulier  sur  la  Diplitherite,  created  the  name, 
and  first  pointed  out,  in  that  and  subsequent 
writings,  the  true  pathology  of  diphtheria.  He 
did  not,  however,  describe  a new  disease.  lit 
only  disentangled  it  from  other  diseases  in  which 
it  had  been  mixed  up  in  description.  Modern 
literary  research  has  shown  that  diphtheria  has 
at  intervals  prevailed,  under  various  names,  in 
many  countries,  from  the  earliest  medico-histo- 
rical times.  Home,  in  his  little  monograph,  de- 
scribes ODly  eight  cases;  and  of  these,  all  of 
which  he  calls  by  the  name  of  ‘ croup,’  five  are 
manifestly  tracheal  diphtheria,  and  three  are 
cases  of  laryngitis.  As  no  false  membrane  was 
seen  in  the  three  cases  of  laryngitis,  he  concluded 
that  it  had  been  absorbed,  or  that  the  treatment 
had  prevented  its  formation ! For  a long  period 
his  successors,  British  and  foreign,  continued  to 
make  similar  mistakes ; and  indeed  till  Breton- 
neau published  the  result  of  his  clinical  study, 
the  error  now  adverted  to  was  universally  ac- 
cepted as  the  truth.  In  ISO],  Dr.  John  Cheynf 
of  Edinburgh  published  his  Essay  on  CynamE 


CROUP. 


320 

Trachealis,  or  Croup,  a pamphlet  of  80  pages 
illustrated  by  five  excellent  plates,  the  work  of 
the  illustrious  Charles  Bell.  Cheyne,  like  Home, 
has  confounded  together  infantile  laryngitis  and 
infantile  tracheal  diphtheriain  one. disease,  which 
he  calls  ‘ eynanche  trachealis  or  croup.’  Ho  at- 
tributes the  recoveries  from  the  former  to  the 
energy  of  the  bleeding  and  purging ; and  the 
deaths  from  the  latter  to  the  imperfect  adoption 
of  that  treatment.  Dr.  Cheyne’s  essay  contains 
only  ten  cases.  In  the  history  of  the  five  which 
terminated  in  recovery,  nothing  is  said  of  false- 
membranes  having  been  seen  ; and  in  four  of  the 
five  which  terminated  in  death,  there  was  found 
false-membrane,  which  is  well  depicted  by  Charles 
Bell  in  the  coloured  plates.  If  the  account  now 
given  of  the  constantly  quoted,  and  often  mis- 
quoted, little  tracts  be  correct,  where  is  the  foun- 
dation for  the  statement  reiterated  up  to  the 
hour  at  which  we  write  by  a succession  of  British 
authors,  that  the  said  writings  of  Home  and 
Cheyne  contain  the  description  of  an  individual 
disease — croup — possessing  essentially  different 
features  from  the  laryngeal  and  tracheal  diph- 
theria of  Bretonneau  ? 

It  must  be  admitted  that,  while  the  inference 
to  which  the  preceding  remarks  are  intended  to 
lead  is  in  accordance  with  the  views  of  some 
eminent  British  physicians,  it  is  at  variance  with 
the  teaching  of  others  who  claim  respectful  atten- 
tion, Dr.  Charles  West,  in  the  edition  of  his 
Lectures  on  the  Diseases  of  Infancy  and  Child- 
hood, published  in  1874,  when  discussing  ‘ Diph- 
theria or  Angina  Maligna,’  says  : — ‘ I have  come 
to  the  conclusion  which  I long  hesitated  .to  adopt, 
that  what  differences  soever  exist  between  croup 
and  diphtheria,  they  must  be  sought  elsewhere 
than  in  the  pathological  changes  observable  in 
the  respiratory  organs.  The  mere  extent  of  false- 
membrane  in  the  air-passages  certainly  affords 
no  ground  for  a distinction  between  the  two 
affections,  though  I think  it  is  more  common  to 
find  the  false-membrane  reaching  to  the  tertiary 
bronchi  in  diphtheria  than  in  primary  croup.’  In 
these  sentences  he  intimates  his  belief  in  a lion- 
diphtheritic  membranous  croup — a disease  which 
many  maintain  has  no  existence,  except  in  books. 
In  the  same  work,  in  the  lecture  on  croup, 
he  says  : — ‘ It  can  scarcely  be  necessary  to  tell 
any  of  you  that  croup  is  the  English  name  for 
the  disease  designated  by  scientific  writers  cy- 
nanche  trachealis  or  eynanche  larynyea.  It  con- 
sists in  inflammation,  generally  of  a highly  acute 
character,  of  the  trachea  or  larynx,  or  both,  which 
terminates  in  the  majority  of  cases  in  the  exuda- 
tion of  false-membrane,  more  or  less  abundantly, 
upon  the  affected  surface.’ — (Lecture  xxiii.  p.  390, 
6th  edition,  London,  1874.)  The  only  case  of 
croup  given  by  Dr.  West  in  the  lecture  is  one 
which,  if  Bretonneau’s  teaching  be  correct,  is  a 
typical  cas6  of  diphtheria  affecting  the  air-pas- 
sages. The  case  and  the  sentence  by  which  it  is 
introduced,  are  subjoined : — 

‘ The  danger,’  says  Dr.  West,  ‘ of  being  lulled 
into  security  by  the  apparent  improvement  of  a 
child  who  has  been  attacked  by  croup,  is  so  serious 
that  before  proceeding  to  consider  the  treatment 
of  the  disease,  I will  relate  to  you  a case  by  way 
of  caution.  On  June  25,  a little  girl,  four  years 
old,  became  hoarse  and  lost  her  appetite,  though 


she  did  not  appear  otherwise  ill.  On  the  27th, 
she  seemed  less  well,  and  in  the  night  was  very 
restless,  and  had  difficulty  of  breathing.  On  the 
28th,  respiration  was  more  difficult,  and  though 
she  had  but  little  cough,  she  seemed  sometimes 
in  danger  of  choking.  In  the  night  a croupy 
sound  accompanied  her  breathiag,  and  violent 
attacks  of  dyspncea  were  of  frequent  occurrence. 
On  the  29th,  she  was  taken  to  a surgeon,  who 
gave  her  some  medicine,  after  each  dose  of  which 
she  was  sick;  and  this  sickness  was  followed  by 
much  relief,  and  by  an  almost  complete  cessation 
of  the  croupy  sound.  This  improvement  was 
thought  to  have  continued  during  the  30th ; the 
child  slept  quietly  during  the  night,  and  was 
considered  so  much  better  by  her  parents  that 
she  was  brought  by  them  to  the  Children’s  Hos- 
pital at  9 a.m.  on  July  1.  As  she  lay  in  the  lap 
in  a sitting  position,  her  countenance  was  pale 
and  livid,  her  respiration  was  sibilant,  her  sur- 
face cool,  her  pulse  very  frequent  and  feeble ; but 
she  did  not  appear  to  be  in  any  of  the  distress 
usual  in  the  advanced  stages  of  croup.  At  9 a.m. 
she  was  admitted;  at  6 p.m.  she  died,  though  no 
great  distress  nor  violent  struggle  for  breath 
preceded  her  death.  The  extensive  deposit  of 
false-membrane  in  the  trachea  and  bronchi 
showed  that  in  spite  of  her  apparent  amendment 
for  a season,  disease  must  all  the  time  have  been 
advancing,  unsuspected  by  her  friends,  overlooked 
even  by  her  medical  attendants.’ 

This  ease,  given  by  Dr.  West  as  a case  of  the 
disease  which  he  calls  croup  in  contradistinction 
to  diphtheria,  will  be  regarded  by  the  medical 
profession  in  France,  and  by  all  other  followers 
of  Bretonneau,  as  a typical  and  graphically  de- 
scribed example  of  diphtheria  implicating  the 
air-passages.  They  will  say  that  it  was  tj'pica! 
in  its  manner  of  invasion,  in  its  course  and  dura- 
tion, in  its  being  relieved  by  emetics,  in  the  anaes- 
thesia and  asphyxia  proclaimed  by  quietude  and 
the  pale  lividity  of  countenance  observed  nine 
hours  before  death ; and  finally,  that  it  was 
typical  in  the  extensive  deposit  of  false-membrane 
in  the  trachea  and;  bronchi. 

In  illustration  of  the  remarks  made  at  the 
beginning  of  this  article  on  the  meanings  of  the 
term  croup,  it  is  well  to  remind  the  reader  that 
Dr.  West's  case,  now  quoted,  will  be  called  croup 
by  French  physicians,  for  they  reserve  that  name 
for  the  manifestation  of  diphtheria  in  the  air- 
passages. 

-ZEtiology. — The  disease  which  Home,  Cheyne, 
West,  Sansom,  and  many  other  older  and  re- 
cent British  authors  of  repute  call  croup,  is  an 
acute  inflammation  of  the  larynx  or  trachea,  or 
of  both,  which,  when  it  runs  its  natural  course, 
generally,  they  say,  terminates  in  membranous 
exudation  on  the  inflamed  mucous  surface.  The 
affection  which  Bretonneau,  Trousseau,  Peter, 
Barthez,  Sanne,  and  the  entire  modern  school  of 
French  physicians,  call  croup,  is  the  membranous 
manifestation  in  the  larynx  and  trachea,  or  in 
both,  of  diphtheria,  a general  asthenic  disease. 
The  French  physicians,  with  whom  agree  George 
Johnson,  Semple,  and  other  British  physicians, 
including  the  writer,  hold  that  membranous  exu- 
dation is  never  a result  of  simple  acute  inflam- 
mation, or,  in  other  words,  that  there  is  no  such 
disease  as  the  croup  of  Home,  Cheyne,  West,  and 


CROUP. 

b.i  usorn,  these  authors  having  blended  two  essen- 
tially different  diseases  in  one  description. 

No  statement  could  have  been  written  intel- 
ligibly in  respect  to  the  aetiology  of  ‘ croup,’  with- 
out these  prefatory  remarks.  The  subject  now 
admits  of  being  very  briefly  disposed  of.  Diph- 
theritic croup,  that  is  to  say,  the  croup  of  French 
authors,  is  considered  in  tho  article  Diphtheria. 
The  common  exciting  causes  of  inflammations  of 
the  larynx  and  trachea  are  exposure  to  chilly 
winds  and  cold  damp  air;  and  the  sudden  tran- 
sitions from  mild  to  cold  wet  weather.  Cold 
wet  places  are  those  in  which  inflammations  of 
the  larynx,  trachea,  bronchi,  and  pulmonary 
parenchyma  are  most  prevalent.  The  much 
greater  frequency  of  these  affections  among 
children  in  the  northern  and  eastern  coasts  of 
Great  Britain  than  in  the  southern  is  attributable 
to  the  greater  rigour  of  the  climate  in  the  former 
regions.  In  some  localities  in  northern  Europe 
inflammation  of  the  air-passages  is  said  to  prevail 
at.  times  among  children  as  au  epidemic.  Perhaps 
a somewhat  exaggerated  impression  exists  as  to 
the  greater  proportion  of  cases  of  inflammation 
of  the  larynx  and  trachea  in  young  children, 
because  in  them  it  generally  causes  stridulous 
breathing.  The  chink  of  the  glottis  being  very 
small  in  young  children  does  not  admit  of  being 
narrowed  by  turgidity  of  the  mucous  membrane 
without  the  causation  of  stridulous  breathing 
to  a greater  or  less  extent.  Even  a slight 
catarrhal  affection  of  the  larynx  and  trachea,  by 
exciting  spasm,  causes  stridulous  or  ‘croupy’ 
breathing  in  a very  young  child,  whereas  a some- 
what acute  inflammation  accompanied  by  con- 
siderable swelling  of  the  same  parts  often  runs 
its  course  in  the  adult  without  producing  noisy 
breathing  or  alarm. 

Treatment. — The  treatment  of  diphtheritic 
croup  is  described  in  the  article  Diphtheria. 

Inflammation  of  the  larynx  and  trachea,  like 
inflammatory  affections  of  the  other  parts  of  the 
air-passages  and  lungs,  requires  to  be  treated  by 
antiphlogistic  measures.  When  the  inflamma- 
tion is  acute,  active  remedies  are  called  for. 
Some  physicians  do  not  hesitate  in  such  cases  to 
bleed  from  the  jugular  vein,  taking  as  much  as 
three  ounces  of  blood  from  a child  two  or  three 
years  of  age.  Others,  including  the  writer,  ab- 
stain from  this  heroic  proceeding,  under  the  con- 
viction that  although  it  often  produces  apparent 
temporary  benefit,  it  is  a benefit  always  fraught 
with  evil.  The  strength  is  dangerously  reduced ; 
a fatal  issue  may  be  precipitated;  and  when 
recovery  does  take  place,  the  course  of  con- 
valescence is  slow  and.  difficult.  It  seems  safer, 
and  every  way  better,  to  Subdue  the  inflamma- 
tion by  blisters  and  carefully  watched  doses  of 
ipecacuan  and  tartar-emetic.  If  the  affection 
be  only  moderately  sthenic,  it  is  prudent  first  to 
use  tho  ipecacuan  by  itself : there  are  many 
cases,  however,  in  which  the  antimonial  must 
not  be  withheld.  Too  large  a dose  of  tartar- 
emetic  may  give  rise  to  alarming  depression. 
Should  such  a stato  be  induced,  the  best  means 
of  averting  danger  is  watchfully  to  administer  a 
little  brandy,  and  apply  a small  blister — say  an 
iuch  and  a half  square — over  the  sternum  about 
tvvo  inches  below  the  manubrium,  a warm  moist 
linseed  poultice  being  placed  over  it  for  three  or 

21 


CROUPOUS,  CROUPY.  :r>l 
four  hours.  Even  when  no  depression  has  been 
occasioned  by  drugs,  a succession  of  small  blis- 
ters to  the  chest  is  of  great  use.  Signal  benefit 
is  often  obtained  by  a short  and  smart  purging 
with  calomel  and  seammony.  In  all  cases,  tho 
legs  must  be  kept  enveloped  in  warm  wrappings, 
moist  warmth  being  preferred  if  it  can  be  un- 
flaggingly  maintained. 

In  most  cases,  the  breathing  is  subject  to 
dyspnceal  paroxysms  arising  from  spasm  of 
the  glottis.  The  muscular  relaxation  which 
follows  the  emetic  action  of  ipecacuan  or 
tartar-emetic  generally  relieves  this  spasm 
with  rapidity  and  for  some  hours.  Tho  vomi- 
tive effort  is  also  useful  in  another  way — in 
clearing  the  air-passages  from  dangerously 
accumulating  mucus,  and  so  admitting  more  air 
into  the  lungs.  When  bronchitis  and  broncho- 
pneumonia are  associated,  as  frequently  happens, 
with  the  laryngeal  and  tracheal  inflammation,  the 
treatment  is  the  same  as  that  which  has  been 
already  described.  In  protracted  cases,  and  in 
weak  children,  it  is  nearly  always  necessary  to 
give,  for  a longer  or  shorter  period,  brandy  or 
some  other  alcoholic  stimulant.  Ammonia  too 
is  generally  indicated.  The  extent  to  which 
stimulants  are  demanded  varies  with  each  case, 
and  also  with  the  varying  circumstances  of  each 
case.  Milk  ought  to  be  the  principal  aliment. 
Beef-tea,  and  arrowroot  made  with  milk  or 
with  brandy,  may  also  be  given  from  time  to 
time. 

Should  diphtheria  bo  prevalent  when  we  have 
under  treatment  cases  of  common  inflammatory 
sore-throat,  we  must  be  specially  on  the  outlook 
for  the  supervention  of  the  former.  Not  in  cases 
of  simple  inflammatory  sore-throat  only,  but  still 
more  in  the  sore-throat  of  scarlatina  and  measles, 
diphtheria  frequently  supervenes  as  a secondary- 
disease,  suddenly  declaring  itself  by  an  exudation 
of  false-membrane  in  the  air-passages.  A new 
principle  of  treatment  must  be  adopted  when 
diphtheria  engrafts  itself  on  the  original  in- 
flammation. Wre  have  then  to  treat  an  asthenic 
general  disease  as  well  as  the  throat-affection. 

The  possibility  of  the  supervention  of  diph- 
theria, with  its  accompanying  prostration  of 
strength  and  dyscrasia  of  the  blood,  is  another 
argument  in  addition  to  those  already  mentioned 
against  the  abstraction  of  blood  in  the  common 
laryngo-tracheal  inflammations  of  yToung  chil- 
dren. 

[The  article  on  Diphtheria  should  be  read  in 
connection  with  this  article.] 

John  Rose  Cokmack. 

CROUP,  FALSE. — A term  commonly  ap- 
plied to  laryngismus  stridulus.  See  Larynx, 
Diseases  of. 

CROUPOUS,  CROUPY  (Seot.  croup, 
to  croak). — These  terms  were  originally  em- 
ployed with  reference  to  the  peculiar  crowing 
or  stridulous  character  of  the  respiration,  cough, 
and  voice  in  certain  affections  of  the  larynx, 
and  signified  ‘ belonging  to  croup’  in  its  clini- 
cal relations ; for  example,  ‘ croupy  cough,’ 
‘croupous  symptoms.’  When  morbid  anatomy 
demonstrated  the  occurrence  of  a fibrinous  exu- 
dation or  false  membrane  upon  the  affected 


322  CROUPOUS,  CROUPY. 
surface  in  a special  form  of  croup,  the  word 
1 croupous  ’ was  used  also  to  designate  this  false 
membrane ; thus,  1 croupous  exudation  ’ and 
‘ croupy  membranes.’  The  application  of  the 
term  was  afterwards  further  extended;  and  it 
is  now  employed  to  indicate  the  process  that 
leads  to  a fibrinous  exudation  in  any  situation 
whatever;  such  as  ‘croupous  inflammation,’  and 
1 croupous  pneumonia.’  Thus  the  words  “ crou- 
pous ’ and  ‘ croupy,’  which  were  originally  asso- 
ciated with  peculiar  -ounds,  have  come  in  a 
remarkable  manner  to  express  certain  physical, 
chemical,  and  microscopical  characters  in  the 
products  of  inflammation.  See  Croup,  Diph- 
theria, and  Inflammation. 

CROWING  CONVULSION. — A popular 
synonym  for  laryngismus  stridulus.  See  Larynx, 
Diseases  of. 

CRURA  CEREBRI,  Lesions  of. — Prom 

anatomical  and  physiological  considerations  we 
should  be  prepared  to  find  that  a solution  of 
continuity  of  the  crus  cerebri  would  interrupt 
the  sensory  and  motor  tracts  for  the  opposite 
side  of  the  body.  And,  further,  as  the  roots  of 
the  third  nerve  pass  through  the  inner  aspect  of 
the  crus  to  their  nucleus  underneath  the  aque- 
duct of  Sylvius,  there  is  considerable  danger 
of  their  being  implicated  in  a lesion  of  the 
crus. 

Hence  we  should  expect,  in  consequence  of 
such  a lesion,  a form  of  alternate  paralysis,  viz., 
oculo-motor  paralysis  on  the  side  of  lesion,  and 
paralysis  of  voluntary  motion  and  sensation  on 
the  opposite  side.  A typical  instance  of  this 
form  of  paralysis  has  been  put  on  record  by 
Weber  (Med.  Clin.  Trans.  18C3).  In  this  case 
there  was  oculo-motor  paralysis  on  the  side  of 
lesion,  and  complete  paralysis  of  voluntary 
motion  and  partial  paralysis  of  sensation  on 
the  opposite  side.  The  partial  escape  of  the 
sensory  tracts  is  accounted  for  by  the  fact  that 
the  sensory  tracts  are  situated  more  to  the  outer 
and  back  part  of  the  crus,  and  hence  tend  to 
escape  destruction  from  a lesion  situated  in  such 
a position  as  specially  to  endanger  the  conti- 
nuity of  the  third  nerve. 

Vaso-motor  paralysis  on  the  hemiplegic  side 
also  occurs  in  a marked  degree,  and  the  tem- 
perature of  the  paralysed  side  may  be  two  or 
three  degrees  above  that  of  the  other. 

D.  Ferrier. 

CRUSTA  LACTEA  ( crusta , a crust,  and 
lactea,  milk-like) ; milk-crust  — A synonym  for 
eczema  pustulosum  of  the  face  and  head,  met 
with  in  infants  at  the  breast.  See  Eczema. 

CRUVEILHIER’S  PARALYSIS.  — A 

synonym  for  progressive  muscular  atrophy.  See 
Muscular  Atrophy,  Progressive. 

CUPPING. — This  is  a mode  of  treatment 
sometimes  employed  to  relieve  congestion  or  in- 
flammation of  internal  parts  by  drawing  blood 
to  the  surface  of  the  body.  When  the  blood 
thus  attracted  to  the  superficial  parts  is  actually 
abstracted  from  the  body  by  means  of  incisions, 
the  operation  is  called  icrf-cupping,  and  this  has 
been  described  in  the  article  Blood,  Abstraction 
of.  Wo  shall  here  describe  dr§/- cupping,  in 


CUTIS  PENDULA. 

which  no  scarifications  are  made,  the  blood  being 
simply  drawn  towards  the  surface  by  atmospheric 
exhaustion,  hypertemia  of  the  subcutaneous  parts 
or  organs  being  thereby  relieved. 

Formerly  cupping  was  extensively  practised, 
but  of  late  years  it  has  fallen  into  disuse.  In 
some  respects  it  serves  the  purpose  of,  but  has  a 
more  powerful  effect  than,  counter-irritants ; 
rapid  and  marked  results  being  sometimes  pro- 
duced upon  the  circulation  of  inflamed  or  ecu 
gested  tissues. 

Modes  of  Application. — Dry  cupping  is  per 
formed  as  follows  : — The  flame  of  a spirit-lamp, 
being  allowed  to  burn  for  an  instant  in  the 
dome  of  a cupping-glass,  is  quickly  withdrawn, 
and  the  cup  is  then  rapidly  and  evenly  applied 
to  the  skin  over  the  affected  part.  The  heat 
expands  the  air  contained  in  the  glass  cupola, 
and,  owing  to  the  contraction  which  ensues 
on  cooling,  the  skin  is  forcibly  sucked  up  into 
the  cup.  It  is  well  first  to  sponge  the  skin  of 
the  selected  spot  wdth  hot  water,  so  as  to  render 
it  more  supple  and  vascular ; slightly  moistening 
the  rim  of  the  cupping-glass  helps  to  increase  the 
degree  of  exhaustion. 

An  excellent  modification  of  cupping,  which 
has  been  demonstrated  to  the  writer  by  Dr. 
Quain,  is  practised  in  the  following  way:  — 
Instead  of  allowing  the  cup  to  remain  station- 
ary after  its  application  to  the  skin,  as  is  usual, 
the  operator  dexterously  slides  it  to  and  fro  along 
the  surface.  When  the  operation  is  to  be  thus 
performed  the  amount  of  surface  drawn  into  the 
glass  must  not  be  considerable.  In  this  way  a 
large  tract  of  skin  may  be  quickly  rendered 
hyperaemic  without  effusion  of  blood  into  its 
meshes,  as  happens  when  the  cups  are  stationary. 

Precautions.  — Cupping-glasses  should  be 
applied  where  the  skin  is  thick  and  cushiony,  as 
over  the  loins,  nape  of  the  neck,  pectoral  region 
of  the  chest,  &e.,  and  not  where  bony  promi- 
nences, or  other  irregularities,  are  likely  to  in- 
terfere with  complete  exhaustion.  The  edges  of 
the  glasses  should  not  be  so  hot  as  to  burn  the 
skin. 

Uses. — Cupping  may  be  advantageously  em- 
ployed in  sthenic  cases  of  cerebral  congestion,  tho 
cups  being  applied  to  the  nape  of  the  neck ; 
in  hypersemiaof  the  spinal  cord;  and  in  inflamma- 
tion or  congestion  of  the  lungs,  kidneys,  or  other 
viscera.  In  renal  ischaemia  it  is  eminently  ser- 
viceable. This  may  be  owing  to  the  fact  that 
the  blood  supply  of  the  skin  of  the  loins  is 
in  intimate  relation  with  that  of  the  kidneys  ; 
the  vascular  supply  to  those  organs  being  thus 
directly  and  immediately  influenced. 

Alfred  Wiltshire. 

CUTIS,  Diseases  cf.  See  Skin,  Diseases  of, 

CUTIS  ANSERINA  (cutis,  the  skin,  and 
anser,  a goose).  A state  of  roughness  of  the 
skin,  resembling  that  of  a goose  when  plucked, 
produced  by  prominence  of  the  pores  or  fol- 
licles. It  is  due  to  contraction  of  the  muscular 
structure  of  the  cerium,  and  is  commonly  occa- 
sioned by  cold. 

CYANIDES,  Poisoning  by. — See  Anti- 
dote ; and  Prussic  Acid,  Poisoning  br. 


CYANOSIS. 

CYANOSIS  ( Kvavbs , blue). — This  \yhich  is 
;eally  not  a disease,  refers  to  the  peculiar  blue 
or  more  or  less  livid  colour  of  the  surface  of  the 
body,  especially  in  certain  parts,  which  is  ob- 
served in  several  affections  that  interfere  with 
the  circulation  and  oxygenation  of  the  blood.  The 
condition  is  most  commonly  associated  with,  and 
reaches  its  highest  development  in  certain  forms 
of  congenital  malformation  of  the  heart,  for  which 
consequently  cyanosis  is  not  uncommonly  used 
as  a synonym.  Lesser  degrees  of  similar  dis- 
colouration are,  however,  not  infrequently  noticed 
in  cases  of  cardiac  disease  developed  after  birth, 
and  they  may  also  accompany  pulmonary  affec- 
tions which  materially  obstruct  the  circulation  ; 
a cyanotic  appearance  is  also  one  of  the  obvious 
effects  resulting  from  all  modes  of  suffocation, 
and  it  is  observed  in  the  collapse-stage  of  cho- 
lera. The  upper  half  of  the  body  may  become 
extremelycyanotic  as  the  result  of  obstruction  of 
the  superior  vena  cava.  For  the  pathology  of 
cyanosis,  see  Heart,  Malformations  of. 

CYNABTCHE  (/«W,  a dog,  and  tcyxw,  I 
strangle).  Synon.  : Hr.  Angvne ; Ger.  die  Breiune. 

This  word  is  used  to  express  an  inflammatory 
condition  of  the  throat,  or  contiguous  parts,  in 
which  difficulty  of  breathing  or  of  swallowing 
exists,  accompanied  by  a sense  or  feeling  of 
choking.  The  term  is  used  synonymously,  more 
frequently  on  the  Continent  than  in  England, 
with  Angina  ; an  affix,  indicative  of  the  seat  or 
nature  of  the  affection,  being  employed  as  a desig- 
nation for  each  of  the  several  forms  or  varieties 
of  disease  affecting  the  throat  or  adjacent  parts. 
Such,  for  example,  are  the  terms  Cynanehe 
laryngea,  or  croup;  Cynanehe  maligna , or  malig- 
nant sore-throat;  Cynanehe  parotidea,  or  mumps  ; 
Cynanehe  pharyngea,  or  inflammation  of  the 
pharynx ; and  Cynanehe  tonsillaris , or  quinsy. 
See  these  several  diseases. 


CYETOMETEH  (ki ipros,  a curve,  and  gerpov, 
a measure). — An  instrument  for  measuring  the 
absolute  and  relative  dimensions  of  the  chest- 
wall.  See  Physical  Examination. 

CYSTICERCUS  {Kusrts,  a bladder,  and 
i cepuos,  a tail). — Description. — Cysticercus  is  a 
bladderworm  furnished  with  a head,  which  is  dis- 
tinctly visible  to  the  naked  eye.  The  form  usually 
found  in  man  is  specifically  identical  with  the 
so-called  pork-measle,  or 
Cysticercus  {tela)  celluloses. 

According  to  Dr.  Giacomiti, 
however,  the  human  measle 
commonly  displays32  cepha- 
lic hooks,  whilst  the  pork- 
measle  carries  21;  more- 
over, in  the  human  variety 
there  is  a greater  adhe- 
rence of  the  measle  to  its 
investing  capsule.  The  only 
other  form  of  cysticercus  at 
present  known  to  infest  the  (telce)ceUulosce, removed 
human  body  is  the  slender- 

necked  bladder  - worm,  or  ters.  After  Allen Thom- 
Cysticercus  tenuicollis.  An  son- 
alleged  example  is  preserved  in  the  anatomical 
museum  attached  to  King’s  College,  London.  This 
parasite  is  of  frequent  occurrence  in  the  sheep. 


Fig.  14. — Cysticercus 


CYSTIC  EKCUS.  326 

Situations  and  Symptoms. — The  clinical  im- 
portance of  the  human  measle  is  chiefly  dm 


Fig.  13. — Portion  of  measled  pork,  showing  Custicerci. 

Nat.  size.  After  Lewis. 

to  the  circumstance  that  it  is  apt  to  take  up  its 
residence  in  the  brain  and  eye ; those  parasites 
occupying  the  cerebrum  being  for  the  most  part 
situated  in  the  grey  or  cortical  substance. 
The  only  serious  attempt  that  has  been  made 
to  establish  diagnostic  signs  by  which  brain- 
cysticerci  might  be  detected  during  life  is  that 
initiated  by  Griesinger,  who  based  his  conclusions 
on  data  supplied  by  the  histories  of  upwards  of 
fifty  cases.  Symptoms  are  exceedingly  variable. 
In  some  cases  they  are  altogether  wanting;  in  a 
second  set,  epilepsy  exists,  without  mental  dis- 
turbance ; in  a third  set,  epilepsy  is  accompanied 
with  mania  or  imbecility ; in  a fourth  set,  mental 
disturbance  may  occur  without  epilepsy;  whilst 
in  another  group  there  is  neither  epilepsy  nor 
mental  disturbance,  until  shortly  before  death, 
wThen  symptoms  of  irritation  or  torpor  gradually 
supervene.  Since  Griesinger  has  himself  re- 
marked that  the  epileptiform  seizures  due  to  cys- 
ticercus are  in  all  respects  like  ordinary  cerebral 
epilepsy,  and  since  also  ‘ the  psychical  disturb- 
ances have  nothing  characteristic  about  them,' 
the  practical  physician  is  naturally  tempted  to 
conclude  that  diagnosis  and  curative  treatment 
are  alike  impracticable.  The  writer,  however,  ob- 
jects to  that  inference,  on  grounds  too  wide  for  dis- 
cussion here ; but,  as  one  source  of  encouragement 
calls  attention  to  the  fact  that  cj'sticerci  are  not 
very  long-lived.  He  has  demonstrated  that  a 
period  of  eight  months  is  amply  sufficient  for  the 
setting  in  of  calcareous  degeneration,  a process 
which  involves  the  speedy  death  of  the  measle. 
If  therefore  the  presence  of  eysticerci  be  so 
much  as  suspected  in  the  brain,  the  prospect  of 
a natural  cure  is  by  no  means  hopeless.  Best, 
both  mental  and  corporal,  would  of  course  tand 
to  assist  nature’s  efforts. 

Cysticerci  may  develop  in  any  part  of  the 
human  body ; their  most  frequent  situation 
being  the  subcutaneous,  areolar,  and  intermus- 
cular connective  tissues.  Amongst  the  more 
remarkable  cases  are  five  recorded  by  Heller, 
and  one  by  Greenhalgh,  where  they  occupied 
the  lip  ; by  Fournier,  where  several  occurred  in 
a boil ; and  one  by  Dupuytren,  where  the  parasite 
lodged  in  the  great  peroneus  muscle.  Mr.  R. 
Davy  lately  recorded  a case  in  which  several  were 
present  in  the  arm ; hut  the  well-known  mul- 
tiple cases  given  by  Giacomini,  Hodges,  Delore, 
and  others,  show  that  hundreds  of  measles  may 
co-exist  in  the  same  human  host.  In  Delore’s 


i2  4 CYSTICERCUS. 

case  there  were  about  2,000,  of  which  no  less 
than  84  were  found  in  the  cerebrum!  Of  in- 
stances where  the  cysticercus  occupied  the  eye  we 
may  particularise  the  cases  by  Windsor,  Logan, 
Estlin,  Rose,  and  Mackenzie  of  Glasgow;  whilstof 
additional  brain-cases,  those  given  by  J.  Harley, 
Hulke,  Burton,  Bouvier,  Er&dault,  and  Toynbee 
are  particularly  noteworthy. 

Amongst  the  most  recent  contributions  to 
our  knowledge  of  cysticerci  are  the  memoirs  of 
Perroncito  ( Della  panicatura  negli  animali,  in 
Annali  del.  R.  Acead.  d’Agricolt.  di  Torino, 
1872);  of  Beeoulet  and  Giraud  (Bull,  de  la  Soc. 
Med.  de  Gand,  1872),  of  Giacomini  (Sul.  Cyst, 
cell,  hominis  e sulla  Tania  med.  &e.,  1874),  of 
Lewis  (Report  on  Bladderworms,  &e.,  1872), 
and  of  Pellizzari,  as  reported  by  Dr.  Tommasi 
in  his  Italian  edition  of  the  writer’s  manual 
of  the  parasites  of  our  domesticated  animals 
(Appendice  Parasiti,  &c.  Vermi,  1874).  A sum- 
mary of  these  last-mentioned  researches  was 
given  by  the  writer  in  the  Bond.  Med.  Record 
for  1874:  (p.  641).  Lastly,  it  is  important  to 
bear  in  mind  that  small  hydatids,  which  are 
also  liable  to  take  up  their  abode  in  the  brain, 
may  very  readily  be  mistaken  for  cysticerci, 
after  death;  and  during  life  they  are  apt  to  give 
rise  to  precisely  similar  symptoms.  The  writer 
has  collected  records  of  more  than  thirty  cases 
where  bladderworms  occurred  in  the  human 
brain.  References  to  most  of  these  are  given 
in  the  Bibliography  of  his  Introduction  to  the 
study  of  Helminthology  (Entozoa,  1864 ; and 
Supplement,  1869).  See  Bladdekworms. 

T.  S.  C'OBBOI-D. 

CYSTINE  or  CYSTIC  OXIDE  &rii, 
the  bladder).- — A peculiar  substance  occurring 
either  in  solution  or  in  the  form  of  small  crystals 
in  the  urine,  or  as  calculi  in  the  urinary  passages. 
See  Urine  and  Calculi. 

CYSTITIS  (kvotis,  the  bladder). — Inflam- 
mation of  the  bladder.  See  Bladder,  Diseases  of. 

CY STS.— Definition. — The  word  cyst  (kvotis, 
the  urinary  bladder)  is  used  in  pathology  for  a 
closed  cavity  containing  fluid  or  soft  matter.  The 
nature  of  the  'wall  is  unimportant ; it  may  be 
newly  formed  or  a pre-existent  structure.  The 
objects  thus  defined  differ  much  among  them- 
selves, and  are  associated  together  rather  from 
convenience  than  on  account  of  any  real  patho- 
logical similarity. 

Classification. — Cysts  may  be  classified  ac- 
cording to  their  structure,  as  simple  or  com- 
pound ; according  to  their  contents,  as  serous, 
mucous,  fatty,  etc.;  or  according  to  their  mode  of 
origin.  The  latter,  though  not  free  from  objec- 
tion, is  the  basis  of  description  which  will  be 
here  adopted.  Cysts  may  originate  (1)  from 
dilatation  of  previously  existing  closed  cavities ; 
(2)  from  retention  of  products  of  secretion  ; (3) 
from  exudation,  or  the  metamorphosis  of  exuded 
products  ; (4)  as  a part  of  new-growth ; (5)  by  a 
vice  of  development ; and,  finally,  (6)  from  the 
growth  of  parasites. 

1.  Cysts  from  Dilatation. — Spaces,  normal 
or  newly  formed,  in  connective  tissue  may,  by  irri- 
tation and  consequent  excessive  exudation,  be  con- 
verted into  cysts;  or  the  same  result  may  happen 


CYSTS. 

from  the  confluence  of  several  such  spaces.  In 
proportion  as  the  wall  becomes  smooth,  and  the 
shape  uniform,  they  may  be  called  cysts.  Bursae, 
whether  normal  or  pathological,  are  cysts. 
Ganglion  in  the  sheath  of  tendon  is  clearly  a 
pathological  cyst.  To  these  and  like  structures 
the  name  Hygroma  has  been  given.  They  all 
contain  clear  serous  fluid,  and  are  lined  by  an 
endothelium.  Hydrocele,  or  dilatation  of  the 
tunica  vaginalis  testis — an  affection  probably 
always  due  to  a low  form  of  inflammation — is 
another  instance.  One  class  of  ovarian  cysts 
comes  under  this  head,  those,  namely,  which  arc 
due  to  simple  dropsy  of  the  Graafian  vesicle. 
Tubo-ovarian  dropsy  has  the  same  explanation ; 
and  cysts  of  the  broad  ligament  are  enlargements 
of  normal  structures  which  are  left  as  relics  of 
the  development  of  the  ovary.  The  thyroid  gland 
seems  from  its  structure,  containing,  as  it  does, 
so  many  closed  follicles,  particularly  disposed  to 
this  kind  of  cyst-formation,  and  this  is  doubtlesu 
the  explanation  of  bronchocele. 

2.  Cysts  from  Retention. — Cystic  formations 
may  result  from  the  obstruction  of  the  natural 
outlet  of  a secreting  organ,  and  tho  consequent 
retention  of  secretion.  It  is  necessary  that  the 
walls  of  the  secreting  cavity  should  admit  of 
enlargement,  and  that  the  tension  should  not 
become  so  great  as  to  check  secretion. 

All  secreting  glands  present  instances  of  such 
cysts.  The  sebaceous  glands  of  the  skin  are  par- 
ticularly liable  to  obstruction  of  their  duct,  and 
in  this  way  are  formed  sebaceous  cysts,  miliaria, 
and  comedones  ; the  contents  of  which  are  some- 
times epithelium  and  the  products  of  normal 
secretion,  sometimes  abnormal  products,  such  as 
pus.  See  Eolliculab  Diseases. 

The  glands  or  mucous  surfaces  are  liable  to 
similar  obstructions,  and  mucous  cysts  result,  such 
as  are  sometimes  seen  in  the  mouth.  Larger 
cysts  in  the  mouth  ( ranula ) result  from  the 
obstruction  of  the  ducts  of  the  salivary  glands, 
or  are  perhaps  connected  with  an  abnormal  pro- 
duction of  gland-substance.  The  stomach  very 
frequently,  other  parts  of  the  intestinal  canal 
more  rarely,  show  similar  cysts,  which,  when  they 
project  and  become  complicated  in  structure, 
are  called  polypi.  They  are  occasionally  seen  on 
the  larynx  and  trachea.  In  no  part  are  mucous 
cysts  more  frequent  than  in  the  uterus,  where 
indeed,  similar  formations,  the  oval  a Xahothi, 
must  be  regarded  as  normal.  The  varieties  here 
met  with  have,  as  Virchow  has  pointed  out,  a 
close  analogy  with  the  various  forms  of  retention- 
cysts  in  the  skin. 

In  the  mamma,  cysts  may  result  from  the  cut- 
ting off  of  portions  of  the  gland-follicles,  but  the 
cysts  contained  in  mammary  tumours  are  not 
always  formed  in  this  way,  some  being  part  of  new 
growths.  In  the  testicle  obstruction  and  cutting 
off  of  seminiferous  tubes  may  lead  to  small  cysts, 
but  these  are  more  often  connected  with  new- 
growths.  The  curious  cysts  known  as  sperma- 
tocele, containing  spermatozoa,  appear  to  arise 
from  a similar  distension  of  detached  portions  of 
testicle-substance,  which,  byr  an  error  of  develop- 
ment, have  failed  to  become  connected  with  the 
excretory  duets.  The  testicle  is  also  liable  to  a 
general  cystic  degeneration,  usually  called  cysto- 
sarcoma.  Cysts  of  the  kidney  are  of  various 


CYSTS. 


kinds,  but  many,  no  doubt,  both  large  and  small, 
result  from  the  dilatation  of  uriniferous  tubules 
and  capsules  of  glomeruli  when  their  outlet  is 
obstructed,  as  occurs  in  the  cirrhotic  form  of 
Bright’s  disease.  The  origin  of  the  very  nume- 
rous microscopic  cysts  has  been  much  disputed. 
The  writer  inclines  to  the  belief  that  they  arise 
from  moniliform  contraction  of  the  uriniferous 
tubes,  especially  such  as  contain  the  hyaline 
cylinders,  known  as  fibrinous  casts.  Another  form 
of  cystic  disease  of  the  kidney  is  developmental. 
In  this  the  whole  of  the  organ  is  converted  into 
a mass  of  cysts,  and  is  usually  much  enlarged. 
This  condition  may  be  congenital,  and  the  organ 
may  be  so  large  as  to  obstruct  parturition.  It 
is  attributed  by  Virchow  to  inflammation  of  the 
calyces  during  intra-uterine  life. 

To  guard  against  a common  error  of  language, 
it  should  be  pointed  out  that  the  condition  of  the 
kidney  which  results  from  the  obstruction  of  the 
ureter,  or  of  the  urinary  passages  lower  down, 
though  sometimes  called  cystic  dilatation  of  the 
aidney,  is  not  properly  a case  of  cyst-formation, 
and  is  better  called  hydronephrosis. 

3.  Cysts  from  Exudation. — Exuded  ma- 
terials, such  as  blood  and  inflammatory  products, 
may,  by  a process  of  degeneration,  central 
softening,  and  external  fibrous  formation,  become 
converted  into  imperfect  cysts,  as  is  seen  in  the 
metamorphosis  of  a blood-clot  in  the  brain,  and 
in  the  termination  of  some  abscesses.  But  since 
the  accumulation  of  fluid  does  not  go  on  con- 
tinually, the  tension  in  such  cavities  is  slight, 
and  they  do  not  approximate  to  a globular 
shape. 

4.  Cysts  from  Hew- Growth. — In  many 
forms  of  new-growth  cysts  are  produced,  but 
not  always  in  the  same  way.  Sometimes,  as 
in  myxoma  and  enehondroma,  they  result  from 
softening  of  portions  of  new-growth  already 
formed.  In  many  sarcomata,  the  production  of 
new  tissue  goes  hand  in  hand  with  that  of  cysts, 
and  is  sometimes  effected  as  in  glandular  organs, 
by  the  formation  of  new  follicular  structures 
without  an  outlet,  sometimes  by  new-growth 
into  the  dilated  cavities.  Polypoid  or  pedun- 
culated growths  on  a free  surface  may  some- 
times, by  the  fusion  of  their  extremities,  en- 
close spaces  which  become  converted  into  cysts. 
We  do  not,  however,  find  cysts  forming  by  them- 
selves a new-growth  of  so  definite  a character  as 
to  deserve  a separate  name. 

5.  Developmental  Cysts. — These  include  («) 
compound  ovarian  cysts  ; (h)  dermoid  cysts.  Cysts 
are  met  with  in  the  ovary  which  come  under 
none  of  the  definitions  just  given,  viz.,  the  so- 
called  compound  multilocular  cysts,  which  con- 
stitute the  well-known  formidable  cystic  disease 
of  the  ovary,  and  sometimes  produce  tumours 
of  immense  size.  In  these  the  originally  simple 
primary  cyst  appears  to  become  complicated  by 
the  formation  in  its  walls  of  secondary  cysts, 
which  may  encroach  upon  or  project  into  the 
primary.  Again  there  may  be  papillary  growths 
starting  from  the  inner  wall  of  the  primary  cyst, 
which  either  fill  it  up,  or  by  fusion  enclose 
spaces,  which  become  secondary  cysts.  Very  com- 
plicated structures  thus  result.  The  contents 
may  vary  in  consistence  and  colour,  from  clear, 
pale,  albuminous  liquid  to  gelatinous  matter,  and 


326 

may  be  stained  through  haemorrhage,  or  purulent 
through  inflammation.  The  origin  of  these  struc- 
tures, which  have  no  precise  parallel  in  other  parts 
of  the  body,  is  extremely  obscure.  It  is  not  even 
certain  whether  the  primary  cysts  commence, 
as  might  seem  prima  facie  highly  probable, 
in  the  Graafian  follicles ; hut  they  are  plainly  due 
to  an  error  of  development,  pcssibly  beginning 
in  early  intra-uterine  life,  and  are  not  set  up  by 
any  external  causes.  The  presence  of  a tubular 

f land-tissue,  such  as  is  found  in  the  rudimentary, 
ut  not  in  the  perfect  ovary,  confirms  this  view, 
by  throwing  cy'st-formation  back  into  an  early 
stage  in  the  development  of  the  organ. 

In  another,  but  rarer  form  of  cystic  disease 
of  the  ovary',  equally  due  to  an  error  of  develop- 
ment, and  sometimes  congenital,  the  whole 
organ  is  found  converted  into  a mass  of  small 
cysts,  with  no  striking  inequality  of  size.  This 
variety  resembles  one  form  of  cystic  disease  in 
the  testicle  and  kidney. 

Dermoid  cysts  are  those  containing  seba- 
ceous matter,  and  which  are  lined  by  a layer  of 
flat  cells  resembling  epidermis.  The  wall  may 
be  complicated  with  connective  tissue,  forming 
papillae  resembling  those  of  true  skin,  and  may 
contain  hairs,  sebaceous  glands,  either  in  con- 
nection with  them  or  unattached,  and  sudori- 
parous glands.  The  accumulation  of  fatty  matter 
within  the  cysts  is  doubtless  the  result  of  the 
continuous  activity  of  the  sebaceous  glands, 
the  products  of  which  cannot  escape.  Large 
masses  of  hair  may  also  be  found,  from  con- 
tinuous growth,  and  there  are  often  numerous 
detached  epidermic  scales.  Such  a cyst  has 
only  the  characters  of  a portion  of  skin,  which 
might  be  imagined  invested  and  included  by 
the  growth  of  the  surrounding  parts  in  an 
early  stage  of  development  — an  explanation 
formerly'  entertained. 

These  simple  dermoid  cysts  are  sometimes 
complicated  by  containing  teeth,  it  may  be  in 
very  large  numbers  ( dentigerous  cysts),  but 
since  teeth  may  also  be  regarded  as  cutaneous 
products,  the  cyst  may  still  have  originated 
in  the  skin.  This  explanation  no  longer  holds, 
however,  when  masses  of  bone  are  found, 
sometimes  serving  for  the  attachment  of  teeth, 
sometimes  separate ; as  well  as  other  tissues,  e.g. 
nervous  tissue  and  striated  muscle.  Cysts  with 
this  variety  of  contents  have  been  called  proli- 
ferative. Dermoid,  dentigerous,  and  proliferative 
cysts  appear  to  be  always  congenital  structures, 
but  may  show  further  growth  and  development 
in  after-life.  At  least  two-thirds  of  the  known 
cases  have  occurred  in  the  ovaries.  Next  to 
these  organs,  the  testicles  are  the  most  frequent 
seat,  but  these  cysts  have  been  also  found  in 
other  parts  of  the  body-cavity,  in  the  medias- 
tinum, lung,  and  even  within  the  skull.  The 
origin  of  these  growths  is  extremely  obscure ; 
but  it  is  desirable  to  reject  entirely  the  hypothesis 
that  a mixod  tumour  of  this  kind  can  be  tho 
remains  of  an  undeveloped  foetus  included  in 
the  perfect  individual ; a hypothesis  rendered 
improbable  by  the  extreme  irregularity  of  the 
tissues  produced,  the  teeth,  for  instance,  some- 
times numbering  one  hundred  or  more.  It 
would  rather  appear  as  if  a portion  of  embryonic 
tissue,  from  the  uppor  and  middle  germinal 


326  CYSTS. 

layers,  became  misplaced  at  an  early  period  of 

development. 

6.  Parasitic  Cysts. — Several  parasitic  ani- 
mals infesting  the  human  body  may  appear  in  an 
encysted  form,  and  may  resemble  in  appearance 
true  pathological  cysts.  The  commonest,  the 
larval  form  of  Tenia  echinococcus , or  hydatid 
cyst,  is  known  by  its  laminated  -wall,  and  by 
containing  a fluid  which  is  not  albuminous, 
but  holds  in  solution  sodium  chloride.  Cysticercus 
cellulose  has  a transparent  wall  and  clear 
contents.  The  other  encysted  parasites  are 
cither  very  small,  as  Trichina  spiralis,  or  unim- 
portant. 

, Contents  op  Cysts.— The  serous  cysts  and 
hygromata  contain  an  albuminous  fluid  like  that 
of  serous  cavities,  which  may  hold  enough  fibri- 


DEATH,  MODES  OE. 

nogenous  material  to  coagulate  spontaneously 
Leucocytes  may  also  be  present.  If  inflammation 
be  set  up,  the  proportion  of  albumin  and  of  leuco- 
cytes becomes  greatly  increased.  In  the  fluid  of 
mucous  cysts  mucin  is  contained;  in  that  of 
colloid  cysts,  little-known  substances  which  are 
allied  to  gelatin.  Sebaceous  cysts  contain  neutral 
fats — sometimes  hard,  sometimes  fluid,  and 
cholesterin.  Both  mucous  and  sebaceous  products 
may  harden  into  concretions,  and  even  become 
calcareous.  In  renal  cysts  urea  has  been  found  ; 
in  biliary  cysts,  bile-pigment;  and  in  general  the 
products  of  special  secretion  may  be  found  in 
cases  of  retention,  at  least  in  early  stages,  but 
if  retention  last  too  long,  special  secretion  may 
cease.  Various  exceptional  contents  have  beer, 
already  enumerated.  J,  F.  Payne. 


D 


DACTYLITIS  (ScIktuAos,  a finger). — A term 
meaning  inflammation  of  the  finger.  It  is  ap- 
plied to  syphilis  and  struma  of  that  organ,  as 
in  the  terms  dactylitis  syphilitica,  and  dactylitis 
strumosa. 

DAWDRITF,  or  Dandruff  (from  two  Saxon 
words  signifying  itchiness  and  foulness). — Synon.  : 
Furfur;  Scurf  of  the  Head. — DandrifF  is  met 
with  in  pityriasis,  chronic  eczema,  and  lepra 
vulgaris  or  psoriasis  of  the  scalp. 

DANDY  TEVER. — A synonym  for  Dengue. 
See  Dengue. 

DARTRE  (Fr.). — This  term  is  the  French 
equivalent  of  the  word  tetter,  and  is  applied  to  a 
variety  of  cutaneous  diseases,  without  strict  limi- 
tation. 

DA  VOS,  in  North  Engadine,  Switzerland. 
A dry,  cold,  bracing,  winter-climate.  Altitude, 
5,177  feet.  Season,  October  to  March.  Winds, 
N.E.  and  S.  Sea  Climate,  Treatment  of  Dis- 
ease by. 

DAY-BLINDNESS. — A disorderof  vision, 
characterised  by  the  patient  being  unable  to  see 
during  the  day : also  called  Nyctalopia.  See 
Vision,  Disorders  of. 

DEAFNESS. — Loss  of  the  sense  of  hearing. 
See  Ear,  Diseases  of,  and  Hearing,  Disorders  of. 

DEATH,  Modes  of. — The  proximato  causes 
of  death,  whether  resulting  from  natural  decay, 
disease,  or  violence,  may  be  reduced  in  ultimate 
analysis  to  two,  namely,  first,  cessation  of  the  cir- 
culation; and,  second,  cessation  of  respiration. 
On  the  continuance  of  these  functions,  and  par- 
ticularly of  the  former  (if  specialisation  is  pos- 
sible where  all  are  essential)  life  of  the  body  as 
i whole,  or  of  the  individual  tissues  and  organs, 
depends.  These  functions  may  cease  from  causes 


directly  operating  on  their  mechanism,  but  they 
may  also  be  brought  to  a standstill  by  causes 
operating  indirectly  through  the  nerve-centres 
which  regulate  them.  Hence  it  is  usual,  in 
accordance  with  Bichat’s  classification,  to  de- 
scribe this  as  a third  mode  of  death ; so  that 
we  speak  of  death  beginning  at  the  heart,  death 
beginning  at  the  lungs,  and  death  beginning  at 
the  head.  This  classification  is  convenient ; for 
though  death  beginning  at  the  head  is,  in  realitv, 
death  from  failure  of  the  respiration  or  circula- 
tion, or  of  both,  through  paralysis  of  the  vital 
nerve-centres,  yet  the  affection  of  the  nervous 
system  is  the  primary  fact,  and  the  phenomena 
are  sufficiently  distinct  and  characteristic  to 
require  separate  consideration.  It  must,  how- 
ever, always  be  borne  in  mind  that,  owing  to  the 
interdependence  of  all  the  vital  functions,  there 
is  no  such  sharp  line  of  demarcation,  in  reality, 
as  we,  for  convenience’  sake,  make  in  theory  be- 
tween the  various  modes  of  death. 

I.  Death  from  failure  of  the  Circulation. 
— This  may  be  (1)  sudden,  as  in  syncope  and 
shock  ; or  (2)  gradual,  as  in  asthenia. 

(1)  Sudden  failure  of  the  Circulation. — As  the 
circulation  of  the  blood  depends  on  the  differ- 
ence in  the  pressure  in  the  arteries  and  veins, 
the  circulation  will  be  brought  to  a standstill  by 
any  cause  which  annihilates,  or  very  greatly 
lowers,  this  differential  pressure.  The  cause  may- 
be in  the  heart,  or  in  the  vessels,  or  in  both. 

(«)  In  the  heart.  As  the  action  of  the  heart 
is  the  chief  factor  in  the  maintenance  of  arte- 
rial tension,  any  organic  or  structural  disease 
of  the  heart,  rendering  it  incapable  of  propelling 
its  contents  into  the  arterial  system,  will  natu- 
rally result  in  cessation  of  the  circulation  and 
death.  Under  this  general  head  are  to  be 
classed  all  diseases  of  the  heart  and  its  annexes 

But  apart  from  structural  disease,  the  heart 
may  suddenly  be  made  to  cease  through  nervous 


DEATH,  MODES  OF. 

influence.  The  heart  may  be  inhibited,  or  be 
made  to  cease  finally  and  for  ever  either  by 
central  causes,  such  as  violent  emotion,  or  a 
blow  on  the  head  ; or  by  reflex  inhibition,  as  in 
the  case  of  a violent  blow  on  the  epigastrium, 
or  sudden  irritation  of  the  sensory  nerves  of 
the. stomach,  as  in  corrosive  poisoning,  and  even 
in  the  ingestion  of  a large  draught  of  cold 
water  when  the  system  is  overheated. 

Death  from  sudden  cessation  of  the  heart’s 
action  is  death  from  syncope.  Momentary  ces- 
sation of  the  heart’s  action  is  transient  syncope 
or  fainting.  There  is  sudden  loss  of  conscious- 
ness, due  mainly  to  the  cessation  of  pressure  in, 
and  anaemia  of  the  cerebral  centres. 

(Z>)  In  the  vessels.  Rapid  fall  of  the  blood- 
pressure,  and  cessation  of  the  circulation, 
will  naturally  be  brought  about  by  rupture 
of  the  vessels,  either  from  injury  or  disease, 
causing  death  by  haemorrhage.  But  besides 
actual  rupture  of  the  vessels,  the  vascular 
area  may  in  certain  conditions  become  so  en- 
larged or  dilated  that  we  may  practically  have 
death  from  haemorrhage  without  any  loss  of 
blood  externally.  This  is  what  we  observe  in 
deatli  from  shock  or  collapse.  In  certain  condi- 
tions, such  as  that  resulting  from  blows  on  the 
abdomen,  the  vascular  area  of  the  abdomen  and 
viscera  may,  become  so  dilated  as  practically  to 
retain  almost  the  entire  volume  of  blood  in  the 
body.  Hence,  even  though  the  heart  may  be 
acting,  yet  the  circulation  throughout  the  body 
generally,  and  especially  in  the  extremities  and 
superficially,  is  practically  nil. 

The  individual  may,  however,  retain  his  con- 
sciousness, and  thus  he  differs  from  a patient  in 
a state  of  syncope.  But  very  frequently  in 
cases  of  blows  on  the  abdomen,  there  is  not 
merely  reflex  dilatation  of  the  abdominal  vessels, 
but  also  reflex  inhibition,  for  a time  at  least,  of 
the  heart,  so  that  we  have  syncope  and  shock 
co-existing.  But  the  symptoms  of  syncope  may 
pass  off,  leaving  those  of  shock  still  remaining. 
Shock,  like  syncope,  may  be  transient  or  fatal. 

(2)  Gradual  failure  of  the  Circulation. — 
This  constitutes  death  from  asthenia.  This  is 
the  natural  termination  of  life,  and  it  is  also  the 
mode  of  death  after  wasting  and  exhausting 
diseases,  cold,  starvation,  &c.  The  vital  powers 
fade  gradually,  while  consciousness  may  bo  re- 
tained up  to  the  last  moment. 

II.  Death,  from  failure  of  the  Respiration. 
— The  various  ways  in  wh  eh  the  function  of 
respiration  may  be  interrupted,  and  the  pheno- 
mena consequent  thereon,  have  been  described 
under  the  head  of  AsrHYxiA,  to  which  article 
reference  may  be  made. 

III.  Death  from  paralysis  of  the  vital 
nerve-centres — Coma. — As  already  remarked, 
death  beginning  at  the  head  ends  by  paralysing 
respiration  and  circulation.  The  nerve-centres 
situated  above  the  medulla  and  poos  are  not 
essential  to  life  except  in  so  far  as  animal  life 
is  concerned,  and  the  possibility  of  adaptation  to 
surroundings.  Diseases  of  the  brain,  however, 
are  liable  to  prove  fatal  by  indirect  action  on 
the  medulla  and  pons  through  pressure,  exten- 
sion of  inflammation,  and  the  like.  Certain 
poisons  also,  whether  introduced  from  without, 
— such  as  opium  and  narcotics  generally, — or 


DEATH,  SIGNS  OF.  327 

arising  within,  owing  to  the  non-elimination  of 
waste  products,  as  in  uraemia,  affect  the  nerve- 
centres,  both  cerebral  and  spinal,  and  not  only 
produce  unconsciousness  or  coma,  but  also 
paralyse  the  respiratory  and  cardiac  centres. 

In  death  arising  in  this  manner,  the  indivi- 
dual lies  unconscious,  reflex  action  becomes 
abolished,  and  the  breathing  becomes  stertorous 
and  ultimately  ceases,  death  occurringquietly  or  in 
convulsions.  In  death  from  coma,  in  addition  to 
the  usual  phenomena  of  asphyxia,  there  in,  as  » 
rule,  more  or  less  marked  congestion  of  the  cere- 
bral and  spinal  centres.  D.  F eerier. 

DEATH,  Signs  of. — It  is  not  always  easy 
to  determine  when  the  spark  of  life  has  bocome 
finally  extinguished.  From  the  fear  of  being 
buried  alive,  which  prevails  more  abroad  than 
in  this  country,  some  infallible  criterion  of  death, 
capable  of  being  applied  by  unskilled  persons, 
has  been  considered  a desideratum,  and  valuable 
prizes  have  been  offered  for  such  a discovery. 
The  conditions  most  resembling  actual  deatli 
are  syncope,  asphyxia,  and  trance,  particularly 
the  last.  We  cannot,  however,  say  that  any 
infallible  criterion  applicable  by  the  vulgar  has 
been  discovered,  and  we  do  not  rely  exclusively 
on  any  one  sign,  but  combine  several. 

The  most  reliable  sign  of  death  is  proof  of 
cessation  of  the  heart’s  action.  This,  however, 
is  net  to  be  inferred  from  mere  pulselessness,  for 
the  heart  may  still  be  beating,  and  resuscitation 
may  be  possible,  when  no  pulse  is  to  be  felt  in 
the  arteries  by  ordinary  manipulation.  The  use 
of  the  stethoscope  is  necessary,  implying,  of 
course,  technical  skill.  Though,  according  to 
Rayer,  the  heart  cannot  cease  to  beat  for  more 
than  seven  seconds  without  death,  yet,  consider- 
ing the  very  slow  and  feeble  action  of  the  heart 
(8  to  10  beats  per  minute)  in  hybernating  animals, 
which  normally  have  a pulse  of  80  to  90  per 
minute,  it  is  well  to  regard  a similar  conditior 
as  possible  in  man,  and  to  spend  in  doubtful 
eases  some  minutes,  up  to  half  an  hour,  ir 
auscultation.  The  so-called  cases  of  life  con- 
tinuing notwithstanding  cessation  of  the  circu- 
lation, as  that  of  Colonel  Townsend,  or  of  the 
Indian  Fakirs,  are  to  be  set  down  as  altogether 
apocryphal,  and  not  scientifically  investigated. 

To  enable  unskilled  persons  to  determine 
whether  the  circulation  continues  or  not,  Magnus 
recommends  the  application  of  a tight  ligature 
on  a finger  or  toe.  If  the  circulation  has  quite 
ceased,  no  change  in  colour  is  produced;  but  if 
circulation  continues,  however  feebly,  the  ex- 
tremity, in  course  of  a longer  or  shorter  period, 
assumes  a livid  tint  from  strangulation  of  the 
venous  flow,  while  a ring  of  arterial  anaemia  is 
observable  at  the  point  ligatured. 

Cessation  of  the  heart’s  action,  if  absolutely 
established,  renders  other  indications  unneces- 
sary. As  accessories  they  are  useful,  but  the 
following  signs  are  none  of  them  individually 
conclusive  taken  alone.  The  first  is  cessation 
of  respiration.  Respiration  may  not  be  very 
obvious,  and  yet  it  may  be  going  on.  The  popu- 
lar methods  of  holding  a cold  mirror  before  the 
mouth  and  nostrils,  and  looking  for  indications 
of  moisture ; placing  a flock  of  cotton  wool  on 
the  lips  to  ascertain  whether  air-currents  exist, 


328  DEATH, 

and  placing  a cup  c.f  water  on  the  chest,  and 
observing  whether  the  reflection  on  its  surface 
moves  or  remains  still,  are  all  well  adapted  for  the 
purpose  in  view. 

With  the  cessation  of  the  circulation  and  vital 
turgor,  the  skin  becomes  ashy  pale,  and  the  tissues 
lose  their  elasticity.  The  eyeball  becomes  less 
tense,  and  the  cornea  becomes  opaque.  The 
pupils  cease  to  react  to  light ; and  there  is  no  vital 
reaction  on  the  application  of  irritants  to  the 
ckin.  Though  the  body  is  dead  as  a whole, 
certain  parts  may  continue  to  retain  their  in- 
dependent vitality  after  somatic  death.  This  is 
seen  in  the  muscles,  which  may  retain  their 
electrical  contractility  from  two  to  three  hours 
after  death.  The  existence  of  electrical  con- 
tractility of  the  muscles  in  a body  supposed  to 
be  dead,  indicates  life,  or  death  within  two  or 
three  hours,  according  to  M.  Eosenthal. 

The  subsequent  changes  which  occur  in  the 
dead  body  not  only  indicate  the  fact  of  death, 
but  aid  in  fixing  the  probable  period  at  which 
death  occurred.  These  are  the  following: — 

(1)  The  cooling  of  the  body. — The  body  after 
death,  except  under  certain  special  circumstances, 
as  in  fatal  cases  of  cholera  and  yellow  fever, 
ceases  to  be  a source  of  heat-production,  and 
therefore  is  to  be  looked  upon  as  an  inert  mass 
possessed  of  a higher  temperature  than  the 
average  medium,  which  parts  with  its  heat  ac- 
cording to  certain  physical  laws.  The  superficial 
coldness  of  collapse,  which  is  due  to  cessation  of 
the  peripheral  circulation,  must  not  be  mistaken 
for  the  cadaveric  coldness,  for  there  is  still  an 
■amount,  of  internal  heat  which  has  to  be  parted 
with,  and  the  body,  cold  to  the  touch  before 
leath,  may  after  death  rise  in  temperature,  as 
the  internal  heat  radiates.  It  is  impossible  to 
describe  here  in  detail  all  the  circumstances 
which  modify  the  rate  of  cooling  of  the  body,  but 
it  may  be  said  in  general  that  all  circumstances 
which  favour  radiation,  convection,  and  con- 
duction of  heat  in  inorganic  bodies  are  equally 
applicable  here,  while  the  opposite  conditions 
retard.  Therefore  a thick  coating  of  adipose 
tissue,  clothing,  &c.,  retard  cooling.  The  exact 
thermometric  observations  of  Drs.  Wilks  and 
Taylor  show  that  at  an  average  temperature, 
and  without  clothing,  a dead  body  cools  at  the 
rate  of  about  1°  Fahr.  per  hour. 

(2)  Hypostasis. — After  death  the  blood  gravi- 
tates to  the  most  dependent  parts,  both  ex- 
ternally and  internally,  giving  rise  to  livid  dis- 
colourations,  termed  hypostases.  These  are  liable 
to  be  confounded  with  ecchymoses  or  extrava- 
sations externally,  and  with  the  results  of  con- 
gestion and  inflammation  in  the  internal  viscera. 
They  differ  from  ecchymoses  in  the  fact  that  the 
blood  is  not  extravasated  into  the  tissues,  but 
still  contained  in  the  vessels,  as  may  be  shown 
by  an  incision  into  the  skin.  So  long  as  the 
blood  remains  fluid,  these  discolourations  may 
be  caused  to  disappear  if  the  position  of  the 
body  be  reversed  ; they  will  again  form  in  the 
parts  which  are  now  the  most  dependent.  They 
usually  occur  in  from  eight  to  ten  hours  after 
death. 

(3)  Rigor  mortis. — After  death  the  muscles 
Keeome  stiff,  giving  rise  to  rigor  mortis  or 
cadaveric  rigidity.  It  is  due  to  coagulation  of 


SIGNS  OF. 

the  muscle-plasma.  This  rigidity  attacks  the 
muscles  usually  in  a certain  definite  order,  be- 
ginning in  the  muscles  of  the  neck  and  face, 
and  gradually  extending  from  above  downwards. 
It  gives  way  to  putrefaction  in  the  same  order, 
so  that  while  the  upper  parts  of  the  body  may 
be  flaccid,  the  legs  may  be  found  rigid.  It  can 
only  be  overcome  by  tearing  the  tissues,  and  if 
overcome  it  does  not  return.  In  this  it  differs 
from  cataleptic  rigidity.  A certain  amount  of 
mobility  is  still  observable  at  the  joints.  In  this 
it  is  unlike  the  stiffness  of  freezing,  in  which  all 
the  parts  are  equally  rigid,  and  crackle  if  beDt. 

The  period  of  the  occurrence  of  rigidity, 
and  the  length  of  its  endurance,  are  extremely 
variable,  so  that  no  definite  practical  rules 
can  be  laid  down.  It  may  be  said  generally, 
however,  that  the  greater  the  store  of  mus- 
cular energy  at  the  time  of  death,  the  longer 
it  is  before  rigidity  sets  in.  and  the  longer  it 
lasts.  On  the  contrary,  the  greater  the  ex- 
haustion, the  sooner  rigidity  sets  in,andthe  sooner 
it  disappears.  Hence  rigidity  is  longer  in  ap- 
pearing in  subjects  dying  suddenly  in  full  mus- 
cular vigour,  than  in  those  dying  from  exhans 
tiou.  As  a rule,  a period  of  relaxation  intervenes 
between  death  aDdthe  occurrence  of  rigidity,  bnt 
in  certain  cases  the  last  muscular  contraction 
seems  to  pass  directly  into  the  rigidity  of  death. 
This  is  seen  more  particularly  in  death  during 
great  nervous  excitement,  as  in  soldiers  in  the 
field  of  battle,  or  in  suicides.  The  same  is  said  to 
occur  also  in  death  from  strychnia-poisoning  and 
in  death  by  lightning. 

Bigidity  may  therefore  occur  immediately  on 
death  or  within  a few  hours.  It  has  never  been 
observed  to  be  delayed  beyond  a day  after  death. 
It  may  last  from  so  short  a time  as  scarcely  to  be 
perceptible,  up  to  a week  or  more. 

(4)  Putrefaction. — After  death  the  tissues  un- 
dergo changes  in  colour,  consistence,  &e.,  by  which 
they  arc  ultimately  resolved  into  their  simple 
elements,  included  under  the  general  term  putre- 
faction. Putrefaction,  however,  may  occur  locally 
during  life,  and  general  septic  changes  may 
occur  to  some  extent  before  death.  The  term, 
however,  is  not  generally  applied  until  the 
changes  are  clearly  perceptible  in  alteration  of 
colour,  consistence,  and  smell.  The  first  external 
sign  is  a greenish  discolouration  of  the  abdomen. 
Internally  the  mucous  membrane  of  the  larynx 
and  trachea  is  the  first  to  exhibit  change  in 
colour  and  consistence.  The  less  compact  tissues 
putrefy  first,  the  fibrous  tissues  resist  longer,  and 
the  compact  tissue  of  the  uterus  resists  longest 
of  all.  In  process  of  time,  however,  the  soft 
tissues  become  entirely  disintegrated  and  the 
skeleton  is  exposed  and  gradually  falls  to  pieces. 

The  rate  of  putrefaction  is  very  variable,  de- 
pending partly  on  the  state  of  the  body  itself, 
but  mainly  on  external  conditions  as  to  tempera- 
ture, moisture,  and  exposure.  A combination  of 
high  temperature,  moisture,  and  free  exposure,  are 
the  most  favourable  conditions  for  rapid  putrefac- 
tion. A high  temperature  alone  without  moisture 
tends  to  dry  the  tissues,  and  thus  to  produce  mum- 
mification, instead  of  colliquative  putrefaction. 
Moisture  alone,  as  when  a body  lies  in  water  or 
moist  earth,  tends  to  produce  a saponification  of 
the  tissues,  more  particularly  the  fatty,  with  tie 


DEATH,  SIGNS  OF. 

formation  of  a substance  termed  adipocere  {see 
Abipocere).  The  course  of  putrefaction  can  be 
stopped  by  antiseptics,  as  in  embalming,  and  in 
certain  cases  of  poisoning,  as  with  arsenic,  as 
also  by  freezing.  Putrefaction  is  more  rapid 
in  air  than  in  water,  and  least  rapid  in  earth. 
Under  ordinary  circumstances  and  average 
temperatures,  signs  of  putrefaction  are  clearly 
visible  on  the  third  day  after  death,  commencing 
with  the  green  hue  of  the  abdomen.  Many 
months  elapse  before  the  soft  tissues  become 
entirely  disintegrated.  The  uterus  has  been 
found  fit  for  judicial  examination  as  long  as 
nine  months  after  death,  where  no  antiseptics 
had  been  employed.  When  such  has  been  the 
case,  however,  there  is  practically  no  limit  to 
the  period  of  preservation — witness  the  Egyptian 
mummies. 

There  is  still  much  to  be  learnt  respecting 
putrefaction,  and  it  is  unsafe  to  lay  down  dog- 
matic rules  as  to  how  far  putrefactive  changes 
shall  have  advanced  at  a given  time,  for  even 
under  apparently  similar  conditions  the  most 
extraordinary  divergences  have  been  recorded. 

D.  Fkrrier. 

DEBILITY  {debilis,  feeble).  Synon.:  Feeble- 
ness; Weakness;  Asthenia;  Fr.  Faiblesse ; Ger. 
Schwdchc. 

Definition. — The  body  or  any  of  its  organs 
are  said  to  be  in  a state  of  debility  when  their 
vital  functions  are  discharged  with  less  than  the 
normal  vigour,  being  reduced  in  the  amount  of 
activity  that  they  display,  and  of  work  that  they 
can  accomplish.  The  term  debility  is  also  em- 
ployed in  a somewhat  different  sense  in  the  case 
of  constitutional  weakness  of  an  organ,  to  convey 
the  notion  of  vulnerability  or  predisposition  to 
disease.  In  this  acceptation,  ‘ pulmonary  de- 
bility,’ for  example,  signifies  a peculiarly  delicate 
‘ build  ’ of  the  lungs,  which  renders  them  more 
than  ordinarily  liable  to  succumb  to  the  causes 
of  disease. 

^Etiology. — Debility  is  frequently  constitu- 
tional and  inherited;  but  it  is  more  often  de- 
veloped after  birth.  It  is  most  commonly  due 
to  impaired  nutrition,  whether  this  be  prolonged 
and  moderate,  as  in  defective  hygiene  or  chronic 
illness,  or,  on  the  other  hand,  rapid  and  extreme, 
as  in  acute  disease.  Another  frequent  cause  of 
debility  is  abuse  of  the  affected  organ.  Over- 
use of  any  part  leads  to  fatigue,  and  if 
frequently  repeated  to  exhaustion,  the  chief 
feature  of  which  is  extreme  debility,  as  in  cases 
of  sustained  mental  exertion  or  of  repeated 
strain  of  the  heart.  On  the  contrary,  an  organ 
may  become  feeble  from  want  of  exercise. 
Paralysed  muscles  furnish  the  best  examples  of 
this  condition,  but  the  same  may  be  seen  in  all 
organs  after  unnatural  rest. 

Symptoms. — Tho  natural  ability  of  the  or- 
gans to  perform  their  functions  varies  extremely 
with  sox,  age,  previous  exercise,  and  many 
other  circumstances.  Debility,  or  the  loss  of 
this  functional  power,  is  therefore  frequently 
ill-defined;  and,  wdien  unquestionably  present, 
may  vary  greatly  in  different  cases,  from  a con- 
dition in  which  fatigue  comes  on  only  somewhat 
earlior  than  usual,  as  in  muscular  debility,  to  a 
state  in  which  the  slight est  exertion  may  ex- 


DECUBITUS.  329 

haust  the  whole  of  the  vital  energy  and  the 
functional  life  of  the  part  may  cease — as  is  seen 
in  the  cardiac  asthenia  of  acute  fevers,  and  less 
markedly  in  certain  chronic  diseases,  such  as 
idiopathic  anaemia  and  Addison’s  Disease. 

Debility  may  be  general , affecting  the  whole 
body ; or  local,  individual  organs  only  being 
involved.  Speaking  generally,  the  symptoms  of 
debility  of  an  organ  may  bo  said  to  be  chiefly 
two.  These  are,  first,  increased  irritability,  or 
an  unnatural  readiness  of  the  part  to  respond  to 
stimulation;  and,  secondly,  a tendency  to  un- 
timely exhaustion.  The  phenomena  of  irrita- 
bility and  exhaustion  naturally  vary  with  tho 
organ  involved.  The  symptoms  of  muscular 
asthenia  are  few  and  simple;  those  of  digestive 
feebleness  are  more  complex  ; and  in  debility 
of  the  nervous  system  the  whole  of  the  mental 
processes,  as  well  as  the  functions  of  organic 
life,  may  be  involved.  For  a specific  account 
of  the  phenomena  of  each  of  these  cases,  and  of 
debility  of  other  parts,  the  reader  is  referred  to 
the  articles  upon  diseases  of  the  several  organs. 

Diagnosis. — Debility  pure  and  simple  is  as 
a rule  easily  distinguished  from  disease  by  the 
absence  of  all  evidence  of  organic  alteration,  and 
especially  of  physical  signs  of  anatomical  change. 
It  is  more  difficult  to  separate  debility  from  dis- 
order or  derangement,  but  careful  observation  will 
generally  determine  in  the  case  of  pure  debility 
that  the  functions  are  normally  discharged  as 
long  as  the  demands  made  upon  them  are  not 
excessive. 

Prognosis. — Debility  due  to  acute  disease 
ma.y,  in  the  absence  of  complications,  be  expected 
to  disappear  during  convalescence.  If  the  cause 
have  been  more  chronic,  and  be  less  easily  removed, 
recovery  will  certainly  be  more  slow  and  less 
satisfactory.  The  prognosis  of  inherited  con- 
stitutional debility,  as  regards  its  disappearance, 
is  nearly  always  unfavourable. 

Treatment. — Debility  must  be  treated  accord- 
ing to  its  cause.  If  nutrition  have  failed,  it 
must  be  restored  as  far  as  possible;  and  until 
this  can  be  done,  stimulants  and  suitable  tonics 
are  indicated — especially  in  the  case  of  acute 
disease.  Rest  is  of  the  first  importance  in  most 
instances;  and  it  is  frequently  alone  sufficient 
to  restore  the  vital  force.  In  a few  cases,  how 
ever,  the  opposite  line  of  treatment  must  be 
followed,  as  in  muscular  debility  from  indo- 
lence or  in  some  forms  of  paralysis.  Where 
the  vital  activity  is  low  from  constitutional 
defect,  age,  or  sex,  the  condition  may  not 
be  remediable  ; and  the  treatment  of  such  cases 
is  chiefly  prophylactic.  The  principal  indica- 
tion then  is  to  secure  the  subject  of  debility 
against  exposure  to  damaging  influences. 

J.  Mitchell  Brtjcb. 

DECLINE  {declino,  I decline). — A popular 
name  for  any  wasting  disease;  it  is  especially 
associated  with  pulmonary  consumption.  Tho 
word  is  also  applied  to  the  period  in  the  course 
of  a disease  when  the  symptoms  are  abating ; 
and  likewise  to  the  time  of  life  when  the  physical 
and  mental  powers  are  failing. 

DECUBITUS  (de,  down,  and  cambo,  I lie). — 
The  lying  posture.  See  Posture. 


330  DEFECATION,  DISORDERS  OF. 

DEFECATION,  Disorders  of. — On  the 

descent  of  the  faeces,  •which  accumulate  in  the 
sigmoid  flexure  of  the  colon,  into  the  rectum, 
the  associated  movements  necessary  for  their 
expulsion  are  excited.  These  movements  are 
chiefly  involuntary,  though  influenced  and  con- 
trolled by  the  will. 

Some  of  the  more  important  difficulties  in- 
terfering with  the  actions  of  defecation  arise 
from  disorders  in  the  nervoussystem,  by  which  the 
movements  are  excited  and  directed.  In  injuries 
and  diseases  of  the  brain  or  cord,  the  control  of 
volition,  especially  its  influence  over  the  sphinc- 
ters, is  annihilated,  whilst  the  excito-motory  move- 
ments depending  on  the  spinal  cord  continue. 
In  these  cases  the  actions  of  defecation  take 
place  only  when  the  need  of  expulsion  arises 
without  any  power  of  the  patient  to  induce 
or  restrain  them.  In  injuries  destroying  the 
lower  part  of  the  spinal  cord,  the  feces  escape  in- 
voluntarily in  varying  quantities  and  at  all  times. 

Serious  troubles  in  defecation  may  also 
arise  from  excessive  as  well  as  from  weak- 
ened action  of  the  muscles  concerned  in  this 
function.  The  sphincter  may  he  irritable  or 
subject  to  spasm,  and  resist  too  forcibly  the  ex- 
pulsive actions  of  defecation  (see  Anus,  Diseases 
of) ; or  the  muscular  fibres  of  the  rectum  may 
lose  their  tone,  be  defective  in  power,  and  inca- 
pable of  properly  extruding  the  feces.  Patients 
thus  situated  are  often  obliged,  when  at.  stool, 
to  use  the  finger  to  dislodge  masses  retained  in 
the  weakened  bowel.  An  atonic  condition  of 
the  rectum  usually  arises  from  over-distension. 
It  may  bo  produced  by  too  free  and  frequent  use 
of  enemata,  the  quantity  injected  being  so  large 
as  to  dilate  the  bowel  and  impair  the  power  of 
its  muscular  coat.  This  atonic  state  of  the 
bowel  is  apt  to  give  rise  to  fecal  accumulations. 
Cases  of  this  kind  are  not  uncommon,  yet  the 
nature  of  the  affection  is  liable  to  be  overlooked. 
The  rectum  may  become  gradually  dilated  and 
blocked  up  by  a collection  of  hard  dry  feces, 
which  the  patient  has  not  the  power  to  expel, 
being  unable  from  loss  of  tone  in  the  distended 
bowel  to  overcome  the  resistance  of  the  sphincter 
to  tho  passage  of  so  great  a body.  Some  indu- 
rated lumps  from  the  sacs  of  the  colon,  on 
reaching  the  rectum,  perhaps  coalesce  so  as  to 
form  a large  mass.;  or  a quantity  accumulated 
in  the  sigmoid  flexure,  on  descending  into  the 
lower  bowel,  becomes  impacted  there.  In  several 
instances  a plum-stone  has  been  found  in  the 
centre  of  the  mass.  Such  a collection  gives  rise 
to  considerable  distress,  producing  constipation, 
a sensation  cf  weight  and  fulness  in  the  rectum, 
tenesmus,  and  forcing  pains  which  women  liken 
to  those  of  labour.  In  cases  of  some  duration, 
where  the  hardened  feces  do  not  quite  obstruct 
the  passage,  they  excite  irritation  and  a mucous 
discharge,  which,  mixing  with  recent  feculent 
matter  passing  over  the  lump,  causes  the  case 
to  be  mistaken  for  diarrhoea.  Injections  have  no 
effect  in  softening  the  indurated  mass : they  act 
only  on  the  surface,  aud  return  immediately, 
there  being  no  room  for  their  lodgment  in  the 
bowel.  The  practitioner  on  passing  his  linger 
finds  the  rectum  blocked  up  with  a large  lump, 
which  feels  almost  as  hard  as  a stone.  In  such 
cases,  the  only  mode  of  giving  relief  is  by 


DEFORMITIES  OF  THE  CHEST, 
mechanical  interference.  The  mass  requires  to 
be  broken  up  and  scooped  out.  After  the  breaking 
up  and  extraction  of  the  larger  portions,  injec- 
tions of  soap  and  water  will  be  sufficient  for  tho 
removal  of  the  remainder.  The  persons  most 
subject  to  these  troubles  are  those  enfeebled  by 
age  or  disease,  especially  women.  They  may  also 
occur  in  infants  who  have  been  operated  on  for  im- 
perforate anus,  when  the  artificial  aperture  con- 
tracts or  is  left  too  small  for  tho  free  passage  of 
the  feces.  In  these  cases  the  distension  of  the 
bowel  is  sometimes  excessive,  and  its  expulsive 
functions  are  seriously  impaired  and  weakened 
See  Faeces  and  Constipation.  T.  B.  Cublino 

DEFERVESCENCE  (de,  down,  and  fir- 
vesco,  I grow  hot). — The  decline  of  fever,  charac- 
terised by  a fall  of  temperature  and  of  pulse,  and 
by  other  phenomena.  See  Fevee. 

DEFORMITIES. — See  Malformations. 

DEFORMITIES  OF  THE  CHEST.— 
Under  this  head  are  included  all  deviations  in 
shape  from  the  normal  chest. 

Deviations  from  the  shape  of  the  typical  thorax 
are  appreciable  by  careful  physical  examination. 
Of  the  various  methods  employed  for  this  pur- 
pose, by  far  the  most  valuable  are  inspection  and 
mensuration.  Although  in  some  few  cases  it 
may  be  important  to  determine  the  exact  amount 
of  deformity  by  mensuration,  there  are  very  few 
deviations  in  shape  or  size  of  the  thorax,  the 
degree  of  which  cannot  he  sufficiently  estimated 
for  clinical  purposes  by  the  eye  and  hand, 
without  the  aid  of  any  special  instruments  for 
measuring. 

Deformities  of  the  chest  may  he  due'either 
to  abnormity  of  the  parietes ; or  to  disease  of 
internal  structures. 

Description. — Deviations  from  the  form  or 
size  of  the  typical  thorax  may  he  either  general 
or  local-,  i.e.  the  abnormity  may  involve  the 
whole  thorax,  or  a part  only. 

I.  General  Deformities. — 1.  General  Dimi- 
nution.— The  chest  may  be  too  small — that  is, 
diminished  in  all  its  diameters  without  being  in 
other  respects  deformed.  Diminution  of  the 
thorax  simultaneously  and  uniformly  in  its 
antero-posterior  and  lateral  diameters  is  effected 
mechanically  by  an  increase  in  the  obliquity  of 
the  ribs.  The  smaller  the  chest  (having  re- 
gard to  the  height  of  the  person)  the  more 
obliquely  are  the  ribs  arranged,  and  the  more 
acute  the  angle  formed  between  each  of  the  true 
ribs  (excepting  the  first)  and  its  cartilage.  The 
intercostal  spaces  of  the  true  ribs  arc  widened 
about  the  junction  of  the  ribs  with  their  carti- 
lages, and  at  the  same  time  the  ribs  posteriorly 
are  approximated  more  closely  to  each  other, 
the  closeness  of  the  approximation  being  in  pro- 
portion to  the  diminution  in  the  size  of  the 
thorax.  The  vertical  diameter  of  the  thorax 
is  lessened  by  an  increase  in  the  height  of  the 
arch  of  the  diaphragm.  The  very  oblique  posi- 
tion of  the  false  ribs,  and  the  height  to  which 
the  diaphragm  rises  into  the  chest,  cause  several 
of  the  false  ribs  to  lie  in  contact  with  the  dia- 
phragm, and  thus  no  portion  of  lung  is  under 
these  ribs.  They  are,  practically  speaking,  no 
longer  part  of  the  chest-walls. 

The  costal  angles  are  diminished  in  proport  i or. 


DEFORMITIES 

fc  the  diminution  of  the  size  of  the  thorax,  i.e.  to 
the  obliquity  of  the  ribs.  The  obliquity  of  the 
ribs  also  causes  the  shoulders  and  the  sternal 
ends  of  the  clavicles  to  droop,  and  at  the 
same  time  to  incline  forwards;  the  upper  part  of 
the  scapula  is  carried  by  the  shoulder  forward, 
the  inferior  tilted  backward.  General  and  sym- 
metrical diminution  in  the  size  of  the  thorax  has 
one  and  only  one  cause,  namely,  small  size  of  the 
lungs.  Small  lungs  may  be  congenital,  i.e.  due 
to  original  conformation  ; or  the  consequence  of 
atrophic  degenerative  changes  incident  to  age. 
In  both  these  cases  the  lungs  are,  in  relation  to 
the  length  of  the  ribs,  disproportionately  small, 
and  as  a necessary  consequence,  the  relatively 
too  long  ribs  are  arranged  more  obliquely  than 
they  are  in  a well-formed  chest,  and  the  dia- 
phragm is  pushed  by  the  abdominal  organs 
higher  into  the  thorax.  When  the  small  size  of 
the  lungs  is  due  to  atrophy,  the  supra-clavieular 
fossae  are  deepened  and  the  vertical  diameter  of 
the  chest  proportionately  diminished.  In  ad- 
vanced life  the  congenitally  small  lungs  are 
frequently  reduced  still  further  in  size  by  tha 
supervention  of  atrophous  emphysema.  The 
congenitally  small  lungs  and  the  consequently 
small  chest  is  one  of  the  characteristics  of  tuber- 
culosis, i.e.  of  that  congenital  organization  in 
which  tubercle  is  likely  in  subsequent  periods 
of  life  to  occur.  Atrophous  emphysema  is  especi- 
ally common  in  those  who  have  either  manifested 
symptoms  of  tubercle  in  their  youth,  or  belong 
to  tubercular  families.  It  is  the  congenitally 
small  lungs  of  childhood  which  are  prone  to 
become  -the  seat  of  tubercle  in  youth,  and  the 
subjects  of  atrophous  emphysema  in  old  age. 

2.  General  Enlargement. — The  thorax  may  be 
too  large,  increased  in  all  its  diameters,  without 
being  otherwise  deformed.  It  is  simply  bigger 
than  it  should  be,  having  regard  to  the  height 
of  the  subject. 

When  the  thorax  is  abnormally  large,  the  ribs, 
instead  of  being  more  obliquely  situated  than 
natural,  as  they  are  in  the  small  thorax,  are 
placed  more  horizontally  than  they  are  in  the 
normal  thorax.  The  angle  formed  between  each 
rib  and  its  cartilage  is  greater  than  in  health; 
while  the  intercostal  spaces,  especially  the  lower, 
are  widened,  and  the  ribs  less  closely  approxi- 
mated, the  arch  of  the  diaphragm  is  lessened 
in  depth,  and  a considerable  mass  of  lung  lies 
under  the  lower  false  ribs,  between  them  and 
the  diaphragm.  The  chest  is  increased  in  all  its 
diameters.  The  shoulders  are  raised.  The 
costal  angles  are  greater  than  natural. 

Increase  in  the  size  of  the  whole  thorax  has 
but  one  cause,  viz.,  increase  in  the  size  of  the  lungs. 
Increase  in  the  size  of  the  lungs  generally,  and 
pretty  uniformly,  is  the  consequence  of  disease, 
and  of  one  disease  only,  viz.,  large-lunged  or  hy- 
pertrophous  emphysema.  When  the  increase  in 
size  of  the  thorax  attending  large-lunged  or  hy- 
pertrophous  emphysema  is  moderate  in  degree, 
the  increase  in  its  size  is  effected  by  the  altered 
position  of  the  ribs  ; but  when  the  lung-disease 
is  extreme,  then  a certain  amount  of  the  enlarge- 
ment is  caused  by  pressure  on  the  inside  of  the 
chest  during  the  violent  expiratory  efforts  of 
severe  cough. 

3.  Irregular  General  Deformities. — In  the  de- 


OF  THE  CHEST.  S31 

formities  above  described  the  antero-posterior 
and  the  lateral  diameters  retain  more  or  less  per- 
fectly their  normal  proportion — both  are  in- 
creased or  both  are  diminished;  in  the  formoi 
case  the  chest  is  on  the  whole  more  barrel-shaped 
than  natural,  but  the  deviation  from  the  normal 
form  is  not  considerable.  If,  however,  the  chest- 
walls  are  from  any  cause  unduly  soft  or  unduly 
rigid,  then  the  actually  or  relatively  soft  portions 
will  recede  during  each  inspiratory  act,  and  local 
deformity  of  the  chest  follows.  The  diameter  of 
the  chest  at  the  part  where  the  absolutely  or 
relatively  soft  portion  of  the  parietes  is  placed 
will  be  diminished.  The  special  deformities  of 
the  chest  which  result  are  due,  therefore,  prima- 
rily to  the  state  of  the  parietes,  and  are  not,  as 
those  previously  described,  secondary  to  con- 
ditions of  the  lungs  themselves. 

a.  Diminution  in  the  antero-posterior  diameter 
of  the  thorax. — The  antero-posterior  diameter  of 
the  thorax  is  frequently  loss  than  that  of  the 
normal  thorax,  the  lateral  diameter  being  pro- 
portionately increased.  The  chest  has  an  oval 
form — it  is  flattened  from  before  backwards. 

The  thorax  flattened  from  before  backwards  is 
usually  associated  with  small  lungs,  but  the 
mechanical  cause  of  the  flattened  form  is  the 
want  of  full  resisting  power  in  the  ribs  and 
considerable  strength  in  the  cartilages.  These 
conditions  of  thorax  arc  common  in  the  subjects 
of  tuberculosis. 

The  flattening  of  the  thorax  is  increased  by  all 
impediments  to  the  free  passage  of  air  through 
the  air-tubes.  In  some  children  suffering  from 
even  slight  bronchial  catarrh,  the  flattening  of 
the  chest  is  seen  to  be  increased  at  each  inspira- 
tion ; and  if  the  impediment  to  the  entrance  of 
the  air  to  the  pulmonary  tissue  be  constant  or 
extreme,  not  only  is  the  flattening  increased 
at  each  inspiration,  but  the  sternum  is  also 
depressed,  especially  at  its  lower  half  below 
the  level  of  the  costal  cartilages,  and  thus  the 
antero-posterior  diameter  of  the  thorax  is  still 
further  diminished  in  the  median  line. 

b.  Increase  in  the  antero-posterior  diameter  of 
the  thorax. — In  rickets  the  cartilages  of  the  ribs 
are  very  firm,  whilstthe  ribs  themselves  are  softer 
than  natural,  and  especially  so  near  to  their 
enlarged  growing  ends — the  softest  part  of  the 
ribs;  that  is  to  say,  just  outside  the  nodule 
formed  at  the  spot  where  cartilage  is  in  the 
process  of  growing  into  bone.  The  consequence 
of  the  extreme  softness  of  the  ribs  at  this  part 
is  that  at  each  inspiration  the  weight  of  the 
atmosphere  presses  inward  the  softest  part  of 
the  ribs,  while  the  sternum  is  borne  forward  by 
the  firm  cartilages.  The  result  is  great  increase 
in  the  antero-posterior  diameter  of  the  thorax, 
and  diminution  of  the  lateral  diameter  at  the 
part  corresponding  to  the  softest  part  of  the 
ribs.  The  depression  of  the  softest  part  of  each 
rib  is  increased  by  the  want  of  resilience  of  the 
softened  structures. 

A groove  is  thus  formed  in  the  thoracic 
walls  just  posterior  to  the  rickety  nodules ; and 
this  groove  being  deepened  at  each  inspiration, 
the  part  of  the  lung  adjacent  is  compressed  in 
place  of  being  expanded  during  the  inspiratory 
act.  At  the  same  time,  in  consequence  of  the 
1 cartilages  and  sternum  being  thrust  forward  at 


DEFORMITIES  OF  THE  CHEST. 


332 

each  inspiration,  air  enters  with  undue  force 
into  the  lung-tissue  subjacent  to  these  parts. 
The  consequence  of  the  excessive  expansion  of 
the  anterior  part  of  the  lung  is  vesicular  emphy- 
sema, and  the  recession  during  inspiration  of  the 
softened  and  imperfectly  resilient  and  therefore 
deeply  grooved  part  of  the  chest-wall  leads  to  col- 
lapse of  the  subjacent  pulmonary  tissue  ; and,  as 
the  effect  of  these  two  conditions,  the  lungs,  when 
the  chest  is  opened,  present  a vertical  groove 
corresponding  to  the  groove  in  the  chest-walls. 
The  antero-posterior  diameter  of  the  thorax  in 
rickets  is  still  further  increased  by  the  curvation 
of  the  spine.  The  muscles  are  weak,  the  child  is 
unable  to  sit  upright,  that  is  to  say  it  is  unable, 
in  consequence  of  the  weakness  of  its  muscles, 
to  support  the  weight  of  the  upper  part  of  its 
body,  the  bones  of  the  spine  are,  in  common 
with  the  other  bones  of  the  body,  softened,  and 
the  result  of  the  weakness  of  the  muscles  and 
the  softness  of  the  vertebrae  is  the  dorsal 
bow. 

When  deformity  of  the  chest  is- the  result  of 
undue  softness  of  the  chest-walls,  the  position  of 
the  solid  organs  subjacent  to  the  parietes  is  fre- 
quently perceptible  to  the  eye.  The  liver  supports 
the  lower  ribs  on  the  right  side,  the  heart  supports 
the  ribs  and  cartilages  over  it  on  the  left  side,  and 
thus  these  organs  cause  local  prominence  of  the 
chest-walls  without  being  themselves  in  any  way 
abnormal. 

In  the  so-called  'pigeon-breast , the  antero- 
posterior diameter  of  the  thorax  is  increased 
in  the  middle  line,  the  lungs  are  small,  the 
ribs  and  cartilages  are  firm,  the  ribs  are  placed 
obliquely  and  the  chest-walls  are  flattened  later- 
ally, and  the  sternum  as  a consequence  is  thrust 
forwards  ; thus  the  chest  in  the  pigeon-breasted 
has  a triangular  form,  the  apex  of  the  triangle 
being  the  sternum.  Impediment  to  the  free 
entrance  of  air  into  the  lower  lobes  of  the  lungs 
will  favour  the  production  of  and  increase  the  de- 
formity. The  chests  of  children  who  suffer  from 
repeated  attacks  of  bronchitis,  but  are  otherwise 
healthy,  are  commonly  the  subjects  of  this  de- 
formity, while  there  is  increased  expansion  and 
subsequent  enlargement  of  the  upper  part  of  the 
chest,  the  lungs  being  more  or  less  collapsed 
below  and  emphysematous  above. 

c.  Transverse  anterior  constriction  of  the  lower 
part  of  the  thorax  is  the  consequence  of  small 
size  of  the  lung,  or  of  imperfect  inspiratory  ex- 
pansion, permanent  or  frequently  recurring  in 
youth.  In  these  cases  the  lower  ribs  are  little 
used  in  respiration,  while  below  they  are  borne 
outwards  or  supported  by  the  liver,  stomach,  and 
spleen,  and  thus  an  imperfectly  formed  trans- 
verse depression  is  produced  in  the  front  of  the 
chest  on  a level  with  the  base  of  the  ensiform 
cartilage. 

The  deviations  from  the  type  of  the  normal 
thorax  hitherto  described  are  bilateral,  and  more 
or  less  symmetrical. 

II. — Local,  unsymmetrical,  and  unilateral 
deformities. — 1.  Fulness  of  the  supraclavicular 
region. — The  supraclavicular  region,  correspond- 
ing to  the  portion  of  the  thoracic  cavity  above 
the  clavicle,  may  be  fuller  than  natural.  The 
causes  of  this  local  bulging  are — a.  Develop- 
ment of  adipose  and  cellular  tissue,  b.  Dis- 


tension of  the  deep-seated  veins,  c.  Large-lung 
emphysema,  in  which  disease  there  is  occa- 
sionally distension  of  that  part  of  the  cavity 
of  the  thorax  which  lies  above  the  level  of  the 
clavicle  ; the  distension  is  due  to  pressure  on 
the  inside  of  this  part  of  the  thoracic  cavity ; 
air  being  forced  violently  into  this  part  of  the 
lung  during  the  powerful  expiratory  effort  of 
cough. 

2.  Depression  of  one  supraclavicular  fossa  is 
caused  by  any  pathological  condition  of  the  apex 
of  the  lung  which  produces  diminution  of  its 
bulk,  e.g.  atrophous  emphysema,  or  chronic  con- 
solidation of  the  apex. 

3.  Elevation  of  one  shoulder. — Occupation  is  a 
common  cause  of  elevation  of  one  shoulder ; thus 
in  clerks,  who  sit  much  at  the  desk,  the  left 
shoulder  is  permanently  a little  higher  than  the 
right,  and  the  upper  portion  of  the  spine  is 
slightly  curved,  the  convexity  being  to  the  left ; 
so  in  those  who  carry  heavyweights  on  one  arm, 
the  opposite  shoulder  is  elevated  and  the  spine 
curved.  Whatever  necessitates  an  increase  in 
the  capacity  of  one  side  of  the  thorax  causes 
elevation  of  the  shoulder  on  the  same  side : thus, 
considerable  dilatation  of  the  heart,  fluid  in  the 
pericardium,  fluid  in  the  pleura,  aneurism  of  the 
arch  of  the  aorta  or  of  the  innominate,  all  lead 
to  elevation  of  the  shoulder.  The  shoulder  is 
depressed  and  carried  forward  when,  from  any 
cause,  the  whole  or  upper  part  of  one  side  of  the 
chest  is  diminished  in  size,  e.g.  when  the  apex 
of  the  lung  is  the  seat  of  chronic  pneumonia  or 
chronic  phthisis! 

4.  Uniform  dilatation  of  one  side  of  the  thorax 
is  due,  with  one  exception,  to  fluid  or  air  in  the 
pleura ; the  exception  is  those  rare  cases  of 
encephaloid  cancer  of  the  lung,  in  which  the 
formation  of  cancer  is  uniformly  diffused  through 
the  lung-tissue,  and  in  amount  so  great  that  the 
lung  ‘ infiltrated’  with  cancer  very  decidedly  ex- 
ceeds in  bulk  the  healthy  lung  inflated  with  ai  r 
by  inspiration. 

In  uniform  dilatation  of  one  side  of  the  thorax, 
the  shoulder  is  raised,  the  ribs  are  placed  more 
horizontally  than  on  the  healthy  side,  the  inter- 
costal spaces  are  widened,  and  the  spine  slightly 
curved.  When  the  enlargement  is  moderate  in 
amount,  the  increase  in  capacity  is  effected  by 
the  altered  position  of  the  ribs  ; but  when  the 
increase  in  size  is  very  considerable,  then  it  is 
due  in  part  to  the  pressure  exercised  by  the  air, 
fluid,  or  cancer-loaded  lung  on  the  inner  side  of 
the  chest-wall. 

5.  Uniform  contraction  of  one  side  of  the  tho 
rax  is  the  consequence  of  any  pathological  con- 
dition which  leads  to  general  and  uniform  reduc- 
tion in  the  size  of  the  lung,  e.g.  cirrhosis  of  the 
lung,  infiltrat  ed  cancer  of  t he  lung,  chronic  tuber- 
cular disease  of  the  lung,  chronic  pneumonia, 
or  the  change  in  the  texture  of  the  lung  which 
follows  long-continued  compression  by  fluid  in 
the  pleura.  When  the  whole  of  one  side  of  the 
thorax  is  reduced  in  size,  the  shoulder  on  that 
side  is  depressed,  the  ribs  are  placed  more 
obliquely  and  are  more  closely  approximated  than 
on  the  opposite  side,  the  intercostal  spaces  are 
narrowed,  and  the  spine  is  curved,  often  consider- 
ably, the  concavity  of  the  curve  being  towards 
the  contracted  side. 


DEFORMITIES  OF  THE  CHEST. 

6.  Lateral  curvature  of  the  spine,  instead  of 
being  the  consequence,  may  be  the  cause  of  defor- 
mity of  the  thorax : the  ribs  are  then  approxi- 
mated on  the  side  and  at  the  part  where  the 
concavity  of  the  curvature  is  placed,  while  they 
are  separated  and  the  shoulder  raised  on  the 
side  of  the  convexity. 

7.  In  angular  curvature  of  the  spine  the  defor- 
mity of  the  thorax  varies  with  the  seat  and  the 
extent  of  the  vertebral  disease ; but,  speaking 
generally,  it  may  be  said  that  in  angular  curva- 
ture of  the  spine  the  antero-posterior  diameter 
of  the  thorax  is  increased  in  proportion  to  the 
amount  of  destruction  of  the  bodies  of  the  ver- 
tebra, and  that  the  ribs  are  in  a corresponding 
degree  approximated. 

8.  Extreme  depression  of  the  lower  part  of  the 
sternum  is  the  consequence  of  softness  of  the 
cartilages  of  the  ribs  and  impediment  to  the 
free  passage  of  the  air  to  the  pulmonary  tissue. 
This  deformity  is  never  congenital,  although 
the  subjects  of  it  often  affirm  it  to  be  so  ; it 
may,  however,  commence  to  be  formed  directly 
after  birth  if  there  be  a congenital  impediment 
to  the  entrance  of  air  into  the  lungs,  e.g.  atelec- 
tasis. 

The  deformity  may  be  the  result  of  direct 
pressure.  In  certain  occupations  pressure  has 
to  be  exerted  on  the  lower  part  of  the  ster- 
num— thus,  some  shoemakers  use  a wooden  in- 
strument which  has  to  be  kept  in  its  place  by 
pressure  against  the  lower  part  of  the  sternum. 
For  direct  pressure  to  produce  this  deformity  it 
must  have  been  applied  in  early  youth,  while  the 
parts  are  still  flexible,  and  have  been  exerted 
frequently  over  a long  period  of  time. 

9.  Congenital  deformities  of  the  thorax  are 
few  iu  number  and  are  due  to  arrest  of  develop- 
ment— for  example,  cleft  sternum,  and  defective 
formation  of  one  or  more  ribs  or  cartilages. 

1 0.  Unsymmetrical  diminution  in  size  of  apart 
of  the  thorax  is  produced  by  any  pathological 
change  which  reduces  the  size  of  the  subjacent 
part  of  the  lung.  All  chronic  inflammatory  or 
congestive  conditions  of  the  apex  of  the  lung, 
whether  primary  or  the  consequence  or  the  con- 
comitant of  the  formation  of  tubercle,  are  at- 
tended by  diminution  of  the  bulk  of  the  part  of 
the  lung  which  is  the  seat  of  the  lesion.  Con- 
siderable loss  of  pulmonary  tissue  is  usually 
accompanied  by  falling  inwards  of  the  chest-wall 
over  the  cavity.1  The  formation  of  a cavity  is 
almost  invariably  attended  by  chronic  inflam- 
matory condensation,  and  this  increases  the  local 
depression  of  the  chest-wall.  In  chronic  thick- 
ening of  the  pleura,  the  chest-wall  at  the  part  is, 
by  the  contraction  of  the  fibrin,  drawn  inwards, 
and  the  lung  subjacent  to  the  thickened  pleura 
being  condensed,  the  chest-wall  is  also  forced 
in  during  inspiration  by  atmospheric  pressure. 
Hence,  after  pleurisy  limited  in  extent  it  is 
common  to  find  permanent  flattening  of  the 
thoracic  parietes  at  the  base  of  the  chest  on 
the  side  affected. 

In  cancerous  infiltration  of  the  lung,  limited 
in  extent,  the  lung-tissue  is  sometimes  so  much 
condensed  that  the  bulk  of  the  cancer  and  lung 
are  less  than  that  of  the  healthy  lung,  and  the 

1 It  is  said  that  a very  large  air-containing  cavity  may 
give  rise  to  local  bulging. 


DEGENERATION.  333 

I chest-walls  as  a consequence  are  flattened  over 
the  seat  of  disease. 

11.  Unsymmetrical  localised  bulging.  If  the 
ribs  are,  in  relation  to  the  size  of  the  lungs, 
disproportionately  long,  and  then-  cartilages 
soft,  then  one  or  more  of  the  cartilages  may 
be  knuckled  forwards ; the  cartilage,  being 
compressed  between  the  end  of  the  rib  and  the 
sternum,  bends  in  an  angle  outwards.  Although 
the  prominence  is  trifling,  it  often  causes  anxiety 
to  parents  and  its  subject.  Local  deformity  of 
this  kind  is  occasionally  the  result  of  repeated 
lateral  compression  of  the  chcst-wall  in  the  ath- 
letic sports  of  young  boys,  e.g.  cricket. 

All  the  diseases  of  the  chest  which  are  accom- 
panied by  general  enlargement  of  both  or  one 
side  of  the  chest,  when  localised,  are  attended 
by  local  bulging  ; thus  a common  cause  of 
abnormal  fulness  of  the  lower  part  of  the  left 
side  of  the  thorax,  posteriorly,  is  emphysema  of 
the  corresponding  part  of  the  lung ; a moderate 
amount  of  fluid  in  the  pleura  is  attended  by  ful- 
ness of  the  lower  part  of  the  chest  on  the  same 
side.  In  both  these  cases  the  ribs  are  raised 
into  an  abnormally  horizontal  position ; the  chest- 
walls  are  not  pushed  outwards,  but  the  ribs  are 
raised,  and  the  intercostal  spaces  are  to  that 
extent  widened.  The  ribs  are  put  into  the  posi- 
tion which  gives  the  greatest  capacity  to  the 
thoracic  cavities  containing  the  fluid  or  the 
enlarged  lung.  Local  bulging  may  be  produced 
by  aneurism  of  the  arch  of  the  aorta  or  of  the 
innominate  artery ; by  growths,  malignant  or 
other,  within  the  chest;  by  chronic  pleurisy 
with  effusion  circumscribed  by  dense  false  mem- 
brane ; by  hydatids  ; or  by  abscess ; and  in  all 
these  cases  the  prominence  is  due  to  direct 
pressure  on  the  inner  side  of  the  chest-wall, 
and  to  changes  in  the  chest- wall  itself. 

Hypertrophy  and  dilatation  of  the  heart  and 
fluid  in  the  pericardium  are  attended  by  fulness 
of  the  pracordial  region.  The  bulging  from 
these  diseases  is  much  greater  in  the  child  than 
in  the  adult.  In  these  cases  a little  of  the  ful- 
ness is  produced  by  a more  horizontal  arrange- 
ment of  the  ribs ; but  when  the  prominence  of  the 
pracordial  region  is  at  all  considerable,  it  is  the 
result  of  the  pressure  exercised  by  the  fluid  or 
by  the  large  and  pow-erfully  acting  heart  on  the 
inner  surface  of  the  corresponding  part  of  the 
chest-wall. 

At  the  part  corresponding  to  the  junction  of 
the  first  and  second  bones  of  the  sternum,  oppo- 
site the  cartilage  of  the  second  rib,  the  sternum 
projects  forward.  This  prominence  is  called  the 
angle  of  Ludovicus.  Any  impediment  to  the 
free  entrance  of  ah  into  the  lungs  may  cause 
depression  of  the  lower  part  of  the  sternum  ; if 
the  ossification  of  the  sternum  is  not  complete 
at  the  junction  of  the  first  and  second  bones, 
undue  prominence  of  this  part  is  the  result. 
Subsequently  a formation  of  bone  takes  place  at 
this  spot,  and  increases  the  prominence. 

WlLLIAH  JENNER. 

DEGENERATION  ( degener , unlike  one’s 
race ; out  of  kind ). 

Definition. — The  word  ‘ degeneration,’  mean- 
ing etymologically  change  or  deterioration  of 
kind,  is  used  in  pathology  for  any  process  by 


DEGENERATION. 


834 

which  a tissue  or  substance  becomes  replaced 
by  some  other,  regarded  as  less  highly  organised, 
less  complex  in  composition,  of  inferior  physio- 
logical rank,  or  less  suited  for*  the  performance 
of  its  original  functions.  While  some  change 
for  the  worse  is  thus  the  essence  of  degenera- 
tion, it  is  of  secondary  importance  by  what  steps 
this  change  is  effected.  It  may  be  by  direct 
chemical  metamorphosis,  as  of  albuminous  into 
fatty  material;  by  infiltration  of  the  tissues 
with  some  new  material,  as  in  albuminoid  de- 
generation ; or  even  by  substitution  of  a newly- 
formed  tissue,  inferior  to  the  original  in  organi- 
sation or  in  functional  efficiency,  as  in  what  is 
called  fibroid  degeneration.  Degeneration  is 
very  closely  connected  with  atrophy,  since  on 
the  one  hand  it  is  often  caused  by  imperfect 
nourishment,  and  on  the  other  hand  may  be  a 
stage  in  progressive  wasting;  so  that  it  may  be 
difficult  to  draw  the  line  between  the  two. 

Summary. — The  following  kinds  of  degenera- 
tion may  be  recognised: — Albuminoid,  Fatty, 
Mucoid  or  Colloid,  Parenchymatous,  Calcareous, 
Pigmentary,  and  Fibroid,  with  possibly  one  or 
two  minor  varieties  of  less  moment.  The  two 
first  - mentioned  are  described  elsewhere  ( see 
Axbuminotd  Disease,  and  Fatty  Degeneration). 

1.  Mucoid  or  Colloid  degeneration  is  in 
one  sense  a physiological  process,  since  it  is 
probably  by  a partial  transformation  of  the  pro- 
toplasm of  epithelial  cells  into  mucin  that  the 
secretion  of  mucus  is  effected. 

Mucoid  and  colloid  degeneration  are  sometimes 
distinguished.  We  are  unable  to  recognise  any 
difference  except  in  situation,  and  this  distinc- 
tion is  better  expressed  in  other  words.  The 
process  consists  in  the  transformation  of  por- 
tions, usually  albuminous,  of  the  tissues  into  a 
semi-transparent  homogeneous  material,  varying 
in  consistency  from  fluid  to  a gelatinous  solid, 
and  consisting  of  altered  albuminates  with  vari- 
able proportions  of  mucin,  a substance  allied  to 
albumin,  but  differing  in  its  entire  insolubility 
in  acetic  acid,  and  solubility  in  alkalies.  All 
masses  of  gelatinous  appearance  have  not  this 
composition,  since  the  colloid  material  which 
fills  some  ovarian  cysts,  that  of  renal  cysts, 
and  probably  that  found  in  some  other  cases, 
is  said  to  contain  no  mucin.  The  thyroid 
gland  when  enlarged  and  cystic,  as  in  one 
form  of  bronchocele,  is  a striking  instance 
of  colloid  degeneration.  The  enlarged  cystic 
vesicles  become  filled  with  colloid  material, 
which  plainly  results  from  a transformation  of 
the  epithelial  elements,  and  possibly  also  of 
some  albuminous  exudation  in  the  original 
vesicles.  Small  masses  of  colloid  material  first 
appear  in  the  cells,  which  become  confluent  into 
homogeneous  masses.  In  colloid  cancer  a simi- 
lar process  appears  to  take  place,  but  is  rather 
synchronous  with,  than  subsequent  to,  the  growth 
of  the  tumour.  The  alveolar  spaces  which  in 
other  forms  of  cancer  are  filled  with  cells,  here 
contain  colloid  material  resulting  from  the 
metamorphosis  of  cells,  and  every  transitional 
stage,  from  the  epithelioid  cancer-cell  to  a 
homogeneous  translucent  mass,  may  often  be 
met  with.  The  stroma  is  unaffected,  and  re- 
mains fibrous.  The  gelatinous  material  of 
colloid  cancer  is  stated  to  contain  more  mucin 


than  that  of  the  enlarged  thyroid.  It  is  instruc- 
tive to  notice  that  this  form  of  cancer  usually 
occurs  or  commences  in  parts  where  epithelium 
is  present,  which  undergoes  the  mucous  trans- 
formation and  secretes  mucus,  as  in  the  sto- 
mach and  intestines.  When  colloid  or  mucoid 
transformation  affects  tissues  of  the  connective 
tissue  group,  it  is  the  intercellular  substance 
which  appears  to  be  chiefly  affected.  This 
change  is  seen  in  the  mucoid  softening  of  car- 
tilage which  sometimes  occurs  in  old  age,  where 
the  chondrin  undergoes  chemical  change,  and  the 
intercellular  substance  softens  into  a diffluent  or 
liquid  substance  containing  mucin.  The  so-called 
mucous  tissue  which  forms  the  umbilical  cord, 
and  the  vitreous  body  of  the  eye,  as  well  as 
certain  fee tal  structures,  consists  essentially  of  a 
reticulated  connective  tissue  with  mucous  inter- 
cellular substance,  and  the  same  tissue  forms  the 
new  growth  called  myxoma,  which  may  therefore 
be  regarded  as  formed  by  mucous  transformation 
of  connective  tissue.  Its  cells  are  quite  unaffected 
by  this  change,  being  either  fixed  stellate  connec- 
tive tissue  cells,  or  migratory  lymphoid  corpus- 
cles. This  view  explains  how  portions  of  other 
tumours,  as  sarcoma,  enchondroma,  and  lipoma, 
are  often  found  to  have  undergone  myxomatous 
degeneration.  All  these  mucoid  or  colloid  sub- 
stances contain  mucin  with  albuminates. 

2.  Parenchymatous  or  Granular  degene- 
ration, also  called  cloudy  swelling,  is  a peculiar 
change  met  with  in  some  epithelial  struc- 
tures, especially  liver-  and  kidney-cells,  and 
muscular  tissue,  occurring  only  in  the  course 
of  some  infective  febrile  diseases,  especially 
typhus,  enteric  fever,  scarlatina,  diphtheria, 
pyaemia,  etc.  The  histological  elements  are 
found  after  death  to  have  lost  their  transpa- 
rency, and  to  be  filled  with  minute  granules,  so 
that  the  general  appearance  is  not  unlike  that  of 
fatty  degeneration.  The  naked-eye  appearance 
of  the  organs  is  also  not  dissimilar;  they  are 
pale,  dull,  and  opaque-looking.  This  change  has 
been  thought  to  be  the  precursor  of  fatty  change : 
but  whether  this  be  so  or  not,  it  is  at  once  dis- 
tinguished by  the  solubility  of  the  granules  in 
acetic  acid,  and  their  insolubility  in  ether.  The 
cause  of  this  degeneration  has  been  asserted  to 
be  simply  high  temperature;  still  it  is  not  found 
in  all  febrile  diseases.  It  has  also  been  regarded 
as  a post-mortem  change,  which  is  possible,  but 
still  this  implies  some  abnormality  in  the  tissues 
during  life. 

Another  change  also  occurring  in  febrile  dis- 
eases is  waxy  or  vitreous  degeneration  of  the 
voluntary  muscles.  They  are  found  after  death 
with  little  or  no  striation,  and  the  myosin  ir- 
regularly coagulated  in  lumps.  That  this  is  a 
change  occurring  after  death  there  can  be  no 
doubt.;  while  it  is  equally  clear  that  this  ab- 
normal coagulation  shows  some  abnormality  cf 
composition  to  have  existed  during  life. 

3.  Calcareous  degeneration  consists  in  the 
deposition  of  calcareous  particles  in  the  elements 
of  a tissue,  or  in  some  inflammatory  products  pre- 
viously formed.  It  is  more  appropriately  called 
calcareous  infiltration  or  d-posit.  When  ihe 
normal  tissues  are  thus  infiltrated,  there  is  not 
of  necessity  any  other  alteration  in  the  tissues 
themselves,  though  the  process  generally  indi- 


DEGENERATION. 

catss  retardation  of  the  circulation  or  arrest  of 
tissue-metamorphosis.  In  the  case  of  inflam- 
matory products,  new-growths,  and  parasites, 
as  well  as  in  other  cases,  the  calcareous  deposit 
follows  on  partial  necrosis  or  local  death.  It  is, 
therefore,  if  not  a degeneration,  the  consequence 
or  accompaniment  of  degeneration.  See  Deposits, 
Calcareous. 

4.  Pigmentary  degeneration  is  a name  which 
has  been  given  to  the  changes  produced  in  a 
tissue  or  organ  by  the  deposition  or  formation 
of  pigment.  It  is  very  doubtful  whether  this 
should  always  be  described  as  a degeneration, 
since  this  change  does  not  necessarily  diminish 
the  vital  activity  of  the  part,  lower  its  physio- 
logical rank,  or  involve  a simpler  chemical  or 
anatomical  composition.  Pigmented  tumours 
do  not  show  less  vitality  than  others,  nor  is 
excessive  pigmentation  of  the  skin  or  any 
organ  where  pigment  normally  occurs,  neces- 
sarily an  accompaniment  of  degeneration.  On 
the  other  hand,  the  pigmentation  of  the  spleen 
and  liver  from  intermittent  fever,  and  that 
which  is  the  consequence  of  chronic  venous  con- 
gestion, are  often  the  accompaniment  of  fibroid 
induration,  and  thus  form  part  of  a degenerative 
process.  Pigmentation  in  general  must  not, 
therefore,  be  identified  with  pigmentary  de- 
generation. 

5.  Fibroid  degeneration  is  the  name  given  to 
a process  in  which  the  original  tissue  becomes 
replaced  by  a form  of  connective  tissue.  It  ia 
also  called  fibroid  substitution  or  fibroid  change. 
In  the  early  stages  of  this  process  we  find  the 
tissues  penetrated  with  numerous  cells  of  the 
lymphoid  type,  which  become  slowly  organised 
into  connective  tissue — at  first  of  the  cytoge- 
nous  form,  and  rarely  very  vascular.  The  in- 
filtrated lymphoid  cells  are  probably  chiefly 
derived  from  the  blood-vessels ; but  some  may 
be,  as  theory  teaches,  the  descendants  of  tissue- 
cells.  The  process  is  essentially  chronic  inter- 
stitial inflammation  ( see  Inflammation).  Since 
the  final  result  of  the  process  is  that  tissue  of 
less  physiological  value  is  substituted  for  the 
original,  the  process  may  be  described  in  general 
terms  as  a degeneration,  though  it  is  not  an 
actual  metamorphosis  of  tissue.  It  finally  leads 
to  induration,  contraction,  and  partial  atrophy. 

J.  F.  Payne. 

DEGLUTITION,  Disorders  of. — Before 
describing  the  disorders  of  deglutition  or  swal- 
lowing. it  is  necessary  to  state  briefly  in  what 
this  physiological  act  consists,  and  how  the 
process  is  performed. 

Physiology  of  Deglutition.  — The  act  of 
deglutition  is  commonly  divided  into  three 
stages.  The  first  is  a voluntary  effort,  accom- 
plished by  means  of  the  tongue  and  the  muscles 
of  the  cheeks  and  mouth,  as  far  back  as  the  ante- 
rior arch  of  the  fauces.  The  second  stage  is  an 
involuntary  act,  though  certain  voluntary  muscles 
are  engaged  in  effecting  it ; and  it  is  accomplished 
by  the  action  of  those  muscles  whose  duty  it  is  to 
retract  the  tongue,  to  raise  the  larynx  and  close 
the  glottis,  to  lift  the  soft  palate,  to  contract 
tho  fauces  and  bring  the  tonsils  in  contact 
with  the  bolus  of  food,  to  close  the  posterior 
nares,  and  to  raise  and  contract  the  pharynx. 


DEGLUTITION,  DISORDERS  OF.  335 
Then  the  food  passes  into  the  oesophagus  cr 
gullet,  when  the  third  stage  is  entered  upon  ; 
and  as  the  morsel  passes  into  this  tube,  a pro- 
gressive undulatory  or  peristaltic  movement 
of  the  gullet  is  produced,  by  which  the  bolus 
is  propelled  into  the  stomach. 

Definition. — Any  condition  which  interferes 
with  the  perfect  integrity  of  this  physiological 
process  constitutes  a disorder  of  deglutition. 
The  general  term  which  is  commonly  applied 
to  this  condition  is  Dysphagia  or  Deglutitio  Irn 
pedita,  as  it  is  sometimes  termed.  But,  in  actum 
fact,  such  conditions  will  be  found  to  be  dependent 
for  the  most  part  on  some  other  morbid  state  of 
the  structures  immediately  concerned  in  the  act  of 
swallowing,  or  of  those  in  close  proximity  to  them. 
Yet,  although  dysphagia  must,  as  a rule,  be  re- 
garded merely  as  a symptom  of  some  more  or  less 
serious  disorder,  still  it  may  be  convenient  and 
useful  to  examine  the  subject  somewhat  more  in 
detail  than  can  be  done  in  the  consideration  of 
those  affections  in  which  it  frequently  plays  so 
prominent  a part. 

^Etiology. — All  affections  of  the  throat 
modify  in  some  way  the  power  of  swallowing, 
and  render  the  act  of  deglutition  painful  and 
difficult.  Thus: — 1.  We  meet  with  it  as  one  of 
the  symptoms  in  acute  catarrh  of  the  pharynx,  in 
tonsillitis,  and  in  ulceration  of  the  throat,  which 
disturbances  are  dependent  upon  some  alteration 
in  the  mucous  membrane,  the  submucous  cellu- 
lar tissue,  or  the  muscular  tissue.  2.  Similarly, 
diseases  of  tho  larynx  may  give  rise  to  disorders 
of  deglutition;  such  as  laryngitis,  inflammation 
of  the  perichondrium  of  the  cartilages,  and 
laryngeal  polypi.  3.  Specific  diseases,  for  ex- 
ample, phthisis,  syphilis,  cancer,  scarlatina, 
measles,  and  croup,  are  another  fertile  cause  of 
difficulty  of  swallowing,  owing  to  their  affecting 
the  throat  in  various  ways.  4.  So  also  are  ner- 
vous affections,  for  instance,  post-diphtheritic 
paralysis,  hysterical  affections,  general  paralysis 
of  the  insane,  progressive  muscular  atrophy,  and 
glosso-laryngeal  paralysis.  5.  Affections  of  the 
salivary  glands,  such  as  parotitis,  may  inter- 
fere with  deglutition.  6.  (Esophageal  disorders, 
whether  functional,  or  causing  organic  obstruc- 
tion, are  important  causes  of  dysphagia.  7. 
Difficulty  of  deglutition  may  result  from  pressure 
upon  some  part  of  the  passage,  as  by  an  aneu- 
rism of  the  thoracic  aorta,  a solid  tumour, 
whether  malignant  or  benign,  or  a retro-pharyn- 
geal abscess.  All  these  causes,  though  in  differ- 
ent. degree,  offer  some  impediment  to  the  act  of 
deglutition. 

Symptoms. — Although  difficulty  in  the  act  of 
swallowing  is  the  essential  symptom  in  many 
and  various  affections,  yet  this  differs  greatly  in 
degree,  as  well  as  in  the  attendant  phenomena, 
according  to  the  pathological  condition  of  the 
parts  involved.  Thus,  when  irritation  of  any 
kind  is  met  with  in  any  part  of  the  track  through 
which  the  bolus  of  food  has  to  pass,  then  the  act 
of  deglutition  is  attended  merely  with  more  or 
less  pain,  which  in  such  cases  constitutes  the 
sole  difficulty  in  the  process.  When,  however, 
the  calibre  of  this  portion  of  the  alimentary 
canal  is  reduced  by  disease  affecting  its  own 
structure,  or  when  it  is  encroached  upon  by 
morbid  growths  or  other  disease  in  its  immediate 


336  DEGLUTITION,  DISORDERS  OF. 
vicinity,  a mechanical  impediment  is  set  up, 
which  necessitates  a certain  amount  of  voluntary 
effort  to  accomplish  the  act.  This  supplementary 
aid  is  usually  sufficient  to  propel  the  bolus  on- 
wards, and  deglutition,  though  slower  than  in 
health,  and  usually  attended  with  pain,  may 
be  successfully  performed.  It  occasionally  hap- 
pens, however,  that  the  obstruction  is  so  great 
as  to  prevent  the  passage  of  at  least  the  larger 
portion  of  the  food  downwards,  and  regurgita- 
tion takes  place  through  the  mouth  or  nostrils. 

A similar  result  is  brought  about  when  para- 
lysis affects  any  portion  of  tho  muscular  struc- 
tures concerned  in  the  act  of  swallowing,  but 
obviously  in  a different  manner.  For  example, 
in  post-diphtheritic  paralysis,  in  consequence  of 
the  implication  of  the  soft  palate  and  neighbour- 
ing structures  in  this  loss  of  power,  the  food, 
instead  of  passing  into  the  gullet,  returns  through 
the  posterior  nares. 

The  dysphagia  occasionally  observed  in  hys- 
terical persons,  and  which  appears  to  partake  of 
the  nature  of  spasm,  differs  essentially  from  those 
forms  already  described,  in  the  fact  that  it  is 
not  a constant  phenomenon. 

In  addition  to  those  varieties  of  dysphagia 
dependent  upon  morbid  conditions  of  the  appara- 
tus concerned  in  the  act  of  swallowing,  another 
kind  may  also  be  induced  by  the  nature  and 
form  of  the  articles  partaken  of.  Thus,  irritant, 
corrosive,  and  very  hot  substances  may  readily 
give  rise  to  difficulty  in  swallowing.  In  like 
manner  dysphagia  of  an  urgent  character  is  often 
caused  by  the  impaction  of  a large  bolus  of  un- 
masticated food  in  the  (Esophagus. 

Treatment. — This  willmanifestly  depend  upon 
the  recognition  of  the  cause  which  gives  rise  to 
the  impediment  in  swallowing.  Cases  of  simple 
catarrh  of  the  mucous  membrane  of  the  throat, 
and  those  produced  by  the  action  of  irritant 
substances  generally,  yield,  after  a short  inter- 
val, to  the  use  of  bland  articles  of  diet  and 
demulcents,  such  as  olive  oil,  milk,  linseed  tea, 
&e.  It  must,  however,  be  borne  in  mind  that 
permanent  stricture  of  the  oesophagus  may  be 
the  result  of  causes  such  as  those  last  mentioned. 
Of  course,  when  abscess  is  the  cause  of  the 
dysphagia,  the  evacuation  of  its  contents  will 
give  immediate  relief.  In  that  form  of  dys- 
phagia dependent  upon  diminution  of  the  calibre 
of  the  oesophagus,  the  question  of  its  treatment 
by  the  use  of  bougies  or  stomach-tubes  should  be 
considered.  See  OEsophagus,  Diseases  of. 

Tho  dysphagia  dependent  upon  specific  dis- 
orders of  the  larynx,  such  as  that  occasioned 
by  phthisis,  syphilis,  cancer,  &c.,  may  often  be 
greatly  mitigated  by  the  use  of  warm  medicated 
sprays  of  a sedative  character,  such  as  bromide 
of  ammonium,  chlorine  water,  or  other  agents. 
In  cases  acknowledging  a nervous  origin,  the 
treatment  must  bear  reference  to  the  general 
nervous  disorder  of  which  the  dysphagia  is  but 
a symptom.  Thus  hysterical  dysphagia  may  be 
speedily  removed  by  the  application  of  galvanism 
in  the  neighbourhood  of  the  oesophagus.  Post- 
diphtheritic  dysphagia  usually  disappears  as  the 
health  of  the  patient  improves,  and  is  to  be  treated 
by  the  administration  of  nervine  tonics,  such  as 
strychnia,  iron,  and  quinine. 

C.  Muirhead. 


DELHI  SORE 

DELHI  SOHE  OH  BOIL.—  Syson. 

Aleppo  Evil;  Mycosis  Cutis  Chronica  (V, 
Carter) ; Lupus  Endemicus  (Lewis  and  Cunning- 
ham) ; Oriental  Sore  (Fox).  Fr . Bouton  d Ale-p  \ 
Ger.  Beule  von  Alep. 

Definition. — An  indurated,  indolent,  and  very 
intractable  sore  ; papular  in  the  early,  encrusted 
or  fungating  in  the  advanced  stages ; spreading 
by  ulceration  of  skin ; single  or  multiple ; and 
often  occupying  extensive  surfaces  of  the  exposed 
parts  of  the  body,  such  as  the  face,  neck,  and 
extremities.  It  is  capable,  if  inoculated,  of  re- 
producing the  disease ; and  it  also  affects  dogs 
and  horses. 

Geographical  Distribution. — This  disease 
occurs  in  India,  especially  the  North-west  Pro 
vinces,  Punjab,  Cabuland  Scinde,  Persia,  Arabia, 
Crete,  the  Sahara  of  Africa,  perhaps  China,  and 
doubtless  wherever  certain  peculiar  conditions  of 
soil  and  hot  climate  co-exist.  Though  called 
Delhi  boil,  it  is  neither  a furunculus,  nor  is  it 
peculiar  to  that  city.  The  Scinde  boil,  the  sores 
of  Roorkie,  Moultan,  Lahore,  Meerut,  other 
crowded  Indian  cities,  and  Aden,  are  probably 
only  varieties,  if  not  identical.  The  same  may 
be  said  of  the  Bouton  d’Alep,  of  Biskra,  Bus- 
sorah,  Baghdad,  and  Crete.  Slight  differences 
may  exist,  but  essentially  they  are  the  same 
disease.  The  Yeinan  and  Cochin  China  sores 
are  probably  varieties,  as  are  other  indolent  in- 
durated and  intractable  sores  occurring  in  per- 
sons of  impaired  health,  residing  in  hot  and 
malarious  climates,  who  use  certain  hard  waters, 
and  in  whom  there  is  neither  syphilitic  nor 
strumous  taint. 

.ZEtiology  and  Pathology. — Drs.  Fleming  and 
Smith,  V.  Carter,  and  Lewis  and  Cunningham 
give  the  best  account  of  the  disease.  Though 
called  a local  disease,  it  is  probable  that  the  state 
of  the  health  has  much  to  do  with  its  production, 
certain  conditions  of  climate,  soil,  and  especially  of 
drinking  water  being  concerned.  Furunculi  of  a 
severe  and  painful  though  different  character  are 
prevalent  in  hot  climates  at  certain  seasons  of  the 
year,  in  enervating  and  malarious  climates  like 
India,  especially  after  the  rains,  i.c.  towards  the 
termination  of  the  most  exhausting  season,  when 
the  vital  powers  have  been  depressed  during 
the  preceding  months,  and  the  functions  of  the 
liver  and  spleen  are  impaired.  The  blood, 
imperfectly  elaborated,  and  not  freed  from  ex- 
crementitious  matter,  is  then  in  a condition  in 
which  it  not  only  ministers  imperfectly  to  nu- 
trition, but  is  prone  to  fibrinous  coagulations, 
which  cause  capillary  embolism,  giving  rise  to 
local  starvation  and  death  of  minute  portions  of 
areolar  tissue  in  or  under  the  integument.  These 
result  in  suppuration,  which  is  set  up  for  the 
purpose  of  getting  rid  of  the  dead  fragment  or 
core.  An  analogous,  though  perhaps  not  pre- 
cisely similar  pathological  condition  may  be  con- 
cerned in  the  causation  of  the  Delhi  sore,  and 
is  not  incompatible  with  an  otherwise  fairly 
good  condition  of  the  general  health.  Water,  soil, 
food,  bites  or  stings  of  insects,  parasites,  insani- 
tary conditions,  such  as  exist  in  crowded  native 
cities,  have  all  been  charged  with  causing  the 
disease.  Improved  hygiene,  planting  of  trees,  and 
change  of  water,  food,  and  locality,  have  all  been 
credited  with  benefit  in  the  treatment  of  it.  The 


DELHI  SORE. 

fact  that  this  peculiar  form  of  sore  manifests  itself 
under  similar  climatic  conditions  in  other  parts  of 
the  world,  which,  it  is  to  be  noted,  are  generally 
those  of  the  more  arid  regions,  and  that  it  occurs 
most  frequently  at  the  most  exhausting  season, 
seems  to  point  to  a constitutional  state  as  a pre- 
disposing cause. 

The  disease  is  not  confined  to  human  beings  ; 
in  Delhi  it  lias  been  observed  that  dogs  are  very 
liable  to  be  affected,  especially  in  the  nose,  and 
this,  from  the  position  of  the  sore,  has  been  ad- 
duced as  strong  evidence  in  favour  of  the  theory 
that  it  is  due  to  the  presence  of  a parasitic  ovum 
which  finds  its  way  there  from  the  water.  In 
some  districts  other  animals  are  affected;  and 
it  seems  probable  that  the  indolent,  indurated, 
and  intractable  sore  that  horses  are  liable  to  in 
India,  called  Bu.rsattie  (Rain  Sore)  is  of  the  same 
character.  Further  investigation  into  the  cau- 
sation and  pathology  of  Delhi  boil  is  needed, 
especially  with  reference  to  the  action  of  drink- 
ing water,  and  the  nature  of  the  structures  that 
form  the  essential  constituents  of  the  disease. 

Anatomical  Characters. — When  the  Delhi 
sore  is  cut  into,  yellowish  points  are  seen,  con- 
sisting of  minute  cellular  growths,  which  have 
been  described  by  Dr.  Smith  as  the  ova  of  a 
parasite  ( Distoma ),  and  by  others  as  of  vegetable 
origin,  but  are  probably  the  result  of  cell- 
growth,  connected  with  the  hair-  and  gland- 
follicles,  perhaps  an  abnormal  development  of 
connective-tissue  corpuscles,  or  an  imperfect  form 
of  granulation.  After  ulceration  has  disinte- 
grated the  surface,  mycelium  or  other  low  forms 
of  organism  may  be  present ; but  it  is  a question 
if  these  be  the  essential  cause,  and  not  rather  an 
accident  of  the  disease,  introduced  from  without. 
Dr.  V.  Carter  refers  Delhi  boil  to  a parasitic 
organism,  consisting  of  spheroids  and  mycelium, 
which  occupies  the  distended  lymphatic  ves- 
sels in  and  around  the  sore,  arranged  in  open  and 
angular  meshes,  the  free  ends  giving  off  conidia 
which  multiply  and  reproduce.  Pale,  round  or 
stellate  granulation-cells  are  found  ; numerous 
bright  orange-tinted  particles,  arranged  as  sphe- 
rical or  ovoid  groups  disseminated  throughout 
the  tissues  of  the  tumour.  These,  it  is  consi- 
dered, are  the  fructification-stage  of  the  fun- 
gus. Lewis  and  Cunningham  describe  lymphoid 
nucleated  cells,  the  products  of  a condition  which 
they  consider  as  identical  with  that  of  lupus,  and 
which  they  ascribe  to  the  action  of  the  chemical 
constituents  of  certain  hard  waters. 

Symptoms. — Delhi  sore  commences  as  a small 
pink  and  reddish  papule,  like  a mosquito  bite, 
which  gradually  extends,  generally  around  a 
hair-follicle  as  its  centre.  This  is  elevated,  and 
after  a time  desquamates.  There  is  itching  and 
a stinging  sense  of  pain ; on  pressure  it  is 
somewhat  boggy.  The  progress  of  the  disease 
is  slow,  often  occupying  several  weeks,  during 
which  time  it  assumes  a semi-transparent  ap- 
pearance, with  blood-vessels  ramifying  near  the 
surfaco.  A vesicle  then  rises,  bursts,  and  gives 
exit  to  an  ichor  which  forms  a crust ; under 
ihis,  suppuration  and  ulceration  take  place  and 
advance  until,  by  the  coalescence  of  several  pa- 
pules and  destruction  of  skin,  an  indurated  sore 
is  formed,  which  is  either  crusted  over  or  fun- 
gates.  The  sore  gradually  invades  the  surrounding 

22 


DEMENTIA.  337 

parts,  and  destroying  the  integument,  may  give 
rise,  especially  on  the  face,  to  deformity  from 
cicatricial  contraction ; and  from  the  irritation 
and  the  pain  it  causes,  may,  when  the  number 
and  extent  of  the  sores  are  large,  seriously  com- 
promise the  health.  An  ordinary  boil  or  abra- 
sion may  assume  these  specific  characters.  The 
disease  is  regarded  as  contagious,  and  apparently 
may  be  produced  by  inoculation  of  the  specific 
cell-matter,  though  not  by  the  pus  which  formt 
on  the  surface. 

Treatment. — Preventive. — Cleanliness  of  per- 
son, clothing,  and  habitation,  good  food,  the  use 
of  pure  drinking  water,  and  careful  attention  to 
the  sanitary  condition  of  the  locality, — avoiding 
overcrowding  and  contact  with  the  disease  in 
men  or  animals, — are  the  best  means  of  prevent- 
ing Delhi  sore. 

Curative. — Change  of  locality,  when  practic- 
able ; in  some  cases  early  destruction  of  the 
sore  by  the  potential  or  actual  cautery;  the  ap- 
plication of  metallic  astringents,  iodine,  carbolic 
acid  lotion  ; pressure ; attention  to  the  state  of 
the  health,  and  any  ailment  that  may  be  pre- 
sent; tonics  and  nutritive  diet,  and  especially 
change  of  drinking  water  ; and  change  to  another 
climate, — are  the  most  effective  measures. 

In  the  advanced  conditions  of  the  disease 
similar  measures  are  indicated.  The  sore,  if 
too  extensive  to  be  destroyed,  should  be  dressed 
with  stimulating  and  astringent  applications. 
Soothing  measures  are  indicated  if  there  is 
pain.  Dlack  wash,  sulphate  and  carbolate  of 
zinc,  copper,  Gurjon  oil,  and  lime  water,  with 
change  of  climate,  and  the  use  of  tonics,  will 
generally  prove  efficient. 

Joseph  Eayrer. 

DELIRIUM  ( deliro , I rave). — A derange- 
ment of  consciousness,  characterised  by  inco- 
herence of  thought,  and  evidenced  by  various 
expressions  and  actions.  See  • Consciousness. 

Disorders  of. 

DELIRIUM  TREMENS  ( delirium  tre- 
mens, trembling  delirium). — A form  of  acute 
alcoholism,  chiefly  characterised  by  delirium  and 
tremors.  See  Alcoholism. 

DELUSION  (dcludo,  I deceive).— A false 
belief  in  some  fact  which  almost  invariably  con- 
cerns the  patient,  of  the  falsity  of  which  he 
cannot  be  persuaded,  either  by  his  own  know- 
ledge and  experience,  by  the  evidence  of  his 
senses,  or  by  the  declarations  of  others.  Such 
delusions,  when  distinguished  from  merely 
erroneous  judgments  upon  abstract  questions, 
generally  indicate  insanity.  See  Consciousness, 
Disorders  of. 

DEMENTIA(<fe,  without,  and  mens,  a mind). 

- — Synon.  : Fr.  Demence-,  Ger.  Blodsinn. 

Definition. — A mental  weakness,  or  a defi- 
ciency rather  than  an  aberration  of  intellect, 
depending  for  the  most  part  on  some  antecedent 
brain-disorder,  such  as  apoplexy  or  epilepsy, 
or  being  the  sequel  and  termination  of  various 
forms  of  insanity.  It  may  also  be  congenital, 
deserving  rather  the  name  of  idiocy;  or  may 
be  due  to  senile  decay. 


DEMENTIA. 


388 

1.  Acute  Primary  Dementia. — There  is  a 
form  of  insanity  known  as  primary  or  acute 
dementia,  which  comes  on  rapidly  without  any 
preceding  disorder,  is  accompanied  ky  the  most 
profound  vacuity  aDd  abeyance  of  all  the  mental 
faculties,  yet  yields  to  treatment  and  disappears, 
leaving  the  patients  sane. 

-ZEtiology. — The  patients  are  young  persons, 
boys  and  girls, — more  frequently  girls.  The 
complaint  is  seldom  seen  in  any  case  beyond 
the  age  of  30,  and  chiefly  in  those  under  20.  It 
seems  to  be  a collapse  of  all  mental  power,  due 
to  great  physical  weakness  and  deficient  nerve- 
force.  Owing  to  imperfect  development,  to  bad  food 
and  living,  or  to  the  patients  having  outgrown 
their  strength,  the  mental  condition  becomes  so 
weakened  that,  with  or  without  some  moral  cause, 
as  a fright  or  a scolding  or  something  apparently 
more  trivial,  or  after  some  illness  slight  or 
severe,  they  suddenly  or  gradually  present  that 
condition  which  is  now  to  be  described.  If  the 
immediate  exciting  cause  is  some  mental  shock 
or  fright,  the  symptoms  may  come  on  rapidly. 
If  they  are  due  to  ill-health  or  some  protracted 
exhausting  occupation,  the  access  may  be  gradual ; 
and  if  it  is  set  down  to  sulkiness,  temper,  or 
idleness,  the  measures  adopted  for  the  correction 
of  the  latter  may  quickly  indicate  the  real  state 
of  things. 

Symptoms. — Nothing  can  appear  more  hopeless 
than  the  appearance  many  of  these  patients  pre- 
sent. The  face  is  vacant,  with  a fatuous  grin,  and 
often  the  saliva  dribbles  continuously.  The  suf- 
ferer sits  motionless  and  lost,  or  automatically 
wags  the  head,  snaps  the  jaws,  or  moves  the  limbs 
for  hours  together  unconscious  of  fatigue.  Or  if  a 
limb  is  placed  in  any  position,  it  is  retained  there 
for  a time  in  a way  that  no  effort  of  will  could 
accomplish.  There  may  be  a repetition  of  some 
word  or  sentence,  but  all  conversation  is  abolished, 
and  the  patient  has  to  be  fed,  washed,  and  tended 
like  a baby. 

The  physical  condition  of  these  patients  is 
peculiar,  and  corresponds  closely  to  the  mental. 
The  heart’s  action  and  the  circulation  are  so  re- 
duced in  strength  that  the  blood  in  the  extremities 
is  stagnant.  Hands  and  feet  are  blue  with  cold 
even  in  the  heat  of  summer.  In  cold  weather 
they  are  covered  with  chilblains,  and  great  care 
must  be  taken,  otherwise  these  will  give  rise  to 
obstinate  sores.  The  tongue  is  pale  and  flabby, 
the  pupils  are  dilated.  There  is  no  rapid  emacia- 
tion, for  tho  waste  here  is  not  great ; neither  is 
sleep  absent,  as  in  mania,  but  it  is  irregular  and 
uncertain. 

Pathology. — Theexternal  physical  manifesta- 
tions sufficiently  indicate  the  condition  of  the 
brain  in  these  patients.  It  is  the  very  opposite  of 
that  in  acute  sthenic  delirious  mania.  In  the  latter 
there  is  an  excessive  discharge  of  nervous  force, 
an  hypersemic  state  of  brain,  and  rapid  brain- 
circulation,  the  whole  leading  in  a short  time  to 
death  by  exhaustion  if  relief  does  not  come.  In 
acute  dementia  we  see  the  very  opposite.  The 
brain-action  is  reduced  to  the  lowest  point,  and 
the  circulation  is  stagnant,  as  in  the  extremities, 
giving  rise  to  passive  congestion  and  oedema. 

Cotjkse,  Terminations,  and  Prognosis. — In 
acute  dementia  there  is  no  sudden  exhaustion; 
but  death,  if  if  occurs,  is  caused,  not  bv  the 


brain-disease,  but  by  a general  failure  of  the 
bodily  strength,  or  by  some  low  form  of  lung- 
disease  — phthisis,  pneumonia,  or  gangrene. 
Death,  however,  in  this  disorder  is  the  excep- 
tion. When  taken  in  time  and  properly  treated, 
the  majority  of  these  seemingly  hopeless  cases 
recover,  and  recover  perfectly. 

Treatment. — The  treatment  of  acute  dementia 
may  be  carried  out  in  a family,  or  even  at  home, 
if  means  are  ample,  and  if  the  necessary  mea- 
sures are  strictly  enforced.  But  it  may  be  neces- 
sary to  feed  the  patient  by  force,  and  that  for  a 
considerable  time,  and  relations  do  not  always 
care  to  enforce  this  to  the  extent  required. 
Abundant  nutrition  is  imperatively  demanded  in 
order  to  restore  the  force  that  is  so  greatly  in 
defect,  and  unless  abundant  nutrition  is  adminis- 
tered, there  will  be  no  recovery,  but  the  patient 
will  die,  or  sink  into  permanent  dementia.  There 
is  not  as  a rule  violent  resistance  to  food,  but  it 
may  be  kept  in  the  mouth  without  being  swal- 
lowed, and  care  must  be  taken  in  feeding,  even  if 
a stomach-tube  be  not  necessary.  Food  should 
be  given  frequently,  and  so  a habit  of  taking  it 
engendered.  Stimulants,  wine  and  brandy,  will 
be  necessary,  especially  in  the  early  stages. 
Equally  necessary  is  warmth ; an  amount  of 
heat  is  required  which  to  those  in  health  wculd 
be  oppressive,  for  the  greatest  heat  of  summer 
fails  to  warm  the  hands  and  feet.  Warm  clothing 
must  be  provided,  and  the  circulation  aided  by  a 
short  sharp  shower-bath,  cold  or  tepid,  and  plenty 
of  friction  afterwards.  Exercise  is  useful  for 
the  same  purpose,  but  this  is  to  be  taken  under 
proper  supervision,  for  it  must  not  be  fatiguing, 
and  due  regard  ought  to  be  bad  to  the  debili- 
tated state  of  the  individual.  In  addition  to 
the  stimulus  of  the  shower-bath,  that  of  elec- 
tricity is  of  great  use  in  acute  dementia.  Here, 
and  in  certain  cases  of  melancholia,  marked 
benefit  follows  the  application  of  the  constant 
current.  Of  drags  the  most  useful  appear  to  be 
steel  and  quinine.  The  former,  in  this  as  in 
almost  every  form  of  insanity,  is  a most  valuable 
tonic : the  choice  of  the  particular  preparation 
should  depend  upon  tho  state  of  the  patient  a: 
the  time. 

2.  Chronic  Primary  Dpmentia. — Dementia, 
however,  may  be  primary,  yet  may  not  be  that 
just  described.  It  may  come  on  gradually ; or 
suddenly  without  previous  mental  affection,  but 
is  in  such  cases  connected  almost  invariably 
with  disease  of  the  brain.  Its  first  and  most 
prominent  symptom  is  loss  of  memory.  In 
connexion  with  apoplectic  or  epileptic  attacks, 
or  after  years  of  drinking,  the  memory  is  found 
defective.  This  may  appear  quite  suddenly,  or 
may  be  noticed  to  come  on  gradually,  being  at 
first  so  slight  as  to  cause  little  alarm.  It  mar 
vary  at  different  times.  If  a patient  is  kept  from 
alcohol,  the  memory  may  gain  strength,  and  if 
epileptic  attacks  are  reduced  in  frequency,  the 
same  thing  may  happen.  The  prognosis  in  all 
such  cases  is  unfavourable,  for  loss  of  memory 
points  to  decided  deterioration  of  brain.  Apart 
from  loss  of  memory,  symptoms  of  dementia  or 
weakness  of  mind  are  occasionally  found  as  the 
first  indication  of  mental  unsoundness,  follcwimr  a 
fright  or  shock  or  some  severe  illness.  If  they 
assume  the  form  of  acute  dementia,  we  may  have 


DEMENTIA. 

(lopes  that  they  ■will  pass  away,  but  if  with  little 
disturbance  of  the  bodily  health  the  mind  be- 
comes weaker  and  weaker,  the  hopes  of  recovery 
are  small. 

3.  Secondary  Dementia.  — Of  dementia 
which  is  the  sequel  to  prior  mental  disorder, 
such  as  mania  and  melancholia,  little  need  bo 
said.  It  varies  in  degree,  but  it  is  not  in  our 
power  to  remove  it.  It  may  be  in  our  power,  how- 
ever, to  ameliorate  in  a great  degree  the  condition 
of  such  patients  when,  as  is  frequently  the  case, 
they  are  found  in  a very  neglected  state.  Their 
friends  think  that  nothing  can  be  done  or  need  be 
done,  and  they  are  allowed  to  lie  in  bed,  often  in  a 
filthy  condition,  or  roam  about  and  get  into  mis- 
chief for  want  of  care  and  skilled  attendance. 
Many  demented  patients  have  far  more  mind 
than  is  generally  imagined  by  the  uninitiated,  and 
can  be  taught  to  be  cleanly,  to  take  their  meals 
in  an  orderly  fashion,  and  to  keep  themselves 
tolerably  neat.  They  are  susceptible  of  amuse- 
ment, and  open  to  reward  for  good  behaviour. 
The  vital  powers  of  demented  patients  are  low, 
and  they  suffer  much  from  cold.  In  winter  their 
ninds  like  their  bodies  are  enfeebled,  and  with 
warm  weather  they  recover  somewhat  of  their 
energy.  There  is  a tendency  in  many  of  these 
patients,  especially  women,  to  become  very  fat, 
and  in  this  condition  they  are  subject  to  bron- 
chitis, and  many  succumb  to  acute  attacks  of 
this  disorder.  They  require  warmth  and  good 
diet,  for  it  is  difficult  to  make  them  take  sufficient 
exercise. 

Females,  in  the  writer’s  experience,  are  more 
prone  to  drift  into  dementia  than  males.  Tho 
latter  present  various  tj'pes  of  chronic  mania, 
with  well-marked  delusions  ; but,  among  private 
patients  at  any  rate,  there  are  fewer  of  the  hope- 
lessly demented  than  among  the  female  inmates 
of  private  asylums.  One  cause  of  this  may  be 
that  the  mortality  amongst  males  is  greater,  and 
thus  fewer  are  left  to  reach  the  demented  stage. 

G.  F.  Blandford. 

DEMODEX  (Sejuas,  a body;  and  Sl/J,  a 
timber- worm).  — A genus  of  acarine  parasites, 
established  by  Owen  for  the  reception  of  the 
human  pimple  mite  (D.  folliculorum),  which  is 
sometimes  spoken  of  as  the  Simonia  or  Entozoon 
folliculorum.  It  infests  the  sebaceous  follicles, 
especially  those  situated  upon  the  sides  and  aim 
of  the  nose.  The  body  is  vermiform,  owing  to 
the  great  length  of  the  abdomen,  but  the  entire 
animal  rarely  exceeds  tho  of  an  inch  from 
head  to  tail.  Gruby  and  others  have  succeeded 
in  inoculating  dogs  with  this  parasite,  which 
has  also  been  found  in  mange- affected  animals 
not  previously  subjected  to  experiment.  In  man, 
when  occurring  in  large  numbers,  they  cause 
the  formation  of  prominent  pimples,  which  often 
present  an  unsightly  appearance.  Each  whitish 
spot  or  enlarged  follicle  presents  to  the  naked 
eye  a terminal  black  point,  and  it  contains  not 
only  full-grown  animals  (having  their  tails 
directed  towards  the  opening)  but  also  eggs, 
larvae,  and  exuviae.  Their  presence  rarely  gives 
rise  to  inconvenience  other  than  that  resulting 
from  unsightliness.  Infected  persons,  however, 
s.rc  extremely  glad  to  get  rid  of  them,  and  this 
may  be  done  by  the  application  of  mercurial 


DENGUE.  339 

ointments,  by  the  frequent  use  of  a corrosive  sub- 
limate lotion  (2  grains  to  1 ounce  of  water),  or.  as 
the  writer  has  found,  by  rubbing-in  glycerine  of 
carbolic  acid  after  warm  water  fomentations.  A 
coarser  method  of  treatment  consists  in  evacua- 
ting the  pustular  contents  by  small  incisions 
and  pressure.  By  forcibly  bursting  the  follicles 
and  squeezing  out  the  contents  small  ugly  scars 
are  apt  to  be  subsequently  formed.  Sec  Acarus. 

T.  S.  Cobbold. 

DEMULCENTS  (demulceo,  I stroke  softly). 

Definition. — Substances  which  soften,  pro- 
tect, and  soothe  mucous  membranes.  They  are 
generally  of  a mucilaginous  character;  and  when 
applied  to  the  skin  are  termed  emollients. 

Enumeration. — Tho  demulcents  in  ordinary 
use  are — Linseed-tea,  Gum,  Starch,  Bread, 
Honey,  Figs  ; Linseed,  Almond,  and  Olive  Oil ; 
Glycerine,  White-of-Egg,  Gelatine,  and  Isinglass. 

Action. — The  chief  action  of  demulcents  is  a 
mechanical  one,  in  forming  a smooth,  soft  coat- 
ing for  an  inflamed  mucous  membrane,  and  thus 
protecting  it  from  external  irritation. 

T.  Lauder  Brunton. 

DENGUE. — Stnon.  : Dandy  fever  (West 
Indies);  Three-day  fever;  Break-bone  fever; 
Er.  and  Ger.  Dengue. 

Definition. — An  infectious,  eruptive  fever, 
commencing  suddenly,  and  characterised  by 
severe  pain  in  the  head  and  eyeballs  ; swelling 
and  pain  in  the  muscles  and  joints,  prone  to 
shift  suddenly  from  joint  to  joint;  catarrhs.! 
symptoms;  sore-throat;  congested  conjunctivas; 
and  affection  of  the  submaxillary  glands.  The 
disease  may  remit,  and  is  liable  to  relapse. 

Natural  History  and  Geographical  Dis- 
tribution.— Dengue  occurs  epidemically  and 
sporadically  in  India,  Burmah,  Persia,  Egypt 
and  other  parts  of  Africa,  North  and  South 
America,  and  the  West  Indies.  It  is  not  known 
in  Britain.  Epidemic  visitations  of  dengue,  ex- 
tending over  wide  tracts  of  country,  occur  at 
considerable  intervals,  and  probably  depend  on 
certain  unknown  atmospheric  and  cosmic  con- 
ditions that  favour  its  development. 

.ZEtiology. — Dengue  attacks  persons  of  all 
ages,  from  infancy  to  extreme  old  age.  1 1 
certainly  is  infections,  as  has  been  proved  by 
many  cases  in  which  the  disease  has  been  con- 
veyed from  person  to  person. 

Symptoms. — Those  characteristic  of  dengue 
are  the  presence  of  severe  continuous  arthritic 
and  muscular  pains  ; great  debility  and  prostra- 
tion ; the  occurrence  of  an  initial  and  a ter- 
minal rubeoloid  or  scarlet  rash  ; fever,  which  is 
subject  to  remissions  and  relapses ; the  possi- 
bility that  convalescence  may  be  tedious  and 
painful,  and  complicated  by  the  continuance  of 
general  cachexia,  pain  and  swelling  of  joints, 
enlargement  of  glands,  orchitis,  weakness  of 
eyes,  deafness,  visceral  disease  (such  as  diarrhoea 
or  dysentery  of  a chronic  and  intractable  charac- 
ter, and  hepatic  derangement)  boils,  carbuncles, 
and  perhaps  insanity.  In  the  female,  uterino 
haemorrhage  and  miscarriage  may  occur. 

The  invasion  of  dengue  is  usually  sudden,  the 
patient  feeling  well  up  to  the  period  of  attack. 
The  earliest  symptom  is  severe  pain  in  eomr 


DENGUE. 


340 

joint,  probably  of  a finger,  which  rapidly  extends 
to  all  the  other  joints  and  bones ; and  this  pain 
during  the  progress  of  the  disease  often  passes 
from  one  joint  to  the  other  by  a sort  of  meta- 
stasis. Sometimes  there  is  a period  of  prelimi- 
nary malaise,  of  one  or  more  days’  duration, 
marked  by  anorexia,  a sense  of  weariness  and 
languor,  giddiness,  nausea,  chilliness  or  rigor, 
severe  pain  in  the  head — localised  or  in  the  eye- 
balls, and  pains  in  the  body,  limbs,  and  joints, 
notably  of  the  fingers  and  toes.  The  attack  is 
often,  however,  strikingly  sudden,  as  was  fre- 
quently seen  in  the  last  Calcutta  epidemic,  com- 
mencing with  violent  pains  and  swelling  of 
the  joints,  or  severe  pains  in  the  head,  eyeballs, 
neck,  and  back.  In  some  epidemics  certain 
phenomena  are  more  prominently  marked  than 
others. 

The  eruption  commences  on  the  third  day. 
The  fever  is  accompanied  by  redness  of  the  face, 
which  is  puffy  and  swollen;  sore-throat;  con- 
gested conjunctiva;  and  a general  redness,  like 
the  scarlatinal  rash,  extending  over  the  whole 
body.  The  tongue  is  red  at  the  tip  and  edges, 
and  loaded  with  white  fur,  through  which  the  red 
papillae  protrude.  Thepulse  is  rapid,  ranging  from 
102  to  120,  or  even  140  ; respiration  is  hurried ; 
and  the  temperature  rises  to  103°  or  even  105°. 
These  symptoms  mark  the  occurrence  of  the 
initial  fever  and  rash,  and  endure  for  a period 
varying  from  one  day  to  forty-eight  hours. 
After  this  the  rash  disappears,  the  fever  sub- 
sides, and  the  remission  lasts  for  a period  of 
two,  three,  or  four  days.  A recurrence  of 
febrile  symptoms  then  takes  place,  accompanied 
by  a second,  or  terminal  rash.  This  differs  in 
character  from  the  first,  resembling  a rubeoloid 
or  even  an  urticarial  eruption,  often  showing 
itself  first  on  the  palms  of  the  hands,  and  in  some 
cases  resulting  in  profuse  desquamation  of  the 
cuticle,  though  it  may  sometimes  be  so  slight 
as  to  be  barely  perceptible.  These  symptoms 
gradually  subside,  leaving  the  patient  weak,  ex- 
hausted, and  often  still  tortured  by  swelling  and 
pain  of  the  joints,  especially  the  smaller  ones, 
which  may  continue  in  this  state  for  weeks, 
making  convalescence  tedious  and  painful.  Or 
there  may  be  repeated  relapses,  prolonging  the 
suffering  and  protracting  recovery. 

Varieties. — The  symptoms  vary  in  different 
cases,  as  to  the  character  of  the  rash,  the  tem- 
perature, and  the  muscular  or  osseous  pains. 

The  rash  not  only  varies  considerably  in  co- 
lour, character,  and  duration,  but  it  is  sometimes 
almost  absent;  in  other  cases  it  is  attended  with 
so  much  hypersemia  and  action  of  the  skin  that 
excessive  desquamation  results.  This  hyper- 
aemia  also  sometimes  expresses  itself  by  haemor- 
rhage from  the  mouth,  nose,  bowels,  and  uterus. 

The  fever  is  sometimes  accompanied  by  de- 
lirium, or  in  children  by  convulsions ; in  the 
latter,  indeed,  these  occasionally  initiate  the 
disease. 

Dengue  occasionally  assumes  a malignant 
form,  where  the  amount  of  poison  received  has 
been  overwhelmingly  large.  Dr.  Charles  says  : 
• Drowsiness  may  have  passed  into  coma ; the 
temperature  verges  on  the  hyperpyretic ; the 
heart  fails,  and  the  lungs  are  cedcmatous  : while 
tbe  whole  surface  is  highly  cyanotic.  These  cases 


have  been  popularly  termed  “ black  fever,”  urn 
are  justly  much  dreaded.’  Happily  such  cases 
are  rare.  Again,  there  are  very  mild  forms  of 
the  disease,  in  which  the  patients  are  scarcely 
ill,  and  where  it  is  not  easy  to  decide  as  to  their 
exact  nature  ; ‘ A trifling  sore  throat  and  slight 
malaise  may  be  all  you  can  lay  hold  of  till  the 
terminal  rash  appears  to  show  you  what  you 
have  had  to  deal  with ; and  even  this  may  not 
be  seen.’ 

Course,  Duration,  and  Complications. — The 
period  of  incubation  of  dengue  is  probably  from 
five  to  six  days ; it  may  be  a day  or  two  more 
or  less  in  some  cases. 

In  simple  and  uncomplicated  cases  the  average 
period  for  the  duration  of  the  disease  may  be 
taken  as  about  eight  days;  but  it  .is  frequently 
prolonged  over  weeks,  and  recovery  is  slow  and 
painful;  the  constitution  often  being  so  much 
shattered  that  complete  restoration  to  strength 
and  vigour  does  not  occur  for  months.  It  is 
rarely  fatal.  Belapses  are  liable  to  be  frequent, 
and  the  patient  may  suffer  more  than  even  a 
second  or  a third  relapse  before  recovery. 

Some  of  the  scquelts  already  mentioned  may 
remain  to  torture  the  patient  and  retard  his 
recovery.  Albumen  is  occasionally  present  in 
the  urine;  but  it  is  not,  as  in  scarlatina,  espe- 
cially in  the  cases  of  children,  a frequent  or 
dangerous  result  of  the  disease. 

Diagnosis. — The  distinction  betwixt  scarla- 
tina and  dengue  is  well  marked ; though  during 
the  outset  there  is  considerable  resemblance 
between  the  two  diseases.  There  is  a high 
temperature  at  first  in  both,  but  it  is  more 
quickly  attained,  and  is  transient  in  dengue  ; in 
scarlatina  it  endures  for  several  days,  whilst  in 
dengue  the  fastigium  gives  a temperature  of 
103°,  or  even  up  to  105°  or  107°,  and  this  being 
attained  it  rapidly  declines.  It  is  exceptional 
to  find  a temperature  above  102°  maintained  in 
dengue.  In  scarlatina  the  period  of  decline  ex- 
tends over  several  days,  and  is  marked  by  slight 
exacerbations  in  the  evening.  In  dengue  it 
occupies  a few  hours,  and  the  temperature  may 
even  fall  below  the  normal  standard.  The  severe 
muscular  and  arthritic  pains  of  dengue  do  not 
occur  in  scarlatina ; and  the  pulse  in  the  latter 
is  much  more  rapid  in  the  early  stages  than  in 
the  former.  The  initial  rash  in  dengue  occurs 
sooner  than  the  eruption  in  scarlatina. 

Prognosis. — An  attack  of  dengue  does  not 
confer  absolute  protection  from  a recurrence  of 
the  disease,  though  it  does  so  to  a great  extent. 

Treatment. — This  is  a specific  fever,  and  has 
to  run  a certain  course.  The  treatment  is 
simple,  and  if  judiciously  directed  mitigates  the 
sufferings,  and  materially  ails  recovery. 

Neither  emetics  nor  active  purgatives  are 
necessary.  They  do  no  good,  but  increase  the 
weakness  and  aggravate  the  suffering  by  the 
muscular  movements  necessarily  induced.  Mode- 
rate action  of  the  bowels  is  advisable,  followed 
by  a warm  carminative  aperient,  or  an  occasional 
dose  of  calomel,  rhubarb,  or  colocynth,  especially 
if  the  bowels  remain  confined,  to  which  there 
does  not  appear  to  be  any  peculiar  tendency, 
though  the  evacuations  may  be  dark  and  often 
slimy,  and  confined  at  the  outset  Salines,  such 
as  the  acetate  of  ammonia,  or  citrate  of  potash 


DENGUE. 

with  nitric  ether,  combined  with  aconite,  are 
good  during  the  pyrexia.  In  cases  of  very  high 
temperature  (105°  to  107°)  Dr.  Charles  suggests 
cold-sponging  as  beneficial ; he  recommends  it 
when  105°  is  reached.  The  danger  to  life  of 
such  a high  temperature  during  the  intense  heat 
of  the  hot  months  in  India  is  great ; and  it  is 
then  that  cold  sponging  or  the  cold  bath  is 
indicated. 

Belladonna  seems  to  confer  great  relief  in 
this  disease  ; ten  to  fifteen  drops  of  the  tincture 
may  be  given,  and  two  or  three  such  doses  at 
intervals  of  an  hour  will  sometimes  produce 
excellent  effects,  and  afford  much  relief.  The 
extract  may  be  given  if  preferred,  in  doses  of 
one-third  of  a grain;  or  the  juice  in  similar 
doses  to  those  of  the  tincture.  For  the  pains 
and  nocturnal  restlessness,  morphia  or  Dover's 
powder  may  be  given.  Liniments  containing 
opium,  belladonna,  and  chloroform  are  service- 
able as  external  applications  to  the  spine,  back, 
and  joints. 

Tonics,  and  a carefully-regulated  nutritious 
diet,  are  also  indicated,  and  depletive  measures 
must  be  avoided.  The  tonics  should  be  of  the 
bitter  vegetable  kind,  such  as  gentian  and  ca- 
lumba;  with  these  may  be  combined  a small 
quantity  of  quinine,  with  a mineral  acid;  or, 

. n some  cases,  the  dilute  phosphoric  acid,  com- 
nined  with  nux  vomica  or  small  doses  of  strych- 
nine. 

Quinine  is  given  more  for  its  tonic  than  for 
its  antiperiodic  effects  ; though,  where  there  is 
a tendency  to  relapses,  the  judicious  administra- 
tion of  five-  or  even  ten-grain  doses  may  be  bene- 
ficial in  arresting  them.  Bromide  of  potassium 
s recommended  by  some  authorities,  and  es- 
pecially when  convulsions  occur  in  children. 
Alkalies,  colchicum,  and  other  remedies  in  use 
in  rheumatism  have  been  found  to  have  little,  if 
any,  effect  in  relieving  the  pains  of  dengue. 

As  to  wines,  claret  is  probably  the  best,  but 
others  may  be  given. 

For  the  irritation  of  the  skin,  which  is  some- 
times very  troublesome,  the  application  of  cam- 
phorated oil,  and  the  use  of  warm  baths  have 
been  suggested. 

As  in  so  many  other  diseases,  especially  those 
that  occur  to  Europeans  in  tropical  climates, 
complete  restoration  to  health  is  likely  to  be 
expedited  and  promoted  by  change  of  air ; and 
if  the  cachexia  be  severe  after  a prolonged 
attack  of  the  disease,  return  to  the  patient's 
native  climate  for  a season  is  desirable. 

Joseph  Father. 

DENTITION,  Disorders  of.  — Stnoit.  : 
Teething;  Fr.  Troubles  de  la  dentition-,  Ger. 
Zahnen. 

General  Rejiarks. — The  period  of  cutting 
the  teeth  has  been  always  recognised  as  a critical 
time,  during  which  the  health  of  young  children 
is  especially  liable  to  become  disturbed  ; and  it 
has  been  a common  practice  amongst  mothers 
to  attribute  every  illness  occurring  in  earlyT  life, 
from  the  irritation  of  scabies  to  the  distortions 
of  rickets,  to  the  same  baneful  influence.  The 
evolution  of  the  milk-teeth  is  no  doubt  attended 
with  some  irritation,  especially  as  at  this  pe- 
riod the  follicular  apparatus  of  the  intestines  is 


DENTITION,  DISORDERS  OF.  341 
undergoing  considerable  development  and  we 
know  that,  on  account  of  the  impressibility  of 
the  nervous  system  in  young  children,  any  irrita- 
tion is  apt  to  be  followed  by  general  disturbance. 
It  is  no  doubt  also  the  case  that  local  functional 
derangements  are  frequent  at  this  period,  but  it 
is  often  unfair  to  attribute  these  directly  to  the 
irritation  of  an  advancing  tooth.  One  of  the 
most  common  direct  results  of  teething  is  py- 
rexia, which  may  be  intense ; and  a feverish  child 
is  particularly  susceptible  to  impressions  of  cold, 
and  to  the  irritation  of  unsuitable  food.  Catar- 
rhal attacks  coming  on  at  this  time  need  not  be 
therefore  the  immediate  result  of  the  condition 
of  the  gum.  It  is  at  least  equally  admissible  to 
attribute  them  to  the  ordinary  causes  of  such 
derangements  acting  upon  a body  rendered  for 
the  time  peculiarly  susceptible  to  injurious  in- 
fluences. This  view  is  supported  by  the  fact 
that  diarrhoea,  which  is  a very  common  compli- 
cation of  dentition,  is  especially  frequent  during 
the  warmer  months,  when  the  temperature  is  apt 
to  undergo  rapid  variations,  while  the  dress  of 
the  child  remains  unchanged;  and  is  far  less 
common  during  the  winter,  when  the  temperature 
is  more  uniform,  and  the  child  is  more  carefully 
guarded  against  the  cold. 

As  a rule,  the  first  milk-tooth  appears  in  the 
seventh  month  after  birth  ; but  dentition  may 
begin  at  an  earlier  period.  It  is  not  rare  for  an 
infant  to  cut  a tooth  at  the  age  of  four  months, 
and  occasionally  at  the  time  of  birth  one  tooth 
is  found  to  be  already  through  the  gum.  In 
eases  where  the  ordinary  time  of  weaning  is 
anticipated,  a pause  generally'  ensues  after  the 
appearance  of  one  or  two  teeth,  and  further  den- 
tition is  delayed  until  the  usual  age.  Constitu- 
tional conditions  influence  the  time  of  teething. 
Thus  tuberculous  and  syphilitic  children  cut 
their  teeth  early,  while  in  rickety  children  the 
teeth  are  very  slow  to  appear. 

In  the  majority  of  cases  the  teeth  pierce  the 
gum  in  the  following  order — lower  central  inci- 
sors, upper  central  incisors,  upper  lateral  incisors, 
lower  lateral  incisors,  first  molars,  canines,  back 
molars.  A child  of  twelve  months  old  should 
have  eight  teeth  and  be  cutting  his  first  molars, 
and  the  whole  number  (twenty)  should  be  through 
the  gum  soon  after  the  end  of  the  second  year. 
The  order  given  above  is  not  adhered  to  invari- 
ably. The  incisors  are  often  cut  irregularly,  and 
the  first  molars  may  precede  the  lateral  incisors. 
The  canines  seldom  or  never  precede  the  first 
molars. 

Some  infants  suffer  more  than  others  from 
the  cutting  of  a tooth,  and  it  is  not  always 
in  cases  where  the  eruption  of  the  teeth  has  been 
delayed  that  dentition,  when  it  occurs,  is  attended 
with  special  inconvenience.  On  the  contrary,  in 
severe  rickets,  where  the  delay  is  great,  the  teeth 
are  often  cut  with  remarkable  ease. 

Syhftoms. — The  phenomena  which  may  bo 
looked  upon  as  natural  to  the  process  of  denti- 
tion are  salivation  ; swelling  of  the  gum,  which 
becomes  more  and  more  tense,  hot,  and  painful ; 
slight  general  pyrexia,  with  flushing  of  one  or 
both  cheeks;  irritability  of  temper;  and  some  de- 
gree of  restlessness  at  night.  These  all  subside 
when  the  point  of  the  tooth  appears  through 
the  gum.  The  complications  not  necessarily 


m DENTITION,  DISORDERS  OF. 
attendant  upon  the  process  are  high,  fever;  in- 
flammation of  the  mouth  and  aphthae  ; vomiting 
(gastric  catarrh) ; diarrhoea  (intestinal  catarrh); 
cough  (pulmonary  catarrh) ; various  eruptions 
of  the  skin,  with,  sometimes,  swelling,  and  even 
suppuration  of  lymphatic  glands  ; and  certain 
troubles  of  the  nervous  system,  such  as  convul- 
sions, squinting,  &c. 

The  peculiarity  of  the  pyrexia  of  dentition  is  its 
irregular  character.  It  is  often  higher  in  the  morn- 
ing than  at  night,  and  varies  in  intensity  in  a 
remarkable  manner  from  day  to  day.  A tempera- 
ture of  104°  Fah.  at  8 a.m.  is  not  at  all  uncommon 
in  a teething  infant;  indeed  such  an  amount  of 
fever  in  the  morning  should  alone  lead  us  to 
inspect  the  mouth,  as  few  diseases  are  marked  by 
so  much  pyrexia  at  that  hour  of  the  day.  It  is 
important  in  practice  to  bear  in  mind  this  simple 
cause  of  elevation  of  temperature,  for  any  disease 
in  a child  is  apt  to  be  complicated  by  teething, 
and  much  needless  anxiety  may  be  occasioned 
by  overlooking  the  condition  of  the  gum.  We 
must  not,  however,  in  every  case  where  the 
gums  are  swollen  and  tense,  rush  to  tho  con- 
clusion that  they  are  the  sole  cause  of  the 
symptoms,  for  the  most  serious  cerebral  disease 
may  co-exist  with  the  eruption  of  a tooth.  Thus, 
to  take  an  example : — if  we  find  cerebral  symp- 
toms to  supervene  in  the  course  of  dentition,  we 
must  most  narrowly  scrutinize  their  character, 
before  passing  them  over  as  merely  harmless 
indications  of  the  general  disturbance.  Head- 
ache, delirium,  vertigo,  startings,  twitchings,  and 
convulsive  attacks,  may  merely  indicate  functional 
disturbance  of  the  brain  such  as  is  common  to 
many  disorders,  and  these  phenomena  are  not 
necessarily  symptomatic  of  cerebral  disease  ; but 
if  the  bowels  become  obstinately  confined,  the 
pulse  slow  and  irregular,  and  the  respiration  un- 
equal and  sighing ; and  if  in  addition  there  be 
photophobia,  with  sullenness  and  tendency  to 
drowsiness,  we  may  conclude  that  something 
more  than  mere  functional  derangement  is  pre- 
sent, and  that  there  is  every  reason  to  suspect 
the  existence  of  tubercular  meningitis. 

Treatment.  v-The  treatment  of  the  complica- 
tions which  occur  during  dentition  must  be  con- 
ducted upon  ordinary  principles.  Aphthae  of  the 
mouth  are  readily  cured  by  the  administration 
of  rhubarb  and  soda,  and  the  application  to 
the  mouth  of  a solution  of  chlorate  of  potash 
or  borax  in  glycerine  (ten  grains  to  the  ounce). 
Perfect  cleanliness  is,  however,  necessary,  and 
the  child's  mouth  should  be  washed  out  each  time 
after  taking  food  with  a piece  of  soft  rag  dipped 
in  warm  water. 

Vomiting  is  best  checked  by  clearing  out  the 
stomach  with  an  emetic  of  ipecacuanha  wine, 
giving  a tea-spoonful  every  ten  minutes  until 
sickness  is  produced.  Afterwards  a few  grains  of 
carbonate  of  soda  may  be  given  with  one  drop  of 
liquor  arsenicalis  in  a tea-spoonful  of  water  three 
times  a day.  Diarrhoea  should  be  treated  on  the 
same  principle : — first  a dose  of  castor  oil  to  re- 
move irritating  secretions  from  the  bowels,  then 
a mixture  containing  chalk  and  catechu,  or  oxide 
of  zinc  (one  grain  to  the  dose).  If  afterwards  the 
motions  continue  large,  pasty-looking,  and  offen- 
sive, and  are  passed  too  frequently  in  the  day,  one 
drop  of  tincture  of  opium  may  be  added  to  tho 


DEODORANTS. 

mixture,  as  there  is  usually  in  such  cases  too  rapid 
peristaltic  action  of  the  iutestines.  In  the  case 
of  either  of  these  derangements  (vomiting  or 
diarrhoea)  it  is  of  great  importance  to  keep  the 
body  warm,  and  this  is  most  effectually  done  by 
applying  a broad  flannel  bandage  to  the  abdo- 
men. The  diet  also  should  be  temporarily  modi- 
fied, reducing  the  quantity  of  farinaceous  matter 
that  is  being  taken,  on  account  of  the  tendency 
to  acid  fermentation  of  food  which  is  set  up  by 
such  a condition  of  the  alimentary  canal. 

Looseness  of  the  bowels  during  dentition  has 
been  looked  upon  by  some  writers  as  a natural 
method  of  relief  to  the  system,  and  fears  have 
been  held  out  of  grave  troubles  which  might 
ensue  if  the  looseness  were  too  suddenly  arrested. 
Such  fears  are,  however,  quite  groundless.  A 
catarrhal  condition  of  the  bowels  should  be 
cured  as  quickly  as  possible,  especially  during 
dentition,  for  it  is  at  this  time  that  the  suscep- 
tibility to  chills  is  so  great,  and  the  danger  of 
severe  choleraic  diarrhcea  being  set  up  is  there- 
fore correspondingly  threatening.  In  some  cases 
of  teething,  where  the  lungs  as  well  as  the 
bowels  are  the  seat  of  catarrh  and  there  is  a risk 
of  bronchitis,  Trousseau  recommends  that  the 
intestinal  derangement  should  not  be  suddenly 
put  an  end  to ; but  even  in  these  cases  a dose 
of  castor  oil  may  be  safely  given  to  remove 
irritating  matters  from  the  canal,  for,  according 
to  the  writer's  experience,  any  irritation  of  the 
bowels  is  apt  rather  to  increase  than  to  diminish 
pulmonary  mischief. 

The  favourite  remedy  for  all  disorders  oc- 
curring at  the  time  of  dentition  is  lancing  the 
gums,  but  the  practice  is  one  which  ought  not  to 
be  pursued  indiscriminately.  Unless  the  gum 
be  actually  swollen  and  tense,  incising  it  has  no 
object  whatever,  for  to  cut  the  top  of  the  gum 
can  have  no  influence  in  promoting  the  develop- 
ment of  the  tooth  below.  If,  however,  there  be 
very  much  inflammation  and  swelling,  and  the 
child  seem  to  be  in  pain,  relief  may  be  obtained 
by  lancing,  but  in  this  case  the  object  is  merely 
to  relieve  tension.  Excitement  of  the  nervous 
system  dependent  upon  the  condition  of  the 
mouth  can  perhaps  be  allayed  by  the  same  means ; 
but  in  the  case  of  convulsions  more  beneSt  is  to 
be  gained  by  the  use  of  warm  baths,  cold  appli- 
cations to  the  head,  and  the  gentle  action  of  a 
mild  aperient.  Eustace  Smith. 

DEODORANTS  (de,  from,  and  odoro,  I 
cause  to  smell). 

Deitnition. — The  term  deodorant,  although 
it  has  a more  extended  signification,  is  generally 
used  to  signify  a substance  that  destroys  offen- 
sive odours. 

General  Principles. — Odorous  bodies  are 
essentially  volatile,  and  those  which  arc  offensive 
frequently  contain  sulphur  in  some  state  of  com- 
bination. Deodorants  usually  produce  the  effect 
for  which  they  are  used  by  causing  a chemical 
change  in  bodies  to  which  they  are  applied;  but 
sometimes  their  action  consists  in  absorbing  and 
condensing  odorous  substances,  aud  thus  de- 
stroying or  counteracting  their  volatility.  Sub- 
stances which,  like  charcoal,  possess  this  latter 
property  may,  however,  indirectly  produce 
chemical  changes  by  bringing  the  odorous  sill- 


DEODORANTS. 

stances  into  contact  with  oxygen  in  a condensed 
and  active  condition. 

Deodorants  may  be  classed  as  volatile  and 
non-volatile. 

1.  Volatile  Deodorants. — These  all  consist 
cf  substances  the  action  of  which  is  immediately 
and  exclusively  chemical.  Being  intended  to  act 
on  bodies  which  are  themselves  volatile  they 
admit  of  more  generally  useful  application  than 
those  which  are  not  volatile. 

Enumeration. — Chlorine  and  its  lower  oxides, 
Sulphurous  Acid,  Nitrous  Acid  and  other  oxides 
of  nitrogen,  Ozone  and  Peroxide  of  Hydrogen  are 
the  most  important  members  of  this  class. 

Application". — In  the  selection  and  use  of 
volatile  deodorants,  it  is  necessary  to  distinguish 
between  bodies  which  possess  the  power  of  de- 
stroying or  removing  a noxious  smell,  and  those 
which  merely  cover  one  smell  by  another.  Car- 
bolic acid,  for  instance,  which  is  a valuable  dis- 
infectant, is  of  little  use  as  a deodorant,  al- 
though its  powerful  odour  may  render  other 
weaker  but  more  objectionable  odours  impercep- 
tible or  indistinguisable.  On  the  other  hand, 
the  so-called  chloride  of  lime  (chlorinated  lime 
of  the  Pharmacopoeia),  while  it  possesses  a 
strong  and  characteristic  smell  itself,  is  capable 
of  destroying  other  noxious  odours,  and  is  an 
excellent  deodorant. 

The  chemical  action  by  which  noxious  odours 
are  destroyed  is  principally  one  of  oxidation,  ! 
and  therefore  this  class  of  deodorants  are  gene- 
rally oxidising  agents.  Ozone,  or  active  oxygen, 
is  the  natural  deodorant  contained  in  the  atmo- 
sphere, which  no  doubt  largely  contributes  to 
the  destruction  of  noxious  vapours  in  the  air. 
Volatile  oils,  which  emanate  from  the  flowers 
and  other  parts  of  plants,  in  contact  with  atmo- 
spheric oxygen  produce  peroxide  of  hydrogen, 
and  this  as  an  oxidising  agent  possesses  deodor- 
ising as  well  as  disinfecting  properties.  The 
moderate  and  judicious  use  of  perfumes  may 
thus  produce  a beneficial  effect,  although  their 
undue  employment,  by  hiding  more  than  remov- 
ing what  is  objectionable  and  may  bo  injurious 
to  health,  cannot  be  recommended.  The  prepa- 
ration called  ‘Sanitas’  is  principally  a solution 
of  peroxide  of  hydrogen. 

2.  Non-volatile  Deodorants. — Enumera- 
tion'.— Among  this  class  of  deodorants  are  in- 
cluded Charcoal,  Earth,  Lime,  Oxide  of  Iron.  Sul- 
phate of  Iron,  Chloride  of  Zinc,  Nitrate  of  Lead, 
and  Permanganate  of  Potash. 

Application". — -Although  very  efficient  when 
brought  into  contact  with  the  class  of  odorous 
substances  referred  to  as  noxious  gases,  these 
deodorants  are  less  generally  useful  than  they 
would  otherwise  be  on  account  of  their  non- 
volatile character.  Charcoal  owes  much  of  its 
efficacy  as  a deodorant  to  the  surface-attraction 
and  power  of  condensation  which  it  possesses,  by 
virtue  of  which  it  brings  noxious  gases  such  as 
sulphuretted  hydrogen  into  contact  with  oxygen 
in  a condensed  and  active  state,  so  that  they  are 
burnt  up  and  resolved  into  innocuous  compounds, 
or  compounds  less  noxious  than  those  from  which 
t Uey  are  produced.  Earth  and  oxide  of  iron,  which, 
like  charcoal,  are  used  in  the  solid  and  dry,  or 
nearly  dry  state,  absorb  and  combine  with,  or 
promote  the  combination  of,  noxious  gases,  pro- 


DEPLETION.  343 

ducing  innocuous  products.  Lime  may  be  used 
either  dry  or  in  the  state  of  milk  of  lime.  The 
other  substances  named  are  used  in  the  form  of 
solution  in  water.  Where  large  quantities  of  de- 
composing animal  orvegetable  matter  are  required 
to  be  deodorised,  dry  lime  or  solution  of  sulphate 
of  iron  (green  vitriol)  may  be  economically  and 
advantageously  used.  T.  Redwood. 

DEPILATORIES  ( depilis , without  hair). 
Simon.  : Psilothron,  Bitsma. 

Definition. — Depilatories  are  agents  used  for 
destroying  the  hair  by  means  of  their  chemical 
properties. 

Enumeration  and  Action.  — Depilatories 
usually  consist  of  powders,  of  which  the  chief  con- 
stituents are  quicklime  (three  parts),  and  sul- 
phuret  of  sodium  (one  part),  diluted  with  (four 
parts  of)  starch.  The  powder  is  mixed  with 
water  to  the  consistence  of  a thin  paste,  and  laid 
on  the  part  to  be  operated  on  by  means  of  an 
ivory  paper-knife.  In  from  five  to  fifteen  mi- 
nutes the  paste  should  be  carefully  scraped  off, 
when  the  hair,  shrivelled  and  burnt,  will  come 
with  it.  Tho  skin  must  then  be  washed  with 
fresh  water,  and  dried,  and  anointed  with  cold 
cream.  A strong  solution  of  sulphuret  of 
barium,  made  into  a thin  paste  with  starch,  is 
a powerful  depilatory. 

Erasmus  Wilson. 

DEPLETION  (i iepleo,  I empty).  Synon.  : 
Fr.  depletion. 

Definition. — By  depletion  is  understood  ( a ) 
the  unloading,  or  rendering  less  full,  of  that 
which  is  over-burdened  or  over-full,  for  ex- 
ample, portions  of  the  turgid  vascular  system 
— as  the  portal  vessels;  or  ( b ) excessive  eva- 
cuation causing  exhaustion — as  in  choleraic  or 
other  severe  diarrhoea. 

Uses. — Depletion,  local  or  general,  as  a thera- 
peutic agent,  may  be  practised  in  a variety  of 
affections,  such  as  cerebral  congestion,  venous 
turgescence,  engorgement  of  the  portal,  system, 
pulmonary  congestion,  renal  ischaemia,  or  general 
plethora. 

Methods. — The  agencies  whereby  depletion 
may  be  produced  are  blood-letting,  general  or 
local,  purging,  sweating,  vomiting,  and  absti- 
nence from  food  and  drink. 

1.  General  Blood-letting. — There  is  no 
more  powerful  or  prompt  depleting  agent  than 
general  blood-letting  by  venesection  or  arterio- 
tomy  ; indeed,  the  chief  indications  for  bleeding 
are  to  be  found  where  it  serves  a depleting  pur- 
pose— as  in  engorgement  of  the  right  heart  and 
venous  system,  visceral  congestion  and  arterial 
turgescence.  (See  Blood,  Abstraction  of.)  It  is 
seldom,  however,  that  abstraction  of  blood  needs 
to  be  carried  to  such  an  extent  as  to  exert  a 
marked  depleting  effect  on  the  whole  system ; 
it  is  required,  rather,  for  the  relief  of  limited 
vaso-motor  disturbances. 

2.  Local  Bleeding. — Bleeding  by  means  of 
leeches,  scarifications,  or  cupping,  may  serve  a 
very  valuable  depleting  purpose  in  limited 
congestions,  as  in  those  of  the  pericardium 
pleura,  peritonaeum,  lungs,  eyes,  kidneys,  tongue, 
uterus,  and  haemorrhoidal  vessels. 

3.  Purgation. — For  general  depleting  pur- 
poses free  purging  by  means  of  hydragoguc- 


344  DEPLETION. 

cathartics  is  the  mcst  efficacious  agent.  In  cere- 
bral, cardiac,  and  hepatic  congestions,  when  it  is 
required  to  give  relief  to  turgid  vessels  without 
abstracting  blood,  nothing  depletes  so  readily, 
efficiently,  and  safely  as  watery  purges.  The  best 
purgatives  are  : — Elaterium,  jalap,  senna,  scam- 
mony,  sulphate  of  magnesia  or  soda,  tartrate 
of  soda,  bitartrate  of  potash,  croton  oil,  and 
gamboge  ; to  which  may  be  added,  podophyllin, 
calomel,  and  antimony.  Watery  purges  have  the 
great  advantage  of  depleting  by  removing  ser- 
osity  from  the  blood-vessels  without  the  loss  of 
red  corpuscles.  In  cerebral  congestion  depletion 
by  means  of  such  purges  is  of  cardinal  service. 
In  congestion  of  the  intestinal  tract  arising  from 
hepatic,  cardiac,  or  pulmonary  disease,  a mer- 
curial followed  by  a saline  purge  is  of  great 
service.  Antimony  has  been  mentioned  in  the 
above  list  because  of  its  usefulness  in  combina- 
tion with  sulphate  of  magnesia  and  other  saline 
surges.  It  should  be  remembered  that  it  also 
acts  as  a depressant,  and  should  only  be  used 
when  such  action  is  permissible. 

4.  Vomiting. — When  used  as  an  emetic, 
antimony  has  a powerfully  depressant,  as  wrell 
is  evacuant  or  depletory  effect;  but  depression 
tnd  depletion  are  not  synonymous.  The  low- 
ering effect  of  free  purging  is  pronounced,  and 
ordinarily,  sufficient.  Emetics  may  act  as 
depletants  by  evacuating  the  contents  of,  or 
producing  a flux  from,  the  stomach  ; but  their 
depressant  action  is  always  to  be  borne  in  mind 
when  used  with  this  object. 

5.  Sweating. — This  is  a less  effectual  mode 
of  depletion.  It  may  serve  a good  purpose, 
when  freely  induced,  in  lowering  arterial  tension, 
as  in  cases  of  renal  disease,  especially  if  there 
be  pyrexia.  Active  exercise,  the  hot  air  (or  Tur- 
kish) bath,  the  vapour  bath,  wet  packing,  jabor- 
andi,  antimony,  and  Dover’s  powder  are  the  usual 
modes  of  exciting  diaphoresis.  Diaphoretics 
are  often  aided  by  copious  draughts  of  hot 
fluids.  The  evacuant  action  of  sweating  and 
purging  may  be  advantageously  combined  when 
speedy  depletion  is  desired.  The  combination 
is  valuable  in  certain  dropsies. 

6.  Abstinence. — General  depletion  may  be 
produced  by  abstinence  from  food  and  drink, 
and  is  sometimes  employed  in  the  treatment  of 
aneurism,  and  of  strangulated  hernia  contain- 
ing omentum,  the  absorption  of  the  fat  of  which 
is  the  object  aimed  at  by  starvation. 

Alfred  Wiltshire. 

DEPOSITS. — The  term  deposit  had  at  one 
time  a much  wider  extension  in  pathology  than 
it  has  now.  In  accordance  with  the  doctrine  of 
morbid  erases  or  dyscrasice,  it  was  customary  to 
regard  cancers  and  all  new-growths,  the  products 
of  tubercular  and  scrofulous  diseases,  as  well  as 
those  of  the  specific  fevers  and  ordinary  inflam- 
mation— in  fact  almost  every  kind  of  morbid  pro- 
duct in  the  body — as  ‘ deposited’  from  the  blood 
in  consequence  of  some  alteration  in  its  composi- 
tion. In  many  of  these  cases  the  term  deposit  is 
still  often  used,  even  though  an  entirely  different 
view  maybe  taken  of  the  processes  leading  to 
these  morbid  changes.  The  name  remains,  though 
the  idea  has  departed  ; and  this  is  also  true 
of  other  morbid  products  called  deposits.  The 


DEPOSITS. 

term  secondary  deposits  was  formerly  used  for 
what  are  now  called  pyaemic  or  secondary  ab- 
scesses, from  a belief  that  pus  was  removed  from 
the  original  seat  of  disease,  and  deposited  in  dis- 
tant parts.  The  term  atheromatous  deposit  is  due 
to  Rokitansky,  who  described  this  change  as  due 
to  thedeposition  upon  the  arterial  wall  of  material 
precipitated  from  the  blood.  In  both  these  cases 
the  term  seems  now  misleading.  Again,  several 
processes  which  we  now  call  degenerations  or 
infiltrations  were  formerly  spoken  of  as  deposits; 
for  example,  lardaceous,  fatty,  and  pigmentary 
deposit;  and  although  these  processes  may  now 
be  better  described  by  another  name,  it  cannot 
be  doubted  that  in  some  of  them  an  extraneous 
substance  is  actually  deposited  in  the  tissues. 
The  term  fibrinous  deposits  was  also  used  for 
the  masses  now  known  as  infarctions  or  blocks 
(as  for  example  in  the  spleen  or  kidneys)  where 
the  appearance  of  a mass  of  extraneous  material 
is  produced  by  the  degeneration  as  a mass  of 
tissue,  mixed  with  products  of  hemorrhage,  in- 
flammation, and  exudation.  In  quite  another 
sense  the  various  substances  precipitated  from 
urine  are  spoken  of  as  urinary  deposits,  with 
which  we  are  not  here  concerned. 

When  these  exceptions  are  made,  the  present 
use  of  the  word  deposit  is  a limited  one,  but  is 
appropriate  in  those  cases  where  something  dif- 
ferent from  the  elements  of  the  tissue,  and  es- 
pecially if  it  be  an  inorganic  material,  is  found 
in  their  substance,  and  when  it  may  reasonably 
be  supposed  that  this  material  has  been  brought 
to  tho  tissues  by  the  circulating  fluid  and  there 
deposited.  The  term  is  clearly  inappropriate 
when  the  foreign  matter  is  formed  by  some 
chemical  change  in  the  substance  of  the  tissue- 
elements,  but  between  such  cases  and  those  just 
mentioned  it  is  very  difficult  to  draw  the  line. 
We  shall  speak,  in  the  sense  just  defined,  of  cal- 
careous, metallic,  and  pigmentary  deposits. 

1 . Calcareous  Deposits. — All  calcification  cf 
the  tissues  of  the  body,  whether  normal  or  degene- 
rated, of  inflammatory  products,  of  new  growths, 
or  of  any  morbid  products,  appears  to  depend 
upon  the  deposition  of  lime-salts  in  the  form  of 
granules,  this  deposition  taking  place  either 
within  the  substance  of  the  elements,  or  more 
rarely  in  the  intercellular  substance,  or,  possibly, 
sometimes  in  the  interstices  of  the  tissue.  Cal- 
careous deposit  takes  place  towards  the  close  of 
life  in  several  parts  of  the  body,  as  in  the  walls 
of  arteries,  in  cartilages  and  tendons,  in  the 
valves  of  the  heart,  the  crystalline  lens  of  the  eye. 
and  other  parts  ; though  in  most  of  these  cases,  if 
not  in  all,  some  other  pathological  change  pre- 
cedes the  deposition  of  lime.  Still  more  frequently 
this  change  occurs  in  masses  of  dead  or  degene- 
rated materials,  as,  for  instance,  in  organs  which 
have  partially  or  wholly  lost  their  vitality,  in 
new-growths  which  have  reached  the  stage  of 
retrogressive  change,  in  old  blood-clots,  or  in 
products  of  bygone  inflammation.  A wasted 
eyeball  always  becomes  partly  calcified  (some- 
times ossified) ; tumours,  such  as  myoma  and 
fibroma,  are  especially  subject  to  caicificaticn ; 
venous  clots  which  remain  long  undisturbed,  as 
in  the  deep  veins  of  the  pelvis,  undergo  the  same 
change,  and  become  phlebolithes.  Old  inflam- 
matory products,  as  pus  and  lymph,  seem  ti 


DEPOSITS. 

become  necessarily  calcified  if  they  are  not  ab- 
sorbed ; so  do  especially  the  products  of  chronic 
degenerative  inflammations  which  have  become 
necrotic,  as  seen  in  scrofulous  lymphatic  glands, 
and  in  tubercular  masses  in  the  lungs.  A 
similar  explanation  applies  to  calcareous  deposit 
in  thewalls  of  arteries,  where  the  lime  is  generally 
deposited  in  new  products  which  result  from 
chronic  arteritis  or  the  atheromatous  process, 
though  lime  may  also  be  deposited  in  the  muscu- 
lar walls  independently  of  atheroma.  Necrotic 
masses  resulting  from  embolic  infarction  are  fre- 
quently calcified.  Parasites  of  all  kinds,  occur- 
ring in  solid  organs,  are  liable  to  become  sur- 
rounded by  a calcified  wall : a change  frequently 
seen  in  hydatid  cysts. 

From  all  this  it  appears  that  calcareous 
deposit  rarely  occurs  in  normal  healthy  tissues, 
but  is  common  in  such  parts  as  are  dead  or  of 
deficient  vitality.  Its  deposition  must  be  attri- 
buted to  some  chemical  reaction  between  the 
tissues  thus  altered  and  the  lime-salts  in  the 
blood,  and  it  is  possible  that  the  presence  of  an 
excessive  quantity  of  lime-salts  in  the  blood 
sometimes  favours  the  change,  since  deposition 
of  lime  in  one  part  sometimes  coincides  with  re- 
moval of  it  from  another  part.  In  senile  decay 
the  wasting  of  bones  goes  on  simultaneously  with 
the  calcifying  processes  just  mentioned,  and  in 
some  rare  cases  rapid  absorption  of  bone  from 
special  disease  has  appeared  to  be  the  determin- 
ing cause  of  its  deposit  elsewhere  by  a sort  of 
calcareous  metastasis. 

2.  Metallic  Deposits. — Other  minerals  be- 
sides lime-salts  are  rarely  found  deposited  in  the 
tissues,  although  in  cases  of  chronic  metallic 
poisonin?,  compounds  of  lead,  silver,  and  copper 
may  be  found  thus  deposited.  Zinc  and  mercury 
are  less  clearly  traced,  but  probably  follow  the 
same  law.  The  state  of  chemical  combination  in 
which  the  metals  occur  is  notpositively  known,  but 
appears  to  be  some  combination  with  albumen. 

3.  Pigmentary  Deposits. — Pigmentation  as 
a process  is  discussed  in  the  article  Degenera- 
tions, and  has  been  shown  to  depend  very  fre- 
quently upon  the  occurrence  of  haemorrhage  and 
transformation  of  the  extravasated  blood.  But 
pigment  is  deposited  in  many  parts  of  the  body, 
both  normally  and  pathologically,  quite  inde- 
pendently of  haemorrhage.  Normally  this  is 
seen  in  the  skin,  the  choroid  coat  of  the  eye,  &c. : 
pathologically  in  the  same  situations,  but  in  ex- 
cessive quantity ; and  also  in  abnormal  situations, 
as  on  the  mucous  membrane  of  the  mouth.  The 
arrangement  of  the  pigment  is  in  every  case  the 
same,  forming  minute  black  granules  in  the  pro- 
toplasm of  the  cells  around  the  nucleus.  Its 
deposition  and  removal  are  regulated  by  causes 
as  yet  very  imperfectly  known,  but  are  probably 
in  some  way  dependent  upon  the  nervous  system. 

The  deposit  of  such  substances  as  fat,  larda- 
ceous  material,  colloid,  &c.,  is  not  a simple  pro- 
cess, but  depends  either  upon  chemical  metamor- 
phosis of  the  cell,  or  on  general  pathological 
changes,  which  are  dealt  with  in  other  parts  of 
this  work.  J.  E.  Payne. 

DERBYSHIRE  NECK. — A synonym  for 
goitre,  which  is  thus  called  from  the  prevalence 
of  the  disease  in  that  county. 


DETERGENTS.  345 

DERIVATIVES  {derive , I drain). 

Definition. — Medical  appliances  or  remedies 
which  lessen  a morbid  process,  such  as  inflamma- 
tion, in  one  part  of  the  body,  by  producing  a flow 
of  blood  or  lymph  to  another  part. 

Enumeration.  — Derivatives  include  — Local 
bleeding,  Cupping,  Leeches,  Blisters,  Sinapisms, 
and  Setons. 

Action. — The  name  ‘derivative’  was  applied 
in  ancient  times  under  the  belief  that  diseases 
were  caused  by  morbid  humours,  which  might 
be  drawn  away  from  the  part  which  they  were 
affecting.  It  is  now  used  chiefly  to  signify  the 
diminution  of  blood  in  an  inflamed  part,  by  in- 
creased circulation  in  some  other  vascular  dis- 
trict, either  adjoining  or  remote  from  it. 

T.  Lauder  Brunton. 

DERMATALGIA  (8ep,ua,  the  skin,  and 
&\yos,  pain). — Pain  and  aching  in  the  skin.  See 
Neuralgia. 

DERMATITIS  (5ep/j.a,  the  skin). — Inflam- 
mation of  the  skin,  a term  applicable  to  every 
variety  of  inflammation  of  the  integument,  but 
especially  to  an  acute  inflammation  attended 
with  exfoliation  of  the  cuticle  and  copious 
desquamation,  for  example,  Dermatitis  Exfolia- 
tiva, the  Pityriasis  rubra  of  Devergie. 

DERMATOLYSIS  {Slp/ua,  the  skin,  and 
Ai/Vis,  a loosening). — Looseness  or  relaxation  of 
the  skin.  See  Cutis  pendula  and  Molluscum. 

DESQUAMATION  [de,  from,  and  squama, 
a scale). — The  process  of  separation  or  shedding 
of  the  epithelium  of  any  surface.  It  is  of  most 
importance  in  connection  with  the  skin  in  scar- 
latina, where  the  epidermis  usually  desquamates 
extensively. 

DESQUAMATIVE  NEPHRITIS.  — A 

synonym  for  certain  forms  of  Bright’s  Disease, 
applied  on  account  of  the  shedding  of  the  epi- 
thelium lining  the  tubules,  which  is  character- 
istic of  the  disease.  See  Bright's  Disease. 

DETERGENTS  ( detergo , I cleanse). 

Definition.— Substances  which  cleanse  the 
skin. 

Enumeration. — The  principal  detergents  are — 
Water,  Soap,  Alkalies,  Ox-gall,  Milk,  Vinegar, 
Charcoal,  Sand,  Oatmeal,  Sawdust,  Pumice- 
stone,  Oil,  and  Borax. 

Uses. — Detergents  are  used  either  to  remove 
extraneous  dirt  adherent  to,  or  epidermal  scales 
which  may  have  accumulated  upon  the  skin,  and 
interfere  with  its  function.  The  chief  detergent 
is  warm  water,  but  its  action  is  greatly  aided 
by  such  substances  as  soap,  alkalies,  borax,  or 
vinegar,  which  act  chemically  in  the  removal  of 
dirt  or  epidermis  ; or  by  such  substances  as  oat- 
meal, sawdust,  charcoal,  pumice-stone,  and  sand, 
which  act  mechanically.  Oil  removes  the  resin- 
ous deposit  left  on  the  skin  by  plasters.  Where 
the  skin  is  tender,  as  in  the  case  of  the  scalp,  and 
where  at  the  same  time  the  detergent  employed 
cannot  very  readily  be  removed,  borax  with  elder- 
flower  water  may  be  found  preferable  to  the  more 
irritating  soaps  as  a means  of  removing  scurf. 

T.  Lauder  Brunton. 


340  DETERMINATION  OF  BLOOD. 

DETERMINATION  OP  BLOOD.— In- 
creased flow  of  blood  to  a part  or  organ,  synony- 
mous with  active  hyperasmia  or  active  congestion. 
See  Circulation,  Disorders  of. 

DEVELOPMENT,  Arrest  of.— The 
causes  of  arrest  of  development  are  in  most 
cases  still  very  doubtful,  and  for  the  most  im- 
portant theories  and  observations  on  the  subject 
the  reader  is  referred  to  the  article  on  Mal- 
formations. Such  arrests  may  take  place  at  any 
stage  in  the  development  of  the  embryo  and  of 
its  organs;  but  only  the  most  important  of  them, 
and  the  mode  in  which  some  typical  examples  are 
brought  about,  will  be  mentioned  here. 

Varieties.— Those  which  occur  very  early 
in  foetal  life  are  complex  and,  for  the  most 
part,  incompatible  with  viability  ; whilst  those 
which  occur  later  often  affect  only  one  organ  or 
a set  of  organs,  and  in  some  cases  form  no  barrier 
to  a prolonged  existence.  Not  only  must  the 
foetus  be.  considered,  but  also  the  placenta  and 
membranes  in  which  it  is  enclosed  in  utcro ; for 
diseases  of  these  lead  to  many  forms  of  monstro- 
sity, either  by  interference  with  the  nutrition  and 
respiration  of  the  embryo,  as  in  the  case  of  many 
so-called  ‘ true  moles  ’ ; or  the  normal  changes 
may  be  checked  by  adhesions  between  them  and 
the  foetus.  Persistence  of  the  umbilical  vesicle  is 
excessively  rare,  but  a patent  vitelline  duct  is  very 
common,  and  explains  many  of  the  diverticula  in 
connection  with  the  small  intestines.  A want  of 
closure  of  the  visceral  laminae  is  the  source  of 
many  deformities,  from  a simple  fissure  in  the 
sternum,  or  a ventral  hernia,  to  a complete  an- 
terior cleft,  with  the  thoracic  and  abdominal  vis- 
cera lying  bare  out  of  the  body-cavity.  In  other 
cases  the  skin  and  muscles  only  may  cover  the 
viscera,  or  the  muscles  may  not  be  developed. 
The  thorax  is  closed  before  the  abdomen,  so  that 
ectopia  of  the  abdominal  is  more  common  than 
of  the  thoracic  viscera.  The  abdomen,  however, 
is  sometimes  closed  in,  whilst  the  thorax  remains 
open,  and  varying  degrees  of  ectopia  cordis  result; 
but  this  is  rarely  complete.  Epispadias  and  hy- 
pospadias to  varying  extents  are  further  examples 
of  imperfect  fusion  of  the  ventral  laminse.  These 
may  or  may  not  be  attended  with  displacement 
or  deficiency  of  the  urinary  and  genital  organs. 
Similarly  from  an  incomplete  fusion  of  the  dorsal 
laminse  the  various  forms  of  spina  bifida  occur, 
and  these  are  generally  accompanied  with  an  ex- 
cess of  fluid  in  the  spinal  canal,  or  hydrorachis. 

The  arrests  in  the  development  of  the  cerebro- 
spinal centres  and  of  the  organs  of  special  sense 
are  very  numerous.  The  whole  brain  may  be  want- 
ing,  or  the  medulla  oblongata  developed  and  the 
remaining  portions  missing,  or  any  given  part  of 
it  maybe  absent  or  quite  rudimentary.  From 
incomplete  fusion  of  the  bones  of  the  skull  hernia 
cerebri  or  encephaloeele  occurs,  and  this  is  gene- 
rally complicated  with  hydrocephalus,  though 
the  latter  is  frequently  found  as  an  independent 
and  solitary  affection.  Coloboma  and  deficiency  of 
the  olfactory,  optic,  or  auditory  nerves  are  well- 
known  examples  of  arrested  development  of  the 
organs  of  special  sense.  The  special  malforma- 
tions of  the  heart  and  vascular  system,  the  diges- 
tive, respiratory,  and  urino-genital  systems,  will 
bo  described  under  the  various  organs;  but  re- 
ference must  here  be  made  to  congenital  fissures 


DIABETES  MELLITUS. 

leading  into  the  pharynx  (persistent  branchial 
clefts),  to  the  various  fissures  of  the  faco  and 
palate,  to  persistent  cloacae,  to  the  numerous 
forms  of  hermaphroditism,  and  to  imperforate 
anus,  as  all  coming  under  this  head.  Varying 
degrees  of  ill-developed  extremities  are  common, 
from  a diminution  of  number,  in  the  fingers  or 
toes,  or  their  coalescence,  to  a complete  absence 
of  one  or  all  the  limbs.  Finally,  ducts,  vessels, 
and  openings — such  as  the  urachus,  ductus  arte- 
riosus, umbilical  vessels,  and  foramen  ovale— 
which  normally  close  soon  after  birth,  may  remain 
patent  throughout  life.  John  Curnow. 

DEVONSHIRE  COLIC.— A synonym  for 
lead  colic,  which  has  arisen  from  the  frequency 
of  lead-poisoning  in  that  county,  supposed  to  he 
due  to  the  contamination  of  cider  by  lead.  See 
Lead,  Poisoning  by. 

DIABETES  INSIPIDUS  (Sid,  through, 
/SaiVoi,  I flow ; and  insipidus,  tasteless). — Synon.  : 
Polyuria;  Fr.  Diabitc  msipide  or  non  sucre ; Ger. 
Polyurie.  Asynonymfor Polyuria.  See P ol vtj ria . 

DIABETES  MELLITUS  (5id,  through, 
[Salvoi,  I flow ; and  rra,  a bee). — Stnon.  • 
Glycosuria;  Fr . Diabete;  Ger.  Hamzuckerruhr. 

Definition. — The  term  Diabetes,  meaning  ai: 
excessive  flow  of  something,  has  been  applied  to 
the  pathological  condition  indicated  by  an  ex- 
cessive flow  of  urine.  It  has,  moreover,  been 
almost  wholly  limited  to  the  kind  of  malady 
characterised  by  the  presence  of  a notable  quan- 
tity of  sugar  in  theurine — a condition  more  strictly 
described  by  the  term  Diabetes  Mellitus.  Another 
condition  is  sometimes  seen  where  no  sugar  is 
to  be  found  in  the  urine,  which  is,  however, 
excessive  in  quantity.  This  is  designated  as 
Diabetes  Insipidus,  or  better,  Polyuria. 

Diabetes  is  a malady  more  or  less  chronic, 
characterised  by  the  persistent  presence  of  a 
notable  quantity  of  sugar  in  the  urine,  which  is  in 
most  cases  markedly  abundant.  It  is  accompanied 
by  thirst,  hunger,  and  bodily  wasting.  If  un- 
relieved it  invariably  tends  to  death.  The  ordi- 
nary form  of  Diabetes  is  thus  to  be  distinguished 
from  certain  other  conditions,  where,  for  instance, 
a small  or  hardly  perceptible  trace  of  sugar  may 
be  detected  in  the  urine ; or  where,  yet  again, 
considerable  quantities  of  that  substance  may  be 
detected  occasionally,  and  for  a short  time  only. 
To  this  abnormal  condition  the  term  Glycosuria 
(y\vKvs,  sweet,  and  ovpov,  urine),  which  is  often 
also  employed  to  describe  artificial  diabetes,  best 
applies. 

General  Considerations. — Three  important 
facts  lie  at  the  bottom  of  our  knowledge  of  the 
pathology  of  Diabetes.1 

These  are : — 

I.  That  grape  sugar  is  found  in  the  healthy 
human  body. 

II.  That  glycogen,  a substance  closely  allied 
in  chemical  composition  to  grape  sugar,  is  also 
found  in  the  healthy  human  body. 

III.  That  both  of  these  may  he  formed  in  the 
healthy  human  body. 

Beyond  these,  certain  other  fairly  definite  pro- 
positions may  be  made. 

1 The  discussion  at  length  of  the  subject  Glreogenoar, 
which  formed  part  of  the  original  article,  has  for  want  ol 
space  been  here  omitted.— Ed. 


DIABETES 

1.  Glycogen  is  found  most  abundantly  in  the 
liver,  insomuch  that,  with  due  precautions,  it  can 
always  be  detected  there  : after  a certain  time 
sugar  takes  the  place  of  glycogen,  but  the  exact 
mode  and  time  of  this  conversion  are  not  known. 

2.  Nevertheless,  it  is  fairly  certain  that  the 
sugar  called  glucose  can  always  be  detected  in 
the  liver  ; still  more  certain  that  it  is  to  be  found 
in  the  blood  ; but 

3.  This  sugar  never  appears  in  any  notable 
quantity  during  a state  of  health  in  the  urine. 

4.  As  sugar  is  not  to  be  found  in  any  appreci- 
able quantity  in  any  other  of  the  excretions,  it 
follows : 

5.  That  this  sugar  must  disappear  in  the  body. 

6.  It  is  commonly  asserted,  and,  upon  the 
whole,  believed,  that  sugar  is  less  plentiful  in 
venous  than  in  arterial  blood. 

7.  Prom.  this,  if  true,  it  follows  that  sugar 
must  be  used  up  in  the  course  of  the  circula- 
tion. 

8.  Where  the  combustion,  or  oxidation,  occurs 
is  not  quite  clear. 

9.  But  it  is  plain  that,  from  a fault  in  either 
direction,  sugar  may  become  over-abundant  in 
the  blood,  namely  : — 

a.  By  over-production,  or 

b.  By  diminished,  consiemption. 

10.  The  over-production  and  the  diminished 
consumption  of  sugar  in  the  body  may  depend 
on  various  causes.  The  most  notable  of  these 
are  (a)  an  increased  ingestion  of  saccharine  ma- 
terial into  the  stomach  and  bowels,  without  a 
corresponding  destruction  ; and  (6)  such  an  alte- 
ration of  nerve-influence  as  will  completely  modify 
the  relative  proportions  of  the  sugar  produced  and 
the  sugar  destroyed. 

1 1 . With  an  excess  of  sugar  in  the  blood,  only- 
one  easy  road  of  egress  from  the  body  is  available, 
that  is,  by  way  of  the  kidneys  ; but  this  is  not  a 
sufficient  outlet  when  there  is  great  superabun- 
dance in  the  blood.  Sugar  may  then  be  found 
in  almost  every  one  of  the  secretions  or  excretions. 

12.  With  this  unnatural  discharge  of  sugar 
there  is  usually  a corresponding  discharge  of 
urine,  but  not  always. 

13.  Thus  there  may  be  no  greatly  increased 
flow  of  urine,  yet  the  urine  may  be  rich  in 
sugar. 

14.  And  yet,  again,  there  may  be  a copious 
flow  of  urine  without  any  sugar,  as  in  Polyuria. 

15.  Hence  the  over-production  or  the  dimin- 
ished consumption  of  sugar  in  the  system  has 
no  necessary  connection  with  increased  flow  of 
urine. 

16.  Both  the  abnormal  action  of  the  liver  and 
that  of  the  kidneys  seem  in  the  main  to  depend 
on  similar  but  not  identical  causes. 

17.  Both  seem  to  be  under  the  control  of  the 
sympathetic,  but  the  special  fibres  are  not  the 
same  as  regards  the  two  organs. 

(a)  In  the  case  of  the  liver  the  fibres  seem  to 
originate  in  the  medulla  oblongata,  to  descend 
in  the  spinal  cord  to  the  lower  cervical  or  upper 
dorsal  vertebrae,  thence  to  leave  the  cord  to  join 
the  gangliated  sympathetic,  and  so  ultimately  to 
reach  the  liver. 

(b)  In  the  case  of  the  kidneys  the  active  fibres 
proceed  further  down  the  spinal  cord,  but  arc 
ultimately  connected  with  the  great  abdominal 


MELLITUS.  347 

plexus,  for  such  it  may  well  be  called,  whence 
the  fibres  proceed  to  the  kidneys. 

AEtiologt. — The  classification  of  cases  of  dia- 
betes according  to  causation  is  in  very  many  cases 
practically  impossible. 

As  to  the  circumstances  that  call  the  morbid 
processes  into  play,  we  know  very  little.  It  is 
certain,  however,  that  the  disease  is  much  more 
frequent  among  men  than  among  women,  and 
among  the  middle-aged  than  among  the  very 
young  or  the  very  old.  The  disease  is  very  much 
more  fatal  in  young  adults  than  in  those  over, 
say,  forty-five.  That  the  disease  is  more  rife  in 
certain  districts  than  in  others  may  probably  be 
best  explained  by  its  undoubted  tendency  to 
heredity.  This  heredity,  as  in  many  other  mala- 
dies, is  peculiar  ; the  diabetic  tendency  in  one 
branch  of  a family  being  represented  in  another 
branch  by  various  nervous  disorders,  especially 
epilepsy  and  imbecility. 

Of  the  so-called  exciting  causes  there  are  two 
of  the  first  rank,  namely,  injury,  or  disease  of  the 
brain ; and  mental  excitement,  or,  perhaps  still 
more,  worry.  Tumours  and  other  local  brain- 
mischiefs  sometimes  give  rise  to  a fatal  diabetes. 
Certain  mental  emotions,  at  once  powerful  and  pro- 
longed, which  maybe  epitomised  in  the  singleword 
strain,  apparently  act  as  exciting  causes  of  dia- 
betes, such  as  continuous  anxiety,  long-lasting 
grief,  or  excitement  followed  by  reaction.  Cer- 
tain errors  of  diet — such  as  excessive  use  of 
hydrocarbons,  especially  sugar — or  other  inter- 
ference with  tho  laws  of  health,  may  originate  a 
fatal  diabetes,  especially  in  those,  who  have  any 
hereditary  tendency  to  the  disease.  It  is  possible 
that  the  frequency  of  the  malady  among  the  Jews 
(as  noted  by  Seegen)  may  be  accounted  for  on 
dietetic  grounds. 

.Anatomical  Characters. — Many  pathological 
conditions  have  been  recorded  as  occurring  in 
those  who  had  been  the  subjects  of  diabetes,  but 
we  know  little  of  its  real  pathology.  In  many 
cases  nothing  which  can  be  directly  connected 
with  the  diabetes  has  been  found  post  mortem. 
Latterly  attention  has  been  mainly  directed  to 
the  investigation  of  certain  parts  of  the  nervous 
system  and  of  the  liver  itself.  Perhaps  the  most 
reliable  data  for  the  ordinary  anatomical  ap- 
pearances are  to  be  found  in  Seegen's  analysis 
of  Bokitansky’s  experience,  embracing  30  ne- 
cropsies. 

Connected  with  the  brain  and  spinal  cord 
various  lesions  have  been  found,  such  as  tumours 
of  different  kinds  pressing  on  the  medulla,  and 
softening,  with  or  without  the  marks  of  extrava- 
sated  blood.  In  some  cases  extravasation  has 
been  the  only  morbid  change  discovered.  In 
two  cases  under  the  writer’s  care  there  were  ex- 
travasations of  blood  in  the  spinal  canal  in  tho 
cervical  and  upper  dorsal  regions,  and  the  same 
was  observed  in  another  case  under  the  care  of 
a colleague.  In  one  of  these  there  was  very 
marked  softening  of  the  cord  in  the  regions 
named.  In  these  three  cases  death  took  place 
suddenly.  Dr.  Dickinson's  theory  of  the  origin 
of  diabetes  in  lesions  of  the  nervous  system,  re- 
presented by  enlarged  perivascular  spaces,  the 
sites  of  existent  or  pre-existent  extravasations 
of  blood  with  destruction  of  the  surrounding 
I nerve  tissue,  is  hardly  tenable.  The  exploration 


248  DIABETES 

of  the  sympathetic  system  has  not  been  more 
satisfactory. 

Rokitansky  found  (in  15  out  of  30  cases) 
that  the  liver  was  enlarged,  hyperaemic  and  hard, 
of  a dark-brown  colour,  with  its  acini  imperfectly 
defined.  The  same  conditions  were  present  in 
the  cases  examined  by  the  writer.  When  the 
disease  has  lasted  a long  time,  the  liver  may  be 
smaller  than  natural.  The  same  would  appear 
to  hold  good  with  regard  to  the  cells  themselves. 
Early  in  the  disease,  the  cells,  especially  in  the 
outer  portions  of  the  acini,  are  large,  plump,  and 
rounded,  instead  of  angular,  with  large  and  dis- 
tinct nuclei.  They  tend  to  assume  a wine-red 
colour  with  solution  of  iodine,  from  the  presence 
of  unchanged  glycogen.  There  are  also  sometimes 
found  signs  of  active  cell-growth  at  this  early 
stage.  Later  the  cells  seem  smaller,  and  as  if 
undergoing  pigmentary  degeneration. 

The  condition  of  the  'pancreas  in  diabetes  is 
highly  interesting.  In  13  out  of  Rokitansky’s 
30  cases,  it  was  strikingly  small,  hard,  and  blood- 
less ; and  in  many  cases  it  has  been  found  so 
shrunken  and  altered  as  to  be  hardly  recognis- 
able save  by  its  connections.  Such  was  the  case 
in  one  instance  the  writer  has  seen,  and  in  all 
his  other  cases  the  pancreas  has  been  abnormal, 
usually  contracted  here  and  there,  hard  and 
knotty.  In  one  case,  however,  the  organ  was 
enlarged  and  more  succulent  than  usual,  pro- 
bably the  first  stage  of  the  mischief.  The  oc- 
currence of  so  important  pancreatic  changes  in 
about  one-half  the  cases  of  diabetes  would  seem 
to  indicate  more  than  a casual  connection  with 
the  disease.  What  this  connection  really  is  re- 
mains unascertained.  Klebs  has  associated  the 
changes  with  disease  of  the  coeliac  plexus.  One 
result  from  the  pancreatic  mischief  is  inability 
to  digest  fat.  This  was  seen  in  one  of  the  cases 
referred  to  above. 

The  kidneys  Rokitansky  found  diseased  in 
20  instances,  but  the  changes  were  not  uniform. 
Usually  they  presented  the  ordinary  indications 
of  hyperaemia,  being  enlarged,  dark  red,  and  full 
of  blood.  Occasionally  there  were  signs  of  more 
extensive  mischief,  the  substance  of  the  kidney 
as  well  as  its  vessels  and  epithelium  being  in- 
volved, and  the  organ  harder  than  natural.  Often 
fatty  changes  occur.  In  one  case  of  the  writer’s 
amyloid  changes  had  begun  in  the  Malpighian 
bodies. 

The  lungs  are  frequently  diseased : in  only  7 
of  his  cases  did  Rokitansky  find  them  normal ; 
Dickinson  only  twice  out  of  27  instances.  The 
changes  included  all  stages,  from  acute  or  chronic 
pneumonia,  to  the  formation  of  numerous  cavities, 
or  even  to  gangrene.  In  one  of  the  writer’s  cases 
the  whole  of  the  upper  lobe  of  one  lung  was  con- 
verted into  a huge  cavity  filled  with  solid  and 
semi-fluid  detritus,  having  no  gangrenous  odour. 
There  had  been  no  expectoration,  and  no 
haemorrhage,  though  vessels  were  exposed. 

The  stomach  and  intestinal  canal  present  little 
beyond  the  ordinary  signs  of  recurrent  or  chronic 
catarrh — thickening,  mammillation,  and  slaty 
pigmentation;  erosions  and  ulcerations  may, 
however,  occur. 

Symptoms. — The  following  sketch  comprehends 
the  more  characteristic  clininal  features  of  dia- 
betes ; but  there  are  often  important  variations 


MELLITUS. 

in  individual  cases,  though  a certain  number  of 
features  are  common  to  all The  patient,  most 
likely  a male  between  twenty  and  forty-five, 
when  he  comes  before  the  physician  has  in  ail 
probability  been  suffering  from  the  disease  for 
some  time  ; for  it  usually  comes  on  insidiouslv. 
He  may  say  that  he  has  been  in  failing  health 
for  a varying  period ; that  he  has  been  very 
thirsty,  and  has  passed  much  water,  having  to 
get  up  repeatedly  for  this  purpose  during  the 
night.  His  appetite  has  been  more  than  hearty  ; 
but  his  food  seems  to  do  him  no  good,  for  he 
has  been  constantly  growing  thinner,  and  he 
feels  weak  and  ill.  On  closer  examination  it  is 
found  that  he  is  daily  passing  as  much  perhaps 
as  eight,  ten,  or  more  pints  of  urine,  light  in 
colour  and  of  a peculiar  sweetish  odour,  of  a 
high  specific  gravity,  perhaps  1040,  and  contain- 
ing an  abundance  of  sugar.  The  skin  is  dry  and 
harsh ; the  tongue  red  and  glazed  or  slightly 
furred  ; the  mouth  dry  and  clammy ; the  lips, 
teeth,  and  gums  are  covered  with  scanty,  sticky 
mucus  ; the  breath  is  often  sweetish,  or  it  may 
be  unpleasant  from  the  state  of  the  mouth  ; the 
bowels  are  confined ; and  the  countenance  wears 
an  expression  of  weariness  and  fatigue. 

From  this  point  the  malady  may  progress  in 
one  or  other  of  two  directions.  Under  judieious 
management  the  symptoms  may  ameliorate. 
Often  the  first  indication  of  improvement  is  a 
copious  perspiration  ; the  thirst  diminishes ; less 
urine  is  passed  ; the  appetite  is  not  so  ravenous  ; 
the  sugar  decreases  in  quantity ; and  with  it  the 
specific  gravity  is  lessened.  Emaciation  ceases, 
and  the  patient  begins  to  regain  weight.  This 
auspicious  commencement  may,  with  time  and 
care,  end  in  a more  or  less  complete  return  to 
health.  Unfortunately  there  is  another  side  to 
the  picture,  for  notwithstanding  all  our  efforts 
the  patient  often  goes  from  bad  to  worse.  AYe 
fail  to  reduce  the  quantity  of  sugar  beyond  a 
certain  point.  The  appetite  gets  more  and  more 
voracious,  especially  for  starchy  articles  of 
food,  for  which  the  patient  will  sometimes 
lie,  steal,  do  anything,  and  yet  there  is  often 
no  feeling  of  satiety.  Sometimes  the  appetite 
fails,  and  then  emaciation  goes  on  still  moro 
rapidly.  All  sexual  power  and  feeling  have  long 
ago  been  lost,  the  testes  sometimes  undergoing 
almost  complete  atrophy.  The  harsh,  dry,  and 
itchy  skin  becomes  the  seat  of  boils,  or  even  of 
carbuncles.  Often  the  sight  is  injured  by  cloudi- 
ness of  the  refractive  media,  especially  of  the 
lens,  or  by  other  and  more  anomalous  changes. 
All  this  time  the  temperature  is  low,  perhaps 
sub-normal ; but  towards  the  later  stages  of  the 
malady  it  often  rises.  Such  a rise  indicates  the 
accession  of  a formidable  complication  which 
might  almost  be  said  to  be  the  natural  ter- 
mination of  diabetes.  This  superadded  mis- 
chief is  a peculiar  insidious  kind  of  pneumonia, 
resembling  acute  pneumonic  phthisis,  and  giving 
rise  to  local  signs  resembling  those  characteristic 
of  that  malady.  The  progress  of  this  lung-mis- 
chief is  rapid,  the  fever  increases,  and  often  there 
is  irrepressible  diarrhoea,  sometimes  of  fatty- 
looking  matter.  As  the  end  approaches,  the  sugar 
usually  disappears  from  the  urine,  which  may 
become  albuminous  and  scanty.  There  may 
even  be  some  oedema  of  the  extremities.  The  end 


DIABETES 

often  comes  swiftly,  and  without  warning,  by 
acute  pneumonia,  or  by  what,  for  want  of  a better 
name,  we  call  diabetic  coma,  or  more  slowly  by 
gradual  exhaustion.  After  the  onset  of  pul- 
monary symptoms  it  is  never  very  long  delayed. 
Such  may  be  said  to  be  the  ordinary  course  of 
a well-marked  case  of  diabetes.  There  are 
cases  slighter,  where  the  history  is  different ; but 
in  both  sets  of  cases  there  are  certain  symptoms, 
which  demand  further  consideration  than  has 
been  given  them  above. 

The  Urine. — The  characteristic  of  the  nrine 
ill  diabetes  is  the  presence  in  it  of  sugar  in 
notable  quantity,  though  this  varies  greatly 
in  different  cases.  In  the  earliest  and  slightest 
forms  of  diabetes,  small  quantities  of  sugar  may 
be  passed  now  and  again,  as  after  a meal  or  the 
consumption  of  an  unusual  quantity  of  starchy  or 
saccharine  food;  but  the  sugar  may  completely  dis- 
appear in  the  interval,  or  may  do  so  finally  by  the 
use  of  an  animal  diet.  The  sugar  thus  excreted  is 
glycose  of  the  kind  called  dextrose,  from  turning 
polarised  light  to  the  right,  is  readily  soluble  in 
water  and  alcohol,  and  easily  ferments.  When  dia- 
betic urine  is  allowed  to  stand  in  a warm  place,  fer- 
mentation soon  sets  in,  gas  being  disengaged,  and 
yeast  deposited  at  tne  bottom  of  the  vessel.  The 
proportion  of  sugar  to  urine  is  usually  from  8 to 
1 2 per  cent.,  but  varies  ; the  total  quantity  passed 
amounting  to  20  or  25  ounces,  or  even  more.  Its 
presence  in  such  proportion  causes  an  increased 
specific  gravity,  though  this  is  not  invariably 
the  case,  inasmuch  as  it  may  vary  from  1,008 
to  1,060  or  1,070.  Along  with  the  presence  of 
sugar,  w'e  almost  invariably  find  an  increase  in 
the  quantity  of  the  urine.  But  neither  is  this 
an  invariable  feature  of  diabetes,  for  sugar  may 
exist  with  a normal  quantity  of  urine,  constituting 
the  so-called  Diabetes  deoipiens.  But  in  most 
cases,  there  is  a marked  increase,  the  quantity 
passed  amounting  to  8,  10,  or  15  pints  daily; 
and  even  the  highest  of  these  rates  has  been 
greatly  exceeded.  With  an  excessive  amount  of 
urine,  its  colour  becomes  lighter;  sometimes  it 
has  a faint  greenish  tint,  and  when  passed  is  quite 
clear.  On  standing  there  is  no  ordinary  sedi- 
ment, though,  as  already  said,  sporules  of  yeast 
may  be  deposited  after  a time.  There  is  on  the 
whole  an  excess — sometimes  a large  excess — of 
urea,  and  if  the  quantity  of  urine  passed  be  small, 
urates  or  other  urinary  ingredients,  as  sulphates 
and  phosphates,  may  appear.  Very  great  incon- 
venience may  arise  in  diabetic  females,  or  even 
in  males,  by  the  arrest  of  saccharine  urine  about 
the  external  genitals,  producing  a raw  or  ecze- 
matous condition  of  the  inside  of  the  thighs 
and  groins.  The  urine  being  also  almost  in- 
variably acid,  is  highly  irritating  to  the  raw  and 
swollen  parts.  Enuresis  is  common,  especially 
at  night,  and  among  diabetic  children.  Albumen 
makes  its  appearance  sometimes  in  tho  progress 
of,  or  in  the  later  stages  of  the  disease. 

The  Digestive  Organs. — As  the  correlative  of 
the  unusual  flow  of  urine  wo  have  also,  as  a 
marked  and  early  symptom  of  diabetes,  extreme 
thirst,  a thirst  too  which  cannot  be  satisfied, 
for  apparently  the  more  the  patient  drinks  the 
greater  is  the  thirst.  This  sensation  is  in  some 
part  due  to  the  dry  and  clammy  condition 
of  the  mouth,  which  it  is  difficult  to  relieve. 


MELLITUS.  349 

Hunger,  or  even  a voracious  desire  for  food,  is 
usually  a prominent  feature  in  diabetes,  but  is 
not  invariably  present,  and  in  the  later  stages 
there  may  be  complete  loss  of  appetite,  amount- 
ing to  a loathing,  especially  for  a restricted  diet. 
It  is  often  impossible  to  satisfy  the  intense  crav- 
ing for  food,  and  should  satiety  be  attained  the 
sensation  lasts  but  for  a little  time.  The  mouth 
isusually  dry  and  parched,  the  saliva  being  scanty 
and  tenacious.  Often  particles  of  food  are  re- 
tained about  the  teeth,  and  there  putrefy,  giving 
rise  to  unpleasant  odours.  The  buccal  fluid  is 
almost  always  acid  instead  of  alkaline,  probably 
from  the  formation  of  lactic  acid.  The  tongue 
is  rarely  perfectly  natural.  Seegen  describes  it 
as  usually  thickened  and  increased  in  volume, 
with  fissures  and  glazed  blood-red  islands  on  its 
surface,  which,  however,  may  present  a general 
coating.  The  teeth  often  fall  out  without  pain 
from  the  retraction  of  the  gums,  and  are  sin- 
gularly liable  to  caries.  Digestion  is  usually 
good,  except  during  catarrh  of  the  stomach,  which 
is  a rather  frequent  condition.  Constipation  is 
the  rule  in  diabetes,  often  to  a troublesome  extent. 
This  arises  partly  from  the  deficiency  of  water  in 
the  bowel ; partly  also  from  the  small  quantity 
of  fecal  residue  from  an  exclusively  meat  diet. 
Diarrhoea,  on  the  other  hand,  is  not  uncommon, 
and  rapidly  deteriorates  the  patient's  strength 

General  Symptoms.— Emaciation  is  an  early 
and  marked  symptom  of  diabetes,  but  not  in- 
variably so,  for  diabetes  often  occurs  and  persists 
in  stout  persons,  without  removing  the  obesity. 
These  are  cases  of  the  more  tractable  kind,  the 
patients  being  usually  somewhat  advanced  in 
life.  Their  complete  cure  is  seldom  effected,  but 
they  do  not  seem  to  suffer  greatly  from  the 
malady.  Though  the  emaciation  is  in  great 
part  due  to  the  removal  of  fat,  and  in  part  to 
the  abstraction  of  water  from  tho  tissues,  there 
seems  to  be  also  an  actual  waste  of  muscular 
substance,  especially  in  the  advanced  stages  of 
the  disease.  With  this  emaciation  are  asso- 
ciated weakness,  weariness,  and  disinclination 
to  exertion.  These  are  often  among  the  earliest 
symptoms  of  the  disease,  often  occurring  long 
before  wasting  is  noticed,  and  increasing 
markedly  towards  the  close  of  the  malady. 
From  various  causes,  one  being,  doubtless,  weak- 
ening of  the  heart,  oedema  of  the  lower  extre- 
mities may  occur,  with  or  without  albuminuria. 
Gangrene  of  the  extremities,  of  the  senile  kind, 
has  been  observed. 

Respiratory  apparatus. — With  regard  to  the 
respiratory  organs,  a peculiar  apple- or  hay-like 
odour  of  the  breath  is  sometimes  observed,  pro- 
bably arising  from  the  production  of  acetone 
mixed  with  alcohol.  But  the  most  serious  pul- 
monary symptoms  are  those  of  phthisis,  resulting 
from  a more  or  less  chronic  pneumonia.  This 
mischief  is  usually  indicated  by  a nightly  rise 
in  tho  temperature,  but  otherwise  may  remain 
for  a time  almost  latent.  It  is  most  com- 
mon in  the  young,  and  towards  the  end  of  the 
disease.  The  expectorated  matters  may  contain 
sugar.  Gangrene  of  the  lung,  or  a form  of  necro- 
sis of  the  lung-tissues,  has  been  noticed.  With 
this  form  of  gangrene  the  sputum  may  be  odour- 
less. 

Skin. — The  skin  is  usually  dry  and  scurfy,  often 


850  DIABETES 

extremely  itchy ; wounds  inflicted  by  scratching 
heal  with  difficulty.  Copious  saccharine  sweat 
is  observed  in  a certain  number  of  instances. 
There  is  a marked  tendency  to  the  formation  of 
boils  and  carbuncles.  Boils  often  occur  early  in 
the  disease,  and  may  give  the  clue  tc  the  exist- 
ence of  diabetes.  Carbuncles  occurring  late  in  the 
disease  may  be  the  immediate  cause  of  death. 

Nervous  System  and  Special  Senses, — The  sight 
is  often  affected  in  diabetes,  most  frequently  by 
the  formation  of  diabetic  cataract.  Operations 
in  such  cases  do  badly  till  the  disease  is  cured, 
and  are  seldom  tried,  for  the  cataract  occurs 
late  in  the  disease,  and  advances  rapidly.  A form 
of  retinitis  not  unlike  that  of  albuminuria  is 
sometimes  found.  Other  forms  of  imperfect  vision 
of  uncertain  origin  occur  in  diabetes.  They  go 
by  the  general  term  of  diabetic  amblyopia. 

Along  with  the  physical,  the  mental  powers 
fail,  and  all  moral  sentiments  become  blunted, 
which,  to  the  friends  of  the  patient,  is  not  the 
least  distressing  feature  in  the  malady. 

Genital  organs. — Early  in  the  history  cf  the 
disease,  all  sexual  appetite  disappears,  and  sexual 
power  soon  fails  in  the  male — but  with  improve- 
ment this  may  return.  In  the  advanced  stages 
amenorrhcea  is  not  unusual  amongst  females. 

Complications. — Several  of  the  symptoms 
just  described  are  regarded  by  some  authorities 
as  complications  of  diabetes  rather  than  as 
belonging  essentially  to  the  disease.  Such  are 
especially  diabetic  cataract  and  amblyopia,  boils 
and  carbuncles,  and  the  chronic  pneumonia  or 
phthisis  in  which  diabetes  so  frequently  ends. 
Gangrene  of  the  extremities  has  also  been  occa- 
sionally observed.  Amongst  the  intercurrent 
diseases  that  are  specially  to  be  watched  for  and 
seriously  regarded,  one  of  the  most  important  is 
albuminuria,  the  appearance  of  which  may  en- 
courage a false  prognosis,  from  the  fall  in  specific 
gravity  of  the  urine  that  attends  it. 

Diagnosis. — The,  diagnosis  of  Diabetes  de- 
pends on  the  discovery  of  sugar,  in  notable 
quantity,  in  the  urine  of  the  patient.  But  before 
the  investigation  for  sugar  is  undertaken,  there 
have  usually  been  observed  by  the  patient  some 
of  the  early  indications  of  diabetes,  of  which  the 
following  are  the  most  frequent,  though  no  one 
definite  symptom  invariably  heralds  the  disease : — 

1.  dryness  of  the  mouth  and  thirst;  2.  bodily 
weakness  and  gradual  emaciation  ; 3.  dryness  of 
skin,  with  itching  and  a tendency  to  succes- 
sive crops  of  boils ; 4.  urination  in  increased  quan- 
tity, the  urine  being  of  a greonish  yellow  tint,  with 
the  odour  described ; 5.  defects  of  vision.  Occasion- 
ally the  attention  of  the  patient  is  drawn  to  the 
state  of  his  urine  by  the  attraction  it  presents  to 
ants,  flies,  and  other  insects ; or  by  the  formation 
of  white  spots  of  sugar  on  his  dress  or  boots  left 
by  the  urine  on  evaporation. 

AVe  must  not  forget  that  in  true  diabetes 
we  find  sugar  in  notable  quantity.  There  are 
often  present  in  the  urine  other  reducing  agents 
(such  as  uric  acid  and  colouring  matters),  so 
that  the  amount  of  sugar  detected  must  be 
such  as  to  admit  of  no  doubt  whatever.  Again, 
the  presence  of  the  sugar  must  be  persistent, 
hence  a single  examination  will  not  suffice  for 
diagnosis  unless  sugar  be  found  in  large  quantity. 
It  may  so  happen  that  the  patient  when  seen  is 


MELLITUS. 

not  passing  sugar,  from  the  influence  of  restricted 
diet,  or  from  some  other  cause,  such  as  pneu- 
monia or  other  feverish  condition.  It  is  theD 
best  to  examine  the  urine  passed  an  hour  or  two 
after  a meal,  or  even  to  permit  the  use  of  starchy 
food  for  a day  or  two,  so  that  the  constitutional 
proclivities  of  the  patient  may  be  the  better  as- 
certained. To  determine  the  existence  of  sugar 
is  net  enough ; it  is  always  necessary  to  deter- 
mine the  quantity  passed,  so  as  to  obtain  a clue 
to  the  intensity  of  the  disease,  and  to  judge  of 
the  effects  of  treatment. 

Qualitative  testing  for  sugar. — 1.  Specific 
gravity. — This  almost  invariably  exceeds  that 
of  the  healthy  secretion.  If  a large  quantity  of 
urine  is  being  passed  daily,  the  specific  gravity 
of  which  is  upwards  of  1030,  we  have  go  oil 
primd  facie  grounds  for  concluding  that  sugar  is 
present.  But  as  urinometers  are  often  inaccu- 
rate, this  criterion  is  of  doubtful  value. 

2.  Formation  of  torulce. — AY  hen  saccharine 
urine  is  allowed  to  stand  for  a time  in  a warm 
place,  sooner  or  later  fermentation  is  set  up,  with 
the  formation  of  yeast-fungus  ( Torula  ccrevisice). 
The  detection  of  the  fungus  by  means  of  the 
microscope  has  been  proposed  as  a test  of  the 
saccharinity  of  the  urine.  Such  a test  is  of  little 
use,  for  the  spores  of  the  ordinary  mildew  fungus 
(Penicillium  glaucum)csxn  hardly  be  distinguished 
from  those  of  the  yeast-fungus,  and  penicillium 
will  grow  on  any  decomposing  organic  matter. 

3.  Fermentation. — The  fermentation  of  saccha- 
rine urine  may  be  greatly  accelerated  by  adding 
to  it  some  fragments  of  dry  German  yeast,  and 
placing  it  in  a moderately  warm  place.  The 
production  of  alcohol  and  carbonic  acid  which 
results  is  a certain  test  of  the  presence  of  sugar 
in  the  urine.  This  procedure,  however,  takes 
some  time  and  is  not  very'  delicate,  requiring 
about  five  parts  of  sugar  in  a thousand,  or  two 
and  a half  grains  to  the  ounce,  to  give  any  satis- 
factory result.  It  is  best  managed  as  follows.  Take 
a large  test-tube,  or  ordinary  medicine-bottle, 
place  in  it  some  fragments  of  yeast,  and  fill  up 
with  urine.  Eit  a cork  with  a hole  bored  through 
it  with  a bent  glass  tube,  one  end  of  which  will 
reach  nearly  to  the  bottom  of  the  bottle  that 
is  to  contain  the  urine.  Fix  the  cork  firmly  in 
the  mouth  of  the  bottle,  so  that  the  bent  end  of 
the  tube  shall  turn  away  from  its  side,  and  over  a 
wine-glass  or  similar  collector.  AA'hen  fermenta 
tion  begins,  the  carbonic  acid  collecting  in  the 
top  of  the  bottle  will  press  downwards  on  the 
fluid,  which  will  thus  be  forced  up  through  the 
bent  tube,  and  fall  into  the  wine-glass  or  other 
receiver.  An  important  and  valuable  modifica- 
tion of  this  test  will  be  noted  hereafter. 

4.  Moore's  test  or  Heller's  lest. — When  saccha- 
rine urine  is  boiled  with  liquor  potassoe  the  sugar 
is  decomposed,  and  a compound  is  formed,  giving 
its  colour,  black  or  brown,  to  the  fluid.  A con- 
venient test-tube  is  filled  one-third  full  with  the 
urine,  and  an  equal  quantity  of  liquor  potassae  is 
added.  The  two  should  then  be  well  mixed  by 
shaking,  and  the  heat  of  a spirit  lamp  applied  to 
the  upper  portion  of  the  mixed  fluids.  If  sugar 
be  present  this  portion  will  gradually  darken, 
the  tint  assumed  varying  in  depth  according  to 
the  quantity  of  sugar  present.  This  test  is  very 
convenient.,  bnt  it  is  liable  to  several  objections 


DIABETES  MELLITUS. 


notably  these : — (a)  It  is  far  from  delicate,  re- 
quiring as  much  as  three  parts  in  a thousand, 
or  a grain  and  a half  of  sugar  to  the  ounce, 
to  afford  any  satisfactory  indication.  (6)  It  is 
practically  useless  for  quantitative  purposes, 
though  the  plan  has  been  tried  of  comparing  the 
colour  produced  -with  the  colours  of  solutions 
containing  know  quantities  of  sugar,  as  is  done 
in  the  Nessler  process  for  substances  producing 
ammonia  and  its  allies,  (c)  It  is  liable  to  tiro 
notable  fallacies.  (1)  High-coloured  urine  is 
always  darkened  in  tint,  sometimes  blackened, 
by  boiling  with  liquor  potass®.  (2)  Liquor 
potass®  very  often  contains  lead,  which  is  liable 
to  be  converted  into  black  sulphide,  when  boiled 
with  caustic  potass,  if  albumen  or  any  organic 
matter  be  present  in  the  urine.  The  former 
of  these  risks  cannot  well  be  obviated.  The 
latter  may,  by  first  testing  the  purity  of  the 
liquor  potass®,  and  keeping  it  in  green  glass 
instead  of  white  glass  bottles. 

5.  Boettgers  test  consists  in  the  action  of 
sugar  as  a reducing  agent  on  bismuth.  A small 
quantity  of  urine  having  been  poured  into  a 
test-tube,  an  equal  bulk  of  a solution  of  car- 
bonate of  soda  (one  part  of  crystallised  carbonate 
of  soda  to  three  of  water)  is  to  be  added,  and  a 
small  quantity  of  the  ordinary  basic  nitrate  of 
bismuth  introduced.  The  whole  is  to  be  heated, 
when  the  appearance  of  a grey  or  black  colour 
will  indicate  the  reduction  of  the  bismuth,  and' 
the  presence  of  sugar.  Albumen  in  the  urine 
gives  rise  to  a si  milar  fallacy  as  in  the  last  test,  by 
the  formation  of  a black  sulphide  of  bismuth. 
Other  metals,  as  silver,  chromium,  and  tin,  may 
be  reduced  in  like  manner,  hut  by  far  the  most 
convenient  practically  is  copper,  which  is  now 
almost  universally  employed  for  this  purpose, 
is  in 

6.  IVommer's  test. — The  usual  mode  of  pro- 
cedure is  to  take  a drachm  or  two  of  urine  in  a 
test-tube,  to  add  to  it  a few  drops  of  solution  of 
sulphate  of  copper,  then  to  add  liquor  potass® 
in  excess,  and  to  boil.  When  sugar  is  present  a 
red  or  orange-coloured  deposit  of  suboxide  of 
copper  should  be  thrown  down.  To  this  simple 
mode  of  testing  there  are  several  objections.  If 
excess  of  copper  be  used  some  of  the  blue  hydrated 
oxide  of  copper  may  remain  unchanged,  and  so 
give  rise  to  confusion.  If  too  much  liquor 
potass*  be  used  it  may  blacken  the  sugar. 
Hence  it  is  better  to  add  the  liquor  potass®  first, 
then  to  add  the  copper  solution  drop  by  drop. 
A bluish-white  precipitate  forms,  which  dissolves 
on  shaking.  In  this  way  a splendid  blue  fluid 
is  produced.  "When  the  precipitate  ceases  to 
dissolve,  neither  reagent  can  be  in  excess,  and 
heat  may  he  applied.  This. solution  of  the  blue 
precipitate  is  due  to  the  presence  of  sugar,  but 
many  other  organic  substances  have  the  same 
effect.  Among  the  substances  which  possess 
this  property,  yet,  do  not  reduce  the  copper  by 
boiling,  is  tartaric  acid,  and  advantage  of  this 
has  been  taken  for  the  production  of  a test-fluid 
not  open  to  the  above  objections.  The  employ- 
ment of  this  is  known  as 

7 Fekling's  test  or  method. — This  testing  fluid 
may  be  procured  ready-made,  but  the  following 
is  the  formula  for  it,  as  slightly  modified  by 
Pavy,  and  fitted  for  daily  use  : — -Five  grains  of 


351 

sulphate  of  copper,  ten  grains  of  neutral  tartrate 
of  potash,  and  two  drachms  of  liquor  potass®.  A 
more  exact  formula  will  be  given  farther  on. 
The  fluid  thus  formed  is  of  an  intense  blue  colour, 
clear  and  bright.  When  the  test-fluid  is  to  be 
used,  a small  quantity  of  it  shoidd  first  be  raised 
to  the  boiling  point,  because  by  prolonged  keeping 
the  tartaric  acid  undergoes  change,  a substance 
being  formed  from  it  which  is  capable  of  reducing' 
copper,  and  might  give  rise  to  confusion.  But 
if  on  boiling  the  test-fluid  no  copper  is  thrown 
down,  the  suspected  urine  should  be  added  drop 
by  drop,  the  mixed  fluid  being  at  the  boil- 
ing point.  If  sugar  be  present  in  quantity  it 
will  throw  down  the  copper  in  the  form  of  a red 
or  orange  precipitate.  The  quantity  of  urine 
added  must  never  exceed  the  bulk  of  the  test- 
fluid,  and  the  upper  portion  of  the  fluid  should  be 
heated,  so  as  to  contrast  with  the  lower  portion. 
Should  suboxide  of  copper  be  thrown  down  when 
the  test-fluid  is  boiled,  the  fluid  must  be  filtered 
before  adding  the  suspected  urine,  or,  still  better, 
a new  fluid  be  prepared.  To  obviate  as  far  as 
possible  such  inconveniences,  the  cupric  and 
alkaline  fluids  should  be  kept  in  separate  bottles 
until  about  to  be  used. 

When  the  quantity  of  sugar  in  the  urine  is 
very  small,  as  may  occur  in  ordinary  diabetes 
after  long  fasting  or  the  use  of  a rigidly  restricted 
diet,  or  during  an  access  of  fever,  still  more 
minute  precautions  must  be  taken.  When,  from 
any  cause,  the  sugar  present  is  less  than  three 
parts  in  a thousand,  various  anomalies  may  occur 
in  the  reaction.  It  is  in  such  cases  that  the 
reducing  power  of  uric  acid  and  the  urinary 
colouring  matters  assumes  importance.  Witli 
this  small  quantity  of  sugar  the  copper  deposit 
is  never  red,  but  yellow ; and  we  may  have  appa- 
rently any  intermediate  shade  of  colour  from  the 
deep  blue  of  the  copper  solution  through  all 
varieties  of  green  to  yellow,  with  or  without 
deposit  after  standing.  Again,  if  the  urine  con- 
tains much  phosphates,  boiling  with  the  alkaline 
solution  may  throw  them  down,  and  if  at  the 
same  time  the  normal  urinary  constituents  reduce 
some  of  the  copper,  the  precipitate  may  roughly 
resemble  a deposit  of  copper  produced  by  sugar. 
It  may  thus  be  necessary  to  decolorise  the  urine, 
which  may  be  done  by  passing  it  repeatedly 
through  a filter  of  animal  charcoal.  Another 
difficulty  is  the  presence  of  albumen  in  the  urine, 
which  renders  the  test  nugatory.  Accordingly 
in  all  cases,  before  applying  any  kind  of  test, 
the  albumen  must  be  removed-  by  boiling  and 
filtration. 

Quantitative  Testing  for  Sugar.  1 .Felling's 
volumetric  method. — This  method,  nowin  common 
use,  is  founded  on  the  fact  that  the  proportion  in 
which  sugar  reduces  copper  is  constant.  One 
equivalent  of  grape  sugar  decomposes  exactly 
ten  of  sulphate  of  copper,  or  180  parts  by  weight 
of  grape  sugar  decompose  1246  8 parts  by 
weight  of  sulphate  of  copper.  This  being  borne 
in  mind,  and  a copper  solution  of  known  strength 
being  used,  it  is  easy  to  determine  the  quantity 
of  sugar  in  any  given  specimen  of  urine.  The 
quantities  may  be  calculated  according  to  the 
metric  system  or  by  grains  and  minims.  If  wp 
adopt  the  metric  system,  our  fluid  will  consist 
of  the  following  ingredients : — 


DIABETES  MELLITUS. 


B6Z 

Sulphate  of  Copper  (crystals)  40  grammes. 

Tartrate  of  Potass  (noutral)  160  grammes. 

Liquor  Sodae  (Sp.  gr.  1T2)  750  grammes. 

AVater  to  1154'5  cubic  centimetres. 

These  should  be  carefully  mixed,  or,  what  is 
better,  the  copper  and  alkaline  solutions  made 
separately,  so  that  five  cubic  centimetres  of  each, 
or  ten  of  the  mixed  fluids,  will  exactly  decompose 
•05  gramme  or  50  milligrammes  of  sugar. 

According  to  the  English  system  of  measure- 
ment, Dr.  Pavy's  solution  is  the  most  convenient. 
It  consists  of  sulphate  of  copper,  320  grains,  dis- 
solved in  ten  ounces  of  distilled  water ; and  tar- 
trate of  potash  (neutral),  640  grains,  with  caustic 
potash  1280  grains,  also  dissolved  in  ten  ounces 
of  distilled  water.  These  fluids  may  be  kept 
separately  or  mixed.  In  mixing,  the  copper 
should  be  added  to  the  alkaline  solution,  not  vice 
versa , to  prevent  the  formation  of  any  precipi- 
tate. One  hundred  minims  of  this  mixed  fluid 
are  decomposed  by  half  a grain  of  sugar.  Only 
a minim  measure  and  a porcelain  capsule  or 
other  vessel,  which  will  stand  heat,  are  required 
for  Pavy’s  solution  in  the  procedure  which  is  as 
follows  : — Most  specimens  of  diabetic  urine,  con- 
taining too  much  sugar  for  accurate  testing, 
first  require  dilution  with  water,  and  the  most 
convenient  degree  of  dilution  is  when  one-tenth 
of  the  fluid  is  urine.  Next  put  ten  cubic 
centimetres  of  the  metric  copper  solution,  or  one 
hundred  minims  of  Pavy’s  solution,  carefully 
measured,  iu  a small  porcelain  capsule.  The 
fluid  being  deep  blue  is  better  for  dilution,  so  as 
to  diminish  the  intensity  of  tint.  Of  course 
this  does  not  alter  the  quantity  of  copper  present 
in  it.  The  porcelain  capsule  with  its  contents 
is  to  be  placed  on  an  iron  retort-stand,  at  such  a 
level  that  the  flame  of  a spirit  lamp  will  easily 
play  on  the  capsule.  Meanwhile  a pipette, 
graduated  from  above  downwards,  either  in 
minims  or  cubic  centimetres,  is  filled  up  exactly 
to  the  0 in  the  graduated  scale  with  the  diluted 
urine.  AATien  the  solution  of  copper  is  boiling, 
the  urine  is  added  to  it  from  the  pipett  e,  drop  by 
drop,  stirring  carefully  the  while,  until  signs  are 
shown  of  a decoloration  of  the  cupric  solution. 
The  moment  all  the  copper  has  been  thrown 
down  as  suboxide,  and  all  shade  of  blue  or  green 
has  disappeared,  the  addition  of  the  diluted  urine 
i s stopped,  and  the  quantity  already  used  read  off  on 
the  graduated  pipette.  To  ascertain  the  quantity 
of  sugar  in  the  urine  is  now  a simple  calculation. 
We  know  how  much  urine  has  been  employed  in 
reducing  the  10  cubic  centimetres,  or  100  minims 
of  the  cupric  fluid,  but  these  measures  represent 
exactly  50  milligrammes  and  half  a grain  of 
sugar  respectively.  The  quantity  contained  in 
the  diluted  urine  being  hence  deduced,  multiply 
this  by  ten,  to  get  the  quantity  contained  in  the 
urine  as  passed.  Next  multiply  by  the  total 
quantity  of  urine  passed  in  twenty-four  hours, 
to  ascertain  the  full  amount  of  sugar  passed  in 
this  period.  In  all  such  analyses  the  sample 
examined  should  be  taken  from  the  mixed  urine 
passed  during  the  whole  twenty-four  hours.  That 
passed  at  night  is  the  richest,  that  passed  in  the 
morning  poorest  in  sugar. 

2.  Eoberts’  fermentation  method,. — We  have 
already  noticed  the  fermentation  method  for 
demonstrating  the  existence  of  sugar  in  urine. 


Dr.  William  Bolerts,  of  Manchester,  has  also 
devised  from  it  a highly  accurate  quantitative 
process.  It  is  as  follows : — 

Put  about  four  ounces  of  the  suspected  urine 
into  a clean  eight-  or  twelve-ounce  glass  bottle. 
Introduce  a piece  of  dry  German  yeast,  about  the 
size  of  the  point  of  the  forefinger,  but  divided  into 
small  pieces.  Cork  the  bottle  with  a grooved 
cork  to  allow  the  escape  of  gas.  Pill  a com- 
panion bottle  quite  full  with  the  urine.  Cork 
quite  tightly,  and  set  both  aside  for  twenty-four 
hours  in  a warm  place — the  mantelpiece  will  do. 
By  the  end  of  that  time  fermentation  will  pro- 
bably have  ceased,  and  the  yeast  fallen  to  the 
bottom ; but  if  not,  being  suspended  it  will  not 
affect  the  specific  gravity  of  the  fluid.  The 
specific  gravity  of  the  two  specimens  must  now 
be  carefully  taken  with  an  accurate  urinometer, 
that  of  the  unfermented  bottle  being  taken  as 
the  standard.  The  fermented  urine  will  have 
lost  weight  from  two  causes.  1st,  the  sugar 
which  gave  the  increased  specific  gravity  has 
been  destroyed ; and,  2nd,  in  its  place  have  been 
formed  alcohol,  which  is  lighter  than  water,  and 
carbonic  acid,  which  has  escaped.  Every  degree 
of  specific  gravity  thus  lost  represents  a grain  of 
sugar  in  the  ounce  of  urine.  Thus,  if  there  is  a 
loss  of  twenty-five  degrees  of  specific  gravity,  the 
urine  would  contain  twenty-five  grains  of  sugar 
in  each  ounce.  Multiply  this  by  the  total  number 
of  ounces  passed,  to  get  the  amount  of  sugar 
discharged  per  diem.  This  plan  is  especially 
useful  for  noting  the  quantity  of  sugar  passed 
day  by  day,  and  can  be  easily  undertaken  by  the 
patient  or  his  friends. 

3.  Estimation  by  the  polariscopc. — A plan  of 
estimating  sugar  employed  a good  deal  abroad, 
depends  on  the  power  of  diabetic  sugar  to  turn 
the  plane  of  polarisation  to  the  right.  The  de- 
gree of  rotation  is  in  proportion  to  the  quantity 
of  sugar  contained  in  the  urine.  The  apparatus 
used  commonly  goes  by  the  name  of  the  Ventske- 
Soleil  apparatus,  from  its  inventors.  It  is  best 
adapted  for  light-coloured  urines.  If  the  urine 
be  deep  in  colour  it  requires  to  be  diluted. 

4.  Estimation  by  specific  gravity. — The  rudest 
mode  of  estimating  sugar  is  by  the  specific  gravity 
of  the  urine.  Since  the  methods-describe!  above 
were  introduced,  there  is  no  excuse  for  its  em- 
ployment save  as  a preliminary  test,  which  may 
suggest  the  idea  of  sugar  in  the  urine.  To 
facilitate  its  use  tables  were  drawn  out,  but 
the  great  increase  of  urea  often  found  in  dia- 
betes renders  the  test  of  but  little  accuracy. 

Prognosis,  Course,  and  Termination*. — The 
prognosis  of  confirmed  diabetes  is  ever  unfavour- 
able. Amelioration  is  common,  but  a perfect 
cure,  save  in  exceptional  cases,  is  rare.  Diabetes 
coming  on  suddenly  and  from  special  causes,  such 
as  injury  to  the  head,  is  more  likely  to  do  well 
than  when  more  gradually  developed.  The  younger 
the  patient,  the  more  sugar  passed,  the  greatei 
the  emaciation  and  debility,  the  worse  the  prog- 
nosis. Diabetes  persistent  with  pure  flesh  diet  is 
worse  than  if  persistent  only  with  a free  starchy 
or  saccharine  diet.  Loss  of  appetite  and  of 
digestive  power,  as  indicated  by  the  condition 
of  the  faeces,  is  of  evil  omen.  AVhen  albumen 
appears  in  the  urine  in  the  course  of  diabetes, 
the  specific  gravity  of  the  fluid  diminishes,  often 


DIABETES  MELLITUS. 


giving  rise  to  a false  impression  to  the  effect  that, 
as  the  specific  gravity  has  decreased,  the  diabetic 
state  must  be  improved.  The  only  true  test  of 
recovery  is  the  power  of  consuming  ordinary 
mixed  food  with  impunity  ; but  Seegen  says  that 
out  of  two  hundred  cases  he  bad  never  seen  this  re- 
sult. But  by  rigid  or  limited  dieting,  the  patient 
may  live,  and  even  enjoy  life,  for  many  years. 
Heredity,  directly  or  collaterally,  adds  to  the 
blackness  of  the  out-look.  Cases  resulting  from 
injury  to  tho  brain  or  other  parts  of  the  nervous 
system  are  often  the  most  hopeful  with  which 
we  have  to  deal,  though  by  no  means  always  so. 
The  course  of  diabetes  is  on  the  whole  chronic. 
Most  frequently  it  develops  gradually,  though  in 
some  cases  suddenly,  and  it  generally  lasts  from 
six  months  to  three  or  four  years.  In  stout  elderly 
persons  it  may  exist  much  longer,  especially  with 
good  digestion  and  alimited dietary.  On  the  other 
hand,  Dr.  Koberts  records  a case  which  proved 
fatal,  after  a well-marked  onset,  in  eight  days — 
the  shortest  period  known  to  the  writer.  Another 
case  was  fatal  in  threo  weeks,  the  patient  being 
three  years  old.  Some  cases  are  recorded  of  death 
at  still  earlier  periods,  hut  these  were  most 
probably  cases  of  long  duration  in  an  unnoticed 
shape  suddenly  developed  into  an  aggravated 
form.  A fatal  termination  of  diabetes  may  be 
brought  about,  as  already  indicated,  in  various 
ways.  Or.e  is  by  diabetic  coma,  not  unlike 
the  first  stages  of  uraemia.  This  may  prove  sud- 
denly fatal,  and  has  been  described  as  due  to 
fat  embolism,  or  to  acetone  in  the  system.  In 
the  advanced  stages  of  diabetes,  the  strength 
being  very  low,  comparatively  slight  causes  may 
produce  fatal  effects. 

Treatment. — Though  we  are  ignorant  on  many 
points  as  regards  diabetes,  yet  when  we  come  to 
its  treatment,  we  have  these  undoubted  facts — 
that  sugar  cannot  he  formed  out  of  nothing  ; and 
that  the  series  of  substances  out  of  which  it  may 
be  formed  is  limited.  And  though  we  cannot 
absolutely  succeed  in  feeding  the  patient  on 
substances  which  will  not  yield  sugar,  we  can 
supply  a nourishing  diet  furnishing  sugar-form- 
ing materials  in  the  scantiest  proportion — an  end 
best  attained  by  a pure  meat  diet.  But  besides 
dietetic  measures,  other,  though  subsidiary, 
means  may  be  taken  to  limit  the  formation  of 
sugar  by  suitable  hygienic  and  medicinal  treat- 
ment, It  is  convenient  to  treat  of  these  sepa- 
rately, though  they  should  be  employed  in 
conjunction. 

Dietetic  treatment. — All  authorities  agree  that 
meat  should  be  the  main  constituent  of  the  pa- 
tient’s food,  and  that  starch,  and  cane  and  grape 
sugar,  should  be  avoided,  as  well  as  the  sub- 
stances containing  them.  The  use  of  fats  and 
oils,  of  fruit-sugar  (levulose),  and  of  milk-sugar, 
is  not  so  definitely  settled.  Three  of  the  ordinary 
constituents  of  meat — gelatine,  glycogen,  and 
glycerine — being  sugar- formers,  the  parts  of  ani- 
mals containing  these  should  as  far  as  possible  be 
avoided.  It  is  very  important  in  constructing  a 
diet  scale  to  give  the  patient  as  much  variety  of 
form  as  possible,  the  basis  remaining  the  samo. 
As  the  diet  of  the  patient  is  the  main  factor  in  his 
treatment,  it  is  worth  the  practitioner’s  while  to 
study  the  various  changes  and  combinations  of 
food  which  may  be  given  with  impunity.  (See  a 

23 


35  3 

long  list  of  available  dishes  in  the  Appendix  of 
Bouchardat’s  work  on  Diabetes.)  As  regards 
vegetables,  the  rule  is  that  all  green  vegetables, 
or  the  green  parts  of  vegetables,  may  be  eaten  ; 
for  where  chlorophyll  is  abundant,  starch  and 
sugar  are  commonly  scanty  ; but  this  rule  has 
important  exceptions,  which  will  readily  occur  to 
the  reader.  Thus  the  green  parts  of  asparagus 
and  celery  may  be  used,  whilst  the  white  portion 
is  highly  saccharine.  Green  artichokes  may  be 
used.  Jerusalem  artichokes  are  objectionable. 
Cabbage  should  be  used  before  it  forms  a white 
heart.  Cauliflower  and  brocoli  are  rather  ques- 
tionable. Scottish  kale  and  spinach  may  alwaj's 
be  used.  Sea-kale  is  forbidden.  Most  fruits 
are  forbidden,  but  nuts  may  be  used  if  they  can 
be  digested.  French  beans  may  be  used  when 
quite  green  ; when  older  the  beans  themselves 
must  be  removed.  Haricot  beans,  peas,  and  all 
cereals ; tapioca,  sago,  arrowroot,  all  forms  of 
macaroni,  potatoes,  carrots,  turnips,  parsnips, 
and  beetroot  are  in  the  forbidden  list.  Water- 
cress, lettuce,  and  all  kinds  of  green  salad  may 
be  freely  used.  Cheese,  especially  of  the  poorer 
kinds,  may  be  used.  Cream,  butter,  and  other 
fatty  articles  may  be  used  in  moderation,  as 
they  are  only  sugar-formers  by  virtue  of  the 
glycerine  they  contain.  Some  kinds  of  gTeen 
pickle  are  useful ; mustard  pickle  should  not  be 
used.  Most  mustard  contains  starch,  but  it 
may  easily  be  got  quite  pure.  To  sweeten  tea 
or  coffee,  mannite  lias  been  suggested ; but  both 
willsoon  be  found  more  refreshing  without  sugar. 
Cocoa  made  from  the  nibs  can  be  used.  Small 
quantities  of  cold  tea  without  milk  or  sugar, 
with  slices  of  lemon  in  it,  will  often  be  found 
palatable,  cleaning  the  mouth  and  relieving 
thirst.  Kinsing  the  moutli  with  iced  water  will 
often  give  more  relief  than  a hearty  draught. 
Slowly  sucking  ico  is  a very  good  plan  for 
relieving  thirst.  All  sweet  drinks  are  in  the 
forbidden  list,  including  most  sherries  and  ports, 
though  some  of  the  former  may  be  found  nearly 
sugar-free.  Nearly  all  brandies  contain  sugar. 
Light  French  and  German  wines  contain  little 
or  no  sugar.  Gingerbeer  and  lemonade  are  very 
objectionable ; so  are  champagne,  sweet  beer, 
cider,  porter  and  stout,  rum  and  gin.  Whisky 
is  probably  the  best  form  of  spirits.  Tho 
use  of  alcohol  iu  these  cases  has  been  gravely 
questioned.  Where  alcohol  has  not  been  used 
before  the  onset  of  the  disease,  the  patient  is 
probably  better  without  it ; but  it  is  quite  clear 
that  in  many  cases  it  may  be  taken  in  modera- 
tion with  advantage. 

There  is  difficulty  in  procuring  a substitute 
for  bread  and  potatoes.  Three  imperfect  sub- 
stitutes are  employed,  viz  : — gluten  bread,  bran 
bread,  and  almond  bread.  Gluten  bread  as  in- 
troduced by  Bouchardat  consists  of  flour  out  ol 
which  nearly,  but  not  quite,  all  the  starch  has 
been  washed.  It  is  tough,  and  patients  tire  ol 
it ; a better  form  of  gluten  bread  is  made  by 
Bonthron  (Eegent  Street,  London).  This  last 
is  palatable  and  nearly  starch-free,  but  does  not 
keep  well.  Bran  bread  is  now  often  made,  in  the 
form  of  biscuits  or  cakes  ; tho  bran  should  always 
be  washed  nearly  free  of  flour.  Bran  bread  is 
hardly  admissible  when  there  is  a tendency  tc 
diarrhoea,  but  may  be  useful  in  constipation 


354  DIABETES  MELLITUS. 

Almond  cakes  were  first  introduced  by  Dr.  Pavy. 
They  are  rather  rich  to  be  eaten  with  meat,  but 
used  by  themselves  or  with  wine  are  excellent. 
Almond  flour  may  now  be  obtained  frcm  which 
much  of  the  oil  has  been  expressed. 

We  pass  over  Dr.  Donkin's  skim-milk  treat- 
ment of  diabetes  with  the  remark  that  in  the 
hands  of  Dr.  Donkin  and  some  others  the 
method  has  been  successful ; in' the  hands  of  many 
eminent  physicians,  both  at  home  and  abroad,  it 
has  done  unmitigated  harm.  Probably  the  ex- 
planation of  any  successful  cases  may  be  found  in 
the  fact,  that  in  certain  conditions  of  diabetes, 
milk  sugar,  as  well  as  certain  other  substances, 
does  not  give  rise  to  grape  sugar.  If  milk  is  to  be 
used,  butter-milk  or  sour  milk  will  be  best.  The 
treatment  by  sugar  or  glycerine  is  self-con- 
demned. 

Hygienic  treatment. — In  this  the  first  and 
most  important  point  is  regular  exercise,  espe- 
cially walking,  not  carried  out  to  fatigue. 
Bouchardat  has  strongly  advocated  gymnastic 
exercises.  These  would  be  useful  in  moderation, 
especially  in  bad  weather.  Nothing  is  more 
grateful  or  beneficial  to  the  skin  after  such 
exercise,  or  even  without  it,  than  a warm  bath, 
temp.  80°  to  90°,  with  a little  common  washing 
soda  in  it.  In  all  cases,  the  avoidance  of  wet 
arid  cold  is  important.  Flannels,  frequently 
changed,  should  be  worn;  and  it  is  always  safer 
to  change  the  clothes  after  the  slightest  exposure 
to  damp.  Little  may  suffice  to  give  rise  to  a 
fatal  pneumonia. 

Medicinal  Treatment. — This  must  be  con- 
sidered as  subsidiary  to  dieting,  but  there  are 
many  cases  where  undoubted  benefit  results  from 
drugs.  Of  those  which  have  been  found  of  real 
value,  the  foremost  is  opium.  Yet  there  is  no 
unanimity  of  opinion  as  to  the  mode  in  which 
opium  acts,  and  its  apparent  effects  are  most 
discordant — in  some  cases  reducing  both  sugar 
and  urine  without  sleepiness,  in  others  speedily 
giving  rise  to  drowsiness  and  even  apparently 
to  coma.  The  varied  susceptibility  of  different 
patients  to  this  drug  is  very  striking.  Some 
will  take  20  or  even  o'O  or  60  grains  a day  with 
no  apparent  physiological  effect  beyond  slight 
contraction  of  the  pupil;  others  again  cannot  en- 
dure even  a few  grams.  The  writer’s  experience 
is  decidedly  in  favour  of  opium.  Codeia  has 
been  strongly  recommended  by  Dr.  Pavy  as  being 
the  influential  ingredient  in  the  raw  opium. 
He  begins  with  doses  of  half  a grain.  Next  to 
opium  come  alkalies,  and  especially  some  alkaline 
waters.  Alkalies  themselves  may  be  given  in 
various  forms — as  cream  of  tartar  to  relieve 
thirst,  as  citrate  or  bicarbonate  of  potash,  or,  if 
there  is  a tendency  to  gastro-intestinal  catarrh, 
as  liquor  potass®,  with-or  without  a bitter.  The 
waters  in  most  repute  in  diabetes  are  those 
of  Carlsbad.  Vichy,  and  Vais.  An  annual  visit 
to  Carlsbad,  with  the  rigid  system  of  regimen 
and  dietary  carried  out  under  the  resident  physi- 
cians, often  suffices,  with  due  care,  to  keep  the 
patient  fairly  well  for  many  years. 

Lactic  acid  has  been  strongly  advocated  by 
Cantani.  His  results  seem  good,  but  he  also 
makes  uso  of  a most  rigid  dietary.  Dr.  B.  Fos- 
terrecords a case  where  acute  rheumatism  seemed 
to  arise  from  the  use  of  lactic  acid.  Pepsine 


DIAPHORETICS. 

and  rennet  have  been  used,  but  without  real 
advantage. 

Of  secondary  remedial  agents,  the  three  most 
important  are  strychnine,  iron,  and  cod-liver  oil ; 
these  favour  nutrition,  and  the  cod-liver  oil 
seems  to  improve  the  temperature  somewhat. 
Laxatives,  not  purgatives,  should  be  used  for  the 
troublesome  costiveness.  Mineral  waters,  castor- 
oil,  or  alkalino  purgatives  suit  best. 

Management  of  a Case  of  Diabetes. — By 
way  of  recapitulation  we  may  say  a few  words 
here  on  the  management  of  a case  of  diabetes. 
When  a patient  comes  under  the  care  of  the 
practitioner  he  must  first  ascertain  the  general 
state  of  the  patient  as  a basis  for  future  com- 
parison. The  patient’s  weight  must  be  carefully 
taken,  and  the  state  of  his  bowels  noted.  The 
quantity  and  characters  of  urine  passed  should 
be  noted  daily  for  a short  time,  the  patient  still 
consuming  ordinary  diet.  After  a day  or  two 
the  restricted  diet  should  be  gradually  com- 
menced, sugar  and  potatoes  being  first  cut  off. 
Next  the  bread  should  go,  being  first  of  all  cut 
down  and  used  toasted  hard  or  torrefied,  and 
this  should  merge  into  the  use  of  bran  cakes  or 
gluten  bread.  Above  all  things,  the  patient 
must  not  be  disgusted  Vitli  his  food,  for  this 
favours  the  secret  consumption  of  forbidden 
dainties.  Week  by  week  the  weight  should 
be  .taken  ; day  by  day  the  sugar  estimated, 
as  may  easily  be  done  by  Roberts’  method, 
and  the  whole  arranged  on  a card  so  as  to 
be  seen  at  a glance.  Warm  baths,  exercise, 
and  the  other  adjuvants  must  he  assiduously 
employed,  and  as  soon  as  the  effects  of  the 
limited  diet  are  clearly  marked,  opium  may  be 
tried.  If  well  borne  it  should  be  used  deter- 
minedly, and  pushed  to  its  physiological  effects, 
as  indicated  by  the  contracted  pupil.  If  the 
patient  is  seen  daily  his  diet  should  be  regulated 
each  day;  if  only  at  intervals  certain  available 
changes  should  be  indicated.  When  convales- 
cence begins,  and  the  urine  has  for  some  time 
been  free  from  sugar,  the  diet  may  be  gradually 
relaxed,  beginning  with  substances  containing 
little  starch  or  sugar,  gradually  extending  to 
bread  in  small  quantity  ; potatoes  should  come 
last,  sugar  itself  never.  When,  with  every  care, 
restriction  of  diet  effects  no  diminution  of  sugar, 
or,  if  that  be  limited,  emaciation  and  weakness 
rapidly  go  on,  it  will  be  a question  whether  it 
may  not  be  best,  as- it  often  is,  to  return  to  a 
practically  unrestricted  diet. 

Alexander  Silver. 

DIAGNOSIS  of  Disease.  See  Disease, 

Diagnosis  of. 

DIAPHORESIS  (5ia,  through,  and  <popea>, 
I convey). — The  act  of  perspiring.  The  term  is 
more  generally  applied  to  perspiration  artificially 
induced. 

DIAPHORETICS  (Sia.  through,  and  <pop(a>, 
I convey). 

Definition. — Remedies  which  increase  the 
secretion  of  sweat.  When  the  increase  is  so 
great  as  to  cause  the  perspiration  to  stand  in 
beads  upon  the  surface,  they  are  usually  termed 
sudorjf.cf. 


DIAPHORETICS. 

Enumeration.  — The  principal  diaphoretic 
measures  are — The  Vapour  Hath,  Turkish  Bath, 
and  Wet  Pack ; AVarm  Drinks  ; Warm  Clothing  ; 
Jaborandi,  Pilocarpin ; preparations  of  Antimony; 
Ipecacuanha ; Opium  and  Morphia  with  their 
preparations;  Sarsaparilla,  Guaiacum,  Serpen- 
tary, Sassafras,  Senega,  Mezereon,  Camphor ; 
Sulphur ; Ammonia  and  its  Carbonate,  Acetate, 
and  Citrate ; Alcohol ; Ethers  (especially  Nitrous 
Ether);  and  Chloroform. 

Action. — The  secretion  of  sweat  usually  con- 
sists of  two  parts,  namely,  a free  supply  of  blood 
to  the  sweat-glands,  and  the  abstraction  from  it 
of  the  materials  for  sweat  by  the  cells  of  the 
gland.  These  two  processes  sometimes  occur 
ndependently  of  each  other.  In  fevers  the 
supply  of  blood  to  the  glands  is  abundant,  but 
'.hey  do  not  secrete;  and  a similar  condition  is 
observed  in  belladonna-poisoning.  Belladonna 
or  atropia  possesses  the  power  of  paralysing  the 
secreting  nerves  of  the  sweat-glands,  just  as  it 
does  those  of  the  salivary  glands,  and  thus  the 
skin  remains  dry,  although  the  cutaneous  vessels 
are  much  dilated.  In  collapse  the  cutaneous 
glands  secrete  a cold  sweat  profuselj-,  although 
tbe  supply  of  blood  to  them  is  deficient. 

The  secreting  cells  appear  to  be  under  the 
influence  of  nerves,  by  exciting  which  secre- 
tion occurs.  The  centres  for  the  secreting 
nerves  of  the  sweat-glands  appear  to  be  situated 
in  the  spinal  cord,  and  in  the  medulla  oblongata. 
The.fibres  seem  to  run  in  the  same  path  as  the 
vaso-motor  nerves.  The  secretory  nerves  of 
the  sweat-glands  may  bo  excited  directly  by  a 
stimulation  of  the  nervous  trunks  in  which  they 
run ; and  the  sweat-centres  may  also  be  reflexly 
excited  by  irritation  of  various  sensory  nerves. 
Certain  substances,  such  as  nicotine  and  carbonic 
acid,  seem  to  stimulate  the  sweat-centres ; whilst 
other  drugs,  such  as  pilocarpin,  appear  to  act 
upon  the  peripheral  terminations  of  the  secretory 
nerves  in  the  sweat-glands  themselves.  Several 
remedies,  at  the  same  time  that  they  excite 
secretion,  likewise  increase  the  flow  of  blood 
through  the  skin,  rendering  it  redder,  warmer, 
and  more  vascular.  Others,  again,  excite  the 
secretion  at  the  same  time  that  they  diminish 
the  cutaneous  circulation.  Diaphoretics  have 
therefore  been  divided  into  two  classes,  the 
former  kind  being  termed  stimulant , and  the 
latter  sedative  diaphoretics.  The  exact  mode 
in  which  each  drug  already  enumerated  produces 
diaphoresis  has  not  yet  been  ascertained,  but 
antimony,  ipecacuanha,  and  jaborandi  are 
classed  as  sedative  diaphoretics,  and  all  the 
others  as  stimulating  ones.  The  supply  of  blood 
and  the  secretion  are  both  increased  by  the 
application  of  warmth,  by  the  ingestion  of  warm 
fluids,  and  by  the  action  of  jaborandi. 

Uses. — -Diaphoretics  are  employed  to  increase 
the  flow  of  blood  to  the  surface,  and  possibly 
to  aid  the  elimination  of  excrementitious  pro- 
ducts in  internal  congestion,  such  as  catarrh 
of  the  respiratory  passages  or  digestive  tract, 
and  in  febrile  conditions  generally.  In  fevers, 
the  cutaneous  circulation  is  generally  active, 
and  the  so-called  sedative  diaphoretics  are  then 
most  useful.  Diaphoretics  are  also  used  to 
increase  the  elimination  of  water  by  the  skin, 
and  thus  lessen  the  accumulation  of  fluid  in 


DIAPHRAGM,  DISEASES  OF.  Sfifi 

dropsy,  or  to  relieve  other  excreting  organs,  such 
as  the  kidneys  in  albuminuria  and  diabetes  insi- 
pidus, or  the  intestines  in  diarrhoea.  In  these 
cases  stimulant  diaphoretics  are  indicated. 

T.  Lauder  Brunton. 

DIAPHRAGM,  Diseases  of. — The  dia- 
phragm may  itself  be  the  seat  of  functional 
disturbance , or  of  organic  lesions ; or  it  may  be 
affected  by  neighbouring  morbid  conditions.  For 
practical  purposes  its  affections  may  be  con- 
veniently discussed  according  to  the  following 
arrangement: — 

1.  Mechanical  Interference. 

2.  Functional  Disorders,  (a)  Paralysis. 
(b)  Spasm. 

3.  Organic  Lesions,  (a)  Injuries,  including 
Ruptures  and  Perforations,  (b)  Iaflammar 
tion,  acute  or  chronic,  (c)  Muscular  Rheu- 
matism. (d)  Atrophy  and  Degeneration. 
( e ) Morbid  formations. 

1.  Mechanical  Interference. — The  dia- 

phragm is  frequently  interfered  with  by  morbid 
conditions  within  the  chest  or  abdomen,  which 
impede  its  action,  displace  it  more  or  less,  either 
upwards  or  downwards,  or  render  it  tense  and 
stretched.  The  entire  structure  may  be  thus 
affected,  or  only  a portion  of  it,  such  as  one 
lateral  half  or  its  central  part.  The  chief  tho- 
racic conditions  by  which  the  diaphragm  may  be 
thus  affected  are  pleuritic  effusion  or  pneumo- 
thorax, emphysema  of  the  lungs,  abundant  peri- 
cardial effusion,  enlargements  of  the  heart,  and 
tumours  within  the  chest.  The  principal  ab- 
dominal conditions  deserving  notice  as  being 
liable  to  produce  this  effect  are  a distended 
stomach,  tympanites,  ascites,  peritonitis,  preg- 
nancy, large  fsecal  accumulations,  and  tumours 
or  enlarged  organs  which  attain  considerable 
dimensions,  especially  ovarian,  hepatic,  splenic 
or  renal  tumours.  It  sometimes  happens  that 
the  diaphragm  is  interfered  with  both  from  its 
thoracic  and  its  abdominal  aspects. 

The  symptoms  induced  by  this  mechanical 
interference  are  readily  explained  by  its  effects. 
A sense  of  uneasiness  and  discomfort  is  often 
experienced  around  the  lower  part  of  the  chest, 
amounting  sometimes  to  considerable  tension 
and  tightness.  There  is  not  any  actual  pain, 
but  in  some  instances,  whore  the  diaphragm  is 
much  pushed  down,  the  patient  complains  of 
a painful  sensation  referred  to  the  ensiform  car- 
tilage, as  if  the  attachment  of  the  diaphragm 
at  this  point  were  being  severely  dragged  upon. 
The  act  of  respiration  is  more  or  less  impeded, 
and  this  often  seems  to  be  the  cause  of  the  dis- 
comfort experienced.  Asensation  frequently  com- 
plained of  by  patients  is  that  they  cannot  take  a 
lull  breath.  Respiration  may  be  much  hurried, 
or  oppressed  and  laboured,  and  not  uncommonly 
the  normal  relation  between  the  thoracic  and 
abdominal  movements  is  markedly  altered,  as 
observed  on  physical  examination,  and  the 
diaphragm  may  so  act  as  to  draw  in  the  lower 
part  of  the  chest-walls  in  inspiration.  Occa- 
sionally a kind  of  spasmodic  cough  seems  to  be 
excited  by  the  tension  of  the  diaphragm  pro- 
duced by  certain  conditions.  The  act  of  cough- 
ing is  also  frequently  rendered  more  or  less  diffi- 
cult and  ineffectual. 


DIAPHRAGM,  DISEASES  OF. 


J5C 

‘2.  Functional  Disorders. — Tho  affections  of 
the  diaphragm  included  within  this  group  are 
(a)  Paralysis ; ( b ) Spasm. 

a.  Paralysis. — The  diaphragm  is  completely 
paralysed  when  the  upper  part  of  the  spinal  cord 
is  destroyed,  whether  as  the  result  of  injury  or 
disease.  If  one  or  both  phrenic  nerves  should  be 
cut  across,  or  destroyed  by  disease,  or  even  se- 
verely compressed,  the  same  effect  will  be  pro- 
duced, either  one  lateral  half  or  the  whole  of  the 
diaphragm  being  paralysed,  according  as  one  or 
both  nerves  are  involved.  This  structure  may 
also  be  implicated  in  the  course  of  diphtheritic 
paralysis. 

Where  paralysis  of  the  whole  diaphragm  is 
suddenly  produced,  death  speedily  ensues  from 
the  grave  impediment  to  the  respiratory  func- 
tion resulting  therefrom.  If  it  is  brought 
about  gradually,  or  if  only  part  of  the  struc- 
ture is  involved,  the  effects  are  seen  in  more  or 
less  interference  with  this  function,  and  with 
the  acts  in  which  respiration  is  concerned. 
Thus  there  will  be  a subjective  sensation  of  dys- 
pnoea, and  of  a want  of  power  to  breathe;  while  the 
respiratory  movements  will  be  hurried,  shallow, 
and  superior-thoracic.  Coughing  cannot  be  per- 
formed efficiently,  and  sputa  cannot  be  expelled, 
while  the  abdominal  acts  for  which  a tense  dia- 
phragm is  required,  such  as  defecation  or  vomit- 
ing, are  also  ineffectual  or  impracticable.  The 
lower  parts  of  tho  lungs  become  more  and  more 
congested,  fluids  accumulate  in  the  air-tubes  and 
pulmonary  vesicles,  which  become  by  degrees 
filled  up,  and  the  patient  ultimately  dies  of 
asphyxia. 

b.  Spasm. — The  diaphragm  may  be  the  seat 
either  of  clonic  or  tonic  spasm  or  cramp.  The 
disorder  may  depend  upon  disease  of  the  nerve- 
centre  at  the  origin  of  the  phrenic  nerves  ; irri- 
tation of  these  nerves  in  their  course;  direct 
excitation  of  the  diaphragm  ; or  reflex  causes. 
Tonic  spasm  is  most  strikingly  observed  in  cases 
of  tetanus  ; of  poisoning  by  strychnia,  or  of  hy- 
drophobia ; but  a form  of  asthmatic  attack  has 
also  been  attributed  to  this  condition  of  the 
diaphragm. 

The  symptoms  will  vary  in  different  cases. 
Tonic  contraction  of  the  diaphragm  gives  rise  to 
severe  pain,  and  a sense  of  constriction  in  the 
corresponding  region,  which  may  come  on  in 
paroxysms  ; clonic  spasms  also  originate  painful 
sensations  after  a time,  which  may  become  very 
considerable.  Hiccup  is  probably  due  mainly 
to  a clonic  spasm  of  the  diaphragm.  If  this 
structure  should  become  rigidly  fixed,  respira- 
tion is  gravely  interfered  with,  and  the  patient 
soon  presents  the  phenomena  of  suffocation, 
which  will  end  fatally  if  the  spasm  is  not  re- 
lieved. In  the  form  of  asthma  supposed  to  be 
due  to  diaphragmatic  spasm,  expiration  is  very 
difficult  and  greatly  prolonged,  inspiration  being 
short  and  abrupt;  the  lungs  are  distended; 
great  distress  is  felt;  and  there  may  be  signs  of 
impending  death  from  suffocation.  A spasmodic 
cough  may  be  due  to  clonic  spasm  of  the  dia- 
phragm. 

3.  Organic  Lesions. — These  may  be  briefly 
considered  in  the  order  in  which  they  were  enu- 
merated at  the  commencement  of  this  article. 

a Injury,  Perforation,  and  Hupture. — 


The  diaphragm  may  be  perforated,  lacerated,  or 
ruptured  in  connection  with  various  forms  of 
injury,  such  as  crushing  accidents,  fractured 
ribs,  penetrating  wounds,  or  gun-shot  injuries. 
Should  the  patient  recover,  a permanent  perfora- 
tion may  be  left.  In  medical  practice  perfora- 
tion of  this  structure  may  be  met  with  as  a con- 
genital condition ; as  the  result  of  the  bursting 
of  some  fluid-collection  through  it,  such  as  an 
empysema,  a hepatic,  renal,  or  other  abscess,  or 
a hydatid-cyst ; or  from  its  destruction  in  the 
progress  of  some  organic  lesion,  such  as 
malignant  disease  or  an  aneurism.  It  may 
occasionally  occur,  independently  of  these  causes, 
owing  to  the  yielding  of  a weak  portion  of  the 
diaphragm,  especially  between  the  attachment 
to  the  ensiform  cartilage  and  tho  seventh  rib. 
In  rare  instances  the  perforation  is  congenital, 
or  a considerable  portion  of  tho  diaphragm  may 
be  deficient.  The  size  and  other  characters 
of  the  perforation  differ  much  in  different 
cases.  If  it  is  produced  by  the  opening  through 
the  diaphragm  of  a fluid-accumulation,  this 
fluid  escapes  from  the  abdominal  into  the  tho- 
racic cavity,  or  vice  versa ; in  other  instances 
the  portions  of  the  thoracic  or  abdominal  organs 
pass  through  the  perforation,  constituting  forms 
of  diaphragmatic  hernia.  The  writer  had  the 
opportunity  of  observing  a remarkable  instance 
in  which  the  entire  stomach  had  passed  through 
an  opening  in  the  diaphragm  into  the  cavity 
of  the  chest.  In  a case  reported  by  Dr.  Little, 
of  Dublin,  the  diaphragm  presented  an  almost 
circular  opening,  well-defined,  sharp,  with  some- 
what thick  edges,  and  through  this  opening 
passed  a hernia  consisting  of  peritoneum  con- 
taining some  omentum,  and  about  fifteen  inches 
of  the  transverse  and  descending  colon. 

To  recognise  clinically  a perforation  or  rup- 
ture of  the  diaphragm  is  generally  no  easy 
matter.  Often  there  are  no  symptoms  referable 
to  this  structure,  though  there  may  be  signs 
indicating  that  its  functions  are  more  or  less 
impeded.  The  occurrence  of  sudden  perforation 
may  be  known  from  tho  previous  existence  of 
some  condition  likely  to  cause  this  event,  such 
as  empysema,  or  an  abdominal  abscess ; the  super- 
vention of  acute  pain,  accompanied  with  indica- 
tions of  shock  or  collapse,  and  the  disappearance 
of  the  signs  of  the  original  morbid  condition ; and 
followed  by  the  development  of  phenomena  re- 
vealing that  fluid  has  passed  through  the  dia- 
phragm, and  accumulated  in  the  thoracic  or  abdo- 
minal cavity,  as  the  case  may  be,  or  that  some 
secondary  affection  lias  been  set  up  as  the  result 
of  the  perforation,  such  as  peritonitis  or  pleurisy. 
A fluid  collection  may,  however,  penetrate  the 
diaphragm  without  giving  rise  to  any  very  evi- 
dent disturbance.  When  an  organ  piasses  through 
the  diaphragm,  the  symptoms  present,  if  any, 
are  more  likely  to  be  associated  with  this  organ 
than  with  the  diaphragm,  and  physical  exami- 
nation may  possibly  detect  the  displacement.  In 
the  case  of  hernia  of  the  stomach,  already  re- 
ferred to,  the  chief  symptom  was  vomiting,  which 
occurred  immediately  after  taking  any  food  or 
drink. 

b.  Inflammation. — The  serous  covering  of 
tho  diaphragm,  either  on  its  thoracic  or  abdomi- 
nal aspect,  is  not  uncommonly  involved  in  cases 


DIAPHRAGM,  DISEASES  OE 
of  acute  pleurisy  or  peritonitis  respectively,  and 
the  inflammatory  process  may  penetrate  its 
structure.  It  may  also  be  involved  by  extension 
from  pericarditis.  Inflammation  of  the  substance 
of  the  diaphragm  may  further  arise  from  injury, 
direct  irritation,  pyaemia,  or  without  any  evident 
cause.  The  anatomical  conditions  observed  are  in- 
creased vascularity;  the  formation  of  lymph  upon 
its  surfaces;  softening  and  degeneration  of  its 
musevlar  tissue ; or,  in  rare  instances,  suppura- 
tion, an  abscess  forming  in  the  substance  of  the 
diaphragm,  or  pus  collecting  under  one  or  other  of 
its  serous  coverings.  Chronic  inflammation  of 
the  diaphragm  may  occur,  leading  to  a fibroid 
change  in  its  muscular  portions,  either  by  exten- 
sion from  neighbouring  structures,  or  as  the 
result  of  chronic  local  irritation. 

The  symptoms  of  acute  inflammation  of  the 
diaphragm  aro  generally  very  obscure  and  ill- 
defined.  The  condition  may  be  indicated  by 
severe  pain  in  the  region  of  this  structure, 
obviously  increased  by  breathing,  so  that  the 
respiration  becomes  instinctively  thoracic,  as 
well  as  hurried  and  shallow ; and  also  much 
aggravated  by  coughing,  defsecation,  or  any 
other  act  which  disturbs  the  diaphragm.  The 
patient  will  probably  be  much  distressed.  More 
or  less  pyrexia  will  probably  be  observed.  If  an 
abscess  should  form,  this  might  burst  either  into 
the  chest  or  abdomen,  and  thus  lead  to  secondary 
pleurisy  or  peritonitis.  Chronic  inflammation 
and  its  consequences  may  possibly  be  suspected 
from  a want  of  free  movement  in  the  diaphragm, 
associated  with  conditions  likely  to  originate 
this  change;  but  it  could  scarcely  be  recognised 
with  any  certainty. 

c.  Muscular  Rheumatism. — The  diaphragm 
may  be  involved  in  this  complaint,  whatever  its 
nature  may  be ; probably  it  is  attended  with 
structural  changes  in  its  tissues.  The  affection 
is  characterised  by  pain  referred  to  the  dia- 
phragm, which  may  be  very  acute  when  it  is  in 
any  way  brought  into  play.  So  long  as  it  is  kept 
at  rest,  there  may  be  no  discomfort,  but  deep 
breathing  causes  considerable  pain,  so  that  the 
respiration  is  carried  on  in  a shallow'  manner, 
and  may  be  entirely  thoracic.  Such  acts  as 
coughing  or  defaecation  cause  much  pain  and  a 
sense  of  aching. 

d.  Atrophy  and  Degeneration. — The  dia- 
phragm may  he  involved  in  the  course  of  pro- 
gressive muscular  atrophy ; it  may  also  be 
atrophied  from  causes  which  produce  general 
wasting;  or  undergo  senile  atrophy  and  degenera- 
tion; or  be  similarly  affected  from  local  causes, 
such  as  interference  with  its  blood-supply  from 
vascular  degeneration,  want  of  action,  or  after 
chronic  inflammation.  These  conditions  might 
give  rise  to  more  or  less  evident  interference 
with  the  functions  of  the  diaphragm,  which  in 
extreme  cases  would  amount  to  their  total  cessa- 
tion, diaphragmatic  breathing  being  rendered 
impossible,  the  symptoms  being  then  the  same 
as  when  the  diaphragm  is  paralysed.  In  cases 
of  progressive  muscular  atrophy  the  fatal  ter- 
mination may  arise  from  this  cause.  There 
would  not  be  any  pain,  hut  uncomfortable  sensa- 
tions might  arise  from  the  impeded  respiration. 

c.  Morbid  Formations. — The  diaphragm  is 
occasionally  the  seat  of  malignant  disease,  being 


DIARRHCEA.  357 

usually  involved  by  extension  from  some  neigh- 
bouring structure.  Non-malignant  solid  growths 
have  in  rare  instances  been  found  in  it.  Parasitic 
formations  may  also  occur  in  it,  namely,  hydatids, 
cysticercus,  and  trichina  spiralis.  Tubercle  is 
occasionally  found  in  the  diaphragm.  Possibly 
malignant  disease  might  be  indicated  by  signs  of 
impeded  diaphragmatic  movements,  with  localised 
pain,  accompanying  indications  of  cancer  in  other 
parts.  The  implication  of  the  diaphragm  in 
trichinosis  may  also  he  recognised  in  some  in- 
stances by  severe  pains,  spasmodic  contractions, 
and  serious  interference  with  diaphragmatic 
respiration.  In  most  cases,  however,  the  pre- 
sence of  any  morbid  growth  in  connection  with 
the  diaphragm  cannot  be  diagnosed  during  life, 
and  is  only  discovered  at  tlie  post-mortem  exa- 
mination. 

Treatment. — But  little  can  he  done  in  most 
cases  in  the  way  of  direct  treatment  in  connec- 
tion with  affections  of  the  diaphragm.  The  most 
obvious  indication  is  to  get  rid,  if  possible,  of 
any  condition  which  is  mechanically  impeding  its 
movements,  and  preventing  it  from  performing 
its  functions.  In  the  next  place,  any  disease  of 
which  the  condition  of  the  diaphragm  is  but  a 
part  must  receive  due  attention,  such  as  progres- 
sive muscular  atrophy,  centric  nervous  disease, 
or  trichinosis.  Painful  affections  might  be  re- 
lieved by  local  applications  of  dry  heat,  fomenta- 
tions, or  anodynes;  and  if  acute  inflammation 
is  suspected,  a few  leeches  might  be  applied. 
Electricity  might  prove  of  service  in  the  treat- 
ment of  some  cases  of  spasm  or  paralysis  of  the 
diaphragm,  the  continuous  current  in  the  one 
case,  the  interrupted  current  in  the  other. 

Frederick  T.  Roberts. 

DIARRHCEA  {flappito,  I flow  away).  — 
Svnon.  : Dcfluxio:  Alvi  Fluxus ; Purging ; Fr. 
Cours  de  Ventre ; Devoyement ; Ger.  Per 
Durchfall  ; Bauchjluss  ; Durchlctuf. 

Definition. — A frequent  and  profuse  discharge 
of  loose  or  of  fluid  alvine  evacuations,  without 
tenesmus. 

-ZEtiology.  — The  causes  predisposing  to 
diarrhoea  are  individual  peculiarity;  childhood 
— especially  the  period  of  first  dentition;  the 
climacteric  period ; and  hereditary  or  acquired 
weakness  of  the  digestive  organs.- — The  exciting 
causes  maybe  thus  classified; — 1.  Direct  irri- 
tation of  the  intestines  bv  (a)  Food  in  excess,  or 
of  improper  quality — for  example,  salted  meat, 
shell-fish,  sour  unripe  fruit  and  vegetables — dis- 
eased, decomposed,  or  imperfectly  masticated  ; 
the  products  of  faulty  digestion  prematurely 
passing  the  pylorus  ; imperfectly  elaborated  and 
fermenting  chyme;  impure  water,  such  as  that 
containing  from  3 to  10  grains  of  putrescent 
animal  matter  per  gallon  (Parkes) ; or  imper- 
fectly fermented  malt  liquors.  ( h ) Purgative 
medicines  and  irritant  poisons,  (c)  Bile,  excessive 
or  acrid.  (<£)  Faces,  retained.  ( [e ) Entozoa — luia- 
brici,  taenia,  trichinae,  and  entophyta — mycosis 
enteralis  (Buhl  and  others).  (/)  The  contents  of  a 
ruptured  abscess  or  hydatid  cyst.  ( g ) Intestinal 
lesion — such  as  tubercular  or  other  ulceration. 
2.  Defective  hygiene. — Diarrhoea  may  arise  from 
the  dwelling  being  damp,  cold,  dark,  and  unventi- 
lated; or  from  foul  emanations  from  decaying 


DIARRHCEA. 


m 

organic,  especially  animal  matter,  sewage,  orfaecal 
collections.  3.  Chills , climatic  variations,  &c. 
Diarrhoea  has  been  attributed  to  insufficient 
clothing;  sudden  exposure  to  cold  and  damp; 
chills,  as  fromwetfeet,  and  damp  bed  or  clothing ; 
over-heating,  as  by  excess  of  bed-clothing ; and 
rapid  variations  of  temperature,  such  as  hot  days 
and  cold  nights.  4.  Nervous  disturbances , for  ex- 
ample, depressing  emotions — fright,  grief;  neu- 
ralgia, hepatalgia  (Trousseau),  dentition,  and 
other  causes  of  reflex  disorder.  5.  Defective 
absorption  with  augmented,  peristalsis,  so  that  the 
food  is  passed  unaltered — Lienteric  diarrhoea. 

o.  Symptomatic  in  various  morbid  states,  for  in- 
stance, in  passive  congestion  of  the  portal  vein 
from  disease  of  the  liver,  heart,  or  lungs  ; perito- 
nitis, especially  puerperal;  organic  disease  cf 
tho  intestines — ulceration  (simple,  typhoid,  tu- 
bercular, cancerous),  lardaceous  degeneration, 
enteritis,  acute  or  chronic;  cholera;  typhoid 
fever  ; dysentery  ; occasionally  in  pyaemia, 
measles,  scarlatina,  confluent  small-pox,  ma- 
laria, gout,  Bright’s  disease  (its  later  stages), 
and  in  anaemia  and  exhaustion,  as  from  over- 
lactation, phthisis,  cancer,  Addison’s  disease, 
Hodgkin’s  disease,  exophthalmic  goitre,  leuco- 
cythaemia,  and  other  affections. 

Frequently  diarrhoea  arises  from  the  combined 
action  of  several  exciting  causes,  as  when  the 
disease  is  epidemic  during  summer  and  autumn 
Foul  emanations  from  decomposing  organic  mat- 
ter, over-crowding,  food  (and  especially  fruit)  in  a 
state  of  incipientdecay,  excessive  heat,  and  chills, 
may  then  collectively  determine  the  result.  In 
children  the  exalted  irritability  of  the  nervous 
system  during  dentition  predisposes  to  diarrhma 
from  slight  determining  causes. 

Description  and  Varieties. — Diarrhoea  may 
be  broadly  divided  into  the  acute  or  occasional,  and 
the  chronic  forms;  and  the  numerous  clinical  and 
pathological  peculiarities  of  different  cases  are 
conveniently  grouped  into  typical  varieties.  The 
general  effects,  varying  according  to  the  inten- 
sity and  duration  of  the  flux,  are  mainly  these : — 
Emaciation,  and,  in  children,  also  arrest  of  growth 
— theweight  either  diminishing  or  ceasing  to  be 
progressive ; ansemia,  indicating  defective  hiema- 
tosis  ; desiccation  of  the  tissues  from  the  rapid 
draining  of  serum  from  the  blood — hence  the 
thirst,  and  the  very  concentrated,  acid,  and  even 
albuminous  urine  observed  whenthere  is  a copious 
watery  outflow  from  the  bowels,  as  in  choleraic 
and  similar  forms  of  diarrhoea. 

It  will  be  expedient  to  describe  briefly  the 
principal  forms  of  diarrhoea. 

1.  Irritative  Diarrhoea. — Stnon.  : Diarrhoea 
Crapulosa  (Cullen). — Simple  flux  from  direct 
irritation  of  the  intestines  is  the  most  common 
variety  of  diarrhoea.  The  evacuations,  usually 
preceded  by  severe  griping  pains,  are  at  first 
feculent  and  usually  fetid  and  sour,  then  watery. 
In  children  (especially  hand-fed)  they  are  often 
like  pale  clay  or  putty,  or  they  contain  dense 
masses  of  undigested  casein  before  being  loose  ; 
after  evacuation  they  frequently  become  green- 
ish, like  chopped  spinach,  from  contact  with  very 
concentrated  acid  urine  converting  the  brown 
colouring  matter  of  the  bile  into  green  biliverdin; 
or  they  are  dark  green  when  passed,  and  may  be 
so  acrid  as  to  excoriate  the  anus,  the  genitals, 


the  inner  parts  of  the  thighs,  and  even  the  heels 
Fever  is  usually  absent. 

Diarrhoea  from  irritation  is  frequently  a pre- 
liminary stage  of  the  inflammatory,  dysenteric, 
and  choleraic  varieties. 

2.  Inflammatory  Diarrhoea. — Stnon.  : Diar- 
rhoea Serosa. — "When  the  causes  of  simple  irrita- 
tion excite  inflammation  of  the  mucous  membrane 
of  the  bowels,  fever  sets  in,  and  the  diarrhoea  in- 
creases. Usually  the  evacuations  become  more 
serous,  and  contain  shreds  of  fibrin  or  mucus  or 
pus.  Before  the  attack  passes  off  the  large  bowels 
are  apt  to  be  the  main  seat  of  inflammation; 
then  the  motions  are  scanty,  frequent,  more 
mucous  or  glairy,  contain  streaks  of  blood  and 
are  passed  with  severe  straining;  while  the 
skin  is  hot  and  dry. 

3.  Choleriform  Diarrhoea — Stnon.  : Cho- 
leraic diarrhoea;  Thermic  diarrhoea  — prevails 
mostly  in  hot  weather.  The  onset,  indicated  by 
vomiting  and  purging,  is  usually  sudden.  At 
first  the  vomited  matters  are  mucous  and  bile- 
tinted,  and  the  dejections  are  feculent — both 
quickly,  however,  becoming  more  and  more  abun- 
dant, watery,  and  colourless.  The  copious  and 
incessant  outflow  of  serum  may  in  a short  time, 
and  especially  in  children,  induce  a striking  re- 
semblance to  the  symptoms  of  Asiatic  cholera — 
a drawn,  sunken,  and  cyanotic  appearance,  loss  of 
temperature,  scanty  secretion  of  urine,  insatiable 
thirst,  and  cramps ; even  in  extreme  cases  the 
fluids  from  the  stomach  and  bowels  are,  how- 
ever, rarely  free  from  bile,  and  are  not  so  like 
rice-water  as  in  true  cholera.  The  collapsed 
algid  condition  as  a rule  rapidly  gives  place  to 
recovery  in  previously  healthy  adults,  while  it  is 
fatal  in  delicate  children,  children  prematurely 
weaned,  the  debilitated,  and  the  aged.  Barely, 
the  cold  stage  being  outlived,  the  patient  becomes 
hot,  and  passes  into  a state  of  stupor,  with  eithtr 
bilious  vomiting  or  purging  and  tympanites — 
the  typhoid  stage.  In  children  death  is  almost 
invariable  if  the  cold  stage  exceeds  twenty-four 
hours. 

4.  Uervous  Diarrhoea. — The  peristaltic  move- 
ments, and  the  activity  of  the  glands  of  the  ali- 
mentary canal,  are  often  increased  by  causes 
operating  through  the  nervous  system.  Diar- 
rhoea from  mental,  and  especially  emotional,  per- 
turbation, is  the  most  common  example.  Even 
a chronic  looseness  may  be  maintained  by  de- 
bility of  the  nervous  system,  induced  by  worry 
and  anxiety.  Exalted  innervation  of  the  bowels 
may  be  natural,  a proneness  to  diarrhoea  from 
slight  exciting  causes  having  always  existed;  or 
acquired,  when,  for  instance,  a flux  once  estab- 
lished is  apt  to  be  maintained.  The  unstable 
nervous  system  of  t he  periods  of  rapid  develop- 
ment and  of  the  climacteric  change  predisposes 
to  it.  It  is  often  an  important  factor  in  chronic 
diarrhoea.  The  intestinal  nerve-centres  may 
become  so  sensitive  (as  in  delicate  children) 
that  every  meal,  however  small,  may  induce  an 
immediate  call  to  stool,  the  motions  being  liquid 
or  pultaceous,  and  pale,  but  otherwise  healthy. 
The  peristaltic  movements  may  be  even  so  in- 
creased as  to  hurry  the  food  through  the  stomach 
and  bowels,  so  that  it  appears  unchanged  in  the 
stools.  Time  is  not  allowed  for  digestion  or 
absorption  to  be  even  begun.  This  form  has 


DIARRIICEA. 


been  termed  Diarrhoea  lienterica,  and  is  most  fre- 
quent in  children  before  the  period  of  the  second 
dentition.  The  increased  tonicity  of  the  mus- 
cular fibres  of  the  alimentary  tract  may  have 
resulted  from  previous  inflammation  of  the 
mucous  surface,  or  is  the  propagation  upwards 
of  some  irritation  (ulcer,  inflammation,  &c.)  of 
the  mucous  membrane  of  the  rectum ; or  it  arises 
from  the  products  of  imperfect  primary  diges- 
tion entering  the  duodenum.  In  adults  indi- 
gestion is  the  usual  cause.  The  appetite  is 
as  a rule  voracious,  and  debility  may  become 
extreme.  In  painful  or  difficult  dentition,  diar- 
rhoea arises  from  irritation  of  the  nerves  of  the 
stomach  and  bowels ; digestion  is  arrested,  and 
the  contents  of  the  alimentary  canal  become 
acid  from  fermentation,  and  are  ejected  by 
vomiting  and  purging. 

5.  Vicarious  Diarrhoea. — Embarrassment  or 
suppression  of  the  functions  of  the  skin,  kidneys, 
or  lungs  may  be  met  by  the  bowels  performing 
additional  excretory  work.  The  flux  thus  set 
up  is  salutary,  because  it  is  compensatory.  Diar- 
rhoea from  chills  (suppressed  perspiration)  is  a 
common  instance,  while  that  from  renal  and 
pulmonary  causes  is  less  frequently  observed, 
and  may  be  misconstrued  by  the  practitioner. 
Inasmuch  as  diarrhoea  usually  diminishes  the 
quantity  of  urine,  even  sometimes  to  the  verge 
of  suppression,  the  reverse  of  this  clinical  fact 
may  be  easily  overlooked  or  misinterpreted. 
Even  when  forewarned,  the  observer  may  at 
times — especially  when  the  urine  is  free  from 
albumen — find  it  difficult  to  determine  whether 
the  diarrhoea  is  a cause  or  an  effect  of  imperfect 
renal  elimination — a distinction  having  all- 
important  bearings  on  the  treatment.  The 
uraemic  and  eliminatory  character  of  it  may  be 
easily  decided  when  the  kidneys  are  known  to 
be  diseased  ; not  so,  however,  when  the  only  thing 
ascertainable  is  scanty — maybe  albuminous — 
urine,  or  total  suppression  of  urine  in  an  elderly 
patient.  In  such  a case  there  may  or  may  not 
be  organic  disease  of  the  kidneys,  and  still  the 
diarrhoea  may  be  uraemic,  inasmuch  as  it  may 
depend  on  ‘ renal  inadequacy.’  Diarrhoea  from 
pulmonary  embarrassment  generally  affords  re- 
lief to  breathing  and  cough.  The  chronic  loose- 
ness of  some  gouty  patients  is  also  eliminatory  : 
when  checked,  gout  is  apt  to  advance  and  the 
health  to  suffer. 

6.  Diarrhoea  from  mechanical  congestion. 
— Draining  of  serum  into  the  bowels  is  a common 
result  of  overloading  of  the  portal  vein  from  an 
impediment  to  the  flow  of  blood,  either  in  the 
vein  itself,  the  vena  cava,  or  the  right  side  of 
the  heart. 

7.  Chronic  Diarrhoea.  Synon.:  Cachectic  diar- 
rhoea.— Chronic  diarrhoea  is  frequently,  if  not 
generally,  unconnected  with  intestinal  lesions ; it 
may  be  maintained  by  chronic  catarrh  of  the  in- 
testines, or  by  an  exhausted  and  impoverished 
state  of  the  system,  as  in  inanition,  either  from 
insufficiency  of  food  or  from  enfeebled  digestion, 
or  in  chronic  wasting  diseases,  such  as  syphilis, 
malaria,  or  scurvy.  The  flux  increasing,  the  debil- 
ity onwhich  it  depends  thereby  perpetuates  itself, 
and  this  vicious  circle  tends  more  and  more  to 
destroy  life  by  anrnmia  and  exhaustion,  and  even 
after  apparent  recovery  there  is  a strong  dis- 


35b 

position  to  revert  to  it.  These  clinical  features 
of  chronic  diarrhoea  are  well  illustrated  by  the 
malady  which,  from  the  paleness  of  the  stools, 
is  commonly  known  in  India  as  ‘ White  Flux’ — 
a result  of  deterioration  of  health  by  climate  and 
malaria.  When  accompanied  by  fever  and  night- 
sweats,  chronic  diarrhoea  is  nearly  always  du* 
to  tuberculisation. 

Diagnosis. — The  different  forms  of  diarrhoea 
may  be  readily  distinguished  from  each  other  by 
a careful  consideration  of  the  causes  and  symp- 
toms. The  diseases  most  apt  to  be  mistaken  for 
diarrhoea  are  epidemic  cholera,  dysentery,  and 
mucous  irritation  of  the  bowels  from  retention 
of  faeces. 

a.  Cholera,  in  its  less  definite  forms,  may  re- 
semble bilious  diarrhoea  and  choleraic  diarrhoea. 
The  probability  in  favour  of  it  may  be  deter- 
mined by  the  absence  of  the  ordinary  causes  of 
diarrhoea,  the  paleness  and  watery  character  of 
the  stools,  tormina beingslight  or  absent,  the  sup- 
pression of  urine,  and  the  early  exhaustion.  The 
presence  of  bile  in  the  stools  is  always  in  favour 
of  diarrhoea.  Vomiting  is  more  frequent  in 
cholera ; when  it  occurs  in  diarrhoea  the  vomited 
matter  usually  contains  bile  and  undigested 
food,  while  in  cholera  it  is  a colourless  fluid. 

b.  Dysentery  is  usually  characterised  by  fever, 
tormina,  and  tenesmus,  and  frequent  scanty 
muco-sanguinolent  evacuations.  Sometimes, 
however,  in  the  early  stage,  the  motions  are 
copious,  watery,  and  fseculent,  as  in  ordinary 
diarrhoea;  but  the  presence  of  tormina  uni 
tenesmus,  and  tenderness  in  the  regions  of  the 
caecum  and  sigmoid  flexure,  indicate  the  dysen- 
teric nature  of  the  disease.  Chronic  diarrhoea 
may  be  distinguished  from  chronic  dysentery  by 
the  absence  of  a history  of  acute  dysentery,  or 
of  mucus  and  tenesmus,  and  the  less  frequent 
discharge  of  blood  in  the  evacuations. 

c.  Mucous  irritation  of  the  bowels. — Retention 
of  faeces  may  induce  a condition  resembling 
diarrhoea — frequent  thin  muco-fseculent  evacua- 
tions, which  are,  however,  shown  on  enquiry  to 
be  somewhat  scanty,  and  voided  with  straining. 

Treatment. — (a)  Diet  and  hygiene.  In  acute 
or  occasional  attacks  of  diarrhoea,  everything 
should  be  taken  in  small  quantity,  and  tepid 
or  cold,  never  hot.  Farinacea — arrowroot,  sago, 
rice,  tapioca,  flour,  and  the  like  are  useful,  and 
may  be  taken  in  milk,  or  in  chicken  or  mutton 
broth,  or  weak  beef-tea.  Animal  broths — and 
especially  beef-tea- — w'hen  concentrated,  or  in 
large  quantity,  are  apt  to  aggravate  diarrhoea. 
Mucilaginous  drinks — white  of  egg  in  water  or 
milk,  rice  or  barley  or  arrowroot  water ; and 
astringent  liquids — infusion  of  dried  whortle- 
berries or  roasted  acorns,  red  light  wines — may 
be  given.  Brandy  is  often  of  service,  and  may  be 
mixed  with  spices  or  with  the  farinacea.  Lime- 
water  with  milk  is  in  many  cases  of  much  value. 

Rest  in  bed  secures  a uniform  w'armth  of  skin, 
and  favours  the  cessation  of  diarrhoea. 

In  children,  errors  of  feeding  should  be  cor- 
rected. Lumps  of  casein  in  the  motions  may 
be  met  by  reducing  the  quantity  of  milk,  and 
regulating  the  time  between  meals,  providing  a 
wet  nurse,  or  substituting  the  milk  of  the  goat 
or  ass  for  that  of  the  cow.  Sometimes,  however, 
milk  in  any  form  must  be  given  up.  The  abdo- 


DIARRHOEA. 


380 

men  should  be  protected  by  a flannel  bandage, 
md  the  feet  and  legs  by  warm  clothing. 

Inasmuch  as  in  chronic  diarrhoea  the  flux  is 
perpetuated  by  the  debility  and  anaemia  which 
it  induces,  and  by  the  activity  of  intestinal 
digestion,  it  has  become  a leading  principle  of 
treatment  to  prescribe  food  rich  in  materials 
for  the  construction  of  the  blood  and  the  tissues, 
and  almost  wholly  disposed  of  by  the  stomach. 
Hence  the  happy  results  frequently  observed 
from  a diet  exclusively  animal,  either  raw  or 
lightly-cooked,  the  digestion  of  which  may  be 
aided  by  hydrochloric  acid  alone  or  with  pepsin. 
Individual  peculiarity  may  be  gratified,  and 
variety  obtained  from  the  use  of  mutton,  veal, 
chicken,  pigeon,  and  game.  Beef,  the  tough  parts 
of  veal,  and  pork  are,  as  a rule,  to  be  avoided. 
Milk  and  farinacea  are  gradually  permitted 
during  the  progress  towards  recovery,  but  the 
period  during  which  they  should  be  interdicted 
may  require  to  be  very  prolonged — even  months. 
The  treatment  by  raw  meat,  strongly  advocated 
by  Trousseau  and  Niemeyer,  has  been  success- 
fully applied  to  nearly  every  variety  of  chronic 
diarrhoea,  but  especially  to  that  obstinate  one 
occurring  from  the  time  of  weaning  to  the  close 
of  the  first  dentition.  The  meat  may  be  pounded 
mto  a pulp  or  finely  minced,  then  mixed  with 
salt,  sugar,  fruit  jelly,  or  conserve  of  roses,  or 
diffused  through  clear  gravy  soup  or  chocolate 
made  with  water  or  wine  ; or  the  juice  may  be 
extracted  from  it  by  pressure.  Notwithstand- 
ing the  prohibition  of  other  food,  it  is  best  to 
begin  with  a small  quantity,  and  to  increase  it 
gradually.  The  only  drink  allowable  is  water 
containing  white  of  egg.  Trousseau  found 
opium  in  small  doses,  chalk,  and  bismuth,  at  and 
between  meals,  to  assist  this  regimen.  When  a 
restricted  animal  diet  cannot  be  digested,  causes 
loathing,  or  aggravates  the  flux,  other  varieties 
of  food  may  be  added,  and  the  feeding  should  be 
as  generous  and  varied  as  possible,  and  adapted 
to  the  digestion  of  the  individual.  Articles  of 
diet  appearing  undigested  in  the  motions  should 
be  avoided.  Low  and  damp  situations  should 
be  exchanged  for  dry  and  open  ones.  Warm 
clothing,  flannel  next  the  skin,  and  flannel  waist- 
belts  should  be  worn. 

(b)  Medicinal  Treatment. — The  kind  and  de- 
gree of  interference  required  should  first  be 
decided  in  each  case  of  diarrhoea.  A routine 
prescription  of  astringents  is  much  to  be  depre- 
cated. When  the  flux  is  moderate  and  salutary 
— for  example,  removing  undigested  or  indi- 
gestible materials  or  irritating  secretions,  re- 
lieving an  engorged  portal  vein,  or  supple- 
menting a suppressed  secretion — it  may  be  left 
uncontrolled  by  medicine,  or  may  be  encouraged 
by  laxatives,  such  as  castor  oil,  rhubarb,  or  a 
saline  aperient,  combined  with  a mild  sedative 
— for  instance,  henbane  or  opium : it  cannot 
be  checked  without  risk.  As  a rule,  the  treat- 
ment of  diarrhoea  should  begin  by  removing 
irritating  substances  from  the  alimentary  canal 
by  aperients  guarded  by  small  doses  of  opium  ; 
and  astringents,  such  as  chalk-mixture  with 
kino,  catechu,  hrematoxylum,  and  opium,  should 
be  held  in  reserve.  A purgative  may  increase 
the  flux,  which,  however,  soon  subsides.  Trous- 
seau advocated  the  use  of  salines — sodas  sulphas, 


soda  tartarata,  magnesias  sulphas — in  progres- 
sively decreasing  doses,  dissolved  in  a small 
bulk  of  water,  in  the  morning  fasting,  while 
others  prefer  castor  oil,  rhubarb,  or  other  ape- 
rients. Castor  oil  is  by  far  the  most  useful 
remedy  for  children,  as  well  as  for  adults  ; for 
the  former  it  should  be  emulsified  in  gum  and 
syrup,  and  for  the  latter  in  yelk  of  egg,  and  as 
occasion  requires  combined  with  a small  opiate, 
for  example,  compound  tincture  of  camphor, 
vinura  opii,  or  tincture  of  opium. 

In  choleraic  diarrhoea,  the  best  results  are 
obtained  from  castor-oil  guarded  by  a small  dose 
of  laudanum  at  the  commencement,  and  repeated 
if  the  disease  is  severe;  while  astringents  and 
opiates  alone  are  withheld  until  the  bowels  are 
relieved  of  offensive  materials,  as  in  the  later 
stages,  the  stools  being  copious  and  watery, 
griping  and  distension  of  the  abdomen  absent, 
and  the  tongue  clean.  Vomiting  should  be  en- 
couraged by  copious  draughts  of  warm  water, 
and,  if  need  be,  by  emetics  of  mustard  or 
ipecacuanha.  In  children,  when  the  motions  are 
colourless,  profuse,  and  incessant,  it  is  best  to 
give  hydrargyrum  cum  ereta  in  small  doses  every 
hour  or  two,  and  a very  small  enema  of  starch, 
containing  phumbi  acetas  or  cupri  sulphas,  with 
laudanum,  which  may  be  repeated  if  necessary ; 
and  the  urgency  of  the  case  may  likewise  demand 
a firm  astringent,  such  as  logwood.  In  the  cold 
stage  there  have  been  recommended  mustard 
baths  (for  twelve  or  fifteen  minutes,  several 
times  a day);  emetics  (ipecacuanha  2 to  3 grains 
twice  or  three  times  in  twenty-four  hours) ; diffu- 
sible stimulants  (ether  in  syrup  every  hour  or 
half-hour);  and  mercurials  (hydrargyrum  cum 
creta) ; in  the  stage  of  reaction,  saline  aperients 
or  calomel  in  small  doses  throughout,  white-of- 
egg  in  water  as  a drink ; and,  vomiting  having 
ceased  and  diarrhoea  being  established,  bismuth, 
chalk,  and  lime  water. 

In  nervous  diarrhoea  the  first  indication  is  to 
allay  reflex  excitability  by  the  bromides,  or, 
these  failing,  by  opium.  When  diarrhoea  is  ex- 
cited by  food,  the  dose  should  be  given  shortly 
before  meals.  In  lientcric  diarrhoea  arsenic  is 
invaluable.  Mal-digestion  should  be  met  by 
hydrochloric  aci3,  bismuth  with  alkalies,  or 
other  appropriate  remedies,  according  to  the 
indications.  Occasional  doses  of  castor-oil — 
alone,  or  with  bismuth  or  small  doses  of  opium 
or  henbane — are  useful  in  clearing  away  fer- 
mentescible  matters,  which  are  apt  to  maintain 
an  irritable  state  of  the  bowels.  Astringents 
should  only  be  prescribed  after  the  failure  of 
these  or  similar  measures. 

In  vicarious  diarrhoea  the  skin  should  be  made 
to  act  freely  by  warm  baths,  or  hot  air  or 
vapour  baths.  In  renal  inadequacy  counter- 
irritation  across  the  loins,  digitalis,  and  nitrate 
of  potash  may  be  likewise  indicated.  The  diar- 
rh<ea  should  not  be  arrested  or  even  cheeked 
unless  it  be  profuse  and  exhausting,  especially 
after  restoring  or  augmenting  the  action  of  the 
skin  and  the  kidneys ; it  is  sometimes  advisable 
to  nurse  and  encourage  it. 

Diarrhoea  from  passive  congestion  of  the  portal 
vein  is  to  be  met  by  treating  the  cause,  for  ex- 
ample, disease  of  the  heart,  by  digitalis,  iron 
and  other  remedies. 


DIARRHCEA. 

The  flux  of  chronic  diarrhoea  cannot  as  a rule 
be  stopped  altogether  by  astringents  only— the 
evacuations  while  thus  retained  may  decompose, 
and  induce  flatulence  and  colic,  or  fever.  The 
general  health  should  be  restored  and  amemia 
removed;  the  secretions  will  then  generally 
improve  and  the  diarrhoea  subside.  Tonics — 
iron,  arsenic,  quinine,  stryehuia — may  be  aided 
by  astringents — mineral  acids,  opium,  bismuth, 
chalk,  or  haematoxylum.  The  best  prepara- 
tions of  iron  are  iron  alum — 3 to  5 grains, 
and  liquor  ferri  pernitratis — 10  to  40  minims. 
Ipecacuanha  and  taraxacum  are  useful  when 
the  skin  and  liver  are  inactive  : from  1 to  3 
grains  of  pulvis  ipecacuanhas  may  be  given 
night  and  morning.  Podophyllum — -2  or  3 

minims  of  a solution  of  1 grain  in  1 drachm  of 
rectified  spirit  three  or  four  times  a day — is 
indicated  when  the  motions  are  wateiy,  pale  or 
high-coloured,  and  passed  with  severe  cutting 
pains.  Saline  purgatives  in  the  early  morning 
are  recommended — 2 drachms  of  sulphate  of 
soda,  sulphate  of  magnesia,  or  soda  tartarata  on 
the  first  day,  then  1 drachm  for  fourteen  days, 
dissolved  in  a small  bulk  of  water,  with  avoid- 
ance of  fluids  after  the  dose — and  from  1 to  2 
grains  of  rhubarb,  also  taken  fasting.  The  pro- 
fuse sweating  and  colliquative  diarrhcea  of  hectic 
is  best  met  by  haematoxylum  and  dilute  sulphuric 
acid,  or  opium  with  astringent  mineral  salts — 
nitrate  of  silver,  sulphate  of  copper,  or  acetate  of 
lead — by  the  mouth  or  rectum. 

Suppressed  secretions,  particular  cachexias, 
disturbed  innervation,  congestion  of  the  portal 
vein,  and  organic  diseases  of  the  intestines,  form 
special  indications  for  treatment  when  diarrhoea 
is  present.  George  Oliver. 

DIATHESIS  (5iaTi'07j^<,  I dispose). — A 
morbid  constitution,  predisposing  to  the  develop- 
ment of  a particular  disease.  Sec  Constitution, 
with  which,  in  a somewhat  more  limited  sense, 
this  term  is  synonymous. 

DIATHETIC  DISEASES— Constitutional 
diseases.  See  Constitutional  Diseases. 

DICHOTISM(5;s,  double,  and  icporos, a stroke) 
is  a term  applied  to  the  second  great  wave  of  the 
pulse.  This  dicrotic  wave  or  dierotism  is  due 
to  a second  expansion  of  the  artery  which  occurs 
during  the  diastole  of  the  ventricle.  The  pulsus 
bis  feriens  of  old  authors  was  a pulse  in  which  a 
second  beat  became  perceptible  to  the  finger; 
an  occurrence  observed  occasionally  as  an  an- 
tecedent of  hsemorrhago  and  also  in  the  course  of 
fevers.  The  second  beat  perceived  by  the  finger 
is  not  always  the  true  dicrotic  wave,  but  may  in 
some  cases  bo  an  exaggerated  tidal  wave.  This 
is  the  wave  perceived  in  the  high  arterial  tension 
sometimes  antecedent  to  haemorrhage.  The  mode 
of  production  of  dicrotism  is  not  quite  agreed 
on ; it  is  favoured  by  a low  state  of  arterial 
tension,  by  elasticity  of  the  arterial  coats,  and 
by  quick  and  strong  ventricular  contractions.  It 
is  generally  considered  to  be  central  in  its  origin, 
and  to  be  a wave  of  recoil  from  the  closed  aortic 
valves  reinforced  by  an  oscillation  set  up  in  the 
aorta.  The  other  view  refers  the  origin  of  the 
dicrotic  wave  to  the  periphery.  The  wave  of 


DIET.  361 

blood  discharged  at  each  ventricular  systole  is,  in 
consequence  of  its  acquired  velocity,  disturbed 
from  its  state  of  equilibrium,  and,  as  a result  of 
the  resistance  offered  by  the  peripheral  vessels, 
reflows  towards  the  heart,  whence  it  is  again 
reflected.  See  Pulse. 

Balthazar  Foster. 

DIET. — Definition. — Diet  may  be  defined 
as  expressing  the  regulation  of  food  to  the  re- 
quirements of  health  and  the  treatment  of 
disease. 

General  Principles. — In  order  to  sustain 
life,  a diet  must  consist  of  a proper  apportion- 
ment of  the  following  alimentary  principles: — • 

1.  Nitrogenous  principles. 

2.  Non-nitrogenous  principles  (fats,  carbo- 

hydrates, &c.) 

3.  Inorganic  materials  (saline  matters  and 

water). 

Whilst  these  principles  hold  different  relative 
positions  of  value,  the  absence  or  deficiency  of 
either  group  will  render  a diet  unfit  for  the 
support  of  life.  Milk,  the  product  provided  by 
Nature  as  the  sole  article  of  sustenance  during 
the  early  period  of  the  life  of  mammals,  may  be 
regarded  as  furnishing  us  with  a typical  dietetic 
representative  of  all  these  principles.  The  egg 
also  holds  a like  position,  and,  as  all  the  parts 
of  the  young  animal  are  evolved  from  it,  must 
needs  comprise  all  the  materials  for  the  deve- 
lopment and  growth  of  the  body. 

The  required  principles  are  contained  in  food 
derived  from  both  the  animal  and  vegetable 
kingdoms,  and  the  diet  may  be  drawn  from 
either ; but,  looking  to  man's  general  inclination 
and  the  conformation  of  his  digestive  apparatus, 
it  may  be  assumed  that  a mixed  diet  is  that 
which  is  designed  in  the  plan  of  Nature  for  his 
subsistence,  and  it  is  that  upon  which  he  attains 
the  highest  state  of  physical  development  and 
intellectual  vigour. 

Animal  food,  being  identical  in  composi- 
tion with  the  body  to  be  nourished  by  it,  is  in 
a state  to  be  more  easily  appropriated  than 
vegetable  food.  It  also  appeases  hunger  more 
thoroughly  and  satisfies  longer  : in  other  words 
it  gives,  as  general  experience  will  coufirm, 
greater  stay  to  the  stomach.  Animal  food  pos- 
sesses stimulant  properties  which  have  sufficed 
in  certain  instances,  as  after  starvation,  and  in 
those  accustomed  to  a vegetable  diet,  to  produce 
a state  allied  to  intoxication.  This  stimu- 
lating effect  is  further  illustrated  by  looking  at 
the  relative  character  of  animal  and  vegetable 
feeders.  Liebig  says  that  it  is  essentially  their 
food  which  makes  carnivorous  animals  in  general 
bolder  and  more  combative  than  the  herbivora 
which  are  their  prey.  lie  then  relates  that  a 
bear  kept  at  the  Anatomical  Museum  of  Giessen 
showed  a quiet  gentle  nature  as  long  as  it  was 
fed  upon  bread,  but  a few  days’  feeding  on  meat 
made  it  vicious  and  dangerous. 

The  standard  diet  framed  by  Moleschott  has 
been  accepted  as  furnishing  a model  of  what  may 
be  considered  the  requisite  proportion  of  ali- 
mentary principles  for  maintaining  health  in 
a person  of  average  stature  under  exposure  to  a 
temperate  climate  and  a moderate  amount  ol 
muscular  work.  It  runs  as  follows: — 


DIET. 


562 


a dr 3 state  required 
In  ounces  avoir. 

. 4-587 

. 2-964 

. 14-250 

, 1-058 


22-859 


This,  it  will  he  seen,  furnishes  a supply  of 
about  23  ounces  of  dry  solid  matter,  and  of  this 
one-fifth  is  nitrogenous.  If  we  reckon  that 
ordinary  food  contains  about  50  per  cent,  of 
water,  then  23  ounces  will  correspond  to  46  ounces 
of  solid  food  in  the  condition  in  which  it  is  con- 
sumed. To  complete  the  alimentary  ingesta,  a 
further  quantity  of  from  50  ounces  to  80  ounces  of 
water  may  be  assumed  to  be  required  to  be  taken 
daily  under  some  form  or  other. 

For  a life  of  i nactivity,  it  must  be  stated  that 
a much  smaller  amount  of  food  will  suffice.  The 
diet,  for  instance,  which  is  ordinarily  supplied 
to  the  patients  of  Guy’s  Hospital,  and  which 
suffices  to  satisfy  and  properly  sustain  them, 
only  contains  about  30  ounces  of  solid  food,  equi- 
valent to  about  17  ounces  of  water-free  material. 

It  has  been  mentioned  that  there  are  reasons 
for  regarding  a mixed  diet  of  animal  and  vege- 
table food  as  best  adapted  to  our  nature,  and  it 
may  probably  be  considered  that  the  most  suit- 
able admixture  contains  about  one-fourth  or 
rather  more  of  animal  food. 

Looked  at  from  the  following  point  of  view,  it 
will  be  seen  that  an  admixture  of  animal  and 
vegetable  food  more  economically  supplies  what 
is  wanted,  than  either  kind  taken  alone,  unless 
the  adjustment  should  be  made  with  the  proper 
apportionment  of  fat  as  a representative  of  a 
non-nitrogenous  article.  It  is  estimated  that 
for  a man  of  medium  stature,  and  performing  a 
moderate  amount  of  work,  about  300  grains  of 
nitrogen  and  4,800  grains  of  carbon  are  daily 
required  to  be  introduced  into  the  system  with 
the  food,  to  compensate  for  the  outgoing  of  these 
elements  that  occurs.  N ow  this  is  yielded,  as 
nearly  as  possible,  in  the  case  of  both  elements, 
by  2 lbs.  of  bread  and  | lb.  of  meat — that  is, 
tt  ozs.  of  solid  food,  of  which  about  one-fourth 
consists  of  animal  matter.  If  the  lean  of  meat 
only  were  consumed,  rather  over  6 lbs.  would  be 
needed  to  furnish  the  requisite  amount  of  car- 
bon, and  there  would  be  a very  large  surplus  of 
unutilisable  nitrogen  ; whilst  if  bread  only  were 
taken,  the  amount  necessary  to  supply  the  re- 
quisite quantity  of  nitrogen  would  be  rather 
more  than  4 lbs.,  and  this  contains  nearly  double 
the  amount  of  carbon  wanted. 

In  order  to  preserve  health  it  is  necessary 
that  a portion  of  the  food  consumed  should  be 
in  the  fresh  state,  and  this  applies  to  both 
animal  and  vegetable  food.  There  may  be  no 
lack  of  quantity,  and  yet  disease  and  death  may 
be  induced  by  inattention  to  this  fact.  Affec- 
tions of  the  scorbutic  class  are  produced,  which 
can  only  be  checked  and  removed  by  the  supply 
of  fresh  food  or  the  juice  of  some  kind  of  suc- 
culent vegetable  or  fruit.  The  efficacy  of  lemon 
and  lime  juice,  for  instance,  is  well  known  in 
the  prevention  and  cure  of  scurvy. 


Climate  influences  the  d-mand  for  food,  and 
instinct  leads  to  the  adaptation  of  diet  to  the 
requirements  that  exist.  Not  only  is  there  a 
correspondence  between  the  amount  of  food  re- 
quired and  the  inclination  for  taking  it,  but  the 
nature  of  the  food  selected  in  different  countries 
varies  and  stands  in  harmony  with  that  which  is 
most  in  conformity  with  what  is  needed.  The 
dwellers  in  the  arctic  regions,  besides  consuming 
a large  quantity  of  food,  partake  of  that  kind 
which  abounds  in  the  most  efficient  form  of 
heat-generating  material,  namely,  oleaginous 
matter.  In  the  tropics,  on  the  other  hand,  it  is 
upon  vegetable  products,  largely  charged  with 
principles  belonging  to  the  carbo-hydrate  group, 
that  the  native  inhabitants  mainly  subsist. 

Labour  necessitates  a supply  of  food  in  pro- 
portion to  the  amount  of  work  done.  The  em- 
ployer finds  that  the  appetite  of  a workman  may  be 
taken  as  a measure  of  capacity  for  work — in  other 
words,  that  a falling  off  of  the  appetite  means  a 
diminished  capacity  for  the  performance  of  labour. 

Until  recently,  it  was  considered,  in  accord- 
ance with  the  teaching  of  Liebig,  that  muscular 
and  nervous  action  resulted  from  an  oxidation 
of  muscular  and  nervous  tissue,  and  that  ac- 
cording to  the  amount  of  action  occurring,  so 
was  a demand  for  the  supply  of  nitrogenous 
alimentary  principles  created  to  replace  the  oxi- 
dised material.  It  is  now  held,  however,  that 
the  non-nitrogenous  elements  of  food  contribute, 
as  well  as  the  nitrogenous,  to  the  production  of 
muscular  and  nervous  force.  Fick  and  Wisli- 
cenus  undertook  a known  amount  of  work  upon 
a non-nitrogenous  diet,  and  proved  that  the 
oxidation  of  their  muscular  tissue,  as  measured 
by  the  amount  of  nitrogen  voided  with  the 
urine,  sufficed  only  for  the  production  of  a small 
proportion  of  the  force  expended  in  the  accom- 
plishment of  the  work  performed.  The  muscles, 
in  reality,  appear  to  stand  in  the  position  of  in- 
struments for  effecting  the  conversion  of  the 
chemical  energy  evolved  by  the  oxidation  of 
combustible  matter  into  working  power.  Fats 
and  carbo-hydrates  can  furnish  the  combustible 
matter  required,  and,  under  ordinary  circum- 
stances, probably  do  largoly,  if  not  chiefly,  supply 
it.  Nitrogenous  matter  can  do  so  likewise,  but 
it  has  to  undergo  a prepaiatory  metamorphosis 
for  effecting  the  separation  of  nitrogen  in  a 
suitable  form  for  elimination.  It  must  be  said, 
however,  that  experience  shows  that  hard  work 
is  best  performed  under  a liberal  supply  of 
nitrogen-containing  food.  The  explanation  of 
this  probably  is  that  it  leads  to  a better-nou- 
rished condition  of  the  muscles  and  of  the  body 
generally.  Under  the  use,  for  instance,  of  ani- 
mal food,  which  is  characterised  by  its  richness 
in  nitrogenous  matter,  the  muscles  are  observed 
to  be  firmer  and  richer  in  solid  constituents 
than  under  subsistence  upon  vegetable  food. 

Persons  who  lead  a sedentary  and  in-door 
life  naturally  require  less  food  than  those  en- 
gaged in  active  work,  and  less  should  be  con- 
sumed by  them  to  prevent  the  system  becoming 
clogged  with  effete  products,  which  act  per- 
niciously in  various  ways  upon  the  body.  The 
food  should  also  be  largely  constituted  of  non- 
nitrogenous  principles,  as  these  tax  the  excretorv 
organs  less  than  the  nitrogenous. 


Alimentary  substances  in 
daily. 

Dry  Food 

Albuminous  matter 
Fatty  matter 
Carbo-hydrates 
Salts 


DIET. 


The  diet  of  infants  is  a branch  of  dietetics 
the  importance  of  which  can  scarcely  be  over- 
rated. The  proper  food  during  the  first  period 
of  infancy  is  that  which  has  been  provided  by 
Nature  for  the  young  of  mammals,  namely,  milk. 
Up  to  about  the  eighth  month  the  infant  is  de- 
signed to  be  sustained  solely  by  its  parent’s 
milk.  The  teeth,  which  ordinarily  begin  to 
show  themselves  about  this  time,  indicate  that 
eom6  solid  matter  should  now  be  consumed,  and 
one  of  the  farinaceous  products  will  be  the  most 
suitable  with  which  to  commence.  Bread,  baked 
flour,  plain  biscuit,  or  one  of  the  numerous  kinds 
of  nursery  biscuits  that  are  made,  may  be  em- 
ployed for  a time  as  a supplement  to  the  former 
food.  At  about  the  tenth  month  the  mother,  who 
ought  previously  to  have  commenced  lessening 
her  own  supply,  should  now  cease  it  altogether. 
As  the  child  advances  through  its  second  year 
and  the  teeth  become  more  developed,  meat, 
preceded  for  awhile  by  gravy,  may  be  given.  If 
the  mother  cannot  sucklo  her  child,  or  a wet 
nurse,  whose  supply  stands  next  best  to  that  of 
the  mother,  be  provided,  the  milk  of  one  of  the 
lower  animals  should  be  obtained,  and  that  of 
the  cow  gives  the  nearest  approach  to  what  is 
wanted.  Cow's  milk,  however,  is  richer  in  all 
its  solid  constituent  principles  than  woman's, 
and  the  addition  of  a solution  of  sugar  or — what 
is  more  in  conformity  with  the  natural  supply- 
sugar  of  milk  (lactine),  in  the  proportion  of  an 
ounce  to  three  quarters  of  a pint,  is  needed  to 
bring  the  two  in  closer  approximation.  The 
milk  of  the  goat  is  even  richer  in  solid  consti- 
tuents than  that  of  the  cow,  and  therefore  stands 
somewhat  further  removed  from  that  of  the 
human  subject.  If,  however,  it  is  not  adapted 
for  infants,  it  is  highly  useful  for  improving 
the  condition  of  badly-nourished  children,  and  is 
sometimes  employed  for  this  purpose. 

Therapeutical  Applications. — The  applica- 
tion of  the  principles  of  dietetics  may  be  success- 
fully brought  to  bear  in  the  treatment  of  corpulency 
and  thinness.  A diet  rich  in  nitrogenous  matter 
conjoined  with  exercise  promotes  the  growth  of 
muscle,  but  the  fat  undergoes  no  increase.  The 
conditions  most  conducive  to  an  increased  accu- 
mulation of  fat  are  a diet  rich  in  either  fat  or 
carbo-hydrates  (provided  the  requisite  amount 
of  nitrogenous  matter  be  present  for  affording 
what  is  wanted  for  the  nutritive  operations  of 
life),  exposure  to  a warm  atmosphere,  and  inac- 
tive habits.  A supply  of  fat  in  a direct  manner, 
leads  to  an  increased  deposition  of  fat  in  the 
system,  but  the  carbo-hydrates  require  in  the 
first  place  to  undergo  assimilative  change  before 
they  can  be  applied  in  the  same  direction. 

The  details  of  the  dietary  to  be  prescribed 
where  the  aim  is  to  produce  increased  stoutness 
and  an  improved  condition  of  the  body,  should 
comprise  such  articles  as  fat  meats,  butter, 
cream,  milk,  cocoa,  chocolate,  bread,  potatoes, 
farinaceous  and  flour  puddings,  oatmeal  porridge, 
sugar  and  sweets,  sweet  wines,  porter,  stout,  and 
ales. 

The  converse  mode  of  dieting  is  necessary  for 
reducing  stoutness.  Mr.  Banting,  by  his  noted 
system  of  dieting,  reduced  his  weight  from 
14  stone  6 lbs.  to  11  stone  2 lbs.  in  about  a 
year.  Besides  altering,  however,  the  character 


360 

of  his  food,  he  limited  the  quantity  in  a manner 
that  must  have  contributed  an  important  share 
towards  producing  tl  e offect  observed ; not  more 
than  twenty-two  to  twenty-six  ounces  of  solid 
food  (corresponding  with  eleven  to  thirteen 
ounces  of  water-free  material)  being  consumed, 
according  to  his  statement,  in  tho  twenty-four 
hours. 

As  a guide  to  the  corpulent  it  may  be  said 
that  the  fat  of  meat,  butter,  cream,  sugar  and 
sweets,  pastry,  puddings,  farinaceous  articles  as 
rice,  sago,  tapioca,  &c.,  potatoes,  carrots,  pars- 
nips, beetroot,  sweet  ales,  porter,  stout,  port 
wine,  and  all  sweet  wines  should  be  avoided,  or 
only  very  sparingly  consumed.  Wheaten  bread 
should  only  be  partaken  of  moderately,  and 
brown  bread  is  to  some  extent  better  than 
white.  The  gluten  biscuits  which  are  prepared 
for  the  diabetic  may,  on  account  of  their  com- 
parative freedom  from  starch,  be  advantageously 
used  as  a substitute  for  bread  in  the  treatment 
of  obesity.  The  articles  that  may  be  taken  to 
the  extent  of  satisfying  a natural  appetite,  are 
lean  meat,  poultry,  game,  eggs,  green  vegetables, 
succulent  fruits,  light  wines,  dry  sherry,  and 
spirits.  Milk  should  only  be  taken  sparingly. 

Holding  tho  position  that  food  does  in  relation 
to  the  operations  of  life,  the  art  of  dietetics  not 
only  bears  on  the  maintenance  of  health  but 
is  capable  of  being  turned  to  advantageous  ac- 
count as  a therapeutic  agency;  and  it  is  not  too 
much  to  say  that  success  in  the  treatment  of 
disease  is  oftentimes  dependent  upon  a display 
of  judicious  management  in  regard  to  food. 

In  the  therapeutic  application  of  dietetics 
the  maxim  should  be  held  in  view  that,  whilst 
the  particular  requirements  are  secured,  there 
should  otherwise  be  no  greater  deviation  from 
what  is  natural  than  the  special  circumstances  of 
the  case  demand. 

The  quantity  of  food  consumed  may  require 
to  be  regulated  as  well  as  its  nature.  The 
quantity  administered  at  a time  should  stand  in 
relation  to  the  power  of  digesting  it;  and  to 
properly  compensate  for  a diminished  capacity 
for  taking  quantity  there  should  be  a correspond- 
ing increase  in  the  frequency  of  administration. 
‘Little  and  often  ’ is  tho  maxim  to  be  followed 
upon  many  occasions,  and  much  will  sometimes 
depend  upon  the  strictness  with  which  it  is 
actod  up  to ; for,  apart  from  harmonizing  with 
what  is  wanted,  upon  the  principle  that  has  just 
been  referred  to,  it  meets  the  defective  aptitude 
that  exists  in  sickness  for  sustaining  any  length- 
ened duration  of  abstinence  from  food. 

In  febrile,  acute  inflammatory,  and  other  con- 
ditions where  there  is  a failure  of  digestive 
power,  the  food  administered  should  be  such  as 
not  to  tax  the  stomach,  and  should  therefore 
consist  of  liquid  materials.  Solid  matter,  by 
remaining  undigested — and  solids  of  an  animal 
nature  are  particularly  likely  to  do  so — would 
act  as  a source  of  irritation  in  the  stomach,  and 
only  serve  to  aggravate  the  condition  of  the  pa- 
tient. The  articles  undersuch  circumstances  to  bo 
selectedfrom  arebeef-tea,  mutton,  veal,  or  chicken 
broth,  whey,  calfs-foot  and  other  kinds  of  jelly, 
arrowroot  and  such-like  farinaceous  articles, 
barley  water,  rice  mucilage,  gum-water,  fruit 
jelly,  and  the  juico  of  fruits,  as  of  lemons. 


DIET. 


3fl4 

oranges,  &c.,  made  into  drinks.  Where  a little 
latitude  is  allowable,  the  employment  of  milk 
and  of  eggs  in  a fluid  form  may  be  sanctioned.  As 
circumstances  permit,  an  advance  may  be  made 
to  solid  substances  which  do  not  throw  much 
work  on  the  stomach,  as  rice,  sago,  tapioca, 
bread  and  custard  puddings,  and  stale  bread  or 
toast  sopped.  Next  may  be  allowed  fish,  be- 
ginning with  whiting.  As  power  becomes  re- 
stored, calves’  feet,  chicken,  game,  and  butcher's 
meat — mutton  to  begin  with — may  be  permitted 
to  follow. 

In  cases  of  ordinary  dyspepsia  the  aim  of  the 
physician  should  be  rather  directed  to  raising,  by 
appropriate  treatment,  the  digestive  capacity  to 
the  level  of  digesting  light  but  ordinary  food, 
than  to  reducing  the  food  to  an  adjustment  with 
a low  standard  of  digestive  power.  Of  butcher’s 
meat,  mutton  is  almost  invariably  found  to  be 
the  most  suitable ; chicken  and  game  are  allow- 
able, also  white  fish  (boiled  or  broiled)  particu- 
larly whiting,  sole,  flounder,  and  plaice.  Stale 
bread,  dry  toast,  plain  biscuits,  floury  potatoes, 
rice,  and  the  various  farinaceous  articles  form 
the  kind  of  food  derived  from  the  vegetable 
kingdom  to  be  selected.  Green  and  other  suc- 
culent vegetables,  it  is  found,  are  more  apt  to 
create  flatulence  than  other  kinds  of  food,  and 
articles  belonging  to  the  cabbage  tribe  are  par- 
ticularly to  be  regarded  as  obnoxious  to  those  who 
have  a tendency  to  this  form  of  derangement. 

Much  depends  in  cases  of  weak  digestion 
upon  the  state  in  which  the  food  reaches  the 
stomach.  Thorough  mastication  affords  great 
assistance  to  the  performance  of  digestion,  and 
when  the  teeth  are  bad  the  food  should  be  finely 
minced,  or  otherwise  minutely  divided  before 
being  eaten.  Regularity  in  the  periods  of  taking 
food,  tends  to  promote  the  orderly  working  of 
the  digestive  organs.  An  interval  of  more  than 
four  or  fire  hours’  duration  between  the  meals  is 
to  be  avoided,  as  it  acts  perniciously  in  several 
ways.  By  inducing  an  exhausted  state  of  the 
system  it  diminishes  the  energy  of  the  digestive 
organs,  and  whilst  having  this  effect  it  at  the 
same  time  calls  for  the  periodical  exercise  of 
increased  energy,  on  account  of  the  larger 
amount  of  food  which  must  he  taken  at  each  meal 
to  compensate  for  the  length  of  time  that  is 
allowed  to  elapse  between  them. 

In  cases  of  ulcer  of  the  stomach,  acute  gastric 
catarrh,  and  vomiting,  the  food  must  be  selected 
from  that  which  is  nutritious  and  at  the  same 
time  taxes  least  the  digestive  powers.  Milk — 
and  this  is  often  better  borne  after  being  boiled 
— milk  and  water,  or  milk  and  soda  water,  will 
frequently  be  found  to  be  tolerated  when  other 
articles  excite  irritation  and  are  returned.  Some- 
times the  milk  may  be  advantageously  mixed  with 
isinglass,  arrowroot,  ground  rice,  or  biscuit  powder. 

In  dysentery  and  other  forms  of  ulcerative 
disease  of  the  intestine,  scrupulous  attention  must 
be  paid  to  diet.  The  food  should  consist  of  arti- 
cles which  are  known  to  exert  the  least  stimulant 
and  irritant  action  on  the  mucous  membrane 
and  muscular  coat  of  the  alimentary  canal,  and 
(hose  which  best  meet  the  demand  in  question 
are  such  as  milk,  isinglass,  and  the  various  fari- 
naceous products,  amongst  which  rice  is  pre- 
eminently valuable.  Next  to  these  come  eggs,  I 


white  fish,  white-fleshed  poultry,  fresh  game,  and 
fresh  meat.  Salted  and  dried  meats  are  highly 
objectionable, and  fruits  and  succulent  vegetables, 
with  the  exception  of  a floury  potato,  should  be 
strictly  shunned.  See  Pkvtonised  Food. 

The  development  of  gout  is  known  to  be  fa- 
voured by  the  consumption  of  a highly  nitro* 
genised  diet,  especially  if  conjoined  with  seden- 
tary habits.  With  those  who  hare  already 
experienced  symptoms  of  the  disease,  and  those 
also  who  have  grounds  for  apprehending  its  in- 
vasion, it  is  important  that  an  excess  of  nitro- 
genous food  should  be  avoided.  The  diet  should 
be  simple,  in  order  that  the  temptation  may  be 
avoided  of  eating  too  much,  and  should  at  the 
same  time  be  adjusted  to  the  mode  of  life.  The 
principle  to  observe  is  that  the  higher  the  degree 
of  inactivity  the  greater  ought  to  be  the  pre- 
ponderance of  food  derived  from  the  vegetable 
kingdom. 

Even  of  more  importance  than  what  is  eaten 
is  what  is  drunk,  where  the  question  of  gout  is 
concerned,  and  observation  shows  that  it  is  not 
distilled  spirits,  but  the  stronger  wines  and  male 
liquors,  which  favour  the  production  of  the  dis- 
order. Nothing  is  more  potent  than  port  wine 
in  leading  to  the  production  of  gout,  and  a few 
years’  liberal  indulgence  in  it  has  often  been 
known  to  be  instrumental  in  bringing  on  the 
disease  where  no  family  predisposition  had  ex- 
isted. Dry  shorn-  and  the  light  wines,  as  claret, 
hock,  &c.,  may  be  drunk,  certainly  in  moderation, 
with  comparatively  little  or  no  fear  of  inducing 
the  disease,  although  any  kind  of  wine  appears 
capable  of  sometimes  acting  as  the  exciting  cause 
of  a paroxysm  where  the  gouty  disposition  is 
already  established.  Stout,  porter,  and  the 
stronger  ales,  especially  those  that  have  become 
hard  from  age,  rank  next  to  port  wine  in  their 
power  of  predisposing  to  gout.  As  regards  the 
light  bitter  beers,  which  are  so  extensively  used 
at  the  present  time,  the  same  must  be  said  of 
them  as  of  the  light  wines,  viz.  that  with  little, 
if  any,  disposition  to  induce  the  disease,  they 
nevertheless  appear  capable  of  sometimes  excit- 
ing its  manifestation  in  a gouty  subject.  A pure 
spirit,  as  whisky,  hollands,  or  brandy,  diluted 
with  water,  often  forms  the  only  kind  of  alcoholic 
drink  that  is  found  to  agree  with  those  who  arc 
suffering  from  gout. 

In  Bright's  disease  with  threatening  uraemic 
poisoning  it  is  a point  of  consideration  to  diminish 
as  far  ns  practicable  the  amount  of  excretory 
matter  to  he  eliminated  by  the  kidney.  The  fats 
and  carbo-hydrates  throw  no  work  upon  the 
kidneys.  Their  products  of  destruction  escape 
through  another  channel.  Nitrogenous  matters, 
on  the  other  hand,  undergo  metamorphosis  in  the 
system,  and  yield  nitrogen-containing  compounds 
— chiefly  urea— to  escape  by  the  kidneys.  In  this 
way  the  kidneys  become  taxed  by  nitrogenous 
food,  and,  to  lessen  the  work  demanded  of  them, 
reason  suggests  that  the  diet  should  preponderate 
in  food  derived  from  the  vegetable  kingdom. 

Iu  diabetes  mcllitus  there  is  a want  of  assimi- 
lative power  over  the  saccharine  and  starchy 
principles  of  food.  Whilst  these  principles  be- 
come utilized  and  lost  sight  of  when  ingested  by 
a healthy  person,  in  the  system  of  the  diabetic 
they  fail  to  become  consumed,  but  pass  off  undot 


DIET. 

the  form  of  sugar  in  the  urine,  giving  rise  to 
severity  of  symptoms  in  proportion  to  the  amount 
of  sugar  escaping.  Much  may  be  done  towards 
subduing  the  symptoms  of  the  disease  by  a pro- 
perly arranged  dietetic  scheme,  and  the  principle 
upon  which  it  requires  to  be  framed  is  the  exclu- 
sion, as  far  as  practicable,  both  from  what  is  eaten 
and  what  is  drunk,  of  articles  containing  saccha- 
rine or  starchy  matters. 

Observation  has  shown  that  the  reaction  of  the 
urine  is  susceptible  of  being  influenced  by  the 
character  of  the  food.  The  effect  of  animal  food 
is  to  increase  the  acidity  of  the  secretion,  whilst 
that  of  vegetable  food  is  to  diminish  it,  and,  even 
it  may  be,  to  produce  alkalinity.  Hence  on 
persons  affected  with  the  lithic  acid  diathesis 
benefit  is  conferred  by  a plan  of  diet  in  which 
animal  food  is  limited,  and  succulent  vegetables 
and  fruits,  with  the  light  wines,  as  claret,  hock, 
&c.,  are  freely  supplied.  On  the  other  hand, 
with  the  phosphatic  diathesis,  the  converse  prin- 
ciple of  action  should  he  adopted. 

F.  W.  Pavy. 

DIGESTION,  Disorders  of.— The  func- 
tion of  digestion  is  of  a physico-chemical  nature, 
being  compounded  of  certain  muscular  acts,  and 
of  certain  processes  exercised  by  the  digestive 
fluids  on  the  ingesta. 

Any  interference  with  the  duo  performance 
of  the  several  components  of  the  function  will 
load  to  indigestion,  and  though  it  may  for  con- 
venience be  desirable  to  consider  these  disturb- 
ances separately,  it  must  be  remembered  that 
the  occurrence  of  one  condition  is  apt  to  be 
quickly  associated  with  another,  and  hence  the 
forms  of  dyspepsia  as  they  usually  present  them- 
selves are  of  a complex  nature,  however  simple 
the  primary  fault  may  have  been.  Nor  is  it 
possiblo  to  consider  irregularities  of  digestion 
only  from  the  point  of  view  of  the  organs  im- 
mediately concerned.  Complicated  as  our  or- 
ganism is,  disturbances  of  other  functions  will 
speedily  make  themselves  felt  in  tho  one  under 
consideration,  and  failures  in  the  absorption  of 
the  digested  food,  or  in  its  subsequent  metabolic 
changes  and  elimination,  will  tell  back  sooner  or 
later  on  that  process  which  is,  strictly  speaking, 
limited  to  its  preparation.  Dyspepsia  then  may 
be  traced  to  (j.)  the  food ; (ii.)  disturbances  of 
tho  so-callod  mechanical  processes,  viz.  the  muscu- 
lar acts,  solution,  &e. ; or  (iii.)  imperfections  in 
tho  chemical  changes  exercised  by  the  digestive 
secretions. 

I.  Imperfections  of  Food. — Imperfections  in 
food,  whether  in  quality  or  quantity,  aro  among 
tho  most  frequent  catises  of  digestivo  disorders. 
A thorough  knowledge  of  tho  principles  of 
dietetics  is  essential,  that  the  errors  may  be 
recognised  and  remedied.  Since  our  digestive 
capability  is  limited,  it  is  obvious  that  when 
thoso  limits  aro  overstepped,  the  domain  of 
disease  is  entered  upon ; and  although  no  very 
absolute  lines  may  be  laid  down  for  universal 
application,  tho  general  rules  for  quantity  and 
kind  aro  capable  of  being  stated.  See  Diet. 

Even  when  the  food  is  as  it  should  be,  dys- 
pepsia may  be  determined  by  perversions  of  the 
appetite;  or,  on  the  contrary,  such  perversions 
may  be  due  to  the  same  causes  which  lead  to  the 


DIGESTION,  DISORDERS  OE.  366 
functional  errors  in  the  digestive  organs.  See 
Appetite. 

(a)  Deficiency  of  Food. — Except  under  raro 
conditions,  such  as  famine,  &c.,  this  is  not  so 
common  a cause  of  disease  as  is  supposed.  We 
habitually  take  a larger  bulk  of  food  than  is 
demanded,  and  it  is  very  certain  that  most 
active  lives  are  led  on  an  amount  of  food  far 
below  what  is  ordinarily  regarded  as  being 
necessary.  May  it  not  be  that  many  of  the 
diseases  looked  upon  as  non-preventible,  more 
particularly  those  connected  with  the  excretory 
organs,  are  really  due  to  their  overwork  in 
getting  rid  of  the  excess  of  the  ingesta  ? Of 
the  signs  and  symptoms  of  starvation  it  is  not 
needed  here  to  treat.  But  there  are  frequent 
occasions  when,  with  no  deficiency  in  the  total 
bulk  of  food  taken,  there  is  yet  a serious  want 
in  one  or  perhaps  more  of  the  needful  alimentary 
principles,  and  this  is  especially  liablo  to  occur 
in  the  feeding  of  children.  Setting  aside  those 
gross  cases  of  cruelty,  when  infants  and  the 
youngest  children  are  fed  almost  from  their 
birth  with  bread,  broth,  or  even  meat,  there  are 
still  too  often  to  ho  met  with  children  whoso 
diet-scale  is  almost  entirely  wanting  in  nitro- 
genous matter.  Fed  upon  milk  and  infants’ 
foods,  the  latter  consisting  of  little  more  than 
starchy  material,  their  tissues  are  ill-formed  for 
the  want  of  proteids,  which,  during  tho  period 
of  growth,  are  required  in  a larger  relative 
proportion.  The  relationship  of  rickets  to 
prolonged  suckling,  with  the  accompanying  de- 
ficiency in  nitrogenous  and  amyloid  food-stuffs, 
is  now  generally  recognised. 

The  effect  of  a deficiency  of  food  is  a general 
state  of  malnutrition,  in  which  any  hereditary 
tendencies  to  diseaso  that  may  exist  have  a 
more  favourable  field  for  development.  There 
is  a gradual  diminution  in  the  weight  of  the 
body,  and  an  imperfect  performance  of  its  func- 
tions, as  indicated  by  muscular  weakness,  mental 
lassitude,  &c. 

Tho  deficiency  in  food  taken  may  result  not  so 
much  from  a defective  supply  of  nutriment,  as 
from  a disinclination  to  eat,  a common  symptom 
in  most  diseases,  especially  in  febrile  states,  self- 
imposed  fasting  too  frequent  or  prolonged,  the 
anorexia  of  the  hysterical  temperament,  and 
obstruction  to  the  entrance  of  food  into  the 
stomach  from  stricture  of  the  oesophagus,  or  the 
appetite  may  be  impaired  by  over-indulgence  in 
alcohol  or  tobacco. 

(/3)  Excess  of  Food. — There  is  very  little 
doubt  but  that  more  food  is  daily  in  the  habit 
of  being  taken  than  is  actually  required  to 
restore  tho  tissue-waste,  as  there  is  equally  little 
doubt  that  much  of  what  is  taken  is  not  in  the 
most  digestible  form.  It  is  open  to  question 
whether  the  appetite  would  be  satisfied  by  the  in- 
gestion of  merely  sufficient  to  balance  the  waste, 
particularly  if  the  gross  bulk  of  the  food  taken 
were  diminished  by  tho  removal,  as  far  as  pos- 
sible, of  all  indigestible  matters,  leaving  little 
more  than  the  needful  alimentary  principles. 
At  the  same  time  it  must  not  be  forgotten  that 
the  appetite  is  very  easily  controlled  by  custom, 
and  determination  can  in  time  overcome  a 
vicious  habit. 

An  habitual  excess  of  food,  at  least  in  this 


DIGESTION,  DISORDERS  OF. 


366 

country,  usually  errs  in  the  disproportionate 
amount  of  nitrogenous  matter  it  contains. 
Remembering  the  relatively  small  quantity  of 
this  principle  that  is  essential,  and  in  -what  a 
number  of  the  ordinary  articles  of  diet  it  is 
contained,  this  statement  will  be  the  more 
readily  accepted.  Now,  since  all  the  proteid 
principles  require,  to  fit  them  for  absorption  into 
the  blood,  a considerable  amount  of  chemical 
alteration,  and,  physiologically  speaking,  there  is 
good  reason  to  believe  that  the  subsequent  me- 
tabolic changes  of  these  matters,  when  absorbed, 
are  more  complex  than  those  undergone  by 
fats  and  amyloids,  it  would  follow  that  those 
organs  concerned  in  effecting  these  changes  are 
very  prone  to  suffer  from  overwork  and  its 
sequelae.  Again,  it  appears  very  probable  that 
when  the  amount  of  nitrogenous  food  taken  is 
much  in  excess  of  what  is  required,  it  under- 
goes certain  oxidation-changes  in  the  blood 
without  becoming  tissue  previously,  and  an 
enormous  ingestion  of  albuminoid  matter  is  fol- 
lowed by  its  elimination  very  much  as  it  is 
taken.  Now,  many  of  the  compounds  resulting 
from  the  oxidation  of  nitrogenous  matter  are 
liable  to  become  positive  poisons  in  the  economy 
when  existing  in  excess,  and  the  proper  elimina- 
tion of  such  materials  is  specially  provided  for 
by  such  organs  as  the  kidneys  and  skin.  The 
frequency  with  which  these  organs  become  the 
seat  of  disease  may  at  least  indicate  the  proba- 
bility of  errors  of  diet  being  an  important  factor 
in  determining  the  morbid  changes,  especially 
as  considerable  relief  is  often  the  result  of  a 
restriction  of  nitrogenous  food.  There  can  be 
little  doubt  but  that  the  large  group  of  diseases 
associated  with  failure  in  elimination  of  nitro- 
genous waste  has  for  a prominent  cause  an 
habitual  excess  of  nitrogenous  food. 

The  results  of  an  excessive  ingestion  of  food 
are  as  numerous  as  they  are  diverse.  In  many 
cases  there  does  not  seem  to  be  either  impair- 
ment of  health  or  shortening  of  life.  In  some 
obesity  and  in  others  leanness  ensues.  In  a 
large  majority  of  individuals  whose  food  is 
much  in  excess  of  their  wants,  particularly  if 
the  exercise  taken  be  but  little,  there  are  vari- 
able symptoms  of  indigestion,  such  as  a general 
feeling  of  lassitude  and  want  of  energy,  both 
muscular  and  mental,  a liability  to  headaches 
chiefly  frontal,  constipation,  or  more  rarely  diar- 
rhoea, high-coloured  urine  depositing  abundance 
of  urates,  a general  disposition  to  sleep,  various 
skin-eruptions,  particularly  acne,  and  not  in- 
frequently a feeble  heart’s  action  from  com- 
mencing fatty  degeneration  of  its  substance. 
Any  or  all  of  these  symptoms  may  exist,  and 
may  he  more  or  less  completely  relieved  by  a 
restricted  diet.  It  is  impossible  to  lay  down 
any  exact  rules  for  the  quantity  of  food  that 
should  be  daily  consumed  ; though  it  is  desirable 
to  remember  that  the  tendency  is  to  take  too 
much,  at  the  same  time  that  age,  season  of  year, 
and  occupation  are  all  circumstances  deter- 
mining variations  both  in  quantity  and  kind. 

(■y).  Improper  Food. — Setting  aside  those  ex- 
treme cases  of  perverted  appetite  occasionally 
soen  in  the  hysterical  condition,  there  yet  re- 
mains a very  constant  violation  of  the  dietetic 
proprieties.  These  errors  may  be  classed  under 


the  following  heads: — 1.  Substances  which  are 
indigestible;  either  essentially  so,  or  from  im- 
perfect preparation  (cooking,  &c.)  2.  Sub- 

stances which,  though  digestible,  arc  innutri- 
tious  or  even  poisonous.  In  the  first  group  are 
included  such  bodies  as  the  pips  and  seeds  as 
well  as  the  skins  and  rinds  of  fruits,  the  husks 
of  corn  and  bran,  the  stalks  and  fibres  of 
leaves,  and  gristle,  elastic  tissue,  and  hairs  in 
animal  food.  For  the  reducing  of  these  to  a 
fluid  and  diflusible  condition  no  chemical  ar- 
rangement exists  in  the  human  organism,  and 
they  are  thrown  off  very  much  in  the  same  state 
as  they  are  swallowed.  Many  articles  of  diet 
depend  in  great  part  for  their  digestibility  on 
their  proper  preparation  by  division,  cooking, 
&c.  Thus  most  vegetables  when  taken  in  the 
raw  state  are  hut  imperfectly  digested,  and  such 
nutritious  food  as  potatoes  becomes  when  un- 
cooked positively  harmful.  The  apparent  value 
of  raw  green  vegetables,  as  lettuce,  endive, 
cress,  &e.,  would  seem  to  depend  on  the  pecu- 
liar condition  of  their  mineral  constituents, 
rather  than  on  the  vegetable  tissues. 

Such  substances  as  the  above-mentioned  are 
apt  to  produce  perversions  of  digestion  in  virtue 
of  the  mechanical  irritation  they  give  rise  to, 
indicated  by  more  or  less  pain  of  a griping 
character  (colic),  and  frequently  accompanied  by 
diarrhoea.  The  constant  ingestion  of  the  more 
formidable  may  even  sot  up  a gastro-enteritis, 
acute  or  chronic.  Occasionally  articles  of  food, 
such  as  brown  bread,  oatmeal  porridge,  &e.,  arc 
taken  for  the  very  aperient  action  they  induce, 
owing  to  the  irritating  nature  of  the  indigestible 
husks  they  contain.  Symptoms  of  acute  dys- 
pepsia very  frequently  follow  the  taking  of 
meat  foods  enveloped  in  greasy  sauces,  since  the 
fat,  being  undigested  in  the  stomach,  prevents 
the  action  of  the  gastric  juice  on  the  proteid 
matter,  which  then  passes  on  into  the  intestines, 
setting  up  irritation  like  any  other  indigestible 
substance.  The  most  interesting  among  those  ar- 
ticles of  diet  which,  though  easily  digested  may 
be  poisonous,  are  those  producing  their  effects 
only  on  certain  individuals.  Such,  for  example, 
are  certain  mushrooms,  shell-fish,  or  indeed  any 
fish.  Remarkable  cases  are  authentically  re- 
corded of  serious  and  even  fatal  results  follow- 
ing their  ingestion.  The  symptoms  maybe  those 
of  an  acute  gastro-enteritis,  or,  as  is  very  fre- 
quently the  case,  an  urticaria  is  the  result,  with 
or  without  swelling  of  the  eyes  and  throat. 
Severe  nervous  prostration  has  been  met  with 
occasionally.  Be  it  understood  that  other  people 
have  partaken  of  the  same  diet  with  no  ill 
results.  The  writer  is  acquainted  with  a gentle 
man  who  for  many  years  was  unable  to  remain  in 
the  rocm  when  fish  of  any  kind  was  on  the  table ; 
its  presence  inducing  severe  vomiting,  abdo- 
minal pain,  and  general  illness;  and  although 
the  effects  are  now  but  slight  from  the  mere 
smell  of  such  food,  very  marked  symptoms  fol- 
low on  partaking  of  any.  The  most  digestible 
and  nutritious  articles  of  food  may  determine 
indigestion  when  taken  too  hot  or  too  cold. 

Finally  must  be  included  those  substances 
which  accidentally  find  their  way  iuto  the  ali- 
mentary canal  with  the  food,  as  entozoa,  ergot 
of  rye;  such  foreign  bodies  as  pins,  needles. 


DIGESTION.  DISORDERS  OF.  367 


joins,  buttons,  &e. ; or  lead  and  other  metallic 
poisons  off  the  hands  of  workers  in  these  poisons  ; 
all  of  which  give  rise  to  definite  and  for  the  most 
part  characteristic  sj-mptoms. 

II.  Irregularities  of  the  Mechanism  of 
Digestion. — The  motor  factors  of  the  digestive 
process  depend  for  their  due  and  normal  per- 
formance on  the  integrity  of  the  muscular  tissue, 
the  nerve-centres,  and  the  connecting  nerves.  The 
several  stages  of  the  entire  process  are  mastica- 
tion, deglutition,  the  churning  movements  of  the 
stomach,  the  peristaltic  action  of  the  intestines, 
and  defecation.  Each  of  these  is  liable  to  im- 
pairment, in  the  direction  of  excess  (spasm),  or  of 
deficiency  (paralysis),  due  either  to  lesions  of  the 
nerve-centres  whence  the  motor  stimuli  ema- 
nate, of  the  nerve-fibres  by  which  these  stimuli 
are  conveyed,  or  of  the  muscular  tissue  by 
which  the  movements  are  performed.  Not  un- 
frequently  more  than  one  of  these  tissues  may  be 
at  fault.  Lastly,  obstructions  to  the  movements 
may  be  caused  by  tumours,  cicatrices,  &c.  Irregu- 
larities of  mastication,  deglutition,  and  defeea- 
tion  are  fully  considered  elsewhere. 

1.  Paralysis. — Arrest  of  the  peristaltic  action 
of  the  gullet,  stomach,  or  intestines,  is  un- 
doubtedly often  associated  with  diseased  con- 
ditions of  the  central  nervous  organs,  but  the 
exact  connection  is  far  from  being  satisfactorily 
known.  Those  lesions  which  interfere  with  the 
action  of  the  vagus  nerve,  and  remove  its  accele- 
rating influence  over  the  peristaltic  movements, 
have  been  regarded  as  most  likely  to  bring  about 
this  condition.  The  nervous  exhaustion  induced 
by  long  fasting,  continued  vomiting,  hysteria, 
and  such  diseases  as  typhus  and  puerperal  fever, 
have  been  noticed  as  removing  the  influence  of 
the  pneumogastric.  Over-brainwork,  with  the 
attendant  altered  conditions  of  cerebral  vascu- 
larity, have  been  found  to  be  accompanied  with 
symptoms  indicating  loss  of  power  of  the  mus- 
cular coat  of  the  bowel ; possibly  in  this  case 
also  the  influence  is  conveyed  by  the  vagus. 

Paralysis  of  the  stomach  and  intestines  is  a 
frequent  result  of  affection  of  these  organs 
themselves.  Inflammation  of  the  peritoneal 
or  mucous  coats,  with  the  subsequent  infiltration 
of  the  muscular  coat  with  the  inflammatory 
products,  materially  diminishes  the  power  of  the 
contractile  tissue.  Degeneration  of  the  organs, 
particularly  the  lardaceous  variety,  which  com- 
mencing in  the  mucous  subsequently  invades 
the  muscular  coat,  obviously  interferes  with  the 
movements.  The  movements  of  the  alimentary 
canal  may  be  considerably  diminished  by  the 
administration  of  certain  drugs,  such  as  opium. 

The  results  of  these  various  paralytic  affec- 
tions are  in  most  cases  sufficiently  apparent. 
Tho  palsied  lips  and  cheeks  and  tongue  tell 
their  own  tale  by  the  half-opened  mouth,  the 
dribbling  saliva,  and  the  cheeks  distended  with 
food  which  cannot  be  kept  between  the  teeth. 
When  the  fauces  and  pharynx  are  affected,  the 
painful  efforts  at  swallowing,  the  rejection  of 
tbod  through  the  nose,  and  the  passage  of  food 
into  the  larynx  are  signs  not  to  be  mistaken. 
Paralysis  of  the  stomach  and  intestines  is  mainly 
recognised  by  the  constipation  from  inability  of 
the  canal  to  propel  its  contents,  and  by  the  dis- 
tension with  gases,  &c.,  which  ensues  ; whilst  the 


involuntary  passing  of  the  ffeces  indicates  para- 
lysis of  the  sphincter  ani. 

2.  Spasm.— Spasmodic  affections  of  the  ali- 
mentary canal  are  characterised  by  an  increased 
motor  activity  dependent  on  many  causes  for  its 
production.  However  diverso  such  causes  may 
be,  they  ultimately  resolve  themselves  either 
into  an  increased  irritability  of  the  nervous 
and  contractile  tissues,  or  into  some  unusual 
or  excessive  stimulation,  arising  ab  extra,  and  so 
producing  its  motor  result  in  a reflex  manner, 
or  originating  automatically  in  the  cells  of  the 
motor  ganglia.  Spasms  affecting  the  organs 
under  consideration  are  determined  both  by  cen- 
tral and  peripheral  causes,  and  occasionally  by 
affections  of  the  nerves  independently  of  the 
nerve-centres.  They  are  mainly  of  the  tonic 
vai’iety,  and  are  usually  accompanied  by  pain. 

It  is  clear  that  with  the  muscular  tissue  of  the 
alimentary  canal  arranged  as  it  is,  when  a con- 
dition of  spasm  exists  obstruction  to  the  passage 
of  the  contents  of  the  canal  will  take  place,  in  pro- 
portion to  the  extent  and  duration  of  the  cramp. 

Spasm  of  the  stomach  and  intestines  is  almost 
invariably  accompanied  by  pain  ; and  it  is  for 
that  symptom,  rather  than  for  any  obstruction, 
that  the  condition  conies  under  notice.  The  pain 
at  the  back,  so  frequently  complained  of  in 
anaemia,  is  believed  to  be  mainly  due  to  gastric 
spasm;  and  in  certain  other  constitutional  states, 
such  as  gout,  it.  may  be  a prominent  symptom. 
Occasionally  it  is  due  to  uterine  or  ovarian  dis- 
turbances, acting  in  a reflex  manner.  Spasm  of 
the  pylorus  is  of  theoretic  rather  than  practical 
interest.  Intestinal  cramp  (colic,  tormina,  &e.) 
is  of  frequent  occurrence  as  the  result  of  ir- 
ritating ingesta,  lead-poisoning,  hernia,  intus- 
susception, and  ulceration  in  malignant  disease. 
These  spasmodic  affections  may  also  result  from 
diseases  of  the  spinal  cord.  How  far  over-action 
of  the  involuntary  muscular  tissue  of  the  ali- 
mentary tract  may  exist  without  pain  is  un- 
certain ; since  we  are  ordinarily  unconscious  of 
the  peristalsis,  it  is  probable  that  any  exaggera- 
tion of  action  is  painful. 

The  normal  tenacity  of  the  sphincter  ani  may 
give  place  to  painful  spasm,  a condition  which  is 
very  apt  to  complicate  fissure  and  ulcer  of  the 
anus. 

Hyperkinesis,  or  exalted  motor  activity  of  the 
muscular  tissue  of  the  digestive  organs,  may  be  a 
part  of  the  general  state  induced  by  such  poisons 
as  strychnine. 

3.  The  due  performance  of  the  mechanism  of 
digestion  may  be  interfered  with  by  alterations  in 
the  condition  of  the  alimentary  canal  caused  by 
various  kinds  of  obstruction  or  dilatation.  Thus 
deglutition  may  be  rendered  difficult  or  even 
impossible  by  a swollen  tongue  or  tonsils,  post- 
pharyngeal abscess,  tumours  of  the  oesophagus  or 
larynx,  or  new  growths  situated  at  the  cardiac 
aperture  of  the  stomach.  The  various  obstructive 
diseases  of  the  pylorus  and  intestines  will  ob- 
viously interfere  with  the  proper  passage  of  the 
contents,  and  in  those  dilatations  of  the  canal, 
which  are  liable  to  develop  above  a stricture, 
the  food  accumulates  and  is  delayed  in  its  passage. 
The  adhesion  of  coils  of  the  bowels  to  each  other 
or  to  adjacent  structures  is  a further  source  of 
imperfect  movement. 


308  DIGESTION.  DISORDERS  OF. 


Lastly,  the  subdivision  of  the  solid  food,  so 
necessary  for  the  effective  action  of  the  digestive 
juices,  is  only  imperfectly  performed  vrhen  the 
teeth  are  deficient  in  number  or  are  carious,  and 
to  this  cause  a large  proportion  of  cases  of  dys- 
pepsia may  be  fairly  assigned. 

So  marked  a perversion  of  the  mechanism  of 
digestion  as  vomiting  is  more  fitly  described  by 
itself,  though  it  is  a very  frequent  symptom  of 
indigestion. 

III.  Imperfection's  in  the  Chemicax  Changes. 
— Our  knowledge  of  the  normal  chemistry  of 
digestion,  much  as  it  has  advanced  of  late,  is 
still  very  far  from  complete,  and,  in  face  of  our 
ignorance,  but  little  can  be  said  of  the  conditions 
existing  in  disease.  Yet  there  are  certainly  no 
departures  from  the  healthy  working  of  the 
body  so  common  as  are  those  associated  with  the 
digestion  of  the  food. 

The  various  secretions,  whose  office  it  is  to 
convert  into  a fluid  and  diffusible  form  those 
alimentary  principles  which  without  such  prepa- 
ration cannot  be  absorbed,  are  formed  from  the 
blood  by  the  salivary,  gastric,  pancreatic,  he- 
patic, and  intestinal  glands.  It  is  clear  that,  for 
these  juices  to  be  secreted  in  proper  quantity  or 
of  proper  composition,  the  blood  no  less  than 
the  secreting  cells  must  be  in  a healthy  con- 
dition. If  the  circulating  fluid  be  laden  with 
imperfectly  secreted  products  of  tissue-change, 
or  if  it  be  charged  with  poison,  of  whatever  ori- 
gin, it  is  not  to  be  expected  that  a normal  secre- 
tion is  to  be  obtained  from  it ; whilst  on  the 
other  hand  a degenerated  secreting  epithelium 
is  unable  to  perform  a function  intimately  de- 
pendent on  the  integrity  of  its  protoplasm.  Of  ne- 
cessity these  two  factors — blood  and  cells— react 
on  one  another;  any  flaw  in  the  one  is  recipro- 
cated by  the  other,  and  thus  becomes  intensified 
by  mutual  interdependence.  Experiment  leads 
us  to  ascribe  the  efficacy  of  these  juices  in  the 
changes  they  effect  to  the  existence  in  them  of 
certain  so-called  ferments,  whilst  the  result  they 
bring  about  is  mainly  one  of  hydration.  How 
fur  the  various  mineral  constituents  of  the  se- 
cretions aid  in  the  process  is  uncertain,  but  at 
least  their  presence  cannot  bo  dispensed  with. 
In  this  way,  the  insoluble  starches  of  our  food  are 
converted  by  the  saliva,  the  pancreatic,  and  pos- 
sibly the  intestinal  juices,  into  soluble  and  diffu- 
sible sugars  ; the  various  proteids  are  rendered 
capable  of  absorption  into  the  blood,  by  the 
gastric  and  pancreatic  juices,  and  perhaps  also 
the  succus  enterieus,  being  changed  into  bodies 
known  as  peptones.  The  fats  are  prepared  for 
absorption  by  the  bile  and  pancreatic  juice,  by 
being  in  part  reduced  to  a sufficiently  minute 
state  of  subdivision  (emulsion)  to  permit  of  their 
passage  through  the  tissue-interstices,  and  partly 
by  being  chemically  altered  into  soaps.  How- 
ever closely  we  may  imitate  the  separate  actions 
of  these  fluids  in  our  test-tubes  and  laboratories, 
the  conditions  are  undoubtedly  much  more  com- 
plicated in  the  alimentary  canal,  where  so  many 
sets  of  changes  are  going  on,  and  so  many  sets  of 
products  are  formed. 

Despite  our  imperfect  knowledge  we  can  yet 
suggest  in  outline  the  causes  of  the  abnormal 
chemical  changes,  however  far  we  may  be  from 
ascribing  with  accuracy  to  their  proper  con- 


ditions the  multiform  symptoms  which  such 
changes  undoubtedly  give  rise  to. 

Primarily  the  secretions  may  be  deficient  in 
quantity,  improper  in  quality,  or  both,  and  the 
folio-wing  are  some  of  the  causes  leading  to  such 
results ; — 

1.  Perverted  nervous  influence.  The  direct 
control  of  the  nervous  system  over  the  quantity 
and  quality  cf  the  secretions  is  well  known,  and 
there  is  every  reason  to  suppose  that  the  tem- 
porary arrest  of  the  salivary  fluid  so  frequently 
accompanying  any  severe  mental  disturbance, 
such  as  fright,  represents,  but  in  a transitory 
manner,  a disturbance  that  may  be  more  lasting 
and  more  serious  in  lesions  of  the  central  nervous 
organs.  The  imperfect  digestion,  as  indicated  by 
the  tongue,  breath,  excreta,  &c.,  so  common  in 
brain-diseases,  even  when  all  precautions  are 
taken,  is  only  to  be  explained  in  this  way.  There 
is  nothing  improbable  in  suggesting  that  a cause 
which  may  in  one  case  bring  about  an  arrest  of 
secretion,  may,  if  prolonged,  induce  a perversion 
of  the  same. 

2.  Abnormal  blood-supply.  A deficiency  in 
blood  being  almost  always  associated  with  an 
alteration  in  its  quality,  it  is  easy  to  see  why  in 
a state  of  anaemia  the  digestive  function  suffers, 
whilst  the  more  it  fails  the  more  will  the  anaemia 
increase.  Henco  the  care  needed  both  in  diet 
and  drugs  for  such  patients.  In  some  cases  the 
blood  may  be  wanting  in  those  constituents  which 
go  to  form  the  secretions.  Occasionally  persons 
are  met  with  who,  from  habit  or  inclination,  take 
a quantity  of  fluid  far  below  the  ordinarily  sup- 
posed requirements.  In  such  the  secretions 
would  seem  to  be  insufficient  in  quantity  to  do 
their  work,  and  an  irritable  form  of  dyspepsia, 
caused  by  the  presence  of  imperfectly  digested 
food,  is  the  result.  Or  again,  certain  symptoms 
may  point  to  a deficiency  in  such  special  elements 
of  the  secretions  as  hydrochloric  acid,  bicarbonate 
of  potash,  &"c.,  and  considerable  relief  or  a cure 
may  follow  the  administration  of  these  substances, 
or  it  may  be  the  ferments  themselves  are  want- 
ing, and  pepsin  or  pancreatin  are  indicated.  It  is 
not  asserted  that  our  knowledge  at  pwesent  leads 
us  to  recognise  with  accuracy  the  exact  nature  of 
the  deficiency  in  the  secretions,  but  in  view  of  the 
relief  that  is  afforded  by  acting  on  the  lines  laid 
down  by  physiology,  it  is  only  reasonable  to 
expect  that  in  time  the  expressions  of  disease  may 
be  more  exactly  defined,  and  so  a rational  basis 
constituted  for  treatment.  After  prolonged  fast- 
ing the  gastric  juice  is  secreted  in  but  small 
amount,  and  under  ordinary  conditions  that  which 
is  first  poured  into  the  stomach  is  far  less  active 
than  that  later  formed.  In  other  words  the 
quality  of  the  secretion  improves  as  the  food, 
which  supplies  its  ingredients,  is  absorbed. 
Hence  the  occasional  advantage  of  prefacing  a 
meal  with  a small  quantity  of  some  piquant  food. 

From  a blood  laden  with  impurities,  whether 
of  ingesta  or  non-eliminated  products  of  tissue- 
waste  or  specific  poisons,  healthy  secretions  are 
not  to  be  expected,  even  did  the  secreting  agents 
remain  healthy.  Thus  the  dyspeptic  symptoms 
associated  with  alcoholism,  gout,  and  the  acute 
specific  diseases  are  to  be  explained. 

3.  It  has  already  been  said  that  it  is  practi- 
cally impossible  to  disassociate  altered  blood 


DIGESTION,  DISORDERS  OE. 


States  from  perverted  tissue-structure ; and  if 
the  nutritivo  fluid  of  the  body  be  diseased,  the 
elements  nourished  by  it  may  be  expected  to  be 
imperfect.  Some  of  these  departures  from  the 
normal  are  not  recognised,  partly  from  the  dif- 
ficulty of  observing  them,  and  still  moro  from 
ignorance  of  the  exact  standard  of  healthy 
structure  in  tissues  which  are  perpetually  chang- 
ing, even  within  healthy  limits.  Other  changes, 
however,  we  can  see ; and  the  degenerate  cells 
of  an  amyloid  liver,  or  the  desquamating  epithelia 
of  the  gastric  follicles  in  scarlatina,  can  no  more 
lie  expected  to  eliminate  healthy  secretions,  than 
can  a fatty  heart  to  contract  properly. 

A further  source  of  disturbance  in  the  chemical 
changes  indigestion  is  to  be  found  in  the  fermen- 
tative and  putrefactive  processes  set  up  in  the 
contents  of  the  alimentary  canal.  How  far  such 
processes  are  normal  is  uncertain  ; but  occasion- 
ally the  contents  of  the  stomach  are  vomited  in 
a state  of  active  fermentation,  and  teeming  with 
living  organisms.  All  ill-smelling  gases  and 
excreta  may  be,  indeed,  indicative  of  the  progress 
of  putrefaction  lower  down  in  the  canal.  That 
gastric  juice  and  bile  will  normally  arrest  putre- 
faction, whilst  pancreatic  juice  favours  it,  is  well 
known,  and  hence  we  are  led  to  infer  some  altera- 
tion in  the  secretions  when  signs  of  decompo- 
sition appear. 

Syjietoms  or  Dyspepsia. — The  almost  num- 
berless symptoms  which  indicate  the  perverted 
functions  above  described,  may  be  considered  as 
those  associated  with  the  special  organ  at  fault; 
and  those  manifested  by  the  system  generally. 

(a)  Among  the  first  group  are  perverted  sen- 
sations. Ordinarily  we  are  unconscious  of  the 
process  of  digestion,  but  in  disease  the  function 
may  be  accompanied  by  alterations  of  sensation, 
varying  from  a mere  sense  of  weight  and  discom- 
fort in  the  abdomen  to  the  severe  spasmodic  pain 
of  colic.  The  ingestion  of  food  maybe  followed 
by  a feeling  of  abnormal  repletion,  or  of  emp- 
tiness with  craving  for  food ; or  there  may  be 
heartburn,  an  ill-defined  sense  of  burning  felt  in 
the  epigastrium  or  over  the  chest,  or  extending 
to  the  throat,  or  positive  pain  or  tenderness  felt 
over  some  tolerably  definite  area.  Sensations  as 
of  excessive  movements  of  the  bowels,  of  sinking, 
or  of  tightness  across  the  abdomen,  are  of  fre- 
quent occurrence. 

(b)  Affections  of  the  appetite  as  results  of 
indigestion  have  already  been  referred  to. 

(e)  The  various  movements  of  the  alimentary 
canal  may  he  interfered  with.  They  may  he  delayed 
or  even  arrested,  as  occurs  in  constipation ; or  exces- 
oive,  with  consequent  diarrhoea.  Vomiting,  either 
directly  or  at  a variable  interval  after  taking 
food,  is  a common  symptom,  with  or  without 
pain  ; very  frequently  the  vomiting  relieves  the 
unpleasant  feelings  that  may  be  present.  Eructa- 
tions of  gas,  hiccough,  and  the  frequent  passing 
of  much  flatus  occur  in  many  cases. 

(i d ) The  vomited  matters  vary  considerably. 
The  food  may  be  ejected  very  much  as  it  has 
been  swallowed,  or  it  may  be  in  a state  of  active 
fermentation  and  turning  into  ferments.  A 
symptom  very  often  complained  of  is  theerueta- 
tation  into  the  mouth  of  a fluid,  which  is  fre- 
quently acrid  and  bitter,  at  other  times  tasteless 
(pyrosis) : it  is  probably  altered  gastric  secretion. 

24 


Blood  may  be  vomited  (hgematemesis) : or  passed 
per  rectum  (melsena).  The  breath  may  oc  foul. 

( e ) The  state  of  the  tongue,  its  ouour,  size, 
and  general  appearance  as  to  fur,  dryness, 
smoothness,  and  prominence  of  papilla,  are  often 
indicative  of  the  condition  of  the  stomach  and 
intesti  nes. 

(/’)  Such  sympathetic  symptoms  as  headache, 
pain  in  the  back  or  in  the  right  shoulder,  dizzi- 
ness, specks  in  the  field  of  vision,  palpitation,  of 
irregular  action  of  the  heart,  cough,  disordered 
urine.  &c„  indicate  the  relation  existing  between 
the  digestive  organs  and  the  body  generally. 

( g ) The  more  gencrcd  symptoms  that  are 
found  associated  with  disordered  digestion  mav 
he  those  of  pyrexia,  when  an  acute  inflammatory 
condition  of  the  digestive  organs  is  the  cause  of 
the  disturbance.  Since,  however,  the  affections 
are  more  usually  of  a chronic  nature,  a genori.t 
wasting  and  emaciation  from  insufficient  nourish- 
ment is  likely  to  ensue.  In  such  a state  tho  pa- 
tient is  prone  to  develop  any  diathesis  to  which 
he  maybe  liable,  such  as  the  neurotic,  cancerous, 
&c.  The  peculiar  sallow,  muddy-looking  akin, 
often  slightly  tinged  with  bile  and  markedly 
amende,  is  characteristic  of  many  cases  of  chronic 
indigestion ; a poorly  nourished  body  can  ill  stand 
the  slightest  fatigue,  though  such  patients  are 
often  apt  to  brighten  up  towards  evening,  and 
indeed  as  a rule  dyspeptic  patients  are  worse  in 
the  morning.  All  conditions  of  disordered  tem- 
perament are  met  with,  from  a confirmed  apathy 
and  hypochondriasis  to  a persistent  and  increas- 
ing irritability.  Whilst  some  patients  are  always 
drowsy,  others  complain  of  a distressing  insomnia, 
or  a troubled  and  dreamy  sleep. 

Teeatmekt. — Oftener  perhaps  than  may  bo 
supposed,  the  cause  of  the  disturbance  of  diges- 
tion is  a removable  one ; in  any  case  it  must  be 
well  searched  for,  and  arrested  if  possible.  A care- 
fully regulated  diet,  botli  as  regards  ordinary  food 
and  drinks  and  special  idiosyncrasies,  is  in  all 
cases  the  most  important,  and  the  means  from 
which  much  good  is  to  be  expected.  Exercise, 
bathing,  occupation  both  mental  and  bodily, 
change  of  scene  and  air,  will  require  attentive 
consideration.  Much,  however,  may  be  done 
with  the  aid  of  drugs.  Sufficient  indications  often 
exist  to  justify  prescribing,  with  perfect  confi- 
dence, such  tonics  as  vegetable  bitters,  quinine, 
strychnine,  and  iron ; such  constituents  of  the 
digestive  juices  as  mineral  acids,  pepsin,  and 
alkalies;  or  drugs  whose  value  appears  mainly 
to  consist  in  their  sedative  action,  as  hvdro- 
eyanie  acid,  bismuth,  opium,  and  belladonna. 
Arsenic,  zinc,  silver,  creasote,  charcoal,  valerian, 
the  hvpo-sulphites,  and  the  carminatives 
generally,  are  a few  among  the  long  list  whose 
value  is  assured  in  different  cases  of  dyspepsia. 
It  is  important  to  attend  to  the  condition  of 
the  bowels  ; as  well  as  to  the  hepatic  functions. 
See  Stomach,  Diseases  of. 

Coxcixsion. — In  the  foregoing  remarks  no 
attempt,  has  been  made  to  enter  into  a detailed 
description  of  the  various  symptoms  of  disordered 
digestion,  or  to  do  more  than  indicate  very  gene- 
rally the  treatment  to  he  followed.  Such  subjects 
are  left  to  the  diseases  treated  of  in  their  respec- 
tive articles.  Nor  has  it  been  thought  desirable 
in  this  article  to  treat  the  subject  from  the  ill- 


370  DIGESTION,  DISORDERS  CE. 
defined  point  of  view  of  * varieties  of  dyspepsia.’ 
Rather  it  has  been  sought  to  bring  the  matter 
of  indigestion  within  the  limits  of  an  anato- 
mieo-physiological  tasis,  since  it  is  only  on 
such  lines  that  the  protean  symptoms  of  dys- 
pepsia can  be  accurately  defined.  At  the  same 
time,  whilst  for  clearness  the  various  causes  have 
been  mado  to  assume  a somewhat  tabular  form, 
it  is  not  intended  that  the  interdependence  of 
these  states  should  be  overlooked,  or  that  one 
only  of  the  causes  mentioned  is  at  work  in  any 
given  case.  The  complexity  and  harmony  of 
our  functions  alike  forbid  such  a mistake  being 
made.  Yet  for  that  mental  analysis  which  the 
formation  of  a diagnosis  presupposes,  somo  such 
scheme  as  the  foregoing  is  essential,  no  less 
than  for  the  adoption  of  a rational  treatment. 

W.  II.  Allchin. 

DIGESTIVE  ORGANS,  Diseases  of  the. 

— The  organs  comprised  in  the  digestive  system 
have  for  their  function  the  preparation  of  the 
solid  and  fluid  ingesta  of  the  body,  so  as  to  fit 
them  for  absorpt  ion  into  the  blood.  Some  of 
the  food  requires  little  or  even  no  such  prepara- 
tion ; some  needs  considerable  treatment,  both 
physical  and  ehemical.  To  effect  this  object  it 
would  appear  to  follow  that  there  should  be  some 
receptacle  or  series  of  receptacles  into  which  the 
food  may  readily  be  taken,  and  from  which  the 
worthless  residue  may  escape,  provided  with 
museular  structures  to  ensure  a movement  of  its 
contents.  It  would  further  follow  that  there 
should  be  certain  organs  communicating  with 
the  foregoing,  whose  function  it  should  be  to 
prepare  those  materials  necessary  to  effect  the 
required  chemical  changes  in  the  food ; and, 
lastly,  that  some  arrangement  should  exist  to 
permit  of  the  ready  absorption  of  the  digestive 
materials.  Such  requirements  we  find  supplied  in 
the  alimentary  canal,  with  its  terminal  apertures, 
and  its  continuous  muscular  coat  so  arranged  as 
to  maintain  a progressive  advance  of  the  contained 
food,  though  with  varying  degrees  of  speed — for 
somo  lengths,  as  through  the  gullet,  without  any 
arrest;  in  others,  as  in  the  stomach,  with  con- 
siderable delay.  Into  this  canal  open  numerous 
glands  (mucous,  salivary,  gastric,  intestinal, 
hepatic,  and  pancreatic),  the  secretions  of  which 
play  each  their  special  part  in  the  conversion  of 
the  food  to  a fluid  and  diffusible  state.  From 
an  anatomical,  and  indeed  a genetic  point  of 
view,  these  glands  may  be  regarded  as  more 
or  less  complicated  diverticula  of  the  mucous 
surface.  In  order  that  the  food  when  so  treated 
may  gain  a ready  entrance  into  the  blood,  the 
surface  of  the  canal  in  contact  with  the  digest- 
ing food — mucous  membrane — offers  various 
modifications — villi,  &c. — to  facilitate  the  process 
of  absorption.  Lastly,  in  beings  so  complex  in 
structure  as  man,  there  is  need  for  some  control- 
ling influence  to  bring  the  operation  of  this  system 
of  organs  into  harmony  with  the  actions  of 
other  and  interdependent  systems.  Such  power 
of  co-ordination  is  exercised  via  the  nervous 
system,  sympathetic  and  cerebro-spinal. 

By  the  expression  ‘diseases  of  the  digestive 
organs’  is  meant,  departures  from  the  normal 
structure  of  the  tissues  of  which  these  organs 
are  composed. 


DIGESTIVE  ORGANS,  DISEASES  OF. 

The  constructive  tissues  of  the  alimentary 
organs  are : — 1.  The  Epithelial ; 2.  The  Connec- 
tive ; 3.  The  Muscular  ; and,  4,  a compound  tex- 
ture— the  Vascular.  Each  of  these  is  subject 
to  its  own  perversions,  either  alone  or  in  common 
with  others. 

^Etiology. — If  we  consider  diseases  to  be 
altered  functions  dependent  on  altered  structure, 
the  latter  being  determined  by  some  perversion 
in  the  normal  stimuli  to  nutrition,  either  heredi- 
tary or  acquired,  we  shall  at  once  recognise  that 
the  opportunities  for  abnormal  stimulation  in  the 
case  of  the  digestive  organs  are  most  numerous. 
Communicating  with  the  external  world  and 
continuously  subject  to  tbe  admission  of  foreign 
matter,  we  have  in  the  character  of  the  ingesta 
abundant  sources  of  disease.  Toxic  agents,  living 
and  dead,  find  ready  entrance,  and  excesses  in 
quantity  of  food,  no  less  than  imperfection  in 
its  quality,  alike  serve  to  produce  those  depar- 
tures from  the  normal  structure  on  which  per- 
versions of  function  depend. 

Furthermore,  the  tissues  of  the  alimentary 
viscera  are,  equally  with  those  of  the  body  gener- 
ally,subject  to  those  more  obscure  hereditary  in- 
fluences which  determine  irregularities  in  struc- 
ture and  their  sequence.  And,  finally,  arrests  in 
development  of  organs,  not  unfrequenfc  in  those 
under  consideration,  complete  the  list  of  possible 
diseases  to  which  the  alimentary  system  is 
liable. 

Nor  is  this  system  independent  of  morbid  con- 
ditions affecting  other  organs.  So  complicated 
as  is  the  human  body  it  is  impossible  that  disease 
should  for  long  be  limited  to  one  region.  Sooner 
or  later  the  functions  which  are  cow  reacting 
the  one  upon  the  other,  to  constitute  the  harmo- 
nious working  of  healthy  life,  will  feel  the  effects 
of  the  one  that  is  out  of  gear,  and  will  respond 
each  in  its  own  manner  to  the  abnormal  condi- 
tion. A disease  primarily  located  in  the  nervous 
system  will  produce  an  effect  in  the  working  of 
the  nutritive  functions,  none  the  less  real 
because  the  exact  lesion  cannot  as  yet  be  deter- 
mined. Failures  in  elimination  of  the  products 
of  tissue-waste  from  structural  diseases  of  the 
excretory  glands,  must  tell  back  on  the  organs 
concerned  in  the  preparation  and  elaboration  of 
the  ingesta,  and  such  conditions  constitute  a fre- 
quent cause  of  disorders  of  digestion.  The  causes 
may  be  thus  tabulated  : — 

A.  Hereditary. 

1.  Arrests  in  development  of  tissues  and 

organs. 

2.  Abnormal  nutritive  stimuli,  determining 

new  growths,  &c. 

11.  Acquired. 

1 . Poisons, 

2.  Imperfections  in  quantity  or  quality  of 

normal  ingesta. 

3.  Failure  of  excretory  functions  with  con- 

sequent circulation  of  an  impure  blood. 

and  malnutrition  of  tissues. 

4.  Trophic  disturbances  acting  via  the 

nervous  system. 

5.  Traumatic. 

Classification  ofDiskases. — Thereis  scarcely 
any  form  of  diseased  structure  that  is  not  to  be 
met  with  in  the  tissues  comprising  the  digestive 
organs.  Since  almost  every  variety  of  texture  is 


DIGESTIVE  ORGANS,  DISEASES  OF  THE. 


found  in  them,  and  there  is  so  extensive  a liability 
to  the  causes  of  disease,  this  result  is  only  to  bo 
expected. 

I.  Affections  of  the  Vascular  State. — 
Regarded  collectively,  the  organs  of  digestion 
present  several  points  in  respect  to  their  blood- 
supply  worthy  of  remark.  First,  the  arrange- 
ment of  the  vessels  is  such  as  to  ensure  a very 
extensive,  and  at  the  same  time,  very  direct 
supply.  The  arteries  to  those  alimentary  organs 
situate  in  the  abdomen  are  almost  all  primary 
branches  of  the  aorta,  and  this,  together  with 
the  numerous  and  free  anastomosis  between 
them,  reduces  to  a minimum  the  chance  of  failure 
in  circulation.  Secondly,  the  blood  from  the  same 
area  is  all  collected  into  one  large  vein,  the 
portal,  and  after  circulating  through  the  liver  is 
carried  by  one — the  hepatic  — directly  into  the 
inferior  vena  cava  close  to  the  right  auricle. 
Such  an  arrangement,  whilst  perhaps  facilitating 
the  direct  return  of  blood,  offers  a double  chance 
— viz.,  in  the  liver  and  in  the  heart — of  producing  a 
very  general  state  of  congestion  of  the  alimentary 
tissue.  Thirdly,  the  existence  of  such  an  organ 
as  the  spleen,  whichby  its  position  and  structure 
allows  of  great  variation  in  the  amount  of  blood 
it  contains,  will  considerably  affect  the  extent  of 
vascularity  of  the  digestive  organs.  Our  know- 
ledge of  the  conditions  determining  the  variations 
in  splenic  blood-capacity  is  most  imperfect, 
beyond  the  fact  of  the  constant  enlargement 
which  the  organ  undergoes  after  a meal  and  its 
subsequent  contraction  after  a few  hours,  the 
enlargement  being  due  in  great  part  to  increase 
in  the  amount  of  blood  contained  in  it.  And, 
lastly,  the  alimentary  organs  probably  undergo, 
within  normal  physiological  limits,  a wider  varia- 
tion in  amount  of  blood  than  does  any  other 
system. 

1.  Hyperemia  is  an  excess  of  blood  in  the 
arterial  side  of  the  capillaries.  How  far  a de- 
termination of  blood  to  the  alimentary  canal 
may  exist,  unaccompanied  by  any  change  in  the 
tissues,  is  a matter  of  doubt.  In  the  normal 
process  of  digestion  this  condition  obtains,  but 
with  it  there  is  an  alteration  in  the  glandular 
epithelia,  if  in  no  other  tissue-elements.  It  is 
conceivable,  however,  that  a vaso-motor  paralysis 
with  consequent  fluxion  may  occur,  and  such  may 
be  the  case  in  certain  mental  states,  as  indicated 
by  diarrhcea.  The  majority  of  circumstances 
that  produce  hyperaemia  do  not  stop  at  that 
point,  but  bring  about  a state  of  catarrh  and  in- 
flammation, in  which  the  epithelial  and  connec- 
tive tissues  are  also  engaged.  Exposure  to  cold 
and  extensive  superficial  burns  probably  produce 
their  well-known  results  of  intestinal  catarrh  in 
this  manner. 

Among  the  digestive  glands,  the  liver  un- 
doubtedly manifests  states  of  simple  hyperaemia 
wi  thout  any  appreciablechangesinthe  parenehym  a 
of  the  tissues.  Excessive  feeding,  irritants  such 
as  spices  and  alcohol,  hot  climates  and  malaria, 
have  all  been  recognised  as  producing  temporary 
enlargements  of  the  liver  from  vascular  engorge- 
ment, although  without  doubt  these  causes  if 
continued  lead  to  structural  affections. 

2.  Congestion,  or  an  excess  of  blood  primarily 
in  the  venous  side  of  the  capillaries,  brought  about 
b 7 some  impediment  to  the  return  of  the  blood 


37i 

in  the  veins,  has  little  or  no  analogy  with  any 
normal  physiological  action.  As  a condition  of 
disease  it  is  more  important  and  far  more  common 
than  the  preceding. 

The  two  chief  causes  leading  to  its  occurrence 
are — (A)  Obstruction  through  the  portal  circula- 
tion in  the  liver,  either  by  compression  of 
the  portal  capillaries  by  cirrhosis,  &c.,  or  pressure 
in  the  portal  trunk  by  enlarged  glands,  tumours, 
&c. ; (B)  as  part  of  a general  congestion  due  tc 
obstruction  at  the  right  side  of  the  heart  from 
tricuspid  dilatation.  Due  to  the  very  direct  com- 
munication of  the  veins  of  the  chylopoietie 
viscera  and  the  right  auricle,  these  organs  are 
among  the  first  to  experience  the  effects  of  the 
cardiac  obstruction.  Congestion  of  the  alimen- 
tary canal  and  glands,  when  due  to  either  of 
these  causes,  is  in  the  main  progressive  in  its 
nature,  though  occasionally  liable  to  temporary 
relief  from  treatment. 

Extreme  conditions  of  vascularity,  especially 
if  associated  with  any  haemorrhage  into  the 
sub-epithelial  tissue,  present  post-mortem  ap- 
pearances often  mistaken  for  irritant  poisons. 

3.  Besults  of  Increased  Vascularity.  — (a) 

Hemorrhage.  Over -fulness  of  the  capillaries, 
from  whatever  cause,  is  liable  to  lead  to  extrava- 
sation of  blood,  either  by  diapadesis  of  the  cor- 
puscles and  transfusion  of  the  fluid  part  of  the 
blood,  or  from  actual  rupture  of  the  vessels.  It 
is  much  more  common  and  far  more  extensive  in 
venous  congestion  than  in  arterial  hyperaemia. 
It  must  not  be  too  readily  assumed  post  mortem 
that  either  of  these  conditions  alone  is  the  cause 
of  the  haemorrhage,  since  minute  ulcers  of  the 
mucous  membrane  communicating  with  mam 
vessels  have  been  met  with.  Dependent  on  the 
course  and  situation,  the  effused  blood  may  vary 
in  colour  from  bright  red  to  a coffee-ground 
appearance.  Haemorrhage  due  to  altered  states 
of  the  blood  is  of  frequent  occurrence  in  pur- 
pura, scurvy,  &c.  (j8)  (Edema.  An  over-dis- 

tension of  the  vessels,  especially  of  the  veins,  if 
it  be  at  all  persistent,  is  invariably  accompanied 
by  an  effusion  of  serum  into  the  substance  of 
the  viscera  themselves  and  into  the  alimentary 
canal,  in  the  latter  case  producing  diarrhoea. 
(y)  Tissues  the  seat  of  a chronic  congestion  in 
time  undergo  certain  structural  changes  as  the 
result  of  their  impaired  nutrition,  which  are 
characterised  by  the  presence  of  an  excessive 
amount  of  connective  tissue,  containing  fewer 
protoplasmic  elements  than  normal,  and  exhibit- 
ing a marked  tendency  to  contract.  The  fibroid 
substitution  may  occur  throughout  the  entire 
digestive  system,  but  is  particularly  noticeable 
in  the  stomach,  intestines,  liver,  and  pancreas. 

4.  Anemia. — The  alimentary  viscera,  in  com- 
mon with  the  rest  of  the  body,  may  share  in 
a general  bloodlessness  due  to  excessive  loss  or 
extreme  malnutrition  from  wasting  disease,  &c. 
A deficiency  of  blood  limited  to  these  organs  is 
not  clinically  met  with. 

5.  Infarctions. — As  compared  wdth  the  brain, 
spleen,  and  kidneys,  the  organs  of  the  alimentary- 
system  would  appear  to  be  less  prone  to  suffm 
from  emboli  and  thrombi,  or  at  all  events  from 
the  effects  of  their  conditions.  A partial  ex- 
ception to  this  general  statement  must  be  made 
in  the  case  of  the  liver,  which  is  a frequent  eeai 


372  DIGESTIVE  ORGANS,  DISEASES  OF  THE. 


jf  abscess  determined  by  the  arrest  in  the  portal 
capillaries  of  septic  particles  taken  up  by  the 
portal  radicals  in  dysentery,  &c.  Emboli,  as  a 
cause  of  gastric  ulcer,  are  probably  not  so  com- 
mon as  has  been  supposed  by  Virchow. 

II.  Structural  Affections. — 1.  Inflammation. 
This  term  is  applied  to  express  those  changes 
which  take  place  in  the  nutrition  of  a tissue 
subsequent  to  the  application  of  some  abnormal 
stimulus  which  shall  not  have  been  sufficiently 
powerful  to  produce  destruction.  The  changes 
in  the  structural  elements  of  the  textures  result 
in  the  production  of  some  material  which  is 
unlike  the  normal  constituents  of  the  part 
affected,  and  also  in  certain  destructive  pheno- 
mena. One  or  other  of  these  aspects  may  pre- 
dominate, as  in  suppuration  and  abscess  or  ulcer- 
ation, &c.  Certain  variations  present  themselves 
in  the  nature  of  the  new-formed  material,  and 
also  in  the  general  course  of  the  process, 
constituting  forms  of  inflammation,  as  simple, 
diphtheritic,  phlegmonous,  aphthous,  &c.  In 
vascular  tissues  there  are  in  addition  to  the  tissue- 
changes  certain  alterations  in  the  circulation  in 
the  affected  region,  commencing  with  hyperaemia 
and  leading  to  a variable  amount  of  stasis. 

Inflammation  as  it  affects  the  alimentary  tract 
offers  no  exception  to  this  description.  The 
transition,  so  far  as  anatomical  appearances  are 
concerned,  from  the  normal  state  of  activity  of 
the  organs,  with  their  increased  vascularity  and 
cloudy  appearance  of  the  epithelial  cells,  to  that 
of  simple  inflammation  or  catarrh,  is  but  a step 
marked  by  no  abrupt  line.  The  entire  canal, 
with  the  gland-ducts  opening  into  it,  may  be 
the  seat  of  various  forms  of  inflammation,  some 
regions  being  rather  more  prone  than  others,  as 
the  fauces,  stomach,  small  intestine,  and  bile- 
ducts. 

It  is  rare  in  inflammation  of  the  canal  for  the 
muscular  tissue  to  share  in  the  process,  which  is 
practically  limited  to  the  epithelial  and  sub- 
epithelial  connective  tissue,  and  a similar  condi- 
tion exists  in  regard  to  the  ducts  of  the  various 
glands.  It  is  a noticeable  fact  that  the  epithelia 
of  the  canal  are  but  little  prone  to  manifest  that 
general  suppurative  form  of  inflammation  accom- 
panied by  a large  production  of  pus  from  the 
general  surface,  such  as  is  so  commonly  seen  in 
the  bronchial,  nasal,  vaginal,  and  other  mucous 
membranes.  In  inflammation  of  the  various 
glands  it  would  appear  that  next  to  the  ducts 
the  connective-tissue  stroma  is  mainly  the  tissue 
affected;  leading  to  a proliferation  of  the  corpuscles 
and  ultimate  formation  of  a less  protoplasmic 
form  of  fibrous  tissue. 

Among  the  chief  results  of  inflammation  are : — 

(a)  Abscess. — This  may  occur  in  any  part  of 
the  submucous  tissue,  in  the  so-called  phleg- 
monous and  pyscmic  inflammation,  but  is  of 
most  common  occurrence  in  the  tonsils  and  in 
the  liver,  often  in  the  lattersituationtheresult  of 
inflammation  determined  by  absorption  into  the 
mesenteric  veins  of  septic  particles  from  dysen- 
teric ulceration. 

(£)  Ulciration. — The  mucous  membrane  of 
the  alimentary  canal  is  particularly  liable  to 
this  morbid  process.  Some  preference  is  exhi- 
bited by  the  different  forms  of  ulcer  for  certain 
regions  of  the  canal,  and  a difference  exists  in 


the  tendency  to  perforate  the  entire  thickness 
of  the  tube,  those  of  shorter  duration  fre- 
quently producing  this  result,  whilst  the  chronic 
ulcers  are  usually  accompanied  by  a slow  forma- 
tion of  indurated  connective  tissue,  which  pro- 
ceeds pari  passu  with  the  destructive  process,  and 
is  especially  likely  to  institute  adhesions  betweeD 
the  canal  and  adjacent  organs.  Ulcers  are  met 
with  in  the  salivary,  hepatic,  and  pancreatic  ducts, 
very  frequently  as  a sequence  of  inflammation 
determined  by  the  passage  of  calculi. 

The  ulcers  which  are  usually  acute  in  their 
course  are: — 1.  Simple.  2.  Aphthous.  These 
forms,  though  they  may  occur  in  any  part  of 
the  mucous  membrane,  are  far  more  commonly 
situated  in  the  gums,  cheeks,  tongue  and  palate. 

3.  Acute  specific  ulcerations,  as  diphtheritic 
and  scarlatinal,  mainly  affecting  the  fauces ; or 
typhoid,  limited  to  the  jejunum  and  ileum,  and 
originating  in  the  solitary  and  agminated  glands. 

4.  Dysenteric. 

The  ulcers  that  are  commonly  chronic  in  their 
course  are  : — 1.  Gastric.  2.  Tubercular,  which 
may  occur  in  any  part  of  the  canal,  but  are 
usually  limited  to  the  same  situation  as  the 
typhoid.  3.  Syphilitic,  most  common  in  the 
month,  fauces,  and  rectum.  4.  Cancerous.  5. 
Dysenteric. 

Ulcers,  the  result  of  injury  or  of  corrosive 
poisons,  may  be  either  acute  or  chronic.  The 
latter  are  rarely  met  with  below  the  stomach. 

( y ) Sloughing  and  Gangrene. — The  inflamma- 
tory state  may  be  so  intense  as  to  lead  to  molar 
death  of  the  area  affected,  with  the  produc- 
tion of  slough.  This  often  follows  scarlatinal 
inflammation  of  the  fauces,  and  the  surface  of 
the  large  intestine  in  dysentery  is  frequently 
covered  by  large  and  numerous  sloughs. 

Gangrene  is  almost  entirely  limited  to  the 
mouth  in  children,  when  it  produces  the  condi- 
tion termed  noma.  The  cheeks  are  usually 
affected  first,  the  process  rapidly  iuvolving  the 
gums,  jaws,  &e.  The  cause  is  very  obscure. 

Post-mortem  softening  and  destruction  of  the 
stomach  and  intestines  is  frequently  met  with, 
and  is  due  to  an  actual  digestion  of  the  viscera 
by  the  gastric  juice,  which,  thus  escaping  from 
the  stomach,  may  cause  destruction  of  adjacent 
organs.  It  is  usually  met  with  when  death  has 
occurred  during  the  process  of  gastric  digestion, 
and  is  more  common  in  infants,  possibly  from 
the  greater  acidity  of  the  products  of  digestion 
(lactic  acid). 

2.  Hypertrophy. — A general  overgrowth  of 
the  normal  tissues  of  the  digestive  organs  is  prac- 
tically unknown.  Certain  parts  may  manifest 
this  condition,  notably  the  muscular  tissue  of 
parts  of  the  canal  above  an  obstruction.  The 
liver  is  described  as  being  occasionally  hyper 
trophied  in  certain  cases  of  diabetes. 

3.  Atrophy. — The  alimentary  organs  may 
share  in  the  general  atrophy  and  wasting  of  old 
age  or  inanition.  This  condition  is  apt  to  follow 
the  disease  of  certain  parts,  as  is  seen  in  the 
thinning  and  shrinking  of  the  stomach  and  intes- 
tines beyond  an  obstruction  or  an  artificial  anus. 
Pressure  on  the  organs,  as  by  tight-lacing,  Ac., 
may  lead  to  the  same  result. 

4.  Degenerations. — Those  morbid  processes  to 
which  the  term  degeneration  is  applied,  and 


DIGESTIVE  ORGANS,  DISEASES  OF. 
which  essentially  consist  in  the  conversion  of  the 
tissues  into  materials  of  a less  complex  chemical 
composition  tha'nnormal,  associated  with  a dimi- 
nished vital  activity,  may  affect  any  or  all  of  the 
structural  elements  of  which  the  digestive  organs 
are  composed.  Albuminoid  infiltration  or  cloudy 
swelling  is  the  invariable  accompaniment  of 
inflammation  of  the  epithelial  and  muscular 
tissues.  Fatty  degeneration  is  a further  result 
of  inflammation,  with  caseation  and  occasional 
calcification.  Although  not  the  commonest 
organs  to  be  so  affected,  yet  not  infrequently 
the  intestine  and  stomach  are  the  seat  of  the 
so-called  amyloid  or  lardaceous  degeneration, 
and  not  always  limited  to  the  vessels,  but  affect- 
ing the  epithelial,  fibrous,  and  muscular  coats. 
The  liver  is  especially  liable  to  undergo  degene- 
ration, both  fatty  and  albuminoid.  Deposition 
cf  pigment  may  be  found  in  the  deeper  epithelial 
strata  of  the  mouth  in  Addison’s  disease,  and  in 
the  liver  in  certain  cases  of  intermittent  fevers. 

0.  Changes  in  the  secretions  of  the  various 
glands  may  result  in  the  production  of  calculi — 
salivary,  pancreatic,  or  biliary. 

6.  New  Growths. — There  is  scarcely  any 
known  form  of  neoplasm  which  may  not  be  found 
n some  region  or  another  of  the  alimentary  tract. 

The  new  growths  limited  to  the  epithelial 
coat,  or  commencing  in  it,  are  condylomata, 
papillomata,  encephaloid,  and  scirrhus. 

In  the  fibrous  tissue  occur  sarcoma,  fibroma, 
.myeloid,  adenoid,  gumma,  enchondroma,  and 
lipoma. 

In  addition  there  may  be  polypi,  or  tumours 
of  the  mucous  membrane  ; myxoma  ; muscular 
tissue  tumour ; cysts ; and  vascular  growths,  such 
as  ntevi  and  haemorrhoids. 

7.  Traumatic. — Certain  parts  of  the  alimen- 
tary tract  are,  from  their  position,  more  liable 
than  others  to  external  injury.  Incised  and 
punctured  wounds  of  the  mouth,  oesophagus, 
stomach,  intestines,  and  liver  are  of  occasional 
occurrence,  and  rupture  of  the  abdominal  tissue 
is  sometimes  met  with.  The  injection  of  corrosive 
substances  may  produce  destruction  of  certain 
parts  of  the  canal,  and  wounds  may  be  deter- 
mined by  foreign  bodies,  as  pins,  fish-bones,  &c., 
which  have  been  swallowed. 

III.  Malformations  and.  Malpositions. 

1.  Hereditary. — Of  these  the  most  important 
are  hare-lip  ; cleft  palate;  fistulous  communica- 
tion between  the  pharynx  and  the  exterior,  or 
between  the  gullet  and  trachea;  intestinal  cceca ; 
imperforate  anus  ; hernias. 

2.  Acquired. — Malformation  and  malposition 
of  the  viscera  may  follow  from  disease.  Com- 
munications between  the  stomach  and  intes- 
tines, or  between  different  coils  of  intestine,  or 
between  the  gall-bladder  and  the  gut,  may  result 
from  chronic  ulceration.  Many  hernise  are  not 
developed  until  long  after  birth,  from  violent 
strains,  &c. 

Stricture  of  various  parts  of  the  canal  is  fre- 
quently associated  with  the  healing  of  ulcers, 
and  with  new  growths.  Dilatation  of  the  canal 
is  apt  to  occur  in  the  proximal,  and  contraction 
on  the  distal  side  of  such  strictures.  The 
intestines  may  be  considerably  displaced  from 
adhesions  following  peritonitis.  Twists  (vol- 
vulus), intussusception,  internal  strangulations, 


DILATATION.  373 

and  prolapsus  ani,  are  more  or  less  common 
affections  of  the  intestines. 

IV.  Abnormal  Contents.  — Concretions, 
chiefly  of  phosphate  of  lime,  are  found  occa- 
sionally in  the  intestine.  They  usually  are 
made  up  of  consecutive,  layers  of  material  de- 
posited by  the  mucous  membrane.  They  fre- 
quently have  as  a nucleus  some  foreign  body. 
Similar  bodies  formed  of  chalk  or  magnesia 
which  has  been  swallowed  have  been  met  with. 
Foreign  bodies,  such  as  pins,  bones,  fruit-stones, 
coins,  &c.,  may  also  lodge  in  the  alimentary 
canal. 

Parasites. — The  chief  of  these  are  Sarcina 
ventriculi,  in  the  stomach ; T;enia  solium ; T. 
mediocanellata;  Bothriocephalus  latus  ; all  in- 
habiting the  small  intestines.  Ttenia  Echino- 
coccus (hydatid)  in  the  liver.  Ascaris  lum- 
bricoides,  chiefly  met  with  in  the  small 
intestines;  and  Oxyuris  lumbricoides  (thread- 
worm) almost  confined  to  the  rectum.  A few 
other  species  are  rarely  found. 

The  gases  of  the  intestines  may  be  so  largely 
increased  in  quantity  as  to  constitute  an  ab- 
normal condition. 

W.  II.  Ali.ciiin. 

DILATATION  ( dilato , I enlarge). 

./Etiology. — Dilatation  of  any  of  the  cavities, 
tubes,  or  orifices  of  the  body  may  either  result 
from  increased  pressure  from  within,  or  from 
diminution  in  tho  resisting  power  of  the  walls 
of  the  tubes  or  cavities.  These  two  causes  are 
frequently  combined,  and,  indeed,  the  latter 
is  often  the  result  of  a long  continuance  of  the 
former.  Increased  pressure  from  within  may 
be  due  either  to  increased  secretion  of  the 
normal  contents  of  the  cavity,  or  to  some  other 
effusion  into  it.  This  is  the  usual  cause  of  dilata- 
tion of  the  closed  cavities  of  the  body;  we  havo 
examples  in  the  ventricles  of  the  brain,  the  peri- 
cardium, the  synovial  cavities,  the  bursae,  tho 
follicles  of  the  thyroid  body  in  cystic  goitre,  and 
the  Graafian  vesicles  in  some  forms  of  ovarian 
dropsy.  In  the  various  tubes  of  the  body,  in- 
creased pressure  from  within  may  arise  from 
obstruction,  and  the  consequent  accumulation 
behind  the  seat  of  obstruction  of  the  substances 
which  it  is  the  function  of  the  tubes  to  transnfit. 

Varieties  and  Characters  . — 1.  Cystic  dilata- 
tion.— In  tubes  which  begin  by  blind  extremities 
the  result  of  dilatation  is  generally  the  forma- 
tion of  a cyst,  and  this  is  the  usual  mode  of 
origin  of  the  large  class  of  retention-cysts , or 
cystic  dilatation.  We  have  examples  in  the 
sebaceous  cysts,  in  the  cysts  of  mucous  mem- 
branes due  to  the  ducts  of  the  mucous  glands 
becoming  obstructed  by  the  products  of  catarrhal 
inflammation,  in  cysts  of  the  kidney  formd?  by 
dilatations  of  the  Malpighian  capsules  and 
uriniferous  tubules,  and  in  dilatations  of  the 
gall-bladder,  and  of  the  pelvis  of  the  kidney. 

2.  Uniform  or  cylindrical  dilatation. — In  tubes 
not  beginning  by  blind  extremities,  the  effect  of 
the  obstruction  is  usually  to  produce  a uniform 
or  cylindrical,  and  not  a cystic  dilatation ; though 
sometimes  one  part  of  the  wall  will  yield,  and  so 
cause  a diverticulum  or  sacculus.  These  uniform 
and  cylindrical  dilatations  may  occur  in  all  the 
tubes  of  the  body.  They  are  met  with  in  the 


Sri  DILATATION. 

oesophagus  and  all  parts  of  the  digestive  canal,  in 
the  heart,  veins,  bladder,  ureters,  bile-ducts,  &c. 
This  form  of  dilatation  may  be  attended  either 
with  thickening  and  hypertrophy,  or  with  thin- 
ning and  atrophy  of  the  walls.  Usually,  when 
the  tubes  are  in  the  main  muscular,  hypertrophy 
occurs,  from  increased  exercise  of  the  muscular 
fibres  in  their  efforts  to  overcome  the  obstruction ; 
but  when  the  walls  are  mainly  fibrous  or  elastic, 
they  generally  become  atrophied  and  thinned. 

3.  Compensatory  or  collateral  dilatation. — An- 
other form  of  dilatation  from  increased  internal 
pressure  may  be  termed  compensatory  or  colla- 
teral dilatation;  it  is  produced  by  the  tubes 
having  to  transmit  an  increased  quantity  of 
fluid  in  consequence  of  the  obstruction  of  other 
channels.  Besides  the  blood-vessels,  we  may 
meet  with  examples  of  compensatory  dilatation 
in  one  ureter  when  the  other  is  blocked,  and  in 
the  bronchial  tubes  and  other  parts.  Resembling 
this  form  in  its  mode  of  origin  is  the  dilatation 
caused  by  tubes  having  to  transmit  substances 
of  too  large  a calibre,  as,  for  example,  in  the  pas- 
sage of  calculi  down  the  gall-duct  and  ureters. 

i.  Dilatation  from  changes  in  the  walls. — The 
last  class  of  dilatations  consists  of  those  due  to 
diminished  power  of  resistance  in  the  walls  of 
the  tubes  or  cavities.  The  most  important  ex- 
amples of  this  class  occur  in  the  circulatory  and 
respiratory  systems ; in  the  heart  from  fatty 
degeneration ; in  the  arteries  from  atheromatous 
changes.  In  the  respiratory  organs  it  occurs 
both  in  the  bronchial  tubes  and  in  the  air-cells. 
Here,  however,  the  loss  of  resisting  power  is 
itself  usually  caused  by  prolonged  increased 
pressure  from  within  ; which  in  the  air-cells,  as 
their  walls  are  elastic  and  not  muscular,  rapidly 
causes  atrophy,  and  subsequent  dilatation. 

W.  Cayley. 

DILUENTS  ( diluo , I wash  or  dilute). 

Definition. — Remedies  which  increase  the 
proportion  of  fluid  in  the  blood. 

Enumeration. — Water  is  the  only  real  diluent. 
It  is  given  for  this  purpose  in  various  forms — 
soups,  ptisans,  barley  water,  toast  and  water, 
milk,  lemonade,  aerated  waters,  &c. — to  quench 
thirst,  and  increase  secretion. 

Uses. — Diluents  are  employed  to  lessen  thirst, 
as  in  fever  and  diabetes.  As  the  thirst  may 
depend  upon  local  dryness  of  the  throat,  as  well 
as  upon  general  want  of  fluid  in  the  system, 
the  power  of  water  to  quench  thirst  may  be 
greatly  increased  by  adding  to  it  a little 
vegetable  or  mineral  acid,  or  some  aromatic, 
such  as  lemon  or  orange  peel,  which  will  stimu- 
late the  flow  of  saliva,  and  thus  tend  to  keep  the 
mouth  moist  after  the  liquid  itself  has  been 
swSHowed.  The  thirst-quenching  power  of 
water  is  also  aided  by  the  addition  of  mucila- 
ginous substances,  such  as  oatmeal,  or  linseed 
as  linseed-tea,  which,  leaving  a mucilaginous 
coat  on  the  inside  of  the  mouth  and  pharynx, 
retard  evaporation,  and  thus  lessen  the  dryness 
of  the  mucous  membrane. 

T.  Lauder  Brunton. 

DIPHTHERIA  (Sup 9lpa,  a skin). — Synon.  : 
fir.  diphtheric,  diphtherite ; Ger.  Diphthcritis. 

Definition. — A specific,  contagious,  asthenic, 
general  disease,  which  sometimes  prevails  as 


DIPHTHERIA. 

an  epidemic,  and  is  endemic  in  certain  places. 
It  is  characterised  by  the  exudation  in  varioui 
situations — particularly  on  the  mucous  surface 
of  the  soft  palate,  uvula,  tonsils,  pharynx, 
larynx,  and  trachea — of  a peculiar  cacoplastic 
lymph,  which,  together  with  epithelial  cells, 
generally  forms  a thick,  tough,  and  stratified 
pellicle  or  false-membrane — a stroma  made  up 
of  mucous  and  epithelial  cells,  arranged  in  layers 
of  the  cacoplastic  exudation. 

Name  and  Synonyms. — In  1826,  Bretonneau 
of  Tours,  in  his  work,  entitled  Itccherches,  §c. 
sar  la  Diphtherite,  created  the  name,  and  first 
pointed  out  the  true  pathology  of  the  disease. 
In  his  latest  memoir  (1855)  he  substituted  the 
term  diphtherie  for  diphtherite,  having  dis- 
covered that  the  disease  is  not  of  an  inflamma- 
tory character.  Diphtheria  was  a word  almost 
unknown  in  English  medical  literature  till  1859, 
when  the  Sydenham  Society  published  a volume  of 
memoirs  on  the  disease,  translated  by  Dr.  Semple 
from  the  French  of  Bretonneau  and  others.  The 
name,  slightly  modified,  has  now  been  appro- 
priated by  all  European  languages ; and  at  pre- 
sent there  is  no  other  word  which  can  correctly 
be  said  to  be  synonymous  with  it,  although  it  is 
equally  true  that  the  disease  diphtheria  has  been 
described  under  many  names,  without,  however, 
an  exact  appreciation  of  its  distinctive  character, 
by  Hippocrates,  Celsus,  Sydenham,  and  others, 
from  the  dawn  of  medical  history  to  the  present 
day.  ‘ Croup,’  in  cases  named  and  described  by 
Home,  Cheyne,  West,  and  others,  is  identical 
with  Bretonneau’s  ‘ croup,’  which  he  also  calls 
tracheal  and  laryngeal  diphtheria;  but,  never- 
theless, croup  and  tracheal  diphtheria  being  de- 
scribed by  the  majority  of  British  authors  as 
different  diseases  are  not  in  a literary  sense 
synonyrmous  terms. 

Geographical  Distribution. — Epidemics  of 
diphtheria  have  occurred  in  many  countries  far 
apart  from  one  another,  and  differing  essentially 
in  physical  features  and  climate.  In  recent 
years  the  geographical  distribution  of  the  dis- 
ease seems  to  have  become  greatly  extended,  a 
circumstance  which  is  probably  attributable  to 
the  increasing  intercommunication  of  peoples. 
Diphtheria  has  its  favourite  localities — localities 
in  which  it  is  always  endemic,  and  frequently 
epidemic.  Among  such  places  may  be  parti- 
cularly mentioned  Florence  and  Paris. 

Aetiology. — The  disease  is  contagious.  Apart 
from  endemic  and  epidemic  causes  affecting  its 
maintenance  in  foci,  and  its  outbursts  at  par- 
ticular times  and  in  particular  places,  there  are 
aetiological  influences  belonging  to  individuals  in 
respect  to ; — 

1.  Accidental  Predisposing  Causes  ; 

2.  Age  ; and 

3.  Heredity. 

1.  Accidental  Predisposing  Causes. — Poverty 
and  its  concomitants — unventilated  filthy  lodg- 
ings, scanty  clothing,  and  imperfect  alimentation 
— impart  to  individuals  a receptivity  for  the 
contagium  of  diphtheria.  A similar  receptivity 
exists  in  tuberculous  persons  and  in  all  cachectic 
subjects.  Scarlatina,  measles,  and  whooping- 
cough  peculiarly  predispose  to  diphtheria.  In 
twenty  years,  Barthez  observed  605  eases  of 
scarlatina ; in  95  of  them,  that  is,  once  in  about 


DIPHTHERIA.  Wa 


every  six  cases,  diphtheria  occurred  as  a secondary 
disease.  Diphtheria  of  the  air-passages  may 
occur  also  as  a secondary  disease  after  a common 
inflammatory  sore-throat,  a circumstance  -which 
has  led  some  to  hold  that  diphtheria  is  an  in- 
flammatory disease.  Recently-delivered  women 
receive  easily  the  diphtheritic  poison.  During 
epidemics  the  influence  of  the  predisposing 
causes  now  enumerated  is  sometimes  strikingly 
exemplified. 

2.  Age. — Diphtheria  is  most  common  between 
the  ages  of  two  and  ten.  Few  persons  are 
attacked  after  thirty  ; but  there  are  occasional 
victims  at  all  ages,  from  the  earliest  infancy  to 
old  age. 

3.  Heredity. — Diphtheria  is  not  an  hereditary 
disease  ; but  a special  aptitude  to  receive  and 
develop  the  poison  evidently  pertains  to  certain 
individuals  and  families.  This  statement  is  borne 
out  by  the  statistical  enquiries  of  Morelli,  Nesti, 
and  .others  in  relation  to  the  recent  epidemics  of 
Florence ; but  the  facts  which  establish  it  beyond 
a possibility  of  doubt  are  the  numerous  cases  of 
particular  families  being  desolated  by  diphtheria 
at  intervals  of  years,  and  when  the  members 
attacked  were  widely  separated.  For  example, 
a child  died  this  year  of  diphtheria  in  Paris  : a 
sister  died  of  the  same  disease  two  years  ago  in 
Florence : about  the  same  date,  an  elder  brother 
similarly  perished  at  the  Cape  of  Good  Hope : 
and  the  mother  of  these  children  was  in  child- 
hood nearly  carried  off  by  the  same  disease. 
Family  histories  of  this  kind  are  so  numerous, 
as  to  lead  to  the  conclusion  that  there  is  often  a 
certain  stamp  of  similarity  of  constitution  per- 
vading a family,  in  virtue  of  which  its  members 
are  specially  disposed  to  receive  and  develop  the 
diphtheritic  contagium. 

Natueal  Couuse. — Diphtheria  has  a tendency 
to  run  a definite  course,  as  may  bo  well  seen  in 
cases  which  are  benignant  or  of  moderate  severity. 
In  the  cases  termed  benignant  by  authors — 
cases  more  numerous  in  some  epidemics  than 
in  others,  and  commonly  met  with  at  the  begin- 
ning and  decline  of  most  epidemics — the  disease 
runs  its  entire  course  in  from  eight  to  ten  days. 
In  this  class  of  eases  complete  and  rapid  recovery 
often  takes  place,  not  only  without  medical 
treatment,  but  also  in  spite  of  the  most  objec- 
tionable measures  having  been  adopted.  In 
many  benignant  cases  the  exudation  is  limited 
to  the  tonsils  and  pharynx,  but  sometimes  it  in- 
vades the  larynx  and  trachea : nevertheless, 
under  both  circumstances,  the  false-membrane 
begins  to  loosen  spontaneously,  and  to  be  got  rid 
of  between  the  fifth  and  seventh  day.  In  cases 
of  very  malignant  type — both  in  those  which 
set  in  suddenly  with  intense  symptoms,  and  in 
those  which  begin  insidiously — the  disease  may 
run  its  course  from  health  to  death  in  less  than 
one  day,  or,  according  to  the  greater  or  less 
severity  of  the  poisoning,  the  fatal  issue,  or  the 
dawn  of  recovery,  may  not  occur  for  several 
days. 

Incubation. — There  is  a great  diversity  of 
opinion  as  to  the  maximum  period  of  incuba- 
tion ; but  the  general  opinion  is  that  it  does 
not  exceed  a few  days.  There  are  facts  and 
reasonings,  however,  which  suggest  the  pos- 
sibility of  the  diphtheritic  poison  remaining 


dormant  in  the  system  for  weeks  or  months,  till 
called  into  activity  by  favouring  circumstances. 

Invasion. — The  invasion  of  the  disease  is  gene- 
rally occult  and  insidious.  Slight  fever,  drowsi- 
ness, general  discomfort,  a little  languor,  loss  of 
appetite,  prostration,  diarrhoea,  rigors,  pallor, 
tickling  cough,  husky  voice,  and  hoarseness, 
often  usher  in  diphtheria;  but  as  these  symptoms, 
separately  or  in  conjunction,  may  occur  in  children 
from  a multiplicity  of  causes,  they  assist  in  form- 
ing a diagnosis  only  when  carefully  studied  in 
conjunction  with  one  another,  and  with  surround- 
ing circumstances.  It  is,  therefore,  very  difficult 
in  most  cases  to  fix  the  exact  date  of  the  com- 
mencement of  the  disease.  Three  or  four  days 
may  be  passed  without  the  manifestation  of 
characteristic  signs,  the  patient  during  that 
time  presenting  no  marked  indications  of 
seriously  deranged  health.  The  invasion- 
symptoms  are  sometimes  so  slight  as  entirely 
to  escape  notice.  Tho  disease  may  suddenly 
explode,  without  the  smallest  warning,  by  ait 
attack  of  stridulous  breathins ; on  looking 
into  the  throat  we  may  then  find  false-mem- 
brane covering  the  tonsils  and  pharynx,  and 
extending  into  the  air-passages,  so  as  dan- 
gerously to  obstruct  the  passage  of  air  into 
the  lungs,  and  excite  spasmodic  exacerbations  of 
dyspnoea.  Sometimes,  on  the  first,  second,  or 
third  day  of  the  disease,  the  patient  is  carried 
off  before  any  exudation  has  taken  place,  the 
patient  dying  in  a state  of  profound  prostration 
from  primary  toxaemia.  The  diphtheritic  poison 
sometimes  kills  without  producing  the  diphthe- 
ritic pellicle. 

Symptoms. — The  symptoms  of  diphtheria  are 
general  and  local. 

The  general  symptoms  of  pharyngeal,  laryngeal, 
and  tracheal  diphtheria  are  those  of  the  general 
specific  disease  of  which  they  are  local  manifes- 
tations. Wherever  the  false  membrane  is  situ- 
ated— whether  on  the  tonsils,  pharynx,  larynx, 
trachea,  bronchial  tubes,  nares,  eyelids,  vulva, 
vagina,  uterus,  anus,  or  on  a wound,  ulcer,  or 
cutaneous  abrasion — its  nature  is  the  same. 
The  general  symptom  never  absent  is  prostra- 
tion of  strength : the  local  symptom  absent  only 
in  a very  few  exceptional  cases  is  the  formation 
of  false-membrane.  The  other  symptoms  of  most 
importance,  but  which  are  more  or  less  fre- 
quently absent,  are  albuminuria,  change  of  tem- 
perature, cutaneous  eruptions,  enlarged  glands, 
and  paralytic  affections. 

1 . Prostration  of  Strength. — This  is  a constant 
symptom,  but  its  degree  is  very  variable.  Some 
patients  succumb  to  the  primary  shock  of  the 
poison.  In  rapidly  fatal  cases,  however,  there  are 
degrees  of  rapidity — there  is  a gradation  of  cases 
from  those  in  which  death  takes  place  in  less 
than  a day  without  any  characteristic  sign 
except  prostration,  to  others  in  which  time  is 
afforded  for  the  formation  of  false  membrane, 
and  the  development  of  some  or  all  of  the  symp- 
toms mentioned  above. 

2.  Formation  of  False-Membrane. — There  ig 
always  an  exudation  of  false-membrane  unless 
the  patient  be  cut  off  before  there  has  been 
time  for  its  formation.  The  nature  of  the  falso- 
membrane  has  been  already  briefly  described  in 
the  definition  of  diphtheria.  Its  existence  is 


DIPHTHERIA. 


376 

sometimes  not  discovered  during  life  ; as,  for 
example,  in  those  rare  cases  in  which  the  exuda- 
tion commences  on  the  lining  of  the  bronchial 
tubes,  and  occasions  death  by  asphyxia  before  it 
has  extended  upwards  to  visible  parts.  As  a gene- 
ral rule — with,  however,  about  two  per  cent,  of 
exceptions — the  exudation  begins  on  the  tonsils 
or  pharynx,  and  next,  but  not  always  in  con- 
tinuity, on  the  larynx.  From  one  to  five,  six, 
or  even  seven  days  may  elapse  between  the  first 
appearance  of  false-membrane  and  its  exudation 
on  the  mucous  membrane  of  the  larynx. 

3.  Albuminuria. — Albuminuria  is  very  com- 
monly met  with.  The  third  and  fourth  days  of  the 
disease  are  the  most  usual  for  the  first  appear- 
ance of  this  symptom;  hut  it  may  occur  on  any 
day  from  the  second  to  the  twelfth  without  the 
occurrence  being  considered  unusual.  It  is  some- 
times permanent  for  days,  and  sometimes  con- 
tinues for  weeks  after  convalescence  has  begun.  Its 
duration  is  from  one  to  sixty  days.  It  is  often 
intermittent,  and  still  more  frequently — without 
quite  ceasing — its  intensity  varies  at  different 
periods  of  the  twenty-four  hours.  It  does  not 
necessarily  indicate  a morbid  state  of  the  kidney, 
and — unlike  the  albuminuria  of  scarlatina — it  is 
not  associated  with  dropsy.  It  originates  in 
different  causes,  which  sometimes  operate  sepa- 
rately or  in  combination.  Probably  the  chief 
causes  are  the  rapid  waste  of  tissue  and  the 
altered  state  of  the  blood,  which  are  very  early 
effects  of  the  poisou  of  diphtheria ; there  conse- 
quently arises  a sudden  necessity  for  an  enor- 
mous discharge  of  effete  matter  by  the  kidneys. 
Another  cause,  one  likewise  almost  always  in 
existence,  is  the  ingestion  of  aliment  much  in 
excess  of  assimilative  power;  the  intermittent 
character  of  this  cause  is  probably  the  explana- 
tion of  the  frequently  intermittent  character  of 
the  albuminuria.  A pulmonary  cause  of  albu- 
minuria frequently  comes  into  operation,  as  in 
pneumonia,  and  during  the  death-agony  from  all 
diseases.  Obstruction  of  the  air-passages  by 
false-membrane  induces  albuminuria  by  produc- 
ing great  congestion  of  the  lungs  with  more  or 
less  asphyxia.  Finally,  a renal  cause  may  occa- 
sionally exist  in  pre-existing  disease  of  the 
kidneys  ; or,  secondarily,  in  their  simple  conges- 
tion from  the  strain  of  the  extra-work,  and  their 
functional  feebleness  through  general  deficiency 
of  innervation.  The  proportion  of  cases  in 
which  albuminuria  occurs  for  one  or  more  days 
is  about  one  in  three  cases  ; but  the  proportion 
is  different  in  different  epidemics.  Albuminuria 
is  not  a sign  of  danger  ; its  prognostic  signi- 
ficance belongs  not  to  itself,  but  to  its  cause  or 
causes. 

4.  Changes  of  Temperature. — High  tempera- 
tures prognosticate  danger;  but  moderate  or  even 
normal  temperatures  areoften  met  with  in  rapidly 
fatal  cases. 

6.  Cutaneous  Eruptions. — Eruptions,  varying 
much  in  appearance,  are  sometimes  seen  in  the 
course  of  diphtheria.  They  seldom  continue  more 
than  three  days,  and  are  sometimes  visiblo  for 
only  a few  hours.  If  the  eruptions  themselves 
were  the  only  guides  to  diagnosis,  the  malady 
might  be  often  mistaken  for  scarlatina.  The 
eruptions  cf  diphtheria  which  simulate  those  of 
scarlatina  are  sometimes  vesicular,  sometimes 


like  urticaria,  and  sometimes  they  occur  m bright 
red  patches — rubeolar,  roseolar,  or  erythematous. 
They  are  not  followed  by  desquamation,  as  in 
scarlatina.  The  appearance  or  non-appearance 
of  these  eruptions  does  not  influence  the  prognosis. 
Ecchymoses  due  to  blood-poisoning  may  also 
occur,  and  are  of  course  of  very  serious  import.. 

G.  Enlarged  Glands. — Glandular  engorgement 
is  often  one  of  the  earliest  indications  of  diph- 
theritic poisoning.  It  is  not  a secondary  result 
of  the  throat-manifestation,  but  belongs  to  the 
general  disease  itself.  In  the  recent  epidemics 
of  Florence,  described  by  Morelli  and.  Nesti. 
turgeseenee  of  the  cervical  glands  is  mentioned 
as  a symptom  commonly  associated  with  general 
anasarca,  and  an  eruption  of  red,  pink,  and  dark 
red  points  on  the  face,  neck,  chest,  and  abdomen. 
This  eruption  was  sometimes  visible  for  only  a 
few  hours,  and  never  for  more  than  three  days. 

7.  Paralytic  Affections.— This  important  sub- 
ject is  only  named  in  this  its  natural  place,  its 
consideration  being  more  conveniently  reserved 
for  a separate  article.  See  Paralysis,  Diph- 
theritic. 

Diagnosis. — "When  diphtheria  has  proved  fatal 
too  soon  to  afford  sufficient  time  for  the  mani- 
festation of  its  characteristic  symptoms  ; and 
also,  when  the  invasion-stage  is  insidious,  the 
diagnostic  difficulties  are  great.  Sanne  believes 
that  the  affection  designated  ‘ throat-herpes  ’ 
( herpes  guttural ) by  Gubler  is  a form  of  diph- 
theria, an  opinion  which,  if  erroneous,  is  not 
easily  controverted.  The  difficulty  of  the  dif- 
ferential diagnosis  fully  explains  an  opinion, 
repeated  by  several  authors,  to  the  effect  that 
the  diphtheritic  nature  of  an  affection  cannot 
be  declared  with  certainty  till  the  membranous 
deposit  has  been  seen  to  extend  from  the  tonsils 
and  pharynx  to  the  respiratory  passages.  Some 
physicians,  among  whom  is  Trousseau,  think  that 
the  herpetic  nature  of  the  affection  is  estab- 
lished when  an  eruption  of  herpes  appears  on 
the  lips.  Sanne  says:  ‘Diphtheria  commences 
with  local  phenomena  which  are  very  varied : the 
form  and  disposition  of  the  false-membrane  are 
insufficient  to  enable  us  to  predict  the  nature  of 
the  malady,  or  to  form  a prognosis  regarding 
it.’  He  adds,  and  with  truth,  if  the  statement 
be  accepted  only  as  a provisional  clinical  fact: 
‘ This  is  one  of  the  most  important  aphorisms 
in  the  doctrine  of  diphtheria.’  Pathologically, 
however,  there  can  he  no  diagnostic  difficulty  in 
these  eases  if  it  be  true,  as  an  increasing  number 
of  physicians  believe,  that  membranous  sore- 
throat  is  always  diphtheritic. 

Prognosis. — The  younger  the  subject,  the  less 
are  the  chances  of  recovery.  This  arises  from 
two  causes,  viz.,  the  smaller  power  in  infancy  to 
resist  depressing  influences ; and  the  narrowness 
of  the  larynx  in  infancy  and  childhood.  The 
elements  of  prognosis  belong  in  part  to  the  in- 
dividual case;  and  are  in  part  common  to  all 
the  cases  occurring  at  the  same  time  and  place. 

First,  in  respect  to  the  individual  element 
The  prognosis  is  unfavourable  if  false-membrane 
has  been  deposited,  and  continues  to  be  formed 
on  the  mucous  membrane  of  the  air-passages 
during  the  first  three  or  four  days  of  the  disease : 
on  the  other  hand,  the  prognosis  is  favourable  if 
these  days  be  passed  without  formation  of  false- 


DIPHTHERIA.  377 


membrane  on  the  air-passages ; but  only  pro- 
•risionally  favourable,  for  a sudden  membranous 
invasion  of  the  air-passages  may  occur  during 
that  period.  If  at  the  seventh  day  the  air-pas- 
sages  be  not  invaded,  if  there  be  adequate  cardiac 
power,  and  if  a fair  amount  of  aliment  be  regu- 
larlyassimilated,  the  prognosis  is  very  favourable. 
We  must,  however,  take  into  account  peculiari- 
ties of  constitution,  the  presence  or  absence  of 
disease  prior  to  the  attack  of  diphtheria,  and 
also  the  exact  significance  of  each  symptom  in 
respect  to  its  individual  gravity,  its  grouping 
with  other  symptoms,  and  the  period  of  the 
malady  at  which  the  prognosis  is  made. 

Secondly,  in  respect  to  surrounding  circum- 
stances. In  cold  damp  weather  the  mortality 
is  greatest.  The  medical  constitution  of  the 
season,  and  the  character  of  an  epidemic  greatly 
influence  prognosis.  In  some  epidemics,  in  which 
the  local  manifestation  of  the  disease  is  limited 
to  the  pharynx,  recovery  takes  place  in  nearly 
every  case.  In  an  epidemic  which  prevailed  in 
France  in  1847,  the  mortality  was  91  percent. 
In  the  first  quarter  of  1876  the  mortality  from 
diphtheria  in  the  hospitals  of  Paris  was  79  75 
per  cent.,  whereas  in  the  six  preceding  years  it 
averaged  only  7654  per  cent. 

Anatomical  Characters. — The  lesions  found 
after  death  from  diphtheria  are  primary  and 
secondary.  The  primary  are  those  found  in 
persons  dying  during  the  natural  course  of  the 
disease;  the  secondary  are  not  direct  results  of 
diphtheria,  but  are  consequent  upon  the  compli- 
cations and  retardations  of  abortive  convales- 
cence. 

1 . Primary  lesions. — In  persons  who  die  during 
the  first  two  or  three  days  of  the  disease,  in  whom 
tnere  are  no  complications,  and  in  whom  there 
has  not  been  time  for  the  formation  of  false- 
membrane,  the  only  morbid  appearance  found  on 
dissection  is  sanguineous  congestionof  the  mucous 
membranes,  lymphatic  glands,  and  internal  or- 
gans. In  those  who  live  a few  days  longer,  say 
till  the  seventh  or  eighth  day  of  the  disease,  a 
similar  state  of  congestion  is  met  with  ; and  there 
are  found  on  mucous  surfaces,  particularly'  on  those 
of  the  pharynx,  larynx,  and  trachea,  layers  of  the 
characteristic  pellicle.  The  only  primary  morbid 
appearances  of  diphtheria,  visible  to  the  unaided 
eye,  are  congestion  of  organs,  and  false-membrane 
on  certain  mucous  surfaces.  To  these  has  of 
course  to  be  added  a dyscrasia  of  the  blood,  which 
probably'  exists  from  the  very  beginning  of  the 
attack. 

2.  Secondary  lesions,  which  aro  numerous, 
vary'  according  to  the  nature  and  duration  of 
each  case.  It  is  particularly  noteworthy  that  in 
the  secondary,  ansemia  replaces  tho  hypersemia  of 
the  primary  morbid  conditions. 

To  the  general  statements  nowmade  in  reference 
to  the  morbid  anatomy'  of  diphtheria,  there  are 
numerous  exceptions;  and  as  one  of  the  more 
important  of  them  may  be  specified  pseudo- 
membranous deposits  in  the  bronchial  tubes,  and 
hepatisation  of  the  lungs  occurring  as  early  as 
the  second  or  third  day. 

A brief  sketch  of  some  of  the  secondary  lesions 
of  diphtheria  is  subjoined : — Lymphatic  glands. — 
Tho  submaxillary  and  parotid  are  the  most 
usually  and  the  most  acutely  affected  : next  in 


order  of  frequency  come  the  superficial  cervical 
glands,  the  deep  cervical  glands,  and  the  mesen- 
teric glands.  Glands  sometimes  suppurate:  when 
this  takes  place  the  pus  is  generally  found  in 
small  circumscribed  depots.  They  are  sometimes 
infiltrated  with  a brownish  sero-sanguTnolent 
fluid:  sections  of  glands  so  affected  resemble 
sections  of  the  healthy  spleen.  The  inner  ear. 
— This  is  sometimes  invaded  by  false-membrane, 
extending  from  the  skin  of  the  outer  ear,  or 
advancing  by  the  Eustachian  tube  from  the 
pharynx.  Connective  tissue. — Sanguinolent  and 
sanguineous  effusions  are  sometimes  found  in 
the  connective  tissue,  particularly  in  that  sub- 
jacent to  mucous  membrane  coated  with  the 
diphtheritic  pellicle.  In  it  abscesses  are  also 
met  with,  in  the  contiguity  of  engorged  and 
suppurating  glands.  Muscular  tissue.— In  pro- 
tracted cases  of  paralysis,  the  muscles  of  the 
arms,  legs,  chest,  and  eye-ball  are  often  found 
to  be  more  or  less  in  a state  of  fatty  or  waxy 
degeneration.  The  muscular  tissue  of  the 
heart  is  likewise  sometimes  similarly  affected. 
Lungs. — Besides  the  primary  specific  lesions  we 
may  find  on  dissection  anatomical  evidence  of 
simple  bronchitis,  pneumonia,  and  pulmonary 
apoplexy  having  occurred  as  secondary  affections. 
Trachea. — Cases  have  been  recorded  in  which  the 
trachea  has  been  found  ruptured,  the  result  of  a 
desperate  struggle  for  breath.  In  tracheotomy- 
cases,  the  pressure  of  a badly  adjusted  canula 
has  frequently  caused  ulceration  of  the  trachea. 
The  cicatrisation  of  the  ulcer  sometimes  pro- 
duces stricture  of  the  passage.  Mediastinum. — 
Abscesses  of  the  mediastinum  occasionally  follow 
tracheotomy.  Kidneys. — A form  of  superficial 

parenchymatous  nephritis,  resembling  the  char- 
acteristic lesion  of  scarlatinal  albuminuria,  is  said 
to  be  a common  pathological  condition  in  diph- 
theria. Perhaps  under  the  term  parenchymatous 
nephritis  many  cases  of  simple  hypersemia  are 
included.  The  condition  of  the  kidneys  in  diph- 
theria requires,  however,  further  investigation. 
The  granular  and  other  degenerations  of  the  kid- 
ney described  as  having  been  met  with,  have  pro- 
bably no  peculiar  or  direct  relation  to  the  diph- 
theria. They  may  either  represent  disease  which 
existed  prior  to  the  diphtheritic  attack,  or 
disease  resulting  from  the  general  damage  to  the 
system  induced  by  that  attack,  just  as  it  might 
have  been  produced  by  an  attack  of  some  other 
debilitating,  blood-disintegrating  malady.  Be 
that  as  it  may,  it  is  important  to  note  that  in 
patients  who  die  in  the  first  days  of  an  attack 
of  diphtheria  after  having  had  intense  albumi- 
nuria, the  only  discoverable  morbid  condition  of 
the  kidney  is  moderate  or  considerable  con- 
gestion. Sanne  explains  the  rarity  of  the  oc- 
currence of  cedema  and  cerebral  symptoms  in 
connection  with  diphtheritic  albuminuria  by  the 
fact  that  one  kidney  only  is  affected  and  not  both, 
as  in  scarlatinous  nephritis.  Nervous  system. — 
Even  when  death  has  been  preceded  by  pro- 
tracted paralytic  affections,  the  most  minute 
microscopic  examination  has  generally  failed 
to  detect  any  morbid  change  in  the  encephalon 
or  spinal  cord.  On  the  other  hand,  in  pro- 
tracted cases  of  diphtheritic  paralysis,  various 
alterations  in  the  nervous  periphery  are  fre- 
quently found. 


DIPHTHERIA. 


578 

Pathology. — Diphtheria  is  a poison-disease 
acting  primarily  upon  the  whole  system ; the 
exudation  of  cacoplastic  lymph  is  a manifest- 
ation of  the  general  poisoning,  and  not,  as 
Trousseau  taught,  an  infection  of  the  patient 
by  the  absorption  of  the  poisonous  material  of 
tho  false-membrane.  Gangrenous  decomposi- 
tion of  the  false-membrane  sometimes,  how- 
ever, becomes  a source  of  secondary  toxaemia. 
The  poisoning  is  then  not  diphtheritic ; it  is 
simply  the  result  of  the  absorption  of  putrid 
matter. 

Treatment. — Few  diseases  more  severely  tax 
the  ingenuity  and  therapeutic  resources  of  the 
physician  than  diphtheria.  He  has  to  devise  and 
carry  out  innumerable  little  details — hygienic, 
dietetic,  and  medicinal — which  do  not  admit  of 
minute  description,  and  yet  upon  the  minutiae 
of  which  success  or  failure  frequently  depends. 
Tho  treatment  must  be  carried  out  on  a rational 
basis,  no  special  trust  being  placed  in  nostrums, 
or  in  any  of  the  so-called  specifics  announced  in 
earlier  and  later  times,  and  some  of  which  are 
still  recommended  by  honest  enthusiasts  of 
limited  experience.  It  is  requisite  to  pay  the 
itmost  attention  to  the  hygienic  surroundings  of 
the  patient.  From  the  first  it  is  necessary  that 
decided  and  well-considered  measures  be  carried 
out  to  support  life,  by  the  administration  of 
alcoholic  stimulants  and  of  easily  assimilated 
aliments.  Medicines  which  have  a depressing  in- 
fluence on  the  nervous  system,  or  which  tend  to 
produce  dyscrasia  of  the  blood,  are  to  be  rigidly 
avoided.  Prostration  of  strength  and  dissolution 
of  the  blood  are  conditions  which  exist  to  a 
greater  or  less  degree  in  every  ease  of  diphtheria ; 
and  for  that  reason,  the  abstraction  of  blood, 
purging,  and  the  use  of  alkalies,  mercurials,  and 
sntimonials  are  inadmissible. 

From  first  to  last  sustaining  and  recuperative 
treatment — alimentary  and  medicinal — is  the 
great  aim.  If  life  be  maintained  for  a certain 
number  of  days,  nature,  even  in  very  severe 
cases,  makes  a decided  curative  effort : in  other 
words,  when  the  disease  has  run  its  natural 
course,  there  is  a greater  or  less  attempt  at  spon- 
taneous recovery.  The  moment  has  then  arrived 
when  the  physician  can  most  usefully  intervene 
with  his  culinary  and  pharmaceutical  resources. 
ft  is  his  therapeutic  opportunity.  A somewhat 
varied  and  well-planned  pepsinated  aliment  and 
ferruginous  medication,  which  had  up  to  that 
stage  produced  little  benefit,  will  then  wonder- 
fully assist  nature  in  accomplishing  a cure. 

ifhe  principal  details  of  treatment  may  be 
considered  under  the  following  heads  : — 1.  Hy- 
giene. 2.  Diet.  3.  Stimulants.  4.  Medicines 
administered  internally.  5.  Applications  to  the 
throat  and  air-passages.  G.  Tracheotomy. 

1.  Hygiene. — The  covering  of  the  patientmust 
be  light ; and  yet  such  as  to  prevent  loss  of 
animal  heat.  The  placing  of  one  or  more  caout- 
chouc bags  filled  with  hot  water  under  the  bed- 
clothes, close  to  the  patient,  is  a simple  and  an 
admirable  method  of  keeping  the  body  warm, 
and  of  enabling  the  windows  to  be  opened  from 
time  to  time,  without  risk,  to  relieve  the  dis- 
tressing air-hunger,  when  there  is  obstruction 
of  the  air-passages,  intensified  by  the  close 
atmosphere  of  a badly-ventilated  room.  The 


temperature  of  the  room  ought  to  vary  little,  g 
temperature  of  about  60°  F.  being  maintained. 
The  patient  ought  t/>  bo  carefully  screened  from 
currents  of  air,  care  being  taken  that  free  venti- 
lation is  not  interfered  with.  A thermometer 
and  a steaming  kettle  are  indispensable  in  the 
room  of  the  diphtheritic  patient.  After  tracheo- 
tomy, the  maintenance  of  good  ventilation,  com- 
bined with  an  equal  temperature  and  a warm 
moist  atmosphere,  is  a paramount  necessity ; and, 
in  all  cases,  and  in  every  stage  of  cases  in  which 
there  exists  diphtheritic  sore-throat,  it  is  impor- 
tant, as  a means  of  moderating  the  paroxysms 
of  glotto-pharyngeal  spasm,  that  the  air  inhaled 
be  soft  and  warm,  and  that  the  temperature  be 
equable.  Even  in  the  rare  cases  in  which  throat- 
affection  is  absent,  it  is  the  duty  of  the  physician 
to  take  the  measures  best  calculated  to  secure 
such  an  atmosphere  as  has  now  been  described, 
for  the  disease  may  at  any  moment  manifest 
itself  in  the  air-passages. 

2.  Diet. — Nutriment  is  urgently  demanded; 
but  it  is  useless — nay,  it  is  mischievous — to  push 
attempts  at  alimentation  beyond  very  moderate 
limits,  so  long  as  the  malady  is  in  the  ascendant. 
Assimilation  is  then  very  nearly  at  a standstill, 
as  is  shown  by  the  rapid  emaciation  which  goes 
on,  even  when  large  quantities  of  food  are  being 
put  within  the  patient,  and  likewise  also  by  the 
albumin  which  is  passed  with  his  urine.  The 
albuminous  urine  of  diphtheria  arises  from  dif- 
ferent causes ; but,  speaking  in  general  terms,  it 
is  correct  to  say  that  it  arises  from  no  renal 
lesions,  and  is  the  expression  of  rapid  waste 
of  tissues  and  of  the  non-assimilation  of  food. 
Alimentation  is  the  most  important,  and  also  the 
most  difficult  part  of  the  treatment.  Patients 
— even  intelligent  adults — often  resolutely  refuse 
food,  and  feel  intense  loathing,  excited  by  the 
more  sight  or  mention  of  any  alimentary  sub- 
stance, and  the  food  taken  is  generally  rejected 
at  once  by  vomiting ; or  if  retained  it  is  very 
sparingly  assimilated.  To  press  food  upon  chil- 
dren in  spite  of  their  loathing  of  it  is  generally 
injudicious : to  press  it  upon  them  in  spite  of  their 
struggles  is  sometimes  even  dangerous,  as  the 
excitement  and  resistance  takes  more  strength 
out  of  the  already  prostrate  patient  than  can  be 
compensated  for  byforcibly  administered  aliment. 
We  ought  to  try  quietly  to  get  the  child  to  take 
frequently  small  quantities  of  milk  or  beef-tea ; 
and  when  we  fail,  we  must  give  enemata  of  beef- 
tea  and  brandy. 

The  food  given  to  diphtheritic  patients  ought 
to  contain  pepsine.  The  quantity  administered 
mustof  course  be  proportionate  to  thatof  the  food. 
In  respect  to  the  dose  of  pepsine,  it  is  necessary 
to  remember  that  genuine  British  pejpsina  porci 
is  four  or  five  times  as  potent  a digestive  as 
Boudault’s  pepsine,  the  mixture  generally  pre- 
scribed in  France.  Pepsinated  pills  of  pounded 
raw  beef,  with  a few  teaspoonfuls  of  the  ex- 
pressed juice  of  raw  or  slightly  roasted  beef,  are 
exceedingly  useful  in  keeping  patients  alive  while 
the  disease  is  expending  its  immediately  de- 
structive powers.  When  the  irritability  of  the 
stomach  does  not  forbid  the  trial,  strong  egg- 
flips  may  be  given.  A strong  egg-flip  may  be 
made  by  beating  up  together  one  teaspoonful 
of  concentrated  Swiss  milk,  one  teaspocnful  of 


DIPHTHERIA. 


brandy,  and  two  or  three  teaspoonfuls  of  water. 
To  these  ingredients,  two  grains  of  vepsina  ford 
may  be  added.  Patients  who  have  moderately 
severe  attacks  of  the  disease,  and  convalescents, 
can  generally  take  such  semi-liquid  aliments  as 
panada  and  chicken  puree  [puree  a la  reine]. 
Occasionally,  hut  not  generally,  patients  can 
take  cod-liver  oil.  Milk  ought  to  enter  largely 
into  the  diet  of  diphtheritic  convalescents.  In 
them,  as  in  all  convalescents,  it  is  an  admirable 
mainstay ; hut  there  are  some  few  cases  in  which 
it  does  not  agree. 

3.  Stimulants. — Diphtheritic  patients  emaciate 
rapidly ; and  together  with,  as  well  as  before  the 
loss  of  flesh,  extreme  prostration  occurs.  Under 
such  circumstances,  the  liberal  exhibition  of 
alcoholic  stimulants  is  imperatively  demanded 
as  the  principal,  and  when  food  is  rejected, 
as  the  only  means  of  supporting  life  during  the 
most  critical  period  of  the  disease.  This  great 
crisis  is  not  generally  prolonged  for  more  than  a 
few  days,  but  stimulants  may  require  to  be  more 
or  less  relied  on  for  a long  time.  Sometimes  for 
hours  or  days  it  may  be  impossible  to  give  any- 
thing more  than  stimulants,  of  which  the  best 
are  alcohol  in  some  form,  tea,  coffee,  and  the  juice 
of  meat.  When  all  kinds  of  food  and  stimulants 
excite  nausea  and  vomiting,  it  is  necessary  to 
discontinue  for  a time  nourishing  the  patient  by 
the  mouth.  For  some  hours — for  from  six  to 
twelve  hours — he  must  be  fed  entirely  by  the 
rectum,  so  that  the  stomach  may  have  an  interval 
of  complete  rest.  In  such  cases  it  is  a good 
practice  to  precede  renewed  attempts  at  feeding 
by  the  mouth,  by  one  or  two  doses  of  creasote 
and  oxalate  of  cerium.  Both  can  be  given  in  very 
small  bulk,  which  is  a great  advantage ; and  no 
other  gastro-sedatives  act  less  as  depressants  of 
the  general  system.  The  ordinary  so-called  crea- 
sote of  commerce  is  bad  carbolic  acid,  which,  in 
place  of  allaying,  frequently  excites  nausea  and 
vomiting.  If  pure  creasote  cannot  be  obtained, 
pure  carbolic  acid  may  be  substituted  for  it. 
The  creasote  may  be  given  made  into  pill  with 
breadcrumb  ; and  the  oxalate  of  cerium  either 
in  the  form  of  pill,  or  wrapped  in  moistened 
wafer-paper  as  a pulpy  bolus.  The  proper 
quantity  of  creasote  to  give  at  one  time  is  from 
half  a drop  to  two  drops,  and  of  oxalate  of  cerium 
from  two  to  four  grains.  In  the  twenty-four 
hours  we  may  administer  as  a maximum,  ac- 
cording to  the  age  of  the  patient  and  the  cir- 
cumstances of  the  case,  from  six  to  eight  drops  of 
the  former,  and  from  twelve  to  sixteen  grains 
of  the  latter.  Of  the  crystals,  liquefied  by  heat, 
one  drop  is  given  in  a tablespoonful  of  thin 
mucilage.  This  may  be  repeated  several  times 
in  the  twenty-four  hours.  When  the  remedies 
now  mentioned  have  failed,  the  nitrate  of  bis- 
muth in  two  or  three  successive  doses  of  ten 
grains  each  may  succeed.  There  are  cases 
in  which  the  nausea  is  so  urgent  a symptom 
that  it  is  impossible,  by  any  medicines,  to  over- 
come it.  We  must  then  trust  entirely  to  the  ap- 
plication of  warm  poultices,  sinapisms,  or  tur- 

rsntine-stupes  to  the  pit  of  the  stomach.  The 
ypodermic  injection  of  morphia,  or  the  adminis- 
tration of  an  enema  containing  hydrochlorato  of 
morphia,  is  another  method  of  allaying  nausea 
and  vomiting,  in  the  gastric  irritability  of  fever 


and  other  diseases,  but  which  is  only  applicable 
in  a limited  number  of  casos  of  diphtheria,  in 
those  cases  in  which  the  asphyxia  is  far  advanced 
and  is  advancing.  The  quantity  of  hydrochlorate 
to  be  administered  in  clyster  depends  much  on  the 
age  of  the  patient.  Sixty  drops  of  the  Liquor 
hydrochloratis  morphiae  of  the  British  Pharma- 
copoeia may  be  given  by  the  rectum  to  an  adult, 
while  from  five  to  tea  drops  is  a sufficient  dose 
in  clyster  for  a child  under  ten  years  of  age. 
Besides  allaying  nausea  and  vomiting,  such  a 
clyster  soothes,  diminishes  the  severity  of  spas- 
modic dyspnoeal  paroxysms,  and  gives  the  sufferer 
rest. 

4.  Medidnes  administered  internally  are  usu- 
ally employed  either  to  accomplish  some  parti- 
cular object ; or  to  exercise  a curative  influence 
on  the  general  disease. 

There  is  another  special  object  for  which  in- 
ternal medicines  are  given,  namely,  the  detach- 
ment and  expulsion  of  false  membranes  from  the 
air-passages.  For  this  purpose  the  administration 
of  emetics  has  been  considered  by  many  as  one 
of  the  essential  parts  of  the  treatment  of  laryn- 
geal, tracheal,  aud  bronchial  diphtheria.  Their 
use  is  unquestionably  indicated  in  certain  cases, 
yet  the  range  of  their  utility  is  very  limited. 
There  are  two  circumstances  which  obviously 
limit  the  advantages  obtainable  by  emetics;  first, 
if  administered  at  an  advanced  stage  of  the  dis- 
ease, or  at  any  stage  when  there  exists  great 
prostration,  the  vomitive  efforts  excited  must  act 
most  prejudicially  when  they  do  not  produce  the 
desired  result  of  expelling  the  falso-membrane 
from  the  air-passages — they  must  draw  danger- 
ously upon  the  waning  strength  of  the  patient, 
and  diminish  his  chances  of  pulling  through  with 
the  aid  of  tracheotomy.  Herein  lies  a great  limi- 
tation of  the  use  of  emetics,  because  the  cases 
are  exceptional  in  which  the  blockade  of  the  air- 
passages  is  effectually  relieved  by  vomitive  ac- 
tion; and  when  no  such  relief  is  obtained,  the 
violent  efforts  excited  by  emetics  only  produce 
unmitigated  evil — a large  withdrawal  of  remain- 
ing vital  power.  Again,  unless  the  exudative 
stage  of  the  disease  be  endod,  the  ejection  of  false- 
membrano  affords  only  a brief  temporary  respite, 
for  new  layers  are  speedily  deposited  to  replace 
those  which  have  been  thrown  off.  These  con- 
siderations show  the  narrow  limits  within  which 
benefit  can  be  obtained  from  vomitive  action,  and 
how  much  evil  may  accrue  to  the  patient  when 
that  action  is  violent.  Should  it  be  judged  ex- 
pedient to  induce  vomiting,  the  emetic  selected 
ought  to  be  one  which  generally  acts  quickly  and 
certainly,  and  which  if  it  fail  to  act  will  not  pro- 
duce dangerous  irritation  of  the  intestines  or 
great  depression  of  the  system.  Tartar-emetic 
must  not  be  employed.  Sulphate  of  copper,  an 
emetic  much  recommended  by  Trousseau  and 
others  under  the  circumstances  now  being  con- 
sidered, is  also  objectionable,  because  if  it  does 
not  promptly  cause  vomiting,  it  will  be  nearly 
certain  to  excite  enteritis  and  formidable  diar- 
rhoea. Ipecacuap  and  sulphate  of  zinc  are  perhaps 
the  safest  emetics  to  administer  to  a diphtheritic 
patient. 

The  repetition  of  dose  after  dose  of  any 
emetic  is  dangerous  practice  in  diphtheria.  For 
i example,  we  may  give,  without  apparent  effect. 


DIPHTHERIA. 


380 

successive  doses  to  a semi-asphyxiated  patient 
whose  functional  life  is  dormant ; and  seeing  that 
we  give  him  no  relief  in  the  way  hoped  for,  we 
proceed  as  our  last  chance  of  saving  him  to 
admit  air  into  the  lungs  by  tracheotomy.  Forth- 
with the  vital  powers  awake,  and  the  accumulated 
doses  speedily  act  with  violence — the  patient  has 
been  saved  by  tracheotomy  only  that  he  may  die 
of  pharmaceutical  poisoning. 

Dr.  Sannd  ( Traite  de  la  Diphtheric,  Paris, 
1877)  suggests  that  the  recently  discovered  medi- 
cine apomorphia  might  be  tried  as  an  emetic  in 
diphtheria.  It  possesses  properties  which  seem 
to  recommend  it  very  specially  in  this  disease. 
This  drug  is  administered  hypodermically.  It 
acts  very  rapidly — in  from  three  to  five  minutes : 
and  supersedes  or  greatly  reduces  the  duration  of 
the  period  of  nausea.  It  frequently  succeeds  when 
other  emetics  have  failed  to  act.  The  advantages 
which  it  possesses  are,  therefore,  facility  of  ad- 
ministration, rapidity  of  action,  and  less  fatigue 
to  the  patient.  The  only  objection  to  its  general 
use  is  the  difficulty  of  preserving  it.’ 

Another  suggestion  of  Dr.  Sanne  is  noteworthy. 
He  proposes  that  trial  be  made  of  jaborandi, 
given  internally,  as  a means  of  producing  de- 
tachment of  the  false  membrane. 

The  medicines  which  have  a curative  influence 
on  the  general  disease  are  few  in  number.  Cer- 
tain medicines — preparations  of  iron,  for  example, 
are,  under  certain  circumstances,  particularly 
useful  in  diphtheria. 

Of  the  medicines  which  have  had  in  their  day 
repute  as  specifics,  or  as  agents  of  high  thera- 
peutic value,  but  have  now  nearly  ceased  to  be 
so  esteemed,  a few  may  be  briefly  mentioned. 
Bromine  and  its  compounds,  sulphuret  of  potash, 
copaiba  and  cubebs,  chlorate  of  potash,  sulphite 
of  soda,  chloride  of  sodium,  carbolic  acid,  sali- 
cylic acid,  chlorodyne,  calomel,  quinine,  per- 
chloride  of  iron,  and  many  other  medicines, 
have  all  been  proclaimed  as  specifics,  or  at  least 
as  wonderfully  potent  in  the  cure  of  diphtheria. 
Perchloride  of  iron  has  a decidedly  beneficial 
action  under  certain  circumstances ; but  this 
action  it  possesses  in  common  with  other  pre- 
parations of  iron.  It  neither  arrests  nor  modifies 
the  character  of  the  malady  in  its  early  and  most 
perilous  stages ; but  its  utility  is  unquestionable 
as  an  adjuvant,  when,  in  the  natural  course  of 
the  disease,  a spontaneous  curative  tendency  has 
begun  to  manifest  itself. 

6.  Applications  to  the  Throat  and  Air-passages. 
— With  a view  todetach,  dissolve,  or  destroy  false- 
membrane,  a greatdiversityof  topicalapplications 
have  been  employed.  Trousseau,  and  those  who 
wrote  underhis  inspiration,  stronglyreeommended 
destruction  of  the  false-membrano  by  various 
caustics  and  solvents.  In  the  (1868)  edition  of 
his  Clinical  Lectures  which  was  in  the  press  at 
the  time  of  his  decease,  Trousseau  insists  that 
the  topical  treatment  is  pre-eminently  the  best 
treatment  of  diphtheria,  adding  that  it  is  as 
much  indicated  in  this  disease  as  in  malignant 
pustule.  Fortunately  this  doctrine  is  no  longer 
in  vogue,  and  when  topical  treatment  is  still  em- 
ployed in  France,  it  is  now  seldom  by  caustics 
or  any  irritating  substances.  Sanne,  writing  in 
1877,  expresses  the  general  sentiment  of  French 
physicians  when  he  says : — ‘ Cauterization  is  now 


generally  abandoned  : it  has  serious  drawbacks : 
it  is  dangerous : it  is  useless.’ 1 The  practice  of 
attempting  to  destroy  the  false  membrane  by 
caustics  and  powerful  solvents  is  unquestionably 
mischievous.  It  irritates  the  parts  and  increases 
the  exudative  tendency.  The  free  application  of 
the  officinal  glycerine  of  borax,  by  means  cf  a 
camel’ s-hair  brush,  is  at  least  harmless,  and  seems 
to  loosen  the  membranous  patches.  Frequently 
washing  out  the  mouth  with  this  preparation, 
diluted  with  from  four  to  eight  parts  of  water,  is 
agreeable  to  most  patients,  and  is  useful  from  the 
local  soothing  which  it  produces.  A very  dilu- 
ted solution  of  hydrochloric  acid  is  equally 
innocuous,  and  as  a mouth-wash  is  pleasant  and 
cleansing.  Lime-water  and  lactic  acid,  used 
separately  or  mixed,  exercise  a powerful  solvent 
action  on  the  false-membrane  ; and  were  it  pos- 
sible to  apply  them  to  it  without  their  coming 
in  contact  with,  and  thereby  irritating  the  con- 
tiguous mucous  surface,  they  might  be  used  with 
advantage,  or  at  least  with  impunity.  A small 
quantity  of  lactic  acid  added  to  an  aqueous  solu- 
tion of  pure  glycerine  or  to  the  glycerole  of 
borax  — one  part  to  fifty  of  glycerine  — is  a 
favourite  topical  application  with  some  practi- 
tioners, and  is  one  which  may  be  used  without 
fear  of  doing  any  harm.  Catheterism  of  the 
larynx,  and  injection  of  solvents  into  the  trachea, 
are  now  generally  looked  upon  as  objectionable 
measures.  They  still  have,  however,  their  advo- 
cates. Dr.  Young  of  Florence  states,  as  the  result 
of  large  experience,  that  he  has  seen  much  benefit 
result  from  throwing  into  the  throat  every  hour, 
by  means  of  a ball  sprav-apparatus,  a solution- 
of  three  drachms  of  lactic  acid  in  eight  ounces  of 
lime-water. 

Notwithstanding  much  that  has  been  written 
in  a contrary  sense,  a careful  review  of  the 
subject  leads  to  the  conclusion  that  very  little 
advantage  is  derived  from  internal  local  applica- 
tions, that  they  are  often  exceedingly  mischievous,- 
and  ought  never  to  be  used  without  the  greatest 
circumspection.  They  do  not  curtail  or  greatly 
modify  the  natural  course  of  the  general  disease  ; 
and  the  local  benefits  which  they  can  confer  are 
limited  to  soothing  the  parts,  and  slightly  dimi- 
nishing the  obstruction  of  the  air-passages. 
Moist  warmth  applied  externally  to  the  throat 
gives  much  comfort  and  is  in  no  way  injurious. 
Only  soothing,  or  at  least  non-irritating  sub- 
stances are  admissible  as  internal  applications. 
It  must  be  remembered  that  topical  applica- 
tions can  hardly  ever  bo  employed  in  young 
children  without  exciting  resistant  struggles, 
which  agitate  and  exhaust  the  patient.  The  risk 
of  incurring  this  danger  often  forbids  their 
employment. 

6.  Tracheotomy. — Besides  the  perils  of  the 
general  disease — prostrating  toxaemia, difficult  nu- 
trition, and  paralysis  of  the  heart  and  respiratory 
muscles — the  patient  has  the  special  risk  of  dying 
asphyxiated  from  obstruction  of  the  air-passages 
by  false-membrane.  This  terrible  danger  is  one  cf 
very  common  occurrence.  When  nature  and  art 
have  failed  to  remove  or  effectually  lessen  the 
mechanical  impediment  to  the  admission  of  air 
to  the  lungs,  the  physician  has  to  decide  whether 
there  be  anyreason  against  his  giving  the  patient 

1 Sann6:  TraiU  de  la  Diphthiru>  Paris,  1S77  : p.  419 


DIPHTHERIA. 

d chance  of  life  by  making  an  entrance  for  the 
air  below  the  membranous  obstruction.  If  this 
one  remaining  chance  remain  in  any  degree,  how- 
ever small,  he  is  bound  to  offer  it  to  his  patient. 
Sometimes  no  such  chance  remains.  What  con- 
ditions exclude  the  possibility  of  saving  life  by 
tracheotomy?  That  is  the  question.  It  is  not 
whether  the  case  be  a favourable  one  for  opera- 
tion ; for  every  diphtheritic  patient  is  an  ex- 
ceedingly bad  subject  for  any  surgical  operation. 
The  simple  question  is  : — Does  tracheotomy  give 
the  smallest  chance  of  life  to  a patient  who 
without  tracheotomy  must  inevitably  die  from 
asphyxia  ? The  answer  to  this  question  may,  as 
a rule,  be  given  in  the  affirmative,  if  the  obstruc- 
tion be  not  below  the  situation  in  which  tracheo- 
tomy is  performed.  If  this  rule  be  followed,  the 
operation  will  often  be  performed  in  very  despe- 
rate circumstances — circumstances  in  which  the 
probabilities  of  success  are  very  small  compared 
with  those  of  non-success.  When  the  pseudo- 
membranous affection  extends  to  the  bronchial 
tubes — when  pneumonia  exists — when  the  diph- 
theria is  an  immediate  sequel  of  measles,  scarla- 
tina, or  typheid  fever — when  the  asthenia  is  ex- 
treme— or  when  the  patient  is  phthisical — the 
probability  of  the  operation  saving  him  is  small ; 
and  yet,  in  most  unfavourable  examples  of  the 
classes  now  mentioned,  success  has  been  obtained. 

John  Rose  Cobmack. 

DIPHTHERITIC. — Relating  to  diphtheria. 
The  term  is  applied  to  the  membrane  formed  in 
diphtheria ; and  it  is  also  associated  with  certain 
symptoms  occurring  in  the  course  of  the  disease, 
such  as  diphtheritic  paralysis.  See  Croupous. 

DIPLOE,  Diseases  of.  Sec  Sxuix,  Diseases 
of. 

DIPLOPIA  (Snr\doi,  double,  and  otttoucu , 
I see). — Double  vision.  See  Strabismus. 

DIPSOMANIA  (8hJ/a,  thirst;  and  fiavla, 
maduess).  — Stnox.  : Oinomania  ; Fr.  Manie 
ebrieuse,  or  erapuleuse ; Ger.  Trunksucht. 

Definition. — An  irritability  of  tko  nervous 
system,  characterised  by  a craving,  generally 
periodic,  for  alcoholic  and  other  stimulants. 

.Etiology. — This  peculiar  condition  may  be 
brought  on  by  a course  of  intemperate  drinking  ; 
but  it  is  seldom  the  result  of  that  cause  alone, 
and  it  is  not  infrequent  in  persons  who  have 
never  been  intemperate  previous  to  the  develop- 
ment of  the  morbid  craving.  The  occurrence  of 
this  form  of  insanity,  as  of  other  degenerative 
nervous  diseases,  may  generally  be  traced  in  the 
family  history  of  the  patients.  But  sunstroke,  a 
blow  on  the  head,  or  other  direct  injury  to  the 
brain  may  excite  it;  and  it  may  be  symptomatic  of 
epilepsy,  or  of  structural  disease  of  the  brain.  It 
may  be  developed  at  any  period  of  adult  life ; 
but  most  frequently  declares  itself  during  the 
pubescent  and.  climacteric  periods. 

Symptoms. — An  instability  of  character  and 
indications  of  peculiar  nervous  irritability  may 
generally  be  recognised  as  having  preceded  the 
distinct  development  of  the  craving.  It  is  also 
usual  to  find  such  persons  as  are  predisposed  to 
the  disorder  abnormaUy  sensitire  to  the  influence 


DISCRETE.  381 

of  stimulants.  Sometimes  very  small  quantities 
of  alcohol  produce  appreciableintoxieation.  The 
duration  of  the  periods  of  craving  is  variable ; 
but  most  commonly  they  last  one  or  two  weeks. 
The  remissions  continue  for  periods  varying  from 
two  to  twelve  months.  During  the  period  of 
craving  the  whole  moral  being  is  enthralled  by 
the  morbid  desire  ; and  the  regard  for  truth, 
decency,  or  duty  is  generally  altogether  lost. 
Moderate  indulgence  in  a stimulant  may  bring 
on  the  morbid  craving ; but  the  desire  is  fre- 
quently developed  without  any  such  introduction. 
Members  of  the  household  in  which  a patient 
lives  can  indeed  often  recognise  the  indications 
of  a coming  attack  by  a restlessness  and  depres- 
sion which  precedes  any  such  indulgence.  During 
the  intervals  the  patient  seems,  except  when 
the  brain  has  been  weakened  by  frequent 
attacks,  to  recover  completely ; and  he  gene- 
rally displays  great  confidence  in  his  ability  to 
resist  the  tendency  in  future.  Repeated  attacks 
always  produce  a permanent  degradation,  both 
intellectual  and  moral ; and  if  the  patient  live 
long  enough  he  lapses  into  a state  of  dementia. 
It  sometimes  happens  that  some  cerebral  lesion, 
of  which  the  dipsomania  had  been  symptomatic, 
manifests  itself  in  paralytic  or  convulsive  symp- 
toms ; and  the  appearance  of  such  phenomena 
is  often  accompanied  by  a modification  of  the 
craving. 

Diagnosis. — True  dipsomania  may  easily  be, 
and  often  is,  confounded  with  mere  habitual 
drunkenness.  In  dipsomania,  however,  there  is, 
as  a fundamental  condition,  a pathological  con- 
dition of  the  brain  which  manifests  itself  irre- 
spective of  external  circumstances  of  temptation. 
In  habitual  drunkenness  the  craving  consists 
mainly  in  a desire  to  keep  up  a condition  of 
stimulation  to  which  the  brain  has  become 
accustomed.  The  habit  is  the  result  merely  of 
compliance  with  a vicious  custom,  and  there  is 
no  such  periodicity  or  independence  of  external 
influences  in  the  symptoms  as  is  found  in  the 
true  disease. 

Treatment.  — Prolonged  abstinence  from 
stimulants,  and  adherence  to  the  tonic  regimen, 
are  the  only  measures  from  which  any  ameliora- 
tion can  be  hoped  for.  It  is  seldom  possible  to 
restrain  the  gratification  of  the  craving  without 
seclusion  in  an  asylum  or  ssene  similar  institu- 
tion ; and  even  when  such  compulsory  restraint 
has  been  successfully  enforced  for  a considerable 
period,  the  morbid  tendency  is  seldom  eradicated. 
The  present  state  of  British  law  does  not,  how- 
ever, permit  us  to  confine  either  the  dipsomaniac 
or  habitual  drunkard  unless  something  more  mor- 
bid than  an  abuse  of  stimulants  can  be  alleged. 
And  it  is  difficult  to  see  how  a law  could  be 
enacted  which  would  be  effectual  without  being 
open  to  serious  abuse.  Public  attention  has, 
however,  been  lately  very  earnestly  directed  to 
the  subject,  and  it  may  be  hoped  that  something 
will  be  done  towards  rendering  efficient  treat- 
ment possible.  John  Sibbald. 

DISCRETE  ( discerno , I separate). — This 
adjective  is  used  in  reference  to  certain  cutaneous 
eruptions  in  which  the  spots  or  pustules  are 
separate  from  each  other;  for  example,  discrete 
small-pox. 


362  DISCUTIENTS. 

DISCUTIENTS  ( discutio , I drive  away). 

Definition. — Local  applications,  which  are 
supposed  to  romove  the  congestion  and  effusion 
of  inflamed  parts,  and  the  swelling  of  the  skin 
over  them. 

Enumeration. — The  chief  discutient  measures 
or  agents  are: — Friction;  Pressure;  Mercury 
and  its  preparations ; Iodine  and  its  prepara- 
tions, including  the  Iodides  of  Potassium,  Lead, 
and  Cadmium. 

Uses. — These  remedies  are  generally  applied 
over  enlarged  joints,  enlarged  glands,  or  cystic 
tumours.  The  most  powerful  amongst  them  are 
mercury  and  iodine  and  their  preparations,  either 
alone  or  in  combination.  Their  action  is  aided 
by  heat  and  pressure.  The  effect  of  the  former 
is  seen  in  the  Indian  treatment  of  goitre,  which 
consists  in  rubbing  iodide  of  mercury  ointment 
over  the  tumour,  and  exposing  the  patient  to  the 
full  rays  of  the  sun,  or  to  the  warmth  of  a large 
fire.  The  beneficial  effects  of  pressure  are  ob- 
served in  the  diminution  which  takes  place  in 
enlarged  and  swollen  joints  under  the  application 
of  mercurial  ointment  or  strapping,  the  friction 
with  the  hand  in  applying  the  ointment,  and  the 
pressure  exerted  by  the  strapping  greatly  in- 
creasing the  efficacy  of  the  mercurial  preparation 
in  removing  swelling.  See  Feiction. 

T.  Lauder  Brunton. 

DISEASE  (des,  from,  and  aise,  ease). — Fr. 
Maladie;  Ger.  Krankheit. 

Definition. — Disease  may  be  defined  as  a 
deviation  from  the  standard  of  health  in  any 
of  the  functions  or  component  materials  of  the 
body.  See  Pathology. 

The  expression  ‘ a disease  ’ is  frequently  used 
with  reference  to  a supposed  unit  of  causation. 
Thus,  it  may  be  applied  to  some  simple  phe- 
nomenon, for  example,  neuralgia,  when  that  phe- 
nomenon is  the  sole  effect  of  a cause  ; or  it  may 
include  many  concurrent  or  consecutive  resultant 
phenomena,  such  as  those  of  syphilis  or  typhoid 
fever. 

General  Considerations. — It  is  well  known 
that  changes  of  function  and  of  structure  are 
brought  about  and  influenced  by  a great  variety 
of  agencies.  These  agencies,  some  of  which  act 
from  within,  others  from  without,  are  recognised 
as  the  causes  of  disease.  Such  changes,  whether 
they  be  functional,  affecting  more  especially 
the  vital  properties  of  the  body,  or  structural, 
affecting  its  physical  properties,  constitute  what 
is  familiarly  known  as  Disease,  which  is  hence 
called  respectively  functional  or  structural.  These 
changes  are  merely  the  evidence  of  an  altered 
or  perverted  action,  which  is  then  in  operation 
or  has  already  occurred,  the  nature  of  which  is 
considered  under  the  head  of  pathology.  When 
these  deviations  from  health  can  be  recognised 
during  life  they  are  described  as  the  symptoms 
or  signs  of  disease.  For  example,  when  a person, 
after  exposure,  it  may  be  to  wet  or  to  cold,  or 
both,  is  found  to  have  an  increased  t emperature, 
with  a quick  pulse  and  perverted  secretions,  and 
to  complain  of  thirst,  and  pain  at  the  joints  with 
effusion  in  and  around  them,  we  say  that  such 
person  is  labouring  under  disease,  and  we  call  it 
1 rheumatism,’  because  that  name  has  been  as- 
signed to  a complexus  of  deviations  from  health, 


DISEASE,  CAUSES  OF. 
such  as  those  then  presented  by  this  individual. 
When  typhoid  poison  has  been  introduced  into 
the  body,  it  leads  in  like  manner  to  a number  of 
functional  and  structural  changes,  which,  taken 
together,  constitute  what  we  call  ‘ typhoid  fever.’ 
Or  again,  under  certain  circumstances  there  ap- 
pears to  be  generated  in  the  system,  whether  as 
the  result  of  a tendency  acquired  before  birth  or 
by  habits  of  life,  an  agency  which,  acting  morbi- 
fically,  produces  a series  of  phenomena  which  we 
call  ‘ gout.’  These  several  forms  of  disease  may 
be  classified  in  groups,  arranged  in  accordance 
wth  the  causes  which  give  rise  to  them,  their 
nature,  their  seat,  their  duration,  &c.  Rules  are 
laid  down  for  the  modes  of  distinguishing  or 
diagnosticating  one  disease  from  another ; for 
prognosticating , as  far  as  may  be,  their  result; 
and  for  their  prevention  and  treatment. 

Thus  it  comes  that  the  discussion  or  description 
of  any  particular  disease  consists  of  an  account  of 
the  causes  that  give  rise  to  it,  or  its  Etiology  ; 
the  changes  of  structure  or  of  function  which 
constitute  it,  that  is,  its  Anatomical  Characters 
and  Pathology  ; the  phenomena  attending  these 
changes,  otherwise,  the  Symptoms  and  Signs  of 
the  disease ; the  facts  that  serve  to  distinguish 
this  particular  disease  from  other  diseases,  that 
is,  its  Diagnosis  ; the  means  of  forecasting  its 
progress  and  termination,  which  constitute  its 
Prognosis  ; and  finally  the  measures  by  which 
it  may  be  prevented,  relieved  or  removed,  that 
is,  its  Treatment.  Throughout  this  work  the 
various  diseases  are,  as  far  as  may  be  practicable, 
discussed  upon  this  uniform  plan. 

As  thus  understood — and  it  is  well  to  re- 
member it— Disease  is  an  abstraction  or  relation, 
and  not  an  entity  having  a special  and  inde- 
pendent existence.  Physiology  has  in  recent 
days  diffused  a clear  and  penetrating  light  over 
many  of  the  processes  of  life  in  health,  which 
were  previously  dark  and  obscure.  Pathology, 
which  is  physiology  applied  to  the  study  of  un- 
healthy function  and  structure,  anxiously  follows 
the  footsteps  of  the  sister  science.  We  are  there- 
fore not  hoping  and  believing  too  much  when  we 
express  our  conviction,  that  the  time  is  not  re- 
mote when  we  shall  be  able  to  trace  those  eurlv 
and  minute  changes  which  constitute  disease,  and 
the  causes  which  give  them  origin,  and  that  we 
shall  thus  be  enabled  to  define  in  a more  philo- 
sophic and  practical  form  what  disease  really  is. 
In  the  meantime  we  must  be  content  to  work 
upon  the  phenomena  before  us,  to  investigate 
so  far  as  we  can  the  causes  of  disease,  how  to 
recognise  its  presence  and  its  nature,  how  to 
estimate  its  progress  and  its  duration,  and  finally 
how  to  prevent  its  occurrence  or  to  cure  it  when 
it  has  occurred.  These  varied  and  important 
points  will  be  found  discussed  as  above  stated 
under  suitable  headings,  in  the  articles  imme- 
diately following,  and  in  other  parts  of  this  work. 

R.  Quain,  MD. 

DISEASE,  Causes  of.  — Definition.  — 
Whatever  is  capable  of  damaging  the  structure 
of  any  organ  or  t issue  of  the  body,  or  interfering 
with  its  function,  may  be  a cause  of  disease. 
This  definition  implies  that  such  causes  are- 
numerous,  and  that  of  many-  science  is  yel 
ignorant.  To  give  a succinct  account  of  thene 


DISEASE,  CAUSES  OF.  883 


Is  therefore  difficult,  nor  is  this  difficulty  dimi- 
nished by  the  fact  that,  in  most  diseases,  we  can 
trace  a succession  or  combination  of  causes. 

General  Classification.  — The  causes  of 
disease  have  been  divided  into  (1)  Predisposing 
or  Remote,  (2)  Exciting  or  Proximate,  and  (3) 
Determining.  Illustrations  will  explain  what  is 
meant  by  these  terms  : — Two  individuals  are  ex- 
posed to  the  contagion  of  typhus  in  equal  degree; 
one,  wearied  by  bodily  and  mental  labour, 
'catches’  the  disease— that  is  to  say,  his  con- 
dition has  predisposed  him  to  the  exciting  cause 
of  the  malady;  the  other,  in  vigorous  health, 
escapes  the  contagion  — the  exciting  cause  of 
disease.  Predisposition  in  fact  prepares  persons 
by  rendering  them  more  susceptible  to  the  in- 
fluence of  exciting  causes  of  disease.  Many  per- 
sons are  predisposed  to  emphysema  because  of 
hereditary  taint ; in  them  the  air  they  breathe 
is  day  by  day  an  exciting  cause  of  this  disease ; 
they  contract  a bronchitis  which,  by  its  attendant 
cough,  determines  the  malady.  Such  illustrations 
might  be  extended  to  a multitude  of  diseases, 
and  justify  the  division  of  causes  which  the  older 
physicians  made.  Predisposition  may  be  in- 
herited ; or  it  may  be  acquired,  and  be  due  to 
various  accidental  causes.  In  most  cases  there 
is  a combination  of  predisposing  causes  ; in  a 
man,  for  example,  lowered  by  fatigue,  want  of 
food,  and  exposure,  debauch  will  readily  excite 
an  attack  of  bronchitis  or  pneumonia.  Prac- 
tically, it  is  often  difficult  to  say  how  much  is 
due  to  predisposition,  but,  though  many  factors 
unite  in  the  predisposition  to  disease,  it  is  pos- 
sible in  most  cases  to  estimate  the  part  played  by 
each.  See  Predisposition  to  Disease. 

Moreover  it  is  not  always  easy  to  distinguish 
predisposing  from  exciting  causes.  Predispo- 
sition carried  to  excess  becomes  an  exciting 
cause  of  disease,  and  in  many  cases  there  is  a 
combination  of  both.  There  are  certain  distinct 
exciting  causes — for  example,  heat,  cold,  or  in- 
juries of  various  kinds,  but  most  of  these  can 
claim  a predisposing  power.  The  eontagia  of 
the  acute  specific  diseases  and  parasites  are  good 
examples  of  direct  exciting  causes. 

In  proceeding  to  discuss  tne  subject  of  ^Etio- 
logy, no  attempt  will  be  made  to  separate  de- 
finitely predisposing  from  exciting  causes  of 
disease.  The  writer  will  endeavour  rather  to 
indicate  as  far  as  possible  under  the  head  of  each 
factor  of  causation  the  direction  in  which  it 
especially  acts. 

1.  Age. — This  has  a most  important  influence 
as  a predisposing  cause  of  disease.  In  Wagner's 
Manual  of  General  Pathology  the  periods  of  age 
are  thus  subdivided ; — 

(1)  Nursing  age  (infancy) — from  birth  to  7th- 

10th  month. 

(2)  Childhood — from  1st  to  2nd  dentition. 

(3)  Boyhood — from  2nd  dentition  to  puberty. 

(4)  Adolescence — from  puberty  to  20th-25th  year. 

(5)  Early  manhood — from  25th  to  45th  year. 

(6)  Later  manhood — from  45th  to  60th  year. 

(7)  Old  age — from  60th  onwards. 

This  division  is  excellent,  but  in  no  definition 
is  there  more  need  to  look  out  for  exceptions 
than  in  that  of  age.  The  term  age  is  strictly 
comparative ; some  individuals  are  old  at  forty, 
others  young  at  sixty.  Persons  fail  with  regard 


to  particular  organs  w.iile  young  in  years  ; and, 
on  the  other  hand,  others  acquire  an  increased 
power  in  the  same  as  years  advance,  of  which 
the  brain  affords  an  apt  illustration.  The  minor 
organs  of  the  body  betray  the  like  peculiari- 
ties, and  in  the  early  decay  of  the  teeth,  the 
changes  in  the  hair  and  the  skin,  we  meet  with 
indications  of  old  age,  though  the  individuals 
are  young  in  years.  But,  generally,  the  pre- 
dispositions of  the  young  and  old  are  striking 
by  their  contrast.  The  young  are  exempt  from 
fatty  degenerations,  which  are  so  common 
amongst  those  of  advanced  life,  and,  in  conse- 
quence, many  diseases  amongst  them  are,  cateris 
paribus,  less  deadly ; and  not  only  does  age,  by 
reason  of  the  changes  which  naturally  occur 
as  life  goes  on,  predispose  to  disease,  but  all 
outward  conditions  become  changed.  Children — 
speaking  generally — are  apt  to  suffer  from  acute 
catarrhal  affections  of  the  mucous  tracts,  glan- 
dular diseases,  skin-diseases,  tuberculosis  of 
acute  type,  scrofulosis,  and  a variety  of  com' 
plaints  traceable  to  improper  feeding,  bad  ven- 
tilation, overcrowding,  and  to  hereditary  taint 
From  acute  tuberculosis  the  aged  are  almost  en- 
tirely exempt,  and  they  do  not  suffer  from  here- 
ditary taint  nearly  so  frequently  as  the  young. 
The  very  young  and  the  very  old  are  equally  sub- 
ject to  bronchial  catarrh,  and  the  mortality  from 
this  disease  at  each  extreme  of  life  is  exceed- 
ingly great.  But  in  the  young  the  predisposi- 
tion to  this  affection  is  almost  invariably  asso 
ciated  with  a predisposition  to  catarrh  of  the 
intestinal  tract,  and  to  diseases  which  indicate 
a general  constitutional  depression ; while  in  the 
old  bronchial  catarrh  is  predisposed  to  by  a 
degenerative  change  in  the  lungs  themselves,  or 
in  the  air-passagos.  In  childhood  there  is  an 
active  stage  of  growth  and  development,  and 
when  one  important  organ  is  affected  the  others 
suffer  with  extreme  rapidity ; the  excito-motory 
system  is  greatly  developed,  and  hence  arises  a 
predisposition  to  spasmodic  diseases — for  ex- 
ample, to  laryngismus  stridulus,  and  to  general 
or  partial  convulsions  during  the  excitement  of 
dentition.  In  the  old  the  tendency  to  spasm 
decreases,  and  convulsions  become  much  less 
marked.  Some  of  the  exanthemata,  especially 
measles,  scarlatina,  and  pertussis,  are  more  com- 
mon amongst  children  than  adults,  which  is 
partly  explained  by  the  fact  that  the  latter  class 
have  passed  through  the  ordeal  of  those  diseases, 
and  are  thus  proof  against  them.  Bickets  also 
is  essentially  a disease  of  infancy  and  early 
childhood. 

The  onset  of  puberty  is  a constant  source 
of  predisposition  to  disease,  for  with  it  comes  a 
complete  transformation  in  the  mental  and  physical 
characters,  so  that  the  individual,  if  not  very  care- 
fully watched,  deviates  from  even  the  most  perfect 
health  into  a permanent  tendency  to  disease.  The 
system  at  this  period — especially  in  the  case  of 
females — is  frequently  unable  to  bear  anything 
wdiich  interrupts  or  interferes  with  its  activity. 
The  generative  organs  undergo  great  changes, 
and  with  them  the  whole  moral  and  physical 
nature  is  altered.  At  this  period  of  life  there  is 
a predisposition  to  both  bodily  and  mental  dis- 
eases. In  fact,  perversions  of  any  organ  or  faculty 
may  be  started,  and,  once  started,  they  are  apt  te 


384 


DISEASE,  CAUSES  OF. 


continue  , so  that  there  is  established,  literally 
speaking,  a permanent  predisposition  to  disease, 
and  this  predisposition  swells  very  largely  the 
list  of  affections  which  are  dealt  with  under  the 
generic  term  Hysteria.  Lung-affections — except- 
ing pure  bronchitis — are  more  common  at  and 
shortly  after  the  time  of  puberty  than  in  previous 
years  ; but,  excepting  in  the  instance  of  phthisis, 
hereditary  taint  is  less  manifested  than  during 
childhood.  Even  hereditary  epilepsy  is,  if  post- 
poned beyond  early  years,  likely  to  be  postponed 
to  the  period  of  adult  life. 

As  has  been  said,  the  degenerations  of  organs 
and  tissues  begin  to  show  with  much  uncertainty, 
but  after  the  fortieth  year  of  life  we  almost  in- 
variably meet  with  one  or  other  of  them.  Their 
degree  and  their  consequences  vary  with  the  sur- 
roundings of  the  individual — with  his  habits,  tem- 
perament, occupation,  andlikeinfluences.  Diseases 
of  the  large  vessels  are  especially  common  at  this 
epoch,  such  as  aneurisms  of  the  aorta  and  of  the 
large  arterial  trunks  in  the  extremities.  Hence- 
forward all  the  diseases  peculiar  to  advancing  age 
become  common.  The  results  of  previous  disease 
are  now  declared  by  a decided  predisposition  to 
exciting  causes  which  have  been  hitherto  with- 
stood. Old  age  is  a relative  term.  A man 
is  old  and  predisposed  to  trifling  excitants 
because  his  lungs  haTe  lost  their  elasticity,  or 
his  brain  its  regularity  of  circulation,  or  his 
heart  its  vigour — in  each  of  these  cases, 
as  in  a host  of  others,  the  predisposition  is 
strictly  one  of  degeneration.  Again,  inherited 
diseases  do  not  declare  themselves  in  some 
cases  till  the  later  years  of  life,  and  of  this  car- 
cinoma is  a striking  example.  The  old  are  pre- 
disposed to  lowering  diseases — low  pneumonia  or 
bronchitis;  and  to  a variety  of  nervous  affections 
which  the  vigorous  can  resist.  In  them  the 
failing  heart-power  tells  a tale ; they  are  the 
subjects  of  general  vascular  dilatation  ; and,  in 
short,  they  succumb  to  insignificant  exciting 
causes,  because  of  the  general  or  partial  decay  of 
the  tissues  and  textures  of  the  body. 

2.  Heredity  is  a prolific  source  of  predis- 
position. There  is  amongst  men  not  only 
an  inheritance  of  such  prominent  diseases  as 
phthisis,  but  of  peculiarities  in  the  manner 
they  meet  and  pass  through  minor  ailments. 
Thus,  in  families  with  a ‘ nervous  history,’  we 
meet  with  predisposition  to  headaches  of  ner- 
vous type,  irregularities  of  digestion  in  the 
form  of  diarrhoea  and  vomiting,  and  a multi- 
tude of  conditions  which  have  of  late  been 
ascribed  to  vaso-motor  disturbances.  The 
members  of  some  families  live  long  in  spite  of 
exposure  to  almost  every  exciting  source  of 
mischief,  and  contrast  most  favourably  with 
others  who,  as  far  as  one  can  determine,  hare 
all  things  in  their  favour.  There  is  no  doubt  that 
the  effects  of  syphilis,  malformations,  gout,  the 
haemorrhagic  diathesis,  and  tuberculosis  are 
handed  down  from  generation  to  generation.  Of 
many  minor  complaints  there  is  less  certainty; 
but  it  is  exceedingly  probable  that  persons  are 
predisposed  to  bronchitis  and  other  catarrhs  by 
inheritance.  It  is  acknowledged  that  epilepsy 
descends  from  parent  to  child,  and  that,  in  fact, 
individuals,  because  of  heredity,  are  often  the 
subjects  of  nervous  diseases  excited  by  causes 


which  those  free  from  taint  are  enabled  to  throw 
off  readily.  The  various  forms  of  insanity  are 
striking  examples.  It  is  supposed  that  the  in- 
heritance lies  in  the  tissues  themselves— that 
there  is  a something  in  the  tissue-elements  which 
predisposes  to  certain  diseases  in  certain  families. 
It  has  been  asserted  that  there  is  even  a predis- 
position by  inheritance  to  the  acute  specific 
diseases — such  as  typhoid  fever  and  diphtheria, 
and  some  remarkable  occurrences  in  this  country 
strongly  bear  out  this  view'. 

3.  Intermarriage. — Intermarriage  certainly 
predisposes  to  disease,  but  it  is  not  easy  to  deter- 
mine how  far  its  predisposing  powers  extend. 
Breeders  of  first-class  animals  practise  inter- 
marriage, and  thereby  develop  speed,  quality, 
and  endurance  in  the  offspring.  It  is  beyond 
question  that  this  practice  of  breeders  of  race- 
horses is  eminently  successful  for  the  time,  but 
it  by  no  means  follows  that  the  permanent  results 
are  good.  We  are  bound  to  look  not  only  to 
the  immediate,  but  to  the  ultimate  results  of 
intermarriage — in  short,  to  decide  wdiether  in 
termarriages  predispose  to  disease,  to  the  injury 
of  the  community.  But  no  rule,  free  from  ex- 
ception, can  be  laid  down  on  this  subject,  for 
beyond  all  doubt  many  intermarriages  have  led 
to  both  physical,  moral,  and  mental  advantages. 
There  is  no  doubt  that  malformations  are  handed 
down,  and  that  vhero  these  are  marked  in 
families  it  is  injudicious  for  persons  to  inter- 
marry. Where  also,  for  example,  serious  diseases, 
such  as  phthisis,  have  been  met  with  on  both 
sides,  it  is  most  advisable  that  intermarriage 
should  not  take  place. 

4.  Sex. — There  are  great  differences  in  the 
organs  and  functions  of  the  sexes,  and  in  conse- 
quence a great  contrast  in  their  predisposition  to 
disease.  The  female  is  more  delicately  constructed 
than  the  male,  and  those  organs  which  tho  two 
sexes  possess  in  common  differ  in  weight  and  in 
‘fineness;’  and  a general  consideration  at  cnee 
indicates  that  the  female  is  less  fitted  than  the 
male  to  resist  many  exciting  causes  of  disease. 
This  is  particularly  evident  at  climacteric  periods 
of  life ; with  the  onset  of  puberty  girls  suffer 
far  more  than  males,  and  especially  from  a 
variety  of  reflex  spasmodic  disorders,  which 
require  but  little  provocation  for  their  develop 
ment.  All  the  phenomena  classed  under  the 
head  of  hysteria  often  occur  at  this  period.  At 
the  same  time,  and  shortly  afterwards,  there  is  a 
tendency  to  ulcer  of  the  stomach,  to  persistent 
constipation,  to  peculiar  attacks  of  neuralgia — 
especially  of  the  intercostal  nerves,  and  to  acute 
rheumatism,  lapsing  into  the  subacute  or  chronic 
kind.  Anaemia  and  chlorosis  are  also  common 
at  the  period  of  puberty,  and  if  then  neglected 
they  are  apt  to  persist,  and  predispose  the  indi  ■ 
vidual  still  more  to  disease. 

Even  so  early  as  the  period  of  puberty  the 
external  circumstances  of  the  sexes  differ,  and 
on  this  depends,  in  a certain  measure,  the 
difference  in  their  predisposition.  Education, 
domestic  habits  and  customs,  and,  above  ail, 
occupation,  play  an  important  part.  But,  under- 
lying these  outside  influences,  there  is  inherent 
in  the  sexes  a difference  in  predisposition ; fer 
when  they  are  exposed,  as  often  happens,  to  the 
same  surroundings,  they  suffer  from  widely  fccjyi 


DISEASE,  CAUSES  OF. 


raxed  diseases.  Males  are  more  subject  to  epi- 
lepsy, tetanus,  gout,  diabetes,  locomotor  ataxy, 
vesical  diseases,  and  acute  lung-affections,  than 
females.  The  list  shows  that  occupations  which 
involve  hard  mental  and  bodily  work  and  con- 
stant exposure  explain  some  of  the  varieties 
in  predisposition.  It  is  probable  that  females 
are  more  frequently  ailing  than  males,  but  very 
often  their  illnesses  are  associated  with  the 
menstrual  functions,  and  are  trifling  in  degree, 
and,  though  more  males  are  born  than  females, 
towards  the  later  years  of  life  the  average  of  the 
sexes  becomes  more  equally  balanced,  because 
the  mortality  of  males  is  greater  than  that  of 
females.  It  is  sufficient  to  allude  to  the  fact 
that  pregnancy  and  lying-in  predispose  females 
to  diseases  from  which  males  are  entirely  exempt ; 
and  that  there  is  a considerable  difference  in  the 
sexes  as  regards  venereal  affections,  both  as  to 
predisposition  and  the  effects  of  that  predisposi- 
tion. 

5.  Temperament  is  important  as  predispos- 
ing to  disease.  Persons  of  sanguine  tempera- 
ment are  disposed  to  congestions  of  organs,  and 
haemorrhages,  on  comparatively  small  provocation. 
Phlegmatic  individuals  are  the  subjects  of  those 
diseases  which  are  readily  excited  by  want  of 
mental  and  bodily  energy  and  activity.  A third 
set  belong  to  the  nervous  temperament ; they  are 
easily  excited  and  easily  depressed,  so  that  excit- 
ants cause  either  a form  of  hysteria  or  hypochon- 
driasis, for  example.  The  predisposition  amongst 
this  class  is  constantly  met  with  in  diseases  of 
an  acute  character.  Nervous  persons  suffer 
quickly  from  delirium  and  other  brain-symptoms, 
which  aggravate  and  render  dangerous  an  other- 
wise hopeful  malady.  In  the  acute  specific 
diseases  this  is  particularly  manifested  ; nervous 
people  are  undoubtedly  predisposed  to  them,  and 
when  once  attacked  are  predisposed  to  dangerous 
complications.  Practically  we  meet  with  ‘mixed’ 
temperaments,  though  one  perhaps  especially 
prevails.  See  Temperament. 

6.  Climate  and.  Locality.  — These  differ 
widely  in  their  predisposition  to  disease.  Persons 
who  have  been  accustomed  to  a particular  cli- 
mate frequently  suffer  when  transferred  to  one 
differing  from  it;  and  on  the  other  hand  tho 
sick  often  benefit  by  change.  Particular  diseases 
flourish  in  particular  climates,  and  particular 
organs  suffer.  In  the  tropics  various  endemic 
fevers  prevail  which  are  unknown  in  this  country, 
for  they  cease  to  exist  when  the  temperature 
sinks  below  a certain  level  (about  60°  Fahr.). 
Frost  very  often  cuts  short  epidemics  in  our  own 
country  in  like  manner.  Particular  organs  are 
predisposed  to  disease  by  climate — the  liver  in 
the  East  Iudies,  the  lungs  and  the  kidneys  in 
regions  where  the  temperature  is  capricious. 
Climates  differ  as  regards  air — whether  moist 
or  dry,  hot  or  cold ; but  besides  these  things 
the  topography  must  be  considered,  and  the 
elevation  of  districts.  Plains,  mountains,  and 
valleys  have  various  predisposing  influences,  and 
while  much  of  such  influence  depends  on  the 
configuration  of  the  country,  no  little  is  due  to 
the  nature  of  the  soil.  No  better  proof  of  the  latter 
fact  can  be  given  than  that  yielded  by  the  observa- 
tions of  Dr.  Buchanan,  who  has  shown  that  where 
t» proper  system  of  drainageof  soil-wateris  carried 

25 


88f 

out,  the  tendency  to  pulmonary  diseases  is  very 
greatly  diminished.  Claysoilsare  cold  and  damp 
and  favour  diseases  aroused  by  these  combined 
agencies  ; sandy  and  gravelly  soils  readily  drain 
themselves,  are  warm  and  dry,  and  thus  far  tend 
to  protect  those  who  live  on  them  against  disease. 
Climates  are  also  modified  by  trees,  rocks,  rivers, 
lakes,  &c.  Detritus  carried  down  by  streams  and 
deposited  along  their  banks  or  at  their  estuaries 
has,  like  ground  vegetation  and  its  decay,  an  un 
doubted  predisposing  influence.  Particular  dis- 
trictsalso  predispose  to  certain  diseases.  Cretinism 
is  most  common  in  close  valleys ; urinary  calculus 
is  endemic  in  many  districts  of  Great  Britain 
and  elsewhere.  In  some  circumscribed  areas 
in  Scotland,  in  Norfolk,  and  other  district, 
individuals  are  especially  liable  to  stone.  The 
influences  of  climate  are  well  shown  by  the 
electric  conditions  of  the  atmosphere;  some 
persons  are  so  predisposed  that  they  can 
foretell  a thunderstorm  by  the  change  in  them- 
selves. Fogs  in  large  cities  depress  most  people  , 
and  it  is  not  too  much  to  say  that  many  diseases 
may  be  traced  to  a predisposition  which  ‘bad 
weather’  has  started.  Alcoholism  has  been  pro- 
voked in  this  way.  It  is  clear,  therefore,  that 
under  the  head  of  climate  there  are  many  combin- 
ing influences,  which  affect  the  moral,  mental,  ami 
bodily  nature  of  individuals,  and  through  one  oi 
all  may  predispose  to  disease.  In  this  country, 
and  probably  elsewhere,  those  who  dwell  on 
mountains  are  less  liable  to  disease  than  the 
dwellers  on  plains ; marshy  plains  especially 
predispose.  It  should  be  remembered,  however, 
that  it  is  not  climate  alone  which  varies  the  pre- 
disposition amongst  persons  residing  in  different 
regions,  for  their  habits,  diet,  &c.,  differ  fat 
more  than  the  climate  in  which  they  dwell, 
and  predisposition  to  disease  should  never  be 
ascribed  solely  to  climatic  conditions  unless 
accidental  influences  have  been  investigated  and 
eliminated.1  See  Climate. 

7.  Town  and  Country. — The  influences  of 
town  and  country,  as  predisposing  to  disease,  re- 
quire a separate  consideration.  With  them  may 
be  considered  dwellings,  and  a variety  of  minor 
sources  of  predisposition.  The  mortality  of  coun- 
try districts  is  less  than  that  of  towns,  but  towns 
differ  in  this  respect  amongst  themselves.  The 
health  of  the  largest  city  in  Great  Britain,  for  ex- 
ample, compares  favourably  with  any  of  the  large 
manufacturing  towns  and  with  many  rural  com- 
munities. It  is  easy  to  understand  that  differences 
must  depend  on  the  occupation,  food,  and  habits 
of  the  people,  and  on  their  external  surroundings 
—air,  light,  drainage,  and  like  conditions.  In 
large  towns  occupations  are  more  lowering  than 
in  country  districts  ; while  the  physical  and  men- 
tal strain  is  greater,  and  has  fewer  interruptions. 
Late  hours,  intemperance,  and  prostitution  prevail 
in  towns  ; but  it  is  by  no  means  certain  that,  in 
proportion  to  the  population,  these  ills  are  less 
frequent  in  the  more  remote  districts.  In 
towns  overcrowding  checks  ventilation,  makes 

1 Imperfect  drainage  leads  to  what  are  popularly  known 
as  ‘ damp  walls  ’ in  dwellings,  and  thus  predisposes  to 
pulmonary  diseases  by  interfering  with  ventilation— in 
fact,  by  preventing  the  admission  of  pure  air  into  such 
dwellings.  This  truth  bears  out  the  teachings  we  have 
derived  from  Dr.  Buchanan’s  investigations  at  Ely  and 
elsewhere. 


m DISEASE,  C 

drainage  difficult,  so  that  subsoils  become  satu-  i 
rated,  clouds  the  atmosphere  with  smoke  and 
dust,  intermingles  the  sexes  (amongst  the  lower 
elasses)  so  that  succeeding  generations  are  stunted 
in  their  development,  and  in  a variety  of  other 
ways  predisposes  to  disease.  But  in  some  towns 
these  evils  have  been  obviated  by  sanitary 
measures,  and  as  a consequence  towns  often  pre- 
dispose less  than  country  districts  to  diseases  due 
to  defective  drainage  and  overcrowding.  Some 
startling  illustrations  of  this  fact  have  occurred 
since  sanitary  science  has  been  acknowledged  to  be 
of  national  importance.  In  villages,  for  instance, 
reputedly  ‘ model,’  epidemics  of  disease  associated 
with  defectivedrainage  and  evil  domestic  arrange- 
ments have  decimated  the  inhabitants,  and  the 
virulence  of  these  epidemics  has  been  greater 
than  that  of  those  met  with  in  large  towns.  The 
latter  are  now-a-days  for  the  most  part  better 
drained  than  country  districts ; thus  milk-epi- 
demics of  typhoid  fever  have  been  imported  into 
large  cities  from  isolated  farms  where  the  drain- 
age alone  seemed  to  be  at  fault.  Amongst  children, 
rickets,  scrofula,  and  tuberculosis  are  far  more 
prevalent  in  town  than  country.  The  mortality 
amongst  yotrtig  ohildren  is  far  greater  in  towns 
than  country  districts.  Adulterations  are  an 
evil  in  large  communities,  affecting  people  of 
all  ages.  From  many  of  these  country  districts 
are  free,  and  especially  is  this  true  as  regards 
milk.  So  while  dwellers  in  the  country  may  have 
had  drainage  and  bad  houses,  they  have  pure  air 
as  a rule,  every  opportunity  of  breathing  it  out 
of  doors,  and  unadulterated  milk.  Even  the 
alcoholised  drinks  in  many  country  districts  are 
home-made  and  harmless  when  compared  with 
the  adulterated  raw  spirits  taken  by  the  lower 
classes  of  largo  towns. 

8.  Hygienic  Conditions.— One  of  the  most 
common  causes  of  disease  coming  under  this 
head  is  want  of  cleanliness.  To  this  is  due  a 
variety  of  skin-diseases,  such  as  eczema  of  the 
scalp  in  children,  diseases  caused  by  pediculi, 
&c.  It  interferes  with  the  functions  of  the 
skin  generally,  and  by  it  even  a common 
cold  is  modified.  Clothing  is  a part  of  this 
subject.  Insufficient  clothing  is  a most  im- 
portant source  of  predisposition,  amongst  the 
rich  as  well  as  amongst  the  poor ; for,  though 
the  climate  of  this  country  is  so  variable,  cor- 
responding adaptations  of  dress  are  for  the  most 
part  neglected.  Flannels  worn  day  and  night  also 
predispose  to  disease.  Clothing  is  used  to  pre- 
vent the  loss  of  heat,  which  occurs  in  three  ways 
— by  radiation,  conduction,  and  evaporation,  and 
a careful  adaptation  enables  us  to  modify  these 
sources  of  loss  in  such  a way  as  to  obviate  a pre- 
disposition to  disease.  There  is  probably  more 
care  taken  in  tropical  climates  to  regulate  the 
heat  of  the  surface  than  in  the  temperate  zones.  A 
very  common  cause  of  predisposition  to  disease  is 
neglect  of  proper  bedding.  Deficient  ventilation 
and  overcrowding  are  prolific  sources  of  mischief. 
Overcrowding  without  ventilation  is  one  of  the 
greatest  evils  of  our  chief  cities  and  towns ; and  not 
only  is  it  in  their  homes  and  workshops  that  popu- 
lations are  overcrowded,  but  in  their  places  of 
recreation,  such  as  theatres,  and  in  their  places 
of  religious  worship.  Briefly  it  may  be  said 
that  overcrowding  predisposes  to  moral,  mental. 


IAUSES  OF. 

I and  physical  deterioration  ; to  epidemic  diseases, 
and  especially  to  typhus  fever;  to  pulmonary 
affections  ; and  to  a variety  of  nervous  diseases. 
By  lowering  the  morale  of  populations  it  increases 
all  other  predispositions,  and,  in  fact,  passes  into 
an  active  exciting  cause  of  disease. 

9.  Occupation. — This  is  a common  cause  of 
disease,  and  is  often  associated  with  want  of 
proper  hygienic  conditions.  The  overcrowded 
in  work-rooms  breathe  an  impure  air,  an  air 
loaded  with  carbonic  acid,  irritant  particles,  aiu; 
various  exhalations,  and  thus  are  liable  to  disease. 
Miners  breathe  an  air  laden  with  carbon  ; knife- 
grinders  inhale  fine  particles  of  metals ; marble- 
polishers  and  masons  are  in  the  same  plight ; 
in  all  three  cases  occupation,  combined  with 
neglect  of  hygienic  precautions,  leads  to  pulmo- 
nary diseases.  Occupation  is  in  many  cases  a 
direct  exciting  cause  of  disease ; for  example, 
workers  in  arsenic,  antimony,  copper,  lead,  the 
mineral  acids,  &c.,  suffer  from  the  poisonous 
effects  of  these  substances.  But  oftentimes  they 
escape  the  direct  influences,  yet  are  subject  to  a 
predisposition  to  various  diseases,  as  a conse- 
quence of  their  occupation.  Various  other  occu- 
pations, such  as  those  of  tailors,  shoemakers, 
milliners,  and  brain-workers,  predispose  to 
disease  in  different  ways. 

Too  much  work  and  too  little  work  (mental  or 
bodily)  predispose  distinctly  to  disease.  Con- 
tinued overwork  reduces  the  system  generally, 
and  special  organs  in  particular,  according  io 
its  nature.  A coachman,  who  uses  for  many 
hours  his  pectoral  muscles  in  driving,  suffers 
chiefly  in  them  when  he  has  an  attack  of  mus- 
cular rheumatism.  So  also  those  who  use  the 
brain  too  much  in  intellectual  work  are  pre- 
disposed to  functional,  aud  even  to  organic 
derangements  of  the  nervous  centres.  Physical 
overwork  is  often  conjoined  with  exposure  ami 
improper  or  irregular  food-supply,  and  the  com- 
bination has  a marked  effect.  It  has  so  predis- 
posed armies  to  disease  that  theirrar.ks  have  been 
decimated  by  fevers,  pneumonia,  aud  bronchitis, 
far  more  than  by  the  cannon  or  by  the  sword. 
Not  a few  medical  men  have  been  affected  by 
the  contagia  of  the  acute  specific  diseases,  be- 
cause when  exposed  to  them  they  were  worn  out 
by  bodily  and  mental  exertion,  and  by  pro- 
tracted fasting.  Over-work  reduces  the  ner- 
vous power,  and  thereby  strikes  at  the  very 
root  of  the  healthy  status.  On  the  other  hand 
a sluggish  use  of  the  mind  and  body  are  favour- 
able to  disease,  and  some  persons  are  so  con- 
stituted that  they  cease  to  be  safe  when  their 
minds  have  lost  the  opportunity  of  active  exer 
cise;  and  the  very  fact  that  they  substitute  an 
abnormal  intellectual  employment  is  proof  of 
this  truth.  And  what  is  true  of  the  mind  is 
true  of  the  body.  A sudden  change  from  active 
bodily  exercise  to  bodily  laziness  predisposes 
largely  to  disease. 

10.  Air.  — The  question  of  air  has  already 
beenalluded  to,  in  considering  climate,  occupation, 
town  and  country,  overcrowding,  &c.,  and  it  is 
scarcely  necessary  to  dwell  much  more  on  i:s 
aetiological  effects.  Air  influences  the  predispesi- 
tion  to  disease  according  to  its  degree  of  rarefac- 
tion, moisture  or  dryness,  warmth  or  coldness, 
and  the  impurities,  mechanical  or  chemical,  which 


DISEASE,  CAUSES  OF. 


may  adulterate  it.  In  the  article  Climate  many 
of  these  atmospheric  conditions  are  fully  dwelt 
upon,  and  their  tendencies  explained.  Impurities 
in  the  air  are  exceedingly  prevalent ; and 
mechanical  substances  suspended  iu  it  can 
excite  irritable  conditions  of  the  air-passages 
which  may  pass  cn  to  inflammation,  and  even 
destruction  of  the  lungs.  Throat  and  laryn- 
geal affections  are  a common  consequence  of 
these  impurities.  All  these  chiefly  occur  amongst 
certain  classes  whose  occupation  loads  the  air 
with  fine  particles  as  already  described.  There 
.s  scarcely  a mineral  used  in  the  arts  which 
cannot,  by  inhalation,  excite  or  predispose  to 
disease.  The  air  may  also  be  rendered  impure 
by  chemical  agencies,  and  the  moment  the 
normal  proportion  of  its  elements  is  disturbed 
.t  becomes  a source  of  disease.  Excess  of  car- 
bonic acid  is  especially  an  element  of  mischief 
— causing  headache,  dyspepsia,  and  nervous 
depression.  The  presence  of  ammonia  and 
of  sulphuretted  hydrogen  is  attended  by  like 
results.  The  human  economy  is,  however, 
so  framed  that  its  organs  can  often  very 
rapidly  throw  off  the  evil  effects  of  these 
gases  when  breathed  in  overcrowded  rooms,  &c., 
10  that  no  permanent  mischief  is  established. 
Poisoned  air  plays  a part  in  the  production  of 
scrofula,  anaemia,  and  lowered  conditions  gener- 
ally ; but  it  is  an  incomplete  comprehension  of 
the  causes  of  these  conditions  to  set  down  all  to 
this  one.  The  air,  also,  may  be  poisoned  by 
other  gases,  such  as  carburetted  hydrogen. 

The  atmosphere  is  modified  by  currents — 
sometimes  to  the  relief,  sometimes  to  the  danger 
of  mankind.  Winds  can  remove  sources  of  con- 
tagion— they  can  ‘ clear  the  air.’  But  they  can 
also  bring  contagion  into  localities  according  to 
many  authorities.  Cholera  and  other  diseases 
have,  it  is  said,  followed  aerial  currents — that  is, 
have  boon  carried  by  them.  East  winds  are  a 
prolific  cause  of  disease  ; they  excite  it  directly, 
and  carry  off  healthy  individuals,  even  though 
the  cold  be  not  extreme.  Sometimes  westerly 
winds  have  a dangerous  influence,  and  in  the 
winter  of  1877-1878  a wave  of  disease,  having 
many  of  the  characteristics  of  ‘ influenza’  was 
carried  across  England  by  a west  wind. 

11.  Previous  Disease. — Previous  disease 
often  predisposes  to  the  same  or  to  some  other 
affection,  and  no  clinical  history  is  of  value 
unless  it  includes  an  account  of  former  ill- 
nesses. In  difficult  and  doubtful  cases  a true 
statement  of  these  often  gives  the  clue  to  diag- 
nosis, and  even  patients  themselves  are  alive 
to  the  value  set  upon  an  accurate  account  of 
their  life-ailments.  An  attack  of  croupous 
pneumonia  predisposes  to  recurrence,  especially 
during  the  twelve  months  succeeding  the  attack ; 
and  it  may  leave  behind  a predisposition  ex- 
tending far  beyond  the  original  disease.  Chorea, 
acute  rheumatism,  tonsillitis,  and  epilepsy  tend  to 
recur,  as  also  do  the  ordinary  convulsions  of  chil- 
dren ; but  in  all  these  and  many  other  cases 
it  is  difficult  to  estimate  the  exact  part  played 
by  derived  predisposition,  because  in  all  the 
primary  predisposition  may  be  the  main  agent 
iu  the  subsequent  attacks.  In  practical 
medicine  it  is  distinctly  recognised  that  cer- 
tain diseases  predispose  to  disease,  and  in 


387 

their  case  recurrence  is,  very  properly,  jealously 
guarded  against.  Pertussis  is  supposed  to  pre- 
dispose to  measles,  and  vice  versa.  There  is 
distinctly  a connection  between  chorea,  rheu- 
matism, and  scarlet  fever,  and  these  diseases 
may  follow  one  another  in  any  order.  Again, 
previous  disease  may  leave  behind  pathological 
lesions  which  remain  in  abeyance  until  excited 
by  causes  which  the  healthy  individual  could 
readily  withstand.  Pertussis  often  ends  to  all  ap- 
pearances favourably,  but  afterwards  the  patienti, 
may  suffer  from  severe  lung-affections,  upon  tri- 
fling exposure  to  exciting  influences.  Calcareous 
deposits  in  the  lungs  may  excite  a new  catarrhal 
phthisis  ; hepatic  mischief  followed  by  collection 
of  gall-stones  in  the  gall-bladder  may  cause 
peritonitis  and  other  diseases.  Slight  complaints 
are  even  more  marked  in  their  predisposing 
powers  than  serious  diseases.  On  the  other  hand, 
previous  disease  sometimes  protects  individuals 
and  communities  ; for  example,  vaccination  can 
save  nations  from  the  most  terrible  of  scourges. 
In  the  case  of  scarlet  fever,  typhus,  pertussis, 
measles,  &c.,  an  almost  perfect  immunity  is  ac- 
quired by  those  who  have  already  suffered  from 
them.  Of  course,  as  with  small-pox,  no  one 
denies  that  second  attacks  of  these  diseases  do 
occur,  but  such  attacks  are  wholly  exceptional. 

12.  Mental  and  Moral  Conditions. — Ba/l 
news  may  cause  sudden  death,  or,  short  of 
tills,  may  interfere  with  the  functions  of  par- 
ticular organs.  Sudden  mental  worry  may 
excite  dangerous  interference  with  digestion,  or 
start  an  abnormal  cardiac  rhythm.  Fright  has 
turned  the  hair  white  within  a few  days  or  hours 
in  healthy  persons.  Mental  and  moral  shock  can 
check  or  increase  the  flow  of  urine,  and,  in 
fact,  can  affect  all  the  excreting  and  secret- 
ing organs  of  the  economy.  Mental  overwork 
can  excite,  per  se,  brain-conditions  of  a dangerous 
nature,  such  as  hypersemia  or  anaemia,  and.  even, 
it  is  said,  meningitis  of  simple  or  tubercular 
form,  according  to  the  inherited  predisposition. 
Undue  or  sudden  emotional  disturbances  can  ex- 
cite serious  mischief,  just  as  they  can  predispose 
to  it.  Again,  the  mind  is  affected  by  imitative 
influences  ; thus  chorea  is  excited  in  some  indi- 
viduals by  watching  choreic  movements,  and  a 
single  hysterical  patient  may  arouse  in  others- 
symptoms  almost  identical  with  her  own.  The 
subject  of  the  direct  influence  of  the  mental  and 
moral  state  on  disease  is,  however,  too  wide  to 
be  here  dwelt  upon. 

13.  External  Physical  Conditions. — These 
are  very  numerous  as  exciting  causes  of  disease. 
Violent  over-exertion  can  cause  herniae,  haemor- 
rhages, as  from  the  vessels  of  the  lungs,  cerebral 
congestions,  and  even  ruptures  of  the  valves  of 
the  heart,  and  in  one  or  all  of  these  cases  lead 
directly  to  death.  Over-exertion  with  the  voice 
may  be  followed  by  pharyngitis  or  laryngitis. 
Syncope  has  occurred  in  the  most  healthy  from 
violent  exertion  in  hill-climbing,  in  boat-racing, 
walking  and  running  matches,  &e.,  acute  dila- 
tation of  the  ventricles  probably  occurring. 
Various  forms  of  direct  injury  are  frequent 
causes  of  disease. 

14.  Poisons. — Poisonous  gases  are  powerful 
excitants  of  disease,  and  so  are  poisons  generally 
whether  animal,  vegetable,  or  inorganic.  Thoy 


388  DISEASE,  CAUSES  OF. 

may  kill  quickly  or  excite  a disease  of  long- 

continued  or  even  permanent  nature. 

15.  Temperature. — Heat  and  cold  carried  to 
excess  may  prove  fatal  at  once.  The  influences 
of  severe  cold  are  described  unde:  the  heading 
cold,  and  it  is  only  with  the  diseases  excited  by 
heat  and  cold  in  the  everyday  acceptation  of 
these  terms  that  we  shall  deal  here.  Long-con- 
tinued heat  lowers  the  vital  powers,  and  may 
excite  such  diseases  as  slight  eczema  of  a 
simple  character,  or  such  grave  affections  as  in- 
flammation of  the  membranes  of  the  brain.  Heat 
may  kill  suddenly,  as  in  sun-stroke,  or  excifo 
cerebral  mischief  just  short  of  death ; while  in 
persons  of  tubercular  diathesis  it  may  induce 
tubercular  meningitis ; and  even  more  general 
effects  follow  severe  local  applications  of  heat. 
Moderate  heat  applied  to  the  back  often  de- 
presses the  heart  even  to  syncope.  Choleraic 
attacks  in  this  country  usually  are  associated  with 
exposure  to  immoderate  heat. 

Cold  is  the  most  common  cause  of  disease  in 
temperate  climates,  especially  in  the  changeable 
climate  of  this  country.  It  can  excite  disease 
directly,  and  can  affect  probably  all  the  organs 
of  the  body,  causing  either  disturbed  function 
or  organic  mischief.  Cold,  when  severe, 
contracts  the  vessels  ; interferes  with  the  circu- 
lation, and  all  vital  activity ; and  in  thi3 
way  may  cause  death.  But  it  is  witli  moderate 
degrees  of  cold  we  have  chiefly  to  deal.  A 
momentary  exposure  to  a cold  draught  is  as 
frequent  an  excitant  of  disease  as  general  ex- 
posure for  a long  time.  A cold  draught  playing 
on  the  cheek  may  cause  facial  paralysis,  sore 
throat,  or  bronchitis  ; that  is  to  say,  cold  applied 
locally  may  excite  disease  in  the  neighbourhood 
of  its  application  or  in  distant  organs.  It  is 
probable,  therefore,  that  cold  may  act  in  several 
ways  : (1)  it  may  interfere  with  circulation  ; (2) 
it  may  affect  the  extremities  of  nerves  and 
excite  disease  by  reflex  action;  or  (3)  it  may 
check  secretions  of  the  skin,  the  mucous  mem- 
branes. &e. 

We  cannot  wonder,  therefore,  that  diseases  of 
the  throat,  larynx,  and  lungs  are  frequently  ex- 
cited by  cold,  Bronchitis  and  pneumonia  are 
its  most  common  results ; and  as  the  young  and 
the  old  aro  less  enduring  of  cold  than  adults, 
it  carries  them  off  with  great  frequency. 
Diarrhoea,  renal  diseases,  congestion  of  the  liver, 
acute  and  chronic  rheumatism,  simple  dyspepsia, 
and  a host  of  other  affections,  are  traceable 
in  many  instances  to  cold.  Predisposition  lias 
much  to  do  with  the  effects  of  cold  ; some  in- 
dividuals suffer  from  one  form  of  disease  when 
exposed  to  it,  others  from  entirely  different 
affections.  In  some,  ‘a  common  cold’ is  most 
evidenced  by  severe  muscular  pains  and  fever, 
in  others  by  a nasal  discharge,  in  others  by  head- 
ache, and  so  on.  Some  persons  never  suffer 
from  ‘ cold  ’ without  having  an  attack  of  herpes 
labialis;  and  numerous  similar  idiosyncrasies 
might  be  given.  The  effects  of  cold  should 
always  be  considered  with  almost  all  predispos- 
ing causes  of  disease.  ‘Cold’  is  a vague  term  and 
not  thoroughly  understood ; there  is  all  the  more 
reason  why,  when  it  comes  under  consideration 
in  individual  cases,  its  precise  effects  should  be 
most  carefully  considered  and  recorded. 


DISEASE,  CLASSIFICATION  OF. 

16.  Diet.  — Food  and  drink  can  by  their 
abuse  excite  disease,  and  gluttony  is  as  powerful 
an  excitant  as  drunkenness,  though  in  temper- 
ance outcries  this  fact  is  almost  completely  lost 
sight  of.  Excess  of  food  does  not  refer  simply 
to  the  quantity  taken,  but  to  its  quality — its 
nature,  richness,  and  the  times  when  it  is  taken. 
Agricultural  labourers  eat  more  than  the  gentry, 
but  live  longer,  and  the  gentry  of  old-fashioned 
type  are  longer-lived  than  whose  who  frequent 
the  fashionable  world.  Excess  of  food  overloads 
the  stomach,  makes  calls  upon  it  which  it  cannot 
meet,  and  dyspepsia  is  the  result.  Excess  of  food, 
if  digested,  charges  the  blood  with  materials  not 
demanded  by  the  economy,  and  disease  of  excre- 
tory organs  or  fatty  degenerations  may  thu3  be 
excited.  Want  of  fool  also  excites  disease,  such 
as  pneumonia,  bronchitis,  or  other  catarrh,  espe- 
cially in  children,  many  deaths  amongst  whom 
are  the  direct  consequence  of  improper  feeding. 
When  the  proper  admixture  of  the  elements 
of  food  is  neglected,  disease  results,  as,  e.g., 
scurvy.  Particular  foods  will  immediately  ex- 
cite violent  gastric  catarrhs  in  some  individuals, 
while  others  can  bear  them  perfectly  well.  Putrid 
food  is  an  active  poison.  Certain  kinds  of  fish  arc 
poisonous  in  themselves,  and  some  vegetable  foods 
laden  with  salts  of  lime  are  supposed  to  cause 
urinary  calculi.  Water  and  milk  are  prolific 
sources  of  mischief,  through  the  impurities  they 
so  often  contain.  The  drinking  waters  of  large 
towns  are  usually  derived  from  rivers,  and  fil- 
tration is  not  a sufficient  purification,  so  that 
disease  may  be  excited  by  their  use.  Alcohol 
is  a most  extensive  source  of  disease  : it  causes, 
when  taken  in  excess,  cerebral,  gastric,  intes- 
tinal, hepatic,  and  renal  affections,  and  can  lower 
the  system  so  far  as  to  predispose  to  other  dis- 
eases. See  Alcoholism;  and  Poisonous  Food. 

17.  Epidemic  Diseases,  Contagion,  Mala- 
ria, Parasites,  and  Growths  are  treated  of 
under  separate  headings.  It  i3  now  generally  es- 
tablished that  the  diseases  known  as  the  acute 
specific  diseases  are  mostly1  direct  consequences 
of  some  contagium.  So  among  the  most  common 
exciting  causes  of  disease  we  must  class  the 
contagia  of  the  several  fevers,  of  syphilis,  &e. 
See  Pehsonal  Health  ; and  Public  Health. 

J.  Pearson  Irvine. 

DISEASE.  Classification  of.  — Various 

classifications  of  diseases,  or  systems  of  nosology, 
have  been  adopted  by  different  writers,  but  it  is 
beyond  the  province  of  this  work  to  discuss  these 
arrangements,  neither  of  which  fulfils  all  that 
is  required,  or  can  be  regarded  as  satisfactory. 
All  that  can  be  done  here  is  to  point  out  the 
characters  upon  which  the  chief  divisions  of 
diseases  are  founded. 

The  first  classification  deserving  of  mention 
is  that  into  (1)  General  and  (2)  Local.  Gene- 
ral diseases  include  those  in  which  the  whole 
sy'stem  is  involved  from  the  commencement, 
and  it  comprehends  as  sub-divisions  (a)  The 
acute  specific  fevers,  and  certain  other  diseases 
due  to  the  introduction  of  some  morbific 
agent  into  the  body  from  without,  or  in  some 
instances  developed  within  the  system,  for 
example,  typhus  and  typhoid  fevers,  scarlatina, 
small-pox,  malarial  fevers,  hydrophobia,  syphilis 


DISEASE,  CLASSIFICATION  OF. 

pyaemia  and  septicaemia.  (i)  The  so-called 
constitutional , cachectic , diathetic , or  blood- 
diseases,  some  of  -which  seem  to  depend  upon 
the  production  of  deleterious  elements  within 
the  system,  which  are  capable  of  recognition, 
such  as  rheumatism  and  gout;  while  others 
are  independent  of  any  such  obvious  patholo- 
gical causes,  but  are  supposed  to  bo  severally 
associated  with  a peculiar  dyscrasia  or  diathesis, 
for  instance,  cancer,  tuberculosis,  scurvy,  rickets. 
Local  diseases  are  those  which  primarily  affect 
particular  organs  or  tissues,  each  being  liable 
;o  its  own  peculiar  lesions.  Thus  we  have 
diseases  of  the  lungs,  heart,  stomach,  liver,  kid- 
neys, brain,  and  the  other  organs  ; of  the  mucous 
membranes,  serous  or  fibro-serous  membranes, 
skin,  periosteum,  bone,  and  other  structures. 
This  division  into  general  and  local  diseases  is 
useful  within  proper  limits,  but  it  must  be  re- 
membered that  general  maladies  are  often  re- 
vealed or  accompanied  by  local  lesions,  and  that 
complaints  which  are  originally  local  often  more 
jr  less  speedily  set  up  general  disturbance.  More- 
over, it  is  still  a question  whether  some  maladies 
are  to  be  regarded  as  general  or  local  in  the  first 
instance.  See  Symmetry  in  Disea.se. 

Another  division  of  diseases,  which  applies 
more  particularly  to  those  which  are  of  a local 
nature,  is  into  (1)  Organic  or  Structural,  and 
(2)  Functional.  These  terms  are  self-ex- 
planatory, the  former  implying  that  there  is 
some  organic  change  in  the  affected  part, 
which  we  can  discover  and  demonstrate  ; the 
latter  indicating  that  there  is  mere  functional 
disorder,  which  is  independent  of  any  recognis- 
able lesion.  That  there  are  structural  changes 
in  many  affections  which  are  regarded  as  func- 
tional is,  however,  highly  probable,  though 
our  means  of  observation  are  not  sufficiently 
powerful  to  enable  us  to  detect  them.  In  con- 
nection with  each  organ,  a special  classification 
of  its  individual  complaints  under  one  or  other 
of  these  primary  headings  is  usually  adopted, 
this  sub-division  depending  upon  the  affections 
to  which  the  particular  organ  is  liable.  As 
illustrations  of  functional  disorders  may  be  men- 
tioned disturbed  action  of  certain  organs,  as  of 
the  heart,  causing  palpitation;  derangement  of 
the  secretory  or  excretory  functions,  as  in  the 
ease  of  the  stomach,  liver,  or  kidneys ; and  many 
nervous  disorders.  Organic  diseases  are  exem- 
plified by  inflammation  and  its  consequences; 
alterations  in  growth  and  development;  degene- 
rations ; malformations  ; and  new  growths.  In 
this  work  it  has  not  been  deemed  advisable  to 
describe  the  diseases  of  the  several  organs  ac- 
cording to  any  definite  scientific  arrangement, 
but  in  some  cases  an  alphabetical  order  has  been 
adopted,  while  in  others  individual  writers  have 
been  allowed  to  classify  the  affections  of  a par- 
ticular organ  according  to  their  own  judgment. 

Again,  diseases  may  be  classified  according  to 
their  causation  and  mode  of  origin.  Thus  they 
are  divided  into(l)  Hereditary,  or  those  which 
are  transmitted  either  directly  from  parents  to 
children,  or  indirectly,  as  the  result  of  a family 
taint ; and  (2)  Acquired,  or  those  which  are 
developed  anew  in  persons  free  from  hereditary 
taint.  When  a morbid  condition  exists  at  birth, 
it  is  said  to  be  Congenital.  Other  divisions, 


DISEASE,  DIAGNOSIS  OF.  38S 

founded  on  an  aetiological  basis,  are  into  (1) 
Contagious  or  Infectious,  and  (2)  Non- 
contagious;  and  into  (1)  Specific,  or  those 
diseases  which  are  due  to  a specific  cause,  and 
(2)  Non-specific. 

There  are  other  classifications  of  diseases, 
which  need  only  be  mentioned  here.  Thus,  ac- 
cording to  their  intensity  and  duration,  they  arc 
said  to  be  (1)  Acute  ; (2)  Sub-acute  ; or  (3) 
Chronic.  Another  arrangement,  founded  on  their 
mode  of  progress,  is  into  (1)  Continuous;  (2) 
Periodical,  or  affections  which  come  on  at  more 
or  less  definite  intervals ; (3)  Paroxysmal, 
or  those  which  are  characterised  by  sudden  or 
acute  paroxysms ; and  (I)  Kecurrent,  or  diseases 
which  tend  to  recur.  Lastly,  according  to  their 
mode  of  distribution  amongst  communities  or 
in  districts,  complaints  are  said  to  be  (1) 
Sporadic  ; (2)  Epidemic ; (3)  Endemic ; 
and  (4)  Pandemic.  The  meanings  of  these 
terms  are  defined  under  their  several  headings, 
but  they  are  sufficiently  familiar  as  indicating 
the  mode  of  distribution  of  the  diseases  to  which 
they  respectively  belong. 

With  regard  to  the  classification  of  diseases 
which  is  likely  to  be  permanently  adopted  in  the 
future  for  general  use,  it  is  probable  that  this 
will  be  founded  on  a pathological  basis,  and  that, 
as  our  knowledge  of  morbid  conditions  and  pro- 
cesses becomes  more  extensive,  accurate,  and 
definite,  it  may  become  possible  to  establish  a 
system  of  nosology  which  will  be  both  scientific 
and  practically  useful. 

Frederick  T.  Egberts. 

DISEASE,  Diagnosis  of  (5ia,  intens.,  and 
yu'itoKco,  I know). — Synon.  ; Fr.  Diagnose-, 
Ger.  dcr  Diagnose. 

Definition. — Diagnosis  is  the  art  of  recog- 
nising the  presence  of  disease,  and  of  distinguish- 
ing different  diseases  from  each  other.  The  term 
is  also  applied  to  the  result  obtained. 

General  Considerations. — The  general  prin- 
ciples only  of  diagnosis  will  be  here  discussed. 
Special  diagnoses  will  be  treated  of  in  connec- 
tion with  the  several  diseases  to  wdiich  they  have 
reference. 

In  many  respects  diagnosis  is  a subject  of 
great  interest  and  importance.  First,  in  a scien- 
tific point  of  view,  it  is  essential  that  all  know- 
ledge should  be  accurate.  Secondly,  accuracy  of 
diagnosis,  founded  upon  a sound  pathology,  en- 
ables us  to  frame  a scientific  classification  of 
disease  in  its  diverse  forms.  It  is  also  by  accu- 
rate determination  of  the  nature  of  the  disease 
which  may  be  present  in  any  given  case  that  we 
are  able  to  anticipate  its  course,  and  to  employ 
the  right  kind  of  remedies  in  its  treatment.  It 
is  imperfection  of  diagnosis  which  leads  in  many 
instances  to  an  under-estimate  of  the  value  of 
therapeutical  agents  ; for  when  the  nature  of  a 
disease  is  mistaken  we  are  led  to  employ  im- 
proper and  unsuitable  remedies,  the  failure  of 
which  is  then  erroneously  attributed  to  the 
inefficiency  of  the  agents,  and  not  to  the  unfitness 
of  the  treatment  employed.  If  our  diagnosis 
had  been  correct  or  complete,  the  remedy  selected 
would  more  often  have  had  the  desired  effect. 

In  order  to  arrive  at  a diagnosis  we  must 
study  the  phenomena  or  characters  of  each  id- 


590  DISEASE,  DIAGNOSIS  OF. 


dividual  case,  and  trace  its  connexion  -with 
those  groups  of  symptoms  which  have  been  pre- 
viously recognised  and  described  as  belonging  to 
special  or  distinct  diseases.  Assuming  that  the 
classification  has  been  already  made,  we  pro- 
ceed to  deal  with  the  means  which  enable  us  to 
identify  each  individual  case,  and  to  connect  it 
with  a previously  classified  disease. 

Means  of  Diagnosis. — To  obtain  accuracy 
in  diagnosis  we  must  bo  prepared  with  a know- 
ledge of  the  several  forms  and  varieties  of 
disease  ; we  must  be  familiar  also  with  the 
functions  and  structure  of  the  several  organs 
'•f  the  body  in  health.  It  is  by  observing  and 
comparing  the  changes  caused  by  disease  in  the 
t hese  functions  and  structures,  that  we  are  en- 
abled to  discover  the  presence  of,  and  to  deter- 
mine the  nature  of  disease.  In  forming,  then, 
a diagnosis  in  any  particular  case,  the  physician 
must,  as  far  as  possible,  keep  in  view  the  real 
or  the  ide.al  condition  of  the  patient  in  a state 
of  health.  Ho  must  endeavour  to  place  him  in 
xs  natural  a position  as  may  bo,  and  as  little 
disturbed  by  the  presence  of  his  attendant,  or 
by  external  circumstances,  as  possible.  The  phy- 
sician must  then  obtain  a history  from  the  patient 
himself  or  from  others  of  the  incidence  of  the 
disease ; and  having  done  this  he  must  proceed  to 
investigate  for  himself  thecondition  of  thepatient. 

1.  Previous  history  of  the  patient. — The  history 
implies  of  course  a statement  of  the  age  and  sex 
of  the  patient,  as  well  as  of  his  home  aud  his  em- 
ployment— each  of  which  may  have  a special  rela- 
tion to  disease.  It  should  also  include  an  inquiry 
into  the  antecedent  generations  of  the  patient, 
and  how  far  he  may  have  any  proclivity  to  con- 
genital disease  or  malformation.  This  inquiry 
should  have  reference  to  both  positive  and  nega- 
tive facts.  It  should  extend  not  only  to  the 
previous  existence  of  disease  in  the  family,  but 
also  to  the  absence  of  particular  diseases  or  types 
of  constitution.  The  patient’s  history  should 
include  a statement  as  regards  the  diseases  and 
injuries  from  which  he  may  previously  have 
suffered;  the  remedies  used  for  them ; and  the 
climatic  and  other  influences  to  which  he  has 
been  exposed.  Nor  must  the  physician  neglect 
to  ascertain  the  history  of  any  children  that 
the  patient  may  havo  had,  as  the  nature  of 
disease  from  which  the  offspring  have  suffered  in 
many  instances  throws  light  upon  the  health  of 
the  parent. 

2.  History  of  present  illness. — The  history  of 
the  present  illness  should  include  the  determina- 
tion of  the  date  of  its  commencement;  its  probable 
cause  ; and  its  progress  as  influenced  by  external 
circumstances,  including  treatment. 

3.  The  present  condition  of  the  patient. — Here 
we  have  to  deal  with  two  classes  of  phenomena; 
namely  (a)  those  feelings  or  facts  of  self-con- 
sciousness which  the  patient  describes  to  us — - 
subjective  phenomena  ; and  ( b ) those  signs  which 
we  ourselves  observe — objective  phenomena. 

a.  Subjective  phenomena.— The  patient  describes 
to  us  his  feelings — as  of  strength  or  weakness, 
of  numbness,  tingling  or  pain,  of  wakefulness  or 
wandering  ; he  can  tell  of  affections  of  vision,  of 
hearing,  of  smell,  or  of  taste;  of  breathlessness, 
cough,  palpitation,  or  of  feelings  of  sinking  or 
faintness;  of  difficulty  of  swallowing,  thirst,  loss 


of  appetite,  nausea  or  sickness,  or  various  sensa- 
tions  and  actions  connected  with  the  abdomen; 
of  feelings  associated  with  the  genito-urinary 
organs,  such  as  pain  or  difficulty  in  passing  water; 
of  cramps,  spasms,  or  other  alterations  of  sensa- 
tion or  motility;  or  of  disturbances  of  sensibility 
and  activity,  &c.  Each  of  these  signs  of  deviatiob 
from  health  will  have  its  own  value  and  signi- 
ficance. The  physician  must  at  the  same  time 
carefully  note  how  far  the  condition  of  the  pa- 
tient is  in  accordance  with  his  statements,  and 
whether  there  may  not  be  present  some  reason 
or  cause  for  concealment  or  exaggeration. 

b.  Objective  phenomena.  In  studying  the  ob- 
jective phenomena  connected  with  disease,  the 
physician  makes  use  of  his  special  senses,  assisted 
by  the  several  instruments  with  which  modern 
science  has  provided  him. 

First,  in  matters  of  eye-sight , he  sees  the 
general  aspect  and  expression  of  the  patient, 
which  will  include  the  colour  of  the  skin  (such 
as  may  result  from  the  fulness  or  emptiness  of 
the  blood-vessels,  from  the  yellowness  caused  by 
jaundice,  from  the  blueness  of  cyanosis,  or  from 
pigmentation,  &c.) ; the  presence  and  character 
of  cutaneous  eruptions  (especially  in  the  exan- 
themata) ; the  expression  proper,  such  as  that 
of  ease  or  suffering,  and  of  depression  or  excite- 
ment ; the  conditions  of  obesity  and  plethora,  or 
of  wasting  and  bloodlessness.  He  will  also  ob- 
serve the  position  of  the  patient,  how  he  lies,  or 
sits,  or  stands,  and  how  breathes  ; the  appearance 
of  the  eyes,  the  tongue,  etc.  Further,  the  sense  of 
sight  will  be  employed  in  determining  conditions 
of  a local  or  less  general  nature.  Observation 
must  be  made  of  the  size,  the  shape,  and  move- 
ments of  parts,  and  of  their  expansion  or  con- 
traction. With  the  aid  of  special  instruments, 
such  as  the  ophthalmoscope,  the  laryngoscope, 
the  various  specula,  sounds,  &c„  the  physician 
will  be  able  to  examine  parts  of  the  body  of  the 
patient,  beyond  the  reach  of  the  unassisted  eye. 
The  chest-measurer  or  the  stethometer  willrender 
more  exact  the  information  already  obtained  by 
the  eye  ancf  hand  as  to  the  size  and  mobility  of 
parts.  The  use  of  each  of  the  several  instruments 
above  mentioned,  as  a means  of  diagnosis,  will 
be  found  described  under  the  heads  of  their  re- 
spective names,  or  in  the  article  on  Phtsical 
Examination. 

The  sense  of  hearing  tells  of  the  character  of 
the  breathing,  the  voice,  and  speech  of  the  patient, 
including  cough,  hoarseness  or  aphonia,  ‘ aphasia,’ 
&c.  But  the  ear  is  especially  applied  to  the  study 
by  auscultation  of  the  sounds  produced  in  con- 
nexion with  the  heart,  the  lungs,  and  other  or- 
gans. The  signs  thus  elicited  will  be  found  fully 
described  elsewhere. 

The  sense  of  touch  or  feeling  will  communi- 
cate a knowledge  of  the  temperature,  of  moisture 
or  dryness,  of  size,  shape,  elevation  ordepression. 
of  smoothness  or  roughness,  of  the  pulse  or  pul- 
sation, vibration,  fremitus,  of  extent  of  move- 
ment, resistance,  softness  or  hardness,  and  of 
fluctuation.  The  accuracy  of  the  results  of  these 
observations  by  touch  may  be  tested  by  the  use 
of  the  thermometer,  the  calipers,  and  the  tape- 
measure. 

The  sense  of  smell  aids  diagnosis  in  certain 
cases.  The  general  odour  of  the  patient  ma) 


DISEASE.  DIAGNOSIS  OF.  39, 


be  observed  in  small-pox,  in  rheumatism,  and 
some  -wasting  diseases  (such  as  phthisis),  and  in 
syphilis;  and  the  odour  of  particular  parts  and 
secretions,  as  the  urine  in  diabetes,  and  in  cases 
of  the  use  of  certain  drugs,  or  in  poisoning.  In- 
formation is  also  afforded  by  the  odour  of  certain 
discharges,  as  in  ozaena,  leucorrhcea,  cancer,  &c. 

The  sense  of  taste  is  seldom  employed  in 
clinical  investigation,  but  the  physician  may  make 
use  of  the  patient's  taste,  as  in  tasting  the  urine 
in  diabetes. 

Further  aids  in  Diagnosis. — Having  thus  sum- 
marily described  the  employment  of  the  special 
senses  in  diagnosis  and  given  examples  of  their 
use,  we  may  briefly  mention  some  other  agencies 
of  more  general  application.  The  acuteness  of 
the  patient's  sense  of  touch  may  be  determined 
by  the  sesthesiometer ; the  capacity  of  the  lungs 
may  be  measured  by  the  spirometer,  and  the 
strength  of  muscles  by  the  dynamometer;  the 
contractility  of  muscles  by  galvanism ; the 
force  and  character  of  the  pulse  aro  determined 
by  the  sphygmograph ; constant  use  is  found  for 
the  microscope,  the  test-tube,  the  spectroscope, 
and  polariscope,  which  aid  in  determining  the 
character  of  the  various  secretions  or  morbid 
matters  that  require  to  be  submitted  to  inves- 
tigation. The  result  of  treatment  may  also  be 
mentioned  as  an  aid  to  diagnosis,  as  for  example, 
when  an  indurated  sore  yields  to  the  use  of  mer- 
eury.  Again,  the  knowledge  that  a person  has 
been  in  a malarious  district  enables  us  to  decide 
on  the  intermittent  nature  of  certain  symptoms 
that  may  be  present.  In  some  cases  it  may  be 
necessary  to  render  a patient  insensible  by  anaes- 
thetics, with  a view  to  making  a complete  ex- 
amination, or  in  investigating  feigned  diseases. 
The  administration  of  small  doses  of  charcoal 
has  been  suggested  as  a means  of  determining 
tho  presence  of  a passago  through  the  bowels 
when  more  or  less  obstruction  exists. 

Such  then  are  the  means  used  for  taking  note 
of  those  deviations  from  health  which  occur  in 
the  several  functions  and  structures  of  the 
body,  and  which  constitute  what  are  known  as 
the  Symptoms  and  Signs  of  Disease ; these 
aro  terms  which  will  be  found  more  specially 
treated  of  under  the  heads  Disease,  Symptoms 
and  Sigus  of ; and  Physical  Examination-. 

The  Difficulties  of  Diagnosis. — It  needs 
scarcely  be  said  here  that  the  practice  of  diag- 
nosis is  not  free  from  great  difficulties.  Wo 
know  how  hard  it  is  to  obtain  in  ordinary  daily 
life  a reliable  account  or  description  of  any  past 
or  present  event.  There  must,  be  still  greater 
difficulty  in  obtaining  an  accurate  medical  history 
of  a patient’s  case.  He  has  to  tell  of  facts  of 
which  practically  he  may  know  much,  but  scien- 
tifically very  little.  He  may  be  forgetfnl  or 
ignorant  on  points  about  which  we  most  need 
to  be  informed.  He  may  be  inclined  to  ex- 
aggerate or  to  suppress  facts  of  material  import. 
Nor  are  the  difficulties  less  in  regard  to  the 
objective  phenomena  with  which  we  have  to  deal. 
The  symptoms  of  a disease  are  rarely  so  clear 
and  definite  as  to  mark  its  nature,  that  is,  to 
be  pathognomonic.  They  are  more  often  slight, 
undefined,  obscure,  and  to  be  found  with  diffi- 
culty. The  symptoms  of  one  disease  may  very 
closely  resemble  thoso  of  another,  whilst  those 


of  the  same  disease  will  vary  at  different  stagea 
and  in  different  individuals.  Again,  the  symp- 
toms of  a disease  may  be  complicated  by  thu 
co-existence  of  those  of  another  disease  ; whilst 
a symptom  sufficiently  striking  in  itself  may- 
be common  to,  and  present  in  several  different 
diseases.  We  need  only  mention,  for  example 
feverishness,  pain,  cough,  breathlessness,  and 
blood-spitting. 

These  are  some  of  the  difficulties  which  he  who 
has  to  study  the  operation  of  disease  in  life,  has 
to  contend  with.  He  must  come  prepared  for 
the  duty  with  a knowledge,  as  we  have  al  readi- 
said,  of  the  body7,  its  structure  and  functions  iu 
health,  and  with  a knowledge  too  of  thoso  com- 
binations of  morbid  actions  which  constitute 
special  forms  of  disease.  For  as  regards  this 
latter  knowledge,  all  the  observations  made 
would  remain  as  isolated  phenomena  if  they 
could  not  in  each  case  be  grouped  as  constituting 
distinct  diseases. 

We  have  thus  indicated  the  difficulties  of 
obtaining  accurate  knowledge  as  regards  both 
the.  subjective  and  objective  phenomena.  The 
difficulties  aro  not  less  when  the  exercise  of  the 
intellectual  and  reasoningfaculties  is  called  upon 
to  analyse,  to  compare,  and  to  group  these  pheno- 
mena. 

The  physician  may  commence  his  inquiry  by- 
tracing  up  the  history  of  the  case  and  its  several 
incidents,  a method  which  is  called  the  synthetical-, 
or  he  may  commence  by  ascertaining  the  present 
condition  of  the  patient,  and  going  as  it.  were 
backwards  in  his  inquiry — a method  which  is 
known  as  the  analytical.  As  a general  rule, 
both  methods  are  combined  in  the  practice  of 
diagnosis. 

Observers  can  sometimes  arrive  at  a direct 
diagnosis , aided  by  the  presence  of  some  charac- 
teristic symptom  or  sign  of  disease.  When 
diseases  which  are  essentially  different  have 
symptoms  more  or  less  common  to  both,  the 
physician  will  have  to  institute  a comparison 
between  them,  until  he  finds  sufficient  evidence, 
in  the  presence  or  in  the  absence  of  some  dis- 
tinctive symptom  or  sign,  to  satisfy  him  as  to 
the  nature  of  the  disease  which  is  present.  By 
being  able  thus  to  trace  the  absence  or  the 
presence  of  a given  symptom,  he  may  be  able  to 
exclude  the  possibility  of  the  existence  of  one 
or  other  of  the  diseases  under  investigation. 
These  modes  of  investigation  will  be  found  fully 
illustrated  in  the  diagnosis  of  the  several  dis- 
eases described  throughout  the  work. 

In  conclusion,  it  must  be  remembered  that  these 
investigations,  which  call  for  the  exercise  of  the 
highest  mental  faculties,  should  be  conducted 
without  prejudice  and  without  haste.  We 
should  never  be  ready  to  accept  as  clear  that 
which  is  obscure,  as  established  that  which  is 
open  to  question  : above  all  we  should  remem- 
ber that,  though  to  err  is  human,  it  is  our  duty 
to  endeavour  to  ascertain  in  each  and  every  case, 
before  commencing  its  treatment,  what  its  real 
nature  is,  as  far  as  it  may  be  possible  for  us  to 
do  so.  It  cannot  be  too  often  repeated  that  the 
application  of  a right  remedy  depends  on  an 
accurate  diagnosis,  and  that  the  prevention  and 
the  cure  of  disease  are  the  aims  and  ultimate 
objects  of  our  science.  E.  Qcain,  MJ5. 


*92 


DISEASE,  DURATION  OF. 

DISEASE,  Duration  of. — The  duration  of 
a disease  signifies  the  period  ■which  elapses  be- 
tween its  onset  and  its  termination,  in  whatever 
way  this  may  take  place.  In  some  instances 
disease  can  hardly  he  said  to  have  any  duration, 
a sudden  lesion  occurring,  which  instantaneously, 
or  in  a very  short  time,  destroys  life ; under  such 
circumstances,  however,  some  previous  disease 
has  usually  existed,  though  perhaps  without 
giving  any  clinical  evidence  of  its  presence, 
which  determines  the  occurrence  of  the  sudden 
result.  This  may  be  illustrated  by  some  cases 
of  apoplexy,  and  of  rupture  of  the  heart  or  of 
an  aneurism.  Most  affections,  as  regards  their 
duration,  come  under  one  of  the  three  categories 
already  referred  to  under  the  classification  of 
diseases,  namely,  acute,  sub-acute,  or  chronic, 
but  it  does  not  serve  any  useful  purpose  to  fix 
any  definite  limit  of  time  as  specially  expressed 
by  each  of  these  terms.  See  Acute,  and 
Chronic. 

Acute  diseases  are  of  limited  duration,  and 
in  many  of  them  this  is  remarkably  uniform, 
as  may  be  illustrated  by  the  acute  specific 
fevers  and  acute  idiopathic  pneumonia.  Even 
in  such  affections,  however,  there  are  deviations 
from  the  ordinary  course,  instances  occurring 
in  which  the  duration  is  longer  or  shorter 
than  that  usually  observed,  and  this  feet  de- 
pends on  various  circumstances,  of  whicli  the 
most  obvious  are  the  intensity  of  the  disease  in 
any  particular  case,  the  previous  condition  and 
surrounding  circumstances  of  the  patient,  the 
occurrence  of  complications,  and  the  treatment 
adopted.  Complaints  which  are  sub-acute  as 
regards  their  duration  may  be  exemplified  by 
many  cases  of  whooping-cough  and  chorea,  and 
by  some  cases  of  pleurisy,  phthisis,  pneumonia, 
gastric  or  enteric  catarrh,  and  certain  skin-affec- 
tions. A large  number  of  diseases  are  chronic 
in  their  duration,  and  many  of  these  when  once 
established  become  permanent,  whilst  others  are 
ultimately  capable  of  being  cured.  As  illustra- 
tions may  be  mentioned  organic  diseases  of  the 
heart,  most  cases  of  phthisis,  cirrhosis  of  the  liver, 
ehronic  Bright’s  disease,  dyspepsia,  many  skin- 
affections,  and  also  morbid  growths  in  various 
structures. 

Some  complaints,  as  regards  their  duration, 
can  only  belong  to  one  or  other  of  the  groups 
just  indicated,  but  a considerable  proportion  may 
in  different  cases  be  either  acute,  sub-acute,  or 
chronic.  Again  it  must  be  borne  in  mind  that 
a disoase  may  be  acute  or  even  sudden  in  its 
origin,  but  afterwards  may  subside  into  a chronic 
malady.  Certain  affections  are  chronic  as  regards 
t.hoir  entire  duration,  but  are  characterised  by 
the  occurrence  at  regular  or  irregular  intervals 
of  acute  or  even  sudden  attacks,  lasting  a more 
or  less  definite  time,  which  course  of  events  is 
exemplified  by  cases  of  ague,  epilepsy,  and 
asthma.  Frederick  T.  Roberts. 

DISEASE,  Germs  of.  — See  Germs  of 
Disease. 

DISEASE,  Prognosis  of  (irpl >,  before,  and 
; nemi.  I know). — Synon.  : Fr.  Pronostic;  Ger. 

I 'rognose. 

Definition. — Prognosis  is  the  art  of  forecast- 
ing the  progress  and  termination  of  any  given  > 


DISEASE,  PROGNOSIS  OF. 

ease  of  disease.  The  term  is  also  applied  to  the 
foreknowledge  thus  obtained. 

General  Considerations. — It  is  a matter  of 
interest  and  often  of  great  importance  to  be  able 
to  indicate  with  precision  how  a case  of  disease  or 
injury  will  he  likely  to  advance  and  terminate. 
This  question  must  be  always  present  to  the  phy- 
sician’s mind ; and  it  can  rarely  be  absent  from 
that  of  the  patient  and  of  those  who  are  in- 
terested in  his  well-being.  It  can  easily  be 
seen  how  much  depends  upon  the  answer  of  the 
physician  to  the  questions  constantly  proposed 
to  him,  How  long  is  this  illness  likely  to  last  ? 
How  is  it  likely  to  terminate  ? If  in  recovery, 
will  the  recovery  bo  complete  or  partial  ? If  in 
death,  when  and  how? 

Grounds  of  Prognosis. — The  knowledge  which 
can  give  trustworthy  answers  to  such  questions 
as  the  preceding  must  be  founded  upon  an  accu- 
rate diagnosis  of  the  nature  of  the  disease  from 
which  the  individual  is  suffering ; upon  the  capa- 
bility of  remedies  to  control  it;  and,  lastly,  upon 
an  estimate  of  the  constitutional  and  vital  powers 
of  the  patient. 

First,  as  regards  the  nature  of  the  disease. 
Some  diseases  which  are  mild  in  their  nature  run 
a definite  course  and  end  favourably;  take,  for 
example,  a simple  catarrh.  Others  commence 
with  great  intensity,  and  come  to  a favourable  or 
unfavourable  termination  very  rapidly,  for  in- 
stance, Asiatic  cholera,  of  which  many  of  the  sub- 
jects die  in  less  than  twent3‘-four  hours  from  the 
time  of  their  first  becoming  manifestly  ill.  A 
third  group,  such  as  typhus,  typhoid  fever,  and 
certain  of  the  exanthemata,  run  a longer  and 
more  defined  course,  seldom  terminating  in  death 
except  after  the  lapse  of  many  days,  nor  in  re- 
covery except  after  a period  of  some  weeks. 
Another  class  of  maladies,  chronic  in  character, 
rarely  acute,  such  as  we  see  in  tubercular  diseases 
of  the  lungs,  render  the  patient  more  or  less  an 
invalid  so  long  as  he  lives,  and  generally  end 
fatally.  The  like  observation  will  apply  to  the 
so-called  malignant  diseases. 

Secondly,  the  intensify  of  the  particular  attack 
affords  further  grounds  for  prognosticating  the 
result.  Thus  iu  a fever,  great  prostration,  high 
temperature,  and  rapid  pulse,  indicative  of  the 
severity  of  the  disease,  must  lead  to  the  forma- 
tion of  an  unfavourable  prognosis;  just  as  great 
debility  and  wasting,  with  disturbance  of  the  nu- 
tritive functions  generally,  would  indicate  a like 
result  in  chronic  diseases. 

Thirdly,  in  regard  of  local  diseases  or  compli 
cations,  whatever  the  nature  of  the  disease  may 
be,  the  organ  affected  must  form  an  important 
element  in  prognosis.  Thus  disease  of  the  brain, 
or  of  the  heart,  or  of  the  lungs,  or,  in  a lesser 
degree,  of  other  viscera,  must,  even  when  not 
specially  severe,  be  looked  upon  as  affording 
abounds  for  anxiety,  from  a prognostic  point  of 
view. 

Fourthly,  as  regards  the  constitution,  age,  and 
sex  of  the  patient,  it  may  be  safely  anticipated 
that  in  a patient  with  a good  consticution  the 
prognosis  will  be  more  favourable  than  in  a per- 
son with  a feeble  or  broken-down  constitution. 
Persons  whose  vital  powers  are  unimpaired  wil! 
resist  disease,  and  recover  under  circumstances 
which  would  be  fatal  to  other  individuals,  is 


DISEASE,  PROGNOSIS  OF. 
rhom,  on  the  one  hand,  plethoric  habits  may 
predispose  to  acute  and  rapid  changes,  or  who, 
on  the  other  hand,  by  degeneration  of  tissues 
may  be  rendered  liable  to  succumb,  and  that 
rapidly,  to  morbid  influences  which  healthier 
textures  could  resist  and  overcome. 

Disease  is  badly  borne  by  the  very  young  and 
the  very  old.  In  very  young  children  disease 
rapidly  runs  its  course,  favourably  or  unfavour- 
ably. The  aged  have  little  power  of  reaction  or 
of  resistance  ; and  disease  in  them,  though  less 
pronounced,  more  frequently  ends  unfavourably. 
In  middle  life,  disease  may  be  expected  to  assume 
an  acute  or  sthenic  form. 

As  a rule,  sex  has  little  influence  on  the  prog- 
nosis of  disease,  except  that  usually  diseases  of 
equal  severity  are  more  amenable  to  treatment 
in  females  than  in  males.  Nervous  symptoms 
are  however  more  easily  developed  in  women, 
exaggerating  a condition  that  might  not  other- 
wise "be  unfavourable.  Menstruation,  pregnancy, 
parturition,  and  lactation  have  all  a certain 
amount  of  influence,  sometimes  favourable  and 
sometimes  the  reverse,  on  disease  in  the  female. 

Fifthly,  with  respect  to  treatment ; a more  or 
less  favourable  prognosis  may  be  founded  upon 
the  fact  that  the  patient  can  enjoy  all  the  ad- 
vantages afforded  by  rest,  diet,  change  of  climate, 
&c.,  which  may  not  be  available  under  other 
circumstances  for  like  cases.  It  is  well  known 
that  there  are  some  remedies  which  have  a spe- 
cific effect  upon  certain  diseases,  as  quinine  upon 
intermittent  fever;  mercury  in  some  forms  of 
syphilis ; iodide  of  potassium  in  certain  stages 
of  the  same  disease  ; and  colchicum  in  gout.  In 
such  cases  a much  more  favourable  prognosis 
can,  of  course,  be  given  than  in  those  for  which 
no  such  remedies  are  known  to  exist.  Experi- 
ence tells  us  that  favourable  results  follow  in 
many  other  cases  in  which  suitable  though  not 
actually  specific  remedies  can  be  applied. 

Taking  into  consideration,  then,  the  above 
conditions— the  nature,  the  intensity,  and  the 
seat  of  the  disease ; the  constitution,  the  resist- 
ing-power,  the  age,  and  the  sex  of  the  patient ; 
and  the  possibility  of  applying  suitable  and 
efficient  remedies — we  are  able,  in  a large  num- 
ber of  cases,  to  arrive  at  an  accurate  conclusion  as 
to  what  the  course  and  result  of  a disease  will  be. 

Difficulties  of  Prognosis. — Still,  to  arrive 
at  an  accurate  prognosis  is  often  very  difficult. 
Disease  is  not  always  identical  in  its  character, 
nor  definite  in  its  progress  or  results.  The  con- 
stitutions of  individuals  vary,  and  it  is  often  very 
difficult  to  measure  their  powers  of  resistance. 
Remedies,  too,  vary  in  their  action  and  their 
operation;  and  sometimes  we  are  deceived  in 
the  best-founded  conclusion  as  to  the  results  that 
they  will  accomplish.  There  are  few  physicians 
who  cannot  recount  the  errors  of  prognosis  made 
by  themselves  or  by  their  colleagues.  Many  per- 
sons now  live  who  had  been  doomed  to  die  ; and 
many  persons  have  died  whose  death  was  not 
anticipated.  It  is  the  duty  of  the  physician, 
whenasked  for  his  opinion,  to  state  it  honestly,  but 
with  great  discretion,  and  in  general  with  as 
much  hope  as  is  fairly  admissible.  He  must  be 
guarded  as  to  the  manner  in  which  his  view  is 
communicated  to  the  patient,  for  there  are  many 
individuals  whose  temperament  is  suet  that  the 


DISEASE,  SYMPTOMS  OF.  393 
progress  of  their  disease  would  bo  greatly  influ- 
enced for  good  or  for  evil  by  the  expression  of  a 
favourable  or  of  an  unfavourable  opinion.  At 
the  same  time,  the  physician  must  avoid  deceit-, 
and  if  there  be  risk  or  danger  in  communicating 
an  unfavourable  prognosis  to  the  patient,  he  must, 
at  least  communicate  it  to  some  judicious  indi- 
vidual amongst  the  patient’s  friends.  Altogether, 
too  much  caution  cannot  be  exercised  in  stating, 
in  any  obscure  case,  what  its  progress  and  result 
will  be.  There  are  many  cases  in  which  the 
medical  attendant  will  be  justified  in  replying 
that  he  is  a physician,  and  not  a prophet.  He 
cannot  always  foretell  results,  his  aim  and  object 
ever  being  to  mitigate  the  patient's  suffering,  to 
prolong  life,  and  to  cure  the  disease  if  possible  : 
full  often  to  profess  or  to  do  more  than  this  is 
beyond  his  art.  R.  Quain,  M.D. 

DISEASE,  Symptoms  and  Signs  of. — When 
disease  affects  any  of  the  functions  or  structures 
of  the  body,  it  produces  certain  altered  actions  or 
changes,  which,  when  observed  during  life,  be- 
come evidences  of  its  presence  and  often  of  its 
nature,  and  which  then  are  called  the  symptoms 
and  signs  of  disease. 

The  terms  symptom  and  sign  are  often  used  sy- 
nonymously, though  the  derivations  of  the  words 
are  by  no  means  the  same.  Symptom , according  to 
its  derivation  ( tri'ixivTaya  = a coincidence)  means 
simply  a coincidence,  that  is  to  say,  it  coincides 
with  the  presence  of  certain  phenomena.  The  term 
sign  (from  sianum ) is  more  distinctive,  and  seems 
more  directly  to  point  to  some  special  or  pecu- 
liar condition.  Recently,  however,  an  attempt 
has  been  made  to  give  a more  special  meaning  to 
these  terms.  Symptom,  more  especially  if  it  be 
characterised  by  the  prefix  vital,  is  intended  to 
refer  to  modifications  of  functions,  or  to  such 
subjective  phenomena  as  we  can  learn  from  the 
patient’s  account  of  his  feelings.  On  the  other 
hand,  the  term  sign,  more  markedly  with  the  pre- 
fi s.  physical,  indicates  those  morbid  changes  which 
are  objective  or  may  be  recognised  by  the  senses 
of  the  physician,  assisted  by  other  appliances. 

It  would  possibly  be  well  if  the  meanings  of  the 
words— symptoms  and  signs  of  disease — as  above 
stated,  were  to  come  into  general  use;  but  there 
are  many  difficulties  in  the  way.  For  example, 
if  the  ear  be  applied  to  the  chest  in  the  case  of 
incompetence  of  the  aortic  valves,  we  hear  a 
murmur,  and  we  say  that  there  are  ‘ physical 
signs  ’ of  aortic  valve  imperfection  ; but  the  loco- 
motive pulse  and  its  peculiar  beat,  would  by  many 
be  called  a ‘symptom’  of  incompetence  of  the 
aortic  valves.  It  is  therefore  extremely  difficult 
to  draw  the  distinctionbet  ween  the  terms  symptom 
and  sign. 

By  whatever  name  these  phenomena  may  be 
called,  we  must  rely  upon  them  as  the  means 
by  which  we  are  enabled  to  form  our  diagnosis. 
The  more  accurate  and  complete  our  knowledge 
of  the  functions  of  the  body  and  of  its  component 
parts,  and  the  more  capable  we  are  of  interpret- 
ing, with  all  the  completeness  possible,  the 
changes  produced  by  disease,  the  more  accurate 
will  be  our  diagnosis  as  to  its  presence  and  its 
nature.  How  these  phenomena  maj'  be  best 
observed  will  be  found  discussed  under  the 
articles  on  Disease,  Diagnosis  of,  and  Physicai 
Examination.  R.  Quain,  M.D. 


m DISEASE,  TERMINATIONS  OF. 

DISEASE,  Terminations  of. — The  termi- 
nations of  a disease  must  be  regarded  both  from 
a pathological  and  from  a clinical  point  of  view. 
Each  pathological  process  or  condition  has  modes 
of  ending  peculiar  to  itself,  but  it  is  beyond  the 
province  of  this  article  to  discuss  these  at  any 
length,  and  one  or  two  illustrations  must  suffice. 
Thus,  inflammation  may  terminate  by  resolu- 
tion ; by  the  formation  of  different  effusions  or 
exudations  ; or  by  causing  suppuration,  softening, 
induration,  ulceration,  or  gangrene.  Fever,  if  it 
end  favourably,  may  terminate  by  crisis,  lysis,  or 
a combination  of  these  modes,  or  in  an  irregular 
fashion.  An  effusion  of  blood  may  remain  more 
or  less  altered ; may  undergo  organization  ; may 
soften  and  undergo  a puriform  change ; may  form 
a cyst;  or  may  be  altogether  absorbed. 

The  clinical  terminations  of  diseases  are  highly 
important,  and  demand  more  consideration.  In 
the  first  place,  a disease  frequently  terminates  in 
the  death  of  the  patient.  This  event  may  take 
place  suddenly  or  very  rapidly,  from  the  occur- 
rence of  some  serious  lesion,  or  of  grave  func- 
tional disorder  of  an  organ  essential  for 
carrying  on  the  phenomena  which  constitute 
life.  In  other  cases  death  is  the  termination  of 
a more  or  less  acute  illness,  either  affecting  a 
person  previously  in  the  enjoyment  of  good 
health  ; or,  what  is  not  uncommon,  being  the 
consummation  of  a chronic  malady,  which 
has  existed  for  a longer  or  shorter  period.  In 
still  other  instances,  death  is  a slow  and  chronic 
process,  the  patient  gradually  sinking,  several 
causes  and  morbid  conditions  often  ultimately 
contributing  to  the  fatal  event.  The  modes  in 
which  death  occurs  are  described  elsewhere,  and 
therefore  need  not  be  discussed  in  this  article. 
See  Death,  Modes  of. 

In  the  next  place,  a large  proportion  of  cases 
of  disease  end  in  complete  and  entire  recovery , 
the  patients  being  restored  to  theii  previous 
6tate  of  health,  and  no  organic  mischief  estab- 
lished. This  result  may  be  expected  in  most 
of  the  ailments  or  functional  disorders  which 
are  of  such  common  occurrence,  provided  proper 
treatment  is  carried  out.  Again,  the  great 
majority  of  cases  of  acutedissase  terminate  incom- 
plete recovery,  taking  them  in  the  mass,  though 
several  affections  of  this  class,  when  they  do  not 
prove  fatal,  are  liable  to  leave  behind  them 
more  or  less  serious  deterioration  of  the  general 
health,  or  even  actual  organic  disease.  In  this 
class  of  eases,  when  recovery  does  ensue,  it  is 
usually  only  after  a more  or  less  prolonged 
period  of  convalescence.  Chronic  complaints,  if 
they  are  of  a structural  nature,  cannot  in  most 
instances  end  in  complete  recovery,  although  to 
all  appearance  the  patient  may  often  be  quite 
restored.  Even  in  these  cases,  however,  an  actual 
cure  may  sometimes  be  effected,  and  that  after  a 
disease  has  had  a prolonged  duration.  This  is 
illustrated  by  several  chronic  skin-affections, 
syphilis,  and  chronic  inflammation  of  mucous 
surfaces.  Or  it  may  happen  that  the  patient 
recovers  perfectly,  only  with  the  destruction  of 
some  structure  which  is  not  essential  to  life, 
such  as  the  lymphatic  glands. 

Thirdly,  partial  or  incomplete  recovery  is  a i 
very  common  mode  of  termination.  This  is  ob- 
served in  many  cases  of  acute  disease,  where 


DISEASE,  TREATMENT  OF. 

either  the  patient  remains  permanently  in  a 
state  of  general  ill-health,  without  any  actual 
structural  lesion  being  discoverable;  or  some 
positive  organic  affection  has  been  established, 
of  which  phthisis  remaining  after  acute  pneu- 
monia, or  cardiac  disease  following  acute  rheuma- 
tism, afford  apt  illustrations.  An  attack  of  an 
acute  malady  may  also  serve  to  bring  out 
some  latent  constitutional  predisposition;  or 
may  leave  the  patient  in  such  a condition  that 
certain  so-called  corstitutional  maladies  are 
readily  originated  from  slight  causes.  Partial 
recovery,  amounting  often  to  very  marked  im- 
provement, may  take  place  in  many  serious 
diseases  of  a chronic  nature.  This  is  illus- 
trated by  numerous  cases  of  pulmonary  con- 
sumption, in  which  disease  great  improvement 
is  often  observed,  not  only  as  regards  the 
symptoms,  but  also  in  the  local  lesions,  so  much 
so  that  patients  not  uncommonly  regard  them- 
selves as  eurod.  Again  there  are  some  com- 
plaints in  which  apparent  recovery  is  brought 
about,  but  a tendency  to  recurrence  remains, 
either  without  any  obvious  reason  or  from  slight 
causes.  Such  affections  are  exemplified  by  ague, 
asthma,  neuralgia,  intestinal  catarrh,  bronchitis, 
and  certain  skin-diseases.  As  instances  of  in- 
complete recovery  may  be  also  mentioned  the 
cure  of  some  prominent  symptom  or  symptoms, 
while  the  disease  which  originates  these  pheno- 
mena continues  unaltered.  Thus,  it  may  bo 
possible  to  get  rid  of  ascites,  which  the  patient 
regards  as  the  disease  from  which  he  suffers, 
while  cirrhosis  of  the  liver,  upon  which  the 
ascites  depends,  is  a permanent  condition;  ex- 
tensive dropsy  and  other  symptoms  associated 
with  cardiac  diseases  may  also  be  got  rid  of.  while 
the  organic  mischief  still  remains.  Sudden 
lesions  may  terminate  in  partial  recovery.  For 
instance,  a case  in  which  a sudden  haemorrhage 
into  the  brain  has  occurred,  attended  with  marked 
apoplectic  and  paralytic  symptoms,  not  uncom- 
monly improves  remarkably  in  course  of  time, 
the  clot  being  moro  or  less  absorbed.  Some  com 
plaints,  which  are  usually  sudden  in  their  onset, 
may  apparently  be  recovered  from  completely, 
but  sometimes  set  up  conditions  which  ultimately 
lead  to  permanent  disease.  Thus  the  passage  of 
a gall-stone  or  of  a renal  calculus  may  excite 
such  irritation  as  to  cause  an  inflammatory  pro- 
cess to  be  set  up,  which  may  induce  perma- 
nent mischief,  such  as  closure  of  the  bile-duct 
or  of  the  ureter  in  the  several  instances,  and 
the  effects  may  not  be  perceptible  until  a con 
siderable  interval  has  elapsed. 

Lastly,  it  must  be  remarked  that  some  affec- 
tions can  hardly  be  said  to  have  any  termina 
tion.  They-  continue  during  the  life  of  the  indi- 
vidual, perhaps  interfering  but  little  or  not  at 
all  with  the  health,  or  at  all  events  not  in  any 
way  contributing  to  the  death  of  the  patient, 
when  that  event  does  happen.  This  applies  to 
many  of  the  ailments  from  which  people  suffer; 
as  well  as  to  many  chronic  organic  diseases  not  in 
themselves  serious  or  giving  rise  to  any  impor- 
tant symptoms,  and  not  implicating  structures 
essential  to  life.  Frederick  T.  Roberts. 

DISEASE,  Treatment  of. — This  term  ha« 
reference  to  the  means  by  which  disease  may  be 


DISEASE.  TREATMENT  OF.  39.« 


prevented — prophylactic  or  preventive  treatment; 
or  its  effects  counteracted  when  it  occurs — reme- 
dial or  curative  treatment. 

1.  Preventive  treatment  will  be  found  dis- 
cussed under  the  heads — Contagion;  Climate; 
Disease,  Causes  of ; Disinfection  ; Malahla  ; 
Personal  Health  ; Public  Health,  &c.  ; as 
well  as  in  the  several  articles  treating  of  special 
diseases.  It  is  therefore  unnecessary  to  say 
more  upon  the  subject  in  this  place. 

2,  Curative  treatment.— Bearing  in  mind  that 
disease  is  a deviation  from  health  in  the  functions 
or  component  materials  of  the  body,  it  must 
be  remembered  that  there  is  in  organized  bodies 
a tendency  to  maintain  their  healthy  function 
and  structure,  and  in  case  of  disease  or  injury 
to  recur  to  it.  This  is  especially  manifest  in 
tl'o  lower  types  of  animals,  which  when  mutilated 
are  capable  of  resuming  more  or  less  completely 
their  original  form,  to  tho  extent  even  of  the  re- 
storation of  parts  that  have  been  lost.  In  man  and 
the  higher  animals  this  power  of  complete  restor- 
ation is  confined  to  the  elementary  cells  and  least 
complex  structures  of  which  the  body  consists  ; 
the  more  complex  tissues  are  not  reproduced,  nor 
are  lost  parts  restored.  There  is,  however,  in  man, 
as  in  all  organised  beings,  a tendency  to  rectify 
deviations  from  health,  and  to  restore  the  or- 
ganization to  its  normal  condition.  To  remove  or 
subdue  the  causes  of  disease,  and  to  aid  this  re- 
storative power  in  the  establishment  of  healthy 
function  and  structure,  is  for  the  cure  of  disease  the 
most  philosophical  indication  that  can  be  adopted. 
But  our  knowledge  of  disease  and  of  remedial 
agents  is  not  sufficient  to  enable  us  always  to 
carry  out  these  principles.  As  the  treatment  of 
disease  has  been  directed  sometimes  to  the  one 
object  and  sometimes  to  the  other,  frequently  to 
neither,  it  has  given  origin  to  a greatvariety  of  sys- 
tems or  methods  of  practice.  Thus  iu  the  earliest 
history  of  the  healing  art,  means  the  most  diverse 
wore  used  for  the  relief  of  suffering.  Sometimes  the 
suffering  or  the  disease  yielded  whilst  these  means 
were  being  employed ; and  it  was  concluded, 
on  very  insufficient  grounds,  that  these  agents 
had  1 cured  ’ the  disease.  Persons  who  had  felt, 
as  they  supposed,  the  beneficial  effects  of  these 
particular  remedies,  communicated  them  to 
others  as  the  result  of  their  experience;  and 
thus  was  established  what  has  been  known  in 
Medicine  as 

Empiricism. — This  mode  of  practice  has  its  ad- 
vantages and  its  disadvantages.  When  aided  by 
accurate  knowledge  and  discrimination  it  often 
leads  to  satisfactory  results ; and  many  remedies 
suggested  by  experience,  and  that  alone,  are 
now  found  to  be  in  accord  with  our  more  ad- 
vanced scientific  knowledge  ; take,  for  example, 
the  use  of  mercury  in  syphilis,  which  though 
long  used  empirically,  is  now  known  to  act  by 
its  control  over  the  nutrition  of  young  cellular 
growths.  So  also  with  respect  to  quinino  and 
other  remedies  of  now  established  usefulness.  On 
the  other  hand,  mere  empiricism,  when  vaguely 
applied,  taints  and  damages  to  this  day  the  treat- 
ment of  disease.  It  is  this  practice  which,  for  ex- 
ample, suggests  opium  to  quiet  a cough  or  a colic, 
without  reference  to  the  cause  of  the  one  or  the 
other,  and  when  an  expectorant  or  a purgative 
Would  have  been  the  suitable  remedy;  and  it  is 


this  empiricism  which  does  such  liarin  in  the 
hands  of  amateur  practitioners,  leading  them  to 
recommend  for  the  relief  of  symptoms  remedies 
which  they  supposed  had  relieved  like  symptoms 
in  other  eases,  however  different  the  real  nature 
or  causes  of  these  symptoms  may  have  been. 

Rational  Treatment.  — On  tho  other  hand, 
modern  science  endeavours  to  take  cognizance 
of  the  nature  of  disease,  and  also  of  the  specific 
action  of  remedies  ; it  seeks  to  counteract  the 
operation  of  the  one  by  the  influence  of  the 
other.  This  constitutes  the  rational  treatment 
of  disease.  To  extend  this  system  should  bo 
the  object  of  the  scientific  practitioner.  On  tho 
one  side,  it  is  his  duty  to  study  the  nature  of 
disease  itself,  its  causes,  and  their  effects;  on 
the  other,  to  study  the  action  of  various  agents  on 
the  living  body  in  health  and  in  disease ; and  if 
possible  to  trace  how  far  the  one  is  capable  of 
combating  and  subduing  the  other.  This  study 
of  scientific  therapeutics  is  of  comparatively 
recent  date,  and  is  now  pursued  with  great  zeal. 
The  results  already  arrived  at  are  alike  satis- 
factory and  encouraging.  As  rational  treatment 
becomes  more  firmly  established,  scientific  medi- 
cine will  take  a more  elevated  and  nobler  position. 
The  modes  or  methods  by  which  the  two  great 
principles  just  alluded  to,  the  foundations  as  they 
are  of  tho  healing  art,  have  been  applied  are 
extremely  various,  and,  although  these  different 
methods  may  be  traced  to  the  one  or  to  the  other, 
they  have  received  distinctive  names,  according 
as  they  are  marked  by  some  special  characteristic. 
A few  of  these  modes  of  treatment  may  bo 
briefly  enumerated. 

1.  Expectant  treatment.— This  mode  of  treat- 
ment is  founded  on  the  principle  that  the  resto- 
rative power  should  be  allowed  entire  freedom  of 
action,  the  practitioner  neither  assisting  nor  in- 
terfering with  its  operation. 

2.  AVhat  is  called  Homcecpatldc  treatment  would 
by  some  persons  be  included  under  the  preceding 
head.  It  proposes  to  treat  disease  by  giving  in  in- 
finitesimal doses  substances  that  aro  supposed  to 
be  capable  of  producing  a diseased  condition  like 
that  which  they  are  intended  to  cure.  It  may  be 
described  in  the  words  of  Moli&re,  who  wrote  long 
before  Hahnemann,  the  inventor  of  homceopathy, 
as  Vart  d'amuscr  le  malade pendant  gae  la  nature 
gverit.  There  is  no  doubt  that  in  this  and  in 
similar  methods  of  treatment,  the  imagination 
plays  an  active  and  useful  part. 

3.  Palliative  treatment  consists  simply  in  the 
adoption  of  means  which  are  calculated  to  soothe, 
and  to  lessen  suffering,  and  thereby  to  prolong 
life  when  the  cure  of  disease  is  not  possible. 

4.  Stimulant  treatment  is  founded  on  a doc- 
trine which  regards  most  forms  of  disease  as 
associated  with  or  dependent  on  a lowered  state 
of  the  vital  powers,  and  which  teaches  that  in 
such  cases  the  free  use  of  stimulants  is  the  prac- 
tice most  to  be  relied  on.  See  Stimulants. 

5.  Antiphlogistic  treatment  is  the  converse  of 
the  preceding.  It  recognises  in  many  forms  of  dis- 
ease increased  nervous,  excitement  and  vascular 
fulness,  which  are  to  be  remedied  by  depressing 
agencies,  such  as  low  diet,  bleeding,  purgation, 
&c.  See  Blood,  Abstraction  of,  and  Depletion. 

6.  Purgative,  diaphoretic,  or  otherwise  eli- 
minative treatment  aims  at  removing  by  thf 


SO 6 DISEASE,  .TREATMENT  OF. 

intestinal  mucous  membrane,  by  tlie  skin,  or  by 
the  secreting  glands  respectively,  certain  morbid 
matters ; and  thus  allowing  the  restorative  power 
of  the  system  to  operate  more  efficiently.  See 
PURGATIVES,  &C. 

7.  The  Water  mre,  including  baths,  acts  partly 
on  the  principle  of  elimination,  partly  by  exert- 
ing a tonic  influence.  See  Baths  and  HYDRO- 
PATHY. 

8.  Revulsive  treatment  acts  by  producing  coun- 
ter-irritation by  means  of  blisters,  setons,  issues, 
and  the  like.  See  Counter-irritants,  Revul- 
sives, &c. 

9.  Dietetic  treatment  constitutes  a greater  or 
less  portion  of  all  modes  of  treatment.  It 
implies  a reference  to  the  kind  of  food  which  is 
adapted  to  the  circumstances  in  which  the  patient 
is  placed,  and  which  is  suitable  in  the  form  of  dis- 
ease from  which  he  is  suffering.  See  Diet. 

10.  The  treatment  by  Climate  operates  more  or 
less  by  removing  the  patient  beyond  the  region 
of  noxious  influences,  and  placing  him  in  circum- 
stances which  promote  healthy  action  of  the 
several  functions. 

It  is  well  known  that  under  these  several  and 
varied  modes  of  treatment  disease  may  yield  and 
patients  may  get  well.  Hence  it  has  been  said 
that  as  different  means  are  made  use  of  to  obtain 
a single  result,  the  treatment  of  disease  can  never 
be  absolutely  scientific.  Phthisis  is  pointed  out, 
for  example,  as  a disease  which  one  person  seeks 
to  relieve  by  cod-liver  oil,  another  by  climate, 
n third  by  tonics,  a fourth  by  sedatives,  a fifth 
by  attention  to  the  digestive  organs,  and  a sixth 
by  counter-irritation.  We  need  scarcely  say 
that  the  disease  bearing  the  name  of  phthisis 
is  an  aggregate  of  phenomena  or  conditions,  the 
relief  of  any  ono  of  which  may  lead  to  the 
amelioration  of  the  others.  Thus  the  general 
health  might  be  improved  by  climate,  and  with 
it  all  the  other  symptoms.  Cod-liver  oil,  with 
remedies  calculated  to  improve  the  digestion, 
may  lead  to  healthy  nutrition,  and  thus  to  miti- 
gation of  all  the  symptoms.  Tho  like  remark 
applies  to  the  other  agencies  mentioned.  The 
treatment  of  disease  must  not,  then,  be  con- 
demned as  unscientific  because  it  cannot  remedy 
a variety  of  morbid  states  by  a single  agent, 
but  would  aim,  on  still  strictly  scientific  prin- 
ciples, by  different  agencies  to  overcome  disease 
the  effects  of  which  are  manifested  in  different 
forms. 

In  conclusion,  it  may  be  repeated  that  the  end 
and  aim  of  the  practitioner  should  be,  if  possible, 
firstly,  to  discover  tho  cause  or  causes  on  which 
the  disease  depends,  and  to  remove  or  counteract 
them  if  practicable ; and,  secondly,  to  endeavour, 
by  every  available  means,  to  restore  to  health 
the  functions  of  the  body,  and  with  that  object 
to  guide  and  assist  Nature,  but  never  to  thwart 
her  operations.  R.  Quain,  M.D. 

DISEASES,  Types  and  Varieties  of. — In 
tho  case  of  many  diseases  more  or  less  distinct 
varieties  are  recognised,  which  in  some  instances 
constitute  well-defined  types.  It  is  important  to 
understand  the  precise  significance  of  these 
terms  in  different  cases. 

In  the  first  place  the  varieties  of  a particular 
affection  may  be  founded  upon  diversities  ob- 


D1S1NFECTION. 

served  in  its  clinical  history.  Thus,  according 
to  the  intensity  of  the  symptoms  and  their  dura- 
tion, a large  number  of  complaints  are,  as  has 
already  been  pointed  out,  divided  into  acute,  sub- 
acute, andchronic  varieties.  Agai  n‘,  many  diseases, 
while  presenting  in  the  majority  of  cases  a cer- 
tain group  of  symptoms,  upon  which  their  general 
clinical  description  is  founded,  exhibit  striking 
differences  in  the  exact  nature  of  the  phenomena 
observed,  as  well  as  :n  their  gravity,  when  the 
mass  of  cases  is  fatten  into  account,  and  on  these 
differences  varieties  or  types  are  founded.  This 
is  well  exemplified  by  some  of  the  acute  spe- 
cific fevers,  such  as  typhoid  fever,  scarlatina, 
measles,  and  small-pox.  Of  those  affections 
several  varieties  are  described,  dependent  upon 
the  severity  of  the  symptoms,  the  nature  of  those 
which  are  most  prominent,  or  the  characters 
of  the  eruption. 

In  the  next  place,  tho  classification  of  a 
disease  into  varieties  may  be  founded  upon 
a pathological  basis.  For  instance,  pulmonary 
phthisis  may  arise  from  different  morbid 
processes,  and  many  attempts  have  been  made 
to  arrange  the  cases  of  this  disease  into 
corresponding  groups.  Illustrations  of  these 
pathological  varieties  are  also  found  in  tho 
different  forms  of  cancer ; varieties  of  pneu- 
monia, of  laryngitis,  and  of  fatty  disease  of 
the  heart ; and  in  the  classification  of  serous 
inflammations  according  to  their  morbidproducts, 
such  as  fibrinous,  serous,  purulent,  &c.  Again, 
such  a pathological  condition  as  dropsy  or  fever 
may  be  divided  into  varieties.  Thus  dropsy  is  ar- 
ranged according  to  its  situation  and  distribution, 
as  anasarca,  ascites,  &c. ; or  according  to  its 
pathological  cause,  whether  cardiac,  pulmonary, 
hepatic,  &e.  Fever  is  recognised  as  having  seve- 
ral important  types,  founded  upon  its  intensity, 
its  course,  and  the  exact  nature  of  the  phenomena 
accompanying  the  pyrexial  state. 

Another  division  of  a disease  into  varieties 
is  (etiological , the  cases  being  grouped  accord- 
ing to  their  causation,  either  the  immediate 
pathological  or  the  more  remote  exciting  causes 
being  employed  as  the  basis  of  division.  Thus 
we  have  the  different  forms  of  meningitis 
(simple,  tubercular,  rheumatic,  &c.) ; the  setio- 
logical  varieties  of  pleurisy  or  peritonitis 
(idiopathic,  traumatic,  perforative,  tubercular, 
secondary,  &c.) ; those  of  joint-inflammation, 
(simple,  rheumatic,  gouty,  scrofulous,  &c.):  or 
those  of  intestinal  obstruction.  .Etiological 
varieties  are  often  at  the  same  time  charac- 
terised by  differences  in  the  pathological  results 
and  products.  Lastly,  it  must  be  mentioned 
that  sometimes  a certain  group  of  symptoms  is 
summed  up  for  convenience  under  some  single 
term,  which  symptoms  really  depend  upon  very 
different  morbid  conditions  and  causes ; and 
therefore  it  often  becomes  necessary  to  classify 
affections  thus  named  into  varieties.  Dyspepsia, 
neuralgia,  apoplexy,  epilepsy,  and  paralysis  will 
afford  illustrations  of  such  an  arrangement. 

Frederick  T.  Roberts. 

DISINFECTANTS.  See  Disinfection. 

DISINFECTION. — Stnon.  : Fr.  Disinfec- 
tion ; Gcr.  Desinficiren. 

Definition. — Disinfection,  in  the  proper  sense 


DISINFECTION. 


of  tlio  term,  means  any  process  by  which  the 
contagium  of  a given  disease  may  be  destroyed 
or  be  rendered  inert. 

Disinfectants,  however,  are  used  in  practice 
for  several  objects,  and  in  consequence  the  term 
has  often  been  vaguely  applied  to  the  use  of 
hea>t  or  chemical  means  for  preventing  the  gene- 
ration or  for  the  destrnction  of  noxious  agents, 
whether  products  of  specific  disease  or  not.  In 
this  vague  and  erroneous  sense  disinfectants  have 
been  confounded  with  deodorants,  which  merely 
cover  or  destroy  offensive  odours  without  affect- 
ing the  contagia;  and  with  antiseptics,  which 
‘ are  fatal  to  the  growth  and  multiplication  of 
microzymes.’  Following  the  line  indicated  by 
Dr.  Baxter  in  his  valuable  report  on  an  experi- 
mental study  of  certain  disinfectants,  it  is  neces- 
sary to  distinguish — - 

1.  The  true  meaning  of  the  word — that  of 
acting  on  the  specific  poisons  of  communicable 
diseases  in  such  a way  as  prevents  their 
spreading. 

2.  That  of  acting  upon  organic  substances  in 
sucli  a way  as  renders  them  less  liable  to 
undergo  molecular  change  and  decomposition, 
whethor  spontaneously  or  under  the  influence  of 
catalytic  agents,  as  in  the  case  of  emulsin  upon 
amygdalin,  or  under  the  influence  of  living  or- 
ganisms, such  as  are  connected  with  fermenta- 
tion and  putrefaction.  Examples  of  this  kind  of 
action  are  seen  in  salting  meat,  and  in  preserving 
small  animals  in  weak  solutions  of  carbolic  acid. 

Ij.  That  of  preventing  or  arresting  decompo- 
sition by  killing  the  torulae  associated  with  fer- 
mentation in  slightly  acid  media,  or  the  bacteroid 
organisms  associated  with  putrefaction  in  neutral 
or  alkaline  media.  Properly  speaking,  this  is 
the  action  of  an  antiseptic,  but  the  relative  power 
of  disinfectants  has  been  largely  estimated  by 
their  efficacy  in  this  respect,  partly,  no  doubt, 
because  antiseptic  power  is  desirable  in  a dis- 
infectant, but  chiefly  because  it  is  so  difficult  to 
submit  disinfectants  to  their  proper  test  by  ex- 
perimenting upon  contagium. 

4.  That  of  the  destruction  of  the  noxious  pro- 
ducts of  the  metabolism  of  dead  organic  matter, 
however  brought  about.  These  products  consist 
chiefly  of  gases  or  vapours,  many  of  which,  such 
as  sulphuretted  hydrogen,  ammonia,  and  sulphide 
of  ammonium,  are  easily  destroyed  by  appro- 
priate agents,  even  when  used  in  a very  dilute 
state,  and  success  in  this  respect  is  no  proof  of 
the  value  of  a disinfectant  in  its  true  sense, 
though  the  power  of  destroying  such  emanations 
is  possessed  by  almost  all  disinfectants  of  prac- 
tical utility. 

Mode  of  Action. — The  manner  in  which  dis- 
infectants are  supposed  to  act  is  very  various. 
Some,  such  as  permanganate  of  potassium,  ozone, 
and  oxygen,  set  free  from  water  by  chlorine,  oxi- 
dise organic  matter.  Others,  such  as  sulphurous 
acid,  withdraw  oxygen,  and  have  a reducing 
influence ; or.  like  chlorine,  may  combine  with 
hydrogen  and  remove  it,  or  form  substitution- 
compounds.  Those  of  a fourth  class,  such  as 
chloride  of  zinc  and  some  other  metallic  salts, 
are  supposed  to  owe  their  activity  to  the  power 
which  they  possess  of  coagulating  albumen  or 
combining  with  it.  Another  class,  of  which 
carbolic  acid  is  the  type,  is  supposed  to  arrest 


3S7 

molecular  changes,  whether  they  be  those  neces- 
sary for  vital  manifestations  or  for  decompo- 
sitions. And  finally,  the  mineral  acids  are 
supposed  to  be  efficacious,  in  part,  at  least,  be- 
cause they  alter  the  reaction  of  the  media  con- 
taining contagia.  Most  disinfectants  act  in 
several  of  these  ways. 

Gexerai,  Remarks. — It  has  been  proved  that 
the  contagia  of  several  diseases  must  consist  of 
minuto  solid  particles,  for  they  are  neither 
soluble,  nor  diffusible,  nor  volatile,  and  we  may 
infer  that  all  other  contagia  are  particulate 
likewise.  A characteristic  of  contagium,  due 
to  its  particulate  nature,  is  that  dilution  lessens 
the  chance  of  infection,  but  has  little  effect  upon 
the  case  if  the  disease  be  taken.  There  is  either 
no  effect  at  all,  or  a full  specific  effect.  Con- 
tagium particles  are  apt  to  exist  as  clouds  in 
air,  water,  or  milk,  instead  of  being  equally 
distributed  throughout ; and  this  bears  upon 
practical  disinfection.  The  particulate  and  non- 
gaseous  form  of  contagium  floating  in  the 
atmosphere  prevents  it  from  being  absorbed  by 
any  liquid  or  solid  disinfectant  which  does 
not  wash  or  come  into  intimate  contact  with 
every  portion  of  the  air,  and  as  this  is  impracti- 
cable, infected  air  can  only  be  puaified  by  gaseous 
disinfectants,  such  as  sulphurous  acid  or  chlo- 
rine. Disinfectants  of  this  kind,  to  be  effective, 
must  be  present  in  such  a quantity  as  is  incom- 
patible with  the  existence  of  human  beings.1 
From  this  it  follows  that  saucers  of  disinfecting 
fluids,  or  irritating  vapours  and  gases  in  the 
sick-room,  are  merely  a useless  annoyance  to 
the  patient,  except  in  so  far  as  they  may  be 
desired  as  deodorants.  The  best  method  for 
dealing  with  infected  air  is  to  replace  it  by  ven- 
tilation, especially  by  means  of  ventilating  open 
fire-places.  The  proper  use  of  volatile  disin- 
fectants is  the  purification  of  walls,  ceilings,  and 
inaccessible  places ; and  for  this  purpose,  if  pos- 
sible, enough  should  be  used  to  saturate  the 
atmosphere,  remembering  that  the  virulent  par- 
ticles are  most  likely  protected  by  being  buried 
in  a bit  of  epithelium  or  surrounded  by  an  albu- 
minous envelope. 

The  nature  of  the  medium  in  which  contagious 
particles  are  suspended  has  the  most  important 
bearing  upon  the  selection  of  a disinfectant. 
The  presence  of  albumen  is  found  to  protect  septic 
germs  to  a considerable  extent  against  the  action 
of  permanganate  of  potassium  and  chlorine,  but 
has  little  or  no  influence  upon  the  action  of  sul- 
phurous acid  and  carbolic  acid.  Dr.  Baxter  gives 
reasons  for  believing  that  the  comparatively 
uniform  quantitative  action  of  carbolic  acid  upon 
contagia  and  septic  microzymes,  as  compared  with 
the  striking  differences  between  the  disinfectant 
action  of  chlorine  and  permanganate  upon  con- 
tagia on  the  one  hand  and  septic  microzymes  on 

1 Though  disinfectant  or  antiseptic  gases  of  such 
strength  as  can  be  tolerated  in  the  sick-rocm  are  utterly 
inept  as  regards  useful  effect  upon  contagium,  it  is  just 
possible  thatthey  may  be  of  service  in  destroying  or  ren- 
dering incapable  of  change  the  organic  matters  evolved 
from  the  skin  and  lungs,  which  are  always  very  noxions. 
and  may  be  especially  so  in  disease.  These  organic  mat- 
ters are  necessarily  more  or  less  re-breathed  unless  tho 
patient  be  placed  in  a current  of  air.  If  ventilation  suffi- 
cient to  prevent  all  odour  cannot  be  provided,  then  some 
gas,  such  as  chlorine  or  ozone,  that  will  destroy  the  caua» 
of  the  odour  is  certainly  desirable. 


DISINFECTION. 


398 

the  other,  is  chiefly  or  entirely  due  to  differ- 
ences in  the  media  in  which  the  respective  par- 
ticles are  suspended,  and  not  to  differences  in 
resisting  power  possessed  by  the  particles  them- 
selves. This  points  to  an  important  advantage 
enjoyed  by  substances  like  sulphurous  acid  or 
carbolic  acid,  which  appear  less  influenced  by 
the  nature  of  the  medium,  and  also  shows  the 
necessity  of  thoroughly  mixing  disinfectants  with 
liquids  or  substances  to  be  disinfected.  The 
alkaline  or  neutral  character  of  virulent  sub- 
stances led  Dr.  Dougall  to  select  dilute  hydro- 
chloric acid,  which  has  little  action  upon  lead 
soil-pipes  in  the  cold,  as  the  best  disinfectant 
for  excreta. 

A cardinal  principle  in  disinfection  is  that  it 
should  he  carried  out  at  the  source,  or  as  near 
the  source  of  the  contagion  as  possible.  Inunc- 
tion with  lard,  with  carbolised  oil  (1  to  40),  or 
with  glycerine,  to  clog  epithelial  scales,  and 
regular  washing  and  change  of  clothing,  will  do 
much  to  protect  the  purity  of  the  air  against  con- 
tagium  proceeding  from  the  skin  in  such  dis- 
eases as  scarlet  fever  and  small-pox.  One  of 
ethereal  solution  of  peroxide  of  hydrogen  to  8 
of  lard  is  an  excellent  application  for  the 
skin  in  typhus.  Discharges  from  the  mouth, 
nose,  and  bowels,  as  well  as  the  urine,  should 
he  received  in  vessels  containing  disinfecting 
solutions  to  cover  them  and  give  protection 
to  the  air ; and  then  larger  quantities,  or  more 
concentrated  solutions,  as  tbe  case  may  be, 
should  be  thoroughly  incorporated  with  the 
discharges  before  they  are  removed  from  the 
original  vessels. 

Of  all  agencies  for  preventing  the  spread  of 
communicable  disease,  cleanliness  is  one  of  the 
most-  important.  Facts  have  been  adduced  point- 
ing to  the  conclusion  that  filth,  when  undergoing 
change  of  a fermentative  or  putrefactive  nature, 
is  in  a condition  the  most  conducive  to  the 
extension  of  infectious  disease.  Pending  the 
removal  of  accumulations  of  dirt,  and  for  the 
protection  of  workmen,  fermentation  may  he 
delayed  by  the  application  of  crude  carbolic 
acid,  chloride  of  zinc,  or  bichromate  of  potash, 
used  in  moderate  quantity  as  antiseptics,  and 
the  whole  accumulation  might  then  be  earthed 
over  if  it  had  to  remain  any  time.  For  real 
disinfection  the  large  quantity  required  and  the 
mixing  necessary  would  be  prohibitory. 

The  ultimate  fate  of  eontagium  is  to  be  de- 
stroyed by  putrefaction,  and  this  appears  invari- 
ably to  destroy  its  specific  infective  power.  In  cer- 
tain cases  where  real  disinfection  is  impracticable, 
as  in  dealing  with  the  accumulation  of  manure 
and  litter  from  a number  of  animals  suffering 
from  cattle-plague,  the  natural  processes  may  he 
hastened  by  stacking  the  material  so  that  it  shall 
‘ heat,’  or  may  oven  he  destroyed  by  sponta- 
neous combustion.  Certainly  putrefaction  should 
not  be  delayed  by  small  additions  of  disinfec- 
tants, which  cannot  accomplish  the  destruction 
of  all  noxious  matter  present. 

Special  Disinfectants.  1.  Heat. — Heat,  dry 
i)T  moist,  is  perhaps  the  best  disinfectant  we. 
possess.  The  experiments  of  Drs.  Henry,  Baxter, 
W.  Roberts  and  others  have  shown  the  effects 
of  this  agent,  upon  vaccine,  malignant  pustule, 
septic  microzymr.s,  scarlet  fever,  plague,  &e. 


High  temperature  and  length  of  exposure  are, 
to  a certain  extent,  mutually  compensatory,  but 
it  appears  that  a temperature  below  140°  F\ 
(60°  C.)  will  not  disinfect  vaccine  even  with  long 
exposure.  Tyndall  points  out  that  some  germs 
seem  to  be  in  a dormant  condition,  in  which  they 
resist  the  action  of  heat  unless  applied  very  long 
or  intermittently,  so  as  to  start  their  vitality 
into  growth,  when  they  are  easily  killed.  Ex- 
perimental facts  show  that  excessive  tempera- 
tures are  as  unnecessary  as  dangerous  in  practical 
disinfection.  It  is  extremely  improbable  that  any 
eontagium  can  withstand  a temperature  of  220°  F. 
(104  o C.),  maintained  during  two  hours.  When 
eontagium  is  shielded  by  thick  material,  into 
which  heat  penetrates  slowly,  the  time  necessary 
to  reach  the  disinfecting  temperature  may  he 
long,  and  hence  the  necessity  fdr  spreading  cloth- 
ing and  opening  out  bedding  in  special  hot-air 
chambers,  where  the  heat  ought  not  to  be  less 
than  220°  l'\  (104  o C.),  nor  more  than  250°  F. 
(121'1°  C.).  Hot-air  chambers  are  usually  built 
of  trick,  and  are  furnished  with  wooden  sup- 
ports for  clothing,  which  should  not  come  in 
contact  with  metal. 

Dr.  James  B.  Russell,  Medical  Officer  of 
Health  for  Glasgow,  has  communicated  to  the 
writer  the  most  important  fact,  that  at  the  In- 
fectious Diseases  Hospital  of  that  city  no  further 
disinfection  of  the  linen  and  clothing  of  the 
patients  is  carried  out  than  is  afforded  by  the  boil- 
ing, washing,  &c.,  requiredin  the  judgment  of  the 
washerwomen  to  cleanse  and  dress  the  clothing  ; 
and  yet  a continuous  careful  scrutiny  has  failed 
to  discover  a single  case  of  disease  propagated 
by  such  clothing.  It  is  probable  that  soda  is 
used  in  the  boiling,  in  some  cases  at  least,  and 
the  extreme  softness  of  Glasgow  water  doubtless 
helps  by  its  osmotic  and  dissolving  power. 

2.  Carbolic  Acid.— A solution  of  this  sub- 
stance of  the  strength  of  5 per  cent..,  or  1 in  20, 
is  the  only  one  fit  for  use  in  disinfection.  For 
steeping  fine  clothing  a solution  should  be 
made  from  crystals.  The  solution  generally 
useful  is  that  obtained  by  making  up  one  gallon 
of  crude  80  per  cent,  acid  to  sixteen  gallons 
with  water.  To  disinfect  a suspected  liquid,  an 
equal  volume  of  one  of  these  solutions  is  needed 
The  results  of  the  experiments  of  Baxter  and 
others  prove  that  ‘ no  virulent  liquid  can  be 
considered  disinfected  by  carbolic  acid  unless  it 
contain  at  least  2 per  cent,  by  weight  of  the  pure 
acid.’  A preparation  called  MacdougaWs  Pou'der 
contains  carbolic  acid,  but  is  inferior  to  the  pure 
kinds,  though  safer  and  more  applicable  in  many 
cases  to  prevent  odour.  .Tu.lging  from  the  light 
of  experiments,  carbolic  acid  vapour  is  quite 
useless,  though  clinically  Mr.  Crookes  and  Mr. 
Hope  thought  it  of  use  in  cattle-plague,  but  the 
animals  and  surroundings  were  drenched  with 
liquid  acid  or  solution.  Though  carbolic  vapour 
appears  impotent  asregards  effect  upon  eontagium 
it  will  preserve  the  freshness  of  a bit  of  meat, 
suspended  in  it  for  months.  Very  small  quan- 
tities of  the  liquid  acid  mixed  with  organic 
fluids ‘enables  them  to  remain  fresh  and  resist- 
decay  for  a long  time.  So  little  as  one-fifth  per 
cent,  preserves  milk.  It  is  obvious  then  that 
small  quantities  of  this  disinfectant,  instead  of 
destroying  eontagium.  may  actually  preserve  its 


DISINFECTION. 


activity,  when  otherwise  it  would  have  sue 
cumbed  to  the  action  of  natural  agencies.  This 
danger  may  accompany  the  limited  use  of  any 
disinfectant  that  has  a ‘pickling’  or  preserva- 
tive action  in  small  quantity.  Owing  partly  to 
the  volatility  of  carbolic  acid,  w'hich  removes  it 
in  time,  and  partly  to  the  peculiarity  of  its 
action,  another  danger  attends  its  use  in  any- 
thing short  of  full  strength  and  full  doses  when 
applied  to  kill  eontagium.  The  acid  may,  for  a 
time,  deprive  the  eontagium  of  its  infective 
power  without  permanently  abolishing  it,  and 
the  virulent  properties  may  be  regained  when- 
ever the  acid  has  evaporated.  This  has  been 
proved  experimentally  by  Dr.  Dougall,  of  Glas- 
gow, who  found  that  vaccine  mixed  with  carbolic 
acid  (1  in  50)  regained  its  infective  power  after 
10  days’  expostire  to  the  air. 

Carbolic  acid  coagulates  albumen  when  in 
sufficiently  strong  solution  ; while  it  restrains 
putrefaction,  and  limits  the  growth  of  low  forms 
of  animal  life.  It  decomposes  potassium  per- 
manganate, and  therefore  cannot  be  used  in 
conjunction  with  this  agent  or  with  chlorine. 
Though  it  does  not  destroy  sulphuretted  hy- 
drogen, it  is  a good  deodoraut  in  some  cases. 
When  Demonstrator  of  Anatomy  to  the  Uni- 
versity of  Edinburgh,  the  writer  experimented 
on  a large  scale  with  different  substances  for 
removing  odour  from  the  hands  of  the  stu- 
dents, after  working  in  the  dissecting-room,  and 
found  that  a 1 per  cent,  solution  of  carbolic  acid 
is  superior  in  efficacy  to  permanganate,  even 
when  strong  enough  to  stain  the  skin,  and  is 
also  preferable  to  chloride  of  lime.  In  this 
connection  it  is  worthy  of  remark  that  the 
‘septic ferment’  connected  with  scpticsemia,  ery- 
sipelas, &c.,  appears  to  be  destroyed  by  rather  less 
carbolic  acid  than  vaccine  requires. 

3.  Sulphur  Dioxide. — The  aqueous  solution 
of  this  substance  contains  sulphurous  acid.  Bax- 
ter’s experiments  show  that  it  is  the  most  potent 
volatile  disinfectant  known ; and  as  it  is  very 
soluble,  and  is  little  affected  by  the  presence  of 
albumen,  it  is  also  powerful  in  the  disinfection 
of  liquids.  It  destroys  sulphuretted  hydrogen 
thus,  SO.,  + 2H,S  = 2H..0  + S3,  and  combines  with 
ammonia.  A strong  solution  of  sulphurous  acid 
is  sold,  but  is  difficult  to  use,  on  account  of  its 
suffocating  odour.  The  solution  can  be  made 
by  deoxidizing  hot  concentrated  sulphuric  acid 
with  copper-turnings  or  charcoal.  For  aerial 
disinfection  the  best  plan  is  simply  to  burn 
sulphur  in  very  large  quantities.  This  dis- 
infectant forms  sulphites,  and  is  a reducing  or 
deoxidizing  agent,  in  the  first  place,  for  it  unites 
with  the  oxygen  of  many  compounds  to  form 
sulphuric  acid;  but  it  may  give  up  oxygen,  and 
when  mixed  with  much  vegetable  matter  the 
sulphur  may  come  off  as  sulphuretted  hydrogen. 
Sulphur  dioxide  and  chlorine,  as  well  as  this 
substance  and  permanganate  of  potash,  mutually 
destroy  each  other,  and  therefore  should  not  be 
used  together.  Sulphur  dioxide  destroys  the 
activity  of  dry  vaccine  on  points  very  rapidly, 
and  even  when  much  diluted  stops  the  amoeboid 
movements  of  living  cells,  kills  vibrios,  and  acts 
deleteriously  on  vegetation.  ‘Whether  chlorine 
or  sulphur  dioxide  be  chosen,  it  is  desirable  that 
the  space  to  be  disinfected  should  be  kept  satu- 


399 

rated  with  the  gas  for  not  less  than  an  hour.’ 

‘ A virulent  liquid  cannot  be  regarded  as  cer- 
tainly and  completely  disinfected  by  sulphur 
dioxide,  unless  it  has  been  rendered  perma 
nently  and  strongly  acid.  The  greater  solubility 
of  this  agent  renders  it  preferable,  cateris  paribus, 
to  chlorine  and  carbolic  acid,  for  the  disinfection 
of  liquid  media  ’ (Baxter).  According  to  Baxter’s 
experiments,  a larger  percentage  of  sulphur  di- 
oxide than  of  carbolic  acid  is  required  for  the 
disinfection  of  the  virus  of  infective  inflammation, 
but  a smaller  percentage  for  other  eontagia.  Sul- 
phur dioxide  preserves  meat  nndother  substances, 
when  in  closed  vessels,  for  very  long  periods.  It 
bleaches  vegetable  colours,  attacks  iron,  and 
is  absorbed  by  cloth  and  leather — facts  to  be 
remembered  in  practical  disinfection.  I lb.  of 
sulphur,  when  burned,  produces  11 '7  cubic  feet 
of  sulphur  dioxide  gas. 

4.  Chlorine  is  most  easily  obtained  from  chlo- 
ride of  lime  or  bleaching  powder,  by  adding 
hydrochloric  or  sulphuric  acid.  Exact  propor- 
tions cannot  be  stated,  as  the  value  of  the 
bleaching  powder  varies  ; but  rather  more  acid 
than  equal  parts  of  bleaching  powder  and  strong 
hydrochloric  acid  may  be  taken.  The  acid 
should  be  diluted  before  use.  Another  method 
is  to  pour  strong  hydrochloric  acid  upon  heated 
binoxide  of  manganese  ; this  method  of  disinfec- 
tion is  impracticable  compared  with  burning  sul- 
phur. For  deodorizingwater-closets,  some  crystals 
of  potassium  chlorate  may  be  thrown  into  a wide- 
mouthed  bottle  containing  dilute  hydrochloric 
acid.  Euchlorine  comes  off  gradually,  and  is  both 
more  effective  and  more  agreeable  than  chlorine. 
The  most  marked  character  of  chlorine  is  it  a 
strong  affinity  for  hydrogen,  which  enables  it  to 
break  up  compounds  containing  that  body,  and 
to  set  free  in  a nascent  or  active  state  the  oxygen 
combined  with  hydrogen  iij  water.  It  is,  there- 
fore, one  of  the  most  universally  applicable  and 
powerful  deodorizers  in  existence.  Direct  ex- 
periment shows  that  ‘ there  is  no  security  for  the 
effectual  fulfilment  of  disinfection  short  of  the 
presence  of  free  chlorine  in  the  virulent  liquid, 
after  all  chemical  action  has  had  time  to  sub- 
side.’ Chlorine  is  soluble  in  water  to  the  extent 
of  2|  volumes  in  one,  and  this  solution  may  be 
used  for  disinfection.  AVhen  merely  used  as  a 
deodorizer,  enough  euchlorine  may  be  expelled 
from  moist  chloride  of  lime  by  the  carbonic  acid 
of  the  air  for  most  purposes. 

5.  Permanganate  of  Potassium. — This  sub- 
stance is  non-puisonous,  and  is  a good  deodo- 
rant, especially  for  the  emanations  from  organic 
bodies.  It  is,  moreover,  free  from  odour,  and 
its  aqueous  solution  shows,  by  loss  of  colour, 
when  it  is  exhausted.  It  is  a very  suitable 
deodorant  for  the  sick-room,  as,  when  dissolved 
in  water  and  a large  surface  of  the  solution  ex- 
posed to  the  air,  it  will  absorb  gases  to  some 
extent.  Contagium  being  non-gaseous,  is  not 
affected,  unless  in  contact  with  the  solution. 
Permanganate  of  potassium  is  a true  disinfec- 
tant, oxidizing  and  destroying  eontagia  as  well 
as  putrid  matters  ; but  the  quantity  required 
and  the  price  render  its  use  almost  impossible, 
for  enough  permanganate  has  to  be  used  to  de- 
stroy the  medium  or  vehicle  bearing  contagium 

I as  well  as  the  contagium  itself.  Condy’s  fluid  if 


DISINFECTION. 


400 

a solution  of  this  substance  in  water.  ‘When 
permanganate  of  potash  is  used  to  disinfect  a 
virulent  liquid  containing  much  organic  matter, 
or  any  compounds  capable  of  uniting  with  the 
permanganate,  there  is  no  security  for  the  effec- 
tual fulfilment  of  disinfection,  short  of  the  pre- 
sence of  undecomposed  permanganate  in  the 
liquid,  after  all  chemical  action  has  had  time  to 
subside’  (Baxter).  When  the  virulent  liquid  or 
matters  are  small  in  quantity,  permaganate 
solution  forms  a capital  receptacle,  and  may 
stand  by  the  bedside  as  a deodorant  till  re- 
quired as  a disinfectant.  The  safe  rule  in 
employing  permanganate  as  a disinfectant  is 
to  add  it  and  mix  till  the  colour  is  retained. 
Permanganate  has  no  effect  in  restraining  the 
appearance  of  bacteria,  or  preventing  the  onset 
of  putrefaction. 

6.  Acids. — The  mineral  acids  and  glacial 
acetic  acid  have  all  disinfecting  power  when 
used  in  sufficient  quantity ; but,  except  sul- 
phurous acid,  there  are  serious  difficulties  in  the 
way  of  their  use,  and  we  have  better  disinfect- 
ants. Hydrochloric  is  inferior  to  chlorine  as  a 
gaseous  agent;  but  the  solution  is  extremely 
cheap,  and  is  useful  for  disengaging  chlorine,  as 
well  as  for  employment  as  a disinfectant.  Chromic 
acid,  which  lias  remarkable  power  in  preventing 
putrefaction  and  killing  microzymes,  is  too  dear 
to  be  used  outside  the  laboratory. 

7.  Nitrous  Acid. — Nitrous  acid  can  be  easily 
disengaged  as  a gas  by  putting  bits  of  copper 
into  nitric  acid,  or  pouring  nitric  acid  upon  saw- 
dust or  starch.  It  is  the  best  deodorant  for  the 
deadhouse,  and,  without  doubt,  it  is  a vigorous 
disinfectant,  but  is  too  dangerous  for  ordinary- 
use,  as  it  may  easily  be  breathed  in  quantity 
sufficient  to  cause  fatal  bronchitis. 

8.  Chloride  of  Lime.  — Bleaching -powder 
gives  off  chlorine  easily,  and  this  probably  ex- 
plains its  disinfecting  power.  It  is  very-  cheap 
and  manageable,  and  hence  of  much  importance. 

In  regard  to  the  agents  hitherto  considered, 
we  have  more  or  less  of  the  sure  light  of  direct 
experiment  upon  contagium ; but  the  claims  of 
the  following  and  a legion  of  other  substances 
asserted  to  be  ‘ powerful  disinfectants,  of  which 
it  is  impossible  to  speak  too  highly,’ rest  entirely 
upon  chemical  theories,  or  the  opinions  of  phy- 
sicians, or  upon  their  power  of  coagulating  albu- 
men, or  of  delaying  or  preventing  putrefaction 
and  fermentation,  or  of  deodorising.  It  will  be 
scarcely  necessary  to  do  more  than  enumerate 
the  best,  as  follows  : — 

9.  Metallic  Salts,  including — a.  Bichromate 
of  Potash,  b.  Sulphate  of  Copper,  c.  Chloride  of 
Zinc  (Burnett's  Fluid)  which  can  be  made  very 
cheaply  by  pouring  hydrochloric  acid  upon 
calamine,  the  native  carbonate,  or  upon  zinc. 
It  seems  to  be  the  most  useful  of  the  metallic 
salts,  d.  Chloride  of  Aluminium,  e.  Ferric 
Chloride,  which,  if  strong,  liberates  offensive 
fumes  from  animal  matters,  but  is  a fair  anti- 
septic and  preservative.  f.  Ferrous  Sulphate, 
g.  The  Waste  Chlorides,  from  the  manufacture 
of  chlorine,  contain  MnCl2,  Fe2Cl6,  and  free 
HC1,  which  cost  next  to  nothing,  and  might  be 
used  for  larger  masses  of  filth  or  drains, 

10.  Ozone. — This  body,  got  by  half  immers- 
ing a stick  of  phosphorus  in  tepid  water,  or 


mixing  gradually  3 parte  strong  sulphuric  acid 
and  2 parts  permanganate  of  potassium,  oxidibes 
organic  matter-,  and  so  destroys  odours.  Tere- 
bene  and  cupralum,  a preparation  containing 
terebene,  are  good  deodorants,  and  give  rise  to 
ozone. 

11.  Charcoal.  — Charcoal  condenses  gases 
within  its  pores  where  combustible  gases  are  de- 
stroyed by  the  condensed  oxygen.  Contagium, 
unless  in  water,  does  not  enter  the  pores,  for, 
being  particulate,  it  is  not  absorbed  from  the  air 
as  gases  are. 

Pkacticae  Disinfection. — In  conclusion  a 
few  remarks  may  be  offered  as  to  the  modes  of 
carrying  out  disinfection  under  circumstances  in 
which  it  is  commonly  required. 

1.  Clothing  and  bedding. — In  dealing  with 
the  ragged  and  worthless  articles  of  the  poor,  local 
authorities  will  generally  find  it  most  satisfac- 
tory to  both  parties  to  burn  them  and  replace 
with  new.  By  such  discreet  generosity  danger 
is  averted,  and  good-will  created,  which  helps 
in  getting  early  information  and  carrying  out 
measures,  and  so,  by  shortening  epidemics,  saves 
expense.  If  not  burned,  clothing  may  be  baked 
(see  Heat),  or  well  boiled  with  soda.  Before 
coming  to  the  washhouse  they  may  steep  in 
5 per  cent,  carbolic  solution,  or  chloride  of  zinc 
(1  to  240),  or  chloride  of  lime  (2  oz.  to  the  gallon). 

2.  Booms. — The  foundation  for  disinfect 
ing  rooms  is  thorough  cleansing  with  soft 
soap  and  hot  water,  which  may  contain  a 
per  cent,  carbolic  acid,  but  the  carbolic 
solution  is  not  so  easily  handled.  The  walls 
and  ceiling  should  be  brushed,  and  wall-paper 
removed.  Furniture,  if  iron,  is  to  be  washed  with 
carbolic  solution,  and  removed  from  the  room. 
Textile  fabrics  should  be  baked  or  boiled, or  spread 
out  in  the  room  for  fumigation,  but  this  is  not 
so  effective,  and  colours  are  bleached.  The 
chimney,  doors,  and  windows  are  to  be  closed,  and 
crevices  covered  with  paper  pasted  on.  Then 
one  or  more  tubs  of  water  are  to  be  placed  in 
the  room,  and  an  earthenware  saucer  containing 
sulphur  placed  over  each,  supported  by  a pair 
of  tongs  laid  across  to  prevent  danger  from  fire. 
The  sulphur  can  be  lighted  by  pouring  a little 
alcohol  upon  it,  or  by  means  of  a live  coal.  The 
usual  rule  is  to  use  1 lb.  of  sulphur  for  each 
1,000  cubic  feet  of  space,  but  this  only  gives 
1-17  percent.  S02  to  the  air,  and  3 lbs.  is  a 
more  satisfactory  quantity.  The  door  is  to 
be  shut  until  next  day,  when  the  windows  and 
doors  are  all  to  be  opened,  and  kept  open  for 
twenty -four  hours.  In  whitewashed  rooms  the 
walls  should  be  scraped,  and  then  washed  with 
hot  lime  in  addition  to  the  fumigation. 

3.  Drains,  Water-closets, &c. — Proper  drains 
remove  sewage  so  swiftly  and  completely,  that 
little  or  no  sewage-gas  is  formed  if  ventilation 
is  given.  For  bad  drains  carbolic  acid,  chloride 
of  zinc,  or  waste  chlorides  from  the  manu- 
facture of  chlorine  are  fair  palliatives.  The 
excreta  from  cases  of  infectious  diseases  require 
a very  large  quantity-  of  disinfectant,  which 
should  be  applied  in  a concentrated  form  before 
they  are  thrown  into  the  water-closet  or  house 
pipes.  When  a reliable  amount  of  disinfectant 
is  in  these  cases  sent  down  the  pipes,  it  is  apt 
to  corrode  them  unless  it  lias  been  allowed  to 


DISINFECTION. 

expend  its  energy  on  the  excreta  alone  in  the 
first  place.  If  small  quantities  of  disinfectants 
are  poured  down  water-closets,  it  is  better  to  mix 
them  with  the  after-flush  water  which  fills  traps 
and  basins,  so  that  the  little  energy  available 
maj'  be  devoted  to  the  destruction  of  any  slime 
adhering,  or  portions  of  organic  matter  retained. 
Permanganate  of  potash  is  the  most  pleasant 
agent  for  thispurpose, though  expensive.  Chloride 
of  zinc,  from  its  cheapness  and  preservative 
power,  is  worthy  of  mention.  "When  there  are 
no  water-closets,  the  excreta  in  cases  of  cholera 
and  typhoid  fever  should  be  received  in  a vessel 
containing  half  a pint  or  more  of  a 1 in  20  solu- 
tion of  commercial  hydrochloric  or  sulphuric  acid, 
and  then  put  along  with  some  chloride  of  lime 
into  a covered  stoneware  vessel  in  the  back  yard. 
After  a few  hours  the  contents  of  this  vessel  may 
be  thrown  into  the  cesspool  or  upon  the  midden. 

4.  Dead  bodies,  if  putrid  or  bearing  conta- 
gium,  should  be  wrapped  in  sheets  wet  with  1 in 
20  carbolic  solution,  or  1 in  40  chloride  of  lime; 
or,  if  coffined,  sawdust  saturated  with  one  of  these 
solutions  should  be  packed  around  them. 

It  is  necessary  clearly  to  keep  in  view  the 
object  desired  when  selecting  disinfectants,  deo- 
dorants, or  antiseptics ; whether  it  be  destruc- 
tion of  contagium,  merely  ‘pickling’  and  pre- 
serving, arresting  pmtrefaction  and  fermentation, 
or  deodorisation.  From  all  that  has  been  said 
it  is  evident  that  the  different  ‘disinfecting’ 
nostrums,  applied  as  their  inventors  direct,  can 
have  little  effect  upon  contagium,  but  may  have 
more  or  less  power  in  the  other  directions  indi- 
cated. James  A.  Russell. 

DISLOCATION  OF  ORGANS  (dis-,  apart, 
and  locus,  a place).  See  Organs,  Dislocation  of. 

DISPLACEMENT  OF  ORGANS.  See 

Organs,  Displacement  of. 

DISSECTION  -WOUNDS.  Sec  Post- 
Mortem  Wounds. 

DISTOMA  (Sis,  double,  and  cttS| ua,  a 
mouth). — Synon.  ; Fluke  ; Fasciola  ; Fr.  dis- 
tome ; Ger.  Leberumrm. — A genus  of  trematode 
parasites,  vulgarly  called  flukes.  The  term  was 
founded  by  Retzius  in  1786;  but  the  title  Fas- 
ciola, previously  employed  by  Linnaeus,  is  the 
more  correct,  especially  when  applied  to  the 
common  liver-fluke,  which  is  an  occasional  in- 
habitant of  the  human  body.  Nearly  twenty  in- 
stances of  the  occurrence  of  this  parasite  ( Distoma 
kepaticum  of  some  writers)  in  man  have  been 
placed  on  record.  Besides  infesting  the  liver- 
ducts  and  gall-bladder,  it  has  been  found  under 
the  skin  behind  the  ear  (Fox),  beneath  the  scalp 
(Harris),  and  in  the  sole  of  the  foot  (Giesker). 

Several  other  species  of  fluke  are  known  to 
infest  mankind,  but  with  the  exception  of  the 
Egyptian  haeinatozoon  ( Bilharzia  hcematohia) 
none  of  them  are  of  frequent  occurrence.  Thus 
the  lancet-shaped  fluke  ( Bistoma  lanceolatum) 
has  thrice  occurred,  leading  to  a fatal  result  in 
a single  instance,  whilst  the  minute  Disioma  hy- 
terop/iytes  has  only  once  been  recorded.  The  large 
human  fluke,  sometimes  known  as  Busk's  fluke 
( Distoma  crassum ) had  also,  until  lately,  only 
once  been  noticed;  but,  through  Dr.  George 
Johnson,  the  writer  has  become  acquainted  with 
26 


DIURETICS.  401 

two  mor6  instances  of  infection  from  this  para- 
site, and  there  is  some  ground  for  believing  the.-, 
the  cases  of  fluke  described  by  Dr. 

Leidy  of  Philadelphia  refer  to  the 
same  parasite.  More  recently  also 
(Lancet,  1875)  Dr.  McConnell  has 
recorded  the  occux-rence  of  an  un- 
doubtedly new  species  from  a Chi- 
nese, for  which  the  writer  has  pro- 
posed the  title  of  Distoma  sinense. 

Large  numbers  infested  the  ducts 
of  the  liver.  Professor  Leuckart 
subsequently  proposed  the  term 
Distoma  spathulatum.  Professor 
McConnell  has  also  discovered  an- 
other fluke  in  man  ( D . conjunctum, 

Cobbold)  previously  only  known  to 
infest  the  fox  and  dog.  Taken  as  Fig.  IS. 
a whole  the  human  flukes  referable  D-ur!r”umx'~i 
to  the  genus  Distoma  have  very  diameters, 
little  clinical  importance;  but, since  After  McCon- 
there  were  striking  symptoms  in  ne!1- 
connection  with  the  above-mentioned  cases  of 
Distoma  crassum  (affecting  an  English  missionary 
and  his  wife  during  their  residence  in  China)  it 
may  be  as  well  to  mention  that  these  large  para 
sites,  individually  varying  from  one  to  three 
inches  in  length,  appear  to  be  capable  of  inducing 
severe  diarrhoea  and  colic.  Their  organisation  is 
totally  distinct  from  that  of  the  common  fluke. 
They  probably  never  gain  access  either  to  the 
liver  or  its  ducts.  ( Proceed . Linn.  Soc.,  Peb. 
1875.)  The  administration  of  santonine,  male 
fern,  and  other  anthelmintics  has  been  unat- 
tended with  positive  results ; those  specimens  that 
were  expelled  seeming  to  have  been,  as  it  were, 
starved  out  by  the  patients  having  been  put 
upon  a milk  diet,  recommended  by  Dr.  Johnson. 
The  missionary  and  his  wife  having  returned  to 
China  were  again  attacked  by  Distoma  crassum. 
In  tire  spring  of  1878,  they  again  consulted  the 
writer  in  London,  not  only  on  their  own  account, 
but  also  on  behalf  of  one  of  their  children,  a little 
girl,  who  had  also  contracted  the  fluke-disorder 
in  China.  Flukes  have  twice  or  thrice  been  de- 
tected in  the  eye,  but  they  appear  to  have  been 
sexually  immature  worms,  referable  probably,  as- 
Leuckart  has  suggested,  to  the  Distoma  l anccola- 
tum.  The  flukes  described  by  Treutler  and  Delle 
Chiaje,  if  genuine,  have  no  clinical  importance. 
See  Bilharzia.  T.  S.  Cobrold. 

DIURESIS  (Sia,  through,  and  ohpeu,  I pass 
water). — A free  excretion  of  urine,  whether 
natural  or  artificially  induced. 

DIURETICS  (Si a,  through,  and  ovpiw,  I pass 
water). 

Definition. — Remedies  which  increase  the 
secretion  of  urine. 

Enumeration. — The  following  comprise  the 
most  important  diuretics: — Water;  salts  of' 
Potash,  Soda,  and  Lithia;  Alcohol,  Nitrous  Ether, 
Turpentine,  Juniper,  Copaiba,  Cantharides, 
Digitalis,  Squill,  Tobacco,  and  Scoparium.  The 
action  of  diuretics  is  often  aided  by  brisk  purga- 
tion, depletion,  counter-irritation  over  the  loins, 
and  sometimes  by  the  use  of  mercury. 

Action. — The  secretion  of  urine  appears  to 
consist  partly  of  mechanical  filtration  of  fluid 


102  DIURETICS, 

through  the  glomeruli  of  the  kidney,  and  partly 
of  secretion  by  the  cells  of  the  urinary  tubules. 
The  filtration  in  the  glomeruli  is  increased  by 
anything  which  raises  the  blood-pressure 
throughout  the  system  generally,  or  in  the 
renal  arteries  locally.  The  systemic  blood- 
pressure  may  be  raised  by  cold  to  the  surface, 
digitalis,  squill,  and  tobacco.  Digitalis,  and 
possibly  other  drugs  have  also  a local  action 
on  the  renal  arteries,  which  are  more  readily 
affected  by  some  drugs  than  other  arteries  in 
the  body.  The  exact  mode  of  action  of  the  other 
diuretics  is  not  determined,  but  common  salt, 
nitrate  of  potash,  urates,  and  urea  increase  the 
flow  of  urine,  even  although  the  pressure  in  the 
vessels  of  the  kidney  is  very  low.  It  is  there- 
fore probable  that  they  stimulate  secretion  by 
acting  on  the  nerves  or  cells  in  the  kidney  itself. 

Uses. — Diuretics  are  employed  to  increase 
the  flow  of  urine,  and  thus  remove  water  or  ex- 
crementitious  products  like  urea  from  the  body. 
They  are  used  in  cases  of  general  dropsy,  or  of 
accumulation  of  fluid  in  the  peritoneum  or  pleura. 
In  febrile  conditions  they  are  given  to  aid  in  the 
elimination  of  waste  matter.  They  are  also 
employed  in  order  to  render  the  urine  more 
watery,  and  thus  prevent  the  deposition  of  solids 
from  it,  and  the  formation  of  calculi  in  the  kid- 
ney or  bladder,  or  to  redissolve  such  concretions 
when  they  are  already  formed.  Digitalis  and 
squill  are  most  useful  in  dropsy  dependent  on 
heart-disease;  the  other  remedies  are  more  effec- 
tive in  dropsy  dependent  on  disease  of  the  kid- 
neys or  liver.  The  action  of  digitalis  and  squill 
is  greatly  assisted  by  the  addition  of  a little  blue 
pill,  and  when  the  kidneys  are  much  congested 
or  pressed  upon  from  without  by  accumulation 
of  fluid  in  the  abdominal  cavity,  diuretics  some- 
times fail  to  act  until  the  congestion  has  been 
relieved  by  depletion  from  the  loins  or  the  use 
of  a brisk  purgative,  and  the  pressure  removed 
by  paracentesis.  T.  Lauder  Brunton. 

DIZZINESS.  See  Vertigo. 

DOGEMIUS  (Sbx.uos,  twisted). — A genus 
of  nemutoid  worms  established  by  Dujardin. 
Sec  ScLEROSTOMA. 

DOTHINENTEKITIS  (SoBtrjy,  a pustule, 
and  evrepov,  the  intestine). — A synonym  for  a 
form  ( f enteritis,  accompanied  by  an  enlargement 
of  the  follicles,  which  causes  them  to  resemble 
pustules.  Sec  Intestine,  Diseases  of. 

DOUCHE  (Ft.). — Definition. — A jet  of 
water  propelled  against  some  part  of  the  body 
through  a doccia  or  pipe.  The  size  of  the  jet  of 
water,  the  degree  of  its  impetus,  and  its  tempera- 
ture, can  all  be  regulated.  A douche  differs  from 
simple  affusion  in  its  application,  being  more 
local,  and  the  force  with  which  it  is  applied  being- 
greater. 

AppuiciTioN  and  Action. — Douches  of  cold 
and  of  hot  water,  of  vapour,  and  occasionally 
of  gas  are  employed;  but  those  by  far  the  most 
commonly  used,  except  where  there  are  hot 
natural  waters,  are  of  cold  water. 

The  immediate  effect  produced  by  a cold 
douche  on  those  who  are  unaccustomed  to  it 
is  a feeling  of  shock,  spasmodic  shortness  of 
breathing,  palpitation  of  the  heart,  and  some 


DOUCHE. 

times  pain  in  the  back  of  £he  head.  Locally  the 
first  effect  of  a douche  is  to  deaden  the  sensi- 
bility of  the  part  to  which  it  is  applied;  but  if 
the  douche  be  powerful  enough,  reaction  of  the 
part  comes  on  in  about  forty  seconds.  This 
continues  for  a time  ; but  if  the  douche  be  kept 
up  for  three  or  four  minutes,  the  pulse  falls  seven 
or  eight  beats,  the  deadening  of  sensibility  re- 
turns, and  the  temperature  of  the  part  is  greatly 
lowered ; when  the  douche  is  withdrawn  re- 
action again  takes  place.  This  alternate  seda- 
tive and  stimulating  effect,  producing  emptiness 
and  turgescence  of  the  vessels,  quickens  the 
action  of  the  capillaries  of  the  part,  and  thus 
favours  the  transmutation  of  tissue.  The  mecha- 
nical effect  of  the  force  with  which  the  douche 
is  applied  must  not  be  overlooked.  If  great,  it 
produces  the  highest  amount  of  stimulation, 
which  may  almost  amount  to  inflammation. 

Different  portions  of  the  body  have  different 
degrees  of  tolerance  of  the  douche.  Thus  the 
extremities  and  the  head  bear  it  better  than  the 
chest,  and  the  chest  somewhat  be:ter  than  the 
abdomen  ; and  the  posterior  aspect  of  the  body 
bears  it  much  better  than  the  anterior.  Patients 
soon  get  accustomed  to  the  cold.  Warm  douches 
produce  less  shock,  and  are  more  easily  borne, 
but  they  are,  comparatively  speaking,  little  cm 
ployed  in  private  houses.  An  alternation  of  hot 
and  cold  douches,  known  somehow  by  the  name 
of  Scotch , is  a valuable  remedy ; in  it  the  hot 
water  rapidly  restores  the  irritability  of  the  part 
deadened  by  the  cold  water,  and  there  is  a maxi- 
mum of  action  and  reaction  of  the  part  obtained. 
Under  particular  circumstances  it  may  be  expe- 
dient to  use  a jet  of  steam,  but  this,  of  course, 
must  be  used  with  caution  ; and  a jet  of  carbonic 
acid  is  sometimes  propelled  against  the  eye  or 
ears,  or  the  neck  of  the  uterus.  What  are  called 
ascending  douches  are  used  for  the  rectum  or  the 
vagina.  Douches  for  the  eye  and  the  ear  have 
been  used  of  late  years.  In  a certain  sense  what 
the  English  call  pumping  is  a variety  cf  the 
douche,  and  the  shower-bath  is  in  reality  merely 
a multiplication  of  fine  douches.  The  action  of 
douches  is  more  or  less  general  according  to  the 
portion  of  the  body  to  which  they  are  applied. 
Thus  the  application  of  a douche  to  the  head 
has  the  most  general  action,  and  that  to  the 
spine  the  next  so.  In  either  case  it  is  impossible 
to  limit  it  very  strictly,  and  there  is  a certain 
amount  of  affusion  besides  the  direct  douche.  A 
douche,  again,  applied  to  one  of  the  extremities 
may  easily  be  localised ; and  a douche  may  be 
applied  only  to  one  part  or  to  several  parts  of 
the  body  in  succession. 

Douches  merely  require  a pipe  with  nozzles 
of  various  sizes  in  connection  with  a cistern  at 
a certain  elevatioD,  or  with  a pumping  machine, 
and  can  easily  be  improvised.  Shower-baths 
can  be  procured  with  equal  facility.  A vapour 
douche  can  be  got  by  attaching  a pipe  to  a vessel 
of  boiling  water.  In  the  case  of  the  fine  douches 
used  for  the  eye.  the  water  is  propelled  with  suf- 
ficient force  by  the  action  of  a caoutchouc  bag 
worked  by  the  hand.  Carbonic  acid  is  practically 
little  used,  and  only  where  there  is  an  abundant 
natural  supply  of  the  gas. 

Perhaps  50°  may  be  considered  the  arerajfc 
temperature  of  a cold  douche,  and  from  tout 


DOUCHE. 

minutes  to  a quarter  of  an  hour  its  average  dura- 
tion. The  course  of  douching  will  probably  ex- 
tend at  least  over  a fortnight.  As  to  the  actual 
temperature  of  the  water,  the  sensation  it  pro- 
duces in  the  patient  depends  most  on  his  con- 
dition. Thus  water  of  45°  may  feel  ice-cold  to 
one  who  has  just  quitted  a hot  bath.  In  like 
manner  a douche  of  slightly-heated  water  may 
appear  quite  warm  when  applied  to  a part  cooled 
by  a cold  douche.  The  temperature  of  a douche 
should  vary  according  to  the  condition  of  the 
patient. 

Uses. — As  a general  rule  we  may  say  that 
douches  are  only  applicable  in  cases  of  chronic 
disease;  that  cold  douches  are  most  useful  in 
constitutional  diseases;  and  that  warm  douches, 
and  the  alternation  of  hot  and  cold,  are  most 
suitable  in  local  affections. 

The  cold  douche,  when  it  is  employed  gradually 
and  with  judgment,  is  found  serviceable,  in 
chlorotic  and  hysterical  conditions,  in  hysterical 
paralysis,  and  in  over-sensibility  of  the  skin, 
with  tendency  to  catch  cold  ; and  of  late  years 
it  has  formed  a part  of  the  special  treatment  of 
phthisis  in  elevated  places.  As  cold  affusion  on 
the  head  is  very  serviceable  in  infantile  con- 
vulsions, so  the  application  of  a douche  of  cold 
water  to  the  head  is  a calmative  and  hypnotic 
in  maniacal  cases.  It  is,  perhaps,  not  so  much 
used  in  this  way  as  formerly,  as  it  has,  like  the 
shower-bath,  come  to  be  considered  a sort  of  pun- 
ishment to  troublesome  lunatics.  Still  it  is  a 
valuable  agent.  Hydropathic  practitioners  have 
found  douches  useful  revulsives  in  congestion  of 
t he  liver  and  of  the  uterus. 

Locally  douches  have  been  used,  but  with 
moderate  benefit  only,  in  some  cases  of  skin- 
affections  and  of  chronic  ulcers.  Their  prin- 
cipal local  application,  however,  is  in  cases  of 
old  sprains,  in  chronic  rheumatism  or  gouty 
thickenings  of  joints,  in  lumbago,  in  some  neu- 
ralgias, and  in  paralysis  when  it  is  not  too  recent. 
The  Scotch  is  far  the  most  effective  for  these 
purposes,  and  there  seems  to  be  some  evidence 
nf  its  having  been  efficacious  in  threatened  tabes 
dorsalis — certainly  more  efficacious  than  any 
other  remedy.  Douching  might  be  used  more 
extensively  in  private  houses ; still,  as  assistance 
is  always  required  by  the  patient,  public  baths 
have  advantages  for  their  application. 

John  Macfherson. 

DRACTTNCUXTIS  (dracunculus,  a little 
dragon). — A synonym  of  the  guinea- worm. 
Under  this  title  the  parasite  was  described  by 
Lister  (Phil.  Trans.,  1690),  and  afterwards  by 
Kaempfer  (1694).  Following  the  latter  autho- 
rity the  writer  has  elsewhere  recognised  the 
term  as  of  generic  value,  but  the  majority  of 
helminthologists,  after  Gmelin,  prefer  to  place 


Fig.  17. — Dracunculus  Jfedinensis.  Reduced  to  J. 


the  worm  under  the  genus  Filaria  (F.  medi- 
nensis).  The  Dracunculus  was  known  before 
the  time  of  Lister,  having  been  described  in  a 
remarkable  work  by  Velscius  (1674)  and  by 
Agatharchidas  as  quoted  by  Plutarch.  There  is. 


DROPSY.  40! 

indeed,  every  reason  to  believe  that  the  so-called 
fiery  serpents  of  Moses  answer  to  the  dracuncnli 
of  Plutarch.  The  matter  is  fully  and  learnedly 
discussed  in  Kiichenmeister's  treatise  ( Parasite o. 
S.  305  ; also  in  the  English  edition,  p.  390  el 
seq.).  See  Guineaworm.  T.  S.  Cobbold. 

DRAINAGE.  See  Public  Health. 

DRASTICS  (Spaa,  I act). 

Definition. — Violent  purgatives. 

Enumeration. — The  drastics  most  frequently 
employed  are; — Hellebore,  Podophyllin,  Gam- 
boge, Elaterium,  Scammony,  Jalap,  and  Croton 
oil. 

For  action  and  uses  of  drastics,  see  Purga- 
tives. T.  Lauder  Bbunton. 

DRIBTJRG,  in  Westphalia.  Strong  Chaly- 
beate Waters.  See  Mineral  Waters. 

DROITWICH,  in  Worcestershire.  Com- 
mon Salt  Waters.  See  Mineral  Waters. 

DROPSY  (lid paip ; from  voap,  water,  and 
ap,  aspect,  appearance). — Synon.  ; Fr.  Hydro- 
pisie;  Ger.  IV asserts ucht. 

Definition. — Accumulation  of  serous  fluid  in 
the  subcutaneous  cellular  tissue,  or  in  a serous 
cavity. 

Dropsy  is  known  by  various  other  names, 
according  to  the  portion  of  the  body  affected 
When  confined  to  the  subcutaneous  cellular 
tissue  it  is  termed  (edema  or  anasarca-,  to  the 
peritoneal  cavity,  ascites.  The  term  is  often 
limited  to  these  two  forms  of  the  disease  ; and 
exudations  similar  to  that  of  ascites  in  other 
cavities  are  termed  hydropericardium,  hydroce- 
phalus, hydrocele,  hydrops  oculi,  hydrops  articuli. 
and  hydrothorax  or  pleural  effusion,  according 
as  they  are  contained  in  the  pericardium,  arach- 
noid, tunica  vaginalis,  eye,  joint,  and  pleura  re- 
spectively. 

Pathology.— The  accumulation  of  fluid  in 
tho  tissues,  or  in  a serous  cavity,  depends  upon 
more  fluid  exuding  from  the  blood-vessels  than 
can  be  taken  up  by  the  absorbents.  So  long  as 
no  obstruction  to  absorption  occurs,  it  rarely 
happens  that  more  fluid  can  exude  from  the  blood- 
vessels than  the  absorbents  can  again  take  up 
Absorption  is  partly  carried  on  by  the  veins,  and 
partly  by  the  lymphatics  ; principally,  however 
by  the  veins.  AVhen  venous  obstruction  takes 
place,  fluid  is  apt  to  accumulate  in  that  part  ol 
the  body  from  which  the  blood  ought  to  return 
by  the  obstructed  vessel.  But  it  does  not 
always  so  accumulate ; for  it  may  happen  that 
the  lymphatics  are  able  to  absorb  all  the  fluid 
which  exudes  from  the  capillaries,  and  to  return 
it  into  the  general  circulation.  Thus  it  has 
been  found  by  Banvier  that  ligature  of  the 
vena  cava  in  a dog  does  not  usually  produce 
oedema  of  the  lower  extremities,  but  if  one 
sciatic  nerve  be  divided  in  such  an  animal, 
tho  corresponding  leg  at  once  becomes  (Edema- 
tous. The  reason  of  this  is  that  so  long  as 
the  nerve  is  intact,  the  lymphatics  can  absorb 
all  the  fluid  which  exudes  from  the  capillaries 
but  when  the  nerve  is  divided  the  artoriec 
dilate,  more  fluid  is  poured  out  than  the  lym 
phatics  can  absorb,  it  accumulates  in  the  tissues 
and  (Edema  ensues.  This  oedema  is  not  due  u 


DROPSY. 


104 

paralysis  of  the  limb,  but  to  paralysis  of  the 
vessels.  For  if  the  sympathetic  fibres  through 
which  the  vaso-motor  nerves  pass  to  the  sciatic 
nerve  are  divided  before  they  join  the  motor 
fibres  of  that  nerve  in  the  sacral  plexus  the 
power  of  movement  remains  unimpaired,  but 
oedema  occurs  just  as  if  the  whole  nerve  had 
been  divided.  If,  on  the  other  hand,  the 
motor  strands  of  the  sacral  plexus  are  cut 
before  they  are  joined  by  the  sympathetic  fibres, 
the  limb  is  as  completely  paralysed  as  if  the 
sciatic  nerve  had  been  cut,  but  no  cedema  takes 
place.  Any  obstruction  to  the  venous  flow  will 
operate  in  the  same  way  as  ligature  of  a vein, 
though  to  a less  extent,  the  effect  varying  accord- 
ing to  the  amount  of  obstruction.  Thus  regurgi- 
tation of  blood  through  the  tricuspid  valve  tends 
to  produce  general  anasarca,  and  obstruction  to 
the  portal  vein  by  cirrhosis  of  the  liver  tends 
to  cause  accumulation  of  fluid  in  the  abdominal 
cavity. 

It  has  been  mentioned  how  great  an  influence 
dilatation  of  the  arteries  from  vaso-motor  paraly- 
sis has  upon  the  production  of  oedema  in  cases 
where  the  veins  are  obstructed.  Arterial  dilata- 
tion may  also  produce  a local  oedema,  even  when 
no  such  obstruction  is  present,  as,  for  instance, 
in  the  tissues  around  an  inflamed  part.  It  has 
been  shown,  however,  by  Winniwarter,  that 
the  walls  of  vessels  in  an  inflamed  part  are  more 
permeable,  and  allow  fluids  to  pass  through  them 
more  easily  than  healthy  vessels  will  do.  It  is 
probably  in  consequence  of  this  that  we  find 
that  a slight  stimulus,  such  as  scratching  the 
skin,  which  ordinarily  produces  in  a healthy 
person  only  slight  dilatation  of  the  capillaries, 
and  consequently  redness  of  the  part  scratched, 
will  produce  an  effusion  from  the  vessels,  and 
local  swelling  of  the  part  at  the  point  scratched 
in  persons  suffering  from  urticaria.  The  same 
thing  takes  place  when  the  skin  is  scratched  in 
the  neighbourhood  of  a part  stung  by  a wasp. 

But  this  alteration  in  the  vessels  is  not  the 
only  cause  of  the  oedema,  which  may  occur 
without  any  obstruction  to  the  circulation.  An 
alteration  in  the  composition  of  the  blood  ap- 
pears to  allow  it  to  permeate  more  easily  into 
the  tissues,  and  to  produce  oedema,  even  when 
there  is  no  obstruction  of  the  veins.  In 
cases  of  anaemia  we  find  oedema  occurring  at 
the  ankles,  although  there  is  no  obstruction  to 
the  venous  circulation  other  than  that  caused 
by  the  weight  of  the  column  of  blood  itself. 
In  these  eases,  however,  we  have  dilatation  of  the 
vessels,  as  is  shown  by  the  form  of  the  sphyg- 
mographic  tracing,  and  an  altered  composition 
of  the  blood  is  evidenced  by  tlie  anaemic  look  of 
the  patient.  The  dropsy  of  scurvy  is  probably 
also  due  to  blood-vascular  disorder.  In  albu- 
minuria tlie  altered  composition  of  the  blood 
appears  to  be  the  chief  factor  in  the  production 
of  cedema,  as  the  pulse  in  such  cases  may  bo 
hard,  evidencing  arterial  contraction,  and  not 
relaxation. 

_2Etioi,ogy.  — General  dropsy  affecting  the 
subcutaneous  tissue,  the  peritoneal  cavity,  and 
the  internal  serous  cavities  and  organs  generally, 
is  usually  the  result  of  albuminuria,  and  most 
frequently  of  that  form  which  depends  on  fatty 
degeneration  of  the  kidney.  In  cirrhotic  disease 


of  the  kidney  the  loss  of  albumen  in  the  urine 
is  much  less,  and  the  alteration  in  the  com- 
position of  the  blood  consequently  is  not  so 
great  as  in  the  first-mentioned  form.  The  arte- 
rial tension  also  is  greater  than  usual,  instead  of 
being  less.  In  the  amyloid  form  the  oedema  is 
generally  moderate. 

The  next  most  common  cause  of  dropsy  is 
tricuspid  regurgitation,  obstructing  the  venous 
circulation  throughout  tho  body.  This  regurgi 
tation  generally  depends  on  dilatation  of  the 
right  ventricle  consequent  upon  obstruction  tc 
the  flow  of  blood  through  the  lungs,  either  from 
chronic  bronchitis  and  emphysema,  or  mitral 
obstruction  and  regurgitation.  Dropsy  from 
cardiac  disease  generally  appears  first  in  the 
feet  if  the  patient  has  been  for  some  time  in  an 
upright  position,  while  dropsy  from  albuminuria 
is  often  first  remarked  by  a puffiness  of  the  eye- 
lids. In  the  former  it  appears  where  the  greatest 
obstruction  to  re-absorption  takes  place,  and  in 
the  latter  case  in  those  parts  where  looseness  of 
the  cellular  tissue  most  readily  allows  of  exuda- 
tion. 

Local  dropsies  have,  as  a rule,  local  causes. 
Even  the  swelling  of  the  feet  in  antemic  young 
women,  although  dependent  on  a general  cause, 
viz.,  dilatation  of  the  vessels,  and  altered  com- 
position of  the  blood,  is  determined  locally  by  the 
greater  obstruction  to  the  venous  circulation 
which  the  pressure  of  the  long  column  of  blood 
in  the  veins  between  the  feet  and  the  heart 
presents.  In  general  dropsy  also,  those  parts 
which  are  most  dependent  are  apt  to  become  most 
swollen.  It  is  not,  however,  always  so,  as  in 
certain  cases  the  dependent  parts  have  been 
noticed  to  be  less  dropsical  than  the  others. 
This  curious  phenomenon  seems  to  be  due  to 
some  vaso-motor  nervous  influence  on  the  vessels 
of  the  dependent  part.  The  local  cedema  of  a 
brawny  character,  often  noticed  around  in- 
flamed parts,  is  partially  due  to  swelling  of  the 
tissues  themselves,  and  partially  to  effusion  of 
fluid  between  them.  This  effusion,  as  has 
already  been  mentioned,  appears  to  be  caused 
both  by  the  dilatation  of  the  vessels  observed 
in  inflamed  parts,  and  by  the  greater  readines- 
with  which  fluids  pass  through  them. 

Dropsy  in  Serous  Cavities. — The  serotu 
cavities  of  the  body,  the  arachnoid,  pleura,  peri 
cardium,  peritonaeum,  &c.,  are  now  known  to  be 
large  lymph-sacs,  in  communication  with  the 
general  lymphatic  system  of  the  body.  Tlie 
fluid  which  exudes  into  them  from  the  blood- 
vessels is, in  the  peritonaeum  and  pleura,  removed, 
at  least  in  part,  by  a pumping  action  in  the 
movements  of  respiration.  The  central  tendon  of 
the  diaphragm  contains  spaces,  the  walls  of  which 
are  alternately  drawn  apart  and  pushed  together 
during  its  ascent  and  descent.  Their  separation 
draws  up  lymph  from  the  abdominal  cavity,  and 
their  compression  forces  it  onwards  through  tho 
lymphatic  vessels.  The  same  thing  occurs  in  the 
costal  pleura,  during  tlie  respiratory  expansion 
and  contraction  of  the  chest.  The  accumulation 
of  fluid  in  serous  cavities  may  be  due,  like  its 
accumulation  in  the  cellular  tissues,  cither  to 
diminished  absorption  or  increased  exudation. 
The  diminished  absorption  occurs  here  in  conse- 
quence of  pressure  upon  veins,  and  possibly  alsr 


DROPSY. 

from  interference  with  the  pumping  action  just 
described.  Accumulation  of  fluid  in  the  ven- 
tricles of  the  brain,  or  in  a sub-arachnoid  cavity, 
is  chiefly  due  to  compression  of  the  veins  of  Galen. 
In  the  peritonaeum  it  may  be  due  to  obstruc- 
tion of  the  portal  vein  by  cirrhosis  of  the  liver 
or  by  the  pressure  of  tumours,  and  it  may 
occur  to  a greater  or  less  extent  in  all  cavities 
of  the  body — from  general  obstruction  of  the 
venous  circulation,  by  disease  of  the  heart  or 
lungs,  in  the  same  way  as  anasarca.  It  may 
also  occur  in  these  cavities  from  alteration  in  the 
flood,  as  in  Bright’s  disease.  Active  dropsy  may 
occur  in  a serous  cavity  from  inflammation,  and 
here  the  exudation  of  fluid  is  much  more  rapid 
than  in  passive  dropsy,  the  vessels  of  the  in- 
flamed part  being  dilated  and  more  pervious  than 
usual. 

Treatment. — The  first  thing  to  be  considered 
in  the  treatment  of  dropsy  is  the  removal  of  its 
cause,  if  this  be  at  all  possible.  Where  it  is  due 
to  obstruction  of  a vein  we  must  hinder,  as  much 
as  possible,  the  accumulation  of  fluid  in  the  vein, 
bv  preventing  the  part  from  remaining  in  a 
dependent  position,  whiie  at  the  same  time  we 
try  to  aid  the  absorption  of  fluid  by  the  lymphatics 
by  gentle  upward  friction.  Where  it  is  due  to 
obstruction  of  the  circulation  in  the  lungs,  we 
must  diminish,  as  far  as  possible,  all  obstructions 
to  the  pulmonary  circulation  by  inhalations, 
emetics,  and  expectorants,  pushed  if  necessary  so 
far  as  to  cause  nausea  or  even  vomiting.  Where, 
the  obstruction  is  due  to  dilatation  or  valvular 
lisease  of  the  heart,  we  must  aid  the  organ  to 
ontraet  more  powerfully  by  the  use  of  cardiac 
stimulants,  such  as  alcohol  and  digitalis.  Digi- 
talis probably  has  a threefold  action  in  cardiac 
dropsy,  by  strengthening  the  heart,  by  contract- 
ing the  vessels,  and  by  stimulating  the  kidneys. 
It  strengthens  at  the  same  time  that  it  slows  the 
cardiac  pulsations,  and  by  making  the  heart  con- 
tract more  powerfully  it  keeps  up  the  onward 
current  of  the  blood  more  efficiently,  and  at  the 
same  time  lessens  the  dilatation  which  tends  to 
render  the  valves  incompetent.  Besides  its  effect 
on  the  heart,  digitalis  has  also  an  action  on  the 
vessels,  causing  the  arterioles  to  contract,  and 
probably  reducing  the  dropsy  in  this  way.  For 
the  contraction  of  the  arterioles  produced  by 
digitalis  is  exactly  the  converse  of  the  condition 
which  occurs  after  division  of  the  vaso-motor 
nerves,  and  which,  as  we  have  seen,  produces 
dropsy  whenever  any  obstruction  of  the  circula- 
tion exists.  It  is  not  known  at  present  whether 
digitalis  also  causes  increased  absorption,  but  it 
seems  highly  probable  that  it  does  so,  because  we 
know  that  it  stimulates  the  vaso-motor  centre, 
and  stimulation  of  this  part  of  the  nervous  system 
has  been  shown  by  Goltz  to  increase  greatly  the 
rapidity  of  absorption  from  the  lymph-sac  of 
the  frog.  In  addition  to  this  action  on  the  heart 
and  vessels  generally,  digitalis  possesses  a specific 
action  upon  the  vessels  of  the  kidney.  It  is  a 
powerful  diuretic,  and  by  thus  lessening  the 
amount  of  water  in  the  blood  it  will  tend  to  in- 
crease the  absorption  of  serous  fluid  either  from 
the  cellular  tissue  or  serous  carities.  AVhen 
".igitalis  alone  does  not  succeed,  the  addition  of 
squill  and  of  a small  quantity  of  blue  pill  fre- 
quently increases  its  efficacy.  Digitalis  succeeds 


DROWNING,  DEATH  BY.  405 
best  in  dropsy  caused  by  valvular  disease  or 
dilatation  of  the  heart.  It  is  not  so  useful  in 
dropsy  arising  from  renal  disease,  and  here  other 
diuretics  are  preferable.  One  of  the  best  is  spirits 
of  juniper,  given  either  as  a mixture  or  in  the 
form  of  Hollands  gin.  Spirits  of  nitrous  ether, 
nitre,  bitartrate  of  potash,  and  broom  are  useful 
in  all  forms  of  dropsy.  Copaiba  occasionally 
succeeds  where  other  diuretics  fail.  It  seems  to 
be  most  successful  in  dropsy  due  to  cirrhosis  of 
the  liver.  Hydragogue  cathartics,  such  as  com- 
pound jalap  powder,  elaterium,  &c.,  which  cause 
copious  watery  secretion  from  the  intestines,  sud- 
plement  the  action  of  diuretics,  and  by  removing 
water  from  the  body,  as  well  as  altering  its 
nutrition,  relieve  or  remove  dropsy.  In  some 
cases  of  Bright’s  disease  considerable  relief  has 
been  obtained  by  the  profuse  sweating  induced 
by  vapour  baths,  hot-air  baths,  jaborandi.  or 
pilocarpin.  AVhen  the  dropsy  does  not  yield  to 
other  remedies,  the  fluid  must  be  removed  by 
paracentesis  in  the  case  of  serous  cavities,  and  by 
very  small  superficial  incisions  or  punctures,  or 
by  the  insertion  of  very  fine  troehars  with  drain 
age-tubes  attached,  in  the  case  of  the  limbs. 

T.  Lauder  B run  ton. 

DROAYNTiN'G,  Death  by. — Drowning  is 
employed,  in  an  extended  sense,  to  signify  death 
from  submersion  in  a liquid  medium,  and  in  a 
more  restricted  sense  to  signify  death  in  conse- 
quence of  obstruction  of  respiration  so  caused. 
Now,  though  death  must  necessarily  ensue  from 
asphyxia,  when  the  air-passages  are  submerged, 
apart  from  any  other  complication,  asphyxia  is 
not  always  the  mode  of  death  in  those  who  were 
alive  at  the  moment  of  submersion.  For  death 
may  result  from  mechanical  injuries,  concussion, 
shock,  syncope,  or  apoplexy  in  the  very  act,  or  at 
the  moment,  of  falling  into  the  water.  Devergie 
estimates  that  12'5  per  cent,  of  deaths  occur 
from  one  or  other  of  these  causes.  In  the  remain- 
ing 87'5  per  cent.,  the  phenomena  of  asphyxia 
pure  and  simple  are  present  only  in  25  percent.., 
while  in  62  5 per  cent,  these  are  more  or  less 
modified  by  the  causes  above-mentioned,  to  which 
must  be  added  the  benumbing  influence  of  cold. 

AATien  death  is  not  sudden  from  shock,  &c., 
the  ultimate  result  is  the  same  in  the  swimmer 
or  non-swimmer,  if  there  be  no  escape  or  rescue. 
All  efforts  to  keep  above  water  fail,  vain  cluteh- 
ings  are  made  at  whatever  comes  within  reach, 
water  is  drawn  into  the  lungs  and  more  or  less 
swallowed,  all  struggles  finally  cease,  and  the 
body  sinks. 

The  indications  of  such  instinctive  efforts  form 
the  most  important  evidence  of  submersion  during 
life.  Drowning  is  not  necessarily  to  be  inferred 
in  the  ease  of  a dead  body  removed  from  the 
water ; for  the  body  may  have  been  thrown  in 
after  death  from  other  causes — asphyrxia  among 
the  rest. 

The  Evidence  of  Death  from  Drowning 
is  cumulative,  for  we  can  scarcely  say  that  there 
is  any  one  indication  invariably  present  which 
can  be  looked  upon  as  due  to  drowning  and 
nothing  else.  But  one  or  other,  or  more,  of  the 
following  appearances  are  generally  found. 

External. — The  face  is  either  pale,  or  more  or 
less  livid,  or  frequently  bloated  if  the  body  hi.s 


106  DROWNING,  DEATH  BY. 
lain  some  hours  in  the  water.  Foam  at  the  mouth 
and  nostrils  is  very  common;  and  the  tongue  is 
swollen  and  congested,  closely  applied  to  the 
teeth,  or  even  clenched  between  them.  The  skin 
is  pale,  or  marked  here  and  there  by  livid  dis- 
colorations, and  the  muscles  of  the  hair-bulbs  are 
rigidly  contracted,  causing  the  appearance  of 
goose-skin,  or  cutis  ayiserina.  The  penis  is  re- 
markably retracted,  so  that  it  appears  quite  small 
in  proportion  to  the  size  of  the  individual. 

Indications  of  struggling  are  frequently  seen 
in  excoriations  of  the  hands,  mud  and  sand  under 
the  nails,  or  even  weeds,  straws,  or  other  small 
objects,  tightly  clenched  in  the  hands. 

Internal. — The  trachea,  bronchi,  and  smaller 
air-tubes  are  congested  and  filled  with  a mucous 
froth,  more  or  less  tinged  with  blood.  The  lungs 
themselves  are  congested,  cedematous,  and  pit 
on  pressure.  Pressure  on  them  causes  froth  to 
exude  into  the  smaller  bronchial  tubes,  and  on 
section  a sanguinolent  froth  and  water  escape. 
Indications  may  be  seen  of  sand,  mud,  or  small 
weeds  drawn  deep  into  the  air-passages  along 
with  the  water  in  which  submersion  took  place. 

The  stomach  contains  water.  If  this  has  any 
special  character  by  which  it  can  be  identified 
v/ith  that  in  which  submersion  occurred,  and  not 
likely  to  have  been  drunk  to  quench  thirst,  it  ex- 
cludes the  theory  of  its  having  been  swallowed 
before  submersion  ; and  is  a strong  presumption, 
if  it  cannot  be  said  to  be  a certainty,  that  it  was 
swallowed  during  the  death-agony,  and  did  not 
find  its  way  into  the  stomach  after  death.  The 
same  may  be  said  of  water  in  the  lungs. 

The  right  side  of  the  heart  and  venous  sys- 
tem in  general  frequently  present  the  appearances 
characteristic  of  asphyxia ; and  the  brain  is  often 
congested. 

Without  relying  on  anyone  sign  as  conclusive, 
we  may  say  that  a body  which  exhibits  goose- 
skin,  retraction  of  the  penis,  excoriations,  &c.,  of 
the  hands,  froth  at  the  mouth,  water  in  the 
lungs  and  stomach,  and  congestion  of  the  right 
heart  and  venous  system,  certainly  died  from 
drowning.  In  the  presence  of  some  and  in  the 
absence  of  other  indications,  a careful  weighing 
of  all  the  facts  is  necessary ; but  in  most  cases 
a satisfactory  conclusion  can  be  arrived  at. 

Complete  submersion  is  usually  sufficient  to 
cause  death  within  two  minutes  ; but  cases  have 
been  recorded  of  resuscitation  after  a much 
longer  period.  Many  of  these  can  be  attributed 
to  the  exaggerated  estimation  of  time  by  anxious 
on-lookers ; but  there  are  other  well-authenti- 
cated instances,  which  may  be  explained  by  the 
supervention  of  syncope  and  temporary  cessation 
of  the  respiratory  process.  That  which  renders 
resuscitation  after  submersion  less  likely  than 
after  a corresponding  period  of  mere  suffocation 
is  the  entry  of  water  into  the  lungs  by  aspiration. 

Treatment. — The  treatment  of  the  drowned 
consists  in  the  persistent  use  of  artificial  respira- 
tion (see  Artificial  Respiration,  and  Resus- 
citation) so  long  as  any  signs  of  life  remain, 
together  with  the  application  of  means  to  coun- 
teract the  great  abstraction  of  body-heat  which 
occurs  even  when  the  aerial  temperature  is  com- 
paratively high.  Before  commencing  the  move- 
ments of  artificial  respiration,  the  mouth  and 
nostrils  should  bo  freed  from  water  and  froth, 


DUMBNESS 

by  holding  the  head  somewhat  low,  face  down- 
wards, for  a few  seconds.  Artificial  respiration 
should  then  bo  immediately  proceeded  with  ; 
and  at  the  same  time  the  wet  clothes  should  ba 
removed  and  the  body  wrapped  up  in  warm 
clothes  obtained  from  bystanders,  pending  the 
arrival  of  warm  blankets,  hot  bottles  or  bricks, 
&c.,  from  the  nearest  house.  Assiduous  friction 
of  the  extremities  should  also  be  kept  up.  These 
directions — artificial  respiration  excepted— natu- 
rally presuppose  assistance.  If  this  be  not  at 
hand,  the  operator  must  rely  mainly  on  artificial 
respiration.  In  the  performance  of  artificial 
respiration  by  Sylvester’s  method,  especial  care 
must  be  taken  against  pressing  on  the  stomach, 
for  as  it  so  frequently  contains  water,  this  may 
be  pressed  up  the  oesophagus,  and  drawn  into  the 
lungs  by  the  next  inspiratory  movement. 

When  spontaneous  respiratory  movements 
commence,  attention  should  be  directed  to  main- 
tain life,  by  the  application  of  warmth  exter- 
nally, assiduous  friction  of  the  limbs  upwards, 
and  the  administration  of  a teaspoonful  of  brandy 
and  water,  wine,  or  coffee.  Lung-complications 
should  be  watched  for  and  counteracted. 

D.  FaaRiBB. 

DROWSINESS. — Inclination  to  sleep.  See 
Sleep,  Disorders  of. 

DRW. — A term  applied  to  certain  morbid 
conditions,  to  express  the  entire  or  comparative 
absence  of  fluid  exudation  or  secretion,  which  is 
often  present  in  such  conditions ; for  example, 
Dry  Gangrene,  Dry  Cavity,  Dry  Catarrh,  and 
Dry  Pleurisy.  The  word  is  also  associated  with 
certain  ausculatory  signs,  which  cbnvey  the 
impression  of  want  of  moisture ; for  example. 
Dry  Rhonchus  and  Dry  Crackle.  See  Physical 
Examination. 

DUCHENNE'S  PARALYSIS.  See 

PsETJnO-HYPERTEOFHIC  PARALYSIS. 

DUCTUS  ARTERIOSUS,  Patency  of.- 

Scc  Heart,  Malformations  of. 

DUMBNESS. — Definition. — The  condition 
of  an  individual  incapable  of  articulating  sounds. 

Dumbness  may  arise  from  a variety  of  causes, 
and  its  prognosis  and  treatment  vary  accordingly. 

1.  Dumbness  due  to  Deafness. — The  most 
frequent  cause  of  so-called  dumbness  is  congenital 
or  early  acquired  complete  deafness,  or  defective 
power  of  hearing,  so  that  the  patient  is  unable  to 
acquire  in  an  ordinary  way  the  knowledge  of  ar- 
ticulate sounds.  It  is  important  to  hear  in  mind 
that  complete  deafness  is  not  essential  to  this 
peculiarity.  Dumbness  is  frequently  met  with  in 
children  and  others  where  the  only  cause  is  defec- 
tive power  of  hearing. 

Treatment. — Whether  the  outcome  of  com- 
plete or  partial  deafness,  the  treatment  must 
be  based  on  the  belief  that  the  articulating  power 
is  latent,  and  may  be  developed  by  imitating 
the  process  of  speaking  in  others,  and  by  a 
methodical  training  in  lip  language.  It  is  most 
important  that  sign  language  should  not  bo 
cultivated  at  the  same  time,  and  that  if  a lan- 
guage of  signs,  whether  by  the  hand  or  gesture, 
have  been  previously  taught,  it  should  he  tho- 
roughly and  at  once  discarded.  With  patients 


DUMBNESS. 

who  have  full  intellectual  power,  and  who  are 
trained  as  indicated  above,  it  will  be  found  that 
for  them  dumbness  is  a misnomer,  articulate 
sounds,  although  with  a defective  modulation, 
being  readily  acquired.  Individuals  comingunder 
this  categoiy  are  erroneously  called  deaf-mutes. 

2.  Dumbness  from  Central  Lesion  of  the 
hypoglossal  nerve.— This  may  arise  from  cere- 
bral haemorrhage,  tumours,  or  embolism,  and  the 
prognosis  is  most  unfavourable.  It  is  usually 
associated  with  other  paralytic  conditions,  but 
is  of  all  the  most  persistent. 

3.  Dumbness  from  peripheral  lesion  of 
the  hypoglossal  nerve. — This  is  much  less 
frequent  as  a cause  of  dumbness  than  central 
lesions ; nevertheless  cases  are  met  with  where 
hydatid  or  other  tumours  result  in  dumbness 
through  pressure  on  the  nerve  itself. 

4.  Dumbness  from  Lead  Poisoning. — 
Among  the  paralyses  arising  from  the  slow 
i fleets  of  imbibition  of  lead  is  paralysis  of  the 
tongue,  with  consequent  loss  of  articulating 
power.  This  defect  is  usually  associated  with 
grave  impairment,  of  other  parts. 

Treatment. — The  treatment  of  dumbness  duo 
to  lead-poisoning  will  be  best  effected  by  elimi- 
nation of  the  poison  by  the  administration  of 
iodide  of  potassium,  and  the  judicious  employ- 
ment of  galvanism  to  the  spinal  system. 

5.  Dumbness  from  congenital  defects  of 
the  tongue  or  of  the  palate. — Various  con- 
genital local  lesions  are  met  with  giving  rise  to 
dumbness. 

Treatment. — Many  of  these  cases  are  reme- 
diable by  surgical  or  surgico-dental  help,  fol- 
lowed by  methodical  teaching. 

G.  Dumbness  from  emotional  lesions. — - 
Dumbness  occasionally  arises  from  great  emo- 
tional disturbance,  such  as  great  anger  or  sudden 
fright.  Moreover,  it  is  often  met  with,  without 
suchmarked  cause,  in  individuals,  especially  of  the 
female  sex,  having  a highly  developed  emotional 
life. 

Treatment. — Cases  of  this  kind  arc  usually 
successfully  treated  by  faradisation  about  the 
muscles  of  the  neck  ; the  patient  at  the  same 
time  being  encouraged  to  call  liis  articulating 
power  into  action,  and  in  proportion  to  his 
success  the  faradic  current  being  discontinued. 
The  moral  treatment  here  indicated  may  be 
greatly  assisted  by  promoting  the  general  health, 
and  placing  the  patient  under  the  best  possible 
circumstances  as  to  hygiene  and  moral  disci- 
pline. 

7.  Dumbness  from  intellectual  disorders. 
— This  is  by  far  the  most  common  cause  of  true 
dumbness.  It  may  arise  from  idiocy  or  im- 
becility of  a congenital  nature  ; from  that  which 
has  been  acquired  early  in  life ; or  from  dementia 
as  the  outcome  of  acute  or  chronic  brain-disease 
in  middle  or  advanced  life.  Among  the  con- 
genitally feeble-minded,  dumbness  is  a very 
frequent  phenomenon.  This  arises  from  the 
ussociation  therewith  of  deformed  mouths  and 
highly-arched  palates ; from  defective  power  of 
co-ordination  of  the  muscles  of  the  tongue;  and 
from  an  inability  to  transform  ideas  into  word- 
signs.  In  the  most  profound  cases  there  is  such 
an  absence  of  ideas  that  language  of  any  kind  is 
not  required. 


DUODENUM,  DISEASES  OF.  4(.; 

Treatment. — The  treatment  of  this  kind  ol 
dumbness  is  one  which  requires  great  tact, 
patience,  and  energy ; and  the  success  will  be 
commensurate  with  these  aids. 

The  physical  health  of  the  individual  should 
be  carefully  attended  to,  so  as  to  induce,  by 
judicious  food,  frequent  bathing,  and  warm 
temperature,  the  highest  amount  of  nervous 
energy.  The  power  of  co-ordination  should  be 
sedulously  cultivated  by  methodical  exercises, 
especially  of  the  hands,  leading  up  to  well- 
devised  tongue-gymnastics.  He  should  then  be 
taught  monosyllabic  sounds,  by  being  shown  the 
object  represented  by  the  sound,  while  he  imitates 
the  sound  when  watching  the  teachers  lips. 
Having  thus  acquired  the  power  of  producing 
the  word-sign  by  imitation  purely,  he  is  next 
taught  to  repeat  it  from  memory  when  shown  the 
object  only.  After  nouns  have  thus  been  taught, 
the  names  of  qualities  and  adverbial  expression^ 
should  be  added,  and  in  this  manner  articulate 
speech  built  up. 

Where  the  feeble  mindedness  has  been  ac- 
quired after  birth,  the  dumbness  resulting  there- 
from should  be  treated  in  a somewhat  similar 
manner  to  that  having  a congenital  origin,  but 
the  prognosis  is  not  so  good. 

Still  more  unfavourable  is  the  forecast  of 
dumbness  when  the  result  of  dementia. 

J.  Langdon  Down. 

DUODENUM,  Diseases  of. — These  may 
be  considered  under  the  heads  of — 1.  Functional 
disorder ; and  2.  Organic  diseases. 

1.  Functional  disorder  of  the  duodenum  is  said 
to  produce  a form  of  dyspepsia,  characterised  by 
pain  in  the  epigastrium  and  right  hypochondrium 
two  or  three  hours  after  meals,  vomiting,  and 
the  distant  effects  of  ordinary  dyspepsia — ver- 
tigo, headache,  drowsiness,  burning  sensation  in 
the  soles  of  the  feet  and  palms  of  the  hands,  & c. 
Imperfect  chymification  which  attends  ordinary 
dyspepsia  may  induce  these  symptoms  by  gene- 
rating products  which  irritate  the  duodenum. 
The  treatment  is  mainly  that  of  disordered 
digestion.  The  bowels  and  the  diet  are  to  be 
carefully  regulated;  and  such  remedies  as  alka- 
lies, bismuth,  oxide  of  manganese,  prussic  acid, 
or  hydrochloric  acid,  exhibited,  according  to  the 
special  requirements  of  each  case. 

2.  Organic  diseases .—  These  are  inflammation : 
ulceration  ; and  new-growths. 

a.  Inflammation. — Synon.  : — Duodenitis;  I'r. 
Duodcnite. — Acute  inflammation  of  the  duodenum 
is  usually  of  a mild  catarrhal  character.  It  either 
forms  part  of  an  enteritis,  oris  an  extension  down- 
wards of  a similar  affection  of  the  stomach.  The 
ordinary  exciting  causes  are  exposure  to  cold, 
and  irritating  ingesta  or  acrid  bile.  Usually 
the  symptoms  of  slight  gastric  catarrh — a loaded 
tongue,  anorexia,  nausea,  vomiting  of  tenacious 
mucus — are  followed  by  jaundice.  When  the 
duodenum  is  invaded  there  is  said  to  be  ful- 
ness and  tenderness  of  the  right  hypochon- 
drium. As  a rule,  however,  new  symptoms  are 
not  set  up  unless  the  bile-ducts  become  ob- 
structed by  mucus  from  extension  of  the  catarrh 
into  them,  when  jaundice  supervenes  without 
pain.  The  attack  usually  lasts  a week  or  a fort 
night,  and,  with  suitable  hygienic  and  dietetif 


103  DUODENUM,  DISEASES  OF. 

treatment,  passes  safely  off;  it  is,  however,  some- 
times followed  by  jaundice  unusually  prolonged, 
and,  even  when  the  bile-ducts  are  free,  by  pros- 
tration and  wasting  out  of  proportion  to  the  mild- 
ness of  the  disease  in  itself.  While  catarrhal 
duodenitis  does  not  present  characteristic  symp- 
toms, it  is,  however,  usually  suggested  by  pain- 
lessjaundice  following  exposure  to  cold,  catarrh 
of  the  stomach,  and  enteritis. 

Treatment. — This  consists  in  rest  in  bed, 
warmth,  liquid  diet,  counter-irritation  by  mustard 
and  hot  poultices,  and  effervescing  salines. 

Chronic  inflammation,  resulting  in  thickening 
of  the  mucous  and  submucous  tissue,  and  even 
adhesion  of  the  duodenum  to  adjacent  organs 
is  usually  associated  with  chronic  ulceration,  or 
with  cancer  of  the  duodenum,  pancreas,  liver,  or 
other  structures.  Contraction  of  the  duodenum 
produces  symptoms  of  obstruction  similar  to 
those  arising  from  stricture  of  the  pylorus. 

b.  Ulceration. — Perforating  ulcer,  similar  to 
that  of  the  stomach,  is  said  to  be  more  frequent 
in  men  than  in  women,  and  hardly  ever  to  occur 
during  childhood  ; while  it  frequently  follows 
severe  and  extensive  burns  and  scalds.  The 
ulcer,  usually  found  in  the  upper  horizontal 
portion,  when  recent  has  clean-cut  edges  free 
from  swelling.  The  wall  of  the  duodenum  may 
be  perforated,  either  without  previous  adhesion, 
being  followed  by  the  signs  of  general  perito- 
nitis ; or  with  adhesion  to  adjacent  parts,  such 
as  the  liver,  the  gall-bladder,  the  pancreas,  the 
colon,  the  hepatic  artery,  or  the  posterior  wall  of 
the  abdomen — into  which  ulceration  extends  to  a 
variable  extent.  Cicatrisation  may  induce  stric- 
ture of  the  duodenum  or  obliteration  of  the  bile- 
duct.  As  a rule  the  symptoms  greatly  resemble 
I hose  of  perforating  ulcer  of  the  stomach;  more 
frequently,  however,  the  disease  is  latent,  and 
induces  very  obscuro  dyspeptic  symptoms  prior 
to  fatal  perforation.  Jaundice  is  not  more  com- 
mon than  in  the  similar  affection  of  the  stomach. 
In  burns  and  scalds  perforation  seldom  occurs 
before  the  tenth  day. 

The  duodenum  may  be  ulcerated  by  the  action 
of  a gall-stone  passing  into  it  directly  from  the 
gall-bladder. 

c.  Kew  growths. — The  most  important  of 
these  is  scirrhous  cancer,  which  may  involve  the 
walls  of  the  duodenum,  usually  by  extension. 
It  tends  to  produce  obstruction,  or  it  may  set 
up  chronic  duodenitis,  or  block  up  the  bile-duct, 
and  thus  give  rise  to  jaundice. 

George  Oliver. 

DURA  MATER,  Diseases  of.  See 

Meninges,  Diseases  of. 

DURATION  OP  DISEASE,  see  Disease, 
Duration  of. 

DYNAMOMETER  (dvrapis,  power ; and 
perpoi a measure). 

Description. — The  dynamometer  is  an  instru- 
ment originally  invented  by  M.  Duclienne,  of 
Boulogne,  for  measuring  and  accurately  recording 
the  strength  of  the  hand-grasp,  and  also  for 
measuring  the  traction  power  capable  of  being 
exerted  by  other  groups  of  muscles.  The  result 
is  shown  by  an  index,  which  traverses  a semi- 
circular dial  bearing  a scale  graduated  so  as  to 


DYSENTERY. 

enable  the  observer  to  record  the  number  of  kilo- 
grammes which  the  applied  pressure  or  traction 
represents.  In  practice  this  instrument  has  been 
principally  employed  for  estimating  the  absolute 
or  comparative  force  of  the  hand-grasp  ; and  in 
view  of  this  restriction,  Duchenne’s  instrument  is 
needlessly  complex.  It  has,  moreover,  the  abso- 
lute disadvantage  of  being  a little  too  broad,  and 
of  requiring  too  much  strength  on  the  part  of  the 
patient  to  move  the  index  over  the  lower  figures 
of  the  dial.  A patient  with  a small  amount  i>. 
motor  power,  especially  if  the  hand  is  small,  is 
often  unable  to  set  the  index  of  this  dynamo- 
meter in  motion.  A cheaper,  simpler,  and  nar- 
rower instrument  has,  therefore,  been  devised 
by  English  makers,  the  index  of  which  can  be 
moved  by  the  application  of  a much  smaller 
amount  of  power.  This  consists  of  a simple 
elliptical  ring  of  steel,  to  the  inner  and  anterior 
face  of  which  is  attached  a brass  semi-circular 
dial  graduated  with  two  rows  of  figures  repre- 
senting pounds  instead  of  kilogrammes.  The 
compression  of  the  steel  ring,  by  lessening  it* 
shorter  diameter,  moves  a metal  bar  projecting 
from  and  sliding  in  a groove  behind  the  dial, 
and  this  by  rack-work  communicates  its  move- 
ment to  tho  index. 

Uses. — The  dynamometer  is  a useful  instru- 
ment, inasmuch  as  it  enables  us  accurately  to  as- 
certain the  relative  compressing  powers  of  the  two 
hands  in  cases  of  incipient  or  actually  developed 
hemiplegia,  and  also  to  learn  in  a positive  and 
definite  manner,  from  time  to  time,  the  amount 
of  improvement  or  the  reverse  which  may  have 
taken  place.  Since  the  power  of  the  muscles  of 
the  fore-arm  and  hand,  like  that  .of  other  groups 
of  muscles,  varies  a good  deal  with  the  general 
state  of  health  of  the  patient,  the  dynamometer 
is  also  capable  of  yielding  valuable  informa- 
tion concerning  the  strength  of  the  patient, 
even  where  wo  have  not  to  do  with  a case  of 
paralysis.  Any  instrument  which,  in  the  place 
of  fleeting  and  more  or  less  vague  impressions 
made  upon  the  mind  of  the  practitioner  at  the 
time,  enables  him  to  make  a more  accurate 
record  in  figures  in  his  note-book,  is  a clear  gain 
to  practical  medicine — more  especially  when  it* 
use  involves  no  appreciable  loss  of  time. 

H.  Charlton  Bastian. 

DYSESTHESIA  (Si's,  with  difficulty,  and 
aia-6a.vop.ai,  I feel). — A term  applied  to  impair- 
ment of  any  of  the  senses,  but  especially  to  that 
of  touch.  See  Sensation,  Disorders  of. 

DYSCRASIA  (Sts.  difficult  or  bad,  and 
Kpdff.s,  a mixture).  A morbid  condition  of 
blood. 

This  term  signifies  more  than  a disposition  to 
disease ; it  implies  tho  presence  of  some  general 
disease  exerting  its  pernicious  effects  upon  the 
blood.  Hectic  fever,  septicaemia,  and  metastatic 
inflammations  are  diseased  conditions  referable 
to  dyscrasiae.  A person  sickening  for  a fever  is 
the  subject  of  a specific  dyscrasia.  See  Blood- 
Disease.  R.  Douglas  Powell. 

DYSENTERY  (Sf/s,  with  difficulty,  and 
HvTepov,  an  intestine).  Synon.  : Fr . Dysenteric  i 
Ger.  Dysenteric. 

Definition  - -A  specific  febrile  disease,  eharse 


DYSENTERY. 


ierized  by  considerable  nervous  prostration  and 
inflammation  of  the  solitary  and  tubular  glands 
of  the  large  intestine;  sometimes  ending  in  reso- 
lution, but  frequently  terminating  in  ulceration, 
occasionally  in  more  or  less  sloughing  or  gan- 
greno  ; always  accompanied  by  tormina  and  tenes- 
mus, the  latter  being  most  marked  when  the 
disease  is  located  in  the  rectum  or  lower  end  of 
tho  sigmoid  flexure  ; stools  at  first  more  or  less 
feculent,  later  on  yielding  dysenteric  products 
without  much  if  any  feculence,  such  as  blood, 
mucus,  slime,  and  gelatinoid  exudation,  or — as 
in  the  sloughing  or  gangrenous  forms — like  the 
washings  of  meat,  and  possessing  a putrid  or 
gangrenous  odour,  and  so-called  epithelial,  ash- 
coloured,  black,  gangrenous,  pus-infiltrated  or 
tubular  sloughs,  chiefly  consisting  of  tough,  im- 
perfectly organised  exudation. 

.Etiology. — In  almost  all,  if  not  in  all,  situa- 
tions where  malarious  fevers  abound,  as  in  the 
vicinity  of  the  swamps  and  sluggish  rivers  of 
tropical  and  sub-tropieal  countries,  dysentery 
prevails  in  proportion  to  the  intensity  and  fre- 
quency of  these  fevers.  When,  on  the  other  hand, 
intormittents  and  remittents  have  been  extin- 
guished by  improved  drainago  and  the  conversion 
of  marsh  into  cultivated  land,  it  becomes  equally 
unknown.  In  orneartho  tropics,  Great  Britain, 
Canada,  the  United  States,  and  in  many  other 
parts  of  tho  world,  its  diminution  has  proceeded 
pari  passu,  with  the  decrement  of  malarious 
fevers.  There  would,  therefore,  seem  to  he  some 
intimate  connexion  between  the  causation  of 
dysentery  and  intermittent  and  remittent  fevers. 

Paroxysmal  fevers  interfere  materially  with 
the  nutrition  and  functions  of  the  digestive  organs, 
and  with  the  proper  nourishment  and  constitu- 
lion  of  the  blood.  Violent  congestion  of  the 
abdominal  viscera  is  one  of  the  special  conditions 
of  the  different  forms  of  ague.  Both  the  liver 
and  spleen  are  liable  to  temporary  and  repeated 
engorgement,  and  so  in  fact  are  all  the  organs 
which  minister  to  gastric  and  intestinal  diges- 
tion. Even  where  malarious  poisoning  may 
never  have  resulted  in  any  of  the  various  forms 
of  periodic  fever,  it  may  impair  the  power  of  the 
organic  nerve-centres  and  the  muscular  tone  of 
the  blood-vessels,  thus  disturbing  the  balance  of 
the  portal  circulation,  and  leading  to  more  or 
less  permanent  repletion  or  congestion.  As  tho 
congestion  is  most  embarrassing  during  diges- 
tion, interfering  with  the  appetite,  and  the 
capacity  for  digesting  and  assimilating  food,  its 
repeated  and  prolonged  existence  must  deterio- 
rate the  quality  and  modify  the  quantity  of  such 
important  secretions  as  the  gastric  juice,  the 
bile,  the  pancreatic  juice,  and  those  furnished  by 
the  follicles  of  Lieberkiihn,  and  by  Brunner's 
and  the  solitary  glands.  Crude  alimentary  prin- 
ciples are  thus  assimilated  from  the  intestinal 
tract.  The  liver  is  especially  liable  to  func- 
tional derangement  from  the  stagnation  and 
slowing  of  the  portal  circulation,  and  thus  it 
happens  that  in  dysentery  hepatic  impairment 
is  almost  an  invariable  accompaniment.  Such 
being  some  of  the  abnormal  conditions  produced 
by  the  operation  of  malaria  in  its  active  or  latent 
form  upon  the  chylopoietic  viscera,  it  is  not 
surprising  that,  under  the  prolonged  strain,  cer- 
tain portions  of  the  alimentary  mucous  membrane 


409 

should  break  down.  Why  the  solitary  glands  of 
the  large  intestine  should  be  the  special  seat  of 
dysentery,  whilst  the  corresponding  glands  it* 
the  small  intestine  should,  with  few  exceptions 
escape,  it  is,  in  the  present  state  of  our  know- 
ledge, impossible  to  say.  The  most  that  can  he 
hazarded  is,  that  the  elementary  structures  of 
these  glands  take  on  morbid  action  through  the 
operation  upon  them  of  a matcries  morhi  derived 
directly  from  their  blood-supply.  That  this 
poison  exists  in  the  blood  may  be  inferred  from 
the  fact  that  constitutional  disturbance  invari- 
ably precedes  and  accompanies  the  earlier  stages 
of  acute  dysentery. 

Unwholesome  drinking-water  is  a fertile  prox- 
imate and  exciting  cause  of  dysenteric  disease. 
Bad  and  unwholesome  food  of  whatever  descrip- 
tion, by  providing  aliment  incapable  of  being 
perfectly  digested,  may  act  in  producing  t.!;e 
disease.  In  like  manner  impure  air  may,  by 
preventing  the  proper  aeration  and  depuration 
of  the  blood,  and  by  promoting  the  retention  in 
it  of  inassimilable  material,  light  up  dysenteric 
inflammation  of  the  solitary  glands.  The  transit 
of  acrid  and  vitiated  bile  and  other  secretions 
poured  into  the  digestive  canal,  often  operates  as 
an  exciting  cause,  and  frequently  determines  a 
morbid  action  which  might  be  otherwise  righted 
by  resolution,  to  advance  to  ulceration,  sloughing, 
or  gangrene.  It  is  thus  that  many  a simple 
hut  neglected  case,  scarcely  at  first  distinguishable 
from  diarrhoea — unless  indeed  every  evacuation 
is  most  carefully  washed  and  scrutinised — ends 
in  destruction  of  large  masses  of  the  mucous 
membrane,  and  death,  from  the  conjoint  effect  of 
exhaustion  and  shock  from  tho  separation  of 
the  sloughs.  Indigestible  articles  of  diet,  which 
cannot  be  reduced  by  the  juices  of  the  digestive 
tract  to  a condition  admitting  of  ready  absorp- 
tion, may  act  as  local  irritants  and  exciting 
causes.  Not  only  is  this  so  in  the  earliest  visible 
stage  or  that  of  active  congestion,  hut  it  becomes 
much  more  susceptible  of  demonstration  in  tho 
exudative  and  ulcerative  phases  of  the  disease, 
by  the  repeated  investigation  of  the  subjective 
and  objective  indications.  Tims  the  aggravation 
of  the  tormina  and  tenesmus  in  adults  and 
children  is  traceable  to  indiscretion  in  diet,  or  to 
the  passage  of  undigested  morsels  of  food,  re- 
cognisable in  the  stools.  Sudden  vicissitudes  of 
temperature  from  a high  to  a low  range,  or  ex- 
posure to  damp  and  cold  combined,  especially 
when  the  vital  powers  are  physiologically  de- 
pressed, by  checking  the  excretory  action  of  the 
skin  and  diminishing  tho  cutaneous  circulation, 
augment  the  portal  congestion  and  excite  dysen- 
teric disease.  This  is  probably  the  reason  why,  in 
a large  proportion  of  cases,  the  onsetof  thedisease 
is  ushered  in  towards  midnight  or  the  early 
morning.  The  influence  of  epidemic  states  of 
of  the  atmosphere  in  the  causation  of  dysentery, 
signifies  only  that  it  is  most  prevalent  at  those 
seasons  when  malarious  fevers  are  most  abundant. 
As  there  is  an  intimate  connexion  between  the 
existence  of  malaria  and  the  prevalence  of  dysen- 
tery, it  is  not  difficult  to  understand  why,  both 
as  regards  type  and  seasonal  frequency,  dysentery 
should  bear  a striking  relation  to  the  severity 
and  seasonal  prevalence  of  malarious  fevers. 

Is  dysentery  a contagious  nr  communicabU 


DYSENTERY. 


no 

disease  ? — Whilst  many  of  the  older  physicians 
held  that  it  might  be  spread  by  contagion  from 
person  to  person,  it  may -be  affirmed  that  the 
experience  of  most  modern  practitioners  is  alto- 
gether opposed  to  this  view.  There  is  no  clear 
and  unimpeachable  evidence  to  demonstrate  that 
it  is  propagated  in  the  same  way  as  typhus  or 
smallpox.  It  may  possibly  be  communicable, 
like  typhoid  fever,  through  air,  water,  or  food — 
liquid  or  solid — charged  with  material  derived 
from  the  undisinfected  and  putrefying  products 
of  the  disorder.  Be  this,  however,  as  it  may, 
the  complete  disinfection  or  destruction  of  the 
alvine  evacuations  should  always  be  regarded  as 
a sanitary  measure  of  supreme  importance. 

Anatomical  Characters  and  Pathology. — 
The  dysenteric  process  generally  consists  of  a 
specific  inflammation  of  the  solitary  glands 
(Parkes,  Baly,  and  others).  The  first  visible 
change  is  congestion,  the  vessels  surrounding  and 
penetrating  the  capsules  being  turgid  and  en- 
gorged with  blood.  The  second  change  is  aug- 
mentation of  their  contents  from  the  accumulation 
of  albuminous  exudation,  and  enlargement  ‘ from 
t he  size  of  a millet  seed  to  a small  shot’  (Baly). 
I’lie  third  change  is,  provided  the  inflammation 
advances,  rupture  of  some  of  the  capillaries  in 
i he  interior  of  these  little  vascular  glands,  ex- 
travasation of  blood, with  the  area  of  the  ordinary 
dark  point  on  the  free  aspect  increased.  Th  & fourth 
stago  is  now  marked  by  atrophy  and  molecular 
disintegration  of  the  free  aspect  of  the  capsular 
wall,  and  escape  of  its  morbid  gelatinoid  blood- 
tinged  contents  into  the  canal  of  the  intestine. 
This  is  the  rule,  but,  in  very  exceptional  cases, 
the  capsule  may  burst  through  the  attached  por- 
tion. lighting  up  inflammation  in  the  neighbour- 
ing connective  tissue  and  muscular  coat.  In  a 
large  number  of  instances,  the  morbid  process 
may  stop  short,  under  proper  treatment,  at  any 
of  the  first  three  stages,  and  repair  is  then 
i ffectod  by  resolution.  In  many  cases  the  morbid 
action  is  cut  short  after  the  completion  of  the 
fourth  stage,  without  further  extension  of  the 
diseaso.  The  adjoining  follicles  of  Lieberkiihn 
do  not,  in  these  cases,  necessarily  participate,  to 
any  great  extent,  in  the  diseased  process.  Under 
these  conditions,  when  the  whole  of  the  exudation 
has  been  expelled,  the  glands  regain  their  tone  and 
functions,  and  recovery — rapid  and  complete — 
ensues.  It  is  not  often  possible  to  illustrate  these 
conditions  in  the  post-mortem  room  ; because, 
when  death  supervenes  from  dysentery  alone,  the 
ravages  committed  upon  every  structure  of  the 
mucous  membrane  are  so  extensive  as  to  destroy 
the  earlier  physical  phases  of  the  disease.  In 
some  cases,  however,  which  have  died  from 
intercurrent  affections,  the  writer  has  been  able 
to  demonstrate  the  earliest  stages  successfully  to 
nis  students,  at  a period  prior  to  the  implication 
of  Lieberkiihn's  follicles,  of  which  the  mucous 
membrane  is  in  great  part  composed,  and  to  ex- 
hibit to  them  the  gelatinoid  exudation,  termed 
by  others  ‘ gelatinous  mucus.’  free  from  or  tinged 
with  blood  taken  from  enlarged  and  diseased 
solitary  glands  ( Indian  Annals  of  Medical 
Science,  p.  190,  No.  xxiii.,  1368). 

When,  owing  to  neglect,  to  constitutional  de- 
fect in  spite  of  the  most  careful  therapeutic  and 
hygienic  management,  or  to  intensity  or  quantity 


of  the  specific  poison,  the  disease  is  not  cured  by 
resolution,  tho  disintegrating  or  ulcerative  pro- 
cess is  developed.  The  whole  of  the  solitary 
glands  engaged  perish.  The  ulceration  involves 
the  neighbouring  tubular  glands,  leading  to  ulcere 
varying  from  the  size  of  a mustard-seed  to  that 
of  a florin  or  more,  in  depth  generally  extending 
to  the  submucous  connective  tissue,  and  not  in- 
frequently laying  bare  the  circular  lamina  of  th.i 
muscular  coat,  sometimes  involving  the  Icngiti- 
dinal  layer  and  perforating  it  as  well  as  th t 
peritoneal  coat,  thus  admitting  of  the  extravasa- 
tion of  the  contents  of  the  bowel  into  the  peri- 
toneal cavity  and  lighting  up  peritonitis,  which, 
if  genera],  is  invariably  morial.  but  which,  if 
local  and  confined  to  the  close  vicinity  of  the 
perforating  ulcer,  is  not  necessarily  so. 

The  ulcers  vary  in  appearance,  size,  and  shape. 
They  may  be  mere  abrasions  without  much  loss 
of  structure,  minute  though  penetrating  rather 
deeply  into  the  submucous  connective  tissue  ; 
irregular,  serpentine,  or  rodent,  with  here  and 
there  portions  of  the  surrounding  mucous  mem- 
brane undermined  and  patulous ; transverse, 
embracing  partially,  or  completely,  the  entire 
circular  outline  of  the  mucous  membrane ; circu- 
lar, or  oval,  with  regular  and  even  margins  ; or 
tubercular,  involving  the  whole  substance  of  the 
mucous  membrane,  looking  as  if  they  had  been 
punched  out  of  it.  These  ulcers,  as  generally 
observed  in  the  post-mortem  room,  are  free  from 
sloughs,  and  present  a pale  ashy  appearance. 
Sometimes  they  are  of  a vermilion  or  purple 
colour,  from  active  or  passive  congestion.  They 
arc  often  covered  with  flakes  of  tenacious  lymph 
or  exudation,  and  this  may  sometimes  be  seen 
spread  over  the  neighbouring  mucous  membrane. 
The  floors  of  theso  ulcers  are  usually  formed  by 
inflamed  and  thickened  submucous  areolar  tissue  : 
but  sometimes  this  has  all  been  destroyed,  and 
then  they  are  constituted  of  the  muscular  coat, 
thickened  and  infiltrated  by  inflammatory  pro- 
ducts ; and  when  the  muscular  structure  has 
itself  yielded  to  the  ulcerative  process,  they  are 
made  up  of  congested  and  swollen  peritoneum 
which,  as  already  stated,  occasionally  becomes 
perforated. 

When  the  ulceration  proceeds  solely  by  mole- 
cular disintegration  massive  sloughs  are  not 
observed.  But  when,  as  not  uncommonly  happens 
in  asthenic,  malaria-stricken,  tubercular  and 
worn-out  constitutions,  tissue-death  occurs  on 
masse,  at  an  early  period  of  the  attack,  slough- 
ing of  the  mucous  membrane,  together  with 
portions  of  the  muscular  coats,  or  gangrene,  is  to 
be  seen.  These  sloughs,  or  gangrenous  portions 
of  tissue,  may  be  limited  in  extent.  Some  or  all 
of  them  may  be  successfully  detached  during  life, 
and  can  be  identified  as  they  are  examined  from 
time  to  time  in  the  stools.  In  the  pest-mortem 
room  they  may  be  found  partly  detached  and 
lying  loose,  mixed  with  the  fluid  contents  of  the 
bowel,  or  attached  more  or  less  firmly,  sometimes 
compiact,  nodular,  eechymosed.  gray  or  olive- 
coloured,  green  or  yellow  and  pus-infiltrated, 
black,  flaky,  shreddy,  shaggy,  floeculent  like 
pieces  of  teased  cotton-wo  >1,  or  ragged  and 
stringy.  In  the  truly  gangrenous  dysentery,  the 
mucous  and  muscular  coats  are  enormously 
thickened,  and  large  portions  are  found  gangre- 


DYSENTERY. 


nous,  varying  in  colour  from  a pale  olive  to  purplo 
or  black.  These  appearances  and  conditions  may 
be  restricted  to  the  caecum  and  ascending  colon, 
or  to  the  sigmoid  flexure,  but  sometimes  they  are 
eo-extensive  with  the  internal  structure  of  the 
large  intestine  from  the  ileo-colic  valve  to  the 
anus.  When  the  ileo-colic  valve  becomes  de- 
stroyed, invagination  of  the  lower  end  of  the 
ileum  into  the  caecum  sometimes  happens,  causing 
intestinal  obstruction,  Occasionally  many  inches 
of  the  gangrenous  mucous  membrane,  with  or 
without  the  muscular  coat,  is  either  found  hang 
ing  loose  in  the  lower  part  of  the  gut,  or  in  pro- 
cess of  being  detruded  from  the  anus. 

In  ordinary  acute  dysentery,  advancing  to 
ulceration  c>r  sloughing,  repair  is,  doubtless, 
accomplished,  as  a general  rule,  by  granulation 
and  cicatrisation.  This  process  can  be  readily 
observed  in  dysenteric  lesions  of  the  mucous 
membrane  of  the  lower  end  of  the  rectum,  and  in 
healing  of  the  surgical  ulcer  within  the  verge  of 
the  anus.  The  reason  why  repair  is  frequently 
accomplished  so  slowly  is  because,  owing  to  the 
irritation  caused  by7  the  exalted  vermicular  con- 
traction of  the  gut  and  the  passage  of  flatus, 
feces,  and  other  products,  it  is  impossible  to 
command  the  physiological  rest  necessary  for 
speedy  and  substantial  granulation  and  cicatri- 
sation. Unless  the  destruction  of  tissue  is  very 
great,  the  contraction  due  to  cicatrisation  does 
not  occasion  much  future  inconvenience.  But  if 
it  embraces  a large  portion  of  or  the  whole  circum- 
ference of  the  mucous  membrane,  the  subsequent 
contraction  may  produce  dangerous  narrowing  of 
the  calibre  of  the  gut,  or  stricture  of  the  sigmoid 
or  rectum.  The  thickening  and  contraction, 
especially  in  the  .attenuated  victims  of  chronic 
dysentery,  can  be  identified  by  physical  exami- 
nation. These  constrictions  are  frequently  the 
mechanical  cause  of  constipation  and  fecal 
accumulations. 

There  is  no  valid  reason  for  believing  that,  in 
true  dysenteric  ulceration,  the  lost  tissue  is  ever 
actually  reproduced.  When  the  ulcers  have  been 
small,  the  contraction  following  repair  issufficient 
to  bring  the  follicles  of  Lieberkiihn  on  all  sides 
into  close  juxtaposition.  And  this  it  is  which 
has  given  rise  to  the  impression  among  some 
pathologists,  that  the  lost  tissues  have  been 
renewed  by7  a process  of  development  and  growth. 
But  whenever  the  ulcers  have  been  too  large  to 
admit  of  obliteration,  microscopical  examination 
shows  that  they  have  been  bridged  over  by  cica- 
tricial tissue,  devoid  of  solitary  and  tubular 
glands  and  sparingly  supplied  with  blood-vessels 
and  absorbents. 

In  addition  to  the  above  anatomical  characters, 
the  mesenteric  glands  are  generally  found  to  be 
enlarged,  and  as  an  accompaniment  or  sequel, 
organic  disease  of  the  liver  or  abscess  is  not 
infrequently  discovered  to  complicate  the  disease. 

Symptoms. — Every  attack  of  acute  dysentery 
is  preeedod  by  disordered  digestion  and  constitu- 
tional disturbance,  indicated  by  loss  or  capricious- 
r.ess  of  appetite  and  furred  tongue,  constipation 
alone  or  alternated  with  looseness,  dryness  of  skin, 
occasional  chilliness  and  general  malaise,  with 
sught  rise  of  the  evening  temperature.  These 
signs  may  be  viewed  as  cotemporaneous  with  the 
progress  of  the  morbid  action  going  on  in  the  soli- 


411 

tary  glands.  As  tho  disease  advances,  there  if 
more  marked  chilliness,  succeeded  by  distinct 
feverishness.  If  the  bowels  have  been  confined, 
they  now  act  spontaneously — expelling,  at  one  oi 
more  acts  of  defecation,  almost  the  wholo  of  the 
contents  of  the  large  intestine.  If  they  have  been 
loose,  with  or  without  aperient  medicines,  the  feeu- 
lence  is  not  so  great  in  quantity.  But  in  either 
case,  beyond  a little  mucus,  there  is  not  as  yet  any 
discoverable  dysenteric  product  in  the  stools. 
Prior  to  this  conservative  evacuation  of  the 
bowels,  the  febrile  excitement  sometimes  runs 
high ; there  is  thirst,  bad  taste  in  the  mouth, 
flatulency,  a variable  amount  of  nervous  and 
muscular  debility,  griping,  an  accelerated  and 
irritable  pulse,  restlessness,  disturbed  sleep,  oi 
actual  insomnia.  During,  and  immediately  after, 
each  evacuation  there  is  tenesmus  or  painful 
straining — most  intense  in  those  cases  where  the 
disease  is  located  in  the  descending  colon,  sig 
moid  flexure, and  rectum.  The  stools  are  offensive, 
but  there  is  nothing  at  this  stage  pathognomonic 
in  their  odour.  If,  as  frequently  happens  in 
private  practice,  the  patient  comes  under  treat- 
ment at  this  period,  a small  dose  of  castor  oil 
guarded  by  laudanum, or  a full  dose  of  ipecacuanha, 
with  absolute  rest  in  bed  and  bland  liquid 
nourishment,  is  sufficient,  in  a certain  proportion 
of  cases,  to  put  a stop  to  the  morbid  action,  and 
to  promote  cure  by  resolution  in  from  twenty- 
four  to  forty-eight  hours. 

When,  however,  the  disease  persists,  the  symp- 
toms continue  in  an  aggravated  form.  The 
tormina  and  tenesmus  become  intensified ; the 
desire  to  go  to  stool  is  more  frequent,  and  to 
remain  on  the  stool  or  bed-pan  more  irresistible 
and  enduring,  especially  if  the  disease  be  concen- 
trated in  the  sigmoid  flexure  or  rectum.  In  rectal 
dysentery,  there  is  dysuria,  frequent  micturition, 
and  sometimes  retention,  from  spasm  due  to 
reflex  action,  necessitating  catheterism.  The 
consumption  of  solid  food — even  of  the  most 
digestible  kind — provokes  and  aggravates  the 
tormina.  The  griping  and  tenesmus  are  now  so 
intensified  in  degree,  and  increased  in  frequency, 
that  each  recurrence  of  them  produces  much 
depression  and  exhaustion,  and  a pinched  and 
anxious  expression  of  the  countenance,  with  aug- 
mented frequency  aud  weakness  of  the  pulse. 
There  is  abdominal  tenderness.  During  the 
acme  of  the  tormina,  the  patient  experiences  dif- 
ficulty in  localising  this  tenderness.  He  will 
then  declare  that  ho  feels  agonising  pain  over 
the  greater  part  of  the  abdomen,  with  or  without 
the  application  of  pressure.  But  in  the  absence 
of  the  tormina,  careful  palpation  will  enable  the 
practitioner  to  localise  it  in  those  portions  of  the 
intestine  above  the  rectum  affected  by  dysenteric 
inflammation.  At  this  stage  the  tumefaction  of 
the  walls  of  the  gut  is  seldom  great  enough  to 
be  distinguished  through  the  abdominal  parietes. 
The  scanty  stools  are  now  characteristic,  consist- 
ing of  mucoid  exudation  tinged  with  blood,  or 
bloody  mucus  or  slime  from  the  inflamed 
tubular  glands,  with  isolated  portions  of  gelali- 
noid  exudation,  more  or  less  coloured  with  blood 
from  inflamed  and  ruptured  solitary  glands,  and 
with  little  or  no  feculence.  These  conditions  are 
cotemporaneous  with  the  rupture  of  the  affected 
solitary  glands,  and  a highly  inflamed  state  of 


DYSENTERY. 


112 

the  adjacent  follicles  of  Lieberkiihn,  as  well  as 
of  the  subjacent  and.  intervening  connective 
tissue.  The  muscular  tissue,  though  not  yet  ne- 
cessarily inflamed,  is  nevertheless  hyper<estbetic. 
It  is  this  liypersesthesia  which  has  more  to  do 
with  the  production  of  the  agonising  tormina 
than  the  diseased  glandular  organs  implanted  in 
and  forming  a constituent  portion  of  the  mucous 
membrane.  These  are  the  symptoms  presented 
3E  a goodly  number  of  cases  met  with  in  private 
practice,  and  in  a smaller  proportion  admitted 
into  hospital.  The  disease  is  said  to  have  lasted 
from  two  to  six  or  eight  days.  In  uncomplicated 
eases  occurring  in  tolerably  good  constitutions, 
they  generally  yield,  without  extension  of  the 
mischief,  to  rest,  bland  liquid  food,  and  full  doses 
of  ipecacuanha. 

In  cases  which  have  been  neglected  or  aggra- 
vated by  indiscretions  in  diet  and  drink,  or  by 
diathetic  or  other  defect  of  constitution,  the 
dysenteric  process  passes  on  to  ulceration.  If  the 
patient  has  not  been  brought  under  proper  thera- 
peutic and  hygienic  management,  the  tormina, 
tenesmus,  local  tenderness,  and  hardening  of  the 
superimposed  abdominal  muscles  are  augmented. 
The  calls  to  stool  are  more  frequent  and  painful. 
The  urine  is  scanty  and  high-coloured,  and  is 
surcharged  with  lithates  and  biliary  pigment. 
The  stools  mainly  consist  of  the  foreign  pro- 
ducts already  described,  but  in  greater  quantity, 
are  now  possessed  of  a peculiar  sickly  smell,  and 
yield  portions  of  exudation  in  masses  of  greater 
or  smaller  size,  simulating  sloughs,  but  which, 
on  microscopical  examination,  are  seldom  found  to 
afford  positive  evidence  of  dead  tissue-elements. 

Unless  the  disease  bends  to.  treatment,  it  may 
terminate  in  sloughing.  This  may  be  restricted 
or  extensive.  Death  of  portions  of  the  mucous 
membrane  is  always  accompanied  by  vital  depres- 
sion or  well-defined  muscular  aDd  nervous  pros- 
tration, cardiac  enervation,  and  an  accelerated 
and  feeble  pulse.  In  some  cases,  tissue-death  en 
masse  happens  at  an  earlier  period,  even  before 
the  rupture  of  the  solitary  glands,  and  the 
sloughs  can  he  discovered  in  the  stools  in  from 
the  eighth  to  tho  thirteenth  day.  The  acme  of 
vital  prostration  is  manifested  during  the  detach- 
ment of  the  sloughs,  when  the  exhaustion  is 
often  much  increased  by  haemorrhage.  Improve- 
ment in  the  strength,  volume,  and  slowing  of  the 
pulse,  and  in  the  expression  of  the  countenance, 
the  comparative  relief  from  tormina  and  tenes- 
mus, cleaning  of  the  tongue,  and  the  substitution 
of  feculence  for  dysenteric  products  in  the  stools, 
signify,  in  these  cases,  tire  probable  cessation  or 
turning-point  of  the  disease.  The  converse  im- 
plies that  the  sloughing  is  extending,  and  a suc- 
cession of  sloughs  of  various  kinds,  with  or 
without  muscular  structure,  continues  to  be  passed, 
which,  in  the  process  of  separation,  are  accom- 
panied by  much  bleeding,  especially  in  patients 
poisoned  by  malaria  or  afflicted  with  the  scor- 
butic or  haemorrhagic  diathesis.  The  abdominal 
tenderness  and  hardening  of  the  parietal  muscles 
are  marked  during  the  separation  of  the  sloughs. 
The  affected  portions  of  the  colon  can  be  felt  to 
ba  swollen,  dough}',  and  ‘puddingy’  (Chevers). 
The  skin,  in  unfavourable  cases,  becomes  clammy, 
foatures  and  eyes  shrunken,  body  emaciated, 
appetite  in  aboyanco,  thirst  great,  and  diet  read  ng 


tongue  dry  and  brown,  pulse  feeble  and  running, 
and  stools  extremely  offensive,  bloody,  slimy  or 
watery,  with  varieties  of  sloughs  and  exudation. 
The  sensibility  becomes  so  blunted  that  the 
stools  are  passed  without  much  pain — often 
involuntarily  ; and  the  patient  eventually  dies 
from  sheer  exhaustion  from  the  extension  of  tho 
sloughing,  or  the  end  may  he  accelerated  by  per- 
foration of  the  bowel  in  one  or  more  places, 
leading  to  extravasation  of  some  of  the  contents 
of  the  intestine  into  the  peritoneum,  axd  general 
peritonitis. 

Sometimes,  from  the  commencement  of  an 
attack,  or  during  the  c cause  of  acute  dysentery, 
rapid  sloughing,  passing  into  gangrene,  of  large 
patches  of  mucous  membrane,  attended  by 
increasing  prbstration  and  soon  merging  into 
collapse,  forms  the  chief  pathological  condition. 
As  this  extends  until,  in  many  instances,  it  in- 
volves almost  the  whole  of  the  mucous  mem- 
brane, submucous  tissue,  and  muscular  structure, 
it  is  characterised  by  intensified  collapse.  The 
tormina  and  tenesmus,  at  first  excruciating,  sud- 
denly disappear,  to  the  delusive  relief  of  the 
sufferer.  Until  the  gangrene  has  spread  to  a 
great  extent,  tho  stools  contain  a large  quantity 
of  slime,  blood,  pellicular-looking  exudation, 
and  much  gelatinoid  exudation ; but  as  the 
living  mucous  membrane  becomes  diminished, 
these  products  also  decrease,  and,  in  their  room, 
we  notice  a watery  product  of  a dark  purple  or 
black  colour,  resembling  the  washings  of  meat, 
giving  off  an  incomparably  offensive  and  gan- 
grenous odour.  To  the  naked  eye,  and  on 
washing,  these  stools  spem  to  he  absolutely 
devoid  of  feculence.  They  yield  a granular 
sediment  of  a black  colour— gangrenous  debris 
blackened  by  the  combination  of  sulphur  with 
the  iron  of  disorganised  cruorin.  Tho  abdomen, 
at  first  doughy,  becomes  tympanitic  and  free 
from  pain  on  pressure,  and  the  surface  cold  and 
clammy;  the  countenance  resembles  the  haggard 
and  sunken  appearance  presented  during  the 
algid  stage  of  cholera;  the  tongue  is  dry.  brown, 
and  fissured:  the  pulse  is  thready  and  rapid; 
food  and  medicines  are  rejected,  the  dejecta  are 
passed  involuntarily,  perception  is  blunted,  de- 
lirium supervenes ; and  the  patient  at  last 
succumbs,  worn  out  and  exhausted,  in  from  the 
sixth  to  the  thirteenth  day,  according  to  the 
range  and  severity  of  the  disease  and  the  con- 
stitutional power  of  the  patient. 

Chronic  Dysentery. — This  is  sometimes  the 
result  of  acute  dysentery,  in  spite  of  the  most 
appropriate  management,  in  persons  poisoned  by 
malaria  and  weakened  by  fatty  or  waxy  degene- 
ration of  the  spleen  or  liver,  or  both,  and  in 
strumous  or  scorbutic  constitutions.  The  dys- 
crasia  may  be  so  pronounced  that  the  material 
exuded  is  incapable  of  healing  up  the  ulcers  by 
granulation  and  cicatrisation.  The  ulcers  are 
repeatedly  disturbed  by  peristalsis,  the  passage 
of  flatus,  faeces,  undigested  morsels  of  solid  food, 
and  the  acrid  unutilised  secretions  of  the  liver, 
stomach,  and  pancreas.  Thus  they  are  liable  to 
become  irritable  from  renewed  congestion  and 
inflammation.  The  muscular  coat  participates 
in  the  excitement  and  becomes  infiltrated  with 
exudation,  which  eventually  becomes  organised 
and  leads  to  thickening.  The  floors  and  sides 


DYSENTERY. 


i'f  the  ulcers  are  constituted  of  unhealthy  struc- 
ture. The  difficulty  thus  experienced  in  effect- 
ing repair  is  augmented.  In  other  cases  the 
intestine  becomes  atrophied,  attenuated,  and 
transparout.  The  stools  are  made  up  of  serous 
exudation,  slime,  blood,  and  sometimes  of  puri- 
form  material,  with  feculence  generally  unformed. 
Almost  every  stool  will  be  found  on  washing  to 
contain  dysenteric  products.  The  appetite  is 
uncertain  ; the  tongue  often  clean,  shining,  and 
devoid  of  epithelium  ; the  pulse  weak  and  irri- 
table ; and  the  abdominal  tenderness  easily 
localised.  Thickening  can  often  be  detected. 
Tormina  are  always  present,  and  unless  the 
diseaso  bo  confined  to  the  cscum  or  ascending 
and  transverse  colon,  there  is  tenesmus.  Multiple 
abscesses  of  the  liver  frequently  supervene  and 
carry  off  the  patient,  or  after  months  or  years 
of  suffering  he  may  perish  from  inanition  and 
exhaustion,  or  from  intercurrent  disease. 

Complications. — Acute  dysentery  is  frequently 
complicated  by  the  various  forms  of  malarious 
fever,  typhoid  fever,  the  tubercular  or  the  haemor- 
rhagic diathesis,  purpura,  scurvy,  hepatic  and 
splenic  enlargement,  malarious  cachexia,  or  ab- 
scess of  the  liver;  and  in  children  by  dentition. 
In  every  case  of  dysentery  the  strictest  atten- 
tion should  be  paid  to  existing  complications. 
In  patients  inhabiting  marshy  districts,  and 
those  following  a seafaring  life,  the  gums  should 
be  carefully  scrutinised  and  the  cutaneous  sur- 
face examined  with  a view  to  ascertain  the  free- 
dom or  otherwise  from  purpuric  or  scorbutic 
taint.  The  history  of  the  patieut  should  be  gone 
into,  in  order  to  make  out  the  probable  diathetic 
proclivities- — acquired  or  hereditary. 

Sequel.*. — That  abscess  of  the  liver,  single  or 
multiple,  frequently  follows  acute  and  chronic 
dysentery,  is  indisputable ; but  whether  as  a 
result  of  the  general  condition  existing,  or  of 
local  pysemic  poisoning  or  embolism  originating 
in  the  veins  within  the  area  of  the  ulcers,  is  still 
an  open  question.  Dysentery  sometimes  termi- 
nates in  permanent  thickening  of  the  parietes  of 
the  gut  with  eventual  contraction  or  stricture, 
causing  constipation,  faecal  accumulation  or  ob- 
struction. When  the  seat  of  stricture  can  be 
reached,  as  in  the  lower  part  of  the  rectum,  much 
relief  can  bo  afforded  by  simple  incision  and  sub- 
sequent dilatation  by  means  of  bougies.  Fissure 
of  the  anus,  or  ulcer  within  the  verge  of  the  anus, 
is  a common  sequel.  Once  diagnosed  by  exami- 
nation of  the  stools  and  by  means  of  the  speculum, 
it  admits  of  speedy  relief  by  incision  end  after- 
surgical  management. 

Diagnosis. — From  diarrhoea,  dysentery  can  be 
diagnosed  by  the  abdominal  tenderness,  tormina, 
tenesmus,  and  the  existence  of  dysenteric  pro- 
ducts in  the  stools.  Dr.  Edward  Goodeve,  late 
Professor  of  Medicine  in  the  Calcutta  Medical 
College,  was  the  first  to  carry  out  the  practice  of 
washing  the  stools  in  dysentery  and  diarrhoea. 
The  stools  are  first  examined  as  they  lay  in  the 
stool-pan.  AVater  is  then  added  in  considerable 
quantity.  Afterashort  interval,  to  allow  the  dysen- 
teric products  to  sink  to  the  bottom,  the  super- 
natant fluid  is  gradually  poured  off.  The  washing 
is  repeated  until  the  foreign  products  remain 
clean  and  destitute  of  much  smell.  A\Thcn  these 
products  are  putrescent,  or  perhaps  in  all  cases, 


41b 

it  is  convenient  to  wash  the  stools  with  a solu 
tion  of  carbolic  acid  or  other  colourless  disin- 
fectant. Dysentery  is  diagnosed  from  fissure  or 
ulcer  of  the  rectum  by  the  fluid  or  loose  charac- 
ter of  the  stools,  with  dysenteric  products,  and 
by  the  absence  of  ulcer,  as  determined  by 
examination  by  means  of  the  anal  speculum. 

Prognosis. — Favourable.  The  following  aro 
to  bo  regarded  as  favourable  features  in  the 
prognosis  of  any  given  case  : — The  ordinary  un- 
complicated form  of  acute  dysentery  ; early 
subsidence  of  the  constitutional  disturbance  : a 
steady,  firm  and  strong  pulse,  with  diminishing 
frequency  and  increasing  power;  moderate 
abdominal  tenderness ; absence  of  tympanites ; 
a placid  and  normal  expression  of  countenance  ; 
absence  of  sloughs  or  putrescent  matters  in  the 
stools  ; early  subsidence  of  tormina  and  tenesmus 
with  the  appearance  of  feculence  and  the  co- 
temporaneous  decrease  of  dysenteric  products ; 
return  of  appetite  and  power  of  digesting  and 
assimilating  food;  and  the  absence  of  inflam- 
matory or  suppurative  mischief  in  the  liver. 

Unfavourable. — Unfavourable  features,  on  the 
contrary,  are  : — The  persistence  of  an  elevated 
temperature  ; quick  pulse  with  increasing  feeble- 
ness ; sudden  freedom  from  tormina,  tenesmus, 
and  abdominal  tenderness,  witli  great  vital 
depression  or  collapse ; doughy  thickening  of 
the  colon  with  dulness  on  percussion  where  there 
should  be  resonance  ; sudden  increase  of  abdo- 
minal tenderness,  with  hiccup,  nausea,  vomiting, 
and  great  nervous  prostration,  tympanites,  and 
peritonitic  pain  with  constant  hardness  and 
tension  of  the  abdominal  muscles  ; increase  of 
putrescent  and  gangrenous  products  in  the  stools 
like  the  washings  of  decomposing  flesh ; exces- 
sive haemorrhage  from  the  bowel;  bleeding  from 
chapped  and  fissured  lips,  gums,  and  mouth; 
harsh,  dry,  black  or  glazed  tongue;  delirium; 
picking  at  the  bed-clothes ; scantiness  or  sup- 
pression of  urine. 

Treatment. — Should  an  aperient  be  required 
in  the  congestive,  exudative,  or  ulcerative  stages 
of  acute  dysentery,  or  in  sudden  relapses  super- 
vening upon  chronic  forms  of  the  disease,  the 
readiest,  simplest,  and  most  painless  is  a tepid 
water  enema  of  from  two  to  four  pints.  After 
the  operation  of  the  enema  or  immediately  the 
patient  presents  himself  suffei'ing  from  any  of 
these  dysenteric  conditions,  in  those  cases  where 
no  preliminary  aperient  is  indicated,  a turpen- 
tine epithem  or  mustard  plaster  should  be  ap- 
plied to  the  epigastrium  for  twenty  minutes.  At 
the  same  time,  from  twenty  grains  to  a drachm 
of  ipecacuanha  suspended  in  two  drachms  of  syrup 
of  orange-peel  and  four  drachms  of  water,  or  in 
half  an  ounce  of  infusion  of  camomile,  with  ten 
grains  of  carbonate  of  soda  or  bismuth,  or  simply 
made  up  into  conveniently  sized  pills,  should  be 
administered,  The  recumbent  posture,  with  the 
head  lower  than  usual,  should  be  enforced. 
Liquids  should  be  resisted  as  much  as  possiblo 
for  an  hour  or  two.  Thirst  may  be  quenched  by 
sucking  pieces  of  ice,  or,  when  this  cannot  be 
procured,  by  cold  water  in  teaspoonsful  at  a timo. 
Nausea  will  probably  occur ; perhaps,  in  some 
cases,  retching  and  vomiting.  11  ut  as  the  vomit 
ing  is  exceptional,  and  when  it  does  occur  seldom 
happens  before  the  lapse  of  an  hour  after  the 


DYSENTERY. 


U4 

exhibition  of  tho  drug,  the  ejected  matter 
usually  consists  of  small  quantities  of  gastric 
secretion.  Should  the  ipecacuanha  be  rejected, 
the  dose  should  be  repeated  as  soon  as  the 
stomaen  has  been  tranquillised.  It  will  be  found 
beneficial  to  time  the  large  doses,  so  as  to  allow 
l>C  one  being  given  night  and  morning  so  long  as 
their  use  is  considered  necessary.  The  signal 
for  the  relinquishment  of  these  doses  is  freedom 
from  tormina  and  tenesmus,  with  the  occurrence 
of  refreshing  sleep,  feculent,  bilious,  or  ipecacu- 
anha stools,  and  restoration  of  the  primary  pro- 
cesses of  assimilation.  If  no  great  amount  of 
disorganisation  of  the  mucous  membrane  has 
taken  place,  these  favourable  changes  are  fre- 
quently noticed  after  the  administration  of  the 
first  or  second  dose,  and  even  if  undoubted  ul- 
ceration has  set  in,  they  aro  generally  discerned 
on  the  second  or  third  day,  or  earlier,  In  either 
case  the  drng  should  be  abandoned,  as  the  dis- 
appearance of  the  tormina  and  tenesmus  and  the 
absence  of  mucus,  blood,  and  slime  from  the 
stools  indicate  the  cessation  of  dysenteric  inflam- 
mation, and  that  tho  affected  portions  of  the 
bowel  have  been  placed  in  the  most  favourable 
condition  to  undergo  cure  by  ‘ resolution,’  if  the 
case  has  not  proceeded  to  ulceration,  or  b}r 
‘ granulation  and  cicatrisation,’  if  rdceration  or 
even  sloughing  has  already  taken  place.  Chalk- 
mixture  with  hyoseyamus  and  astringents  is  now 
quite  sufficient  to  wind  up  the  cure.  In  some 
cases  ferruginous  and  bitter  tonics  are  demanded, 
to  give  tone  to  the  digestive  organs,  and  to  improve 
the  condition  of  the  blood.  Counter-irritation 
by  means  of  turpentine  epithems  and  mustard 
plasters  to  the  abdomen,  or  fomentation,  are  valu- 
able adjuncts  in  the  management  of  the  disease. 

The  diet  should  consist  of  chicken  broth,  beef- 
lea,  essences  of  chicken,  mutton,  or  beef;  sago, 
arrowroot,  or  tapioca;  and  small  quantities  of 
port  wine  or  brandy.  During  tho  active  period 
of  the  disease  all  food  should  be  given  in  a 
liquid  form.  The  disturbing  effect  of  the  ipe- 
cacuanha given  as  above  directed  is  only  tem- 
porary. Abundance  of  time  is,  therefore,  avail- 
able between  the  large  doses  for  the  digestion 
and  assimilation  of  liquid  food.  As  the  stools 
become  more  feculent  and  consistent,  solid  food 
in  the  shape  of  tender  chicken,  lamb,  and  mut- 
ton, with  biscuit  and  bread,  light  sago,  rice,  or 
tapioca  pudding  should  be  allowed.  Potatoes 
and  other  vegetables  should  be  avoided  until 
the  tone  of  the  digestive  system  has  been  fully 
re-established.  When  the  dysentery  is  compli- 
cated with  a purpuric  or  scorbutic  condition  of 
the  blood,  the  administration  of  the  juice  of  the 
grape,  orange,  pomegranate,  lime,  and  bael 
sherbet,  are  essentially  necessary  as  dietetic 
rather  than  therapeutic  agents. 

Opium  by  the  mouth  is  seldom  required. 
When  swallowed  it  ‘ locks  up  ’ the  secretions  of 
the  liver,  pancreas,  and  alimentary  mucous  mem- 
brane, rather  favouring  than  reducing  the  inflam- 
mation of  the  solitary  and  tubular  glands. 
These  bad  effects  counterbalance  the  benefits 
derived  from  the  sleep,  diminution  of  peristaltic 
action,  and  temporary  decrease  of  tormina  and 
tenesmus  consequent  on  narcotism.  This  ex- 
plains why  the  real  character  of  the  disease  is 
often  completely  masked  by  opium,  acd  why 


apparent  amendment  is  taking  place,  whilst  de- 
structive ulceration  and  sloughing  of  the  mucous 
membrano  is  rapidly  extending.  As  ipecacuanha 
speedily  brings  about  all  the  good  without  any 
of  the  evil  effects  of  opium,  this  narcotic,  in  any 
form,  excepting  as  an  enema  or  suppository  to 
relieve  tenesmus,  particularly  in  sigmoidal  or 
rectal  dysentery,  is  not  ODly  superfluous  but  in- 
jurious. There  is  less  objection  to  uniting  '.he 
ipecacuanha  with  such  remedies  as  are  acknow- 
ledged to  possess  the  power  of  lessening  the  irri- 
tability of  the  stomach,  and  of  increasing  its 
tolerance  of  the  drug,  without  interfering  with 
the  functional  activity  of  those  organs  whose 
secretions  we  are  endeavouring  to  promote  with 
a view  to  rectify  the  disturbed  balance  of  the 
portal  circulation.  On  the  contrary  medicines 
cf  this  order  may  he  beneficially  associated  with 
ipecacuanha — such  as  carbonate  of  soda,  bismuth, 
chloroform,  camphor,  and  hyoseyamus. 

When  dysentery  occurs  in  pregnant  women, 
large  doses  of  ipecacuanha  are  not  contra-indi- 
cated ; Decause,  if  the  disease  be  allowed  to  pro- 
ceed (which  is  more  likely  to  happen  under  the 
old  than  the  ipecacuanha  treatment)  abortion  or 
premature  labour  is  almost  certain  to  follow ; 
and  when  such  a complication  supervenes,  in  tho 
later  months  of  gestation,  the  mortality  almost 
surpasses  that  of  any  other  disease.  "When  the 
dysenteric  inflammation  is  summarily  put  a stop 
to  by  the  ipecacuanha,  abortion  or  premature 
labour  is  prevented.  Under  the  opiate  method 
of  management,  premature  labour  is  not  averted, 
but,  in  the  majority  of  cases,  occurs  at  the  acme 
of  the  disease,  when  the  sloughs  are  being  thrown 
off ; and  the  patient  succumbs  to  the  conjoint 
shock  to  the  system.  In  dysentery  complicated 
with  pregnancy  opiate  enemata  to  relieve  irrita- 
tion in  the  rectum  aro  more  essential  and  per- 
missible than  under  other  circumstances. 

In  the  acute  dysentery  of  children  ipecacuanha 
is  invaluable.  For  a child  of  six  months  a grain, 
and  for  a child  of  one  year  two  grains,  should  be 
given  with  an  equal  quantity  of  carbonate  of 
soda,  night  and  morning,  until  the  tormina,  tenes- 
mus, and  slimy  and  bloody  stools  are  replaced 
by  relief  from  pain  and  by  feculent  evacuations. 
It  will  not  often  be  necessary  to  continue  the 
drug  beyond  two  or  three  days  at  a time.  But  it 
shouldbe  recollected  that  tho  disease  adheres  with 
greater  tenacity  to  children  than  to  adults ; and 
although  we  observe  that  ipecacuanha  has  an  im- 
mediately beneficial  effect  in  diminishing  the  blood, 
mucus,  slime  and  frequent  stools,  still  we  find 
that  dysenteric  or  slimy  motions  with  undigested 
food  continue  to  pass.  In  that  ease  the  ipecacu- 
anha, combined  with  chalk,  bismuth,  carbonate 
of  soda,  or  aromatic  powder,  should  be  repeated, 
once  or  twice  a day,  for  a certain  period,  till 
healthy  evacuations  are  restored.  The  gums 
must  be  lanced  when  necessary ; turpentine 
liniment  or  stupes  may  be  applied  to  the  abdo- 
men ; weak  chicken-broth  or  arrowroot  should 
be  temporarily  substituted  for  mill; ; and,  above 
all,  food  must  be  given  in  small  quantities  at  a 
time,  and  at  regularly  stated  periods.  From  the 
age  of  one  year  the  dose  is  regulated  by  adding 
one  grain  for  each  additional  year  of  age  up  to 
eighteen,  when  the  doses  indicated  for  adults 
should  be  employed. 


DYSENTERY. 


In  cases  where  evident  malarious  taint  per- 
vades the  system  and  complicates  acute  dysen- 
tery, disulphate  of  quinine  is  indispensably 
necessary.  A scruple  of  the  antiperiodic  will  be 
most  speedily  absorbed  if  dissolved  in  water 
acidulated  with  sulphuric  acid,  and  the  exhibi- 
tion of  this  may  precede  by  an  hour  the  first 
dose  of  ipecacuanha.  Ten-grain  doses  should  be 
given  midway  between  the  large  doses  of  ipeca- 
cuanha, or  during  abatement  of  febrile  excite- 
ment. mtil  the  feverish  symptoms  have  been 
subdued.  Quinine  here  s quite  as  important  as 
ipecacuanha,  lor.  until  it  h;.3  successfully  cheeked 
1 he  disturbing  influence  which  malarious  poison- 
ing exercises  upon  the  capillaries  of  the  portal 
and  general  circulatory  systems,  the  good  effects 
which  ipecacuanha  produces  are  only  temporary 
and  incomplete.  The  mildest  febrile  exacerbations 
of  a miasmatic  origin  re-excite  dysenteric  action, 
and  thus  undo  the  good  effected  by  the  action  of 
the  ipecacuanha.  Hence,  the  urgent  necessity 
for  removing  without  delay  every  vestige  of 
masked  or  active  malarious  fever  complicating 
dysentery.  No  drug  enables  us  to  accomplish 
this  object  so  safely  and  so  quickly  as  the  disul- 
phate of  quinine  in  large  dose  i. 

When  ipecacuanha  fails  to  preserve  the  life  of 
the  patient,  its  failure  may  be  generally  attri- 
buted to— ( 1)  coexistence  of  abscess  of  the  liver  ; 
(2)  unchecked  malarious  poisoning;  (3)  per- 
manent enlargement  of  spleen  or  liver,  or  both  ; 
(4)  irretrievable  constitutional  cachexia ; (5) 
Addison's  disease  of  the  supra-renal  capsules ; 

(6)  morbus  Brightii ; (7)  phthisis  or  tubercu- 
losis ; (8)  strumous  disease  of  the  mesenteric 
glands;  (9)  peritonitis  with  or  without  per- 
foration of  the  gut;  or  (10)  the  existence  of  ex- 
tensive sloughing  or  eangrene. 

The  advantages  of  the  ‘Ipecacuanha  Treat- 
ment’ (for  the  revival  of  which  the  profession 
are  indebted  to  Mr.  Scott  Docker,  of  the  2nd 
battalion  of  the  7th  Royal  Fusiliers,  stationed  at 
the  Mauritius, — Lancet  of  July  31  and  August 
14,  1858)  in  the  congestive,  exudative,  and 
ulcerative  stage  of  almost  every  form  and  type 
of  acute  dysentery,  as  well  as  in  the  acute  at- 
tacks supervening  upon  chronic  dysentery,  may 
be  briefly  stated  to  consist  in  (1)  its  simplicity, 
(2)  its  safety',  (3)  its  certainty  compared  with  any 
other  method,  (4)  the  promptitude  with  which 
the  inflammation  is  stopped,  (5)  the  rapidity 
with  which  repair  takes  place — (a)  by  reso- 
lution or  (b)  by  granulation  and  cicatrization, 

(0)  conservation  of  the  constitutional  powers, 

(7)  abbreviation  of  the  period  required  for  con- 
valescence, (8)  decrease  in  the  frequency  of 
chronic  dysentery,  (9)  decrease  in  the  frequency 
of  abscess  of  the  liver,  (10)  diminution  of  mor- 
tality to  cases  treated — all  of  which  are  accom- 
plished, ( a ) without  local  or  general  blood- 
letting, ( b ) without  salivation,  (ci  without 
calomel  and  irritating  purgatives,  and  (d)  with- 
out opium  by  the  mouth. 

Ipecacuanha  in  large  doses  may  be  said  to 
fulfil  many  important  indications.  It  produces 

(1)  all  the  benefits  that  have  been  ascribed  to 
blood-letting  without  robbing  the  system  of  one 
drop  of  blood,  (2)  all  the  advantages  of  mercurial 
and  other  purgatives  without  their  irritating 
a tion,  (3)  all  Ihe  good  results  of  antimonials 


416 

and  sudorifics  without  any  of  their  uncertainty, 
(4)  all  the  euthanasia  ascribed  to  opium  without 
masking,  if  not  aggravating,  the  disease  whilst 
the  mischief  is  silently  accumulating  within. 
Thus,  we  possess  in  ipecacuanha  a non-spoliative 
antiphlogistic , a certain  chologogue  and  unirrital- 
ing  purgative,  a powerful  sudorific,  and  a harm- 
less sedative  to  the  heart  and  the  muscular  fibres 
of  the  intestines. 

The  objections  which  have  been  urged  against 
large  doses  of  ipecacuanha  in  dysentery  are,  first, 
its  ‘depressing  influence’  kept  up  by  nausea 
and  vomiting ; and,  secondly,  that  it  is  liable  to 
set  up  ‘uncontrollable  vomiting.’ 

First,  the  depressing  power,  nausea,  and 
vomiting  have  all  been  over-estimated.  Nausea 
is  only  a temporary  and  evanescent  effect. 
Vomiting  is  an  exceptional  occurrence ; and 
even  when  it  does  supervene,  it  seldom  lasts 
long.  As  much  nourishment,  therefore,  as  may 
be  required  to  support  the  strength  can  be  al- 
lowed in  the  intervals  between  the  large  doses 
of  ipecacuanha.  But  what  contributes  more  to 
the  conservation  of  the  patient’s  stamina  and  to 
the  prevention  of  depression  or  asthenia,  is  the 
speedy  cessation  of  the  dysenteric  process  accom- 
plished by  the  drug,  followed  by  refreshing  sleep 
and  the  power  of  digesting  and  assimilating 
nourishing  food.  Such  remarkable  results  as 
these  soon  reconcile  any  patient  suffering  from 
dysentery  to  an  otherwise  disagreeable  remedy. 

Secondly,  when  uncontrollable  sickness  and 
vomiting  succeed  the  employment  of  this  drug 
in  the  manner  already  recommended,  the  exist- 
ence of  one  or  other  of  the  serious  conditions 
previously  enumerated  may  be  more  than  sus- 
pected. In  the  absence  of  these  complications, 
unmanageable  vomiting  is  seldom  if  ever  wit- 
nessed. Hence,  in  a preponderating  majority 
of  the  cases  of  dysentery  met  with  this  ob- 
jection is  quite  untenable.  The  truth  is  that 
every  physician  who  has  used  ipecacuanha  in 
heroic  doses  soon  learns  that  depression  of  the 
vital  powers  from  it  is  not  to  be  feared,  and  is 
surprised  at  the  small  amount  of  vomiting  that 
follows  its  administration,  and  at  the  unexpected 
ease  with  which  the  stomach  tolerates  its  presence. 

When  dysentery  becomes  chronic  no  time 
should  be  lost  in  counselling  removal  from  a 
malarious  to  a non-malarious  and  mild  climate 
A sea  voyage — provided  easily  digestible  food 
can  be  secured — is  often  attended  by  the  hap- 
piest results.  To  men  so  afflicted  ‘the  salt 
ration,’  as  remarked  by  Dr.  Maclean,  1 is  simply 
destruction.’  The  clothing  should  be  warm,  and 
flannels  always  worn  around  the  abdomen;  Dr. 
Maclean  also  recommends  ‘the  use  of  a water  belt 
over  the  abdomen  for  some  hours  daily.  This  acts 
as  a fomentation,  and  the  steady  uniform  pres- 
sure it  maintains  seems  to  favour  the  absorption 
of  the  fibrine  effused  between  the  intestinal 
coats.  If  there  be  much  uneasiness  about  the 
fundament,  a water  compress  over  the  anus 
affords  more  relief  than  opiate  enemata.’  The 
food  should  be  chiefly  concentrated  soups,  milk 
and  lime-water,  and  sago,  cornflour,  arrowroot 
&c.,  egg-flip  with  port,  sherry,  or  brandy;  or,  if 
solid  food  can  be  digested,  the  tenderest  chicken, 
lamb,  or  mutton,  with  bread  and  biscuit,  may  be 
allowed.  Beyond  airing  in  a carriage  nr  chair,  an 


410  DYSENTERY. 

exercise  should  be  attempted.  Thepositionshould 
generally  be  recumbent  or  semi-recumbent.  The 
erect  position  excites  peristaltic  action,  and  thus 
disturbs  the  physiological  rest  required  to  facili- 
tate the  repair  of  the  ulcers.  Antiscorbutic 
juices  should  be  given  where  there  is  the  least 
taint  of  scurvy  or  purpura.  Frequent  blistering 
does  much  good.  All  forms  of  counter-irritation 
are  beneficial. 

Gallic  acid,  acetate  of  lead,  sulphate  of 
copper,  nitrate  of  silver,  are  reputed  to  act 
beneficially.  Dr.  Maclean’s  favourite  remedy, 
‘particularly  in  men  returning  from  tropical 
regions,  anaemic  from  loss  of  blood  and  the  de- 
praving influence  of  malaria,  is  the  solution  of 
the  pernitrate  of  iron.  Under  this  remedy  the 
whole  system  often  rallies  wonderfully,  the  con- 
dition of  the  blood  improves,  colour  returns  to 
the  blanched  cheek,  the  stools  become  more 
natural  and  less  frequent,  the  appetite  improves, 
and  digestion  is  more  perfectly  performed.  The 
citrate  of  iron  and  quinine  may  after  a time  be 
substituted.’  As  nearly  all  chronic  cases  are 
underlain  by  a malarious  taint,  quinine  should 
form  an  important  element  in  the  therapeutic 
management,  and  the  greatest  care  should  be 
taken  to  secure  for  the  residence  of  the  patient 
a climate  at  once  mild  and  temperate  and  free 
from  suspicion  of  malaria.  Bathing  during  con- 
valescence is  an  efficient  and  welcome  auxiliary. 
Tepid  or  warm  baths  medicated  with  Tidman’s 
sea-salt  or  with  nitro-muriatic  acid  act  in  stimu- 
lating the  secreting  function  of  the  skin.  But 
it  will  often  happen  that,  in  spite  of  the  most 
careful  dietetic,  hygienic,  and  therapeutic  ma- 
nagement, no  substantial  progress  towards  the 
repair  of  the  ulcers  is  made,  and  the  patient 
eventually  dies,  worn  out  from  suffering  and  the 
asthenia  consequent  literally  on  inanition. 

Joseph  Ewart. 

DYSIDROSIS  (fit's,  with  difficulty,  and 
iSpcos,  sweat  '. — This  is  a disorder  of  the  sweat- 
folliclcs  hitherto  confounded  with  eczema,  and 
first  differentiated  therefrom  and  accurately 
described  by  the  writer.  It  occurs  in  winter  as 
well  as  in  summer,  and  often  in  those  who  per- 
spire freely ; and  it  attacks  the  hands  chiefly,  and 
especially  the  interdigital  and  the  palmar  sur- 
faces. The  disease  is  characterised  by  the 
development  of  vesicles,  which  are  not  formed  in 
the  usual  way  in  the  rete,  but  are  distensions  of 
the  sweat-apparatus  by  sweat  secreted  in  excess, 
and  which  fails  to  find  its  way  outward  free 
upon  the  surface.  These  sweat-vesicles  are  at 
first  situated  beneath  the  level  of  the  skin,  and 
indeed  appear  as  little  boiled  sago-grains  im- 
bedded deeply  in  the  substance  of  the  skin,  and 
when  once  seen  arc  readily  recognised  again.  If 
pricked,  a little  sweat  oozes  out.  In  the  earliest 
stage  the  reaction  of  the  fluid  may  be  acid,  but 
it  soon  becomes  alkaline  from  admixture  of  seros- 
ity.  These  vesicles  are  distinct  the  one  from  the 
other  at  first,  and  are  scattered  about  the  inter- 
cligital  surfaces  or  the  palms,  or  they  may  be 
grouped.  In  some  cases  their  fluid  contents  dry 
away,  and  a little  dryness  and  perhaps  slight 
degeneration  follow.  They  may  enlarge  and  be- 
come prominent  upon  the  surface,  or  run  together 
into  bullse,  and  if  the  sweat-secretion  is  free,  large 
bullae  may  form.  Usually  the  cuticle  becomes 


DYSURIA. 

white  and  opaque  from  maceration  in  the  fluid 
which  collects  beneath  it ; and  subsequently  it 
peels  off  in  a membranous  manner,  leaving  be- 
hind, however,  a dry  reddened  surface,  but  not 
a discharging  one  as  in  eczema.  One  or  both 
hands  may  be  affected ; and  the  feet  may  also  be 
attacked.  The  disease  occurs  in  connection  with 
nervous  debility.  It  may  be  attended  with  much 
itching  or  burning  pain  ; and  may  be  accompa- 
nied by  miliaria. 

Anatomical  Characters. — If  a portion  of 
skin  be  excised  and  examined  in  the  early  stage 
of  the  disease,  it  will  be  observed  that  there  is 
no  true  dermic  inflammation,  but  that  the  mor- 
bid changes  are  limited  to  the  sweat-apparatus, 
as  the  writer  has  shown  ( Pathological  (Society's 
Transactions , 1879).  The  sweat-gland-coils  are 
congested,  and  the  results  of  such  congestion 
are  also  seen  in  the  duct-walls  as  they  run 
upward  to  the  Malpighian  layer,  where  the 
vesicles  are  formed.  In  the  early  condition  the 
sweat- ducts  are  dilated,  and  choked  by  epithelial 
debris,  and  gradually  this  portion  and  the  rete 
layer  immediately  outside  the  ducts,  dilate  into 
vesiculations  under  the  pressure  of  the  fluid 
poured  out  into  the  tube.  In  later  stages  the 
effusion  is  so  free,  and  the  distension  of  the  tis- 
sues so  decided,  that  the  nature  of  the  original 
formation  of  the  vesicles  is  not  recognised,  and 
the  vesicles  may  simulate  those  of  eczema,  save 
that  the  amount  of  inflammatory  products  is 
less,  and  there  is  no  distinct  connection  between 
vesicles  and  engorged  papillary  vessels  beneath. 
In  the  earlier  stages  of  the  vesicles,  however, 
ducts  can  be  distinctly  traced  entering  the  vesi- 
cles from  above  and  leaving  them  from  below, 
which  conclusively  proves  that  the  vesicles  are 
formed  in  connection  with  the  sweat- apparatus. 

Treatment. — This  consists,  internally  in  ex- 
hibiting diuretics,  to  be  followed  by  nervine 
tonics  according  to  circumstances,  and  locally  in 
the  use  of  soothing  and  astringent  applications. 

TrLBURT  Fox. 

DYSIIENOEEHCEA  (Ms.  with  difficulty; 
mv,  a month ; and  pew,  I flow. — Difficult  and 
painful  menstruation.  See  Menstruation,  Dis- 
orders of. 

DYSOREXIA  (Ms,  with  difficulty,  and 
opefts,  the  appetite). — An  obsolete  term  for  im- 
paired or  depraved  appetite.  See  Appetite, 
Disorders  of. 

DYSPEPSIA  (Sis,  with  difficulty,  and 
ireVru,  I concoct). — A synonym  for  indigestion. 
See  Digestion,  Disorders  of. 

DYSPHAGIA  (fit's,  with  difficulty,  and 
<fiayw,  I eat). — Difficulty  in  swallowing.  See 
Deglutition,  Disorders  of. 

DYSPHONIA  (fits,  with  difficulty,  and 
<f> owt),  the  voice). — Difficulty  in  producing  vocal 
sounds,  so  that  the  voice  is  more  or  less  en- 
feebled. See  Yoice,  Affections  of. 

DYSPNOEA  (fits,  with  difficulty,  and 
I breathe). — Difficulty  of  breathing.  See  Res- 
piration, Disorders  of. 

DYSURIA  (fits,  with  difficulty,  and  oipia, 
1 pass  water). — Difficult  or  painful  micturition 
See  Micturition,  Disorders  of. 


E 


EAR,  Diseases  of. — The  natural  division 
of  the  ear  into  external,  middle,  and  internal, 
suggests  a rational,  as  well  as  a convenient  classi- 
fication of  the  disorders  to  which  the  auditory 
apparatus  is  liable. 

I.  External  Ear. — In  examination  of  the  ex- 
ternal meatus  and  tympanic  membrane,  bright 
diffused  daylight,  or,  when  this  is  not  obtain- 
able, light  from  a bull’s-eye  lamp  lit  with  gas, 
is  the  best  for  illumination,  and  the  light 
should  be  reflected  from  a concave  perforated 
mirror  of  eight-inch  focus  down  a tubular  spe- 
culum. In  any  operative  proceedings  the  mirror 
should  be  worn  on  the  forehead,  as  in  examining 
the  throat,  but  otherwise  should  be  held  in  the 
hand.  As  great  variations  in  the  calibre  of  the 
auditory  meatus  are  mot  with,  it  is  necessary 
to  be  provided  with  specula  of  several  sizes, 
the  most  convenient  form  being  that  known  as 
Gruber’s. 

Of  the  affections  of  the  external  ear  the  most 
important  are  the  following: — 

1.  Eczema. — Although  the  acute  form  of 
eczema  occasionally  affects  the  auricle  and  ex- 
ternal auditory  meatus,  it  is  far  more  common  to 
meet  with  the  chronic  variety.  Elderly  females 
are  especially  subject  to  eczema  of  the  ear,  and 
it  is  to  its  long  continuance  that  the  remarkable 
narrowing  of  the  external  meatus  throughout  its 
whole  extent,  met  with  occasionally  in  the  sub- 
jects of  this  complaint,  is  generally  attributable. 
Such  narrowing  will  often  amount  to  almost  com- 
plete closure,  and  it  is  in  these  instances  that, 
eczema  becomes  the  cause  of  greatly  impaired 
hearing ; for  when  this  condition  is  arrived  at, 
the  passage  down  to  the  tympanic  membrane  is 
at  times  so  small  as  only  to  admit  of  a very 
small  probe.  It  is  for  this  reason  that,  although 
no  special  methods  of  treatment  are  called  for, 
beyond  what  is  necessary  when  parts  other  than 
the  ear  are  affected  with  eczema,  it  is  of  the 
greatest  importance  to  keep  the  meatus  sedu- 
lously free  from  secretion,  and  this  occasionally 
is  not  a very  easy  matter. 

2.  Changes  in  cartilage. — Another  condi- 
tion, in  which  the  external  passage  becomes  sub- 
ject to  partial  closure,  is  shrinking  of  the  carti- 
laginous part  of  the  meatus.  This  again,  is  a 
complaint  of  old  age,  and  is  attributable  to 
no  known  cause.  It  is  readily  relieved  by  the 
patient  wearing  a piece  of  silver  tube,  to  keep 
the  passage  patent. 

3.  Bony  growths  in  the.  osseous  part  of  the 
canal  present  two  entirely  distinct  phases : one 
in  which,  beyond  the  enlargement  of  bone,  there 
is  no  discoverable  disease,  and  no  impairment  in 
hearing  power ; the  other  where  the  growth 
would  seem  to  owe  its  origin  to  some  irritation. 

In  the  first  case,  the  enlargements  are  very 
frequently  symmetrical  in  either  ear,  and  syn- 
chronous in  their  growth.  So  exactly  is  this  so, 
that  of;en  where  they  exhibit  three  curves  iu 
one  part  of  the  boDy  canal  on  one  side,  the 
curves  will  be  found  to  be  precisely  similar  in  size 
■md  position  in  the  other  ear.  As  the  enlarge- 

27 


ments  are  not  attended  with  pain,  the  patient 
will  obviously  bo  quite  ignorant  of  his  con- 
dition, until  his  attention  is  directed  to  one  tn< 
by  a slight  accumulation  of  cerumen,  which  will 
suffice  to  obstruct  the  passage  of  sound  to  tin 
tympanum. 

In  the  other  example  alluded  to,  disease  of 
the  tympanum  precedes  the  so-termed  exostosis, 
and  a perforation  of  the  tympanic  membrane, 
attended  with  a purulent  discharge,  will  be 
present  perhaps  for  some  years  before  the 
growth  of  bone  is  discovered.  It  is  in  such  a 
case  that  sometimes  the  exostosis,  by  preventing 
the  escape  of  pus,  becomes  the  indirect  cause  of 
death  due  to  cerebral  abscess.  This  is  especially 
so  where,  in  addition  to  the  exostosis  in  the 
meatus,  there  is  a polypus  growing  from  the 
tympanic  cavity. 

Treatment. — With  this  complication,  or  where 
the  meatus  becomes  completely  closed,  and  in 
these  two  cases  alone,  it  occasionally  becomes 
imperative  to  remove  the  bony  growth.  The 
position  of  the  tumours,  and  their  extreme  hard- 
ness, make  this  no  simple  task  ; and  (except  in 
the  instance  mentioned  by  the  late  Mr.  Syme. 
w'hen  they  were  exceptionably  friable)  their  re- 
moval has  been  attended  with  great  difficulty. 

Up  to  the  present  time  two  modes  of  proceed- 
ing have  been  the  most  successful.  The  first  of 
these  is  as  follows : — -Two  needles  being  inserted 
into  the  base  of  the  growth,  holes  having  been 
drilled  for  this  purpose,  the  continuous  current 
derived  from  ten  to  twenty  pairs  of  plates  (Stoh- 
rer’s  battery)  has  been  passed  through  them  for 
a few  minutes,  and  in  the  course  of  about  six 
weeks  the  bone  thus  destroyed  has  become  loose, 
and  is  readily  removed  with  forceps.  The  second  . 
method  consists  in  grinding  the  bone  away  by 
means  of  a drill,  now  in  common  use  with  den- 
tists. Either  proceeding  is  attended  with  so 
much  pain  that  an  anaesthetic  is  necessary. 

4.  Inflammation.  — The  external  auditory- 
meatus  is  subject  to  inflammation,  diffused  or 
circumscribed,  the  latter  occurring  in  the  form 
of  small  abscesses  or  boils.  Both  affections  are 
attended  by  acute  pain,  and  in  each  the  general 
health  of  the  patient  has  been  out  of  order  for 
some  time  previous  to  the  local  trouble. 

Treatment. — Treatment  in  the  direction  of 
improving  the  general  health  ; and  local  bleed- 
ing by  means  of  leeches  applied  in  front  of  the 
tragus,  will  often  rapidly  relieve  the  diffused 
form  of  inflammation ; hut  when  it  has  con- 
tinued for  a long  period  (as  it  not  infrequently 
does),  in  addition  to  the  soft  tissues  the  pe- 
riosteum becomes  affected.  The  passage  then 
throughout  its  whole  extent  becomes  so  swelled 
as  to  nearly  close  the  external  opening,  and  pain 
is  constant.  The  only  treatment  which  gives 
complete  and  permanent  relief  under  these  cir- 
cumstances is  to  make  two  or  three  free  incisions 
down  to  the  hone,  along  the  whole  extent  of  the 
osseous  part  of  the  canal.  A convenient  instru- 
ment for  this  purpose  is  a small  sharp-pointed 
curved  bistoury.  As  to  the  propriety  of  openiug 


U8 


EAR,  DISEASES  OF. 


abscesses  in  this  situation  there  can  be  noquestion, 
for,  owing  to  the  extreme  denseness  of  the  tissues 
and  their  approximation  to  bene  in  the  external 
auditory  canal,  abscess  in  this  part  is  slow  in  its 
progress  and  attended  with  very  great  suffering. 
These  abscesses  being  especially  liable  to  recur,  a 
proper  regimen  and  medicines  appropriate  to  the 
failure  in  general  health  are  required. 

5.  Fungi. — The  external  auditory  meatus  has 
been  occasionally  found  to  be  the  seat  of  two 
varieties  of  vegetable  fungus,  namely,  Aspergillus 
flavus  and  nigricans.  The  symptoms  which 
they  have  given  rise  to  have  been  great  irri- 
tation, and  a slight  discharge.  They  have  been 
readily  destroyed  by  syringing,  and  the  local 
application  of  spirits  of  wine. 

6.  Polypus  of  the  ear  is  usually  preceded  by 
inflammation  in  the  tympanic  cavity  and  perfo- 
ration of  the  membrane  ; and  is  considered  along 
with  diseases  of  the  middle  ear. 

7.  Hffimatoma  Auris.  Sec  ILtsmatoma 
AlTRtS. 

II.  Middle  Ear. — All  affections  of  the  mid- 
dle ear  originate  in  some  part  of  that  tract  of 
mucous  membrane  which,  commencing  where 
the  Eustachian  tube  opens  into  the  pharynx, 
forms  the  lining  of  this  tube,  and  of  the  cavity, 
of  the  tympanum,  finally  becoming  the  inner- 
most layer  of  the  tympanic  membrane.  To  the 
character  of  this  tissue  is  due  the  term  catarrh, 
which,  in  its  two  forms  of  purulent  and  non- 
purulent,  is  used  in  describing  any  deviation 
from  health  which,  directly  or  indirectly,  is  the 
cause  of  pathological  change  in  the  Eustachian 
tube  or  tympanum. 

1.  Obstruction  of  the  Eustachian  Tube. — 
One  of  the  most  frequent  conditions  under  which 
the  Eustachian  tubes  become  the  seat  of  ob- 
struction is  that  met  with  in  children  or  young 
persons.  The  subjeots  of  this  affection  present 
a very  characteristic  aspect.  They  breathe 
almost  entirely  through  the  mouth,  which, 
sleeping  or  waking,  is  kept  partially  open  ; their 
tonsils  are  often  enlarged,  and  they  snore  loudly 
during  sleep.  The  mucous  membrane  of  the 
nares  and  pharynx  is  swollen,  and  secretes  in 
excess;  owing  to  this  tumid  state  of  the  fauces 
the  passages  to  the  Eustachian  tubes  in  this 
situation  do  not  admit  of  the  constant  necessary 
supply  of  air  to  the  tympana.  The  air  in  these 
cavities  undergoes  partial  absorption,  and  thus 
becomes  more  rare  than  that  external  to  the 
tympanic  membrane ; the  density  of  tho  outer 
air  remaining  tiro  same,  the  equilibrium  from 
pressure  is  destroyed ; the  membrane,  conse- 
quently, is  retracted,  the  chain  of  ossicles  are 
pressed  inwards,  and  thus  the  conduction  of 
sound  becomes  interfered  with — in  short,  the 
patient  is  more  or  less  deaf.  In  these  cases 
inspection  of  the  tympanic  membrane  at  once 
reveals  the  state  of  affairs.  As  the  cavity  of  the 
tympanum  is  notinvolved  in  the  catarrhal  change, 
its  translucency  and  lustre  are  not  impaired  ; the 
handle  of  the  malleus  is  tilted  inwards,  the  head 
of  this  bone  is  unusually  prominent,  and  there 
is  a distinct  fold  crossing  the  upper  part  of  the 
posterior  section  of  the  membrane.  Where  the 
obstruction  has  lasted  for  a long  period,  the 
membrane  will  appear  to  be  almost  fallen  in 
dpon  the  walls  of  the  tympanum,  and  the  pro- 


montory and  incus  may  be  distinguished.  If 
under  these  conditions  the  tympanum  be  in- 
flated on  Politzer's  plan,1  an  instant  return  to 
good  hearing  follows,  but  in  the  course  of  a few 
days  the  improved  hearing  partially  dies  away, 
leaving  the  patient,  however,  in  some  degree 
better  than  before  the  operation. 

Treatment. — This  should  be  twofold.  In 
the  first  place  the  tympanum  should  be  regularly 
inflated,  and  this  may  be  practised  at  first  every 
three  or  four  days,  and  gradually  at  longer  inter- 
vals. Secondly,  astringent  applications  should 
be  applied  to  the  pharynx.  Of  these  applications 
one  of  the  best  is  a solution  of  perchloride  of 
iron,  2 drachms  to  1 ounce  of  water,  and  it  should 
be  used  daily  by  moans  of  a curved  camel’s-hair 
throat-brush.  When  the  nares  are  much  ob- 
structed, great  benefit  will  follow  the  use  of  sa- 
line solutions  through  the  nasal  douche,  or  they 
may  be  insufflated,  that  is,  drawn  up  through 
the  patient’s  nose  into  the  pharynx  and  then 
spat  out. 

If  the  tonsils  are  so  much  enlarged  as  to  in- 
terfere with  the  respiration,  it  will  be  necessary 
to  remove  them  ; but  the  reason  for  this  pro- 
ceeding is  not  that  they  press  upon  the  opening 
of  the  Eustachian  tube,  but  because  their  pre- 
sence keeps  up  the  unhealthy  condition  of  the 
pharynx. 

Under  this  routine  of  treatment  the  patients 
completely  recover  their  hearing ; the  space  of 
time  during  which  it  is  necessary  to  continue 
treatment  varying  according  to  the  obstinacy 
which  each  case  manifests. 

Obstruction  of  the  Eustachian  tubes  in  adults 
presents  certain  well-marked  differences  from  the 
affection  as  it  prevails  in  children.  An  ordinary 
cold  is  the  beginning  of  the  trouble.  It  is  m«re 
usual  to  find  one  instead  of  both  tubes  ob- 
structed, and  more  often  than  not  the  tympanic 
cavity  is  involved  in  the  catarrh.  Where  this 
is  not  the  case — and  it  will  be  evident  from  the 
retained  lustre  and  transparency  of  the  mem- 
brane— the  same  principles  of  treatment  as  are 
pursued  in  the  ease  of  children  will  hold  good, 
except  in  so  far  that  the  affection  in  grown-up 
persons  is  less  persistent  after  the  tube  has  beer, 
once  artificially  opened ; and  that,  to  effect  tins, 
Politzer’s  method  is  sometimes  not  sufficient,  or. 
even  if  so,  not  as  efficacious  as  the  Eustachian 
catheter.  It  must  also  be  borne  in  mind  that 
in  the  treatment  of  cases  in  which  one  ear  is 
healthy,  by  means  of  the  catheter  the  affected 
car  exclusively  may  be  subjected  to  the  air- 
douche,  whilst  with  Politzer’s  method  it  is  im- 
possible to  avoid  forcing  a stream  of  air  into 
the  healthy  tympanum,  and  this  is  not  always  an 
advisable  proceeding. 

The  Eustachian  Catheter. — The  following  is 
the  mode  of  using  the  Eustachian  catheter: — 

‘ Place  the  patient  in  a chair,  and  let  him  lean 
back;  steady  his  head  with  the  left  hand  firmly 
fixed  on  the  top  of  it;  hold  the  catheter  lightly 
in  the  right  hand,  with  the  curve  downwards 

1 This  method  of  inflating  the  middle  ear  (now  in  such 
general  use)  consists  in  passing  a stream  of  air  from  an 
india-rubber  bag  through  one  nostril  whilst  the  patient 
swallows  some  water.  The  operator  at  the  same  tilin’ 
closes  one  nostrilwith  the  forefinger  of  the  left  hand,  soil 
completes  the  closure  of  the  other  with  the  thumb.  T . - 
month  must  lie  kept  firmly  shut. 


EAR,  DISEASES  OF. 


And  piss  it  quickly  in  this  position  through  the 
inferior  meatus  of  the  nose  to  the  posterior  wall 
of  the  pharynx.  When  this  is  felt, -withdraw  the 
catheter  about  half  an  inch,  and  tilt  the  point 
of  the  curved  end  rather  upwards,  and  to  the 
left  or  right,  according  to  the  side  which  is  being 
operated  upon.  Now  hold  the  catheter  and  end 
of  the  patient's  nose  steadily  between  the  thumb 
and  the  first  two  fingers  of  the  left  hand.  All 
this  time  the  ear  of  the  patient  and  that  of  the 
surgeon  are  connected  with  the  otoscope.  The 
point  of  the  catheter  is  now  supposed  to  be  in 
the  pharyngeal  orifice  of  the  Eustachian  tube, 
but  the  only  certain  sign  of  this  being  the  case 
is  that  when  air  is  forced  into  the  catheter  it  will 
be  heard  through  the  otoscope  to  impinge  upon 
the  tympanic  membrane  when  a stream  of  air  is 
passed  down  the  catheter.’ 

The  catheter  may  be  made  of  silver  or  of 
vulcanite,  but,  of  whatever  material,  it  must  be 
inflexible  whilst  being  used.  Beyond  this,  suffice 
it  to  say  here  that  in  practised  hands  its  em- 
ployment is  invaluable,  and  indispensable  in  the 
treatment  of  most  affections  of  the  middle  ear, 
not  only  in  overcoming  obstruction  of  the  Eusta- 
chian tube,  but  also  as  a means  by  which  injec- 
tion of  fluids  may  be  applied  to  the  cavity  of  the 
tympanum.  In  making  use  of  the  air-douche 
an  indiarubber  bag  fitted  to  the  catheter  should 
be  employed,  and  in  using  injections  to  the  tym- 
panum a similar  arrangement  is  necessary. 

2.  Catarrhal  Inflammation  of  the  Tym- 
panum.— When  the  tympanic  cavity  has  be- 
come involved  in  the  catarrhal  state,  or  when  the 
affection,  instead  of  proceeding  up  the  Eustachian 
tubes,  begins  in  the  tympanum,  as  it  frequently 
does,  those  changes  have  commenced  which,  of 
all  others,  form  the  most  frequent  impediments 
to  the  conduction  of  sound — in  other  words, 
which  make,  the  subjects  in  which  they  are  found 
more  or  less  deaf;  and  it  may  be  broadly  stated 
that  the  extent  to  which  this  affection  is  reme- 
diable depends  directly  upon  the  time  at  which 
the  patients  suffering  from  it  apply  for  treat- 
ment. In  the  early  stages,  the  obstruction  to 
the  passage  of  sound  through  the  tympanum  is 
solely  due  to  the  effusion  of  mucus  in  this  situ- 
ation, and  this  is  easily  demonstrated  by  the 
moist  gurgling  sound  which  inflation  of  the 
tympanum  produces,  as  may  be  heard  upon  con- 
necting the  ears  of  the  patient  and  surgeon  by 
means  of  a piece  of  indiarubber  tubing.1  After- 
wards comes  what  may  be  termed  the  dry  stage, 
i.c.  when  the  fluid  portion  of  the  mucus  has  suf- 
fered absorption,  and  when  any  of  the  products 
of  inflammation  ma}T  have  become  more  or  less 
organised,  or  at  least  in  a condition  which,  if  not 
interfered  with,  suffers  no  further  change.  The 
morbid  conditions  which  result  from  non-puru- 
lent  catarrh  of  the  tympanum  are  twofold.  First, 
those  which  affect  the  tympanic  membrane,  and 
are,  therefore,  demonstrable  during  life ; secondly, 
those  which  are  met  with  after  death  in  the  tym- 
panic cavity.  The  first  of  these  include  changes 
in  curvature,  in  colour,  and  in  consistence. 

The  slighter  changes  in  curvature  have  been 

1 This  tubing  should  always  be  used,  whether  air  or 
fluids  are  being  injected  through  the  Eustachian  tube,  for 
upon  the  sounds  thus  heard,  as  well  as  on  the  patient's 
own  perception,  the  answer  to  the  question  whether  the 
inflation  is  complete  depends. 


419 

noticed  in  speaking  of  obstruction  of  the  Eusta- 
chian tube,  which  condition  is  necessarily  more 
or  less  present  m all  eases  where  the  tympanum 
has  been  the  seat  of  catarrh,  and  these  changes 
are  met  with  indefinitely  increased  until  the  state 
of  complete  collapse  is  reached. 

In  this  condition  the  membrane  has  the  appear- 
ance of  being  in  close  apposition  to  the  walls  of 
the  tympanum,  and  iapped  round  the  ossicles,  so 
that  the  forms  of  the  malleus,  incus,  and  some- 
times the  stapes  are  distinctly  traceable. 

In  so  extreme  an  example,  the  membrane  is 
generally  bound  down  to  the  tympanic  wall  by 
adhesions.  The  first  change  which  the  mem- 
brane exhibits  is  a loss  of  its  lustre  and  trans- 
parency ; it  becomes  opaque.  Further  altera- 
tions iu  colour,  in  cases  of  longstanding,  consist 
in  the  formation  of  patches  of  brown,  yellow 
(colour  of  parchment),  and  white.  Variations  in 
consistency  will  include  thickening  throughout 
the  membrane,  or  in  parts  of  it,  especially  in  the 
cases  of  dense  chalk  deposits  (phosphate  oflime) ; 
and  thinning  in  places,  so  observable  sometimes 
that  inflation  will  induce  bladder-like  protrusions, 
which,  as  inflation  is  suspended,  fall  back  again  : 
changes  in  all  these  respects  completely  meta- 
morphosing the  appearance  of  the  membrane. 
After  death,  within  the  tympanum  may  he  found 
collections  of  dried  mucus  around  the  ossicles  ; 
thickening  of  the  lining  membrane;  hands  of 
adhesion  in  all  directions  ; and  anchylosis  of 
the  ossicles  to  each'  other,  as  well  as  between  the 
stapes  and  fenestra  ovalis. 

As  additional  evidence  during  life  of  obstruc- 
tion in  the  tympanum,  it  may  be  mentioned  that 
sounds  from  a vibrating  tuning-fork  placed  on 
the  vertex  are  intensified  witen  such  obstruction 
exists,  and  the  nerve  remains  unimpaired : this 
test  is  especially  valuable  where  one  ear  is 
healthy,  inasmuch  as  the  sound  will  be  heard 
exclusively  on  the  deaf  side,  this  being  due  t- 
the  fact  that  vibrations  of  sound  thus  conveyed 
to  the  auditory  nerve,  on  their  passage  outwards 
through  the  tympanum,  meet  with  the  obstruc- 
tion in  this  position,  and  are  reflected  on  to  the 
labyrinth.  The  appearances  above  described, 
together  with  the  history  of  the  case,  serve 
sufficiently  to  distinguish  affections  of  the  con- 
ducting from  those  of  the  nervous  apparatus, 
and  the  sounds  which  are  produced  upon  inflation 
of  the  tympanum,  whether  of  a moist  or  drv 
character,  give  evidence  as  to  whether  the  mucu- 
in  the  cavity  of  the  tympanum  is  in  a more  or 
less  fluid  state,  or  has  reached  the  dry  stage 
where  the  fluid  part  of  the  secretion  has  become 
absorbed,  the  more  solid  portion  remaining. 

In  the  first  of  these  conditions,  the  inflation  at 
once  increases  the  hearing  power ; in  the  second, 
it  produces  no  change  in  the  hearing.  An  indica- 
tion in  this  direction  is  a most  useful  guide  iu 
respect  of  treatment,  for  whatever  differences  in 
opinion  may  exist  as  to  details  in  relation  to  this 
subject,  experience  has  amply  shown  that  the 
injection  of  fluids  into  the  tympanum  is  for  the 
majority  of  cases  the  treatment  of  all  others  the 
most  successful,  and,  speaking  generally,  it  may 
he  said  that  when  the  sounds  which  accompany 
inflation  of  the  tympanum  are  of  a moist  charac- 
ter (showing  that  undue  secretion  from  the  mucus 
membrane  is  going  on),  astringents,  such  as  su! 


120 


EAR,  DISEASES  OF. 


phate  of  zinc,  1 to  2 grains  to  the  ounce  of  luke- 
warm water,  will  be  found  most  efficacious  ; and 
that  when  the  dry  stage  has  been  arrived  at, 
alkaline  solutions — bicarbonate  of  soda  or  potash, 
5 grains  to  the  ounce,  or  still  better  an  injection 
containing  hydrochlorate  of  ammonia,  5 grains  to 
the  ounce — should  be  substituted. 

Injecting  the  Tympanum.- — There  are  three 
modes  of  injecting  the  tympanum,  and  their  order 
of  efficiency  stands  as  follows  : — Firstly,  when  the 
Eustachian  catheter  has  been  placed  in  position, 
a few  drops  of  the  injectionare  introduced  intoit 
from  a small  glass  syringe,  and  forced  into  the 
tympanum  by  means  of  an  indiarubber  bag,  the 
nozzle  of  which  is  made  to  fit  the  open  end  of 
the  catheter.  Secondly,  a few  drops  are  placed 
in  the  inferior  naris,  on  the  same  side  as  the  ear 
under  treatment,  and  injected  in  front  of  a stream 
of  air  blown  to  the  tympanum  on  Politzer'splan, 
the  patient’s  head  being  inclined  to  the  side  to 
be  acted  upon.  Thirdly,  the  fluid  being  arranged 
in  precisely  the  same  way,  the  patient  forces  it 
up  the  Eustachian  tube  by  attempting  to  blow 
through  the  nostrils,  whilst  the  mouth  and  nose 
are  closed. 

The  injection  may  with  benefit  generally  be 
repeated  every  other  day  for  from  two  to  four 
weeks,  but  for  this  no  rule  can  be  laid  down 
which  would  apply  in  every  case. 

Such  is  the  briefest  outline  of  the  treatment 
under  which  these  cases  recover  in  greater  or 
less  degree.  The  degree  of  improvement  varies 
within  wide  limits,  but  the  greater  benefits  may 
always  unhesitatingly  be  predicted  during  the 
moist  stage  of  the  catarrh.  Indeed,  the  necessity 
for  early  treatment  is  abundantly  shown,  in  the 
instance  of  catarrhal  affection  of  the  middle  ear, 
by  the  extremely  satisfactory  termination  of 
cases  treated  early  in  the  disease,  and  the  slight 
relief  which  but  too  often  follows  when  the  affec- 
tion has  been  allowed  to  proceed  for  years  un- 
checked. In  such  cases  as  the  latter,  the  fact 
that  considerable  quantities  of  inspissated  mucus 
have  been  found  in  the  tympanic  cavities  first 
suggested  the  operation  of  making  an  incision 
into  the  tympanic  membrane,  and  attempting  the 
removal  of  mucus  through  the  incision  bypassing 
a stream  of  air  through  the  tympanum.  This 
proceeding,  with  certain  modifications  afterwards 
introduced,  is  no  doubt  very  useful  in  cases 
favourable  for  its  employment,  but  it  should 
be  reserved  for  those  which  have  defied  the  less 
severe  means,  and  where  there  is  unmistakable 
evidence  of  an  obstruction  to  the  passage  of 
sound  through  the  tympanum.  Experiments 
with  tho  tuning-fork, . already  referred  to,  give 
valuable  evidence  in  this  direction;  but  for 
a detailed  account  of  this  method  of  treatment, 
introduced  some  years  ago  by  Mr.  Hinton,  the 
reader  is  referred  to  Questions  of  Aural  Sur- 
gery. Suffice  it  to  say  hero  that  an  incision 
about  one-eighth  of  an  inch  in  length  is  made  in 
the  posterior  section  of  the  membrane  with  a 
cataract- needle,  and  this  is  followed  by  passing  a 
stream  of  fluid  (a  weak  solution  of  soda)  through 
the  tympanum  and  Eustachian  tube  by  means  of 
a syringe  made  to  fit  the  external  meatus.  In 
appropriate  cases  it  is  often  undoubtedly  of  very 
great  service,  and  is  neither  a dangerous  nor  a 
harmful  proceeding  so  long  as  there  is  no  nervous 


complication  ; where,  however,  this  is  present, 
surgical  interference  has  at  times  proved  most 
disastrous. 

Another  operation,  performed  by  Dr.  Weber 
Leil  of  Berlin,  consists  in  the  division  of  the 
tensor  tympani  muscle,  but  up  to  the  present 
time  the  results  at  the  hands  of  others  do  not 
warrant  it  as  a recognised  operation  for  the  re- 
lief of  conditions  inducing  deafness. 

3.  Purulent  Catarrh  of  the  Tympanum- 
Perforation, — The  form  of  tympanitis  in  which 
the  effused  products  become  purulent,  is  an  acute 
and  generally  an  extremely  painful  affection. 
Usually  the  pus  rapidly  makes  its  escape  from 
the  tympanum  into  the  external  meatus,  by  a 
process  of  ulceration  through  the  tympanic  mem 
brane,  leaving  as  its  result  a perforation  of  this 
structure.  In  quite  the  early  stage  the  affection 
may  often  be  cut  short  by  the  free  application  of 
leeches  in  front  of  the  tragus,  followed  by  foment- 
ations, but  more  often  than  not  the  membrane 
has  given  way  before  tho  patient  comes  under 
observation.  Even  then,  if  the  tympanic  cavity 
be  emptied  of  the  pus  by  the  free  use  of  Folit- 
zer's  inflation  and  repeated  syringing,  the  open- 
ing will  often  close,  and  leave  very  little,  indeed 
sometimes  hardly  any  appreciable  deafness.  If, 
however,  a purulent  discharge  through  the  open- 
ing be  allowed  to  go  on  unheeded  for  any  length 
of  time,  it  is  the  exception  for  the  perforation  to 
heal.  This  condition  is  constantly  seen  after 
scarlet  fever,  measles,  or  any  of  the  exanthemata. 
A perforation  of  the  tympanic  membrane  pre- 
sents an  infinite  variety  of  aspects,  from  a small 
pin-hole  to  nearly  complete  loss  of  the  membrane, 
but  there  will  always  be  a slight  remaining 
external  rim  of  membrane.  This  latter  is 
perhaps  the  most  frequent  of  all  forms  of  per 
foration,  and  especially  when  the  ulceration 
dates  from  an  attack  of  scarlet  fever.  Although 
the  handle  of  the  malleus  occasionally  remains, 
it  more  usually  comes  away  in  these  and  other 
cases  where  the  loss  of  tissue  is  very  extensive. 
The  head  of  this  bone,  however,  may  always  be 
distinguished,  unless  there  has  been  complete 
disorganisation  of  the  tympanic  cavity.  Among 
other  forms  of  perforation  commonly  met  with 
may  be  mentioned  those  in  which  the  anterior 
or  posterior  half  of  the  membrane  is  left,  and  is 
bounded  internally  by  the  handle  of  the  malleus  ; 
the  so-called  reniform  perforation,  where  the 
lower  part  of  the  membrane  is  lost  and  the 
umbo  of  the  malleus  indicates  the  position  of 
the  hilus  of  the  kidney ; and  the  small,  smooth- 
edged  circular  perforation  which  is  common  alike 
to  all  parts  cf  the  membrane.  Occasionally, 
though  not  very  often,  the  tympanic  membrane 
is  the  seat  of  a double  perforation.  Similar 
variations  in  hearing  accompany  this  condition, 
between  slight  deafness  and  total  loss  of  hearing 
power.  The  size  of  the  perforation  affords  no 
guide  in  this  respect,  extreme  loss  of  heariDg 
being  met  with  when  the  perforation  is  very 
small,  and  very  slight  deafness  where  the  less 
of  tissue  has  been  most  extensive,  so  that  it  may 
be  unhesitatingly  stated  that  the  loss  of  the  mem- 
brane is  but  in  a very  small  degree  the  cause  of 
the  deafness  in  these  cases,  the  disorganisation 
in  the  tympanic  cavity  mainly  accounting  for 
this.  Such  disorganisation  is  at  times  so  com- 


EAR,  DISEASES  OF.  421 


plcte  (especially  after  scarlet  fever)  as  to  include 
the  loss  of  all  the  ossicles,  total  deafness,  and 
paralysis  of  the  muscles  supplied  by  the  portio 
dura.  A very  small  perforation  in  the  anterior 
and  superior  part  of  the  membrane  may  from 
its  position  escape  notice,  but  the  diagnosis  can 
bo  always  verified  by  the  facility  with  which  air 
may  be  made  to  pass  through  the  opening,  or 
the  reverse,  provided  that  the  communication 
botween  the  Eustachian  tube  and  the  tympanum 
is  not  closed  by  cicatricial  tissue — a very  rare 
condition  when  so  little  of  the  membrane  has 
suffered  ulceration. 

Treatment. — The  treatment  of  purulent  tym- 
panitis and  perforation  will  include  assiduous 
cleanliness  ; keeping  the  Eustachian  tube  free 
from  obstruction ; and  the  use  of  astringent 
injections.  When  the  exposed  surface  of  the 
tympanum  is  covered,  as  it  sometimes  is,  with 
exuberant  granulations,  much  benefit  will  be 
derived  from  the  application  of  solid  nitrate 
of  silver  to  the  granular  surface,  care  being 
taken  not  to  touch  any  other  part.  As  the 
condition  of  the  ear  improves  under  these 
measures,  so  will  the  hearing  power  vastly  in- 
crease when  it  has  not  been  completely  lost;  but 
there  still  remains  the  ofttimes  invaluable  appli- 
cation of  what  is  spoken  of  as  the  artificial  mem- 
brane. Of  all  kinds,  the  best  undoubtedly  is  the 
flattened  pad  of  moistened  cotton-wool,  applied 
by  the  patient,  every  morning,  with  a pair  of 
forceps  constructed  for  the  purpose.  Until  this 
be  tried  in  each  case  it  is  impossible  to  say 
whether  it  will  do  good;  but  when  it  is  useful — 
as  it  is  in  a large  number  of  cases — by  its 
help  the  patient  will  recover  very  good  hearing, 
and  this  even  when  the  perforation  has  existed 
for  a period  of  many  years.  That  its  effects  de- 
pend upon  the  support  which  it  gives  to  the 
ossicles,  thus  re-establishing  the  normal  pressure 
of  the  stapes  upon  the  fenestra  ovalis,  has  been 
unquestionably  demonstrated. 

4.  Polypus. — One  of  the  most  frequent  com- 
plications in  cases  of  perforation  of  the  tympanic 
membrane  is  polypus,  a term  employed  to  desig- 
nate a fleshy  tumour  in  the  ear.  Although  polypi 
are  occasionally  present  in  the  meatus  indepen- 
dently of  perforation,  the  most  usual  situation 
from  which  they  arise  is  the  lining  membrane  of 
the  tympanum.  Sometimes  the  exact  point  of 
origin  is  the  edge  of  a perforation,  and  still  more 
rarely  the  sides  of  the  meatus.  In  size  these 
growths  vary  from  a small  protrusion  through  a 
perforation,  to  a tumour  which  entirely  fills  the 
meatus  and  projects  externally  from  the  ear.  In 
this  latter  instance  the  growth presentsa  very  dis- 
tinctive appearance,  not  unlike  a raspberry.  Sec- 
tions of  aural  polypi  hardened  in  chromle  acid 
with  few  exceptions  show  the  structure  to  be  fibro- 
eellular,  the  fibrous  element  preponderating  over 
the  cellular  in  proportion  to  the  age  of  the  tumour. 

Treatment. — In  all  cases  polypi  should  be  re- 
moved, and  the  best  instruments  for  this  purpose 
are  the  rectangular  ring  polypus  forceps,  or,  in 
the  case  of  a large  growth,  a Wilde’s  snare.  Owing 
to  their  remarkable  tendency  to  recur,  removal  is 
only  the  preliminary  step  in  treatment.  The  prin- 
cipal part  of  1 his  consists  in  their  complete  eradi- 
ation bv  caustics.  Of  these,  the  most  efficacious 
and  convenient  is  chlor-acetic  acid,  and  later  in 


the  treatment  nitrate  of  silver.  The  acid  may  be 
applied  on  a very  small  camel’s-hair  brush,  or 
on  the  point  of  a probe  defended  by  a small  twist 
of  cotton  wool,  and  a convenient  form  of  nitrate 
of  silver  is  a bnlb  of  the  melted  salt  fused  on  to 
a probe  or  platinum  wire.  The  caustic  should  be 
applied  daily  for  some  time  after  the  polypus 
has  been  removed,  and  then  less  frequently.  The 
treatment  should  also  include  the  same  scrupulous 
cleanliness  and  application  of  astringents,  so  de- 
sirable in  the  case  of  perforations.  It  is  simply 
to  the  want  of  attention  to  details  that  failure  in 
the  treatment  of  aural  poly'pus  may  be  ascribed. 

Complications  of  Tympanic  Disease.  — a. 
Facial  Paralysis. — This  is  due  to  inflammation 
around  the  portio  dura  in  its  passage  through  the 
aqueduct  of  Fallopius.  When  suppuration  in  the 
tympanic  cavity,  with  caries  of  the  bony  canal, 
precedes  or  accompanies  the  loss  of  function  in 
the  nerve,  recovery  is  hopeless;  but  when  the 
paralysis  follows  a subacute  catarrh  of  the  tym- 
panum, not  ending  in  a perforation,  as  is  some- 
times the  case,  the  paralysis  in  time  disappears 
no  less  certainly  than  when  it  is  dependent  upon 
an  affection  of  the  nerve  at  a point  after  its  exit 
from  the  temporal  bone. 

b.  Pytcmia:  Cerebral  Abscess ; and  Meningitis. 
When  the  mastoid  cells  become  the  seat  of  in- 
flammation, the  pain,  tenderness,  and  pitting  on 
pressure  over  the  mastoid  process,  will  at  once 
suggest  an  early  incision  down  to  the  bone,  and 
it  maybe  truly  said  that  this  is  often  delayed 
too  long,  and  perhaps  is  never  done  too  soon. 
Again,  when  the  symptoms  point  definitely  to 
pus  within  the  mastoid  cells,  the  bone  should  bo 
pierced  so  as  to  make  the  external  opening  com- 
municate freely  with  the  cells.  Relief  given  in 
this  way  will  occasionally  be  the  means  of  saving 
life,  by  preventing  the  absorption  of  poisoned 
material  into  the  lateral  sinus.  Besides  pyaemia 
thus  induced,  other  fatal  issues  which  suppura- 
tion in  the  middle  ear  frequently  entail  have 
their  starting  point  in  the  tympanic  cavity,  and 
in  such  instances  cerebral  abscess  cr  meningitis 
may  be  the  immediate  cause  of  death.  In  the  latter 
case  a post-mortem  examination  reveals  pus  in 
the  arachnoid  cavity,  or  between  the  roof  of  the 
tympanum  and  the  dura  mater  ; in  the  former, 
the  seat  of  the  abscess  may  be  either  in  the  cere- 
brum or  cerebellum  ; this  portion  of  the  brain 
(the  cerebellum)  being  more  generally,  though 
not  always,  the  part  affected  when  the  mastoid 
cells  are  involved  as  well  as  the  tympannm. 

The  pathology  of  cerebral  abscess,  as  a result  of 
ear-disease,  cannot  with  truth  be  said  in  all  cases  to 
bo  completely  explainable,  and  this  for  the  follow- 
ing reason  ; — Whilst  in  most  cases  a distinct  com- 
munication can  be  traced  between  the  diseased 
roof  of  the  tympanum  and  the  sac  of  the  ab- 
scess, in  a few  the  most  careful  examination  fails 
to  show  any  connection  between  the  two,  the 
abscess  being  separated  from  the  bone  by  healthy 
brain-tissue.  Occasionally,  no  disease  can  be 
detected  in  the  bone  itself,  and  this  even  after 
the  bone  has  been  macerated  and  sections  of  it 
made. 

Fatal  terminations  of  this  nature  most  fre- 
quently occur  when  cleanliness  and  local  treat- 
ment of  the  ear  have  been  neglected.  Hence  the 
necessity  for  such  care. 


EAR,  DISEASES  OF. 


422 

Bat  the  fact  that  even  under  the  most  favour- 
able conditions  such  evonts  are  possible  when 
there  is  a fistulous  opening:  in  the  tympanic 
cavity  should  induce  caution  with  Insurance 
offices  in  taking  the  lives  of  persons  with  this 
lesion,  at  the  ordinary  premiums.  Fatal  cases 
of  this  kind  might  seem  in  practice  to  be  almost 
divisible  into  two  classes,  namely,  those  in  which 
cerebral  symptoms  come  on  soon  after  the  estab- 
lishment of  the  perforation ; and  others  where 
Lhere  has  been  a purulent  discharge  from  the  ear 
( that  is,  from  the  tympanum)  for  many  years  before 
the  advent  of  such  symptoms.  In  this  latter  class 
must  be  included  those  cases  in  which  the  tem- 
poral bone  has  become  the  seat  of  caries  ; and  it 
may  be  stated,  subject  to  no  exceptions,  that 
whenever  exposed  bone  can  bo  detected  by  means 
of  examination  with  a probe  within  the  cavity  of 
the  tympanum,  the  subjects  of  this  condition  are 
always  more  or  less  in  a perilous  state,  and  that 
at  any  time  fatal  symptoms  may  commence  with 
a severe  rigor,  the  earliest  of  all  succeeding 
symptoms.  For  this  reason,  even  when  exposed 
bone  cannot  bo  absolutely  demonstrated  in  the 
way  mentioned,  the  existence  of  bone-granulations 
where  there  is  a perforation  of  the  tympanic 
membrane  should  he  regarded  as  a most  serious 
complication.  The  same  danger,  though  in  a 
very  much  less  degree,  may  be  said  to  be  present 
when  dead  bone  can  be  detected  in  the  mastoid 
process — in  a less  degree,  because  the  outer  table 
of  the  bone  is  often  affected  whilst  the  inner 
remains  healthy.  The  dead  bone  then  in  the 
former  position  becomes  exfoliated,  and  the  ex- 
ternal wound  heals.  Such  are  briefly  the  points 
of  importance  in  connection  with  caries  of  the 
temporal  bone.  How  caries  of  the  mastoid 
process  may  be  obviated  by  a timely  perforation 
of  the  mastoid  cells,  and  how  the  chief  part  of 
the  temporal  bone  may  when  carious  be  removed 
and  the  patient  survive,  may  be  seen  on  reference 
to  a paper  entitled  ‘ Disease  of  the  Mastoid 
Bono’  by  the  writer  of  this  article  in  the  Tran- 
sactions of  the  Medical  and  Chimrgical  Society 
for  1879. 

c.  Malignant  Disease.-—  In  the  paper  just  men- 
tioned is  also  reported  a case  of  malignant  disease 
of  the  ear,  in  which  the  cavity  of  the  tympanum, 
having  been  the  seat  of  suppuration  for  some  time, 
became  affected  with  epithelial  growth,  which 
caused  the  death  of  the  patient.  From  all  recorded 
cases  of  malignantdiseaseof  the  ear  it  would  seem 
that  the  seat  of  origin  of  the  new-growth  will  be 
found  to  be  the  lining  membrane  of  the  tympanic 
cavity,  and  that  a purulent  discharge  from  this 
surface  always  precedes  the  appearance  of  the 
cancer,  and  must  therefore  bo  regarded  as  the 
exciting  cause  of  the  growth.  In  its  early  stages 
cancer  in  this  situation  bears  a strong  resemblance 
to  the  ordinary  forms  of  polypus.  The  same 
cause,  then,  which  in  some  cases  calls  into  being 
a polypus  may  occasionally  give  rise  to  malignant 
disease,  and  this  without  any  predisposing  cause 
(so  far  as  can  be  ascertained)  in  the  patient 
towards  cancerous  growth. 

III.  Internal  Ear. — -Apart  from  deafness 
due  to  local  changes  in  the  external  or  middle 
ear,  the  function  of  hearing  is  subject  to  impair- 
ment from  causes  which  have  their  seat  in  the 
aervous  structures  of  the  ear;  in  other  words, 


although  the  conduction  of  sound  may  be  good, 
the  perception  of  sound  may  be  faulty.  The  in- 
ability to  hear  the  vibrations  of  sound  conveyed 
through  the  cranial  bones,  such  as  from  a vibra- 
ting tuning-fork  placed  upon  the  vertex,  is  in- 
dicative of  this  condition.  For  the  rest,  the 
absence  of  tympanic  disease,  and  the  history  of 
the  case,  must  supply  the  evidence  required  fora 
diagnosis.  Familiar  examples  of  this  nature  are 
the  deafness  which  often  accompanies  old  age,  or 
which  is  left  after  fevers  when  the  middle  ear  has 
not  suffered;  the  two  forms  of  syphilitic  ner- 
vous affection  mentioned  below ; the  sudden  and 
sometimes  total  loss  of  hearing  which  occasion- 
ally follows  severe  mental  shock  ; the  deafness 
after  loud  explosions  near  the  ear,  so  common  in 
artillery-men  and  naval  men  ; and  that  which  is 
caused  by  blows  on  the  head  and  boxes  on  the 
ear.  An  attack  of  mumps  will  sometimes  leave 
behind  an  irremediable  loss  of  hearing  in  one  or 
both  ears,  unattended  with  any  discoverable 
change  in  the  tympanum.  In  a similar  way 
weakly  women  occasionally  become  more  or  less 
deaf  during  their  confinement,  and  this  symptom 
becomes  aggravated  when  each  successive  child  is 
born.  In  connection  with  this  subject,  prolonged 
suckling  may  be  mentioned  as  one  of  the 
numerous  debilitating  causes  which  undoubtedly 
aggravate  the  trouble  of  an  already  impaired 
ear. 

Among  the  nervous  affections  of  the  auditory 
apparatus  possessingeertain  characteristics  which 
serve  to  distinguish  it  from  others  is  the  so-termed 
Meniere’s  disease,  an  attack  of  whichat  times  gives 
cise  to  symptoms  whi  ch  would  be  alarming  if  their 
true  origin  passed  unrecognised.  A patient  who 
suffers  in  this  way  is  seized  with  an  attack  of 
vertigo  so  severe  that  he  not  infrequently  falls, 
and  for  some  hours  afterwards  requires  assistance 
in  walking ; occasionally  vomiting  succeeds  the 
giddiness  ; and  he  recovers  to  find  himself  very 
deaf  in  one  ear,  with  which  previously  he  had 
heard  well.  Milder  attacks  of  the  same  nature 
generally  follow  the  first,  and  each  one  leaves 
the  patient  more  deaf.  Although  the  presump- 
tive evidence  is  in  favour  of  the  theory  that  the 
seat  of  morbid  changes  in  Meniere’s  disease  is  in 
the  semi-circular  canals,  up  to  the  present  this 
point  has  not  been  quite  satisfactorily  deter- 
mined. No  treatment  appears  to  exercise  any 
influence  upon  the  disease. 

Syphilis. — The  affections  of  the  ear  due  to 
syphilitic  disease  demand  separate  consideration, 
and  they  occur  under  the  following  varieties: — 
Firstly,  in  the  form  of  sores  and  warts  in  the 
external  meatus,  which  yield  to  local  treatment. 
Secondly,  affections  of  the  middle  ear  during  the 
secondary  ulceration  of  the  throat,  the  treatment 
for  which,  beyond  specific  medicines,  in  no  way 
differs  from  what  is  useful  in  the  ordinary  catarrh 
of  the  same  parts.  Thirdly,  failure  in  hearing 
power  during  the  secondary  stages,  unattended 
with  any  change  in  the  middle  ear.  This  disap- 
pears under  constitutional  remedies.  Fourthly, 
the  loss  of  function  in  the  auditory  nerve,  so  com- 
monly met  with  in  the  subjects  of  inherited  syp  ■ 
ilis.  In  these  patients  the  hearing  power  begins  to 
fail  between  five  and  fifteen  years  of  age  (very  sel- 
dom later  in  life) ; and  proceeds  to  very  great  and 
often  total  deafness,  the  period  between  good  hear 


EAR,  DISEASES  OE. 

U'g  and  the  extreme  point  of  deafness  arrived  at 
varying  from  a few  weeks  to  several  years.  From 
this  cause  children  sometimes  become  in  the  course 
of  a month  or  six  weeks  totally  deaf,  but  such 
rapidity  is  exceptional.  Experience  has  shown 
how  powerless  treatment  is  to  arrest  the  progress 
of  this  affection,  so  that  attention  should  be 
confined  to  preventing  its  subjects  from  becoming 
dumb,  if  they  are  attacked  after  they  have 
acquired  speech  and  before  they  are  likely  to 
forget  it,  viz.  from  about  four  to  seven  years  of 
age.  This  is  best  attained  by  teaching  them  lip- 
reading,  and  if  they  can  read,  by  making  them 
do  so  {aloud)  several  times  each  day.  In  tfois 
way  a child  will  retain  its  recollection  of  lan- 
guage when  otherwise  speech  would  pass  away. 

W.  B.  Dalby. 

EAUX-BONNES,  in  France. — Sulphur 
waters.  See  Mineral  Waters. 

EAUX-CHAUDES,  in  France. — Sulphur 
waters.  See  Mineral  Waters. 

EBUBNATION  ( ebur , ivory). — A state  of 
bone-tissue  in  which  it  assumes  the  whiteness, 
smoothness,  and  hardness  of  ivory,  in  consequence 
of  an  increased  deposit  of  calcareous  matter.  It 
occurs  chiefly  in  rheumatoid  arthritis.  Rheu- 
matoid Arthritis. 

ECBOLICS  (e/c^oAr;,  abortion). — This  name 
is  given  to  the  measures  that  produce  abortion. 
In  moderate  doses  echolic  drugs  act  as  emmena- 
gogues.  See  Emmenagogues. 

ECCHYMOSIS  {Ik,  out  of,  and  x^s, 
juice). — An  extravasation  of  blood  into  the  cel- 
lular tissue,  due  either  to  injury  or  to  disease. 
It  presents  at  first,  a more  or  less  blue  or  bluish- 
black  appearance,  which  changes  with  age,  passing 
through  green  to  yellow.  See  Extravasation. 

ECHINOCOCCUS  (e’xiVor,  a sea-urchin,  and 
k/i«kos,  a grain). — This  term,  in  its  original  gene- 
ric signification,  was  employed  by  Rudolplii  for 
the  purpose  of  including  several  varieties  of  blad- 
der-worm infesting  man  and  animals  {Echino- 
coccus ho  minis ; E.  veterinorum;  E.  granulosus, 
Qc.)  These  different  bladder-worms  are  now  col- 
lectively spoken  of  as  hydatids,  and  all  of  them 
are  known  to  be  mere  varieties  of  the  common 
hydatid,  which  (as  proved  by  the  experimental 
researches  first  successfully  instituted  by  Von 
Siehold,  and  subsequently  verified  by  Haubner, 
Kuclienmeister,  Leuckart,  Nettleskip,and  others) 
forms  one  of  the  larval  or  sexually  immature  stages 
of  growth  of  a small  tapeworm,  normally  resi- 
dent in  the  intestinal  canal  of  the  dog  and  wolf 
{Tania  echinococcus).  From  a physiological  point 
of  view,  a thorough  knowledge  of  the  mode  of 
origination  and  development  of  tho  so-called 
echinococcus  becomes  most  instructive  ; hut  a full 
exposition  of  the  histological  and  other  changes 
that  accompany  the  metamorphoses  cannot  he 
given  in  this  place.  Practically,  the  term  echino- 
coccus has  at  length  come  to  ho  employed  in 
such  a restricted  sense  as  to  refer  only  to  the 
scolices,  or  heads  of  the  future  Ttenise,  which 
are  normally  developed  from  the  granular  layer 
or  internal  membrane  of  the  hydatid.  Different 
opinions  exist  respecting  the  precise  structural 
changes  involved  in  their  formation,  but  what  is 
already  known  and  accepted  by  helminthologists 


ECSTASY.  42? 

is  the  result  chiefly  of  the  labours  of  Leuckart 
Naunyn,  Rasmussen,  Wilson,  and  Huxley.  The 
clinical  and  hygienic  bearings  of  this  subject  in 
relation  to  the  so-called  echinococcus-disease  will 
be  discussed  elsewhere.  See  Hydatids. 

T.  S.  COBBOLD. 

ECHINOEHYNCHUS  {Ixivos,  a sea-ur- 
chin, and  pvyxos,  a beak). — A genus  of  thorn- 
headed  worms,  belonging  to  the  order  Aeantho- 
cephala.  Until  the  year  1857  there  does  net 
appear  to  have  been  a well-authenticated  instance 
of  the  occurrence  of  this  form  of  entozoon  in 
the  human  body.  In  that  year  a young  example 
{E.  hominis,  LanibD,  was  found,  post  mortem,  in 
the  small  intestine  of  a hoy.  nine  years  of  age, 
who  died  of  leukaimia  {Prayer  V icrtdjalirschrifi, 
1859.)  This  specimen  measured  less  than  a 
quarter  of  an  inch  in  length.  It  has  been  sup- 
posed that  the  parasite  was  an  immature  example 
of  Ech.  gigas,  hut  this  view  lias  been  disproved 
by  Leuckart.  Whether  it  ho  a new  and  alto- 
gether distinct  species  remains  uncertain.  The 
more  recent  instance  alleged  by  Welch  cannot  be 
accepted  as  genuine,  hut  must  he  referred  to 
Pentastoma.  T.  S.  Cobbold. 

ECLAMPSIA  {luXafiTra,  I flash,  I explode). 
— This  term  is  now  used  as  a synonym  for  con- 
vulsions, whatever  may  be  their  cause.  See 
Convulsions. 

ECPHYMA  (e/c,  out  of,  and  (pvga,  a swelling). 
A growth  from  the  integument.  The  term  was  em- 
ployed by  Mason  Good  as  a designation  for  warts 
and  corns,  hut  is  at  present  almost  obsolete. 

ECSTASY  I amaze). — Definition. 

The  term  ecstasy  has  been  applied  to  certain 
morbid  states  of  tho  nervous  system,  in  which 
the  attention  is  occupied  exclusively  by  one 
idea,  and  the  cerebral  control  is  in  part  with- 
drawn from  the  lower  cerebral  and  certain  reflex 
functions.  These  latter  centres  ma)'  he  in  a 
condition  of  inertia,  or  of  insubordinate  activity, 
presenting  various  disordered  phenomena,  for 
the  most  part  motor. 

Description. — The  subjects  of  ecstatic  phe- 
nomena are  commonly  of  the  female  sex,  or  are 
men  who  lead  celibate  and  ascetic  lives.  To 
these  individuals  they  are  in  tho  present  day 
almost  confined.  In  the  middle  ages,  on  several 
occasions,  under  special  circumstances,  an  in- 
tense dominant  emotion,  with  some  attendant 
ecstatic  manifestations,  spread  widely  by  a sort 
of  moral  contagion. 

Women  who  are  the  subjects  of  this  morbid 
state  are  usually  single,  frequently  present 
menstrual  irregularities,  and  often  distinct  evi- 
dences of  hysteria,  of  which  the  ecstatic  condi- 
tion may  he  but  a part.  The  immediate  cause  of 
the  attack  is  usually  some  repeated  vivid  emotion, 
commonly  religious,  sometimes  one  of  fear.  The 
direction  taken  by  tho  motor  or  other  phenomena, 
of  the  ecstatic  state  is  often  very  obviously  de- 
termined by  imitation.  With  this  are  associated, 
in  some  cases,  assertions  of  supposed  facts,  which 
transcend  the  ordinary  course  of  natural  phe- 
nomena, and  which  have  been  proved,  in  many 
instances,  to  depend  on  intentional  fraud. 

As  forms  of  ecstasy  we  have  the  condition  oi 


424  ECSTASY. 

religious  enthusiasts,  -who  lose,  in  their  one 
dominant  emotion,  all  control  over  the  other 
mental  processes,  and  the  latter  may  act  in  entire 
subordination  to  their  religious  feeling.  Dreams 
and  visions  are  determined  by  the  ecstatic 
emotion,  and  add  to  its  intensity.  All  conscious- 
ness of  the  body  may  be  lost,  so  that  all  sensation 
may  seem  to  be  gone  for  a time:  -while  the  cor- 
poreal functions,  ingestion  and  egestion,  are  re- 
duced to  a minimum,  and  a little  exaggeration 
may  represent  them  as  in  complete  abeyance. 
Hence  the  ‘ fasting  girls  ’ of  various  countries,  by 
whom  ‘stigmata’  marks,  in  the  position  of  the 
nails  employed  in  crucifixion,  are  sometimes  pre- 
sented, probably  by  artificial  production,  possibly 
by  the  influence  of  the  mental  state  on  the  pro- 
cesses of  nutrition.  In  some  hystero-epilepties 
a state  of  ecstasy — of  rapt,  intense  emotion — 
forms  part  of  the  paroxysmal  seizures,  and  then 
wild  muscular  spasms  replace  the  tranquil  repose 
of  the  more  volitional  ecstatics.  Occasionally — - 
when  an  intense  emotion  is  shared  by  many  per- 
sons— insubordinate  muscular  movements  occur, 
of  a rhythmical  character,  seen  in  the  Jumpers 
and  Shakers  of  the  present  day,  and  more 
strikingly  in  some  of  the  dancing  religions  cere- 
monies of  half-civilised  races,  and  in  the  dancing 
epidemics  of  the  middle  ages.  Such  were  the 
original  dance  of  St.  Vitus,  in  which  the  exciting 
emotion  was  religions ; and  the  tarantella,  in 
which  the  excitant  was  terror  at  the  supposed 
consequences  of  the  bite  of  the  tarantula,  which 
the  dance  was  intended  to  avert. 

Treatment. — It  is  rarely  now  that  ecstatic 
manifestations  have  to  he  treated  except  as  part 
of  pronounced  hysteria,  and  the  treatment  is 
that  of  the  hysterical  state  which  underlies  the 
ecstasy.  The  measure  of  paramount  importance 
is  the  substitution  of  a ‘ healthy  moral  atmo- 
sphere ’ for  that  under  which  the  symptoms  have 
arisen ; and  the  exposure  of  actual  fraud.  Oc- 
casionally, oven  now,  examples  of  solitary  ecstasy 
come  under  observation.  In  these  considerable 
care  and  tact  are  needed.  Ecstatics  are  not  amen- 
able to  the  motives  which  influence  most  per- 
sons, and  if  there  is  actual  fraud,  will  some- 
times die  rather  than  be  found  out.  In  the 
case  of  fasting  girls,  due  observation  of  the  body- 
weight  during  a short  time  will  answer  as  well 
as,  and  is  much  safer  than,  a long  exclusion  of 
food.  But  the  removal  of  the  ecstatic  to  other 
surroundings  is  the  most  important  step  for  both 
detection  and  cure.  W.  R.  Gowers. 

ECTHYMA  (tK0icv,  I burn  out.) — A pustule 
or  pimple ; pathologically  occupying  a mid-place 
between  a pustule  and  a furuncle.  The  so-called 
tar-acne,  the  small  inflammatory  pustules  deve- 
loped around  a mother-boil,  and  the  commoner 
eruptions  produced  by  iodine  and  bromine,  are 
examples  of  ecthyma.  See  Skin,  Diseases  of. 

ECTOPIA  («k,  out  of,  and  Tiiiros,  a place). — 
An  abnormal  protrusion  or  displacement  of  a 
part;  for  example,  ectopia  vesica,  protrusion  of 
tho  bladder.  See  Organs,  Displacement  of. 

ECTOZOA  (errbj,  without,  and  fuor,  an 
animal). — A term  employed  by  some  naturalists 
to  embrace  all  the  external  parasites.  See 
E?izoa. 


ECZEMA. 

ECTROPION-  ) , . - , 

ECTROPIUM//*’  0Ut  °f>  3Dd  'P'™'  1 
turn). — A condition  in  which  the  eyelid  becomes 
everted,  so  that  the  conjunctival  surface  is  ex- 
posed. See  Eye  and  its  Appendages,  Diseases  of 

ECTROTIC  (Jktitp&itku,  I miscarry).— A 
term  applied  to  arresting  the  course  of  a mor- 
bid process,  fur  example,  the  development  of 
small-pox.  The  agent  by  which  the  pustule  is 
made  to  abort,  namely,  the  ectrotic,  may  in  this 
instance  be  a point  of  nitrate  of  silver.  A 
coating  of  plaster,  and  especially  substances 
which  will  exclude  the  light,  such  as  mercurial 
ointment,  or  an  ointment  of  lampLlack,  are  like- 
wise employed  as  ectrotics  of  small-pox. 

Erasmus  Wilson. 

ECZEMA  (^x<je'w,  I bubble  up). — Synon.  : 
Fr.  Eczema  ; Ger.  Eczem. 

Definition  and  General  Remarks. — Eczema 
is  an  inflammation  of  the  skin,  remarkable  for 
a multiple  series  of  pathological  symptoms,  and 
for  extremes  in  degree  of  development  and  dura- 
tion. It  may  he  taken  as  the  type  of  inflamma- 
tion of  the  integument,  and  as  an  illustration  of 
the  varied  pathological  manifestations  of  the 
skin.  As  in  other  organs,  the  inflammation  may 
bo  acute  or  chronic,  may  vary  in  severity  and 
extent,  and  may  occur  at  every  period  of  life ; 
hut  the  special  position  and  functions  of  tho 
skin  render  the  progress  of  eczema  always  uncer- 
tain and  slow. 

TEtiology. — The  proximate  cause  of  eczema 
is  hypersemia.  Every  exciting  cause  giving  rise 
to  hyperaemia  is  capable  of  producing  eczema, 
and  if  the  tissue  of  the  skin  be  weak  will 
necessarily  he  the  occasion  of  that  affection.  It 
is  in  this  way  that  local  irritants  act  on  a 
susceptible  skin,  so  as  to  produce  eczema ; such, 
for  example,  as  heat  and  moisture,  friction, 
mechanical  and  chemical  stimulants,  and  ob- 
structed venous  circulation.  It  is  in  this  way 
that  a poultice,  a water-dressing,  a stimulating 
lotion,  or  the  action  of  the  sun  or  of  a pungent 
atmosphere,  may  he  the  local  cause  of  eczema. 
Constitutionally,  disturbed  nervous  function, 
however  induced,  by  producing  disturbance  of 
the  circulation  and  nutrition  of  the  skin,  is 
among  the  commonest  of  the  causes  of  eczema. 
The  starting  point  may  he  malassimilation 
occurring  at  any  period  of  life  ; malassimilation 
will  act  as  a disturber  of  nutrition  and  circula- 
tion of  the  skin,  and  those  pathological  processes 
known  as  eczema  will  be  the  result.  In  this 
manner  we  may  trace  back  the  cause  to  dis- 
ordered digestion,  painful  dentition,  painful 
menstruation,  pregnancy  and  parturition,  or 
nervous  shock  ; and  we  are  led  to  the  conclusion 
that  feeble  digestion,  assimilation,  and  nutrition 
constitute  a predisposing  cause  of  general  and 
cutaneous  debility,  which  only  requires  tho 
interposition  of  an  exciting  cause  to  become  an 
eczema.  That  eczema  is  powerfully  under  the 
influence  of  the  nervous  system  is  shown  by  the 
sudden  and  sometimes  periodical  exacerbations 
of  its  symptoms,  and  their  subsidence  under  the 
influence  of  agents  which  soothe  and  tranquillisu 
the  nerves.  In  the  simplest  form  of  expression 
eczema  may  be  said  to  be  a general  as  well  as  a 
local  debility,  and  to  be  induced  and  kept  up  br 


ECZEMA.  425 


every  cause  which  tends  to  lower  the  life-force 
of  the  organism. 

Eczema  is  specific  neither  in  its  nature  nor  in 
its  cause.  Every  cause  of  irritation  acting  on  a 
frame  and  on  a tissue  enfeebled  by  disordered 
function  is  capable  of  becoming  a cause  of  this 
affection.  It  is  hereditary  only  in  the  sense  of 
the  transmission  of  natural  tendencies  from 
parent  to  offspring,  and  not  by  virtue  of  any 
special  virus  or  causa  morbi ; and  for  a similar 
reason  it  is  non-contagious.  Nurses  are  occa- 
sionally affected  with  eczema  from  contact  with 
the  acrid  secretions  poured  out  by  the  inflamed 
skin,  but  the  same  result  would  follow  in  an 
equal  degree  from  contact  uuder  similar  circum- 
stances with  any  other  kind  of  irritant  fluid, 
the  two  essential  factors  of  eczema  being  a sus- 
ceptible skin,  natural  or  artificial,  and  the 
presence  of  an  irritant.  The  warmth,  the 
moisture,  and  the  stimulation  of  the  wash-tub 
are  as  active  a cause  of  eczema  to  a sensitive 
skin  as  the  most  profuse  contact  with  eczematous 
discharge.  And  there  is  no  more  energetic 
generator  of  eczema  than  the  sun's  rays  when 
operating  on  the  enfeebled  integument  of  the 
victims  of  a city  life. 

Symptoms  and  Varieties. — The  objective  signs 
of  eczema  are — redness,  slight  swelling,  papula- 
tion, vesiculation,  exudation,  incrustation,  des- 
quamation, thickening,  hardening,  fission  or  chap- 
ping ; and  the  subject  ive  sensations,  burning  heat, 
itching,  and  pain.  The  whole  of  these  symptoms 
are  not  necessarily  present  at  the  same  time, 
but  they  may  all  be  in  existence  at  once  on 
different  parts  of  the  same  person,  and  their 
separate  preponderance  is  marked  by  distin- 
guishing names,  constituting  the  so-called  va- 
rieties of  Eczema.  Thus,  for  example,  when 
the  prevailing  symptom  is  redness,  the  case  is 
oro  of  E.  erythematosum,  and  may  subside  with 
simple  desquamation.  When  the  hypersemia 
causes  congestion  of  the  follicles  and  their  up 
rising  in  the  form  of  pimples,  the  case  is  termed 
E.  papulosum.  With  the  moderate  swelling  or 
oedema  which  always  characterises  eczema  re- 
sulting from  serous  effusion,  there  is  commonly 
exudation  beneath  the  horny  cuticle,  giving  rise 
to  small  vesicles,  or  E.  vesiculosum,  the  typical 
eczema  of  Willan  ; and  in  a pyogenic  consti- 
tution these  vesicles  may  be  converted  into 
pustules,  constituting  E.  pustulosum  or  impetigi- 
nosum.  When  tho  exudation  from  the  surface 
is  so  excessive  as  to  sweep  away  the  cuticle 
completely,  and  pour  forth  from  tho  inflamed 
skin  like  a veritable  catarrh,  the  form  is 
termed  E.  ickorosum  seu  madidans,  and,  from 
the  depth  of  colour  of  the  vascular  base  which 
supplies  the  exudation,  E.  rubrum.  "When  the 
exuded  secretion  is  dry  on  the  inflamed  surface 
in  the  form  of  crusts,  the  case  is  one  of  E.  crus- 
taceum , and  is  well  illustrated  by  tho  crusta 
ladea  of  children.  When,  in  consequence  of 
thickening  of  the  affected  integument  conse- 
quent on  interstitial  exudation,  the  cuticle  is 
produced  in  excessive  quantity,  and  continues  to 
desquamate,  the  eczema  is  termed  squamosum, 
and  is  the  psoriasis  of  Willan  and  Bateman.  In 
a moro  advanced  degree  of  thickening,  accom- 
panied with  induration,  and  in  chronic  stages  of 
the  disease,  the  skin  is  apt  to  crack  and  break, 


constituting  E.  fissum,  the  cracks  and  chaps  being 
termed  rliagades.  Such  a form  is  not  uncommon 
in  the  palm  of  the  hand,  and  constitutes  one  of  tho 
varieties  of  psoriasis  palmaris. . When,  from  anv 
cause,  a state  of  permanent  hypertemia  is  main- 
tained in  a part,  such  as  the  lower  extremities, 
where  it  is  likewise  associated  with  obstructed 
venous  circulation,  the  whole  of  the  fibrous  and 
epidermic  tissues  are  apt  tobecome  hypertrophied, 
giving  rise  to  E.  hypcrtrophicum. 

Besides  these,  the  varieties  of  eczema  due  to 
the  predominance  of  a particular  symptom,  we 
recognise  dry  eczema  or  E.  siccum,  and  moist 
eczema  or  E.  humidum,  together  with  other  varie- 
tiesconsequent  on  locality,  such  as  the  scalp,  the 
face,  the  flexures  of  the  joints,  the  perineum,  and 
the  palms  of  the  hands.  We  also  distinguish,  as 
dependent  on  severity  and  duration,  acute  and 
chronic  eczema,  and  on  period  of  life,  E.  in  fantile. 

Eczema  must  be  considered  as  one  of  the  most 
pruriginous  of  the  affections  of  the  skin ; hence 
its  Greek  names  psora  and  psoriasis,  the  former 
being  applied  to  its  more  acute,  and  the  latter 
to  its  chronic  form.  Itching  is  most  severe  in 
the  dry  forms  of  the  disease,  such  as  the 
erythematous,  the  papulous,  and  the  desquamat- 
ing kinds,  and  is  relieved  by  the  exudative 
process,  whether  occurring  normally  or  produced 
artificially  by  the  action  of  tho  nails  or  envelop- 
ment. In  the  moist  forms  the  suffering  assumes 
the  character  of  pain,  tingling,  shooting,  and 
aching,  the  pain  being  sometimes  so  severe 
as  to  be  suggestive  of  the  term  E.  neurosum. 

Eczema  being  an  inflammation  of  the  surface- 
membrane  of  the  exterior  of  the  body,  is  not 
unfreauently  associated  with  a similar  inflam- 
mation of  the  mucous  membrane  of  the  air- 
passages  of  the  lungs,  giving  rise  to  bronchitis ; 
hence  the  complication  of  eczema  infantile  with 
bronchitis  is  far  from  uncommon,  and  in  that 
respect  is  frequently  derivative,  a sudden  increase 
of  the  cutaneous  inflammation  relieving  the 
mucous  membrane,  and  vice  versa ; and  this 
association  of  bronchitis  and  eczema  is  sometimes 
maintained  during  the  whole  lifetime  of  the 
individual.  Sometimes  the  eczematous  bron- 
chitis subsides  into  a chronic  asthma,  and  some- 
times eczema  alternates  with  hay-asthma.  Not 
unfrequently  eczema  alternates  with  gout,  rheu- 
matism, or  neuralgia,  acting  as  a substitute  for 
those  affections  and  suggesting  the  commonly 
received  opinion  that  eczema  is  a consequence 
of  the  gouty  diathesis.  Another  and  a common 
complication  of  eczema  are  boils;  and,  in  weakly 
constitutions  lymphadenomatous  tumours  are 
met  with  in  the  axillae,  and  sometimes  in  the 
eczematous  portions  of  the  skin.  The  complica- 
tion of  eczema  with  haemorrhoids  and  varicose 
voins  of  the  lower  limbs  is  a well-recognised 
fact ; in  the  latter  instance  the  dilated  and 
obstructed  veins  being  not  only  the  exciting 
cause  of  the  eczema,  but  leading  to  hypertrophous 
enlargement  of  the  integument  and  cellular  struc- 
tures of  the  limb — to  a state  that  may  fairly  be 
compared  with  elephantiasis  Arabum. 

Course,  Terminations,  and  Prognosis. — 
The  prognosis  of  eczema  will  be  mainly  in- 
fluenced by  the  cause  of  the  disease  and  the 
constitution  of  the  patient ; and,  although  con- 
stantly teazing  and  generally  tedious,  it  has  a 


126  ECZEMA, 

natural  tendency  to  cure,  and  very  rarely 
imperils  life.  It  is  chiefly  obnoxious  through 
its  itching,  which  is  sometimes  so  great  as  to 
produce  violent  excitement  of  the  nervous 
system ; and  prolonged  nervous  irritation  in- 
creases the  exhaustion  of  the  sufferer.  Where 
the  health  of  the  patient  is  in  other  respects 
fairly  good  the  prognosis  will  be  favourable  ; but 
where  exhaustion  of  power  prevails,  where  assi- 
milation is  seriously  disturbed,  and  where  much 
irritability  of  the  nervous  system  exists,  the 
prognosis  must  be  correspondingly  unfavour- 
able. Thus  eczema  infantile,  even  when  exten- 
sive, is  easy  of  cure  if  the  constitution  of  the 
child  be  moderately  good;  the  same  may  be 
said  of  the  eczema  which  depends  on  vaccina- 
tion, dentition,  and  growth.  The  eczema  of 
puerperal  patients  yields  without  difficulty  to 
a tonic  and  nutritive  regimen.  The  eczema 
which  is  substitutive  of  dyspepsia,  gout,  rheu- 
matism, or  neuralgia,  is  especially  influenced  by 
the  vitality  of  the  constitution,  and  so  also  is  that 
which  is  due  to  exhausted  nerve-power.  The 
neglected  eczema  of  infancy  and  childhood  may 
be  prolonged  for  a lifetime  and  eczema  is  not 
unfrequently  one  of  the  indications  of  broken 
health,  which  may  alternate  with  other  manifes- 
tations of  disorder  of  internal  organs,  or  may  be 
associated  with  or  follow  disease  of  the  kidneys, 
and  so  prove  fatal.  Eczema  must,  therefore,  be 
regarded  as  a subjective  rather  than  an  objective 
disease,  and,  although  troublesome  and  tedious, 
is  generally  curable.  It  may  annoy  the  patient 
for  many  months  or  years,  recurring  with  fresh 
force  from  time  to  time,  changing  with  the 
seasons,  and  as  a complication  of  other  diseases, 
contributing  secondarily  to  the  destruction  of 
life. 

Tbeatment. — The  treatment  of  eczema  must 
be  constitutional  as  well  as  local ; in  a very  few 
instances  of  chronic  eczema,  when  all  participa- 
tion with  the  original  cause  has  ceased,  local 
treatment  alone  may  be  sufficient,  but  such  cases 
are  exceptional.  Constitutionally  it  will  be 
needful  to  promote  and  regulate  the  functions  of 
digestion  and  assimilation,  and  restore  the  powers 
of  the  system  ; hut  as  eczema  always  implies  a 
want  of  vital  power,  a conservative  treatment 
must  be  maintained  throughout.  Our  best  regu- 
lators of  the  digestive  functions  are  saline  pur- 
gatives with  hitter  infusions,  quinine  andiron; 
sometimes  nitro-muriatic  acid  with  a bitter  in- 
fusion, and  a mild  aperient  pill.  When  these 
have  effected  their  purpose,  we  may  have  re- 
course to  more  decided  tonics,  such  as  the  citrate 
of  quinine  and  iron,  strychnine,  cinchona  with 
sulphuric  acid ; or  wlien  assimilative  debility 
prevails,  to  the  citrates  of  potash  and  ammonia. 
Where  there  is  much  nervous  irritability  the 
bromides  of  potassium  and  ammonium  are  ser- 
viceable ; and  in  the  gouty  diathesis  moderate 
doses  of  blue  pi'll,  eolchieum,  and  diuretics. 

It  is  not  until  these  remedies  have  performed 
their  share  of  duty  that  vre  should  call  into  use 
the  valuable  aid  of  arsenic,  and  then  arsenic,  as 
a nerve-tonic  and  an  assimilative  tonic,  may  he 
said  to  be  specific.  To  effect  these  purposes  it 
should  he  given  in  small  doses,  e.g.  two  to  four 
minims  of  liquor  arsenicalis  or  the  lydrochloric 
solution,  in  combination  with  wine  of  iron  or 


EGYPT,  UPPER 

tincture  of  cinchona.  In  some  instances  the  per- 
chloride  of  mercury  with  bark  has  also  provoil 
advantageous.  Alkalies,  as  a rule,  are  objection- 
able. and  if  found  necessary  for  a while,  should 
be  discontinued  as  soon  as  they  produce  a de- 
bilitating influence  on  the  vital  powers.  In  some 
few  instances,  where  nervous  irritability  is  the 
prevailing  diathesis,  arsenic  may  be  adopted  from 
the  beginning  of  the  treatment,  and  infants  in 
general  require  no  preparation  for  its  use. 

The  local  treatment  of  eczema  should  be  alle- 
viative  in  the  acute  forms  and  stages  of  the 
affection,  and  stimulant  in  its  chronic  forms. 
First  amongst  the  soothing  remedies  is  the  ben- 
zoated  oxide  of  zinc  ointment ; whilst  the  stimu- 
lants are  represented  by  the  mercurial  ointments, 
alkaline  ointments,  and  tar.  The  oxide  of  zinc 
ointment  is  especially  intended  to  form  a thin 
coating  of  protection  to  the  inflamed  skin,  and 
therefore,  where  it  cannot  be  secured  by  a 
bandage  will  require  to  be  repeated  several  times 
a day ; for  a like  reason,  and  to  prevent  the  re- 
moval of  the  artificial  covering  so  produced, 
washing  of  the  diseased  skin  should  be  carefully 
prohibited. 

In  the  earliest  stages  of  the  eruption  great 
comfort  may  be  afforded  by  dusting  the  eruption 
with  starch  powder,  or  starch  powder  with  the 
oxide  of  zinc,  or  simply  with  fuller's  earth  ; and 
zinc  powder  suspended  in  lime  water  forms  a 
very  useful  lotion  for  protecting  the  eruption 
from  the  atmosphere  at  all  stages  of  its  progress. 
This  latter  application  is  also  serviceable  in  re- 
lieving the  distressing  pruritus  which  always 
accompanies  eczema.  However,  the  most  im- 
portant of  the  remedies  for  the  relief  of  itching 
are  the  preparations  of  tar,  and  especially  a tar 
lotion  composed  of  soft  soap,  tar,  and  alcohol, 
more  or  less  diluted,  and  sometimes  combined 
with  hydrocyanic  acid. 

Where  eczema  is  accompanied  with  much  infil- 
tration and  oedema  of  the  integument,  especially 
occurring  in  the  extremities,  a process  of  sweat- 
ing the  limb  by  means  of  water-dressing  and  a 
waterproof  envelope  has  been  adopted  with 
considerable  success.  And  a modification  of 
this  treatment  by  the  use  of  the  envelope  at 
night,  and  the  zinc  ointment  during  the  day,  may 
be  very  conveniently  adopted  in  cases  where  the 
patient  is  unable  to  keep  his  bed,  and  is  called 
upon  to  pursue  his  daily  avocations  in  life  during 
the  continuance  of  the  treatment. 

In  very  chronic  cases,  again,  where  there,  is 
considerable  hardness  and  condensation  of  the 
skin,  it  may  be  necessary  to  apply  a blister  over 
the  part,  and  afterwards  dress  the  blistered 
surface  with  zinc  ointment;  or,  a milder  course 
consists  in  the  application  of  a strong  alkaline 
solution  or  soap.  Erasmus  Wilsox. 

ECZEMA  Marginatum.  Sec  Texea. 

EFECrSlOH  (e,  out,  and  /undo,  I pour).— 
The  escape  of  a fluid  from  its  natural  channel 
or  cavity  into  the  substance  of  organs  or  the 
cellular  tissue,  or  from  free  surfaces.  As  ex- 
amples, may  be  mentioned  dropsy  in  its  various 
forms,  and  effusions  resulting  from  inflamma- 
tion. 

EGYPT,  UPPER.  — A very  dry.  ton:-. 


EGYPT,  UPPER. 

winter-climate.  Mean  winter  temperature,  62°. 
Season,  October  to  March.  See  Climate,  Treat- 
ment of  Disease  by. 

ELECTRICITY. — The  purposes  for  which 
electricity  is  employed  in  medicine  are  various. 
It  is  used  as  a stimulant  to  excite  muscular  and 
nervous  tissue  which  is  the  seat  of  paralysis  or 
pain,  and  as  a st  imulant  to  the  tissues  generally ; 
its  chemical  action  may  be  employed  for  dis- 
solving tissues  and  coagulating  blood  within 
aneurismal  sacs;  and  its  thermal  effects  are 
employed  in  surgery  for  heating  cauteries. 
Electricity  is  used  in  its  three  forms  of  (1) 
Franldinic , Static,  or  Frictional  electricity;  (2) 
Faradism  ( i.e . electricity  generated  by  induction, 
whether  voltaic  or  magnetic) ; and  (3)  Galvanism. 
or  Voltaism,  which  owes  its  existence  to  chemical 
action. 

Apparatus. — Franklinic  electricity,  which  is 
generated  by  the  friction  of  glass  discs  or  cylin- 
ders, and  which  was  formerly  much  in  vogue,  has 
now  become  nearly  obsolete  in  therapeutics,  and 
need  not  detain  us  in  an  article  like  the  present. 

Faradic  batteries  should  consist  of  (1)  a coil 
nf  insulated  copper  wire,  the  ends  of  which 
are  in  connection  with  the  plates  of  a gal- 
vanic cell.  This  is  called  the  primary  coil, 
and  contains  a bundle  of  soft  iron  wire  in  its 
interior.  2.  A second  coil  of  insulated  copper 
wire  made  of  finer  wire  and  containing  a greater 
number  of  spirals  than  the  primary,  which  is 
made  to  slide  over  the  primary ; this  is  called 
the  secondary  coil.  3.  An  interrupter,  capable 
of  interrupting  the  current  automatically  and 
with  great  rapidity  by  means  of  the  constantly 
recurring  magnetic  action  of  the  bundle  of  iron 
wires  in  the  interior  of  the  primary  coil.  These 
batteries  should  have  means  of  graduating  the 
intensity  of  the  current  of  either  coil,  and  of 
including  the  patient  in  the  circuit  of  either  coil 
without  altering  the  connections  of  the  conduct- 
ing wires.  Sometimes  the  galvanic  element  is 
replaced  by  a large  magnet,  as  in  the  well-known 
rotating  magneto-induction  apparatus. 

Galvanic  batteries  when  used  for  therapeutic 
or  electrolytic  purposes  should  be  composed  of 
(1)  a large  number  of  small  cells  of  low  electro- 
motive force,  and  as  constant  in  their  action  as 
possible.  The  cells  known  as  the  ‘ Leclanche  ’ 
are  the  best.  (2)  Means  of  including  in  the 
circuit  any  number  of  cells  at  will,  so  that  there- 
by the  intensity  of  the  current  maybe  regulated. 
(3)  Means  of  opening  or  closing  the  circuit  at 
will  and  of  reversing  the  direction  of  the  current 
without  altering  the  position  of  the  current- 
carriers  (rheophores)  on  the  patient’s  body.  This 
is  effected  by  means  of  a simple  contrivance 
known  as  a key  and  commutator'. 

Batteries  which  are  required  for  heating 
wires  and  cauteries  must  be  composed  of  cells 
of  high  electromotive  force  and  as  large  as  is 
practically  possible.  The  number  of  cells  or 
elements  is  of  less  importance  than  their  size. 
It  is  not  unusual  to  have,  for  this  purpose, 
Groves’  or  Bunsen's  cells  capable  of  containing  a 
pint  of  liquid  each. 

The  essential  and  distinctive  differences  of 
the  two  forms  of  current  (galvanic  and  faradic) 
are  the  following : — 


ELECTRICITY.  42? 

The  Galvanic  Current  is  (1)  continuously 
evolved  (hence  it  is  spoken  of  frequently  as  the 
‘ continuous  current  ’ ).  (2)  It  flows  always  in  ike 
same  direction,  i.e.  from  the  positive  pole  (which 
is  in  connection  with  the  copper  or  receiving 
plate)  to  the  negative  pole  (which  is  in  connection 
with  the  zinc  or  generating  plate).  This  fact 
must  be  constantly  borne  in  mind,  because  the 
action  of  the  two  poles  is  markedly  different, 
and  it  has  been  asserted  (on  very  doubtful 
evidence,  however)  that  the  direction  of  the 
current  in  the  body,  whether  towards  the  nerve- 
centres  or  towards  the  periphery,  has  an  im- 
portant effect  upon  the  physiological  and  thera- 
peutical results.  (3)  It  has  well-marked  chemical 
and  thermal  effects.  This  action  is  most  marked 
at  the  negative  pole,  with  which  if  a moderately 
intense  current  be  used,  heat,  redness,  inflamma- 
tion. and  even  sloughing  of  the  skin  maybe  readily 
produced.  It  is,  therefore,  always  necessary  to 
frequently  change  the  position  of  the  negative 
pole  on  the  body.  (4)  It  has  electrolytic  effects. 
When  a galvanic  current  is  passed  through  a 
conducting  compound  liquid,  decomposition  of 
the  liquid  results,  oxygen  (if  water  only  be  used) 
and  acids  (if  saline  solutions  be  used)  being 
evolved  at  the  positive  pole,  while  hydrogen  or 
alkalies,  as  the  case  may  be,  are  evolved  at  the 
negative  pole.  Since  the  human  body  consists 
of  a mass  of  cells  which  contain  and  are  bathed 
in  saline  fluids,  many  of  the  phenomena  observed 
on  passing  galvanic  cui’rents  through  the  human 
body,  or  any  part  of  it,  are  probably  due  to  this 
electrolytic  action.  Faraday  called  the  positive 
pole  the  anode,  and  the  negative  pole  the  cathode , 
and  these  terms  are  frequently  employed. 

Induced  Current. — With  regard  to  the  in- 
duced current,  the  following  points  must  be  re- 
membered. (1)  It  is  momentary  in  duration.  (2) 
Its  direction  is  constantly  changing,  so  that  in 
using  it  it  is  lessnecessary  to  distinguish  between 
the  poles.  (3)  Its  chemical,  thermal,  and  electro- 
lytic effects  are  nil.  (4)  It  has  much  greater 
‘ tension  ’ than  the  galvanic  current,  that  is,  it 
overcomes  the  resistance  of  the  body  with  far 
greater  ease.  (5)  It  causes  the  contraction  of 
healthy  muscle  far  more  readily  than  the  galvanic 
current.  Muscular  contractions  only  occur  at  tho 
moment  of  making  or  breaking  a current,  and  it 
is  mainly  to  the  rapid  interruptions  of  the  in- 
duced current  that  its  high  stimulating  power 
is  due.  The  current  of  the  secondary  coil  has 
greater  tension,  more  penetrating  power,  and 
greater  stimulating  power  than  the  current  of 
the  primary  coil  or  ‘ extra-current.’  This  is  due 
to  its  being  composed  of  finer  wire  and  having  a 
greater  number  of  turns. 

The  stimulating  effects  of  the  galvanic  cur- 
rent which  cause  muscular  contraction,  occur 
only  at  the  moment  of  making  or  breaking  the 
current  and  not  during  its  continuance,  and  the 
stimulating  effect  of  the  two  poles  is  different, 
as  may  he  demonstrated  by  the  ‘ Polar  method 
of  investigation,’  instituted  by  Brenner,  of  St. 
Petersburg.  If  one  rlieophore  ho  placed  on  an 
indifferent  part  of  the  body,  as  the  lack,  and 
the  other  be  placed  over  a nerve-trunk  or 
muscle,  we  are  able  by  means  of  tho  commutator 
and  key  to  study  the  action  of  either  pole  on 
nerves  and  muscles  during  the  making  and 


ELECTRICITY. 


(28 

breaking  of  the  current.  With  weak  currents 
it  is  found  that  contraction  ensues  only  when 
the  stimulating  rheophore  is  negative  (cathode), 
and  only  on  closing  the  circuit.  This  is  called 
Cathodal  Closure  Contraction  (C.C.C.).  If  the 
strength  of  the  current  be  slightly  increased  we 
get  contraction  also  when  the  stimulating  rheo- 
phore is  positive  (anode),  and  the  circuit  is 
opened  (A.O.C.).  Next  follows  Anodal  Closure 
Contraction  (A.C.C.),  but  Cathodal  Opening 
Contractions  (C.O.C.)  never  occur  in  healthy 
muscles  with  any  currents  short  of  those  of  un- 
bearable intensity. 

The  galvanic  current,  unlike  the  induced  cur- 
rent, affects  the  nerves  of  special  sense.  If  ap- 
plied in  the  neighbourhood  of  the  eyes,  flashes  of 
light  are  seen,  and  blindness  has  resulted  in  one 
case  from  the  incautious  application  of  strong 
currents  to  the  face.  The  gustatory  nerve  is 
affected  in  a similar  way,  and  the  ‘galvanic  taste’ 
is  perceived  when  the  rheophores  are  placed  on 
tue  cheek.  The  taste  is  acid  with  the  positive, 
but  metallic  and  coppery  with  the  negative  pole. 
If  the  rheophores  are  held  to  the  ear  rumbling 
noises  are  produced,  and  it  is  said  that  stimula- 
tion of  the  olfactory  nerve  will  give  rise  to  a 
peculiar  smell. 

Onimus  has  pointed  out  a further  distinction 
between  the  induced  and  the  galvanic  current. 

‘ An  induced  current,’  he  says,  ‘only  acts  during 
the  infinitely  short  time  of  its  passage,  after 
which  everything  returns  to  order.  ...  It  can 
never  be  anything  else  but  a series  of  slight 
excitements.'  With  constant  currents  real  ex- 
citement is  determined  only  at  the  times  of 
making  and  breaking.  . . . It  is  during  the  silent 
period,  however,  that  the  principal  action  of  the 
continuous  current  makes  itself  felt.’ 

It  is  certain  that  the  rapid  interruptions  of  the 
induced  current  and  the  strong  muscular  con- 
tractions caused  thereby,  are  capable,  if  the 
current  be  moderately  strong,  of  rapidly  and 
completely  exhausting  the  irritability  of  a 
muscle,  and,  if  this  fact  be  not  constantly  borne 
in  mind,  harm  instead  of  good  will  result  from 
the  application  of  faradism.  The  galvanic  cur- 
rent, on  the  contrary,  possesses  remarkable 
refreshing  effects,  a fact  which  has  been  de- 
monstrated by  Heidenhain  on  frogs,  and  by  the 
writer  on  the  human  subject.  It  is  found'  that 
a man  can  sustain  a weight  at  arm’s  length  far 
longer  than  he  otherwise  could,  if  a galvanic 
current  he  passed  through  the  nerves  of  the  limb. 
The  feeling  of  fatigue  can  be  removed  by  the 
application  of  the  current,  and  the  force  of  mus- 
cular contraction  is  increased  thereby.  These 
facts  have  important  therapeutic  bearings. 

Modes  of  Application. — To  apply  electricity 
we  need  to  have  conducting  wires  and  rheophores 
nr  current-carriers  attached  to  the  battery.  The 
best  conductors  are  made  of  ordinary  telegraph 
wire,  which  should  be  as  thick  as  is  compatible 
with  pliability.  Telegraph  wire  is  not  damaged 
by  moisture  and  can  be  readily  connected  to  all 
forms  of  batteries  and  rheophores,  and  is  there- 
fore economical  as  well  as  convenient.  Rheo- 
phores  vary  much  in  design.  They  should  all  have 
insulating  handles,  and  the  junction  between 
the  conductor  and  rheophore  should  be  about  the 
middle  of  its  length,  30  that  l oth  conductors  may 


he  held  in  one  hand  without  risk  of  the  metallio 
junctions  coming  in  contact.  The  most  gener- 
ally useful  rheophore  is  the  sponge-holder.  An 
excellent  sponge-holder,  which  retains  the 
sponge  with  absolute  firmness,  has  been  made 
for  the  writer  by  Messrs.  Weiss,  from  a design 
by  Kidder  of  New  York.  Rheophores  should  be 
of  different  sizes,  from  a sponge  as  big  as  half- 
a-crown  to  the  pointed  extremity  of  an  olive- 
shaped conductor.  They  should  be  made  of 
metal  and  not  carbon,  because  the  latter  is  too 
brittle.  They  may  be  obtained  in  the  form  of 
discs,  balls,  points ; and  of  endless  design  for 
reaching  particular  organs  and  regions,  as  the 
eye,  ear,  larynx,  bladder,  rectum,  and  uterus. 
They  are  usually  covered  with  wash-leather,  and 
used  moist.  A wire  brush  is  useful  for  influencing 
the  skin.  The  dry  hand  of  the  operator,  who 
allows  the  current  to  pass  through  his  own 
body  to  that  of  the  patient,  may  be  used  for  the 
same  purpose.  It  is  often  convenient  to  fix  ono 
rheophore  to  the  patient's  body,  which  may  be 
accomplished  by  placing  an  ordinary  sponge  on 
the  surface  of  the  body,  laying  thereupon  the 
raked  end  of  the  conducting  wire,  and  securing 
the  whole  with  one  turn  of  a bandage.  If  we 
wish  to  influence  the  surface  only,  we  may  use 
one  rheophore  dry;  hut  if  we  wish  to  affect 
deeper-lying  structures  we  must  overcome  the 
resistance  of  the  epidermis  by  thoroughly 
moistening  it  with  hot  salt-and-water.  We  may 
use  one  rheophore  dry,  and  one  moist ; or  we 
may  use  as  a rheophore  a porcelain  or  gutta- 
percha vessel  containing  water,  into  which  the 
limb  is  placed. 

There  are  two  methods  of  applying  electricity, 
known  as  general  electrisation  and  localised  elec- 
trisation. By  the  former  method  we  pass  the 
current  through  the  entire  body  or  great  part 
of  it ; it  has  been  employed  for  many  diseases, 
but  its  utility  is  doubtful.  By  the  latter  method, 
which  we  owe  to  Duchenne,  we  seek  to  influence 
special  nerves,  muscles,  or  organs,  and  to  limit 
the  action  of  the  current  strictly  to  these  parts. 
If  we  wish  to  influence  a muscle  we  may  do 
so  either  by  applying  the  rheophores  directly 
over  the  fibres  of  a muscle  (both  the  rheophores 
being  held  in  one  hand  and  ‘promenaded’ over 
the  whole  surface  of  the  muscle).  This  is  the 
direct  method,  and  is  the  method  advocated  by 
Duchenne.  Or,  instead  of  trying  to  influence  the 
muscle  itself,  we  may  stimulate  the  nerve  sup- 
plying it,  and  so  cause  the  muscle  to  contract. 
This  is  the  indirect  method,  advocated  by 
Ziemssen.  It  is  effected  by  using  two  rheo- 
phores of  different  sizes.  A large  rheophore  is 
affixed  to  an  indifferent  part  of  the  body,  while 
with  a small  pointed  rheophore  an  endeavour  is 
made  to  touch  the  exact  point  where  the  nerve 
we  seek  to  influence  is  most  superficial.  Neither 
of  these  methods  is  to  be  exclusively  adhere  1 
to.  Certain  deep-lying  muscles,  such  as  the 
diaphragm  and  the  supinator  brevis,  are  only 
capable  of  indirect  stimulation.  It  will  be  found 
also  that,  in  certain  diseased  conditions,  muscles 
will  not  respond  to  stimulation  through  the 
nerves,  hut  only  to  the  direct  application  of  the 
current.  When  we  wish  to  use  the  refreshing 
effects  of  the  current,  as  in  eases  of  paralysis 
which  are  on  the  road  to  recovery,  or  in  cases  of 


ELECTRICITY. 


fatigued  muscles,  &c.,it  is  advisable  to  combine 
the  application  of  the  galvanic  current  with 
a rhythmical  exercise  of  the  affected  muscles. 
Benedict  lays  it  down  as  a rule  that  the  locus 
morbi,  be  it  brain,  spinal  cord,  nerve,  or  muscle, 
should  always  be  included  between  the  rheo- 
phores. 

Diagnostic  and  Therapeutical  Uses.  — - 
1.  Diagnostic  Uses  of  Electricity. — Eor  pur- 
poses of  diagnosis,  electricity  is  of  undoubted 
service,  since  by  its  means  we  are  often  enabled 
to  distinguish  between  paralysis  due  to  central 
lesion  and  paralysis  due  to  peripheral  lesion.  We 
are  accustomed  to  speak  of  a paralysis  as  ‘ cen- 
tral ’ so  long  as  that  portion  of  a nerve-centre 
is  sound  from  which  the  nerves  supplying  tne 
paralysed  muscles  take  origin.  Thus  in  cases  of 
damage  to  one  corpus  striatum,  the  spinal  ccrd 
and  the  greater  part  of  the  brain  being  healthy, 
we  speak  of  the  case  as  one  of  central  paralysis. 
In  cases,  too,  of  paraplegia  from  local  injury, 
the  cord  below  the  injury  being  healthy  (notwith- 
standing that  all  mental  control  is  cut  off)  we 
speak  of  the  paralysis  as  central.  In  such  cases 
of  central  paralysis  we  find  (a)  that  reflex  stimu- 
lation of  the  muscles  is  possible,  ( b ) that  the 
muscles  undergo  but  little  wasting,  and  ( c ) that 
the  irritability  of  the  muscles  to  faradism  is 
scarcely  diminished.  We  speak  of  paralysis  as 
due  to  a peripheral  lesion  whenever  the  paralysed 
muscles  are  cut  off  from  communication  with 
their  nerve-centres,  or  directly  communicate  with 
centres  whose  physiological  activity  has  been 
destroyed  by  disease.  In  such  cases  we  find  (a) 
that  reflex  stimulation  of  the  paralysed  muscles 
is  no  longer  possible,  ( b ) that  the  paralysed  mus- 
cles waste  with  remarkable  rapidity,  and  (c)  that 
the  irritability  of  the  muscles  to  faradism  is 
rapidly  diminished,  and  is  generally  ultimately 
destroyed.  To  establish  the  fact  of  diminished 
irritability  to  faradism  is  generally  not  difficult, 
and  in  cases  of  paralysis  affecting  one  side  of  the 
body  only  it  is  done  by  comparing  the  paralysed 
muscles  with  their  healthy  fellows.  We  must 
take  care  that  the  current  does  not  vary  in  in- 
tensity, and  that  it  passes  through  exactly  similar 
lengths  of  the  body  for  the  stimulation  of  both 
sets  of  muscles.  It  will  be  found  convenient  to 
fasten  one  rheophore  to  the  middle  line  of  the 
body  (a  big  sponge  tied  to  the  back  of  the  neck 
answers  well),  and  then  when  the  patient’s 
limbs  are  arranged  exactly  symmetrically,  test  the 
healthy  muscles  first  with  a small  or  pointed 
rheophore  and  determine  the  current  of  least 
intensity  which  will  cause  contraction.  Then  the 
rheophore  is  to  be  applied  to  exactly  the  same 
spot  on  the  opposite  limb,  and,  if  contraction  fol- 
lows as  readily  as  on  the  healthy  side,  we  know 
that  there  is  no  diminution  of  irritability.  If, 
however,  contraction  do  not  follow,  we  increase 
the  strength  of  current,  and  so  determine  to  what 
extent  the  irritability  is  diminished,  and  whether 
or  no  it  is  completely  extinguished.  We  should 
add  that  in  cases  of  peripheral  paralysis  the  di- 
minution and  extinction  of  iiritability  does  not 
supervene  immediately  on  the  occurrence  of  the 
paralysing  lesion,  but  only  after  the  lapse  of  a 
week  or  ten  days.  In  cases  of  paraplegia  or  other 
cases  in  which  paralysis  affects  both  sides  of  the 
bodyit  is,  of  course,  impossible  to  compare  a para- 


429 

lysed  muscle  with  its  healthy  fellow,  and  in  such 
cases  we  can  only  judge  of  the  amount  of  irrita- 
bility by  experience  and  mental  comparison  with 
previous  cases.  It  is  found,  in  cases  of  peripheral 
paralysis,  that  after  complete  extinction  of 
faradie  irritability  the  muscles  will  respond  to 
a slowly  interrupted  galvanic  current,  and  that 
not  unfrequently  the  irritability  of  the  muscles 
to  galvanism  is  greater  on  the  paralysed  than  on 
the  sound  side  of  the  body.  It  is  said  by  some 
German  writers  that  not  merely  quantitative  but 
qualitative  changes  take  place  in  the  irritability 
of  these  muscles  and  that  the  Anodal  Closure  Con- 
traction (A.C.O.)  soon  becomes  very  marked,  and 
equals  or  even  surpasses  in  force  the  Cathodal 
Closure  Contraction  (C.C.C.) ; and  further  that 
the  Cathodal  Opening  Contraction  soon  becomes 
more  marked  than  the  Anodal  Opening  Contrac- 
tion. These  reactions,  which  are  supposed  to  de- 
pend upon  degenerative  changes  in  the  muscle, 
have  been  spoken  of  as  the  degenerative  reactions. 
These  quantitative  and  qualitative  changes 
in  irritability  are  found  (1)  insomeforms  of  para- 
plegia due  to  degenerative  changes  in  the  cord  ; 
(2)  in  so-called  spinal  paralysis  both  of  infants 
and  adults  ; (3)  in  traumatic  paralysis  due  to 
injury  of  the  nerve-trunks ; (4)  in  rheumatic 
paralysis,  that  is,  paralysis  due  to  ‘rheumatic’ 
thickenings  of  the  neurilemma  ; and  (5)  in  lead- 
paralysis. 

In  ordinary  hemiplegia  the  irritability  cf  the 
muscles  remains,  as  a rule,  unchanged.  In  some 
cases,  however,  the  irritability  is  increased  in 
the  early  stages ; and  occasionally  after  the 
paralysis  has  lasted  some  time  we  find  slight 
diminution  of  irritability.  In  the  disease  known 
as  Progressive  Muscular  Atrophy,  the  irrita- 
bility of  the  wasted  muscles  to  faradism  remains 
undiminished  to  the  end. 

2.  Therapeutical  Uses  of  Electricity. — 
a.  In  Paralysis. — The  treatment  of  paralysis  by 
means  of  electricity  must  be  conducted  rationally 
and  with  discrimination.  By  means  of  electricity 
we  may  attempt  to  remove  the  cause  of  the  para- 
lysis by  influencing  the  nutrition  of  the  parts 
where  such  cause  is  situated,  by  acting  on  the 
sympathetic  nerve-branches  supplying  the  blood- 
vessels of  the  part.  Thus  it  is  asserted  that  the 
absorption  of  a clot  in  the  brain  may  be  hastened, 
and  that  the  nutrition  of  a damaged  brain  may  be 
improved,  by  acting  upon  the  cervical  sympathetic 
nerve.  To  influence  the  cervical  sympathetic  we 
place  one  rheophore  over  the  superior  cervical 
ganglion  (which  may  be  reached  by  pressing  in- 
wards behind  the  angle  of  the  jaw),  and  the 
other  on  the  back,  over  the  first  and  second 
cervical  vertebrae.  The  use  of  such  a proceeding 
is  more  than  doubtful,  and  in  case  of  any  improve- 
ment occurring  it  would  be  impossible  to  know 
to  what  such  improvement  ought  to  be  attributed, 
since  the  passage  of  a current  across  the  upper 
part  of  the  neck  must  influence  many  important 
nerves  besides  the  sympathetic.  On  the  whole, 
we  think  that  galvanisation  of  the  sympathetic 
is  not  to  be  advised  in  the  early  stages  of 
paralysis.  Galvanisation  of  the  sympathetic  has 
been  employed  in  chronic  degenerative  changes 
in  the  brain  or  cord,  but  with  very  doubtful 
success. 

The  localised  application  of  the  electric  cur- 


ELECTRICITY. 


t30 

rent  to  the  paralysed  muscles  is  of  undoubted 
service,  and  in  employing  it  we  should  bear  in 
mind  the  following  rules.  1.  As  to  the  object 
of  our  treatment  we  should  remember  the  words 
of  Sir  T.  Watson,  ‘ That  our  aim  is  to  preserve 
the  muscular  part  of  the  locomotive  apparatus 
in  a state  of  health  and  readiness,  until  perad- 
venture  that  portion  of  the  brain  from  which 
volition  proceeds  having  recovered  its  function, 
or  the  road  by  which  its  messages  travel  having 
been  repaired,  the  influence  of  the  will  shall 
again  reach  and  reanimate  the  palsied  limbs.’ 
2.  Always  to  employ  that  form  of  current  to 
which  the  muscles  most  readily  respond.  Thus 
if  the  muscles  act  readily  to  faradism,  then 
faradism  is  to  be  used.  In  some  cases  of  peri- 
pheral palsy  we  find  that  contraction  follows 
only  on  the  application  of  a very  strong  galvanic 
current,  very  slowly  interrupted,  and  accord- 
ingly a slowly  interrupted  galvanic  current  must 
be  used.  As  me  case  improves  we  shall  find 
that  a weaker  current  produces  similar  results, 
and  that  the  muscle  contracts  with  moderately 
rapid  interruptions.  And  so  will  improvement 
gradually  take  place  in  favourable  cases  till 
faradic  irritability  and  lastly  voluntary  power 
are  restored.  3.  Always  to  employ  the  weakest 
currents  which  will  cause  muscular  contraction, 
and  never  to  run  the  risk  of  exhausting  a muscle 
by  causing  a too  prolonged  contraction.  Each 
muscle  should  be  taken  in  turn,  and  be  made  to 
contract  two  or  three  times  in  succession,  and 
having  gone  over  the  whole  of  the  paralysed 
muscles  seriatim  the  process  may  be  repeated. 
An  application  of  this  kind  every  other  day  is 
usually  sufficient.  4.  If  the  paralysis  to  the 
will  remain  absolute,  and  if  the  contractility 
of  the  muscles  be  perfect,  we  do  no  good  by  per- 
severing with  electrical  treatment.  This  con- 
dition is  often  met  with  in  hemiplegia.  The 
patient  is  absolutely  helpless  on  one  side, 
although  the  paralysed  muscles  are  in  no  degree 
wasted,  and  their  irritability  remains  normal. 
.).  If  the  paralysis  to  the  will  remain  absolute, 
and  if  the  irritabilityofthe  musclesbediminished, 
then  electricity  is  useful,  in  so  far  as  it  helps  to 
improve  the  nutrition  of  the  muscles  and  restore 
their  normal  degree  of  irritability.  The  normal 
degree  of  irritability  and  nutrition  being  re- 
stored (the  paralysis  to  the  will  remaining  ab- 
solute) electrical  treatment  may  be  discontinued. 
6.  If  the  irritability  to  both  forms  of  current  has 
completely  disappeared,  we  are  not  justified  in 
persevering  too  long,  nor  in  holding  out  delusive 
hopes  to  the  patient.  Nevertheless,  treatment 
should  not  he  abandoned  without  a patient  trial. 
[For  the  treatment  of  special  forms  of  paralysis 
by  electricity,  the  reader  is  referred  to  the  ap- 
propriate sections  of  this  wrork.] 

/3.  In  Painful  Affections. — The  power  of  elec- 
tricity to  relieve  pain  is  very  great.  The  relief 
is  usually  temporary,  but  in  many  cases  is  perma- 
nent. Electricity  may  act  by  serving  to  divert  the 
mind  from  troubles  real  or  fancied,  or  its  counter- 
irritating  effects  may  serve  the  same  purpose  as 
other  counter-irritants  whoso  power  to  relieve 
pain  is  well  recognised.  Occasionally  electricity 
will  give  relief  when  eveiy  known  remedy  has 
failed,  and  in  such  cases  we  must  suppose  that 
it  acts  by  bringing  about  some  change  in  the 


nerves  themselves  by  its  specific  action  on  ner- 
vous tissue.  All  three  forms  of  electricity  are 
employed  for  the  relief  of  pain,  but  the  galvanic 
current  will  be  found  the  most  generally  appli- 
cable. Some  writers  insist  that  the  anode 
(positive  pole)  shall  be  applied  to  the  painful 
spot.  Strong  faradisation  serves  in  some  cases 
to  give  relief.  The  effects  of  galvanism  should 
be  tried  in  every  case  of  neuralgia,  but  it  is  not 
capable  of  relieving  all  cases,  and  disappointment 
is  not  unfrequent.  Where  muscular  movements 
increase  the  neuralgic  pains,  a rhythmical  exercise 
of  the  affected  muscles  should  be  conjoined  with 
the  galvanism.  Headache  of  all  kinds  not  un- 
frequently  yields  to  electricity ; lumbago,  sciatica, 
and  those  painful  muscular  conditions  which 
we  call  ‘rheumatic,’  are  quickly  relieved  by  it. 
Tinnitus  aurium  will  sometimes  yield  to  the 
galvanic  current  when  all  other  remedies  have 
failed. 

y.  In  Spasmodic  Diseases. — In  the  treatment 
of  spasmodic  diseases,  electricity  is  of  limited 
utility.  Some  forms  of  tremor  are  relieved  by  it. 
Some  aggravated  cases  of  writer's  cramp  have 
yielded  to  it  when  all  other  remedies  have  failed, 
and  a few  cases  of  clonic  torticollis  have  received 
undoubted  benefit  by  its  judicious  application. 
Tonic  spasm  of  internal  organs,  such  as  the  bowel 
and  bladder,  has  been  relieved  by  the  galvanic 
current. 

8.  In  other  diseases. — In  addition  to  the  treat  - 
ment of  diseases  of  a purely  nervous  character, 
electricity  has  been  employed  as  a remedial  agent 
in  diseases  whose  origin  is  not  so  obviously  con- 
nected with  the  nervous  system.  It  has  relieved 
the  paroxysms  of  angina  pectoris,  and  the  burn- 
ing pains  which  accompany  herpes  zoster.  It  has 
been  employed  in  the  treatment  of  many  obsti- 
nate skin-diseases  by  American  physicians,  and 
Dr.  Cheadle  has  recorded  a case  in  which  the 
dilated  vessels  in  a case  of  acne  rosacea  were 
made  to  contract  by  faradisation.  Rheumatic 
gout  is  said  to  have  been  benefited  by  a ‘ central ' 
application  of  galvanism  (one  pole  to  the  nucha, 
and  the  other  to  the  epigastrium).  The  flow 
of  urine  in  diabetes  has  been  stated  to  he  di- 
minished by  a similar  process ; and  the  symptoms 
of  exophthalmic  goitre  have  (it  is  said)  been 
diminished  by  galvanisation  of  the  cervical  sym- 
pathetic. There  is  in  fact  scarcely  a disease, 
from  epilepsy  to  chilblains,  in  which  it  has  not 
been  alleged  that  electricity  has  been  of  use. 
In  obstetric  medicine,  for  the  arrest  of  post- 
paftum  haemorrhage,  faradisation  is  now  one  of 
the  recognised  means  to  be  employed  ; and  it  has 
been  of  more  doubtful  service  for  the  rectifica- 
tion of  displacements  of  the  uterus.  Ovarian 
pain  and  tenderness  have  been  relieved  by  the 
galvanic  current,  and  amenorrluea  has  often 
yielded  to  electricity. 

e.  Galvano-cautcry  and  Gal vano-jnuicittre. — 
The  chemical  and  thermal  effects  of  galvanism 
are  largely  employed  both  in  surgery  and  medi- 
cine. Its  thermal  effect  has  been  used  for  the 
heating  of  cauteries;  and  cauteries  so  heated 
have  very  obvious  advantages  over  all  other 
forms.  The  chemical  effect  of  the  negative  pole 
has  been  used  as  a caustic  for  the  destruction 
of  tissues,  and  tumours  of  considerable  size 
have,  it  is  said,  been  ‘dispersed’  by  this  means. 


ELECTRICITY. 

Galvano-puncture  has  been  used  in  the  treat- 
ment of  hydatid  cysts  of  the  liver,  but  it  is  at 
least  doubtful  -whether  simple  puncture  is  not 
quite  as  serviceable.  Galvano-puncture  seems 
likely  to  take  a recognised  position  among  the 
means  at  our  disposal  for  the  treatment  of  aortic 
aneurisms.  Several  cases  have  been  recorded  in 
which  improvement  has  followed  this  method  of 
treatment,  and  it  seems  possible  that  the  opera- 
tion may  be  accomplished  without  danger  and 
almost  without  discomfort  to  the  patient.  The 
current  employed  should  be  generated  by  a 
number  of  small  cells  of  low  electromotive  power 
(Smee’s  cells  as  modified  by  Eoveaux  seem  the 
best).  Each  pole  should  terminate  in  a fine  steel 
needle,  carefully  insulated  except  at  the  point. 
Both  these  needles  should  be  passed  completely 
into  the  aneurismal  sac,  care  being  taken  that 
the  points  of  the  needles  are  free  in  the  sac,  and 
that  they  do  not  touch,  but  are  separated  by  an 
interval  of  an  inch  or  inch  and  a half.  When 
the  current  passes,  the  whole  of  its  effect  will  be 
exerted  on  the  blood  within  the  sac ; and,  owing 
to  the  insulation  of  the  needles,  the  coverings  of 
the  sac  will  receive  no  damage.  The  effect  of 
che  current  is  to  cause  a firm  coagulum  to  form 
round  the  posit  ive  pole,  while  the  liberation  of  gas 
at  the  negative  pole  causes  there  a frothy  soft 
coagulum.  As  a rule  the  gas  generated  is  swept 
onwards  by  the  blood-current  and  causes  no 
trouble,  but  occasionally  distension  of  the  sac 
has  resulted.  The  clot  formed  at  the  positive 
pole  seems  to  act  as  a foreign  body,  and  further 
coagulation  may  take  place  around  it,  until  com- 
plete consolidation  of  the  aneurism  has  resulted. 
It  will  be  found  that  a current  from  ten  or  twelve 
cells  can  be  borne  for  an  hour  or  more,  and  that 
no  chloroform  will  be  needed  for  the  operation. 
When  the  needles  are  withdrawn  the  orifices 
must  be  closed  by  collodion.  A repetition  of  the 
operation  is  generally  necessary,  and  may  be 
performed  at  suitable  intervals. 

G.  V.  Poore. 

ELEPHANTIASIS  AEAB1JM  (<=’ \4<pas, 
an  elephant).— Synox.  : Fr.  Elephantiasis-,  Ger. 
Elephantiasis. 

Deeixitiox. — A non-contagious  disease,  cha- 
racterised by  recurrence  of  febrile  paroxysms, 
attended  by  inflammation  and  progressive  hyper- 
trophy of  the  integument  and  areolar  tissue, 
chiefly  of  the  extremities  and  genital  organs ; 
and  occasionally  by  swelling  of  the  lymphatic 
glands,  enlargement  and  dilatation  of  the  lymph- 
atics, and  in  some  cases  by  the  co-existence  of 
chyluria,  and  the  presence  in  the  blood  of  cer- 
tain nematode  hoematozoa ; together  with  various 
symptoms  indicative  of  a morbid  or  depraved 
state  of  nutrition. 

iEnoroGY. — Elephantiasis  is  endemic  in  India, 
the  Malayan  peninsula,  China,  Egypt,  Arabia, 
the  West  Indies,  and  parts  of  America,  chiefly  in 
localities  within  the  influence  of  the  sea  air  ; and 
it  occurs  sporadically  all  over  the  globe,  except- 
ing, perhaps,  in  the  extreme  north  and  south. 
Certain  conditions  of  soil  and  climate,  such  as 
humidity,  heat,  malarious  influences,  and  proxi- 
mity to  the  sea-coast,  seem  to  be  concerned  in 
producing  the  disease  and  influencing  its  develop- 
ment. Removal  from  the  territorial  endemic  area 


ELEPHANTIASIS.  4 31 

chocks  the  disease,  whilst  return  there  reproduces 
it.  Elephantiasis  affects  both  sexes,  and  persons 
of  all  ages  and  conditions  of  life.  No  race  is 
exempt,  but  it  is  much  more  frequent  in  dark 
than  in  fair  races  ; and  more  men  suffer  from  it 
than  women.  It  occurs  at  all  ages,  but  is  most 
common  in  adult  and  middle  life,  comparatively 
rarely  beginning  in  young  children  or  in  the  aged. 
Elephantiasis  is  doubtfully  hereditary ; but  Rich- 
ards found  that  of  236  persons,  73  per  cent,  had 
one  or  both  parents  affected.  Various  causes  are 
assigned  for  the  disease.  Air,  water,  food,  and, 
as  it  is  common  near  the  sea-coast,  eating  fish 
have  been  frequently  credited  with  producing  it. 
The  presence  or  vicinity  of  certain  forms  of 
vegetation,  and  the  geological  formation  of  the 
soil,  have  also  been  regarded  as  predisposing  and 
determining  causes.  Climate  and  locality,  com- 
bined with  bad  living,  are  doubtless  the  real 
predisposing  causes;  and  it  is  probable  that,  as 
Dr.  T.  Lewis  has  suggested,  i t may  be  found  to  be 
intimately  associated  with  the  presence  in  the 
blood  of  certain  parasites.  No  race  is  exempt 
from  the  disease,  but,  whatever  may  be  the  ex- 
planation, the  white  suffer  less  than  the  dark 
races.  It  does  occur  occasionally,  though  very 
rarely,  in  the  pure  European  in  India,  but  more 
frequently  in  those  of  mixed  descent ; it  will 
generally  be  found  that  where  it  occurs  in  persona 
of  apparently  European  parentage,  there  is  a 
mixture,  however  slight,  of  dark  blood. 

Anatomical  Characters. — The  hypertrophy 
of  elephantiasis  in  most  cases  appears  to  be 
simply  an  increase  in  the  natural  elements  of 
the  part,  the  blood-vessels  and  lymphatics  shar- 
ing in  the  growth.  In  other  cases  the  lymphatics 
and  lymph-spaces  are  most  concerned,  giving 
rise  to  a condition  that  has  been  described  as 
nevoid  elephantiasis,  in  which  the  appearance 
is  presented  of  a soft  and  fluctuating  swelling, 
which  when  punctured  gives  issue  to  a white  or 
pinkish  fluid,  very  closely  resembling  chyle.  The 
lymphatic  glands  also  share  in  the  enlargement. 
In  other  respects  the  progress  of  this  is  like  that 
of  the  ordinary  form  of  the  disease. 

The  Filaria  sanguinis-hominis  is  sometimes 
found  in  great  numbers  in  the  bloo  l of  persons 
suffering  from  elephantiasis.  Sec  Eilaria  Sax- 
Grixis-HoMixis. 

Symptoms. — The  ordinary  form  in  which  ele- 
phantiasis presents  itself  is  hypertrophy  of  the 
integument  and  areolar  tissue  of  some  part  of 
the  trunk  or  limbs,  and  notably  of  the  legs  and 
genital  organs.  The  skin  becomes  enormously 
thickened  by  hypertrophy  of  all  the  fibrous  ele- 
ments of  its  structure,  attended  by  the  deposit 
of  a quantity  of  albuminous  fluid  in  the  cells  of 
the  areolar  tissue.  The  papillae  are  prominent 
and  much  increased  in  size.  The  integument  is 
formed  into  hard  masses  or  folds,  with  a rugose 
condition  of  the  surface,  not  unlike  the  appear- 
ance of  an  elephant's  leg.  The  feet  ani  toes  are 
sometimes  almost  hidden,  and  the  scrotum  or 
labia  form  enormous  outgrowths.  The  scrotum 
often  attains  great  weight,  and  may  be  accom- 
panied by  large  hydroceles.  Scrotal  tumours 
have  been  removed  weighing  upwards  of  100  lbs. 

The  onset  of  elephantiasis  is  frequently  violent 
and  attended  with  great  suffering,  there  in 


ELEPHANTIASIS  ARABUM. 


432 

high  fever ; intense  pain  in  the  lumbar  region, 
groin,  spermatic  cords,  and  testes,  which  become 
swollen;  while  acute  hydroceles  form.  These 
symptoms  are  often  attended  with  sympathetic 
vomiting,  nausea,  and  rapid  erythematous  swell- 
ing of  the  external  parts ; and,  if  the  extremi- 
ties be  attacked,  the  swelling  may  be  tense  and 
painful,  accompanied  by  much  effusion  into  the 
areolar  tissue.  The  surface  of  the  integuments 
is  much  inflamed,  and  sometimes  discharges  a 
serous  ichor  or  chylelike  fluid,  according  to  the 
extent  to  which  the  lymphatics  are  engaged  in 
the  particular  case.  The  great  tension  and  swell- 
ing of  the  spermatic  cords  are  apt  to  dilate  tho 
abdominal  rings  so  widely,  that  after  recovery 
the  patient  may  suffer  from  hernia. 

In  some  cases  of  elephantiasis  the  integuments 
are  also  the  seat  of  a dilated  and  turgid  condition 
of  the  lymphatic  vessels,  which  during  the 
periods  of  vascular  excitement,  when  the  febrile 
attacks  occur,  give  way  and  discharge  a chyle- 
like fluid;  in  other  cases  the  surface  temporarily 
assumes  a herpetic  condition,  which  weeps  an 
acrid  and  offensive  serous  exudation. 

Elephantiasis  not  unfrequently  occurs  without 
much  or  any  obvious  injury  to,  or  disturbance  of 
the  general  health  during  the  intervals  between 
the  febrile  attacks,  which  in  some  cases  are  few 
and  slight.  The  appetite,  spirits,  and  strength 
are  good,  the  functions  are  all  normally  performed, 
and  the  only  inconvenience  is  that  due  to  the 
size  and  weight  of  the  outgrowth.  On  the  other 
hand,  it  is  frequently  quite  the  reverse ; the 
rapidly  recurring  febrile  attacks,  pain,  exhaus- 
tion, suffering,  and  visceral  complications,  in- 
duce a state  of  cachexia  and  debility  sometimes 
so  serious  as  to  render  even  surgical  interference 
impracticable.  Withal,  hepatic  and  splenic  en- 
largements do  not  as  a rule  result  from  the  per- 
sistence of  the  elephantoid  fever  alone  ; though 
not  unfrequently,  as  a more  direct  result  of 
malarious  poisoning,  they  seriously  complicate 
the  evils  of  the  sufferer’s  condition.  Albuminuria, 
as  well  as  chyluria,  is  occasionally  present. 

In  some  cases,  after  the  outgrowth  has  at- 
tained a certain  bulk,  it  ceases  to  grow  altogether, 
or  increases  slowly  and  insidiously  without 
febrile  disturbance,  and  in  such  cases  the  general 
health  remains  good.  But  there  is  generally  a 
tendency  to  recurrence  of  the  fever  once  or  twice 
a month,  when  the  parts  affected  become  tense, 
hot,  painful,  and  swollen,  and  often  discharge 
a serous  or  lymph-like  fluid,  which  may  be  acrid 
and  offensive.  Some  tumours,  on  the  other  hand, 
are  very  slightly,  if  at  all  so  affected,  and  remain 
perfectly  dry.  Iu  all  cases,  however,  some  growth 
goes  on,  and  even  when,  as  occasionally  happens, 
fever  has  ceased  to  recur,  there  may  he  a gradual, 
but  slow  and  painless,  increase  of  the  hypertro- 
phy. The  greatest  variety  and  uncertainty  ob- 
tains in  the  duration  and  progress  of  the  growth ; 
sometimes  it  is  very  rapid,  at  other  times  it  is 
slow,  with  intermissions  of  activity  and  indolence 
of  development* 

The  disease  elsewhere  than  in  the  genitals, 
unless  it  be  accompanied  by  exhaustion  and  de- 
bility, causes  no  failure  in  the  generative  powers 
in  either  sex.  Women  may  have  a tendency  to 
miscarry  when  suffering  from  elephantiasis. 

Course,  Duration,  and  Terminations. — Ac- 


cording to  Richards,  the  average  duration  of  the 
disease,  as  deduced  from  the  observation  of  636 
cases,  was  11^  years;  and  he  notes  that  the 
earliest  age  was  nine  years,  whilst  the  latest 
at  which  he  observed  it  was  eighty  years.  It 
appears  from  this  that  tho  disease  has  little 
influence  in  shortening  life. 

Pathology. — The  outgrowths  in  elephantiasis 
are  the  local  expressions  of  a constitutional 
disease,  and  are  not  to  he  regarded  merely  from 
their  local  point  of  interest.  They  are  tho  re- 
sult of  certain  climatic  influences  whose  exact 
nature  is  not  at  present  determined;  though, 
considering  the  geographical  range  of  the  area 
where  the  disease  is  endemic,  it  seems  probable 
that,  whatever  other  cause  may  he  at  work,  the 
so-called  malarious  influences  play  an  important 
part  in  its  production. 

The  recent  researches  of  Dr.  T.  Lewis  into  the 
pathology  of  chyluria  in  India,  and  his  discovery 
of  certain  haematozoa  in  the  blood  of  those  af- 
fected with  that  disease,  coupled  with  the  fact 
that  the  subjects  of  chyluria  and  haematozoa  are 
also  frequently,  if  not  always,  affected  by  ele- 
phantiasis with  its  febrile  paroxysms,  hyper- 
trophied integument,  and  lymphatic  disturbance, 
are  very  suggestive  of  a community  of  origin  of 
these  morbid  conditions. 

Teeatment. — Little  has  yet  been  done  by  con- 
stitutional treatment  in  eases  of  elephantiasis. 
Remedies  useful  during  the  febrile  paroxysms 
have  little  power  in  preventing  recurrence  or 
in  checking  the  disease.  Iodine,  combined  with 
quinine,  arsenic,  and  iron,  has  been  found  useful 
to  a certain  extent.  During  the  febrile  state 
salines,  diaphoretics,  and  such  remedies  as  are 
needed  during  the  pyrexial  state  of  malarious 
fevers,  are  indicated.  Opium  may  he  necessary 
to  relieve  the  intense  pain  which  often  accom- 
panies the  onset  of  the  stage  of  excitement. 
When  the  febrile  stage  has  passed,  quinine  is 
useful,  which,  if  anaemia  exist,  should  be  com- 
bined with  iron.  The  local  application  of  iodiuo 
in  such  forms  as  the  iodide  of  lead  or  the  bin- 
iodide  of  mercury  has  been  thought  useful ; hut 
as  this  is  generally  combined  with  pressure  in  the 
recumbent  posture,  the  benefit  is  probably  due 
to  the  latter.  Such  measures,  along  with  im- 
proved hygienic  conditions,  may  no  doubt  control 
the  progress  of  the  disease  and  relieve  suffering. 
No  remedy,  however,  is  so  potent  as  change  of 
climate,  by  removal  from  the  endemic  site  of  the 
disease.  This,  if  effected  in  the  earliest  stages, 
may  completely  arrest  the  disease,  an  1 perhaps 
even  disperse  any  incipient  structural  change. 
This  has  been  observed  in  the  rare  cases  in  which 
elephantiasis  occurs  in  Europeans,  who  on  re- 
turning to  Europe,  have  after  a time  lost  the 
disease,  and  almost,  or  entirely,  any  hypertrophic 
changes  that  may  havo  occurred.  Natives  of  India 
improve  if  they  leave  the  endemic  area  during  the 
early  stages,  and  go  and  reside  in  other  and  drier 
localities.  However,  when  the  hypertrophy  is 
advanced,  the  paroxysms  of  fever  are  still  liable 
to  recur,  even  when  the  climate  is  changed,  though 
with  less  violence. 

Surgical  treatment,  where  the  hypertrophy  is 
advanced,  is  often  most  successful  in  relieving 
the  sufferer,  not  only  of  the  local  trouble,  but 
also  of  the  fever.  Tumours  of  the  genital  organs, 


ELEPHANTIASIS. 

sometimes  of  enormous  size,  are  now  removed 
with  complete  success  and  comparatively  small 
mortality.  Before  commencing  the  operation, 
especially  in  the  case  of  a large  scrotal  tumour, 
it  is  well  to  drain  it  of  blood  by  placing  the  pa- 
tient on  his  hack,  and  elevating  the  tumour  on  the 
abdomen  for  an  hour  or  so,  during  which  time 
pressure  by  a bandage  (a  modification  of  Es- 
march's) may  be  tried,  and  cold  (ice)  may  be 
applied.  During  the  operation  the  application 
of  a whipcord  ligature  drawn  tightly  round  the 
neck  of  the  tumour  also  prevents  loss  of  blood. 

The  removal  of  a scrotal  tumour  is  effected  by 
incisions  along  the  course  of  the  cords  and  the 
dorsum  penis.  The  cords,  testicles,  and  penis 
are  turned  out  by  a few  touches  of  the  knife, 
and  then  reflected  and  held  up  on  the  abdomen, 
while  the  mass  of  the  tumour  is  rapidly  swept 
away  by  a few  bold  incisions  in  the  perinaeum. 
The  numerous  venous andarterial bleeding  points 
should  then  be  arrested  and  the  wound  dressed 
with  oiled  lint  covered  with  antiseptic  dressing. 
No  attempt  should  be  made  to  preserve  flaps 
of  integument  either  for  the  penis  or  testes. 
It  is  unnecessary,  and  almost  certain  to  be 
followed  by  recurrence  of  the  disease.  The 
process  of  cicatrisation  goes  on  rapidly,  and 
in  from  two  to  four  months  all  is  closed  in 
by  cicatrical  tissue,  which  gradually  perfects 
itself,  and  has  no  liability  to  become  the 
seat  of  a return  of  the  disease.  If  the  shock 
be  severe  the  patient  should  be  Left  on  the 
table  until  reaction  has  thoroughly  set  in.  Of 
193  cases  of  scrotal  elephantiasis  operated  on 
in  the  Medical  College  Hospital  in  Calcutta,  18’2 
per  cent,  proved  fatal. 

Joseph  Fayree. 

ELSTER.  in  Saxony. — Alkaline  sulphated 
waters.  See  Mine  hat.  Waters. 

EMACIATION  ( eniacio , I make  lean). — 
Wasting  or  loss  of  flesh.  The  terra  is  applied 
both  to  the  process  of  wasting,  and  to  the  con- 
dition that  results  therefrom.  See  Atrofhy. 

EMBOLISM  (%gfio\ov,  a plug). — Synon.  : 
Fr.  embolie  ; Ger.  Embolie. 

Definition. — The  arrest  in  the  arteries  or. 
capillaries  of  some  solid  body,  which  has  been 
carried  along  in  the  course  of  the  circulation. 

Pathology. — Emboli  usually  consist  of  por- 
tions of  fibrine  derived  from  thrombi  of  the  veins 
or  heart,  or  of  vegetations  detached  from  the 
cardiac  valves.  They  may,  however,  be  formed 
by  fragments  of  tumours  which  have  grown 
into  the  blood-vessels,  or  of  other  foreign  bodies 
which  have  obtained  entrance  into  the  circu- 
lation. 

The  effects  of  embolism  may  be  divided  into 
two  classes : — First,  those  which  are  caused  by  the 
arrest  of  the  circulation ; and  secondly,  those 
which  are  due  to  any  specially  irritating  proper- 
ties of  the  embolus. 

The  embolus  may,  first,  be  supposed  to  con- 
sist of  some  indifferent  substance  not  possessing 
any  irritating  qualities.  The  effects  which  may 
then  be  caused  by  arterial  embolism  are  mainly 
these -First,  a transient  anaemia  of  the  territory 

28 


EMBOLISM.  433 

supplied  by  the  blocked  artery.  This  may  pass 
away  without  leaving  any  permanent  conse- 
quences. Secondly,  necrosis  of  this  territory.  This 
may  be  either  sudden,  in  the  form  of  gangrene ; or 
more  gradual,  in  the  form  of  softening  or  wither- 
ing. Thirdly,  the  formation  of  a luemorrhagic 
infarction,  that  is,  congestion  of  the  territory,  fol- 
lowed by  extravasation  of  blood  into  the  tissues, 
and  so  the  formation  of  a firm,  solid  patch  of  ft 
dark  red  colour,  usually  of  a wedge  shape,  with, 
the  apex  towards  the  embolus,  and  the  base  to- 
wards the  periphery.  In  very  soft  organs, 
the  brain,  the  extravasation  may  break  down  the 
tissue  and  cause  the  ordinary  phenomena  of  an 
apoplectic  clot.  These  haemorrhagic  infarctions 
undergo  various  subsequent  changes.  Usually  n 
process  of  degeneration  setsin;  the  blood-pigmem 
passes  through  its  usual  transformations,  the 
patch  changes  from  dark  red  to  tawny  and  yellow, 
undergoes  molecular  disintegration,  shrinks  away, 
and  ultimately  leaves  a depressed  fibrous  patch 
in  which  the  remains  of  the  altered  blood, 
crystals  of  hmmatoidin,  &c.,  may  often  be  re- 
cognised. Sometimes  the  patch  softens  down 
into  a puriform  fluid,  which  may  become  sur- 
rounded by  a fibrous  capsule,  and  ultimately  dry 
up,  or  even  calcify.  When  recent  these  patches 
are  usually  surrounded  by  a halo  of  congested 
vessels. 

The  cause  which  determines  these  different 
results  of  arterial  embolism  is,  in  the  main,  the 
anatomical  arrangement  of  the  blood-vessels. 
Supposing  the  embolus  to  be  lodged  in  an  artery 
which  gives  off  anastomotic  branches  between  the 
seat  of  the  embolus  and  the  final  capillary  distri- 
bution, the  effect  in  most  cases  will  be  transient 
ausemia,  the  collateral  channels  will  enlarge,  and 
the  circulation  will  be  again  restored.  A throm- 
bus will  form  on  the  embolus  and  will  extend 
back  to  the  next  arterial  branch,  and  the  changes 
described  in  the  article  on  thrombosis  will  take 
place  in  it  (see  Thrombosis).  If  the  blocked  artery 
be  of  large  size,  and  supply  important  organs,  the 
symptoms  of  temporary  arrest  of  function  of  the 
part  supplied  by  the  artery  will  follow,  as  transient 
paralysis,  dyspnoea,  coldness  of  the  extremities, 
&c.,  according  to  the  artery  affected.  Should, 
however,  the  artery  be  small,  and  not  supply  im- 
portant organs,  no  symptoms  whatever  will  be 
caused,  and  this  is  the  case  in  the  majority  ol 
embolisms.  Supposing,  however,  the  artery  is 
what  Cohnheim  calls  a terminal  artery,  i.e.  one 
which  gives  off  no  anastomotic  branches  be- 
tween the  embolus  and  the  final  capillary  dis- 
tribution, and  that  the  capillary  anastomosis 
with  other  arterial  territories  is  insufficient  to 
supply  a collateral  circulation,  and  that  the 
presence  of  valves  prevents  the  reflux  of  blood: 
into  the  territory  from  the  veins,  it  is  manifest 
that  the  embolism  must  completely  cut  off  the 
blood-supply,  and  consequently  cause  necrosis  in 
some  form  or  other  of  the  territory. 

The  network  of  anastomosing  channels  is, 
however,  so  close  in  most  parts  of  the  body,  that 
in  order  to  produce  this  effect  it  is  necessary  either 
that  the  main  artery  of  the  part  be  obstructed,  or 
else  that  there  be  multiple  embolisms  blocking  up 
at  the  same  time  several  arterial  branches,  and 
so  stopping  the  channels  of  collateral  circula- 
tion. 


13  i EMBOLISM, 

The  mode  in  which  the  haemorrhagic  infarction 
is  produced  is  still  a subject  of  dispute.  Ac- 
eording  to  Cohnheim,  whose  views  until  recently 
were  generally  accepted,  the  haemorrhage  is  due 
to  a reflux  from  the  veins  into  the  territory  sup- 
plied by  the  blocked  artery.  This  first  causes 
congestion,  and  then  extravasation,  in  conse- 
quence of  impairment  of  nutrition  of  the  walls 
of  the  blood-vessels,  for  the  integrity  of  which 
the  circulation  of  the  blood  is  essential.  Accord- 
ing, then,  to  Cohnheim,  in  order  to  produce  the 
phenomena  of  the  hsemorrhagic  infarction  it  is 
necessary  that  the  artery  be  a terminal  one,  i.e. 
one  which  gives  off  no  anastomotic  branches  for 
some  distance  before  its  final  capillary  distribu- 
tion, and  that  the  veins  be  not  furnished  with 
valves.  These  conditions  are  met  with  in  the 
spleen,  the  kidney,  the  brain,  certain  branches 
of  the  pulmonary  artery  supplying  surface 
lobules,  and  the  central  artery  of  the  retina; 
and  on  these  grounds  he  accounts  for  the  fre- 
quent occurrence  of  haemorrhagic  infarctions  in 
these  organs,  though  there  is  no  reason  to  sup- 
pose that,  with  the  exception  of  the  lungs,  embo- 
lisms are  more  frequent  in  them  than  in  other 
parts. 

The  more  recent  researches  of  Dr.  M.  Litten, 
Zeitschrift  fur  klinische  Medicin,  Vol.  I.,  render, 
however,  these  views  no  longer  tenable.  He 
shows  by  experiments  on  the  kidney,  spleen, 
lung,  &c.,  that  if  the  blocked  artery  be  a strictly 
terminal  one,  i.e.  one  whose  area  of  distribu- 
tion has  no  other  arterial  supply,  the  phenomena 
of  the  hemorrhagic  infarction  do  not  accur, 
even  though  the  vein  have  no  halves ; and  under 
other  circumstances  that  the  infarction  takes 
place  although  the  vein  has  been  ligatured,  hence 
the  cause  of  the  infarction  cannot  be  venous 
reflux.  Thus  if  both  the  renal  artery  and  vein 
be  ligatured,  infarction  of  the  kidney  takes  place, 
the  kidney  receiving  a sufficient  collateral  supply 
of  blood  from  other  sources;  but  if  the  capsule 
wore  first  stripped  off,  and  the  kidney  be  left 
attached  only  by  the  renal  artery  and  vein,  no 
infarction  took  place,  though  the  vein  was  left 
pervious.  Similar  results  were  obtained  in  other 
organs ; hence  it  would  seem  evident  that  the 
congestion  and  infarction  following  embolism 
are  produced  by  an  afflux  of  arterial  blood  into 
the  territory  from  collateral  channels.  Should 
these  be  numerous,  and  should  small  arteries 
open  directly  into  the  anaemic  territory,  the  cir- 
culation will  soon  be  restored,  and  no  infarction 
will  take  place ; should,  however,  the  communi- 
cation be  imperfect,  and  only  by  means  of  capil- 
laries, a congestion  of  the  territory  leading  to 
diapedesis  and  infarction  will  result,  the  vis  a 
tergo  being  insufficient  to  propel  the  blood  on- 
wards into  the  veins. 

He  has  also  shown  that  the  vessels  in  which 
the  circulation  has  been  arrested  retain  their 
integrity  much  longer  than  was  supposed  by 
Cohnheim,  and  that  in  the  kidney  long  before  the 
vessels  suffer  necrosis  of  the  epithelium  takes 
place,  the  nuclei  of  the  cells  disappear,  their 
protoplasm  coagulates,  and  they  become  con- 
verted into  swollen  hyaline  masses  ( coagulation 
necrosis),  which  have  a remarkable  tendency  to 
calcification.  Hence  the  wedge-shaped  white 
Bmbolisms  often  seen  in  the  kidney  are  not  pro- 


EMETICS. 

duced  by  decolorisation  of  hsemorrhagic  infarc- 
tions, but  are  simply  the  result  of  the  necrosis 
of  the  epithelium ; and  the  halo  of  injection 
which  is  often  seen  to  surround  them  is  due  to 
inflammatory  congestion  caused  by  the  presence 
of  the  necrosed  patch. 

This  explanation  of  the  mode  of  production 
of  the  haemorrhagic  infarction  is  more  closely 
in  accord  with  the  view  originally  propounded 
by  Virchow,  who  regarded  the  haemorrhage  as 
due  to  collateral  fluxion. 

We  have  now  to  consider  the  effects  of  emboli 
which  possess  irritating  or  poisonous  qualities, 
such  as  those  derived  from  the  puriform  softening 
of  venous  thrombi  in  cases  of  septic  inflamma- 
tion, &c.  The  mechanical  effects  will  be  the  same 
as  those  of  the  previous  class  ; but,  in  addition, 
these  emboli  set  up  a suppurative  inflammation 
in  their  vicinity,  quite  independent  of  any  ob- 
struction of  the  circulation.  Hence  it  is  that  we 
meet  with  pyaemic  abscesses,  as  the  result  of 
infecting  emboli,  in  all  parts  of  the  bodj’,  while 
the  effects  of  obstructed  circulation  are,  for  the 
most  part,  confined  to  certain  organs.  Thus 
the  liver  is  very  frequently  the  scat  of  embolic 
abscesses,  while  haemorrhagic  infarctions  do  not 
occur  there.  In  the  lung,  where  in  parts  ter- 
minal arteries  are  found  but  for  the  most  part 
there  is  free  anastomosis,  the  two  processes  are 
often  seen  side  by  side.  The  different  effects  of 
these  two  classes  of  embolism  are  very  manifest 
in  the  capillaries.  Simple  emboli,  of  such  small 
size  as  to  become  first,  arrested  in  the  capillaries, 
either  cause  no  permanent  change  at  ail,  or.  at 
most,  produce  a punctiform  haemorrhage.  Infect- 
ing emboli,  on  the  other  hand,  give  rise  to  the 
miliary  abscesses  so  characteristic  of  pyaemia. 

W.  Catlet. 

EMESIS  I vomit). — A synonym  for 

vomiting.  See  Vomiting. 

EMETICS  (eue'u),  I vomit). — Synon.:  Fr. 
Emetiqucs  ; Ger.  Brcchmittcl. 

Definition. — Agents  that  produce  vomiting. 

Enumeration. — Copious  draughts  of  luke- 
warm water,  Mustard,  Sulphate  of  Zinc,  Sulphate 
of  Copper,  Carbonate  of  Ammonia,  Common  Salt, 
Alum,  Chamomile,  Tartar  Emetic,  Ipecacuanha, 
and  Apomorphia. 

Action. — The  act  of  vomiting  consists  in  the 
simultaneous  spasmodic  contraction  of  the  dia- 
phragm and  abdominal  muscles,  and  relaxation 
of  the  cardiac  orifice  of  the  stomach,  so  that 
its  contents  are  expelled.  When  the  diaphragm 
and  abdominal  muscles  contract,  but  the  cardiac 
orifice  remains  closed,  so  that  the  contents  of 
the  stomach  cannot  escape,  the  expulsive  efforts 
are  termed  retching.  The  nervous  centre  which 
regulates  these  movements  is  situated  in  the 
medulla  oblongata  ; and  it  maybe  excited  either 
directly  by  the  action  upon  it  of  drugs  carried 
to  it  by  the  blood,  or  reflexly  by  irritation  of 
various  nerves.  The  drugs  that  act  directly  upon 
it  have  the  same  action,  whether  they  are  intro- 
duced immediately  into  the  circulation  or  a!>- 
sorbed  by  the  stomach.  They  may  thus  produce 
vomiting  and  evacuation  of  the  stomach  without 
being  taken  into  the  stomach  at  all,  and  on  this 


EMETICS. 

account  they  are  < ermed  indirect  emetics,  although 
they  act  directly  upon  the  vomiting  centre.  Such 
are  ipecacuanha,  apomorphia,  and  tartar  emetic. 
SimilarljAhe  drugs  that  excite  it  reflexly  are 
still  ternM  direct  emetics,  because  they  are  ap- 
plied directly  to  the  stomach.  Such  are  the  sul- 
phates of  zinc,  copper,  and  alumina  ; carbonate 
of  ammonia;  salt;  mustard ; and  chamomile, 
which  irritate  the  nerves  of  the  stomach.  Tick- 
ling the  fauces  with  a feather,  or  with  the  finger, 
also  excites  reflex  vomiting,  and  may  be  adopted 
either  alone,  or  in  order  to  aid  the  action  of  other 
emetics.  The  terms  direct  and  indirect,  there- 
fore, as  applied  to  emetics,  relate  to  the  stomach 
and  not  to  the  centre  for  vomiting. 

Direct  emetics,  as  they  stimulate  the  nerves 
of  the  stomach  only,  have  little  action  except 
that  of  simply  exciting  vomiting.  The  indirect 
emetics,  which  excite  vomiting  by  their  action 
on  the  medulla  oblongata,  act  also  on  other 
parts  of  the  nervous  system,  and  cause  secretion 
of  saliva,  secretion  of  mucus  from  the  oesophagus, 
stomach,  and  bronchial  tubes,  an  1 perspiration. 
They  also  cause  much  nausea,  depression  of  the 
circulation,  and  loss  of  nervous  and  muscular 
power.  Further,  the  vomiting  they  induce  is  more 
continuous  and  violent,  and  often  expels  the 
contents  of  the  gall-bladder,  causing  part  of 
tho  bile  to  flow  into  the  stomach,  and  be  thus 
evacuated. 

Uses. — Emetics  are  employed  to  remove  the 
contents  of  the  stomach  under  various  circum- 
stances. Firstly,  when  the  food  is  causing  irri- 
tation, and  not  undergoing  proper  digestion,  as, 
for  example,  in  dyspepsia,  or  sick-headache ; and 
in'  such  cases  large  draughts  of  lukewarm  water, 
of  mustard  and  water,  or  of  an  infusion  of  cha- 
momile are  usually  found  beneficial.  Secondly, 
in  cases  of  poisoning ; and  here  mustard,  sulphate 
of  zinc,  or  sulphate  of  copper  are  best,  as  they 
empty  the  stomach  most  quickly  and  effectually. 
Thirdly,  to  cause  the  expulsion  of  bile  from  the 
gall-bladder,  or  remove  bile  from  the  body  in 
biliousness,  fevers,  and  ague.  When  the  bile- 
duct  is  stopped  by  a small  gall-stone,  the  pres- 
sure exerted  on  the  gall-bladder  during  vomit- 
ing has  been  known  to  cause  the  expulsion  of  the 
calculus.  In  biliousness,  excess  of  bile  is  more 
readily  removed  by  vomiting  than  by  purging,  as 
there  is  no  opportunity  for  the  bile  to  be  ab- 
sorbed on  its  way  from  the  gall-bladder  to  the 
mouth,  whereas  it  may  undergo  absorption  on  its 
passage  through  the  intestines.  It  is  supposed  by 
some  that  various  poisons  circulate  occasionally 
in  the  bile,  such  as  the  malarious  poison  which 
occasions  ague,  and  possibly  other  septic  poisons 
which  give  rise  to  fevers.  The  advantage  of 
emetics  in  ague  is  undoubted,  as  it  can  certainly 
sometimes  be  cured  by  them  without  quinine, 
and  the  action  of  quinine  is  always  aided  by 
their  use.  They  have  also  been  recommended  in 
the  early  stages  of  continued  fevers.  In  such  cases 
tartar  emetic  or  ipecacuanha  are  most  service- 
able. Fourthly,  to  cause  expulsion  from  the  air- 
passages  of  false  membrane  in  croup  or  diphtheria, 
or  of  secretions  in  bronchitis  and  phthisis.  For 
these  purposes  ipecacuanha  is  the  emetic  most 
frequently  chosen,  but  if  it  does  not  act  rapidly 
,r-  croup,  sulphate  of  zinc  or  sulphate  of  copper 
may  be  employed,  and  in  cases  of  either  croup  or 


EMMENAGOGUES.  43.1 

bronchitis  where  there  is  great  depression  of  the 
circulation  carbonate  of  ammonia  may  be  used 
with  advantage,  as  it  not  only  causes  vomiting, 
but  at  the  same  time  stimulates  circulation. 

T.  Lauder  Brunton. 

EMMENAGOGFES  (efj.fj.qra,  the  menses, 
andayw,  I move  or  expel). 

Definition.  — Emmenagogues  are  remedial 
agents  which  stimulate  or  restore  the  normal 
menstrual  function  of  the  uterus,  or  cause  ex- 
pulsion of  its  contents. 

Enumeration. — Emmenagogues  may  be  either 
indirect,  as  Iron,  Strychnia,  and  other  tonics, 
Warm  Hip-baths,  Leeches,  Mustard  Stupes, 
Aloetic  purgatives,  &e. ; or  direct,  as  Rue,  Borax, 
Savin,  Myrrh,  Cantharides,  Guaiacum,  Apiol, 
Quinine,  Digitalis,  and  Ergot — most  of  which, 
when  given  in  larger  doses,  produce  abortion,  and 
are  called  Ecbolics.  The  most  efficient  means, 
however,  of  obtaining  this  last-named  action 
are  those  of  a mechanical  nature,  so  well  known 
to  obstetricians,  and  directed  either  to  the  actual 
rupture  of  the  membranes,  or  to  their  separation 
from  the  cervix. 

Action. — The  indirect  emmenagogues  act  by 
improving  the  quality  of  the  blood,  giving  tone 
to  the  nervous  system,  or  irritating  adjacent 
parts  or  organs,  from  which  a stimulating 
influence  is  conveyed  by  reflex  action  to  tin- 
womb. 

The  direct  drugs  in  moderate  doses  gently 
stimulate  the  uterus,  promoting  the  menstrual 
flow,  or  even  checking  it  when  in  excess;  but 
when  further  pushed  they  cause  powerful  con- 
traction of  the  unstriped  muscular  fibre,  of 
which  its  walls  are  mainly  composed.  Ergot, 
which  is  the  principal,  and  in  fact  almost  the 
only  really  useful  member  of  the  group,  is  be- 
lieved to  act  either  directly  on  the  museulai 
tissues  themselves,  or  through  the  intermediate 
intervention  of  some  central  orperipheral  Dervous 
influence. 

Uses.— Checked  or  retarded  menstruation  fre- 
quently results  from  anaemia  or  general  debility, 
and  the  indirect  emmenagogues  will  under  these 
circumstances  usually  effect  a cure.  If.  however, 
the  case  prove  more  obstinate,  a little  ergot 
added  to  the  iron  will  often  restore  the  sus- 
pended function.  If  even  this  do  no  good, 
some  mechanical  impediment  probably  exists, 
or  some  altered  physical  condition  of  the  womb 
which  mere  drugs  cannot  rectify.  Ergot  is  fre- 
quently employed  in  cases  of  lingering  labour  from 
simple  inertia  of  the  uterus,  but  its  use  must  bo 
strictly  confined  to  those  eases  in  which  there  is 
no  marked  disproportion  between  the  maternal 
passages  and  the  head  of  the  child.  Advantage 
is  also  taken  of  its  contractile  powers  in  the 
treatment  of  uterine  haemorrhages,  or  for  the 
destruction  of  the  smaller  varieties  of  polypi, 
which  are  so  frequently  contained  within  the 
womb,  by  cutting  off  their  blood-supply. 
Finally,  it  may  be  necessary,  under  certain  con- 
ditions, to  induce  abortion  or  premature  labour, 
as  when  constant  sickness,  or  albuminuria,  or 
compression  of  adjoining  neighbouring  viscera 
seems  to  endanger  the  mother’s  life,  or  when 
pelvic  distortion  renders  it  impossible  for  a 
living  child  to  be  born  at  full  term.  lYhen  fh> 


436  EMMENAGOGUES. 

medical  attendant  has  made  up  his  mind  that 
interference  is  necessary,  he  generally  has  re- 
course to  one  or  other  of  the  mechanical  methods 
■which  are  fully  described  in  works  more  particu- 
larly devoted  to  obstetrics. 

ItoBERT  FaRQUHARSON. 

EMOLLIENTS  ( emollio , I soften). — Defi- 
nition.—Substances  that  soften  and  relax  the 
parts  to  which  they  are  applied. 

. Enumeration. — The  principal  emollient  ap- 
plications are : — Warm  water,  Steam,  Poultices 
made  of  substances  which  retain  heat  and  mois- 
ture, for  example,  linseed-meal,  bread,  bran,  flour, 
oatmeal,  and  figs;  Fatty  Substances,  as  linseed, 
olive,  almond,  and  neat’ s-foot  oil,  lard,  and  suet; 
Spermaceti,  Wax  ; Soap  Liniment  and  other  lini- 
ments ; Glycerine  ; and  Paraffines,  such  as  vase- 
line, unguentum  petrolei,  &c.  To  these  may  be 
added  such  substances  as  do  not  properly  relax 
tho  tissues,  but  protect  the  surface  from  irritation, 
such  as  White  of  Egg,  Gelatine,  Isinglass,  Collo- 
dion, and  Cotton-wool. 

Action. — Emollients  relieve  the  tension  and 
pain  of  inflamed  parts  by  their  action  both  upon 
the  blood-vessels  and  upon  the  tissues  them- 
selves. They  cause  all  the  contractile  tissues  to 
relax  and  dilate,  and  thus,  lessening  pressure 
upon  the  nerves  of  the  part,  they  relieve  pain. 
They  soften  superficial  parts  by  supplying  them 
with  either  fat  or  moisture,  and  by  increasing 
the  supply  of  blood.  In  this  way  they  prevent 
the  skin  from  cracking  after  exposure  to  cold. 
When  the  cuticle  is  lost  they  form  a covering, 
under  which  the  skin  may  heal;  and  they  pre- 
vent the  injurious  consequences  of  friction  from 
without. 

Uses. — Fatty  emollients  are  used  to  prevent 
the  skin  or  mucous  membranes  from  cracking;  to 
prevent  irritation  or  ulceration  between  parts 
constantly  in  contact,  as  on  the  limbs  of  children 
near  the  joints  ; to  prevent  bed-sores  ; to  aid  the 
healing  of  blisters  ; or  in  skin-diseases,  such  as 
eczema.  They  are  also  used,  especially  in  the  form 
of  linimentum  calcis,  as  applications  in  burns  and 
scalds,  for  which  purpose  such  substances  as 
cotton-wool  are  likewise  frequently  employed. 
Mucilaginous  substances  are  useful  when  swal- 
lowed to  relieve  pain  and  irritation  in  the  throat, 
and  to  lessen  irritable  cough ; and  such  substances 
as  figs  are  employed  to  protect  the  intestines 
from  injury  by  hard  and  pointed  substances  which 
have  been  swallowed.  Warmth  and  moisture  are 
applied  in  the  form  of  poultices  to  the  surface  in 
pustules,  boils,  carbuncles,  and  deep-seated  in- 
flammation of  the  limbs,  and  in  inflammation  of 
the  internal  organs  {sec  Pouetices).  In  the  form 
of  vapour  they  are  useful  in  inflammation  of  the 
air-passages  (sec  Inhalations). 

T.  Lauder  Brunton. 

EMPHYSEMA  of  Lungs.  See  Lungs, 
Emphysema  of. 

EMPHYSEMA,  SUBCUTANEOUS  (eV, 
m,  and  <pvaa , wind). — Synon.  : Fr.  emphysema ; 
Ger.  Windgeschwulst. — Subcutaneous  emphysema 
is  the  distension  of  the  spaces  of  the  areolar  tissue 
with  air  or  any  other  gas.  There  is  thus  produced 
a swelliug,  in  slight  cases  affecting  a very  limited 
area,  in  extreme  cases  extending  to  the  subcuta- 


EMPHYSEMA,  SUBCUTANEOUS. 

neous  tissue  of  the  whole  body.  Unless  the  tension 
is  great  the  swelling  is  slightly  lobulated ; it  is 
elastic,  and  although  the  finger  sinks  readily  into 
it.  no  lasting  impression  is  left.  When  the  area 
affected  is  small,  the  gas  can  be  driven  in  any 
direction  by  the  pressure  of  the  hand.  On  pal- 
pation a peculiar  fine  crepitation  is  felt,  which  is 
absolutely  diagnostic.  On  percussion  there  is 
superficial  resonance,  the  noce  resembling  that 
obtainable  from  a bladder  loosely  filled  with  air. 
Unless  the  gas  causing  the  emphysema  is  the  pro- 
duct of  decomposition  of  gangrenous  tissues,  as 
in  spreading  gangrene,  there  is  no  redness  of  the 
skin.  The  swelling  usually  forms  rapidly  and 
may  extend  in  a few  minutes  over  the  greater 
part  of  the  body.  In  such  eases  it  is  mostmarked 
where  the  subcutaneous  tissue  is  lax.  In  tho 
face  the  features  are  obliterated,  and  the  eyes 
closed  by  the  swelling  of  the  lids.  The  scrotum 
and  penis  become  enormously  distended. 

-Etiology  and  Pathology. — Wound  of  the 
lung  from  a broken  rib  or  from  a stab  is  the 
most  common  cause  of  subcutaneous  emphysema. 
If  from  a stab,  it.  can  only  occur  when  the  opening 
in  the  pleura  and  that  in  the  skin  no  longer  cor- 
respond with  each  ether,  in  consequence  of  an 
alteration  in  the  position  of  the  patient,  or  when 
the  wound  has  been  artificially  closed.  When  from 
wound  of  the  lung,  it  may  occur  with  or  without 
pneumothorax.  Nothing  is  more  common  than 
to  find  a limited  ^lphysematous  swelling  round 
a fractured  rib,  without  any'  signs  of  air  in  the 
pleural  cavity.  This  arises  either  from  adhesions 
existing  between  the  parietal  and  visceral  layers, 
or  from  the  escape  of  air  being  very  limited.  In 
severe  eases  with  pneumothorax  the  mechanism 
of  the  production  of  emphysema  is  as  follows : — A 
wound  in  the  lung  always  allows  air  to  pass  from 
it  readily,  hut  from  the  wayr  in  which  the  soft 
pulmonary  tissue  falls  together,  no  amount  of 
force  can  drive  air  through  the  wound  in  the 
opposite  direction.  It  thus  acts  somewhat  like 
the  valve  of  an  air-pump.  The  first  effect  of  the 
escape  of  air  into  the  pleural  cavity  is  to  cause 
collapse  of  the  lung.  As  the  chest  expands  with 
each  inspiration  air  rushes  from  the  wound  in  the 
lung  into  the  pleural  cavity:  as  it  contracts  in 
expiration,  the  air,  being  unable  to  pass  back  by 
the  wound,  is  driven  through  the  opening  in  the 
parietal  pleura  into  the  subcutaneons  cellular 
tissue.  In  such  cases  there  is  gradually  increas- 
ing dyspnoea,  with  great  distension  of  the  sub- 
cutaneous cellular  tissue,  and  unless  relief  is 
given  the  patient  dies  asphyxiated. 

Emphysema  occasionally  occurs  front  rupture 
of  some  of  the  air-vesicles  during  a violent  ex- 
piratory effort.  Walshe  states  that  this  accident 
has  happened  from  ‘ the  efforts  in  parturition, 
defaecation,  raising  weights,  coitus,  violent  cough- 
ing, paroxysms  of  rage,  excessive  laughter,  and 
hysterical  convulsions.’  The  air  usually  escapes 
first  into  the  cellular  tissue  between  the  lobules 
of  the  lung,  giving  rise  to  the  condition  known 
as  interlobular  emphysema.  It  then  finds  its 
way  into  the  mediastinum  and  from  thence  to 
the  root  of  the  neck.  Interlobular  emphysema 
gives  rise  to  intense  dyspnoea,  and  has  been 
known  to  cause  sudden  death.  Emphysema  has 
also  been  seen  as  a consequence  of  ulceration  of 
the  trachea,  and  in  a few  very  rare  cases  as  the 


EMPHYSEMA,  SUBCUTANEOUS, 
result  of  ulceration  proceeding  from  a cavity  in 
the  lung  through  the  adherent  pleura  and  inter- 
costal muscles  to  the  subcutaneous  cellular 
tissue. 

Localised  emphysema  of  the  face  is  a symptom 
of  fractures  implicating  the  antrum. 

Emphysema  of  the  flanks  is  an  occasional  symp- 
tom of  rupture  of  the  third  part  of  the  duodenum, 
behind  the  peritoneum,  and  of  perforation  of  the 
caecum  at  its  posterior  part. 

Emphysema  of  the  perineum  and  scrotum  may 
arise  from  a wound  of  the  bowel  in  the  adminis- 
tration of  an  enema. 

In  non-penetrating  wounds  of  the  thorax  and 
abdomen,  a small  quantity  of  air  may  find  its  way 
into  the  areolar  tissue  in  the  immediate  neigh- 
bourhood, in  consequence  of  the  movements  of 
respiration.  In  compound  fractures  emphysema 
is  often  found  extendingsome  distance  above  and 
below  the  wound,  if  the  patient  has  been  carried 
some  distance  and  the  injured  limb  much  shaken. 

Emphysema  from  the  gases  produced  by  de- 
composition is  only  seen  in  cases  of  rapidly  spread- 
ing moist  gangrene. 

Progress  and  Terminations.- — The  effects  of 
emphysema  differ  with  the  source  of  the  gas. 
When  the  air  comes  from  a superficial  wound  of 
the  lung,  it  has  no  tendency  to  cause  decomposi- 
tion of  the  effused  blood  with  which  it  may  come 
into  contact.  Thus,  in  surgical  cases,  no  evil 
consequences  result  from  emphysema  around  a 
simple  fracture  of  a rib.  This  is  explained  by  the 
fact  that  the  gas  in  the  air-vesicles  is  absolutely 
free  from  solid  particles  of  any'  kind;  as  shown 
by  Tyndall's  experiment,  in  vrhich  the  residual 
air,  in  forced  expiration,  makes  a gap  in  the 
beam  of  an  electric  light  when  breathed  across 
it.  On  the  other  hand,  air  admitted  from  with- 
out, as  in  a compound  fracture,  tends  to  favour 
the  decomposition  of  the  effused  blood,  and  ren- 
ders treatment  by  occlusion  or  by  antiseptic 
dressing  difficult  and  uncertain.  In  ordinary 
eases  the  effused  air  is  rapidly  absorbed  without 
causing  inconvenience  of  any  kind.  If  the  amount 
of  air  in  the  tissues  be  very  great,  and  the  case 
be  complicated  by  pneumothorax,  fatal  dyspnoea 
may  occur,  unless  relieved  by  treatment. 

Treatment. — The  swelling  itself  requires 
usually  no  treatment,  the  gas  being  absorbed 
without  difficulty.  If  it  is  complicated  by 
pneumothorax,  or  if  the  dy'spncea  be  such  as  to 
threaten  death,  the  wound,  if  one  exists,  must  be 
opened  up,  or,  if  there  is  none,  a free  opening 
must  be  made  into  the  pleural  cavity'.  If  the 
swelling  be  such  as  seriously  to  inconvenience 
the  patient,  a few  punctures  may  be  made  with  a 
triangular  needle.  Emphysema  from  intestinal 
flatus  is  always  limited,  and  requires  no  treatment 
beyond  that  applicable  to  the  cause  of  the  escape 
°f  gas.  Marcus  Beck. 

EMPIRICAL  (eV,  by,  and  ireipa,  experience). 
This  term  is  applied  to  treatment  founded  on 
experience,  as  opposed  to  rational,  founded  on 
scientific  reasoning.  See  Disease,  Treatment  of. 

EMPROSTHOTONOS  (IpirpoaOtv,  for- 
wards, and  Te'u'a,  I stretch.)  — A bending  or 
drawing  forwards  of  the  body,  due  to  tonic  con- 
traction of  the  muscles,  observed  in  some  eases 
of  tetanic  convulsions.  See  Tetanus. 


ENDERMIC.  437 

EMPYEMA  (eV,  in,  and  rthov,  pus). — 

Strictly  speaking  this  term  signifies  a collection 
of  pus  within  the  cavity  of  the  pleura,  but  it  is 
often  conventionally  used  to  denote  any  inflamma- 
tory effusion  in  that  situation  which  has  assumed 
a chronic  character.  See  Pleura,  Diseases  of. 

EMS,  in  Germany. — Thermal  muriated 
alkaline  waters.  See  Mineral  Waters. 

ENCEPHALITIS  (iyaicpaXos,  the  brain). 
Inflammation  of  the  brain  and  its  mem- 
branes ; or,  more  properly,  inflammation  of  the 
brain-substance  itself.  See  Brain,  Inflamma- 
tion of. 

ENCEPHALOCELE  (eyKe<paXos,  the  brain, 
and  K-rjA-n,  a tumour). — A hernial  protrusion  of  a 
portion  of  the  brain-substance  through  an  open- 
ing in  the  skull,  which  may  be  either  congenital 
or  the  result  of  accident.  See  Brain,  Malforma- 
tions of. 

ENCEPHALOID  (iyKe<pa\os,  the  brain). — 
A form  of  cancer,  so  named  on  account  of  its  ob- 
vious resemblance  to  brain-tissue.  See  Cancer. 

ENCHONDROMA  (iv,  in,  and  x^pos, 
cartilage). — A new-growth  consisting  of  car- 
tilaginous tissue.  See  Tumours. 

ENCYSTED  (eV,  in,  and  j,  a bladder). 
— Contained  within  a cyst.  A term  applied  t< 
new-growths  or  collections  of  fluid  thus  enclosed. 

ENDARTERITIS  (erSov,  withiD,  and 
aprrip'ia,  an  artery). — Inflammation  of  the  inter- 
nal coat  of  an  artery.  The  disease  is  generally 
chronic  or  subacute,  rarely  acute.  Two  special 
forms  of  endarteritis  have  been  described, 
namely,  endarteritis  deformans,  or  atheromatous 
disease  (see  Arteries,  Diseases  of,  and  Athe- 
roma) ; and  syphilitic  endarteritis,  which  most 
frequently  affects  the  vessels  of  the  brain,  but 
the  specific  nature  of  which  has  lately  been 
questioned  (see  Syphilis,  and  Brain,  Vessels  of. 
Diseases  of). 

ENDEMIC  (eV,  in,  and  8 rj/.ios,  a people). — This 
term  is  applied  to  diseases  that  prevail  in  par- 
ticular localities  or  districts,  and  which  are  due 
to  special  aetiological  conditions  existing  there. 
See  Disease,  Causes  of. 

ENDERMIC  (eV,  in,  and  Sep/ia,  the  skin). 
A term  generally  applied  to  the  method  of  in- 
troducing remedies  through  the  skin.  The  horny 
layers  of  the  cuticle  interpose  so  effective  a barrier 
between  most  remedial  agents  and  the  absorptive 
surface  of  the  true  skin,  that  the  endermic  plan 
of  treatment  when  introduced w'as  looked  upon  as 
a therapeutic  gain.  The  ease  with  which  drugs 
could  thus  be  administered,  and  the  excellent 
results  obtained  in  neuralgia  and  other  nervous 
affections,  were  held  to  far  more  than  counter- 
balance the  pain  of  the  application,  the  resulting 
disfigurement,  and  the  occasional  troublesome 
ulceration  which  ensued.  And,  although  the 
hypodermic  syringe,  with  its  greater  rapidity 
and  efficiency,  has  rendered  the  endermic  method 
almost  obsolete,  there  are  still  circumstances 
which  might  induce  us  to  use  it.  For  instance,  a 
blistered  surface  might  be  ready  to  hand ; or  it 
might  be  considered  advisable  to  combine  counter- 


138  ENDERMIC. 

irritation  with  the  subsequent  local  use  of  morphia 
or  other  sedative  drugs ; or  it  might  not  be  pos- 
sible to  procure  an  instrument  for  subcutaneous 
injection,  oran  invincibleo'jection  might  be  made 
to  the  needle-prick,  which  is  sometimes  a source 
of  apprehension  to  sensitive  natures,  and  we 
might  then  be  glad  to  avail  ourselves  of  a mode- 
rately efficient  substitute. 

Mode  op  AppLtCATtON. — We  detach  the  epi- 
dermis either  by  any  ordinary  blistering  appli- 
cation, or  by  the  button-cautery,  and  after  its 
careful  removal,  we  apply  our  selected  drug  to 
the  raw  surface,  in  the  form  either  of  powder 
or  of  an  ointment,  which  latter  plan  has  seemed 
to  the  writer  rather  more  efficient,  as  ensuring 
more  prolonged  contact,  the  application  being  also 
less  easily  washed  away  by  the  effusion  of  serum 
from  the  skin.  The  principal  remedies  nsed  in 
this  way  have  been  morphia,  which,  in  doses  of 
from  a quarter  of  a grain  to  two  grains,  is  un- 
doubtedly beneficial  in  cases  of  neuralgia,  sciatica, 
and  localized  rheumatism ; strychnia,  which  was 
formerly  much  employed  in  amaurosis,  lead  palsy, 
infantile  paralysis,  and  other  nervous  affections, 
in  doses  of  from  -jVgrain  to  one  grain;  and 
quinine,  which  in  6-grain  doses  has  apparently 
cured  obstinate  cases  of  ague. 

Robert  Farquiiarson. 

ENDOCARDITIS  (tviov,  within,  and  Kap- 
dta,  the  heart). — Inflammation  of  the  lining 
membrane  of  the  heart.  See  Heart,  Inflam- 
mation of. 

ENDOGASTRITIS  (eyS  ov,  within,  and 
yaariip,  the  stomach). — Inflammation  of  the 
mucous  membrane  of  the  stomach.  See  Stomach, 
Diseases  of. 

ENDOMETRITIS  (eySoy,  within,  and 
xfjTTjp,  the  womb).- — Inflammation  of  the  lining 
membrane  of  the  uterus.  See  Womb,  Diseases 
of. 

ENDOPERICARDITIS.  — Inflammation 
of  the  endocardium  and  pericardium  together. 
See  Heart,  Inflammation  of ; and  Pericardium, 
Diseases  of. 

ENEMA  (ivlripi,  I inject). — Synon.  : Lave- 
ment; Clyster;  Er.  Clystere  ; Lavement ; Ger. 
Klystier. 

Definition.— An  enema  is  a liquid  injected  by 
means  of  a suitable  instrument  into  the  rectum 
or  the  colon. 

Instruments. — Various  instruments  are  used 
for  the  administration  of  enemata: — 1.  A simple 
elastic  bottle  with  ivory  or  gum-elastic  pipe, 
which  has  superseded  the  old  bag  and  pipe.  2. 
An  india-rubber  bottle  with  flexible  tube  at 
either  end  and  double  action.  3.  An  ordinary 
piston  syringe,  worked  by  the  hand,  which  is 
either  simple,  or  provided  with  a double  action, 
so  as  to  supply  a continuous  stream.  The  sim- 
plex enema  made  by  Messrs.  Arnold  is  very  con- 
venient ; the  piston  works  on  a spring,  and  re- 
quires no  packing.  4.  A French  instrument, 
known  as  the  irrigateur,  worked  by  a spring. 
5.  The  hydraulic  enema,  which  consists  of  a 
piece  of  india-rubber  tubing  about  sis  feet  long, 
furnished  with  an  ordinary  ivory  rectum-pipe  at 
the  one  end,  and  a metal  cone,  or  a screw  nozzle, 


ENEMA. 

at  the  other.  The  tube,  being  filled  with  the 
injection,  has  one  end  placed  i;.  the  containing 
reservoir,  or  is  connected  by  the  screw ; while 
the  pipe  at  the  other  end  is  introduced  into  the 
bowel.  The  vessel  supplying  the  injection  being 
placed  on  an  elevation,  the  liquid  gravitates  into 
the  bowel,  filling  the  large  intestine.  When  it 
is  desirable  to  inject  a large  quantity  the  patient 
should  lie  first  on  the  left  side,  then  on  the  back, 
and  lastly  on  the  right  side,  to  promote  the  filling 
of  the  whole  intestine.  In  all  cases  care  should 
be  taken  to  prevent  the  injection  of  air  into  the 
bowel,  and  also  to  ascertain  that  the  nozzle  of 
the  injecting  pipe  is  free  in  the  rectum,  not 
thrust  against  the  sacrum,  or  into  a hard  fecal 
mass. 

Varieties  and  Hses. — The  chief  varieties  and 
uses  of  enemata,  are  as  follows  : — 

1.  Anthelmintic  Enemata.  — To  cure  thread- 
worms injections  of  salt  and  water,  or  lime-water, 
or  from  two  to  four  drachms  of  spirits  of  turpen- 
tine diffused  by  yolk  of  egg  in  four  ounces  of 
water  are  serviceable.  The  enema  of  aloes  or  of 
assafoetida  may  also  he  employed  in  the  small 
quantity  just  named. 

2.  Antispasmodic  Enemata. — Puerperal 
convulsions  have  been  relieved  by  the  in- 
jection of  half  a drachm  or  more  of  chloral 
hydrate.  Injections  of  assafcetida  or  of  rue 
are  also  given.  Injections  of  warm  water 
with  5ij  or  5iij  of  sulphuric  ether  have  some- 
times relieved  spasmodic  invagination  of  the 
bowels.  When  the  intestine  is  tympanitic  and 
distended,  the  enema  terebinthinae  acts  well  as  a 
stimulant  and  carminative. 

3.  Astringent  Enemata.— These  are  used 
either  to  check  diarrhoea,  to  arrest  luemorrhage, 
or  to  cure  ulceration  and  mucous  discharges. 
For  the  first  of  these  purposes  the  enema  opii  is 
valuable.  In  cases  of  haemorrhage  from  tho 
bowels,  as  well  as  from  the  womb,  injections  of 
ice-cold  water  are  frequently  used.  Ulceration 
with  mucous  discharge  is  often  successfully 
treated  by  enemata  of  nitrate  of  silver  (five 
grains  to  one  pint  of  distilled  water),  of  sulphate 
of  zinc  or  alum  (one  or  two  grains  to  the  ounce 
of  water),  or  of  sulphate  of  copper  (one  grain  to 
the  ounce  of  water). 

4.  Emollient  Enemata. — Demulcents,  such 
as  decoctions  of  starch,  linseed,  or  barley,  or 
pure  linseed  oil,  are  at  times  used  with  the  object 
of  imparting  nourishment  to  the  system,  and  of 
soothing  an  irritable  mucous  membrane. 

In  dysentery,  from  four  to  six  pints  of  warm 
water,  or  of  milk  and  water,  havo  been  injected 
as  an  internal  fomentation. 

5.  Nutrient  Enemata. — In  eases  of  ex- 
haustion enemata  of  beef-tea  and  eggs  beaten 
up  are  used  ; about  four  or  six  ounces  should  be 
given  at  once.  Should  the  rectum  become  irri- 
table, the  irritability  may  be  often  lessened  by 
adding  a few  drops  of  laudanum  to  each  enema. 
Defibrinated  blood,  in  its  recent  or  dried  form, 
has  lately  been  recommended  as  a material  fi  r 
nutrient  enemata  (see  paper  by  Dr.  Sansom  on 
Supplementary  Alimentation,  Lance',  1 SSI,  vol.  i. 
p.  288).  The  digestion  and  assimilation  of  nu- 
trient enemata  maybe  facilitated  by  the  addition 
of  preparations  of  pancreas  and  pepsine.  See 
Peptonised  Food,  page  111G. 


ENEMA. 

Injections  of  brandy  and  ■water,  or  beef  tea 
and  brandy,  bare  been  given  with  benefit  in 
(jrostration  from  uterine  haemorrhage. 

6.  Sedative  Enemata. — These  are  often  em- 
ployed in  painful  affections  of  the  rectum  and 
bladder.  The  enema  opii,  containing  half  a 
drachm  to  a drachm  of  tincture  of  opium,  is 
well  suited.  In  spasm  of  the  bowels  and  in 
hernia  the  enema  tabaci  may  be  resorted  to,  but 
it  may  produce  faintness  and  collapse.  An 
infusion  of  twelve  grains  of  dried  belladonna  leaf 
in  six  ounces  of  hot  water  is  also  used  with 
advantage. 

7.  Purgative  Enemata. — These  are  used  to 
overcome  constipation.  For  this  purpose — in  the 
case  of  an  adult — from  one  to  two  pints  of  fluid 
must  be  slowly  pumped  into  the  bowel.  If  the 
process  be  conducted  gradually,  stopping  oc- 
casionally and  making  pressure  on  the  anus  if 
the  injection  threaten  to  come  away,  as  much 
as  four  or  five  pints  can  be  got  into  the  bowel. 
The  injection  should  be  retained  as  long  as 
possible,  as  thus  a complete  evacuation  is  in* 
sured.  As  a general  rule  about  a pint  of  liquid 
is  enough  for  an  adult ; for  an  infant  an  ounce  ; 
for  a child  of  four  years,  four  to  six  ounces. 

Composition. — Soap  and  water,  gruel  with  olive 
oil,  castor  oil,  and  sometimes  oil  alone,  may  be 
used.  The  enema  magnesiae  sulphatis  contains 
one  ounce  of  epsom  salts,  and  is  an  efficient 
purgative.  Enema  aloes  is  also  recognised.  In 
cases  of  intestinal  obstruction  the  introduction 
of  a large  volume  of  soap  and  water — with  oil, 
perhaps,  added — by  means  of  the  gravitation- 
tube,  may  be  had  recourse  to  with  advantage. 
Obstruction  due  to  impacted  feces  generally 
yields  to  this  method  of  treatment. 

The  frequent  use  of  very  large  injections  is 
undesirable,  lest  undue  distension  result.  The 
frequent  use  of  injections  washes  away  the  mucus 
designed  to  lubricate  the  bowel. 

John  C.  Thoeowgood. 

ENGADINE,  UPPER, in  Switzerland. — 
A bracing  mountain  climate.  Elevation  of 
valley  5,000  to  6,000  feet.  Season,  June  to 
September.  See  Climate,  Treatment  of  Disease 

by- 

EUGHIEU,  in  France. — Sulphur  waters. 
See  Mineeal  Waters. 

ENGLISH  CHOLERA. — A synonym  for 
simple  cholera  or  choleraic  diarrhoea.  See 
Choleraic  Diarehcf.a. 

ENGORGEMENT.— Overloading  of  the 
vessels,  or  of  the  heart,  with  blood.  A synonym 
for  congestion.  See  Circulation,  Disorders  of. 

ENTERAL  GIA  (evrepov,  the  intestine, 
and  &\yos,  pain). — Synon.  : Enterodynia;  JVeu- 
ralgia  mesentcrica  vcl  meseraica  ; Colic. 

The  terms  enteralgia  and  colic — generally  re- 
garded as  synonymous — include  all  forms  and 
degrees  of  paroxysmal  intestinal  pain  in  cases 
where  there  is  no  febrile  disturbance.  Enter- 
aigia,  implying  more  especially  the  neuralgic 
nature  of  the  sensori-motor  disturbance,  is  some- 
times preferred,  as  by  those  who  hold  that  colic 
proper — of  which  lead-colic  is  a typical  example 
as  disti  ngui shed  from  symptomati  c coli  cky  pains — 


ENTOZOA.  Li  L- 

I is  a visceral  neuralgia.  It  is  likewise  frequently 
applied  to  colic  occurring  in  neurotic,  asthenic, 
anaemic,  or  gouty  subjects,  even  when  there  is 
a local  exciting  cause,  such  as  flatus,  retained 
faeces,  &c. ; and  to  conditions  in  which  pain 
predominates  over  spasm.  The  clinical  features 
of  enteralgia  are,  however,  indistinguishable  from 
those  of  colic;  a similar  local  disturbance,  ac- 
cording to  its  intensity,  is  reflected  by  the  nerves 
to  the  heart  and  the  peripheral  arteries — the 
action  of  the  former  becoming  slow  and  feeble, 
and  the  latter  contracting,  hence  arising  th- 
small,  infrequent,  tense  pulse,  the  cool  pale  skin, 
and  the  other  signs  of  collapse  which  mark  the 
distant  effects  of  colic;  and,  as  in  this  disorder, 
the  termination  of  the  attack  may  be  sudden, 
perhaps  following  the  expulsion  of  flatus  or 
feces — a free  perspiration,  a copious  flow  of  pale 
urine,  the  menstrual  or  lochial  or  other  discharge, 
or  a fit  of  the  gout. 

Treatment.  — The  main  indications  in  the 
treatment  of  enteralgia  are  to  endeavour  to  re- 
move any  cause  of  the  pain  ; and  to  administer 
opium  or  other  anodynes  for  the  relief  of  the 
suffering.  See  Colic,  Intestinal. 

George  Oliver. 

ENTERIC  FEVER.  — A synonym  for 
typhoid  fever.  Sec  Typhoid  Fever. 

ENTERITIS  (evrepor,  a bowel). — Inflam- 
mation of  the  intestines.  See  Intestines,  Dis- 
eases of. 

ENTEROCELE  (evrepov,  a bowel,  anil 
ktjXti,  a tumour). — A hernia  containing  a por- 
tion of  bowel.  See  Hernia. 

ENTOPHYTE  (cribs,  within,  and  (puror,  a 
plant). — A plant  parasitic  in  any  part  of  the  body. 
Entophytic  Diseases  are  diseases  that  are  sup- 
posed to  depend  upon  the  growth  of  such  plants, 
as,  for  example,  fungus-foot.  See  Fungus  Foot  of 
India. 

ENTOZOA  (eVTOj,  within,  and  (jcDoy,  an 
animal). — This  term  not  only  embraces  ail  the 
animal  parasites  coming  under  the  category  of 
‘worms,’  or  ‘intestinal  worms,’  but  also  a great 
variety  of  creatures  which  take  up  their  resi- 
dence in  the  soft  and  hard  tissues  as  well  as  in 
the  cavity  of  the  digestive  organs  of  their  human 
and  animal  bearers.  Under  the  article  Para- 
sites is  given  a definition  which  will  probably 
be  found  more  comprehensive  than  any  hitherto 
offered.  In  this  place,  with  the  double  view  cf 
facilitating  reference  and  supplying  an  epitome 
of  the  whole  subject,  a complete  alphabetical 
list  of  the  separate  headings  under  which  the  en- 
tozoa  are  discussed  in  the  body  of  this  work  is 
appended.  The  articles  stand  as  follows:  — 
Acephalocysts ; Ascarides;  Bilharzia;  Bladder- 
worms  ; Bothrioccphalus  ; Chigoe  (Sandworm) ; 
Cysticercus ; Demodex : Distoma ; Dracuncu- 
lus;  Echinococcus;  Echinorhynchus;  Fasciola; 
Filaria;  Filaria  Sanguinis-Hominis  ; Fluke; 
Guinea-worm;  Haematozoa  (Blood- worms);  Hel- 
minths; Hydatids;  Intestinal  worms;  Lum- 
bricus  ; Measle ; CEstrus  (Buts,  Maggots,  Insect 
Parasites,  Gadfly);  Oxyuris;  Parasites;  Pen 
tastoma*;  Round-worms;  Sclerostoma (Anchylos- 
tomum,  Dochmius) ; Seat-worm  ; Taenia ; Tape- 


140  ENTOZOA. 

worm;  Thread-worm;  Trichina;  Trichinosis; 
ITiehocephalus ; Vermes ; Whip- worm. 

The  Ectozoa  are  noticed  under  the  article 
Epizoa.  T.  S.  Cobbold. 

EWTOZOON  FOLLICULOEUM.  — A 
synonym  of  the  animalcule  of  the  follicles  of 
the  skin,  otherwise  named  acarus  (Simon),  demo- 
dex  (Owen),  and  steatozoon  folliculorum  (Eras- 
mus Wilson).  See  Acarus  and  Demodex. 

ENTBOPIOH  (eV,  in,  and  rpcVoi,  I turn). — 
A morbid  condition  in  which  the  eyelid  is  in- 
verted, so  that  its  free  margin  is  directed 
towards  the  oye.  See  Eye  and  its  Appendages, 
Diseases  of. 

EHtTB.ES.IS  (eV,  in,  and  dvpeui,  I pass  the 
urine). — Involuntary  discharge  or  incontinence 
of  urine.  See  Micturition,  Disorders  of. 

EPHELIS  (<hrl,  dneto,  andi)A.ios,  the  sun). — 
Synon.  : Sunburn  ; Fr.  Ephelide ; Ger.  Sonnen- 
flecken. — This  word  is  applied  to  pigmentary  dis- 
coloration of  the  skin,  of  a brown,  grey,  or  black 
colour,  resulting  from  the  stimulus  of  light  and 
heat,  as  of  the  sun’s  rays,  or  scorching  by  fire. 
Two  principal  varieties  of  the  affection  have  been 
noted,  namely,  Ephelis  solaria,  and  Ephelis  ig- 
nealis.  See  Pigmentary  Skin-Diseases. 

Erasmus  Wilson. 

EPHEMERAL  FEVER  (e<p',  upon,  and 
r/yipa,  a day). — A mild  form  of  milk-fever,  so 
called  on  account  of  the  rapidity  with  which  it 
subsides,  lasting  not  more  than  a day.  See  Milk- 
Fever. 

EPHIDROSIS  (eVl,  upon,  and  iSpioi,  I 
sweat). — A term  signifying  a state  of  sweating, 
end  synonymous  with  Idrosis.  See  Perspiration, 
Disorders  of. 

EPIDEMIC  ( epidemicus , affecting  the  people  ; 
from  eirl,  upon,  and  Sripos,  a people). — The  word 
epidemic  is  used  in  two  senses  by  medical  writers 
and  by  medical  men,  namely,  (1)  in  a general 
sense,  and  (2)  in  a technical  sense. 

As  a general  term,  the  word  signifies  ‘ com- 
mon to,  or  affecting,  a whole  people,  or  a great 
number  in  a community;  prevalent;  general.’ 
( Webster’s  Dictionary.)  It  is  in  this  sense  that 
the  word  is  used  when  it  is  applied  to  mental, 
moral,  and  social  phenomena,  as,  for  example, 
when  we  speak  or  write  of  ‘ epidemic  suicide,’ 

‘ epidemic  folly.’  This  employment  of  the  word 
is  consistent  with  received  literary  practice. 
Thus  we  read,  ‘ There  was  a time  when  wit  was 
epidemic.'  ( Atheneeum .)  Again,  M.  Littre,  writing 
to  the  Temps : — 1 It  argues  great  confidence  in 
oneself  and  one’s  own  enlightenment  to  treat 
with  haughty  disdain,  and  without  reserving  any 
compromise,  the  opinion  of  so  many  citizens,  and 
to  regard  it  as  a case  of  epidemic  aberration .’ 

As  a technical  term  having  reference  to  disease, 
the  word  epidemic  has  several  different  mean- 
ings attached  to  it.  All  these  meanings  include 
the  notion  of  general  prevalence  among  a com- 
munity or  a people,  but  some  of  them  would  go 
on,  beyond  what  etymology  justifies,  to  attach  a 
peculiar  hypothetical  or  theoretical  conception 
to  the  term.  Thus  (a)  Mayne  restricts  the  term 
to  diseases  which  are  contagious,  making  con- 
tagion the  essence  of  epidemicity,  as  lie  would 
phrase  it ; ( b)  Dunglison  implies  by  the  term  a 


EPIDEMIC. 

particular  constitution  of  the  air  (‘  constiiutio 
aeris,  cr  condition  of  the  atmosphere ’) ; (c)  other 
authoritative  writers  use  the  term  as  signifying 
a widespread  cause,  telluric,  atmospheric,  cosmic, 
as  the  case  may  be,  acting  at  the  same  moment 
of  time  on  many  individuals,  or  as  something 
occult,  regarding  which  speculation  is  vain,  and 
which  they  designate  epidemic  constitution  or 
epidemic  ivjlucnce. 

The  foregoing  technical  significations  attached 
to  the  word  epidemic  are  not  less  misleading 
than  insufficient.  Mayne's  definition  imposes  an 
arbitrary  limitation  upon  the  meaning  of  the 
word,  while  it  involves  but  a partial  notion  of  the 
phenomena  of  epidemic  prevalence  of  contagious 
diseases.  Dunglison’s  definition  does  not  rest 
upon  a scientific  foundation,  and  its  phraseology, 
derived  from  a period  when  medicine  was  still 
hampered  with  semi-mystical  speculations,  can- 
not well  be  dispossessed  of  the  vague,  traditional 
meanings  which  adhere  to  the  word  ‘constitu- 
tion.’ Other  technical  definitions  (if  that  can 
be  called  a definition  which  makes  obscure  what 
should  be  rendered  clear)  rest  on  mere  assump- 
tions or  relegate  the  term  to  the  incompre- 
hensible and  insoluble.  Of  these  last-named 
definitions  Leon  Colin  has  recently  said : — 
‘ They  signify  implicitly  a common  cause,  ap- 
parently indecomposable,  to  which  individuals 
are  not  exposed  successively  bnt  simultaneously 
....  a something  isolated,  impersonal,  inac- 
cessible to  reason,  detached  from  the  disease 
itself,  the  epidemic  genius  [constitution,  in- 
fluence] ....  a creative  force  of  the  different 
epidemic  affections,  compelling,  directing,  ex- 
tinguishing them.’ 

The  promiscuous  use  of  the  word  epidemic  in 
medical  literature  and  medical  talk,  and  the 
different  irreconcileable  significations  attached  to 
it  as  a technical  term,  have  been,  and  still  con- 
tinue to  he,  sources  of  almost  hopeless  confusion 
in  treating  of  diseases  in  respect  to  which  the 
phenomenon  of  (etymologically)  epidemic  pre- 
valence is  observed.  It  is  not  difficult  to  appre- 
hend how  this  has  come  about.  The  diseases  iu 
question  (the  morbi  populares  of  some  writers) 
include  among  their  number  plague,  the  erup- 
tive and  continued  fevers,  influenza,  malignant 
cholera,  &c.  ‘ They  have  the  peculiar  character 

of  attacking  at  intervals  great  numbers  of  people 
within  a short  period  of  time;  they  distinguish 
one  country  from  another,  one  year  from  another; 
they  have  proved  epochs  in  chronology;  and, 
as  Niebuhr  has  shown,  have  influenced  not  only 
the  fate  of  cities,  such  as  Athens  and  Florence, 
but  of  empires ; they  decimate  armies,  disable 
fleets  ; they  take  the  lives  of  criminals  that 
justice  has  not  condemned  ; they  redouble  the 
dangers  of  crowded  hospitals;  they  infest  the 
habitations  of  the  poor,  and  strike  the  artizan 
in  his  strength  down  from  comfort  into  helpless 
poverty ; they  carry  away  the  infant  from  the 
mother's  breast,  and  the  old  man  at  the  end  of 
life ; but  their  direst  eruptions  are  excessively 
fatal  to  men  in  the  prime  and  vigour  of  age.' 
(Wm.  Farr.)  Exercising  at  all  times  in  their 
greater  and  more  fatal  prevalence  the  pro 
foundest  influence  over  the  mind,  as  well  o/ 
the  people  generally  as  of  the  medical  pro- 
fession, these  diseases,  partly  from  the  terror 


EPIDEMIC. 


.hey  inspire,  partly  from  the  extreme  com- 
plexity of  the  phenomena  they  display,  have 
formed  a never-ceasing  subject  of  the  wildest 
speculation.  No  part  of  medicine  has  retained 
so  much  of  the  semi-mystical  teachings  of  the 
older  physicians  as  that  which  relates  to  epi- 
demics, and  general  history  has  contributed 
with  medical  history  to  propagate  in  regard 
to  epidemics  that  habit  of  thought  which  refers 
the  unknown  to  the  occult — using  the  latter 
term  in  the  sense  in  which  it  is  applied  with 
regard  to  the  imaginary  sciences  of  the  Middle 
Ages.  Much  of  the  speculation  as  to  epidemics 
which  passes  current  for  science  at  the  present 
day  is  in  reality  an  unsuspected  continuation 
of  the  mystical  teachings  of  earlier  medicine : 
magnetism,  or  electricity,  for  example,  taking 
the  place  of  Saturn  or  Mercury  in  the  scheme 
of  causation.  The  terminology  is  modernised, 
but  the  underlying  conception  remains  the 
same.  Again,  the  so-called  'precursors1  of  epi- 
demics which  still  find  a place  in  treatises  on 
medicine  are  the  relics  of  the  doctrine  of  por- 
tents of  the  Middle  Ages.  They  rest  on  the 
assumption  of  an  epidemic  being  determined  by 
gome  common  extra-mundane  or  intra-mundane 
cause,  of  which  it  is  but  one  of  several  effects. 
The  celestial  ‘ portents,’  such  as  comets  and 
meteors,  and  the  more  manifest  telluric  1 por- 
tents,’ such  as  earthquakes  and  volcanic  erup- 
tions, have  been  discarded ; but  the  ‘ portents  ’ 
derived  from  exceptional  developments  of  insect 
life,  from  murrain,  from  unusual  prevalence  of 
certain  diseases,  and  from  remarkable  perturba- 
tions of  the  weather,  are  retained  under  the 
denomination  of  • precursors.’  For  example,  the 
earlier  epidemics  of  malignant  cholera  which 
visited  Europe  were  believed  to  have  been 
heralded  by  an  unusual  prevalence  of  ‘ fevers  ’ 
and  of  diarrhceal  affections.  The  epidemic  of 
1865-66  gave  an  excellent  opportunity  of  study- 
ing the  facts  bearing  on  this  question.  Europe 
was  taken  by  surprise  when  cholera  appeared  in 
I860,  on  the  south  coast  of  the  Mediterranean, 
at  Alexandria,  and  began  thence  to  extend  ra- 
pidly to  the  southern  and  eastern  shores  of  that 
sea.  It  was  not,  indeed,  until  the  disease  had 
effected  a lodgment  in  several  parts  of  the  Con- 
tinent that  the  attention  of  governments  and  the 
public  with  regard  to  it  was  fully  aroused.  No 
change  of  the  public  health  in  the  several  places 
visited  by  the  epidemic  had  occurred  of  such  a 
nature  as  to  givo  rise  to  any,  even  the  least  sus- 
picion, of  impending  pestilence.  Moreover,  not- 
withstanding the  prevalence  of  steppe  murrain 
and  of  cerebro-spinal  fever  in  Northern  Europe 
at  the  beginning  of  1865,  there  was  nothing  to 
suggest  (indeed  it  was  not  suggested)  that  these 
phenomena  were  ‘ precursors  ’ of  the  coming 
epidemic  of  cholera,  or  of  the  extension  of 
yellow  fever  to  the  shores  of  England  the  same 
year.  In  fact,  the  different  occurrences  were 
parts  of  contemporaneous  rather  than  successive 
phenomena.  The  condition  of  the  public  health 
preceding  the  appearance  of  cholera  in  England, 
and  especially  in  respect  to  diarrhceal  antece- 
dents, was  made  the  subject  of  careful  study 
by  the  late  Professor  Parkes  and  others.  These 
observers  failed  to  obtain  any  inkling  of  a 
change  in  the  public  health  which  could  be  rc- 


441 

garded  as  presaging  pestilence — of  the  existence, 
in  short,  of  any  so-called  ‘ epidemic  constitution.’ 
It  is  true  that  John  Sutherland  had  described 
an  increase  of  ‘ fevers  ’ and  diarrhceal  disease  in 
Malta,  as  preceding  the  appearance  of  cholera 
there,  in  June  1S65,  observing  that: — ‘These 
facts  are  sufficient  to  show  that  long  hefora 
cholera  began  to  come  towards  the  north-west, 
there  were  indications  of  a changed  condition  of 
the  public  health  in  Malta  ; ’ ancl  after  giving  an 
account  of  two  groups  of  choleraic  cases  which 
occurred  in  May,  he  adds,  ‘ It  appears  to  me 
scarcely  possible  to  escape  from  the  conclusion 
that  long  before  cholera  appeared  in  Malta,  pos- 
sibly before  the  first  outbreak  in  Arabia,  the 
earliest  wave  of  the  coming  epidemic  had  passed 
over  those  islands.’  But  while,  according  to  Dr. 
Sutherland,  the  coming  epidemic  was  thus  clearly 
foreshadowed  in  Malta,  no  change  in  the  public 
health  presaged  its  appearance  in  Gibraltar  in 
July.  The  absence  of  all  foreshadowing  of  the 
epidemic  at  Gibraltar  can  hardly  be  reconciled 
with  the  suggested  presence  of  such  foreshadow- 
ing at  Malta.  The  facts  which  have  been  in- 
terpreted as  presaging  the  appearance  of  cholera 
in  the  latter  island  are,  indeed,  to  be  regarded 
as  coincidental  rather  than  related.  It  is  true, 
also,  that  MAI.  Didiot  and  Gues  have  en- 
deavoured to  show  that  prior  to  the  appearance 
of  cholera  at  Alexandria  in  1S65,  choleraic  dis- 
ease existed  in  Marseilles,  and  that  the  outbreak 
of  the  epidemic  in  the  latter  town  was  preceded 
hv  ‘ une  constitution  medieale  cholerique.’  The 
evidence  they  advance  in  support  of  their  con- 
clusions simply  shows  that  deaths  from  infantile 
cholera,  which,  as  they  properly  remark,  is  ‘ a la 
verite,  frequente  a Marseille,’  and  from  so- 
called  ‘ sporadic  ’ cholera,  are  apt  to  occur  in 
Marseilles  during  the  months  of  .May  and  June, 
as  perhaps  in  every  city  and  town  of  southern 
and  central  Europe. 

Another  illustration  to  the  same  effect  as  the 
above,  in  regard  to  the  1 precursors  ’ of  epi- 
demics, is  furnished  by  the  history  of  the 
small-pox  epidemic  of  1869-73,  the  greatest 
epidemic  of  this  disease  in  recent  times — a true 
pandemic  (irdi/Srj.uos,  from  irai>,  all,  and  Sijfios,  the 
people)  extension  of  the  malady.  The  acutost 
observers  were  taken  by  surprise  with  the  ma- 
lignity and  diffusibility  of  the  disease  during 
the  epidemic — phenomena  wholly  unforeseen. 
Here,  again,  the  study  of  the  diseases  preceding 
or  accompanying  the  epidemic  yields  no  facts  of 
variation  in  their  prevalence,  from  which  the 
approach  of  a great  epidemic  might  have  been 
inferred,  nor  give  any  hint  that  they  were  depen- 
dent with  it  on  some  common  cause. 

There  were  concurrent  phenomena  of  disease 
during  both  epidemics,  hut  they  were  concur- 
rences of  certain  diseases  existing  at  the  same 
time  among  the  population  affected  by  the  great 
epidemic,  and  some  of  them  probably  Jiaving 
certain  secondary  elements  of  causation  in  com- 
mon. This  is  a different  question  to  that  of  an 
assumed  "epidemic  influence’  or  ‘epidemic  con- 
stitution.’ The  subject  of  the  concurrence  of 
epidemics  is  a new  field  of  investigation,  which 
has  lately  been  opened  by  an  arithmetical  study 
of  George  Buchanan's,  relating  to  epidemics 
iu  numerous  extra-metropolitan  registration  sub- 


442  EPIDEMIC. 

districts  in  England.  This  study  -was  directed 
to  ascertain- — as  necessarily  introductory  to  a 
statistical  investigation  regarding  community  of 
causation  or  mutual  antagonism  of  various  epi- 
demics— the  arithmetical  probability  of  their 
concurring  as  a mere  matter  of  chance.  The 
data  used  were  taken  from  a particular  quarterly 
return  of  the  Registrar- General,  and  they  ex- 
tended to  946  occurrences  of  epidemics  (small- 
pox, measles,  scarlet-fever,  diphtheria,  whoop- 
ing-cough, fevers,  and  diarrhoea  and  simple 
cholera)  in  1,490  districts.  The  result  showed 
a good  deal  of  general  correspondence  between 
the  calculated  number  of  concurrences  and  the 
actually  observed  number,  but  with  departures, 
of  more  or  less  magnitude,  of  the  actual  from 
the  calculated  degree  of  concurrence,  which  de- 
serve to  be  followed  up  by  further  investigation. 
The  departures  were  shown  in  an  excessive  fre- 
quency of  the  concurrence  of  measles  with  the 
other  epidemics,  of  diarrhoea  with  all  other  epi- 
demics except  small-pox,  and  of  scarlet-fever 
with  the  ‘fever’  of  the  Registrar-General.  On 
the  other  hand,  it  is  of  interest  to  observe  that 
there  was  an  absence  of  any  notable  excess  of 
frequency  of  concurrence  between  scarlet-fever 
and  diphtheria,  or  between  scarlet-fever  and 
whooping-cough. 

In  view  of  the  extreme  looseness  with  which 
the  word  epidemic  is  used  in  medicine,  some- 
times simply  as  a descriptive  term,  sometimes 
as  a technical  or  quasi-technical  term  involving 
various  hypothetical  and  theoretical  conceptions 
inconsistent  with  each  other,  and  sometimes  as 
implying  an  occult  influence,  it  would  be  well  if 
it  could  be  discarded  from  medical  literature 
and  language.  Epidemic,  in  its  present  medical 
uses,  is  an  instance  of  words  which,  as  E icon 
says,  when  writing  of  the  effects  exercised  by  a 
bad  and  inapt  formation  of  words  on  the  human 
mind, 1 force  the  understanding,  throw  everything 
into  confusion,  and  lead  mankind  into  vain  and 
innumerable  controversies  ’ (Nov.  Org.  App.  43). 
But  the  retention  of  the  word,  from  its  long  and 
familiar  usage,  is  practically  a necessity  in 
medicine;  moreover,  it  would  bo  difficult  if  not 
impossible  to  find  a substitute  which,  if  the 
word  he  used  in  its  ordinary  signification,  would 
supply  its  place. 

It  is  suggested  here  that  the  technical  mean- 
ing of  the  word  epidemic  should  he  assimilated 
to  tho  common  meaning;  or,  more  accurately, 
that  the  technical  meanings  now  attached  to  the 
word  should  he  abandoned,  and  the  word  used 
in  medicine  in  the  same  sense  as  in  general 
literature  and  in  ordinary  converse;  that  is 
to  say,  as  a merely  quantitative  term  appli- 
cable to  particular  phenomena,  whether  patho- 
logical, mental,  or  social,  in  so  far  as  they  are 
‘ common  to  a whole  people,  or  to  a great  number 
in  a community ; ’ or  in  a word  are  ‘ prevalent  ’ 
or  ‘general.’  In  this  way  not  only  would  the  con- 
fusion arising  from  the  present  medical  uses  of 
the  word  be  got  rid  of,  but  the  scientific  study 
of  epidemic  phenomena  would  he  facilitated  iu 
the  only  direction  which  gives  promise  of  suc- 
cessful issue.  As  Leon  Colin  has  aptly  written  ; 
— ‘ It  is  the  disease  which  constitutes  the  epi- 
demic, not  the  epidemic  the  disease.  The  evil 
always  remains  the  same,  the  number  of  affected 


EPIDEMIC  MENINGITIS. 

alone  being  increased.’  The  medical  study  ,! 
epidemics  is  essentially  a study  of  the  indivi- 
dual diseases  which  are  apt  to  become  epidemic, 
and  not,  as  has  been  too  commonly  the  ease 
hitherto,  of  some  figment  of  the  imagination 
(epidemic  constitution,  or  influence,  or  genius), 
apart  from  the  diseases.  It  is  only  in  propor- 
tion as  researches  have  been  directed  to  particu- 
lar diseases  liable  to  become  epidemic,  and  to 
the  conditions  under  which  they  prevailed  epide- 
mically, that  recent  advances  in  our  knowledge 
of  epidemics  have  been  made.  In  this  country 
the  two  most  important  events  which  have  oc- 
curred in  this  connection  of  late  years  were  the 
discrimination  of  typhus  from  typhoid , by  A.  P. 
Stewart  and  Wm.  Jenner,  and  the  researches  on 
the  typhus  of  horned  cattle  (steppe-murrain,  cat- 
tle-plague), promoted  by  the  Royal  Commission 
of  1865-66,  on  Cattle-Plague.  The  discrimina- 
tion of  typhus  from  typhoid  proved  that  the  volu- 
minous speculations  which  to  that  time  wero  cur- 
rent on  the  epidemiology  of  the  continued  fevers 
of  this  country,  then  regarded  as  hut  one  disease 
presenting  several  varieties,  were  for  the  most 
part  meaningless  verbiage,  by  showing  that  the 
two  most  common  forms  of  fever  were  distinct 
diseases  clinically,  pathologically,  and  setiolo- 
gically.  This  discovery  proved  to  he  the  in- 
auguration of  a true  method  of  investigation 
concerning  epidemics,  by  making  evident  that 
epidemic  phenomena  did  not  admit  of  accurate 
study,  except  in  so  far  as  it  was  based  upon  a 
just  discrimination  of  the  diseases  manifesting 
them,  and  upon  their  clinical  and  pathological 
histories.  The  same  lesson  was  taught,  not  less 
clearly,  although  in  another  fashion.  by  the  re- 
searches promoted  by  the  Royal  Commission  on 
Cattle  Plague,  with  which  the  names  of  Lionel 
Beale  and  Burdon  Sanderson  are  especially  con- 
nected. These  researches  demonstrated  the 
essentially  infectious  nature  of  the  malady,  and 
that  its  prevalence  was  dependent  upon  the  dis- 
semination of  the  infection,  directly  or  indi- 
rectly, from  animals  sick  of  the  disease  to  the 
healthy.  It  was  shown,  indeed,  in  the  patho- 
logical laboratory,  that,  preconceived  doctrines  of 
some  occult  epidemic  influence  which  had  been 
submitted  to  the  Commission  as  determining  the 
prevalence  of  the  cattle-plague  had  no  existence 
in  fact  when  the  disease  was  subjected  to  ex- 
perimental study,  and  that  its  conditions  of  pre- 
valence were  fully  within  human  control.  These 
researches  proved  the  starting-point  of  those  im- 
portant investigations  on  the  intimate  pathology 
of  contagion  carried  out  by  Burdon  Sanderson  and 
Klein,  for  the  Privy  Council,  under  the  direction 
of  John  Simon,  and  to  which  Wm.  Roberts  and 
others  have  independently  contributed  so  largely 
— investigations  which  promise  speedily  to  revo- 
lutionise our  knowledge  of  the  intimate  pathology 
of  infectious  diseases.  It  is  interestiwr  to  note 
that  the  Royal  Commission  on  Cattle-Plague  in- 
cluded the  following  medical  members: — Richard 
Quain  (M.D.),  H.  Bence  Jones,  E.  A.  Parkes,  T. 
Wormald,  and  B.  Ceely.  See  also  Pk.riodicitv 
ix  Disease.  J.  Nettex  Radcliffe. 

EPIDEMIC  CEREBRO-SPINAL  ME- 
NINGITIS.— A synonym  for  cerebro-spir.ai 
fever.  See  Cerebeo-spixai.  Fevek. 


EPIDEMICS,  OCCURRENCE  OF. 

EPIDEMICS,  Occurrence  of.  See  Perio- 
dicity in  Disease. 

EPIDERMIS,  Diseases  of.  See  Skin, 
Diseases  of. 

EPIDERMOPHYTON  (eVl,  upon;  Sep^a, 
the  skin  ; and  (purer,  a plant). — The  name  of  the 
epiphyte,  or  parasitic  fungus,  of  phytosis  versi- 
color, also  called  Microsporon.  See  Epiphyta. 

EPIDIDYMITIS  (eVl,  upon,  and  S lSu/jos,  a 
testicle). — Inflammation  of  the  epididymis.  See 
Testes,  Diseases  of. 

EPIGASTRIC  REGION. — This  region  is 
situated  at  the  upper  and  central  part  of  the 
abdomen,  just  below  the  ensiform  cartilage,  and 
between  the  sloping  margins  of  the  thorax  down 
to  the  level  of  the  ninth  cartilage,  corresponding 
to  what  is  popularly  known  as  the  ‘ pit  of  the 
stomach.’  The  structures  within  the  abdominal 
cavity  which  normally  occupy  the  epigastrium 
are  the  greater  part  of  the  stomach,  a small 
portion  of  the  liver,  and  more  deeply  a part  of 
the  pancreas,  the  aorta  giving  off  thecceliac  axis 
and  superior  mesenteric  branch,  the  vena  cava 
inferior,  the  veins  forming  the  commencement  of 
the  portal  vein,  the  receptaculum  chyli,  and  the 
solar  plexus. 

Clinical  Investigation. — Clinically,  it  will 
be  found  that  patients  frequently  complain  of 
abnormal  sensations  specially  referred  to  the 
epigastrium.  These  are  generally  associated  with 
the  stomach,  and  may  merely  amount  to  a sense 
of  discomfort,  fulness,  or  tightness ; or  to  actual 
pain  of  varying  character,  more  or  less  severe 
according  to  the  condition  upon  which  it  de- 
pends, and  often  much  influenced  by  the  inges- 
tion of  food.  Sensations  of  trembling,  throbbing, 
or  sinking  in  the  pit  of  the  stomach  are  also 
of  common  occurrence,  especially  in  females. 
These  are  often  merely  of  a nervous  character. 
In  some  cases  there  is  evident  tenderness,  either 
over  the  entire  epigastrium  or  in  some  limited 
spot,  and  it  is  important  to  recognise  whether 
this  is  superficial  or  felt  more  or  less  deeply,  for 
it  may  be  connected  with  the  supierficial  struc- 
tures, the  peritoneum,  the  liver,  the  stomach, 
or  the  pancreas.  The  sensation  experienced  in 
connection  with  hunger  is  referred  mainly  to  the 
epigastrium,  and  it  may  be  of  a painful  cha- 
racter. Here  may  also  be  noticed  the  epigastric 
pain  termed  gastralgia  or  gastrodynia,  which 
is  usually  feit  chiefly  when  the  stomach  is 
empty,  being  relieved  by  taking  food.  A most 
unpleasant  sensation  at  the  pit  of  the  stomach 
accompanies  nausea,  which  may  be  of  a horrible 
but  indescribable  character;  while  violent  vomit- 
ing or  retching  causes  considerable  pain  or  aching 
in  this  region,  partly  associated  with  the  stomach, 
partly  with  the  abdominal  u'alls.  Heartburn  is 
another  sensation  which  seems  to  start  from  the 
epigastrium.  Sometimes  the  pain  is  situated 
deeply,  or  shoots  towards  the  back.  This  may 
depend  upon  disease  affecting  the  posterior  wall 
of  the  stomach,  pancreatic  disease,  aneurism,  or 
other  causes.  A sensation  of  tension  or  actual 
paiu  is  sometimes  experienced  just  below  the 
Dnsiform  cartilage  in  cases  where  the  diaphragm 
is  much  pressed  downwards,  as  from  extreme 


EPIGASTRIC  REGIO  N 4-13 

emphysema,  abundant  accumulation  of  fluid  or 
air  in  the  pleura,  or  extensive  per.oaalial  eliUsion. 
A deep  pain  is  not  uncommonly  "eferied  to  the 
epigastrium  in  cases  of  Addiucn’s  disease,  and 
also  in  those  of  pernicious  anaemia.  Probably 
this  is  connected  with  the  sympathetic  plexuses. 

Physical  examination  of  the  epigastric  region 
is  often  of  the  greatest  value,  ai  d important 
objective  signs  of  various  morbid  conditions  may 
thus  be  readily  recognised.  Of  course  organs 
wdiich  are  normally  confined  to  other  regions  may 
enlarge  so  as  to  extend  into  the  epigastrium,  or 
may  become  very  movable  and  consequently  be 
felt  in  this  region.  It  may,  moreover,  be  occu- 
pied, along  with  other  parts  of  the  abdomen,  by 
growths  or  accumulations  of  fluid.  The  objec- 
tive signs  and  conditions  which  are  more  espe- 
cially connected  with  the  epigastrium  may  be 
indicated  as  follows  : — 

1.  It  is  customary  to  apply  the  hand  over  the 
epigastrium  for  the  purpose  of  counting  the 
respirations,  if  these  cannot  be  reckoned  by 
merely  watching  the  patient  breathing. 

2.  Morbid  conditions  of  the  abdominal  walls 
may  be  confined  to  the  epigastric  region,  such  as 
an  abscess ; and  here  it  may  be  remarked  that  the 
recti  muscles  frequently  become  veiy  hard  and 
rigid  when  palpation  is  practised  over  this  part, 
and  so  might  be  in  danger  of  being  mistaken  for 
some  serious  lesion,  unless  care  wero  exercised 
in  the  examination. 

3.  Growths  connected  with  the  peritoneum, 
especially  the  great  omentum,  may  be  felt  chiefly 
or  entirely  in  the  epigastrium  in  some  instances. 

4.  Abnormal  states  of  the  stomach  are  neces- 
sarily revealed  mainly  by  corresponding  signs  in 
the  epigastrium.  Thus  there  may  be  evidence  of 
dilatation  of  this  organ  ; carcinomatous  infiltra- 
tion of  its  anterior  wall ; a localised  tumour  ; or 
of  some  accumulation  in  its  interior,  whether 
solid  or  liquid.  It  must  be  remarked,  however, 
that  the  stomach,  when  diseased,  frequently 
extends  into  other  regions  beyond  the  epigas- 
trium. 

5.  When  the  liver  is  the  seat  of  organic  disease, 
this  is  often  revealed  in  the  epigastric  region, 
usually  along  with  other  regions,  but  sometimes 
the  abnormal  physical  signs  are  noticed  specially 
in  this  part.  Thus  a cancerous  mass  may  present 
here,  or  a hydatid  tumour  or  hepatic  abscess  may 
tend  in  this  direction.  The  gall-bladder  has  also 
occasionally  been  found,  when  the  seat  of  some 
accumulation  or  of  malignant  disease,  to  have 
been  displaced  towards  the  epigastrium  and  be- 
come fixed  there. 

6.  Pulsation  is  not  uncommonly  felt  in  toe 
epigastrium.  When  situated  at  its  upper  part, 
just  below  the  ensiform  cartilage,  it  depends 
upon  the  heart,  usually  its  right  side,  being  duo 
either  to  shortness  of  the  sternum,  displacement 
of  the  heart,  or  enlargement  of  its  right  cavities. 
Very  often  a pulsation  is  felt,  and  sometimes  even 
seen,  due  to  a pulsating  aorta;  and  an  impulse 
from  this  vessel  may  be  transmitted  through  an 
enlarged  pancreas,  or  through  an  abscess  of  the 
liver,  of  which  the  writer  has  seen  a mprked 
example.  Occasionally  an  impulse  in  the  epi- 
gastrium is  connected  with  an  aneurism,  either  of 
the  aorta  or  of  one  of  its  branches.  A pulsation 
in  this  region  has  also  been  attributed  to  regur- 


844  EPIGASTRIC  REGION, 

gilation  of  Hood  from  the  right  auricle  into  the 
inferior  vena  cava  and  hepatic  vein,  in  cases  of 
tricuspid  incompetency.  A murmur  may  some- 
times be  heard  in  the  epigastrium.  Usually  this 
is  a conducted  cardiac  murmur,  but  occasionally 
it  depends  on  an  aneurism. 

Frederick  T.  Roberts. 

EPIGLOTTIS,  Diseases  of.  /Ste  Larynx, 
Diseases  of. 

EPILEPSY  (c-jnAa/ijSavw,  I seize  upon'. — 
Synon.  : Morbus  comitialis,  sctcer,  major , c$c. ; 
Er.  ftpilepsie,  haut  mal,  §c. ; Ger.  Fcdlsuchi. 

Definition. — An  apyretic  nervous  affection, 
characterised  by  seizures  of  loss  of  consciousness, 
with  tonic  or  clonic  convulsions. 

Of  these  two  features — muscular  spasms  and 
loss  of  consciousness,  neither  is  alone  sufficient 
to  establish  the  existence  of  epilepsy.  Still,  each 
of  these  two  kinds  of  symptoms,  when  occurring 
in  the  form  of  an  attack,  is  an  epileptiform  mani- 
festation, as  we  find  that  patients  who  generally 
have  convulsions  only,  are  sometimes  simulta- 
neously seized  with  unconsciousn  ess,  and  vice  versa. 
that  in  those  very  rare  cases  in  which  patients  are 
attacked  only  with  loss  of  consciousness,  without 
any  marked  spasmodic  action  of  any  muscle,  there 
are  sometimes  complete  fits  of  epilepsy.  The 
relationship  between  the  two  essential  character- 
istics of  epilepsy  was  well  exemplified  in  the 
cases  of  t.wo  patients  who  were  placed  under  the 
writer's  care  in  London,  in  1860,  by  his  lamented 
friend,  Dr.  W.  Baly.  These  patients,  who  were 
brother  and  sister,  were  both  incompletely  epi- 
leptic: one  had  only  attacks  of  convulsions,  the 
other  only  attacks  of  loss  of  consciousness.  Their 
father  had  been  completely  epileptic,  and  one  of 
these  two  young  patients  had  inherited  one  aspect 
of  the  disease,  the  other  the  other  aspect. 

Efforts  in  two  absolutely  opposite  directions 
ntve  been  made  to  modify  the  significance  of  the 
word  Epilepsy.  Some  writers  give  that  name  only 
to  the  special  affection  which  others  call  Idiopathic 
Epilepsy.  Other  physicians  have  considered  as 
belonging  to  epilepsy,  most  if  not  all  of  the  non- 
febrile  affections  consisting  in  attacks  of  aphasia, 
of  amaurosis,  of  paralysis,  &c.,  or  of  disordered 
involuntary  movements  (choreic,  tremulous,  ro- 
tatory, &c.).  There  is  no  doubt  that  all  apyretic 
nervous  affections,  appearing  in  seizures,  have  in 
that  feature  a common  link  with  epilepsy,  and  it 
would  be  important  to  have  a name  for  that  group 
of  paroxysmal  neuroses.  But  the  word  epilepsy 
must  remain  for  the  special  morbid  manifesta- 
tions that  we  have  mentioned.  As  regards  the 
application  of  the  word  epilepsy  to  those  cases 
only  in  which  no  organic  disease  either  of  the 
nervous  centres  or  other  organs  can  be  looked 
upon  as  a cause  of  that  convulsive  affection, 
neither  the  symptoms,  nor  the  prognosis,  nor  the 
principal  rules  of  treatment,  show  that  we  must 
entirely  separate  the  idiopathic  from  the  other 
kinds  of  epilepsy.  It  is,  however,  important,  as 
will  be  shown  hereafter,  to  try  to  find  out,  in 
every  case  of  epilepsy,  whether  this  convulsive 
affection  is  of  the  kind  we  call  idiopathic,  or 
proceeds  from  a peripheric  or  central  organic 
lesion  or  irritation,  or  from  some  alteration  of 
the  blood. 

Pathology. — Under  tiiis  head  it  is  only  ne- 


EPILEFSY. 

cessary  to  give  an  idea  of  the  state  of  the  ner- 
vous system  that  seems  to  exist  in  epilepsy.  As 
early  as  1857,  the  writer,  in  his  work  on  this 
affection,  showed  that  it  essentially  consists  in 
an  increased  excitability  of  certain  parts  of  the 
nervous  system.  This  augmentation  of  excita- 
bility may  exist  only  in  the  cerebro-spinal  centres, 
or  partly  there  and  partly  also  in  some  peripheric 
parts  of  the  nervous  system.  The  analysis  of 
phenomena  when  epilepsy  is  gradually  produced 
in  animals  leads  forcibly  to  that  view.  We  find  in 
these  animals,  that,  after  a few  days  have  passed 
from  the  time  of  the  lesion  which  causes  epilepsy 
(either  a section  of  the  sciatic  nerve  or  of  a lateral 
half  of  the  spinal  cord,  in  the  dorsal  region),  the 
first  change  manifested  consists  in  an  increase  of 
the  reflex  power  of  certain  parts  of  the  skin  of  the 
face  and  neck,  while  a greater  excitability  takes 
place  in  the  medulla  oblongata,  in  the  upper  part 
of  the  cervical  region  of  the  spinal  cord,  and  in 
some  parts  of  the  trigeminal  and  of  the  two  or 
three  first  cervical  nerves.  Gradually  the  reflex 
excitability  of  the  nerve-cells  in  direct  communi- 
cation with  the  fibres  of  the  nerves  we  have  named 
increases,  so  that  the  irritation  of  the  skin  of  the 
face  andneck,  instead  of  producing  only,  as  at  first, 
a reflex  contraction  of  the  neighbouring  muscles, 
causes  a tonic  spasm  of  all  the  muscles  of  the 
trunk,  neck,  and  head,  on  the  side  of  the  lesion  and 
of  the  irritation.  Later  on  the  reflex  spasmodic 
action  extends  to  the  other  side,  and  at  last,  a 
complete  attack  of  epilepsy  (a  month  or  later  after 
the  traumatic  injury  which  acts  as  a cause) 
supervenes,  characterised,  as  in  man,  by  loss  of 
consciousness,  with  tonic  or  clonic  couvuisions. 
In  cases  of  injury  to  certain  parts  of  the  base  of 
the  brain  in  some  animals,  the  same  changes  may 
take  place,  but  with  two  differences  : 1st,  the 
rapidity  of  increase  in  the  reflex  excitability  of 
the  parts  above-named  is  very  much  greater  than 
after  an  injury  to  the  spinal  cord  or  to  the 
sciatic  nerve;  2ndly,  the  zone  of  skin  that  ac- 
quires the  power,  when  irritated,  to  give  rise  to 
an  attack,  is  on  the  opposite  side  to  that  of  the 
brain-injury,  while  it  is  on  the  corresponding 
side  to  that  of  the  lesion  of  a nerve  or  of  the 
spinal  cord. 

Want  of  space  prevents  the  writer  from  giving 
the  many  reasons  which  show  that  what  takes 
place  in  animals  rendered  epileptic  by  the  lesions 
mentioned,  applies  in  a great  measure  to  the  pro- 
duction of  epilepsy  in  man.  It  will  suffice  to 
state  that  thero  are  abundant  facts  which  tend 
to  establish  the  conclusion  that  in  all  nervous 
affections  in  which  there  are  seizures,  attacks,  or 
fits  of  any  kind,  the  essential  feature  is  a morbid 
increase  of  the  reflex  excitability,  while  the  dif- 
ferences between  the  various  symptomatic  mani- 
festations depend  on  what  nerve-cells  are  altered 
in  their  vital  properties.  In  other  words,  we 
would  say  that,  although  there  is  the  same  morbid 
change,  there  are  epileptiform,  choreic,  amaurotie, 
paralytic,  aphasic  phenomena,  according  to  the 
particular  nerve-cells  in  which  tha:  change  takes 
place. 

Nothing  has  resulted  from  the  efforts  that  have 
been  made  to  establish  the  theory  that  epilepsy 
depends  on  disease  in  any  part  having  a special 
name  in  the  nervous  centres.  The  so-called  scat  oj 
epilepsy  has  been  successively  placed  in  the  cere 


EPILEPSY. 


bellum,  the  cornu  ammonis,  tlio  pons  Varolii,  the 
medulla  oblongata,  the  convolutions  of  the  brain, 
&c.  There  is  just  as  much  reason  to  place  that 
seat  in  those  parts,  as  there  would  be  to  place  it 
in  the  mucous  membrane  of  the  bowels  or  in  the 
sole  of  the  foot,  or  in  aDy  peripheric  part  of  the 
nervous  system,  where  an  Irritation  is  found 
causing  epilepsy.  In  cases  such  is  these  last, 
as  well  as  in  the  preceding,  the  very  same  things 
occur  ; an  irritation  starts  from  the  place  tv  Here 
wo  find  an  organic  lesion,  and  proceeds  to  nerve- 
cells  in  the  base  of  the  brain  and  in  the  upper 
part  of  the  cord  (or  in  one  of  those  parts  alone). 
Through  this  irritation  those  nerve-cells  havo 
their  nutrition  altered,  and  after  a time  they 
acquire  that  morbid  excitability  which  is  the 
essence  of  epilepsy.  We  do  not  think  it  will  ever 
be  possible  to  recognise  what  cells  are  altered, 
as  it  is  quite  likely  that  the  change  in  them  is 
more  dynamical  than  physical,  and  that  no  more 
microscopical  differences  could  be  detected  be- 
tween two  of  them,  one  normal  and  the  other 
possessing  great  morbid  reflex  power,  than  there 
are  visible  differences  between  two  pieces  of 
magnet — one  poor,  the  other  rich  in  magnetic 
power. 

The  true  seat  of  epilepsy  therefore  is  in  nerve- 
cells,  having  the  power  of  producing  morbid 
reflex  muscular  contractions  ; but  the  location  of 
these  cells  must  be  variable,  as  is  shown  by  the 
fact  that  the  first  symptom  of  an  attack  may  be 
in  the  most  different  parts  of  the  body.  That 
these  cells  are  located  chiefly  in  the  base  of  the 
brain  is  a conclusion  borne  out  by  many  facts. 
But  as  we  have  ascertained,  experiments  on  ani- 
mals show  that  the  very  same  kind  of  epi- 
leptiform convulsions  can  take  place  after  an 
irritation  of  the  skin,  whether  the  nervous  system 
is  left  entire  or  diminished  notably  by  the  abla- 
tion of  the  brain  and  cerebellum,  and  also  of  the 
pons  Yarolii  and  part  at  least  of  the  medulla 
oblongata.  The  spinal  cord  has  therefore  a share 
in  the  production  of  epileptiform  convulsions, 
and  as  we  know  that  it  can,  in  man  as  well  as 
in  animals,  arrest  the  activity  of  the  brain  under 
some  stimulation,  we  may  easily  admit  that  it 
may  help  in  producing  in  man  an  arrest  of  cere- 
bral activity  during  a fit  of  epilepsy. 

-SvrionoGT. — Heredity  deserves  to  be  noticed 
first  in  this  respect,  not  because  it  is  the  most 
frequent,  but  because  it  is  a most  undeniable 
cause.  If  we  canvass  what  has  been  said  by  many 
writers  on  the  subject  of  the  heredity  of  epilepsy, 
we  find  that  most  statistics  published  do  not  give 
sufficient  details  to  enable  us  to  ascertain  what 
are  the  morbid  states  of  the  brain  in  a parent 
which  can  cause  epilepsy  in  the  offspring. 
Pritchard  has  justly  shown  that  all  neuroses 
have  the  greatest  relationship  one  to  another. 
It  is  but  natural,  therefore,  that  epileptics  are 
very  often  found  to  have  had  a father  or  a mother 
attacked  with  some  nervous  disorder.  Moreau 
has  shown  that  epileptics  often  have  insane  per- 
sons as  their  parents.  If  we  put  together  those 
three  groups  of  affections — organic  disease  of  the 
brain,  neuroses,  and  insanity — we  find  that  epi- 
lepsy will  often  exist  in  the  offspring  of  people 
who  have  been  attacked  with  an  affection  be- 
longing to  one  of  those  three  groups. 

As  regards  the  influence  of  sex,  we  believe  that 


there  is  a marked  difference  among  women  and 
men  of  somewhat  advanced  age,  the  proportion  of 
women  being  larger  than  that  of  men : but  this 
is  not  the  case,  and  it  is  even  in  seme  degree 
the  reverse,  for  people  under  twenty-five  years 
of  age. 

Age  has  certainly,  independently  of  sex,  a de- 
cided influence  on  the  appearance  of  epilepsy. 
The  following  table  given  by  Hasse  is  important, 
as  it  is  the  most  extensive.  It  agrees  fully  with 
the  results  of  the  writer’s  own  observation  : 


e at  commencement 

Xo.  attacked 

Congenital 

87 

Under  1 year  of  age  . 

25 

Erom  2 to  10  . 

. 281 

.,  10  „ 20  . 

. 364 

„ 20  „ 30  . 

111 

„ 30  „ 40  . 

59 

„ 40  „ 50  . 

. 51 

„ 50  „ 60  . 

13 

„ 60  „ 70  . 

•i 

995 

It  is  difficult  to  say  at  what  age  hereditary 
epilepsy  is  most  prone  to  make  its  appearance. 
The  writer's  experience  seems  to  show  that  it  is 
between  ten  and  twelve  in  beys  as  well  as  in 
girls.  It  is  certainly  by  far  more  frequent  to 
find  that  inheritance  manifests  itself  before  than 
during  the  period  of  change  that  puberty  causes. 
Romberg,  Dr.  Russell  Reynolds,  and  several 
other  writers  have  already  pointed  out  that  such 
is  the  general  rule. 

Is  puberty  itself  a cause  of  epilepsy?  This  is 
clearly  proved  by  the  large  number  of  epileptics 
who,  as  shown  in  the  preceding  table,  have 
been  attacked  between  the  ages  of  ten  and  twenty 
(364  out  of  995). 

Of  other  causes  the  most  powerful  are  not 
those  usually  stated.  In  patients  under  fifteen 
years  of  age  the  most  frequent  cause  after 
heredity  is  some  more  or  less  obscure  altera- 
tion of  nutrition  of  the  brain,  or  congestion  of 
that  organ  or  of  its  membranes,  remaining  a 
more  or  less  considerable  time  after  typhoid 
fever  or  scarlatina.  It  is  frequent,  indeed,  that 
in  examining  such  patients  (even  when  there  are 
reasons  to  believe  in  heredity),  there  are  a num- 
ber of  symptoms  showing  some  deficiency  in  the 
action  of  the  brain,  as  regards  its  motor,  sensi- 
tive, or  sensorial  functions.  It  is  most  important 
to  detect  those  symptoms  (and  they  are  so  slight 
generally  that  they  would  not  be  noticed  if  not 
most  carefully  looked  for),  as  the  form  of 
epilepsy,  due  to  or  allied  with  the  cerebral 
alteration  which  then  exists,  is  often  curable,  or 
at  least  can  be  considerably  benefited  by  treat- 
ment. 

Of  the  different  tetiological  factors  we  havo 
mentioned — heredity,  age,  puberty,  sex,  fevers — ■ 
none  but  heredity  can  be  looked  upon  as  a real 
and  direct  cause  of  the  form  of  epilepsy  which 
is  called  idiopathic.  The  other  factors  only  give 
origin  to  predisposing  conditions ; excepting 
fevers,  which  can  do  more,  as  they  may  cause 
diathetic,  sympathetic,  or  symptomatic  epilepsy. 

Purely  ‘psychical  and  emotional  causes  seem  to 
be  by  far  less  frequent  than  has  been  supposed. 
They  act  chiefly,  if  not  only,  as  means  of  bring- 


EPILEPSY. 


m 

ing  on  attacks  in  persons  more  or  less  ready  to 
have  them. 

If  idiopathic  epilepsy  he  set  aside,  we  find  that 
the  aetiology  of  the  other  forms  of  that  affection  is 
much  more  easily  found  out,  and  that  almost  al- 
ways the  cause  is  some  recognisable  irritation 
of  a part  of  the  nervous  system.  Diseases  or 
injury  of  any  part  of  the  trunk  and  limbs  or  of 
the  viscera;  diseases  or  injury  of  any  part  of  the 
eerebro-spinal  centres  or  of  their  meninges,  oft  en 
produce  epilepsy.  The  mucous  membrane  of 
the  bowels  and  the  cerebral  meninges  are  the 
parts  most  capable  of  giving  rise,  not  only  to 
simple  convulsions,  but  also  to  sympathetic  epi- 
lepsy. Among  the  various  organs  constituting 
the  encephalon,  those  having  the  greatest  power 
of  giving  rise  to  symptomatic  epilepsy  are  the 
optic  thalami  and  the  convolutions,  especially 
those  of  the  parietal  lobes.  Bat  it  would  be 
quite  wrong  to  conclude  from  the  facts  recently 
discovered  by  Fritsch  and  Hitzig,  in  their  experi- 
ments on  dogs  and  other  animals,  that  certain 
parts  of  the  cortex  cerebri,  near  the  fissure  of 
Rolando,  are  much  more  connected  with  epilepsy 
than  any  other.  The  truth  is  that  that  neurosis 
can  be  caused  by  a disease  of,  or  an  injury  to,  any 
part  of  the  eerebro-spinal  centres : the  anterior, 
the  posterior,  as  well  as  the  middle  lobes,  the 
base  of  the  brain  as  well  as  the  cerebellum  or 
the  spinal  cord. 

Sympathetic  epilepsy  is  very  frequently  due  to 
an  irritation  of  the  sexual  organs,  especially 
brought  on  hv  masturbation.  In  Anglo-Saxon 
countries,  where  children  of  the  two  sexes  are 
less  watched  and  less  warned  against  the  dangers 
of  that  fatal  habit  than  in  other  civilised  countries, 
epilepsy  due  to  that  cause  is  particularly  fre- 
quent. 

Alterations  of  blood,  in  quantity  or  quality, 
are  certainly  favourable  circumstances,  if  nothing 
more,  in  the  production  of  epilepsy.  As  regards 
the  experiments  of  Kussmaul  and  Tenner,  we 
will  say  that  although  a rapid  and  considerable 
loss  of'blood  can  cause  an  epileptiform  attack, 
it  has  not  been  shown  that  such  a cause  has 
produced  epilepsy.  It  is  nevertheless  true  that 
anaemia  is  a very  frequent  factor  in  the  causation 
of  epilepsy  or  any  other  neurosis.  A weak  and 
slow  action  of  the  heart  also  is  found  in  a num- 
ber of  cases  to  be  among  the  causes  of  epilepsy. 
But  the  reverse  is  sometimes  observed;  and  we 
have  not  rarely  seen  cases  of  epilepsy  in  which 
the  pulse  was  strong  and  beating  more  than  100 
times  a minute,  without  any  disease  of  the  heart 
or  of  any  other  organ,  that  could  account  for  this 
great  activity  of  circulation.  In  these  cases  the 
only  morbid  condition  that  could  he  looked  upon 
as  a cause  of  epilepsy  was  the  abnormal  circula- 
tion. In  a case  of  this  kind,  placed  under  the 
writer’s  care  by  Sir  Thomas  Watson,  the  patient 
was  rapidly  benefited  by  treatment,  and  has  had 
no  more  attacks  since  1863,  so  that  that  lend  of 
epilepsy  is  sometimes  curable,  as  is  the  form  due 
to  anpemia. 

Whether  epilepsy  due  to  syphilis  or  to  Bright’s 
disease,  or  to  affections  of  the  liver,  is  ever  pro- 
duced in  a direct  way,  and  exclusively  by  some 
alteration  of  the  blood,  is  not  yet  established ; 
1 ,ut  it.  ;s  certain  that,  especially  where  there  exists 
one  of  tiie  two  last  causes  just  mentioned,  the 


state  of  that  fluid  has  a notable  share  in  the 
production  of  the  neurosis.  But  other  astiolo- 
gical  factors  then  exist:  an  irritation  of  the 
nerves  of  the  kidneys,  or  of  the  liver,  or  of  the 
meninges,  and  some  alteration  of  structure  of 
blood-vessels  or  of  other  parts  of  the  brain,  or 
sometimes  a morbid  deposit  in  the  encephalon,  or 
its  membranes. 

Symptoms. — We  shall  consider  this  part  of 
the  subject  under  three  heads : — the  premonitory , 
the  'paroxysmal,  and  the  inter-paroxysmal.  symp- 
toms. 

1.  Premonitory. — The  frequency  of  premoni- 
tory symptoms,  according  to  the  writer's  expe- 
rience, is  much  greater  than  is  generally  known. 
It  is  extremely  important  to  find  out  the  existence 
of  these  warnings,  as  in  many  cases  attacks  may 
easily  he  prevented  if  we  know  when  they  are 
on  the  point  of  taking  place.  When  we  say  that 
premonitory  indications  are  extremely  frequent, 
we  do  not  mean  that  the  classic  or  Galenic  aura 
is  often  found.  That  vague,  queer,  and  unex- 
plained sensation,  whether  accompanied  or  not 
by  a muscular  contraction,  is  certainly  more  fre- 
quent than  is  admitted,  but  is  by  far  less  often 
observed  than  the  other  kinds  of  warnings. 
Among  the  premonitory  symptoms,  there  are  four 
oftener  observed  than  others : — one  is  a change  of 
temper  (irascibility  appearing  or  increasing); 
another  is  a vascular  contraction  in  the  feet  or 
hands,  producing  a diminution  of  temperature ; 
and  the  two  others  a spasmodic  state  of  some 
muscle,  cr  an  optical  illusion  or  hallucination. 
It  is  impossible  to  sum  up  the  various  manifes- 
tations which  indicate  that  an  epileptic  attack  is 
forthcoming.  Alterations  of  the  various  functions 
of  the  brain,  sensations  of  all  kinds,  headache 
or  backache,  vertigo,  sensorial  disturbances,  sleep- 
lessness or  sleepiness,  palpitation,  dilatation  or 
contraction  of  blood-vessels  anywhere,  altered 
breathing,  diminution  or  increase  of  the  various 
secretions  (of  the  skin,  mucous  membranes,  or 
of  the  visceral  glands),  haemorrhages  from  the 
nostrils  or  other  parts,  fever,  more  or  less  marked 
weakness  (general  or  local),  hunger  or  thirst, 
disgust  for  food  or  drinks,  sexual  appetite  or  the 
diminution  or  loss  of  sexual  desire  or  power, 
erection  of  the  penis,  spasm  of  the  bladder, 
sometimes  with  involuntary  evacuations  of  urine, 
involuntary  expulsion  of  feces,  cramps,  trembling, 
choreic  movements,  tendency  ro  run  forwards, 
backwards,  or  round,  rigidity  or  convulsions  of  a 
limb  or  other  parts,  paralysis  of  a limb  or  other 
parts,  etc., — such  is  an  abbreviated  list  of  the 
forerunners  which  have  been  noticed  by  a num- 
ber of  observers,  and  all  of  which  we  have  seen, 
or  have  been  found  in  our  patients. 

Sometimes  one  or  several  of  these  symptoms 
will  appear  a day  or  two  before  the  attack,  hut 
generally  the  warning  shows  itself  a few  hours, 
or  a very  much  shorter  time  (even  only  a few 
seconds  or  a minute  or  two)  before  the  seizure. 
In  cases  of  epilepsy  due  to  organic  cerebral 
disease,  or  to  cerebral  congestion  (much  more 
rarely  in  other  cases),  there  occurs  rather  fre- 
quently, either  during  the  attack  or  before  it. 
drawing  of  the  head  towards  one  shoulder.  If 
this  occur  before  the  loss  of  consciousness  it  is 
a most  valuable  warning,  as  it  is  then  almost 
always  possible  to  produce  an  abortion  of  the 


EPILEPSY. 


attack.  Premonitory  symptoms  unfortunately 
are  sometimes  deceptive,  as  they  may  appear 
more  or  less  frequently  -without  being  followed 
by  the  attack ; and  in  cases  in  which  warnings 
usually  precede  the  seizures,  there  are  some- 
times attacks  without  any  forerunner. 

2.  Paroxysmal. — As  regards  the  paroxysmal 
symptoms,  they  vary  considerably  according  to 
the  kind  of  attak.  If  the  attack  is  one  of  petit- 
mal  ( epilepsia  mitior),  there  may  be  no  other 
symptom  than  a loss  of  consciousness,  with  either 
a fixed  state  of  the  muscles  of  the  eye,  or  a slight 
contraction  of  one  or  more  muscles  of  the  face 
or  neck,  or  a movement  of  the  lips,  tongue,  and 
throat,  as  in  the  act  of  swallowing.  If  we  spoke 
according  to  our  personal  observation,  we  should 
affirm  that  an  attack  of  petit-mal  never  con- 
sists in  a loss  of  consciousness  only,  without  the 
least  trace  of  any  other  trouble  whatsoever. 

CAUSES. 

1.  Excitation  of  certain  parts  of  the  excito- 
motor  organs  of  the  nervous  centre. 

2.  Contraction  of  the  facial  blood-vessels. 

3.  Contraction  of  the  blood-vessels  of  the  cere- 
bral lobes. 

4.  Extension  of  the  excitation  in  the  excito- 
motory  organs  of  the  nervous  centre. 

5.  Tonic  contraction  of  some  respiratory  and 
vocal  muscles. 

6.  Further  extension  of  the  excitation  in  the 
excito-motory  organs. 

7.  Loss  of  consciousness  alone,  or  with  tonic 
spasm  in  trunk  and  limbs. 

8.  Laryngismus,  trachelismus,  and  rigid  spasm 
of  some  respiratory  muscles. 

9.  Insufficient  breathing;  rapid  consumption 
of  oxygen,  and  detention  of  venous  blood  in  the 
encephalon. 

10.  Asphyxia  and  perhaps  pressure  by  accumu- 
lated venous  blood  in  the  base  of  the  brain. 

11.  Exhaustion  of  the  nervous  power  generally, 
and  of  the  reflex  excitability  especially  ; return 
of  regular  respiratory  movements. 

Space  does  not  permit  of  our  insisting  on  the 
explanations  given  in  this  table.  We  will  only 
say  that  the  loss  of  consciousness  is  too  rapid, 
too  complete,  to  be  due  only  or  chiefly  to  a con- 
traction of  the  blood-vessels  of  the  cerebral  lobes. 
In  that  case,  as  well  as  in  cases  of  loss  of  percep- 
tion and  volition  from  a hnemorrhage,  a softening, 
or  some  other  disease  of  the  brain,  it  is  owing  to 
an  inhibition  of  the  activity  of  cerebral  nerve- 
cells  that  this  symptom  appears. 

We  will  add  to  the  above-given  list  of  symp- 
toms that  besides  t.hesudden  loss  of  consciousness, 
with  tonic  spasm  of  the  muscles  of  the  eye,  face, 
neck,  chest,  and  limbs,  and  the  uttering  of  a loud 
cryr,  which  we  observe  iu  the  beginning  of  a 
complete  attack  of  epilepsy,  there  is  sometimes 
biting  of  the  tongue  or  lips.  After  the  first 
stage,  which  is  usually  extremely  short  (not  last- 
ing generally  more  than  from  10  to  20  seconds), 
general  clouic  convulsions  appear,  the  face  be- 
comes more  or  less  violet  or  purple,  the  tempera- 


447 

Dr.  Bussell  Reynolds,  however,  states  that  he  has 
seen  such  attacks,  and  therefore  we  must  admit 
that  sometimes  a pure  and  simple  loss  of  per- 
ception and  volition  is  all  that  exists  in  a seizure 
of  epilepsia  mitior.  In  such  an  attack  the  patient 
may,  if  walking,  continue  to  walk,  but  if  talking, 
he  stops — generally  for  so  short  a time,  however, 
that  the  trouble  may  pass  absolutely  unnoticed 
by  listeners.  Usually  an  attack  of  that  kind  lasts 
only  from  one  to  four  or  more  seconds. 

An  attack  of  complete  epilepsy  ( epilepsia  greo- 
vior)  is  a very  complex  series  of  phenomena. 
Years  ago  (in  1857)  the  writer  gave  the  follow- 
ing table,  which  shows  at  the  same  time  in  what 
order  and  by  what  mechanism  the  symptoms  ap- 
pear. Only  on  a few  points  has  he  to  alter  the 
views  held  twenty  years  ago.  It  will  be  seen 
that  in  this  table  the  effects  successively  pro- 
duced become  causes  in  their  turn. 

EFFECTS. 

1.  Contraction  of  blood-vessels  of  the  brain 
and  face  ; tonic  spasm  of  muscles  of  the  eye  and 
face. 

2.  Facial  paleness. 

3.  Loss  of  consciousness  ; congestion  in  the 
base  of  the  brain  and  the  spinal  cord. 

4.  Tonic  contraction  of  the  laryngeal,  the  cer- 
vical, and  some  respiratory  muscles  (laryngismus 
and  trachelismus). 

5.  Epileptic  cry. 

6.  Tonic  contraction  reaching  most  muscles  of 
trunk  and  limbs. 

7.  Fall  or  precipitation,  forward  or  backward, 
to  the  ground. 

8.  Insufficient  breathing;  obstacle  to  entrance 
of  blood  into  the  chest,  and  to  its  issue  from  the 
cranio-spinal  cavity. 

9.  Increasing  asphyxia. 

10.  Clonic  convulsions  everywhere;  contrac- 
tions of  the  bowels,  the  bladder,  the  womb;  in- 
crease of  secretions  ; efforts  to  inspire. 

1 1 . Cessation  of  the  tit ; coma  or  fatigue ; head- 
ache ; aud  sleep. 

ture  of  the  body  rises,  the  skin  becomes  covered 
with  perspiration,  and  saliva,  reddened  by  blood 
or  not,  flows  out  of  the  mouth. 

After  the  cessation  of  the  convulsions,  the 
patient  is  often  so  exhausted  that  the  limbs  fall, 
if  lifted  up,  as  if  they  were  quite  paralysed  ; the 
respiration  is  stertorous ; and  the  heart  beats  with 
great  force  and  rapidity.  If  care  be  not  taken  to 
have  the  tongue  brought  forward,  and  if  the  head 
be  not  placed  on  one  side,  the  heavy  breathing 
and  the  comatose  state  which  often  exist,  con- 
tinue for  a long  time.  Even  if  care  be  taken 
about  the  position  of  the  tongue,  these  disturbed 
states  of  the  brain  and  breathing  may  last  an 
hour  or  longer,  in  very  bad  cases.  In  some  epi- 
leptics who  have  a series  of  fits  in  rapid  succes- 
sion, there  is  a more  or  less  prolonged  period 
of  coma  after  each  attack.  Sometimes  in  such 
cases  death  terminates  the  scene  after  a more  or 
less  considerable  number  of  attacks. 

On  waking  up  either  from  the  coma  or  the 


EPILEPSY. 


448 

sleep  following  an  attack,  most  patients  are,  very 
tired  ; their  limbs  and  trunk  aching  as  well  as 
their  head.  Usually  there  is  some  mental  alte- 
ration, often  consisting  of  confusion  or  stupor, 
and  sometimes  delirium.  The  mind,  however, 
may  be  quite  clear,  even  after  a violent  attack, 
and  the  head  free  from  pain,  the  only  effect  of  the 
fit  being  general  lassitude.  On  the  contrary, 
after  an  apparently  slight  seizure,  there  is  some- 
times considerable  mental  disorder.  The  degree 
and  duration  of  stupor  after  an  attack  have  no 
relation  to  the  duration  of  the  convulsive  period. 
Stupor  is  an  effect  of  asphyxia  and  is,  therefore, 
in  direct  relation  with  laryngismus,  trachelis- 
mus,  and  the  spasms  of  the  thoracic  muscles, 
of  the  diaphragm,  and  perhaps  of  the  bronchial 
tubes  also.  It  has  been  stated  and  denied  that 
the  urine  passed  after  an  attack  of  epilepsy  some- 
times contains  albumen,  in  patients  free  from 
kidney-disease.  In  at  least  two  cases  the  writer 
has  ascertained  that  there  was  a notable  amount 
of  albumen  in  the  first  issue  of  urine  after  attacks 
in  which  there  had  been  violent  spasmodic  con- 
tractions of  the  abdominal  and  thoracic  muscles. 
These  two  patients  afforded  no  evidence  of 
disease  of  the  kidneys  or  of  the  heart. 

Attacks  of  epilepsy  are  sometimes  very  slight, 
consisting  only,  besides  the  loss  of  consciousness, 
of  an  extremely  short  tonic  spasm  of  muscles  of 
the  trunk,  the  neck,  the  head,  and  the  limbs. 
But  even  in  the  shortest  and  slightest  attack  of 
that  kind  the  epileptic  cry  may  be  uttered  and 
the  tongue  may  be  bitten. 

The  symptoms  of  a seizure  of  epilepsia  mitior 
( petit-mal ) are  very  different  from  those  of  a vio- 
lently convulsive  attack  of  epilepsy  ( haut-mal ). 
The  loss  of  consciousness  occurs  only  for  one  or 
a few  seconds,  and  the  spasmodic  contractions 
take  place  in  a few  muscles  only,  in  the  face, 
tongue,  throat,  eyes,  and  neck.  If  seized  while 
standing  up  the  patient  very  rarely  falls,  and  on 
the  contrary,  if  walking,  he  may  continue  his 
movement  as  regularly  as  before  the  fit.  If  at- 
tacked while  speaking,  he  stops  while  the  con- 
sciousness is  lost,  and  on  recovering  it  he  may 
complete  the  unfinished  sentence,  so  that  the  by- 
standers may  know  nothing  of  what  has  occurred. 
Sometimes,  however,  the  patient’s  mind  is  deeply 
altered,  even  when  the  attack  of  petit-mal  has 
been  as  short  and  slight  as  possible. 

Nocturnal  attacks  of  epilepsy  may  occur  with- 
out any  knowledge  of  their  having  taken  place. 
Indeed,  the  writer  has  sometimes  been  consulted 
by  persons  who  only  asked  for  advice  on  account 
of  headaches,  and  who  had  no  pain  in  the  head 
except  after  nocturnal  attacks  of  epilepsy  oc- 
curring without  their  knowledge.  In  such  cases 
the  patient,  after  a seizure  during  sleep,  wakes 
up  tired,  as  if  he  had  walked  considerably ; he 
has  pains  in  the  limbs,  the  back,  and  the  head. 
He  finds  his  mind  confused,  and  his  memory 
affected;  he  feels  disinclined  to  get  out  of  bed 
or  to  exert  himself  in  any  way;  and  he  often  is 
excitable  or  depressed.  Sometimes  his  tongue 
or  his  lips  are  sore,  and  if  the  pillow  is  examined 
it  shows  bloody  spots.  More  rarely  it  is  found 
that  an  involuntary  evacuation  of  urine  has 
soiled  the  bed.  Anyone  sleeping  within  hearing 
distance  of  the  patient  may  be  wakened  by  the 
piercing  epileptic  cry,  and  then  hear  the  noise 


of  the  shaking  of  the  bed,  caused  by  the  con- 
vulsive movements.  Such  attacks,  although  very 
frequent  and  also  very  violent,  may  remain  alto- 
gether unknown  and  unsuspected  by  the  patient 
and  liis  friends. 

3.  inter-paroxysmal. — The  general  health  of 
epileptics  is  usually  very  poor.  Besides  the 
alterations  of  their  mental  powers,  and  especially 
of  their  memory,  the)'  show  a great  deal  of  ex- 
citability and  often  depression  of  spirits.  Their 
circulation  and  their  digestion  are  often  affected. 
There  is  nothing  special  to  them,  however,  either 
in  the  morbid  state  of  their  mind  and  of  their 
feelings,  or  in  the  disturbances  of  their  physical 
health.  We  do  not  consider  the  mental  aber- 
rations observed  in  the  inter-paroxysmal  state 
as  elements  in  the  symptomatology  of  epilepsy'. 
These  aberrations  can  exist  without  epilepsy, 
and  in  a great  majority  of  cases  epilepsy  is  un- 
accompanied by  them. 

The  frequency  of  attacks  varies  immensely  in 
epilepsy.  In  one  case  the  writer  learned  that  for 
more  than  seventeen  years  the  patient  had  passed 
no  night  without  a fit,  and  for  more  than  ten 
years  the  average  nightly  number  of  fits  had  been 
about  twelve,  which  gives  a total  of  more  than 
forty  thousand  attacks  in  ten  years.  On  the 
other  hand,  he  was  once  consulted  by  a patient, 
sixty-two  years  old,  who  has  had  hut  seven 
attacks  since  the  first  occurred,  forty-three  years 
ago,  the  interval  between  that  and  the  second 
fit  having  been  thirteen  years,  and  the  interval 
between  the  two  last  seizures  having  been  seven 
years.  Between  extremely  different  cases  like 
the  two  just  mentioned,  we  find  the  greatest 
variety  as  'regards  the  frequency  of  attacks. 
Usually,  however,  there  are  a number  of  fils 
every  month.  If  there  are  attacks  with  ex- 
tremely violent  convulsions,  the  frequency  is  gene- 
rally much  less  than  when  the  convulsions  are 
slight.  Seizures  of  petit-mal  are  usually  very 
frequent.  A perfect  periodicity  is  extremely 
rare,  but  an  approximation  to  periodicity  is  not 
rare,  especially  in  women.  Singular  and  inex- 
plicable periods  will  sometimes  exist ; the  writer 
knows  of  a number  of  cases  with  a weekly 
periodicity,  and  of  a case  in  which  for  years 
attacks  recurred  every  forty-nine  days. 

Diagnosis. — In  most  eases  it  is  easy  to  dis-> 
tinguish  epilepsy  from  the  few  affections  which 
resemble  it.  Sometimes,  however,  difficulties 
exist.  There  is  no  essential  difference  between 
the  attacks  of  eclampsia  in  women  and  children 
and  attacks  of  epilepsy,  except  the  existence  in 
eclampsia  of  a peripheric  cause  of  irritation, 
which  is  likely  to  disappear.  But  those  purely 
reflex  epileptiform  attacks  of  women  and  chil- 
dren are  sometimes  succeeded  by  genuine  attacks 
of  epilepsy,  changes  in  the  nervous  centres  occur- 
ring during  the  eclamptic  attacks,  which  lay  the 
foundation  of  persistent  epilepsy,  showing  itself 
after  the  peripheric  irritation,  which  was  the 
first  cause,  has  ceased  to  exist.  It  is  some- 
times, therefore,  almost  impossible,  in  children 
especially,  to  say  if  we  have  to  deal  with  eclampsia 
or  epilepsy.  The  same  may  be  said  of  all  kinds  of 
attacks  of  loss  of  consciousness  and  convulsions 
due  to  a peripheric  cause,  whether  we  call  the 
affection  eclampsia  or  reflex  epilepsy.  {See 
I Convulsions.)  The  first  cause  in  those  eases  mat 


EPILEPSY. 


cease  to  exist  without  our  discovering  positively 
that  it  has  disappeared,  and  still  attacks  may 
continue.  As  the  treatment  is  to  be  very  much 
the  same,  except  that  in  purely  reflex  epilepsy 
we  have  to  fight  against  the  peripheric  cause 
besides  making  use  of  means  against  epilepsy 
itself,  a mistake  is  not  dangerous. 

Hysteria  sometimes  borders  on  epilepsy,  so 
much  so  that  we  must  accept  for  certain  groups 
ot  nervous  symptoms,  the  name  of  hystero- 
epilepsy.  Usually,  however,  there  is  no  com- 
plete loss  of  consciousness  in  hysteria  : there  is 
rather  a disordered  consciousness.  The  con- 
vulsions generally  do  not  follow  the  ordinary 
cycle  of  those  of  epilepsy  : they  are  not  merely 
tonic  first  and  then  clonic ; they  often  are  alter- 
nately, and  many  times  successive!}7,  clonic  and 
tonic.  They  sometimes  resemble  voluntary 
movements  rapidly  executed.  The  attack  is  not 
followed  by  the  stupor  that  follows  so  often  a 
fit  of  epilepsy.  Before  and  after  the  attack, 
the  patient  exhibits  (or  has  done  so)  purely 
hysterical  symptoms.  Usually,  pressure  on  the 
ovary  during  the  attack  stops  or  increases  it, 
while  nothing  of  the  kind  is  found  in  a fit  of 
epilepsy,  except,  of  course,  one  of  hystero- 
epilepsy,  in  which  case  the  two  affections  are 
blended  in  one. 

Epilepsia  mitior  ( 'petit-mal ) sometimes  cannot 
be  easily  distinguished  from  syncopal  attacks. 
Usually,  however,  the  pulse  does  not  lose  so 
much  in  frequency  and  force  in  petit-mal  as  it 
does  in  fainting.  The  loss  of  consciousness  lasts 
for  a shorter  period  in  peiit-mal  than  in  syncope. 

Between  idiopathic  epilepsy  and  cerebral 
epilepsy,  there  are  generally  very  marked  differ- 
ences. In  epilepsy  due  to  disease  of  the  brain, 
attacks  are  almost  always  preceded  by  an  aura, 
consisting  either  in  referred  sensations  or  in 
cramps  ; in  such  attacks,  convulsions  hften  occur 
without  loss  of  consciousness  ; very  frequently 
the  convulsions  are  unilateral,  either  on  the 
paralysed  side  or  on  the  other  side ; and  almost 
invariably,  if  they  are  not  clearly  unilateral, 
differences  in  intensity,  in  kind,  and  in  duration 
exist  as  regards  the  spasmodic  contractions  be- 
tween the  two  sides  of  the  body. 

. Prognosis. — Inherited  epilepsy  is  very  rarely 
cured.  The  writer  can  positively  state,  how- 
ever, that  it  may  be  cured.  Among  other  good 
cases  of  persistent  cure,  he  has  seen  two  ex- 
tremely remarkable.  The  patients  were  first 
cousins,  and  had  inherited  the  disease  from  a 
grandmother:  one  of  them  died  from  a fall  while 
intoxicated,  five  years  after  his  last  attack  of 
epilepsy;  the  other  died  in  China,  from  typhoid 
fever,  seven  years  after  his  last  attack.  They 
had  both  been  treated  for  about  two  years,  in 
1852  and  1853. 

There  is  a very  great  difference  as  regards 
prognosis  between  pure  idiopathic  epilepsy  and 
other  forms  of  that  neurosis.  The  chances  of 
cure,  although  never  great,  are  by  far  greater 
when  some  curable  or  amendable  organic  altera- 
tion exists,  as  a cause  of  epilepsy,  than  when  no 
such  thing  exists.  One  form  of  this  nervous 
affection — that  which  is  due  to  some  congestion 
or  even  a more  serious  alteration  of  the  brain, 
—consecutive  to  typhoid  fever,  scarlatina,  or 
measles,  is  very  often  much  benefited  by  treat- 

29 


44‘J 

ment,  if  not  cured.  Epilepsy  caused  by  disease 
of  the  brain — syphilitic  or  not — is  much  more 
curable  than  any  other  form  of  that  neurosis. 
Epilepsy  beginning  in  childhood,  from  teething 
or  a bowel-complaint,  and  having  lasted  many 
years,  is  almost  incurable. 

Complications  and  Sequelae. — Epilepsy  has 
no  necessary  or  usual  complication.  The  dis- 
eases which  accompany  it  often  are  frequently 
its  causes  and  not  complications.  Bright's  dis- 
ease and  other  organic  affections  of  the  kidney, 
diseases  of  the  liver,  the  womb,  and  other  viscera, 
when  allied  with  epilepsy,  if  they  have  not  been 
the  first  and  only  cause  of  it,  are  powerful  addi- 
tional causes.  There  are  no  sequelae  of  epilepsy- 
worth  mentioning  except  some  amnesia,  which  we 
invariably  find  in  patients  cured  of  that  affection, 
after  having  suffered  from  it  for  many  years. 

Treatment. — A most  important  fact  ouaht  at 
first  to  be  pointed  out  under  this  head:  it  is  that 
as  every  attack  causes  in  the  nervous  centres 
changes  which  prepare  other  attacks,  it  is  essen- 
tial to  produce,  if  possible,  the  abortion  of  attacks 
whenever  warnings  occur.  The  treatment  to  obtain 
such  an  abortion  varies  with  the  kind  of  warning. 
In  cases  in  which  a real  aura  exists  many  means 
can  be  employed  with  the  greatest  benefit.  The 
writer  long  since  showed  that  the  old-fashioned 
mode  of  prevention  of  attacks,  consisting  in  the 
application  of  a ligature  round  a limb,  acts  not 
as  the  Galenic  doctrine  supposed  that  it  did,  that 
is,  by  barring  the  way  to  something  going  up  to 
the  brain;  but,  on  the  contrary,  in  doing  just  the 
reverse,  that  is,  bysendingan  irritation  towardsor 
rathc-r  to  the  nervous  centres.  The  writer  has  also 
shown  that  the  ligature  need  not  be  left  appliod, 
and  that  a greater  success  is  obtained  by  tying 
suddenly  and  very  quickly  a handkerchief  or  a 
band,  and  repeating  this  tying  several  times  in 
succession,  than  by  applying  the  ligature  even  very 
tightly  and  leaving  it  so.  He  has  also  demon- 
strated:— 1st.  That  the  ligature  can  do  good  even 
when  applied  on  another  limb  than  that  where 
the  aura  is  felt,  although  it  is  usually  more  effi- 
cacious on  the  latter  ; and  2nd.  That  pinching  or 
striking  the  skin,  or  irritating  its  nerves  by  heat, 
by  cold,  by  galvanism,  or  by  repeated  pricks  with 
a needle,  will  generally  do  as  much  good  as  the 
ligature. 

In  those  cases  in  which  an  involuntary  mus- 
cular contraction  takes  place  before  an  attack — 
that  is  before  the  loss  of  consciousness — one  of 
the  most  efficient  means  to  produce  an  abortion 
cf  the  fit  is  to  draw  forcibly  on  the  contracted 
muscles,  so  as  to  elongate  them.  Eor  instance, 
in  those  cases  in  which  the  unconsciousness  is  pre- 
ceded by  a contraction  of  the  muscles  of  the  neck, 
drawing  the  chin  towards  one  shoulder,  turning 
forcibly  and  rapidly  the  head  towards  the  opposite 
shoulder,  gives  in  most  cases  a very  good  chance 
of  checking  completely  the  tendency  to  the  fit.  In 
case  of  contraction  of  the  flexor  muscles  of  the 
forearm,  forcible  extension  of  the  hand  over  the 
fore-arm  may  succeed  in  preventing  the  attack. 
A blow,  pressure,  or  friction  on  parts  where  some 
muscles  become  rigid,  may  have  the  same  favour- 
able effect. 

If  there  are  disturbances  of  breathing  among 
the  premonitory  symptoms,  the  inhalation  of 
ether  or  chloroform  may  prove  successful.  Ir 


EPILEPSY. 


150 

cases  of  laryngismus  similar  means  cr  the  cau- 
terisation of  the  fauces  by  a strong  solution  of 
nitrate  of  silver  has  been  found  most  useful  by 
the  writer.  The  ise  of  anaesthetics  as  a means 
of  warding  off  an  attack  is  too  much  neglected. 
By  the  help  of  ether  in  inhalations  we  have  suc- 
ceeded, with  Mr.  It.  Dunn,  in  preventing  an 
attack  in  a patient  who  had  had  a fracture  of 
the  arm  in  a previous  seizure,  and  who  used  to 
have  a fit  regularly  every  week.  A whole  week 
was  gained  in  that  way.  In  some  cases  the  re- 
currence of  attacks  has  been  warded  off  by  giving 
chloroform  or  ether  (by  inhalation)  to  patients 
who  had  had  the  first  of  what  would  have  been 
otherwise  a series  of  many  fits.  There  is,  in 
cases  in  which  a fit  is  expected,  a considerable 
chance  of  preventing  it  by  etherisation  or  chlo- 
roformisation. 

According  to  the  kind  of  warning  and  to  its 
seat  one  means  or  another  out  of  a very  large 
number  (only  some  of  which  we  shall  mention), 
ought  to  be  used.  An  emetic,  a purgative,  a 
stimulant,  the  immersion  of  the  two  hands  in 
hot  water,  the  application  of  a lump  of  ice  to  the 
hack  of  the  neck  or  between  the  shoulder-blades, 
the  subcutaneous  injection  of  a solution  of  ,3  of 
a grain  of  atropine  with  5 of  a grain  of  morphine, 
powdered  asarum  taken  as  snuff,  a dose  of  25 
grains  of  hydrato  of  chloral,  the  inhalation  of 
a small  doso  of  nitrite  of  amyl,  extremely  rapid 
and  ample  voluntary  respiratory  movements  for 
five  or  six  minutes,  jumping,  running  for  at  least 
ten  minutes,  reading  very  loud  and  fast — such 
are  some  of  the  means  which  wo  have  found  to 
be  the  most  successful. 

The  second  point  of  importance  about  treat- 
ment is  to  try  to  discover  a part  of  the  body 
which  can  by  irritation  give  rise  to  a premonitory 
symptom  of  an  attack,  or  even  to  an  attack  it- 
self. If  such  a part  is  discovered,  counter- 
irritation of  some  kind  is  to  he  applied  there. 
Our  remarks  must  be  confined  to  saying,  that 
hard  pressure  on  certain  parts  of  the  head,  the 
spine,  the  breast,  the  abdomen,  or  the  limbs, 
has  in  a number  of  cases  produced  an  attack  or 
some  symptoms  of  it.  We  have  seen  the  passage 
of  a galvanic  current  produce  the  same  effect.  In 
such  cases  a blister  or  other  local  application  has 
done  good  in  diminishing  the  violence  or  frequency 
of  attacks,  and  even,  in  a few  instances,  helped 
notably  to  a cure. 

The  modes  of  treatment  of  epilepsia  gravior  or 
mitior  which  chiefly  deserve  to  he  noticed  are 
the  following : — - 

Against  idiopathic  epilepsy  the  most  powerful 
means  consists  in  the  simultaneous  use  of  some 
tonic  remedy  (such  as  strychnine  or  arsenic)  in 
a solution  to  he  taken  after  meals  ; and  of  a mix- 
ture composed  more  or  less  like  the  following: — 

R Potassii  iodidi,  3ij. 

Potassii  bromidi,  3j. 
j\  mmonii  bromidi,  3iij. 

Potass®  bicarbonatis,  3j. 

Tinct.  calnmb®  f.  31 
Aqu®  destillat®  f.  Jvj. 

Of  this  solution  may  he  given  to  adults  four 
doses  a day,  three  of  one  teaspoonful  each  before 
meals,  and  the  fourth  of  three  teaspoonfuls  at 
bed-time  with  as  much  water  as  desired.  Ac- 
cording to  many  circumstances  the  dose  of  one 


or  another  of  the  ingredients  is  to  be  changed. 
For  example,  if  the  petit-mal  exists  alone,  o' 
coexists  with  the  complete  epilepsy,  the  dose  of 
the  bromide  of  ammonium  must  he  larger,  and 
that  of  the  other  bromide  diminished.  If  there 
is  a weak  pulse  the  sesquicarbonate  of  ammonia 
is  to  be  substituted  for  the  bicarbonate  of  potash. 
In  the  writer’s  work  on  functional  nervous 
affections  all  the  rules  relating  to  that  mixture 
are  given,  and  we  will  only  say  now  that  ice 
use  is  by  far  more  beneficial  than  that  of  any  of 
its  ingredients  alone  or  of  two  of  them.  Twc 
essential  rules  are  to  be  followed  when  either 
such  a mixture  or  any  of  the  many  bromides  is 
employed  against  epilepsy ; the  first  is,  that  there 
ought  to  he  no  interruption  whatever  in  the  use  of 
such  remedies,  as  the  whole  benefit  that  may  have 
been  obtained  may  be  lost  at  once  after  an  inter- 
ruption of  even  only  a few  days;  the  second  is 
that  the  treatment  must  he  persevered  with  for 
at  least  two  years  after  the  appearance  of  the 
last  attack.  There  is  no  marked  harm  in  the 
great  majority  of  cases  from  a prolonged  use 
of  a mixture  like  the  above ; many  patients 
have  taken  it  for  several  years,  and  some  for 
six,  eight,  or  ten  years  without  any  marked  bad 
effect. 

Idiopathic  epilepsy  (either  the  complete  or  the 
incomplete,  that  is  the  jietit-mal)  has  been  suc- 
cessfully treated  (very  rarely  cured,  hut  often 
benefited)  by  the  use  of  a number  of  remedies. 
Judging  by  his  own  experience,  the  writer  names, 
as  the  most  powerful,  atropine  and  the  ammo- 
mated  sulphate  of  copper.  Although  not  able 
general^  to  produce  as  much  and  especially  as 
prompt  a good  effect  as  the  above  mixture,  these 
two  remedies  have  the  superiority  over  this  mix- 
ture that  they  need  not  be  constantly  used,  and 
that  there  is  no  necessity  of  continuing  to  employ 
them  longer  than  eight  or  ten  months  after  the 
last  attack,  liext  in  importance  after  the  three 
means  spoken  of,  will  come  the  cotyledon  umbili- 
cus, the,  nitrate  of  silver,  and  zinc  preparations, 
especially  the  bromide  of  zinc. 

The  other  forms  of  epilepsy  require  pretty  much 
the  same  modes  of  internal  treatment ; hut,  of 
course,  according  to  the  cause  of  each  form  some 
special  means  should  be  employed.  In  the  above 
prescription  the  dose  of  the  iodide  of  potassium 
must  become  as  large  as  that  of  the  bromide  of 
potassium,  when  syphilis  is  considered  to  he  the 
cause  of  epilepsy,  and,  if  needed,  mercury  should 
he  administered  also.  If  epilepsy  depends  on 
some  visceral  affection  it  is  clear  that  the  treat- 
ment should  he  directed  against  that  affection. 
But  if  the  liver  is  diseased  from  some  influence 
of  malaria  the  sulphate,  of  quinine  should  not  he 
given,  as  it  is  almost  always  a bad  remedyagainst 
epilepsy,  often  more  hurtful  than  it  can  be  useful. 
Arsenic  then  should  he  the  remedy  used  against 
the  sequel®  of  fever  and  ague.  If  quinine  must 
he  employed  in  eases  of  clearly  periodical  epi- 
lepsy, the  valerianate  should  be  given  rather  than 
the  sulphate. 

It  may  seem  strange  that  we  do  not  name  iron 
among  the  remedies  against  epilepsy.  The  writer  s 
experience  shows  that  in  most  cases  iron  is  rather 
harmful  than  useful.  It  is  only  in  cases  of  epi- 
lepsy allied  with  or  caused  by  chlorosis  or  con- 
siderable anaemia  that  its  good  effect  is  often 


EPILEPSY. 


EPILEPTIC  INSANITY.  451 


very  marked.  Even  then,  we  have  sometimes 
found  manganese  more  serviceable.  There  is, 
however,  one  salt  of  iron — the  citrale — which, 
although  less  powerful  against  a deficiency  of 
olood-globules,  is  however  less  apt  to  give  rise 
to  attacks  than  are  most  ferruginous  preparations 
in  a number  of  cases. 

Of  other  internal  remedies,  cod-liver  oil  if 
well  borne  is  certainly  useful,  especially  against 
th e petit-mcd.  The  importance  of  giving  simul- 
taneously with  the  bromides  either  arsenic 
or  strychnine  has  been  already  mentioned.  Ar- 
senic alone  can  do  much  against  any  form  of 
epilepsy,  perhaps  chiefly  against  petit-mal,  but 
the  writer  does  not  personally  know  of  a single 
case  of  cure  by  its  use.  Strychnine  can  also 
alone  do  good,  but  less  than  arsenic.  Digitalis 
or  digkaline  have  been  credited  as  having  effected 
cures  ; so  have  turpentine  and  a number  of  other 
medicines.  The  writer  has  obtained  only  a very 
.imited  good  from  the  use  of  digitalis  or  tur- 
pentine. As  regards  the  curative  influence  of  the 
nitrite  of  amyl,  it  is  yet  sub  judire. 

From  counter-irritation  there  is  a great  deal  to 
be  expected.  Ice  (not  in  a bag)  the  actual  cautery, 
blisters,  &c.,  applied  to  the  back  part  of  the  neck 
and  between  the  shoulder-blades,  are  most  useful 
in  any  form  of  epilepsy,  especially  when  there  is 
a great  deal  of  headache  and  considerable  heat 
in  the  head.  When  attacks  are  very  violent  and 
frequent,  there  is  some  good,  and  at  times  a de- 
cided amelioration  to  be  obtained  from  croton  oil 
applications  on  a great  part  of  the  shaved  head. 
Setons  and  issues  very  rarely  do  any  good,  and 
often  weaken  and  irritate. 

A circular  blister  round  a limb,  a finger  or  a 
toe,  is  most  useful  in  cases  of  an  aura  starting 
from  those  parts.  It  is  known  that  in  such 
cases  a nerve  has  been  divided,  sometimes  with 
great  success.  Of  more  serious  operations,  there 
is  one  which  ought  to  be  completely  rejected, 
unless  there  is  good  reason  to  suspect  the  exist- 
ence of  an  intracranial  aneurism  on  the  carotid 
artery  or  one  of  its  branches,  namely,  the  liga- 
ture of  that  artery  in  the  cervical  region.  Al- 
though beneficial  in  a few  cases  it  is  a dangerous 
operation,  and  much  inferior  to  many  other 
means  of  treatment.  Trepanning  the  cranium, 
except  on  clear,  rational  ground,  is  certainly 
to  be  avoided,  although  it  has  in  a few  such 
cases  cured  or  ameliorated  the  condition  of 
the  patient.  But  when  the  attacks  are  ex- 
tremely violent  and  frequent,  especially  if  they 
seem  to  endanger  the  life  of  the  patient,  and 
when  there  is  a clear  evidence  of  pressure 
exerted  on  the  brain,  that  operation,  which  in 
such  cases  has  often  been  useful,  ought  to  be 
resorted  to,  after  the  failure  of  other  means. 
Laryngotomy  or  tracheotomy  are  to  be  rejected, 
except  in  those  instances  in  which  the  operation 
would  have  to  be  performed  even  if  there  were 
no  epilepsy.  In  cases  of  laryngeal  epilepsy  the 
writer  has  found  the  cauterisation  of  tho  fauces 
and  of  the  larynx  itself  with  a strong  solution 
of  nitrate  of  silver  a very  useful  means,  and  even 
in  one  case  a means  of  complete  and  persistent 
cure. 

During  an  attack  of  epilepsy,  excepting  what 
simple  common  sense  suggests,  there  is  very 
little  to  be  done.  Pressure  on  one  or  on  both 


carotid  arteries,  which  we  now  know  to  act  on 
account  of  the  accompanying  pressure  on  the  par 
vagum  and  on  the  cervical  sympathetic  nerves, 
will  sometimes  considerably  shorten  an  attack, 
especially  if  there  is  violent  action  of  the  heart. 
At  the  time  convulsions  cease,  the  tongue  ought 
to  be  drawn  forward  and  the  head  of  the  patient, 
if  not  his  body,  turned  sideways,  so  as  to  avoid 
the  covering  of  the  larynx  by  the  half-paralysed 
tongue.  No  other  interference  at  all  with  the 
patient  should  be  tho  rule  after  the  attack. 

C.  E.  Brown-Seqcard. 


EPILEPTIFORM 

EPILEPTOID 


. — Partaking  of  the 


characters  of  epilepsy  ; terms  generally  applied 
to  convulsions.  See  Convulsions. 


EPILEPTIC  INSANITY.— The  different 
classifications  of  mental  diseases  agree  generally 
in  making  a separate  division  of  the  intellectual 
derangement  related  to  epilepsy.  This  latter 
ranks  prominently  among  the  predisposing  causes 
of  insanity,  but  has  not  been  found  to  proceed 
from  it,  unless  the  epileptiform  convulsions  ob- 
served with  the  majority  of  mental  affections  be 
improperly  regarded  as  epilepsy.  Evidently, 
the  fits  of  petit  mal  are  associated  with  insanity 
more  frequently  than  even  the  most  violent  <>! 
grand  mat-,  however,  from  this  association  it 
does  not  necessarily  follow,  as  currently  believed, 
that  insanity  should  be  a mere  consecutive  acci- 
dent of  the  fit.  Falret,  endeavouring  to  recon- 
cile the  views  on  the  subject  put  forward  by 
French  alienists,  asserts  that  insanity  chiefly 
occurs  as  a consequence  of  epileptic  attacks  re- 
curring at  short  intervals  after  a prolonged  sus- 
pension of  the  disease — which  is  very  true.  Yet, 
insanity  may  besides  break  out  after  nocturnal 
attacks,  or  seizures  of  petit  mal,  without  any 
relation  whatever  to  the  length  of  their  suspen- 
sion, or  number ; and  mania — usually  of  the  most 
furious  character — may  also  appear  as  a fore- 
runner instead  of  the  sequel  of  the  fit;  or  it  may 
originate  with  the  very  first  epileptic  seizure 
and  recur  continually  thereafter.  Lastly,  the 
existence  of  epilepsy  and  paralysis  brings  about - 
from  the  beginning,  a gradual  though  obvious 
impairment  of  the  intellectual  faculties,  whirl: 
becomes  exacerbated  by  the  fits,  and  terminates 
in  dementia.  No  less  open  to  objection  is  the 
kindred  nature  of  the  physical  and  psychical 
manifestations  of  epilepsy,  admitted  by  Falret. 
to  establish  thereupon  the  intellectual  petit  mal 
and  the  intellectual  grand  mal.  The  first  cor- 
respond with  the  incoherent  and  violent  state 
described  as  furious  mania.  The  second  may 
continue  from  several  hours  to  several  days,  con- 
stituting an  intermediate  condition  between  the 
irregularities  of  character  which  attend  the  fit, 
and  the  highest  disturbance  of  the  furious  mania- 
cal seizures.  In  the  midst  of  this  confusion  of 
mind  epileptics  recall  to  their  memory  the  painful 
past  impressions,  which  spontaneously  spring  up 
in  their  imagination,  always  the  same  at  every 
new  access,  and  give  themselves  up  to  instanta- 
neous, sudden  acts  of  violence.  After  such  fit 
of  violence,  the  epileptic  either  quickly  returns 
to  himself,  regaining  his  consciousness  and  ren- 
dering an  imperfect  account  of  his  misdeeds,  or, 
on  the  contrary,  he  escapes,  running  away  a a 


152  EPILEPTIC 

bewildered  and  greatly  agitated  condition.  In 
either  case  the  confusion,  if  not  the  complete 
oblivion  of  what  has  happened,  is  almost  always 
a striking  essential  feature  of  this  mental  state, 
bo  much  resembling  the  awakening  from  a dread- 
ful dream.  The  foregoing  phenomena  are,  indeed, 
exhibited  by  the  insane  epileptic  ; but  the  dis- 
tinction between  the  intellectual  grand  mal  and 
the  intellectual  petit  mal,  and  their  respective 
reference  to  the  physical  paroxysms  of  epilepsy, 
supposed  by  Falret,  implies  an  essential  connec- 
tion which  is  far  from  being  constant.  The  most 
fearful  fits  of  rage,  or  frenzy,  may  follow  the 
petit  mal,  or  may  burst  out  without  any  visible 
attack  at  all,  while  nocturnal  fits,  or  petit  mal 
and  grand  mal,  recurring  separately  or  together, 
may  often  herald  a harmless  insanity  with  the 
highest  degree  of  melancholia  with  stupor,  with- 
out the  least  violent  reaction — which,  as  set 
forth  by  Falret,  should  exclusively  occur  upon 
the  physical  grand  mal.  In  other  common  in- 
stances, the  epileptic,  without  any  dejection  or 
stupor,  but  excessively  disposed  to  react  violently 
on  the  slightest  moral  or  physical  incitation,  talks 
and  acts  coherently,  in  an  apparently  rational 
manner,  but  actually  without  any  appreciation 
whatever  of  his  outward  relations — a strange 
state  that  may  occur  along  with  diurnal  or  noc- 
turnal fits,  or  irrespective  of  any  manifest  physi- 
cal paroxysm,  as  the  only  exponent  of  the  epi- 
leptic malady.  For  all  these  reasons,  instead  of 
attempting  to  establish  an  immediate  relation 
of  cause  to  effect — which  cannot  be  proved — 
between  the  psychical  and  physical  paroxysms, 
it  is  safer  to  regard  epileptic  insanity,  or,  using 
a more  adequate  term,  cerebral  epilepsy — as  one 
of  the  manifestations  per  sc  of  the  spasmodic 
neurosis,  recognising  its  essential  source,  not  in 
this  or  that  kind  of  fits,  nor  in  their  frequency, 
but  in  the  very  pathogenetic  elements  of  the 
disease.  Unconsciousness,  with  an  excessive 
reflex  susceptibility,  displays  itself  as  the  chief 
characteristic  of  cerebral  epilepsy,  capable  of 
occurring  either  alone,  or  coupled  with  any 
other  form  of  the  epileptic  malady,  preceded 
sometimes  by  an  aura,  identical  to  that  which 
may  foretell  other  attacks. 

Description. — Assuming  the  practical  view 
above  maintained,  it  is  readily  observed  that  epi- 
leptic insanity — like  every  other  variety  of  in- 
sanity-manifests itself  under  an  intermittent,  a 
remittent,  and  a continuous  form. 

The  intermittent  form  is  characterised  by 
periodical  attacks,  breaking  out  at  irregular  in- 
tervals, either  before  or  after  the  fits,  which, 
moreover,  often  explode  as  though  they  were  an 
interenrrent  accident  of  the  maniacal  seizure. 
When  this  latter  directly  follows  the  grand 
mal,  the  patient  instantly  passes  from  the  clonic 
stage  of  the  fit  into  the  maniacal,  without  any 
intermediate  period  of  sleep  or  coma.  The  inter- 
mittent attacks  of  cerebral  epilepsy  rarely  last 
less  than  two  or  three  hours  ; they  may  be  de- 
veloped one  or  more  days  after  instead  of  closely 
accompanying  the  fits,  and  ordinarily  have  then 
a longer  duration ; or,  again,  the  intellectual 
disorder  may  reach  its  most  dreadful  stage 
without  any  spasmodic  fit  being  seen  or  sus- 
pected. Morel  proclaims  that  in  these  cases  the 
occurrence  of  convulsions  never  fails  to  disclose 


INSANITY . 

the  true  nature  of  the  insanity,  as  such  patients 
ultimately  arrive  at  the  convulsive  fit  and  die. 
This,  however,  is  too  absolute  a statement,  for 
undoubted  cases  of  cerebral  epiiepsy  are  fre- 
quently met  with,  without  the  supervention  of 
any  spasms  in  the  final  state  of  cerebral  conges- 
tion, the  patient  sinking  into  a profound  coma, 
but  sometimes  executing  automatically  in  this 
insensible  state  the  same  movement  of  the  head, 
or  some  other  habitual  gesture.  It  is  in  inter- 
mittent cerebral  epilepsy  that  unconsciousness 
appears  most  strikingly,  although  no  reference 
has  been  hitherto  made  to  its  clinical  or  far- 
reaching  medico-legal  significance,  nor  to  the 
explanation  it  furnishes  to  the  strange  oblivion 
or  amnesia,  so  peculiar  to  epileptics  after  the 
commission  of  their  criminal  acts.  Eeligious 
monomania  and  erotomania  are  common  in  the 
earliest  stages  of  intermittent  cerebral  epilepsy. 
However,  the  peculiar  disposition  to  wander  about 
in  an  aimless  manner,  the  volubility  and  instan- 
taneous changes  characteristic  of  the  deportment 
of  individuals  labouring  under  this  stage,  maybe 
transformed  into  an  opposite  manner  of  acting, 
the  epileptic  then  remaining  for  hours  or  days 
entirely  motionless  and  silent,  with  a sullen  ex- 
pression of  countenance,  in  a physical  and  mental 
condition  which  almost  verges  on  catalepsy,  and 
involuntarily  passing  his  urine  and  excrements, 
like  those  suffering  from  stupidity  or  melancholia 
attonita. 

No  complete  recovery  of  intellectual  sound- 
ness takes  place  between  the  paroxysms  or 
maniacal  exacerbations  of  remittent  epileptic 
insanity.  In  the  continuous  form  the  mental 
trouble  persists  throughout,  not  essentially  modi- 
fied by  the  recurrence  of  the  fits.  In  either 
instance  dementia,  imbecility,  or  a range  of 
symptoms  very  similar  to  those  of  general 
paresis,  is  more  noticeable  than  the  uncon- 
sciousness with  high  irritability  and  sudden 
violent  acts  observed  in  the  intermittent  cases. 
The  remittent  and  continuous  forms  offer  no  em- 
barrassment as  to  their  diagnosis,  and  affor .. 
upon  close  examination,  the  most  typical  exam- 
ples of  folic  circidaire. 

The  intermittent  cerebral  epilepsy,  which 
occurs  in  no  proximate  connection  with  any 
fit  of  grand  mal  or  petit  'mal,  corresponds  to 
the  lariated  epilepsy  of  Morel,  intellectual  epi- 
lepsy of  Maudsley,  psychical  epilepsy  of  Ivraft- 
Ebing ; and  most  of  the  cases  of  the  so-called 
instinctive  mania  ( manic  sans  delire),  and  of 
mania  transitoria  also  belong  to  this  category. 
The  main  points  to  observe  in  this  perplexing 
aspect  of  the  spasmodic  neurosis  are  the  follow- 
ing:-— Cerebral  epilepsy  implies  an  advanced 
stage  of  the  epileptic  malady,  but  may  and  does 
nevertheless  appear  at  any  time  throughout  its 
progress,  even  when  it  has  been  developed  in  a 
sort  of  hidden  or  larvatcd  manner.  The  dis- 
crimination between  larvatcd  epilepsy  and  other 
forms  of  intermittent  mania  is  rendered  easy  by  a 
reliable  account  of  the  antecedents  of  the  patient. 
The  demonstration  of  parents  stained  with  any 
constitutional  nervous  disease,  or  addicted  to  in- 
temperance, an  extreme  susceptibility  to  anger, 
with  strange  peculiarities  of  character,  moral 
depravity,  and  a more  or  less  dwarfed  develop- 
ment of  the  intellectual  faculties,  in  addition  to 


EPILEPTIC 

'lie  onset  of  fits  during  infancy,  or  adolescence, 
and  subsequent  vertigo  or  fainting  fits  or  in- 
stantaneous absence  and  giddiness,  are  elements 
of  diagnosis  which  evince  the  true  epileptic 
Dature  of  any  transitory,  instinctive,  or  mental 
disorder  that  has  recurred  without  variation, 
or  with  such  a complete  resemblance  to  the 
preceding  paroxysms  as  we  notice  but  excep- 
tionally in  any  other  kind  of  mania.  The  at- 
tacks of  cerebral  epilepsy  recur  with  the  period- 
icity and  similar  premonitory  symptoms  peculiar 
to  other  epileptic  paroxysms.  When  displayed 
from  the  beginning,  as  after  traumatic  injury 
to  the  head,  syphilis,  &c.,  they  ordinarily  recur 
at  shorter  intervals  than  otherwise.  The  mani- 
festations of  cerebral  epilepsy  are  never  soli- 
tary, they  involve  a repetition  of  fits  of  men- 
tal or  physical  character.  Consequently,  sueh 
insanity,  as  already  advanced,  discloses  an  active 
but  not  ultimate  progress  of  the  epileptic  malady, 
and  hence  the  possibility  of  its  cure  or  relief. 
Epileptic  insanity  is  rarely  manifest  before 
nuberty,  for  idiotcy  accompanies  congenital  epi- 
lepsy in  idiotic  epileptics,  and  imbecility  the 
epilepsy  which  develops  itself  during  childhood 
in  epileptic  imbeciles.  There  is  a clear  relation 
between  the  intensity  and  length  of  the  epileptic 
insanity  and  the  impediment  to  the  cerebral  cir- 
culation, which  in  its  extreme  degrees  may  ter- 
minate in  meningitis.  Giddiness  withperspiration 
of  the  head,  sometimes  very  profuse,  and  epis- 
taxis,  are  symptoms  existing  during  or  imme- 
diately after  the  paroxysms.  The  cerebral 
congestion  is  further  betrayed  by  the  bloated  and 
livid  appearance  of  the  face;  the  injection  of  the 
conjunctivse,  with  a thick  white  discharge  col- 
lected in  the  angles  of  the  eyelids  ; and  the  heavy 
look  of  the  patient.  The  pupils  during  the  ex- 
acerbations of  the  paroxysm — when  the  patient 
becomes  boisterous  and  violent,  exhibit  a dilata- 
Lion  and  contraction,  like  that  which  may  last 
for  several  seconds  or  even  a minute  after 
the  fits  of  petit  mal  or  grand,  mal.  Slowness  of 
the  respiratory  activity,  with  marked  loss  of  its 
normal  relation  to  the  pulse,  is  regularly  detected 
in  every  case  where  the  epileptic  habit  has  become 
well  established,  as  also  an  increased  temperature 
of  the  skin  before  the  explosion  of  the  attack, 
ordinarily  attended  with  incontinence  of  urine 
when  it  takes  place  during  sleep  in  nocturnal 
epilepsy.  There  is  always  at  the  close  of  the 
fit  of  epileptic  insanity  a period  of  sleep,  which 
effects  the  transition  to  a sound  condition  of 
mind.  This  sleep  may  bo  prolonged  several 
hours,  accompanied  by  a heavy  breathing  or 
snoring,  which  makes  it  easily  mistaken  for  the 
sleep  of  drunkenness,  a mistake  strongly  coun- 
tenanced by  the  quick  recovery  of  the  patient. 
Another  conspicuous  sign  of  epileptic  insanity  is 
the  epileptic  echo,  or  repetition  by  the  patient  of 
the  same  word  or  phrase  addressed  to  him,  or 
present  in  his  mind.  Romberg  has  described 
the  echo  sign  as  indicative  of  softening  in  cere- 
bral diseases,  but  in  epilepsy  it  chiefly  evinces  a 
perverted  will.  The  phenomenon  renders  itself 
very  evident  in  the  writings  of  the  epileptic  in- 
sane. even  during  the  very  occurrence  of  tbe 
fit,  thus  affording  confirmation  of  the  automatic 
repetition  of  motory  and  intellectual  acts  so 
peculiar  to  epilepsy. 


INSANITY.  453 

Morbid  sensorial  phenomena  of  various  kinds 
existed  in  80  per  cent,  of  267  cases  of  epileptic 
insanity.  Hallucinations  of  hearing  were  re- 
corded in  62  percent.  of  the  said  number;  of  sight 
in  53  per  cent. ; of  hearing  and  sight  in  42  per 
cent.  ; of  smell  in  6 percent. ; and  finally  about 
30  per  cent,  of  the  cases  showed  some  disturbance 
of  general  sensibility,  such  as  anaesthesia,  hy- 
persesthesia,  &e.  If  we  take  into  account  the 
almost  constant  occurrence  of  some  of  these  mor- 
bid sensations,  and  the  hyperaesthetic  condition 
attending  epileptic  insanity,  it  will  not  be  diffi- 
cult to  realise  the  manner  in  which  its  victims 
are  fascinated  by  the  feelings  they  experience, 
which  ordinarily  assume  the  most  frightful  and 
deceitful  character.  Whenever  we  have  data  for 
comparison,  we  shall  see  that  the  hallucinations 
of  hearing  are  the  most  frequent,  as  shown  by 
the  foregoing  statistics.  Morel  has,  with  great 
propriety,  insisted  on  the  unmistakable  character 
of  these  hallucinations  of  hearing,  and  the  piercing 
sudden  noises,  usually  heard  by  epileptics,  dif- 
fering entirely  from  the  noises  complained  of  by 
those  labouring  under  the  delirium  of  persecu- 
tions, which  always  lead  an  attentive  observer 
to  a definite  diagnosis  of  cerebral  epilepsy. 

Tbe  intellectual  aura,  which  like  precursory 
clouds  of  a threatening  storm  may  anticipate  the 
outbreak  of  a fit  of  cerebral  epilepsy,  is  an  acces- 
sory symptom  common  to  all  the  attacks,  already 
noticed  in  the  general  description.  In  regard 
to  the  moral  and  intellectual  changes  which  cha- 
racterise epilepsy,  and  may  be  superinduced  from 
its  very  outset,  effacing — as  Maudsley  says — the 
moral  sense  as  it  effaces  the  memory,  there  is  one 
brief  remark  to  be  made.  Such  moral  depravity 
is  more  apt  to  occur  from  the  very  inception  of 
tbe  attacks,  when  epilepsy  is  induced  by  a trau- 
matic injury  to  the  head ; its  appreciation  is 
beset  with  difficulties,  and  although  these  morbid 
dispositions  do  not  constitute  a state  of  insanity, 
they  must  place  tbe  epileptic — as  justly  declared 
by  Baillarger — beyond  the  common  rule,  and  ex- 
tenuate at  least  his  legal  responsibility. 

Legai.  Relations. — Bearing  in  mind,  the  reflex 
nature  of  the  physical  and  mental  phenomena 
inherent  in  epilepsy,  and  our  inability  to  avoid 
tbe  effects  of  reflex  actions,  it  follows  as  a matter 
of  course  that  epileptics  should  be  regarded  irre- 
sponsible for  any  criminal  act  they  might  commit 
under  the  influence  of  a paroxysm.  Those  familiar 
with  epileptics  know  that  the  majority  have  no 
knowledge,  or  at  least  a very  imperfect  idea,  of 
their  misdeeds,  such  state  of  unconsciousness  being 
the  chief  characteristic  of  epileptic  insanity 
generally.  This  unconscious  cerebration  exhibits 
itself  in  a high  degree  in  epilepsy,  but  is  not 
peculiar  to  it,  for  we  observe  it  more  or  less  in 
all  forms  of  insanity,  and  notably  in  somnambu- 
lism. Finally, a clear  demonstration  of  the  above- 
described  phenomena  is  indispensable  before  we 
can  fully  appreciate  or  decide  upon  tbe  nature 
of  any  act  perpetrated  during  an  alleged  condition 
of  epilepsy. 

The  reasons  here  briefly  presented  for  the  ir- 
responsibility of  confirmed  epileptics  prove  no 
less  forcibly  that  society,  in  its  turn,  must  be 
protected  from  their  misdeeds,  since  they  are 
unquestionably  thexnost  dangerous  class  of  in- 
dividuals. Therefore  criminal  epileptics  should 


154  EPILEPTIC  INSANITY. 

never  be  allowed  to  go  at  largo  until  sufficient 
time  has  elapsed  to  demonstrate  the  arrest  of 
their  malady,  upon  continued  observation  by  a 
competent  physician. 

Treatment. — The  treatment  of  epileptic  in- 
sanity does  not  differ  from  that  of  epilepsy  gene- 
rally (see  Epilepsy).  Let  it  be  simply  noticed 
thatergotine  in  doses  of  three  to  six  grains,  and 
succus  conn  in  doses  of  three  drachms  to  one 
ounce,  in  often  repeated  doses,  with  counter-irri- 
tation to  the  lower  part  of  the  neck  (seton  or 
cautery),  and  cold  shower-baths  or  packing,  are 
among  the  most  reliable  means  to  be  resorted  to, 
to  abate  or  prevent  the  great  excitement  of  the 
insane  epileptic.  M.  Gr.  Echeverria. 

EPIPHORA  (eirl,  upon,  and  <f>e'p«,  I carry). 
A flow  of  tears,  so  persistent  that  they  run  down 
the  cheek,  due  either  to  obstruction  of  the 
lachrymal  duct  or  to  excessive  secretion.  See 
Lachrymal  Apparatus,  Diseases  of. 

EPIPHYTA  (eirl,  upon,  and  tpurby,  a plant). 
These  are  the  plant-like  organisms  found  on 
the  skin,  and  its  appendages  or  on  mucous  sur- 
faces, the  so-called  vegetable-parasites,  originating 
certain  diseases,  such  as  the  various  forms  of  tinea 
and  thrush.  The  more  important  of  them  are  the 
Achorion,  Trichophyton,  and  Microsporon.  The 
achorion  Schoenleinii  is  the  vegetable  fungus 
which  constitutes  the  mass  of  the  crusts  of  favus, 
and  belongs  to  the  group  of  Oidiie.  The  tricho- 
phyton is  the  dermatophyte  of  tinea  and  sycosis, 
and  is  found  in  the  substance  of  the  hair  as  well 
as  in  the  epidermis.  The  microsporon,  termed 
Epidermophyton  by  Bazin,  is  the  parasitic  fungus 
of  phytosis  versicolor.  Both  the  latter  are  mem- 
bers of  the  group  of  Torulacese.  See  Epiphytic 
Skin-Diseases,  and  Aphthae.  Erasmus  Wilson. 

EPIPHYTIC  SKIN-DISEASES,— 

Synon.  : Vegetable  parasitic  skin-diseases ; 

Tinea ; Dermatophytic  diseases. 

Definition. — Epiphytic  diseases  are  diseases 
due  to  the  attack  upon  the  integuments  of  para- 
sitic fungi. 

Description. — Speaking  generally  it  may  be 
said  that  an  epiphytic  disease  consists  of  three 
component  elements— (a)  a soil  favourable  to  the 
growth  of  the  attacking  epiphyte  ; ( b ) the  grow- 
ing epiphyte  itself ; and  ( c ) the  effects  produced 
upon  the  skin-tissues  by  the  development  and 
increase  amongst  them  of  the  epiphyte. 

Epiphytic  Soil.  — As  regards  the  soil  it  is 
difficult  to  exactly  describe  it,  but  it  is  indis- 
putable that  the  young,  those  whose  assimila- 
tion is  at  fault,  the  lymphatic,  and  fair  children, 
furnish  a soil  peculiarly  favourable  to  the  growth 
of  vegetable  parasites. 

The  Epiphyte. — The  epiphyte  itself  consists  of 
reproductive  cellular  bodies  called  conidia  or 
sometimes  spores,  formed  of  an  outer  envelope 
composed  of  cellulose,  and  an  inner  membrane 
or  utricle,  enclosing  granules  floating  in  a liquid, 
and  mycelial  filaments.  The  spores  are  round 
(as  in  tinea  tonsurans)  or  oval  (as  in  favus). 
having  an  average  diameter  of  ’006  mm.,  and 
furnished  in  most  cases  with  a nucleus.  These  co- 
nidia are  double-contoured,  solitary,  or  arranged 
in  rows,  or  massed  in  groups  (tinea  versicolor). 
The  mycelial  threads  vary  somewhat  in  appear- 
ance ; they  may  be  fine  transparent  filaments,  or 


EPIPHYTIC  SKIN-DISEASES. 

large  distinct  double-walled  tubes.  They  are 
jointed  by  real  dissepiments,  and  more  or  less  con- 
stricted, and  contain  granules  and  cells,  whilst 
the  terminal  filaments  bear  various  forms  of 
fructification.  In  many  cases  there  is  a stroma, 
made  up  of  a number  of  very  small  grannies, 
resulting  from  the  subdivision  of  the  grannies  and 
cells  in  the  interior  of  the  filaments,  and  even  of 
the  conidia.  Some  question  the  vegetable  nature 
of  these  fungus-elements,  and  aver  that  they  re- 
present a granular  degeneration  of  normal  skin- 
structure  ; but  no  transitional  stages  have  been 
discovered  betwixt  the  two  structures.  Further, 
these  fungi  can  he  made  to  develop  the  character- 
istic fructification  of  the  common  moulds  of  un- 
doubted vegetable  nature,  and  similar  fungi  occur 
in  situations — as  the  hard  structure  of  corals,  &e. 
— in  which  they  could  not  have  been  derived  from 
any  kind  of  epithelial  or  other  animal  tissue. 
Conidia  may  readily  be  mistaken  for  fatty  gra- 
nules and  vice  versd.  But  the  former  refract  light 
strongly,  are  nucleated,  and  unaffected  by  ether  in 
the  least  degree. 

Effects. — Concerning  the  effects  induced  by 
their  growth  in  the  skin,  it  may  he  said  that 
fungi  act  like  ordinary  irritants,  inducing  in- 
flammation of  the  skin ; and  as  the  fungi  grow 
equally  in  all  directions  from  a given  centre, 
the  eruption  is  usually  circular.  Its  signs  are 
most  marked  at  the  circumference,  where  the 
fungus  is  in  its  most  active  state ; but,  in  ad- 
dition, the  fungus  invades  the  epithelial  tis- 
sues ; grows  downwards  into  the  follicles, 
causing  irritation  and  effusion  therein ; then  gra- 
dually attacks  the  hairs  or  hair-shafts,  absorbing 
their  moisture,  separating  the  component  fibres, 
and  causing  the  hairs  to  become  thickened, 
more  or  less  opaque,  twisted,  uneven  in  size 
along  the  shaft,  and  brittle,  so  that  they  easily 
break.  Nothing  but  the  growth  of  fungi  in  them 
can  produce  the  disease  of  the  hair  observed  in 
the  epiphytic  diseases. 

Varieties. — There  are  seven  clinical  varieties 
of  undoubted  epiphytic  diseases,  and  an  ad- 
ditional one,  about  which  great  difference  of 
opinion  has  been  expressed.  The  seven  are  as 
follows  : — 

1.  Tinea  favosa  or  favus,  or  honeycomb  ring- 
worm, caused  by  the  achorion  Schonleinii. 

2.  Tinea  tonsurans  (ordinary  ringworm  of  the 
scalp),  the  fungus  occurring  in  connection  with 
it  being  termed  trichophyton  tonsurans. 

3.  Tinea  kerion,  a modification  of  the  last- 
named,  having  the  same  parasite,  and  being 
characterised  by  inflammatory  prominence  of 
the  follicles,  and  exudation  therefrom  of  viscid 
fluid. 

4.  Tinea  circinata  (ordinary  ringworm  of  the 
body),  including  the  ringworms  of  Oriental 
places, — Burmese,  Chinese,  Indian  ringworm, 
&c.,  having  the  same  parasite  as  tinea  tonsurans, 
and  only  differing  from  it  essentially  in  the  fact 
of  its  occurrence  on  the  non-hairy  parts. 

5.  Tinea  sycosis,  or  ringworm  of  the  beard ; 
the  parasite  being  microsporon  mentagraphytes. 

C.  Tinea  versicolor  or  phytosis  versicolor,  the 
chloasma  of  English  writers ; the  parasite  of 
which  is  microsporon  furfur. 

7.  Onychia  parasitica  or  onychomycosis,  para- 
sitic disease  of  the  nails,  caused  by  the  growth 


EPIPHYTIC  SKIN-DISEASES, 
in  the  nail  of  the  fungus  of  tinea  tonsurans  or 
tinea  favosa ; in  other  words,  the  trichophyton 
or  the  achorion. 

At  one  time  it  was  thought  that  the  disease 
known  as  tinea dccalvans  was  parasitic  and  caused 
by  the  growth  of  the  microsporon  Audouinii,  but 
this  is  at  present  a disputed  point.  See  Alopecia. 

These  several  variecies  of  tinea  will  be  de- 
scribed in  detail  under  that  heading. 

Treatment. — The  principles  of  treatment  in 
parasitic  disease  consist  in  improving  the  tone 
of  the  nutrition,  and  in  bringing  parasiticides 
into  contact  with  the  fungus-elements,  so  as 
to  ensure  their  destruction ; the  latter,  however, 
is  a matter  of  much  difficulty  when  the  fungi 
are  imbedded  deep  in  the  hair-follicle,  or  in  the 
lower  parts  of  the  shafts  of  the  hairs  of  the 
scalp.  See  Tinea.  Tilbury  Eox. 

EPIPLOITTS  (eiriTr \oov,  the  omentum). — 
Inflammation  of  the  epiploon  or  great  omen- 
tum. See  Periton.t;um,  Diseases  of. 

EPISPADIAS  (eVl , upon,  and  o-ttoco,  I 
draw). — A malformation  of  the  penis,  in  which 
the  urethra  opens,  on  its  upper  surface.  Sec 
Penis,  Diseases  of. 

EPISPASTICS  ( eVl, upon, and  atrda.  Idraw). 
Substances  which,  when  applied  to  the  skin,  are 
capable  of  producing  a blister.  See  Counter- 

irritants. 

EPISTAXIS  (fVI.upon,  and  ardfa,  I drop). 
Synon.  : Er.  Epistaxis ; Ger.  Nascnbluten. 

Definition. — Epistaxis  signifies  a bleeding 
from  the  nose. 

^Etiology. — Epistaxis  is  either  traumatic  or 
idiopathic. 

The  traumatic  form  may  be  occasioned  by 
violent  sneezing,  by  snuffing  up  irritating  sub- 
stances, or  by  direct  violence  ; hut  in  these  cases 
there  frequently  appear  to  he  general  or  local 
predisposing  causes,  to  account  for  the  readiness 
with  which  it  occurs,  such  as  a hsemorrhagic 
diathesis,  an  inflammatory  or  congestive  hyper- 
emia, or  some  ulceration  of  the  mucous  mem- 
brane. 

The  idiopathic  form  of  epistaxis  frequently 
occurs  in  children,  particularly  hoys,  just  before 
or  about  the  age  of  puberty,  and  in  girls  as  a 
form  of  vicarious  menstruation.  Epistaxis  may 
he  one  of  the  forms  of  bleeding  in  persons  of 
hremorrhagie  diathesis,  inwhich  case  it  is  a source 
of  anxiety  and  difficulty.  Occurring  in  advanced 
life,  it  may  he  indicative  of  over-distension  or 
obstruction  of  the  cerebral  venous  system  from 
chronic  Bright's  or  cardiac  disease ; and  the 
blood  which  flows  is  then  often  venous  in  ap- 
pearance, Occasionally  it  occurs  as  a spontaneous 
relief  to  determination  of  blood  to  the  head,  in 
which  form  the  blood  generally  proceeds  from 
one  nostril  only.  In  other  instances  epistaxis 
is  connected  with  serious  disorder  of  the  blood, 
ns  in  the  specific  fevers.  Thus  it  is  often  asso- 
ciated from  the  outset  with  remittent,  enteric, 
typhus,  or  scarlet  fever,  and  is  indeed  regarded 
in  some  degree  as  pathognomonic  of  enteric 
fever.  It  may  also  attend  scurvy,  purpura  hse- 
morrhagiea,  splenic  disease,  pyaemia,  and  erysi- 
pelas, being  a sequence  of  the  septic  condition. 

In  its  passive  form,  epistaxis  is  often  associ- 


EPISTHOTOKOS.  45b 

ated  with  organic  disease  of  the  heart,  pleurisy, 
emphysema;  or  with  ascites  or  ovarian  dropsy, 
on  account  of  pressure  on  the  diaphragm  inducing 
a stasis  of  the  venous  circulation.  It  may  occur 
spontaneously  from  exposure  either  to  great  cold 
or  great  heat,  or  a sudden  change  from  cold  to 
heat,  or  from  the  diminution  of  atmospheric 
pressure,  as  in  going  up  high  mountains. 

Symptoms. — Haemorrhage  from  the  nose  is  too 
familiar  to  demand  description  in  this  place. 
The  flow'  of  blood  may  be  either  continuous  or 
drop  by  drop.  As  a rule,  the  escape  of  blood  is 
from  one  nostril,  bleeding  from  both  being  rare. 
It  may  last  a very  short  time,  or  for  some  hours, 
and  in  severe  instances  for  days,  causing  syncope, 
or  even  being  attended  with  fatal  results.  It  is 
at  times  met  with  as  occurring  periodically. 

Diagnosis. — Epistaxis  must  not  be  confounded 
with  haemoptysis,  as  may  happen  if  the  epistaxis 
takes  place  posteriorly,  and  the  blood  passes  into 
the  mouth. 

Treatment. — "When  epistaxis  is  obviously  a 
salutary  process,  as  it  undoubtedly  is  in  a good 
many  instances,  it  subsides  spontaneously ; where 
it  occurs  frequently  and  severely,  recourse  must 
be  had  to  mechanical,  cutaneous,  and  internal 
remedies.  The  local  application  of  cold  in 
the  form  of  cold  water  or  iced  compresses  to 
the  nose,  neck,  or  forehead  is  most  useful,  acting 
as  these  agents  do  either  directly  or  by  inducing 
a reflex  effect  on  the  vaso-motor  nerves.  Simple 
pressure  upon  the  nostril,  or  upon  the  septum 
nasi,  by  compressing  the  bleeding  nostril  with 
the  finger  of  the  opposite  hand,  while  the  arm  of 
the  affected  side  is  raised  above  the  head,  is  the 
most  readily  practicable  and  effectual  of  ail 
measures.  The  application  of  mustard  over  ths 
stomach  or  upon  the  ankles  is  sometimes  success- 
ful. When  simple  means  fail,  astringents,  either 
in  the  form  of  solution  or  powders,  may  he  in- 
jected into  the  cavities,  or  applied  on  plugs  of 
lint  or  cotton-wool,  such  as  alum,  acetate  of  lead, 
the  salts  of  iron,  or  gallic  or  tannic  acid. 

Internally,  the  frequent  administration  in 
small  doses  of  tinctura  ferri  perchloridi,  tur- 
pentine, bromide  of  potassium,  or  belladonna  and 
quinine  may  he  necessary  in  cases  of  periodic 
attacks. 

In  very  severe  cases  the  operation  of  plugging 
the  nares,  and  thereby  favouring  the  formation 
of  a clot,  must  he  resorted  to,  and  the  most  ready 
and  easiest  method  is  by  the  employment  of  Bel- 
locq’s  sound,  or  more  properly  canula.  If,  how- 
ever, this  instrument  be  not  at  hand,  a catheter 
or  an  eyed  probe  should  be  threaded  with  a stout 
silk  or  hemp  ligature,  and  pushed  along  the  floor 
of  the  nose,  until  it  protrudes  beyond  the  velum 
palati ; one  end  of  the  thread  should  now  he 
pulled  out  of  the  mouth  by  the  fingers  or  forceps, 
and  a roll  of  lint  or  a piece  of  sponge  tied  to  it, 
and  then  pushed  up  behind  the  velum.  Tbs 
catheter  and  the  attached  thread  being  now  with- 
drawn through  the  nostril,  the  plug  is  pulled 
forcibly  against  the  posterior  nares,  and  by  the 
pressure  exerted  the  haemorrhage  can  generally 
be  arrested.  Edward  Bellamy. 

EPISTHOTONOS  (imo-dev,  forwards,  and 
tAvw,  I extend). — A synonym  for  emprosthotc 
nos.  See  Empeosthotonos. 


t56  EPITHELIOMA. 

EPITHELIOMA  (eVl,  upon,  &£\\a,  I grow 
— epi  thelium ; and  &ybs,  like). — A variety  of  cau- 
ser, consisting  essentially  cf  epithelial  elements. 
See  Canceb. 

EPITHELIUM,  Diseases  of.— The  differ- 
ent kinds  of  epithelium  must  be  separately  con- 
sidered, as  they  differ  in  their  pathological 
relations,  namely,  squamous  and  cylindrical  epi- 
thelium of  mucous  surfaces ; serous  epithelium,  or 
endothelium ; and  finally  spheroidal  or  glandular 
epithelium.  The  last  kind  will  be  better  treated 
of  under  the  heads  of  the  several  glands. 

A.  Diseases  op  Squamous  and  Cylindrical 
Epithelium.— 1.  Catarrhal  Inflammation. — 
Both  varieties  of  epithelium  occurring  on  mucous 
surfaces  are  subject  to  inflammation,  which 
usually  takes  what  is  called  the  catarrhal  form. 

Catarrhal  inflammation  is  characterised  by 
hyperaemia,  swelling  of  the  tissue,  rapid  pro- 
duction and  casting-off  of  cells,  and  increased 
production  of  the  normal  mucous  secretion  of 
ihe  parts,  without  the  production  of  any  coagu- 
lable  exudation,  or  any  layer  of  new  material. 
The  cells  thrown  off  are  partly  epithelial,  partly 
leucocytes  or  pus-cells.  The  secretion  contains 
mucin.  The  proportion  of  the  various  factors  of 
catarrhal  inflammation  varies  greatly,  sometimes 
hyperaemia  with  swelling,  sometimes  cell-produc- 
tion, sometimes  fluid  secretion  predominating ; 
and  these  differences  sometimes  mark  different 
degrees  or  stages  of  the  inflammatory  process. 
When  the  number  of  leucocytes  thrown  off  is 
very  large,  the  catarrh  becomes  purulent,  which 
differs  only  from  the  other  in  degree.  Catarrhal 
inflammation  is  the  ordinary  result  of  irritation 
applied  to  a mucous  surface ; but  it  persists 
after  the  irritation  has  ceased,  and  has  a 
marked  tendency  to  become  chronic.  While  the 
chief  share  in  producing  and  maintaining  the 
phenomena  of  catarrh  must  be  referred  to  the 
condition  of  the  blood-vessels  of  the  mucous 
membrane,  the  part  played  by  the  epithelial 
eells  in  these  processes  is  a point  of  great  in- 
terest and  importance,  though  as  yet  imperfectly 
determined.  These  cells,  whether  squamous  or 
cylindrical,  enlarge  and  alter  in  shape,  while 
there  must  be  (since  so  many  are  shed)  a rapid 
new  formation  of  them  ; but  the  seat  of  this 
new  formation,  whether  in  the  normal  or  the  pa- 
thological condition,  is  still  obscure.  Further, 
it  is  not  unusual  to  find  swollen  epithelial  eells 
which  show  division  of  the  nuclei  or  partial 
division  of  the  cell  itself,  and  others  which  show 
within  their  substance  several  smaller,  round- 
ish bodies,  with  the  general  character  of  young 
cells.  These  appearances  have  been  regarded 
as  indicating  (1)  multiplication  of  cells  by 
fission,  (2)  endogenous  cell-formation  within  the 
mother-cells,  and  (3)  the  origin  of  the  numerous 
pus-corpuscles  seen  on  the  inflamed  surface. 
There  is,  however,  no  reason  for  thinking  that 
new  epithelial  cells  are  thus  formed.  By  others 
again  the  presence  of  pus-corpuscles  or  young 
cells  within  the  epithelial  cells  is  regarded  as 
an  unimportant  and  accidental  complication,  the 
young  cells  which  possess  the  power  of  migra- 
tion being  absorbed  into  the  protoplasm  of  the 
epithelial  cells,  so  as  to  appear  as  if  originally 
formed  there.  The  production  of  vacuoles  or 


EPITHELIUM,  DISEASES  OF. 

spaces  in  the  altered  epithelial  elements  is  also 
explained  in  two  ways,  either  as  a part  of  the 
process  of  cell-proliferation,  or  as  indicating 
partial  absorption  of  the  substance  of  the  celL 
It  must  therefore  be  regarded  as  still  uncertain, 
whether  epithelial  cells  do,  by  a process  of  pro- 
liferation, give  rise  to  any  new  elements. 

2.  Croupous  Inflammation. — Croupous  in- 
flammation is  distinguished  by  showing,  in  addi- 
tion to  hyperaemia  and  swelling,  the  production 
of  a layer  of  new  material,  or  false  membrane, 
easily  detached  from  the  surface.  This  form  is 
usually,  if  not  exclusively,  seen  on  surfaces 
covered  with  cylindrical  epithelium,  as  in  the 
air-passages.  The  false  membrane,  composed  of 
fibrin  cementing  together  layers  of  detached 
epithelium  and  leucocytes,  does  not  owe  its 
origin  to  any  alteration  of  the  epithelium  itself. 

Croupous  inflammation  of  epithelial  surfaces 
has  been  regarded  as  always  indicating  some 
specific  form  of  inflammation.  It  now  appears, 
however,  that  it  may  be  produced  by  simple 
irritation,  such  as  that  which  produces  the 
catarrhal  form,  provided  the  irritation  be  suffi- 
ciently intense. 

3.  Diptheritie  Inflammation. — This  is  a 
name  used  with  much  variation  of  meaning,  hut 
generally  to  signify  a process  in  which  there  is 
production  of  a false  membrane  closely  adherent 
to  the  epithelial  surface,  and  which  is  accom- 
panied by  some  degree  of  necrosis  or  gangrene. 
In  the  production  of  the  diphtheritic  false  mem- 
brane an  important  part  has  been  assigned  to 
the  epithelium,  it  being  held  that  the  new 
material  which  appears  like  exuded  fibrin  is 
really  produced  by  a metamorphosis  (the  so-called 
fibrinous  transformation)  of  the  . pavement  epithe- 
lium. It  is  pretty  clear  that  when  this  condition 
occurs  on  surfaces  covered  with  this  variety  ot 
epithelium  some  such  change  in  the  epithelium 
does  take  place,  but  not  that  the  membrane  is 
made  up  wholly  or  even  in  any  large  degree  of 
such  altered  cells.  Moreover,  even  this  cannot, 
be  clearly  traced  on  surfaces  covered  with  cylin 
drical  epithelium.  The  membranes  consist  in 
large  measure  of  cast-off  epithelium,  and  also  (as 
the  writer  holds)  partly  of  fibrin,  though  the  pre- 
sence of  the  latter  constituent  is  denied  by  some 
authors.  It  should  be  noted  that  the  terms 
croupous  and  diphtheritic  inflammation,  as  here 
used,  are  not  synonymous  with  the  diseases 
named  croup  and  diphtheria. 

4.  Patty  Degeneration. — It  is  very  common 
to  find  the  protoplasm  of  both  squamous  and 
cylindrical  epithelial  cells  dotted  with  oil-glo- 
bules, so  much  so  that  this  must  be  considered 
normal,  to  a certain  extent,  in  some  glandular 
epithelium  (as  kidney),  and  does  not  appear  to 
interfere  with  the  function  of  the  cells.  When 
the  fatty  change,  however,  is  extensive,  and 
more  especially  when  the  whole  body  of  the  cell 
is  opaque,  the  condition  must  be  regarded  as  one 
of  fatty  degeneration  (see  Fatty  Degeneration). 
This  is  seen  in  the  stomach  in  cases  of  alcohol- 
ism, in  poisoning  with  metals  or  phosphorus, 
and  in  cases  which  are  probably  nothing  more 
than  chronic  catarrh.  It  is  also  seen  in  the 
alveolar  epithelium  in  pulmonary  emphysema. 
Fatty  degeneration  appears  in  epithelium  to  b< 
a process  leading  to  atrophy. 


EPITHELIUM,  DISEASES  OF. 

5.  Mucous  or  Colloid  Degeneration. — 
Epithelial  cells,  especially  in  parts  which  are 
naturally  adapted  to  the  production  of  mucus, 
particularly  cylindrical  epithelium,  are  liable 
to  undergo  a form  of  degeneration  in  which  a 
portion  of  their  protoplasm  becomes  converted 
into  mucous  substance,  and  thus  liquefied.  Cells 
having  this  character  are  often  seen  in  catarrhal 
conditions  of  the  mucous  membrane  of  the  air- 
passages,  but  the  change  does  not  appear  to  occur 
as  a substantive  disease.  It  has  not  been  traced 
in  squamous  epithelium. 

C.  Albuminoid  (Waxy  or  Amyloid)  De- 
generation.— This  form  comparatively  rarely 
affects  epithelial  cells,  but  still  in  cases  of  albu 
minoid  disease  we  may  sometimes  find  that  the 
mucous  surface  of  the  intestines  is  stained  with 
iodine  in  the  characteristic  manner.  In  one  or 
two  cases  the  writer  has  observed  a similar 
change  in  the  surface  of  the  pelvis  of  the  kidney, 
and  even  the  bladder,  where  there  has  been 
albuminoid  disease  of  the  kidney. 

B.  Diseases  of  Endothelium. — The  single 
layer  of  flat  epithelium  found  on  serous  surfaces, 
which  differs  so  much  from  the  other  forms  as 
to  be  now  generally  known  by  another  name, 
endothelium,  differs  also  in  its  pathological  re- 
lations. 

1.  Catarrhal  Inflammation  is  unknown  on 
serous  membranes,  their  characteristic  form  of 
inflammation  being  exudative  and  fibrinous, 
corresponding  thus  to  the 

2.  Croupous  Inflammation  of  mucous  sur- 
faces. In  this  inflammation  the  endothelium 
does  not  necessarily  take  any  part,  though  when 
the  inflammation  is  once  established  the  endo- 
thelium is,  in  part,  simply  shed,  in  part  shows 
changes  of  a proliferative  kind ; cell-division, 
multiplication,  and  endogenous  cell-formation 
being  observed  here  with  less  ambiguity  (as  it 
appears  to  the  writer)  than  in  the  epithelium  of 
mucous  surfaces.  Similar  changes  appear  to 
occur  in  chronic  inflammation  of  serous  sur- 
faces, and  to  play  an  important  part  in  the  pro- 
duction of  fibrous  adhesions  between  opposing 
surfaces. 

3.  Fatty  Degeneration. — Endothelial  cells 
are  also  subject  to  fatty  degeneration,  which  may 
be  very  clearly  seen  in  surfaces  macerated  by  a 
collection  of  fluid,  as  in  serous  effusions  of  the 
peritoneum  or  pleura. 

The  other  pathological  changes  of  endothelium 
have  not  been  studied. 

The  epithelium  (or  endothelium)  lining  the 
inner  surfaces  of  the  walls  of  arteries  and  veins, 
closely  resembles  the  endothelium  of  serous 
surfaces.  It  is  very  subject  to  fatty  degenera- 
tion, as  maybe  seen  on  examining  atheromatous 
arteries.  Proliferative  changes  have  also  been 
traced  by  some  observers  in  the  process  of  occlu- 
sion of  ligatured  arteries  or  veins  obstructed  by 
thrombosis  ; but  they  do  not  appear  to  play  any 
important  part  in  idiopathic  disease. 

C.  Diseases  of  Glandular  Epithelium. — The 
diseases  of  glandular  epithelium  are  best  spoken 
of  under  the  head  of  diseases  of  the  several 
g'ands.  See  Breast,  Diseases  of ; &c. 

J.  F.  Payne. 

EPITHEM  (eirl,  upon,  and  -rlBripi,  I place). 


ERGOTISM.  457 

A general  term  for  a class  of  external  applica- 
tions which  are  soft  and  moist,  such  as  poultices 
and  fomentations.  See  Fomentations,  and  Poul- 
tices. 

EPIZOA  (eVl,  upon,  and  (dor,  an  animal). — A 
term  formerly  much  used  by  zoologists  to  charac- 
terise a peculiar  and  distinct  group  of  parasitic 
creatures  which  attach  themselves  to  fishes,  but 
now  more  generally  employed  to  embrace  all 
kinds  of  parasites  having  the  habit  of  residing 
in  or  upon  the  surface  of  the  body  of  man  and 
animals.  In  the  wrriter’s  judgment  the  more  com- 
prehensive term  F.ctozoa  is  preferable,  and  the 
distinctions  which  have  been  created  as  to  the 
relative  value  of  these  two  terms  ought  to  be 
abolished.  In  any  case  it  should  be  understood 
that  the  equivalent  terms  epizoa  and  ectozoa 
have  no  zoological  significance,  being  simply  em- 
ployed for  convenience’  sake  when  we  are  speak- 
ing of  external  parasites,  of  whatever  character ; 
in  contradistinction  to  the  term  entozoa.  The 
epizoa  comprise  such  parasites  as  lice  and  mites 
( Dermatozoa ),  and  the  term  might  also  be  made 
to  include  fleas,  bugs,  and  other  creatures  whose 
residence  on  the  surface  is  only  occasional,  and 
of  very  short  duration.  See  Parasites,  and 
Entozoa;  also  Acarus,  Demodex,  Chigoe,  Pe- 
diculus,  and  CEstrus.  T.  S.  Cobbold. 

EPULIS  (eirl,  upon,  and  oZ\ov,  the  gum). 
See  Mouth,  Diseases  of. 

EQ/ULNIA  ( equus , a horse). — A synonym  for 
glanders.  See  Glanders. 

EQDXNTA  MITIS.  See  Glanders. 

ERETHISM  (ipeOifa,  I irritate). — A con- 
dition of  excitement  or  irritation,  affecting 
either  the  whole  system  or  a particular  organ 
or  tissue.  The  word  has  been  especially  ap- 
plied to  the  condition  of  the  body  in  the  early 
stage  of  acute  diseases,  and  also  to  that  in- 
duced by  the  too  free  use  of  mercury  ( mercurial 
erethism').  See  Mercury,  Poisoning  by. 

ERGOTISM. — Synon.  : Morbus  cercalis;  Fr. 
Ergotisms  ; Ger.  Ergotismus,  Kriebclkrankheit. 

Definition. — A disease  due  to  the  action  of 
ergot  upon  the  organism. 

Aetiology. — This  disease  derives  its  name 
from  the  fact  that  it  is  the  result  of  the  ingestion 
of  ergot — the  stroma  of  a fungus  called  Clavi- 
ccps  qmrpurea,  which  grows  parasitieally  in  the 
ear  of  the  Rye.  In  some  seasons  this  form  of 
blight  affects  the  grain  so  extensively  that  ten 
per  cent,  of  the  meal  may  consist  of  ergot.  The 
phenomena  to  be  described  as  symptoms  of  er- 
gotism have  been  regularly  and  exclusively 
traced  to  the  use  of  articles  of  food  made  from 
rye-meal  thus  contaminated.  The  appearance 
and  severity  of  the  disease  vary  with  the  amount 
of  ergot  consumed.  Children  at  the  breast  are 
never  attacked.  Ergotism  h; is  frequently  broken 
out  in  well-marked  epidemics,  after  unfavour- 
able harvests.  In  ruder  times  it  constituted  a 
severe  form  of  scourge  ; but  now  it  usually  oc- 
curs sporadically,  or  is  limited  to  families  or 
small  communities. 

Anatomical  Characters. — Nothing  definite 
is  known  respecting  the  morbid  anatomy  a i 
ergotism. 


158  ERGOTISM. 

Symptoms. — "Within  a few  days  of  the  first 
ingestion  of  meal  poisoned  with  ergot,  the 
ordinary  phenomena  of  irritant  poisoning  are 
developed,  namely,  vomiting,  diarrhraa,  severe 
abdominal  pains  and  cramps,  and  general  depres- 
sion— giddiness  and  headache  being  specially 
marked. 

Along  with  the  preceding,  certain  special 
symptoms  gradually  make  their  appearance.  The 
first  and  most  characteristic  of  these  is  formi- 
cation, attended  with  severe  itching  of  the  skin 
of  the  extremities.  The  other  special  senses, 
such  as  vision  and  hearing,  may  also  become 
disordered.  Occasional  spasms  occur  in  the 
muscles.  Ravenous  hunger  is  said  to  be  a strik- 
ing symptom  in  some  instances.  The  pulse  is 
infrequent  and  small.  Respiration  is  not 
markedly  disturbed. 

The  remaining  phenomena  peculiar  to  ergot- 
ism are  usually  described  ns  belonging  to  two 
forms,  tba  gangrenous  and  the  spasmodic,  accord- 
ing as  the  circulation  or  the  nervous  system  is 
chiefly  affected. 

a.  Gangrenous  Ergotism. — Gangrene,  due  to 
ergot,  is  peculiar  only  in  respect  cf  its  cause. 
The  toes,  fingers,  feet,  ears,  and  nose  are  the 
parts  most  commonly  attacked.  The  incipient 
discolouration,  pain,  and  swelling  are  observed 
within  a period  of  two  days  to  three  weeks  from 
the  commencement  of  the  other  toxic  symptoms. 
The  necrotic  process  passes  through  the  ordinary 
stages  of  development;  may  be  either  ‘wet’  or 
‘ dry ; ’ and  advances  to  complete  separation  of 
the  part,  if  this  have  not  been  previously  re- 
moved by  operation. 

b.  Spasmodic  Ergotism. — The  leading  symptom 
of  this  form  of  the  disease  is  the  occurrence  of 
severe  intermittent  cramps  or  painful  spasms, 
specially  affecting  the  lower  extremities.  These 
develop  into  tonic  contraction  of  the  muscles, 
with  fixation  of  the  limbs;  and  end  perhaps  in 
general  convulsions,  prostration,  unconscious- 
ness, and  death.  Abortion  does  net  appear  to 
be  of  frequent  occurrence. 

Course,  Duration,  and  Terminations. — Many 
cases  of  ergotism  are  acute  rather  than  chronic  ; 
but  when  gangrene  appears,  the  course  may  he 
vei'y  protracted  and  variable.  Spasmodic  er- 
gotism may  last  from  two  weeks  to  as  many 
months.  The  mortality  is  said  to  have  fallen 
from  sixty  to  ten  per  cent.  In  a few  cases,  reso- 
lution occurs  in  affected  extremities. 

Pathology. — Beyond  its  effect  as  an  irritant 
poison,  the  specific  influence  of  ergot  is  exerted 
upon  the  organs  of  circulation,  upon  the  central 
nervous  system,  and  upon  the  uterus. 

The  Circulation. — Ergot  produces  a remark- 
able slowing  of  the  cardiac  rhythm ; the  ar- 
teries become  contracted,  with  diminution  or 
even  disappearance  of  their  channel,  or  formation 
of  thrombi ; the  blood-pressure  falls ; and  the 
veins  become  dilated  and  distended.  The  most 
recent  and  consistent  theory  respecting  these 
phenomena  is,  not  that  the  muscular  coats  of  the 
arteries  actively  contract,  hut  that  the  venous 
walls  are  primarily  relaxed.  The  veins  are  thus 
overfilled,  and  the  arteries  drained  of  blood  ; the 
biood-pressure  is  lowered  ; and  the  heart  being 
insufficiently  fed,  contracts  feebly  and  slowly. 

The  Nervous  System. — Certain  of  the  spinal 


ERUCTATION. 

centres,  both  motor  and  sensory,  are  first  stimu- 
lated and  afterwards  paralysed  by  ergot — di- 
rectly, according  to  some  authorities,  indirectly 
according  to  others. 

The  Utencs.  — The  unquestionable  action  of 
ergot  upon  the  uterus  is  explained  by  some 
authorities  as  due  to  stimulation  of  the  centre 
for  the  uterus  in  the  cord.  Others  consider  that 
ergot  acts  upon  the  muscular  fibres  of  the  organ, 
either  directly  or  indirectly  through  the  blood- 
supply. 

Whatever  may  be  the  value  of  the  several  ‘ ex- 
planations ’ of  the  action  of  ergot,  the  facts  con- 
nected with  it  suffice  to  account  for  the  specific 
phenomena  of  ergotism.  The  small,  feeble,  and 
infrequent  pulse  are  due  to  interference  with  the 
circulation;  while  the  painful  spasms,  aswell  as 
the  formication  and  other  sensory  disturbances, 
are  the  direct  result  of  the  action  of  the  poison 
upon  the  cord.  The  gangrene  may  also  be  partly 
due  to  the  latter  cause. 

Diagnosis. — The  occurrence  of  gangrene  in 
a number  of  young  and  previously  healthy 
persons  should  remove  all  difficulty  from  the 
diagnosis  of  ergotism.  The  spasmodic  form  of 
the  disease  may  be  distinguished  from  epidemic 
cerebro-spinal  fever  by  the  absence  of  pyrexia. 

Prognosis. — The  prognosis  depends  chiefly 
upon  the  early  recognition  and  removal  of  the 
cause.  The  probability  of  the  escape  of  affected 
extremities  may  he  estimated  by  the  degree  to 
which  the  gangrenous  process  had  advanced. 

Treatment. — The  treatment  of  ergotism  con- 
sists in  removing  the  cause  of  the  disease;  in 
hastening  the  elimination  of  the  poison  by  the 
cautious  administration  of  emetics  and  purga- 
tives ; in  allaying  the  symptoms  of  gastro-ente- 
ritis  ; and  in  supporting  the  strength  of  the 
patient  by  internal  and  external  stimulants, 
such  as  alcohol,  warmth,  and  friction.  Gangrene 
must  be  averted  by  careful  local  stimulation, 
by  means,  for  example,  of  warm  fomentations; 
or  treated,  if  it  should  arise.  See  Gangrene. 

J.  Mitchell  Bruce. 

EROSION  (erodo,  I gnaw). — A superficial 
destruction  of  tissue,  caused  especially  by  fric- 
tion, pressure,  corrosion,  or  certain  forms  of 
ulceration. 

EROTOMANIA  (epas.  love,  and  pctv'ix,  mad- 
ness).— Synon.  : Lore-melancholy.  Satyriasis  (in 
men);  Nymphomania(inwomen) ; Fr. Monoinanu 
irotique  ; Ger.  Licbcswuth. — Insanity  character- 
ised by  excessive  sexual  excitement ; sometimes 
symptomatic  of  cerebral  lesion,  sometimes  of  dis- 
order in  the  reproductive  organs.  See  Insanity. 

ERRATIC  ( erro , I wander). — Wandering, 
shiftiug,  or  irregular.  Applied  to  pains,  erup- 
tions on  the  skin,  and  other  morbid  phenomena 
when  they  shift  or  move  from  place  to  place. 

ERUCTATION  {cructo,  I belch).— Defini- 
tion.— The  sudden  escape  or  expulsion  of  gas 
from  the  stomach  upwards,  with  or  without  an 
admixture  of  portions  of  liquid  or  solid  food,  or 
of  gastric  juice,  or  other  liquids.  . 

Description. — The  act  of  eructation  may  be 
voluntary  or  involuntary.  In  the  former  c.ise 
a small  portion  of  air  is  first  swallowed,  and  b) 


ERUCTATION. 

the  oTer-distension  thus  produced  the  escape  of 
a portion  of  the  caseous  contents  of  the  stomach 
is  favoured.  When  involuntary,  we  must  sup- 
pose that  the  cardiac  orifice,  which  is  closed  in 
the  normal  state  of  digestion,  is  relaxed,  and 
thus  permits  the  rejection  of  portions  of  un- 
digested matter.  Erom  the  violence  with  which 
eructations  often  fake  place,  we  may  also 
assume  that  the  muscular  coat  of  the  stomach 
contracts  spasmodically  at  the  same  moment 
that  the  relaxation  of  the  cardiac  opening  oc- 
curs. The  nature  of  the  material  rejected  varies 
greatly.  Sometimes  it  is  tasteless,  in  others  acid, 
and  in  rarer  instances  alkaline. 

ZEtiology. — Eructations  occur  in  all  gastric 
diseases  attended  with  an  undue  formation  of 
gas.  They  are  constantly  complained  of  in  atonic 
dyspepsia,  more  especially  in  that  form  which 
occurs  in  elderly  people,  and  are  probably  the 
result  of  an  imperfect  contraction  of  the  sto- 
mach, preventing  the  due  expulsion  of  the 
digested  food  into  the  intestine.  They'  form  a 
prominent  and  distressing  symptom  in  dilatation 
of  the  stomach.  In  such  cases  the  patient  often 
complains  of  a sense  of  fermentation  in  his 
abdomen,  and  immense  quantities  of  gas  are 
expelled,  generally  mixed  with  an  acid  or  acrid 
fluid. 

Treatment. — The  indications  in  the  treat- 
ment of  eructations  are  to  prevent  the  decom- 
position of  food,  and  the  formation  of  gases  and 
other  products ; to  restore  tone  to  the  stomach, 
and  remove  anyr  morbid  condition  of  this  organ; 
and  to  give  remedies  with  the  view  of  absorbing 
gases,  or  assisting  the  act  of  eructation.  See 
Stomach,  Diseases  of.  Samuel  Fexwick. 

ERUPTIOH  ( eruptio , a bursting  forth). — ■ 
This  term  is  commonly  applied  to  a pathological 
manifestation  in  the  skin  ; more  or  less  general ; 
sometimes  marked  by'  colour,  sometimes  by  pro- 
minence, but  more  frequently  by  both.  When 
sudden  and  hypercemic,  a term  derived  from  the 
efflorescence  of  a plant,  namely,  exanthema,  is 
employed,  as  in  the  instance  of  the  exanthematous 
eruptions — scarlatina,  rubeola,  roseola,  and  va- 
riola. The  term  is  equally  applicable  to  less  acute 
forms  of  dermatosis,  such  as  urticaria,  eczema, 
impetigo,  ecthyma,  acne,  and  furunculus  ; and  is 
also  used  for  still  more  chronic  forms  of  disease, 
for  example,  lepra  vulgaris  ; and  for  outgrowths 
cf  the  skin,  due  to  aberration  of  nutrition,  as  in 
the  instance  of  warts  and  molluscous  tumours. 

Erasmus  Wilson. 

ERYSIPELAS  (ipva,  I draw,  and  w e\as, 
near). — Syxox.  : Lat.  Erysipelas ; Er . Ert/sipele; 
Ger.  Erysipelas.  Popular  names  : — St.  Anthony’s 
Fire  (English) ; the  Rose  (Scotch) ; der  Rothlavf, 
and  die  Rose  (Ger.) 

Definition. — Inflammation  of  the  integument 
tending  to  spread  indefinitely  ( Royal  College  of 
Physicians'  Komcnclature  of  Diseases).  The  vague- 
ness of  this  definition  indicates  the  looseness 
with  which  the  term  is  employed.  The  features 
common  to  all  inflammations  usually  spoken  of 
as  erysipelatous  are  fever,  usually  preceding  the 
local  phenomena  ; and  an  inflammation  tending 
to  spread  indefinitely  by  means  of  the  lymph- 
spaces  and  lymphatic  vessels  of  the  affected  part. 


ERYSIPELAS.  459 

Summary  of  Varieties. — Erysipelas  is  usually 
divided  into  (a)  Simple  Cutaneous,  ( b ) Phleg- 
monous or  Ccllulo-cutaneous,  and  (c)  Cellular,  or 
Diffuse  Cellulitis  (Nunneley).  In  addition  to 
these  three  chief  varieties,  erysipelatous  inflam- 
mation of  the  lymphatic  vessels  and  veins,  and 
of  serous  and  mucous  membranes,  is  also  de- 
scribed. 

Pathology. — All  the  inflammatory  affections 
thus  loosely  classed  together,  as  erysipelas  in  it  s 
various  forms,  have  one  feature  in  common.  They 
all  belong  to  the  class  of  infective  inflammations 
— that  is  to  say,  the  inflammatory  products  pos- 
sess the  property  of  setting  up  an  inflammation 
similar  in  character  to  that  at  the  original  focus 
in  any  part  with  which  they  may  come  in  contact. 
In  erysipelas  these  infective  products  diffuse 
themselves  by  the  lymphatic  vessels  and  lymph- 
spaces,  and  thus  set  up  a spreading  lymphatic 
inflammation.  As  the  poison  diffuses  itself,  it 
seems  in  most  cases  to  lose  its  intensity,  and 
thus  the  spreading  is  finally  arrested.  Of  the 
exact  nature  of  the  poison  we  know  nothing 
definite.  As  in  other  infective  inflammation 
the  exudation-matter  contains  minute  organisms 
(micrococci) ; but  the  part  these  play  in  produc- 
ing the  disease,  and  their  mode  of-  origin,  are 
matters  of  dispute.  The  poison,  whatever  it 
may  be,  is  communicable  from  one  individual  to 
another.  It  is  probable,  however,  that  simple 
cutaneous  erysipelas  differs  entirely  in  nature 
from  cellulo-cutaneous  and  cellular  erysipelas. 
The  two  latter  are  in  most  cases  purely  local  in 
origin,  and  the  poison  which  causes  them  pro- 
bably varies,  both  physically  and  chemically,  in 
different  cases.  In  some  cases  it  may  be  merely 
decomposing  animal-matter,  in  others  it  may  be 
something  as  truly  specific  as  the  infective  pro- 
ducts of  malignant  pustule  or  the  poison  of  a 
venomous  reptile.  The  effect  produced  by  the 
inoculation  of  such  poisons  depends  to  a great 
extent  npon  the  susceptibility  of  the  individual. 
This  is  increased  by  all  bad  hygienic  conditions, 
and  above  all  by  the  abuse  of  alcohol  and  con- 
sequent visceral  disease.  When  these  affections 
commence  apparently  spontaneously,  careful  in- 
quiry will  almost  invariably  show  that  the  start- 
ing point  has  been  some  local  injury  occurring 
in  a person  previously  in  ill-health.  Simple 
cutaneous  erysipelas,  on  the  other  hand,  par- 
takes much  more  of  the  nature  of  an  acute 
specific  fever.  It  is  communicable  not  only  by 
direct  inoculation,  but  by  infection  ; there  is  a 
distinct  period  of  incubation,  the  duration  of 
which  is  uncertain  (variously  stated  from  a few 
days  to  two  weeks) ; the  constitutional  symptoms 
precede  the  local  inflammation,  often  by  a day  or 
more ; and  the  disease  occurs  in  epidemics.  It 
differs  from  other  acute  specifics  in  its  extremely 
irregular  course,  and  by  its  not  conferring  on 
the  patient  any  immunity  from  a second  attack; 
in  fact,  one  attack  predisposes  to  another.  Two 
views  are  therefore  held  by  different  authors 
with  regard  to  it.  On  the  one  hand  some  con- 
sider it  primarily  a general  disorder,  the  local 
manifestation  of  which  is  a diffuse  inflammation 
starting  from  any  wound  that  may  exist  on  the 
person  of  the  patient,  or,  failing  that,  choosing 
by  preference  the  points  of  junction  of  mucous 
membrane  and  skin.  On  the  other  hand  it  is 


ERYSIPELAS. 


160 

described  as  originally  a purely  local  inflam- 
mation, infective  in  character,  and  secondarily 
giving  rise  to  constitutional  disturbance.  Others 
again  suppose  both  forms  to  exist,  and  describe 
them  as  traumatic  or  surgical , and  idiopathic  or 
medical  erysipelas.  At  the  present  time  the 
question  cannot  be  considered  as  definitely 
settled. 

2Etiology. — I.  Infection.  Erysipelas  -,s  un- 
doubtedly infectious  and  inoculable,  as  the  ex- 
perience of  hospitals  sufficiently  teaches  us.  Its 
power  of  infection  is,  however,  not  very  great, 
certainly  much  less  than  that  of  measles  or  scarlet 
.fever,  and  probably  about  equal  to  that  of  diph- 
theria. The  development  of  the  disease  will  de- 
pend, therefore,  to  a great  extent  upon  the  patient 
and  his  surroundings. 

II.  Predisposing  causes.  A.  In  the  patient: 
1.  Constitutional  predisposition.  This  is  said  to 
be  increased  by  a previous  attack,  and  some- 
times to  be  hereditary.  2.  Disease  of  some  im- 
portant viscus,  especially  liver  and  kidneys.  3. 
The  presence  of  a wound.  4.  Age.  This  has  little 
effect ; the  disease  affects  all  ages  alike.  5.  Sex. 
Erysipelas  is  said  to  be  most  common  in  women, 
especially  at  the  menstrual  period.  6.  Intem- 
perance arid  want  of  proper  food  are  great 
predisposing  causes. 

B.  In  the  patient’ s surroundings.  1.  Meteoro- 
logical conditions.  East  winds,  low  temperature, 
excessive  moisture,  cold  and  heat,  have  all  been 
considered  causes.  It  is  said  to  be  most  com- 
mon in  spring  and  autumn.  On  all  these  points 
there  is  no  really  reliable  evidence. 

2.  General  hygienic  conditions.  Overcrowd- 
ing in  hospitals,  want  of  ventilation,  dirt  of  all 
kinds,  bad  food  and  impure  water  are  all  pre- 
disposing causes. 

S.  Epidemic  influences.  Erysipelas  undoubt- 
edly occurs  in  epidemics,  and  the  type  of  the 
disease  often  varies  in  different  outbreaks. 

We  shall  now  proceed  to  discuss  in  detail  the 
several  varieties  of  erysipelas  summarised  above. 

I.  Simple  Cutaneous  Erysipelas. — This  is 
the  most  typical  form  of  the  disease. 

Anatomical  Characters. — The  post-mortem 
appearances  of  erysipelas  are  by  no  means 
characteristic.  The  redness  of  the  inflamed 
area  of  course  fades  after  death,  leaving  a faint 
yellowish  tint.  The  skin  feels  hard  and  inelastic, 
and  the  subcutaneous  tissue  contains  an  excess 
of  serous  fluid.  In  very  acute  cases  there  may 
be  the  usual  signs  of  blood-change  seen  in  all 
malignant  fevers — early  post-mortem  staining, 
imperfect  coagulation  of  the  blood,  subserous 
peteehi®,  swollen  and  soft  spleen,  and  cloudy 
swelling  of  the  liver  and  kidneys.  Hiller  states 
that  microscopic  examination  of  the  blood  before 
death  shows  many  of  the  white  corpuscles  to 
have  undergone  degenerative  changes  and  be- 
come converted  into  masses  of  highly  refracting 
granules.  Busk  has  described  plugs  of  such 
altered  corpuscles  in  the  small  vessels  of  the 
lung,  and  Bastian  has  observed  a similar  condi- 
tion in  the  vessels  of  the  brain.  Microscopic 
examination  of  the  affected  part  of  the  skin 
shows  large  numbers  of  migrating  leucocytes, 
lying  in  the  spaces  of  the  fibrous  tissue, 
amongst  the  fat-cells,  and  in  the  lumen  of  the 
lymphatic  vessels.  They  are  especially  abundant 


round  the  small  vessels.  Lukomsky  (Virchows 
Arcliiv , Band  lxv.)  has  described  the  presence 
of  micrococci  filling  the  lymph-spaces  and  lym- 
phatic vessels  at  the  advancing  margin  of  the 
erysipelatous  inflammation.  These  are  not  ob- 
served where  the  rash  is  receding,  nor  in  those 
parts  which  have  been  affected  for  any  length  of 
time.  This  observation  has  been  confirmed  by 
subsequent  observers. 

Symptoms. — In  simple  erysipelas  the  constitu- 
tional symptoms  usually  precede  the  local.  The 
invasion  is  marked  by  chilliness,  seldom  by  an 
actual  rigor;  loss  of  appetite;  general  malaise; 
nausea,  but  seldom  actual  vomiting;  headache; 
pain  in  the  limbs ; and  the  usual  signs  of  pyrexia. 
The  invasion  is  tolerably  sudden.  The  temper- 
ature rapidly  rises  to  about  103°  F.  or  higher. 
The  rarer  symptoms  at  this  stage  are  epistaxis 
in  adults,  and  convulsions  in  children.  Usually 
within  twenty-four  hours  of  the  invasion  the 
characteristic  cutaneous  inflammation  appears, 
It  may,  however,  commence  simultaneously  with 
the  febrile  disturbance,  or  be  delayed  even  for 
two  or  three  days.  Frequently  the  lymphatic 
glands  nearest  to  the  part  are  swollen  before 
the  cutaneous  eruption  appears  ; afterwards  they 
are  invariably  enlarged  and  tender.  The  local 
inflammation  usually,  if  not  always,  starts  from 
some  wound,  scratch,  or  abrasion.  It  commences 
indifferently  in  a fresh  wound  or  a granulating 
sore.  When  no  wound  can  be  recognised  as  its 
starting-point  it  usually  starts  from  the  junction 
of  mucous  membrane  and  skin,  most  commonly 
from  the  corner  of  the  eye,  causing  a swelling 
across  the  bridge  of  the  nose.  It  may  also  start 
from  the  angle  of  the  mouth,  the  externalauditory 
meatus,  or  the  anus.  It  may  commence  in  the 
nasal  fossae  or  pharynx,  and  extend  outwards  to 
the  skin  of  the  face.  Possibly  in  all  cases  it 
starts  from  some  slight  abrasion  which  is  scarcely 
to  be  detected  (Trousseau).  The  inflamed  skin 
is  bright  red  in  colour,  with  s metimes  a 
yellowish  tinge ; the  redness  advances  in  all 
directions,  but  tisually  most  rapidly  in  that  of 
the  lymph-stream.  The  advancing  margin  is 
irregular,  sharply  defined,  and  very  slightly 
raised.  The  cutis  is  cedematous,  and  pressure 
with  the  finger-nail  leaves  a deep  and  abiding 
mark.  Where  the  subcutaneous  areolar  tissue 
is  lax,  as  in  the  eyelids  or  scrotum,  it  also 
becomes  greatly  swollen.  In  the  limbs  the  sub- 
cutaneous swelling  is  great  only  in  severe  cases. 
In  many  cases  small  vesicles  rise,  which  may 
coalesce,  formingblebs  of  considerable  size.  These 
ordinarily  contain  clear  yellow  serum,  which,  in 
bad  cases,  may  bo  stained  with  blood-pigment. 
As  these  bull®  burst  they  dry  up.  forming  scabs 
on  the  surface,  but  no  ulceration  takes  place 
benea,tb  these  scabs.  The  inflammation  has  but 
little  tendency  to  end  in  suppuration ; when 
this  does  occur  it  is  in  those  parts  in  which  the. 
oedema  has  been  greatest,  as  the  eyelids.  There 
is  heat,  tension,  and  pain  in  the  affected  part,  and 
a peculiar  sensation  of  stiffness,  which  may  even 
precede  the  appearance  of  the  redness.  The 
febrile  symptoms  which  usher  in  the  a'.taek  re- 
main unrelieved  so  long  as  the  redness  continue?, 
to  spread.  The  pulse  is  at  first  quick  and  full, 
but  it  soon  loses  force,  and  in  bad  cases  be- 
comes extremely  rapid  and  feeble.  It  is  by  the 


ERYSIPELAS. 


pulse,  more  than  anything  else,  that  the  gravity 
of  the  case  is  marked.  The  temperature  seldom 
rises  above  106°  E.,  though  107'5°  F.  has  been 
recorded.  The  daily  variations  are  not  great, 
there  being  merely  the  usual  slight  morning  fall 
and  evening  rise.  Delirium  is  not  uncommon  at 
night,  even  in  mild  cases.  In  erysipelas  of  the 
head  it  may  be  a prominent  symptom.  It  is 
usually  due  to  theblood-condition,  and  not,  as  was 
formerly  supposed,  to  extension  of  the  inflam- 
mation to  the  membranes  of  the  brain.  This, 
however,  does  occur  in  rare  cases,  especially 
in  erysipelas  of  the  orbit  or  in  that  following  a 
compound  fracture  of  the  skull.  The  tongue  is 
always  foul  and  usually  dry,  in  bad  cases  becom- 
ing cracked  and  brown,  with  sordes  on  the  lips 
and  teeth.  In  erysipelas  of  the  head  the  fauces 
are  always  red  and  congested,  even  when  the 
inflammation  has  not  actually  extended  to  that 
part.  The  bowels  are  sometimes  confined,  but 
diarrhoea  with  offensive  motions  is  liable  to  occur. 
There  is  nothing  characteristic  about  the  urine. 
As  in  other  acute  febrile  diseases  it  frequently 
contains  a small  quantity  of  albumen.  In 
erysipelas  of  the  head,  when  the  disease  reaches 
its  height,  the  appearance  is  often  hideous  in  the 
extreme,  thefeatures  being  completelyobliterated 
by  the  swelling  of  the  lax  subcutaneous  tissue,  and 
the  face  further  disfigured  by  the  scabs  formed 
by  the  dried  blebs.  The  duration  of  simple 
erysipelas  is  very  uncertain.  The  cessation  of  the 
disease  is  marked  by  the  inflammation  ceasing 
to  extend,  and  by  a simultaneous  fall  of  temper- 
ature, often  very  sudden.  This  may  occur  as 
early  as  the  fifth  day,  or  be  delayed  till  the  end 
of  the  second  or  middle  of  the  third  week.  As 
the  rash  fades  its  margin  loses  its  distinct  out- 
line, and  the  redness  shades  off  insensibly.  It  is 
not  uncommon  to  see  the  inflammation  spreading 
at  one  part,  fading  at  another.  After  the  sub- 
sidence of  the  inflammation  there  is  desquama- 
tion of  the  cuticle,  and  in  erysipelas  of  the  head 
often  complete  loss  of  hair,  which  is,  however, 
never  permanent.  Suppuration  occasionally  takes 
place  in  the  nearest  lymphatic  glands.  Even 
after  a mild  attack  the  patient’s  strength  is  much 
reduced,  and  he  often  remains  -weak  and  anaemic 
for  a considerable  time.  Relapses  are  by  no 
means  uncommon.  When  death  occurs  from 
simple  cutaneous  erysipelas,  it  arises  most  fre- 
quently from  exhaustion.  It  may  also  be  due  to 
the  gravity  of  the  blood-change.  Occasionally 
the  fatal  termination  is  preceded  by  violent 
delirium  ending  in  coma.  Sometimes  it  is  due  to 
some  complication,  as  pleurisy  or  pneumonia,  or 
in  very  rare  cases  meningitis.  When  sloughing 
of  the  skin  or  suppuration  occurs,  death  may 
take  place  from  septicaemia  or  pyaemia. 

Varieties. — Some  waiters  have  divided  simple 
erysipelas  into  medical  and  surgical — or  idio- 
pathic and  traumatic — and  have  described  these 
varieties  as  distinct  diseases.  They  are,  however, 
probably  identical,  for  the  following  reasons : — 
they  closely  resemble  each  other  in  mode  of  inva- 
sion, course,  and  pathological  changes;  infection 
from  so-called  idiopathic  erys;pelas  will  give  rise 
to  the  traumatic  form  in  patients  suffering  from 
tm  open  wound ; and  during  an  outbreak  of 
.rysipelas  in  a surgical  ward  patients  without 
open  wounds  are  occasionally  attacked  by  the 


4111 

idiopathic  form  Erysipelas  has  also  been  sub- 
divided according  to  the  part  it  attacks,  as 
erysipelas  faciei,  capitis,  scroti,  &e. 

Erysipelas  occasionally  affects  the  mucous 
membrane  of  the  pharynx  and  upper  part  of  the 
larynx.  This  form  presents  some  peculiarities, 
and  is  spoken  of  as  erysipelatous  pharyngitis 
and  laryngitis.  The  invasion  and  constitutional 
symptoms  are  similar  to  those  of  simple  cutaneous 
erysipelas.  There  is  a bright  redness  of  the 
back  of  the  pharynx  and  the  fauces,  always  ac- 
companied by  considerable  oedema  of  the  soft 
palate  and  some  swelling  of  the  tonsil.  The 
glands  at  the  angle  of  the  jaw  are  swollen  and 
tender.  The  danger  of  this  affection  arises  from 
extension  to  the  glottis,  causing  oedema  glottidis, 
with  intense  dyspnoea,  expiration  being  more 
easy  than  inspiration,  and  both  liable  to  ob- 
struction by  spasm.  In  such  cases  tracheotomy 
or  laryngotomy  may  be  required  at  any  moment 
to  prevent  death  from  asphyxia.  In  other  case-- 
the  inflammation  may  extend  forwards  and  ap- 
pear on  the  face,  either  at  the  nostril  or  mouth, 
and  afterwards  extend  as  ordinary  facial 
erysipelas. 

Erysipelas  occasionally  attacks  new-born 
infants,  starting  from  the  navel  or  genitals. 
This  form  has  been  spoken  of  as  E.  neonatorum. 
Serous  membranes,  especially  the  peritoneum, 
are  said  sometimes  to  be  affected  by  erysipelas 
following  w'ounds.  In  lying-in  women  the 
poison  of  erysipelas  seems,  in  common  with  that 
of  many  other  unhealthy  inflammations,  to  be 
capable  of  causing  puerperal  fever. 

Dermatologists  have,  according  to  their  wont, 
invented  a name  for  every  possible  variation. 
Thus  when  the  inflammation  spreads  at  one  part 
while  fading  at  another  it  has  been  called  E.  am- 
bulans  or  erraticum ; wflien  spreading  in  a winding 
course,  E.  serpens ; when  causing  small  vesicles, 
E.  vesiculare  or  miliare;  when  blebs  form,  E. 
bullosum;  when  there  is  much  swelling,  E. 
cedematosum,  &c.  Such  names  are  useless,  and 
may  be  multiplied  ad  infinitum. 

Diagnosis. — When  the  eruption  is  fully  de- 
veloped it  is  scarcely  possible  to  mistake  the 
disease.  During  the  stage  of  invasion,  before 
the  appearance  of  the  rash,  diagnosis  is  impos- 
sible. Simple  diffuse  inflammation  round  a wound 
or  abscess  is  distinguished  from  erysipelas  by 
the  absence  of  the  characteristic  invasion,  and  of 
the  sharply  defined  border.  Simple  erythema 
differs  from  erysipelas  in  the  absence  of  fever, 
and  in  the  eruption  being  composed  of  numerous 
isolated  patches.  Occasionally,  in  malignant 
small-pox,  there  may  be  much  redness  and  swell- 
ing of  the  face  before  the  appearance  of  the 
vesicles,  but  the  symptoms  of  invasion  are  much 
more  severe  than  those  of  erysipelas. 

Prognosis. — The  prognosis  depends  chiefly 
upon  the  gravity  of  the  general  symptoms.  The 
following  are  bad  signs  : — high  fever,  violent 
delirium,  excessive  diarrhoea,  early  prostration, 
and  very  dry  tongue  with  sordes.  Tho  extent  of 
the  inflammation  is  of  less  importance.  Old  age, 
disease  of  the  kidneys  or  liver,  and  especially 
chronic  alcoholism,  add  greatly  to  the  gravity  of 
the  case.  When  erysipelas  affects  the  pharynx 
there  is  always  danger  from  oedema  glottidis.  In 
uncomplicated  cases  the  death-rate  is  not  high 


462 


ERYSIPELAS. 


Of  25  eases  treated  in  the  medical  wards  of 
University  College  Hospital  from  1872  to  1876, 
only  one  died,  and  lie  was  suffering  from  chronic 
Bright’s  disease. 

Treatment. — 1.  Constitutional.  Erysipelas 
being  a most  exhausting  and  depressing  disease, 
no  antiphlogistic  treatment  is  ever  justifiable. 
Clear  the  bowels  at  the  commencement  cf  the 
attack,  but  avoid  violent  purgation.  Only  two 
drugs  have  any  reputation  in  the  treatment  of 
erysipelas.  The  tincture  of  perchloride  of  iron, 
in  large  and  repeated  doses,  has  been  strongly 
recommended  by  Hr.  Reynolds  and  others,  and 
is  stated  by  some  to  act  as  a specific.  To  be  of 
any  use  it  must  be  given  in  doses  of  forty  minims 
every  four  hours.  Aconite  if  administered  as 
soon  as  the  temperature  begins  to  rise  is  said  to 
cut  the  attack  short.  It  may  be  given  in  half- 
minim  or  minim  doses  of  the  tincture,  at  first 
every  quarter  of  an  hour  for  on  6 or  two  hours, 
and  afterwards  hourly  till  the  skin  becomes 
moist  and  the  temperature  falls,  but  its  effects 
must  be  very  carefully  watched,  to  avoid  danger- 
ous depression.  The  diet  must  be  as  nourishing 
ns  possible  ; beef-tea,  eggs  and  milk,  &c.  Solid 
food  can  never  be  taken  during  the  advance  of 
the  disease.  Stimulants  are  usually  required, 
and  the  amount  must  be  regulated  by  the  pulse. 
Large  quantities  are  often  necessary. 

2.  Local. — Local  treatment  is  very  various. 
Warmth  and  avoidance  of  variations  of  temper- 
ature are  essential.  Cold  is  utterly  inadmissible  : 
it  aggravates  the  inflammation,  and  tends  to  cause 
ruppuration  or  even  sloughing.  Hot  fomenta- 
tions or  hot  baths  may  be  employed  when  the 
part  affected  renders  them  admissible.  In  other 
cases  dry  warmth  must  be  used;  it  is  best  ob- 
tained by  covering  the  affected  part  with  a thick 
layer  of  cottonwool.  Poultices  should  be  avoided, 
ns  they  needlessly  irritate  the  skin,  and  are  dirty 
and  apt  to  get  cold.  With  the  application  of 
warmth  innumerable  varieties  of  local  applica- 
tions have  been  recommended.  These  may  be 
divided  thus: — (a)  Indifferent  applications.  These 
are  intended  only  to  exclude  the  air,  but  they 
have  the  disadvantage  of  shutting  in  the  secre- 
tion of  the  skin.  The  most  common  of  these 
are  collodion,  oil,  and  a thick  layer  of  flour  or 
starch  under  cotton  wool.  {]>)  Sedative  applica- 
tions. The  most  important  remedy  of  this  class 
is  belladonna.  It  is  best  applied  as  a paint  com- 
posedof  equal  parts  of  the  extraetand  glycerine. 
It  is  especially  useful  when  there  is  much  in- 
flammation of  the  lymphatic  vessels  and  glands, 
(c)  Fowerful  Astringents.  Valette  of  Lyons  recom- 
mends a 30  per  cent,  solution  of  perchloride  of 
iron ; Kigginbottom  a solution  of  the  ‘brittle  stick 
of  nitrate  of  silver’  20  grains  to  one  drachm  of 
water.  Before  applying  either  of  these  the  skin 
must  be  carefully  washed  with  soap  and  water  to 
free  it  from  grease.  The  perchloride  of  iron  must 
be  rubbed  in  with  a glove.  ( d ) Antiseptic  appli- 
cations. Marshall  recommends  creasote  made 
into  a paste  with  kaoline  ; Dewar,  equal  parts  of 
sulphurous  acid  (B.P.)and  glycerine;  tincture  of 
iodine  is  a common  application.  Lately  Hueter 
has  practised  the  subcutaneous  injection  of  a 30 
per  cent,  solution  of  carbolic  acid.  He  states 
that  this  causes  an  immediate  arrest  of  the 
inflammation  for  a email  distance  round  the 


puncture  ; if,  therefore,  the  treatment  is  adopt  ed 
at  so  earl)'  a stage  that  the  area  of  inflammation 
can  be  surrounded  by  four  or  five  punctures  the 
disease  may  be  checked.  Beyond  this  there 
would  be  danger  of  carbolic  acid  poisoning, 
(e)  Drawing  a limiting  line  in  front  of  the 
advancing  rash.  This  has  been  done  with  solid 
nitrate  of  silver  and  with  blistering  fluid.  It  is 
utterly  useless. 

Erysipelas  of  the  fauces  is  best  treated  by  the 
local  application  of  a strong  solution  of  per- 
chloride of  iron.  If  there  is  oedema  gloltidis 
the  swollen  parts  must  be  scarified,  and  if  that 
fails  to  give  relief,  tracheotomy  maybe  necessary. 

II.  Phlegmonous  or  Cellulo-cutaneoue 
Erysipelas  was  described  by  Dupuytren  under 
the  name  of  ‘ diffuse  phlegmon.’ 

Anatomical  Characters.  — Incisions  made 
into  the  inflamed  part  in  the  early  stages  show 
the  spaces  of  the  areolar  tissue  distended  with 
serous  fluid ; a little  later  on  the  fluid  is  found  to 
be  turbid,  resembling  thin  pus ; later  still  the 
subcutaneous  cellular  tissue  is  represented  by 
masses  of  shreddy  sloughs  soaked  in  a puriform 
fluid.  Unless  exposed  to  the  air  by  incisions  or 
by  sloughing  of  the  skin  these  sloughs  are  free 
from  any  odour  of  decomposition  and  contain  no 
gas.  There  is  nothing  characteristic  in  the  post- 
mortem appearances  of  the  internal  organs. 

Symptoms. — The  invasion  is  usually  marked 
by  chilliness  or  a rigor,  elevation  of  tempera 
ture,  nausea,  headache,  and  general  malaise. 
The  local  inflammation  may  commence  in  some 
wound  or  abrasion,  but  it  may  also  arise  spon- 
taneously. Erom  the  beginning  there  is  marked 
(ndema  of  the  subcutaneous  tissue.  The  skin  is 
reddened,  but  the  margin  of  the  redness  is  not 
sharply  defined,  and  swelling  and  tenderness  of 
the  lymphatic  glands  is  often  absent.  As  the 
area  of  inflammation  extends,  the  affected  part 
becomes  tense  and  brawny,  and  vesicles  or  large 
blebs  form.  The  tension  may  become  so  great 
that  firm  pressure  with  the  finger  scarcely  makes 
any  impression.  In  a few  clays  from  the  com- 
mencement of  the  disease,  the  greater  part  of  a 
limb  may  he  involved.  If  unrelieved  by  treat- 
ment the  tint  of  the  redness  becomes  more 
dusky,  and  dark  purple  patches  appear.  At  the 
same  time  the  tension  becomes  less,  and  gives 
place  to  a soft,  boggy  feeling,  indicating  slough- 
ing of  tile  subcutaneous  cellular  tissue.  Then 
livid  patches  appear,  which  break  down  into 
sloughs.  As  these  sloughs  separate,  large 
shreddy  masses  of  gangrenous  cellular  tissue 
can  be  drawn  out,  leaving  the  undermined  skin 
connected  with  the  deeper  parts  only  by  bands 
containing  the  larger  vessels.  Finally,  the  re- 
maining skin  being  insufficiently  nourished  may 
thin  and  melt  away,  leaving  large  tracts  of  the 
fascia  and  muscles  beneath  exposed  to  view.  In 
this  way  if  proper  treatment  be  not  adopted  in 
time,  the  greater  part  of  a limb  may  be  denuded 
of  its  cutaneous  and  subcutaneous  covering.  The 
extreme  stage  may  be  reached  in  a week  or  ten 
days,  but  a longer  time  usually  elapses  before 
all  the  sloughs  are  separated.  In  the  earlier 
stages  there  is  much  burning  and  tensive  pain, 
but  this  subsides  as  gangrene  sets  in.  The  con- 
stitutional symptoms  are  grave  from  the  begin- 
ning. There  is  high  fever,  the  thermometeroften 


ERYSIPELAS.  403 


reaching  105°  F.  The  tongue  is  dry  and  brown, 
and  sordes  accumulate  on  the  lips  and  teeth  ; 
there  is  total  loss  of  appetite  ; and  diarrhoea  is  a 
frequent  symptom.  The  pulse,  at  first  full  and 
bounding,  soon  loses  force,  becoming  rapid  and 
weak.  Delirium,  usually  of  the  muttering  type, 
is  always  present  in  severe  eases.  Death  occurs 
from  exhaustion  or  from  some  complication,  such 
as  pneumonia,  pleurisy,  &c.  During  the  sepa- 
ration of  the  sloughs  septicaemia  and  pyaemia 
are  of  frequent  occurrence.  The  disease  most 
commonly  attacks  one  of  the  limbs,  but  it  is 
occasionally  seen  in  the  scrotum,  and  a peculiarly 
virulent  form  has  been  described  as  affecting  the 
face.  Phlegmonous  erysipelas  most  commonly 
occurs  in  adult  patients  of  broken  constitution, 
suffering  usually  from  the  effects  of  the  abuse 
of  alcohol,  or  from  some  disease  of  the  liver  or 
kidney. 

Diagnosis. — From  simple  erysipelas  the  phleg- 
monous form  is  distinguished  by  the  great  swell- 
ing and  brawny  hardness,  by  the  want  of  a 
sharply  defined  edge,  and  by  the  early  tendency 
to  sloughing;  from  spreading  gangrene  by  its 
slower  progress,  and  the  absence  of  the  rapid 
decomposition  and  development  of  gas  in  the 
tissues.  Acute  necrosis  somewhat  resembles 
it,  but  this  disease  is  limited  to  young  subjects, 
the  swelling  is  less  brawny,  and  when  pus  forms 
there  is  distinct  fluctuation  and  not  the  boggy 
feeling  of  phlegmonous  erysipelas. 

Prognosis. — The  prognosis  is  always  grave, 
especially  if  there  is  any  delay  in  adopting  the 
proper  treatment.  Early  failure  of  the  heart’s 
force,  excessively  dry  tongue,  diarrhoea  and  vo- 
miting are  bad  signs.  The  gravity  of  the  case 
increases  directly  with  the  area  affected. 

Treatment. — The  patient  must  be  supported 
by  good  beef-tea.  milk  and  eggs,  and  stimulants 
are  usually  required  to  be  freely  given.  No  de- 
pletory measures  are  ever  justifiable.  Ammonia- 
and-bark  is  sometimes  of  service.  Locally  tbe 
treatment  in  very  mild  and  doubtful  cases  must 
consist  in  the  application  of  hot  fomentations,  and 
extract  of  belladonna  made  into  a paint  with  an 
equal  amount  of  glycerine.  As  soon  as  there 
are  any  signs  of  tension,  free  incisions  must  be 
made  to  relieve  it.  The  patient's  danger  will 
be  greatly  lessened  if  these  are  made  with  all  the 
precautions  of  Lister's  antiseptic  method. 

III.  Diffuse  Cellulitis,  or  Cellular  Ery- 
sipelas.— In  this  disease  the  inflammation  is 
confined  to  the  subcutaneous  cellular  tissue,  or 
to  the  planes  of  areolar  tissue  amongst  muscles 
or  beneath  fasciae.  The  course  of  the  inflam- 
mation is  similar  in  many  respects  to  that  of 
phlegmonous  erysipelas,  the  only  important  dif- 
ference being  that  the  skin  remains  unaffected, 
or  is  only  implicated  in  the  later  stages  as  a 
consequence  of  the  sloughiiig  of  the  subcuta- 
neous tissues. 

Anatomical  Characters. — The  post-mortem 
appearances  are  similar  to  those  of  phlegmonous 
erysipelas. 

Symptoms. — The  local  signs  of  diffuse  cellu- 
litis when  occurring  in  the  subcutaneous  tissue 
or  beneath  the  superficial  fascia,  are  marked 
oedematous  swelling,  gradually  becoming  brawny, 
slight  redress  of  the  skin,  and  usually  mottling 
from  over-distension  of  the  superficial  veins. 


There  is  no  sharp  limit  to  the  swelling.  There 
is  intense  tensive  or  burning  pain,  increased  by 
movement,  and  acute  tenderness  on  pressure 
The  neighbouring  lymphatic  glands  are  in  most 
cases  swollen  and  tender.  As  the  disease  ad- 
vances, the  swelling  becomes  doughy,  and  pos- 
sibly an  indistinct  sensation  of  fluctuation  may 
be  felt.  The  skin  now  becomes  redder,  and  the 
gangrenous  inflammation  may  even  extend  to  it, 
unless  prevented  by  treatment.  An  incision  in  the 
osdematous  or  brawny  stage  merely  shows  the 
areolar  spaces  distended  with  serum,  sometimes 
clear,  more  often  turbid.  If  the  incision  be 
delayed  till  the  later  stages  the  affected  cellular 
tissue  is  reduced  to  a mass  of  shreddy  sloughs 
soaked  in  pus.  Gas  does  not  form  amongst 
these  sloughs  till  after  air  has  been  admitted 
from  without.  In  mild  cases  the  inflammation 
may  localise  itself,  and  lead  to  the  formation  of 
a large  abscess.  The  constitutional  symptoms 
are  always  grave.  The  temperature  is  high, 
10I0  to  105°  F.  There  are  tho  usual  symp- 
toms of  fever  ; the  tongue  is  foul  and  speedily 
becomes  dry  ; vomiting  and  diarrhoea  are  not 
uncommon ; the  pulse,  at  first  quick  and  full, 
soon  becomes  feeble  and  rapid.  There  is  almost 
always  delirium.  Tbe  disease  usually  runs  a 
rapid  course,  two  or  three  days  sometimes  being 
sufficient  for  it  to  reach  its  extreme  stage. 

Diffused  cellulitis,  as  above  described,  is  most 
frequently  the  result  of  a poisoned  wound;  it 
may  then  start  from  the  wound  or  make  its  ap- 
pearance at  a distant  part.  It  forms  the  most 
fatal  variety  of  post-mortem  wound ; and,  as  is 
well  known,  in  such  cases  the  puncture  may  ap- 
pear healthy,  whilst  tho  areolar  tissue  in  the 
pectoral  region  may  be  the  seat  of  most  acute 
diffuse  inflammation.  The  bite  of  the  less  poi- 
sonous reptiles  causes  a similar  diffuse  inflam- 
mation. Diffuse  cellulitis  of  the  pelvis  is  a 
common  cause  of  death  after  lithotomy,  and  is 
not  uncommon  in  women  after  labour.  Diffuso 
cellulitis  beneath  the  pericranial  aponeurosis  is 
of  frequent  occurrence  after  scalp  wounds.  Oc- 
casionally the  disease  arises  spontaneously,  and 
it  is  then  most  common  in  the  upper  limb,  but 
it  has  been  seen  in  the  areolar  tissue  of  the 
neck  and  in  many  other  regions.  In  pyaemia 
and  septicaemia  patches  of  diffuse  cellulitis  may 
appear  in  intermuscular  spaces,  or  in  the  subcu- 
taneous tissue. 

Diagnosis. — The  diagnosis  of  cellulitis  is  often 
difficult  when  the  mischief  is  deep-seated.  The 
cedema,  pain,  and  tenderness,  with  the  severe 
constitutional  symptoms,  are  the  chief  guides  ; 
but  even  when  these  are  well  marked,  the  extent 
of  the  inflammation,  an  1 the  necessity  for  active 
treatment  are  often  difficult  to  determine. 

Prognosis. — This  depends  much  upon  tho 
cause  and  upon  the  previous  health  of  the  patient. 
It  is  a very  bad  sign  when  the  gravity  of  the 
general  symptoms  is  out  of  proportion  to  the 
local  mischief.  In  the  pelvis  cellulitis  may  be 
fatal  from  peritonitis;  in  the  neck  it  is  very 
fatal ; it  is  much  less  dangerous  in  the  limbs. 
When  it  occurs  as  a part  of  pyaemia  or  septicaemia 
the  prognosis  is  of  course  very  grave. 

Treatment. — Early  incisions  into  the  inflamed 
cellular  tissue,  with  antiseptic  applications,  and 
abundant  support,  form  the  only  reliable  treat- 


m ERYSIPELAS, 

ment  in  severe  cases.  In  slight  cases  the  appli- 
cation of  extract  of  belladonna  and  glycerine 
(equal  parts),  -with  hot  fomentations,  may  lead 
to  resolution  or  limitation  of  the  inflammation. 

IV.  Erysipelatous  Lymphangitis.  — In- 
flammation of  the  superficial  lymphatic  vessels 
is  a common  accompaniment  of  all  varieties  of 
erysipelas ; but  in  some  cases  it  forms  by  far 
the  most  prominent  local  morbid  condition. 

Symptoms. — This  affection  is  characterised  by 
red  lines  running  in  the  course  of  the  lymphatic 
vessels  from  some  local  sore  or  wound.  The  lines 
are  at  first  tolerably  sharply  defined,  and  about 
a quarter  of  an  inch  in  width,  but  after  a short 
time  they  spread  out  and  several  may  coalesce, 
forming  a patch  exactly  resembling  simple  cu- 
taneous erysipelas.  There  is  slight  cedema,  some 
pain  and  stiffness,  and  acute  tenderness  on  pres- 
sure. The  lymphatic  glands  to  which  the  vessels 
lead  are  swollen  and  tender.  The  constitutional 
symptoms  are  the  same  as  in  simple  erysipelas. 

Diagnosis. — This  affection  can  only  be  mis- 
taken for  phlebitis,  but  the  diagnosis  is  easily 
made  by  observing  the  course  of  the  lines,  and  by 
the  absence  of  the  knotted  cord  formed  by  the 
coagulation  of  the  blood  in  an  inflamed  vein. 

Treatment. — The  treatment  is  the  same  as  in 
simple  erysipelas.  The  extract  of  belladonna 
and  glycerine  is  especially  useful  in  this  form  of 
erysipelatous  inflammation. 

V.  Erysipelatous  Phlebitis. — Inflammation 
of  the  superficial  veins,  rapidly  spreading  in  the 
course  of  the  circulation,  accompanied  by  throm- 
bosis, redness  of  the  skin,  and  acute  tenderness, 
has  been  supposed  by  some  authors  to  be  ery- 
sipelatous in  character.  The  only  evidence  in 
favour  of  this  view  is  that  the  invasion  and' the 
constitutional  symptoms  resemble  those  of  ery- 
sipelas, and  that  the  affection  is  not  uncommon 
during  epidemics  of  erysipelas.  See  Veins, 
Diseases  of. 

Various  other  diseases  have  been  classed  as 
erysipelatous : the  chief  of  these  are  whitlow, 
some  forms  of  puerperal  fever,  and  diffuse  perito- 
nitis after  operations  affecting  the  peritoneum  ; 
all  these  will  be  described  elsewhere.  Diffuse 
inflammation  not  unfrequently  occurs  after  punc- 
tures made  to  allow  of  the  escape  of  the  fluid  in 
the  dropsy  of  Bright’s  disease.  That  punctures 
made  into  feebly  nourished  tissues  bathed  in 
decomposable  serous  fluid  should  set  up  diffuse 
inflammation  is  not  surprising,  hut  evidence  is 
wanting  to  prove  that  such  inflammation  is 
necessarily  connected  with  erysipelas. 

Marcus  Beck. 

ERYTHEMA  (ipvSpbs,  red).  Svnon.  : Rose- 
rash  ; Fr.  Err/theme ; Ger.  Hautrothe. 

Definition. — A non-infeetive  superficial  in- 
flammation of  the  skin.theessential  characteristic 
of  which  is  redness,  which  disappears  on  pres- 
sure by  the  finger,  reappearing  when  the  pressure 
is  removed.  The  hue  may  vary  from  a bright 
rose  to  a dark  blue  red ; it  may  or  may  not  he 
accompanied  by  swelling;  the  part  may  he  hot- 
ter than  natural;  and  the  appearance  may  pre- 
sent itself  as  spots,  circumscribed  or  diffuse,  or 
as  wheals.  It  is  sometimes  attended  by  a sensa- 
tion of  slight  burning  or  itching,  but  generally 
gives  rise  to  no  subjective  symptoms.  After  it 


ERYTHEMA. 

has  disappeared  the  skin  is  either  normal,  or 
remains  slightly  pigmented,  or  desquamates. 
Generally  there  is  an  increase  of  temperature, 
with  slight  feverish  symptoms.  Erythema  may 
he  either  symptomatic  or  idiopathic. 

a.  Symptomatic  Erythema. — .Etiology and 
Varieties. — Erythema  occurs  in  rare  instances 
after  the  administration  of  drugs.  Cases  are  re- 
corded after  the  ingestion  of  arsenic,  belladonna, 
chloral,  copaiba,  cubebs,  digitalis,  iodides,  opium, 
quinine,  salicylic  acid,  stramonium,  strychnia,  and 
turpentine.  The  rash  usually  appears  immediately 
after  the  absorption  of  the  medicine  into  the  circu- 
lation ; after  arsenic  it  appears  at  a later  period. 

Exposure  to  heat  or  cold,  and  contact  with 
various  acrid  or  poisonous  substances  are  also 
common  causes  of  erythema.  Friction  and,  in 
the  absence  of  cleanliness,  the  secretions  of  the 
skin  itself,  may  give  rise  to  it,  as  when  erythema 
intertrigo  is  produced  between  the  scrotum  and 
thighs  by  the  imitation  of  profuse  sweat  and 
sebaceous  secretions.  The  blush  of  shame  and 
anger  is  an  erythema  produced  by  the  immediate 
action  of  the  vaso-motor  nervous  system. 

Variola,  cholera,  enteric  fever,  rheumatic  fever, 
and  various  other  less  distinctly  defined  febrile 
conditions,  are  frequently  accompanied  during 
various  stages  of  their  course  by  a more  or  less 
generally  diffused  aud  mostly  ephemeral  form 
of  erythema. 

The  roseola  infantilis  of  authors  is  an  ery- 
thema that  accompanies  intestinal  disturbance, 
teething,  and  various  other  disordered  condi 
tions  of  the  system  in  children.  Its  appearance 
may  exactly  simulate  that  of  measles  or  scar- 
latina, but  it  differs  from  these  in  disappearing  in 
less  than  twenty-four  hours,  and  in  leaving  no 
desquamation  behind  it. 

The  erythema  that  accompanies  small-pox 
— roseola  variolosa — appears  generally  on  the 
second  day  of  the  disease,  either  as  a diffuse 
redness  of  the  whole  integument,  or  as  bright 
red  spots,  which  are  seen  first  on  the  face  and 
then  on  other  parts  of  the  body.  It  lasts  from 
twelve  to  thirty-six  hours,  aud  disappears  when 
the  small-pox  eruption  begins  to  show  itself.  A 
special  limited  form  of  erythema  has  been  ob- 
served on  the  second  and  third  days  of  small- 
pox, extending  from  the  hypogastrium  down 
the  front  of  the  upper  two-thirds  of  the  thighs ; 
the  affected  surface,  when  the  legs  are  closed, 
having  the  form  of  a triangle  the  base  of  which 
is  across  the  lower  part  of  the  abdomen.  This 
surface  remains  almost  or  entirely  free  from  the 
variolous  pustules,  and  many  of  the  cases  in 
which  it  is  present  end  fatally. 

From  the  third  to  the  eighteenth  day  after 
vaccination,  small  or  large  erythematous  patches 
— roseola  vaccina — are  sometimes  seen,  generally 
on  the  arms,  but  also  ou  other  parts  of  the 
body.  They  usually  disappear  within  twenty- 
four  hours,  and  leave  neither  desquamation  nor 
pigmentation. 

The  forms  of  erythema  mentioned  above  can 
not  be  considered  as  being  in  themselves  specific 
varieties  of  disease,  and  pathologically  consist 
in  a temporary  injection  of  the  capillary  blood- 
vessels of  the  skin.  They  are  to  be  distin 
guisbed  from  the  erythemata  that  run  a distinct 
course,  terminating  in  pigmentation  and  desqua 


ERYTHEMA. 

/nation,  and  in  -which  the  capillary  injection  is 
accompanied  by  exudation. 

b.  Idiopathic  Erythema. — I.  Erythema  mul- 
tiforme.— This  form  of  idiopathic  erythema  is 
most  commonly  seen  in  spring  and  autumn,  and 
is  distinguished  by  its  localisation.  It  begins 
on  the  backs  of  the  hands  and  feet,  and  fre- 
quently is  found  in  these  situations  only.  In 
some  cases  it  extends  up-wards  to  the  shoulders 
and  hips,  and  in  very  rare  cases  is  also  found 
on  the  trunk. 

The  appearance  consists  in  flattened  papules 
from  the  size  of  a pea  to  that  of  a bean,  of  a 
dark  blue  or  brown-red  colour.  They  are  sur- 
rounded on  their  first  appearance  by  a red  zone 
which  soon  disappears,  and  the  border  of  the 
papule  then  stands  out  in  fuller  relief.  The 
mildest  form  of  this  disease  consists  in  papules 
which  disappear  after  a few  days — erythema 
papulation  seu  tuberculatum.  Instead  of  thus 
disappearing  it  may  spread  outwards  from  the 
edge,  and  flatten  and  become  pale  in  the  centre, 
thusforming  a red  ring,  the  condition beingknown 
as  erythema  annulare.  While  the  first  circle 
persists  a second  ring  may  form  round  it,  and 
the  circles  may  be  constituted  by  small  papules, 
forming  the  condition  recognised  as  erythema  iris 
seu  mamellatum.  Another  stage  may  be  reached 
by  the  enlarging  circles  meeting,  and  so  forming 
segments  of  a circle,  constituting  the  form  known 
as  erythema  gyratum  seu  marginatum. 

At  any  of  these  stages  the  eruption  may  dis- 
appear. The  sequlae  are  slight  pigmentation 
and  desquamation. 

The  disease,  whose  different  stages  have  re- 
ceived the  different  names  above  indicated,  has 
been  designated,  on  account  of  the  different 
forms  under  which  it  may  be  seen,  erythema 
exsudativum  multiforme.  It  is  accompanied  by  a 
slight  feeling  of  burning,  or  by  veryslight  itching. 
Constitutional  symptoms  are  only  present  excep- 
tionally, and  when  the  eruption  is  universal. 
Hebra  relates  that  in  a woman  who  died  whilst 
an  eruption  of  erythema  gyratum  was  on  the 
skin,  similar  red  rings  were  found  in  the  small 
intestine.  It  is  most  common  in  adolescence, 
and  is  more  frequent  in  males  than  in  fe- 
males. 

II.  Erythema  nodosum. — This  name  is  given  to 
a disease  characterised  by  the  appearance  on  the 
skin,  and  chiefly  on  that  of  the  lower  extremi- 
ties, of  pale  red  hemispherical  or  oval  swellings. 
These  vary  in  size  from  that  of  a pea  to  that  of 
a hen’s  egg,  and  are  painful  on  pressure.  Fever 
is  sometimes  present. 

The  swellings  are  at  first  pale  red  with  a 
yellowish  tinge,  later  dark  red,  and  finally  livid; 
after  they  disappear  they  leave  behind  them 
a yellow  pigmentation  similar  to  that  which 
follows  a contusion.  The  number  of  swellings 
may  vary  from  a very  few  on  the  lower  extremi- 
ties to  successive  crops  on  different  parts  of  the 
limbs  and  trunk.  In  the  latter  case  the  feverish 
\ symptoms  are  well-marked.  The  course  of  the 
disease  is  completed  in  two  to  four  weeks.  The 
swellings  never  suppurate,  never  itch,  are  always 
painful,  and  the  redness  never  spreads  to  the 
adjoining  skin.  This  variety  can  occur  in  com- 
bination with  the  previously  described  forms  of 
erythema  multiforme.  It  is  a disease  of  child- 

30 


EUSTRONGYLUS  GIGANS.  465 

hood  and  adolescence,  and  is  chiefly  seen  in 
females. 

Prognosis. — The  prognosis  of  the  special 
forms  of  erythema — multiforme  and  nodosum — 
is  always  favourable.  Those  varieties  seen  in 
the  course  of  other  diseases  do  not  modify  the 
prognosis  of  the  particular  disease  which  eacli 
accompanies. 

Treatment. — The  treatment  of  erythema  con- 
sists in  palliating  the  attendant  symptoms. 
Dusting  with  flour,  or  the  application  of  spirit- 
lotion,  should  be  employed  when  productive  of 
a sense  of  comfort  to  the  patient.  In  erythema 
nodosum  warm  applications  of  infusion  of  poppies 
or  chamomile  are  soothing;  while  aperients,  and, 
when  fever  is  present,  gentle  diaphoretics  may 
be  given  internally.  In  many  such  cases  tonics, 
especially  quinine,  are  required. 

George  Thin. 

ESCHAROTICS  ( itrxapa , a slou^i). 

Definition. — Escharotics  are  substances  that 
completely  destroy  the  tissues  to  which  they  are 
applied,  and  produce  a slough.  They  are  dis- 
tinguished from  other  caustics  simply  by  the 
greater  intensity  of  their  action. 

Enumeration. — The  chief  escharotics  are  : — 
The  hot  iron,  Sulphuric  Acid,  Nitric  Acid,  Po- 
tash, Chloride  of  Antimony,  Chloride  of  Zinc, 
Acid  Nitrate  of  Mercury,  Bromine,  Chromic 
Acid,  and  Lime.  Weaker  caustics  are — Nitrate 
of  Silver,  Sulphate  of  Copper,  Sulphate  of  Zinc. 
Iodine,  Carbolic  Acid,  Arsenious  Acid,  Sulphide 
of  Arsenic,  and  Dried  Alum. 

Action.— Escharotics  combine  with  the  tissues 
and  destroy  them.  Around  the  part  thus  killed 
inflammation  is  set  up,  and  the  part  is  separated 
as  a slough.  Besides  their  local  action  these 
agents  act  reflexly  on  other  parts  of  the  body 
through  the  nerves  of  the  region  to  which  they 
are  applied. 

Uses. — Escharotics  are  employed,  first,  to 
destroy  the  virus  in,  and  the  tissues  around,  a 
poisoned  wound,  and  thus  prevent  the  absorption 
of  the  poison,  for  example,  in  bites  by  snakes  or 
rabid  animals,  or  in  cases  of  inoculation  with 
syphilis,  or  with  animal-poisons  in  dissection  or 
post-mortem  examinations.  Secondly,  they  are 
used  to  destroy  unhealthy  tissue,  such  as  exu- 
berant granulations,  and  to  remove  excrescences 
and  morbid  growths,  as  warts,  condylomata,  nsevi, 
polypi,  haemorrhoids,  and  cancer.  Thirdly,  they 
are  used  to  open  abscesses,  especially  those  of 
the  liver.  For  this  purpose  caustic  potash  is 
usually  employed.  Lastly,  by  means  of  escha- 
rotics it  is  usual  to  establish  issues,  and  thus 
react  beneficiallj'  on  distant  organs. 

T.  Lauder  Brunton. 

ESSENTIAL  PARALYSIS.— A synonym 
for  infantile  paralysis.  See  Infantile  Paralysis. 

ETHER,  Uses  of.  See  Anesthetics. 

ETIOLOGY.  See  Disease,  Causes  of. 

EUSTACHIAN  TUBE,  Diseases  of.  Sf< 

Ear,  Diseases  of. 

EUSTRONGYLUS  GIGAS.  ,5* 

SCLEROSTOMA. 


168  EVACUANTS. 

EVACUANTS  ( evacuo , I empty). — Defini- 
tion.— Medicines  used  to  produce  some  evacua- 
tion from  tlie  body. 

Enumeration. — The  chief  evacuants  are:— 
Sternutatories,  Expectorants,  Sialagogues,  Eme- 
tics, Cholagogues.  Purgatives,  Diaphoretics,  and 
Diuretics.  See  the  several  articles  upon  these 
subjects. 

EXACERBATION  ( exacerho , I make  vio- 
lent).— Increase  in  the  severity  of  the  symptoms 
of  a disease. 

EXANTHEMA,  EXANTHEMATA.— 

(d£,  out,  and  avdeui,  I blossom). — Synon.  : Fr. 
ExantMme ; G-er.  Ausschlag. 

Definition.— A rash  or  eruption  on  the  skin. 

The  use  of  this  term,  once  denoting  any  cuta- 
neous eruption,  is  now  restricted  to  the  eruptive 
fevers  called  the  exanthemata.  Dermatologists 
discriminate  the  febrile  rashes  or  exanthems  of 
local  or  individual  origin — urticaria,  erythema, 
and  roseola — from  the  true  exanthemata,  which 
are  acute  specific  infectious  diseases,  namely, 
Typhus,  Variola,  Varicella,  Morbilli,  Rotheln, 
Dengud,  Scarlet  Fever,  Typhoid  or  Enteric  Fever, 
and  perhaps  Erysipelas.  In  this  article  some 
leading  features  of  these  diseases  will  be  shortly 
stated  ; and,  as  each  of  them  will  be  found  fuilv 
discussed  under  their  several  heads,  it  is  only 
necessary  further  to  notice  certain  less  defined 
and  regular  eruptions  associated  with  fever. 

All  the  exanthemata  are  attended  with  fever 
and  enlargement  of  the  lymphatic  glands. 

Typhus-. — The  mulberry  rash  appears  suddenly 
on  the  fourth  and  fifth  days  of  illness  as  a dull  red 
mottling  of  irregular,  persistent,  non-elevated 
spots  ; the  fever,  high  at  the  commencement,  con- 
tinues so  after  the  rash  is  fully  developed. 

Typhoid. — In  typhoid  fever  the  small,  raised, 
rose-spots  do  not  appear  till  the  second  week  of 
fever;  sparsely  scattered  on  the  trunk,  the}' 
fade  on  pressure,  disappearing  in  three  or  four 
days,  while  new  spots  arise. 

Small-pox. — Marked  fever  of  sudden  ingress 
occurs  two  day's  before  the  raised  eruption; 
sometimes  arose  rash  first  appears,  but  the  severe 
symptoms  begin  a full  day  before  this  and  not 
more  than  two  day's  before  the  characteristic 
spots  appear.  The  cervical  glands  are  enlarged. 

Varicella. — The  eruption  begins  on  the  first 
day  of  illness ; the  fever  is  often  high  and  comes 
on  suddenly,  but  enlarged  cervical  glands  and 
spots  somewhere  are  always  to  be  found  at  the 
same  time. 

Measles. — Three  days  of  fever  and  catarrh, 
with  palpable  enlargement  of  the  cervical  glands, 
precede  the  rash  ; there  is  then  sudden  increase  of 
fever,  subsiding  while  the  rash  is  at  its  height. 

Rotheln ; Rubeola  sine  catarrho. — The  rash 
appears  within  a few  hours  of  the  first  feeling 
of  illness,  which  is  slight  and  soon  over.  The 
rash  is  at  first  spotted  rather  than  finely  diffused. 
By  the  time  it  is  fully  out  the  fever  has  subsided, 
but  the  enlarged  cervical  glands  which  marked 
the  ingress  alway'S  remain  to  indicate  a specific 
disease;  fine  desquamation  rarely  follows,  and 
there  is  no  albuminuria.  Rotheln  is  invariably 
transmitted  by  contagion,  the  incubation  being 
fr  mi  two  to  three  weeks ; this  long  period  of 
incubation  causes  the  source  of  infection  to  be 


EXANTHEMA. 

often  overlooked,  and  even  the  possibility  of  it 
to  be  denied;  when  carried  to  a family  or  school 
either  an  unnecessary  alarm  of  measles  is  raised, 
or  the  next  sufferers  are  said  to  have  all  drunk 
cold  water  together  after  being  heated. 

Dengue. — Widely-spread  in  Africa,  the  warmer 
parts  of  America,  and  both  the  Indies,  dengue 
may  possibly  bo  limited  to  hot  climates ; its  pre- 
sence with  us  is  as  yet  undetermined.  The  rash 
is  at  first  discrete,  like  that  of  measles,  but  fol- 
lows soon  after  infection,  and  the  disease  in  its 
general  course  is  allied  to  scarlet  fever. 

Scarlet  h ever. — The  finely  diffused  redness  is 
found  on  the  skin  and  in  the  mouth  and  throat 
often  within  a few  hours  of  the  sudden  ingress 
offerer;  the  fever  increases  with  the  develop- 
ment of  the  rash,  both  persisting  for  several 
days.  Often  the  throat  is  first  complained  of;  the 
glands  at  the  angle  of  the  jaw  are  full  and  tender. 
Scarlatina  is  often  declared  three  or  four  days 
after  surgical  operations.  The  skin  is  not  swelled 
as  in  erysipelas,  nor  the  redness  so  circumscribed ; 
the  throat  also  is  redder;  the  cervical  glands  are 
enlarged  in  both. 

Epidemic  Roseola.  — An  epidemic  roseola, 
having  such  relation  to  scarlet  fever  as  rotheln 
to  measles,  has  but  slender  claim  to  autonomy. 
Mild  cases  of  scarlet  fever  often  begin  with  a 
finely-diffused  redness  shortly  after  some  feeling 
of  faintness  or  giddiness ; an  incubation  of  from 
three  days  to  a week  is  observed ; sometimes 
albuminuria  occurs  as  an  early  symptom.  The 
finely-diffused  rash,  enlarged  cervical  glands,  and 
slight  sore-throat,  even  with  very  little  elevation 
of  temperature,  raise  the  suspicion  of  scarlet 
fever;  should  albuminuria  follow',  or  any  shreddy 
desquamation  of  the  hands  and  feet,  no  uncertainty 
remains.  Scarlet  fever  so  modified  often  spreads 
and  gives  rise  to  the  severer  forms  of  the  disease 
when  it  has  been  called  only  rose  rash  or  roseola ; 
the  use  of  these  terms  without  a distinctive  quali- 
fication always  leaves  a doubt  as  to  the  complete- 
ness and  safety  of  the  diagnosis. 

Erythema  comes  nearest  to  these  cases  in  ap- 
pearance, so  near  as  often  to  be  spoken  of  as  re- 
current scarlet  fever  or  erysipelas,  but  there  is  no 
enlargement  of  the  cervical  glands  in  erythema, 
and  so  little  fever  that  the  temperature  of  the 
reddened  skin  is  barely  elevated  above  the  nor- 
mal. Since  Fuller’s  Exanthcmatologia  this  kind 
of  flush  passes  under  different  names  of  roseola, 
according  to  the  variations  in  shape  of  the  red 
patches,  or  the  seasons  of  the  year  at  which  they 
occur. 

Erythema  nodosum  is  often  preceded  by  slight 
fever  for  a day  or  two;  this  may  reach  102°, 
but  subsides  as  the  red  swellings  appear  ; locally 
there  is  little  or  no  elevation  of  temperature 
even  when  the  tender  part  feels  hot. 

Exanthematous  Roseola  occurring  in  the  course 
of  otner  specific  diseases  is  distinguished  from 
the  roseola  which  depends  on  nerve-irritation, 
caused,  for  example,  by  acrid  ingesta,  by  the 
presence  either  of  high  fever,  or  of  glandular 
enlargement,  or  of  both,  as  when  it  precedes  the 
true  variolous  eruption.  During  enteric  fever  this 
form  of  roseola  may'  occur  quite  independently  of 
the  special  lenticular  rose-spots. 

An  eruption  of  this  kind  is  not  infrequent  iu 
the  early  stages  of  diphtheria,  sometimes  as  a 


EXANTHEMA. 

diffused  rash  limited  to  certain  parts  of  the  chest 
and  body,  or  as  discrete  spots  on  the  limbs  and 
back  of  the  hands  and  feet.  Influenza,  and  some 
forms  of  catarrh,  winter  ‘ colds,’  or  summer  diar- 
rhoea a3  noticed  by  Bateman,  may  begin  with 
punctiform  roseola  on  the  back,  shoulders,  and 
chest,-  the  cervical  glands  are  perceptibly  en- 
larged, though  there  may  be  little  fever.  In 
these  cases  it  is  not  the  roseola,  but  the  specific 
disease  on  which  it  depends,  that  might,  without 
precautions,  be  communicated  to  others. 

Syphilitic  Boseola. — A special  roseola  marks 
the  secondary  stage  of  syphilis ; in  appearance  it 
resembles  the  rash  of  measles ; so  does  the  roseola 
ab  ingestis  when  produced  by  cubebs,  but  this  has 
neither  fever  nor  glandular  enlargement. 

The  absence  of  fever  from  the  roseola  after 
raccination  refers  this  form  of  eruption,  like  that 
occurring  from  dentition,  to  the  class  of  rashes 
from  nerve-irritation.  Vaccinia  is  itself  an  ex- 
anthem in  the  wider  definition  of  the  term,  re- 
produced after  a definite  period  of  incubation  by 
inoculating  a special  contagium.  Wanting  this 
character  the  different  forms  of  herpes  are  ex- 
cluded, though  resulting  from  a general  febrile 
disturbance:  though  inoculable,  ecthyma  and  im- 
petigo are  local  affections  not  belonging  to  the 
exanthemata.  William  Squire. 

EXCITANTS  ( excite , I excite). — It  seems 
hardly  necessary  to  give  any  special  considera- 
tion to  this  therapeutical  class,  as  all  that  may 
be  said  on  the  subject  ranges  itself  with  greater 
propriety  under  the  heading  Stimulants.  Stimu- 
lation is,  in  fact,  a degree  of  excitement,  and  it 
is  only  when  its  effects  are  more  vigorously  pushed 
that  we  obtain  that  inebriation  or  exhilaration 
which  is  so  commonly  observed  to  follow  the  use 
of  alcohol,  ether,  and  the  anaesthetic  vapours.  See 
Stimulants.  Robert  Earquuarson. 

EXCITIN' O-  CAUSE.  See  Disease,  Causes 

of. 

EXCITO-MOTOR  Disorders.  See  Reflex 
Disorders. 

EXCORIATION  (ex,  from,  and  corium,  the 
skin). — The  superficial  destruction  of  a portion 
of  the  skin  or  mucous  membrane. 

EXERCISE. — Definition. — In  its  widest 
and  most  correct  signification,  exercise  is  the 
setting  in  motion  any  active  body  ; and  when  the 
term  is  used  in  a physiological  connection,  it  may 
refer  to  the  functional  activity  of  any  of  the  or- 
gans, whether  muscular,  nervous,  nutritive,  se- 
cretory, or  reproductive.  In  this  very  compre- 
hensive sense,  the  subject  of  Exercise  includes 
a large  portion  both  of  hygifene  and  of  thera- 
peutics. The  popular  signification  of  Exercise  is, 
however,  much  more  limited  than  the  preceding, 
having  reference  only  to  the  muscles  directly, 
and  to  the  parts  called  into  play  through  the 
same — especially  the  circulatory  and  rospiratory 
systems. 

Whether  in  its  wider  or  in  its  narrower  sense, 
exercise  has  several  important  relations  to  Medi- 
cine. 1.  It  is  essential  to  the  preservation  of 
health  ( see  Personal  Health).  2.  It  has  to 
be  regarded  as  frequently  associated  with  the 
•ousation  of  disease  ( see  Disease,  Causes  of).  3. 


EXERCISE.  467 

Exercise  is  a most  rational  and  successful  means 
of  treatment  in  certain  disorders  and  diseases 
(see  Movement,  Therapeutics  of).  4.  Exercise  is 
often  abused;  and  excessive  indulgence  in  some 
forms  of  it  gives  riso  to  serious  consequences. 
The  present  article  will  be  devoted  to  the  con- 
sideration of  Exercise  in  the  last-named  aspect 
only ; and  the  subject  will  be  discussed  accord- 
ing to  the  more  limited  and  popular  definition  of 
the  term. 

Abuse  of  Exercise. — From  the  moment  an 
infant  is  born  until  the  end  of  life,  exercise,  duly 
apportioned  to  rest,  is  the  normal  state  of  ex- 
istence; and  whilst  continued  overstrain  of  any 
portion  of  the  human  machine  is  the  forerunner 
of  disease,  so,  on  the  other  hand,  is  equally,  if 
not  more  so,  that  want  of  exercise  which  induces 
wasting  and  degeneration. 

Principles.  — Dr.  Parkes,  in  his  Practical 
Hygiene , has  given  a very  complete  statement  of 
the  results  of  the  investigations  of  himself  and 
others  on  the  changes  effected  by  the  stimulus 
of  muscular  exercise  on  the  various  organs  and 
tissues  of  the  body,  from  which  he  has  drawn  the 
following  conclusions 

‘ The  main  effect  of  exercise  is  to  increase  the 
oxidation  of  carbon,  perhaps  also  of  hydrogen. 
It  also  eliminates  water  from  the  body,  and  this 
action  continues — as  seen  from  Pettenkofer  an  i 
Voit's  experiments — for  sometime;  after  oxer 
cise  the  body  is  therefore  poorer  in  water, 
especially  of  the  blood  ; it  increases  the  rapidity 
of  circulation  everywhere,  as  well  as  the  pres- 
sure on  the  vessels,  and  therefore  it  causes  in 
all  organs  a more  rapid  outflow  of  plasma  and  a 
more  active  absorption — in  other  words,  a quicker 
renewal. 

‘In  this  way,  also,  it  removes  the  product  of 
their  action  which  accumulates  in  organs  ; and 
restores  the  power  of  action  to  the  various  parts 
of  the  body.  It  increases  the  outflow  of  warmth 
from  thebody  by  increasing  perspiration.  It  there- 
fore strengthens  all  parts.  It  must  be  com- 
bined with  increased  supply  both  of  nitrogen 
and  carbon  (the  latter  possibly  in  the  form  of 
fat),  otherwise  the  absorption  of  oxygen,  the 
molecular  changes  in  the  nitrogenous  tissues, 
and  the  elimination  of  carbon,  will  be  checked. 
There  must  also  be  an  increased  supply  of  salts, 
certainly  of  chloride  of  sodium,  probably  of 
potassium  phosphate  and  chloride.  There  must 
be  proper  intervals  of  rest,  or  the  store  of 
oxygen,  and  of  the  material  in  the  muscles, 
which  is  to  be  metamorphosed  during  contrac- 
tion, cannot  take  place.  The  integrity  and 
perfect  freedom  of  action  both  of  the  heart  and 
lungs  is  essential,  otherwise  neither  absorption 
of  oxygen,  nor  elimination  of  carbon,  can  go  on, 
nor  can  the  necessary  increased  supply  of  blood 
be  supplied  to  the  acting  muscles  without  in- 
jury.’ 

Tho  proper  amount  of  exercise  requisite  for 
health  is  difficult  to  determine,  in  consequence  of 
the  varied  constitutions  of  individuals.  It  may, 
however,  be  accepted  that  whilst  in  youth  the 
great  spirit  of  emulation  tends  to  an  overstrain 
of  mind  or  body,  so,  as  life  advances,  one  or  other 
or  both  are  liable  to  be  allowed  to  pass  into  a 
state  of  unhealthy  inactivity. 

Since  the  recent  more  general  practice  of 


468  EXERCISE. 

gymnastics  in  this  country,  and  the  stimulus 
that  has  been  given  to  aquatic  exercises  by  our 
University  competitions,  great  attention  has 
been  drawn  to  the  efleet  of  bodily  exercise 
on  health,  and  more  especially  with  regard  to 
the  heart  and  lungs,  these  being  the  organs 
upon  which  its  influence  is  most  immediately 
exerted. 

a.  Prolonged  and  Excessive  Exercise. — Of  all 
exercises,  rowing  is  the  one  which  is  generally 
accepted  as  the  best  variety  to  select  if  we  are 
to  endeavour  by  a consideration  of  its  influence 
upon  those  who  practise  it  to  form  an  estimate 
of  the  effect  of  a continuous  strain  on  the  cir- 
culation and  respiration  ; yet  the  difficulty  of 
procuring  trustworthy  evidence  on  such  a sub- 
ject is  extreme.  Dr.  Morgan,  in  his  University 
Oars , by  collecting  the  various  experiences  of 
nearly  all  the  men  who  rowed  in  the  University 
races  from  1829  to  1869,  has  obtained  about  the 
most  accurate  testimony  available  in  regard  to 
one  aspect  of  the  subject.  These  men  are  unani- 
mous in  their  belief  that  they  experienced  no 
injury  from  the  great  strain  they  underwent  in 
their  youth.  But  it  must  be  borne  in  mind  that 
they  were  the  picked  athletes  of  their  colleges, 
men  with  large  frames  and  full  chests,  typical 
specimens  of  health,  capable  of  undergoing  very 
prolonged  exertion  with  but  passing  fatigue,  and 
to  whom  no  permanent  injury  could  be  antici- 
pated, aftercareful  training,  from  an  exceptional 
display  of  strength.  Such  evidence  affords  no 
clue  to  the  effect  of  the  strain  imposed  on  the 
heart  by  the  two  hundred  or  more  of  each  Uni- 
versity, who  annually  use  the  utmost  exertion 
to  belong  to  the  chosen  few,  and  many  of  whom, 
unguided  in  their  violent  efforts  to  achieve  suc- 
cess, have  in  after-life  to  pay  the  penalty  of  al- 
lowing mere  feeling  or  spirit  of  emulation  to 
overrule  their  reason. 

b.  Exercise  under  Unnatural  Conditions. — But 
it  is  not  only  the  case  that  exercise  which  is 
excessive  or  too  prolonged  proves  highly  dele- 
terious ; even  a moderate  amount  of  exercise 
under  unnatural  conditions  may  prove  equally 
harmful.  Thus  the  young  soldier  of  light  frame, 
with  irritable  palpitating  heart,  who  has  broken 
down  in  his  preliminary  training,  is  a marked 
and  good  example  of  the  early  injurious  effect  of 
overstrain  of  the  heart,  under  the  impediment 
caused  by  tight  clothing  and  accoutrements  to 
the  free  expansion  of  his  chest.  Mhen  at  rest 
he  feels  perfectly  well,  and  has  little  or  no  sensa- 
tion of  throbbing  in  his  chest.  So  soon,  however, 
as  he  puts  on  his  tunic  and  accoutrements,  and 
begins  his  drill,  throbbing  occurs  with  more  or 
less  violence,  accompanied  with  a feeling  of  op- 
pression, and  with  difficulty  of  breathing,  and  this 
being  followed  by  a sensation  of  faintness,  sick- 
ness, or  dizziness,  he  has  to  fall  out  of  the  ranks. 
At  first  the  condition  of  the  heart  is  one  purely 
of  functional  disturbance,  which,  though  render- 
ing him  unfit  for  the  duties  of  a soldier,  does  not 
interfere  with  his  gaining  his  livelihood  as  a 
civilian. 

This  functional  derangementof  the  heart,  which 
is  readily  shown  by  the  dicrotism  in  the  sphyg- 
mographic  tracing  of  the  radial  pulse  when 
auscultation  can  detect  little  or  no  change  in 
the  heart-sounds,  is  frequently  found  in  those 


EXFOLIATION". 

youths  of  delicate  frame  in  our  schools  and  col- 
leges, who,  ‘ breaking  down  ’ in  attempting  feats 
of  strength  or  in  the  preliminary  training,  ex- 
perience no  ill-effects  in  the  ordinary  avocations 
of  after-life  from  that  overstrain  of  heart  which, 
if  neglected,  would  be  apt  to  lead  to  graver  forms 
of  heart-disease. 

Whether  it  be  by  sudden  or  prolonged  violent 
exertion,  by  rowing,  or  by  running,  or  by  the  many 
other  severe  exercises  of  the  body  entailed  be- 
labour or  pleasure,  there  can  be  no  doubt  that 
the  heart  and  lungs  have  at  times  an  inordinate 
amount  of  strain  forced  upon  them,  which,  in  a 
state  of  health,  or  under  favourable  circum- 
stances, they  may  reasonably  be  expected  to 
bear  with  no  more  injury  than  temporary  dis- 
tress, and  that  this  capability  to  bear  strain  is 
greatly  enhanced  by  careful  training. 

It  is  customary  for  the  healthy  boy,  however, 
owing  to  the  character  of  his  amusements,  always 
to  be  in  training,  so  far  as  his  body  is  concerned, 
and  with  very  little  supervision  he  ought  to  suffer 
no  harm  from  sudden  and  exceptional  strains.  But 
it  is  very  different  with  men  who  have  settled 
down  into  the  real  business  of  life,  but  who, 
during  their  nominal  periods  of  rest  from  their 
daily  labours,  undertake  violent  exercises  with- 
out any  preliminary-  training,  and  thus  throw  such 
an  unexpected  strain  on  the  heart  and  great 
blood-vessels,  that  instead  of  mere  functional 
disturbance,  as  in  early  life,  they  sow  the  seeds 
of  organic  disease.  Such  being  the  case,  how  much 
more  injurious  must  sudden  overstrain  be  to  a 
heart  already  weakened  by  disease  ? There  is 
often  found  amongst  men  a great  aversion  to 
having  their  hearts  examined,  and  when  disease 
is  discovered  it  is  sometimes  considered  of  ques- 
tionable advantage  to  inform  the  sufferer  of  his 
condition  ; but  this  is  a mistake,  for  from  warn 
of  knowledge  of  his  state  he  may,  by  unnecessary- 
strain,  rapidly  aggravate  it,  and  thus  shorten  a 
life  which  might  otherwise  have  been  much  pro 
longed. 

The  purport  of  these  observations  is  thus  tf 
point  out  that: — Firstly,  whereas  exercise  is 
necessary-  to  preserve  our  bodies  in  a proper  state 
of  healthy  activity,  its  tendency,  when  carried  to 
extremes,  is  to  set  up  organic  lesions.  Secondly, 
that,  as  in  some  athletic  competitions  a very 
great  strain  is  thrown  upon  the  thoracic  organs, 
it  is  essential  that  no  boys  of  delicate  frame 
should  be  allowed  to  take  part  in  them,  or  in  the 
preliminary  training,  excepting  under  careful 
medical  supervision.  And.  thirdly,  that  in  man- 
hood no  violent  competition  should  be  under- 
taken, which  would  throw  a great  strain  upon 
the  thoracic  organs,  without  their  being  pre- 
viously examined  and  pronounced  sound,  nor 
until  their  full  powers  have  been  brought  into 
play  by  careful  preliminarv  training. 

A.  B.  R.  Mtebs. 

EXFOLIATION  {ex,  from,  and  folium,  a 
leaf). — The  separation  of  a portion  of  dead  bone 
or  cartilage  from  the  living  tissue,  in  the  form 
of  layers  ( see  Bone,  Diseases  of).  The  term  is 
also  applied  to  the  separation  of  a false  mem- 
brane which  has  been  mistaken  for  the  whole 
mucous  lining  of  the  bladder  or  uterus.  SiJ 
Bladder,  Diseases  of. 


EXHAUSTION. 

EXHAUSTION  (cx,  from,  and  haurio,  I draw 
out). 

Definition-.  — Exhaustion  is  a phenomenon 
which  all  irritable  tissues  can  be  made  to  mani- 
fest, and  consists  in  a failure  to  respond  to  stimu- 
lation. Exhaustion  of  muscle  and  nerve  is 
brought  about  by  excessive,  quickly  repeated,  or 
continuous  stimulation.  It  is  favoured  by  cut- 
ting off,  or  by  an  alteration  in  the  quality  of,  the 
blood-supply  ; by  previous  insufficient  exercise 
of  function ; by  exposure  to  extremes  of  temper- 
atore;  by  an  insufficient  supply  of  oxygen;  by 
an  excessive  supply  of  carbonic  acid ; and  by 
exposure  to  certain  toxic  agents.  These  facts, 
which  have  been  established  by  physiological 
experiments,  are  fully  borne  out  by  clinical  ex- 
perience. 

Exhaustion  may  be  general  or  local. 

1.  General  Exhaustion. — General  exhaus- 
tion is  brought  about  by  over-work,  whether 
physical  or  mental,  and  especially  by  unremit- 
ting and  monotonous  duties  which  keep  the 
same  paths  of  action  in  a state  of  constant  ac- 
tivity. It  is  not  often,  if  ever,  that  any  per- 
manent harm  is  produced  in  a healthy  man  by 
mere  physical  labour,  however  great;  but  ex- 
cessive mental  labour,  especially  if  it  be  mo- 
notonous, is  certainly  capable  of  permanently 
damaging  the  nervous  tissues.  When  in  addi- 
tion to  hard  mental  work,  which  is  performed 
voluntarily,  some  constant  stimulus,  which  can- 
not bo  arrested,  unceasingly  works  upon  the 
brain,  exhaustion  quickly  results ; as  when,  for 
example,  a man  who  is  harassed  by  trying  to 
earn  sufficient  for  his  family  meets  with  some 
shock  to  his  nervous  system  (such  as  a railway 
accident,  the  sudden  death  of  a dear  relative, 
or  a severe  money  loss)  which  haunts  him  like 
a spectre  day  and  night,  robs  him  of  his  rest, 
and  deprives  him  of  his  appetite.  General  ex- 
haustion is  favoured  by  all  conditions  which 
give  rise  to  ausemia  or  faulty  nutrition,  such  as 
hemorrhage,  prolonged  pyrexia,  inadequate  diet, 
persistent  morbid  discharges,  or  venereal  excess  ; 
by  the  retention  in  the  tissues  of  the  products 
of  their  activity,  which  is  favoured  ly  working 
in  a foul  atmosphere,  or  by  derangement  of  the 
excreting  functions  ; by  exposure  to  extremes  of 
temperature ; and  by  a previous  condition  of 
excessive  slothfulness.  General  exhaustion  may 
occasionally  be  suddenly  induced  by  physical 
causes,  such  as  a severe  injury  (collapse  from 
shock),  or  psychical  causes,  such  as  fright. 

Symptoms. — The  symptoms  of  general  exhaus- 
tion are; — 1.  Loss  of  sleeping  power,  persistent 
dreaming,  talking  in  the  sleep  and  somnambulism. 
The  patient  may  wake  in  the  morning  feeling  to- 
tally unrefreshed.  2.  Incapacity  for  work,  and 
inability  to  seriously  apply  the  mind  to  one  sub- 
ject  for  any  length  of  time.  3.  Headache,  and  a 
feeling  of  oppression  in  the  head.  4.  Languor 
and  general  lassitude.  5.  A rapid  feeble  pulse.  6. 
An  anxious  expression  of  face ; and  (as  stated  by 
Dr.  George  Johnson)  a contracted  and  sluggish 
pupil.  In  addition  to  these  we  may  get  tremor, 
delirium,  hypochondriasis,  hysteria,  epilepsy, 
chorea,  mania,  and  general  paralysis.  Two  in- 
etances  have  come  within  the  writer’s  know- 
ledge of  transient  hemiplegic  symptoms  having 
been  induced  by  excessive  application  to  literary 


EXOPHTHALMIC  GOITRE.  469 
work.  The  digestion  is  often  deranged,  and 
functional  disturbance  of  the  heart  is  common. 
Occasionally  the  urine  is  altered  in  quality,  and 
may  contain  alkaline  phosphates  or  sugar. 
More  rarely  it  manifests  excessive  acidity. 

2.  Local  Exhaustion. — Local  exhaustion  is 
the  result  of  excessive  local  stimulation,  and  it  is 
particularly  liable  to  occur  as  a prominent  symp- 
tom in  patients  who  are  suffering  from  general 
exhaustion.  The  loss  of  power  in  the  rectum 
which  results  from  the  excessive  use  of  purga- 
tives ; the  failure  of  the  uterus  in  eases  ci 
protracted  labour ; and  the  failure  of  the  volun- 
tary muscles  which  occurs  ia  those  professional 
ailments  of  which  ‘ writer’s  cramp  ’ is  the  type, 
may  be  taken  as  examples  of  local  exhaustion. 

Treatment. — In  the  treatment  of  exhaustion 
the  main  indications  are  to  lighten  the  labour,  and 
obtain  rest.  In  cases  of  general  exhaustion  it  is 
often  advisable  to  administer  narcotics,  such  as 
opium,  hydrate  ofehloral,  or  bromide  of  potassium, 
and  it  will  be  generally  found  that,  when  once 
refreshing  sleep  has  been  established,  the  more 
aggravated  symptoms  will  subside.  Fresh  air 
and  a good  diet  are  most  necessary.  Stimulants 
must  be  used  with  great  caution,  for  it  is  clearly 
not  desirable  to  goad  the  exhausted  organs  into 
further  action,  although  it  may  be  necessary  to 
employ  stimulants  to  give  temporary  power  while 
the  faculty  of  sleeping  is  being  re-established. 
All  causes  of  anamia  must  be  removed.  When 
recovery  is  established,  the  patient  must  be  en- 
couraged to  relieve  the  monotony  of  his  life  by 
some  pursuit  which  should  be,  as  it  were,  the 
complement  of  his  ordinary  occupation.  Thus 
the  head-worker  should  endeavour  to  amuse 
himself  in  his  leisure  hours  by  gentle  out-docr 
exercise,  by  music  or  painting,  or  by  practising 
some  handicraft.  Sec  Debility,  and.  Fatigue. 

G.  Y.  Poore. 

EXOMPHALOS  beyond,  and  ofi<pa\bs, 
the  navel). — A term  applied  to  umbilical  hernia. 
See  Hernia. 

EXOPHTHALMIC  GOITRE  (eft-,  out, 
and  o<p8a\ubs,  the  eye ; and  goitre). — Synon.  : 
Graves’  Disease : Basedow's  Disease ; Fr.  Maladie 
de  Graves,  Goitre  cxopkthalmiquc ; Ger.  Glotsau- 
genhropf,  Basedows’ che  Krankheit. 

Definition. — Enlargement  with  vascular  tur- 
gescence  of  the  thyroid  gland,  accompanied  by 
protrusion  of  the  eyeballs,  breathlessness,  pal- 
pitation, and  anaemia. 

./Etiology. — This  disease  is  comparatively 
rare  among  men.  It  occurs  most  frequently  in 
women  between  the  ages  of  twenty  and  thirty, 
but  is  met  with  amongst  older  persons.  Pa- 
tients suffering  from  it  often  belong  to  the  so- 
called  nervous  diathesis.  Its  occurrence  is  often 
preceded  by  menstrual  disturbance  and  anaemia. 
Sometimes  no  exciting  cause  can  bo  discovered, 
but  in  many  cases  it  comes  on  after  violent  ner- 
vous excitement. 

Symptoms. — Before  exophthalmic  goitre  makes 
its  appearance,  alterations  in  temper  are  fre- 
quently observed,  the  patient  becoming  irritable 
and  depressed.  Functional  disturbances  of  the 
circulation  and  heart  occur  at  frequent  intervals, 
the  heart  palpitating,  the  face  flushing,  and  a 


-470  EXOPHTHALMIC  GOlTRK. 
sensation  of  fulness  being  felt  in  the  head,  eyes, 
and  throat.  The  palpitation  increases,  the  eyes 
become  prominent,  and  a visible  swelling  appears 
over  the  thyroid  gland.  The  eyes  are  lustrous  and 
projecting,  and  there  is  frequently  a slight  loss  of 
co-ordination  between  their  movements  and  those 
of  the  eyelids,  so  that  when  the  eyes  are  quickly 
cast  down  the  eyelids  follow  them  so  slowly  that 
a white  ring  of  sclerotic  may  be  noticed  between 
the  iris  and  the  lower  margin  of  the  upper  eyelid. 
Usually  there  is  no  disturbance  of  vision.  The 
exophthalmia  is  most  marked  during  emotional 
excitement  and  at  the  menstrual  period,  and  at 
these  times  the  patient  suffers  from  an  increased 
feeling  of  fulness  in  the  eyeballs.  Sometimes 
the  projection  of  the  eyeballs  is  so  great  that 
the  lids  do  not  perfectly  cover  them,  and  inflam- 
mation and  ulceration  may  consequently  occur. 
The  thyroid  is  generally  unequally  enlarged.  Its 
size  varies  from  time  to  time,  increasing,  like  the 
protrusion  of  the  eyeballs,  with  emotion.  It  is 
soft  and  elastic,  and  pulsates,  so  that  it  has  some- 
times been  mistaken  for  aneurism.  The  palpi- 
tation of  the  heart  is  generally  noticed  before 
either  the  exophthalmos  or  enlargement  of  the 
thyroid,  and  is  the  first  symptom  to  attract 
the  patient’s  attention.  It  is  increased  by 
emotion  or  exertion ; and  the  violent  cardiac 
action  frequently  produces  a prominence  of  the 
prscordial  region.  The  cardiac  pulsations  are 
rapid  and  sometimes  irregular.  The  cardiac 
sounds  are  loud ; and  a soft,  systolic  bellows- 
murmur  is  frequently  audible  at  the  base,  and  in 
the  large  arteries.  The  carotids  are  sometimes, 
but  not  always,  dilated.  The  circulation  appears 
to  be  rapid,  the  veins  filling  quickly  when 
emptied,  and  pulsation  being  felt  even  in  small 
arteries.  The  temperature  is  frequently  high. 
There  is  a feeling  of  general  debility.  The  di- 
gestion is  sometimes  normal,  at  other  times  the 
appetite  is  diminished  or  capricious,  and  diarrhoea 
may  occur.  The  swelling  of  the  neck  may  give 
rise  to  a feeling  of  difficulty  of  breathing;  and 
the  voice  sometimes  becomes  altered  and  hoarse, 
or  may  be  lost  entirely.  The  course  of  the 
disease  varies  considerably ; it  may  sometimes 
go  on  increasing  for  several  months,  then  it  be- 
comes stationary  for  one  or  two  years,  and  after- 
wards begins  to  decline.  The  temper  improves, 
the  appetite  increases,  and  menstruation  fre- 
quently is  re-established.  The  palpitation,  en- 
largement of  the  thyroid,  and  prominence  of 
the  eyes  gradually  diminish,  although  they  rarely 
disappear  completely.  Death  may  occur  from 
intercurrent  disease,  from  organic  cardiac  lesions, 
or  from  gradual  wasting.  Danger  is  also  said  to 
arise  from  pressure  on  the  trachea  by  the  en- 
larged thyroid. 

Pathology. — The  protrusion  of  the  eyeballs  is 
due  either  to  dilatation  of  the  vessels  in  the  orbit, 
or  to  contraction  of  the  involuntary  muscular 
fibres  in  the  orbital  membrane  which  covers  the 
spheno-maxillarv  fissure,  or  possibly  to  both 
causes  combined.  The  enlargement  of  thethyroid 
is  due  to  dilatation  of  the  vessels  of  the  gland. 
After  the  disease  has  lasted  some  time,  increased 
formation  of  tissue  in  the  thyroid  gland  may 
occur.  Palpitation  of  the  heart  is  probably  due 
to  stimulation  of  the  accelerating  cardiac  nerves  ; 
and  this,  as  well  as  the  alteration  in  the  nerves 


EXPECTORANTS. 

of  the  orbit  and  thyroid,  has  been  ascribed  to 
disease  of  the  lower  cervical  sympathetic  ganglia, 
in  which  increased  connective  tissue  and  dimin- 
ution of  ganglionic  cells  have  been  observed. 

Diagnosis. — When  the  three  leading  symp- 
toms are  present,  it  is  impossible  to  confound 
exophthalmic  goitre  with  any  other  disease.  The 
enlargement  of  the  thyroid  is  distinguished  in 
this  disease  from  that  of  cystic  goitre  by  its 
greater  elasticity,  by  its  paroxysmal  enlarge- 
ment, and  by  its  pulsation.  The  exophthalmos 
is  distinguished  from  that  due  to  disease  of  the 
orbit  or  cranium  by  being  equal  in  both  eyes, 
and  by  the  absence  of  squint.  It  is  distin- 
guished from  prominence  due  to  cardiac  diseaso 
by  the  lustrous  appearance  of  the  eye ; from 
hydrophthalmia  by  the  natural  condition  of  the 
pupil ; and  from  the  prominence  which  may  occur 
in  myopia  by  the  vision  being  natural,  and  by  the 
paroxysmal  increase  of  the  prominence  in  ex- 
ophthalmic goitre. 

Prognosis. — This  must  be  guarded,  the  disease 
not  being  very  amenable  to  treatment,  and  very 
rarely  disappearing  altogether,  although  after 
continuing  for  some  years  it  may  gradually  im 
prove. 

Treatment. — The  treatment  of  exophthalmic 
goitre  chiefly  consists  in  securing  fresh  air, 
gentle  exercise,  the  avoidance  of  the  least  fatigue 
or  emotional  disturbance,  and  careful  diet.  Iron 
is  sometimes  useful,  the  milder  forms,  such  as 
the  tartarated  iron  or  citrate  of  iron  and  ammo- 
nia, being  preferable  to  the  more  powerful  pre- 
parations. Quinine,  alone  or  in  combination  with 
digitalis — and  perhaps  with  belladonna — often 
produces  good  results.  Aloes  and  myrrh  may  be 
employed  to  keep  the  bowels  open.  Galvanism  to 
the  neck  has  sometimes  been  productive  of  bene- 
fit, one  pole  being  placed  in  the  nape  of  the  neck 
and  the  other  over  the  sides  of  the  thyroid  tumour. 
When  the  eyeballs  are  so  prominent  as  to  become 
liable  to  inflammation  and  ulceration,  care  must 
be  taken,  by  means  of  a shade,  to  protect  them 
from  irritation  ; and  if  this  should  prove  unavail- 
ing, the  inflammation  must  be  treated  by  appro- 
priate remedies.  T.  Lauder  Brunton. 

EXOSTOSIS  (e(cu,  out  of,  and  orriov,  a 
bone). — A bony  outgrowth  from  any  part  of  the 
skeleton.  See  Bone,  Diseases  of. 

EXPECTANT  ATTENTION.— An  im- 
portant mental  state.  See  Mesmerism. 

EXPECTORANTS  (cx,  out  of,  and  pectus, 
the  chest). — Synon.  : Fr.  Expectorants',  Ger. 
Auswurfsbefordernde  Mtitel. 

Definition. — Medicines  which  facilitate  the 
removal  of  secretions  from  the  air-passages. 

Enumeration.  — The  leading  expectorants 
are : — (A)  Ipecacuanha,  Antimony,  and  Iodide  of 
Potassium ; Chlorides  of  Potassium,  Sodium, 
and  Ammonium ; and  Inhalation  of  Steam.  (B) 
Squill,  Senega,  Benzoin,  Benzoic  Acid,  Benzoate 
of  Ammonia ; Myrrh,  Storax,  Balsam  of  Tolu, 
Balsam  of  Peru.  Ammoniaeum,  Gallanum,  Assa- 
foetida,  Anise,  Fennel,  Larch  Bark.  Tar,  Copaiba, 
Vapour  of  Chlorine,  Iodine,  Ammonia,  Creasote, 
and  Carbolic  Acid.  (C)  Ammonia,  Carbonate  of 
Ammonia,  Strychnia,  Nux  Vomica,  and  Bella- 
donna. 

Action. — The  mode  of  action  of  expectorant? 


EXPECTORANTS. 

is  not  -well  understood,  and  any  explanation  of 
it  in  the  present  state  of  our  knowledge  can 
only  be  regarded  as  provisional.  Expectorants 
may  be  divided  into  two  classes: — 1.  Those 
which  modify  the  nature  of  the  secretions  from 
the  respiratory  passages ; and,  2.  those  which 
modify  the  respiratory  movements  by  which 
the  secretions  are  expelled.  In  considering  the 
mode  of  action  of  the  first  class  it  must  be 
remembered  that  the  secretions  from  the  respi- 
ratory passages  depend,  like  many  other  secre- 
tions, on  two  factors,  the  direct  influence  of  the 
nerves  upon  the  secreting  structures,  and  the 
amount  of  blood  supplied  to  them.  Each  of 
these  two  factors  may  be  influenced  to  a dif- 
ferent extent  by  various  drugs.  As  has  already 
been  said,  the  exact  action  of  each  cannot  be  de- 
termined at  present,  but  the  first  class  of  expec- 
torants may  be  subdivided  into  two  divisions 
which  are  distinguished  in  the  foregoing  enu- 
meration as  A and  B.  The  division  A rather 
diminish  than  increase  the  activity  of  the  cir- 
culation, and  are  therefore  called  sedative  expec- 
torants. The  division  B somewhat  increase  the 
circulation,  and  are  called  stimulating  expec- 
torants. Those  comprised  under  C stimulate  the 
respiratory  centre  in  the  medulla  oblongata,  and 
increase  the  respiratory  movements. 

Uses. — Sedative  expectorants  (class  A)  are 
useful  when  there  is  congestion  of  the  respira- 
tory passages,  with  very  scanty,  tough  expec- 
toration, as  in  commencing  bronchitis.  In  such 
circumstances,  when  dry  rales  are  heard  abun- 
dantly, with  few  or  no  moist  rales,  the  patient 
often  coughs  until  quite  exhausted,  bringing  up 
scarcely  anything.  The  administration  of  seda- 
tive expectorants  renders  the  secretion  from 
the  respiratory  passages  more  fluid,  abundant, 
and  easy  to  expectorate.  When  these  expec- 
torants do  not  succeed  in  ordinary  doses,  their 
action  may  be  much  assisted  by  the  administra- 
tion of  a purgative,  or,  still  better,  by  giving 
either  ipecacuanha  or  tartar  emetic  in  such  a 
large  dose  as  to  produce  sickness  and  vomiting. 
When  the  distress  of  the  patient  is  great,  the 
abstraction  of  a small  quantity  of  blood  by 
cupping  or  by  venesection  may  give  great  relief. 
The  inhalation  of  steam  alone  is  also  beneficial, 
and  the  air  of  the  patient’s  chamber  should  be 
kept  warm  and  moist.  Stimulating  expectorants 
(class  B)  do  more  harm  than  good  when  admi- 
nistered in  the  conditions  just  described,  but  are 
beneficial  when  the  acute  symptoms  have  passed 
oif.  When  this  is  the  case,  but  the  expecto- 
ration is  tough  and  somewhat  scanty,  squill  is  a 
useful  expectorant ; but  when  the  expectoration 
is  abundant,  benzoin,  balsams,  or  ammoniacum 
are  preferable.  In  chronic  bronchitis,  inhalations 
of  ammonia,  chlorine,  iodine,  creasote,  carbolic 
acid,  or  pine  oil  are  useful.  When  the  expecto- 
ration is  foetid,  chlorine,  iodine,  and  carbolic 
acid  inhalations  are  best.  The  expectorants 
which  act  on  the  respiratory  movements  (class 
C)  are  useful  in  cases  of  debility,  as  they  stimu- 
late the  respiratory  nervous  centre  in  the  medulia 
oblongata,  as  well  as  assist  the  failing  circula- 
tion. They  may  be  advantageously  combined 
with  stimulating  expectorants,  such  as  squill  or 
benzoin,  according  to  the  nature  of  the  secretion. 

T.  Laudbe  Reunion. 


EX  PECTORATION.  47 1 

EXPEC'l  OKATION  (ex,  out  of,  and  pectus, 
the  chest). 

Definition. — This  word,  which  strictly  means 
the  act  of  expelling  anything  from  the  chest,  is 
usually  applied  to  the  matter  so  expelled,  which 
is  also  called  sputum  or  phlegm. 

The  Act  of  Expectoration. — The  smaller 
bronchial  tubes  are  kept  free  from  obstruction  by 
the  action  of  ciliated  epithelium.  The  area  of 
the  smaller  tubes  being  greater  than  that  of  their 
trunks,  the  air  passes  more  forcibly  through  the 
latter,  and  so  tends,  even  in  natural  breathing,  to 
carry  speedily  away  any  accumulated  secretion. 
The  forcible  acts  of  coughing  (see  Cough)  and 
‘hawking’  increase  the  natural  force  and  fulness 
of  the  expiratory  effort,  and  clear  the  air-pas- 
sages ; the  repeated  closure  of  the  glottis  iu 
coughing  increases  still  further  the  expulsive 
effect,  by  causing  the  air  to  escape  in  sudden 
jerks.  If,  in  consequence  of  laryngeal  disease, 
the  glottis  cannot  close,  the  act  of  expectora 
tion  becomes  painful  and  difficult.  Efforts  at 
expectoration  are  also  laboured  and  futile  if, 
in  consequenco  of  emphysema  or  muscular  weak- 
ness, the  power  to  take  a deep  inspiration  is  lost. 

Inability  to  expectorate  is  often  the  imme- 
diate cause  of  death,  the  ‘ suffocative  catarrh  ’ of 
the  dying  being  another  name  for  accumulation 
of  phlegm,  which  the  patient  is  powerless  to 
remove.  By  teaching  the  patient  ‘ how  to  ex- 
pectorate,’ by  the  administration  of  a timely 
stimulant  or  a quickly  acting  emetic, or  by  change 
of  posture,  life  may-  in  such  a case  be  prolonged. 
Should  the  sufferer  be  allowed  to  get  flurried, 
the  breathing  becomes  more  and  more  shallow, 
and  deep  inspiration  and  free  expectoration  are 
impossible.  If,  however,  the  patient  can  be  in- 
duced to  breathe  calmly  and  deeply,  to  assume 
a more  easy  posture,  and  to  swallow  a solution  of 
ammonia  with  ether,  the  breathing  gradually 
becomes  less  shallow  and  rapid,  air  enters  the 
deeper  parts  of  the  lung,  and  power  is  gained  to 
evacuate  the  accumulated  secretion.  The  act  of 
expectoration  is,  as  a rule,  most  easy  in  that 
posture  in  which  respiration  is  most  free. 
Sometimes,  when  the  secretion  comes  mainly 
from  one  lung,  the  aid  of  gravitation  may  be 
called  in  to  empty  the  obstructed  tubes. 

Characters  and  Varieties. — Before  auscul- 
tation was  practised,  diagnosis  was  often  based 
on  the  character  of  the  expectoration,  unwar- 
rantable importance  having  been  attached  to  the 
distinction  between  pus  aud  mucus,  on  the  as- 
sumption that  pus  was  diagnostic  of  phthisis. 
At  the  present  time  we  are  apt  to  lose  much  by 
falling  into  the  opposite  error. 

In  health,  the  secretion  from  the  mucous 
membrane  of  the  air-tubes  is  a transparent, 
colourless,  slightly  glutinous  liquid,  like  thin 
mucilage;  it  contains  mucin,  a varying  quantity 
of  saline  matter,  and  water. 

The  saline  matter  is  abundant  in  the  trans- 
parent viscid  expectoration,  deficient  in  the 
opaque  and  less  tenacious  kind,  least  in  that 
which  is  actually  purulent. 

The  ordinary  mucous  secretion  is  increased  in 
quantity  and  viscidity  as  a result  of  simple 
catarrhal  inflammation  of  the  bronchial  mem- 
brane. When  bronchitis  has  existed  for  some  days, 

I a change  occurs  in  the  character  of  the  secretion 


172  EXPECTORATION. 

Lest  cad  of  being  transparent  and  viscid,  it  becomes 
semi-transparent  and  then  opaque,  the  colour 
changing  to  a yellow  or  greenish  hue. 

The  sputum  becomes  frothy  from  the  admix- 
ture of  air;  and  rusty  or  prune-juice-coloured  if 
the  inflammatory  action  extends  to  the  ultimate 
bronchial  ramifications,  and  is  of  so  intenseakind 
as  to  allow  of  oozing  from  the  capillary  vessels.* 

Fibrinous  moulds  of  the  bronchial  tubes,  or 
chalky  masses  consisting  of  inspissated  and  cal- 
cified cheesy  matter,  arc  not  unfrequently  expec- 
torated. 

The  dark  grey  or  blackish  stain  often  seen  in 
expectoration  maybe  derived  from  carbon  in  the 
atmosphere;  or,  if  it  fade  on  the  addition  of 
nitric  acid,  it  may  be  due  to  pulmonary  pigment 
formed  under  slight  irritation. 

The  expectoration  may  afford  important  aid  in 
diagnosis,  as  may  be  illustrated  by  the  following 
examples : — If  a person  with  severe  chest-com- 
plaint coughs  frequently  and  spits  only  frothy 
salivary  fluid,  we  may  suspect  pleurisy.  If  the 
fluid  is  glairy  like  white  of  egg,  we  may  suspect 
bronchitis.  If  it  has  a rusty  tinge  and  resembles 
thick  gum-water  coloured  with  blood,  we  are  not 
likely  to  err  in  recording  pneumonia.  If  there  is 
a sudden  gush  of  feetid  pus  we  may  diagnose  ab- 
scess in  the  lung  or  an  empyema. 

Purulent  expectoration  mayoccur  in  bronchitis 
as  well  as  in  phthisis,  but  if  long-continued,  and 
unaccompanied  by  distinct  rhonchus,  it  almost 
always  comes  from  a vomica. 

In  phthisis  the  sputum  is  at  first  salivary 
or  frothy,  the  result  of  irritation ; then  viscous, 
indicative  of  more  confirmed  affection  of  the 
mucous  membrane  ; and  subsequently  dotted  and 
streaked  with  blood.  Whitish  opaque  spots, 
giving  a pearly  aspect  to  the  expectoration,  next 
appear;  those  enlarge,  become  flocctdent  and 
ultimately  nummular,  being  inspissated  and 
moulded  in  a cavity.  As  the  diseaso  advances 
and  involves  both  lungs,  the  expectoration  is 
entirely  purulent,  and  shortly  before  death  is 
often  surrounded  with  a pinkish  halo.  On 
placing  under  the  microscope  one  of  the  small 
pearly  points  described,  masses  consisting  of 
several  air-cells  choked  with  granules,  or  mere 
fragments  of  elastic  tissue  may  occasionally  be 
seen.  By  the  addition  of  acetic  acid  the  sputa 
may  be  rendered  transparent,  and  the  elastic 
tissue  is  then,  if  present,  more  certainly  detected  ; 
but  practically  the  experienced  eye  is  the  best 
guide  in  the  selection  of  those  small  pin-head 
flocculi  of  expectoration,  in  which  the  microscopic 
particles  of  lung-tissue  are  to  he  detected. 

The  microscope  may  be  also  helpful  by  indi- 
cating, from  the  character  of  the  cells,  the  part 
of  the  respiratory  tract  involved,  and  the  degree 
of  disease  existing. 

Treatment. — In  treatment,  much  may  be 
gained  by  study  of  the  expectoration.  The  cough 
may  often  bo  relieved,  and  the  dyspnoea  and 
other  symptoms  removed,  by  effecting  an  altera- 
tion in  the  nature  of  the  secretion. 

If  by  the  frothy  character  of  the  sputa  con- 
gestive disorder  is  indicated,  this  may  be  met 
by  the  application  of  warm  poultices,  turpentine 
stupes,  or  hot  flannels  externally ; and  by  such 
moans  as  are  calculated  to  reduce  fever  and  ir- 
ritability, namely,  the  administration  of  salines 


EXPOSURE,  EFFECTS  OF. 

with  antimony  or  aconite.  If  the  expectoration  is 
too  viscid  and  glutinous  for  easy  removal,  lemon- 
juice,  liquor  potass®,  soda,  or  various  inhala- 
tions give  relief,  by  lessening  the  tenacity  of  tho 
secretion;  or  the  change  from  tenacious  and 
transparent  to  opaque  less  adhesive  secretion 
may  be  hastened  by  giving  iodide  of  potassium 
with  a few  drops  of  antimonial  wine. 

When  muco-purulent  secretion  is  established 
and  shows  no  sign  of  diminution,  the  use  of  senega 
and  of  the  gum-resins  is  indicated ; while  ben- 
zoin, tolu,  and  copaiba  are  also  of  value.  Acetic 
or  tannic  acid,  given  in  small  and  frequently  re- 
peated doses,  reduces  the  quantity  of  secretion. 

When  the  combined  glairy  and  muco-purulent 
condition  of  the  expectoration  and  other  symp- 
toms give  evidence  of  bronchitis  of  an  established 
kind,  associated  with  gout  or  abdominal  torpor,  a 
combination  of  calomel  with  antimony  and  guaia 
cum  (as  in  Plummer’s  pill)  is  of  the  greatest  ser- 
vice ; but  this  treatment  needs  perseverance,  dis- 
crimination, and  watchfulness.  The  morbid  surface 
may  at  the  same  time  be  medicated  by  the  inhala- 
tion of  tar,  creasote,  or  oil  of  juniper,  until,  with 
the  improvement  of  the  general  health,  under  cod 
liver  oil  and  iron,  the  evil  is  entirely  removed. 

E.  Symes  Thompson. 

EXPOSURE,  Effects  of. — Were  the  term 
‘exposure’  to  be  taken  in  its  widest  signifi- 
cance, it  might  fairly  assume  to  include  a range 
of  subjects  only  bounded  by  the  limits  of  prac 
tical  medicine.  Infection  naturally  implies  ex- 
posure to  some  contagious  influence,  poisonous 
gases,  or  malarious  or  other  unhealthy  emana- 
tions, hearing  in  their  train  a formidable  se- 
quence of  ill  results.  Many  of  the  disorders 
which  impair  our  comfort  aDd  shorten  our  lives 
may,  in  short,  be  traced,  in  some  degree,  to  ex- 
posure of  some  kind,  to  an  excess  of  heat  or  of 
cold,  to  a variety  of  complicated  reactions, 
arising,  in  whole  or  in  part,  from  unnatural  im- 
pressions made  on  the  physiological  processes  of 
life  by  various  external  agencies.  Any  study  of 
our  subject,  however,  from  this  extended  point 
of  view,  would  clearly  he  out  of  place  here,  and 
effects  of  extreme  elevation  and  depression  of 
temperature  will  be  fully  considered  elsewhere, 
so  that  exposure,  in  the  sense  in  which  it  will 
be  treated  here,  may  be  narrowed  down  to  tho 
results  which  ensue  when  persons  of  average 
constitution-power  are  submitted,  for  a longer  or 
shorter  time,  to  the  influence  of  ordinary  cold,  or 
wet,  or  damp.  Now,  it  is  an  old  saying,  that  if 
five  or  six  people,  of  either  sex,  suffer  shipwreck, 
or  are  wet  through,  or  excessively  chilled  by 
moist  cold,  each  will  probably  suffer  in  some  dif- 
ferent way.  One  may  altogether  escape,  and 
not  experience  inconvenience  of  any  kind ; a 
second  may  ‘ catch  ’ — as  the  popular  expression 
puts  it — a sore  throat,  or  a ‘ bad  cold;'  whilst 
a third  may  be  seized  with  pneumonia,  and  a 
fourth  with  rheumatic  fever. 

Individual  constitution  or  peculiarity  of  sys- 
tem partly  explains  these  differences,  and  the 
familiar  term  of  a ‘ weak  point  somewhere,’  if  not 
convoying  much  impression  of  scientific  accuracy, 
is  right  so  far  in  showing  that  the  internal  con- 
gestion caused  by  sudden  contraction  of  eutaner.as 
arterioles  is  most  naturally  directed  to  that  organ 


EXPOSURE,  EFFECTS  OF. 
w hose  vessels  have  been  weakened  by  previous 
inflammation.  If  the  patient,  therefore,  have  pre- 
viously suffered  from  tonsillitis,  or  bronchial  con- 
gestion, or  rheumatism,  he  will  be  predisposed  to 
a recurrence  of  the  same  affection  on  a renewal 
of  the  exciting  cause.  If,  again,  from  sedentary 
occupation  and  over-indulgence  in  nitrogenous 
food  his  blood  be  overcharged  with  the  products 
of  retrograde  metamorphosis  or  of  imperfect 
assimilation,  it  only  needs  the  closure  of  the 
eliminatory  agency  of  the  skin,  to  provoke  the 
irritation  of  internal  organs,  and  to  induce  an 
attack  of  gout  or  rheumatism,  or  an  acute  in- 
flammation of  kidneys  or  liver.  The  effects  of 
exposure,  even  in  this  limited  sense,  are  thus 
tolerably  various  both  in  extent  and  in  degree, 
and  may  be  studied  on  a large  scale  during  our 
greater  campaigns,  and  in  lesser  degree  during 
the  ordinary  autumn  manoeuvres,  when  the 
weather  happens  to  be  unfavourable.  Here, 
however,  everything  injurious  is  minimised  by 
the  healthy  condition  of  the  men,  their  good 
clothing  and  food,  and  the  enforced  reg»larity 
of  habits,  which  prevent,  in  great  measure,  one 
of  the  most  fertile  causes  of  damage  from  ex- 
posure. It  is  now  well  known  that  nothing 
tends  so  seriously  to  impair  the  power  of  bear- 
ing either  extreme  of  temperature  as  the  exces- 
sive indulgence  in  strong  drink;  so  that  in 
treating  anyone  who  has  been  exposed  to  tho 
influence  of  cold  and  wet,  we  must  not  forget  to 
take  also  into  account  the  probable  combination 
of  tho  depressing  effects  of  alcohol  on  the 
nervous  system.  Illustrations  of  this  must  be 
familiar  to  all,  and  we  must  all  have  met  with 
numerous  eases  in  which  tramps  or  other  per- 
sons with  weakened  bodily  vigour  have  been 
brought  into  our  hospitals,  suffering  from  the 
effects  of  exposure  in  various  degree. 

Treatment. — In  seeking  to  remedy  the  effects 
just  described,  it  will  be  found  that  some  of 
the  cases  will  recover  under  the  influence  of 
warmth  and  good  food,  and  the  generally  in- 
vigorating effects  of  careful  nursing,  whilst 
others,  on  the  other  hand,  may  succumb  to  the 
rapidly  destructive  tendencies  of  acute  disease, 
or  to  the  slower  pathological  processes  of  chronic 
lung  or  kidney  degeneration.  In  the  treatment, 
therefore,  of  such  cases,  we  must  not  only  add  to 
the  genial  influences  of  home  or  hospital  care 
such  special  drugs  as  the  varied  development 
of  symptoms  may  require,  but  we  must  carefully 
take  into  account  the  occurrence  of  various  se- 
rious or  profoundly  disorganising  complicating 
causes.  Thus  if  our  patient  has  been  found  in 
an  insensible  state,  we  may  reasonably  suspect 
apoplexy  or  alcoholic  or  narcotic  poisoning,  and 
act  accordingly.  And  only  when  all  such  sus- 
picion is  finally  removed  can  we  rest  on  our 
oars,  and  confine  our  attention  to  the  immediate 
effects  which  follow  exposure  of  the  kind  indi- 
cated above.  Warmth,  rest,  and  the  regulated 
use  of  stimulants  and  food  will  now  be  indi- 
cated, and  must  be  employed,  with  all  the  pre- 
cautions suggested  by  the  ordinary  principles  of 
therapeutics,  and  common  sense. 

Robert  Farquharsox. 

EXSANGUINE  (ex,  without,  and  sanguis, 
Wood). — Deprived  more  or  less  of  blood — blood- 


EXTRAVASATION.  471* 

less.  Sometimes  used  synonymously  with  anaemic. 
See  Anaemia. 

EXTRA-UTERINE  PREGNANCY.  — 

See  Pregnancy,  Disorders  of. 

EXTRAVASATION  {extra,  without,  and 
vasa,  vessels). — Syxon.  : Fr.  Extravasation ; Ger. 
Extraiasat. 

Definition. — Extravasation  is  the  escape  of 
any  of  the  fluids  of  the  body,  normal  or  ab- 
normal, from  the  vessel,  cavity,  or  canal  that 
naturally  contains  it,  and  its  diffusion  into  the 
surrounding  tissues.  The  result  of  the  effusion 
is  also  called  an  extravasation.  Extravasation 
is  the  effect  of  rupture  or  perforation  of  the 
walls  of  a hollow  organ,  and  may  therefore  be 
due  to  injury,  to  weakness  of  the  parietal  struc- 
tures, to  morbid  conditions  of  the  blood,  or  to 
increase  of  internal  pressure.  See  Perforations 
and  Ruptures. 

The  fluids  most  frequently  found  extravasated 
are  blood,  urine,  bile,  the  contents  of  the  alimen- 
tary canal,  and  certain  constituents  of  morbid 
growths  and  fluid  collections.  The  present  ob- 
servations will  apply  chiefly  to  extravasation  of 
blood. 

Extravasation  of  Blood. — The  blood  is 
peculiarly  liable  to  extravasation,  tho  vessels 
being  universally  distributed,  much  exposed 
to  injury,  and  subject  also  to  a constant  pressure 
from  within,  which  may  be  suddenly  and  greatly 
increased.  Any  portion  of  tire  circulatory  sys- 
tem may  give  way ; either  the  heart,  as  in  fatty 
degeneration;  the  arteries,  as  in  aneurism;  the 
capillaries,  as  in  pulmonary  luemorrhage ; and 
the  veins,  as  in  the  subcutaneous  rupture  of  a 
varix. 

When  the  effusion  takes  place  into  one  of  the 
serous  sacs,  it  forms  a collection  of  blood,  vari- 
ously named  hemothorax,  hematocele , Ac.  If  the 
subcutaneous,  submucous,  or  other  connective 
tissue,  or  the  substance  of  an  organ  be  invaded, 
the  effused  blood  finds  its  way  between  the  ele- 
mentary textures,  separating  and  compressing 
them ; and  there  are  formed  wliat  are  described 
simply  as  extravasations  of  blood,  or  more  defi- 
nitely, according  to  their  extent,  as  parenchy- 
matous or  interstitial  hemorrhages  or  apoplexies, 
suffusions,  ccchymoses,  pctcchie,  or  vibices.  The 
seat  of  effusion  appears  of  the  colour  of  blood  or 
its  derivatives  : but  if  much  below  the  surface, 
the  extravasation  may  not  he  visible  for  some 
days,  after  which  time  it  appears  of  a bluish, 
greenish,  or  yellowish  hue.  The  extravasated 
blood  generally  coagulates  ; the  fibrin  and  al- 
buminous substances  are  absorbed  ; and  the  pro 
ducts  of  decomposition  of  haemoglobin,  which  are 
much  more  slowly  removed,  give  rise  to  the  dis- 
colourations.  Much  less  frequently  the  effused 
blood  becomes  encapsuled,  forming  a hematoma 
or  blood-cyst.  In  other  cases  it  decomposes, 
and  sets  up  gangrene  around,  or  inflammation  of 
the  nature  of  severe  cellulitis,  which  may  end 
in  ulceration  of  the  surface.  When  the  blood  is 
forced  between  the  coats  of  the  perforated  vessel, 
there  is  formed  what  is  called  a dissecting  aneur- 
ism. If  the  extravasated  blood  escape  from  the 
surface  of  the  skin  or  mucous  membranes,  one 
form  of  hemorrhage  cr  a bloody  flux  is  the  lesult 


m SXTRAVASATION. 

The  symptoms  of  extravasation  of  blood  are 
eo  various  that  they  cannot  be  stated  in  general 
terms.  If  extensive  and  affecting  vital  parts, 
the  effusion  may  be  attended  by  shock,  syncope, 
or  death ; and  it  may  lead  to  constitutional  dis- 
turbance in  many  forms.  Local  pain  is  not 
common  unless  the  extravasation  be  severe. 
The  pressure  of  the  effused  blood  upon  the 
vessels,  nerves,  and  muscles  of  the  part,  for  ex- 
ample in  a limb,  may  produce  paralysis,  disturb- 
ances of  sensibility,  oedema,  loss  of  temperature, 
and  even  gangrene.  As  a rule,  however,  extrava- 
sations of  blood  are  very  limited  in  size,  give 
rise  of  themselves  to  no  serious  symptoms,  and 
readily  disappear  by  absorption. 

J.  Mitchell  Bruce. 

EXTROVERSION  {extra,  outwards,  and 
verto,  I turn). — The  eversion  or  turning  inside- 
out  of  a part,,  as  the  eyelids  or  bladder.  In  the 
bladder,  extroversion  is  associated  with  that  con- 
dition, usually  congenital,  in  which  the  anterior 
wall  of  this  organ  and  of  the  abdomen  are  de- 
ficient, and  its  posterior  wall  projects  through 
the  opening  thus  formed. 

EXUDATION"  ( exudo , I sweat). — The  pro- 
cess by  which  certain  of  the  elements  of  the 
blood  pass  through  the  walls  of  the  blood- 
vessels into  the  surrounding  tissues,  as  in  in- 
flammation. It  also  indicates  the  products  of 
the  process  when  they  are  of  a fibrinous  or 
coagulable  character.  See  Inflammation. 

EXUDATION  -CORPUSCLES.  - The 

cells  found  in  inflammatory  products,  whatever 
may  be  their  origin.  See  Inflammation. 

EYE,  and  its  Appendages,  Diseases  of. — 
It  will  be  most  convenient  to  arrange  the  con- 
sideration of  the  diseases  of  the  eye  according  to 
the  anatomical  order  of  the  structures  affected, 
namely: — I.  Diseases  of  the  Conjunctiva;  II. 
Diseases  of  the  Cornea;  III.  Diseases  of  the 
Sclerotic;  IV.  Diseases  of  the  Iris  ; V.  Diseases 
of  the  Crystalline  Lens;  VI.  Glaucoma;  VII. 
Diseases  of  the  Optic  Norve  and  Retina  ; VIII. 
Diseases  of  the  Choroid ; IX.  Diseases  of  the 
Vitreous  Body  ; and,  X.  Diseases  of  the  Eyelids.1 

I.  Diseases  of  the  Conjunctiva. 

1.  Inflammation.  Synon.  : Conjunctivitis. — 
The  conjunctiva  is  exceedingly  liable  to  inflam- 
mation, and  its  inflammations  are  commonly  ar- 
ranged in  groups,  which  are  sufficiently  distinct 
in  their  typical  examples,  but  are  not  separated 
by  any  definite  boundary  lines. 

In  their  earlier  stages  inflammations  of  the 
conjunctiva  possess  many  characters  in  common. 
They  are  all  attended  by  the  four  signs  of  inflam- 
mation— heat,  redness,  swelling,  and  pain ; al- 
though both  the  heat  and  the  swelling  are  usually 
kept  within  limits  by  the  discharge,  which  is 
often  free,  sometimes  profuse,  at  first  mucous, 
afterwards  muco-purulent  or  truly  purulent  in 
character.  If,  however,  the  exudation  be  of  a 
firmer  consistence  than  usual,  it  not  only  pro- 
duces a superficial  discharge,  but  distends  the 
meshes  of  the  sub-mucous  tissue,  elevates  the 
conjunctiva  from  the  sclerotic,  and  causes  it  to 

1 See  also  Vision,  Disorders  of ; Ophthalmoscope  ; 
and  Ophthalmoscope  in  Medicine. 


EYE,  DISEASES  OF. 

overlap  the  corneal  margin  as  a swollen  ridge , 
a condition  which  is  known  as  chemosis.  The 
redness  depends,  of  course,  on  the  degree  of 
the  congestion,  which  may  or  may  not  he  suf- 
ficient to  obliterate  the  intervascular  meshes, 
and  to  produce  an  uniform  colour ; and  the 
paiu  is  not  severe,  except  in  cases  of  very 
dense  sub-conjunctival  swelling.  From  other 
forms  of  inflammation,  that  of  the  conjunctiva 
is  distinguished  by  certain  negative  characters. 
Unless  as  a result  of  secondary  changes,  or  as  o 
mechanical  effect  of  the  presence  of  a film  of 
turbid  secretion,  the  transparency  of  the  cornea 
is  not  affected,  and  the  acuteness  of  vision  is  not 
impaired.  The  congestion  is  limited  to  the 
conjunctiva,  and  the  distended  vessels  can  be 
emptied  for  a moment  by  pressure  through  the 
lower  lid,  so  as  to  reveal  a glimpse  of  the  white 
sclerotic  underneath. 

In  mild  cases  conjunctivitis  is  an  unimportant 
affection,  but  in  its  more  severe  forms  it  is 
attended  by  two  distinct  sources  of  danger. 
Durii^r  its  acute  stage  it  may  produce  partial  oi 
complete  necrosis  of  tho  cornea,  leading  to  great 
impairment  of  sight  and  not  seldom  to  blind 
ness;  and  when  chronic  it  often  occasions  great 
hypertrophy  of  the  papilla;  of  the  portion  of  the 
membrane  which  lines  the  lids.  These  papilla 
may  even  become  converted  into  shaggy  or 
warty  excrescences,  which  mechanically  irritate 
the  corneal  surface,  and  cause  the  development 
of  vessels  beneath  its  epithelium.  In  timo  the 
papillae  dwindle,  and  the  effusion  round  about 
them  contracts,  thus  rendering  the  tarsal  car- 
tilage (especially  that  of  the  upper  lids)  incurved, 
and  bringing  the  cilia  to  rest  upon  the  surface  of 
the  eyeball.  Great  distress  and  permanent  im- 
pairment of  vision  may  be  thus  occasioned  ; and 
the  progress  of  the  contraction  may  he  so  slow 
as  to  deprive  it  of  any  manifest  connection  with 
the  inflammation  in  which  it  had  its  origin. 

The  chief  varieties  of  conjunctivitis  are : — (a) 
infantile-,  (b)  simple  or  catarrhal ; (c)  contagious-, 
and  (d)  diphtheritic. 

(a)  Infantile  Conjunctivitis.  Synon.  ; Ophthal- 
mia neonatorum. 

-Etiology  and  Symptoms.— Infantile  conjunc- 
tivitis is  probably  due,  in  most  cases,  to  direct 
inoculation  with  vaginal  secretion.  It  usually 
commences  on  or  about  the  third  day  after  birth, 
and  passes  rapidly  into  the  purulent  form.  It  is 
attended  by  considerable  puffy  swelling  of  the 
lids,  and  by  profuse  thick  discharge,  which  soon 
dries  upon  the  tarsal  margins,  and  often  causes 
them  to  cohere.  If  neglected  or  improperly 
treated,  the  disease  often  leads  to  sloughing  oi 
the  cornea  ; hut  it  may  always  he  cured  if  it  is 
seen  while  the  cornea  is  still  bright. 

Treatment. — The  treatment  required  is  to 
wash  away  the  discharge  carefully  and  fre- 
quently ; to  apply  an  astringent  lotion  (the  best 
is  a solution  of  2 grains  of  nitrate  of  silver  to  an 
ounce  of  distilled  water)  to  the  conjunctival  sur- 
face every  four  hours,  or  less  frequently  when 
improvement  is  established ; and  to  anoint  tho 
edges  of  the  lids  with  simple  ointment  to  prevent 
their  agglutination.  In  cases  of  inherited  syphilis 
mercurial  inunction  should  be  prescribed  ; the 
infant's  food  must  be  carefully  regulated  if  it  is 
brought  up  by  hand,  and  if  it  is  very  feeble  it  may 


EYE.  AND  ITS  APPENDAGES,  DISEASES  OF. 


take  a little  cod-liver  oil,  combined  in  an  emul- 
sion with  two-minim  doses  of  liquor  cinchonas. 
Where  the  mother’s  milk  fails,  it  is  often  de- 
sirable to  obtain  a wet-nurse;  but  the  local 
treatment  is  that  which  is  chiefly  important,  and 
upon  which,  in  most  cases,  entire  reliance  may  be 
placed. 

(b)  Simple  or  Catarrhal  Conjunctivitis. 

/Etiology  and  Symptoms. — This  form  of  con- 
junctivitis is  usually  due  to  exposure  to  cold  or 
to  some  chemical  or  mechanical  irritant.  Its 
most  distinctive  character  is  that  the  discharge 
is  chiefly  mucous,  and  has  not  much  tendency  to 
become  purulent. 

Treatment. — In  every  case  the  surface  of  the 
eyeball,  and  the  lining  membrane  of  the  lids, 
should  be  carefully  examined  for  any  foreign 
body  which  may  be  the  cause  of  the  trouble ; and 
if  such  should  be  found  and  removed,  there  will 
seldom  be  need  for  further  treatment.  If  there 
is  no  foreign  body,  the  2-grain  solution  of  nitrate 
of  silver  may  be  placed  within  the  conjunctival 
sac,  by  means  of  a quill  or  dropping  bottle,  every 
two  or  three  hours,  and  speedy  recovery  will 
usually  be  the  result.  During  the  treatment  the 
eyes  should  have  functional  rest,  and  should  be 
sheltered  from  external  cold,  from  dust,  or  from 
glare. 

(c)  Contagious  Conjunctivitis.  Synon: — Puru- 
lent Ophthalmia. 

In  this  form  the  discharge  rapidly  assumes  a 
purulent  character.  This  may  happen  when 
the  simple  form  is  aggravated  by  the  state 
of  the  patient  or  by  accidental  circumstances  ; 
or  when  the  disease  is  produced  by  inocula- 
tion with  the  discharge  from  a similar  case, 
or  with  contagious  pus  from  the  urethral  or 
vaginal  mucous  membrane.  The  state  of  the 
patient  which  is  most  likely  to  promote  the  deve- 
lopment of  the  contagious  form  is  that  in  which 
the  conjunctiva  is  beset  with  the  granular  semi- 
transparent bodies,  formed  by  aggregations  of 
lymph-corpuscles,  which  are  known  as  ‘sago- 
grains’  or  follicular  granulations.  These  bodies 
are  commonly  present  in  the  eyelids  of  persons 
(especially  of  young  persons)  who  are  crowded 
together  under  insanitary  conditions  of  living,  as 
in  barracks,  camps,  or  badly  regulated  schools  ; 
and  their  presence  renders  the  conjunctivitis  of 
simple  irritation  prone  to  assume  a purulent 
character.  It  is  impossible  to  say  how  soon  the 
discharge  of  conjunctivitis  becomes  contagious, 
or  capable  of  reproducing  the  disease  in  others ; 
but  its  activity  in  this  respect  seems  to  bear 
some  proportion  to  the  intensity  of  the  inflamma- 
tion which  produces  it ; and  the  activity  of  gonor- 
rhoeal pus  is  probably  greater  than  that  of  any 
conjunctival  product.  In  the  more  intense  forms 
of  purulent  ophthalmia  there  is  great  swelling 
of  the  lids  and  of  the  ocular  conjunctiva,  early 
chemosis,  and  a tendency  to  speedy  sloughing 
of  the  cornea  ; while  the  milder  forms  pass  into 
the  catarrhal  by  imperceptible  gradations. 

Treatment. — In  the  space  available  for  the 
purpose  in  these  pages,  the  treatment  of  con- 
tagious conjunctivitis  cannot  be  described  in 
detail.  It  mainly  rests  upon  the  action  of  local 
astringents,  graduated  in  strength  according  to 
the  severity  and  the  stage  of  the  disease.  In  the 
worst  cases  the  eyelids  must  be  everted,  and  the 


whole  of  the  palpebral  conjunctiva  carefully 
touched  with  a stick  composed  of  one  part  of 
nitrate  of  silver  fused  with  four  parts  of  nitrate 
of  potash.  The  caustic  should  be  neutralised 
by  a drop  or  two  of  a solution  of  common  salt, 
applied  by  means  of  a camel’s-hair  pencil,  before 
the  lid  is  suffered  to  return  into  contact  with  the 
cornea ; and  the  cauterization  must  be  done  care- 
fully and  with  a light  hand,  so  that  the  result- 
ing eschar  may  include  only  the  epithelium  ; for 
if  the  basement  membrane  is  destroyed,  there 
will  be  danger  of  subsequent  adhesions  between 
the  eyelids  and  eyeball.  The  cauterization  should 
be  repeated  about  every  eight  hours,  or  as  soon 
as  the  eschar  falls,  and  in  the  intervals,  if  the 
patient  is  awake,  the  conjunctiva  should  be 
gently  syringed  every  hour  with  a weak  alum 
lotion  at  a comfortable  temperature.  The  tension 
of  chemosis  may  be  diminished  by  radial  in- 
cisions, outwards  from  the  corneal  margin,  carried 
nearly  down  to  the  sclerotic  ; the  strength  must 
be  supported  by  good  diet  and  tonics  ; and  the 
nervous  system  calmed  by  anodynes.  In  milder 
cases  the  principle  of  treatment  must  be  the  same, 
but  the  local  applications  less  severe  ; and  in 
chronic  cases  the  local  applications  must  be  con- 
tinued, after  apparent  recovery,  so  long  as  any 
residual  thickening,  capable  of  undergoing  even- 
tual contraction,  can  bo  found  lurking  in  the 
palpebral  folds. 

( d )  Diphtheritic  Conjunctivitis.  This  malady 
has  chiefly  been  made  known  to  us  by  the 
observations  of  German  writers,  and  very  few 
authentic  instances,  if  any,  have  been  recorded 
in  tliis  country.  But  it  has  from  time  to  time 
prevailed  extensively  in  Berlin,  and  might  at 
any  time  make  its  appearance  amongst  ourselves. 

Symptoms.  - — Diphtheritic  conjunctivitis  is 
attended  with  great  heat  and  pain,  and  with  very 
hard,  brawny  swelling  of  the  eyelids ; but  its 
most  characteristic  symptom  is  the  infiltration 
of  the  sub-conjunctival  tissue  by  the  so-called 
diphtheritic  effusion,  which  does  not  form  a 
pellicle  upon  the  surface,  but  distends  and  fills 
the  cavities  of  the  areolar  tissue.  The  result  is 
to  produce  a pale,  firm  swelling  of  the  conjunc- 
tiva, and  a great  tendency  to  rapid  sloughing  of 
the  cornea.  The  subjects  of  the  malady  are 
mostly  feeble  and  badly-fed  children,  and  the 
cases  are  described  as  being  almost  hopeless 
unless  early  admitted  into  hospital. 

Treatment. — The  indications  for  treatment 
are  chiefly  to  support  the  strength  by  suitable 
regimen  ; to  apply  ice  or  bags  of  freezing  mixture 
to  the  lids  during  the  hot  stage ; and  to  change 
the  cold  applications  for  hot  ones  as  soon  as  the 
period  of  resolution,  absorption,  or  repair  can  be 
said  to  have  commenced.  In  the  meantime  iron 
and  quinine  should  generally  be  administered 
internally. 

2.  Episcleritis. — An  affection  which  is  appa- 
rently but  not  really  conjunctival,  being  situated 
in  the  tissue  between  the  conjunctiva  and  the 
sclerotic,  is  that  which  has  received  the  name  of 
episcleritis,  and  which  was  formerly  described  as 
‘sclerotitis  with  inflammation  of  the  insertion 
of  a rectus  muscle.’ 

Symptoms. — It  appears  as  an  elevated  patch 
of  congestion,  gradually  passing  into  the  natural 
level  and  appearance  of  tko  parts,  and  seated  cu 


EYE,  AND  ITS  APPENDAGES,  DISEASES  OF. 


176 

the  ocular  surfaeo  near  the  corneal  margin,  most 
frequently  on  the  temporal  side.  On  close  exa- 
mination, the  congestion,  with  the  exception  of 
a few  dilated  vessels,  is  seen  to  be  sub-conjunc- 
tival,  and  to  be  attendant  upon  a circumscribed 
but  not  sharply  defined  swelling  or  thickening, 
which  is  adherent  to  the  sclerotic,  and  which 
presents,  in  the  interstices  between  the  blood- 
vessels, an  appearance  as  if  it  consisted  of  some 
new  deposit,  generally  of  a yellowish  tint,  ex- 
ternal to  that  membrane.  The  swelling  is  indo- 
lent, chronic,  and  in  itself  generally  painless, 
although  it  is  sometimes  accompanied  by  severe 
neuralgia.  The  subjects  are  most  frequently 
women,  especially  such  as  are  anaemic  or  other- 
wise out  of  condition.  Episcleritis  may  last  for 
months  with  little  change,  and  it  seems  to  be 
harmless  as  regards  the  other  structures  of  the 
eye. 

Treatment. — The  writer  has  found  episcleritis 
resist  all  medication  except  the  internal  ad- 
ministration of  mercury,  to  which  it  will  often 
yield  in  the  courso  of  a short  time.  The  best 
preparation  is  the  perchloride,  in  doses  not  ex- 
ceeding i of  a grain,  which  may  usually  be  com 
bined  with  five  or  ten  minims  of  the  tincture  of 
perchloride  of  iron.  At  the  same  timo  it  is  often 
desirable  to  sprinkle  a little  dry  calomel  over 
tlie  swelling  once  in  twenty-four  hours;  but  this 
application  is  less  important  than  the  internal 
treatment,  and  should  not  be  continued  unless 
it  is  soon  and  distinctly  beneficial. 

3.  Hemorrhage. — Effusion  of  blood  beneath  the 
conjunctiva  may  occur  spontaneously,  but  is  gene- 
rally traceable  either  to  a direct  injury  or  to  vio- 
lent exertion.  Thus  it  may  follow  slight  blows 
upon  the  eyeball,  as  from  a twig  or  switch;  or  may 
be  produced  by  a paroxysm  of  coughing,  especially 
in  pertussis;  or  may  occur  from  the  rupture  of 
■i.  vessel  during  parturition,  or  upon  lifting  a 
heavy  weight.  It  is  always  unsightly.  When 
traceable  to  any  of  the  foregoing  causes,  the 
hsemorz-hage  is  usually  a matter  of  no  moment ; 
but  when  it  happens  during  the  night  in  young 
people,  it  should  lead  to  a suspicion  of  nocturnal 
epilepsy,  which  has  often  been  first  discovered 
by  its  means.  Moreover,  in  advanced  life,  more 
especially  when  occurring  without  adequate  cause, 
it  may  point  to  arterial  brittleness,  of  a kind 
which  may  indicate  danger  of  a like  hsemor- 
rhage  within  the  cranium.  On  these  grounds,  it 
is  a symptom  which  always  calls  for  full  inquiry 
into  its  causes,  and  which  may  sometimes  afford 
useful  warning  of  impending  danger. 

Treatment. — Absorption  may  he  promoted  by 
coveriug  the  closed  lids  by  a compress  moistened 
with  a lotion  of  spirit  and  water,  or  of  tincture 
of  arnica  and  water  if  an  appearance  of  more 
decided  medication  is  desired. 

II.  Diseases  of  the  Cornea. — Diseases  of 
the  cornea,  as  already  indicated,  are  often  second- 
ary to.  those  of  the  conjunctiva,  and  may  arise 
in  their  course  as  complications. 

1 . Ulceration. 

2Etioeogy  and  Symptoms. — To  the  present 
group  belong  all  the  corneal  ulcerations  ofpuru- 
lent  ophthalmia,  whether  infantile  or  of  a later 
period  of  life ; and  also  tlie  forms  of  corneal 
nicer  which  are  produced  by  the  friction  of 
eyelids  rendered  rough  by  inflammation,  or  by 


the  friction  of  eyelashes  which  have  been  turned 
inwards  by  distortion  of  the  tarsal  cartilage. 
When  ulceration  of  the  cornea  occurs  in  the 
course  of  conjunctivitis,  it  at  once  invests  the 
latter  malady  with  a highly  formidable  charac- 
ter. The  corneal  tissue,  once  destroyed  by  ulcera- 
tion, is  not  reproduced  in  its  original  transpa- 
rency, hut  only  as  a more  or  less  dense  and 
opaque  white  cicatrix,  which  is  at  the  same  time 
disfiguring  to  the  appearance  and  an  impediment 
to  vision.  If  the  ulcer  should  perforate,  the  iris 
almost  necessarily  becomes  adherent  to  the  cica- 
trix ; and  if  the  loss  of  substance  is  of  large 
superficial  extent,  the  resulting  cicatrix  is  often 
thin  and  feeble,  so  that  it  is  rendered  prominent 
by  the  pressure  within  the  eye,  producing  the 
condition  which  has  been  called  ‘staphyloma,’ 
and  gradually  elevating  and  distorting  the  sur- 
rounding portions  of  clear  cornea.  The  first 
effect  of  the  healing  of  a corneal  ulcer  is  generally 
to  flatten  the  natural  curvature  of  the  membrane ; 
but  the  secondary  effect,  if  the  cicatrix  be- 
comes prominent,  may  be  to  modify  this  curvature 
in  various  ways.  Hence  it  follows,  even  when  a 
cicatrix  of  the  cornea  is  surrounded  by  a still 
transparent  annulus,  behind  which  an  artificial 
pupil  may  easily  be  made  by  the  excision  of  a 
portion  of  the  iris,  that  the  surgeon  cannot  pre- 
dict with  any  certainty  the  quality  of  the  vision 
which  will  be  obtained,  unless  he  is  able,  before 
operating,  to  determine  the  state  of  the  corneal 
curvature.  This  is  only  possible  when  the 
margin  of  the  pupil  is  so  far  free  that  it  can  be 
dilated  with  atropine  sufficiently  to  render  tha 
fundus  of  the  eye  visible  with  the  ophthal- 
moscope. When  this  can  be  done,  any  portion 
of  cornea  through  which  a clear  view  of  the 
retinal  vessels  can  be  obtained  by  the  surgeon 
will  also  afford  clear  vision  of  external  objects  to 
the  patient;  but,  if  no  such  place  can  be  discovered, 
a very  cautious  opinion  should  be  given  with 
regard  to  the  degree  of  benefit  which  maybe  hoped 
for  from  an  operation. 

Treatment. — The  extreme  importance  of  the 
cornea  to  the  visual  function  renders  it  necessary 
that  its  integrity  should  be  guarded  with  tlie 
greatest  possible  care.  In  any  case  of  conjuncti- 
vitis, of  even  moderate  severity,  the  cornea  should 
he  watched  from  day  to  day,  and  any  appearance  of 
turbidity  about  its  central  portion,  or  of  elevation 
or  irregularity  of  the  epithelium  at  its  margin, 
should  lead  to  a reconsideration  of  the  treatment 
which  is  being  pursued.  The  former  of  these 
conditions  is  tho  ordinary  precursor  of  sloughing 
ulcer  cr  necrosis ; the  latter,  of  the  extension  to 
the  cornea  of  an  inflammatory  process. 

The  general  principles  which  govern  the  treat- 
ment of  sloughing  ulcer  are,  that  the  eye  should 
be  kept  under  the  influence  cf  eserine,  which 
has  a marked  effect  in  checking  the  extension  ot 
ulceration  by  arresting  the  migration  of  white 
corpuscles  ; that  any  astringents  which  may  be 
applied  to  tho  conjunctiva  should  be  prevented 
from  coming  into  contact  with  the  cornea ; that 
strength  should  be  supported,  pain  relieved,  and 
local  nutrition  stimulated  by  hot  applications. 
When  the  ulcer  continues  to  spread,  its  progress 
may  often  be  arrested  by  diminishing  the  tension 
of  the  globe  by  the  evacuation  of  the  aqueous 
humour;  and  this  may  be  accemplished  either 


EYE.  AND  ITS  APPENDAGES,  DISEASES  OF.  4 


by  repeated  paracentesis  at  the  corneal  margin, 
or  by  Saemisck’s  method  of  cutting  through  the 
base  of  the  ulcer,  and  reopening  the  incision 
daily  until  a process  of  repair  is  well  esta- 
blished, or  by  the  performance  of  iridectomy. 
Of  these  three  courses,  the  last-named  is  the 
most  generally  applicable.  It  not  only  produces 
the  immediate  effect  which  is  desired,  but 
it  has  also  the  incidental  advantage  of  esta- 
blishing an  artificial  pupil  at  the  side  of  the 
cicatrix. 

The  application  of  eserine  is  best  effected  by 
using  a solution  of  the  neutral  sulphate,  of  the 
strength  of  four  grains  to  the  ounce  of  distilled 
water ; and  a drop  of  this  solution  may  be  placed 
within  tho  conjunctival  sac  twice  or  thrice 
daily. 

The  sloughing  ulcers  of  the  cornea  which  arise 
from  causes  other  than  conjunctivitis,  as  injury, 
or  failure  of  nutrition,  must  be  treated  upon  the 
sam9  principles  which  have' already  been  laid 
down.  There  are,  however,  inflammatory  ulcers 
which  require  the  use  of  local  applications  of  a 
stimulating  kind,  among  which  dry  calomel  and 
other  mercurials  hold  a prominent  place.  Such 
ulcers  have  usually  a leash  of  vessels  running 
from  the  corneal  margin,  and  are  often  obstin- 
ately recurrent ; whence  they  are  known  as 
‘recurrent  vascular  ulcers.’  They  are  usually- 
connected  with  some  manifest  systemic  derange- 
ment, and  are  often  attended  by  photophobia. 
They  leave  scars  upon  tho  cornea,  of  a size  and 
opacity  proportionate  to  their  extent  and  depth  ; 
and  on  this  account  it  is  -desirable,  whatever 
constitutional  treatment  may  be  required,  to  heal 
the  ulcers  themselves  as  speedily  as  possible,  by 
the  aid  of  local  applications.  In  the  early  stages 
of  the  ulceration,  eserine  should  be  used ; but 
afterwards  either  dry  calomel  or  an  ointment 
containing  from  ten  to  thirty  grains  to  the  ounce 
of  the  precipitated  yellow  oxide  of  mercury, 
which  may  be  thrown  down  by  any  alkali  from 
a solution  of  the  perchloride.  This  ointment 
was  introduced  into  practice  by  Dr.  Pagenstecher, 
of  Wiesladen,  and  is  often  called  by  his  name. 
In  very  obstinate  cases  Mr.  Critchett  recom- 
mends setons  in  the  temporal  regions ; but  the 
operation  of  iridectomy  will  often  afford  a still 
more  efficacious  remedy.  Where  there  is  much 
photophobia,  the  use  of  eserine  is  especially 
indicated,  because,  in  addition  to  its  action  above 
mentioned,  it  produces  contraction  of  the  pupil, 
and  thus  gives  comfort  by  lessening  the  quan- 
tity of  light  which  is  admitted  into  the  eye.  If 
the  photophobia  is  very  severe  or  intractable,  it 
is  often  beneficial  to  divide  the  orbicularis  muscle 
freely  at  the  outer  canthus,  so  as  to  diminish  the 
pressure  which  is  caused  by  its  spasmodic  con- 
traction, and  which  sometimes  seems  to  be  a 
chief  cause  of  the  irritability.  After  such  an 
incision,  a cold  compress  should  be  applied,  and 
the  patient  kept  in  the  dark  for  a few  hours, 
after  which  there  will  often  be  a marked  alle- 
viation of  this  distressing  symptom,  and  a 
greatly  increased  general  amenability  to  treat- 
ment. 

2.  Inflammation.  Synon.  : Keratitis. — Inflam- 
mation of  the  cornea  presents  three  distinct  types, 
the  suppurative,  the  vascular  and  the  inter- 
stitial. 


(a)  Suppurative  keratitis.  Suppurative  inflam- 
mation or  abscess  of  the  cornea  seems  to  bo  essen- 
tially a phlegmon  or  boil  of  the  corneal  tissup, 
a portion  of  which  dies,  and  is  cast  off  in  ills 
form  of  a slough. 

SvarFroMS. — The  abscess  commences  as  a very 
tender  grey  spot  in  the  cornea,  surrounded  by  a 
zone  of  turbidity,  and  accompanied  by  a good  deal 
cf  ciliary  neuralgia,  aswcllas  byavariabie  degree 
cf  lachrymation,  conjunctival  congestion,  and  in- 
tolerance of  light.  Under  tho  influence  of  atro- 
pine, hot  fomentations,  and  such  constitutional 
treatment  as  the  state  of  the  patient  may  demand, 
the  threatened  suppuration  is  sometimes  averted, 
and  the  turbidity  clears  away.  More  commonly 
pus  is  formed,  and  makes  its  way  either  ex- 
ternally, leaving  an  ordinary  ulcer  ; or  internally, 
producing  the  condition  called  hypopyon,  in  which 
there  is  pus  in  the  anterior  chamber.  Some- 
times it  separates  the  corneal  lamina  to  a con 
siderable  extent  before  perforating  them,  and  is 
then  called  onyx,  from  a fanciful  resemblance  to 
the  lunula  at  the  base  of  a finger-nail. 

Teeatmevt. — "When  suppuration  is  no  longer 
doubtful,  the  best  practice  is  to  evacuate  tho 
abscess  by  a puncture  from  within,  by  thrusting 
a cutting  needle  into  the  anterior  chamber 
near  the  corneal  margin,  and  then  causing  its 
point  to  penetrate  the  cavity  of  the  abscess. 
The  mingled  pus  and  aqueous  humour  will 
escape  as  the  needle  is  withdrawn,  and  its 
wound  of  entrance  may  bo  reopened  once  or 
twice  daily  by  a probe,  so  as  to  insure  the 
complete  removal  of  all  inflammatory  pro- 
ducts, until  the  healing  process  has  made  some 
way.  If  the  abscess  has  burst  internally  before 
the  case  is  seen,  atropine  should  be  applied 
without  delay.  If  the  pupil  dilates  fully,  and  the 
quantity  of  pus  in  the  anterior  chamber  is  but 
small,  the  case  may  be  left  to  the  vis  medicatrix 
natures,  care  being  taken  to  enforce  rest  and  to 
exclude  noxious  influences.  If  the  quantity  of 
pus  is  large,  it  should  be  let  out  by  paracentesis ; 
and  if  the  atropine  reveals  adhesions  of  the  iris, 
iredectomy  should  at  once  be  performed.  An 
abscess  which  has  burst  externally  leaves  simply 
an  ulcer,  generally  with  a disposition  to  heal 
readily,  and  requiring  only  such  treatment  as 
has  already  been  described. 

( b ) Vascular  Keratitis.  Vascular  inflammation 
of  the  cornea  is  often  a very  severe  and  protracted 
malady,  which  usually  leaves  behind  permanent 
opacity  and  impairment  of  sight. 

Symptoms. — It  commences,  in  typical  cases,  by 
tho  formation  of  two  crescent-shaped  patches  of 
vascularity,  one  at  the  upper  and  the  other  at  the 
lower  portion  of  the  cornea.  The  patches  are 
formed  by  the  development  on  the  corneal  sur- 
face of  innumerable  fine  blood-vessels,  so  closely 
packed  together  that  the  interstices  which  sepa- 
rate them  are  scarcely  discernible  by  the  naked 
eye,  and  the  affected  parts  present  an  uniform 
aspect  of  vivid  redness.  The  crescents  are  some- 
what elevated  above  the  general  corneal  surface, 
and  each  crescent  is  bordered,  along  its  con 
cave  or  advancing  edge,  by  a line  of  precursory 
epithelial  turbidity.  At  the  same  time  that  tho 
crescents  increase  in  size,  the  borders  of  precur- 
sory turbidity  are  pushed  before  them  ; until  at 
first  these,  and  afterwards  the  crescents  them 


EYE.  AND  ITS  APPENDAGES,  DISEASES  OF. 


178 

selves,  may  meet  and  coalesce  on  the  horizontal 
diameter  of  the  cornea,  so  that  its  whole  surface 
may  become  uniformly  red.  When  this  stage  is 
reached,  vision  is  almost  abolished,  but  there 
may  still  be  much  intolerance  of  light.  The 
corneal  tissue  is  softened,  and  its  margin  is  sur- 
rounded by  a zone  of  sclerotic  vascularity,  which 
is  visible  through  the  congestion  of  the  con- 
junctiva. As  the  inflammation  subsides  the  vas- 
cular crescents  slowly  recede  from  the  centre  of 
the  cornea  towards  its  circumference,  and  finally 
disappear,  leaving  behind  them  a dense  opacity 
of  an  extremely  obstinate  character.  A severe 
case  of  vascular  keratitis  generally  affects  both 
eyes,  and  threatens  a long  period  of  actual  blind- 
ness, followed  by  a long  period  of  very  imperfect 
vision.  The  worst  examples  of  the  malady  are 
those  which  have  been  treated  at  the  outset  ty 
astringent  or  irritating  applications  ; and,  even  .n 
the  slighter  forms,  the  malady  is  nearly  always 
obstinate  and  protracted.  As  long,  however,  as  the 
march  of  the  vascular  crescents,  or  their  precur- 
sory turbidity,  has  not  encroached  upon  the  por- 
tion of  cornea  in  front  of  the  pupil,  so  long  vision 
is  not  seriously  jeopardised. 

Treatment. — The  great  object  of  treatment  is 
to  arrest  the  new  vascular  development  at  a com- 
paratively early  stage ; and  for  this  purpose  it  is 
necessary  to  have  recourse  to  eserine  and  seda- 
tives locally,  and  to  such  constitutional  treatment 
as  the  general  condition  may  require.  A solution 
of  two  grains  of  the  neutral  sulphate  of  eserine 
to  an  ounce  of  distilled  water  should  be  dropped 
into  the  eye  twice  daily,  and  the  closed  lids 
should  be  frequently  fomented  with  hot  poppy 
decoction,  or  with  cold  solution  of  extract  of 
opium  in  water,  according  as  one  or  the  other 
temperature  is  the  more  agreeable  to  the  feelings 
of  the  patient.  Apart  from  any  special  indication, 
the  medicines  most  generally  useful  are  those 
which  appear  to  influence  local  nutrition  through 
the  central  nervous  system,  such  as  the  iodide 
and  bromide  of  potassium,  and  the  sulphate  of 
quinine.  These,  if  they  are  likely  to  exert  a 
beneficial  effect,  generally  do  so  speedily ; and  if 
the  malady  should  be  rapidly  extending,  it  is 
always  prudent  to  reconsider  the  prescription 
without  much  loss  of  time.  In  severe  cases, 
especially  when  the  lids  are  somewhat  tumid  and 
there  is  much  photophobia,  a leech  may  often  be 
applied  with  advantage,  usually  over  the  temporal 
muscle,  close  to  the  outer  margin  of  the  orbit, 
or  a little  blood  may  be  taken  more  rapidly,  by 
means  of  Heurteloup’s  artificial  leech;  and 
when,  notwithstanding  treatment,  the  malady 
pursues  its  course  unchecked,  a large  iridectomy 
should  be  made  without  undue  delay.  The 
operation  not  only  tends  to  arrest  the  vascular 
formation,  but  it  also  leaves  alateral  pupil  through 
which  good  sight  may  often  be  obtained  long  be- 
fore the  transparency  of  the  central  parts  of  the 
cornea  is  restored. 

Development  of  vessels  vpon  the  cornea. — It 
is  necessary  carefully  to  distinguish  vascular 
keratitis,  properly  so  called,  from  that  develop- 
ment of  vessels  upon  the  cornea  which  may 
occur  in  connection  with  the  cicatrisation  of 
ulcers,  or  in  consequence  of  the  friction  of  lids 
left  granular  by  conjunctivitis.  In  both,  these 
forms  the  new  vessels  are  arborescent,  an  1 irregu- 


lar in  their  distribution,  instead  of  being  closely 
packed  together:  and  they  are  not  attended  by 
the  pink  zone  of  circum-corneal  congestion,  which 
is  never  absent  in  true  corneal  inflammation. 

The  vessels  which  attend  the  formation  of 
cicatrices  generally  dwindle  in  course  of  time ; 
while  those  produced  by  granular  lids,  and  which, 
when  mey  aro  very  abundant  and  closely  set, 
constitute  the  condition  called  pannus,  will  often 
disappear  without  direct  treatment  if  the  stato 
of  the  lids  themselves  can  be  favourably  modi- 
fied by  the  application  of  astringents.  In  many 
cases  the  vascular  network  of  pannus  will  be 
comparatively  absent  from  the  lower  third  of  the 
cornea,  so  that  sight  may  be  much  improved  by 
an  artificial  pupil  made  in  a downward  direction. 
When  pannus  covers  the  whole  cornea  with  a close 
vascular  network,  so  that  sight  is  almost  de- 
stroyed, and  when  it  resists  milder  treatment,  it 
may  sometimes  be  cured  by  inoculation  with  the 
discharge  of  infantile  purulent  ophthalmia.  The 
pus  is  inserted  between  the  lids,  and  the  artifi- 
cial malady  suffered  to  run  its  course  unchecked, 
except  by  cleanliness  and  frequent  bathing. 
When  the  discharge  has  ceased,  the  cornea  will 
often  clear  in  a surprising  manner,  and  its  ab- 
normally vascular  state  protects  it,  to  a very 
great  degree,  against  the  risk  of  sloughing.  Still, 
this  risk  is  by  no  means  absent,  and  the  treat- 
ment by  inoculation  should  be  regarded  only  as 
a last  resource. 

(c)  Interstitial  Keratitis.  This  is  a chronic 
malady  which  is  seen  chiefly,  or  perhaps  exclu- 
sively, in  the  subjects  of  inherited  syphilis,  who 
possess  the  peculiar  teeth  and  facies  which  Mr. 
Hutchinson  has  shown  to  be  characteristic  of 
their  inheritance.  The  disease  was  long  de- 
scribed as  a variety  of  ‘ strumous  ophthalmia ; ' 
and,  although  the  late  Sir  William  Wilde  pointed 
out  how  frequently  it  was  associated  with  deaf- 
ness, and  also  laid  stress  upon  the  value  of  per- 
chloride  of  mercury  in  its  treatment,  its  syphi- 
litic character  seems  to  have  been  first  suspected 
by  Mr.  Hutchinson,  who,  having  once  obtained 
the  clue,  followed  it  with  characteristic  diligence 
until  he  arrived  at  a conclusive  demonstration  of 
the  accuracy  of  his  suspicion. 

Symptoms. — Interstitial  keratitis  commences 
as  a slight  cloudiness  of  the  central  portion  of 
the  cornea,  with  some  roughening  or  irregularity 
of  the  epithelium.  It  extends  from  the  centre 
towards  the  margin,  and  is  liable  to  be  attended, 
in  different  cases  and  at  different  stages  of  its 
course,  by  variable  degrees  of  ciliary  and  cor- 
neal congestion,  and  intolerance  of  light.  If 
neglected,  or  if  treated  by  irritants,  it  is  liable 
to  assume  the  characters  of  vascular  keratitis, 
and  also  to  extend  to  the  iris,  in  such  instances 
often  doing  irreparable  mischief.  It  is  most 
common  during  childhood,  but  its  appearance 
may  be  delayed  until  adolescence,  or  even  until 
adult  age.  It  attacks  both  eyes,  one  commonly 
somewhat  later  than  the  other,  and  its  course  is 
often  protracted  over  several  months.  When 
severe,  it  leaves  some  residual  cloudiness  of  the 
cornea,  and,  even  when  mild,  it  is  doubtful 
whether  the  cornea  ever  entirely  regains  the 
transparency  of  health.  Still,  when  a case  is 
seen  and  judiciously  treated  early,  the  prognosis 
may  generally  be  a favourable  one. 


EYE.  AND  ITS  APPENDAGES.  DISEASES  OF.  47 


Treatment. — Tho  treatment  consistsprimarily 
in  the  avoidance  of  all  irritants;  the  use  of  eserine 
end  local  sedatives;  and  the  administration  of 
perchloride  of  mercury,  or  of  iodide  of  potas- 
sium, with  or  without  iron  or  cod-liver  oil. 
When  they  are  not  contra-indicated  by  any  special 
circumstances,  the  perchloride  of  mercury  and 
the  oil  are  the  remedies  on  which  the  greatest 
reliance  may  be  placed.  The  earliest  indications 
of  photophobia,  showing,  as  they  do,  that  light 
is  acting  as  an  irritant,  should  be  met  by  con- 
finement to  an  almost  darkened  room,  and  by 
frequent  bathing  of  the  closed  lids  with  cold 
water ; but  in  fine  weather  daily  exercise  should 
be  taken  in  the  open  air,  the  eyes  being  covered 
for  the  time  with  a black  silk  bandage  and  com- 
presses of  carded  wool,  so  as  to  exclude  light 
entirely.  As  soon  as  photophobia  subsides,  these 
precautions  may  be  left  aside — the  eserine  and 
mercury  being  still  continued,  at  least  until  the 
acute  stage  of  the  malady  has  entirely  passed 
away.  After  this  the  absorption  of  residual 
opacity  may  be  promoted  by  tho  application, 
once  daily,  of  a morsel  of  an  ointment  contain- 
ing a small  quantity  (about  ten  grains  to  an 
ounce)  of  the  precipitated  yellow  oxide  of  mer- 
cury. 

In  cases  which  have  been  neglected,  or  aggra- 
vated by  irritants  in  their  early  stages,  and  in 
which  the  phenomena  of  ordinary  vascular  kera- 
titis become  grafted  upon  the  interstitial,  it  is 
generally  desirable  to  perform  iridectomy  with 
as  little  delay  as  possible. 

3.  Arcus  Senilis. — The  condition  thus  named 
(although  the  adjoctive  is  not  always  appropriate) 
is  fully  described  elsewhere.  (See  Arcus  Senilis.) 
It  may  be  distinguished  from  the  peripheral 
zones  of  opacity,  which  are  sometimes  left  after 
tho  subsidence  of  certain  forms  of  keratitis,  by 
til  circumstance  that  arcus  never  extends  quite 
to  the  margin  of  the  cornea,  but  is  always  sur- 
rounded by  an  annulus  of  transparent  tissue. 

Besides  the  foregoing,  there  are  a few  other 
forms  of  corneal  disease,  of  comparatively  rare 
occurrence,  which  it  would  be  beyond  the  limits 
of  these  pages  to  describe,  but  which  must  be 
treated  on  the  same  general  principles ; and  there 
is  also  the  malformation  known  as  ‘ conical 
cornea,’  which  falls  wholly  within  the  domain 
of  surgery. 

III.  Diseases  of  the  Sclerotic. — Diseases 
of  the  Sclerotic,  which  were  onco  regarded  as  a 
numerous  and  important  group,  have  been  re- 
duced by  recent  investigations  to  comparatively 
insignificant  proportions. 

Inflammation.  — Synon.  : — Sclerotitis.  — Ex- 
cepting in  a narrow  annulus  immediately  around 
the  cornea,  the  sclerotic  is  almost  extra-vascular ; 
and  any  real  inflammation  of  its  structure  is 
almost  confined  to  this  particular  region,  where 
it  seldom  occurs  excepting  as  a complication,  or 
as  a part  of  some  of  the  more  severe  forms  of 
iritis  or  keratitis,  especially  when  either  of  these 
affections  extends  to  the  ciliary  body.  In  such 
cases  we  often  see  the  sclerotic  undergo  inflam- 
matory softening,  as  a result  of  which  the  ciliary 
region  may  be  much  altered  in  shape,  yielding  to 
the  distension  of  the  eyeball  and  to  the  traction 
of  the  recti  muscles,  and  becoming  distinctly 
elongated.  Occasionally  the  sclerotic  may  be  so 


much  softened  and  thinned  as  to  bulge  into  ir- 
regular prominences  around  the  cornea,  generally 
under  the  upper  lid  ; and  this  condition  is  de- 
scribed as  sclerotic  staphyloma. 

Treatment. — The  inflammations  thus  arising 
call  for  no  other  treatment  than  that  which  is 
demanded  by  the  more  important  inflammations 
of  the  cornea,  the  iris,  or  tho  ciliary  body,  with 
which  they  are  associated  ; except  that  any  evi- 
dence of  yielding  of  the  sclerotic  would  be  a 
reason  iu  itself  for  the  performance  of  iridec- 
tomy, in  order  to  preserve  the  shape  of  the  eye- 
ball by  diminishing  its  tension.  It  wus  onco 
believed  that  the  sclerotic,  in  its  character  of  a 
fibrous  membrane,  was  especially  prone  to  gouty 
or  rheumatic  inflammation ; and  it  is  perhaps 
true,  though  certainly  not  proven,  that  the  ten- 
dency of  iritis  or  of  keratitis  to  spread  to  tho 
anterior  sclerotic  zone  is  moro  marked  in  persons 
of  gouty  or  rheumatic  diathesis  than  in  others. 
The  possibility  is  at  any  rate  sufficient  to  require, 
ia  all  these  cases,  an  investigation  of  the  ten- 
dency to  lithic  acid  formation,  and  the  use  of 
appropriate  remedies  when  this  tendency  is  dis- 
covered. Butalarge  proportion  of  the  examples 
of  supposed  gouty  or  rheumatic  ophthalmia  are 
nothing  more  than  cases  of  the  sub-acuto  or 
remittent  form  of  glaucoma ; and  the  pain  asso- 
ciated with  them  is  not  really  rheumatic  but 
simply  tensive.  Vision  has  been  irretrievably 
lost,  in  hundreds  of  instances,  because  a belief  in 
the  rheumatic  character  of  these  affections  has 
interfered  with  the  timely  performance  of  iri- 
dectomy; and  the  proposal  to  adopt  the  epithet 
‘ rheumatic,’  in  any  form  of  eye-disease,  is  one 
which  should  be  scrutinised  very'  closely  before 
it  is  accepted  as  a guide  to  practice. 

IV.  Diseases  of  the  Iris. — In  so  far  as  they 
come  into  the  province  of  the  physician,  diseases 
of  the  iris  are  not  numerous,  and  arc  almost 
limited  to  the  varieties  of  inflammation  of  that 
membrane. 

1.  Inflammation.  Synon.  : Iritis. — Iritis  may 
be  classified  according  to  its  actual  or  supposed 
causes,  as  rheumatic  or  syphilitic  ; or  according 
to  the  nature  of  the  morbid  process,  as  plastic, 
serous,  or  suppurative.  The  former  classification 
must  often  rest  upon  very  slender  grounds,  and 
the  latter  has  the  great  advantage  of  expressing 
facts  rather  than  inferences. 

(a)  Plastic  Iritis.  Symptoms. — In  plastic 
iritis  the  first  symptom  is  usually  some  loss 
of  the  natural  lustre  of  tho  surface  of  tho  iris, 
and  of  the  clear  definition  of  its  fibres,  together 
with  some  damping  or  alteration  of  its  colour. 
These  changes  are  probably  always  due  to 
turbidity  of  the  aqueous  humour,  and  they 
may  be  imitated  more  or  less  closely  by  tur- 
bidity of  the  cornea,  and  especially  by  dis- 
turbance of  its  epithelium.  In  iritis,  however, 
they  are  associated  with  a diminished  range  and 
quickness  of  pupillary  variation  tinder  variations 
of  light ; and,  in  a short  time,  with  the  effusion  of 
plastic  lymph,  by  which  the  margin  of  the  pupil 
becomes  tied  down,  here  and  there,  to  the  surface 
of  the  anterior  capsule  of  the  crystalline  lens. 
At  the  same  time  there  is  usually  some  con- 
gestion of  the  conjunctiva,  and  of  the  zone  of 
fine  vessels  immediately  around  the  cornea  m 
the  sclerotic.  There  is  frequently  more  or  less 


480  EYE,  AND  ITS  APPENDAGES,  DISEASES  OF. 


pain,  especially  towards  night,  but  this  is  a 
very  uncertain  symptom.  In  severe  cases,  and 
especially  in  such  as  are  clearly  syphilitic  in 
their  character,  the  quantity  of  effused  lymph 
may  be  very  considerable,  so  as  quite  to  cover 
the  pupil,  while  in  mild  cases  it  is  only  sufficient 
to  fasten  down  the  margin  here  and  there. 
Iritis  is  sometimes  a very  insidious  and  seem- 
ingly slight  affection,  the  real  gravity  and  im- 
portance of  which  may  be  wholly  overlooked  by 
the  patient. 

T itEA.TMEttT. — The  first  principle  of  treatment 
is  to  prevent  the  formation  of  adhesions, -or  to 
break  them  if  they  have  been  formed ; and  for 
this  purpose  our  main  reliance  must  be  placed 
upon  the  instillation  of  atropine.  The  anatomical 
structure  of  the  eye  is  such  that  a moderately 
contracted  pupil  is  in  contact  with  the  lens-surface, 
while  a fully  dilated  pupil  is  separated  from  it  by 
a film  of  aqueous  humour.  Hence,  as  long  as  the 
pupil  is  contracted,  any  lymph  which  is  effused 
tends  to  the  immediate  formation  of  adhesions  ; 
while,  as  soon  as  the  pupil  is  dilated,  the  lymph 
diffuses  itself  harmlessly  in  the  surrounding 
fluid,  and  no  adhesions  are  produced.  In 
ordinary  circumstances,  and  in  cases  of  only 
ordinary  severity,  the  iritis  then  runs  its  course 
without  inflicting  any  permanent  injury,  and 
vision  is  completely  restored  as  soon  as  reso- 
lution has  taken  place.  When,  on  the  contrary, 
the  pupil  cannot  he  dilated,  the  lymph  deposited 
in  the  area  of  the  pupil  forms  an  impediment  to 
vision  ; and  the  adhesions  themselves  tend  to 
render  the  iritis  a recurrent  affection,  which 
is  apt  to  return  again  and  again  until  the  eye 
is  disorganised  and  destroyed. 

The  first  principle  of  treatment  is,  therefore, 
to  produce  and  maintain  dilatation  of  the  pupil ; 
and  for  this  purpose  it  is  necessary  to  use  a 
watery  solution  of  a salt  of  atropine.  The  neu- 
tral sulphate  is  the  one  best  adapted  for  the 
purpose,  and  it  should  generally  be  of  the 
strength  of  four  grains  to  the  ounce  of  distilled 
water.  The  pharmacopoeial  solution  of  atropia, 
which  contains  spirit,  should  he  avoided  on 
account  of  its  irritating  action.  Of  the  pure 
watery  solution,  a drop  should  be  carefully 
placed  within  the  lids  by  a dropping-tube  or 
quill,  repeated  in  five  minutes,  and  again  in 
another  five  minutes,  and  this  threefold  appli- 
cation should  be  repeated  three  times  a day.  A 
mydriatic  agent  still  more  powerful  and  more 
rapid  in  its  action  than  atropine  has  lately  been 
introduced  into  practice  in  duboisin,  the  active 
principle  of  an  Australian  shrub,  Duboisia 
myoporoides.  Duboisin  should  be  used  in  a 
watery  solution,  of  the  strength  of  four  grains 
to  the  ounce  ; and  it  is  said  to  have  less  tendency 
than  atropine  to  produce  local  irritation.  If 
the  pupil  can  be  fully  dilated  in  twenty-four 
hours,  no  other  treatment  will  be  necessary  than 
to  maintain  th9  dilatation  by  using  atropine  less 
frequently,  and  to  protect  the  eye  from  being 
injured  by  exertion,  or  by  exposure  to  great 
variations  of  temperatime  or  of  light.  If,  on 
the  contrary,  after  the  use  of  atropine  for  twenty- 
four  hours,  the  pupil  either  remains  contracted 
or  dilates  irregularly,  showing  that  it  is  bound 
down  here  and  there,  it  is  necessary  to  have 
recourse  to  mercury  without  further  delay,  and 


to  use  one  of  the  preparations,  snch  as  blue  pill 
or  calomel,  with  which  the  effect  of  the  medicine 
upon  the  system  can  be  rapidly  secured.  There 
is  never  any  occasion  to  carry  the  effect  of  the 
mercury  farther  than  to  the  formation  of  a slight 
line  upon  the  gums ; and,  in  most  cases,  as  soon 
as  this  line  is  perceptible,  a notable  amelioration 
of  the  eye-symptoms  will  be  observed.  It  is 
desirable,  however,  that  this  degree  of  mercurial 
influence  should  be  reached  quickly,  in  order  to 
cut  short  the  disease  as  soon  as  possible ; and 
when  it  has  been  reached,  it  will  usually  require 
to  be  maintained,  for  some  days  at  least,  by  the 
administration  of  smaller  and  less  frequent  closes. 
In  favourable  cases,  under  the  combined  influence 
of  atropine  and  mercury,  the  effused  lymph  will 
be  absorbed,  the  adhesions  broken  through,  and 
the  eye  restored  to  its  original  condition.  In 
those  of  a less  favourable  character  the  inflam- 
mation will,  indeed,  subside ; but  the  adhesions 
will  remain,  and  the  pupil  will  be  left  perma- 
nently more  or  less  crippled  and  distorted. 
Whether  or  not  sight  will  be  impaired  will 
chiefly  depend  upon  whether  the  effused  lytnph 
has  formed  a film  or  membrane  across  the  pupil- 
lary opening.  In  the  worst  cases,  notwithstand- 
ing treatment,  the  inflammation  may  extend  to 
tho  ciliary  body  and  choroid,  and  may  produce 
functional  destruction  of  tho  eye.  This  scarcely 
happens  except  when  the  iritis  has  been  of  great 
original  severity,  and  when  it  has  been  neglected, 
or  aggravated  by  irritants,  in  its  early  stages. 
Even  the  suspicion  of  iritis  should  absolutely 
preclude  the  use  of  the  astringent  applications 
on  which  we  have  mainly  to  rely  in  the  treat 
ment  of  tho  inflammations  of  the  conjunctiva. 

If  an  iritis  is  not  seen  until  it  has  been  three 
or  four  days  iu  existence,  so  that  the  adhesions 
have  had  time  to  acquire  a certain  degree  of  firm- 
ness, it  is  not  desirable  to  wait  twenty-four  hour*! 
before  having  recourse  to  mercury.  The  mineral 
should  be  given  without  further  delay,  so  that  it 
may  be  abandoned  if  atropine  should  dilate  the 
pupil,  and  may  be  pushed  if  dilatation  cannot  be 
produced. 

While  the  atropine,  or  atropine  and  mercury, 
are  being  employed,  the  remainder  of  the  treat- 
ment must  he  governed  by  general  considera- 
tions. Best  of  the  other  eye  must  be  strictly 
enforced  ; local  depletion  may  be  practised  when- 
ever the  congestion  is  considerable  in  degree ; 
and  such  a regimen  and  mode  of  life  must  he  * 
prescribed  as  the  patient  can  bear.  U nless  there 
is  photophobia,  it  is  seldom  or  never  necessary 
to  exclude  light  altogether  from  the  eye ; and, 
when  photophobia  is  present,  it  is  better  to  ap- 
ply a protective  bandage  than  to  keep  the  patient 
in  a dark  room.  The  latter  practically  excludes 
him  from  cheerful  companionship,  and  leaves 
him  to  dwell  upon  his  troubles  in  darkness  and 
solitude.  Pain,  if  present,  should  always  be  sub- 
dued, either  by  combining  a sufficient  dose  of 
opium  with  the  mercury,  or  by  the  subcutaneous 
injection  of  a solution  of  morphia.  However  the 
anodyne  is  administered,  pro vi  don  should  be 
made  for  repeating  it  sufficiently  often  to  pro- 
duce and  maintain  the  desired  effect. 

When  recovery  takes  place  leaving  adhesions, 
these  will,  in  tho  majority  of  cases,  lead  to  a 
second  attack  of  iritis,  and  this  is  almost  alwav; 


EYE,  AND  ITS  APPENDAGES,  DISEASES  OF. 


fiis  predecessor  of  regular  recurrence.  In  a few 
cases,  however,  the  second  attack  does  not  follow  ; 
hut,  whenever  it  occurs, 'the  tendency  to  future 
mischief  should  be  stopped  by  surgical  means 
either  by  the  detachment  of  the  adhesions  or  by 
the  performance  of  iridectomy. 

(6)  Serous  Iritis.— The  serous  form  of  iritis 
differs  from  the  plastic  in  the  greater  quantity 
and  the  more  liquid  condition  of  the  effusion, 
which  dors  not  form  adhesions,  but  distends  the 
eyeball  and  compresses  its  contained  structures. 
Iu  a -well-marked  case  the  pupil  is  contracted  and 
insensible  to  atropine  (which  in  all  probability  is 
not  absorbed)  ; the  aqu-ous  humour  is  turbid ; 
the  iris  is  pushed  back  and  its  anterior  surface 
appears  concave ; vision  is  greatly  impaired  , and 
the  eyeball  is  perceptibly  hardened  to  the  touch. 

Treatment. — Until  the  distension  is  relieved, 
no  remedies  will  be  effectual ; and,  when  it  is 
relieved,  they  generally  cease  to  be  needed.  The 
treatment  should  be  either  by  frequently  repeated 
paracentesis  of  the  anterior  chamber  or  by  a 
large  iridectomy,  and  the  latter  is  generally  to  be 
preferred.  Serous  iritis  occurs  chiefly  in  persons 
of  unhealthy  or  broken-down  constitution  ; which 
may  perhaps  account  for  the  unorg  vnizable  char- 
acter of  its  products.  As  soon  as  the  distension 
of  the  eyeball  is  relieved,  the  pupil  is  readily 
dilated,  and  the  iritis  soon  subsides. 

( c ) Suppurative  Iritis.  — In  a sm  dl  number  of 
cases  iritis  assumes  from  the  first  a suppurative 
character,  and  leads  to  the  formation  of  pus  in  the 
anterior  chamber. 

Treatment. — Such  a condition  calls  for  atro- 
pine ; for  stimulating  and  ionic  medicines  rather 
than  for  mercury;  and  for  the  evacuation  of  the 
pus  by  paraoent'  sis  if  it  is  considerable  in  quan- 
tity, or  if  its  pre-cnee  appears  to  be  a source  of 
increased  irritation. 

2.  Inflammation  of  thr  ciliary  hotly  and  choroid. 
Synon.:  Cyclitis  ; Irido  choroiditis. — In  some 
instances,  which  fortunately  are  not  nume- 
rous, iritis  is  not  confine  1 to  the  membrane  in 
which  it  originates,  but  spreads  backwards  to 
the  ciliary  body  and  the  choro-d.  The  most 
marked  examples  are  those  in  which  the  original 
inflammation  has  been  excited  by  morbid  changes, 
resulting  sometimes  from  disease,  but  more  fre- 
quently from  injury,  in  the  opposite  eye:  and 
these  cases  are  called  sympathetic  ophthalmia. 
They  have  been  abundantly  sho  rn  to  depend 
upon  the  propagation  of  peripheral  irritation 
through  a nervous  centre,  and  they  point  very 
clearly  to  the  presence  of  some  central  nerve- 
irritarion,  or  functional  failure,  as  the  essential 
point  of  difference  between  the  iritis  which  dies 
out  as  a localised  affection,  and  that  which 
spreads  by  continuity  to  the  deeper  parts  of  the 
eye.  However  occasioned,  the  issue  of  decltred 
irido-cyclitis  or  irido  choroiditis  is  generally 
disastrous  : for  the  inflammation  is  always  of  a 
plastic  character,  and  the  effused  lymph  is  scarcely 
ever  absorbed  iu  time,  or  with  sufficient  com- 
pleteness, to  prevent  its  contraction  from  in- 
flicting profound  injury  upon  the  visual  appa- 
ratus. The  perceptive  layer  of  the  retina  is 
not  only  in  contact  with  the  choroid,  hut  the 
rods  and  cones  derive  the  materials  of  their 
nutrition  from  the  chorio-capillaris  ; and  hence, 
as  regards  these  delicate  structuies,  auinflamma- 

31 


481 

tion  of  the  choroid,  upon  which  they  are  directly 
dependent,  is  of  far  greater  importance  lhan  an 
inflammation  of  the  retina  itself,  which  may  be 
limited  to  the  connectbe  tissue  of  the  fibre- 
layer,  and  may  leave  the  percipient  elements 
almost  unaffected. 

(Symptoms. — The  first  sign  of  the  extension 
backwards  of  iritis  is  usually  furnished  by  ten- 
derness of  the  ciliary  zone,  so  t at  this 
region  feels  acutely  the  slightest  touch  of  a 
probe,  or  of  the  end  of  a rolled  paper  spill, 
which  is  a more  delicate  instrument  for  testing 
the  sensibility  of  tile  ocular  surface.  At  the 
-ame  time  there  is  always  a greater  degree  of 
impairment  of  vision  than  the  iiitis  aluue  will 
explain,  together  with  increase  1 general  conges- 
tion of  the  eye,  and,  in  many  cases,  with  an 
appearance  of  visible  vessels  on  the  iris. 

Treatment. — The  treatment  io  be  pursued 
d es  not  differ  materially  from  that  which  is 
re  uired  by  the  more  severe  forms  of  simple 
ii  itis  ; and  consists  of  depletion  from  the  temple, 
generally  by  means  of  Heurteloup's  leech ; the 
application  of  atropine;  the  administration  of 
mercury,  both  internally  and  by  inunction  upon 
the  brow  ; the  cntrol  of  pain;  and  the  main- 
tenance of  str-ngth.  In  symp-ithetic  cases,  the 
eye  in  which  the  mischief  originated  should  be 
removed,  even  although  the  usefulness  of  this 
proceeding  is  somewhat  doubtlul  when  once  the 
second  ry  affection  is  established.  It  is  often 
necessary  carefully  to  continue  the  use  of  mer- 
cury for  a long  period,  generally  in  the  form  of 
small  doses  of  toe  perchloride  combined  with 
iron  ; and  it  is  chiefly  when  this  lias  been  done 
that  some  small  vestige  of  vision  is  save  I out  of 
the  wreck.  The  lens,  in  such  cases,  often  be- 
comes coated  by  lymph,  and  ultimately  requires 
removal;  and  it  may  be  necessary  to  p-rform 
iridectomy  for  closure  of  the  pupil  more  than 
once,  in  consequence  of  the  tendency  of  the  arti- 
ficial opening  to  be  drawn  together  again  by 
contraction.  On  account  of  the  severity  of  sym- 
pathetic ophthalmia,  and  ot  its  generally  unfa- 
vourable termination,  it  is  a rule  of  practice  to 
anticipate  its  occurrence,  and  to  remove  a dis- 
eased or  in  ured  eye  which  is  l.kely  to  produce 
it  before  ihe  mischief  has  been  done. 

V.  Diseases  of  the  Crystalline  Lens  are 
separately  treated. of  under  the  article  Cataract. 

VI.  Glaucoma. — In  its  modern  signification, 
this  word  is  applied  to  denote  all  the  cond.tions 
which  are  produced  by  a morbid  increase  oi 
tension  within  the  eye,  that  is  to  say.  by  an  excess 
of  its  contained  fluids;  and  the  diffireut  forms 
of  the  affection  are  mainly  due  to  uitierence? 
in  the  rate  at  which  the  tension  increases. 

Symptoms.— If  the  increase  be  rapi  I,  ihe  loss 
of  sight  will  be  rapidly  pro  luC' d,  and  will  be 
associated  with  other  changes  occasioned  by  sud- 
den interference  with  the  circulation  and  innerva- 
tion a d by  sudden  stretching  of  the  o ular  tunics. 
When,  on  the  other  hand,  the  increase  of  tension 
is  very  gradual,  so  that  the  e\ e has  rime  to  become 
accustomed  to  the  new  conditions  as  they  are 
produced,  ti  e symptoms  ottm  present  a decep- 
tive resemblance  to  simple  atrophy ; and  these 
cases  were  at  one  time  described  as  ‘ atrophy 
with  excavation  of  the  optic  nerve.’  In  some 
of  the  more  acute  forms  ox  increased  tension,  the 


182  EYE,  AND  ITS  APPENDAGES.  DISEASES  OF. 


pupil  presents  a clouded  aspect  of  a greenish 
colour;  and  it  was  to  cases  of  this  class  that 
the  word  glaucoma  (from  yAavubs,  sea-green)  was 
originally  applied,  at  a time  when  the  pathology 
of  the  condition  was  not  understood.  When 
this  pathology  was  rendered  clear,  and  when 
it  became  known  that  the  glaucoma  of  the 
ancients  was  in  all  essential  respects  identical 
with  cases  in  which  the  most  manifest  symptoms 
were  of  a different  kind,  the  word  was  retained 
as  a convenient  general  term,  to  express  states  of 
disease  to  which  it  had  no  longer  any  apparent 
reference ; and  hence  we  still  speak  of  glaucoma, 
although,  in  the  great  majority  of  the  cases  in 
which  we  do  so,  the  green  aspect  of  the  pupil  is 
conspicuous  by  its  absence. 

The  estimation  of  increased  tension  by  the 
fingers  is  a matter  which  requires  the  tactus 
eruditus , and  is  best  accomplished  by  directing 
the  patient  to  close  the  eyes  gently,  and  to  cast 
them  downwards.  The  tips  of  the  two  fore- 
fingers should  then  be  placed  upon  the  upper 
lid  immediately  tielow  the  margin  of  the  orbit, 
and,  when  one  finger  has  fixed  the  eye  by  hold- 
ing it  gently  back  against  the  orbital  contents 
as  far  us  it  will  recede,  the  other  estimates  the 
degree  in  which  it  may  be  dimpled  by  slight 
pressure.  This  degree  varies  to  some  extent 
in  different  persons  within  physiological  limits, 
but  a morbid  increase  of  tension  can  scarcely 
be  missed  if  it  is  looked  for.  Moreover,  the 
diagnosis  of  glaucoma  does  not  rest  upon  in- 
creased tension  alone,  but  upon  the  combination 
of  increased  tension  with  decreasing  sight.  The 
rate  of  slow  increase  which  may  simulate 
atrophy,  or  of  rapid  increase  which  may  simu- 
late inflammation,  are  matters  of  detail  which 
should  not,  in  either  case,  be  suffered  to  obscure 
the  true  nature  of  the  morbid  process. 

Treatment. — The  treatment  of  glaucoma  is 
entirely  surgical,  the  affection  being  capable  of 
arrest  by  iridectomy  or  sclerotomy  in  the  great 
majority  of  cases.  In  the  more  acute  forms,  an 
operation,  if  performed  sufficiently  early,  usually 
restores  vision  to  its  integrity;  hut  the  time 
during  which  this  can  be  done  is  limited,  and  in 
the  more  chronic  forms  no  operation  will  do 
more  than  preserve  what  amount  of  sight  is  still 
retained.  Hence  it  is  important  that  treatment 
should  not  be  delayed  by  any  error  of  diagnosis; 
ar.d  the  points  to  which  attention  should  chiefly 
Lo  directed,  in  any  case  of  impairment  of  vision 
in  which  the  question  may  arise,  are  increasing 
hardness  of  the  eyeball  as  determined  by  palpa- 
tion, and  gradual  contraction  of  the  field  of 
vision.  Whs  never  the  eye  is  becoming  harder, 
and  the  circumferential  extent  of  vision  is  nar- 
rowing in,  the  case  is  one  in  which  an  operation 
should  be  accomplished  with  as  little  delay  as 
possible.  At  the  same  time,  until  the  operation 
can  be  performed,  a four-grain  solution  of  eserine 
should  be  applied  every  four  hours;  tiiis  drug 
having  a marked  effect  in  controlling  and  dimin- 
ishing tension.  The  more  acute  cases  of  glau- 
coma are  attended  by  much  pain  from  the 
distension  of  the  ocular  tunics,  and  often  by 
congestion  and  inflammation,  the  results  of  this 
distension ; and  such  cases  were  at  one  time 
described  as  ‘ acute  internal  arthritic  ophthal- 
mia,’ or  by  some  similar  name.  Vision  has 


been  irretrievably  lost,  in  hundreds  of  cases,  b7 
endeavours  to  control  this  form  of  glaucoma  by 
medical  treatment,  to  the  neglect  of  operation  • 
and  the  erroneous  practice  has  been  kept  alive 
by  the  circumstance  that  some  of  the  cases 
will  undergo  partial  and  temporary  amendment. 
In  such  circumstances,  however,  the  vision 
never  rises  to  the  degree  of  acuteness  which 
existed  prior  to  the  attack,  and  the  amendment 
is  never  more  than  temporary.  Another  in- 
crease of  tension  sood  ociurs ; and,  without  sur- 
gical aid,  blindness  sooner  or  later  closes  the 
srene. 

VII.  Diseases  of  the  Optic  Nerve  and 
Eetma. — As  shown  I yi  he  ophthalmoscope,  these 
diseases  cover  a very  wide  field  of  pathology.  In 
order  to  understand  them  accurately,  it  is  neces- 
sary to  bear  in  mind  the  anatomy  and  relative 
arrangement  of  the  affected  tissues.  The  optic 
nerve  in  the  orbit  is  invested  by  a double 
sheath,  and  the  interval  between  its  layers, 
which  is  continuous  with  the  sub-arachnoid 
space,  terminates  in  a cul-de-sac  towards  the 
eyeball,  the  two  layers  becoming  intimately- 
united  where  they  blend  with  tne  sclerotic.  At 
this  point,  the  opening  in  the  sclerotic  for  the 
admission  of  the  optic  nerve  is  crossed  by  a film 
of  perforated  connective  tissue,  the  lamina  cri- 
brosa , with  which  the  sheaths  of  the  nerve-fibres 
blend,  or  in  which  they  are  lost,  so  that  the 
nerve  anterior  to  the  lamina  consists  of  a bundle 
of  unsheathed  fibres,  envelopingtlie  central  artery 
of  the  retina,  which  enters  the  eye  with  them, 
and  the  central  vein  of  the  retina,  which  passesout 
in  the  same  position.  On  entering  the  eye  the 
nerve-fibres  bend  round  to  form  the  anterir- 
layer  of  the  retina,  which  contains  also  the 
retinal  blood-vessels  almost  to  their  ultimate 
divisions,  together  with  some  delicate  connective 
tissue.  The  capillary  circulation  of  the  nerve 
itself  is  derived  from  the  anterior  cerebral  artery, 
and  is  distinct,  save  for  a very  slight  amount  of 
anastomosis,  from  the  capillary  circulation  of  the 
sheath,  which  is  fed  by  the  arteries  of  the  pia 
mater.  It  follows  that  hyperaemia  of  the  sheath, 
or  of  the  circle  surrounding  the  nerve,  may  exist 
without  hyperaemia  of  the  proper  nerve-tissue, 
and  it  has  been  supposed  that  fluid  pressure  in 
the  intervaginal  sp  ice  m ay  iiaterpose  an  obstacle 
to  the  circulation  in  the  vessels  which  pass 
through  the  sclerotic  foramen,  and  may  thus 
occasion  dropsy  of  the  termination  of  the  nerve 
within  the  eye.  Of  the  two  foregoing  conditions, 
either  may  undergo  res  alution  haarmlessly,  or 
may  produce  such  changes  in  or  around  the  nerve 
as  to  occasion  atrophy  and  loss  of  sight.  Neither 
of  them  interferes  with  sight  directly,  because 
the  circulation  may  be  seiiously  disturbed  by  a 
degree  of  pressure  which  is  insufficient  to  stop 
the  conduction  of  impressions  through  the  nerve- 
fibres.  There  is  yet  a third  condition,  properly 
called  optic  neuritis,  or  neuritis  descendens,  iu 
which  the  capillary  network  of  the  nerve  itself 
participates  in  changes  propagated  downwards 
from  the  cerebrum,  and  in  which  impairment 
of  vision  holds  a very  early  place  among  the 
symptoms. 

1.  Perineuritis. — The  true  perineuritis,  iu 
which  the  unchanged  nerve-disc  is  surrounded 
by  a zone  of  high  vascularity-,  is  ouly  seen  as  a 


EYE,  AND  ITS  APPENDAGES,  DISEASES  OF.  463 


result  of  meningitis,  which  may  be  either  tuber- 
cular or  due  to  other  causes.  It  was  at  one  time 
hoped  by  Bouchut,  by  whom  this  especial  phe- 
nomenon was  first  described,  that  perineuritis 
might  serve  as  a diagnostic  sign  in  cases  of 
doubtful  meningeal  inflammation  ; but  this  ex- 
pectation has  not  been  realised.  The  perineuritis 
itself  has  only  been  observed  in  cases  the  charac- 
ter of  which  was  scarcely  doubtful,  and  which,  in 
most  instances, haveterminated  fatally.  Very  pro- 
bably, however,  it  would  be  found,  if  looked  for, 
in  those  cases  of  exanthematous  and  other  fevers 
which  are  attended  by  cerebral  symptoms,  fol- 
lowed after  recovery  by  impairment  of  vision. 
In  these  we  eventually  find,  as  a rule,  a partial 
nerve-atrophy,  which  does  not  lead  on  to  com- 
plete blindness,  but  which  does  not  appear  to 
be  susceptible  of  improvement;  and  this  partial 
atrophy  may  no  doubt  be  due  to  the  pressure  of 
periueural  exudation  during  its  contracting  stage. 

Treatment. — The  treatment  of  perineuritis 
must  generally  be  that  of  the  affection  in  which  it 
has  its  origin  ; but,  in  any  fever  in  which  this 
symptom  had  been  detected,  it  would  be  a question 
whether  mercury  should  not  be  cautiously  ad- 
ministered for  a considerable  time  after  conva- 
lescence, in  order  to  promote  the  absorption  of 
any  effused  lymph  by  which  the  optic  nerve  en- 
trance might  be  constricted. 

2.  Choked  Disc.  Synon.  : Dropsy  of  the  Optic 
Nerve  Entrance.  This  is  a condition  chiefly  seen  in 
connection  with  intracranial  tumours,  whether 
syphilitic,  tubercular,  or  of  some  other  kind;  and 
it  almost  invariably  affects  both  eyes.  It  was 
formerly  supposed  to  be  due  to  the  pressure  of 
fluid  driven  down  the  intervaginal  space  around 
the  nerve,  and  so  constricting  the  latter  at  the 
terminal  cul-de-sac  as  to  impede  the  outflow  of 
venous  blood.  This  hypothesis  is  now  generally 
abandoned,  but  the  condition  visible  with  the 
ophthalmoscope  is  one  of  distension  and  tortuo- 
sity of  the  retinal  veins  ; arrest  of  the  capillary 
circulation  ; impediment  to  the  arterial  inflow  ; 
dropsical  effusion  into  the  disc-tissues ; and, 
sometimes,  secondary  inflammatory  changes, 
such  as  effusion  and  cell-proliferation,  compar- 
able to  the  erythema  which  occurs  in  the  inte- 
gument of  a dropsical  limb.  All  these  changes 
may  exist  without  impairment  of  vision,  because 
they  neither  affect  the  perceptive  layer  of  the 
retina,  nor  arrest  the  conduction  through  the 
nerve-fibres.  At  a later  period,  however, 'when 
any  plastic  elements  in  the  exudation  begin  to 
undergo  contraction,  the  interference  with  the 
circulation  becomes  more  complete,  the  nerve- 
fibres  themselves  become  compressed,  and  then 
failure  of  sight  commonly  occurs.  At  the  same 
period,  the  nerve  passes  into  a state  of  atrophy 
from  the  interference  with  its  circulation;  and 
these  cases  of  nerve-atrophy  were  once  sources 
of  great  perplexity  to  surgeons,  and  were  re- 
ferred to  alcohol,  tobacco,  and  to  other  causes 
which  probably  had  very  little  to  do  with  them. 
In  consequence  of  the  sight  not  being  affected 
during  the  preliminary  stage,  the  occurrence  of 
thie  stage  was  for  a long  time  absolutely  over- 
looksd,  and  was  only  discovered  when  phy- 
sicians began  to  use  the  ophthalmoscope,  as  an 
ordinary  instrument  of  diagnosis,  in  all  cases  of 
cerebral  affection.  It  was  then  soon  established, 


notably  by  the  labours  of  Drs.  Hughlings  Jackson, 
Buzzard,  and  Cliffor  1-Allbutt,  that  the  atrophy 
had  been  preceded  by  swelling  of  the  disc  and  by 
obstruction  of  its  circulation  ; and  it  was  shown 
before  long  that  the  cases  of  atrophy  which  had 
this  history  were  recognisable,  after  the  swelling 
had  pissed  away,  by  the  tortuosity  of  the  retinal 
veins  which  was  left  behind,  and  by  the  way  in 
which  these  veins  were  lilted  into  l>dd  curves  at 
the  margin  of  the  disc;  this  alteration  of  their 
original  course  having  been  due  to  the  swelling, 
and  remaining  after  the  swelling  had  subsided. 
The  contraction  of  the  effusion,  and  the  conse- 
quent atrophy  of  the  nerve-fibres  and  closure  of 
the  capillary  vessels,  would  be  likely  to  occur 
earlier  in  some  parts  of  the  disc  than  in  others; 
and  hence,  at  the  time  when  commencing  failure 
of  sight,  first  induced  the  patient  to  seek  advice 
on  account  of  it,  the  disc  was  commonly  seen  to 
be  invaded  by  sectors  of  whiteness,  but  to  retain 
its  vascularity,  or  perhaps  more  ihan  its  normal 
vascularity,  in  other  parts;  while,  at  the  same 
time,  the  sight  was  first  lost  in  those  regions  of 
the  retina  the  fibres  from  which  were  first  com- 
pressed. Hence  it  follows  that  a partial  invasion 
of  the  disc  by  atrophic  changes,  and  a pirtial 
invasion  of  the  field  of  vision  by  blind  portions, 
are  am- mg  the  earliest  symptoms  in  eases  of  tho 
class  under  consideration  ; and  these  symptoms 
were  at  one  time  referred  rather  to  the  nervous 
centres  than  to  the  retina  or  the  disc  itself,  to 
changes  in  which  they  are  now  attributed.  A 
not  uncommon  clinical  history  in  such  cases  is 
that  there  lias  beeu  constitutional  syphilis,  im- 
perfectly treaied,  and  ultimately  producing  head- 
ache or  other  cerebral  symptoms,  which  have 
probably  called  for  the  administration  of  iodide 
of  potassium  and  have  been  relieved  by  it.  Some 
weeks  afterwards  there  is  for  the  first  time  a 
complaint  of  failing  sight;  and  then  the  ophthal- 
moscope reveals  that  the  discs  are  passing  into 
atrophy,  that  the  retinal  veins  are  lifted  into 
prominent  curves  at  tne  disc-margins,  and  that 
their  further  course  over  the  retina  is  generally 
serpentine.  In  many  cases,  the  recovery  of  the 
patient,  as  far  as  general  hf  ,ith  is  concerned, 
leaves  the  precise  character  of  the  intra-vranial 
mischief  doubtful;  but,  in  tatal  cases,  a tumour 
is  the  morbid  condition  most  frequently  dis- 
covered. See  Ophthalmoscope  in  Medicine. 

When  the  merely  passive  dropsical  effusion 
into  the  disc  becomes  complicated  with  inflam- 
matory changes,  as  results  of  the  disturbance  of 
the  tissues,  the  sight  begins  to  fail  before  atrophic 
changes  become  manifest;  and  such  cases  are 
very  difficult  to  distinguish  from  those  in  which 
there  is  (If)  primary  or  descending  neuritis.  The 
blood-supply  of  the  optic  nerve  beingderived  from 
the  anterior  cerebral  artery,  we  may  reasonably 
expect  to  find  capillary  engorgement  of  the  nerve- 
substance  of  the  disc  in  connection  with  arterial 
hypersemia  of  the  brain  ; and  this  capillary  en- 
gorgement may  pass  into  inflammation,  either  of 
local  origin  or  by  transmission  down  war,  s from 
above.  In  any  case,  if  the  first  changes  in  the  disc 
are  of  the  character  of  neuritis  rather  than  of  ob- 
struction, we  see  capillary  or  arterial  hypenemia 
of  the  nerve-substance  rather  than  venous  conges- 
tion ; and  effusion  of  plastic  material  upon  the 
disc  itself,  with  comparatively  little  prominenco 


484  EYE,  AND  ITS  APPENDAGES.  DISEASES  OF. 


or  di&o-swelling,  and  ■with  comparatively  little 
extension  over  the  disc-margins  upon  the  sur- 
rounding retina.  At  the  same  time,  even  in  die 
early  stage  of  the  affection,  we  find  great  impair- 
ment of  sight,  the  conducting  power  of  the  nerve- 
fibres  being  seriously  injured.  Such  cases  are 
frequently  syphilitic,  and,  unless  the  absorption 
of  the  effusion  should  be  quickly  brought  about 
by  treatment,  its  contraction,  like  that  of  the 
effusion  of  obstruction,  soon  occasions  atrophic 
changes.  In  these  cases,  however,  the  swelling 
having  been  absent  or  inconsiderable,  the  vessels 
do  not  show  that  elevation  into  bold  curves  at 
the  disc-margin  which  has  already  been  described ; 
and  the  contraction  beinginterstitinl  in  the  nerve- 
substance,  and  from  the  first  affecting  veins  and 
arteries  in  an  equal  degree,  the  arterial  intlowis 
diminished  pari  passu  with  the  diminution  of  the 
vein-channels,  and  the  latter  vessels  are  seldom 
distended  in  such  a manner  as  to  render  them 
distinctly  varicose  or  tortuous.  The  u'timate  re- 
sult is  a white  disc,  on  which  the  arteries  and 
veins  are  dwindled  to  threads,  or  at  least  greatly 
reduced  from  their  normal  calibre. 

We  may  therefore  have  three  conditions  which 
in  their  typical  forms  are  tolerably  distinct,  but 
which  are  prone  to  run  into  one  another  by  al- 
most imperceptible  gradations,  and  which  may 
all  lead  on  to  atrophy  and  complete  blindness  : 
namely,  perineuritis,  neuritis,  and  choked  disc. 
The  liability  to  the  last-mentioned  condition 
should  be  carefully  remembere  1 by  physicians, 
and  should  lead  to  careful  ophthalmoscopic  ex- 
amination in  all  cases  of  obstinate  headache  or 
other  cerebral  symptoms  of  obscure  origin,  more 
especially  in  a patient  with  a syphilitic  history. 

Treatmemt. — It  is  manifest  that  the  best  hope 
of  preventing  ultimate  blindness,  in  persons  in 
whom  choked  disc  has  occurred,  will  be  secured 
oy  the  administration  of  medicines  calculated  to 
assist  the  absorption  of  the  effusion,  and  by  con- 
tinuing these  medicines,  with  comparatively 
small  reference  to  the  general  symptoms,  until 
the  discs  have  cleared.  The  writer  has  seen  such 
clearing  occur,  without  loss  of  sight,  in  circum- 
stances which  rendered  it  almost  certain  that 
neglect  of  the  disc-effusions  would  have  been 
followed  by  blindness  at  no  distant  date.  The 
same  general  rule  will  apply,  of  course,  to  the 
more  directly  inflammatory  effusions  of  neuritis 
or  perineuritis  ; and,  when  we  find  any  one  of 
the  three  conditions  passing  into  atrophy,  or 
when  we  find  commencing  atrophy  in  discs  which 
show  traces  of  past  effusion,  the  principle  of 
treatment  is  to  endeavour  to  promote  the  ab- 
sorption of  any  contracting  material  which  may 
be  the  physical  cause  of  the  atrophy : and  then, 
when  this  has  been  done,  to  seek  to  stimulate  the 
nutrition  of  the  nerve-fibres,  and  to  assist  them 
to  recover  from  the  shock  which  they  have  sus- 
tained. The  mode  of  fulfilment  of  the  first  in- 
dication must  depend  mainly  upon  whether  there 
is  a history  of  syphilis,  and,  if  so,  upon  the 
manner  in  which  it  has  been  treated.  In  the 
numerous  cases  in  which  a short  course  of  mer 
cury  has  been  administered,  enough  to  alleviate 
secondary  symptoms,  but  wholly  insufficient  to 
eradicate  the  disease,  it  will  generally  be  desir- 
able to  give  iodide  of  potassium  in  full  doses  for 
a time,  and  to  follow  this  by  the  prolonged  ad- 


ministration of  the  perchloride  of  mercury,  in 
the  hope  of  really  curing  the  patient.  There  are, 
in  the  writer’s  opinion,  few  things  better  worth 
remembering  in  therapeutics  than  that  the  iodide, 
immeasurably  the  most  va'uable  drug  which  we 
possess  as  a remedy  fora  late  syphilitic  symptom, 
is  none  the  less  almost  useless  as  a reme  iy  for 
constitutional  syphilis.  It  will  remove  the  pre- 
sentsymptom.  speedilr  and  otten  completely ; but 
it  can  scarcely  be  said  to  have  any  tendency  to 
prevent  the  recurrence  of  syphilitic  symptoms  at 
a future  time,  in  the  same  or  in  some  different 
form.  For  this  purpose,  the  only  trustworthy 
agent  is  mercury;  and  therefore,  while  1 1 . e ad- 
ministration of  the  iodide  for  a sufficient  time, 
and  in  sufficient  quantities  to  test  its  power  of 
do'mg  good,  will  be  enough  in  the  cases  iD  which 
syphilis  is  neither  known  nor  suspected,  the 
iodide  must  be  followed  by  mercury  whenever  a 
syphilitic  history  of  the  affection  is  either  clear 
or  highly  probable.  The  second  indication,  to 
stimulate  the  nutrition  of  the  nerve-fibres,  is 
usual  1,  best  accomplished  by  strychnia,  given  at 
such  intervals  and  in  such  doses  as  to  produce 
evidence  of  its  constitutional  effect  before  its 
administration  is  abandoned.  It  may  perhaps  bo 
most  effectually  given  by  hypodermic  injection; 
but  this  is  a point  which  must  be  settled  in  ac- 
cordance with  the  circumstances  of  the  case  in 
each  individual  instance. 

3.  Sclerosis  of  the  Optic  K erve . — Besides  the 
consecutive  forms  of  atrophy  above  enumerated, 
there  is  yet  another  of  common  occurrence,  which 
is  either  a prmary  sclerosis  of  the  optic  nerve, 
or  a sclerosis  secondary  to  a similar  affection  of 
other  parts  of  the  nervous  centres.  This  form  of 
atrophy  is  not  preceded  by  effusion,  nor  is  it 
attended  by  any  marked  decrease  in  the  ealibro  of 
the  central  vessels  of  the  retina,  even  when  the 
capillary  circulation  of  the  disc  has  almost 
wholly  disappeared.  It  is  often  seen  in  connec- 
tion  with  disease  of  the  spinal  cord,  as  in  lo- 
comotor ataxy;  and  also  occurs  in  apparently 
healthy  people,  seemingly  as  a purely  local  affoc. 
tion. 

Sclerosis  is  easily  distinguished  from  the 
atrophies  consecutive  to  effusion,  whether  activo 
or  passive,  by  the  circumstance  that  the  effusion, 
as  it  undergoes  contraction,  tends  to  render  the 
nerve-tissues  opaque  as  wed  as  to  bleach  them, 
and  thus  leaves  a disc-surface  of  an  almost  ivory 
whiteness  and  of  uniform  colour.  In  sclerosis, 
on  the  other  hand,  the  nerve-tissue  disappears  to 
a great  extent,  ant*  reveals  the  mottle  I surface, 
often  of  a bluish-white  tint,  of  the  lamina 
cribrosa  When  this  is  plainly  seen,  and  when, 
at  the  same  time,  the  vessels  are  neither  much 
diminished  in  calibre  nor  altered  in  their  normal 
curvatures,  sclerosis  may  be  assumed  to  exist; 
and  this  form  of  atrophy  may  also  be  distin- 
guished front  that  which  is  produced  by  the  mast 
chronic  forms  of  glaucoma,  by  the  circumstance 
that  in  the  latter  the  vessels  bend  into  the  ex- 
cavated disc  at  its  margin,  while  in  the  former 
they  pass  over  the  margin  in  straight  lines  or 
nearly  so.  Chronic  glaucoma  would  also  bo 
distinguished  by  the  character  of  the  failure 
of  sight,  which  would  be  marked  by  regular  or 
almost  concentric  contraction  of  the  field  of 
vision,  even  when  central  vision  was  only  a little 


EYE,  AND  ITS  APPENDAGES,  DISEASES  OF.  480 


impaired;  and  also  by  the  gradual  hardening  of 
the  eyeball,  which  would  be  present  in  glaucoma 
and  absent  in  nerve-sclerosis.  Still  it  cannot  be 
denied  that  this  particular  diagnosis  is  not  with- 
out its  difficulties,  and  that  iu  certain  cases  it 
has  given  rise  to  differences  of  opinion  between 
men  of  large  experience  on  all  sides  of  the  ques- 
tion at  issue. 

The  diagnosis  is  important  as  well  as  difficult ; 
since  the  mischief  of  glaucoma  may  admit  of 
arrest  by  iridectomy  or  sclerotomy;  so  that  to 
mistake  chronic  glaucoma  for  atrophy,  and  to 
neglect,  operation,  may  be  to  condemn  the  patient 
to  unnecessary  blindness.  The  opposite  error  can 
at  least  do  no  harm  ; and  therefore,  whenever  a 
doubtreally  exists  uponlhe  point,  the  most  proper 
course  is  to  give  the  benefit  of  that  doubt  to  the 
patient,  and  to  advise  the  performance  of  an  opera- 
tion which  cannot  injure,  and  which  may  relieve 
him.  The  atrophy  of  sclerosis  scarcely  admits  of 
treatment,  but  it  may  perhaps  sometimes  be  de- 
layed, or  even  prevented  from  becoming  complete, 
by  the  administration  of  full  doses  of  strychnia 
and  iron. 

4.  Atrophy  from  other  causes. — Besides  the 
foregoing  forms  of  atrophy,  there  is  a variety 
which  appears  to  be  associated  with  chronic  lead- 
poisoning,  and  in  which  the  discs  may  acquire  a 
peculiar  gray  or  bluish  tint ; and  the  optic  nerves 
may  also  undergo  secondary  wasting  in  conse- 
quence of  other  conditions  presently  to  be  men- 
tioned, such  as  obstruction  of  the  central  artery 
by  an  embolus,  or  the  long  continuance  of  pig- 
mentary retinitis. 

o.  Retinal  Hemorrhage. — The  chief  disorders 
of  the  retin  il  cireu  ation  displayed  hy  the  oph- 
thalmoscope are  haemorrhages,  which  may  be 
attended  by  very  different  circumstances,  and 
may  present  widely  different  characters. 

a.  Single. — When  blood  proceeds  from  one  of 
the  larger  veins  of  the  retina,  which  yield  a con- 
siderable quantity,  and  which  are  situated  im- 
mediately underneath  the  limiting  membrane,  the 
haemorrhage  usually  spreads  out  over  the  fundus 
as  a red  patch  of  uniform  colour  and  aspect.,  and 
vision  is  suddenly,  and  sometimes  almost  totally, 
obscured.  The  writer  has  seen  such  bleeding 
occur  from  the  yielding  of  a vessel  during  par- 
turition ; hut  this  accident  is  extremely  rare, 
and  the  large  haemorrhages  in  question  are  cer- 
tainly more  common  in  women  at  the  period  of 
cessation  of  the  menstrual  function  than  under 
any  other  circumstances.  At  this  time,  and  when 
the  health  is  not  seriously  affected,  a favourable 
prognosis  may  be  given  with  some  confidence; 
for  the  blood  will  before  long  be  absorbed,  and 
restoration  of  vision,  at  least  in  a considerable 
degree,  may  be  expected.  The  writer  has  once 
seen  complete  restoration  to  the  normal  standard, 
but  this  is  an  exceptional  occurrence. 

Treatment. — The  only  treatment  necessary  is 
to  pay  attention  to  the  requirements  of  the  general 
health;  and  to  prescribe  sucli  diet,  medicines, 
regimen,  and  habits  as  may  tend  to  calm  and 
equalise  the  circulation,  and  to  prevent  local  con- 
gestions. The  occurrence  of  sudden  loss  of  sight 
in  one  eye  will  justify  the  suspicion  of  haemor- 
rhage; but  the  suspicion  can  only  be  converted 
into  certainty  by  the  ophthalmoscope. 

b.  Multiple. — A form  of  venous-  haemorrhage 


which  at  first  seems  less  formidable,  because  it 
is  attended  by  a smaller  degree  of  immediate 
interference  with  sight,  hut  which  calls  for  a less 
favourable  prognosis,  is  that  in  which  the  haemor- 
rhages are  multiple,  often  singly  of  small  size, 
and  scattered  over  the  whole  fundus  of  the  eye. 
The  appearances  which  tney  present  differ,  ap- 
parently in  accordance  with  their  precise  position 
in  the  retina.  If  they  proceed  from  vessels  which 
are  superficial,  the  blood  is  spread  out,  as  in  the 
last  variety.  in  round  or  oval  patches  beneath  the 
limiting  membrane,  but,  if  the  vessels  lie  a little 
deeper,  and  are  fairly  engaged  in  the  fibre-layer, 
the  blood  will  separate  the  fibres  and  find  its  way 
between  them, forming  flame-shaped  or  brush-like 
jatches,  which  are  often  very  numerous.  Such 
multiple  haemorrhages  aro  very  slowly  absorbed, 
and  have  a tendency  to  recur ; so  that  they  must 
always  be  regarded  as  placing  the  sight  in  serious 
jeopardy.  They  are  often  monocular,  and  they 
do  not  poirt  to  any  definite  disturbance  of  the 
general  health.  The  only  endeavour  so  to  con- 
nect them  with  which  the  writer  is  acquainted 
was  made  by  Mr. Hutchinson,  v ho  described  some 
cases  of  flame-shaped  haemorrhage  in  persons  all 
of  whom  he  said  were  ‘gouty  ; ’ but  it  will  cer- 
tainly be  the  experience  ol  most  practitioners  that 
flame-shaped  haemorrhages  occur  in  manypatients 
who  are  not  ‘ gouty  ’ in  the  ordinary  sense,  and 
that  they  do  not  occur  in  vast  numbers  of  those 
about  the  reality  of  whose  gout  there  can  be  no 
question.  The  presence  of  multiple  haemorrhages 
is  sometimes  attended  by  a considerable  degree 
of  irritation,  or  even  inflammation,  in  the  tissues 
among  which  the  blood  has  been  effused ; and 
this  condition,  in  which  the  retina  between  the 
blood-spots  may  become  opalescent  or  turbid, 
has  been  described  as  a form  of  retinitis — Retinitis 
apoplectica.  I he  element  of  inflammation,  in 
such  instances,  is  probably  merely  a reaction 
consequent  upon  the  injury  inflicted  upon  the- 
tissues,  and  it  cannot  be  inferred  that  the  bleed- 
ing is  itself  the  result  of  any  inflammatory  pro- 
cess. 

Treatment. — In  this,  as  in  the  former  variety, 
there  is  no  special  indication  for  treatment,  which 
must  be  confined  to  the  correction  of  any  mani- 
fest disorder  of  the  general  health,  followed,  in 
most  instances,  by  the  administration  of  iodides 
or  bromides,  as  medicines  calculated  to  assist  in 
the  absorption  and  removal  of  the  effused  pro- 
ducts. Any  indication  of  a general  haemorrhagic 
tendency,  or  of  a state  allied  to  purpura  or  scurvy, 
would  require,  of  course,  full  consideration  and 
appropriate  treatment.  The  extent  of  the  ulti- 
mate injury  to  sight  will  usually  depend  upon  the 
extent  to  which  the  perceptive  elements  of  the 
retina  have  been  compressed  or  disorganised, 
either  by  the  bleeding  itself,  or  by  other  changes 
consecutive  to  it. 

c.  Arterial. — Haemorrhages  which  are  distinctly 
arterial  are  not  uncommon  in  the  fundus  of  the 
eye,  and  can  generally  be  distinguished  with- 
out difficulty  from  the  venous  variety,  not  only 
by  the  colour  of  the  effused  blood,  but  also  by 
the  situation  of  the  hloodpatch,  and  by  its  mani- 
fest relations  to  a small  arterial  branch,  which 
may  often  be  seen  to  have  dwindled  or  closed 
be>ond  the  point  at  which  it  has  given  way.  Ar- 
terial haemorrhages  are  mostly  multiple,  but  of 


J86  EYE,  AND  ITS  APPE! 

small  individual  extent ; and,  when  not  in  the 
immediate  neighbourhood  of  the  optic  disc,  are 
most  commonly  seen  near  the  outer  limits  of  the 
ophthalmoscopic  field  of  view.  Tiey  are  gene- 
rally attended  by  sufficient  impairment  of  vision 
to  occasion  complaint,  and  thus  to  lead  to  their 
detection ; but  they  seldom  occasion  blindness. 
They  call  for  an  examination  of  the  urine  for 
albumen,  and,  failing  any  evidence  of  renal  mis- 
chiof  they  are  chiefly  important  as  indications 
of  a weakened  and  brittle  state  of  the  arterioles, 
likely  to  lead  to  intracranial  hmmorrhago. 

Treatment. — Arterial  hsemorrhages  into  the 
. retina  point  to  the  necessity  of  diminishing,  as 
much  as  may  be  possible,  the  strain  upon  the 
arterial  coats,  by  such  means  as  the  avoidance 
of  muscular  exertion  or  mental  emotion,  and  by 
seeking  to  diminish  the  quantity  of  the  circulating 
blood  by  a diminution  in  the  quantity  of  fluid 
ingested.  Even  when  all  precautions  have  been 
taken,  arterial  retinal  haemorrhages  are  common 
forerunners  of  apoplexy. 

G.  Embolism  of  the  Central  Artery  of  the  Retina. 
Embolism  of  the  central  artery  of  the  retina,  or 
of  one  of  its  branches,  is  a condition  of  not  in- 
frequent occurrence. 

Symptoms. — When  sudden  blindness  of  one  eye 
occurs  in  a person  who  is  the  subject  of  valvular 
disoaso  of  the  heart,  the  diagnosis  can  scarcely  be 
doubtful;  but  the  ophth dmoscopic  appearances 
will  suffice  to  remove  doubt  it  it  should  exist. 
The  immediate  effect  of  the  sudden  arrest  of  the 
arterial  circulation  of  the  retina  is  to  render  that 
membrane  opaque  and  of  a milky  whiteness,  ex- 
cept over  the  macula  lutea,  where  the  absence  of 
connective  tissue  prevents  any  such  change  from 
being  produced.  Here,  and  here  only,  the  original 
transparency  is  retained,  and  the  colour  of  the 
choroid  is  seen  through  ; with  the  result  that  the 
macula  appears  as  a cherry-red  spot  in  the  midst 
of  a white  surface.  When  not  concealed  by  the 
opacity,  the  larger  veins  of  the  retina  are 
diminished  in  calibre  and  contents,  and  their 
blood  is  sometimes  broken  up  into  detached  por- 
tions separated  by  interspaces.  The  arteries 
are  ernptyv  and  are  either  invisible  or  traceable 
as  white  lines  of  fibrous  tissue  in  the  general 
milkiness  of  the  fundus.  The  disc  is  usually 
bleached,  but  it  will  sometimes  happen  that  its 
condition  may  bo  temporarily  obscu  red  by  arterial 
haemorrhage,  occurring  from  some  twig  given  off 
just  below  the  seat  of  the  embolus,  and  entering 
the  eye  independently. 

The  driving  home  of  the  embolus  will  throw 
upon  such  a twig  the  whole  force  of  the  circula 
tory  vis  a tcryo.  and  may  thus  rupture  it — an  oc- 
currence of  which  i he  writer  has  seen  several  ex- 
amples. The  blood  so  effused  is  usually  absorbed 
in  a very’  few  days,  revealing  the  white  disc  and 
the  collapsed  arteries,  and  removing  any  uncer 
tairity  which  might  have  existed  with  regard 
to  the  diagnosis.  The  opalescence  of  the  retina 
also  disappears  before  long,  and  then  only 
the  secondary  nervo-atrophy  and  the  disappear- 
ance of  the  arteries  remain  to  disclose  the  nature 
of  the  original  affection.  Embolism  seems  to  be 
a perfectly  hopeless  condition,  because  there  is 
no  anastomosis  between  the  retinal  and  other 
Vessels  of  a sufficient  extent  to  maintain  a col- 
lateral circulation.  The  writer  has  met  with  one 


DAGES,  DISEASES  OF. 
instance  in  which  only  a sector  of  the  field  was 
affected,  and  wi  h one  in  which  embolism  of  a very 
small  branch  produced  Ess  of  sight  over  all  the 
peripheral  parts  of  toe  field,  leaving  central  vision 
almost  intact;  but  such  cases  are  among  the 
curiosities  of  ophthalmology,  and  complete  and 
permanent  loss  of  sighi  of  the  affected  eye  is  the 
result  which  must  always  be  anticipated. 

7.  Retinitis,  Ib  tin'tis  is  commonly  described 
as  occurring  in  three  chief  forms,  the  albumin- 
uric, the  S’/yhilitic,  and  the  pigmentary ; bat  tho 
writer  is  inclined  to  believe  that  only  the  last 
of  these  three  is  a genuine  retinitis,  and  that  in 
tho  others  the  inflammation,  if  it  should  exist,  is 
merely  a secondary  consequence  of  the  irritation 
produced  by  the  presence  of  adventitious  deposits. 

a.  Albuminuric  Retinitis.  In  the  so  called 
albuminuric  retinitis,  the  sequence  of  events 
appears  to  lend  some  support  to  the  contention  of 
Sir  Wdliam  Gull  and  Dr.  Sutton,  to  the  effect 
that  the  renal  disease  is  not  an  original  affection, 
but  only  a result  of  morbid  or  degenerative 
changes  which  are  common  to  the  whole  of  the 
small  arteries  of  the  body. 

Symptoms. — In  many  cases  of  albuminuria, 
the  sight  is  not  affected  from  first  to  last, 
and  the  retinae  remain  healthy.  In  some,  the 
retinal  changes  precede  the  appearance  of  al- 
bumon  in  the  urine;  and,  in  the  majority,  the 
renal  and  retinal  changes  are  coincident.  The 
retinal  changes  are  of  two  kinds  ; namely,  arte- 
rial haemorrhages,  occurring  in  the  tibre-laver, 
so  that  the  blood-patches  assume  a (b  rillated 
aspect  with  brush-like  terminations;  and  the 
formation  of  white  patches,  either  of  cholesterine 
deposit  or  of  fatty  degeneration,  or  of  both  com- 
bined, scattered  irregularly  over  the  fundus,  but 
often  grouped  into  a stellate  figure  around  the 
macula  lutea,  and  into  an  irregular  ring  aronnd 
the  disc.  To  these  appearances  are  added,  in 
some  cases,  those  of  swelling  of  the  disc-margins 
with  effusion  into  the  retinal  fibre-layer;  and, 
when  the  last-named  appearances  are  presented, 
there  is  always  a far  greater  deteri  'ration  of 
sight  than  when  they  are  absent.  It  is  a matter 
of  daily  occurrence  that  the  existence  of  renal 
disease  is  not  suspected  until  impairment  of 
sight  loads  to  an  ophthalmoscopic  examin  Hon, 
and  this  to  the  discovery  of  the  retinal  changes ; 
and,  in  every  hospital,  cases  which apfly  for  re- 
lief to  the  ophthalmic  department  are  ei.iiStantly, 
on  this  ground,  transferred  to  the  physician. 

Treatment.  — The  treatment  of  the  renal 
maladies  which  produce  albuminuria  is  in  no 
way  modified  on  accountof  the  presem-eef  a reti- 
nal complication ; and  the  unfavourable  prognosis 
which  must  generally  be  given  as  regards  life 
throws  into  comparative  insignificance  the  gra- 
dual failure  of  vision,  which  seldom  proceods  to 
complete  blindness. 

t>.  Syphilit  c retinitis.  This  is  usually  an  inci- 
dent of  the  most  advanced  stages  of  tne  disease, 
and  is  most  frequently  seen  in  persons  who  have 
been  inadequately  treated  during  the  primary 
stage,  but  who  have  for  some  months  or  even  for 
a year  or  two  been  true  from  symptoms. 

Symptoms.  — Dimness  of  sight  is  then  com- 
plained of,  ana  the  retina  is  found  to  present 
scattered  patches  of  very  irregular  outline,  and 
of  a filmy  whitish  aspect.  Such  patches  may 


EYE.  AND  ITS  APPENDAGES.  DISEASES  OF. 


be  more  or  less  obscured  by  slight  general  tur- 
bidity of  the  retina  itself,  or  of  the  vitreous  body 
in  its  immediate  vicinity,  the  latter  condition 
being  of  itself  almost  conclusive  of  the  nature  of 
the  malady. 

Treatment. — The  treatment  must  be  greatly 
governed  by  the  past  history  of  the  case,  but 
may  in  most  instances  turn  upon  the  use  of  iodide 
of  potassium  for  the  relief  of  the  retinal  troubles, 
followed  by  a sufficient  course  of  mercury  for  the 
eradication  of  the  syphilitic  taint. 

c.  P gmentary  Retinitis.  This  appears  to  be 
a true  inflammation  of  the  retina,  differing  from 
the  foregoing  affections  in  that  it  attacks  the 
percipient  elements,  instead  of  the  fibre-layer  or 
the  connective  tissue  of  the  membrane. 

./Etiology. — The  subjects  of  pigmentary  reti- 
nitis are  of  all  ages,  from  nine  or  ten  years  to 
seventy;  and,  in  some  instances,  the  duration  of 
the  disease  has  been  as  much  as  twenty  years, 
from  the  first  appearance  of  the  symptoms  to 
their  ultimate  termination  in  blindness.  As  a 
rule,  however,  the  patients  are  young  adults, 
or  persons  not  past  middle  age. 

It  is  a remarkable  feature  of  pigmentary  re- 
tinitis that  it  almost  invariaoly  attacks  more 
than  one  member  of  a family;  and  it  has  been 
said  to  be  especially  frequent  in  the  offspring  of 
marriages  of  consanguinity,  but  this  statement  is 
not  borne  out  by  English  experience.  During 
the  last  twenty  years  the  writer  has  only  met 
with  one  family  in  whom  the  malady  had  this 
history. 

Anatomical  Characters.— From  the  extreme 
chronicity  of  its  course,  from  its  obstinacy,  and 
from  its  peculiar  anatomical  distribution,  pig- 
mentary retinitis  should  probably  bo  regarded, 
together  with  some  forms  of  choroiditis,  as 
having  its  analogies  among  some  of  the  chronic 
okin- diseases  rather  than  with  any  other  re- 
tinal affection.  It  commences  in  a n irrow 
annulus  near  the  equator  of  the  eyeball,  and 
gradually  spreads  inwards  towards  the  optic 
disc;  the  tissues  affected  are  the  perceptive 
and  pigmentary  layers  of  the  retina  and  the 
subjacent  ch'irio-capillaris,  which  slowly  become 
disorganised  and  matted  together  in  one  com- 
mon and  undisticguishable  ruin.  Coincidently 
with  the.  progress  of  the  disease,  pigment  is 
deposited  in  the  parts  affected,  and  in  the  retina 
superficial  to  them,  in  the  form  of  irregular 
lines  and  striations,  and  especially  along  the 
course  of  the  main  arterial  branches.  As  the 
annulus  of  disease  gradually  doses  in  upon  the 
macula,  the  optic  disc  undergoes  atrophy  of  a 
kind  which  gives  it  a peculiar  > int  of  whiteness, 
Very  readily  recognisable  when  it  has  once  been 
noticed,  and  the  central  vessels,  both  veins  and 
arteries,  dwindle  in  size. 

Symptoms. — The  subjective  symptoms  are  as 
characteristic  as  the  ophthalmoscopic  appear- 
ances. Over  the  region  actually  invaded,  the 
perceptive  elements  of  the  retina  are  destroyed, 
and  the  power  to  receive  visual  impressions  is 
lost.  The  fibre-layer  not  being  implicated,  the 
conduction  of  impressions  from  parts  of  the  re- 
tina more  peripheral  than  the  disease  may  remain 
unaffected  ; and  hence  wo  may  havo  a b ind  zone 
surrounding  the  centre  of  the  field  of  vision,  and 
miiTounded  itself  by  a zone  still  more  external, 


487 

in  whicb  dim  vision  is  preserved.  But.  the  salient 
symptoms  are  two  : the  gradual  contraction  of 
the  field  of  vision  due  to  the  progressive  en- 
croachments of  the  disease;  and  night-blindness, 
due  to  the  nerve-atrophy,  which  interferes  with 
the  conduction  or  perception  of  any  but  strong  im- 
pressions. When  these  symptoms  co-exist,  when 
the  field  of  vision  is  small  and  becoming  gradu- 
ally smaller,  and  when  the  patient,  who  can  still 
see  fairly  in  the  daytime,  can  scarcely  find  his 
way  about  as  dusk  begins  to  fall,  we  may  predict 
the  ophthalmoscopic  appearances  with  a very 
near  approach  to  certainty.  The  optic  disc  will 
be  unnaturally  pale,  and  the  fundus  overstrewn, 
towards  the  periphery,  with  irregular  black 
lines  and  stripes,  of  which  it  is  quite  possible 
that  none  may  be  visible  within  that  portion  of 
the  field  of  the  ophthalmoscope  which  includes 
the  disc. 

Diagnosis. — Pigmentary  retinitis  may  pos- 
sibly be  mistaken  for  the  most  chronic  form  of 
glaucoma,  on  account  of  the  contraction  of  the 
field  of  vision  ; but  it  may  be  distinguished  by 
the  absence  of  high  tension,  by  the  nig'  t-blind- 
ness,  and  by  the  pigmentation  of  the  retina.  It 
may  also  be  mistaken  for  the  at  rophy  of  sclerosis, 
but  only  if  the  ophthalmoscopic  examination  is 
limited  to  the  nerve-disc,  to  the  exclusion  of  the 
surrounding  parts  of  the  fundus. 

Treatment. — In  the  treatment  of  a disease  so 
essentially  chronic,  it  is  difficult  to  arrive  at  any 
trustworthy  evidence  concerning  the  efficacy  of 
a remedy,  but  the  prolonged  administration  of 
iron,  rather  as  a food  than  as  a medicine,  is  at 
least  of  a certain  degree  of  util  ty  in  arresting 
the  progress  of  the  malady.  The  preparation 
employed  is  probably  not  material,  and  some 
may  be  found  to  suit  particular  persons  better 
that  others  ; but  the  writer  is  accustomed  to  be- 
gin with  the  tincture  of  the  perchloride,  in  dosea 
of  five  miniins,  well  diluted  and  given  three  times 
a day  as  part  of  a meal. 

8.  Detachment  of  the  Retina.  Synon.  ; — Sub- 
retinal  dropsy.  This  is  a con  lition  the  causes  of 
which  have  never  been  satisfactorily  explained. 

The  first  symptom  which  attracts  the  attention 
of  the  patient  is  the  loss  of  part,  usually  either 
the  upper  or  the  lower  part,  of  the  field  of  vision  ; 
and  it  is  manifest  that  loss  of  the  upper  part  of 
the  field  means  detachment  of  the  lower  part  of 
the  retina,  and  vice  versa.  Detachment  is  some- 
times produced  by  a blow  or  injury,  but  more 
frequently  it  occurs  without  any  assignable  cause, 
either  local  or  constitutional.  One  or  both  eye3 
may  be  affected. 

The  diagnosis  of  the  disease  is  rendered  easy 
by  the  ophthalmoscope,  which  exhibits  the  de- 
tached portion  as  a sort  of  floating  prominence, 
projecting  into  the  interior  of  the  eyeball,  gene- 
rally bluish-white  in  colour,  and  crossed  by  the 
retinal  blood-vessels. 

The  prognosis  is  very  unfavourable  in  the 
majority  of  instances,  and  treatment  is  seldom 
effectual. 

Treatment.  — Cases  have  been  recorded  in 
which  disappearance  of  the  sul>-retinal  fluid,  and 
restoration  of  vision,  have  followed  prolongod 
confinement  in  the  supine  posture  ; and  the  occur- 
rence of  improvement  after  spontaneous  rupture 
of  the  detached  portion  suggested  to  Von  Graefe 


188  EYE.  AND  ITS  APPENDAGES.  DISEASES  OF. 


the  advisability  of  producing  such  a rupture  by 
artificial  means.  Various  operations  have  been 
undertaken  for  this  purpose,  and  also  for  the 
evacuation  of  Gie  sub-retinal  fluid  through  a 
puncture  in  the  outer  tunics  of  the  eye,  and  arb 
said  by  those  who  have  performed  them  to  have 
been  in  a few  instances  partially  successful ; but 
l he  evidence  in  their  favour  is  at  present  very 
fee’le,  and  hardly  establishes  more  than  that 
attempts  of  such  a nature  may  be  made,  if  it  is 
certain  that  the  sight  will  be  irretrievably  lost  in 
the  absence  of  interference.  The  tendency  of  de- 
tachment, especially  in  the  npper  portion  of  the 
retina,  is  to  increase  until  the  whole  membrane 
is  elevated  from  the  choroid,  aud  vision  is  en- 
tirely destroyed.  It  must  be  borne  in  mind  that 
detachment,  may  be  simulated,  or  may  even  be 
caused,  by  the  growth  of  intra-ocular  tumours, 
sarcomatous  or  gliomatous,  which  may  demand 
the  early  removal  of  the  eyeball.  Such  cases 
would  be  distinguished  from  simple  detachment 
by  the  increased  hardness  of  the  eyeball,  which 
the  morbid  growth  would  necessarily  occasion, 
and  which  would  be  the  more  significant  in- 
asmuch as  detachment  alone  is  usually  accom- 
panied by  diminished  tension. 

9.  Glioma.  This  name  has  been  given  by 
Virchow  to  a malignant  growth  which  has  its 
origin  in  the  neuroglia,  or  connective  tissue  of 
the  nervous  system,  and  which  was  formerly 
described  as  encephaloid  cancer.  When  origina- 
ting in  the  retina,  it  early  produces  loss  of 
sight,  and  presently  shows  through  the  pupil  as 
a substance  of  a primrose-yellow  colour,  by 
which  the  still  transparent  lens  is  pressed  for- 
ward towards  the  cornea.  It  is  chiefly  a disease 
of  childhood,  and  has  been  seen  by  the  writer 
as  early  as  the  fifth  week  of  infant  life.  It  is 
liablo,  by  superficial  observers,  to  be  mistaken 
for  congenital  or  infantile  cataract,  an  error 
which  must  be  carefully  guarded  against,  be- 
cause the  early  and  entire  removal  of  the  eye, 
together  with  as  much  of  the  optic  nerve  as  can 
be  reached,  furnishes  the  only  hope  of  preserving 
the  life  of  the  patient.  When  the  operation  ;s 
performed  sufficiently  early,  it  has  in  a few  in- 
stances been  completely  successful,  cases  having 
been  recorded  in  which  no  recurrence  of  cancer 
has  happened  after  the  lapse  of  years.  In  the 
great  majority,  however,  recurrence  and  death 
have  terminated  the  history. 

10.  Sarcoma.  This  differs  from  glioma  in 
having  its  origin  in  the  choroid,  and  in  being 
of  a darker  colour,  and  sometimes  pigmented 
or  melanotic.  It  is  at  least  equally  malignant, 
produces  similar  symptoms,  and  requires  the 
same  treatment. 

VIII.  Diseases  of  the  Choroid. — Diseases 
of  the  choroid,  recognisable  by  the  ophthalmo- 
scope, are  almost  limited  to  certain  chronic  forms 
of  inflammation  and  of  atrophy ; for,  in  any 
acute  choroiditis,  there  is  always  too  much  tur- 
bidity of  the  vitreous  body  to  allow  the  state  of 
the  membrane  to  be  seen. 

1.  Chronic  Choroiditis. — The  chronic  forms  of 
choroiditis  are  remarkable  for  leading  to  an  un- 
due formation,  or  to  a great  displacement,  of 
the  choroidal  piixment ; and  to  the  ultimate  com- 
plete wasting  and  disappearance  of  the  portions 
of  the  choroid  which  are  affected,  so  that  over 


these  portions  there  will  ultimately  be  no  cho- 
roid visible,  and  the  ordinary  re  1 colour  of  the 
fundus  will  be  replaced  by  the  ivory  whiteness 
of  the  inner  surface  of  the  sclerotic. 

Chronic  choroiditis  may  bo  divided  into  two 
chief  varieties,  the  disseminated  and  the  diffused. 
The  disseminated  occurs  chiefly  in  children,  and 
chiefly,  perhaps  exclusively,  in  those  who  are  the 
subjects  of  inherited  syphilis.  It  is  seldom  seen 
until  its  period  of  activity  is  past.  A child  is 
brought  on  account  of  defective  vision,  which  has 
probably  existed  from  birth  or  from  a time  but 
little  subsequent  to  it;  and  the  ophthalmoscope 
disp'ays  a number  of  small  while  spots,  with 
black  borders,  scattered  irregularly  over  the 
fundusof  theeye.  The  white  spots  are  patches  of 
choroidal  atrophy,  and  the  black  borders  are  rings 
of  increased  pigment-formation,  by  which  the 
spots  of  inflammation,  which  must  have  been  com- 
parable to  little  pimples,  have  been  surrounded. 

Treatment. — Such  cases  admit  of  no  treat- 
ment, except  in  the  rare  instances  in  which  some 
active  mischief  may  be  detected,  in  the  shape  of 
small  patches  or  spots  in  which  effusion  has  not 
yet  passed  into  atrophy,  and  in  which  such  an 
antisyphilitic  treatment  should  be  employed  as 
the  state  of  the  patient  may  otherwise  permit  or 
indicate. 

Diffused  choroiditis  is  more  frequently  an  affec- 
tion of  adult  age  ; and,  although  very  trequently 
syphilitic,  is  not  invariably  so.  It  differs  from 
the  foregoing  chiefly  in  the  absence  of  any  defined 
shape  or  precise  limitation  of  rho  parts  affected. 
In  the  early  stages  the  choroid  is  seen  to  be 
troubled  by  congestion  or  effusion,  and  these 
conditions  pass  gradually  into  abnormal  pigmen- 
tation and  atrophy.  The  course  of  the  disease 
may  be  very  chronic  and  irregular,  aud  different 
stages  of  it  may  be  seon  at  the  same  time  in 
different  parts  of  the  same  eye. 

The  prognosis  m ay  in  general  be  moderately 
favourable ; for,  although  the  choroiditis  destroys 
the  portion  of  retina  immediately  in  front  of  it, 
its  extension  is  very  capricious,  and  it  may  often 
be  arrested  in  time  to  leave  large  portions  of  the 
eye,  and  espec:ally  the  central  portions,  unhurt. 
When  it  occurs  in  the  vicinity  of  the  macula 
lutoa,  so  as  to  imperil  central  vision,  it  is  much 
more  formidable  than  when  confined  to  the  more 
peripheral  parts  of  the  choroidal  membrane. 

Treatment. — Whenever  there  is  a history  of 
syphilis,  this  must  be  taken  as  the  clue  to  treat- 
ment ; and,  if  no  syphilis  can  be  discovered,  the 
chief  reliance  must  be  placed  upon  rest  of  the 
eyes,  occasional  depletion  from  the  temples  by 
Heurteloup's  leech,  counter-irritation  by  blisters 
or  setons,  and  such  internal  medication  as  the 
general  state  of  the  patient  may  suggest. 

IX.  Diseases  of  the  Vitreous  Body. — 
Diseases  of  the  vitreous  body  are  as  yet  very 
imperfectly  understood,  and  we  know  little  more 
concerning  them  than  that  this  substance  is 
liable  to  become  turbid  in  certain  forms  of  acuto 
general  inflammation  of  the  eye;  and  that  it  is 
sometimes  rendered  turbid,  without  inflammation, 
by  the  presence  of  floating  films  which  may  be 
readily  seen  by  the  ophthalmoscope,  and  which 
may  be  so  numerous  as  to  forma  serious  impedi- 
ment to  vision. 

1.  Turbidity.  Turbidity  of  the  vitreous  is  very 


EYE,  AND  ITS  APPENDAGES,  DISEASES  OP. 


common  in  syphilitic  cases ; but  the  films  referred 
io  are  seen  when  no  syphilis  can  be  suspected. 
Their  number,  and  their  free  movements,  show 
that  the  vitreous  must  in  great  measure  have 
lost  its  natural  semi-solid  consistence,  and  have 
become  fluid ; but  little  or  nothing  is  known  of 
their  actual  pathology. 

Treatment. — The  most  effectual  treatment  for 
flocculi  in  the  vitreous  is  usually  diaphoresis  by 
the  subcutaneous  injection  of  from  two  to  four 
minims  of  a 10  per  cent,  solution  of  hydro- 
chlorate of  pilocarpine,  which  may  be  repeated 
on  alternate  days.  Local  counter-irritation  with 
iodine  may  also  be  practised;  and  iodide  of 
potassium  may  be  given  internally  in  such  doses 
as  circumstances  will  allow. 

2.  Mnscte  VoLitantes.  A phenomenon  referred 
to  the  vitreous  body  is  the  appearance  of  the 
moving  particles,  or  strings  of  beaded  filaments, 
which  are  commonly  called  musoee  volitantes. 
True  muse*  are  known  by  the  negative  cha- 
racter that  the  particles  which  produce  them 
cannot  be  seen  by  the  ophthalmoscope;  and 
by  the  positive  character  that  they  never  so 
intervene  between  the  eye  and  an  object,  how- 
ever small,  as  to  exclude  the  latter  from  view. 
They  are  seen  most  readily  against  a white 
field,  as  a white  wall,  or  a white  cloud,  or  in 
the  illuminated  field  of  a microscope  when 
there  is  no  object  in  view  ; and  they  float  about 
with  uncertain  movements,  but  always  a little 
out  of  the  direct  line  of  sight.  They  are  occasioned 
by  the  filamentous  framework  of  the  vitreous 
body,  and  by  the  cell-nuclei  or  other  irregu- 
larities upon  the  filampnts.  These  bodies,  wirhout 
being  opaque,  yet  differ  in  the  precise  degree  of 
their  transparency  from  the  fluid  which  surrounds 
them ; and  hence  they  cast  upon  the  retina 
shadows,  which  are  then  mentally  projected 
outwards  into  space  as  floating  objects.  The 
projected  shadows  appear,  of  course,  enormously 
larger  than  the  micrascopic  specks  which  pro- 
duce them, and  the  latter  are  wholly  unimportant 
and  of  no  morbid  signification.  Muse*  may  be 
discovered  by  any  person  by  the  simple  expedient 
of  looking  through  a very  fine  perforation  in  a 
metal  disc  at  a bright  surface  ; and  they  are 
more  conspicuous  to  some  persons  than  to  others, 
on  account  of  the  varying  differences  which  may 
exist  in  different  eyes  or  in  the  same  eyes  at 
different  times  or  under  different  conditions, 
between  the  index  of  refraction  of  the  filaments 
and  nuclei  and  that  of  the  surrounding  fluid. 
Moreover,  by  the  operation  of  an  obvious  physi- 
cal law,  the  more  distant  the  particle  from  the 
retina,  the  larger  will  be  its  shadow  upon  that 
membrane,  and  the  larger  and  more  conspicuous 
will  i'  appuar.  For  this  reason,  and  on  account 
of  the  elonga'ion  of  the  myopic  eyeball,  muse* 
are  usually  more  complained  of  by  the  short- 
sighted than  by  others.  They  are  often  sources 
of  great  uneasiness  to  patiems;  but,  when  om-e 
their  true  churn  e'er  is  known,  they  may  bo  entirely 
disrcgaided  as  harmless  appearances,  the  natural 
results  of  physiological  structure.  It  is  often 
important  that  the  phy-ician  should  bo  able 
to  make  their  nature  understood,  in  order  that 
ne  may  dissipate,  once  for  all.  the  unfounded 
apprehensions  which  may  be  occasioned  by  their 
presence. 


X.  Diseases  of  the  Eyelids.— The  external 
surfaces  of  the  eyelids,  as  parts  of  the  common 
integument,  are  liable  to  all  its  diseases,  and 
may  thus  participate  in  ervsipelatous  inflamma- 
tion. in  eruptions,  and  in  the  results  of  injury, 
besides  becoming  the  seats  of  naevi,  molts, 
warts,  and  other  growths.  Among  the  diseases 
special  to  the  formation  of  the  eyelids,  the  most 
important  are  the  variations  of  shape  to  which 
they  are  subject,  generally  from  the  contraction 
of  inflammatory  exudations,  but  someiimes  from 
perverted  muscular  action;  the  cystic  tumours 
which  are  produced  by  obstruction  of  the  orifices 
of  meibomian  glands  ; the  inflammation  of  the 
follicles  of  the  eyelashes,  or  blephariris  ; spas 
modic  closure,  from  abnormal  muscular  contrac- 
tion ; and  either  patency  or  passive  closure,  from 
paralysis.  Many  of  these  affections  are  distinctly 
surgical,  and  others  are  only  parts  or  symptoms 
of  more  general  disorders. 

1.  Blepharitis.  Blepharitis,  or  inflammation 
of  the  follicles  of  the  eyelashes  has  received 
a great  variety  of  names  from  different  writers, 
and  is  frequently  known  as  tinea  tarsi,  or,  in  its 
more  advanced  stage,  as  lippitndo.  The  disease 
consists  essentially  of  an  inflammation  of  the 
lining  membrane  of  a hair-follicle  from  which  an 
eyelash  springs. 

Symptoms. — The  first  manifest  symptoms  are 
a small  swelling  close  to  the  edge  of  the  eyelid, 
generally  of  the  upper  lid  ; and  the  formation  of 
a crust  around  the  bases  of  the  cilia  whi  h pro- 
ceed from  the  swollen  part.  The  swelling  does 
nor.  exrend  farther  up  the  lid  than  to  the  breadth 
of  about  a line,  but  it  soon  spreads  along  the 
border  until  the  whole  length  is  involved,  and  it 
usually  spreads  also  to  the  lower  lid,  manifestly 
in  consequence  of  the  contagious  character  of  the 
discharge.  If  the  crust  is  removed,  and  if  the 
part  from  wh  ch  it  springs  is  magnified  and 
carefully  examined,  it  will  be  seen  that  the 
mouths  of  the  follicles  are  sompwtat  open,  no 
longer  fitting  closely  to  the  issuing  hairs;  and, 
in  a few  moments,  a clear  fluid  will  I e seen  to 
exude,  and  speedily  to  dry  into  a crust  or  film, 
which  covers  the  opening  as  if  with  a varnish. 
Many  of  the  hairs  in  the  affected  follicles  are 
loosened,  and  fall  readily,  or  may  be  removed 
painlessly  by  slight  traction.  If  the  case  is  neg- 
lected. the  follicles  are  before  long  destroyed  as 
hair-hearing  organs,  so  that  the  lost  cilia  are 
no  longer  reproduced  ; and.  at  the  same  time,  the 
exudation  which  constitutes  the  subcutaneous 
swelling  of  the  lid-margin  begins  to  undergo 
contraction,  and  in  this  way  gradually  everts 
the  cartilage  of  the  lid.  The  edges  of  the  lids 
become  red,  swollen,  and  unsightly;  the  lach- 
rymal puncta  are  displaced  outwards  in  such  a 
manner  that  they  can  no  longer  take  up  the 
tears  ; the  eyes  have  lost  the  protection  of  the 
lashes,  and  are  exposed  to  numerous  sources  of 
irritation  from  atmospheric  particles  and  other 
causes,  so  as  to  be  esp-eially  prone  to  con- 
junctival and  corneal  inflammations;  and  these 
results  are  almost  incurable.  It  is  therefore 
very  important  that  blepharitis  shoul  I be  effec- 
tually treated  in  its  early  stages,  when,  if  only 
due  care  be  taken  in  the  selection  and  use  of 
remedies,  it  is  an  exceedingly  trivial  affection. 

Treatment. — The  must  essential  part  of  the 


490  EYE,  AND  ITS  AI  PENDAGES.  DISEASES  OF 


treatment  is  to  remember  that  the  secret  ion  which 
forms  the  crust  is  of  such  a nature  that  it  is  not 
very  easy  of  removal,  and  t hat  while  it  remains  in 
situ , no  remedies,  however  judiciously  chosen,  can 
obtain  access  to  the  parts  really  affected  by  the 
disease.  The  crust  is  composed  partly  of  the 
already  mentioned  secretion  fr  m the  inflamed 
surfaces,  partly  of  the  greasy  secretion  of  the  mei- 
bomian glands, and  it  istheadmixture of  thelatter 
which  renders  the  crusts  difficult  of  removal  by 
water  alone.  A solution  of  bicarbonate  of  soda., 
of  the  strength  of  five  grains  to  the  ounce  of  warm 
water,  will  remove  them  readily  ; and  this  solu- 
tion should  be  applied  in  such  a manner  as  to  soak 
into  the  crusts  and  loosen  them  thoroughly  be- 
fore any  attempt  is  made  to  detach  them.  As 
soon  as  they  are  detached,  the  surface  beneath 
should  be  gently  dried  with  a morsel  of  absorb  nt 
rag,  and  then  an  astringent  should  be  applied 
immediately,  so  that  it  may  find  its  way  down 
into  the  depths  of  the  hair  follicles,  and  may  thus 
reach  the  seat  of  the  malady.  The  best  astrin- 
gent is  generally  the  ointment  of  the  precipitated 
yellow  oxide  of  mercury,  or  Pagenstecher's 
ointment,  already  recommended  for  the  cure  of 
ulcers  of  the  cornea;  and  ibis  may  he  applied 
to  the  affected  part  by  the  tip  of  a finger.  If 
amendment  does  not  speedily  follow,  it  may  be 
suspected  that  the  crusts  have  been  imperfectly 
removed,  or  the  applications  imperfectly  made, 
and  it  will  be  well  for  the  practitioner  person 
ally  to  superintend  the  process.  When  this  has 
been  done,  if  the  affection  continues  obstinate, 
some  other  astringent  should  be  tried,  and  the 
nitrate  of  silver  is  among  the  best  for  this  pur- 
pose. Amendment  of  the  lid-margin  may  gener- 
ally be  quickly  produced  ; but  the  disease  will 
for  a long  time  lurk  in  the  depths  of  the  follicles, 
and  the  trea'met  t must  be  continued  until  all 
subcutaneous  swelling  has  disappeared  from  the 
lid-margins.  Unless  this  be  done,  speedy  re- 
lapse is  inevitable,  the  inflammation  soon  creeping 
out  of  the  follicles  again  and  recovering  the 
ground  of  which  it  had  been  deprived.  Such  a 
result  is  constantly  seen  in  hospital  practice,  in 
spite  of  all  elforts  to  guard  against  it,  and,  in 
undertaking  the  care  of  blepharitis,  it  is  always 
desirable  to  warn  parents  of  the  perseverance 
which  will  lie  required,  and  of  the  great  impor 
tance  of  obtaining  a radical  cure.  There  can  be 
no  doubtthat  blepharitis  is  exceedingly  contagious 
through  the  medium  of  its  secretion,  conveyed 
upon  sponges,  towels  or  fingers,  and  thisshould  be 
fully  recognised  whenever  it  attacks  children  who 
are  attending  a school.  The  name  ‘ tinea  tarsi  ’ 
may  perhaps  be  takej)  as  the  expression  of  a belief 
that  the  disease  is  allied  to  tinea  tonsurans,  and 
that  it  is  produced  by  the  growth  of  a parasitic 
fungus.  The  writer  does  not  at  present  see  any 
sufficient  ground  for  the  adoption  of  this  opinion. 

2.  Entropium  and  ictropium.  Incurvation  and 
excurvation  of  the  eyelids  maybelook-d  upon  as 
purely  surgical  maladies.  The  former  exposes 
the  eyes  to  injury  from  the  irritation  of  inturned 
eyelashes  ( trichiasis );  the  latter  from  foreign 
bodies  of  various  kinds. 

Treatment.— The  remedy  for  both,  when 
any  is  practicable,  must  usually  bo  sought  in  a 
surgical  operation.  An  exception  depends  upon 
the  fact  that  ectropium  is  sometimes  produced 


by  paralysis  of  the  facial  nerve,  which  renders 
the  orbicularis  muscle  flaccid  and  powerless,  and 
permits  the  lower  lid  to  fall  downwards  under 
the  influence  of  gravity.  The  cure  of  the  gene- 
ral nerve-affecti  in  may  restore  the  power  of 
the  muscle,  and  may  in  time  lead  to  complete 
recovery  of  the  natural  position  of  the  lid.  In 
such  cases,  even  if  .electricity  does  not  form 
part  of  the  general  treatment  of  the  paralysis, 
it  may  generally  be  applied  with  benefit  to  tha 
orbicularis. 

3.  Blcpharospasmus.  This  term  is  generally 
employed  to  denote  an  intcrmiitont  closure  of 
the  eyelids  by  an  involuntary  action  of  the  or- 
bicularis in  response  to  some  concealed  source 
of  irritation  ; and  is  thus  broadly  distinguished 
from  the  spasm  which  accompanies  photophobia. 

Symptoms. — The  spasm  is  most  liable  to  occur 
in  circumstances  of  mental  excitement.  Thus, 
in  one  of  the  writer’s  patients,  who  was  a skilful 
cook,  the  eyes  were  apt  to  close,  and  to  remain 
closed  for  some  minutes,  at  the  critical  period 
of  an  important  dish.  Another  patient  was 
a schoolmistress,  and  tile  spasm  would  inter- 
rupt the  progress  of  a lesson  to  a class,  being 
doubtless  to  some  extent  excited  by  the  dread 
of  its  occurrence.  In  a third  case,  the  patient 
being  a gentleman  habituated  to  riding  and 
driving,  the  spasm  would  be  excited  by  physical 
irritants,  such  as  wind  or  dust,  and,  almost  cer- 
tainly, by  circumstances  which  required  the  eyes 
to  be  wide  oppn  as  a condition  of  safe  guidance. 
The  motor  nerves  appear,  as  a rule,  to  be  merely 
the  passive  conductors  of  a reflected  impulse, 
and  the  trouble  seems  usually  tu  be  dependent 
upon  a morbid  condition  of  the  fifth,  or  upon  a 
source  of  irritation  in  some  peripheral  [part  from 
which  a twig  of  the  fifth  passes  to  the  centre. 

Treatment. — In  the  treatment  of  such  cases, 
it  is  sometimes  possible  to  find  the  twig  which 
conveys  the  impression  ; that  is  to  say.  to  dis- 
cover a point  where  pressure,  sufficiently  firm 
to  arrest  conduction,  will  at  once  relax  the 
spasm.  Such  points  should  be  looked  lor  at  the 
supra-orbital  notch,  over  the  malar  bone,  and  in 
any  other  situation  suggested  by  special  circum- 
stances; and,  if  a p int  at  which  pressure  will 
arrest  the  spasm  is  discovered,  we  learn  at  once  by 
what  branch  of  the  fifth,  and  therefore  approxi- 
mately from  what  region,  the  irritation  is  con- 
veyed, and  where  its  source  is  to  be  sought  for. 
If  nothing  can  be  discovered  by  careful  examina- 
tion, decayed  teeth,  accumulations  of  cerumen 
in  the  ears,  and  conjunctival  granulations  are 
possible  conditions  which  should  he  looked  for. 
and  which  should  receive  attention  if  they  aro 
found.  When  all  other  treatment  has  failed, 
the  spasm  has  sometimes  !>een  stopped  by  sub- 
cutaneous section  of  a sensory  nerve ; and  this 
may  always  be  practised  hopefully  if  the  spasm 
can  he  arrested  hv  pressure  on  some  definite  spot, 
which  must  then  serve  for  the  guidance  of  the 
knife.  If  no  such  spot  can  be  found,  section  of 
the  supra-orbital  nerve,  and  next  of  the  sub- 
cutaneous malar,  may  be  attempted ; since 
neither  of  these  are  sufficiently  important  for 
their  temporary  disablement  to  be  set  against 
even  the  possibility  of  relief  from  a very  dis- 
tressing attention.  In  some  cases,  however,  it 
would  appear  that  the  mischief  must  be  cettial 


EYE,  AND  ITS  APPENDAGES,  DISEASES  OF. 


and  that  no  section  of  an  afferent  nerve  can  be 
useful.  The  division  of  the  motor  nerves  of  the 
orbicular  muscles,  if  it  could  be  successfully 
accomplished,  would  produce  a paralysis  even 
more  injurious  than  the  spasm;  and  the  cases 
in  which  the  latter  is  due  to  central  irritation 
or  other  trouble,  unless  they  can  be  relieved  by 
medicine,  and  by  the  rectification  of  whatever 
may  be  manifestly  wrong  in  the  condition  of 
the  patient,  offer  very  small  hope  of  improve- 
ment. iec  Facial  Spasm. 

4.  Ptosis. — Ptosis  is  a condition  of  permanent 
passive  closure  of  an  upper  eyelid  as  a consequence 
of  paralysis  of  its  levator  muscle,  or  it  may  hap- 
pen in  consequence  of  this  muscle  having  been 
torn  from  its  attachment  to  the  tarsal  cartilage, 
so  that  it  can  no  longer  modify  the  position  of 
the  lid. 

Symptoms. — Paralytic  ptosis  may  be  either 
pariial  or  complete,  according  to  the  degree  of 
the  nerve-affection  ; and  as  the  levator  palpehr® 
is  supplied  by  the  third  nerve,  which  supplies 
also  the  superior,  the  internal,  and  the  inferior 
rectus,  as  well  as  the  inferior  oblique,  the 
sphincter  papillae,  and  the  ciliary  muscle,  ptosis 
is  usually  accompanied  by  paralysis  of  one  or 
more  of  these  muscles.  When  they  are  all 
affected,  the  eyeball  is  turned  outwards  by  the 
action  of  the  external  rectus,  and  is  immovable 
in  other  directions  excepting  feebly  by  the  su- 
perior oblique.  The  pupil  is  dilated,  and  tho 
power  of  adjusting  the  eye  for  near  vision  is  im- 
paired or  lost,  although  when  the  lid  is  raised, 
near  objects  can  still  he  distinctly  seen  by  the 
aid  of  a convex  lens.  When  all  the  muscles 
supplied  by  the  third  nerve  are  affected,  the  I 
inference  is  that  the  cause  of  paralysis  is  acting 
upon  the  common  trunk  of  the  nerve  ; and  such 
a cause  is  not  unfrequently  the  presence  of 
periosteal  swelling  at  the  sphenoidal  fissure.  If 
only  some  of  the  muscles  are  affected,  the  in- 
ference is  that  the  cause  of  the  paralysis  is 
either  limited  to  the  central  nuclei  of  origin  of 
certain  filaments,  or  else  that  it  is  situated  an- 
teriorly to  the  division  of  the  main  trunk  into 
the  branches  which  proceed  to  different  parts ; 


491 

and  it  is  conceivable  that  the  limitations  of  tht 
paralysis  may  point,  with  tolerable  certainty,  to 
the  precise  locality  of  the  disorder. 

The  causesof  ptosis,  as  of  other  paralytic  affec- 
tions of  single  cranial  nerves,  apart  from  injuries 
and  the  pressure  of  morbid  growths,  may  almost 
be  reduced  to  syphilis  and  to  impaired  nutrition  of 
the  centres,  the  latter  usually  connected  with  hard 
mental  work  and  worry.  In  every  case,  evidence 
of  syphilis  should  be  carefully  sought  for;  and, 
if  found,  should  determine  the  nature  of  the  treat- 
ment, as  it  will  also  of  the  prognosis,  which,  in 
such  instances,  may  he  generally  favourable.  In 
cases  of  the  second  class,  where  there  is  no  evi- 
dence of  syphilis,  and  where  the  symptoms  point 
to  general  impairment  of  nervous  eneigy,  tho 
administration  of  iodide  of  potassium,  in  com- 
bination with  tonics,  will  sometimes  be  useful, 
but  the  main  reliance  must  be  placed  upon  rest, 
good  living,  and  external  surroundings  favour- 
able to  the  restoration  of  health. 

5.  Diplopia. — Double  vision,  although  it  has 
no  proper  relation  to  the  subjects  treated  of  in 
the  present  section,  is  yet  so  far  allied  to  ptosis 
that,  when  occurring  suddenly,  it  is  almost 
always  an  effect  of  paralysis  or  of  paresis  either 
of  the  sixth  nerve  of  one  eye,  supplying  its 
external  rectus,  or  of  the  branch  of  the  third 
which  supplies  its  internal  rectus.  In  the 
former  case  the  affected  eye  will  deviate  inwards, 
and  will  have  limited  range  of  movement 
towards  the  outer  canthus  ; while  in  the  latter 
case  these  conditions  will  be  reversed. 

As  regards  tho  causes  and  treatment  of  these 
limited  forms  of  paralysis,  there  is  nothing  to  add 
I to  what  has  already  been  stated  about  ptosis.  It 
is  sometimes  desirable,  while  the  diplopia  con- 
tinues, to  exclude  the  deviating  eye  from  vision 
by  a shade,  an  opaque  spectacle  glass,  or  other 
suitable  contrivance,  on  account  of  the  vertigo  and 
uncertainty  of  gait  which  may  bo  occasioned  by 
the  double  images. 

See  also  Exophthalmic  Goitre.  ; Lachrymal 
Apparatus, Diseases  of;  Lagophthalmos;  Orbit, 

I Diseases  of ; Strabismus  ; Stye  ; and  Vision.  Dis- 
orders of  R.  Brudexell  Carter. 


F 


FACIAL  PARALYSIS.— Synon.:  Paraly-  | 
sis  of  the  Portio  dura ; Bell’s  Paralysis. 

Definition. — Paralysis  of  the  muscles  of  the 
face,  due  to  disease  or  injury  of  the  nucleus  or 
fibres  of  the  portio  dura  of  the  seventh  pair  of 
nerves. 

Above  the  nucleus,  in  the  middle  of  the  pons, 
the  motor  tract  decussates  and  mingles  with  that 
from  the  arm  and  leg;  damage,  therefore,  in  the 
upper  part  >f  the  pons,  crus,  corpus  striatum,  or 
hemispheres  produces  facial  paralysis  as  a part 
of  hemiplegia.  This  paralysis,  on  the  same  side 
as  in  the  limbs,  is  partial  only,  affecting  chiefly 
the  muscles  of  unilateral  use  (as  the  2ygomatici 
and  muscles  about  the  angle  of  the  mouth) ; and 


very  little  those  of  bilateral  use,  in  the  upper 
part  of  the  face  (orbiculares  palpebrarum,  and 
frontales).  In  this  article  paralysis  from  damago 
lo  the  fibres  or  nucleus  of  the  nerve  will  alone 
be  considered. 

./Etiology. — (1)  The  most  common  cause  of 
facial  paralysis  is  damage  to  the  nerve  as  it 
passes  through  the  narrow  canal  in  the  temporal 
bone.  There  the  slightest  effusion  will  cause 
pressure  on  tho  nerve.  Such  effusion  may  he  due 
to  exposure  to  cold — ‘rheumatic;’  contiguous 
bone-disease — caries;  syphilis;  or  haemorrhage ; 
but  often  occurs  without  discoverable  cause. 
Cold  has  been  supposed  to  act  most  commonly 
by  paralysing  the  peripheral  nerve-twigs,  bul 


FACIAL  PARALYSIS. 


192 

this  is  rarely,  if  ever,  the  case ; since  in  all 
cases  lasting  more  than  a few  days,  evidence 
of  changed  nutrition  may  be  detected  in  the 
nerve-trunk  as  it  emerges  from  the  stylomastoid 
foramen.  (?)  Injury  to  t lie  nerve  outside  the 
skull  by  blows,  or  incised  wounds,  or  parotid 
and  other  tumours,  is  an  occasional  catse.  (3) 
Within  the  skull  the  nerve  may  be  damaged  by 
meningitis,  acute  or  chronic,  and  especially  by 
syphilitic  inflammation,  or  by  pressure  of  neigh- 
bouring growths  This' radicular  fibres  within  the 
pons,  or  the  nucleus  beneath  the  fourth  ventricle, 
may  be  damaged  by  haemorrhage,  softening,  or 
growth  affecting  that  part. 

Doubl e 'facial  par  ay  sis  is  very  rare,  and  is  due 
to  damage  to  the  nerves  at  the  base  cf  the  brain 
from  meningitis,  or  symmetrical  syphilitic  dis- 
ease ; or  to  an  affection  of  the  nuclei  by  disease 
of  the  pons,  or  by  loss  of  function  of  the  n-rve- 
cells  composing  the  nuclei.  Syphilis  and  diph- 
theria are  the  most  common  antecedents. 

Symptoms. — The  onset  of  facial  paralysis  is 
usually  gradual,  occupying  from  a few  hours  to 
three  or  four  days  in  its  development.  It  is 
found,  for  instance,  one  morning  that  in  drink- 
ing the  fluids  run  out  of  ihe  side  of  the  mouth ; 
the  face  is  noticed  to  be  a litile  unsymmetrical ; 
at  night  the  eye  cannot  be  completely  closed ; 
and  next  morning  the  paralysis  is  fonncl  to  be 
complete. 

In  complete  unilateral  facial  paralysis  all  the 
muscles  on  one  side  of  the  face  are  paralysed.  At 
rest,  the  smooth  forehead  and  lowered  angle  of 
the  mouth  are  the  chief  indications,  but  on  move- 
ment the  difference  between  the  two  sides  bee  mies 
very  marked;  the  one  half  of  the  forehead  moves 
alone  in  frowning  or  elevation  of  the  eyebrow. 
The  eyelids  cannot  be  bi-ought  together,  and  in 
the  attempt  to  close  the  eye  the  eyeball  is  rolled 
upwards  so  that  only  the  sclerotic  appears  be- 
tween the  gaping  lids;  the  patient  commonly 
imagining  that  the  eye  is  shut.  During  sleep 
the  eye  remains  open.  In  smiling,  the  lips 
may  he  displaced  altogether  to  the  healthy  side, 
from  the  unopposed  ac  ion  of  the  zygomatic 
muscles,  the  nostril  of  the  affected  side  cannot 
be  dilated,  the  upper  lip  cannot  be  raised,  the 
cheek  flaps  loosely  from  the  relaxation  of  the 
buccinator,  and  from  the  same  cause  food  accu- 
mulates between  the  jaws  and  the  cheek. 
Whistling  is  impossible,  from  the  paralysis  of 
half  of  the  orbicularis,  and  the  lips  cannot  be 
approximated  sufficiently  ev<  n to  permit  of  a 
caudle  being  blown  out.  When  the  lesion  is 
between  the  origin  of  the  large  petrosal  and  the 
chorda  tympani  nerves,  taste  is  pari  ly  or  entirely 
lost  in  the  front  of  l he  tongue.  The  loss  of  power 
of  recognising  acid  and  saline  substances  is 
most  marked,  but  bitters  and  sweets  are  also  not 
tasted  in  this  part.  In  rare  instances  loss  of 
taste  has  followed  division  of  the  nerve  outside 
the  skull.  When  the  disease  is  above  thj origin 
of  the  great  superficial  petrosal,  the  uvula  is 
said  to  be  oblique,  from  paralysis  of  its  muscle, 
and  the  pala'e  to  be  motionless  on  that  side.  Of 
this  there  is  much  doubt.  Obliquity  of  the 
uvula  is  common  under  normal  conditions.  The 
writer  has  never  seen  paralysis  of  the  palate  or 
uvula  in  these  cases 

In  some  cases  giddiness  marks  the  onset  of 


facial  paralysis.  In  less  severe  cases  there  mav 
not  be  complete  loss  of  power,  but  the  loss  is  at 
first  pretty  equally  distributed  over  all  parts  of 
the  face. 

In  cases  which  recover,  some  return  of  power 
takes  place  in  from  a week  to  two  months,  uDd 
improvement  is  u-ually  earliest  in  the  upper 
part  of  the  face;  the  power  of  frowning,  wink- 
ing, and  closing  the  eye  being  soonest  regained, 
that  of  moving  the  lip  and  mouth  returning  last. 
Kven  after  several  months  of  immobility,  re- 
covery may  take  place,  but  in  these  cases  it  is 
rarely  complete,  and  a troublesome  condition  is 
apt  to  supervene:  some  of  the  muscles,  espe- 
cially the  zygomatici,  become  shortened  in  late 
rigidity,  and  hence  at  rest  the  naso-labial 
wrinkie  is  deeper  on  the  paralysed  than  on  the 
healthy  side,  although  the  possible  movement 
may  be  much  slighter.  This  condition  some 
times  comes  on  rather  suddenly.  If,  in  addition, 
a troublesome  associated  over-action  of  muscle 
manifests  itself,  whereby  the  orbicularis  pal- 
pebrarum and  the  zygomatic  and  other  muscles 
about  the  mouth  act  togeiher,  in  smilii  g the 
eye  shuts,  and  on  closing  the  eye  the  mouth  is 
drawn  upwards. 

The  electrical  condition  of  the  muscles  is 
very  important.  It  is  that  always  seen  in  para- 
lysis from  nerve-lesion.  The  muscles,  after  a day 
or  two  of  slightly  increased  irritability  to  both 
'aradisation  and  the  slowly  interrupted  battery 
current,  lose  gradually  their  irritability  to  the 
former,  retaining  that  to  the  latter,  and  even  ex- 
hi-  iting  to  it  increased  irritability,  so  that  they 
act  to  a smaller  number  of  cells  than  on  the 
healthy  side.  In  the  nerve,  on  'he  other  hand, 
the  irritability  is  lost  to  both  forms  of  electricity, 
this  loss  p receding  pari  passu  wi t h the  degene- 
ration which  follows  separation  of  the  Dcrvo 
from  its  nutrient  centre.  In  slighter  and  more 
transient  forms  of  facial  paralysis  the  change  in 
irritability  of  muscle  and  nerve  may  be  slight, 
but  even  in  most,  which  last  but  a few  days,  a 
slight  change  in  irritability  may  be  discovered. 

Diagnosis. — The  diagnosis  of  facial  paralysis 
is  easy.  It  is  important  to  observe  all  the 
muscles  of  the  face,  and  to  ascertain  ihe  electri- 
cal reaction,  in  order  to  d termine  whether  it 
is  the  variety  now  described,  or  is  cerebral  and 
part  of  an  unnoticed  hemiplegia.  The  recogni- 
tion of  ilie  place  of  tile  lesion  is  less  easy. 
When  within  the  pons,  ii  is  often  associated  with 
paralysis  of  the  sixth  nerve,  or  with  hemiplegia 
of  the  opposite  side  from  damage  to  the  fibres 
from  the  limbs.  At  the  base  of  the  brain  the 
auditory  nerve  is  u-ually  affected  at  the  same 
time.  AVhere  there  are  no  other  paralyses,  the 
disease  is  probably  within  the  bony  canal. 
Deviation  of  the  uvula  is  a guide  of  most 
doubtful  value.  Special  inquiry  should  be  made 
for  ear-disease,  for  syphilis,  or  for  a blow. 

Prognosis. — The  majority  of  cases  of  facial 
paralysis  are  due  to  rheumatic  affection  of  the 
nerve,  and  recover,  but  the  duration  of  some  of 
these  is  con-iderable.  In  recent  syphilitic  cases 
the  prognosis  is  good.  In  caries  of  the  temporal 
hone  and  in  intracranial  disease,  unless  syphi- 
litic and  recent,  the  prognosis  is  less  far  urable. 
Whatever  be  the  cause,  the  electrical  reaction  of 
the  nerve  and  muscles  affords  valuable  infmna- 


FACIAL  PARALYSIS. 

l ion,  since  in  proportion  to  the  slightness  of  the 
change  in  relation  to  the  length  of  time  the 
symptoms  have  lasted,  will  the  degree  and  dura- 
tion of  the  affection  be  less. 

In  double  facial  paralysis  the  probability  of 
central  mischief  will  render  the  prognosis  less 
favourable,  but  recovery  may  be  hoped  for  if 
there  are  no  symptoms  of  disease  damaging 
structures  contiguous  in  position,  and  not  merely- 
related  in  function,  and  if  the  disease  bo  of  short 
duration. 

Treatment. — The  treatment  jf  facial  paraly- 
sis will  depend  on  the  probable  cause.  When 
due  to  the  effects  of  cold,  hot  fomentations  to  the 
side  of  the  head  and  face  may  be  employed  in 
the  early  stage  of  the  affection,  and  afterwards 
counter-irritation  by  blisters  behind  the  ear. 
At  first,  diuretics  and  small  doses  of  iodide  of 
potassium,  and  subsequently  tonics,  aro  useful. 
Electricity  to  the  muscle  and  the  nerve  is  of 
great  service ; faradisation  should  be  used  if 
the  muscles  will  respond  to  it;  if  nut.  the  voltaic 
current,  slowly  interrupted  by  a commutator, 
or  by  the  negative  pole  being  moved  over  the 
individual  muscles,  and  only  such  strength  being 
employed  as  shall  produce  distinct  muscular 
contraction.  If  the  faradic  irritability  be  lost 
at  first  it  will  return  as  the  muscles  recover, 
and  faradisation  should  then  be  employed.  If 
electricity  does  no  more,  it  keeps  up  the  nutri- 
tion of  the  muscular  fibres  and  aids  the  recovery 
of  function  in  the  nerve.  Ultimate  recovery  is 
thus  more  speedy  and  more  complete  than  with- 
out local  treatment.  Rubbing  may  be  employed, 
the  individual  muscles  being  subjected  to  a pro- 
cess of  gentle  shampooing.  The  treatment  of 
the  late  contraction  which  occurs  in  severe  cases 
is  often  difficult.  Faradisation  of  the  opposite 
side  of  the  face  lias  been  suggested,  but  can 
scarcely  be  of  service.  The  zygomatic  muscles 
may  be  elongared  a little  by  frequent  gentle 
traction,  and  the  other  contracted  muscles  should 
be  gently  rubbed,  so  as  to  lengthen  them.  In- 
unctions of  oleate  of  morphia  may  be  tried.  The 
muscles  that  are  contracted  should  not  be  fara- 
dised.  The  condition  usually  lessens  after  a time, 
but  often  remains  fur  many  months,  or  even 
years. 

Where  facial  paralysis  is  due  to  syphilis,  it 
usually  readily  yields  to  antisvphi li  tie  treatment, 
if  recent;  but  even  here  electricity  is  use  ul, 
since  degeneration  of  nerve  and  muscle  rapidly 
occurs.  In  intracranial  disease  the  Treatment  of 
the  ficial  paralysis  is  usually  subordinate  to 
that  of  its  cause.  When  there  is  indication  if 
sudden  and  increasing  mischief  at  the  nucleus  of 
the  nerve,  galvanism  must  be  employed  with 
caution. 

The  treatment  of  double  facial  paralysis  pre- 
sents no  special  points  for  consideration. 

W.  R.  Gowers. 

FACIAL  SPASM.  — Synon.  : Mimic  cramp. 
Fr.  Tic  convu/sif.  When  affecting  the  eyelids, 
Blepharospasm  ; Nictitation. 

Definition-.  — Spasm,  sometimes  tonic  but  more 
often  clonic,  involving  some  of  or  all  the  muscles 
Supplied  by  the  facial  nerve. 

jEnoi.o  ;y  and  Symptoms. — Spasm  in  the  face 
may  be  part  of  a wider  convulsive  movement,  as 


FAUCES,  EXAMINATION  OF.  49a 
in  epilepsy,  hysteria,  chorea,  or  torticollis,  dis- 
e'-isss  dependent  on  central  change.  Secondly,  it 
may  be  due  to  irritation  of  the  trunk  of  the  facial 
nerve  by  growths,  pressure,  or  caries  of  the  tem- 
poral bone.  Spasm  of  this  form  may  follow  facial 
paralysis.  Thirdly,  it  is  very  commonly  reflex, 
produced  by  the  application  of  cold,  by  intestinal 
worms,  or  especially  by  some  disease  or  injury  oi 
the  fifth  nerve.  Affections  of  the  eye  frequently 
lead  to  spasmodic  closure  of  the  lids  — blepharo- 
spasm. Lastly,  in  other  eases  no  cause  can  be 
ass:gned  for  it,  especially  in  the  local  clonic 
spasm  affecting  the  eyelids — one  or  both — and 
known  as  involuntary  winking  or  nirtiiation.  The 
latter  form  is  seen  especially  in  neurotic  persons  ; 
in  nervous  children  it  is  not  uncommon,  and  in 
hysterical  girls.  It  is  markedly  increased  by 
emotion  and  attention.  All  forms  cease  during 
sleep. 

Prognosis.—  The  prognosis  of  facial  spasm 
is  good,  if  the  cause  can  be  discovered.  Where 
there  is  no  discoverable  source  of  reflex  irritation 
the  affecrion  is  often  most  obstinate. 

Treatment. — General  tonics  and  local  seda- 
tives are  the  most  important  elements  in  the 
treatment  of  most  forms  of  facial  spasm.  When 
irritation  affects  the  fifth  or  the  facial  nerve, 
counter-irritation  by  blisters  is  useful.  A care- 
ful search  must  be  made  for  reflex  or  other 
causes,  and  if  possible  they  must  be  removed, 
decayed  teeth  extracted,  and  neuralgia  relieved. 
When  there  are  tender  places  in  the  course  of 
the  fifth  nerve,  pressure  on  which  stops  the 
spasm,  mil'll  improvement  can  usually  be  ob- 
tained. Morphia,  belladonna,  and  aconite  are 
the  best  local  sedatives ; the  former  may  be  used 
its  a hypodermic  injection  or  by  inunction.  Ar- 
senic may  be  injected  in  some  cases  with  ad- 
vantage. Iron  and  quinine  arc  useiul,  especially 
the  latter.  Bromides  and  phosphorus  are  of  little 
value.  Where  the  affection  runs  into  an  habitual 
movement,  facial  gymnastics  may  be  of  service. 
A weak  voltaic  current,  applied  from  the  ear  to 
the  muscles,  unbroken,  may  do  some  good;  but 
it  rarely,  if  ever,  affects  a euro.  The  same  is 
true  of  the  application  of  vultaism  to  the  sym- 
pathetic. See  Eye,  and  its  Appendaoes,  Dis- 
eases of.  W.  R.  Gowers. 

FACIES  HIPPOCRATIC  A (Latin).— A 

peculiar  expression  of  the  face,  so  named  from 
having  been  graphically  described  by  Hippo- 
crates. It  is  most  strikingly  observed  in  persons 
exhausted  by  copious  discharges,  as  in  cholera, 
by  prolonged  wasting  diseases,  or  by  starvation  ; 
and  especially  before  impending  death.  It  is  thus 
described  by  Hippocrates: — ‘A  sharp  nose,  hol- 
low eyes,  collapsed  temples:  the  ears  eld,  con- 
tracted, and  their  lobes  turned  out;  the  skin 
about  the  forehead  being  rough,  distended,  and 
parched;  the  colour  of  the  whole  face  being 
green,  black,  livid,  or  lead-coloured.’ 

FAUCES,  Examination  of. — Ati  examination 
of  the  faces  frequently  atibrds  valuable  ev  denco 
of  the  condition  of  the  organs  engaged  in  the 
process  of  digestion,  and  furnishes  important 
data  on  which  to  found  a diagnosis,  and  suggest, 
a rational  treatment.  Not  only  may  structural 
changes  in  the  alimentary  tract  be  discovered, 
but  also  the  completeness  of  action  of  iho  various 


194  FJECES.  EXAMINATION  OF. 


digestive  juices  be  recognised.  As  with  the 
examination  of  the  renal  secretions,  a previous 
knowledge  of  the  healthy  characteristics  is  an 
essential;  that  being  granted,  the  investigation 
may  be  pursued  on  the  same  lines  in  both  cases, 
as  regards  the  general,  microscopic,  and  chemical 
characters.  Since,  however,  these  characters  are 
more  directly  dependent  on  the  ingesta,  and  less 
upon  the  excretions,  their  examination  cannot  be 
so  valuable  an  index  of  tissue-change  as  is  the 
investigat'on  of  the  urine. 

1.  Physical  examination.  — 1.  Quantity. 
This  is  extremely  variable.  Taking  the  normal 
average  for  an  adult  to  be  about  o ounces  daily,  it 
may  vary  from  to  lllj  ounces.  The  quantity 
would  seem  to  bear  no  relation  to  the  size  or 
weight  of  the  indivi  lual,but  is  rather  intiuen :ed 
by  the  quantity  and  kind  of  food,  and  the  acti- 
vity of  the  secretions  of  the  alimentary  canal. 
As  a rule,  the  amount  is  increased  by  a vege- 
table diet.  In  children  it  would  seem  the  total 
daily  amount  is  relatively  slightly  greater, 
whilst  in  old  age  there  is  an  absolute  diminution. 
When  in  disease  the  quantity  is  increased  it  is 
chiefly  of  the  fluid  portion,  whilst  a diminution 
affects  both  the  solid  and  fluid  parts.  Tea  is 
said  to  diminish  the  quantity  of  the  faeces 
(Chambers).  See  Constipation,  and  Diahrucea. 

2.  Co.nsistknce  ANi>  Appearance, — Depar- 
tures from  the  normal  cylindrical  shape  are  fre- 
quent, and  depend  very  much  on  the  existence  of 
constipation  or  diarrhoea.  In  infants  the  evacua- 
tions should  be  unformed  and  of  a pappy  consis- 
tency. The  contents  of  the  bowels  pass  from  a 
semifluid  condition  in  the  ileum  to  the  firmer 
state  in  the  colon,  mainly  from  an  absorption  of 
fluid  constituents  ; should  thero  be  any  delay  in 
the  passage  the  motions  are  liable  to  become 
hard  and  nodular  (scybala),  and  this  may  occa- 
sionally be  extreme,  the  farces  having  all  the 
appearance  of  sheep's  dung,  and  being  passed 
with  considerable  piin.  On  the  other  hand,  an 
increased  frequency  of  action  of  the  bowels  (diar- 
rhoea), is  associated  with  motions  of  all  degrees 
of  fluidity.  Tins  is  very  marked  in  the  various 
forms  of  irritation  to  which  the  intestinal  mucous 
membrane  is  liable,  from  the  simple  effects  of  a 
saline  purg-  to  the  extreme  conditions  of  ulcer 
ation,  as  in  typhoid  fever  or  dysentery. 

The  existence  of  haemorrhoids,  rectal  growths, 
or  an  enlarged  prostate,  may  be  recognised  by 
groovings  and  marks  on  the  excrement.  Among 
drugs,  iron  and  vegetable  astringents  will  render 
the  faeces  hard  and  firm.  Occasionally  the  mo- 
tions are  passed  in  a fermenting  condition,  due 
to  the  presence  of  sarcinse,  and  present  a frothy 
brown,  or  yeast-like,  appearance,  similar  to  cer- 
tain vomits. 

3.  Colour. — This  is  dependent  on  the  bile- 
pigments,  and  is  subject  to  considerable  variation 
even  within  the  limits  cf  health.  The  usual 
brown  colour  becomes  much  darker  if  long  re- 
tained, or  with  an  exclusively  meat  diet,  and 
pale  yellow  with  milk  food,  as  seen  in  infants, 
and  tends  towards  a greenish  tint  when  vege- 
tables form  the  bulk  of  the  food. 

The  most  important  abnormal  causes  affecting 
the  colour  are  the  following: — 

(a)  Bile — Obstruction  to  the  passage  of  bile 
:UwO  the  duodenum,  causing  the  motions  to  be 


clay-coloured,  or  putty-like.  Such  evacuations 
are  often  combined  with  distinctly  bile-coloured 
fluid,  which  is  secreted  by  the  mucous  membrane 
of  the  bowels  from  the  bile-laden  blood,  &c.,  as 
is  the  coincident  high-coloured  urine.  In  extreme 
anaemia  and  the  rickety  cachexia  ihe  stools  are 
usually  pale  from  deficiency  of  bile-pigment. 

()3)  Blood.— This  may  either  appear  as  streaks 
or  patches  of  pure  blood  on  the  surface  of  the 
motion,  as  is  the  case  when  haemorrhoids  or 
ulceration  of  the  rectum  exists.  Or  the  fsecer 
may  be  of  a uniform  brick-red  or  almost  black 
colour  when  there  has  been  a haemorrhage  from 
the  intestinal  surface,  the  blood  becoming  inti- 
mately mixed  with  the  faeces,  and  more  or  less 
affected  by  the  sulpherrtted  hydrogen  of  the 
bowels,  forming  a black  sulphide  of  iron.  If  the 
blood  has  escaped  into  the  stomach  the  action  A 
the  gastric  juice  on  the  blood-pigments  is  such 
as  to  convert  the  faeces  into  a tarry- looking 
material  of  a very  characteristic  appearance. 
See  Helena. 

(y)  Articles  cf  Diet,  Drugs.  <fe. — Among  the 
former  may  be  mentioned  spinach,  coffee,  claret, 
and  porter,  which  confer  on  the  excrement  their 
characteristic  tints.  Among  the  latter,  logwood 
and  charcoal  may  be  detected  by  their  colour  iD 
the  faeces.  Sails  of  iron  and  bismuth,  by  being 
converted  into  the  sulphides,  render  the  motions 
black  or  olive-green. 

The  exact  cause  of  the  green  6tools  so  fre- 
quently seen  in  children  during  dentition  is  un- 
certain ; whether  it  be  due  to  a direct  conversion 
of  blood  that  has  been  slowly  effused  iuto  the 
alimentary  canal,  by  the  digestive  juices  and 
gases,  or  whether  it  be  bile-pigment  altered  by 
these  same  agents.  Inasmuch  as  the  biliary 
colouring  matters  are  more  or  less  directly  ob- 
tained from  the  haematin  of  the  blood,  the 
original  source  of  this  green  colour  (biliverdin) 
is  the  same  in  both  cases.  But  its  occurrence 
cannot  he  certainly  taken  as  an  indication  of 
increased  secretion  of  bile,  for  it  possibly  may 
depend  on  a diminished  absorption. 

4.  Odour. — The  characteristic  odour  of  the 
faeces  is  in  part  due  to  certain  substances  deve- 
loped during  pancreatic  digestion  and  partly  to 
special  secretions  from  the  glands  of  the  colon, 
as  well  as  to  certain  articles  of  diet  such  as 
garlic,  or  of  medicine  such  as  sulphur.  Disturb- 
ance of  either  of  the  above  conditions  will  affect 
the  odour.  Absence  of  Idle  from  the  alimentary 
canal,  by  interfering  with  the  pancreatic  diges- 
tion, and  also  by  the  want  of  its  own  special 
antiputrescent  power,  is  accompanied  with  very 
ill-smelling  motions.  In  this  case  the  faeces  may 
be  almost  putrid,  which  is  not  a normal  con- 
dition. This  state  is  still  more  marked  in  cer- 
tain diseases  cf  the  colon,  as  dysentery,  when 
the  evacuations  are  of  a most  foul  and  acrid 
character.  In  children  the  alvine  dischargesare 
vpry  apt  to  be  offensive  from  errors  in  diet,  or  to 
emit  a peculiar  sour  odour. 

5.  Foreign  bodies. — By  inspection  of  the 
evacuations  we  may  discover  : 

(а)  Substances  accidentally  swallowed,  such  as 
coins,  pins,  &c. 

(б)  Indigestible  food,  such  as  fish-bones,  cherry- 
stones, &c. 

(<-)  Undigested  food. — Portions  of  food  thal 


FAECES.  EXAMINATION  OF.  49* 


have  escaped  digestion.  In  certain  severe  dis- 
turbances of  the  digestive  functions  some  of  the 
food  may  be  passed  scarcely,  if  at  all.  altered 
soon  after  ingestion,  and  may  be  easily  recog- 
nised. This  condition,  known  as  lieDtery,  is  es- 
pecially prone  to  occur  in  the  intestinal  catarrh 
of  young  children  during  dentition. 

(ci)  Fatty  or  soapy  mosses. — These  may  follow 
the  administration  of  oils — castor,  cod-liver,  &e. 
They  are  more  likely  to  occur  when  the  biliary 
and  pancreatic  secretions  aredeficient,  and  appear 
as  nodular  masses,  as  large  as  filberts,  or  as 
cylindrical  pieces,  which  have  been  compared  to 
macaroni.  Curdy  lumps  derived  from  milk 
are  ofren  met  with  in  infantile  diarrhoea. 

(e)  Entozoa,  such  as  segments  of  taenia,  the 
various  round-worms,  or  the  contents  of  hydatid 
cysts  that  may  have  burst  into  the  canal. 

(/)  Gall-stones,  int> stinal  concretions,  mu- 
cous or  membranous  casts  of  the  intestines,  por- 
tions of  bowel  sloughed  off  from  intussusception, 

Je- 
ll. Microscopical  examination. 

Method.  — The  evacuations,  when  of  ordi- 
nary consistency,  require  to  be  shaken  up  with 
two  or  three  times  their  bulk  of  distilled  water 
and  al:owed  to  stand.  This  may  be  repeated 
several  times,  and  the  washings  successively 
submitted  to  microscopic  examination,  as  well  as 
the  final  sediment.  When  the  discharges  are 
very  fluid  this  process  is  not  needed. 

Constituents. — The  usual  microscopic  con- 
stituents of  the  faeces  are— 

(a)  Undigested  and  indigestible  residues  of  the 
food.  Such  are  starch-cells,  woody  fibres,  par- 
ticles of  husks  of  corn  and  other  seeds  ; muscu- 
lar fibres  with  their  characteristic  structure  and 
generally  bi  e-stained ; shreds  of  elastic  tissue 
and  fibres  from  the  blood-vessels;  portions  of 
cartilage;  hairs. 

(5)  Epithelium.  — This  is  derived  from  the 
mucous  membrane  of  the  canal.  The  cells  may  be 
more  or  less  distinct  and  separate,  or  form  by  co- 
hesion amorphous  yellowish  masses  which  consti- 
tute a considerable  portion  of  the  solid  matter. 

(7)  Oil.—  Occasional  oil-globules  are  seen. 

(8)  Crystals  of  triple  phosphates. 

(e)  Amorphous  granular  matter. 

Since  the  nature  of  the  food  varies  so  widely 
it  is  impossible  to  state  anything  in  regard  to 
the  relative  proportions  in  which  these  objects 
occur.  In  certain  states  they  are  found  absent 
or  in  excess.  When  from  any  cause  the  fats  are 
imperfectly  digested  they  may  be  recognised  in 
the  discharges.  Crystals  of  ammonio-magnesian 
phosphates  are  very  abundant  in  typhoid  eva- 
cuations. The  spores  of  fungi,  and  the  ova  of 
intestinal  parasites,  and  the  hooklets  of  hydatids 
may  be  met  with,  and  bacteria  would  seem  to  be 
very  frequent,  possibly  in  connection  with  pan- 
creatic digestion. 

III.  Chemical  examination. — The  imperfect 
knowledge  we  possess  of  the  actual  chemistry  of 
the  tissues  and  secretions,  with  the  exceeding 
variety  in  the  composition  of  the  ingesta,  pre- 
vents our  obtaining,  from  any  analysis  of  the 
fteces,  much  information  of  a practical  character. 
It  is  seldom  if  ever  that  such  examination  fur- 
nishes evidence  of  primary  importance,  as  dees 
the  urine  ; it.  is  only  occasionally  that  the  results 


correspond  to  what  other  signs  and  symptoms 
indicate  to  be  the  case. 

On  an  average  the  faeces  contain  about  23  per 
cent,  of  solid  matter  to  77  per  cent,  water,  but 
this  proportion  is  liable  to  the  widest  varia- 
tions both  in  health  and  disease.  Thus  in 
cholera-stools  the  solid  residue  may  be  but  a 
few  grains  per  pirn. 

1.  Special  Constituents. — Two  bodies — ex- 
cretin and  stercorin — have  been  described  as 
characteristic  of  the  faeces.  Both  are  non-ni- 
trogenous,  crystallizable,  non-saponifiable  bodies, 
the  former  containing  sulphur.  They  differ  in 
their  crystalline  form  and  solubility  in  alco- 
hol and  ether.  They  appear  to  be  closely  re- 
lated to  cholestprin,  with  which  in  many  points 
they  agree.  It  is  found  that  when  the  bile 
which  normally  contains  cholesterin  is  prevented 
reaching  the  intestines,  that  neither  of  these 
bodies  occur  in  the  faeces;  and  that  they  are 
also  absent,  being  replaced  by  cholesterin  in  the 
meconium,  and  in  starving  an  i hybernating  ani- 
mals, when  there  is  no  obstruction  in  the  bile- 
flow.  Flint  considers  about  ten  grains  per  diem 
to  be  the  average  amount  of  stercorin  and  the 
excretin  of  Marcet  to  be  about  a fifth  of  that. 
Cholesterin  itself,  except  in  very  small  quanti- 
ties, cannot  be  regarded  as  a normal  constituent 
of  the  faeces,  but  the  precise  significance  of  its 
occurrence  is  uncertain. 

2.  Fatty  Acids,  Fats  and  Soaps. — Excre- 
tolic  acid,  one  of  the  fatty  series,  is  described  b}’ 
Marcet  as  a constant  ingredient.  Free  stearic 
and  margaric  acids  only  occur  in  minute  pro- 
portions, in  ordinary  circumstances,  but  are 
readily  increased  to  considerable  amounts  when 
the  alkaline  secretions  of  the  liver  and  pancreas 
are  prevented  entering  the  intestines.  A vege- 
table diet  is  also  said  to  increase  them.  Butyric 
acid  does  not  seem  to  be  of  normal  occurrence  in 
human  faeces.  The  presence  of  neutral  fats  in 
the  excrement  may  be  taken  to  indicate  that 
there  has  been  excessive  ingestion  or  a dimi- 
nished digestion,  since  under  ordinary  circum- 
stances they  would  be  absorbed.  The  soda  and 
potash  soaps  ordinarily  formed  by  the  ingested 
fats  with  the  bile  and  pancreatic  juices  should 
be  in  great  part  taken  up  by  the  lacteals ; but 
a portion  meeting  with  any  lime  or  magnesian 
salts  that  may  be  in  the  alimentary  canal,  form 
with  them  insoluble  hard  soaps  which  are  passed 
in  the  fseces.  Marcet  describes  a case  in  which 
a large  quantity  of  bi-stearate  of  soda  was 
voided,  the  bile  and  pancreatic  juices  having 
been  absent  from  the  intestine. 

3.  Salts. — They  form  but  a small  amount, 
and  are  chiefly  the  earthy  and  triple  phosphates, 
with  small  quantities  of  iron  and  silica;  there 
is  a marked  absence  of  chlorides.  When  the 
stools  are  very  alkaline  the  triple  phosphates 
may  be  very  abundant,  and  in  cholera-dis- 
chirges  the  whole  amount  of  salts  is  largely 
increased,  there  being  nearly  an  ounce  in  every 
hundred  fluid  ounces  of  evacuation,  a large  pro- 
portion of  which  consists  of  chlorides. 

4.  Pigment. — The  ordinary  colour  of  the  fieces 
is  due  to  a modification  of  the  bile-pigments, 
but  the  exact  nature  of  the  change  is  unknown. 
The  absence  of  colour  from  the  discharges  when 
there  is  an  arrest  of  bile-flow  has  been  referred 


406  F2ECES,  EXAMINATION  OF. 
to ; but  though  clay-coloured  stools  as  a rule 
do  indicate  such  arrest  it  is  not  invariably  so, 
for  the  writer  has  met  with  a caso  in  which 
normally  coloured  faeces  in  the  small  intestines 
were  absolutely  deprived  of  their  pigment  in 
passing  over  a diseased  portion  of  the  lower  end 
of  the  ileum. 

5.  Mucus,  Ai.nuMEN',  Ac. — There  is  usually 
a small  amount  of  mucus  passed  with  the  faeces, 
and  this  may  be  considerable  in  amount,  re- 
sembling jelly,  when  any  irritation  of  the  rectum 
or  colon  exists,  or  occasionally  more  condensed, 
forming  cylindrical  casts  of  portions  of  the  canal. 

Albumen  as  such  can  scarcely  be  looked  upon 
as  a normal  ingredient  of  the  evacuations,  but 
the  fluid  part  of  cholera-stools,  which  resembles 
blood-serum  in  composition,  contains  a very  ap- 
preciable quantity. 

Ferments  similar  in  action  to  ptyalin  and 
pepsin  are  described  as  existing  in  the  feces, 
but  how  they  may  be  modified  in  disease  is 
quite  unknown. 

Next  to  the  undigested  and  indigestible  resi- 
dues of  food,  the  feces  may  be  regarded  as  an 
excretory  channel  of  certain  materials  from  the 
blood  by  means  of  the  bile.  The  other  digestive 
juices  are  probably  re-absorbed.  As  an  index, 
however,  of  bile-excretion,  the  freces  are  very 
unreliable,  inasmuch  as  no  ingredient  of  the  bile 
is  normally  found  in  them  as  such.  Whether 
pigment,  bile-acids,  or  cholestearin,  they  all 
undergo  a change.  The  occurrence,  therefore, 
of  any  of  these  materials  in  the  alvine  dis- 
charges m iy  be  taken  as  evidence  that  the 
changes  in  the  biliary  constituents  which  should 
take  place  in  the  intestines  are  interfered  wirh. 

6.  Reaction. — As  a rule,  the  reaction  of  the 
feces  is  acid,  showing  that,  there  is  no  putrid 
decomposition.  Occasionally,  however,  it  may 
he  slightly  alkaline.  When  the  strongly  alka- 
line secretions  of  the  liver  and  pancreas  are 
prevented  through  obstruction  or  disease  irom 
entering  the  canal,  the  motions  may  he  strongly 
acid  from  the  existence  of  free  fatty  acids. 

For  the  Diagnostic  Characters  of  the 
Faeces  in  disease,  see  Stools,  Characters  of. 

AV.  H.  Allchin. 

F2ECES,  Involuntary  Discharge  of. — 

Under  normal  circumstances  the  feces  are  re- 
tained within  the  rectum  by  the  closure  of  the 
sphincter  ani.  AVhen  defecation  takes  place 
the  sphincter  is  relaxed,  there  is  increased  peri- 
stalsis of  the  lower  bowel,  and  there  is  pressure 
on  the  intestines,  from  the  contraction  of  the 
expiratory  muscles  with  the  glottis  close  1.  The 
nerve-governance  of  these  three  phases  of  the  act 
is  different  in  each  case.  Tiie  contraction  of 
the  abdominal  muscles  is  mainly  due  to  an  effort, 
of  the  will.  The  activity  of  the  colon  and  rec- 
tum is  reflex,  from  irritation  of  the  intestinal 
gangli  i by  the  accumulated  feces.  Lastly,  the 
relaxation  of  the  sphincter  depends  on  the  inhibi- 
tion of  the  tonic  centre  in  the  lumbar  enlargement 
of  the  spinal  cord  : such  inhibition  being  brought, 
about  either  in  a reflex  manner  from  the  rectum 
or  directly  from  the  cerebral  centres.  It  is  ob- 
vious that  the  relaxation  of  the  sphincter  is  the 
most  important  stage  in  the  act,  for  until  that 
takes  place  no  discharge  can  occur.  Up  to  a cer- 


F.ECES,  IN\TOLUNTARY  DISCHARGE  OF. 
tain  point  the  increased  peristalsis  and  prc-sure 
on  the  bowels  may  be  resisted  by  a voluntarily 
increased  contraction  of  the  sphincter,  but  at  a 
certain  stage  the  inhibiting  influence  is  exerted, 
and  relaxation  results.  Since  this  influence  is 
beyond  the  control  of  the  will,  it  would  follow  that 
the  chief  causes  of  the  involuntary  discharge  of 
the  feces  are  to  be  found  in  those  conditions 
which  interfere  with  the  normal  tonicity  of  the 
sphincter.  At  the  same  time,  any  circumstances 
which  may  increase  the  pressure  of  the  abdomi- 
nal muscles  or  the  activity  of  the  bowels  much 
beyond  what  ordinarily  occurs,  may  lead  to  an 
involuntary  discharge. 

./Etiology. — The  causes  of  involuntary  dis- 
charge of  feces  may  be  thus  tabulated: — 

1.  Violent  contraction  of  the  expiratory  muscles , 
such  as  may  be  induced  by  strychnia-poisoning. 
It  is  of  rare  occurrence  in  tetanus. 

2.  Increased  peristaltic  action  of  the  intestines. 
This  is  chiefly  dependent  on  causes  of  irritation 
situate  in  the  bowels  themselves,  such  as  inflam- 
mation or  ulceration  of  the  walls  ; irritating  con- 
tents ; worms.  Ac.  Extreme  fluidity  of  the  faeces 
is  frequently  sufficient  to  induce  their  partially 
involuntary  discharge,  and  is  noticeable  in  the 
diarrhoea  of  infants  and  children. 

3.  Abnormal  relaxation  of  the  sphincter  ani. 
As  already  said,  the  previous  mentioned  causes 
are  powerless  to  produce  the  discharge  of  the 
feces  until  the  sphincter  yields : and  how  far  the 
sphincter  may  relax  as  a result  of  their  efforts, 
or  independent  of  them,  is  not  easy  to  determine. 
The  nervous  influence  emanating  from  the  lumbar 
centre  which  normally  determines  the  tonic  state 
of  the  sphincter  may  be  inhibited-— 

a.  Rejlcx/y,  as  from  worms,  fissure  of  the  anus, 
or  calculus  vesicte.  It  is  quite  true  that  the 
immediate  result  of  irritating  the  sphincter  is  to 
determine  in  a reflex  manner  an  increase  of  its 
contraction,  as  may  be  experienced  in  introducing 
instruments,  Ac.,  into  the  rectum  ; but  it  would 
also  seem  that  at  a certain  point  the  irritation 
may  lead  to  an  arrest  of  the  tonic  influence,  and 
so  allow  the  sphincter  to  yield,  and  this  is  parti- 
cularly the  case  with  affections  of  the  bladder. 

/3.  From  cerclral  disease.  That  certain  emo- 
tional conditions  may  lead  to  involuntary  d-.  fe- 
cal ion  is  well  known,  and  that  a similar  result 
follows  some  diseases  of  the  cerebral  centres  is 
not  uncommon.  The  paralysis  of  the  sphincter 
that  occurs  under  these  circumstances  i-  brought 
about  by  inhibiting  the  normal  tonic  stimulus 
emanating  from  the  lumbar  centres.  Involun- 
tary evacuations  frequently  occur  in  epileptic  fits ; 
iu  profound  coma'ose  states  induced  by  apoplexy, 
opium  and  other  forms  of  poisoning;  and  in 
death  by  hang  ng  or  suffocation.  Its  occurrence 
can  scarcely  be  regarded  as  indicating  lesion  of 
any  one  part  of  the  cerebral  centres,  but  rather  as 
a result  of  what  at  present  are  termed  general 
brain-states.  It  constitutes  a troublesome  com- 
plication iu  such  chronic  forms  of  brain-disease 
as  general  softening,  paralysis  of  the  insane.  Ac. 

y.  From  spinal  disease.  The  relaxation  of  the 
sphincter  may  of  course  be  produced  by  disease 
or  injur)'  of  the  lumbar  enlargement  of  the  spinal 
curd.  Inasmuch  as  it  is  from  the  cells  of  this 
region  that  the  normal  tonic  influence  is  under- 
stood to  emanate,  a destruction  of  the  nervous 


FAECES,  INVOLUNTARY  DISCHARGE  AND  RETENTION  OF. 


tissue  can  readily  be  understood  to  prevent  the 
origination  of  such  stimulus  to  contraction.  It 
is  noticeable  that  changes  in  the  substance  of  the 
cord  itself,  myelitis,  &e.,  are  more  frequently 
accompanied  by  paralysis  of  the  sphincter  than 
is  spinal  meningitis. 

8.  From  local  disease.  The  control  over  the 
sphincter  may  be  lost  from  injury  to  the  muscle 
itself,  as  occurs  in  laceration  of  the  perinaeum,  in- 
volving the  lower  end  of  the  bowel. 

Treatment. — Beyond  removal,  when  possible, 
of  the  cause,  no  direct  treatment  of  incontinence 
of  faeces  is  of  avail.  As  a distressing  complication 
of  certain  diseases  of  the  nerve-centres,  which  are 
too  frequently  incurable,  little  remains  to  be  done 
for  it  beyond  adopting  such  measures  as  will 
permit  of  the  escape  of  the  discharge  with  evory 
regard  to  cleanliness.  W.  H.  Allchin. 

E.33CES,  Retention  of. — 2Etiolojy. — In  the 
absence  of  mechanical  obstruction,  such  as  adhe- 
sions, bands  of  false  membrane,  uterine  pressure, 
stricture,  tumours,  morbid  growths,  or  haemor- 
rhoids, the  main  causes  of  fecal  accumulation 
are: — (a)  a sub-paralysis  of  the  intestinal  mus- 
cular fibres  from  defective  innervation,  or  from 
over-distension  of  the  walls  of  some  portion  of 
the  largo  bowel ; ( b ) loss  of  reflex  irritability  of 
the  rectum ; and  (c)  dryness  of  the  mucous  sur- 
face of  the  colon.  Hence  it  is  frequently  met 
with  in  the  debilitated,  the  bedridden,  the  para- 
lysed, the  aged,  and  the  sedentary,  and  women 
are  more  prone  to  it  than  men.  Loss  of  reflex 
sensibility  in  the  rectum  is  frequently  the  sole 
cause.  The  feces  delivered  into  the  rectum  by 
the  contractions  of  the  sigmoid  flexure  and  the 
descending  colon  no  longer  excite  the  act  of  de- 
fecation, and  collecting  there  as  a large  dessicated 
mass,  determine  a gradual  and  painless  retention 
in  the  colon,  and  particularly  in  the  most  disten- 
sible parts — the  sigmoid  flexure  and  the  caecum. 
The  accumulation  once  set  up  tends  also  to  per- 
petuate itself  by  arresting  more  and  more  the 
peristaltic  movements,  and  leading  to  atrophy  of 
the  walls  of  the  bowels. 

Symptoms.  — Faeces  often  accumulate  slowly 
and  without  the  knowledge  of  the  patient ; 
hence  in  cases  in  which  sensibility  has  been 
blunted  by  age,  disease,  or  great  debility,  the 
discovery  of  large  collections  in  the  rectum  or 
colon  may  surprise  even  the  practitioner,  who  is 
generally  led  to  a local  examination  by  disturb- 
ances set  up  by  the  retention.  There  is  usually 
constipation  or  an  insufficient  discharge  of  solids ; 
a regular  and  even  excessive  relief  of  the  bowels 
does  not,  however,  exclude  accumulation,  for 
even  fluid  feces  may  pass  through  the  centre  of 
or  over  old  collections.  The  evacuations  are 
lumpy,  or  consist  of  detached  hard,  dry,  dark 
scybala,  or  of  a single  mass  ; when  the  accumu- 
lated matters  are  dislodged  by  aperients,  they 
often  emit  an  offensive  and  sour  odour.  Faecal 
collections  in  the  rectum  and  sigmoid  flexure  are 
apt  to  excite  tenesmus  and  frequent  voiding  of 
mucus  and  blood,  but  without  the  putrid  flesh- 
like odour  of  dysenteric  evacuations;  and  the 
linger  encounters  a mass  of  hardened  feces  in  the 
rectum. 

An  accumulation  in  the  caecum,  or  any  part 
l'f  the  colon,  may  be  detected  through  the  abdo- 
32 


491 

minal  wall  as  a tumour  more  or  less  movnbk 
and  uneven,  and  doughy  to  the  touch;  and  in 
rare  cases  the  large  bowel  throughout  may  be 
so  greatly  distended  as  to  apparently  fill  the 
abdomen  with  a solid  mass  which,  like  other 
fecal  collections,  yields  to  the  firm  pressure  of 
the  finger.  A tympanitic  state  of  the  abdomen 
may.  however,  so  obscure  the  examination  as  to 
prevent  the  recognition  of  even  moderately  large 
accumulations. 

Flatulence,  colicky  pains,  inflammation,  (typhli- 
tis, colitis),  ulceration  and  perforation — the  caecum 
is  by  far  the  principal  seat  of  this  accident — and 
intestinal  obstruction,  are  not  uncommon  results 
of  retention  of  feces,  concerning  which  the  reader 
is  referred  to  the  articles  on  Constipation  ; 
C-ecum,  Diseases  of ; Colon,  Diseases  of ; Flatu- 
lence ; and  Colic. 

Treatment. — A hard  ball  of  feces  or  of 
agglutinated  scybala  in  the  rectum  resisting  dis- 
lodgment  by  aperients,  or  enemata,  should  be 
broken  up  and  removed,  by  introducing  within 
the  sphincter  two  or  three  fingers,  a scoop,  or  the 
handle  of  a spoon.  This  may  be  facilitated  by 
introducing  the  fingers  within  the  vagina  in  the 
female.  Faecal  concretions  in  this  situation,  even 
though  not  impacted,  may  require  similar  me- 
chanical aid ; and  in  consequence  of  the  hardness 
and  size  of  these  bodies  the  extraction  is  fre- 
quently difficult.  When  purgatives  and  injec- 
tions fail — the  former  perhaps  aggravating  the 
vomiting  induced  by  the  obstruction— a long 
elastic  tube  should  be  passed  through  the  indu- 
rated mass  which  resists  its  progress,  and  warm 
olive  oil,  followed  by  milk  or  gruel,  should  be 
gradually  injected  by  the  stomach-pump  or 
Davidson’s  syringe;  sometimes,  however,  large 
injections  as  ordinarily  administered,  repeated 
twice  or  three  times  a day,  render  this  proceed 
ing  unnecessary.  The  removal  of  collections  of 
hard  feces  in  the  rectum  may  be  facilitated  by 
macerating  them  with  suppositories  of  cacao- 
butter,  or  of  glue  or  isinglass  softened  in  cold 
water,  While  a brisk  aperient,  such  as  a full 
dose  of  calomel,  or  castor  oil  with  croton  oil, 
may  afford  timely  aid,  the  general  medicinal 
treatment  of  the  accumulation  should  consist 
of  a prolonged  course  of  gentle,  yet  efficient 
evacuants  combined  with  tonics.  The  gradual 
collection  of  feces,  the  toneless  state  of  the 
walls  of  the  large  bowel,  the  scanty  secretion 
of  intestinal  mucus,  and  the  loss  of  reflex  sen- 
sibility in  the  rectum,  require  the  persever- 
ing use  of  these  remedies.  A pill  containing 
aloes,  belladonna,  and  nux  vomica — to  which 
extract  of  colchicum  is  often  a useful  addition 
— generally  affords  the  most  satisfactory  results- 
When  aperients  fail  to  dislodge  the  fecal  collee 
tions,  and  the  abdomen  becomes  painfully  dis- 
tended, a combination  of  opium,  belladonna,  and 
aloes,  given  at  regular  intervals — the  dose  of 
aloes,  at  first  small,  being  increased  as  the  pain 
diminishes — may  enable  the  bowel  to  overcome 
the  difficulty;  but  when  there  is  severe  pain, 
and  above  all  obstinate,  and  especially  sterco- 
raceous  vomiting,  opium  and  belladonna  should 
be  given  alone  or  with  nux  vomica  until  the 
subsidence  of  these  symptoms,  when  aloes  may 
be  prescribed  along  with  these  agents  with  the  best 
effect.  Obstruction  from  paralysis  of  a portion  oi' 


m F^CES,  RETENTION  OF. 
the  bowels  in  which  faeces  have  accumulated  may 
be  met  by  strychnia,  ‘ restoring  capacity  of  action,’ 
followed  by  a mild  aperient  which  promotes 
peristalsis,  or  by  the  interrupted  galvanic  current. 
Distressing  tympanites,  which,  thwarting  the 
peristaltic  movements,  intensifies  the  obstruc- 
tion, has  been  overcome  by  puncture  of  the 
caecum  with  a fine  trochar  or  aspirator  after 
failure  of  other  means;  but  this  proceeding  is  not 
unattended  with  danger  of  fatal  peritonitis  from 
fsecal  extravasation,  or  from  perforative  ulcera- 
tion set  up  by  the  punctures,  and  cannot  be 
safely  recommended.  George  Oliver. 

FAINTING, — A popular  synonym  for  syn- 
cope. See  Syncope. 

FAINTNESS. — Faintness  signifies  a feeling 
of  great  weakness  or  exhaustion,  as  if  the  sub- 
ject of  it  were  about  to  become  exhausted,  or  to 
sink  or  faint. 

FALLING  SICKNESS.  — A popular 
synonym  for  epilepsy.  See  Epilepsy. 

FALLOPIAN  TUBES,  Diseases  of. — 

The  oviducts  are  liablo  to  the  following  morbid 
conditions: — 1.  Malformations;  2.  Displace- 
ments; 3.  Contractions;  4.  Dilatations;  5.  In- 
flammation ; 6.  New  Growths ; and,  7.  Tubal 
Pregnancy. 

1 . Malformations. — The  Fallopian  tubes  may 
be  congenitally  wanting,  either  on  one  or  on  both 
sides ; or  they  may  be  impervious ; and,  instead 
of  a single  opening  into  the  abdominal  cavity 
there  may  be  two  or  more. 

2.  Displacements.  — • The  tubes  may  bo 
stretched  or  widely  displaced  from  their  normal 
position  by  growths  or  effusions  in  their  neigh- 
bourhood, such  as  ovarian,  parovarian,  &c. 

3.  Contractions. — These  canals  may  be  im- 
pervious, from  inflammation  of  the  lining  mem- 
brane, or  from  peritonitis,  pressure,  or  torsion. 

4.  Dilatations. — The  Fallopian  tubes  maybe 
distended,  even  to  a great  degree,  by  (a)  mucous 
or  serous  fluid  ( hydro-salpinx ) ; ( b ) pus  ( pyo-sal - 
pinx) ; or  (c)  blood  ( hcemo-salpinx ).  In  hydro- 
salpinx the  tubes,  if  much  distended,  become  sac- 
culated, giving  rise  to  a string  of  cystic  tumours. 
The  fluid  collects  chiefly  at  the  abdominal  end  of 
the  tube,  but  occasionally  it  may  escape,  and  in 
large  quantity,  through  the  uterus.  Should  the 
tube  burst  and  discharged  contents  into  the  peri- 
toneal cavity  serious  results  may  ensue,  especially 
if  the  fluid  be  pus.  When  haemo-sa'lpinx  is  the 
result  of  menstrual  retention  from  atresia  uteri, 
bursting  of  the  tubes  internally  is  apt  to  follow 
operations  for  the  relief  of  the  obstruction. 

5.  Inflammation. — Inflammation  of  the  Fal- 
lopian tubes  ( salpingitis ) is  apt  to  be  caused  by 
gonorrhoeal  infection,  or  it  may  occur  during  the 
puerperal  state.  Stenosis  or  pyo-salpinx  may 
be  the  result. 

6.  New  Growths. — The  Fallopian  tubes  may 
be  the  seat  of  the  following  new  growths — fibroid 
tumours,  mucous  polypi,  cysts,  cancer  and 
tubercle.  Lipomata,  involving  the  integrity  of 
the  tubes,  may  also  arise  in  the  adjacent  tissues. 
Fibroids  resemble  those  of  the  uterus,  and  may 
attain  a considerable  size.  Small  polypi  growing 
into  the  canal  may  partially  obstruct  the  duet. 
The  cvsts  are  usually  the  so-ealled  hydatids  of 


FASCIAE. 

Morgagni,  an  embryological  relic  ; but  other 
small  simple  cysts  may  be  met  with  at  the  orifice 
of  the  tube,  around  the  morsus  diaboli.  Pri- 
mary cancer  of  the  tubes  rarely,  if  ever,  occurs. 
Tubercle,  however,  may  be  primary,  and  may 
occur  before  puberty.  It  usually  begins  at  the 
abdominal  end,  and  may  lead  to  blocking  of  the 
tube. 

7.  Tubal  Pregnancy. — An  important  affec- 
tion of  the  Fallopian  tubes  is  that  arising  from 
the  variety  of  extra-uterine  pregnancy  called 
tubal,  where  the  product  of  conception  grows 
within  the  tube  in  some  part  of  its  course.  This 
abnormity  is  apt  to  be  attended  with  very  serious 
results,  bursting  of  the  tube  frequently  occurring 
about  the  third  month  of  gestation  ; and  serious, 
sometimes  fatal,  internal  haemorrhage  may  hence 
ensue.  Tubal  gestation  usually  occurs  on  one 
side  only,  while  other  affections  of  the  tubes  are 
often  symmetrical,  a point  of  diagnostic  impor- 
tance. See  Pregnancy,  Disorders  of. 

Regurgitation  of  blood,  of  septic  matters, 
and  of  fluids  injected  into  the  uterus,  sometimes 
takes  place  along  the  Fallopian  tubes,  and  this 
accident  is  always  attended  by  grave  conse- 
quences. 

Mechanical  Obstruction  of  the  Fallopian 
tubes  is  not  an  infrequent  cause  of  sterility. 

Treatment. — The  diagnosis  of  affections  of 
the  Fallopian  tubes  being  difficult,  their  treatment 
is  likewise  obscure  ; and  must  be  in  a measure 
guided  by  general  principles  in  each  case.  In 
pyo-salpinx  severe  peritonitis  and  death  may  re- 
sult from  rupture  of  the  sac,  as  may  speedy  dis- 
solution from  internal  haemorrhage  in  tubal  ges- 
tation. In  the  former  case,  and  in  hydro-salpinx, 
puncture  with  the  aspirator  might  be  permissible 
were  a clear  and  unequivocal  diagnosis  made. 
In  the  latter  case  proximal  ligature  of  the  impli- 
cated tube  might  save  life,  but  the  diagnosis  is 
surrounded  by  so  many  difficulties  that  such  an 
operation  can  only  rarely  be  justified. 

Alfred  Wiltshire. 

FALSE  MEMBRANE. — An  inflammatory 
exudation  of  a fibrinous  character,  which  is  de- 
posited in  layers,  chiefly  on  mucous  surfaces, 
and  occasionally  on  abrasions  of  the  skin.  It  is 
well  exemplified  by  the  deposit  in  diphtheria  and 
plastic  bronchitis. 

FAMILY  DISEASES.— Diseases  which 
are  found  to  run  in  families,  or  diseases  to  which 
members  of  tho  same  family  seem  peculiarly 
liable.  See  Disease,  Causes  of. 

FARADISATION,  Uses  of.  See  Elec- 
tricity. 

FARCY. — A synonym  for  glanders.  See 
Glanders. 

FASCIAE  (, fascia , a band). — The  fasciae  are 
subjects  of  medical  and  surgical  interest,  with  re- 
spect both  to  their  anatomical  relations,  to  the 
diseases  to  which  they  are  liable,  and  to  points  of 
diagnosis  in  connection  with  them. 

I.  Anatomical  Relations  of  Fasciae. — The 
situation  and  connections  of  the  fasciae,  according 
as  they  are  fasciae  of  investment  or  fa-vice  of 
attachment,  are  of  the  grtai<-?t  practical  impor 


FASCIAE.  490 


tance  in  the  following  classes  of  diseases: — 1. 
Suppuration ; 2.  Extravasations,  and  Cellular 
Emphysema  ; 3.  Eternise  ; 4.  Dislocations  ; 5. 
Diseases  of  Encapsuled  Organs ; and,  6.  New 
Growths. 

1.  Suppuration.  — The  physical  influences 
exerted  by  fasciae  upon  pus  are  chiefly  two. 
First,  fasciae  may  limit  the  size  of  an  abscess, 
determine  its  tension  and  the  many  results  of  the 
same,  and  thus  affect  both  the  local  phenomena 
and  the  general  symptoms.  Secondly,  when  the 
pus  is  not  confined,  the  fasciae  serve  to  deter- 
mine the  course  that  it  will  take  and  the  situa- 
tion in  which  it  will  discharge.  Every  abscess 
may  be  said  to  be  influenced  in  this  way  by 
tlie  relations  of  fasciae,  but  certain  fasciae  havo 
to  be  specially  noted  as  causing  pus  to  burrow, 
and  hence  they  should  be  enumerated  here : — 

a.  Fascia  of  the  Head  and  Neck. — The  fasciae 
of  the  scalp ; the  temporal  fascia  ; the  cervical 
fascia ; and  the  post-pharyngeal  fascia,  which 
conducts  pus  from  the  cervical  vertebrae  to  the 
parotid  region  and  tonsil,  and  to  the  region  of 
the  carotid  vessels. 

b.  Fascia  of  the  Upper  Extremity. — -The  axil- 
lary fascia  ; and  the  deep  fascia  of  the  upper 
extremity  generally,  including  the  palmar  fascia 
and  the  sheaths  of  the  tendons. 

c.  Fascia  of  the  Thorax. — The  fasciae  of  the  in- 
tercostal spaces  and  of  the  mammary  region ; the 
fascia  reaching  from  the  neck  to  the  upper  part 
of  the  pericardium  and  the  aorta,  and  to  the 
posterior  mediastinum,  respectively;  the  fasciae  of 
the  anterior  mediastinum ; and  the  fasciae  con- 
nected with  the  diaphragm — all  of  which  deter- 
mine the  course  of  intrathoracic  abscesses. 

d.  Fascia  of  the  Abdomen  and  Pelvis. — The 
transversalis  fascia  ; the  fasciae  connected  with 
the  transversalis  muscle,  especially  posteriorly, 
which  influence  the  course  of  lumbar  abscess ; the 
sheaths  of  the  psoas  and  the  iliacus  ; the  pelvic, 
recto-vesical,  obturator  and  anal  fasciae ; the 
fascial  investment  of  the  prostate  ; the  superfi- 
cial and  deep  layers  of  the  superficial  fascia  of 
the  perinaum  ; the  superficial  and  deep  layers 
of  the  triangular  ligament ; and  the  fascial  in- 
vestments of  the  rectum,  bladder,  uterus,  and 
vagina,  which  determine  the  course  of  purulent 
collections  in  the  pelvis. 

e.  Fascia  of  the  Lower  Extremity. — The  fascia 
lata  and  its  processes ; the  tensor  fasciae  femoris ; 
the  popliteal  fascia  ; the  deep  fascia  of  the  leg ; 
and  the  plantar  fascia  and  its  compartments. 

2.  Extra vasations  and  Cellular  Emphysema. 
— When  blood  or  urine  escapes  from  its  natural 
reservoirs,  or  when  air  or  gas  has  found  its  way 
amongst  the  tissues,  the  direction  that  the  ex- 
tra vasated  substance  takes  is  markedly  influenced 
by  the  fasciae  with  which  it  comes  in  contact. 
The  principal  fasciae  of  importance  in  this  re- 
spect are  as  follows  : — 

a.  Fascia  of  the  Head  and  Neck.  — The  fasciae 
of  the  scalp,  and  the  cervical  fascia. 

b.  Fascia  of  the  Thorax. — The  fasciae  of  the 
intercostal  spaces  ; and  the  mediastinal  fasciae, 
through  connections  with  the  cervical. 

c.  Fascia  of  the  Upper  Extremity , — The  deep 
fascia  in  general. 

d.  Fascia  of  the  Abdomen  and  Pelvis. — Scarpa’s 
fascia,  or  deep  layer  of  the  superficial  fascia  ; 


both  layers  of  the  superficial  and  of  the  deep 
perineal  fascia ; and  the  fasciae  of  the  prostate 
and  bladder — all  being  of  the  greatest  import- 
ance in  cases  of  extravasation  of  urine  or  fieces. 

e.  Fascia  of  the  Lower  Extremity. — The  fascia 
lata  in  general ; the  popliteal  fascia  ; the  deep 
fascia  of  the  leg ; and  the  plantar  fascia. 

3.  Hernle. — The  occurrence  of  hernia,  and  the 
direction  that  they  take,  are  in  a great  measure 
determined  by  the  condition  of  the  fasciae  in 
contact  with  the  viscera.  Most  important  in  this 
relation  may  be  mentioned — the  fascia  transver- 
salis, the  iliac  fascia,  the  sheath  of  the  femoral 
vessels,  the  obturator  fascia,  the  cribriform  fascia, 
and  the  fascia  lata. 

4.  Dislocations.  — Certain  fasciae  serve  as 
supports  for  the  heads  of  bones,  and  for  the  vis- 
cera ; and  these  will  have  an  important  influence 
either  in  promoting  or  in  preventing  dislocation, 
displacement,  or  other  injury  of  these  parts,  as 
the  case  may  be.  The  shoulder  is  supported  by 
the  costo-coracoid  fascia,  and  this  relation  con- 
siderably affects  the  signs  of  dislocation  at  that 
joint.  In  fractures  of  the  patella,  the  fasciae  of  the 
knee-joint  promoto  separation  of  the  fragments. 
The  fascia  of  the  neck  helps  to  support  the 
pericardium,  and  must  limit  the  displacements 
of  the  heart.  The  bicipital  fascia  of  the  fore- 
arm protects  the  brachial  artery  beneath  it  in 
venesection,  at  the  bend  of  the  elbow.  On 
the  other  hand,  the  attachment  of  the  cervical 
fascia  to  the  jugular  veins  facilitates  the  entrance 
of  air  into  the  circulation  through  a wound  at 
this  point.  And,  lastly,  the  pelvic  viscera  are 
supported  by  the  transversalis,  pelvic,  iliac, 
and  recto-vesical  fasciae ; whilst  the  cord  and 
testis  have  their  special  fasciae  to  keep  them  in 
position. 

o.  Diseases  of  Encapsuled  Organs. — A con- 
siderable number  of  organs,  many  important 
vessels,  and  a great  variety  of  muscles  are  con- 
tained in  distinct  fascial  capsules,  sheaths,  or 
envelopes,  which  will  affect  the  course  of  the 
diseases  of  these  structures  in  many  ways — de- 
fining their  limits,  or  determining  the  direction 
in  which  they  spread,  and  thus  influencing  both 
their  local  and  general  phenomena.  This  has 
been  already  alluded  to  under  the  first  head ; but 
it  is  necessary  to  enumerate  here  the  principal 
fasciae  that  act  in  this  way,  namely  : — a.  Arterial 
sheaths : — of  the  carotid,  subclavian,  thoracic- 
aortic,  and  femoral.  b.  Muscular  sheaths: — 
of  the  masseter,  buccinator,  psoas,  iliacus,  quad- 
ratus  lumborum,  erector  spinae,  pectineus,  rectus 
abdominis,  levator  ani,  tensor  vaginae  femoris, 
and  the  palmar  and  plantar  muscles,  c.  Visceral 
capsules of  the  thyroid  gland,  parotid  and  sub- 
maxillary glands,  tongue,  prostate,  penis,  vagina, 
bladder,  rectum,  and  mamma. 

6.  New  Growths. — The  direction,  rapidity, 
and  extent  of  spread  of  new  growths  are  con- 
siderably modified  in  certain  situations  by  the 
relations  of  the  fasciae  above  described. 

II.  Pathological  Relations  of  Fascia. — 
The  principal  diseases  of  fascia  are: — 1.  In- 
flammation and  its  results ; 2.  Ossification  ; 3. 
Calcification ; 4.  Rheumatism ; 5.  Gout ; G 
Syphilis;  7.  Contraction;  and  8.  Extension. — 
None  of  these  conditions  can  be  said  to  be  com 
mon,  or  of  serious  importance. 


500  FASCLE. 

1.  Inflammation. — Inflammation  involving  a 
fascia  is  usually  secondary,  having  spread  to  it 
from  the  neighbouring  structures,  and  especially 
from  the  muscle  or  organ  of  -which  the  fascia 
may  form  the  sheath.  Even  under  these  circum- 
stances, a fascia  rather  resists  than  participates 
in  the  inflammatory  process,  as  has  been  de- 
scribed above ; and  when  it  is  involved  it  tends  to 
ulcerate  on  account  of  its  feeble  vitality,  and  to 
!>e  discharged  in  the  form  of  sloughs.  The  heal- 
ing process  is  extremely  slow  in  fasciae,  and  after 
serious  lesion  their  function  is  never  completely 
restored. 

2.  Ossification. — Occasionally  in  aged  per- 
sons portions  of  fasciae  are  found  transformed 
into  bony  tissue. 

3.  Calcification.— Calcification  is  very  rare 
in  fasciae. 

4.  JRhecmatism. — The  condition  known  as 
muscular  rheumatism,  or  according  to  its  situa- 
tion as  lumbago,  torticollis,  &e.,  is  believed  by 
some  authorities  to  involve  the  fibrous  coverings 
or  fasciae  of  the  affected  parts.  In  the  same  way, 
many  of  the  aches  of  some  forms  of  ‘chronic 
rheumatism’  may  possibly  have  their  seat  in 
fasciae ; and  certain  cases  of  neuralgia  are  pro- 
bably to  be  referred  to  rheumatic  inflammation 
of  the  nerve-sheath. 

5.  Gout. — Amongst  the  pains  of  the  gouty 
subject  are  some  which  are  no  doubt  due  to 
affections  of  fasciae,  such  as  pains  in  the  heel  and 
instep,  and  neuralgia  of  the  sciatic,  the  anterior 
crural,  and  the  brachial  nerves. 

6.  Syphilis. — Syphilis  may  attack  the  fasciae 
iu  the  form  of  nodes,  which  in  places  of  low  vas- 
cularity are  apt  to  ulcerate,  as,  for  example,  at 
the  inner  aspect  of  the  knee. 

7.  Contraction. — Contraction  is  the  most 
obvious  of  the  morbid  conditions  of  fasciae,  giving 
rise  as  it  does  to  well-marked  deformities.  The 
fascia  of  the  hand  and  foot  are  most  liable  to 
this  change,  with  the  result  of  unnatural  flexion 
of  the  fiDgers  and  toes.  Such  contraction  of  the 
palmar  and  plantar  fasciae  may  be  due  to  wounds, 
burns,  or  inflammation  from  any  cause,  or  to 
gout  or  rheumatism  ; it  is  sometimes  congenital ; 
and  it  sometimes  occurs  without  evident  cause. 

8.  Extension. — A fascia  or  sheath,  though 

extremely  inelastic,  is  liable  to  be  stretched  by 
swelling  of  the  parts  which  it  envelopes ; and,  if 
the  cause  do  not  speedily  disappear,  may  remain 
more  or  less  permanently  extended.  The  best 
instance  of  this  condition  is  pendulous  abdomen 
after  pregnancy  or  other  form  of  abdominal  en- 
largement. J.  3Iitchell  Bruce. 

FASCIOLA  (fasciola , a thin  band). — A genus 
of  trematode  parasites  of  which  the  common  liver- 
fluke  forms  a good  type.  This  entozoon  (F.  he- 
patica)  is  characterised  by  the  possession  of  a 
branched  intestinal  canal,  thus  differing  from  the 
flukes  belonging  to  the  genus  Distoma,  in  which 
the  canal  is  simple  and  bifurcated.  The  liver- 
fluke  is  of  rare  occurrence  in  man,  though  ex- 
tremely abundant  in,  and  destructive  to,  rumina- 
ting animals.  See  Distoma.  T.  S.  Coisbold. 

FASTIN' G. — The  manifestation  of  vital 
activity  implies  consumption  of  material;  and 
unless  the  supply  of  material  in  the  form  of 


FASTING, 

food  is  equivalent  to  the  loss  occurring,  a pro- 
gressive wasting  of  the  body  and  failure  ot 
power  must  ensue.  Hence  these  phenomena 
constitute  the  necessary  accompaniments  of 
fasting;  and  with  its  prolongation  the  question 
resolves  itself  into  one  of  time — when  the  exhaus- 
tion of  material  shall  have  proceeded  to  such  an 
extent  as  to  render  the  continuance  of  life  im- 
possible. 

Pathology. — To  Chossat  we  are  indebted  for 
showing  that  the  immediate  cause  of  death  from 
fasting  is  a reduction  of  the  bodily  temperature. 
At  first  there  is  a gradual,  but  not  very  ex- 
tensive fall.  Afterwards  a more  rapid  decline 
occurs,  until  the  reduction  amounts  to  about  29° 
or  30°  (Fahr.)  below  the  normal  point,  when 
death  ensues.  Chossat  noticed  that  if,  whilst  in 
the  state  of  torpor  preceding  death,  the  tempera- 
ture of  the  animal  experimented  on  was  raised  by 
exposure  to  artificial  warmth,  a restoration  of 
consciousness  and  muscular  power  was  induce':; 
and  some  of  his  subjects  of  experiment  which 
were  thus  rescued  from  impending  death  after- 
wards thoroughly  revived  on  being  supplied  with 
food. 

Symptoms. — The  most  prominent  symptoms 
arising  from  fasting  are  those  due  to  the  special 
sensations  produced  by  the  absence  of  food  and 
fluid,  and  those  attributable  to  a decline  of  the 
physical  and  mental  power.  In  the  first  place 
there  is  great  uneasiness  in  the  epigastrium. 
This  is  followed  by  a sense  of  sinking  in  the  same 
region,  accompanied  by  insatiable  thirst ; and 
if  fluid  be  persistently  withheld  as  well  as  food, 
the  thirst  becomes  the  chief  source  of  distress. 
The  countenance  assumes  a pale  and  cadaverous 
appearance,  and  a look  of  wildness  is  presented 
about  the  eyes.  Emaciation  becomes  more  and 
more  marked,  and  with  it  there  is  a decline  of 
the  bodily  strength.  There  is  also  failure  of  the 
mental  power.  Stupidity  may  advance  to  im- 
becility; and  a- state  of  maniacal  delirium  fre- 
quently supervenes.  Life  terminates  either 
calmly  by  gradually  increasing  torpidity,  or,  it 
may  be,  suddenly  in  a convulsive  paroxysm. 

Duration  of  Life. — The  usual  duration  of 
life  under  complete  absence  of  food  and  drink 
may  be  said  to  be  from  eight  to  ten  days.  The 
special  circumstances,  however,  existing  may 
exert  a modifying  influence,  and  from  the  nature 
of  these  the  period  may  be  either  diminished  or 
increased.  A stout  person,  as  may  be  readily 
understood,  has  a chance  of  living  loDger  than  a 
thin  one,  on  account  of  the  store  of  combustible 
material  which  may  be  drawn  upon  being  larger. 
Exposure  to  cold  in  conjunction  with  starvation 
very  much  hastens  death.  The  presence  of 
moisture  in  the  atmosphere  favours  the  pro- 
longation of  life,  by  diminishing  the  exhalation 
of  fluid  from  the  body.  It  may  be  assumed  to 
be  owing  to  the  existence  of  warmth  and  mois- 
ture that  persons  buried  in  mines,  or  otherwise 
similarly  placed,  have  been  known  to  live  con- 
siderably beyond  the  ordinary  period. 

The  Welsh  fasting  girl,  about  whom  so  much 
excitement  was  created  in  1869.  lived  exactly 
eight  days  from  the  time  she  was  placed  under 
systematic  inspection  to  solve  the  problem  of 
whether  she  could  exist,  as  had  been  alleged  bj 
her  parents,  for  an  indefinite  period  without  fooa! 


FASTING. 

It  appears  that  during  the  first  part  of  the  time 
she  was  cheerful  and  exhibited  nothing  extra- 
ordinary. Later  on  it  was  found  that  she  could 
not  be  kept  warm,  and  ultimately  she  sank  into 
a state  of  torpor,  from  which  she  could  not  he 
roused  and  which  speedily  terminated  in  death. 

In  the  Troedyrhiw  colliery  near  Pontypridd 
an  inundation  occurred  in  1877,  which  led  to  the 
imprisonment  of  four  men  and  a boy  in  one  of 
the  headings  of  the  mine.  The  accident  hap- 
pered  on  Wednesday  evening,  the  11th  of  April. 
Efforts  were  at  once  made,  by  means  of  a cutting, 
to  reach  the  chamber  in  which  the  imprisoned 
persons  were  confined,  and  to  release  them.  This 
was  not  accomplished  till  the  afternoon  of  Thurs- 
day, the  19th,  when  all  were  rescued  alive  and 
did  well.  They  had  been  imprisoned  in  an  at- 
mosphere of  compressed  air  nearly  eight  days, 
without  food  but  within  reach  of  water.  The 
more  recent  case  of  Dr.  Tanner  throws  no  new 
light  upon  the  subject. 

Treatment. — Caution  is  required  in  the  ad- 
ministration of  food  after  prolonged  fasting. 
Sudden  transitions  of  all  kinds  are  trying  to  the 
body ; and,  instead  of  allowing  the  rescued  sufferer 
to  gratify  his  desire  to  eat  and  drink  according 
to  his  inclination  after  several  days’  abstinence, 
the  supply  of  both  food  and  drink  should  at 
first  be  limited,  and  afterwards  gradually  in- 
creased. There  is  reason  to  believe  that  the 
non-observance  of  this  rule  has  upon  some 
occasions  been  followed  by  disastrous  conse- 
quences which  a different  plan  might  have 
averted.  F.  W.  Paw. 

PAT. — Fat  becomes  a disease  under  the  fol- 
lowing circumstances : — 

1.  As  Obesity. — Fat  may  be  found  generally 
diffused  in  excessive  quantity  beneath  the  skin, 
beneath  serous  membranes,  and  in  and  upon  the 
various  tissues  and  organs  of  the  body.  This 
condition  constitutes  what  is  known  as  Obesity. 
The  subject  will  be  found  fully  discussed  under 
that  head. 

As  a Partial  Growth  of  fat,  which  some- 
times occurs  in  paralysed  muscles,  and  consti- 
tutes a characteristic  feature  of  what  is  called 
pseudo-muscular  hypertrophy.  See  Pseudo-Hy- 
PEBTEOPnic  Paralysis. 

2.  As  Fatty  Interstitial  Growths. — Fat  as 
fat-tissue  becomes  more  especially  a disease 
when  it  is  deposited  upon  and  in  the  textures  of 
organs,  interfering  with  their  structure  and  func- 
tions. It  does  this  by  pressing  upon  the  elements 
of  the  organ  invaded ; and  its  effects  are  more 
particularly  seen  when  it  invades  the  muscular 
tissue  of  such  an  organ  as  the  heart,  the  fibres  of 
which,  becoming  more  or  Jess  atrophied  and  dis- 
torted in  their  course  and  direction,  are  rendered 
inadequate  for  the  performance  of  their  functions. 
See  Heart,  Fatty  Diseases  of. 

3.  As  Fatty  Tumours. — Fat  may  also  occur 
in  isolated  or  circumscribed  masses,  constituting 
what  are  known  as  Fatty  Tumours  or  Lipomata. 
See  Tumours. 

4.  As  Fatty  Infiltration. — Fat  in  the  form 
of  oily  particles  is  found  to  be  present  in  excess 
in  the  cells  of  various  secreting  organs,  constitu- 
ting fatty  infiltration.  Thus  it  appears  in  the 
epithelium  of  the  intestinal  mucous  membrane 


FATIGUE.  501 

during  digestion  ; in  the  cells  of  the  liver  and 
biliary  passages  ; and  in  the  kidneys  of  certain 
animals — for  instance,  the  cat.  When  this  con- 
dition becomes  permanent  it  must  be  considered 
as  a disease.  Glandular  organs  thus  affected,  as 
in  the  case  of  the  liver,  assume  a buff  or  yellow 
colour,  and  become  softer  and  more  friable  than 
normal;  while  microscopically  their  cells  are 
found  to  contain  one  or  more  large  well-defined 
oil-globules,  which  tend  to  eoalesce  and  occupy 
the  cell.  The  quantity  of  oily  matter  in  the  cells 
may,  however,  vary  from  time  to  time,  and  the 
infiltration  may  be  either  of  a transient  or  of  a 
permanent  character.  In  the  one  case,  the  func- 
tion of  the  organ  may  not  be  materially  interfered 
with  ; in  the  other  case,  the  activity  of  the  cells 
may  lie  so  far  affected  as  greatly  to  impair  the 
secreting  functions  of  the  organ. 

The  causes  of  fatty  infiltration  are  of  two 
kinds — general  and  local.  First,  the  general 
causes  are  (1)  a superabundance  of  fatty  matters 
in  the  blood,  as  occurs  in  persons  who  indulgo 
in  rich  food  and  in  beverages  containing  alcohol ; 
(2)  imperfect  oxidation,  as  in  chronic  tuberculosis 
of  the  lungs;  and  (3),  according  to  some  observers, 
the  metastasis  of  fatty  deposits  from  one  part 
of  the  body  to  another. 

Secondly,  with  respect  to  the  local  causes  of 
fatty  infiltration,  one  is  a peculiar  affinity  or 
selective  power  of  the  cells  of  certain  tissues,  by 
virtue  of  which  they  incorporate  with  their  sub- 
stance oily  or  fatty  matter.  This  facility  has 
been  explained  in  the  case  of  the  cells  of  the  liver 
and  of  the  passages  traversed  by  bile,  by  the  pre- 
sence of  that  fluid,  which,  as  Virchow  and  others 
describe,  is  a powerfully  determining  cause  of 
the  infiltration  of  fat  into  protoplasm.  Another 
local  cause  of  the  accumulation  of  oil  in  cells  is 
their  inactivity  or  imperfect  power  of  eliminat- 
ing it,  as  is  found  to  occur  in  the  cartilages  of  the 
aged,  and  in  inactive  muscles. 

It  must  be  said  here,  with  respect  to  the  ap- 
pearance of  fat  in  the  last-named  situations, 
that  though,  in  some  cases,  it  is  derived  unques- 
tionably from  the  fat  contained  in  the  blood  or 
chyle,  it  may  in  other  instances  be  derived  from 
the  disintegration  of  the  protein  elements  of  the 
tissues.  This  subject,  however,  will  be  found 
discussed  in  the  article  upon  Fatty  Degenera- 
tion. E.  Quain,  M.D. 

FATIGUE  ( fatigo , I weary). 

General  Remares. — Fatigue  is  a regular  and 
constantly  returning  symptom  experienced  by  all 
persons.  Periods  of  functional  activity  invariably 
alternate  with  periods  of  repose  during  which  the 
waste  caused  by  the  exercise  of  function  is  re- 
paired. We  are  indebted  to  Sir  James  Paget  for 
having  pointed  out  that  * rhythmic  nutrition  is  a 
law  of  nature,’  and  although  the  truth  of  this 
dogma  is  recognised  on  all  hands,  and  may  be 
said  to  be  axiomatic,  it  has  hardly  received  that 
careful  consideration  at  the  hands  of  practical 
physicians  which  it  deserves.  Our  whole  life  is 
composed  of  a series  of  vibrations — periods  of 
tension  alternating  with  periods  of  relaxation  ; 
and  although  the  rapidity  of  these  vibrations 
varies  immensely,  they  are  recognisable  in  all 
our  acts,  whether  voluntary  or  otherwise.  The 
vibrations  of  the  heart  are  about  seventy  in  a 


FATIGUE. 


502 

minute,  those  of  the  respiratoiy  organs  about 
sixteen.  The  whole  body  requires  a certain 
period  of  absolute  and  continuous  repose  in 
each  twenty-four  hours  (amounting  to  nearly 
one-third  of  the  period),  so  that  we  may  say  its 
rate  of  vibration  is  once  in  the  twenty-four  hours. 
In  like  manner  tho  period  of  relaxation  of  the 
heart  is  about  one-third  of  the  total  period  of  a 
revolution,  and  this  proportional  correspondence 
between  a local  and  a general  condition  is  not  a 
little  interesting  and  suggestive.  Again  it  is 
universally  ordained  amongst  civilised  nations 
that  once  in  every  seven  days  there  shall  be  a 
remission  of  labour  and  a change  of  occupation  ; 
and  we  recognise  the  fact  that  it  is  highly  ad- 
visable for  those  who  are  occupied  in  one  pursuit 
to  break  away  from  it  at  least  once  a year  and 
indulge  in  that  variety  of  work  which  we  call 
amusement. 

Fatigue  occurs  directly  we  attempt  to  alter  the 
rhythm  of  our  vital  vibrations  by  prolonging 
the  periods  of  tension  at  the  expense  of  tho  period 
of  relaxation,  or  by  demanding  for  any  length  of 
time  a quickening  of  the  normal  rate  of  vibra- 
tion. We  recognise  the  fact  that  athletes  who 
over-train  run  risks  of  cardiac  troubles  and  loss 
of  wind  ; that  the  man  who  from  any  cause  is 
unable  to  sleep  runs  a serious  risk  of  permanent 
impairment  of  health ; and  when  we  find  patients 
pursuing  their  avocations  too  zealously  we  know 
that,  if  such  offence  against  the  laws  of  nature  be 
persisted  in,  general  paralysis,  or  other  forms  of 
• break-down,’  are  likely  to  be  the  result. 

Fatigue  may  be  general  or  local,  and  both 
forms  may  be  either  acute  or  chronic.  That 
fatigue  in  all  its  forms  is  due  to  impaired 
nutrition  there  can  be  little  doubt,  and  we  shall 
find  that  tho  symptoms  of  chronic  fatigue  are 
often  the  prelude  of  definite  and  recognisable 
degenerative  changes. 

Description. — General  Fatigue. — General 
fatigue  is  recognised  with  ease  both  in  its  acute 
and  chronic  forms.  There  is  a disability  to  per- 
form either  mental  or  physical  work,  and  this  dis- 
ability is  noticed  first  in  work  requiring  attention 
or  sustained  effort,  and  last  in  those  acts  which 
have  become  automatic  or  secondarily  automatic. 
The  symptoms  of  general  fatigue  are  usually  re- 
ferable to  the  nervous  centres. 

Local  Fatigue. — Local  fatigue  is  either  acute 
or  chronic,  and  the  symptoms  of  it  are  referable 
usually  to  the  muscles ; but  we  must  always  bear 
in  mind  that  muscle  and  motor-nerve  are  prac- 
tically one  and  indivisible,  and  that  recent 
experiments  have  given  great  probability  to  the 
idea  that  every  muscle  is  connected  with  a cer- 
tain definite  spot  in  the  brain.  When,  there- 
fore, we  speak  of  a sense  of  fatigue,  we  must 
necessarily  be  in  doubt,  notwithstanding  the 
fact  that  the  symptoms  are  apparently  located 
in  the  muscles, whether  thebrain,  nerve,  or  muscle, 
ono  or  all  of  them,  be  really  at  fault. 

Acute  local  fatigw. — The  symptoms  of  acute 
local  fatigue  are,  first,  loss  of  power  to  a 
greater  or  less  extent.  By  too  frequent  or  too 
prolonged  stimulation  the  irritability  of  the 
muscular  tissue  becomes  exhausted,  and  it  either 
refuses  to  respond,  or  responds  but  feebly  to  the 
stimulus  of  the  will ; whilst  our  power  of  adjusting 
the  force  of  contraction  to  the  act  to  be  accom- 


plished is  lessened,  and  accuracy  of  movement 
and  delicacy  of  co-ordination  are  destroyed.  The 
second  symptom  of  acute  fatigue  is  tremor,  as 
everyone  must  have  experienced  who  has  been 
called  upon  for  any  unusual  exertion.  The  third 
symptom  is  cramp-like  contraction ; and  the 
fourth  is  pain,  the  pain  being  the  pain  of  fatigue, 
and  absolutely  distinct  from  other  varieties  of 
pain.  Fatigue  is  caused  far  sooner  by  prolonged 
muscular  effort  than  by  repetitions  of  short  mus- 
cular efforts  having  due  intervals  of  relaxation  be- 
tween them.  Anyone  who  has  attempted  to  hold 
out  a weight  at  arm’s  length  knows  the  impossi- 
bility of  continuing  the  effort  for  any  length  of 
time;  and  it  is  proverbially  true  thatstanding  in 
one  position  is,  to  most  people,  far  more  tiring 
than  walking,  the  reason  being  that  in  standing 
the  muscles  which  support  the  body  are  subjected 
to  a prolonged  strain  while  in  walking  we  use  the 
muscles  on  either  side  of  the  body  alternately. 
The  great  increase  of  power  which  we  obtain  by 
using  the  muscles  on  either  side  of  the  body 
alternatively  would  seem  to  be  one  of  the  chief 
reasons  for  the  bilateral  symmetry  of  the  body. 
Not  only  is  sustained  effort  a far  more  potent 
cause  of  fatigue  than  repeated  effort,  but  we  find 
that  when  fatigue  supervenes,  actions  requiring 
sustained  effort  are  the  first  to  fail,  and  in  this 
local  fatigue  resembles  general  fatigue.  The 
last  acts  to  be  affected  by  fatigue  are  such  as 
are  automatic,  and  are  accomplished  without 
mental  effort,  and  by  the  expenditure  of  the 
least  possible  amount  offeree.  It  isquite  possible 
to  exhaust  a muscle  by  artificial  stimulation,  and 
if  ono  of  the  small  interossei  muscles  be  con- 
tinuously faradised,  it  will  be  found  that  in  a 
very  short  time  its  power  of  contraction  to  any 
form  of  stimulus  may  be  absolutely  abolished. 
It  is  tolerably  certain  that  the  brain  can  have 
no  share  in  artificial  fatigue  thus  produced, 
and  there  seems  good  reason  to  suppose  that,  in 
some  people  of  energetic  temperament,  the  irrita- 
bility of  a muscle  may  be  exhausted,  while  the 
power  of  mental  stimulation  remains  almost  un 
impaired. 

Chronic  local  fatigue. — This  form  of  fatigue 
has  causes  and  symptoms  similar  to  those  of 
acute  local  fatigue,  and  there  can  be  little  doubt 
that  this  condition  is  a common  cause  of  many 
of  those  chronic  maladies  which  seem  to  result 
from  overwork,  and  are  characterised  by  irregular 
muscular  action.  That  some  cases  of  writer's 
cramp  (see  Writer's  Cramp)  are  due  to  chronic 
fatigue  of  certain  muscles  employed  in  writing, 
and  particularly  of  those  subjected  to  prolonged 
effort,  there  can  be  little  doubt.  Some  cases  of 
torticollis  seem  due  to  the  same  cause.  Duchenne 
and  Brudenell-Carter  have  pointed  out  how,  in 
cases  of  ‘ short  sight,’  the  strain  on  the  internal 
recti  has  caused  troubles  of  vision,  and  oven 
brain-symptoms,  and  quite  lately  Mr.  C.  B. 
Taylor,  of  Nottingham,  has  shown  reason  for 
including  in  the  category  of  fatigue-diseases  a 
peculiar  form  of  nystagmus,  occurring  amongst 
miners,  who  try  their  eyes  by  working  in  the  dark. 

Treatment.— The  treatment  of  fatigue  in  all 
its  forms  is  rest,  and  the  restoration  of  the 
proper  rhythm  of  nutrition,  if  this  be  found  per- 
verted, by  substituting  rhythmical  exercises  for 
unrhythmical  efforts.  G.  V.  Poorr. 


FATTY  DEGENERATION'. 


FATTY  DEGENERATION. — Synon.  • 

Fr.  btghierescence  graisseuse  ; Ger.  Fettige  Meta- 
morphose. 

Definition. — The  process  by  which  protein  ele- 
ments are  converted  into  a granular  fatty  matter. 

Seats  of  Occurrence. — This  change  may  oc- 
cur in  any  of  the  component  elements  of  the 
body,  whether  normal  or  abr-ormal. 

Physiologically.  The  production  of  milk  from 
the  protoplasm  of  the  mammary  cells,  and  of 
sebum  from  the  cells  of  the  sebaceous  glands, 
are  instances  of  fatty  degeneration.  The  cells 
of  the  corpus  luteum  are  partly  in  a condition  of 
fatty  degeneration  ; and  it  is  by  a similar  change 
in  the  peripheral  cells  of  the  mature  fetal  por- 
tion of  the  placenta  that  normal  involution  of 
;hat  organ  is  accomplished.  Non-vascular  struc- 
tures, such  as  the  cartilages,  the  cornea,  and  the 
intima  of  blood-vessels,  frequently  undergo  fatty 
transformation  of  part  of  their  substance.  In  a 
less  marked  form,  fatty  degeneration  occurs  in 
the  walls  of  the  uterus  and  other  muscular  or- 
gans when  returning  to  their  ordinary  size  after 
temporary  hypertrophy. 

Pathologically.  As  a purely  morbid  process, 
fatty  change  is  most  frequently  met  with  in  the 
muscular  tissue  of  the  heart,  in  the  walls  of 
capillaries,  and  in  the  urinary  tubules ; but  it 
also  occurs  in  the  central  nervous  system,  consti- 
tuting the  condition  known  as  ‘ white  softening’; 
in  the  liver;  and  in  tubercular  deposits,  cancer- 
ous growths,  infarcts,  and  inflammatory  products 
in  any  situation  whatever. 

Anatomical  Characters. — Physical  Charac- 
ters.— An  organ  that  has  undergone  fatty  de- 
generation presents  the  following  physical  cha- 
racters. The  bulk  and  weight  are  generally 
increased  ; the  consistence  is  reduced,  sometimes 
to  a pulp,  as  in  white  softening  of  the  brain  ; 
the  colour  is  changed,  either  as  a whole  or  in  the 
affected  portions  of  the  organ,  into  a buffy  or  yel- 
lowish bloodless  hue ; and  the  resistance  or  firm- 
ness is  diminished,  so  that  the  affected  tissue  is 
markedly  flabby,  and  readily  yields  to  pressure. 
The  solid  cut  surface  may  appear  compact  and 
shining;  and  the  section  leaves  a greasy  stain 
upon  the  knife  and  fingers.  When  fatty  degener- 
ation is  greatly  advanced,  as  it  may  bo  seen,  for 
example,  in  the  liver,  a portion  of  the  organ 
l hrown  into  water  will  float. 

Microscopical  Characters. — In  fatty  degenera- 
tion the  muscular  tissue  of  the  heart  and  the  walls 
of  capillaries  are  most  suitable  for  microsco- 
pical investigation.  The  earliest  changes  in  the 
i ardiac  muscle  in  fatty  degeneration  are  loss  of 
sharpness  of  the  individual  striae  and  theappear- 
auce  of  minute  particles  of  oil  between  the  ele- 
ments. These  changes,  beginning  near  the  nu- 
clei, spread  throughout  the  fibres  in  a longitu- 
dinal direction,  while  the  particles  increase  in 
size  and  assume  the  well-known  characters  of  oil- 
globules.  When  the  process  is  advanced,  the  whole 
of  the  sarcous  substance  is  replaced  by  fatty 
particles  contained  within  a delicate  albuminous 
envelope.  Finally  the  degenerated  fibres  either 
become  atrophied  by  absorption  of  certain  parts  of 
the  fat,  and  so  disappear ; or  suffer  rupture  with 
discharge  of  their  contents.  The  fatty  nature  of 
the  change  is  proved  by  the  solubility  in  ether  of 
the  particles  that  have  escaped  from  the  fibres. 


5011 

Fatty  degeneration  of  the  walls  of  vessels  ia 
best  seen  in  the  capillaries  and  smallest  arteries. 
The  tunics  first  lose  their  normal  translucency  ; 
minute  granules  appear  in  their  substance  ; and 
these  increase  to  form  unmistakable  oil-glo- 
bules. Finally  the  vessel  gives  way,  and  the  oily 
particles  and  blood  are  discharged  into  the  peri- 
vascular space. 

In  the  other  organs  referred  to,  the  microsco- 
pical characters  agree  with  those  just  described, 
with  certain  differences  dependent  upon  the 
special  structure  of  each.  Thus  fatty  degener- 
ation of  a leucocyte  leads  to  the  formation  of 
the  body  known  as  a compound,  granular  cor- 
puscle, in  which  the  oil-drops  finally  replace  the 
whole  of  the  protoplasm.  In  ‘ white  softening  ’ 
of  nervous  tissue,  the  nerve-cells  and  probably 
all  the  nuclei  of  the  part  are  converted  in  a great 
measure  into  granular  corpuscles ; and  theso 
breaking  down  into  afatty  detritus,  the  whole  con- 
stitutes a soft  ereamy-looking  substance,  which, 
as  Virchow  expresses  it,  ‘ is  milk  in  the  brain, 
instead  of  in  the  mammary  gland.’  ‘ Yellow  tu- 
bercle ’ consists  in  part  of  cells  and  nuclei  that 
have  undergone  fatty  degeneration,  and  of  fatty 
detritus.  In  the  case  of  the  uterus  during  in- 
volution the  fat  is  probably  rapidly  absorbed,  so 
that  the  appearances  presented  to  the  eye  are 
those  rather  of  atrophy  than  of  replacement  of 
the  muscular  substance  by  fat. 

Pathology. — -We  have  now  to  trace  whence 
comes  the  fat  that  is  found  in  this  form  of  do- 
generation,  and  how.  It  is  evident  that  in  a 
number  of  instances — such  as  the  production  of 
milk  and  sebum — fatty  degeneration  is  a truly 
physiological  change,  which  is  subservient  to 
health  when  active,  while  its  derangement  or 
cessation  constitutes  disease.  In  other  cases  the 
process  is  essentially  pathological,  as,  for  example, 
in  fatty  degeneration  of  the  heart  and  white  soft  - 
ening of  the  brain ; the  functional  activity  of 
the  part  being  impaired,  or  so  abolished  that  the 
name  of  necrobiosis,  or  death-in-life,  has  been 
given  to  the  condition.  The  fatty  change  in 
the  two  instances  is,  however,  manifestly  one 
and  the  same.  The  condition  known  as  fatty  de- 
generation had  long  been  described,  and  it  has 
always  been  a favourite  subject  with  pathologists 
to  discover  its  nature  and  its  cause.  It  was 
generally  assumed  that  the  fatty  matter  present 
was  introduced  from  without,  being  deposited 
from  the  blood  as  morbid  material  in  place  of 
the  pre-existing  tissues  which  were  absorbed. 
Modern  research  has  demonstrated  that  this  is 
not  so,  and  that  fat  is  derived  from  a molecular 
change  in  the  tissue  or  textures  in  which  it  is 
found.  The  subject  is  one  of  immense  impor- 
tance, involving  the  whole  field  of  pathology ; and 
it  is  but  right  to  state  that  our  acquaintance 
with  the  true  nature  of  the  process,  is  almost 
entirely  due  to  the  investigations  of  Dr.  Quain, 
which  were  published  in  the  Medico-Chirurgical 
Transactions  for  1 850,  and  with  reference  to  which 
Sir  James  Paget  has  remarked: — ‘Dr.  Quain  has 
candidly  referred  to  many  previous  observers  by 
whom  similar  changes  were  recognised  ; but  tho 
honour  of  tho  full  proof,  and  of  the  right  use  of 
it,  belongs  to  himself  alone.’ — Lectures  on  Sur- 
gical Pathology,  1st  ed.  vol.  i.  p.  107,  note.  Dr. 
Quain’s  conclusion  was  that  the  molecular  fattj 


504  FATTY  DEGENERATION, 
rjattcr  in  the  degenerated  fibre  was  the  result  of 
a chemical  or  physical  change  in  the  composition 
of  the  tissue,  occurring  independently  of  those 
processes  which  we  call  vital.  The  arguments 
which  he  adduced  in  support  of  this  view  were 
the  following : — (1 ) That  in  the  formation  of  the 
substance  known  as  adipocere  from  albuminous 
material  after  death,  the  places  of  the  muscu- 
lar fibres,  blood-vessels,  and  nerves  are  occupied 
by  fatty  matter  which  could  not  have  existed  in 
them  as  such  during  life.  (2)  That  a true  fatty 
degeneration  may  be  artificially  produced  post 
mortem.  (3)  That  masses  of  albuminous  mate- 
rial deprived  of  nutrition  in  any  part  of  the 
body,  or  the  centre  of  non-vascular  structures 
such  as  tubercle,  undergo  fatty  degeneration  to 
a marked  degree.  (4-)  That  the  circumstances 
nnder  which  fatty  degeneration  occurs  in  the 
living  body  exhibit  impairment  of  general  and 
local  nutrition,  such  as  blood-disorder,  or  dis- 
ease of  the  nutrient  vessels.  More  than  twenty 
years  later  (1871),  Dr.  Quain’s  conclusions  re- 
specting the  nature  of  fatty  degeneration  were 
experimentally  confirmed  in  the  living  animal  by 
the  investigations  of  Bauer  and  Yoit,  of  Munich. 
On  administering  phosphorus  to  a starving  dog, 
in  which  the  amount  of  nitrogen  (urea)  daily  ex- 
creted had  become  constant,  these  experimenters 
found  that  the  amount  of  the  excretion  was 
thereby  increased  threefold;  that  this  nitrogen 
was  derived  from  the  albumen  of  the  tissues  and 
net  of  the  blood ; and  at  the  same  time  that  three 
times  the  normal  amountofoil  had  accumulated 
in  the  viscera.  This  oil  could  have  its  origin  only 
in  the  transformed  or  decomposed  albumen  of 
the  organism;  the  other  product  being  the  urea 
which  had  been  excreted.  The  same  results 
have  been  observed  in  poisoning  by  phosphorus 
in  the  human  body. 

Many  other  instances  of  the  formation  of  a 
fatty  from  a nitrogenous  body  might  be  adduced 
if  .necessary,  such  as  the  ripening  of  cheese  ; the 
increased  flow  of  milk  on  a meat  diet ; the  for- 
mation of  wax  by  bees  from  sugar  and  albumen ; 
the  production  of  fatty  acids  and  their  allies 
from  proteid  compounds  in  the  process  of  pan- 
creatic digestion;  the  increase  of  oil  in  olives  by 
keeping ; and  the  development  of  a rancid  oil  in 
the  flake  of  salmon  under  similar  circumstances. 
The  numerous  instances  just  adduced  combine  to 
strengthen  the  position — which  was,  however, 
sufficiently  established  by  Dr.  Quain— that  m 
true  fatty  degeneration,  the  nitrogenous  material 
of  the  tissues  themselves,  and  not  the  blood, 
must  be  considered  the  source  of  the  oily  matter. 
It  has  been  said  that  the  circumstances  under 
which  fatty  degeneration  occurs  are  further  con- 
firmatory evidence  in  the  same  direction.  These 
must  now  be  considered. 

Conditions  of  Occurrence. — The  circum- 
stances under  which  fatty  degeneration  occurs 
are  either  such  as  affect  the  nutrition  of  the  whole 
system  generally,  or  of  a given  organ,  or  portion 
of  it,  specially. 

General. — When  the  amount  of  blood  in  the 
body  is  quickly  reduced,  for  example,  by  severe 
but  not  actually  sudden  haemorrhage,  death  may 
occur  from  fatty  degeneration  of  the  heart,  the 
voluntary  muscles  and  the  other  viscera  being 
likewise,  but  less  seriously,  affected.  Again, 


FATUITY. 

general  fatty  degeneration  is  frequently  due  to 
depraved  quality  of  blood,  and  especially  to  the 
presence  in  it  of  certain  poisons,  such  as  phos- 
phorus, arsenic,  antimony,  and  the  more  complex 
animal- poisons  of  the  acute  specific  fevers. 

Local. — Disease  of  the  nutrient  artery  of  a 
part  is  the  morbid  condition  most  frequently  as- 
sociated with  localised  fatty  degeneration.  A 
good  instance  of  this  is  furnished  by  fatty  de- 
generation of  patches  of  the  muscular  tissue  of 
the  heart  corresponding  with  degeneration,  ob- 
struction, or  compression  of  a branch  of  a coro- 
nary artery.  Another  excellent  example  of  the 
same  is  white  softening  of  the  brain  from  vas- 
cular degeneration.  This  is  analogous  to  what 
occurs  in  dry  gangrene,  with  the  exception  that 
decomposition  takes  place  in  the  latter,  probably 
from  the  admission  of  air. 

Summary. — When  wo  review  the  circumstances 
under  which  fatty  degeneration  is  found  to  occur, 
we  discover  that  the  condition  that  is  common 
to  them  all  is  interference  with  nutrition,  and 
especially  with  the  process  of  oxidation.  The 
red  corpuscles  are  believed  to  be  primarily- 
affected  in  phosphorus-poisoning:  they  are  nu- 
merically reduced  in  continued  haemorrhage: 
and  they  do  not  reach  the  tissues  in  sufficient 
numbers  when  the  vessels  are  obstructed,  or 
otherwise  diseased.  In  the  cases  of  the  hyper- 
trophied uterus  and  heart,  of  the  placenta,  and 
probably  of  the  corpus  luteum,  the  degeneration 
is  probably  due  to  the  decline  or  cessation  of 
functional  activity,  and  the  consequent  decrease 
in  the  blood-supply  to  the  large  mass  of  proto- 
plasmic structures. 

With  respect  to  the  intimate  or  essential  nature 
of  fatty  degeneration,  it  may  bo  stated  as  highly 
probable,  as  far  as  our  present  knowledge  ex- 
tends, that  the  metabolism  or  decomposition  that 
is  constantly-  going  on  in  living  protoplasm  is 
not  simple  or  immediate ; but  that  a primary 
decomposition  occurs  of  albuminous  substances 
into  urea  (or  its  allies)  and  fat,  and  a further 
or  secondary  decomposition  of  the  fat  into  car- 
bonic acid  and  water.  If  the  amount  of  oxygen 
furnished  by  the  blood  is  deficient,  whether 
absolutely  or  relatively,  the  primary  decom- 
position of  the  protoplasm  alone  may  be  effected; 
and  the  secondary  decomposition,  or  the  oxida- 
tion of  fat  into  carbonic  acid  and  water,  m3y 
not  occur.  The  result  therefore  of  an  absolute  or 
relative  deficiency  of  oxygen  in  protoplasmic  tis- 
sues will  be  the  aceumufation  of  fat  within  them. 

Effects. — The  physical  effects  of  fatty  de- 
generation of  a tissue  have  been  already  de- 
scribed under  the  head  of  physical  characters, 
being  chiefly — change  of  colour,  diminished  con- 
sistence and  resisting  power,  softening,  rupture, 
dilatation  and  excavation,  and  alteration  cf  size. 
The  chief  physiological  effect  is  diminished 
functional  power  or  activity,  which  is  especially 
marked  in  muscular  parts  such  as  the  heart,  and 
in  the  kidneys. 

Treatment. — The  subject  of  the  treatment  of 
fatty  degeneration  will  be  found  discussed  under 
the  head  of  the  diseases  of  the  several  organs 
which  it  may  affect.  J.  Mitchell  Bruce. 

FATUITY  I fat  nus,  silly). — Mental  imbeca 
lity.  See  Imukciuty. 


FAUCES,  DISEASES  OF. 

FAUCES,  Diseases  of.  See  Thboat,  Dis- 
eases of. 

FAVUS  ( favus , a honeycomb).— Synon.  : 
Tinea  favosa ; Fr.  Favus;  Ger.  Wachsgrind. 

.ZEtioloqy.—  Favus  is  very  uncommon  in  Eng- 
land; it  is  more  frequently  seen  in  Scotland  and 
abroad.  It  usually  attacks  the  scalp,  rarely  the 
body,  of  young  children  amongst  tho  poorer 
members  of  the  community.  It  may  be  contracted 
from  certain  animals,  especially  mice. 

Anatomical  Characters. — If  the  favi  be  ex- 
amined microscopically — that  is,  if  small  portions 
be  placed  in  potash  and  put  under  the  microscope 
— they  are  seen  to  be  made  up  entirely  of  fungus. 
The  fungus  by  its  growth  irritates  the  scalp, 
and  making  its  way  down  the  hair-follicles,  it 
finds  access  to  tho  hair-shafts,  which  are  swollen, 
altered  in  texture,  and  loaded  with  fungus- 
elements,  whilst  the  hair-forming  apparatus  be- 
comes more  or  less  destroyed  and  the  hair  falls. 
The  fungus  ( achorion  Sch'onleinii ) consists  of  oval, 
nucleated  conidia,  gAg  inch  in  diameter,  free, 
jointed  or  constricted;  large  branching  or  tortuous 
mycelial  filaments,  gA_  inch  or  so  in  diameter, 
filled  with  granules  and  spores  ; and  stroma  made 
up  of  minute  cellular  elements. 

Description. — The  characteristic  feature  of 
the  disease  is  the  development  of  light  sul- 
phur-coloured, circular,  cupped  crusts,  called 
favi,  penetrated  by  the  hairs  in  their  centres. 
At  first  a minute  opaque  spot  is  visible  beneath 
the  epidermis,  and  this  gradually  enlarges  into 
a favus.  These  favi  are  about  the  size  of  a split- 
pea,  or  larger,  varying,  in  fact,  from  5'j  to  j|  of  an 
inch  in  diameter,  and  A to  ^ of  an  inch  in  depth. 
They  lie  or  are  imbedded  in  a depression  of  the 
derma,  and  are  convex  therefore  on  their  under 
aspect,  but  concave  above,  and  the  surface  has  a 
stratified  appearance.  These  favi  maybe  discrete 
orcrowd  together  into  an  irregular  mass,  in  which 
the  distinctness  of  the  several  favi  is  more  or 
less  lost.  In  severe  cases  redness,  soreness,  tume- 
faction of  the  scalp,  and  baldness  result. 

Diagnosis. — Favus  may  be  mistaken  for  im- 
petigo at  first  sight,  but  only  by  a careless 
observer,  because  characteristic  favi  are  always 
present. 

Treatment. — The  treatment  is  both  disap- 
pointing and  tedious.  The  patient  must  be  placed 
under  the  best  hygienic  regime ; his  nutrition 
must  be  improved  by  good  living,  and  tho  exhi- 
bition of  cod-liver  oil,  steel,  and  quinine;  the 
favi  must  be  removed  by  poulticing;  and  para- 
siticides must  be  continuously  applied,  in  con- 
junction with  the  practice  of  epilation.  At  first 
sulphurous  acid  lotion  (one  part  to  three  or  four 
of  water)  may  bo  continuously  soaked-in  for 
some  time  ; and  this  may  be  followed  by  the 
infriction  of  iodide  of  sulphur  ointment,  double 
strength,  if  it  can  be  borne,  to  which  is  added 
oil  of  cade  in  tho  proportion  of  two  drachms  of 
the  latter  to  an  ounce  of  the  former. 

Tilbury  Fox. 

FEBRICULA  ( febricula , slight  fever). — 
Synon.;  Fr.  Febriculc ; Ger.  Febricula. 

Definition. — Simple  fever,  of  one  {Ephemera) 
cr  not  more  than  a few  days’  duration ; not  pre- 
ceded by  any  one  known  invariable  antecedent; 
and  not  attended  by  any  one  definite  organic  lesion. 


FEBRICULA.  505 

It  may  well  be  doubted,  however,  whether  such 
a thing  as  simple  fever,  in  the  strict  sense  of  the 
term,  exists  ; anyhow  it  must  be  one  of  the  rarer 
forms  of  disease.  The  conditions  which,  from 
our  necessarily  imperfect  knowledge,  it  is  con- 
venient to  call  Febricula  are  numerous  and  of 
great  practical  importance.  They  may  be  some- 
what roughly  grouped  as  follows  : — 

1.  Abortive  or  incomplete  forms  of  some  one 
or  other  of  the  specific  continued  fevers,  namely, 
typhus,  typhoid,  or  relapsing.  The  writer’s  own 
experience  leaves  no  doubt  in  his  mind  that 
such  irregular  forms  are  met  with  during  epi- 
demics of  those  diseases. 

2.  Instances  of  some  of  the  exanthemata,  es- 
pecially scarlatina  and  modified  variola,  in  which 
the  usual  rash  is  either  absent  or  so  slight  or 
brief  as  to  pass  unnoticed. 

3.  Intermittent  fevers  in  which  for  some 
reason  or  other  the  paroxv-sms  do  not  recur,  or 
only  at  uncertain  and  distant  intervals. 

4.  Cases  in  which  the  local  symptoms  usually 
attending  certain  forms  of  fever  are  very  slight 
or  very  obscure,  and  therefore  difficult,  perhaps 
impossible,  to  detect.  Instances  of  this  occur  in 
connection  with  tonsillitis,  erysipelas,  rheumatic 
fever,  and  tubercular  disease. 

5.  Cases  in  which  considerable  febrile  move- 
ment is  present  during  the  development  of  the 
primary  as  well  as  of  the  secondary  symptoms 
of  syphilis,  and  of  which  it  is  not  easy  to  ascer- 
tain the  real  cause. 

6.  Fever  as  the  consequence  of  exposure  to  a 
high  external  temperature,  for  instance,  th efebris 
ardens  of  tropical  climates  (Murchison);  and  of 
violent  and  prolonged  muscular  exertion. 

7.  Fever  as  the  consequence  of  irritation  of 
any  organ  or  tissue,  such  as  the  stomach  by  in- 
digestible matttr,  of  tho  colon  by  scybala ; or  of 
catarrh  of  a mucous  surface,  for  example,  urethral 
fever. 

8.  Certain  ill-understood  but  not  uncommon 
disorders  of  nervous  centres,  cerebral,  spinal,  or 
sympathetic,  are  often  followed  by  febrile  move- 
ment. 

Anatomical  Characters. — Fever,  however 
caused,  which  runs  high  produces  congestions 
and  tissue-changes  in  the  viscera,  especially  in 
the  lungs;  but,  in  view  of  the  short  duration  of 
febricula,  it  would  in  most  cases  be  impossible  to 
decide  whether  any  pathological  change  found 
after  death  were  the  consequence  or  the  cause, 
of  the  febrile  movement.  It  is  possible,  but  not 
yet  proved,  that  there  may  exist  some  contagion 
capable  of  producing  febricula,  and  febricula 
only. 

Symptoms. — Febricula  is  characterised  by  a 
rise  of  temperature,  rarely  exceeding  102'5°F., 
but  sometimes,  especially  in  cases  due  to  ex- 
posure, reaching  105°  F.  or  even  higher,  al- 
though only  for  a short  time.  The  access  of 
fever  may  be  gradual,  or  marked  by  slight  rigors ; 
and  some  or  all  of  the  common  clinical  sj-mptoms 
of  fever  may  be  present  in  varying  proportion 
and  in  greater  or  less  degree,  such  as  general 
malaise ; dry  skin  ; frequent  pulse,  amounting 
to  100  or  120  per  minute;  tongue  furred  and 
with  a more  or  less  distinct  central  dry  reddish- 
brown  streak;  thirst,  loss  of  appetite,  and 
nausea ; constipation ; scanty  high-coloured  urine ; 


506  FEBR10ULA. 

and  headache,  intolerance  of  light,  slight  deaf- 
ness, restlessness,  sleeplessness,  and  slight  de- 
lirium at  night. 

Diagnosis. — The  diagnosis  of  febrieula  rests 
upon  the  exclusion  of  all  the  other  recognised 
kinds  of  idiopathic  or  of  symptomatic  fever.  As 
a matter  of  practical  diagnosis  at  the  bedside, 
almost  every  disease  attended  by  rise  of  temper- 
ature is  now  and  then,  at  its  outset,  mistaken  for 
febrieula. 

Puognosis. — The  prognosis  depends  upon  the 
degree  and  duration  of  the  pyrexia,  but  in  this 
country  is  almost  always  favourable. 

Treatment. — In  the  absence  of  any  special 
indication,  rest  in  bed  for  a day  or  two,  liquid 
food  until  the  desire  for  solids  returns,  and,  if 
constipation  be  a marked  feature  of  the  case,  a 
moderate  dose  of  some  mild  purgative,  will  be 
sufficient.  It  is,  however,  always  prudent  to 
remember  that  what  seems  to  be  febrieula  may 
be  the  beginning  of  some  serious  and  perhaps 
highly  infectious  disease.  Cooling  drinks  such 
as  Citrate  of  Potash  in  effervescence,  Liquor  Am- 
monite Acetatis  with  a little  Spirit  of  iEther  ; 
or  Nitro-hydrochloric  or  Dilute  Nitric  Acid  (one 
drachm  to  a pint  of  water)  with  some  fresh 
lemon-juice  added,  may  be  given  according  as 
the  one  or  the  other  is  grateful  to  the  patient. 
Anything  like  active  treatment,  except  the  use  of 
the  cold  or  tepid  bath  in  cases  of  heat-fever,  is 
unnecessary,  rarely  does  good,  and  is  almost 
always  positively  injurious.  J.  Andrew. 

FEBRIFUGES  ( febris , a fever,  and  fugo,  I 
drive  away).  Svnon.  : Antipyretics. 

Definition. — External  applications  or  in- 
ternal remedies  which  tend  to  lower  the  bodily 
temperature  when  it  has  been  abnormally  raised 
by  the  processes  of  fever.  « 

Enumeration. — The  principal  febrifuges,  given 
in  the  order  of  their  activity,  are:  Cold  Baths; 
Cold  Affusion  or  Wet  Pack;  Alcohol,  and  Dia- 
phoretics ; Salicylic  Acid,  Quinine,  Digitalis,  and 
Aconite ; Trimethylamine  ; Iron ; and  Water  and 
Diluents  generally. 

Action. — Following  Professor  Binz,  we  may 
divide  febrifuges  into  two  classes: — 1.  those 
which  directly  withdraw  heat  from  the  fevered 
organism ; and,  2.  those  which  lessen  its  pro- 
duction. 

1.  In  the  first  division  we  must  give  the  fore- 
most place  to  cold  baths,  which  powerfully  ab- 
stract caloric  from  the  surface  of  the  body  and 
rapidly  cool  down  the  blood.  Diaphoretics  and 
alcohol  act  more  feebly  in  the  same  direction,  by 
dilating  the  cutaneous  arterioles,  and  thus  allow- 
ingthe  mass  of  the  circulating  fluid  to  be  effec- 
tually exposed  to  the  chilling  influence  of  the  air. 
See  Cold,  Therapeutics  of ; and  Diaphoretics. 

2.  Secondly,  we  have  to  consider  those  drugs 
which  actually  check  the  febrile  condition  itself, 
and  our  explanation  of  their  effects  must  natu- 
rally depend  on  the  views  held  regarding  the 
intimate  nature  of  fever.  If  we  believe  in  an  over- 
borne or  paralysed  condition  of  the  nervous  sys- 
tem as  any  essential  factor,  or  if  we  look  upon  the 
vascular  structures  as  primarily  at  fault,  then  we 
must  shape  our  theories  accordingly ; but  if  we 
believe,  with  our  best  authorities,  that  the  true 
explanation  must  be  looked  for  in  the  introduc- 


FEIGNED  DISEASES, 
tion  of  extraneous  ferments  or  septic  material 
into  the  blood,  the  matter  is  much  simplified. 
Quinine  and  salicylic  acid  then  merely  act  in 
virtue  of  then-  antiseptic  power  over  protoplasm  ; 
aud  if  malaria  really  depends  on  the  fermenting 
influence  of  vegetable  germs  from  decaying  vege- 
tation, then  the  so-called  specific  action  of  quinine 
is  readily  explained.  Again,  temperature  may 
be  lowered  by  checking  the  oxidation  of  the 
tissues,  and  interfering  with  the  oxygenating 
function  of  the  haemoglobin,  and  alcohol  is  said 
more  particularly  to  act  by  lessening  the  activity 
of  secreting  cells.  The  free  use  of  water  tends 
to  promote  excretion,  and  thus  to  remove  the 
products  of  oxidation. 

Uses. — Antipyretic  treatment  is  not  adopted 
in  this  country  as  a matter  of  routine,  holding  as 
we  do  that  temperatures  raised  within  certain 
limits  are  not  per  se  elements  of  danger,  and  that 
even  although  we  may  effectually  cool  down  our 
patient,  the  progress  of  the  disease  may  go  on 
quite  unchecked.  Butwhen  thethermometerregis- 
ters  105°,  and  still  tends  upwards,  we  know  that 
dangerous  limits  are  reached,  and  that  as  a rule 
life  is  not  long  sustained  after  107°.  It  then 
becomes  our  duty  to  interfere,  and  this  is  best 
done  by  plunging  our  patient  into  a bath  at  95°, 
and  gradually  cooling  it  down  to  65°.  When  the 
temperature  goes  down  to  within  4°  or  5°  of  the 
normal  we  remove  him  to  bed,  remembering  the 
dilatation  of  vessels  which  must  follow  the  con- 
tracting effect  of  cold,  and  the  consequent  cooling 
process  which  must  continue  to  go  on.  Here,  as 
in  all  febrile  conditions,  the  thermometer  is  onr 
surest  guide,  and  we  must  be  directed  by  it  as  to 
when  to  resume  the  treatment,  for  frequent  repeti- 
tion may  be  needed,  and  on  the  Continent  as  many 
as  200  baths  have  been  given  in  the  course  of  a 
single  illness.  Along  with  this  the  Germans  com- 
bine theuseof  largedosesof quinine;  but  notwith- 
standing the  marked  tolerance  of  the  drug  under 
pyrexial  conditions, the  danger  of  perilous  depres- 
sion from  such  free  medication  is  no  imaginary 
one ; and,  putting  ague  apart,  we  find  this  valu- 
able drug  most  beneficial  in  such  fevers  as  seem 
to  owe  their  origin  to  septic  poisoning.  Digitalis 
is  not  a powerful  antipyretic,  and  in  large  doses 
is  too  depressing  to  the  heart,  and  too  apt  to 
produce  gastric  derangement,  to  inspire  much 
confidence ; while  veratria  seems  simply  to  act 
by  throwing  the  patient  into  a form  of  col- 
lapse. The  influence  of  salicylic  acid  over 
acute  rheumatism  is  remarkable,  as  it  seldom 
fails  to  reduce  temperature  and  relieve  pain  in 
forty-eight  hours,  but  in  other  feverish  condi- 
tions its  beneficial  action  is  by  no  means  so  well 
marked.  Iron  is  of  value  in  erysipelas,  and  exerts 
some  controlling  power  over  acute  rheumatism. 
Aconite  and  diaphoretics  are  of  undoubted  ser- 
vice in  aiding  the  defervescence  of  some  of  the 
minor  febrile  disorders.  II.  Farquharson. 

FEBRIS  (Latin).  See  Fever. 

FEIGT7ED  DISEASES. — No  insignificant 
part  of  the  real  difficulty  in  the  practice  of  our 
profession  depends  on  what  we  may  call  feigned 
diseases.  The  art  of  diagnosis  consists  in  the 
power  of  recognising  morbid  conditions  with 
skill  and  promptitude  ; and  in  proportion  to  th' 
natural  sharpness  and  weli-digested  experience 


FEIGNED  DISEASES. 


of  the  medical  man,  is  his  success  in  the  discri- 
mination of  one  symptom  from  another  which 
resembles  it  more  or  less  superficially.  Many 
disorders  possess  a strong  family  likeness  in 
their  very  early  stages,  whilst  others  may  prove 
deceptive  throughout  their  whole  career,  and  if 
to  this  we  add  tho  efforts  at  deception  occasion- 
ally resorted  to  by  impostors,  we  see  the  caution 
which  must  of  necessity  be  adopted  by  those  who 
exercise  their  calling  within  wide  limits.  In 
considering,  therefore,  the  subject  of  Feigned 
Diseases  a greater  amount  of  order  may  attend 
our  studies  if  we  adopt  the  following  simple 
classification : — 

1.  Those  diseases  which  naturally  resemble 
one  another,  and  in  the  deception  attending  tho 
diagnosis  of  which  tho  patient  has  no  share. 

2.  Those  diseases  which  are  also  difficult  of 
diagnosis,  but  in  which  the  patient  involuntarily 
deceives  under  some  morbid  nervous  impulse. 

3.  Cases  in  which  tho  patient  sets  himself 
deliberately  and  elaborately  to  deceive  those 
around  him. 

1.  Under  this  heading  we  may  perhaps  in- 
clude the  exanthemata  and  other  acute  feverish 
affections,  which  are  confessedly  difficult  of  diag- 
nosis before  the  eruption  or  other  marked  points 
of  difference  are  fully  established.  Important 
though  it  may  be,  in  the  case  of  public  schools  or 
large  bodies  of  men,  to  act  promptly  in  the  faco 
of  such  an  emergency,  the  medical  man  will 
often  feel  himself  compelled  to  postpone  his  de- 
cision, but  he  should  at  the  same  time  act  on  the 
defensive  by  tho  timely  exercise  of  quarantine 
and  hygienic  precautions.  Some  diseases,  again, 
are  difficult  to  distinguish  from  one  another, 
even  after  their  prodromata  have  passed  away, 
and  among  these  we  may  include  small-pox  and 
pustular  syphilis,  which  occasionally  in  our  own 
experience  have  caused  more  than  a shade  of 
suspicion  to  pass  over  the  mind ; whilst  mild 
variola  and  severe  varicella  must  always  have 
too  many  points  in  common,  to  render  them 
otherwise  than  stumbling-blocks  even  to  the 
initiated.  Various  forms  of  roseola  may  closely 
simulate  measles  ; scabies  is  often  hardly  to  be 
picked  out  from  amongst  the  eruptions  which  its 
irritation  causes;  whilst  throat-affections  may  ap- 
parently overlap  each  other  and  engender  the  idea 
of  diphtheria  where  nothing  more  than  super- 
ficial or  aphthous  ulceration  really  exists.  But 
it  is  when  the  ailment  under  which  our  patient 
labours  resembles  something  else  during  its 
whole  career,  that  mistakes  are  naturally  most 
likely  to  arise.  We  are  frequently  shocked  with 
some  scandal  in  which  the  innocent  victim  of 
brain-  or  other  organic  disease  has  been  consigned 
toapolice-cell,  and  where  the  plea  of  drunkenness 
Las  been  attempted  to  be  sustained  by  the  guar- 
dians of  the  public  peace.  So  difficult  i s it  to  make 
a really  trustworthy  diagnosis  between  the  coma 
of  alcohol,  of  uraemia,  of  opium,  and  of  certain 
apoplectic  conditions,  that  the  really  cautious 
and  well-informed  practitioner  would  prefer  not 
to  attempt  to  do  so  offhand.  It  is  impossible  to  lay 
down  any  general  rules,  but  we  may  remember 
that  alcohol  in  poisonous  doses  lowers  the  tem- 
perature and  dilates  the  pupil ; that  in  uraemia 
an  examination  of  the  urine  will  put  us  in  the 
tight  track  ; whereas  opium  will  produce  a con- 


53? 

tracted  pupil ; and  in  cerebral  haemorrhage  some 
elevation  of  the  body-heat  may  not  improbably 
be  observed. 

But  all  these  points  may  fail  us  from  time  to 
time,  and  we  had  best  act  at  all  times  as  though 
the  case  were  really  a serious  one,  and  worthy 
of  being  treated  by  all  the  best  resources  of  the 
medical  art. 

A very  little  consideration  will  enable  every 
experienced  practitioner  to  recall  other  instances 
of  this  sort  of  natural  mimicry ; of  the  difficulty 
he  must  often  experience  in  deciding  between 
syphilitic  and  other  brain-affections  ; of  the  close 
affinity  between  pulmonary'  consumption  and 
dilatation  of  the  bronchial  tubes ; of  the  resem- 
blance between  specific  and  malignant  ulcera- 
tions ; between  various  diseases  of  tho  testicle, 
the  bladder,  and  the  stomach,  respectively'.  All 
these  form  part  of  the  regular  teaching  of  medicine 
and  surgery,  and  will  be  treated  of  at  greater  or 
loss  length  elsewhere. 

2.  We  must  now  consider  the  cases  in  which 
diseases  are  feigned  not  by  the  direct  action  of 
the  patient  himself,  but  because  he  is  unable  to 
resist  the  vagaries  of  his  weak  and  excitable 
nervous  system. 

Problems  of  the  greatest  complexity  and  diffi- 
culty are  here  presented  to  the  medical  man  and 
require  for  their  due  solution  much  tact  and  ex- 
perience. Functional  affections  so  closely  simu- 
late organic  disease  under  these  circumstances 
that  suspicion  is  often  completely  disarmed,  and 
treatment  adopted  the  very  opposite  of  that 
which  would  most  probably  prove  curative. 
Hysteria,  in  its  protean  forms,  supplies  the 
greater  number  of  these  cases,  and  may  very 
closely  simulate  a large  variety',  more  especially 
of  neurotic  conditions.  Paraplegia,  incon- 
tinence of  urine,  joint-affections — in  short, 
almost  any  disease  which  does  not  admit  of 
palpable  objective  demonstration — may  thus  be 
feigned,  and  very  severe  treatment  may  even  be 
adopted  under  the  belief  that  real  organic 
changes  have  to  be  met  by  the  usually  appro- 
priate remedies.  It  is  only  necessary  for  us  to 
refer  thus  briefly  to  these  perplexing  cases  here  ; 
but  it  must  always  remain  an  interesting  pro- 
blem as  to  how  the  mechanism  of  causation 
here  works,  so  to  speak,  and  whether  the  patient 
actually  suffers  the  acute  pain  of  which  she  com- 
plains so  forcibly.  Sympathy,  as  we  well  know, 
however,  is  quite  thrown  away  when  dealing  with 
these  persons ; and  apparent  roughness,  with 
nervine  tonics,  and  mental  discipline,  will  often 
effect  a cure,  when  the  most  elaborate  combina- 
tions of  other  drugs  ignominiously  fail.  A sudden 
shock,  the  pressure  of  poverty,  or  the  absolute 
necessity  for  immediate  exertion,  will  often  effec- 
tually and  permanently  arouse  the  bedridden 
hypochondriac  of  many  years,  and  restore  him  to 
his  friends  as  a useful  member  of  society,  and  wo 
need  never  despair  of  success  even  under  appa- 
rently hopeless  circumstances.  And  although  in 
minor  measure  the  hypochondriac  may  fancy  that 
every  organ  in  succession  is  the  seat  of  disease, 
and  may  even  succeed  in  thus  imposing  on  the 
unwary,  the  experienced  practitioner  will  speedily 
detect  the  fiction  and  be  able  to  relieve  the  un- 
happy sufferer  from  the  weight  of  his  woes. 

But  let  it  not  be  forgotten  that  ■ expectant 


508  FEIGNED  DISEASES, 
attention,’  or  the  constant  direction  of  the  mind 
to  the  supposed  morbid  condition  cf  any  par- 
ticular organ,  may  actually  catch  the  unconscious 
deceiver  in  his  own  net  by  converting  mere 
functional  disturbance  into  organic  disease. 

■ To  the  third  division  of  our  subject  the 
term  Feigned  Diseases  can  perhaps  alone  strictly 
be  applied.  Here  we  are  met  face  to  face  with 
deliberate  and  premeditated  imposture,  and  there 
is  nothing  for  it  but  to  match  our  own  wits 
against  those  of  the  deceiver,  and  to  thwart  his 
native  cunning  by  the  superior  sharpness  of 
science.  Now,  there  is  nothing  in  the  history  of 
medicine  more  remarkable  than  the  elaborate  ex- 
pedients adopted,  and  the  amount  of  actual  dis- 
comfort and  suffering  endured,  by  persons  who 
have  been  desirous  of  escaping  military  or  other 
duty.  The  exhaustive  works  of  Gavin  and  Mar- 
shall, and  Boisseau  and  others,  give  us  details  no 
less  ingenious  than  interesting  of  these  devices ; 
but  it  is  curious  to  note  in  how  limited  a range 
the  more  traditional  modes  of  imposture  seem  to 
run.  and  how  the  same  old  stories  are  made  to 
do  duty  over  and  over  again.  Thus  we  read  of 
blindness,  and  deafness,  and  epilepsy,  and  para- 
lysis being  carefully  imitated,  and  can  hardly 
withhold  our  admiration  from  the  astonishing 
tenacity  with  which  the  apparent  symptoms 
were  duly  maintained.  Incontinence  of  urine, 
dysentery,  haemoptysis,  jaundice,  and  insanity 
were  among  the  most  favourite  roles  in  the 
repertoire,  and  ingenious  as  were  tho  prepara- 
tions for  duly  sustaining  the  part,  no  less  in- 
genious were  the  means  for  detection,  which 
usually  proved  successful.  However  carefully 
the  impostor  had  studied  his  character,  some 
little  point  was  usually  omitted.  The  yellow 
conjunctiva  of  jaundice  can  hardly  be  feigned  ; 
the  incontinence  of  urine  was  generally  found  to 
bo  attended  by  an  expulsive  effort;  the  blood 
apparently  proceeding  from  the  lungs  was  by  no 
means  intimately  mixed  with  the  pulmonary 
mucus ; the  blindness,  or  the  deafness,  or  the 
paralysis  were  not  proof  against  some  sudden 
shock  or  mental  impression.  Most  of  the  cases 
so  carefully  described  by  writers  on  military 
medicine  are  now  mere  matter  of  history,  and 
are  hardly  likely  to  occur  again.  And  the 
reasons  for  this  are  twofold.  First : the  in- 
ducement for  deception  is  practically  gone.  In 
former  days,  when  the  soldier’s  pay  was  small 
and  his  hygienic  condition  bad,  discharge  from 
the  service  as  an  invalid  was  eagerly  prized  as  a 
means  of  escaping  irksome  duty,  but  things  have 
greatly  changed  for  the  better  of  late  years. 
Not  only  is  the  emolument  and  the  comfort  of 
our  army  vastly  increased,  but  short  service  and 
the  Eeserve  enables  men  to  retire  early  into  civil 
life,  whilst  the  abolition  of  bounty  has  removed 
the  principal  pecuniary  inducement  for  frequent 
desertion  and  re-enlistment.  It  is  now  found 
much  easier  for  a man  simply  to  desert  than  to 
go  through  any  elaborate  process  for  the  per- 
sonification of  disease.  Again,  the  savage  process 
of  forcible  impressment  for  naval  service  was 
naturally  productive  of  many  attempts  to  escape 
from  the  hard  work  and  ferocious  discipline  of 
our  men  of  war.  Secondly:  the  process  of 
science  and  improved  means  of  diagnosis  have 
rendered  the  task  of  the  impostor  difficult,  if  not 


FEVER. 

well-nigh  hopeloss.  Feigned  blindness  can  hardly 
resist  the  test  of  the  ophthalmoscope ; electricity 
will  clear  up  many  apparently  anomalous  nervous 
symptoms;  the  stethoscope  and  the  sphygmograph 
will  tell  us  the  real  condition  of  the  heart ; and 
careful  observation  will  detect  the  rougher  at- 
tempts to  deceive.  Again,  malingering  may  often 
be  exposed  by  examination  under  chloroform  or 
ether.  We  are  not  likely  now  to  be  taken  in  by 
a piece  of  liver  tied  to  the  breast  to  simulate 
cancer,  or  by  an  artificial  nasal  polypus;  and 
although  skin-diseases  and  ulcerations  may  be 
made  or  kept  up  by  local  applications,  we  only 
require  a suspicion  to  cross  our  minds  to  put  us 
on  the  right  track  for  discovery. 

We  are  not,  however,  to  suppose  that  all 
attempts  at  deception  have  finally  passed  away, 
that  feigned  diseases  are  now  things  of  the  past. 
Anyone  whose  practice  lies  ameng  prisoners  or 
soldiers  or  schoolboys  will  very  soon  be  convinced 
to  the  contrary.  Experience,  however,  will  soon 
show  him  what  the  schemers  are,  and  enable  him 
t;  circumvent  their  endeavours ; and  the  range 
of  symptoms  simulated  will  soon  be  found  to  bo 
singularly  narrow.  Subjective  sensations  are  of 
course  very  difficult  to  detect,  and  if  a headache, 
or  pain  in  the  back  or  leg  or  arm,  be  complained 
of  by  the  sufferer,  real  or  assumed,  we  may  often 
find  it  best  for  our  own  reputation  to  give  him 
the  benefit  of  the  doubt.  A case  which  hap- 
pened to  the  writer  whilst  medical  officer  to 
Rugby  School,  forcibly  illustrates  this  position. 
A little  boy  complained  on  several  successive 
mornings  of  most  severe  pain  in-  the  right  calf, 
rendering  him  almost  or  quite  unable  to  walk. 
Inspection  could  discover  nothing  wrong,  there 
was  no  redness  nor  tenderness,  and  he  had  no 
recollection  of  any  injury.  Some  suspicion  of 
malingering  was  aroused,  but  it  was  thought  most 
prudent  to  allow  him  to  remain  at  rest.  Four 
days  later  a red  spot  appeared  about  the  middle 
of  the  calf,  followed  by  a superficial  abscess, 
which  broke  in  due  course,  giving  exit  to  half  an 
ordinary  sewing  needle,  which  had  evidently  been 
working  its  way  gradually  upwards  among  the 
muscles  of  the  leg.  How  it  obtained  admittance 
could  not  bo  ascertained.  Whilst  proceeding, 
therefore,  with  due  caution,  the  practitioner  must 
endeavour  to  hold  the  balance  bet  ween  an  excess 
of  suspicion  and  a too  credulous  attitude,  remem- 
bering that  the  good  of  society  and  of  the  public 
service  must  be  fairly  considered,  whilst  all  care 
must  be  taken  not  to  confound  the  innocent  with 
the  guilty  in  dealing  with  disorders  which  in- 
genuity has  occasionally  been  enabled  to  feign. 

Robert  Fakquharson. 

FEIGNED  INSANITY.  -See  Insanity, 
Feigned. 

FESTEB. — A superficial  suppuration  result- 
ing from  irritation  of  the  skin ; the  pus  being  de- 
veloped in  vesicles  of  irregular  figure  and  extent. 
The  suppurating  inflammation  caused  by  a thorn 
or  splinter  of  wood  forced  into  the  flesh  is  a com 
mon  example  of  a fester. 

FEVER  (Jcrveol  am  hot). — Synon.  : Purexiu : 
Fr.  Fievre ; Ger.  Ficbcr. 

Definition. — One  of  the  most  remarkable 
facts  in  connection  with  disease,  is  the  rise  of 
temperature  which  is  attendant  upon  almost 


FEVER. 


every  disturbance  to  ■which  the  body  is  sub- 
jected. This  rise  of  the  temperature  of  the 
body,  when  it  attains  a certain  height,  and  lasts 
a certain  time,  is  called  Fever,  and  is  accompanied 
by  derangement  of  function,  attributable  to  the 
febrile  condition  itself,  and  in  a measure  inde- 
pendent of  the  initial  cause. 

General  Considerations.  — Fever  plays  so 
important  a part  in  acute  disease  generally,  is 
accepted  so  universally  as  a mark  of  the  severity 
of  the  disease,  and  so  often  presents  itself  as 
apparently  the  chief  antagonist  with  which  the 
physician  or  surgeon  has  to  contend,  that  the  at- 
tempt to  penetrate  the  secret  of  its  essential  nature 
lias  always  been  a favourite  task,  and  every  school 
in  every  age  has  had  its  theory  of  the  febrile  pro- 
cess. It  is  only,  however,  within  comparatively 
fow  years  that  exact  measurement  of  the  body- 
heat  by  the  clinical  thermometer,  combined  with 
chemical  examination  of  the  various  excretions 
at  different  temperatures,  and  aided  by  the  ex- 
perimental method  of  investigation,  has  furnished 
the  data  for  such  a theory.  A minute  descrip- 
tion of  fever  in  the  abstract,  distinguishing,  as 
would  be  required,  between  phenomena  proper 
to  fever,  and  phenomena  due  to  the  condition 
or  lesion  on  which  the  fever  depended  would 
be  lengthy,  and  so  crowded  with  qualifications 
and  exceptions  as  to  be  vague  and  unsatisfactory. 
The  attempt,  indeed,  would  have  a more  radical 
defect.  Either  some  variety  of  fever  must  be 
taken  as  a type  to  which  other  forms  are  re- 
ferred, which  is  vicious  in  principle ; or  all  the 
phenomena  of  all  febrile  conditions  must  be 
enumerated  and  classified,  which  would  con- 
found the  accidental  with  the  essential,  and 
would  result  in  a heterogeneous  collection  of 
facts  without  due  relation  among  themselves. 

A mere  outline  therefore  will  be  given  of  the 
principal  deviations  from  normal  functional  ac- 
tion observed  in  fever,  and  the  space  set  apart 
for  the  subject  will  be  reserved  for  an  exposi- 
tion of  what  is  known  of  the  nature  of  the 
febrile  process. 

Description. — In  every  attack  of  fever  there 
are  traceable  the  three  stages  of  invasion,  domina- 
tion, and  decline,  with  or  without  an  antecedent 
period  of  incubation.  They  may  all  be  run  through 
in  the  course  of  a few  hours,  as  in  a paroxysm  of 
ague,  or  they  may  extend  over  weeks. 

The  period  of  invasion  is  characterised  by  a 
rising  internal  temperature,  while  the  surface 
may  remain  cold  and  pale,  the  patient  feeling 
chilly  and  suffering  from  rigors  or  shivering ; 
the  pulse  is  frequent,  but  generally  small  and 
long,  from  contraction  of  the  arteries.  During 
the  dominance  of  fever  the  temperature  re- 
mains high,  the  skin  is  hot,  and  the  shiverings 
are  replaced  by  a subjective  sense  of  heat ; the 
pulse  is  now  full  and  bounding  from  relaxation 
of  the  arterial  wall.  The  decline  is  indicated 
by  a falling  temperature,  a softer  and  less  fre- 
quent pulse,  and  by  a return  towards  normal 
conditions  generally ; it  may  be  initiated  or  ac- 
companied by  a critical  sweat  or  other  evacua- 
tion. Death  may  take  place  at  any  period  of 
the  disease. 

Taking  the  temperature  as  the  index  of  the 
duration  and  character  of  each  stage,  we  may 
find  it  in  the  first  stage  rising  abruptly  or 


509 

gradually,  continuously  or  with  remissions.  If 
the  invasion  extends  over  several  days  as  in 
enteric  fever,  nocturnal  exacerbations  and  morn- 
ingremissions  are,  as  a rule,  observed.  A rapid 
rise  of  temperature  is  usually  continuous,  or 
nearly  so.  When  the  opportunity  occurs  of 
making  the  observation,  as  in  intermittent  or 
relapsing  fever,  or  when  fever  is  experimentally 
induced  in  animals,  or  in  man  by  surgical  opera- 
tion or  accidental  septic  inoculation,  the  increased 
heat  is  found  to  be  the  initial  phenomenon,  pre- 
ceding the  rigors  and  all  other  symptoms. 

The  end  of  the  period  of  invasion,  and  the 
setting  in  of  the  stage  of  dominance,  is  more 
distinctly  marked  by  the  change  in  the  character 
of  the  pulse,  and  by  the  determination  of  blood 
to  the  surface,  together  with  the  substitution  of 
the  subjective  sensation  of  heat  for  that  of  cold, 
than  by  the  thermometer. 

During  the  dominant  stage  the  temperature 
remains  at,  or  oscillates  about,  a given  point, 
and  the  fever  is  considered  to  be  moderate  if 
the  morning  temperature  is  102°  or  under,  and 
the  evening  not  above  103°;  to  bo  high  when  it 
ranges  between  103°  in  the  morning  and  101°  in 
the  evening;  and  to  be  severe  when  these  limits 
are  exceeded ; while,  with  rare  exceptions,  a 
temperature  of  100°  indicates  great  danger.  As 
the  stage  advances,  the  heat  may  gradually  rise 
or  fall;  the  oscillations  being  slight  or  consider- 
able, and  at  times  irregular  and  extreme.  Except 
when  the  fever  is  due  to  local  inflammation,  or 
to  continual  entry  into  the  blood  of  morbid  par- 
ticles or  fluids,  the  duration  of  the  dominance 
is  usually  in  proportion  to  the  time  occupied  by 
the  invasion. 

The  decline  again  is  generally  abrupt,  and  has 
the  character  of  a crisis  when  the  invasion  has 
been  rapid,  and  is  protracted  when  it  has  been 
gradual. 

A fatal  termination  may  be  ushered  in  by 
hyperpyrexia ; more  commonly  the  temperature 
falls  below  the  normal  point  and  there  is  collapse. 

The  pulse  is  always  increased  in  frequency  by 
fever,  but  while  during  the  height  of  the  disease 
there  is  usually  some  relation  between  the  body- 
heat  and  the  pulse-rate,  the  pulse  is  often  ex- 
tremely frequent  before  the  temperature  has 
reached  its  height  during  the  invasion,  and  it 
does  not  in  all  cases  fall  with  it  pari  passu  in 
the  decline.  The  different  stages  are  marked 
rather  by  differences  in  the  character  of  the 
pulse  than  in  its  rapidity;  during  the  period  of 
invasion  the  arteries  are  more  or  less  in  spasm, 
and  the  pulse  is  small  and  long ; during  the 
dominance,  with  certain  exceptions,  the  arterial 
walls  relax,  the  vessels  are  large,  and  the  pulse 
full  and  bounding;  as  the  fever  declines  the 
arteries  are  still  further  relaxed,  but  the  action 
of  the  heart  is  less  powerful,  so  that  the  pulse 
becomes  softer. 

Respiration  is  frequent,  following  as  a rule 
the  pulse : the  amount  of  carbonic  acid  expired 
is  greatly  increased. 

The  tongue  is  generally  more  or  less  furred, 
its  appearance  varying  with  the  degree  and  kind 
of  fever  and  with  its  cause.  It  becomes  brown 
and  dry,  or  unnaturally  red  in  protracted  and 
adynamic  fever,  when  the  teeth  and  lips  may 
also  be  ceated  with  sordes.  There  are  almost 


FEVER. 


310 

always  thirst  and  loss  of  appetite.  The  bowels 
are  usually  confined. 

The  secretions  are  all  more  or  less  modified. 
The  perspiration  may  be  greatly  increased  as  in 
acute  rheumatism,  or  apparently  checked,  caus- 
ing the  skin  to  be  dry  and  burning.  The  amount 
of  urine  will  vary  to  a certain  extent  inversely 
with  the  amount  of  perspiration ; but  the  ten- 
dency is  to  increase,  and  the  solid  organic  mat- 
ters— urea  and  other  nitrogenised  substances— 
are  always  considerably  augmented  in  quantity. 
The  chloride  of  sodium,  on  the  contrary,  ,‘s  dimi- 
nished. 

The  characteristic  nervous  phenomena  of  the 
stage  of  invasion  are  rigors,  which  may  be  slight, 
and  represented  only  by  shivering  or  chilly  sensa- 
tions, or,  on  the  other  hand,  may  be  intensified 
to  convulsion.  Severe  headache  is  more  common 
at  this  period  than  in  the  later  stage,  and  there 
is  usually  considerable  depression.  When  the 
fever  has  reached  its  height  the  rigors  will  have 
ceased,  and  there  maybe  little  or  much  delirium 
according  to  the  severity  of  the  attack,  or  the 
idiosyncrasy  of  the  patient,  or,  again,  accord- 
ing to  the  kind  of  disease  giving  rise  to  the  fever. 

Pathology. — The  description  of  the  febrile 
state  has  been  cut  short  in  order  to  leave,  place 
for  a discussion  of  the  nature  and  cause  of  the 
febrile  process. 

This  will  be  facilitated  by  a brief  reference 
to  the  production  and  regulation  of  the  heat 
of  the  body  in  health,  and  would  be  compara- 
tively easy  had  physiologists  arrived  at  a com- 
plete and  satisfactory  solution  of  this  problem. 
In  the  normal  state  the  main  source  of  animal 
heat  is  blood-  and  tissue-combustion.  Another 
very  slight  and  unimportant  cause  will  be  ob- 
structed motion  of  the  blood  in  the  capillaries : 
of  direct  conversion  of  nerve-force  into  heat  we 
know  nothing  definite.  The  interesting  and 
difficult  part  of  the  question  is  that  which  re- 
lates to  the  regulation  of  the  temperature.  It 
has  been  found  that  the  changes  which  evolve 
heat  are  most  active  in  muscle,  in  the  nervous 
structures,  and  in  the  abdominal  viscera ; while  in 
the  lungs,  any  combustion  which  may  take  place 
is  not  more  than  will  counteract  th6  loss  of  heat 
by  evaporation  and  by  the  expired  air.  The 
skin,  on  the  other  hand,  is  the  great  cooling 
agent;  there  is  little  combustion  of  its  struc- 
tures and  it  is  continually  losing  heat  by  conduc- 
tion when  the  surrounding  temperature  is  low, 
but  still  more  abundantly  by  evaporation  under 
all  conditions  of  external  temperature.  Heat  is 
thus  abstracted  from  the  blood  circulating  in, 
and  immediately  beneath,  the  skin.  At  first  sight 
then  it  would  seem  that  the  mechanism  by  which 
the  temperature  was  regulated  was  extremely 
simple,  and  that  it  was  to  be  found  in  the  vaso- 
motor system  of  nerves.  There  being  an  internal 
heat-producing  mass  of  tissue,  and  an  external 
refrigerating  surface,  to  raise  the  temperature, 
the  arterioles  of  the  skin  are  contracted,  shutting 
off  the  blood,  while  those  of  the  deeper  structures 
are  relaxed,  allowing  it  to  reach  them  in  greater 
abundance ; in  this  way  a double  influence  is 
exerted,  less  heat  is  lost  by  the  skin,  and  more 
is  produced  in  the  muscles  and  other  internal 
parto.  Conversely,  the  temperature  would  be 
lowered  by  flushing  the  skin  wi‘h  blood — which 


would  thus  be  exposed  to  cooling  influences — and 
diverting  it  from  the  heat-forming,  deep-seated 
structures.  This  explanation,  however,  is  inade- 
quate ; it  is  true  that  the  distribution  of  the 
blood,  superficially  or  deeply,  by  means  of  the 
vaso-motor  nervous  system,  contributes  largely 
to  the  regulation  of  the  temperature,  but  heat- 
production  in  muscle  or  gland  is  not  directly 
proportionate,  simply  to  the  amount  of  blood 
circulating  through  it;  tissue-combustion,  and 
consequent  evolution  of  heat,  are  excited  or  re- 
pressed by  cerebro-spinal  nerves  not  governing 
the  arteries.  The  nervous  system  thus  inter- 
venes directly  in  heat>production  as  well  as 
indirectly  through  its  influence  on  the  circula- 
tion, and  it  has  been  shown  that  the  stimulus 
to  tissue-change  and  heat-production  is  a reflex 
from  peripheral  impressions.  This  is  not  the 
place  to  discuss  the  question  whether  there  are 
special  thermal  nerves  and  centres,  but  it  may 
be  said  that  this  has  not  been  proved. 

Taking  the  increased  heat  as  the  charac- 
teristic of  fever,  the  first  question  which  arises 
is  whether  this  is  due  to  increased  production  of 
heat,  or  to  diminished  loss.  While  the  diminished 
circulation  in  the  skin,  in  the  early  stage,  will 
obviously  tend  to  retain  heat  within  the  body, 
there  is  now  no  room  for  doubt  that  there  is 
increased  heat-production ; the  temperature  rises 
in  spite  of  profuse  perspiration,  when  of  course 
heat  is  very  rapidly  lost,  as  in  acute  rheumatism, 
or  when  perspiration  has  been  induced  by  jabo- 
randi  before  a paroxysm  of  ague  (Ringer)  ; and 
it  has  been  shown  by  direct  experiment  that  in 
fever  a man  raises  the  temperature  of  a given 
quantity  of  water  in  which  he  is  immersed 
more  quickly,  and  to  a higher  point,  than  in 
health  (Liebermeister).  It  is  unnecessary  to 
give  other  proofs  or  further  refutation  of  the 
hypotheses  which  explain  the  heat  of  fever 
solely  by  diminished  escape  of  heat  from  the 
body. 

It  may  further  be  taken  as  certain  that  the 
immediate  cause  of  the  increased  generation  of 
heat  is  increased  blood-  and  tissue-oxidation. 
This  is  shown  by  the  increased  products  of  com 
bustion  given  off  in  the  different  excretions. 
The  febrile  elevation  of  temperature  is  attended 
at  once  by  increase  in  the  amount  of  carbonic 
acid  expired.  This  is  more  marked  during  the 
rise  than  when  the  heat  has  attained  its  maxi- 
mum, because  the  increasing  temperature  expels 
the  gases  of  the  blood,  and  the  greater  rapidity 
of  the  circulation  sends  the  blood  more  freely 
and  quickly  through  the  lungs,  and  exposes  it 
more  to  the  air.  At  first  there  will  thus  be 
eliminated  not  only  the  carbonic  acid  formed 
under  the  influence  of  the  febrile  process,  but 
that  which  was  held  in  solution  by  the  cooler 
blood,  and  is  driven  off  as  its  temperature  rises  ; 
when  the  expulsion  of  dissolved  carbonic  acid  is 
completed,  the  amount  excreted  will  be  dimi- 
nished by  so  much,  but  it  still  remains  larger  than 
at  the  normal  temperature. 

A similar  indication  of  increased  tissue-com- 
bustion is  furnished  by  the  urine.  The  amount 
of  urea  is  usually  absolutely  increased,  notwith- 
standing a diminished  consumption  of  nitro- 
genised food  ; or  if  the  urea  itself  is  not  excreted 
in  larger  quantity,  there  is  more  nitrogenised 


FEVER. 


waste  in  other  forms.  The  total  of  nitrogenised 
matter  contained  in  the  urine  is  always  aug- 
mented by  fever. 

The  real  difficulty  of  the  problem  arises 
when  we  inquire  what  is  the  cause  of  the  in- 
creased tissue-combustion.  It  has  been  already 
stated  that  the  distribution  of  the  blood  to  the 
deep  structures  and  organs  and  to  the  skin 
respectively  is  not  a sufficient  explanation  of 
the  physiological  balance  of  heat ; but  it  might 
be  supposed  that  the  greater  rapidity  of  the 
circulation  in  fever  renewing  the  supply  of 
oxygenated  blood  within  the  structures  more 
frequently  and  more  freely,  would  account  for 
the  greater  oxidation.  The  rise  of  temperature, 
however,  is  not  in  proportion  to  the  flow  of 
blood  through  the  vessels,  and  hyperpyrexia 
is  often  coincident  with  a failing  circulation, 
the  heat,  indeed,  apparently  in  some  cases 
actually  increasing  after  death. 

One  step  towards  the  solution  which  may  be 
considered  certain  is  that  the  nervous  system  is 
concerned  in  the  maintenance  of  the  heat  of 
fever.  Each  disease  has  its  own  characteristic 
range  and  variations  of  temperature,  and  this  fact 
alone,  that  febrile  heat  is  not  vague  and  irregu- 
lar, but  that  there  is  the  substitution  of  a 
morbid  for  a normal  balance,  is  evidence  of 
nervous  control.  Numerous  observed  facts  and 
experiments  point  to  the  same  conclusion.  We 
need  only  mention  the  hyperpyrexia  often  re- 
sulting from  injuries  to  the  brain,  and  following 
section  of  the  cord  in  the  cervical  region. 

Another  item  of  positive  knowledge  obtained 
by  experiment  is  that  pyrexia  may  be  excited 
by  the  introduction  into  the  blood  of  septic  or 
ether  matters,  which,  it  is  important  to  note, 
need  not  be  particulate,  but  may  be  diffusible 
fluid.  The  increased  heat  may  therefore  be  in- 
dependent of  capillary  embolisms  and  of  bacteroid 
or  other  organisms. 

Now  in  disease  or  after  injuries  we  have 
almost  always  both  causes  in  possible  operation 
— an  impression  on  the  nervous  system,  and  the 
entry  of  altered  organic  matters  into  the  blood. 
In  endeavouring  to  assign  prominence  to  one  or 
other,  we  have,  on  the  one  hand,  such  facts  as 
the  hyperpyrexia  of  cerebral  lesions,  which 
cannot  be  due  to  blood-contamination,  and,  on 
the  other,  the  teachings  of  antiseptic  surgery, 
which  demonstrate  that  absorption  of  putrescent 
discharges  is  the  great  cause  of  surgical  fever. 
It  still  remains  to  be  determined  whether  the 
presence  in  the  blood  of  foreign  matters  gives 
rise  directly  to  increased  activity  of  oxidation, 
or  whether  the  poison,  as  we  may  call  it,  pro- 
duces this  result  through  its  action  on  the  ner- 
vous system,  either  by  affecting  the  nerve- 
centres  themselves,  or  by  producing  irritation  in 
the  capillaries,  which  is  carried  to  the  nerve- 
centres,  and  reflected  along  efferent  nerves.  In 
the  present  state  of  our  knowledge  this  question 
cannot  be  definitely  settled. 

If  a theory  of  the  febrile  process  is  to  be 
formed  it  must  be  based  upon  a theory  of  the 
relation  between  the  nervous  system  and  the 
rrocesses  of  nutrition  and  oxidation,  and  es- 
pecially the  latter.  Numerous  facts  of  disease 
and  of  experiment  point  to  the  conclusion  that  the 
circulation  of  duly  oxygenated  blood  through  the 


oil 

tissues  at  the  usual  rate  would,  without  some 
check  to  oxidation,  result  in  more  rapid  tissue- 
change  and  the  production  of  a higher  tempera- 
ture than  the  established  norm.  The  restrain- 
ing power  is  supplied  by  the  nervous  system, 
the  loss  of  this  influence  being  illustrated  in 
hyperpyrexia.  The  mode  in  which  the  nervous 
system  acts  may  be  represented  as  being  through 
the  tension  maintained  in  the  nerve-centres. 
All  nervous  actions  have  the  character  of  phe- 
nomena of  tension,  and  the  tension  generated  in 
the  cells  is  sustained  in  the  nerve-fibres  to  their 
peripheral  terminations,  where  they  are  merged 
in  the  structures,  and  so  blended  with  them  that 
all  nutritive  and  oxidative  changes  are  common 
to  the  nerve-endings  and  the  tissues  in  which 
they  end.  If  we  suppose  that  the  nerve-tension 
can  modify  chemical,  action,  as  can  electrical 
tension  or  thermal  conditions,  and  that,  vice 
versa,  the  nutritive  and  oxidation  changes  in  the 
tissues  can  influence  the  tension  of  the  nervous 
structures,  we  can  represent  to  ourselves  the 
interaction  between  the  nervous  system  and  the 
blood  and  tissues  in  the  febrile  process.  When 
from  disease  or  injury  of  the  great  nerve-centres 
their  power  of  maintaining  tension  is  abolished, 
and  their  influence  destroyed,  the  affinities  of 
the  blood  and  tissues  have  unrestricted  play,  and 
the  result  is  hyperoxidation  and  pyrexia.  When, 
on  the  other  hand,  septic  matters  or  other  sub- 
stances are  introduced  into  the  blood,  acting  as 
ferments  or  in  some  other  way,  they  increase 
oxidation,  and  directly  raise  the  temperature, 
overpowering  the  restraining  influence  of  the 
nerves  until  this  is  reinforced,  which  may  pos- 
sibly occur  through  increased  evolution  of  energy, 
resulting  from  the  increased  activity  of  meta- 
morphosis. We  cannot,  however,  here  develop 
or  fully  elaborate  this  hypothesis. 

Theatjeent. — The  treatment  of  fever  is  of 
course  primarily  directed  to  the  removal  of  the 
cause  on  which  it  depends,  but  together  with  the 
measures  adapted  tothis  end  are  usuallvemployed 
means  for  the  moderation  of  the  febrile  process 
as  such,  and  these  may  at  times  take  the  first 
place.  We  can  do  little  more  than  mention  the 
more  important  of  them,  taking  first- what  may 
be  called  the  general  methods,  andpremisingthat 
rest  in  bed,  simple  food,  &c.,  are  taken  as  under- 
stood. Venesection  is  now  scarcely  ever  practised 
as  a means  of  combating  fever.  Purgatives  are 
often  useful,  as  are  also  diaphoretic  and  diuretic 
salines,  with  abundance  of  water  to  drink,  either 
alone  or  in  the  form  of  some  agreeable  tisane. 
Free  action  of  the  secretions,  which  is  the  object 
of  these  remedies,  is  of  service  in  removing  the 
increased  products  of  oxidation,  the  water  taken 
co-operating  by  acting  as  a solvent  and  vehicle, 
and  it  is  possible  that  medicines  which  promote 
this  activity  may  directly  bring  down  the  tem- 
perature. When,  for  example,  perspiration  has 
been  induced,  a coincident  fall  of  temperature 
may  be  due  more  to  some  change  antecedent  to 
the  perspiration  than  to  the  loss  of  heat  by 
transpiration  and  evaporation. 

Of  special  measures  for  the  reduction  of  febrile 
heat  when  this  is  becoming  dangerous,  either 
from  its  intensity  or  duration,  the  first  to  be 
mentioned  is  the  cool  or  cold  bath.  This  should 
be  resorted  to  in  all  cases  of  hyperpyrexia,  fron 


512  FEVEIi 

whatever  cause;  its  efficacy,  first  established  in 
the  high  temperature  of  acute  rheumatism  and 
enteric  fever,  has  been  proved  also  in  cases  of 
septic  hyperpyrexia  after  ovariotomy,  and  even  in 
injuries  to  the  brain.  Here  the  water  may  be 
positively  cold.  When  the  bath  is  employed 
to  control  temperature,  not  dangerous  from  its 
height,  but  from  its  duration,  as  in  enteric 
fever,  it  need  not  be  lower  than  70°  or  65° 
Fahr.  An  ice-cap  devised  by  Mr.  Knowsley 
Thornton,  for  applying  cold  of  32°  to  the  entire 
head,  has  been  found  useful  in  hyperpyrexia 
following  ovariotomy. 

Many  alkaloids  havo  the  property  of  reducing 
febrile  temperatures  when  taken  in  large  doses. 
The  most  powerful,  and  the  one  most  generally 
employed  to  combat  fever,  is  quinine.  When 
given  for  this  purpose,  it  is  administered  in  doses 
of  from  ten  to  twenty  or  even  thirty  grains  once 
in  twenty-four  or  forty-eight  hours,  or  three 
to  six  grains  of  the  neutral  sulphate  may  be 
injected  under  the  skin.  Salicylic  acid  has  a 
remarkable  influence  on  the  temperature  in  acute 
rheumatism,  and  some  effect,  though  far  less 
marked,  in  fever  from  other  causes.  It  may  be 
added  that  when  pericarditis  has  come  on  in 
rheumatic  fever,  this  drug  usually  altogether 
fails  to  influence  the  temperature.  The  only 
other  drug  which  need  be  specially  mentioned  is 
aconite,  the  mode  of  action  of  which  is  totally 
different  from  that  of  quinine,  and  of  which  it 
may  almost  be  said  that  it  antagonises  the  fever 
process  rather  than  reduces  temperature  ; its 
most  marked  influence  being  on  the  force  of  the 
heart  and  the  contraction  of  the  arteries.  The 
opportunity  for  the  manifestation  of  its  powers 
occurs  in  the  early  stage  of  catarrhal  fever,  the 
result  of  chill.  Given  in  frequent  small  doses 
(a  drop  or  two  of  the  tincture  every  five  minutes 
till  twenty  minims  or  half  a drachm  has  been 
taken)  when  the  temperature  is  rising,  the  pulse 
frequent  and  hard,  with  headache  and  burning 
skin,  the  effects  are  often  striking.  When  a 
local  inflammation  is  established,  it  is  no  longer 
of  much  use  ; and  when  the  fever  is  protracted, 
as  in  enteric  fever,  or  when  there  is  pneumonia, 
it  may  he  dangerous,  from  its  depressant  influence 
on  the  heart.  W.  H.  Broadbent. 

FIBRILLATION,  Muscular.— A local- 
ised quivering  or  flickering  of  muscular  fibres. 
See  Motion,  Disorders  of. 

FIBRINOUS  CLOT.  See  Clot. 

FIBRINOUS  CONCRETION.  See  CON- 
CRETION. 

FIBROID  DEGENERATION.— A mor- 
bid change  which  consists  in  the  substitution  of 
a tissue  somewhat  resembling  fibrous  tissue  for 
other  structural  elements ; some  pathologists 
consider  this  change  to  be  of  the  nature  of  a de- 
generation. See  Degeneration,  and  Cirrhosis. 


FILAR IA  SANGUINIS-HOMINIS 

FIBRO-PLASTIC  GROWTH.— A form 
of  new  growth,  composed  of  fibro-plastic  ele- 
ments. See  Tumours. 

FICUS  UNGUIUM  (ficus,  a fig;  unguis,  a 
nail). — A disease  of  the  posterior  wall  of  the  nail. 
See  Nails,  Diseases  of. 

FILARIA  SANGUINIS-HOMINIS.— 

In  the  article  Chtlukia  a full  account  is  given 
of  the  embryo-Filaria  sanguinis-hominis,  the  hoe- 
matozoon  which  is  ordinarily  found  associated 
with  this  disease.  Since  that  article  was  written, 
the  writer  has  succeeded  in  obtaining  what  is 
beyond  question  the  mature  form  of  the  helminth. 
On  the  7th  August,  1877,  two  living  specimens 
were  found — a male  and  a female — in  the  per- 
son of  a young  Bengalee,  affected  with  well- 
marked  naevoid  elephantiasis  of  the  scrotum,  as- 
sociated with  the  presence  of  embryo-filari®  in 
the  blood.1  The  diseased  tissues  were  removed 
by  the  late  Dr.  Edward  Gayer,  of  Calcutta,  to 
whose  kindness  the  writer  is  indebted  for  the 
opportunity  of  examining  them.  Unfortunately 
the  specimens  were  much  injured  by  the  needles 
used  to  tease  the  clot  in  which  they  were  found  : 
the  terminal  ends  of  the  male  could  not  be  found, 
nor  the  caudal  end  of  the  female,  although  the 
fragments  of  both  specimens  manifested  active 
movements.  They  were  attenu- 
ated, fine,  thread-like  worms, 
of  a white  colour ; the  cuticle 
was  smooth  and  devoid  of  trans- 
verse markings. 

The  fragment  of  the  male  speci- 
men measured  half  an  inch  in 
length,  and  ^|6"  transversely ; it 
was  thinner  than  the  female,  but 
of  firmer  texture,  and  manifested 


Fio.  IS.  Anterior 
end  of  Filaria  san- 
guinis-hominis. — 
Mature  form  x 100 
diameters. 


Fio.  IP.  A portion  of  the 
mature  Filaria  sanguinis 
llominis,  showing  uterine 
tubules  filled  with  ova  in 
various  stages  of  develop- 
ment; also  the  intestinal 
tube,  x 100  diameters. 


FIBROID  PHTHISIS. — A name  given  to 
certain  cases  of  phthisis  in  which  a considerable 
development  of  fibroid  tissue  is  found  to  occur  in 
the  lungs.  See  Phthisis. 


greater  tendency  to  coil.  The  intestinal  canal 
measured  [*030  mm.]  across,  and  the  sperm- 
tube  jjoo"  t'016  mm.]. 

The  length  of  the  portion  of  the  female  worm 


FIBROMA. — A form  of  tumour  composed  of 
fibrous  tissue.  See  Tumours. 


' For  further  details,  see  Indian  ifedieal  Gatette,  Pent 
1,  1877  ; The  Lancet,  Sept.  29,  1877  ; and  CenlraiHaa.** 
die  medicinische  Wissemcha/len,  No.  <3,  1877. 


FILARIA  SANGUINIS-HOMINIS 

which  had  been  secured  was  1|",  and  its  greatest 
width  about  ylD'.  It  was  packed  with  ova  and 
embryos  in  various  stages  of  development ; the 
latter,  especially  those  which  were  mature,  mani- 
fested active  movements.  The  head  is  slightly 
club-shaped ; the  mouth  does  not  manifest  any 
very  distinctly  marked  labial  sub-divisions,  nor 
are  there  any  chitinous  processes  evident  either 
before  or  after  death. 


The  following  measurements  may  prove  use- 
ful to  future  observers  : — 

of  an  in.  mm. 


Oral  aperture  to  end  of  (Esophagus 

~ or 

•45 

Diameter  of  oral  aperture  . 

i 

:iooo  ’> 

•008 

Width  of  extreme  end  (anterior) 

l 

517  ’» 

•047 

Ditto  anterior  end  at  ‘ neck  ’ 
Ditto  opposite  junction  of  in- 

1 

545  »* 

•0+5 

testine  with  oesophagus 
Ditto  about  ^ inch  from  an- 

1 

222  ” 

•112 

terior  end  . . . . 

Width  where  packed  with  ova  and 

1 

153  »’ 

•162 

embryos  .... 

Width  of  uterine  tube  filled  with 

1 

100  >» 

•25 

ova  ..... 

1 

•112 

Ditto  alimentary  tube  . 

1 

6G6  » 

•037 

The  ova  do  not  possess  any  distinctly  marked 
‘shell’;  from  the  smallest  to  the  largest  nothing 
but  a delicate  pellicle  can  be  distinguished  as 
enveloping  the  embryo  in  all  its  stages.  The 
average  of  six  measurements  of  the  least  advanced 
kinds  of  ova,  that  is,  those  in  which  the  outline 
of  the  embryo  was  not  distinctly  evident,  was 
[•01 S mm.]  by  s " [-012  mm  ] ; whilst  the 


Fig.  2il.  Ova  and  embryos  of  Filaria  sanguinis-hominis 
x 303  diameters. 

average  measurements  of  three  ova  in  which  the 
embryos  were  visible  were  ^ " [-037  mm.]  by 
['03  mm.].  A\  hen  the  latter,  after  having 
arrived  at  this  stage  of  development,  are  examined 
during  life,  it  is  in  many  instances  difficult  to 
state  whether  they  are  to  be  considered  as  freed 
embryos  or  not,  as  the  ‘shell’  has  become  so 
attenuated  and  translucent  as  only  with  difficulty 
to  be  distinguished.  It  is  possible  that  when  the 
embryo  acquires  worm-like  proportions  the  en- 
velope is  not  lost  in  this  species  so  long  as  it  con- 
tinues in  the  blood. 

With  regard  to  the  relation  of  the  mature 
fdaria  sanguinis-hominis  to  pathological  pheno- 
mena nothing  very  decisive  can  be  said ; hut  when 
it  is  considered  that  the  blood  of  some  animals 
is  found  occasionally  to  harbour  minute,  active 
organisms,  in  great  numbers  sometimes,  without 
appreciable  injury,  it  seems  not  improbable  that 
the  parental  forms  of  nematoid  haematozoa, 
rather  than  the  embryos,  may  be  the  more  hurt- 
33 


FISTULA.  613 

fill  to  the  animal  economy.  The  lesions  induced 
by  the  growth  of  the  filaria  sanguinolenta  in  the 
arterial  walls  of  dogs,  to  which  the  writer  lias 
elsewhere  drawn  attention,  appear  to  lendsupport 
to  such  a view. 

In  1877,  Dr.  Cobbold  announced  that  Dr 
Bancroft,  of  Brisbane,  had  discovered  specimen-* 
of  what  were  believed  to  be  mature  forms  of  the 
filaria.  A dead  specimen  was  found  in  a lyn  ■ 
phatic  abscess  of  the  arm ; and  on  a second 
occasion  four  living  specimens  were  obtai.  ed 
from  a hydrocele  of  the  spermatic  cord.  They 
were  of  the  thickness  of  a hair  and  from  3 to  -4 
inches  in  length.  A minute  description  of  thorn 
by  Dr.  Cobbold  appeared  in  the  Lancet  of  ti  e 
6th  October,  1877.  The  persons  from  whom  the 
specimens  were  obtained  had  not  suffered  from 
either  chyluria  or  naevoid  elephantiasis,  nor  wire 
they  known  to  harbour  embryo  nematodes  in 
their  blood.1 

Timothy  Richards  Lewis. 

FILARIiE  ( filum , a thread). — A genus  of 
nematoid  worms,  not  very  clearly  defined,  but 
which  contains  a variety  of  thread-like  parasites 
whose  body  is  of  uniform  thickness  throughout, 
and  at  least  fifty  times  longer  than  it  is  broad. 
Under  this  head  are  often  included  several  human 
parasites,  such  as  the  Dracunculas,  or  Guinea- 
worm  (Filaria  medinensis),  and  the  lung  strougle 
(F.  bronchialis),  in  addition  to  a variety  of  larval 
or  sexually  immature  nematoids,  whose  genetic 
relations  aro  only  very  imperfectly  understood. 
In  the  latter  category  may  be  placed  Bristowe 
and  Rainey's  entozoon  (F.  trachealis) ; Von 
Nordmann's  eye-worm  (F.  uculi-humani  or  F. 
lentis) ; the  laa , infesting  the  eyes  of  the  Angola 
Coast  and  Gaboon  negroes  (F.  loa);  and  lastly, 
the  nematoid  hsmatozoon  (F.  sanguinis-hominis) 
recently  described  by  Lewis  in  his  illustrated 
memoir.  It  may  be  doubted  if  any  of  the  above- 
mentioned  parasites  ought  to  be  included  in  the 
genus  Filaria,  as  understood  by  modern  hel- 
minthologists, but,  practically,  it  is  still  found 
convenient  thus  to  speak  of  them.  The  Dra- 
euneulus  will  be  found  described  under  Guinea 
Worm;  whilst  the  microscopic  nematoid  infest- 
ing the  blood  will  be  found  noticed  under  the 
articles  H.hmatozoa,  Chyluria,  and  Filaria 
Sanguinis-hominis.  T.  S.  Cohbold. 

FISH-SKIN  DISEASE  — A synonym  for 
ichthyosis.  See  Ichthyosis. 

EISSUEE  (findo,  I cleave). — A narrow  and 
superficial  crack  or  solution  of  continuity,  ob- 
served on  the  skin  and  mucous  membranes,  and 
especially  near  the  line  of  junction  of  these 
structures,  as  on  the  lips  and  anus.  See  Anus. 
Diseases  of ; and  Chaps. 

FISTULA  (Jistula , a pipe). — A narrow  track 
or  canal  leadingfrom  a free  surface,  and  extending 
more  or  less  deeply  to  some  seat  of  local  irrita- 
tion, or  it  maybe  constituting  an  abnormal  com- 

1 The  researches  o£  Dr.  Hanson,  of  Amoy,  confirmed 
by  Dr.  Lewis,  show  that  embryo  filarise  in  the  blood  aie 
imbibed  by  the  mosquito,  or  other  intermediary  host  ; 
undergo  developmental  changes  ; and  are  discharged  inlo 
water  with  the  larvae  of  the  insect.  Infection  probably 
occurs  through  this  medium.  Dr.  Hanson  has  recently 
stated  ( Medical  Times,  June  1881)  that  the  habitat  of  the 
parent  filaria  is  in  the  lymphatic  trunks. — Ed. 


J14  FISTULA, 

aranication  between  two  or  more  cavities,  as  in 
the  case  of  vesico- vaginal  or  recto-vaginal  fistula. 
See  Abscess. 

FISTULA  IN  ANO.  See  Rectum,  Dis- 
eases of. 

FIT. — A popular  synonym  for  a sudden  seizure 
characterised  by  loss  or  disturbance  of  conscious- 
ness from  any  cause,  with  or  without  convulsions. 
( See  Convulsions,  Epilepsy,  Hysteria,  and  Syn- 
cope.) The  term  is  also  applied  to  a sudden  or 
acute  seizure  of  certain  diseases,  such  as  gout, 
asthma,  and  ague. 

FLATULENCE  {flatus,  a puff  of  wind). 
Synon.  : Fr.  Flatulence  ; Ger.  Flatulenz. 

Definition. — The  undue  generation  of  gases 
in  the  stomach  and  intestines. 

.(Etiology. — The  principal  cause  of  flatulence 
is  fermentation  or  decomposition  of  the  contents 
of  the  stomach  and  bowels — a condition  usually 
induced  by  embarrassment  of  function.  Hence  it 
is  a common  symptom  in  dyspepsia — especially 
the  atonic  forms  as  met  with  in  the  debilitated 
and  the  aged — constipation,  gastritis,  enteritis, 
hepatic  disorders,  intestinal  obstruction,  &c. 
When  flatus  is  generated  too  rapidly  to  be  ac- 
counted for  by  fermentation,  as  in  hysteria,  hypo- 
chondriasis, and  other  forms  of  nervous  debility, 
it  has  been  ascribed,  but  incorrectly,  to  secretion 
of  gases  from  the  mucous  membrane. 

Symptoms. — The  clinical  phenomena  vary  as 
flatus  is  retained  or  discharged ; and  with  the  seat 
of  its  formation,  whether  chiefly  in  the  stomach  or 
intestines.  In  the  former  the  concomitant  symp- 
toms are  those  of  dyspepsia,  and  in  the  latter 
there  is  usually  constipation.  As  a rule,  how- 
ever, flatulence  pervades  at  the  same  time  more 
or  less  all  the  hollow  viscera,  and  indicates  torpor 
of  the  digestive  organs.  It  is  apt  to  lead  to  these 
further  evils: — {a)  Pain  from  distension  or  from 
irregular  and  forcible  contractions  of  the  walls — 
hence  gastrodynia  and  colic  are  apt  to  arise;  (b) 
arrest  of  the  normal  movements  of  the  stomach  and 
intestines,  and  consequent  accumulation  within 
them  of  fermentable  matters,  with  further  gene- 
ration of  gases,  leading  to  paralytic  distension  : 
hence  dilatation  of  the  stomach  and  colon,  tym- 
panites or  meteorism,  and  aggravation  of  pre- 
existing dyspepsia  or  constipation  may  ensue ; and 
(e)  pressure  on  adjacent  organs,  e.g.  on  the  heart 
and  lungs,  inducing  palpitation  and  irregular  ac- 
tion of  the  heart,  precordial  anxiety,  faintness, 
vertigo,  dyspncea  or  even  asphyxia. 

In  tympanites  there  is  a rapid  generation  of 
flatus,  which  overpowers  the  contractility  of  the 
hollow'  viscera;  and  the  abdomen  is  round,  tense 
and  tympanitic.  When  this  condition  is  accompa- 
nied by  fever  and  diarrhoea,  typhoid  fever  should 
be  suspected  ; but  if  fever  be  absent,  while  there 
is  bilious  or  stercoraceous  vomiting,  probably 
intestinal  obstruction  exists — intussusception, 
internal  strangulation,  hernia,  &c. 

Treatment. — (a)  Imprisoned  flatus  should  be 
dislodged  by  friction  of  the  abdomen  with  stimu- 
lating liniments,  and  gentle  kneading  of  the  most 
distended  parts ; large  draughts  of  hot  water; 
spirit  and  hot  water;  ammonia,  ether,  or  spirits  of 
chloroform  ; aromatic  stimulants — ginger,  cloves, 
mint,  anise,  cajeput,  camphor,  eascarilla.  &c. 


FLUKE. 

When  flatulence  is  chiefly  intestinal,  enemata 
containing  laudanum  with  assafeetida,  turpen- 
tine, or  rue ; and  pilula  assafeetidse  composita 
with  extractum  nucis  vomica,  and  an  aperient 
are  the  most  useful  measures. 

( b ) The  generation  of  flatus  should  he  arrested. 
Fermentation  may  be  checked  by  sulphite  or 
sulpho-carbolate  of  soda,  sulphurous  acid,  car- 
bolic acid,  creasote,  or  charcoal — from  the  poplar 
or  vegetable  ivory — immediately  after  food,  and 
by  correcting  and  toning  the  digestive  organs. 
Food  likely  to  ferment  or  lodge,  such  as  starch, 
sugar,  fruits  or  vegetables,  and  warm  liquids — es- 
pecially tea  and  soups — should  be  avoided ; the 
meals  should  be  well  masticated  and  solid  through- 
out, and  liquids  should  only  betaken  sparingly  at 
the  close  or  an  hour  after.  In  some  eases,  however, 
flatulence  is  connected  with  an  insufficient  supply 
of  fluids,  and  can  only  be  met  by  increasing  it. 
Alkalies — carbonate  of  magnesia,  soda,  or  lime— 
and  bitters,  especially  strychnia,  are  often  useful 
in  the  flatulence  of  hysteria,  hypochondriasis,  the 
very  nervous  and  the  aged  (Trousseau,  Niemeyer) ; 
but  perhaps  the  best  results  follow  alkalies 
with  nux  vomica  and  bismuth  an  hour  before,  and 
hydrochloric  acid  alone  or  with  Liebreich's  Pepsin 
Essenz  or  other  reliable  preparation  of  pepsin 
after  food.  It  is  also  essential  to  see  that  the 
action  of  the  liver  is  healthy.  George  Oliver. 

FLEXION  (. fleeto , I bend).— A bending 
This  term  is  applied  either  to  the  act  of  bending, 
as  in  some  methods  of  treatment,  for  example 
the  cure  of  aneurism  or  the  reduction  of  dislo- 
cations; or  to  the  condition  in  which  parts  are 
bent,  as  tbe  result  of  disease  or  of  disorder,  as 
when  the  limbs  or  certain  internal  organs  aro 
bent  upon  themselves.  See  Womb,  Diseases  of. 

FLOODING. — A popular  term  for  excessive 
discharge  of  blood  from  the  womb.  See  Men- 
struation, Disorders  of;  and  Pregnancy.  Dis- 
orders of. 

FLUCTUATION  {fluctus , a wave). — A 
physical  sign  consisting  in  a wave-like  or  undu- 
lating sensation.  It  is  elicited  by  a peculiar 
mode  of  palpation  with  the  one  hand  while  per- 
cussion is  made  with  the  fingers  of  the  other; 
and  is  due  to  the  presence  of  a fluid  in  a natural 
cavity  such  as  the  peritoneum,  or  in  an  abnormal 
closed  space,  such  as  a cyst  {see  Physical 
Examination).  The  term  fluctuation  as  used  by 
the  surgeon  has  a somewhatdiflferent  signification, 
being  applied  to  the  sensation  of  the  presence  of 
a fluid  which  may  be  felt  when  alternate  pressure 
with  the  fingers  is  made,  as  over  the  seat  of  an 
abscess.  See  Abscess. 

FLUKE. — In  its  original  signification  this 
term  means  anything  flat;  but,  in  connection 
with  internal  parasites,  it  refers  generally  to 
the  common  liver-entozoon  and  its  allies,  which 
happen  to  be  more  or  less  flat  or  leaf-shaped. 
Tho  liver-fluke  belongs  to  the  genus  Fasciola , 
though  more  commonly  spoken  of  as  a Distoma. 
Some  of  the  flukes  of  man,  as  well  as  of  ani- 
mals, have  a rounded  form,  quite  unlike  that 
shown  ly  the  ordinary  liver  fluke.  IV  ith  <>•  e or 
two  notable  exceptions,  the  flukes  are  destitute 
of  clinical  importance.  Under  this  head  mils' 


FLUKE. 

also  be  mentioned  a remarkable  fluke  recently 
discovered  by  Dr.  Lewis  in  India,  and  called  by 
him  Ampkistoma  kominis.  As  there  is  ground 
for  believing  that  several  allied  species  (A.  Haw- 
/cesii,  A.  Collinsii,  &c.)  prove  injurious  to  ele- 
phants and  horses,  it  is  possible  that  the  human 
amphistome  may  be  productive  of  severe  intes- 
tinal mischief.  See  Distoma,  and  Bilharzia. 

T.  S.  CoBBOLD. 

[ (Latin). — A flow  or  excessive  dis- 

charge  from  a mucous  surface  through  any  of  the 
natural  passages,  of  serum,  blood,  mucus,  pus,  or 
the  various  secretions.  As  illustrations  of  fluxes 
may  be  mentioned  salivation,  bronchorrhcea, 
biliary  flux,  diarrhcca,  dysentery  or  bloody  flux, 
jholera,  and  leucorrhcea  or  white  flux  {Fluor 
ilbus). 

i’CETUS,  Diseases  of  the.— Two  classes 
of  abnormal  conditions  are  seen  in  the  fetus, 
namely: — Those  which  depend  upon  some  inter- 
ference with  the  process  of  development,  such 
as  malformations,  monstrosities,  &c.,  and  those 
which  are  the  result  of  disease.  This  article 
treats  of  the  latter  only. 

1.  AmptUation. — Amputation,  partial  or  com- 
plete, of  fetal  limbs,  may  take  place,  from  con- 
striction of  the  limb  by  a band  of  the  amnion. 
An  attempt  at  reproduction  of  the  lost  limb  is 
sometimes  seen,  in  the  shape  of  rudimentary 
fingers  and  toes,  projecting  from  the  stump. 
That  such  a stump  is  the  result  of  amputation 
is  proved  by  the  fact,  that  the  part  cut  off  has 
been  found  in  utcro. 

2.  Spontaneous  fractures  and  dislocations. — 
Fractures  and  dislocations  occur  in  utcro,  the 
latter  being  the  more  rare.  They  are  due  to 
some  condition  of  the  bones  and  ligaments  re- 
spectively, leading  to  undue  fragility  of  those 
structures ; for  they  are  always  multiple,  and  are 
not  accompanied  with  bruising  of  the  adjacent 
soft  parts. 

3.  Tumours. — New  growths  are  met  with  in 
the  fetus— cysts  of  various  kinds,  fibromas, 
lipomas,  &c.  That  most  special  to  the  fetus 
is  a tumour  situated  over  the  coccyx,  which 
may  be  as  large  as  a fetal  head.  Such  tumours 
are  spheroidal  or  ovoidal  in  shape,  elastic  in 
consistence  and  present  rounded  inequalities  on 
the  surface.  On  section  they  are  found  to  con- 
sist of  strong  fibrous  trabecula?,  in  the  meshes 
of  which  are  numerous  small  cysts  lined  with 
epithelium.  It  is  thought  by  many  that  they 
originate  in  Luschka’s  gland.  Another  special 
kind  of  tumour  is  that  known  as  a fatal  inclusion 
— a swelling  usually  on  the  lower  part  of  the 
trunk,  and  containing  some  part  of  another  fetus, 
more  or  less  imperfectly  developed. 

4.  Inflammation  of  serous  m'mbrancs. — This 
form  of  disease  may  occur  in  the  foetus,  such  as 
pleurisy  and  peritonitis.  The  morbid  anatomy 
of  these  changes  does  not  differ  from  that  in  the 
adult.  Peritonitis  is  often  found  associated  with 
syphilis ; and  it  appears  to  be  almost  always  fatal 

! to  the  fetus. 

I 5.  Visceral  Inflammation.— Inflammation  of  the 
lungs  has  been  met  with,  in  the  form  of  grey  or 
white  lobular  hepatization.  It  is  most  frequent 
in  syphilis.  Enteritis  has  also  been  described. 


FfETUS,  DISEASES  OF  THE.  515 
Various  malformations  of  the  heart  which  are 
met  with  can  be  explained  by  supposing  the  oc- 
currence of  endocarditis  during  fetal  life  ; but 
there  is  no  proof  that  the  fetus  is  subject  to 
rheumatism.  Virchow  describes  encephalitis. 

6.  Specific  Fevers. — The  morbid  changes  of 
enteric  fever  havo  been  found  in  the  fetus  In 
pregnant  women  suffering  from  intermittent  fever, 
paroxysms  of  convulsive  movements  of  the  child 
have  been  felt  to  occur  as  regularly  as  the  attacks 
of  ague  in  the  mother;  and  the  child  when  brum 
has  been  found  to  have  a large  spleen.  Chil- 
dren have  also  been  born  with  skin-eruptions 
thought  to  resemble  those  of  measles,  scarlatina, 
and  smallpox.  The  facts  as  to  the  last-named 
disease  are  the  most  numerous  and  probable. 
The  eruption  of  variola  in  the  fetus  differs 
somewhat  from  that  seen  after  birth,  because, 
the  skin  of  the  fetus  being  bathed  with  fluid,  no 
crusts  form,  and  the  pustules  run  a course  like 
those  on  mucous  membranes. 

7.  Diseases  of  the  Skin.  — The  fetus  is  subject 
to  skin-diseases.  Pustules  of  ecthyma  ; patches 
of  erythematous  redness  ; ulceration  of  the  skin, 
and  syphilitic  eruptions  have  been  seen.  Intra- 
uterine ichthyosis  is  met  with.  Children  have 
been  born  jaundiced,  but  only  by  mothers  them- 
selves suffering  from  that  disease.  But  women 
with  jaundice  do  not  always  bear  jaundiced  chil- 
dren. Jaundiceisnotnecessarilyfatultothe  fetus. 

8.  Si/philis. — Syphilis  leads  to  various  lesions 
in  the  fetus,  and  while  it  usually  proves  fatal, 
the  subjects  of  it  that  may  survive  till  birth 
are  feeble  and  badly  nourished.  Flat  tubercles 
occur  on  different  parts  of  the  skin,  especially 
round  the  mucous  orifices;  and  pemphigus, 
affecting  chiefly  the  palms  of  the  hands  and  the 
soles  of  the  feet,  may  be  seen.  The  occur- 
rence of  peritonitis  has  already  been  mentioned. 
Yellow  indurated  nodules,  of  varying  size  and 
number,  may  be  found  in  the  liver,  as  well  as 
similar  nodules  in  the  lungs.  A peculiar  change 
has  been  described  in  the  thymus  gland,  in  which 
this  structure  externally  appears  healthy,  but 
when  cut  into  and  compressed  exudes  a whitish 
puriform  fluid.  Other  changes  have  been  re- 
corded, affecting  thu  spleen,  pancreas,  and  supra- 
renal capsules,  but  they  are  not  distinctive. 
Changes  in  the  bones  have  also  been  described, 
consisting  of  an  osteo-chondritis,  affecting  the 
ends  of  the  long  bones,  most  frequently  the 
lower  end  of  the  femur. 

9.  Rachitis. — Rickets  is  met  with  in  utcro. 
The  changes  it  produces  are  like  those  seen  after 
birth.  It  is  thought  to  be  one  of  the  causes  of 
spontaneous  fractures. 

10.  Tuberculosis.  — Tuberculosis  sometimes 
commences  in  the  fetus,  tubercles  having  been 
found  in  the  mesentery  and  in  the  lungs. 

11.  Dropsies. — Dropsy  is  met  with  in  the 
fetus,  sometimes  of  the  serous  cavities,  of  which 
hydrocephalus  is  the  most  common.  It  is  often 
associated  with  rickets.  Next  in  frequency 
comes  ascites,  and  lastly  hydrothorax,  which  in 
very  rare.  These  affections  may  destroy  fetal 
life  in  utero\  but  they  more  often  lead  to  death 
because  they  render  destructive  operations 
necessary  before  delivery  can  be  accomplished. 
General  anasarca  is  also  met  with,  and  there  ie 
reason  to  believe  that  it  depends  upon  disease  of 


51 C FCETUS,  DISEASES  OF  THE. 

the  placenta,  impairing  the  excretory  function 
of  that  organ.  It  is  always  fatal,  if  not  before, 
within  a few  hours  after,  birth. 

12.  Visceral  diseases. — Hypertrophy  of  the 
liver,  spleen,  or  kidneys  may  occur  in  the  feetus. 
Cystic  disease  of  the  kidney  may  be  met  with,  the 
organ  being  converted  into  a mass  of  cysts  con- 
taining no  trace  of  secreting  structure.  Both 
kidneys  are  usually  affected,  and  the  disease  is 
generally  associated  with  some  malformation 
elsewhere.  Hydronephrosis,  single  or  double, 
along  with  dilatation  of  the  ureter,  or  ureters 
and  bladder,  has  been  seen,  dependent  upon  im- 
permeability of  some  part  of  the  urinary  passages. 
Any  of  these  visceral  diseases  may  form  a 
tumour  so  large  as  to  impede  delivery.  None  of 
thorn  can  be  diagnosed  before  birth.  Concretions 
of  uric  acid  and  urates  are  not  uncommon. 

The  Causes  of  Death  of  the  Foetus. — The 
various  causes  of  death  of  the  feetus  in  utero 
may  now  be  briefly  considered.  The  first  of 
these  is  injury,  as  when  the  mother  receives  a 
blow  upon  the  abdomen,  or  has  a fall.  Such 
occurrences  rarely  directly  injure  the  foetus,  al- 
though this  has  been  known  to  happen.  When 
they  prove  fatal  to  the  feetus,  they  do  so  by  lead- 
ing to  haemorrhage  into,  or  separation  of,  a por- 
tion of  placenta,  and  consequent  disturbance  of 
the  foetal  circulation.  Poisons  in  the  mother’s 
blood,  such  as  lead,  urea,  or  carbonic  acid  (as  in 
the  case  of  heart-disease  with  cyanosis),  may  lead 
to  death  of  the  foetus.  Syphilis  has  already  been 
referred  to.  Epileptiform  convulsions  may  de- 
stroy foetal  life,  either  by  asphyxia,  or  by  leading 
to  haemorrhage  into  the  placenta.  Extreme 
ancemia  and  the  cancerous  cachexia,  are  among 
the  causes  of  foetal  death.  Any  kind  of  disease 
attended  v/ith.  pyrexia  will  also  destroy  foetal  life 
if  the  temperature  rise  high  enough.  A tempera- 
ture exceeding  105°  Fahr.  appears  to  be  invari- 
ably fatal  to  the  foetus.  Certain  diseases  of  its 
appendage smay  lead  to  death  of  the  feetus,  such 
as  fatty  degeneration,  or  oedema,  of  the  placenta ; 
obliteration  of  the  umbilical  vessels ; or  inter- 
ruption of  the  circulation  in  the  cord  by  knots  in 
it,  or  pressure  upon  it.  It  is  believed  that  there 
are  some  diseases  of  the  mother's  uterus  which 
lead  to  death  of  the  foetus  ; but  what  they  are  is 
not  known.  It  is  said  that  some  women  acquire 
a habit  of  having  dead  children.  This  means  that 
there  are  cases  in  "which  an  apparently  healthy 
woman  will  repeatedly  have  dead  children,  the 
cause  of  whose  death  a skilled  observer  cannot 
find  out.  In  other  words,  there  are  causes  of 
foetal  death  as  yet  unknown. 

The  Consequences  of  Death  of  the  Feetus. 
A dead  foetus  while  retained  in  utero,  and  thus 
protected  from  the  air,  does  not  putrefy,  but  un- 
dergoes a process  of  maceration.  The  whole 
body  becomes  soft  and  flaccid,  its  tissues  being 
infiltrated  with  fluid ; but  it  has  no  putrid  odour. 
The  skin  presents  bullae  filled  with  reddish  serum, 
and  the  epidermisis  readily  detached  with  slight 
friction.  The  surface  is  of  a cyanotic  colour, 
which  after  exposure  to  the  air  becomes  of  a 
more  or  less  bright  red ; it  is  not  greenish,  as 
is  seen  in  putrefaction.  The  cellular  tissue  is 
infiltrated  with  bloody  serum.  The  viscera 
have  lost  their  distinctive  tints,  and  become  of 
a reddish-brown  colour.  The  cranial  bones  are 


FOMENTATION. 

abnormally  mobile,  overlapping  one  another  to 
a greater  extent  than  normal;  and  the  periosteum 
may  be  stripped  off  them.  These  appearances 
are  much  the  same,  whatever  be  the  cause  of 
death,  but  they  vary  in  degree  according  to  the 
length  of  time  whichhas  elapsed  since  death. 

Besides  the  diseases  of  the  foetus  described 
above  there  are  others  which  are  not  fatal,  and 
the  chief  interest  of  which  lies  in  their  courso 
and  treatment  after  birth.  These  are  discussed 
in  other  articles,  and  for  that  reason  are  not 
mentioned  here.  G.  E.  Hebmax. 

FOLIE  ClftCULAIHE  {French).  — This 
term  is  applied  by  the  French  psychological 
physicians  to  a variety  of  insanity  characterised 
by  alternations  of  excitement  and  depression. 
The  patient  passes  through  an  attack  of  mania 
of  perhaps  an  ordinary  character  but  when  he 
appears  to  have  recovered  he  sinks  into  melan- 
cholia, and  thence  emerges  again  to  become 
maniacal  and  excited.  The  duration  of  each 
stage  may  vary  from  weeks  to  months ; some- 
times one  state  will  follow  the  other  immediately ; 
in  other  cases  a period  of  convalescence  will 
intervene,  during  which  the  patient  appears 
well,  and  can  hardly  be  considered  insane.  Yet 
the  prognosis  is  extremely  unfavourable  in  all 
such  cases,  and  it  is  of  great  importance  in 
estimating  the  extent  of  recovery  of  a patient 
that  it  should  be  clearly  ascertained  that  the 
attack  is  not  one  of  a series  following  one  another 
in  the  manner  mentioned.  G.  F.  Blaxdfoed. 

FOLLICLES,  Diseases  of  ( follietilus , dim. 
of  follis,  a bag). — The  name  ‘ follicle  ’ has  been 
applied  to  a great  variety  of  different  structures, 
which  have  in  common  the  shape  of  a bag  or 
sac,  whether  circular  or  elongated  in  outline ; for 
example — the  Graafian  follicles,  the  lymphatic 
(Peyerian)  follicles  of  the  intestine,  and  the  fol- 
licles of  the  mucous  membrane  of  the  stomach, 
intestine,  and  uterus.  The  name  has  been  fur- 
ther extended  to  include  glands  somewhat  more 
complex  in  structure,  such  as  the  sudoriparous 
glands  or  sweat-follicles,  the  sebaceous  follicles, 
and  the  tonsils;  as  well  as  the  saccular  depres- 
sions in  which  the  hair  and  the  teeth  take  thoir 
origin.  The  name  Synovial  Follicles  is  sometimes 
given  to  processes  of  synovial  membrane  inva- 
ginated  in  the  capsule  of  a joint. 

For  an  account  of  the  diseases  of  these  various 
structures,  the  reader  is  referred  to  the  several 
articles  uuder  which  they  are  discussed;  but  so 
far  as  the  true  follicles  are  concerned,  the  fol- 
lowing may  be  said  to  be  the  principal  morbid 
changes  to  which  they  are  liable : — Atrophy ; 
Hypertrophy;  Obstruction,  and  Distension; 
Inflammation;  Ulceration;  Cystic  Disease; 
New  Growths  ; Tubercle ; Acute  Specific  pro- 
cesses, such  as  the  typhoid ; and  Parasitic  disease. 

FOMENTATION  {fovea,  I keep  warm). 

Synon.  : Fr  .Fomentation-,  Ger.  Balling. 

Definition".  —Fomentation  is  the  application 
to  the  surface  of  the  body  of  flannels,  cloths,  or 
sponges  moistened  with  hot  water,  either  pure  or 
containing  some  medicinal  substance  in  solution 

Action. — The  action  of  a simple  fomentation 
is  the  same  as  that  of  a poultice.  By  its  warmth 
and  moisture  it  tends  to  relax  the  muscular  fibre.-1 


fomentation. 

sf  the  skin,  end  soften  the  cuticle,  thus  relieving 
tension,  and  diminishing  pain  and  irritation.  In 
the  early  stages  of  inflammation  it  favours  re- 
solution, by  maintaining  the  temperature  and 
promoting  active  circulation  through  the  area 
which  has  suffered  from  the  injurious  influence 
which  has  started  the  process.  In  the  later 
stages  it  promotes  and  hastens  suppuration,  by 
causing  dilatation  of  the  vessels,  and  hastening 
exudation  and  cell-multiplication.  A fomenta- 
tion is  superior  to  a poultice  in  lightness  and 
cleanliness,  but  unless  care  be  taken  it  loses  its 
heat  more  quickly.  This  disadvantage  may  be 
overcome  by  covering  the  fomentation  with  a 
thick  layer  of  cotton-wool. 

Application  and  Uses. — A fomentation  is 
thus  applied : — A piece  of  coarse  flannel,  or  of 
spongio-piline,  sufficiently  large  to  cover  the  af- 
fected part  when  folded  into  two  layers,  is  put 
uto  a basin  and  boiling  water  is  poured  upon  it. 
It  is  then  lifted  from  the  basin  with  a pair  of  tongs 
or  some  convenient  instrument,  and  dropped  on 
lie  wringer.  This  is  a stout  piece  of  towelling 
with  a stick  attached  to  each  end.  The  sticks 
then  being  twisted  in  opposite  directions,  as 
much  water  as  possible  is  squeezed  out  of  the 
flannel.  It  is  then  immediately  placed  on  the 
affected  part,  and  covered  with  a large  piece  of 
oiled  silk  or  indiarubber  sheet  extending  at  least 
one  inch  on  each  side  of  it.  Over  this  may  be 
placed  a thick  layer  of  cotton-wool,  and  a bandage. 
If  the  flannel  be  not  squeezed  sufficiently  dry  it 
will  wet  the  bed  or  clothing.  If  not  sufficiently 
covered  with  oiled  silk  and  wool  it  soon  becomes 
cold.  Whatever  means  may  be  taken  to  retain 
tho  heat  of  a fomentation,  it  can  be  kept  above 
the  temperature  of  the  body  only  for  a few 
minutes.  If,  therefore,  the  full  effect  of  fomen- 
tation is  desired  to  he  obtained,  the  flannels  must 
be  changed  every  twenty  minutes.  In  many  parts 
a sponge,  or  a piece  of  spongio-piline,  wrung  out 
of  boiling  water  forms  a most  convenient  form 
of  fomentation.  When  the  fore-arm  or  hand  is 
affected,  a bath  of  hot  water  may  he  substituted 
for  fomentations.  The  temperature  of  the  water 
must  he  maintained  by  the  repeated  addition 
of  small  quantities  of  boiling  water. 

Fomentations  are  especially  useful  in  all  cases 
of  erysipelas  and  diffuse  cellulitis,  and  in  boils. 
In  peritonitis  they  are  borne  more  easily  than 
poultices,  on  account  of  their  greater  lightness. 
Whenever  they  can  be  employed  they  are 
superior  to  poultices  on  account  of  their  cleanli- 
ness. They  are  not  applicable  to  cases  in  which 
there  is  a discharging  wound  or  abscess,  asunder 
such  conditions  the  cloths  become  foul. 

Varieties. — If  it  is  desired  to  add  some  slight 
counter-irritation  to  the  warmth  and  moisture, 
the  fomentation  may  be  sprinkled  with  turpen- 
tine before  it  is  applied.  This  forms  the  ordinary 
turpentine-stupe.  The  sedative  action  of  the 
fomentation  may  be  increased  by  sprinkling  it 
with  laudanum.  The  ordinary  poppy-fomentation 
is  efteu  used  with  the  same  intention.  It  is  thus 
prepared  Half  a pound  of  poppy-heads  with 
the  seeds  taken  out  is  boiled  for  ten  minutes  in 
four  pints  of  water,  and  the  liquid  then  strained 
off.  The  decoction  is  kept  warm  over  a fire  and 
the  flannels  lipped  in  it  and  applied  as  before 
described  about  every  half-hour.  The  term 


FOECIBLE  FEEDING.  51', 
‘dry  fomentation’  is  sometimes  applied  to  bags 
of  salt,  hot  bran,  or  chamomile  flowers  ; or  piece3 
of  flannel  toasted  before  a fire  and  applied  hot. 
These  often  give  relief  in  cases  of  intestinal, 
renal,  or  biliary  colic.  hi  Ait  errs  Beck. 

FOMITES  ( fomes , fuel). — Substances  ca- 
pable of  retaining  contagium-particles,  and  thus 
of  being  the  means  of  propagating  any  infectious- 
disease.  The  most  important  fomites  are  bed- 
clothes, bedding,  woollen  garments,  carpets,  cur- 
tains, letters,  &c.  See  Contagion. 

FOOD.  See  Aliments,  and  Diet. 

FOOD,  .iEtiology  of. — See  Disease,  Causes 
of ; and  Digestion,  Disorders  of. 

FOEAMEN  OVALE,  Patency  of. — Set 
Heart,  Malformations  of. 

FOECIBLE  FEEDING.— In  the  treat- 
ment of  insanity  it  not  unfrequently  happens 
that  we  are  compelled  to  administer  food  by 
force  to  patients  who,  for  one  reason  or  another, 
refuse  to  take  it.  The  majority  of  them  are  melan- 
cholic persons  who  think  they  ought  not  to  eat, 
or  try  to  commit  suicide  by  starvation,  and  many 
axe  in  a feeble  bodily  condition  when  they  com- 
mence this  refusal.  Such  persons  must  be  fed  by 
force  without  delay.  Strong  patients  may  be 
allowed  a longer  time,  for  many  refuse  from  whim 
or  obstinacy,  and  hunger  will  soon  overcome  their 
disinclination.  Some  patients  in  a state  of  acute 
delirium  will  take  no  food ; they  must  be  fed  at 
once,  and  it  is  important  that  they  should  be 
fed  without  a protracted  and  exhausting  struggle, 
for  they  will  resist  desperately  unless  completely 
overmastered.  In  almost  every  case  feeding 
should  he  done  early : the  sooner  it  is  done,  tho 
shorter  will  be  the  period  during  which  it  will 
he  required.  What  method  is  to  be  adopted  ? 
The  various  plans  range  from  merely  feeding 
with  a spoon  as  one  feeds  a child  to  sending 
food  down  the  oesophagus  with  a tube  passed 
through  the  mouth  or  nose,  tho  patient  being 
restrained  in  a chair  or  on  a bed  by  attendants 
or  mechanical  restraint.  The  mode  of  feeding 
varies  according  to  the  resistance,  and  no  one 
method  is  applicable  to  every  case.  There  is  no 
need  to  pass  an  oesophageal  tube  down  the  throat 
of  a man  whose  resistance  is  passive  and  easily 
overcome ; on  the  other  hand  we  occasionally 
find  patients  of  great  muscular  strength  and 
indomitable  will,  who  can  hardly  be  fed  with 
safety  in  any  way  except  by  the  stomach-tube. 
Of  these  we  may  speak  first.  In  what  position 
are  they  to  be  fed,  sitting  or  lying  down  ? If 
they  are  to  he  held  by  attendants  no  doubt  the 
recumbent  posture  is  the  one  in  which  the  latter 
can  exercise  most  power.  But  when  a man  is  so 
strong  that,  as  we  axe  told,  five  attendants  must 
hold  him,  a struggle  will  not  be  unattended  with 
danger,  for  tho  five  are  not  all  acting  together, 
and  he  gets  loose  now  a leg  and  now  an  arm,  to 
the  great  discomposure  of  the  operator : more- 
over this  struggle  repeated  three  times  a day 
soon  renders  him  a mass  of  bruises.  He  should 
be  placed  in  a strong  wooden  chair,  and  by  sheets 
wound  round  his  body,  arms,  and  legs  he  can  he 
fastened  to  the  chair  so  completely  that  he  is  as 
incapable  of  movement  as  if  he  were  paralysed, 


518  FORCIBLE  FEEDING. 

yet.  lie  gets  no  bruise,  and  the  operator  acts  upon 
bitn  free  from  all  inconvenience.  Some  -writers 
advocate  feeding  by  the  nose,  and  prefer  this 
method  to  passing  a tube  through  the  mouth. 
But  if  a long  tube  is  used  it  is  apt  to  get  into 
the  larynx,  and  if  the  food  is  passed  into  the  nose 
through  a funnel  or  feeder,  it  is  often  ejected 
again.  The  only  advantage  of  feeding  through 
the  nose  is  that  we  are  not  compelled  to  force 
open  the  mouth.  This  is  a work  of  difficulty  if  the 
patient  is  strong  and  his  teeth  perfect,  unless  we 
are  provided  with  the  screw-key  invented  for 
this  purpose : with  this  there  is  little  difficulty, 
and  only  bungling  will  injure  the  teeth  or  gums, 
if  the  patient  is  properly  secured  and  the  head 
held  by  an  attendant,  not  between  his  knees  but 
in  his  hands.  If  the  oesophageal  tube  be  of  good 
size  it  cannot  enter  the  larynx.  The  wooden 
termination  of  the  tube  must  be  short,  so  as  to 
allow  of  its  curving.  The  operator  standing  in 
front  passes  the  tube  through  the  hole  of  the 
gag,  inclining  it  to  the  patient’s  loft,  so  as  to 
avoid  the  vertebrae.  It  may  be  held  by  the 
tongue,  but  at  the  first  inspiration  the  hold  is 
relaxed,  and  it  glides  down  the  asophagus. 
The  food  may  be  poured  down  it  by  a funnel  or 
pumped  down  by  the  pump.  The  next  class  of 
patients,  making  less  resistance,  may  be  fed  by 
Paley's  feeder,  a glass  vessel  with  a flattened  spout 
which  goes  over  the  tongue  : the  food  is  emitted, 
a little  at  a time,  by  means  of  a spring,  and 
finds  its  way  down  the  gullet.  A certain  number 
of  patients  may  he  fed  by  getting  a funnel 
behind  the  teeth  and  pouring  food  into  it;  and 
others  by  holding  the  mouth  open  by  means  of 
two  spoons,  and  then  pouring  food  in.  Tho 
objection  to  the  latter  method,  and  to  its  many 
modifications,  is  the  time  taken  up  in  the.  opera- 
tion, whereby  great  fatigue  and  exhaustion  are 
produced.  G.  T.  Blandford. 

FORMICATION'  ( formica , an  ant). — An 
abnormal  subjective  sensation  referred  to  the 
skin,  which  is  described  as  of  a ‘ creeping  charac- 
ter, and  as  resembling  the  crawling  of  ants  upon 
the  surface.  See  Sensation,  Disorders  of. 

FOURTH  NERVE,  Diseases  of. — Morbid 
states  of  the  fourth  nerve  are  shown  in  spasm  or 
paralysis  of  the  superior  oblique  muscle  which  it 
supplies.  Little  is  known  of  overaction  of  this 
muscle.  Clonic  spasm  in  it  is  seen  in  rotatory 
nystagmus.  Paralysis  is  not  uncommon.  Its 
usual  causes  are  inflammation  of  the  nerve-sheath 
from  cold ; syphilitic  affections  of  the  nerve  or  of 
its  membranes  ; cerebral  tumours  &c.,  pressing 
on  or  injuring  the  nerve  at  its  origin  from  the 
valve  of  Vieussens,  or  in  its  course  around  the 
crus ; aneurism ; exostoses  or  growths  in  the 
orbit;  and  degeneration  of  the  nucleus,  in  common 
with  the  nuclei  of  the  other  nerves  of  the  ocular 
muscles. 

Symptoms. — Even  in  complete  paralysis  of  the 
superior  oblique  muscle  there  is  little  obvious 
deviation  of  the  affected  eye.  Movement  down- 
wards is,  however,  defective,  and  therefore  diplo- 
pia exists  when  the  eye  is  moved  below  a line 
which  runs  obliquely  downwrards  from  the  healthy 
to  the  paralysed  side,  through  the  point  of  mid- 
fixation. Movements  which  necessitate  a down- 
ward position  of  the  head  are  therefore  chiefly 


FRAMBCESIA. 

intertered  with,  and  it  is  common  for  the  first 
discovery  of  a defect  to  be  that  the  patient 
becomes  giddy  when  he  goes  downstairs,  in  con- 
sequence of  seeing  two  flights  of  stairs  before 
him  instead  of  one.  The  chief  visible  defect  in 
movement  of  the  affected  eye  (examined  alone) 
is  downwards  and  inwards,  because  it  is  when  the 
eyeball  is  moved  in  these  directions  that  the 
superior  oblique  has  most  influence  on  the  ver- 
tical position  of  the  eyeball.  The  defect  in  tho 
rotation  of  the  eyeball  is  greatest  when  it  is  moved 
downwards  and  outwards.  The  diplopia  which 
exists  when  both  eyes  look  down  is  homonymous, 
that  is,  the  image  formed  by  the  affected  eye  is 
on  the  same  side  as  that  eye.  The  left  eye  being 
higher  than  the  right,  its  image  (the  left)  appears 
lower  than  the  right  image.  The  action  of  the 
superior  oblique  being  to  move  the  upper  end  of 
the  vertical  axis  of  the  eye  inwards,  there  is  in 
its  paralysis  an  abnormal  divergence  of  the  upper 
ends  of  the  vertical  axes,  and  the  double  images 
(being  always  inverted)  will  cor.  verge : theirnpper 
ends  being  nearer  together  than  the  lower.  This 
is  due  to  the  obliquity  of  the  false  left  image,  and 
this  obliquity  is  greatest  when  the  eyeball  is 
moved  to  the  left  and  downwards,  because  in  this 
position  the  rotatory  powerof  the  superior  oblique 
is  greater,  and  the  obliquity  is  least  in  looking 
inwards  and  downwards.  Thus  the  convergence 
of  the  images  is  greatest  when  the  difference  in 
height  is  least,  and  vice  versd.  When  the  paralysis 
of  the  superior  oblique  has  existed  for  sometime, 
a secondary  contraction  of  the  inferioroblique  may 
cause  crossed  diplopia  in  looking  upwards. 

Treatment. — The  treatment  of  paralysis  of 
the  fourth  nerve  is  in  the  main  that  of  its  cause. 
AVhen  due,  as  it  very  commonly  is,  to  syphilis, 
iodide  of  potassium  in  full  doses,  with  or  without 
mercury,  is  necessary.  Smaller  doses  of  iodide 
with  quinine  or  iodide  of  iron  are  also  useful  for 
rheumatic  paralysis.  Blisters  to  the  templo  in 
the  early  stages  are  useful.  A little,  but  not 
much,  good  may  be  effected  by  applying  the 
constant  current  from  the  eyelid  to  the  forehead 
(Benedikt),  a few  cells  only  being  used. 

W.  R.  Gowers. 

FRAGILITAS  CRINIUM  (. fragilitas . 
brittleness ; crinis,  the  hair).  See  Hair,  Diseases 
of. 

FRAGILITAS  OSSIUM.  — A diseased 
condition  of  the  bones  in  which  they  are  ex- 
tremely fragile,  so  that  they  are  liable  to  fracture 
from  very  slight  causes.  See  Bone,  Diseases  of. 

FRAMBCESIA  ( framboise , a strawberry). — 
Synon.  : Yaws  ; Fr.  and  Ger.  Plan. 

Definition. — Framboesia  consists  of  an  erup- 
tion of  yellowish  or  reddish-yellow  tubercles  ; 
which  gradually  develop  into  a moist  exuding 
fungus  without  constitutional  symptoms,  or  with 
such  only  as  result  from  ulceration  and  prolonged 
discharge,  namely,  debility  and  prostration. 

^Etiology. — This  disease  is  peculiar  to  the 
African  race,  both  in  their  native  country  and 
in  the  West  Indies.  Yaws  are  epidemic;  they 
are  also  contagious  by  actual  contact,  and  conse- 
quently inoculable.  The  period  of  incubation  of 
the  poison  ranges  from  three  to  ten  weeks,  and 
except  in  rare  instances,  the  disease  occurs  onlf 
once  in  a lifetime. 


FRAMBCESIA. 

Symptoms. — The  tubercles  begin  with  little  or 
no  hypersemia,  and  range  in  size  between  that  of 
a pin’s  head  and  a prominent  mass  one  or  two 
inches  in  diameter.  Some  subside  without  piercing 
the  cuticle,  and  disappear  without  causing  dis- 
organisation of  the  skin.  When  the  cuticle 
is'  penetrated,  the  tubercles  assume  the  appear- 
ance of  a fungous  mass  of  spheroidal  figure, 
yellowish  or  pinkish  in  colour,  and  moistened 
with  a dirty-yellow,  foetid  secretion.  At  a 
later  period  the  fungus  shrinks  in  size,  and  is 
converted  into  a yellow  and  brownish  scab  ; at 
other  times  the  ulceration  extends  deeply  and 
widely  into  the  tissues.  The  subsidence  of  the 
eruption  is  succeeded  by  a pigmented  stain,  and 
the  healing  of  the  ulcers  by  a pigmentary  cicatrix. 

The  eruption  selects  by  preference  as  the  seat 
of  its  development,  the  face  and  neck,  the  limbs, 
the  feet,  and  the  genital  region,  and  is  frequently 
found  around  the  mouth,  the  apertures  of  the 
nostrils,  the  eyelids  and  the  anus,  where  it  is 
apt  to  present  a thick  fringe  of  tubercles  or  a 
broad  prominent  band  or  ridge. 

Course  and  Terminations. — Tho  ordinary 
duration  of  framboesia  extends  from  two  to  four 
months,  but  frequently  this  period  is  prolonged 
to  one  or  several  years.  AYhen  it  is  irregular  in 
its  development  the  constitution  is  apt  to  suffer, 
ulcers  form  around  the  joints,  the  joints  swell, 
the  discharge  from  the  ulcers  is  excessive,  the  ex- 
halations of  tho  body  are  highly  offensive,  and 
the  patient  is  crippled  for  life,  or  in  some  in- 
stances relieved  only  by  death. 

Treatment. — The  treatment  of  j'aws,  accord- 
ing to  the  best  authorities,  consists  in  cleanliness, 
generous  diet,  the  local  use  of  carbolic  acid 
lotions  and  diluted  nitrate  of  mercury  ointment ; 
and  the  employment  of  constitutional  remedies, 
of  which  the  most  useful  are  mercury,  with  sar- 
saparilla or  a decoction  of  the  woods,  iodide  of 
potassium,  and  tonics.  Erasmus  Wilson. 

FRANCE,  South  of.— The  eastern  part 
(Mediterranean  Coast)  is  dry  and  bracing,  with  a 
very  clear  atmosphere.  The  chief  resorts  in  it 
are  Cannes,  Mentone,  IIteres,  and  Nice.  The 
western  part  is  moist  and  mild  but  variable,  the 
principal  places  in  it  being  Arcachon,  Biarritz, 
and  Pau.  See  Climate,  Treatment  of  Disease  by. 

FRANZENSBAD,  in  Austria. — Alkaline 
Bulpbated  waters.  See  Mineral  Waters. 

FRECKLES. — Synon.  : Lentigines ; lenti- 
culte ; Fr.  ephelides ; Ger . Sommersprossen,  Som- 
merjlecJcen. — A freckle  is  a pigmentary  discolora- 
tion of  the  skin,  which  has  received  its  Latin  or 
technical  name  from  a resemblance  in  colour, 
figure,  and  size  to  a lentil.  It  varies  in  tint  from 
yellow  to  olive,  from  brown  to  black  ; and  is  met 
with  on  the  exposed  parts  of  the  skin,  particu- 
larly the  face,  neck,  and  hands,  and  occasionally 
on  the  covered  parts  of  the  body  (‘  cold  freckles '). 
It  is  usually  found  in  children  and  women  in  whom 
the  skin  is  sensitive  and  delicate,  and  has  ob- 
tained its  German  synonyms  from  its  greater 
frequency  in  the  summer  season.  See  Pigmenta- 
tion, Disorders  of.  Erasmus  Wilson. 

FREMISSEMENT  CATAIRE  (fremisse- 
fnent,  purring ; catciire,  connected  with  a cat). 


FRICTION.  51 V 

A physical  sign  felt  on  applying  the  hand  over 
the  region  of  the  heart  or  great  vessels  in  certain 
morbid  conditions  ; and  compared  to  the  sensa- 
tion conveyed  to  the  hand  by  the  purring  of  a eat 
This  sign  is  more  commonly  known  as  ‘ thrill  ’ or 
‘ purring  tremor.’  See  Physical  Examination. 

FREMITUS  {fremitus,  a loud  noise). — A 
group  of  physical  signs,  elicited  by  placing 
the  hand  over  the  respiratory  organs,  while 
the  patient  speaks  {vocal  fremitus),  or  coughs 
{tussive  fremitus)-,  or  in  certain  morbid  condi- 
tions when  the  patient  simply  breathes  ( rhoi s- 
chal,  and  friction- fremitus).  A fremitus 
may  sometimes  also  be  felt  over  the  cardiac 
region  in  connection  with  the  movements  of  tho 
heart,  when  the  surfaces  of  the  pericardium  are 
much  roughened.  Another  form  of  fremitus  is 
a peculiar  sensation  called  hydatid  fremitus, 
which  may  be  elicited  by  a special  mode  of  per- 
cussion over  hydatid  tumours  in  some  cases.  See 
Physical  Examination. 

FRICTION. — Synon.  : Rubbing  ; Fr.  Fric- 
tion ; Ger.  Beilmng. 

Definition. — By  friction  we  mean  surface- 
rubbing, as  distinguished  from  shampooing,  or  as 
it  is  sometimes  called  medical  rubbing,  a process 
of  manipulation  by  which  deep  pressure  is  made 
upon  the  muscles. 

Applications  and  Uses. — Friction  is  usefully 
employed  over  the  surface  of  a limb,  or  the  trunk, 
for  a variety  of  purposes.  It  is  especially  useful 
when  the  circulation  is  enfeebled,  either  by  the  ex- 
ternal application  of  cold,  amounting  when  in  a 
severe  degree  to  frost-bite,  or  in  eases  of  paralysis. 
The  effect  is  still  further  increased  by  the  use  of 
various  stimulating  liniments  and  embrocations, 
more  especially  when  it  is  desirable  to  excite  a 
certain  amount  of  counter-irritation  over  a large 
cutaneous  surface  for  the  relief  of  congestion  or 
inflammation  of  internal  organs. 

Another  object  with  which  friction  is  largely 
employed  in  medicine,  is  to  facilitate  the  ab- 
sorption and  introduction  into  the  system  of 
various  remedial  agents  applied  externally, 
instead  of  being  administered  internally  by  the 
stomach.  By  this  means  gastric  irritation  and 
disturbance  are  avoided,  and  tho  effects  of  the 
remedies  upon  the  system  can  be  more  closely 
watched  and  regulated.  In  this  way  mercury 
is  frequently  introduced  into  the  system  by  tho 
process  commonly  spoken  of  as  rubbing  in,  and 
salivation  can  be  more  easily  avoided  or  checked 
at  its  commencement  than  when  mercury  is  ad- 
ministered by  the  mouth.  The  part  of  the  body 
selected  for  this  purpose  is  that  along  the  inner 
side  of  the  thigh  up  to  the  groin,  and  mercury, 
rubbed  in,  in  the  form  of  ointment,  every  night 
and  morning,  will  generally  affect  the  system  in 
a few  days. 

Another  instance  of  friction  is  to  he  found  in 
the  fattening  of  children  by  the  process  of  rub- 
bing in  oil — fresh  neat's-foot  oil  is  the  best — 
every  night  and  morning,  over  the  chest,  abdo- 
men, arms,  and  thighs.  Emaciated  children 
thus  treated  gain  in  weight  by  the  absorption 
of  the  oil ; and  not  only  do  they  fatten,  but 
their  general  nutrition  and  health  are  im- 
proved, often  with  the  diminution  of  glandular 
swellings  and  the  disappearance  of  coughs,  so 


520  FRICTION. 

Ihat  there  is  some  ground  for  the  belief  in  the 
curative  influence  of  this  method  of  medication 
in  incipient  phthisis.  William  Adams. 

FRICTION-FREMITUS.— The  form  of 
fremitus  produced  by  the  rubbing  together  of 
surfaces  roughened  by  various  morbid  conditions, 
as  of  the  pleura  in  breathing,  or  of  the  pericar- 
dium from  the  movements  of  the  heart.  See 
Fremitus,  and  Physical  Examination. 

FRICTION-SOUND.— A physical  sip, 
heard  on  auscultation,  and  due  to  the  rubbing 
against  each  other  of  serous  surfaces  that  have 
lost  their  natural  smoothness  and  moistness  from 
any  cause.  See  Physical  Examination. 

FRIEDRICHSHALL,  in  Germany.— Sul- 
pliated  waters.  See  Mineral  Waters. 

FROST-BITE. — A local  effect  of  extreme 
cold  upon  any  of  the  tissues  of  the  body.  Sec 
Cold,  Effects  of  Extreme  or  Severe. 

FUMIGATION  (fitmigo,  I smother). 

Definition. — This  is  a mode  of  employing 
certain  medicinal  agents  which  are  capable  of 
being  volatilised  by  heat,  the  vapour  being  then 
allowed  to  escape  into  an  apartment,  or  to  come 
in  contact  with  articles  of  clothing  and  other 
objects,  for  purposes  of  disinfection  {see  Disin- 
fection) ; or  being  allowed  to  act  upon  the  sur- 
face of  the  body  as  a whole,  or  upon  certain  parts 
of  it,  for  therapeutic  purposes,  either  local  or 
general,  on  being  absorbed.  The  chief  agents 
which  are  thus  used  are  sulphur  and  mercury. 

Modb  of  Application  and  Uses. — The  mode 
of  using  sulphur  as  a disinfectant  will  he  found 
sufficiently  explained  under  the  article  Disinfec- 
tion. The  vapour  may  also  he  brought  with  a 
therapeutic  object  into  contact  with  the  body  or 
any  part  of  it  in  the  dry  state,  the  sulphur  being 
burnt  in  a suitable  apparatus.  As  a general 
application  it  is  used  for  the  cure  of  itch ; as 
a local  application  in  diseases  of  the  throat,  and 
various  other  affections. 

Mercurial  fumigation  is  now  commonly  effected 
by  means  of  the  moist  mercurial  vapour  bath,  in 
which  the  skin  is  exposed  to  the  fumes  of  mer- 
cury volatilized  by  heat  and  mixed  with  steam, 
in  a suitable  apparatus.  This  process  is  more 
effectual  than  dry  fumigation,  for  the  moistened 
skin  is  more  capable  of  receiving  and  absorbing 
the  mercurial  vapour  which  settles  upon  it.  It 
is  not  desirable  to  produce  profuse  perspiration, 
as  this  exhausts  the  patient,  and  washes  the 
mercurial  film  from  the  body. 

Various  preparations  of  mercury  have  been 
tried,  but  by  far  the  best  is  calomel  as  recom- 
mended by  Mr.  Lee,  which  is  capable  of  being 
more  completely  volatilized  than  any  other  form 
and  with  aless  degree  of  heat,  whilst  the  amount 
administered  is  more  accurately  known.  The 
quantity  used  for  each  bath  may  be  varied  from 
10  to  30  grains,  and  given  daily  or  at  such  inter- 
vals as  circumstances  indicate.  The  body  should 
be  protected  from  cold  after  leaving  the  bath, 
and  night  is  the  best  time  for  its  use,  as  the 
patient  can  then  go  to  bed  enveloped  in  the 
cloak  or  blanket  which  has  been  employed  in 
the  process,  and  upon  which  much  of  the  vapour 
has  collected.  Salivation  is  readily  and  often 


ED NG U .5-DISEASE  OF  INDIA. 

quickly  produced  by  this  method,  so  that  the 
gums  must  be  carefully  watched  and  the  doee 
regulated.  The  time  ordinarily  required  for 
the  hath  is  about  20  minutes,  but  if  headache 
or  lassitude  be  caused,  it  must  not  be  so  pro- 
longed. 

The  advantages  of  this  practice  are  that  mer- 
cury can  be  introduced  into  the  system  withon. 
giving  rise  to  the  intostinal  derangements,  loss 
of  appetite,  &c.,  which  its  exhibition  by  the 
mouth  sometimes  occasions,  and  its  direct  action 
upon  the  skin  often  appears  to  he  of  service. 
There  is,  however,  the  disadvantage  that  in  some 
cases  the  mercurial  fumes  may  cause  a syphilitic 
eruption  to  inflame  and  spread. 

Mercurial  fumigation  has  been  employed  for 
primary  syphilis,  but  it  answers  best  in  the 
secondary  stage  of  the  disease,  and  especially 
for  the  dry  eruptions.  Sometimes  it  is  useful  for 
the  tertiary  manifestations  which  resist  iodide  of 
potassium,  but  it  should  be  tried  very  cautiouslv 
in  these  cases. 

In  certain  cases  where,  from  feeble  health  or 
other  causes,  it  is  not  advisable  to  influence  the 
system  with  mercury,  the  calomel  vapour  may 
be  directed  upon  some  local  parts,  such  as  an 
ulcerated  spot.  This  local  application  has  been 
found  serviceable  in  treating  intractable  sores  in 
advanced  syphilis,  in  severe  and  obstinate  ulcera- 
tion of  the  throat,  and  in  some  other  conditions 
Geo.  G.  Gascoten. 

FUNCTIONAL  DISEASES  — A class  cf 
diseases  in  which  an  anatomical  change  cannot 
be  detected  to  account  for  their  presence.  See 
Disease,  Classification  of. 

FUNGI,  Diseases  due  to.  See  Parasites, 
Diseases  from  ; and  Mushrooms,  Poisoning  by. 

FUNGOID  {fungus,  a mushroom). — A term 
applied  to  superficial  granulations  and  morbid 
growths,  especially  those  of  a malignant  nature, 
when  they  sprout  rapidly  and  assume  an  appear- 
ance somewhat  like  a mushroom.  See  Cancer, 
and  Ulceration. 

FUNGUS -DISEASE  OF  INDIA  — 

Synon.  : Madura  Foot,  Mycetoma  ; Morlus  tu- 
bcrculosus  pedis  ; Fr.  Degeiicrcscence  endemiqut 
des  os  die  pied  • Perical. 

Definition. — A diseased  condition  of  the 
hands  and  feet,  occurring  in  India,  characterised 
by  enlargement  and  distortion  of  the  affected 
extremity,  due  to  thickening  of  the  cutaneous 
tissues,  with  degeneration  and  subsequent  frac- 
ture of  the  osseous  structures.  Two  forms  of 
the  malady  are  described — one,  the  pale  or 
ochroid  form,  characterised  by  the  presence  of 
minute  globular  fatty  particles  like  fish-roe, 
and,  though  very  rarely,  by  the  existence  of 
minute  pink  concretions  not  unlike  red-pepper 
granules  ; the  other,  the  melanoid  or  dark  form, 
characterised  by  the  existence  of  black  or  dark 
brown  masses,  varying  in  size  from  that  of 
a grain  of  gunpowder  to  a walnut,  and  composed 
of  fungoid  filaments,  cells,  and  pigmentary  de- 
posit. 

Description. — This  remarkable  disease  of  the 
extremities  does  not  appear  to  have  been  ob- 
served hitherto  beyond  the  limits  of  Bindostan. 


FUNGUS-DISEASE  OF  INDIA. 


and  has  rarely  been  seen  to  affect  any  but  the 
natives  of  that  country.  No  case  of  a European 
or  half-caste  has  been  recorded  as  suffering  from 
a typical  form  of  the  malady.  The  foot  has  been 
observed  to  be  affected  more  often  than  the 
hand ; hence  it  was  common  formerly  to  find  the 
malady  referred  to  as  one  peculiar  to  the  foot. 
It  has  been  recognised  as  a distinctive  disease 
in  India  for  more  than  thirty  years,  and  was 
described  by  Goodfrey,  of  Madras,  in  the  Lancet 
in  1816,  and  by  Eyre  in  the  Indian  Annals  of 
Medical  Science  in  I860.  It  is  to  Dr.  Vandyke 
Carter,  however,  that  we  are  chiefly  indebted  for 
what  is  known  of  the  malady,  clinically  and 
pathologically,  and  his  writings  date  as  far  back 
as  1860.  His  recently  published  memoir  on  the 
disease  (Mycetoma,  or  the  Fungus  Disease  of 
India , 1874)  contains  a summary  of  all  that  had 
been  written  regarding  it  up  to  the  period  of 
publication.1  The  foot  or  hand  affected  with  the 
disease  presents  appearances  not  unlike  what 
are  observed  in  some  of  the  forms  of  caries — 
especially  those  of  scrofulous  origin.  When  it 
is  the  foot  that  is  affected,  it  is  found  to  be  con- 
siderably increased  in  circumference,  the  enlarge- 
ment seldom  extending  far  beyond  the  ankle ; 
the  foot  is  prone  to  run  in  a line  with  the  leg,  and 
may  be  everted  or  inverted.  It  is  not,  however, 
in  the  aspect  presented  by  the  limb  that  the 
leading  peculiarity  consists,  but  in  the  character 
of  the  discharges  from  the  sinuses,  the  openings 
of  which  are  scattered  all  over  the  surface  of  the 
affected  tissue.  It  is  this  peculiarity  which  led 
Dr.  Carter  to  separate  the  disease  into  two  forms, 
(1)  the  ‘pale’ or ‘ochroid,’  thedischarge  ofwhick 
consists  of  whitish-yellow  roe-like  bodies  of 
about  the  size  of  millet-seed  ; and  (2)  the  ‘ dark  ’ 
or  ‘ melanoid,’  so  called  from  the  dark  brown  or 
even  black  granular  bodies  that  constantly 
escape  through  the  sinuses,  not  unlike  grains  of 
coarse  gunpowder.  The  first  form  may  be  said 
to  present  two  or  three  varieties,  according  to 
the  modified  character  of  the  discharges  : these 
will  be  referred  to  more  definitely  farther  on. 
The  malady  would  appear  to  occur  more  fre- 
quently in  Madras,  Bombay,  and  the  more  west- 
erly and  north-westerly  parts  of  India  than  in 
Bengal  proper.  This,  however,  seems  to  apply 
more  especially  to  the  dark  variety ; for,  whilst 
no  well-authenticated  case  of  this  form  has  been 
recorded  as  having  manifestly  originated  in  the 
last-named  province,  cases  of  the  pale  variety  are 
not  unfrequent.  So  far  as  the  foot  is  concerned, 
the  pale  form  is  manifestly  the  one  most  com- 
monly met  with  all  over  India,  at  least,  if  any 
inference  may  be  drawn  from  the  fact,  that 
whilst  the  writers  have  had  the  opportunity  of 
examining  two  or  three  hands  affected  with  the 

1 Bibl  : Carter,  H.  V.  Trans.  Med.  & Phys.  Soc.  of  Bombay, 
1860-02.  Trans.  Path.  Soc.  of  London,  vol.  xxiv.  1878.  On 
Mycetoma,  or  the  Fungus-dLease  of  India,  London,  1874. 
Carter,  H.  J.  Ann. and  Mag. Mat.  Hist.,  vol.  ix.  1862.  Jour- 
nal Linn.  Soc.  vol.  viii.  1865.  B rkeley,  Inlell.  Observ.  No. 
x.,  November,  1862.  Journal  Linn.  Soc.,  vol.  viii.  p.  135, 
1865.  Quart.  Journal  Micr.  Sc.,  New  Series,  vol.  xiv. 
1874.  Nature,  Novembrr  9,  1876.  Bristowe,  Trans.  Path. 
Soc.,  vol.  xxii.  1871.  Ho<rg — , Monthly  Micr.  Journal, 
August,  1871.  March.  1872.  Lewis  and  Cunningham. 
Eleventh  Ann.  Report  of  Sanitary  Commissioner  with  the 
Government  of  India.  1875.  Indian  Annals  of  Med.  Sc., 
vol.  xviii.  1876  (Reprint).  Tilbury  Fox  and  Farquhar, 
V<>  certain  Endemic  Shin  and  other  diseases  of  India.  &c., 
.876. 


521 

dark  variety,  they  have  not  seen  one  affected 
with  the  pale  ; nor  can  they  find  any  account  of 
such  a case  having  been  witnessed.  The  distor- 
tion of  the  hand  affected  in  this  manner  is  very 
peculiar — it  is  shortened  and  thickened,  owing 
to  the  destruction  of  tho  carpus  and  metacarpus, 
and  the  consequent  irregular  tension  of  the  ex- 
tensor and  flexor  tendons. 

Anatomical  Characters. — On  laying  open 
a characteristic  specimen  of  the  disease,  the 
bones  are  found  to  be  extremely  softened,  so 
that  they  can  readily  be  divided  by  means  of  a 
common  knife.  The  interior  of  the  hand  or  foot 
is  found  to  be  occupied  by  a series  of  sharply 
defined  cavities,  some  quite  isolated,  but  the 
majority  communicating  with  one  another  and 
with  the  exterior  by  a series  of  complex  channels 
or  sinuses  containing  glairy  fluid  and  solid  con- 
cretions in  various  proportions.  Both  cavities 
and  channels  are  lined  by  a dense,  glistening 
membrane  composed  of  white  fibrous  and  elastic 
tissue.  The  surrounding  tissues  are  generally 
in  a very  fatty  condition,  and,  where  the  disease 
is  of  long  standing,  are  more  or  less  completely 
blended  into  an  indistinguishable  mass.  So  far 
a common  description  is  applicable  to  both  forms 
of  the  disease ; but  on  proceeding  to  the  con- 
sideration of  the  contents  of  the  cavities,  great 
differences  present  themselves. 

Pale  Form. — The  paleor  ochroid  form  iscapable 
of  subdivision  into  several  varieties,  according  to 
the  nature  of  its  morbid  products.  In  the  com- 
monest and  most  characteristic  variety  the  cavi- 
ties and  Channels  contain  masses  of  spherical 
bodies  like  fish-roe,  of  a pinkish-yellow  or  white 
colour,  surrounded  by  gelatinous  glairy  matter. 
In  certain  cases,  however,  the  roe-like  bodies 
are  almost  or  eutirely  absent,  and  the  gelatinous 
matter  and  liquid  oil  are  generally  diffused 
throughout  the  tissues.  In  a third  and  very 
rare  variety  the  section  looks  as  though  be- 
sprinkled with  grains  of  red-pepper,  from  the 
presence  of  innumerable  minute  concretions  of 
a bright  red  hue. 

Dark  Form. — The  appearances  presented  in  the 
dark  form  of  the  disease  are  strikingly  different. 
Here,  in  place  of  the  roe-like  bodies  of  the  previous 
form,  the  cavities  and  channels  contain  masses  of 
a dark  brown  or  black  colour.  These  masses  vary 
greatly  in  size,  some  not  being  larger  than  the  nor- 
mal fat-lobules  surrounding  them,  others  attaining 
to  the  size  of  a small  orange.  The  larger  masses 
greatly  exceed  any  of  the  roe-like  masses  of  the 
pale  variety  in  size,  and  their  consistence  is  also 
much  firmer  than  that  of  the  latter.  They  are 
tuberculated  on  the  surface,  and  closely  resemble 
truffles  in  appearance.  On  section,  they  present 
a more  or  less  distincrly  radiating  structure,  and 
the  interior  is  generally  somewhat  lighter  in 
colour  than  the  tuberculated  exterior  coating.  In 
some  cases  they  are  tightly  fitted  into  the  cavi- 
ties in  which  they  lie,  but  in  others  they  lie 
loose  and  are  surrounded  by  a certain  amount  of 
gelatinous  matter.  The  amount  of  the  latter 
present  is,  however,  much  less  than  in  the  pale 
form. 

The  masses  of  morbid  material  in  both  forms 
are  primarily  situated  in  spaces  normally 
abound’ng  in  fat.  Long  series  of  them  are 
frequently  interpolated  among  the  loculi  in  the 


FUNGUS-DISEASE  OF  INDIA. 


522 

subcutaneous  tissue,  between  healthy  fat-lobules ; 
others  occupy  the  interior  of  the  bones;  and  a 
third  series  are  developed  in  the  pads  of  fat 
lying  around  muscles  and  tendons.  The  muscles 
and  tendons  in  such  cases  may  frequently  be 
found  quite  intact,  although  surrounded  by 
masses  of  the  morbid  material.  Due  to  this 
persistence,  fracture  and  crushing  of  the  softened 
bones  often  occurs,  and  it  is  on  this  that  the  dis- 
tortion of  the  affected  part  is  in  many  cases 
in  great  measure  dependent. 

Minute  characters  of  the  morbid  products. — The 
roe-like  particles  are  composed  of  a nucleus  of 
granular,  waxy  consistence,  surrounded  by  a 
fringe  of  radiating  crystals.  They  appear  to  be 
almost  entirely  composed  of  fatty  matter,  and  no 
traces  of  the  presence  ot  parasitic  organisms  of 
any  kind  can  be  detected  in  them.  The  bright 
red  particles  occurring  in  certain  cases  of  the 
ochroid  form  are  concretions,  consisting  iu  great 
part  of  phosphates  and  carbonates,  and  contain- 
ing a considerable  proportion  of  iron.  The  dark 
masses  present  in  the  other  form  of  the  disease 
are  of  much  more  complex  structure.  In  all,  or 
almost  all,  cases  they  contain  septate  fungoid 
filaments  in  greater  or  less  proportion.  These 
are  sometimes  difficult  to  distinguish,  but  may 
generally  be  detected  by  allowing  portions  of  tho 
material  to  soak  for  some  days  in  liquor  potassae. 
Tho  proportion  which  the  filaments  bear  to  the 
entire  muss  when  thus  separated,  is  in  any  case 
very  small,  and  in  some  cases  extremely  so,  for 
on  the  completion  of  the  soaking  only  a very 
small  quantity  of  colourless  fiocculi,  consisting  of 
masses  of  branched  filaments  mixed  with  empty 
cyst-like  cells,  is  left  behind  in  the  fluid.  The 
latter  has  assumed  a brown  colour  from  the  solu- 
tion of  the  dark  mass.  The  filaments  and  cysts 
(see  tho  accompanying  figure)  in  so  far  as  tests 


Fin.  21. — Fungoid  Filaments  and  Capsules  obtained  after 
prolonged  maceration  of  the  black  suhstance  in  caustic 
potash,  x 500. 

have  yet  determined,  are  indistinguishable  from 
undoubted  fungal  elements.  They  are,  as  a rule, 
quite  empty,  aud  show  no  signs  of  growth,  or 
indeed  of  life.  The  basis  iu  which  they  are  im- 
bedded varies  greatly  in  different  cases.  In  some 
instances  it  is  soft  and  contains  much  oily  matter, 
but  in  the  more  advanced  cases  this  is  almost 
absent.  It  is  then  only  soluble  by  means  of 
alkalis.  The  ash  consists  mainly  of  calcium 
phosphate  and  is  red,  due  to  the  presence  of 
oxide  of  iron. 

The  fungoid  filaments  have  never  yet  been 


shown  to  bo  capablo  of  any  further  development. 
All  attempts  at  cultivation  have  failed  in  causing 
them  to  assume  any  form  by  which  their  true 
nature  and  relationships  may  be  determined. 
They  have  never  given  any  unequivocal  signs  of 
life  external  to  the  body,  even  when  exposed  to 
conditions  favourable  to  the  growth  of  tungi  as 
demonstrated  by  the  development  of  various  ex- 
traneous moulds  upon  the  surface  of  the  black 
masses  themselves,  or  on  the  media  in  which 
they  were  immersed. 

Symptoms. — Dr.  Carter  writes:  ‘As  a rule  the 
local  indications  of  this  disease  are  the  same  for 
all  its  forms ; for  commonly  it.  is  not  possible  to 
discriminate  the  several  varieties  by  simple  in- 
spection or  bare  clinical  history  of  the  case  ’ The 
statements  made  by  the  patients  as  to  the  mode 
of  origin  and  progress  of  these  complaints  are 
very  various,  but,  taken  generally,  they  seem  to 
imply  that  tho  symptoms  are  analogous  to  those 
usually  observed  in  deep-seated  di.-ease  of  the 
osseous  and  adjoining  tissues.  Eventually  a 
more  or  less  hard  lump  is  felt  in  the  solo  of  the 
foot  or  palm  of  the  hand,  or  in  several  places. 
Generally  one  or  more  abscess-like  formations 
occur,  and  ultimately  several  sinuses  are  estab 
lished,  the  latter,  as  a rule,  preseuting  a peculiar 
mamillated  appearance — the  ‘ tubercles,’  appa- 
rently, of  earlier  writers.  Along  with  these 
changes,  enlargement  and  distortion  of  the 
affected  member  take  place,  but  unaccompanied 
with  severe  pain.  Discharges  set  in,  more  or 
less  offensive,  according  to  the  nature  of  the  sub- 
jacent degeneration,  and  the  limb  becomes  not 
only  useless,  but  a burden  to  its  owner.  In  this 
manner  the  sufferer  may  go  on  for  from  one  to 
fifteen  or  more  years,  unless  relief  he  sought  in 
a surgical  operation. 

Pathology. — The  occurrence  of  the  fungoid 
filaments  in  the.  products  of  the  dark  variety  of  the 
disease,  has  caused  many  author-  to  regard  them 
as  the  essential  cause  of  it.  There  are,  however, 
good  grounds  for  rejecting  such  a conclusion. 
Had  the  dark  form  of  the  disease  been  theonly  one 
with  which  we  were  acquainted,  there  might  have 
been  some  cause  to  regard  tt  as  due  to  parasitic 
agency.  When,  however,  we  find  that  the  pale 
form,  whilst  causing  all  the  important  lesions 
present  in  the  other,  shows  a total  absence  of  all 
fungoid  elements  in  its  products,  we  are  forced  to 
regard  such  elements  as  of  secondary  importance. 
The  only  means  of  overcoming  this  objection 
would  be  a demonstration  that  the  products  of 
the  pale  form  are  due  to  a degeneration  of  the 
black  matter,  in  the  course  of  which  the  fungoid 
elements  disappear.  No  such  demonstration  has 
been  given,  and,  on  the  contrary,  it  has  been 
shown  that  each  form  is  capable  of  running  an 
entirely  independent  course,  the  gradual  trans- 
formation of  the  normal  fat  having  been  traced 
in  the  one  case  to  the  production  of  the  r 'e-like 
particles,  and  in  the  other  to  that  of  the  black 
masses  in  which  the  fungoid  elements  are  im- 
bedded. Were  the  pale  form  the  only  one  known 
the  disease  might  be  described  as  a mere  de-gene- 
ration of  the  fatty  tissues,  with  tho  results  con- 
sequent on  the  presence  of  the  morbid  products 
of  the  process  in  the  surrounding  parts ; but 
this  explanation,  although  so  far  applicable  to 
the  dark  form,  throws  no  light  on  the  source  of 


FUNGUS-DISEASE  OF  INDIA. 


GALACTAGOGUES. 


523 


the  fungoid  elements.  They  are  present  in  masses 
which  are  entirely  isolated  in  the  tissues,  having 
no  communication  wkh  one  another  or  with  'he 
exterior.  There  is  no  evidence  of  their  passage 
from  one  cavity  to  another — on  the  contrary 
they  are  absolutely  limited  to  the  contents  of  the 
cavities,  the  membranous  walls  of  the  latter  and 
the  intervening  tissues  never  showing  any  traces 
of  a spreading  mycelium,  or  of  any  other  fungal 
elements. 

Assuming  the  filaments  to  be  of  undoubted 
fungal  origin,  the  facts  point  rather  to  their 
simultaneous  and  independent  development  in 
multiple  centres,  than  to  their  spread  from  one 
to  another.  The  fact  of  the  necessity  of  a suit- 
able soil  or  nidus,  in  addition  to  the  mere  pre- 
sence of  germs,  in  order  to  secure  the  development 
of  organisms,  is  generally  accepted.  That  germs 
of  most  various  kinds  must  constantly  be  intro- 
duced into  the  blood,  is  a self-evident  fact. 
Putting  their  introduction  by  means  of  the  lungs 
out  of  the  question,  their  constant  introduction 
from  the  intestinal  canal  can  hardly  be  denied. 
It  can  he  demonstrated  that  the  intestinal  con- 
tents abound  in  vegetable  organisms — spores, 
bacteria,  &c.— in  a living  condition.  As  it  is  an 
ascertained  fact  that  solid  particles  of  inorganic 
matter  of  far  larger  size  than  many  of  these 
germs  can  enter  the  circulation,  it  can  hardly  he 
denied  that  the  latter  may,  and  indeed  must, 
enter  also.  So  long  as  such  bodies  do  not  meet 
with  conditions  favourable  to  development,  they 
are  no  doubt,  destroyed  and  utilised  by  the  living 
matter  of  the  blood  and  other  tissues.  If,  how- 
ever, they  are  deposited  in  a medium  favourable 
to  them,  they  will  grow  and  undergo  such  de- 
velopment as  they  are  capable  of.  The  morbid 
products  of  the  disease  here  described  are  practi- 
cally dead  material,  external  and  extraneous  to 
the  bodj-,  and  it  has  been  experimentally  demon- 
strated that  when  removed  from  the  body  they 
form  a basis  capable  of  supporting  the  growth  of 
fungal  organisms.  Given  these  two  conditions 


— the  constant  presence  ofgerms  in  the  circulation. 

and  the  possession  of  a suitable  soil  for  fungi — 
and  the  difficulty  of  accounting  for  the  presence 
of  fungal  elements  in  the  latter  appears  in  great 
part  to  disappear. 

Prognosis. — Both  forms  of  the  disease  run 
a very  chronic  course,  and  often  without  very 
materially  affecting  the  general  health  of  the 
patient ; in  some  cases,  however,  great  emaciation 
accompanies  the  disease.  With  regard  to  the 
duration  of  the  malady,  it  may  be  stated  that 
cases  have  been  recorded  as  having  existed  for 
various  periods  up  to  twentv-six  and  thirty  years. 

Treatment. — There  are  no  instances  recorded 
of  a spontaneous  cure  having  been  effected,  nor 
have  remedial  applications  proved  of  material 
permanent  value  in  either  form  of  the  disease. 
Removal  of  all  the  diseased  tissue,  by  amputation 
of  the  affected  extremity,  is  the  only  remedy 
which  meets  with  general  approval.  The  subse- 
quent treatment  resolves  itself  into  that  of  an 
ordinary  surgical  operation. 

D.  D.  Cunningham. 

. T.  E.  Lewis. 

FUNGUS  BYEMATODES  ( fungus , a 
mushroom  ; aijict,  blood,  and  eTSoj,  like). — A 
synonym  for  soft  malignant  growths,  which  are 
exuberant  and  highly  vascular,  and  therefore 
peculiarly  liable  to  bleed.  See  Canceb,  and 
Tumours. 

FURFUH. — -Synon.  : Scurf,  Dandruff. — A 
branlike  desquamation  of  the  skin,  met  with  in 
several  cutaneous  diseases,  more  especially  pity- 
riasis, psoriasis,  and  ichthyosis.  Sec  Skin,  Dis- 
eases of. 

FURFURACEOUS  {furfur,  bran).— A term 
applied  to  a condition  in  which  the  epidermis  is 
shed  in  the  form  of  bran-like  scales.  See  Furfur. 

PURUN CULU S {fervio, I boil). — A synonym 
for  boil.  See  Boil. 


Gr 


GADFLY. — The  popular  name  for  a genus 
if  insects  whose  larvie  infest  man  and  the  lower 
animals.  Sec  (Estrus. 

GALACTAGOGUES  (ya\a,  milk,  and  ay  a, 
I move). 

Definition. — Agencies  which  increase  the  se- 
cretion of  the  mammary  gland. 

Enumeration. — The  most  common  galacta- 
gogues  are : — Mental  Emotions  , Local  Nervous 
Stimulation ; Warmth  ; good  Food  ; Alcohol ; Ja- 
borandi ; the  fresh  leaves  of  the  Castor  Oil  plant ; 
Tonics ; and  Electricity. 

Action. — When  wo  consider  how  powerfully 
mental  processes  may  affect  the  activity  of  nerves 
supplying  the  secreting  structure  of  glands,  we 


can  understand  how  these  may  influence  the  secre- 
tion of  milk,  as  of  the  sweat,  the  saliva,  and  the 
tears.  The  maternal  feelings  of  joy,  as  well  as  the 
reflex  stimulation  of  the  infant’s  lips,  act  most 
rapidly  in  developing  the  functions  of  the  breast. 
Warmth  and  good  diet  also  play  their  part  in  the 
process.  Alcohol  in  the  form  of  malt  liquors,  or 
malt-extract,  is  a useful  adjunct ; and  so  are  such 
tonics  as  iron,  which  counteract  in  some  measure 
the  severe  drain  on  the  constitutional  resources. 
Little  use  has  yet  been  made  in  actual  practice 
of  those  drugs  which  are  specially  credited  with 
galactagogue  properties  ; but  we  are  told  on 
good  authority  that  a poultice  made  of  the  fresh 
leaves  of  the  castor-oil  plant,  aided  by  teaspoon- 
ful doses  of  a fluid  extract  prepared  from  the 


624  GALACTAGOGUES. 

same,  have  a markedly  stimulating  influence  on 
the  mammary  secretion.  Belladonna  is  well 
known  to  dry  up  the  milk;  and  jaborandi,  which 
is  its  antagonist  in  so  many  respects,  has  been 
shown  to  have  here  also  a directly  opposite  effect, 
and  to  be  a drug  of  which  further  use  may  yet 
be  made  when  we  wish  to  excite  or  re-establish 
the  proper  functions  of  the  mammary  gland. 

Robert  Farquharson. 

GALACTIDROSIS  (yd\a,  milk,  and  iSpdr, 
perspiration). — A term  signifying  milky  perspi- 
ration. See  Perspiration,  Disorders  of. 

GALACTORRHCE  A (ya\a,  milk,  and  peco, 
I flow). — An  excessive  flow  of  milk.  See  Lac- 
tation, Disorders  of. 

GALL-BLADDER  AND  GALL-DUCTS. 

Diseases  of. — These  affections  may  be  con- 
sidered in  the  following  order:— 

1.  Catarrh  of  the  Bile-passages. — This  dis- 
ease very  rarely  gives  opportunities  for  examin- 
ation after  death.  At  the  time  after  death  that 
it  is  customary  to  make  post-mortem  examin- 
a'ions  in  this  country,  all  redness  of  the  duct 
has  usually  disappeared ; and  there  are  left  only 
swelling  and  pallor  of  the  mucous  membrane, 
which  is  covered  with  a tenacious  glassy 
or  purulent  secretion.  By  this  swelling  and 
secretion,  the  bore  of  the  duct  is  often  greatly 
narrowed  ; and  it  can  be  seen  that  no  bile  has 
passed  over  it  for  some  days,  as  all  colour  has 
disappeared  from  the  affected  part  of  the  tube. 
In  judging  of  this,  however,  no  pressure  must 
have  been  made  upon  the  gall-bladder  during 
the  earlier  part  of  the  examination.  These 
appearances  are  most  pronounced  in  the  common 
duct  and  the  gall-bladder ; they  are  gradually 
lost  in  the  hepatic  duct  and  its  branches  in  the 
liver.  Ths  process  seems  most  intense  at  the 
duodenal  end  of  the  gall-duct,  and  the  orifice  of 
the  papilla  itselfis  often  found  plugged  by  mucus, 
an  appearance  which  certainly  favours  the  notion 
that  the  catarrh  is  propagated  from  the  stomach 
and  duodenum.  This  is  believed  to  be  the  com- 
monest source  of  catarrh  of  the  bile-ducts. 
It  is  also  seen  in  nutmeg-liver  and  cirrhosis; 
and  a tendency  to  chronic  catarrh  is  set  up  by 
tho  presence  of  foreign  bodies  in  the  ducts,  such 
as  gall-stones. 

Symptoms. — Jaundice  is  often  the  first  symp- 
tom which  draws  the  attention  of  the  patient  to 
his  health  in  a case  of  catarrh  of  the  bile-duets, 
although  in  a certain  number  of  cases  this  is 
preceded  by  symptoms  of  gastric  disorder,  such 
as  vomiting  or  -wise  of  sickness,  loss  of  appetite, 
and  furred  tongue ; or,  on  the  other  hand,  by  diar- 
rhoea. The  jaundice  lasts  about  three  weeks, 
sometimes  as  much  as  six  or  eight  weeks.  After 
this,  suspicion  should  be  aroused  whether  some- 
thing more  than  a simple  catarrh  be  not  present. 

Diagnosis. — The  diagnosis  depends  upon  the 
absence  of  any  physical  signs  indicating  organic 
change  in  the  liver;  and  on  the  presence 
of  gastric  symptoms.  Thus  nearly  all  cases 
of  simple  jaundice  are  diagnosticated  by  some 
physicians  as  cases  of  catarrh  of  the  bile-ducts. 
As  the  greater  number  of  the  patients  recover, 
eery  few  opportunities  are  given  for  verifying 
this  diagnosis;  but  in  those  which  have  been 


GALL-BLADDER  AND  GALL-DTJCTS. 
examined,  plugs  of  mucus  in  the  ducts  have  not 
unfrequently  been  found.  The  catarrh  caused 
by  gall-stones  is  lost  in  the  jaundice  and  pain 
associated  therewith. 

Treatment. — The  treatment  should  at  first 
be  directed  to  the  gastric  symptoms,  beginning 
with  a purgative,  followed  by  a course  of  effer- 
vescing alkaline  medicines,  and  restricted  diet. 
Later  on,  dilute  nitro- hydrochloric  acid  taken 
before  meals  is  often  very  useful. 

2.  Inflammation  and  its  Results. — In  some 
cases  of  typhus  and  typhoid  fever,  and  in  other 
typihoid  states,  the  gall-ducts  and  gall-bladder 
become  ulcerated , or  filled  with  purulent  fluid,  or 
covered  with  croupous  exudation.  The  same  thing 
may  happen  when  gall-stones  are  impacted  in  the 
ducts.  The  gall-ducts  are  sometimes  obliterated 
by  fibrous  bands  passing  over  them.  Sometimes 
they  suffer  a congenital  obliteration  by  the  over- 
growth of  the  fibrous  tissue  around  them. 

3.  Dilatation. — The  gall-ducts  and  gall- 
bladder become  dilated  whenever  there  exists  an 
obstruction,  either  pressing  on  the  ducts  from  the 
outside,  or  formed  within  them.  The  first  result 
is  dilatation  of  the  ducts  behind  the  obstruc- 
tion. The  gall-bladder  becomes  much  dilated, 
often  filled  with  a thick  green  bile.  If  the 
obstruction  last  loDg,  the  coloured  part  of  the 
bile  is  absorbed,  and  its  place  taken  by  a colour 
less  fluid,  either  viscid  or  limpid.  This  fluid 
contains  neither  bile-pigment  nor  bile-acids,  is 
often  albuminous,  and  contains  abundance  of 
mucus.  The  ducts  outside  the  liver  may  he 
enormously  distended.  It  is  common  to  see 
them  as  big  as  the  middle  finger.  Within  the 
liver  they  are  also  dilated,  but  not  to  so  great  a 
degree  ; and  they  are  more  dilated  on  the  left 
than  on  the  right  side.  The  dilatation  of  the 
ducts  may  become  cystic,  and  sometimes  moni'.i- 
form.  The  writer  has  always  been  able  to  find 
columnar  epithelium  in  these  dilated  ducts.  In 
some  cases  of  long-continued  obstruction,  the 
contents  of  the  bile-ducts  become  colourless ; 
in  other  cases,  purulent;  and  small  abscesses 
form  around  the  bile-ducts,  and  open  into  them. 
These  abscesses  may  be  multiple  ; or,  more  com- 
monly, only  a single  large  one  is  formed.  The 
abscess  or  the  dilated  gall-duets  may  rupture 
into  the  peritoneum,  and  cause  fatal  peritonitis. 

4.  Cancer. — Primary  cancer  of  the  gall-ducts 
and  gall-bladder  is  sometimes  met  with ; or  they 
may  be  aflfeeted  secondarily. 

5.  Foreign  bodies  are  occasionally  met  with 
in  the  gall-ducts.  The  most  common  of  all  are, 
of  course,  gall-stones.  Much  less  common  are  en  • 
tozoa,  such  as  the  Distoma  hepaticum,  hydatids. 
or  the  two  kinds  of  ascaridcs. 

Symptoms. — In  all  these  different  morbid 
states,  it  is  usually  only  possible  to  say  at  the 
bedside  that  the  large  bile-ducts  are  obstructed ; 
a more  complete  diagnosis  is  commonly  impos- 
sible. Jaundice  is  an  important  symptom,  as 
without  it  diseaso  of  the  bile-ducts  cannot  be 
diagnosticated.  It  is  commonly  very  intense, 
the  urine  being  deeply  coloured,  and  the  faeces 
quite  colourless.  The  enlargement  of  the  liver, 
if  present,  is  commonly  uuiform,  the  surface 
being  smooth,  and  the  edges  well-defined.  The 
gall-bladder  may  often  be  felt  at  the  edge  of 
the  right  lobe  as  a rounded  tumour ; this  is 


GALL-BLADDER  AND  GALL-DUCTS. 

then  a sure  sign  of  the  obstruction  of  the  gall- 
ducts.  In  simple  diseases  of  the  gall-ducts  there 
is  an  absence  of  splenic  tumour,  of  ascites,  and  of 
other  symptoms  of  portal  obstruction.  In  many 
cases,  however,  diseases  of  the  liver  and  of  the 
gall-ducts  are  so  intimately  bound  up  together, 
that  they  cannot,  during  life,  be  separated. 

Prognosis. — The  prognosis,  if  simple  catarrh 
of  the  gall-ducts  and  gall-stones  can  be  excluded, 
is  unfavourable. 

Treatment. — The  treatment  must  be  con- 
ducted on  general  principles. 

6.  Enlargement  of  the  Gall-bladder.— 
The  gall-bladder  cannot  be  felt  in  health  during 
life.  But  it  may  often  readily  enough  be  made 
out  where  there  exists  any  obstruction  in  the 
common  or  cystic  duct,  so  that  it  becomes  dis- 
tended with  fluid.  It  may  also  be  felt  when  the 
walls  become  fibrous  or  ealeified,  or  the  seat  of 
cancer ; or  when  its  cavity  is  filled  with  gall- 
stones. A tumour  may  then  be  felt  under  the 
Iwrder  of  the  right  lobe  of  the  liver,  in  the  situ- 
ation of  the  gall-bladder.  When  filled  with  fluid, 
a rounded,  sometimes  oblong,  sometimes  pear- 
shaped  tumour  is  felt;  in  other  cases  it  has  an 
irregular  shape,  or  a somewhat  rounded  outline. 
A greatly-distended  gall-bladder  has  been  mis- 
taken for  ascites,  and  tapped.  The  diagnosis  de- 
pends chiefly  on  the  situation  of  the  swelling,  and 
even  then  the  distended  gall-bladder  maybe  mis- 
taken for  hydatid-disease  of  the  liver-substance 
nr  of  the  omentum,  or  for  a tumour  of  a neigh- 
bouring organ  which  has  pressed  against  the  liver. 
The  difficulty  of  the  diagnosis  is  much  increased 
if  the  liver  be  moved  from  its  natural  place, 
for  then  the  position  of  the  gall-bladder  be- 
comes uncertain.  Bamberger  says  he  has  often 
mistaken  a softened  cancerous  nodule  of  the 
liver  for  a distended  gall-bladder.  If  it  be 
certain  that  a fluctuating  tumour  be  the  gall- 
bladder, and  no  jaundice  be  present,  a diagnosis 
may  safely  be  made  of  hydrops  cystidis  felleae, 
or  dropsy  of  the  gall-bladder ; but  if  jaundice  be 
present,  or  if  the  tumour  do  not  fluctuate  but 
appear  solid,  there  are  then  no  definite  rules  for 
diagnosis  ; all  depends  upon  the  surrounding 
facts  of  the  case.  Dropsy  of  the  gall-bladder 
is  not  a dangerous  disorder,  and  requires  no 
treatment;  while  the  prognosis  and  treatment 
of  the  other  states  depend  entirely  on  their 
respective  causes. 

7.  Perforation.  — Perforation  of  the  gall- 
bladder or  of  the  gall-ducts  is  generally  the  re- 
sult of  ulceration,  due  to  gall-stones,  inflamma- 
tion, and  other  causes.  Fatal  peritonitis  ensues  if 
tlie  perforation  occur  into  the  abdominal  cavity. 
Frequently,  however,  previous  adhesions  have 
been  formed  between  tho  biliary  reservoir  or 
duct,  and  the  neighbouring  organs  or  the  abdo- 
minal wall,  and  the  result  of  this  is — - 

3.  Biliary  Fistula. — This  may  exist  between 
the  gall-bladder  or  gall-ducts  and  the  surface  of 
the  body,  the  stomach,  colon,  or  duodenum.  Very 
rarely  gall-stones  find  their  way  into  the  urinary 
tract.  J.  Wickham  Legg. 

GALL-STONES. — Synon.  : Hepatic  Cal- 
culi; Cholelithiasis;  Fr.  Calculs  biliaires ; Ger. 
Gallcnsteine. 

Description. — Gall-stones  are  seen  in  man  and 


GALL-STONES.  525 

most  of  the  vertebrate  animals,  and  in  some  mol- 
luscs. They  are  especially  common  in  oxen.  They 
are  found  in  the  biliary  passages  ; most  usually 
in  the  gall-bladder,  or  the  cystic  and  common 
duct ; more  rarely  in  the  hepatic  duct,  and  in  its 
branches  within  the  liver.  They  vary  in  size 
from  fine  gravel  to  concretions  five  inches  long. 
The  largest  are  commonly  single,  and  then  they 
are  rounded  or  oval  in  shape.  The  smaller  ealeu'  i 
are  usually  numerous,  being  then  tetrahedral  o: 
wedge-shaped,  showing  the  facets  or  plane  sm  - 
faces  caused  by  mutual  pressure.  They  are  never 
lighter  than  water  when  first  removed  from  the 
body.  Only  after  drying  do  they  float.  Their 
consistence  when  raised  to  the  ordinary  tem- 
perature of  the  body  becomes  much  less,  so  that 
they  can  be  moulded  by  the  fingers.  Their 
colour  varies  from  white  to  almost  black ; most 
commonly  it  is  brown. 

Dr.  Thudichum  thinks  that  the  nuclei  of  gall- 
stones are  mostly  formed  of  casts  of  the  hepatic 
ducts.  There  is  rarely  more  than  one  nucleus. 
Its  chemical  composition  is  a compound  of  lime 
and  bile-pigment,  or  traces  of  mucus  and  phos- 
phatic  earths.  The  chief  chemical  constituent 
of  human  gall-stones  is  cholesterin  ; some  gall- 
stones are  wholly  composed  of  this  substance  ; 
most  contain  70  or  80  per  cent.  Other  constitu- 
ents of  gall-stones  are  the  bile-pigments,  either 
by  themselves,  or  in  combination  with  lime. 
Very  small  quantities  of  the  bile-acids  are  found, 
and  these  are  also  in  combination  with  lime.  It 
is  rare  to  find  gall-stones  with  any  large  amounts 
of  carbonate  or  phosphate  of  lime,  though  the  ash 
of  nearly  all  gall-stones  shows  a large  amount  of 
carbonate  of  lime,  the  product  of  the  combustion. 
Traces  of  copper,  iron,  and  manganese  are  found 
in  nearly  all  gall-stones.  Lime-salts  of  the  fatty 
acids  are  likewise  found. 

TEtiologt. — Age  has  a very  great  influence 
in  the  production  of  gall-stones  ; they  are  ex- 
ceedingly rare  in  infancy  and  childhood,  their 
frequency  increases  after  the  age  of  puberty,  and 
they  become  still  more  common  after  thirty. 
Women  are  thought  to  be  more  liable  than  men 
to  gall-stones.  In  cancer  of  the  liver,  gall-stones 
are  certainly  very  commonly  found,  while  on  the 
other  hand  in  cirrhosis  they  are  scarcely  ever 
seen.  Want  of  physical  exercise  and  indulgence 
in  rich  diet  seem  to  favour  their  production. 

Pathology. — What  is  the  cause  of  the  first 
formation  of  a gall-stone?  It  is  not  simply  con- 
centration of  the  bile,  since  the  cholesterin  and 
pigment  remain  in  solution  so  long  as  the  bile 
is  unchanged ; but  the  beginning  of  decompo- 
sition of  the  bile-acids  causes  a precipitation. 
The  cholesterin  is  likewise  thrown  down  when 
the  reaction  of  the  bile  changes  from  alkaline  to 
acid.  Gorup-Besanez  and  Dr.  Thudichum  have 
kept  bile  several  months,  and  found  the  reaction 
at  the  end  of  that  time  acid,  with  an  abundant 
sediment.  It  is  thus  probable  that  the  retention 
of  bile  in  the  gall-bladder  or  gall-ducts  favours 
the  growth  of  these  concretions.  It  is  also  pro- 
bable that  gall-stones  are  sometimes  dissolved 
spontaneously,  as  erosions  may  sometimes  be 
seen  on  them ; or  they  may  break  up,  and  thus 
pass  out. 

Symptoms. — Gall-stones  while  still  in  the 
gall-bladder  rarely  give  any  signs  of  their 


526 


GALL-STONES. 


GANGLION. 


presence.  They  are  frequently  found  in  the  gall- 
bladders of  persons  who  during  life  had  no 
symptoms  which  could  be  referred  to  the  liver. 
It  is  when  they  begin  to  leave  the  gall-bladder, 
and  escape  into  the  cystic  and  common  duct,  that 
symptoms  arise  of  gall-stone  colie.  They  often 
begin  with  a dull  pain  near  the  liver,  with 
vomiting,  rigors,  and  elevation  of  temperature;  or, 
quite  suddenly,  a severe  pain  in  the  right  hypo- 
chondrium  comes  on,  described  as  shooting, 
stabbing,  burning,  &c.  The  pain  extends  into 
the  epigastrium,  rarely  to  the  left  hypochon- 
drium,  to  the  right  shoulder,  and,  according  to 
some,  even  into  the  extremities.  The  pain  is  very 
intense,  and  may  give  rise  to  delirium  and  con- 
vulsions in  nervous  persons,  or  to  hysterical 
attacks  in  women.  Vomiting  is  usually  present ; 
and,  as  the  attacks  most  often  come  on  after 
eating,  at  first  only  the  food  taken  is  thrown  up, 
and  then  a colourless  mucus.  The  right  hypo- 
chondrium  is  usually  very  tender,  and  the  muscles 
are  rigid.  The  pulse  is  not  increased  in  frequency, 
being  indeed  rather  below  than  above  the  natural 
number.  In  violent  attacks  the  pulse  becomes 
very  frequent  and  small,  or  almost  imperceptible  ; 
the  eyes  are  surrounded  with  dark  marks ; the 
nose  is  pointed;  the  breath  is  cool;  and  cold 
sweats  break  out  over  the  body.  In  this  state 
death  may  occur,  but  it  is  a rare  event.  A few 
hours  after  the  attack,  the  conjunctiva  may  show 
a yellow  tinge,  which  will  gradually  spread  from 
the  upper  part  of  the  trunk  all  over  the  body. 
The  jaundice  is  more  or  less  intense  according 
to  the  shape  of  the  gall-stone — whether  com- 
pletely obstructing  the  duct,  or  merely  causing  a 
hindrance  to  the  passage  of  the  bile.  In  some 
cases  jaundice  may  bo  altogether  wanting,  as 
when  the  stone  is  in  the  cystic  duct.  The  jaun- 
dice may  last  an  indefinite  time.  The  duration 
of  the  attack  of  colic  itself  varies  ; usually  not 
lasting  more  than  a few  hours,  it  may  extend 
over  several  days.  As  soon  as  the  gall-stone 
reaches  the  duodenum  the  attacks  are  over,  the 
stools  become  dark,  and  the  jaundice  begins  to 
disappear.  When  the  gall-stones  reach  the  in- 
testine, they  are  commonly  evacuated  with  the 
faeces;  some  cases  have,  however,  been  recorded 
in  which  they  were  so  large  that  symptoms  of 
intestinal  obstruction  were  caused  and  death  re- 
sulted. 

Diagnosis. — The  diagnosis  of  gall-stones  is 
often  more  or  less  difficult.  Some  physicians 
think  that  the  diagnosis  should  not  be  made 
unless  the  concretions  be  found  in  the  stools  ; and 
tho  search  for  them  should  be  made  by  passing 
the  feces  through  a sieve.  It  is  agreed  by  nearly 
all  that  it  cannot  be  made  if  there  be  no  jaun- 
dice present.  Cancer  of  the  head  of  the  pancreas 
may  readily  be  mistaken  for  gall-stones  in  the 
common  duct. 

Prognosis.— It  is  almost  impossible  to  make 
a trustworthy  pirognosis  in  these  cases.  The 
physician  can  never  speak  confidently,  or  feel 
quite  happy  when  treating  a case  which  he  looks 
upon  as  one  of  gall-stones. 

Treatment. — The  treatment  of  gall-stones 
may  be  discussed  under  two  heads  : during  the 
paroxysm  of  the  colic ; and  between  the  attacks. 

During  the  paroxysm,  the  great  object  of  the 
physician  is  to  relieve  the  pain.  This  may  best 


be  done  by  full  doses  of  morphia ; and  if  this  be 
rejected  by  vomiting,  it  may  be  administered 
hypodermically.  The  patient  may  be  put  in  a 
warm  bath  and  kept  there,  the  heat  being  main- 
tained by  the  renewal  of  the  warm  water.  Should 
these  means  fail,  chloroform  or  ether  may  be 
inhaled.  J 

Between  the  attacks  of  biliary  colic  a great 
number  of  remedies  have  been  propped : the 
most  popular  is  Durande’s,  which  consists  of 
three  parts  of  ether  and  two  parts  of  turpentine : 
the  best  plan  is  to  give  10  to  20  minims  of  this 
mixture  three  times  a day,  enclosed  in  capsules 
or  pearls.  The  German  physicians  have  great 
confidence  in  thp  alkaline  mineral  waters,  especi- 
ally Carlsbad.  Some  think  this  due  simply  to 
the  large  amount  of  water  daily  ingested,  causing 
a large  flow  of  bile.  Others  recommend  purga- 
tives,^ as  castor  oil,  or  taraxacum ; or  aqua  regia. 
Emetics.have  been  employed,  but  they  are  danger- 
ous on  account  of  the  straining  which  they  cause, 
and  which  may  lead  to  the  rupture  of  a vessel.  ’ 
J.  Wickham  Lego. 

GALLOPING  CONSUMPTION.  — A 

popular  name  for  phthisis  when  it  runs  an  acute 
or  rapid  course.  See  Phthisis. 

GALVANISM,  Uses  of.  See  Electhicitt. 

GANGLION  (yay-yKibv,  a hard  gathering). 
This  term  is  applied  to  a variety  of  somewhat 
different  affections,  including: — 1.  The  simple 
ganglion.  This  is  a cystic  tumour  formed  in  con- 
nection with  the  sheath  of  a tendon.  2.  The  com- 
pound or  diffuse  ganglion,  which  consists  of  a 
chronic  effusion  into  the  common  sheath  of  a 
group  of  tendons,  giving  rise  to  a fluctuating 
swelling.  One  variety  of  this  contains  the  so- 
called  melon-seed  bodies.  3.  The  term  is  ex- 
tended by  s*>me  writers  to  enlargements  of  the 
bursae  mucosae.  See  Bursts,  Diseases  of. 

1.  Simple  Ganglion. — Description. — The 
simple  ganglion  forms  a rounded  tumour,  occa- 
sionally lobulated,  situated  in  the  immediate 
neighbourhood  of  some  tendon.  The  most  com- 
mon situations  are  the  dorsum  of  the  hand,  the 
dorsum  of  the  foot,  the  palm  of  the  hand  at  the 
root  of  a finger,  and  behind  the  outer  or  inner 
malleolus.  The  tumour  varies  in  size  from  a 
pea  toa  pigeon’s  egg.  It  may  fluctuate  distinctly, 
or  be  so  tense  as  to  seem  absolutely  solid.  It  is 
not  adherent  to  the  skin  or  to  the  tendon  with 
which  it  is  in  relation.  It  is  painless,  hut  often 
gives  rise  to  a sense  of  weakness  iu  the  affected 
part.  The  wall  is  composed  of  a more  or  less 
delicate  fibrous  tissue,  fusing  with  the  surround- 
ing areolar  tissue,  and  lined  by  an  imperfect 
layer  of  endothelial  cells.  Its  contents  are  most 
usually  semi-solid,  like  apple-jellv,  but  sometimes 
fluid.  They  are  said  to  be  neither  albuminous  nor 
gelatinous,  but  colloid  in  character.  As  to  the 
exact  nature  of  the  tumour  opinions  differ,  and 
probably  it  is  not  always  the  same.  It  is  said 
to  arise  in  the  following  ways  ; 1st.  by  a hernial 
protrusion  from  the  sheath  of  a tendon,  the  neck 
of  which  becomes  gradually  contracted  and 
finally  closed,  so  giving  rise  to  a cyst  in  intims.te 
connection  with  the  sheath.  2nd.  Gosselin  has 
described  small  follicles  or  sub-synovial  crypLT, 
which  he  believes  may  become  dilated,  so  na  tc 


GANGLION. 

form  ganglia.  3rd.  The  tumour  may  be  a cyst 
of  entirely  new  formation. 

Treatment. — Painting  with  iodine  is  of  little 
or  no  use.  Forcible  rupture  of  the  cyst  by  a 
blow  or  pressure  sometimes  effects  a cure  ; but 
the  besf,  treatment,  is  to  puncture  the  tumour 
with  a clean  grooved  needle,  and  to  squeeze  out 
the  contents,  afterwards  applying  pressure  or  a 
blister  over  the  collapsed  cyst.  This  treatment 
may  require  to  be  repeated  more  than  once. 

2.  Compound  or  Diffuse  Ganglion.— 
Description. — This  disease  is  almost  exclusively 
confined  to  the  sheath  of  the  comm^ti  flexors  of 
the  fingers.  It  may  consist  of  a tdmple  dropsy 
of  this  sheath,  forming  an  hour-glass-shaped 
swelling  in  the  front  of  the  wrist,  the  constric- 
tion being  caused  by  the  annular  ligament ; or, 
in  other  cases,  the  tumoui  may  contain  melon- 
seed  bodies,  which  give  riixi  to  a sense  of  soft 
crackling  when  it  is  manipuluted.  These  melon- 
seed  bodies  are  smooch,  oval  and  flattish  in 
shape,  and  of  a pearly-white  colour.  They  are 
of  almost  cartilaginous  toughness,  and  on  sec- 
tion present  an  aeper  ranee  of  concentric  lamina- 
tion. Under  the  microscope  they  are  found  to 
be  composed  of  very  imperfect  fibroid  tissue. 
Their  origin  is  somewhat  doubtful.  They  have 
been  supposed  to  be  due,  first,  to  hypertrophy  of 
the  fringes,  normally  found  on  a synovial  mem- 
brane, the  pedunculated  projections  so  formed 
being  ultimately  broken  loose  by  the  movement  of 
the  tendons  ; secondly,  to  the  form>tion  of  pedun- 
culated warty  outgrowths  on  the  synovial  mem- 
brane, which  become  free  ill  the  same  way ; 
thirdly,  to  fibrinous  deposits  taking  place  from 
the  fluid  in  the  ganglion ; and,  fourthly,  to 
the  results  of  accidental  haemorrhage.  AVlien 
these  bodies  are  abundant,  the  fluid  is  usually 
scanty. 

Aetiology. — The  cause  of  this  affection  is  un- 
certain, but  it  must  be  remembered  thatinmany 
cases  it  is  due  to  the  irritation  caused  by  the 
earliest  stage  of  disease  of  the  carpus. 

Treatment. — The  treatment  of  compound 
ganglion  is  unsatisfactory.  Iodine  is  useless. 
Aspiration  followed  by  the  injection  of  iodine 
has  occasionally  been  of  service.  An  incision 
made  into  each  end  of  the  tumour,  followed  by 
drainage  under  antiseptic  dressing,  is  often  of 
use.  In  extreme  cases  Syme  recommended  lay- 
ing the  whole  cyst  open,  and  allowing  it  to 
granulate.  This  always  left  much  stiffness  in 
the  tendons.  When  melon-seed  bodies  are  pre- 
sent, they  must  be  removed  by  incision,  and  the 
case  treated  antiseptieally.  Marcus  Beck. 

GANGLIONIC  NERVOUS  SVSTEM, 
Diseases  of.  <S,e  Sympathetic  Nerve,  Diseases 
of. 

GAN GRENE  (7 palvut,  I corrode). — Synon.  : 
Mortification;  Sphacelus;  Fr.  Gangrene ; Ger. 
der  Brand. 

Definition. — Gangrene  is  the  arrest  of  the 
functions  of  organic  life  in  a circumscribed  por- 
tion of  the  soft  parts  of  the  body,  leading  to  tbe 
Complete  death  of  the  same. 

The  whole  process  of  death  is  included  under 
the  term  gangrene— the  result  being  mortifica- 
tion, or  necrosis  cf  the  invaded  tissue,  organ,  or 
limb. 


GANGRENE.  527 

Classification. — Clinically,  gangrene  varies 
greatly  according  to  its  position,  cause,  extent, 
the  powers  of  the  patient,  and  the  existence  of 
complications  The  disease  may  also  be  classified 
atiologically  and  pathologically,  into  spontaneous 
or  traumatic,  dry  or  moist,  chronic  or  acute 
gangrene,  senile  gangrene,  and  h"spital  gangrene. 
The  division  into  dry  and  moist  gangrene,  although 
convenient,  has  little  pathological  significance, 
being  founded  on  physical  characters.  Both  dry 
and  moist  gangrene  may  arise  from  similar 
causes,  and  coexist  even,  in  different  parts  of  the 
invaded  structures ; and  it  cannot  always  be  pre- 
determined whether  a gangrene  shall  be  of  the 
dry  or  of  the  moi.-t  form.  Dry  gangrene  is  usually 
dependent  on  senile  changes,  limited  in  extent, 
and  chronic  in  progress  ; the  parts  first  affected 
having  time  to  dry  up  as  the  disease  invades 
those  adjacent,  and  becoming  mummified,  hard,  and 
black,  resembling  the  knuckle  of  a Spanish  ham. 
Moist  gangrene  occurs  when  a larger  area  of 
living  tissue  suddenly  mortifies,  and  especially  if 
it  have  been  previously  inflamed  or  gorged  with 
fluid  ; the  dead  parts  becoming  rapidly  trans- 
formed into  a deliquescent  putrid  mass,  infiltrated 
with  gas.  To  this  type  belong  many  different 
forms  of  gangrene,  for  instance,  that  following 
the  obliteration  of  the  main  artery  of  a limb 
by  a ligature,  or  its  becoming  plugged  by  an 
embolus,  or  the  form  called  spreading  traumatic 
gangrene,  or  gangrene  affecting  an  internal 
organ. 

^Etiology. — The  causes  of  gangrone  may  be 
local,  constitutional,  or  a combination  of  both. 
Amongst  local  causes  we  find  intense  inflamma- 
tion of  some  organ  or  tissue,  such  as  pneumonia, 
noma,  cellulitis,  anthrax,  or  phlegmonous  erysi- 
pelas. Injuries  and  mechanical  violence  of  va- 
rious kinds;  and  extremes  of  heat  or  cold,  as 
seen  in  burns  and  scalds  or  in  frostbite,  also  lead 
to  gangrene.  Gangrene  may  be  produced  either 
as  the  direct  consequence  of  the  long-continued 
application  of  cold,  or  as  the  result  of  the  sub- 
sequent inflammatory  reaction.  Local  arrest  of 
the  circulation,  as  in  a strangulated  hernia,  an 
intussusception,  or  internal  strangulation,  a liga- 
tured haemorrhoid,  a too  tightly  bandaged  limb, 
or  severo  paraphimosis,  may  lead  to  gangrene.  It 
may  also  occur  from  extravasation  of  urine  or 
faeces.  Continued  pressure  produces  a variety  of 
gangrene  called  bedsore,  especially  in  lowly  vita- 
lised parts,  and  in  persons  suffering  from  chronic 
diseases,  or  from  certain  lesions  of  the  nervous 
centres.  See  Ulcer  and  Ulceration. 

One  of  the  most  frequent  constitutional  or 
general  causes  of  gangrene  is  deficient  blood- 
supply,  dependent  upon  disease  of  the  arteries 
and  heart,  the  result  usually  of  systemic  decay, 
whence  the  term  senile  gangrene.  Gangrene  may 
occur  in  the  course  of  certain  severe  diseases, 
as  diabetes,  typhus,  typhoid,  measles,  and  scar- 
latina; embolism  being  in  many  cases  the  imme- 
diate cause  of  the  complication.  The  gangrene 
due  to  ergotism  is  probably  induced  by  the  effect 
of  the  poison  on  the  blood-vessels.  A peculiar 
form  of  gangrene  sometimes  met  with  in  the  ex- 
tremities— the  gangrene  symetrique  of  the  French, 
is  one  in  which  no  more  definite  cause  can  be 
found  than  antemia,  and  an  extremely  feeble  cir- 
culation. And,  finally,  there  is  hospital  r/angrene — 


GANGRENE. 


628 

pourriture  d'hopital,  a diseaso  seldom  met  with 
now  except  amongst  wounded  soldiers  accumu- 
lated in  great  numbers  in  foul  hospitals  near  a 
battle-field. 

Symptoms.- — The  symptoms  of  gangrene  vary 
with  the  species,  the  extent,  and  the  stages  of  the 
disease,  and  with  the  rapidity  of  its  progress; 
and  also  according  as  it  is  dry  or  moist,  incipient 
or  complete.  The  importance  of  the  tissue  or 
organ  invaded,  and  the  presence  or  absence  of 
complications,  such  as  renal  or  cardiac  disease, 
or  of  fever,  also  create  differences. 

The  earliest  symptoms  are  those  of  diminished 
circulation,  sensibility,  and  temperature,  together 
with  change  of  colour  in  the  part  affected.  Pain 
is  one  of  the  primary  symptoms,  and  often  pre- 
cedes the  others.  In  dry,  senile,  or  chronic 
gangrene,  there  may  in  some  cases  be  few  symp- 
toms beyond  moderate  local  pain  and  discomfort, 
though  oftentimes  the  pain  is  intense;  whilst, 
when  the  type  is  of  the  moist  or  acute  variety, 
the  symptoms  are  usually  more  severe,  and  have 
a tendency  to  lapse  into  those  called  the  typhoid 
or  septicsemic.  Between  these  two  forms  there 
is  every  intermediate  grade  of  severity.  The 
amount  of  fever  varies  at  the  outset,  but  it 
is  usually  considerable.  The  patient  generally 
suffers  much  from  pain,  restlessness,  and  want 
of  sleep ; the  appetite  is  bad ; the  tongue  is 
loaded ; and  the  pulse  is  feeble  or  intermittent. 
When  the  disease  becomes  arrested,  the  dead  por- 
tion of  tissue  slowly  separates  and  drops  off,  or 
is  removed ; very  often,  however,  the  disease 
steadily  progresses,  and  the  patient  dies  from 
exhaustion,  or  more  rapidly  from  the  absorption 
of  septic  matter. 

Such  being  the  principal  symptoms  of  gangrene 
in  general,  we  may  next  describe  the  symptoms 
of  the  leading  varieties  of  the  disease. 

Dry  or  Chronic  Senile  Gangrene. — In  the  dry 
form  of  senile  gangrene  the  part  is  gradually 
starved  to  death.  The  disease  generally  occurs  in 
the  toes,  very  rarely  in  the  fingers  ; and  is  either 
spontaneous  or  excited  by  some  trivial  cause.  A 
discoloured  patch  appears  on  one  of  the  toes, 
of  a dusky  reddish-brown  colour,  which  soon  be- 
comes dry  and  black  in  the  centre.  The  disease 
spreads  very  slowly  to  the  adjacent  parts.  First, 
a zone  of  discoloration  appears  from  the  blood 
stagnating  in  them;  then  they  become  livid,  red, 
and  inflamed  ; afterwards  darker ; and,  finally, 
black  and  dry.  One  or  several  toes  may  be 
involved,  or  the  foot  in  whole  or  in  part.  The 
patient  generally  dies  sooner  or  later,  exhausted 
by  pain,  and  from  general  feebleness  of  the 
vital  powers.  Sometimes  a line  of  demarcation 
appears,  the  dead  parts  separate,  and  recovery 
follows ; but  as  a rule  relapses  take  place. 

Moist  or  Acute  Senile  Gangrene. — This  form  of 
senile  gangrene  is  more  active  in  its  progress, 
and  more  rapidly  fatal.  It  is  often  ascribed  to 
some  slight  local  irritation  or  injury,  such  as  an 
inflamed  corn  or  nail.  The  affected  toe  becomes 
dusky-red,  swollen,  and  extremely  painful;  soon 
after  the  dark  hue  of  absolutely  dead  tissue 
appears,  following  closely  the  zone  of  inflamma- 
tion ; and  this  gradually  spreads  onwards  till  the 
whole  foot  or  possibly  the  leg,  if  the  patient  sur- 
vive, becomes  implicated.  Beyond  the  gangre- 
nous area  the  skin  is  mottled,  and  presents  all 


the  appearances  due  to  impeded  circulation.  In 
this  type  of  gangrene,  stasis  of  the  Llood  and 
coagulation  first  take  place  in  the  capillaries 
and  extend  thence  to  the  smaller  arteries.  It 
occurs  in  elderly  persons  with  feeble  circulation, 
due  to  fatty  heart  and  atlieromatons  arteries 

Gangrene  from  Arterial  Obstruction. — The 
most  common  form  of  moist  gangrene  is  that 
due  to  sudden  arterial  obstruction — when  the 
collateral  supply  cannot  establish  itself  witli 
sufficient  rapidity.  It  is  acute,  and  a large  part 
of  the  body  being  at  once  engaged,  the  tissues  da 
not,  as  in  dry  gangrene,  have  time  to  dessicate 
pari  passu  with  the  spread  of  the  disease.  It 
may  happen  after  ligature  of  a main  trunk  for 
aneurism ; or  by  the  formation  of  a fibrinous  clot 
upon  the  roughened  wall  of  an  atheromatous 
vessel,  and  consequent  plugging ; or  by  embolism 
of  some  artery.  An  entire  limb  may  thus  he 
lost.  Venous  obstruction  per  se  does  not  pro- 
duce gangrene.  In  cases  due  to  embolism— a 
form  rare  in  the  upper  limbs,  but  common  in  the 
lower  extremities,  and  more  especially  in  tho 
anterior  tibial  arteries — sudden  and  severe  pain 
marks  the  onset  of  the  disease.  The  tempera- 
ture of  the  part  rapidly  falls ; livid  discoloration 
and  loss  of  sensibility  ensue ; the  veins  if  emptied 
fill  very  slowly  ; the  skin  mottles;  bullae  form 
filled  with  turbid  fluid  ; the  colour  changes  from 
whitish  grey  to  green,  olive,  or  black ; and  the 
affected  tissue  at  length  becomes  a deliquescent 
putrid  mass,  often  crepitating  from  gas  impri- 
soned in  the  meshes  of  the  cellular  tissue.  The 
tendons,  blood-vessels,  and  nerves  resist  the  dis- 
integrating process  longest. 

Gangrene  from  Inflammation . — Gangrene  u» 
the  result  of  intense  inflammation  is  likewise 
of  the  moist  type.  When  it  supervenes,  the  ten- 
sion, pain,  and  swelling  of  the  inflamed  area  sub- 
side ; the  part  becomes  soft  and  pasty ; the  colout 
changes  into  dusky  violet,  brown,  or  black ; and 
all  the  evidences  of  rapid  decomposition,  varying 
with  the  part  affected,  and  the  acuteness  of  the 
inflammation,  make  their  appearance. 

Gangrene  as  a Complication  of  General 
Disease. — Gangrene  is  occasionally  met  with  in 
the  later  stages  of  typhoid  fever,  or  even  during 
convalescence ; and  usually  occurs  in  the  lower 
limbs,  though  sometimes  iD  the  lungs,  or  face. 
It  is  of  vascular  origin,  and  is  a most  grave  com- 
plication. In  form  it  may  be  either  dry  or 
moist,  and  may  be  of  either  of  two  kinds.  One 
is  of  early  occurrence  in  the  progress  of  the 
disease,  and  generally  affects  the  toes  symme- 
trically ; the  other  occurs  later,  or  during  con- 
valescence, and  is  of  embolic  origin. 

Measles  is  prone  in  some  cases  to  occasion 
gangrene,  generally  affecting  the  face,  the  vulva, 
or  the  lungs.  Scarlatina  and  some  forms  of  ery- 
sipelas are  also  occasionally  followed  by  extensive 
gangrene.  The  disease  has  been  also  observed 
during  some  epidemics  of  cholera.  Gangrene 
produced  by  the  prolonged  consumption  of 
diseased  rye-bread  chiefly  occurs  in  the  male 
adult,  and  very  rarely  in  women  or  children. 
Other  symptoms  of  ergotism  will  then  be  pre- 
sent, gangrene  being  a late  occurrence.  Gan- 
grene from  ergotism  precisely  resembles  ordinary 
6enile  gangrene.  It  almost  invariably  appears  in 
the  lower  limbs;  and  when  aivia  of  demarcatior 


GANGRENE. 

forms,  this  generally  seems  to  correspond  with  the 
nearest  joint.  In  diabetic  gangrene  no  special 
rascular  deficiency  can  be  traced.  The  vitality 
of  the  tissues  seems  impaired  by  the  giycosuric 
condition,  and  some  slight  accidental  cause  pro- 
vokes a gangrenous  inflammation. 

Hospital  Gangrene. — Hospital  gangrene  presup- 
poses a wound  : the  lesion  on  invasion,  ceases  to 
discharge,  and  becomes  covered  with  a grey  tena- 
cious slough  extending  from  the  centre  towards 
the  edges,  which  become  much  inflamed  and 
everted.  The  patient  rapidly  lapses  into  a typhoid 
condition;  and  the  issue  is  generally  fatal. 

Acute  Traumatic  or  Spreading  Gangrene. — 
This  form  also  follows  upon  an  injury,  which  may 
be  either  slight  or  severe.  It  is  generally  seen  in 
one  of  the  extremities,  originating  in  a wound 
and  rapidly  spreading  towards  the  trunk — Gan- 
grene J'oudroyante.  It  is  in  many  eases  inti- 
mately associated  with,  and  probably  induced  bv, 
septic  infection  of  the  system.  It  is  usually  fatal, 
and  scarcely  amenable  to  treatment. 

Visceral  Gangrene. — The  gangrene  of  internal 
organs  will  be  found  described  in  connection  with 
the  diseases  of  the  several  organs. 

Progkkss. — The  progress  of  gangrene  depen- 
dent on  constitutional  causes  is  too  often  from 
bad  to  worse ; ami  a fatal  issue  may  supervene 
without  any  attempt  at  repair.  The  gangrenous 
inflammation,  preceding  the  actual  death  of  the 
part,  continually  invades  fresh  tissues  ; the  fever 
increases;  a sallow  sunken  countenance,  with 
rapid  thready  pulse,  sordes,  muttering  delirium, 
tympanites,  hiccough,  subsultus,  scanty  loaded 
urine  or  even  suppression,  supervene ; the  weak- 
ness increases ; and  death,  preceded  by  collapse, 
takes  place. 

In  other  cases,  especially  those  dependent  on 
local  causes,  there  is  a tendency  to  limitation  : 
and  the  process  by  which  this  is  accomplished  is 
the  same  for  all  kinds  of  gangrene,  in  every  part 
of  the  body.  In  superficial  structures  a red  band 
of  healthy  inflammation  will  be  observed  at  the 
junction  of  the  living  with  the  dead  part,  called 
the  line  of  demarcation  ; active  cell-infiltration 
takes  place  ; and  a separating  wall  of  fibrin  and 
young  cells  is  established  in  the  layor  of  living 
tissue  nearest  to  the  dead  structures.  This  becomes 
by  degrees  converted  into  an  ordinary  granulating 
surface,  and  the  dead  tissue  is  detached  and  east 
off.  The  time  required  for  this  separation  varies 
with  the  bulk  of  the  dead  portion,  the  nature  of 
the  tissue,  and  the  vitality  of  the  individual. 
The  risk  of  septicaemic  poisoning  is  present 
throughout  the  entire  course  of  the  disease. 
Diagnosis. — The  diagnosis  of  gangrene  of  ex- 
( ternal  parts  cannot  be  attended  with  any  dif- 
ficulty ; the  evidence  of  its  presence  being  readily 
appreciated  when  the  symptoms  already  de- 
scribed make  their  appearance. 

Prognosis. — The  prognosis  of  a case  of  gan- 
grene will  mainly  depend  on  the  likelihood  of 
the  disease  becoming  limited,  the  strength  of  the 
patient,  and  the  conditions  in  which  he  is  placed ; 
which  are  all  at  first  difficult  to  determine.  The 
cause  of  the  gangrene,  and  the  presence  or  ab- 
sence of  organic  mischief  elsewhere,  also  exercise 
a great  influence.  When  the  malady  is  depen- 
dent on  a constitutional  cause,  there  will  be 
little  tendency  to  delimitation,  and  a bad  pro- 

34 


GARGLE.  V2S 

spect  of  recovery.  When  the  cause  is  local,  and 
the  destruction  of  tissue  neither  extensive  mu- 
invading  a vital  part,  the  prognosis  will  be  favour- 
able. But  a local  injury,  when  the  condition-, 
are  unfavourable,  may  fa  followed  by  a severe 
and  extensive  gangrene,  or  some  essential  part, 
of  the  body  may  become  implicated. 

Treatment. — When  gangrene  is  imminent,  oik 
first  care  should  be  to  adopt  means  to  support  tht 
vital  warmth  of  the  part,  and  to  encourage  an  l 
relieve  the  embarrassed  circulation.  When  tht 
disease  is  fully  developed,  our  attention  rau-i 
be  directed  to  control  as  far  as  practicable  tin- 
spread  of  the  disease  ; to  favour  the  separation 
of  the  dead  tissue  ; and  to  keep  the  parts  a.- 
clean  and  harmless  as  possible.  We  must  als- 
anticipate  complications,  or  combat  them  when 
they  occur;  and  support  the  patient's  strength 
by  good  food,  stimulants,  and  fresh  air,  together 
with  opiates  sufficient  to  allay  pain.  A limited 
traumatic  gangrene  is  to  be  treated  as  an  or- 
dinary sloughing  wound.  If  a complete  por- 
tion of  a limb  be  involved  amputation  shuiikl 
be  performed,  as  soon  as  the  line  of  demarca- 
tion is  established.  In  gangrene  due  to  arterial 
obstruction  the  extremity  should  bo  raised  to 
assist  the  return  of  venous  blood;  antiseptic 
dressings  and  cotton-wool  applied  locally ; and 
plenty  of  bland  food  administered  at  frequent 
intervals.  When  the  whole  limb  is  affected, 
nature  may  be  assisted  hv  completing  the  ampu- 
tation of  the  part  as  soon  as  the  limiting  line 
is  distinct'-.  In  gangrene  caused  by  the  ligature 
or  rupture  of  a main  artery,  or  the  pressure  cl 
an  aneurism,  amputation  close  to  the  seat  of  tin 
lesion  may  at  once  be  performed,  as  the  gangrene 
cannot  extend  higher  than  this  point ; but  even 
under  these  circumstances  it  will  often  be  saf6i 
to  await  indications  of  a commencing  demarca- 
tion and  then  to  amputate  close  to  it.  In  spread- 
ing traumatic  gangrene  early  amputation  of  the 
affected  limb  has  been  strongly  recommended  ; 
but  as  this  cannot  remove  the  already  poisoned 
condition  of  the  blood,  upon  which  in  all  proba- 
bility the  gangrene  depends,  it  is  clearly  a useless 
measure,  as  the  gangrenous  action  would  invade 
the  stump.  In  eases  where  traumatic  gangrene 
is  localised  and  dependent  merely  upon  the  vio- 
lence of  the  injury,  the  vitality  of  the  individual 
will  be  sufficient  to  overcome  the  mischief,  un- 
less it  be  very  extensive.  A line  of  demarcation 
will  appear,  and  then,  but  not  before,  will  it  be 
proper  to  amputate,  unless  the  part  be  other- 
wise hopelessly  injured,  or  a large  articulation 
opened,  when  immediate  amputation  is  indicated. 
For  the  treatment  of  gangrene  occurring  in  inter- 
nal organs  the  reader  is  referred  to  the  articles 
on  diseases  of  the  several  viscera. 

William  Mac  Coemac. 

GARGLE  (yapyapifa,  I wash  the  throat). — 
Stnon.  : Fr.  Gargarisme\  Ger.  Gurqelmittel. 

Definition.  — Gargles  are  liquids  employed 
for  the  production  of  local  effects  on  the  throat 
and  pharynx. 

Mode  of  Gargling. — This  consists  in  taking 
about  a table- spoonful,  more  or  less,  of  the  gargle 
into  the  mouth,  throwing  back  the  head,  and 
agitating  the  liquid  by  the  air  expelled  through 
the  larynx.  With  some  persons  the  gargle  goee- 


530  GARGLE, 

little  beyond  tho  uvula  and  base  of  the  toncue ; 
but  if  tho  head  be  thrown  well  back,  the  fluid 
can  be  made  to  pass  into  tho  cavity  of  the  pha- 
rynx, and  may  even  reach  the  larynx  and  vocal 
cords.  The  tension  of  the  muscles,  in  thus  throw- 
ing back  the  head,  i3  apt  to  provoke  efforts 
at  deglutition,  so  that  sometimes  small  portions 
of  the  gargle  may  be  swallowed ; and  occasionally 
the  effort  terminates  abruptly  in  the  patient 
jerking  his  head  forwards,  and  expelling  the  gargle 
forcibly  through  the  nose. 

Dr.  H.  Guinier  of  Cauterets  has  demonstrated 
a method  of  gargling  the  laryngeal  cavity.  His 
instructions  are  as  follows: — 1.  Slightly  to  raise 
the  head  ; 2.  To  open  the  mouth  moderately ; 3. 
To  protrude  the  chin  and  lower  jaw;  4.  To  emit 
the  sound  of  the  double  vowel  at.  These  four 
movements  open  largely  the  back  of  the  mouth, 
lift  the  velum  palati  and  uvula,  separate  the 
bass  of  the  tongue  from  the  posterior  wall,  and 
allow  the  liquid  used  for  gargling  to  gravitate 
into  tho  cavity  of  the  larynx.  One  expiratory 
act  is  the  only  respiratory  movement  that  is  now 
possible,  deglutition  is  under  control,  and  the 
gargle  bathes  the  pharynx  and  supraglottic  por- 
tion of  the  larynx. 

Uses  and  Composition. — The  use  of  gargles 
is  contra-indicated  in  parenchymatous  inflamma- 
tions of  the  tonsils,  and  in  ail  cases  where  move- 
ment of  the  fauces  causes  severe  pain  ; and  where, 
i s in  some  persons,  an  inability  exists  to  retain 
I quid  beyond  the  anterior  pillars  of  the  fauces, 
for  these  it  is  more  convenient  to  apply  the 
fluid  to  the  fauces  and  pharynx,  either  by  injec- 
tion, or  in  the  form  of  a medicated  spray,  or  else 
hv  aid  of  a brush  or  sponge. 

Gargles  vary  in  composition  according  to  their 
object.  If  prescribed  with  the  view  of  exercising 
the  muscles  of  the  soft  palate  and  pharynx,  and 
thereby  increasing  their  tone,  cold  or  iced  water 
is  generally  sufficient.  If  with  the  view  of  re- 
ducing and  allaying  local  inflammatory  conditions 
of  the  throat,  solutions  of  chlorate  or  nitrate  of 
potash  or  of  borax  (two  drachms  to  eight  ounces), 
or  of  liquor  ammonias  acetatis  (one  part  in  four), 
combined  with  deeoctum  lini  eompositum,  thin 
gruel,  or  water,  and  used  warm,  are  the  best. 
When  it  is  desirable  to  excite  the  mucous 
membrane  and  neighbouring  glands  to  further 
secretion,  and  thus  reduce  local  congestion, 
stimulant  gargles  are  useful,  such  as  the  tinctures 
of  capsicum  (half-drachm  to  eight  ounces),  arnica, 
myrrh,  pyrethrum,  and  eucalyptus  rostrata  (two 
drachms  to  eight  ounces) ; this  class  of  gargles 
often  relieving  the  deafness  caused  by  obstruction 
of  the  Eustachian  tubes,  by  increasing  the  pha- 
ryngeal secretion.  To  check  excessive  secretion 
astringents,  in  tho  form  of  the  salts  of  iron  and 
zinc,  iron-alum,  or  alum  (forty  grains  to  eight 
ounces),  tannin  (half-drachm  to  eight  ounces),  or 
rhatanv  infusion,  are  advisable.  If  we  require  to 
check  ulceration,  or  to  dilute  and  purify  foul  or 
putrid  secretions  from  the  throat  and  tonsils, 
antiseptic  gargles,  composed  of  the  solutions  of 
permanganate  of  potash  (two  drachms  to  half-a- 
pint),  of  chlorinated  soda  (one  drachm  to  eight 
ounces),  of  sulphurous  acid  (one  part  in  four), 
nr  of  glycerine  of  carbolic  acid  (half-ounce  to 
eight  ounces),  will  answer  the  purpose.  In  cases 
ot  syphilitic  sore- throat,  a gargle  of  porchloride 


GASTRALGIA. 

of  mercury  (three  grains  to  eight  ounces)  lias 
been  recommended.  In  many  eases  combina- 
tions of  different  kinds  of  gargles  are  beneficial. 
Water,  barley-water,  rose  or  orange-flower- 
water,  sweetened  with  a little  honey,  glycerine, 
or  syrup,  constitute  the  bases  of  most  gargles. 

John  C.  Thorowgood. 

GASTEIN,  in  the  Austrian  Alps.  Simple 

thermal  waters.  See  Mineral  Waters. 

GASTRALGIA  (ycurTTjp,  the  stomach,  and 
SAyos,  pain). — Synox.  : Gastrodynia ; Fr.  Gas- 
trahjie;  Ger.  Magenschmerz. 

Definition. — Pain  in  the  stomach,  which 
occurs  in  various  gastric  disorders,  and  which, 
considered  by  itself,  is  not  much  to  be  relied  on 
as  a sign  of  disease. 

Symptoms. — In  acute  erythematous  gastritis 
a burning,  painful  sensation  affecting  the  sto- 
mach, and  not  unfrequent ly  extending  up  the 
cesophagus,  is  felt  almost  immediately  after 
taking  food  or  a stimulant  liquid.  In  acute 
catarrhal  gastritis  pain  is  seldom  complained 
of.  In  ordinary  chronic  gastritis  it  is  usually 
absent;  or,  at  most,  only  a slight  heaviness 
or  fulness  after  food  forms  a symptom  of  the 
malady.  In  what  tho  writer  has  named  ‘ eczema 
of  the  stomach  ’ the  pain  is  very  severe,  comes 
on  two  or  three  hours  after  food,  and  is  tem- 
porarily relieved  by  eating.  The  same  kind  of 
pain  may  be  observed  whenever  there  is  pro- 
fuse mucous  secretion,  but  it  is  less  severe  than 
in  cases  where  gastric  disturbance  replaces 
eruptions  of  the  skin.  The  pain  accompanying 
pyrosis  is  of  a spasmodic  character,  and  is  re- 
lieved by  the  ejection  of  a tasteless  fluid.  Severe 
pain  is  a common  accompaniment  of  atonic  dys- 
pepsia, occurring  in  nervous  or  hysterical  persons. 
It  comes  on  when  the  stomach  is  empty,  but  is 
often  aggravated  directly  after  food,  and  is  re- 
lieved by  the  escape  of  flatus,  and  by  stimulants. 
The  most  severe  gastralgia  is  that  accompanying 
ulceration  of  the  stomach.  In  this  disorder  it  is 
referred  to  one  spot,  and  is  likewise  often  felt  in 
the  back.  The  mere  fact  that  a pain  in  the 
epigastric  region  is  confined  to  one  small  spot 
should  induce  the  practitioner  to  view  the  case 
with  suspicion.  The  pain  in  ulceration  is  usually 
absent  when  the  stomach  is  empty,  hut  comes  on 
from  two  to  ten  minutes  after  food.  In  other 
instances  a longer  period,  such  as  half  an  hour, 
elapses  ; but  it  is  this  definito  relation  to  the 
digestive  process  that  makes  the  pain  of  ulcer- 
ation characteristic  of  the  disease.  It  is  usually 
said  that  when  the  pain  comes  on  directly  after 
food  the  cardiac  region  is  the  seat  of  the  ulcer, 
and  where  a longer  interval  takes  place  the  sore 
will  be  found  near  the  pylorus.  This,  if  true  as 
a general  rule,  is,  nevertheless,  open  to  many 
exceptions ; for.  as  a patient  observed,  the 
pain  occurred  later  after  taking  food  in  propor- 
tion as  she  improved  in  health,  and  the  first 
evidence  of  a relapse  was  the  shortness  of  the 
interval  of  ease  after  eating.  In  cancer  the  pain 
is  more  continuous  than  in  simple  ulcer ; it  is 
less  influenced  by  the  digestive  process,  and  is 
more  diffused.  It  is,  however,  no  uncommon 
circumstance  to  find  cancer  of  the  stomach  with- 
out any  complaint  of  pain.  The  softer  kinds  of 
malignant  growth  seem  to  the  writer  least  apt  to 


GASTRALGIA. 

tause  suffering,  probably  because  the  peritoneum 
is  less  liable  in  such  cases,  than  in  the  other 
forms,  to  be  affected  Avitli  inflammatory  action. 
Neuralgia  of  the  stomach  is  a favourite  disease 
■with  some  authors.  There  is  no  doubt  that  the 
normal  sensibility  of  the  stomach  is  vastly  ex- 
aggerated under  some  conditions,  but  the  writer's 
observation  leads  him  to  believe  that  neuralgic 
pain  affecting  the  stomach,  independently  of 
other  disease , is  a much  rarer  complaint  than  is 
generally  supposed  ( see  Stomach,  Diseases  of). 
The  writer  has  met  with  three  different  forms  of 
pain  in  the  region  of  the  stomach  ascribed  to 
neuralgia,  which  are  evidently  of  a different  na- 
ture— 1.  Where  severe  pain  has  come  on  at  some 
period  of  the  day  at  a certain  hour,  at  a consider- 
able period  after  the  commencement  of  digestion. 
In  many  of  these  cases  it  has  been  evident  on 
.nquiry  that  the  apparent  periodicity  was  the 
result  of  the  punctual  disposal  of  the  chief  meal 
of  the  day.  They  were,  in  fact,  cases  of  chronic 
catarrhal  gastritis  attended  with  considerable 
secretion  ; most  of  them  occurred  in  gouty  men, 
and  might  be  classed  under  the  head  of  eczema, 
rather  than  of  neuralgia  of  the  stomach.  2.  Cases 
such  as  the  following: — A young  lady  had  suf- 
fered for  many  months  from  agonising  pain  in  the 
left  hypochondrium,  coming  on  at  each  menstrual 
period,  and  resisting  all  methods  of  treatment. 
In  this  and  other  similar  cases,  it  will  be  found 
that  the  seat  of  the  pain  is  really  external,  in 
the  intercostal  nerve,  and  not  in  the  stomach 
itself.  3.  Severe  attacks  of  pain  in  the  left  hy- 
pochondrium and  epigastrium  in  females  of  a 
nervous  temperament,  who  had  either  been  born, 
or  had  passed  most  of  their  lives,  in  tropical 
countries.  The  real  seat  of  the  pain  in  such 
cases  appears  to  be  the  colon  ; there  is  always 
constipation ; and  a mild  aperient  and  tonic  treat- 
ment is  usually  effectual  in  removing  or  ame- 
liorating the  complaint.  S.  Fenwick. 

GASTRIC  FEVER  (yaor-l/p,  the  stomach). 
A popular  name  for  a febrile  condition  attended 
with  prominent  gastric  symptoms  ; as  well  as  for 
typhoid  fever.  See  Typhoid  Fever. 

GASTRIC  GLANDS,  Diseases  of  ( yaarnp , 
the  stomach).  See  Stomach,  Diseases  of. 

GASTRIC  ULCER  (yaar^ip,  the  stomach). 
Sec  Stomach,  Diseases  of. 

GASTRITIS  (yaariip,  the  stomach). — In- 
flammation of  the  stomach.  See  Stomach,  Dis- 
eases of. 

GASTRODYNIA  (yaar^p,  the  stomach, 
and  oShr-p,  pain).  — A painful  affection  of  the 
I stomach,  generally  considered  as  of  a neuralgic 
character.  See  Gastp.algia. 

GAST  FiO-ENTERIC  (yaaryp,  the  stomach, 
and  ei/repM,  the  intestine). — This  term  isapplied 
1 to  those  morbid  states  in  which  the  stomach  and 
the  intestine  are  simultaneously  affected.  The 
j continuity  and  similarity  in  structure  of  these  vis- 
cera render  them  peculiarly  liable  to  coincident 
disease;  and  this  is  more  particularly  noticed  in 
* affections  of  an  inflammatory  type  (gastro-enteri- 
bs),  or  of  a degenerative  nature.  At  the  same  time, 
m gastritis  may  occur  and  run  its  course  without 
j any  indication  that  the  intestine  is  in- 

volved, so  enteritis  may  be  developed  with  little 


GENERAL  PARALYSIS.  5Si 
or  no  disorder  of  the  stomach.  The  same  causes 
appear  to  determine  similar  diseases  in  the 
stomach  and  in  the  intestine  ; but.  why  at  one 
time  both  should  suffer,  and  at  another  time  one 
should  escape,  is  not  known.  Occasionally  it 
would  seem  that  the  entire  alimentary  canal 
beyond  the  oesophagus  is  attacked  at  once,  and 
thegastro-intestinal  catarrh  of  children  is  a good 
example  of  this.  Sometimes  the  disorder  com- 
mences in  one  part  of  the  canal,  and  spreads  until 
both  the  stomach  and  the  intestine  are  involved. 
See  Intestines,  Diseases  of ; and  Stomach,  Dis- 
eases of.  W.  H.  Aixchin. 

GASTRORRHCEA  {yaaa^p,  the  stomach, 
and  p«v,  I flow). — An  excessive  flow  of  mucus 
from  the  lining  membrane  of  the  stomach,  due 
to  catarrh.  See  Stomach,  Diseases  of. 

GELATINIFORM  CANCER.— A syno- 
nym for  colloid  cancer.  See  Cancer. 

GENERAL. — This  word,  as  employed  in 
relation  to  medicine,  has  several  applications. 
Tlius  we  speak  of  a general  disease,  which  is  a dis- 
ease affecting  the  whole  system,  as  distinguished 
from  a local  affection.  As  further  examples 
may  be  mentioned  general  debility,  general 
paralysis,  and  general  dropsy.  So,  with  respect 
to  therapeutics,  general  treatment  refers  to  re- 
medial measures  intended  to  affect  the  organism 
as  a whole.  In  connexion  with  the  sciences  < i 
therapeutics,  pathology,  &c.,  the  word  general 
is  intended  to  express  the  essential  principles  o) 
these  sciences,  as  distinguished  from  their  special 
divisions. 

GENERAL  PARALYSIS  OP  THE 
INSANE. — Synon.  : General  Paresis  ; Fr. 

Parcdysie  generale  incomplete ; Pericnceplialite 
chronique  diffuse ; Ger.  AUgemeine  progressive 
Gchirnldhmztng ; Paralytischer  Blodsinn. 

Definition. — A gradual  loss  of  the  power  of 
coordinated  movement,  accompanied  by  gradually 
increasing  mental  disturbance  and  decay. 

^Etiology. — The  subjects  of  general  paralysis 
are  most  frequently  of  the  male  sex,  and  between 
30  and  50  years  of  age.  It  may  be  brought  on  by 
excessive  mental  labour,  by  severe  anxiety,  by 
alcoholic  or  venereal  excess,  or  by  any  prolonged 
strain  upon  the  mental  organisation.  Tt  may 
also  be  induced  by  a blow  or  other  direct  injury 
to  the  head.  Hereditary  predisposition  is  prob- 
ably not  without  influence  upon  its  production  ; 
but  this  is  not  so  frequently  present  as  in  most 
other  forms  of  insanity'.  The  disease  most  fre- 
quently attacks  personswho  have  previously  been 
apparently  in  the  enjoyment  of  vigorous  health. 

Anatomicae  Characters. — Authorities  are  not 
agreed  upoti  the  precise  nature  of  the  pathologi- 
cal changes  characteristic  of  this  disease.  The 
most  frequently  described  lesions  are  congestion 
and  thickening  of  the  membranes  of  the  brain  ; 
and  degeneration  of  the  cortical  substance, 
shown  by  a fatty  or  shrunken  condition  of  the 
nerve-cells,  and  an  augmentation  of  the  connective 
tissue.  The  degeneration  has  been  traced  by 
some  observers  into  the  spinal  cord  and  the 
sympathetic  ganglia. 

Symptoms. — 1.  Physical.  The  physical  symp- 
toms of  general  paralysis  of  the  insane  arc  first 
apparent  in  the  muscles  of  articulation  and  ex- 
pression. There  is  an  occasional  thickness  ai 


532  GENERAL  PARALYSIS. 

utterance,  perhaps  observable  only  in  the  pronun- 
ciation of  the  more  complex  sounds,  and  a peculiar 
convulsive  tremor  of  the  upper  lip  accompanying 
the  least  excitement.  A similar  fibrillar  trem- 
bling may  also  be  observed  in  the  tongue,  when 
an  attempt  is  made  to  hold  it  out.  This  loss 
of  muscular  control  gradually  spreads  over  the 
whole  system,  its  onward  course  being,  however, 
not  infrequently  interrupted  by  very  remarkable 
though  generally  brief  remissions.  Before  the 
patient  is  laid  completely  prostrate,  the  affection 
both  of  articulation  and  of  gait  strongly  resembles 
the  failure  of  coordinate  movement  produced  by 
drunkenness.  In  the  last  stage  the  patient  lies 
quite  helpless ; the  power  of  articulation  and  every 
kindof  voluntary  movement  are  lost;  there  is  also 
a strong  tendency  to  the  formation  of  bed-sores; 
and  spots  of  ecchymosis  are  apt  to  appear  on 
the  application  of  even  gentle  pressure.  In- 
equality of  the  pupils  is  usual  from  the  com- 
mencement of  the  illness ; but  they  do  not  often 
remain  long  in  one  condition,  sometimes  one 
pupil  and  sometimes  the  other  being  dilated  or 
contracted.  A characteristic  feature  of  the 
disease  is  the  occurrence  of  congestive  or  epilep- 
tiform attacks,  but  they  are  very  variable,  both 
in  their  frequency  and  in  the  stage  at  which  they 
are  first  observed. 

2.  Mental.  These  symptoms  generally  pre- 
cede the  physical,  though  some  cases  occur  in 
which  the  condition  of  the  mind  is  not  such  as 
to  attraet  attention  till  some  time  after  the 
motor  symptoms  have  become  obvious.  Sleep- 
lessness and  general  restlessness  are  usually  the 
first  indications  of  the  derangement,  and  with 
these  may  be  associated  transient  states  of  de- 
pression and  hypochondriacal  fancies.  Enfeeble- 
ment,  shown  by  forgetfulness  and  incapacity  for 
continuous  thought,  isgenerally  an  earlysymptom ; 
and  in  some  eases  a gradual  increase  of  this 
enfeeblement,  till  absolute  fatuity  is  reached, 
constitutes  the  prominent  mental  symptom.  A 
common  condition  from  the  commencement  is  an 
inordinate  disposition  to  embark  in  any,  even 
the  most  impracticable,  undertaking  that  may 
be  suggested.  There  is  always  observed  a pe- 
culiar facility  of  disposition,  generally  good- 
humoured,  but  liable  to  be  interrupted  by  fits 
of  passionate  excitement.  Frequently  there  is  a 
very  remarkable  extravagance,  both  in  thought 
and  act.  In  most  cases  acute  maniacal  attacks 
take  place,  in  which  the  excitement  presents  a 
specially  extravagant  character.  The  semblance 
of  probability  and  coherence  found  in  ordinary 
acute  mania  is  generally  absent.  The  prevailing 
ideas  are  of  grandeur,  colossal  size,  infinite 
number,  power,  wealth,  and  rank,  all  heaped 
together  in  wild  confusion . Every  such  maniacal 
attack  marks  an  appreciable  step  in  the  progress 
of  mental  decay ; and  the  tendency  is  always 
more  or  less  steadily  to  complete  fatuity.  In 
some  comparatively  rare  cases,  especially  where 
there  is  a tendency  to  phthisis,  the  mental  con- 
dition is  mainly  one  of  depression.  Remarkable 
remissions  of  all  the  symptoms  are  sometimes 
met  with. 

Diagnosis. — The  diseases  from  which  general 
paralysis  of  the  insane  requires  to  be  distinguished 
are  paralysis  due  to  cerebral  haemorrhage,  em- 
bolism, encephalitis,  or  tumour  of  the  brain  • nys- 


GERMS  OF  DISEASE. 

terical  and  tonic  paralysis ; locomotor  ataxv 
alcoholic  insanity  ; senile  dementia ; and  mus- 
cular atrophy.  The  diagnosis  is  generally  easy, 
if  attention  be  paid  to  the  presence  or  absence  ol 
the  convulsive  tremors  in  the  muscles  of  articula- 
tion at  the  commencement;  the  general  and  pro- 
gressive course  of  the  loss  of  coordination ; and 
the  peculiar  mental  facility  and  extravagance. 

Prognosis. — Complete  recovery  seldom,  if 
ever,  takes  place  in  general  paralysis  of  the 
insane.  The  ordinary  duration  of  the  disease  is 
from  a few  months  to  three  or  four  years,  though 
cases  of  ten  years’  duration  occasionally  occur. 

Treatment. — In  ordinary  circumstances  the 
treatment  cannot  be  properly  carried  out  in  a 
private  house  ; removal  to  an  asylum  will  there- 
fore generally  be  necessary.  Little  benefit  is  to 
be  derived  from  drugs.  The  conditions  of  ex- 
citement are  held  by  some  to  be  moderated  by 
small  doses  of  Calabar  bean;  and  turpentine 
enemata  are  frequently  useful  in  the  epileptiform 
attacks.  The  diet  ought  to  be  nutritious,  but 
non-stimulating.  The  food  ought  to  be  minced 
or  pulpy,  and  care  should  be  taken  to  prevent  an 
accumulation  of  it  in  the  pharynx,  as  fatal  choking 
is  sometimes  produced  in  that  way.  If  this  should 
be  threatened,  the  tongue  should'  be  immediately 
pulled  forward,  and  the  bolus  extracted  with  the 
finger.  On  account  of  the  liability  to  bed-sores, 
the  patient  should  as  long  as  possible  be  pre- 
vented from  lying  constantly  in  bed. 

John  Sibbald. 

GEEMS  03?  DISEASE. — This  is  a phrase 
in  common  use,  the  acceptation  of  which  is  va- 
rious, and  often  more  or  less  vague.  So  far  as 
it  refers  to  actual  things  or  objects,  they  also  are 
probably  diverse  in  nature,  though  at  present 
our  knowledge  of  most  of  them  is  based  rather 
upon  conjecture  than  actual  experience. 

As  a phrase,  ‘germs  of  disease’  is  most,  com- 
monly used  in  the  following  modes : — 

a.  A person  may  be  said  to  inherit  the  germs 
of  disease  when  there  is  reason  to  believe  that 
the  constitutional,  general,  or  local  disease  from 
which  he  is  suffering  is  of  a kind  which  has  been 
common  in  the  family  or  stock  whence  he  has 
descended,  and  when  the  disease  is  one  which 
seems  prone  to  manifest  itself  in  this  way. 
It  may,  in  this  sense,  be  said  that  a person  in- 
herits the  germs  of  gout,  scrofula,  tuberculosis, 
syphilis,  or  cancer  ; and,  in  either  of  such  cases 
(with  the  possible  exception  cf  the  two  latter), 
no  one  would,  on  reflection,  be  able  to  find  that 
he  meant  anything  else  than  that  the  patient 
had  inherited  a certain  general  disposition, 
habit,  or  bodily  tendency,  in  which,  under  the 
influence  of  slight  exciting  causes,  this  or  that 
morbid  condition  should  be  prone  to  manifest 
itself. 

b.  In  a still  looser  sense,  the  phrase  is  sometimes 
used  to  signify  the  mere  commencement  or 
initial  stage  of  a certain  disease,  as  when  it  is 
said  that  the  germs  of  a •phthisical  patients 
malady  date  from  a certain  catarrhal  attack,  or 
that  a patient  now  suffering  from  a severe  bruin- 
affection  contracted  the  germs  of  his  disease  in 
India  or  elsewhere,  on  the  occasion  of  some 
slight  sunstroke.  Here  the  expression  would 
be  used  in  a purely  metaphorical  sense. 


GERMS  OF  DISEASE. 

c.  The  phrase  is  most  commonly  employed, 
however,  in  reference  to  the  real  or  supposed 
causes  of  communicable  morbid  processes  or  dis- 
eases, either  local  or  general — those  which  spread 
either  from  part  to  part  in  the  same  person,  or 
from  person  to  person  in  the  same  commu- 
nity. 

In  the  spread  from  part  to  part,  as  during  the 
‘ generalization  ’ of  some  malignant  new-growth, 
the  agency  of  ‘ germs  of  disease  ’ is,  perhaps,  not 
^infrequently  more  imaginary  than  real.  Results 
are  apt  to  be  ascribed  to  ‘infection’  wherenothing 
of  the  kind  lias  been  in  operation — as  when  si- 
milar perverted  tissue-changes  may  chance  to 
manifest  themselves,  either  simultaneously  or 
consecutively,  in  different  parts  of  the  body,  as 
results  of  some  single  or  similar  underlying 
cause. 

In  tho  spread  from  person  to  person  of  local 
or  general  contagious  affections,  the  same  pos- 
sible source  of  fallacy  has  to  be  borno  in  mind. 
We  must  be  upon  our  guard  against  ascribing 
too  general  an  influence  to  ‘germs  of  disease.’ 
In  certain  cases  these  may  have  been  in  the  first 
place  non-existent,  as  when  such  a disease  has 
been  ‘ autogenetic,’  and  in  no  sense  a derivative 
of  antecedent  disease  of  the  same  kind.  This 
caution  is  especially  applicable  in  regard  to  such 
an  affection  as  erysipelas — which,  although  cer- 
tainly contagious,  is  also  on  very  good  grounds 
judged  to  be  ‘ generable,’  especially  during  cer- 
tain states  of  lowered  health  induced  by  renal 
disease andsomeothervisceral affections.  Though 
not  so  certainly  known,  it  is  by  many  deemed 
probable  that  a similar  caution  may  be  necessary 
in  regard  to  more  general  contagious  affections, 
such  as  diphtheria,  typhoid  and  typhus  fever, 
and  cholera,  which,  though  certainly  contagious, 
may  also  be  autogenetic.  On  this  subject,  how- 
ever, much  doubt  and  uncertainty  still  prevail. 

The  consideration  of  this  third  use  of  the 
phrase  ‘ germs  of  disease,’  conducts  us  naturally 
to  the  question  as  to  the  nature  of  the  things  or 
objects  which  may  be  included  under  tho  same 
name,  and  this  again  to  the  modes  in  which  they 
operaie.  As  these  are  questions,  however,  which 
have  already  been  discussed  under  Contagion, 
they  will  only  be  very  briefly  referred  tc  here. 

The  different  kinds  of  contagia,  whilst  they 
are  all  of  them  to  be  regarded  as  products 
thrown  off’  from  the  body  of  a person  suffering 
from  a communicable  affection,  may  in  essence 
be  either  (1)  not-living  chemical  compounds; 
(2)  cast-off  and  altered  tissue-elements;  or  (3) 
cast-off  micro-organisms  of  a low  type,  either 
in  their  ‘finished’  condition  or  in  a germ-stage. 

Whilst  it  cannot  positively  be  said  that  we 
have  as  yet  discovered  contagia  belonging  to  the 
first  category,  our  knowledge  is  a trifle  more 
definite  in  regard  to  the  existence  of  those  per- 
taining to  the  second  and  third  categories.  In 
what  propirtion  these  latter  kinds  of  contagia 
exist,  however,  for  different  communicable  dis- 
eases, still  remains  to  be  discovered. 

Suehdifferentkinds  of ‘germs  of  disease  ’might 
take  effect  in  two  distinct  modes,  and  only  in  two, 
since  the  probable  modes  of  operation  of  those 
belonging  to  tho  first  and  second  varieties  are 
not  at  present  capable  of  being  discriminated 
from  one  another. 


GIDDINESS.  533 

First,  we  have  tho  mode  of  action  of  contagia 
in  the  spread  of  local  affections,  such  as  ophthal- 
mias, gonorrhoeas,  and  erysipelatous  inflamma- 
tions. Chemical  compounds,  or  diseased  tissue- 
elements,  or  both  in  combination,  thrown  off 
from  such  foci  of  disease,  and  falling  upon  suit- 
able situations  in  other  human  beings,  are  capa- 
ble of  determining  inflammations  of  like  kind,  in 
which  multitudes  of  new  contagia,  also  of  lib- 
kinds,  are  ‘independently’  produced — that  is, arc- 
produced  otherwise  than  by  processes  of  organic 
reproduction.  IIow  far  such  chemical,  or  ‘ contact 
actions  ’ (not  necessarily  producing  inflamma- 
tions) may  take  part  in,  and  lie  at  the  root  of 
the  very  complex  group  of  morbid  processes 
constituting  this  or  that  general  contagious  af- 
fection, or  so-called  ‘ specific  fever,’  is  not  at 
present  known.  The  processes  must  be  some- 
what of  this  kind,  if  the  operating  contagia  are 
not  living  organisms;  and  even  where  they  are 
of  this  type,  it  is  possible  that  the  same  sort  of 
process  may  obtain. 

Secondly,  where  micro-organisms  (bacilli,  mi- 
crococci, &c.)  are  the  contagia,  they  are  believed 
to  produce  their  effects  by  the  continuous  mul- 
tiplication, or  ‘ organic  reproduction,’  of  such  in- 
dependent units  in  the  tissues  and  blood  (one  or 
both)  of  the  individual  affected.  The  multipli- 
cation of  such  units,  and  the  chemical  changes 
in  the  tissues  attendant  thereupon,  are  therefore 
believed  to  be  the  sole  and  efficient  causes  of  the 
groups  of  symptoms  and  tissue-changes  consti- 
tuting the  particular  general  or  local  communi- 
cable disease,  and  the  myriads  of  contagious 
elements  produced  during  its  progress  are  re- 
garded as  lineal  descendants  of  those  which  ini- 
tiated the  morbid  symptoms. 

In  the  event  of  its  being  true,  as  some  hold, 
that  such  living  organisms  as  are  met  with  in  the 
blood,  and  are  believed  to  be  at  times  the  causes 
of  certain  of  the  communicable  diseases,  can 
arise  ‘ independently’  within  the  body  (by  ‘ hete- 
rogenesis ’ or  by  ‘ archebiosis  ’),  the  second  as- 
sumed mode  of  operation  of  contagia  would  havo 
to  be  more  or  less  completely  renounced  in  favour 
of  the  first.  The  contagia,  even  in  this  latter  case, 
might  simply  set  up  morbid  processes,  which,  in- 
stead of  being  simple  (as  in  those  caused  by  the 
pus-corpuscle  and  its  fluids  from  some  seat  of 
virulent  inflammation)  might  be  complex,  pro- 
longed, and  linked  together,  so  as  to  constitute 
the  morbid  processes  typical  of  some  particular 
specific  fever.  At  some  stage  of  this  complicated 
chain  of  processes,  and  somewhere  (that  is,  either 
in  some  organ  or  tissue,  or  in  tho  blood),  organ- 
isms may  arise  de  novo , which,  either  alone  or 
with  their  parent  fluids  or  tissue-elements,  are 
again  capable  of  acting  as  contagia.  But  the  or- 
ganisms in  such  a case  could  not  be  regarded  as 
direct  descendants  of  the  original  contagia,  and 
similarly  no  one  would  think  of  regarding  the 
pus-corpuscles  met  with  in  a case  of  purulent 
ophthalmia  or  gonorrhoea,  as  direct  lineal  de- 
scendants of  those  which  may  have  taken  part  in 
occasioning  one  or  other  of  such  diseases. 

H.  Charlton  Bastian. 

GIDDINESS  (Sax.  gidig,  turning  or  whirl- 
ing round). — A synonym  for  vertigo.  See  Ver- 
tigo. 


53  J GINGIVITIS. 

GINGIVITIS  (gingii ce,  thegums). — Inflam- 
mation of  t.he  dims.  See  Mouth,  Diseases  of. 

GLANDERS. — Svitox.  : Equinia ; Fr.  Morve ; 
Ger.  Eotz.  Its  associated  condition  is  named 
Farcy ; F r.  Farcin  ; Ger.  Wurm  ; Hautunirm. 

Definition. — A contagious  febrile  disease, 
communicated  to  man  from  the  horse,  ass,  or 
mule,  characterised  by  specific  inflammatory 
lesions  of  the  nasal  and  respiratory  mucous 
membranes,  and  of  the  lymphatic  vessels  and 
glands,  with  gehei'al  pyrexia,  pains  in  the  joints 
and  muscles,  and  great  prostration,  usually  ac- 
companied by  a pustular  cutaneous  eruption. 

The  local  manifestations  vary  in  order  of 
appearance,  and  in  comparative  severity  in 
different  cases.  In  those  in  which  the  nasal  and 
respiratory  mucous  membranes  are  earliest  or 
most  severely  affected,  the  disease  is  customarily 
called  Glanders  ; while  to  those  in  ' which  the 
lymphatic  system  first  and  especially  suffers, 
+he  designation  Farcy  is  applied.  But  no  suffi- 
cient reason  exists  for  considering  glanders  and 
farcy  as  distinct  diseases.  They  are  commonly 
associated,  and  whichever  set  of  symptoms  may 
appear  first,  the  other,  as  a rule,  sooner  or  later 
follows.  Further,  it  lias  been  proved  that  the 
same  virus  may  give  rise  to  either  set  of  symp- 
toms, or  to  both.  And  it  would  seem  that  the 
order  of  appearance  is  determined  in  great  mea- 
sure by  the  mode  of  communication  of  the  virus, 
as  well  as  to  some  extent  perhaps  by  the  condi- 
tion and  constitution  of  the  recipient. 

Glanders  in  man  is  a very  rare  disease ; and 
it  is  only  within  the  last  sixty  or  seventy  years 
that  its  occurrence  has  been  clearly  recognised, 
and  its  history  made  out.  When  it  does  occur, 
it  proves  fatal  in  a very  large  proportion  of 
cases.  Taking  the  acute  and  chronic  cases  to- 
gether, 208  out  of  245  are  recorded  as  having 
terminated  fatally.  Nevertheless  out  of  2,026,296 
deaths  in  England  and  Wales  during  the  four 
years  1871  1874  only  19  are  registered  as  duo 
to  glanders. 

JEtiology.— There  is  no  evidence  to  suggest 
that  glanders  ever  originates  in  man.  whatever 
may  be  the  case  with  regard  to  the  lower  animals. 
It  is  always  communicated,  and  almost  always  by 
direct  inoculation  of  virus  from  a diseased  animal. 
In  some  few  instances  the  disease  has  been  com- 
municated from  man  to  man.  It  is  scarcely  ever 
met  with  except  among  those  who  are  more  or 
less  constantly  employed  among  horses,  and  who 
are  therefore  liable  from  time  to  time  to  come  in 
contact  with  diseased  animals,  or  the  morbid 
discharges  from  them.  The  mode  of  communi- 
cation can  in  most  cases  be  easily  traced.  The 
rarity  of  the  disease  in  man,  considered  in  con- 
junction with  its  comparative  frequency  and  the 
rapidity  with  which  it  spreads  among  horses, 
would  seem  to  indicate  that  the  virus  is  fixed, 
and  not  readily  diffusible  through  the  air,  and 
that  man  is  not  very  susceptible  of  its  influence. 

In  most  cases  the  history  renders  it  clear  that 
the  virus,  in  semi-liquid  or  semi-solid  form,  has 
been  received  through  some  cut  or  abrasion  of 
the  skin  or  mucous  membrane.  In  some  few 
instances  it  appears  probable  that  the  virus  in 
similar  form  may  have  been  absorbed  through 
the  unbroken  mucous  membrane  or  skin.  But 


GLANDERS. 

there  is  at  present  no  sufficient  evidence  to  show 
that  glanders,  any  more  than  syphilis,  can  be 
communicated  by  ‘a  volatile  infecting  principle, ’ 
although  by  some  it  is  maintained  that  such 
communication  may  take  place.  If  it  were  so, 
the  disease  would  probably  spread  more  fre- 
quently and  extensively,  an!  become  compara- 
tively common. 

Symptoms  and  Cuuese. — However  the  virus  of 
glanders  may  have  been  communicated,  a period 
of  incubation,  varying  from  three  to  eight  days, 
and  in  some  rare  instanc-s  prolonged  even  to  three 
weeks  or  more,  ensues  before  the  symptoms  of 
constitutional  infection  become  manifest.  The 
longer  the  period  of  incubation  the  less  acute,  as 
a rule,  is  the  course  of  the  disease.  The  duration 
of  the  disease,  as  well  as  the  order  of  develop- 
ment of  the  local  affections,  varie  greatly  in 
I different  cases.  Hence  the  classification,  on  the 
one  hand,  into  cases  of  acute , subacute,  and 
chronic  glanders ; and,  on  the  other,  into  cases  of 
acute  and  chronic  glanders,  and  acute  and  chro- 
nic farcy.  But  nothing  like  clear  lines  of  distinc- 
tion can  he  drawn  between  any  of  these  classes. 

The  earliest  constitutional  symptoms  are  a 
sense  of  general  discomfort,  fatigue,  prostration, 
and  chilliness,  with  headache, and  obscure  pains  in 
the  muscles  and  joints.  As  the  disease  advances 
these  pains  become  more  severe,  and  simulate 
those  of  rheumatism.  Pyrexia,  at  first  but 
slight,  rapidly  becomes  established.  The  pulse 
is  quickened  and  sometimes  fulL  the  skin  hot 
and  dry,  the  tongue  foul,  the  urine  scanty  and 
high-coloured ; and  the  patient  suffers  much 
from  restlessness,  sleeplessness,  and  loss  of  appe- 
tite, often  with  obstinate  constipation.  Some- 
times the  feverishness  is  intermittent,  but  more 
frequently  continued,  or  intermittent  at  very 
irregular  intervals.  Still  later  rigors  occur, 
more  severe  than  such  as  may  have  occurred 
at  an  earlier  period,  followed  by  profuse  sour 
perspirations  and  clamminess  of  skin  ; the  pulse 
becomes  very  rapid,  weak,  and  compressible ; 
diarrhoea,  with  very  foetid  stools,  succeeds  the 
constipation  ; the  thirst  is  excessive  ; respiration 
becomes  more  and  more  difficult  and  laboured  ; 
low  delirium,  with  tremors,  is  followed  bv  coma; 
and  death  ensues  from  exhaustion.  In  the  acuta 
form,  the  disease  runs  its  course  in  an  average 
period  of  about  sixteen  days;  some  cases  have 
terminated  fatally  within  a week ; others  have 
been  prolonged  for  four  weeks.  In  the  less  acute 
form  the  duration  may  be  from  six  weeks  to  two 
months.  And  in  the  most  chronic  form,  in 
which  all  the  symptoms  are  less  severe,  the 
duration  may  extend  over  several  months,  and  in 
some  cases  recovery  ultimately  takes  place. 

Local  Manifestations.  — In  association  with 
the  constitutional  symptoms  thus  indicated,  the 
followingloeal  manifestations  present  themselves, 
but.  as  already  stated,  somewhat  differently  in 
different  cases. 

The  wound  or  abrasion  through  which  the 
virus  has  been  introduced,  or  the  spot  at  which 
it  has  been  applied  (for  the  wound  may  have 
healed),  becomes  inflamed,  tense,  painful,  and 
surrounded  by  spreading  erysipelatous  redness. 
The  ulcer  which  appears  enlarges,  assumes  an 
unhealthy,  corroded,  chancroid  aspect,  and  dis- 
charges dirty  sanious  and  often  offensive  matters 


GLANDERS. 


The  lymphatic  vessels  of  the  part  become  in- 
flamed, and  present  a knotted,  cord-like.  and  sub- 
sequently irregularly  nodulated  condition — the 
farcy-huds  in  the  human  subject.  The  glands 
are  infiltrated  and  enlarged,  and  the  whole  part 
is  swollen  and  cedematous.  The  lymphatic 
glands-  and  vessels  of  other  parts  subsequently 
become  affected,  but  not  perhaps  to  the  same 
extent  as  in  the  horse.  Resolution  and  absorp- 
i ion  to  a greater  or  less  extent  sometimes  take 
place;  but  much  more  frequently  suppuration 
of  low  type,  abscess-formation,  and  the  pro- 
duction of  foul,  ulcerating  cavities,  with  hard 
irregular  edges,  and  fistulae  follow.  At  a 
variable  period  in  the  course  of  the  disease, 
from  within  forty-eight  hours  to  the  end  of 
three  or  four  weeks,  an  eruption,  regarded  as 
characteristic,  appears  on  the  skin.  This  first 
shows  itself  as  scattered  collections  of  red  spots, 

‘ which  are  very  small  and  resemble  fleabites, 
and  soon  acquire  a papular  elevation,  subse- 
quently rising  above  the  level  of  the  surface, 
like  small  shot,  assuming  a yellow  colour.  They 
lie  in  a kind  of  hole  in  theeorium,  as  if  the  latter 
had  been  punched  out’  (Virchow).  They  appear 
to  be  due  to  the  deposit  of  some  neoplastic 
material,  which  subsequently  softens  and  breaks 
down.  By-and-by  they  become  vesicular  (some 
say  from  the  first  they  are  vesicular),  and  then 
rapidly  sero-purulent,  with  inflamed  livid -bases. 
IV  hen  close  together  these  pustules  become 
confluent,  and  give  rise  to  irregular  ulcerated 
surfaces,  with  soft,  brownish,  sloughy  coating. 
Large  collections  of  similar  deposit  in  the  sub- 
cutaneous tissue  give  rise  to  hard,  painful,  boil- 
like formations,  which  breaking  down  lead  to 
extensive  sloughing  of  the  skin  and  deeper 
structures,  with  thick,  dirty  white,  or  san- 
guineous offensive  discharge. 

The  mucous  membranes — and  first,  and  es- 
pecially that  of  the  nose — are  sooner  or  later 
affected  by  specific  inflammation  and  ulceration. 
Whether  the  inflammatory  process  begins  in  them 
or  in  the  skin  is  not  clearly  made  out.  It  probably 
does  so  in  many  instances,  but  in  some  cases  in 
man,  as  commonly  in  the  horse,  the  disease  is  pro- 
bably communicated  by  application  of  virus  to 
the  mucous  membrane  of  the  nose  or  other  part 
of  the  respiratory  passages,  which  thus  becomes 
primarily  affected. 

When  the  nose  is  affected  (as  is  always  the 
case  in  the  form  of  the  disease  especially  called 
glanders),  there  is  first  a discharge  of  compara- 
tively thin,  colourless,  ‘ catarrhal  ’ mucus.  This 
soon  becomes  thicker  and  coloured;  and  there  is 
considerable  pain,  heat,  redness,  and  cedematous 
swelling  about  the  nose  itself  and  the  adjacent 
parts  of  the  face.  Ultimately  the  discharge 
becomes  thi  k,  sticky,  tenacious,  and  semi-puru- 
lent,  of  a dirty  yellow  or  brownish  colour,  and 
often  stained  with  blood.  In  all  cases  probably 
there  is  ulceration  of  the  mucous  membrane, 
following  tubercle-like  deposits  in  it,  and  the 
ulceration  sometimes  extends  so  deeply  as  to 
lead  to  perforation  of  the  septum,  or  partial 
destruction  of  the.  turbinated  or  palate  bones. 
The  ulceration  often  occurs  only  in  the  upper 
part  of  the  nose,  and  the  mucous  membrane  of 
the  frontal  and  other  sinuses  is  liable  to  be 
similarly  affected.  When  the  lymphatic  and 


533 

cutaneous  systems  suffer  first  and  especially,  tho 
nasal  mucous  membrane  is  not  affected  until 
towards  the  termination  of  the  case  ; and  in  some 
instances  death  has  occurred  before  this  affection 
of  the  nose  has  taken  place. 

Bronchial  catarrh  with  rhonchi  heard  all  over 
the  chest,  accompanied  by  severe  cough  with 
profuse  expectoration,  indicates  the  implication 
of  other  parts  of  the  respiratory  mucous  mem- 
brane. The  conjunctiva  and  the  mucous  mem- 
brane of  the  mouth,  gums,  fauces,  and  especially 
the  tonsils,  are  often  affected  to  a serious  extent ; 
so  also  is  the  larynx,  hoarseness,  pain,  and 
difficulty  in  speaking  resulting  therefrom. 

Anatomical  Characters. — The  pathological 
lesions  found  on  post-mortem  examination  are 
such  as  might  he  anticipated  from  the  signs  an.J 
symptoms  manifested  during  life.  To  these, 
however,  may  he  added  fluidity  of  tho  blood  ; 
softness  and  rottenness  of  the  muscles,  with 
haemorrhagic  abscesses  in  them  (considered  by 
Billroth  as  characteristic) ; patches  of  grey  hepati- 
zation in  the  lungs,  or  lubular  pneumonia  ; ab- 
scesses in  the  parotid,  submaxillary,  and  cervical 
glands,  &c. 

Diagnosis. — The  diagnosis  of  glanders  in  man 
may  bp  difficult  in  the  early  stage,  particularly 
if  the  history  be  defective,  and  no  external  wound 
appear.  But  when  the  disease  is  fully  developed, 
the  signs  and  symptoms,  espeeially-if  taken  in 
conjunction  with  the  occupation  and  history  of 
the  sufferer,  are  sufficiently  characteristic.  In 
some  rare  instances,  however,  in  which  the  con- 
stitutional symptoms  have  been  slight,  and  the 
local  manifestations  have  very  slowly  developed 
themselves,  great  difficulty  has  arisen,  and  the 
true  nature  of  the  disease  has  not  even  been  re- 
cognised until  after  death.  Rheumatism,  typhoid 
fever,  and  pyaemia,  and,  in  regard  to  the  more 
chronic  cases,  syphilis  and  tuberculosis,  are  the 
diseases  with  which  it  is  said  that  glanders 
may  possibly  be  confounded. 

Prognosis. — The  prognosis  in  glanders  must 
be  extremely  unfavourable.  Two  or  three  cases 
only  are  ou  record  in  which  recovery  has  taken 
place  from  the  more  acute  form  of  the  disease. 
In  the  more  chronic  forms,  however,  the  deaths 
have  been  only  about  fifty  per  cent.  The  more 
slowly  and  less  severely  the  symptoms  develop 
themselves,  and  the  longer  the  patient  survives, 
the  better  is  the  chance  of  ultimate  recovery. 

Trkatment.  — The  constitutional  treatment 
should  be  supporting,  stimulating,  and  soothing, 
and  varied  from  time  to  time  according  to  the 
indications  afforded.  Quinine  in  large  doses  and 
perchloride  of  iron  may  he  useful.  But  at 
present,  although  very  many  drugs  have  been 
tried,  none  has  been  found  having  any  marked 
specific  effect  on  the  course  of  the  disease. 
Locally  any  suspicious  wound  should  be  freely 
cauterized  as  soon  as  attention  is  directed  to  it. 
All  abscesses  and  collections  of  morbid  material 
should,  as  far  as  possible,  he  freely  incised,  and 
their  contents  thoroughly  evacuated.  The  ro 
suiting  cavities  and  fistulm  should  be  frequently 
and  thoroughly  washed  out  with  disinfectants, 
and  poultices  should  be  applied.  The  operator, 
and  those  who  dress  the  wounds,  should  wear 
indiarubber  gloves.  Inhalations  of  iodine  or  car- 
bolic acid  vapour  should  he  frequently  practised ; 


?S6  GLANDERS. 

and  the  nose  thoroughly  syringed  from  time  to 
time  with  disinfectant  solutions,  as  carbolic  acid, 
iodized  water,  or  Condy's  solution. 

Arthur  E.  Durham. 

GLANDULAR  DISEASES.— A general 
denomination  for  diseases  of  glands  of  all  kinds. 
See  Bronchial  Glands,  Lt.upiiatic  Glands, 
and  Mesenteric  Glands,  Diseases  of ; also  tho 
several  special  glands. 

GLAUCOMA  (yAavi<bs,  sea-green). — In  its 
modern  acceptation,  this  word  is  used  to  include 
all  the  conditions,  whether  acute  or  chronic,  pri- 
mary or  secondary,  which  are  produced  by  height- 
ened tension  or  increased  fluid-pressure  within 
the  eyeball.  The  word  was  originally  applied 
only  to  those  cases  of  heightened  tension  in  which 
there  is  a greenish  opaque  appearance  behind 
the  pupil.  See  Eye  and  its  Appendages,  Diseases 
of. 

GLEET. — Synon.  : Fr.  Goutte  militaire ; 
Gcr.  Naohtrippcr. 

Definition. — A urethral  discharge,  milky, 
viscid,  scant  in  quantity,  appearing  as  a drop 
at  the  meatus  urinarius,  or  as  shreds  floating  in 
the  urine. 

IEtiology  and  Symptoms. — The  causes  of  gleet 
are  : — (1)  Chronic  inflammation  of  patches  of 
the  mucous  membrane  of  the  urethra,  remaining 
after  acute  gonorrhcea  ; (2)  Chronic  congestion 
(inflammatory  or  other)  of  the  prostate  ; (3) 
Granular  patches  and  warts ; and  (4)  Follicular 
sinuses. 

1.  Chronic  inflammation  of  the  urethra. 
In  the  first  form,  which  is  by  far  the  most 
common,  the  interior  of  the  urethra,  naturally 
pale-pink  where  unaffected,  is  dull  red,  or  pur- 
plish red,  or  pale  and  streaky.  These  red 
patches  are  less  elastic  than  the  unaffected  parts, 
and  frequently,  in  course  of  time,  develop  into 
bands  of  stricture-tissue  leading  to  more  or  less 
contraction.  The  most  common  positions  in  order 
of  frequency  are,  first,  the  first  inch  from  the 
meatus  ; then  at  2 to  3 inches ; lastly  at  41  to  6 
inches,  or  in  the  bulbous  portion  of  the  urethra. 
Several  months,  probably  always  over  six,  are 
needed  to  develop  the  patches  of  inflammation 
into  fibrous  bands. 

Clap  has  preceded  the  present  discharge  some 
months,  or  even  a year  or  two,  apparently  subsid- 
ing altogether  for  one  or  two  months,  and  return- 
ing again  without  obvious  cause.  Pain  is  either 
absent ; or  slight  smarting  or  tickling  is  felt  at  the 
parts  chronically  inflamed,  during  micturition  or 
at  other  times.  The  precise  situation  of  the  in- 
flamed patches  is  ascertained  by  passing  a bullet- 
sound  or  bougie  (No.  14  or  16,  English)  along  the 
passage,  or  the  urethrometer,  if  the  meatus  urina- 
rius be  too  small  to  admit  such  a bougie.  As  the 
bullet  reaches  an  inflamed  spot,  slight  resistance 
is  noted ; and  the  patient  feels  pain  when  it  passes 
over  the  inflamed  or  rigid  patch.  Both  resistance 
and  pain  cease  when  the  patch  is  left  behind. 
Should  the  chronic  inflammation  have  existed 
long  enough  to  produce  fibrous  bauds,  the  on- 
war  1 passage  of  the  bullet-sound  is  checked,  or 
arrested  wholly  if  the  hands  be  too  short  to 
permit  the  bullet  to  slip  past.  A smaller  bullet 
>r  diminution  of  the  urethrameter's  bulb  allows 


GLEET. 

the  obstruction  to  be  passed,  and  denotes  the 
degree  to  which  the  normal  expansilo  capacity 
of  the  urethra  has  been  contracted. 

2.  Chronic  congestion  of  the  prostate. — 
Prostatic  gleets  are  caused  by  (a)  extension  of 
gonorrhoeal  inflammation  to  the  prostatic  urethra 
— chronic  prostatitis;  or  (6)  irritation  and  con- 
gestion of  a sympathetic  kind,  excited  by  mastur- 
bation, excessive  coitus,  stone  in  the  bladder,  or 
piles — the  ‘ irritable,’  or  ‘ relaxed  ’ prostate. 

(a)  In  chronic  prostatitis,  with  a history  of 
preceding  gonorrhoea,  there  is  a scanty  dis- 
charge, seen  only  at  the  meatus  when  several 
hours  have  elapsed  since  micturition  ; or  there 
are  shreds  in  the  urine.  The  pain  consists  of  a 
sensation  of  heat  extending  along  the  whole 
urethra,  often  radiating  to  the  buttocks,  hut 
felt  most  after  micturition.  At  other  times 
there  is  dull  pain  in  the  perinaeum,  a sense 
of  weight  or  fulness  of  the  rectum,  rather 
worse  when  lying  down,  and  by  night  than  by 
day.  Micturition  is  performed  once  or  twice, 
or  more  times,  by  night.  When  micturition 
is  attempted,  the  urine  is  often  slow  to  come, 
and  usually  a few  drops  dribble  off  after  the 
stream  ceases.  Walking  fatigues  easily,  and 
brings  on  the  sense  of  fulness  in  the  rectum. 
The  finger  in  the  rectum  generally  finds  no  en- 
largement, but  slight  tenderness  of  the  prostate. 
A bullet-bougie  or  sound,  bent  one  inch  from 
the  point  at  an  angle  of  136°,  traverses  the 
urethra  without  causing  pain  tili  the  bulbo- 
membranous  part  is  reached.  The  instrument 
is  there  grasped  for  a few  seconds,  to  pass  on 
again  to  the  neck  of  the  bladder ; here,  again, 
pain  is  felt  and  resistance  made;  tho  latter 
ceases  suddenly  as  the  sound  enters  the  bladder, 
though  the  pain  still  remains.  As  the  instrument 
is  withdrawn,  it  is  expelled  rapidly  until  it  is 
beyond  the  bulb,  where  it  lies  quietly  enough, 
and  all  pain  ceases.  The  urine  withdrawn  from 
the  bladder  through  a catheter  is  normal,  and 
free  from  muco-pus. 

(A)  The  ‘ relaxed  ,’  or  ‘ irritable, ' prostate  is 
caused  most  often  by  masturbation,  or  by  un- 
satisfied sexual  excitement,  which  lead  to  frequent 
determination  of  blood  to  the  prostate,  without 
also  obtaining  that  speedy  evacuation  of  the  blood 
which  follows  the  sedative  influence  of  the 
natural  gratification.  The  gland  is  turgid,  very 
sensitive,  and  tender,  the  crypts  and  follicles 
secreting  an  abnormal  quantity  of  mucus.  The 
swelling  of  the  gland  may  be  sufficient  to  alter 
the  shape  of  the  urethra;  hence  micturition 
may  be  impeded,  and  occasionally  accompanied 
by  smarting  pain.  A dull  heavy  sensation,  hardly 
amounting  to  pain,  is  referred  to  the  anus  or 
perinteum  ; and  the  pressure  of  hard  faeces  during 
defecation  is  often  distinctly7,  painful.  The  pas- 
sage of  a bougie  along  the  urethra  causes  little 
pain  till  the  prostate  is  reached,  when  the  patient 
may  even  scream  with  exaggerated  expression 
of  the  pain  he  feels.  The  instrument  is  grasped 
by  spasm  for  a few  seconds,  when  it  passes  into 
the  bladder,  and  no  more  pain  is  felt.  The  dis- 
charge observed  by  the  patient  is  transparent, 
colourless,  glutinous,  scanty,  except  when  lie 
strains,  or  is  excited  by  erotic  desire,  when 
several  drops  may  come  away  at  a time.  In 
middle-aged  men  urethral  stricture  is  sometime 


GLEET.  537 


also  present,  and  aggravates  the  prostatic  irrita- 
tion. The  reflex  and  sympathetic  derangements 
attract  more  attention  than  the  local  condition. 
An  almost  invariable  accompaniment,  if  not  a 
consequence,  is  dyspepsia  with  its  various  symp- 
toms ; very  common,  also,  are  aches  and  pains 
in  the  lower  extremities,  loins,  and  other  parts. 
There  is  often  great  weariness,  especially  after 
sexual  intercourse.  Intellectually  and  morally 
the  patient  is  much  affected.  Dread  of  impo- 
tence, of  loss  of  memory,  of  insanity,  or  even  of 
paralysis,  is  often  a leading  symptom. 

3.  Warts  and.  granular  patches. — Warts, 
which  are  most  commonly  situated  just  within 
the  meatus,  may  stud  the  whole  length  of  the 
urethra.  Near  the  meatus  they  are  arboriform, 
lower  down  sessile  or  only  slightly  peduncu- 
lated. Identical  in  structure  with  the  warts  on 
the  glans  or  furrow  of  the  penis,  they  are  ordi- 
narily papillomata. 

4.  Follicular  sinuses. — Follicular  sinuses, 
inflamed  during  acute  gonorrhoea,  often  secreto 
discharges  long  after  the  gonorrhoea  is  ended. 
In  the  anterior  urethra  rarely  more  than  one  or 
two  crj-pts  are  thus  chronically  inflamed  ; but 
in  the  prostatic  portion  several  crypts  secrete  a 
thin  translucent  fluid,  and  this  form  may  be 
looked  on  as  one  of  chronic  prostatitis.  In  cases 
of  hypospadias,  at  the  extreme  end  of  the  ex- 
posed urethra,  there  is  in  many  persons  on  each 
side  of  the  orifice  a natural  crypt  three-quarters 
of  an  inch  long.  These  often  continue  to  dis- 
charge thin  rnuco-pus  long  after  gonorrhoea  has 
subsided.  Other  sinuses,  but  shorter  ones,  open 
in  the  situation  of  the  lacuna  magna  of  the 
uormal  urethra.  None  of  these  follicular  sinuses 
ever  form  indurated  patches  iu  the  substance  of 
the  urethra  ; hence  they  never  cause  stricture. 
This  may,  however,  sometimes  result  from  the 
bursting  of  an  inflamed  and  suppurating  sub- 
mucous gland,  which  before  its  evacuation  may 
have  projected  on  the  wall  of  the  urethra,  and 
thus  temporarily  produced  a narrowing.  The 
discharge  from  such  a cavity  is  much  more 
copious  than  from  a simple  follicle,  and  very 
slow  to  dry  up,  though  that  usually  happens 
spontaneously  if  there  be  no  stricture  to  prevent 
the  easy  outflow  of  the  urine. 

Treatment.  — 1.  Inflammatory  'patches.  — 
When  the  pain  experienced  from  passage  of  the 
exploring  sound  is  acute,  the  resistance  small, 
and  the  discharge  white  and  thick,  the  condition  is 
mainly  one  of  congestion  ; and  the  injection  of 
three  or  four  minims  of  a solution  of  ten  to 
twenty  grains  of  nitrate  of  silver  to  the  ounce, 
by  means  of  a Guyon’s  bullet-catheter  and  syringe 
at  the  places  where  pain  is  felt,  is  then  a useful 
measuro.  This  may  he  repeated  in  three  or  four 
days,  if  needed.  If  there  be  cling  or  hitch  as  the 
bullet  passes  along  the  urethra,  the  passage  of  a 
lull-sized  (No.  25  or  26,  French)  metal  sound  twice 
weekly  is  requisite.  When  no  cling  exists,  the  last 
remains  of  the  discharge  may  be  dried  up  by 
using  soluble  bougies  at  night  (‘  Porte  remede 
Eteynal  ’)  for  ten  to  fourteen  nights.  When  con- 
gestion has  become  induration,  or  even  contrac- 
tion, which  does  not  yield  to  gradual  dilatation, 
die  fibrous  band  should  be  divided  by  a urethra- 
:ome  of  suitable  shape,  uni  il  the  urethrameter, 
expanded  to  the  largest  size  in  which  it  moves 


freely  along  the  unaffected  parts,  travels  without 
hitch  or  cling  past  the  contracted  patches. 

2.  Chronic  prostatitis. — Usually  the  euro  is 
slow,  and  depends  much  on  regimen  and  diet ; 
with  abstinence  from  alcohol,  fatigue,  lascivious 
thoughts,  and  sexual  excitement.  To  relieve 
pain  and  irritation,  mild  belladonna  and  opium 
suppositories  may  be  employed ; when  the  dis- 
charge is  opaque  and  tolerably  copious,  two 
minims  of  copaiba  in  essence  of  cinnamon  and 
water,  or  a drachm  of  solution  of  sandal- wood 
oil,  with  buchu  and  cubebs,  are  useful.  Locally, 
when  the  prostatic  tenderness  has  subsided,  cool 
hip-baths  for  five  minutes  night  and  morning, 
beginning  at  85°  F.,  and  gradually  lowering  the 
temperature  to  50°  F.,  are  beneficial.  After  a 
week  or  two  the  bath  may  be  taken  at  50J  F., 
and  lowered  by  ice  to  40°  F.,  with  advantage. 
The  sitting  should  not  exceed  five  minutes,  but 
the  baths  should  be  continued  for  several  weeks. 
Counter-irritation  is  most  useful  when  there  is 
pain  and  considerable  irritation.  It  should  be 
applied  over  a large  surface  by  the  caustic  solu- 
tion of  iodine.  It  is  at  best  an  uncertain  remedy. 

The  ‘ relaxed'  prostate  requires  great  tact 
and  perseverance  for  its  cure.  Regulation  of 
the  digestion,  prescription  of  suitable  occupa- 
tion, and  encouragement  of  the  patient  to  throw 
off  his  mental  despondency,  comprise  the  general 
treatment.  Locally,  if  the  prostate  be  not 
extremely  sensitive,  the  passage  of  the  steel 
sound  on  alternate  days  is  most  beneficial. 
Dreaded  as  is  the  first  passage  of  the  sound,  the 
relief  that  follows  is  so  satisfactory  that  the 
patient  seldom  objects,  and  generally  demands 
its  repetition.  When  the  passage  of  the  instru- 
ment is  really  agonising,  the  patient  should  be 
aDtesthetised,  his  bladder  emptied  by  catheter, 
and  ten  to  twenty  minims  of  a twenty-grain  to 
the  ounce  solution  of  nitrate  of  silver  thrown 
into  the  prostato-membranous  urethra  by 
Thompson’s  prostatic  injector.  This  may  ba 
followed  by  a subcutaneous  injection  of  one- 
third  of  a grain  of  morphia  before  the  patient 
recovers  his  consciousness.  He  should  keep  his 
bed  for  one  or  two  days  afterwards,  and  his 
room  three  or  four  days  more.  Repetition  is 
seldom  required,  as  the  sound  is  then  well  borne. 
As  a completion  of  the  cure,  a long  voyage  and 
a year  spent  in  Australian  or  New  Zealand 
sheep-farming  are  most  useful. 

3.  Granular  patches. — These  are  best  treated 
by  passing  along  the  urethra  a bougie,  which 
has  been  dipped  for  three  inches  or  more  into 
an  ounce  of  melted  cacao  butter  holding  sus- 
pended in  it  five  to  ten  grains  of  peroxide  of 
mercury  or  nitrate  of  silver.  When  cold,  this 
bougie  may  be  inserted  into  the  urethra  for  teu 
or  fifteen  minutes,  till  the  warmth  of  the  body 
has  melted  off  the  cacao  butter,  by  which  plan 
the  stimulant  is  directly  applied  to  the  granular 
patch.  Again,  twenty  drops  of  a thirty-graia 
to  the  ounce  solution  of  nitrate  of  silver  may 
be  thrown  on  to  the  granulations  by  a bulbous 
syringe.  These  strong  injections  should  be 
made  only  when  the  patient  can  rest  in  his 
room  for  twenty-four  hours  afterwards.  The 
pain  is  sometimes  severe,  and  needs  hot  baths, 
opium,  and  other  anodynes,  to  allay  it. 

li’arts  should  ba  exposed  by  an  aural  specu- 


533  GLEET. 

turn  or  endoscope,  and  touched  by  a wire  armed 

with  lunar  caustic. 

4.  Follicles.—  The  follicles  can  also  be  reached 
through  the  speculum,  and  a slender  wire  armed 
with  caustic  run  into  the  mouth  of  the  follicle. 
Usually,  when  the  discharge  is  due  solely  to 
follicles,  it  is  better  let  alone.  The  long  sinuses 
met  with  at  the  end  of  the  urethra  in  hypospa- 
dias may  be  first  cauterised  ; and  then,  if  caustic 
be  not  sufficient,  slit  up  with  a fine  knife  and 
ranaliculus-direetor.  Berkeley  Hill. 

GLEICHEHBEKG,  in  Austria.  Muri- 
ated  alkaline  waters.  See  Mineral  Waters. 

GLOBUS  HYSTERICUS  ( globus , a ball ; 
hysteria's , connected  with  hysteria). — Synon.  : 
Er.  globe  hysterique;  Ger.  hysteriscke  Kvgel. — A 
subjective  sensation  experienced  by  hysterical 
patients,  as  of  choking,  or  of  a ball  rising  in 
the  throat.  See  Hysteria. 

GLOSSALGIA  (yXaocra,  the  tongue,  and 
tiAyos , pain). — Pain  in  the  tongue.  See  Tongue, 
Diseases  of. 

GLOSSITIS  (y\a<rcra,  the  tongue). — Inflam- 
mation of  the  tongue.  See  Tongue,  Diseases  of. 

GLOSSO-PHAEYUGEAL  NERVE, 
Diseases  of. — The  glosso-pharyngeal  nerve  is 
the  special  nerve  of  taste  for  the  back  of  the 
tongue  and  the  soft  palate,  and  of  common  sensa- 
tion fi  r the  same  region,  and  in  part  for  the  upper 
portion  of  the  pharynx,  the  eustachian  tube,  and 
the  tympanum.  It  is  also  the  motor  nerve  for 
the  stylo-pharyngeus,  the  middle  constrictor  of 
the  pharynx,  the  levator  palati,  and  the  azygos 
uvulae  muscles.  It  is  doubtful  whether  the  fibres 
for  the  two  latter  muscles  arise  from  the  roots 
of  the  glosso-pharyngeal. 

Paralysis. — Very  little  is  known  of  the  pre- 
cise effects  of  paralysis  limited  to  the  glosso- 
pharyngeal nerve,  since  it  is  very  rarely  paralysed 
alone.  Sensation  in  the  fauces  is  certainly  lost, 
and  also  taste  in  the  back  of  the  tongue  and 
palate,  perhaps  also  to  a slight  extent  in  the 
front  of  the  tongue.  The  middle  constrictor  of 
the  pharynx  is  paralysed, and  perhaps  also  certain 
movements  of  the  palate  and  the  uvula.  From 
their  position,  the  fibres  of  origin  are  commonly 
damaged  in  conjunction  with  fibres  of  the  hypo- 
glossal, spinal  accessory,  and  pneumogastric.  The 
common  causes  of  damage  in  this  situation  are 
meningitis,  syphilitic  and  other  growths,  and  bone- 
diseases.  The  nerve  may  also  be  paralysed  from 
disease  of  its  nucleus  of  origin  in  the  medulla 
oblongata,  and  then  commonly  in  association  with 
the  nerves  to  the  larynx,  the  tongue,  and  often 
the  lips  (see  Labio-glosso-laryngeal  Paralysis). 
The  sensory  part  of  the  nerve  may  then  escape, 
and  only  the  motor  part  be  paralysed.  The 
causes  of  paralysis  from  disease  of  the  nucleus 
are  slow  degeneration,  softening,  hsemorrhage, 
and  probably  the  effects  of  diphtheria.  In  diag- 
nosing paralysis  of  the  levator  palati  and  azygos 
uvulae,  care  must  be  taken  to  remember  how  often 
the  arches  of  the  palate  are  unequal,  and  the 
uvula  is  oblique,  under  normal  conditions.  De- 
fects of  movement  must  be  looked  for,  and  especi- 
ally the  unequal  dimpling  of  the  base  of  the  uvula 
in  the  pronunciation  of  ‘ ah ! ’ 

Spasm. — Nothing  is  known  cf  separate  spasm 


GOITRE. 

in  the  muscles  supplied  by  the  glosso-pharyngeal 
nerve.  In  conjunction  with  the  other  motor  and 
sensory  nerves  to  the  pharynx,  it  tikes  part  in 
the  production  of  the  spasm  of  hydrophobia,  and 
in  some  hysterical  phenomena.  For  over-action 
in  the  special  seDsory  function  of  the  nerve,  see 
Taste,  Disorders  of. 

Treatment. — The  treatment  of  disorders  of 
the  glosso-pharyngeal  nerve  is  never  special,  but 
always  that  of  the  cause,  and  is  sufficiently  de- 
scribed in  the  several  articles  which  deal  with 
the  above-mentioned  aetiological  conditions. 

W.  R,  Gowers. 

GLOSSO-PHARYNGEAL  PARALY- 
SIS.— A synonym  for  Labio-glosso-laryngeal 
paralysis.  See  Labio-glosso-laryngeal  Paraly- 
sis. 

GLOSSY  SKIN  is  the  name  given  to  a 
peculiar  atrophic  condition  of  the  skin,  seen  prin- 
cipally in  the  hands,  in  consequence  of  irritative 
lesions  of  the  nerves  of  the  forearm.  The  skin 
of  the  back  of  the  hand,  fingers,  and  even  that  of 
the  palm  is  thin,  smooth,  shining,  without  fur- 
rows, and  redder  than  natural — either  uniformly 
or  in  pat  ches.  The  skin  seems  as  if  it  wer6  stretched 
over  subjacent  parts,  which  are  firmer  than  natu- 
ral. It  may  be  more  or  less  fissured,  or  even 
denuded  of  epidermis  in  patches.  Secretion  of 
sweat  may  be  increased  or  altered  in  quality. 
The  parts  may  or  may  not  be  the  seat  of  neuralgic 
pains.  It  was  thought  by  Paget  (who  described 
this  condition  in  the  Medical  Times  and  Gazette  for 
May,  1864)  to  be  a very  rare  affection,  but  it  was 
observed  by' Weir-Mitchell  and  his  colleagues,  in 
the  late  American  war,  no  less  than  19  times  in  50 
cases  of  partial  division  of  the  nerves  of  the  fore- 
arm. It  may  occur  also  as  a sequence  of  disloca- 
tions of  the  wrist.,  where  the  median  nerve  is 
compressed  or  otherwise  damaged. 

GLOTTIS,  Diseases  of.  — See  Larynx, 

Diseases  of. 

GLYCOSURIA  (y\ vkvs,  sweet,  and  olpov, 
urine). — A condition  of  urine  in  which  sugar  is 
present ; generally  used  as  a synonym  for  dia 
betes.  See  Diabetes. 

GOiTRE. — Synon.:  Bronehocele  ; Derby- 
shire Neck  ; Fr.  Goitre ; Ger.  Kropf ; Struma. 

Definition. — Simple  hypertrophy,  or  cystic, 
fibroid,  or  fibro-cy'stie  enlargement  of  the  thyroid 
gland. 

zEtiology. — a.  Locality.  Goitre  is  prevalent 
in  magnesian-limestone  districts,  for  example, 
Derbyshire — hence  the  name  ‘ Derbyshire  neck.’ 
Amongst  the  continental  countries  it  prevails  in 
are:  France,  mostly  in  Savoy ; Germany,  mostly 
in  the  Black  Forest;  Austria,  mostly  in  Styria; 
Northern  Italy,  mostly  about  the  Alps;  Switzer- 
land, mostly  in  the  Valais  ; and  Russia,  mostly 
about  the  Altai  mountains  in  Siberia. 

b.  Water-supply . — Whenever  goitre  has  arisen 
without  being  inherited  the  cause  in  far  the 
greater  number  of  cases  can  be  traced  to  some 
impurity  in  the  potable  water.  What  this  im- 
purity is,  has  not  as  yet  been  satisfactorily  de- 
termined, although  it  has  been  proved  that  the 
water  used  in  goitrous  districts  has  percolated 
through  a soil  which  contains  an  impurity,  which 
is  the  cause  of  the  malady.  Snow-water  was  id 


GOITER 


former  days  considered  to  be  tbe  cause,  but  this 
opinion  is  met  by  the  statement  that  goitre  does 
not  exist  in  Greenland  or  Lapland,  and  that  it 
is  prevalent  in  Sumatra,  where  there  is  never 
ant'  snow.  The  impurity  is  stated  by  many  to 
be  due  to  an  excess  of  lime  and  maguesia,  which 
theory  seems  borne  out  by  a geological  examina- 
tion of  the  localities  in  which  goitre  is  indige- 
nous in  England.  In  the  Indian  Punjaub,  where 
goitre  affects  60  per  cent,  of  the  population,  59 
grains  of  lime  have  been  found  in  a gallon  of  water, 
‘ 10  grains  being  an  undesirable  proportion  ’ (Pro- 
fessor Frankland).  The  latest  authorities  on 
the  cause  of  goitre  believe  the  impurity  to  be  of 
a metallic  Dature  (probably  some  form  of  iron), 
and  have  shown  that  metalliferous  earths,  it 
may  be  said  almost  without  exception,  tire  to  be 
found  in  the  neighbourhood  of  the  magnesian 
limestone  districts,  where  goitre  prevails.  In 
many  limestone  localities  also  bronchocele  is 
entirely  absent.  Scotland,  Ireland,  Norway,  and 
Sweden  are  comparatively  exempt  from  the 
disease,  although  mountain  limestone  is  found 
largely^  present  in  their  geological  formation. 
Why  potable  water  is  the  cause  of  goitre  has 
yet  to  be  definitely  determined. 

c.  Other  causes. — Epidemics  of  goitre  have 
been  notified,  as  chiefly  occurringamongst  soldiers 
in  France,  probably  the  result  of  forced  marches 
through  goitrous  districts,  combined  with  scarcity 
of  food.  In  such  districts  the  practice  of  carry- 
ing loads  on  the  head  seems  largely  to  increase 
the  ratio  of  the  disease.  The  notion  that  goitre 
is  indigenous  to  mountainous  districts  only  is 
set  aside  by  the  fact  that  in  some  plains,  those  of 
Lombardy  for  instance,  goitre  is  present.  Many 
other  theories  have  been  suggested. 

Women  in  this  country  are  much  more  liable 
to  suffer  from  bronchocele  than  men,  perhaps  on 
account  of  their  being  more  frequently  water- 
drinkers,  for  in  India  it  has  been  noticed  that 
both  sexes  suffer  alike.  During  the  time  of 
puberty  the  disease  commouly  first  appears, 
although  it  may  occur  from  any  time  of  life  up 
to  forty  y'ears  of  age,  children  having  even  been 
horn  with  a thyroid  enlargement. 

Anatomical  Characters. — The  whole  of  the 
thyroid  gland,  or  both  lobes,  or  one  lobe  only, 
may  be  the  seat  of  the  goitrous  enlargement. 
The  isthmus  is  rarely  affected  by  itself.  In  ex- 
ceptional cases  an  accessory  lobe  is  present,  and 
becomes  enlarged.  The  enlargement  may  be 
simple  soft  hypertrophy  of  the  gland,  cystic,  or 
fibroid;  or  cysts  may  be  found  interspersed  in 
the  substance  of  a fibroid  enlargement.  Cysts 
are  formed  from  the  normal  follicles  of  the  thy- 
roid, by  their  distension  with  colloid  material, 
the  epithelial  lining  degenerating  as  the  cysts 
increase  in  size.  The  cyst-wall  is  formed  by  the 
inter-lobular  septa  and  capsule  of  the  gland.  In 
pure  cysts  the  serous  fluid  which  is  secreted 
lrom  the  walls  replaces  the  colloid  contents.  In 
Hie  fibroid  form  the  connective  stroma  increases 
at  the  expense  of  the  follicles,  and  tough  bands 
of  nucleated  fibrous  tissue  traverse  the  organ  in 
ail  directions,  the  change  generally  commencing 
contrally  and  extending  peripherally.  The  fol- 
licles m-stly  atrophy',  but  some  may  persist  in 
the  form  of  small  cysts. 

Goitres  in  some  countries  are  allowed  to  reach 


6S0 

I such  dimensions  that  the  inhabitants  have  to 
support  them  in  bags.  A cystic  goitre,  as  a rule, 
projects  externally,  but  often  the  fibroid  variety 
does  not. 

Symptoms  and  Complications. — The  appear- 
ance of  the  swelling,  and  a sense  of  fulness  in  the 
neck,  are  often  the  only  symptoms  of  goitre. 
Added  to  the  sense  of  fulness,  there  may  be  a 
feeling  of  dragging  or  constriction  about  the 
throat.  More  serious  symptoms  are  sometimes 
present,  namely,  dysphagia  and  dyspnoea.  The 
former  is  rarely  present  except  when  the  tumour 
has  reached  an  immense  size,  or  when  it  presses 
on  the  (Esophagus,  as  happens  when  the  lateral 
lobes  meet  behind  the  gullet.  Dyspnoea,  a moro 
common  symptom;  may  be  due  to  pressure  from 
the  goitre  on  the  front  and  sides  of  the  trachea 
(found  more  commonly  in  y'oung  people,  before 
the  tracheal  rings  have  gained  much  power  of 
resistance),  or  on  both  recurrent  laryngeal  nerves, 
causing  partial  paralysis  of  the  abductors  of  the 
vocal  cords  (crico-arytenoidei-postici  muscles)  ; 
or  to  a portion  of  the  gland  passing  behind  the 
trachea,  or  becoming  enlarged  beneath  the  ster- 
num. There  is  often  a temporary  enlargement 
of  a goitre  during  the  catamenial  period  and 
pregnancy;  and  flooding  in  childbirth  is  not  un- 
common. A tendency  to  the  hemorrhagic  dia- 
thesis has  been  noted.  Exophthalmos,  with 
palpitation  of  the  heart,  may  accompany  goitre. 
See  Exophthalmic  Goitre. 

Cretinism  is  met  with,  but  rarely,  in  the 
goitrous  districts  of  this  country.  More  than 
half  the  number  of  cretins  are  born  of  goitrous 
parents,  but  a goitrous  enlargement  Deed  not 
necessarily  be  present  in  a cretin,  for  instances 
of  cretinism  have  been  reported  in  which  the  gland 
has  been  entirely  absent ; still  they  have  the  same 
setiological  connection.  When  the  thyr  fid  gland 
is  absent  and  cretinism  prevails,  Dr.  Hilton 
Fagge  believes  that  fatty  tumours  will  be  found, 
almost  without  exception,  in  the  posterior  tri- 
angles of  the  neck. 

Diagnosis. — A soft  hypertrophy  of  the  thyroid 
gland  can  be  diagnosed  by  its  general  diffusive- 
ness, and  the  want  of  consistent  hardness. 

The  presence  of  a cystic  goitre  can  be  ascer- 
tained by  the  fluctuation  of  fluid  within  its  walls. 
Illumination  of  the  sac  fir  the  purpose  of  dia- 
gnosis is  of  no  use.  Any  doubt  can  be  cleared  up 
by  passing  a very  fine  trochar  into  its  centre. 
Owing  to  the  fact  that  some  cystic  goitres  con- 
tain a large  amount  of  soft  trabecular  structure, 
the  fluid  withdrawn  is  likely  to  be  mixed  with 
blood.  When  the  fluid  has  been  entirely'  with- 
drawn from  a pure  cyst,  it  often  happens  that 
blood  will  be  freely  discharged  from  the  mucous 
walls. 

A fibroid  enlargement  of  the  thyroid  gland  can 
be  diagnosed  by  the  consistency  and  hardness  of 
its  substance.  In  some  cases,  fibroid  nodules  lie 
scattered  in  a general  hypertrophy  of  the  gland, 
and  may  be  of  stony'  hardness,  hiome  difficulty 
may  be  experienced  in  distinguishing  between  a 
globular  fibroid  and  a small  cystic  goitre  that 
has  thick  walls,  both  of  which  lie  deeply  in  the 
neck ; hut  if  the  exploratory  examination  ho 
made,  as  recommended  above,  the  difference  can 
at  once  be  recognised. 

The  diseases  which  simulate  goitre  are  cancer 


GOITRE. 


540 

of  the  thyroid  gland ; calculus  imbedded  in  its  sub- 
stance; lymphadenoma ; aneurism;  and  fatty  and 
other  tumours  of  the  neck.  A leading  point  in 
making  a diagnosis  is  to  ascertain,  by  directing 
the  patient  to  swallow,  whether  *he  swelling  is 
attached  to  the  trachea.  In  the  cases  of  cancer 
and  lymphadenoma,  the  history  and  general  con- 
dition of  the  patient  will  give  a leading  clue.  In 
connection  with  cancer,  it  must  be  borne  in  mind 
that  a fibroid  enlargement  of  the  gland  may  be- 
come the  seat  of  carcinomatous  change.  "When 
a fibrous  goitre  closely  overlies  the  carotid  artery, 
a forcible  pulsation  is  conveyed  through  the  tu- 
mour, simulating  an  aneurism. 

Prognosis. — The  prognosis  in  goitre  is  Tory 
favourable.  The  occurrence  of  death  from  suffo- 
cation, due  solely  to  the  effects  of  a goitrous  en- 
largement, is  extremely  rare.  It  occurs  in  those 
countries  where  little  or  no  treatment  is  tried,  the 
tumours  being  allowed  to  attain  an  immense  size 
- — their  weight  sometimes  reachingseveral  pounds. 
The  disease  is  more  likely  to  endanger  life  when 
the  gland  passes  behind  the  trachea  and  com- 
pletely embraces  it.  All  the  varieties  of  goitre 
are  amenable  to  treatment,  hut  especially  the 
cystic.  Goitres  have  been  known  to  disappear 
without  any  treatment.  This  result  may  he  due 
to  the  removal  of  the  affected  person  from  en- 
demic influences ; or  it  may  happen  when  the 
enlargement  has  arisen  during  pregnancy. 

Treatment. — The  general  rules  requiring  at- 
tention are  removal  of  the  patient  from  a goitrous 
district,  or  complete  abstinence  from  drinking 
water,  unless  it  has  been  ascertained  to  be  per- 
fectly pure.  General  medicinal  remedies  are  only 
of  service  when  the  gland  is  enlarged  by  fibroid 
change,  and  then  iodide  of  potassium  (two  to 
three  grains  twice  a day),  with  or  without  iron, 
may  be  tried.  When  the  hypertrophy  is  of  the 
simple  soft  form,  blistering,  or  painting  the  sur- 
face with  the  tincture  of  iodine,  or  the  use  of 
iodine  ointment,  will  be  sufficient.  If  the  enlarge- 
ment is  fibroid  and  of  some  consistence,  then  in- 
jections of  the  tincture  of  iodine  into,  or  setons 
passed  through,  the  substance  of  the  gland,  are 
most  useful.  Fluoric  acid  has  been  given  inter- 
nally, with  or  without  the  injections  ( Lancet , 
March  19,  1881).  The  injection  of  mxvto  cj 
of  tincture  of  iodine  should  be  used  twice  a 
week,  then  weekly,  and  afterwards  fortnightly. 
The  greater  number  of  cases  answer  well  to  this 
treatment,  whilst  on  others  no  impression  can 
be  made.  The  time  the  treatment  takes 
depends  on  the  size  of  the  goitre  ; a month 
is  the  minimum  required  for  the  cure  of  a very 
small  goitre.  The  process  to  he  followed  when 
injecting  is  as  follows  : — Having  frozen  the  skin 
over  the  portion  decided  upon  for  injection,  by 
means  of  the  ether  spray,  and  care  being  taken 
to  avoid  transfixing  any  vein  or  the  trachea,  the 
needle  of  the  syringe  is  pushed  into  the  substance 
of  the  goitre,  and  the  fluid  injected  slowly.  The 
best  form  of  syringe  for  the  purpose  is  one  similar 
to  that  used  for  hypodermic  injection,  made  with 
a screw-piston.  Pain  in  the  course  of  neigh- 
bouring nerves  is  sometimes  felt  during  the  injec- 
tion, for  instance  in  the  ear  or  at  the  root  of  a- 
tooth.  When  the  operation  isfinished,  the  needle 
should  be  rapidly  withdrawn,  and  the  skin  where 
the  puncture  has  been  made  rolled  between  the 


finger  and  thumb,  to  prevent  any  escape  of  the 
iodine.  If  the  needle  be  passed  well  into  the  sub- 
stance of  the  goitre,  no  fear  need  be  entertained 
of  the  formation  of  an  abscess.  In  favourable 
cases  there  will  be  a gradual  enlargement  of  the 
tumour,  with  a slight  degree  of  pain,  for  some 
eight  or  twelve  hours;  after  that  time  the  brou- 
cboecle  will  very  slowly  decrease  in  size.  As  a 
rule,  in  two  or  three  weeks' timeit  will  be  evident 
whether  the  injection  is  to  prove  effective.  By 
this  form  of  treatment  all  sears  are  avoided.  The 
length  of  time  required  for  its  adoption  is  often 
an  objection,  even  when  improvement  is  noted; 
a case  occurred  in  the  writer’s  experience  in  which 
the  time  needed  for  the  completion  of  the  euro 
was  over  a year,  the  neck  being  reduced  from  17| 
to  13^  inches.  Setons  made  of  from  two  to  eight 
lengths  of  silk  form  a very  serviceable  plan  for 
the  treatment  of  fibrous  goitres.  In  employing 
either  injections  or  setons  it  is  not  necessary  for 
the  patient  to  discontinue  his  usual  employment. 

Biniodide  of  mercury  smeared  over  the  en- 
largement, the  patient  being  then  made  to  sit 
with  his  neck  exposed  to  the  rays  of  the  sun  for 
many  hours,  has  proved  an  effectual  remedy  in 
India.  A Captain  Cunningham,  the  originator  of 
this  plan,  treated  gratuitously  about  60,000 
natives  in  two  years.  He  is  said  to  have  never 
produced  salivation,  and  to  have  rarely  failed  in 
effecting  a cure.  Ligature  of  the  thyroid  arteries 
has  only  proved  of  temporary  benefit.  Division 
of  the  isthmus  has  been  advised  when  dyspnoea 
is  present.  A goitre  may  be  removed  when  it 
endangers  life  or  keeps  the  patient  from  work. 
The  operation  is  one  of  comparative  safety  under 
the  antiseptic  system,  and  when  each  vessel  is 
divided  between  ligatures. 

The  treatment  of  cystic  goitre  is  of  one  kind, 
and  is  always  successful.  The  plan  consists  in 
emptying  the  cyst  with  a trochar  and  canula,  and 
then  injecting  a solution  of  iron  (two  drachms 
of  the  tincture  to  an  ounce  of  water)  sufficient  to 
expand  the  cavity  again.  The  patient  should  be 
kept  in  bed  on  account  of  the  rise  of  temperature, 
after  a successful  injection,  with  the  canula 
plugged,  until  the  third  or  fourth  day,  when  a 
suppurative  discharge  should  have  been  set  up. 
The  metal  canula  should  then  be  replaced  by  an 
india-rubber  one  (made  with  a middle  layer  of 
webbing),  the  canula  being  cut  shorter  as  the 
cyst  becomes  smaller,  and  poultices  applied  until 
the  goitre  has  disappeared.  A cure  will  he 
effected  in  one  month  to  four  or  five  months. 

During  the  injection  of  the  iron-solution  into 
cystic  goitres,  it  may  happen  that  air  passes  into 
a vein  which  has  been  wounded  by  the  trochar. 
As  this  accident  has  been  followed  by  instan-* 
taneous  death,  the  writer,  to  prevent  this  acci- 
dent, uses  conjointly  the  two  following  plans, 
taking  care  to  avoid  superficial  veins : — 1.  A tape 
is  passed  round  the  neck  under  the  base  of  the 
goitre,  and  held  tightly  by  an  assistant  standing 
behind  the  patient,  whilst  the  injection  is  going 
on,  and  for  two  or  three  minutes  after.  2.  The 
nozzle  is  fixed  at  right  angles  to  the  body  of  the 
syringe,  enabling  the  injection  to  be  made  with- 
out holding  the  syringe  below  the  level  of  the 
opening  into  the  cyst,  and  preventing  the  inje-i- 
tion  of  air.  See  Thtkoid  Gland,  Diseases  of. 

Pugin  Thoknto>u 


G ON  AGRA. 

GONAGEA,  (yivv,  the  knee,  and  aypa,  a sei- 
£uro). — An  attack  of  gout  in  the  knee.  See  Gout. 

G-ONABTHRITIS  {yow,  the  knee,  and 
Ep9pov,  a joint).  — Inflammation  of  the  knee- 
ioint.  See  Joints,  Diseases  of. 

GONORRHOEA  ( yovr/ , seed,  and  pica,  I 
flow). — Stnos.  : Clap,  Blenorrhagia  ; Fr.  Chaude- 
pisse ; Ger.  Tripper. 

Definition. — A contagious  purulent  inflamma- 
tion, affecting,  in  men,  the  urethral  mucous  mem- 
brane and  its  continuations ; in  women,  the 
vaginal  mucous  membrane  and  its  continuations. 
Occasionally  the  conjunctival  and  rectal  mucous 
membranes,  to  which  the  nasal  has  been  added 
on  doubtful  evidence,  are  attacked  by  gonorrhoea. 
Certain  rheumatoid  affections  and  other  compli- 
cations, to  be  hereafter  mentioned,  also  attend 
the  disease. 

Aetiology.  — The  causes  of  gonorrhoea  are 
predisposing  and  exciting.  The  chief  predispos- 
ing causes  are  the  lymphatic  temperament ; 
great  sexual  excitement  and  other  fatigue ; alco- 
holic excess ; gout ; previous  attacks,  especially 
an  uncured  gleet ; and  lastly,  a peculiar  proneness 
to  urethritis  in  certain  persons.  The  exciting 
causes  include: — (1)  Contagion  with  (a)  gonor- 
rhoeal pus,  or  (b)  acrid  discharges  not  generated 
by  gonorrhoea  ; (2)  excessive  irritation  of  the  ure- 
thra by  prolonged  or  repeated  coitus  ; (3)  mas- 
turbation ; (4)  instrumentation;  and  (o)  the  use 
of  injections  after  coitus. 

Gonorrhoea  differs  so  considerably  in  the  two 
sexes,  owing  to  the  diversity  of  seat  of  the  dis- 
order, that  its  description  may  be  conveniently 
divided  into  two  parts. 

(A.)  Gonorrhoea  in  the  Male. — 

Anatomical  Characters. — The  seat  of  urethri- 
tis is  at  first  the  mucous  membrane  of  the  fossa 
navicularis,  whence  it  travels  onwards,  commonly 
net  extending  further  than  to  the  bulbous  or 
membranous  portion  of  the  urethra.  The  inflam- 
mation then  dies  away  gradually,  leaving  patches 
of  the  mucous  surface  here  and  there  still  in- 
flamed. But  the  inflammation  may  extend  to  the 
submucous  tissue,  to  the  glands  abcut  the  urethra, 
to  the  prostate,  to  the  neck  of  the  bladder,  and  to 
the  epididymis  in  one  direction,  or  to  the  bladder 
or  even  to  the  kidneys  in  another.  Renal  inflam- 
mation nevertheless  is  most  frequently  excited 
by  sympathetic  irritation,  when  the  neck  of  the 
bladder  is  attacked,  and  cnly  with  excessive 
rarity  by  continuous  extension  alcng  the  bladder 
and  ureters.  As  the  inflammation  localises  itself 
in  the  urethra,  it  penetrates  more  deeply,  reach- 
ing the  follicles  and  submucous  tissue,  and  may 
thus  cause  thickening  and  induration  of  the  ure- 
thra at  these  points. 

In  the  acute  stage  there  is  general  uniform 
congestion  ; as  inflammation  subsides,  the  gene- 
ral redness  becomes  patchy,  arborescent,  and 
punctiform.  The  swelling  disappears,  leaving 
areas  of  thickened  mucous  membrane,  fine  gra- 
nulations which  develop  occasionally  into  warts, 
and  a plugged  condition  of  the  ducts  of  the  sub- 
mucous and.  mucous  glands,  which  possibly  may 
cause  peri-urethral  abscess  or  subsequent  gleet. 
After  a lapse  of  time  the  indurated  patches  may 
contract,  and  thereby  cause  irregularity  and  stric- 
ture of  the  urethra. 


GONORRHOEA.  541 

Symptoms. — The  length  of  the  interval  be- 
tween contagion  and  the  development  of  the 
symptoms  in  gonorrhoea  varies  from  twelve  hours 
to  eight  days ; but  the  great  majority  of  claps  are 
evident  on  the  fourth  or  fifth  day  after  inter- 
course. Usually  early  manifestation  of  inflamma- 
tion denotes  a severe  attack.  Urethritis  from 
contagion  differs  in  no  respect  from  inflammation 
otherwise  excited,  and  has  no  necessary  period 
of  incubation. 

In  the  first  stage,  redness,  scanty  sticky  dis- 
charge, and  smarting  in  micturition  are  the 
leading  symptoms.  Febrile  disturbance  at  this 
early  period  is  most  rare.  On  the  other  hand, 
the  discharge  in  many  cases  precedes  all  other 
symptoms.  Towards  the  end  of  the  first  week, 
swelling  generally  of  the  penis,  especially  of  the 
urethra,  sets  in,  accompanied  by  copious  yellow- 
ish-green discharge,  smarting  in  the  urethra, 
and  aching  in  the  penis,  perinseum,  and  groins. 
Painful  micturition  and  erections  at  night  are 
frequent  ( see  Chordes)  ; and  general  febrile  dis- 
turbance is  sometimes  present.  Naturally  the 
disorder  subsides  in  four  or  six  weeks,  by  gradual 
cessation  of  the  symptoms  ; but  it  is  frequently 
prolonged  or  brought  back  to  its  first  intensity 
by  neglect  of  the  precautions  necessary  against 
irritation. 

The  patients’  habits  often  induce  variations 
from  the  ordinary  course,  as  regards  the  amount 
of  discharge  and  the  severity  of  the  symptoms. 
In  all  cases  relapses  or  re-kindling  of  the  acutely 
inflammatory  stage  are  common.  The  acute  stage 
of  the  disorder  terminates  in  one  of  three  ways : 
— Cessation  of  pain  and  discharge  ; cessation  of 
pain,  with  diminution  of  the  still  purulent  dis- 
charge; cessation  of  all  symptoms,  except  a mi- 
nute quantity  of  thin  whitish  discharge  or  gleet. 
This  scanty  discharge  is  most  commonly  caused 
by  chronic  inflammation  at  one  or  two  places, 
continued  after  the  inflammation  has  ceased  else- 
where. Sometimes  a stricture,  a small  wart,  or 
a relaxed  prostate  secretes  shreds  of  mucus,  and 
thus  causes  gleet.  Sec  Gleet. 

Thus  the  course  of  gonorrhoea  has  been  di- 
vided into  four  stages: — Preliminary  congestion, 
lasting  three  or  four  days ; acute  increasing 
inflammation,  lasting  ten  to  twenty  days  ; station- 
ary stage,  of  uncertain  duration  ; and,  lastly, 
subsiding  stage,  also  of  uncertain  duration.  The 
discharge  varies  from  its  usual  form  of  yellow 
pus,  being  in  some  cases  viscid,  like  mucus, 
in  others  serous  and  very  liquid ; in  rare  in- 
stances it  is  rosy  or  pinkish  for  some  days. 

Diagnosis.  - — The  distinction  of  urethritis 
caused  by  contagion  from  that  excited  by  other 
causes  is  impossible  when  the  history  of  the 
patient's  antecedents  is  wanting.  Certain  com- 
plications of  gonorrhoea  are  said  to  follow 
urethritis  only  when  that  is  excited  by  contagion. 
This  proposition  is  not  so  clearly  established 
that  it  may  serve  to  decide  the  origin  of  a given 
case  to  be  contagious  or  non-contagious.  To 
distinguish  urethritis  from  urethral  chancre  is 
easy : urethral  chancre  is  never  more  than  one 
inch  from  the  meatus,  nearly  always  situate  just 
within  the  entry,  and  the  ulcerated  surface  can 
be  seen  if  the  lips  of  the  urethra  be  separated, 
or  a short  aural  speculum  be  introduced.  The 
discharge  also  from  a chancre  is  not  creamy,  but 


GONORRHCEA. 


542 

shreddy.  The  pain  in  micturition  is  stinging, 
but  limited  to  one  spot.  Syphilis  may  accompany 
urethritis,  but  the  disease  has  its  proper  initial 
sore  or  other  characteristic  symptoms.  Occasion- 
ally a slight  muco-purulent  discharge  'without 
pain  or  much  swelling  is  present  during  the 
period  of  the  initial  lesion  in  syphilis.  This  always 
subsides  spontaneously  in  one  or  two  weeks.  In 
balanoposthitis  {gonc^rhoia  externa ) there  is  no 
urethral  discharge.  When  the  free  border  of 
the  prepuce  is  exceedingly  small,  it  may  be  most 
difficult  to  be  certain  that  the  discharge  does 
not  come  from  the  meatus  tirinarius  as  well  as 
from  the  surfaces  of  the  prepuce  and  glans. 
Usually,  a thorough  syringing  under  the  fore- 
skin will  wash  away  the  pus,  and  permit  the 
meatus  urinarius  to  be  watched  while  the  urethra 
is  pressed ; if  pus  oozes  forth  it  is  secreted  in 
the  urethra.  Abscess  of  the  prostate  or  peri- 
nseum  may  cause  urethral  discharge,  which  is 
distinguished  from  gonorrhoea  by  the  history 
and  condition  of  the  patient. 

Pitoois'osis. — The  prognosis  of  gonorrhoea  is 
favourable  if  proper  precautions  be  taken  early. 
But  in  spite  of  precaution,  the  disease  is  sometimes 
most  severe,  especially  in  younglads  of  lymphatic 
temperament,  or  in  men  of  nervous  irritable 
constitution.  Gonorrhoea  is  said  also  to  be 
liable  to  run  a severe  course  in  persons  who 
suffer  from  acne.  During  its  continuance  any 
of  the  complications  hereafter  mentioned  may 
arise.  Further,  gonorrhoea  has  caused  death 
through  pysemia ; and  more  often  still  it  origi- 
nates anchylosis  or  destruction  of  joints,  or  other 
painful  disablements;  while  it  is  the  predomi- 
nating cause  of  stricture. 

Treatment. — The  treatment  of  urethritis  may 
be  (1)  abortive ; and  (2)  systematic.  Abortive 
treatment  is  intended  to  cut  short  the  disease  by 
large  doses  of  specifics,  or  by  caustic  injections, 
before  acute  inflammation  arrives.  It  is  always 
dangerous,  and  rarely  successful.  Systematic 
treatment  consists  in  at  first  removing  all  sources 
of  irritation  and  allaying  acute  inflammation. 
Abstinence  from  alcoholic  liquors,  sexual  excite- 
ment, and  severe  exercise  is  necessary.  Tepid 
baths  and  great  cleanliness,  with  support  for  the 
penis  and  testes,  are  useful.  Painful  micturition 
is  often  relieved  by  immersi  )Z  the  penis  in  ice- 
cold  water  during  the  act.  A light  diet  of  fish, 
milk,  and  vegetables,  with  salines  and  laxa- 
tives, should  be  ordered.  When  the  acute  stage 
is  passed,  the  continuance  of  the  congestion  is 
shortened  by  astringent  injections  and  the  ad- 
ministration of  copaiba,  sandal  oil,  and  cubebs. 
But  these  should  he  withheld  while  there  is 
smarting,  copious  greenish  discharge,  and  dull- 
red  congestion  of  the  urethra. 

Complications  and  Seque^e. — The  compli- 
cations of  gonorrhoeal  urethritis  are — (1)  Ba- 
lano-posthitis ; (2)  Phimosis  or  paraphimosis; 
(3)  Retention  of  urine;  (4)  Lymphangitis  and 
Adenitis  (Sympathetic  bubo) ; (5)  Hcemorrhage 
from  the  urethra ; (6 ) Peri-urethral  abscess  (a) near 
the  glans.  ( b ) between  the  layers  of  the  perinceal 
fascice,  (e)  Cowperitis;  (7)  Inflammation  of  the 
neck  of  the  bladder  ; (8)  Prostatitis  ; (9)  Inflam- 
mation of  the  spermatic  cord,  epididymitis,  and 
orchitis ; (10)  Inflammation  of  the  rectal  mucous 
membrane;  (1 1)  Conjunctivitis  by  contact ; (12) 


Sclerotitis  and  iritis;  (13)  Rheumatism  of  the 
fasciae,  great  nerves,  or  joints  ; acute  synovitis, 
bursitis,  abscess,  pyaemia;  (14)  Stricture;  and 
(15)  Warts.  Several  of  these  complications  are 
described  in  special  articles,  to  which  the  reader 
is  referred ; but  a few  of  them  require  brief 
notice  here. 

Stricture,  or  the  development  of  tough  fibrous 
bands  in  the  submucous  tissue  in  limited  areas 
of  the  urethra,  which  prevent  the  canal  from 
expanding  during  the  flow  of  urine,  is  caused 
by  long-lasting  congestion  and  inflammation ; 
the  most  common  seat  being  the  penile  portion  of 
the  canal,  and  especially  the  inehnearest  themea- 
tus  urinarius,  whilst  those  causing  most  trouble 
are  commonly  at  the  bulbo-membran-  >us  portion. 
Slowly  produced,  these  contractions  seldom 
attract  attention  till  two  or  three  years  have 
elapsed,  and  very  frequently  not  until  eight  or 
ten  years  have  passed  away. 

Easily  curable,  in  the  early  stages,  these  con- 
tractions, by  exciting  reflex  irritation,  first  of 
the  bladder,  subsequently  of  the  kidney,  in- 
directly cause  parenchymatous  induration  and 
atrophy  of  the  secreting  tissue  of  the  latter,  and 
thus  seriously  affect  the  nutrition  of  the  body, 
thereby  generating  a long  chain  of  morbid 
changes,  which  not  infrequently  end  in  death. 

Retention  of  urine  is  produced  by  gonorrhoea  in 
two  ways: — (1)  During  the  acute  inflammatory 
stages  by  muscular  spasm  closing  the  congested 
mucous  membrane  at  the  bul bo-membranous  por- 
tion. This  is  of  course  a temporary  evil,  though 
often  very  painful  while  it  lasts.  The  bladder 
should  at  once  be  emptied  by  passing  a small 
(No.  6 or  7 English  scale)  flexible  catheter,  and 
the  recurrence  of  the  spasm  prevented  by  saline 
purges,  rest,  warm  baths,  and  opiates.  (2)  In 
the  tightly-narrowed  urethra,  when  stricture  lias 
formed,  a small  amount  of  local  swelling  or 
spasm  may  block  the  passage.  The  immediate 
treatment  consists  in  passing  a catheter  fine 
enough  to  get  through  the  contraction  with  the 
adjuvants  just  mentioned,  and  subsequently  di- 
lating the  contracted  parts  by  one  of  the  various 
methods  employed  by  surgeons  for  that  purpose. 

Hcemorrhage  from  the  urethra  is  caused  by 
rupture  of  the  blood-vessels  of  the  corpus  spon* 
giosum  during  the  violent  erections  of  chordee. 
Rarely  copious  or  serious,  in  some  cases  it  has, 
like  hcemorrhage  from  other  trivial  causes,  been 
dangerous  from  its  obstinacy.  Ice-cold  wrap- 
pings, notably  the  india-rubber  coil  with  ice- 
cold  water  flowing  through  it,  generally  arrest 
the  bleeding  speedily.  If  requisite,  a catheter 
may  bo  passed,  and  the  penis  compressed  by  a 
bandage  tightly  wound  round  the  organ. 

Inflammation  of  the  neck  of  the  bladder , or.  as 
it  is  often  called,  inflammation  of  the  bladder, 
though  real  cystitis  is  rare  in  gonorrhoea,  con- 
sists of  extension  of  the  mucous  inflammation  to 
the  neck  of  the  bladder,  and  is  a tedious,  often 
very  harassing  accompaniment  of  gonorrhoea.  It 
seldom  occurs  until  the  gonorrhoea  has  lasted 
two  or  three  weeks,  and  it  may  develop  at  aDy 
time  during  the  contiruance  of  that  disease.  It 
is  denoted  by  very  frequent  calls  to  micturate; 
great  pain  during,  and  especially  scalding  at  the 
end  of  micturition,  caused  by  muscular  spasm  of 
the  deeper  peri-urethral  muscles  ; with  cxtrusios 


GONORRHCEA. 


along  with  the  last  drops  of  urine  of  a small 
quantity  of  muco-pus  or  blood.  The  usual 
gonorrhoeal  discharge  ceases  almost  entirely 
during  the  attack,  bur,  usually  returns  when  the 
inflammation  of  the  neck  subsides.  Never  dan- 
gerous, this  affection  derives  its  importance 
wholly  from  the  great  amount  of  distress,  mental 
and  bodily,  which  it  causes.  It  is  best  com- 
bated by  rest,  warm  baths,  anodynes,  and  very 
light  diet.  It  is  very  prone  to  relapse. 

Prostatitis,  that  is,  inflammation  of  the  sub- 
stance of  the  prostate,  is  a severe  complication. 
It  causes  swelling  of  the  prostate  ; painful,  slow 
micturition,  and  often  complete  retention  ; a sense 
of  fulness  or  weight  at  the  anus ; and  sometimes 
great  irritation  of  the  bowel,  with  constant  de- 
sire to  defaecate.  Prostatitis  may  cause  abscess, 
and  usually  leaves  enlargement  of  the  organ.  If 
suppuration  takes  place,  pain  increases  till  matter 
escapes  ; then  sudden  relief  follows.  The  abscess 
most  commonly  opens  into  the  urethra,  and  the 
pus  comes  away  with  the  urine ; but  it  may  open 
into  the  rectum,  the  perinmum,  or  the  bladder. 

The  treatment  consists  mainly  in  allaying 
irritation  and  pain  by  hot  baths,  fomentations, 
and  opium  ; and  when  retention  occurs,  the  regu- 
lar passage  of  a catheter  is  requisite.  "When 
fluctuation  is  evident,  abscesses  must  be  opened 
in  the  rectum  or  perinseum.  "When  the  abscess 
has  burst  spontaneously,  it  visually  closes  in 
course  of  timo,and  the  discharge  ceases  altogether 
or  dwindles  to  a scanty  gleet  of  no  importance. 
Should  the  discharge  continue  copious  without 
abatement  after  several  weeks,  or  the  patient 
suffer  much  distress,  an  incision  through  the 
perinseum  is  proper,  through  which  to  drain  and 
close  the  abscess. 

(B.)  Gonorrhceain  the  Female — Vaginitis. 
This  may  be  acute  or  chronic.  The  inflamma- 
tion begins  at  the  fore  part  of  the  vagina,  extend- 
ing to  the  uterus  in  one  direction,  and  to  the 
urethra  in  the  other.  WThen  attacking  the  vulva, 
it  causes  occasionally  abscess  of  accessory  parts, 
for  instance,  of  Bartholini’s  gland,  or  of  the 
lymphatic  glands.  In  the  cervix  uteri  and  in  the 
urethra  it  becomes  very  obstinate. 

Stmptoms. — These  consist,  in  the  acute  stage, 
of  swelling  of  the  genitals,  heat,  or  itching,  smart- 
ing on  making  water,  and  aching  pains  in  the 
back  and  loins.  The  mucous  membrane  becomes 
dry  and  bright  red.  At  first  the  mucus  is  thin 
and  transparent,  but  soon  becomes  thick,  creamy, 
and  copious.  The  mucous  membrane  is  more  or 
less  studded  with  little  eminences  ( vaginitis 
granulosa ).  The  inflammation  becomes  chronic 
in  from  six  to  ten  or  twelve  days  ; the  pain, 
swelling,  and  congestion  diminish  or  cease  ; the 
discharge,  less  creamy,  remains  plentiful.  It  is 
usually  secreted  in  the  cul-de-sac,  or  in  the  cer- 
vix, or  seme  other  part  less  easily  cleared  than 
the  anterior  part  of  the  vagina.  These  parts, 
while  inflamed,  retain  a brighter  red  colour 
than  the  rest  of  the  mucous  membrane.  Not  in- 
frequently, when  the  inflammation  has  ceased  in 
the  vagina,  pus  can  still  be  squeezed  from  the 
meatus  urinarius  or  some  of  the  crypts  opening 
round  that  orifice,  if  the  finger  be  drawn  for- 
wards along  the  under  surface  of  the  urethra. 

The  duration  is  extremely  variable  ; if  assidu- 
ously treated,  so  that  extensiou  to  the  cul-de-sac 


543 

or  cervix  uteri  is  prevented,  the  disease  has  a 
duration  of  about  three  weeks.  But  when  theso 
parts  or  the  urethra  are  invaded,  the  duration 
is  most  uncertain,  the  disease  lasting  often  for 
months  or  even  years.  The  length  of  time  that 
the  discharge  remains  contagious  is  also  most 
uncertain.  Probably  any  discharge,  however 
scanty  and  serous  it  may  have  become,  may 
cause  disease  if  increased  by  accidental  irritation. 

Tuagnosis. — This  depends  on  the  swelling  and 
red  congestion  in  the  acute  stage,  and  on  partial 
excoriation  and  copious  discharge  in  the  chronic 
stage.  The  distinction  between  vaginitis  from 
contagion  and  vaginitis  from  non-specific  irrita- 
tion is  always  difficult,  and  sometimes  impossible, 
being  mainly  determined  by  collateral  evidence. 
It  generally  has  a contagious  origin  if  there  be 
pus  in  the  urethra. 

Prognosis. — This  is  favourable.  Sometimes 
the  disorder  is  cured  before  it  becomes  chronic; 
and  dangerous  complications  are  very  uncommon. 

Treatment. — The  treatment  of  vaginitis  in  the 
acute  stage  consists  in  allaying  irritation  by  rest, 
in  bed,  warm  baths,  frequent  injections  of  warm 
water,  or  warm  but  very  weak,  astringent  solu- 
tions, and  moderate  purgation.  The  habits  and 
health  of  the  patient  must  be  regulated,  and  all 
causes  of  excitement  withdrawn  When  conges- 
tion has  subsided,  stronger  astringent  injections 
should  be  efficiently  applied,  so  that  the  whole 
mucous  surface  of  the  vagina,  especially  that  of 
the  cul-de-sac,  is  thorougtdy  laved.  Alum  or 
tannin  should  be  applied  in  powder,  by  means 
of  the  speculum,  to  the  dt-eper  parts  of  the  canal. 

Complications.— The  complications  of  gonor- 
rhoeal vaginitis  are  various.  Among  the  earliest  is 
vulvitis.  The  labia  and  clitoris  grow  red,  swell, 
and  a foetid  discharge  is  secreted.  The  patches  of 
epithelium  peel  from  the  mucous  surfaces,  pro- 
ducing excoriation  and  occasionally  ulceration  of 
the  mucous  follicles.  Usually,  if  the  parts  are 
kept  clean,  the  irritation  subsides  in  a few  days. 

Urethritis  is  the  most  constant  accompaniment 
of  gonorrhoea.  Barely  so  acute  as  to  cause  much 
irritation,  it  may  produce  severe  suffering.  It 
begins  with  itching  and  smarting  at  the  meatus, 
which  is  red  and  swollen.  A purulent  or  mucous 
discharge  oozes  from  the  passage,  unless  the 
patient  have  just  micturated  ; even  then  a little 
can  be  found  in  the  mouths  of  two  follicles 
which  open  close  to  the  meatus.  This  discharge 
is  very  persistent,  and  is  probably  a source  of 
contagion  long  after  the  disease  is  cured  else- 
where. The  treatment  of  urethritis  consists  of 
frequent  baths,  astringent  injections,  and  copaiba 
internally.  Obstinate  chronic  discharges  maybe 
arrested  by  caustic  solutions,  carefully  applied. 

Acute  inflammation  of  the  cervix  and  os  uteri 
is  a frequent  consequence  of  gonorrhoea.  The 
neck  of  the  uterus  is  swollen,  red,  and  often 
excoriated  about  the  os,  whence  a copious  dis- 
charge issues,  at  first  clear  and  viscid,  then 
purulent.  This  subsides  to  a thin  mucus,  and 
either  shortly  ceases,  or  more  commonly  passes 
into  chronic  catarrhal  flux,  which  lasts  an  indefi 
nite  time,  aud  long  retains  its  contagious  quality. 
The  acute  inflammation  is  best  treated  by  com- 
plete rest,  warm  baths,  warm  injections,  and 
saline  aperients.  In  the  chronic  stage  its  treats 
ment  is  that  of  uterine  catarrh. 


64-1  GONORRHCEA. 

Metritis,  perimetritis,  and  ovaritis  may  also 
result  from  gonorrhoea.  See  Ovaky,  Diseases  of ; 
and  Womb,  Diseases  of.  Berkeley  Hill. 

GONOESHCEAL  RHEUMATISM. — An 

affection  of  the  joints  associated  with  gonorrhoea. 
See  Rheumatism,  Gonorrhceal. 

GOOSE-SKIN-. — -A  condition  of  the  skin  in 
which  this  structure  is  rough  and  wrinkled,  like 
that  of  the  goose.  It  is  of  a transient  character, 
being  due  to  contraction  of  the  muscular  fibres  of 
the  skin,  producing  wrinkling  of  the  integuments, 
and  prominence  of  the  hair-follicles ; and  is  ob- 
served as  the  result  of  the  direct  application  of 
cold,  or  of  a shock,  and  in  the  early  stages  of  fevers. 

GOUT  ( guttci , a drop). — Synon.  : Podagra, 
Chiragra,  Gonagra  (when  the  disease  affects  the 
foot,  hand,  or  knee  respectively) ; Fr.  Goutte ; 
Ger.  Gicht.  The  name  gout  is  supposed  to  have 
originated  in  the  idea  of  the  dropping  of  a morbid 
fluid  into  the  joints,  and  is  of  very  ancient  date. 

Definition.— Gout  is  a general  or  constitu- 
tional disease,  probably  depending  upon  the 
presence  in  the  system  of  excess  of  uric  acid, 
the  complaint  being,  in  fact,  a manifestation  of 
the  lithic  or  uric  acid  diathesis , lithiasis , or  lithce- 
mia.  It  may  be  hereditary  or  acquired ; and  is 
characterised  ordinarily  by  a peculiar  inflam- 
mation of  the  joints — articular  or  regular  gout, 
attended  with  the  deposit  of  urates  in  their  struc- 
tures, affecting  usually  and  especially  the  smaller 
joints,  and  at  first  more  particularly  the  meta- 
tarso-phalangeal  articulation  of  the  great  toe, but 
afterwards  extending  to  other  joints.  Similar 
deposits  of  urates  may  occur  in  other  tissues  in 
course  of  time ; and  certain  organs  of  the  body 
are  liable  to  become  the  seat  of  functional  dis- 
orders, or  of  pathological  changes,  during  the 
progress  of  the  disease — non-articular  or  irre- 
gular gout ; while  it  is  also  often  attended  with 
general  symptoms.  Gout  in  the  early  part  of  its 
course  is  usually  an  acute  affection,  occurring  in 
periodic  attacks  or  ‘ fits  ’ ; but  subsequently  it 
tonds  to  become  more  or  less  chronic  and  per- 
manent, though  even  then  generally  presenting 
exacerbations  from  time  to  time.  The  gouty 
diathesis  may,  however,  be  present  without  giving 
rise  to  any  joint-affection  or  other  evident  organic 
mischief. 

.Etiology  and  Pathology. — The  aetiology 
and  pathology  of  gont  are  intimately  associated, 
and  must  be  considered  in  their  mutual  relations ; 
and  there  are  certain  definite  points  which  re- 
quire to  be  noticed  in  this  connection. 

1.  It  is  necessary  to  determine  the  immediate 
pathological  cause  of  the  gouty  diathesis  and  its 
accompanying  phenomena.  Many  views  have 
been  advanced,  but  they  all  belong  to  either  of 
two  groups,  namely,  the  humoral  or  anti-humoral, 
the  former  attributing  the  complaint  to  some 
morbid  condition  of  the  blood  and  secretions ; 
the  latter  to  some  functional  disorder  or  organic 
change  affecting  certain  systems  of  the  body, 
and  especially  the  nervous,  vascular,  or  digestive 
systems.  Loss  of  nervous  tone,atropho-neurosis, 
venous  and  capillary  congestion,  and  plethora  of 
the  chylo-poietie  viscera,  are  among  the  con- 
ditions to  which  gout  has  thus  been  attributed. 
In  the  writer's  opinion  an  essential  element 


GOL'T. 

in  the  development  of  gout  consists  in  the  pre- 
sence of  some  special  morbific  agent  in  the 
system : and  it  is  now  almost  universally  ad- 
mitted that  this  agent  is  uric  or  lithic  acid,  which 
accumulates  in  the  body  in  abnormal  quantity  • 
A variable  amount  of  this  substance  is  being 
constantly  formed  in  the  system  during  the  pro- 
cesses connected  with  nutrition,  but  within  cer- 
tain limits,  which  probably  differ  in  different 
persons  and  under  different  circumstances,  it  is 
capable  of  being  eliminated  by  the  kidneys  or  of 
being  destroyed,  and  only  when  the  acid  accumu- 
lates beyond  such  limits  are  the  gouty  phenomena 
developed.  In  short,  gout  may  be  regarded  as 
a manifestation  of  the  so-called  lithic  acid  dia- 
thesis, lithiasis,  or  lithcemia.  The  acid  exists  in 
the  body  as  urate  of  soda,  and  in  the  gouty 
diathesis  this  salt  is  present  not  only  in  the 
serum  of  the  blood,  but  also  in  the  fluid  that 
diffuses  from  it  into  all  the  vascular  and  non- 
vascular  structures  of  the  body  (Bence-Jones). 
There  are  several  arguments  in  support  of  this 
view: — (1)  Gout  occurs  under  circumstances 
which  are  known  to  induce  in  various  ways 
the  presence  of  excess  of  uric  acid  in  the  sys- 
tem ; and,  further,  the  causes  which,  are  most 
liable  to  bring  on  a gouty  paroxysm  are  those 
which  temporarily  increase  this  excess.  (2) 
While  in  the  blood  of  healthy  persons  the  quan- 
tity of  uric  acid  present  is  so  minute  that  it 
cannot  he  detected  by  any  ordinary  tests,  in 
gout  this  substance  may  be  obtained  from 
blood -serum,  even  in  a crystalline  form,  either 
before  or  during  an  acute  attack  in  early 
cases,  or  at  any  time  in  chronic  cases.  It  has 
also  been  found  in  the  fluid  contained  in  blebs 
raised  by  blisters,  provided  they  are  applied  at 
a distance  from  the  seat  of  any  acute  gouty  in- 
flammation ; in  inflammatory  effusions  in  serous 
cavities;  and  in  dropsical  fluids,  such  as  ascites. 
(3)  Along  with  these  indications  of  the  presence 
of  excess  of  lithic  acid  in  the  system,  during  an 
attack  of  acute  gout  the  absolute  quantity  dis- 
charged in  the  urine  is  considerably  diminished; 
while  in  chronic  cases  of  the  disease  it  is  habi- 
tually more  or  less  deficient,  and  at  times  may 
be  almost  entirely  absent.  (4)  Deposits  of 
urates,  especially  of  urate  of  soda,  are  formed 
in  the  joints  and  other  structures  in  gout,  and 
this  is  the  only  disease  in  which  such  for- 
mations are  found.  Every  attack  of  gouty  in- 
flammation is  attended  with  the  deposit  of  urates 
in  the  affected  tissues,  but  the  quantity  is  not 
in  proportion  to  its  intensity,  and  therefore  can- 
not be  merely  the  effect  of  such  inflammation. 

Assuming  this  view  of  tli9  essential  nature  of 
the  gouty  diathesis  to  be  correct,  different 
theories  are  held  to  account  for  the  excess  of 
lithic  acid  in  the  system,  and  they  are  probably 
all  more  or  less  true  in  different  cases,  in  some 
instances  the  accumulation  being  explicable  in 
more  ways  than  one.  Undoubtedly  uric  acid  is 
often  formed  in  excess,  so  that  it  cannot  be 
adequately  got  rid  of  by  elimination  or  in  any 
other  way.  This  excessive  formation  occurs  in 
many  cases  without  giving  rise  to  the  pheno- 
mena of  gout,  because  so  long  as  the  kidneys 
are  in  good  condition,  and  the  nutritive  processes 
are  satisfactorily  carried  on,  the  acid  is  elim:- 
nated  or  destroyed.  Again,  it  is  supposed  that 


GOUT. 


lithic  acid  may  undergo  imperfect  oxidation 
and  destruction  in  the  body.  Both  these  dis- 
orders have  been  attributed  by  some  writers 
to  a supposed  influence  of  the  nervous  sys- 
tem. Others  attach  considerable  importance 
to  hepatic  derangements  in  the  causation  of 
gout;  and  here- it  may  be  remarked  that  a 
distinct  connection  has  been  traced  in  some  in- 
stances between  this  complaint  and  diabetes. 
Furthermore,  the  presence  of  an  undue  quantity 
of  other  acids  in  the  blood  may  in  some  instances 
account  for  lithoemia.  If,  from  various  causes, 
such  as  deficient  action  of  the  skin,  excessive 
consumption  of  acids  or  acid-producing  food,  or 
the  formation  of  acids  in  undue  quantity  during 
the  process  of  digestion,  these  acids  are  present 
in  excess  in  the  blood,  from  their  greater  affinity 
they  combine  with  the  alkalies  in  this  fluid,  and 
diminish  the  alkalinity  of  the  blood-serum,  so 
that  it  is  less  able  to  hold  uric  acid  or  urate  of 
soda  in  solution.  Deficient  elimination  is  an 
important  cause  of  lithiasis,  and  is  often  asso- 
ciated with  other  causes.  It  has  been  proved 
experimentally  that  in  birds,  if  the  ureters  are 
tied,  uric  acid  is  deposited  all  through  the 
tissues,  but  especially  in  the  kidneys.  It  has 
been  suggested  that  in  some  cases  of  the  gouty 
diathesis  the  kidneys  are  congenitally  small, 
and  therefore  cannot  properly  excrete  even  a 
normal  quantity  of  uric  acid,  but  especially  any 
excess  of  this  substance.  Functional  disturb- 
ances of  the  kidneys  are  also  liable  temporarily 
to  interfere  with  their  eliminating  power,  being 
often  associated  with,  and  probably  due  to,  ex- 
cessive formation  of  urates;  while  in  course  of 
time  these  organs  become  the  seat  of  serious 
organic  mischief  in  gouty  eases,  which  gravely 
limits  their  excretory  power,  and  in  extreme 
cases  arrests  it  entirely. 

2.  We  are  now  in  a position  to  discuss  the 
circumstances  under  which  the  gouty  diathesis 
is  developed,  and  the  more  obvious  causes  with 
which  this  condition  is  associated.  There  are 
certain  causes  which  may  be  regarded  as  more  or 
less  predisposing , and  these  will  bo  subsequently 
considered  ; but  setiologieally  cases  of  gout  may 
be  conveniently  arranged  into  three  main  groups, 
according  as  the  disease  arises  from  : — a.  Heredi- 
tary transmission,  b.  Certain  errors  in  regard 
to  food  and  drink  ; often  associated  with  deficient 
exercise,  c.  Impregnation  of  the  system  with 
lead.  In  not  .a  few  instances,  however,  it  must 
be  remembered  that  these  causes  are  more  or  less 
combined. 

a.  Hereditary  transmission.  Gout  is  one  of 
the  most  striking  examples  of  a hereditary  dis- 
ease, and  once  established,  it  may  be  trans- 
mitted for  several  generations,  even  when  every 
endeavour  is  made  to  eradicate  it ; but  as  the  con- 
trary is  generally  the  case,  the  malady  being  as  a 
rule  more  or  less  intensified  by  pernicious  habits, 
it  becomes  in  most  cases  a permanent  legacy, 
handed  down  from  one  generation  to  another. 
Garrod  found  that  in  more  than  half  his  cases 
hereditary  taint  could  be  traced  distinctly ; and 
the  proportion  is  much  greater  in  the  upper 
classes.  It  sometimes  happens  that  when  gout 
becomes  developed  de  novo  in  an  individual, 
children  born  previously  are  free  from  the  com- 
plaint, while  those  born  subsequently  are  liable 
35 


64,‘> 

to  bo  affected.  Hereditary  influence  may  be  so 
powerful  that  gout  arises  without  any  other 
cause  whatever;  but  most  commonly  this  is 
aided  by  indulgence  in  certain  habits  to  be  pre- 
sently mentioned,  perhaps  not  to  an  extent  which 
would  be  considered  excessive  for  people  in 
general,  but  which  is  excessive  for  persons  pro- 
disposed  to  gout.  This  complaint  sometimes  ex- 
emplifies the  so-called  ‘law  of  atavism,’  but  this 
is  usually  due  to  the  fact  that  in  the  generation 
free  from  gout  every  precaution  is  taken  to  avoid 
causes  which  tend  to  originate  a gouty  paroxysm, 
these  precautions  being  subsequently  neglected 
The  hereditary  nature  of  gout  is  shown  not  un- 
frequently  in  the  age  at  which  the  disease  reveal- 
itself.  Should  the  predisposition  be  powerfu 
the  complaint  may  appear  even  in  children  ; and 
the  younger  the  subject  who  is  attacked  with  gout, 
the  more  likely  is  there  to  be  an  hereditary  tain;. 
The  explanation  of  the  transmission  of  gout  in 
this  manner  is  a mere  matter  of  theory,  and  tlir 
excess  of  uric  acid  in  the  system  has  been  ac- 
counted for  in  all  the  ways  already  mentioned. 

b.  Errors  relating  to  fond , drink,  and  exercise. 
In  a considerable  number  of  cases  gout  is  origi- 
nated de  novo,  in  consequence  of  certain  errors 
affecting  the  diet  and  habits  ; or  an  inherited  ten- 
dency to  the  disease  is  considerably  aggravated 
and  promoted  in  this  way.  In  general  terms 
these  errors  may  be  summed  up  as  excessivn 
eating,  especially  of  particular  articles  of  food  ; 
undue  indulgence  in  alcoholic  drinks  ; and  in 
dolent  habits,  with  deficient  exercise.  They 
are  frequently  associated  in  the  production  of 
gout,  and  not  a few  persons  who  eat  and  drink 
to  excess,  are  saved  from  becoming  gouty  because 
they  are  of  active  habits,  xvork  hard,  and  take 
a considerable  amount  of  exercise. 

Although  all  kinds  of  food  may  assist  mon- 
or  less  in  developing  the  gouty  diathesis,  those 
elements  which  aro  rich  in  nitrogen  are  most 
injurious,  and  especially  meat.  Beef  is  believed 
by  many  to  be  particularly  baneful.  The  writer 
has  heard  vegetarians  affirm  that  meat  is  the 
great  cause  of  gout,  and  that  it  never  occurs  when 
a vegetable  diet  is  adhered  to,  but  for  such  a 
statement  there  is  no  adequate  proof.  At  the 
same  time  it  must  be  acknowledged  that  this- 
complaint  is  often  in  no  small  degree  attributable 
to  the  amount  of  meat  which  is  consumed.  Many 
articles  of  diet,  either  from  their  own  nature,  or 
from  tho  manner  in  which  they  are  cooked,  may 
help  in  the  production  of  gout,  by  giving  rise 
to  digestive  disorders. 

The  relation  of  intemperance  in  the  use  of  al- 
coholic drinks  to  tho  gouty  diathesis  is  highly 
important,  and  is  abundantly  proved  by  every 
day  experience.  The  more  potent  wines  have 
the  greatest  influence  in  causing  gout,  and  port- 
wine  has  proverbially  been  regarded  as  the  most 
injurious  of  all.  Burgundy,  madeira,  sherry, 
and  marsala  aro  also  undoubtedly  capable  of 
developing  gout,  or  of  keeping  up  the  disease. 
The  lighter  wines  are  much  less  injurious,  but 
champagne,  and  especially  sweet  champagne, 
certainly  often  promotes  the  gouty  condition. 
Hock,  sauterne,  moselle,  and  light  claret  seem 
to  be  least  injurious,  but  even  these,  if  in- 
dulged in  to  excess,  may  in  course  of  time 
set  up,  or,  at  any  rate,  intensify  the  gouty  dia- 


GOUT. 


546 

thesis.  Malt-liquors  stand  next  to  -wines  as 
originators  of  gout,  and  undoubtedly  those  -who 
partake  very  freely  of  this  class  of  alcoholic 
beverages  are  not  uncommonly  affected.  In 
this  way  the  di-ease  may  be  usually  accounted 
for  when  it  occurs  among  the  labouring  and 
poorer  classes,  but  it  muBt  be  remembered  that 
in  these  persons  an  inherited  tendency  to  the 
complaint  may  exist.  Brewer’s  draymen  espe- 
cially drink  large  quantities  of  ale  or  porter, 
and  the  writer  has  met  with  instances  in  which 
the  habitual  daily  consumption  has  been  ac- 
knowledged as  averaging  from  two  to  four 
gallons.  Spirits  are  comparatively  feeble  in 
their  power  of  producing  gout,  as  is  proved 
by  the  rarity  of  the  disease  in  those  countries 
where  this  class  of  drinks  are  chiefly  used,  such 
as  Scotland.  Rum  is  said  to  form  an  exception 
to  this  statement.  Cider  and  perry  may  unques- 
tionably set  up  gout,  if  taken  to  excess,  but  they 
are  much  more  powerful  when  sweet  and  not 
properly  fermented.  Excessive  indulgence  in  a 
mixture  of  alcoholic  drinks  is  probably  more  de- 
leterious than  if  one  is  adhered  to.  The  expla- 
nation of  the  differences  in  the  tendency  to 
develop  gout  exhibited  by  the  various  kinds  of 
beverages  is  not  very  clear.  They  do  not  depend 
directly  upon  the  amount  of  alcohol  which  they 
severally  contain,  but  the  admixture  of  certain 
other  ingredients  with  the  alcohol  renders  it  far 
more  potent  in  producing  this  effect,  and  the 
more  alcohol  then  present,  the  greater  is  the  like- 
lihood of  gout  being  originated.  It  is  not,  how- 
ever, definitely  known  what  these  ingredients 
really  are.  At  the  same  time  it  may  be  affirmed, 
as  regards  wines,  that  their  quality  has  much 
to  do  with  their  tendency  to  induce  gout.  1'ae- 
titious  wines  and  others  of  inferior  quality,  as 
well  as  those  which  are  very  sweet,  or  which 
contain  much  tannin,  aro  most  liable  to  produce 
this  complaint.  Drinks  which  cause  a marked 
diuretic  action  are  less  capable  of  inducing  the 
gouty  state  than  those  which  have  but  little  of 
such  an  action. 

The  modes  in  which  the  errors  as  regards 
food  and  drink  induce  lithiasis  are  probably 
various.  They  often  directly  lead  to  the  for- 
mation of  excess  of  nitrogenous  products,  and 
especially  of  uric  acid,  more  than  can  be  elimi- 
nated or  destroyed  in  the  system.  Again,  over- 
eating and  drinking  frequently  cause  undue  pro- 
duction of  other  acids  during  digestion,  which 
take  the  place  of  uric  acid,  and  prevent  its 
elimination.  Moreover,  these  habits  disorder  the 
digestive  functions,  cause  congestion  of  the  cliylo- 
poietic  viscera,  interfere  with  the  hepatic  func- 
tions, and  ultimately  setup  a permanent  dyspeptic 
condition,  all  of  which  assist  in  the  develop- 
ment of  the  gouty  diathesis.  It  has  been  sup- 
posed that  indigestion  from  any  cause  might 
originate  this  condition,  but  according  to  tbe 
writer’s  experience  this  is  certainly  not  the  case. 
Persons  who  are  hereditarily  gouty  often  suffer 
from  dyspepsia,  hut  the  disease  may  appear  in 
such  individuals  when  digestion  has  always  been 
carried  on  without  the  slightest  discomfort. 
Those  who  indulge  in  the  habits  which  originate 
gout  de  novo  are  generally  dyspeptic,  as  the 
-esult  of  these  very  habits.  So  Disc. 

With  respect  to  deficient  exercise,  this  un- 


doubtedly promotes  the  development  of  gout  in 
many  cases.  Persons  who  follow  sedentary  occu- 
pations, or  who  live  indolent  and  lazy  lives,  are 
certainly  more  liable  to  the  disease  , and  not  a 
few  become  gouty  because  they  are  able  to  ‘ keep 
a carriage,’  and  thus  are  deprived  of  the  exer- 
cise which  they  were  previously  accustomed  to 
take.  This  cause  probably  acts  by  limiting  the 
conversion  of  uric  acid  int  i other  waste  products, 
which  can  be  more  easily  got  rid  of;  and  also  ly 
increasing  dyspepsia,  in  consequence  of  the  organs 
which  are  concerned  in  the  process  of  digestion 
doing  their  work  slowly  and  imperfectly. 

c.  Another  group  of  cases  of  gout  which  origi- 
nate de  novo,  are  those  which  occur  in  connection 
with  lead-impregnation  of  the  system.  Dr.  Garrod 
found  among  his  hospital  patients,  that  about  30 
per  cent,  of  those  suffering  from  gout  had  been 
subjected  to  the  influence  of  lead  in  their  various 
occupations  ; and  in  the  writer's  experience,  no; 
only  has  the  relation  between  lead-poisoning  and 
gout  been  frequently  exemplified,  but  some  of  the 
worst  cases  of  this  disease  in  its  chronic  forms 
occurred  in  persons  who  were  distinctly  under 
the  influence  of  lead.  This  metal  does  not 
appear,  however,  to  originate  the  gouty  diathesis, 
unless  aided  by  more  or  less  indulgence  in 
alcoholic  drinks,  though  the  amount  of  the 
latter  consumed  is  usually  far  less  than  would 
alone  account  for  the  condition.  It  bus  also  beeu 
found  that  gouty  persons  are  remarkably  sus- 
ceptible to  the  influence  of  lead  ; and  that  wh"ti 
this  metal  is  given  to  such  persons  for  medicinal 
purposes,  it  is  very  liable  to  bring  on  a severe 
attack  of  acute  gout.  Garrod's  observations 
seem  to  show  that  lead  acts  by  diminishing 
the  excretion  of  uric  acid  by  the  kidneys  ; and 
this  authority  states  that  the  blood  of  individual* 
suffering  from  lead-pAralysis  always  contains  an 
abnormal  amount  of  uric  acid,  and  that  the  same 
probably  holds  good  in  all  cases  of  lead-colic. 

3.  Predisposing  causes. — It  is  next  requi- 
site to  notice  briefly  the  predisposing  causes 
of  gout.  Beginning  with  age,  distinct  gouty 
attacks  in  a large  majority-  of  cases  make  their 
first  appearance  in  persons  between  thirty  and 
thirty-five  or  forty  years  old.  Those  which 
occur  under  thirty  are,  with  rare  exceptions, 
more  or  less  hereditary.  'Well-marked  gout  is 
exceedingly  rare  under  twenty-,  but  it  may  occur 
even  in  children, being  then,  however,  invariably 
strongly  hereditary.  The  complaint  usual’y 
appears  before  fifty,  and  becomes  progressively 
less  frequent  in  its  manifestation  for  the  first  time 
after  this  period  of  life.  It  is  quite  exceptional 
for  gout  to  commence  after  sixty-five,  but  it 
may-  begin  even  in  extremo  old  age.  The  cases  in 
which  the  disease  is  developed  during  or  after 
middle  life  mainly-  originate  de  novo,  and  one  of 
the  reasons  assigned  for  the  less  frequent  appear- 
ance of  tho  complaint  as  ago  advances  is,  that 
then  people  usually  become  more  careful  in 
their  mode  of  living,  and  more  temperate  in 
their  habits.  With  regard  to  sc- r.  males  are  far 
more  commonly  the  subjects  of  well-marked  gout 
than  females.  This  is  mainly  accounted  for  by 
the  difference  in  tho  habits  of  the  two  sexes. 
It  has  also  been  partly  attributed  to  the  • ccur- 
renee  of  menstruation  in  females,  which  .acts 
to  some  extent  as  a safeguard,  and  in  these 


GOUT. 


subjects  gout  generally  appears  after  the  cessa- 
tion of  this  function.  When  strongly  heredi- 
tary, gout  may  appear  even  in  young  females, 
of  which  the  writer  has  seen  some  well-marked 
examples. 

Bodily  conformation  and  temperament  have 
been  credited  with  a predisposing  influence,  per- 
sons of  a sanguine  temperament,  and  of  corpulent, 
fuil-blooded,  plethoric  habit  of  body,  being  sup- 
posed to  be  most  subject  to  this  disease,  and  to 
have  it  in  its  most  acute  form.  These  conditions 
are  often  produced  by  the  very  habit  s which  origi- 
nate gout,  and  certainly  persons  who  are  gouty 
by  inheritance  often  do  not  present  any  of  these 
characteristics,  while  those  presenting  marked 
contrasts  in  appearance  and  temperament  seem  to 
be  equally  the  subjects  of  the  complaint.  It  is 
not  uncommon  in  individuals  of  a nervous  tem- 
perament, thin  and  wiry  in  frame,  aud  they  are 
said  to  be  more  subject  to  the  irregular  and 
asthenic  forms  of  the  disease.  Social  'position 
and  occupation  materially  influence  the  occur- 
rence of  gout.  Formerly  the  complaint  was  met 
with  almost  entirely  among  the  higher  classes, 
and  it  was  looked  upon  as  an  aristocratic  disease. 
Now,  however,  it  is  common  enough  among  the 
middle  classes,  chiefly  those  who  are  in  affluent 
circumstances ; while  there  are  several  occupa- 
tions in  connection  with  which  the  disease  is  very 
prevalent,  such  as  butlers,  coachmen,  butchers, 
publicans  and  barmen,  coal-heavers, porters,  hair- 
cutters,  and  painters,  or  others  who  have  to  do 
with  lead.  It  was  at  one  time  believed  that 
high  mental  endowments  predisposed  to  gout ; 
this  was  obviously  a mistake,  although  ex- 
cessive mental  labour,  prolonged  worry,  and 
other  causes  which  exhaust  and  depress  the 
nervous  system,  do  seem  to  predispose  to  the 
disease.  As  regards  climate,  those  climates 
which  are  cold  or  temperate,  and  especially  at 
the  same  time  damp  and  changeable,  present  by 
far  the  greatest  number  of  cases  of  gout,  and  in 
most  tropical  countries  this  complaint  is  un- 
known. This  depends  partly  upon  the  differences 
in  the  nature  and  amount  of  the  alcoholic  drinks 
employed ; partly  upon  the  effect  of  climate  as 
regards  the  functions  of  the  skin. 

4.  Thus  far  we  have  been  concerned  with  the 
pathology  and  {etiology  of  th e gouty  diathesis. 
Now  we  have  to  discuss  briefly  these  points  in 
relation  to  the  local  manifestations  of  the  disease, 
and  especially  to  the  occurrence  of  acute  attacks. 
Athough  the  presence  of  excess  of  uric  acid  in  the 
system  is  an  essential  element  in  the  pathology 
of  gout,  such  excess  is  often  present,  and  yet 
none  of  its  more  characteristic  phenomena  are 
observed.  An  individual  in  this  condition  is, 
however,  at  any  time  liable  to  an  attack  of  dis- 
tinct gout,  from  the  action  of  certain  causes 
which  would  have  no  such  effect  upon  other  per- 
i sons.  If  from  any  cause  the  amount  of  lithic  acid 
m the  blood  is  suddenly  or  rapidly  increased,  an 
acute  attack  of  articular  gout  may  be  expected, 
or  some  internal  manifestation  of  the  disease. 
This  is  believed  to  be  directly  due  to  the  action 
of  the  urate  upon  the  tissues  of  the  joint,  which 
is  supported  by  the  fact  that  even  after  the  first 
attack  a distinct  deposit  of  lithates  is  found 
m them,  which  increases  with  each  subsequent 
attack.  Two  views  are  held  as  to  the  explana- 


541 

tion  of  its  mode  of  action.  According  to  one 
view  the  urate  merely  acts  as  a local  irritant,  it 
being  supposed  that  different  morbific  agents  in 
the  system  affect  different  tissues,  and  that  this 
one  acts  specially  upon  the  structures  which  are 
found  in  joints,  setting  up  an  inflammatory  pro- 
cess. The  degree  of  inflammation  is,  however,  by 
no  means  in  proportion  to  the  amount  of  lithatea 
which  are  deposited ; indeed,  the  contrary  is 
usually  the  case,  for  as  a case  of  gout  becomes 
more  and  more  chronic,  the  deposit  often  becomes 
very  abundant,  though  the  paroxysms  pro- 
gressively diminish  in  intensity;  while  it  is  often 
found  in  other  structures  besides  those  connected 
with  articulations,  without  causing  any  evident 
inflammation.  The  second  view  is  that  the  acute 
paroxysm  is  the  result  of  an  attempt  on  the 
part  of  the  articular  structures  to  eliminate  the 
morbid  material,  a chemical  process  of  oxida- 
tion being  set  up  in  the  parts  where  urates  are 
most  able  or  liable  to  accumulate,  by  which  they 
are  converted  into  urea,  carbonates,  &c.,  and  so 
got  rid  of.  This  process  gives  rise  to  congestion, 
followed  by  inflammation  and  its  attendant  phe- 
nomena. It  has  been  proved  that  the  inflam- 
matory process  does  destroy  the  urate  in  the 
blood  of  the  affected  parts,  and  probably  the  salt 
which  has  actually  been  thrown  out  is  also  partly 
destroyed.  No  uric  acid  can  be  detected  in  the 
fluid  of  a blister  placed  directly  over  an  articula- 
tion which  is  the  seat  of  acute  gout.  According 
to  this  theory  the  gouty  paroxysm  is  to  some  de- 
gree salutary,  as  it  helps  to  get  rid  of  the  excess 
of  uric  acid  in  the  system. 

It  is  a well-known  fact  that  gout  tends  spe- 
cially to  attack  the  smaller  joints,  and  above  all 
the  metatarso-phalangeal  joint  of  the  great  toe, 
which  is  the  one  usually  first  affected.  This  is 
explained  in  the  following  way ; in  gout  it  is 
believed  that  those  tissues  are  chiefly  attacked 
which  are  either  non-vascular,  or  which  are  sup- 
plied with  but  few  vessels,  and  through  which 
the  fluids  pass  with  difficulty,  especially  cartila- 
ginous, fibrous,  and  ligamentous  tissues.  Such 
tissues  are  found  in  large  proportion  in  the 
smaller  joints.  These  are  also  distant  from  the 
centre  of  circulation,  and  the  blood  passes 
through  them  in  a comparatively  feeble  and 
languid  stream.  They  are,  moreover,  much  ex- 
posed to  the  influence  of  cold  and  wet.  And 
lastly,  with  reference  to  the  metatarso-phalan- 
geal  joint  of  the  great  toe  more  particularly, 
this  joint  is  peculiarly  liable  to  injury  from 
pressure,  supporting  the  weight  of  the  body, 
sudden  shocks,  &e.  Another  point  observed  in 
the  history  of  gout  is,  that  during  an  acute 
paroxysm  several  joints  are  often  attacked  in 
succession,  while  the  inflammation  subsides  in 
those  first  affected,  often  with  striking  sudden- 
ness. This  is  accounted  for  by  the  deposit  of 
urates  in  different  joints  successively,  and  when 
inflammation  is  thus  excited  in  them,  it  tends 
to  subside  iu  those  previously  affected.  Not  un- 
commonly corresponding  joints  on  opposite  sides 
of  the  body  are  implicated  alternately,  probably 
through  their  nervous  connection  in  the  spinal 
cord.  As  gout  advances  in  its  progress,  the 
articulations  become  more  and  more  involved 
with  each  attack,  because  those  first  involved 
become,  as  it  were,  saturated  with  urates,  and 


GOUT. 


548 

therefore  new  tissues  of  the  same  class  are  in- 
vaded. 

An  acute  paroxysm  of  gout  may  come  on 
without  any  evident  exciting  cause  whatever, 
especially  if  the  disease  is  strongly  hereditary, 
or  has  been  long  established.  Under  these  cir- 
cumstances outbreaks  of  the  complaint  seem  to 
become  habitual  at  certain  seasons,  or  they  arise 
from,  very  slight  causes,  which  need  to  be  less  and 
loss  obvious  as  the  case  progresses.  Often,  how- 
ever, some  distinct  exciting  cause  can  be  made 
out,  affecting  the  digestive  organs,  the  vascular 
or  nervous  systems,  the  functions  of  the  skin  or 
kidneys,  or  disturbing  the  system  in  other  ways. 
The  most  important  are  eating  or  drinking  too 
much,  either  on  some  particular  occasion,  or 
habitually  for  a longer  or  shorter  period,  until 
at  last  a fit  of  gout  terminates  the  indulgence, 
it  being  borne  in  mind  that  even  apparent 
moderation  may  be  excessive  for  a gouty  person ; 
indigestible  articles  of  food ; neglect  of  the  act 
of  defaecation,  or  constipation ; undue  physical 
work  or  exertion ; exposure  to  cold  or  wet, 
or  suppression  of  perspiration ; excessive  men- 
tal work  or  worry;  emotional  causes,  sudden, 
powerful,  or  depressing,  such  as  sudden  joy, 
a fit  of  rage,  or  deep  grief ; haemorrhage,  acute 
illness,  or  other  debilitating  causes ; or  in- 
jury. The  implication  of  a particular  joint 
may  be  also  due  to  injury,  which  may  be 
very  slight,  such  as  the  pressure  of  a boot,  or 
the  toe  being  trodden  upon.  Injury  to  the  knee 
has  caused  that  articulation  to  be  first  affected. 
As  predisposing  causes  of  acute  gouty  attacks, 
climate  and  season  are  highly  important.  Their 
characteristics  have  already  beeu  indicated,  and 
undoubtedly  gouty  paroxysms  may  often  be 
averted  by  residence  in  a warm  climate,  either 
permanently  or  during  the  colder  seasons  of  the 
year.  Early  attacks  seem  to  be  most  frequent 
ia  the  spring ; then  they  occur  also  in  the 
autumn ; and  subsequently  they  become  more 
frequent  and  irrogular  in  their  onset.  One 
seizure  predisposes  to  another,  and  it  is  a special 
feature  of  gout  that  it  tends  to  recur,  this  ten- 
dency increasing  with  each  succeeding  paroxysm, 
until  finally,  in  many  cases,  the  patient  cannot  be 
said  to  be  ever  free  from  the  complaint.  The 
occupation  of  an  individual  may  predispose  to 
the  occurrence  of  gout  in  particular  joints ; thus 
butlers  have  it  in  the  feet,  coachmen  and  washer- 
women iu  the  hands. 

It  is  found  in  process  of  time  that  gouty  con- 
cretions form  in  other  parts  besides  in  the  joints. 
This  is  easily  explained  by  the  fact  that  urates 
tend  to  deposit  in  certain  other  structures  which 
are  but  slightly  vascular,  besides  those  forming 
part  of  the  articulations.  Vascular  tissues  seem 
to  destroy  urates  iu  their  passage  through  them, 
and  thus  they  are  prevented  from  doing  any 
harm  to  these  tissues.  The  presence  of  urates 
in  the  blood  will  account,  not  only  for  the  chronic 
gouty  state,  but  also  for  acute  attacks  affecting 
internal  organs,  or  so-called  irregular  gout.  It 
lias  been  maintained  that  the  development  of  gout 
m other  structures  besides  the  joints  is  influenced 
by  the  diathesis  and  habits  of  the  individual, 
but,  it  is  doubtful  how  far  this  is  borne  out  by 
actual  experience. 

Anatomical  Chabactebs. — In  its  most  typical 


manifestations  gout  is  characterised  anatomi- 
cally by  the  occurrence  of  a peculiar  form  of 
inflammation  affecting  certain  joints,  this  being 
invariably  attended  with  the  deposit  of  urate 
in  connection  with  their  structures.  Taking  an 
individual  articulation,  this  is  at  first  the  seat  of 
an  acute  inflammatory  process,  indicated  by  the 
usual  signs  of  increased  vascularity  and  redness, 
tumefaction,  and  serous  effusion  into  the  interior 
of  the  joint,  as  well  as  into  the  surrounding 
tissues.  The  results  of  post-mortem  examina- 
tion show  that  even  iu  the  very  earliest  period 
a deposit  of  urate  takes  place ; and  as  the  attacks 
become  repeated  again  and  again,  the  signs  of  in- 
flammation become  less  and  less  prominent,  while 
the  deposit  increases,  until  at  last  it  may  form 
considerable  masses,  and  infiltrate  extensively  all 
the  structures  entering  into  the  formation  of  the 
articulation.  The  joint  then  becomes  perma- 
nently enlarged  and  distorted,  while  the  liga- 
ments are  thickened  and  more  or  less  stiff  or 
quite  rigid,  and  ultimately  complete  anchylosis 
may  be  produced.  The  deposit  seems  to  com- 
mence in  the  substance  of  the  cartilage  covering 
the  ends  of  the  bon  es,  starting  near  its  superficial 
or  free  surface,  and  gradually  extending  more 
deeply,  though  for  a time  a thin  layer  of  carti- 
lage lies  between  it  and  the  cavity  of  the  joint. 
This  deposit  at  first  forms  a whitish  opacity,  but 
as  it  becomes  more  abundant  it  encrusts  the  car- 
tilages, and  also  the  inner  surface  of  the  liga- 
ments, and  the  surfaces  of  fibro-cartilages  where 
these  exist.  More  or  less  extensive  spots  or 
patches  become  in  time  distinctly  visible,  and 
even  the  entire  surfaces  of  the  bones  forming  a 
joint  may  be  covered  with  a chalky-looking  sub- 
stance. The  synovial  membrane  may  also  pre- 
sent white  points,  but  the  synovial  fringes  at 
their  margins  seem  to  escape,  on  account  of  their 
vascularity.  In  the  larger  articulations  the 
synovial  fluid  may  be  thickened,  and  may  even 
contain  separate  crystals  or  tufts  of  the  urate. 
Subsequently  the  ligaments  and  adjoining  struc- 
tures are  infiltrated,  and  it  is  to  this  cause  that 
the  stiffness  or  rigidity  of  gouty  joints  is  mainly 
due.  Distinct  masses  of  deposit  may,  however, 
form,  and  these  also  interfere  with  movement. 
They  are  known  as  tophi  or  chalk-stones.  In 
course  of  time  the  tissues  covering  a gouty  joint 
may  be  destroyed,  including  the  skin,  the  chalky- 
looking  substance  being  thus  exposed,  and  un 
healthy  suppuration  and  ulceration  set  up. 

The  opaque  white  substance  characteristic  of 
gouty  inflammation  is  found  on  microscopic  exa- 
mination to  consist  of  fine  crystals,  in  the  form 
of  needles  or  prisms.  They  are  chiefly  arranged 
in  minute  clusters,  radiating  from  a centre ; 
and  in  the  cartilages  they  form  a more  or  less 
compact  network.  Chemical  examination  shows 
that  they  are  composed  of  urate  of  soda. 

With  reference  to  the  joints  which  are  affected 
in  gout,  as  has  been  already  indicated,  the  meta- 
tarso-phalangeal  articulation  of  the  great  toe  is 
the  one  primarily  attacked  in  a large  majority  of 
cases.  In  rare  instances,  where  an  opportunity 
has  been  afforded  of  making  a post-mortem  ex- 
amination after  only  one  or  two  gouty  fits  hav6 
occurred,  this  joint,  on  one  or  both  sides,  has 
alone  presented  any  change,  even  after  many 
years  have  elapsed  since  the  occurrence  of  tue 


GOUT. 


attacks.  As  usually  seen,  however,  the  disease 
has  progressively  involved  many  joints.  In  the 
feet  it  may  implicate  all  the  articulations,  but  it 
is  a curious  fact  that  the  tarso-metatarsal  and 
the  phalangeal  joints  of  the  great  toe  generally 
escape,  or  are  but  little  affected.  Similarly  all 
the  joints  of  the  hands  and  fingers  are  often  in- 
volved. The  gouty  change  not  uncommonly 
extends  to  the  larger  joints,  more  especially 
those  of  the  legs,  but  the  shoulder  and  hip- 
joints  aro  but  little  liable  to  be  attacked.  In 
exceptional  cases  other  articulations  are  found 
involved,  such  as  the  temporo-maxillary,  those 
of  the  spinal  column,  of  the  pelvis,  or  even  of 
the  larynx. 

Coming  now  to  other  structures,  deposits  of 
urate  may  occur  in  various  parts  of  the  body,  in 
connection  with  bursae,  tendons  and  aponeuroses, 
sheaths  of  muscles,  the  sclerotic  coat  of  the  eye, 
the  cartilages  of  the  external  ear,  eyelids,  nose, 
or  larynx,  or  under  the  skin.  More  or  less 
effusion  may  be  present  iu  burs*  at  the  same 
lime.  In  a case  which  came  under  the  writer's 
notice,  and  in  which  there  was  not  the  slightest 
hereditary  taint,  in  addition  to  numerous  tophi 
in  the  auricles,  there  was  a mass  in  the  bursa 
over  the  right,  olecranon  as  large  as  an  egg,  a 
smaller  one  over  the  left  elbow,  several  distinct 
deposits  over  both  patellae,  and  others  in  con- 
nection with  the  tendons  of  the  hands,  especially 
.he  right. 

As  regards  bone,  the  periosteum  is  often 
affected,  and  some  writers  have  described  a de- 
posit of  urate  in  bone  itself ; but  Garrocl  has 
not  found  evidence  of  its  having  originated  in 
this  tissue.  He  considers  that  the  periosteal 
formations  sometimes  acquire  sufficient  size  to 
press  on  the  osseous  tissue,  and  to  cause  its  ab- 
sorption. 

The  condition  of  the  kidneys  induced  by  the 
gouty  diathesis  is  of  great  importance,  and  these 
organs  probably  begin  to  be  diseased  at  a very 
early  period  ill  the  history  of  a case  of  gout,  for 
they  may  be  found  distinctly  affected  when  there 
have  been  little  or  no  external  manifestations  of 
the  complaint.  In  the 'first  instance  a deposit  of 
urate  of  soda  takes  place,  probably  within  the 
renal  tubuli,  which  afterwards  involves  their 
walls,  and  penetrates  to  the  intertubular  tissue. 
This  is  seen  in  the  form  of  white  streaks  in  the 
course  of  the  tubuli,  and  of  white  points  at  the 
extremities  of  the  papillae.  The  deposit  goes 
on  increasing,  and  a chronic  inflammatory  pro- 
cess is  set  up,  ending  ultimately  in  the  production 
of  the  ‘ granular  contracted  kidney’  (see  Bright's 
Disease).  Other  morbid  states  in  connection 
with  the  urinary  organs  observed  in  some  cases 
of  gout  are  the  presence  of  calculi,  consisting  of 
uric  acid,  urates,  or  oxalates;  chronic  cystitis; 
or  urethritis. 

In  the  course  of  gout  morbid  changes  of  other 
kinds  often  arise,  affecting  different  structures 
and  organs,  and  either  occurring  as  acute  events, 
which  may  even  prove  fatal,  or  being  of  a chronic 
nature.  These  need  be  only  mentioned  here,  and 
they  mainly  include  congestion,  catarrh,  or  severe 
inflammation  of  some  part  of  the  alimentary  canal ; 
catarrh  of  the  air-passages,  chronic  bronchitis, 
and  emphysema  of  the  lungs  ; fatty  disease  of  the 
liver;  meningitis,  neuritis,  cerebral  haemorrhage ; 


543 

cardiac  changes,  including  chronic  valvulitis  and 
degeneration  of  the  valves,  and  hypertrophy, 
followed  by  degeneration,  of  the  cardiac  walls ; 
atheromatous  changes  in  the  vessels,  hypertrophy 
of  the  muscular  coat  of  the  small  arteries,  or 
arterio-capillary  fibrosis;  and  various  diseases  of 
the  skin,  such  as  erythema,  urticaria,  eczema, 
psoriasis,  &c.  How  Jar  some  of  these  conditions 
can  be  attributed  to  the  gouty  diathesis,  or  are 
merely  the  result  of  the  same  causes  which  have 
induced  this  diathesis,  may  be  fairly  disputed. 
It  is  worthy  of  remark  that  acute  inflammation 
in  connection  with  the  heart  is  not  met  with  in 
cases  of  gout,  and  this  has  been  attributed  to 
the  great  vascularity  of  the  endocardium  and 
other  cardiac  tissues,  for  which  consequently  the 
urate  has  no  affinity,  or  it  is  destroyed  in  its 
passage  through  them. 

The  condition  of  the  blood  in  gout  may  be 
here  noticed.  In  early  cases  the  chief  deviation 
from  the  healthy  state  presented  by  this  fluid 
is  that  during  the  acute  paroxysms  the  serum 
contains  a distinct  excess  of  uric  acid,  in  the 
form  of  urate  of  soda  ; and  this  can  be  obtained 
in  appreciable  quantity,  even  in  a crystalline 
form.  In  the  intervals  the  blood  is  quite  nor- 
mal. When  the  gouty  condition  becomes  chronic, 
the  excess  of  uric  acid  is  constant,  and  oxalic 
acid  can  also  be  frequently  detected.  In  course 
of  time  the  serum  becomes  lowered  in  its  specific 
gravity,  its  albumen  is  deficient,  and  its  re- 
action is  less  alkaline,  in  extreme  cases  be- 
coming almost  neutral,  owing  to  the  presence  of 
excess  of  acids.  When  the  kidneys  are  impli- 
cated, urea  also  tends  to  accumulate  in  the  blood, 
and  may  be  obtained  in  variable  quantity.  The 
red  corpuscles  often  diminish  in  number;  and 
the  blood  deteriorates  in  quality  as  a whole  in 
many  cases  of  chronic  gout. 

Symptoms. — The  clinical  history  of  gout  is  a 
very  varied  one,  and  the  symptoms  observed  in 
different  cases  which  are  regarded  as  of  a gouty 
nature  are  exceedingly  numerous  and  diverse. 
Whether  the  phenomena  attributed  to  this 
disease  are  always  fairly  explicable  by  the  pre- 
sence of  excess  of  uric  acid  in  the  system  is,  to 
say  the  least,  a matter  of  considerable  doubt.  It 
must  ever  be  borne  in  mind  that  the  habits  which 
generate  gout  often  give  rise  to  syTmptoms,  and 
even  to  definite  morbid  changes,  which  cannot 
justly  be  looked  upon  as  part  of  this  com- 
plaint. Again,  the  custom  which  some  practi- 
tioners adopt,  of  looking  upon  every  acute  illness 
particularly  inflammation  of  organs,  occurring  in 
gouty  subjects,  as  being  due  to  the  lithsmie 
condition,  and  of  a special  nature,  and  applying 
the  term  ‘ gouty  ’ to  every  such  complaint,  is 
certainly  going  too  far,  though  it  may  be 
acknowledged  that  gout  does  often  modify  their 
clinical  history.  It  is  not  easy  within  a limited 
space  to  give  even  a sketch  of  the  various 
clinical  phases  of  gout,  but. before  considering 
the  symptoms  in  detail,  it  may  be  well  to  in- 
dicate their  general  nature.  1.  In  its  typical 
form  gout  is  in  its  early  stages  attended  with 
acute  symptoms  referable  to  certain  joints,  and 
these  tend  to  recur  at  intervals,  constituting 
‘ fits  of  gout,’ the  intervening  periods  becoming 
shorter  and  shorter  as  the  case  progresses — Acuti 
Articular  or  Begular  Goat.  2.  These  attacks 


GOUT. 


550 

culminate  in  obvious  chronic  changes  in  the 
affected  joints,  with  corresponding  symptoms — - 
Chronic  Articular  Gout — but  even  then  acute 
paroxysms  are  liable  to  arise  from  time  to  time. 
3.  In  connection  with  the  acute  attacks,  and 
somet  mes  preceding  them,  general  or  constitu- 
tional symptoms  are  usually  observed ; and 
symptoms  belonging  to  this  class  become  per- 
manent in  most  cases  of  chronic  gout.  4.  When 
gout  affects  other  organs  and  structures  besides 
thejnints, corresponding  symptoms  are  developed, 
according  to  the  part  implicated.  In  general 
terms  these  may  be  grouped  as  cases  of  so-called 
Non-articular , Irregular,  Misplaced,  or  Anomalous 
Gout ; and  when  such  symptoms  are  acute  in 
their  character,  affecting  some  internal  organ, 
and  coming  on  during  the  course  of  an  attack 
of  acute  articular  gout,  the  joint-symptoms  at 
the  same  time  subsiding,  this  constitutes  what 
is  termed  Retrocedent  gout.  It  is  supposed  to  be 
due  to  exposure  to  cold  or  other  causes  checking 
the  articular  inflammation,  the  elimination  of  uric 
acid  being  thus  interrupted,  so  that  it  accumu- 
lates in  the  system.  The  symptoms  thus  grouped 
together  may,  however,  be  conveniently  sub- 
divided as  follows : — (a)  Those  indicating  more 
or  less  functional  disorder  of  certain  organs, 
varying  much  in  intensity,  and  either  being  con- 
stantly present,  or  only  coming  on  at  intervals. 
( b ) Those  due  to  acute  inflammatory  affections 
of  organs,  (c)  Those  resulting  from  the  chronic 
changes  in  tissues  and  organs  induced  by  gout, 
and  from  the  deposit  of  urates  in  different  parts. 
Having  given  this  outline,  we  may  now  discuss 
the  symptoms  of  gout  in  some  detail,  but  it  will 
be  convenient  in  doing  so  to  adopt  a somewhat 
different  arrangement  from  that  just  sketched. 

1.  Premonitory  Symptoms. — There  are  cer- 
tain symptoms,  of  a somewhat  indefinite  char- 
acter, and  not  of  any  marked  intensity,  which 
are  often  met  with  in  gouty  subjects,  or  even  in 
persons  who  have  never  actually  suffered  from 
declared  gout,  but  which  distinctly  depend  upon 
the  lithaemic  condition.  These  may  be  regarded  as 
premonitory  symptoms,  for  they  frequently  give 
warning  that  the  gouty  condition  is  in  process  of 
development,  and  if  duly  recognized,  enable  the 
patient  so  to  regulate  his  mode  of  living  as  to 
ward  off  the  disease.  Indeed,  it  will  bo  found 
on  careful  inqttiry  that  gouty  phenomena,  which 
may  be  very  marked,  are  commonly  noticed  from 
time  to  time  before  the  first  actual  fit  of  gout 
occurs,  and  there  may  even  be  suspicious  twinges 
or  uncomfortable  sensations  about  the  toes  or 
fingers  now  and  then.  In  a large  number  of 
cases,  however,  no  definite  premonitory  symptoms 
immediately  precede  the  first  gouty  paroxysm  ; 
but  iu  connection  with  subsequent  paroxysms, 
prodromata  are  usually  marked,  so  that  confirmed 
gouty  patients  can  predict  when  an  attack  is 
imminent.  As  to  the  nature  of  these  symptoms, 
they  vary  in  different  persons,  and  this  is  sup- 
posed to  depend  upon  individual  predisposition. 
The  most  obvious  are  digestive  and  hepatic 
disorders,  attended  with  marked  flatulence  and 
eructations,  heartburn,  acidity,  and  constipation 
or  diarrhoea,  with  unhealthy  stools,  the  tongue 
being  often  large,  flabby,  and  much  furred ; 
palpitation  or  uncomfortable  sensations  about 
the  heart ; catarrh  of  the  throat  and  respiratory 


passages,  violent  fits  of  sneezing,  or  asthmatic 
attacks  ; derangements  of  the  nervous  system, 
indicated  by  a liability  to  headaches,  giddi- 
ness. noises  in  the  ears,  disorders  of  vision, 
marked  irritability  of  temper  and  fretfulness  or 
lowness  of  spirits,  languor,  impairment  of  mental 
vigour  and  intellectual  hebetude,  heaviness  or 
drowsiness,  sleep,  however,  being  restless,  dis- 
turbed, attended  with  unpleasant  dreams,  and 
often  with  grinding  of  the  teeth,  numbness  or 
tingling  in  the  limbs,  especially  in  the  fingers  or 
toes,  neuralgia  in  various  parts,  twitchings, 
startings  in  the  limbs,  or  muscular  cramps, 
especially  in  the  calves  of  the  legs  ; prefuse 
perspirations  ; certain  skin-affections  ; and 
changes  in  the  urine.  This  excretion  usually 
tends  to  become  high-coloured,  deficient,  and  to 
deposit  lithates  abundantly,  or  even  lithicacid 
crystals,  though  at  the  same  time  the  quantity 
of  this  acid  eliminated  within  the  twenty  four 
hours  is  below  the  normal.  In  advanced  cases 
of  gout,  however,  the  urine  presents  very  differ- 
ent characters  from  those  just  stated,  as  will  be 
hereafter  pointed  out,  and  when  habitually  de- 
positing urates,  it  may  become  pale,  watery,  and 
clear  immediately  before  an  acute  attack  super- 
venes. Some  patients  are  warned  of  the  approach 
of  a gouty  fit  by  feeling  unusually  well,  both 
physically  and  mentally. 

2.  Acute  Articular  Gout. — It  is  only  with 
the  occurrence  of  the  first  acute  attack  of  gout 
that  the  disease  is  usually  regarded  as  estab- 
lished. The  paroxysm  as  a rule  comes  on  during 
the  night,  while  the  patient  is  asleep  in  bed,  and 
it  is  said  to  commence  usually  between  2 and 
Oi.M.  The  patient  is  disturbed  out  of  his  sleep  by 
uneasiness  or  pain,  generally  referred  to  the  ball  of 
the  great  toe  on  one  side,  and  the  corresponding 
joint  is  found  to  be  inflamed,  the  inflammation 
increasing  in  intensity,  until  it  usually  becomes 
extremely  severe.  In  some  instances  the  cor- 
responding joints  on  both  sides  are  attacked 
simultaneously,  in  rapid  succession,  or  alter- 
nately. Although,  however,  in  the  majority  of 
cases  gout  first  attacks  the  metatarso-phalangeal 
articulation  of  the  great  toe,  it  must  not  be  for- 
gotten that  it  may  start  in  any  of  the  smaller 
joints  of  the  foot  or  hand,  or  even  in  the 
middle-sized  joints,  especially  the  knee  or  ankle. 
Indeed,  exceptional  cases  have  come  under  the 
writer's  notice,  which  there  was  every  reason  to 
believe  were  of  a gouty  nature,  and  in  which  the 
disease  implicated  several  joints  at  a very  early- 
period  of  its  course,  the  feet,  however,  being 
free.  In  such  instances  it  may  be  that  there  is 
a true  combination  of  rheumatism  and  gout. 

Proceeding  now  to  notice  the  clinical  charac- 
ters of  the  joint-affection,  severity’  of  the  pain  is 
certainly  a striking  feature  in  the  majority  of 
cases  of  acute  gout,  especially  in  early  attacks. 
When  the  foot  is  affected,  any  attempt  to  stand 
causes  much  pain  from  the  first,  and  the  suffer- 
ing speedily  increases,  until  it  becomes  very  in- 
tense, in  some  instances  almost  unbearable.  In 
character  it  varies,  and  is  described  in  different 
cases  as  burning,  throbbing,  aching,  tearing, 
plunging,  boring,  piercing,  &c.  The  pain  pre- 
vents sleep  during  the  night,  but  towards  morn- 
ing it  tends  to  diminish,  and  during  the  day 
there  is  usually’  comparative  ease,  an  exacerba- 


GOUT. 


tion  again  taking  place  as  evening  approaches, 
which  goes  on  increasing  towards  night.  Ten- 
derness is  very  marked,  and  is  often  so  exquisite 
that  the  patient  dreads  to  be  touched,  and  can- 
not bear  the  least  movement  or  jarring  of  the 
affected  part,  or  sometimes  even  the  weight  of 
the  bedclothes,  or  the  slightest  shaking  of  the 
room.  The  objective  signs  of  inflammation  in  con- 
nection with  a gouty  joint  also  soon  become  very 
prominent  as  a rule.  These  are  marked  redness, 
which  may  be  very  deep  and  sometimes  tends  to 
lividity,  while  the  veins  are  often  enlarged  and 
turgid;  considerable  local  heat,  as  evidenced  to 
the  touch  and  by  the  thermometer ; and  much 
swelling,  the  skin  covering  the  part  assuming  a 
tense  and  shining  appearance,  or  even  a con- 
siderable extent  of  the  limb  being  oedematous. 
When  several  joints  in  the  foot  or  hand  are 
affected,  diffused  redness  and  swelling  are  no- 
ticed. The  tumefaction  is  not  only  due  to  effu- 
sion into  the  interior  of  the  articulation,  but 
also  into  the  surrounding  tissues,  oedema  being 
a marked  feature  in  connection  with  gouty 
inflammation.  This  can  be  better  appreciated 
when  the  acute  symptoms  subside,  so  that  pres- 
sure can  be  borne,  which  shows  the  pitting 
characteristic  of  cedema,  and  this  ma.y  hold  on 
for  some  time  after  the  other  signs  have  dis- 
appeared. However  intense  the  objective  signs  of 
inflammation  may  bo,  acute  gout  never  ends  in 
suppuration.  As  they  subside,  marked  desqua- 
mation of  the  skin  usually  takes  place,  which  is 
partly  due  to  the  intensity  of  the  inflammation, 
partly  to  the  oedema,  the  vitality  of  the  epi- 
thelium being  thus  destroyed.  As  the  swelling 
increases,  the  subjective  sensations  generally 
diminish  in  severity;  but  during  the  progress 
towards  recovery,  intense  itching  is  apt  to  super- 
vene. 

An  acute  attack  of  gout  is  almost  always 
attended  with  more  or  less  general  symptoms; 
but  it  is  an  important  fact  that  their  severity 
depends  upon  the  extent  and  intensity  of  the 
local  manifestations  of  the  disease,  and  upon  the 
accompanying  symptoms.  Chills  or  even  actual 
rigors  may  be  felt  at  the  outset,  followed  by 
febrile  phenomena,  sometimes  slight,  in  other 
cases  considerable,  the  pyrexia  being  ns  a rule 
strictly  secondary  or  symptomatic.  The  skin 
feels  hot,  and  usually  perspires,  but  not  pro- 
fusely ; the  temperature  is  moderately  raised, 
presenting  no  definite  variations,  though  marked 
remissions  are  generally  observed  towards  morn- 
ing ; the  pulse  is  increased  in  frequency;  and  the 
digestive  organs  are  much  disordered,  as  evi- 
denced by  anorexia,  thirst,  furred  tongue,  and 
constipation.  The  urine  is  generally  deficient 
in  quantity,  and  may  be  very  scanty,  high- 
coloured,  and  concentrated ; its  acidity  is  in- 
creased ; and  on  standing  an  abundant  deposit 
of  amorphous  lithates  often  forms,  varying  in 
colour  according  to  circumstances,  being  pale- 
buff,  yellowish-red,  dark  or  brick-red,  or  intense 
pink  if  the  fever  is  high.  The  relative  quantity 
of  uric  acid  in  a particular  specimen  of  urine  is 
often  increased,  but  the  absolute  amount  dis- 
charged within  the  twenty-four  hours  is  much 
diminished.  The  patient  is  usually  exceedingly 
restless,  and  cannot  lio  with  comfort  in  any 
position  ; sleep  is  much  disturbed  or  altogether 


551 

I prevented  ; and  cramps  of  the  calves  of  the  legs 
or  of  other  muscles  may  still  further  increaso  his 
sufferings.  All  these  symptoms  tend  to  increase 
the  constitutional  disorder.  The  temper  is 
generally  very  irritable,  or  may  even  be  violent. 

The  duration  of  the  first  fit  of  gout  varies 
according  to  circumstances,  such  as  the  severity 
of  the  attack,  the  diet  and  regimen  adopted,  and 
probably  the  kind  of  treatment  which  is  em- 
ployed. It  usually  ranges  from  four  or  five  days 
to  a week  or  ten  days,  but  may  last  two  or  three 
weeks  or  more,  there  being  then  commonly 
intermissions  or  remissions,  and  several  joints 
being  involved  in  succession.  The  termination 
of  the  gouty  paroxysm  may  be  attended  with 
critical  phenomena,  such  as  free  perspiration, 
diarrhcea,  or  a very  abundant  discharge  of  urates. 
After  the  attack  the  patient  may  not  recover  hia 
former  state  of  health  for  some  time  ; but  not 
uncommonly  he  feels  better  than  before,  and  as 
if  the  system  had  got  rid  of  some  deleterious 
element.  As  a rule  the  affected  joints  are  appa- 
rently quite  restored  after  early  attacks  of  gout ; 
but  it  must  be  remembered  that  even  after  a 
single  fit  they  are  the  seat  of  permanent  morbid 
changes,  and  these  may  be  distinctly  evidenced 
by  more  or  less  deformity  or  stiffness.  (Edema 
may  also  remain  for  a considerable  time,  especi- 
ally if  the  inflammatory  condition  has  been  pro- 
longed. 

One  of  the  characteristic  features  of  gout  is 
the  tendency  which  it  exhibits  to  recurrence  in 
its  acute  form.  This  may  not  happen  if  the 
patient  is  sufficiently  careful,  but  such  an  event 
is  of  rare  occurrence.  The  rule  is  for  the  attacks 
to  be  repeated,  and  to  recur  with  ever-increasing 
frequency.  In  not  a few  instances  the  second  fit 
does  not  occur  until  an  interval  of  two  or  three 
years  or  more  has  elapsed,  but  in  most  this  is 
not  prolonged  beyond  a year.  The  same  in- 
terval may  be  noticed  between  the  next  few 
paroxysms,  but  as  the  disease  progresses  they 
return  twice  a year,  then  more  frequently,  and  at 
last  become  more  or  less  constant.  At  the  same 
time  the  mischief  extends  as  regards  the  joints.  It 
may  be  limited  to  the  great  toe  for  some  time,  but 
in  successive  fits  spreads  to  the  other  articula- 
tions of  the  foot,  to  the  hands,  the  ankles  and 
knees,  the  wrists  and  elbows,  and  occasionally  even 
to  the  hips  and  shoulders.  In  short,  gout  tends 
in  time  to  involve  nearly  all  the  joints  indiscrimi- 
nately, and  several  may  be  implicated  during  a 
fit.  Moreover,  those  articulations  which  are  re- 
peatedly attacked  become  more  aud  more  dis- 
abled and  deformed,  until  a condition  of  chronic 
gout  issetup.  The  symptoms  in  connection  with 
a particular  joint  tend  to  diminish  in  intensity 
the  more  often  it  is  affected.  As  additional 

i articulations  become  involved,  however — and 
many  may  be  implicated  at  the  same  time — the 
general  symptoms  often  increase  in  severity,  and 
the  patient  does  not  recover  in  the  intervals.  The 
duration  of  the  attacks  becomes  longer  as  their 
frequency  increases.  The  rapidity  of  the  pro- 
gress of  gout  is  very  different  in  different  cases : 
and  the  time  taken  to  produce  permanent  mis- 
chief in  the  joints  varies  considerably. 

It  must  be  borne  in  mind  that  variations  in 
the  intensity  and  exact  characters  of  the  symp- 
toms of  acute  gout  are  observed  in  some  cases 


GOUT. 


>52 

fn  feeble  persons  the  subjective  and  objective 
symptoms  may  be  comparatively  slight,  the  in- 
flammation assuming  an  asthenic  character,  but 
then  the  ultimate  effects  upon  the  joints  are 
often  much  worse.  Again,  the  pain  in  connection 
with  a particular  joint  depends  considerably  on 
its  structure,  being  usually  much  more  marked  if 
its  ligaments,  or  the  parts  around,  are  rigid  and 
unyielding.  Previous  injury  or  disease  affecting 
a joint  may  likewise  modify  the  symptoms. 
Some  individuals  suffer  much  more  than  others, 
being  more  susceptible  of  painful  impressions. 

3.  Chronic  Articular  Gout. — In  course  of 
time  more  and  more  of  the  joints  become  per- 
manmtly  and  obviously  changed,  and  prevented 
from  fulfilling  their  functions  properly,  so  that 
a condition  of  chronic  articular  gout  is  esta- 
blished, exacerbations  still  occurring,  however — 
indeed  with  much  greater  frequency — but  being 
much  less  acute  in  their  intensity  than  in  the 
early  stages  of  the  disease,  and  longer  in  dura- 
tion. It  need  hardly  be  remarked  that  there 
is  no  distinct  line  of  demarcation  between 
acute  and  chronic  gout.  The  hands  are  par- 
ticularly liable  to  be  much  altered  by  the 
effects  of  gouty  inflammation.  The  permanent 
changes  are  indicated  by  the  articulations 
becoming  enlarged,  deformed,  and  irregular  in 
shape,  often  presenting  nodulations  or  bulg- 
ings,  which  may  attain  a large  size,  owing  to  the 
abundance  of  the  deposited  urates.  They  are 
also  stiff  and  crippled  in  their  movements,  at 
last  becoming  quite  immovable  and  rigid,  or  even 
completely  anchylosed  ; and  being  either  perma- 
nently flexed,  extended,  or  sometimes  even  bent 
backwards.  The  interference  with  movement 
and  the  deformity  do  not  bear  any  necessary 
proportion  to  each  other,  the  one  or  the  other 
predominating  according  to  the  mode  in  which 
•lie  deposit  of  urate  of  soda  has  taken  place. 
Tho  more  this  infiltrates  the  ligaments  and  sur- 
rounding tendons,  the  greater  becomes  the  im- 
pediment to  movement.  Gouty  concretions  in 
connection  with  joints  feel  hard,  and  by  their 
mere  mechanical  and  irritative  effects  they  are 
liable  to  cause  damage  to  the  adjoining  struc- 
tures. They  may  be  seen  stretching  or  shining 
through  tho  skin,  and  causing  it  to  assume  a 
bloodless  appearance,  or,  on  the  other  hand, 
rendering  it  congested  and  bluish,  the  veins 
also  being  enlarged.  Ultimately  a gouty  ab- 
scess may  form  around  the  concretions,  which 
opens  externally ; or  the  skin  may  merely  give 
way  from  the  continued  pressure.  Thus  the 
chalk-stones  are  exposed,  and  come  away  either 
in  a liquid  form  or  as  solid  particles  or  masses, 
or  occasionally  there  is  a free  discharge  of  pus 
as  well.  Ulcers  are  left,  of  an  unhealthy  end 
atonic  character,  and  usually  presenting  no  dis- 
position to  heal.  There  may  be  a number  of 
these  ulcers  in  the  same  individual,  on  tho 
hands  and  feet.  When  bursae  are  involved, 
much  deformity  is  produced.  They  are  easily 
felt,  usually  presenting  a combination  of  hard- 
ness and  fluctuation,  due  to  the  presence  of 
concretions  and  of  fluid  in  the  bursal  cavity. 
These  signs  are  chiefly  noticed  in  the  bursa 
over  the  olecranon.  Abscesses  may  also  form 
in  connection  with  these  deposits,  and  the  latter 


may  thus  be  completely  got  rid  of,  the  abscess 
subsequently  healing  rapidly. 

In  cases  of  chronic  articular  gout  the  general 
system  necessarily  tends  to  become  affected.  The 
patients  are  generally  more  or  less  feeble  and 
wanting  in  tone;  they  may  be  thin  and  pale  or 
sallow-looking ; or  plethoric,  but  with  flabby 
tissues,  and  presenting  signs  of  languid  circula- 
tion, with  enlarged  capillaries  about  the  face. 
They  often  suffer  from  disorders  of  digestion  and 
other  symptoms  already  described;  but  not  un- 
commonly, as  gout  assumes  a more  chronic  form, 
patients  feel  better,  becoming  habituated  to  the 
morbid  condition  of  the  blood.  It  is  remark- 
able that  those  suffering  from  numerous  gouty 
abscesses  often  exhibit  but  little  general  dis- 
turbance, probably  because  the  system  is  thus 
rid  of  the  morbid  materials.  The  urine  in  chronic 
gout  generally  becomes  abundant,  very  watery 
and  pale,  of  low  specific  gravity,  deficient  in  solid 
ingredients,  especially  in  uric  acid,  which  at 
times  may  be  almost  completely  wanting,  or  it 
may  be  thrown  out  in  an  intermittent  manner. 
Deposits  of  urates  are  not  often  observed  in 
cases  of  advanced  chronic  gout,  except  perhaps 
before  the  occurrence  of  an  acute  exacerbation. 

4.  Irregular  Gout. — The  clinical  pheno- 
mena which  are  recognised  as  irregular  manifes- 
tations of  gout  may  assume  either  an  acute  or 
chronic  form.  They  may  be  observed  in  persons 
who  are  distinctly  subject  to  articular  gout ; or 
in  those  in  whom  the  disease  is  not  so  obviously 
revealed.  Moreover,  their  intensity  is  often  in 
an  inverse  ratio  to  that  of  the  joint-affection, 
and  the  two  classes  of  symptoms  may  exhibit  a 
remarkable  tendency  to  alternation,  when  the 
articular  symptoms  are  prominent  those  con- 
nected with  other  parts  being  slight  or  absent, 
and  vice  versd.  This  may  be  noticed  with  both 
acute  and  chronic  symptoms,  and  the  former  are 
particularly  liable  to  arise  when,  from  any  cause, 
during  the  progress  of  a gouty  fit  the  joint- 
inflammation  is  suppressed  suddenly  or  rapidly 
— retrocedent  gout.  At  other  times  the  internal 
symptoms  seem  to  be  due  to  a want  of  develop- 
ment of  the  external  phenomena — suppressed  gout, 
and  when  the  latter  appear,  the  former  subside. 

It  must  suffice  to  indicate  here  the  general 
nature  of  the  symptoms  of  irregular  gout.  The 
acute  symptoms  are  mainly  associated  either 
with  the  alimentary  canal,  the  vascular  system, 
the  respiratory  organs,  or  the  nervous  system. 
In  connection  with  the  alimentary  canal,  acute 
dysphagia  may  occur,  attended  with  spasm  of  the 
pharynx  and  oesophagus.  The  most  important 
symptoms  belonging  to  this  group  are,  however, 
those  due  to  some  gastric  disturbance.  This  may 
be  of  the  nature  of  severe  cramp  or  gastralgia, 
characterised  by  a sudden,  acute,  spasmodic  pain 
in  the  epigastrium,  relieved  by  pressure,  and 
accompanied  with  a sense  of  great  weight  and 
oppression  ; the  patient  presenting  an  aspect  of 
much  suffering,  distress,  and  anxiety ; or  being 
even  more  or  less  collapsed  and  prostrated.  In 
other  cases  the  symptoms  are  those  of  acuto 
gastritis,  bilious  vomiting  being  prominent. 
Intestinal  colic,  or  even  muco-enteritis,  may  also 
occur  in  connection  with  gout.  The  vascular 
system  is  not  uncommonly  implicated.  The 


GOUT.  5b  3 


heart  is  liable  to  be  disturbed  in  its  action 
during  the  attacks  of  gastralgia,  but  this  dis- 
turbance may  also  be  observed  independently. 
It  is  usually  of  nervous  origin,  and  may  be 
evidenced  in  various  ways.  Thus  there  may  be 
severe  palpitation,  the  action  of  the  heart  being 
very  rapid,  irregular,  or  even  intermittent,  this 
being  accompanied  with  most  unpleasant  sensa- 
tbnsover  the  cardiac  region,  praecordial  anxiety, 
>ften  a feeling  of  oppression  or  constriction,  dys- 
pnoea or  a sense  of  suffocation,  and  much  distress, 
anxiety,  and  dread  of  death ; the  pulse  tends  to 
be  weak  and  small,  or  may  be  irregular  ; some- 
times the  attacks  aro  attended  with  signs  of 
collapse.  In  other  instances  the  cardiac  disorder 
is  evidenced  by  vi-ry  feeble  or  slow  action,  with 
a tendency  to  syncope.  Again,  there  may  be  all 
the  phenomena  of  a severe  anginal  attack,  this 
probably  partly  depending  upon  the  circulation 
in  the  vessels  being  impeded.  It  must  be 
once  more  noted  here  that  there  is  no  true 
gouty  acute  inflammation  connected  with  the 
heart,  although  certain  chronic  changes  some- 
times observed  at  post-mortem  examinations  have 
been  attributed  to  such  a condition.  Irregu- 
lar gout  affecting  the  respiratory  system  is 
mainly  indicated  by  asthmatic  attacks.  In 
some  cases  there  is  a marked  liability  to  acute 
catarrh  of  tho  air-passages.  Pulmonary  con- 
gestion is  also  supposed  to  be  a manifestation 
of  retrocedent  gout  in  some  cases,  but  there  is 
no  such  special  disease  as  gouty  pneumonia. 
In  connection  with  the  nervous  system  gout  may 
give  rise  to  attacks  of  severe  headache ; delirium 
or  even  acute  mania ; epileptiform  fits  ; cerebral 
nr  spinal  meningitis  ; acute  neuralgia,  either 
external  or  internal,  and  especially  sciatica, 
probably  due  to  neuritis;  or  severe  muscular 
cramps.  Apoplexy  from  cerebral  haemorrhage 
has  been  often  attributed  to  suppressed  or  retro- 
cedent gout,  and  if  the  vessels  of  the  brain  are 
diseased,  it  is  possible  that  there  may  be  some 
connection  between  them.  Cerebral  congestion 
might  also  occur  in  gout,  and  give  rise  to  a 
temporary  apoplectic  attack.  Among  the  acute 
forms  of  irregular  gout  are,  for  example,  sldn- 
affoctions,  eczema,  erythema,  or  urticaria  ; affec- 
tions of  mucous  membranes,  such  as  the  conjunc- 
tivse  and  lachrymal  passages ; functional  renal 
disorder,  with  albuminuria,  or  irritability  of  the 
bladder ; and  local  signs  of  inflammation,  associ- 
ated with  the  deposit  of  urates. 

Many  of  the  mure  chronic  symptoms  asso- 
ciated with  gout  have  already  been  pointed  out, 
when  speaking  of  its  premonitory  symptoms,  and 
only  certain  phenomena  need  be  alluded  to  here. 
Chronic  skin  diseases  are  of  frequent  occurrence, 
namely,  psoriasis,  chronic  eczema,  prurigo, 
either  local  or  general,  and  acne.  These 
may  alternate  very  distinctly  with  articular 
gout,  and  they  are  often  intensified  by  causes 
which  increase  the  lithaemic  condition.  In 
*ome  gouty  subjects  daily  paroxysms  of  heat 
and  redness  of  the  nose,  attended  with  severe 
itching  and  irritation,  cause  considerable  annoy- 
ance or  distress.  Many  of  these  individuals  are 
also  liable  to  chronic  catarrh,  affecting  the 
throat  and  the  air-passages ; and  in  time  they 
t'ftvn  becomo  permanently  asthmatic,  the  lungs 
bting  emphysematous,  and  dry  bronchial  catarrh 


being  established.  Gravel  or  urinary  calcu- 
lus gives  rise  to  symptoms  referred  to  the 
urinary  organs  ; and  those  indicative  of  chronic 
urethritis  or  cystitis  may  be  present,  espe- 
cially in  persons  advanced  in  years.  Perma- 
nent disorders  of  sensation,  or  slight  local 
paralysis  may  be  observed  in  gout,  owing  to 
chronic  changes  involving  particular  nerves. 
Gouty  persons  are  usually  very  sensitive  to 
pain.  Tophi  can  he  seen  or  felt,  provided  they 
are  superficial.  Those  connected  with  the 
helix  of  the  external  ear  are  most  common ; 
but  they  should  also  be  looked  for  in  the 
sclerotic  or  eyelids,  in  the  nose,  and  under  the 
skin,  in  the  region  of  tendinous  aponeuroses,  es- 
pecially in  the  log  or  thigh.  The  xvriter  had  the 
opportunity  of  observing  a case  in  which  an  ex- 
tensive formation  of  urates  occurred  in  the  outer 
part  of  the  thigh,  apparently  associated  with  the 
fascia  lata.  These  gouty  concretions  are  origi- 
nally liquid,  and  if  one  is  punctured  at  an  early 
period,  an  opalescent  or  milky  fluid  escapes, 
which  on  microscopic  examination  is  found  to 
contain  an  abundance  of  delicate,  acieular  crys- 
tals ; subsequently  they  become  more  consistent, 
and  ultimately  quite  solid  and  hard,  being  then 
made  up  entirely  of  these  crystals,  which  are 
closely  aggregated  together  and  interlaced. 
Taking  the  ear  as  an  illustration,  at  first  a small 
elevation  appears  under  the  skin  of  the  helix, 
like  a vesicle,  having  a soft  feel.  This  gradually 
hardens,  until  finally  a little  bead-like  or  pearl- 
like body  is  formed,  presenting  a whitish  colour 
as  seen  through  the  skin.  In  course  of  time 
the  cutaneous  covering  may  be  destroyed,  leaving 
the  little  chalk-stone  exposed ; or  this  may  even 
become  detached,  so  that  only  a small  depres- 
sion is  left. 

5.  Symptoms  due  to  chronic  organic 
diseases. — In  addition  to  what  has  been  stated 
under  the  preceding  heading,  it  is  desirable  just 
to  notice  separately  certain  diseases  of  organs 
which  may  be  associated  with  the  gouty  diathesis. 
Disease  of  the  kidney  is  indicated  mainly  by  the 
changes  in  the  urine,  which  may  be  slightly  albu- 
minous, or  even  contain  a few  casts.  Other  symp- 
toms of  chronic  Bright’s  disease  maybe  present, 
but  it  must  be  remembered  that  in  the  form  of 
renal  disease  associated  with  gout  the  symptoms 
are  often  very  obscure.  The  chronic  cardiac 
diseases  observed  in  gout  aro  revealed  mainly 
by  their  respective  physical  signs  ; and  there 
may  be  symptoms,  first  of  excessive  cardiac  action 
from  hypertrophy,  and  subsequently  of  cardiac 
failure.  The  vascular  changes  are  evidenced  by 
examination  of  the  arteries  ; and  by  their  effects 
upon  the  circulation.  Fatty  liver  can  only  be 
discovered  by  physical  examination. 

Diagnosis. — -The  degree  of  difficulty  expe- 
rienced in  arriving  at  a diagnosis  with  respect 
to  gout,  is  very  variable  in  different  cases, 
whether  in  definitely  fixing  upon  this  disease,  or 
in  distinguishing  it  from  other  affections.  Often 
the  diagnosis  is  perfectly  clear,  but  in  some 
instances  it  may  be  extremely  difficult  to  form  a 
positive  opinion.  It  must  be  remembered  that 
there  may  be  a distinct  gouty  diathesis  present, 
and  symptoms  resulting  therefrom  may  arise, 
which  it  is  important  to  recognise,  whilo  the 
joints  are  quite  free  from  any  apparent  mis- 


GOUT. 


554 

chief.  It  is  also  desirable  to  be  able  to  make 
out  any  tendency  to  the  development  of  this 
diathesis.  In  most  cases,  however,  the  diagnosis 
has  to  deal  with  the  nature  of  an  articular 
affection,  and  to  determine  whether  this  is  gouty 
or  not.  The  chief  diseases  from  which  gout  has 
thus  to  be  distinguished  are  acute  or  chronic 
rheumatism,  and  rheumatoid  arthritis.  The 
data  upon  which  a conclusion  has  usually  to  be 
formed  with  regard  to  a first  attack,  are  the 
presence  or  absence  of  a hereditary  tendency  to 
gout,  as  well  as  its  intensity;  the  age  and  sex  of 
the  patient;  his  social  position,  occupation,  and 
previous  habits;  the  presence  or  absence  of  any 
obvious  cause  for  the  attack,  or  of  premonitory 
symptoms  ; the  localisation  and  characters  of 
the  joint-affection  ; the  general  symptoms;  the 
characters  of  the  urine;  the  duration  of  the  ill- 
ness ; and  the  condition  of  the  heart.  These 
different  points  have  already  been  sufficiently 
discussed  in  their  relation  to  gout,  but  the  dis- 
tinctions presented  by  acute  rheumatism  may  be 
briefly  indicated.  The  absence  of  any  hereditary 
tendency  to  gout  in  any  doubtful  case  may  be  in 
favour  of  rheumatism,  and  possibly  this  com- 
plaint may  be  hereditary.  It  occurs  most  fre- 
quently for  the  first  time  in  early  life,  from  sixteen 
to  twenty  years  of  age,  aDd  is  not  uncommon  evon 
in  young  children.  Rheumatism,  though  more 
common  among  males,  often  attacks  females.  This 
complaint  is  not  favoured  by  the  habits  which 
generate  or  promote  gout,  and  affects  all  classes 
of  persons,  but  especially  those  who  from  their 
occupation  are  liable  to  be  exposed  to  cold  and 
wet.  Such  exposure,  or  some  other  definite 
cause  originating  ‘ a cold,’  usually  accounts  for 
an  attack  of  acute  rheumatism,  and  it  is  not  pre- 
ceded by  any  particular  premonitory  symptoms. 
The  joints  involved  aro  the  middle-sized  or  the 
larger  oues,  several  of  which  are  generally  im- 
plicated in  succession  during  the  illness,  the 
rheumatic  inflammation  exhibiting  an  erratic 
character ; the  local  sj'mptoms  tend  to  be  less 
severe  than  in  gout;  there  is  less  marked  oedema 
about  the  joiuts,  and  no  enlargement  of  the  veins 
or  subsequ-nt  desquamation  are  observed.  It  must 
not  be  overlooked,  however,  that  gout  may  attack 
the  middle-sized  joints.  Pyrexia  is  high  as  a 
rule,  and  is  often  quite  out  of  proportion  to  the 
extent  of  the  articular  affection ; while  profuse 
acid  perspiration  is  almost  always  a prominent 
phenomenon.  The  urine  is  simply  febrile.  The 
attack  lasts  a considerable  time,  perhaps  several 
weeks,  if  it  is  at  all  severe ; while  during  its 
course  some  acute  cardiac  inflammation  is 
liable  to  supervene,  and  this  may  happen  even 
when  the  joint-affection  is  but  slight.  The 
subsequent  progress  of  gout  is  important  in 
diagnosis,  for  its  tendency  to  periodic  recurrence 
is  a marked  feature  in  its  history,  and  if  the 
metatarso-phalangeal  joint  of  the  great  toe  is 
alone  inflamed  several  times  in  succession,  or 
even  if  only  the  smaller  joints  of  the  feet  and 
hands  are  implicated,  the  diagnosis  of  gout  is 
tolerably  certain.  The  permanent  articular 
changes  induced  bjr  gout  also  become  evident  in 
time ; as  well  as,  perhaps,  tophi  in  other  parts, 
which  should  be  carefully  searched  for  in  any 
doubtful  case,  especially  in  connection  with  the 
external  ear,  the  nose,  and  bursae.  Moreover, 


the  urine  presents  peculiar  changes  as  the  disease 
progresses,  and  may  give  evidence  of  renal 
mischief.  In  very  doubtful  cases  it  might  be 
desirable  to  raise  a blister,  or  even  to  take  a 
little  blood  from  the  patient,  and  endeavour  to 
obtain  crystals  of  uric  acid  from  the  serum. 

Rheumatoid  arthritis  is  usually  met  with  in 
females  between  twenty  and  forty  years  old. 
There  is  no  hereditary  taint,  or  a history  of  any 
such  habits  as  generate  gout,  but,  on  the  contrary, 
the  patients  are  generally  poor,  hard- worked,  anci 
badly-fed,  and  consequently  weak  and  wanting  in 
tone ; all  joints  seem  to  be  equally  liable  to  he 
affected,  both  1 irge  and  small,  and  the  symptoms 
are  not  of  a very  acute  character,  though  the  p.iin 
may  be  very  severe,  but  they  tend  to  continue  for 
a long  period  ; the  general  symptoms  are  mainly 
those  of  debility  and  anaemia.  Rheumatoid 
arthritis  is  a disease  which  tends  to  progress, 
involving  joint  after  joint,  but  it  presents  no 
periodicity  in  its  attacks,  and  often  advances 
without  any  intermission,  as  a subacute  orchronic 
disease.  Ultimately  it  often  causes  much  defor- 
mity and  crippling  of  the  articulations,  but  this 
results  from  a very  different  pathological  change 
from  that  which  takes  place  in  gout,  for  there 
is  not  the  slightest  deposit  of  urates,  either  in 
the  joints  or  elsewhere , nor  in  the  most  extreme 
cases  can  any  uric  acid  be  obtained  from  the 
serum.  The  urine  presents  no  special  characters ; 
and  the  kidneys  are  not  diseased. 

As  exceptional  points  bearing  upon  the  diag 
nosis  of  gout  in  joints,  the  following  may  he 
mentioned.  It  has  happened  that  pysemia  be 
ginning  in  the  great  toe  has  been  mistaken  for 
gout,  but  the  progress  of  the  case  would  soon 
clear  up  any  doubt  under  such  circumstances. 
Again,  articular  inflammation  from  injury  might 
resemble  gout ; and,  moreover,  it  must  be  borne 
in  mind  that  such  an  injury  may  really  set  up 
gouty  inflammation  for  the  first  time,  so  that  the 
joint  may  not  recover  properly.  In  some  indi- 
viduals the  ends  of  the  phalanges  of  the  fingers 
aro  enlarged,  especially  terminal  ones,  and  cause 
nodulations— digitorum  nodi — which  resemble 
those  of  gout,  and  are  by  some  regarded  as  being 
of  a gouty  nature. 

The  importance  of  recognisinor  the  signs  of  the 
gouty  diathesis,  apart  from  the  joint-affection, 
has  already  been  alluded  to.  Equally  important 
is  it  to  he  prepared  for  the  acute  symptoms  in 
connection  with  internal  organs  which  occur  in 
this  diathesis,  whether  along  with  or  indepen- 
dent of  articular  disease.  Lastly,  in  any  gouty 
case  the  detection  of  the  organic  diseases  liable 
to  be  set  up  in  its  course  is  of  great  moment  in 
diagnosis,  especially  renal  disease  ; and  also  the 
association  with  their  proper  cause  of  catarrhal 
affections,  skin-diseases,  and  other  complaints, 
when  these  are  due  to  gout. 

Prognosis. — The  first  point  relating  to  the 
prognosis  of  gout  which  calls  for  notice  refers  to 
the  immediate  dangers  in  any  particular  case. 
A simple  acute  attack  of  articular  gout  rarely, 
if  ever,  kills  the  patient.  When,  however,  in- 
ternal organs  are  implicated,  the  mitter  becomes 
much  more  serious,  and  a fatal  result  may  occur, 
so  that  the  prognosis  must  be  a guarded  one 
under  such  circumstances.  The  danger  then 
becomes  much  greater  if  the  complaint  has  been 


GOUT. 


luug-cstablished,  and  if  the  kidneys  or  other 
organs  have  become  structurally  diseased.  Indeed 
these  diseases  of  organs  themselves  are  attended 
with  grave  dangers,  and  may  give  rise  to  fatal  con- 
sequences at  any  time.  Again,  any  acute  inflam- 
mation occurring  in  a confirmed  gouty  subject 
is  the  more  serious  on  this  account ; and  the 
same  remark  applies  to  injuries  and  shocks  of  all 
kinds,  so  that  in  such  cases  the  prognosis  is  less 
favourable  than  it  otherwise  would  be. 

In  the  next  place  the  future  of  a gouty  patient 
has  to  lie  considered,  as  regards  the  prevention 
of  subsequent  attacks,  or,  indeed,  the  cure  and 
eradication  of  the  disease.  It  must  always  be 
recognised  that  gout  is  a recurrent  affection  and 
complete  immunity  can  never  be  guaranteed, 
once  the  complaint  lias  declared  itself.  At  the 
same  time  undoubtedly  not  a few  cases  have 
occurred  in  which  there  lias  been  but  one 
attack,  but  this  can  only  be  expected  under  cer- 
tain conditions.  In  giving  an  opinion  on  this 
point,  the  prognosis  in  any  individual  case 
will  depend  upon: — 1.  The  degree  of  hereditary 
tendency  to  gout.  2.  The  age  of  the  patient ; 
for  the  earlier  the  period  at  which  the  disease 
begins,  the  less  hopeful  is  the  prospect  of  a 
cure.  3.  The  time  the  complaint  has  lasted 
from  its  commencement ; and  the  frequency  and 
duration  of  the  gouty  fits.  If  gout  has  become 
established,  and  especially  if  distinct  chalk-stones 
have  formed,  it  is  quite  impossible  to  eradicate 
it.  4.  The  habits,  mode  of  living,  and  occupa- 
tion of  the  patient.  It  is  only  when  the  patient 
is  prepared  to  adhere  strictly  to  proper  rules  of 
liviug  that  a cure  can  be  hoped  for.  Those  who 
in  their  occupation  are  liable  to  drink  much, 
or  who  are  exposed  to  cold  or  wet,  are  less 
likely  to  be  cured.  It  may  bo  remarked  here 
that  gouty  subjects  are  less  able  than  others  to 
resist  exposure. 

Another  point  bearing  upon  prognosis  refers 
to  the  duration  of  life  in  gouty  persons.  If  the 
disease  comes  on  late  in  life,  and  the  paroxysms 
only  occur  at  long  intervals,  w hile  the  organs  are 
free  from  any  organic  mischief,  gout  may  not 
appreciably  shorten  life,  and  the  patients  may 
even  enjoy  good  health  up  to  an  extreme  old  age, 
provided  they  are  sufficiently  careful  in  their 
mode  of  living,  and  no  accidental  complications 
arise.  Chronic  gout  unquestionably  does  tend  to 
shorten  the  duration  of  life,  to  a greater  or  less 
degree  in  proportion  to  its  severity,  and  more 
especially  to  the  indications  present  that  the 
kidneys,  heart,  or  other  important  organs  are 
organically  diseased.  This  tendency  is  now  re- 
cognised by  most  life-insurance  companies. 

It  has  been  supposed  that  gout  is  a protection 
against  certain  other  diseases,  such  as  phthisis 
and  diabetes,  and  therefore  its  presence  has 
been  in  some  instances  regarded  as  a benefit, 
but  how  far  there  is  any  real  foundation  for  this 
belief  is  a matter  of  considerable  doubt. 

Treatment. — It  is  important  at  the  outset  to 
lay  stress  upon  the  fact  that,  although  there  are 
certain  well-definel  principles  applicable  to  the 
treatment  of  gout  in  its  various  phases,  it  is  a 
great  mistake  to  follow  a regular  routine  method 
under  all  circumstances,  and  every  case  must  bo 
considered  on  its  own  merits,  both  as  regards 
the  patient  himself  and  his  surrounding?.  It 


65  5 

will  be  convenient  to  discuss  this  subject  under 
certain  general  headings,  premising  that  the 
administration  of  medicines  is  often  the  least 
important  part  of  the  treatment,  and  that  the 
habits  of  life  of  the  patient  always  need  thorough 
supervision  in  all  their  details. 

1.  Preventive  and  Curative  Treatment. — - 
In  a number  of  cases  the  primary  object  whieli 
should  be  aimed  at  is  to  prevent  the  develop- 
ment of  gout;  or  to  eradicate  the  tendency  to 
subsequent  attacks,  if  it  has  one?  declared  itself, 
and  to  rid  the  system  of  the  conditions  which 
induce  this  complaint.  These  objects  have  espe- 
cially to  be  kept  in  view  in  dealing  with  indi- 
viduals who  have  a marked  hereditary  pre- 
disposition to  gout;  in  cases  where  it  has 
appeared  at  a comparatively  early  period  of  life, 
whether  as  a hereditary  or  acquired  comp'aint, 
or  where  it  is  in  an  early  stage;  and  in  persons 
who,  from  their  occupation,  known  habits,  or 
the  symptoms  they  present,  are  likely  to  be- 
come gouty.  Moreover,  even  when  confirmed 
gout  has  been  established,  preventive  tre  itment 
may  be  carried  out,  with  the  view  of  diminish- 
ing the  number  of  acute  attacks,  or  even 
possibly  of  averting  them  altogether;  and  of 
obviating  the  implication  of  organs  essential 
to  the  well-being  of  the  economy.  In  order  to 
carry  out  these  objects  in  any  particular  case, 
the  patient  must  intelligently  recognise  the  fact 
that  success  in  treatment  mainly  depends  upon 
himself,  and  upon  his  willingness  constantly  to 
regulate  his  mode  of  living  according  to  principles 
suitable  to  his  condition,  which  nee  I to  be  more 
or  less  strict  in  different  instances.  The  general 
nature  of  the  rules  to  be  adopted  will  be  evident 
from  a consideration  of  what  has  been  stated  in 
discussing  the  aetiology  and  pathology  of  gout, 
but  they  require  to  be  briefly  noticed  here.  The 
ends  sought  in  carrying  out  these  rules  are  to 
prevent  an  undue  formation  of  urates  in  the  sys- 
tem ; to  maintain  the  digestive  and  assimilative 
organs  in  a condition  of  healthy  activity ; and  to 
promote  the  elimination  of  urates  by  the  kidneys, 
especially7  if  at  any  time  there  appears  to  be  a 
tendency  to  their  accumulation  in  the  body7. 

(a)  Diet. — Moderation  iu  the  quantity  of  food 
is  the  first  point  to  be  attended  to  in  the  treat- 
ment of  the  gouty  diathesis.  It  is  not  neces- 
sary or  desirable  to  restrict  persons  who  are 
gouty  to  a very  low  diet,  as  is  sometimes  done, 
especially  if  they  are  in  any  way  weak,  but  an 
amount  sufficient  for  proper  nourishment  in  each 
individual  case  must  be  consumed,  and  at  no 
meal  should  the  stomach  be  uncomfortably  filled. 
The  meals  must  be  taken  at  regular  times,  and 
not  hurriedly,  so  as  to  avoid  boiling  of  the  food. 
Very  late  dinners,  as  well  as  suppers,  should  bo 
prohibited,  but  it  suits  many  persons  better  to 
dine  at  six  or  half-past  six  o'clock  than  at  mid- 
day. The  nature  of  the  food  is  highly  important. 
It  is  quite  unnecessary,  and  probably  would  be 
in  most  instances  injurious,  to  restrict  the  pa- 
tient to  a vegetable  diet,  but  a due  proportion 
of  animal  and  vegetable  substances  should  be 
allowed.  At  the  same  time,  in  persons  who 
have  any  tendency  to  gout,  an  essential  part  of 
the  treatment  often  consists  in  diminishing  the 
amount  of  meat  which  they  consume,  this  being 
far  in  excess  of  what  is  needed,  or  can  be  got 


GOUT. 


656 

rid  cf  by  the  system  ■without  injuring  it.  In- 
deed, the  aim  must  be  to  reduce  all  kinds  of 
nitrogenized  food,  whether  animal  or  vegetable, 
to  such  an  amount  as  the  system  can  satis- 
factorily dispose  of,  due  regard  being  had  to 
the  proper  nutrition  and  strength  of  the  body, 
and  thus  to  diminish  the  waste-products  result- 
ing therefrom.  As  regards  the  kinds  of  animal 
food  which  are  suitable  for  gouty  subjects,  white 
fish,  chicken  or  fowl,  game,  and  mutton  are 
the  best  forms.  Tender  and  underdone  beef  may 
be  taken  in  moderation  from  time  to  time.  Pork 
or  veal,  dried  and  salted  meats,  and  rich  dishes 
of  all  kinds,  had  better  be  avoided.  Such  vege- 
tables should  be  partaken  of  as  are  known  to  be 
digestible,  but  those  which  contain  much  woody 
fibre,  or  which  create  flatulence,  must  not  be 
indulged  in.  There  is  a notion  that  celery 
is  beneficial  in  gouty  cases,  and  the  writer  has 
recently  met  with  an  intelligent  person,  who  has 
long  been  a martyr  to  gout,  and  he  strenuously 
affirms  that  he  has  derived  much  benefit  from 
taking  celery  freely,  both  in  an  uncooked  form 
and  stewed.  Gouty  subjects  should  either  ab- 
stain altogether  from,  or  only  take  a very  limited 
quantity  of,  sugar  and  saccharine  articles  of  diet. 
Hence,  although  digestible  fruits  may  often  be 
taken  with  advantage  in  moderation,  those  which 
are  very  sweet  must  be  used  with  particular 
caution.  Stewed  and  baked  fruits  often  agree 
well,  but  fruit-tarts,  and,  indeed,  pastry  of  all 
kinds,  should  be  interdicted.  The  juice  of  oranges 
or  lemons  is  considered  beneficial  for  gouty  per- 
sons, and  perhaps  with  good  reason.  It  may  be 
laid  down  as  a rule  to  be  invariably  followed, 
that  such  persons  should  always  limit  themselves 
to  simple  meals,  and  not  indulge  in  a number  of 
courses ; and  that  they  should  avoid  everything 
which  their  experience  tells  them  is,  in  their 
case,  indigestible.  It  has  been  recommended 
that  salt  should  be  avoided  by  gouty  subjects, 
so  as  not  to  add  sodium  to  the  system,  for  com- 
bination with  uric  acid. 

(b)  Drink. — The  question  of  drink  demands 
the  most  careful  consideration  and  attention  in 
every  case  in  which  gout  is  either  threatened  or 
has  become  established.  It  may  he  affirmed 
that  no  strict  rules  can  be  laid  down,  applicable 
to  all  cases,  but  there  are  certain  broad  prin- 
ciples which  have  to  be  borne  in  mind.  An 
abundance  of  good  and  pure  drinking-water  is  to 
be  commended,  but  it  should  be  taken  mainly 
between  meals.  It  is  a good  plan  for  the  sub- 
jects of  lithiasis  to  take  a tumblerful  of  water 
before  retiring  to  rest  at  night.  Effervescing 
potass-  or  lithia-water  may  be  substituted  for 
ordinary  water  with  advantage,  the  dissolved 
salts  forming  soluble  compounds  with  uric  acid, 
but  soda-water  must  be  avoided.  Tea  and  coffee 
may  be  taken  in  moderation,  provided  they  do 
not  disagree.  With  reference  to  alcoholic  drinks, 
in  a considerable  number  of  instances  one  of 
the  first  objects  in  the  treatment  of  the  gouty 
diathesis  should  be  the  regulation  of  the  use  of 
this  class  of  beverages.  This  indication  is  ob- 
vious enough  when  the  condition  is  evidently  due 
mainly  to  excessive  indulgence  in  these  bever- 
ages ; but  even  when  the  patient  is  temperate,  it 
may  he  that  in  his  case  the  amount  consumed 
Deeds  to  be  reduced  or  total  abstinence  enforced, 


especially  if  there  should  be  a strong  hereditary 
predisposition  to  gout,  or  if  the  complaint  appears 
in  early  life.  Some  patients  are  undoubtedly 
better  if  they  take  no  stimulants  whatever; 
others,  however,  can  take  proper  kinds  in  mode- 
ration with  advantage.  It  may  be  laid  down  as 
a general  rule  that  malt  liquors  and  all  stronger 
wines  are  injurious,  and  should  be  interdicted. 
Those  which  are  most  suitable  are  good  claret, 
hock,  urosello,  chablis,  or  sauterne.  Even  these 
must,  however,  be  only  indulged- in  in  strict 
moderation.  A small  quantity  of  good  dry  sherry 
suits  some  gouty  patients  very  well.  A little 
brandy,  well-diluted,  often  agrees  better  than 
any  other  kind  of  alcoholic  liquor ; or  in  some 
cases  whisky  or  gin  may  he  substituted.  What- 
ever stimulant  is  selected,  it  should  only  be  taken 
at  meal-times,  and  the  habit  of  drinking  between 
meals  is  strongly  to  be  deprecated.  Persons  who 
are  distinctly  gouty  should  avoid  any  excess  on 
every  occasion ; and  even  if  they  do  not  abso- 
lutely abstain,  they  may  find  it  beneficial  to  do 
so  from  time  to  time,  especially  if  there  should 
be  an  abundant  deposit  of  lithates  in  the  urine, 
or  if  symptoms  should  occur  which  the  patient 
recognises  as  being  of  a gouty  nature.  It  is 
highly  important  that  any  alcoholic  drink  em- 
ployed by  gouty  subjects  should  be  sound  and  of 
good  quality,  There  can  be  no  doubt  but  that 
due  attendance  to  the  rules  just  sketched  will 
prevent  the  development  of  gout  where  it  is 
threatened,  and  will  also  check  its  progress,  and 
avert  the  occurrence  of  acute  attacks.  The 
difficulty  is  to  persuade  patients  to  carry  them 
out  properly. 

(c)  General  hygiene. — Inadequate  exercise  is 
a hygienic  error  which  has  frequently  to  be 
rectified  in  the  treatment  of  the  gouty  state 
Sedentary  habits  must  be  combated,  whether 
due  to  the  occupation  or  to  indolence  ; and  it 
must  be  insisted  upon  that  a due  amount  of 
out-door  exercise  is  taken  daily,  though  violent 
exertion,  tending  t.o  cause  fatigue  and  exhaus- 
tion, must  be  avoided.  Walking  and  horse- 
exercise  are  highly  beneficial,  especially  in  the 
case  of  those  who  live  rather  too  freely. 
Even  carriage-exercise  is  useful,  so  that  th? 
patient  may  have  the  benefit  of  the  fresh  air. 
General  active  habits  should  be  encouraged,  and 
any  disposition  to  undue  luxuriousness  in  the 
mode  of  living  checked.  The  patient  should 
retire  to  rest  and  get  up  early.  Another  point 
of  importance,  more  particularly  with  reference 
to  the  vocation  of  the  patient,  whether  profes- 
sional or  other,  is  that  he  should  as  much  a? 
possible  avoid  excessive  mental  labour,  or  any 
great  strain  upon  the  mental  faculties,  but 
especially  worry  and  anxiety  of  all  kinds.  The 
writer  has  at  present  under  observation  a case 
in  which  the  influence  of  these  causes  in  bring- 
ing out  eczema  and  other  irregular  symptoms  of 
gout  is  strikingly  illustrated.  It  is  also  im- 
portant to  pay  attention  to  the  cutaneous  func- 
tions, and  to  protect  the  surface  of  the  body 
from  the  injurious  effects  of  cold.  Warm  cloth- 
ing should  be  worn,  in  keeping  with  the 
weather,  and  those  who  can  hear  it  may  wear 
flannel  next  the  skin.  With  regard  to  baths, 
many  persons  are  decidedly  the  better  for  using 
a coll  or  tepid  bath  every'  morning,  followed 


by  energetic  friction  ; in  other  cases  the  employ- 
ment of  the  warm  bath  at  proper  intervals,  or 
even  of  the  Turkish  bath,  answers  best.  It  is 
certainly  beneficial  in  some  instances,  either  for 
those  who  are  already  afflicted,  or  those  who  are 
threatened  with  gout,  to  go  through  a course  of 
treatment  in  a hydropathic  establishment  from 
time  to  time,  under  due  medical  supervision. 
Climate  demands  attention,  whenever  the  cir- 
cumstances of  the  patient  allow  a choice  to  be 
made.  It  may  be  advisable  for  gouty  patients 
to  reside  permanently  in  some  warm  and  equable 
climate,  or  at  any  rate  during  the  winter  and 
early  spring.  In  this  way  attacks  may  often  be 
warded  off,  and  the  disease  thus  prevented  from 
making  progress.  Those  who  are  obliged  to 
remain  in  this  climate  during  the  inclement 
seasons  should  avoid  exposure  to  wet  and  cold, 
;is  well  as  sudden  changes  of  temperature,  and 
night  air.  Their  bedrooms  should  be  warm  and 
well-ventilated ; and  during  cold  weather  it  may 
be  desirable  to  keep  a small  fire  burning  during 
the  night.  Heated  and  badly-ventilated  rooms, 
as  well  as  crowded  places  of  public  resort,  must 
be  eschewed. 

(d)  Medicinal  treatment. — There  can  be  no 
doubt  but  that  the  judicious  use  of  certain 
medicines  may  assist  materially  in  warding  off 
or  mitigating  the  gouty  condition,  and  in  pre- 
venting the  occurrence  of  acute  paroxysms.  Those 
which  are  specially  called  for  in  cases  of  estab- 
lished chronic  gout  will  be  presently  considered. 
In  the  meantime,  it  may  be  stated  that  the 
digestive  functions  require  particular  attention, 
and  medicines  which  promote  these  functions  are 
often  of  the  greatest  service,  if  they  should  be 
disordered,  and  especially  if  there  should  'be  a 
tendency  to  undue  formation  of  acids  in  the 
stomach.  A course  of  alkalies  or  acids,  accord- 
ing to  the  indications  in  each  case,  may  prove  most 
serviceable,  combined  with  some  simple  bitter  in- 
fusion or  tincture.  Certain  alkalies  and  alkaline 
earths  are  also  valuable  on  account  of  their 
power  in  promoting  elimination  of  lithic  acid, 
by  forming  soluble  salts  with  this  acid,  which 
pass  away  in  the  urine,  and  some  of  them  pro- 
bably act  beneficially  in  other  ways.  Those 
which  are  most  useful  for  this  purpose  are  salts 
of  potash  and  lithia,  but  some  practitioners 
prefer  magnesia  or  lime.  The  best  alkaline 
salts  are  the  citrate  or  carbonate,  or  bromide 
of  lithium  may  be  employed,  the  urate  of 
lithia  being  the  most  soluble  of  all.  Soda-salts 
should  not  be  used,  except  when  it  is  desired 
merely  to  influence  the  digestive  functions. 
Either  of  the  salts  above-mentioned  may  be  em- 
ployed from  time  to  time,  and  they  must  be 
taken  well-diluted,  and  on  an  empty  stomach. 
Magnesia  or  its  carbonate  may  be  given  with 
advantage  if  there  is  much  acidity,  and  if 
the  bowels  are  habitually  constipated,  Saline 
aperients  are  often  of  great  service,  and  they 
may  be  beneficially  administered  in  small  doses, 
freely  diluted,  and  regularly  repeated,  when 
they  also  act  on  the  other  excreting  orgafis.  In 
many  cases  other  aperients  may  be  employed 
at  intervals  with  advantage,  but  strong  pur- 
gatives must  only  bo  used  with  much  caution, 
and  this  especially  applies  to  mercurial  prepa- 
rations, which,  if  taken  too  freely,  may  preve 


GOUT.  557 

highly  injurious  to  patients  who  have  any  ten- 
dency to  gout.  The  administration  of  chcla- 
gogues  from  time  to  time  may  be  of  considerable 
service.  Medicines  may  be  given  to  assist  the 
action  of  the  skin,  if  this  should  be  defective,  such 
as  liquor  ammonite  acetatis. 

(c)  Mineral  Waters  and  Baths.  — Certain 
mineral  waters  are  of  the  greatest  value  in  the 
treatment  of  the  gouty  diathesis,  and  they  offer 
the  advantage  that  patients  will  often  use  them, 
habitually  or  at  intervals,  when  they  will  not 
undergo  a course  of  regular  medicinal  treatment ; 
while  the  water  thus  taken  internally  is  itself  of 
service.  Many  of  these  agents  must,  however, 
be  employed  only  under  proper  medical  super- 
vision, otherwise  they  may  do  considerable  harm. 
Space  will  not  permit  any  lengthy  discussion  of 
this  subject  here,  and  it  must  suffice  to  mention 
that  in  different  cases  the  kind  of  mineral  water 
employed  must  be  varied  according  to  the  object 
desired  to  be  accomplished,  and  according  to 
the  indications  presented  by'  the  patient,  for 
what  suits  one  may  be  highly  injurious  to 
another.  These  waters  are  employed  both  in- 
ternally and  in  the  form  of  baths,  some  of  them 
belonging  to  the  class  of  thermal  waters.  Those 
chiefly'  used  in  gouty-  conditions  are  the  waters 
of  Bath,  Buxton,  Harrogate,  Leamington,  and 
Cheltenham  in  this  country;  Strathpeffer  and 
Moffat  in  Scotland  ; and  Carlsbad,  Vichy,  Wies- 
baden, Baden-Baden,  Ems,  JRoyat,  Aix-la-Cha- 
pelle,  Aix-les  Bains,  Friedrichsliall,  Hunyadi 
Janos,  Pullna,  Seidlitz,  Homburg,  Kissingen, 
Wildbad,  Bagatz,  Gastein,  Elster,  Tarasp,  Apol- 
linaris,  and  similar  waters  from  foreign  countries. 
Some  of  these  may  be  taken  regularly  or  at  in- 
tervals, for  the  purposes  which  they-  respectively 
fulfil ; or  if  circumstances  permit,  a systematic 
course  of  treatment  from  time  to  time,  at  certain 
of  the  places  mentioned,  may  be  recommended. 
See  Minerax,  Waters. 

Before  leaving  the  subject  of  the  preventive 
treatment  of  gout,  it  needs  to  be  insisted  upon 
that  those  who  are  particularly  liable  to  this 
disease,  whether  from  their  occupation  or  any 
other  cause,  should  pay  special  attention  to 
preventive  measures ; and  also  that  those  in 
whom  the  disease  has  already  manifested  itself 
must  take  every  precaution  to  avoid  the  known 
causes  of  acute  attacks,  for  each  attack  tends 
to  make  matters  worse. 

2.  Treatment  of  Acute  Gout. — When  a 
fit  of  acute  articular  gout  sets  in,  it  is  on  no 
account  to  be  permitted  to  run  its  course  unmodi- 
fied by  treatment,  else  serious  mischief  is  liable 
to  arise.  At  the  same  time  it  is  requisite  to 
refrain  from  adopting  too  active  measures.  Out 
objects  should  be  to  shorten  the  attack ; to  restore 
the  affected  parts  to  their  normal  condition  ; and 
to  relieve  symptoms.  In  the  first  place,  atten- 
tion must  be  paid  to  the  diet.  The  aim  should 
be  to  make  this  as  low  as  is  compatible  with 
the  condition  of  the  patient,  ^specially  if  the 
attack  presents  an  acute  and  sthenic  type. 
In  young  and  strong  patients  the  diet  should 
at  first  consist  of  farinaceous  substances,  a 
little  milk,  and  abundance  of  water,  barley- 
water,  or  toast-and-water.  Those  who  are 
advanced  in  years,  weak,  or  broken-down  in 
health,  or  who  have  long  suffered  from  gout, 


GOUT. 


568 

require  a more  nutritious  diet,  but  it  should 
be  easily  digestible,  consisting  of  beef-tea  and 
good  soups,  milk,  eggs  beaten  up,  and  such 
articles,  the  quantities  being  regulated  by 
the  requirements  of  each  case.  As  the  symp- 
toms subside,  the  food  must  be  gradually 
improved,  fish,  fowl,  and  meat  being  allowed 
in  succession,  but  in  strict  moderation,  and 
due  care  must  be  exercised  subsequently.  If 
possible,  r.ll  kinds  of  alcoholic  stimulants 
should  be  interdicted,  but  it  may  not  be 
desirable  to  cut  them  off  entirely  in  some  cases, 
either  on  account  of  the  previous  habits  or 
present  condition  of  the  patient,  and  then  it  is 
best  to  give  a definite  quantity  of  brandy  or 
whisky,  well -diluted,  with  the  food.  Tor  those 
who  cannot  take  spirits,  the  writer  has  found  a 
little  good  hock  or  sauterne  answer  well. 

As  regards  medicinal  agents,  colehicum  has 
long  held  the  most  prominent  place  in  the  treat- 
ment of  acute  gout,  and  is  regarded  almost  as  a 
specific.  There  can  be  no  doubt  as  to  the 
influence  of  this  drug  in  relieving  the  inflam- 
matory symptoms,  and  shortening  the  paroxysms 
of  gout,  although  it  is  by  no  means  settled  how 
it  acts.  Its  effects  must  be  watched,  however, 
for  it  does  not  agree  in  every  case.  It  has  been 
alleged  that  colchicum  renders  the  patient 
more  liable  to  subsequent  attacks  of  gout,  but 
for  this  notion  there  does  not  seem  to  be  any 
real  foundation.  The  tincture  or  wine  of 
colchicum  maybe  given  in  doses  of  ten  to  twenty 
or  even  twenty-five  minims  every  four  or  six 
hours,  and  either  of  these  may  be  combined 
with  the  citrate  or  carbonate  of  potash  or 
lithia,  these  salts  being  also  of  great  service  in 
tho  treatment  of  acute  gout.  It  is  necessary  to 
keep  the  bowels  acting  freely  by  means  of 
suitable  aperients,  and  saline  purgatives  are 
of  considerable  value  for  this  purpose.  Other 
aperients,  such  as  compound  rhubarb  pill, 
colocynth,  podophyllin.  or  even  calomel  or  blue 
pill,  may  be  employed  in  appropriate  cases. 
Diluents  may  be  given  freely,  in  order  to  promote 
the  action  of  the  kidneys  ; and  if  the  cutaneous 
functions  appear  to  be  defective,  some  mild  dia- 
phoretic may  be  administered,  or  it  may  even  be 
desirable  to  employ  the  hot-air  or  vapour-bath. 
Medicines  may  be  needed  for  the  relief  of  symp- 
toms, especially  pain  and  sleeplessness,  for 
which  Dover’s  powder  or  other  preparations 
of  opium,  chloral,  or  bromide  of  potassium  may 
be  indicated.  In  very  severe  cases  hypodermic 
injection  of  morphia  is  of  much  service. 

Venesection  ought  never  to  be  practised  in  the 
treatment  of  acute  articular  gout ; for  although 
immediate  improvement  may  perhaps  be  thus 
produced,  the  ultimate  results  are  highly  unsatis- 
factory. Even  the  local  removal  of  blood,  by 
means  of  leeches  applied  near  an  affected  joint, 
is  dangerous,  and  had  better  be  avoided,  on 
account  of  the  permanent  local  mischief  which 
such  a measure  is  lip.blo  to  induce. 

Local  treatment. — The  affected  parts  in  acute 
gout  should  be  kept  entirely  at  rest,  and  placed 
in  a comfortable  position,  supported  by  pillows, 
and  either  horizontal  or  elevated,  according  to 
tho  feelings  of  the  patient.  In  ordinary  cases 
it  is  sufficient,  to  wrap  up  the  joints  in  flannel, 
or  to  surround  them  with  cotton-wool  completely 


covered  with  oil-silk  or  other  impervious  mate- 
rial, by  which  means  a kind  of  local  vapour-bath 
is  kept  up.  If  the  pain  is  considerable,  local 
applications  must  be  used,  of  which  the  most 
useful  are  warm  fomentations,  to  which  tincture 
of  opium  or  belladonna  may  be  added,  poppy 
fomentations,  localised  steaming,  belladonna 
liniment,  tincture  of  aconite,  oleate  of  morphia, 
or  a solution  containing  morphia  and  atropine. 
Those  last-mentioned  may  besmeared  or  painted 
over  tho  surface,  or  applied  by  means  of  lint 
covered  with  oil-silk.  A blister  in  the  neigh- 
bourhood of  a gouty  joint  may  be  of  service,  if 
the  attack  he  asthenic,  and  also  if  effusion 
or  much  stiffness  remain.  During  recovery, 
benefit  may  be  derived  from  car  ful  friction 
with  some  stimulating  liniment,  shampooing, 
gentle  passive  movements,  douching  with  salt 
and  water,  or  the  application  of  a light  bandage 
or  elastic  support,  should  there  be  a tendency  to 
permanent  thickening  and  stiffness,  or  to  oedema 
and  enlargement  of  the  veins. 

The  acute  forms  of  irregular  gout  must  ho 
treated  according  to  their  nature,  and  here 
it  must  suffice  to  offer  a few  general  remarks 
on  the  subject.  If  serious  internal  symptoms 
arise,  which  are  distinctly  of  a gouty  nature,  and 
especially  if  they  occur  as  retrocedent  pheno- 
mena, it  is  important  to  try  to  excite  inflam- 
mation in  the  joints,  by  means  of  local  heat, 
friction,  and  sinapisms.  Colchicum  may  be  of 
service  in  the  n on-articular,  as  well  as  in  the 
articular  form  of  gout.  In  painful  affections 
opium  or  other  anodynes  are  called  for;  and 
frequently  the  administration  of  alcoholic  and 
other  stimulants  is  indicated,  with  anti-spas- 
modies,  such  as  ammonia,  ethers,  camphor, 
musk,  or  belladonna,  especially  when  tho  sto- 
mach or  heart  is  affected.  In  conditions  at- 
tended with  signs  of  much  depression  or  collapse, 
external  heat  may  he  applied  over  the  body,  or 
sinapisms  to  the  limbs  and  over  the  cardiac 
region.  In  the  treatment  of  inflammatory  dis- 
eases associated  with  gout  much  care  is  required, 
especially  in  resorting  to  depletory  measures. 
The  existence  of  the  diathesis  must  always  be 
borne  in  mind. 

3.  Treatment  of  Chronic  Gout. — When 

gout  becomes  an  established  chronic  disease,  the 
same  general  rules  of  treatment  a re  to  be  observed 
as  in  the  prevention  or  attempted  cure  of  thecorn- 
plaint,  but  they  often  need  modification  in  par- 
ticular cases,  according  to  the  conditions  present. 
Similar  medicines  are  also  indicated,  and  lithia 
is  particularly  valuable,  and  may  even  aid  in 
removing  gouty  deposits ; but  others  may  be 
added  to  the  list,  which  are  suitable  in  different 
cases.  Thus,  colchicum  is  often  of  much  service, 
taken  habitually  or  from  time  to  time,  in  the 
form  of  extract  at  night,  or  a few  minims  of 
tincture  or  wine  two  or  three  times  a day,  com- 
bined with  other  medicines.  Among  the  many 
therapeutic  agents  employed  in  the  treatment  of 
chronic  gout  under  different  circumstances  may 
be  mentioned  benzoic  acid  or  benzoate  of  ammo- 
nia, phosphate  of  ammonia,  phosphate  of  soda, 
iodide  of  potassium,  bromide  of  potassium,  car- 
bonate of  alumina,  lime-juice,  guaiaeum,  ammo- 
niaeum,  and  tonics,  especially  quinine,  tincture 
or  infusion  of  cinchona,  or  mild  ferruginous 


GOUT. 

preparations.  Undoubtedly  most  of  these  are 
of  use  in  appropriate  eases  of  chronic  gout, 
to  serve  their  special  purposes.  Symptoms  con- 
nected with  various  organs  frequently  call  for 
attention  in  this  disease,  and  they  must  be  treated 
by  appropriate  remedies.  It  may  be  remarked 
that  if  diarrhoea  should  set  in  in  gouty  cases,  it 
should  not  be  hastily  arrested,  as  this  may  bo  a 
tr.rde  of  relief  to  the  system.  With  regard  to 
I he  local  conditions  in  chronic  gout,  it  .s  affirmed 
I hat  the  prolonged  use  of  some  of  the  mineral 
waters  previously  mentioned,  both  internally  and 
in  the  form  of  baths,  such  as  those  of  Aix-la- 
Chapelle,  Aix-les-Bains,  and  Baden-Baden,  may 
succeed  in  removing  to  some  extent  deposits  of 
urates,  and  in  diminishing  stiffness  and  thicken- 
ing of  joints.  For  these  purposes  local  measures 
may  also  be  of  service  in  some  instances,  pro- 
vided the  morbid  changes  are  not  too  far  ad- 
vanced, namely,  occasional  blistering  or  appli- 
cation of  iodine;  the  prolonged  use  of  wet  ban- 
dages ; friction  with  liniments ; shampooing  and 
passive  movements ; or  systematic  compression 
by  means  of  some  plaster.  Solutions  of  alkalies  or 
alkaline  carbonates,  and  especially  of  carbonate 
of  lithia,  have  been  kept  applied  to  gouty  joints 
and  other  parts  for  along  time,  under  the  belief 
that  deposits  of  urates  may  be  thus  dissolved. 
In  the  writer’s  experience  no  such  effect  has  ever 
been  thus  produced,  although  the  constant  ap- 
plication of  moisture  may  be  useful.  Superficial 
accumulations  of  urates  should  not  be  interfered 
with  unless  they  become  troublesome,  when  it 
may  be  desirable  to  puncture  the  skin,  and  let 
the  contents  out.  The  propriety  of  removing 
large  masses  by  operation  may  come  up  for  con- 
sideration, but  this  should  only  be  attempted  if 
there  is  every  probability  that  they  can  be  en- 
tirely removed  without  any  difficulty,  and  if  the 
patient  is  in  a fit  state  for  the  operation.  When 
abscesses  or  ulcers  form,  they  come  under  the 
treatment  of  the  surgeon;  hut  it  may  be  observed 
that  simple  dressings  usually  answer  best  in 
these  cases,  and  they  may  sometimes  be  advan- 
tageously dressed  with  solution  of  carbonate  of 
potash  or  lithia.  It  must  not  be  attempted  to 
heal  them  up  too  rapidly,  as  the  discharge  may 
be  a relief  to  the  system,  and  it  may  even  be 
necessary  to  enlarge  the  opening  of  an  abscess. 
Uuder  an}-  treatment  it  is  by  no  means  an  easy 
matter  to  induce  gouty  sores  to  heal. 

The  treatment  of  the  various  chronic  organic 
diseases  which  are  liable  to  arise  in  the  course 
of  gout  must  always  be  kept  in  mind,  but  the 
reader  is  referred  to  other  appropriate  articles 
for  a consideration  of  this  part  of  the  subject. 

Frederick  T.  Roberts. 

GRAIN'D  MAL.  (Fr.) — A term  applied  to 
epilepsy  when  it  assumes  the  form  of  a severe 
convulsive  attack.  See  Epilepsy. 

GRANULAR  KIDNEY. — A morbid  con- 
dition of  the  kidney,  in  which  this  organ  is 
the  seat  ot  fibroid  change,  and  as  a result 
becomes  contracted,  hard,  and  granular.  See 
Bright's  Disease. 

GRANULAR  LIVER. — A synonym  for 
cirrhosis  of  the  liver,  in  which  the  organ  presents 


GRAVEL.  659 

a granular  appearance,  on  its  surface  and  on 
section.  See  Liver,  Diseases  of. 

GRANULATION ( granulum , a littlcgrain). 
In  medical  pathology,  granulation  is  synonym- 
ous with  tubercle  in  its  isolated  form,  the  indi- 
vidual tubercles  beiug  called  ‘grey’  or  ‘ yellow' 
granulations,  according  to  their  appearance.  See 
Tubi«cle.  In  surgical  pathology,  the  term 
granulations  is  applied  to  small  vascular  pro- 
minences, consisting  of  embryonic  tissue,  growing 
on  the  surface  of  wounds  or  ulcers,  and  by  which 
the  healing  process  is  carried  on — whence  the 
expression  ‘ healing  by  granulation.’  When  granu- 
lations assume  the  appearance  of  an  exuberant 
growth  they  constitute  what  is  called  ‘proud 
flesh’  ( see  Cicatrization,  and  Ulcer.) 

GRANULIE  (French).— A synonym  for 
tuberculosis.  See  Tuberculosis. 

GRAVEDO,  ( gravis , heavy). — A sjmonym  for 
common  catarrh  ; so  applied  on  account  of  the 
sensation  of  weight  in  the  head  present  in  that 
affection.  See  Catarrh. 

GRAVEL.  — Definition.  — The  deposit  in, 
and  escape  from  the  urinary  passages  of  grittv 
particles  with  the  urine. 

JEtiology. — The  same  causes  which  produce 
dyspepsia  are  frequently  productive  of  lithie 
acid  gravel,  such  as  indolent  habits,  excess  of 
food  and  drink — especially  of  nitrogenous  and 
saccharine  articles,  and  the  too  free  indulgence 
in  the  use  of  fermented  liquors.  Endemic  causes 
connected  with  climate  and  the  nature  of  the 
drinking  water,  hereditary  predisposition,  and 
many  slight  or  serious  organic  diseases,  may 
explain  the  appearance  of  gravel  in  those,  and 
especially  in  women,  who  commit  no  dietetic 
excess,  or  who  are  total  abstainers.  See  Oxalic 
Acid  Diathesis,  Phosphatic  Diathesis,  and 
Uric  Acid  Diathesis. 

Varieties. — Gravel  maybe  composed  of  (1’] 
litbic  acid  and  its  compounds ; (2)  oxalate  of 
lime;  (3)  phosphate  of  lime;  or  (4)  the  triple 
phosphate  of  lime,  magnesia,  and  ammonia. 
By  far  the  most  common  form  of  gravel,  and 
that  which  alone  need  now  be  considered,  is  the 
lithie  acid.  This,  owing  chiefly  to  its  great 
insolubility,  is  frequently  deposited  in  the  kid- 
ney and  bladder,  and  is  seen  in  the  newly- 
passed  urine  in  the  form  of  the  well-known 
reddish-brown  crystals,  often  described  as  re- 
sembling Cayenne  pepper  grains.  The  super- 
natant urine  is  generally  clear,  rather  dark  in 
colour,  and  of  a distinctly  acid  reaction. 

Symptoms. — The  passage  of  uric-acid  crystals 
or  gravel  frequently  eaus-s  no  subjective  symp- 
toms, and  is  consistent  with  perfect  health. 
Sometimes,  however,  it  gives  rise  to,  or  is 
accompanied  ly,  both  general  and  local  dis- 
turbance of  function.  The  general  symptoms 
are  those  of  dyspepsia,  namely,  flatulence  and 
heartburn  after  meals,  eructations,  headache, 
muscular  cramp,  depression  of  spirits,  and  a 
sense  of  malaise.  Locally,  there  is  dull  aching 
in  the  lumbar  region,  not  increased  by  move- 
ment ; frequent  micturition ; a sense  of  heat 
and  irritation  at  the  neck  of  the  bladder  and 
along  the  urethra,  especially  during  and  after 
voiding  water ; and  sometimes  the  appearance 


560  GRAVEL. 

of  a faint  cloud  of  mucus  or  a slight  tinge  of 
blood  in  the  urine. 

Treatment. — -From  what  has  been  said,  it 
follows  that  the  most  important  points  in  the 
treatment  of  gravel  are  strict  limitation  as  to 
the  quantity  of  food;  the  avoidance  of  highly- 
seasoned,  very  rich,  or  sweet  dishes;  the  pre- 
ference for  vegetable  rather  than  for  animal 
food  ; abundant  exercise  in  country  ai  r ; and 
the  absence  or  very  sparing  use  of  alcoholic 
liquors.  Medicinally  there  maybe  given  diuretics, 
to  increase  the  quantity  of  the  urine  and  facilitate 
the  escape  of  gravel ; pure  water,  alkalis,  and 
alkaline  waters  freely  diluted,  to  act  as  solvents 
of  uric  acid;  and  saline  aperients  and  saline 
waters,  to  promote  digestionaud  assistin ensuring 
the  free  action  of  the  liver  and  alimentary  canal. 

W.  Cadge. 

GRAVES’  DISEASE.— A synonym  for 
exophthalmic  goitre,  to  which  the  late  Dr.  Graves 
of  Dublin  called  special  attention.  See  Exoph- 
thalmic Goitre. 

GREEN-SICKNESS. — A popular  synonym 
for  chlorosis,  applied  on  account  of  the  greenish 
colour  of  the  skin  sometimes  present  in  that  dis- 
ease. See  Chlorosis. 

GRIPPE  (Fr.) — A French  synonym  for  in- 
fluenza. See  Influenza. 

GROWTH,  Disorders  of.— See  Atropht, 
Hypertrophy,  and  Malformations. 

GRUTUM. — A term  applied  to  small,  hard, 
white  globules  developed  from  the  epidermis, 
and  commonly  met  with  on  the  face,  especially 
on  the  eyelids,  cheeks,  and  temples.  They  are 
called  grutum,  from  bearing  some  resemblance 
to  oatmeal  grits  ; and  have  likewise  boen  named 
milium,  as  comparing  them  in  size  and  roundness 
of  figure  to  millet-seeds.  Other  of  their  syno- 
nyms are  miliary  tubercles  and  pearly  tubercles. 

Erasmus  Wilson. 

GUINEA-WORM. — Synon.  : Dracunculus  ; 
Filaria  medinensis.  Supposed  by  some  persons 
to  be  the  ‘ fiery  serpent  ’ of  Mosaic  history. 

Description.- — The  Guinea-worm  is  a nema- 
toid  parasite,  usually  measuring  from  one  to  three 
feet  in  length,  and  having  a breadth  of  about  one- 
tenth  of  an  inch.  Examples  have  been  described 
as  reaching  six  feet  in  length.  In  the  adult  con- 
dition it  infests  the  feet  and  legs,  as  well  as  other 
parts  of  the  body  that  are  much  exposed.  The 
female  only  is  known,  but  its  more  or  less  finely 
pointed  and  subulate  tail  has  often  caused  it  to 
be  described  as  the  male  parasite  (by  Owen  and 
others).  The  anatomy  of  the  worm  has  been  de- 
scribed by  Busk,  Carter,  and  Leuekart,  and  more 
particularly  by  Bastian,  who  has  also  thrown 
much  light  upon  the  structure  and  development 
of  the  embryos  as  they  are  found  within  the  body 
of  the  parent  worm  (Linn.  Trans.  1863,  p.  101  ct 
seq.)  The  discovery  of  the  viviparous  mode  of 
reproduction  of  the  dracunculus  is  probably  due 
to  Jacobson, whose  observations  were  subsequently 
verified  by  Owen,  Busk,  Bastian,  the  writer,  and 
also  by  Robin,  Carter.  Davaine,  and  Moquin- 
Tandon.  As  regards  the  development  of  the  worm 
outside  the  body  of  the  parent,  the  only  obser- 
vations of  importance  are  those  of  the  Russian 


GUINEA-WORM. 

traveller,  Eedschenko.  According  to  the  deceased 
savant  (as  verbally  communicated  to  the  writer 
during  his  visit  to  England),  the  escaped  em- 
bryos of  the  Guinea-worm  perforate  the  skin  of 
minute  aquatic  crustaceans  (Cyclops).  Here, 
after  a period  of  only  twelve  hours,  the  embryos 
undergo  a first  change  of  skin,  parting  with  their 
long  fine  tails,  which  eventually  become  compara- 
tively blunt  and  forked.  At  the  expiration  of 
one  month  and  six  days  they  acquire  their  highest 
larval  stage  of  growth  within  the  Cyclops,  traces 
of  the  reproductive  organs  being  already  seen  ; 
and  thus,  aloDg  with  the  intermediate  hosts,  as 
young  males  and  females,  they  are  transferred  to 
the  human  stomach.  Eedschenko  expressed  his 
belief  that  it  was  either  in  the  stomach  or  in  the 
intestine  that  they  subsequently  copulated,  pro- 
ducing a progeny  after  the  manner  of  Trichina; 
the  males  perishing  and  passing  away  per  annm, 
whilst  the  females  migrated  through  the  tissues 
towards  the  surface  of  the  body.  Whether  or  not 
this  view  be  correct,  Fedschenko's  discover)'  of 
the  fact  that  the  dracunculus  needs  to  pass  through 
the  body  of  an  intermediary  bearer  loses  none  of 
its  practical  and  scientific  interest.  In  Dr.  Bas- 
tian’s  opinion  the  young  dracunculi  are  the  pro- 
duct of  a non- sexual  process.  It  should  not  be 
forgotten  that  Dr.  Carter,  who  is  a great  authority 
on  all  matters  connected  with  the  nat  ural  history 
of  the  guinea-worm,  has  stated  that  in  a school 
of  fifty  boys  bathing  in  a pond,  the  sediment  of 
which  swarmed  with  microscopic  tank-worms 
( Urobales palustris),  no  less  than  twenty-one  were 
attacked  with  dracunculus  during  the  year ; 
whilst  the  hoys  of  other  schools,  bathing  else- 
where on  the  island  of  Bombay,  were,  with  one  or 
two  individual  exceptions,  not  affected.  Facts 
of  this  kind  long  led  the  writer  and  others  to 
suppose  that  sexual  maturity  was  attained  prior 
to  the  entrance  of  the  worms  into  the  human 
hearer.  Thus,  the  writer  has  stated  it  to  be 
probable  ( Entozoa , 1861,  p.  388)  that  ‘ the  sexes 
associate  in  muddy  waters  during  the  monsoon, 
after  which  act  the  males  perish,  whilst  the 
females  are  left  to  find  their  opportunity  for  a 
mode  of  direct  entrance  into  and  further  develop- 
ment within  the  human  body.’  It  is  clear  that 
some  waters  are  more  infested  by  young  guinea- 
worms  than  others.  It  is  also  tolerably  certain 
that  human  infection  is  due  to  the  passive  immi- 
gration of  the  parasites.  We  fear,  however,  that 
the  notion  of  ingress  in  a direct  manner  through 
the  ducts  of  the  skin  must  now  be  abandoned. 
Its  former  acceptance  appeared  to  he  in  entire 
harmony  with  the  data  supplied  by  Indian  army 
surgeons  and  other  observers. 

The  geographical  distribution  of  the  guinea- 
worm  is  limited  to  inter-tropical  climates,  being, 
for  the  most  part,  confined  to  certain  districts  id 
Asia  and  Africa.  It  occurs  also  iu  the  island  o: 
Cur.-njoa  and  in  Brazil.  [On  this  subject  see  Dr. 

J.  F.  daSilva  Lima's  Memoir  in  The  Veterinarian 
for  February,  1879.]  It  is  endemic  in  its  action, 
all  races  of  mankind,  without  reference  to  age  or 
sex,  being  liable  to  be  attacked  in  the  guinea- 
worm  districts. 

Treatment. — Clinically  speaking,  the  mode  of 
treatment  pursued  at  the  present  day  does  not 
differ  materially  from  the  old  method  adopted 
by  the  Persian  surgeons,  who  extracted  the  worm 


GTJINEA-W  OEM. 

by  gentle  and  continuous  traction,  winding  the 
exposed  end  of  the  worm  round  a small  stick  of 
iron-,  bone,  or  wood.  If  the  parasite  be  rup- 
tured, local  and  even  severe  constitutional  mis- 
chief is  apt  to  ensue.  SccDracunculus. 

T.  S.  Cobbold. 

GUMMA  (Lat.,  gum). — A growth  occurring 
in  syphilis,  so  named  on  account  of  its  supposed 
superficial  resemblance  to  gum.  See  Syphilis. 

GUMS,  Diseases  of. — See  Mouth,  Diseases 
of. 

GURGLING. — A physical  sign  heard  on 
auscultation  of  the  chest  or  abdomen  in  certain 
conditions,  due  to  the  movement  of  gas  and  fluid 
within  a cavity,  whether  normal  or  abnormal. 


H HEMACYTOMETER.  501 

A gurgling  sensation  may  also  be  felt  at  times  in 
the  intestines,  as  over  the  csecum  in  typhoid 
fever.  See  Physical  Examination. 

GUTTA  ROSACEA  (gutta,  a drop;  rosa- 
cea, rosy). — A synonym  for  Acne  rosacea.  Set 
Acne. 

GYMNASTICS  ( yv/xvds , naked).  See  Exfb 
cise. 

GYNAECOLOGY  {yvvij,  a woman,  ami 
\6yos,  a word). — This  term  in  its  literal  sense 
means  a doctrine  or  discourse  concerning  women. 
In  medical  language,  it  comprehends  the  study 
of  the  diseases  peculiar  to  women.  See  Women, 
Diseases  Peculiar  to. 


H 


HABIT  OE  BODY. — This  expression  sig- 
nifies the  sum  of  the  physical  qualities  of  an 
individual,  and  is  sometimes  used  synonymously 
with  constitution.  Thus  we  speak  of  a full  habit, 
a spare  habit,  and  an  apoplectic  habit. 

HABITS.  See  Disease,  Causes  of;  and 
Pehsonal  Health. 

HAEMACYTOMETER  (aTpa,  blood,  kotos, 
a cell,  and  pirpov,  a measure). — Definition. — 
An  instrument  by  the  aid  of  which  the  number 
of  corpuscles  contained  in  a given  volume  of 
blood  can  be  ascertained. 

Description. — All  methods  employed  for  this 
object  consist  in  making  a definite  dilution  of  a 
certain  quantity'  of  blood,  and  counting  the  number 
of  blood-corpuscles  in  a certain  volume  of  this 
dilution.  Vierordt,  who  originated  the  method, 
drew  uniform  lines  of  diluted  blood  upon  a 
slide,  and,  after  it  was  dry,  counted  the  cor- 
puscles in  a certain  length  of  line.  Cramer 
substituted  for  these  lines  what  may  be  termed 
a capillary-  cell ; and  Potain  and  Malassez  em- 
ployed a capillary  tube,  and  a microscope  pro- 
vided with  an  eyepiece  ruled  in  squares.  Hayem 
substituted  for  the  tube  a cell,  the  depth  of 
which  gave  one  dimension  of  the  volume  of  dilu- 
tion, while  the  lines  upon  the  eyepiece  furnished 
the  others.  The  writer’s  instrument  is  an  adapta- 
tion of  Hayem’s,  with  certain  modifications;  the 
diluting  apparatus  is  similar,  but  of  different 
capacity,  and  the  lateral  dimensions  of  the  vo- 
lume of  dilution  are  obtained,  not  by  a micro- 
scope-eyepiece, but  by  lines  engraved  upon  the 
glass  slide  at  the  bottom  of  the  cell.  The  in- 
strument can  thus  be  used  with  any  microscope, 
m important  convenience  in  practical  use.  The 
alteration  in  the  capacity  of  the  diluting  mea- 
sures facilitates  the  counting,  and  provides  a 
much  simpler  mode  of  statement  of  the  result. 
The  apparatus,  which  is  made  by  Hawksley, 
consists  of  (1)  a pipette  graduated  to  995  cubic 

36 


millimeters  for  measuring  the  diluting  solution 
(2)  a capillary  tube  for  measuring  the  blood, 
containing  five  cubic  mm. ; (3)  a small  glass  jar 
and  stirrer  for  making  the  dilution ; and  (4)  the 
cell  for  counting,  -2  mm.  deep,  and  ruled  at  the 
bottom  in  squares,  each  -1  mm.  in  length  and 
breadth.  The  slide  bearing  the  cell  is  fixed  on 
a small  metal  plate,  to  which  two  springs  are 
attached ; these  keep  the  cover-glass  in  posit  ion 
when  applied. 

Various  solutions  have  been  employed  for 
making  the  dilution.  That  which  the  writer  has 
found  to  answer  best,  as  differentiating  most 
clearly  the  red  and  white  corpuscles,  consists  of 
sulphate  of  soda,  10A  grains ; acetic  acid,  1 
drachm  ; distilled  water,  6 ounces. 

In  using  the  hsemacytometer,  a drop  of  the 
dilution  is  placed  in  the  centre  of  the  cell ; the 
cover-glass  and  springs  are  applied ; and  in  a few 
minutes  the  corpuscles  have  sunk  to  the  bottom  of 
the  cell,  and  are  seen  lying  within  the  squares. 
The  dilution  of  5 cnim.  of  blood  in  995  emm.  of 
solution  is  1 in  200 ; each  square  contains  the 
corpuscles  from  a volume  of  dilution  • 2 mm.  in 
one,  and  -1  mm.  in  each  of  the  other  dimensions 
— that  is,  2 cubic  T nun.,  or  the  '002  part  of  a 
cubic  mm.  But  the  dilution  being  1 in  200  this 
volume  of  dilution  contains  just  -00001  cm.  of 
blood.  The  number  of  corpuscles  in  a square, 
multiplied  by  100,000,  is  thus  the  number  in  a 
cubic  millimeter  of  blood — the  common  mode  of 
statement.  In  order  to  limit  error,  the  number 
of  corpuscles  in  ten  squares  should  be  counted, 
and  this  number  multiplied  by  10,000  is  the 
number  per  cubic  millimeter.  The  average 
number  in  health  is  about  5.000,000.  Blood  of 
normal  richness,  then,  contains  about  50  corpus- 
cles per  hsemacytometer  square.  Therefore  the 
number  in  two  squares  of  the  instrument  will 
always  represent  the  proportion  of  the  corpus- 
cular richness  to  normal  blood(  = 100) — that  is, 
the  percentage  proportion  to  normal.  It  is,  there- 


562  HEMACYTOMETER, 

fore,  convenient  to  take  the  volume  of  blood 
represented  by  the  two  squares  ('00002  cubic 
millimeter)  as  the  standard  volume,  or  ‘ hsemic 
unit.’  Eor  instance,  it  is  found  that  the  blood 
diluted  presents  in  ten  squares  375  corpuscles 
or  75in  two  squares  (‘haemic  unit’) — that  is,  75 
per  cent,  compared  with  the  normal.  To  learn 
the  number  per  cubic  millimeter  we  have  only 
to  multiply  375  by  10,000,  = 3,750,000.  In 
counting  the  white  corpuscles,  if  they  are  not  in 
considerable  excess,  it  is  most  convenient  first 
to  ascertain  the  number  of  red  corpuscles  per 
square,  and  note  how  many  squares  are  con- 
tained in  a field  of  the  microscope.  If  then  the 
focus  is  raised  so  that  the  corpuscles  are  becom- 
ing indistinct,  the  white  ones,  from  their  higher 
refracting  power,  will  appear  like  bright  points, 
and  the  number  in  a series  of  fields  can  easily 
be  counted.  Eor  example,  the  number  of  red 
corpuscles  per  square  has  been  found  to  be  40, 
and  the  field  contains  15  squares,  that  is,  600 
corpuscles  per  field.  Ten  fields  contain  1 5 white 
corpuscles ; the  proportion  of  white  to  red  will, 

therefore,  be  1 to  -— = 1 to  400. 

15 

With  this  apparatus  we  may  readily  ascer- 
tain, within  a small  limit  of  unavoidable  error, 
the  corpuscular  richness  of  the  blood,  an  impor- 
tant element  in  many  morbid  states,  such  as 
anaemia;  and  we  can  thus  ascertain  the  indi- 
cations for,  and  observe  the  effect  of,  therapeutic 
agents.  It  is,  however,  very  desirable  in  these 
cases  to  ascertain  also  the  richness  of  the  cor- 
puscles in  haemoglobin  ( sec  Hjemoglothnometeu). 
The  instrument  may  also  be  employed  for  ascer- 
taining the  globular  richness  of  milk  or  other 
liquids.  W.  R.  Gowers. 

HiEMATEMESIS  (alyta,  blood,  and  e’yuew,  I 
vomit). — Synon.  ; Fr.  Hematemesc ; Ger.  Blut- 
brechen. 

Definition*. — Vomiting  of  blood,  dependent 
on  a variety  of  morbid  conditions. 

.ZEtiology  and  Pathology. — Haemorrhage 
into  the  stomach  may  arise — 1.  From  the  laying 
open  of  an  artery.  2.  From  venous  or  capillary 
congestion  of  the  mucous  membrane.  3.  From 
causes  affecting  the  blood  itself,  so  that  it  tends 
to  transude  through  the  vessels  under  pressure 
of  the  circulation. 

1 .  The  most  frequent  cause  of  haematemesis  is 
an  ulcer  of  the  stomach.  It  occurs,  according  to 
the  late  Dr.  Brinton,  in  about  one-third  of  all 
the  cases  of  gastric  ulcer  that  come  under  treat- 
ment. The  bleeding  usually  takes  place  shortly 
after  a meal,  and  the  quantity  rejected  varies 
greatly.  In  some  cases,  it  is  so  small  that  it 
may  require  careful  examination  to  discover  it ; 
whilst  in  others  enormous  quantities  are  vo- 
mited, and  often  also  passed  through  the  bowels. 
The  splenic  artery  is  most  frequently  the  source 
of  the  bleeding,  but  it  may  arise  from  the 
coronary,  the  superior  pyloric,  or,  more  rarely, 
from  the  blood-vessels  of  some  of  the  neigh- 
bouring organs,  such  as  the  pancreas,  liver,  or 
spleen,  to  which  the  stomach  has  become  at- 
tached, and  which  may  happen  to  form  the  base 
of  the  ulcer.  It  is  not  necessary  that  the  ulcer 
should  be  of  large  size  to  produce  haemorrhage. 
Although  it  is  most  apt  to  occur  in  chronic 


H2EMATEME8I3. 

cases,  instances  have  been  recorded  in  which  a 
large  vessel  had  been  laid  open  by  an  ulcer  so 
small  as  to  require  careful  search  for  its  detec- 
tion. It  must  be  borne  in  mind  that  extensive 
bleedings  may  take  place  without  any  vomiting, 
and  the  source  of  the  fatal  illness  be  overlooked. 
Such  cases  are  not  of  infrequent  occurrence,  and 
warn  the  practitioner  that  he  should  be  on  the 
alert,  whenever  signs  of  haemorrhage  present 
themselves,  and  that  he  should  not  rely  too  much 
on  the  absence  of  pain  and  vomiting.  In  cancer 
of  the  stomach  profuse  haemorrhage  is  less  com- 
mon than  in  simple  ulcer;  the  larger  vessels  being 
probably  compressed  by  the  new  growth,  which 
ordinarily  commences  in  the  submucous  tissue 
immediately  above  them.  But  a constant  oozing 
of  blood  is,  on  the  contrary,  more  common  than 
in  simple  ulceration.  This  blood,  acted  on  by 
the  gastric  juice,  constitutes  the  ‘ coffee  ground’ 
vomiting  of  the  older  authors.  Its  occurrence 
used  to  be  looked  upon  as  pathognomonic  of 
malignant  disease,  but  it  is  now  known  that  its 
presence  only  shows  that  the  bleeding  has  taken 
place  slowly  and  in  small  quantities  at  a time. 
Occasionally  profuse  haemorrhage  takes  place 
from  the  rupture  of  an  aneurism  into  the 
stomach  ; and  in  a case  which  came  under  the 
writer's  notice  at  the  London  Hospital,  fatal 
vomiting  of  blood  resulted  from  the  perforation 
of  the  aorta  by  a fish-bone  that  had  become  im 
pacted  in  the  oesophagus. 

2.  Congestion  of  the  portal  system  is  a very 
frequent  cause  of  hoematemesis.  The  most 
marked  and  fatal  cases  ot'  this  kind  occur  along 
with  plugging  of  the  vena  portse  or  its  large 
branches  with  blood-clots  or  cancerous  matter. 
Such  cases  are  very  rare,  and  vomiting  of  blood, 
arising  from  venous  congestion,  ordinarily  results 
from  cirrhosis,  chronic  congestion,  and  other  dis- 
eases of  the  liver,  in  which  the  portal  circu- 
lation is  obstructed.  More  rarely  the  like  oc- 
currence is  observed  in  persons  suffering  from 
diseased  heart,  especially*  where  there  is  narrow- 
ing of  the  mitral  orifice.  In  such  cases,  ther^ 
is  generally  a co-existence  of  chronic  catarrhal 
gastritis,  and  in  all  probability  the  bleeding 
takes  place  from  the  haemorrhagic  erosions  so 
common  in  that  condition.  In  one  form  of  this 
disease  enormous  quantities  of  mucus  are  dis- 
charged. Sometimes  there  is  considerable  bleed- 
ing in  these  cases,  but  they  are  distinguishable 
from  ulcer  by  the  absence  of  pain  ; by  the  vomit- 
ing being  only  occasional;  and  also  by  the  fact 
that  the  blood-stained  vomit  generally  follows  a 
profuse  evacuation  of  colourless  mucus,  and  is 
always  of  a dark  colour.  In  females  thus  af- 
fected the  catamenial  discharge  is  generally  pro 
fuse  ; and  the  attacks  of  vomiting  do  not  neces- 
sarily coincide  with  the  menstrual  periods.  It 
has  always  been  held  that  hsematem<  sis  may  re- 
place the  menstrual  discharge.  Without  denying 
this,  the  writer  has  never  met  with  a well-marked 
case  of  the  kind.  Hsematemesis  due  to  acute 
congestion  is  also  a coustant  result  of  irritant 
poisoning. 

3.  Hsematemesis  also  arises  from  causes  affect- 
ing the  blood,  and  predisposing  it  to  ooze  through 
the  walls  of  the  veins  or  capillaries.  It  occurs 
in  this  way  in  purpura,  yellow  fever,  and  in  some 
cases  of  typhus.  In  jaundice,  where  bleeding 


H2EMATEMESIS. 

hom  tho  gams  and  other  mucous  membranes  is 
60  often  observed,  life  may  be  suddenly  destroyed 
by  htematemesis.  Occasionally  a haemorrhagic 
tendency  manifests  itself  suddenly,  without 
apparent  cause,  as  in  a case  observed  by  the 
writer,  in  which  a woman,  about  fifty  years  of 
age,  was  affected  with  severo  bleeding  from 
the  nose,  followed  by  excessive  menstrual  dis- 
charge, on  the  cessation  of  which  profuse  haema- 
temesis  took  place,  from  which  she  sank.  She 
had  no  jaundice  nor  other  apparent  cause  for  her 
illness,  and  after  death  the  most  careful  scrutiny 
failed  to  detect  disease  in  any  organ.  To  this 
class  of  causes  we  should  probably  refer  the 
htematemesis  occurring  in  acute  atrophy  of  the 
liver,  and  in  pyaemia,  as,  in  all  probability,  the 
oozing  of  blood  through  the  vessels  arises  from 
changes  effected  in  its  chemical  or  physical  com- 
position. 

Symptoms. — Generally  the  patient  in  haemate- 
mcsis  is  suddenly  attacked  with  faintness,  accom- 
panied by  a feeling  of  weight  at  the  pit  of  the 
stomach,  the  countenance  is  pale,  the  pulse  f eeble 
and  compressible,  and  in  some  cases  actual  syncope 
occurs.  This  state  terminates  by  vomiting,  and  a 
greater  or  less  quantity  of  blood  is  rejected  from 
the  stomach.  When  a large  blood-vessel  has 
been  laid  open,  and  the  bleeding  has  taken  place 
rapidly,  the  blood  may  be  florid  ; but  generally 
the  haemorrhage  goes  on  so  slowly  that  time  is 
given  for  the  action  of  the  gastric  juice  upon  it, 
and  consequently  it  is  of  a dark  colour.  It  is 
not  often  that  the  stomach  is  completely  emp- 
tied, or  perhaps  the  bleeding  persists  in  small 
quantities  after  the  vomiting  has  ceased,  so 
that  the  stools  are  generally  of  a dark  or  pitchy 
character,  from  the  admixture  of  blood  that 
has  passed  into  the  intestines.  The  haemorrhage 
may  cease  soon  after  the  stomach  has  been  emp- 
tied, or  the  vomiting  of  blood  may  recur  from 
time  to  time,  or — and  this  is  very  apt  to  occur  in 
gastric  ulcer — months  or  years  may  elapse  before 
it  again  takes  place. 

Diagnosis. — In  some  cases,  when  the  blood  has 
been  slowly  effused  into  the  stomach,  there  may 
be  difficulty  in  determining  whether  the  dark 
colour  arises  from  bile  or  blood.  The  micro- 
scope or  spectroscope  will  be  enough  to  settle 
this  point ; or  the  liquid  may  be  boiled  with  alco- 
hol, and  tested  for  the  biliary  salts.  It  is  not 
always  easy  to  ascertain  whether  the  blood  has 
come  from  the  lungs  or  from  the  stomach,  as  the 
patient  is  sometimes  so  much  alarmed  that  he 
cannot  say  whether  it  was  brought  up  by  cough- 
ing or  vomiting.  As  a general  rule,  the  blood 
from,  the  lungs  is  florid,  mixed  with  mucus, 
alkaline,  and  frothy;  that  from  the  stomach  of 
darker  colour,  intermixed  with  particles  of  food, 
and  in  masses.  Again,  haemoptysis  is  generally 
preceded  by  symptoms  referable  to  heart  or 
lungs,  such  as  cough,  expectoration,  and  dyspnoea ; 

, haematemesis  by  tho  symptoms  indicative  of 
' gastric  or  hepatic  disease,  such  as  those  de- 
scribed above. 

Prognosis. — As  a general  rule  this  is  favour- 
j,  able  in  haematemesis,  more  especially  in  first 
attacks.  Dr.  Brinton  calculated  that  death  re- 
sulted from  this  cause  in  only  3 to  5 per  cent, 
of  tho  cases  of  gastric  ulcer ; and  it  is  still  less 
frequently  fatal  where  it  proceeds  from  hepatic 


ILZEM ATINU RIA,  PAROXYSMAL.  563 

congestion  or  cirrhosis.  Still,  the  possibility  of 
the  bleeding  arising  from  flooding  of  the  portal 
vein,  from  the  opening  of  a large  artery,  or  from 
the  bursting  of  an  aneurism,  should  be  kept  in 
view,  and  the  patient  carefully  watched. 

Treatment. — Where  a large  quantity  of  blood 
has  been  ejected  from  the  stomach,  the  treatment 
must  be  prompt  and  decided.  The  patient  should 
be  maintained  in  a recumbent  posture,  and  kepi 
perfectly  quiet.  All  food  must  be  forbidden,  and 
pieces  of  ice  placed  in  the  mouth  to  suck.  If  faint- 
ness he  present,  it  is  better  not  to  give  brandy, 
which  almost  always  brings  on  vomiting,  but  to 
apply  ammonia  to  the  nostrils  ; or,  if  necessary, 
an  enema  containing  brandy  may  be  given. 

The  best  styptics  are  gallic  acid,  alum,  and 
acetate  of  lead.  The  gallic  acid  may  be  given  in 
10-grain  doses,  along  with  10  or  15  minims  of 
dilute  sulphuric  acid,  and  should  be  repeated 
frequently.  Alum  may  be  prescribed  in  infusion 
of  loses;  and  the  acetate  of  lead  in  2-grain  doses 
in  the  shape  of  a pill,  or  combined  with  acetic 
acid.  Oil  of  turpentine  is  also  used.  Where  the 
bleeding  is  slight,  and  there  is  good  reason  to 
believe  it  arises  from  portal  congestion,  the  best 
treatment  is  to  give  a small  dose  of  calomel,  fol- 
lowed bysulphate  of  magnesia  and  dilute  sulphuric 
acid  in  infusion  of  roses  every  three  or  four  hours, 
until  purging  is  produced. 

For  some  days  after  severe  hasmatemesis,  t.1  ■« 
strictest  quiet  should  be  maintained;  and,  in  toe 
case  of  ulcer  of  the  stomach,  opium  should  be 
used,  and  the  diet  most  carefully  regulated;  it 
rendered  necessary  by  persistent  bleeding,  nutri- 
tive enemas  should  be  substituted  for  food  by 
the  mouth,  and  all  purgatives  avoided.  When  tho 
haemorrhage  has  arisen  from  portal  congestion,  a 
free  action  on  the  intestinal  canal  should  be  com- 
menced in  a few  days  after  the  cessation  of  tho 
htemorrhage,  so  as  to  diminish  the  amount  ot 
blood  in  the  venous  system  of  the  alimentary 
organs.  S.  Fenwick. 

HIEMATHIDROSIS  (aTpa,  blood,  and 
ISpas,  sweat).— Bloody  sweat.  See  Perspira- 
tion, Disorders  of. 

H-ZEMATHORAX.  See  Hjemato-thorax. 

H-ZEMATTN". — See  Hjemoglohin. 

ELZEMATINTTRIA,  PAROXYSMAL 

(hsernatin ; and  olpov,  the  urine). — Synon.  : 
Haemoglobinuria. 

Definition. — A paroxsymal  affection  of  the 
system ; manifesting  itself  by  changes  in  the 
urine  ; caused  sometimes  by  malaria,  and  some- 
times by  other  conditions  not  yet  determined  ; 
consisting  in  no  anatomical  change  as  yet  recog- 
nised ; and  characterised  by  the  occasional  occur- 
rence of  constitutional  disturbance,  with  discharge 
of  dark,  blood-stained  nrine. 

jETiot-oGY. — The  most  important  extrinsic 
cause  of  the  tendency  to  this  disease  is  malarious 
poison,  the  most  important  cause  of  the  parox- 
ysm is  exposure  to  cold  or  wet ; but  the  tendency 
may  exist  without  malarial  poison,  and  the  attack 
may  occur  apart  from  any  special  exposure 
Amongst  intrinsic  causes,  sex  is  evidently  im 
portant,  for  the  disease  is  almost  confined  to 
males.  It  may  occur  in  children,  and  may  occa 
sionally  recur  during  a period  of  years. 


564  HiEMATINURIA,  PAROXYSMAL. 

Anatomical  Characters. — The  disease  not 
being  fatal,  there  is  no  evidence  as  to  the  exist- 
ence of  any  anatomical  change  in  the  kidneys. 

Symptoms. — Hsematinuria  is  paroxysmal,  but 
not  distinctly  periodic.  It  may  commence  in  child- 
hood or  during  adult  life.  The  attacks  may  occur 
once,  twice,  or  thrice  a day,  on  alternate  days, 
once  a week,  or  quite  irregularly.  The  paroxysm 
may  commence  abruptly  without  any  premonitory 
symptom,  but  is  more  commonly  ushered  in  by 
a feeling  of  uneasiness  in  the  loins  and  limbs, 
by  shivering,  and  general  chilliness.  Sometimes 
it  is  preceded  by  slight  jaundice,  furred  tongue, 
and  other  symptoms  of  gastric  catarrh ; and 
sometimes  albuminuria  precedes  by  a few  hours 
or  a day  the  occurrence  of  hsematinuria.  The 
more  abrupt  attacks  frequently  terminate  by  the 
discharge  of  the  peculiar  urine,  and  the  next 
urine  is  normal,  or  nearly  so.  In  some  cases  albu- 
minuria lingers  for  a time  after  the  discoloration 
h as  passed  off.  The  characters  of  the  urine  are  very 
peculiar.  Its  colour  is  like  porter,  or  like  muddy 
port  wine  ; its  specific  gravity  ranges  from  1015 
to  1035;  it  is  acid,  or  faintly  alkaline;  highly 
albuminous ; sometimes  it  contains  excess  of  urea ; 
and  throws  down  a copious  sediment.  This  con- 
tains very  few  or  no  blood-corpuscles,  but  an 
immense  amount  of  granular  blood-pigment,  with 
numerous  tube-casts— hyaline  or  epithelial,  often 
loaded  or  coated  with  amorphous  granular  matter, 
and  with  minute  crystals  of  oxalate  of  lime. 
The  colour  is  not  due  to  blood-corpuscles,  and  it 
is  said  not  to  be  due  to  haamatin,  but  to  haemo- 
globin. In  some  cases  the  urine  is  less  affected, 
being  merely  albuminous,  and  not  depositing  pig- 
ment. It  may  be  doubted  whether  this  condition 
should  be  admitted  to  the  same  category  as  the 
disease  under  discussion,  but  cases  which  have 
come  under  the  writer's  observation  seem  to  show 
that  it  is  entitled  so  to  rank. 

Diagnosis. — The  only  diseases  with  which  in- 
termittent haematinuria  is  likely  to  be  confounded 
are  haematuria,  and  renal  calculus  or  gravel.  From 
the  former  it  is  distinguished  by  the  abundance  of 
'the  blood-pigment,  and  the  extreme  rarity  of 
blood-corpuscles;  from  the  latter  by  the  short 
duration  of  the  attacks,  the  presence  of  the  cha- 
racteristic deposit,  with  the  fact  that  the  pains 
affect  both  loins,  not  merely  one.  It  is  some- 
times important  to  distinguish  the  milder  forms, 
in  which  merely  albuminuria  occurs,  from  conges- 
tion or  from  commencing  inflammatory  Bright’s 
disease.  It  is  not  always  possible  to  distinguish 
these  during  the  early  hours  of  the  attack ; but 
the  amount  of  general  disturbance,  the  state  of 
the  tongue,  the  slight  jaundice,  the  suddenness 
of  the  onset,  and  the  absence  of  dropsy,  generally 
suffice  to  make  it  clear. 

Prognosis. — The  prognosis  is  good  in  paroxys- 
mal hsematinuria,  as  to  the  individual  par- 
oxysm. The  tendency  to  the  disease  is  also 
not  unfrequently  got  rid  of.  It  has  not  proved 
fatal  in  any  case.  But  it  appears  sometimes  to 
usher  in,  or  to  constitute,  an  early  symptom  of 
Bright’s  disease — the  cirrhotic  form. 

Treatment. — As  the  paroxysm  is  spontane- 
ously recovered  from,  little  need  be  done,  except- 
ing with  the  view  of  alleviating  the  discomfort 
of  the  patient.  He  should  go  to  bed  and  be 
kept  warm,  and  have  abundance  of  warm  drinks. 


HEMATOCELE. 

In  respect  of  diminishing  or  removing  the  ten 
dency  to  the  malady,  various  remedies  have  been 
found  useful,  among  which  may  be  mentioned 
quinine,  tincture  of  cinchona,  iron,  arsenic,  and 
chloride  of  ammonium. 

T.  Grainger  Stewart. 

HAEMATOBIUM  (uT/ia,  the  blood,  and  Bios, 
life). — A synonym  for  haematozoon.  See  Hema- 

TOZOA. 

HA1MATOCELE  (aTyua,  blood,  and  kt)A7j,  a 
tumour). — Synon.  : Fr.  Hematocele  ; Ger.  Illut- 
geschwulst. — Definition. — The  swelling  occa- 
sioned by  effusion  of  blood  in  the  sac  of  the  tunica 
vaginalis,  or  in  a cyst  connected  with  the  testicle. 

Aetiology  and  Symptoms. — The  extravasa- 
tion of  blood  in  hsematocele  may  take  place 
in  a healthy  state  of  the  parts,  or  it  may  suc- 
ceed or  be  combined  with  hydrocele.  In  both 
cases  it  may  be  occasioned  by  a blow,  or  by  vio- 
lent efforts  made  in  straining,  especially  in  old 
persons,  or  when  the  blood-vessels  are  diseased. 
It  may  happen  also  from  the  accidental  wound  of 
a vessel  in  tapping  a hydrocele.  The  blood 
effused,  if  small  in  quantity,  mixes  with  the  fluid 
of  the  hydrocele,  occasioning  slight  enlargement 
without  disturbance.  If  it  be  large  in  quantity, 
coagula  are  formed  ; inflammation  is  excited  in 
the  tunica  vaginalis ; and  plastic  exudation  occurt 
on  its  inner  surface,  sometimes  forming  layers, 
and  rendering  the  sac  extremely  dense  and  firm. 

The  testicle  preserves  the  same  relation  to  the 
remainder  of  the  tumour  as  in  hydrocele,  being 
situated  at  its  posterior  part.  Its  position,  how- 
ever, is  liable  to  similar  alterations  as  occur  in 
hydrocele,  which  are  very  difficult  of  detection, 
owing  to  the  great  thickening  of  the  parts. 

Diagnosis. — A hsematocele  may  be  distin- 
guished from  a hydrocele  by  the  absence  of  trans- 
parency ; the  obscure  character  of  the  fluctuation; 
the  heavy  feel  of  the  tumour  when  balanced  in 
the  hand ; and  tho  sudden  and  accidental  mode 
of  its  occurrence.  In  old  chronic  cases,  in  which 
the  tunica  vaginalis  and  its  envelopes  have  be- 
come much  thickened  and  indurated,  the  tumour 
possesses  so  firm  a character,  and  feels  so  heavy 
and  solid,  that  it  is  very  liable  to  be  mistaken 
for  a chronic  enlargement  of  the  testicle  ; and  the 
diagnosis,  at  all  times  difficult,  in  some  instances 
cannot  be  satisfactorily  made  out  by  the  most 
experienced  hands.  The  records  of  surgery  fur- 
nish many  cases  in  which  castration  has  beeD 
performed  owing  to  a mistaken  diagnosis.  "When 
doubt  exists,  it  should  be  removed  by  the  intro- 
duction of  a trochar  or  by  an  incision  before  any 
serious  operation,  such  as  castration,  is  under- 
taken. 

Treatment. — When  hsematocele  succeeds  a 
hydrocele,  the  blood,  if  small  in  quantity,  mixes 
with  the  fluid  of  the  hydrocele  without  producing 
irritation.  The  tinged  fluid  may  be  removed  by 
tapping,  and  the  operation  can  be  repeated  after- 
wards at  intervals  until  the  fluid  is  free  from 
discoloration.  Even  when  inflammation  arises,  if 
the  sac  be  tapped  and  tension  removed,  and  the 
patient  be  kept  at  rest,  with  ice  applied  to  tho 
part,  the  inflammation  may  subside.  When, 
however,  the  blood  eSused  is  large  in  quantity, 
and  when  the  inflammation  is  acute  and  threatens 
suppuration,  the  tumour  should  be  punctured  at 


HEMATOCELE. 

,t3  upper  part,  a director  introduced,  and  the  sac 
freely  laid  open  by  incision.  This  must  be  done 
with  care,  so  as  to  avoid  wounding  the  testicle. 

A chronic  haematocele  with  a very  thickened  sac 
must  be  cut  into  in  the  same  way  ; and  lateral 
portions  of  the  sac  may  be  excised,  so  as  to  lessen 
i he  wound  for  healing.  The  practitioner  must 
bear  in  mind  that  the  testicle  is  sometimes 
situated  in  front,  as  in  cases  of  inversion,  and  is 
then  very  liable  to  injury  in  the  operation  of  in- 
cision, and  even  in  tapping. 

Encysted  hsematocele.— Encysted  hsemato- 
cele  implies  an  effusion  of  blood  in  the  sac  of  an 
encysted  hydrocele : and  the  treatment  is  the 
same  as  that  required  for  ordinary  haematocele. 

Hsematocele  of  the  Cord. — Blood  may  also 
be  effused  in  the  areolar  tissue  of  the  spermatic 
cord,  constituting  diffused  haematocele  of  the 
cord  ; or  in  a cyst  in  the  cord,  constituting  en- 
cysted hsematocele  of  the  cord.  Such  cases  are 
very  rare.  T.  B.  Curling. 

HAIMATOIDIN. — See  HAaiOGLoniN. 

HEMATOMA  (ai/iaria,  I fill  with  blood).— 
A peculiar  form  of  bloody  tumour,  or  a collection 
of  extravasated  blood  that  has  undergone  cer- 
tain changes.  It  is  observed  more  especially  in 
connection  with  the  ear,  the  scalp,  and  the 
meninges.  See  Cephalhematoma  ; HMmatoma 
Aueis  ; Meninges,  Cekebrax,  Haematoma  of ; 
and  Tumours.  The  term  is  sometimes  also  ap- 
plied to  fungus  haematodes. 

HEMATOMA  A HE.  IS  (aiyaToa,  I fill 
with  blood  ; auris,  of  the  ear). — Synon.  : The 
Insane  ear ; Fr.  Othematome ; Hematome  de 
l' oreille  dcs  alicnes  ; Ger.  Othamatoma  ; Ohrblut- 
gesckwalst  von  Geisteskranken. 

Definition. — An  affect  ion  of  the  auricle,  which 
occurs  almost,  if  not  quite  exclusively,  in  the 
insane,  and  consists  in  the  effusion  of  blood  or 
bloody  serum  between  the  cartilage  and  its  peri- 
chondrium, to  such  an  extent  as  to  form  a distinct 
tumour. 

Etiology. — In  most  of  the  few  cases  of  hsema- 
toma  auris  which  have  been  published  to  show 
that  this  disease  may  occur  in  the  sane,  the  de- 
scription given  of  the  patients  rather  points  to 
their  insanity  than  otherwise.  It  is  most  com- 
mon in  cases  of  general  paralysis  and  mania  (acute 
and  chronic),  but  also  occurs  in  melancholia, 
dementia,  and  idiocy.  It  is  about  four  times 
as  frequent  in  men  as  in  women ; and  more  often 
affects  the  left  ear  than  the  right.  Sometimes 
both  ears  are  affected,  but  seldom  at  the  same 
time.  There  would  seem  to  be,  in  many  or  all 
of  the  insane,  a morbid  condition  of  the  vessels 
or  other  tissues  of  the  auricle,  which  predisposes 
to  the  occurrence  of  hiematoma.  If  this  condition 
be  present  to  a sufficient  degree,  the  disease  may 
arise  spontaneously;  in  other  cases  a very  slight 
injury  may  be  sufficient  to  cause  it;  whilst  in 
others  very  considerable  violence  is  necessary  for 
its  production. 

Symptoms  and  Course. — The  disease  first 
makes  itself  evident  by  the  appearance  of  a 
swelling  of  about  the  size  of  a horse-bean  ; this 
is  almost  always  upon  the  anterior  surface  of 
the  pinna,  and  usually  in  the  neighbourhood  of 
tile  fossa  of  the  antihelix.  The  skin  over  the 
tumour  is  generally  of  a reddish  or  bluish- 


HEMATOMA  AUEIS.  065 

red  colour,  but  may  be  unaltered  at  first ; the 
temperature  of  the  ear  is  sensibly  raised;  the 
swelling  is  very  painful  and  tender ; there  is  no 
extravasation  of  blood  from  the  cutaneous  vessels ; 
and  the  tumour  is  not  oedematous.  At  this  stage, 
the  effusion  which  has  taken  place  between  the 
cartilage  and  its  perichondrium  consists  of  dark 
red  fluid  blood.  In  rare  cases  the  swelling  does 
not  increase  further  ; the  inflammatory  symptoms 
subside  after  about  a week;  absorption  gradually 
takes  place  ; and  only  a slight  thickening  remains. 
More  usually  the  tumour  increases  and  may  at- 
tain the  size  of  a hen’s  egg ; it  becomes  tense,  elas- 
tic, distinctly  fluctuating,  and  hot ; and  is  often 
of  a bright  red  colour.  Its  prominent  anterior 
wall,  consisting  of  skin,  cellular  tissue,  and  peri- 
chondrium, is  felt  to  be  thinner  and  less  resisting 
than  the  posterior,  which  contains  the  ear-car- 
tilage. In  certain  cases,  however,  owing  to  the 
brittle  cartilage  having  split  up,  and  portions  of 
it  having  adhered  to  either  wall,  both  walls 
present  irregularly  alternating  characters.  The 
time  which  a haematoma  takes  to  attain  its 
largest  size  varies  from  a week  to  a month ; it 
then  generally  involves  the  whole  of  the  concha, 
occluding  the  external  auditory  meatus ; the 
folds  of  the  auricle  are  lost,  with  the  exception 
of  the  helix  (which  appears  as  a band  running 
round  the  tumour),  and  the  dependent  lobule. 
The  weight  of  the  tumour  causes  the  whole  ear 
to  fall  somewhat  forwards  and  outwards.  Some- 
times, especially  in  the  presence  of  constant  or 
repeated  irritation,  the  inflammatory  stage  may 
last  many  weeks,  and  the  deformity  which  always 
results  from  the  affection  is  thereby  greatly  in- 
creased. Unless  subjected  to  violence,  it  very 
rarely  happens  that  the  tumour  opens  spontane- 
ously, although  its  tense  and  inflamed  appearance 
often  seems  to  indicate  that  such  an  occurrence 
is  imminent.  If  rupture  does  take  place,  suppu- 
ration ensues  ; portions  of  cartilage  come  away; 
the  cavity  closes  very  slowly ; and  great  defor- 
mity results.  The  most  common  course  is  for 
the  inflammatory  symptoms  gradually  to  subside. 
The  anterior  wall  becomes  firmer,  owing  to  a 
new  deposit  cf  cartilage  upon  its  inner  surface ; 
the  sense  of  fluctuation  is  gradually  lost ; and 
the  tumour  slowly  diminishes  in  size,  often  yield- 
ing a somewhat  doughy  sensation  to  the  touch. 
Occasionally,  at  this  stage,  some  gaseous  contents 
have  been  observed  in  the  cavity.  The  colour 
of  the  skin  over  the  tumour  becomes  gradually 
more  dusky ; it  then  passes  into  yellow  and, 
later  on,  into  an  unnatural  pallor.  As  the  fluid 
contents  become  absorbed,  the  tumour  becomes 
harder  and  smaller;  folds  again  appear  in  the 
auricle,  but  do  not  correspond  to  the  original 
ones;  and  the  pinna  remains  permanently  thick- 
ened, puckered,  and  often  nodular. 

Anatomical  Characters. — Many  of  these  have 
been  given  above  in  explanation  of  symptoms, 
and  do  not  require  to  be  repeated.  A shrivelled 
auricle,  which  has  previously  been  affected  by 
bsmatoma,  presents,  on  section,  two  distinct 
layers  of  cartilage  ; these  are  of  varying  thick- 
ness, and  separated  from  each  other  by  vascular 
fibrous  tissue,  which  often  contains  within  it 
other  small  isolated  plates  of  cartilage,  and  some 
times  also  small  portions  of  bone.  The  fibrous 
tissue  is  the  organised  product  of  the  original 


C66  H2EMAT0MA  AURIS. 

effusion  ; the  two  layers  of  cartilage,  hare  been 
developed  upon  the  inner  surfaces  of  the  peri- 
chondrium; the  loose  portions  of  cartilage  and 
bona  which  are  occasionally  seen,  are  developed 
from  the  fibrous  tissue.  It  used  to  be  supposed 
that  the  bone  (which  is  soft,  vascular,  and  con- 
tains well-developed  Haversian  systems)  resulted 
from  ossification  of  the  ear-cartilage  ; but  the 
writer  has  shown  elsewhere  {Brit.  Med.  Jour- 
nal, Oct.  1873)  that  this  is  not  the  case. 

Pkognosis. — The  local  affection  is  in  no  way 
dangerous,  but  it  always  leaves  behind  it  a per- 
manent characteristic  deformity  of  the  auricle. 
The  sense  of  hearing  is  only  affected  by  the  oc- 
clusion of  the  auditor}’  meatus ; but  this  condition 
very  rarely  persists  after  the  acute  stage.  The 
occurrence  of  haematoma  auris  affects  tne  prog- 
nosis of  the  mental  disease  unfavourably,  but 
does  not  necessarily  indicate  the  approach  of 
a fatal  termination  to  the  case. 

Treatment. — Protection  of  the  part  from 
injury  is  usually  all  that  is  necessary.  Cooling 
applications  might  be  useful  if  inflammation  were 
excessive.  The  tumour  should  not  be  opened;  nor 
should  a portion  of  the  anterior  wall  be  removed, 
as  has  been  recommended;  these  procedures  only 
lead  to  suppuration.  It  is  useless  to  empty  the 
cavity  by  aspiration,  as  it  fills  again  with  great 
rapidity.  The  treatment  by  pressure  is  very 
painful,  and  yields  no  good  result. 

Chas.  S.  W.  Cobbold. 

H JEM ATO -PERICARDIUM  (cupa,  blood  ; 
repl,  about ; and  xap^ia,  the  heart). — An  extra- 
vasation of  blood  into  the  sac  of  the  pericardium. 
See  Pericardium,  Diseases  of. 

HJEMATO-THORAX  (aTfta,  blood,  and 
6wpa£,  the  chest). — An  extravasation  of  blood 
into  the  pleural  cavity.  See  Pleura,  Diseases  of. 

HJEMATOZOA  (aTjaa,  blood,  and  an 
animal). — This  term  is  of  general  application 
to  all  kinds  of  animal  parasites  dwelling  in  the 
blood  and  blood-vessels ; but  its  employment 
is  often  restricted  to  certain  of  the  nematoid 
entozoa,  which  display  this  habit  in  a more 
marked  degree  than  the  other  parasites  are  wont 
to  do.  All  classes  of  helminths  are  liable,  at 
some  time  or  other  in  the  course  of  their  life- 
time, to  take  up  their  residence  in  the  blood,  but 
in  the  case  of  the  Tania,  or  rather  of  their  prosco- 
lices,  this  period  is  of  very  short  duration.  One 
or  two  species  only  of  fluke-worms  or  trematodes 
play  a similar  role  in  man,  the  most  important 
being  the  Bilharzia,  which  gives  rise  to  an  en- 
demic hsematuria  at  the  Caps,  and  elsewhere  in 
Africa  {see  Bilharzia).  Our  knowledge  of  the 
nematoid  hsematozoa  dates  at  least  as  far  back  as 
the  time  of  Ruyseh  (166.5)  who  was  acquainted 
with  the  strongyles  which  produce  aneurism  in 
the  horse  and  other  solipeds;  whilst  more  than 
half  a century  later  the  subject  received  additions 
from  the  writings  of  Schulze  (1725)  and  Chabert 
(1782);  and  subsequently  from  the  memoir  by 
Rayer  (1843).  About  the  latter  period  also 
the  observations  by  Grube  and  Delafond  ‘ on  a 
verminiferous  condition  of  the  blood  of  dogs, 
caused  by  a great  number  of  liaematozoa  of  the 
genus  Filaria,’  excited  much  attention  ; but  until 
quite  recently  it  was  not  so  much  as  suspected 


HJEMATURIA. 

that  similar  microscopic  filariae  infested  tne 
human  body.  In  1872  Dr.  Lewis  announced  the 
important  discovery  of  the  existence  of  nematoid 
worms  in  the  living  human  subject  also.  See 
Chyluria;  and  Filaria  Sanquinis-Hominis. 

T.  S.  Cobbold. 

HEMATURIA  ( alxa , blood,  and  ovpoy, 
urine). — Synon.:  Fr.  Hematurie ; Ger.  BkUhamen. 

Description. — Hsematuria  is  a symptom  of 
many  different  morbid  conditions  of  the  system, 
and  of  the  urinary  tract.  The  quantity  of  blood 
discharged  in  the  urine  varies  greatly,  and  the  ap- 
pearance of  the  urine  corresponds.  Sometimes  it 
is  dark,  loaded  with  clots ; sometimes  it  is  merely 
smoky,  or  of  a faintly  pink  hue.  It  is  albuminous, 
and  corpuscles  (often  altered  by  soaking  in  the 
urine)  may  be  discovered  by  the  microscope,  some- 
times becoming  swollen,  sometimes  shrunken. 
The  following  are  the  best  tests'  for  detecting 
the  presence  of  blood  in  the  urine. — 1.  Guaiacum. 
When  equal  parts  of  tincture  of  guaiacum  and 
oil  of  turpentine  are  shaken  together  to  make 
an  emulsion,  and  the  urine  is  cautiously  added, 
an  intense  blue  colour  is  produced  if  blood  be 
present.  2.  Spectrum  analysis.  Very  minute  quan- 
tities of  blood  in  the  urine  show  absorpt:on-lines 
between  Frauenhofer's  lines  D and  E in  the  yellow 
and  green  of  the  spectrum.  See  Spectroscope. 

The  blood  in  haematuria  may  be  derived  from 
the  urethra.  If  so,  it  precedes  the  stream  of 
urine,  sometimes  forms  a long  thin  clot,  and  may 
escape  in  the  intervals  of  micturition.  Sometimes 
it  is  derived  from  the  prostate  gland  or  the 
bladder.  When  it  has  lain  in  the  bladder  and 
been  poured  out  in  considerable  quantity,  it  is 
often  in  clots ; and  when  the  urine  is  voided,  the 
first  part  is  frequently  clear,  the  last  loaded 
with  blood.  Blood  may  also  be  derived  from 
the  ureter  or  the  pelvis  of  the  kidney.  Some- 
times clots  in  the  form  of  moulds  of  these  struc- 
tures may  be  recognised.  At  other  times  the 
blood  is  derived  from  the  substance  of  the  kidney, 
and  then  is  intimately  mixed  up  with  the  urine, 
which  frequently  exhibits  bloody  tube-casts. 

./Etiology  and  Pathology. — Urethral  haemor- 
rhage is  due  to  local  inflammation  or  rupture  of 
vessels.  Prostatic  haemorrhage  may  be  due  to 
malignant  disease,  to  tumours,  to  inflammation, 
or  to  scrofulous  affection  of  that  organ.  Vesical 
haemorrhage  results  from  malignant  disease,  from 
simple  villous  growth,  inflammation,  ulceration, 
tubercular  disease,  or  the  irritation  of  calcu- 
lus. Haemorrhage  from  the  ureters  or  pelvis 
of  the  kidney  may  be  due  to  the  presence  of  calculi, 
or  to  unexplained  causes.  Haemorrhage  from  tho 
kidney  may  be  due  to  cancer,  tubercle,  suppura- 
tive nephritis,  or  to  the  irritation  of  crystals  or 
amorphous  concretions  within  the  uriniferous 
tubules.  Haemorrhage  occurs  also  in  all  the 
forms  of  Bright's  disease,  especially  in  the  early 
stage  of  the  inflammatory  form,  and  the  advanced 
stage  of  the  cirrhotic.  It  results  moreover  from 
over-doses  of  turpentine  and  cantharides,  and  from 
rupture  of  the  kidney.  Sometimes  it  is  a manifes- 
tation of  purpura  haemorrhagica,  more  rarely  of 
scorbutus ; and  occasionally  it  occurs  in  the  course 
of,  or  as  a sequel  of  eruptive  or  continued  fevers. 
It  is  alsooccasionally  vicarious.  Renal  haemorrhage 
occurs  in  Egypt,  Mauritius,  and  other  localities 


HAEMATURIA. 

in  consequence  of  the  presence  in  the  pelvis  of 
tile  kidney  of  a minute  parasite,  the  Bilharzia 
haematobia ; or  of  the  presence  in  the  blood  of 
the  Filaria  sanguinis-hominis.  See  Bilharzia  ; 
Chtlokia  ; and  Filaria  Sanguinis-Hominis. 

Treatment. — The  treatment  of  haematuria 
must  vary  according  to  the  lesion  to  which  the 
haemorrhage  is  due,  but  where  the  symptom  is  so 
urgent  as  to  demand  treatment  for  itself,  the 
most  important  points  to  be  attended  to  are  rest ; 
free  relief  of  the  bowels  ; the  application  of  ice- 
bags  over  the  source  of  the  haemorrhage  ; along 
with  the  internal  administration  of  astringents, 
especially  gallic  acid,  ergot  of  rye,  perehloride 
or  pernitrate  of  iron,  turpentine,  or  acetat6  of 
lead,  with  or  without  opium.  If  these  do  not 
succeed,  the  subcutaneous  injection  of  ergotine 
is  often  efficacious.  Surgical  interference  may 
be  required  for  relief  of  symptoms  due  to  co- 
agula.  T.  Grainger  Stewart. 

H-33MIC  ASTHMA. — A form  of  asthma, 
dependent  upon  an  abnormal  condition  of  the 
blood.  See  Asthma. 

H2EMIC  MURMUR. — A murmur  connected 
with  the  condition  of  the  blood,  as  in  anaemia. 
See  Antemia  ; and  Physical  Examination. 

HAEMIN.— See  Hemoglobin. 

HAEMOGLOBIN"  (euga,  blood,  and  globus, 
a ball).  Synon.  : — Haem,atoglobulin ; Hfemato- 
crys tiffin ; Crnorin  (Stokes).— This  substance, 
which  is  of  great  physiological  interest,  is  of  an 
extremely  complex  nature,  being  a compound  of 
two  bodies,  the  one  a proteid  known  as  globulin 
or  globin  ; and  the  other  a nitrogenous  derivative 
called  hsematin.  These  two  substances  are  com- 
bined in  the  proportion  of  8 7 '5  per  cent,  of 
globulin  to  12‘41  per  cent,  of  haematin  (Schmidt) ; 
and  the  provisional  formula  of  hfemoglobin,  ac- 
cording to  Hoppe-Seyler,  is  C600  H960  N151  Fe  S3 
01,9.  If  wre  estimate  the  red  corpuscles  as  form- 
ing about  32  per  cent,  of  ordinary  blood,  haemo- 
globin may  be  considered  as  forming  13  to  14 
per  cent,  of  the  same  blood. 

Haemoglobin  presents  a singular  exception  to 
the  general  law  of  diffusion,  inasmuch  as,  though 
it  readily  crystallises,  it  will  not  diffuse  through 
membrane  as  such  without  decomposition.  A 
considerable  variety  in  the  shape  of  the  crystals 
is  met  with  in  different  animals  ; in  man  they 
occur  as  elongated  prisms. 

The  most  important  property  of  this  compound 
ts  its  affinity  for  oxygen.  In  some  obscure  man- 
ner this  gas  enters  into  a loose  combination  with 
haemoglobin,  forming  oxy-hcemoglobin ; and  is 
then  conveyed  by  the  red  corpuscles  through- 
out the  body;  separating  again  from  its  con- 
veyer in  the  tissues.  The  haemoglobin  thus 
deprived  of  its  oxygen  is  known  as  reduced 
hemoglobin,  and  is  of  a purplish  colour,  whilst 
the  oxy-haemoglobin  is  of  a scarlet  tint.  It  is 
thus  that  the  difference  in  colour  between  arte- 
rial and  venous  blood  is  mainly  to  be  accounted 
for.  It  is  to  be  noted  that  whatever  be  the 
[ nature  of  the  combination  that  exists  between 
the  oxygen  and  its  carrier,  it  is  such  that  the  gas 
retains  its  properties  as  a gas,  and  the  union  may 
bo  roughly  compared  to  a mere  solution  of  the  gas 
in  a fluid.  The  recent  experiments  of  Malassez, 
Uayem,  Gowers,  and  others  have  furnished 


HAEMOGLOBIN  567 

us  with  means  of  estimating  within  very  reason- 
able limits  the  quantity  of  red  corpuscles  coniaine  ! 
in  any  sample  of  blood  (see  Hemacytometer)  : 
and  further  by  a comparison  of  its  colour  with 
that  of  a solution  of  known  strength  the  per- 
centage of  haemoglobin  in  it  may  be  ascertained 
with  tolerable  accuracy  ( see  Hiemoglobinomb- 
ter).  We  are  as  yet  unacquainted  with  the  varia 
tion  in  its  amount  in  the  majority  of  diseases,  but 
a very  considerable  diminution,  even  to  the  extent 
of  25  per  cent.,  has  been  met  with  in  chlorosis. 
Whether  with  the  alteration  in  quantity  of  haemo- 
globin there  is  any  change  in  its  composition  i3 
uncertain  ; from  the  improvement  following  the 
administration  of  iron  in  certain  cases  of  anaemia 
it  would  seem  that  there  may  be.  As  regards  the 
iron  constituent  of  this  compound,  amounting  to 
•4  or  -5  per  cent.,  it  has  been  suggested,  although 
on  no  very  good  grounds,  that  the  oxygen-carry- 
ing property  is  due  to  this  element.  It  is  notice- 
able that  in  some  of  the  lower  animals  copper  has 
been  met  with,  taking  the  place  of  iron. 

From  a pathological  point  of  view,  haemo- 
globin is  chiefly  of  interest  in  respect  to  its 
derivatives,  which  are  easily  obtained  by  the 
action  of  heat,  acids,  alkalies,  &c.,  and  also  on 
account  of  the  relationship  that  exists  between 
this  substance  and  the  various  pigments  met  with 
inthebody.  The  chief  derivatives  of  Inemoglobin, 
namely,  haematin,  liaematoidin,  and  haemin,  will 
now  be  described. 

Haematin. — C6SH70  N3  Fe3  O10  (Hoppe-  Seyler). 
Haematin  may  be  obtained  from  red  blood,  cor- 
puscles by  treatment  with  alcohol,  acidulated 
with  sulphuric  acid. 

Hsematin  is  an  amorphous  dark-brown  powder. 
A solution  gives  a characteristic  absorption-band 
in  the  spectrum,  different  from  those  produced 
by  licemoglobin.  It  gives  a green  solution  when 
boiled  with  caustic  potash. 

.Hoematoidin  (aig a,  blood,  and  eTSos,  appear- 
ance). (C1;H1SN-  O3). — Hsematoidin  maybe  pre- 
pared from  haematin  by  the  action  of  acids,  which 
remove  the  iron.  This  substance  is  crystalline 
(rhombic  prisms  or  needles),  and  of  a red  or 
greenish-red  colour ; a fact  which  shows  that  the 
colour  of  haemoglobinis  not  dependent  on  theiron. 
It  is  of  considerable  pathological  interest,  being 
frequently  found  in  old  clots,  and  in  the  cavity  of 
ruptured  Graafian  follicles ; it  is  the  cause  also 
of  the  staining  so  often  seen  in  the  neighbour- 
hood of  extravasations  of  blood,  varying  from 
lemon-yellow  up  to  reddish  black. 

Haemin  (Ctt9H70  N9Fe2  O10  2 HC1). — Haemin, 
which  may  be  prepared  from  dried  haemoglobin 
by  treatment  with  glacial  acetic  acid,  in  the  pre- 
sence of  an  alkaline  chloride,  is  a hydrochlorate 
of  haematin.  It  crystallises  tolerably  readily  in 
needles  or  rhombic  plates,  and  thus  becomes  an 
easy  means  of  detecting  the  presence  of  blood  in 
stains  of  a doubtful  nature. 

The  relationship  of  haemoglobin,  haematin, 
hsematoidin,  and  haemin  to  the  pigments  of  tho 
body  is  of  the  greatest  interest.  It  would  seem 
that  the  haemoglobin  is  the  source  of  all — biliary, 
urinary,  &c.  Bilirubin  is  closely  allied  to,  if 
not  identical  with,  liaematoidin ; and  a play  of 
colours — the  result  of  oxidation — may  be  ob- 
tained from  the  latter  when  treated  with  nitric 
acid,  similar  to  that  produced  by  the  bile-pig 


\ 


568  HAEMOGLOBIN 

Rents  under  the  same  condition.  The  injection 
of  haemoglobin  into  the  blood  is  followed  by 
the  presence  of  bile-pigments  in  the  urine,  and 
an  increase  of  bilirubin  in  the  bile.  Melanin, 
the  black  pigment  often  found  in  connection 
with  new-growths,  especially  with  those  of  a 
malignant  character,  also  appears  to  be  directly 
drawn  from  haemoglobin.  The  colouring  matter 
of  the  blood  is  obviously  associated,  in  some 
way  other  than  that  of  its  oxygen-carryiDg  func- 
tion, with  the  nutrition  of  the  tissues,  in  con- 
nection with  the  obscure  but  unquestionable 
influence  of  pigments.  W.  H.  Allchin. 

HA®MOGLOBINOMETER(Hmmoglobin; 
and  jit eVpon,  a measure).— Definition. — An  in- 
strument for  the  clinical  estimation  of  the 
amount  of  haemoglobin  in  blood. 

Description. — The  promotion  of  haemoglobin 
may  be  ascertained  by  estimating  the  amount  of 
iron  in  the  blood,  or  the  amount  of  dilution 
necessary  to  obscure  a certain  absorption-band  in 
the  spectrum  (see Spectroscope).  Neithercf  these 
methods  is,  however,  available  for  clinical  use. 
Simpler  methods  have  therefore  been  contrived, 
which  proceed  by  comparing  the  colour  of  diluted 
blood  with  that  of  solutions  of  carmine  and  picro- 
carmine.  By  this  combination  the  tint  of  blood 
and  even  its  spectrum  may  nearly  be  obtained 
(Malassez).  Coloured  discs  have  been  employed 
for  the  same  purpose  (Hayem).  In  these  methods 
a given  dilution  of  blood  is  made,  and  this  is  com- 
pared with  the  tint  of  the  standards.  In  the 
haemoglobinometer  designed  by  the  writer  (and 
made  by  Hawksley)  the  blood  is  progressively 
diluted  until  it  reaches  the  tint  of  a standard  the 
colour  of  which  corresponds  to  a dilution  of  1 part 
of  healthy  blood  in  100  of  water.  The  degree  of 
dilution  necessary  to  make  the  two  correspond 
represents  the  amount  of  hsemoglobin.  The 
apparatus  consists  of  two  tubes  of  exactly  equal 
diameter,  and  a capillary  pipette,  holding  20 
cubic  mm.,  for  measuring  the  blood.  One  tube 
is  filled  with  a standard,  consisting  of  glycerine 
jelly  coloured  to  the  required  tint.  The  other  is 
graduated,  each  division  being  equal  to  the  vo- 
lume of  blood  taken  (20  cubic  mm.),  so  that  100 
divisions  equal  100  times  the  volume  of  blood. 
The  dilution  is  made  by  a pipette  stopper,  and 
the  number  of  degrees  of  dilution  necessary  in- 
dicates the  percentage  proportion  of  the  haemo- 
globin of  the  blood  examined  to  normal  blood. 
For  example,  the  blood  of  a patient  being  pro- 
gressively diluted,  is  found  to  reach  the  tint  of 
the  standard  when  the  amount  of  water  added  cor- 
responds to  4-5  degrees  of  dilution  ; the  blood  ex- 
amined therefore  contains  45  per  cent,  of  the  nor- 
mal quantity  of  haemoglobin.  W.  R.  Gowers. 

H-EMOPERICARDITTM.  See  IIaiuato- 
PERICARDIUM. 

HAEMOPHILIA  (alua,  blood,  and  <pi\ia, 
predisposition  for). — Svnon. : Hmmorrhaphilia  ; 
Hmmorrhagic  diathesis  ; Bleeders ; Er.  Hemo- 
philie;  Ger.  Bluterkrankheit. 

Definition. — A congenital  disease,  often  he- 
reditary, characterised  by  a tendency  to  immo- 
derate bleedings,  whether  spontaneous  or  trau- 
matic, and  to  obstinate  swellings  of  the  joints. 

aEtiology. — Men  are  far  more  liable  than 
women  to  this  disease;  the  proportion  being 


Haemophilia. 

about  eleven  to  one.  Women  who  suffer  from 
haemophilia  show  much  less  typical  specimens 
of  the  disease  than  men,  and  rarely  die  from 
haemorrhage,  although  floodings  and  profuse 
menstruation  are  common. 

The  best-ascertained  cause  of  haemophilia  is 
hereditary  predisposition.  No  other  cause  is 
known  with  anything  like  certainty.  In  a bleeder 
family,  the  disease  descends  to  the  boys  through 
the  mothers,  the  women  remaining  quite  healthy 
and  apparently  free  from  all  disease.  The 
fathers  do  not  seem  to  transmit  the  disease  to 
their  sons ; at  least,  instances  of  this  are  rare. 
The  women  of  bleeder  families  are  remarkably  fer- 
tile. Some  have  thought  this  disease  to  be  more 
common  in  Germany,  but  this  is  probably  owing 
to  the  greater  attention  paid  to  the  disease  in 
that  country.  Cases  have  been  met  with  in  the 
Indian  Archipelago,  North  America,  the  Scan- 
dinavian kingdoms,  and  elsewhere.  The  disease 
is  not  limited  to  the  Aryan  races,  as  the  Jews, 
a Semitic  nation,  are  singularly  liable  to  it. 

Anatomical  Characters. — No  morbid  ap- 
pearances have  yet  been  found  after  death  with 
any  constancy.  The  blood-vessels  examined  with 
the  microscope  have  shown  no  change.  The 
blood  is  apparently  unaltered.  Yet  it  is  most 
probably  the  vessels  which  are  at  fault;  as 
in  most  of  the  other  haemorrhagic  diseases  about 
which  much  is  known,  the  vessels  have  been 
found  diseased.  The  swellings  of  the  joints 
appear  to  be  due  to  the  extravasation  of  blood 
within  the  articulation. 

Symptoms. — The  first  signs  of  haemophilia  are 
commonly  seen  during  the  first  year  of  life ; but 
sometimes  they  are  delayed  until  the  beginning 
of  the  second  dentition.  Cases  on  record  of  a much 
later  appearance  of  the  first  symptoms  are  not 
trustworthy.  It  is  very  rare  for  bleedings  to  be 
noticed  at  birth.  There  is  nothing  about  the 
subjects  of  haemophilia,  when  not  suffering  from 
bleeding,  to  distinguish  them  from  ordinary  per- 
sons. They  look  well;  and  nothing  amiss  can 
be  discovered  by  physical  examination  in  chest 
or  belly.  It  is  stated,  also,  that  the  boys  have 
often  good  ability  and  do  well  at  school. 

There  are  three  well-marked  degrees  of  haemo- 
philia. The  first  is  the  most  typical  and  charac- 
teristic, in  which  there  is  a tendency  to  every 
kind  of  haemorrhage,  traumatic  or  spontaneous, 
interstitial  or  superficial.  The  swelling  of  the 
joints  is  well-marked.  This  degree  is  scarcely 
ever  seen  in  women ; but  it  is  the  most  common 
among  men.  In  the  second  degree,  spontaneous 
haemorrhages  from  the  mucous  membranes  only 
are  present.  The  third  degree,  in  which  the 
tendency  is  little  marked,  is  seen  only  amongst 
the  women  of  bleeder  families  ; and  shows  itself 
only  by  spontaneous  ecchymoses. 

Ha-morrhage.  — Spontaneous  bleedings  are 
sometimes  preceded  by  prodrome.  These  are 
symptoms  of  unusual  fulness  and  plethora.  The 
mucous  membranes  supply  the  blood  in  this 
case  ; in  childhood  bleeding  from  the  nose  being 
the  most  common,  and  also  the  most  fatal,  al- 
though bleedings  from  the  bowel,  mouth,  or  chest 
may  also  occur.  There  is  only  one  known  in 
stance  of  death  from  hsematuria.  The  traumatic 
bleedings  vary  much  in  intensity,  even  in  the 
same  individual.  Death  has  followed  division  o.1 


HAEMOPHILIA. 

the  fraenum  of  the  tongue,  vaccination,  leeching, 
and  the  extraction  of  a tooth.  This  last  is  a 
very  common  cause  of  death,  and  ought  never  to 
be  undertaken  in  haemophilia.  If  abscesses  be 
opened,  furious  bleeding  commonly  takes  place  ; 
and  the  same  occurs  if  a blood-tumour  or  ex- 
travasation of  blood  be  interfered  -with. 

The  bleeding  is  nearly  always  capillary,  and 
may  kill  in  a few  hours  or  after  some  ■weeks. 
The  quantity  of  blood  lost  is  sometimes  enor- 
mous. After  the  bleeding  the  patients  are  ex- 
tremely anaemic ; and  this  state  may  last  for 
months. 

Besides  superficial  bleedings,  interstitial 
haemorrhages,  ecchymoses,  and  blood-tumours 
may  be  observed,  whether  spontaneous  or  trau- 
matic. A bruise  which  a healthy  person  would 
not  feel  may  fill  the  connective  tissue  of  a limb 
with  blood ; or  the  bleeding  may  be  circum- 
scribed, and  form  a tumour  instead. 

Swelling  of  the  joints. — This  chiefly  affects 
the  larger  joints,  the  knee  being  most  commonly 
attacked.  The  joint,  most  commonly  after  some 
injury,  becomes  swollen  and  painful,  and  appa- 
rently filled  with  fluid;  there  is  fever;  and  this 
state  may  last  for  many  weeks,  and  is  very  apt 
to  relapse  during  convalescence. 

Diagnosis. — The  diagnosis  of  haemophilia  is 
often  easy.  If  a boy  have  suffered  repeatedly 
from  early  infancy  from  abundant  bleedings — 
especially  traumatic — and  from  joint-affections, 
there  can  be  no  doubt  of  the  diagnosis.  It  is 
made  more  certain  by  the  existence  of  hereditary 
predisposition.  In  women  the  diagnosis  must 
lie  made  with  more  care,  as  they  are  subject  to 
a haemorrhagic  disorder  which  first  appears  about 
puberty,  but  which  is  not  hereditary. 

Prognosis. — The  prognosis  is  bad  as  regards 
complete  recover}',  though  not  so  serious  with 
respect  to  lifo  as  was  formerly  thought. 

Treatment. — In  the  treatment  of  the  bleed- 
ings of  haemophilia,  styptics  are  of  little  use. 
The  spontaneous  form  should  not  at  first  be  in- 
terfered with ; but  the  traumatic  may  often  be 
stayed  at  its  first  onset  by  the  judicious  use  of 
compression.  The  tincture  of  perchloride  of  iron 
seems  the  best  internal  remedy.  In  the  last  re- 
sort, transfusion  may  be  had  recourse  to.  In  the 
intervals  of  haemorrhages,  meat  diet,  cod-liver 
oil  and  steel,  and  residence  in  a warm  climate, 
are  the  most  appropriate  remedies.  All  surgical 
or  medical  procedures  by  which  blood  is  drawn 
must  be  strictly  avoided.  There  are,  hoivever, 
only  two  instances  on  record  of  disagreeable 
consequences  following  vaccination.  Marriage 
should  be  forbidden,  especially  to  women  who  do 
not  themselves  suffer  from  the  disease,  but 
belong  to  bleeder  families. 

The  joint-affection  must  be  treated  chiefly  by 
rest  and  the  application  of  splints. 

J.  Wickham  Legg. 

HAEMOPTYSIS  (aT/j.a,  blood,  and  tttvw,  I 
spit). — Synon.  : Pneumonorrhagia ; Bronchor- 
rhagia;  Pr.  Hemoptysie  ; Ger . Bluthusten. 

Definition. — Blood-spitting  having  its  source 
i in  pulmonary  or  bronchial  haemorrhage. 

The  restriction  of  the  term  haemoptysis,  as  thus 
defined,  has  the  sanction  of  long  usage  and  con- 
venience. Haemorrhage  from  an  aneurism  open- 


H HEMOPTYSIS.  569 

ing  through  the  lung  or  air-passages  would  not 
strictly  be  included  in  such  a definition. 

Spitting  of  blood  when  it  arises  from  other 
and  less  important  sources  comes  under  the 
denomination  of  false  or  spurious  haemoptysis. 

.Etiology  and  Pathology. — The  causes  of 
haemoptysis  in  the  widest  sense  of  the  term,  and 
having  regard  to  its  pathology,  may  be  thus 
enumerated : — - 

I.  Haemorrhage  from  the  pulmonary  ar 
tery  or  its  radicles. 

1.  Btipture  or  wound  of  the  lung  from  ex- 
ternal violence. 

2.  Active  hyperaemia  of  the  lungs — inflamma- 
tory, vicarious,  or  induced  by  violent  effort  or 
excitement.  The  active  hyperaemia  may  be  pri- 
mary as  regards  the  lungs  ; or  may  supervene  or 
he  attendant  upon  disease  already  present  in 
them. 

3.  Mechanical  hyperaemia  of  the  lungs,  secon- 
dary to  heart-disease,  or  embolism  of  one  of  the 
pulmonary  branches,  or  to  pressure  from  tumours, 
such  as  enlarged  bronchial  glands  (see  Bronchial 
Glands,  Diseases  of). 

4.  Necrotic  division  of  vessels  in  the  course 
of  softening  of  tubercular  or  other  consolidations 
in  destructive  lung-diseases— phthisis,  tubercu- 
losis, cancer. 

5.  Aneurismal  dilatation  or  simple  erosion  of 
branches  of  the  pulmonary  artery,  exposed  in  the 
course  of  excavation  of  the  lung,  or  ulceration  of 
the  bronchial  mucous  membrane. 

6.  Primary  atheroma  of  the  pulmonary  artery 
within  the  lung. 

II.  Haemorrhage  from  the  bronchial  ca- 
pillaries. 

Capillary  haemorrhage  from  the  bronchial  mu- 
cous membrane. 

III.  Haemorrhage  from  the  aorta,  or  one 
of  its  great  branches. 

Aneurism  rupturing  through  the  lung  or  into  a 
bronchus. 

Details  respecting  the  pathology  of  these  se- 
veral forms  of  haemoptysis  will  be  found  under 
the  headings  of  the  principal  diseases  giving 
rise  to  them.  There  are  a few  additional  re- 
marks, however,  that  should  be  introduced  here. 

The  pathology  of  haemoptysis  occurring  in 
early  phthisis— of  which  it  is  one  of  the  most 
frequent  symptoms— is  stilt  somewhat  obscure. 
Besides  the  active  hyperaemia  above  referred  to, 
that  is,  the  inflammatory  congestion  that  consti- 
tutes the  first  stage  of  some  kinds  of  phthisis,  and 
tends  to  recur  at  different  periods  of  the  disease  ; 
besides  also  the  necrotic  division  of  vessels,  or 
their  aneurismal  dilatation,  which  more  espe- 
cially account  for  the  haemorrhage  occurring  in 
the  later  stages  of  the  disease ; there  are  other 
conditions  present  in  early  phthisis  which  pro- 
bably have  much  to  do  with  the  occurrence  of 
haemoptysis.  The  minute  blood-vessels  are  im- 
portantly concerned  in  the  very  earliest  stage  of 
phthisical  lung-disease  in  one  or  other  of  three 
ways : — 

(a)  Their  walls  become  the  seat  of  nuclear 
proliferation,  and  hence  become  softened ; and  ( b ) 
these  vessels  become  more  or  less  extensively 
blocked,  not  merely  as  the  result  of  the  inflam- 
matory stasis  w'hieh  may  affect  their  capillaries, 
but  by  the  pressure  of  surrounding  tubercular 


HAEMOPTYSIS. 


570 

growth,  (c)  It  is  very  possible  that  in  the  ill- 
developed  lungs  of  small-chested  people,  who  in- 
herit a tendency  to  consumption,  the  vessels  are 
also  morbidly  frail,  and  are  apt  to  give  way  in 
any  temporary  hyperaemia.  Some  persons  are 
remarkably  subject  to  irregular  distribution  of 
blood;  they  are  liable  to  chills,  cold  extremities, 
and  transient  flushings ; and  a •pulmonary  blush  is 
as  conceivable  as  a temporary  flush  elsewhere, 
and  would  favour  the  occurrence  of  haemorrhage. 

It  has  been  alleged  that  the  hsemoptysis  oc- 
curring in  all  stages  of  phthisis  frequently  has 
its  source  in  hsemorrhage  from  the  bronchial 
tubes,  and  that  this  bronchial  haemorrhage  may 
give  rise  secondarily  to  phthisis,  or  may,  when 
it  occurs  in  the  course  of  that  disease,  set  up 
fresh  centres  of  mischief  in  the  lungs  by  inhala- 
tion of  blood  to  distant  portions.  In  the  entire 
absence  of  reliable  pathological  grounds  for  this 
view,  and  in  the  abundance  of  anatomical  evi- 
dence, clinical  experience,  and  weight  of  autho- 
rity in  favour  of  the  pulmonary  origin  of  haemop- 
tysis, we  are,  in  the  opinion  of  the  writer,  justi- 
fied in  believing  that  decided  haemoptysis  origi- 
nating in  haemorrhage  from  the  bronchial  mucous 
membrane  is  exceedingly  rare,  excluding,  perhaps, 
syphilitic  ulceration  of  the  bronchi.  Blood  in- 
haled to  distant  portions  of  lung  may,  however,  as 
shown  by  Dr.  Reginald  Thompson,  undergo  changes 
resulting  in  fresh  pulmonary  destruction. 

Description. — The  quantity  of  blood  brought 
up  in  haemoptysis  varies  from  a mere  streak  to 
two  or  three  quarts.  When  blood  is  expectorated 
in  largo  quantity,  it  is  pure  and  unmixed;  and 
either  dark  and  venous,  or  bright  arterial.  The 
first  and  last  portions  are  usually  more  or  less 
aerated.  If  in  small  quantity,  the  blood  is  most 
generally  bright  and  frothy,  it  may  be  only  a speck 
or  two  upon  the  sputum,  or  it  may  be  in  several 
mouthfuls  of  pure  aerated  blood.  It  commonly 
happens  that  this  mitigated  and  more  character- 
istic hsemoptysis  precedes  the  rarer  attack  of  pro- 
fuse hsemorrhage  that  may  prove  instantly  fatal. 
Hsemoptysis  is  sometimes  scanty,  dark,  and  clot- 
ted, usually  from  a small  portion  of  bloxl  having 
been  detained  in  the  lung  before  being  expecto- 
rated. 

In  decided  haemoptysis  the  shock  to  the  sys- 
tem is  always  great.  The  patient  is  alarmed  and 
anxious,  especially  on  the  first  attack.  The  sense 
of  weakness  and  prostration  is,  indeed,  often  pro- 
longed after  the  attack — not  necessarily  a severe 
one  as  regards  quantity  of  blood  lost — has  ceased. 
The  face  is  often  flushed,  the  extremities  cold. 
The  temperature  is  usually  depressed ; after  a few 
hours  it  becomes  normal,  and  it  may  continue  so, 
or  it  may  rise  in  the  course  of  forty-eight  hours 
or  within  five  days.  This  elevation  of  tempera- 
ture may  depend  (a)  upon  return  of  the  previous 
fever  after  being  temporarily  checked  by  hsemor- 
rhage ; (b)  upon  the  cause  which  has  also  produced 
the  haemoptysis  ; or  (c)  upon  the  secondary  conse- 
quences of  the  hsemorrhage.  It  has  been  clearly 
shown  that  the  inhalation  of  blood  into  the  bron- 
chial tubes  and  pulmonary  alveoli  sometimes 
sets  up  broncho-pneumonia,  and  thus  may  give 
rise  to  fresh  centres  of  phthisical  disease.  Tho 
later  the  rise  of  temperature  up  to  the  fifth  day, 
the  more  reason  we  have  for  regarding  it  as  due 
to  secondary  pneumonia. 


Anatomical  Characters.  — These  depend 
very  much  upon  the  nature  of  the  disease  which 
has  preceded  the  hsemoptysis.  In  cases  of  death 
from  haemoptysis  there  are  the  usual  appearances 
— pallor  of  organs,  empty  and  contracted  ven- 
tricles, &c. — of  death  from  haemorrhage.  The 
bronchial  tubes  of  both  luDgs  are  found  to  con- 
tain clots.  The  healthy  portions  of  lung  are 
found  inflated  from  obstructions  in  the  bronchi, 
impeding  the  exit  of  air ; they  are  generally 
pale,  but  beautifully  speckled  by  pink  spots, 
marking  the  lobules  into  the  air-cells  of  which 
blood  has  been  inhaled.  If  death  take  place 
several  days  after  profuse  haemoptysis,  any  blood 
which  remains  in  the  hronclii  is  dark  and  disor- 
ganised, and  patches  of  consolidation  may  some- 
times be  found,  having  for  their  centres  the 
stained  appearance  attributable  to  inhaled  blood. 
More  or  less  bronchitis  is  also  noticeable.  It  is 
rare  to  find  fatal  haemoptysis  without  the  pre- 
sence of  cavities,  which  are  also,  more  or  less, 
filled  with  blood-clot.  In  almost  every  instance 
of  fatal  haemoptysis  in  phthisis,  sufficient  dili- 
gence will  discover  either  an  aneurism  of  a pul- 
monary vessel  within  a cavity,  or  ulcerative  ero- 
sion of  an  exposed  vessel.  The  writer  has  found 
such  a condition  in  fifteen  eases  at  various  ages, 
including  cue  infant  seven  months  old. 

Significance  of  Bjeuoptysis. — No  modifica- 
tion in  our  views  respecting  the  nature  of  phthisis 
can  lessen  the  significance  of  hsemoptysis  as  being 
one  of  its  most  important  positive  signs.  Thus 
regarded,  it  is  a warning  that  may  sometimes 
save,  and  very  often  prolong  life,  by  drawing  our 
early  attention  to  a condition  that  might  other- 
wise remain  too  long  concealed ; but,  lightly  con- 
sidered and  carelessly  treated,  it  is  but  the  pre- 
cursor of  destructive  disease. 

Diagnosis. — Genuine  haemoptysis  can  rarely 
be  mistaken  by  a skilled  observer  present  at  the 
attack.  The  gurgling  in  the  bronchi,  the  loose 
cough,  and  repeated  expectoration  of  bright  frothy 
blood  are  quite  characteristic.  The  blood  is  dis- 
tinctly expectorated  with  cough,  not  vomited ; 
and  its  quality  is  distinctly  fresh,  not  changed. 
In  lisematemesis,  with  which  haemoptysis  is 
sometimes  confounded,  the  blood  is  brought  up 
by  vomiting ; is  more  or  less  mixed  with  the  con- 
tents of  the  stomach  ; and,  save  when  the  haemor- 
rhage is  very  rapid  and  abundant,  presents  a 
dark  grumous  appearance,  owing  to  the  action 
of  the  gastric  fluid  upon  it  ( see  Hjematemesis). 
It  may,  too,  be  observed  that  the  blood  does  not 
come  from  the  nose,  unless  a small  quantity  be 
projected  through  the  nostrils  with  the  spasmodic 
cough.  If,  as  often  happens,  no  medical  attendant 
is  at  hand  at  the  moment  of  the  attack, the  appear- 
ance ofthebloodis  usually  sufficient  for  diagnosis; 
and  if  tho  hsemoptysis  have  been  at  all  copious, 
any  further  expectorations  for  the  next  few  horn's 
are  sanguineous.  The  fact  of  this  sanguineous 
colouration  of  the  sputa  having  existed  for  some 
hours,  or  a day  or  two  after  an  haemoptysis,  is 
positive  evidence  of  the  haemoptysis  having  been 
genuine.  In  cases  of  very  copious  hsemorrhage 
from  a large  pulmonary  branch,  the  blood 
brought  up  is  d;irk  and  venous. 

It  is  very  important  in  investigating  tin 
cause  of  hsemoptysis  to  be  as  gentle  as  possible 
in  physical  examination,  IV e can  listen  to  the 


HAEMOPTYSIS. 

lungs  in  front  and  to  the  heart  without  moving 
the  patient  or  requiring  him  to  breathe  deeply ; 
we  can  make  a note  of  the  temperature  ; and  at 
the  time  we  should  do  no  more. 

The  throat  should  always  beexaminedin  doubt- 
ful cases  of  haemoptysis,  as  the  blood  will  some- 
times be  found  to  have  issued  from  an  ulcerated 
tonsil,  or  even  from  enlarged  vessels  on  the  pos- 
terior wall  of  the  pharynx.  Spurious  hemoptysis, 
however,  may  be  defined  as  the  escape  of  a blood- 
stained mucus  from  the  throat  or  gums.  In  cases  of 
spurious  haemoptysis  there  is  usually  distinct  evi- 
dence of  a morbid  condition  of  these  parts.  The 
mucous  membrane  of  the  fauces  is  relaxed;  the 
gums  are  spongy,  and  often  bleed  when  the  teeth 
are  brushed  in  the  morning.  Sometimes  this  con- 
dition of  gums  arises  from  insufficient  attention 
to  the  teeth ; carious  stumps  and  much  tartar 
round  the  teeth  causing  irritation  and  spongi- 
ness of  the  gums.  The  patients  are  usually 
anaemic  and  short-breathed,  and  often  complain 
of  morning  cough,  but  there  is  no  evidence  of 
lung-disease.  The  blood-stained  mucus  is  usually 
ejected  in  the  morning,  on  waking,  and  often  es- 
capes from  the  mouth  during  the  night,  staining 
the  pillow.  On  examination,  it  is  found  to  be  a 
pink,  watery  mucus,  uniformly  stained,  and  con- 
taining comparatively  few  blood-corpuscles. 

Treatment. — Absolute  rest  is  the  first  thing 
to  be  observed  in  the  treatment  of  all  attacks  of 
haemoptysis.  The  patient  should  lie  down  with 
the  head  and  shoulders  raised  by  pillows.  He 
should  not  talk.  The  room  should  be  kept  quiet 
and  cool ; the  bed-clothes  should  be  light,  but  suffi- 
cient ; and  warmth  should  be  applied  to  the  feet. 
A little  ice  in  the  mouth,  or  some  iced  water  to 
sip,  will  ease  the  cough  and  tend  to  check  haemor- 
rhage. The  patient  must,  if  possible,  be  reassured 
as  to  the  absence  of  present  danger,  and  the 
shock  to  the  system  allayed  without  the  use  of 
stimulants.  Sometimes  opium  may  be  usefully 
given  for  this  purpose,  due  regard  being  had 
to  the  habits  and  idiosyncrasies  of  the  patient. 
Astringett  medicines  are  not  always  needed  in 
haemoptysis,  especially  in  attacks  in  which  the 
haemorrhage  is  presumably  capillary  ; they  may, 
however,  be  given  in  such  cases  in  small  doses. 
To  be  really  useful  in  haemoptysis,  astringents 
must  be  given  in  full  doses.  Those  most  used  are 
acetate,  of  lead,  four  grains,  every  three  or  four 
hours ; alum,  twenty  grains,  with  dilute  sul- 
phuric acid,  thirty  minims,  every  four  hours; 
gallic  acid,  twenty  to  thirty  grains  every  half- 
hour  or  hour,  for  two  or  three  doses,  followed  by 
ten-grain  closes  every  three  hours ; oil  of  tur- 
pentine. thirty  minims  every  two  hours  in  sweet- 
ened mucilage  or  in  milk,  for  a couple  of  doses, 
then  in  half  or  third  doses;  liquid  extract  of 
ergot  in  half-drachm  or  drachm  doses,  every  two 
or  three  hours  ; ten-  or  fifteen-minim  doses  of 
the  pernitfate  or  persulphate  of  iron  solution,  or 
thirty  or  forty  minims  of  the  perchloride  freely 
diluted.  Of  the  above-mentioned  astringent 
remedies,  alum  and  sulphuric  acid,  gallic  acid, 
and  ergot  are  the  best  in  the  greater  number  of 
eases.  Acetate  of  lead  is  less  applicable  to  cases 
of  lung-hcemorrhage  than  in  bowel  or  kidney  le- 
sions. Ergot  is  to  be  preferred  in  those  cases  in 
which  we  infer  that  a considerable  vessel  has 
givt  u way.  It  may  also  be  given  in  the  form  of 


HAEMORRHAGE.  571 

ergotin— ^ to  2 grains  hypodermically ; but  thus 
given  it  sometimes  causes  much  local  inflamma- 
tion. Oil  ofturpentine  is  certainlyone  of  the  most 
powerful  of  astringents  in  pulmonary  haemorrhage, 
and  may  be  usefully  held  in  reserve.  When  freely 
administered  the  condition  of  the  urine  must  be 
carefully  noted.  Cases  of  haemoptysis  only  rarely 
occur  in  which  it  is  well  to  give  the  iron  astrin- 
gents. As  a rule  they  tend  to  increase  pulmonary 
congestion;  but  in  some  cases,  in  which  haemop- 
tysis has  a tendency  to  continue  after  the  patient 
has  been  brought  to  a state  of  profound  anaemia 
from  the  first  outburst,  they  may  be  usefully  given, 
their  effect  being  carefully  watched.  Digitalis 
is  a drug  sometimes  of  great  value  in  haemop- 
tysis ; it  is  best  adapted  to  those  cases  in  which 
there  is  much  excitement  of  circulation.  Incases, 
for  instance,  in  which  the  haemoptysis  has  been 
determined  by  intemperance,  or  in  full-blooded 
people  by  effort,  tincture  of  digitalis  in  twenty-  or 
thirty-minim  doses  may  be  given.  In  such  cases, 
in  which  the  portal  system  is  usually  congested, 
sulphate  of  magnesia  and  dilute  sulphuric  acid 
may  be  combined  with  the  digitalis,  and  given 
every  four  or  six  hours  for  a couple  of  days  or 
so.  In  the  treatment  of  haemoptysis  it  is  usually 
necessary  to  counteract  the  effect  of  the  astrin- 
gent upon  the  bowels  by  purgatives  or  laxatives. 
An  enema  maybe  necessary  to  enable  the  bowels 
to  act  easily  and  without  straining.  The  use  of 
the  bed-pan  must  of  course  be  enjoined. 

Counter-irritation  is  of  great  value  in  the  treat- 
ment of  many  cases  of  hsemoptysis,  chiefly  in 
those  cases  in  which  the  haemorrhage  is  not  great, 
and  occurs  in  the  course  of  phthisis,  being  due 
either  to  local  pulmonary  congestion,  or  to  active 
hyperoemia  of  the  walls  of  a cavity.  Blisters 
are,  as  a rule,  best  avoided  in  copious  haemoptysis 
during  the  stage  of  shock.  Continuous  cold,  to 
the  chest  is  decidedly  to  be  deprecated.  The 
intermittent  application  of  cold  may  sometimes 
be  employed,  but  is  a measure  of  doubtful  ex- 
pediency. 

The  temperature  and  pulse  of  the  patient 
should  be  carefully  watched  during  an  attack  of 
haemoptysis,  and  for  a few  days  afterwards. 

The  diet  must  at  first  be  restricted  to  cold 
nutritious  fluids ; stimulants,  except  in  special 
cases,  must  be  interdicted. 

The  treatment  of  false  or  spurious  hemoptysis 
depends  upon  its  cause.  In  most  cases  the  cause 
being  anaemia,  with  a relaxed  and  morbid  con- 
dition of  mucous  membranes,  an  acid  preparation 
of  iron  containing  some  chlorate  of  potash  and 
glycerine  will  speedily  cure  the  malady.  When 
the  gums  are  spoDgy,  the  addition  of  finely 
powdered  kino  or  catechu  to  a chalk  or  charcoal 
tooth-powder,  or  the  addition  of  some  glycerine 
of  tannin  to  the  tooth-water  will  prove  efficacious. 
Astringent  gargles  will  suggest  themselves  in 
fitting  cases  ; and  fruit  and  vegetables  must  be 
added  to  the  diet.  R.  Douglas  Powell. 

HAEMORRHAGE  (aT/ta,  blood,  and  priyi 'u,ui, 
I burst  forth). — Synon.  : Fr.  Hemorrhagic ; Ger, 
Bluffluss. 

Definition. — The  escape  of  blood  from  any 
part  of  the  circulation,  and  its  discharge  from  the 
body. 

AVhen  blood  escapes  from  any  of  its  natural 


HAEMORRHAGE. 


672 

reservoirs,  it  is  cither  extravasated  into  the 
neighbouring  organs  or  cavities,  or  flows  from 
one  of  the  surfaces  or  orifices  of  the  body.  In 
the  latter  case  only  is  the  term  ‘ haemorrhage  ’ 
strictly  applicable  ( see  Extravasation).  This 
distinction,  however,  is  not  always  carefully  ob- 
served; and  such  expressions  as  ‘cerebral  haemor- 
rhage,’ ‘ haemorrhage  into  the  pericardium,’  and 
‘ haemorrhagic  eruptions  ’ are  applied  in  connec- 
tion with  what  are  more  correctly  called  extrava- 
sations of  blood. 

.(Etiology. — Haemorrhage  is  almost  always 
due  to  a solution  of  continuity  of  some  part  of 
the  circulatory  system,  whether  by  injury  or  by 
disease.  Haemorrhage  from  the  external  surface 
of  the  body  is,  with  few  exceptions,  the  result 
of  wounds  or  other  form  of  injury;  but  ulcer- 
ation— either  simple  or  malignant — frequently 
lays  open  a vein  or  an  artery,  and  aneurism  of 
the  great  vessels,  and  even  of  the  heart,  may 
also  give  rise  to  external  bleeding.  Haemorrhage 
from  internal  organs,  on  the  contrary,  is  most 
frequently  the  result  of  disease,  as,  for  instance, 
ulceration  or  aneurism,  or  of  circulatory  distur- 
bance, such  as  congestion.  Great  excitement 
or  severe  exertion  is  one  of  the  chief  determining 
causes  of  haemorrhage,  by  producing  great  or 
sudden  rise  of  the  general  blood -pressure, 
whether  by  cardiac  disturbance  or  by  obstruc- 
tion of  the  terminal  vessels,  and  may  even  lead 
to  the  rupture  of  healthy  vessels.  Local  distur- 
bances of  the  blood-pressure  give  rise  in  the  same 
way  to  congestion  or  hyperaemia,  and  finally  to 
haemorrhage.  The  principal  causes  of  haemor- 
rhages of  this  class  are  diseases  of  the  heart,  of 
the  great  vessels,  of  the  respiratory  organs,  and 
of  the  liver,  and  sudden  variations  in  the  atmo- 
spheric pressure  or  in  the  temperature  ; and  such 
hsemorrluges  are  also  in  some  instances  undoubt- 
sdly  of  a vicarious  nature.  Certain  conditions  of 
the  blood  are  believed  to  predispose  to  haemor- 
rhage, as,  for  example,  in  scurvy,  purpura,  the 
malignant  fevers,  chronic  Bright’s  disease,  and 
alcoholism.  There  is,  probably,  however,  a lesion 
of  the  vessel-walls  in  some  of  these  diseases. 
A peculiar  condition  of  body  is  known  as  the 
hamorrliagic  diathesis  or  haemophilia  ; the  sub- 
jects of  which  exhibit,  amongst  other  forms  of 
debility,  a remarkable  tendency  to  profuse  hae- 
morrhage from  trivial  causes.  See  Hemophilia. 

Seats  and  Varieties. — Bleeding  from  the  sur- 
face of  the  body,  whatever  its  origin,  is  simply 
called  heemorrhage,  and  its  exact  source  and  situ- 
ation are  otherwise  defined.  On  the  other  hand, 
when  blood  escapes  by  any  of  the  natural  open- 
ings of  the  body,  and  is  derived  from  an  internal 
organ,  the  haemorrhage  is  described  by  a special 
name.  Haemorrhage  from  the  nose  is  called 
epistaxis ; from  the  ear  otorrhagia ; from  the 
stomach  heematemesis  ; from  the  respiratory  tract 
heemoptysis ; and  from  the  urinary  tract  hema- 
turia. Blood  passed  per  anurn , after  undergoing 
certain  changes  to  be  referred  to  immediately, 
is  called  meieena.  Menorrhagia  and  metrorrhagia 
are  the  names  given  to  profuse  bleeding  from 
the  genital  organs  in  the  female,  at  the  menstrual 
period  and  at  other  times,  respectively. 

Description. — The  local  phenomena  that  cha- 
racterise haemorrhage  from  the  external  parts  of 
the  body,  vary  with  the  source  of  the  blood.  If 


it  proceed  from  an  artery  of  considerable  size, 
it  escapes  in  the  form  of  a jet.  which  is 
strengthened  at  each  beat  of  the  pulse  as  an  ac- 
tive spurt.  Blood  discharged  from  an  opened  vein 
either  flows  in  an  abundant  continuous  stream, 
or  wells  up  from  the  depth  of  the  tissues  in 
which  the  vessel  lies.  Capillary  haemorrhage  is 
generally  much  less  profuse,  and  is  most  fre- 
quently seen  in  the  form  of  oozing.  Blood  pro- 
ceeding from  internal  organs  is  variously  dis- 
charged by  the  several  outlets.  Sometimes  it 
is  immediately  expelled,  especially  if  in  quantity; 
or  it  may  escape  even  when  in  small  quantity, 
owing  to  gravitation,  as  in  haemorrhage  from  the 
nose.  Mcst  frequently  the  blood  is  retained  for 
a time,  and  then,  acting  as  a foreign  body,  is 
ejected ; for  example,  in  bleeding  from  the 
stomach,  bowels,  or  bladder. 

Characters. — Blood  flowingfrom  the  surface  of 
the  body  usually  presents  its  familiar  characters. 
The  colour  of  the  blood  will  be  scarlet  when 
it  is  derived  from  an  artery;  purple,  with  a ten- 
dency to  become  scarlet  on  the  surface,  when  it 
flows  from  a vein  ; and  of  a tint  intermediate  be- 
tween these  two  colours  when  the  haemorrhage  is 
capillary.  Inall cases, thebloodcoagulatesmoreor 
less  abundantly  around  the  seat  of  haemorrhage. 

In  haemorrhage  from  internal  organs,  on  the 
contrary,  the  blood  is  frequently  coagulated ; 
more  or  less  mixed  with  the  fluids  of  the  part ; 
or  otherwise  altered  during  its  transit.  The 
following  are  the  principal  changes  that  blood 
undergoes  in  its  passage  towards  the  several  out- 
lets of  the  body  : — 

Blood  flowing  from  the  external  ear.  or  from 
the  anterior  nares,  is  frequently  thin  and  watery, 
if  the  haemorrhage  have  lasted  for  any  length  ■ f 
time.  Blood  discharged  from  the  posterior  nares 
is  often  coagulated,  black,  and  mixed  with  thick 
mucus.  In  haemorrhage  from  the  mouth,  the 
blood  may  be  derived  from  that  cavity ; from 
the  fauces  ; from  the  respiratory  passages ; or 
from  the  upper  portion  of  the  digestive  tract — 
especially  the  stomach.  "When  the  blood  flows 
from  some  part  of  the  mouth,  such  as  the  gums, 
tongue,  palate,  or  cheeks,  it  is  more  or  less  in- 
timately mixed  with  frothy  saliva  and  mucus.  In 
haemorrhage  from  the  respiratory  passages,  or 
from  the  stomach  through  the  mouth,  the  ejected 
blood  varies  extremely  in  different  instances. 
Haemorrhage  from  the  genito-urinary  tract  is 
also  specially  described.  Haemorrhage  from 
the  bowels  is  not  peculiar,  if  the  source  of  the 
blood  be  near  the  anus,  or  if  the  bleeding  be 
very  profuse  ; taking  the  form  sometimes  of  a 
gush  of  fresh,  warm  blood,  at  other  times  of  a 
mere  red  streak  upon  the  faeces.  If  the  blood 
be  derived  from  a higher  part  of  the  intestines, 
the  appearace  of  it,  when  discharged,  will  be  dif- 
ferent. Generally  it  is  so  far  altered  by  tho 
action  of  the  various  intestinal  contents,  as  to  be 
converted  into  a black  tarry-looking  mass  (see 
Meljena).  Less  frequently,  the  bleeding  may  be 
so  profuse  as  to  fill  a considerable  portion  cf  the 
bowel,  and  clots  of  blood  may  then  be  passed,  as 
in  some  cases  of  haemorrhage  in  typhoid  fever. 
The  peculiar  characters  of  menstrual  blood  are 
described  elsewhere.  Hemorrhage  from  the  atom 
in  large  quantity  consists  of  unaltered  blood 
whether  coagulated  or  not. 


HAEMORRHAGE. 

Course  and  Terminations. — Haemorrhages 
caused  by  wounds  are  generally  most  profuse  at 
first;  and,  unless  they  prove  fatal  speedily,  or 
are  artificially  arrested,  gradually  cease.  On 
the  contrary,  haemorrhages  duo  to  disease  are 
freouentlv  insignificant  at  first,  and  increase  in 
amount ; or  they  recur  again  and  again  : n variable 
quantity. 

Many  natural  causes  contribute  to  the  arrest 
of  haemorrhage,  the  most  important  being — 
weakening  of  the  force  of  the  heart  by  the  loss 
of  blood ; the  contraction  of  the  coats  of  the 
vessels  at  the  seat  of  lesion  ; the  coagulation  of 
the  blood — first  around,  and  then  within  the 
open  vessel;  the  pressure  of  the  extravasated 
blood  in  the  surrounding  tissues ; and  the  in- 
creased coagulability  of  the  blood  after  the  flow 
has  continued  for  some  time.  The  relief  of  the 
local  disturbance  of  pressure  by  the  occurrence 
of  the  haemorrhage,  is  alone  sufficient  in  many 
instances  to  arrest  the  flow. 

Effects. — The  effects  of  haemorrhage  are 
chiefly  exerted  upon  the  system  generally ; and 
theyare  therefore  remarkably  uniform,  whatever 
maybe  its  locality.  The  circumstances  that  more 
especially  affect  the  intensity  of  the  effects  or 
symptoms  are  two,  namely,  the  amount  of  blood 
lost,  and  the  rapidity  of  the  flow.  When  haemor- 
rhage is  at  once  free  and  persistent,  syncope 
rapidly  ensues,  probably  accompanied  by  convul- 
sions, and  ending  speedily  in  death  unless  the 
bleeding  either  spontaneously  cease,  or  be  arti- 
ficially arrested.  The  sudden  loss  of  one  half 
of  the  total  amount  of  blood  in  the  body  (say 
five  pounds)  is  said  to  be  sufficient  to  cause 
death.  On  the  other  hand,  enormous  quantities 
of  blood  may  be  lost  without  a fatal  result  if 
the  haemorrhage  be  slow,  or  frequently  repeated 
with  considerable  intermissions.  The  condition 
of  the  subject  of  the  haemorrhage  then  becomes 
ono  of  anaemia  {see  Anemia).  More  moderate 
bleedings  frequently  repeated  produce  faintness, 
and  may  cause  a certain  degree  of  pallor,  which 
shortly  disappears.  Moderate  haemorrhages  from 
certain  situations,  for  example  from  the  nose,  rec- 
tum, or  even  the  lungs,  may  sometimes  relieve 
congestion,  and  be  attended  with  great  relief 
and  benefit. 

Local  effects  do,  however,  occur  in  some  forms 
of  haemorrhage.  Haemoptysis  may  be  accom- 
panied by  inhalation  of  blood,  and  lead  to  inflam- 
mation or  more  complex  disease  of  the  lungs. 
Haemorrhage  into  the  uriniferous  tubules  causes 
plugging  of  these,  and  discharge  of  blood-casts. 
Blood  retained  in  the  generative  or  in  the  respi- 
ratory passages  occasionally  becomes  decomposed. 
The  special  symptoms  of  the  several  forms  of 
haemorrhage  are  described  under  the  head  of 
each. 

Treatment. — The  treatment  of  haemorrhage 
from  external  parts  is  a subject  of  purely  surgi- 
cal interest;  but  it  may  be  said  that,  in  cases  of 
emergency,  moderate  pressure  with  the  finger  or 
other  means,  on  the  seat  of  the  bleeding,  is  gene- 
rally practicable  and  successful.  Hsmorrhage 
from  internal  parts  requires  special  treatment 
according  to  the  particular  organ  from  which  it  is 
proceeding.  The  reader  is,  therefore,  referred  to 
the  several  articles  on  Epistaxis,  Hikmatemesis, 
Hsmatuela,  Haemoptysis,  Meubna,  and  Men- 


HEMORB  HOLDS.  573 

struation,  Disorders  of;  as  well  as  to  the  articles 
on  Hemostatics,  and  Styptics. 

J.  Mitchf.ll  Bruce. 

HAEMORRHAGIC  {al/ia,  blood,  and  priyvufu, 
I burst  forth). — Associated  with  haemorrhage. 
The  word  is  applied  to  certain  inflammatory 
products  or  to  effusions  when  they  contain  blood, 
as  in  hemorrhagic  peritonitis  ; and  to  varieties  ol 
certain  diseases  in  which  extravasations  or  haemor- 
rhages from  free  surfaces  occur,  for  example, 
hemorrhagic  small-pox,  hemorrhagic  measles,  and 
hemorrhagic  purpura. 

HAEMORRHAGIC  DIATHESIS.  Set 
Hemophilia. 

HAEMORRHOIDS  (alua,  blood,  and  pea,  I 
flow). — Synon.  ; Piles ; Er.  Hemorrhoid.es  ; Ger. 
Hemorrhoiden. 

Description.— The  hsemorrhoidal  veins  dis- 
tributed to  the  lower  part  of  the  rectum  are  very 
liable  to  become  dilated  and  varicose,  giving  rise 
to  a disease  termed  hemorrhoids  or  piles.  When 
the  plexus  beneath  the  mucous  membrane  within 
the  external  sphincter  is  thus  affected,  the 
hsemorrhoids  are  said  to  be  internal.  When  the 
veins  beneath  the  integuments  outside  the  muscle 
are  enlarged,  the  haemorrhoids  are  called  external. 
Internal  and  external  haemorrhoids  very  fre- 
quently co-exist. 

External  Hsemorrhoids. — Wo  may  distin- 
guish two  kinds  of  external  piles: — (1)  A san- 
guineous tumour.  (2)  A cutaneous  excrescence  or 
outgrowth. 

(1)  The  sanguineous  tumour  consists  of  a soft- 
ish  elevation  of  the  skin  near  the  margin  of  the 
anus,  of  a rounded  form,  and  a livid  or  slightly 
blue  tinge.  On  cutting  into  it,  we  find  a dark- 
coloured  coagulum  enclosed  in  a cyst. 

(2)  The  cutaneous  excrescence,  or  second  form 
of  external  piles,  consists  of  a flattened  prolon- 
gation of  skin,  due  to  hypertrophy  of  the  epi- 
dermis, papillae,  and  cutaneous  layers.  It  is 
generally  the  result  of  the  first  form,  a project- 
ing fold  left  after  absorption  of  the  coagulum 
having  undergone  further  growth.  Often  there  is 
only  a single  broad  flat  excrescence  at  the  side  of 
the  anus  ; hut  sometimes  there  are  two,  one  on 
each  side  ; and  occasionally  there  are  several  en- 
circling the  anus.  Similar  excrescences  occur  as 
the  result  of  irritating  discharges  from  the  bowel, 
and  are  common  in  stricture  and  chronic  ulcera- 
tion of  the  rectum. 

Internal  Hemorrhoids.  — Internal  piles 
seldom  attract  attention  until  they  have  becomeso 
developed  as  to  protrude  at  the  anus  in  defeca- 
tion. They  then  exhibit  a remarkable  diversity 
of  appearance,  according  to  their  number,  size, 
and  condition.  The  protrusion  may  consist  of 
only  one  large  pile,  found  usually  towards  the 
perineum,  especially  in  women.  More  commonly 
there  are  three  distinct  prominent  growths,  dif- 
fering in  size,  one  at  each  side  of  the  anus,  and 
a third  in  front — the  latter,  the  perineal,  being 
the  largest.  In  old  cases  they  may  be  more 
numerous — as  many  as  four  or  five.  The  distinc- 
tion between  them  is  commonly  well-marked,  but 
not  always,  for  the  piles  sometimes  merge  into 
each  other,  so  that  the  protrusion  forms  nearly  c 


HAEMORRHOIDS. 


b74 

circular  prominence.  The  aspect  of  extruded 
piles  depends  much  upon  their  condition,  whether 
congested,  inflamed,  or  constricted  by  the  sphinc- 
ter. In  an  inactive  state,  and  in  a relaxed 
condition  of  the,  sphincter,  they  form  softish 
tumours  of  a granular  appearance,  presenting 
just  at  the  orifice  of  the  anus;  but  when  pro- 
truded and  congested,  they  constitute  large  tense 
tumid  swellings,  of  a deep  red  colour  and  smooth 
surface,  which  readily  bleed.  When  haemor- 
rhoids are  of  large  size,  the  integuments  at  the 
margin  of  the  anus  become  everted,  and  form  a 
broad  band  girting  the  base  of  the  tumours. 
The  skin  thus  everted  is  liable  to  b6  mistaken 
for  external  piles,  and  to  be  excised  in  opera- 
tions— an  error  very  likely  to  be  followed  by 
serious  contraction  of  the  anus. 

./Etiology. — Haemorrhoids  are  a disease  of 
middle  and  advanced  age.  They  rarely  occur 
before  puberty  ; and  but  few  persons  in  after-life 
altogether  escape  them.  All  circumstances  which 
determine  blood,  to  the  rectum,  or  which  impede 
its  return  from  the  pelvis,  tend  to  produce  this 
disease.  There  is  in  many  persons  a natural 
predisposition  to  the  complaint,  which  may  be 
hereditary.  But  a predisposition  is  most  fre- 
quently acquired  by  sedentary  habits,  indulg- 
ences at  table,  and  excitement  of  the  sexual  or- 
gans. Haemorrhoids,  though  a common  disease 
in  both  sexes,  occur  more  frequently  in  males 
than  in  females.  Few  women  bear  children  with- 
out becoming  in  some  degree  affected  by  them  ; 
but  the  urinary  and  genital  disorders  of  the  other 
sex,  combined  with  freer  habits  of  living,  lead- 
ing to  congestion  of  the  liver,  are  still  more  fertile 
sources  of  piles. 

Symptoms. — The  symptoms  produced  both  by 
external  and  internal  piles  vary  greatly  in  differ- 
ent subjects,  and  in  different  stages  of  the  com- 
plaint. 

External  piles  cause  a feeling  of  heat  and  ting- 
ling at  the  anus.  A costive  motion  is  followed 
by  a burning  sensation,  and  the  excrescence  be- 
comes swollen  and  tender  on  pressure,  so  as  to 
render  sitting  uneasy.  This  congested  state  of 
the  pile  may  pass  off;  or  it  may  lead  to  inflam- 
mation accompanied  with  eorsiderable  enlarge- 
ment of  the  haemorrhoid,  forming  an  oval  tumour, 
red,  tense,  and  extremely  tender.  The  inflamma- 
tion may  subside  or  go  on  to  suppuration.  When 
the  matter  is  discharged,  a clot,  of  blood  escapes 
with  it,  the  abscess  closes,  and  the  dilated  vein 
is  usually  obliterated,  the  pile  being  reduced  to 
a small  flap  of  integument.  External  piles  rarely 
give  rise  to  bleeding. 

Internal  piles,  when  slight,  may  exist  for  years, 
causing  little  inconvenience  besides  slight  bleed- 
ing after  a costive  motion  ; with  occasionally  a 
feeling  of  fulness,  heat,  and  itching  just  within 
the  anus.  If  only  small,  they  protrude  slightly 
with  the  mucous  membrane  in  defecation.  return- 
ing afterwards  within  the  sphincter.  When  of 
large  size,  the  piles  always  protrude  at  stool,  and 
require  to  be  replaced,  the  patient  usually  push- 
ing them  up  with  his  fingers.  In  a lax  state  of 
the  sphincters,  and  in  a loose  hypertrophied  con- 
dition of  the  mucous  membrane  from  which  they 
spring,  haemorrhoids  come  down,  even  when  the 
patient,  stands  or  walks  abnut,  so  as  to  prove 
exceedingly  troublesome,  and  to  interfere  with 


his  taking  walking  exercise.  In  consequence  of 
the  irritation  from  pressure  and  friction  to  which 
the  protruding  piles  are  liable,  their  mucous 
surface  becomes  tumid  and  abraded,  and  fur- 
nishes a free  mucous  discharge  tinged  with  blood, 
which  soils  the  linen.  They  are  often  so  sore 
that  the  patient  is  obliged  to  keep  the  recumbent 
posture,  the  pressure  in  sitting  causing  more  or 
less  uneasiness. 

Persons  subject  to  piles  frequently  suffer  no 
inconvenience  from  them  until  irritated  by  an 
unusually  costive  motion,  or  by  a smart  purga- 
tive ; or  when,  under  the  excitement  of  wine,  the 
growths  become  congested  and  inflamed,  and 
cause  spasm  of  the  sphincter  muscle.  Then  they 
have  what  is  termed  an  ‘ attack  of  piles  ’ — that 
is  to  say,  they  experience  a sensation  of  heat, 
weight,  and  fulness  just  within  the  rectum,  fol- 
lowed by  considerable  pain  at  stool,  and  some- 
times irritation  about  the  bladder.  These 
symptoms,  which  are  often  attended  with  febrile 
disturbance,  arise  from  inflammation  and  swelling 
of  the  piles,  which  afterwards  subside,  but  seldom 
without  leaving  some  enlargement  of  the  growths. 
The  formation  and  increase  of  piles  seem  indeed 
to  arise  chiefly  from  a determination  of  blood  to 
the  rectum.  This  is  greatly  promoted  by  stimu- 
lating drinks,  so  that  some  patients  never  suffer 
from  the  complaint  except  after  indulging  in 
this  way.  They  are  then  rendered  sensible  of 
an  afflux  of  blood  by  a sense  of  heat  or  intoler- 
able itching  at  the  anus. 

Strangulation. — "When  internal  piles  of  some 
sizo  protrude  at  the  anus  and  are  not  returned, 
they  are  liable  to  be  constricted  and  strangulated 
by  the  external  sphincter.  The  contracted  muscle 
impedes  the  return  of  blood,  and  occasions  in- 
flammatory swelling  cf  the  piles,  which  may 
become  strangulated  and  mortify.  In  this  way 
haemorrhoids  of  large  size  have  been  known  to 
slough  off,  the  patient  being  relieved  of  the 
annoying  complaint  by  a sort  of  natural  process. 
An  occurrence  of  this  kind  is  attended  with  a 
good  deal  of  pain  and  suffering,  but  is  free  from 
danger.  In  general,  the  extremities  only  of  one 
or  two  of  the  larger  growths  perish,  and  the 
patients,  though  experiencing  relief,  are  by  no 
means  cured  of  the  disease. 

Hemorrhage.  — One  of  the  most  common 
symptoms  of  internal  haemorrhoids,  indeed  that 
from  which  the  name  of  the  complaint  is  derived, 
is  haemorrhage,  which  occurs  when  the  bowels 
are  evacuated.  The  bleeding  varies  greatly  in 
amount.  Sometimes  the  motions  are  merely 
tinged  with  a few  drops  of  blood;  in  other  in- 
stances the  quantity  lost  is  considerable,  several 
ounces  being  voided  at  stool.  The  bleeding  may 
be  irregular,  occurring  only  after  costive  motions, 
or  in  certain  states  of  health  ; or  it  may  take 
place  daily,  going  on  even  within  the  bowel,  and 
producing  the  usual  symptoms  of  derangement 
from  continued  losses  of  blood,  such  as  blanched 
complexion,  loss  of  strength,  quick  small  pulse, 
and  even  oedema  of  the  feet.  The  character  of  the 
bleeding  also  varies,  being  sometimes  venous, 
sometimes  arterial.  There  are  persons  who  are 
liable  to  discharges  of  blood  from  the  litemor- 
rhoidal  veins,  either  at  regular  periods  or  when, 
from  good  living  or  want  of  exercise,  the  habit 
is  fuller  than  usual.  In  theso  cases  from  three 


HAEMORRHOIDS. 

to  six  ounces  of  blood,  or  even  more,  pass  away 
at  stool,  following  the  evacuation  ; and  the  blood 
which  is  voided  is  of  a dark  colour  and  evidently 
venous.  Such  discharges  must  not  be  rashly 
interfered  with.  They  relieve  congestion  of  the 
liver  and  kidneys,  help  to  ward  off  attacks  of 
gout,  and  prevent  fits  of  apoplexy  ; so  that  in 
many  persons  they  are  rightly  regarded  as  safety- 
valves.  But  the  bleeding  which  most  commonly 
occurs  from  internal  piles  is  undoubtedly  arterial, 
taking  place  from  arteries  enlarged  by  disease. 
The  vessels  on  the  spongy  surface  of  the  mucous 
membrane  readily  give  way  when  blood  is  de- 
termined to  the  part  in  defaecation,  or  when 
abraded  by  the  passage  of  hard  faeces.  An  artery 
of  some  size,  exposed  by  ulceration,  continues  to 
pour  oat  blood,  weakening  the  patient  and  giving 
rise  to  the  symptoms  above  described.  Some- 
times a small  artery  on  the  prominent  part  of  a 
protruded  pile  may  be  observed  pumping  out 
blood.  That  lifemorrhage  of  this  character  is 
good  for  the  health,  is  quite  a mistaken  notion; 
and  it  is  important  that  the  practitioner  should 
distinguish  the  bleeding  taking  place  as  a con- 
sequence of  local  disease,  from  that  which  arises 
from  a constitutional  plethora  or  congestion  of 
the  internal  organs. 

Treatment.  -When  piles  are  small  and  cause 
but  little  inconvenience,  the  treatment  is  very 
simple.  Persons  with  this  complaint  should  take 
wine  in  great  moderation,  if  at  all ; and  in  most 
instances  they  would  do  well  to  abstain  entirely 
from  stimulating  drinks.  Many  individuals  never 
suffer  from  piles  except  after  taking  a glass  of 
spirits  and  water,  or  a few  glasses  of  wine. 
Such  persons  should  become  water-drinkers. 
Active  exercise  in  the  open  air  should  be  taken 
daily,  and  the  patient  should  avoid  sitting  too 
long  at  the  desk,  because  it  is  by  prolonged 
sedentary  occupation  and  the  neglect  of  the  rules 
of  health  that  haemorrhoidal  complaints  are  in- 
duced. Chairs  with  cane  seats  are  to  be  recom- 
mended. The  bowels  must  be  carefully  regu- 
lated, so  as  to  avoid  hard  and  costive  motions, 
as  well  as  frequent  action.  Irritating  the  rectum 
by  active  and  repeated  purging  is  more  hurtful 
even  than  constipation.  On  the  other  hand, 
when  the  liver  is  congested,  or  its  secretions  are 
sluggish,  and  when  the  bowels  are  costive,  a mild 
cathartic,  by  clearing  the  intestines,  especially 
the  colon,  unloads  the  congested  vessels,  and  re- 
lieves the  piles.  Lenitive  electuary,  rendered 
more  active  when  necessary  by  the  addition  of 
tartrate  of  potash,  may  be  taken  at  bedtime;  or 
the  compound  liquorice  powder  of  the  Prussian 
pharmacopoeia,  Carlsbad  salts,  or  the  foreign 
mineral  waters — the  Pullna,  the  Friedrichshall, 
or  the  Hunyadi-Janos — taken  in  the  morning 
fasting,  answer  well  with  many  persons,  and 
ensure  a comfortable  relief.  Half  a pint  of  cold 
spring  water  injected  into  the  rectum,  in  the 
morning  after  breakfast,  has  a very  beneficial 
effect  on  the  hemorrhoids,  by  constringing  the 
vessels,  and  softenina:  the  motions  before  the 
usual  evacuation.  Lhe  relief  afforded  by  this 
treatment,  combined  with  care  in  the  mode  of 
living,  is  often  remarkable.  Ordinary  venous 
bleeding  may  be  stopped  in  this  way.  If  neces- 
sary, iced  water,  or  an  astringent  injection, 
such  as  a solution  of  tannic  acid  or  Infusion  of 


HAIR,  DISEASES  OF.  575 

rhatany,  may  he  used;  or  an  astringent  sup- 
pository. When  the  bleeding  is  arterial,  injec- 
tions are  not  so  successful,  and  operative  treat- 
ment often  becomes  necessary.  When  there  is 
a slimy  discharge  from  the  surface  of  an  exposed 
internal  pile,  benefit  may  be  derived  from  the 
daily  application  of  tannic  acid,  mild  citrine 
ointment,  or  the  solid  sulphate  of  copper. 

External  piles,  when  large  and  troublesome, 
and  internal  piles  when  of  such  a size  as  to  pro- 
trude at  stool  and  to  be  subject  to  inflammation, 
ulceration,  and  frequent  bleeding,  can  be  removed 
only  by  operation.  T.  B.  Curling. 

H-TEMOSTATICS  (apua,  blood,  and  (TTarbs, 
stopped). 

Definition. — Internal  remedies  and  local  ap- 
plications which  arrest  haemorrhage. 

Enumeration. — The  chief  haemostatics  are  ; — 
The  Ligature;  Pressure  ; Rest;  Cold;  the  Actual 
Cautery  ; Astringents ; and  the  whole  class  of 
Styptic  drugs. 

Actions  and  Uses. — When  taken  in  their 
widest  sense,  it  is  evident  that  haemostatics 
must  include  all  the  various  means  which  have 
been  devised  to  stop  bleeding.  Externally 
we  must  vary  our  plan  of  treatment  according 
to  circumstances.  No  surgical  principles  are 
better  founded  than  those  which  enjoin  us  to  tie 
a wounded  artery,  and  to  apply  pressure  to  a vein ; 
and  for  the  absolute  arrest  of  haemorrhage  from 
any  readily  accessible  part  a most  powerful  aid 
has  lately  been  provided  in  Esmarch’s  elastic 
bandage.  When  the  bleeding  depends  on  general 
capillary  oozing,  the  application  of  ice  may  often 
prove  effectual ; and  where  this  fails,  recourse 
must  be  had  to  some  of  the  numerous  articles 
of  the  pharmacopoeia,  already  referred  to,  which 
are  endowed  with  styptic  properties.  (Sec 
Styptics.)  An  example  of  the  successful  appli- 
cation of  a haemostatic  is  the  arrest  of  uterine 
haemorrhage  by  means  of  injections  of  percliloride 
of  iron. 

In  the  case  of  undue  haemorrhage  from  a leech- 
bite,  if  milder  remedies,  such  as  pressure,  do  not 
succeed,  we  may  apply  the  solid  nitrate  of  silver, 
or  include  the  bleeding  point  in  a loop  of  twisted 
suture.  Absolute  rest  is  essential  for  the  suc- 
cessful treatment  of  haemorrhage  ; and  the  regu- 
lation of  the  diet  and  of  the  bowels  is  equally 
to  bo  attended  to.  For  the  details  of  treatment 
in  each  particular  form  of  haemorrhage,  the 
reader  is  referred  to  ILematemesis,  IIiemo 
philia,  Hemoptysis,  Melina,  &e. 

Robert  Farquharson. 

HAIMOTHOKAX.  See  Hjsmato-thorax. 

HAIH,  Diseases  of. — Aberrations  of  the 
hair  from  the  normal  and  healthy  standard  may 
be  comprised  under  three  heads — quantity, 
quality , and  direction. 

Alterations  in  quantity. — As  regards  quan- 
tity of  the  hair,  there  may  be  either  excess  nr 
diminution. 

Excess  of  hair. — Excess  may  be  the  consequence 
of  multiple  development  from  the  follicles,  lead- 
ing to  the  production  of  a greater  numberof  hairs 
than  usual;  or  it  may  result  from  excessive 
growth,  which  brings  into  view  the  usually  in- 
visible hairs  of  the  body,  more  or  less  generally 


HAIR,  DISEASES  OF. 


576 

or  partially.  Of  the  latter  kind  are  the  hairy 
men  and  women  of  whom  so  many  instances  are 
recorded ; and  the  abnormal  growth  of  hair  on 
parts  of  the  body  where  its  presence  is  normally 
but  little  perceptible,  for  example,  on  the  face  of 
women,  in  the  form  of  moustache,  whisker,  or 
beard.  The  hair  of  the  head,  as  well  as  that  of 
the  beard,  sometimes  attains  an  excessive  length. 
Moreover,  hair  may  be  abnormal  in  situation  as 
well  as  in  growth,  as  seen  in  the  varied  examples 
of  pilous  ntevi. 

Diminution  of  hair. — Diminution  may  present 
itself  as  shortness  in  length  from  slowness  of 
growth,  or  numerical  deficiency  from  arrest  of 
growth  ; and  the  latter  may  proceed  onwards  to 
baldness  more  or  less  complete.  See  Baldness. 

Alterations  in  quality. — Alterations  of 
quality  of  the  hair  are  manifested  by  variations 
in  its  'physical  conditions,  alterations  of  colour, 
and  pathological  changes  of  structure. 

Physical  conditions.  ■ — - The  hair,  normally 
smooth,  lustrous,  soft,  and  elastic,  may  become 
rough,  dull,  harsh  and  rigid,  or  brittle. 

Colour. — Alteration  in  colour  of  the  hair 
usually  ranges  between  the  lighter  tints  of 
childhood  and  the  darker  hues  of  the  adult, 
and  the  arrest  of  pigmentation  which  gives  rise 
to  the  greyness  of  every  period  of  life  and  the 
hoariness  of  old  age.  Absence  of  pigment,  com- 
plete or  partial,  is  sometimes  congenital.  Alter- 
ations of  the  colour  of  the  hair  occasionally  take 
place  during  the  course  of  a serious  illness ; or 
the  hair  may  become  blanched  in  the  space  of  a 
few  hours  from  mental  disturbance.  There  is 
another  aberration  of  colour  of  the  hair,  which 
consists  of  an  alternation  of  brown  and  white  in 
narrow'  segments,  extending  from  end  to  end  of 
the  hair — a kind  of  ‘ringed’  or  ‘ banded ’ hair. 
A few  examples  of  this  peculiar  change  in  the 
hair  have  been  preserved  and  recorded. 

Structure.— Aberrations  in  structure  of  the 
hair  are  showm  by  its  atrophy  or  attenuation; 
by  its  defective  consolidation;  by  a patholo- 
gical alteration  of  its  elementary  constituents  ; 
and  by  the  morbid  changes  induced  by  syphilis. 
It  is  not  uncommon  to  find  the  hair  dwindled 
to  a mere  vestige  of  its  original  bulk ; and, 
when  this  takes  place,  it  is  apt  to  break  off 
near  the  point  of  attenuation,  and  present  the 
appearance  of  a club-shaped  stump.  Broken  hairs 
of  this  character,  with  filamentary  pedicles,  are 
found  at  the  circumference  of  a spot  of  alopecia 
areata.  Or  the  hairs  may  be  fragile  in  texture, 
and  break  partially  through  at  short  distances, 
so  as  to  give  a speckled  appearance  to  the  hair- 
shaft.  This  change  is  generally  met  with  in  the 
thick  hairs  of  the  whiskers  and  beard,  and  is 
termed  trichoclasia  or  fragilitas  crinium.  In 
tinea  the  formative  cells  of  the  hair  retain  their 
elementary  fetal  form,  or  proliferate  in  the 
substance  of  its  shaft,  rendering  it  brittle  and 
causing  its  destruction  ; the  cell-proliferation  con- 
stituting the  trichophyton  among  the  parasitic 
fungi.  In  syphilis,  the  hairs  of  the  whiskers  and 
beard  have  been  found  swollen,  as  though  vari- 
cose, and  discoloured  from  imperfect  cell-develop- 
ment. 

Alterations  in  direction. — Altered  direction 
of  the  hair  is  met  with  on  the  edges  of  the  eye- 
lids, where  the  hair  may  grow  inwards  and 


press  against  the  cornea,  so  as  to  give  rise  to 
conjunctivitis ; this  form  of  affection  being  termed 
trichiasis.  The  matting  or  felting  of  the  hair  in 
plica  polonica  may  likewise  be  ascribed  to  mis- 
direction, though  in  a different  sense,  namely,  as 
resulting  from  neglect. 

.Etiology  and  Pathology. — Numerical  quan- 
tity of  hair  can  be  considered  pathological  only 
when  that  quantity  interferes  by  its  excess  with 
the  comfort  and  convenience  of  the  individual. 
This  can  rarely  occur  when  the  hair  is  produced 
in  normal  situations,  and  grows  to  excessive 
length,  the  remedy  being  obvious.  But  when 
it  is  developed  on  the  face  of  the  female  in  the 
form  of  moustache,  whiskers,  or  beard,  it  is  then 
an  annoyance  very  nearly  approaching  to  that  of 
a disease.  This  is  still  further  increased  when 
the  greater  part  of  the  body  becomes  invested, 
as  sometimes  occurs,  with  a thick,  hairy  cover- 
ing. An  excess  of  pilous  growth  is,  in  general, 
a mere  augmentation  of  a natural  function ; oc- 
casionally, it  appears  to  be  the  result  of  a sub- 
stitutive function,  as  in  sterile  females,  or  when 
the  procreative  power  is  exhausted  through  age; 
and  at  other  times,  as  in  pilous  naevi.  it  is  due  to 
abnormal  organisation  of  the  affected  skin. 

Diminution  of  quantity  of  hair,  and  arrest  of 
pilous  growth,  must  in  every  instance  be  due  to 
aberration  of  nutrition,  and  atrophy  of  the  for- 
mative papilke  of  the  hair.  This  may  be  the 
consequence  of  debility,  however  induced,  whether 
by  age  or  disease.  Very  commonly  the  hair 
breaks  away  from  the  papilla  without  undergoing 
any  previous  alteration  of  figure.  At  other  times 
it  becomes  attenuated  and  starved  before  it 
eventually  drops  off.  Sometimes  the  nutritive 
power  is  simply  suspended  ; while  at  other  times 
it  is  completely  arrested,  temporarily  or  perma- 
nently, and  gradually  or  on  a sudden.  After  serious 
illness  the  hair  is  apt  to  fall  off;  not  unfrequently 
this  occurs  after  puerperal  confinement ; drop- 
ping off  of  the  hair  is  known  to  be  a frequent 
concomitant  of  syphilis  ; and  it  presents  the  cha- 
racteristics of  a nerve-lesion  in  alopecia  areata. 
In  cases  of  universal  baldness  the  skin  is  soft, 
pulpy,  and  feeble  ; deficient  in  colour  as  well  as 
in  firmness  and  tone ; and  smooth  from  the  absence 
of  papilla;. 

Alteration  of  colour  of  the  hair  is  generally 
attributable  to  variations  in  quantity,  and  modifi- 
cation of  pigment.  But  in  cases  of  sudden  blanch- 
ing of  the  hair,  the  apparent  whiteness  has  been 
found  to  depend  on  the  rapid  development  of 
a gaseous  fluid  within  the  substance  of  the  hair, 
obscuring  the  pigmentary  granules  to  which  its 
colour  is  due.  This  has  likewise  been  observed 
to  be  the  case  in  the  instance  of  ringed  or  banded 
hair. 

Alterations  of  structure  of  the  hair  are  for  the 
most  part  due  to  modifications  of  development  and 
growth  of  its  constituent  cells.  The  elementary 
cells  may  be  produced  in  greater  or  loss  quan- 
tity, changing  the  hulk  of  the  hair ; they  may  be 
more  or  less  abundantly  and  completely  con- 
verted into  hair-fibre  ; they  may  retain  perma- 
nently their  undeveloped  or  cell-character  ; or 
they  may  become  the  subject  of  an  abnormal  pro- 
liferation within  the  shaft  of  the  hair.  As  the 
firmness,  elasticity,  and  pliancy  of  the  hair  are 
due  to  the  perfection  of  its  development,  so  die 


HAIR,  DISEASES  OF. 
opposite  qualities  are  referable  to  abnormal  de- 
velopment. The  shaft  of  the  hair  often  varies  in 
its  diameter;  the  medullary  space  equally  varies ; 
it  may  be  fractured  completely,  as  in  ringworm  ; 
or  partially,  and  with  slight  force,  as  in  tricho- 
clasia.  The  hair  of  ringworm  is  made  up  of 
round  cells  and  proliferating  cells,  with  a defi- 
ciency of  fibrous  structure  ; hence  it  dries  and 
shrivels  up  as  though  withered,  or  breaks  off 
close  to  the  head,  leaving  behind  short  stumps. 
When  syphilis  attacks  the  hair,  its  structure  is 
likewise  rendered  brittle. 

Treatment. — The  therapeutical  treatment  of 
the  diseases  of  the  hair  may  be  summed  up  very 
briefly.  Where  the  hair  is  in  excess  it  must  be 
removed;  where  it  is  deficient  it  must,  if  pos- 
sible, be  restored ; and  where  its  structure  is 
altered,  it  must  be  repaired  by  renovating  the 
health  of  its  formative  organ,  the  skin. 

Contrivances  for  removing  the  hair  are  termed 
depilatories  ; they  act  for  the  most  part  by  de- 
stroying and  dissolving  the  hair.  Their  applica 
tion  requires  caution,  on  account  of  their  irritant 
qualities,  and  they  are  open  to  the  objection  of 
being  merely  temporary  in  their  effects.  The 
only  trustworthy  depilatory  is  the  razor.  See 
Depilatories. 

For  defect  of  growth  in  length,  as  also  in 
quantity,  we  must  have  recourse  to  tonic  or  sti- 
mulant remedies.  Tonics,  such  as  arsenic,  qui- 
nine, and  iron,  improve  the  nutritive  power  of 
the  skin;  and  stimulants  for  external  apph’ca- 
tion  arouse  the  energies  of  the  tissues  of  the 
skin,  more  especially  those  of  the  blood-vessels 
and  nerves.  The  usual  stimulants  adopted  for 
this  purpose  are  ammonia,  cantharides,  mustard, 
the  various  stimulating  liniments,  and  acetic 
acid.  See  Baldness. 

For  the  purposes  of  fashion  or  convenience, 
the  colour  of  the  hair  may  be  discharged  by 
solutions  of  oxygen,  notably  the  peroxide  of  hy- 
drogen ; and  also  by  alkalies,  with  more  or  less 
injury  to  the  hair.  It  may  be  restored  arti- 
ficially by  the  various  hair-dyes,  which  are  either 
temporary  or  permanent.  Of  the  former  kind 
are  the  permanganate  of  potash,  and  the  black 
oxide  of  lead ; and  of  the  latter  the  black  oxide 
of  silver. 

Alterations  of  structure  of  the  hair  due  to 
debility  of  the  skin  require  the  aid  of  constitu- 
tional tonics  and  local  stimulants.  Where  ring- 
worm is  the  cause  of  the  morbid  change  of  the 
hair,  there  is  a chronic  inflammation  to  be  sub- 
dued, as  well  as  a feebleness  of  nutritive  power 
to  be  repaired.  In  the  fall  of  the  hair  from 
syphilis,  the  specific  remedies  for  that  disease 
are  required. 

Aberration  of  direction  of  the  hair  may  be 
corrected  by  avulsion  with  the  forceps ; and  the 
felting  of  the  hair  in  plica  polonica  may  be  pre- 
vented by  ordinary  care  and  attention. 

Erasmus  Wilson. 

HALL,  in  Austria.  Common  salt  waters. 
See  Mineral  Waters. 

HALLUCINATION  ( hallucinor , I blun- 
der).— A false  perception  of  an  organ  of  sense, 
for  which  there  is  no  external  cause  or  origin 
(see  Illusion)  ; as  when  a man  in  total  darkness 
thinks  he  sees  an  object.  Hallucinations  of  all 

37 


HANGING,  DEATH  BY.  57’ 

the  senses  occur,  the  most  frequent  being  those 
of  sight  and  hearing.  They  may  be  found  in  per- 
sons not  insane,  but  indicate  a disordered  state 
of  brain. 

HAJNGING,  Death  by. — Hanging  is  the 

effect  of  suspension  of  the  body  by  the  neck  by 
means  of  a ligature  or  noose,  the  constricting 
force  being  the  weight  of  the  body,  wholly  ci 
in  part,  or  the  weight  multiplied  by  the  distance 
through  which  the  body  falls.  The  mode  oi 
death  varies  according  to  these  circumstances 
With  a loug  drop,  the  method  now  usually  em 
ployed  in  judicial  hanging,  and  particularly  i; 
the  knot  is  under  the  chin,  death  is  not  unfre- 
quently  due  to  fracture,  or  displacement,  of  the 
cervical  vertebrae,  and  injury  to  the  medulla 
oblongata.  Death  may  also  occur,  without  such 
anatomical  lesion  of  the  cervical  vertebrae,  from 
shock  or  syncope,  or,  as  it  is  termed  by  Casper, 
neuro-paralysis. 

When  death  does  not  occur  in  either  of  these 
ways,  it  is  the  result  of  asphyxia  from  occlusion 
of  the  air-passages,  or  rather  of  asphyxia  in  com- 
bination with  coma,  caused  by  compression  of  the 
cerebral  blood-vessels.  Though  compression  of 
the  carotids  and  jugulars  may  be  maintained  for 
a considerable  time  without  a fatal  result,  if  the 
trachea  is  open  below  the  point  of  constriction, 
whereas  death  speedily  ensues  if  the  air-passages 
are  also  occluded,  yet  death  may  result  from  the 
disturbance  of  the  cerebral  circulation  alone,  and 
the  two  causes  always  operate  conjointly  in  every 
case,  in  varying  proportions. 

Phenomena. — When  death  is  not  instantaneous, 
as  in  cases  of  injury  to  the  medulla,  or  from 
neuro-paralysis,  convulsive  movements  of  the  type 
seen  in  asphyxia  may  continue  for  some  minutes 
after  suspension,  and  the  heart  may  continue  to 
beat  for  a considerable  period  after  all  other  vital 
movements  have  ceased. 

Subjects  who  have  been  partially  hanged  have 
described  various  sensations,  more  or  less  plea- 
surable, similar  to  those  of  cerebral  congestion 
and  narcotic  stupor. 

Post-mortem  Appearances. — The  appearances 
found  after  death  by  hanging  are  not  uniform  or 
constant ; and  there  is  no  single  sign  invariably 
present  diagnostic  of  death  by  hanging.  Indica- 
tive of  suspension,  hut  not  necessarily  of  deatli 
so  caused,  is  the  mark  of  the  cord  on  the  neck. 
Usually  it  is  above  the  hyoid,  passing  obliquely 
upwards  behind  the  ears,  and  losing  itself  id 
the  occiput.  But  the  position  may  vary  ac- 
cording to  the  tightness  of  the  noose  before 
suspension,  or  the  position  of  the  head  and  direc- 
tion of  the  pressure.  It  is  generally  single,  hut 
if  the  cord  should  have  been  twisted  twice  round 
the  neck,  two  marks  may  be  found,  one  circular 
and  the  other  oblique.  The  characters  of  the 
mark  differ  somewhat  according  to  the  texture 
and  thickness  of  the  ligature.  Usually  it  is  a 
shallow  groove  or  furrow  of  a whitish  or  brown- 
ish hue  and  parchmenty  consistence,  occasionally 
abraded,  rarely  ecchymosed;  but  it  may  have  livid 
edges  or  a chocolate  tint.  The  appearances  may 
vary  in  different  parts  of  the  same  mark.  The 
subcutaneous  cellular  tissue  is  compressed  and 
silvery.  Occasionally  minute  extravasations 
are  seen  in  the  deeper  layers  of  the  skin.  The 


578  HANGING,  DEATH  BY. 

middle  and  internal  coats  of  the  carotids  are 
sometimes  lacerated ; and  where  the  momentum 
has  been  great,  lacerations  of  the  cervical  muscles, 
fracture  of  the  larynx,  rupture  of  the  thyro- 
hyoid ligaments,  and  fracture  or  dislocation  of 
the  cervical  vertebrae,  with  injury  to  the  medulla 
and  effusion  into  the  spinal  canal,  have  been 
found.  All  the  appearances  usually  found  in  the 
neck  in  cases  of  hanging  may  be  produced  by 
suspension  of  the  dead  body,  especially  if  the  legs 
are  pulled  forcibly  downward. 

The  face  is  sometimes,  but  not  commonly,  dis- 
torted and  expressive  of  suffering.  Usually  it 
is  placid  and  pale,  though  if  the  body  have  hung 
for  some  time,  it  becomes  very  livid.  The  eyes 
are  sometimes  very  prominent,  and  the  pupils 
are  usually  dilated.  Frothy  mucus  may  be  found 
at  the  mouth  and  nostrils.  The  tongue  is  pressed 
against  the  teeth  and  indented,  or  it  may  be 
clenched  between  the  jaws.  The  base  of  the 
tongue  is  injected.  The  hands  are  often  tightly 
clenched,  the  nails  even  being  driven  into  the 
palms.  Erection,  or  semi-erection,  of  the  penis  in 
men,  with  expulsion  of  semen  or  prostatic  fluid, 
and  vascular  turgescenee  of  the  genitals  in  fe- 
males, with  sanguinolent  effusion,  are  frequently 
observed.  Expulsion  of  the  contents  of  the  bladder 
and  rectum  is  likewise  common.  The  condition  of 
the  brain  varies.  Congestion  is  sometimes  pro- 
nounced, at  other  times  not  very  marked.  The 
mucous  membrane  of  the  larynx  and  trachea  is 
congested,  and  mucous  froth  is  present.  The 
lungs  are  at  times  pale  and  distended ; at  other 
times  collapsed.  The  condition  of  the  heart  and 
venous  system  characteristic  of  asphyxia  is  com- 
mon. Marked  redness  of  the  mucous  membrane 
of  the  stomach,  simulating  irritant  poisoning, 
has  been  occasionally  noted.  The  determination 
of  the  fact  of  death  by  hanging  depends  on  a con- 
sideration of  these  various  phenomena,  and  the 
absence  of  other  causes  of  death. 

Accident,  Suicide,  oe  Homicide? — Hanging 
is  rarely  homicidal.  It  signifies  great  dispropor- 
tion of  strength  between  the  assailant  and  the  vic- 
tim ; and,  therefore,  in  the  absence  bf  this  condi- 
tion. there  will  he  injuries  indicativeofastruggle. 
Apart  from  collateral  circumstances,  homicide 
can  only  be  argued  from  the  presence  of  such 
injuries  as  could  not  have  been  self-inflicted,  or 
caused  accidentally  during  the  act  of  suspension. 
Occasionally  hanging  is  accidental,  as  in  foolish 
experiments  and  insane  imitation.  It  is  not 
necessary  that  the  body  should  be  entirely  off 
the  ground  to  cause  death  by  hanging.  Many 
instances  are  recorded  of  suicide  by  hanging  in 
most  extraordinary  positions  calculated  to  throw 
the  greater  part  of  the  body -weight  on  the  noose. 

Treatment. — This  is  rarely  called  for,  except 
in  accidents  or  attempted  suicide.  The  body  must 
be  cut  down,  and  artificial  respiration  employed. 
Venesection  may  be  had  recourse  to  for  relieving 
cerebral  congestion.  Sec  Artificial  Respira- 
tion; and  Resuscitation.  D.  Ferriee. 

HARROGATE,  in  Yorkshire.  Saline, 
chalybeate,  and  sulphur  waters.  See  Mineral 
Waters. 

HASTINGS,  on  the  South-East  Coast  of 
Sussex.  A mild  climate.  Mean  winter  tem- 


HAY  FEVER. 

perature,  39°  Fahr.  Exposed  to  the  east,  but 
sheltered  from  the  north.  See  Climate,  Treat- 
ment of  Disease  bv. 

HAUT  MAE  (Fr.) — A synonym  for  epi- 
lepsia gravior.  See  Epilepsy. 

HAY  FEVER. — Synon.  : Catarrhus  cestivus: 
Bostock’s  catarrh ; Hay  asthma ; Fr.  Asthmc 
d'ete ; Ger.  Friihsommercatarrh. 

Definition. — A catarrhal  affection  of  the 
mucous  membrane  of  the  eyes,  nose,  mouth, 
pharynx,  larynx,  and  bronchi,  accompanied  by 
dyspnoea ; induced  by  the  action  of  the  pollen 
of  various  plants,  chiefly  of  the  graminace®; 
prevalent  during  the  hay  season,  but  subsiding 
at  its  close  ; and  varying  in  severity  according 
to  certain  atmospheric  conditions,  and  the  amount 
of  pollen  present  in  the  air. 

^Etiology. — Hay  fever  exists  in  Europe  gene- 
rally, but  it  is  by  far  most  common  in  England, 
where  the  annual  number  of  cases  is  double  that 
of  any  other  country.  It  prevails  more  among 
men  than  women,  probably  because  the  former 
are  most  exposed  to  the  atmosphere ; and  inhabi- 
tants of  towns  visiting  the  country  are  more 
liable  to  attack  than  the  country  people  them- 
selves. It  lias  been  ascribed  by  some  writers 
to  the  sun's  heat  in  the  summer  months,  also 
to  certain  odours,  vegetable  and  animal;  hut 
the  experiments  of  Mr.  C.  H.  Blackley  show 
it  to  bo  due  to  the  specific  influence  on  certain 
mucous  membranes  of  the  pollen  grains  of  the 
following  natural  orders  of  plants : — Ranuncu- 
lace®,  Papaveracese,  Fumariace®,  Crucifer®,  Vio- 
lace®,  Caryophyllace®,  Geraniace®,  Leguminos®, 
Umbellifer®,  Rosace®,  Liliace®,  Composit®, 
Graminace®,  and  others,  both  exotic  and  native. 
Pollen  was  applied  to  the  mucous  membrane 
of  the  (1)  nares,  (2)  larynx,  trachea,  bronchial 
tubes  (by inhalation),  (3)  conjunctiv®,  (4)  tongue, 
lips,  and  fauces;  and  in  all  these  cases  it  produced 
the  symptoms  of  hay  fever,  the  pollen  of  grasses 
being  most  potent.  Amongst  these  secale  cereale, 
or  rye,  exercised  most  marked  effects,  though 
greater  influence  is  generally  attributed  to  an- 
thoxanthum  odoratum. 

It  has  been  found  that  large  quantities  of 
pollen  float  in  the  air  during  the  summer  months; 
and  that  the  number  of  cases  of  hay  lever  depends 
on  the  amount  present,  which  increases  in  warm 
damp  weather,  decreases  when  it  is  very  dry  and 
hot.  and  often  nearly  disappears  after  heavy 
rain  Cold  weather  reduces  the  number  of  suf- 
ferers by  checking  the  inflorescence  of  plants. 
The  higher  strata  of  the  atmosphere  appear 
to  contain  more  than  that  immediately  over- 
lying  the  soil,  and  Mr.  Blackley  found  the 
greatest  number  of  pollen-particles  at  between 
1,000  and  1,500  feet  above  the  earth's  surface, 
whither  they  are  probably  carried  by  aerial  cur- 
rents. The.  number  of  pollen-grains  present 
reaches  its  maximum  in  June,  when  Mr.  Blackley 
collected  880  in  a day  on  a square  centimetre  of 
glass.  The  size  aud  forms  of  the  pollen-grains 
vary  greatly  in  the  different  species,  but  this 
does  not  seem  to  influence  their  action,  whicl: 
appears  to  depend  on  the  pollen-sac  absorbing 
moisture  from  the  contiguous  mucous  membrane 
and  bursting,  when  the  minute  granules  it  con- 
tains are  thus  extruded  and  cause  irritation 


HAY  FEVER. 

Symptoms. — An  attack  of  hay  fever  generally 
occurs  without  any  premonitory  disturbance,  im- 
mediately on  the  application  of  the  pollen  to  the 
mucous  surfaces,  for  instance,  when  the  person  en- 
ters a hay-field.  The  first  symptoms  are  itching 
of  the  parts-  with  which  the  particles  come  in  con- 
tact, beginning  with  the  hard  palate  and  fauces, 
and  then  extending  to  the  nostrils,  the  eyes,  and 
face,  though,  if  the  wind  be  strong,  the  eyes  may 
be  first  attacked.  The  catarrhal  stage  follows, 
marked  by  violent  fits  of  sneezing,  and  running 
from  the  eyes  and  nose,  with  occasional  pains  in 
the  head  and  in  the  frontal  sinuses ; then  the  sub- 
mucous tissue  of  the  nares  swells ; and  in  a short 
time  both  nostrils  become  blocked  and  imper- 
vious to  air.  A change  to  the  recumbent  posi- 
tion, however,  if  the  patient  lies  on  one  side, 
will  often  reopen  the  uppermost  nostril,  while 
the  other,  from  the  force  of  gravity,  becomes 
still  more  occluded.  The  sneezing  will  continue 
without  fresh  application  of  pollen,  as  at  night, 
when  tho  subsidence  of  the  swelling  restores, 
or  even  exaggerates,  tho  sensibility  of  the 
Schneiderian  membrane.  The  alse  nasi  become 
red  and  inflamed,  and  occasionally  bleed.  The 
discharge  after  this  becomes  less  in  quantity,  in- 
spissated and  puriform,  and  finally  subsides.  In 
the  eves,  the  swelling  of  the  submucous  tissue 
causes  closure  of  the  lachrymal  canals  and  nasal 
ducts,  and  considerable  injection  of  the  conjunc- 
tival capillaries  is  apparent.  Sometimes,  but 
rarely,  oedema  of  the  eyelids  follows.  Similar 
to  the  nose-symptoms  are  those  occurring  in  tho 
throat,  some  swelling  taking  place  in  the  pha- 
rynx, which  gives  rise  to  partial  closure  of  the 
Eustachian  tubes,  and  hence  to  a certain  degree 
of  deafness.  Slight  feverishness  is  occasionally 
present,  the  pulse  quickening  to  100,  and  the 
temperature  slightly  rising ; but  in  a large  num- 
ber of  cases  pyrexia  is  entirely  absent.  The 
changes  which  take  place  in  the  mucous  mem- 
brane of  the  air-passages  give  rise  to  asthmatic 
symptoms,  such  as  tightness  of  the  chest,  diffi- 
cult and  wheezy  breathing,  with  prolonged  ex- 
piration, and  some  dry  cough,  followed,  at  the 
close  of  the  attack,  by  expectoration. 

The  catarrhal  symptoms  are,  however,  more 
characteristic  than  the  asthmatic,  which  are  not 
invariably  present. 

The  liability  to  attack  lasts  generally  from 
three  to  four  weeks  in  summer,  but  its  duration 
depends  on  the  presence  of  the  exciting  cause, 
which,  if  not  removed,  may  cause  the  malady 
to  last  for  months.  A fall  of  rain  will  diminish 
the  disorder  by  clearing  the  air  of  pollen  ; exer- 
cise, which  increases  the  number  of  respirations 
and,  therefore,  of  pollen-grains  inspired,  will 
j render  it  more  severe  ; wdiile  each  attack  makes 
| jfie  individual  more  susceptible  to  this  subtle 
influence,  and,  consequently,  augments  the  pro- 
| liability  of  other  seizures.  As  a rule,  hay  fever 
has  no  complications,  and  passes  away  completely 
i on  the  removal  of  the  exciting  cause.  Constant 
recurrence  of  the  attacks  has  been  noticed  to 
lead  to  deafness,  owing  to  catarrh  of  the  Eusta- 
; ehian  tubes. 

Diagnosis. — The  diagnosis  of  hay  fever  from 
other  affections  is  easy,  as  the  occurrence  of  the 
catarrhal  symptoms  only  in  summer  separates  it 
from  an  ordinary  ‘ cold  in  the  head  ’ ; while  their 


HEADACHE.  579 

combination  with  dyspnoea  in  hay  fever  prevents  it- 
being  mistaken  for  spasmodic  asthma  arising  from 
other  causes,  in  which  there  is  usually  no  catarrh. 

Prognosis. — The  prognosis  is  favourable  if 
the  patient  lie  removed  from  the  exciting  cause, 
as  the  asthmatic  symptoms  seldom,  if  ever,  load 
to  pulmonary  emphysema,  or  to  any  permanent 
change  in  the  bronchi. 

Treatment. — The  most  obvious  course  in  the 
treatment  of  hay-fever,  but  not  always  the  most 
easy  one,  is  to  avoid  exposure  to  pollen.  Mr. 
Blackley  notices  that  a small  amount  of  this 
material  might  exist  without  giving  rise  to 
hay  fever,  but  if  ten  grains  of  pollen  were 
detected  on  the  glass  slide  exposed  to  the  air 
for  twenty-four  hours,  symptoms  were  sure  to 
appear  in  persons  liable  to  it.  Sufferers  from 
this  complaint  should  avoid  hay-fields,  hay- 
ricks, and  much  exposure  and  exertion  in  tho 
country  during  the  hay  season,  and  should  remain 
to  a great  extent  within  doors ; but  where  circum- 
stances admit,  change  to  the  seaside  is  highly 
desirable,  and  it  generally  effects  a speedy  cure. 
Even  on  the  coast  some  care  must  be  taken  to 
select  a locality  free  from  vegetation  ; for  if  tho 
wind  blows  from  the  land,  where  liay-grass  be 
flowering  at  the  time,  an  attack  may  be  induced. 
Choice  should  be  made  of  a seaside  place  backed 
with  high  cliffs,  and  where  the  prevailing  winds 
are  from  the  sea.  Of  other  localities,  high  moun- 
tain stations,  where  there  is  more  grazing  than 
hay-growing,  and  closely  inhabited  cities  with 
few  parks  or  grassy  squares,  are  to  be  preferred. 
Cotton-wool  and  other  respirators  available  aro 
sometimes  used  with  advantage. 

The  medicinal  treatment  consists  in  first  com- 
bating the  general  predisposition  to  the  com- 
plaint by  tonic  measures;  and,  secondly,  in  allay- 
ing the  local  irritation. 

The  first  object  is  best  achieved  by  shower 
baths,  and  by  such  tonics  as  iron,  quinine,  mix 
vomica,  sulphate  of  zinc,  and  arsenic.  Lotions  of 
sub-acetate  of  lead  or  sulphate  of  zinc  applied  to 
the  eyes  and  inner  surface  of  the  nostrils  give 
some  relief ; but  the  writer  has  found  tho  most 
successful  results  from  the  use  of  the  spray-appa- 
ratus, containing  solutions  of  carbolic  acid  (eight 
grains  to  an  ounce),  sulphurous  acid  (equal  parts 
with  water),  sulphate  of  quinine  (two  grains  with 
acid  to  an  ounce),  and  tannic  acid  (four  grains  to 
an  ounce).  Tho  spray  may  be  applied  to  all  the 
irritated  surfaces — eyes,  nose,  throat,  and  larynx 
— with  great  relief.  C.  Theodore  Williams. 

HEADACHE. — Synon. : Cephalalgia;  Fr. 
Doulcur  de  itte ; Ger.  Kopfschmer?. — Pain  or 
uneasiness  in  the  head  is  very  variable  in  its 
nature,  and  produced  by  a great  number  of  causes. 
It  is  present  at  some  period  or  other  in  the 
course  of  most  acute,  and  many  chronic  diseases; 
and  may  be  associated  or  not  with  organic  change 
in  the  brain,  or  in  other  organs  of  the  body. 

Symptoms. — Headache  presents  many  varieties. 
It  may  be  slight  or  most  intense ; superficial  o: 
deep-seated.  It  may  be  more  or  less  confined  to 
particular  parts,  as  the  forehead,  the  temples,  the 
occiput,  or  vertex.  Sometimes  the  pain  is  limited 
to  one  spot,  producing  the  sensation  as  if  a nail 
were  being  driven  into  the  head,  when  it  is  called 
chivies.  It  may  extend  over  onesided  the  head. 


HEADACHE. 


5S0 

as  in  hemicrania  or  megrim ; or  be  generally 
diffused.  Headache  presents  every  variety  of 
character — dull,  sharp,  cutting,  &c.  Its  acces- 
sion may  be  sudden  or  gradual ; and  the  pa- 
roxysms may  be  of  the  shortest  possible  duration, 
or  may  extend  over  hours,  days,  or  months.  The 
pain  may  be  simple,  or  associated  -with  various 
perverted  sensations,  such  as  giddiness,  tingling 
in  the  limbs,  disordered  hearing,  or  disturbances 
of  vision. 

Varieties. — For  practical  purposes  headaches 
may  be  arranged  in  the  following  order : — 

1.  Structural  headache,  or  headache  depen- 
dent upon  disease  within  the  cranium. 

2.  Congestive  headache. 

3.  Nervous  or  sick  headache — hemicrania  or 
megrim. 

4.  Toxcemic  headache. 

1.  Structural  headache.  This  may  be  due  to 
any  of  the  many  forms  of  disease  of  the  brain, 
or  of  its  membranes,  such  as  meningitis,  cerebral 
softening,  abscess  of  the  brain,  cerebral  tumour, 
&c. ; or  it  may  be  premonitory  of  cerebral  soften- 
ing. It  is  nevertheless  often  wanting  in  these 
disorders,  and  the  locality  of  the  pain,  when 
present,  by  no  means  corresponds  with  that  of 
the  lesion.  As  a rule  the  pain  of  organic  disease 
is  fixed  and  habitual,  though  sometimes,  as  in 
abscess  or  cancerous  tumour,  it  may  be  of  an 
intermittent  character.  If  there  be  sickness 
associated  with  it,  the  sickness  occurs  without 
any  apparent  gastric  disorder,  and  the  pain  con- 
tinues after  the  sickness  ceases.  Stooping  and 
even  the  recumbent  posture  aggravate  the  pain, 
whilst  it  is  lessened  by  elevating  the  head.  If 
organic  disease  be  suspected,  the  collateral  symp- 
toms must  be  carefully  scrutinised  and  weighed. 
It  rarely  happens  that  organic  disease  needs  to 
be  inferred  from  pain  alone. 

2.  Congestive  headache.  Many  forms  of  head- 
ache depend  upon  a greater  or  less  degree  of  con- 
gestion of  the  vessels  of  the  brain ; the  congestion 
being  either  active  or  passive. 

Active  congestion  may  be  caused  by  hyper- 
trophy of  the  left  ventricle  of  the  heart,  general 
plethora,  catamenial  irregularities,  mental  or 
emotional  excitement,  and  other  conditions.  The 
pain  in  such  cases  is  of  an  obtuse  character,  af- 
fecting the  whole  or  a part  of  the  head,  particu- 
larly the  forehead  and  occiput.  It  is  accom- 
panied with  a sense  of  pulsation  in  the  ears, 
flushed  face,  glittering  eyes,  and  giddiness  on 
stooping. 

Passive  congestion  may  be  produced  by  dys- 
pnoea, by  asthma,  by  valvular  defects  in  the 
heart,  or  by  defective  action  of  the  liver,  bowels, 
and  skin;  it  may  be  the  after-effect  of  drunken- 
ness ; or  may  result  from  any  cause  which  can 
produce  a state  of  debility  in  the  vessels  of  the 
brain,  such  as  general  anaemia,  exhaustion  from 
fatigue,  loss  of  blood,  leucorrhcea,  or  that  fol- 
lowing over-excitement,  mental  exertion,  or 
bodily  fatigue — causes  which  all  favour  conges- 
tion. When  the  headache  is  induced  by  anaemia 
or  debility,  the  pain  is  most  generally  across  the 
forehead  or  at  the  top  of  the  head. 

3.  Nervous  or  sick  headache,  hemicrania  or 
megrim.  This  disorder  is  discussed  in  a separate 
article.  See  Meorim. 

4.  Toxcemic  headache.  The  headache  which 


attends  all  fevers  and  inflammatory  disorders, 
though  due  in  some  measure  to  cerebral  conges- 
tion, is  chiefly  caused  by  the  action  of  the  blood, 
altered  in  character  and  elevated  in  temperature, 
on  the  nervous  elements  of  thebraiD.  In  uraemia 
likewise  the  headache  which  frequently  precedes 
or  accompanies  the  other  symptoms  pointing  to 
the  existence  of  renal  disease,  results  from  the 
morbid  condition  of  the  blood.  So  also  in  some 
persons,  breathing  the  impure  air  of  a crowded, 
room,  or  the  products  of  the  combustion  of  gas, 
will,  by  the  imperfect  decarbonisation  of  the 
blood,  speedily  produce  a headache. 

Besides  the  above  varieties  of  headache,  pain 
about  the  head  external  to  the  brain  may  be  pro- 
duced by  rheumatic  affections  of  the  scalp,  with 
tenderness  of  the  skin  and  rheumatism  in  other 
parts ; by  syphilitic  affections  of  the  periosteum 
or  bone ; by  inflammation  cf  the  scalp,  commenc- 
ing erysipelas,  &c. ; and  by  trigeminal  and  other 
varieties  of  neuralgia.  From  neuralgia  headache 
may  be  discriminated  by  its  mode  of  accession ; 
by  the  generally  longer  duration  of  the  attack ; 
and  by  the  more  complete  intermissions. 

Treatment. — The  treatment  of  headache  must 
necessarily  depend  upon  the  peculiarities  of  each 
individual  case.  In  organic  or  toxaemic  headache 
the  disease  with  which  it  is  associated,  and  not 
the  symptom  itself,  will  of  course  be  the  object 
of  consideration,  and  the  treatment  will  be  found 
discussed  in  connection  with  these  special  mor- 
bid states.  The  same  remark  applies  to  many 
forms  of  congestive  headache,  such  as  those 
produced  by  disease  of  the  heart,  asthma,  &c. 
If  catamenial  irregularities  or  uterine  disorders 
are  the  exciting  cause,  these  must  be  treated 
by  appropriate  measures.  If  ansemia  or  de- 
bility be  present,  then  in  the  intervals  between 
the  paroxysms,  iron  in  some  form,  either  alone 
or  in  combination  with  quinine  or  some  vegetable 
bitter,  must  be  given.  During  the  paroxysms  a 
little  sal  volatile,  a cup  of  soup  or  strong  tea  or 
coffee,  or  some  weak  alcoholic  stimulant  may  be 
of  service.  Where  ansemia  is  not  a prominent 
symptom,  or  when  the  disorder  assumes  a period- 
ical or  intermittent  character,  quinine  alone,  in 
doses  of  two  or  three  grains  twice  or  three  times 
a day,  may  be  given ; and  if  this  fails  to  afford 
relief,  arsenic  is  often  of  signal  service.  Great 
benefit  is  frequently  afforded  in  the  latter  cases 
by  the  administration  during  the  paroxysm  of 
alcohol.  Except  when  the  headache  is  associated 
with  general  plethora  or  active  congestion,  strong 
purgatives  are  to  be  avoided,  and  the  bowels  are 
to  be  regulated  by  the  mildest  aperient  which 
will  answer  the  purpose.  The  patient's  habits 
and  mode  of  life  must  also  be  strictly  regulated; 
and  care  must  be  enjoined  as  to  diet,  sleep, 
clothing,  and  exercise,  especially  if  the  headache 
be  associated  with  dyspepsia.  If  dyspeptic 
symptoms  are  prominent,  or  if  the  p>ain  be  con- 
nected with  a gcuty  diathesis,  then  these  disorders 
must  be  treated  with  their  appropriate  remedies. 

If  during  the  paroxysms  the  head  be  hot  and 
the  face  flushed,  warm  or  cold  lotions,  iced  water, 
or  eau-de-Cologne  may  be  applied ; a warm 
douching  may  be  useful  in  some  cases.  Occa- 
sionally in  severe  attacks  a few  leeches  may  be 
placed  on  the  temples  with  advantage,  or  a blister 
to  the  nape  of  the  neck,  but  never  if  the  face  be 


HEADACHE. 

pale,  and  the  pulse  feeble.  Compression  of  the 
temporal  arteries  ■with  a pad,  sustained  pressure 
around  the  head,  or  holding  the  arms  high  above 
the  head,  will  sometimes  relieve  severe  headache. 

The  treatment  of  sick-headache  is  discussed 
inder  the  article  Megrim.  P.  W.  Latham. 

HEALTH,  Maintenance  of.  See  Disease, 
Causes  of ; Personae  Health  ; and  Public 
Health. 

HEARING,  Disorders  of. — These  disorders 
may  be  grouped  under  three  classes,  namely  : — 

(a)  Partial  or  complete  loss  of  hearing,  or  deaf- 
ness ; ( b ) Exalted  hearing  (so-called) ; (c)  Per- 
verted hearing  or  Tinnitus.  They  may  be  due 
to  various  conditions  quite  independent  of  any 
actual  disease  of  the  auditory  apparatus,  and 
only  such  causes  of  disordered  hearing  will  be 
considered  in  the  present  article  as  are  not  due 
to  changes  in  the  conducting  portion  of  the 
ear,  which  can  be  demonstrated  by  the  different 
methods  of  examination,  or  to  recognised  affec- 
tions of  the  nervous  apparatus  connected  with 
hearing.  These  will  be  found  discussed  under 
he  article  Ear,  Diseases  of. 

(a)  Partied  or  complete  loss  of  hearing.- — Per- 
haps the  deafness  due  to  accumulations  of  ceru- 
men, which  so  frequently  interfere  for  a time  with 
the  hearing  of  persons  whose  ears  are  free  from 
disease,  should  be  regarded  as  disordered  hear- 
ing, rather  than  as  a symptom  of  a pathological 
condition.  As  nothing  more  energetic  than  careful 
syringing  is  required  to  remove  such  obstructions, 
it  will  be  sufficient  to  observe  that  in  this  proceed- 
ing the  nozzle  of  the  syringe  should  be  directed 
along  the  roof  of  the  external  canal.  Amongst 
a very  large  number  of  people  with  the  organs  of 
hearing  in  an  apparently  healthy  state,  some  few 
will  be  found  upon  whom,  throughout  their  lives, 
lertain  notes  produce  no  response.  They  will 
iot,  for  example,  be  able  to  hear  the  sounds  made 
by  grasshoppers,  or  the  singing  of  some  birds — 
the  call  of  a partridge,  for  instance;  and  in  most 
persons,  as  age  advances,  the  very  high  notes  are 
lost.  To  prove  this,  it  is  only  necessary  toblow 
one  of  Mr.  Galton’s  whistles  in  a room  full  of 
people,  when  a considerable  proportion  of  the 
assembly  will  fail  to  catch  the  high  notes,  which 
are  distinctly  heard  by  the  rest ; and  although 
this  failure  is  also  noticeable  in  many  nervous 
affections,  all  other  sounds  will  perhaps  be  heard 
quite  normally  by  these  individuals.  Emotional 
influences  play  a very  large  part  in  the  destruction 
or  suspension  of  hearing,  and  this  is  especially  ob- 
servable in  the  case  of  women.  The  unexpected 
sight  of  a dead  husband,  hearing  of  the  death  of 
a dear  friend,  the  proposal  of  a severe  surgical 
operation  on  a relative,  a quarrel,  an  alarm  of 
thieves,  and  witnessing  a carriage  accident,  have 
each  within  the  knowledge  of  the  writer  been 
followed  by  intense  and  sudden  deafness,  which 
has  only  been  partially  recovered  from.  The 
same  effect  has  been  noticed  with  men  who  have 
been  subjected  to  prolonged  mental  strain,  in  con- 
nection with  literary  work,  or  during  commercial 
crises.  It  has  been  recorded  that  adeaf  and  dumb 
child  has  suddenly  recovered  hearing,  after  the 
discharge  from  the  bowels  of  eighty-seven  lum- 
brici,  and  a large  number  of  oxyurides  ( Journal 
~f  Med.  Society , 1844).  Complete  loss  of  hearing, 


HEART,  DISEASES  OF.  581 

extending  over  several  months,  was  on  one  occa- 
sion followed  by  perfect  hearing  in  a girl  of 
fifteen,  on  the  first  appearance  of  menstruation. 
The  temporary  effect  of  quinine  and  salicylic  acid 
on  the  hearing  is  well  known,  but  when  quinine 
has  been  administered  in  large  doses,  and  for  a 
long  period,  this  special  sense  is  not  unusually 
injured  permanently.  Amongst  the  diseases 
which  often  induce  a lasting  deafness,  without 
any  perceptible  local  change  in  the  conducting 
portion  of  the  ear,  may  be  included  mumps, 
many  of  the  fevers,  and  diphtheria  ; for  although 
in  the  two  latter  examples  the  middle  car 
often  suffers,  this  is  not  always  the  case,  and 
the  immediate  cause  of  the  deafness  must  be 
sought  in  the  products  of  inflammation  which 
have  been  left  within  the  cranium.  The  same 
explanation  is  probably  also  the  correct  one  in 
those  instances  where  children  lose,  for  ever  all 
hearing  power,  after  cerebral  excitement  or  con- 
gestion. Habitual  and  obstinate  constipation  is 
sometimes  attended  with  loss  of  hearing,  which 
returns  after  the  action  of  purgative  medicine. 
A clot  of  blood  within  the  cranium,  whilst  caus- 
ing hemiplegia  of  the  opposite  side,  may  de- 
stroy the  hearing  of  the  same  side  as  the  effu- 
sion ; and  a case  is  on  record  in  which  closure 
of  the  cerebro-spinal  foramen  gave  rise  to  this 
symptom. 

(b)  Exalted  hearing.  — What  is  termed  ex- 
alted hearing  will  generally,  on  careful  examina- 
tion be  found  to  be  not  so  much  a definite  change 
in  the  capacity  of  the  hearing  apparatus  to  re- 
ceive impressions,  as  an  inability  on  the  part  of 
the  patient  to  receive  such  impressions  without 
an  undue  effect  on  the  nervous  centres  being  pro- 
duced. Thus  in  many  inflammatory  states  of  the 
brain  or  its  membranes  this  symptom  is  often  a 
prominent  one.  It  is  also  not  uncommonly  met 
with  in  hysterical  and  nervous  persons. 

(c)  Perverted  hearing. — Attendant  on  most  of 
the  above  examples,  and  closely  allied  to  deaf- 
ness, is  the  often  persistent  tinnitus  ; but  there 
are  conditions  in  which  this  distressing  symptom 
is  the  chief  and  solitary  trouble.  Thus  tinnitus, 
with  a feeling  of  pulsation  in  the  ear,  is  occasion- 
ally the  first  warning  of  an  intracranial  aneurism ; 
whilst  a furious  tinnitus  and  the  hearing  of  strange 
noises  sometimes  precede  an  attack  of  acute  mania. 
Patients  who  have  been  the  subjects  of  malarial 
fevers  and  sunstroke  often  complain  of  tinnitus ; 
and,  as  in  all  cases  of  disease  of  the  ears,  when 
present  it  is  the  most  intractable  of  symptoms, 
so  it  is  when  the  ears  have  not  been  the  seat  of 
any  malady  or  injury. 

Treatment. — Insomuch  as  all  the  above  states 
of  disordered  hearing  may  strictly  be  said  to  be 
due  to  causes  which  are  in  themselves  abnor- 
malities of  one  part  or  another  of  the  organism, 
it  is  to  these  that  the  treatment  will  naturally 
be  directed  rather  than  to  alterations  in  hearing 
which  in  truth  are  merely  symptoms.  See  Ear, 
Diseases  of ; and  Tinnitus.  W.  B.  Dalby. 

HEART,  Diseases  of. — The  study  of  this 
class  of  diseases  has  reference  to  the  immediate 
pathological  changes  which  occur  in  the  heart 
itself,  and  to  the  consequences  or  results  of 
these  changes  upon  its  function,  that  is  to  say, 
I upon  the  circulation  of  the  blood.  The  latter 


582  HEART,  DISEASES  OE. 

portion  of  the  subject  will  be  found  discussed 
under  the  head  Circulation',  Diseases  of  Organs 
of ; and  it  will  therefore  be  necessary  in  this 
place  to  summarize  only  the  morbid  changes  which 
affect  the  heart  itself,  and  this  merely  as  an  in- 
troduction to  the  full  description  of  those  changes 
contained  in  the  articles  which  follow  here,  or 
which  will  be  found  in  other  parts  of  this  wort. 

1.  The  heart  may  be  displaced,  misplaced,  or 
malformed.  2.  Its  various  textures,  including 
the  coverings,  the  lining  membrane,  the  valves, 
and  the  walls,  are  liable  to  acute  and  chronic  iip- 
fiammation  and  their  effects.  3.  The  organ  itself 
may  be  increased  in  size,  either  by  general  dilata- 
tion of  one  or  of  more  of  its  cavities,  or  partially, 
as  by  aneurism  of  the  walls ; or  by  the  addition  to 
its  volume,  by  hypertrophy  of  its  muscular  struc- 
ture, of  the  fatty  tissue  which  exists  beneath 
the  pericardium,  or  of  the  connective  tissue  which 
binds  the  muscular  fibres  together.  4.  Its  vol- 
ume may  be  diminished  by  simple  or  general 
atrophy,  or  by  the  walls  of  one  or  more  of  its 
cavities  being  wasted  and  thinned.  5.  Its  walls 
are  liable  to  various  forms  of  degeneration — more 
especially  fatty,  granular,  calcareous,  and  pig- 
mentary. 6.  They  may  be  the  seat  of  fibroid 
disease ; and  of  various  morbid  growths,  such  as 
cancer,  tubercle,  and  syphilitic  formations,  or 
hydatids.  7.  Congestion  and  hcemorrhage  may 
occur  in  the  walls  of  the  heart.  8.  These  are 
liable  also  to  such  injuries  as  rupture — whether 
spontaneous  or  as  the  result  of  violence ; and  to 
various  kinds  of  wounds  and  their  effects.  9.  And 
lastly,  the  reader  will  find  discussed  under  the 
head  of  functional  disorders  of  the  heart,  certain 
disturbances  in  its  action  and  sensibility  which 
cannot  be  clearly  referred  to  any  structural 
lesion. 

HEART,  Abscess  of.  Sec  Heart,  Inflam- 
mation of;  and  Heart,  Pyaemic  Abscess  of. 

HEART,  Aneurism  of.  — Definition.  — 
A depression  or  a sacculus  formed  in  the  wails  of 
the  heart,  communicating  with  one  or  more  of 
its  cavities. 

The  term  aneurism  of  the  heart  has  not  been 
always  used  in  this  sense.  It  was  first  applied  by 
Lancisi  and  subsequently  by  Bouilleau  to  every 
dilatation  of  the  heart,  whatever  its  cause  or  its 
character.  The  first  case  of  the  disease,  as  the 
term  is  now  understood,  was  published  by  Galeatti 
in  1757.  In  this  country,  Dr.  Thurnam,  Dr. 
Peacock,  and  others  have  treated  the  subject  fully. 
In  France  aneurism  of  the  heart  liasbeen  described 
specially  by  Breschet  and  by  Pelvet ; whilst  in 
Germany,  Lobstein,  Lobl,  and  Hartmann  have 
written  upon  it  at  length.  A full  account  of  the 
researches  of  these  and  several  other  writers  will 
be  found  in  the  work  of  M.  Pelvet — Des  An'e- 
vrysmes  du  Cxur,  Paris,  1867. 

TEtiology  and  Pathology. — The  essential  con- 
dition  which  leads  to  aneurism  of  the  heart  is  a 
change  in  a portion  of  the  heart’s  texture,  by  which 
the  resisting  power  of  the  affected  part  against  the 
pressure  of  the  blood  from  withm  the  cavity  is 
diminished.  Under  such  circumstances  a simple 
depression,  corresponding  to  the  weakened  spot, 
may  he  first  formed  on  the  inner  surface  of  the 
heart.  This  gradually  continues  through  the 
cardiac  wall  towards  the  external  surface,  wliero 


HEART,  ANEURISM  OF. 
tho  resistance  becomes  less,  and  where  a pouch 
or  sac  is  then  formed,  communicating  with  tho 
cavity  of  the  heart,  it  may  be  by  a neck.  The 
weakened  condition  referred  to  is  attributable  in 
different  instances  to  inflammation  of  the  sub- 
stance of  the  heart,  whether  acute  or  chronic ; to 
syphilitic  or  other  growths;  and  to  fatty  de- 
generation. 

(a)  Inflammation  of  the  heart,  affecting  either 
the  endocardium  or  the  substance  of  tho  heart 
itself,  may  lead  to  ulceration  and  softening ; and 
both  conditions  have  been  found  in  connection 
with  aneurism.  Inflammation  may  also  lead  to 
the  formation  of  pus  in  the  walls  of  the  heart; 
and  cases  are  recorded  in  which,  the  contents  of 
the  sac  thus  formed  having  been  discharged  into 
the  circulation,  the  cavity  became  converted  into 
an  aneurismal  pouch  (Dr.  Wilks,  Path.  Soc. 
Trans.,  vol.  xii.).  Cases  of  aneurism  of  this 
character  may  be  regarded  as  originating  in  acute 
inflammation  of  the  heart. 

In  a still  larger  number  of  cases,  in  which  the 
endocardium  and  pericardium,  as  well  as  the 
muscular  walls,  are  involved,  we  find  a develop- 
ment of  fibroid  tissue — a cirrhosis,  as  it  were,  of 
the  heart,  as  the  result  of  chronic  inflammatory 
action.  In  these  cases  the  fibroid  tissue  is 
stretched  at  each  systole  of  the  heart,  and  it  re- 
turns less  and  less  to  its  former  dimensions, 
owing  to  its  want  of  elasticity.  Thus  by  degrees 
the  portion  of  the  heart  affected  yields  and  is 
pushed  outwards,  forming  a sac  of  a more  or  less 
globular  shape. 

( b ) Growths  in  the  heart,  whether  syphilitic, 
or  tuberculous,  undergoing  the  process  of  soften- 
ing, may  lead  to  the  formation  of  aneurism,  as  in 
the  conditions  just  described. 

(c)  Fatty  degeneration  may  give  rise  to  the  for 
mation  of  aneurism.  First,  a circumscribed  spot 
of  softened  tissue  in  the  wall  of  the  heart,  the 
result  of  fatty  degeneration,  yields  without  rup- 
ture, to  the  pressure  of  the  blood  from  within, 
and  thus  allows  of  the  formation  of  an  aneurismal 
pouch.  Secondly,  partial  rupture  may  take  place 
in  the  muscular  wall,  and  hsemorrhage  occurring 
at  this  point,  constitutes  what  is  called  * cardiac 
apoplexy  ’ ( see  Heart,  Haemorrhage  into  the 
Walls  of).  The  clot  thus  formed  undergoes  tho 
changes  usual  in  extravasated  blood  ; and  a cyst 
results,  which  may  ultimately  communicate  with 
one  of  the  cavities  of  the  heart.  Meriedec 
Laennec,  who  wrote  on  aneurisms  of  the  heart, 
believed  that  this  form  of  disease  was  almost 
exclusively  thus  developed. 

With  reference  to  the  relative  frequency  of 
the  various  causes  of  cardiac  aneurism,  just 
enumerated,  the  writer  finds  that  out  of  a total  of 
56  cases,  the  histories  of  which  were  collected 
by  himself,  in  21  the  walls  had  undergone  fibroid 
changes ; in  6 there  was  fatty  degeneration ; in 
o the  disease  was  the  result  of  ulceration;  in  2 
cases  it  appeared  to  have  originated  in  abscess ; 
and  in  24  the  materials  were  not  sufficient  for 
arriving  at  an  accurate  conclusion. 

Age. — With  regard  to  the  age  at  which  this 
disease  occurs,  in  51  of  the  56  cases  just  alluded 
to  the  oldest  was  eighty-two,  the  youngest  a 
child  of  twelve.  Two  cases  occurred  between 
ten  and  twenty  years  of  age.  9 betw-een  twenty 
and  thirty,  8 between  thirty  and  forty,  7 bo 


HEART,  ANEURISM  OF. 


tween  forty  and  fifty,  7 between  fifty  and  sixty, 
10  between  sixty  and  seventy,  6 between  seventy 
and  eighty,  and  2 between  eighty  and  ninety 
years  of  age. 

Sex. — Of  the  56  cases,  39  were  males  and  17 
females. 

Anatomical  Chaeactees. — Keeping  in  view 
the  several  conditions  just  described,  under  which 
aneurism  of  the  heart  can  occur,  we  may  expect  to 
find  a corresponding  variety  of  morbid  appearances. 
On  laying  open  the  pericardium  in  cases  in  which 
aneurism  of  the  heart  exists,  adhesions  which  are 
more  or  less  universal  or  which  may  be  limited  to 
the  seat  of  the  disease,  are  very  frequently  found. 
The  heart  itself  is  generally  enlarged ; and  where 
the  aneurism  projects  externally  it  is  altered 
in  shape,  so  much  so  in  some  instances  that  the 
organ  looks  like  a double  heart.  The  sac  may 
project  from  the  walls  as  a rounded  or  conical 
tumour;  or,  as  in  an  instance  that  came  under 
the  notice  of  the  writer,  it  may  assume  the 
appearance  of  an  elongated  sac  winding  round 
the  base  of  the  aorta.  Again,  no  appearance  of 
anything  abnormal  may  be  observed  until  the 
heart  is  laid  open,  when  a depression  or  an 
opening  may  be  discovered  in  the  walls  of  the 
ventricle,  or  in  the  septum.  In  some  instances 
more  than  one  pouch  is  formed,  in  communica- 
tion with  the  cavity  of  the  heart  by  a separate  or 
by  a common  opening.  The  size  of  the  tumour 
may  vary  from  that  of  a small  bean  to  that  of  an 
average-sized  cocoa-nut.  The  opening  leading 
into  the  pouch  may  be  the  widest  part  of  the 
sac,  the  aneurism  being  a mere  depression  like 
a watch-glass  or  half-an-egg ; or  there  may 
exist  a constricted  or  defined  neck,  leading  to  a 
tumour  bulging  from  the  walls.  The  size  of  the 
opening  may  vary  from  a couple  of  inches  across, 
to  one  capable  of  admitting  only  a probe.  The 
neck  is,  in  a few  cases,  described  as  hard  and 
cartilaginous ; in  others,  as  being  smooth  and 
regular,  or  jagged  and  irregular.  The  walls  of 
the  tumour  may  be  formed  by  the  dilated  and 
thin  walls  of  the  heart ; or  by  the  walls  consider- 
ably thicker  than  natural,  and  altered  in  tex- 
ture. A very  usual  condition  to  find  is  that 
the  walls  of  the  sac  consist,  proceeding  from 
within  outwards,  of  endocardium ; fibroid  tissue, 
with  or  without  portions  of  muscular  tissue;  and 
pericardium.  This  condition  was  described  as  oc- 
curring in  eleven  cases.  In  eight  cases  the  walls 
were  said  to  consist  only  of  the  endocardium 
ani  pericardium,  with  fibroid  tissue  between  ; 
but  it  was  found  that  at  the  base  of  the  tumour, 
in  all  these  cases,  all  the  layers  of  the  heart- 
tissue  were  present,  and  that  it  was  only  towards 
the  apex  of  the  swelling  that  the  muscular  layers 
disappeared.  In  three  cases  the  walls  of  the 
aneurism  were  said  to  be  composed  of  a thin 
membrane,  which  appeared  to  consist  of  endo- 
cardium and  pericardium  only.  In  three  cases 

I the  walls  were  of  cartilaginous  consistence,  with 
bony  plates  interspersed  in  the  tissue.  The 
thickness  of  the  walls  of  the  sac  varied  from  that 
of  paper  to  three  lines  or  more.  In  fourteen 
cases  the  wall  of  the  tumour  was  strengthened 
by  the  adherent  pericardium.  The  aneurismal 
cavity  in  the  majority  of  cases  was  lined  by 
smooth  membrane  ; but  in  a few  instances,  ap- 
patently  of  acute  formation,  the  walls  consisted 


583 

of  muscular  fibres,  torn  and  separated  by  the 
blood  which  had  been  extravasated  amongst 
them.  The  contents  of  the  sac  are  generally  in 
the  form  of  blood-clots  or  layers  of  fibrin,  the 
outermost  layers  of  which  may  be  more  or  less 
organised  and  adherent  to  the  wall. 

Heat. — Of  the  56  cases  already  alluded  to,  52 
were  in  the  left  ventricle,  3 in  the  right  ventricle., 
and  1 in  the  right  auricle.  Of  the  52  cases  in 
which  the  aneurism  was  situated  in  the  left 
ventricle,  22  occupied  the  apex,  1 1 the  base,  and 
17  were  in  intermediate  situations.  Several 
cases  have  been  recorded,  in  which  the  aneurism 
was  situated  in  the  muscular  septum  between 
the  ventricles;  in  the  ‘undefended  space;’  or 
at  the  base  immediately  below  the  aortic  valves. 
A cose  of  the  last-named  form  was  recorded 
by  the  writer  in  the  third  volume  of  the  Trans- 
actions of  the  Pathological  Society.  These  two 
last  forms  are  generally  associated  with  endo- 
cardial inflammation  and  ulceration. 

Symptoms. — In  13  of  the  56  cases  referred  to, 
the  aneurism  was  not  discovered  until  after  death  ; 
no  mention  being  made  of  signs  or  symptoms  of 
its  previous  existence.  In  the  remaining  cases, 
symptoms,  more  or  less  marked,  indicative  of 
heart-disease  were  present.  These  symptoms 
were  chiefly — pain,  dyspnoea,  liviclity  of  the  sur- 
face, palpitation,  and  ix-regularity  of  the  pulse.  In 
It)  cases  murmurs  were  heard,  accompanying  or 
replacing  the  sounds  of  the  heart.  We  thus  see 
that  the  symptoms  of  aneurism  are  such  as  may 
exist  in  common  with  other  lesions  of  the  heart : 
and  it  is  extremely  doubtful,  except  in  presence 
of  some  special  circumstances  indicative  of  this 
condition,  whether  we  have  at  our  command  the 
means  of  diagnosing  the  existence  of  cardiac 
aneurism.  The  writer  not  long  since  saw,  with 
Dr.  Holman,  of  Reigate,  a case  of  grave  heart  - 
disease,  in  which  extended  dulness  to  the  lefl 
and  below  the  usual  situation  of  the  apex-beat, 
with  a feeble  impulse  in  the  same  situation 
led  to  a suspicion  of  the  probable  existence  c t 
cardiac  aneurism. 

Peogress,  Duration,  and  Terminations. — • 
Pathological  testimony  fully  justifies  the  infer- 
ence that  certain  cardiac  aneurisms — such  aa 
those  which  originate  in  inflammatory  softening, 
ulceration,  or  the  opening  of  cysts  into  the 
cavities  of  the  heart — are  acute  in  their  forma- 
tion. But  the  like  evidence  further  testifies  that 
the  formation  of  most  other  aneurisms,  and  the 
progress  of  all,  are  of  a slow  or  chronic  character. 
Still,  it  would  seem  to  be  difficult  if  not  impos- 
sible to  determine  the  duration  of  the  disease  in 
any  given  instance,  inasmuch  as  many  cases,  for 
example,  have  been  found  ill  tho  post-mortem 
room,  which  had  not  given  rise  to  any  special 
symptoms ; whilst  in  other  cases  the  pre-exist- 
ence of  heart-disease  before  the  formation  of 
aneurism  rendered  it  equally  impossible  to  fix  a 
date  for  the  development  of  the  latter  special 
disease. 

Death  may  result  from  the  disturbance  of  the 
heart’s  action,  induced  by  the  presence  and  extent 
of  the  disease  ;'  from  the  aneurism  opening  into 
the  pericardium;  or  from  its  burrowing  in  the  wall 
of  the  heart,  and  opening  into  another  cavity  oi 
the  organ  different  from  that  in  which  it  origin- 
ated. Lastly,  one  or  two  cases  are  recorded  ir 


584  HEART,  ANEURISM  OF:  AND  CONGENITAL  MISPLACEMENT  OF 


which  a cure  of  the  disease  had  apparently  been 
effected  by  the  walls  of  the  sac  becoming  in- 
durated or  calcified. 

Diagnosis  and  Prognosis. — Seeing  how  ex- 
tremely obscure  the  clinical  history  of  these 
cases  is,  it  would  be  impossible  to  speak  more 
definitely  either  as  to  the  diagnosis  or  the  prog- 
nosis of  the  disease  than  has  been  done  under 
the  preceding  head. 

Treatment. — The  treatment  of  cardiac  aneu- 
rism must  be  such  as  would  be  adopted  in  any 
other  form  of  grave  heart-disease,  and  according 
to  the  circumstances  of  each  case.  We  can  only 
seek  to  mitigate  the  more  urgent  symptoms, 
whether  local  in  the  heart  itself,  or  more  gene- 
rally affecting  the  distant  organs. 

R.  Quain,  M.D. 

HEART,  Apoplexy  of.  See  Heart,  Hae- 
morrhage into  Walls  of. 

HEART,  Atrophy  of. — Definition.  — A 
diminution  in  the  size  and  weight  of  the  heart 
as  a whole ; or  a diminution  in  size  of  one  part 
of  the  heart  in  relation  to  the  whole  organ. 

.Etiology. — The  causes  of  atrophy  of  tho 
heart  are  either  general  or  local.  With  respect 
to  the  general  causes  of  atrophy,  the  heart  is 
found  reduced  in  volume  together  with  the  other 
organs  of  the  body,  in  cases  of  marasmus,  of 
phthisis,  of  syphilis,  cancer,  Sec.  Probably  one 
of  the  smallest  hearts  on  record — one  which 
weighed  but  3^  ounces — was  found  by  Dr. 
Church  in  the  body  of  a woman  aged  forty- 
seven,  who  died  of  cancer  of  the  pylorus,  after 
an  illness  characterised  by  ‘gradual  starvation’ 
of  more  than  seventeen  months’  duration.  With 
reference  more  especially  to  phthisis,  as  affect- 
ing the  size  of  the  heart,  an  analysis  of  171  cases 
made  by  the  writer  at  the  Brompton  Hospital, 
showed  that  this  organ  was  below  the  average 
weight  in  54’4  per  cent.  Diseases  of  a sub- 
acute character,  such  as  typhoid  fever  when  pro- 
tracted in  its  course,  may  lead  likewise  to  wast- 
ing of  the  heart.  The  heart  is  also  occasionally 
congenitally  small. 

The  local  causes  of  atrophy  of  the  heart  are 
chiefly  two,  namely  (1),  pressure  by  pericardial 
adhesions  upon  the  heart  in  certain  cases  of 
generally  impaired  health,  by  mediastinal  tu- 
mours, by  fatty  growth  beneath  the  pericardium, 
and  other  conditions;  and  (2)  interference  with 
the  circulation  in  the  coronary  arteries,  as  in  the 
conditions  just  enumerated,  or  as  a result  of  mal- 
formation or  of  disease  of  the  vessels  themselves. 

Partial  atrophy  of  the  heart,  when  it  occurs, 
is  generally  referable  to  insufficient  blood-sup- 
ply  from  vascular  disease  or  local  pressure ; or 
-to  fatty  infiltration. 

Anatomical  Characters. — The  heart  in  sim- 
ple atrophy  presents  a general  uniform  diminution 
in  size,  as  regards  both  its  walls  and  its  cavities ; 
and  in  its  weight.  In  local  atrophy,  a portion 
of  the  cardiac  wall,  more  or  less  extensive,  or 
of  one  of  the  divisions  or  cavities  of  the  heart, 
may  be  found  to  be  below  the  ordinary  dimensions. 
The  colour  of  the  atrophied  heart  may  be  nor- 
mal ; it  is  frequently  pale ; and  it  is  occasionally 
of  a deep  reddish-brown.  The  pericardium, 
not  shrinking  proportionately  with  the  muscular 


substance,  may  present  a puckered,  opaque,  and 
cedematous  aspect,  ‘like  a withered  anple’ 
(Laennec) ; and  for  the  same  reason  the  coro- 
nary vessels  may  be  tortuous  and  prominent. 
The  consistence  of  the  walls  is  generally  firmer 
than  natural ; and  the  muscle  may  be  even 
tougher,  except  where  the  atrophy  is  due  to 
the  presence  of  fat,  in  which  case  the  fibres  are 
friable,  and  on  microscopical  examination  pre- 
sent the  appearances  of  fatty  degeneration.  In 
simple  atrophy  of  the  heart,  the  muscular 
fibres  undergo  diminution  in  volume ; and  they 
may  also  be  actually  reduced  in  number.  Atro- 
phy of  individual  muscular  fibres  is  also  found 
as  the  result  of  interstitial  fatty  or  fibroid 
growth ; and  this  when  extensive  has  been 
somewhat  erroneously  named  ‘ yellow  atrophy.’ 
Another  variety,  which  is  most  frequently  found 
in  the  marasmus  of  old  age,  is  known  as  brown 
atrophy  of  the  heart.  In  such  cases  the  muscu- 
lar tissue  is  of  a dark  or  dirty  reddish-brown 
colour,  which  proves  on  microscopical  examina- 
tion to  be  due  to  the  presence  of  numerous 
shining  yellow  or  brown  pigment-particles  with- 
in the  muscular  fibres,  and  specially  abundant 
either  around  the  nuclei  or  between  the  ultimate 
fibrill®. 

Symptoms.— The  symptoms  and  signs  of  atro- 
phy of  the  heart  are  those  which  might  be  ex- 
pected to  result  from  diminished  size  and  power 
of  that  organ.  The  characteristic  phenomena 
are  those  of  feeble  circulation.  The  physical 
signs  are  chiefly  diminished  praecordial  dulness : 
a feeble  impulse,  the  apex -beat  being  within  and 
above  the  usual  situation ; diminished  area  of 
audible  sounds ; and  a small,  weak  pulse. 

Diagnosis. — The  above  signs  and  symptoms, 
in  association  with  general  wasting,  afford  suffi- 
cient grounds  for  the  diagnosis  of  atrophied  and 
feeble  heart.  Emphysema,  pericardial  effusion, 
and  other  causes  of  diminished  cardiac  dulness 
and  weakness  of  impulse,  must  be  excluded  by  the 
ordinary  modes  of  investigation.  There  are  no 
special  means  by  which  partial  atrophy  of  the 
heart  can  be  diagnosed,  except,  possibly,  that  the 
presence  of  this  condition  may  be  assumed  where 
the  functions  of  the  organ  are  disturbed  in  the 
absence  of  valvular  or  other  of  the  more  common 
forms  of  cardiac  disease,  sufficient  to  explain  the 
symptoms. 

Treatment. — The  treatment  of  atrophy  of  the 
heart  is  the  treatment  of  the  primary  disease  upon 
which  it  depends,  so  far  as  is  possible. 

R.  Quain,  MJD. 

HEART,  Calcification  of.  See  Heart,  De- 
generations of. 

HEART,  Cancer  of.  See  Heart,  Morbid 

Growths  in. 

HEART,  Cirrhosis  of.  See  Heart,  Fibroid 

Disease  of. 

HEART,  Congenital  Misplacement  of. — 

Synon.  : Ectopia  Cordis  (Breschet),  Ectocardia 
(Alvarenga). 

The  heart  is  occasionally  found  to  occupy  & 
wrong  position,  and  such  misplacement  may 
either  be  within  the  cavity  of  the'  thorax,  or 
external  to  it. 

1.  Of  the  internal  malpositions — ectopia  ccrdu 


HEART.  CONNECTIVE-TISSUE  HYPERTROPHY  OF.  585 


intrathoracica  or  ectocardia  intrathoracica — the 
most  common  is  that  to  which  the  term  dexio- 
cardia  has  been  applied,  in  which  the  heart  is 
in  a very  similar  position  on  the  right  side  of  the 
chest  to  that  which  it  should  occupy  on  the  left. 
This  condition  may  coexist  with  transposition  of 
the  other  viscera  of  the  body,  or  it  may  occur 
alone.  Instances  of  the  former  kind  have  long 
been  placed  on  record,  cases  having  been  met 
with  in  Rome  in  1643,  in  Paris  in  1650,  and  in 
London  in  1694.  When  the  heart  is  misplaced, 
the  aorta  generally  follows  an  irregular  course, 
crossing  the  right  bronchus  and  passing  down  to 
the  right  side  of  the  bodies  of  the  vertebrae  ; and 
the  right  carotid  and  subclavian  arteries  are 
given  off  as  separate  vessels,  while  the  brachio- 
cephalic trunk  is  situated  on  the  left  side.  In 
some  instances,  however,  the  vessels  at  the  arch 
are  not  transposed;  whilst  in  others  the  aorta, 
after  passing  over  the  right  bronchus,  crosses 
the  spine  and  follows  its  usual  course  to  the 
left  of  the  bodies  of  the  vertebra.  In  cases  of 
transposition  the  heart  itself  may  be  well-formed ; 
or  it  may  be  very  imperfectly  developed. 

In  another  kind  of  misplacement,  mesocardia, 
the  heart  is  situated  more  in  the  median  line 
than  natural — a position  which  it  occupies  in  the 
foetus  at  the  earlier  periods.  Cases  have  also 
been  recorded  in  which  the  organ  occupied  a 
transverse,  and  an  antero-posterior  direction. 

2.  Of  the  external  misplacements,  those  in 
which  the  heart  is  situated  external  to  the  tho- 
racic cavity — ectopia  or  ectocardia  extrathoracica 
— the  most  common  is  that  in  which,  from 
deficiency  of  some  part  of  the  sternum,  the  organ 
lies  in  front  of  the  chest— ectopia  cordis  or  ecto- 
cardia pectoralis.  In  other  cases,  from  deficiency 
in  some  portion  of  the  diaphragm,  the  heart  is 
placed  in  the  abdomen,  either  lying  in  the  canty, 
or,  if  the  integuments  are  partially  defective,  in 
a sac  in  the  pracordia — ectopia  cordis  or  ecto- 
cardia ahdominalis.  In  a third  form  the  heart 
lies  at  the  root  of  the  neck — ectopia  cordis  or 
ectocardia  cephcdica.  Of  these  forms,  examples 
are  related  or  referred  to  in  the  memoirs  of 
Breschet  and  Alvarenga,  and  various  others 
have  been  published  since  the  appearance  of  the 
memoir  of  Breschet. 

Symptoms,  Duration,  and  Terminations. — 
When  the  heart  is  well-formed,  its  malposition 
within  the  thorax  does  not  necessarily  cause 
such  interference  with  its  functions  as  to  be  pro- 
ductive of  symptoms,  or  materially  to  curtail  the 
duration  of  life.  Indeed,  cases  are  on  record  in 
which  the  heart  and  other  viscera  have  been 
transposed  in  persons  who  had  never  presented 
any  signs  of  disorder  of  the  circulation,  and 
who  lived  to  very  advanced  ages.  When,  how- 
ever, the  organ  is  also  defective,  and  especially 
when  the  displacement  is  external  to  the  thoracic 
cavity,  life  is  usually  only  of  short  duration — 
though  some  remarkable  cases  of  external  dis- 
placements are  on  record,  in  which  the  patients 
survived  to  advanced  ages. 

Malformation  of  the  Pericardium.  — 
Closely  allied  to  the  cases  of  misplacement  of 
the  heart  are  those  in  which  the  organ,  though 
occupying  its  natural  position,  is  not  covered  by 
the  pericardium,  but  lies  in  contact  with  the  lung 
in  the  left  pleural  cavity.  Of  this  form  of  ano- 


maly various  instances  are  recorded — the  first 
undoubted  case  of  the  kind  being  probably  that 
represented  by  Dr.  Baillie,  in  1778.  The  defect 
seems  to  consist  in  the  pericardium,  which  is 
apparently  reflected  from  the  external  coat  of  the 
aorta,  not  being  prolonged  so  as  to  cover  the 
front  of  the  heart  and  become  attached  to  the 
diaphragm.  The  imperfectly  developed  mem- 
brane is  represented  by  a kind  of  loose  fold,  or 
pocket,  which  is  found  on  the  right  side  or  upper 
part  of  the  heart. 

Effects. — This  condition  does  not  seem  mate- 
terially  to  interfere  with  the  functions  of  the 
organ.  Cases  are  recorded  in  which  the  sub- 
jects lived  to  middle  age ; and  the  writer  has 
himself  seen  it  in  a man  who  died  of  heart- 
disease  at  seventy-five.  T.  B.  Peacock. 

HEART,  Congestion  of. — Attention  was 
first  directed  to  this  morbid  condition  of  the 
heart  by  Sir  William  Jenner  ( Medico- Chirur - 
gical  Transactions,  vol.  xliii.  p.  199).  The  coro- 
nary veins,  like  the  veins  of  other  parts,  are 
subject  to  engorgement,  when  the  flow  of  the 
blood  from  them  into  the  right  auricle  is  inter- 
rupted. The  most  common  cause  of  this  is 
dilatation  and  distension  of  the  cavities  of  the 
right  side  of  the  heart,  which  conditions  are 
themselves  usually  due  either  to  emphysema  or 
to  valvular  disease  of  the  heart.  Disease  of,  or 
pressure  on,  the  trunks  of  the  coronary  veins 
may  be  regarded  as  less  frequent  causes  of  the 
same  result. 

Anatomical  Characters. — Congestion  of  the 
heart  is  recognised,  when  recent,  by  the  fulness  ol 
the  veins  on  the  surface  of  the  organ;  cedema  ol 
the  loose  connective  tissue  at  the  base ; and 
ecchymosis  of  the  pericardium  and  endocardium. 
The  pericardial  sac  contains  some  serous  or 
sero-sanguinolent  effusion ; and  the  mouth  of  the 
coronary  sinus  may  be  found  to  be  dilated.  When 
the  congestion  is  slight, gradually  developed,  and 
of  long  standing,  the  venous  fulness  gives  rise 
to  an  increased  formation  of  connective  tissue 
in  the  walls  of  the  heart,  which  become,  in  con- 
sequence, tough  and  indurated  ; whilst  the  dila- 
tation of  the  cavities,  with  which  the  congestion 
is  associated,  is  rendered  permanent  by  the  same 
cause.  When  divided  with  the  knife,  the  cardiac 
walls  do  not  fall  inwards ; their  substance  feels 
like  a piece  of  leather;  and  the  section  has  a 
smooth  homogeneous  appearance.  Microscopi- 
cally, the  connective  tissue  seems  to  be  increased 
in  quantity ; and  the  muscular  fibres  are  in  a 
condition  of  granular,  fatty,  and  pigmentary  de- 
generation. 

Congestion  of  the  heart  possesses  no  direct 
clinical  relations.  J.  Mitchell  Bruce. 

HEART,  Connective-Tissue  Hypertro- 
phy of. — Definition.— An  excessive  develop- 
ment of  the  connective  tissue  which  exists  be- 
tween the  muscular  fibres  of  the  heart,  causing 
an  increase  of  the  volume  of  the  organ. 

Anatomical  Characters.  — In  connective- 
tissue  hypertrophy  the  heart  is  enlarged  more 
or  less  uniformly  as  regards  the  walls  of  its 
several  cavities,  and  usually  greatly,  weighing 
in  some  instances  as  much  as  forty  ounces. 
The  thickness  of  the  walls  is  increased,  as  in 
simple  hypertrophy ; and  their  density  and 


586  HEART,  CONNECTIVE-TISSUE  HYPERTROPHY  OF;  AND  DEGENERATION'  OF. 


consistence  are  such  that  they  present  a firm, 
tough,  leathery  character.  When  cut  the  edges 
do  not  collapse,  but  continue  stiff  and  prominent. 
The  colour  of  a heart  in  this  condition  may  vary 
from  pale  buff  to  deep  purple,  according  to  the 
amount  of  connective  tissue  and  of  blood  pre- 
sent in  the  vessels.  Microscopically  there  is  seen 
— not  the  usual  limited  amount  of  intermuscular 
fibrillar  tissue  and  connective-tissue  cells,  but 
a decided  hyperplasia  of  these  elements,  in  the 
form  of  connective  tissue,  of  which  all  stages  of 
development  may  sometimes  bo  observed,  from 
the  round  and  spindle-shaped  cell  to  the  perfect 
bundle  of  fibrillae.  Betweon  the  individual 
bundles  of  connective  tissue  lie  the  muscular 
fibres,  which  are  also  hypertrophied,  but  which 
are  more  or  less  compressed,  and  are  occasion- 
ally in  a condition  of  granular  or  fatty  degene- 
ration. 

There  is  a certain  amount  of  anatomical  re- 
semblance, but  a very  clear  pathological  dis- 
tinction between  this  form  of  heart-disease  and 
the  change  described  by  Sir  William  Jenner  as 
fibroid  disease  of  the  heart  resulting  from  con- 
gestion (see  Heart,  Congestion  of).  Connective- 
tissue  hypertrophy  may  also  to  some  extent  be 
compared  with  the  fibrosis  described  by  Sir 
William  Gull  and  Dr.  Sutton  as  existing  in  the 
walls  of  arteries  and  other  tissues. 

ZEtiology. — Cases  of  hypertrophy  of  the  heart 
have  been  described  by  several  writers  in  which 
there  was  disease  neither  of  the  valves,  vessels, 
nor  kidneys  to  account  for  it,  and  which  the 
writer  believes  to  be  due  to  the  pathological 
changes  here  described.  A remarkable  specimen 
is  preserved  in  the  museum  of  St.  George’s  Hos- 
pital, consisting  of  a heart  weighing  forty  and 
a half  ounces,  which  was  removed  from  the  body 
of  an  under-butler,  in  the  post-mortem  examina- 
tion of  whom  nothing  was  found  which  could 
satisfactorily  explain  the  occurrence  of  the  en- 
largement. The  writer  is  indebted  to  Dr.  Whip- 
ham  for  an  opportunity  of  examining  this 
specimen,  which  was  found  by  his  friend,  Dr. 
Mitchell  Bruce,  to  possess  the  microscopical 
characters  above  referred  to.  This  and  similar 
cases  exhibit  no  appearance  of  chronic  inflamma- 
tory action,  and  thus  differ  altogether  from  exam- 
ples of  that  form  of  fibroid  degeneration  which 
is  described  under  a separate  heading  (see 
Heart,  Fibroid  Disease  of).  In  the  cases  now 
described  there  is  a simple  hyperplasia  of  con- 
nective tissue,  the  origin  of  which  cannot  be 
fully  explained.  In  Germany  similar  enlarge- 
ment of  the  heart  is  said  to  have  been  more 
especially  found  in  gourmands,  and  hence  it 
derived  a characteristic  appellat  ion.  The  existence 
of  connective-tissue  growth  being  thus  deter- 
mined, the  effect  of  its  presence  on  the  muscular 
tissue  is  obvious.  The  connective  tissue,  sur- 
rounding, as  it  must  do,  the  muscular  fibres,  in- 
terferes with  their  free  action,  to  overcome  which 
there  will  be  a natural  tendency  to  increased 
action,  and  consequent  hypertrophy  of  the  mus- 
cular fibres  themselves.  It  is  very  probable  that 
it  is  to  these  two  processes  going  on  simulta- 
neously that  the  great  increase  in  the  size  of  the 
heart  is  due. 

Symptoms  and  Diagnosis. — In  a remarkable 
case  recorded  by  the  late  Dr.  Hyde  Salter,  which 


the  writer  believes  to  have  been  of  the  nature 
here  described,  acute  or  severe  cardiac  dyspnce.a 
and  haemoptysis,  from  which  the  patient  had  suf- 
fered for  several  weeks,  were  the  most  prominent 
symptoms.  The  heart-sounds  were  natural,  ex- 
cept that  the  first  was  dull  and  defective.  Tho 
pulse  was  84.  The  symptoms  increased  in  seve- 
rity, and  were  aggravated  by  excessive  epistaxis. 
The  patient  died  after  being  in  hospital  for 
fourteen  days.  At  the  post-mortem  examination 
the  heart  was  found  to  be  of  great  size,  and  there 
was  no  disease  either  of  the  valves  or  of  the 
vessels  or  of  the  kidneys  to  account  for  it.  In 
the  case  of  the  butler  in  St.  George's  Hospital, 
it  is  recorded  that  he  continued  going  about 
until  within  a few  days  of  his  death.  These 
and  some  like  cases  indicate  that  we  can  do  little 
in  the  way  of  diagnosis  beyond  recognising  the 
presence  of  cardiac  hypertrophy  by  the  usual 
signs ; and  if  the  hypertrophy  be  considerable, 
and  if  there  be  no  valvular  disease  and  no  kidney 
disease,  we  might  not  be  far  wrong  in  considering 
that  the  hypertrophy  was  caused  bv  increase  of 
some  other  element  than  that  of  the  muscular 
fibres. 

Treatment. — If  the  opinion  be  co  rrect  that 
this  form  of  disease  finds  its  origin  in  excessivo 
alimentation,  it  would  he  well  to  place  the 
patient  in  such  circumstances  as  would  prevent 
this,  giving  attention  at  the  same  time  to  other 
hygienic  conditions.  The  more  aggravated 
symptoms  of  cardiac  disease  must  be  treated  on 
general  principles.  R.  Quaen,  M.D. 

id  WART,  Coverings  of.  Diseases  of.  See 
Pericardium,  Diseases  of. 

HEART,  Degenerations  of. — The  degene- 
rations that  affect  the  heart  may  he  enumerated 
as  follows: — 1.  Fatty;  2.  Parenchymatous;  3. 
Albuminoid  ; 4.  Pigmentary  ; 5.  Cartilaginous : 
6.  Calcareous ; and  7.  Vitreous.  The  condition 
which  has  been  called  ‘ fibroid  degeneration  ’ of 
the  heart  is  described  under  the  heads  of  Heart, 
Fibroid  Disease  of ; and  Heart,  Syphilitic 
Disease  of. 

1.  Fatty. — This  form  of  degeneration  of  the 
heart  being  of  special  importance  is  discussed  in 
a separate  article.  See  Heart,  Fatty  Degene- 
ration of. 

2.  Parenchymatous, — Stnon.  : Granular  de- 
generation; Cloudy  Swelling;  ? Parenchymatous 
inflammation. 

ZEtiology. — This  form  of  degeneration  of  the 
heart  is  generally  met  with  in  the  acute  specific 
fevers,  especially  typhus,  typhoid  fever,  diph- 
theria, and  septicaemia ; and  is  probably  refer- 
able to  the  action  either  of  the  poison  or  of  the 
high  temperature  attending  the  disease-process 
upon  the  muscular  substance. 

Anatomical  Characters. — The  disease  gem- 
rally  attacks  the  heart  as  a whole.  The  orgaD 
appears  somewhat  enlarged,  extremely  soft- 
flabby  as  well  as  friable,  and  of  a dirty  grayish- 
red  colour.  The  pericardium  is  ecchymosed,  dull, 
and  swollen,  and  the  epicardial  flit  has  more  or 
less  completely  disappeared.  Microscopically, 
the  muscular  fibres  are  found  to  be  dull  and 
granular,  swollen,  and  variously  ruptured  ; theii 


HEART,  DEGENERATIONS  OF. 

etriations  are  indistinct;  and  the  addition  of 
acetic  acid  removes  many  of  the  granules  from 
the  fibres,  whilst  it  brings  more  distinctly  into 
view  a few  fatty  globules,  and  frequently  an 
increased  number  of  pigment-parlicles. 

Symptoms. — Inasmuch  as  parenchymatous  de- 
generation of  the  heart  is  usually  but  a compli- 
cation of  some  acute  specific  disease,  the  condition 
of  the  patient  is  one  of  great  febrile  prostra- 
tion with  cardiac  asthenia.  The  physical  signs, 
which  are  regarded  as  more  distinct  evidence  than 
the  symptoms  of  the  condition  of  the  heart,  are 
— feebleness,  advancing  to  complete  absence, 
of  the  apex-impulse,  or  more  rarely  palpitation ; 
and  progressive  weakening,  and  finally  loss  of 
the  first  sound.  The  pulse  has  been  described 
os  corresponding  with  the  condition  of  the  heart, 
except  in  some  cases  where  it  is  imperceptible, 
although  associated  with  cardiac  palpitation. 

Course  and  Terminations. — The  course  and 
terminations  of  granular  degeneration  of  the 
heart  are  inseparable  from  those  of  the  pri- 
mary disease.  In  typhus  the  average  date  of 
the  appearance  of  the  symptoms  and  signs  just 
described  is  the  sixth  day  of  the  fever,  and  they 
usually  cease  on  the  fourteenth  day.  A large 
proportion  of  cases  prove  fatal  at  or  before  that 
time. 

Prognosis. — The  existence  of  this  kind  of 
degeneration  of  the  heart  adds  seriously  to  the 
gravity  of  a case  of  fever  ; and  the  danger  in- 
creases with  the  rate  and  weakness  of  the  pulse, 
and  the  feebleness  of  the  cardiac  impulse  and 
first  sound.  The  return  of  the  latter  under 
treatment  justifies  a favourable  prognosis. 

Treatment. — The  treatment  of  parenchyma- 
tous degeneration  of  the  heart  is  in  no  respect 
different  from  that  of  the  fever  in  which  this 
condition  originates.  The  appearance  of  the 
characteristic  symptoms  and  signs  of  the  cardiac 
affection  is,  however,  to  be  regarded  as  an  im- 
portant indication  for  the  use  of  alcoholic  stimu- 
lants, which  are,  as  a rule,  well  borne  in  such 
cases,  and  act  very  beneficially. 

3.  Albuminoid. — This  kind  of  degeneration 
has  been  said,  with  a certain  amount  of  possi- 
bility, to  have  been  found  in  the  heart.  It  is 
certainly  excessively  rare. 

4.  Pigmentary. — Pigment-granules,  in  the 
form  of  shining  yellow  particles,  are  almost 
invariably  found  in  the  muscular  fibres  of  the 
heart  in  chronic  cardiac  disease.  In  certain 
cases  of  atrophy  known  as  ‘ brown  atrophy,’  as 
well  as  in  tile  granular  degeneration  just  de- 
scribed, these  pigment-particles  are  decidedly 
increased  in  number,  and  collected  towards  the 
axis  of  the  fibres.  A somewhat  similar  appear- 
ance is  seen  in  the  heart  in  jaundice. 

The  condition  is  of  purely  pathological  in- 
terest. 

5.  Cartilaginous. — Portions  of  the  myocar- 
dium have  frequently  been  described  as  ‘carti- 
laginous ’ or  1 fibro-cartilaginous,’  but  it  would 
appear  that  in  theseinstances  the  muscular  tissue 
was  replaced  by  dense  firm  fibroid  tissue  only. 
See  Heart,  Fibroid  Disease  of. 

6.  Calcareous. — Calcification  of  pericardial 
adhesions  is  not  very  rare  ; and  in  some  of  the 
recorded  instances  of  this  condition,  plates  of 
the  same  material  have  been  found  projecting 


HEART,  DILATATION  OF.  587 
into  the  substance  of  the  heart,  appearing  as 
if  formed  within  the  myocardium.  Besides  this 
class  of  cases,  instances  of  true  deposit  of  calca- 
reous particles  within  the  individual  muscular 
fibres  have  been  described.  This  appears  in  the 
form  of  small,  pale,  gritty  deposits,  taking  the 
place  of  the  normal  muscular  tissue  on  the  sur- 
face, in  which,  on  microscopical  examination,  the 
muscular  fibres  were  found  to  have  become  solid 
and  opaque,  whilst  hydrochloric  acid  or  sulphuric 
acid  removed  the  opacity  with  the  evolution  of 
gas,  the  addition  of  the  latter  acid  also  pro- 
ducing gypsum  crystals.  It  is  probable  that  in 
other  recorded  instances,  the  calcareous  parti- 
cles were  situated  outside  the  muscular  fibres, 
and  may  have  been  the  products  of  a caseous 
nodule,  whether  syphilitic  or  ‘ tubercular’  in 
origin. 

This  form  of  disease  appears  to  possess  no 
special  clinical  relations. 

7.  Vitreous.  — Vitreous,  waxy,  or  colloid 
degeneration,  as  described  by  Zenker,  occurs  in 
the  myocardium,  as  it  does  in  the  voluntary 
muscles.  J.  Mitchell  Bruce. 

HEART,  Dilatation  of. — Definition. — 
Dilatation  of  the  heart  may  occur  in  two  forms, 
in  the  one  it  involves  only  a limited  portion  of 
the  cardiac  walls  and  constitutes  an  aneurism  ; 
in  the  other  there  is  uniform  enlargement  of 
one  or  more  of  the  heart's  cavities,  and  dilatation 
in  the  usual  acceptation  of  the  word  is  present. 
To  this  latter  condition,  however,  the  names 
‘ aneurism’  and  ‘ passive  aneurism  ’ of  the  heart 
were  formerly  applied.  Dilatation  is  probably 
always  associated  with  hypertrophy. 

BStiologt. — The  occurrence  of  dilatation  im- 
plies that  the  wails  of  the  heart  which  yield,  are 
too  weak  to  resist  successfully  the  internal  pres- 
sure to  which  they  are  exposed.  This  defective 
relation  may  be  due  either  to  actual  enfeeble- 
ment  of  the  heart’s  walls,  which  renders  them 
unequal  to  the  task  normally  devolving  on  them ; 
or  to  excessive  blood-pressure,  which  even  the 
healthily-constituted  walls  are  unable  to  with- 
stand. The  enfeeblement  of  the  heart  may  be  a 
consequence  of  fatty  or  other  degeneration ; or, 
as  is  probably  more  frequently  the  case,  may  be 
inherent  but  unconnected  with  visible  textural 
disease.  The  excessive  blood-pressure  may  be 
dependent  on  actual  obstruction  to  the  circula- 
tion which  the  heart  is  called  upon  to  surmount ; 
or  on  undue  rapidity  of  action  which  (other 
things  being  equal)  implies  an  unwonted  expen- 
diture of  force.  As  a matter  of  fact,  however, 
dilatation  and  hypertrophy  are  generally  if  not 
always  associated  ; and  the  processes  by  which 
these  combined  conditions  are  attained  are  more 
complicated  than  the  foregoing  statement  might 
lead  one  to  suppose.  It  will  be  convenient, 
therefore,  to  consider  certain  cases  seriatim. 

1.  In  obstructive  disease  at  the  aortic  orifice  ; 
in  general  stricture  of  the  minute  systemic  ar- 
teries, such  as  occurs  in  connection  with  con- 
tracted granular  kidneys ; and  indeed  in  all 
cases  in  which  resistance  is  offered  to  the  free 
discharge  of  blood  from  the  left  ventricle,  pro- 
gressive hypertrophy  of  the  walls  of  that  ven- 
tricle takes  place.  But  the  hypertrophy  is  com- 
plicated even  from  the  beginning  with  dilata- 


HEART,  DILATATION  OF. 


688 

tion.  The  hypertrophy,  at  any  i-ate  at  first, is  sim- 
ply compensatory,  and  may  be  taken  as  a mea- 
sure of  the  excess  of  resistance  which  the  heart 
is  called  upon  to  overcome.  The  dilatation, 
however,  is  in  no  sense  compensatory,  and  is 
probably  to  be  regarded  as  a measure  of  the  in- 
ability of  the  walls  to  cope  successfully  with  the 
extra  work  required  of  them.  It  is,  moreover, 
obvious  that  the  occurrence  of  dilatation,  by  in- 
creasing the  area  of  resistance  to  the  endo-ven- 
tricular  blood-pressure,  increases  pro  tanto  the 
muscular  effort  requisite  for  the  propulsion  of 
the  blood  into  the  aorta ; and  by  enlarging  the 
capacity  of  the  ventricular  cavity  and  conse- 
quently the  amount  of  blood  to  be  discharged 
from  it.  on  that  account  also  throws  additional 
labour  on  the  muscular  walls  of  the  ventricle. 
Thus  the  hypertrophy  and  dilatation  react  on 
one  another ; and  the  hypertrophy,  which  was 
probably  at  first  simply  compensatory  of  the 
mechanical  obstacle  to  the  discharge  of  the  nor- 
mal contents  of  the  ventricle,  ends  by  becoming 
— or  rather  striving  to  become — compensatory 
not  only  of  this  but  of  the  virtual  weakness  of 
the  heart  which  dilatation  entails. 

2.  In  regurgitant  disease  at  the  aortic  orifice, 
hypertrophy  and  dilatation  of  the  left  ventricle 
also  take  place.  But  in  this  case,  while  the 
hypertrophy  probably  reaches  a higher  degree 
of  development  than  in  simple  obstruction, 
dilatation  preponderates  from  first  to  last;  and 
the  ventricle  attains  larger  dimensions  than  in 
perhaps  any  other  form  of  disease.  But  to  what 
are  the  hypertrophy  and  dilatation  due  in  this 
case  ? There  is  no  impediment  to  the  escape  of 
blood  through  the  aortic  orifice,  and  therefore 
primd  facie  no  need  for  compensative  hyper- 
trophy. There  is  no  doubt  that  here  hypertrophy 
waits  on  dilatation.  The  first  effect  of  regur- 
gitation is,  that  during  diastole  the  ventricle 
becomes  more  rapidly  and  completely  filled  with 
blood  than  it  does  under  other  circumstances, 
and  that  the  subsequent  contraction  of  the  au- 
ricle tendsTo  distend  it  unnaturally  with  blood. 
The  result  is  that,  on  the  principles  above  enun- 
ciated, the  walls  of  the  ventricle  have  to  en- 
counter a larger  area  of  pressure,  and  to  expel  a 
larger  amount  of  blood  than  natural,  and  hence 
are  called  upon  to  make  excessive  effort,  and 
hypertrophy  ensues.  Thus  the  tendency  to  dila- 
tation causes  the  tendency  to  hypertrophy ; and 
both  acting  continuously  promote  the  progressive 
increase  in  the  capacity  of  the  ventricular  ca- 
vity, and  in  the  thickness  of  the  ventricular  walls. 

It  is  probable  in  both  cases,  but  more  espe- 
cially in  the  latter  of  them,  that  ere  long  the 
ventricle  fails  to  expel  the  whole  of  its  contents 
into  the  aorta  at  each  contraction,  and  that  the 
retention  of  this  residual  blood  becomes  an  im- 
portant factor  in  promoting  dilatation. 

3.  The  effects  of  continued  violent  action  of 
the  heart,  whether  caused  by  nervous  influence  or 
by  muscular  effort  are  much  the  same  as  those 
of  obstructive  disease.  For  both  increased 
rapidity  of  contraction,  and  increased  amount  of 
blood  to  be  expelled  at  each  beat,  other  things 
beiDg  equal,  imply  increased  expenditure  of 
force ; and  the  persistence  of  either  or  both  of 
these  conditions,  therefore,  the  supervention  of 
hypertrophy  and  dilatation. 


4.  The  above  discussion  relates  especially  to 
dilatation  and  hypertrophy  of  the  left  ventricle. 
But,  mutatis  mutandis,  ft  applies  with  equal 
force  to  dilatation  and  hypertrophy  of  the  other 
sections  of  the  heart.  Thus,  in  mitral  valve 
disease,  the  left  auricle  undergoes  hypertrophy 
and  dilatation — the  dilatation  preponderating 
in  regurgitant  disease  of  the  valve,  the  hyper- 
trophy preponderating  in  obstructive  disease. 

5.  In  pulmonic  valve  disease  the  right  ven- 
tricle becomes  hypertrophied  and  dilated— the 
dilatation  being  greatest  where  there  is  pulmo- 
nic regurgitation,  the  hypertrophy  being  greatest 
where  the  disease  is  obstructive. 

6.  In  tricuspid  valve  disease  the  right  auricle 
suffers,  becoming  chiefly  dilated  in  the  presence 
of  tricuspid  regurgitation,  chiefly  hypertrophied 
when  there  is  obstruction.  And  thus,  also,  just 
as  when  the  systemic  circulation  is  impeded  the 
left  side  of  the  heart  suffers,  so  when  the  pul- 
monic circulation  is  obstructed,  the  right  side 
of  the  heart  undergoes  enlargement. 

In  all  cases,  therefore,  hypertrophy  and  dila- 
tation seem  to  result  concurrently  ; but  whether 
the  one  or  the  other  condition  preponderates, 
depends  partly  on  the  particular  nature  of  the 
cause  to  which  the  hypertrophy  and  dilatation 
are  due,  partly  on  the  inherent  strength  or  weak- 
ness of  the  cardiac  walls.  In  all  cases,  too,  the 
other  cavities  of  the  heart,  besides  that  primarily 
and  directly  implicated,  suffer  according  to  their 
position  from  the  effects  of  the  greater  or  less 
work  which  sooner  or  later  is  cast  upon  them. 

The  temporary  dilatation  which  is  described 
as  occurring  in  acute  febrile  disorders,  such  as 
typhus,  is  due  mainly  to  enfeebiement  of  the 
cardiac  walls. 

Anatomical  Characters. — In  dilatation  of 
the  heart,  the  cardiac  walls  may  be  either  thin- 
ner or  thicker  than  natural,  or  may  retain  their 
normal  thickness.  It  is  a question,  however, 
whether,  excepting  in  the  case  of  partial  dilata- 
tion or  aneurism,  dilatation  ever  takes  place 
independently  of  hypertrophy ; for  even  as  re- 
gards the  auricles,  where  dilatation  with  atten- 
uation is  chiefly  observed,  there  is  reason  to 
believe  that  the  attenuation  is  not  commensu- 
rate with  the  extension  which  accompanies  it, 
and  consequently  that  the  total  bulk  of  muscular 
tissue  is  increased.  When  dilatation  is  asso- 
ciated with  no  apparent  change  in  the  thickness 
of  the  walls,  hypertrophy  is  of  course  present. 

It  must  be  mentioned,  however,  that  it  is 
often  very  difficult  to  determine  on  post-mortem 
examination  the  true  relation  between  the  thick- 
ness of  the  cardiac  walls  and  the  capacity  of 
the  cardiac  cavities.  For  their  apparent  rela- 
tion is  largely  dependent  on  the  condition  of  the 
cavities  at  the  moment  of  death,  as  to  systole 
or  diastole ; and  on  the  state  of  the  heart  as  to 
cadaveric  changes  at  the  time  of  post-mortem 
examination. 

The  form  which  the  heart  assumes  in  dila- 
tation is  the  same  as  that  which  it  assumes 
in  hypertrophy-,  and  indeed  as  the  two  con- 
ditions are  probably  always  associated,  it  is 
needless  to  endeavour  to  establish  any  distinc- 
tion between  them  in  this  respect.  If  the  dila- 
tation be  general,  the  form  of  the  heart  remains 
unchanged,  but  its  size  is  uniformly  augmented. 


HEAKT,  DILATATION  OF. 


If  the  left  ventricle  be  mainly  affected,  the  heart 
appears  not  only  enlarged  but  elongated,  the 
Left  ventricle  taking  more  than  its  due  share  in 
the  formation  of  the  cardiac  apex.  If  the  right 
ventricle  be  specially  implicated,  the  heart  be- 
comes enlarged,  in  its  transverse  diameter ; it  is 
more  rounded  in  its  contour  as  seen  from  the 
front  than  it  should  be ; and  its  apex  is  obtuse, 
and  either  bifid,  from  the  fact  that  the  apices 
of  both  ventricles  take  an  equal  share  in  the 
formation  of  the  cardiac  apex,  or  formed  wholly 
by  the  right  ventricle.  If  the  auricles  be  dilated, 
they  constitute  large  masses  on  both  sides  of  the 
root  of  the  aorta  and  pulmonary  artery. 

The  walls  of  the  dilated  heart  vary  not  only 
in  thickness  but  also  in  quality.  Thus  they  may 
be  preternaturally  firm  or  preternaturally  soft; 
they  may  be  healthy  in  structure,  or  may  pre- 
sent more  or  less  degenerative  change. 

Consequences  of  Dilatation. — Dilatation  of 
the  ventricles,  especially  if  it  be  considerable,  is 
apt  to  disarrange  the  mechanism  of  the  auriculo- 
ventricular  valves.  It  was  shown  many  years 
ago  by  Mr.  Wilkinson  King  that  even  in  mere 
temporary  distension  of  the  right  ventricle  a 
kind  of  safety-valve  action  of  the  tricuspid  valve 
took  place,  in  consequence  of  which  regurgitation 
of  blood  was  permitted  from  the  ventricle  into 
the  auricle.  And  since  his  time  it  has  been 
clearly  demonstrated,  both  by  clinical  and  by  post- 
mortem evidence,  that  established  dilatation  of 
the  right  or  left  ventricle  is  liable  to  be  attended 
with  persistent  regurgitation  of  blood  through 
the  corresponding  auriculo-ventricular  orifice. 
The  defaulting  valve  under  these  circumstances 
has  a natural  aspect;  but  careful  examination 
shows  either  that  the  orifice  has  undergone  dilata- 
tion in  company  with  the  ventricle — the  valve 
itself  presenting  no  corresponding  increase, 
or  that  there  is  a want  of  relation  between  the 
size  cf  the  musculi  papillares  and  chordae  ten- 
dine®  on  the  one  hand,  and  the  capacity  of  the 
ventricle  on  the  other,  which  interferes  with  the 
due  closure  of  the  valve. 

It  is  obvious  that  if  regurgitation  becomes 
established,  the  usual  consequences  of  regurgita- 
tion will  presently  ensue ; namely,  in  connection 
with  affection  of  the  left  side  of  the  heart,  dilata- 
tion and  hypertrophy  of  the  left  auricle,  and  sub- 
sequently congestion  of  the  lungs  and  pulmonary 
apoplexy ; and  in  connection  with  affection  of 
the  right  side  of  the  heart  dilatation  and  hyper- 
trophy of  the  right  auricle,  fulness  of  the  systemic 
veins,  anasarca,  nutmeg  liver,  and  congested,  in- 
durated kidneys.  It  is  also  obvious  that,  even  if  no 
regurgitant  condition  be  developed,  dilatation  of 
heart,  which  implies  feebleness  of  heart  and  im- 
perfect circulation,  must  ultimately  induce  the 
ordinary  remote  consequences  of  heart-disease. 
A further  consequence  of  dilatation  and  other 
cardiac  affections  attended  with  feeble  circula- 
tion is  the  formation  of  thrombi  during  life, 
both  in  the  heart  itself,  and  in  other  parts  of  the 
vascular  system.  Mr.  Wilkinson  King  has  de- 
monstrated that  dilatation  of  the  left  auricle  may 
cause  compression  of  the  left  bronchus. 

Symptoms. — Since  dilatation  of  the  heart  rarely 
if  ever  exists  alone,  but  is  associated  with  hyper- 
trophy, valve-disease,  degenerations,  and  other 
eonditions,  it  is  almost  impossible  to  make  any 


589 

definite  statement  with  regard  to  the  signs  and 
symptoms  by  which  its  presence  may  be  recog- 
nised. Still  there  is  no  doubt  that  dilatation  is 
one  of  the  most  important  factors  of  heart- 
disease,  clinically  considered;  and  that  its  super- 
vention materially  affects  the  patient’s  condition, 
and  prospect  of  life.  Dilatation  implies  weakness, 
and  as  a rule  over-distension  of  the  implicated 
cavities  with  blood,  which  probably  never  becomes 
wholly  expelled. 

The  physical  signs  of  dilatation  are  necessarily 
in  many  respects  the  same  as  those  of  hyper- 
trophy. The  praecordial  dulness  is  increased  in 
area — the  extent  and  form  of  this  area,  and  the 
situation  of  the  apex-beat,  being  determined  by 
the  general  size  of  the  heart,  aud  the  relative 
dimensions  of  its  component  parts.  In  propor- 
tion, however,  as  dilatation  preponderates  over 
hypertrophy,  the  impulse  of  the  heart  becomes 
weak,  and  possibly  to  some  extent  diffused.  In 
extreme  dilatation,  as  in  extreme  weakness  from 
other  causes,  the  sounds  of  the  heart,  and  espe- 
cially the  first  sound,  are  enfeebled.  And  it 
may  be  asserted  that  generally  the  tendency  of 
dilatation  is  to  shorten  the  first  sound,  and  to  give 
it  the  characters  of  the  second  sound.  It  has 
nevertheless  been  observed  over  and  over  again 
that  it  is  in  the  concurrence  of  hypertrophy  and 
dilatation  that  the  cardiac  sounds  are  apt  to  attain 
their  greatest  intensity.  The  feebleness  of  the 
heart’s  action  is  generally  attended  before  long  by 
more  or  less  irregularity ; and  even  in  the  absence 
of  valve-disease,  a mitral  or  tricuspid  systolic 
murmur,  implying  regurgitation,  is  apt  to  be 
established. 

The  symptoms  of  dilatation  are  to  a large 
extent  those  of  cardiac  obstruction,  and  more 
especially  of  mitral  disease.  The  patient  com- 
plains of  weight,  oppression  or  uneasiness  in  the 
cardiac  region,  with  probably  a sense  of  flutter- 
ing there,  and  of  a tendency  to  sighing  respira- 
tion. He  becomes  short-breathed,  and  may 
have  extreme  dyspnoea.  His  face  is  apt  to  be- 
come livid  ; his  surface  pale  or  ghastly  ; his  ex- 
tremities cold  and  blue ; and  his  pulse  weak 
and  irregular.  Dilatation  of  the  systemic  veins 
arises  sooner  or  later ; and  subsequently  general 
anasarca,  pulsation  of  the  veins  in  the  neck, 
epigastric  pulsation,  and  pulsation  of  the  liver, 
together  with  the  other  usual  consequences  of 
heart-disease.  The  chief  of  these  are — conges- 
tion of  the  lungs,  with  pulmonary  apoplexy, 
cough,  and  expectoration  of  blood  ; congestion, 
enlargement,  and  tenderness  of  the  liver,  with 
jaundice;  and  congestion  of  the  kidneys,  at- 
tended with  the  discharge  of  scanty,  high- 
coloured,  heavy  urine,  containing  albumen  and 
possibly  blood.  Other  symptoms  referable  to 
the  nervous  and  digestive  organs,  which  need 
not  be  enumerated,  are  also  liable  to  supervene. 

The  symptoms  will  vary,  of  course,  according  as 
the  left  or  the  right  ventricle  is  mainly  affected. 
In  the  former  case  we  are  liable  to  have  at  first 
irregularity  and  feebleness  of  pulse  with  tendency 
to  faint ; then  pulmonary  complications ; and  at  a 
later  period,  symptoms  referable  to  the  systemic 
venous  circulation.  The  latter  case  is  one  of 
considerable  interest ; because  in  a large  number 
of  instances  it  is,  in  its  most  marked  form,  a 
consequence  of  emphysema  of  the  lungs,  or  of 


590  HEART,  DILATATION  OF. 
other  analogous  conditions,  and  moreover  is  apt 
to  come  on  very  rapidly.  Under  these  circum- 
stances, there  is  necessarily  much  dyspnoea,  but 
the  systemic  venous  and  capillary  systems  speed- 
ily become  over-loaded ; extreme  cyanosis  often 
develops  rapidly ; and,  before  long,  all  the  other 
symptoms  referable  to  disease  of  the  right 
side  cf  the  heart  become  established:  namely, 
pulsation  of  the  veins  in  the  neck,  epigastric 
pulsation,  pulsation  of  the  liver,  general  anasarca, 
with  perhaps  petechial  extravasations,  jaundice 
from  nutmeg  liver,  and  albuminuria  from  conges- 
tion of  the  kidneys. 

Prognosis. — There  is  no  doubt  that  some 
degree  of  dilatation  of  the  heart,  and  more  especi- 
ally of  the  right  ventricle,  may  arise,  either  from 
over-exertion,  or  from  functional  disturbances, 
and  in  connection  ■with  pulmonary  disorders. 
But  such  dilatation  is  for  the  most  part  tempor- 
ary or  remediable  ; and  only  by  continuance  of 
its  cause  becomes  established  and  a matter 
of  serious  importance.  In  the  same  way  there  is 
no  doubt  that  the  dilatation  which  comes  on  in 
the  course  of  organic  disease  of  the  heart  or 
lungs,  or  of  other  organic  diseases  which  influ- 
ence the  action  of  the  heart,  is  remediable  within 
certain  limits  by  due  attention  to  the  conditions 
under  which  it  arises.  Nevertheless  it  is  certain 
that  the  presence  of  dilatation  of  the  heart  in 
connection  with  other  diseases,  more  especially 
those  of  the  heart,  lungs,  or  kidneys,  is  a grave 
source  of  danger;  and  that  in  the  great  majority 
of  cases  it  is  of  fatal  omen,  aggravating  the 
patient’s  cardiac  symptoms,  and  hastening  his 
death. 

Treatment. — The  treatment  of  dilatation  of 
the  heart  merges  in  that  of  the  other  cardiac 
conditions  with  which  it  is  associated,  and  in 
that  of  other  diseases  in  the  course  of  which  it 
may  have  supervened.  It  may  be  stated,  gener- 
ally, however,  that  the  treatment  is  that  of 
cardiac  debility,  and  of  distension  of  the  heart 
with  blood. 

The  chief  indications,  therefore,  are  rest  of 
mind  and  body ; avoidance  of  exposure  to  ccld 
and  wet ; the  exhibition  of  ample  nutritious  and 
readily  digestible  food ; due  attention  to  the 
action  of  the  bowels,  kidneys,  and  skin  ; and 
the  employment  of  medicines  likely  to  regulate 
and  strengthen  the  action  of  the  heart.  For 
the  last  purpose  digitalis  in  small  doses  is 
universally  acknowledged  to  be  of  great  value. 
And  it  is  in  most  cases  desirable  to  combine  the 
digitalis  with  iron,  or  some  vegetable  tonic. 
Ammonia  and  other  diffusible  stimulants  are 
often  called  for,  and  are  of  great  service.  In 
cases  where  there  is  much  lividity,  and  evidence 
of  stagnation  of  blood  in  the  right  side  of  the 
heart,  removal  of  blood  by  venesection  may  he 
of  use. 

When  the  dilatation  is  due  to  pulmonary  dis- 
ease, this  of  course  requires  primary  and  especial 
treatment.  J.  S.  Bristowe. 

HEART,  Displacements  of. — Besides  the 
displacements  of  the  heart  that  occur  as  the  re- 
sult of  disease,  there  are  certain  changes  of 
position  which  this  organ  undergoes  in  health. 
The  most  important  of  these  physiological  dis- 
placements of  the  heart  are — first,  its  vertical 


HEART,  DISPLACEMENTS  OF. 

movements  in  respiration ; and,  secondly,  the 
alterations  in  its  situation  corresponding  with 
changes  in  the  bodily  posture.  The  present 
article,  however,  will  deal  only  with  the  former 
class,  or  abnormal  displacements  of  the  heart. 

^Etiology. — The  heart  may  he  congenitally 
displaced — a condition  which  is  described  under 
the  head  of  Heart,  Congenital  Misplacement 
of.  These  cases  being  excepted,  the  causes  of 
displacement  of  the  heart  may  be  arranged  in 
two  classes — namely,  (1)  conditions  that  exert 
pressure ; and  (2)  conditions  that  exercise  trac- 
tion upon  the  heart. 

(1)  The  heart  is  pressed  or  pushed  out  of 
position  by  effusions  of  fluid — inflammatory, 
serous,  or  bloody — into  either  pleural  cavity; 
by  pneumothorax  of  either  side  ; by  intratho- 
raeic  tumours — whether  mediastinal  (including 
aneurism  and  abscess),  pulmonary,  or  parietal  ; 
by  hypertrophous  emphysema,  or  other  causes  of 
enlargement  of  the  lungs ; by  extensive  pneu- 
monic consolidation  ; or  by  abundant  pericardial 
effusion  of  any  kind.  Certain  conditions  of  the 
abdominal  contents  produce  a similar  effect, 
for  example — gaseous  distension  of  the  stomach 
and  intestines;  enlargement  of  the  liver  and 
other  solid  organs ; abdominal  tumours  of  all 
kinds  ; the  pregnant  uterus ; and  ascites,  when 
considerable.  Hernia  of  the  abdominal  viscera 
through  the  diaphragm,  and  abscesses  connected 
■with  the  diaphragm,  also  cause  displacement  of 
the  heart. 

(2)  The  heart  suffers  traction,  or  is  drawn  out 
of  position  during  absorption  of  pleuritic  effusion 
with  imperfect  expansion  of  the  lung,  on  either 
side  ; by  the  contraction  of  pleuro-pericardial 
adhesions,  of  pulmonary  cirrhosis,  or  of  cavities 
in  phthisis;  in  collapse  of  either  lung  from 
pressure  on  the  main  bronchus  ; and  in  some 
forms  of  deformity  of  the  chest  from  curvature 
of  the  spine. 

Mechanism  of  Displacement. — The  causes 
just  enumerated  constitute  in  each  instance 
what  may  he  called  the  displacing  force.  When 
this  force  belongs  to  the  first  or  pressure  class, 
it  acts  against  the  surface  of  the  pericardium 
and  heart  that  is  opposed  to  it,  and  presses  or 
pushes  it,  a tergo,  away  from  its  own  seat,  in  the 
direction  of  least  resistance.  Thus  the  heart  is, 
speaking  broadly,  pushed  towards  the  left  by 
effusion  into  the  right  pleural  cavity ; towards 
the  right  by  similar  disease  on  the  left  side; 
downwards  by  tumours  in  the  region  of  the 
base  ; and  upwards  by  gaseous  distension  of  the 
stomach. 

On  the  other  hand,  when  the  displacing  force 
is  of  the  nature  of  traction,  the  heart  is  drawn 
a fronte , that  is,  towards  the  seat  of  the  force. 
Thus,  when  a cavity  in  a phthisical  lung  is  con- 
tracting, the  pericardium  and  heart,  as  well  as 
the  walls  of  the  chest,  are  displaced  towards  the 
healing  area.  It  must  be  observed,  however, 
that  in  this  class  of  cases,  actual  traeti  n,  in 
the  strict  sense,  is  rare,  and  that  the  displacing 
force  is,  in  reality,  the  atmospheric  pressure; 
the  heart  and  the  other  organs  being  ‘sucked’ 
towards  the  potential  vacuum,  in  the  same  way 
as  water  is  ‘drawn’  into  a syringe.  Still,  in 
a very  small  number  of  cases,  the  pericardium 
does  actually  become  involved  in  a healing  pro- 


HEART,  DISPLACEMENTS  OF. 


cess  in  the,  lungs  ; and  it  and  the  heart  are 
dragged  towards  the  cicatrix. 

Besides  the  displacing  force,  there  are  at 
work  in  dislocation  of  the  heart  certain  other 
agencies,  which  contribute  to  the  result,  -whether 
their  effect  be  to  increase  or  to  diminish  that  of 
the  chief  cause. 

a.  The  weight  of  the  heart  manifestly  favours 
displacement  in  different  directions,  according 
to  the  posture.  Thus,  in  the  erect  posture,  it 
favours  downward,  and  limits  upward  displace- 
ment. However,  the  weight  of  the  heart  is  com- 
paratively insignificant,  and  ma j be  practically 
disregarded. 

h.  The  resistance,  positive  or  negative,  of 
neighbouring  parts  must  be  taken  into  account. 

'1  he  heart  when  disturbed  from  its  position  will 
move  in  the  direction  of  least  resistance.  Thus 
it  cannot  be  displaced  to  any  extent  either  for- 
wards or  backwards ; but  is  moved  with  com- 
parative ease  towards  either  pleural  cavity.  The 
resistance  interiorly  is  greater  under  the  right 
half  of  the  diaphragm  than  under  the  left.  On 
the  other  hand,  the  resistance  around  may  be- 
come negative ; for  example,  in  left  pleural 
effusion  the  corresponding  half  of  the  diaphragm 
is  pushed  downwards,  and  the  accompanying 
downward  displacement  of  the  cardiac  apex  is 
thus  increased. 

c.  The  heart  is  attached  at  its  root;  and, 
speaking  broadly,  this  is  a fixed  point,  at  the 
right  and  upper  extremity  of  the  long  cardiac 
axis.  This  attachment  will  limit  and  otherwise 
modify  displacements  of  the  heart  in  all  direc- 
tions, especially  downwards.  Round  this  point 
as  a centre,  and  with  the  long  axis  as  the  radius, 
the  apex  of  the  heart  will  describe  an  arc  of 
a circle,  cutting  the  surface  of  the  chest  in 
the  left  axilla,  the  left  submammary  region,  the 
epigastrium,  the  right  submammary  region,  and 
the  right  axilla. 

d.  The  tendency  that  the  heart  has  to  rotate 
or  roll  on  one  or  other  of  its  axes  is  also  affected 
by  its  attachment  at  the  root.  If  the.  heart  lay 
free  in  the  pericardial  cavity,  there  would  be  no 
limit  to  such  rotation  under  the  influence  of 
pressure  or  of  traction.  The  base  being  fixed, 
rotation  is  greatly  limited,  and  does  not  occur 
to  any  extent  except  around  the  longitudinal 
axis;  the  left  ventricle,  for  example, being  rotated 
more  forwards  or  more  backwards,  as  the  case 
may  be.  Rotation  round  the  transverse-hori- 
zontal and  the  antero-posterior-horizontal  axes 
is  very  limited. 

Anatomical  Characters  and  Effects. — The 
only  essential  change  that  the  heart  is  found  to 
have  undergone  in  displacement  is  an  alteration 
of  its  relations  to  the  surrounding  parts.  The 
softer  parts  of  the  cardiac  wall,  however,  such 
as  the  auricles,  are  sometimes  compressed  to  a 
moderate  degree.  The  pericardium  is  partly 
dislocated  and  partly  stretched.  The  great  ves- 
sels at  the  base  of  the  heart  and  at  the  root  of 
the  neck  may  be  elongated,  shortened,  twisted, 
or  bent,  according  to  the  particular  form  of 
displacement ; and  the  circulation  within  them 
impeded  The  neighbouring  organs  are  variously 
displaced  and  compressed.  One  of  the  effects 
often  seen  after  displacement  is  permanent 
fixation  of  the  pericardium  and  heart  in  their 


591 

new  position,  for  example,  in  the  pleural  cavity, 
on  the  disappearance  of  the  original  cause. 

The  effects  of  displacement  of  the  heart  upon 
its  functions  differ  greatly  in  the  two  classe-  of 
dislocation  to  which  we  have  referred  : — 

In  displacement  duo  to  pressure,  the  heart  is 
compressed  between  the  displacing  force  and 
the  resistance  in  other  directions,  and  the  dis- 
location is  generally' rapid.  Fortunately,  in  most 
cases  of  such  displacement  the  resistance  is 
slight ; and  the  heart,  if  healthy,  suffers  little 
or  no  real  compression  of  its  substance  or  cavi- 
ties between  the  two  forces,  the  mobile  and 
compressible  lung  especially  yielding  before  it. 
But  if  the  heart  be  diseased — and  especially  if 
its  walls  be  weak,  degenerated,  or  dilated — 
moderate  compression  may  cause  embarrassment 
of  the  cardiac  action  and  even  fatal  paralysis  ; 
and  the  rapidity  or  even  suddenness  with  which 
displacement  generally  occurs  when  due  to  pres- 
sure— for  example,  in  pneumothorax,  is  another 
and  perhaps  the  principal  cause  of  this  embar- 
rassment. 

On  the  other  hand,  when  the  heart  is  drawn 
out  of  its  normal  situation  towards  a phthisical 
cavity,  or  towards  either  pleural  cavity  from 
which  an  inflammatory  effusion  is  being  absorbed, 
the  displacement  occurs,  not  because  there  is  want 
of  space,  but  because  there  is  excess  of  space 
within  the  thorax.  The  process  is  also  very 
gradual.  The  effects,  therefore,  upon  the  func- 
tional activity  of  the  heart  may  be  said  to  be 
few,  though  the  unusual  pulsation  may  be  a source 
of  inconvenience,  and  even  of  anxiety  to  the 
patient.  In  very  rare  cases,  the  heart  and  peri- 
cardium when  thus  displaced,  may  be  involved 
in  the  fibrotic  process  goiDg  on  in  the  lung  or 
pleura,  and  the  adhesions  thus  established  may 
ultimately  interfere  with  the  cardiac  action. 

Symptoms. — In  displacement  of  the  heart, 
special  symptoms  are  frequently  slight  or  alto- 
gether wanting;  or  they  are  inseparable  from 
the  symptoms  of  the  original  cause.  This  may 
be  said  to  be  almost  invariably  the  case  when 
the  displacement  is  due  to  gradual  traction,  as 
in  phthisis.  In  the  pressure  class  of  cases,  on 
the  contrary,  there  are  frequently  developed,  and 
that  rapidly  or  suddenly,  symptoms  due  to  com 
pression  of  the  heart,  such  as  a sense  of  dis- 
tress, stifling,  and  pain  over  the  prrecordium  or  at 
the  epigastrium,  or  even  true  angina  ; dyspnoea, 
perhaps  amounting  to  orthopncea;  palpitation; 
blueness  of  the  surface  ; and  irregularity  and 
feebleness  of  the  pulse.  When  the  displacement 
is  due  to  upward  pressure  from  gaseous  disten- 
sion of  the  stomach  and  intestines,  the  above 
symptoms  may  be  associated  with  flatulence  or 
‘ spasms,’  and  are  relieved  by  the  erect  posture, 
eructation,,  vomiting,  and  the  administration  of 
carminative  and  absorbent  remedies.  If  this 
condition  be  not  removed  within  a short,  time, 
it  may  become  aggravated,  pass  into  a state  of 
collapse,  and  end  in  death. 

Varieties  and  Physical  Sions.  — The  va 
rieties  of  cardiac  displacement,  according  to  the 
direction  in  which  the  dislocation  occurs,  may. 
for  clinical  purposes,  be  said  to  be  as  follows  : — 
towards  the  left,  towards  the  right,  downwards, 
upwo.rds,  backwards,  and  forwards.  It  must  be 
observed,  however,  that  this  is  only  a broad 


592  HEART,  DISPLACEMENTS  OF. 


general  classification,  and  that  the  heart  is  very 
rarely  displaced  in  an  absolutely  horizontal,  or 
in  an  absolutely  vertical  plane.  The  exact  direc- 
tion taken  in  each  variety  will  now  be  described, 
as  well  as  its  special  causes,  and  the  physical 
signs  by  which  it  may  be  recognised. 

1.  Displacement  towards  the  Left. — This, 
the  most  common  variety  of  marked  cardiac  dis- 
location, is  most  frequently  caused  by  contraction 
of  the  left  lung  from  any  of  the  conditions  already 
enumerated,  and  effusions  into  the  right  pleural 
cavity.  Right  pneumothorax,  and  tumours  con- 
nected with  the  right  side  of  the  chest,  with  the 
mediastinum,  or  with  the  right  lobe  of  the  liver, 
are  less  common  conditions  that  lead  to  the  same 
result.  The  distance  towards  the  left  to  which 
the  heart  is  dislocated  varies,  the  extreme  limit 
being  probably  the  vertical  axillary  line.  During 
its  progress  towards  the  left,  the  heart  is  rota- 
ted around  its  longitudinal  axis,  so  that  the 
right  ventricle  is  more  exposed  anteriorly ; and 
the  apex  is  moved,  at  first  somewhat  downwards, 
and  afterwards  upwards. 

The  visible  and  palpable  impulse  is  found  to 
the  left  of  its  normal  situation,  and  either  lower 
or  higher  than  it,  or  on  the  same  level  with  it, 
according  to  the  degree  of  displacement.  In 
some  cases  due  to  contraction  of  the  left  lung, 
the  impulse  may  be  found  in  any  one  or  in 
all  of  the  left  intercostal  spaces  from  the  base 
to  the  apex  of  the  heart,  and  of  different  rhythm 
in  the  different  spaces.  If  the  displaced  heart 
be  the  seat  of  valvular  disease,  thrill  may 
be  felt  in  an  unusual  situation,  for  example, 
in  the  left  axilla.  The  area  of  percussion- 
dnlness  is  altered  in  outline,  being  invaded  on  the 
Tight  side  either  by  the  dulness  due  to  effusion 
there,  or  by  resonance  due  to  pneumothorax  or  to 
encroachment  of  the  right  lung -border;  whilst  it 
is  either  transposed  towards  the  left  axilla,  or 
blended  with  unnatural  dulness  over  the  left 
lung.  The  cardiac  sounds  are  reduced  in  loudness 
over  the  normal  praecordium,  whilst  they  are  un- 
naturally loud  towards  the  left  axilla  and  up  the 
left  front.  Structural  murmurs  if  present  are 
similarly  transposed,  as  regards  the  seat  of  their 
greatest  intensity  and  the  lines  of  their  convexion. 
A systolic  murmur  may  be  developed  at  the 
base  of  the  heart  from  distortion  of  the  great 
vessels. 

2.  Displacement  towards  the  Eight.  — 
This  form  of  dislocation  of  the  heart  is  the  re- 
sult of  effusion  into  the  left  pleural  cavity ; of 
contracting  processes  connected  w'ith  the  right 
lung  or  pleura;  of  left  pneumothorax;  and  of 
tumours  of  the  left  side  of  the  chest  or  in  the 
mediastinum.  The  heart  may  be  displaced  to- 
wards the  right  side  until  the  impulse  is  found 
in  the  axillary  region.  During  its  lateral  move- 
ment, the  heart  is  rotated  on  its  longitudinal  axis 
in  such  a manner  that  the  left  ventricle  is  more 
exposed ; and,  at  the  same  time,  the  apex  is  first 
depressed  towards  the  epigastrium,  and  after- 
wards raised  towards  the  right  axilla,  as  the  dis- 
placement increases. 

The  physical  signs  correspond  closely  with 
those  enumerated  under  left  displacement — the 
two  sides  being,  of  course,  exactly  reversed.  The 
cardiac  impulse  is  most  frequently  transferred 
to  the  epigastrium  and  the  region  between  that 


and  the  right  nipple.  A new  area  of  pulsation  is 
sometimes  developed  in  the  second  and  third 
right  interspaces,  close  to  the  sternum,  and  indi- 
cates the  displaced  position  of  the  right  auricle, 
if  prsesystolic,  or  of  the  aorta,  if  systolic  and 
followed  by  palpable  shock  in  diastole.  The 
description  of  the  auscultatory  phenomena,  as 
regards  both  sounds  and  murmurs,  does  not  re- 
quire to  be  repeated. 

3.  Displacement  Downwards. — This  is  an 
exceedingly  common  form  of  cardiac  displace- 
ment, though  seldom  extreme  in  degree.  It  is 
the  constant  result  of  hypertrophous  emphysema 
of  the  lungs  ; and  may  also  be  caused  by  the 
downward  pressure  of  tumours  at  the  base  of 
the  heart,  such  as  aneurism,  and  by  collapse  of 
the  stomach  and  intestines.  Displacement  of  the 
heart  downwards  is  limited  by  the  diaphragm, 
and  by  the  attachment  of  the  pericardium  and 
great  vessels  at  the  root  of  the  heart.  At  the 
same  time  the  apex  may  either  move  somewhat 
towards  the  left  in  its  descent  if  the  downward 
pressure  be  uniform,  as  in  emphysema;  or  it 
may  ascend  somewhat  towards  the  left  if  the 
pressure  be  exerted  chiefly  upon  the  base. 

The  ordinary  cardiac  impulse  is  generally  quite 
imperceptible  in  this  form  of  displacement,  on 
account  of  enlargement  of  the  lungs ; or  it  is 
greatly  weakened,  and  situated  in  the  sixth 
left  space,  or  lower,  to  the  left  of  its  normal 
position.  A new  area  of  systolic  pulsation  is 
perceptible  in  the  epigastrium,  generally  well 
marked,  and  connected  with  the  right  ventricle. 
The  praecordial  dulness  is  usually  completely 
replaced  by  pulmonary  resonance ; or,  more 
rarely,  confused  by  the  dulness  of  some  form  of 
mediastinal  tumour.  The  cardiac  sounds  are 
feeble,  or  absent,  over  their  usual  seat ; and  are 
heard,  instead,  over  the  epigastric  triangle  and 
the  lower  left  cartilages. 

4.  Displacement  Upwards.— The  many  ab- 
dominal causes  of  this  form  have  been  already 
mentioned,  as  well  as  the  symptoms  due  to 
compression  of  the  heart  which  characterise  it 
when  so  produced.  The  heart,  as  a whole,  is 
moved  upwards  in  the  chest,  and  at  the  same 
time  the  apex  passes  more  or  less  towards  the 
left,  and  the  right  ventricle  may  become  some- 
what more  exposed  anteriorly. 

The  cardiac  impulse  is  elevated  until  it  is 
found  on  the  nipple-level,  or  even  higher;  or  it 
is  lost,  along  with  the  area  of  percussion-dul- 
ness,  behind  the  inferior  border  of  the  left  lung. 
The  sounds  of  the  heart  are  transposed  upwards 
and  weakened.  The  displacement  of  the  cardiac 
apex  towards  the  left  axilla  in  pericardial  effu- 
sion is  described  elsewhere,  < See  Peeicabdioi, 

Diseases  of. 

o.  Displacement  Backwards. — This  variety 
of  displacement  of  the  heart  is  very  uncommon ; 
and  when  it  does  occur,  is  generally  referable 
either  to  abundant  pericardial  effusion,  or  to 
backward  curvature  of  the  spine  (kyphosis)  in 
the  dorsal  region.  A certain  amount  of  back- 
ward displacement  is,  however,  not  so  rare  in 
extensive  excavation  of  the  left  lung,  in  associa- 
tion with  other  forms  of  dislocation.  The  base 
of  the  heart  is  then  the  part  most  transposed 
into  the  left  paraspioal  groove,  and  the  apex  is 
tilted  somewhat  forwards  as  well  as  elevated. 


HEART,  DISPLACEMENTS  OF;  AND  FATTY  DEGENERATION  OF.  693 


The  physical  signs  of  back-ward  displacement 
are  those  of  the  cause  of  the  malposition  rather 
than  any  that  can  be  referred  to  the  condition 
itself. 

6.  Displacement  Forwards. — Displacement 
forwards  is  also  very  rare,  although  it  is  fre- 
quently simulated  by  bulging  of  the  prsecordium 
in  enlargement  of  the  heart.  The  chief  cause  of 
it  is  the  presence  of  a tumour  in  the  medias- 
tinum— especially  aneurism  of  the  descending 
aorta,  or  enlargement  of  the  bronchial  glands. 
The  amount  of  actual  transposition  is  neces- 
sarily exceedingly  small,  the  anterior  border  of 
the  lungs  being  compressed  or  pushed  aside,  but 
the  further  progress  of  the  heart  forwards  being 
arrested  by  the  anterior  wall  of  the  chest. 

The  physical  signs  are,  therefore— increase  of 
the  area  and  strength  of  pulsation  and  of  per- 
cussion-dulness  over  the  prsecordium ; bulging  of 
the  same  in  young  subjects ; and  increased  loud- 
ness of  the  cardiac  sounds  in  that  situation. 

7.  Complex  Displacements. — Ithas  already 
been  indicated  that  displacements  of  the  heart, 
strictly  speaking,  occur  almost  without  excep- 
tion m more  than  one  of  the  directions  described, - 
and  they  may  all,  therefore,  be  said  to  be  gene- 
rally more  or  less  complex.  Dislocation  at  once 
upwards  and  towards  either  side  is  especially 
common,  as  the  result  of  contracting  processes 
in  the  apex  of  the  lung. 

Diagnosis. — After  the  full  account  that  has 
been  given  of  the  several  forms  of  displacement 
of  the  heart,  there  ought  to  be  no  great  difficulty 
in  diagnosing  them  from  each  other,  as  well  as 
from  the  conditions  which  simulate  them.  These 
must  be  carefully  remembered.  The  chief  of 
these  are:  — (1)  physiological  displacements, 
already  referred  to ; (2)  cardiac  enlargement, 
especially  when  attended  with  bulging  of  the 
prsecordium  ; (3)  pulsating  tumours  of  the  chest 
and  abdomen,  particularly  aneurism  of  the 
aorta  ; (1)  adhesion  of  the  pericardium ; and  (5) 
atrophy  of  the  lungs  from  any  cause. 

Treatment.- — The  rational  treatment  of  dis- 
placement of  the  heart  would  he  to  remove  its 
cause ; but  when  the  cause  is  of  the  nature  of 
traction,  treatment  is  very  rarely  called  for,  even 
if  it  were  possible.  In  displacement  due  to  pres- 
sure, on  the  contrary,  treatment  is  often  urgently 
indicated,  perfectly  practicable,  and  highly  suc- 
cessful. The  unpleasant  sensation  of  pulsation 
complained  of  in  some  instances  of  displace- 
ment— for  example,  in  phthisis — is  frequently 
relieved  by  an  assurance  on  the  part  of  the  physi- 
cian that  the  palpitation  is  of  no  import ; and  by 
the  application  of  a simple  plaster,  containing  iron, 
belladonna,  or  opium.  J.  Mitciieix  Bruce. 

HEART,  Embolism  of.  Sec  Heart, Throm- 
bosis of. 

HEART,  Fatty  Degeneration  of. — Stnon.  ; 
Fr .Degenercscencegraisseiiscd.it  Cceur ; Grev.Fettige 
Metamorphose  des  Herzens. 

Definition. — The  process  by  which  the  mus- 
cular fibres  of  the  heart  are  converted  into  a gra- 
nular fatty  matter.  The  term  is  also  used  to 
express  the  state  of  the  heart  in  which  this 
chango  has  been  accomplished. 

-Etiology  and  Pathology. — The  process  by 
which  the  protein  elements  of  animal  bodies,  in- 

38 


eluding  muscular  fibre,  are  converted  into  gra 
nular  fatty  matter,  as  well  as  the  circumstances 
under  which  this  change  occurs,  have  been  al- 
ready so  fully  discussed  under  the  head  of  Fatty 
Degeneration,  that  it  is  unnecessary  to  repeat 
what  will  be  found  there.  It  will  suffice  to  sav 
here,  that  when  the  process  of  nutrition  is  inter- 
fered with  in  the  tissue  of  the  heart,  this  change 
takes  place,  and  is  best  illustrated  in  the  local  ot 
limited  form  of  disease,  which  occurs  when  the 
coronary  circulation  is  obstructed.  This  is  seen 
in  cases  of  thickening  or  calcification  of  one  of  the 
trunks,  or  of  the  branches  of  these  vessels,  and 
is  more  marked  by  reason  of  the  fact  that  the 
coronary  arteries  do  not  freely  communicate 
with  each  other.  The  fatty  change  is  found  to 
occur  in  the  more  diffused  or  general  form  in 
those  diseases  in  which  the  vital  powers  are 
lowered,  as  in  certain  forms  of  chronic  eaclieotie 
disease,  in  poisoning  by  phosphorus,  or  after 
loss  of  blood.  In  certain  other  conditions,  such 
as  acute  specific  fevers,  the  tissue  of  the  heart 
becomes  softened,  and  under  the  microscope 
presents  a granular  appearance,  which  is  be- 
lieved by  some  pathologists  to  be  an  incipient 
stage  of  fatty  degeneration.  We  might  also  refer 
to  the  more  or  less  diffused  form  of  fatty  de- 
generation which  takes  place  in  cases  of  enlarged 
heart,  the  result,  not,  as  Rokitansky  supposed, 
of  a disturbance  of  the  nervous  functions,  but  of 
the  fact  that  these  enlarged  hearts  require  a 
larger  supply  of  the  materials  for  nutrition  than 
can  be  furnished  to  them  by  the  coronary  arte- 
ries, which  in  such  cases  are  frequently  them- 
selves diseased,  both  at  their  origin  and  in 
their  course.  Lastly,  fatty  degeneration  of  the 
heart  is  found  to  occur  after  delivery  in  some 
instances,  in  which  the  organ  had  become  en- 
larged during  pregnancy. 

Certain  other  circumstances  connected  with  the 
origin  of  the  disease  require  to  be  mentioned 
here.  In  reference  to  sex,  the  disease  is  more 
frequent  in  males,  in  the  proportion  of  nearh- 
two  to  one.  With  respect  to  age,  in  his  original 
memoir  on  this  subject,  the  writer  found  that 
nearly  one-half  of  all  the  cases  observed  were 
over  sixty  years  of  age.  In  the  late  Dr.  Hayden's 
valuable  work  on  Diseases  of  the  Heart,  the  pro- 
portion stated  of  cases  under  sixty  years  of  age 
shows  a larger  number  of  young  persons  whose 
hearts  have  undergone  this  change  as  a result  of 
wasting  disease — a result  which  is  evidently  due 
to  the  greater  care  with  which  microscopical 
examinations  of  the  heart  have  been  made  in 
recent  times.  As  regards  social  position,  of 
thirty-three  cases  formerly  noted  by  the  writer, 
the  subjects  of  the  disease  are  stated  to  have 
belonged  to  the  higher  ranks  in  nine  cases ; to 
the  middle  class  in  eight  cases;  and  to  the  lower 
class  in  sixteen  cases.  This  enumeration  con- 
trasts with  the  proportion  in  which  fatty  growth 
appears  on  the  heart ; seven  of  fifteen  cases 
belonging  to  the  first  class ; six  to  the  second  ; 
and  only  two  to  the  third.  Fatty  degeneration 
and  fatty  growth  on  the  heart  are  thus  seen  to 
occur  under  very  different  conditions.  Tho  lat- 
ter is  the  result  of  the  accumulation  in  the  blood 
of  the  elements  of  fat;  the  former  is  the  result 
of  decay  and  disintegration. 

Anatomical  Characters. — In  fatty  degenera- 


HEART,  FATTY  DEGENERATION  OF. 


594 

iion  the  heart  is  found  to  be  enlarged  in  about 
two-thirds  of  the  cases  recorded  both  by  Dr. 
tlayden  and  the  present  writer.  It  is  not  imfre- 
■puently  simply  dilated.  To  find  a fat  heart  of  an 
average  size,  or  even  occasionally  below  it,  is 
not  a very  exceptional  occurrence.  The  colour 
of  the  heart’s  substance  is  pale,  sometimes  as 
pale  as  ‘ a dead  leaf,’  but  more  generally  it  is 
of  a yellowish- brown  or  buff,  or  muddy  pink 
colour.  This  discolouration  is  generally  seen  in 
spots  or  patches ; and  though  the  whole  heart 
may  be  pale,  the  spots  being  still  paler  when 
seen  beneath  the  endocardium,  give  the  tissue 
a mottled  look.  The  same  appearance  may  be 
seen  beneath  the  pericardium,  and  in  the  sub- 
stance of  the  heart.  With  the  progress  of 
disease  the  spots  run  together,  giving  portions 
of  the  walls  a uniform  buff-coloured  character, 
whilst  the  rest  of  the  organ  retains  its  ordinary 
aspect.  The  consistence  also  varies  from  that 
of  mere  flabbiness  or  softness,  to  such  a condi- 
tion as  permits  of  the  tissue  being  torn  like 
wet  brown  paper.  The  organ  then  feels  like  a 
piece  of  wet  chamois  leather,  or  a wet  glove.  In 
other  CHses  the  heart  retains  in  appearance 
much  of  its  ordinary  solidity,  but  the  tissue 
nreaks  down  on  pressure,  as  does  a lung  con- 
solidated by  pneumonia.  This  is  a state  which 
more  frequently  occurs  in  hypertrophied  hearts. 
In  addition  to  these  changes  in  size,  colour,  and 
consistence,  others  have  to  be  noted.  The  fibrous 
character  of  the  heart’s  structure,  even  to  the 
naked  eye,  disappears  ; in  some  cases  the  tissue 
resembles  that  of  a fatty  or  boiled  liver.  In 
other  instances  the  cut  or  torn  surface  has  a 
granular  appearance,  notunlike  that  of  the  lung 
m an  early  stage  of  grey  hepatization.  These 
different  appearances  may  in  a great  measure  he 
duo  to  the  greater  or  less  fluidity  of  the  oily  mat- 
ter present,  as  well  as  to  the  extent  and  degree 
to  which  the  disease  has  advanced.  Further 
varieties  in  appearance  may  he  caused  by  the 
presence  of  a greater  or  less  quantity  of  blood, 
or  of  its  colouring  matter,  in  the  heart’s  texture  or 
in  its  cavities,  by  which  the  lining  membrane  may 
in  the  latter  case  he  dyed  of  a deep  purple  colour. 

Microscopical  characters. — The  microscopical 
characters  of  this  disease  will  be  found  so  fully 
described  under  the  head  Fatty  Degeneration, 
that  it  is  needless  here  to  do  more  than  refer 
me  reader  to  that  article. 


All  parts  of  the  heart’s  fibres  are  subject  to 
fatty  degeneration,  but  not  equally  so.  It  is  most 
frequently  found  in  the  left  ventricle ; next  in 
the  right  ventricle;  then  in  the  right  auricle; 
and  least  frequently  in  the  left  auricle.  It  is 
generally  more  evident  in  the  column®  carnc®, 
and  in  the  inner  layers  of  the  muscular  walls, 
than  elsewhere. 

Effects. — Of  the  structural  lesions  occurring 
in  the  heart  when  the  seat  of  fatty  change,  one  of 
the  most  important  is  rupture,  which  was  found 
in  twenty-five  out  of  sixty-eight  cases  of  fatty  or 
softened  heart,  the  histories  of  which  were  col- 
lected by  the  writer.  Partial  rupture  leading  to 
the  formation  of  what  has  been  called  cardiac 
apoplexy,  is  another  condition  which  has  been 
described.  The  clot  in  such  cases,  if  it  lose  its 
colour,  may  produce  an  appearance  like  an  en- 
cysted abscess  ; and  a consecutive  false  aneurism 
of  the  walls  of  the  heart  may  be  thus  formed,  as 
well  as  by  simple  yielding  of  a portion  of  the 
6cftened  cardiac  wall.  Tho  involvement  of  the 
column®  carne®  may  lead  to  imperfect  action  of 
the  valves.  Valvular  disease  itself  is  not  often 
present  in  connection  with  fatty  heart.  Dr. 
Henry  Kennedy,  in  a recent  interesting  work 
on  this  subject,  points  out  that  the  valves  are 
affected  only  about  once  in  nine  cases ; and  he 
further  shows  that,  when  the  valves  are  affected, 
it  is  chiefly  the  aortic  valves  that  are  involved. 

Of  the  effects  of  fatty  degeneration  upon  the 
functions  of  the  heart,  the  most  prominent  are 
those  which  exhibit  the  deficient  powers  of  the 
organ.  Coma,  preceded  or  not  by  giddiness,  has 
been  described  by  several  winters  in  connection 
with  feeble  powers  of  the  circulation.  Dr.  Adams 
of  Dublin  has  mentioned  as  many  as  twenty 
attacks  in  one  of  his  cases  of  fat  heart ; and  the 
writer  has  noticed  the  occurrence  of  evenmore  fre- 
quent seizures.  Syncope — ‘cardiac  syncope’— is 
a term  very  frequently  used  by  the  older  writers ; 
and  it  is  a term  which  may  be  well  applied  to 
the  condition  of  faintness  which  is  frequently 
found  in  connection  with  fatty  heart.  In  some 
cases  the  feeling  of  syncope  amounts  to  nothing 
more  than  a simple  sense  of  faintness — that  the 
patient  must  fall  if  ho  do  not  lay  hold  of  some- 
thing. In  other  instances  this  symptom  is 
accompanied  by  a feeling  of  impending  death; 
and  such  patients  do  frequently  die.  In  the 
cases  collected  by  the  writer,  thirteen  out  of 
thirty-three  died  of  what  he  proposed  to  call 
syncope  Icthalis,  or  ‘ fatal  syucope ; ’ and  it 
would  be  possible,  no  doubt,  now  greatly  to  extend 
the  number  of  eases  that  have  proved  fatal  in 
this  way.  Death  may  result  in  such  cases  from 
cardiac  failure,  as  indicated  by  a flabby  heart 
containing  blood  in  tho  left  ventricle;  or,  where 
there  is  a less  amount  of  degeneration,  by 
irregular  action  or  spasm,  with  emptiness  of  the 
ventricles. 

Pain  is  another  effect.  It  may  occur  inde- 
pendently of,  or  he  associated  with  syncope — 
syncope  anginosa.  See  Angina  Pectoris. 

The  respiration  is  considerably  affected,  m 
all  cases  of  fatty  degeneration,  either  as  simple 
breathlessness,  especially  on  exertion,  or  in  that 
peculiar  form  which  has  been  called  Cheyn* 
Stokes  respiration. 

Symptoms  and  Diagnosis. — There  is  no  doubt 


Jits.  ££.  Fatty  Degeneration  of  the  Heart,  x 400  diam. 


HEART,  FATTY  DEGENERATION  OF. 


that  many  cases  occur  in  which  fatty  degenera- 
tion is  found  in  the  heart  after  death,  where  its 
presence  during  life  had  not  been  suspected. 
This  is  more  especially  the  case  in  those  examples 
of  exhausting  disease  in  which  the  heart  parti- 
cipates. In  such  cases  the  requirements  of  the 
system  may  not  be  out  of  proportion  to  the 
powers  of  the  heart;  and  death  may  come  on 
slowly  and  insidiously  without,  our  attention 
being  attracted  to  the  state  of  this  organ.  In  a 
second  class  of  cases,  in  which  the  heart  suffers 
from  some  local  cause,  as,  for  example,  from 
disease  of  the  coronary  arteries,  whilst  the  sys- 
tem generally  maintains  its  powers  more  or  less 
fully,  the  balance  between  the  system  and  the 
heart  is  lost,  and  diagnostic  evidence  of  the 
change  that  has  occurred  in  the  central  organ, 
sufficiently  clear  and  pointed,  may  be  traced 
without  difficulty.  Amongst  the  symptoms  of 
the  disease  we  then  observe  various  modifica- 
tions of  the  phenomena  of  drowsiness  and  coma ; 
faintness  and  syncope;  disordered  respiration; 
pain  in  the  region  of  the  heart ; and  disturbed 
pulsation.  For  example,  the  patient  complains 
in  the  earlier  stages  of  being  easily  exhausted, 
particxdarly  by  mounting  heights;  he  feels,  he 
says,  faint  on  reaching  the  top  of  the  stairs; 
though  not  giddy,  he  feels  ho  must  fall ; though 
not  breathless  or  fainting,  lie  sighs  deeply  and 
seeks  the  air.  Any  unusual  excitement,  a heated 
jr  a close  atmosphere,  produces  the  like  effects. 
At  the  same  time  there  is  often  experienced  an 
uncomfortable  feeling  of  choking  or  fulness  in 
.he  chest.  In  the  intervals  the  individual  may 
bo  fairly  well. 

As  the  disease  advances,  the  attacks  become 
more  frequent  and  severe,  and  often  disturb 
and  distress  the  patient  at  night.  The  temper 
is  observed  to  become  irritable.  The  expression 
of  the  features  frequently  appears  anxious,  and 
the  countenance  sallow.  Copious  perspiration 
from  very  slight  causes,  sometimes  coldness  of 
the  extremities  and  swelling  of  the  ankles, 
appear  amongst  the  incidents  of  the  disease. 
The  pulse  is  generally  affected  ; but  how  must 
no  doubt  depend  in  a great  measure  upon  the 
part  of  the  heart  affected,  and  on  the  extent  and 
degree  of  the  disease.  In  the  writer's  opinion, 
iutermittenee  and  irregularity  are  the  more 
frequent  alterations ; weakness  is  another ; and 
slowness — often  remarkable — is  a third.  Quick- 
ness of  the  pulse,  more  especially  when  it  in- 
creases with  age,  has  been  dwelt  upon  by  Dr. 
Kennedy  as  a symptom  deserving  of  attention 
in  the  diagnosis  of  fatty  degeneration.  The 
irregularity  may  be  constant.  The  writer  has 
seen  it  present  during  the  slight  disturbances 
above  described ; and  he  has  seen  it  disappear 
altogether  when  the  patient  was  in  tolerable 
health,  to  return  as  the  effect  of  any  depress- 
ing cause,  the  more  marked  because  that  cause 
may  be  far  too  inefficient  to  affect  a sound  heart. 

The  breathing  is  always  more  or  less  affected  in 
cases  of  fatty  degeneration  of  the  heart.  In  some 
instances  it  is  represented  as  a sense  of  choking 
or  suffocation ; the  person  feels  as  if  he  were 
breathing  through  a sponge.  The  difficulty  in 
some  instances  is  so  slight  as  scarcely  to  be  re- 
garded; in  others  so  severe  that  the  smallest 
effort,  particularly  in  mounting  ascents,  is  most 


595 

painful.  A peculiarity  sometimes  observed  is 
that  the  ascent  of  a gentle  height  is  distressing, 
while  the  person  can  read  aloucl  without  incon- 
venience. A character  of  the  respiration  first 
described  by  Dr.  Cheyne  of  Dublin,  and  after- 
wards by  Dr.  Stokes,  is  by  some  regarded  as 
diagnostic  of  fatty  degeneration  of  the  heart. 
It  is  thus  described  by  Dr.  Stokes : ‘ A form  cf 
respiratory  distress  peculiar  to  this  affection 
(fatty  degeneration  of  the  heart),  consisting  of 
a period  of  apparently  perfect  apnoea,  succeeded 
by  feeble  and  short  inspirations,  which  gradually 
increase  in  strength  and  depth  until  the  respi- 
ratory act  is  carried  to  the  highest  pitch  of 
which  it  seems  capable,  when  the  respirations, 
pursuing  a descending  scale,  regularly  diminish 
until  the  commencement  of  another  apnceal 
period.  Dr.  Hayden,  in  writing  on  this  sub- 
ject, mentions  a case  in  which  during  the  period 
of  apnoea  there  was  no  change  in  the  heart’s 
action ; a second  case  in  which  the  action  of  the 
heart  and  the  pulse  underwent  no  change  during 
the  period  of  apnoea  and  dyspnoea  ; whilst  in  a 
third  case,  during  the  paroxysm  of  dyspnoea, 
the  heart’s  action  was  remarkably  irregular. 
It  should  be  stated  with  regard  to  this  symp- 
tom that,  though  frequently  present,  it  is  by  no 
means  characteristic  of  fatty  degeneration  only. 
It  is  by  some  said  to  be  more  frequently  asso- 
ciated with  disease  of  the  aorta.  Various  ex- 
planations of  this  phenomenon  have  been  given. 
Dr.  Little  (Dublin  Journal  of  Med.  Sci.,  No.  91) 
believes  that  it  is  due  to  derangement  of  the 
dynamic  adjustment  between  the  right  and  left 
ventricles  of  the  heart.  Dr.  Hayden  (op.  cit.) 
connects  it  with  atheromatous  or  calcareous 
change  with  dilatation  of  the  arch  of  the  aorta, 
involving  loss  of  elasticity  in  its  walls.  The  late 
Professor  Laycoek  thought  (Dublin  Journal  of 
Med.  Sci.,  July  1873)  that  this  phenomenon  de- 
pended upon  ‘ sentient  palsy  of  the  respiratory 
centre,’  or  ‘ a paresis  of  reflex  sensibility  of  the 
mucous  membrane  of  the  lung.’  See  Respira- 
tion, Disorders  of. 

Another  phenomenon,  said  to  be  diagnostic  of 
fatty  degeneration  of  the  heart,  is  arcus  senilis — 
a pearly  crescentic  opacity  of  the  upper  and  lower 
portions  of  the  circumference  of  the  cornea,  which 
must  be  distinguished  from  the  opaque  annulus 
which  occasionally  surrounds  the  entire  cornea. 
Mr.  Canton  was  the  first  to  describe  the  nature  of 
this  change  as  fatty  degeneration.  It  is  quite 
true  that  when  fatty  degeneration  is  present  in 
the  cornea  it  may  possibly  bo  found  in  the 
muscular  fibres  of  the  heart  and  in  the  arteries. 
Still  it  by  no  means  follows  that  the  degeneration 
must  exist  in  any  particular  part  or  organ  ; and 
therefore  this  appearance  in  the  cornea  cannot 
be  regarded  as  at  all  pathognomonic  of  fatty 
degeneration  of  the  heart. 

As  the  disease  progresses  still  farther,  the 
symptoms  become  more  marked ; the  various 
effects  of  feeble  and  languid  circulation  show 
themselves;  angina  may  perhaps  become  fully 
developed ; or  the  patient  may  be  cut  off  suddenly 
by  one  or  other  of  the  effects  connected  either 
immediately  or  remotely  with  the  lesion  itself. 
Of  eighty-three  cases  of  ‘ fatty  disease  ’ of  the 
heart  collected  by  the  writer,  sixty-eight  died 
suddenly. 


SO 6 HEART,  FATTY  DEGENERATION 

Physical  Signs.  — The  physical  signs  that 
characterise  fatty  disease  are  not  many.  They 
are — a feeble  impulse  of  the  heart,  proportionate 
to  the  extent  and  the  degree  of  the  disease ; a 
feeble  muffled  first  sound,  under  like  conditions, 
sometimes  scarcely  audible.  When  the  heart 
is  enlarged,  the  impulse  ■will  be  extended,  and  so 
likewise  will  be  the  dulness.  A murmur  may 
be  present,  as  suggested  by  Rokitansky,  from  de- 
generation of  the  column®  carnese.  The  second 
sound  is  often  distinct  and  clearly  accentuated, 
as  compared  with  the  first. 

Diagnosis. — The  diagnosis  of  the  presence  of 
this  degenerative  change  in  the  absence  of  any 
alteration  in  the  size  of  the  heart  must  be 
founded  upon  a consideration  of  the  symptoms 
and  physical  signs  above  described.  When  the 
heart  is  hypertrophied  or  dilated  only,  the  pre- 
sence of  fatty  degeneration  is  more  difficult  of 
diagnosis  by  its  physical  signs.  We  must  then 
seek  to  trace  how  far  the  usually  well-marked 
signs  of  hypertrophy  of  the  organ  are  modified 
by  those  wo  have  described  as  being  present  in, 
and  characteristic  of,  fatty  degeneration.  The 
same  observations  will  apply  to  dilatation  or 
thinning  of  the  walls.  This  special  condition  has 
its  own  well-marked  phenomena,  which  will  be 
found  described  elsewhere  {sec  Heart,  Dila- 
tation of).  These  signs  will  be  more  or  less 
modified  in  proportion  to  the  degree  and  extent 
of  any  fatty  change  that  may  be  present. 

Progress,  Duration,  and  Terminations. — 
It  is  impossible  to  determine  the  duration  of  a 
disease  the  date  of  origin  of  which  is  in  most 
cases  very  obscure.  Still  there  are  grounds  for 
believing  that  persons  with  a certain  amount  of 
degenerated  tissues  in  their  hearts  have  gone  on 
living  during  periods  extending  over  thirty  or 
forty  years.  On  the  other  hand,  death  has  oc- 
curred from  fatty  degeneration  of  the  heart,  deter- 
mined -post  mortem,  in  which  the  entire  absence 
of  symptoms  until  a few  months  before  the  fatal 
event  justified  the  opinion  that  the  duration  of 
the  disease  had  not  much  exceeded  the  period 
just  mentioned.  AVhen  fatty  degeneration  occurs 
as  the  result  of  phosphorus-poisoning,  or  of 
certain  exhausting  diseases,  the  progress  of  the 
change,  which  can  be  determined,  is  rapid.  In 
such  cases,  the  morbid  process  is  not  confined  to 
the  heart  alone,  and  therefore  when  death  occurs, 
it  cannot  well  be  attributed  solely  to  the  condi- 
tion of  this  organ. 

Death  from  fatty  disease  of  the  heart  is  fre- 
quently sudden,  the  proportion  being  as  five  to 
one  compared  with  other  modes  of  death,  this 
disease  existing  to  a noticeable  extent.  The 
immediate  causes  of  death  are  those  which 
have  been  already  alluded  to  when  treating  of 
the  effects  of  the  disease,  namely,  syncope,  coma, 
and  rupture  of  the  heart;  the  first  and  last  of 
these  contributing  nearly  the  whole  number  of 
those  that  die  suddenly.  Such  facts  indicate 
very  strongly  the  necessity  of  avoiding  any 
mental  excitement  or  physical  exertion  which 
might  lead  to  these  results.  Here  it  might  also 
be  well  to  remember,  with  reference  to  the  ad- 
ministration of  anaesthethics,  that  chloroform  has 
an  especially  depressing  effect  on  the  heart's  action, 
and  that  when  the  heart’s  power  is  enfeebled  by 
the  disease  which  we  are  here  describing,  a very 


OF;  AND  FATTY  GROWTH  ON. 

small  dose  of  this  anaesthetic,  which  would  have 
little  or  no  effect  on  a healthy  heart,  may  prove 
fatal.  This  opinion  was  first  expressed  by  the 
writer  many  years  ago,  and  it  has  been  fully  con- 
firmed by  numerous  cases  of  death  which  have  oc- 
curred during  the  administration  of  chloroform. 

Prognosis  and  Treatment. — The  prognosis 
of  fatty  degeneration  of  the  heart  will  depend 
in  a great  measure  upon  a knowledge  of  its  causi 
and  its  extent.  In  cases  where  the  disease  origi 
nates  in  constitutional  causes,  such  as  in  phos- 
phorus-poisoning, and  in  cases  where  it  is  of  the 
nature  of  involution — for  example,  after  parturi- 
tion— there  is  good  ground  for  believing  that,  tLe 
cause  being  removed,  the  effect  will  cease,  and  a 
fairly  healthy  condition  of  the  organ  be  restored. 
On  the  other  hand  when  the  coronary  arteries 
are  obstructed,  and  degeneration  is  thereby 
set  up,  or  when  nutrition  generally  is  impaired, 
and  all  the  tissues  are  more  or  less  undergoing  this 
change,  the  prognosis  must  be  in  the  highest 
degree  unfavourable,  more  especially  so  if  in  the 
latter  case  the  patient  cannot  be  placed  in  a 
condition  by  which  this  degenerative  tendency 
may  be  counteracted.  The  treatment  consists 
in  the  adoption  of  all  the  measures  calculated  to 
improve  the  general  health — such  as  pure  fresh 
air,  wholesome  food,  and  temperance,  together 
with  moderate  exercise,  either  carriage,  riding, 
or  walking,  if  it  can  be  accomplished  without 
causing  pain  or  breathlessness.  Everything 
which  may  tend  to  lay  stress  on  the  heart’s 
action,  such  3S  walking  uphill  or  making  efforts, 
or  mental  excitement,  should  be  avoided.  With 
reference  to  drugs,  such  tonics  as  can  be  best 
tolerated  by  the  patient  might  be  given.  We 
may  mention  iron — especially  dialysed  iron — ■ 
phosphorus  in  small  doses,  and  strychnia. 
Special  attention  must  be  paid  to  the  condition  of 
the  excretory  organs,  such  as  the  kidneys  and 
liver,  which  are  liable  to  become  congested  when 
the  cardiac  action  is  feeble.  Lastly,  it  may  he 
said  that  in  cases  of  syncope,  in  addition  to  the 
administration  of  the  usual  stimulants,  galva- 
nism applied  from  the  back  of  the  neck  to  the 
prsecordium  by  the  interrupted  current,  has  in  a 
few  instances  been  known  by  the  writer  to  be 
useful.  For  further  information  on  the  subject 
of  Fatty  Degeneration  of  the  Heart  the  reader 
may  consult  the  complete  and  very  valuable 
article  by  Dr.  Hayden  in  his  work  on  Diseases 
of  the  Heart;  and  a memoir  by  the  writer 
in  the  3Srd  volume  of  the  Mcdico-Chimrgicul 
Transactions  (1850).  R.  Quain,  M.D. 

HEART,  Fatty  Growth  on. — Synon.  : Fr. 
Hypertrophic  graisscusc  du  Coeur\  Ger.  Fettioe 
Infiltration  des  Herzens. 

Definition. — The  growth  of  fat  on  the  surface 
and  in  the  substance  of  the  heart,  in  quantity 
sufficient,  to  interfere  with  its  functions,  and 
thus  to  constitute  a disease. 

FEtiology. — In  our  inquiries  concerning  the 
cause  of  this  condition,  we  are  met  with  the 
problem,  still  to  be  solved,  Why  are  certain 
individuals,  and  certain  parts  of  the  body,  more 
prone  to  the  formation  of  fat  than  other  persons 
and  other  parts  ? We  can  ascertain  with  some 
degree  of  certainty  the  circumstances  which  pr<* 
mote  the  formation  of  fat  in  general ; and obsei- 


HEART,  FATTY  GROWTH  OH.  597 


rations  collected  by  the  writer  and  others  show 
that  when  fat  is  thus  formed  throughout  the 
system,  the  heart  is  likely  to  partake  largely  of 
the  accumulation.  We  may  accordingly  refer 
to  the  article  Obesity,  in  which  the  causes  of 
fatty  growth  in  general  will  be  found  discussed. 

Of  fifteen  cases  of  extreme  fatty  growth  on  the 
heart  collected  by  the  writer,  eleven  occurred  in 
very  fat  individuals,  and  only  one  in  a person 
who  was  described  as  being  ‘ thin.’  Age  seems  to 
exert  a decided  influence  upon  the  formation  of 
fat  upon  the  heart.  It  is  very  scanty  in  infancy, 
and  is  rarely  present  in  any  quantity  before  the 
thirtieth  year.  Corvisart,  however,  quotes  from 
Hercking  the  case  of  a child  whose  heart  seemed 
wanting,  so  great  was  the  quantity  of  fat  in 
which  it  was  embedded.  Of  the  fifteen  cases 
just  referred  to,  thirteen  were  above  fifty  years, 
and  one  only  under  that  age.  Males,  according 
to  the  same  data,  are  more  liable  to  accumula- 
tion of  fat  on  the  heart  than  females,  the  re- 
spective numbers  being  as  twelve  to  three. 

Anatomical  and  Pathological  Characters. 
A certain  amount  of  fat-tissue,  which  is  not 
inconsistent  with  health,  occupies  a definite 
position  in  the  structure  of  the  heart.  It  is 
seen  most  abundantly  in  the  groove  between  the 
auricles  and  the  ventricles;  and  as  the  distribu- 
tion of  this  tissue  bears  a relation  here,  as  in 
other  parts,  to  that  of  the  blood-vessels,  it  first 
appears  in  the  course  of  the  primary  branches  of 
the  coronary  arteries;  then  in  the  course  of  the 
secondary  branches — that  is,  in  the  groove  over 
the  septum,  which  marks  the  boundary  between 
the  ventricles;  and,  lastly,  it  follows  the  distri- 
bution of  the  small  lateral  branches.  These 
branches  are  more  superficial  over  the  right  ven- 
tricle than  over  the  left ; hence  the  former  is 
found  always  and  more  abundantly  covered  with 
fat.  A fringe  of  fat  is  also  found  at  the  apex  of 
the  heart ; and  frequently  around  the  margins 
of  the  auricles.  A mass  of  superabundant  fat 
will  of  itself  be  sufficient  to  press  on  and  em- 
barrass the  action  of  the  heart ; but  fat  rarely 
exists  in  this  abundance  on  the  surface  of  the 
organ  without  insinuating  itself  between,  and 
encroaching  on,  the  muscular  fibres.  In  this 
way  the  muscular  portions  of  the  walls  of  the 
organ  become  thinner  and  thinner,  until  the 
columnae  carneie  may  appear  to  arise  from  a 
mass  of  fat.  This  state  constitutes  what  was 
once  regarded  as  fatty  degeneration  of  the  heart, 
and  which  has  also  been  called  ‘fatty  metamor- 
phosis;’ but  it  is  in  many  cases  nothing  more  in 
reality  than  a simple  hypertrophy  of  fat.  In  parts 
of  hearts  which  are  less  affected,  that  is,  where  fat 
is  not  very  abundant,  simple  striae  of  yellow  tis- 
sue will  be  observed  lying  amongst  the  mus- 
cular fibres — an  appearance  often  found  in  the 
auricles. 

Microscopical  appearances. — 'When  a portion 
of  heart  suffering  from  fatty  growth  in  a high 
degree  is  examined  with  the  microscope,  it  will 
be  found  that  where  the  growth  is  most  ad- 
vanced, that  is,  towards  the  external  surface, 
very  few  muscular  fibres  can  be  seen,  and  that 
the  very  wide  intervals  between  them  are  occu- 
pied by  fat-cells.  (See  Fig.  23.)  Proceeding  in- 
wards, themuscular  fibres  become  more  evident; 
the  fat-cells  become  fewer ; and,  finally,  we  reach 


the  muscular  fibres  beneath  the  endocardium, 
with  a few  fat-cells  lying  here  and  there  amongst 
them.  It  is  worthy  of  note  that  the  fibres,  though 
overwhelmed  by  fat,  may  still  retain  their  orga- 
nisation. In  all  cases,  however,  the  course  and 
direction  of  the  fibres  are  more  or  less  modified 
and  distorted.  The  fact  that  the  fibres  still 
exist,  though  concealed,  affords  an  explanation  of 


Fso.  23.  Fatty  growth  in  the  substance  o£  the  Heart, 
x 400  diam. 

the  persistence  of  the  heart’s  action  in  those  in- 
stances in  which  the  muscular  walls  appear  to 
a greater  or  less  extent  replaced  by  fat.  It  might 
also  be  mentioned  that  small  masses  of  fatty 
tissue  sometimes  appear  beneath  the  endocar- 
dium, varying  in  size  from  that  of  a pin’s  head 
to  that  of  a pea.  The  writer  has  seen  these  little 
fatty  tumours  in  cases  where . there  was  a con- 
siderable, but  not  an  excessive,  amount  of  fat 
upon  the  surface  of  the  heart. 

Effects. — The  fat  accumulated  on  the  heart 
and  in  its  substance,  may  be  supposed  to  act 
mechanically;  and  by  its  pressure  upon  the  mus 
cular  fibres,  on  the  nerves,  and  on  the  blood- 
vessels, to  impede  the  function  of  the  organ, 
embarrass  its  nutrition,  and  produce  those  effects 
which  may  be  briefly  enumerated  as — a languid 
and  feeble  condition  of  the  circulation,  with  a 
sense  of  uneasiness  and  oppression  in  the  chest ; 
embarrassment  and  distress  in  breathing,  drow- 
siness, even  coma;  syncope,  perhaps  angina  pec- 
toris, it  may  be  death.  Rupture  of  the  heart 
sometimes  results.  Such  an  enumeration  of  evils, 
in  which  there  is  no  evidence  of  any  other  lesion 
of  the  heart’s  texture,  save  an  accumulation  of 
fat  , would  suffice  to  render  this  condition  a source 
of  very  grave  import,  but  we  cannot  always  be 
quite  clear  on  the  subject,  because  in  the  par- 
ticular cases  quoted  we  cannot  be  certain  that 
some  degeneration  of  the  muscular  fibres  did 
not  co-exist.  It  would  be  well,  therefore,  not 
to  dwell  too  much  on  such  effects  as  proceeding 
from  and  dependent  on  fatty  growth  alone. 

Diagnosis. — The  presence  of  an  excessive  de- 
posit of  fat  about  the  heart  must,  in  a great 
measure,  be  a matter  of  inference  during  life. 
Where  one  or  more  of  the  effects  mentioned 
above  as  having  been  noticed  in  cases  of  this 
kind,  are  present ; when  the  pulse  is  small  and 
weak;  when  the  first  sound  of  the  heart  is 


■398  HEART,  FATTY  GEOWTH  OH. 
feeble,  and  the  impulse  weak  ; when  the  extent 
of  dulness  on  percussion  is  increased;  and 
when  these  phenomena  occur  in  a fat  person,  it 
may  be  inferred  that  the  heart  is  too  fat.1  But, 
on  the  other  hand,  it  must  not  be  overlooked 
that  these  symptoms  and  signs  may  be  found  in 
cases  of  fatty  degeneration  of  the  walls  of  the 
heart,  in  cases  where  the  amoimt  of  fat-tissue 
is  but  moderate.  Hay,  more,  as  already  stated, 
both  conditions  are  often  present  in  the  same 
heart,  thus  rendering  distinctive  diagnosis  im- 
possible. It  is  said  that  the  presence  of  water 
in  the  pericardium  may  be  confounded  with  the 
presence  of  fat  upon  the  heart ; but  the  history 
and  general  features  of  the  case  in  the  former 
condition  should  be  sufficient  to  prevent  all 
difficulty  in  the  diagnosis.  See  Pericardium, 
Diseases  of. 

Treatment. — The  treatment  of  fatty  accumu- 
lation on  the  heart  is  so  intimately  associated 
with  the  subject  of  the  formation  of  fat  in  ge- 
neral, that  this  point  can  be  discussed  with  more 
advantage  in  its  wider  relations  (see  Obesity). 
Whilst  the  treatment  directed  to  this  point  is 
being  carried  out,  we  can  do  little  more  for  the 
heart  itself  than  aim  at  giving  strength  to  the 
portion  of  its  texture  still  available  for  duty — 
by  tonics,  steel,  quinine,  phosphorus,  &c. ; se- 
condly, by  lightening  as  far  as  possible  the  work 
which  the  heart  has  to  do ; and  thirdly,  by  at- 
tending to  the  excreting  organs,  so  as  to  prevent 
congestion  there,  and  consequently  embarrass- 
ment to  the  weak  heart.  R.  Quain,  M.D. 

HEART,  Fibroid  Disease  of. — Synon.  : 
Chronic  Myocarditis. 

Definition. — A morbid  condition  in  which  the 
muscular  fibres  of  a portion  of  the  walls  of  the 
heart  are  replaced  by  fibroid  tissue. 

.ZEtiology. — Fibroid  disease  of  the  heart  is 
met  with  most  frequently  in  middle-aged  male 
subjects.  The  disease  is  supposed  to  be  occa- 
sionally but  an  extension  between  the  muscu- 
lar bundles  of  a chronic  process  that  has  com- 
menced with  endocarditis  or  pericarditis.  The 
cause  of  this,  which  is  generally  rheumatism, 
is  then  regarded  as  the  cause  of  the  fibroid 
growth ; but  in  reality  it  is  more  probable  that 
in  such  cases  the  serous  inflammation  is  the 
result,  and  not  the  cause,  of  the  fibroid  change. 
Fibrosis  is  sometimesthe  consequence  of  acute  in- 
terstitial myocarditis.  In  a considerable  number 
of  cases  of  fibroid  disease,  and  in  most  of  the  cases 
of  so-called  ‘ fibrinous  deposit,’  the  change  is  pro- 
bably syphilitic  in  its  nature.  In  other  instances 
it  appears  to  be  senile,  and  to  be  associated 
with  degenerative  changes  in  the  vessels,  or 

1 Dr.  Henry  Kennedy,  of  Dublin,  in  a recently  pub- 
lished special  monograph  on  Fatty  Heart,  states  that 
the  points  upon  which  the  diagnosis  of  fatty  growth 
on  the  heart  mainly  turn  are  the  following: — ‘First,  a 
large  full  pulse,  beating  at  the  natural  standard  of  fre- 
quency ; secondly,  evidence  derived  from  percussion  of 
the  heart's  dulness  being  more  extended  than  natural ; 
thirdly,  the  possible  presence  of  a soft  systolic  murmur 
over  the  aortic  orifice,  occupying  the  first  sound  of  the 
heart  only,  and  leaving  the  second  normal ; and,  lastly, 
the  condition  of  the  individual  as  to  his  being  fat  or 
otherwise  ’ (p.  30).  The  present  writer  hesitates  to  agree 
with  Dr.  Kennedy  as  to  the  condition  of  the  pulse  gene- 
rally, and  certainly  this  description  will  not  apply  in  the 
cases  of  those  persons  of  small  frame,  noth  small  arteries, 
who  often  become  obese  and  present  symptoms  of  fat- 
hcart  after  the  middle  period  of  life. 


HEART,  FIBROID  DISEASE  OF. 

chronic  disease  of  the  kidneys.  Increase  of 
fibrous  tissue  in  the  myocardium  may  also  he 
the  result  of  prolonged  moderate  congestion  of 
tho  coronary  veins.  Very  frequently  no  evident 
cause  of  the  disease  can  be  discovered. 

Anatomical  Characters. — Our  knowledge  of 
the  pathology  of  this  disease  is  in  a great  mea- 
sure due  to  the  remarkable  number  of  cases 
that  havo  been  described  in  the  Transactions 
of  the  Pathological  Society,  the  first  speeimi  , 
of  which  was  presented  by  Dr.  Qnain  in  the  year 
1850.  Fibroid  disease  of  the  heart  occurs  most 
frequently  in  the  walls  of  the  ventricles.  It  is 
met  with  under  several  different  forms.  In  rare 
instances,  which  are  best  described  as  cases  of 
connective-tissue  hypertrophy  of  the  heart,  there 
is  an  uniform  increase  of  fibrous  tissue  between 
the  muscular  fibres  throughout  the  whole  organ 
{see  Heart,  Connective-Tissue  Hypertrophy  of). 
In  other  instances,  the  disease  appears  as  a local 
thickening  of  the  connective  tissue  underneath 
an  opacity  of  the  endocardium  or  of  the  pericar- 
dium, whence  septa  run  outwards  or  inwards 
between  the  muscular  bundles.  Most  frequently, 
however,  it  presents  the  appearance  of  a fibroid 
patch,  generally  situated  near  the  apex  of  the 
heart,  replacing  the  muscular  substance  through- 
out its  whole  thickness,  and  over  a greater  or  less 
extent  of  surface,  even  to  as  much  as  a consider- 
able portion  of  one  ventricle,  and  consisting  of 
dense,  firm,  inelastic,  greyish-white  fibrous  tissue. 
Smaller  patches,  nodules,  scars  and  streaks  may 
be  found  in  the  deeper  parts  of  the  myocar- 
dium. The  apices  of  the  papillary  muscles, 
again,  may  become  fibroid,  especially  in  chronic 
valvular  disease.  Polypoid  tumours,  composed 
of  fibrous  tissue,  have  been  met  with  ou  the 
endocardial  surface  of  the  heart,  that  is,  pro- 
jecting into  one  of  the  cavities  ; more  especially 
into  the  left  auricle.  Possibly  the  detachment 
of  such  a polypus  may  be  one  mode  of  origin  of 
the  ‘fibrinous  balls’  or  ‘concretions’  occasion- 
ally found  lying  free  in  the  auricular  cavities. 
Fibroid  and  ‘ fibrinous  ’ formations  due  to 
syphilis  are  described  in  the  article  Heart, 
Syphilitic  Disease  of. 

Microscopically,  fibroid  disease  of  the  myo- 
cardium presents  a concomitant  increase  of  the 
connective-tissue  elements,  and  decrease  by 
atrophy  of  the  muscular  fibres.  Occasionally, 
in  an  early  stage,  as  well  as  at  the  margins  of  the 
older  patches,  round  and  spindle-shaped  cells  and 
bundles  of  young  fibrillae  have  been  observed. 
The  latter  increase  in  size  and  in  number,  press 
upon  the  intervening  muscular  fibres,  and  finally 
unite  and  form  bands  or  patches  of  ordinary 
fibroid  tissue.  Meanwhile,  the  muscular  fibres 
gradually  become  attenuated,  granular,  or  fatty ; 
and  at  last  they  disappear  by  absorption,  or 
patches  of  them  may  be  imprisoned  within  the 
fibroid  growth. 

The  effects  upon  the  heart  of  fibroid  changes 
in  its  walls  vary  with  their  situation  and  ex- 
tent. If  a large  portion  of  the  wall  of  cno 
cavity  is  fibrotie,  irregular  patchy  dilatation  of 
the  chamber  ensues.  Localised  fibrosis,  espe- 
cially’- if  it  commence  beneath  the  endocardium, 
gives  rise  to  aneurism  of  the  heart,  by  the  yield- 
ing of  the  diseased  area  to  the  intra-ventricu- 
lar  pressure  (see  Heart,  Aneurism  of).  Deeper 


HEART.  FIBROID  DISEASE  OF:  AND  FUNCTIONAL  DISORDERS  OF.  59!} 


or  more  limited  patches  or  lines  of  cirrhosis 
cause  irregularity  or  puckering  of  the  cardiac 
walls;  and  valvular  insufficiency  may  result 
from  this,  or  from  fibrosis  and  functional  dis- 
turbance of  the  papillary  muscles.  Lastly, 
fibroid  disease  occasionally  involves  the  conus 
arteriosus  in  an  annular  form,  giving  rise  to  con- 
striction and  the  formation  of  so-called  ‘ cardiac 
stenosis.’ 

Symptoms. — The  symptoms  of  fibroid  disoase 
of  the  heart  vary  greatly  in  different  instances, 
according  to  the  extent,  situation,  and  other 
conditions  of  the  growth.  When  the  fibrosis  is 
very  limited,  few  symptoms  can  be  expected  to 
be  present.  In  the  majority  of  cases  in  which  a 
considerable  portion  of  the  cardiac  wall  has  been 
found  diseased,  the  symptoms  have  been  described 
as  those  of  ‘ordinary  heart-disease’;  namely, 
dyspnoea  on  exertion;  praeeordial  pain  or  distress; 
occasional  palpitation;  small,  weak,  or  irregular 
pulse;  dropsy;  and  visceral  complications.  Asa 
rule,  no  endocardial  murmur  has  been  present ; 
but  fibrosis  of  the  papillary  muscles  may  some- 
times give  rise  to  the  signs  of  incompetence  of 
the  auriculo-ventricular  valves.  The  symptoms 
of  cardiac  aneurism  and  of  syphilitic  disease  of 
the  heart,  as  well  as  those  of  connective-tissue 
hypertrophy,  are  elsewhere  described. 

Course  ax’d  Terminations. — The  course  of 
fibroid  disoase  of  the  heart  is  generally'  chronic, 
although  urgent  symptoms  are  sometimes  ob- 
served a short  time  only  before  death.  At- 
tacks of  ?oain,  palpitation,  and  dyspnoea  may 
occur  and  subside  long  previous  to  the  last 
fatal  illness.  The  development  of  cardiac  aneu- 
rism, and  its  possible  terminations,  will  modify 
the  course  of  the  disease.  Sudden  death  may 
occur,  with  or  without  previous  cardiac  symp- 
toms, and  must  bo  regarded  as  a special  mode 
of  termination  of  fibroid  disease  of  the  heart. 
Otherwise  the  cases  generally  end  by  pulmonary 
complications,  dropsy,  and  exhaustion. 

Diagnosis. — Fibroid  disease  of  the  myocar- 
dium has  to  be  diagnosed  from  chronic  valvular 
disease;  from  enlargement  due  to  extracardiae 
causes,  such  as  renal  disease,  gout,  or  emphy- 
sema ; and  from  fatty  degeneration.  Under  all 
circumstances,  an  accurate  diagnosis  is  extremely 
difficult,  if  not  impossible.  The  presence  of  a 
murmur  does  not  exclude  fibrosis,  as  the  valves 
may  become  secondarily  involved  ; and  valvular 
disease  is  not  always  att^ided  by  a murmur. 
The  other  cardiac  lesions  mentioned  must  be  ex- 
cluded in  the  ordinary  way. 

Prognosis. — When  fibroid  disease  of  tbe  heart 
is  attended  with  symptoms  sufficient  to  establish 
a diagnosis,  the  prognosis  is  unfavourable  as 
regards  life,  although  it  may  not  be  imme- 
diately so. 

Treatment. — This  consists  in  relieving  and 
supporting  the  heart  by  every  possible  means, 
especially  by  rest  and  cardiac  stimulants,  such  as 
alcohol  and  ether.  Iodide  of  potassium  may  bo 
given  with  benefit  in  some  cases,  especially  if 
there  be  a history  of  syphilis.  Digitalis  will 
have  to  he  administered  with  great  circum- 
spection. J.  Mitchell  Bruce. 

HEART,  Functional  Disorders  of. 

Definition.  —A  disturbance  in  the  functions  of 


the  heart,  with  or  without  pain ; having  origin 
in  causes  other  than  inflammation,  or  struc- 
tural changes  in  the  heart  itself ; and  for  the  most 
part  paroxysmal  in  character. 

This  definition  comprises  various  disorders 
in  the  dynamical  functions  and  sensibility  of  the 
heart,  from  the  slightest  disturbance  of  only 
momentary  duration,  to  urgent  symptoms  of  ccn- 
siderabie  persistence. 

^Etiology. — The  frequency  of  the  occurrence 
of  functional  disorders  of  the  heart,  and  the 
similarity  of  many  of  the  symptoms  exhibited  t. 
those  met  with  in  organic  diseases,  as  well  as 
the  fact  that  these  functional  disorders  may  co- 
exist with  organic  disease,  thus  greatly  exagge 
rating  the  apparent  gravity  of  the  latter,  render  it 
important  to  accurately  determine  how  much  of 
the  disturbance  may  be  due  to  the  one  or  to  the 
other  of  these  causes. 

To  estimate  the  immediate  or  proximate  cause 
of  functional  disturbance  of  the  heart,  regard 
must  be  bad  to  its  structure  ; and  how  this  is 
nourished,  and  its  motions  regulated.  For  ade- 
quate and  equable  dynamical  movement,  the  pri- 
mary requirement  is  a healthy  development  of 
muscular  structure.  Weak  muscular  fibre,  apart 
from  degenerations  by  disease,  becomes  a pre- 
disposing cause  of  feeble  and  irregular  action. 
But  as  the  regular  recurrence  of  the  muscular 
contraction  and  expansion  must,  moreover,  be 
ascribed  to  the  agency  of  the  cardiac  ganglia, 
the  vagus  nerve,  and  the  nerves  and  ganglia  of 
the  sympathetic  system,  all  nourished  and  excited 
by  the  blood,  any  abnormal  conditions  of  those 
have  also  their  effect.  Interference  with  the  func- 
tions of  these  several  nerves  may  so  modify  the  ac- 
tion of  the  heart  as  to  cause  deficiencies  of  power 
of  every  variety  and  extent,  giving  rise  to  illustra- 
tions of  abnormal  contractility  and  irritability, 
which  the  heart  exhibits  in  common  with  all 
other  muscles.  Bat  the  heart  further  possesses 
the  distinguishing  feature  of  rhythmical  action. 
There  are  cogent  grounds  for  the  belief  that 
this  is  not  only  due  to  the  intrinsic  ganglionic 
system  of  nerves ; but,  as  errors  of  rhythm 
are  certainly  induced  by  such  causes  as  improper 
diet,  dyspepsia,  the  presence  of  worms,  consti- 
pation, injuries  or  deformities  of  the  chest,  and 
diseases  of  the  lungs,  there  can  be  no  doubt  that 
ibe  heart  is  also  liable  to  reflex  irritation  of  the 
pneumogastric  and  sympathetic  nerves.  The 
rhythmical  action  is  also  shown  by  experiment 
to  be  dependent  on  the  blood,  whether  venous 
or  arterial ; for  without  a supply  of  blood  rhyth- 
mical action  ceases.  The  healthy  action  of 
the  heart,  and  the  controlling  energy  of  its 
nerves,  greatly,  if  not  entirely,  depend  on  the 
supply  of  healthy  blood  ; and  any  failure  of  the 
supply,  whether  in  quantity  or  quality,  shows 
itself  by  disturbance  in  the  functions  of  the 
heart.  Moreover,  the  muscular  substance  of  the 
heart  itself  is  nourished  by  the  blood  circulating 
in  the  coronary  arteries,  and  thus  becomes  sus- 
ceptible to  the  quality  and  condition  of  the  blood 
so  distributed  ; hence  a blood  too  rich  in  fibrin  or 
red  globules,  and  thereby  inducing  plethora,  fre- 
quently causes  over-action  of  the  heart  and  pal- 
pitation, whilst  in  anaemia  a deficient  amount  of 
blood  induces  a weak  and  often  excited  and  irre- 
gular action.  The  predisposing  causes,  in  addi 


HEART,  FUNCTIONAL  DISORDERS  OF. 


400 

lion  to  those  already  named,  may,  therefore,  be 
classed  thus : — ( 1 ) Those  conditions  aeting  through 
or  upon  tlio  nervous  system,  such  as  the  general 
exhaustion  of  the  nervous  system,  all  forms  of 
reflex  irritation,  venereal  excesses,  vain  longings, 
purposeless  occupations  and  amusements,  pro- 
tracted mental  exercise,  abstinence  from  ade- 
quate repose,  &c.  (2)  Those  conditions  acting 

upon  the  general  blood-supply  of  the  body,  and 
consequently  affecting  the  special  blood-supply 
of  the  heart,  such  as  the  turgid  and  plethoric 
states  of  gross  feeders,  depraved  states  caused  by 
bad  and  deficient  diet,  and  all  forms  of  blood- 
disorder,  as  anaemia,  gout,  scurvy,  &c.  To  these 
must  be  added  the  special  temperament  and  per- 
sonal peculiarities  of  the  individual,  a congenital 
or  superimposed  want  of  vigour,  general  debility, 
deformities  of  the  ribs  and  spinal  column,  a small 
weak  heart,  uterine  irritation,  hysteria,  adynamic 
fevers,  and  the  special  sanitary  influences  under 
which  the  individual  is  placed.  Amongst  the 
immediately  exciting  causes  may  be  named 
mental  shock  or  distress ; protracted  and  unusual 
physical  exertion  ; various  articles  of  diet,  as  tea, 
coffee,  &c. ; tobacco  in  excess  ; many  medicines, 
as  aconite  and  digitalis ; as  also  prolonged  ab- 
stinence, exposure  to  cold,  and  notably  blows  on 
the  epigastrium. 

Symptoms. — A paroxysmal  attack  of  a func- 
tionally increased  impulse  is  often  accompanied 
by  a series  of  nervous  sensations — such  as  a 
feeling  of  choking,  at  times  amounting  to  a true 
globus  hystericus ; flushing  of  the  face,-  heat  and 
pain  of  the  head,  with  a sensation  of  a whizzing, 
or  rushing  upwards  of  the  sounds  of  the  heart ; 
dimness  of  vision,  with  photophobia ; and  a ten- 
dency to  syncope,  and  to  clammy  perspirations 
with  cold  shivering.  The  voluntary  muscles  may 
refuse  to  act,  so  that  the  gait  becomes  tottering, 
or  the  patient  grasps  adjacent  objects  to  steady 
himself,  yet  there  is  neither  paralysis  nor  ver- 
tigo. The  respiration,  though  not  generally  em- 
barrassed, may  become  irregular  and  oppressed, 
presenting  the  phenomena  of  a short  inspi- 
ration with  a prolonged  expiration  ; but  if  the 
paroxysms  have  been  induced  by  a congested  1 
state  of  the  right  heart  from  using  undue  exer- 
tion, independently  of  any  frequency  of  cardiac 
impulse,  the  breathing  may  he  accelerated  and 
accompanied  with  dyspnoea,  or  even  apneea,  and 
a short  dry  cough.  Illustrations  of  this  class  of 
symptoms  often  occur  in  those  of  sanguine  and 
nervous  temperaments;  and  maybe  the  result  of 
violent  and  too  protracted  exercise,  of  emotional 
excitements,  or  of  the  over-indulgence  in  stimu- 
lants or  food  when  associated  with  lives  of  idle- 
ness and  inactivity.  Should  the  increased  im- 
pulse be  associated  with  rhythmical  disturbance, 
there  is  for  the  most  part  consciousness  of 
the  existence  of  such  states,  more  especially  on 
the  first  ingress  of  the  attack,  so  that  it  be- 
comes a source  of  much  anxiety  and  even  of 
terror,  inducing  the  self- conviction  of  the  exist- 
ence of  organic  disease.  The  head-symptoms 
also  become  more  marked,  and  associated  with 
local  pains  and  tinnitus  aurium ; whilst  the 
breathing  is  marked  by  sighing,  and  often  be- 
comes lessened  in  frequency.  The  irregular 
form  of  nervous  palpitating  heart  is  often  asso- 
ciated also  with  haemic  diseases,  and  with  ner- 


vous affections,  as  chorea,  masturbation,  &c. 
When  such  diseases  as  scurvy  or  chlorosis  exist, 
the  attacks  become  less  paroxysmal  and  more 
persistent ; there  is  more  pectoral  complication, 
even  to  dyspnoea ; the  headache  is  sometimes  so 
bewildering  that  the  mind  becomes  alarmed 
with  vague  apprehensions  of  danger,  which 
give  rise  to  general  restlessness;  the  integu- 
ments over  the  region  of  the  heart,  as  well  as  of 
the  face,  and  even  of  the  extremities,  may  become 
puffy  and  oedematous,  especially  in  cases  of  ex- 
treme chlorosis,  with  enlargement  of  the  thvroid 
gland  and  exophthalmos,  where  the  morbid  con- 
ditions inducing  these  may  also  possibly  cause 
the  irregular  palpitation. 

When  functional  disorder  occurs  with  a 
diminished  impulse,  the  general  symptoms  group 
themselves  under  anxiety  and  lowness  of 
spirits,  or  actual  despondency,  with  mental  and 
bodily  incapacity  for  exertion  ; flatulent  dys- 
pepsia, with  cold  clammy  extremities ; anorexia, 
or,  may  be,  depraved  appetite  ; exhaustion,  with 
tendency  to  faintness  ; and,  should  irregularity 
of  cardiac  action  be  very  marked,  there  may  be 
a sensation  of  praeeordial  pain.  Males  are  more 
subject  to  this  form  of  functional  disorder  than 
females,  and  it  chiefly  occurs  in  persons  having 
a normally  small  and  feeble  heart,  or  where  a 
state  of  general  nervous  debility  is  super- 
imposed. 

When  the  distinctive  feature  of  functional  dis- 
order is  rhythmical  error,  and  this  is  appreciable 
to  the  patient,  the  special  symptom  is  that 
of  extreme  anxiety,  even  to  the  fear  of  impend- 
ing death  ; occasionally  a single  intermission  is 
so  prolonged  as  to  induce  the  impression  that 
escape  has  only  occurred  by  a miracle.  These 
alarms  often  induce  a palpitation  not  belonging 
to  the  rhythmical  disorder.  But  if  the  rhyth- 
mical error  be  associated  with  a deficiency  of 
systolic  force,  temporary'  paralysis  of  the  heart's 
action  or  syncope  may  be  induced,  and  in  some 
extreme  cases  the  functions  may  be  weakened 
even  to  extinction.  Such  forms  of  disorder 
occur  in  those  having  normal  but  weak  hearts; 
in  the  dyspeptic ; in  the  gouty,  especially  if  an 
attack  is  impending  ; and  in  those  whose  habits 
and  occupations  involve  exhaustion  of  the  ner- 
vous system.  They  are  a characteristic  of  old 
age,  hut  may  be  sympathetically  induced  in  the 
young;  and  may  be  observed  in  the  course  of 
many  diseases,  such  as  tuberculosis,  rheumatism, 
liver-affections,  or  when  malignant  disease  is 
making  its  ravages. 

Prmcordial  pain  is  by  no  means  an  unusual 
symptom  accompanying  functional  affections  of 
the  heart ; it  may  aggravate  the  urgency  of  these 
disorders,  yet  appears  to  be  little  influenced  by 
them.  The  pain  does  not  march  pari  passu 
with  the  irregularity  or  strength  of  the  impulse. 
The  pain  may  be  persistent,  while  the  asso- 
ciated disease  may  be  paroxysmal ; and  in  this 
respect  it  differs  from  prcecordial  anxiety,  which 
is  essentially  paroxysmal,  and  acquires  urgency 
from  the  symptoms  with  which  it  may  be  asso- 
ciated. 

Physical  Signs. — The  physical  signs  referring 
to  the  cardiac  action  may  be  conveniently  sepa- 
rated iuto  the  following  groups,  although  in 
practice  they  will  be  found  mingled  or  associated 


HEART.  FUNCTIONAL  DISORDERS  OF.  G01 


with  each  other: — (1)  Increased  or  diminished 
impulse,  connected  or  unconnected  -with  increased 
rapidity  or  rhythmical  irregularity ; (2)  rhyth- 
mical disturbance , with  intermissions,  the  im- 
pulse being  normal  or  diminished  ; (,3)  increased 
or  diminished  frequency,  the  rhythm  and  force 
being  normal. 

(1) The  eases  in  which  an  increased  impulse 
is  the  distinctive  feature  of  the  heart’s  disturb- 
ance present  many  varieties,  chiefly  referable 
to  force  and  regularity ; but  to  the  simple  forms 
of  increased  and  accelerated  impulse  there  is  so 
very  frequently  added  rhythmical  disturbance, 
that  this  complication  is  perhaps  the  one  most 
usually  occurring.  The  rhythmical  disturbance 
may  occur  both  in  the  force  and  the  rapidity  of 
the  systolic  contractions,  or  it  may  result  in  a true 
intermittence,  or  occasionally  the  irregularities 
thus  induced  may  be  so  great  as  to  defy  definite 
appreciation,  save  as  a tumultuous  whole.  On 
palpation,  the  impulse,  abrupt  in  stroke,  pre- 
sents the  characteristic  of  a sudden  bound,  now 
strong,  now  failing,  sometimes  so  rapid  as  to  com- 
municate the  impression  of  a fremitus  or  agita- 
tion, then  a pause,  or  true  intermittence  followed 
by  hurry,  or  more  evident  irregularity.  On 
auscultation,  the  sounds  are  more  difficult  of 
appreciation  than  in  simple  palpitation  ; they  are 
loud  and  clear,  and  sometimes  so  exaggerated 
and  pronounced  as  to  be  audible  both  in  the 
mammary  and  epigastric  regions.  But  whether 
the  exaggerations  of  sound  and  impulsebe  more  or 
less,  they  w:ll  be  found  to  act  in  unison  with  each 
other ; the  impulse  and  sounds  increase  together 
and  diminish  together.  When  there  is  an  un- 
usual amount  of  irregular  functional  excitement 
in  systole,  there  may  be  occasionally  heard,  as 
a passing  not  permanent  occurrence,  a reduplica- 
tion of  the  second  sound,  very  rarely  of  the  first; 
and  usually  the  first  portion  of  the  divided  or 
cleft  sound  is  the  most  accentuated.  This  redu- 
plication, though  it  may'  be  met  with  in  active 
inflammatory  diseases,  is  chiefly  the  concomi- 
tant of  functional  disorders  of  the  nervous  heart 
only,  and  it  rarely  or  never  occurs  in  chronic 
diseases  of  the  heart.  The  pulse  is  generally 
sharp  and  jerking;  it  does  not  always  beat  in 
unison  with  the  systole  of  the  heart ; if  there  be 
plethora,  it  has  a force  and  fulness  not  otherwise 
observable ; and  if  there  exist  congestion  of  the 
right  ventricle,  it  becomes  contracted  and  dimin- 
ished in  force. 

In  cases  where  the  impulse  is  diminished  in 
effort,  the  special  characters  are  somewhat  nega- 
tive ; the  impulse  and  sounds  being  feeble,  but 
otherwise  normal,  unless  the  systole  be  excited 
by  mental  shock  or  any  undue  bodily  exertion, 
when  irregularity  and  increase  of  impulse,  with 
some  slight  sharpness  of  the  sounds,  take  place. 
The  first  sound  may  suggest,  rather  than  have, 
a sharp  ringing  tone ; while  the  second  is  pro- 
longed. 

(2)  With  respect  to  errors  in  rhythmical  action, 
separately  considered,  it  must  here  be  noted  that 
the  chief  and  characteristic  errors  may  be  classi- 
fied under  the  distinct  heads  of  irregularity  and 
intermittence  Irregularity  may  be  in  the  force 
or  in  the  fruquency  of  one  or  more  beats,  and 
presents  the  many  varieties  which  a want  of 
normal  uniformity  may  suggest ; the  minute  and 


particular  enumeration  of  these  is  rather  satisfy- 
ing to  curiosity  than  instructive.  It  is  sufficient 
to  say  that  every  variety  of  irregular  frequency 
may  occur  ; while,  with  certain  beats,  force  may 
be  increased  or  diminished.  Sometimes  there 
appears  to  be  a kind  of  order  in  rhythmical  dis- 
orders, that  is,  short  series  of  varying  irregu- 
larities may  regularly  succeed  each  other;  there 
maybe  a fluttering  or  trembling,  or  that  vibratory 
or  vermicular  motion  to  which  the  term ‘thrill’ 
has  been  given.  True  intermittence  is  not  so  fre- 
quent as  irregularity;  but  when  intermittence 
does  occur,  it  is  generally  associated  with  irre- 
gularity. These  disturbances  may  be  only 
momentary  or  of  long  duration,  slight  or  con- 
siderable; but,  however  this  may  be,  their 
character  is  determined  by  the  irregularity  of 
the  systole,  or  the  prolonging  of  the  period  of 
intermission. 

The  physical  examination  of  this  form  of  func- 
tional disorder  shows  no  marked  peculiarities, 
excepting  those  of  systolic  irregularity.  To  the 
ear  is  revealed  irregularity  in  the  recurrence 
and  duration  of  thesounds,  from  the  slightest 
appreciable  pause  to  the  most  rapid  and  confused 
trembling,  with  very  manifest  alterations  in  tone 
and  pitch.  The  sounds  generally  aro  intensified, 
the  first,  sound  being  sometimes  heightened  to 
the  extent  of  a sharp  knock ; whilst  the  second, 
save  in  intensity,  is  not  materially  altered.  In 
extreme  cases  there  may  be  so  much  ventricular 
irregularity  as  to  induce  in  place  of  sounds  an 
ill-defined  fremitus  ; and  so  much  force  as  to  pro- 
duce a metallic  ringing,  with  a rubbing  murmur 
on  the  systole.  Thus  the  impulse  of  the  heart, 
which  in  health  is  rarely  appreciable,  and  its 
friction  never,  respectively  become  so  to  the  touch 
and  to  the  ear  ; and  the  abnormal  sounds  may 
exist  to  such  an  extent  as  to  entirely  obscure  the 
first  sound. 

Occasionally  there  is  met  with  an  appreciable 
rhythmical  disturbance  in  the  pulse,  which  is  not 
found  to  exist  in  the  heart — false  intermittence. 
The  heart  only  indicates  irregularity  of  power ; 
and  as  there  is  occasional  failure  of  force  in  the 
already  weak  systolic  contractions,  the  impulse 
is  not  communicated  to  the  artery  at  the  wrist. 
These  false  intermissions  accompanying  irregu- 
larity most  frequently  occur  when  the  heart  is 
oppressed  by  flatus  in  the  neighbouring  viscera, 
or  is  excited  by  injurious  articles  of  diet,  as  tea, 
or  by  the  use  of  tobacco,  &c.  The  sensation  com- 
municated to  the  patient  is  that  of  a disagreeable 
flutter  or ‘tumbling  over’  of  the  heart,  which 
tends  to  alarm,  although  habit  may  to  a certain 
extent  ameliorate  the  terror. 

Rhythmical  irregularity  occasionally  appears 
as  a normal  condition,  having  a life-long  exist- 
ence. Some  cases  are  marked  by  an  extension 
of  the  pause,  with  unsteadiness  of  the  systolic 
impulse  ; others  by  its  apparent  extinction,  so 
that  there  exists  a rapidity  of  beats  defying  all 
analysis.  There  is  in  these  cases  usually  a small 
weak  heart,  with  systolic  impulse  devoid  of 
energy.  Both  these  classes  of  cases  present  t he 
remarkable  feature  of  losing  much  of  their  dis- 
tinctive irregularity  when  under  the  influence  of 
a febrile  attack  ; the  slow  pulse  becomes  quicker 
and  more  steady,  the  rapid  one  less  frequent  and 
more  distinct ; but  the  feeling  is,  ne"erthelesa, 


HEART,  FUNCTIONAL  DISORDERS  OF. 


502 

not  so  comfortable  as  when  the  heart’s  action  is 
in  its  state  of  normal  irregularity. 

(3)  Functional  disorder  occasionally  assumes 
the  form  of  either  increased  or  of  diminished 
frequency,  while  the  force  and  rhythm  remain 
normal.  Each  of  these  conditions  may  be  con- 
genital and  proper  to  the  individual,  or  may  be 
the  result  of  abnormal  influences.  The  func- 
tionally fast  beat  is  generally  induced  by  other 
diseases,  as  fever,  diabetes,  tuberculosis,  &c.,  and 
is  indicative  of  injury  to  normal  innervation. 
The  slow  and  drawling  beat  is  generally  met  with 
where  the  nerve-power  is  healthy,  but  the  heart 
itself  is  weak  or  fatty ; or  there  is  a pervertod  in- 
nervation under  the  influence  of  digitalis,  aconite, 
or  injury  to  the  ganglionic  system — a blow  in  the 
epigastrium  offering  a familiar  example. 

Inorganic  murmurs  are  frequently  heard  in 
functional  disorders  of  the  heart,  and  more 
especially  in  those  cases  of  haemic  disorder 
where  the  systolic  impulse  is  increased,  with 
rhythmical  irregularity.  These  murmurs  have 
the  special  characters  usually  attached  to  such 
sounds.  They  are  systolic,  basic,  and  chiefly 
heard  in  the  prsecordial  region,  with  conduc- 
tion in  the  course  of  the  great  vessels.  There 
is  no  apex-murmur ; but  at  the  apex,  synchro- 
nously with  the  murmur,  the  first  sound  is  clearly 
defined,  with  a metallic  ringing  sound.  The  tone 
of  these  murmurs  is  musical,  cooing,  soft,  of 
low  pitch  ; the  seat  is  in  the  aortic  valves,  and, 
as  a rule,  they  are  always  accompanied  with  palpi- 
tation : this  palpitation  may  be  persistent,  while 
the  murmurs  are  not  so.  It  is  remarkable  how 
large  may  be  the  amounts  of  blood  drained  from 
the  system,  and  the  frequency  of  the  discharges, 
provided  there  be  no  diseased  condition  of  the 
blood  itself,  without  inducing  the  presence  of  a 
murmur.  But  under  these  circumstances,  though 
there  be  no  murmur,  the  first  sound  is  usually 
flapping  in  character,  and  the  second  ringing  in 
tone.  The  murmurs  in  chlorosis  and  spansemia, 
and,  when  they  occur,  in  ichorrhoemia  and  leukae- 
mia, have  their  seat  for  the  most  part  in  thepulmo- 
nary  valves,  and  are  not  traceable  in  the  courso 
of  the  larger  arteries ; they  are  also  generally 
associated  with  the  venous  hum  to  be  heard  in 
the  jugular  veins. 

OoxirncATioxs  and  Sequelae. — The  several 
functional  disorders  of  the  heart  are  often  com- 
plicated with  other  diseases — many  external  to 
the  heart,  and  some  of  the  heart  itself.  The 
more  prominent  of  the  former  are  disorders  of 
the  nervous  system  and  of  the  blood.  Many 
of  these  have  been  already  referred  to.  For 
the  most  part,  those  associated  with  a perverted 
innervation  are  examples  of  irritability,  and  ex- 
hibit rhythmical  disorder,  with  pain.  Haemic 
diseases  induce  the  simpler  forms  of  palpitation  ; 
anosmia,  gout,  and  dyspepsia  induce  palpita- 
tion with  rhythmical  disorder ; spansemia  and 
chlorosis  induce  all  these  disorders,  with  mur- 
murs superadded.  The  diseases  of  the  heart 
with  which  functional  symptoms  of  disorder  are 
often  found  complicated  are  mainly  degenera- 
tions of  the  walls,  or  valvular  diseases.  In  all 
these  eases  the  amount  and  urgency  of  the 
functional  heart-disease  is  no  indication  of  the 
urgency  of  the  disease  with  which  it  may  be 
complicated. 


Are  there  any  distinct  morbid  states  or  othei 
sequela  traceable  to  functional  disorder  of  the 
heart  ? This  may  be  a difficult  question  to  answer 
dogmatically.  Doubtless  frequent  and  prolonged 
attacks  of  functional  disorder  are  seen  to  occur 
without  inducing  any  such.  On  the  other  hand, 
the  long  continuance  of  functional  disorder  is 
often  marked  by  a depreciation  of  mental  and 
bodily  vigour.  More  specific  organic  changes  are 
generally  found  to  be  due  to  some  one  or  other 
of  the  diseases  with  which  the  functional  dis- 
order has  been  in  its  course  associated. 

Diagnosis. — In  order  to  make  a correct  diag- 
nosis, the  first  consideration  is  to  ascertain  the 
entire  absence  of  organic  disease;  and,  if  it  be 
present,  whether  it  is  adequate  to  cause  the  full 
amount  of  the  symptoms  exhibited.  Supposing 
this  to  have  been  done,  if  the  agitation  of  the 
heart  is  not  only  excessive,  sudden,  and  appa- 
rently increased  in  strength,  even  to  violence, 
but  has  often  the  features  of  spasm  rather  than 
the  calmness  of  rhythmical  order;  while  the 
sounds  are  pari  passu  increased  in  sharpness 
and  intensity,  and  diffused  over  a larger  area 
than  is  proper  to  them  ; and  the  pulse  does  not 
partake  of  the  simulated  force  of  the  heart 
— the  presence  of  an  excited  functional  impulse 
may  be  assumed.  The  concurrence  of  some  symp- 
toms usually  associated  with  organic  disease, 
as  dyspnoea  or  even  apncea  and  oedema,  may, 
as  has  been  shown,  be  due  to  the  presence  of 
chlorosis.  So  also  where  there  is  a deficient 
impulse,  if  the  heart  have  its  normal  position 
and  dimensions  ; if  the  sounds  though  weak 
be  natural  in  tone  and  quality,  in  the  absence 
of  any  abnormal  physical  disease,  it  maybe  con- 
cluded the  cause  is  functional  only.  The  same 
may  be  said  of  rhythmical  irregularities.  "When 
any  of  these  symptoms  are  associated  with 
haemic  murmurs,  the  character  of  the  murmur, 
its  seat,  and  its  persistency  must  be  considered 
in  connection  with  the  absence  or  the  presence 
of  haemic  diseases.  The  symptoms  of  each  of 
these  several  forms  of  functional  disorder  have 
been  so  fully  described  that  there  is  no  need  to 
repeat  them  here.  It  must,  however,  be  always 
borne  in  mind  that  the  absence  of  the  physical 
signs  of  disease  is  not  always  conclusive  of 
there  being  no  structural  lesion,  for  there  may 
be  lesions,  and  important  ones  too.  that  do  not 
yield  evidence  of  their  existence.  The  occurrence 
of  the  secondary  changes,  the  immediate  result 
of  various  congestions,  is  often  an  indication 
that  the  heart-symptoms  are  due  to  the  presence 
of  organic  disease  ; still  it  is  not.  always  so.  f r 
congestions  of  the  lungs  and  liver,  and  cedenrr 
may  be  the  consequence  of  spansemia  or  ot 
other  morbid  conditions  of  the  blood.  Hence, 
when  these  are  present,  the  symptoms  exhibited 
by  a disordered  heart  may  not  be  due  to  struc- 
tural disease ; and  the  same  may  be  said  of  the 
effects  of  muscular  exercise  and  of  position,  for 
either  or  both  of  these  may  distress  if  there  be 
present  any  anaemic  condition  or  an  intercostal 
neuralgia.  Nor,  on  the  other  hand,  does  the 
occasional  subsidence  of  urgent  symptoms,  so 
frequently  the  case  in  functional  disorder,  ab- 
solutely affirm  the  conclusion  that  there  is  no 
organic  disease ; for  occasionally  in  the  latter 
the  normal  rhythm  and  force  of  the  heart  roa* 


HEART,  FUNCTIONAL  DISORDERS  OF.  Gu3 


reassert  themselves;  but  then  in  these  cases 
there  remain  the  other  characteristics  of  the 
organic  affection.  Frequent  examination  and 
an  accomplished  experience  will  generally  lead 
to  a just  diagnosis. 

Prognosis.— -The  prognosis  of  functional  dis- 
orders of  the  heart,  for  the  most  part,  is  favour- 
able. Where  there  are  baneful  constitutional 
tendencies,  or  complications  with  other  diseases, 
the  prognosis  must  not,  however,  be  always  so 
considered.  In  the  leucophlegmatic  temperament 
the  paroxysms  may  be  severe  and  abiding, 
and  generally  distressing  to  the  nervous  system. 
If  the  symptoms  be  so  urgent  as  to  distend  the 
right  heart,  the  liver  may  become  loaded,  and 
dropsy  may  ensue.  In  this  temperament  mental 
shocks  may  induce  palpitation,  irregularity,  and 
syncope,  whence  may  ensue  not  only  permanent 
heart -affection  and  eventually  disease,  but  even 
immediate  death.  When  functional  disorder  is 
the  concomitant  of  scurvy  or  anaemia,  the  prog- 
nosis is  not  always  favourable.  Still  in  the 
young  and  middle-aged  there  is  good  chance  of 
ultimate  recovery;  for  if  these  diseases  be  sub- 
dued the  functional  disorder  subsides.  When 
occurring  in  the  aged,  or  in  those  having  a con- 
stitutional tendency  to  hypochondriasis,  or  when 
associated  with  organic,  diseases,  or  excited  by 
inflammations  of  the  endocardium,  a less  favour- 
able prognosis  must  be  given.  Functional 
rhythmical  irregularity,  for  the  most  part,  does 
not  indicate  danger,  but  it  may  do  so  if  asso- 
ciated with  some  obscure  structural  lesion. 
Nevertheless,  cases  of  simple  functional  dis- 
order, so  severe  as  apparently  to  indicate  an 
immediately  fatal  termination,  prove,  for  the 
most  part,  manageable,  and  result  in  a restora- 
tion to  health.  The  freedom  of  the  heart  from 
all  agitation  and  other  indications  of  disease, 
before  and  after  an  attack,  is  due  to  its  being  a 
normal  and  uninjured  organ  ; and  though  liable 
during  an  attack  to  the  morbid  influences  of 
6pasms  and  congestive  loading,  it  still  may  be 
a healthy  organ.  This  holds  whether  the  pa- 
roxysms be  short  or  prolonged,  occurring  rarely, 
or  frequently  recurring.  They  are  distressing 
but  not  dangerous. 

Treatment.— Treatment  should  have  refer- 
ence primarily  to  the  paroxysm,  and  then  to  its 
exciting  causes,  the  indications  being,  first,  the 
mitigation  of  the  symptoms ; and,  secondly,  the 
prevention  of  their  recurrence. 

Treatment  of  the  paroxysms. — Towards  the 
former,  it  should  be  ascertained,  where  possible, 
whether  the  attack  be  essentially  due  to  irri- 
tability in  the  heart  itself,  or  whether  it  have 
its  origin  in  some  co-existing  excentric  cause. 
The  constitutional  tendency  and  the  exciting 
causes  should  be  well  considered ; for  the  treat- 
ment of  apparently  similar  attacks  under  the 
widely  opposite  causes  of  a plethora  or  an 
anaemia  must  be  varied  accordingly.  Slight 
cases  subside  of  themselves ; but  in  more  per- 
sistent attacks,  for  the  most  part,  relief  is  ob- 
1 tamed  by  warm  carminatives  or  stimulants,  or 
by  antispasmodics,  as  ammonia,  camphor,  ether, 
assafcetida,  musk,  valerian,  or  sumbul.  Where 
irritability  of  the  heart  itself  is  the  cause  of 
the  attack,  it  is  generally  best  met  by  seda- 
tives, as  opium,  hyoscyamus,  hydrocyanic  acid, 


and  in  some  cases  digitalis.  If  the  attack  be 
due  to  derangement  of  tho  stomach,  as  from 
the  presence  of  the  gouty  acids,  an  alkali  may 
be  useful.  In  extreme  cases,  and  where  head- 
symptoms  supervene,  the  extraction  of  a small 
quantity  of  blood  by  leeches  or  venesection  may 
be  useful.  The  mental  or  moral  treatment  is  of 
the  greatest  moment.  A confident  and  cheering 
prognosis  conduces  to  recovery,  and  prevents  the 
nervousness  which  exhausts  and  tends  to  pro- 
long the  disorder. 

Treatment  between  the  paroxysms. — The  pa- 
roxysmbeing allayed,  it  is  then  well  to  examine 
carefully  into  the  state  of  health,  so  as  to  ascer- 
tain if  there  be  any  of  those  disordered  condi- 
tions which  may  probably  have  been  its  exciting 
cause.  Dyspepsia  is  to  be  relieved,  the  liver 
is  to  be  set  right,  the  uterine  functions  are  to 
be  restored  to  regularity,  loaded  bowels  relieved, 
plethora  subdued;  spanaemia  and  chlorosis 
strengthened  into  health,  exhaustion  compen- 
sated for,  and  debility  counteracted ; and  the 
over-worked  must  seek  renovation  in  travel  and 
cheerful  recreation.  In  persons  prone  to  these 
disorders  many  precautions  should  be  observed. 
The  young  and  the  plethoric  must  avoid  ex- 
tremes of  diet  and  exercise  ; the  food  should  be 
moderate  in  quantity  and  unstimulating  in 
quality;  and  exercise  should  be  unfatiguing, 
and  chiefly  taken  in  the  open  air.  Hot  and 
ill-ventilated  rooms,  and  the  postponement  of 
sleep  by  late  hours,  should  be  especially  avoided. 
A careful  mental  discipline  should  be  observed  ; 
and  this  must  be  sought  in  a healthy  exercise  of 
the  brain,  and  restraining,  by  a well-ordered 
intellectual  culture,  the  tendency  to  vain  imagi- 
nings and  emotional  passions.  The  constitu- 
tionally nervous  and  irritable  in  mind  must 
sedulously  avoid  exciting  situations,  as  well  as 
exhaustion  by  overwork.  The  sluggish  and  hy- 
pochondriacal must  resist  the  temptations  to 
inaction,  seeking  to  overcome  these  tendencies 
by  exercise ; by  cold  bathing,  more  especially 
by  means  of  the  shower-bath ; and,  if  the 
bowels  be  confined,  by  the  judicious  use  of 
aperients.  As  all  the  varieties  of  functional 
disorder  of  the  heart  are  peculiarly  under  the 
influence  of  a morbid  will,  it  becomes  of  the 
first  importance  that  the  medical  attendant 
should  generally  encourage  and  cheer;  and  as 
soon  as  careful  investigation  has  satisfied  the 
requirements  of  a just  prognosis,  further  inves- 
tigations by  tho  stethoscope  should  be  avoided. 
Empirical  investigations  tend  to  prolong  the 
disordered  action,  and  perhaps  so  to  impress  the 
imagination  as  to  forbid  recovery. 

Tiiojias  Shatter. 

HEART,  Htemorrhage  into  the  "Walls 
of. — Synon.  : Cardiac  Apoplexy. 

Definition. — Extravasation  of  blood  into  the 
substance  of  the  heart. 

•/Etiology  and  Pathology. — Blood  is  extra- 
vasated  into  the  substance  of  the  heart  in  various 
pathological  conditions,  but  as  these  are  de- 
scribed under  their  respective  headings,  it  will 
not  be  necessary  in  this  place  to  do  moro  than 
refer  to  them. 

Rupture  of  the  heart  is  the  most  frequent 
origin  of  haemorrhage  into  the  walls  of  the  organ. 


504  HEART,  HAEMORRHAGE  INTO  WALLS  OF;  AND  HYPERTROPHY  OF 


Tbe  blood  in  these  cases  may  be  derived  from 
the  cavity  of  the  ventricle,  and  forced  between 
the  muscular  fibres  at  each  contraction.  More 
rarely,  a partial  rupture  of  the  wall  may  occur, 
unconnected  with  the  cavities,  and  haemorrhage 
take  place  into  the  seat  of  the  lesion  from  one 
of  the  coronary  vessels  or  their  branches,  con- 
stituting what  has  been  called  cardiac  apoplexy. 
In  both  classes  fatty  degeneration  is  generally 
the  cause  of  the  rupture. 

The  formation  of  false  consecutive  aneurism 
of  the  heart  may  be  attended  with  haemorrhage 
into  the  walls  ; an  abscess,  blood-cyst,  hydatid- 
cyst,  or  gumma  having  burst  or  made  its  way 
into  one  of  the  cavities. 

The  coronary  arteries  may  be  the  source  of 
the  haemorrhage ; for  instance,  in  rupture  of  co- 
ronary aneurism ; in  cases  of  cancerous  ulcera- 
tion of  their  walls ; and  in  embolism  or  throm- 
bosis of  their  lumen,  leading  to  infarction. 

Ecchymosis  of  the  heart  is  a form  of  haemor- 
rhage belonging  to  a different  category.  It  is 
generally  met  with  in  association  with  paren- 
chymatous degeneration  of  the  heart,  for  ex- 
ample in  the  acute  specific  fevers;  with  that 
form  of  fatty  degeneration  which  is  produced  by 
certain  poisons,  such  as  phosphorus  and  arsenic; 
and  with  other  pathological  states  in  which 
ecchymoses  occur  in  the  viscera  generally,  as  in 
purpura  and  scurvy,  and  especially  in  cardiac 
and  pulmonary  disease. 

In  cases  of  non-fatal  haemorrhage  into  the 
walls  of  the  heart,  the  blood  undergoes  the 
changes  usual  in  extravasations,  and  gives  rise 
to  the  collections  of  pigment-particles  which 
are  sometimes  found  between  and  upon  the 
muscular  fibres  ; to  blood-cysts  ; or  to  collections 
of  puriform  matter. 

Hiemorrhage  into  the  myocardium  possesses 
tn  special  clinical  relations. 

•T.  Mitchell  Bruce. 

HEART,  Hydatid-Disease  of.  — A con- 
siderable number  of  cases  have  been  recorded,  in 
which  hydatids,  in  the  wider  sense  of  the  term, 
have  been  found  in  the  human  heart.  According 
to  Dr.  Cobbold.  3'5  per  cent,  of  all  cases  of  hyda- 
tids in  man  occur  in  this  situation. 

Anatomical  Characters. — Hydatid-cysts  of 
the  heart  are  either  simple  or  multiple,  the  latter 
being  the  more  common  of  the  two  forms.  They 
are  situated  in  the  myocardium  of  either  side  of 
the  heart ; but  tend  naturally  by  enlargement  to 
project  either  into  the  pericardial  sac  or  into 
one  of  the  cardiac  cavities,  in  the  form  of  a pro- 
minent cystic  tumour.  In  this  condition  they 
have  generally  been  found  post  mortem ; but  it 
is  probable  that  in  other  cases  the  parasite  may 
undergo  degenerative  changes  in  the  heart,  as  in 
other  organs,  without  its  existence  being  sus- 
pected during  life  or  discovered  after  death.  In 
other  instances,  the  hydatids  rupture  or  are  dis- 
lodged from  their  seat  in  the  cardiac  wall — 
either  inwards  or  outwards,  or  in  both  directions 
at  once.  In  the  first  event,  the  parasite  or 
its  contents  or  fragments  become  impacted  in 
the  cardiac  cavities  or  orifices,  or  give  rise  to 
embolism  of  the  great  vessels  or  of  a distant 
branch.  Rupture  of  a cyst  into  the  pericardial 
sac  causes  pericarditis;  and  rupture  both  inter- 


nally and  externally  has  given  rise  to  haemoperi- 
cardium. 

Hydatids  of  the  heart  are  frequently  associated 
with  the  same  disease  in  other  viscera.  The 
appearance  and  structure  of  the  entozoon  do  not 
require  to  be  described  here.  See  Hydatids. 

Symptoms. — In  several  cases  of  this  disease, 
the  subjects  have  died  suddenly  during  exertion, 
or,  as  in  a case  recorded  by  Dr.  Wilks,  after  a 
hearty  meal.  These  persons  were  not  known  to 
have  suffered  previously  from  symptoms  referable 
to  the  heart.  In  other  instances,  the  ordinary 
phenomena  of  chronic  cardiac  disease  were  pre- 
sent,including  endocardial  murmurs;  but  it  is  not 
certain  that  these  were  always  due  to  the  pre- 
sence of  the  hydatids  in  the  heart.  A sudden 
fatal  termination  will  be  the  result  of  internal 
rupture  and  embolism,  or  of  liaemopericardium, 
as  described  above. 

Diagnosis. — Hydatid-disease  of  the  heart  does 
not  appear  to  have  ever  been  suspected  during 
life.  Cardiac  symptoms  and  signs,  or  sudden 
death,  occurring  in  an  individual  known  to  be 
suffering  from  hydatids  of  other  viscera,  would 
suggest  that  the  heart  was  also  affected. 

Treatment. — The  disease  cannot  be  said  to 
have  any  special  interest  therapeutically. 

J.  Mitchell  Bruce. 

HEART,  Hypertrophy  of. — Synon.  : Fr. 
Hypertrophie  du  Occur ; Ger.  Hypertrophic  des 
Herzens. 

Definition. — Hypertrophy  of  the  heart,  in  a 
wide  acceptation  of  the  term,  may  be  said  to  ex- 
press an  increase  in  the  size  and  weight  of  the 
organ,  due  to  an  excessive  development  of  somo 
one  of  the  constituent  elements  of  its  walls.  In 
the  sense  in  which  it  is  generally  used,  however, 
hypertrophy  of  the  heart  signifies  an  excessive 
development  of  the  muscular  substance  only. 

Such  hypertrophy  may  be  regarded  as  a conser- 
vative process;  and  is  not  intended  to  include 
those  changes  in  the  size  of  the  heart  in  which 
the  connective  and  fatty  tissues  are  in  excess. 

Varieties. — The  varieties  of  hypertrophy  of 
the  heart  were  first  carefully  described  by  M. 
Bertin  in  1811,  who  demonstrated  that  the  change 
in  hypertrophy  is  the  result  of  an  increase  of 
nutrition.  He  described  three  forms,  which  most 
succeeding  writers  have  referred  to,  namely: — 
(1)  Simple  Hypertrophy,  in  which  the  parietes  of 
the  compartments  are  thickened,  the  cavities 
retaining  their  natural  dimensions  ; (2)  Hyper- 
trophy with  Dilatation  ( Exccntric  Hypertrophy), 
in  which  the  cavities  are  increased  in  capacity, 
while  the  parietes  are  either  of  natural  or  of 
augmented  thickness;  (3)  the  so-called  Con- 
centric Hypertrophy,  or  Hypertrophy  with  Dimi- 
nished Cavities,  in  which  new  material  was  sup- 
posed to  be  added,  chiefly  in  the  interior  of 
the  ventricular  walls.  Cruveilhier  and  Budd 
pointed  out  that  the  condition  called  concentric 
hypertrophy  is  the  result,  not  of  hypertrophy, 
but  of  a powerful  contraction  of  the  organ  sud- 
denly' arrested,  ns  it  were,  by  death.  Budd 
found  that  the  hearts  of  persons  who  had  died  a 
violent  death  presented  this  so-called  concentric, 
hypertrophy : but  that  such  hearts  became  re- 
laxed. nnd  showed  the  normal  size  of  cavitiej 
and  thickness  of  walls,  after  maceration.  Roki- 


HE/iKT  HY P EItTR 0 P H Y OF. 


tansky  and  Bamberger  acknowledge  the  rarity 
of  concentric  hypertrophy,  hut  think  it  does 
sometimes  occur.  It  is  said  to  have  been  found 
in  the  right  ventricle  in  some  cases  of  congenital 
malformations.  Hypertrophy  may  affect  only 
one  compartment  of  the  heart,  or  more  than  one, 
but  the  organ  is  seldom  enlarged  throughout. 
The  ventricles  are  much  more  frequently  hyper- 
trophied than  the  auricles,  and  the  left  ventricle 
more  frequently  than  the  right ; but  the  right 
auricle  more  frequently  than  the  left  auricle — 
which  last  shows  the  change  very  seldom. 

iETioLoav  and  Pathology. — The  heart  being 
a muscular  organ,  whatever  calls  forth  increased 
frequency  and  force  of  its  action  induces  hyper- 
trophy of  its  muscular  tissue.  The  great  causes 
of  this  hypertrophy  are  certain  obstructive  con- 
ditions in  the  circulatory  apparatus,  which  will 
be  noticed  in  detail.  But  many  circumstances 
might  be  enumerated  as  predisposing  causes. 
Thus,  males,  from  the  nature  of  their  occupa- 
tions, are  twice  as  prone  tocardiachypertrophy  as 
females.  In  advanced  age  degenerative  vascular 
changes  are  apt  to  induce  this  result. 

Dr.  Quain  ( Lumlcian  Lectures,  1872)  has 
classified  the  exciting  causes  of  hypertrophy 
under  three  heads : — nervous,  mechanical,  and 
nutritive.  1.  Amongst  nervous  causes  are  those 
emotional  conditions  that  produce  frequent  pal- 
pitation, and  prolonged  mental  excitement  or 
strain.  The  immoderate  use  of  strong  coffee, 
tea,  or  spirituous  liquors  might  come  under  this 
head.  2.  Amongst  mechanical  and  physical  causes 
are  all  those  obstructive  conditions  to  be  after- 
wards specially  examined.  Violent  athletic  or 
other  exercises,  which  notably  accelerate  the  con- 
tractions of  the  heart,  or  produce  excessive  blood- 
pressure,  may  be  mentioned  here.  It  has  been 
pointed  out  that  great  muscular  exertion  with  the 
arms  is  specially  prone  to  cause  hypertrophy,  as 
in  the  case  of  hammermen,  &c.  Prolonged  working 
in  a bent  or  constrained  position  is  also  mentioned 
as  a cause.  In  fact,  any  prolonged  impediment 
to  the  free  action  of  the  heart,  or  to  the  onward 
current  of  the  circulation,  tends  to  cause  hyper- 
trophy of  the  heart.  Thus,  in  addition  to  val- 
vular lesions,  pericardial  adhesion  is  an  important 
cause.  Diseases  of  the  vessels,  by  diminishing 
their  elasticity  and  increasing  the  friction,  dis- 
placements of  the  heart,  and  deformities  of  the 
chest  or  spinal  column,  by  twisting  or  constricting 
the  aorta,  are  all  causes  of  some  obstruction  to 
the  blood-current.  The  heart  becomes  enlarged 
in  pregnancy — but  resumes  its  ordinary  size  by 
involution — as  the  womb  itself  does.  A very 
important  cause  of  cardiac  hypertrophy  is 
chronic  Bright’s  disease.  Aneurisms  also  some- 
times induce  hypertrophy,  for  the  physical  rea- 
son that  the  resistance  encountered  by  a liquid 
flowing  through  a tube  is  increased  by  the  pre- 
sence of  any  abrupt  dilatation  and  contraction 
of  the  calibre  of  the  tube.  Conditions  of  the 
lungs  associated  with  persistent  obstruction  to 
the  passage  of  blood  through  them  (emphy- 
sema, asthma,  phthisis,  compression  from  hydro- 
thorax, &c.)  may  induce  hypertrophy  of  the 
right  side  of  the  heart.  Hypertrophy  also  fol- 
lows upon  dilatation,  because  additional  force  is 
required  to  propel  the  larger  volume  of  blood, 
»part  from  any  valvular  lesion.  So  mere  plc- 


6t>rf 

thora  may  tend  to  cause  hypertrophy,  which  also 
ensues  upon  the  distension  of  the  cardiac  walls 
which  results  from  myocarditis.  3.  With  regard 
to  the  nutritive  causes  of  hypertrophy  of  the 
heart,  the  state  of  the  local  nutrition  and  the 
nutritive  quality  of  the  blood  have  both  to  be 
taken  into  account.  Ilicli  nitrogenous  food,  and 
the  use  of  ferruginous  medicines,  will  favour 
hypertrophic  changes.  AVith  the  increase  of  tho 
muscular  structure  there  is  proportional  enlarge- 
ment of  the  coronary  arteries,  so  that  the  hyper- 
trophied organ  has  an  increased  blood-supply. 

The  most  important  conditions  of  obstruction 
connected  with  cardiac  hypertrophy  are  the  fol- 
lowing : — (a)  Stcjwsis  of  the  aortic  valves  is  a 
common  cause  of  hypertrophy  of  the  left  ven- 
tricle. The  opening  is  not  only  narrowed,  but 
is  also  rendered  more  rigid,  and  thus  increased 
force  is  necessary  to  propel  the  blood.  Along  with 
the  valvular  lesion  there  may  also  be,  especially 
in  advanced  life,  a loss  of  elasticity  and  a rough- 
ening of  the  inner  coat  of  the  aorta  from  degene- 
rative changes — conditions  which  increase  the 
mechanical  strain  upon  tho  left  ventricle.  ( b ) 
Aortic  regurgitation  often  induces  so  great  en- 
largement of  the  left  ventricle,  from  hypertrophy 
and  dilatation,  that  the  heart  in  such  cases  merits 
the  name  cor  bovinum.  The  back-flow  of  blood 
increases  the  intra-ventricular  pressure,  tends 
to  dilate  the  cavity,  and  calls  forth  augmented 
efforts  of  ventricular  contraction,  (c)  Aortic  aneu- 
rism is  usually  instanced  as  a cause  of  cardiac 
hypertrophy,  and  we  gave  above  the  physical 
explanation  of  this  result.  But,  as  a matter  of 
fact,  many  cases  of  aortic  aneurism  have  been 
recorded  not  accompanied  by  cardiac  hyper- 
trophy, though  some  degree  of  this  change  is 
usually  expected.  Of  course,  other  tumours,  by 
pressing  upon  any  of  the  great  arterial  trunks, 
may  induce  cardiac  hypertrophy.  ( d ) Chronic 
Bright's  disease  (contracted  kidney)  is  a very 
important  cause  of  left-heart  hypertrophy,  the 
hypertrophy  being  often  of  the  purest  type,  with- 
out dilatation.  This  change  is  the  result  of  the 
great  increase  of  blood-tension  produced  by  the 
resistance  offered  to  the  blood  in  the  small  arteries 
through  the  whole  body,  as  well  as  in  the  kidneys, 
(e)  As  the  result  of  mitral  stenosis,  the  left  auricle 
becomes  somewhat  thickened  and  dilated;  and  the 
further  backward  blockage  of  the  blood  produces 
pulmonary  engorgement,  and  hypertrophy  with 
dilatation  of  the  right-heart.  (/)  Similar  results 
follow  the  more  common  lesion — mitral  incompe- 
tency. Blood  regurgitates  at  each  ventricular 
systole  into  the  left  auricle,  which  has  thus  to 
sustain  the  ventricular  impulse  in  addition  to  the 
pressure  from  excessive  fulness.  H3rpertrophy 
and  dilatation  of  the  left  auricle,  engorgement  of 
the  lungs,  and  hypertrophy  with  dilatation  of  the 
right-heart,  are  the  natural  consequences.  In- 
deed, hypertrophy  of  the  right  ventricle  is  almost 
always  associated  with  dilatation,  and  the  double 
change  is,  in  almost  every  case,  consequent  upon 
pulmonary  obstruction,  which  may  be  caused  by 
primary  changes  in  the  lungs  themselves  (see  g), 
but  is  far  more  frequently  secondary  to  left- 
heart  disease  (mitral  lesions).  (g)  In  emphy- 
sema, fibrosis,  and  consolidated  or  compressed 
conditions  of  the  lungs,  the  impediment  to  the 
pulmonary  circulation  induces  hypertrophy  with 


HEART,  HYPERTROPHY  Of. 


406 

dilatation  of  the  right  ventricle.  Diseases  of  the 
'pulmonary  orifice  are  very  rare  ; so,  too,  is  tri- 
cuspid stenosis.  (h)  But  tricuspid  regurgitation 
is  common  as  a result  of  dilatation  of  the  right 
ventricle ; and  this,  in  its  turn,  causes  dilatation, 
usually  with  considerable  hypertrophy,  of  the 
right  auricle.  General  systemic  venous  obstruc- 
tion follows  upon  right-heart  blockage ; and 
Hope  says  that  venous  retardation  may  "work 
backwards  through  the  capillaries  to  the  minute 
arteries,  the  consequent  increased  resistance  in 
which  may  induce  left-heart  hypertrophy. 

Anatomical  Chaeactees. — -The  fundamental 
anatomical  change  in  cardiac  hypertrophy  is  an  in- 
crease of  the  proper  muscular  tissue  of  the  heart. 
There  is  no  growth  of  new  tissue  different  from 
the  normal  heart-muscle;  there  is  simply  an 
increase  in  the  number  of  muscular  fibres  in  all 
respects  similar  to  those  normally  occurring  in 
the  organ.  Along  with  the  hypertrophy  of  the 
muscular  tissue,  there  may  be  also  more  or  less 
increase  of  the  connective  tissue  between  the 
muscular  bundles ; and  this  fibrous  hyperplasia 
may  be  excessive,  as  Dr.  Quain  has  pointed  out, 
constituting  a so-called  ‘ false  hypertrophy,’  in 
which  the  colour  of  the  cardiac  walls  varies  from 
the  natural  to  a light  grey  hue.  There  may  be 
hypertrophy  of  only  one  part  of  the  cardiac  walls, 
abnormal  thinning  being  found  in  other  parts. 
The  organ  may  be  greatly  enlarged  from  general 
dilatation,  without  any  notable  thickening  of  the 
walls  ; but  the  capacity  of  the  chambers  should 
always  be  carefully  noted  in  estimating  the  de- 
gree of  hypertrophy,  as  there  may  be  a greatly 
augmented  extent  of  wall,  although  its  actual 
thickness  seems  normal.  Simple  hypertrophy  is 
neai’ly  always  the  first  condition,  preceding  hy- 
pertrophy with  dilatation.  The  greatest  cardiac 
enlargements  result  from  left-sided  hypertrophy. 
Some  examples  of  cor  bovinum  have  attained  the 
enormous  weight  of  40  oz.  The  wall  of  the  left 
ventricle  may  become  thickened  to  one  or  even 
one-and-a-half  inches,  instead  of  the  normal  six 
or  seven  lines  ; and  the  thickest  part  is  usually 
about  the  middle  of  the  ventricles.  The  inter- 
ventricular septum  is  not  so  liable  to  hypertrophy 
as  the  rest  of  the  ventricular  parietes.  The 
right  ventricular  wall  maybe  thickened  to  the  ex- 
tent of  one  inch,  instead  of  the  normal  two-and- 
a-lialf  lines,  and  its  greatest  thickness  is  at  its 
base.  The  column*  carnese  of  the  right  ventricle  are 
even  more  liable  to  hypertrophy  than  the  wall.  In 
dilatation  with  hypertrophj'  the  column*  carne* 
become  stretched  and  attenuated.  The  substance 
of  an  hypertrophied  left  ventricle  can  generally 
be  torn  with  ease,  whilst  that  of  an  hypertrophied 
right  ventricle  is  usually  tough  aDd  leathery. 
The  auricular  walls  are  rarely  thickened  to  more 
than  twice  the  natural  thickness,  and  are  almost 
always  dilated  considerably  if  hypertrophied 
at  all.  In  marked  hypertrophy,  the  heart  pre- 
sents a change  of  configuration,  becoming  more 
globular,  and  having  the  apex  tilted  up.  If 
the  enlargement  is  mainly  on  the  right  side,  the 
sphericity  of  the  organ  is  a marked  characteristic, 
and  its  long  diameter  has  a tranverse  direction 
in  the  chest.  Of  course,  other  pathological  con- 
ditions, as  valvular  lesions,  or  the  results  of  endo- 
carditis or  of  pericarditis,  may  also  be  present. 
In  true  hypertrophy  the  coronary  arteries  become 


enlarged.  There  may  sometimes  be  found  accu- 
mulations of  fusiform  involuntary  fibres,  which 
have  not  developed  into  the  higher  state  of  striped 
fibres. 

Symptoms  and  Signs. — Precise  physical  signs 
are  all-important  in  establishing  a diagnosis  in 
cardiac  enlargements,  and  it  is  always  exnedieut 
at  once  to  ascertain  which  chamber  or  chambers 
is  or  are  affected.  It  must  not  be  forgotten  that 
simple  hypertrophy  may  exist  without  producing 
symptoms  attracting  the  attention  of  the  patient, 
and  that  there  is  a natural  tendency  to  some 
degree  of  cardiac  hypertrophy  with  the  advance 
of  age.  Dyspnoea. — In  moderate  hypertrophy 
without  complication,  there  is  usually  easy  and 
natural  breathing  when  the  patient’s  body  and 
mind  are  at  rest.  But  mental  excitement  or 
bodily  effort  at  once  induces  more  or  less  of 
temporary  dyspneea.  In  some  cases  the  due 
expansion  of  the  lungs  may  be  mechanically 
impeded  by  the  increased  volume  of  the  heart. 
In  excentric  hypertrophy  with  dilatation,  more 
especially  when  the  right  cavities  are  thus  af- 
fected, pulmonary  congestion  and  oedema  arc 
very  usually  present,  and  then  marked  dyspnoea 
is  a prominent  and  distressing  symptom.  Cough. 
— In  simple  hypertrophy  there  may  be  an 
occasional  dry  irritating  cough,  and  in  young 
phlethoric  women  a wheezing  cough  may  be 
complained  of.  In  right-side  enlargements  when 
pulmonary  obstruction  and  dropsical  effusions 
supervene,  cough  is,  in  most  cases,  a very  fre- 
quent and  painful  addition  to  the  other  sources 
of  discomfort  to  the  patient.  Heemoptysis  and 
other  hemorrhages. — Hsemoptysis  from  capillary 
engorgement  is  common,  being  generally  active 
and.  sudden.  Niemcyer  points  out  that,  in  left- 
heart  hypertrophy,  there  is  often  active  disten- 
sion, and  sometimes  rupture,  of  the  branches  of 
the  bronchial  arteries.  In  left  hypertrophy, 
too,  the  cerebral  arteries  are  specially  liable  to 
give  way.  In  right-side  enlargement  with  pul- 
monary obstruction,  the  blockage  may  influence 
the  vessels  of  the  liver  and  the  portal  system 
generally,  so  as  to  produce  liaematemesis  or 
melrena.  Epistaxis  may  also  be  due  to  cardiac 
enlargement.  Palpitation  is  a common  symptom 
in  all  organic  diseases  of  the  heart,  and  is  often 
very  marked  in  cardiac  enlargements.  The  least 
excitement,  bodily  or  mental,  may  induce  a 
greater  or  less  degree  of  this  symptom.  Especi- 
ally in  excentric  hypertrophy  with  dilatation, 
most  distressing  paroxysms  of  palpitation  are 
apt  to  occur  from  time  to  time.  Besides  bodily 
and  mental  excitement,  other  conditions,  such  as 
indigestion,  flatulence,  or  an  overloaded  stomach, 
readily  call  forth  this  symptom.  "When  there  is 
much  dilatation,  the  palpitation  may  be  irregular 
and  intermittent,  and  is  then  more  particularly 
a very  alarming  symptom.  Pulse. — In  s.mple 
hypertrophy  the  pulse  is  stronger,  fuller,  tenser, 
less  compressible  than  natural,  and  dax  .s  longer 
under  the  finger,  the  hypertrophied  walls  re- 
quiring more  time  for  contraction,  and  contract- 
ing with  greater  force  than  normal.  When 
dilatation  relatively  exceeds  the  hypertrophy 
there  is  diminished  strength,  hut  more  fulness, 
and  sometimes  marked  slowness  of  the  pulse.  In 
aortic  obstruction  with  left  hypertrophy  the  pulse 
is  strong,  incompressible,  small,  and.  sustained 


HEART.  HYPERTROPHY  OF.  C07 


In  aortic  regurgitation  it  feels  as  if  liquid  balls 
passed  under  the  finger.  In  mitral  obstruction 
it  is  frequently  small  and  irregular.  In  mitral 
regurgitation  it  is  irregular  in  size  (not  necessarily 
in  rhythm).  In  enlargement  of  the  right  ventricle 
the  pulse,  as  a rule,  is  small,  -weak,  and  perhaps 
intermittent  or  irregular.  When  atheroma  of 
the  vessels  is  associated  with  cardiac  hypertrophy, 
the  pulse  is  bounding.  In  the  mere  hypertrophy 
of  old  age  it  is  full  and  slow,  but  not  very  incom- 
pressible. Certain  cerebral  symptoms  ought  to 
be  mentioned  in  connection  with  the  other  more 
direct  signs  of  cardiac  hypertrophy.  A feeling 
of  fulness,  or  perhaps  of  throbbing,  may  be  felt 
in  the  head  after  great  muscular  exertion  or 
mental  excitement.  In  pronounced  cases  there 
may  be  headache,  ringing  in  the  ears,  vertigo, 
muses  volitantes,  and  disturbing  dreams.  The 
bright  and  shining,  or  perhaps  the  blood-shot, 
condition  of  the  eyes,  is  an  indication  of  the 
hypersemia  of  the  cerebral  vessels. 

Hypertrophy  of  the  Left  Ventricle.— Simple 
hypertrophy  of  this  portion  of  the  heart  does 
not  tisually  produce  much  disturbance  of  re- 
spiration, but  palpitation  is  a prominent  symp- 
tom, and  cerebral  complications  are,  as  we 
have  seen,  by  far  most  frequent  in  this  form  of 
cardiac  change.  On  inspection , the  prsecordium 
sometimes  shows  a bulging,  more  especially  in 
young  subjects,  whose  sternal  cartilages  are 
less  resistant.  Walshe  says  there  may  be  some 
convexity  of  the  cardiac  region  from  the  third  to 
the  seventh  cartilages,  and  that  the  interspaces 
are  rendered  wider,  but  do  not  bulge.  In  simple 
hypertrophy  the  area  of  impulse  may  be  seen  to 
be  enlarged,  and  to  be  located  more  to  the  left 
and  lower  down  than  normal.  On  palpation 
the  apex-impulse  may  be  felt  to  be  greatly 
augmented  in  force,  and  to  extend  perhaps  over 
the  fourth,  fifth,  and  sixth  interspaces.  When 
there  is  very  great  hypertrophy  of  the  left  ven- 
tricle, without  pericardial  adhesion  or  much 
dilatation,  the  apex-beat  may  be  felt,  powerful 
and  well-defined,  even  in  the  seventh  or  eighth 
intercostal  space.  Dr.  Walshe  describes  the 
sensation  as  a slow  heavi  ng,  or  a pushing  forward 
as  if  against  an  obstacle.  The  duration  of  the 
heaving  impulse  is  in  proportion  to  the  degree 
of  hypertrophy.  The  impulse  is  often  strong 
enough  to  visibly  move  the  bed-clothes,  and  even 
to  raise  the  head  of  the  auscultator  by  the  im- 
pact against  the  stethoscope.  Of  course  a larger 
portion  than  usual  of  the  heart’s  surface  impinges 
against  the  chest-wall.  With  coexistent  valvu- 
lar lesions,  a vibratory  jarring  sensation  may 
be  felt  on  palpation ; and  with  pericardial  ad- 
hesions the  impulse  may  be  a sort  of  jogging 
motion. 

In  hypertrophy  with  dilatation  the  impulse  is 
less  powerful,  but  is  seen  and  felt  over  a wider 
1 area  than  in  simple  hypertrophy.  The  contrac- 
tions are  felt  more  like  sharp  blows  or  shocks, 
and  the  vibrations  are  conveyed  to  greater  dis- 
tances, in  some  cases  extending  to  the  top  of  the 
i chest-wall.  With  great  dilatation  the  pulse 
may  be  very  slow,  weak,  and  compressible.  On 
l percussion,  the  areas  of  both  the  superficial  and 
the  deepcardiacdulness  are  found  to  be  increased, 
especially  towards  the  left.  In  excessive  hyper- 
trophy with  dilatation,  the  dulness  may  extend 


from  the  upper  border  of  the  third  rib  down  to 
the  eighth  rib,  and  from  an  inch  to  the  right  of 
the  sternum  to  the  anterior  axillary  line.  Dulness 
may  also  be  detected  in  the  left  back.  Emphy- 
sema and  possible  consolidation  of  the  lungs 
must  be  borne  in  mind  in  marking  out  the  area 
of  cardiac  dulness.  On  auscultation,  the  systolic 
sound  is  less  clear  and  defined  than  normal  in 
simple  hypertrophy;  it  is  prolonged  in  proportion 
to  the  degree  of  hypertrophy,  and  is  muffled  in 
character,  as  the  muscular  sound  is  excessively 
pronounced,  and  obscures  that  of  the  auriculo- 
ventricular  valves.  When  there  is  much  hyper- 
trophy, the  first  sound  may  be  of  a metallic  cha- 
racter. The  post-systolic  silence  is  shortened, 
and  the  second  sound  is  loud.  When  there  is 
dilatation  with  hypertrophy  the  first  sound  is 
more  audible  and  distinct,  and  the  second  sound 
is  louder. 

Hypertrophy  cf  the  Bight  Ventricle  — In  en- 
largements of  this  ventricle,  inspection  may  re- 
veal a rounded  smoothness  of  the  epigastrium, 
with  perhaps  some  bulging  of  the  ensiform  and 
lower  left  costal  cartilages.  The  apex-beat  may 
be  seen  to  be  very  diffused,  extending  towards 
the  tip  of  the  ensiform  cartilage.  Facial  livi- 
dity  is  frequently  seen;  and  jugular  pulsation 
may  be  observed  when  there  is  tricuspid  re- 
gurgitation. Palpation  over  the  lower  part  of 
the  sternum  detects  an  impulse,  which  feels  as 
if  immediately  under  the  hand,  and  wants  the 
heaving  character  of  the  impulse  of  a hyper- 
trophied left  ventricle.  Epigastric  pulsation  is 
often  very  pronounced.  The  liver-pulsation  in 
such  cases  may  result  either  from  venous  regur- 
gitation, or  from  right  systolic  action  exerted 
through  the  diaphragm.  On  percussion,  the 
inferior  line  of  dulness  is  found  to  extend  lower 
down  and  farther  towards  the  right  than  normal, 
sometimes  reaching  an  inch  or  more  beyond  the 
right  sternal  edge.  The  dulness  may  be  con- 
tinuous with  that  of  the  liver.  On  auscultation, 
the  first  sound  is  more  distinct  than  natural,  and 
seems  quite  superficial.  The  second  sound  is 
also  louder,  and  its  reduplication  is  not  uncom- 
mon. 

Hypertrophy  of  the  Auricles.  — It  is  always 
difficult  to  speak  very  definitely  of  the  condition 
of  the  auricles  during  life.  They  are  never  hy- 
pertrophied without  being  also  dilated,  and  such 
states  are  uniformly  connected  with  lesions  of  the 
auriculo-ventricular  valves.  Dulness  due  to  an 
enlarged  left  auricle  may  extend  up  to  the  second 
left  intercostal  space  ; that  due  to  an  enlarged 
right  auricle  may  be  found  in  the  third  and 
fourth  interspaces  at  the  right  sternal  edge. 
Jugular  pulsation  maybe  found  along  with  right 
auricular  enlargement,  which  itself  can  hardly 
ever  occur  without  an  abnormal  condition  of  the 
right  ventricle. 

Complications  and  Sequel.®:. — Simple  hyper- 
trophy of  the  heart  may  go  on  quietly  for  a 
long  time,  just  balancing  the  obstructive  in- 
fluence, and  giving  rise  to  no  other  form  of 
disease.  But  when  there  is  dilatation  as  well  as 
hypertrophy,  then  palpitation,  dyspnoea,  venous 
congestion,  and  serous  effusions  are  the  ordinary 
results.  Diseased  conditions  of  the  arteries  may 
occur  simultaneously,  or  rnav  he  induced  by  the 
long-continued  additional  strain  put  up  n them 


603  HEART,  HYPERTROPHY  OF. 
by  a hypertrophied  heart.  Cerebral  haemorrhage 
often  occurs  in  connection  with  an  hypertrophied 
left  ventricle,  as  in  Bright’s  disease ; although 
there  are  very  frequently  other  factors,  besides 
the  mere  excessive  propulsive  power  of  the  heart, 
in  the  production  of  apoplexy.  Pulmonary 
and  general  congestion  and  cedema  are  the  usual 
attendants  of  mitral  lesions  with  right-side  en- 
largements. Pulmonary  hsemorrhagic  infarction 
(the  so-called  1 pulmonary  apoplexy  ’)  generally 
results  from  embolism  of  the  branches  of  the  pul- 
monary artery,  and  takes  place  in  connection  with 
right-side  enlargement.  Sanguineous  exudation 
in  the  tract  of  the  bronchial  mucous  membrane 
may  occur  in  left-heart  hypertrophy.  Persons 
suffering  from  cardiac  hypertrophy  are  apt  to 
be  gravely  affected  by  acute  febrile  diseases, 
because  the  resultant  acceleration  of  the  heart’s 
action  increases  the  embarrassment  of  the  organ. 
Of  course,  hypertrophied  cardiac  walls  are  sub- 
ject to  the  fatty  degenerative  changes  described 
elsewhere.  As  has  been  alluded  to  already,  the 
chief  result  of  right-side  dilatation  is  obstruc- 
tion to  the  venous  return.  The  hepatic  circula- 
tion and  the  portal  system  generally  are,  in 
particular,  rapidly  overfilled,  the  whole  venous 
system  being  ultimately  affected.  The  kidneys 
likewise  suffer.  The  natural  results,  in  addition 
to  characteristic  changes  in  the  chronically  con- 
gested organs,  are  serous  effusions  into  the  cavi- 
ties and  subcutaneous  areolar  tissue. 

Diagnosis. — An  extended  area  of  dulness ; dis- 
placement of  the  apex-beat;  anda  slow,  heaving 
systolic  action,  with  augmented  force  of  impulse, 
are  the  chief  diagnostic  physical  signs  of  cardiac 
hypertrophy.  In  young  and  thin  people  the  last 
of  these  signs  may  seem  to  be  present,  but  the 
accompanying  conditions  readily  exclude  hyper- 
trophy, especially  the  non-extension  of  the  car- 
diac dulness.  An  emphysematous  left  lung  may 
mask  hypertrophy  when  present ; and  lung-con- 
solidation might,  though  only  for  a moment, 
suggest  it  when  absent.  In  pericardial  effusion 
the  triangular  shape  of  the  area  of  dulness,  with 
the  apex  of  the  triangle  upwards,  is  a distinctive 
feature  ; there  would,  moveover,  be  the  history 
of  an  acute  disease,  with  lancinating  pain,  dys- 
pnoea or  suffocative  sensations,  and  other  symp- 
toms not  found  in  mere  enlargement  of  the  heart. 
Pleuritic  effusion  or  aneurism  would  be  still  more 
readily  discriminated.  The  differential  diagnosis 
between  left-heart  and  right-heart  enlargements 
has  been  sufficiently  discussed  in  speaking  of 
the  symptoms  and  signs.  Dilatation  as  dis- 
tinguished from  hypertrophy,  is  characterised 
by  the  feebleness  and  diffuseness  of  the  apex- 
beat,  which  may  even  be  quite  imperceptible ; by 
t he  great  irregularity  and  intermittency  of  the 
heart’s  action  ; and  by  the  general  signs  and 
symptoms  of  a feeble  circulation. 

Prognosis. — Simple,  uncomplicated  hyper- 
trophy, as  in  the  young,  and  in  athletes,  is  not 
incompatible  with  long  life,  if  the  cause  be  re- 
moved in  time.  According  to  the  extent  and 
degree  of  complication,  whether  in  the  form  of 
valvular  lesions  or  co-existent  pulmonary  dis- 
ease, the  prognosis  will  be  unfavourable.  When 
the  cardiac  change  is  itself  producing  secondary 
lesions,  as  degenerations  of  the  arterial  coats, 
when  dilatation  is  advancing,  and  when  there  is 


HEART,  INFLAMMATION  OF. 

Bright’s  disease,  the  prognosis  becomes  very 
unfavourable. 

Treatment.—  -Hypertrophy  being  in  itself  a 
conservative  change,  protective  from  worse  re- 
sults, the  primary  object  is  to  remove,  if  possible, 
the  cause  of  the  hypertrophy.  To  aim  merely 
at  reducing  the  hypertrophy,  irrespectively  of 
its  cause,  as  by  lowering  the  nutrition,  would 
gravely  favour  the  worse  evil  of  dilatation. 
General  therapeutic  principles,  and  the  morbid 
conditions  accompanying  the  hypertrophy,  must 
therefore  be  carefully  attended  to.  All  mental 
and  bodily  exertion  which  excites  the  circulation 
must  be  scrupulously  avoided.  All  alcoholic 
stimulants  should  be  interdicted,  and  no  more 
wine  allowed  than  such  as  may  seem  to  benefit 
digestion.  The  diet  should  be  carefully  selected, 
nitrogenous  food  being  generally  necessary. 

. The  digestive  organs  must  be  sedulously  looked 
after,  not  only  because  good  nutrition  is  very 
important,  but  also  because  flatulence  and 
dyspepsia  directly  embarrass  the  heart's  action. 
Mild  saline  and  aloetic  aperients  should  be  given. 
Diuretics  will  be  necessary  if  there  is  a tendency 
to  dropsy,  and  in  all  cases  great  attention  must 
be  paid  to  the  removal  of  congestion  when  it 
affects  important  organs,  and  the  restoration  of 
their  functions  when  affected,  more  especially  of 
the  liver  and  the  kidneys.  When  there  is  great 
excess  of  cardiac  action,  direct  cardiac  sedatives, 
as  digitalis,  hydrocyanic  acid,  conium,  and  bel- 
ladonna, are  called  for.  When  there  is  dilatation 
and  feebleness  of  texture  with  the  hypertrophy 
iron  and  digitalis  are  the  chief  remedial  drugs. 

J.  R.  Wabdell. 

HE-ART,  Inflammation  of. — Inflammation 
of  the  heart  may  affect  either  the  lining  mem- 
brane, or  the  substance  or  walls  of  the  organ; 
and  the  subject  will  be  best  discussed  under  the 
separate  heads  of  Endocarditis  and  Myocarditis. 
Inflammation  of  tho  investing  membrane  of  the 
heart  is  described  in  the  article  Pericardium, 
Diseases  of. 

I.  Endocarditis.  Synox.  : Fr.  Endocardite; 
Ger.  Endocarditis. 

Definition. — Inflammation  of  the  lining  mem- 
brane of  the,  heart. 

Inflammation  of  the  endocardium  maybe  either 
acute  or  chronic.  The  acute  form  alone  will  he 
discussed  here;  chronic  endocarditis  being  re- 
ferred to  under  the  head  of  Heart,  1 alTes  of. 
Diseases  of. 

•/Etiology. — -Endocarditis  generally  occurs  in 
association  with  acute  rheumatism : less  fre 
quently  with  the  other  acute  specific  febrile 
diseases,  such  as  scarlet  fever,  measles,  erysipe- 
las, pysemiaand  septicaemia — including  pnerper.d 
fever ; and  much  more  rarely  with  typhoid  fever 
and  variola.  Occasionally  it  is  observed  in  the 
course  of  pregnancy,  and  after  parturition;  in 
acute  and  chronic  Bright's  disease ; and  in  syphi- 
lis. Wounds  and  other  injuries  of  the  heart, 
such  as  rupture  of  the  valves,  may  also  leal  to 
endocarditis  ; and  local  inflammation  of  the  en 
docardium  is  frequently  the  resultof  the  unnatural 
contact  of  one  part  of  it  with  another  during  the 
cardiac  revolution,  as.  for  example,  by  growths 
from  the  walls  or  valves,  or  by  unnatural  blood- 


HEART,  INFLAMMATION  OF. 


currents.  It  also  occurs  in  chorea,  perhaps  from 
the  last  of  the  causes  just  enumerated. 

Age  is  an  important  predisposing  factor  in  the 
aetiology  of  acute  endocarditis,  the  occurrence  of 
which  as  a complication  of  acute  rheumatism  is 
certainly  most  frequent  in  young  subjects,  and 
declines. as  age  advances.  "Women  are  also  more 
subject  to  rheumatic  endocarditis  than  men. 

The  localisation  of  the  endocardial  inflamma- 
tion appears  to  be  determined  chiefly  by  pressure 
and  tension,  rather  than  by  any  peculiarity  of 
the  membrane  itself,  or  of  the  blood  in  contact 
with  it.  Thus  the  left  ventricle  is  almost 
the  sole  seat  of  the  disease  in  the  adult,  and  the 
right  ventricle  in  the  foetus ; whilst  endocarditis 
is  rarely  seen  beyond  fhe  boundaries  of  the 
valves,  that  is,  the  parts  most  subjected  to 
strain.  In  the  same  way,  chronic  endocarditis 
is  usually  due  to  increased  pressure  within  the 
heart,  as  in  chronic  Bright’s  disease,  and  in  con- 
ditions that  entail  prolonged  severe  strain  upon 
the  valves  during  exertion.  A similar  cause  is 
at  work  in  pregnancy. 

In  a certain  number  of  instances  of  the  ulcera- 
tive form  of  endocarditis,  the  origin  of  the  disease 
has  been  traced  in  connection  with  the  presence 
of  an  ulcerating  surface  or  foul  wound  in  some 
part  of  the  body,  most  frequently  in  the  female 
genital  organs  post  partum. 

Axatomical  Characters. — Inflammation  of 
the  endocardium  affects  chiefly  the  valves  and 
the  chordae  tendine®,  and  especially  the  lines  of 
contact  or  the  surfaces  of  the  valves  exposed  to 
the  force  of  the  blood-current.  The  endocardium 
of  these  parts  at  first  appears  slightly  swollen, 
velvety,  soft,  and  of  various  shades  of  red ; 
whilst  the  lines  or  points  of  contact  of  the 
valves  present  warty  enlargements  of  a similar 
character,  which  are  known  as  ‘ vegetations.’ 
As  the  process  advances,  the  inflamed  areas 
become  more  opaque  and  firm;  and  a fibrinous 
deposit  is  entangled  with  their  surface.  When 
the  endocarditis  has  gone  thus  far,  resolution 
is  probably  rare  ; and  the  most  common  result 
is  what  is  known  as  ‘ chronic  valvular  disease,’ 
that  is,  that  the  affected  parts  are  left  opaque, 
puckered,  and  thickened  by  growth  of  connec- 
tive tissue,  whilst  the  vegetations  develop  into 
firm  fibroid  or  even  cartilaginous-like  bodies. 
As  a consequence  of  these  changes,  the  valves  may 
become  much  altered  in  size  and  shape,  and  the 
ostia  contracted  and  irregular,  so  that  the  mutual 
adaptation  of  the  parts  is  greatly  disturbed. 
Other  results  of  inflammation  are  not  uneonvmon 
:n  the  progress  of  endocarditis,  such  as  adhesions 
, between  the  neighbouring  structures,  and  ossifi- 
, cation  or  calcification  of  the  altered  tissues.  La- 
ceration of  the  valves  and  rapture  of  the  chordae 
tendine®  during  the  stage  of  diminished  resist- 
ance, ulceration,  suppuration,  and  the  formation 
of  aneurism  are  rarer  events. 

The  microscopical  appearances  of  inflammation 
of  the  endocardium  correspond  with  the  naked- 
eye  characters.  In  the  early  stages,  the  proper 
tissue  of  the  endocardium  is  swollen  by  hyper- 
emia, oedema,  aud  the  appearance  between  its 
fibres  of  a number  of  leucocytes  ; the  latter 
rapidly  multiply  to  form  the  bulk  of  the  vege- 
tations; and  the  surface  presents  various  thick- 
nesses of  deposited  fibrin,  which  in  its  turn  may 

39 


60“ 

become  organised.  The  further  development 
of  the  new  cells  into  connective  tissue  gives 
rise  to  the  opacity,  thickening,  and  puckering  of 
the  valves,  and  to  the  formation  of  permanent 
vegetations. 

The  effects  of  these  changes  upon  the  fuve 
tions  of  the  valves  and  their  appendages  are  de 
scribed  in  the  article  Heart,  Valves  of,  Diseases 
of.  Particles  of  fibrin,  and  even  of  the  vegetations 
are  occasionally  detached  from  the  endocardium 
and  give  rise  to  embolism. 

In  a special  form  of  the  disease,  which  is  knowi 
as  ulcerative  endocarditis,  the  morbid  appeu 
ances  are  at  first  not  unlike  those  described  abovt 
as  characterising  the  early  stage  of  the  ordinary 
affection ; but  the  process  pursues  a differem 
course,  and  becomes  mainly  destructive  in  it; 
nature.  The  edges  or  surfaces  of  the  valvrs  then 
present  spots  or  patches  of  loss  of  substance 
having  an  eroded  appearance,  and  an  irreguD  > 
base,  covered  with  granular  matter,  and  fringe;! 
by  vegetations.  These  diseased  are*  may  ad- 
vance to  actual  perforation,  burrowing  abscess, 
or  aneurism.  Microscopically  examined,  the 
patches  prove  to  be  are*  of  ulceration,  and  the 
granular  matter  of  their  base  has  been  found  by 
Virchow  and  others  to  contain  organisms,  which 
were  seen  at  the  same  time  in  the  capillaries  oi 
distant  parts  of  the  body. 

Symptoms. — The  symptoms  of  endocarditis  are 
inseparable  from  the  symptoms  of  the  disease 
with  which  it  is  associated,  and  the  diagnosis  of 
it  is  made  almost  entirely  from  tho  presence  of 
physical  signs.  Thus  fever  probably  precedes 
the  advent  of  endocarditis,  in  every  case ; and 
it  cannot  be  said  that  the  simple  uncomplicated 
disease  in  any  respect  affects  either  the  pyrexia 
or  any  other  element  of  the  same.  Local  symp- 
toms are  almost  equally  rare,  unless  the  endo- 
carditis leads  to  serious  lesion  of  the  cardiac 
valves.  As  long  as  these  remain  sound,  and 
the  disease  is  acute  and  does  not  involve  deeper 
structures,  pain  in  the  heart,  prmcordial  distress, 
syncope,  shortness  of  breath,  and  other  symptoms 
of  heart-disease  cannot  be  said  to  occur  at  all 
frequently  in  endocarditis.  The  cardiac  contrac- 
tions are  necessarily  increased  in  frequency;  and 
palpitation  and  dyspncea  may  occur  on  movement. 
It  is  otherwise  when  the  inflammation  has  lasted 
so  long  as  to  render  the  valves  incompetent,  or 
to  obstruct  the  orifices  ; or  when  the  myocardium 
is  attacked,  and  dilatation  ensues.  The  symptoms 
just  enumerated  then  make  their  appearance,  as 
well  as  those  of  secondary  involvement  of  the 
lungs,  of  the  circulation,  and  of  the  system  gene- 
rally. 

Ulcerative  endocarditis,  unlike  the  ordinarv 
form  of  the  disease,  is  manifested  by  severe  and 
striking  symptoms,  although  amongst  these  the 
phenomena  of  cardiac  inflammation  are  compa- 
ratively subordinate  to  those  of  general  infection. 
It  is  on  this  account  that  ulcerative  endocarditis 
has  only  recently  been  definitely  recognised  as  a 
distinct  form  of  disease,  the  condition  of  tho  endo- 
cardium post  mortem  having  apparently  been 
disregarded  in  the  presence  of  serious  lesions  of 
the  other  viscera,  of  the  blood-vessels,  and  of  the 
blood  itself.  Commencing  with  a sudden  rigor,  in 
the  course  of  acute  rheumatism,  during  the  puer- 
peral state  in  women,  or  in  a case  of  chronic 


1 


HEART,  INFLAMMATION  OF. 


310 

valvular  disease,  ulcerative  endocarditis  either 
resembles  a simple  continued  or  typhoid  fever 
from  first  to  last,  or  assumes  a markedly'  pyaemic 
character.  In  the  former  case,  gastro-enteric 
symptoms  and  splenic  enlargement  may  be 
strongly  marked ; whilst  in  the  second  case, 
vomiting  and  diarrhoea,  jaundice,  albuminuria, 
and  various  eruptions,  with  pyrexia  of  a pysemic 
or  remittent  type,  are  prominent  phenomena.  In 
both  forms  the  case  steadily  progresses  towards 
a fatal  termination.  A loud  systolic  murmur  is 
generally  present  from  the  first,  and  may  point 
to  the  heart  as  the  primary  skat  of  disease  ; but 
in  ulcerative  endocarditis,  as  in  simple  endocar- 
ditis, special  local  symptoms  are  rare. 

Physical  Signs. — The  physical  signs  of  acute 
endocarditis  are — increased  extent  andfrequency, 
with  variable  strength,  of  the  visible  and  pal- 
pable impulse;  moderate  increase  in  the  area  of 
prsecordial  duiness ; and  various  alterations  in 
the  cardiac  sounds.  At  the  beginning  of  endo- 
carditis, the  first  sound  at  the  left  apex  is  fre- 
quently heard  prolonged  and  hollow,  or  muffled ; 
and,  as  the  process  advances,  this  alteration  of 
character  may  gradually  pass  into  a murmur, 
which  is  at  first  indistinct,  but  afterwards  well- 
formed.  If  the  aortic  valves  are  affected,  the 
second  sound  may  similarly  lose  its  characters, 
become  dull,  and  finally  be  converted  into,  or  be 
complicated  with,  a murmur.  The  most  frequent 
murmur  in  acute  endocarditis  is  mitral  systolic ; 
aortic  murmurs  are  decidedly  less  common  ; and 
mitral  prsesystolic  murmur  is  very  rare.  Various 
inorganic  murmurs  may  appear,  and  either  dis- 
appear or  continue  during  the  course  of  the 
disease. 

Complications, — Endocarditis  is  itself  always 
a complication  of  the  diseases  previously  men- 
tioned. Myocarditis  and  pericarditis  may  be  cor- 
rectly regarded  as  complications  of  endocarditis, 
when  the  inflammation  begins  in  the  lining  mem- 
brane of  the  heart.  According  to  some  authorities, 
clots  may  form  in  the  heart  in  endocarditis,  and 
give  rise  to  very  urgent  symptoms  (see  Heart, 
Thrombosis  of).  Embolism  may  arise  from  de- 
tachment of  fragments  of  coagula  or  vegetations  ; 
and  this  condition,  and  the  development  of 
pycemic  symptoms  are  essential  elements  in  the 
course  of  the  ulcerative  form  of  the  disease. 
Congestion  or  inflammation  of  the  lungs  fre- 
quently occurs  in  association  with  endocarditis, 
and  so  may  albuminuria. 

Course,  Terminations,  and  Sequels. — The 
course  of  simple  endocarditis  is  very  uncertain, 
and  varies  with  the  course  of  the  original  disease 
with  which  it  is  associated,  as  well  as  with  the 
complications.  If  acute  rheumatism  be  checked 
in  a few  days,  inflammation  of  the  endocardium 
may  bo  expected  to  be  also  arrested.  In  a con- 
siderable number  of  cases,  however,  endocarditis 
passes  on  to  chronic  valvular  disease.  For  ex- 
ample, the  late  Dr.  Sibson  found  that  seventeen 
jut  of  seventy  cases  of  endocarditis  with  mitral 
systolic  murmur  ended  in  established  valvular 
disease,  and  less  than  a half  of  the  cases  with 
diastolic  basic  murmur. 

simple  endocarditis  very  rarely  proves  fatal; 
hu'  the  ulcerative  form  is  believed  to  be  uni- 
f.itmly  so  in  the  course  of  a few  days,  or  it  may 
be  weeks.  On  the  other  hand,  simple  endocar- 


ditis, being  by  far  the  most  common  cause  at 
valvular  disease  of  the  heart,  leads  indirectly  to 
much  suffering,  and,  as  a rule,  ultimately  to 
death. 

Diagnosis.  — The  diagnosis  of  endocarditis 
depends  upon  the  discovery  of  the  development 
of  an  endocardial  bruit  of  organic  origin  during 
the  course  of  one  of  the  diseases  alrea  ;y  named. 
From  functional  murmurs  the  bruits  of  vsirular 
inflammation  may  be  diagnosed  under  different 
circumstances — first,  by  their  locality,  which  is 
most  frequently  the  mitral  area ; secondly,  by  their 
time,  diastolic  or  prsesystolic  murmurs  Leing  al- 
ways organic ; and,  thirdly,  by  their  association 
with  pericardial  friction.  The  special  characters 
of  inorganic  murmurs  are  described  elsewhere. 
Chronic  valvular  disease  may  he  diagnosed  from 
acute  eudoearditis  by  the  presence  of  cardiac 
enlargement  and  other  weil-known  signs ; of 
marked  cardiac  symptoms — especially  pain  and 
dyspnoea ; and  of  visceral  complications.  Much 
more  difficult  of  diagnosis  is  acute  endocarditis 
occurring  in  the  course  of  chronic  valvular  dis- 
ease. Change  of  the  character  of  the  murmur,  if 
this  have  been  observed  previously,  may  lead  to 
the  suspicion  of  fresh  inflammation,  but  cannot 
establish  the  diagnosis  of  its  existence,  which 
may  not  be  discoverable.  The  diagnosis  of  the 
precise  seat  of  endocarditis  on  the  various  valves 
is  discussed  in  the  article  Heart,  Valves  and 
Orifices  of,  Diseases  of. 

It  is  often  impossible  to  diagnose  ulcerative 
endocarditis  from  typhoid  fever  or  pyaemia  re- 
spectively, according  to  the  form  that  it  assumes; 
unless  the  aetiology  of  the  case,  the  precise  cha- 
racter of  the  pyrexia,  and  the  occurrence  of  ms- 
tastases  he  very  carefully  regarded,  along  with 
the  development  of  a murmur  at  one  or  more  of 
the  cardiac  orifices,  and  possibly  of  pericarditis. 

Prognosis. — The  immediate  prognosis  of  acute 
endocarditis  is  generally  favourable,  and  maybe 
safely  estimated  by  the  absence  of  local  symp- 
toms. The  remote  prognosis,  on  the  other  hand, 
as  regards  both  life  an  1 health,  is  exceedingly 
bad,  inasmuch  as  endocarditis  so  frequently 
ends  in  chronic  valvular  disease.  The  proba- 
bility of  this  result  of  acute  inflammation  of  the 
valves  is  frequently  difficult  or  impossible  to  esti- 
mate. A feeble,  soft,  and  smooth  murmur,  or  a 
feeble  and  grave  murmur,  is  much  more  likely  to 
disappear  than  a loud  extensive  well-defined 
bruit.  The  probability  of  the  disappearance  of 
diastolic  basic  murmurs  may  be  best  estimated 
by  the  absence  of  the  effects  produced  by  aortic 
incompetence  upon  the  heart  and  vessels. 

Treatment. — The  treatment  of  acute  endocar- 
ditis  has  to  be  discussed  under  three  heads, 
namely,  first,  preventi  ve ; secondly,  immediate  ; 
and  thirdly,  subsequent  treatment. 

a.  Preventive  treatment. — When  a patient  is 
suffering  from  any  disease  which  may  become 
complicated  with  endocarditis,  and  especially 
if  lie  be  suffering  from  acute  rheumatism,  every 
means  must  be  adopted  to  prevent,  as  far  as 
possible,  the  occurrence  of  this  complication. 
Thus,  in  acute  rheumatism  it  is  all-important 
to  cheek  at  once  the  intensity  of  the  disease  by 
recourse  to  salicylic  acid  or  its  salts,  and  ether 
means  ; for  experience  shows  that  endocarditis, 
when  it  does  occur  in  acute  rheumatism,  generally 


HEART,  INFLAMMATION  OF. 


611 


makes  its  appearance  within  the  first  week. 
Again,  the  duration  of  the  primary  disease  must 
be  curtailed  if  possible, inasmuch  as  endocarditis, 
although  it  generally  appears  early,  may  pos- 
sibly occur  at  any  period  of  the  disease.  Thus 
the  medicinal  preventive  treatment  of  endo- 
carditis in  these  cases  resolves  itself  into  the 
medicinal  treatment  of  acute  rheumatism.  Ano- 
ther point  of  equal  importance  in  the  prevention 
of  endocarditis  is  diminution  of  the  cardiac 
activity.  We  have  seen  that  the  pressure  within 
the  heart  is  an  important  factor  in  the  causation 
of  endocarditis;  and  this  pressure  must  be  reduced 
by  diminishing  the  work  to  be  done  by  the  heart, 
without  lowering  the  cardiac  power.  Rest  must 
therefore  be  enforced  in  the  recumbent  posture 
— an  end  which  is  usually  already  secured  by  the 
presence  of  acute  rheumatism  of  the  joints.  The 
personal  comfort  of  the  patient  must  be  zealously 
attended  to,  and  pain  relieved,  so  that  restless- 
ness and  irritability  may  be  avoided,  and  for  this 
purpose  carefully  selected  anodynes  may  be  ne- 
cessary. Stimulants  must  be  cautiously  ordered  ; 
the  bowels  should  be  regularly  and  fully  moved; 
and  the  various  secretions  are  to  be  kept  as  active 
is  possible. 

b.  Treatment  during  an  attack. — When  endo- 
carditis has  actually  made  its  appearance,  the 
various  means  just  insisted  upon  must  be  en- 
forced as  rigorously  as  before,  so  as  to  diminish 
the  intensity  of  the  inflammation,  and  to  limit 
the  extent  of  surface  involved.  Rest  is  still  of 
the  first  importance.  The  medicinal  treatment 
of  the  original  disease — especially  of  acute  rheu- 
matism— must  be  persevered  in.  Local  applica- 
tions to  the  prscordium,  such  as  cataplasms,  or, 
in  cases-  of  sthenic  inflammation,  leeching,  are 
often  of  great  service.  The  administration  of 
stimulants  will  require  the  greatest  care;  excite- 
ment of  the  heart,  on  the  one  hand,  being 
avoided,  and,  on  the  other  hand,  digitalis,  am- 
monia, or  alcohol  being  employed,  if  symptoms 
of  cardiac  distress  supervene.  Equal  caution  is 
demanded' in  the  use  of  anodynes  which  may  be 
indicated  to  relieve  distress  connected  with  the 
joints ; and  local  applications,  such  as  cotton- 
wool, poultices,  aconite,  and  belladonna,  should 
be  employed  in  preference  to  opium,  chloral,  and 
other  cardiac  depressants. 

In  ulcerative  endocarditis,  quinine  in  large 
doses,  and  salicylic  acid  are  the  remedies  which 
appear  to  promise  most  success ; and  all  the 
ordinary  measures  for  support  in  fever  must  be 
persevered  with. 

c.  Treatment  after  cm  attack. — When  the  pri- 
mary disease,  such  as  rheumatism,  has  subsided, 
and  the  restoration  of  the  various  functions  in- 
dicates that  convalescence  has  commenced,  the 
physician  must  not  forget  the  state  of  the  endo- 
cardium that  has  recently  been  inflamed,  which 
is  probably  still  in  a condition  of  great  physical 
weakness,  and  the  seat  of  new  cell-growth.  In- 
stead of  urging  the  patient  to  sit  up  and  walk 
about  under  these  circumstances,  as  must  have 
; been  frequently  done  under  the  ‘rival  methods ’of 
I treating  acute  rheumatism,  we  should  recommend 

a very  gradual  return  to  exercise,  and  the  most 
jealous  avoidance  of  actual  exertion.  There  can 
| t-e  no  question  that,  at  this  stage,  rest  for  several 
weeks  is  of  more  importance  than  medicinal 


treatment.  At  the  same  time  various  tonic  and 
other  remedies  should  be  employed. 

II.  Myocarditis. — Synon.  : Carditis;  Fi\ 
Myocardite ; Gcr.  Myocarditis. 

Definition-. — Inflammation  of  the  walls  of  tha 
heart. 

This  disease  may  he  either  acute  or  chronic  ; 
but  the  latter  form,  which  is  attended  with  the 
formation  of  fibroid  tissue  in  the  myocardium, 
is  described  under  the  head  of  Heart,  Fibroid 
Disease  of.  Pyaemie  inflammation  of  the  sub- 
stance of  the  heart  also  constitutes  such  a special 
form  of  disease  that  it  is  treated  separately 
(see  Heart,  Pysemic  Abscess  of).  Acute  myo- 
carditis alone,  therefore,  has  to  be  considered  in 
the  present  article. 

.Etiology. — A certain  amount  of  myocarditis 
is  sometimes  associated  with  acute  endocarditis 
and  pericarditis,  and  depends  upon  the  samo 
causes;  the  most  frequent  being  acute  rheuma- 
tism. Jn  a small  proportion  of  cases,  rheumatic 
myocarditis  appears  to  occur  independently  cl 
inflammation  of  the  lining  or  of  the  covering 
membrane.  In  the  great  majority  of  recorded 
cases  of  localised  myocarditis  ending  in  ab- 
scess, the  cause  of  the  disease  was  altogether 
obscure.  It  has  been  observed  most  frequently 
in  males,  and  before  the  twenty-fifth  year  of  life. 
Exposuro  to  cold,  severe  exertion,  and  local  in- 
jury are  mentioned  amongst  exciting  causes,  but 
with  questionable  correctness. 

Anatomical  Characters. — Acute  inflamma- 
tion of  the  myocardium  generally  involves  the 
connective  tissue  as  well  as  the  muscular  fibres  ; 
but  in  a few  instances  the  latter  alone  have  been 
found  affected,  constituting  so-called  ‘parenchy- 
matous myocarditis. 

The  ordinary  form  of  the  disease  is  charac- 
terised by  the  appearance  of  leucocytes  between 
the  muscular  fibres  of  the  heart.  In  one  class  of 
cases,  the  inflammation  is  moderate  in  intensity 
but  diffused  in  extent,  affecting  one  or  more  layers 
of  muscle  underlying  the  endocardium  or  pericar- 
dium, which  are  also  inflamed  ; in  another  class 
of  cases,  the  inflammation  is  more  active,  and 
proceeds  to  the  formation  of  abscess,  whilst  it  is, 
as  a rule,  comparatively  localised. 

In  the  first  or  diffused  form,  the  myocardium, 
as  it  is  seen  through  its  inflamed  covering,  ap- 
pears of  a mottled  opaque  huffy  colour,  and 
is  somewhat  swollen  and  softened.  The  micro- 
scopical characters  consist  chiefly  in  the  appear- 
ance of  leucocytes  and  inflammatory  eifhsion 
in  the  intermuscular  connective  tissue;  swell- 
ing, opacity,  nuclear  proliferation,  and  rupture 
of  the  muscular  fibres,  followed  by  fatty  de- 
generation and  atrophy  of  the  same;  and  the 
ordinary  inflammatory  changes  of  the  vessels 
of  the  part.  Beyond  this  stage,  unless  the 
case  prove  fatal,  the  diffused  form  of  myo- 
carditis passes  into  a chronic  condition  : and  it 
ends  either  in  fibroid  disease  with  a moderate 
amount  of  atrophy,  by  development  of  the  inflam- 
matory products  and  atrophy  of  the  affected 
fibres;  in  fatty  degeneration;  in  calcification;  or 
in  cardiac  aneurism. 

Suppuration  of  the  heart,  on  the  other  baud, 
generally  takes  the  form  of  swollen  yellowish- 
white  patches  or  abscesses,  surrounded  by  dirty- 
red  or  ecchymosed  tissue,  boggy  or  pulpy  to  t h. 


312  HEART,  INFLAMMATION  OF. 

finger,  and  containing  on  section  a small  quantity 
of  variously-coloured  puriform  matter,  consisting 
of  pus  and  muscular  debris.  In  the  same  cases 
a,  great  part  of  the  walls  of  the  heart  may  be 
in  a condition  of  parenchymatous  degeneration ; 
and  in  some  recorded  instances  the  whole  of 
the  cardiac  tissue  is  described  as  infiltrated 
with  pus.  Abscesses  resulting  from  acute  loca- 
lised myocarditis  are  generally  very  small,  vary- 
ing from  the  size  of  a pea  to  that  of  a nut. 
They  may  either  burst  externally  into  the  peri- 
cardial sac,  or  internally  into  one  of  the  cavi- 
ties or  through  one  of  the  valves,  leading  to 
pyaemia,  and  to  the  formation  of  an  acute  cardiac 
aneurism ; or  the  pus  may  make  its  way  both 
externally  and  internally,  and  lead  to  fatal  haemor- 
rhage into  the  pericardium.  In  other  cases  the 
pus  undergoes  the  usual  changes,  and  becomes 
inspissated  or  cheesy,  or  calcification  takes  place. 

In  both  forms  of  interstitial  myocarditis  the 
left  ventricle  is  most  frequently  the  seat  of  in- 
flammation. 

Symptoms.' — The  principal  symptoms  of  acute 
rheumatic  myocarditis  are  restlessness  and  urgent 
dyspnoea;  severe  pain  and  distress  referred  to 
the  prsecordium ; and  palpitation,  which  gradually 
passes  into  irregularity  and  greatly  increased  fre- 
quency, and  finally  into  complete  cardiac  failure. 
The  pulse  corresponds.  The  countenance  is  an- 
xious and  pale,  or  cyanosed.  The  mind  is  fearful 
and  distressed  at  first,  and  delirium  frequently 
supervenes  before  death,  especially  in  young  sub- 
jects. Vomiting  is  not  uncommon, 

The  physical  signs  are  generally  associated  with 
those  of  endo-  and  peri-carditis ; but  when  un- 
complicated may  be  described  as — violent  cardiac 
impulse  at  first,  which  rapidly  loses  in  strength 
and  regularity,  while  it  increases  in  frequency  ; a 
somewhat  increased  area  of  cardiac  dulness ; and 
short  sharp  sounds,  afterwards  becoming  duller 
and  more  feeble. 

When  these  symptoms  and  signs  make  their 
appearance,  they  generally  run  their  course  ra- 
pidly, and  end  in  death.  In  a small  number  of 
cases  they  as  rapidly  disappear. 

The  symptoms  of  localised  suppurative  myo- 
. carditis  leading  to  abscess  are  not  unlike  those 
just  recorded.  There  are  the  same  distressing 
symptoms  locally,  with  restlessness  and  anxiety, 
passing  on  to  delirium,  and  ending  in  collapse. 
Rigors  have  been  observed  in  some  cases  ; and  a 
peculiar  pustular  eruption  on  the  skin  in  other 
cases.  The  physical  signs  also  are  not  special  ; 
excepting  that  a murmur  may  be  suddenly  de- 
veloped by  rupture  or  perforation  of  part  of  the 
wall  or  of  a valve. 

The  majority  of  cases  of  abscess  of  the  heart 
prove  fatal  by  asthenia  ; hut  the  other  termi- 
nations of  abscess  mentioned  above  will  be 
attended  by  their  respective  symptoms,  and  the 
possibility  of  sudden  death  is  especially  to  be 
noted. 

Diffuse  parenchymatous  myocarditis  is  clini- 
cally known  only  as  a cause  of  sudden  death. 

Complications. — The  complications  of  acute 
myocarditis  have  already  been  sufficiently  indi- 
cated, such  as,  first,  setiologically,  pericarditis, 
endocarditis,  acute  rheumatism,  and  other  causes 
of  these  forms  of  inflammation ; and,  secondly, 
pathologically,  rupture  of  the  cardiac  walls  or 


HEART,  MALFORMATIONS  OF. 

valves,  acute  cardiac  aneurism,  hsemoperieardiutn 
embolism,  and  septicaemia. 

Coubse  and  Terminations. — The  course  ot 
acute  interstitial  myocarditis,  as  already  stated,  is 
generally  rapid,  extending  from  a few  hours  to 
eight  days  in  different  cases.  Death  occurs,  in  the 
great  majority  of  cases,  from  the  effects  of  cardiac 
failure,  if  the  inflammation  be  extensive  or  pro- 
ceed to  suppuration.  The  formation  of  acute 
aneurism  by  internal  rupture,  the  production  cf 
pericarditis  by  external  rupture,  and  other  com- 
plications will  variously  modify  the  progress  and 
termination  of  cardiac  abscess.  Simultaneous 
rupture  both  externally  and  internally  causes 
sudden  death. 

Diagnosis. — The  diagnosis  of  acute  myocar- 
ditis is  extremely  difficult.  Occurring  in  con- 
nection with  acute  rheumatism,  it  has  to  be 
distinguished  from  endo-  and  pericarditis.  The 
absence  of  murmur  and  of  the  characteristic 
signs  of  pericarditis,  along  with  symptoms  of 
cardiac  failure  and  severe  local  phenomena,  such 
as  pain,  distress,  dyspnoea,  and  finally  collapse, 
should  generally  serve  to  establish  the  diagnosis 
of  inflammation  of  the  walls  of  the  heart.  It 
cannot  be  said  that  cardiac  abscess  has  ever  yet 
been  diagnosed;  but  the  careful  consideration  of 
all  the  points  in  the  case,  and  the  sudden  de- 
velopment of  a murmur  indicative  of  rupture 
of  portion  of  the  wall,  or  of  a valve,  may  here- 
after ensure  greator  success.  In  the  event  of 
the  development  of  the  last-named  sign,  and  of 
septicaemia  or  embolism,  cardiac  suppuration 
would  have  to  be  carefully  diagnosed  from  ulce- 
rative endocarditis.  In  children,  acute  myocar- 
ditis has  to  he  distinguished  from  acute  meningeal 
inflammation,  an  object  which  may  be  effected 
by  the  careful  observation  of  the  signs  and 
symptoms  connected  with  the  heart. 

Prognosis. — The  prognosis  of  myocarditis, 
when  it  is  either  so  extensive  or  so  intense  as  to 
give  rise  to  unequivocal  symptoms,  is  extremely 
unfavourable. 

Treatment. — The  two  principal  indications 
of  treatment  in  acute  inflammation  of  the  sub- 
stance of  the  heartare  to  support  and  strengthen 
that  organ,  and  to  relieve  the  pain  and  distress. 
Local  anodynes,  especially  in  the  form  of  the 
preparations  of  belladonna  and  poultices ; and 
stimulating  ‘counter-irritants,’  such  as  mustard 
cataplasms,  will  conduce  tofulfil  the  second  indica- 
tion. Such  relief  is  the  first  essential,  if  rest  is  to 
be  secured.  The  patient  must  be  spared  the  very 
smallest  exertion.  Food  must  be  given  in  small 
quantities,  and  be  easily  digestible  ar.d  highly 
nutritions  ;■  the  bowels  must  be  kept  open ; and 
the  flow  of  urine  should  be  as  free  as  possible. 
Alcoholic  stimulants  will  be  urgently  called  for: 
and  palpitation  may  be  regarded  as  an  indication 
of  the  necessity  for  these,  as  .much  as  weakness 
of  the  impulse.  Digitalis,  ammonia,  and  other 
cardiac  stimulants  should  he  given  cautiously, 
at  the  same  time,  so  as  to  strengthen  the  car- 
diac action,  whilst  diuresis  is  encouraged. 

J.  Mitchell  Brcce. 

HEAET,  Malformations  of. — Synon.  : Ft 

Affections  Congenitalcs  du  Cceur ; Ger.  Missbil- 
dunqcn  des  Her  sens. 

Classification  and  Description  — The  car- 


HEART,  MALFORMATIONS  OF. 


diac  anomalies  of  development  may  be  classed  as 
follows  : — 

I.  Those  dependent  on  arrest  of  the  process 
of  development  at  an  early  period  of  foetal  life, 
so  that  the  organ  retains  its  most  rudimentary 
form,  the  auricular  and  ventricular  cavities  being 
still  single  or  presenting  only  slight  indications 
of  division,  and  the  primitive  arterial  trunk 
being  retained,  or  the  aorta  and  pulmonary  ar- 
tery being  very  imperfectly  evolved. 

II.  Those  in  which  the  defective  conformation 
occurs  at  a more  advanced  period,  when  the 
auricular  and  ventricular  partitions  are  already 
partly  formed,  and  the  aorta  and  pulmonary 
artery  more  or  less  completely  developed.  Such 
are  the  cases  in  which,  with  imperfect  separation 
of  the  ventricles  and  auricles,  the  arterial  or 
auriculo-ventricular  passages  are  constricted  or 
obliterated,  and  the  origins  of  the  aorta  and  pul- 
monary artery  are  misplaced. 

III.  Cases  in  which  the  development  of  the  or- 
gan has  progressed  regularly  till  the  later  periods 
of  fatal  life,  so  that  the  auricular  and  ventricular 
septa  are  complete,  and  the  primary  vessels  have 
their  natural  connections,  but  in  which  there  are 
defects  which  prevent  the  heart  undergoing  the 
changes  which  should  ensue  after  birth : such  are 
the  premature  closure  of  the  foramen  ovale,  the 
non-development  of  the  ductus  arteriosus,  or  the 
occurrence  of  slighter  sources  of  obstruction  at 
the  arterial  or  auriculo-ventricular  passages  or  in 
the  course  of  the  aorta. 

IV.  Cases  in  which  there  is  some  irregularity 
in  the  formation  of  the  valves,  or  in  the  connec- 
tions with  the  vessels,  or  in  the  vessels  them- 
selves, which,  though  not  immediate  sources  of 
obstruction,  may  become  so  during  the  progress 
of  life,  so  as  to  lay  the  foundations  of  subsequent 
disease. 

I.  Cases  of  the  first  class  are  of  very  infre- 
quent occurrence,  and  are  the  more  rare  accord- 
ing to  the  extent  of  the  imperfection.  The  first 
case  of  simply  biloeulate  heart  was  placed  on 
record  by  Mr.  Wilson,  in  the  Philosophical 
transactions,  in  1788,  and  the  specimen  is  pre- 
served in  Dr.  Baillie’s  museum,  in  the  possession 
of  the  Royal  College  of  Physicians.  The  ano- 
maly was  found  in  the  body  of  a child,  which 
survived  for  seven  days.  From  defect  in  the 
diaphragm,  the  heart  lay  in  a sac  on  the  upper 
surface  of  the  liver  ; and  the  organ  was  found  to 
consist  of  an  undivided  auricle  and  ventricle, 
and  a single  artery,  evidently  the  primitive  arte- 
rial trunk,  which  first  gave  off  a vessel  which  fur- 
nished the  branches  to  the  lungs,  and  the  vessels 
to  the  head  and  upper  extremities.  The  coronary 
arteries  arose  by  a common  trunk  from  the  aorta 
before  its  final  division.  Since  the  publication 
of  this  case,  others  have  been  placed  on  record 
illustrating  the  gradual  advancement  from  the 
simple  to  the  more  complicated  forms — the  ven- 
tricle becoming  more  completely  divided,  the 
septum  of  tho  ventricles  being  more  fully  de- 
veloped, and  there  being  two  vessels  given  off 
from  the  ventricle,  though  in  some  cases  one 
of  these  may  be  abortive,  or  if  there  be  only  a 
single  vessel,  that  being  shown  by  the  origin 
of  the  coronary  arteries  from  its  commencement 
to  be  really  the  aorta. 

II  Of  the  second  class,  the  examples  which 


613 

have  been  described  are  much  more  numerous. 
In  cases  of  this  kind  the  auricles  and  ventricles 
are  fully  formed,  though  the  septa  which  divide 
them  are  incomplete,  and  there  is  usually  more 
or  less  displacement  of  the  origins  of  the  primary 
vessels,  so  that  the  aorta  more  especially  may 
come  to  arise  partly  or  almost  entirely  from  the 
right  ventricle  ; or  the  points  of  origin  of  the 
vessels  maybe  transposed,  the  aorta  arising  from 
the  right  ventricle,  and  the  pulmonary  artery 
from  the  left.  Cases  of  the  former  description, 
in  which  the  septum  of  the  ventricles  is  incom- 
plete, and  the  aorta  misplaced  to  the  right,  are 
almost  always  found  to  coexist  with  some  ob- 
struction to  the  passage  of  the  blood  from  the 
right  ventricle,  either  (1)  from  smallness  of  the 
pulmonary  artery ; (2)  from  imperfection  of  the 
valves ; (3)  from  constriction  at  the  outlet  of 
the  right  ventricle,  or  at  the  end  of  the  conus 
arteriosus  or  infundibular  portion  of  the  ven- 
tricle ; or  (4)  from  constriction  at  the  com- 
mencement of  the  conus  or  point  of  union  be- 
tween that  portion  of  the  ventricle  and  the  sinus. 
A case  of  the  second  description  was  published 
by  Sandifort,  in  1777,  and  one  occurred  to  Dr. 
Hunter  in  1761,  but  was  not  published  till  1763. 
The  fourth  form  of  obstruction,  or  that  occa- 
sioned by  constriction  between  the  sinus  and 
the  infundibular  portion  of  the  right  ventricle, 
has  only  recently  been  explained,  though  cases 
of  the  kind  have  for  some  years  been  placed  on 
record.  It  is  indeed  probable  that  the  existence 
of  a very  decided  partition  in  this  situation  led 
to  the  idea  entertained  by  some  of  the  older  pa- 
thologists, that  the  heart  occasionally  had  three 
ventricular  cavities.  The  abnormal  septum  is 
partly  formed  by  hypertrophy  of  the  muscular 
structure,  and  partly  by  the  endocardium  be- 
coming thickened;  and  in  some  cases  very  decided 
obstruction  is  so  caused.  The  defect  is  generally 
developed  at  an  early  period  cf  foetal  life.  The 
septum  of  the  ventricles  is  therefore  incomplete, 
the  defect  being  at  the  posterior  part,  so  that  the 
aorta  comes  to  arise  from  the  sinus  of  the  right 
ventricle,  while  the  pulmonary  artery  takes  its 
origin  from  the  infundibular  portion,  which 
seems  to  constitute  a distinct  cavity.  The  heart 
thus,  as  pointed  out  by  Mr.  Grainger,  bears  an 
almost  exact  resemblance  to  the  condition  of  the 
organ  in  the  turtle.  In  the  turtle  there  are  two 
aortic  ventricles  and  one  pulmonic  ventricle ; the 
right  aortic  and  the  pulmonic  ventricle  being  the 
analogues  of  the  sinus  and  infundibular  portion 
of  the  right  ventricle,  and  being  in  connection, 
while  the  left  aortic  ventricle  is  distinct. 

Much  more  rarely  there  has  been  found  an 
entire  obliteration  of  the  orifice  or  trunk  of  the 
pulmonary  artery,  the  first  case  of  this  descrip- 
tion of  anomaly  having  also  been  published  by 
Dr.  Hunter  at  the  same  time  as  the  former  case. 
Much  more  rarely  the  defect  in  the  ventricle  has 
been  found  in  connection  with  obstruction  or 
obliteration  of  the  right  auriculo-ventricular,  the 
left  auriculo-ventricular,  or  the  aortic  aperture. 
AVhere  the  septum  of  the  ventricles  is  incom- 
plete, the  defect  generally  exists  at  the  base,  at 
the  part  which  has  been  termed  the  undefended 
space— the  space  which  intervenes  between  the 
contiguous  sides  cf  the  left  and  posterior  semilu- 
nar segments,  where  on  the  left  side  the  muscle  is 


HEART,  MALFORMATIONS  OF. 


514 

naturally  deficient;  and  in  this  way  a connection 
may  exist  between  the  left  ventricle  and  right 
auricle  or  ventricle,  either  immediately  above 
or  below  the  right  auriculo-ventricular  opening. 
More  rarely  the  septum  between  the  left  ventricle 
and  the  conus  arteriosus  of  the  right  ventricle  is 
defective ; and  still  more  rarely  an  aperture  exists 
at  a lower  part  of  the  septum.  The  portion  of  the 
septum  dividing  the  left  ventricle  from  the  sinus 
of  the  right  is  termed  by  Rokitansky  the  poste- 
rior— that  between  the  left  ventricle  and  conus 
arteriosus,  the  anteriorseptum.  With  the  defects 
now  mentioned,  the  auricular  septum  may  also 
be  incomplete,  or  the  foramen  ovale  may  be  still 
open,  or  the  ductus  arteriosus  pervious.  Indeed, 
when  the  pulmonary  artery  is  much  contracted  or 
impervious,  one  or  other  of  the  former  conditions 
necessarily  exists,  and  the  ductus  arteriosus  be- 
comes the  means  by  which  the  blood  is  conveyed 
to  the  lungs,  though  occasionally  there  are  com- 
pensatory branches  derived  from  the  aorta  or 
one  of  the  large  vessels  also  distributed  to  the 
lungs. 

The  transposition  of  the  aorta  and  pulmonary 
artery  also  occurs  at  an  early  period  of  fcetal  life. 
The  first  case  of  the  kind  recorded  was  related 
by  Dr.  Baillie  in  1797  ; the  specimen  is  figured 
in  his  plates,  and  still  exists  in  the  museum  in 
the  possession  of  the  Royal  College  ofPhysicians. 
In  this  anomaly  the  septum  of  the  ventricles  is 
generally  defective,  and  the  two  fcetal  passages 
open,  and  the  organ  may  indeed  be  very  defective 
in  conformation.  The  heart  also  is  often  mis- 
placed in  the  chest.  Another  form  of  defect  is 
that  in  which  the  descending  aorta  is  given  off 
from  the  pulmonary  artery  through  the  ductus 
arteriosus.  This  condition  is  apparently  the  result 
of  imperfect  development  of  the  isthmus  aortse 
between  the  origin  of  the  left  subclavian  artery 
and  the  point  of  entrance  of  the  duct,  so  that 
an  adequate  supply  of  blood  cannot  be  conveyed 
from  the  ascending  into  the  descending  aorta. 
Generally  the  condition  coexists  with  defect  of 
the  septum  of  the  ventricles,  as  in  two  cases 
formerly  in  the  possession  of  Sir  Astley  Cooper, 
and  now  contained  in  the  museum  of  St. 
Thomas’s  Hospital,  described  by  Dr.  Farre  in 
1814.  In  some  instances  of  this  kind  the  por- 
tion of  aorta  between  the  loft  subclavian  artery 
and  the  duct  is  imperforate,  and  yet  in  others, 
as  in  a case  related  by  Steidelle  and  referred  to 
by  Hein  in  1816,  there  is  no  connection  between 
the  two  portions  of  the  aorta,  the  ascending 
part  giving  off  the  vessels  to  the  head  and  upper 
extremities,  the  descending  portion  being  wholly- 
derived  from  the  pulmonary  artery.  This  form 
of  defect  is  closely  allied  to  the  cases  which  are 
occasionally  seen  in  after-life,  in  which  there  is 
constriction  or  obliteration  of  the  isthmus  aortse 
beyond  the  left  subclavian  artery,  the  circulation 
being  maintained  through  collateral  channels. 

III.  The  third  class  of  cases  consists  in  the 
premature  closure  of  the  foramen  ovale ; or  the 
non-development,  or  disappearance,  at  an  early- 
period  of  foetal  life,  of  the  ductus  arteriosus ; or 
in  diseased  conditions  of  the  valves,  which  pre- 
vent the  heart  undergoing  the  changes  which 
should  ensue  after  birth. 

The  first  condition  is  of  very  rare  occurrence. 
The  first  case  recorded  was  related  by  Vieussens 


inl715.  In  these  cases  the  blood  during  foetal  life 
being  all  transmitted  through  the  right  cavities 
and  the  pulmonary  artery  and  duct,  those  portions 
of  the  heart  are  unduly  developed,  while  the  left 
side  of  the  organ  becomes  atrophied.  In  the 
second  class  of  eases  the  heart  is  defectively-  de- 
veloped, and  the  right  ventricle  gives  origin  to 
the  aorta,  and  often  also  vessels  are  distributed 
from  the  aorta  to  the  lungs,  while  the  ordinary- 
pulmonary  artery  may  be  very  small  in  size, 
or  may-  be  entirely  absent.  In  a case  of 
this  kind,  described  by  Dr.  Ramsbotham,  the 
pulmonary  artery-  is  said  not  to  exist : but  bv  ex- 
amination of  the  specimen  preserved  in  the  Lon- 
don Hospital  Museum,  the  writer  has  ascertained 
that  this  is  not  correct.  The  artery  exists  as  a 
very-  small  vessel,  but  the  scanty  supply  of  blood 
to  the  lungs  which  itfurnished  was  complemented 
by  small  vessels  from  the  aorta.  In  eases  which 
are  not  of  uncommon  occurrence,  and  may  be 
classified  with  the  malformations  now  spoken 
of,  but  which  are  closely-  allied  to  the  next  class, 
there  exists  some  source  of  obstruction  to  the 
transmission  of  the  blood  from  or  into  the  right 
ventricle,  which  determines  the  imperfect  clo- 
sure of  the  foramen  ovale,  or  the  patency  of  the 
ductus  arteriosus.  The  obstruction  in  these  cases 
generally  depends  on  disease  of  the  pulmonic 
valves,  or  obstruction  at  the  end  or  beginning 
of  tile  conus  arteriosus,  or  at  the  right  auriculo- 
ventricular  aperture. 

IV.  The  fourth  class  of  malformations  con- 
sists of  defects,  of  a slighter  description,  of  the 
valves,  or  narrowing  of  the  orifices,  or  of  the 
isthmus  aortse. 

The  semilunar  valves  may  be  excessive  or  de- 
fective in  number.  The  former  condition  probably 
does  not  materially  interfere  with  the  functions 
of  the  heart — the  latter  often  does  so,  and  es- 
pecially- when,  as  is  very  frequently  the  case,  the 
valves  become  the  seat  of  disease  in  after-life. 
If  there  be  only  two  valves,  one  of  them  imper- 
fectly representing  two  distinct  segments,  there 
is  great  liability  to  incompetence.  If  there  be 
only-  one  valve,  representing  three  imperfect 
segments,  obstruction  is  almost  necessarily  occa- 
sioned. 

It  is  probable  that  the  cases  in  which  the 
tricuspid  valve  is  found  represented  by  a kind 
of  membranous  diaphragm,  stretched  across  the 
orifice  and  perforated  in  the  centre,  and  some  of 
the  so-called  cases  of  button-hole  mitral,  are  also 
of  congenital  origin. 

It  is  not  considered  necessary  in  this  article  to 
refer  to  many  examples  of  these  different  forms 
of  malformation,  or  to  allude  to  other  of  the 
less  important  deviations  from  the  natural  con- 
formation of  he  heart.  The  subject  will  be  found 
more  fully  treated  of  in  the  works  of  Dr.  Farre1 
and  Gintrac3  and  Freidberg,3  in  the  papers  of 
Dr.  Che  vers, 4 and  in  the  writer’s  own  work.5 
The  more  recently  published  cases  also  are  ah- 

1 On  Malformations  of  the  Human  Heart.  London.  1S14. 

3 Observations  et  Recherches  sur  la  Cyanose , ou  JJaladie 
Bleue.  Paris,  1S24. 

3 Die  angebornen  Kranl’heitcn  des  Herzens  etc.  Leipzig, 
1S44. 

* Collection  of  facts  illustrative  of  Morbid  Conditions  of 
the  Pulmonary  Artery.  London,  1851,  and  Medical  Gazette, 
1845  to  1851. 

s * Malformations  of  the  Human  HearL  Second  edition 
1SGG. 


HEART.  MALFORMATIONS  OF.  61c 


ftr&cted  in  the  treatise  of  Taruffi,1  and  numerous 
examples  of  different  forms  of  malformation  are 
gi'-en  by  Rokitansky.2 

Mode  of  Formation. — It  is  probable  that  all 
the  different  forms  of  irregularityin  the  develop- 
ment of  the  heart  are  due  to  arrest  of  develop- 
ment, occurring  at  different  periods  of  evolution, 
so  that  the  heart  retains  the  forms  proper  to  it 
at  such  stages.  The  cause  to  which  this  arrest 
is  to  bo  ascribed  can  rarely,  however,  be  traced 
in  cases  where  the  defect  is  great,  such  as  those 
cf  biloculato  heart,  or  where  the  vessels  are 
transposed  with  or  without  very  marked  imper- 
fection in  the  organ  itself.  These  defects  must 
be  ascribed  to  the  imperfect  evolution  of  the 
double  set  of  cavities,  and  of  the  pulmonary 
artery  and  aorta  from  the  primitive  trunk  and 
branchial  arches.  In  the  less  marked  defects, 
however,  the  irregularity  can  often  be  traced  to 
a source  of  obstruction  to  the  transmission  of 
the  blood  through  one  or  other  of  the  apertures 
or  vessels.  Such  obstruction  is  much  the  most 
common  in  connection  with  the  right  ventricle 
and  pulmonary  arlery.  In  cases  of  this  kind 
the  septum  of  the  ventricles  is  deficient,  so  that 
the  aorta  arises  wholly  or  in  part  from  the 
right  ventricle.  Dr.  Hunter,  in  the  paper  before 
referred  to,  when  describing  a ease  of  obstruction 
of  the  pulmonic  orifice  with  defect  in  the  septum 
of  the  ventricles,  suggested  that  the  imperfection 
in  the  septum  was  probably  caused  by  the  pul- 
monic obstruction.  Meckel,  however,  adopted 
the  view  that  the  primary  defect  was  in  the 
septum  of  the  ventricles,  and  that  the  pulmonary 
artery  became  more  or  less  abortive  from  being 
thrown  out  of  the  course  of  the  circulation  by 
the  ready  outlet  afforded  for  the  blood  from  the 
right  ventricle  into  the  aorta.  The  former  view 
seems,  however,  to  afford  the  more  satisfactory 
explanation,  and  is  in  accordance  with  the  almost 
constant  occurrence  of  disease  of  the  valves  in 
those  cases.  According  to  the  view  of  Meckel, 
the  pulmonary  artery  should  simply  be  small,  as 
when  the  ductus  arteriosus  is  absent,  like  the  case 
of  Dr.  Ramsbothain  before  referred  to,  but  such 
a condition  is  very  rarely  found.  The  excess  in 
the  number  of  the  semilunar  valves  might  seem 
to  afford  an  example  of  redundant  development, 
but  this  condition  also  probably  depends  on  ar- 
rest of  development ; though,  as  we  do  not  clearly 
understand  the  mode  in  which  these  valves  are 
developed,  it  is  impossible  to  express  a very 
decided  opinion  as  to  the  cause  of  the  apparent 
oxcess. 

Symptoms  and  Diagnosis. — There  cannot 
generally  be  much  difficulty  in  recognising  a 
case  of  malformation  of  the  heart  during  life. 
Not  only  in  cases  of  a very  marked  kind  is  there 
generally  a complete  history  of  the  condition  of 
the  subject  during  its  short  life,  hut  the  symp- 
toms are  also  very  characteristic.  The  child  is 
very  markedly  cyanotic;  the  cheeks,  lips,  hands, 
and  feet  are  excessively  livid;  the  fingers  and 
toes  are  clubbed;  the  nails  are  incurved;  and 
the  patient  is  liable  on  any  excitement,  or 
ou  exposure  to  cold,  to  attacks  of  dyspnoea, 
otten  followed  by  convulsions.  There  are  also 
often  present  difficulty  of  breathing,  cough,  and 

1 Sullc  Malallie  congenite , etc.,  del  cuore.  Bologna,  1875. 

1 Die  defecte  dcr  Scheideicande  des  Herzens.  Wien,  1875. 


expectoration  of  blood;  with  palpitation,  and 
often  pulsation  of  the  vessels  of  the  neck. 
If  also  there  be  any  obstruction  at  or  near  the 
pulmonary  orifice,  there  will  be  a harsh  systolic 
murmur  heard  in  the  course  of  the  pulmonary 
artery;  and  if  there  be  a defect  in  the  septum 
of  the  ventricles,  the  murmur  will  be  heard 
probably  also  in  the  course  of  the  aorta.  Often 
there  are  unhealthy  ulcerations  about  the  fin- 
gers, toes,  and  anus  or  Y'ulva.  If  the  case  do 
not  attract  notice  till  late  in  life,  there  will 
probably  be  less  marked  signs  of  obstruction  to 
the  circulation,  and  possibly  they  may  be  entirely 
absent,  and  there  may  be  no  history  of  the 
patient's  previous  condition.  In  cases  of  this 
kind  the  probability  will  be  that  if  there  is  e 
murmur  at  the  pulmonary  artery  there  is  some 
defect  at  or  near  the  orifice  of  that  vessel, 
with  or  without  an  aperture  in  the  septum  of 
the  ventricles  or  an  open  state  of  the  ductus 
arteriosus.  The  former  condition  is  so  rare  as 
the  result  of  disease  in  after-life,  that  if  the  signs 
point  to  pulmonic  valvular  disease,  its  congenital 
origin  may  safely  he  surmised.  The  open  fora- 
men ovale  and  ductus  arteriosus  could  prohahlj 
not  be  diagnosed  with  any  certainty,  though 
cases  have  occurred  in  which  peculiar  murmurs 
• noticed  during  life  ivere  supposed  to  ho  so  pro- 
duced. It  might  he  supposed  that  when  so 
small  a proportion  of  the  blood  is  subjected  to 
the  influence  of  the  air,  as  in  some  of  these  cases, 
the  temperature  of  the  patient  ivould  not  reach 
the  natural  standard,  hut  the  most  careful  obser- 
vation of  the  temperature  of  children  lahourina 
under  congenital  cardiac  cyanosis  has  generally 
failed  to  detect  any  marked  difference  between 
them  and  other  children  of  about  the  same  age. 

Cyanosis. — There  are  few  subjects  which 
have  excited  more  discussion  than  the  causes  of 
Cyanosis  or  Morbus  Coerulus.  Morgagni,  in  1761, 
when  describing  the  case  of  a girl  who  had  ob- 
struction at  the  orifice  of  the  pulmonary  artery 
with  an  unclosed  foramen  ovale,  expressed  the 
opinion  that  the  general  congestion  was  probably 
the  cause  of  the  remarkable  lividity  which  had 
been  noticed  during  life;  and  Dr.  Hunter,  in 
1783,  in  describing  a case  of  pulmonic  obstruction 
with  imperfection  in  the  septum  of  the  ventricles, 
ascribed  the  lividity  to  the  intermixture  of  the 
venous  and  arterial  currents  of  blood.  These 
views  have  since  received  support  from  various 
writers.  The  view  of  Morgagni  has  been  main- 
tained by  Louis,  and  that  of  Hunter  by  Gintrae. 
It  has  been  i-ery  fully  shown  that  there  is  no  just 
and  constant  relation  between  tho  intensity  of  the 
cyanosis  and  the  amount  of  intermixture,  and  in- 
deed that  very  marked  cyanosis  may  exist  without 
any  intermixture  ; while  on  the  other  hand  in  all 
cases  of  marked  cyanosis  there  are  present  causes 
capable  of  producing  great  venous  congestion. 
The  writer  is,  therefore,  of  opinion  that  the 
evidence  is  very  greatly  in  favour  of  the  correct- 
ness of  the  views  of  Morgagni  and  Louis,  that 
the  cyanosis  results  from  stasis  of  the  blood, 
though  probably  other  causes  conduce  to  the  in- 
tensity and  peculiarity  of  discoloration.  Thus, 
probably,  the  defect  must  he  congenital,  or.  at 
least,  of  very  long  duration,  so  that  the  smaller 
vessels  may  become  greatly  dilated  ; the  integu- 
ments must  be  thin,  so  as  to  allow  the  colour  o / 


516  HEART,  MALFORMATIONS  OF. 

‘he  blood  more  readily  to  be  seen,  and  lastly — 
probably  also  from  the  very  small  portion  of  the 
blood  which  can  be  subjected  to  the  influence  of 
the  air — the  whole  mass  is  of  an  unusually  dark 
colour,  and  so  the  intensity  of  the  lividity  is 
increased. 

Duration  and  Terminations. — The  duration 
of  life  in  the  subjects  of  the  different  forms  of 
malformation  varies  greatly,  according  to  the 
degree  of  the  defect  in  the  heart.  In  cases  in 
which  the  organ  presents  a very  rudimentary 
condition,  life  can  only  be  prolonged  for  a few 
hours  or  days ; while  in  the  slighter  forms  of 
defect  the  patient  may  survive  to  puberty  or  to 
manhood  or  womanhood,  or  even  to  more  ad- 
vanced age.  Thus,  in  cases  of  contraction  of 
the  pulmonary  artery,  without  other  defect  in 
the  organ,  cases  are  on  record  in  which  patients 
lived  to  44  and  63 ; when,  with  the  pulmonic 
disease,  the  foramen  ovale  was  unclosed,  the 
subjects  have  reached  40  and  57-  Where  the 
septum  of  the  ventricles  was  deficient,  nine 
patients  are  stated  to  have  lived  to  between  20 
and  30.  Where  the  ductus  arteriosus  was  still 
open,  patients  lived  to  13^  and  19  years ; but 
of  course  these  ages  are  the  extremes,  and  by  far 
the  largest  proportion  of  the  subjects  die  much 
younger.  When  the  pulmonic  orifice  or  artery 
is  impervious,  but  few  patients  survive  for  more 
than  two  years,  but  cases  are  cn  record  in  which 
9 and  12  years  of  age  were  attained;  the  age 
being  greater  according  to  the  facility  afforded 
for  the  transmission  of  the  blood  from  the  right 
side  of  the  heart,  as  when  the  septum  of  the 
ventricles  was  imperfect,  than  when  the  ventri- 
cles were  completely  separated. 

Transposition  of  the  aorta  and  pulmonary 
artery  is  a defect  incompatible  in  any  of  its  forms 
with  the  prolongation  of  life  for  any  lengthened 
period.  Four  cases  are,  however,  on  record  in 
which  the  patient  survived  to  between  2 and  3 
years  of  age— the  imperfection  of  the  septum  of 
the  ventricles  tending  in  these  cases  also  to  the 
prolongation  of  life. 

The  most  common  causes  of  death  in  cases  of 
malformation  of  the  heart  are  affections  of  the 
brain  and  lungs,  haemoptysis,  &c. ; and,  if  the  pa- 
tient survive  for  a sufficient  period,  tuberculous 
affections.  Notwithstanding  the  very  great  ob- 
struction to  tlie  circulation,  dropsical  symptoms 
do  not  generally  arise  to  any  marked  degree. 

Treatment. — It  is  scarcely  necessary  to 
speak  of  the  treatment  of  these  cases.  It  must 
consist  in  protection  against  cold ; in  the  main- 
tenance of  bodily  and  mental  quiet ; and  in  the 
use  of  a nutritious  and  easily  digestible  diet. 

T.  B.  Peacock. 

HEART,  Morbid  Growths  in.  — The 

various  forms  of  morbid  growth  that  have  been 
met  with  in  the  heart  may  be  thus  enumerated 
in  the  order  of  their  frequency : — 1.  Malignant 
disease ; 2.  Lymphomatous  or  lymph-adeno- 
matous growths;  3.  Non-malignant  tumours; 
and  4.  Cysts.  Fibroid  growths,  syphilitic  gum- 
mata,  and  tubercle,  as  well  as  hydatids  affecting 
the  heart,  are  discussed  separately  under  their 
respective  heads.  Calcareous,  cartilaginous,  and 
osseous  changes  of  the  myocardium  are  noticed 
in  the  article  Heart,  Degenerations  of. 


HEART,  MORBID  GROWTHS  IN. 

1.  Malignant  Disease  of  the  Heart. — 

Cancer,  although  the  most  common  if  the  new 
formations  found  in  the  heart,  is  still  very  rare 
in  this  situation,  and  is  a subject  chiefly  of 
pathological  interest. 

IEtiology. — Malignant  disease  of  the  heart 
is,  with  very  few  exceptions,  always  secondary; 
and  the  primary  growth  may  have  its  seat  in 
any  part  whatever  of  the  body.  Occasionally 
the  heart  becomes  involved  by  continuity,  the 
lungs  and  mediastinum  being  the  seat  of  the 
primary  disease.  Cases  have  occurred  at  all 
periods  of  life,  from  infancy  to  old  age  ; but  at 
least  one-half  of  the  subjects  have  been  in  the 
middle  period  of  life.  The  disease  has  been 
most  frequently  found  in  males. 

Anatomical  Characters. — Carcinoma,  epi- 
thelioma, and  sarcoma,  inclnding  colloid  cancer 
and  melanosis,  have  all  been  found  in  the  heart 
in  different  instances.  Any  part  of  the  organ 
may  he  affected,  and  the  right  side  appears  to  be 
more  frequently  invaded  than  the  left ; but  the 
disease  is  generally  multiple.  The  morbid  growth 
generally  presents  itself  at  or  upon  either  of  the 
surfaces  of  the  heart,  rather  than  in  the  sub- 
stance of  the  myocardium.  In  these  situations 
there  appear  one  or  more  masses  of  malignant 
disease,  which  are  generally  easily  distinguished 
from  the  cardiac  tissue  around;  and  which  pos- 
sess the  ordinary  characters  of  such  formati  ns. 
according  to  their  respective  forms,  encephaloil 
being  the  most  common,  and  epithelioma  by  far 
the  most  rare.  Any  difficulty  in  the  recognition 
of  the  disease  is  removed  by  section  and  micro- 
scopical examination.  The  extent  of  cardiac  wall 
involved  by  the  growth  is  sometimes  great.  When 
the  masses  of  malignant  disease  project  exter- 
nally, they  arc  frequentlyasscciated  with  pericar- 
ditis, either  local  or  general.  Prominent  nodules 
in  the  interior  of  the  heart  may  cause  local 
endocarditis  ; and  in  other  instances  the  valves 
and  their  appendages  may  he  so  involved  that 
incompetence  results.  In  very  rare  cases  malig- 
nant disease  of  the  heart  proceeds  to  ulceration. 

Symptoms. — Of  thirty-six  cases  of  mal-gnant 
disease  of  the  heart,  the  histories  of  which 
were  collected  by  Dr.  Quain,  in  thirty  either 
there  were  no  symptoms  present,  or  they  were 
not  recorded.  In  one  of  the  remaining  six 
cases,  the  subject  of  the  disease,  a man  of  thirty 
seven,  in  whose  heart  a single  large  mass  of 
encephaloid  cancer  was  found  post  mortem,  had 
been  subject  to  attacks  of  excruciating  pain  in 
the  praecordial  region,  to  dyspnoea,  palpitation, 
and  vomiting ; and  death  occurred  suddenly. 
Pain  in  the  chest  and  oppression,  not  referable  to 
other  causes,  are  recorded  in  two  other  cases ; 
and  in  the  fourth  there  were  anginal  seizures. 
Iu  cases  of  cancer  of  the  heart  spreading  from 
the  mediastinum  or  lungs,  dyspnoea,  cough,  ar.d 
pain  are  necessarily  frequent  symptoms. 

With  respect  to  the  physical  signs  of  malig- 
nant disease  of  the  heart,  tenderness  on  per- 
cussion over  the  prseeordium  (in  association 
with  local  pain),  pericardial  friction,  and  endo- 
cardial murmurs  duo  to  involvement  of  the 
valvular  apparatus  in  the  new  growth,  appear 
to  be  the  only  phenomena  that  have  been  specially 
observed. 

The  disease  naturally  ends  in  death:  and  iv 


HEART,  MORBID  GROWTHS  IN. 

more  than  one  instance  this  termination  was 
Midden,  and  perhaps  directly  due  to  the  affection 
of  the  heart. 

Diagnosis. — This  condition  has  probably  never 
been  diagnosed  during  life.  The  appearance  of 
true  cardiac  pain,  or  of  any  of  the  physical  signs 
just  mentioned,  in  the  course  of  a case  of  cancer, 
would,  however,  bo  strong  evidence  that  the 
heart  was  secondarily  involved. 

Treatment. — The  treatment  of  malignant 
disease  of  the  heart  is  necessarily  limited  to  the 
relief  of  any  symptoms  that  may  be  present, 
and  does  net  differ  from  the  treatment  of  cardiac 
distress  from  other  causes. 

2.  Lymphoma  of  the  Heart.  — Lympho- 
matous  or  lymphadenomatous  growths  have  been 
met  with  in  the  heart  in  several  cases  in  which 
the  disease  was  general,  but  this  affection  of  the 
organ  cannot  be  said  to  have  any  clinical  im- 
portance. 

3.  Non-Malignant  Tumours  of  the  Heart. 
These  growths  are  also  of  purely  pathological 
interest,  and  are  amongst  the  very  rarest  of 
morbid  appearances  in  connection  with  the  heart. 
Myomata  have  been  recorded  as  instances  of 
this  class  of  diseases.  Lipomata  lying  under  the 
endocardium  are  referred  to  in  the  article  Heart, 
Fatty  Growth  on. 

4.  Cysts  of  the  Heart.— The  occurrence  of 
true  cysts  in  the  myocardium  (hydatids,  ab- 
scesses, hsematomata,  and  softening  gummata 
being  excluded)  is  doubtful. 

J.  Mitchell  Bruce. 

HEART,  Palpitation  of.— Synon.  : Fr. 

Ptlpitation  da  Coeur  ; Ger.  Herzklopfen. 

Definition. — Abnormal  movement  of  the 
heart,  whereby  the  force  of  the  systolic  contrac- 
tions is  increased  to  such  a degree  as  to  give 
rise  to  a sensation  of  discomfort  or  distress  on 
the  part  of  the  patient. 

2Etiology. — The  immediate  or  proximate 
cause  of  palpitation  is  an  over-stimulation  of 
the  excitability  of  the  muscular  structure  of  the 
heart,  induced  by  functional  errors  of  the  cardiac 
ganglia  and  of  the  vagus,  or  of  those  nerves  which, 
proceeding  from  the  ganglia  of  the  great  sympa- 
thetic, supply  tho  heart.  It  is  therefore  a true 
neurosis.  The  disordered  action  of  these  nerves 
may  be  induced  either  directly  or  by  reflex  action ; 
but  in  either  case  the  phenomena  as  regards  the 
heart  are  the  same,  namely,  the  morbid  activity 
of  a normal  function,  which  must  be  here  con- 
sidered as  independent  of  any  accompanying  or- 
ganic lesion. 

The  predisposing  and  exciting  causes  of  palpi- 
tation of  the  heart  are  various.  The  chief  pre- 
disposing causes  are  to  be  found  in  the  nervous 
and  excitable  temperaments;  general  debility; 
inanition ; exhaustion,  whether  bodily  or  mental; 
early  age;  hysteria;  venereal  excesses;  and  in 
deterioration  of  the  blood,  as  occurs  in  gout, 
scurvy,  chlorosis,  or  spansmia.  Amongst  the 
exciting  causes  may  be  classed  violent  exercise  ; 
mental  shock,  emotion,  and  all  forms  of  sudden 
excitement  of  the  nervous  system;  dissipation; 
injurious  articles  of  diet ; and  dyspepsia. 

Symptoms. — Palpitation  may  be  found  in  the 
form  of  (1)  a single  action ; or  (2)  a series  of  ac- 
tions, which  may  become  prolonged,  and  of  such 


HEART,  PALPITATION  OF.  617 
a character  as  to  be  esteemed  chronic.  The  single 
abnormal  beat  not  unfrequently  occurs  during  a 
first  sleep,  and  the  patient  is  wakened  by  a con- 
sciousness of  it.  Sleep  may  then  return,  and  the 
attack  subside  without  other  inconvenience ; or  it 
may  be  associated  with  a feeling  of  weight,  ful- 
ness, anxiety,  sinking,  or  even  pain  of  the  prte- 
cordia.  More  frequently,  however,  the  attacks 
are  prolonged  and  paroxysmal,  recurring  with  an 
accelerated  and  uncertain  frequency,  and  varying 
rapidity.  In  the  patient  the  act  of  palpitation 
causes  various  and  widely  different  sensations. 
There  may  be  a mere  occasional  flutter,  or  a 
slightly  increased  action  continuing  for  a time  ; 
or  there  may  be  increased  action  attended  with 
great  rapidity,  and  such  violence  that  the  heart 
appears  forcibly  to  strike  the  chest- walls,  dif- 
fusing its  influence  over  the  whole  sternal  region, 
and  even  at  times  agitating  the  whole  body  (a 
phenomenon  probably  due  to  an  associated 
general  nervous  agitation) ; or  the  heart,  again, 
may  seem  to  the  sufferer  to  rise,  as  it  were,  into 
the  throat.  With  these  several  forms  there  may 
be  the  accompanying  symptoms  of  choking — the 
globus  hystericus ; vertigo ; tinnitus  aurium ; 
impaired  vision,  with  a feeling  of  distension  of 
the  eyeballs  ; a copious  secretion  of  pale  limpid 
urine;  a clammy  coldness  of  the  extremities; 
fear  of  death  ; partial  unconsciousness ; or  actual 
syncope.  Paroxysms  such  as  these  may  be  pre- 
ceded by  a somewhat  prolonged  state  of  cerebral 
disturbance,  as  evidenced  by  heat  of  brow  and 
vertex,  headache,  and  an  inaptitude  to  think  or 
regulate  the  thoughts  ; and  as  there  is  generally 
a self-consciousness  of  the  abnormal  action  of 
the  heart,  the  anxiety  on  this  account  serves  to 
impress  the  mind  with  so  much  fear  and  inquie 
tude,  as  to  tend  to  increase  and  prolong  the  dis- 
order that  has  induced  them. 

Physical  Signs. — The  physical  examination 
of  the  heart  shows  the  apex-beat  to  be  normal 
in  position,  but  diffused  and  much  exaggerated 
in  force.  The  area  of  dulness,  as  a rule,  is  not 
enlarged  upwards,  but  it  may  be  temporarily 
enlarged,  under  certain  circumstances,  towards 
the  right  side.  The  sounds,  always  exaggerated, 
at  times  become  very  much  so,  and  usually  with  a 
sharp  metallic  ring.  Occasionally  a kind  of  remit- 
ting humming  sound  is  superadded,  and  maybe 
heard  even  by  the  patient ; but  this  is  never  con- 
stant. Sometimes  the  sounds  are  heard  over  a 
great  extent  of  surface  ; but  this  extent  is  no 
measure  of  their  intensity,  for  they  may  not  be 
loud,  but  abnormally  clear  and  distinct  only.  Oc- 
casionally there  is  a pericardial  rubbing  accom- 
panying the  mitral  apex-shock,  simulating  the 
friction-sound  of  pericarditis,  but  there  is  never 
true  friction-sound.  The  basic  second  sound, 
more  frequently  than  the  first,  presents  the  me- 
tallic ring.  Sometimes  it  becomes  lower-pitched 
and  less  clicking  than  in  an  ordinary  paroxysm 
of  palpitation;  and  may  even,  as  also  the  first 
sound,  so  lose  sharpness  and  abruptness  as  to 
assume  somewhat  of  the  character  of  a soft 
murmur.  The  aorta,  carotids,  and  large  arteries 
also  throb,  and  have  an  excited  impulse.  Tho 
smaller  arteries  are  not  sensibly  affected.  The 
pulse  at  the  wrist  is  often  no  indicator  of  the 
amount  of  action  exhibited  by  the  heart.  Some- 
times it  has  the  character  of  being  sharp  and 


518  HEART,  PALPITATION  OF. 

jerking,  -without  force  ; or,  should  the  right  side 
of  the  heart  become  loaded  with  blood,  it  may 
be  small  and  soft,  and  weak.  On  the  subsidence 
of  a paroxysm,  the  ventricular  impulse  may 
drop  to  its  natural  force  and  frequency,  and  the 
sounds  be  unaccompanied  by  any  exaggerations. 
Nevertheless,  though  the  attack  may  have  sub- 
sided, there  may  be  some  slight  irritability  of 
the  heart’s  action  perceptible  for  some  short  time 
afterwards. 

Diagnosis. — Though  the  diagnosis  of  palpita- 
tion of  the  heart  in  some  cases  may  present  dif- 
ficulty, yet,  in  the  absence  of  evidence  of  struc- 
tural lesion,  an  increased  impulse  presenting  the 
above  distinctive  characters  may  be  assumed  to 
be  functional  in  its  origin,  and  not  dependent  on 
any  organic  disease  of  the  heart  itself.  We 
have,  in  fact,  to  do  with  an  exaggeration,  some- 
times highly  marked,  of  the  natural  nervous 
susceptibilities  of  the  heart  ; and  this  nervous 
increase  of  impulse,  even  when  only  slight,  is 
usually  more  appreciated  by  the  patient,  more 
painful,  and  more  a source  of  anxiety  lhan  is 
that  attending  organic  disease,  especially  in  its 
earliest  stages. 

Treatment. — The  treatment  of  palpitation 
should  in  every  case  be  directed  to  remedy  or  to 
remove  the  exciting  cause  of  the  attacks,  and 
to  render  the  nervous  system  less  susceptible. 
In  the  simpler  forms  that  which  is  prophylactic 
is  all  that  is  necessary.  In  more  marked  attacks 
general  care,  with  quiet,  may  be  sufficient ; or 
tho  administration  of  an  alkali  with  warm 
restoratives.  In  the  protracted  and  severer 
forms  of  attack,  besides  ether  and  ammonia, 
digitalis,  aconite,  colchicum,  chloral  hydrate,  and 
tho  bromides  may  be  occasionally  resorted  to. 

T.  Shapter. 

HEART,  Pyaemic  Abscess  of. — Defini- 
tion. — Abscess  of  the  heart  occurring  in 
pyaemia. 

./Etiology. — Abscess  of  the  heart  has  been 
most  frequently  observed  in  cases  of  pyaemia 
following  acute  necrosis  of  bone  or  diffuse  peri- 
ostitis, and  less  frequently  after  phlebitis,  chronic 
or  acute  arthritis,  urethral  stricture,  chronic 
abscess,  and  cancerous  ulceration.  In  eleven 
out  of  fourteen  cases,  the  histories  of  which 
were  collected  by  Dr.  Quain,  the  age  of  the 
patients  was  seventeen  years  or  under;  and 
twelvo  out  of  the  same  fourteen  cases  were 
males.  In  other  words,  pyaemic  abscess  of  the 
heart  has  been  most  frequently  found  in  eases 
following  injury  to  a bone  or  to  a joint  in  boys. 
In  older  subjects  it  has  been  associated  with 
pyaemia  secondary  to  one  or  other  of  the  diseases 
just  mentioned.  In  a few  cases  no  primary  dis- 
ease was  discovered. 

Anatomical  Characters. — Pyaemic  disease 
cf  the  walls  of  the  heart  has  been  most  fre- 
quently observed  in  the  left  ventricle,  towards 
the  base  and  in  the  papillary  muscles.  In  the 
great  majority  of  eases,  pericarditis  co-exists, 
and  very  frequently  endocardial  inflammation 
also.  The  pysemic  foci  are  generally  multiple ; 
and  appear  at  first  as  small,  slightly  elevated, 
yellowish  or  buff-coloured,  softened  patches, 
projecting  either  on  the  external  or  on  the  inter- 
nal surface  of  the  heart,  and  covered  with  in- 


HEART,  PYeEMHJ  ABSCESS  OF. 
flammatory  deposit.  On  section,  these  patches 
either  present  an  appearance  of  diffused  yellowish 
softening,  or  contain  one  or  more  collections  of 
dark  dirty  puriform  matter,  with  ragged,  ill- 
defined  boundaries,  as  if  formed  by  destruction 
of  the  discoloured  tissue  around,  and  varying  in 
size  from  that  of  a pea  to  that  of  a pin’s  I, cad. 

Microscopically  examined,  the  yellowish  pat- 
ches prove  to  be  portions  of  the  myocardium 
which  are  infiltrated  with  pus  and  granular 
matter ; the  muscular  tissue  itself  being  in  a 
condition  of  granular  or  fatty  degeneration.  Tha 
puriform  material  represents  an  advanced  stage 
of  the  same  change,  consisting  of  granular  mat- 
ter and  other  muscular  debris,  blood,  and  fre- 
quently pus-corpuscles.  The  several  stages  of 
the  pyaemic  process  have  been  found  side  by  side 
in  some  cases ; and  embola  have  been  discovered 
in  the  branches  of  the  coronary  arteries,  where 
they  may  have  served  as  the  foci  of  the  abscesses. 
The  walls  of  the  heart  are  sometimes  in  a con- 
dition of  softening  throughout.  Pyaemic  abscess 
of  the  heart  occasionally  hursts ; and  the  con- 
tents either  make  their  way  into  the  left  ven- 
tricle— producing  cardiac  aneurism,  and  perhaps 
giving  rise  to  further  embolism  and  pyaemic 
disease— or  into  the  pericardial  sac. 

Symptoms. — Whatever  the  symptoms  of  py- 
semic  abscess  of  the  heart  may  be,  they  have  in 
recorded  cases  been  completely  obscured  by  the 
general  symptoms  of  pyaemia,  and  by  the  local 
symptoms  and  signs  of  pericarditis.  Thus,  the 
patients  are  described  as  presenting  a febrile, 
typhoid,  or  pyaemic  appearance,  an  anxious 
look,  dyspnoea,  and praecordial  pains;  pericardial 
friction  has  been  generally  discovered  over  the 
heart.  Delirium  probably  occurs  more  frequently 
than  in  ordinary  cases  of  pyaemia,  hut  may  he 
referable  to  the  accompanying  pericarditis.  Tho 
physical  signs  found  in  these  cases  are  chiefly 
those  of  acute  pericarditis.  Sometimes  an  en- 
docardial bellows-murmur  may  be  heard,  duo 
either  to  valvular  lesion,  or  to  the  formation  cf 
an  acute  aneurism  of  the  cardiac  wall. 

Course  and  Terminations. — The  cases  of 
pyaemia  in  which  the  heart  has  been  found  post 
mortem  to  be  involved,  have  generally  proved 
rapidly  fatal,  the  patients  dying  from  exhaus- 
tion. Rupture  of  the  abscess  in  either  direction 
may  tend  to  accelerate  the  fatal  termination: 
but  complete  rupture  of  the  wall  iu  both  direc- 
tions, with  sudden  death  from  lise mo-pericardium, 
as  in  non-pyaemic  abscess  of  the  heart,  does  not 
appear  to  be  on  record. 

Diagnosis. — In  every  case  of  pyaemia  the 
physical  condition  of  the  heart  should  he  regu- 
larly investigated ; and  there  should  no  longer 
be  any  risk  of  acute  inflammation  of  the  heart 
or  pericarditis  being  mistaken  for  meningitis  or 
simple  delirium.  Pyaemia  with  multiple  arthritis 
and  involvement  of  the  heart  is  more  difficult  of 
diagnosis  from  ordinary  acute  rheumatism  with 
cardiac  inflammation ; and  mistakes  iu  such  cases 
have  not  unfrequently  occurred.  The  history  of 
the  case,  including  the  evidence  of  a definite  in- 
jury, however  slight,  is  of  the  greatest  value  : but 
a careful  consideration  of  all  the  facts  of  the 
case  alone  can  prevent  mistakes.  The  only  dii- 
fieulty  that  remains  in  the  diagnosis  of  pyaemic 
abscess  of  the  heart  is  the  determination  of  its 


HEART,  PYjEMIC  ABSCESS  OF. 
existence  in  the  presence  of  pericarditis,  which 
is  rarely  absent.  For  this  purpose  the  facts  of 
the  aetiology  of  the  case  are  more  important  than 
the  symptoms ; and  especially  the  occurrence  of 
an  injury  to  the  periosteum  of  a youthful  subject 
as  the  original  cause  of  the  pyaemia.  As  a 
matter  of  fact,  the  symptoms,  either  general  or 
local,  appear  never  to  have  suggested  the  diag- 
nosis of  pysemic  abscess  of  the  heart. 

Prognosis. — If  a diagnosis  of  abscess  of  the 
heart  can  be  made  in  pyaemia,  the  only  possible 
prognosis  that  can  be  given  is  one  of  speedy 
death. 

Treatment. — The  treatment  of  pyaemia  affect- 
ing the  heart  cannot  be  said  to  differ  in  any 
important  respect  from  that  of  ordinary  cases  of 
the  disease  (see  Pyaemia).  The  accompanying 
pericarditis  will  call  for  local  treatment. 

J.  Mitchell  Bruce. 

HEART,  Rupture  of. — The  heart  is  liable 
to  rupture  from  external  injuries,  and  from 
causes  acting  from  within.  The  latter  are  called 
spontaneous  ruptures,  and  these  only  will  be  con- 
sidered here.  Spontaneous  ruptures  may  affect 
either  the  walls  or  the  valves.  The  latter  form 
of  lesion  will  be  found  discussed  under  the  head 
of  Heart,  Valves  of,  Diseases  of. 

.ZEtiology'. — Rupture  of  tho  walls  may  be  said 
never  to  occur  spontaneously  when  the  heart  is 
healthy.  The  following  have  been  enumerated  by 
different  writers  as  tho  diseased  conditions  of  the 
heart’s  walls  that  predispose  to  rupture: — a thin 
or  atrophied  condition,  simple  softening,  a ‘ gelati- 
niform’  condition  of  the  walls,  apoplectic  or  hte- 
morrhagic  effusion  into  the  walls,  abscess,  ulcera- 
tion, and  fatty  degeneration.  The  writer  finds 
from  a table  of  100  cases  of  rupture,  the  his- 
tories of  which  he  has  collected  from  different 
sources,  that  the  heart  had  undergone  fatty  de- 
generation in  77;  in  6 the  walls  were  described 
simply  as  being  softened ; in  1 there  was  rup- 
ture of  an  aneurismal  dilatation ; in  1 there 
was  bursting  of  an  abscess;  in  12  the  heart  is 
said  to  have  been  healthy  in  texture,  or  not  to 
have  been  examined ; but  in  most  of  these  latter 
cases  mention  is  made  of  the  previous  existence 
of  endocarditis,  or  of  changes  in  the  coronary 
arteries,  fully  justifying  the  impression  that 
there  was  disease  of  the  texture  of  the  heart. 

The  influence  of  age  in  relation  to  rupture  of 
the  heart  can  be  distinctly  traced.  For  example, 
of  the  100  cases  just  referred  to,  63  were 
above  the  age  cf  sixty  years.  Arranged  in 
decades,  the  cases  stand  thus  : — 2 were  between 
ten  and  twenty  ; 1 between  twenty  and  thirty  ; 
3 between  thirty  and  forty ; 6 between  forty 
and  fifty;  13  between  fifty  and  sixty  ; 33  between 
sixty  and  seventy ; 21  between  seventy  and 
eighty  ; G were  over  eighty ; and  in  2 the  age  is 
not  stated.  With  respect  to  sex,  of  98  out  of 
100  cases  in  which  it  is  mentioned,  54  were  males 
and  44  females. 

The  exciting  cause  of  rupture  of  the  heart  is 
usually  some  mental  excitement  or  physical 
effort ; but  the  accident  may  occur  when  the 
subject  of  it  is  at  rest,  or  pursuing  the  ordinary 
avocations  of  life. 

Anatomical  Characters. — Scat.  In  76  cases 
out  of  the  100  to  which  we  have  already  alluded, 


HEART,  RUPTURE  OF.  619 

the  left  ventricle  was  the  seat  of  the  rupturo ; 
and  in  43  of  these  cases  the  lesion  was  in  the 
anterior  wall.  Tho  right  ventricle  was  found 
ruptured  13  times,  nine  instances  occurring  in  its 
anterior  wall.  The  right  auricle  was  ruptured 
seven  times;  the  left  auricle  twice;  and  a rupture 
was  found  in  the  septum  four  times.  These  re- 
sults correspond  remarkably  with  those  of  other 
writers  on  the  subject.  Elleaume  (Mon.  des 
Hopit.,  1858)  in  55  cases  found  the  rupture  43 
times  in  the  left  ventricle,  seven  times  in  the 
right  ventricle,  three  times  in  the  right  auricle, 
and  twice  in  the  left  auricle. 

On  examining  a heart  in  which  rupture  lias 
occurred,  the  torn  part  is  found  to  present 
different  characters  in  different  cases.  The 
lesion  may  be  complete,  causing  perforation  of 
the  wails ; or  it  may  be  incomplete.  In  com- 
plete rupture  the  opening  is  sometimes  barely 
sufficient  to  admit  a probe,  whilst  in  other 
instances  it  may  bo  two  or  three  inches  in 
length.  The  rent  is  sometimes  longer  exter- 
nally, and  sometimes  it  is  longer  internally. 
There  may  be  but  one,  or  there  may  be  more 
than  one,  rupture ; and  in  the  latter  case  the 
ruptures  may  or  may  not  communicate  with  one 
another.  In  incomplete  rupture  the  injury  may 
be  confined  to  the  internal  surface,  or  to  the  ex- 
ternal surface,  or  it  may  occur  in  the  substanee 
of  the  walls.  The  edges  of  the  rent  are  ragged, 
irregular,  and  sometimes  ecchymosed.  The  irre- 
gularity of  the  edges  is  due  to  the  manner  in 
which  the  muscular  fibres  are  torn,  whether  across 
or  split  longitudinally.  This  description  refers 
more  correctly  to  rupture  iu  a heart  that  is  the 
subject  of  fatty  degeneration.  The  appearances 
are  different  when  the  rupture  is  secondary  to 
an  abscess,  or  to  ulceration,  or  to  certain  other 
causes  presently  to  be  described.  In  such  cases 
the  lesion  has  been  described  as  a rent,  tear, 
ulceration,  or  perforation.  The  condition  of  the 
heart  in  the  majority  of  cases  of  rupture  has 
been  already  referred  to  in  this  article  under 
the  head  of  JEtiology.  Ecchymoses  are  some- 
times found  in  the  vicinity  of  the  lesion.  The 
pericardium  generally  contains  an  effusion  of 
blood,  which  often  surrounds  the  heart  with 
coagulum,  leaving  the  sac  filled  until  serum,  to 
the  amount,  it  may  be,  of  thirty  ounces,  as 
in  an  instance  which  came  under  the  writer’s 
notice. 

Mechanism. — Rupturo  of  the  heart  is  doubt- 
less nearly  always  the  result  of  a strain  or  of 
pressure  acting  upon  the  muscular  walls.  The 
walls  of  the  healthy  heart  are  sufficiently  strong 
to  resist  any  ordinary  force  to  which  they  are 
exposed.  But  when  they  are  softened  by  de- 
generation, or  are  very  thin,  as  is  sometimes  the 
case  in  the  auricles  or  the  rightventricle,  theymay 
give  way  before  the  pressure  to  which  they  are 
exposed  during  muscular  efforts  or  strains,  or 
even  in  the  ordinary  action  of  the  organ.  Thus, 
when  a part  of  the  wall  of  the  heart  is  weakened 
by  softening  or  other  cause,  this  spot  may  be,  as 
it  were,  torn  across  by  the  contraction  of  the 
healthy  fibres  among  which  it  is  situated.  Or 
again,  when  the  walls  of  the  heart  are  thick,  it 
may  be  that  the  outer  surface,  being  strained 
over  the  contents  of  a distended  ventricle,  as 
would  be  the  outer  surface  of  an  overbent  hoop 


620  HEART,  RUPTURE  OF. 

gives  way,  tears,  and  the  opening  gradually 
extends  from  without  inwards.  These  facts 
enablo  us  to  understand  why  rupture  is  more 
frequent  in  the  left  than  in  the  right  ventricle. 
A further  explanation  is  to  be  found  in  the  fact 
that  the  left  ventricle  is  more  frequently  than 
the  right  the  seat  of  fatty  degeneration,  from 
causes  elsewhere  alluded  to  (see  Heart,  Fatty 
Degeneration  oj.).  There  is  yet  another  way  in 
which  softening  leads  to  rupture.  A softened  spot 
occurs  in  the  substance  of  the  heart,  and  into 
it  hoemorrhage  takes  place,  constituting  what  is 
termed  apoplexy  of  the  heart.  At  times  this 
haemorrhagic  softening  may  yield  either  exter- 
nally or  internally,  and  give  rise  to  rupture. 
Lastly,  the  writer  has  seen  more  than  once  a 
small  spot  of  softening  with  loss  of  substance 
occurring  on  the  internal  surface  of  the  ventri- 
cular wall,  most  frequently  in  the  left ; this 
softening  and  breaking  down  of  tissue  gradually 
insinuates  itself  amongst  the  muscular  fibres, 
until  finally  perforation  of  the  outer  wall  of  the 
heart  occurs. 

Symptoms. — The  symptoms  of  rupture  of  the 
heart  may  be  described  as  those  which  are  pre- 
monitory ; and  those  which  occur  at  the  time  of 
the  accident.  The  former  are  such  as  indicate  a 
diseased  condition  of  the  organ— namely,  breath- 
lessness on  exertion,  palpitation,  more  or  less 
irregularity  of  pulse,  and  faintness.  In  some 
instances  recorded  these  symptoms  were  so  slight 
as  hardly  to  attract  attention ; in  others  so 
severe  as  to  cause  intense  suffering.  In  the 
majority  of  the  cases  noted  in  the  table  referred 
to,  no  mention  is  made  of  any  preceding  symp- 
toms, death  being  sudden.  In  several  cases  it  is 
.distinctly  stated  that  no  symptoms  preceded  the 
fatal  attack. 

The  occurrence  of  the  lesion  itself,  when  the 
patient  has  lived  long  enough  to  describe  his 
sensations,  has  always  been  marked  by  intense 
cardiac  suffering,  more  or  less  distress  in 
breathing,  restlessness,  rapid  and  irregular 
pulse,  faintness,  pallor,  coldness  of  the  skin, 
sometimes  vomiting,  and  by  various  nervous 
Bj'mptoms.  When  life  is  prolonged  beyond  a few 
minutes,  there  may  be  more  or  less  intermission 
in  the  progress  of  these  symptoms ; but  the  whole 
attack  is  marked  by  anguish  more  or  less  severe. 
The  duration  of  the  attack  itself  from  the  first 
fatal  seizure  varies  remarkably.  In  71  out  of 
the  1 00  cases  alluded  to,  death  wras  sudden,  occur- 
ring within  one  or  two  minutes.  One  patient, 
however,  lived  eight  days,  1 six  days,  1 three 
days  ; 5 lived  over  forty-eight  hours,  3 lived 
under  twenty-four  hours,  and  1 9 under  twelve 
hours. 

The  special  symptoms  indicative  of  a fatal 
seizure  are,  in  addition  to  those  already  men- 
tioned, severe  praecordial  pain,  dyspnoea,  vomit- 
ing, cyanosis,  pallor,  loss  of  consciousness,  and 
convulsions.  These  symptoms,  or  some  of  them, 
were  noted  in  44  out  of  the  100  cases  ; and 
in  24  of  these  the  patient  lived  for  more  than 
five  minutes  after  seizure,  and  in  some  of  the 
Cases  for  more  than  twelve  hours.  These  cases, 
doubtless,  are  instances  in  which  the  muscular 
fibres  are  torn  apart  layer  by  layer  successively. 
In  the  other  20  cases  ti«  patient  was  seized 
with  severe  pain,  and  then  expired ; or  with 


HEART,  SOFTENING  OF. 
dyspnoea  and  some  of  the  other  symptoms  men- 
tioned above,  and  lived  but  a few  seconds. 

T\\e  physical  signs  of  complete  rupture  having 
occurred,  so  far  as  can  be  ascertained,  are  merely 
— a greater  or  less  amount  of  dulness  in  the  re- 
gion of  the  heart;  the  impulse  diminished;  the 
Bounds  muffled,  distant,  or  imperfectly  developed ; 
and  the  pulse  weak  and  intermittent. 

Course  and  Terminations. — The  difference 
in  the  progress  of  ihe  fatal  malady  depends 
much  upon  the  seat  of  the  rupture,  on  the  size 
of  the  opening,  and  on  the  rapidity  with  which 
the  extension  of  the  laceration  takes  place. 
In  the  cases  in  which  the  septum  is  torn,  there 
is  no  external  haemorrhage,  and  life  is  pro- 
longed until  the  patient  dies  from  disturbance  in 
the  functions  of  such  an  important  organ  as  the 
reart.  ( See  a case  reported  by  Dr.  Peacock, 
Pathological  Transactions,  vol.  v.)  The  progress 
of  the  symptoms  is  also  influenced  by  the 
direction  and  course  of  the  rupture.  If  the  torn 
fibres  overlap  from  the  inside  or  from  the  out- 
side, the  injury  penetrates  slowly  through  the 
cardiac  wall,  and  the  fatal  progress  is  also  slow. 
(See  cases  recorded  by  the  writer  in  the  Patho- 
logical Transactions,  vol.  iii.,  and  also  in  vol.xii.; 
and  a case  by  Dr.  Peacock  in  vol.  xvii.  of  the 
same  Transactions.) 

Prognosis. — As  far  as  is  known,  rupture  of 
the  heart  is  always  fatal.  Still  it  is  possible 
that  such  an  accident,  owing  to  the  small  size 
of  the  opening,  its  incomplete  character,  and  its 
occlusion  by  a coagulum,  may  not  prove  fatal. 
Numerous  instances  are  recorded  of  severe 
wounds  of  the  heart,  the  subjects  of  which 
have  survived.  Ollivier  has  collected  29  such 
cases,  only  two  of  which  proved  fatal  within 
forty-eight  hours,  the  others  living  from  four  to 
eight  days.  Cases  are  recorded  in  which  persons 
have  survived  many  years  severe  wounds  of 
this  important  organ.  These  cases,  however, 
differ  from  thoso  of  rupture  in  this  particular, 
that  they  occur  in  the  healthy  organ,  whilst 
spontaneous  rupture  occurs  in  the  heart  when 
it  is  seriously  diseased  (sec  Heart,  Wounds 
of). 

Treatment. — In  the  way  of  treatment  of 
rupture  of  the  heart  little  can  be  done.  The 
patient's  sufferings  may  perhaps  be  relieved  by 
the  hypodermic  injection  of  morphia,  or  by  the 
use  of  other  sedatives.  Perfect  rest  should,  if 
possible,  be  maintained. 

E,  Quain,  H.D. 

HEABT,  Softening  of. — This  term  was 
formerly  applied  to  several  conditions  of  the 
heart  in  which  the  consistence  of  the  cardiac  tis- 
sue was  diminished,  whilst  the  process  to  which 
it  was  due  was  obscure  or  anomalous.  It  is 
probable  that  under  the  name  of  softening  of  the 
heart  there  were  especially  included  instances  of 
acute  myocarditis,  parenchymatous  degeneration, 
and  fatty  degeneration.  In  the  present  more 
advanced  state  of  cardiac  pathology,  it  seems 
desirable  that  the  expression  ‘softening,’ while 
retained  to  express  a familiar  physical  condition, 
should  cease  to  he  employed  as  a classifying 
term — that  is,  to  designate  any  specific  anato- 
mical state. 

J.  AlrrrHEi-L  Bruce 


HEART,  SYPHILITIC  DISEASE  OF. 

HEART,  Syphilitic  Disease  of. — Syphilitic 
disease  of  the  heart  is  by  no  means  a rare  con- 
dition, haring  been  found  in  a large  number  of 
instances  in  which  the  specific  nature  of  the 
lesion  was  determined  'with  certainty ; -whilst,  in 
another  series  of  cases,  similar  anatomical  ap- 
pearances were  present,  although  the  existence  of 
syphilis  -was  not  ascertained.  Syphilitic  disease 
of  the  heart  is  therefore  of  much  pathological 
interest ; but  it  cannot  be  said  that  a great 
deal  is  known  as  yet  with  respect  to  its  clinical 
history. 

-•Etiology. — There  appears  to  be  nothing  of 
importance  known  as  to  the  causes  of  the 
localisation  of  syphilis  in  the  heart.  The  con- 
genital as  well  as  the  acquired  form  of  the  dis- 
ease has  been  met  with. 

Anatomical  Characters. — This  morbid  con- 
dition presents  two  leading  appearances  post 
mortem.  The  first  is  the  well-marked  syphilitic 
gumma,  which  closely  resembles  the  same  form 
of  growth  as  it  is  met  with,  for  example,  in  the 
liver  and  testicles.  Gummata  of  the  heart  appear 
as  pale  3'ellow  patches  in  the  cardiac  wall,  or  as 
yellowish  nodules  which  are  found  on  section. 
They  present  a Yariety  of  appearances,  according 
to  their  age.  When  young  they  are  firm  or  even 
scirrhoid ; elastic,  and  homogeneous ; creak  on 
section ; and  are  very  slightly  succulent : but 
when  older,  they  become  soft  and  cheesy,  like  a 
mass  of  ‘ yellow  tubercle.’  In  either  form' the 
masses  are  not  isolated,  but  pass  continuously 
into  the  myocardium,  either  directly,  or  through 
the  medium  of  soft  vascular  connective  tissue, 
so  that  they  have  generally  been  described  in 
this  country  as  ' infiltrations  ’ or  ‘ deposits.’ 
The  supeijacent  endocardium  or  pericardium 
is  vascularised  and  dull  in  the  early  stage  of 
the  nodules  ; opaque  and  thickened  in  the  more 
advanced.  The  masses  or  nodules  occur  in 
various  numbers  in  different  instances,  but  are 
generally  multiple.  They  may  be  found  in  any 
part  of  the  heart.  Gummata  most  frequently 
become  caseous  in  the  centre,  as  described ; and 
they  majr  then  soften  more  completely  and  dis- 
charge inwards,  leading  to  acute  cardiac  aneurism 
and  ulcer  of  the  wall ; but  more  frequently  the 
cheesy  products  are  in  a great  measure  absorbed, 
leaving  a puckered  fibroid  patch  behind. 

The  second  form  of  syphilitic  disease  of  the 
heart  is  the  fibroid  patch.  This  is  sometimes 
well-defined  and  localised,  and  in  such  instances 
it  represents  the  stage  of  full  development  of  an 
area  of  ordinary  syphilitic  interstitial  inflam- 
mation. In  other  specimens,  the  fibroid  patches 
appear  as  irregular  masses  of  indurated  fibroid 
tissue,  occupying  part  of  the  wall  of  the  heart, 
and  sending  septa  into  the  depth  of  the  myocar- 
dium, whilst  the  endocardium  and  pericardium 
that  correspond  to  them  are  opaque,  thickened, 
and  puckered.  The  syphilitic  nature  of  such 
patches  may  be  determined  by  the  presence  of 
specific  lesions  in  other  viscera. 

A form  of  the  disease  intermediate  between 
the  two  forms  just  described  is  one  in  which 
the  outer  zone  of  the  gumma  has  undergone 
development  into  fibroid  tissue,  and  the  caseous 
centre  remains  as  a ‘fibrinous’  mass. 

The  microscopical  characters  of  syphilitic 
growths  do  not  require  to  be  described  here. 


HEART,  THROMBOSIS  OF.  621 
In  the  heart,  the  primary  seat  of  the  disease  is 
the  intermuscular  tissue ; the  muscular  fibres 
lying  imbedded  in  the  gummatous  products  ur 
in  the  fibroid  growth  being  either  healthy  in 
appearance,  or  fattily  degenerated  and  broken  up. 

Syphilitic  endarteritis  ( obliterans ) may  also 
occur  in  the  vessels  of  the  myocardium,  and 
give  rise  to  infarction  of  the  walls  of  the  heart. 

Amongst  the  occasional  effects  of  syphilitic 
disease  of  the  heart  are  chronic  aneurism  of  the 
walls  ; distortion  of  the  ostia  and  of  the  valves 
and  their  appendages  ; and,  more  frequently, 
adhesion  of  the  pericardium.  Some  of  the  other 
viscera  present,  as  a rule,  evidence  of  syphilitic 
disease. 

Symptoms.— The  subjects  of  syphilis  of  the 
heart  may.  from  a clinical  point  of  view,  be 
divided  into  three  classes.  The  first  class  of 
patients  suffer  from  some  one  or  other  of  the 
ordinary  symptoms  of  chronic  cardiac  disease, 
such  as  dyspncea,  cardiac  distress,  palpitation, 
pulmonary  complications,  and  general  dropsy; 
whilst  the  physical  signs  are  those  of  cardiac 
enlargement,  and  perhaps  of  valvular  incompe- 
tence. Praecordial  uneasiness,  syncopal  attacks, 
and  remarkable  infrequency  of  the  pulse,  have 
been  prominent  features  in  several  recorded 
cases. 

The  second  class  of  subjects  of  this  disease 
die  suddenly,  after  few  if  any  complaints  refer- 
able to  the  heart. 

The  third  class  die  of  syphilitic  marasmus, 
and  may  or  may  not  present  some  evidence — by 
physical  signs  or  otherwise — that  the  heart  is 
not  sound. 

In  many  of  the  cases,  other  symptoms  of 
visceral  syphilis — for  example,  phenomena  con- 
nected with  the  brain  and  nervous  system — have 
been  prominent. 

Diagnosis. — "Well-defined  symptoms  or  physi- 
cal signs,  such  as  these  just  mentioned,  con- 
nected with  the  heart,  occurring  in  a syphilitic 
subject,  would,  in  the  absence  of  other  more 
probable  causes,  such  asahistory  of  endocarditis 
or  Bright’s  disease,  furnish  considerable  grounds 
for  the  diagnosis  of  specific  cardiac  disease. 

Prognosis. — If  such  a diagnosis  were  posi- 
tively made,  the  prognosis  would  be  more  favour- 
able than  it  is  perhaps  in  any  other  form  of 
chronic  heart-disease,  inasmuch  as  the  condition 
might  be  successfully  removed  by  treatment. 

Treatment. — Anti-syphilitic  remedies,  espe- 
cially iodide  of  potassium,  should  be  freely  tried, 
along  with  the  other  remedies  indicated  on 
general  principles.  J.  JHitctiell  Bruce. 

HEAbRT,  Thrombosis  of. — Synon.  : Heart- 
clotting ; Fr.  Thrombose  cardiaque  ; Ger.  Geriii 
nungen  im  Herzen  ; Hcrzpolypen. 

Definition. — Coagulation  of  the  blood  within 
the  cavities  of  the  heart  during  life. 

./Etiology.— Thrombosis  of  the  heart  is  most 
frequently  due  to  local  arrest  of  the  movements 
of  the  blood,  comparatively  or  absolutely,  within 
its  cavities.  Such  arrest  is  itself  generally 
referable  to  weakness  of  the  cardiac  contractions, 
whether  associated  with  dilatation  secondary  to 
valvular  or  pulmonary  disease,  or  due  to  some 
primary  affection  of  the  muscular  walls.  Tbe 
peculiar  saccular  condition  of  the  extremities  of 


HEART,  THROMBOSIS  OF. 


522 

the  auricular  appendages,  and  the  trabecular 
arrangement  cf  the  column®  earnene  of  the 
ventricles,  as  well  as  the  distance  of  the  same 
parts  from  the  main  blood-currents,  determine 
the  favourite  localisation  of  the  thrombosis. 
Roughening  of  the  endocardium  is  another  cause 
of  thrombosis,  but  one  which  is  to  be  considered 
less  common  than  the  causes  already  men- 
tioned, unless  the  fibrinous  coagula  of  endocar- 
ditis, or  vegetations,  be  regarded  as  thrombi, 
which,  in  the  strict  sense  of  the  term,  they 
partly  are.  Possibly  certain  conditions  of  the 
blood  may  contribute  to  the  occurrence  of  car- 
diac thrombosis.  Finally,  thrombi  once  formed 
tend  to  promote  the  further  progress  of  the  con- 
dition. 

Anatomical  Characters.  — Coagula  found 
within  the  heart  are  of  two  kinds,  which  have 
been  termed  active  and  'passive,  according  as 
they  are  formed  during  life,  or  at  or  after 
death,  respectively ; and  the  characters  of  the 
former,  with  which  alone  we  are  here  concerned, 
cannot  be  understood  until  those  of  the  latter 
have  been  briefly  described. 

Passive  coagula  are  found  in  the  heart  in  most 
necropsies,  occupying  the  track  of  the  principal 
blood-currents.  Frequently  they  appear  as  black 
or  red  blood-clots,  occupying  the  auricles  princi- 
pally, and  moulded  in  their  cavities.  In  other 
cases  they  take  the  form  of  masses  of  firm 
whitish  fibrino,  cleaving  with  some  tenacity  to 
the  endocardium,  but  not  truly  adherent ; matted 
with  the  chordae  tendine®  and  column®  carnese ; 
and  projecting  some  distance  into  the  pulmo- 
nary artery.  Or,  thirdly,  passive  coagula  may  be 
a combination  of  the  two  previous  forms,  the 
upper  part  (according  to  the  position  of  the  body) 
being  decolourised  or  fibrinous,  and  the  deeper 
part  resembling  more  an  ordinary  blood-clot.  In 
certain  cases  these  passive  clots  are  peculiar. 
In  phthisis  and  other  diseases  proving  fatal  by 
very  slow  exhaustion,  they  are  remarkably  firm 
and  fibrinous,  and  closely  matted  amongst  the 
chord®  tendine® — appearances  which  seem  to 
indicate  that  coagulation  was  slowly  proceeding 
for  some  time  before  tho  heart  had  finally 
ceased  to  beat.  In  an®mia  they  are  jelly-like 
and  translucent.  In  leuk®mia  they  are  soft  and 
creamy  in  appearance,  and  yield,  when  broken 
up,  a puriform  fluid.  In  the  acute  exanthemata 
these  passive  clots  are  soft  and  friable  ; and  in 
many  cases  of  these  and  of  other  forms  of  acute 
disease  and  of  sudden  death,  no  coagula  are  found 
in  the  heart,  which  contains  only  fluid  blood. 

Active  coagula — the  result  of  thrombosis  of 
the  heart — are,  on  the  contrary,  situated  in 
the  saccular  appendages  of  the  auricles,  at  the 
apex  of  the  ventricles,  and  in  the  recesses 
behind  and  between  the  column®  earne® — in 
other  words,  as  far  as  possible  from  the  track 
of  active  blood-currents.  In  these  situations 
they  may  be  seen  projecting  in  the  form  of 
fleshy  knobs  or  globes,  with  their  free  surface 
smooth  and  rounded.  Their  deep  surface  is  ad- 
nerent  to  the  endocardium,  from  which,  however, 
it  can  generally  be  separated  without  much  diffi- 
culty, leaving  behind  it  a discoloured  mark.  If 
the  thrombus  be  incised,  it  will  be  found  to  be 
laminated  in  structure,  somewhat  after  the  fashion 
of  an  onion.iheeolourofthesection  being  greyish- 


brown  or  yellowish,  with  irregular  patches  of 
red  and  black.  In  most  instances  the  centre  is 
less  firm  than  the  periphery  ; and  usually  it  is 
of  a fluid  consistence,  in  the  form  of  a foul, 
sanious,  puriform  substance. 

If  the  process  of  thrombosis  have  been  pro- 
ceeding for  some  time,  these  formations  may 
extend  in  all  directions,  embrace  the  column® 
carne®,  coalesce  in  front  of  them,  and  finally 
may  fill  up  a considerable  portion  of  one,  or 
even  of  more  than  one,  cavity.  The  thrombi 
are  generally  friable  ; but  sometimes  they  gain 
in  firmness  by  the  deposit  of  lime-salts  within 
them ; and  at  other  times  it  is  possible  that  they 
become  detached  and  form  into  the  ‘ fibrinous 
balls’  which  have  occasionally  been  found  lying 
free  in  the  cavities  of  the  auricles.  Cardiac 
thrombi  may,  in  part  at  least,  be  reabsorbed. 
They  frequently  give  way  during  life ; and 
portions  of  them,  as  well  as  of  their  puriform 
contents,  are  conveyed  into  the  circulation, 
causing  embolism  and  pyaemia. 

It  may  be  added  that  embolism  of  the  heart 
has  frequently  been  found— thrombi  or  simple 
clots,  sometimes  of  remarkable  size,  having 
been  carried  from  the  veins,  and  arrested  in 
the  heart  or  in  the  mouth  of  the  pulmonary 
artery. 

Symptoms. — The  clinical  phenomena  associated 
with  true  cardiac  thrombosis  may  be  best  de- 
scribed as  those  of  the  last  stage  of  chronic  dis- 
ease of  the  heart.  Prmcordial  distress  and  restless- 
ness; irregularity  and  feebleness 'of  the  pulse; 
oedema  and  coldness  of  tho  extremities : pulmo- 
nary congestion,  infarction,  and  oedema  ; dulness 
of  expression,  and  sopor,  broken  by  low  weak  de- 
lirium ; with  other  symptoms,  as  well  as  with  tho 
signs  of  cardiac  failure  and  imperfect  emptying 
of  the  cavitiesin  systole — all  these  phenomena  are 
associated  with  the  process  of  active  coagulation 
within  the  heart.  It  would  not,  however,  be 
correct  to  describe  these  phenomena  as  symptoms 
directly  referable  to  the  thrombosis.  All  that 
can  be  said  is.  that  in  such  a case  thrombosis 
is  probably  going  on  and  increasing  the  embar- 
rassment and  the  gravity  of  the  condition.  An 
unusual  dcgrc-e  of  cyanosis  appears  in  some 
instances.  Tho  symptoms  of  arterial  embolism 
may  suddenly  make  their  appearance  from  de- 
tachment of  particles  of  the  clots ; and,  if  the 
puriform  contents  find  their  way  into  the  circu- 
lation, septiemmia  may  result. 

The  dislodgment  cn  masse  of  a large  venous 
thrombosis,  and  the  impaction  of  the  same,  or 
of  a ‘ fibrinous  ball,’  in  one  of  the  ostia  of  the 
heart  have  caused  sudden  death  in  several  cases. 

Passive  coagulation. — It  should  be  added  that 
the  appearance  of  the  ‘passive’  form  of  coagula- 
tion w-ithin  the  heart,  which  has  been  already 
referred  to  as  a postmortem  process,  or  one  oc- 
curring in  articulo  mortis,  has  been  otherwise 
interpreted  by  some  authorities,  who  regard 
passive  coagula  as  formed  ante  mortem,  and  as 
giving  rise  to  severe  symptoms  by  the  embar- 
rassment which  they  produce  in  the  circulation. 
The  symptoms  caused  by  this  condition  are  said 
to  be — gr«at  prscordial  pain  and  distress;  tumul- 
tuous action  of  the  heart,  passing  on  to  irregu- 
larity, flickering,  and  finally  arrest,  whilst  tho 
pulse  is  very  feeble  ; urgent  dyspnoea;  cyanosis- 


HEART,  THROMBOSIS  OF. 
hemoptysis;  coldness  of  the  extremities  ; deepen- 
ing stupor;  and  coma  ending  in  death — in  short., 
the  congeries  of  symptoms  which  would  be  re- 
ferred by  most  authorities  to  failure  of  the 
muscular  walls  of  the  heart,  the  coagulation 
being  regarded  by  the  latter  as  only  another 
result  of  the  same  condition. 

Diagnosis. — In  the  presence  of  the  very  se- 
rf uis  and  complex  conditions  with  which  cardiac 
thrombosis  is  usually  associated,  the  question  of 
its  existence  can  hardly  be  said  to  occur  to  the 
physician  as  a point  of  great  importance.  An 
unusual  degree  of  cyanosis,  especially  if  it  be 
progressive,  favours  the  recognition  of  this  state ; 
and  in  the  absence  of  valvular  disease,  the  occur- 
rence of  embolism  or  pyaemia  would  tend  to  con- 
lirm  it. 

Treatment. — The  treatment  of  cardiac  throm- 
bosis consists  in  the  treatment  of  its  cause  ; and 
nothing  is  demanded  or  can  be  done  for  the 
former  which  is  not  indicated  for  the  relief  of 
the  latter. 

Those  authorities  who  see  in  ‘passive’  coagula 
the  evidence  of  rapid  ante-mortem  thrombosis, 
recommend  the  use  of . stimulants,  and  even  of 
certain  drugs  which  are  supposed  to  have  a sol- 
vent effect  on  fibrinous  deposits,  especially  am- 
monia. J.  Mitchell  Beuce. 

HEART,  Tuberculosis  of. — Independently 
of  the  pericardium,  the  heart  itself  is  believed 
to  be  rarely  the  seat  of  tubercular  disease. 
Grey  miliary  tubercles  have  been  found  in  the 
connective  tissue  of  the  wall  of  the  heart,  in 
some  cases  of  acute  general  tuberculosis.  In 
other  instances  the  ‘ tubercle  ’ has  been  of  the 
yellow  or  cheesy  kind,  in  the  form  of  small 
nodules  lying  at  various  depths  in  the  muscular 
tissue  beneath  the  pericardium  ; the  latter  also 
being  frequently  afiected,  as  well  as  the  lungs, 
intestines,  and  other  organs. 

There  appears  to  bo  no  evidence  that  tubercu- 
losis of  the  myocardium  gives  rise  to  definite 
Bymptoms,  or  that  it  can  be  recognised  during 
life.  J.  Mitchell  Beuce. 

HEART,  Valves  and  Orifices  of,  Diseases 
of. — Classification. — The  diseases  of  the  valves 
andorificesof  the  heart  which  produce  mechanical 
disorders  of  the  circulation,  by  establishing  ab- 
normal relations  between  those  parts,  are  of  two 
kinds — obstructive  and  regurgitant.  Valvular 
disease,  on  the  one  hand,  is  said  to  be  obstruc- 
tive when  narrowiug  of  an  orifice  presents  an 
obstacle  to  the  passage  of  the  blood-current — a 
condition  better  named  stenosis.  On  the  other 
hand,  when  the  blood  regurgitates  or  flows  back 
through  an  orifice,  in  consequence  of  imperfect 
; closure  of  the  valves,  due  either  to  valvular 
changes  or  to  widening  of  the  orifice,  the  condi- 
tion is  called  regurgitation  or  insufficiency. 

Aneurism  of  the  valves  of  the  heart  will  be 
discussed  separately.  See  Heaet,  Valves  of, 
Aneurism  of. 

^Etiology. — Each  of  the  orifices  may  be 
affected  with  one  or  both  forms  of  disease,  but 
the  frequency  with  which  the  several  orifices  are 
attacked  varies.  The  results  of  organic  disease 
are  chiefly  met  with  in  the  left  side  of  the 
heart,  and  are  duo  .o  local  inflammation — endo- 


HEART,  VALVES  OF,  DISEASES  OF.  623 
carditis  and  its  consequences ; or  to  chronic 
degenerative  changes,  such  as  atheroma.  In 
adult  life  the  valves  of  the  left  side  are  more 
frequently  affected  than  those  of  the  right,  be- 
cause they  have  to  bear  a much  greater  pres- 
sure ; but  in  fcetal  life,  when  the  condition  is 
reversed,  the  right  valves  suffer  more.  Endo- 
carditis is  commonly  of  rheumatic  origin,  and 
attacks  the  mitral  more  frequently  than  the 
aortic  valves  ; the  former  having  to  sustain  the 
full  force  of  the  ventricular  systole,  while  the 
latter  only  bear  the  force  of  the  aortic  recoil. 
In  addition  to  rheumatic  fever,  the  chief  diseases 
which  tend  to  develop  endocarditis  are — pyaemia, 
puerperal  fever,  the  exanthemata,  chronic  renal 
disease,  and  syphilis.  The  aortic  valves  are 
more  commonly  affected  than  the  mitral  by 
chronic  endarteritis  extending  from  the  aorta, 
the  chief  causes  of  which  are  gout,  old  age, 
syphilis,  and  the  abuse  of  alcohol.  These  facts 
explain  why  mitral  affections  (commonly  rheu- 
matic) occur  mostly  in  early  life,  and  aortic 
affections  in  later  life.  ATalvular  lesions  are  more 
common  in  men  than  in  women,  from  the  strain 
of  the  heart  incidental  to  more  laborious  occu- 
pations. Strain  helps  to  sw»-ll  the  greater  pro- 
portion of  disease  of  the  aortic  valves,  which  are 
liable  to  rupture  from  effort ; but  similar  acci- 
dents may  occur  to  the  mitral  valve  and  its 
tendinous  cords. 

Anatomical  Characters. — The  pathological 
changes  in  the  valves  and  orifices  of  the  heart, 
which  cause  valvular  defects,  are  mostly  the 
results  of  acuto  or  chronic  endocarditis.  In 
the  acute  form,  the  valvular  defect  is  caused  by 
the  growth  of  vegetations  which  prevent  the 
action  of  the  valve-segments  ; or  by  softening 
and  ulceration  of  the  valve-structure,  which  lead 
to  valvular  aneurism  and  perforation,  or  to  loss 
of  substance  and  consequent  insufficiency.  The 
more  chronic  form  of  inflammation  produces 
thickening  of  the  valves  from  overgrowth  of  the 
connective  tissue,  with  subsequent  calcareous 
degeneration  and  retraction  from  shrinking  of 
the  hyperplastic  connective  tissue ; or  adhesion 
of  the  valve-segments  causing  stenosis. 

Aortic  stenosis  is  generally  the  result  of 
thickening  and  calcareous  degeneration  of  the 
valves,  or  of  deformity  of  the  valves  from  vege- 
tative growths,  which  obstruct  the  free  passage 
of  the  blood  from  the  ventricle.  Sometimes  it  is 
due  to  adhesion  of  the  valves  preventing  their 
elevation,  and  causing  them  to  form  a diaphragm 
with  a narrow  central  aperture.  More  rarely  it 
is  caused  by  contraction  of  the  fibrous  ring  of 
the  aortic  orifice,  or  by  endocardial  thickening 
producing  contraction  immediately  beneath  the 
valves. 

Mitral  stenosis  results  most  frequently  from 
thickening  and  rigidity  of  the  valves,'  which 
adhere  at  their  edges  to  each  other,  so  as  to 
form  a diaphragm  between  the  auricle  and  the 
ventricle.  This  diaphragm  is  usually  funnel- 
shaped,  with  a button-hole  aperture  sometimes 
not  larger  than  a goose-quill.  In  these  cases 
the  tendinous  cords  of  the  valve  are  shortened, 
and  their  muscles  thickened.  In  some  cases  the 
valves  are  smooth  and  thin  ; in  others  they  are 
thickened,  studded  with  vegetations,  rough  and 
calcareous.  This  latter  state  may  cause  stenosis. 


HEART,  VALVES  AND  ORIFICES  OF,  DISEASES  OF. 


624 

without  any  funnel-formation,  as  may  also  fibri- 
nous clots  or  polypi  obstructing  the  orifice. 
In  many  cases  of  mitral  stenosis,  the  valves  are 
also  insufficient. 

Aortic  insufficiency  often  depends  on  dilatation 
of  the  aortic  orifice,  due  to  softening  of  the 
aortic  coats,  with  little  or  no  change  in  the 
valves,  which  are  incapable  of  closing  the  en- 
larged orifice.  Vegetations,  thickening,  retrac- 
tion, calcareous  degeneration,  adhesions,  per- 
forations, loss  of  substance,  and  rupture  of  the 
valve-segments  by  effort  are  all  causes  of  aortic 
insufficiency.  In  rupture  of  the  valves,  a full 
description  of  which  was  first  given  by  Dr.  Quain 
(Edin.  Monthly  Journ.  1846),  the  valve-segment 
is  torn  from  its  angles  of  attachment,  and  its  free 
edge  retroverted  towards  the  ventricle.  This 
accident  happens  more  frequently  in  cases  where 
the  valves  were  previously  diseased,  and  in  such 
cases  further  laceration  may  occur. 

Mitral  insufficiency  is  due  to  thickening,  re- 
traction, or  deformity  from  vegetations  of  the 
valve-curtains;  adhesion  of  the  curtains  to  each 
other  or  to  the  ventricular  wall ; and  calcareous 
degeneration.  In  some  instances,  one  of  the 
valves  is  perforated  or  torn ; and  sometimes  the 
tendinous  cords  are  shortened  and  thickened,  or 
ruptured  as  the  result  of  degeneration,  prevent- 
ing the  normal  action  of  the  valve-curtains.  In 
rarer  cases  associated  with  dilated  ventricle,  the 
papillary  muscles  are  so  weakened  by  degene- 
ration that  they  can  no  longer  aid  in  the  closure 
of  the  orifice.  Dilatation  of  the  left  auriculo- 
ventricular  orifice  is  also  a cause  of  mitral  in- 
sufficiency. 

Valvular  defects  on  the  right  side  of  the  heart 
are  due  to  similar  changes.  They  arise  chiefly 
during  fcetal  life,  when  the  right  cavities  hare 
to  bear  greater  pressure.  In  adult  life  these 
defects  are  generally  associated  with  diseases  of 
tho  lungs,  which  cause  increased  tension  in  the 
right  cavities,  leading  to  their  dilatation. 

Combined  valvular  lesions  are  not  infrequent. 
The  most  common  are  stenosis  and  insufficiency 
of  the  aortic  valves,  and  the  same  morbid  changes 
of  the  mitral  valves.  In  the  last  stages  of  both 
forms  of  aortic  valve-disease,  the  mitral  valve 
becomes  insufficient,  either  from  chronic  endocar- 
ditis, or  from  dilatation  of  the  ventricle  and  of 
the  auriculo- ventricular  orifice.  Mitral  stenosis 
is  not  very  frequently  associated  with  aortic  in- 
sufficiency, but  is  more  commonly  connected  with 
some  degree  of  narrowing  at  the  aortic  orifice. 
Tricuspid  insufficiency  is  usually  met  with  in 
the  last  stages  of  diseases  of  the  left  heart. 

Symptoms. — Valvular  diseases  of  the  heart 
produce  a series  of  morbid  phenomena,  which 
are  connected  together  by  a necessary  sequence. 
Each  and  every  form  of  valvular  defect  impairs 
the  perfection  of  the  heart  as  a pumping  machine, 
and  disturbs  the  normal  relations  between  the 
contents  of  the  arteries  and  of  the  veins.  Wher- 
ever the  valve-mischief  is,  and  whatever  its 
nature,  it  robs  the  arterial  circulation  and  en- 
riches the  venous.  In  front  of  the  lesion  there 
is  less  blood;  behind  it  there  is  more.  In  aortic 
valvular  diseases,  the  first  effects  are  increase 
of  the  blood-pressur6  in  the  left  ventricle,  and 
lessened  blood-pressure  in  the  aorta  ; next,  from 
tlie  difficulty  which  the  auricle  has  in  emptying 


all  its  contents  into  an  overful  ventricle,  there 
is  produced  increased  pressure  in  the  left  auricle 
and  pulmonary  veins.  Mitral  valve-lesions  cause 
similar  results : first,  increased  pressure  in  the 
left  auricle,  less  pressure  in  the  left  ventricle, 
and  consequently  lessened  pressure  in  the  aorta; 
with  a gradual  increase  of  pressure  extending 
from  the  left  auricle  to  the  pulmonary  veins. 
Aortic  affections  thus  act  first  on  the  arterial, 
and  secondly  on  the  pulmonary  circulation ; while 
mitral  lesions  affect  the  pulmonary  vessels  more 
immediately.  The  final  results  of  the  two  forms 
are,  however,  identical,  and  may  be  stated  in 
the  form  of  a law,  namely,  that  all  valvular 
diseases  of  the  heart  tend  to  lessen  the  quantity 
of  blood  in  the  arterial  system,  and  to  produce 
overfulness  and  stasis  in  the  veins.  From  this 
there  follow  various  associated  visceral  dis- 
orders. These  disorders,  how'ever,  vary  greatly 
in  the  period  of  their  occurrence,  and  in  the 
intensity  of  their  manifestations.  This  result 
is  due  to  the  more  or  less  perfect  way  in  which 
the  original  valvular  defect  has  been  compen- 
sated for,  by  changes  in  the  power  of  the  car- 
diac muscle  and  in  the  capacity  of  the  cardiac 
cavities.  These  changes  often  suffice  to  maintain 
fairly  the  normal  balance  between  the  arterial 
and  venous  contents,  thus  compensating  for  the 
valve-lesion  ; and  the  process  by  which  this  is 
effected  demands  careful  consideration. 

Compensation. — Compensation  is  effected  dif- 
ferently, according  to  the  form  of  disease.  It 
may  be  stated  generally,  that  it  consists  in  hy- 
pertrophy of  the  cavity  immediately  behind  the 
defect.  Now  hypertrophy  means  increased  con- 
tractile power,  and  this  means  better  filling  of 
the  arteries,  and  consequently  increased  arterial 
tension.  Thus  it  makes  up  for  the  valvular  in- 
competency, which  tends  to  lessen  arterial  ten- 
sion. When  the  increased  power  of  the  ventricle 
exactly  balances  the  effects  of  the  valvular  mis- 
chief, the  compensation  is  complete. 

In  aortic  stenosis,  hypertrophy  of  the  left 
ventricle  is  the  mode  in  which  compensation  is 
effected ; the  obstacle  to  the  blood-current  is 
overcome  by  increased  power. 

In  aortic  insufficiency  there  is  some  dilatation 
of  the  ventricle  as  the  primary  result  of  the 
lesion.  This  is  counterbalanced  by  greater  hyper- 
trophy, and  as  long  as  the  dilatation  does  not 
progress,  the  insufficiency  is  compensated  for. 
A sufficient  excess  of  blood  is  thrown  into  the 
aorta  at  each  systole  to  allow  for  the  regurgita- 
tion during  each  diastole,  and  thus  the  balance 
is  maintained,  though  not  always  equably. 

In  mitral  lesions  the  left,  auricle  is  dilated  as 
the  primary  consequence  of  the  condition  of  the 
valves ; hypertrophy  follows,  but  is  insufficient 
to  prevent  increased  fulness  of  the  pulmonary 
veins.  This  impedes  the  circulation  in  the 
lungs  ; and  increased  tension  in  the  pulmonary 
artery  soon  begets  the  necessary  hypertrophy 
of  the  right  ventricle.  It.  is  by  means  of  this 
increased  power  of  the  right  ventricle,  that  the 
blood  is  driven  through  the  lungs  in  spite  of  the 
defect  in  tho  left  heart,  and  pulmonary  stasis 
is  prevented;  and  the  blood  entering  the  left 
auricle  under  greater  vis  a tergo,  the  cornpen 
sation  of  the  valvular  defect  is  effected.  The 
compensation,  from  the  nature  of  the  means  on 


HEART,  VALVES  AXD  ORIFICES  OF,  DISEASES  OF.  c>2o 


which  it  deDends,  is  manifestly  less  perfect  than 
m aortic  lesions. 

On  the  right  side  of  the  heart  similar  modes 
of  compensation  are  observed. 

The  basis  of  the  salutary  changes  just  de- 
scribed is  increased  cardiac  nutrition ; and 
consequently  a free  coronary  circulation  is  a 
necessity.  Conditions  which  interfere  "with  this 
prevent  compensation,  and  so  diminish  the  dura- 
tion of  life.  Wherever  the  compensation  begins 
to  fail,  dilatation  of  the  cavities  and  vessels 
behind  the  lesion  commonces.  This  may,  however, 
be  checked,  and  the  power  of  the  heart  restored 
for  a time.  Sooner  or  later,  however,  changes 
in  the  nutrition  of  the  cardiac  muscle,  in  the 
vessels,  and  in  the  general  nutrition,  bring  on 
failure  of  compensation.  The  cardinal  symptom 
in  such  eases  is  weakened  contractile  power  of 
the  heart,  or  asystoly  (Beau).  In  this  state, 
the  cavity  chiefly  affected  has  no  longer  power 
to  expel  its  contents  fully  into  the  vessels,  and 
consequently  becomes  gradually  and  increasingly 
distended.  Failing  compensation  in  aortic  valve- 
disease  manifests  itself  by  dilatation  of  the  left 
ventricle,  and  the  development  of  secondary 
mitral  insufficiency.  Similar  retro-dilatation 
marks  the  failure  in  mitral  cases,  only  here  it  is 
the  right  ventricle  which  dilates,  and  tricuspid 
insufficiency  and  general  venous  stasis  are  added 
to  the  pre-existing  pulmonary  engorgement. 

The  earliest  symjjtoms  of  Jailing  compensation 
are  attacks  of  palpitation  from  very  slight 
exertion  or  excitement,  or  during  sleep.  Irre- 
gularity of  the  pulse  soon  follows,  if  it  have 
not  previously  existed.  This  is  especially  the 
case  in  mitral  disease.  The  irregularity  is  due 
not  so  much  to  true  cardiac  intermission  as 
to  abortive  contractions,  which  do  not  reach  the 
wrist ; or  to  contractions  unequal  in  force  or  in 
the  quantity  of  blood  expelled.  The  pulse  is 
small,  unequal,  irregular,  and  compressible.  In 
aortic  valvular  disease  true  intermissions  occur, 
and  are  of  grave  import.  With  failing  cardiac 
power  there  usually  supervene  cardiac  oppression, 
anginous  attacks  from  distension  of  the  cavities 
of  the  heart,  and  faintness  and  giddiness  from 
cerebral  anaemia. 

Visceral  complications. — The  most  important 
of  the  associated  disorders  of  chronic  valvular 
disease,  depending  on  defective  contraction  of 
the  heart,  are  the  visceral  congestions. 

In  the  lungs,  the  habitual  engorgement  of 
mitral  diseases  produces  a hyper-secretion  of 
mucus  and  a state  of  chronic  catarrh.  Tho 
blood-vessels  also  undergo  changes  from  the 
excessive  intra-vascular  pressure,  and  become 
dilated,  varicose,  and  atheromatous : whence 

oedema  and  haemorrhage  arise.  In  mitral  stenosis 
especially,  grave  and  frequent  attacks  of  hsemor- 
. rhage,  with  laceration  of  the  pulmonary  substance, 

‘ are  liable  to  occur.  The  lungs,  from  repeated  at- 
i tacks  of  this  kind,  undergo  brown  induration.  The 
varicose  condition  of  the  vessels  in  the  alveoli 
interferes  with  oxidation,  and  so  aids  in  the 
deterioration  of  blood,  which  the  other  visceral 
, congestions  favour. 

In  the  liver,  tho  general  venous  stasis  is  felt 
by  the  obstruction  to  the  passage  of  blood  from 
The  hepatic  veins  into  the  inferior  cava.  Passive 
congestion  ensues,  and  ‘ nutmeg  liver  ’ results. 

40 


This  term  ‘ nutmeg  liver  ’ refers  to  the  rough 
changes  in  the  viscus,  the  dark  congested  centre 
of  each  lobule  being  surrounded  by  a paler  area. 
In  course  of  time  the  compression  of  the  central 
cells  of  each  lobule  by  the  distended  veins  leads 
to  atrophy ; the  liver,  from  being  large,  shrinks 
in  very  chronic  cases  to  half  its  size;  and  the 
condition  may,  1 ike  true  cirrhosis,  lead  to  ascites. 
The  passive  congestion  in  the  liver,  as  in  the 
lung,  causes  catarrh  of  the  tubes,  and  may  thus 
be  productive  of  jaundice.  Amongst  othor 
symptoms  associated  with  the  hepatic  congestion 
may  be  mentioned  haemorrhoids  and  epistaxis. 

The  spleen  is  a very  easily  distended  organ, 
and  suffers  like  the  liver,  buc  frequently  before 
it;  and  this  may  partly  account  for  the  pain 
which  is  often  complained  of  beneath  the  left 
ribs.  In  long-standing  cases  the  spleen  becomes 
tougher,  and  the  capsule  opaque  and  thickened ; 
while  haemorrhagic  infarcts  arc  common. 

From  the  hepatic  congestion  there  naturally 
follows  distension  of  all  tho  other  radicles  of  the 
portal  vein  : hence  the  congestion  and  chronic 
catarrh  of  the  stomach  and  intestines,  which  im- 
pede digestion  and  assimilation,  and  so  reinforce 
the  other  causes  producing  the  cachexia  of 
chronic  valvular  disease. 

In  all  cases  of  valvular  disease,  when  the 
mechanical  effects  extend  to  the  general  circula- 
tion, the  function  of  the  kidneys  is  more  or  less 
disordered.  The  first  stage  of  general  circu- 
latory trouble  is  lessened  arterial  tension  ; this 
makes  itself  felt  in  the  Malpighian  tufts,  and 
is  manifested  by  scanty,  dense,  high-coloured 
urine.  When  the  more  advanced  circulatory 
trouble — namely,  general  venous  stasis — is  deve- 
loped, a further  change  takes  place  in  the  urine. 
The  arterial  anaemia  keeps  it  still  scanty  and 
dense,  but  the  venous  stasis  in  the  kidney  leads 
to  the  transudation  of  serum — a dropsy  of  the 
kidney  as  it  were  ; and  consequently  albumen 
appears  in  the  urine.  Long-continued  venous 
congestion  ends  in  structural  changes,  which,  as 
elsewhere,  consistin connective-tissue  hyperplasia 
and  degenerative  (rarely  fatty)  changes  in  the 
tubules.  Theso  renal  changes  sometimes  add 
uraemia  to  the  patient’s  ailments. 

In  the  brain,  decided  alterations  are  not  found, 
except  when  a detached  vegetation  produces 
embolism  and  its  special  phenomena.  The  brain- 
substance  is,  however,  generally  cedematous,  and 
the  membranes  are  thickened.  Delirium  is  an 
occasional  symptom  in  heart-disease,  and  when 
present  to  any  degree  is  of  evil  import.  Tho 
blood-vessels  of  the  general  circulation  are  fre- 
quently affected  with  atheroma  in  hypertrophy 
of  the  left  ventricle,  and  it  is  these  degenerative 
changes  which  favour  the  occurrence  of  apo- 
plexy. 

General  dropsy. — Themechanical  impediments 
to  tho  circulation  which  produce  these  several 
visceral  congestions,  also  manifest  themselves 
in  the  general  dropsy  which  is  common  in  the 
last  stages  of  heart-disease.  The  dropsy  begins 
as  a puffiness  of  the  ankles  at  bed-time.  The 
general  venous  stasis,  thus  first  indicated,  ad- 
vances slowly  and  surely,  if  not  checked,  to 
general  anasarca,  and  even  to  dropsy  of  tho 
serous  cavities.  The  increased  venous  tension, 
and  the  hydraemia  of  blood-deterioration,  are 


I 


526 


HEART,  VALVES  AND  ORIFICES  OF.  DISEASES  OF. 


the  causes  of  this  serous  transudation,  which 
shows  itself  first  in  the  feet,  the  most  dependent 
portions  of  the  body,  where  the  pressure  of  the 
blood-column  is  naturally  greatest.  The  hori- 
zontal posture,  by  distributing  the  pressure,  is 
sufficient  at  first  to  disperse  the  oedema  of  the 
ankles.  General  anasarca  is  much  more  frequent 
in  mitral  than  in  aortic  lesions. 

In  some  cases  a solid  form  of  edema  is  ob- 
served. This  occurs  mostly  in  the  last  stages  of 
valvular  affections,  and  is  due  to  thrombosis  of 
venous  trunks,  in  which,  the  circulation  being 
much  impeded,  coagulation  easily  takes  place. 
The  termination  of  the  external  jugulars  is  a 
common  site  for  such  thrombosis ; and  the  left 
innominate  vein,  from  its  transverse  position, 
and  from  its  emptying  almost  at  right  angles  to 
the  current  in  the  superior  vena  cara,  is,  in  the 
writer's  experience,  more  commonly  obstructed 
than  the  right.  Solid  oedema  is  consequently 
seen  more  frequently  on  the  left  side  of  the 
head  and  neck  and  in  the  left  arm,  than  on  the 
right  side. 

Defective  compensation. — The  phenomena  just 
described  are  associated  with  valvular  diseases 
of  the  heart,  as  the  consequences  of  partial  or 
defective  compensation.  These  conditions  are 
more  or  less  developed  according  to  the  indi- 
vidual case,  and  consequently  give  rise  to  symp- 
toms in  varying  degrees.  These  symptoms  will 
now  be  described. 

Palpitation  is  intimately  related  to  the  state 
of  cardiac  nutrition  and  innervation,  and  lias  no 
special  connection  with  any  form  of  valvular  dis- 
ease. Cardiac  pain,  varying  in  intensity  from 
mere  uneasiness  to  the  agony  of  angina,  is  most 
common  in  aortic  cases,  and  is  associated  with 
endarteritis,  or  with  dilatation  of  the  left  ven- 
tricle, oris  a neuralgia  of  the  cardiac  plexus.  In 
mitral  affections,  pain  arises  from  over-distension 
of  tho  left  auricle,  and  its  pressure  on  neighbour- 
ing parts,  and  later  on  from  dilatation  of  the 
right  ventricle.  Dyspnoea  may  be  present  in 
any  form  of  valvular  disease,  but  it  is  often  ab- 
sent from  the  earlier  history  of  aortic  cases, 
while  some  dyspnoea  is  always  present  in  mitral 
cases.  This  difference  is  due  to  the  absence  of 
pulmonary  congestion  in  aortic  affections,  whilst 
it  is  more  or  less  present  from  the  first  in  mitral 
affections.  The  dyspnoea  is  a breathlessness 
rather  than  a difficulty  of  breathing.  It  is 
panting  and  gasping  in  its  character,  with  ac- 
celeration of  the  rate.  It  is  aggravated  by  any 
movement,  and  often  compels  the  patient  to  sit 
upright  (orthopncea).  Headache,  vertigo,  dream- 
ing, night-frights,  and  sleeplessness  are  other 
symptoms,  which  depend  on  disordered  cerebral 
circulation.  Sleeplessness  is  one  of  the  most 
distressing  of  all  symptoms,  and  can  only  be 
relieved  when  tho  dyspnoea  is  lessened.  Other 
more  special  symptoms  will  be  found  in  certain 
cases,  and  will  be  traceable  to  the  disturbances 
in  the  circulation,  which  the  particular  form 
of  valvular  disease  has  engendered. 

Physical  signs. — The  physical  signs  associated 
with  valvular  affections  may  be  said  to  be — first, 
lliose  of  alteration  in  the  size  of  the  heart; 
and  secmdly,  those  of  mechanical  disorders 
of  t he  circulation;  together  with  one  or  more 
endocardial  murmurs.  The  persistence  of  a 


murmur  is  the  cardinal  sign,  and  if  the  murmur 
be  either  diastolic  or  prsesystolic  in  its  rhythm 
it  is  of  absolute  value.  A systolic  murmur  may- 
be caused  by  poverty  of  blood — antemia,  espe- 
cially at  the  base  of  the  heart.  But  in  such  a 
case— that  is,  in  haemic  murmur — there  is  no 
cardiac  hypertrophy-,  as  indicated  by  increased 
cardiac  dulness,  though  there  is  often  nervous 
overaetion  of  the  heart.  There  is  no  accentua- 
tion of  the  pulmonary  second  sound,  inasmuch 
as  there  is  no  extra  fulness  of  the  pulmonary 
blood-vessels  from  obstructed  circulation.  The 
pulse  in  anaemia  is  generally  quick,  ample, 
and  compressible,  but,  withal,  jerky  ; while  with 
an  organic  systolic  murmur  it  is  generally-  slow, 
rising  gradually  under  the  finger,  and  not  very 
compressible,  (aortic  stenosis),  or  small,  irregu- 
lar, and  unequal  (mitral  insufficiency).  The 
clinical  methods  of  investigating  valvular  lesions 
are  mainly  inspection,  palpation,  percussion,  and 
auscultation.  The  signs  of  each  form  of  valve- 
disease  are  stated  below;  and  on  these  the  special 
diagnosis  rests. 

Diagnosis. — In  Aortic  stenosis  there  is  often 
some  prominence  of  the  praecordial  region,  and  a 
steady  forcible  impulse  is  perceived  below  and 
to  the  left  of  its  normal  position.  A thrill, 
systolic  in  time,  may  often  be  felt  at  the  base 
of  the  heart.  On  auscultation,  a loud,  frequently 
rough,  rasping,  sometimes  musical,  murmur  is 
heard  with  the  first  sound  at  mid-sternum,  and 
also  at  the  second  right  intercostal  space.  The 
murmur,  commencing  with  the  first  sound,  ex- 
tends to  the  succeeding  second  sound,  which  is 
often  not  very  distinct.  The  murmur  is  audible 
all  over  the  upper  part  of  the  thorax,  especially 
on  the  right  side ; is  conducted  along  the  great 
vessels  to  the  left  vertebral  groove,  and  it  may  bo 
even  to  the  lower  dorsal  vertebrae ; and  is  occasion- 
ally heard  at  the  apex  of  the  heart.  The  pulse 
is  regular,  slow,  retarded  by  the  narrowing  ol 
the  aortic  orifice, and  slowly  developed  under  the 
finger.  The  spby-gmogram  (see  tig.  S2)  shows 
the  line  of  ascent  to  he  oblique  or  broken,  instead 
of  nearly  vertical;  the  summit  is  generally 
blunt ; and  the  line  of  descent  shows  small  or  no 
secondary  waves,  and  ill-developed  dicrotism. 
Aortic  stenosis  when  moderate,  requiring  only 
hypertrophy  of  the  left  ventricle  for  its  compen- 
sation, is  often  very-  perfectly  remedied  by  this 
change,  and  produces  little  or  no  disorder  of 
the  circulation.  When  the  stenosis  is  great, 
epileptiform  and  syncopal  attacks  may  occur, 
and  lead  to  sudden  death.  When  the  com- 
pensation fails,  the  mitral  valve  often  yields, 
from  the  dilatation  of  the  left  ventricle,  and 
degeneration  of  the  papillary  muscles.  Then 
the  pulmonary  second  sound  becomes  accen- 
tuated ; the  pulmonic  circulation  is  embarrassed  ; 
and  dyspnoea,  bronchial  catarrh,  pulmonary  hae- 
morrhage, oedema,  and  cyanosis  supervene. 

In  Aortic  insufficiency,  inspection  discovers  a 
more  forcible  and  diffused  impulse,  lower  than 
natural,  sometimes  as  low  as  the  seventh  inter- 
costal space,  and  outside  the  nipple  line.  The 
praecordial  region  may  be  bulging  from  the 
violent  action  of  the  heart;  pulsation  may  he 
seen  in  the  upper  intercostal  spaces  at  the  right 
edge  of  the  sternum  ; and  a thrill  may  some- 
times be  felt  there.  The  great  vessels  of  the  neck 


HEART,  VALVES  AND  ORIFICES  OF,  DISEASES  OF.  627 


pulsate  visibly.  The  area  of  cardiac  dulness  is 
increased  in  all  directions,  but  mainly  verti- 
cally. On  auscultation,  a murmur  is  heard,  re- 
placing and  folio-wing  the  secoud  sound,  of  a 
blowing  or  hissing  character,  rarely  rough.  It  is 
usually  loudestat  mid-sternum  and  in  the  second 
right  intercostal  space  ; and  it  is  conducted  up- 
wards to  the  right  clavicle,  but  mainly  down- 
wards to  the  xiphoid  cartilage.  It  is  not  heard 
at  the  back  of  the  chest.  It  may  be  conducted 
to  the  apex  of  the  heart  rather  than  to  the  ensi- 
form  cartilage;  and  this  occurs,  in  the  writer’s 
opinion,  when  the  posterior  or  mitral  segment 
of  the  aortic  valves  is  the  incompetent  one, 
as  the  regurgitant  current  then  falls  on  the 
mitral  valve,  and  the  murmur  is  thus  conducted 
to  the  apex.  The  second  sound  may  be  wholly 
lost  at  the  base  of  the  heart,  being  replaced 
by  the  murmur;  but  in  some  cases  it  is  audible — 
this  being  due  either  to  normal  closure  of  one 
or  two  aortic  segments,  or  to  the  propagated  pul- 
monic second  sound.  If  audible  in  the  carotids, 
the  second  sound  is  aortic,  and  is  of  some  value 
as  indicating  partial  competency  of  the  valves. 
The  second  sound  is  often  audible  at  the  apex. 
The  first  sound  at  the  base  is  almost  always 
modified,  being  generally  murmurish  and  often 
obscured  by  a systolic  murmur,  due  to  slight 
obstruction  from  thickening  of  the  valve-seg- 
ments, and  the  vigour  of  the  ventricular  systole. 
In  some  cases  there  is  no  distinct  first  sound 
audible  at  base  or  apex  ; its  absence  being  pos- 
sibly due  to  noiseless  closure  of  the  mitral  valve 
by  the  intra- ventricular  blood-pressure  before 
the  systole  occurs.  In  the  majority  of  cases  the 
insufficiency  is  no  doubt  associated  with  some 
stenosis,  and  the  murmur  is  double;  a short  rough 
systolic  portion,  with  a softer,  longer,  and  more 
hissing  diastolic  portion.  This  double  murmur 
might  be  well  called  the  vp  and  down  murmur 
of  aortic  valve-disease  : the  two  descriptive  words 
indicating  the  length,  and,  to  some  extent,  the 
characters  of  its  component  parts. 

The  signs  connected  with  the  pulse  in  aortic 
insufficiency  are  very  significant.  As  the  pulsa- 
tions of  the  aorta  are  visible  to  the  right  of 
the  sternum,  so  the  arteries  often  beat  visibly  all 
over  the  body,  even  to  the  radial,  temporal,  and 
dorsal  arteries  of  the  foot.  The  ophthalmoscope 
has  shown  the  same  phenomenon  in  the  central 
artery  of  the  retina.  This  remarkable  move- 
ment of  the  arteries  is  due  to  two  causes: — 
first,  to  the  hypertrophy  and  dilatation  of  the 
left  ventricle,  w hich  throws  an  excessive  quantity 
of  blood  into  the  vessels  at  each  systole;  and, 
secondly,  to  the  sudden  collapse  of  the  arte- 
. ries,  due  to  the  aortic  insufficiency.  The  arterial 
recoil  during  the  ventricular  diastole  is  not  op- 
posed, as  iu  health,  by  the  resistance  of  the  per- 
fectly closed  aortic  valves  and.  consequently,  the 
: blood-column  is  not  sustained,  and  the  arteries 
i collapse.  These  locomotive  features  in  the  pulse 
are  generally  increased  by  elevating  the  arm.  The 
pulse  is  sudden,  short,  large,  regular,  rapidly 
collapsing,  and  vibratory.  The  sphygmographic 
tracing  bringa  out  these  characters:  the  line  of 
ascent  is  vertical  and  lofty;  the  summit  is  sharp 
wd  pc.nted ; the  li  e of  descent  falls  rapidly,  and 
a broken  by  a series  of  secondary  waves  due 
o vibratory  conditions,  but  has  an  ill-developed 


dicrotism.  The  post-dierotic  portion  of  tho 
tracing  falls  rapidly,  from  the  absence  of  a sus- 
tained blood-column.  The  longer  and  more  ob- 
lique this  portion  of  the  tracing,  ceteris  parilms, 
the  less  copious  the  regurgitation  (see  fig.  81). 

Aortic  insufficiency  often  lasts  for  many  year9 
without  producing  any  obvious  disturbance  of 
the  systemic  and  pulmonic  circulations ; lienco 
the  absence  of  dyspncea  and  oedema.  The  hyper- 
trophy and  dilatation  of  the  left  ventricle,  which 
form  the  compensation,  suffice  to  prevent  ill 
effects.  At  each  systole  the  dilated  ventricle 
throws  sufficient  blood  into  the  aorta  to  allow 
for  the  reflux,  and  to  maintain  a fair  arterial 
lension.  Thus  the  compensation  is  perfect.  In 
many  cases,  however,  if  the  reflux  is  free,  and 
the  coronary  segments  of  the  aortic  valves  are 
affected,  the  coronary  arteries,  which  are  mainly 
filled  by  the  arterial  recoil,  are  deprived  of  the 
full  force  of  the  blood-wave,  and  the  nutrition 
of  the  heart  consequently  suffers.  This  is  the 
great  source  of  failing  compensation,  and  the 
mal-nutrition  of  the  cardiac  muscle  soon  leads  to 
dilatation  of  tho  ventricle,  secondary  mitral  in- 
sufficiency, and  atrophy. 

When  the  hypertrophy  is  excessive,  as  it  is  iD 
some  cases,  there  are  flushings  of  the  head  and 
face,  headache,  vertigo,  and  violent  arterial  action 
all  over  the  body. 

In  Mitral  stenosis  there  is  rarely  any  promi- 
nence of  the  praecordial  region  ; and  in  its  earlier 
stages  neither  increase  of  the  cardiac  dulnesc, 
nor  alteration  in  the  position  of  the  impulse. 
The  impulse,  when  regular,  is  fairly  distinct,  bait 
it  is  often  very  irregular  and  is  associated  with 
a thrill,  which  precedes,  runs  up  to,  and  termi- 
nates in  the  impulse.  In  advanced  cases,  the 
area  of  cardiac  dulness  is  increased  laterally;  the 
impulse  is  diffused,  and  may  be  seen  in  the  epi- 
gastrium; and  the  left  auricular  systole  may  be 
noticed,  if  the  chest  be  thin,  in  tho  third  left 
intercostiil  space.  The  sounds  heard  on  auscul- 
tation in  this  lesion  vary.  The  pathognomonic 
sign  is  a murmur  preceding  the  systole,  and 
ending  with  its  commencement.  This  is  best 
called  the  prcesystolic  murmur  (also  ‘ auricular 
systolic’) ; and  is  produced  when  the  contracting 
auricle  forces  blood  under  high  pressure  into  the 
ventricle.  It  is  the  passage  of  a stream  of  blood 
in  a state  of  high  tension  into  blood  already  in 
the  ventricle  which  causes  the  murmur.  The  first 
portion  of  the  blood  passes  from  the  auricle  into 
tho  ventricle  noiselessly ; and  it  is  only  when 
a stream  of  higher  tension  is  forced  into  it  by 
the  true  auricular  systole  that  the  murmur  is 
developed.  The  murmur  is,  therefore,  short  in 
most  instances,  occupying  the  last  part  of  dia- 
stole ; runs  up  to  the  first  sound ; and  ends 
abruptly  in  it.  The  position  in  winch  the  mur- 
mur is  best  heard  in  its  typical  praesystolic  form 
is  at  the  left  apex  itself  or  a little  above — that 
is,  lower  than  a mitral  regurgitant  murmur. 
The  funnel-like  shape  of  the  mitral  valve-curtains 
iu  these  cases  accounts  for  this,  as  the  button- 
hole aperture  through  which  the  blood  passes  is 
closer  to  the  apex. 

The  murmur  in  this  form  is  not  heard  far  from 
its  seat  of  production,  is  soft  and  puffing,  but  may 
be  harsh.  It  fills  commonly  only  the  last  part  of 
the  diastolic  period.  In  some  cases  the  murmur  ij- 


328  HEART,  VALVES  AND  ORIFICES  OF,  DISEASES  OF. 


longer,  rougher,  more  rolling  or  grinding,  and 
ends  abruptly  with  the  first  sound,  which  is  very 
flapping  in  tono,  and  might  easily  be  mistaken 
for  the  second  sound  conducted.  The  careful 
observation  of  the  impulse  or  of  the  carotid  pulse 
with  the  finger  while  auscultating,  is  necessary 
in  order  to  avoid  the  error. 

A special  peculiarity  of  the  praesystolic  mur- 
mur is  its  variability:  it  is  the  only  organic 
murmur  which  disappears  and  reappears  as  the 
heart-conditions  change.  For  instance,  a mur- 
mur, inaudible  while  the  patient  is  at  rest,  is 
developed  by  a little  exercise ; or  again,  an  irre- 
gular tumultuous  action  of  the  heart  masks  all 
murmur,  which  becomes  distinct  as  the  heart 
steadies  down  under  the  action  of  digitalis.  In 
other  cases  there  is  no  distinct  murmur,  but  only 
a slightly  prolonged  and  rough  or  grinding  first 
sound.  In  cases  of  mitral  stenosis  there  is  ac- 
centuation of  the  pulmonary  second  sound,  from 
the  greatly  increased  tension  in  the  lesser  circu- 
lation ; there  may  also  bo  a doubling  or  redupli- 
cation of  the  second  sound  at  the  base.  This  re- 
duplication is  a sign  of  great  value  in  cases  in 
which  the  prolonged  or  grinding  first  sound  is  the 
only  sign.  The  reduplication  of  the  second  sound 
is  due  to  a want  of  synchronous  closure  of  the 
pulmonic  and  aortic  valves,  from  their  altered 
relative  tension.  A doubling  of  the  first  sound 
is  sometimes  noticed,  probably  duo  to  retarded 
closure  of  the  mitral  valve,  from  lessened  fulness 
of  the  left  ventricle. 

The  rhythm  of  the  heart  is  frequently  greatly 
disordered  in  mitral  stenosis,  and  also  in  mitral 
insufficiency.  A few  beats  occur  regularly,  or 
nearly  so,  and  then  a series  of  very  small  hurried 
ones  follows,  to  be  again  succeeded  by  stronger 
and  better  pulsations.  These  irregularities  are 
referable  to  the  varying  charges  of  blood  on 
which  the  ventricle  contracts.  The  over-dis- 
tended right  cavities  and  the  left  auricle  con- 
tract rapidly  to  expel  their  contents,  but  the 
narrowed  mitral  orifice  does  not  allow  a full 
charge  to  pass  into  the  ventricle;  the  diastole 
is  too  short  for  this  purpose;  and  the  wave  of 
contraction  passes  on  to  the  ventricle  from  the 
auricle,  producing  a series  of  small  ineffective 
pulse-beats,  each  representing  the  small  charge 
sent  into  the  aorta.  When  the  series  of  ineffec- 
tive contractions  ceases,  the  next  diastole  is 
longer;  and  the  succeeding  systole  sends,  as  the 
sphygmograph  shows,  a fuller  charge  into  the 
arteries.  During  the  small  irregular  beats  the 
prresystolic  murmur  is  often  indistinguishable, 
but  is  again  heard  with  the  succeeding  slower 
and  more  effective  beats.  This  irregularity  in 
the  heart’s  rhythm,  however,  is  not  present  in 
all  cases  of  mitral  stenosis.  In  some  instances 
the  heart’s  action  and  the  pulse  are  regular.  The 
sphygmograph  in  such  cases  records  a small 
pulse  of  low  tension,  with  a little  inequality  in 
the  volume  of  the  beats ; this  inequality  is  often 
increased  by  exercise.  In  other  cases  the  pulse- 
tracing is  small,  irregular,  and  unequal  in  its 
pulsations,  and  marked  by  true  and  false  inter- 
missions (see  fig.  84). 

In  the  earlier  stages  of  mitral  stenosis  tho  face 
may  be  pale,  and  the  congestive  symptoms  which 
mark  mitral  insufficiency  are  absent  till  the  later 
stages.  This  form  of  valvular  lesion  gives  rise 


more  commonly  than  mitral  insufficiency  to 
haemorrhagic  infarction  in  tho  lungs ; but  in 
other  respects  the  pulmonary  and  systemic  circu- 
lations suffer  in  the  same  way  as  described  in 
the  other  form  of  mitral  disease. 

In  Mitral  insufficiency  inspection  discovers 
some  slight  prominence  of  the  praecordial  region, 
with  increased  impulse,  the  apex  often  beating 
to  the  left  of  the  nipple  line.  The  area  of  car 
diae  dulness  is  augmented  mainly  in  a lateral 
direction,  from  the  hypertrophy  of  the  right 
ventricle.  On  auscultation,  a murmur  is  heard 
with  the  first  sound,  and  following  it;  loudest  at 
the  apex ; loud  along  the  left  edge  of  the  heart ; 
but  absent  or  not  so  distinct  over  the  right  heart 
and  at  the  base.  The  murmur  is  propagated  to- 
wards the  left  axilla,  and  is  audible  in  most  cases 
in  the  left  vertebral  groove.  The  murmur  is 
usually  loud,  blowing,  and  distinct  in  its  cha- 
racter, keeping  the  same  tone  throughout.  The 
true  first  sound  is  generally  obscured  by  it,  but 
in  some  cases  may  be  heard  through  it,  and  is 
then  due  to  the  partial  closure  of  the  mitral,  or 
to  the  action  of  the  right  aurieulo- ventricular 
valves.  The  pulmonic  second  sound  is  commonly 
accentuated.  The  pulmonic  first  sound  has  iD 
some  cases  a murmurish  character,  due  pro! ably 
to  the  vigour  of  the  right  ventricular  systole. 

The  radial  pulse  in  cases  of  fairly  perfect  com- 
pensation is  regular,  but  quick,  small,  weak,  and 
easily  compressible ; and  the  sphygmograph 
shows  low  tension,  and  an  inequality  in  the  sizo 
of  the  pulsations.  In  cases  of  less  perfect 
compensation,  it  becomes  irregular  and  inter- 
mittent. In  all  cases  the  pulse-heat  is  weak  in 
comparison  with  tho  vigour  of  the  ventricular 
systole  ( see  fig.  83). 

There  is  no  unusual  fulness  of  the  superficial 
veins  in  the  earlier  stages  of  mitral  insufficiency. 
Later,  when  the  right  cavities  become  over- 
distended, the  veins  of  the  neck  become  full  and 
may  even  pulsate.  This  is  very  distinct  when 
the  tricuspid  valve  gives  way.  In  all  cases 
slight  exertion  is  sufficient  to  induce  dyspnoea ; 
and  there  is  an  ever-present  tendency  to  bron- 
chial catarrh,  from  the  congested  state  of  the 
lungs.  When  asystoly  comes  on,  the  murmur 
becomes  less  distinct ; the  heart’s  action  is  rapid, 
irregular,  and  tumultuous ; the  accentuation  of 
the  pulmonary  second  sound  is  lost;  dyspnoea 
becomes  orthopncea ; and  cyanosis,  oedema,  and 
haemorrhagic  infarction  of  the  lungs,  with  general 
and  visceral  dropsy  close  the  case. 

Many  cases  of  mitral  regurgitation  obtain 
fairly  perfect  compensation;  but  the  disease, like 
mitral  stenosis,  of  necessity  entails  some  dyspnma 
on  exertion,  and  keeps  up  constantly  an  engorged 
state  of  the  pulmonary  vessels. 

Valvular  affections  of  the  right  heart,  arising 
from  disease,  are  rare.  Those  of  the  pulmonic 
valves  are  very  rare  ; cases  are  on  record,  how- 
ever, of  pulmonary  stenosis,  and  a few  of  pul- 
monary insufficiency.  In  the  first  case  the 
systolic  murmur  is  loud  and  superficial,  and  is 
heard  loudest  at  the  third  left  costal  cartilage 
close  to  the  sternum,  and  in  the  second  left  inter- 
costal space ; it  is  not  usually  conducted  across 
the  sternum,  nor  upwards  to  the  right  clavicle, 
as  is  an  aortic  murmur.  A diastolic  pulmonic 
murmur  is  soft  and  blowing ; and  is  heard  loudest 


HEART.  VALVES  AND  ORIFICES  OF,  DISEASES  OF.  629 


in  the  same  situations,  and  downwards  towards 
the  ensiform  cartilage. 

The  tricuspid  valves  are  more  frequently  af- 
fected. Tricuspid  insufficiency  is  indeed  a common 
sequence  of  disease  of  the  left  side  of  the  heart. 
Structural  changes  in  these  valves  are,  however, 
rare.  Tricuspid  insufficiency  does  not  always 
produce  a murmur;  when  present  this  is  soft 
and  short,  and  is  heard  nearer  the  middle  line 
than  a mitral  murmur,  at  the  base  of  the  ensi- 
form cartilage.  The  pulsations  of  the  cervical 
veins  may  indicate  the  lesion  when  the  murmur 
is  absent. 

Tricuspid  stenosis  causes  a praesystolic  mur- 
mur, harsh  in  character,  loudest  at  the  base  of 
the  ensiform  cartilage  and  towards  the  left  edge 
of  the  sternum,  not  propagated  towards  the  left 
heart,  and  not  audible  at  the  back  of  the  chest, 
though  faintly  conducted  along  the  sternum  to 
the  base  of  the  heart.  A praesystolic  thrill  may 
be  present.  Mitral  stenosis  has  been  observed 
in  association  with  this  lesion,  and  two  praesys- 
tolic  murmurs  may  be  made  out  in  such  cases. 

The  physical  signs  and  the  diagnosis  of  com- 
bined valve-lesions  remain  to  be  described.  The 
mitral  and  aortic  valves  may  each  be  affected 
with  stenosis  and  insufficiency,  from  a single 
attack  of  endocarditis,  or  from  one  lesion  arising 
as  a consequence  of  the  other.  The  double  aortic 
murmur,  above  described,  indicates  the  aortic 
combination ; but  it  must  be  always  remarked 
that  the  systolic  murmur  in  these  cases  may 
exist  with  little  or  no  actual  stenosis. 

In  the  double  form  of  mitral  disease,  either 
defect  may  exist  alone  at  first,  and  afterwards 
be  associated  with  the  signs  of  the  second.  In 
some  cases  the  praesystolic  murmur  may  fail  to 
be  heard,  and  a systolic  murmur  may  alone  be 
audible  ; in  other  cases,  there  is  a prolonged 
apex-murmur  which  slightly  changes  tone  ; in 
other  cases,  again,  a short  grinding  praesystolic 
murmur  is  followed  occasionally,  at  an  interval, 
by  a soft,  blowing,  systolic  one.  The  combination 
of  aortic  with  mitral  disease  may  be  recognised 
by  the  presence  of  their  special  murmurs. 

Prognosis.  — It  is  very  difficult  to  state 
general  rules  of  prognosis  in  valvular  affections 
of  the  heart,  as  so  much  depends  on  the  pecu- 
liarities of  each  case.  There  are,  neverthe- 
less, certain  broad  rules.  As  regards  origin, 
rheumatic  inflammation  is  less  serious  than 
degenerative  change,  which  occurs  later  in  life, 
and  is  necessarily  progressive.  Accidental  rup- 
ture is  the  gravest  form  of  origin.  The  valve 
affected  is  also  a prognostic  element;  but  any 
attempt  to  arrange  cases  in  order  according  to 
the  seat  of  the  valvular  defect,  must  be  open  to 
so  many  exceptions  that  it  must  not  be  too  much 
trusted.  Speaking  generally,  however,  tricuspid 
lesions  are  gravest,  mitral  less  so,  and  aortic — 
especially  aortic  stenosis — probably  least  so. 
When  the  heart  fails,  and  asystoly  supervenes, 
the  prognosis  is  worse,  however,  in  aortic  cases 
than  in  mitral. 

Aortic  cases  are  often  free  for  years  from  any 
grave  symptoms.  When  the  murmur  is  conducted 
to  the  left  apex,  the  prognosis  is  more  favour- 
; able,  as,  the  aortic  segment  affected  being  non- 
coronary, the  muscle  of  the  heart  is  not  robbed 
of  its  blood.  The  presence  of  the  second  sound 


over  the  carotids  is  favourable.  The  pulse- 
tracing also  affords  valuable  aid  in  prognosis,  as 
it  gives,  by  the  size  of  the  dicrotic  wave  and  the 
obliquity  of  the  line  of  descent,  a rough  measure  of 
the  amount  of  insufficiency.  There  is  much  more 
risk  of  sudden  death  in  aortic  cases  than  in  mitral. 

In  mitral  lesions  the  dangers  arise  from  the 
pulmonary  complications ; embolism  is  more 
common  than  in  aortic  affections.  Mitral  cases 
can  be  rescued  from  asystoly  more  commonly, 
and  die  of  advanced  cardiac  cachexia,  generally 
with  dropsy.  Under  favourable  conditions  of 
life,  requiring  little  physical  exercise  and  causing 
no  emotional  excitement,  both  forms  of  mitral 
disease  are  compatible  with  many  years  of  life. 
When  they  are  conjoined,  the  prognosis  is  more 
unfavourable.  In  cases  of  sudden  insufficiency, 
produced  by  rupture  of  the  valve-curtains  or  of 
the  tendinous  cords,  death  may  occur  very  rapidly 
from  the  disturbance  of  the  circulation. 

The  whole  question  of  prognosis  turns  princi- 
pally on  the  state  of  the  myocardium.  So  long 
as  this  is  sound,  compensation  maybe  maintained; 
the  moment  degeneration  sets  in,  asystoly  and  all 
its  evil  train  of  symptoms  come  on.  Thus  asys- 
toly coming  on  gradually,  without  any  previous 
overstrain  of  the  heart,  is  always  most  grave. 
Each  successive  attack  becomes  graver,  and 
the  visceral  congestions  which  accompany  it 
more  stubborn.  Albuminuria  is  a good  index  of 
the  gravity  of  the  congestion,  and  is  serious  in 
proportion  to  the  frequency  with  which  it  has 
occurred.  In  some  cases  a copious  flow  of  lim- 
pid urine  is  a very  grave  symptom.  Dropsy  of 
the  extremities,  and  of  the  cavities  more  espe- 
cially, is  bad,  as  indicating  failure  in  the  peri- 
pheral circulation.  Next  to  the  cardiac  muscle, 
the  state  of  the  peripheral  vessels  is  most  im- 
portant; thus,  atheroma  and  other  conditions, 
such  as  febrile  attacks,  add  to  T.he  danger  by 
interfering  with  the  circulation.  The  general 
nutrition  of  the  patient  suffering  from  valvular 
disease  also  enters  into  the  prognostic  problem. 
There  is  a cachexia  proper  to  the  end  of  heart- 
cases,  which  is  clue  to  the  gradual  deterioration 
of  the  nutritive  fluids  by  the  long-continued 
visceral  congestions  which  hinder  assimilation 
and  excretion.  Blood  is  less  perfectly  made  and 
less  perfectly  purified  ; hence  the  steady  deterio- 
ration of  cardiac  cachexia,  which  is  always  of 
evil  import  as  regards  duration  of  life.  Valvular 
diseases  are,  however,  in  numerous  instances 
compatible  with  many  years  of  life.  In  some 
the  healthy  expectation  of  life  may  be  attained  ; 
and,  in  many,  years  of  comparatively  active  life 
are  enjoyed.  In  the  poor,  the  prognosis,  as  to 
duration,  is  not  favourable ; but  in  the  well-to- 
do,  all  observers  see  many  cases  extending  over 
a great  number  of  years. 

Treatment. — Valvular  affections  of  the  heart, 
whether  the  result  of  rheumatic  inflammation  or 
of  degenerative  change,  are,  as  a rule,  incurable. 
Some  few  cases  of  rheumatic  origin  lose  the  signs 
of  valvular  disease,  and  are  practically  restored 
by  the  after-processes  (for  example,  contraction) 
in  the  inflamed  valve ; and  some  few  cases  also  of 
mitral  insufficiency,  associated  with  dilated  left 
ventricle,  are  cured  by  treatment.  These  excep- 
tions are,  however,  few ; and  as  we  cannot  repair 
the  valve-mischief,  in  the  vast  majority  of  cases 


HEART,  VALVES  AND  ORIFICES  OF,  DISEASES  OF. 


£30 

our  treatment  must  be  directed  to  aid  the  com- 
pensatory hypertrophy,  and  to  check  the  develop- 
ment of  the  consequences  of  the  defect.  The 
maintenance  of  the  nutrition  of  the  substance  of 
the  heart  is,  therefore,  the  main  object  of  treat- 
ment; just  as  the  state  of  the  nutrition  of  the 
heart  is  the  key  to  the  prognosis.  On  this  account 
the  general  regimen  of  heart-cases  is  very  im- 
portant. 

General  regimen. — The  diet  should  in  all 
rases  of  valvular  disease  of  the  heart  be  un- 
Btimulating  but  sustaining,  consisting  of  a good 
proportion  of  albuminous  food  (underdone  meat, 
eggs,  and  fish),  with  wine  in  moderate  quantity, 
and  some  chalybeate  water.  There  should  be  no 
unnecessary  excitement  of  the  heart,  either  by 
exercise  or  emotion.  All  atliletics  and  violent 
efforts  should  be  avoided  by  the  young,  espe- 
cially in  mitral  cases.  In  aortic  cases,  steady 
exercise  without  strain  is  beneficial.  The  resi- 
dence should  be  so  situated  as  to  avoid  the 
necessity  of  exertion,  sudden  changes  of  tem- 
perature, cold,  and  damp.  The  chief  object  of 
the  regimen  should  be  to  prevent  ansemia; 
hence  plenty  of  fresh  air  is  essential.  Tobacco 
is  injurious.  In  early  life  over-exertion  and 
exposure  to  cold — in  adult  life,  emotional,  sen- 
sual, and  dietetic  excesses,  are  the  chief  dangers. 
The  propriety  of  marriage  must  be  considered 
in  each  case  on  its  merits.  AVomen,  as  a rule, 
should  not  marry ; when  affected  with  mitral 
disease  they  are' often  barren.  To  men  marriage 
is  more  generally  permissible. 

Medicinal  treatment. — The  therapeutics  vary 
according  to  the  stage  of  the  cardiac  disease.  The 
mechanical  defect  of  a valve  first  makes  itself 
felt  by  palpitation  and  praecordial  pain ; these 
symptoms  pass  away  when  compensation  is 
effected,  but  till  then  require  treatment.  In 
cases  of  mitral  disease,  tincture  of  digitalis  (n\x 
doses)  relieves  the  palpitation  ; chloric  ether  is 
also  a useful  adjunct.  In  aortic  cases,  ether, 
diffusible  stimulants,  small  doses  of  opium  and 
belladonna,  with  the  local  application  of  bella- 
donna to  the  praecordial  region,  are  valuable 
remedies. 

The  prsecordial  pain,  mostly  retro-sternal,  may, 
when  severe,  require  a few  leeches  or  cupping, 
but  generally  yields  to  mild  counter-irritants, 
such  as  turpentine  or  mustard.  Internally,  the 
bromides  are  useful ; when  the  pain  occurs 
paroxysmally,  ethereal  preparations  and  am- 
monia act  well. 

AVhen  the  compensatory  changes  in  the  heart 
are  effected,  the  palpitat  ion  and  pain  decline,  and 
the  chief  indication  is  to  keep  up  the  nutrition  of 
the  heart  by  the  hygienic  rules  above  given,  and 
by  the  administration  of  preparations  of  steel, 
combined  with  arsenic,  strychnia,  quinine,  and 
mineral  acids.  Chalybeate  waters  are  also 
useful  adjuncts.  The  syrup,  infusion,  and  tinc- 
ture of  the  prunus  virginica  are  preparations 
of  value  in  some  cases  after  the  use  of  digitalis. 
The  secretions  should  be  carefully  watched,  and 
the  bowels  opened  freely  every  day,  so  as  to  avoid 
straining,  and  to  relieve  the  portal  circulation. 
The  quantity  of  urine  should  be  daily  noticed,  as  it 
is  a capital  index  of  the  state  of  arterial  tension. 
Patients  in  whom  the  most  perfect  compensation 
exists,  are,  nevertheless,  in  a state  of  imminent 


trouble,  for  an  exaggeration  of  a physiological 
act  or  emotion  may  disturb  the  unstable 
equilibrium  of  their  health.  In  most  cases  the 
compensation  breaks  down  sooner  or  later ; and 
then  begin  the  symptoms  depending  on  pulmo- 
nary congestion  and  general  visceral  engorge- 
ment, with  the  consequent  impoverishment  of  the 
blood.  Dyspnoea  marks  the  beginning  of  these 
troubles ; anaemia  and  dropsy  the  close.  The 
pulmonary  congestion  soon  manifests  itself  by 
bronchial  catarrh,  which  requires  expectorants 
in  various  combinations,  while  friction,  poultices, 
and  counter-irritation  are  applied  to  the  chest- 
walls.  In  capillary  bronchitis  with  rapid  pul- 
monary congestion,  it  is  sometimes  necessary  to 
bleed  from  the  arm  to  relieve  the  over-distended 
cavities  of  the  right  side  of  the  heart.  Nausea- 
ting doses  of  ipecacuanha,  or  actual  emetics  of 
sulphate  of  zinc,  are  sometimes  very  useful. 

For  the  general  visceral  congestions  our 
chief  remedies  are,  firstly,  diuretics ; and,  failing 
these,  hydragogue  cathartics.  Of  diuretics,  the 
salts  of  potash,  squills,  broom,  chimaphiln, 
spirits  of  nitrous  ether,  juniper  and  digitalis 
are  the  most  useful.  The  hydragogue  cathartics, 
which  relieve  the  over-distended  portal  vessels 
primarily,  and  the  general  circulation  secondarily, 
are  also  most  valuable  ; of  these  the  compound 
powders  of  scammony  and  jalap  in  20-  to  fO-grain 
doses  : bitartrate  of  potash  in  electuary,  3j  to 
3ij,  every  morning;  sulphate  of  magnesia;  pi- 
lula  scammonii  composita  ; elaterium  ; senna ; 
and  gamboge  are  the  most  trustworthy.  By  the 
judicious  use  of  an  occasional  purgative,  and  the 
administration  of  a suitable  diuretic,  aided  by 
cupping,  poultices,  and  sometimes  a small  blister 
over  the  loins,  combined  with  rest  and  stimu- 
lants, the  worst  cases  of  dropsy  from  cardiac 
failure  are  often  saved. 

For  the  dyspnoea  and  the  insomnia,  two  of 
the  worst  symptoms,  we  have  a remedy  of  great 
power  in  the  subcutaneous  injection  of  morphia 
in  doses  of  one-sixth  of  a grain  upwards.  This 
remedy  acts  often  like  a charm,  and  may  be 
used  even  in  the  worst  cases  of  both  mitral 
and  aortic  disease,  but  always  with  caution. 
Albumen  in  the  urine  does  not  necessarily 
contraindicate  its  use.  In  some  cases  chloral 
and  bromide  of  potassium,  alone  or  in  combina- 
tion, are  valuable  remedies  for  the  insomnia, 
but  they  must  be  given  cautiously.  The  bromides 
may  also  be  prescribed  with  other  sedatives  for 
the  dyspnoea.  The  compressed  air  bath  in  some 
cases  also  relieves  the  last  symptom. 

Dropsy,  like  the  visceral  congestions  with 
which  it  is  associated,  requires  the  use  of  diure- 
tics and  hydragogue  cathartics.  AVhen  these  foil, 
the  swollen  limbs  may  be  sometimes  punctured 
with  benefit.  Continued  friction  of  the  limbs,  by 
stimulating  the  vessels,  will  often  cause  consider- 
able anasarca  to  disappear.  The  drug  on  which 
main  reliance  must  be  placed  when  general 
dropsy  supervenes  is  digitalis.  This  remedy  has 
so  great  a share  in  the  therapeutics  of  heart- 
disease,  and  a knowledge  of  its  action  is  so  im- 
portant, that  it  must  be  discussed  separately 
and  last.  Whatever  views  may  be  held  as  to 
the  physiological  action  of  digitalis,  its  greatest 
triumphs  are  seen  clinically  in  the  treatment  ci 
valvular  diseases,  when  cyanosis,  distended  jucro 


HEART.  VALVES  OF,  DISEASES  OF,  AMD  ANEURISM  OF.  fi3) 


lars,  dyspncea,  congested  viscera,  dropsical  limbs, 
scanty  urine,  tumultuous  heart-action,  and  quick, 
irregular,  and  failing  pulse,  indicate  asystoly. 
This  assemblage  of  symptoms  is  mostly  seen  in 
mitral  cases,  and  it  is  precisely  in  this  class  that 
the  drug  is  most  valuable.  Under  its  use  ‘ the 
pulse  grows  in  force,  fulness,  and  regularity ; the 
arterial  tension  rises;  the  pulmonary  congestion 
diminishes;  the  kidneys,  before  inactive,  wake  up 
to  their  work:  and  the  advancing  dropsy  recog- 
nises its  master  and  beats  a sullen  retreat.’  In 
mitral  stenosis  these  good  results  are  due  not 
only  to  the  increased  vigour  given  by  the  drug 
to  the  contractile  power  of  the  heart,  but  also 
to  the  fact  that  by  its  slowing  action  the  dia- 
stolic period  of  each  revolution  is  lengthened, 
and  the  time  thus  increased  during  which  the 
over-full  auricle  can  force  its  contents  through 
the  narrowed  mitral  orifice  into  the  left  ventricle. 
Digitalis  here  not  only  obtains  a better  filling 
of  the  ventricle,  but  a more  effective  discharge 
of  its  contents  when  filled ; and  thus,  under  its 
use,  beat  by  beat,  the  general  and  pulmonary 
venous  congestion  is  relieved.  In  mitral  insuffi- 
ciency it  is  almost  equally  potent.  In  both  forms 
certain  of  its  good  effects  would  seem  to  be  due 
to  some  influence,  probably  through  the  pneumo- 
gastric  nerves,  in  producing  contraction  of  the 
pulmonary  blood-vessels.  It  is  perhaps  this 
property  which  makes  it  valuable  in  pulmonary 
haemorrhages  independent  of  heart-disease. 

In  aortic  valvular  diseases  digitalis  is  not  so 
valuable  a remedy.  In  these  cases  the  assemblage 
of  symptoms  mentioned  above  is  not  met  with, 
except  sometimes  in  the  later  stages,  when  the 
mitral  valve  is  secondarily  affected,  and  the 
case  is  not  one  of  pure  aortic  disease.  In  these 
compound  cases  the  drug  is  valuable,  especially 
in  combination  with  stimulants.  In  aortic  in- 
sufficiency alone,  f he  slowing  action  of  the  digitalis 
produces  evil  by  increasing  the  length  of  the 
diastolic  period  of  each  revolution,  during  which 
the  regurgitation  takes  place.  The  force  it  may 
give  to  the  systole  is  no  gain  in  the  face  of  this 
slowing  action,  inasmuch  as  the  aortic  recoil  gains 
in  the  same  proportion  as  the  ventricular  systole, 
and  thus  forces  blood  back  into  the  ventricle 
with  increased  vigour  during  the  lengthened 
diastole.  It  is  important  in  aortic  insufficiency 
to  encourage  the  frequency  of  the  cardiac  action  ; 
hence  these  cases  are  so  constantly  the  better 
for  bodily  activity ; and  so,  when  the  toning 
effects  of  digitalis  are  required,  it  should  always 
be  given  in  combination  with  ether  and  ammonia, 
to  keep  up  quick  action  of  the  heart,  and  to 
prevent  the  vertigo  and  syncope  which  may 
otherwise  occur.  When  there  is  excessive  hyper- 
trophy in  cases  of  aortic  insufficiency,  digitalis  is 
useful  sometimes  in  quieting  palpitation,  reducing 
excessive  frequency,  and  lessening  headache  and 
; vascular  excitement.  Caffeine  and  veratrum 
viride  also  relieve  these  symptoms ; but  a few 
drops  of  nitrite  of  amyl  inhaled  from  cotton- 
wool are  more  rapidly  and  surely  beneficial  than 
any  other  remedy.  In  aortic  stenosis  digitalis 
is  rarely  required.  The  simple  mode  of  compen- 
sation makes  these  cases  require  little  treatment  . 
Digitalis  is  sometimes  useful  in  combination  with 
stimulants  to  give  vigour  to  the  myocardium, 
and  check  the  tendency  to  dilatation.  If  it  slows 


the  action  of  the  heart  notably,  its  effect  becomos 
hurtful.  Nux  vomica  often  prevents  this. 

In  combined  valvular  lesions,  the  predominant 
lesion  must  be  the  guide  in  the  use  of  digitalis  ; 
but  it  may  be  given  advantageously  whenever  the 
general  signs  of  venous  stasis  are  present.  The 
diuretic  power  of  the  drug  is  one  of  the  best  test* 
of  its  beneficial  action.  Relying  on  th's  test,  the 
writer  often  gives  digitalis  for  weeks,  nay,  months 
at  a time,  and  obtains  improvement  in  the 
nutrition  of  the  heart  which  lasts  long  after  its 
discontinuance.  Digitalis  effects  this  improve- 
ment by  increasing  the  vigour  of  the  coronary 
circulation,  and  thus  builds  up  new  heart-muscle 
to  compensate  a valvular  defect. 

The  preparations  of  digitalis  which  may  be 
used  are,  the  powder  in  I-  to  1-grain ; the  tincture 
in  tux.  to  xxx.;  and  the  infusion  in  Jj  to  ovj 
doses.  As  a diuretic  in  cases  of  dropsy,  the  old 
combination  of  squill,  digitalis,  and  blue  pill  is 
invaluable.  Balthazar  Foster. 

HEART,  Valves  of,  Aneurism  of. — Defi- 
nition.— A valvular  aneurism  is  a circumscribed 
pouching  or  sacculation  of  one  of  the  valve- 
segments. 

Description. — Two  forms  of  aneurism  of  the 
valves  of  the  heart  are  met  with.  In  the  one, 
the  whole  thickness  of  the  valve  is  dilated  by 
the  blood-pressure  to  form  the  pouch;  in  the 
other,  one  of  the  lamellae  being  ulcerated  by 
endocarditis,  the  blood  pushes  the  remaining 
lamella  before  it  to  form  a sac.  The  second 
form,  which  is  sometimes  called  ‘ acute  valvular 
aneurism,’  occurs  most  commonly  in  ulcerative 
endocarditis.  Valvular  aneurisms  vary  in  size, 
from  a pea  up  to  a pigeon’s  egg.  The  orifice  is 
almost  invariably  towards  the  greatest  blood- 
pressure — those  on  the  mitral  valve  opening  to- 
wards the  left  ventricle;  those  on  the  aortic  valves 
towards  the  aorta.  They  are  usually  rounded 
in  shape,  but  may  have  irregular  prolongations 
between  the  lamellae  of  the  valves.  Valvular 
aneurisms  are  sometimes  multiple.  The  valves 
of  the  right  side  of  the  heart  are  seldom  affected. 
The  mitral  valves  are  the  seat  of  the  larger 
aneurisms,  and  are  twice  as  often  aneurismal  as 
the  aortic  valves. 

Valvular  aneurisms  terminate  commonly  by 
early  rupture,  giving  rise  to  perforation  and 
consequent  insufficiency  of  the  valve,  and  often 
leading  to  considerable  laceration.  Rupture 
occurs  more  rapidly  in  aneurism  of  the  aortic 
valves.  Mitral  aneurisms  occasionally  become 
chronic,  and  filled  with  coagulum ; and  aortic 
valve  aneurism  may  also  be  found  filled  with 
solid  clot. 

Symptoms. — The  clinical  history  of  this  form 
of  disease  is  defective.  When  seated  on  the 
mitral  valve,  aneurisms  usually  give  rise  to  no 
signs  until  the  perforation  and  laceration  of  the 
valve  suddenly  develop  the  murmur  of  mitral 
insufficiency.  An  aneurism  of  one  of  the  aortic 
segments  causes  a soft  systolic  murmur  over  the 
valves,  which  one  day,  as  the  sac  ruptures,  is 
supplemented  by  the  murmur,  and  accompanied 
by  the  symptoms  of  aortic  insufficiency.  The 
phenomena  of  this  accident  are  similar  to  those 
of  sudden  rupture  of  an  aortic  valve. 

Balthazar  Foster. 


632  HEART,  WOUNDS  OF. 

HEART,  Wounds  of. — Synon.  : Fr.  Bles- 
sures  du  C<zur\  Ger.  Herzmmden. 

The  subject  of  wounds  and  other  injuries  of 
the  heart  belongs  more  properly  to  the  domain 
of  Surgery,  but  being  in  several  respects  of  much 
medical  interest,  it  requires  to  be  briefly  dis- 
cussed here. 

-ZEnonoGY  and  Anatomical  Characters.— 
Wounds  of  the  heart  may  be  punctured,  incised, 
or  lacerated  ; and  inflicted  with  a variety  of 
weapons  or  other  sharp  bodies,  as  well  as  by 
projectiles,  especially  bullets.  Traumatic  rup- 
tures and  contusions  form  another  consider- 
able class  of  injuries  of  the  heart,  which  chiefly 
result  from  falls,  crushing  accidents  (for  ex- 
ample, being  ‘ run  over’),  and  blows.  Injuries 
of  the  heart  due  to  the  entrance  of  foreign  bodies, 
such  as  a needle  or  a bone,  may  be  inflicted  in 
some  rare  cases  from  the  interior  of  the  oesophagus 
or  stomach  ; the  most  remarkable  case  of  this 
kind  being  one  of  wound  of  the  pericardium 
from  behind  by  the  point  of  a sword  which  a 
juggler  had  attempted  to  ‘swallow.’ 

Post  mortem , the  chest-wall  generally  presents 
evidence  of  the  wound  that  has  been  inflicted. 
The  pericardium  rarely  escapes  injury  ; its  sac  is 
found  to  contain  blood  in  recent  cases,  or  effused 
lymph  or  pus  when  life  has  been  preserved  for  a 
few  days  or  more.  The  walls  of  the  heart  at 
the  seat  of  injury  present  different  appearances, 
according  to  the  precise  nature  of  the  lesion. 
Punctured  and  incised  wounds  may  be  of  all 
sizes;  takeeithera  director  an  oblique  direction 
through  the  muscular  fibres ; and  are  generally 
penetrating.  Bullet-wounds  cut  away  a portion 
of  the  heart,  whether  at  the  borders  or  from  the 
thickness  of  the  organ.  Traumatic  ruptures 
present  special  characters  (see  Heart,  Rup- 
ture of).  In  all  the  varieties  of  injury  of  the 
heart,  the  wound  is  found  plugged  with  blood- 
clot,  the  edges  being  either  infiltrated  or  eechy- 
mosed  and  torn.  In  cases  that  do  not  prove 
rapidly  fatal,  the  usual  signs  of  inflammation,  or 
healing,  and  even  cicatrization,  are  found  in  the 
heart ; or  aneurism  of  the  cardiac  w7alls  may  be 
developed  as  a result  of  the  latter.  The  valves 
and  their  appendages  are  frequently  incised  or 
otherwise  injured.  In  some  cases  a portion  of 
the  weapon,  projectile,  or  foreign  body  may  be 
found  in  the  heart.  The  ventricles — and  espe- 
cially the  right  ventricle — are  the  parts  of  the 
heart  most  commonly  injured.  The  great  vessels, 
lungs,  and  the  arteries  of  the  chest-wall,  may 
also  be  wounded  in  different  instances. 

From  these  appearances  it  is  evident  that 
wounds  of  the  heart  may  prove  rapidly  fatal 
by  loss  of  blood,  by  shock,  or  by  compression  of 
the  heart  resulting  from  haemorrhage  into  the 
pericardium;  whilst,  at  a later  stage,  pericarditis, 
myocarditis,  and  secondary  haemorrhage  may  be 
expected  to  supervene. 

Symptoms,  Course,  and  Terminations. — In 
about  one-third  of  recorded  cases  of  injury  of  the 
heart,  either  death  is  immediate — fainting,  con- 
vulsions, and  the  other  symptoms  of  syncope, 
as  well  as  those  of  shock,  being  the  prominent 
phenomena,  along  with  external  haemorrhage ; or 
<he  patient  drops  dead  after  a few  moments,  dur- 
ing which  time  he  may  have  undergone  consider- 
able exertion.  In  a second  class  of  cases,  tho 


HEARTBURN. 

symptoms  of  syncope  or  of  shock  occur  imme- 
diately, but  death  does  not  at  once  ensue.  The 
patient  then  lies  in  a state  either  of  unconscious- 
ness or  of  complete  prostration.  In  the  latter 
event  he  complains  of  a sense  of  great  debility, 
praecordial  oppression,  dyspnoea,  and  suffocation ; 
the  surface  is  cold,  pallid,  and  trembling ; vomit- 
ing may  occur;  and  there  is  usually  haemorrhage 
from  the  region  of  the  heart.  Death  occurs  after 
minutes  or  hours,  either  from  exhaustion  due 
chiefly  to  continued  or  repeated  loss  of  blood,  or 
from  compression  of  the  heart.  In  a third  series  of 
cases,  the  course  is  more  protracted.  The  patient, 
after  suffering  from  the  symptoms  just  enume- 
rated, but  in  a less  degree,  passes  through  the 
various  phases  of  constitutional  disturbance  com- 
monly observed  in  severe  wounds,  complicated, 
however,  with  pericarditis,  myocarditis,  and  re- 
peated haemorrhage ; and  dies  of  exhaustion  after 
an  illness  of  weeks  or  months.  Lastly,  in  a 
small  proportion  of  cases,  the  patient  survives 
the  various  accidents  and  complications  just  de 
scribed,  and  the  wound  of  the  heart  heals;  but  it 
sometimes  happens  that  symptoms  of  aneurism 
of  the  cardiac  walls,  or  cf  incompetence  of  the 
valvular  apparatus,  are  developed  as  the  result 
of  the  lesion. 

Diagnosis. — Wounds  of  the  heart  can  usually 
bo  diagnosed  without  difficulty  by  the  situation 
of  the  external  injury,  and  the  severity  of  tile 
symptoms.  Similar  symptoms  may,  however, 
follow  injuries  of  the  great  vessels  in  the  neigh- 
bourhood of  the  heart,  or  of  the  arteries  of  the 
walls  of  the  chest,  if  the  haemorrhage  be  profuse ; 
but  unless  there  be  almost  complete  certainty 
that  a vessel  within  reach  is  the  only  seat  of  the 
bleeding,  the  diagnosis  should  be  left  undecided, 
and  all  dangerous  interference  avoided. 

Prognosis. — Injury  of  the  heart  is  generally 
to  be  regarded  as  certain  to  end  in  death ; but 
it  should  not  be  forgotten  thatas  many  as  12  per 
cent,  of  recorded  cases  are  said  to  have  recovered. 
Some  very  remarkable  instances  have  occurred  of 
recovery  after  very  severe  injury  to  this  organ  ; 
for  example,  a case  in  which  a bullet  was  lodged 
in  the  substance  of  the  heart  for  twenty  years. 
(Sec  British  Medical  Journal,  March  23*,  iS67.) 
The  prognosis  may  be  broadly  estiaiated  by  the 
severity  of  the  immediate  symptoms.  Traumatic 
rupture  of  the  heart  is  said  to  have  invariably 
proved  fatal. 

Treatment. — In  wounds  of  the  heart,  the 
haemorrhage  must  be  at  once  arrested  by  the 
usual  surgical  means;  immediate  death  must  be 
prevented  by  cautious  stimulation ; and  the  pa- 
tient must  be  kept  in  such  a condition  that,  whilst 
life  is  preserved,  the  danger  of  inflammatory 
reaction  in  the  region  of  the  heart,  and  of  fresh 
haemorrhage,  is  reduced  to  a minimum.  It  is  on 
this  account  that  restorative  measures  are  to  be 
guardedly7  employed  at  first,  and  resorted  to  in  the 
further  progress  of  the  case  only7  when  urgently 
indicated.  Absolute  rest  of  body  and  mind  is 
indispensable.  Nervine  and  cardiac  sedatives, 
such  as  bromide  of  potassium,  morphia,  chloml- 
liydrate,  and  belladonna,  may  be  of  great  service 
when  used  with  judgment 

J.  Mitchell  Bruce. 


HEARTBURN".  — Svnon.  : Cardialgia.  - 


HEARTBURN. 

Heartburn  is  a hot  or  scalding  sensation,  usually 
referred  to  the  cardiac  orifice  of  the  stomach,  but 
in  some  cases  diffused  over  the  whole  abdomen. 
It  is  frequently  accompanied  by  eructations  of  a 
very  acid  character ; and  the  fluid  rejected  from 
the  stomach  produces  a sensation  of  scalding  in 
the  throat  and  oesophagus. 

IEtiologv. — Heartburn  exists  ina  very  marked 
degree  in  dilatation  of  the  stomach,  being  pro- 
duced by  the  decomposition  of  indigestible  food 
retained  in  this  organ.  It  constantly  accom- 
panies chronic  catarrhal  gastritis,  the  retained 
mucus  enclosing  particles  of  food  in  a state  of 
decomposition,  which  set  up  fermentation  in  the 
materials  of  each  meal  as  soon  as  it  is  swallowed. 
Heartburn  is  common  in  the  later  period  of  preg- 
nancy, probably  because  the  stomach  is  so  dis- 
placed that  it  is  unable  properly  to  expel  its 
contents. 

Treatment. — This  sensation  is  best  treated  by 
antacids,  such  as  chalk,  magnesia,  alkalies,  and 
alkaline  waters.  In  some  cases  powdered  char- 
coal relieves  it.  The  diet  for  persons  that  suffer 
severely  from  heartburn  requires  careful  regula- 
tion. All  articles  of  food  containing  much  fat, 
sugar,  or  starch,  should  be  avoided.  The  use  of 
tobacco  should  be  interdicted ; the  writer  has  fre- 
quently seen  obstinate  cases  kept  up  by  smoking 
and  chewing.  Alcoholic  stimulants  should  be 
used  very  sparingly,  the  least  likely  to  do  harm 
being  brandy  mixed,  with  Vichy  or  potass  water. 
The  writer  has  obtained  good  results  by  sub- 
stituting gluten  bread  for  the  ordinary  baker’s 
bread,  and  where  this  could  not  be  taken,  has 
found  advantage  from  the  use  of  aerated  or  some 
other  kind  of  unfermented  bread.  Some  women 
who  suffer  severely  from  heartburn  when  preg- 
nant find  relief  from  eating  lettuce. 

S.  Fenwick. 

HEART-CLOTS.  See  Heart,  Thrombosis 

of. 

HEAT,  2Etiology  of.  See  Disease,  Causes 
of ; and  the  following  article. 

BEAT,  Effects  of  Severe  or  Extreme.— 
(A)  Constitutional  Effects  of  Severe  Heat 
applied  generally. — The  constitutional  or 
general  effects  of  exposure  of  the  whole  body 
to  high  temperatures  vary  with  the  source  and 
degree  of  heat,  the  slowness  or  rapidity  of  tran- 
sition from  lower  temperatures,  and  the  length 
of  exposure ; as  well  as  with  the  age,  constitu- 
tion, habit  and  health  of  the  body;  and  they  are 
liable  to  be  more  or  less  modified  or  obscured  by 
various  coneomitantcircumstances  and  conditions, 
such  as  the  barometric  pressure,  the  hygrometric 
state,  and  the  purity  or  impurity  of  the  atmo- 
sphere. 

The  range  of  temperature  within  the  limits  of 
which  life  can  be  maintained  appears  to  be 
greater  in  the  case  of  man  than  in  that  of  most 
of  the  lower  animals,  in  virtue  of  greater  power 
of  accommodation  to  external  influences,  without 
undue  elevation  or  lowering  of  the  temperature 
of  the  body.  But  in  every  case  any  such  com- 
bination of  external  circumstances  as  causes 
tho  temperature  of  the  body  to  rise  10°  to  15° 
above  the  normal  standard  speedily  proves  fatal. 

Artificial  heat. — Numerous  observations  and 


HEAT,  EFFECTS  OF  SEVERE.  633 
experiments  show  that  in  dry  air  exposure  to 
very  high  temperatures  can  be  borne,  during 
periods  varying  with  circumstances,  without 
danger  or  even  serious  inconvenience,  tho  tempe- 
rature of  the  body  being  kept  down  within  safe 
limits  by  evaporation  from  the  surface  and  from 
the  lungs.  Thus,  in  Dobson’s  experiments,  a 
temperature  of  210°  was  sustained  during  twenty 
minutes  ; Blagden  exposed  himself  during  eight 
minutes  to  a temperature  of  260° ; Chantrey’s 
workmen  were  accustomed  to  enter  a drying  oven 
in  which  the  thermometer  stood  at  350° ; and 
Chabert,  the  ‘ Fire  King,’  is  said  to  have  fre- 
quently exposed  himself  to  a temperature  of 
from  400°  to  600°.  Glass-workers,  metal-foun- 
ders, gas-stokers,  engineers  in  steamboats — espe- 
cially in  the  tropics  — bakers’  oven-builders, 
and  others  constantly  carry  on  their  work  in 
temperatures  of  from  120°  to  160°,  or  even 
higher,  to  say  nothing  of  the  blasts  of  radiant 
heat  to  which  some  are  from  time  to  time  ex- 
posed. In  moist  air , evaporation  from  the  sur- 
face and  its  cooling  influence  being  diminished 
or  prevented,  much  lower  temperatures  speedily 
become  insupportable.  Berger  was  unable  to 
remain  in  a vapour  bath  the  temperature  of 
which  had  risen  from  106°  to  120°,  although  he 
had  easily  borne  a temperature  of  230°  in  dry 
air  for  five  minutes. 

The-  effects  upon  the  temperature  of  the  body, 
pulse,  respiration,  &c.,  recorded  by  previous 
observers,  are.  in  the  main,  supported  by  the 
recent  careful  experiments  of  Dr.  Fleming  in  the 
Turkish  bath.1  He  found  that  exposure  during 
an  hour  to  a temperature  commencing  at  170° 
and  lowered  to  about  130°,  caused  the  tempera- 
ture of  his  body  (taken  by  a specially  devised 
thermometer  in  the  mouth),  to  rise  rapidly  during 
the  first  ten  minutes  from  a normal  average  of 
97 '65°  to  99-23  (a  rise  of  D6°)  ; and  then  more 
slowly  until  the  end  of  fifty  minutes,  when  the 
highest  point  101‘3°  (arise  of  37°)  was  reached. 
His  pulse  rose  during  the  first  ten  minutes 
from  78  to  91  beats  in  the  minute,  and  like 
the  temperature  attained  its  maximum — 115, 
at  the  end  of  fifty  minutes.  His  breathing  first 
diminished  in  rapidity  from  22  5 to  20-8,  and 
then  increased  to  25  4 in  actual  rapidity,  but 
maintained  a diminished  ratio  to  the  pulse.  The 
arterial  tension  seemed  to  be  increased  by  the 
greater  rapidity  of  the  heart’s  action,  combined 
with  the  gorged  state  of  the  capillary  circulation. 
The  quantity  of  material  eliminated  during  the 
hour  amounted  to  forty-four  ounces.  The  pro- 
portion of  chlorides  in  the  urine  passed  after  the 
bath  (3’65  in  the  1,000)  was  little  more  than  half 
that  in  the  sweat  (6'05)  collected  during  the  hath, 
and  much  less  than  in  the  urine  previously  passed 
(5-68).  The  proportion  of  urea  in  the  urine  was 
slightly  increased,  and  the  sweat  contained  T55 
in  the  1,000. 

The  effects  felt  by  those  exposed  to  great  heat 
vary  with  the  temperature,  the  length  of  expo- 
sure, and  the  collateral  circumstances.  A sensa- 
tion of  warmth,  at  first  agreeable,  is  succeeded  by 
one  of  oppressive  and  then  painful  heat,  until 
this  is  again  relieved  by  the  establishment  of 
copious  evaporation  from  the  surface.  Pleasant 

' Journal  of  Anatomy  and  Physiology , July  1879. 


HEAT,  EFFECTS  OF  SEVERE  OH  EXTREME. 


S34 

stimulation,  and  some  degree  of  excitement  of 
the  nervous  and  muscular  systems,  are  quickly 
followed  by  languor,  lassitude,  listlessness,  feel- 
ings of  exhaustion,  indisposition  to  mental  effort 
or  muscular  exertion,  dizziness,  tendency  to 
sleep,  faintness  and  unconsciousness,  sometimes 
accompanied  or  preceded  by  convulsions.  If 
relief  is  not  afforded  death  ensues.  If  timely 
relief  is  afforded,  more  or  less  speedy  and  com- 
plete recovery  may  be  brought  about. 

Symptoms  and  conditions  closely  or  exactly 
resembling  those  of  sunstroke,  may  be  produced 
by  exposure  to  an  artificially  heated  atmosphere, 
or  to  blasts  of  radiant  heat  from  fires  or  fur- 
naces. If  the  symptoms  have  been  severe  and 
persistent,  or  if  the  sufferer  has  been  exposed 
to  repeated  attacks,  permanent  damage  to  the 
health,  and  especially  to  the  nervous  system, 
almost  certainly  results,  in  spite  of  apparent 
temporary  recovery.  In  many  cases  general  de- 
bility and  deterioration,  in  some  cardiac  troubles, 
and  in  others  insanity,  have  been  recorded  as 
the  persistent  after  effects. 

Bernard,  Delaroche,  and  others  have  shown 
that  animals  exposed  to  temperatures  of  from 
130°  or  lower,  to  150°  and  upwards,  quickly  die. 

The  post  mortem  examination  of  animals  so 
killed  showed  that  the  heart  had  entirely  ceased 
to  beat  at  the  moment  of  death,  and  that  neither 
it  uor  the  muscular  coat  of  the  intestines  could 
by  any  means  be  stimulated  to  contract  again. 
The  muscular  fibres  of  the  heart  examined  micro- 
scopically appeared  rigid  and  coagulated  (Kiihne 
and  Ranvier).  Further,  the  blood  in  both  arteries 
and  veins  was  dark  coloured.  Rigor  mortis  set 
in  very  early,  and  general  decomposition  very 
speedily  commenced.  It  would  thus  appear  that 
(apart  from  sudden  shock  to  the  system  gene- 
rally). the  cause  of  death  from  exposure  to  high 
temperatures  is  to  bo  found  in  the  effect  produced 
on  the  muscular  system  of  organic  life,  and 
especially  on  the  heart.  The  cardiac  myosin 
coagulates  at 1)5°;  and  at  a temperature  con- 
siderably short  of  this  its  condition  must  be 
seriously  affected. 

Anatomical  Characters. — The  post  mortem 
appearances  met  with  in  the  human  subject  in 
cases  iu  which  death  has  been  attributed  to  the 
2-eneral  effects  of  heat  have  not  been  uniform. 
The  following  case,  however,  recorded  by  C. 
Speck1  is  noteworthy.  A girl,  ®t.  fourteen,  the 
subject  of  chronic  disease  of  many  of  her  joints, 
was,  on  the  advice  of  a quack,  wrapped  in  a 
sheepskin  warm  from  the  carcase,  laid  in  bed, 
surrounded  with  hot  loaves  fresh  from  the  oven, 
and  covered  by  the  clothes.  In  about  an  hour 
she  complained  of  pains,  especially  to  one  arm. 
She  soon  fell  asleep.  It  was  noticed  that  her 
chest  rose  and  fell  strongly.  She  perspired 
freely,  and  the  sweat  was  frequently  wiped  off. 
She  became  very  pale,  and  about  three  hours  after 
tho  commencement  of  the  treatment  she  expired, 
without  having  recovered,  or  at  any  rate  mani- 
fested, consciousness.  On  post  mortem  examina- 
tion the  next  day  (the  weather  being  cool  and 
dry)  advanced  decomposition  was  found;  the 
blood  being  black  and  fluid,  and  the  blood-ves- 
sels, cavities,  and  tissues  generally  full  of  gas. 
The  heat  of  loaves  fresh  from  the  oveu,  such  as 
1 Vierteljahrschrift  fur  gerichtliche  Median,  1874 ; p.  249. 


were  put  round  the  child,  was  found  to  he 
185°. 

Teeatment. — The  immediate  treatment  to  be 
adopted  in  the  case  of  those  suffering  from 
exposure  of  the  whole  body  to  heat  consists 
essentially  in  removal  into  a cooler  atmosphere ; 
quiet  rest  in  the  recumbent  position:  fannin?; 
cool  or  even  cold  affusions  or  sponging,  especially 
over  the  head  and  spine — the  effect,  however, 
being  carefully  watched ; and  the  administra- 
tion of  cool  or  lukewarm  fluid  in  small  quantity 
at  a time,  with  some  stimulant.  Copious  draughts 
of  cold  water  in  a highly  heated  state  of  body 
are  liable  to  give  rise  to  dangerous  or  even  fata! 
results.  Bleeding  is  not  to  be  recommended. 

The  after  treatment  must  be  conducted  on 
general  principles,  and  determined  by  the  con- 
dition of  the  patient,  and  the  indications  afforded 
in  the  particular  case. 

Climatic  and  Solar  Heat. — The  effects  of 
climatic  heat  experienced  on  transition  from 
temperate  to  tropical  regions  are  as  follows  : — 
1st.  The  average  temperature  of  the  body  rises 
•5°  to  1°  according  to  Davy  and  Crombie,  or  to 
a somewhat  greater  extent  according  to  others. 
The  daily  fluctuations  of  bodily  temperature  in 
health  in  India  correspond  to  those  in  England. 
The  normal  temperature  of  native  Indians  is 
about  hah’  a degree  higher  than  that  of  Euro- 
peans (Cromhie).  2nd.  The  pulse  is  quickened 
according  to  most  observers,  but  Rattray  says 
this  is  incorrect.  3rd.  The  breathing  becomes 
slower  and  less  deep,  falling  from  about  sixteen 
to  about  twelve  or  thirteen  per  minute.  Less 
carbonic  acid  and  less  water  are  thus  exhaled. 
4th.  The  skin  acts  much  more  freely,  its  excretion 
being  increased  by  about  24  per  cent.  (Rattray). 
The  continued  hyperaemia  and  over  action  of  the 
skin,  however,  are  liable  to  be  followed  by  con- 
gestion and  obstruction  of  the  sweat  follicles, 
giving  rise  to  ‘ prickly  heat.’  5th.  The  urine 
is  diminished  in  quantity,  and  in  amount  of  urea 
and  chlorides.  The  experiments  of  Becher  (con- 
firmed by  those  of  Forbes  Watson)  showed  a con- 
stant relation  between  the  temperature,  and  the 
urea  and  chloride  of  sodium  got  rid  of  by  the 
kidneys.  As  the  temperature  rose  from  50 3 to 
70°  an  increase  was  found  ; but  with  a further 
rise  from  70°  to  90°  an  almost  equally  constant 
diminution  occurred.  6th.  The  appetite,  espe- 
cially for  animal  food,  is  diminished,  and  the 
digestive  powers  seem  lowered.  7th.  Lassitude, 
languor,  want  of  vigour,  indisposition  to  exer- 
tion, and  a se.nse  of  exhaustion  of  mind  and  body 
are  experienced  in  degrees  varying  with  circum- 
stances; the  depressing  effects  being  most  felt 
when  the  heat  is  not  only  great  but  continuous 
day  and  night,  and  when  the  atmosphere  is 
moist. 

The  effects  of  the  radiant  heat  of  the  sun,  as 
distinguished  from  those  of  atmospheric  heat, 
are  uot  well  made  out.  It  would  appear  probable, 
however,  that  a physiological  effect  adverse  to  per- 
spiration is  produced  by  the  direct  rays  (Parkes  . 
and  that  thus,  as  well  as  from  rapid  evapora- 
tion, the  skin  gets  dry.  and  becomes  liable  to 
certain  structural  changes,  such  as  :he  formation 
of  pigment,  & c. 

Exposure  to  the  direct  rays  of  the  sun,  or  to 
great  or  continued  heat  in  the  shade,  especially 


HEAT,  EFFECTS  OF  SEVERE  OR  EXTREME. 


cndpr  unfavourable  atmospheric  and  general 
conditions,  may  give  rise  to  heat-fever  (Causis), 
heat-apoplexy,  or  one  or  other  of  the  forms  of 
sunstroke.  See  Sunstroke. 

(Z>)  Local  Effects  of  Severe  Heat : Burns 
and  Scalds. — The  local  effects  of  heat  vary 
with  the  degree,  the  length  of  exposure,  the 
medium  of  application,  and  the  part  acted  upon. 
Bums  result  from  ‘ dry,’  Scalds  from  ‘ moist  ’ heat. 

Symptoms. — A comparatively  slight  degree  of 
heat  causes  vascular  turgescence,  redness,  ting- 
ling, pain,  and  tenderness,  which  soon  subside. 
Desquamation  of  the  epidermis  may  follow,  but 
no  permanent  trace  of  injury  is  lelt.  A higher 
degree  causes  severe  burning  pain,  and  great 
redness  of  surface,  followed  by  effusion  of  serum 
beneath  the  cuticle  (vesication.)  Complete  re- 
storation without  scar  is  usually  effected.  Still 
higher  degrees  of  heat  or  longer  exposure  cause 
intense  pain,  and  immediate  destruction,  or  con- 
secutive destructive  inflammation,  of  the  true 
skin  to  a greater  or  less  depth.  Sloughing  and  sup- 
puration follow,  and  permanent  scarring  results. 
Violent  heat  and  prolonged  exposure  cause  com- 
plete disintegration  and  charring  of  the  struc- 
tures especially  acted  upon,  followed  by  de- 
structive inflammation  and  sldughing  of  others 
to  a still  greater  depth  and  extent..  Loss  of  parts 
and  more  or  less  serious  deformity  and  scarring 
necessarily  result.  The  separation  of  sloughs, 
and  the  processes  of  repair  after  severe  burns, 
take  place  slowly ; and  as  a rule  the  patient 
suffers  much  more  acutely,  and  during  a much 
longer  period,  than  after  other  forms  of  injury 
involving  equally  extensive  destruction  of  tissue. 

The  constitutional  effects  of  burns  and  scalds 
vary  with  the  superficial  extent  and  situation, 
rather  than  with  the  depth  of  the  injury.  Thus 
an  extensive  burn  or  scald  over  the  abdomen 
affecting  only  the  skin  is  much  more  likely  to 
prove  fatal  than  a deep  burn  of  one  of  the  extre- 
mities, penetrating  oven  to  the  bone,  but  of 
comparatively  small  superficial  area.  If  more 
than  half  the  surface  of  the  body  is  affected  the 
sufferer  rarely  recovers. 

Death  may  result  from  shock  to  the  system, 
either  immediately  on  receipt  of  the  injury,  or 
after  a period  of  from  two  or  three  to  forty-eight 
hours  or  more.  During  this  time  the  sufferer 
remains  in  a state  of  collapse  or  prostration,  with 
pallor  of  complexion,  lowness  of  temperature, 
coolness  of  breath,  small  or  imperceptible  pulse, 
dryness  of  tongue  and  mouth,  and  sometimes  de- 
lirium, rigors,  or  convulsions.  In  such  cases,  post- 
mortem examination  shows  only  congestion  of  the 
viscera,  and  especially  of  the  brain.  In  some 
instances,  characterised  by  painfully  laboured 
and  frequent  efforts  at  respiration,  tumultuous, 
irregular,  feeble  and  very  frequent  action  of  the 
heart,  and  great  prcecordial  distress,  death  would 
appear  to  be  due  to  cardiac  thrombosis,  rather 
than  to  simple  nervous  shock  (Brown).  In  many 
severe  cases  the  blood  has  been  found  on  micro- 
scopical examination  altered  in  appearance,  the 
red  corpuscles  being  separated  into  ‘ numerous 
little  bits’  (Ponfick  and  Schmidt).  And  it  is 
readily  conceivable  that  such  destruction  of 
corpuscles  may  give  rise  to  severe  symptoms,  or 
even  cause  death. 

In  about  forty-eight  hours,  more  or  less  if 


63a 

the  immediate  effects  of  the  injury  have  been 
survived,  the  stage  of  reaction  and  inflammation 
sets  in.  The  patient  revives,  and  some  degree 
of  general  pyrexia  becomes  manifost.  The  pulse 
becomes  quicker  and  fuller;  the  temperature 
rises ; and  the  burnt  part  begins  to  discharge 
pus,  usually  of  an  offensive  odour.  Thirst,  with 
dry  red  tongue,  want  of  appetite,  vomiting 
and  constipation,  followed  by  diarrhoea — some- 
times  with  blood  in  the  evacuations — are  com- 
monly experienced  during  the  ensuing  period  ; 
and  inflammation  of  internal  parts  often  occurs, 
although  the  special  signs  and  symptoms  afforded 
may  be  obscure.  The  pleurae  and  lungs,  the 
peritoneum,  and  the  gastro-intestinal  mucous 
membrane  (particularly  that  of  the  duodenum) 
are  especially  liable  to  be  affected.  Evidence  of 
inflammation  of  one  or  more  of  these  parts,  and 
not  uncommonly  of  ulceration  of  the  duodenum,  is 
afforded  on  post  mortem  examination  in  cases  in 
which  death  has  occurred  during  this  period.  It 
has  been  suggested  that  capillary  embolism,  from 
the  presence  of  disintegrated  blood  in  the  ves- 
sels, may  cause  in  some  cases  the  lesions  of  the 
internal  organs  (Brown). 

In  the  course  of  about  a fortnight  after  the 
inj  ury,  as  a general  rule,  the  sloughs  will  have 
separated,  the  acute  symptoms  will  have  sub- 
sided, and  granulation  and  suppuration  will  have 
been  established.  But  a low  form  of  chronic 
inflammatory  mischief  in  the  internal  organs  may 
still  be  going  on,  and  lead  to  fatal  result ; or  the 
patient  may  sink,  worn  out  by  suffering,  and  ex- 
hausted by  the  profuse  discharge  from  the  sup- 
purating surface,  or  by  persistent  diarrhoea, 
accompanied  or  not  by  blood  in  the  motions. 
Sometimes  the  kidneys  are  affected,  and  blood  or 
bloody  casts  may  be  found  in  the  urine.  Pyae- 
mia,  erysipelas,  or  tetanus  may  occur  and  cause 
death ; but  there  would  not  appear  to  be  any 
special  liability  to  these  diseases  after  burns  or 
scalds. 

Treatment. — Local  treatment. — Slight  super- 
ficial burns  of  small  extent  require  little  in  the 
way  of  treatment.  Immersion  in  cold  water  ac- 
cording to  some,  in  hot  water  according  to  others, 
or  exposure  before  the  fire,  affords  the  readiest 
means  of  obtaining  immediate  relief.  After- 
wards the  part  maybe  covered  with  flour,  starch, 
oxide  of  zinc,  bismuth,  or  collodion,  and  wrapped 
round  with  cotton-wool  to  protect  it  from  the 
air  and  from  accidental  irritation.  In  cases  in 
which  there  is  vesication,  the  blisters  should 
be  pricked,  the  serum  evacuated,  and  the  cuticle 
left  to  form  a natural  protective  covering,  which 
may  be  advantageously  strengthened  and  kept 
in  position  by  a layer  of  collodion.  But  the 
punctures  should  be  left  open.  Lint  soaked  in 
oil,  or  smeared  with  vaseline  or  some  such  mate- 
rial, should  be  applied,  and  the  whole  covered  with 
cotton-wool.  A mixture  of  chalk  or  whitening 
and  vinegar,  of  the  consistence  of  thick  cream, 
is  said  to  form  an  excellent  application  in  such 
cases,  speedily  relieving  pain,  and  helping  to 
constitute  a good  protective  covering. 

Severe  and  extensive  burns  and  scalds  de- 
mand in  their  treatment  the  most  careful 
management,  and  the  greatest  possible  patience, 
gentleness,  and  firmness;  for  even  if  life  be 
preserved,  the  most  pitiable  disfigurements  and 


C3G  HEAT,  EFFECTS  OF  SEVEKE. 
deformities  are  liable  to  result  from  cicatricial 
contractions,  unless  proper  preventive  measures 
are  perseveringly  carried  out.  So  soon  as  may 
be  after  the  injury,  the  clothes  should  be  re- 
moved from  the  patient  with  the  greatest  care 
— being  cut  away  piecemeal  if  needful,  and  not 
removed  in  such  way  as  to  tear  off  epidermis 
or  scorched  or  charred  parts.  The  whole  burnt 
surface  should  then  be  covered  as  quickly  as 
possible  with  the  dressing  considered  best,  and 
enveloped  in  thick  layers  of  cotton-wool  lightly 
bandaged  on.  Different  dressings  have  been  ad- 
vocated from  time  to  time,  but  probably  there  is 
none  better,  or  more  generally  and  readily  applic- 
able in  hospital  practice  at  any  rate,  than  Carron 
oil  (a  mixture  of  equal  parts  of  linseed  oil  and 
limewater).  The  addition  of  a little  carbolic 
acid  is  advantageous.  A less  disagreeable  ap- 
plication may  be  made  by  substituting  olive  or 
aimond  oil  for  linseed  oil.  White  lead,  putty 
made  thin  by  addition  of  oil,  calamine  ointment, 
carbolised  oil,  solution  of  carbonate  of  soda,  car- 
bolic lotion,  flour,  and  starch,  are  among  the 
other  materials  that  have  been  recommended. 
Whatever  the  material  selected,  it  should  be 
slightly  warmed,  and  applied  very  thickly  spread 
on  broad  strips  of  lint,  in  such  way  as  to  facili- 
tate future  dressing  bit  by  bit,  and  so  as  to  avoid 
extensive  exposure  of  raw  surface.  The  first 
dressing  should  be  allowed  to  remain  undisturbed 
as  long  as  possible — until,  indeed,  the  offensive- 
uess  of  the  discharge,  or  the  discomfort  of  the 
patient,  indicates  the  necessity  for  its  removal. 
The  earlier  dressings,  however  gently  carried 
out,  occasion  so  much  suffering  to  the  patient 
that — in  the  case  of  children  especially — it  is 
often  desirable  to  administer  chloroform.  Poul- 
tices are  sometimes  useful  in  aiding  the  separa- 
tion of  sloughs.  Any  needful  washing  or  clean- 
sing is  best  done  by  aid  of  the  steam  spray- 
producer,  a weak  solution  of  carbolic  acid  or  of 
borax  being  used.  AVhen  suppuration  is  es- 
tablished, and  the  surface  clean,  the  applica- 
tion may  be  varied  according  to  the  indications 
afforded.  Calamine  or  zinc  or  lead  ointment, 
with  or  without  the  addition  of  some  anodyne; 
and  lotions  of  lead,  morphia,  and  glycerine,  or  of 
sulphate  of  zinc,  are  amongst  those  commonly 
employed.  Iodoform,  with  extract  of  hemlock 
and  spermaceti  ointment,  has  been  strongly 
recommended  as  tending  to  soothe  pain,  to  deo- 
dorise the  discharge,  and  favour  healing.  Exu- 
berant granulations  may  be  treated  with  nitrate 
of  silver  in  solution,  or  by  the  application  of  the 
solid  stick.  When  the  granulating  surface  is  in 
a healthy  state,  cicatrisation  may  be  very  mate- 
rially expedited  by  skin-grafting. 

During  cicatrisation,  and  even  for  some  time 
afterwards,  it  is  of  the  greatest  importance  to 
keep  all  parts  in  such  position  as  that  there  shall 
be  as  little  deformity  as  possible  from  growing 
together  of  surfaces,  and  contraction  of  scars. 
This  is  to  be  effected  or  attempted  by  position, 
by  mechanical  apparatus,  and  by  the  application 
of  strips  of  adhesive  plaster  and  bandages  in 
manner  determined  by  the  circumstances  and 
conditions  in  each  particular  case. 

Constitutional  treatment. — In  the  early  stages, 
alcoholic  stimulants,  or  ammonia,  and  external 
warmth  are  especially  requisite,  and  such  light 


HEAT,  THERAPEUTICS  OF. 

nourishment  as  can  be  taken.  Opiates  or  other 
anodynes,  as  chloral  or  bromide  of  potassium, 
are  to  be  administered  according  to  the  indica- 
tions afforded,  for  the  purpose  of  allaying  pain 
and  soothing  the  nervous  system.  AVhen  sup- 
puration is  established,  a full  allowance  of  good 
nourishing  food,  with  some  alcoholic  stimulant, 
should  be  given,  and  such  tonics  as  seem  most 
suitable.  Small  doses  of  opium  at  regular  in- 
tervals often  prove  very  beneficial.  The  com- 
plications that  may  arise,  such  as  affections  of 
the  internal  organs,  &c.,  must  be  treated  in 
accordance  with  general  principles,  but  all  de- 
pressing medicines  as  a rule  should  be  avoided. 

Arthur  E.  Durham. 

HEAT,  Therapeutics  of. — Principles. — 
The  primary  effect  of  external  heat  applied  lo- 
cally to  the  animal  body  is  that  of  an  excitant 
or  stimulant.  There  occurs  redness  with  tur- 
gescence  of  the  small  vessels,  in  the  part  to 
which  the  heat  is  applied,  along  with  slight 
augmentation  of  temperature,  and  pain.  In- 
creased beyond  a certain  degree,  heat  ceases  to 
be  a stimulant,  its  prolonged  action  causing 
greater  pain,  exhaustion,  depression,  and,  if  the 
action  be  very  intense,  decomposition  of  the  or- 
ganized tissues.  See  preceding  article. 

Experiments  have  shown  that  by  increased 
heat  the  electric  currents  in  the  nerves  are  de- 
stroyed. It  may  therefore  he  assumed  that  the 
nerves  become  less  able  to  conduct  impressions 
either  to  or  from  the  brain,  and  that  heat  may 
act  as  a sedative  to  painful  nerves. 

Moderate  heat  applied  generally,  that  is,  to 
the  whole  body,  produces  a number  of  important 
physiological  effects  which  are  fully  described 
in  the  preceding  article,  to  which  the  reader  is 
referred. 

Applications  and  Uses. — Heat  is  employed 
in  the  treatment  of  disease  as  a general  or  local 
stimulant,  a local  depressant,  a caustic,  or  a 
counter-irritant;  and  that  in  the  form  either  of 
dry  or  of  moist  heat. 

Dry  heat. — The  primary  exciting  and  stimu- 
lating action  of  heat  may  be  made  available 
to  rouse  the  nervous  and  vascular  systems.  The 
use  of  the  hot  air  bath  (Turkish  Bath),  and  that 
of  the  sand-bath  are  discussed  in  the  article  on 
Baths.  In  some  parts  of  the  South  of  France, 
baths  of  hot  sand  ( arena  catida ) are  used  in  the 
treatment  of  rheumatism,  paralysis,  and  spasm; 
the  sand  acting  as  a stimulant  and  sudorific.  To 
restore  the  circulation,  bottles  of  hot  water  are 
placed  in  the  axillae,  and  against  the  feet  and 
thighs,  in  cases  of  collapse  of  the  system,  with 
coldness  of  the  extremities  and  great  failure  of 
circulation,  as  in  the  treatment  of  collapse  from 
the  shock  of  an  injury,  or  from  such  diseases  ss 
cholera,  or  of  the  apparently  drowned. 

Dry  heat  may  also  be  applied  to  the  abdomen, 
in  the  form  of  tins  or  bottles  of  hot  water,  or 
bags  of  heated  salt  or  sand,  to  relieve  painful 
spasm  and  colic.  Hot  water  enclosed  inan  india- 
rubber  bag  is  sometimes  of  service  to  allay  undue 
irritability  of  the  spinal  nerves.  The  therapeutical 
application  of  heat  as  a counter-irritant  will  be 
found  described  elsewhere.  See  Counter-irri- 
tants. 

Moist  heat. — Heat  and  moisture  together  tend 


HEAT,  THERAPEUTICS  OF. 

to  cause  relaxation  of  the  tissues,  thus  removing 
the  tension  and  pain  due  to  inflammation.  Moist 
heat  is  employed  locally  in  the  form  of  the  local 
vapour  hath,  fomentations,  and  poultices.  See 
Fomentations  ; and  Poultices. 

Moist  heat  is  applied  to  the  surface  of  the 
body  generally,  chiefly  in  the  form  of  the  va- 
pour hath.  See  Baths. 

John  C.  Ihorowgood. 

HEAT  - STROKE.— A synonym  for  sun- 
stroke. See  Sunstroke. 

HECTIC  EEVER  (Iktikos,  habitual). — 
Synox.  : Fr.  Iiectique ; Ger.  Hecti&ch. 

.Etiology. — The  variety  of  fever  thus  named 
has  long  received  special  recognition,  inasmuch  as 
it  presents  certain  prominentandpeculiarfeatures, 
as  regards  its  course  and  attendant  phenomena. 
It  occurs  in  association  with  some  wasting  and  ex- 
hausting disease,  especially  when  this  is  accom- 
panied by  a profuse  and  constant  drain  from  the 
system,  and  more  particularly  when  there  is  chronic 
suppuration,  with  an  abundant  discharge  of  pus. 
Hectic  fever  is  most  frequently  noticed  in  cases 
of  pulmonary  phthisis,  in  a large  proportion  of 
which  it  appears  in  various  degrees  during  some 
part  of  their  course,  chiefly  in  the  advanced 
btages.  Other  conditions  deserving  of  mention 
in  connection  with  which  it  may  supervene  are 
empysema,  especially  if  there  is  an  external  fis- 
tula, tubercular  ulceration  of  the  intestines, 
chronic  purulent  discharge  from  the  kidney, 
hepatic  abscess,  chronic  dysentery,  and  any  form 
of  external  chronic  abscess  attended  with  much 
discharge.  Fever  of  a hectic  type  sometimes 
occurs  in  cases  of  acute  inflammation  ; and  it  is 
occasionally  observed  in  chronic  affections  un- 
attended with  suppuration,  such  as  cancer  and 
lymphadenoma.  Pathologically  it  seems  to  be 
connected  with  the  absorption  of  pus  or  other 
morbid  products  into  the  blood.  See  Fever. 

Symptoms. — Hectic  fever  is  established  gra- 
dually, becoming  more  and  more  distinct,  until  it 
assumes  its  typical  characters.  It  is  more  or  less 
paroxysmal,  being  at  first  indicated  by  slight 
pyrexia  towards  evening  and  during  the  night, 
the  temperature  being  a little  raised,  and  the 
pulse  hurried.  During  the  day  there  is  no  fever 
at  this  time,  but  as  the  case  progresses  it  becomes 
constant,  though  exacerbations  occur  at  night, 
and,  it  may  be,  also  in  the  morning,  tho  parox- 
ysms thus  occurring  either  once  cr  twice  within 
the  twenty-four  hours,  and  the  pyrexia  being  re- 
mittent. In  typical  hectic  there  is  a complete 
febrile  cycle,  beginning  with  chills  or  even  a dis- 
tinct rigor,  followed  by  considerable  heat  of  skin, 
the  temperature  continuing  to  rise,  and  ending 
in  more  or  less  profuse  perspiration,  especially 
about  the  head  and  chest,  sometimes  so  abundant 
as  to  saturate  the  bed-clothes  or  even  the  bed- 
ding. Patients  often  feel  subjectively  very  hot, 
the  palms  of  the  hands  and  soles  of  the  feet 
having  a burning  sensation.  The  pulse  tends  to 
become  very  frequent  and  quick,  and  is  easily 
hurried  and  excited,  being  at  the  same  time 
weak,  soft,  and  compressible.  Not  uncommonly  a 
bright  red  or  pink  spot  appears  on  each  cheek 
during  the  paroxysm,  known  as  the  hectic  flush, 
and  this  may  contrast  markedly  with  the  general 
pallor  of  the  face,  tho  eyes  being  also  bright, 


HEMERALOPIA.  637 

clear,  and  sparkling.  The  mind  is  unaffected, 
and  the  mental  faculties  may  be  unusually  bright 
and  vivid.  After  a febrile  exacerbation  the  urine 
may  present  excess  of  lithates.  Hectic  fever 
does  not  always  show  all  its  typical  features,  and 
even  in  the  same  case  variations  are  noticed  in  tho 
precise  characters  of  the  paroxysms.  It  is  usually 
accompanied  with  other  symptoms  due  to  the 
disease  with  which  it  is  associated ; while  it  itself 
tends  to  cause  wasting  and  debility,  as  well  as  a 
sense  of  exhaustion  after  each  attack.  In  most 
instances  a fatal  termination  ultimately  ensues, 
but  if  the  condition  upon  which  hectic  depends 
is  curable,  recovery  may  take  place. 

Treatment. — The  first  principle  in  the  treat- 
ment of  hectic  fever  is  to  attend  to,  and  cure,  if 
possible,  the  condition  upon  which  it  depends, 
and  especially  to  diminish  or  stop  suppuration. 
General  tonic  treatment  will  also  help  in  prevent- 
ing the  paroxysms.  These  may  he  directly  checked 
in  appropriate  cases  by  full  doses  of  quinine,  sali- 
cine,  or  other  antipyretics,  given  before  the  usual 
time  for  their  occurrence.  Sponging  the  skin 
freely  may  also  prove  of  service  in  some  instances. 
The  treatment  of  hectic  in  phthisis  runs  into  that 
of  night-sweats,  and  can  he  more  conveniently 
discussed  under  that  disease.  See  Phthisis. 

Frederick  T.  Roberts. 

HELIOSIS  ( , I expose  to  the  sun). — A 
method  of  treatment  for  certain  diseases,  which 
consists  in  exposing  the  patient  to  the  rays  of 
the  sun.  The  term  is  also  employed  as  a syno- 
nym for  sunstroke.  See  Sunstroke. 

HELMINTHIASIS  (eA/j-ivs,  a worm) —The 
condition  of  system  upon  which  the  development 
of  worms  in  any  part  of  the  body  depends.  The 
term  is  also  applied  to  the  diseases  characterised 
by  the  presence  of  worms. 

HELMINTHICS  (e\jaiw,  a worm).— Of  or 
belonging  to  worms.  A synonym  for  anthel- 
mintics. See  Anthelmintics. 

HELMINTHS  (e'X/ii vs,  a worm).  — This 
term  is  often  employed  in  preference  to  ods  or 
other  of  the  various  synonyms  with  which  it  is 
regarded  as  equivalent  (worms,  intestinal  worms, 
vermes,  entozoa,  internal  parasites,  and  so  forth). 
Thus,  Yon  Siebold  (who  speaks  of  the  Helminths 
as  forming  a class  of  animals,  nearly  all  of  whose 
members  are  parasitic)  admits  that  tho  only 
character  common  to  the  greater  part  of  the 
whole  group  is  their  peculiar  mode  of  life.  The 
study  of  the  helminths  forms  what  is  often 
called  the  science  of  Helminthology.  In  accord- 
ance with  professional  custom,  it  has  beer, 
thought  desirable,  in  the  present  work,  to  speak 
of  the  helminths  as  constituting  the  class  Ento- 
zoa, under  which  heading,  therefore,  more  de- 
tailed references  are  given.  T.  S.  Cobbold. 

HEMERALOPIA. — The  etymology  of  this 
term  is  uncertain,  and  its  real  meaning  has  never 
been  definitively  settled.  Some  winters  derivo 
the  word  from  yp-lpa,  the  day,  and  &<f/,  the  eye,  and 
in  conformity  therewith,  use  it  to  signify  day- 
sight  or  night-blindness,  that  is,  a state  of  vision 
in  which  objects  are  seen  by  day-light  or  by 
strong  artificial  illumination,  but  become  more  or 


538  HEMERALOPIA, 

less  invisible  when  in  deep  shade  or  in  twilight. 
Others,  on  the  contrary,  employ  the  term  in  the 
opposite  sense  of  day-blindness  or  night-sight, 
deriving  it  from  fip.4pa,  dip,  and  a,  priv.  or  aAabs, 
blind.  It  is  used  in  the  latter  sense  in  this  work, 
and  may,  therefore,  be  defined  as  a disorder 
of  vision,  in  which  objects  cannot  be  seen  well 
cr  without  pain  by  daylight  or  by  strong  artificial 
light,  but  are  more  clearly  or  comfortably  seen 
in  a deep  shade  or  by  twilight.  See  Vision,  Dis- 
orders of. 

HEMIANESTHESIA  (ftpuavs,  the  half; 
a,  priv. ; and  ai.aQ6.vop.ai,  I feel). — Paralysis  of 
sensation  affecting  one  side  of  the  body.  See 
Sensation,  Disorders  of. 

HEMIAN ALGESIA  (fcnrur,  the  half ; av, 
without;  and  &Ayos,  pain). — Insensibility  to 
painful  impressions,  affecting  one  side  of  the 
body.  See  Sensation,  Disorders  of. 

HEMICRANIA  (vpiavs,  the  half,  and 
xpav\ov,  the  head.) — Pain  limited  to  one  side  of 
the  head.  The  term  is,  however,  generally  used 
as  synonymous  with  megrim.  See  Megrim. 

HEMIOPSIA  half,  and  H, 

the  eyo). — A derangement  of  vision  in  which 
only  one  half  of  an  object  is  seen  by  one  eye. 
See  Vision,  Disorders  of. 

HEMIPLEGIA  {'nptavs,  the  half,  and 
aXiiaaui,  I strike). — Paralysis  of  motion  of  one 
6ide  of  the  body  ; sometimes  applied  to  loss  both 
of  motion  and  of  sensation.  See  Paralysis, 
Motor. 

HEPATALGIA  (Ijirap,  the  liver,  and  aKyos, 

I ain). — Strictly  this  word  signifies  pain  in  con- 
nection with  the  liver.  It  has,  however,  been 
specially  applied  to  a supposed  neuralgic  pain 
referred  to  this  organ,  coming  on  in  paroxysms, 
and  said  to  be  of  a severe  character  in  some 
instances,  so  as  to  simulate  hepatic  colic. 
Whether  there  is  any  such  affection  is  exceed- 
ingly doubtful,  and  probably  in  cases  of  supposed 
hepatalgia  the  neuralgia  is  either  superficial,  or 
there  is  some  tangible  but  undiscovered  cause  for 
the  piain,  connected  with  the  liver  or  some  neigh- 
bouring structure. 

Frederick  T.  Rcberts. 

HEPATIC  DISEASES.  See  Liver,  Dis- 
eases of. 

HEPATISATION  (rji rap,  the  liver).— A 
term  applied  to  the  condition  produced  by  acute 
inflammation  of  the  lung,  in  which  the  pulmo- 
nary substance  becomes  solid  and  friable, 
resembling  somewhat  the  liver  in  its  physical 
characters.  See  Lungs,  Inflammation  of. 

HEPATITIS  (ryaap.  the  liver). — Inflamma- 
tion of  the  liver.  See  Liver,  Inflammation  of. 

HEPATOCELE  (pn ap,  the  liver,  and  ktjKtj, 
a tumour). — Hernia  of  the  liver.  See  Liver, 
Displacements  of. 

HEREDITARY  {hares,  an  heir). — This 
term,  as  used  in  relation  to  medicine,  is  applied 
to  the  transmission  of  constitutional  conditions,  or 
of  diseases  from  parent  to  offspring.  Sec  Disease, 
Causes  of;  '<nd  Predisposition  to  Disease. 


HERNIA. 

HERMAPHRODITE  {‘Epprjs,  Mercury, 
and  ’AtppoSirrj,  Venus). — A term  applied  to  an 
individual  in  whom  the  formation  of  the  sexual 
organs  is  such  as  to  give  rise  to  the  impression 
that  both  the  male  and  the  female  organs  are 
present.  See  Malformations. 

HERNIA  ( hernia , a rupture). — Definition. 
This  word  is  used  in  surgery  to  express  the 
pirotrusion  of  any  viscus  from  the  cavity  m 
which  it  is  naturally  placed.  In  this  article, 
however,  tne  observations  are  exclusively  re- 
stricted to  protrusions  of  the  viscera  of  the 
abdomen  through  the  walls  of  that,  cavity,  and 
it  is  only  intended  to  give  a mere  outline  of  the 
subject,  its  full  discussion  being  beyond  the 
scope  of  this  work,  as  it  is  mainly  connected 
with  surgery. 

General  Remarks. — Hernial  displacements 
take  place  in  both  sexes  and  at  all  ages.  The 
most  striking  objective  sign  of  the  existence  of  a 
hernia  is  a fulness  or  swelling  in  one  or  other 
of  those  regions  of  the  abdomen  where,  from  the 
anatomical  construction  of  its  walls,  the  tissues 
are  weakest.  When  the  parietes  are  defective, 
.n  consequence  of  local  disease  or  injury,  vis- 
ceral protrusions  may  cccur  at  those  spots  : and 
also,  as  the  result  of  congenital  malformation 
in  both  sexes,  a fruitful  cause  of  hernia  being 
the  non-closure  of  the  vaginal  process  of  the 
peritoneum  at  birth,  or  a patulous  state  of  the 
umbilical  aperture.  Such  a protruded  viscus 
forms  a hernial  swelling  or  tumour.  The  tumour 
is  composed  of  a sac,  its  contents,  and  the  tissues 
outside  the  sac.  The  sac  is  composed  of  a pro- 
longation of  the  peritoneum  in  most  eases  ; and 
its  orifice,  neck,  or  abdominal  aperture  consti- 
tutes, with  the  tissues  around  it,  a frequent 
cause  of  impediment  to  replacement  or  ‘ reduc- 
tion ’ of  the  hernia.  The  hernia  may  he  a part 
of  any  abdominal  viscus,  but  those  most  mobile 
are  usually  displaced.  Thus,  in  the  majority 
of  cases,  either  the  omentum  or  small  intestines, 
together  or  singly,  form  the  hern: a.  The  tissues 
outside  the  sac  tire  those  which  exist  in  tho 
region  where  the  tumour  is  formed,  and  they  are 
frequently  described  as  the  coverings  of  the  sac. 

Every  hernial  tumour  possesses  a neck,  bedv, 
and  fundus. 

The  first  or  earliest  objective  symptom  of  a 
hernial  protrusion  is  an  unusual  fulness,  as,  for 
example,  in  the  groin  in  a case  of  inguinal  her- 
nia. This  swelling  is  transient,  appearing  ami 
disappearing  in  relation  to  the  actions  or  posture 
of  the  individual.  When  pressed  with  the  finger 
the  swelling  disappears ; but  it  is  readily  repro- 
duced if  the  patient  contracts  the  abdominal 
muscles,  and  then  with  the  finger  an  impulse 
is  felt,  produced  by  the  protruding  viscus.  By 
slow  degrees  the  bulk  of  the  swelling  increases, 
until,  if  no  support  or  ‘ truss  ’ ho  used,  veiy 
large  tumours  are  formed. 

Classification. — The  most  practical  classifi- 
cation of  hernial  protrusions  is  based  upon  the 
usual  triple  division  of  the  abdomen  into  regions, 
namely,  the  epigastrium,  mesogastrium,  and  hy- 
pogastrium. 

1.  Protrusions  in  the  epigastric  region  are  very 
rare.  Theyar e^a)  Diaphragmatic;  aad  (b) Epigas- 
tric. The  first  is  due  either  to  relaxation  of  the 


HERNIA. 


tissue  of  the  diaphragm  muscle,  or  to  its  lacera- 
tion. In  some  cases  congenital  deficiency  of  the 
muscle  is  the  primary  cause ; in  others  the 
natural  openings  in  the  muscle  become  dilated. 
Signs  of  this  hernia  are  very  obscure  : but  when 
the  protrusion  depends  upon  laceration  of  the 
muscle,  the  occurrence  of  a recent  injury  may 
excite  suspicion,  when  associated  with  abnormal 
sounds  in  the  thorax. 

Epiqastric  hernia  escapes  at  the  region  formed 
by  the  cartilages  of  the  false  ribs  on  either  side 
of  the  linea  alba.  It  is  very  rare,  and  as  the 
abdominal  orifice  of  the  sac  is  usually  large, 
the  hernia  is  eas'ly  reduced. 

2.  The  hernias  in  the  mesogastrium  are  (a) 
Ventral;  (b)  Umbilical;  and  (c)  Lumbar.  The 
term  ventral  is  given  to  any  hernial  protrusion 
escaping  through  abnormal  openings  in  the  walls 
of  the  abdomen,  to  which  no  special  name  is 
given.  They  aro  seen  in  the  region  of  the  linea 
alba,  above  the  umbilicus,  but  most  frequently 
belotv;  in  the  line  of  the  linea  semilunaris  ; and 
even  opposite  the  muscular  walls.  Commonly  of 
traumatic  origin,  their  nature  is  clearly  shown  by 
the  ready  manner  in  which  the  protruded  viscus 
can  be  pressed  sack  into  the  abdomen.  They 
sometimes  enst  o upon  the  weakening  of  the 
walls  after  distension,  or  upon  the  loss  of  tissue 
following  abscess. 

Umbilical  hernia  is  met  with  at  all  ages  and 
in  both  sexcj.  It  forms  a tumour  at  the  site 
of  the  umbilibusin  the  first  instance,  and  gra- 
dually descends  over  the  linea  alba  as  its  bulk 
increases.  < erv  soon  after  birth  this  variety  of 
hernia  appears.  The  protrusion  takes  place  at 
the  um  llical  ring,  and  pushing  before  it  the 
peritoneum,  an  acquired  hernial  sac  is  formed. 
To  prevent,  therefore,  the  development  of  the  sac 
in  infancy,  and  to  assist  the  closure  of  the  ring 
in  the  linea  alba,  a slightly  convex  disc  of  cork, 
enclosed  in  washleather,  should  be  strapped 
over  the-umbilical  aperture.  The  prognosis  of 
infantile  umbilical  hernia  is  favourable,  for  the 
aperture  closes  with  age,  and  the  tissues  continue 
firm. 

In  adult  life  this  kind  of  hernia  is  frequent 
in  fat  individuals.  The  tumour  often  acquires 
enormous  proportions.  Its  contents  consist  of 
small  intestine  and  omentum,  with  not  uncom- 
monly a portion  of  the  transverse  colon.  Accu- 
mulations of  fecal  matter  therein  often  give  rise 
to  obstruction,  and  the  symptoms  arising  in  con- 
sequence of  this  state  more  or  less  resemble 
those  of  strangulated  small  intestine.  A correct 
diagnostication  of  their  cause  may  usually,  how- 
ever, be  arrived  at  from  the  history  of  the  attack, 
the  comparative  mildness  of  the  malady,  and  the 
alleviation  of  the  symptoms  by  exciting  the  action 
of  the  bowels.  The  contents  of  this  form  of 
hernia,  when  of  long  standing,  often  become 
adherent  or  bound  by  bands  to  the  sac,  in  which 
state  they  remain  permanently  irreducible. 

hen  the  protruded  viscus  can  be  entirely 
reduced  within  the  abdominal  cavity,  a suitable, 
well-fitting  truss  should  be  worn  constantly,  and, 
if  irreducible,  one  adapted  to  the  circumstances 
ef  the  case  must  be  used. 

Lumbar  hernia  takes  place  in  the  loins.  It 
is  a very  rare  variety,  and  usually  occurs  as  the 
risnlt  of  ; u injury. 


639 

3.  The  hernia  in  thehvpogastrium  are  themost 
numerous  and  the  most  common.  They  include 
(a)  Inguino-scrotal  or  Inguino-labial.  above  Pou- 
part's  ligament;  ( b ) Femoral,  below  Poupart's 
ligament  ; (c)  protrusions  through  the  apertures 
of  the  pelvis  in  front,  beneath  the  horizontal 
ramus  of  the  pubes  — Obturator;  ( d ) beneath 
the  arch  of  the  pubes — Perineal ; (e)  Pudendal  \ 
(/)  Vaginal ; and  ( g ) behind,  through  the  ischiatic 
notch — Ischiatic. 

Inguinal  hernia  is  seen  at  all  ages  and  in  both 
sexes.  The  following  varieties  are  described — 
the  oblique  or  external ; and  the  direct  or  internal. 
In  the  first,  the  orifice  of  the  sac  is  outside  the 
course  of  the  internal  epigastric  artery  ; in  the 
second  it  is  internal  to  the  same  vessel.  When 
the  protrusion  forming  an  inguinal  hernia  does 
not  descend  below  the  inguinal  canal  it  is  termed 
a bubonocele ; but  when  it  occupies  the  scrotum  or 
labium  it  forms  an  inguino-scrotal  or  inguino- 
labial  tumour.  The  essential  difference  between 
the  inguinal  hernia  of  youth  and  of  middle  age  is 
due  to  the  constitution  of  the  sac  which  encloses 
the  protrusion.  From  infancy  to  early  adult  life 
protruding  viscera  escape  from  the  abdomen  into 
a serous  sheath,  continuous  with  the  parietal 
peritoneum,  the  vaginal  process  of  that  mem- 
brane, which  extends  into  the  scrotum  or  labium. 
In  middle  life  and  afterwards  the  parietal  peri- 
toneum is  thrust  through  the  apertures  or  weak 
points  in  the  abdominal  walls  bv  the  protruding 
viscus.  In  this  way  two  distinct  kinds  of  hernial 
sac  are  formed ; the  first  being  due  to  a congenital 
defect  ; the  second,  to  a mechanical  and  ac- 
quired cause.  In  practice,  it  is  very  important 
to  bear  these  distinctions  in  mind.  In  the  first 
kind  a truss  is  applied  to  prevent  the  passage  of 
the  viscus  into  the  sheath,  in  the  hope  that  by 
this  means  its  walls  may  unite  and  its  orifice 
contract — in  fact,  to  assi-t  nature  in  accom- 
plishing that  condition  the  failure  of  which  per- 
mits the  protrusion  to  take  place.  Put,  in  the 
second,  a truss  is  used  to  prevent  the  protruding 
viscus  pushing  the  peritoneum  before  it  and  so 
forming  for  itself  a sac.  Thus,  it  the  develop- 
ment of  the  sac  be  arrested,  there  can  be  no 
hernial  tumour. 

Inguinal  hernfe  occupy  the  inguinal  canal, 
and  are,  therefore,  in  relation  with  the  spermatic 
cord  of  the  male  and  the  round  ligament  of 
the  female.  They  escape  from  the  canal  through 
the  external  abdominal  ring  into  the  scrotum 
or  labium.  The  neck  of  the  tumour  is  always 
therefore  above  Poupart’s  ligament,  and  to  the 
inner  side  of  the  external  pillar  of  the  external 
abdominalring.  This  anatomical  fact  constitutes 
the  main  distinction  between  inguinal  and  femoral 
hernia. 

Femoral  hernia  forms  a tumour  at  the  inner 
and  upper  part  of  the  thigh,  immediately  be- 
low the  pubic  attachments  of  Poupart  s ligi- 
ment.  Those  structures  are  in  immediate  re- 
lation with  the  neck  of  the  sac.  The  protrusion 
escapes  at  the  femoral  aperture,  the  site  of  the 
entrance  of  the  lymphatic  vessels  of  the  thigh  to 
the  abdominal  cavity.  The  neck  of  the  sac  is 
therefore  to  the  inner  side  of  the  sheath  of  the 
femoral  vessels,  although,  in  proportion  to  the 
bulk  of  the  tumour,  its  body  may  overlie  it,  and 
even  extend  upwards  above  Poupart's  ligament 


HERNIA. 


640 

and  outwards  towards  the  crest  of  tho  ilium. 
The  sac  of  a femoral  hernia  is  always  an  acquired 
formation.  Hence  the  importance  of  wearing  a 
truss  after  observing  tho  slightest  indication  of 
a femoral  protrusion.  Tor  if  the  yielding,  re- 
laxed, parietal  peritoneum  be  supported  at  the 
crural  aperture  by  a well-adjusted  pad,  a visceral 
hernia  must  be  avoided,  as  there  will  be  no  sac 
into  which  it  can  escape.  In  other  words,  arrest 
the  development  of  the  sac  and  there  can  be  no 
hernia. 

To  discriminate  between  a femoral  and  an  in- 
guinal hernia,  place  the  index  finger  upon  the 
spinous  process  of  the  pubes  ; if  the  neck  of  the 
tumour  is  to  its  outer  side,  and  the  whole  length 
of  Poupart’s  ligament  can  be  traced  above  it,  a 
femoral  hernia  exists.  Should  precisely  the  con- 
verse conditions  be  ascertained,  the  tumour  will 
depend  upon  an  inguinal  protrusion.  Another 
method  for  diagnosis  is  the  direct  and  careful 
examination  of  the  site  of  the  femoral  aperture. 
If  it  is  clearly  and  distinctly  tangible  and  well- 
defined,  it  cannot  be  occupied  by  a hernial  pro- 
trusion. 

This  hernia  is  most  common  in  the  adult 
female.  It  has  been  developed  before  ten  years  of 
age,  is  rare  between  that  age  and  twenty,  but  very 
frequent  in  persons  between  twenty  and  forty 
years  old.  Prolific  women  are  more  frequently  the 
subjects  of  this  hernia  than  tho  single  and  sterile. 

Obturator  hernia  escapes  from  tho  pelvis 
through  the  thyroid  foramen,  and  traverses  the 
canal  normally  occupied  by  the  obturator  nerve 
and  vessels.  It  is  rarely  met  with.  A fulness, 
rather  than  a tumour,  is  produced  by  the  pro- 
trusion at  the  inner  or  pubic  region  of  the  thigh, 
beneath  the  pectineus  muscle,  and  accompanied 
by  a peculiar  numbness  and  pain,  which  may  be 
traced  to  the  distribution  of  the  filaments  of  the 
obturator  nerve.  The  lives  of  patients  have  been 
lost  in  consequence  of  overlooking  these  hernfe  ; 
the  cause  of  death  being  only  ascertained  post 
mortem. 

Perineal,  pudendal , vaginal,  and  ischiatic  her- 
nias are  very  rarely  seen.  The  name  assigned  to 
each  indicates  the  locality  in  which  the  tumour 
is  formed,  and  for  a special  description  of  them, 
the  reader  must  be  referred  to  monographs  on 
the  subj  ect  of  this  article. 

Effects  and  Theatment. — We  must  next,  as 
briefly  as  possible,  describe  generally  the  various 
morbid  conditions  which  the  hernia  itself  may 
undergo,  and  the  means  by  which  fatal  conse- 
quences from  such  conditions  may  be  averted. 

All  hernial  protrusions  are  reducible  or  irre- 
ducible ; that  is,  they  can  be  restored  to  their 
normal  situation,  or  they  may  be  permanently 
confined  to  the  region  in  which  they  are  pro- 
truded. 

The  treatment  of  all  reducible  hernfe  consists 
in  the  employment  of  means  to  prevent  the  es- 
cape of  the  protrusion.  To  effect  this  object 
various  kinds  of  bandages  or  trusses  have  been 
devised.  Each  kind  of  hernia  requires  its  special 
form  of  truss,  and  every  individual  should,  as  far 
as  practicable,  obtain  a truss  well  fitted  to  his 
or  her  configuration.  The  essentials  of  a good 
truss  consist  in  the  spring  having  sufficient 
power  to  support  the  hernia  and  prevent  its 
escape,  while  it  should  not  be  so  strong  as  to 


injure  the  structures  about  the  abdominal  rings. 
The  pad  should  be  firm,  of  a shape  suitable  to 
the  case,  and  of  a size  not  inconvenient  to  the 
wearer. 

The  irreducibility  of  a hernia  depends  on  its 
bulk,  adhesions,  and  special  anatomical  con- 
ditions. Under  such  circumstances  special  ban- 
dages must  be  employed. 

But  other  much  more  important  morbid  states 
of  the  protruded  viscus  than  the  above,  cause 
impediments  to  the  reduction  of  a hernia,  namely 
— 1,  constriction  by  the  tissues  around  the  orifice 
of  the  sac;  2,  accumulation  of  fecal  matter  in 
the  protruded  viscus;  3,  inflammation  of  the 
hernia  ; and  4,  strangulation  when  a part  of  the 
alimentary  canal  forms  the  hernia. 

1.  Those  hernfe— for  example,  the  inguinal 
— which  pass  through  openings  in  the  muscular 
walls  of  the  abdomen,  are  liable  to  constriction 
from  contraction  of  the  muscular  tissue.  In- 
guinal hernfe  of  long  standing,  and  more  than 
ordinary  bulk,  are  very  prone  to  become  irredu- 
cible in  consequence  of  muscular  contraction. 
Such  cases  are  well  adapted  to  illustrate  the 
effects  of  anaesthetics,  and  their  influence  on 
muscular  irritability.  If  the  patient  be  placed 
under  the  full  influence  of  chloroform,  the  ab- 
dominal muscles  become  relaxed,  and  the  hernia 
quickly  reduced. 

2.  Those  hernial  protrusions  formed  of  large 
intestine,  such  as  occur  at  the  umbilicus,  fre- 
quently become  irreducible  from  accumulations 
of  stercoraceous  substances.  In  these  cases  ene- 
mata,  and  even  purgative  medicines,  frequently 
relieve  the  symptoms. 

3.  Inflammation  excited  in  an  omental  pro- 
trusion may  cause  temporary  and  even  perma- 
nent irreducibility.  Local  and  constitutional 
symptoms  of  a rather  severe  type  sometimes 
attend  such  cases.  The  usual  methods  adopted 
to  induce  resolution  must  be  employed. 

4.  A morbid  state  of  the  protruded  bowel 
termed  strangulation  has  next  to  be  described. 
A patient  the  subject  of  this  state  remains  in 
the  greatest  danger  to  life  so  long  as  the  exci- 
ting cause,  the  constriction  of  the  bowel,  exists. 
Hour  by  hour  that  danger  increases,  and  although 
rare  instances  of  recovery  might  be  quoted  after 
the  continuance  of  strangulation  for  many  hours, 
the  majority  of  patients  die  because  the  intestine 
was  not  liberated  early  enough.  A hernia  is  de- 
scribed as  strangulated  when  subject  to  a con- 
striction which  at  first  impedes,  and  sooner  or 
later  arrests  the  circulation  of  the  blood  in  its 
capillary  vessels.  The  passage  of  stercoraceous 
material  is  necessarily  stopped.  The  local  and 
constitutional  symptoms  are  strikingly  charac- 
teristic. Very  frequently  the  first  symptom  is 
vomiting,  unaccompanied  by  any  alvine  evacua- 
tion. The  vomiting  continues,  and  is  excited 
by  ingesta.  This  state  is  probably  due  to  mere 
obstruction  of  the  alimentary  canal,  but  it 
ought  always  to  excite  the  anxious  solicitude  of 
the  medical  attendant,  to  ascertain  whether  the 
patient  has  any  outward  signs  of  a hernial  tumour. 
He  must  examine  those  regions  at  which  pro 
trusions  commonly  occur,  and  never  rest  content 
with  the  statements  of  the  sufferer.  At  first 
the  pulse  is  not  affected  in  a very  marked  way, 
but  as  vomiting  continues  the  heart  beats  more 


HERNIA. 

rapidly,  whilst  the  pulse  becomes  ■weaker  and 
tontracted.  The  surface,  especially  that  of  the 
extremities,  becomes  cold  ; the  countenance  aged 
and  anxious;  the  visage,  lips,  and  hands  shrivelled 
and  bluish ; the  prostration  extreme.  The  tu- 
mour is  painful  when  touched,  and  it  may  have 
increased  in  size  and  become  tense.  All  these 
facts  indicate  progressive  morbid  changes  in  the 
tissues  of  the  strangulated  bowel,  as  well  as  in 
that  part  of  the  alimentary  canal  above  the 
hernia.  Besides  the  mere  act  of  vomiting  all 
ingesta,  the  characters  of  the  fluid  vomited  must 
be  carefully  noted.  Usually,  at  first,  it  is  the 
food  last  swallowed,  more  or  less  digested  and 
mingled  with  bile;  in  the  second  stage  it  becomes 
yellowish  and  greenish;  and  at  last  it  is  sterco- 
raeeous,  that  is,  offensive  to  smell,  of  a brownish 
colour  and  froth}-,  and  often  in  great  quantity. 
Now  the  only  treatment  of  these  urgent  symp- 
toms consists  in  the  liberation  of  the  bowel  by 
surgical  means.  In  the  mean  time  palliatives 
may  be  employed,  opium  administered  by  the 
mouth,  enemata  injected,  local  applications  of 
ice  used,  and  gentle  taxis  applied. 

John  Birkett. 

HERNIA  CEREBRI.  See  Brain,  Malfor- 
mations of;  and  Skull,  Diseases  of. 

HERPES  {spiral,  I creep).  Synon.  : Fr. 
Herpes ; Ger.  Flechte. 

Definition. — A term  applied  to  an  eruption  of 
vesicles  on  an  inflamed  patch  of  integument. 

^Etiology. — A.  predisposing  cause  of  herpes  is 
the  gouty  or  rheumatic  diathesis.  It  is  often 
excited  by  chill  or  by  irritation  of  a mucous 
membrane — of  the  air-passages  in  the  case  of 
herpes  labialis,  and  of  the  urinary  passages  in 
herpes  prteputialis. 

Varieties  and  Symptoms. — The  commonest 
forms  of  this  disease  are  herpes  zoster,  herpes  la- 
bialis, and  herpes  prceputialis  ; to  which  may  be 
added  herpes, facialis,  herpes  collaris,  herpes  crura- 
iis,  and  so  forth.  In  herpes  labialis  and  praputi- 
alis,  the  inflamed  patch  is  generally  single ; but  in 
the  other  forms  the  patches  may  range  from  five 
to  ten  in  number,  and  vary  in  size  from  a small 
blotch,  scarcely  an  inch  in  diameter,  to  one  of 
three  or  four  inches.  The  patches  follow  the 
course  of  distribution  of  the  nerves ; and  on  the 
trunk  of  the  body  form  a kind  of  festoon,  extend- 
ing from  the  spine  behind  to  the  middle  line 
in  front.  This  is  especially  the  ease  in  herpes 
zoster,  likewise  called  zona  and  shingles,  where 
the  blotches,  following  the  course  of  one  or  more 
intercostal  nerves,  form  a half  belt  or  circle 
around  the  waist.  The  eruption  of  herpes  is  uni- 
lateral. It  has  a regular  course  of  from  ten  to 
twenty  days. 

The  vesicles  of  herpes  are  developed  in  groups, 
ranging  in  number  from  two  or  three  to  twenty 
or  thirty,  and  in  size  from  that  of  the  head  of  a 
pin  to  that  of  a small  pea.  The  fluid  contained 
within  them  is  at  first  transparent ; it  then  be- 
comes opalescent,  opaque,  purulent,  and  some- 
times purplish  from  admixture  with  blood  ; and 
finally  the  eruption  terminates  in  a scab  more  or 
less  dark-coloured,  and  more  or  less  deeply  im- 
oedded  in  the  skin,  which  often  leaves  at  its  fall 
» permanent  cicatrix. 

Herpes  is  accompanied  with  a burning,  ting-  I 

41 


HICCUP  OR  HICCOUGH.  641 

ling,  and  pricking  sensation,  and  occasionally 
with  severe  neuralgic  pains.  The  neuralgia  may 
either  precede  or  follow  the  eruption  ; and  occa- 
sionally it  is  intense  and  of  long  duration.  See 
Dr.  Sangster ; Lancet,  vol.  i.  1882. 

Treatment. — The  treatment  of  herpes  is  both 
constitutional  and  local.  In  slight  cases,  as  the 
eruption  runs  a regular  course,  and  tends  to 
spontaneous  cure,  no  constitutional  treatment  is 
necessary.  If  thought  desirable,  treatment  should 
be  restricted  to  regulating  the  digestive  and  assi- 
milative functions  ; strengthening  nerve-power  ; 
and,  where  severe  pain  or  neuralgia  is  present., 
administering  quinine  or  sedatives.  Locally, 
dredging  with  flour  or  some  absorbent  powder 
affords  relief ; and  especially  the  application  of 
a lotion  of  oxide  of  zinc  and  lime-water.  Over 
these  should  be  placed  a sheet  of  cotton-wool ; 
and  the  latter  must  be  kept  in  place  by  means 
of  a light  bandage.  In  very  painful  cases,  the 
subcutaneous  injection  of  morphia  may  be  re- 
quired, or  the  application  of  anodyne  liniments. 

Erasmus  Wilson. 

HETEROLOGOUS  (erepor,  other,  and 
\6yos,  nature).  — A word  used  to  characterise 
any  morbid  product,  whether  fluid  or  solid,  which 
is  different  in  composition  or  structure  from  the 
normal  fluids  or  solids  of  the  body. 

HETEROMORPHOUS  {erepos,  other,  and 
poorp1)],  form). — Applied  to  new  formations  which 
are  different  in  form  and  structure  from  the 
normal  tissues. 

HETEROTOPOUS  (erepoy,  other,  and 
riiros,  a place). — Misplaced.  A term  applied  to 
the  appearance  either  of  a normal  tissue  in  an 
unnatural  situation —for  example,  of  hairs  on 
mucous  surfaces ; nr  of  morbid  growths  in  un- 
usual places — for  instance,  of  epithelioma  in  ner- 
vous tissue. 

HICCUP  or  HICCOUGH.— Synon.  : Sin- 
gultus; Fr.  Hoquet ; Ger.  dcr  Schluckcn. 

Description. — Hiccup,  according  to  physiolo- 
gists, is  a sudden  spasmodic  descent  of  the 
diaphragm  accompanied  by  a spasmodic  closure 
of  the  glottis,  the  characteristic  noise  being 
caused  by  the  incoming  column  of  air  striking 
against  the  partially  closed  glottis.  The  as- 
sumption of  a spasmodic  closure  of  the  glottis  in 
hiccup  seems  scarcely  warrantable.  Normally 
the  descent  of  the  diaphragm  in  each  respiratory 
act  is  accompanied  by  a contraction  of  the  pos- 
terior crico-arytsenoid  muscles,  which  causes  an 
outward  rotation  of  the  arytaenoid  cartilages,  and 
a dilatation  of  the  glottic  aperture.  The  dia- 
phragmatic and  the  laryngeal  acts  keep  time 
together,  and  in  health  the  rhythm  of  sixteen  or 
eighteen  to  the  minute  is  maintained.  If,  how- 
ever, the  diaphragm  give  a sudden  descending 
jerk  irrespective  of  any  respiratory  need,  as  is 
the  case  in  hiccup,  and  this  jerk  occur  at  a time 
when  the  dilators  of  the  glottis  are  not  acting, 
a noise  will  be  produced  by  the  rush  of  air 
through  the  insufficiently  widened  glottic  aper- 
ture. It  seems  certainly  possible  to  account  for 
the  noise  of  hiccup  by  the  mere  fact  of  the 
descent  of  the  diaphragm  occurring  when  the 
glottis  is  not  properly  open.  The  noise  is  not 
a constant  phenomenon,  and  during  an  attack  of 


>12  HICCUP  OR  HICCOUGH, 
hiccup  it  never  occurs  during  ordinary  inspira- 
tion. or  without  the  spasmodic  action  of  the 
diaphragm,  although  the  latter  phenomenon  may 
occur  without  the  former. 

■(Etiology. — Hiccup  may  be  produced  by  any 
irritation  of  the  phrenic  nerve — its  origin,  its 
course,  or  the  ultimate  twigs  which  are  distributed 
to  the  under  surface  of  tile  diaphragm.  Undue 
distension  of  the  stomach  by  being  overfilled  with 
food  or  drink,  or  by  an  accumulation  of  wind  due 
to  faulty  digestion,  is  the  most  common  cause  of 
hiccup.  Its  occurrence  from  this  cause  is  far 
more  common  in  children  than  in  adults.  Con- 
vulsions and  muscular  spasms  generally  are 
more  easily  caused  in  the  young,  and  hiccup  in 
this  respect  follows  the  ordinary  rule.  Hiccup 
is  produced  by  direct,  or  by  reflex  irritation. 
With  many  persons  the  introduction  of  hot 
spiced  or  peppery  foods  into  the  stomach  imme- 
diately produces  hiccup,  and  the  writer  knows 
one  or  two  persons  in  whom  hiccup  is  produced 
by  the  passage  of  hot  fluids  through  the  pharynx. 
It  is  a frequent  symptom  in  peritonitis  when  the 
peritoneal  covering  of  the  diaphragm  becomes 
affected.  It  sometimes  occurs  in  cases  of  cancer 
of  the  stomach ; occasionally,  perhaps,  from  over- 
distension of  the  organ,  but  more  often-  from  an 
extension  of  the  cancerous  disease  to  the  peri- 
toneal surface  of  the  stomach.  It  is  occasionally 
a troublesome  symptom  during  convalescence  in 
cholera,  and  is  often  accompanied  by  eructations 
of  wind,  and  sometimes  by  vomiting.  If  hiccup 
occur  with  any  persistency  in  the  course  of 
typhoid  fever,  it  is  often  an  indication  of  per- 
foration and  the  onset  of  general  peritonitis. 
Although  most  frequently  a symptom  of  gastric 
or  abdominal  disturbance,  hiccup  occasionally 
occurs  as  a true  neurosis.  It  may  accompany 
hydrocephalus  or  meningitis,  and  is  then  due 
probably  to  an  implication  of  the  cerebral  origin 
of  the  phrenic  nerve.  Cases  of  obstinate  hic- 
cupping in  hysterical  subjects  have  been  recorded, 
and  cases  of  paroxysmal  hiccup  have  been  ob- 
served by  Liveing,  Prichard,  and  others,  which 
have  been  regarded  as  instances  of  modified 
epilepsy. 

Treatment. — The  treatment  of  hiccup  will 
depend  upon  the  cause.  An  emetic  to  empty  the 
stomach,  or  a stimulant  to  increase  its  natural 
peristaltic  action,  will  often  give  relief.  If  we 
can  succeed  in  producing  a forcible  action  of  the 
diaphragm,  we  may  often  succeed  in  curing  it, 
as  it  were,  of  the  trick  of  spasmodic  action. 
Attempts  to  count  a hundred  without  drawing 
breath,  or  to  hold  the  breath  for  a minute,  are 
familiar  remedies  for  hiccup,  and,  by  producing 
a feeling  of  suffocation,  and  necessitating  a vio- 
lent descent  of  the  diaphragm,  they  are  often 
successful.  Warm  applications  or  counter- 
irritation applied  to  the  diaphragmatic  region  or 
over  the  cervical  spine,  may  occasionally  give 
relief.  Pressure  upon  the  trunk  of  the  phrenic 
nerve  by  means  of  the  finger  applied  over  the 
scalenus  anticus  muscle,  is  said  also  to  have  given 
relief  occasionally  in  obstinate  cases.  Amongst 
the  drugs  wdiich  have  been  recommended  for  the 
relief  of  hiccup  are  chloroform  (administered in- 
fernally), either  alone  or  combined  with  opium, 
camphor  in  the  form  of  a spirit  solution,  in  doses 
if  twenty  drops  and  upwards,  valerianate  of  zinc, 


HORNS. 

belladonna,  bromide  of  potassium,  musk,  art- 
acids, 'and  in  very  severe  cases  morphia  adminis- 
tered hypodermically.  G.  V.  Poonp.. 

HIPPURIA  GViroj,  a horse,  and  ohpor, 
urine). — The  condition  of  the  urine  in  which  it 
contains  hippuric  acid  in  excess.  See  Urine, 
Morbid  Conditions  of. 

HISTRIONIC  SPASM  (liistrio,  an  actor). 

A synonym  for  facial  spasm,  so  called  on  account 
of  the  contortions  of  the  face  to  which  th:6 
affection  gives  rise.  See  Facial  Spasm. 

HIVES. — A popular  term  for  chicken-pox. 
See  Chicken-pox. 

HOARSENESS  (Sax.,  has,  having  a rough 
voice). — Roughness  of  the  voice,  due  to  disease 
or  disorder  connected  with  the  larynx.  See 
Voice,  Disorders  of. 

HOBNAIL  LIVER. — A name  given  to  a 
cirrhotic  liver,  when  it  presents  small  promi- 
nences on  its  surface,  resembling  hobnails.  See 
Liveii,  Cirrhosis  of. 

HODGKIN’S  DISEASE. — A synonym  for 
Lymphoma.  See  Lymphoma. 

HOMBHRG,  in  Germany.  Common  salt 
waters.  See  Mineral  Waters. 

HOMICIDAL  INSANITY.  See  Criminal 
Irresponsibility  ; and  Insanity,  Impulsive. 

HOMOLOGOUS  (<5 fibs,  like,  and  \6yos,  na- 
ture).— Jn  pathology  this  term  is  applied  to  new 
growths  presenting  the  same  structure  as  nor- 
mal tissues,  such  as  fatty  or  fibrous  tumours. 

HOOPING-COUGH.  See  Whooping 

Cough. 

HORDEOLUM  (Jiordeum,  a barley-corn). 
A synonym  for  stye.  See  Stye. 

HORN-POX. — A popular  term  for  a variety 
of  chicken-pox.  See  Chiceex-pgx. 

HORNS — Synon.  : Cornua.  Definition. — 
Horns  are  epidermic  and  epithelial  formations, 
consequent  on  hypertrophy  of  the  horny  product 
of  the  integument. 

Description. — Horns  generally  occur  singly. 
Sometimes  they  attain  a size  of  several  inches  in 
length  and  in  circumference.  They  have  been 
met  with  on  all  parts  of  the  body,  more  particu- 
larly on  the  scalp,  the  face,  the  glans  penis,  and 
the  glans  clitoridis. 

Pathology. — When  the  inspissated  product  of 
the  follicles  of  the  skin,  consisting  of  laminated 
epithelium  and  sebaceous  matter,  is  exposed  to 
the  air,  it  dries,  becomes  hard  and  transparent, 
and  is  in  fact  converted  into  a mass  having  most 
of  the  properties  of  horn.  This  is  the  prin- 
cipal source  of  the  horns  of  the  integument — an 
accumulation  of  the  contents  of  a follicle ; the 
protrusion  of  that  substance  through  the  dila- 
ted aperture  of  the  follicle,  sometimes  through  a 
large  opening  resulting  from  atrophy  or  ulcera- 
tion ; its  dessication  by  the  atmosphere  ; and  its 
growth  by  continued  additions  to  its  base.  lieing 
essentially  the  protrusion  of  a soft  substance 
through  a constricted  aperture,  the  surface  of  tbs 


HORNS. 

Lorn  will  be  modelled  in  figure  by  the  shape  of 
that  aperture  ; in  consequence  of  desiccation,  its 
shaft  will  be  smaller  than  its  base  ; and  it  will  be 
liable  to  be  bent  or  twisted  in  the  operation  ot' 
protrusion.  Hence  these  horns  are  generally  curved 
or  twisted,  and  have  been  compared  to  the  beak 
of  a bird,  or  the  horn  of  the  goat.  A section  of  the 
horn  affords  similar  evidence  of  its  manner  of 
formation  and  growth,  it  being  always  laminated 
n structure. 

Another  kind  of  horn  is  sometimes  met  with 
on  the  glans  penis  and  clitoridis,  and  is  the  pro- 
duct of  hypertrophy  of  the  papillae.  This  form  of 
errowth  is  fibrous  in  structure,  like  a wart,  which 
in  fact  it  closely  resembles;  whilst  in  the  same 
situation  concreted  masses  are  occasionally  formed, 
constituted  by  a combination  of  both  processes, 
namely,  papillary  hypertrophy  and  accumulation 
of  follicular  substance.  There  is,  however,  an 
important  difference  between  the  two  kinds  of 
horn,  the  sebaceous  and  the  epidermic,  namely, 
that  the  former  is  the  mere  result  of  increased 
activity  of  function,  whilst  the  latter  is  the  con- 
sequence of  hypersemia  or  inflammation. 

Treatment. — Horny  matter  being  susceptible 
of  disintegration  by  moisture,  the  sebaceous  horn 
may  be  so  thoroughly  softened  by  envelopment 
.n  a waterproof  covering,  or  by  a poultice,  as 
to  be  easily  broken  away  at  its  base.  The  folli- 
cular bed  from  which  it  has  been  removed  may 
then  be  cleared  by  a small  scoop,  when  the  sac  will 
contract  and  close.  Sometimes  it  maybe  thought 
desirable  to  sponge  the  surface  with  a solution  of 
chloride  of  zinc  or  sulphate  of  copper ; but  opera- 
tion by  the  knife  seems  quite  uncalled  for.  In 
the  instances  of  epidermic  and  epithelial  horn, 
however,  it  will  be  necessary  to  have  recourse  to 
caustics,  especially  potassa  fusa ; and  when  the 
case  evinces  great  obstinacy,  or  where  an  epi- 
theliomatous  degeneration  is  suspected,  the  use 
rf  the  knife  becomes  essential. 

Erasmus  Wilson. 

HORRIPILATION  ( horreo , I bristle  up, 
and  pilus,  a hair). — A sensation  of  chilliness  and 
creeping,  the  hairs  appearing  to  stand  on  end. 

HOSPITALS. — The  subjects  having  rela- 
tion to  hospitals  will  be  treated  of  under  the 
! following  heads  : — I.  Hospitalism  ; II.  Hos- 
pitals, Administration  of ; JII.  Hospitals,  Con- 
struction of;  IV.  Nursing  ; and  V.  Nurses, 
Training  of.  The  reader  is  referred  to  these 
several  articles. 

HOSPITALISM. — The  term  ‘ Hospitalism  ’ 
was  introduced  into  medical  literature  by  Sir  J. 
Simpson  ( Edinburgh  Medical  Journal,  March, 
1869), but,  as  far  as  the  writer  can  see.  no  exact  de- 
finition of  it  was  given  by  its  author.  It,  however, 
was  evidently  intended  to  signify  ‘the  hygienic 
' evils  which  the  system  of  huge  and  colossal  hos- 
pital edifices  has  hitherto  been  made  to  involve’ 
— lo  use  Sir  J.  Simpson’s  own  words.  These  evils 
.Appeared  to  him  so  evident,  and  so  necessarily  con- 
nected with  the  size  of  the  hospital,  that  he  taught 
and  in  fact  the  sole  object  of  bis  papers  was 
o teach)  that  our  system  ought  to  be  revolution- 
sed — ‘hospitals  changed  from  being  crowded 
Maces,  with  a layer  of  sick  on  each  flat,  into 
illagcs  or  cottages,  with  one,  or  at  most  two 
'atients  in  each  room — the  village  constructed  of 


HOSPITALISM.  643 

iron  instead  of  brick  or  stone,  and  taken  down 
and  rebuilt  every  few  years.’ 

Mr.  Erichsen  has,  to  some  oxtent,  accepted  the 
teaching  of  Sir  J.  Simpson,  though  he  allows 
that  some  of  it  is  very  questionable.  His  tract 
on  the  subject  of  Hospitalism  has  the  advantage 
of  being  written  in  a more  sober  style  than  Sir 
J.  Simpson's,  and  also  of  putting  the  question  in 
a clearer  light. 

By  the  term,  1m  says,  ‘ is  meant  a general 
morbid  condition  of  the  building,  or  of  its  atmo- 
sphere, productive  of  disease.  . . . Doubtless,’ 
says  Mr.  Erichsen,  ‘ all  the  septic  diseases  that 
are  met  with  in  hospitals  may  be  encountered  in 
the  practice  of  surgeons  out  of  these  institutions, 
but  they  are  unquestionably  infinitely  more  com- 
mon in  hospital  than  in  private  practice,  and  their 
causes  are  certainly  different.’ 1 The  writer 
believes,  on  the  contrary,  that  if  a hospital  bo 
properly  managed  there  is  no  general  morbid 
condition  of  the  building — that  there  is  no  reason 
for  thinking  that  septic  diseases  are  more  com- 
mon relatively  in  hospitals  than  out  of  them, 
and  that  their  causes  are  identical  wherever  they 
occur. 

And  if  the  term  Hospitalism  is  to  be  taken  in 
the  sense  in  which  Sir  J.  Simpson  evidently  in 
tended,  that  is,  as  meaningto  convey  the  idea  that 
there  is  an  inevitable  tendency  to  the  generation 
of  septic  disease  in  large  hospitals,  that  that 
tendency  becomes  greater  as  the  size  of  the 
hospital  is  increased,  and  that  it  increases  as  tho 
hospital  grows  older,  the  writer  has  no  hesita- 
tion in  saying  that  there  is  no  such  thing  as 
Hospitalism.  No  doubt  the  aggregation  of  the 
sick  and  wounded  in  hospitals  is  a cause  of  dan- 
ger, and  much  care  and  vigilance  is  required  to 
keep  hospitals  healthy.  But  the  clangers  are-in 
no  sense  peculiar  to  hospitals.  The  surgical 
affections  which  spring  up  in  hospitals — ery- 
sipelas, phagedsena,  pyaemia,  and  allied  affections 
— all  of  them  prevail  in  private  practice,  and,  as 
far  as  has  been  shown,  prevail  equally.2  Further, 
although  the  perfect  publicity  of  ourhospital  prac- 
tice enables  us  to  obtain  tolerably  accurate  data 
for  a comparison  of  the  experience  of  the  smaller 
and  larger  hospitals  of  this  and  other  towns,  no 
one  has  ever  seen  the  least  reason  for  believing 
that  the  smaller  are  in  any  respect  healthier  than 
the  larger,  while  several  of  the  hospitals  that 
have  been  longest  built  are  renowned  for  their 
healthy  condition,  and  in  many  large  hospitals, 
parts  of  which  are  ancient  and  other  parts  modern, 
the  former,  if  equally  or  better  constructed,  arc 
(under  similar  conditions  of  cases  and  manage- 
ment) as  healthy  or  more  healthy  than  the  parts 
more  recently  built. 

The  subject  is  not  one  which  can  be  passed 
over  as  dealing  with  an  insignificant  question,  or 
one  of  verbal  interest  only.  The  doctrines  which 
Sir  James  Simpson  taught  led  him  to  deprecate 

1 On  Hospitalism,  p.  37. 

2 It  is  not.  of  course,  meant  that  pyiemia,  for  instance, 
is  seen  as  often  in  private  as  in  hospital  practice,  because 
its  causes  are  less  often  met  with  in  the  former  than  the 
latter;  but,  if  due  allowance  be  made  for  this  obvions  con- 
sideration, there  is  much  reason  to  acquiesce  in  the  con 
elusion  to  which  Sir  J.  Paget's  ample  experience  bus 
led  him,  that  pycemia  is  just  as  frequent  in  private  as  it. 
hospital  practice  (Cit'n.  Soc.  Trans  vol.  vii.  p.  lvi.).  Ery- 
sipelas seems  to  be  more  frequent  and  more  fatal  at  the 
present  time  in  London  private  practice  than  in  hospitals 


HOSPITALISM. 


344 

altogether  the  construction  of  any  hospital  of  con- 
siderable size,  and  to  advocate  some  extravagant 
scheme  for  substituting  small  detached  tempo- 
rary sheds  for  our  present  permanent  hospitals. 
The  same  views  led  Mr.  Erichsen  to  say  that 
when  a hospital  had  become,  as  he  phrased  it, 

* pyaemia-stricken,’ it  ought  to  be  destroyed,1  while 
similar  ideas  have  led  others,  such  as  Dr.  Farr 
and  Miss  Nightingale,  to  question  whether  hos- 
pitals had  not  destroyed  more  lives  than  they 
had  saved.  Such  doctrines  should  not  be  passed 
over  in  silence,  since  they  exercise  a great  in- 
fluence on  the  public,  on  whose  co-operation 
the  efficiency  of  our  hospital  system  is  to  a great 
extent  based.  And  certainly  a theory  which  has 
received  the  support,  however  qualified,  of  so 
eminent  a hospital  surgeon  as  Mr.  Erichsen, 
cannot  be  considered  as  of  no  importance. 

It  is  therefore  necessary  to  point  out  to  the 
reader  that  the  theory,  as  so  stated  (and  stated 
quite  correctly  after  Sir  J.  Simpson’s  writings), 
is  utterly  disproved  by  the  experience  of  all 
well-managed  hospitals,  both  before  and  after 
the  introduction  of  the  antiseptic  method  of 
dressing  wounds.  It  must  be  noticed,  in  the  first 
place,  that  the  basis  of  the  theory  was  entirely 
what  is  called  ‘ statistics,’  that  is,  a hasty  infer- 
ence from  figures,  showing  the  results  of  a large 
number  of  cases  on  either  side.  Now  nothing  is 
more  dangerous  than  to  draw  conclusions  from 
such  figures,  which  are  quite  unsupported  by  any 
histories  of  the  cases  on  which  they  are  founded.2 
The  success  of  a surgical  operation  depends 
more  on  the  antecedents  of  the  operation  than 
on  its  consequents,  and  the  healthiness  of  hos- 
pitals depends  far  more  on  other  circumstances 
than  on  their  construction,  size,  or  age.  Nay 
more,  the  success  of  surgical  operations  does  not 
necessarily  vary  with  the  healthiness  of  the  hos- 
pital. In  the  healthiest  hospital  a careless  sur- 
geon, house-surgeon,  or  nurse  may  make  havoc 
of  the  major  operations  while  all  is  going  on  well 
with  the  general  run  of  patients. 

For  all  these  reasons,  any  one  of  which  would  be 
sufficient,  the  conclusions  of  Sir  J.  Simpson  aro 
to  be  utterly  repudiated,  and  to  be  considered 
the  more  mischievous  because,  while  they  allege 
imaginary  causes  of  danger,  they  thereby  conceal 
those  which  aro  real  and  certain,  and  necessarily 
induce  surgeons  and  managers  of  hospitals  to 
overlook  details,  attention  to  which  is  always 
followed  by  success  in  the  treatment  of  grave 
surgical  cases,  and  by  a condition  of  hospital 
hardly  if  at  all  inferior  to  the  best  circumstances 
under  which  private  practice  is  carried  on. 

The  writer  must  not  be  misunderstood,  as  if 
he  thought  the  details  of  hospital-construction 
unimportant.  The  principles  of  construction 
which  are  now  accepted  for  the  building  of  a 
hospital  will  be  found  at  pp.  647-652  ; but  it 
has  been  shown  to  demonstration  that,  provided 
wards  be  well,  but  not  excessively,  ventilated, 
and  kept  perfectly  clean,  and  provided  the 
beds  are  far  enough  apart,  the  precise  ground 
plan  of  the  hospital  matters  little — that  the 

1 On  Hospitalism,  p.  98. 

‘ The  writer  lays  less  stress  on  the  total  absence  of  any 
guarantee  for  the  accuracy  of  Sir  J.  Simpson's  table  of 
cases  in  private  practice,  and  is  willing,  for  the  sake  of 
arguni  mt,  to  assume  that  the  figures  are  correct. 


doctrines  so  much  insisted  on  Dy  the  French 
writers  on  hospitals  as  to  the  superiority  of  the 
‘ pavilion  plan,’  as  to  the  unhealthiness  of 
upper  storeys  and  so  on,  and  which  have  been 
adopted  as  if  they  were  unquestionable  truths 
by  many  writers  on  the  subject,  have  led  to 
much  waste  of  money  on  buildings  too  scattered 
for  hospital  service,  which  have  turned  out 
to  be  no  healthier  than  the  more  compact  and 
convenient  structures  which  they  superseded. 
But  we  ought  not,  in  reaction  from  these  exag- 
gerations. to  undervalue  the  importance  of  good 
ventilation,  good  aeration,  proper  isolation  of 
beds,  and,  above  all,  scrupulous  cleanliness,  in 
hospital  wards.  These  essentials  being  secured, 
the  writer  is  persuaded  that  a hospital  may  be 
just  as  healthy  with  thirty  wards  as  with  three, 
with  twenty  patients  in  each  ward  as  with  two, 
and  with  five  storeys  as  with  one.  Far  more 
important,  and  far  too- little  thought  of,  till 
within  the  last  few  years,  is  the  amount  of 
attention  given  to  the  personal  care  of  the  pa- 
tients. This  is  particularly  the  case  in  the 
treatment  of  open  wounds.  Everyone  who  has 
been  much  in  hospitals  must  have  often  seen, 
and  especially  abroad,  surgeons,  dressers,  and 
nurses  hurry  from  one  patient  to  another,  hardly 
washing  or  wiping  their  instruments,  still  less 
their  hands,  and  using  thesamo  dressingmaterials 
for  one  case  after  another.  Surgical  practice 
cannot  be  safely  carried  on  in  this  way,  how- 
ever healthy  in  itself  the  hospital  may  be.  The 
first  care  of  a surgeon  in  charge  of  hospital- 
wards  ought  to  be  to  impress  upon  all  his  assist- 
ants, and  never  to  forget  in  his  own  person,  that 
the  success  of  surgical  practice  depends  more 
upon  minute  care  in  the  dressing  of  cases,  than 
on  all  other  matters  put  together.  Our  surgical 
wards  have  become  far  more  healthy  since  the 
introduction  of  antiseptic  surgery;1  and  that 
this  must  be  largely  due  to  the  increased  care  in 
the  minuti*  of  surgical  treatment  which  has 
followed  on  the  discussion  of  this  method  is 
proved  by  the  fact  that  it  is  as  conspicuous  in 
some  of  those  who  reject  as  those  who  follow 
Mr.  Lister’s  teaching. 

If  it  were  not  true  that  the  septic  diseases,  or 
erysipelatous  diseases,  which  interfere  so  much 
with  the  success  of  operations  in  our  hospitals, 
depend  in  a very  large  proportion  of  cases  on 
the  method  of  dressing  the  wound  and  not 
on  matters  conveyed  by  the  atmosphere,  how 
could  the  success  of  the  so-called ‘open  method’ 
of  dressing  wounds  be  explained?  In  this  method 
the  wound  is  left  freely  exposed  to  that  hospital 
air  which  is.  we  are  told,  charged  with  deadly 
miasma.  The  size  of  the  wards,  number  of 
beds,  &c.,  are  all  of  course  unchanged;  but  care 
is  taken  to  see  that  the  wound  is  well  drained  of 

all  putrefiable  discharges, and  kept  perfectly  clean. 

If  Sir  J.  Simpson's  theory  were  true,  we  ought 
to  have  an  increased  mortality  following  on  the 
freor  exposure  to  this  deadly  atmosphere.  On 
the  contrary,  the  perfect  drainage  of  the  wound, 
and  tlie  care  taken  to  keep  it  free  from  a., 
putrefying  matters,  are  followed  by  results 

1 The  late  Mr.  Callender  stated  it  as  his  deliberat 
opinion  that  the  great  surgical  operations  are  ten  tines 
more  successful  in  hospitals  now  than  they  used  to  be  in 
the  past  generation. 


HOSPITALISM. 

which  can  hardly  be  surpassed.  Thus  Dr.  James 
Wood,  of  the  Bellevue  Hospital,  New  York,  re- 
lates, that  in  wards  which  had  been  recently 
vacated  on  account  of  an  outbreak  of  puerperal 
fever,  he  treated  fourteen  successive  cases  of 
unselected  amputation  of  the  limbs  successfully, 
by  merely  leaving  the  flaps  ununited,  the  raw 
surfaces  exposed  to  the  air,  but  carefully  drained, 
and  all  putrescible  matters  continually  removed ; 1 
and  this  is  only  one  of  many  proofs  which  have 
recently  been  given  of  the  fact  that  there  are 
many  other  plans  of  treating  wounds  besides 
that  which  is  specially  designated  ‘ antiseptic,’ 
under  which,  conjoined  with  proper  construction 
and  general  management,  a hospital  may  be  as 
healthy  as  a private  house. 

This  statement,  which  is  made  after  long  ex- 
perience, and  with  a conscientious  conviction  of 
its  truth,  by  no  means  asserts  that  it  is  as  easy  to 
keep  a hospital  healthy  as  a private  sick-room, 
or,  in  other  words,  that  the  aggregation  of  the 
sick  and  wounded  involves  no  dangers.  Such  a 
doctrine  would  be  absurd  ; but  the  dangers  are 
the  same  in  kind,  and  the  precautions  required 
are  the  same,  with  a single  exception.  Hospitals, 
like  private  houses,  must  be  kept  well-aired, 
well-drained,  scrupulously  clean,  properly,  but 
not  excessively,  lighted,2  and  so  forth.  The  great 
difference  in  the  precautions  required  to  ensure 
the  salubrity  of  hospitals  and  private  houses  is, 
in  one  word,  to  guard  against  direct  infection,  and 
this  may  occur  in  two  ways.  Surgically,  infection 
is  carried  directly  by  careless  dressing — and  every 
hospital  surgeon  must  have  remarked  that  as  he 
himself  is  more  watchful  and  careful,  and  as  he 
has  the  good  fortune  to  be  surrounded  by  more 
careful  assistants,  his  cases  do  better;  and  in  the 
present  healthy  condition  of  most  of  our  large 
LondonHospitals,  such  precautions  of  themselves 
suffice  to  raise  the  success  of  surgical  practice  to 
the  same  level  as  it  reaches  in  private  houses. 
The  second  way  in  which  infection  may  be  carried 
is  by  direct  proximity  or  contact.  This  is  more 
important  in  medical  cases,  and  the  obvious 
danger  of  the  spread  of  infectious  fevers  has  led 
the  managers  of  most  of  our  general  hospitals  to 
exclude  such  diseases  from  their  wards  as  small- 
pox, scarlet  fever,  and  typhus,  while  other  affec- 
tions are  admitted,  which,  though  contagious,  are 
so  in  a less  degree,  as  tj’phoid  fever,  erysipelas, 
diphtheria,  &c.  Enough,  or  more  than  enough, 
has  been  done  in  this  direction — that  is,  the 
public  safety  might  be.as  well  consulted  if  typhus 
and  scarlet  fever  cases  were  still  admitted  (as 
before  the  institution  of  special  hospitals  for  such 
cases  they  used  to  be)  into  the  wards  of  our  general 
hospitals  in  small  numbers,  and  under  striet  pre- 
cautions. Anyhow,  it  appears  that  there  is  little 
if  any  evidence  of  spread  of  disease  from  such 
cases  reputed  to  be  infectious  as  are  still  to  be 
found  in  our  general  hospitals.  Hearing  that 
some  distinguished  surgeons  teach  confidently 
that  pyaemia  and  erysipelas  are  usually  propa- 
gated by  contagion,  the  writer  has  often  watched 
the  progress  of  such  cases  when  originating  in 

1 New  York  Medical  Journal , Jan.  1876. 

’ Most  of  our  hospitals  are  too  light,  and  too  des- 
titute of  the  means  of  excluding  the  light.  No  doubt 
( flood  of  light  in  the  ward  is  very  useful  in  detecting 
(lilt,  but  it  sadly  interferes  with  the  repose  which  many 
medical  and  surgical  cases  require. 


HOSPITALS,  ADMINISTRATION  OE.  645 

hospital  or  admitted  from  without,  but  has  never 
been  able  to  verify  any  spread  of  the  disease 
from  them,  though  he  does  not  deny  the  possi- 
bility of  such  an  occurrence. 

To  sum  up  the  whole  matter — the  writer  would 
define  the  term  ‘ Hospitalism  ’ as  expressing  the 
danger  which  exists  in  hospitals  of  contamination 
from  the  aggregation  of  patients  — and  would 
add  that  the  extent  to  which  such  contamina- 
tion prevails  has  been  greatly  exaggerated  by 
theoretical  writers  ; that,  as  far  as  the  general 
atmosphere  of  the  ward  is  concerned,  the  danger 
maybe,  and  appears  in  all  well-managed  hospitals 
really  to  be,  obviated  by  ventilation  and  cleanli- 
ness ; and  the  more  immediate  danger  from  the 
contiguity  of  patients  cannot  be  shown  to  produce 
any  appreciable  effect,  while  the  danger  of  con- 
tamination of  wounds  by  putrefying  materials 
demands  constant  vigilance  to  counteract  it ; but 
with  such  vigilance  seems  to  he  so  far  counter- 
acted that  hospital  practice  is,  for  anything  we 
know,  as  successful  as  private  practice  in  similar 
cases.  This  is  not  an  entirely  satisfactory  result, 
inasmuch  as  practice  in  a hospital,  where  every 
patient  is  under  the  strictest  regimen  and  sur- 
veillance, ought  to  be  much  more  successful  than 
private  practice,  where  the  conditions  are  very 
different  in  these  respects  ; but  we  are  making 
rapid  advances  towards  this  desirable  and  per- 
fectly attainable  end.  T.  Holmes. 

HOSPITALS,  Administration  of. — The 
administration  of  a hospital  should  be  so  framed 
as  to  enforce  the  necessary  economy  consistent 
with  the  due  supply  of  the  requirements  for  the 
sick. 

Governing  Body. — The  administration  is  in 
the  hands  of  a governing  body,  which  usually 
consists  of  a committee  or  board,  with  an  officer 
in  direct  communication  with  them,  who  acts 
as  their  representative.  The  governing  body 
provides  for  the  general  supervision  and  disci- 
pline of  the  establishment,  and  for  the  financial 
arrangements.  In  this  body  is  vested  the  ap- 
pointment and  removal  of  all  members  of  the 
staff  of  the  hospital.  It  makes  all  general 
regulations  after  consultation  with  the  profes- 
sional department,  as  to  internal  economy, 
admission  and  discharge  of  patients,  distribution 
of  beds,  dietary  and  other  matters.  It  takes 
steps  for  raising  the  funds  to  support  the  hos- 
pital, and  regulates  the  expenditure. 

Governor  or  Treasurer. — The  active  represen- 
tative of  the  governing  body  is  generally  termed 
Governor  or  Treasurer.  He  exercises  a general 
supervision  over  the  structure  and  the  disci- 
pline of  the  establishment.  The  chief  executive 
officer  immediately  under  the  governing  body  is 
called  the  Steward , or  sometimes  the  Secretary. 
He  has  the  control  of  all  servants  not  included 
in  the  nursing  staff — such  as  porters,  ambulance- 
men, engine-man,  bath-assistants,  and  other  male 
attendants.  He  sees  that  all  structural  appli- 
ances are  in  good  order,  and  that  cleanliness 
and  discipline  are  maintained  throughout  the 
building.  He  controls  the  issue  of  all  orders 
for  the  supply  of  goods,  provisions,  fuel,  &c., 
and  watches  that  they  are  used  with  a due  re- 
gard to  economy.  He  countersigns  all  orders  for 
payment  after  they  are  passed  by  the  treasurer 


HOSPITALS,  ADMINISTRATION  OF. 


546 

and  is  responsible  for  the  hospital  accounts. 
He  sees  that  the  records  of  admission,  discharge, 
a,nd  death  are  duly  kept  by  the  professional 
staff.  He  is  responsible  for  the  safe  custody  of 
clothiDg,  money,  and  property  brought  in  by  the 
patients,  till  their  discharge.  He  has  charge  of 
the  correspondence. 

Clerk;  or  Assistant  Steward. — The  secretary 
or  steward  is  assisted  by  an  assistant  or  clerk. 
This  latter  receives  all  provisions  and  stores, 
sees  that  they  are  correctly  delivered,  and  is 
responsible  for  their  safe  custody  until  distri- 
buted to  an  authorized  person.  He  sees  that 
the  diet-tables  are  prepared  from  the  pre- 
scription papers,  and  that  the  articles  of  food 
supplied  to  patients  are  strictly  in  accordance 
with  the  diet-table,  or  else  specially  ordered  by 
the  physician  or  surgeon. 

Professional  Staff. — The  professional  staff  di- 
rects the  proceedings  to  be  taken  for  the  well- 
being and  cure  of  the  patients.  It  consists  of  the 
consulting  and  visiting  physicians  and  surgeons  ; 
the  assistant  physicians  and  surgeons  ; and  the 
resident  and  house-physicians  and  surgeons,  and 
assistants  continually  present  in  the  hospital. 

Medical  Committee. — The  professional  staff 
forms  a medical  committee  with  a specified  quo- 
rum. This  committee  is  consultative  only,  and 
advises  the  governing  body  on  all  matters  con- 
cerning the  medical  and  surgical  departments  of 
the  hospital,  the  admission  and  discharge  of 
patients,  the  distribution  of  beds,  the  dispen- 
sary, the  in-patients,  out-patients’  department, 
and  the  students.  The  medical  committee,  more- 
over, puts  forward  recommendations  for  the  pur- 
chase of  instruments,  apparatus,  and  medicines. 
The  committee  provides  for  a descriptive  record 
of  cases  admitted  into  the  hospital;  and  for  the 
efficient  instruction  of  students. 

Physicians  and  Surgeons.— The  physicians, 
surgeons,  assistant  physicians  and  assistant  sur- 
geons undertake  the  charge  of  the  wards  and 
'out-patients’  departments,  and  attend  at  the 
hospital  at  fixed  times.  The  physicians  and 
surgeons  order  the  diet  of  the  patients,  and  no 
article  of  diet  which  does  not  appear  in  the 
diet-table  is  supplied  unless  specially  ordered 
by  them. 

Resident  Medical  Officers. — The  resident  medi- 
cal officers  control  the  treatment  of  patients  in 
the  absence  of  the  physicians  and  surgeons  ; 
and  have  a disciplinary  control  over  the  dressers 
and  clinical  clerks.  They  decide  on  the  admis- 
sibility or  otherwise  of  applicants  for  relief, 
when  not  admitted  directly  by  the  physicians 
and  surgeons,  as  well  as  on  the  wards  in  which 
the  in-patients  are  to  be  placed,  and  are  respon- 
sible for  their  care  until  seen  by  the  physicians 
and  surgeons.  They  visit  the  wards  and  dispen- 
sary, according  to  the  regulations,  to  see  that 
the  patients  are  duly  attended  to.  They  super- 
intend the  conduct  of  the  assistants  of  the 
medical  officers,  and  of  the  dispenser  and  his 
assistants,  of  pupils  (if  any),  and  of  patients ; 
give  notice  of  any  misconduct  of  the  nurses 
and  servants  to  the  matron  or  lady  super- 
intendent; and  inform  the  governor  or  secretary, 
the  physician,  surgeon,  and  governing  body,  of 
any  matter  requiring  their'  attention.  They 
are  responsible  that  the  records  of  cases  are 


properly  made  out.  In  most  cases,  however,  tfci» 
duty  is  now  performed  by  registrars. 

Dispenser. — The  dispenser  acts  under  the  resi- 
dent medical  officer,  subject  to  regulations  laid 
down  by  the  governing  body. 

Nursing  Department. — The  nursing  depart- 
ment is  under  a trained  matron,  who  should  be 
lady  superintendent  of  the  training  school,  and 
head  of  all  the  women  employed  in  the  hos- 
pital. 

Matron  or  Lady  Superintendent. — The  whole 
responsibility  for  nursing,  internal  management, 
care  of  linen  and  housekeeping,  and  the  discip- 
line and  training  of  nurses  is  vested  in  the  trained 
female  head  of  the  nursing  staff,  by  whatever 
title  she  be  called.  To  the  governing  body  of 
the  hospital  she  is  responsible  for  the  conduct, 
discipline,  and  duties  of  her  nurses.  To  the 
governing  body  and  the  physicians  and  suigeons 
in  charge  of  wards  she  is  responsible  for  the 
care  and  cleanliness  of  the  wards,  for  the  care 
and  cleanliness  of  the  sick,  and  for  the  linen. 
She  is  responsible  to  the  medical  officers  that 
their  orders  about  the  treatment  of  the  sick  are 
strictly  carried  out.  To  fulfil  these  responsibili- 
ties, she  has  the  power  of  engaging,  appointing, 
and  dismissing  all  Durses,  female  servants,  and 
probationers,  subject,  of  course,  to  the  general 
control  of  the  governing  body.  The  nursing 
establishment  cannot  be  made  responsible  on  the 
side  of  discipline  to  the  medical  officers,  or  the 
governor  of  a hospital.  Simplicity  of  rules,  plac- 
ing the  nurses  in  all  matters  regarding  manage- 
ment of  sick  absolutely  under  the  orders  of  the 
medical  staff,  and  in  all  disciplinary  matters  ab- 
solutelyunder  the  lady  superintendent  or  matron, 
to  whom  the  medical  officers  should  refer  all 
cases  of  neglect,  is  very  important.  Any  remiss- 
ness or  neglect  of  duty  is  as  much  a breach  of 
discipline  as  drunkenness  or  other  .bad  conduct, 
and  can  only  be  dealt  with  to  any  good  purpose 
by  report  to  the  matron.  But  neither  the  medical 
officer  nor  any  other  male  head  should  ever  have 
power  to  punish  for  disobedience.  His  duty 
should  end  with  reporting  the  case  to  the  fe- 
male head,  who  is  responsible  to  the  governing 
authority  of  the  hospital,  as  all  her  nurses  and 
servants  are,  in  the  performance  of  their  duties, 
immediately  responsible  to  the  matron  only.  If 
the  matron  or  lady  superintendent  does  not 
exercise  the  authority  entrusted  to  her  with 
judgment  and  discretion,  it  is  then  the  legiti- 
mate province  of  the  governing  body  to  into 
fere  and  to  remove  her. 

The  matron  resides  in  the  hospital  where  liei 
nurses  and  probationers  are  at  work. 

In  a hospital  of,  say,  above  300  beds,  and  with 
a training  school  of.  say.  above  twenty  proba- 
tioners (which  all  such  hospitals  ought  to  in- 
clude), the  trained  matron  should  have  three 
trained  representatives  or  assistants — one  in 
the  training  school  as  mistress  of  probationers 
or  home-sister ; and  two  'in  the  hospital, — 
one  by  day  as  assistant  matron  (or  superinten- 
dent), and  one  by  night  as  night  superintendent 
of  nurses ; and  of  these  two  the  night  repre- 
sentative is  the  more  important.  Besides  the 
trained  assistant,  matron  (superintendent'!  who 
should  have  such  inspection  of  the  wards  as 
the  matron  may  commit  to  her,  the  matron  will 


HOSPITALS,  ADMINISTRATION  OF. 
require  one  linen-assistant  and  housekeeper,  who 
might  also  have  the  charge  and  inspection  of  the 
nurses’  rooms,  if  the  trained  assistant  matron 
has  not  time.  She  should  ‘ mother  ’ the  -ward- 
maids,  and  have  some  ‘ gathering  ’ for  them. 

Nurses  and  Servants. — Under  the  matron  there 
should  he  distinct  grades  of  nurses,  and  distinct 
duties  for  each  grade : — 1.  Trained  chief  nurses 
(ward  sisters.)  2.  Trained  nurses  (day).  3.  Trained 
nurses  (night),  at  least  equal  in  pay  and  status 
to  the  day-nurses.  4.  Probationers  in  training. 
5.  Ward-maids,  and  nursemaids  for  children's 
wards.  6.  Dormitory  and  stairs  women.  7.  Fe- 
male cook,  and  her  assistants  under  the  house- 
keeper. The  hospital  cook  in  a large  hospital 
would  probably  be  a man,  and  under  the  steward. 
The  sisters,  nurses,  and  probationers  would  re- 
quire a female  cook,  under  the  matron.  All 
women  employed  in  the  hospital  should  reside  in 
the  hospital. 

Night  Superintendent. — The  (trained)  night 
superintendent  of  nurses  should  be  in  charge  of 
the  night-nursing,  in  communication  with  the 
ward  sisters,  as  well  as  of  the  night-nurses; 
should  see  that  the  ventilation  and  tempera- 
ture of  the  wards  is  maintained — directed  by 
the  medical  staff.  She  must  be  one  qualified 
not  only  to  have  charge  of  nurses  and  have 
some  ‘gathering’  for  night-nurses  by  day,  but 
to  train  probationers  told  off  to  accompany'  her 
at  night,  to  their  own  benefit  and  hers. 

Assistant  Matron. — The  assistant  matron  is 
to  have  special  charge  over  the  nurses’  rooms, 
to  see  that  the  nurses  rise  in  time  to  wash 
themselves,  strip  their  beds,  empty  their  slops, 
and  have  breakfast,  beforo  going  on  duty ; 
that  later  they  make  their  beds  and  put  their 
rooms  in  order ; that  they  never  wash  their 
own  clothes  in  their  own  rooms,  but  all 
nurses’  washing  should  be  done  for  them;  that 
they  go  quietly  to  bed  at  night,  and  lights 
be  put  out  at  a certain  hour ; that  their  rooms 
are  always  clean,  in  order,  wholesome  and  cheer- 
ful. Without  this  constant  supervision  what  is 
necessary  for  the  nurses’  health  is  not  done ; 
the  same  for  night  nurses  is  yet  more  important. 
Nurses’  meals  should  always  be  presided  over 
by  some  such  authority. 

The  hospital  night  nurses  should  have  two 
hot  meals  in  the  common  dining  room,  it  might 
be  in  the  probationers’  home,  say  at  9.30  a.m. 
and  9.30  p.m.,  ready  and  prepared  for  them. 
And  sisters,  staff  nurses,  and  ward-maids  should 
have,  though  at  different  hours — as  all  cannot 
be  absent  from  the  wards  at  once — dinner  and 
Rupper,  each  set  together  in  a common  dining- 
room, away  from  the  ward  air.  No  nurse  should 
have  to  prepare  her  meals  for  herself. 

Laundry. — In  small  and  moderate-sized  hos- 
pitals, when  there  is  a laundry  attached  to  the 
hospital,  the  supervision  should  be  under  the  lady 
superintendent  or  matron.  In  large  hospitals,  it 
would  be  advisable  for  the  laundry,  which  should 
in  all  cases  be  in  a building  entirely  detached,  to 
be  worked  independently,  under  the  general 
supervision  of  the  governor  or  secretary’. 

Chaplain. — The  religious  care  of  the  patients 
is  generally  provided  for  by  the  appointment  of 
one  or  more  permanent  chaplains,  or  by  visits 
and  religious  services  of  other  ministers  whom  the 


HOSPITALS,  CONSTRUCTION  OF.  647 
patients  may  desire  to  attend  them;  subject, 
however,  to  the  opinion  of  the  medical  attendant. 
as  to  how  far  the  state  of  health  of  the  patient 
will  admit  of  such  visits,  and  to  the  visits 
being  made  at  such  times  as  do  not  interfere 
with  the  discipline  of  the  hospital. 

DonGLAS  Galton. 

HOSPITALS,  Construction  of. '—A  hos- 
pital or  infirmary  is  a building  intended  for  the 
reception  and  treatment  of  sick  aud  injured 
persons,  under  conditions  favourable  for  their 
recovery. 

A hospital  must  be  so  constructed  and  ar- 
ranged as  to  enable  a limited  staff  of  medical 
men,  nurses,  and  assistants  to  minister  to  the 
necessities  of  a large  number  of  sick,  and  to  pro- 
mote their  speedy  restoration.  The  conditions 
essential  for  such  objects  are  as  follows ; — 

(1)  Pure  air.  There  should  be  no  appreciable 
difference  in  purity  between  the  air  inside  the 
wards  and  that  outside  the  building. 

(2)  The  air  supplied  should  be  capable  of 
being  warmed  to  any  required  extent. 

(3)  Pure  water  should  be  supplied  for  internal 
use,  and  sufficient  also  to  ensure  the  removal  of 
impurities  to  a distance  from  the  hospital. 

(4)  The  most  perfect  cleanliness  within  and 
around  the  building  should  be  enforced. 

These  conditions  depend  on — 

(1)  The  site  of  the  proposed  hospital. 

(2)  The  form  of  the  rooms  or  wards  in  which 
the  sick  are  to  be  placed,  so  as  to  ensure  purity 
of  air  and  convenience  of  nursing;  these  rooms 
forming  the  principal  units  of  hospital-construc- 
tion. 

(3)  The  distribution  of  these  units,  and  of  the 
other  accessories,  which  combined  constitute  the 
hospital. 

1.  Sites  of  Hospitals. — The  local  climate 
should  be  healthy,  and  there  should  be  a free 
circulation  of  air  over  the  district.  Town  site? 
should  be  avoided  as  far  as  possible.  When 
necessarily  placed  in  a town,  a space  free  from 
buildings  should  be  reserved  on  all  sides.  There 
should  be  no  nuisances,  damp  ravines,  muddy 
creeks,  undrained  or  marshy  ground,  near  the 
site,  or  in  such  a position  that  the  prevailing 
winds  would  blow  effluvia  arising  from  them 
over  the  hospital.  The  site  selected  for  a hos- 
pital should  not  receive  the  drainage  of  higher 
ground,  and  the  natural  drainage  outlets  should 
be  sufficient.  There  should,  if  possible,  be  no 
buildings  near  a hospital  except  those  connected 
with  its  object.  The  number  of  sick  to  be  al- 
lowed per  acre  will  depend  practically  upon  the 
arrangement  of  the  buildings  in  which  they  are 
lodged. 

2.  Form  and  Distribution  of  the  Parte 
of  a Hospital. — The  structural  arrangements 
of  a hospital  should  be  such  as  to  secure  free 
circulation  of  air. 

The  Warp. — The  basis  upon  which  the  struc- 
tural arrangements  rest  is  the  ward.  The  ad- 
ministration, means  of  access,  and  disciplino 
must  be  made  subsidiary  to  the  question  as  to 

1 This  article  has  reference  more  especially  to  penxm- 
nent  general  hospitals.  The  principles  apply  equally  to 
special  temporary  field  or  other  institutions  for  ‘ the  cure 
of  the  sick.’ 


HOSPITALS,  CONSTRUCTION  OF. 


348 

how  the  sick  arc  to  get  well  in  the  shortest  pos- 
sible time,  and  at  the  least  expense;  and  this, 
so  far  as  the  structure  is  concerned,  is  mainly 
determined  by  the  form  of  the  wards. 

Size. — The  size  of  a ward  depends  upon  the 
number  of  patients  which  it  should  contain, 
and  upon  the  cubic  space  and  floor  space  which 
should  be  allotted  to  each  patient.  The  dis- 
ciplinary and  economical  dispositions  in  a hos- 
pital require  that  each  head  nurse  should  have 
(he  patients  allotted  to  her  placed  under  her 
immediate  eye.  Economy  of  labour  requires 
that  the  hospital  should  be  so  laid  out  as  to 
enable  the  largest  number  of  patients  to  be 
nursed  by  a given  number  of  nurses.  The 
number  to  be  placed  in  a ward  therefore  depends 
upon  the  number  which  can  be  efficiently  nursed  ; 
and  the  form  of  the  ward  must  be  as  much  cal- 
culated to  facilitate  nursing,  as  to  ensure  free 
circulation  and  change  of  air.  From  twenty  to 
thirty-two  beds  have  been  taken  as  the  unit  for 
ward-construction.  In  hospitals  where  cases  of 
more  than  ordinary  severity  are  likely  to  be 
received,  it  would  be  necessary  to  diminish  the 
size  of  the  wards  on  grounds  of  health.  Small 
wards  containing  one  or  more  beds  are  also  re- 
quired for  isolating  certain  cases  or  for  various 
necessary  objects. 

Form  of  ward  - construction.  — The  general 
form  of  ward-construction  is  mainly  governed 
by  the  question  of  the  renewal  of  air.  The  air 
within  an  inhabited  space,  enclosed  on  all  sides, 
is  vitiated  by  the  emanations  proceeding  from 
the  bodies  of  those  who  inhabit  it,  and  espe- 
cially by  the  effect  on  it  of  their  respiration.  In 
all  sickness,  and  all  surgical  cases,  wounds  with 
discharge,  or  sores,  these  emanations  are  greater 
in  quantity,  and  more  poisonous  in  quality,  than 
from  persons  in  health ; whilst  , at  the  same  time, 
most  cases— medical  and  surgical — are  more 
susceptible  to  these  emanations.  Stagnation  in 
the  movement  of  the  air  leads  to  rapid  decom- 
position of  these  emanations.  If  they  diffused 
themselves  uniformly  throughout  the  space, 
which  in  fact  they  do  not,  ventilation  would  be 
comparatively  simple,  and,  whatever  the  cubic 
space,  the  air  would  attain  a permanent  degree 
of  purity,  or  rather  impurity,  theoretically  de- 
pendent upon  the  rate  at  which  emanations  are 
produced,  and  the  rate  at  which  fresh  air  is  ad- 
mitted. Hence  the  same  supply  of  air  would 
equally  well  ventilate  any  space  ; but  the  larger 
the  cubic  spaee,  the  longer  it  will  be  before  the 
air  in  it  attains  its  permanent  condition  of  im- 
purity, and  the  more  easily  will  the  supply  of 
fresh  air  be  brought  in  without  altering  the 
temperature,  and  causing  injurious  draughts. 
The  amount  of  air  which  should  be  removed, 
and  its  place  supplied  with  fresh  air,  is  at  least 
3,000  cubic  feet  per  patient  per  hour ; but  this 
must  depend  to  some  extent  upon  the  emana- 
tions of  the  patients,  which  vary  with  the  dis- 
eases or  injuries  they  are  suffering  from.  The 
ventilation  of  each  ward  should  be  kept  inde- 
pendent of  other  wards  or  rooms. 

Means  of  ventilation.  — The  change  of  air 
may  be  effected  in  various  -ways.  For  instance, 
the  air  may  be  drawn  out  by  a fan  ; or  it  may 
be  removed  by  a shaft,  whose  act  ion  depends  on 
the  difference  of  the  temperature  of  the  air  in  I 


the  shaft  and  that  in  the  outer  atmosphere.  Of 
this  the  ordinary  fireplace  is  one  example ; a 
caldron  of  water  kept  boiling  for  the  use  of  the 
hospital  by  a steam  pipe  is  another;  a sunlight 
is  a further  example  ; and  a heated  shaft  con- 
nected with  flues  led  from  holes  in  the  wall  near 
the  patients’  beds,  through  each  of  which  air  is 
drawn  into  the  shaft,  is  another  method.  Theo- 
retically it  is  thus  quite  possible  so  to  arrange 
the  ventilation  mechanically  that  a specified 
quantity  of  air  at  a fixed  temperature  shall  be 
brought  into  the  ward  by  day  and  by  night. 
Practically,  however,  hospitals  dependent  upon 
such  means  alone  for  ventilation,  require  an 
attention  which  they  can  rarely  or  never  receive, 
and,  except  under  favourable  circumstances,  are 
not  healthy. 

The  emanations  from  the  body  do  not  uni- 
formly diffuse  themselves;  they  hang  about  as 
the  smoke  of  tobacco  may  be  said  to  do.  In 
wards  into  which  a fixed  quantity  of  air  is 
forced,  there  is  not  even  a uniform  degree  of 
impurity;  consequently  it  is  necessary,  in  order 
to  ensure  the  purity  of  the  air  of  a ward,  that 
means  should  exist  for  absolutely  sweeping  out 
at  intervals  all  the  impure  air  from  it,  and  start- 
ing afresh  with  pure  air.  This  is  best  effected 
by  the  direct  action  of  currents  of  fresh  air 
brought  in  by  open  windows  placed  on  opposite 
sides  of  the  wards.  The  distance  between 
windows  for  this  purpose  must  not  be  too  great 
to-prevent  their  efficient  action  in  moving  the 
air.  Twenty-four  feet  is  a good  width,  but 
opposite  windows  for  such  an  object  should  in  no 
case  be  more  than  from  thirty  to  thirty-five  feet 
apart.  The  space  between  the  windows  should 
not  be  obstructed  by  walls  or  partitions.  The 
number  of  patients — that  is  to  say,  the  sources 
of  impure  emanations — placed  between  opposite 
windows,  should  be  limited  to  two  rows.  In  the 
daytime,  and  when  the  weather  admits  of  open 
windows,  a ward  with  windows  opening  on  both 
sides  can  easily  be  kept  fresh  ; but  for  other 
seasons  it  is  necessary  to  provide  openings  for 
the  escape  of  impure  air,  and  for  the  admission 
of  fresh  air  which  shall  not  cause  draughts. 

For  the  purpose  of  removal  of  air,  shafts 
carried  up  from  near  the  ceiling-level  to  above 
the  roof  are  convenient,  the  lower  ends  being 
louvered  to  prevent  patients  feeling  down- 
draughts which  may  occasionally  prevail.  The 
most  powerful  engine  of  ventilation  for  drawing 
out  the  air  is  an  open  fire-place. 

In  order  to  prevent  the  temperature  of  the 
ward  from  being  lowered  by  the  extraction  of  air, 
that  is,  to  maintain  an  equable  temperature,  and 
to  prevent  draughts,  air  warmed  to  a moderate 
degree  should  replace  that  removed  by  the  fire- 
place or  by  other  openings.  Means  for  the 
admission  of  air  in  an  upward  current  should  be 
provided  direct  from  the  open  air,  independent 
of  the  windows  and  doors;  for  this  purpose  tubes 
with  bends,  which  favour  the  collection  of  dirt, 
are  objectionable.  Sherringham's  ventilators, 
which  are  easily  cleaned,  placed  between  the 
windows  near  the  ceiling  answer  well;  they  admit 
the  air  without  perceptible  draught,  and  also  fre- 
quently act  as  outlets  when  open  on  the  leewanl 
side  of  award.  The  external  air  may  be  warmed 
as  it  enters  by  being  made  to  pass  over  hot-war<v 


HOSPITALS,  CONSTRUCTION  OF.  649 


or  steam  tubes.  Openings,  if  placed  close  to  the 
floor  under  the  beds,  should  be  capable  of  being 
easily  and  securely  closed.  All  openings  for  the 
admission  of  fresh  air  should  be  so  placed  as  to 
be  easily  examined  and  cleaned  throughout  their 
■whole  length,  and  this  should  be  done  at  least 
once  a year. 

Superficial  area. — The  next  most  important 
element  in  the  question  of  ward-construction  is 
the  superficial  area  to  be  allotted  to  the  pa- 
tients, which  is  even  more  important  than  cubic 
space,  for  on  this  depends  the  distance  of  the  sick 
from  each  other,  the  facility  of  moving  round  the 
sick,  shifting  beds,  cleanliness,  and  other  points 
of  nursing.  If  there  be  a medical  school  at- 
tached to  the  hospital,  the  question  of  area  has 
to  be  considered  with  reference  to  affording  the 
largest  amount  of  accommodation  practicable  for 
the  teacher  and  his  pupils  without  their  breath- 
ing up  the  patients’  air.  A ward  with  windows 
improperly  placed,  so  as  not  to  give  sufficient 
light,  or  where  the  beds  are  so  placed  that  the 
nurse  must  necessarily  obstruct  the  light  in 
attending  to  her  patients,  will  require  a large 
floor-space,  because  the  bed-space  must  be  so 
arranged,  and  of  such  dimensions,  as  to  allow 
of  sufficient  light  falling  on  the  beds.  In  well- 
constructed  wards  with  opposite  windows,  the 
greatest  economy  of  surface-area  can  be  effected, 
because  the  area  can  be  best  allotted  with  refer- 
ence both  to  light  and  to  room  for  work.  In  a 
ward  24  feet  in  width,  with  a window  for  every 
bed  or  every  two  beds,  a 7 ft.  6 in.  bed-space 
along  the  walls  would  probably  be  sufficient  for 
nursing  purposes.  This  would  give  90  square  feet 
per  bed,  and  there  should  be  as  little  reduction 
as  possible  below  this  amount  for  average  cases 
of  sickness,  but  this  space  is  much  too  small  for 
surgical,  fever-,  or  lying-in  wards,  which  should 
also  be  for  a much  smaller  number.  The  Herbert 
Hospital,  without  a medical  school,  has  99  super- 
ficial feet  per  bed  ; St.  Thomas’  Hospital,  with  a 
medical  school,  has  120  superficial  feet  per  bed. 
The  bed-space  should  be  larger  if  the  locality  is 
less  healthy. 

The  area  allotted  to  patients  practically  settles 
the  cubic  space,  because  wards  should  not  be  less 
than  12  feet  high,  though  as  a rule  they  need 
not  exceed  14  feet  in  height. 

In  a good  situation,  and  for  ordinary  cases  of 
disease,  those  spaces  which  are  enough  for 
nursing  and  for  ward-administration  would,  with 
good  ventilation,  be  sufficient  for  all  sanitary 
purposes ; but  for  such  cases  as  typhus  or  other 
epidemic  diseases,  operations,  and  bad  surgical 
diseases,  a larger  space  and  area  would  be  re- 
quired. AVhen  severe  cases  of  this  class  come 
into  an  ordinary  hospital,  the  simplest  plan  is 
to  leave  the  bed  vacant  adjacent  to  that  occu- 
pied by  the  patient. 

Lying-in  wards  should  never  contain  more 
than  from  one  to  four  beds.  In  recent  French 
hospitals  these  wards  contain  one  bed  each,  and 
the  only  access  to  them  is  from  an  open  verandah 
and  through  a small  ante-room.  Ovariotomy,  and 
0'her  operations  of  the  highest  risk,  should  be 
performed  in  a one-bed  ward.  When  space  per- 
mits, a room  may  be  provided  for  the  use  of 
patients  when  convalescent,  and  able  to  be 
temporarily  absent  from  the  wards.  The  same 


observation  applies  to  grounds  for  outdoor  exer- 
cise. But  separate  convalescent  hospitals  or 
homes  are  better,  both  for  health  and  discipline. 
If  hospitals  are  provided  for  special  infectious 
diseases,  every  patient  should  be  placed  in  a 
separate  hut-ward.  Cleanliness  and  abundance  of 
fresh  air  is  the  best  safeguard  against  infection. 

Materials. — With  a view  to  economise  heat 
in  winter,  and  to  keep  the  rooms  cool  in  summer, 
the  walls  should  be  hollow,  and  all  wards 
should  be  ceiled,  unless  the  roof  is  constructed 
of  a good  non-conducting  material.  The  best 
lining  for  a hospital-ward  would  be  an  imper- 
vious polished  surface,  which  on  being  washed 
with  soap  and  water,  and  dried,  would  be 
made  quite  clean.  Plaster,  wood,  paint,  and 
varnish  all  absorb  the  organic  impurities  given 
off  by  the  body.  Parian  cement  polished  is  the 
best  material  at  present  known  for  walls,  but  it 
is  costly,  and  it  can  only  be  applied  on  brick  or 
stone  walls,  and  not  on  woodwork,  because,  being 
inelastic,  it  is  liable  to  crack.  Cracks  in  a hos- 
pital ward  are  inadmissible,  as  they  get  filled 
with  impurities,  and  harbour  insects.  The 
numerous  joints  required  for  glazed  bricks,  or 
tiles,  render  the  use  of  these  questionable  for 
wards.  In  default  of  Parian  cement,  the  safest 
arrangement  is  plaster  lime-whited  or  painted, 
which  should  be  periodically  scraped,  and  be 
then  again  lime-whited  or  painted. 

The  floor  should  be  as  non-absorbent  as  pos- 
sible, and  for  the  sake  of  warmth  to  the  feet  it 
must  in  this  country  be  of  wood.  Oak,  or  other 
close  hard  wood,  with  close  joints,  oiled  and 
beeswaxed,  and  rubbed  to  a polish,  makes  a very 
good  floor,  and  absorbs  little  moisture.  The 
joints  should  be  like  those  of  the  best  parque- 
terie,  affording  no  inlet  for  dirt.  There  should 
be  no  sawdust,  or  other  organic  matter  subject 
to  decay,  under  the  floor.  When  a ward  is  placed 
over  another,  it  is  essential  that  the  floor  should 
be  non-conducting  of  sound,  and  that  it  should  be 
so  formed  as  to  prevent  emanations  from  patients 
in  the  lower  ward  passing  into  the  upper  wards. 
Practically,  with  care,  a well-laid  oak  floor,  with 
a good  beeswaxed  surface,  can  always  be  kept 
clean  by  nibbing. 

There  should  be  as  little  woodwork  as  possible 
in  a ward,  besides  the  floor;  and  what  wood- 
work there  is  should  be  varnished,  so  as  to 
admit  of  easy  washing  and  drying.  The  cleanest 
and  most  durable  material  is  varnished  light- 
coloured  wainscot  oak  or  teak. 

The  form  of  the  windows  must  be  considered,  in 
their  aspect  of  affording  light  as  a necessary  means 
of  promoting  health,  of  affording  ventilation,  of 
facilitating  nursing,  and  of  enabling  the  patients 
to  read  in  bed.  Light  can  always  be  modified 
for  individual  patients.  In  order  to  give  cheer- 
fulness to  the  wards,  and  to  renew  the  air  easily, 
the  windows  should  extend  from  within  2 feet 
or  2 feet  6 inches  from  the  floor — so  that  the 
patients  can  see  out — to  within  1 foot  from  the 
ceiling.  An  end  window  to  a long  ward  is  an 
element  of  cheerfulness,  and  materially  assists 
the  renewal  of  the  air  at  night.  It  is  essen- 
tial to  cleanliness  that  every  part  of  the  ward 
should  be  light.  One  superficial  foot  of  win- 
dow-space to  from  50  to  55  cubic  feet  of 
space,  will  afford  a light  and  cheerful  room,  but 


HOSPITALS,  CONSTRUCTION  OF. 


350 

this  depends  much  on  aspect  and  upon  the 
walls  being  light-coloured.  To  economise  heat 
in  wards,  it  is  desirable  to  make  the  windows  of 
plate  glass ; double  windows  of  ordinary  glass 
would  secure  the  same  object  and  facilitate  ven- 
tilation, but  they  are  troublesome  to  clean,  and 
give  a gloomy  appearance  to  a room.  The  best 
form  of  sash  for  ventilation  in  this  climate  is 
the  ordinary  sash,  opening  at  top  and  bottom ; 
but  windows  made  in  three  or  four  sections,  each 
of  which  falls  inwards  from  an  axis  at  the 
bottom  of  the  section,  possess  many  advantages 
for  hospitals. 

Ward  offices. — The  Ward  offices  are  of  two 
kinds  : — 

1.  Those  which  are  necessary  for  facilitating 
the  nursing  and  administration  of  the  wards,  as 
the  head-nurse’s  room  and  ward-scullery. 

2.  Those  which  are  required  for  the  direct  use 
of  the  sick,  so  as  to  prevent  any  unnecessary  pro- 
cesses of  the  patients  taking  place  in  the  ward ; 
as,  for  instance,  the  ablution-room,  the  bath-room, 
the  water-closets,  urinals,  and  sinks  for  empty- 
ing slops.  There  should,  in  addition  to  the 
bath-room  here  mentioned,  be  a general  bathing- 
establishment  attached  to  every  hospital,  with 
hot,  cold,  vapour,  sulphur,  medicated,  shower, 
and  douche  baths.  Hot  and  cold  water  should 
be  laid  on  to  all  ward-offices  in  which  the  use 
of  either  is  required,  because  of  the  economy  of 
labour  in  the  working  of  the  hospital.  For 
the  same  reason,  when  the  wards  are  on  two 
or  more  floors,  lifts  should  be  provided  to  carry 
up  coals,  trays,  and  patients.  The  ward-offices 
should  have  ample  window-space.  There  should 
be  no  dark  corners  or  closed  spaces  under  sinks. 
Nothing  should  be  kept  in  these  offices  which  is 
not  in  constant  use,  and  everything  in  use  should 
be  open  to  'mspeetion.  All  fittings  should  be 
light-coloured,  so  as  to  show  dirt. 

1.  The  head-nurse  or  sister's  room  should  be 
sufficiently  large  to  contain  her  bed,  and  to  be 
also  her  sitting-room.  It  should  be  light,  airy, 
and  well-ventilated.  It  is  necessary  to  discipline 
that  it  should  be  close  to  the  ward  door,  and 
that  it  should  when  practicable  have  a window 
looking  into  the  ward.  If  the  head-nurse  has  two 
wards  to  supervise,  her  room  should  be  placed  be- 
tween the  two.  with  a window  opening  into  each. 

There  should  be  a ward-scullery  to  each  ward, 
and  so  situated  as  to  be  under  the  head-nurse’s 
eye.  The  scullery  should  be  supplied  with 
efficient,  simple  apparatus  for  its  purposes ; there 
should  be  a small  range  for  ward-cooking,  so 
that  the  nurse  can  warm  the  drinks,  prepare 
fomentations,  &c.  Shelves  or  racks  should  be 
provided;  There  should  also  be  a small  larder, 
with  free  circulation  of  air,  for  temporarily 
keeping  provisions  fresh.  In  the  scullery,  or 
adjacent  to  it,  a hot  closet  should  be  provided 
for  airing  clean  towels  and  sheets.  Foul  linen 
should  not  be  retained  near  the  wards,  or  in 
the  hospital  building.  It  should  all  be  placed 
in  baskets,  on  wheels,  and  conveyed  as  soon  as 
possible  to  the  laundry.  Ward  sweepings  and 
refuse  should  similarly  be  placed  in  movable 
receptacles,  and  taken  out  of  the  building  with 
as  little  delay  as  possible  ; structural  provision 
for  the  retention  of  these  in  or  near  the  hospital 
is  undesirable. 


2.  The  ablution-room,  water-closets,  c.,  ought 
to  be  as  near  as  possible  to  the  ward,  but  cut 
off  from  it  by  a lobby,  with  windows  on  each 
side,  having  its  ventilation  and  warming  distinct 
from  that  of  the  ward  and  that  of  the  ward- 
offices,  so  as  to  prevent  the  possibility  of  foul 
air  passing  from  the  ward-offices  into  the 
wards.  The  ward-offices  will  be  most  conve- 
niently placed  at  the  end  of  the  ward  farthest 
from  the  entrance  and  nurse's  room ; and  dis- 
tributed at  each  side,  so  as  to  enable  the 
ward  to  have  an  end  window.  In  this  arrange- 
ment the  ablution-room  would  be  on  one  side  of 
the  ward,  and  should  contain  a small  bath-room 
with  a fixed  bath  of  copper,  supplied  with  hot 
and  cold  water.  A lavatory  table  of  impervious 
material,  such  as  slate  or  common  marble,  with 
a row  of  sunk  porcelain  basins  with  outlet 
tubes  and  plugs,  each  basin  supplied  with  hot 
and  cold  water,  should  be  placed  in  the  same 
compartment  as  the  bath,  but  separated  from  it 
by  a partition  and  door.  There  should  also  be 
room  for  a portable  bath  for  each  ward ; and 
there  should  be  a sink  on  the  floor  level  for 
running  off  the  water  from  the  bath  after  it  has 
been  used. 

On  the  other  side  of  the  end  window  of  the 
ward  would  be  placed  the  water-closets.  These 
should  never  be  against  the  inner  wall,  but 
always  against  the  outer  wall  of  the  compart- 
ment in  which  they  are  placed.  A pan  of  a 
hemispherical  shape,  never  of  a conical  shape, 
with  a syphon,  abundantly  supplied  with  water 
to  flush  it  out  all  round  with  a large  forcible 
stream,  is  the  best  contrivance  for  the  water- 
closet  of  a hospital.  The  urinal  should  be  of  a 
shape  to  be  easily  cleaned.  The  sink  for  slops, 
bed-pans,  expectoration-cups,  &c.,  which  should 
have  a compartment  of  its  own  adjoining  the 
water-closets,  should  be  a large,  deep,  round, 
pierced  basin  of  earthenware,  with  a cock  ex- 
tending far  enough  over  the  sink  for  the  stream 
of  water  to  fall  directly  into  the  vessel  to  be 
cleaned,  and  with  an  ample  supply  of  water  in  a 
full  stream;  this  sink  should  be  so  arranged  as 
to  be  flushed  out  like  a water-closet  pan,  and  it 
should  be  so  placed  as  to  make  it  unnecessary 
for  male  patients  to  pass  the  nurse  on  their  way 
to  thew.c.  There  should  be  a special  receptwle 
near  the  sink,  ventilated  to  the  outer  air.  for  keep- 
ing chamber  utensils,  &c.,  for  the  examination 
of  the  medical  officer. 

“Walls  of  ablution-rooms  and  water-closets 
should  be  covered  with  white  glazed  tile,  slate 
(enameded  or  plain),  or  Parian  cement ; plaster 
is  not  a good  covering  for  them  on  account  of 
their  liability  to  be  splashed,  and  of  the  neces- 
sity for  their  being  frequently  washed  down. 
There  should  be  separate  private  water-closets 
for  the  nurses;  and  also  water-closets  for  the 
patients  when  in  day-rooms  or  recreation- 
grounds.  The  ablution-room  and  water-closets 
should  be  supplied  with  plenty  of  fresh  air. 
warmed  when  necessary,  and  abundance  of 
light,  so  as  to  ensure  there  being  no  dark  cor- 
ners. Three  water-closets  per  ward  will  suffice 
for  a ward  of  thirty-two  beds,  but  two  at  least 
will  be  required  for  even  a twelve-bed  ward. 

The  water  supply  should  provide,  in  addition 
to  pure  water  for  general  consumption,  a servic* 


HOSPITALS.  CONSTRUCTION  OF.  651 


of  distilled  water  for  dressings  and  suchlike 
purposes. 

3.  Aggregation  of  "Ward-Units  in  the 
Construction  of  a Hospital. — The  principles 
upon  which  these  units  of  hospital-construction, 
or,  as  they  are  generally  termed,  pavilions, 
when  so  constructed,  should  be  aggregated,  are 
as  follows:  — 

(1)  There  should  be  free  circulation  of  air 
botween  the  pavilions. 

(2)  The  space  between  them  should  bo  ex- 
posed to  sunshine,  and  the  sunshine  should 
fall  on  the  windows,  for  which  purpose  it  is 
desirable  that  the  pavilions  should  be  placed  on 
a north  and  south  line. 

(3)  The  distance  between  adjacent  pavilions 
should  not  be  less  t han  twice  the  height  of  the 
pavilion  reckoned  from  the  floors  of  the  ground- 
floor  ward.  This  is  the  smallest  width  between 
pavilions  which  will  prevent  the  lower  wards 
from  being  gloomy  in  this  climate ; where  there 
is  not  a free  movement  of  air  round  the  build- 
ings, this  distance  should  he  increased. 

(4)  The  arrangement  of  the  pavilions  should 
be  such  as  to  allow  of  convenient  covered  com- 
munication between  the  wards,  without  interfer- 
ing witli  the  light  and  ventilation,  and  there- 
fore the  top  of  the  covered  corridor  uniting  the 
ends  of  pavilions  should  not  be  carried  above 
the  ceiling  of  the  ground-floor  wrards.  Each 
block  of  wards,  that  is,  each  pavilion,  should 
have  its  own  staircase. 

(5)  No  ward  should  be  so  placed  as  to  form 
a passage-room  to  other  wards. 

(6)  As  a general  rule,  there  should  not  be 
more  than  two  floors  of  wards  in  a pavilion.  If 
there  are  three  floors  or  more,  the  distances 
between  the  pavilions  become  very  considerable 
because  of  the  rule  already  mentioned,  which 
ought  to  be  absolutely  observed,  which  regu- 
lates the  distance  at  which  the  pavilions  must 
be  kept  apart.  Besides,  when  two  wards  open 
into  a common  staircase,  there  is,  with  every 
care,  to  some  extent  a community  of  venti- 
lation : this  will  prevail  even  if  the  staircase  be 
furnished  with  permanent  openings  to  the  outer 
air.  When  there  are  as  many  as  four  wards 
one  over  the  other,  the  staircase  becomes  a 
powerful  shaft  for  drawing  up  to  its  upper  part, 
and  thence  into  the  ward,  the  impure  air  of  the 
lower  wards.  Similarly,  heated  impure  air  from 
the  windows  of  the  lower  wards  has  occasion- 
ally a tendency  to  pass  into  the  windows  of  the 
wards  above.  Eor  the  same  reason  the  upper 
floor  over  the  wards  should  not  be  used  as  a 
dormitory  for  nurses.  Similarly  if  there  is  a 
basement  under  sick  wards,  it  should  not  he 
used  for  any  purpose,  such  as  cooking,  or  for  the 
reception  of  perishable  stores,  fromw'hich  smells 
could  penetrate  into  the  wards;  and  it  is  best 
not  to  continue  the  staircase  into  the  basement, 
for  with  every  care  the  basement  will  always 
form  a receptacle  for  ground  air,  which  should 
be  kept  out  of  the  hospital  if  possible. 

There  is  a limit  to  the  numbers  which  should 
be  congregated  under  one  roof.  This  limit  will 
depend  very  much  on  the  nature  of  the  cases. 
In  town  hospitals,  a double  pavilion  should  not 
contain  above  80  to  100  beds. 

The  size  of  any  given  hospital  ought  not  to  be 


determined  by  increasing  the  number  of  beds  in 
any  one  building,  but  by  increasing  the  number 
of  units  or  wards.  So  far  as  the  sick  are  con- 
cerned, they  would  be  better  placed  in  single 
detached  wards  ; or,  for  convenience  of  adminis- 
tration, in  wards  all  on  one  floor — opening  out 
of  a common  corridor.  But  on  town-sites  the 
cost  of  land  makes  it  absolutely  essential  to 
build  hospitals  as  compactly  as  possible  ; more- 
over, economy  in  the  current  expenses  will  ho 
best  secured  by  a building  with  wards  on  two  or 
more  floors,  provided  with  lifts  and  other  labour- 
saving  appliances. 

In  addition  to  the  larger  wards,  it  is  necessary, 
as  already  stated,  to  have  a few  wards  of  one  or 
two  beds  each  for  special  cases. 

Corridors  should  connect  the  pavilions  on  the 
level  of  the  lower  floor  of  wards  only.  They 
should  be  kept  as  low  as  possible,  so  as  not  to  im- 
pede the  circulation  of  air  between  the  pavilidns ; 
they  should  bo  lighted  by  windows  on  both 
sides,  opening  widely,  or  removable  in  warm 
weather ; and  they  should  be  provided  with  ample 
means  of  ventilation,  and  with  fresh  warmed  air 
in  cold  weather,  so  as  to  prevent  draughts. 

The  staircases  should  he  treated  similarly  as 
to  light  and  ventilation,  and  it  is  desirable  to 
cut  otf  the  counecting  corridors  from  adjacent 
staircases  by  swing-doors.  These  arrangements 
prevent  draughts,  and  cause  the  passages  and 
staircases  effectually  to  cut  off  the  ventilation 
of  one  pavilion  from  that  of  another. 

The  staircases  for  patients  should  he  broad 
and  easy ; the  rise  of  each  step  should  not  ex- 
ceed four  inches  in  height,  and  the  tread  should 
be  at  least  one  foot  in  width ; there  should  be  a 
handrail  on  each  side,  and  a landing  after  every 
six  or  eight  steps  provided  with  seats.  Tho 
patients  in  their  beds  may  be  wheeled  on  to  the 
roof  of  the  corridors  between  the  pavilions,  or 
on  to  a broad  balcony  outside  the  end  window  of 
the  ward,  in  fine  weather. 

4.  Administrative  Buildings. — The  ne- 
cessary subsidiary  accommodation  may  he  briefly 
described. 

Operating  rooms , dispensary,  and  school.  — - 
These  should  include  examining  room,  surgery, 
drug  store,  and  operating  theatre  ; the  latter 
having  roof-light  from  the  north,  and  being  of 
easy  access  to  the  surgical  wards  ; there  being 
one  theatre  for  male,  and  one  for  female  patients. 
Special  wards  for  such  cases  as  ovariotomy  should 
contain  but  one  bed.  A dead-house  and  post- 
mortem room,  with  ample  means  of  cleanliness, 
should  be  provided,  quite  outside,  and  detached 
from  the  hospital.  Where  a school  is  to  he  estab- 
lished, the  necessary  lecture-rooms,  laboratories, 
dissedting-rooms,  &c.  should  be  kept  entirely 
separate  from  the  building  for  the  sick. 

All  rooms  should  he  plain,  and  without  pro- 
jections or  ornaments,  which  form  a resting- 
place  for  dust. 

Officers’  quarters. — Apartments  for  the  resi- 
dent physician  and  surgeon,  matron,  nurses,  and 
servants  should  not,  if  practicable,  be  placed  un- 
der the  same  roof  with  the  sick.  All  the  rooms 
should  he  light  and  airy.  The  resident  physicians 
and  surgeons  should  have  each  a bed-room  and 
sitting-room,  with  proper  convenience  adjacent, 
and  a dining-room  for  joint  use. 


352  HOSPITALS,  CONSTRUCTION  OF. 

The  dispenser,  if  resident,  requires  a bed- 
room and  sitting-room.  An  office  is  required 
for  the  steward  (purveyor  or  financial  officer); 
and  a room  for  meetings  of  the  governing  body. 
Each  ordinary  nurse  should  have  a separate 
bed-room ; neither  bare,  tarnished,  nor  dismal ; 
■where  she  may  obtain  pure  air  while  she  sleeps — 
the  night  nurses’  bed-rooms  being  apart,  where 
they  may  not  be  disturbed  by  noise.  There 
should  be  bath  and  closet  accommodation  near ; 
but  women  should  each  be  allowed  a wasbstand 
and  foot-bath  in  their  own  room.  The  head-nurse 
or  1 sister  ’ sleeps  in  her  own  room,  overlooking 
her  ward ; but  if  there  is  no  common-room,  she 
would  have  better  health  if  a small  fitting- 
room,  as  well  as  bed-room,  could  be  given  her  off 
her  ward.  The  head-nurses  or  ‘ sisters  should 
hare  a dining-room,  and  also  a comfortable  well- 
furnished  sitting-room.  They  will  work  better 
in  their  wards  if  they  themselves  are  made  com- 
fortable. For  sisters  and  nurses  now-a-days 
are,  or  ought  to  be,  educated  women.  It  is 
most  undesirable  that  they  should  seek  necessary 
amusement  all  out  of  doors.  Nurses  should  dine 
in  the  sisters’  dining-room,  but  at  a different 
hour ; and  in  a large  hospital  there  would  pro- 
bably be  required  an  additional  dining-room  for 
ward-assistants.  In  hospitals  with  an  estab- 
lishment for  training  nurses,  which  every  large 
hospital  ought  to  have,  the  probationers  or 
pupil  nurses  (in  a proportion  not  exceeding  one 
to  every  ten  or  twelve  patients)  would  live  in  a 
‘ home  ’ under  the  hospital  roof,  and  under  the 
direction  of  the  hospital  matron. 

The  ‘ Home’ should  consist  of : — 1.  Class-room 
and  nurses’  library,  large,  airy,  and  convenient. 
2.  One  or  two  dining-rooms,  in  which  sisters 
and  nurses  might  also  dine,  and  pantry  adjoin- 
ing. 3.  Two  rooms  and  an  office  for  the  ‘ home 
sister’  (classmistress).  4.  One  separate  bed-room 
for  each  probationer,  sufficient  to  contain  press, 
table,  chair,  book-shelf,  washstand,  bedstead, 
and  arm-chair. 

Each  floor  should  have  a bath-room  and  other 
conveniences.  Bed-rooms  for  probationers  on 
night-duty  should  be  cut  off  from  the  noise  of 
the  ‘ Home.’  There  should  also  bo  provided 
one  sick  room ; one  visitors’  room ; and  ser- 
vants’ offices  and  bed-rooms  for  cook  and  other 
necessary  servants. 

Stores  for  bedding  and  linen,  kitchen  and 
'provision  stores. — The  kitchen  and  all  those 
stores  between  which  and  the  wards  there  is  a 
constant  movement,  should  be  as  central  as  pos- 
sible, so  as  to  save  labour ; but  the  kitchen  should 
be  carefully  cut  off  from  the  corridor  connecting 
the  pavilions.  Attached  to  the  kitchen  should 
be  a good  scullery,  larder,  and  serving  con- 
veniences. There  should  be  a large,  well-aired, 
well-lighted,  well- warmed,  well-arranged  linenry 
and  mending  room.  The  hospital  laundry  should 
be  detached  from  the  hospital.  Special  care 
should  be  taken  to  make  the  laundry  buildings 
airy  and  very  light,  with  ample  means  of  venti- 
lation for  removing  the  steam,  which  is  heavily 
charged  with  organic  impurity,  and  with  ample 
{pace  for  the  washers.  They  should  have  sepa- 
rate drying  and  ironing  rooms. 

Out-patients  department. — Those  hospitals 
which  afford  out-door  relief  require  a dispensary 


HYDATIDS. 

for  out-door  sick.  This  should  always  have  an 
entrance  separate  from  the  hospital,  and  should 
never  be  under  or  near  a ward,  or  in  the  space 
between  adjacent  wards.  It  is  placed  in  proxi- 
mity to  the  hospital,  for  the  convenience  of  the 
medical  men,  and  medical  school  (if  any),  and  in 
order  to  be  near  the  drug-store  and  apothecary’s 
shop ; but  it  should  be  entirely  detached,  with 
a free  air-space  between,  and  no  direct  commu- 
nication be  possible. 

The  out-patients’  department  requires  a large 
airy  waiting-room,  with  separation  of  sexes, and 
separate  closet  accommodation  for  males  and 
females,  which,  without  great  care,  may  (even 
when  detached)  become  a nuisance  to  the  sick 
wards  ; a consulting  room  for  each  of  the  ph)T- 
sicians  and  surgeons;  to  which  should  be  attached 
a small  lavatory  and  all  necessary  convenience 
for  the  complete  examination  of  patients.  The 
out-patients’  department  of  Children’s  Hospitals 
requires  more  care,  and  more  ample  space  in 
waiting-rooms,  because  each  patient  is  brought 
by  its  nurse.  The  entrance  and  exit  should  be 
through  different  doors. 

In  every  large  hospital  should  be  provide  1 a 
well-ventilated  chapel,  capable  of  being  well 
warmed. 

The  position  and  general  construction  of  the 
administrative  buildings  should  be  made  quite 
subservient  to  the  accommodation  for  the  sick, 
and  to  the  broad  general  principle  that  these 
buildings  should  not  interfere  with  the  circula- 
tion of  the  air  round,  or  the  light  of,  the  wards. 

Douglas  Galtox. 

HUM,  VENOUS. — A continuous  murmur 
heard  in  the  veins,  generally  observed  in  cases 
of  anaemia.  Sec  An.emia  ; and  Physical  Exami- 
nation. 

HUMID  ( humidus , moist). — Moist — in  con 
tradistinction  to  dry.  Applied  to  rales  (set 
Physical  Examination)  ; to  characterise  a va- 
riety of  asthma  attended  with  expectoration  ( see 
Asthma)  ; and  also  to  particular  climates.  See 
Climate. 

HUMORAL  (humor,  a humour). — Of  or  re- 
lating to  the  humours.  Chiefly  tised  as  a term 
for  a pathological  doctrine — the  humoral  patho- 
logy— which  associates  all  diseases  with  morbid 
states  of  the  fluids  of  the  body  (sec  Blood- 
disease).  The  word  is  also  sometimes  employed 
as  synonymous  with  humid,  when  applied  to 
asthma. 

HHNYADI  JANOS,  in  Hungary.  Sul- 

phated  waters.  See  Mineral  Waters. 

HYDATIDS  (uSotIs,  a drop  of  water). — 
Stnon.  : Fr.  Hydatidc ; Ger.  Blasenvmrm. 

General  Remarks. — This  term  is  now  re- 
stricted to  those  bladder-worms  which  are  larval 
forms  of  the  so-called  Tania  echinococcus — a mi- 
nute tapeworm  residing  in  the  dog  and  wolt. 
Formerly  all  the  bladder-worms  were  apt  to  1 e 
spoken  of  as  hydatids,  and  thus  we  had  the  H - 
datis  celluloses,  H.crratica,  Hydatigena  granulosa. 
and  so  forth.  Thev  were  also  frequently  called 
accphalocysts,  and  thus,  following  I.uennec,  we 
had  the  Accphalocystis  granulosa.  A.  cx  gcna  and 
endogena  of  Kuhl  and  John  Hunter,  A.  su-culi 


HYDATIDS. 


gera,  &c.  Again,  they  -were  as  often  charac- 
terised as  various  species  of  Echinococcus,  whence 
we  had  the  Echinococcus  hominis,  E.  veterinorum, 
E.  polymorphic,  E.  granulosus,  and  so  on.  At 
length,  all  these  numerous  forms  of  hydatid 
were  reduced  to  a very  few  types,  and  now  we 
are  all  agreed  that  there  is  only  one  true  larval 
species,  although  it  is  liable  to  assume  a practi- 
cally endless  variety  of  shapes. 

That  the  minute  tapeworm  ( Taenia  echinococcus) 
is  really  the  sexually  mature  condition  of  the 
ordinary  hydatid,  as  known  to  physicians  and 
surgeons,  was  first  experimentally  proved  by 
Nanny n,  who,  in  1864-,  fed  two  dogs  with  liver 
hydatids,  previously  ascertained  to  contain  heads 
( scolices ).  The  first  dog,  destroyed  twenty-eight 
days  afterwards,  yielded  a negative  result ; but 
the  second  dog,  killed  thirty-five  days  subse- 
quent to  the  feeding,  contained  numerous  exam- 
ples of  Tania  echinococcus  in  the  sexually  mature 
condition. 

By  feeding  dogs  with  fresh  and  perfectly 
formed  hydatids  we  have  thus  obtained  the  mi- 
nute tapeworm  which  selects  for  its  abode  the 
upper  part  of  the  small  intestine.  Conversely, 
hydatids  may  be  reared  by  feeding  animals  with 
the  eggs  of  the  Tania  echinococcus.  It  appears 
that  the  formation  of  all  true  hydatids,  whether 
developed  in  mankind  or  in  animals,  results  from 
the  ingestion  of  the  tape-worm  eggs.  The  eggs 
may  be  swallowed  either  with  food  or  drink.  In 
this  way,  impure  water  is  doubtless  the  most 
common  source  of  hydatid  disease.  All  open 
waters,  if  dogs  abound  in  the  neighbourhood, 
are  liable  to  be  contaminated  with  the  fatal 
germs.  The  careless  drinking  of  unfiltered  or 
insufficiently  filtered  water  may  lead  to  hydatid 
infection. 

The  formation  of  hydatids,  after  the  eggs  have 
been  swallowed,  is  a very  slow  process.  What 
we  know  on  this  point  is  principally  due  to  tho 
researches  of  Leuekart ; but  our  knowledge  of 
the  intimate  structure  of  the  perfected  organism, 
as  such,  has  been  very  carefully  worked  out  by 
a number  of  observers,  amongst  whom,  after 
Leuekart,  stand  the  names  of  Basmussen, 
Naunyn,  Heller,  Yon  Siebold,  Eschricht,  Wage- 
ner,  Kiichenmeister,  Erasmus  Wilson,  Busk,  and 
Huxley.  In  this  connection  also,  particular 
mention  must  he  made  of  the  researches  of 
Virchow,  who  was  the  first  to  make  us  acquainted 
with  the  true  nature  of  the  multilocular  form  ( Echi- 
nococcus multilocularis ) which  has  also  been  inves- 
tigated, amongst  others,  byLuschka,  Leuekart,  and 
Heller.  In  the  more  purely  pathological  and 
statistical  aspects  of  the  subject,  the  writings  of 
Bokitansky,  Schleisner,  Wunderlich,  De  Haen, 
Krabbe,  Kleneke,  Livois,  and  Davaine  hold  a 
conspicuous  place ; whilst  clinically  wo  have 
space  only  to  particularise  the  memoirs  of  Mur- 
chison, Begbie,  Cleghorn,  MacgiUivray,  Bobert- 
son,  Dougan  Bird,  and  especially  Hearn  ( Kystes 
Hydatiques  du  Poumon  ; Paris,  1875).  From  the 
above  statement,  it  will  readily  be  understood 
that  the  literature  of  the  subject  is  of  very  great 
extent ; but  those  who  desire  an  exhaustive 
knowledge  of  the  subject  should  also  consult 
Dr.  Albert  Neisser's  admirable  compilation  ( Die 
Echinococcenkrankhcit : Berlin,  1877).  In  this 
plaeo  it  is  only  intended  to  offer  a brief  account 


653 

of  the  general  structure  of  hydatids,  with  a 
resume  of  the  facts  of  their  distribution  and 
prevalence  in  particular  countries,  and  their 
occurrence  in  the  organs  of  the  body  selected 
for  residence.  Bemarks  on  treatment,  and  on  the 
hygienic  bearings  of  the  subject  will  fitly  close 
the  article. 

Description.  — Pathologists  recognise  three 
varieties  of  hydatid,  namely,  the  exogenous,  en- 
dogenous, and  multilocular.  The  first  of  these  is 
sparingly  found  in  man,  but  very  common  in  tho 
lower  animals.  The  second  is  rare  in  animals,  but 
frequent  in  the  human  subject.  The  third  variety 
is  found  in  man,  very  rarely  ; Professor  Bollinger 
having  also  found  it  in  the  liver  of  a calf 
(Deutsch.  Zeitsch.  f.  Thicrmcd. ; 1876).  Thepre 
cise  mode  of  origination  and  growth  cannot  be 
discussed  here.  Practically,  it  is  of  little  moment 
which  of  the  various  hypotheses  we  accept ; 
nevertheless  the  subject  is  of  the  highest  interest 
when  viewed  from  a physiological  standpoint. 
Whilst  there  is  rarely  any  difficulty  in  determin- 
ing the  character  of  ordinary  hydatids,  whether 
of  the  exogenous  or  endogenous  kind,  the  multi- 
locular form  is  very  apt  to  be  overlooked  or  mis- 
interpreted. It  has  been  mistaken  for  alveolar 
colloid,  with  which  latter  product,  as  remarked 
by  Virchow,  it  has  nothing  whatever  in  com- 
mon. There  is  reason  to  believe  that  some  of 
the  so-called  examples  of  cirrhosis  of  the  live- 
are  neither  more  nor  less  than  multilocular  hy- 
datid growths.  Professor  Heller,  of  Kiel,  has 
called  our  attention  to  several  preparations  in 
the  London  Museums,  which  he  thinks  may  be 
of  this  order,  but  the  writer  has  not  found  oppor- 
tunity to  examine  them  microscopically.  Con- 
densing Leuckart’s  description,  which  we  have 
ourselves  verified  from  the  examination  of  a 
specimen  kindly  supplied  by  Heller,  it  may  be 
said  that  the  essential  characters  of  this  growth 
are  marked  by  a tough,  well-defined  fibrous 
limiting  capsule,  consisting  of  a dense  stroma, 
whence  bands  of  connective  tissue  pass  off  in 
every  direction,  penetrating  the  entire growth,  and 
leaving  small  interstices.  These  interstices  or 
alveoli  are  irregular  in  shape,  lined  with  vesicles 
that  are  filled  with  a gelatiniform  plasma,  occa- 
sionally containing  also  the  so-called  echinococcus- 
heads.  Here  and  there  small  blood-vessels  may 
be  seen,  and  also  collapsed  bile-ducts,  but  no  trace 
of  any  true  glandular  parenchyma  of  the  organ 
affected. 

Ordinary  hydatids,  whilst  presenting  variable 
shapes  according  to  the  nature  of  the  organ 
occupied,  commonly  exhibit  a thick  investing 
capsule  derived  from  the  tissues  of  the  infested 
part.  Within  this  capsule  or  cyst  we  first  come 
upon  a thick,  homogeneous,  laminated,  elastic 
membrane,  which,  if  withdrawn,  displays  a 
peculiar  tremulous  motion,  coiling  upon  itself 
wherever  it  happens  to  be  divided  by  the  scalpel. 
This  is  the  so-called  cuticular,  structureless  layer, 
or  ectocyst  of  Huxley.  Within  this  outer  layer, 
and  closely  applied  to  it,  lies  the  delicate  endocyst 
of  the  same  authority.  This  is  a thin,,  soft, 
comparatively  non-elastic,  granulated  membrane, 
forming  the  essentially  vital  part  of  the  bladder- 
worm.  From  this  inner  membrane  buds  are 
produced,  and  these  gemmie  become  transformed 
into  echinococcus-heads  both  in  a direct  and 


654 


HYDATIDS. 


indirect  maimer.  Commonly  they  form  broad 
capsules  containing  numerous  heads,  some  of 
which,  by  a process  of  eversion,  may  be  seen 


Fw.'t4.  Hydatid  of  four  weeks’  growth,  showing  ecto- 
cyst  and  endocyst.  x 60.  After  Leuckart. 

projecting  into  the  general  cavity  of  the  mother- 
hydatid.  At  other  times  by  a process  of  what 
is  termed  proliferation,  daughter  and  even 
grand-daughter  hydatids  are  formed  within  the 


Bin.  25.  Group  of  Echinococci,  with  their  hook-crowns 
inverted,  x ISO  diam.  After  Busk. 

original  maternal  hydatid,  and  these  smaller 
hydatids  (constituting  an  agamogenetie  bladder- 
worm  progeny)  in  their  turn  produce  echino- 
coccus-heads within  them.  The  precise  mode 
of  origination  of  these  buds 
is  still  a subject  of  dispute, 
notwithstanding  the  re- 
markable investigations  of 
Leuckart,  Naunyn,  and 
Rasmussen.  Neither  of  the 
two  former  authorities  be- 
lieves that  the  heads  can  be 
formed  in  a direct  manner 
from  the  endocyst,  as  de- 
scribed andfiguredby  Hux- 
ley. The  question  as  to  the 
existence  of  cilia  on  the  en- 
docysts  and  brood-capsules 
is  also  unsettled.  Cilia  have 
been  noticed  by  Owen,  Le- 
Fio.  26.  The  so-called  bert,  and  Whittell.  These 
Echino  occui  head, show-  various  authorities  aver 

ko°ks-  that  they  occur  outside  the 

cilia,  and  corpuscles.  , ■ , . . _ 

x 250  diam.  After  so-called  echinococci.  Hux- 
Huxley.  ley  looks  upon  them  as 

having  a connection  only  with  the  water-vascular 
system,  whilst  Leuckart  entirely  failed  to  detect 
them  anywhere.  We  are  not  here  called  upon  to 


pursue  this  part  of  the  subject  further,  but  may 
remark  in  passing  that  the  little  sacs  now  termed 
brood-capsules  by  Leuckart  and  others  were  well 
known  to  Erasmus  Wilson,  who  figured  them  in 
1845,  and  also  to  Busk,  who  previously  spoke  of 
them  as  ‘granulations’  (1844). 

Occukrencb.  — The  prevalence  of  hydatids 
in  any  country  bears  a strict  relation  to  the 
degree  of  intimacy  subsisting  between  its  in- 
habitants and  the  dogs  employed  by  them  for 
domestic  purposes.  If  in  this  respect  Iceland 
holds  pre-eminence ; the  explanation  is  not  fir  to 
seek.  As  remarked  by  Krabbe,  it  is  not  neces- 
sary to  suppose  that  the  Icelanders  actually 
devour  the  excrement  of  dogs,  although,  to  be 
sure,  canine  faeces,  according  to  Schleisner.  figure 
amongst  the  remedial  agents  employed  by  quacks 
and  empirics.  It  is  sufficient  for  the  purpose 
of  infection  that  the  natives  and  their  dogs  share 
the  same  habitation,  that  the  animals  are  fondly 
caressed,  that  they  feed  off  the  same  plates  (which 
they  are  often  encouraged  to  lick  clean,  in  order 
that  their  masters  may  be  spared  the  trouble  of 
having  them  washed),  and  that  they  sleep  with 
the  peasants  in  the  same  bed.  Thus,  as  Krabbe 
says,  either  through  carelessness,  ignorance,  or  in- 
difference on  the  part  of  the  natives,  the  eggs  of 
the  hydatid-forming  tapeworm  have  abundant  op- 
portunity of  gaining  access  to  the  human  bearer. 
To  a certain  extent,  as  Krabbe  observes,  this 
close  relationship  and  high  degree  of  infec- 
tion are  forced  upon  the  poor  people  by  the 
rigours  of  the  climate,  and  insufficient  resources 
of  the  country.  Nevertheless,  it  is  clear  that  a 
very  large  amount  of  echinococcus-disease  exists 
in  countries  where  there  is  comparative  freedom 
from  these  disadvantages.  The  circumstance 
that  the  germs  are  far  too  small  to  be  seen  by 
the  naked  eye,  and  that  they  maybe  distributed 
by  various  possible  agencies  (long  after  they 
have  either  been  passed  with  the  faeces,  or  have 
been  dispersed  by  the  semi-independent  and 
sexually  ripe  proglottides),  is  alone  sufficient  to 
ensure  infection,  provided  the  necessary  sanitary 
precautions  are  not  adopted.  Openmtural  waters, 
however  pure  and  sparkling  they  may  look,  are 
apt  to  contain  hydatid  germs  in  all  countries 
where  dogs  abound.  Thus  it  is  that  cattle  be- 
come infected;  not  alone  indeed  by  drinking 
foul  water,  but  also  by  grazing  in  districts  where 
the  eggs  of  the  Tenia  echinococcus  are  dispersed 
by  winds,  rain,  and  even  insects  flying  away 
from  the  germ-infected  faecal  matter  on  which 
they  had  previously  settled  for  repast.  Of 
course,  direct  contact  with  infested  dogs  renders 
infection  almost  a matter  of  certainty.  .Anyone 
who  has  witnessed  the  migration  of  tapeworm 
proglottides  on  the  surface  of  the  bodies  of  cats 
and  dogs,  will  readily  understand  how  it  comes 
to  pass  that  the  mere  act  of  coaxing  a Jog’s  back 
is  sufficient  to  convey  numerous  germs  to  the 
hand,  whence  they  maybe  transferred  to  the  lips 
and  mouth  of  the  human  bearer.  It  is  fortunate, 
indeed,  that  in  European  countries  our  Tenia 
echinococcus  is  comparatively  rare  in  the  dog. 
But  for  this  circumstance,  hydatids  might  be- 
come almost  as  prevalent  amongst  the  peasantry 
of  our  own  couutry  as  they  are  known  to  be  in 
Iceland.  Probably  the  next  most  infested  terri- 
tory is  that  of  Victoria  (Australia).  On  this 


HYDATIDS. 


point  the  -writer  has  collected  much  convincing 
evidence ; recently  confirmed  by  Dr.  David 
Thomas,  of  Adelaide.  According  to  one  local 
authority,  not  only  has  the  disease  been  more  or 
less  prevalent  in  the  Victoria  colony  for  many 
■years  past,  but  it  is  ‘ greatly  on  the  increase  in 
the  human  subject.’  It  would  be  easy  to  multi- 
ply statements  bearing  out  the  same  truth,  but 
the  subject  is  too  special  fcr  detailed  treatment, 
and  it  has  been  dealt  with,  at  some  length,  in 
the  writer’s  general  treatise  ( Parasites ; London, 
1879).  Those,  also,  who  desire  to  obtain  a general 
notion  ot'  the  frequency  of  hydatids  in  England 
would  do  well  to  reflect  upon  the  amount  of 
collateral  evidence  supplied  ly  the  numerous 
specimens  preserved  in  the  museums  of  the 
metropolis  and  elsewhere.  In  the  face  of  facts, 
patent  to  all.  it  must  be  obvious  that  the  amount 
of  hydatid  disease  now  existing  everywhere,  is 
susceptible  of  being  greatly  diminished  by  the 
introduction  of  appropriate  sanitary  regulations. 
In  what  these  regulations  consist  may  be  readily 
gathered  from  the  circumstances  connected  with 
infection.  To  some  extent,  Iceland  has  already 
moved  in  the  matter,  following  the  counsel  of 
Dr.  Krabbe. 

Situation's. — The  relative  prevalence  of  hyda- 
tids in  particular  organs  of  the  body  is  a matter 
of  great  concern,  clinically  and  hygienically. 
The  writer  has  been  at  some  pains  to  open  up 
this  subject,  and  from  the  data  collected  inde- 
pendently by  Davaine  and  himself,  the  results 
obtained  may  be  relied  on  as  approximately 
correct.  Deduced  to  the  lowest  number  of  prac- 
1 tically  available  or  useful  terms,  our  statistics 
1 stand  as  follows  : — 

Organs  affected.  Davaine.  The  writer.  Total. 


Liver  . . . . 

165 

161 

. 326 

Abdomen,  pelvic  cavity, 

and  spleen 

26  . 

45 

. 71 

Lungs  .... 

40  . 

22 

. 62 

Kidneys  and  bladder  . 

30  . 

23 

. 53 

Brain  . . . . 

20  . 

22 

. 42 

Bones  . 

17  . 

16 

. 31 

Heart,  and  pulmonary 

vessels 

12  . 

13 

. 25 

Miscellaneous 

63  . 

25 

. 92 

Grand  total  . 

373  . 

327 

. 700 

Notwithstanding  certain  apparent  differences, 
the  results  separately  obtained  by  Davaine  and  the 
writer  show  a remarkable  correspondence.  Thus, 
in  the  case  of  those  organs  respecting  which  no 
dispute  could  well  arise  as  to  the  real  seat  of  the 
disorder,  the  results  are  tolerably  uniform.  This 
is  seen  in  the  case  of  the  liver,  brain,  heart,  and 
bones.  Even  in  those  instances  where  the  re- 
sults do  not  appear  to  correspond,  the  explana- 
tion of  the  discrepancies  is  very  simple.  One 
example  will  suffice  to  illustrate  this  point.  The 
twenty-six  abdominal  cases  credited  toDavaine’s 
record  are  all  placed  by  him  under  the  heading 
jf  ‘ Pelvis.’  whilst  all  those  cases  placed  by  the 
writer  under  the  abdominal  series  not  only  in- 
dude  hydatids  of  the  pelvic  cavity,  but  also  two 
j rom  the  spleen  and  nineteen  from  the  perito- 
neum and  intestines,  besides  others. 

1 As  the  facts  thus  stand,  it  is  instructive  to 
! ctiee  that  the  liver  cases  comprise  nearly  461 
er  cent.  Comparatively  recent  computations 


655 

by  Dr.  Albert  Neisser,  based  on  083  cases,  afford 
a percentage  of  45'765  for  liver  cases.  It  is 
especially  worthy  of  remark  also  that  no  in- 
considerable proportion  of  the  bladder-worms 
occupy  organs  of  vital  importance  to  the  host. 
If,  in  reference  to  sanitation,  statisticians  would 
obtain  an  adequate  conception  of  the  cause  of  the 
fatal  power  of  hydatids,  they  should  look  close 
into  this  matter.  Let  them  note  the  fact  that  in 
6 per  cent,  of  all  the  eases  collected  by  Davaine 
and  the  writer  the  eutozoon  occupied  the  brain  ; 
in  about  31  per  cent,  they  took  up  their  resid- 
ence in  the  heart ; and  probably  in  not  less  than 
15  per  cent,  of  all  the  other  cases  they  operated 
to  bring  about  the  death  of  the  human  bearer. 
The  writer  is  of  opinion  that  (excluding  the  eases 
cured  by  surgical  interference)  the  echinoccocus- 
bladderworm  proves  fatal  to  25  per  cent,  of  all 
the  human  victims  it  attacks.  Animal-bearers, 
on  the  other  hand,  comparatively  rarely'  succumb 
to  hydatid  invasion.  (For  further  details  see 
Lancet,  Jan.  19,  1875,  p.  850  ; British  Medical 
Journal,  1875 ; and  the  writer's  treatise  on 
Parasites,  1879,  pp.  121-141.) 

Diagnosis. — Many  cases  of  hydatids  present 
extreme  difficulty  in  respect  of  diagnosis,  espe- 
cially those  occupying  the  cavity  of  the  chest.  To 
diagnose  hydatids  of  the  brain,  heart, and  kidneys 
is  rarely  possible,  unless  very  strict  attention 
be  paid  to  the  symptoms,  and  to  the  condi- 
tions under  which  the  patient  has  been  living. 
In  kidney  cases,  the  escape  of  smad  vesicles  with 
the  urine,  would,  of  course,  help  to  decide  the 
matter.  In  heart-cases  it  is  rare  that  any  pre- 
monitory symptom  of  the  affection  shows  itself. 
Under  ordinary  circumstances,  where  these  and 
certain  other  oraans  are  out  of  the  question,  the 
presence  of  a fluctuating  tumour,  without  any 
concomitant  inflammatory  symptoms,  especially' 
if  it  be  seated  in  the  region  of  the  liver,  would 
to  most  of  ns  at  once  suggest  the  likelihood  of 
the  occurrence  of  an  hydatid  growth.  Much  has 
been  said  of  Piorri’s  ‘hydatid  fremitus,’  which, 
however,  scarcely  differs  from  the  ordinary  im- 
pulse communicated  by  fluid  matter  within  any 
other  kind  of  tumour.  Speaking  generally,  the 
accidental  discharge  of  one  or  more  aeephaloeysts 
constitutes  the  most  common  and  absolutely  cer- 
tain means  of' diagnosis.  That  these  formations 
are  frequently  discharged  by  the  natural  outlets  of 
the  body  is  well  known  to  every  practitioner ; and 
not  unfrequently  has  the  scalpel  of  the  surgeon 
evacuated  them,  when  their  presence  was  not  so 
much  as  suspected  by  the  operator.  How  con- 
stantly their  presenco  within  the  vis-’era  is  alto- 
gether overlooked  is  a matter  well  known  to 
every  pathologist  connected  with  our  large  hos- 
pitals. 

Treatment. — The  treatment  cf  hydatid- dis- 
easo  may  naturally  be  spoken  of  under  three 
heads,  namely,  surgical,  medical,  and  prophy- 
lactic or  preventive. 

Surgical.  — With  the  first  method  we  have 
of  course  little  to  do  here,  but  in  respect  of 
diagnosis  it  is  obvious  ih  t the  surgeon  must 
often  require  the  assistance  of  the  physician.  In 
the  matter  of  operative  treatment,  the  writer  has 
elsewhere  taken  occasion  to  comment,  incident- 
ally, upon  the  remarkable  amount  of  success 
obtained  by  Dr.  MacGillivray,  at  the  Bendigc 


HYDATIDS. 


G5G 

Hospital.  (See  his  records  given  from  time  to 
time  in  the  Australian  Medical  Journal .) 

Medical. — As  regards  the  success  of  medical 
treatment,  the  opinion  long  ago  expressed  in  the 
writer's  Introductory  treatise  still  holds  good 
(Entozna,  1861,  p.  285).  As  then  stated,  ‘a 
great  deal  of  nonsense  has  been  written  about 
the  efficacy  of  particular  drugs,’  but,  making 
allowance  for  the  advantages  secured  by  aspira- 
tion and  electrolysis,  we  think  that  the  words 
spoken  by  Dr.  Todd  in  1851,  are  still  very  near 
the  truth: — ‘I  know  of  no  cure  for  hydatids  but 
the  evacuation  of  them.  There  is  a popular 
notion  that  salt  will  kill  the  hydatid.  Iodide 
of  potassium  has  also  been  frequently  tried, 
but  I have  never  seen  any  real  benefit  from 
the  use  of  these  remedies.’  Since  Dr.  Todd’s 
time,  the  employment  of  several  other  drugs 
has  been  warmly  advocated  by  different  physi- 
cians, amongst  whom  the  names  of  Dr.  Leared, 
Dr.  HjalteliD,  and  Dr.  Bird  stand  out  most  pro- 
minently. According  to  the  two  first-named 
observers  kamala  has  the  power  of  destroying 
hydatids.  If,  however,  anyone  will  take  the 
trouble  to  peruse  Dr.  MacGillivray’s  record  of 
his  efforts  to  obtain  proof  of  the  alleged  cura- 
tive properties  of  kamala,  when  administered 
internally,  they  will  at  once  perceive  that  this 
much  over-praised  drug  has  ‘ no  influence 
whatever  on  the  disease.’  In  like  manner,  the 
writer  fears  that  the  alleged  virtues  of  tur- 
pentine in  this  respect,  as  advocated  by  Austra- 
lian practitioners,  will  turn  out  to  be  an  entire 
mistake.  It  is  all  very  well  to  speak  of  turpen- 
tine and  certain  other  well-known  anthelmintics 
as  powerful  taeniafuges ; but  it  is  quite  another 
thing  to  assert  that  these  drugs  can  destroy 
bladder- worms  by  the  ordinary  mode  of  oral  ad- 
ministration. As  stated  in  the  early  part  of  this 
article,  the  essentially  vital  part  of  the  hydatid 
is  the  granular  endocyst,  and  to  reach  this  the 
poisou  must  not  only  penetrate  the  more  or  less 
dense  capsule  of  connective  tissue,  but  also  the 
laminated  ectocyst.  If  the  advocates  of  kamala 
had  reflected  on  the  enormous  quantity  of  the 
drug  necessary  to  produce  any  sensible  effect 
on  the  hydatid,  they  would  probably'  not  have 
attempted  its  employment.  In  like  manner,  not- 
withstanding what  has  been  said  of  the  power  of 
turpentine,  in  respect  especially  ‘of  its  property 
of  accumulating  in  the  system,’  we  must  express 
ourselves  as  exceedingly  sceptical  as  to  the  likeli- 
hood of  turpentine  being  of  any  more  curative 
value  than  kamala  when  prescribed  internally. 
In  regard  to  the  successful  employment  of  iodine 
and  other  chugs  for  the  purposes  of  injection, 
after  evacuation  of  the  fluid  contents  of  hydatid 
cyst3.  there  can  be  no  doubt  as  to  the  good  re- 
sults frequently  obtained ; nevertheless,  as  M. 
Boinot  and  others  long  ago  pointed  out,  cer- 
tain precautions  are  necessary,  especially  when 
dealing  with  growths  occupying  the  neighbour- 
hood of  serous  cavities.  In  this  connection  Da- 
vaine’s  Trade  des  Entozoaires  should  be  con- 
sulted, and  also  Hearn’s  clinical  work,  which,  so 
far  as  hydatids  of  the  thoracic  cavity  are  con- 
cerned, is  thoroughly  exhaustive  and  reliable. 
We  are  entirely  in  accord  with  Hearn,  who 
affords  us  a true  criterion  of  his  estimate  as  to 
the  value  of  drugs  when  he  incidentally  remarks 


that  the  medical  treatment  of  hydatids  in  no 
way  affects  the  prognosis. 

Prophylactic.— The  prophylactic  treatment  of 
hydatids  deserves  the  most  serious  attention 
of  those  interested  in  the  advance  of  State 
medicine.  As  all  the  circumstances  favour- 
able to  the  production  of  the  echinococcus 
disorder  are  now  well  known,  it  clearly  fol- 
lows that  the  malady  falls  within  the  category 
of  those  endemics  which  admit  of  being  either 
largely  checked,  or  altogether  stamped  out. 
There  is  no  need  to  recapitulate  the  aetiology  of 
the  subject  at  any  length,  and  the  writer  can 
only  again  insist  upon  the  adoption  of  those  mea- 
sures which  he  has  sought  to  enforce  for  many 
years  past.  He  has  recommended  that  boiling 
hot  water  should  be  thrown  over  the  faeces  of 
clogs,  not  only  in  kennels,  but  in  all  places  where 
the  excreta  are  exposed.  To  attempt  to  collect 
and  burn  the  faeces  would  be  too  troublesome  a 
process,  and  not  so  effective,  since  a large  num- 
ber of  the  invisible  eggs  scattered  on  the  ground 
or  flooring  would  inevitably  escape.  lu  this 
view,  tho  late  Dr.  Leared's  proposal  that  everv 
dog  should  be  efficiently  purged  with  an  anthel- 
mintic and  cathartic  at  certain  intervals  is 
worthy  of  attention.  Dr.  Leared  further  advised 
that  the  excreta  should  be  buried;  but  the 
writer's  plan  of  destruction  of  the  germs  by  boil- 
ing water  seems  more  effective  and  more  easy  of 
accomplishment.  Professor  Leuckart,  in  an  ela- 
borate but  popularly  written  article,  embodying  a 
review  of  all  the  more  important  facts  of  helmin- 
thological study  in  relation  to  the  public  health 
( TJnsere  Zeit,  1862,  s.  651),  gives  an  admirable 
summary  of  the  sanitary  bearings  of  the  subject 
in  the  following  terms : — ‘ In  order  to  escape  th6 
dangers  of  infection,  the  dog  must  be  watched, 
not  only  within  the  house,  but  whilst  he  is 
outside.  He  must  not  be  allowed  to  visit 
either  slaughter-houses  or  knackeries,  and  care 
must  be  taken  that  neither  tho  offals  nor  hyda- 
tids found  in  such  places  are  accessible  to  him. 
In  this  matter  the  sanitary  inspector  has  many 
important  duties  to  perform.  The  carelessness 
with  which  these  offals  have  hitherto  been  dis- 
posed of,  or  even  purposely  given  to  the  dog, 
must  no  longer  be  permitted,  if  the  welfare  of 
the  digestive  organs  of  mankind  is  to  be  con- 
sidered. What  good  results  may  follow  from 
the  adoption  of  these  precautions  may  be  readily 
gathered  from  the  consideration  of  the  fact  that, 
at  present,  almost  the  sixth  part  of  all  the  in- 
habitants annually  dying  in  Iceland  fall  victims 
to  the  echinococcus  epidemic.’  The  Leipzig  hel- 
minthologist next  dwells  upon  the  conditions 
already  shown  to  be  so  eminently  favourable 
to  the  production  of  the  disorder,  and  concludes 
by  remarking  that  ‘cleanliness  is  one  of  the 
most  important  preservatives  against  infection. 
Without  doubt  this  is  so ; but.  as  a matter  of 
fact,  no  amount  of  care  in  this  respect  will 
ensure  immunity  from  hydatid  disease.  Occa 
sionally,  though  happily  very  rarely,  the  most 
delicately  nurtured  persons,  who  have  all  their 
lifetime  lived,  as  it  were,  in  the  lap  of  luxury, 
fall  victims  to  the  malady.  One  such  case,  that 
of  a lady,  was  not  very  long  ago  brought  under 
the  writer's  notice  by  an  eminent  practitioner, 
who  tapped  the  abdominal  tumour,  at  first  sue 


HYDATIDS. 

cessfully,  but  on  a second  occasion  -with  a fatal 
result  to  the  patient.  The  explanation  of  the 
occasional  occurrence  of  hydatids  in  high  life  is 
not  far  to  seek.  The  act  of  drinking  a glass  of 
water  from  some  doubtfully  good  or  untiltered 
source,  or,  still  more  probably,  the  partaking  of 
salad  (derived  from  some  market-garden  source, 
nnd  not  properly  cleansed  before  being  sent  to 
table),  is  quite  sufficient  to  account  for  infection. 
A single  invisible  germ  or  echinococcus-ovum 
thus  transferred  to  the  stomach  of  the  human 
host,  is  capable,  after  a lengthened  interval,  say 
of  a year,  of  presenting  itself  as  an  hepatic  tu- 
mour of  considerable  dimensions.  "VVhat  obtains 
thus  infrequently  amongst  well-to-do  persons  in 
life,  must  necessarily  happen  more  commonly  to 
those  whose  occupations  naturally  bring  them 
more  directlyin  contact  with  the  ordinary  sources 
of  infection.  In  a paper,  ‘On  the  comparative 
prevalence  of  different  forms  of  entozoa  infesting 
the  dog ' (Linn.  Soc.  Journ.,  1867)  the  writer 
has  called  attention  to  the  desirability  of  insti- 
tuting special  investigations  in  reference  to  the 
frequency  of  the  occurrence  of  the  hydatid  tape- 
worm in  the  dog  in  England.  By  adopting,  both 
at  home  and  in  our  colonies,  the  admirable  mode 
of  procedure  initiated  by  Krabbe  in  Iceland  and 
Denmark,  a large  amount  of  valuable  informa- 
tion, available  for  sanitary  guidance,  could  not 

I fail  to  be  obtained.  Hundreds  of  dogs  are  an- 
nually destroyed  in  this  country,  yet  no  public 
officer,  possessing  a practical  knowledge  of  the 
subject,  has  ever  examined  their  carcases  with 
the  view  of  ascertaining  the  prevalence  or  other- 
wise of  parasites  within  them.  The  amount  of 
good  winch  has  already  been  accomplished  by 
private  efforts  (not  unattended  with  personal 
sacrifices)  in  this  direction  is  by  no  means  incon- 
siderable. These  efforts  have  led  to  the  discovery 
of  the  causes  of  several  destructive  epidemics. 
In  respect  of  the  sexually  mature  echinococcus 
tapeworm,  Dr.  Krabbe  has  shown  that  r.o  less 
than  28  per  cent,  of  Icelandic  dogs  are  infested. 
His  investigations  have  thus  furnished  us  with 
a striking  result,  which,  to  the  thoughtful  and 
cultured  sanitarian,  readily  explains  the  extra- 
ordinary prevalence  of  hydatids  in  that  country. 
See  Acephalocysts  ; Bladder-worms  ; and 
Echinococcus.  T.  S.  Cobdold. 

HYDATIDS,  UTERINE.  See  Mole. 

HYDRIEMIA  (uSwp,  water,  and  afpa,  the 
blood). — A watery  condition  of  the  blood.  See 
Anukmia;  and  Blood,  Morbid  Conditions  of. 

HYDRAGOGUES  (SSaip,  water,  and  &yu, 

- drive). — Synon,  : Fr.  Hydragogues  ; Ger.  IVas- 
erlreibcnde  Slittcl. 

Definition. — Purgative  medicines  which  cause 
■ copious  watery  discharge. 

; Enumeration. — Hydragogue  purgatives  in- 
lude  : — Bitartrate  of  Potash,  Buckthorn,  Colchi- 
um,  Colocynth,  Croton  Oil,  Elaterium,  Gamboge, 
lellcbore,  Jalap,  Podophyllin,  and  Scammony. 
Action. — It  has  been  supposed  by  some 
riters  that  the  action  of  the  drugs  included 
ji  the  present  class  is  due  only  to  the  in- 
•eased  peristaltic  action  which  they  produce, 
his,  however,  is  not  the  case,  as  certainly 
'me,  if  not  all,  of  those  just  enumerated,  induce 


HYDROCELE.  GY, 

a free  secretion  of  fluid  by  the  intestinal  mucous 
membrane,  while  at  the  same  time  they  stimulate 
the  peristaltic  action  of  the  bowel,  and  cause  the 
evacuation  of  this  watery  fluid. 

Uses. — Hydragogues  are  chiefly  employed  for 
the  removal  of  fluid  from  the  body,  in  cases 
either  of  general  anasarca  or  of  dropsical  effu- 
sion in  serous  cavities.  They  may  be  employed 
to  assist  the  action  of  the  kidneys  when  this  is 
insufficient ; and  it  has  been  observed  not  un- 
frequently,  when  the  secretion  of  urine  has  pre- 
viously been  deficient,  that  it  becomes  greatly 
increased  after  a free  discharge  of  fluid  has  take; 
place  from  the  bowels,  in  consequence  of  the 
administration  of  a hydragogue  cathartic.  £ e 
Purgatives.  T.  Lauder  Brunton. 

HYDRAR GYRIASIS  ( hydrargyrum , mer- 
cury).— Tho  state  produced  by  the  introduction 
of  mercury  into  the  system.  See  Mercury. 
Poisoning  by. 

HYDRARTHROSIS  (SSwp,  water,  and 
apSpov,  a joint). — Effusion  of  a serous  fluid  into 
a joint.  See  Joints,  Diseases  of. 

HYDRO  A (vScop,  water). — A term  used  by 
Hippocrates,  and  expressive  of  a sweat-eruption. 
By  the  Latins  the  condition  was  named  sudamina, 
and  in  modern  times  it  is  called  miliaria.  The 
term  hydroa  has  also,  with  doubtful  propriety, 
been  applied  to  the  larger  vesicle  of  herpes  ; and 
more  recently  to  herpes,  or  rather,  pemphigus  iris. 

Erasmus  Wilson. 

HYDROADENITIS  (vSoip,  water,  and 
a5 V,  a gland). — Description. — -This  affection 
was  first  described  by  Verrieuil  and  Bazin  as  a 
minute  phlegmon  of  the  sweat-gland,  resulting 
in  a flat  pustule,  and  met  with  chiefly  in  those 
situations  where  the  sudatory  glands  are  most 
largely  developed,  for  example,  in  the  axilla,  on 
the  areola  of  the  nipple,  and  at  the  verge  of  the 
anus.  Hydroadenitis  occurs  singly  or  in  crops.  It 
first  becomes  developed  into  a small  tubercle : 
and,  when  pus  forms,  it  breaks  upon  the  surface, 
and  the  tubercle  subsides.  The  disease  has  been 
attributed  to  irritation  from  friction,  discharges, 
or  absence  of  cleanliness  ; and  is  said  to  be  fa- 
voured by  an  unhealthy  constitution. 

Treatment. — After  the  more  obvious  indica- 
tions of  improvement  of  the  general  health  and 
removal  of  local  irritants  have  been  attended  to, 
it  has  been  recommended  to  paint  the  affected 
part  with  the  liniment  of  iodine. 

Erasmus  Wilson. 

HYDROCARDIA  (Soup,  water,  and  napSia. 
the  heart). — An  effusion  of  serous  fluid  into  tho 
pericardial  sac.  See  Pericardium,  Diseases  of. 

HYDROCELE  (SScop,  water,  and  n-fiK-q,  a 
tumour). — Synon.:  Er.  Hydrocele ; Ger.  Was- 
serbruch. 

Definition. — A swelling  produced  by  a col- 
lection of  fluid  in  connection  with  the  testicle  or 
spermatic  cord. 

Description.— The  principal  forms  of  hydro- 
cele of  the  testicle  are  the  vaginal,  the  congenital, 
and  the  encysted. 

Vaginal  Hydrocele. — Description. — This  is 
a chronic  dropsical  effusion  into  the  sac  of  the 
tunica  vaginalis.  The  fluid  is  a pale-yellowish 
serum,  which  in  old  cases  is  often  loaded  with  cho- 


HYDROCELE. 


S58 

lesterine.  The  quantity  varies,  butseldom  exceeds 
twenty  ounces.  The  writer  has  removed  as  many 
as  forty-eight  ounces.  The  testicle  is  usually 
Bituated  at  the  back  part  and  rather  below  the 
centre  of  the  sac  ; but  its  position  may  be  altered 
by  adhesions;  and,  in  cases  of  congenital  inver- 
sion, the  testicle  is  in  front  of  the  sac.  In  old 
hydroceles  the  sac  is  often  greatly  thickened  by 
deposition  of  lymph  on  the  tunica  vaginalis,  and 
its  conversion  into  fibrous  tissue,  wliieh  is  some- 
times the  seat  of  calcareous  deposits.  It  is  gene- 
rally single,  but  often  oecurs  on  both  sides.  Vagi- 
nal hydrocele  forms  an  oval  or  pyriform  swelling, 
which  fluctuates;  has  a smooth,  even  surface;  and 
commences  at.  the  lower  part  of  the  scrotum,  very 
gradually  and  without  pain.  When  examined 
by  transmitted  light  it  is  found  to  be  trans- 
lucent, except  at  the  back  part,  where  the  tes- 
ticle is  situated.  Owing  to  the  tunica  vaginalis 
remaining  unobliterated  for  some  distance  along 
the  cord,  the  swelling  occasionally  assumes  an 
elongated  form,  and  extends  up  towards  the  in- 
guinal canal.  A hydrocele  sometimes  varies  in 
size,  becoming  larger  and  more  tense  during  the 
day  than  when  the  patient  first  rises  in  the  morning. 

^Etiology. — Hydrocele  is  a common  disease, 
especially  in  warm  climates;  and  occurs  at  all 
periods  of  life,  but  is  most  common  iu  middle  age. 

Diagnosis. — The  circumstances  — that  the 
swelling  commences  below;  that  the  spermatic 
cord  can  be  detected  above  the  tumour;  that 
the  testicle  cannot  be  felt;  and  that  the  tumour 
receives  no  impulse  on  coughing,  and  does  not 
vary  in  size  on  pressure— are  signs  distinguishing 
a hydrocele  from  an  inguinal  rupture.  When 
the  sac  is  much  thickened,  so  as  to  obscure  fluc- 
tuation, and  prevent  the  passage  of  rays  of  light, 
the  tumour  may  be  mistaken  for  a limmatocele, 
or  disease  of  the  testicle,  and  the  diagnosis  is 
difficult. 

Treatment. — In  infants,  vaginal  hydrocele 
usually  disappears  under  the  application  of  weak 
tincture  of  iodine.  Acupuncture,  causing  the  fluid 
to  escape  into  the  areolar  tissue  of  the  scrotum, 
is  the  only  operation  that  is  required. 

In  the  adult  external  remedies  are  of  no  use. 
It  is  usual  to  resort  at  once  to  operative  treat- 
ment, palliative  or  radical.  The  palliative  opera- 
tion consists  in  puncturing  the  tumour  with  a 
Iroehar,  and  evacuating  the  fluid  accumulated  in 
the  tunica  vaginalis.  The  hydrocele  usually  re- 
turns in  the  course  of  two  or  three  months,  and 
then  the  operation  must  be  repeated,  or  the 
patient  must  undergo  radical  treatment.  This 
may  be  effected  by  incision  or  excision  of  the 
sac  ; by  the  passage  of  a seton ; or  by  injection 
of  the  sac  with  a stimulating  fluid.  The  latter 
is  the  plan  commonly  resorted  to ; and  the  fluid 
almost  invariably  employed  is  the  tincture  of 
iodine.  The  only  apparatus  required,  in  addition 
to  a medium-sized  trochar,  is  a glass  syringe. 
The  writer  generally  injects  about  a drachm  of 
strong  tincture,  which  he  leaves  in  the  sac.  It. 
causes  considerable  pain,  extending  to  the  loins ; 
but  all  suffering  may  be  prevented  by  ether  or 
chloroform  inhalation.  The  iodino  acts  as  a 
stimulant,  stirring  up  mild  inflammation,  and 
causing  a rapid  return  of  swelling,  which  gradu- 
al! v subsides  until  t lie  patient  is  cured.  Com- 
pression with  strapping  helps  the  absorption.  In 


double  hydrocele,  injection  may  be  performed  on 
both  sides  at  the  same  time.  Injection  rarely 
fails  to  cure  the  hydrocele.  If  it  does  not  suc- 
ceed, recourse  can  bo  had  to  the  seton;  or,  in 
cases  of  thickened  sac,  to  incision  or  excision. 

Congenital  Hydrocele. — In  children,  *be 
original  communication  between  the  cavities  cf 
the  peritoneum  and  of  the  tunica  vaginalis  some- 
times fails  to  be  obliterated  ; and  fluid  accumu- 
lated in  the  sac  constitutes  the  variety  ternieo 
congenital  hydrocele.  The  communication  is 
usually  small  in  size. 

Diagnosis.  • — - Congenital  hydrocele  is  easily 
distinguished  from  ordinary  hydrocele  by  the 
absence  of  a defined  boundary  on  the  upper 
part  of  the  tumour;  by  the  impulse  received  on 
coughing ; and  by  pressure  causing  the  disappear- 
ance of  the  swelling,  and  rendering  the  testiclo 
perceptible.  It  is  distinguished  from  a reducible 
hernia  by  the  fluctuation  and  transparency  of  the 
swelling ; by  the  absence  of  gurgling  accompany- 
ing its  disappearance  on  pressure ; and  by  the 
slow  return  of  the  swelling  on  the  patient  assu- 
ming the  erect  posture. 

Treatment. — Congenital  hydrocele  is  readily 
cured  by  tho  gentle  pressure  of  a truss  on  the 
inguinal  canal,  so  as  to  occasion  obliteration  of 
the  neck  of  the  sac,  after  which  the  fluid  usually 
becomes  absorbed. 

Encysted  Hydrocele.— Iu  this  form  of  hy- 
drocele fluid  is  effused  into  an  adventitious  cyst 
distinct  from  tho  vaginal  sac,  developed  in  the 
areolar  tissue  beneath  the  visceral  portion  of  the 
tunica  vaginalis  investing  the  head  of  the  epidi- 
dymis.  As  the  cyst  enlarges,  the  epididymis  be- 
comes flattened  and  displaced  to  one  side,  whilst 
the  testicle  is  found  cither  in  front  or  at  the 
bottom  of  the  cyst.  The  fluid  contained  in  the 
sac  differs  from  that  of  vaginal  hydrocele  in  being 
less  in  quantity,  perfectly  limpid  and  colourless, 
and  nearly  free  from  albumen.  The  fluid  some- 
times contains  spermatozoa  in  great  abundance, 
rendering  it  opaque  and  milky-looking.  Theii 
presence  is  owing  to  the  rupture  of  one  of  the 
tubes  of  the  epididymis,  and  the  escape  of  semen 
into  the  sac  of  the  hydrocele. 

Diagnosis. — An  encysted  hydrocele  is  dis- 
tinguished from  vaginal  hydrocele  by  the  posi- 
tion of  the  testicle  at  the  bottom  of  the  tumour; 
and  generally  by  the  colourless  character  of  the 
fluid  evacuated. 

Treatment. — When  large  in  size,  so  as  to  lw 
inconvenient,  encysted  hydroeele  may  be  treated 
in  the  same  way  as  vaginal  hydrocele,  and  in- 
jection is  attended  with  the  same  success. 

Hydrocele  of  the  Cord. — Hydrocele  occurs 
in  the  spermatic  cord  in  two  forms — diffused  and 
encysted. 

The  diffused,  which  is  very  rare,  is  simply  an 
cedema  of  the  areolar  tissue  of  the  cord. 

Encysted  hydrocele  of  the  cord  arises  from  a 
collection  of  fluid  in  the  unobliterated  funicular 
process  of  peritoneum,  which  is  carried  down  in 
the  natural  transition  of  the  testicle.  It  produces 
a small  swelling  in  the  cord,  of  an  oval  form, 
abovo  and  distinct  from  the  testicle,  more  i 
less  transparent,  and  quite  movable.  The  swell- 
ing, when  small,  is  of  no  importance:  and  u 
seldom  requires  treatment.  S-.c  Testes,  Diseases 
of.  T.  B.  Ctri.ing. 


HYDROCEPHALOID  DISEASE. 

HYDROCEPHALOID  DISEASE.— This 
term  is  one  which  has  been  applied  to  a set  of 
symptoms,  ill-defined  in  their  mode  of  grouping, 
occasionally  met  with  in  delicate  children  soon 
after  they  have  been  weaned.  The  symptoms  may 
in  some  "cases  have  been  due  to  reflex  disturbance 
of  the  nervous  system  induced  by  improper  food ; 
they  may  appear  as  the  sequence  of  some  exhaust- 
ing disease,  such  as  a prolonged  diarrhoea ; or 
they  may  be  concomitants  of  a pneumonia  in  its 
initial  stages.  In  each  of  these,  as  well  as  in  other 
allied  conditions,  there  may  be  a febrile  eleva- 
tion of  temperature ; combined,  in  the  first  place, 
with  undue  irritability  and  extreme  restlessness, 
whilst  later  on  signs  of  mental  sluggishness  and 
stupor  may  supervene.  Such  symptoms  are  apt 
to  be  met  with  where,  in  addition  to  a depres- 
sion of  the  vital  powers,  there  is  a reflex  dis- 
turbance of  brain-functions.  The  condition  was 
specially  described  by  Marshall  Hall,  by  whom 
the  above  name  was  given.  It  may  be  well, 
therefore,  to  quote  from  his  own  description  : — 

1 This  affection  may  be  divided  into  two  stages  : 
the  first  that  of  irritability ; the  second  that  of 
torpor.  In  the  former  there  appears  to  be  a 
feeble  attempt  at  reaction ; in  the  latter  the 
powers  appear  to  be  more  prostrate.  These  two 
stages  resemble  in  many  of  their  symptoms  the 
first  and  second  stages  of  hydrocephalus  respec- 
tively. 

‘ In  the  first  stage  the  infant  becomes  irritable, 
restless,  and  feverish ; the  face  flushed,  the  sur- 
face hot,  and  the  pulse  frequent ; there  is  an 
undue  sensitiveness  of  the  nerves  of  feeling,  and 
the  little  patient  starts  on  being  touched  or  on 
hearing  any  sudden  noise  ; there  are  sighing  and 
moaning  during  sleep,  and  screaming ; the  bow- 
els are  flatulent  and  loose,  and  the  evacuations 
are  mucous  and  disordered. 

‘ If  through  an  erroneous  notion  as  to  the  nature 
of  this  affection,  nourishment  and  cordials  he  not 
given,  or  if  the  diarrhoea  continue,  either  spon- 
taneously or  from  the  administration  of  medicine, 
the  exhaustion  which  ensues  is  apt  to  lead  to  a 
very  different  train  of  symptoms.  Tiic  counte- 
nance becomes  pale,  and  the  cheeks  cool  or  cold ; 
the  eyelids  are  half-closed,  the  eyes  are  unfixed 
and  unattracted  by  any  object  placed  before  them, 
the  pupils  unmoved  on  the  approach  of  light ; the 
breathing,  from  being  quick,  becomes  irregular 
and  effected  by  sighs  ; the  voice  becomes  husky, 
and  there  is  sometimes  a husky,  teasing  cough  ; 
and  eventually,  if  the  strength  of  the  little  pa- 
tient continue  to  decline,  there  is  a crepitus  or 
rattling  in  the  breathing.  The  evacuations  are 
usually  green ; the  feet  are  apt  to  be  cold.’ 

But  in  such  groups  of  symptoms  there  is 
nothing  distinctive;  and  the  term  hydrocephaloid, 
which  is  now  seldom  heard,  might  be  discarded. 
Its  use  can  scarcely  he  justified  merely  on  the 
i ground  that  the  symptoms  met  with  under  such 
* conditions  are  apt  to  be  occasionally  confounded 
with  those  which  usher  in  the  commencement  of 
; acute  hydrocephalus.  AVe  do  not  diminish  the 
difficulties  — already  sufficiently  pronounced  — 
' Resetting  the  early  diagnosis  of  this  latter  affee- 
tion,  by  endeavoring  to  group  together  under 
,one  name  a set  of  symptoms  which,  on  different 
occasions,  have  no  other  common  bond  than  that 
they  are  apt  to  occur  in  delicate  children,  the 


HYDROCEPHALUS,  CHRONIC.  659 

tone  of  whose  nervous  system  has  been  lowered, 
and  thereby  rendered  more  ini  table  than  natural. 
AVe  should  be  really  better  without  such  a name, 
especially  now  that  bleeding  and  lowering  treat- 
ment are  no  longer  in  vogue  for  the  amelioration 
of  the  grave  organic  affection  with  which  the 
states  in  question  may  occasionally  be  con- 
founded. H.  ClIABLTON  Bastian. 

HYDROCEPHALUS,  Acute  (ti&ap,  water, 
and  Ke<f>a \r),  the  head). — A synonym  for  Tuber- 
cular Meningitis.  Tuberculosis  plus  a meningeal 
inflammation  is  the  generating  condition ; and 
acute  hydrocephalus  is  only  the  occasional, 
though  very  frequent,  concomitant.  See  Mex- 
exgitis,  Tubercular. 

HYDROCEPHALUS,  Chronic.—  Stxon.: 
AVater  on  the  Brain  ; hydrops  Capitis ; Fr.  Ey- 
drociphale ; Eydropisie  du  Cerveau ; Ger.  Dcr 
Wasserlcopf ; Hirnwassersucht. 

Definition. — A gradual  accumulation  of  se- 
rous fluid  within  the  lateral  and  third  ventricles 
of  the  brain  ; causing  them  to  become  more  or 
less  distended,  and  the  head  enlarged ; occurring 
principally  in  infants  or  very  young  children ; 
and  leading  to  restlessness,  irritability,  or  con- 
vulsions, followed  by  dulness,  drowsiness,  mo- 
tor weakness  or  actual  paralysis,  together  with 
failure  of  mind  and  of  the  special  senses. 

The  essential  condition  in  this  malady  is  the 
intra-ventricular  effusion.  The  cases  in  which 
the  fluid  has  been  found  outside  the  brain  and 
within  the  arachnoid  sac  are,  in  all  probability, 
merely  examples  of  the  disease  in  which  intra- 
ventricular effusion  having  previously  been  well- 
marked,  the  distended  corpus  callosum,  or,  it 
may  he,  the  floor  of  the  third  ventricle  has  given 
way,  and  allowed  the  fluid  to  pass  beneath  the 
arachnoid.  The  so-called  extra- ventricular  form 
of  the  disease  is,  therefore,  in  the  majority  of 
cases,  merely  a secondary  and  altogether  acci- 
dental condition. 

As  a sequence  of  a large  arachnoid  hoemor- 
rhage,  serous  fluid  may  also  he  found  within  the 
araclmoid  cavity  ; this,  however,  is  a condition 
which  has  no  real  title  to  he  mentioned  under 
the  head  of  chronic  hydrocephalus,  as  some- 
writers  have  done.  And  the  same  remark 
applies  to  those  accumulations  of  serous  fluid 
which  take  place  beneath  the  arachnoid,  as  a 
sequence  of  wasting  or  atrophy  of  the  cerebrai 
hemispheres,  one  or  both.  The  collection  of  fluid 
in  such  cases  is  to  he  regarded  as  a simple  se- 
quence of  the  atrophy,  and  is  of  itself  unpro- 
ductive of  morbid  symptoms. 

^Etiology. — Two  principal  groups  of  causes 
are  appealed  to  as  productive  of  chronic  hydro- 
cephalus. In  certain  cases  the  affection  is  believed 
to  be  idiopathic , due  to  an  ‘ essential  dropsy,’  oc- 
casioned by  an  inflammatory  affection  of  the  lin- 
ing membrane  of  the  ventricles.  In  other  pa- 
tients, however,  this  affection  is  distinctly  second- 
ary or  symptomatic , and  then  may  be  caused  by 
one  or  other  of  two  principal  sets  of  conditicns. 
Thus  (1)  it  is  often  occasioned,  as  writers  of  the 
last  century  pointed  out,  by  the  pressure  of  scrof- 
ulous or  other  tumours  upon  the  ‘ straight  sinus,' 
producing  mechanical  congestion  of  the  great 
veins  of  Galen  as  well  as  of  their  radicles  on  the 
walls  of  the  lateral  ventricles,  and,  as  a conse- 


560  HYDROCEPHALUS,  CHRONIC. 

pence,  an  increasing  dropsical  condition  of  the  former  pass,  -when  the  disease  lapses  into  a 
ventricles  themselves.  (2)  More  rarely  it  seems  chronic  and  stationary  condition. 


to  be  produced  or  to  remain  as  a sequence  of 
an  attack  of  acute  hydrocephalus.  This  latter 
mode  of  origin  is  admitted  by  some  authors,  and 
denied  by  others.  It  is  at  least  a possible  mode 
of  origin,  although  one  which  is  difficult  to  be 
established  with  certainty.  By  far  the  largest 
percentage  of  cases  probably  belong  to  the  first 
set  of  the  ‘ symptomatic  ’ category. 

The  disease  is  sometimes  congenital,  and  may 
be  so  far  developed  during  uterine  life  as  to  cause 
great  difficulties  in  parturition — frequently  ne- 
cessitating the  sacrifice  of  the  life  of  the  child. 
At  other  times  the  enlargement  of  the  head 
begins  to  show  itself  soon  after  birth,  or  at  some 
period  before  tho  end  of  the  first  or  second  year. 
Or  it  may  reveal  itself  later  still  in  childhood; 
much  more  rarely  during  adolescence  ; and  more 
rarely  still  in  adult  life. 

Congenital  ‘ microcephalism  ’ must  not  be  con- 
founded with  hydrocephalus.  It  is  true  that  in 
certain  small-headed  infants,  having  the  cranium 
malformed  and  the  sutures  ossified,  an  excess  of 
fluid  may  be  found  within  the  head  ; but  then 
the  fluid  in  these  cases  is  situated  outside  the 
atrophied  brain,  and  not  within  the  ventricles. 
The  two  conditions  are,  in  fact,  totally  opposite 
m nature. 

Atvatomicai,  Characters.  — Three  different 
states,  in  regard  to  size  of  head,  have  been  de- 
scribed as  existing  in  this  affection  : — (1)  where 
the  head  is  smaller  than  natural ; (2)  where  the 
head  is  of  natural  size ; and  (3)  where  the  head 
is  more  or  less  considerably  enlarged. 

Those  of  the  first  category  ought  not  to  be 
ncluded  at  all.  They  are  the  cases  of  ‘ mi- 
crocephalism ’ above  referred  to.  Those  of  the 
second  category  could  never  be  diagnosed  with 
any  degree  of  positiveness  during  life;  and  it. 
may,  indeed  be  questioned  whether  such  cases 
exist  to  any  large  extent,  except  as  more  or  less 
transitory  stages  of  instances  of  the  disoase  per- 
taining to  the  third  of  the  above  categories. 

Of  course,  in  all  tho  cases  in  which  the  head 
ultimately  becomes  enlarged  from  the  presence  of 
mi  excess  of  fluid  within  the  lateral  and  third 
ventricles,  there  must  have  been  a stage  during 
which  these  ventricles  were  merely  full  of  fluid, 
and  during  which  pressure-symptoms  were  more 
or  less  marked — even  without  the  existence  of 
actual  enlargement  of  the  head.  Such  symptoms 
alone,  however,  do  not  often  form  a sufficiently 
precise  combination  to  enable  us  to  do  more  than 
entertain  a vague  suspicion  that  we  may  have 
to  do  with  a case  of  chronic  hydrocephalus. 
We  mostly  need  the  objective  sign  of  enlarge- 
ment of  the  head,  to  enable  us  to  arrive  at  a 
positive  diagnosis  of  this  disease ; but  as  soon 
as  this  sign  declares  itself  to  a well-marked  ex- 
tent, there  are  few  affections  of  the  brain  which 
can  be  diagnosed  with  more  certainty  than  the 
one  which  we  are  now  considering. 

Even  the  cases  in  which  the  head  is  distinctly 
enlarged  differ  amongst  themselves,  since  in  some 
of  them  (a)  both  sutures  and  fontanelles  are 
widely  open ; whilst  in  others  (4)  the  sutures, 
and  perhaps  the  fontanelles,  are  completely 
closed.  It  seems  probable  that  the  latter  may 
represent  conditions  into  which  some  of  the 


Owing  to  the  separation  of  the  cranial  bones 
in  young  infants,  this  disease,  when  it  occurs  ir. 
them,  soon  becomes  associated  with  an  actual 
enlargement  of  the  head,  which  increases  rapidly. 
In  consequence  of  the  distending  pressure  from 
within,  caused  by  the  increasing  size  and  fulne-s 
of  the  ventricles,  the  bones  entering  into  the  for 
mation  of  the  vault  of  the  cranium  become 
separated  from  one  another,  though  the  bones  of 
the  face  remain  unaltered.  The  frontal,  parietal, 
the  superior  part  of  the  occipital,  and  a small  part 
of  the  squamous  portion  of  the  temporal  bones 
become  expanded  and  thinner  than  natural,  at 
the  same  time  that  they  are  separated  from  one 
another — especially  in  the  regions  of  the  anterior 
and  posterior  fontanelles,  and  of  the  sagittal  suture. 
In  such  regions,  when  the  enlargement  is  extreme, 
a sense  of  fluctuation  is  often  recognisable.  The 
forehead  becomes  prominent  and  overhanging, 
whilst  the  eyeballs  are  depressed;  and  as  the  face 
remains  unaltered  or  even  becomes  emaciated,  it 
seems  altogether  unnaturally  small,  and  thus 
contributes  to  produce  a most  characteristic 
appearance  (‘facies  hydrocephalica ’),  which  is 
often  intensified  by  the  old-looking,  and  more  or 
less  blank,  expressionless,  aspect  of  the  face. 

The  cranial  bones  are  often  very  thin,  bnt 
occasionally  they  may  be  unusually  thick  through- 
out— even  in  young  children. 

The  circumference  of  the  head,  even  of  a 
young  child,  may  in  hydrocephalus  easily  reach 
24  to  30  inches  or  even  more.  Where  the  en- 
largement becomes  extreme,  the  weight  of  the 
head  is  so  great  that  it  cannot  be  maintained  iD 
the  upright  position.  It  has  to  be  supported  by 
the  hand  or  some  artificial  support ; or  else  the 
child  does  not  attempt  to  rise  from  the  recum- 
bent position.  The  size  attained  by  the  head  in 
certain  cases  has  been  comparatively  enormous  . 
thus,  in  an  altogether  exceptional  case,  recorded 
by  Cruikshank,  it  is  said  to  have  measured,  in  a 
child  sixteen  months  old,  no  less  than  52  inches 
in  circumference,  and  the  amount  of  fluid  con- 
tained within  the  crauium  was  found  to  weigh  as 
much  as  twenty-seven  pounds. 

The  fluid  is  generally  slightly  albuminous ; 
possesses  some  saline  constituents ; and  has  a 
specific  gravity  ranging  from  1,006  to  1,014. 
Its  composition  agrees  pretty  closely  with  that 
of  dropsical  fluids  generally. 

In  the  great  majority  of  cases,  as  already 
stated,  the  fluid  is  contained  within  the  more  or 
less  distended  lateral  and  third  ventricles  of  the 
brain.  The  upper  and  lateral  parts  of  the  cere- 
bral hemispheres,  as  well  as  the  corpus  callosum, 
become  thinned  and  distended,  so  as  to  resemble 
a mere  bag,  the  walls  of  which  are  represented  ex 
ternally  by  pale  unfolded  and  much  flattened  cow 
volutional  matter,  and  internally — next  the  fluid 
itself — by  the  lining  membrane  of  the  ventricles. 
This  latter  has  become  much  thicker  and  tougher 
than  natural ; it  may  also  be  more  or  less  granu- 
lar on  the  surface  ; and  often  shows  an  increased 
number  of  distended  vessels.  These  appearances 
are,  however,  not  to  be  taken  as  an  indication 
of  the  inflammatory  origin  of  the  malady,  as 
some  observers  seem  to  suppose.  They  may 
be  found,  as  the  writer  has  seen,  well-marked. 


HYDROCEPHALUS,  CHRONIC.  661 


in  cases  where  the  effusion  and  distension  has 
been  the  result  of  a mere  mechanical  congestion, 
produced  by  pressure  upon  the  commencement 
of  the  straight  sinus,  owing  to  a tumour  in  the 
middle  lobe  of  the  cerebellum.  On  the  other 
hand,  some  years  ago  the  writer  examined  the 
head  of  a hydrocephalic  child  who  died  in  Univer- 
sity College  Hospital,  in  whom  the  most  careful 
search  revealed  nothing  that  could  have  produced 
mechanical  congestion,  and  in  which  there  was, 
moreover,  no  sign  of  anything  like  an  inflam- 
matory condition  of  the  walls  of  the  greatly  dis- 
tended lateral  ventricles.  To  fall  back  upon  the 
hypothesis  of  an  ‘ essential  dropsy’  was  felt  to  be 
far  from  satisfactory.  Such  a phrase  cannot  indeed 
be  regarded  as  conveying  any  real  explanation  of 
the  condition  in  question. 

The  shape  of  the  ventricles  and  of  the  com- 
pressed ganglia  about  the  base  are,  of  course, 
greatly  altered.  The  foramen  of  Munro  may 
be  half  an  inch  or  more  in  diameter.  The  optic 
and  olfactory  tracts  and  lobes  are  also  often  much 
altered  by  pressure. 

The  brain-substance  may  be  even  tougher 
than  natural,  because  the  long-continued  mecha- 
nical congestion,  which  exists  in  so  many  cases, 
favours  the  overgrowth  of  the  neuroglia ; and, 
indeed,  it  would  appear  probable  that  in  some 
instances  the  overgrowth  of  this  mere  connective 
substance  is  well-marked.  For,  notwithstanding 
all  the  pressure  upon  and  distension  of  the  brain- 
substance,  this  rarely  shows  signs  of  atrophy.  It 
is  rather  the  reverse.  The  mere  brain  alone  of  a 
jj  hydrocephalic  child,  after  the  fluid  has  been  eva- 
i euated,  commonly  weighs  more  than  the  brain 
j of  a healthy  child  of  the  same  age.  Thus  in  an 
instance  that  came  under  the  writer’s  notice, 
j the  brain  of  a child  five  years  of  age  weighed 
.•other  more  than  52  oz. 

In  those  cases  in  which  during  life  the  fluid  has 
j escaped  from  the  ventricles  through  a rupture  in 
' the  corpus  callosum,  the  brain  has  been  found 
more  or  less  flattened  and  collapsed  in  the  lower 
. part  of  the  enlarged  cranium,  whilst  the  escaped 
fluid  occupies  the  arachnoid  cavity  above  it. 

Symptoms. — Chronic  hydrocephalus  begins  to 
I manifest  itself  in  various  ways,  and  also,  as  above 
M:ated,  at  various  ages.  The  great  bulk  of  the  cases 
j are  either  congenital,  or  commence  before  the  fifth 
. month.  But  in  certain  rare  instances,  the  head 
may  begin  to  enlarge  long  after  the  union  of  the 
• sutures,  in  early  adult  life,  or  even  beyond  middle 
age. 

As  to  modes  of  commencement,  at  least  four, 
pretty  distinct  from  one  another,  may  be  en- 
| countered.  (1)  The  disease  maybe  ushered  in 
I by  a period  of  fretfulness  and  irritability,  with 
or  without  the  occurrence  of  convulsions  and 
strabismus,  before  any  enlargement  of  the 
■ head  is  detected.  Or  (2)  slow  enlargement  of 
the  head  may  be  noticed  as  the  first  event.  In 
•ome  cases,  this  enlargement  not  only  sets  in,  but 

I may  continue  for  months,  till  notable  increase 
n size  has  taken  place,  and  yet  the  child  may 
.exhibit  no  morbid  symptom  whatever.  The  wri- 
er has  seen  a well-marked  instance  of  this  in  a 
I'.hild  whoso  head  had  been  enlarging  for  eighteen 
nonths(the  process  beginning  when  it  was  a year 
•Id),  and  in  whom,  though  the  head  was  twenty- 
cur  inches  in  circumference,  no  other  morbid 


signs  or  symptoms  presented  themselves.  (3) 
Chronic  hydrocephalus  may  supervene  in  a child 
after  a fall,  through  the  intermediation  of  cere- 
bellar disease.  The  writer  had  under  his  care  a 
little  girl  four  years  old,  who,  after  falling  from 
a table  and  striking  the  occiput  severely,  suf- 
fered for  from  twelve  to  eighteen  months  from 
symptoms  indicative  of  cerebellar  disease,  after 
which  the  head  began  to  enlarge,  and  hydroce- 
phalus became  the  apparently  dominant  condi- 
tion. Complete  blindness  ensued,  then  convul- 
sions set  in,  and  in  the  midst  of  one  of  these  the 
patient  died.  A tumour  of  the  middle  lobe  of 
the  cerebellum  was  found,  plus  all  the  signs  of 
a well-marked  hydrocephalus.  (4)  The  disease 
may  occur  as  a sequence  of  an  attack  resembling 
acute  hydrocephalus  (tubercular  meningit  is) : that 
is  to  say,  a child  appears  to  suffer  for  a time 
from  what  is  regarded  as  tubercular  meningitis  ; 
the  symptoms  then  undergo  some  mitigation  ; 
they  become  more  or  less  chronic ; and  ulti- 
mately the  head  begins  to  enlarge,  as  it  does  in 
chronic  hydrocephalus.  There  is  some  doubt 
about  the  real  nature  of  the  starting-point  in 
this  mode  of  origin.  The  initial  symptoms  may 
not  in  reality  have  been  those  of  tubercular 
meningitis.  The  chronic  disease  and  its  symp- 
toms may  occasionally  be  initiated  in  an  acute 
manner. 

It  may  be  easily  imagined  that  the  subsequent 
course  of  the  symptoms  in  persons  suffering  from 
chronic  hydrocephalus,  beginning  in  these  various 
ways,  may  also  be  subject  to  great  variations. 

As  the  head  enlarges,  or  as  thepressure  within 
increases,  sensations  of  weight  or  pain  may  be 
experienced.  The  child  may  show  increased 
fretfulness  and  irritability ; or  its  manner  may 
become  more  dull  and  heavy  than  natural.  At 
other  times  there  is  no  noticeable  change  in  theso 
respects. 

In  the  ‘ symptomatic  ’ forms  associated  with 
tumours,  there  is  apt  to  be  vomiting  of  a very 
obstinate  and  paroxysmal  character,  together 
with  continuous  pain,  marked  by  exacerbations. 
Convulsions,  either  unilateral  or  general,  may  also 
occur,  as  well  as  paralysis  of  one  or  other  of  tho 
ocular  muscles.  In  such  cases,  too,  in  compara- 
tively early  stages,  ophthalmoscopic  examination 
will  frequently  reveal  optic  neuritis,  which  has 
a tendency  to  go  on  to  white  atrophy,  with  tho 
production  of  more  or  less  complete  blindness. 

In  later  stages  of  the  disease  mental  action 
becomes  increasingly  impaired,  there  is  loss  cl 
memory,  dulness,  and  a great  tendency  to  sleep 
during  the  day.  There  may  be  marked  weak- 
ness or  actual  paralysis  of  limbs.  Children 
affected  to  this  extent  often  keep  to  the  recum 
bent  position,  having  at  last  no  power  of  sitting 
up,  or  even  of  raising  their  head  from  the  pillow. 
The  appetite  sometimes  remains  good ; at  other 
times  ic  becomes  much  impaired,  and  a gradual 
emaciation  ensues.  Blindness,  more  rarely  deaf- 
ness, loss  of  smell,  and  impairment  of  other  senses 
tend  gradually  to  reveal  themselves  after  a time. 

Complications. — In  all  cases  where  the  hydro- 
cephalus is  itself  symptomatic  of  some  primary 
intra-cranial  disease,  interfering  with  the  proper 
return  of  blood  from  the  ventricles  and  cenrral 
portions  of  the  brain,  the  symptoms  reselling 
from  this  latter  state  of  things  are  necessarih 


662  HYDROCEPHALUS,  CHRONIC. 

complicated  with  others  immediately  produced 
by  the  original  morbid  condition.  Hence  the 
very  great  variations  encountered  in  the  grouping 
of  symptoms  in  different  cases. 

Diagnosis. — Some  remarks  have  already  been 
incidentally  made  upon  this  subject  under  the 
head  of  Anatomical  Characters. 

"Where  the  head  becomes  distinctly  enlarged, 
with  widely  separated  sutures  and  open  fonta- 
nelles,  there  can  be  scarcely  any  room  for  doubt 
about  the  diagnosis.  But  before  the  head  is 
distinctly  enlarged,  the  diagnosis  of' chronic  hy- 
drocephalus with  any  degree  of  certainty  is  im- 
possible. In  many  cases  also  where  the  head  is 
only  slightly  enlarged,  and  the  sutures  are  not 
opened,  it  may  be  very  difficult,  for  a time,  to 
pronounce  an  opinion  as  to  whether  or  not  an 
infant  or  young  child  is  hydrocephalic.  Natural 
variations  in  the  size  of  the  head  are  consider- 
able ; and  it  may  also  be  enlarged  from  rickets, 
or  from  that  very  rare  condition  known  as  ‘ hy- 
pertrophy of  the  brain.’  Even  great  thickenings 
of  the  bones  of  the  head  have  occasionally  given 
rise  to  uncertainties  in  regard  to  diagnosis.  But 
in  all  these  cases,  in  order  to  enable  the  prac- 
titioner to  arrive  at  a trustworthy  opinion,  the 
particular  form  of  the  head  has  to  be  considered, 
together  with  the  sum-total  of  the  various  symp- 
toms which  may  have  preceded  or  accompanied 
its  increase. 

Whether  in  any  particular  case  we  have  to  do 
with  an  instance  'of  ‘ idiopathic  ’ or  of  ‘ sympto- 
matic ’ hydrocephalus,  often  cannot  be  settled  ; 
but  in  others  it  can  be  decided  by  reason  of  the  ex- 
istence of  a set  of  symptoms  distinctly  pointing 
to  the  presence  of  an  intracranial  new  growth. 

Prognosis. — Hydrocephalus  often  proves  fatal 
in  the  course  of  a few  months ; or  it  may  be  less 
r.ipid,  entailing  death  only  after  a year  or  two. 
Its  progress  is  variable,  however.  Remissions 
and  stationary  conditions  are  apt  to  occur, 
chequered  by  periods  in  which  there  are  distinct 
exacerbations  of  all  the  symptoms. 

Occasionally  one  of  these  stationary  condi- 
tions becomes  prolonged,  and  the  individual  may 
live  for  years.  Some  hydrocephalic  subjects 
have  subsequently  lived  on  to  the  age  of  twenty, 
thirty,  or  even  forty  years.  In  a few  exceptional 
cases  a cure  seems  to  have  been  effected,  either 
naturally  or  under  the  influence  of  remedial 
agencies. 

Death  may  take  place  in  convulsions ; from 
.slow  exhaustion  with  emaciation  ; or  from  inter- 
current pneumonia  or  some  other  acute  disease. 

Treatment. — Very  little,  unfortunately,  can 
be  done,  in  the  majority  of  cases,  to  produce 
decided  or  lasting  improvement.  This  is  espe- 
cially so  in  those  instances — only  too  numerous 
— in  which  the  hydrocephalus  is  due  to  some 
scrofulous  or  other  tumour  interfering  with  the 
retimi  of  blood  from  the  ventricles. 

Blistering  of  the  scalp,  with  mercurial  inunc- 
; lMis.  formerly  much  lauded,  may  do  a great 
deal  more  harm  than  good ; and  the  same  may 
be  said  in  reference  to  pressure  of  the  enlarged 
bead  by  strapping  or  bandages.  This  latter  is 
a barbarously  coarse  method  of  treatment,  which 
has  happily  fallen  into  disuse.  Blistering  may  do 
good  in  some  cases,  but  it  should  bo  cautiously 
had  recourse  to. 


HYDRONEPHROSIS. 

The  general  health  of  the  child  must  be  main 
tained  as  much  as  possible,  by  the  aid,  if  neces- 
sary, of  tonics  and  cod-liver  oil.  Purgation  and 
diuretics  may  also  be  had  recourse  to.  Iodide 
of  potassium  may  be  given  internally  in  gradu- 
ally increasing  doses,  as  even  young  children 
bear  this  remedy  well.  Bromide  of  potassium 
will  also  help,  perhaps,  to  mitigate  vomiting  and 
convulsions,  when  those  are  urgent  symptoms. 

It  may  be  worth  while  in  suitable  cases  to  try 
the  effect  of  greatly  diminishing  the  amount 
of  fluids  taken,  so  as  to  reduce  the  fulness 
of  the  vascular  system.  The  writer  has  had 
reason  to  believe  that  this  method  is  well  wor- 
thy of  being  attempted,  where  other  means  hare 
failed,  and  where  there  is  any  chance  of  being 
able  to  carry  it  out. 

Puncture  of  thehead  has  been  much  landed,  and 
practised  by  many,  but  with  an  amount  of  fail- 
ure and  fatality  that  has  caused  the  method 
almost  to  have  fallen  into  disuse.  If  in  any 
given  case  we  could  be  reasonably  certain  that 
the  hydrocephalus  belonged  to  the  ‘ idiopathic  ’ 
variety  (if  there  really  are  such  cases),  the 
method  might  be  had  recourse  to,  with  much 
more  chance  of  success  than  if  it  wfre  occa- 
sioned by  some  mechanical  pressure,  which 
persists  and  prevents  the  return  of  blood 
from  the  central  parts  of  the  brain.  Puncture 
of  the  head  can  scarcely  be  compared  with 
puncture  of  the  chest,  because  (even  apart  from 
the  greater  risks  attaching  to  the  former  opera- 
tion), a puncture  of  the  chest  in  a case  of  pleurisy 
lias  a fair  chance  of  being  actually  curative,  whilst 
puncture  of  the  head  in  hydrocephalus,  in  the  ma- 
jority of  cases  and  for  the  reason  above  indicated, 
could  only  be  palliative.  Still  the  cases  of  this 
disease  are  so  grave  that  where  the  sutures  are 
opened,  where  the  patient's  condition  is  rapidly 
getting  worse,  and  death  seems  otherwise  in- 
evitable, the  question  of  performing  the  opera- 
tion. at  least  once,  ought  to  be  entertaiued  as  a 
barely  possible  means  of  affording  relief. 

H.  Charlton  Bastiax. 

HYDKOMETEA  (55up,  water,  and  py-rpa, 
the  womb). — Dropsy  of  the  womb.  See  IYojib, 
Diseases  of. 

HYDRONEPHROSIS  (vSatp,  water,  and 

vftppbs,  the  kidney).  Svxox. : Dropsy  of  the  kid- 
ney ; Fr.  Hi/drojiephrose ; Ger . Hydronephrose. 

Definition. — A chronic  disease  of  the  kidney 
caused  by  obstruction  of  the  ureter ; consisting  in 
dilatation  of  the  pelvis,  and  commonly  of  the 
ureter,  with  more  or  less  extensive  atrophy  of 
the  substance  of  the  organ  ; usually  affecting  ono 
kidney,  sometimes  both ; characterized  clinically 
by  the  presence  of  a soft  fluctuating  tumour  in 
the  renal  region,  but  most  distinctively  by  sudden 
discharge  of  urine  with  collapse  of  the  tumour ; 
and  resulting,  if  not  relieved,  in  complete  de- 
struction of  the  kidney. 

^Etiology. — Among  the  most  common  causes 
of  hydronephrosis  are  obstruction  of  the  ureter 
at  its  lowest  part,  in  consequence  of  pressure  by 
new  formations,  particularly  carcinoma  of  the 
uterus;  the  impaction  of  calculi  of  various 
kinds  ; and  tumour  of  the  ovary.  More  rarely 
it  is  induced  by  new  formations  in  the  bladder; 
stricture  of  the  urethra;  the  pressure  of  the 


hydronephrosis. 

pregnant,  prolapsed,  or  retroflexed  uterus  ; and 
exceptionally  it  is  met  with  without  apparent 
cause.  In  such  eases  it  is  to  be  referred  to 
some  contraction,  due  to  inflammation  or  other 
cause,  which  has  disappeared.  The  condition 
is  also  sometimes  congenital,  being  due  to 
malformations,  such  as  impermeable  ureter,  or 
valve-like  obstruction  to  the  passage  of  urine 
downwards.  From  whatever  cause  the  obstrue- 
may  spring,  accumulation  of  urine  takes  place 
behind  it,  leading  to  gradual  distension  of  the 
organ.  See  Ureters,  Diseases  of. 

Anatomical  Characters. — In  the  earlier  stage 
of  hydronephrosis  there  is  simple  dilatation  of  the 
pelvis  of  the  kidney.  As  the  disease  advances, 
the  dilatation  increases,  the  organ  becomes  more 
p.nd  more  distended,  and  the  ureter  often  becomes 
bo  dilated  or  elongated  as  to  present  the  appear- 
ance of  a bluish-white  tube,  as  large  as  or  even 
larger  than  the  inferior  vena  cava.  Coincidently 
with  this  distension  the  substance  of  the  kidney 
atrophies.  At  first  the  apices  of  tho  cones 
become  flattened  and  wasted,  but  gradually  the 
renal  substance  becomes  more  involved,  until  at 
length,  in  old-standing  cases,  scarcely  any  trace 
of  it  remains,  and  the  kidney  is  represented  by 
a large  lobulated  bag,  whose  fibrous  walls  are 
distended  by  clear  fluid.  Commonly  one  kidney 
only  is  affected,  especially  when  extreme  dila- 
tation exists,  but  in  some  instances  both  kidneys 
are  involved.  There  is  a case  on  record  where 
the  whole  abdominal  cavity  was  occupied  by  an 
enormous  tumour,  containing  sixty  pounds  of 
fluid. 

Symptoms. — In  the  slighter  cases  of  hydrone- 
phrosis there  are  no  symptoms  of  such  a kind  as  to 
attract  attention.  This  condition  is  often  an  un- 
important complication  of  other  serious  diseases. 
In  the  more  severe  cases  there  are  no  consti- 
tutional symptoms,  but  the  local  changes  are 
well-marked.  There  is  a tumour  situated  in  the 
lumbar  region,  extending  upwards,  downwards 
into  adjacent  regions,  or  forwards  towards  the 
anterior  abdominal  wall.  The  colon  is  usually 
in  front  of  the  tumour,  and  always  displaced  and 
compressed,  so  that  constipation  frequently  co- 
exists with  hydronephrosis.  The  mass  is  often 
lobulated,  always  undulating  in  character  ; and 
frequently  fluctuation  may  be  detected.  The  most 
conclusive  evidence  of  the  condition  is  afforded 
by  the  discharge  of  a large  quantity  ot'  urine, 
generally  of  low  specific  gravity,  and  often  con- 
, tabling  mucus,  coincidently  with  the  disappear- 
ance or  diminution  of  the  tumour.  It  sometimes 
happens  that  the  obstruction  is  permanently  re- 
moved, and  dilatation  alone  remains  as  evidence 
of  the  old  obstruction.  Hydronephrosis,  when 
double,  sooner  or  later  proves  fatal  by  suppression 
of  urine  or  urtemia.  When  only  existing  on  one 
6ide,  it  has  proved  fatal  by  pressure  upou  neigh- 
bouring parts ; by  the  supervention  of  impaction 
of  stone  in  the  kidney  of  the  opposite  side ; or 
from  other  causes. 

Diagnosis. — The  distinction  of  hydronephrosis 
from  ascites  may  be  sometimes  difficult  when 
the  disease  affects  both  sides.  The  diagnosis  is 
, partly  to  be  made  by  observing  the  effects  of 
change  of  posture,  hydronephrosis  being  much  less 
influenced  thereby  than  ascites.  The  history  and 
mode  of  origin  of  the  affection  also  afford  indi- 


nYDROPHOBIA.  S6a 

cations.  From  hydatids  of  the  kidney  it  is  some- 
times impossible  to  discriminate  hydronephrosis, 
but  the  history  of  the  case  and  the  characters  of 
the  urine  often  afford  a clue.  If  there  be  tumour 
on  both  sides,  it  is  extremely  unlikely  to  be 
hydatid.  From  ovarian  tumour  the  diagnosis  is 
to  be  made  by  the  history  of  the  case ; the  position 
of  the  mass;  its  relations  to  the  colon;  and- by 
vaginal  and  rectal  examination.  From  peri- 
nephritic  abscess  hydronephrosis  is  distinguished 
by  its  being  less  hard,  and  by  tho  absence  of 
pain  and  fever. 

Prognosis. — The  prognosis  is  always  serious ; 
but  if  one  of  the  kidneys  be  sound  it  becomes 
enlarged,  and  does  double  work,  and  so  long  as 
this  condition  continues,  the  patient  may  suffer 
little  inconvenience. 

Treatment. — Careful  manipulation  of  the  tu- 
mour is  often  useful  in  extreme  conditions ; and 
tapping  with  the  aspirator  may  be  employed. 

T.  Grainger  Stewart. 

HYDROPATHY  (SSap,  water,  andirdflor,  a 
disease). — A synonym  for  hydrotherapeutics. 
See  Hydrotherapeutics. 

HYDROPERICARDIUM  (05  up,  water; 
and  •pericardium , the  pericardium). — An  accu- 
mulation of  serum  in  the  pericardium,  either 
dropsical  or  inflammatory.  See  Pericardium. 
Diseases  of. 

HYDROPHOBIA  (uSap.  water,  and  <p<S/3 ui. 
fear).  — Synon.  : Rabies;  Dog- madness  ; i’r. 
Lyssa  ; la  Bage ; Ger.  Hundnvuth  ; Wasscrsch.cn. 

Definition. — An  acute  disease,  produced  by 
the  inoculation  of  a specific  animal  poison  ; mani- 
festing itself  by  symptoms  due  to  disturbance  of 
thecentralnervous  system;  and  almost  invariably 
proving  fatal. 

^Etiology. — Never  spontaneous  in  man,  the 
sole  cause  of  hydrophobia  is  inoculation  with 
the  poison  of  a rabid  animal,  almost  inva- 
riably with  the  saliva,  the  inoculation  being 
commonly  effected  by  a bite.  In  about  nine- 
tenths  of  the  cases,  the  disease  is  contracted 
from  dogs ; in  most  of  the  remainder  from  eats  ; 
in  very  few  cases  from  foxes  or  wolves.  It  has 
been  acquired  from  a wound  received  during 
the  dissection  of  a rabid  animal.  It  is  probable, 
although  not  certain,  that  inoculation  with  the 
blood  of  a rabid  animal  will  produce  the  disease. 
The  poison  is  not  known  to  be  present  in  any 
other  secretion  than  the  saliva.  Commencing 
decomposition  is  said  to  destroy  its  activity,  but 
it  is  probable  that  the  dried  saliva  will  retain  its 
virulence  for  a considerable  period. 

Inoculation  takes  place  more  certainly  by  a 
bite  on  an  uncovered  part  of  the  body,  as  on  the 
hands  and  face,  than  by  a bite  inflicted  through 
the  clothes.  It  may  occur  without  a bite,  as  by  a 
lick  upon  an  abrasion.  It  has  followed  the  scratch 
of  a cat,  probably  by  the  animaUssaliva  beingthus 
inoculated.  A healthy  dog  has  communicated  the 
disease  by  a bite  given  immediately  after  it  had 
been  fighting  with  a rabid  animal,  the  saliva  of 
which,  no  doubt,  was  hanging  about  its  jaws. 
The  disease  has  resulted  from  the  teeth  being 
used  to  loosen  a knot  upon  a rope  with  which  a 
rabid  dog  had  been  tied. 

It  has  been  asserted  that  the  disease  may 


HYDROPHOBIA. 


5i>4 

arise  from  the  Lite  of  a healthy  dog,  but  this  is 
improbable.  Cases  are  on  record,  however,  in 
which  the  disease  ha3  followed  the  bite  of  adog, 
which  did  not  at  the  time,  or  for  several  weeks 
afterwards,  present  the  recognised  symptoms  of 
the  disorder.  It  seems  possible  that  in  rare 
cases  rabies  may  affect  a dog  as  a mild  and  in- 
significant malady. 

When  no  preventive  measures  are  adopted,  at 
least  half,  perhaps  two-thirds,  of  persons  bitten 
escape.  The  immunity  maybe  due  partly  to 
the  bites  being  inflicted  through  clothes;  partly 
to  individual  insusceptibility,  which  has  been 
found  to  exist  in  animals  as  well  as  in  man. 
When  preventive  measures  are  adopted  as  soon 
as  possible,  the  proportion  of  those  who  escape 
is  much  greater. 

More  males  than  females  suffer,  the  propor- 
tion being  three  to  one.  So,  too,  in  dogs.  The 
largest  number  of  cases  occur  in  the  middle 
period  of  life,  doubtless  from  greater  exposure 
to  the  cause.  Children,  however,  often  suffer, 
being  helpless  and  bitten  about  the  face.  Most 
cases  are  contracted  from  straying  or  pet  dogs. 

Th a period,  of  incubation  is  longer  than  that  of 
any  other  acute  specific  disease,  and  is  singularly 
variable.  It  is  rarely  less  than  a month,  the  short- 
est on  record  having  been  about  twelve  days. 
The  average  period  is  six  or  seven  weeks.  In 
about  half  the  cases  it  is  between  one  and  threo 
months.  In  some  cases  it  is  longer,  reaching  six, 
nine,  or  twelve  months.  Cases  have  been  recorded 
in  which  two.  three,  five,  and  even  ten  years  in- 
tervened. Most  authorities  believe  that  such 
cases  were  either  not  true  hydrophobia,  or  were 
due  to  a second  unknown  infection.  If  we  admit, 
however,  as  we  must  do,  that  twelve  or  eighteen 
months  may  elapse,  we  can  scarcely  deny  the 
possibility,  or  oven  probability,  of  longer  periods. 
It  is  as  hard  to  explain  an  incubation  period  of 
one  year  as  of  five  years. 

Anatomical  Ckaeactebs. — General  fluidity  of 
the  blood,  such  as  is  met  with  after  death  from 
acute  septic  diseases  ; redness  of  the  throat  and 
pharynx,  and  occasionally  of  the  salivary  glands  ; 
together  with,  in  some  cases,  evidence  of  con- 
gestion of  the  brain  and  spinal  cord,  constitute 
the  chief  morbid  appearances  visible  to  the 
naked  eye.  The  microscope  has  shown  that 
there  is  evidence  of  inflammation  (congestion 
and  leucocytal  infiltration)  in  the  salivary  glands 
(Coats) ; and  that  minute  changes  in  the  nerve- 
centres  are  almost  constantly  to  be  found 
(Clifford  Allbutt,  Hammond,  Benedikt,  Coats, 
and  the  writer).  Of  eight  eases  examined  by 
the  writer,  the  minute  changes  in  seven  were  dis- 
tinct, and  in  character  and  position  so  far 
characteristic  that,  given  the  fact  of  an  acute 
disease,  a post-mortem  diagnosis  might,  in  the 
vast  majority  of  cases,  be  made  with  certainty 
by  the  microscope.  The  essential  change  con- 
sists in  the  accumulation  of  leucocytes  around  the 
vessels,  and  their  infiltration  into  the  adjacent 
tissue  ; this  change  having  a special  distribution, 
being  either  confined  to,  or  most  intense  in,  the 
region  of  the  medulla  which  is  contiguous 
to  the  lower  part  of  the  fourth  ventricle,  that  is, 
the  neighbourhood  of  the  respiratory  centre. 
Here  we  have  also  the  convulsive  centre,  and  the 
centre  for  deglutition.  The  change  is  most  intense 


in  the  hypoglossal,  glosso-pharyngeal,  and  vagal 
nuclei  and  their  neighbourhood.  There  is  little 
or  no  change  in  the  upper  part  of  the  medulla, 
corpora  quadrigemina,  cerebellum,  or  basal  gan- 
glia. In  the  convolutions  a similar  but  slighter 
alteration  is  present  in  some  cases.  It  may 
occur  throughout  the  grey  matter  of  the  cord, 
but  is  here  usually  slight,  and  often  absent.  In 
the  most  affected  regions,  traces  of  ante-mortem 
clots  and  even  of  inflammation  of  the  walls  of 
the  minute  vessels  may  be  found  in  some  cases. 
Perivascular  areas  of  disintegration  are  com- 
mon ; but  such  frequently  occur  apart  from 
hydrophobia  or  any  other  disease.  Minute 
extravasations  are  common,  partly  mechani- 
cal. The  only  change  in  the  nerve-elements 
themselves  consists  in  a granular  degeneration 
of  the  ganglion-cells  of  the  regions  chieflv 
diseased.  In  the  dog  the  changes  are  quite 
similar  in  characters  and  distribution. 

Symptoms. — During  the  period  of  incubation  of 
hydrophobia  there  are  commonly  no  symptoms. 
V esicles  under  the  tongue  were  formerly  described, 
but  their  occurrence  has  not  been  confirmed. 
Occasionally  pain  and  discomfort  have  been  felt 
in  the  seat  of  the  wound,  explicable,  in  part,  by 
the  attention  directed  to  it.  Mental  depres- 
sion has  been  noted,  also  probably  due  to  anxietv 
regarding  the  possible  consequence  of  the  bite." 

The  onset  of  the  acute  symptoms  is  commonly 
attended  by  no  local  disturbance,  sometimes  by 
pain,  rarely  by  actual  inflammation,  in  the  wound. 
The  first  evidence  of  the  impending  disorder  is 
usually  malaise,  mental  depression,  disturbed 
sleep,  and  some  discomfort  about  the  throat,  with 
a difficulty  in  swallowing,  especially  liquids. 
The  attempt  occasions  some  spasm  in  the  throat, 
which  soon,  if  not  at  first,  involves  the  muscles 
of  respiration,  causing  a short,  quick  inspiration, 
a 1 catch  in  the  breath,’  resembling  that  due  to 
an  affusion  of  cold  water.  In  a few  hours  this 
increases  to  a strong  inspiratory  effort,  in  which 
the  extraordinary  muscles  of  respiration  take 
more  part  than  the  diaphragm  ; the  shoulders 
are  raised  ; the  angles  of  the  mouth  are  drawn 
outwards.  The  saliva,  which  is  abundant  and 
viscid,  cannot  be  swallowed.  It  hangs  about 
the  mouth,  and  the  patient  is  annoyed  by  his 
efforts  to  get  rid  of  it.  As  the  intensity  of  the 
spasm  increases,  so  docs  the  readiness  with  which 
it  is  excited.  The  mere  contact  of  water  with 
the  lips,  or  cutaneous  impressions,  as  a draught 
of  air,  will  bring  on  a paroxysm.  The  distress 
it  occasions  leads  to  a mental  state  which  in- 
creases the  readiness  with  which  the  spasm  is 
produced.  The  mere  sight  of  water,  or  the 
sound  of  dropping  water,  will  cause  it  (hence  the 
name),  and  even  analogous  visual  impressions, 
as  a sudden  light  or  the  reflection  from  a looking- 
glass.  Thus  the  respiratory  spasm  excited  by 
swallowing  liquids,  which  is,  as  it  were,  the 
key-note  of  the  disease,  extends  on  the  one  hand 
to  widely-spread  muscular  spasm,  and  on  the 
other  to  mental  disturbance.  In  each  of  these 
directions  the  symptoms  develop.  The  spasm, 
from  being  limited  to  the  muscles  of  respiration, 
may  become  general  and  convulsive  (tetanoid  or 
co-ordinated)  iu  character ; still  excited  by  the 
same  causes.  The  mental  distress  passes  intc 
disturbance,  in  which  the  balance  of  reason  « 


HYDROPHOBIA. 


lost,  continuously  or  during  the  paroxysms.  In 
the  frenzy,  the  horror  of  the  distress  is  trans- 
ferred to  the  attendants  by  whom  any  discom- 
fort may  have  been  occasioned,  and  during 
the  paroxysms  the  patient  may  attempt  to  bite 
them,  and  even  others.  Consciousness  may  so 
far  remain  that  in  the  intervals  he  may  beg 
those  whom  he  regards  to  keep  away.  The 
saliva  is  ejected  with  force,  and  the  patient 
hawks  it  up  with  a noise  ‘like  a dog.’  The 
sight  of  a dog  has  been  known  greatly  to  inten- 
sify the  disturbance ; and  this,  strangely  enough, 
in  eases  in  which  the  sufferer  had  no  suspicion 
of  the  nature  of  his  affection.  The  delirium  may, 
in  some  cases,  be  continuous  and  violent.  As 
the  mental  disturbance  increases,  the  respiratory 
spasm  and  convulsion  may  lessen,  or  the  latter 
may  persist  to  the  end. 

Vomiting  is  common,  and  is  often  an  early 
symptom,  a greenish-brown  liquid  being  ejected. 
Priapism  or  nymphomania  occasionally  occurs. 
The  temperature  is  usually  raised  two  or  three 
degrees.  Albumen  is  often  present  in  the  urine ; 
and  sometimes  sugar. 

Duration  and  Terminations. — The  duration 
of  hydrophobia  is  usually  from  one  to  four  days ; 
sometimes  it  lasts  six,  eight,  or  ten  days.  In  the 
rare  cases  which  have  recovered,  the  duration 
of  the  acute  affection  has  been  from  four  to  ten 
days,  although  slight  spasmodic  symptoms  have 
lasted  for  a longer  time,  as  does  the  spasm  of 
whooping  cough. 

The  common  cause  of  death  is  exhaustion 
from  the  attacks  of  fury  and  convulsion,  often 
aided  by  manifest  cardiac  failure,  which  may 
occur  early,  and  be  out  of  proportion  to  the  gene- 
ral asthenia.  Sometimes  the  patient  has  died 
asphyxiated  in  a paroxysm  of  respiratory  spasm ; 
partly,  perhaps,  from  spasm  of  the  glottis. 

Varieties. — The  relative  degree  of  the  above- 
described  symptoms  varies  in  different  cases. 
The  mental  disturbance,  or  general  muscular 
spasm,  may,  respectively,  predominate  over  the 
respiratory  throat-spasm,  even  in  the  early  stages, 
and  may  impress  a special  character  on  the 
attack,  so  that  it  resembles  in  the  one  case  a pri- 
mary mental  affection,  in  the  other  general  con- 
vulsive affection,  as  tetanus. 

Pathology. — We  know  nothing  of  the  nature 
of  the  poison  of  rabies.  It  has  been  thought 
thatitis  not  at  once  generalised,  but  develops  in 
the  wound,  and  subsequently  affects  the  system. 
The  symptoms  indicate  a primary  action  on  the 
uerve-centres,  especially  on  the  respiratory  re- 
gion of  the  medulla,  spreading  more  widely,  in 
its  ultimate  action,  in  the  medulla  and  to  the 
brain  and  cord.  The  vascular  changes,  from 
their  variability  and  occasional  absence,  are 
probably  secondary  effects  of  the  disturbed  action 
of  the  nerve-centre,  produced  by  the  poison  car- 
ried by  the  blood. 

The  first  effect  of  the  poison  is  probably  to 
lessen  the  ‘ resistance  ’ of  the  medullary  centres. 
Their  action  becomes  spasmodic ; is  excited  with 
undue  readiness,  especially  by  reflex  influences ; 
and  spreads  too  widely.  The  secondary  vascular 
changes  may  have  their  own  effects.  They  are, 
esin  other  functional  diseases,  somewhat  random 
in  distribution  within  the  affected  area.  By  the 
infiltration  of  leucocytes,  the  tissue  may  be  broken 


665 

1 up,  and  what  are  practically  tninute  points  of 
suppuration  may  result.  If  the  part  damaged  is 
important,  grave  consequences  may  ensue.  The 
nucleus  of  thepneumogastric  is  often  so  damaged, 
and  thus  we  can  understand  the  occurrence  of 
cardiac  failure.  The  changes  in  the  convolu- 
tions and  the  spinal  cord  are  probably  propor- 
tioned to  the  mental  or  tetanoid  symptoms  re- 
spectively. The  mental  excitement  no  doubt 
acts  upon  and  increases  the  irritability  of  the 
medulla  (Putnam).  Conversely,  the  disturbance 
of  the  latter  may  help  to  determine  the  direction 
of  the  mental  disturbance  due  to  the  poison. 

Diagnosis. — The  symptom  of  greatest  diagnos- 
tic value  is  the  respiratory  spasm  excited  by 
attempts  to  swallow,  increasing  until  it  re- 
sembles a convulsive  action,  and  accompanied 
after  a time  by  mental  disturbance.  In  certain 
diseases  of  the  throat  and  chest,  especially  oeso- 
phagitis and  pericarditis,  a reflex  throat-spasm 
may  occur,  but  in  such  cases  there  are  commonly 
pain  or  other  obtrusive  signs  of  the  local  affec- 
tion. When  the  mental  disturbance  occurs  early, 
the  affection  may  be  confounded  with  acute 
mania : the  association  with  slight  respiratory 
spasm  is  still  the  most  important  diagnostic  in- 
dication. In  cases  (if  such  occur)  in  which  this 
symptom  is  absent,  the  diagnosis  is  a matter  of 
great  difficulty,  and  can  only  be  made  by  the 
history  of  the  antecedent  bite,  the  rapid  course 
of  the  disease,  and  its  association  with  other  con- 
vulsive phenomena  and  with  salivation.  Prom 
tetanus,  hydrophobia  is  distinguished  by  the  lato 
period  after  the  bite  at  which  the  symptoms 
develop ; the  absence  of  trismus  and  of  con- 
tinuous spasm ; and  the  presence  of  paroxysmal 
respiratory  spasm,  of ' aversion  to  liquids,  and 
of  mental  disturbance.  Too  much  weight  must 
not  be  given  to  the  general  character  of  the  con- 
vulsive symptoms,  if  other  signs  of  the  disease 
are  present,  since  there  is  probably  a tetanoid 
form  of  hydrophobia,  in  which  general  spasms 
occur  early;  but  they  intermit,  and  are  excited 
by  attempts  at  deglutition,  and  there  is  no 
trismus.  Organic  brain-diseases  accompanied  by 
delirium  and  convulsions,  occurring  after  a bite, 
have  been  mistaken  for  hydrophobia,  as  in  a case 
in  which  the  nature  of  the  disease  was  only  dis- 
covered when,  after  exhumation,  meningeal  hae- 
morrhage was  found.  Here  also  the  respiratory 
spasm  is  absent. 

Mere  mental  excitement,  directed  to  the  dis- 
ease, may  determine  symptoms  of  dysphagia 
somewhat  resembling  the  genuine  disease — ‘spu- 
rious hydrophobia’  as  it  has  been  termed.  After 
a period  of  anxiety  regarding  the  consequences 
of  a bite,  spasm  in  the  throat  is  felt  in  swallow- 
ing. The  patient's  fears  are  intensified,  the 
symptom  increases,  and  even  the  medical  atten- 
dant may  be  deceived.  The  spasm,  however,  is 
not  of  the  respiratory  character  of  genuine  hy- 
drophobia. Recovery  commonly  ensues  on  the 
mind  being  tranquillised,  or  by  the  application  of 
some  remedy  in  which  the  patient  has  confidence. 
It  must  be  remembered  that  in  some  cases  of 
genuine  hydrophobia  the  influence  of  the  patient’s 
mental  state  has  been  very  clearly  traceable  even 
in  the  early  symptoms. 

The  distinction  of  genuine  from  spurious 
hydrophobia  is  often  rendered  difficult  by  the 


S66  HYDROPHOBIA, 

fact  that  the  latter  usually  follows  suspicious 
bites,  and  that  the  former  may  be  distinctly  in- 
tensified by  the  patient’s  nervous  fears.  The 
untypical  character  of  the  spasm  in  the  spurious 
disease  (mere  dysphagia) ; the  fact  that  an  effort 
removes  this  difficulty,  and  that  once  overcome 
it  does  not  return ; the  stationary  condition  : the 
absence  of  mental  symptoms  beyond  anxiety ; and 
I lie  disappearance  of  the  symptoms  when  this  is 
removed,  are  the  important  guides. 

Prognosis. — Hydrophobia  is  practically  fatal, 
but  not  certainly  so;  and  the  patient  personally 
should  unquestionably  receive  the  ‘ benefit  of 
the  doubt.’  Cases  differ  in  the  intensity  and 
rapidity  of  their  course  ; and  the  less  rapidly  the 
symptoms  are  evolved,  the  greater  is  the  hope, 
slight  though  it  still  is,  that  an  exception  to  the 
common  fatality  may  be  obtained.  The  prog- 
nosis is  better  the  longer  the  spasm  remains 
limited;  it  is  worse  if  there  are  general  con- 
vulsions, mental  disturbance,  and  signs  of  exhaus- 
tion or  of  disproportionate  heart-failure. 

Treatment. — Adequate  measures  against  the 
spread  of  rabies  would  undoubtedly  lessen,  per- 
haps entirely  prevent,  the  occurrence  cf  hydro- 
phobia in  man ; but  the  discussion  of  these  is 
beyond  the  scope  of  this  article  (see  Rabies). 
When  a person  has  been  bitten  by  a suspicious 
or  doubtful  animal,  the  circulation  in  the  part 
should,  if  possible,  be  at  once  arrested  by  a tight 
ligature  above  the  place;  the  wound  should  be 
washed  ; and  then  it  should  be  allowed  to  bleed 
freel)r.  It  may  probably  be  sucked  with  im- 
punity if  the  mouth  is  rinsed  with  water,  or  better 
still  with  vinegar  and  water,  after  each  act,  and 
if  there  are  no  abrasions  in  the  mucous  mem- 
brane. The  act  has  been  supposed  tobe  dangerous ; 
but  all  experience  is  opposed  to  this.  Poisons 
have  to  remain  for  some  minutes  in  contact 
with  a mucous  membrane  before  they  are  ab- 
sorbed, and  during  the  act  of  sucking  there  is  a 
How  from  the  mucous  membrane  into  the  mouth, 
which  must  be  opposed  to  absorption.  As  soon 
as  possible  the  wound  should  be  cauterised.  Of 
chemical  caustics, nitrate  of  silver,  freely  applied 
at  once,  is  probably  effectual.  If  any  time  hare 
elapsed,  nitric  acid  or  liquid  carbolic  acid  is  pre- 
ferable. The  actual  cautery,  applied  deeply  and 
freely,  is  an  efficient  and  ready  means.  If  prac- 
ticable, free  excision  of  the  bite  is  wise ; and 
should  not  be  neglected,  even  though  the  cautery 
has  before  been  used,  if  there  is  any  doubt  as  to 
the  thoroughness  of  the  application. 

The  methods  adopted  for  the  treatment  of  the 
developed  disease  have  been  numerous.  All  so- 
called  ‘specifics’  have  been  proved  to  be  useless. 
An  attempt  has  been  made  to  eliminate  the  poison 
by  administering  large  doses  of  mercury,  and  by 
diaphoresis.  The  two  have  been  combined  in  the 
mercurial  vapour  bath.  Two  or  three  cases  are 
on  record  in  which  this  method  has  been  success- 
ful ; many  in  which  it  lias  been  powerless.  Of 
late  it  has  been  but  little  tried. 

Attention  has  been  lately  directed  to  curara  as 
a remedy  for  hydrophobia.  Hirst  recommended 
half  a century  ago  by  an  Englishman  (Sewell),  it 
was  tried  in  small  doses  and  failed.  Niemeyer 
suggested  larger  doses,  and  in  a ease  by  Offen- 
burg  it  was  apparently  successful ; and  since 
then  another  case,  in  America,  has  recovered 


HYDRORHACHIS. 

under  its  use.  In  many  cases  it  has  failed — in 
all  cases  in  this  country  up  to  the  present  time. 
It  is  recommended  that  it  should  be  used  in  in- 
jections of  from  -jb  to  3 of  a grain,  repeated 
every  quarter  or  half  an  hour,  until  the  severity 
of  the  paroxysms  is  lessened.  This  point  ma”v 
not,  however,  be  reached  until  general  mus- 
cular paralysis  is  imminent  or  produced,  ami 
then  artificial  respiration  may  be  necessary  until 
the  effect  has  passed  away.  As  often  as  this  w 
the  case,  and  the  spasms  recur,  another  injection 
must  be  given.  In  hydrophobia  there  is  remark- 
able tolerance  of  the  drug,  poisonous  doses  (one 
grain  repeated)  of  active  curara  having  in  one 
case  been  without  any  effect  (Curtis).  This  is, 
perhaps,  a hopeful  fact,  as  it  indicates  that  curara 
has  an  action  to  which  the  changes  in  the  central 
nervous  system  are  opposed. 

Sedatives  have  been  the  remedies  commonly 
employed,  and  of  these  the  best  are  chloral  anil 
morphia.  One  case  (probably  genuine),  in  which 
morphia  and  calabar  bean  were  used,  recovered 
(Nicholls)  ; and  one  in  which  chloral  was  em- 
ployed lived  for  ten  days  (Sansom).  The  effect  of 
the  two  on  the  respiratory  centre  in  animals 
suggests  their  joint  use.  The  morphia  should  be 
given  by  hypodermic,  the  chloral  by  rectal  in- 
jection. Chloroform  is  useful  in  moderating  the 
paroxysms,  but  appears  somewhat  inferior  to 
chloral.  Other  sedatives — Indian  hemp,  &:c. - 
have  appeared  of  inferior  value. 

Cold  affusions  to  the  cervical  spine  and  head 
were  used  in  India  in  two  cases  which  recovered, 
the  throat  and  spine  being  blistered  with  nitrate 
of  silver,  and  chloroform  administered.  Ice  to 
the  spine  has  been  tried  without  effect.  Tra- 
cheotomy was  recommended  by  Marshall  Hall  id 
one  case.  Death  from  laryngeal  spasm,  is,  how- 
ever, too  rare  to  justify  the  measure. 

In  all  cases  tranquillity  is  of  the  greatest  impor- 
tance. Every  excitant  of  spasm  should  he  avoided; 
the  patient  being  kept  in  a dim  still  room,  and 
friends  as  much  as  possible  excluded.  Next  in  im- 
portance is  nourishment,  which  should  be  given  by 
the  rectum,  if  spasm  is  excited  by  the  attempt  to 
swallow.  Restraint, which  may  be  necessary,  should 
he  as  little  as  possible,  but  it  should  he  effectual. 

The  saliva  of  persons  suffering  from  hydro- 
phobia has  been  proved  to  be  capable  of  com- 
municating the  disease  to  animals.  Henco  th# 
attendants  should  be  cautioned  to  have  no  un- 
covered abrasion  on  the  hands,  and  to  wash  from 
the  eyes  or  face  any  saliva  which  may  have  been 
spit  on  them;  and  if  they  are  bitten  hv  the  patient, 
the  wound  should  he  treated  as  if  it  had  been 
inflicted  by  a rabid  animal.  These  precautions 
remove  all  danger ; and  any  anxiety  the  subjects 
may  feel  may  be  relieved  by  the  assurance,  that 
of  the  thousands  of  persons  who  have  attended 
on  patients  with  hydrophobia,  no  authentic  in- 
stance has  ever  been  recorded  in  which  the  disease 
was  contracted  either  by  attendance  during  life, 
or  inspection  after  death.  W.  R.  Gowers. 

HYDROPS  (SSwp,  water). — A synonym  f'r 
dropsy.  See  Dnorsr. 

HYDRORHACHIS  (uScep.  water,  and  fia.\is. 
the  spine). — A collection  of  fluid  in  the  spinal 
canal.  The  term  is  commonly  used  as  a synonym 
for  spina  bifida.  Sic  Spina  blfida. 


HYDROTHERAPEUTICS. 


HYDRO  THERAPEUTICS  (SSap,  water, 
Hid  depairevu,  I treat). — Synon.  : Water-cure  ; 
Hydropathy;  Fr.  Hydrothcrapcutique ; Ger. 
WasserhcilkiLr.de. 

It  would  bo  out  of  place  were  we  to  enter  here 
into  a description  of  the  sources  and  the  composi- 
tion of  the  numerous  varieties  of  water  used  for 
hygienic  and  dietetic  purposes ; but  we  may  refer 
to  Dr.  Parkes’  instructive  Manual  of  Practical 
Hygiene.  We  intend  to  divide  this  article  into  (1) 
a short  sketch  of  the  history'  of  the  water-cure  or 
hydrotherapeutics ; (2)notesontke internaluseof 
water,  and  on  the  more  common  hydrotherupeunic 
procedures ; and  (3 ),  a consideration  of  the  morbid 
conditions  suitable  forhydrotherapeutic  treatment. 

History  of  the  Water-cure. — Although  the 
old  Greek  and  Roman  physicians  occasionally 
employed  water  internally  and  externally  in  the 
treatment  of  disease,  the  systematic  water-treat- 
mentseemsto  have  gained  ground  for  the  first  time 
in  the  15th  and  in  the  beginning  of  the  16th  cen- 
tury in  Italy  and  France,  and  again  after  a period 
of  oblivion  in  the  17th  century,  especially  in  Eng- 
land (Floyer,  T.  Smith),  and  in  the  beginning 
of  the  18th  century  in  Germany  (F.  Hoffmann). 
The  next  important  scientific  application  we  owe 
to  J.  G.  and  J.  S.  Hahn,  who,  towards  the  middle 
of  the  18th  century,  treated  febrile  diseases  with 
cold  sponging,  and  were  so  convinced  of  the 
beneficial  result,  that  one  of  them  when  attacked 
with  typhoid  ■ fever  subjected  himself  to  this 
treatment.  It  fell,  however,  again  into  neglect, 
until  towards  the  latter  part  of  the  18th  century, 
when  Wm.  Wright,  James  Currie,  W.  Jackson, 
and  others  resuscitated  the  cold  water  treatment 
in  fevers,  and  strengthened  their  reasoning  by 
thermometric  observations.  In  spite  of  the  results 
obtained,  not  only  in  England  but  also  in  Ger- 
many, amopgst  others  by  Reuss,  Frohlieh,  Bran- 
dis, and  Horn,  the  method  was  again  falling  into 
disuse,  when,  soon  after  1820,  a small  farmer, 
Vincent  Priessnitz,  of  Graefenberg,  in  Silesia, 
began  to  treat  every  kind  of  ailment,  chronic  as 
well  as  acute,  with  various  hydrotherapeutic  pro- 
cedures, and  added  to  the  external  applications 
the  abundant  internal  use  of  water,  combined  with 
active  exercise,  and  a very  simple  diet ; prohibit- 
ing at  the  same  time  nil  alcoholic  beverages,  and 
also  tea  and  coffee.  Priessnitz  gradually  made 
considerable  changes  in  his  method  of  treatment. 
For  the  original  packing  during  several  hours  in 
dry  woollen  blankets  covered  with  feather-beds, 
and  followed  by  cold  affusions,  he  substituted 
packing  in  wet  linen  sheets  during  several  hours, 
followed  by  a full  bath  or  a douche ; and  at  a 
still  later  period,  he  frequently  employed  cold 
wet  packing  of  only  1.5  or  20  minutes’  duration, 
repeated  several  times  on  the  same  day  ; he 
introduced  also  the  method  of  rubbing  the  whole 
body  with  a cold  wet  or  dripping  sheet  instead 
of  the  full  bath,  and  made  extensive  use  of 
partial  baths,  as  hip  or  sitz  baths,  baths  for  the 
hands,  the  arms,  the  feet,  wet  abdominal  belts, 
and  wet  compresses  over  different  parts  of  the 
body.  Priessnitz  seemed  to  search  for  a univer- 
sal method  applicable  to  all  cases.  One  of  the 
guiding  ideas  was  that  disease  of  the  most 
diflerent  nature  was  caused  by  an  acrid  humour 
>n  the  blood,  and  that  the  skin  was  the  organ 
through  which  this  humour  was  to  be  removed. 


66“ 

Though  the  success  of  such  treatment,  com- 
bined with  active  exercise  in  a healthy  mountain- 
ous country,  and  simple  diet,  w.^s  considerable  in 
many  cases,  the  indiscriminate,  too  energetic, 
and  protracted  use  often  led  to  unfavourable 
results,  and  the  system  was  beginning  to  be 
regarded  as  a species  of  quaekerv,  when,  about 
thirty  years  ago,  some  establishments  were 
placed  under  the  superintendence  of  regularly 
educated  physicians,  who  studied  He  phys  iological 
effects  of  the  different  forms  of  bacninu.  and  modi- 
fied them  with  regard  to  duration,  temperature. 
&e.,  according  to  the  requirements  of  individual 
cases,  combining  pharmaceutical  remedies  witli 
hydrotherapeutic  procedures  when  required.  Thus 
a more  or  less  modified  water-cure  has  at  last 
become  a branch  of  rational  medicine,  at  least  in 
France  and  Germany  ; and  a new  impulse  has 
been  given  to  it  lately,  by  the  employment  of 
various  forms  of  baths  in  the  treatment  of  fevers. 
In  this  country  there  is  as  yet,  very  little  system- 
atised relation  between  the  special  hydrothera- 
peutic and  the  general  medical  treatment ; and  the 
experience  gained  at  hydrotherapeutic  establish- 
ments is  not  communicated  and  discussed  in  our 
medical  societies,  and  scarcely  ever  in  the  general 
medical  journals.  This  is  much  to  be  regretted, 
for  there  can  be  no  doubt  that  hydrotherapeutic 
measures  might  be  more  widely  introduced  with 
great  advantage  into  our  hospitals,  as  well  as  into 
our  private  practice  ; but  this  is  not  likely  to  be 
the  case  so  long  as  the  medical  profession  has  not 
fuller  opportunities  for  studying  the  effects  of 
water  treatment.  The  fault  may  lie  to  some  de- 
gree in  the  nature  of  most  of  the  establishments 
for  the  water-cure ; but  this  might  be  remedied  if 
more  establishments  were  to  be  erected  under  the 
guidance  of  superior  members  of  the  profession  — 
establishments  where  the  usual  medical  treat- 
ment would  in  suitable  cases  go  hand  in  hand 
with  hydrotherapeutic  management. 

Internal  Therapeutic  Use  of  Water,  and 
the  more  Common  External  Hydrothera- 
peutic Procedures. — The  dietetic  necessity  of 
water  is  well  known ; life  cannot  exist  without 
it, ; all  our  tissues  contain  an  indispensable  pro- 
portion of  water;  we  constantly  lose  a large 
amount -by  respiration,  and  by  all  excretions;  all 
the  internal  functions  of  tissue-change  are  depen- 
dent on  a certain  quantity  of  water ; this  want 
is  supplied  by  the  solid  and  fluid  food  which  we 
take,  water  included;  while  temporary  excess  of 
supply  leads  to  increased  discharge  by  the  excre- 
tions, and  temporary  deficiency  to  a diminution 
of  the  water  of  the  excretions.  An  increased  in- 
gestion of  water  further  leads,  for  a time  at  least, 
to  an  increased  removal  of  the  products  of  retro- 
gressive tissue-change ; the  tissues  and  the  blood 
itself  are,  so  to  speak,  washed  out  by  it ; and,  as 
the  consequence  of  the  increased  removal  of  the 
used-up  material,  the  body  is  enabled  to  take  in  a 
larger  amount  of  new  substance,  and  hence  we 
observe  not  rarely  increase  of  weight  as  the  effect 
of  plentiful  water-drinking,  if  not  carried  to  excess 
as  regards  quantity  and  time  ; the  secretions  of 
the  urine,  bile,  saliva,  and  pancreatic  juice,  appear 
to  be  increased  by  the  abundant  internal  use  of 
water,  as  weUas  the  perspiration , though  the  latter 
to  some  degree  requires  the  concomitant  influence 
of  high  external  temperature  or  bodily  exercise. 


HYDROTHERAPEUTICS. 


668 

Water  lias  also  an  important  share  in  all 
internal  courses  of  mineral  waters.  Used  by 
:tself,  it  can  exercise  some  good  influence  in 
cases  of  gout  and  gravel,  in  haemorrhoidal  com- 
plaints, imperfect  secretion  of  bile,  and  constipa- 
tion from  sluggish  peristaltic  action.  As,  how- 
ever, excessive  water-drinking,  according  to 
Priessnitz’s  original  plan,  is  apt  to  cause  dys- 
peptic troubles,  water  is  now,  in  general,  used 
internally  only  either  for  dietetic  purposes,  or  to 
assist  in  other  courses  of  treatment. 

The  external  use  of  cold  water  admits  of  a 
very  great  variety  of  applications,  and  a corre- 
sponding variety  of  effects  on  the  body.  The  two 
main  effects  of  the  different  forms  of  cold  baths  are 
abstraction  of  heat,  with  its  further  influences  on 
the  functions  of  the  body;  and.  stimulation  of  the 
cutaneous  nerves,  and  through  these  of  the  nerve- 
centres.  Both  effects  are  usually  combined,  but 
in  some  forms  of  bath,  the  stimulation  or  the 
exciting  effect  preponderates;  in  others  the  ab- 
straction of  heat,  with  its  calming  or  depressing 
ivjlumce.  Hence  the  different  forms  of  baths, 
or  rather  hydrotlierapeutic  procedures,  may  be 
divided  into  stimulating  and  calming,  but  it  is  to 
lie  borno  in  mind  that  there  is  no  strict  line  of 
distinction.  With  this  limitation  we  may  regard 
as  stimulating— the  full  cold  batli  of  short 
duration,  the  stimulating  action  of  which  is 
increased  by  motion  of  the  water,  be  it  natural 
or  artificially  imparted;  the  rapid  wash-down, 
either  by  means  of  a large  sponge,  or  by  means 
of  a wet  sheet,  with  or  without  friction ; the 
spouting  of  the  back,  and  the  pail-douche;  the 
needle-bath  or  circular  shower-bath ; the  different 
forms  of  the  rain-bath,  and  the  usual  shower- 
bath;  the  great  variety  of  other  douches;  and  the 
running  or  flowing  sitz-bath.  The  immediate 
effects  of  these  stimulating  forms,  in  a constitu- 
tion endowed  with  a certain  amount  of  reactive 
power,  are  exhilaration,  increased  activity  of  cir- 
culation and  muscular  force,  and  improved  appe- 
tite and  digestive  power.  By  altering  the  dura- 
tion of  the  bath,  and  the  temperature  of  the 
water,  the  effects  may  be  considerably  modified, 
and  thus  adapted  to  different  conditions. 

The  more  calming  forms  are — the  wet  sheet- 
envelope,  entire  or  partial;  the  impermeable  wet 
compresses;  the  full  cold  bath  of  long  duration 
and  without  motion;  the  sitz,  tile  shallow,  and 
foot  baths  without  motion ; and  the  full  bath  of 
higher  temperature.  Depression  through  ab- 
straction of  heat  exceeds  the  stimulation  in  these 
forms  : diminution  of  nervous  irritability,  of  sen- 
sation and  mental  activity,  and  of  the  frequency 
of  the  pulse  and  energy  of  circulation  : a feeling 
of  lassitude;  and  a tendency  to  sleep,  are  the 
principal  effects.  These  forms  can,  however,  bo 
modified,  and  the  effects  vary  in  proportion.  Thus 
the  wet  sheet-envelope  allows  ample  variation  by 
using  warm  or  cold  water,  by  using  the  sheet 
dripping  or  wrung  out,  by  making  the  sheet  fit 
tightly  round  the  neck,  by  moving  the  sheet  to 
and  fro,  by  frequently  changing  the  sheet,  &e. 
The  calming  and  stimulating  form  may  be  further 
combined  by  using,  first,  the  wet  sheet-envelope, 
or  the  woollen  blanket-envelope,  for  a sufficient 
period  to  produce  perspiration;  and  then  a more 
or  less  cold  bath  or  shower-bath  of  short  dura- 
tion. The  physician  has,  indeed,  infinite  varieties 


of  application  at  his  disposal,  to  be  used  accor- 
ding  to  necessity. 

Powerful  and  most  important  hydrotherapeu- 
tic  helps  are  the  different  vapour-  and  hot  air- 
baths  (Russian,  Roman,  Turkish  baths),  com- 
bined with  douches  and  baths  of  various  tem- 
peratures. These  kinds  of  baths  are,  however, 
treated  of  in  another  article.  See  Baths. 

A plain  nourishing  diet,  without  or  with  only 
a limited  amount  of  stimulants;  outdoor  exercise 
in  proportion  to  the  strength  of  the  individual; 
and  in  some  cases  active  or  passive  gymnastics, 
are  likewise  to  be  regarded  as  valuable  adjuvants 
in  the  hydrotherapeutic  treatment  of  chronic 
diseases ; for  muscular  exercise  means  not  only 
increased  action,  oxidation,  excretion,  and  de- 
velopment of  muscle,  but  also  increased  gene- 
ral circulation  and  respiration,  increased  inhala- 
tion of  oxygen,  and  increased  production  of  heat, 
so  necessary  in  the  cold  water-cure.  There  is 
also  no  reason  whatever  why  pharmaceutic-, 1 
remedies  should  not  be  combined  with  the  water- 
cure  treatment — a method  which,  as  already 
mentioned,  is  frequently  adopted  in  the  best  esta- 
blishments. 

Therapeutic  Effects,  and  Morbid  Condi- 
tions Suitable  for  Hydrotherapeutic  Treat- 
ment.—The  principal  results  of  weil-adapted 
courses  of  cold  water  treatment  arc  : — improved 
nutrition  and  action  of  the  skin ; increased  tone  of 
the  nerve-centres  ; regulation  of  the  circulation  ; 
amelioration  of  the  sanguification  and  nutri- 
tion ; and  acceleration  of  the  retrogressive  tissue- 
changes.  It  is  essential  for  such  successful  results 
that  the  organism  be  able  to  stand  a certain 
amount  of  abstraction  of  heat ; that  it  be  capable 
of  more  or  less  energetic  reaction  ; and  that  the 
digestive  and  assimilative  organs  be  able  to  take 
up  a fair  amount  of  nourishing  material,  which  is 
required  by  the  increased  demand  on  the  body. 

Acute  febrile  diseases. — Amongst  the  oldest 
therapeutic  uses  of  the  cold  bath,  though  it  has 
only  lately  been  more  extensively  revived,  is  the 
employment  of  different  forms  of  cold  baths  in 
acute  febrile  diseases,  attended  with  a high  de- 
gree of  pyrexia.  The  moderately  cold  or  the 
cooled-down  bath,  as  proposed  by  Dr.  von  Ziems- 
sen  of  Munich,  is  the  form  principally  employed: 
but  cold  affusions,  the  shower-bath,  the  wet  en- 
velope frequently  changed,  cold  compresses,  the 
application  of  ice  in  substance,  washing  with 
iced  water,  and  iced  enemas  are  likewise  appli- 
cable ; and  the  liberal  internal  allowance  of  cold 
water  forms  an  important  part  of  the  dietetic 
management  of  this  class  of  diseases. 

Typhoid  fever. — Typhoid  fever  is  the  disease 
in  which  this  treatment,  with  numerous  modifica- 
tions, has  been  most  generally  adopted.  As  soon 
as  the  temperature  of  the  patient  reaches  102’0° 
to  103°  Ruhr.,  he  is  placed  in  a bath  of  about  90° 
Fahr.,  and  the  temperature  is  gradually  cooled 
down,  by  the  addition  of  cold  water,  to  80°  or  60° 
Fahr..  according  to  the  patient’s  power  of  reaction. 
The  patient  is  kept  in  the  bath  generally  from  10 
to  lo  or  20  minutes,  when  slight  shivering  often 
manifests  itself.  The  patient's  temperature,  me  i- 
sured  in  the  rectum,  is  usually  reduced  by  this 
procedure  about  1 )°  to  5°  Fahr.,  not  immediately, 
but  within  the  first  hour  after  the  bath.  As 
often  as  the  temperature  may  again  reach  102 ’O’ 


HYDROTHERAPEUTICS. 


to  103°,  the  patient  is  again  placed  in  the  bath. 
Thus,  during  thp  height  of  the  pyrexia  three  to 
five  baths  may  be  required  in  twenty-four  hours, 
while  later  on  about  two  are  usually  sufficient, 
and  often  only  one.  Instead  of  the  bath  gra- 
dually eoolcd-down,  a bath  of  a.  temperature 
between  60° and  90°  Fahr.,  may  be  given,  accord- 
ing to  the  condition  of  the  individual  patient. 
The  frequent  and  careful  use  of  the  thermometer 
is  an  essential  element  in  this  method  of  treat- 
ment, which  may  be,  as  it  often  is,  advantageously 
combined  with  the  administration  of  alcohol, 
quinine,  and  other  remedies.  The  earlier  the 
baths  are  commenced,  the  greater  seems  to  be 
their  influence  in  mitigating  the  severity  of  the 
disease  and  its  sequel®,  and  in  shortening  its 
duration.  In  the  numerous  accounts  of  Ger- 
man physicians  (Brand,  Ziemssen,  Zimmermann, 
Jixrgensen,  Liebermeister,  &c.)  it  is  claimed 
that  the  mortality  is  considerably  less  with  this 
than  with  the  expectant  or  any  of  the  other  usual 
modes  of  treatment. 

Hyperpyrexia. — A still  bolder  use  may  b6  made 
of  the  cold-water  treatment,  in  those  rarer  cases 
of  hvperpyrexia  occasionally  occurring  in  the 
course  of  rheumatic  fever,  when  the  temperature 
rises  to  10S°  Fahr.  and  more;  and  where  very 
cold  and  prolonged  baths,  the  application  of  ice- 
bags,  &c.,  appear  to  be  the  only  means  of  saving 
life.  ( See  Dr.  Wilson  Fox,  Treatment  of  Hyper- 
pyrexia ; the  writer's  case  in  the  Clinical  So- 
ciety’s Transactions,  vol.  v.  ; and  several  other 
papers  in  the  Clinical  Society’s  Transactions.) 

Scarlet  Fever. — In  scarlet  fever  we  have  found 
warmer  baths  (80°  to  98°  Fahr.)  more  generally 
applicable  than  quite  cold  or  cooled-down  baths, 
though  in  cases  attended  by  a high  degree  of 
pyrexia  and  brain-symptoms  these  are  preferable. 

Hectic  fever. — In  hectic  fever,  connected  with 
various  chronic  diseases,  the  effect  of  hydro- 
therapeutic  treatment  is  less  decided,  and  not 
yet  sufficiently  tested. 

Digestive  derangements  of  the  most  different 
kind,  associated  with  sluggish  venous  circulation 
in  the  abdominal  organs — conditions  which  may 
be  grouped  together  under  the  term  abdominal 
venosity,  tendency  to  haemorrhoids,  to  hypochon- 
driasis, &c.,  are  ofteu  the  objects  of  the  water 
cure,  which  may  be  useful  bystimulating  the  phy- 
sical and  psychical  energy  of  the  nervous  system, 
as  well  as  the  nutrition  and  tissue-change,  by  in- 
vigorating the  skin.  Habitual  constipation  from 
this  cause  is  often  relieved  by  the  hydrothera- 
peutic  belt.  In  this  class  of  cases  the  common 
salt  waters,  and  the  alkaline  sulphatic  waters  are 
more  frequently  used,  and  are  often  preferable ; 
they  may,  however,  be  advantageously  combined 
with  judicious  hydrotherapeutic  treatment. 

Chronic  metallic  poisoning  may  be  treated  in 
some  cases  with  equal  benefit,  if  there  is' suffi- 
cient reactive  power,  at  cold  water  establishments, 
as  at  the  thermal  sulphur  and  simple  thermal 
spas.  The  external  hydrotherapeutic  procedures 
aiming  at  increased  perspiration  and  tissue- 
change.  are  in  this  class  aided  by  the  abundant 
internal  use  of  water,  in  order  to  wash  out  the 
tissues,  and  especially  the  liver. 

Skin-weakness  or  atony  of  the  skin  is  often  the 
cause  of  frequently  recurring  attacks  of  diarrhoea 
with  neuralgic  pains,  of  tendency  to  catarrh  of 


669 

the  respiratory  mucous  membrane,  and  of  rheu- 
matism. Gently  stimulating  hydrotherapeutic 
appliances,  with  gradually  increasing  energy,  are 
here  mostly  useful,  unless,  as  in  impeded  con- 
valescence, the  reactive  power  is  so  reduced  that 
the  gaseous  thermal  salt  baths  and  mountain-air 
are  preferable,  while  in  others  sea-air  and  sea- 
baths  are  successful  competitors  cf  the  water- 
cure. 

Hysteria. — In  hysteria  and  hysterical  affec- 
tions the  water  cure  has  obtained  many  good 
results,  not  by  the  internal  use  of  water,  but  by 
the  milder  forms  of  baths.  Functional  hyper- 
aethesia  and  anaesthesia,  hemicrania,  spinal  irrita- 
tion, intercostal  neuralgia,  and  other  forms  of 
neuralgia  depending  on  imperfect  nutrition  and 
tissue-change,  are  likewise  often  benefited. 

Organic  diseases  of  the  nerve-centres  are  not 
suitable  for  treatment  in  cold  water  establish- 
ments, excepting  occasionally  for  palliative  pur- 
poses. 

Bheumatism  and  gout. — In  muscular  rheuma- 
tism the  original  supporters  of  the  water-cure 
considered  their  plan  as  infallible,  but  this  is 
by  no  means  the  case.  The  diaphoretic  methods, 
namely,  the  woollen  blanket-pack  and  the  wet 
sheet-envelope,  often  prove  useful ; but  we  know 
also  of  many  failures  in  even  good  establishments. 
The  exposure  toall  weathers  during  the  cure  ought 
certainly  not  to  be  imitated  by  such  invalids,  and 
the  access  of  cold  air  to  the  wet  body  is  to  be 
more  carefully  avoided  than  it  often  is.  The 
course  must  not  be  prolonged  too  much  at  one 
time,  but  may  be  repeated  after  an  interval  of 
months,  which  may  he  spent  with  advantage  at 
sheltered  seaside  localities,  at  moderate  elevations, 
with  the  help  of  pine-leaf  baths,  or  at  one  of  the 
gaseous  thermal  saline  spas. 

Hheumatic  and  gouty  swellings  of  joints  require 
great  care  in  their  management.  The  enfeebled 
invalid  is  rarely  a fit  object  for  the  water-cure  ; 
but  the  stimulating  local  compress,  more  or  less 
impermeable,  is  a useful  element  in  the  treatment 
of  such  cases. 

Milder  cases  of  gout  may  expect  benefit  from 
the  usual  hydrotherapeutic  treatment,  in  so  far 
as  it  aims  at  increased  retrogressive  tissue- 
change,  and  invigoration  of  the  nervous  system, 
especially  if  this  treatment  is  associated  with 
great  moderation  in  the  use  of  stimulants,  and 
also  of  food  in  general;  but  local  packing  not 
rarely  causes  fits  of  gout.  The  more  serious 
forms  of  gout  are  too  much  complicated  with 
various  defects  of  constitution  to  encourage  us 
in  recommending  cold-water  treatment. 

Chronic  affections  of  the  skin. — In  some  dis- 
eases of  this  kind,  such  as  prurigo,  urticaria, 
eczema,  and  local  perspirations,  a more  or  less 
modified  hydrotherapeutic  treatment  is  an  im- 
portant adjuvant. 

Syphilis. — The  favourable  results  obtained  in 
syphilis,  or  rather  in  the  often  complicated  con- 
ditions of  lues,  have  greatly  contributed  to  the 
reputation  of  the  water-cure ; but  the  latter  is 
only  an  excellent  adjuvant  to  pharmaceutical 
treatment  in  these  cases,  in  a similar  way  as  the 
sulphur  waters  are ; and  many  of  the  cures  of 
so-called  lues  may  he  regarded  as  cures  of  mcr- 
curialism. 

Catamenial  irregularities  are  not  rarely  treated 


r,  70  HYDROTHERAPEUTICS. 
at  hydrotherapeutie  establishments.  Profuse 
menstruation  is  often  checked  by  the  regular  use 
of  the  colil  hip  bath  of  short  duration,  namely, 
three  to  fire  minutes  ; in  insufficient  menses,  on 
the  other  hand,  warm  hip-baths  of  ten  to  fifteen 
minutes’  duration  are  frequently  useful,  combined 
ia  some  cases  with  the  wet  sheet-envelope;  and 
dysmenorrhcea  is  likewise  occasionally  treated 
with  advantage  by  the  partial  wet  sheet- envelope. 

This  list  of  morbid  conditions  which  tnay  be 
more  or  less  benefited,  might  easily  be  increased  ; 
and  this  is  not  astonishing  if  it  is  considered  that 
hydrotherapeutie  treatment  can  be  infinitely 
modified  and  adapted  to  the  powers  of  the  con- 
stitution; and  that  it  may  be  assisted  by  varying 
hygienic,  climatic,  dietetic,  and  pharmaceutical 
influences  ; for  there  does  not  exist  any  antagon- 
ism between  hydrotherapeutie  and  other  rational 
treatment,  the  former  being,  in  fact,  only  part  of 
tho  latter.  Hence,  however,  it  is  also  evident 
that  the  treatment  in  well-arranged  hydrothera- 
peutie establishments  ought  to  be  under  the 
guidance  of  the  most  intelligent  physicians,  just 
as  is  the  case  at  all  the  best  spas ; indeed  the  phy 
siciar.  at  such  an  establishment  ought  to  be  of  a 
very  superior  kind,  possessing  in  a more  than 
usual  degree  the  gift  of  recognising  all  the  in- 
dividual peculiarities  of  the  constitution,  espe- 
cially the  amount  of  reacting  power,  adapting 
the  principal  remedy  to  every  individual  case, 
and  combining  other  elements  of  treatment  with 
hydrotherapeutie  management  wherever  this  is 
necessary.  In  the  same  way  as  wo  demand  in 
suitable  cases  the  administration  of  other  re- 
medies together  with  water-treatment  in  bydro- 
therapeutic  establishments,  so  we  must  also 
express  a wish,  that  our,  of  such  establishments, 
hydrotherapeutie  elements  should  be  more  gene- 
rally combined  with  the  usual  medical  treatment. 
For  this  purpose  it  is  to  be  desired  that  well- 
conducted  establishments  should  bo  in  or  near 
large  towns,  in  order  that  persons  following  their 
usual  occupations  might  undergo  certain  kinds 
of  treatment  at.  such  establishments,  or  that  at- 
tendants from  such  establishments  might  bo  sent 
to  tho  house  of  invalids.  Hermann  Weber. 

HYDRO  THORAX  (u'Soi p,  water,  and  edpat;, 
the  chest). — Dropsy  of  the  pleura.  See  Pleura, 
Diseases  of. 

HYDRUBIA  (l!5ojp,  water,  and  ovpov,  urine). 
A profuse  flow  of  watery  urine.  See  Urine, 
Morbid  Conditions  of. 

HYERES,  ia  Var,  Eranee.  Dry,  warm 
climate.  Town  three  miles  from  the  sea.  Much 
exposed  to  N.W.  wind  (Mistral)  in  spring.  See 
Climate,  Treatment  of  Disease  by. 

HYGIENE  (uy.Gi a,  health). — The  science 
and  art  relating  to  the  preservation  of  health. 
Sec  Personal  Health  ; and  Public  Health. 

HYPAEMIA  (u7 rb,  under,  and  aT/xa,  blood). — 
Deficiency  of  blood  in  a part;  a synonym  for 
local  anaemia.  See  Circulation,  Disorders  of. 

HYPASSTHESIA  ({mb,  under,  and  ataBnais , 
sensation).— Diminished  sensibility  of  a part. 
See  Sensation,  Disorders  of. 

HYPERAEMIA(6ivip,  over  or  excessive,  and 


HYPERTROPHY. 

OL/ia,  blood), — Excess  of  blood  in  a part.  Set 
Circulation,  Disorders  of. 

HYPERJESTHESIA  (imbp,  over,  and  af<r- 
d-qais,  sensation). — Increased  sensibility  of  apart, 
See  Sensation,  Disorders  of. 

HYPERALGESIA  (vrip,  over,  and  SXyos, 
pain). — Undue  sensibility  to  painful  impressions. 
See  Sensation,  Disorders  of. 

HYPERIDROSIS  (uir  bp,  excessive,  and 
ISpiis,  sweat).  — Excessive  perspiration ; also 
termed  idrosis,  ephidrosis,  and  sudatoria.  See 
Perspiration,  Disorders  of. 

HYPERINOSIS  (in’ip,  over,  and  is,  ivos, 
flesh). — Excess  of  fibrin  in  the  blood.  See 
Biood,  Morbid  Conditions  of. 

H YPERMETROPIA  (uni  pp.tr  pos,  beyond 
all  measure,  and  £u|/,  the  eye). — A congenital  or 
acquired  error  of  refraction  of  the  eye,  in  which, 
owing  to  low  refractive  power  of  the  dioptric 
media,  or  too  little  convexity  of  the  refracting 
surfaces,  or  unnatural  shortness  of  the  anterio- 
posterior axis  of  the  eyeball,  parallel  rays  of  light 
do  not,  while  the  accommodation  js  in  repose, 
converge  to  a focus  on  the  layer  of  rods  and  cones 
of  tho  retina,  as  in  the  normal  or  emmetropic 
eye,  but  to  an  imaginary  point  somewhere  be- 
hind. It  is  the  opposite  of  Myopia,  and  is  some- 
times called  Hyperopia  or  Hyperpresbyopia.  See 
Vision,  Disorders  of. 

HYPEROPIA  (ivep,  above,  and  &\f/,  the 
eye).  See  Hypermbthopia. 

HYPERPLASIA  (vw ip,  over,  and  n\iaaa, 
I mould  or  form). — An  excessive  growth  of 
normal  tissue-elements,  which  may  lead  to 
hypertrophy,  or  to  the  formation  of  distinct 
tumours.  See  Hypertrophy;  and  Tumours. 

HYPERPRESBY  OPIA  (unip,  above, 
i -pia0us,  old,  and  &b,  the  eye).  See  Hypermb- 
TROPIA. 

HYPERPYREXIA  (inxip,  excessive,  and 
Trvpel'ia,  fever). — Excessive  pyrexia.  See  Fever  ; 
and  Temperature. 

HYPERTROPHY  (unip,  over;  and  rpo<pn, 

nourishment). 

Definition. — The  word  ‘ hypertrophy’  signi- 
fies excessive  nourishment,  butis  in  practice  used 
to  designate  the  result  of  excessive  nourishment, 
that  is,  excessive  growth.  Hypertrophy  may  be 
general  ox  partial. 

I.  General  Hypertrophy. — General  hyper- 
trophy, though  a remarkable  condition,  is  of  little 
practical  importance.  It  is  known  only  in  those 
individuals  of  enormous  size,  who  are  called 
‘giants.’  The  production  of  giants  depends  on 
causes  entirely  unknown,  since  it  is  noticeable 
that  this  condition  commonly  affects  only  one  in 
a family,  and  is  in  its  most  conspicuous  forms 
not  hereditary.  Giants  are  usually  of  feeble  con- 
stitution, and  deficient  in  procreative  power.  The 
name  macrosomatia  has  been  given  to  a condi- 
tion equally  unexplained,  in  which  the  whole 
body  becomes  enlarged  in  a monstrous  degree. 
This  condition  has  been  observed  to  be  in  some 
instances  congenital,  or.  at  least,  to  begin  in  very 
early  life.  True  general  hypertrophy  does  net 
appear  to  be  capable  of  being  produced  by  any 
artificial  means,  since  excessive  feeding  either 


HYPERTROPHY. 


produces  hypertrophy  almost  confined  to  one 
tissue,  namely,  fat,  or  else  fails  to  produce  any 
enlargement  at  all. 

II.  Partial  Hypertrophy. — By  this  is  meant 
(a)  excessive  increase  of  any  part  of  the  body 
during  the  period  of  natural  growth,  either  iu 
intra-uterine  or  extra-uterine  life;  or  (6)  in- 
crease of  a part  already  completely  formed. 
According  to  this  distinction  hypertrophy  may 
be  classified  as  congcniiil  or  acquired. 

1 . Congenital  Hypertrophy.  — Congenital 
hypertrophy  is  that  condition  in -which  seme  part 
of  the  body  begins  from  the  first  to  grow  so 
rapidly  as  to  attain  a size  far  beyond  the  normal. 
This  condition  has  been  seen  tc  affect  one  side  of 
the  body,  or  one  limb  only,  which  thus  becomes 
much  larger  than  its  fellow  on  the  other  side. 
Such  a condition  might  be  in  theory  difficult  to 
distinguish  from  atrophy  of  the  opposite  side,  or  of 
the  other  limb,  that  is,  from  hemiatrophy  {see 
Atrophy)  ; but  in  general  the  hypertrophic  side 
is  so  far  beyond  the  normal  size  as  to  prevent 
ambiguity.  One  remarkable  case  is  on  record  in 
which  one  leg  and  arm  assumed  the  proportions 
of  those  of  a giant,  whilst  the  other  remained 
unaltered.  Sometimes  a congenital  hypertrophy 
occurs  without  this  unilateral  character,  as  in 
the  case  reported  by  Mr.  Curling  of  a girl  aged 
fifteen,  who  had  several  fingers  of  both  hands 
enlarged  in  an  extraordinary  degree  without  any 
assignable  cause,  the  equality  of  the  two  sides 
being  nevertheless  preserved.  Such  instances, 
although  unexplained,  must,  it  would  seem,  be 
put  into  the  same  class  as  the  gigantic  growth  of 
the  whole  of  the  body.  Hypertrophy  of  special 
tissues  is  also  sometimes  congenital,  as  of  the 
skin  in  ichthyosis.  Hypertrophies  similar  to 
those  here  called  congenital  may  occur,  though 
rarely,  in  adult  life.  The  enlarged  part  is  found 
to  be  highly  vascular,  to  have  an  increased  tem- 
perature, and  to  preserve  its  normal  proportions. 
The  cause  is  in  these  cases  equally  unknown. 

2.  Acquired  Hypertrophy. — Acquired  hyper- 
trophies appear  to  result,  roughly  speaking,  from 
the  following  causes  : — (a)  increased  work ; ( b ) 
pressure  ; (e)  inflammation;  ( d ) increased  supplies 
of  nourishment ; or  ( e ) physiological  changes. 

{a)  Increased  work. — Increased  use  of  the 
part  can  produce  hypertrophy  only  in  those 
organs  which  have  an  active  function,  especially 
the  muscles.  It  is  a matter  of  familiar  observa- 
tion that  voluntary  muscles  increase  in  size -when 
much  employed,  as  is  seen  in  the  often  men- 
tioned arm  of  tile  blacksmith  or  the  leg  of  the 
ballet-dancer.  In  order  to  produce  this  increase, 
the  exercise  must  be  of  a certain  degree  of  inten- 
sity, but  not  excessive.  It  must  be  frequently 
repeated,  with  intervals  of  rest;  and  at  the  same 
time  the  nutrition  of  the  wholo  body  must  be 
good.  In  the  absence  of  these  conditions,  exer- 
cise is  more  likely  to  produce  wasting.  The  ex- 
planation of  this  familiar  process  is  still  obscure. 

Hypertrophy  of  the  heart  occurs  in  cases  where 
that  organ  is  made  to  work  at  a higher  tension 
th  in  the  normal,  and  this  higher  tension  can  only 
result  from  increased  resistance  to  the  flow  of 
Mood,  either  at  the  orifice  of  the  heart,  or  in  the 
peripheral  vessels.  Hence  the  conditions  most 
eomii'only  giving  rise  to  it  are  valvular  disease, 
dspccial'y  st-nos;s  ; and  obstruction  of  the  arteries, 


671 

either  by  tha  thickening  of  their  walls,  or  by  con- 
traction  of  their  muscular  coats.  The  right  side 
of  the  heart  will  also  become  hypertrophied  when 
any  condition  whatever  hinders  the  passage  of 
blood  through  the  lungs.  Disease  of  the  kidneys 
is  a frequent  cause  of  enlargement  of  the  left 
ventricle  of  the  heart,  though  iu  what  way  iu 
still  a matter  of  discussion.  It  is  only  quite 
clear  that  the  kidney-disease  in  some  way  in- 
creases the  resistance  in  the  smaller  arteries  and 
capillaries. 

Hypertrophy  of  the  smooth  or  involuntary 
muscular  fibres  also  occurs  whenever  that  tissue 
has  to  contract  for  a long  period  under  a higher 
tension  than  the  normal.  Thus  the  walls  of  the 
bladder  becomo  thickened  in  cases  where,  from 
obstruction  of  the  passages,  the  evacuation  of 
urine  is  effected  with  more  difficulty,  and  under 
a higher  pressure,  than  usual.  In  the  same  way 
the  walls  of  the  stomach,  the  oesophagus,  and  in- 
testinesbecome  hypertrophied  in  cases  of  obstruc- 
tion to  the  passage  of  food  through  the  alimen 
tary  canal. 

The  explanation  commonly  given  of  these 
cases  of  hypertrophy  in  the  contractile  organs 
is,  that  in  consequence  of  obstruction  the  organ 
has  to  contract  with  greater  force  than  usual, 
and  thus  becomes  hypertrophied  in  the  same 
manner  as  a voluntary  muscle,  which  is  fre- 
quently exercised.  It  is,  however,  clear  that 
this  so-called  explanation  does  not  account  for 
the  connection  between  obstruction  and  more 
powerful  contraction.  The  only  explanation  that 
can  be  given  is  that  in  these  cases  pressure  or 
tension  on  the  organ  itself  is  the  stimulus  to 
contraction,  and  that  the  force  of  contraction 
appears  to  depend  roughly  upon  the  strength  of 
the  tension  which  produces  it. 

There  is  less  evilence  that  nervous  or  glandu- 
lar structures  undergo  hypertrophy  in  conse- 
quence of  their  increased  use  ; but  if  one  kidney 
be  destroyed  the  other  is  generally  found  en- 
larged; and  some  authorities  believe  in  an  in- 
crease in  the  size  of  the  brain  from  mental 
activity. 

(6)  Pressure. — Pressure  appears  to  produce 
hypertrophy  only  when  it  is  moderate  and  in- 
termittent. Excessive  or  continuous  pressure 
rather  produces  atrophy.  Thickening  cf  the 
epidermis  from  external  pressure  is  the  most 
familiar  instance.  Pressure,  perhaps,  leads  to 
hypertrophy  by  causing  an  increase  of  the  flow 
of  blood. 

(c)  Inflammation. — Inflammation  when  chro- 
nic is  a cause  of  hypertrophy  in  some  of  the 
tissues,  more  especially  in  various  forms  of  con- 
nective tissue.  This  is  constantly  the  case  in 
chronic  interstitial  inflammation  of  solid  organs, 
ia  which  indeed  it  is  impossible  to  draw  the 
line  between  inflammation  and  fibrous  hyper- 
trophy. But  it  should  be  remembered  that  this 
condition  is  usually  accompanied  by  atrophy  of 
the  other  tissues,  so  that  the  size  of  the  organ 
itself  is  more  likely  to  he  diminished  than-  in- 
creased. The  serous  membranes,  as  the  pleura, 
peritoneum,  and  dura  mater,  become  thickened 
from  chronic  or  repeated  inflammation.  Thus 
periostitis  is  a frequent  cause  of  hypertrophy 
of  the  hones.  The  skin  also  becomes  thick- 
ened :n  chronic  eczema,  and  this  condition  may 


HYPERTROPHY. 


672 

extend  to  the  subcutaneous  tissue.  Acute  in- 
flammation, on  the  other  hand,  is  more  likely  to 
produce  wasting  of  the  organ  it  affects. 

( d ) Increased  nourishment. — It  must  be  re- 
garded as  doubtful  whether  increased  nourish- 
ment alone  is  capable  of  producing  enlargement 
of  any  part  of  the  body.  It  certainly  does  not 
necessarily  do  so,  as  is  shown  by  the  case  of 
experimental  hyperoemia.  When  this  condition 
is  produced,  for  instance,  by  section  of  the  eer 
vieal  .sympathetic  nerve,  in  one  side  of  the 
face  and  head  of  an  animal,  hypertrophy  is 
only  a rare  and  occasional  consequence.  When, 
however,  the  increased  supply  of  nutrition  in 
the  form  of  blood  is  combined  with  some  irrita- 
tion or  functional  stimulus,  we  often  find  Hy- 
pertrophy - result.  Thus,  for  instance,  reflex 
hypersemia  of  the  skin  of  the  face  or  blushing, 
which  is  produced  by  numerous  internal  causes, 
such  as  gastric  or  uterine  derangement,  may 
subsist  for  years  and  reach  a very,  high  degree 
without  altering  the  nutrition  of  the  part.  Hut 
if  there  should  be  in  addition  some  disturbance 
or  inflammation  of  the  glands  of  the  skin,  we 
have  the  conditions  called  acne  rosacea,  &c., 
in  which  hypertrophy  is  an  important  element. 
Almost  the  only  instance  that  can  be  quoted 
of  hypertrophy  from  increase  of  blood-supply 
alone  is  that  of  the  corpus  luteum  during  preg- 
nancy, when  the  ovary  participates  in  the  func- 
tional hyperaemia  of  the  uterus.  The  well-known 
experiment  of  Hunter  should  also  not  be  for- 
gotten, in  which  he  transplanted  the  spur  of  a 
cock  from  its  foot  to  its  head,  and  found  it  to 
increase  in  size. 

It  is,  however,  important  to  remember  that 
hypertrophy,  however  produced,  is  always  ac- 
companied by  an  increased  supply  of  blood,  and 
enlargement  of  the  vessels. 

(e)  Physiological  changes.  — Physiological 
hypertrophies  form  an  important  class.  One  of 
the  best  instances  is  that  of  the  enlargement 
of  the  uterus  during  pregnancy.  This  enlarge- 
ment is  clearly  not  the  consequence  of  hyper- 
cemia  alone,  nor  of  increase  of  the  functional 
activity  in  the  muscular  walls,  though  both 
these  conditions  are  present ; but  must  proceed 
from  some  direct  physiological  stimulus  like 
that  which  determines  the  growth  of  the  em- 
bryo itself.  The  hypertrophy  affects  all  parts 
of  the  organ — its  mucous  and  serous  coats,  as 
well  as  the  muscular  walls.  Enlargement  of 
the  mamma?  appears  to  arise  from  similar 
causes ; and  it  is  even  probable  that  swelling  of 
the  thyroid  may,  through  some  obscure  con- 
nection with  the  sexual  organs,  be  caused  in  the 
same  way.  Some  instances  of  hypertrophy  we 
cannot  in  any  way  explain,  such  as  the  appa- 
rently spontaneous  enlargement  of  the  tonsils, 
spleen,  and  thymus  gland,  which  are  sometimes 
observed.  The  same  is  true  of  the  enlargement 
of  the  prostate  which  is  so  common  in  old  age. 
These  changes  have  been  sometimes  explained 
by  a supposed  derangement  of  the  so-called 
trophic  nerves,  but  this  explanation  only  puts 
the  difficulty  a little  further  back. 

Process  of  Hypertrophy. — It  has  been  a 
question  whether  hypertrophy  depends  upon 
the  increase  in  the  size  of  the  minute  ele- 
ments of  an  organ,  or  only  on  increase  of 


their  number.  There  can  oe  no  doubt  that 
the  former  change  often  occurs.  Thus,  in 
the  pregnant  uterus  the  muscular  fibres  have 
been  found  from  seven  to  eleven  times  as  long 
as  natural,  and  from  twice  to  seven  times  as 
wide.  In  a remarkable  case  of  enlargement 
of  the  nerves,  described  by  Dr.  Moxon,  the 
nerve-fibres  were  found  to  be  on  an  average 
three  times  and  some  of  them  even  forty  times  as 
large  as  normal.  When  enlargement  of  one  kid- 
ney takes  place  as  a consequence  of  destruction 
of  the  other,  the  tubules  and  Malpighian  tufts 
are  found  greatly  increased  in  size.  In  hyper- 
trophy of  the  heart,  the  muscular  bundles  are 
found  to  be  thickened,  though  the  fibrillae  are 
unchanged ; but  in  most  eases  multiplication  of 
the  tissue-elements  is  the  chief  cause  of  the 
increase  in  size.  To  this  latter  process  Virchow 
gives  the  name  of  hyperplasia,  and  it  is  ini 
portant  to  remember  that,  though  constantly 
occurring  in  hypertrophy  of  organs,  it  does  not 
necessarily  lead  to  the  latter  change. 

1 False’  Hypertrophy. — We  sometimes  have 
to  distinguish  between  true  and  false  hypertrophy, 
meaning  by  the  latter  a process  in  which  an  organ 
becomes  outwardly  increased  in  size,  owing  to 
the  deposition  within  it  of  some  foreign  material, 
or  to  mere  distension.  Thus  in  a fatty  liver 
the  real  liver-tissue  is  wasted,  but  is  replaced  by 
fat.  An  emphysematous  lung  appears  to  be  in- 
creased in  size,  but  has  actually  suffered  atrophy. 
The  substance  of  the  brain  in  hydrocephalus 
may  be  greatly  reduced  in  volume,  though  the 
head  appears  of  enormous  size.  The  very  re- 
markable disease  called  ‘ Duchenne’s  Paralysis' 
is  an  instance  of  apparent  hypertrophy  of  the 
muscles,  through  deposition  of  fat  between  the 
fibres.  Finally,  it  should  be  remembered  that, 
hypertrophy  is  not  necessarily  a progressive  or 
permanent  condition,  but  may  be  only  a 6tage  in 
some  chronic  morbid  process  of  w hich  the  termi- 
nation is  atrophy.  This  is  very  clearly  seen  in 
the  process  called  ‘ fibroid  degeneration,’  else- 
where described. 

Theatmext. — No  general  rules  can  be  laid 
down  for  the  treatment  of  hypertrophy.  When 
it  is  connected  with  increased  functional  acti- 
vity, it  is  usually  a favourable  rather  than  a 
hurtful  condition,  though  in  some  cases  it  may 
appear  that  the  hypertrophy  more  than  compen- 
sates the  deficiency  or  irregularity  by  which  it 
is  produced.  But  even  if  this  be  so,  the  cure  ef 
excessive  hypertrophy  is  not  within  our  powers. 
Those  forms  of  hypertrophy  which  are  most 
likely  to  be  injurious  or  fatal  are  unfortunately 
those  of  which  the  origin  and  conditions  arc 
most  obscure,  such,  for  instance,  as  enlargement 
of  the  prostate,  the  thyroid,  or  the  spleen.  The 
only  hypertrophic  condition  which  appears  to 
be,  generally  speaking,  amenable  to  treatment 
is  that  of  fibrous  thickening.  V henever  the 
thickened  fibrous  tissue  is  accessible  to  direct 
treatment,  we  may  probably  be  able  to  produce 
a beneficial  effect  by  the  application  of  counter- 
irritants,  or  by  special  stimulants.  such  as  iodine. 
The  administration  of  iodine  or  iodide  of  potas- 
sium internally  also  has  a remarkable,  and  as  yet 
unexplained  effect  in  many  such  cases.  It  is. 
however,  well  to  point  out  that  when  functional 
hypertrophy  has  resulted  from  some  obs  tacit 


HYPERTROPHY. 

or  undue  resistance,  it  may  entirely  subside 
when  that  resistance  is  removed.  Thus  if  the 
uterus  have  enlarged  around  a fibrous  tumour, 
it  may  regain  its  normal  bulk  when  the  tumour 
is  removed ; and  we  sometimes  see  a sensible 
diminution  in  the  size  of  a hypertrophied 
heart  when  the  derangements  which  produce  it 
no  longer  act.  Moreover,  hypertrophy  may  be 
completely  reduced  by  a general  lowering  of 
the  nutrition  of  the  body.  Thus,  in  early  stages 
of  pulmonary  phthisis,  the  heart  may  bo  hyper- 
trophied, but  when  death  occurs  in  a late  period 
of  the  disease,  the  organ  is  rarely  found  enlarged, 
and  is  even  wasted ; though,  according  to  Dr. 
Peacock’s  tables,  less  so  than  in  other  wasting 
diseases.  J.  P.  Payne. 

HYPINOSIS  (virb,  under,  and  is,  Ivbs,  flesh). 
Deficiency  of  fibrin  in  the  blood.  See  Blood, 
Morbid  Conditions  of. 

HYPNOTICS  (virvos,  sleep). — Measures 
that  induce  sleep.  See  Narcotics. 

HYPNOTISM  (virvos,  sleep). — A synonym 
for  Braidism.  See  Braidism  ; and  Mesmerism. 

HYPOCHONDRIAC  REGION  (inrb, 
uuder,  and  x^bpos,  a cartilage). — This  region  is 
double,  right  and  left,  occupying  the  upper  part 
of  the  abdomen  on  either  side  of  the  epigastrium, 
and  partly  corresponding  to  the  lower  regions  of 
the  chest,  being  almost  entirely  covered  in  by  the 
ribs  and  their  cartilages.  Each  hypochondrium 
is  bounded  below  by  a horizontal  line  at  the  level 
of  the  ninth  costal  cartilage ; and  internally  by 
a vertical  line  from  the  eighth  cartilage  down- 
wards. The  organs  situated  in  the  right  hypo- 
chondrium are  the  liver  and  gall-bladder  mainly ; 
with,  more  deeply,  the  pyloric  end  of  the  stomach, 
part  of  the  duodenum,  and  the  hepatic  flexure  of 
the  colon.  Iu  the  left  region  lie  the  spleen,  a 
small  portion  of  the  left  lobe  of  the  liver,  the 
fundus  of  the  stomach,  the  tail  of  the  pancreas, 
and  the  splenic  flexure  of  the  colon.  Thegastro- 
splenic  fold  of  peritoneum,  with  its  vessels,  passes 
from  the  stomach  to  the  spleen. 

Clinical  Investigation. — Ir.  must  be  borne  in 
mind  that  morbid  conditions  within  the  chest  not 
uncommonly  originate  clinical  phenomena,  both 
subjective  and  objective,  in  connection  with  one 
or  other  hypochondriac  region,  and  these  must 
always  he  taken  into  consideration  when  investi- 
gating any  particular  case.  Jn  making  a diag- 
nosis, no  reliance  whatever  can  be  placed  on 
mere  sensations  referred  to  these  regions,  but 
physical  examination  is  in  every  instance  required, 
in  order  to  determine  the  conditions  present,  and 
especially  palpation  and  percussion.  Moreover, 
it  must  be  remembered  that  disease  of  an  im- 
portant and  serious  nature  may  arise  without  the 
occurrence  of  any  unusual  feelings.  Pain  of 
various  kinds  is  often  complained  of,  and  when 
'referred  to  the  right  hypochondrium  is  usually 
supposed  to  be  connected  with  the  liver;  but  it 
'^nay  depend  upon  affections  of  the  superficial 
tructures  ; peritonitis  ; right  pleurisy  or  pneu- 
monia ; or  conditions  associated  with  the  pylorus, 
uodenum,  or  colon.  A characteristic  pain  start- 
mg  from  this  region  is  that  of  hepatic  colic,  usu- 
lly  due  to  the  passage  of  a gall-stone.  Persons 
'ho  are  hypochondriacal  not  uncommonly  refer 
43 


HYPOCHONDRIASIS.  67H 

some  abnormal  sensation  to  their  right  hypoclion  ■ 
driura,  for  which  there  is  really  no  obvious  cause. 
In  the  left  hypochondrium  pain  may  also  be  due 
to  affections  of  the  walls,  or  of  structures  within 
the  thorax  ; of  the  cardiac  end  of  the  stomach  ; of 
the  colon  ; or,  in  exceptional  cases,  of  the  spleen 

The  morbid  conditions  which  are  capable  of 
originating  abnormal  physical  signs  in  the  hypo- 
chondriac region  may  also  be  either  thoracic  cr 
abdominal.  Of  the  former,  pleuritic  effusion  is 
the  most  frequent ; and  on  the  right  side  this 
condition  may  cause  marked  depression  of  the 
liver.  In  exceptional  instances  the  heart  is  so 
enlarged  as  to  reach  the  left  hypochondrium  ; and 
the  writer  has  met  with  a case  in  which  a large 
thoracic  aneurism  presented  in  this  region.  As  re- 
gards abdominal  diseases  in  the  right  hypochon- 
drium, abnormal  physical  signs  are  usually  assu 
dated  with  the  liver,  which  is  altered  iti  position, 
shape,  size,  or  physical  characters.  Occasionally 
they  are  connected  with  the  abdominal  walls ; the 
gall-bladder ; or  the  stomach,  duodenum,  or  colon. 
On  the  left  side  enlargement  of  the  spleen  is  the 
main  condition  discovered  bv  physical  examina- 
tion ; but  the  stomach  may  also  give  signs  of  dis- 
tension in  this  direction,  or  of  organic  disease  of 
its  walls.  Exceptionally  the  colon  may  present 
abnormal  physical  signs.  Growths  may  originate 
here  in  connection  with  the  peritoneum,  and  the 
writer  has  recently  had  under  observation  a case 
in  which  a growth  started  from  the  left  hypo- 
chondrium, probably  of  a malignant  nature,  and 
involving  more  than  one  structure,  but  it  was 
impossible  to  say  where  it  commenced.  Of  course 
the  hypochondria  are  involved  along  with  other 
regions  in  general  enlargement  of  the  abdomen  ; 
and  organs  from  other  regions  may  so  inereaus 
in  size  in  certain  diseases  as  to  extend  into  one 
or  both  of  these  regions. 

Frederick  T.  Roberts. 

HYPOCHONDRIASIS  (urrb,  under,  ar.d 
X<5v5pos,  a cartilage).— Synon.:  Fr.  Hypochondric ; 
Ger.  Hypochondria. 

Description. — The  term  hypochondriasis  is 
derived  from  an  ancient  hypothesis  that  the 
symptoms  of  this  disorder  were  due  to  perturba- 
tions of  natural  force  generated  in  the  liver  and 
pylorus,  to  which  idea  the  frequent  prevalence 
of  flatulence  in  the  disorder  conduced.  The  con- 
dition thus  called  is  realty  a disease  of  the  nervous 
system.  It  is  a form  of  mental  unsoundness 
closely  allied  to  melancholia,  of  which,  indeed.it 
often  forms  the  initiatory  stage.  It  is  charac- 
terised by  a morbid  anxiety,  either  without  any. 
or  having  only  very  slight  foundations,  relative 
to  the  state  of  physical  health.  The  patient 
thinks  about  his  health  unduly,  observing  him- 
self with  restless  care,  examining  especially  the 
characteristics  of  his  secretions,  translating  into 
evidence  of  progressive  organic  mischief  every 
trivial  departure  from  perfect  action  of  his 
organs,  and  becoming  more  and  more  absorbed 
in  precautions  against  the  malady  with  which  hi 
believes  himself  affected.  Nothing  that  happens 
tends  to  the  side  of  reassurance.  If  his  sleep 
be  disturbed,  the  symptom  may  be  portentous, 
he  thinks,  of  brain-softening ; if  it  be  sound, 
the  patient,  instead  of  being  comforted,  fears 
apoplexy.  Constipation  of  tho  bowels  signifies 


HYPOCHONDRIASIS. 


574 

obstruction;  a slight  diarrhoea  implies  coming 
exhaustion.  Everything  which  he  reads  or  hears 
in  reference  to  disease,  the  patient  applies  to  his 
own  case,  examining  himself  on  every  point  thus 
presented  to  his  mind,  and  rarely  failing  to  find 
something  which  dovetails  with  symptoms  of  his 
own.  For  he  recognises  only  the  points  of  re- 
semblance ; the  features  of  difference  are  uncon- 
sciously ignored.  In  some  cases  the  patient  is 
constant  in  referring  his  troubles  to  one  particu- 
lar organ.  Year  after  year  his  story  is  the  same  ; 
it  is  his  stomach,  liver,  brain,  or  some  other  or- 
gan which  is  in  fault ; but  always  the  same.  In 
other  instances  there  is  a vacillation  quite  as 
remarkable.  Pouted,  perhaps,  by  the  convincing 
arguments  of  his  adviser,  he  is  forced  to  yield  the 
position  which  he  had  assumed,  but,  only  to  take 
au  equally  strong  one  in  reference  to  some  other 
part  of  his  frame.  These  diversities  strongly 
recall  the  fixed  and  shifting  delusions  of  in- 
sanity. He  is  prone  to  wander  from  one  doctor 
to  another,  often  carrying  with  him  a bundle  of 
prescriptions  and  a long  written  list  of  ques- 
tions, which  must  receive  categorical  smswers. 
Apparently  satisfied  at  the  time,  he  speedily 
recollects  some  point  upon  which  he  has  not  re- 
ceived assurance,  and  this  he  conceives  vitiates 
the  whole  of  the  explanation  and  advice  which 
have  been  given  to  him,  and  he  is  plunged  again 
into  his  previous  state  of  anxiety  and  doubt. 
Where  circumstances  do  not  involve  forced  la- 
bour for  existence,  the  patient  passes  his  time 
in  chasing  his  health,  which  is  always  contriving 
to  elude  his  grasp.  If  ho  holds  an  appointment, 
he  will  resign  it  in  order  to  have  full  oppor- 
tunity for  studying  himself,  and  his  occupation 
once  gone,  he  finds  too  late  that  it  was  his  best 
friend,  and  he  then  ascribes  to  his  forced  idleness 
all  the  ills  which  had  induced  him  to  seek  re- 
tirement. 

In  many  cases  the  most  careful  examination 
can  di-cover  no  signs  of  disease,  and  the  patient 
wears  the  aspect  of  health ; or  there  may  be  a 
worn,  anxious  look.  In  others  there  may  he, 
especially  in  the  digestive  organs,  slight  devia- 
tions from  perfect  integrity,  which  explain  some 
of  tho  symptoms,  but  not  the  exaggerated  appre- 
hensions to  which  they  give  rise. 

Hypochondriasis  is  a chronic  disorder.  It  may 
continue,  and  this  most  frequently,  as  a harm- 
less peculiarity  attached  to  a life  which  is  not 
perceptibly  shortened  in  length,  though  often 
sadly  diminished  in  utility  and  happiness,  by  its 
symptoms.  Or  there  may  he  an  improvement 
practically  amounting  to  a cure,  which  will  en- 
dure for  a longer  or  shorter  period.  In  the 
decline  of  life,  however,  there  is  very  apt  to  be 
a return  of  symptoms.  Or  hypochondriasis  may 
pass  into  true  melancholia,  aud  then  the  bodily 
health,  previously  the  constant  object  of  solici- 
tude, improves  wonderfully.  Indeed,  nothing 
more  is  heard  about  it. 

iETWLOGY. — Hypochondriasis  is  very  much 
more  common  in  the  male  than  the  female  sex. 
The  period  of  life  most  prone  to  it  is  from  20 
to  40  years  of  age.  It  is  apt  to  occur  in  those 
who  inherit  a tendency  to  insanity,  and  the  dis- 
ease in  its  own  peculiar  form  is  often  hereditary. 
Excesses  of  various  kinds,  especially  on  the  side 
of  the  sexual  system,  will  precipitate  the  ap- 


pearance and  :ntensifv  the  symptoms  of  tht 
affection,  hut  it  is  doubtful  whether  they  can  al- 
together originate  it.  The  same  may  be  said  of 
gout,  which  is  apt  to  be  associated  with  the  con- 
dition and  to  complicate  its  symptoms.  Depress- 
ing moral  circumstances  also  are  not  without 
influence  in  determining  an  onset  of  hypochon- 
driasis in  those  predisposed.  This  is  especially 
true  of  mental  strain.  The  frequent  occurrence 
of  some  deviation  from  healthy  condition  in  the 
liver,  stomach,  or  bowels,  which  is  noted  in  these 
cases,  would  suggest  that,  probably  through  an 
interruption  to  the  perfect  nutrition  of  the  body, 
diseases  of  these  viscera  bear  their  part  in  the 
causation  of  hypochondriasis.  The  intercurrence 
of  internal  luemorrhoids  with  bleeding  is  very 
common,  and  this  would  manifestly  tend  to  keep 
up  if  it  did  not  originate  the  disease.  Stricture 
and  chronic  nicer  of  the  intestines  are  occasion- 
ally associations  which  probably  also  influence 
the  appearance  of  hypochondriasis. 

Anatomical  Characters. — There  are  no  ana- 
tomical characters  peculiar  to  the  disease. 

Diagnosis. — When  careful  examination,  which 
must  never  be  omitted,  bas  disproved  the  exist- 
ence of  organic  disease  tending  to  produce  the 
symptoms  described  by  the  patient,  it  sometimes 
becomes  a question  whether  the  case  be  one  of 
hypochondriasis  or  of  melancholia. 

In  the  former  there  is  no  tendency  to  suicide; 
on  the  contrary  a strong  desire  to  live  pervades 
the  sufferer’s  mind,  and  impels  him  to  endlesi 
search  for  the  cure  of  his  ailments.  He  delights 
in  consulting  medical  men  and  entering  into  the 
minutest  details  which  he  thinks  can  aid  theie 
in  helping  him.  Up  to  a certain  point  his  stor> 
is  frequently  characterised  by  a logical  a curacy 
which  fails  him,  however,  in  some  point  of  great 
importance,  by  which  the  conclusions  are  inva- 
lidated. The  melancholic  patient,  on  the  otliei 
hand,  is  often  suicidal  and  always  despairs  of  any 
relief  to  his  condition,  the  description  of  which  as 
given  by  him  is  confused,  frequently  incoherent, 
and  unintelligible. 

Prognosis. — Early  and  marked  hypochondri- 
asis occurring  in  a person  with  a strong  heredi- 
tary taint  of  insanity,  without  any  definite  cause 
of  mental  depression,  is  of  ill  omen.  Such  a case 
very  often  drifts  into  melancholia. 

The  prognosis  is  favourable,  perhaps,  tho  less 
strongly  marked  the  hereditary  predisposition  and 
the  more  evident  and  adequate  the  immediate 
causes  to  which  the  patient  has  been  exposed, 
the  most  potent  of  which  are  sexual  or  alcoholic 
excesses,  mental  strain  or  shock,  or  the  sudden 
change  from  a life  of  activity  to  one  of  forced 
and,  as  the  sequel  shows,  uncongenial  leisure. 

Treatment. — Moral  treatment  is  alone  of  any 
influence  in  a large  majority  of  cases.  Where 
there  is,  however,  manifest  anaemia,  a history  of 
syphilis,  evidences  of  gouty  mal-assimilation,  ac- 
cumulation of  faeces,  catarrh  of  the  intestinal 
canal,  or  haemorrhoids,  the  therapeutics  proper 
to  these  conditions  should  be  employed.  Alco- 
holic stimulants  should  be  avoided.  Travel 
especially  under  judicious  companionship,  an-, 
the  encouragement  of  regular,  definite,  and  nsetu! 
employment  for  the  attention  and  the  i.mwI 
powers,  are  the  most  potent  means  of  treatment, 
by  which  the  disease  may  bo  often  much  amt- 


hypochondriasis. 

.iorated,  and  sometimes  cured  Ridicule  of  the 
patient's  sufferings  will  rarely  or  never  be  of 
service,  but  at  the  same  time  a habit  of  pre- 
scribing for  all  the  symptoms  as  they  arise  must 
oe  avoided.  T.  Huzzaed. 

HYPODERMIC  INJECTION (uwb, under, 
and  S 4pna,  the  skin).— The  effective  introduction 
of  remedial  agents  into  the  system  by  subcuta- 
neous injection  was  rarely  possible  until  the  dis- 
covery of  the  alkaloids  enabled  us  to  administer 
an  active  dose  in  very  small  bulk.  Dr.  Alexander 
Wood,  of  Edinburgh,  undoubtedly  deserves  the 
credit  of  bringing  this  principle  practically  before 
the  profession ; and,  improved  as  it  has  been  by 
Mr.  Hunter  and  others,  the  hypodermic  method 
is  now  justly  regarded  as  one  of  the  most  active 
and  reliable  of  our  therapeutic  resources.  It 
may  be  used  in  two  essentially  different  ways. 

I.  The  remedy  is  thrown  into  the  subcutaneous 
cellular  tissue  by  means  of  a sharp-pointed  hollow 
needle,  attached  to  a carefully  graduated  glass 
syringe.  The  little  prick  must  be  made  as  ra- 
pidly as  possible,  either  by  direct  puncture,  or 
in  a mors  valvular  direction,  through  a pinched- 
up  fold  of  skin ; and  care  must  of  course  be  taken 
to  avoid  the  neighbourhood  of  all  important 
structures.  The  solution  employed  must  be  small 
in  quantity  and  bland  in  quality,  and  must  be 
slowly  introduced,  as  pain  usually  follows  the  too 
sadden  or  forcible  depression  of  the  piston  ; and 
we  must  satisfy  ourselves  before  we  begin  to  in- 
ject, that  the  point  of  the  instrument  has  passed 
fairly  through  the  skin,  without  imbedding  itself 
in  the  substance  of  the  muscles.  When  carefully 
performed,  the  advantages  of  this  plan  are  great, 
for  not  only  is  it  economical,  drugs  administered 
in  this  way  acting  much  more  powerfully  than 
: when  given  by  the  mouth  ; but  absorption  is  very 
rapid,  and  the  desired  effect  is  swiftly  and  surely 
produced.  The  drawbacks  of  the  hypodermic 
j method  are — the  pain  of  puncture  (which  may  be 
alleviated  by  a slight  preliminary  freezing  of  the 
skin);  an  occasional  tendency  to  irritation  and 
the  formation  of  abscess;  and,  where  morphia  is 
concerned,  the  risks  of  nausea  and  syncope,  and 
the  dangers  attending  the.  not  very  remote  possi- 
bility of  acquiring  opium-eating  habits. 

The  principal  drugs  used  hypodermically  in 
this  way  are  the  following  : — 

1.  Morphia. — Morphia  thus  administered 
forms  by  far  our  most  effectual  remedy  for  the 
relief  of  suffering.  In  all  varieties  of  neuralgia, 
in  the  wearing  agony  of  cancer  and  other  in- 
curable disorders,  as  well  as  in  a host  ot  painful 
iud  irritative  affections,  we  derive  invaluable  aid 
rom  the  use  of  the  hypodermic  syringe : remem- 
bering that  the  dose  must  at  first  be  small,  not 
■xceeding  i of  a grain,  and  that  we  derive  no 
iPecial  advantage  from  injecting  directly  over 
'lie  spot  whero  the  uncomfortable  sensations  are 
pit.  Recollecting  also  the  occasional  occur- 
'encu  of  sickness  and  faintness,  we  shall  do  well 
:o  enforce  the  recumbent  posture;  to  keep  our 
atient  under  observation  for  a few  minutes 
fter  the  operation  is  over  : and  perhaps  to  com- 
inOyH  grain  of  atropia.  which  seems  to  have  in 
brne  measure  the  power  of  preventing  the  de- 
pressing action  which  morphia  occasionally  dis- 
ays  when  administered  alone. 


HYPOGASTRIC  REGION.  076 

2.  Atropia. — Anstie  had  great  faith  in  atropia, 
as  the  best  of  all  remedies  for  pain  in  the  pelvic 
viscera;  and  its  injection  hypodermically  has 
been  attended  with  good  results  in  the  nocturnal 
sweating  of  phthisis  in  doses  of  ylg  to  ^ grain ; 
and  also  as  an  antidote  in  opium- poisoning,  even 
up  to  half-a-grain. 

3.  Ergotine. — Ergotineaets  most  effectively  in- 
cases  of  htemorrhage,  its  chief  disadvantage  being 
the  development  of  black  painful  lumps  at  the 
site  of  puncture.  The  average  dose  is  2 grains. 

4.  Quinine. — This  useful  drug  has  been  ex- 
tensively used  in  tropical  climates  by  hypodermic 
injection  for  ague,  sunstroke,  &c. ; but  the  great 
pain  attending  the  operation,  and  the  subsequent 
liability  to  the  formation  of  abscess,  have  proved 
effectual  barriers  to  the  general  introduction  of 
the  practice  into  this  country. 

5.  Other  drugs. — Chloral,  where  subcutane- 
ously used,  also  causes  severe  suffering,  with  the 
production  of  unhealthy  ulcerations  of  the  skin. 
Many  persevering  attempts  have  been  made,  but 
have  not  yet  been  successful  in  overcoming  the 
very  irritating  effects  of  mercury  when  employed 
in  this  way.  Out  of  the  large  number  of  other 
drugs,  the  subcutaneous  use  of  which  has  been 
tried  from  time  to  time,  we  are  unable  to  report, 
any  substantial  advantage  thus  gained  over  their 
administration  by  the  mouth. 

II.  The  second  hypodermic  method  is  that  re- 
commended by  Bartholow  and  various  Ameri- 
can and  Continental  physicians,  and  usually  called 
the  deep  or  parenchymatous  method.  This  essen- 
tially consists  in  plunging  the  point  of  the  needlo 
into  the  muscles,  and  forcing  the  fluid  freely 
amongtheir  fibres,  and  into  the  immediate  neigh- 
bourhood of  painful  nerves.  Wo  are  told  that 
in  this  way  chloroform  is  a very  certain  remedy 
for  neuralgia;  that  strychnia  is  indicated  in 
infantile,  reflex,  hysterical,  and  Lad  palsy;  and 
that  carbolic  acid  is  useful  in  erysipelas.  As 
yet,  however,  there  is  not  much  British  ex- 
perience to  quote  in  confirmation  of  this  prac- 
tice. 

In  conclusion,  we  may  note  that  most  hypoder- 
mic solutions  are  readily  destroyed  by  mould  ; 
and  that  Dr.  Sansom  has  suggested  a very 
handy  series  of  gelatine  disks,  which  will  keep 
well  in  all  climates,  and  which  may  readily  l< 
melted  down  when  required  for  use. 

Robeet  Farquharson. 

HY'PO GASTRIC  REGION  (M,  under, 
and  yaiTTTip,  the  belly). — The  hypogastric  region 
is  conventionally  described  as  lying  between  the 
right  and  left  inguinal,  below  the  umbilical,  and 
above  the  pubic  regions. 

Anatomical  Relations. — The  surface  of  the 
hypogastric  region  in  ordinary  persons  is  flat, 
showing  the  muscular  reliefs ; it  is  rounded  in 
children  ; and  in  some  individuals,  much  ema- 
ciated from  disease,  it  becomes  concave. 

The  median  furrow  disappears  below  the 
umbilicus,  owing  to  the  approximation  of  the 
recti  muscles. 

The  integument  is  very  elastic  and  movable 
especially  at  the  sides. 

The  superficial  fascia  consists  of  two  lamina., 
between  which  lie  the  subcutaneous  vessels  : but 
in  the  middle  line  these  laminse  are  blended.  B 


676  HYPOGASTRIC  REGION. 

is  strengthened  at  its  lower  part  by  the  tri- 
angular fascia. 

The  aponeuroses  of  the  external  and  internal 
oblique  muscles  are  united  in  the  linea  alba, 
and  form  a portion  of  the  sheath  of  the  rectus. 

The  recti  muscles  themselves  have  their  inferior 
attachments  in  this  region,  along  the  line  ex- 
tending between  the  spine  and  the  symphysis  of 
the  pubes;  their  outer  edges  curve  outwards, 
and  become  straight  as  they  enter  the  sheaths. 

The  pyramidales,  two  small  triangular  muscles, 
arise  from  the  pubes,  lie  in  the  same  sheaths 
as  the  recti,  and  assist  in  closing  in  the  abdo- 
minal parietes  anteriorly  and  below. 

Immediately  beneath  the  recti  is  the  fascia 
transversalis,  with  a little  loose  areolar  tissue 
and  fat,  the  fascia  being  tolerably  adherent 
along  the  central  line.  Beneath  the  fascia  trans- 
versalis there  is  a considerable  amount  of  loose 
areolar  tissue,  between  it  and  the  parietal  peri- 
toneum, which  in  this  region  is  very  loosely 
attached,  and  reflected  off  the  bladder  on  to  the 
fascia  transversalis.  Enclosed  in  folds  of  the 
peritoneum  lie,  on  either  side,  passing  upwards 
to  the  umbilicus,  the  remains  of  the  hypogastric 
arteries ; and  from  the  apex  of  the  bladder  in 
the  middle  line,  passing  to  the  umbilicus,  is  the 
obliterated  urachus,  which  acts  as  the  superior 
ligament  of  the  bladder. 

The  viscera  corresponding  to  the  hypogastric 
region  are : — the  bladder  when  full ; and  the  small 
intestine,  covered  by  the  great  omentum.  When 
the  bladder  is  full,  the  intestines  are  pushed 
aside,  and  the  former  then  lies  against  the  pubes 
and  recti.  In  children  the  bladder,  being  an 
abdominal  rather  than  a pelvic  viscus,  always 
lies  in  this  region.  During  pregnancy  the 
uterus  also  corresponds  with  the  hypogastric 
region. 

The  vessels  are  the  deep  epigastric,  with  the 
veins  which  pass  obliquely  inwards  from  the 
internal  iliac.  They  lie  between  the  peritoneum 
and  the  transversalis  fascia. 

The  nerves  are  derived  from  the  lower  inter- 
costals  and  lumbar.  The  lymphatics  pass  into  the 
inguinal,  superficial  pubic,  and  lumbar  glands. 

Clinical  Relations. — The  hypogastric  re- 
gion is  of  clinical  importance  chiefly  from  an 
operative  point  of  view.  It  is  in  the  median 
furrow  of  this  region  that  the  operation  of 
tapping  in  ascites  is  usually  performed ; and 
that  the  principal  incision  is  made  in  ovario- 
tomy, the  Caesarian  section,  and  supra-pubie 
lithotomy.  The  bladder  is  occasionally  tapped 
above  the  pubes.  The  presence  of  the  distended 
bladder  or  of  the  pregnant  uterus,  forming  a tu- 
mour in  the  hypogastrium,  has  been  already  re- 
ferred to.  Enlargements  here  from  these  causes 
have  to  he  diagnosed  from  pelvic  tumours  of  va- 
rious kinds,  which,  in  growing  upwards  into  the 
abdomen,  occasionally  occupy  the  middlo  line  in- 
stead of  either  groin.  The  only  morbid  con- 
dition of  the  abdominal  parietes  in  the  hypo- 
gastric region  that  requires  special  mention  is 
abscess  connected  with  disease  of  the  lumbar 
spine,  which  occasionally  points  above  the  pubes, 
on  either  side  of  the  middle  line.  The  pus  in 
such  a case  is  situated  between  the  peritoneum 
and  the  fascia  transversalis. 

Edward  Bellamy. 


HYPOGLOSSAL  NERVE,  DISORDERS  OP 

HYPOGLOSSAL  ITESVE,  Disorders  of 

The  hypoglossal  nerve  is  the  motor  nerve  for 
the  tongue,  and  for  most  of  the  other  muscles 
which  are  attached  to  the  hyoid  bone,  the  excep- 
tions being  the  stylo-hyoid,  the  mylo-hyoid,  and 
the  middle  constrictor  of  the  pharynx.  It  also 
supplies  the  sterno-thyroid  muscle. 

1.  Paralysis. — Paralysis  of  this  nerve  is 
shown  chiefly  by  the  resulting  interference  with 
the  movement  of  the  tongue — ‘ glossoplegia.’ 

.^Etiology. — The  nerve  may  he  damaged  in 
any  part  of  its  course  by  the  growth  of  tumours ; 
but  is  most  commonly  affected  at  its  origin 
within  the  spinal  canal,  by  pressure  from  tumours, 
meningitis,  or  syphilitic  growths,  or  by  caries  of 
the  upper  cervical  vertebra.  The  tongue  is  also 
paralysed  by  disease  of  the  nucleus  of  origin  of 
the  hypoglossal  fibres,  hut  its  paralysis  is  then 
associated  with  that  of  the  lips,  and  commonly 
also  of  the  palate,  pharynx,  and  glottis  {see  Labio- 
glosso-Laryngeal  Paralysis).  Disease  of  the 
motor  tract  above  the  nucleus  also  causes  para- 
lysis of  the  nerve,  together  with  the  face,  arm, 
and  leg  of  the  same  side.  Bilateral  glossoplegia 
commonly  results  from  disease  of  the  nucleus  or 
its  neighbourhood.  Unilateral  paralysis  is  due 
to  disease  of  the  motor  tract,  above  the  nucleus, 
rarely  of  tho  nucleus  itself,  often  of  the  fibres  of 
the  nerve  within  or  outside  the  medulla. 

Symptoms. — In  unilateral  paralysis,  the  tongue 
at  rest  is  in  its  normal  position  in  the  mouth, 
but  its  root  is  higher  up  on  the  paralysed  than 
on  tho  normal  side,  in  consequence  of  the  loss 
of  the  tonic,  or  voluntary,  contraction  of  the 
posterior  fibres  of  the  hyoglossus.  Within  the 
mouth  the  tongue  is  moved  freely  to  the  healthy 
side,  but  is  not  moved  to  the  paralysed  side. 
When  protruded  it  deviates  towards  the  paralysed 
side,  because  the  protrusion  is  the  result  of  the 
action  of  the  fibres  of  the  genio-glossus,  and  the 
tongue  is  pushed  over  towards  the  weaker  side. 
In  bilateral  paralysis  the  tongue  lies  in  the 
mouth  behind  the  teeth,  and  cannot  bo  pro- 
truded. If  the  loss  of  power  is  complete,  the 
tongue  cannot  be  projected  over  the  lower  teeth. 
It  is  broad  and  flabby,  if  there  is  no  atrophy,  and 
sometimes  when  atrophy  is  associated  witli  fatty 
overgrowth.  When  there  is  much  wasting,  the 
part  affected  is  shrunken  and  wrinkled.  In 
unilateral  paralysis,  articulation  and  deglutition 
are  little  impaired.  The  pronunciation  of  labials, 
and  the  production  of  falsetto  notes  may,  how- 
ever, he  difficult.  In  bilateral  paralysis,  articu- 
lation is  impossible.  Phonation  is  not  impaired, 
unless  the  larynx  is  also  paralysed.  The  masti- 
cation of  food  is  impeded,  because  the  food  can- 
not be  moved  about  the  mouth.  Deglutition  is 
also  interfered  with,  because  the  food  cannot  be 
rolled  into  the  fauces ; and  soft  foods,  when  j 
they  reach  the  pharynx,  may  be  driven  again 
into  the  mouth  in  consequence  of  the  absence  of 
the  natural  supporting  movement  of  the  tongue. 
Taste  is  not  primarily  affected,  but  may  be  some- 
what dulled,  because  the  patient  is  unable  to 
move  substances  about  the  mouth. 

Diagnosis. — The  position  of  the  lesion  is  in- 
dicated bythe  associations  of  the  paralysis.  If 
the  disease  is  in  the  motor  tract  above  the 
nucleus  (pons,  crus,  or  hemisphere),  there  is 
hemiplegic  weakness  on  the  side  of  tho  paralysis 


HYPOGLOSSAL  NERYE,  DISORDERS  OF. 
jf  the  tongue.  In  disease  of  the  nucleus  the 
paralysis  is  commonly  bilateral,  is  associated 
with  paralysis  of  the  lips  and  throat,  and  there 
,s  usually  wasting.  Disease  of  the  fibres  of 
oipgin  within  the  medulla  is  associated  with 
paralysis  of  the  opposite  limbs,  so  that  the  tongue 
deviates  from  the  paralysed  side.  When  the 
disease  is  at  the  surface  of  the  medulla,  the 
paralysis  is  commonly  unilateral,  and  is  asso- 
ciated with  paralysis  of  the  corresponding  half 
of  the  palate  and  vocal  cord  (Hughlings  Jack- 
son.)  In  disease  of  the  fibres  of  origin  within 
or  outside  the  medulla,  there  is  commonly  wast- 
ing. The  diagnosis  of  the  pathological  cause  of 
the  paralysis  rests  on  the  course  of  the  affection, 
and  on  the  presence  of  any  causal  and  associated 
iondition. 

Prognosis. — This  is  usually  unfavourable,  on 
account  of  the  gravity  of  the  disease  which 
lamages  the  nerve  or  centre.  Even  in  syphilitic 
rases,  recovery  is  often  incomplete. 

T reatment. — -The  treatment  of  paralysis  of 
the  hypoglossal  nerve  is  that  of  the  causal 
lisease.  Tonics,  counter-irritation,  iodide  of 
potassium  and  mercury,  with  occasionally  the 
application  of  electricity  to  the  tongue,  are  the 
most  important  remedies  to  be  employed,  accord- 
ing to  the  setiologieal  indication.  The  most  con- 
venient method  of  applying  electricity  is  by 
means  of  a tongue  depressor  in  a wooden  handle, 
;he  blade  being  insulated  by  a coating  of  sealing 
rax  where  it  comes  in  contact  with  the  lips. 

2.  Spasm. — Spasm  in  the  parts  supplied  by 
the  hypoglossal  nerve  is  rare.  The  tongue  parti- 
cipates in  the  convulsive  movements  in  epilepsy, 
is  jerked  between  the  champing  jaws,  and 
thus  becomes  bitten.  Cases  have  been  met  with 
in  which  the  tongue  is  affected  with  a ‘functional 
spasm’  in  speaking,  analogous  to  ‘ writer's  cramp,’ 
but  these  are  so  rare  as  scarcely  to  need  detailed 
description.  W.  R.  Gowers. 

HYPOSPADIAS  (™b,  under,  and  o-n-dSiov, 
a space'). — A malformation  of  the  penis  in  which 
the  orifice  of  the  urethra  is  underneath  or  behind 
the  glans.  See  Malformations.' 

HYPOSTASIS  (uirb,  under,  and  crraoi,  I 
stand). — Definition. — This  term  is  applied  to 
that  condition  of  the  vessels  of  a part,  which 
consists  in  an  overfulncss,  caused  mainly  by  a 
dependent  position,  with  a varying  degree  of 
diminution  in  the.  rate  of  flow  of  the  contained 
fluid. 

Pathology. — The  entire  conditions  of  the 
venous  circulation  are  such  as  to  readily  favour 
a stasis  or  stagnation  of  the  blood-flow  ; and  a 
trifling  cause,  such  as  would  in  no  way  affect 
the  arterial  flow,  may  easily  impede  the  venous 
current.  The  veins  also  are,  as  a rule,  less 
firmly  supported  by  the  surrounding  tissues 
than  the  arteries;  and  this,  with  their  thinner 
coats,  slighter  elasticity  and  resistance,  render 
them  easily  liable  to  distension  by  the  blood  in 
congestion.  If  a dependent  position  be  added  to 
these  conditions,  thereby  offering  a resistance 
to  the  return  flow  of  the  blood,  whilst  it  favours 
'.he  circulation  in  the  arteries,  a combination 
jf  circumstances  exists  to  which  the  term 
ii/postatic  congestion  is  applied.  The  liability 
>f  the  veins  of  the  leg  to  become  congested, 


HYSTERIA.  677 

leading  to  a varicose  condition  and  its  results, 
is  an  example  of  this  state.  If,  in  addition 
to  all  these  factors,  the  heart  be  enfeebled  and 
the  arterial  tone  he  diminished,  obviously’  an- 
other cause  for  stagnation  is  introduced,  and  of 
necessity  will  manifest  itself  most  in  those  situa- 
tions predisposed  to  stasis.  Such  a state  is  seen 
in  the  hypostatic  congestion  of  the  lungs,  which 
usually  attends  in  a greater  or  less  degree  all 
pyrexial  conditions.  The  recumbent  attitude, 
the  enfeebled  heart,  and  the  lax  vessels  emi- 
nently favour  an  overfulness  of  the  veins.  It 
is  obvious  that  although  the  excess  of  blood 
primarily  occurs  on  the  venous  side  of  the  capil- 
lary system,  very  soon  the  arterial  area  will  share 
in  the.  engorgement,  and  the  whole  vascular  sys- 
tem of  the  part  become  overfilled. 

Results. — The  pathological  results  of  such  a 
state  are  very  much  the  same  as  those  following 
any  congestion.  The  distended  vessels,  with  the 
increased  blood-pressure  that  co-exists,  readily 
permit  of  a transudation  of  the  fluid  part  of 
the  blood,  hence  oedema;  if  the  conditions  be 
extreme,  capillary  rupture  may  take  place,  and 
haemorrhagic  effusions  result.  Any  continuance 
of  this  state  will  lead  to  malnutrition  of  the 
tissues  affected;-  the  proper  supply  of  arterial 
blood  is  interfered  with;  and  the  part  is  loaded 
with  an  effete  venous  blood,  and  infiltrated  with 
serum.  Hence  the  structural  repair  of  the 
tissues  is  improperly  performed,  and  there  is  a 
tendency  to  the  development  of  an  imperfect  form 
of  connective  tissue ; or,  on  the  other  hand,  the 
destructive  ratherthanthe  productive  aspect  may 
predominate,  and  ulceration  follow.  When  the 
hypostasis  is  associated  with  an  acute  general 
state,  as  of  the  lungs  in  any  specific  febrile  disease, 
it  is  very  apt  to  pass  on  into  a form  of  inflamma- 
tion characterised  by  a want  of  acuteness.  There 
are  the  same  inflammatory  products,  the  same 
changes  in  the  vessels  and  tissues  of  the  lungs,  and 
very  much  the  same  symptoms  as  occur  in  the 
course  of  an  ordinary  pneumonia,  but  they  are 
less  severe  in  character,  and  on  the  whole  do 
not  tend  so  readily  to  a favourable  resolution. 

Treatment. — Recognising  the  cause,  altera- 
tion of  position  is  obviously  the  rational  treat- 
ment of  hypostatic  congestion ; additional  sup- 
port by  bandaging  is  often  advisable.  In  acute 
febrile  diseases  stimulants  are  of  much  service 
in  the  prevention  or  relief  of  this  condition  in 
connection  with  the  lungs,  should  the  heart’s 
action  he  enfeebled.  AV.  H.  Allchin. 

HYSTERALGIA  ( itr-rtpa , the  womb,  and 
&\yos,  pain). — Pain  in  the  womb,  frequently 
supposed  to  be  of  a neuralgic  nature.  See  Womb, 
Diseases  of. 

HYSTERIA  (boTtpa,  the  womb). — Synon.  : 
Fr.  Hysterie  ; Ger.  Hysterie. 

Hysteria  is  a term  the  etymology  of  which  is 
misleading,  and  had  best,  therefore,  be  disre- 
garded. It  is  often  improperly  applied  to  cases  of 
simple  malingering,  and  others  which  do  not  ad- 
mit of  ready  explanation.  Its  use  is  best  restricted 
to  a condition  of  the  nervous  system  fairly  defined, 
but  the  intimate  pathology  of  which  is  not  known, 
characterised  by  the  occurrence  of  convulsive 
I seizures  and  by  departures  from  normal  function 
I of  various  organs,  leading  to  very  numerous  and 


HYSTERIA. 


G7S 

often  perplexing  symptoms.  These  are  apt  to 
simulate  those  commonly  arising  from  definite 
alterations  of  structure,  but  differ  from  the  latter 
in  the  fact  that  they  may  often,  even  when  at 
their  worst,  be  removed  instantaneously,  usually 
under  the  influence  of  strong  emotion.  It  would 
ecem  that  there  is  a disturbed  or  congenitally 
defective  condition  of  the  cerebral  substance,  in- 
volving in  all  cases  the  highest  nervous  centres, 
and  in  various  examples  extending  more  or  less 
also  to  some  of  those  which  preside  over  auto- 
matic phenomena.  Partial  or  complete  suspen- 
sion of  inhibitory  influence  would  appear  to  be 
the  most  patent  result  of  the  condition,  whatever 
it  be,  and  this  is  recognised  as  well  in  regard 
to  the  mental  as  to  the  more  evidently  physical 
processes  belonging  to  cerebral  function.  A 
laugh  which  cannot  be  checked,  but  continues 
until  tears  flow,  or  the  limbs  become  convulsed, 
is  a typical  example  of  such  a suspension  of  con- 
trol, and,  if  studied,  throws  light  upon  the  nature 
of  a considerable  portion  of  the  phenomena  of 
hysteria.  The  jerking  expirations  of  laughter 
arise  from  excitation  of  the  respiratory  centre, 
and  when  this  excitation,  uncontrolled  by  higher 
centres,  acquires  an  abnormal  strength,  it  extends 
to  other  parts  of  the  medulla  oblongata  and  spinal 
cord,  and  produces  general  convulsions.  It  over- 
flows, as  it  were,  into  other  nervous  centres  which 
in  health  would  receive  none  of  the  exciting 
impulse.  Between  the  lowest  (automatic)  func- 
tions of  the  cerebro-spinal  nervous  system  and 
the  highest  (psychical)  there  is  an  evcr-in- 
creasingly  complex  system  of  excito-motor  pro- 
cesses, which  may  be  in  part  or  wholly  under 
the  pathological  influence,  whatever  it  be.  Hence 
the  bizarre  character  of  the  hysterical  pheno- 
mena, and  the  circumstance  that  the  symptoms 
always  include  modifications  of  those  processes 
which  underlie  the  mental  faculties.  The  sus- 
pension of  the  power  of  control  possessed  by  the 
higher  centres  explains  the  irregular  movements, 
spasms,  and  convulsions.  Hyperaesthesia  and  pain 
are  dependent,  probably,  in  hysteria,  upon  such 
a molecular  change  being  initiated  in  the  sensory 
ganglionic  centres  as  is  ordinarily  propagated 
from  the  periphery.  Hysterical  paralysis,  on 
the  other  hand,  signifies  that  the  power  of  the 
higher  centres  in  liberating  movements  is  in 
abeyance.  In  hysterical  anaesthesia  it  is  pro- 
bably feeling  or  sensory  perception  and  not  tho 
function  of  the  sensory  apparatus  which  is  in 
abeyance,  whilst  the  reflex  actions  which  result 
from  excitation  of  sensory  nerves  are  performed 
iu  an  orderly  manner.  A patient  may  work  a 
needle  with  fingers  which  can  be  touched  or 
pricked  without  the  act  being  felt.  Tactile  im- 
pressions are  conveyed  to  the  ganglionic  centres 
by  the  afferent  nerves,  and  excite  the  action  of 
efferent  nerves  so  that  the  muscles  are  con- 
tracted. What  is  wanting  is  the  participation 
uf  those  higher  centres  in  which  consciousness 
runs  parallel  to  this  physiological  action. 

.ZEtiology. — Predisposing  causes. — A state  of 
more  or  less  imperfect  development  of  the 
higher  nervous  centres  of  congenital  origin  very 
frequently  underlies,  it  is  probable,  the  various 
circumstances  which  apparently  conduce  to  the 
hysterical  conditions. 

The  female  sex  is  much  more  prone  than  the 


male  to  the  affection,  which  usually  occurs  le- 
tween  the  ages  of  fifteen  and  thirty,  and  most 
frequently  of  all  between  fifteen  and  twentv. 
Luxury,  ill-directed  education,  aDd  unhappy 
surroundings,  celibacy  where  not  of  choice  but  en- 
forced by  circumstances,  unfortunate  marriages, 
alcoholism,  premature  cessation  of  ovulation, 
and  long-continued  trouble — all  predispose  to 
hysteria.  A somewhat  frequent  antecedent  is  a 
long  and  wearisome  nursing  of  a sick  relation, 
with  much  broken  rest.  The  disorder  is  only  ex- 
ceptionally found  in  women  suffering  from  dis- 
eases of  the  genital  organs,  and  its  relation  to 
uterine  and  ovarian  disturbance  is  probably 
neither  more  nor  less  than  that  which  obtains  in 
other  neuroses.  Exception  must  be  made  in  the 
case  of  prostitutes  affected  with  venereal  disor- 
ders, who  are  very  prone  to  hysteria.  In  this 
class,  however,  the  condition  is  complicated  hy 
the  physical  and  moral  influences  to  which  their 
life  subjects  them,  and  amongst  these  alcohol 
frequently  occupies  a very  important  place. 
Like  epilepsy,  migraine,  and  some  forms  of  in- 
sanity, hysteria  is  prone  to  ho  intensified  at  the 
catamenial  period. 

The  occurrence  of  hysteria  (although  compara- 
tively rare)  in  males  is  sufficient  of  itself  to  dis- 
prove the  uterine  theory  ofcausation. 

Determining  causes. — These  include  painful 
impressions;  long  fasting;  strong  emotions; 
imitation  ; and  shock  to  the  nervous  system,  phy- 
sical or  moral. 

Symptoms  and  Diagnosis. — In  the  limited 
space  in  which  it  is  necessary  that  the  subject  of 
hysteria  should  be  treated,  it  will  be  best  to 
describe  together  some  of  the  most  frequent 
forms  which  the  neurosis  takes,  and  the  principles 
upon  which  a diagnosis  can  be  made.  Hysteria 
produces  symptoms  which  may  be  referred  t > 
every  function  of  the  body.  For  consideration 
they  may  be  roughly  classed  in  the  following 
groups,  it  being  understood  that  all  may  occur 
either  coincidontly  or  in  succession  : — 1.  Mental. 
2.  Sensory.  3.  Motor.  4.  Circulatory.  5.  Visceral. 

1.  Mental. — The  intelligence  may  be  apparently 
of  good  quality,  the  patient  evincing  sometimes  re- 
markable quickness  of  apprehension ; but.  carefully 
tested,  it  is  found  to  be  wanting  in  the  essentials 
of  the  highest  class  of  mental  power.  The  me- 
mory may  be  good,  but  judgment  is  weak,  and 
the  ability7  to  concentrate  the  attention  for  any 
length  of  time  upon  a subject  is  absent.  So  also 
regard  for  accuracy,  and  the  energy  Deccssary  to  i 
ensure  it  in  any  work  that  is  undertaken,  are  defi- 
cient. Tho  emotions  are  excited  with  undue  readi- 
ness, and  when  aroused  are  incapable  of  control. 
Tears  are  occasioned  not  only  hy  pathetic  ideas 
but  by7  ridiculous  subjects,  and  peals  of  laughter 
may  incongruously  greet  some  tragic  announce- 
ment. Or  tho  converse  may  take  place;  the 
ordinary  sigus  of  emotion  may  he  absent,  and  I 
replaced  by7  an  attack  of  coma,  convulsion,  pain, 
or  paralysis.  Perhaps  more  constant  than  any 
other  phenomena  in  hysteria  is  a pronounced 
desire  for  the  sympathy  and  interest  of  others. 
This  is  evidently  only  one  of  the  most  charac- 
teristic qualities  of  femininity  uncontrolled  by 
the  action  of  the  higher  nervous  centres,  which 
in  a healthy  state  keep  it  in  subjection.  Then 
is  very  frequently  not  only  a deficient  regard  fa 


HYSTERIA. 


truthfulness,  hut  a proneness  to  active  deception 
and  dishonesty.  So  common  is  this,  that  the 
various  phases  of  hysteria  are  often  assumed  to 
bo  simple  examples  of  voluntary  simulation,  and 
the  title  of  disease  refused  to  the  condition.  But 
it  seems  more  reasonable  to  refer  the  symptom 
to  impairment  of  the  highly  complex  nervous 
processes  which  f>  >rm  the  physiological  side  of 
the  moral  faculties. 

2.  Sensor//. — Pain,  hypereesthesia,  and  anaes- 
thesia occur  with  perhaps  equal  frequency.  The 
diagnosis  of  the  hysterical  origin  of  such  altera- 
tions of  sensibility  is  effected  partly  by  excluding 
the  presence  of  other  causes,  and  partly  by  con- 
sideration of  any  accompanying  or  antecedent 
peculiarities  of  manner  and  conduct.  Hysterical 
pain,  where  it  is  associated  with  some  evident 
local  change,  is  found  to  be  greatly  in  excess  of 
that  which  would  ordinarily  accompany  the  ob- 
served cause.  Where  pain  or  hyperesthesia  is 
complained  of  in  situations  and  of  a character 
which  would  commonly  point  to  some  existing  in- 
flammation, it  is  necessary,  by  examination  of  the 
pulse  and  temperature,  to  exclude  such  a condi- 
tion. Hysterical  pain  is  apt  to  cease  suddenly 
when  the  attention  is  diverted,  and  to  be  in- 
creased by  inquiry  and  sympathy.  Some  of  the 
most  common  seats  of  pain  and  tenderness  are 
the  following : — 

( a ) The  lower  part  of  the  side  of  the  chest 
(usually  the  left)  simulating  intercostal  neu- 
ralgia, but  distinguished  from  it  by  the  tenderness 
being  wide-spread,  superficial,  and  not  confined 
to  certain  points.  Pressure  here  will  sometimes 
occasion  disturbances  of  respiration  and  circu- 
lation. 

(4)  Some  of  the  vertebral  spines,  ttsually  in 
the  cervical  and  upper  dorsal  region.  Prom  the 
error  of  mistaking  this  for  commencing  disease 
of  the  vertebrae  numbers  of  young  women  have 
been  confined  to  a couch  for  months  or  years, 
and  their  health  permanently  damaged.  The 
points  of  diagnosis  are  the  patient’s  antecedents; 
there  is  often  a history  of  aphonia,  or  paraly- 
sis, or  hysterical  fits.  Or  it  may  happen  that, 
long  after  tho  pain  has  been  first  complained 
of,  the  patient  has  been  seen  to  take  a prodigious 
amount  of  exercise  on  some  one  occasion  without 
complaint.  A very  much  slighter  pressure,  too, 
causes  pain  than  is  at  all  usual  in  vertebral 
caries.  It  lias  to  be  remembered,  however,  that 
a patient  affected  with  vertebral  disease  may 
also  be  hysterical. 

(c)  Acute  pain  in  a joint,  occurring  usually 
some  little  time  after  a slight  injury  and  giving 
riso  to  suspicion  of  inflammation,  hut  distin- 
guished from  this  by  the  fact  that  after  a few  days 
of  great  pain  the  joint  does  not  feel  hot  to  the 
touch,  and  is  not  swollen,  and  that  the  thermo- 
meter shows  no  rise  of  temperature.  The  pain 
is  more  easily  excited,  too,  by  touching  the  skin 
than  by  pressing  the  articulatory  surfaces 
, against  each  other. 

It  is  necessary  to  remember  that  in  locomotor 
ataxy  there  may  be  exquisite  pains  (of  a shoot- 
ing character)  having  their  seat  in  a joint  or  its 
; neighbourhood,  and  accompanied  by  some  local- 
t 'sed  hyperesthesia  of  the  skin.  The  disease 
rarely  affects  ycung  females,  but  it  may  do  so, 
tnd  the  condition  is  then  extremely  liable  to  be 


GiD 

mistaken  for  hysteria.  The  chief  points  0/  dia- 
gnosis are,  that  in  locomotor  ataxy  then,  will 
be — 1.  absence  of  patellar  tendon  reflex  , 2.  a 
peculiar  character  of  the  pains— lightning-like  ; 
3.  probably  some  analgesia  of  the  extremities ; 
and  4.  an  ataxic  gait.  See  Locomotor  Ataxy. 

( d)  Tenderness  of  the  mamma  or  dar'  ing  pains 
through  its  substance,  recalling  those  cx  scirrims. 
The  absence  of  any  lump,  and  tho  effect,  of  en- 
gaging attention,  will  serve  to  distinguish. 

( e ) Pain  in  the  head  of  very  severe  character 
‘ like  a nail  being  driven  into  the  skull  ’ (claims). 
This  is  probably  neuralgic,  and  is  by  no  means 
confined  to  the  hysterical.  There  is  also  a more 
diffused  pain,  described  as  of  great  violence  and 
exceedingly  obstinate.  This  pain  is  sometimes 
suggestive  of  cerebral  tumour,  from  which,  how 
ever,  it  may  often  he  distinguished  by  the  fact 
that  the  ophthalmoscope  shows  no  optic  neuritis, 
and  that  there  is  no  vomiting.  But  gTeat  caution 
is  necessary  in  coming  to  a conclusion  that  severe 
and  long-continued  pain  in  the  head  is  hysterical. 
And  here  it  may  he  well  to  say  that  in  an  accu- 
rate knowledge  of  the  characteristics  of  the  dis- 
ease stipposed  to  he  simulated  lies  the  only 
safety  as  regards  diagnosis.  Nor  must  it  he  for- 
gotten that  persons  with  serious  organic  disease 
are  frequently  affected  also  with  hysterical  symp- 
toms. 

(/')  Epigastric  tenderness.  Careful  pressure 
will  often  show  that  the  tenderness  is  at  the 
origin  of  the  recto-abdominalis  muscles,  and  not 
in  the  stomach.  But  there  is  sometimes  pain  in 
the  stomach  itself,  and  this  may  he  associated 
with  disgust  for  food  or  depraved  appetite. 

( g ) Tenderness  in  one  or  other  iliac  region, 
deep  pressure  upon  which  will  sometimes  evolve 
hysterical  symptoms,  and  also  in  some  cases  of 
hysterical  convulsions  will  check  the  paroxysm. 

Anasthesia  may  involve  (though  rarely)  the 
whole  body.  It  is  more  commonly  confined  to 
one  half,  and  this  the  left,  and  is  then  frequently 
associated  with  tenderness  in  the  iliac  region  of 
the  same  side  ; or  it  may  be  limited  to  a small 
patch.  The  sense  of  touch  often  remains  whilst 
painful  impressions  and  those  of  temperature 
cannot  be  perceived.  The  antesthesia  may  be 
confined  to  the  surface,  or  involve  as  well  the 
deeper  structures,  into  which  pins  may  he  stuck 
without  evoking  signs  of  pain.  The  left  con- 
junctiva is  often  the  seat  of  anaesthesia,  so  that 
it  may  be  touched  or  even  rubbed  without  any 
reflex  movements  of  the  eyelids  being  excited. 
So  also  the  pharynx  may  be  tickled  without 
exciting  the  ordinary  spasmodic  contraction,  and 
the  epiglottis  touched  by  the  finger  without 
inconvenience.  .Such  affections  of  cutaneous 
sensibility  may  have  to  be  looked  for,  as  thev 
are  often  unsuspected  by  the  patient  herself.  As 
regards  diagnosis  tie  existence  of  peripheral 
nerve-lesions  may  be  excluded,  by  theabsence  of 
trophic  disturbance.  The  condition  is  not  likely 
to  be  confounded  with  hemiplegia,  unless  perhaos 
when  it  has  immediately  followed  a convulsive 
attack,  and  is  accompanied  by  apparent  loss  of 
power  in  the  limbs.  Examination  of  the  patient 
and  her  history  will  suffice  for  the  diagnosis.  The 
other  special  senses  also  may  be  disordered  in 
hysteria.  There  may  be  intolerance  of  light, 
subjective  sense  of  taste  or  smell,  roaring  noise; 


I 


HYSTERIA. 


580 

n the  ears ; or,  conversely,  loss  of  sight  (either 
n Half  of  both  eyes,  or  in  one  eye),  loss  of  smell, 
jv  taste,  or  hearing.  Or  there  may  be  feelings 
an  of  a limb  <or  other  part  being  enormously 
enlarged,  of  the  body  being  confined  in  a stiff 
c;ise,  of  the  feet  being  drawn  up  by  strings 
under  them,  of  ‘pins  and  needles’  around  the 
waist,  or  of  numbness  and  coldness  in  one  half 
of  the  body  (almost  always  the  left).  It  may  be 
said  generally  of  the  disorders  of  sensation  that 
they  are  capricious  in  their  appearance,  coming 
and  going,  as  they  would  not  did  they  depend 
upon  organic  disease  (this  recurrence  is  especi- 
ally significant) ; that  they  are  very  apt  to  ensue 
upon  some  moral  shock  or  convulsive  seizure ; 
a nd  that  careful  examination  will  prove  them  to 
be  unaccompanied  by  such  other  symptoms  as 
would  be  likely  to  be  present  did  they  depend 
upon  the  organic  alteration  which  they  simulate. 

3.  Motor. — The  principal  motor  symptoms  in 
hysteria  are  local  spasm,  more  or  less  general 
convulsion,  and  paralysis.  The  most  common  of 
all  symptoms  of  hysteria  is  the  globus  hi/stericvs. 
A lump  appears  to  the  patient  to  arise  from  the 
epigastrium  like  an  egg,  and,  travelling  upwards 
to  the  throat,  causes  a sensation  of  choking,  and 
is  often  accompanied  by  an  outburst  of  tears. 

Spasm  affecting  some  out  of  the  various  muscles 
concerned  iu  the  respiratory  acts  gives  rise  to  a 
great  variety  of  symptoms  highly  characteristic 
of  hysteria.  There  may  be  cough  of  a peculiarly 
sharp,  ringing  character,  constant  except  during 
sleep,  unaccompanied  by  expectoration,  strongly 
influenced  by  moral  causes.  A little  observation 
will  show  that  the  cough  does  not  occur  when 
the  patient  is  quite  alone  and  apparently  no  one 
within  earshot,  but,  on  the  other  hand,  it  is 
greatly  intensified  by  enquiry  and  solicitude.  It 
ceases  during  sleep.  Sometimes,  instead  of  cough, 
a loud  expiratory  sound  is  produced,  of  most  dis- 
cordant character,  resembling,  perhaps,  a railway 
whistle,  the  quacking  of  a duck,  or  the  barking 
of  a dog ; and  this  may  take  place  irregularly,  or 
may  be  marked  'by  a curiously  distinct  periodi- 
city. Or  there  may  bo  rapid,  deep  whooping 
inspirations,  with  signs  of  suffocation.  Occasion- 
ally with  the  hysterical  cough  there  is  a hyper- 
secretion of  mucus  ; and  if,  as  often  happens, 
there  is  also  disturbance  of  digestive  functions 
and  consequent  tendency  to  emaciation,  and  at  the 
same  time  such  constriction  of  the  air-passages 
as  gives  rise  to  sibilant  rales,  a prima  facie  re- 
semblance to  phthisis  is  presented,  which  can 
only  be  distinguished  by  prolonged  observation, 
aided  by  the  stethoscope  and  thermometer. 
Laughing  and  crying  are  very  frequent  forms  of 
expiratory  spasm.  Y’awning,  hiccough,  and  sneez- 
ing are  also  met  with.  Clonic  spasm  of  muscles, 
especially  of  those  movingtliehead  and  shoulders, 
or  back,  is  not  uncommon.  Or  one  of  the  muscles 
of  the  thigh  may  be  so  affected,  and  the  apparent 
pulsation  caused  by  the  rhythmical  contractions 
give  rise  to  a suspicion  of  aneurism. 

Tonic  spasm  of  one  or  more  muscles  of  a limb 
is  still  moro  frequent.  It  is  often  very  obstinate, 
and  after  enduring  for  months  or  years  may  sud- 
denly resolve  without  any  permanent  alteration 
bring  left  behind. 

(infraction  of  a limb  thus  produced  may  con- 
o.-,io  during  sleep  and  even  resist  the  influence 


of  chloroform  inhalation,  unless  this  is  pushed  tc 
its  full  extent.  Should  one  of  the  abdominal 
muscles  be  thus  affected,  an  abdominal  tumour 
is  produced,  which  may  be  mistaken  for  some 
growth  in  the  cavity ; and  if  the  pulsations  of 
the  aorta  should  be  communicated  to  it,  a strong 
prima,  facie  resemblance  to  abdominal  aneurism 
is  caused.  The  best  mode  of  diagnosis  is  by 
faradisation,  which,  if  persevered  in  for  several 
minutes,  will  exhaust  the  muscular  contractility 
and  cure  the  ailment  if  it  he  of  this  kind.  If  it 
is  not  a ‘ phantom  tumour  ’ of  this  description 
but  a genuine  growth,  the  muscle  will  he  con- 
tracted by  the  current,  and  it  may  then  be  pos- 
sible to  feel  the  tumour  as  something  evidently 
distinct  from  the  muscle. 

Convulsive  seizures  are  of  common  occurrence, 
and  are  usually  preceded  by  a sense  of  suffoca- 
tion, difficulty  of  swallowing,  pain  in  the  bellv 
or  stomach,  headache,  vertigo,  or  some  inde- 
scribable sensation  in  one  of  the  extremities. 
There  is  often  a cry  as  of  one  being  choked, 
unlike  the  peculiar  availing  shriek  which  ushers 
in  the  epileptic  seizure.  Usually  there  is  not 
the  extreme  suddenness  of  attack  which  charac- 
terises epilepsy,  but  the  patient  may  be  manifestly 
struggling  against  the  seizure  for  a small  but 
appreciable  interval.  When  at  last  she  falls, 
she  does  not  usually  do  so  with  violence  enough 
to  receive  severe  injury,  and  positions  of  danger 
are  generally  avoided.  The  epileptic  often  falls 
in  the  fire,  the  hysterical  patient  never.  The 
spasms  of  muscles  which  succeed  are  often  tetanic 
in  character,  and  sometimes  wear  an  aspect  of 
design— the  patient  grips  articles  with  her  hands 
or  teeth.  The  face  may  be  more  or  less  red.  In 
epilepsy  it  is  usually  first  pale  and  then  livid. 

There  is  often  more  or  less  complete  opistho- 
tonos, which  is  usually  absent  in  epilepsy.  It  is 
doubtful  how  far  consciousness  is  ever  completely 
lost,  but  though  for  the  most  part  it  is  retained 
during  the  attack,  there  are  certainly  cases  in 
which  it  is  to  a great  extent  in  abeyance.  It  is 
characteristic  of  hysteria  that,  however  rapid  and 
violent  the  contortions,  the  patient  usually  avoids 
inflicting  any'  serious  injury  upon  herself.  During 
the  attack  gesticulations  and  language  are  apt  to 
he  used  which  may  be  reproachful,  or  marked  by 
an  amatory  character  as  regards  some  bystander, 
such  as  is  calculated  to  cause  embarrassment. 
There  may  be  a single  convulsive  seizure,  ter- 
minated by  a fit  of  weeping  and  the  passage  of 
a large  quantity  of  almost  co  ourless  urine  of 
low  specific  gravity.  Or  there  may  be  a succes- 
sion of  attacks  extending  somet  imes  over  several 
hours.  The  tongue  is  not  bitten.  As  a rule 
the  hysterical  patient  rapidly  returns  to  her 
ordinary  condition  after  the  outburst  is  com- 
pleted, and  fails  to  show  the  heaviness  and  ten- 
dency to  sleep  which  is  characteristic  of  epilepsy. 
The  variety  seen  in  the  character  of  hysterical 
convulsions  suggests  that  the  pathological  influ- 
ence involves  the  nervous  centres,  sometimes  more 
and  sometimes  less  extensively;  showing  every 
degree  of  muscular  movements,  from  those  of  a 
highly  co-ordinated  or  quasi-voluntary  kind,  down 
to  those  of  a simply  tetanic  form,  such  as  appear 
to  indicate  either  that  control  of  the  reflex  func- 
tion of  the  spir.al  cord  is  tvinpoiarily  suspemu-:. 
or  that  the  cerebellar  in  flu  arc.  as  Hugh  bug: 


HYSTERIA. 


Jackson  thicks,  is  being  allowed  to  have  full 
play,  owing  to  some  peculiar  condition  of  the 
terebrum  interfering  for  a time  with  its  normal 
power  of  antagonism.  But  it  must  be  borne  in 
mind  that  the  hysterical  patientmay,  like  others, 
become  epileptic,  and  that  there  is  nothing  to  pre- 
vent the  chronic  epileptic  betraying  occasionally 
symptoms  of  hysteria.  Such  mixed  cases  are 
often  difficult  of  diagnosis,  and  it  is  usually  only 
a prolonged  observation  which  succeeds  in  dis- 
tinguishing the  nature  of  the  condition.  Move- 
ments which  somewhat  resemble  those  of  chorea 
aro  occasionally  met  with,  but  their  character 
and  the  surrounding  circumstances  usually  make 
it  easy  to  distinguish  them. 

Paralysis  may  affect  any  of  the  limbs  in 
hysteria,  but  paraplegia  is  the  more  usual  form. 
Hemiplegia  is  comparatively  rare.  The  muscles 
retain  their  nutrition.  There  is  often  at  first 
a slight  loss  of  irritability  to  induced  currents, 
but  after  a very  few  applications  this  becomes 
normal.  At  first,  too,  considerable  electro-cuta- 
neous and  electro-muscular  insensibility  may  be 
present.  If  the  form  of  paralysis  be  hemiplegic, 
the  mouth  is  not  affected;  if  paraplegic,  the 
sphincters  are  not  paralysed,  and  there  is  never 
any  bedsore.  If  the  arm  be  the  limb  affected, 
and  the  examiner,  after  flexing  it  slightly  leaves 
go,  it  will  sometimes  remain  in  the  flexed  position, 
which  it  would  not  do  in  hemiplegia.  It  is  note- 
worthy that  in  half  the  cases  of  hysterical  paraly- 
sis, there  is  no  history  of  antecedent  convulsions. 
Cutaneous  anaesthesia  of  the  extremities  will 
give  rise  sometimes  to  a pseudo-paralysis,  and 
muscular  anaesthesia  may  cause  symptoms  of 
ataxy.  These  may  be  distinguished  from  the 
result  of  organic  change  by  careful  examination. 
Hysterical  speechlessness  may  be  distinguished 
from  aphasia  by  the  patient  being  able  to  write 
down  with  great  facility  the  wishes  she  is  unable 
to  express  in  speech;  andfromlocalised  paralysis  of 
the  tongue,  by  her  being  perfectly  able  to  swallow. 

4.  Circulatory. — There  may  be  syncope  which 
will  simulate  dying.  After  an  indescribable  sen- 
sation at  the  heart — a fulness  or  stifling  feeling 
— the  pulse  becomes  almost  imperceptible,  the 
patient  is  speechless,  and.  for  periods  varying 
in  length,  is  apparently  in  a most  precarious 
condition,  recovery  taking  place  after  prolonged 
sighing.  Or  there  may  be  tumultuous  action  of 
the  heart.  The  abdominal  aorta  (and  sometimes 
also  other  arteries)  is  occasionally  the  seat  of 
powerful  pulsations,  which  are  visible  in  their 

, effects  upon  the  abdominal  wall  and  strongly 
suggest  the  existence  of  aneurism.  The  capillary 
circulation  may  be  deranged  in  the  two  directions 
of  hyperaemia  and  ischaemia.  In  the  former  there 
is  a patch  of  redness  of  the  skin  accompanied 
by  a feeling  of  burning  and  tenderness  ; in  the 
latter,  which  is  especially  seen  in  conjunction 
with  analgesia,  the  skin  is  pale  and  no  bleeding 
follows  the  pricks  of  a'  pin.  In  a recorded  case, 
pressure  upon  a tender  spinous  process  checked 
the  radial  pulse  for  a time. 

5.  Visceral. — Vomiting  is  sometimes  a very 

; obstinate  symptom,  all  food  taken  being  speedily 

ejected,  the  fcondition  lasting  a surprisingly  long 
Vine,  often  for  many  months,  without  usually  so 
much  prostration  as  might  be  expected,  but  never- 
theless with  groat  loss  of  weight.  Or  there  may 


681 

be  such  an  active  aversion  from  food  as  renders  it 
very  difficult  to  support  nutrition;  or  a depraved 
appetite  may  cause  substances  to  bo  swallowed 
which  have  no  nutritious  property.  In  the  belly 
there  is  frequently  a hyper-secretion  of  gas  with 
spasm  of  the  bowels,  causing  borborygmi  and 
noisy  eructations.  Intestinal  gas  may  be  im- 
prisoned between  two  points  of  spasmodic  con- 
traction of  the  intestine,  giving  origin  to  a 
tumour  capable  of  being  moved  about  in  the 
abdominal  cavity,  and  of  sudden  resolution. 
These  balloons,  it  is  probable,  are  sometimes 
mistaken  for  tumours  of  the  spleen,  kidney,  or 
other  organ.  It  is  not  uncommon  to  have  reten- 
tion of  urine,  the  bladder  becoming  greatly  dis- 
tended, but  contracting  at  once  and  expelling 
its  contents  if  the  patient  be  placed  in  a hip-bath, 
and  a bucket  of  cold  water  be  thrown  over  tho 
pelvis.  In  other  cases  there  is  an  unduly  fre- 
quent desire  to  empty  the  bladder.  Tho  secretion 
of  urine  may  be  suppressed  almost  entirely  (but 
this  is  very  rare),  the  little  urine  that  is  passed 
containing  an  unusual  proportion  of  urea,  which 
is  also  found  in  the  vomiting  accompanying 
this  condition. 

There  is  sometimes  very  obstinate  constipation 
giving  rise  to  enormous  impaction  of  faeces — 
occasionally  also  diarrhoea. 

Cases  occur  in  which  the  symptoms  of  cerebro- 
spinal sclerosis  of  the  disseminated  form,  after 
persisting  perhaps  for  many  months  in  a young 
woman,  rapidly  or  even  suddenly  disappear.  The 
close  resemblance  to  a disease  which  is  not  only  in- 
curable but  tends  to  become  progressively  worse, 
is  so  strong  that  it  is  often  impossible  to  form  a 
diagnosis,  and  a very  guarded  prognosis  becomes 
necessary.  In  the  present  state  of  our  know- 
ledge it  is  customary  to  class  such  cases  with 
those  of  hysterical  paralysis ; but  it  is  quite  a 
question  whether  they  are  not  really  cases  of 
incipient  cerebro-spinal  sclerosis,  recovering  ere 
the  stage  of  irreparable  change  is  arrived  at. 
There  is  good  reason  to  think  that  cases  of  dis- 
seminated cerebro-spinal  sclerosis  are  not  at  all 
unfrequently  supposed  to  be  simple  examples 
of  hysteria.  Tho  disease  is  characterised  in  its 
early  stage  (tho  only  period  when  mistake  is 
possible)  by  some  general  weakness  of  limbs, 
accompanied  by  slight  tremors  on  voluntary 
movement  only,  and  an  utterance  which  is  slow 
and  drawling,  with  occasional  slurring  of  words. 
Careful  examination,  especially  noting  the  cir- 
cumstance that,  for  example,  the  arm  only  shakes 
when  the  patient  is  directed  to  take  hold  of  an 
object,  is  usually  sufficient  to  distinguish  the  dis- 
ease from  hysteria,  but  there  is  sometimes  con- 
siderable difficulty,  and  caution  should  be  ob- 
served in  avoiding  hasty  conclusions. 

Sequeue. — Hysterical  symptoms  sometimes 
pass  into  thoso  of  mania,  melancholia,  and  occa- 
sionally also  of  dementia. 

Prognosis. — This  is  favourable  as  regards  life, 
death  from  hysteria  being  very  rare.  Recovery 
for  a time  is  common  enough,  but  too  often  thero 
is  a return  of  the  disease,  the  symptoms  being 
usually  of  a different  kind.  Some  patients  will 
run  through  almost  every  conceivable  phase  of 
the  disorder  in  turn.  As  a rule  thero  is  a ten- 
dency to  cessation  of  the  disease  after  the  climac- 
teric period.  It  occasionally  happens,  however, 


582  HYSTERIA. 

that  the  disease  is  continued  into  an  advanced 

period  of  life. 

Treatment. — If  Medicine  were  in  a position  to 
regulate  the  mode  of  life,  food,  education,  and 
especially  the  selections  for  propagation  of  the 
species,  it  is  probable  that  in  succeeding  genera- 
tions hysteria  would  become  more  and  more 
rare  in  the  race.  It  can  do,  however,  but  little 
for  the  individual.  Intercurrent  maladies  must 
of  course  receive  the  treatment  proper  to  them. 
Where  anaemia  is  present  much  good  may  often 
be  done  by  iron.  States  of  malnutrition  tend  to 
precipitate  and  intensify  hysterical  symptoms; 
and  to  remedy  these  is  often  to  do  much  for  the 
concomitant  nervous  disorder. 

But  probably  the  greatest  amount  of  benefit 
which  can  be  brought  to  bear  upon  the  hysterical 
patient  is  through  her  surroundings.  A girl  who 
has  not  spoken  above  a whisper  for  months  whilst 
at  home,  will  often  recover  her  natural  tone  of 
voice  in  a week  if  placed  under  the  judicious 
discipline  of  strangers.  This  is  a well-known 
circumstance,  and  the  fact  has  tended  very  much 
to  the  belief  that  hysteria  is  simply  vicious 
simulation.  Such  an  inference  is  unjust. 

That  an  altered  relation  of  the  ganglionic 
nerve-cells  to  the  blood-sunply  forms  at  least  a 
part  of  the  pathology  of  hysteria  appears  pro- 
bable from  the  effects  of  fasting  in  provoking 
hysterical  outbursts,  and  the  influence  of  food 
and  stimulants  in  postponing  them.  Ammonia  in- 
haled by  the  nostrils  is  a well-known  and  valuable 
agent  for  the  purpose.  Alcohol  should  be  avoided 
altogether,  as  there  is  great  danger  of  excess. 

It  is  through  the  sensory  nerves  that  the  most 
rapid  influence  is  brought  to  bear  upon  the 
hysterical  condition.  Thus  cutaneous  antesthesia 
and  hyperaesthesia  may  often  be  rapidly  cured 
by  the  application  of  strong  induced  currents 
to  the  portion  of  skin ; aphonia  by  acting  in  a 
similar  way  upon  the  skin  covering  the  larnyx. 
Paralysis  of  the  limbs  is  in  many  cases  quickly 
cured  by  the  same  means. 

Hysterical  convulsions  may  almost  always  he 
cut  short  by  douching  the  patient  very  freely 
indeed  with  cold  water.  This  should  be  poured 
from  a height  upon  the  face.  For  a few  seconds 
there  is  no  perceptible  effect,  then  the  breathing 
becomes  gasping,  and  the  patient  seeks  by  moving 
away  to  avoid  any  further  application.  It  often 
happens  that  the  remembrance  of  this  treatment 
serves  to  prevent  a repetition  of  convulsions,  hut 
it  would  be  wrong  to  conclude  from  this  that  the 
proceedings  of  the  patient  had  been  voluntary. 
The  effect  of  the  cold  douche  is  to  create,  through 
the  medium  of  the  cutaneous  nerves,  a sudden 
change  in  the  character  of  the  blood-circulation, 
which  may  well  influence  the  state  of  the  gang- 
lionic nerve-centres.  The  supposition  seems  fair 
that  to  remember  the  shock  is  to  have  a weak 
excitement  of  the  nerve-eentres  which  were 
strongly  excited  by  the  application. 

Bromide  of  potassium,  which  is  of  such  value 
in  the  grand  mal  of  epilepsy,  has  no  influence  in 
preventing  hysterical  convulsions.  In  a doubtful 
case  the  exhibition  of  this  drug  is  therefore 
useful  for  purposes  of  diagnosis.  Valerian  (the 
powder  or  tincture)  has  an  unquestionable  effect 
in  the  convulsive  and  spasmodic  symptoms  of 
hysteria,  little  or  none  probably  upon  the  para- 


HYSTERO-EPILMFSV. 
lytic  phases.  Assafcetida  by  enema  is  useful  in 
tympanites  and  colic  of  hysterical  origin.  Small 
doses  of  strychnia  and  opium  are  useful  in 
relieving  some  of  the  distressing  feelings  com- 
plained of  by  hysterical  patients. 

If  is  often  a question  whether  the  hysterical 
should  marry.  Where  the  disorder  is  slight  and 
the  general  health  is  good,  marriage  may  be  ad- 
vised, supposing  that  the  prospects  of  a happv 
union  are  favourable.  But  in  very  severe  cases, 
and  especially  when  there  is  also  a strong  neurotic 
history  in  the  family,  it  should  ho  discounte- 
nanced. Nothing  hut  harm  can  he  expected  from 
the  strain  of  domestic  cares  upon  a congenitally 
defective  nervous  system.  T.  Buzzard. 

HYSTERICAL  INSANITY.  — Almost 

every  variety  of  insanity  may  present  in  certain 
patients  features  which  are  commonly  known  and 
termed  ‘ hysterical.’  Melancholic  individuals 
will  be  afflicted  with  hysterical  paraplegia  or 
other  paralyses.  Some  w'ill  become  cataleptic 
or  apparently  unconscious,  others  will  display 
all  the  phenomena  of  hystero-epilepsy.  Not 
unfrequently  do  we  see  a violent  outburst  of 
acute  mania  culminating  and  subsiding  in  a 
brief  period  of  time,  resembling  in  this  an  ordi- 
nary attack  of  ‘ hysterics.’  It-  may  he  doubtful, 
however,  whether  hysterical  insanity  should  bo 
looked  upon  as  a special  variety  of  the  malady. 
It  seems  more  correct  to  look  upon  it  as  insanity 
occurring  in  hysterical  patients,  and  character- 
ised by  the  phenomena  peculiar  to  them.  We 
may  expect  sudden  changes  of  symptoms,  sudden 
improvements,  and  sudden  relapses. 

Prognosis. — The  prognosis  is  unfavourable, 
as  this  insanity  is  found  in  patients  of  an  un- 
stable nervous  organization,  prone  to  frequent 
derangement.  Even  if  recovery  takes  place, 
subsequent  attacks  are  not  unlikely  to  occur. 

Treatment. — Such  persons  require  above  all 
others  moral  treatment.  Medical  treatment 
should  be  directed  towards  the  improvement  of 
the  general  health  rather  than  the  removal  of 
special  symptoms.  G.  F.  Blandford. 

HYSTERITIS  (uerre'pa,  the  womb). — In- 
flammation of  the  womb.  See  Womb,  Diseases  of. 

HYSTERO-EPILEPSY.  — Stnon.  : Fr. 

Hystcro-L'pilcpsic ; Hysiirie  eptfeytifemne ; Ger. 
Hystcroepi  lepsic. 

Definition. — A term  applied  to  a form  of 
hysteria  of  unusual  gravity,  the  convulsions  in 
their  violence  recalling  those  of  epilepsy,  and 
characterised  by  the  occurrence  of  remarkable 
forms  of  anaesthesia,  paralysis,  and  contraction  cf 
muscles. 

AEtiology. — The  condition  is  one  which  must 
be  classed  with  hysteria,  and  not  with  epilepsy, 
and  the  circumstances  which  tend  to  the  pro- 
duction of  the  former  disease  are  here  equally 
potent.  See  Hysteria. 

Symptoms  and  Diagnosis. — It  is  to  the  French 
school,  and  especially  to  Professor  Charcot  "t 
Paris,  that  we  owe  the  most  important  deseri]'- 
lions  of  this  disease,  which  would  appear  to  be 
more  common  on  the  Continent  than  in  England. 
The  symptoms  may  be  divided  into: — 1.  Moto:\ 
and  2.  Sensory. 

1.  Motor. — Convulsive  seizures  occur,  preceded 


HYSTERO- 

by  an  hysterical  aura  (abdominal  or  epigastric), 
which  usually  gives  the  patient  timely  warning 
enough  to  enable  her  to  place  herself  in  a position 
of  safety.  Then  there  is  a shriek,  the  face  is 
pallid,  and  she  falls  (perhaps  whilst  endeavouring 
to  quit  the  room),  the  features  become  distorted, 
and  the  limbs  pass  into  a state  of  tonic  rigidity. 
There  is  foaming  at  the  mouth,  sometimes  the 
longue  is  bitten,  and  there  may  be  some  clonic 
convulsions  with  lividityof  features.  Relaxation 
of  the  muscles  and  a more  or  less  comatose  con- 
dition succeed,  to  be  followed  shortly,  however, 
by  contortions  and  gesticulations  of  a violent 
character,  coarsely  suggestive  of  the  influence  of 
various  passions — wrath,  fear,  disgust,  lust.  Or 
there  may  be  meaningless  writhings,  presenting 
a hideous  aspect.  To  this  phase  sometimes  suc- 
ceeds hallucination  of  vision,  or  of  hearing.  Rats 
and  serpents  and  other  objects  of  horror  are  seen. 
The  attack  ends  with  sobs  or  hysterical  laughter. 
There  may  remain  a temporary  inability  to  empty 
the  bladder  or  to  swallow  food. 

Convulsive  seizures  of  this  co-ordinated  or 
purposive  character,  although  much  more  com- 
mon in  the  female  than  the  male  sex,  are  by  no 
means  confined  to  the  former.  The  condition  is 
not  unfrequently  observed  in  boys,  less  often  in 
men.  In  the  latter  there  is  usually  the  history 
of  some  great  moral  shock  antecedent  to  the 
first  outbreak. 

In  patients  liable  to  attacks  such  as  have  been 
described,  it  is  not  uncommon  to  find  a contracture 
of  one  or  more  limbs.  This  may  assume  the 
hemiplegic  or  paraplegic  form ; and  it  may  be  of 
a passing  character,  lasting  a few  days  only,  or 
enduring  for  many  years.  The  attitude  may  be 
either  that  of  rigid  flexion  or  extension  ; and  it 
is  found  to  remain  during  sleep,  only  relaxing 
under  the  profound  effect  of  chloroform  narcosis. 
The  limb  so  affected  does  not  suffer  in  its  nutri- 
tion, and  the  reaction  of  the  muscles  to  electrical 
currents  remains  normal. 

The  contractures,  as  well  as  the  sensory  dis- 
turbances described  below,  may  be  said  to  be 
practically  confined  to  patients  of  the  female  sex. 
It  is  very  rare  indeed  to  find  them  in  males. 

2.  Sensory. — It  has  been  noted  that  in  female 
patients  thus  affected  (as  indeed  is  common  in 
hysteria  generally)  there  is  apt  to  be  a pain  in 
one  or  other  iliac  region,  most  often  the  left, 
which  is  sometimes  constant,  and  in  other  cases 
is  only  discovered  by  pressure.  The  seat  of  this 
pain  is  thought  to  he  the  ovary,  and  it  is  found 
that  whilst  a moderate  pressure  in  this  region 
may  determine  the  production  of  the  aura  and 
sometimes  of  an  hysterical  attack,  energetic  com- 
pression at  the  spot  will  very  often  cut  short  the 
convulsive  seizure. 

Anesthesia  and  analgesia  are  apt  to  be  found 
sometimes  in  both  sides,  but  much  more  fre- 
quently in  ODe  half  of  the  patient’s  body,  parted 
off  from  the  other  by  the  median  line,  and  thus 
involving  apparently  half  the  head,  face,  and 
trunk,  as  well  as  the  upper  and  lower  extremi- 
ties, though  it  may  he  in  different  degrees  of 
intensity.  It  not  seldom  happens  that  the  patient 
is  herself  unaware  of  the  existence  of  this  in- 
sensibility until  examination  has  disclosed  it. 
The  loss  of  sensibility  sometimes  affects  also  the 
Special  senses ; and  smell,  taste,  hearing,  sight, 


•EPILEPSY'.  C83 

and  the  perception  of  colour,  may  each  or  all  bo 
lost  on  one  side. 

Accompanying  the  analgesia  it  is  often  seen 
that  the  pin-prick  employed  to  test  the  condition 
fails  to  draw  blood  on  the  affected  side,  whilst 
readily  doing  so  in  the  opposite  limb. 

Where  there  is  loss  of  power  of  the  limbs  with 
contracture  and  anaesthesia  following  a convul- 
sive seizure,  it  is  not  difficult  for  the  condition 
to  be  ascribed  to  an  attack  of  hemiplegia,  result- 
ing from  organic  disease,  and  there  is  sometimes 
a doubt  on  this  matter  which  is  not  easily  resolved. 
The  points  of  most  value  in  making  a differential 
diagnosis  are  the  following: — a.  The  absence 
from  the  first  of  any  deviation  of  thr  tongue  or 
facial  paralysis.  After  a time,  no  doubt,  in 
some  cases  of  hemiplegia  of  organic  origin  these 
symptoms  become  scarcely  visible,  but  it  may 
be  said  that  practically  at  the  onset  they  are 
always  present  to  a greater  or  less  extent,  b. 
The  extent  and  completeness  of  the  analgesia, 
especially  the  mode  in  which  it  affects  the  trunk, 
which  ordinarily  escapes  in  hemiplegia.  Such 
complete  anfesthesia  as  occurs  in  these  cases  is 
rarely  observed  in  hemiplegia  of  cerebral  origin. 
In  spinal  hemiplegia,  again,  it  would  occupy,  as 
Brown-Seqnard  has  pointed  out,  the  side  of  the 
body  opposite  to  that  affected  with  motor  paraly- 
sis. Besides  these  there  is  rarely  much  difficulty 
in  finding  in  the  symptoms,  surroundings,  or 
history  of  the  patient,  circumstances  which,  com- 
bined with  those  described,  throw  a strong  light 
on  the  nature  of  the  condition.  The  hysterical 
patient  may  present,  for  example,  retention  of 
urine,  ovarian  tenderness,  and  tympanites ; and  in 
her  history  there  may  be  an  account  of  aphonia, 
convulsive  seizures  occurring  under  emotion, 
hysterical  cough,  or  some  other  feature  which 
tends  to  stamp  the  case  as  one  belonging  to  this 
great  neurosis. 

Occasionally  these  contractures  remain  perma- 
nent. Much  more  frequently  they  relax,  after  a 
longer  or  shorter  period,  and  the  relaxation  almost 
always  takes  place  suddenly,  usually  under  the 
influence  of  some  moral  shock. 

It  will  sometimes  happen  that  paresis  and 
contracture  of  a limb  will  occur  without  any  pre- 
vious history  of  hysterical  symptoms,  and  the 
possibility  of  this  must  always  be  borne  in  mind. 
Where  there  is  during  many  hours  a long-con- 
tinued succession  of  fits  with  brief  intervals  of 
immunity,  considerable  doubt  may  arise  as  to 
the  nature  of  the  attacks,  because  a very  similar, 
numerous,  and  rapid  recurrence  of  fits  sometimes 
takes  place  in  true  epilepsy.  We  are  indebted 
to  Charcot  for  the  observation  that  whilst  in  the 
case  of  the  epileptic  seizures  of  this  kind  the 
temperature  is  observed  to  rise  greatly  (attaining, 
for  instance,  a height  of  105°  E.),  no  such  great 
increase  is  noted  when  the  fits  are  of  hysterical 
origin — a slight  elevation  only  occurring. 

In  cases  of  hystero-epilepsy  it  has  been  noted 
that  there  is  often  colour-blindness,  affecting  the 
eye  on  the  same  side  as  the  hemiansesthesia  — 
the  order  of  disappearance,  in  most  cases,  being 
the  following : — violet,  green,  red,  orange,  yellow, 
blue.  Violet  is  the  colour  most  easily  lost,  red 
and  blue,  according  to  Charcot,  being  those  which 
persist  most,  except  in  those  cases  where  achro- 
matopsia is  absolute,  that  is,  where  the  patient 


884  HYSTERO-EPILEPSY. 

looking  at  a painting  sees  nothing  but  black  and 

white. 

Remarkable  results  hare  been  known  to  follow 
the  application  of  metallic  plates  and  the  ap- 
proach of  a powerful  magnet  to  the  anaesthetic 
side  of  the  body.  It  is  found  that  if  a small  plate 
of  some  metal  be  applied  for  a few  minutes  to  the 
skin,  a return  of  sensibility  occurs,  touches  and 
pricks  previously  unperceired  are  felt,  and  colour- 
vision  is  restored  in  the  affected  eye.  The 
particular  metal  which  will  effect  this  change 
has  to  be  sought  by  experiment ; in  one  person 
gold,  in  another  silver,  in  others  again  iron, 
tin,  or  copper,  alone  producing  the  effect.  So 
again  it  is  stated  that  the  approach  (with- 
out actual  contact)  of  a powerful  horse-shoe 
magnet  will  produce  a similar  effect  to  the 
contact  of  a metal.  In  either  case,  pari  passu 
with  the  return  of  sensibility  on  the  affected 
side,  it  is  noted  that  the  other  half  of  the  body 
acquires  the  anaesthetic  state.  There  is  a trans- 
ference apparently  of  the  phenomena.  The  ap- 
proach of  a magnet,  it  is  also  found,  will  cause 
a contracture  to  relax,  the  relaxation  lasting  for 
many  hours.  But  in  this  case,  again,  the  eorre- 
spouding  limb  of  the  previously  normal  side  is 
found  to  present  evidence  of  paresis.  In  two 
instances  Rosenthal  and  the  writer  have  found 
defective  electrical  excitability,  as  tested  by 
sudden  interruption  of  a strong  voltaic  current, 
in  the  cerebral  hemisphere  opposite  to  the  side 


ICHTHYOSIS. 

which  is  marked  by  anaesthetic  symptoms.  In 
the  writer’s  own  case  the  experiment  was  followed 
by  considerable  improvement  in  the  cutaneous 
sensibility. 

Treatment. — Cases  of  hystero-epilepsy  are 
not  amenable  to  any  treatment  by  drugs,  Power- 
ful  moral  impressions,  especially  energy  and 
commanding  influence  in  the  medical  attendant, 
are  more  potent  than  anythirg  else  in  bringing 
about  recovery,  but  it  is  not  always  that  these 
can  be  brought  to  bear.  It  is  desirable,  there- 
fore, that  in  suitable  cases  the  influence  of  the 
measures  just  described  should  be  tested.  In 
cases  of  convulsion  strong  pressure  should  be 
made  upon  that  ovarian  region  in  which  tender- 
ness is  discovered.  In  examples  of  contracture 
and  hemiamesthesia  an  application  of  metallic 
plates  of  various  kinds  may  well  be  made  to  the 
skin  of  the  affected  side. 

Very  useful  effects  are  often  produced  by  the 
application  of  strong  Faradic  currents,  which 
may  require  to  be  persisted  in  ere  any  iufluence 
is  produced.  Blisters  also  repeated  every  three 
or  four  days  are  occasionally  very  useful  in 
causing  the  relaxation  of  a contractured  limh  and 
the  return  of  sensibility  to  an  anaesthetic  skin. 

Removal  of  the  patient  from  the  family  circle 
and  the  society  of  frightened  or  sympathising 
friends,  is  in  most  cases  a sine  qua  non  of  suc- 
cessful treatment. 

T.  Buzzard 


I 


ICE,  Therapeutics  of.  See  Cold,  Thera- 
peutics of. 

ICHOB.BH2EMIA  (ix«p,  puriform  matter, 
and  alpa,  the  blood). — A morbid  condition  of  the 
bloo  I,  caused  by  the  absorption  of  septic  mate- 
rials. See  Pyaemia  ; and  Septic.emia. 

ICHTHYOSIS  (t’x9“s»  a fish).— Synon.  : 
Fish-skin  disease;  Fr.  Ichthyosc,  Ger.  Fisch- 
schuppenausschlog . 

Definition. — An  affection  of  the  skin  which 
has  received  its  name  from  the  breaking  up  of  the 
cuticle  into  polygonal  are*,  which  suggest  the 
idea  of  the  scales  of  the  fish.  The  surface  of 
the  skin  is  dry,  rigid,  rough,  and  greyish  in 
colour  ; and  the  cuticle  exfoliates  in  fragments, 
which  in  one  place  resemble  dust,  and  in  others  j 
are  composed  of  thin  glistening  laminae,  like  those 
of  mica  or  bran. 

.(Etiology. — As  a defect  of  development  and 
normal  growth  of  the  skin,  ichthyosis  is  a con- 
genital affection,  and  often  hereditary ; and  the 
degree  of  its  manifestation  will  depend  on  acci- 
dental circumstances  of  various  kinds,  and  more 
particularly  on  such  as  appertain  to  food  and 
cleanliness. 

Anatomical  Characters.— In  ichthyosis  the 
cuticle  is  more  abuudaut  than  natural ; the 


fibrous  tissue  of  the  derma  is  condensed  and 
hard  ; the  papill*  cutis  are  enlarged  and  elon- 
gated ; the  subcutaneous  connective  tissue  is 
lax  and  fatless  ; and  the  whole  organ  is  de- 
void of  succulence  and  elasticity.  In  a word, 
it  may  be  said  to  be  starved.  The  remain- 
ing characteristics  of  the  disease  are  such  as 
might  be  predicted  from  this  description.  The 
cuticle  formed  in  excess  is  hard  and  brittle,  and 
breaks  up  into  fragments  corresponding  with  the 
are*  of  the  lines  of  motion  and  wrinkles  of  the 
skin ; the  fragments  being  simply  pulverulent 
in  one  part,  as  upon  the  inner  side  of  the  limlis, 
the  neck,  and  front  of  the  trunk ; angular  and 
prominent  in  the  neighbourhood  of  the  joints; 
and  smooth,  flat,  and  polyhedral  on  the  inter- 
nodal  parts  of  the  limbs.  The  follicles  of  the 
skin  are  filled  with  dry  exuvi*  and  dry  seba- 
ceous substance,  which  in  some  situations  con- 
cretes on  the  surface,  thereby  increasing  the 
thickness  of  the  epidermic  crust.  The  skin  as  a 
whole  is  marked  with  coarse  wrinkles,  resulting 
from  the  stiffness  and  hardness  of  its  substance ; 
and  from  the  looseness  of  the  subcutaneous  ti- 
sue,  it  moves  freely  on  the  fascia  beneath.  V bile 
the  general  character  of  the  integument  is  that 
of  want  of  harmony  as  to  growth  with  the  rest 
of  the  body  of  the  individual,  there  is  a defect 


ICHTHYOSIS. 

pf  die  jily  secretion  of  the  skin,  sometimes  also 
of  its  aqueous  secretion ; a want  of  the  clearness, 
transparency,  and  lustre  which  arc  met  with  in 
the  healthy  skin;  aud  an  exhalation  of  an  un- 
pleasant odour. 

Varieties. — The  most  striking  modifications 
of  ichthyosis  are-  to  he  looked  for  on  the  limbs, 
where  the  disease  is  most  marked,  and  the  scales 
of  greatest  magnitude;  on  the  hands  and  feet, 
which  are  dry  and  horny  and  deeply  wrinkled  ; 
on  the  neck  and  trunk,  where  the  exfoliation  is 
pulverulent ; and  upon  the  face,  where  the  cuticle 
is  shining,  roughened  by  the  edges  of  exfoliating 
lamime,  and  seemingly  distended,  altering  the 
complexion  to  a brick  or  apple-red.  Another 
modification  results  from  the  presence  of  an  ex- 
cess of  sebaceous  substance,  which,  by  its  adhe- 
sion to  the  skin,  produces  prominent  scales — Ich- 
thyosis sebacca — varying  in  thickness  in  different 
parts  of  the  body,  and  sometimes  giving  rise  to 
spines  of  considerable  length  and  thickness — 
Ichthyosis  spinosa. 

These  modifications  occasion  a certain  diver- 
sity of  appearance  in  the  affection,  which  has 
suggested  a variety  of  synonyms.  Thus,  when 
its  conspicuous  symptom  is  dryness  of  the  skin, 
we  have  termed  it  Xeroderma.  When  the  net- 
work of  lines  which  bounds  its  scales  has  at- 
tracted especial  attention  it  has  been  named 
Ichthyosis  reticulata.  When  the  mother-of-pearl- 
like  polish  of  the  smooth  area  within  the  meshes 
of  the  lines  of  motion  has  been  conspicuous  it  has 
been  called  Ichthyosis  nitida  and  Ichthyose  nacree. 
When  the  concretion  of  the  epidermic  and  seba- 
ceous substance  assumes  the  figure  of  the  scales 
of  reptiles,  the  term  sauriasis  is  applicable,  and 
Ichthyosis  serpentina ; whilst  the  elongated  form 
of  crust  has  given  origin  to  the  term  Ichthyosis 
hystrix,  the  ‘ porcupine  disease.’ 

Treatment. — These  considerations  lead  us  to 
the  principles  of  treatment  of  ichthyosis,  and 
suggest  as  primary  indications : — first,  to  pro- 
mote an  improved  nutrition  of  the  body ; secondly, 
to  effect  the  removal  of  the  excess  of  epidermic 
matter  and  sordes  ; and,  thirdly,  to  stimulate  the 
innervation  and  circulation  of  the  skin  by  in- 
unction and  friction.  The  first  of  these  indica- 
tions is  to  be  achieved  by  the  use  of  nutritious 
food,  cod-liver  oil,  arsenic,  iron,  and  tonics  in 
general ; the  second,  by  saponaceous  ablutions 
and  frictions,  and  especially  by  the  Turkish  bath 
and  shampooing;  and  the  third,  by  frictions  of 
oily  and  gently  stimulating  liniments  into  the 
skin  ; one  of  the  most  suitable  of  these  remedies 
for  the  purpose  being  the  oleum  theobromae,  or 
cocoa  butter.  Erasmus  Wilson. 

IOTERTJS  (ifcrls,  a weasel ; with  yellow  eyes). 
A synonym  for  jaundice.  See  Jaundice. 

ICTUS  SOLIS  {ictus,  a stroke  ; sol,  the  sun). 
A synonym  for  sunstroke.  See  Sunstboke. 

IDIOCY  {ISiuTtjs,  a person  private  or  apart). 
Stnon.  : Feeble-mindedness;  Fr.  Demence  innee; 
Idiotisme ; Ger.  Die  Spracheigenheit ; Blbdsinn. 

Definition. — Mental  deficiency  occurring  dur- 
ing infancy  or  the  early  periods  of  life. 

I _ The  term  idiocy  is  not  a scientific  one,  but  it 
is  convenient  to  employ  it  here  to  include  a class 
nf  maladies  which  differ  essentially  from  insanity 


IDIOCY.  685 

both  as  to  their  nature  and  treatment.  Tho 
strict  meaning  of  an  idiot  is,  ‘ a solitary  one.’ 
but  it  has  become  so  much  used  as  a term  of 
opprobrium  that  it  were  well  if  tho  phrase, 

1 feeble-minded,’  could  take  its  place. 

Description. — The  term  idiocy  covers  such  a 
large  area,  and  includes  such  a great  variety  of 
cases,  that  there  is  endless  gradation  in  its  mani- 
festations, from  slight  departure  from  a normal 
condition,  to  that  state  of  profound  idiocy  in 
which  the  unfortunate  subject  thereof  sees  no- 
thing, feels  nothing,  does  nothing,  and  knows 
nothing.  The  typical  illustration,  however,  is 
best  conveyed  by  reference  to  an  average  condi- 
tion. For  the  most  part,  the  lesion  is  not  only  a 
psychical  one,  but  profoundly  affects  the  physical , 
and  frequently  the  moral  life.  The  stature  is 
less  than  normal,  with  great  tendency  to  assume 
a stoopiDg  posture.  The  skin  is  often  coarse, 
deficient  in  elasticity,  and  lax,  with  increased 
development  of  areolar  tissue.  The  muscles  are 
weak  and  flabby,  and  respond  feebly  and  irre- 
gularly to  the  action  of  the  will.  The  bones  are 
often  yielding  and  deformed.  The  circulatory 
system  is  usually  weak,  rendering  the  patient 
liable  to  destructive  chilblains  and  frostbite, 
inducing  perilous  effects  from  exposure  to  a low 
temperature,  and  rendering  slow  any  reparative 
process.  The  lungs  are  extremely  liable  to  in- 
flammatory attacks,  both  in  their  bronchial  tubes 
and  parenchyma,  and  prone  to  tubercular  disease 
if  the  subject  be  resident  on  a clay  soil.  The 
digestive  system  is  liable  to  be  deranged  by  de- 
fective mastication  of  food,  and  alternately  sub- 
ject on  theonehand  to  constipation  from  defective 
innervation,  and  on  the  other  hand  to  diarrhoea 
from  catarrh,  resulting  from  rapid  alternations  ot 
temperature.  The  sexual  functions  are  often  ab- 
normal ; there  is  a tendency  to  masturbation  very 
early  in  life,  while  puberty  itself  is  generally  de- 
layed, and  often  sterility  exists.  There  is  not 
unfrequently  phimosis  and  undescended  testis  in 
the  male,  and  non-development  of  the  ovary  in  the 
female.  The  motor  functions  are  abnormal;  there 
is  usually  defective  co-ordination,  resulting  in  a 
deficiency  in  purposive  acts,  while  there  is  a ten- 
dency to  the  production  of  purely  rhythmical  and 
automatic  movements.  There  is  diminished  sen- 
sibility, so  that  what  is  painful  to  others  is  borne 
with  complacency.  Speech  is  defective,  partly 
from  want  of  co-ordination  of  the  muscles  of  the 
tongue,  partly  owing  to  deformations  of  the  mouth 
and  palate,  and  partlyto  inability  to  convertideas 
into  words.  The  sight  is  often  defective,  due  to 
hypermetropia,  to  imperfect  retinal  sensibility,  to 
congenital  cataract,  or  to  diminishedaccommoda- 
tion.  These  conditions  are  frequently  associated 
with  strabismus  or  nystagmus.  The  sense  of 
smell  islessened,  and  the  discrimination  of  odours 
almost  nil.  The  sense  of  taste  is  defective,  lead- 
ing to  the  eating  of  things  of  an  unpalatable,  and 
even  repugnant  nature.  The  faculty  of  hearing 
is  not  much  interfered  with,  except  in  cases  where 
there  has  been  destructive  disease  of  the  ear. 
The  faculties  of  observation  and  attention  are 
limited.  There  is  generally  great  fondness  for 
music,  and  simple  airs  are  often  readily  learned. 
The  memory  is  not  usually  very  defective,  and 
there  are  often  instances  of  remarkable  power  in 
this  respect.  There  is  very  little  imagination  oi 


IDIOCY. 


586 

power  of  abstract  thought,  while  judgment  and 
reasoning  power  are  almost  entirely  absent. 

Classification. — The  best  classification  of 
idiocy,  the  one  which  most  assists  in  the  progno- 
sis and  treatment,  is  that  which  is  based  on  its 
aetiology.  The  whole  of  the  eases  may  be  di- 
vided into  three  important  groups,  which  groups 
afterwards  admit  of  subdivision.  The  primary 
groups  are:— 1.  Congenital ; 2.  Developmental-, 
and,  3.  Accidental. 

1.  Congenital  idiocy. — The  congenital  group 
includes  all  those  cases  which  at  the  period  of 
birth  manifest  signs  of  defective  mental  power, 
associated  usually  with  conditions  of  the  head, 
skin,  and  other  organs,  which  are  indicative  of 
a congenital  origin.  They  are  cases  which  have 
never  possessed  ordinary  mental  power.  The 
congenital  group  contains  the  following  subdivi- 
sions:—a.  Strumous;  b.  Microcephaiic ; c.  Macro- 
cephalic  ; d.  Hydrocephalic ; e.  Eclampsic  ; ,/’. 
Epileptic  ; g.  Paralytic ; and  h.  Choreic. 

2.  Developmental  idiocy. — The  developmental 
group  includes  a smaller  number  of  cases,  where 
the,  child  is  born  manifesting  an  average  intelli- 
gence through  infancy,  or  even  up  to  the  com- 
mencement of  puberty,  but  from  causes  which 
have  influenced  the  nutrition  of  the  embryo 
during  its  intra-uterine  life,  is  born  with  a pro- 
clivity to  mental  break-down  during  one  of  the 
developmental  crises ; the  crises  being  the  periods 
of  the  first  dentition,  of  the  second  dentition,  and 
of  puberty.  The  group  includes  those  cases  in 
which  speech  and  mental  faculties  are  lost  in 
children  in  whom  previously  the  intelligence  was 
good — cases  where  the  brain  and  nervous  power 
was  sufficient  tor  its  early  years,  but  insufficient 
to  carry  it  through  evolutional  stages.  They 
usually  present  outward  signs  in  their  cranium 
or  else  where  that  the  tendency'  to  catastrophe  was 
born  with  them.  The  developmental  group  em- 
braces the  foliowingsubdivisions  : — a.  Eclampsic; 
b.  Epileptic;  and  c.  Choreic. 

3.  Accidental  idiocy. — The  accidental  group 
includes  all  those  cases  of  idiocy  where  the 
child  has  been  born  with  a normal  nervous 
system,  free  from  any  present  or  potential  defect, 
when  unfortunately  a fall,  a fright,  epilepsy,  the 
result  of  some  peripheral  irritation,  disease  of 
the  bones  of  the  ear  sequential  to  measles  or 
scarlet  fever,  meningitis,  or  other  cause,  may  lead 
before  puberty  to  mental  break-down — a break- 
down not  of  a genetic,  but  of  a purely  accidental 
origin.  (For  the  group  of  idiots  produced  by 
endemic  influence  see  Cretinism.)  The  accidental 
group  includes: — a.  Traumatic;  b.  Inflamma- 
tory , and  c.  Epileptic  idiocy. 

TEtiology.  - The  production  of  idiocy'  is  mul- 
tiform in  its  causation ; often  more  than  one 
factor  has  been  at  work.  The  congenital  kinds 
are  produced  by  neuroses,  struma,  tuberculosis, 
alcoholism,  over-intellectual  work,  over-sexual 
indulgence,  and  constitutional  debility'  of  the 
progenitors.  Syphilis  holds  but  a very  unim- 
portant place.  Intermarriage  of  relations,  where 
there  is  a constitutional  taint,  in  consequence  of 
its  insuring  the  existence  of  two  potent  factors; 
fright  and  emotional  disturbance,  or  anxiety  of 
any  kind  on  the  part  of  the  mother  during  her 
pregnancy;  and  prolonged  parturition  and  sus- 
pended animat  ion  at  birth,  are  also  to  be  reckoned 


as  causes  of  congenital  idiocy.  The  developmental 
kinds  have  their  proclivity  given  to  them  by 
causes  affecting  their  nutritive  life  in  utero\ 
notably  emotional  disturbances,  and  sickness 
produced  by  the  pregnancy  or  a prolonged  sea- 
voyage.  The  exciting  cause  is  a developmental 
crisis,  such  as  occurs  at  the  periods  of  dentition, 
and  the  evolution  of  puberty.  Masturbation  is 
a most  important  factor  in  determining  this  kind 
of  idiocy.  The  accidental  kinds  are  produced  by 
injuries  to  the  cranium  of  any  kind,  sunstroke, 
exanthematous  disease,  tubercular  or  other  forms 
of  meningitis,  inanition,  epilepsy  referable  to 
worms,  masturbation,  or  other  sources  of  peri- 
pheral irritation. 

Prognosis. — In  idiocy  the  future  of  the  patient 
will  he  forecast  by  reference  to  the  nature  of  the 
case.  Other  things  being  equal,  patients  para- 
lysed or  epileptic  are  less  amenable  to  treatment 
than  others,  but  the  worst  results  are  obtained 
among  cases  of  accidental  origin.  It  is  impor- 
tant to  recognise  the  fact  that  congenital  cases, 
with  marked  traces  of  their  infirmity  in  their 
faces  and  bodies,  are,  for  the  most  part,  more 
susceptible  of  improvement  than  the  develop- 
mental, and  these  again  than  the  accidental,  who 
may  have  no  appearance  of  idiocy  in  their  faces 
or  bodies ; that,  in  fact,  the  prognosis  is  often 
inversely  as  the  patient  is  winsome,  fair  to  look 
upon,  and  comely. 

Treatment. — The  treatment  of  idiocy  consists 
of  a judicious  combination  of  medical,  physical, 
moral,  and  intellectual  agencies.  The  patient 
should  he  rescued  from  his  solitary  life,  and  have 
the  companionship  of  his  peers.  He  should  he 
surrounded  by  influences,  both  of  Artand  Nature, 
calculated  to  make  his  life  joyous,  to  arouse  his 
observation,  andtc  quicken  his  power  of  thought. 
The  basis  of  all  treatment  should  be  medical  in 
an  enlarged  sense.  Success  can  only  be  obtained 
by  keeping  the  patient  in  the  highest  possible 
health.  The  dietary  should  be  liberal,  contain- 
ing a fair  proportion  of  nitrogenous  elements, 
while  rich  also  in  phosphatic  and  oleaginous  con- 
stituents. The  food  should  be  presented,  too.  iD 
a form  suited  to  the  masticatory  power  of  the 
patient.  It  is  of  importance  that  the  rooms 
should  be  well-ventilated,  whilst  kept  warm; 
and  daily  baths  with  shampooing  should  he 
employed.  Of  first  importance,  is  the  soil : a 
clay  soil  is  fatal  to  all  proper  progress,  inducing 
tuberculosis,  and  lowering  the  vital  power. 
Physical  training  forms  an  important  part  of 
treatment.  The  attenuated  muscles  have  to  be 
nourished  by  calling  into  exercise  their  functions, 
and  the  automatic  and  rhythmic  movements  have 
to  be  replaced  by  others  which  are  the  product 
of  the  will.  The  simplest  movements  should  be 
first  taught,  then  the  more  complex,  thus  causing 
to  grow  up  together  the  mandate  and  the  result. 
From  purposeless  acts  the  idiot  thus  builds  up  a 
series  of  co-ordinated  and  voluntary  movements 
which  are  applicable  to  the  wants  of  da  ly  life. 
The  training  has  to  be  carried  out  in  minute 
detail,  so  that  every  voluntary  muscle  and  every 
congeries  of  muscles  may  be  called  into  action, 
and  trained  to  fulfil  with  rapidity  the  end  for 
which  they  are  designed.  The  moral  education 
is  of  paramount  importance.  The  pupil  has  to 
be  taught  to  subordinate  bus  will  to  that  of  an- 


IDIOCY. 

other.  He  has  to  learn  obedience,  that  right 
doing  is  productive  of  pleasure,  and  that  wrong- 
doing is  followed  by  deprivation  thereof.  Cor- 
poral punishment  should  be  forbidden ; the 
affective  faculties  of  the  patient  should  be  culti- 
vated, that  the  deprival  of  the  love  of  his  teacher 
should  be  felt  as  the  greatest  punishment,  and 
the  manifestation  of  it  his  highest  reward.  In 
no  case  should  the  punishment  interfere  with 
hygienic  treatment.  The  intellectual  training 
must  be  based  on  a cultivation  of  the  senses. 
The  patient  should  be  taught  the  qualities,  form, 
and  relation  of  objects  by  their  sense  of  touch; 
to  apprehend  colour,  size,  number,  shape,  and 
relation  by  sight;  to  understand  the  varieties  of 
sound  when  addressed  to  the  ear ; the  qualities 
of  objects  by  the  taste  and  smell.  These  lessons 
should  be  of  the  simplest  at.  first,  and  gradually 
cumulative.  Nothing  should  be  left  to  the  ima- 
gination. The  idiot  must  be  taught  the  concrete, 
not  the  abstract.  It  is  in  this  way  we  should  give 
him  the  basis  from  which  the  reasoning  and  re- 
flective faculties  can  be  built  up.  Synchronously 
with  this,  use  should  be  made  of  the  physical 
powers  'which  have  been  cultivated.  He  should 
bo  taught  to  dress  and  undress  himself,  to  acquire 
habits  of  order  and  neatness,  to  use  the  spoon  or 
knife  and  fork,  to  walk  with  precision,  to  handle 
with  tact.  The  defective  speech  is  best  over- 
come by  a well-arranged  plan  of  tongue-gym- 
nastics, followed  by  a cultivation  of  the  purely 
imitative  powers.  J.  Langdon  Down. 

IDIOPATHIC  (fSios,  peculiar,  and  irdflos,  a 
disease). — A term  applied  to  a morbid  condition 
when  it  arises  primarily,  and  not  in  consequence 
of  some  other  disease  or  injury.  It  is  used  in 
contradistinction  to  symptomatic  and  traumatic. 

IDIOSYNCRASY  (15ios,  peculiar;  <rvv, 
with ; and  Kpaa is,  constitution  or  temperament). 

Definition. — This  term,  like  many  others 
used  in  science,  has  a more  restricted  application 
than  its  etymology  would  indicate.  From  mean- 
ing the  personal  constitution  of  an  individual,  it 
has  come  to  mean  any  peculiar  and  not  obviously 
correlated  reactions  against  external  influences 
exhibited  by  any  individual.  It  is  not  to  be 
confounded  with  ‘constitution,’  which  is  the 
foundation  of  the  individual,  his  powers,  capaci- 
ties, and  organisation  ; nor  with  ‘ temperament,’ 
which  denotes  the  correlation  of  powers  and 
tendencies  with  the  physical  conformation  of  the 
individual,  which  has  therefore  a generic  or  race 
application,  and  which  is  defined  by  some  writers 
as  the  ‘general  form’  of  the  man.  Commonly, 
any  single  peculiarity  of  a person  is  spoken  of  as 
‘an  idiosyncrasy,’  so  that  one  individual  may, 
in  this  sense  of  the  word,  manifest  several  idio- 
syncrasies or  personal  attributes. 

Description. — Idiosyncrasies,  so  defined,  may 
be  mental  or  physical ; may  be  innate  or  ac- 
quired ; may  be  permanent  or  temporary. 

The  existence  of  idiosyncrasies  being  declared 
chiefly  through  the  agency  of  nerves,  and  their 
operations  being  mostly  capable  of  being  brought 
under  laws  of  innervation,  Prochaska,  Claude 
Bernard,  and  other  authorities  have  regarded 
them  as  ‘a  peculiar  affection  of  the  nervous 
system.’  But  a review  of  the  phenomena  ad- 
mitted to  belong  to  the  class  will  be  found  to 


IDIOSYNCRASY.  687 

compel  us  to  recognise  in  many  cases  a more 
comprehensive  relation,  involving  the  whole  or- 
ganism, or  parts  of  it  other  than  the  nervous 
system. 

In  the  enumeration  of  the  principal  kinds  of 
idiosyncrasies,  to  purely  mental  manifestations 
of  likes  and  dislikes  toward  persons,  things,  and 
pursuits, — affections  covered  by  such  terms  as 
‘ sympathy,’  ‘ antipathy,’  ‘ predilection,’  etc.. — 
must  be  added  reactions  in  which  the  mind,  the 
emotions,  and  the  organic  nervous  system  are 
affected  simultaneously,  but  in  varying  propor- 
tions, by  impressions  received  through  organs  of 
sense. 

For  example,  vision  may  be  the  channel  of 
affection.  Syncope  is  produced  in  some  persons 
by  the  sight  of  blood;  or,  as  is  related  by 
Prochaska,  swooning  may  invariably  occur  on 
the  sight  of  beetroot.  As  regards  olfaction,  some 
people  are  distressfully  affected,  in  both  bodily 
and  mental  ways,  by  the  exhalations  from  certain 
animals,  the  cat  in  particular ; in  others,  horror 
and  fainting  are  induced  by  the  odour  of  roses  or 
of  apples.  And  so  on  through  the  rest  of  the  senses. 

In  another  group  of  idiosyncrasies  the  higher 
nervous  centres  play  no  part,  the  phenomena 
being  of  reflex  production  through  the  spinal 
centres,  or  being  due  to  direct  poisoning  of  the 
system  or  of  organs.  Among  foods  or  drugs 
swallowed,  among  gases  or  dusts  inhaled,  among 
substances  brought  into  contact  with  the  skin, 
many,  harmless  to  the  majority  of  men,  are  for 
this  or  that  individual  irritants  or  poisons.  For 
instance,  eggs,  honey,  sugar,  or  fish  may*  produce 
gastric  pain,  nausea,  or  vomiting;  strawberries 
are  to  a few  persons  a most  deadly  poison,  pro- 
ducing symptoms  of  intense  nervous  shock ; con- 
vulsive spasms  may  be  excited  by  the  smell  ol 
musk  or  civet ; asthma  by  the  inhalation  of  the 
powder  of  ipecacuanha;  urticaria  by  the  eating 
of  shell-fish,  or  even  by  the  application  of  the 
yolk  of  egg  to  the  skin. 

Some  men  there  are  love  not  a gaping  pig  ; 

Some  that  are  mad  if  they  behold  a cat ; 

And  others,  when  the  bag-pipe  sings  i’  th*  nose. 

Cannot  contain  their  urine. 

Merchant  of  Venice. 

Idiosyncrasies  confronting  the  use  of  drugs 
have  a special  interest  for  the  medical  man. 
They  may  be  of  a qualitative  nature,  as  in  the 
production  of  unusual  symptoms  with  dangerous 
or  fatal  results  by  anaesthetics,  or  in  iodism  ; or 
of  a quantitative  nature,  as  in  the  case  of  opium 
and  belladonna,  minute  doses  of  which  will  poi 
sen  some  persons,  while  doses  of  them,  large 
enough  to  destroy  a dozen  average  individuals, 
may  be  taken  by  one  here  and  there  with  im- 
punity. 

The  consideration  of  this  part  of  our  subject 
introduces  the  question  of  the  variations  of 
idiosyncrasies.  The  transient  oddities  of  sus 
ceptibility  arising  in  pregnancy,  hysteria,  and 
madness,  are  excluded  by  some  authors  from  the 
category,  but  as  they  only  differ  in  their  tran- 
sitory character  from  other  idiosyncrasies,  we 
shall  here  associate  them  with  those  modifications 
of  reactive  sensibility  to  which  the  term  is  com- 
monly extended.  Seeing  that  the  causes  of  innate 
idiosyncrasies  are  for  the  most  part  unexplained, 
we  may’  search  out  in  varying  or  acquired  idio- 


6S8  IDIOSYNCRASY, 

syncrasies  varying  correlations  which  may  help 
us  to  the  ultimate  better  understanding  of  the 
former  group.  Thus  we  know  that  intolerance 
cf  opium  may  arise  in  some  morbid  states  the 
nature  of  which  is  fairly  known  ; that  tolerance 
of,  or  comparative  indifference  to,  the  same  drug 
may  be  attained  by  its  constant  use.  As  in 
pregnancy  now  idiosyncrasies  appear,  so  age, 
habits,  and  state  of  body  may  each  and  all 
modify  the  reaction  of  any  individual  towards  his 
surroundings;  may  change  his  behaviour  under 
the  influence  of  drugs ; may  at  one  time  charm 
him  against  morbid  poisons,  at  another  time  leave 
him  their  easy  victim;  may  make  him  inflame 
sometimes  in  a suppurative,  sometimes  in  a 
plastic  way.  From  this  point  of  view,  we  may 
with  Claude  Bernard  summarise  idiosyncrasies 
as  being  ‘mere  manifestations  of  the  ordinary 
laws  of  physiology.’ 

Imaginary  idiosyncrasies. — Persons  are  not 
unfrequently  met  with  who,  held  by  prejudice, 
or  misled  by  fancies  or  unsound  judgments, 
declare  that  particular  foods  and  medicines  dis- 
agree with  them.  It  may  often  be  found,  on 
investigation,  that  the  assertion  is  incorrect. 
The  obstacles  offered  to  effective  treatment  by 
such  fancies  are  sometimes  of  grave  importance, 
tasking  severely  the  sagacity  of  the  medical  man 
in  the  way  of 'analysis,  and  his  skill  in  the  way 
of  counteraction.  But  when  the  idea  of  their 
existence  shall  have  been  proved  in  any  case  to 
be  unfounded,  it  is  generally  possible  to  evade 
such  obstacles  by  tact,  or  to  undermine  them  by 
argument,  and,  most  of  all,  to  dissipate  them  by 
firmness.  William  M.  Obd. 

IDROSIS  (ISpas,  sweat).  A synonym  for 
hyperidrosis.  See  Peeseidation,  Disorders  of. 

IDE O -TYPHUS. — A synonym  for  typhoid 
fever.  See  Typhoid  Fevee. 

ILEUM,  Diseases  of.  See  Intestines, 
Diseases  of. 

ILEUS  I twist). — A synonym  for  an 

intestinal  obstruction.  See  Intestinal  Obstbuc- 
tion. 

ILIAC  REGION.— Tho  iliac  region,  or 
region  of  the  iliac  fossa,  is  limited  laterally  and 
superiorly  by  the  crest  of  the  ilium,  anteriorly 
by  Poupart's  ligament,  and  internally  and  below 
by  the  brim  of  the  true  pelvis  or  inner  edge  of 
the  psoas  magnus  muscle. 

Anatomical  Relations. — That  portion  of  the 
abdominal  cavity  which  corresponds  to  these 
boundaries,  contains  the  following  viscera  on 
the  right  side  : — the  eteeum,  the  vermiform  ap- 
pendix, some  coils  of  the  small  intestines,  and 
the  ureter;  and  on  the  left  side: — the  sigmoid 
flexure  of  the  colon  and  small  intestines,  and  the 
ureter. 

In  front  of  the  cavity  is  the  ilio-inguinal  re- 
gion. which  forms  its  anterior  parietes,  and  from 
which  surface  all  examinations  of  the  region 
are  instituted.  Exploration  is  difficult  in  obese 
persons,  and  to  facilitate  it  we  must  relax  the 
abdominal  parietes  by  flexing  the  thigh,  and  by 
pressing  the  fingers  immediately  above  the  crural 
arch. 


IUAC  REGION. 

The  'peritoneum  is  but  very  slightly  united  to 
the  subjacent  tissues,  and  is  easily  separated  from 
them.  It  completely  covers  in  the  left  iliac  fossa ; 
but  on  the  right  side,  owing  to  the  presence  of 
the  caecum,  this  investment  is  incomplete  (see 
Lumbab  Region). 

The  sub -peritoneal  cellular  tissue  may  be  re- 
garded as  being  composed  of  two  distinct  layers. 
The  first,  immediately  beneath  the  peritoneum, 
is  a continuation  of  the  lax  cellulo-fatty  enve- 
lope of  the  kidney  and  caecum,  passing  with  the 
femoral  vessels  into  the  crural  canal,  and  with 
the  spermatic  cord  into  the  scrotum.  The  deeper 
or  sub-aponeurotic  layer  lies  beneath  the  sheath 
of  the  iliaco-psoas  muscle,  being  continuous  above 
with  the  sub-pleural  cellular  tissue,  and  accom- 
panying this  muscle  downwards  as  far  as  its  in- 
sertion into  the  lesser  trochanter. 

The  arteries  of  this  region  are  the  common 
and  external  iliac,  and  their  branches. 

The  nerves  of  the  iliac  fossa  are  the  lumbar 
plexus  (the  trunks  of  which  lie  in  the  iliaco- 
psoas  muscle)  and  its  branches ; and  the  solar, 
renal,  hypogastric,  and  lumbo-aortic  branches  of 
the  sympathetic. 

The  fascia  iliaca  is  attached  above  to  the  en- 
tire inner  lip  of  the  iliac  crest.  Internally  it  is 
blended  with  the  sheath  of  the  psoas  at  tho  level 
of  the  promontory  of  the  sacrum ; and  below  this 
point  it  becomes  fixed  to  the  brim  of  the  true 
pelvis,  passing  behind  the  vessels  and  giving  off 
a thin  cellular  lamella  in  front  of  them. 

The  shea  th  of  the  psoas  muscle  is  attached  above 
to  the  ligamentum  areuatum  internum;  it  en- 
closes the  psoas  anteriorly  (the  posterior  portion 
of  its  envelope  being  formed  by  the  lumbar  ver- 
tebrae); it  is  blended  externally  with  the  sheath 
of  the  quadrates  lumborum ; whilst  internally 
it  is  attached  to  the  anterior  common  ligament. 
Interiorly  it  is  continuous  with  the  fascia  iliaca. 

The  osseous  layer  corresponds  with  tho  iliac 
bones. 

Pathological  and  Clinical  Relations. — The 
viscera  which  have  been  enumerated  above,  as 
being  contained  in  the  iliac  region  of  the  abdo- 
men, present  various  diseased  conditions,  which 
cannot  be  satisfactorily  diagnosed  without  a prac- 
tical knowledge  of  its  anatomical  relations,  and 
especially  of  the  faseite,  sub-aponeurotic,  and 
aponeurotic  structures  of  the  iliac  region.  Thus 
in  the  right  iliac  region  the  physician  meets  with 
tumours  and  other  diseases  of  the  caecum,  ver- 
miform appendix,  and  lower  part  of  the  ileum, 
including  the  local  lesions  of  typhoid  fever  (see 
Cjeccm,  Diseases  of).  In  the  left  iliac  region, 
the  diseases  of  the  sigmoid  flexure  possess  equally 
important  relations.  The  tumours,  extravasa- 
tions, and  abscesses,  which  may  commence  in  the 
pelvis,  frequently  make  their  way  into  either 
iliac  region ; and  this  is  also  the  seat  of  morbid 
conditions  connected  with  the  ureterin  themiddle 
portion  of  its  course,  as  well  as  partly  of  the  pain 
in  renal  calculus.  In  the  sub-peritoneal  tissue 
we  meet  with  bloody  or  urinary  infiltrations, 
focal  abscesses,  and  perityphlitic  or  idiopathic 
abscesses  independent  of  any  intestinal  lesion. 
Collections  of  pus  beneath  the  fascia  are  generally 
dependent  on  caries  of  the  vertebra,  and  may 
either  he  confined  to  the  iliac  fossa,  or  lie  within 
the  sheath  of  the  psoas  muscle  (psoas  abscess! 


ILIAC  REGION. 

Again,  lumbar  abscesses  may  point  anteriorly, 
and  be  diagnosed  by  palpation  of  the  abdominal 
walls. 

This  region  is  the  seat  of  ligature  of  the  com- 
mon, external,  or  internal  iliac  arteries.  The 
pulsation  of  the  two  former  can  generally  be 
felt ; and  it  must  be  borne  in  mind  that  the 
abdominal  aorta  pulsates  in  the  left  iliac  region. 

Edward  Bellamy. 

ILLUSION. — A false  or  mistaken  percep- 
tion of  ono  of  the  senses,  as  when  a person  sees 
or  hears  something,  and  takes  it  to  be  something 
else.  The  term  has  been  used  as  synonymous 
with  delusion  and  hallucination.  Illusions  may 
occur  in  the  sane  as  well  as  the  insane.  See 
Hallucination. 

IMBECILITY.  Sec  Dementia  ; and  Idiocy. 

IMPETIGIN ODES.  — Impetiginous  : that 
is,  having  the  character  of  impetigo ; hence, 
eczema  impetiginodes.  See  Impetigo. 

IMPETIGO. — Synon.  : Fr.  Impetigo  ; Ger. 
Eiterjlechte. 

Definition.  — A term  used  by  Celsus  and 
Pliny,  apparently  signifying  ah  impetu  agens, 
that  is,  breaking  out  with  violence  or  impetu- 
osity. In  modern  dermatology  the  term  is  re- 
stricted to  an  eruption  of  small  pustular  vesicles, 
accompanied  wi th  but  little  redness  or  inflamma- 
tion, and  that  of  a superficial  character ; hence, 
the  individual  pustules  have  been  termed  psg- 
dracia  or  ‘ cold  pustules,’  in  contradistinction  to 
the  pustules  of  ecthyma,  which  are  termed  pMy- 
caeia,  or  ‘ hot  ’ and  inflammatory  pustules. 

^Etiology. — Impetigo  is  an  outbreak  of  a 
sensitive  and  weakly  skin,  associated  with  nutri- 
tive debility;  and  is  more  common  in  children 
and  women  than  in  men. 

Varieties. — Impetigo  presents  itself  in  three 
forms.  First,  it  occurs  as  an  eruption  of  isolated 
pustules,  distributed  more  or  less  generally, 
when  it  is  called  Impetigo  sparsa.  Secondly,  it 
is  found  as  a congregation  of  pustules  forming 
blotches,  rarely  exceeding  one  or  two  inches  in 
diameter,  constituting  Impetigo  confcrta  and  Im- 
petigo figurata.  And,  thirdly,  it  is  seen  as  a 
complication  of  eczema,  representing  a pj'ogenie 
tendency,  .13  Ee-ema  impetiginodes.  In  children 
it  is  apt  to  occur  on  the  face,  hands,  and  feet, 
and  particularly  in  the  region  of  the  mouth,  nos- 
trils, and  ears  ; and,  from  its  frequent  spreading 
through  a whole  family  or  neighbourhood,  has 
awakened  a suspicion  of  contagion,  and  as  such, 
received  from  tho  late  Dr.  Tilbury  Fox  the  name 
of  impetigo  contagiosa  (see  Impetigo  Contagiosa). 
Dr.  Fox  likewise  detected  epiphytes  in  this  form 
of  eruption.  Nevertheless,  impetigo  will  best  be 
regarded  as  a simple  pyogenic  eczema,  and  not 
ordinarily  contagious. 

Description.— Pathologically,  impetigo  is  a 
vesicle  containing  pus  or  a muco-purulent  fluid, 
rather  than  a true  pustule,  and  varies  in  size 
from  a mere  point,  not  larger  than  a pin’s 
head,  to  a hemisphere  of  a quarter  of  an  inch 
in  diameter.  With  the  smaller  dimension,  it 
iften  occupies  the  aperture  of  a follicle  ; whilst 
vhen  more  extensive,  it  spreads  over  the  sur- 
’ace  occupied  by  several  of  these  apertures.  The 
»lour  of  its  contents  likewise  varies  in  dif- 

44 


IMPETIGO  CONTAGIOSA.  68! 
ferent  specimens,  being  sometimes  brightly  yel 
low,  at  other  times  cream-coloured,  and  in  tin 
‘epidemic’  variety  almost  colourless.  After  a 
few  days  the  secretion  dries  up  into  a crust, 
of  yellowish  or  brownish  colour ; and  the  crust 
varies  in  figure  and  thickness  according  to  the 
activity  of  the  secreting  process,  or  the  un- 
disturbed condition  of  the  pustules.  On  the 
face  of  children  it  will  sometimes  dry  up  inti 
a crust  of  considerable  dimensions;  and  in  this 
state,  when  it  retains  its  yellow  colour,  is  ai 
example  of  what  tho  ancients  denominated  me- 
litagra.  More  frequently,  however,  the  crust 
is  discoloured  and  blackened  by  admixture  with 
blood;  and  when  associated  with  eczema,  is 
capable  of  forming  a mask  over  the  whole  face — 
Impetigo  larvalis — or,  in  the  case  of  infants  at  the 
breast,  an  impetiginous  crusta  lactca. 

Prognosis. — The  prognosis  of  impetigo  turns 
upon  the  fact  that  it  results  from  nutritive  de- 
bility. It  is  perfectly  curable,  is  by  no  means 
grave  in  its  nature,  and  disappears  completely 
when  the  health  and  strength  of  the  patient  are 
restored;  in  ordinary  cases,  in  two  or  three 
weeks. 

Treatment! — If  any  derangement  of  digestion 
and  secretion  be  evident  in  a case  of  impetigo, 
this  should  be  regulated  before  tonics  are  resorted 
to.  The  diet  and  regimen  should  be  nutritive  and 
wholesome ; while  the  tonics  most  suitable  to  such 
cases  are  iron,  quinine,  arsenic,  nitrohydrochlorie 
acid,  and  cod-liver  oil.  Locally,  the  blotches 
should  be  kept  covered  with  the  oxide  of  zinc 
ointment,  or  with  a lotion  of  lime-water  and 
oxide  of  zinc.  Tho  former  of  these  remedies 
preserves  the  softness  and  pliancy  of  the  crusts  ; 
whilst  the  latter  dries  them  up.  Both  pro- 
cesses promote  their  removal ; and  in  the  selec- 
tion of  the  remedy  the  best  guide  will  be  the 
amount  of  discharge,  the  degree  of  irritability  of 
the  skin,  and  especially  the  sensations  of  the 
patient.  Erasmus  Wilson. 

IMPETIGO  CONTAGIOSA  ( impetigo , a 
scabbing  disease  of  the  skin ; contagiosa,  conta- 
gious).— Definition. — A contagious  vesieo-pus- 
tular  disease ; sometimes  epidemic;  attacking 
children  in  the  vast  majority  of  cases;  and  often 
affecting  several  members  of  the  same  family. 

Symptoms. — This  disease,  which  was  first  de- 
scribed by  the  writer,  is  sometimes  attended  at 
tho  outset  with  pyrexial  disturbance.  The  erup- 
tion first  makes  its  appearance  about  the  face, 
and  indeed  is  chiefly  marked  in  this  situation  ; 
but  it  may  appear  on  the  neck,  head,  and  limbs, 
and  more  rarely  on  the  trunk.  The  eruption  is 
composed  of  one  or  more  crops ; and  begins  by 
the  formation  of  vesicles,  which  develop  into 
little  bullse.  The  contents  of  these  become 
milky,  and  then  sero-purulent ; and  speedily  dry 
into  light-yellow  scabs  which  look  as  if  stuck 
on,  unless  the  spots  are  injured  by  scratching. 
Mothers  describe  these  little  vesico-pustules 
in  their  early  stage  as  ‘little  watery  heads’  or 
‘ watery  pocks.’  The  significant  features  of  these 
spots  are  their  separateness;  their  superficiality: 
their  replacement  by  the  flattened  scabs  ; and  the 
contagious  quality  of  the  fluid  contents  of  the 
vesico-pustules.  Very  often  bullse  appear  about 
the  hands  of  the  children  affected. 


590  IMPETIGO  CONTAGIOSA. 

Treatment.  — The  treatment  of  contagious 
impetigo  consists  in  applying  the  unguentum  hy- 
drargyri  ammoniati  in  a diluted  form  to  the  red 
surfaces  beneath  the  scabs,  by  which  the  charac- 
ters of  this  secreting  surface  are  altered,  so  that 
the  disease  is  not  spread  by  auto-inoculation.  As 
each  spot  tends  to  run  a definite  and  short  course, 
the  whole  disease  is  quickly  cured  by  the  preven- 
tion of  its  spread  in  this  manner.  The  general 
health  may  require  attention.  Tilbury  Fox. 

IMPOTEWCT  (in,  not,  and potens,  capable). 
Synon.  : Fr.  Impuissance ; Ger.  Impotent. 

^Etiology  and  Pathology. — Impotency  im- 
plies an  incapacity  for  sexual  intercourse,  and 
it  arises  from  various  causes.  The  testicles 
are  the  organs  which  furnish  spermatozoa,  the 
element  essential  to  impregnation.  Their  func- 
tions may  become  suspended,  or  be  incapable 
of  excitement;  or  they  may  be  exerted  to  ex- 
cess, improperly  excited,  and  so  abused  as  to 
fail  prematurely ; or  these  organs  may  become 
impaired  or  destroyed  by  disease. 

The  impulse  for  commerce  with  the  other  sex 
exists  in  different  degrees  of  force  in  different 
men.  A certain  degree  of  vigour  is  necessary 
to  bear  the  nervous  excitement  attending  it; 
hence  in  advanced  years,  and  in  weak  and  sus- 
ceptible individuals,  the  frame  is  unable  to  sus- 
tain frequent  coition  with  impunity.  Rules  have 
been  given  for  regulating  the  sexual  functions, 
and  restricting  their  exercise  within  due  bounds. 
The}’'  are, however,  of  little  value,  for  the  powers 
vary  greatly  in  different  persons,  and  also  at 
different  periods  of  life,  and  what  is  moderation 
in  one  man,  or  at  one  period  of  life,  is  excess  in 
another  man,  or  at  another  time  of  life.  When- 
ever the  sexual  act  is  followed  by  a prolonged 
sense  of  debility  and  lassitude,  an  uncomfortable 
feeling  in  the  head,  and  disinclination  for  either 
physical  or  mental  exertion,  the  limits  consistent 
with  health  have  been  exceeded. 

In  adult  persons  of  recluse  and  studious  habits 
the  testicles  often  continue  dormant  for  years. 
Like  the  mammae  in  the  unmarried  female,  though 
inactive,  they  remain  sound  and  competent  for 
secretion  when  duly  excited  and  called  upon  to 
exercise  their  functions.  The  case  is  different 
later  in  life.  Thus  widowers,  after  remaining 
chaste  for  some  time,  on  marrying  have  been 
doomed  to  disappointment.  Inaction  has  has- 
tened the  natural  decline.  After  middle  age,  as 
life  advances,  the  testicles  diminish  in  size,  and 
become  soft  and  flaccid ; the  secretion  of  semen 
becomes  languid ; and  the  desire  and  power  to 
indulge  in  coition  gradually  subside.  The  period 
of  life  at  which  these  changes  become  marked 
varies  in  different  men,  but  most  persons  are  con- 
scious of  some  decline  in  sexual  vigour  after  the 
age  of  forty.  There  are  some  remarkable  in- 
stances on  record  of  men  who  are  reported  to 
have  been  capable  of  the  reproductive  act  in  very 
advanced  life.  Cato,  the  censor,  is  said  to  have 
had  a son  at  eighty  years  of  age.  Zadislas, 
king  of  Poland,  at  the  age  of  ninety,  married  his 
second  wife,  and  had  two  sons.  The  writer  has 
often  detected  spermatozoa  in  the  fluid  from  the 
testicles  of  very  old  men,  one  a tailor  aged  eighty- 
seven.  Duplay  discovered  them  in  nine  octoge- 
narians. Though  the  scantily  secreted  sperm 


IMPOTENCY. 

may  retain  its  fecundating  properties,  old  meu 
may  still  fail  in  the  other  conditions  essential  to 
the  due  performance  of  the  sexual  functions. 

The  testicles  are  under  the  influence  of  the 
brain,  which  animates  and  controls  the  desire 
for  sexual  intercourse.  An  emotion  of  the  mind, 
as  sudden  disgust  or  anger,  arrests  the  secretion 
of  these  glands  as  quickly  and  as  effectually  as 
a strong  mental  impression  stops  the  secretion 
of  gastric  juice,  and  takes  away  the  appetite  for 
food.  An  attack  of  apoplexy,  or  severe  injury 
to  the  head,  may  extinguish  all  desire  as  well  a? 
capacity  for  coition.  A gentleman,  aged  thirty- 
four,  had  a concussion  of  the  brain  which  ren- 
dered him  insensible  for  twelve  hours.  For  four 
months  afterwards  he  lost  all  sexual  power,  and 
on  its  recovery  it  remained  feeble.  There  are 
several  cases  on  record  in  which  severe  injury  of 
the  head  has  been  followed  by  complete  wasting 
of  the  testicles,  as  well  as  by  permanent  impo- 
tency. Diseases  and  injuries  of  the  spinal  cord, 
producing  paraplegia,  have  no  direct  effect  on  the 
testicles,  but  destroy  the  power  to  copulate. 

Some  men  are  but  little  susceptible  to  the 
influence  of  the  female  sex,  and  though  of 
vigorous  mould,  they  have  not  only  passed  a life 
of  absolute  chastity,  but  have  never  evinced  the 
slightest  disposition  for  sexual  enjoyment.  This 
arises  probably  from  some  cerebral  imperfection. 
Owing  to  the  same  cause,  the  testicles  may  re- 
main undeveloped  in  adult  age,  attended  with  an 
absence  of  sexual  desires.  Cases  of  wasting  of 
the  testicles  after  injuries  of  the  head,  and  the 
non-development  of  these  organs,  with  absence 
of  the  venereal  appetite,  in  certain  cretins  and 
idiots,  tend  to  strengthen  this  view. 

The  most  common  cause  of  impotency  is  want 
of  self-confidence — excessive  apprehension  of  ill- 
ability  to  perform  well  the  duty  of  thesex,  a feeling 
which  is  often  greatly  aggravated  by  the  perusal 
of  the  productions  of  quacks  and  other  impostes 
When  persons  entertain  these  groundless  fears,  it 
may  be  long  before  success  attends  their  efforts, 
every  failure  adding  to  the  evil  by  diminishing 
the  reliance  upon  their  powers.  In  the  case  of 
persons  recently  married,  who  may  be  affected 
with  this  form  of  impotency,  a tonic  may  be  pre- 
scribed. and  the  patient  be  directed  to  abs  ain 
from  all  attempts  at  intercourse  whilst  under 
treatment,  and  we  may  rest  satisfied  that  not 
many  days  will  pass  over  before  nature  asserts 
her  empire.  These  cases  must  not  be  lightly 
treated.  The  patient  is  in  great  distress  of  mind. 
The  true  cause  of  failure  may  be  explained  to  him. 
and  he  may  be  confidently  assured  of  the  ground- 
less character  of  his  fears,  and  of  the  influence  of 
his  doubts  and  apprehensions  in  preventing  him 
from  fulfilling  his  desires.  Encouraging  assur- 
ances will  do  more  in  effecting  a cure  than  stimu- 
lating medicines  or  any  sort  of  medical  treatment 
A single  success  banishes  at  once  all  hts  fears, 
and  gives  security  for  the  future. 

Excessive  exercise  of  the  sexual  functions  is 
a frequent  cause  of  impotency,  and  its  too  early 
indulgence  often  entails  a loss  of  power  in  middle 
age.  This  is  often  the  case  in  the  despotic 
countries  of  the  East.  Another  result  of  in- 
ordinate excitement  of  the  organs  is  frequent 
involuntary  discharges  of  the  spermatic  fluid 
Varicocele  tends  gradually  to  impair  the  nntr- 


IMPOTENCE. 

lion,  rttid  diminish  the  secreting  powers  of  the 
testicles.  When  limited  to  one  side,  as  usual,  a 
varicocele  need  not  disturb  the  mind  of  the  patient. 
Diseases  -which  destroy  the  substance,  or  pro- 
duce wasting  of  the  testicle,  necessarily  prevent 
its  secreting.  The  functions,  however,  of  this 
gland  are  not  very  readily  impaired  by  disease, 
and  so  long  as  a small  part  remains  entire,  the 
organ  may  be  fitted  to  perform  its  office  suffi- 
ciently for  the  end  destined  by  nature.  A person 
who  has  lost  both  testicles  by  operation  after 
arriving  at  puberty,  may  experience  desire,  have 
erections,  accomplish  coitus,  ancl  even  emit 
fluid  for  many  mouths  and  even  years  afterwards, 
but  he  soon  loses  the  capacity  to  impregnate,  and 
all  sexual  power  gradually  subsides. 

Virility  is  more  or  less  affected  by  constitu- 
tional diseases.  Few  complaints  have  greater 
influence  in  impairing  the  generative  functions 
than  those  of  the  kidney.  Diuretics,  as  the 
nitrate  of  potash,  carbonate  of  soda,  &c  , are 
well  known  to  act  as  anaphrodisiacs.  In  irrita- 
tive dyspepsia,  with  deposits  in  the  urine  of 
earthy  phosphates  or  oxalate  of  lime,  there  is 
generally  some  inability.  Impotency  in  these 
cases  is  only  one  of  the  manifestations  of  defec- 
tive assimilation  and  depressed  vital  force.  The 
treatment  of  such  cases  by  mineral  acids  and 
other  remedies  calculated  to  improve  the  general 
health  is  very  successful  in  restoring  sexual 
vigour.  In  diabetes  and  albuminuria  the  repro- 
ductive organs  are  weak  and  often  quite  inactive, 
but  may  regain  tone  as  the  kidneys  are  restored 
to  a healthy  state. 

Impotency  sometimes  occurs  in  middle  life 
without  any  obvious  cause.  In  such  persons  the 
writer  has  noticed  a constitutional  change  similar 
to  that  which  occurs  in  eunuchs,  but  less  marked. 
They  have  been  observed  to  grow  sleek  and  cor- 
pulent, to  have  a scanty  beard,  and  to  be  indis- 
posed to  active  muscular  exertion.  In  general 
they  evince  no  unhappiness  at  their  altered  con- 
dition. In  atonic  impotency,  tho  external  organs 
i afford  indications  of  the  want  of  power.  Not 
only  are  the  testicles  soft  and  flaccid,  from  the 
absence  of  blood  in  the  vessels  and  sperm  in 
the  tubes,  but  the  penis  is  small  and  shrivelled, 

, and  the  glans  relaxed.  The  scrotum  is  also 
i loose.  These  parts  are  pale,  feel  cold,  and  their 
sensibility  to  contact  is  diminished. 

Treatment. — Certain  medicines,  reputed  to 
| possess  the  property  of  stimulating  and  invigor- 
ating the  sexual  organs,  have  been  classed  as 
aphrodisiacs,  and  some  of  them  are  said  to  be  used, 
especially  in  the  East,  by  the  sensualist,  to  excite 
the  organs  when  exhausted  by  satiety  and  excess. 
Several  act  on  and  stimulate  the  urinary  organs, 
and  thereby  give  temporary  power  to  the  func- 
tion of  erection ; but  they  produce  little  or  no 
effect  on  the  special  sexual  organs.  They  deter- 
mine blood  to  the  penis,  and  cause  morbid  erec- 
tions, without  any  voluptuous  sensations  and 
j desires.  Such  appears  to  be  the  character  of 
the  influence  produced  by  cantharides,  the  most 
common  of  this  class  of  medicines,  and  the  chief 
ingredient  of  quack  medicines  for  impotency. 
There  are,  however,  certain  cases  in  which  can- 
tharides is  useful.  In  an  atonic  state  of  the 
[organs, in  which  the  erections  are  feeble,  unstable, 
md  insufficient —ten  to  fifteen  minims  of  the 


IMPULSE.  691 

tincture  may  be  given  every  three  or  four 
hours  for  a short  time  before  the  occasion  arises 
for  tho  exercise  of  the  sexual  functions.  Diluto 
phosphoric  acid,  the  phosphate  of  iron,  the 
liquor  strychnia?,  and  ergot  of  rye  are  remedies 
which  may  be  given  in  impotency.  The  condi- 
tions to  which  those  aphrodisiac  remedies  are 
chiefly  applicable  is  when  the  introinittent  organ 
is  but  feebly  excited,  and  does  not  maintain  the 
physical  state  necessary  for  penetration,  during 
the  period  of  congress.  Such  torpidity  may  exist 
in  persons  in  whom  desires  are  at  times  strongly 
felt,  and  the  functions  of  the  testicles  properly 
performed.  In  these  cases, also  in  timid  persons, 
and  in  others  whose  organs  are  inexcitable  from 
long  disuse,  stimulating  treatment  may  conduce 
to  success,  and  ensure  confidence  for  tho  future. 
But  these  remedies  exert  no  influence  in  a con- 
stitutional apathy  of  the  sexual  functions.  They 
have  rarely,  also,  more  than  a temporary  effect ; 
and  in  persons  advanced  in  life,  when  the  parts, 
having  fulfilled  their  office,  are  experiencing  their 
natural  decline,  they  operate  injuriously,  and 
tend  to  produce  congestion  of  the  prostate  and 
local  disease.  In  those  cases  also  in  which  the 
sexual  organs  are  weakened  or  prematurely  ex- 
hausted by  excess,  they  are  likewise  hurtful,  as 
well  as  fruitless.  After  such  abuses  a period  of 
repose  is  required,  and  by  the  avoidance  of  all 
sources  of  excitement,  and  by  diet  and  remedies 
adapted  to  invigorate  the  body,  such  as  the  pre- 
parations of  steel,  a gradual  restoration  of  the 
procreative  functions  may  be  hoped  for. 

Electro-magnetism  is  a remedy  of  some  efficacy 
in  certain  forms  of  impotency.  Interrupted 
currents  (Earadic)  may  be  passed  in  two  direc- 
tions, from  the  perineum  to  the  glans  penis  in 
cases  of  defective  erectile  power,  and  from  tlm 
groin  along  the  spermatic  cord  to  the  testicles, 
in  cases  where  these  organs  are  soft  and  flaccid 
and  where  secretion  is  languid.  The  results  are 
often  disappointing.  In  cases  in  which  the 
desires  are  strong,  but  the  erections  feeble,  the 
sensibility  of  the  glans  penis  is  so  lowered  that 
the  friction  of  coition  is  incapable  of  maintain- 
ing prolonged  distension  of  the  organ,  and  erec- 
tion subsides  shortly  after  penetration  and  before 
completion  of  the  act.  A few  applications 
the  electric  current,  by  rendering  the  glans  penis 
more  sensitive,  may  cause  a more  persistent  dis- 
tension of  the  organ  under  the  natural  excitement. 
Electro-magnetism  succeeds  more  frequently  in 
impotency  of  this  character  than  where,  in  addi- 
tion to  defective  erection.  tl;e  desires  are  feeble, 
and  the  testicles  soft  and  inelastic  ; and  yet  the 
repetition  of  the  remedy  has  succeeded  in  some 
instances  of  this  less  hopeful  kind  in  rou-ing  a 
dormant  power,  causing  secretion  to  be  resumed 
and  erections  to  return.  The  special  treatment 
required  in  cases  due  to  injury  of  the  central 
nervous  system,  after  recovery  from  head-symp- 
toms, is  the  use  of  electro-magnetism,  applied 
from  the  occiput  along  the  spine. 

T.  B.  Curling. 

IMPULSE  ( impello , I thrust  forwards). — A 
sensation  of  a stroke  communicated  to  the  hand 
for  example,  by  the  action  of  the  heart  or  the 
pulsation  of  an  aneurism ; or  by  the  sudden 
movement  of  a fluid  when  agitated  in  any  waj 


302  IMPULSE 

(see  Physical  Examination).  The  term  is  also 
employed  in  connection  with  a mental  condition 
in  insanity.  See  Insanity,  Varieties  of. 

IMPULSIVE  INSANITY.  See  Insanity, 
Varieties  of. 

INCARCERATION  (in,  in,  and  career,  a 
prison). — A condition  of  hernia  in  which  it  cannot 
be  reduced,  on  account  of  obstruction  at  the  neck 
of  the  sac  or  from  some  other  cause.  See  Hernia. 

INCOHERENCE  (in,  not;  con,  together ; 
and  hoereo,  I stick). — Inconsecutive  or  ‘ wan- 
dering’ thought,  as  expressed  in  speech.  See 
Consciousness,  Disorders  of. 

INCOMPETENCE  (in,  not,  and  competo, 
I meet  accurately). — In  its  general  sense  this 
term  ’ signifies  inability  of  a part  to  perform  its 
functions.  It  is  mainly  applied  to  imperfection 
in  the  closing  apparatus  of  an  orifice,  such  as  the 
valves  of  the  heart  or  the  pylorus.  See  Heart, 
Valves  of,  Diseases  of. 

INCOMPRESSIBLE.  — Incapable  of  per- 
ceptibly yielding  to  pressure.  Usually  applied 
to  the  pulse.  See  Pulse. 

INCONTINENCE  (in,  not,  and  contineo,  I 
hold). — In  medical  language  incontinence  signi- 
fies inability  to  retain  the  urine  or  faeces,  so 
that  they  are  discharged  involuntarily.  See 
Defecation,  Disorders  of ; and  Micturition, 
Disorders  of. 

INCUBATION  (inculo,  I hatch). — Defini- 
tion.— The  development  of  disease  from  infecting 
particles,  and  the  time  occupied  in  the  process. 

Period  of  Incubation. — The  period  of  incu- 
bation is  the  interval  between  exposure  to  infec- 
tion and  the  appearance  of  the  resulting  disease. 
It  is  divided  into  two  stages,  those  of  latency,  and 
of  invasion ; the  one  has  reference  to  supposed 
changes  in  the  infecting  particles,  the  other  to 
noticeable  changes  in  the  health  of  the  person 
infected ; the  first  stage  is  of  variable  duration 
and  without  definite  symptoms,  while  in  the 
second  the  disease  is  progressing  and  the  patient 
is  said  to  be  sickening  for  it,  its  duration  being 
nearly  constant  for  each  special  disease.  The 
division  is  not  well-marked  ; there  are  changes 
in  the  so-called  latent  period  which  do  not 
always  escape  detection,  while  those  of  the 
invasion  have  often  to  be  considered  as  part  of 
the  disease.  Where  the  latent  stage  is  much 
prolonged  a dormant  period  is  inferred,  for  it  is 
possible  that  infection  may  remain  in  the  body 
for  a time  dormant ; this  term  is  only  applicable 
to  certain  conditions  under  which  infection  is 
transmitted,  and  instead  of  speaking  of  the  long 
intervals  of  inactivity  at  which  epidemics  recur 
as  periods  of  latency  or  of  incubation,  it  is  to 
these  periods  of  quiescence  that  the  term  dor- 
mant should  be  restricted. 

The  results  of  septic  infection  are  manifested 
in  the  body  without  any  true  incubation. 

Incubation  properly  refers  only  to  the  latent 
periods  of  infection  in  the  acute  specific  diseases ; 
still  it  is  usual  and  often  convenient  to  reckon 
the  period  of  incubation  as  extending  to  the  full 
development  of  the  more  characteristic  signs  of 
each  of  these  diseases. 

The  duration  of  this  period  differs  for  different 


INCUBATION. 

classes  of  infectious  diseases,  and  in  a less  degree 
for  each  disease  ; it  varies  within  certain  limits 
for  the  same  disease,  but  is  sufficiently  constant 
to  afford  some  distinctive  characters  useful  in 
diagnosis  and  a knowledge  of  which  is  essential 
to  preventive  medicine.  The  germs  of  all  the 
incubative  diseases  are  reproduced  in  the  bodies 
of  the  sick;  to  stop  infection  the  susceptible -who 
have  been  exposed  to  it  should  not  mix  with 
others  till  the  incubation-period  has  passed  with- 
out signs  of  illness.  Hence  it  is  important  to 
ascertain  the  laws  regulating  the  incubation  of 
each  specific  infection,  and  to  define  the  limits 
of  variation.  The  invasion-stage  of  all  these 
diseases  is  already  infectious. 

1.  Variola  and  Vaccinia. — In  small-pox,  after 
infection,  the  eruption  occurs  in  fourteen  days, 
and  marked  illness  begins  two  days  sooner.  This 
is  so  well  established  as  to  afford  a guide  to  the 
source  of  infection,  by  which  it  may  frequently  be 
discovered.  Dr.  Gregory's  experience  only  fur- 
nishes one  case  in  which  the  interval  was  pro- 
longed to  fifteen  days.  As  short  an  interval  as 
twelve  days  may  be  met  with,  though  rarely,  in 
small-pox  modified  by  vaccination  or  by  a pre- 
vious attack.  Small-pox  by  inoculation  is  de- 
veloped in  nine  days ; a local  vesicle  appears  on 
the  fourth  day,  there  is  glandular  sympathy  on 
the  sixth,  and  febrile  disturbance  on  the  seventh 
and  eighth  days.  Exactly  this  course  is  observed 
in  vaccinia  resulting  from  vaccination. 

2.  Varicella. — Chicken-pox  has  an  uncertain 
incubation-period,  varying  from  ten  or  twelve  to 
fifteen  or  even  nineteen  days.  The  eruption 
begins  with  the  first  symptoms  of  illness. 

3.  Morbilli. — Measles  has  twelve  days  of  in- 
cubation, reckoning  to  the  appearance  of  the  rash, 
or  eight  days  from  infection  to  the  sickening ; the 
latent  period  may  be  only  four  or  six  days,  that 
of  invasion  may  extend  to  six  instead  of  four 
days.  The  general  experience  of  schools  and 
hospitals  gives  ten  days  from  rash  to  rash,  which 
is  twelve  days  for  incubation.  Measles  results 
from  inoculation  in  seven  or  eight  days ; the 
shortest  instance  from  infection,  one  of  fifty  cases 
traced  by  the  writer,  was  eight  days,  the  two 
longest,  sixteen  and  eighteen  days  ; but  it  may 
possibly  extend  to  twenty-one  days. 

4.  Bdt/icln. — Botheln  has  an  incubation-period 
of  not  less  than  ten  to  fourteen  days,  frequently 
extending  to  seventeen  or  twenty-one  days.  Very 
little  illness  precedes  the  rash. 

5.  Mumps. — Mumps  usually  takes  from  four- 
teen to  twenty-one  days  for  incubation;  the 
shortest  period  is  ten  days;  the  longest  that  has 
come  under  the  writer's  observation  was  twenty- 
two  days.  Symptoms  referable  to  the  invasion- 
stage  may  be  noticeable  for  a week  before  the 
swelling  of  the  parotids ; the  latent  stage  may 
continue  from  eight  days  to  twenty. 

6.  Pertussis. — This  generally  has  one  week,  or 
even  two,  of  incubation  before  the  first  febrile 
and  catarrhal  symptoms  appear;  there  is  often 
a latent  period  of  only  four  or  five  days,  as  some 
cough  may  precede  the  fever ; the  distinctive 
cough  is  seldom  heard  till  after  the  second  week; 
the  shortest  period  in  which  it  has  been  known 
to  occur  is  eight  days. 

7.  Influenza. — Influenza  has  a very  short  in 
cubation-period,  reckoned  by  hours. 


IN’CUBATION'. 


S.  Scarlet  Fever. — Scarlet  fever  lias  a short 
incubation-period ; from  three  to  fivo  or  six  days 
is  the  time  in  -which  the  disease  is  usually  de- 
c hired ; it  may  appear  in  less  than  two  days  ; the 
longest  interval  is  seven  or  eight  days.  There 
ace  instances  where  exposure  to  this  infection 
has  produced  no  effect  until  after  some  accident 
or  surgical  operation,  the  rash  then  appearing  in 
from  three  to  five  days.  Supposing  infection  to 
have  been  received  a week  previously,  twelve 
days  would  not  be  too  much  to  allow  for  such 
possible  extension  of  the  incubation-period. 
After  removal  from  a source  of  scarlet  fever, 
those  who  have  no  symptoms  of  the  illness  with- 
in one  week  will  generally  escape. 

9.  Diphtheria. — Diphtheria  may  be  developed 
in  three  or  four  days  ; an  interval  of  from  six  to 
sight  days  is  not  unfrequent.  Sometimes  two 
or  three  days’  fever  precedes  the  first  local  signs ; 
or  these  may  appear  at  the  very  commencement, 
and  the  ineubation  be  reduced  to  a single  day. 
On  separating  the  healthy  from  the  sick,  more 
than  a week  must  elapse  before  immunity  can  be 
preheated. 

10.  Typhoid  Fcv  r. — In  enteric  fever,  the  oc- 
currence of  the  first  symptoms  in  a large  number 
of  eases,  traced  by  Buchanan,  was  eleven  days 
after  the  operation  of  the  cause,  many  other  cases 
occurring  two  or  three  days  biter.  Dr.  Hunter  of 
Linlithgow  gives  one  case,  with  a single  definite 
exposure,  where  the  prodromata  occurred  in  the 
early  part  of  the  third  week  with  a rigor  at 
the  end  of  it,  twenty-one  dayselapsingbefore  the 
fever  was  marked  ; certain  interruptions  to  the 
febrile  process  may  still  further  prolong  the 
interval.  An  incubation-period  of  only  five  days 
has  been  noted,  once  from  contaminated  milk, 
and  once  from  infection  ; there  are  instances  of 
an  eight  days’  incubation  when  some  of  the 
poison  has  been  inhaled. 

11.  Typhus. — Typhus  has,  in  the  great  pro- 
portion of  cases,  twelve  days  of  incubation.  The 
late  Dr.  Murchison  gives  three  cases  that  have 
exceeded  this  period  by  two  or  three  days,  and 
one  of  twenty-one  days ; ten  of  his  cases  fell  short 
of  it  by  two,  six,  or  eight  days ; one  of  these  did 
not  exceed  two  days,  and  in  two  of  them  the 
latent  period  must  have  been  a few  hours  only. 
The  distinctive  rash  appears  on  the  fourth  or  fifth 
day  of  illness. 

12.  Relapsing  Fever.  —This  fever  has  five  days 
of  incubation  ; this  exactly  agrees  with  the  life 
history  of  the  spirillum  observed  in  the  blood 
during  the  fever ; the  incubation-period  may, 
however,  be  prolonged  to  seven,  nine,  or  twelve 
days,  or  shortened  to  two  days  ; many  cases  have 
succeeded  almost  immediately  on  exposure  to 
a concentrated  infection. 

13.  Plague. — Plague  is  communicated  in  from 
two  to  five  days ; the  fever  may  commence  on  the 
first  day,  the  glandular  swellings  on  the  third, 
or  sometimes  glandular  tenderness  begins  with 
the  fever.  A period  of  four  days  suffices  to  set 
up  the  constitutional  symptoms  when  the  plague 
is  conveyed  by  inoculation. 

If.  Yellow  Fever. — Yellow  fever  has  a short 
incubation  of  from  two  to  six  days,  rarely 
exceeding  eight  days.  Dr.  Cargill  of  Jamaica 
given  a case  fatal  the  day  after  exposure  to  infec- 
tion. 


693 

15.  Dengue. — Dengue  is  quickly  developed, 
usually  in  three  days.  The  febrile  ingress  is 
sudden,  and  precedes  the  rash  only  by  a few 
hours. 

16.  Cholera. — Incubation  in  cholera  lasts  from 
a few  hours  to  four  days.  The  reports  of  numer- 
ous commissions  give  from  one  to  five  days  ; 
within  five  days,  before  the  third,  and  not  later 
than  the  fourth  day.  Individual  cases  often  fall 
on  the  second  or  third  day ; the  premonitory 
diarrhoea  should  be  considered  as  part  of  the 
disease. 

17.  Malaria. — The  infection  of  true  malaria  is 
not  given  off  by  the  bodies  of  the  sick,  but  limited 
to  certain  localities.  This  kind  of  miasm,  to  which 
the  term  infection  is  sometimes  improperly  re- 
stricted, has  a marked  period  of  incubation,  which 
is  often  a lengthened  one.  The  non-contagious 
malarious  fevers  of  the  West  Coast  of  Africa  often 
show  an  incubation-period  of  ten  to  twelve  days. 
In  July,  1810,  our  troops  in  Sicily  fell  ill  with 
remittent  fever  thirteen  or  fourteen  days  after 
exposure  to  malaria.  Men  continued  to  fall  ill 
for  twelve  days  after  their  removal  from  the  in- 
fected site.  Labourers  going  to  our  fen-districts 
for  the  harvest  seldom  had  ague  till  the  end  of 
their  month’s  work,  and  often  not  till  two  or  three 
weeks  after  their  return.  Ague  may  not  appear 
till  months  after  residence  in  a marshy  district. 

IS.  Syphilis. — The  induration  of  a syphilitic 
sore  appears  after  ten  days  ; six  weeks  later  the 
rash  or  sore  throat.  The  localised  changes  of  the 
initiatory  period  may  occupy  from  three  days  to 
three  weeks  or  even  longer  ; in  the  shortest 
instances  with  immediate  adenopathy  the  erup- 
tion follows  in  six  weeks.  John  Hunter  gives 
the  interval  from  the  local  to  general  infection  as 
two  months ; this  may  extend  to  eighty  days. 
Other  constitutional  symptoms  occur  at  much 
longer  intervals.  The  contagion  of  secondary 
syphilis  requires  five  weeks  or  longer  to  become 
manifest. 

19.  Rallies. — Hydrophobia  presents  us  with 
the  longest,  and  also  with  the  most  variable 
period  of  incubation ; this,  however,  has  a limit  of 
great  practical  value  ; the  shortest  interval  known 
is  a fortnight,  so  that  ill  effects  felt  in  a less 
time  than  this,  or  following  rapidly  after  the 
bite,  are  readily  distinguished  from  rabies.  The 
usual  period  of  incubation  is  six  weeks.  Three 
weeks  is  an  exceptionally  short  period,  three 
months  not  exceptionally  long.  Dr.  Mead  gives 
cases  occurring  after  eleven  and  fifteen  months. 
An  interval  of  thirteen  years  has  recently  been 
recorded.  After  the  second  month  has  elapsed 
the  fear  of  any  ulterior  consequences  becomes 
less  and  less.  In  the  dog  the  usual  interval  is 
from  three  to  six  or  eight  weeks  ; it  has  occurred 
after  three  months,  and  in  one  instance  recorded 
by  Youatt  after  seven  months.  The  shortest  in- 
terval given  byEegnault,  from  the  bite  to  signs 
of  rabies  in  the  dog,  is  ten  days  ; of  his  sixty- 
eight  cases  ten  were  from  a fortnight  to  three 
weeks,  and  fifty-seven  at  longer  intervals. 

The  incubation-periods  of  these  widely-differing 
diseases,  while  retaining  distinctive  differences, 
merge  into  each  other.  The  longest  intervals 
observed  for  scarlet  fever  and  diphtheria  corre- 
spond with  the  shortest  observed  in  measles  and 
small-pox,  while  the  longest  in  these  diseases 


394  INCUBATION. 

and  in  mumps  come  near  the  shortest  period  for 
hydrophobia  or  ague.  Many  important  diseases 
are  separated  widely  and  distinctly  by  their 
length  of  incubation,  as  small-pox  from  cholera, 
yellow  fever  and  plague  from  typhus,  and  still 
more  widely  from  the  recurrent  paludal  fevers. 

William  Squibs. 

INDIAN  RINGWORM.  See  Epiphytic 
.Skim-Diseases. 

INDICATION  (indico,  I point  out). — That 
which  suggests  or  clearly  demonstrates  the 
course  to  be  pursued,  and  the  remedies  to  be 
adopted  by  the  practitioner,  either  for  the  pre- 
vention, or  in  the  actual  treatment  of  disease. 

INDIGESTION. — Difficulty  in  digestion. 
See  Digestion,  Disorders  of. 

INDURATED  CHANCRE. — A synonym 
for  hard  chancre.  See  Syphilis. 

INDURATION  ( induro , I harden).  — A 
term  applied  to  the  process  or  condition  of  har- 
dening of  the  tissues  from  any  cause. 

INFANTILE  CONVULSIONS.  — See 

Convulsion's  ; and  Infants,  Diseases  of. 

INFANTILE  PARALYSIS.  — Synon.: 

Fr.  Paralysic  essentielle  de  I'enfancc  (Laborde)  ; 
Paralysie  atrophique  graisseuse  de  F enfance 
(Duchenne) ; Gev.  Kinderlahmung. 

^Etiology. — This  is  a disease  which  affects 
children  at  an  age  varying  from  a few  months 
to  a few  years,  and  commonly  during  the  first 
dentition.  Antecedent  events,  such  as  falls,  in- 
juries, and  dentition,  have  been  assigned,  but  on 
no  sufficient  evidence,  as  causes  of  this  lesion  ; 
and  beyond  the  fact  that  infancy  is  a distinct 
predisposing  cause,  almost  nothing  is  positively 
known  in  regard  to  the  setiology  of  this  affection. 
Its  onset  is  often  quite  sudden,  in  the  midst  of 
what  appears  to  be  perfect  health. 

Anatomical  Chabactees.— Recent  microsco- 
pical investigation  of  the  spinal  cord  and  mus- 
cles has  thrown  much  light  on  tho  morbid 
anatomy  of  infantile  paralysis.  In  most  cases 
the  atrophied  muscles  are  found  to  have  under- 
gone fatty'  degeneration,  with  disappearance,  to 
a greater  or  less  extent,  of  the  transverse  stri®. 
Oil-globules  and  numerous  fat-cells  are  also 
found  between  the  fibres. 

It  has  been  shown  by  the  investigations  of 
Cornil,  Provost  and  Vulpian,  Charcot  and  J offroy, 
and  the  writer,  that  in  fatal  cases  of  infantile  pa- 
ralysis the  spinal  cord  and  its  nerves  are  affected 
by  a variety  of  lesions.  These  morbid  changes 
consist  of  atrophy  of  the  anterior  cornua  and  their 
nerve-cells;  of  granular  disintegration  and  atro- 
phy of  the  anterior  nerve-roots ; and  of  atrophy 
of  the  anterior  columns,  particularly  in  the  cer- 
vical and  lumbar  enlargements,  where  the  nerves 
that  supply  the  atrophied  limbs  are  given  off. 
Corpora  amylacea  have  also  been  found  both  in 
the  white  and  grey  substances. 

Symptoms. — Infantile  paralysis  is  usually  pre- 
ceded by  pyrexia,  and  more  or  less  pain  in  the 
back.  The  attack  is  generally  sudden,  and 
sometimes  is  accompanied  by'  convulsions,  which 
are  at  once  followed  by  paralysis,  but  without 
loss  of  sensibility'.  The  lower  extremities  are  | 


INFANTILE  PARALYSIS, 
generally  the  first  invaded,  and  the  paralysis 
rarely  attacks  the  upper  extremities  alone.  In  the 
begiuning  it  is  more  or  less  generalized,  bnt  after 
a time  it  becomes  limited  to  groups  of  muscles, 
to  particular  muscles,  or  to  one  member.  The 
muscles  most  prone  to  ho  affected  are  those  at 
tile  anterior  part  of  the  Rg — the  extensors  of  the 
toes,  and  the  flexors  of  the  foot;  the  extensors 
and  supinators  of  the  hand ; the  extensors  of  the 
leg ; and  the  muscles  of  the  foot.  In  some  in- 
stances tho  disease  fixes  on  single  muscles,  par- 
ticularly the  extensor  longus  digitorum  pedis, 
the  tibialis  anticus,  the  sterno-mastoid,  or  the 
deltoid.  There  is  a loss  of  five  or  more  degrees 
of  temperature  in  the  parts  affected  ; and  their 
reflex  excitability,  as  well  as  their  electric  con- 
tractility, is  more  or  less  diminished,  and  some- 
times completely  abolished.  After  a period 
varying  from  one  to  two  or  more  months,  the 
paralysed  muscles  begimto  waste.  This  wasting 
is  much  more  rapid  than  in  progressive  muscular 
atrophy,  and  is  in  proportion  to  the  loss  of  elec- 
tro-muscular contractility.  Bones  and  ligaments 
are  also  often  involved  in  the  atrophy. 

After  a period,  varying  from  a few  days  to  a 
few  weeks,  those  muscles  of  which  the  structure 
has  remained  unaltered  may  recover  their  volun- 
tary contractility,  and  then  the  paralysis  disap- 
pears ; but  this  period  is  sometimes  more  pro- 
tracted. In  those  which  regain  their  voluntary 
and  electric  contractility,  nutrition  improves,  and 
their  volume  increases  ; whereas  those  muscles 
which  remain  paralysed  undergo  progressive 
atrophy,  accompanied  by  granular  or  fatty  de- 
generation. The  tonic  force  of  those  muscles, 
therefore,  which  have  preserved  or  have  re- 
covered their  contractile  power,  not  being  op- 
posed by  their  antagonists,  which  have  undergone 
atrophy  and  degeneration,  a variety  of  deformi- 
ties and  unnatural  attitudes  gradually  ensue, 
and  call  for  the  skill  of  the  surgeon.  The  most 
important  of  these  club-foot  deformities  are 
talipes  cquinus,  equino-varus,  cquino-valgus,  cal- 
caneus or  cahanes-valgus,  and  varus. 

Prognosis. — This  will  depend  on  the  nature 
and  extent  of  the  morbid  changes  that  have 
taken  place  in  the  nervous  centres  and  in  the 
muscles.  The  extent  of  these  changes  can  he 
surmised  by  the  electro-muscular  test.  Just  in 
proportion  as  a paralysed  muscle  loses  its  elec- 
tro-muscular contractility  and  sensibility  does  it 
undergo  atrophy,  and  subsequently'  pass  rapidly 
into  a state  of  granular  or  fatty  degeneration. 
If,  therefore,  the  electric  contractility  of  the 
affected  muscles  he  lost  to  the  induced  and  con- 
tinuous current,  the  prognosis  will  be  of  the 
gravest  character. 

Treatment. — In  the  treatment  of  this  disease 
both  general  and  local  means  must  be  adopted. 
In  the  acute  stage,  rest  in  the  recumbent  pos- 
ture is  of  great  importance.  When  the  muscles 
have  become  affected  by'  paralysis  and  atrophy, 
local  as  well  as  general  means  of  treatment 
must  be  employ®!.  Of  the  local  means  elec- 
tricity is  one  of  the  most  important.  If  the  in- 
duced current  should  fail  to  produce  contraction 
of  the  affected  muscles,  the  continuous  current 
should  be  employed.  Shampooing,  friction,  and 
the  application  of  hot  water  to  the  muscles  are 
also  useful.  The  subcutaneous  injection  of  mi- 


1 MEANT I LE  PARA  LYSIS. 

nine  quantities  of  strychnia  the  writer  has  used 
with  great  advantage  in  several  cases.  At  the 
onset  of  the  paralysis  he  decidedly  recommends 
n repetition  of  blisters  to  that  portion  of  the  spine 
from  which  the  nerves  supplying  the  affected 
muscles  proceed. 

In  the"  later  stages  of  the  disease,  when  it  is 
manifested  chiefly  by  paralysis  and  atrophy  of 
muscles,  the  most  approved  general  remedies 
consist  of  strychnine,  cod-liver  oil,  the  prepa- 
rations of  cinchona  and  iron,  arsenic  and  phos- 
phorus, together  with  attention  to  the  secre- 
tions and  excretions,  and  to  ordinary  hygienic 
measures.  J.  Lockhart  Clarke. 

INFANTILE  KEjMITTENT  FEVEB. 

By  some  authorities  a disease  thus  named  has 
been  regarded  as  a special  kind  of  lever  ; but 
the  condition  is  probably  either  typhoid  fever  of 
a mild  type,  or  febrile  disturbance  accompany- 
ing disorders  of  the  alimentary  canal. 

INFANTS,  Diseases  of. — There  are  few 
disorders  which  can  be  said  to  be  peculiar  to  in- 
fancy and  childhood.  The  diseases  to  which 
children  are  liable  are,  as  a rule,  those  which 
attack  older  persons,  and  present  the  same  pa- 
thological characters.  But  disease  as  it  occurs 
in  children  does  yet  require  especial  study,  for 
the  symptoms  by  which  it  is  accompanied  often 
differ  widely  from  those  with  which  ordinary 
hospital  practice  has  rendered  us  familiar.  Chil- 
dren are  not  merely  adults  in  miniature.  They 
have  special  peculiarities  of  constitution,  which 
impress  their  own  stamp  upon  all  acute  diseases, 
and  often  raise  up  a number  of  accessory  pheno- 
mena which  overshadow  the  main  symptoms,  and 
obscure  a case  which  but  for  them  would  be 
simple  and  clear. 

General  Characters. — The  most  striking  pe- 
culiarity of  childhood  is  the  marked  excitability 
of  the  nervous  system ; for  the  promptness  and 
intensity  with  which  the  whole  system  reacts 
against  any  source  of  irritation  is  a cause  of  con- 
tinual embarrassment  to  the  physician.  A frag- 
ment of  indigestible  food,  for  example,  may  pro- 
duce high  fever,  or  alarming  agitation,  and  even 
throwthe  child  into  convulsions  : a slight  irrita- 
tion of  the  larynx  may  produce  severe  spasm, 
and  simulate  for  the  time  all  the  symptoms  of 
true  diphtheritic  croup.  The  beginning  of  acute 
disease  is  almost  invariably  accompanied  by  pro- 
found general  disturbance  ; but  disturbance  as 
profound  may  be  excited  by  the  simplest  func- 
tional disorder,  so  that  the  severity  of  the  symp- 
toms is  no  guide  at  all  to  the  severity  of  the 
lesion  with  which  we  have  to  deal.  In  all  cases, 
therefore,  it  is  of  importance,  if  possible,  to 
pick  out  the  local  symptoms — those,  namely, 
which  point  to  mischief  of  any  special  organ — 
and  separate  them  from  others  which  are  expres- 
sive merely  of  the  general  distress.  Such  local 
symptoms  are  the  cough,  rapid  breathing,  and 
active  nares  which  point  to  acute  lung-disease  ; 
the  squinting  and  immobility  of  pupils  which 
are  so  characteristic  of  cerebral  affections  ; and 
the  peculiar  jerking  movement  of  the  legs  which, 
combined  with  hardness  of  the  abdominal  mus- 
cles, betrays  the  existence  of  colicky  pain.  Such 
local  symptoms  are  not,  however,  always  to 
bo  discovered,  and  even  if  present  may  not  fur- 


INFANTS,  DISEASES  OF.  fiat 
nish  trustworthy  indications ; for  so  great  is  the 
sympathy  in  the  young  child  of  distant  organs 
with  one  another — linked  together  as  they  are 
by  the  impressionable  nervous  system — that  the 
organ  from  which  the  more  definite  symptoms 
appear  to  arise,  may  not  be  the  organ  which  is 
actually  the  seat  of  disease.  The  two  organs 
which  are  most  frequently  found  to  present  these 
deceptive  manifestations  are  the  stomaeh  and 
the  brain.  The  sympathy  of  the  stomach  wit:- 
an  irritable  condition  of  other  parts  of  the  body 
continues  more  or  less  through  life  : the  vomiting 
of  pregnancy  and  of  disordered  uterine  function 
in  the  female,  and  of  cerebral  and  renal  diseases 
in  both  sexes,  being  matter  of  common  observa- 
tion. In  the  child,  however,  this  sympathy  is 
carried  to  its  highest  point.  Vomiting  is  a common 
symptom  at  the  beginning  of  every  acute  disease, 
and  in  many  children  any  casual  disturbance  is 
apt  to  be  attended  by  it.  The  brain,  again,  ex- 
hibits a close  sympathy  with  irritation  of  the 
more  important  organs.  In  some  cases  of  pneu- 
monia, notably  those  where  the  inflammation  is 
seated  at  the  apex  of  the  lung,  headache,  vertigo, 
delirium,  and  stupor  may  be  so  marked  that  the 
ordinary  symptoms  of  the  disease  are  completely 
obscured,  and  the  case  is  mistaken  for  one  of 
meningitis.  Again,  the  violent  nocturnal  de- 
lirium so  often  excited  by  the  irritation  of  worms 
in  the  alimentary  canal,  must  be  within  the  ex- 
perience of  all. 

The  nervous  excitability  of  children,  and  its 
influence  upon  the  system  generally,  is  well  illus- 
trated by  the  high  temperature  noticed  in  many 
children  on  the  first  evening  after  admission  intc 
the  wards  of  a hospital.  The  elevation  varies  in 
degree  in  different  children;  but  if  the  patient 
be  not  a mere  infant,  it  is  usually  over  100°, 
although  the  complaint  be  one  not  ordinarily 
.attended  by  pyrexia. 

Perhaps,  however,  the  most  familiar  instance 
of  the  impressibility  of  the  nervous  system  is 
seen  in  the  case  of  convulsions.  A ‘fit’  in  the 
child  has  a very  different  meaning  to  a similar 
attack  in  tire  adult.  In  the  latter  it  is  usually 
evidence  of  a grave  centric  lesion,  and  its  occur- 
rence occasions  the  greatest  anxiety.  In  the 
child,  on  the  contrary,  it  is  a common  expression 
of  the  perturbation  of  the  nervous  sysrem,  set 
up  in  response  to  some  excentric  irritation,  and 
often,  as  in  the  case  of  theonsetof  acute  disease, 
is  analogous  to  the  rigor  which  ushers  in  an  acute 
attack  in  older  persons.  Sometimes,  it  is  true, 
convulsions  are  produced  in  the  child,  as  in  the 
adult,  by  severe  cerebral  disease  : but  in  such 
cases  the  fits  are  frequently  repeated,  and  are 
succeeded  by  rigidity,  paralysis,  and  other  signs 
of  centric  irritation.  As  a rule,  single  fits,  or 
convulsions  occurring  without  other  signs  of 
nerve-lesion  in  a healthy  child,  are  purely  re- 
flex, and  have  no  gravity  whatever. 

The  impressibility  of  the  nervous  system  is 
increased  by  causes  which  produce  a sudden 
depression  of  strength,  such  as  a bad  attack  of 
diarrhoea,  or  loss  of  blood,  and  in  one  chronic 
disease — rickets — the  nervous  irritability  is  very 
great.  The  effect  of  chronic  wasting  upon  the 
child  is,  however,  usually  to  produce  an  opposite 
result ; and  under  the  long-continued  influence 
of  enfeebling  disease  the  excitability  of  the  r.er> 


i9G  INFANTS.  DISEASES  OF. 


vous  system  becomes  gradually  less  and  less 
manifest,  until  it  finally  disappears  almost  en- 
tirely. It  is  of  importance  to  the  practitioner  to 
bear  this  fact  in  mind,  for  in  a child  much 
reduced  by  chronic  illness,  the  presence  of  an 
intercurrent  acute  complication — such  as  inflam- 
mation of  the  lung — may  be  indicated  by  very 
few  symptoms,  the  system  having  become  almost 
insensible  to  nervous  impressions. 

Another  peculiarity,  which  strikes  the  atten- 
tion of  anyone  accustomed  only  to  disease  as  it 
occurs  in  the  adult,  is  the  vast  preponderance  in 
infantile  disorders  of  mere  disturbance  of  func- 
i ion.  and  the  disastrous  consequences  which  may 
ensue  from  such  derangements.  Infants  rapidly 
part  with  their  heat,  and  are  easily  chilled. 
They  are  therefore  excessively  sensitive  to 
changes  .of  temperature.  A catarrh  is  a common 
ailment  in  the  young  child,  and  is  attended  by 
various  dangers  according  to  the  part  of  the 
mucous  tract  which  is  affected  by  it.  Gastric 
catarrh  with  violent  and  repeated  vomiting,  and 
intestinal  catarrh  with  uncontrollable  diarrhoea, 
are  answerable  for  a large  proportion  of  the 
deaths  amongst  young  children  during  the 
warmer  months.  Even  in  cases  where  the  catarrh 
affecting  the  digestive  organs  is  of  a less  acute 
and  violent  character,  the  issue  is  often  very 
serious.  The  gradual  failure  in  nutrition,  which  is 
the  result  of  such  an  impediment  to  the  digestion 
of  food,  is  a common  cause  of  wasting  in  young 
children  ; and  unless  measures  be  taken  early  to 
restore  the  proper  working  of  the  alimentary 
functions,  the  case  may  end  fatally.  In  tho 
autumn  and  winter  the  bronchial  mucous  mem- 
brane is  more  frequently  attacked.  In  such  cases, 
however  apparently  slight  may  be  the  catarrh,  a 
weakly  infant  is  always  exposed  to  the  danger  of 
pulmonary  collapse;  and  a rapid  interference 
with  the  respiratory  function,  such  as  takes  place 
when  collapse  of  some  extent  of  lung  is  quickly 
brought  about,  is  often  a cause  of  sudden  death. 

It  is  in  consequence  of  this  frequency  of  func- 
tional derangements,  and  their  dangerous  cha- 
racter, that  post-mortem  examinations  in  infants 
are  so  often  unsatisfactory  in  finding  any  appear- 
ances explanatory  of  the  cause  of  death. 

Clixicat,  Exawixatiox. — The  clinical  exami- 
nation of  young  children  requires  tact  and 
patience,  but  unless  the  child  be  very  unruly  it 
is  not  difficult.  The  patient  cannot  himself  de- 
scribe his  symptoms,  but  all  necessary  informa- 
tion can  be  gained  from  the  parents.  Mothers 
are,  as  a rule,  good  observers,  and  allowing  for 
their  natural  anxiety  and  a slight  tendency  to 
exaggeration,  their  statements  can  usually  be 
relied  upon.  We  can  thus  learn  the  previous  state 
of  the  child,  the  exact  date  at  which  his  symp- 
toms began,  and  the  order  in  which  they  ap- 
peared. "infants  should  be  always  stripped  for 
examination,  so  that  the  whole  body  may  be 
exposed  to  view.  Before,  however,  ordering  the 
removal  of  the  clothes,  we  should  be  careful  to 
satisfy  ourselves  upon  certain  points  which  can 
only  be  properly  observed  while  the  child  is  in 
repose.  Thus,  in  order  to  count  the  pulse  and 
respiration,  perfect  quiet  is  ind  spensable,  for  the 
least  movement  quickens  the  heart’s  action,  and 
alters  the  rapidity  of  the  breathing.  At  the 
same  time  the  temperature  can  be  taken  by  the 


thermometer  in  the  rectum.  The  whole  body 
should  then  be  examined  for  spots  or  swell 
ings  ; the  condition  of  the  skin  can  be  noted 
— whether  dry  or  moist;  and  we  can  ascertain 
the  state  of  the  belly,  with  regard  to  hardness 
or  softness  of  the  abdominal  walls,  and  the  size 
of  the  liver  and  spleen.  If  the  child  cry  at  the 
time,  we  mark  the  character  of  the  voice,  for 
hoarseness  is  an  early  sign  of  congenital  syphilis. 

In  the  physical  examination  of  the  chest  in  a 
child,  it  is  important  to  attend  to  tho  following 
points  : — To  employ  percussion  of  the  two  sides 
at  the  same  period  of  the  respiratory  movement, 
that  is,  during  expiration  or  during  inspiration  ; 
to  strike  gently  with  two  fingers,  for  by  this  means 
a larger  volume  of  sound  is  brought  out,  and 
slight  dulness  is  more  easily  detected ; alwave 
to  use  a stethoscope  instead  of  the  unassisted 
ear,  in  order  to  limit  the  area  listened  to ; and  to 
manage  so  that  the  child’s  mouth  be  open  during 
auscultation,  so  as  to  hinder  the  transmission  t* 
sounds  from  the  throat.  In  an  infant  the  back 
is  best  examined  by  placing  the  child  on  the 
nurse's  left  shoulder,  with  his  left  arm  round 
her  neck.  If  the  chin  be  now  depressed  by  the 
nurse’s  hand  on  the  child’s  head,  the  muscles  of 
both  shoulders  are  relaxed.  The  front  and  sides 
of  the  chest  can  be  examined  as  the  infant  lies 
on  his  back.  AVe  must  rememberthat  the  breath- 
sounds,  especially  that  of  inspiration,  are  of  a 
more  blowing  quality  in  the  child  than  they  are 
in  the  adult;  and  that  there  is  naturally  less 
resonanco  at  the  right  base,  on  account  of  the 
proportionately  greater  size  of  the  liver. 

At  the  end  of  the  examination  the  mouth 
should  be  looked  at  for  signs  of  aphthte  or 
thrush  ; and  the  condition  of  the  gums,  as  to  heat 
and  swelling,  should  be  ascertained.  Lastly,  the 
throat  is  to  be  inspected — depressing  the  tongue 
with  the  handle  of  a spoon.  If  there  be  disorder 
of  the  digestive  apparatus,  such  as  sickness, 
constipation,  or  diarrhoea,  it  must  not  be  for- 
gotten to  examine  always  and  carefully  the  dis- 
charges. The  urine  should  not  be  overlooked. 

Diagxosis. — Diagnosis  in  the  young  child  is 
sometimes  very  difficult,  but  it  is  often  easy 
enough.  Being  aware  of  the  nervous  excita- 
bility in  young  subjects,  we  are  prepared  for 
evidences  of  general  disturbance,  and  look  for 
more  special  symptoms — such  as  will  indicate 
local  distress,  and  direct  our  attention  to  a par- 
ticular organ.  AYo  are  also  guided  by  a history 
of  the  attack,  as  gathered  from  the  mother,  and 
can  put  our  suspicions  to  the  test  by  a careful 
exploration  of  the  whole  body.  In  the  investi- 
gation our  general  knowledge  of  the  course  of 
disease  will  be  of  service.  Thus,  many  disorders 
have  known  pathological  consequences,  and  are 
apt  to  be  followed  by  special  sequelae.  Measles 
and  hooping-cough  leave  behind  them  a tendency 
to  catarrhal  pneumonia,  and  a liability  to  tuber- 
culosis. Scarlatina  often  leads  to  acute  desqua 
mative  nephritis  and  dropsy.  Other  diseases 
again  encourage  particular  susceptibilities — as 
rickets,  which  renders  the  body  exceptionably 
sensitive  to  changes  of  temperature,  and  provokes 
catarrhal  derangements.  In  doubtful  cases  wo 
must  not  forget  to  take  prevailing  epidem  es  into 
account,  as  the  beginning  of  zymotic  diseases  in 
often  excessively  puzzling.  In  all  cases,  especially 


INFANTS,  DISEASES  OF. 
if  the  patient  be  an  infant,  it  is  important,  to 
inquire  into  the  hygienic  and  dietetic  arrange- 
ments to  which  the  child  is  subjected.  When 
we  are  still  undecided,  after  having  exhausted  all 
means  of  investigation,  we  must  be  contented 
to  wait  for  further  indications,  and  no  positive 
opinion  should  be  hazarded  while  any  doubt 
remains. 

Treatment. — Children,  as  a rule,  respond 
well  to  treatment.  This  may  be  explained 
partly  by  the  large  proportion  of  mere  functional 
derangements  in  the  illnesses  to  which  they 
are  subject,  and  partly  by  the  state  of  constant 
change  through  which  the  body  is  passing ; 
growth  and  development  are  active  in  organs, 
and  the  tendency  is  to  repair.  The  term  treat- 
ment, however,  includes  far  more  than  the  mere 
giving  of  physic.  A complete  change  in  all  the 
influences  acting  upon  the  patient — a recon- 
struction of  the  dietary',  and  a reformation  in 
the  hygienic  arrangements,  especially'  with  regard 
to  air,  light,  and  clothing — will  often  prove  of 
immense  service,  and  be  of  far  more  value  than 
actual  drug-giving  in  furthering  the  recovery'  of 
the  child. 

In  the  treatment  of  acute  illness  we  must 
remember  that  young  children  cannot  bear 
lowering  measures ; but  we  must  not  therefore 
rush  to  the  opposite  extreme,  for  unless  suffer- 
ing  from  temporary  exhaustion,  they  are  far 
from  being  benefited  by  profuse  stimulation. 
In  the  beginning  of  acute  inflammatory  diseases 
stimulants  are  injurious.  Even  in  chronic  ail- 
ments, such  as  rickets,  where  a certain  amount 
of  alcohol  is  often  of  service,  wine  should 
be  given  with  caution,  and  its  effects  upon 
the  digestion  carefully  watched ; it  can  only 
be  given  with  advantage  so  long  as  it  im- 
proves the  appetite,  and  increases  the  digestive 
power. 

With  regard  to  medicines  little  need  be  said 
in  this  place.  It  may  be  remarked  that,  on 
account  of  the  tendency  to  acid  dyspepsia  in  all 
children,  alkalies  are  of  especial  service ; and 
that  they  should  be  always  combined  with  an 
aromatic,  on  account  of  the  value  of  the  latter 
in  stimulating  the  alimentary  mucous  membrane, 
and  relieving  the  flatulence  and  other  painful 
consequences  of  indigestion.  It  is  important 
also  to  remember  that  children  are  wonder- 
fully tolerant  of  certain  drugs,  while  they  bear 
others  very  badly.  Belladonna  may  be  given  to 
infants  and  children  in  very  large  doses.  They 
are  also  more  tolerant  of  arsenic  than  their 
elders.  To  the  action  of  opium,  however, 
they  are  excessively  susceptible,  and  the  drug 
should  be  given — to  infants  especially' — with 
extreme  caution. 

Eustace  Smith. 

INFARCT  ( infarcio , I cram  in).- — This  term 
was  formerly  applied  to  any  kind  of  infiltration 
of  an  organ ; but  its  use  is  now  almost  confined 
to  the  expression  hemorrhagic  infarct.  A 
haemorrhagic  infarct  is  a firm,  red,  usually 
wedge-shaped  patch,  which  is  found  in  certain 
organs  as  the  effect  of  arterial  embolism,  or, 
nore  immediately',  of  the  congestion  and  ex- 
ravasation  of  blood  to  which  the  embolism  gives 
ise.  See  Embolism. 


INFILTRATION.  697 

INFECTION  j 

INFECTIOUS  l (inficio,  I stain).— There 

INFECTIVE  j 

is  much  ambiguity  and  want  of  precision  in  the 
application  of  these  terms,  and  it  is  only  intended 
here  to  attempt  to  define  them  according  to 
their  several  uses,  the  reader  being  referred  for 
fuller  illustration  to  the  appropriate  articles. 
Usually,  they  are  coupled  with  diseases  which 
are  known  to  be  capable  of  transmission  from  eno 
animal  to  another  of  a different  class,  or  from 
one  individual  to  another  of  the  same  species. 
In  general  language  such  diseases  are  said  to 
be  infectious,  and  to  be  conveyed  by'  infection. 
These  words  are,  however,  often  employed  in  a 
more  definite  and  limited  sense,  as  signifying  the 
transmission  of  affections  of  this  kind  without 
the  necessity  of  any  direct  contact  between  the 
individuals,  or  of  any  obvious  application  of  the 
morbific  agent  to  the  body,  or  its  immediate 
introduction  into  the  system,  this  agent  being 
conveyed  through  the  atmosphere,  and  taken  in 
mainly  by  respiration.  This  limited  meaning  is 
employed  in  contradistinction  to  contagion  and 
contagious,  which  then  imply  direct  contact,  and 
to  inoculation-,  in  this  sense  some  affections  being 
regarded  as  infectious  but  not  contagious,  and 
vice  versa.  The  word  infection  is  sometimes  used 
as  synonymous  with  the  contagium  or  agent  by 
which  a communicable  disease  is  conveyed.  An 
important  application  of  the  term  infective  is  that 
in  relation  to  the  effects  resulting  from  certain 
morbid  products,  which  have  been  made  evident 
during  recent  years,  mainly  by  the  investigations 
carried  on  in  experimental  pathology.  Thus  it 
has  been  found  that  the  introduction  of  tubercle 
subcutaneously  will  lead  to  the  formation  of  a 
similar  product  in  different  organs  of  the  body'; 
and  the  same  result  may  follow  mere  suppuration 
under  certain  conditions,  as  well  as  the  accumu- 
lation in  the  body  of  caseous  material.  The  morbid 
products  are  absorbed,  and  originate  tuberculosis 
by  an  infective  process.  It  is  even  maintained 
that  tuberculosis  may  be  produced  in  this  way 
by  merely  introducing  tuberculous  material  into 
the  stomach,  as  in  the  form  of  diseased  meat. 
Again,  the  inoculation  of  septic  matter  has  been 
proved  to  cause  septicaemia  and  pysemia  by  a 
similar  process.  When  certain  morbid  con- 
ditions have  been  established  within  the  system, 
other  parts,  more  or  less  distant  from  the  pri- 
mary seat  of  mischief,  often  become  involved  by 
infection  within  the  body  itself,  in  consequence 
of  the  products  being  conveyed  by  the  blood- 
vessels or  ly'mphatics  to  these  remote  parts,  and 
there  undergoing  further  multiplication  and 
growth.  Indeed  the  whole  system  may  thus 
become  tainted,  including  the  blood  and  other 
fluids.  Illustrations  of  this  signification  of 
infection  are  afforded  by  cancer,  syphilis,  tuber- 
culosis, and  suppuration,  the  last-mentioned  not 
only  being  liable  to  originate  secondary  collec- 
tions of  pus,  but  also  being  the  usual  cause  of 
pytemia.  See  Contagion-. 

Frederick  T.  Roberts. 

INFILTRATION  [in,  into,  and  filtro,  I 
filter). — This  term  was  formerly  applied  to  the 
effusion  of  a fluid  into  the  interstices  of  a tissue, 
especially  connective  tissue.  Now,  however,  its 


I 


898  INFILTRATION, 

meaning  has  been  extended  to  imply  the  diffu- 
sion of  any  solid  or  fluid  morbid  product  in  the 
midst  of  tissue-elements,  such  as  is  seen  in  cal- 
careous, albuminoid,  fatty,  and  tubercular  infil- 
tration. See  Degeneration. 

INFLAMMATION  (inflammo,  I set  on  fire). 
Syxon.  : Fr.  Inflammation-,  Ger.  Entziindung. 

Definition. — Very  numerous  definitions  have 
been  given  of  inflammation.  The  most  generally 
received  has  been  that  attributed  to  Celsus,  which 
gives  the  four  marks  of  inflammation  as  rubor, 
tumor,  calor,  dolor-,  but  this  appears  to  have 
been  really  due  to  Erasistratus,  who,  according 
to  Galen,  first  gave  precision  to  the  conception 
of  simple  burning,  as  understood  by  the  older 
Greek  physicians,  and  applied  the  name  cpXeyixovri 
^previously  synonymous  with  <p\6yacris)  to  a 
swelling,  which  had  also  the  characters  of  heat, 
pain,  throbbing,  and  resistance.  The  definition 
was  thus  based  upon  the  notion  of  swelling, 
and  would  hardly  have  taken  this  particular 
form  had  it  been  derived  from  superficial  inflam- 
mations. Although  the  four  ‘ cardinal  ’ signs 
may  still  be  recognised  in  what  wo  call  inflam- 
mation, the  definition  is  best  derived  from  a 
cause  known  to  be  capable  of  producing  it,  and 
we  say  that  inflammation  is  a scries  of  changes 
in  a -part  identical  with  those  which  are  produced 
in  the  same  part  by  injury  ; and,  for  the  sake  of 
precision,  injury  by  a chemical  or  physical  irri- 
tant. The  most  evident  result  of  a slight  and 
temporary  irritation  is,  in  vascular  parts,  hyper- 
asmia,  and  inflammation  may  be  regarded  as 
produced  by  a more  intense  action  of  the  same 
cause  as  produces  simple  hypersemia;  but  it  is 
not,  as  formerly  said,  a kind  of,  or  a further  de- 
gree of,  hypersemia.  The  minute  study  of  in- 
flammation is  best  conducted  by  continuous 
observation  on  transparent  parts  of  animals  seen 
under  the  microscope,  especially  the  mesentery 
and  tongue  of  the  frog,  No  non-vascular  part 
is  equally  available  for  continuous  observation 
in  a living  state,  but  by  special  methods  the  pro- 
cess may  be  followed  in  the  frog's  cornea. 

Description  of  the  process  in  vascular 
parts. — When  the  mesentery  or  tongue  of  a 
frog  is  drawn  out  and  placed  under  the  micro- 
scope, the  contact  of  the  air  soon  determines 
inflammation  ; and  by  means  which  need  not  here 
be  described,  both  the  vessels  and  the  tissue-ele- 
ments may  be  observed  for  hours  together.  The 
earliest  change  seen  in  the  vessels  of  a part  thus 
exposed  is  dilatation,  first  of  the  arteries,  then 
of  the  veins,  the  capillaries  being  little  affected. 
The  dilatation  of  the  vessels  is  accompanied  at 
first  by  acceleration  of  the  blood-stream,  most 
noticeable  in  the  arteries;  but  the  acceleration 
does  not  last  more  than  half  an  hour  or  an  hour, 
and  it  then  gives  place  to  retardation,  which  con- 
tinues as  long  as  the  inflammation  lasts.  The 
‘primary  acceleration’  is,  however,  sometimes 
absent  or  too  short  in  its  duration  to  be  notice- 
able. So  far,  the  process  is  doubtless  the  same  as 
in  active  hypersemia  produced  by  local  irritation. 
Whether  the  first  dilatation  is  due  to  direct  para- 
lysis of  the  muscular  walls  of  the  arteries,  or  to 
a reflex  action  passing  through  the  spinal  cord, 
or  to  an  inhibitory  action  passing  through  nerve- 
ganglia  in  the  arterial  walls,  is  uncertain.  There 


INFLAMMATION. 

need  not,  however,  be  any  reflex  action  through 
the  spinal  cord,  as  dilatation  may  take  place 
when  the  part  is  disconnected  from  the  great 
nerve-centres. 

From  this  point  begin  the  phenomena  peculiar 
to  inflammation.  The  dilatation  of  arteries  may 
go  on  increasing  for  ten  or  twelve  hours,  till 
these  have  double  their  original  diameter,  and 
pulsation  becomes  very  prominent  in  them.  Tiie 
capillaries  look  as  if  gorged  with  corpn-1--. 
forming  a quasi-solid  mass.  The  blood-current  in 
all  the  vessels  becomes  slower  and  slower,  til  it 
is  almost  stagnant.  This  condition  is  known  as 
stasis.  At  the  same  time  certain  peculiarities 
are  observed  in  the  behaviour  of  the  red  cor- 
puscles and  leucocytes  in  the  veins.  In  ordinary 
conditions  of  the  circulation,  the  central  part 
only  of  the  vein  (as  of  the  artery)  is  occupied  by 
the  corpuscles,  which  move  on  mingled  together. 
But  during  stasis  the  corpuscles,  especially  the 
leucocytes,  spread  over  the  marginal  portion  of 
the  vein  usually  free  from  them,  and  the  leuco- 
cytes begin  to  drag  along  the  walls  of  the  vein,  as 
if  adherent,  till  at  length  they  form  a layer  lining 
the  wall  of  the  vessel,  while  the  red  corpuscles 
are  carried  on  by  the  current.  In  the  capillaries, 
this  marginal  layer  is  never  perfectly  established, 
though  leucocytes  may  be  seen  momentarily  ad- 
hering to,  or  moving  slowly  along  the  walls.  In 
the  arteries,  no  such  process  is  observed,  except 
(according  to  Cohnheim)  it  may  be  for  a moment 
during  the  diastole  of  the  pulse.  When  this 
marginal  position  of  leucocytes  is  established, 
and  the  stasis  is  at  its  height,  begins  the  process 
which,  observed  long  ago  by  Waller,  and  less 
clearly  though  earlier  by  William  Addison,  was 
re-observed  and  brought  into  notice  by  Cohn- 
heim. In  the  words  of  the  last-named  observer : 
‘ On  the  outer  contour  of  the  wall  of  a vessel, 
usually  a vein,  in  which  the  marginal  layer  of 
leucocytes  is  well  developed,  sometimes  first  in 
a capillary,  is  seen  a small  projection  which  en- 
larges in  length  and  breadth,  and  becomes  a 
roundish  colourless  lump.  This  again  enlarges, 
puts  out  new  pointed  projections,  and  gradually 
withdraws  itself  from  the  wall  of  the  vessel,  till 
it  is  attached  to  it  only  by  a long  narrow  stem. 
Finally  this  attachment  also  is  broken,  and  we 
see  a colourless  contractile  body  with  one  long 
process  and  several  shorter,  with  one  or  several 
nuclei,  in  fact,  a leucocyte.'  The  same  process  is 
going  on  meanwhile  at  other  points  of  the  veins 
and  capillaries,  till  at  length,  either  quickly  or 
slowly,  the  outer  surface  of  all  the  visible  veins 
becomes  covered  with  several  rows  of  leucocytes, 
while  their  interior  shows  the  same  appearance  as 
before.  That  the  leucocytes  seen  outside  were 
formerly'  inside  the  veins,  having  simply  passed 
through  the  walls,  admits  of  no  reasonable  doubt, 
though  it  is  often  difficult  for  the  eye  to  seize 
the  precise  moment  of  passage.  In  the  arteries 
nothing  of  the  kind  is  seen.  In  the  capillaries 
the  emigration  of  leucocytes  is  very  evident,  and 
accompanied  by  the  passage  of  red  corpuscles  also 
through  the  walls,  which  does  not  take  place  id 
the  veins  proper.  The  latter  process  was  ob- 
served by  Strieker  before  the  revival  of  the  ob- 
servation of  emigration  of  leucocytes. 

Accompanying  the  extravasation  of  the  blood 
corpuscles,  there  is  always  a copious  exuhatioa 


INFLAMMATION". 


of  serum,  which  goes  far  beyond  physiological 
limits.  Aided  by  this  and  by  their  own  spon- 
taneous movements,  the  leucocytes  are  carried 
far  and  wide  into  the  tissue,  till  the  whole  field, 
that  is,  the  whole  mesentery,  is  so  crowded  with 
them,  that  nothing  else  can  be  seen.  The  red 
corpuscles,  on  the  other  hand,  remain  more  closely 
in  the  neighbourhood  of  the  vessels.  When  the 
exudation,  carrying  with  it  the  corpuscles,  and  con- 
taining, as  it  does,  coagulable  material,  reaches 
the  surface,  it  forms  the  layer  or  false  mem- 
brane of  inflammatory  lymph,  seen  in  inflamma- 
tions of  serous  surfaces. 

Cause  of  stasis  and  cell-emigration.  — The 
processes  just  described  mark  inflammation  oif 
sharply  from  simple  hyperaemia.  The  produc- 
tion of  stasis  was  at  one  time  ascribed  to  thick- 
ening of  the  blood  from  transudation  of  serum  ; 
also  to  coagulation  in  the  vessels  ; to  the  adhe- 
siveness of  leucocytes ; and  to  a change  in  the 
tissues  external  to  the  vessels.  But  there  is 
little  doubt  that  the  essential  factor  is  a change 
in  the  constitution  of  the  vascular  wall,  though 
it  is  still  possible  that  this  may  be  connected 
with  a change  in  the  tissues  outside.  The  same 
change,  while  it  retards  the  passage  of  blood, 
makes  the  vascular  wall  permeable  to  the  cor- 
puscles, and  favours  exudation.  What  the  change 
is  we  cannot  say,  but  it  seems  probable  that  it 
is  the  same  as  the  walls  of  vessels  undergo 
when  inadequately  nourished.  Two  classes  of 
experiments  throw  light  on  this  point. 

It  has  been  found  by  Byneck  that  other  fluids 
than  blood,  such  as  milk,  pass  with  greater 
difficulty  than  usual  through  the  vessels  of  an 
irritated  part ; and  that  stasis  can  be  produced 
in  the  vessels  of  a frog,  which  is  kept  alive  by 
the  circulation  of  salt-solution  instead  of  blood 
in  its  vessels.  Cohnheim  has  also  shown  that  a 
state  of  the  vascular  walls  similar  to  that 
which  may  be  presumed  to  exist  in  inflamma- 
tion, may  be  produced  by  shutting  off  the  blood 
from  the  vessels  for  a certain  time.  He  put  a 
ligature  round  the  tongue  of  a frog,  and  ob- 
served the  vessels  after  the  ligature  was  cut. 
If  the  blood  had  been  excluded  for  I welve  to 
twenty-four  hours  only,  the  vessels  on  the  return 
of  the  blood  passed  into  a condition  of  simple 
hypersemia ; but  if  longer,  stagnation,  marginal 
position  of  leucocytes,  and  extravasation  of  cor- 
puscles were  observed,  and  these  phenomena  were 
more  marked  the  longer  the  ligature  had  remained, 
provided  it  was  not  long  enough  entirely  to  de- 
stroy the  vitality  of  the  part.  From  these  experi- 
ments we  must  conclude  that  the  cause  of  stasis 
and  its  attendant  phenomena  is  not  in  the  blood 
or  the  cells,  but  in  the  walls  of  the  vessels,  and 
that  the  change  in  these  is  of  the  nature  of  de- 
generation. 

Changes  of  the  tissue-elements.  — These  changes 
are  most  simply  seen  in  non-vasculur  parts, 
which  will  be  first  considered.  Alterations  in 
cartilage-cells  diming  ulceration  were  observed 
long  ago  by  Goodsir  and  Kedfern,  but  were  not 
then  thought  to  belong  to  inflammation,  non- 
vascular  parts  being  not  thought  liable  to  this 
process.  Lately  the  cornea  has  been  taken  as  the 
type  of  non-vascular  tissues.  If  the  cornea  of  a 
frog  be  irritated  by  touching  a small  spot  with 
nitrate  of  silver,  and  cut  out  within  from  twelve 


G99 

to  twenty-four  hours  afterwards,  many  of  tile 
fixed  corpuscles  are  found  to  be  already  altered. 
Their  processes  are  become  shorter  and  thicker  ; 
their  bodies  of  irregular  shape  ; and  they  often 
show  amoeboid  movements,  and  become  converted 
into  many-nucleated  protoplasmic  masses,  re- 
sembling what  are  in  some  other  parts  called 
giant-cells.  Finalty,  in  their  place  may  be  seen 
groups  of  new  cells,  or  pus-corpuscles.  But  there 
are  always  some  corneal  corpuscles  which  re- 
main quite  unchanged.  These  changes  cannot  be 
traced  farther,  as  the  cornea  soon  becomes  turbid, 
and  the  whole  field  of  observation  crowded  with 
leucocytes. 

It  is  still  a matter  of  dispute  whether  these 
changes  are  truly  reproductive  or  only  degene- 
rative ; and  whether  any  new  cells  are  really 
formed  from  the  fixed  pus-corpuscles  of  the  cornea, 
or  whether  the  origin  of  these  leucocytes  is  the 
same  as  of  those  which  are  seen  surrounding 
the  veins  and  capillaries  of  the  inflamed  frog’s 
mesentery.  On  the  one  hand,  it  is  said  that  the 
cornea  can  be  excised  so  early  as  to  preclude  the 
possibility  of  migratory  corpuscles  finding  their 
way  from  the  vessels  surrounding  the  cornea, 
and.  that  even  then  groups  of  leucocytes  are 
found  in  the  place  of  corneal  corpuscles,  which 
must  have  been  produced  by  germination  from 
them.  On  the  other  hand  it  is  urged  that,  even 
supposing  it  impossible  that  these  cells  could 
come  from  the  surrounding  blood-vessels,  the 
conjunctival  lymph-sac  contains  lymph-cor- 
puscles which  might  travel  into  the  cornea. 
Further,  the  leucocytes  of  the  blood  have  been 
coloured  by  injecting  colouring  matter  into  the 
veins,  which  the  leucocytes  take  up,  and  cells 
thus  marked  are  found  among  those  supposed  to 
be  derived  from  the  corneal  corpuscles.  "With- 
out discussing  these  conflicting  arguments,  we 
may  say  that  we  believe  the  truth  to  be  this  : 
that  young  cells,  undistinguishable  from  leu- 
cocytes or  pus-corpuscles,  are  formed  by  a pro- 
cess of  growth,  cell-division,  and  germination, 
affecting  the  fixed  corneal  corpuscles,  but  that 
the  number  of  these  is  inconsiderable  compared 
with  those  which,  even  in  a non-vascular  tissue 
like  the  cornea,  are  derived  from  the  vessels. 

The  process  of  inflammation  in  other  non- 
vascular  parts,  such  as  cartilage,  lias  been  studied 
in  the  same  way  as  in  the  cornea,  in  all  caseo 
with  the  disadvantage  that  continuous  observa- 
tion is  impossible.  The  general  result  is  the 
same,  namely,  that  changes  are  seen,  apparently 
without  any  participation  of  the  vessels,  which 
are  regarded  by  some  as  showing  degeneration 
and  breaking  up  of  the  fixed  tissue-elements ; 
by  others  as  showing  germination  and  formation 
of  new  cells,  but  which  in  any  case  do  not  play 
an  important  part  in  the  whole  inflammatory 
process. 

Tissue-changes  in  vascular  parts.-—  These, 
though  apparently  more  ambiguous  than  in  non- 
vascular  parts,  are  yet  sometimes  susceptible  of 
more  minute  study.  In  the  omentum  of  mam- 
malia, changes  occur  during  inflammation  in 
which  unbiassed  observation  can  hardly  see  any- 
thing else  than  cell-division,  growth,  and  germi- 
nation. There  is  indeed  reason  to  believe  that 
such  appearances  are  found  normally,  as  evidence 
merely  of,growth,  but  the  inflammatory  changes 


INFLAMMATION. 


,'00 

are  distinguished  from  the  normal  by  thur 
greater  frequency  and  luxuriance.  In  fibrous 
connective-tissue  similar  processes  have  long 
been  observed,  and  since  attention  was  drawn  to 
them  by  Virchow,  have  been  regarded  till  lately 
as  showing,  in  the  clearest  manner,  that  the 
fixed  cells  of  tire  tissue  germinate  and  produce 
new  elements.  This  ‘proliferation  of  connec- 
tive tissue  ’ was  regarded,  especially  by  German 
pathologists,  as  an  obvious  fact,  and  as  the 
explanation  of  many  morbid  processes.  But  it 
is  now  known  that  what  were  regarded  as  con- 
nective-tissue corpuscles  are  really  spaces,  which 
may  become  filled  with  leucocytes  migrated  from 
neighbouring  blood-vessels,  and  when  the  cells 
proper  can  be  seen,  the  latter  are  often  unaltered. 
Around  inflamed  parts  the  connective-tissue  is 
often  found  infiltrated  with  young  cells,  the  origin 
of  which  was  formerly  set  down  to  proliferation. 
But  it  seems  more  simple  to  regard  this  ‘ small- 
celled  infiltration,’  which  is  a very  frequent 
accompaniment  of  inflammation,  as  resulting 
from  migration  of  leucocytes  from  the  veins  and 
capillaries  of  the  inflamed  part.  The  possibility, 
however,  of  ‘ connective-tissue  proliferation  ’ can- 
not be  doubted;  and,  if  it  occurs,  the  number  of 
elements  thus  produced  will  not,  as  in  the  case 
of  non-vascular  parts,  be  necessarily  limited. 
With  respect  toother  tissues,  such  as  muscle, 
nerve,  &c.,  very  conflicting  statements.have  been 
published.  Some  years  ago  numerous  observa- 
tions were  made,  supposed  to  show  the  formation 
of  new  cells  from  the  connective- tissue  stroma 
of  inflamed  parts ; it  was  then  supposed  that 
more  specialised  elements,  such  as  muscle-fibre, 
epithelium,  &c.,  could  not  produce  the  same  ; 
afterwards  the  same  appearances  were  seen  in 
these  tissues,  and  interpreted  in  the  sense  which 
has  been  explained  above.  The  recent  observa- 
tions of  Strieker  and  his  pupils  tend  to  show 
that  the  tissues  take  part  in  the  formation  of 
pus-corpuscles, in  true  suppuration  if  not  inlower 
degrees  of  inflammation,  but  do  not,  we  think, 
materially  alter  the  views  to  be  derived  from  a 
direct  study  of  the  inflammatory  process. 

Besides  the  twofold  origin  of  new  cells  above 
indicated,  there  is  reason  to  believe  that  the 
leucocytes  emigrated  from  the  vessels,  and  per- 
haps those  produced  from  the  tissues,  further 
divide  and  ‘proliferate.’  Strieker  and  Klein 
have  both  observed  actual  cell-division  take 
place  under  the  microscope ; so  that  some  of 
the  new  cells  are  regarded  as  the  descendants  of 
emigrated  corpuscles.  We  may  compare  the 
new  cells  of  inflamed  parts  to  the  population  of 
a colony,  where  most  are  emigrants,  or  the  de- 
scendants of  emigrants,  but  some  few  trace  their 
descent  from  the  aboriginal  inhabitants. 

Beyond  the  proauction  of  new  cells,  the  tissues 
outside  the  vessels  cannot  be  said  to  play  an  ac- 
tive partin  inflammation.  Their  passive  changes 
are,  however,  important.  These  are  chiefly  de- 
generative, that  is,  necrosis  of  the  elements  takes 
place,  preceded  by  various  kinds  of  degeneration. 
Connective-tissue  fibres  soften  ; muscular  fibres 
undergo  fatty  degeneration;  and  epithelium  also 
wastes  by  means  of  fatty  degeneration,  and 
on  surfaces  is  shed  off.  Nerve-tissue  and  all 
special  tissues  soften,  liquefy,  and  disappear.  In 
places  where  there  is  a large  collection  of  pus- 


corpuscles,  all  tissue-elements  become  absorbed, 
and  the  debris  is  either  carried  away  by  the  lym- 
phatics and  veins,  or  becomos  mingled  with  pus. 
In  fact,  along  with  nutritive  and  germina'tive 
processes,  there  are  destructive  and  atrophic 
processes  equally  active. 

We  must  now  consider  the  products  and  results 
of  inflammation,  without  further  distinguishing 
between  the  share  of  the  vessels  and  of  the 
tissues. 

Products  and  Results. — All  inflammatory 
products  result  either  from  exudation  (with  or 
without  participation  of  the  tissues),  or  from 
new  growth.  The  exudative  products  are  serum, 
mucus,  and  fibrin ; which  by  combination  with 
leucocytes,  form  inflammatory  lymph  and  pus. 
New  growth  takes  place  from  the  vessels  in  the 
form  of  vascular  connective  tissue,  of  which  a 
special  form  are  granulations.  With  regard  to 
exudations,  no  clear  line  can  bo  drawn,  at  any 
stage  of  the  process,  between  serous  and  fibrinous 
exudations,  inflammatory  lymph,  and  pus ; the 
differences  being  only  of  degree. 

. "Exudations . — Serous  and  mucous  exudations 
can  only  when  excessive  he  regarded  as  products 
of  inflammation.  The  fluids  formed  in  inflamma- 
tions of  serous  cavities  differ  from  those  produced 
in  passive  exudations  (or  dropsies),  in  containing 
more  fibrin  and  more  albumen.  But  inflam- 
matory exudations  vary  in  this  respect,  and  are 
sometimes  scarcely  to  be  distinguished  from 
simple  serous  effusions.  The  fluids  poured  out 
on  serous  surfaces  in  acute  inflammation  always 
coagulate,  and  even  in  chronic  cases  can  often  be 
shown  to  be  capable  of  coagulation.  On  mucous 
surfaces,  on  the  contrary,  the  exudation  does  not 
as  a rule  coagulate.  That  this  is  owing  in  some 
way  to  the  action  of  the  epithelium  seems  most 
probable,  whether  it  is  that  filtration  through 
epithelium  alters  the  composition  of  the  fluid,  or 
whether  the  living  epithelium  prevents  coagula- 
tion in  the  same  way  as  the  endothelium  of  the 
vessels  prevents  coagulation  of  the  circulating 
blood.  When,  however,  the  epithelium  is  re- 
moved, a fibrinous  layer  may  be  produced  on  the 
mucous  surface ; and  the  same  result  seems  to 
follow  the  application  of  very  powerful  irritants, 
as  in  croupous  inflammations.  Mucous  exuda- 
tions contain  mucin,  as  well  as  serum-albumen, 
in  variable  proportions. 

Fibrinous  exudations,  in  coagulating,  entangle 
whatever  leucocytes  may  he  either  extruded 
with  the  exudation,  or  present  in  the  tissues. 
The  properties  of  the  coagulated  mass  differ  ac- 
cording to  the  proportion  of  corpuscles.  Heneo 
it  was  at  one  time  usual  to  distinguish  fibrinous 
from  corpuscular  lymph,  or  even  to  regard  ficrin 
as  a mixed  substance,  partly  made  up  of  cor- 
puscles. It  is  now  known  that  these  differences 
do  not  show  any  corresponding  differences  m the 
composition  of  the  blood,  but  depend  upon  the 
facility  with  which  the  corpuscles  leave  the 
vessels.  The  product  called  inflammatory  lymph 
consists  of  coagulated  fibrin  entangling  leuco- 
cytes, the  two  constituents  being  in  varying  pro- 
portions. The  fibrin  does  not  differ  from  that 
of  blood-clot ; and  may  therefore  he  formed  ir.  the 
same  way  by  a reaction  between  the  exuded  con- 
stituents of  blood.  But  it  is  not  a constant  pro- 
duct of  inflammation,  aud  hence  has  been  thought 


INFLAMMATION. 


701 


rc  owe  its  production  to  local  causes  —that  is, 
to  reaction  between  the  tissues  and  the  exudation. 
Thus  tibrin  is  formed  on  serous  surfaces  where 
normally  one  of  the  fibrin  constituents  is  found, 
and  for  the  same  reason,  in  connective  tissue  ; 
but,  as  stated  above,  not  generally,  cn  inflamed 
mucous  surfaces,  or  in  epithelial  structures.  But 
since  it  is  possible  that  in  these  cases  the  exuda- 
tion becomes  altered  by  filtration  through  the 
tissues,  there  is  no  reason  to  doubt  that  fibrin, 
or  both  its  chemical  constituents,  may  be  exuded 
from  the  vessels.  Formerly  great  importance  was 
attached  to  this  product.of  inflammation.  It  was 
regarded  as  capable  of  forming,  by  organisation, 
new  tissues;  and  by  degeneration,  pus  and  other 
things.  But  it  is  quite  uncertain  whether  lymph 
is  ever,  strictly  speaking,  organised  into  tissue, 
and  the  formation  of  pus  must  be  considered  as 
differing  from  that  of  ordinary  lymph  only  in 
degree. 

Pus. — Pus  is  inflammatory  exudation  in  which 
the  corpuscles  greatly  predominate,  and  the  in- 
termediate substance  is  liquid.  It  is  thus  diffi- 
cult to  draw  a line  between  pus  and  softer  forms 
of  inflammatory  lymph,  but  the  former  does  not 
contain  fibrin,  nor  does  it  coagulate  spontaneously. 
The  following  analysis  of  pus  may  be  taken  as 
representing  an  average  specimen ; — 


Water  ....  887'6 
Pus-cells  and  mucus  . . 46'5 

Albumen  ....  43'8 

Fat  and  cholesterin  . . 10’9 

Sodium-chloride  . . . 5'9 

Other  alkaline  saits  . . 3'2 

Earthy  phosphates  and  iron  . 2'1 


1000-0 

It  is  noticeable  that  pus  contains  a much  larger 
proportion  of  fat  than  any  other  inflammatory 
products,  cr  than  blood.  Its  specific  gravity  is 
1-030  or  1-033.  The  appearance  of  pus  is  well 
known;  it  is  a creamy  fluid,  which,  when  normal 
or  ‘ laudable  ’ and  fresh,  has  a very  faint,  not  of- 
fensive odour,  and  no  sign  of  putrefaction.  Under 
certain  circumstances,  it  has  a strong  ammoniacal 
or  putrefactive  odour,  and  is  described  as  ‘ un- 
healthy,’ or  sanious.  When  allowed  to  stand,  all 
pus  separates  into  a liquid  portion  or  ‘serum;’ 
and  a sediment  consisting  chiefly  of  the  cor- 
puscles. The  serum  resembles  blood-serum, 

, containing  paraglobulin  or  fibrino-plastic  sub- 
stance, potash-albuminate  (or  casein),  ordinary 
serum-albumen,  and  myosin.  Other  constituents 
of  pus  are  protagon,  chondrin,  gelatin,  leuein, 
tyrosin,  and  xanthin. 

Pus-corpuscles.  — The  corpuscles  of  fresh 
newly-formed  pus,  as  seen,  for  instance,  on  an  in- 
flamed mucous  surface,  are  not  distinguishable 
from  leucocytes  of  the  blood,  showing  active 
amoeboid  movements,  and  continual  change  of 
form.  Most  corpuscles  from  large  collections  of 
pus,  such  as  abscesses,  are  already  dead,  being 
nearly  spherical  in  form,  with  the  appearance  of 
a cell-wall,  and  showing  when  acted  upon  by 
acetic  acid  three  or  more  small  nuclei. 

Suppuration. — While  the  production  of  indi- 
vidual pus-corpuscles  is  to  be  explained  in  the 
same  way  as  that  of  inflammatory  cells  in  general, 
there  are  some  reasons  for  thinking  that  the 
formation  of  pus  requires,  in  addition,  more  special 


causes.  Where  a collection  of  pus,  or  an  abscess, 
is  formed,  it  is  probable  that  the  tissue-cells 
take  an  especially  active  part  in  the  formation  of 
new  elements.  Suppuration  is  preceded  by  har- 
dening and  swelling  of  the  connective  tissue,  a 
change  which  Strieker  refers  entirely  to  enlarge- 
ment of  the  connective-tissue  bundles.  He  as- 
serts that  even  in  the  cornea  this  hardening 
is  seen  in  those  parts  where  pus  is  afterwards 
formed.  While,  therefore,  we  cannot  say  that  pus 
is  formed  solely  from  connective  tissue,  we  admit 
that  the  proliferation  of  the  tissues  has  a more 
important  share  in  suppuration  than  in  other 
forms  of  inflammation. 

Another  most  important  view  as  to  the  cause 
of  suppuration  is  suggested,  though  not  proved,  by 
modern  processes  in  surgery,  which  show  that  the 
entire  exclusion  of  air  containing  solid  particles, 
and  any  air  but  that  which  has  been  subjected  to 
the  action  of  antiseptics,  prevents  the  occurrence 
of  suppuration,  even  after  severe  injuries  or 
operations.  It  is  probable,  therefore,  that  these 
septic  particles  or  bacteria  are  largely  concerned 
in  the  production  or  keeping  up  of  the  suppura- 
tion, as  distinguished  from  milder  forms  of  in- 
flammation. 

Vascular  connective  tissue. — When  a part  has 
been  destroyed  by  inflammation,  the  lost  tissue 
is  replaced  by  the  preliminary  formation  of  a 
peculiar  structure,  consisting  of  a highly  vascular 
connective-tissue  framework,  containing  an  ex- 
cessive number  of  leucocytes.  The  vessels  are 
of  delicate  structure,  and  easily  lacerated.  This 
tissue  also  contains  nerves.  It  has  been  com- 
pared to  the  cellular  structure  which  composes 
the  embryo,  or  to  embryonic  tissue,  but  the  great 
predominance  of  vessels  constitutes  an  important 
difference.  Such  tissue  always  originates  as  an 
outgrowth  of  the  vessels  of  the  inflamed  part  ; 
it  grows  into  regular  connective  tissue,  and  is 
thus  the  most  important  means  of  replacing  the 
tissue  destroyed.  When  produced  on  a surface, 
and  growing  out  in  the  form  of  tufts,  it  receives 
the  name  of  granulations-,  and,  as  is  well  known, 
ulcers  and  cavities  become  filled  up  by  it.  There 
is  no  doubt  that  granulation-tissue  may  form 
fibrous  tissue,  and  probably  other  forms  of  con- 
nective tissue  ; but  it  is  still  uncertain  whether 
epithelial  structures  ever  pass  through  this  stage, 
and  whether  nervous  or  muscular  tissue  is  ever 
thus  regenerated. 

Varieties. — The  most  striking  differences  be- 
tween different  kinds  of  inflammation  are  those 
depending  upon  the  differences  of  tissues,  and 
of  the  situations  in  which  it  occurs. 

1.  Catarrhal. — On  mucous  membranes,  the 
exudation  is  mucous,  does  not  coagulate,  and  con- 
tains only  detached  epithelial  cells,  with  scattered 
leucocytes  ; the  process  readily  becomes  chronic ; 
but  the  effect  on  the  body  as  a whole  is  less  marked 
than  in  other  forms.  This  is  catarrhal  inflam- 
mation, a term  which  is  with  less  propriety 
transferred  to  inflammations  of  the  skin,  the 
lung,  and  some  glandular  organs. 

If  catarrhal  inflammation  is  very  severe  it 
becomes  purulent,  and  the  exudation  consists 
chiefly  of  pus,  little  or  no  mucus  being  produced. 
This  purulent  catarrh  is  especially  characteristic 
of  specific  inflammations  of  the  mucous  surfaces, 
such  as  virulent  conjunctivitis  or  gonorrhoea. 


INFLAMMATION. 


702 

2.  Croupous  or  fibrinous. — Croupous  inflam- 
mation is  that  form  in  which  a coagulable  exu- 
dation is  formed  upon  a mucous  surface.  In 
diphtheritic  inflammation  there  is,  besides  a 
membranous  exudation,  some  necrosis  of  the 
mucous  membrane.  In  these  forms  the  tendency 
is  to  acute,  not  chronic,  disease ; and  the  general 
symptoms  are  strongly  marked.  The  name  croup 
has  also  been  transferred  to  certain  inflamma- 
tions of  the  lung  (‘croupous  pneumonia')  and  of 
the  kidney,  but,  in  the  latter  case  especially,  with 
doubtful  propriety. 

The  fibrinous  form  may  be  regarded  as  the 
normal  or  usual  form  of  inflammation  of  serous 
membranes  and  connective  tissue. 

On  serous  surfaces  the  lowest  degree  of  in- 
flammation is  seen  in  a serous  exudation,  con- 
taining little  or  no  plasma,  hardly  to  be  distin- 
guished from  simple  dropsy ; but  there  is  no 
dear  line  between  this  and  a coagulable  exuda- 
tion, or  fibrinous  inflammation.  This  too,  if 
still  more  severe,  may  become  purulent ; and, 
as  we  see  in  the  pericardium  or  pleura,  a 
purulent  may  succeed  to  a fibrinous  inflammation. 
Finally,  vascular  connective  tissue,  forming  adhe- 
sions, is  generally  produced.  In  areolar  connec- 
tive tissue,  and  in  the  interstitial  tissue  of  various 
organs,  the  same  stages  may  be  distinguished, 
known  as  inflammatory  oedema,  which  occurs  near 
a focus  of  acute  inflammation;  inflammatory 
hardening,  such  as  precedes  the  formation  of  an 
abscess ; and,  finally,  either  abscess  itself  or 
purulent  infiltration — -the  two  forms  of  suppura- 
tion in  connective  tissue. 

3.  Parenchymatous. — It  is  not  so  easy  to  define 
the  kinds  of  inflammation  as  affecting  the  special 
elements  or  parenchyma  of  organs.  The  lung 
appears  to  be  an  exception  to  the  general  rule 
that  epithelial  surfaces  show  the  catarrhal  form 
of  inflammation,  since  lobar  pneumonia  is  a type 
of  the  fibrinous  form ; but  it  should  be  remem- 
bered that  the  anatomical  structure  of  the  air- 
vesicles  more  resembles  a serous  than  a mucous 
surface,  having  only  a single  layer  of  epithe- 
lium ; and  that  a catarrhal  form  of  inflammation 
is  always  the  result  of  mechanical  injury  to  the 
lung. 

The  name  parenchymatous  inflammation  has 
been  given  to  those  changes  occurring  in  the 
special  tissues  of  organs,  independent  of  their 
connective-tissue  framework.  The  only  factor 
common  to  all  such  appears  to  be  a granular 
degeneration  of  the  protoplasma  of  their  cells, 
identical  with  what  is  elsewhere  called  albumi- 
nous degeneration,  though  it  may  end  in  fatty  or 
other  degeneration.  In  contradistinction  to  this, 
inflammation  of  the  connective-tissue  framework 
is  termed  interstitial  inflammation. 

i.  Phlegmonous. — Phlegmonous  inflammation 
is  the  same  as  acute  interstitial  inflammation, 
that  is,  the  formation  of  abscess. 

5.  Indurative.  — Indurative  inflammation  is 
that  in  which  new  connective-tissue  is  produced 
in  the  interior  of  organs.  This  is  chronic  inter- 
stitial inflammation. 

6.  Degenerative. — This  variety  of  inflamma- 
tion hardly  needs  explanation. 

7.  Scrofulous. — Scrofulous  inflammation  is 
that  type  which  occurs  in  cachectic  persons, 
whose  tissues  are  easily  injured  and  heal  slowly. 


Such  persons  are  subject  to  chronic  inflammations, 
which,  further,  involve  destruction  of  tissue,  and 
in  which  the  inflammatory'  products  readily  un- 
dergo degeneration ; unless  these  characters  of 
destruction  and  degeneration  are  present,  the 
name  scrofulous  has  no  precise  meaning.  Stru- 
mous is  a word  better  forgotten,  being  synony- 
mous with  scrofulous,  and  liable  to  be  misunder- 
stood. 

8.  Infective. — Infective  inflammations  are  those 
produced  by  the  passage  into  the  blood  of  infec- 
tive matter  derived  from  some  previously  existing 
inflammation.  Pyaemia  is  a type  ; perhaps  also 
tuberculosis. 

9 . Chronic.  — Most  inflammations  have  at 
first  a typical  course,  reaching  their  acme  and 
then  declining.  If  the  decline  is  not  followed 
by  resolution  they  become  chronic.  Others, 
again,  show  from  the  first  the  character  they 
all  alcng  maintain.  Chronic  inflammations  are 
usually  distinguished  by  the  persistence  of 
that  condition  of  the  vessels  which  permits  exu- 
dation and  cell-emigration,  with  less  hypertemia 
and  general  fever  than  in  the  acute  form.  On 
mucous  surfaces  the  chronic  form  differs  little 
from  the  acute,  except  in  these  two  respects. 
In  serous  membranes  chronic  inflammation  pro- 
duces fibrous  adhesions,  with  little  or  no  liquid 
exudation.  In  the  interstitial  tissue  of  solid 
organs  a large  amount  of  new  connect  ive-tissu6 
is  produced  by  chronic  inflammation,  which  first 
compresses  the  special  elements,  causing  them  to 
waste,  and  then  contracts  in  hulk,  so  that  the 
organ  becomes  atrophied,  and  usually  harder  and 
more  fibrous.  This  is  the  process  called  ‘ fibroid 
degeneration,’  as  in  cirrhosis  of  the  liver.  ‘Chro- 
nic parenchymatous  inflammations’  are  simple 
degenerations,  as  seen  in  the  kidney. 

TfiioiiNATioxs.— The  most  favourable  termi- 
nation of  inflammation  is  what  is  called  resolution, 
in  which  the  vascular  phenomena  and  tissue- 
changes  decline  together,  and  pass  away  without 
leaving  any  tangible  material  result.  Even  in 
the  apparently  most  perfect  cases  of  resolution, 
there  is  little  doubt  that  products  of  exudation 
remain  when  the  vascular  changes  have  subsided, 
and  are  slowly  removed  by  the  lymphatics. 
Other  so-called  terminations  are  necrosis,  or  total 
death  of  the  part;  and  partial  destruction  by  sup- 
puration or  ulceration.  But  if  any  loss  of  sub- 
stance occurs,  the  inflammatory  process  cannot 
be  regarded  as  at  an  end  till  the  loss  is  wholly 
or  partially  restored  by  newly-formed  connective- 
tissue.  W here  there  is  no  destruction  of  tissue, 
but  only  masses  of  liquid  or  solid  exudation,  the 
inflammation  is  not,  strictly  speaking,  resolved 
till  these  are  removed.  Very  frequently  an  acute 
passes  into  a chronic  inflammation. 

Consequence*. — (1)  Local  consequences. — If 
an  inflamed  part  does  not  simply  return  to  its 
original  state,  atrophy  is  the  most  common  con- 
sequence. Hypertrophy  can  hardly  he  said  to 
occur  in  the  part  actually  inflamed,  though  it 
may  in  adjoining  parts,  as  we  see  in  enlargement 
of  bone  from  periostitis.  False  hypertrophy , from 
new  formation  of  connective-tissue,  is  common, 
but  as  such  tissue  contracts,  the  final  result  is 
atrophy.  The  hardness  of  this  tissue  causes  in- 
duration to  be  put  down  among  the  consequences 
of  inflammation. 


INFLAMMATION. 


(2)  General  consequences. — The  effect  of  in- 
flammation on  the  -whole  body  is  to  produce  the 
condition  of  fever,  -which  is  discussed  in  another 
part  of  this  work.  It  will  suffice  here  to  say 
that  fever  involves  raising  of  the  body-tempera- 
ture, weakening  and  acceleration  of  the  heart, 
and  disturbance  of  the  nervous  system,  as 
well  as  of  all  the  nutritive  processes.  It  was 
formerly  supposed  that  local  inflammation  pro- 
duced fever  simply  through  the  increased  pro- 
duction of  heat  by  more  rapid  tissue-change 
in  the  inflamed  part  ; this  process  raising 
the  temperature  of  the  blood  passing  through 
the  part,  and  thus  of  the  whole  body  by  means 
of  the  blood.  But  this  simple  explanation  is 
not  adequate.  It  has  even  been  much  disputed 
whether  the  heat  of  inflamed  parts  ever  surpasses 
that  of  the  blood.  The  temperature  of  inflamed 
external  parts  is  higher  than  the  normal  in  that 
situation,  or  than  that  of  a corresponding  part, 
not  inflamed,  on  the  other  side  of  the  body.  But 
this  is  also  the  case  in  hypersemia,  in  which  con- 
dition the  external  temperature  never  surpasses 
that  of  internal  organs.  Experiments  on  inflam- 
mation have  led  to  very  conflicting  results:  those 
of  Simon  and  Weber  being  directly  opposite  to 
those  of  Jacobson  and  others.  But  even  if  we 
assume  an  actual  production  of  heat  in  inflamed 
parts,  this  will  not  be  enough,  as  is  shown  by 
calculation,  to  account  for  the  rise  of  tempera- 
ture in  the  whole  body.  It  has  also  been  sup- 
posed that  some  fever-producing  or  pyrogenic 
substance  passes  into  the  blood  from  every  in- 
flamed part,  and  causes  increased  tissue-change, 
with  consequent  increased  production  of  heat 
through  the  whole  body.  But  till  the  pyrogenic 
substance  is  known,  this  view  does  not  go  bey-ond 
hypothesis.  Finally,  it  is  held  that  the  nervous 
system  has  a large,  or  even  the  chief  share  in  the 
production  of  fever  ; the  inflamed  part  acting 
through  the  nerves  on  the  centre  controlling  the 
temperature  of  the  body,  which  physiologists 
place  in  the  medulla  oblongata.  But  none  of 
these  theories  is  definitely  established,  and  the 
manner,  therefore,  in  whihh  local  inflammation 
produces  fever  is  not  yet  perfectly  understood. 
The  degree  in  which  local  inflammations  cause 
fever  varies,  and  does  not  appear  to  depend 
wholly  on  the  mass  or  the  intensity  of  the  inflam- 
mation, though  both  these  conditions  are  partly 
concerned.  Acute  inflammations  produce  more 
fever  than  chronic ; those  of  connective-tissue 
more  than  those  of  mucous  surfaces ; and,  most  of 
. all,  those  which  end  in  suppuration.  In  infective 
inflammations  the  fever  is  generally  high,  but 
not  to  be  attributed  to  the  local  inflammation, 
being  a concurrent  effect  of  the  same  cause — the 
infective  poison.  Besides  general  fever,  the 
special  condition  called  pyeemia,  in  which  other 
local  inflammations  result,  may  be  a consequence 
ofprimaryinflammation ; but  here,  probably,  some 
other  factor  is  at  work.  See  F'ever  ; and  Py;emia. 

-^Etiology. — Most  inflammations  are  caused 
by  some  injury — either  mechanical,  as  by  actual 
violence ; or  physical,  as  changes  of  temperature  ; 
or  chemical,  by  powerfully  acting  substances,  as 
acids,  alkalies,  and  many  more.  A most  impor- 
tant secondary  factor  is  the  condition  of  the 
body,  whether  under-  or  over-nourished,  or  in 
some  other  way  wrong  ; and  this  may  probably 


703 

be  still  more  closely  defined  as  the  condition  of 
the  blood-vessels.  Many  parts  of  the  body-,  as 
the  skin  and  the  stomach,  are  constantly  exposed 
to  injury,  but  do  not  become  inflamed  unless  from 
some  internal  cause;  and,  therefore,  a change 
of  nutrition  may  be  the  apparent  or  immediate 
cause.  It  is  also  clear  that  certain  inflamn  a- 
tions,  as  herpes  zoster,  are  determined  by  dis- 
turbance of  the  nerves ; and  it  is  very  probable 
that  similar  nervous  disturbances  cause  other 
local  inflammations.  Besides  these  there  are  cer- 
tain specific  causes,  namely,  infective  or  specific 
poisons,  which,  when  introduced  into  the  blood, 
produce  local  inflammations.  Many  local  in- 
flammations, external  and  internal,  appear  to 
arise  spontaneously,  neither  irritation  nor  fault 
of  nutrition  being  easily  traced.  Such  are,  for 
example,  carbuncle  and  pneumonia.  But  in  these, 
as  in  others,  it  is  already’  probable  that  some 
infective  cause  is  at  work.  It  is  also  probable, 
and  in  some  cases  proved,  that  other  inflamma- 
tions which  were  at  one  time  thought  spontaneous, 
are  really  secondary,  depending  upon  some  pre- 
vious local  inflammation,  even  without  what  is 
called  actual  pyaemia.  Thus  the  number  of  such 
apparently  spontaneous  inflammations  is  gradu- 
ally lessening. 

Treatment. — We  shall  divide  this  subject 
into  the  treatment  of  directly  accessible  (chiefly 
external)  inflammations ; and  that  of  indirectly 
accessible  (internal).  Treatment  will  also  differ 
according  as  the  inflammation  is  acute  or  chronic; 
according  to  the  stage,  if  acute;  and  also  accord- 
ing to  the  constitution  of  the  patient. 

a.  Directly  accessible. — Directly’  accessible  in- 
flammation in  an  early  stage  may  be  treated  by 
local  blood-letting,  and  by  astringents.  The 
benefit  of  local  blood-letting  in  an  early-  stage  is 
undoubted,  and  is  probably  due  to  its  relieving 
the  condition  of  stagnation,  and  permitting  freer 
circulation  of  blood  in  the  part.  The  type  of 
astringents  is  cold.  When  the  vascular  disturb- 
ance, that  is,  hypersemia,  is  great,  and  the  general 
fever  high,  cold,  produced  either  by  ice  or  evapo- 
ration, is  generally  the  best  treatment.  In  the 
case  of  mechanical  injuries,  for  instance,  it  may 
be  regarded  as  an  ascertained  fact  that  if  any 
injured  part  be  kept  cold  during  the  period  of 
reaction,  the  inflammation  is  less  severe.  When 
the  condition  of  stasis,  with  exudation,  is  set  up, 
the  effect  of  cold  is  less  marked ; and  if  a tem- 
porary benefit  is  produced,  the  condition  after  the 
application  of  cold  is  stopped  may  be  as  bad  as 
ever,  or  perhaps  worse.  The  defect  of  cold  as  an 
antiphlogistic  seems  to  be  that,  though  it  reduces 
hypersemia,  and  if  sufficiently  intense  actually 
checks  inflammation,  it  does  not  remove  the  con- 
dition of  the  vascular  wall  on  which  stasis  and 
the  associated  changes  depend.  Cold  is  also  a 
powerful  nervous  sedative,  and  reduces  the  ner- 
vous irritability  of  inflamed  parts.  It  is  remark- 
able that  an  effect  like  that  of  cold  is  produced 
by  solutions  of  certain  'metallic  salts,  especially 
those  of  lead,  zinc,  silver,  and  bismuth.  These 
salts  furnish  the  most  certain  and  direct  means 
of  treating  an  inflammation  in  parts  actually 
accessible  to  their  action.  Hence  they-  are  used 
in  superficial  inflammations  of  the  mucous  mem- 
branes, such  as  the  digestive  mucous  membrane 
I and  the  conjunctiva,  and  of  the  skin.  Their  uo«- 


I 


INFLAMMATION. 


704 

is  limited  by  the  difficulty  of  bringing  them  in 
actual  contact  with  deeper  inflamed  parts.  But 
Mr.  Hutchinson  has  shown  that  even  in  severe 
injuries  the  antiphlogistic  effect  of  lead  is  quite 
equal  to  that  of  cold,  if  it  can  be  made  to  pass 
deeply  enough  into  the  injured  parts.  These 
mineral  (and  vegetable  astringents  also)  act  more 
potently  on  the  exudative  processes  of  inflam- 
mation, than  on  the  vascular  disturbance.  Ilonce 
their  activity  is  most  valuable  when  that  of 
cold  ends ; and  they  have  a striking  effect  on 
chronic  inflammations  which  are  unaffected  by 
cold.  Even  'pressure  may  be  useful  as  an  astrin- 
gent, as  we  see  in  strapping  a testicle  or  an  in- 
flamed joint.  In  applying  all  astringents,  it  is 
of  the  first  importance  to  be  sure  that  they 
actually  arrive  at  the  inflamed  part.  In  apply- 
ing ice  to  the  chest  for  pneumonia  or  pericarditis, 
for  instance,  this  result  is  very  doubtful. 

In  the  treatment  of  even  acute  inflammations, 
the  precisely  opposite  application,  that  of  heat, 
is  sometimes  valuable.  Hot  and  cold  have  re- 
spectively always  had  their  partisans,  and  have 
been,  we  think,  needlessly  opposed.  If  it  were 
possible  to  apply  a temperature  high  enough  to 
kill  leucocytes,  it  is  probable  that  most  inflam- 
mations might  be  suddenly  brought  to  an  end. 
Almost  the  only  instance  of  this  is  the  cure  of  a 
whitlow  on  the  finger  by  plunging  it  into  hot 
water ; a treatment  which  would  be  more  satis- 
factory if  the  necessary  temperature  were  pre- 
cisely fixed.  Short  of  this,  heat  doubtless 
increases  the  activity  of  most  inflammatory  pro- 
cesses. But  heat  combined  with  moisture  is  the 
typo  of  an  emollient,  by  which  the  substance 
of  inflamed  tissues  is  relaxed,  the  blood-vessels 
dilated,  the  sense  of  tension  and  nervous  irritation 
removed,  and  though  exudation-processes  are 
probably  encouraged,  the  mechanical  condition  of 
stasis  is  relieved,  and  resolution  is  thus  hastened. 
When  pus  is  forming,  there  is  little  doubt  that 
heat  and  moisture  (in  the  form  of  poultices  and 
fomentations),  hasten  the  process,  and  increase 
the  amount  of  pus  formed  ; but  the  amount  of 
pus  is  often  of  no  great  consequence,  and  it  is  more 
important  to  hasten  the  process.  Thus  it  may  be 
the  right  treatment  for  suppuration.  When  pus 
is  once  formed,  the  same  treatment  is  useful  in 
guiding  it  in  the  direction  in  which  it  is  least 
hurtful.  Finally,  it  may  be  beneficial  to  apply 
heat  and  moisture  superficially,  to  relieve  deep- 
seated  organs,  by  stimulating  the  vascular  and 
lymphatic  circulation  through  the  skin.  Thus,  in 
applying  poultices  for  pneumonia  we  do  not  make 
the  lung  or  even  the  pleura  hotter,  but  relieve 
the  overloaded  blood-vessels  and  lymphatics. 

Further,  in  treating  all  superficial  inflamma- 
tions we  must  guard  against  anything  which  in- 
creases the  injury,  such  as  movement,  further 
irritation  by  the  air  or  anything  contained  in 
the  air.  Thus,  in  some  skin-diseases,  as  herpes 
zoster,  secondary  inflammation  is  prevented  by 
an  artificial  covering  of  collodion.  Antiseptic 
surgery  shows  that  not  the  air,  but  something 
in  the  air,  is  to  be  feared,  and  if  this  is  excluded 
much  inflammation  is  prevented.  The  benefits 
of  mechanical  rest  in  treating  injuries  of  the 
limbs  need  not  be  more  than  mentioned ; nor  that 
of  physiological  rest,  wherever  it  can  be  obtained, 
in  threatened  or  existing  inflammation  of  any 


active  organ  whatever — for  example,  the  brain, 
the  stomach,  or  the  kidney. 

In  many  acute  inflammations,  however,  where 
the  course  of  the  inflammation  is  known,  and  we 
know  we  cannot  absolutely  stop  the  process,  our 
best  method  may  be  merely  to  apply  palliatives, 
that  is,  to  adopt  an  expectant  method. 

Diet  is  also  cf  great  importance.  There  is 
little  doubt  that  the  intensity  of  all  inflamma- 
tions is  lessened  by  greatly  diminishing  the  fex-d 
taken.  In  some  acute  inflammations,  especially 
fevers,  we  may  pursue  a different  system,  with 
the  view  of  saving  the  patient’s  strength ; but 
it  is  possible  that  in  the  reaction  against  the 
starving  process,  feeding  may  be  sometimes  car- 
ried too  far. 

In  the  treatment  of  chronic  inflammation  in 
accessible  parts,  the  first  aim  will  be  to  check 
the  exudation  and  cell-migration,  that  is,  to  bring 
the  vascular  wall  into  a healthy  state.  Here  we 
find  that  metallic  and  vegetable  astringents  are 
most  useful.  But  it  may,  with  the  same  object, 
be  well  to  draw  more  blood  into  the  part,  in  order 
that  the  vascular  wall  may  be  better  nourished. 
This  is  effected  by  stimulants,  which  are  of  well- 
known  efficacy  in  chronic  inflammation.  These 
agents  are  for  the  most  part  the  same  as  astrin- 
gents, but  in  a more  concentrated  form — nitrate 
of  silver,  sulphate  of  copper,  &e. ; but  also  some 
aromatic  substances,  as  tar,  which  is  used  in 
chronic  inflammations  of  the  skin,  copaiba  for 
the  urethra,  &c.  Again,  it  may  happen  that  it  is 
best  to  sweep  the  old  tissue  away,  and  allow  new 
vessels  to  be  formed,  which  will  probably  have 
healthier  walls.  This  is  effected  by  destructive 
caustics,  as  nitrate  of  silver,  potassa  fusa,  chloride 
of  zinc,  or  even  the  actual  cautery. 

In  chronic  inflammations,  internal  treatment  iE 
often  of  great  service,  as  we  shall  presently  show. 

b.  Indirectly  accessible. — The  treatment  of  in- 
directly accessible  inflammations,  or,  what 
amounts  to  the  same  thing,  the  treatment  l>y 
internal  (general)  methods  even  of  directly  ac- 
cessible inflammations,  is  much  less  satisfactory 
than  the  local. 

The  first  indication  is  to  give  the  part  actual 
rest,  mechanical  or  physiological ; the  next,  to 
consider  if  there  is  any  way  of  reducing  the  inten- 
sity, either  of  the  local  reaction,  or  of  the  fever.  Of 
such  means  the  chief  are  general  blood-letting: 
the  general  application  of  cold;  and  certain  drugs 
called  vascular  depressants,  such  as  mercurials, 
antimonials,  purgatives,  digitalis,  aconite,  qui- 
nine, and  a number  more. 

Of  general  blood-letting  we  cannot  say  much 
here.  There  can  be  little  doubt  that  it  often 
lowers  the  energy7  of  inflammatory  processes  in 
an  early  stage.  If  it  has  gone  out  of  use,  it  is 
probably  because  the  course  of  many  diseases 
is  now  better  known,  and  we  do  not  expect  to 
cut  them  short ; because  the  list  of  infective  dis- 
eases is  enlarged  ; and  because  the  benefits  are 
supposed  to  be  outweighed  by  the  supposed  draw- 
backs in  diminishing  the  strength  of  the  patient. 
Of  cold  baths  we  need  only  here  say  that  they  are 
far  more  potent  in  checking  the  condition  of  fever, 
than  in  stopping  local  inflammation.  Of  drugs. 
digitalis  is  supposed  to  act  by  depressing  the 
heart’s  action ; but  in  theory  this  is  doubtful,  and 
in  practice  we  see  little  effect  on  organic  inflam- 


INFLAMMATION. 

mations.  Aconite  also  has  little  local  effect,  but 
does  modify  the  febrile  state.  Quinine  is  thought, 
on  theoretical  and  experimental  grounds,  to  check 
the  emigration  of  leucocytes,  and  to  kill  organ- 
ised bodies  or  germs  resembling  bacteria.  The 
first  belief  is  experimentally  true  if  the  drug  is 
in  a certain  degree  of  concentration;  but  we  have 
no  safe  meaus  of  introducing  it,  in  this  degree  of 
concentration,  into  the  blood.  Alcohol  even  has 
been  recommended  as  an  antiphlogistic,  on  the 
ground  that  it  lowers  the  temperature  in  health. 
But  even  this  is  not  constant,  and  there  is  no 
good  reason  for  thinking  that  it  has  this  effect 
in  fevers,  still  less  that  it  checks  the  inflamma- 
tory process.  If  alcohol  be  given,  it  must  be  on 
other  grounds.  Salicylic  acid,  carbolic  acid,  and 
thymol  are  lauded  as  destroying  fever-germs  ; 
but,  as  -with  quinine,  we  cannot  get  them  into  the 
blood  in  sufficient  concentration,  and  if  we  could, 
it  is  probable  that  other  more  serious  disturb- 
ances would  be  produced. 

The  conclusion  must  be  that  there  is  no  one 
drug  which  is  capable  of  controlling  local  pro- 
cesses of  inflammation,  though  the  resulting  con- 
dition of  fever  may  be  modified. 

The  use  of  mercurials  andantimonials  seems  to 
have  been  affected  by  the  same  considerations  as 
blood-letting.  Tlie  action  formerly  attributed 
to  them  is  now  doubted,  and  it  is  further  thought 
they  do  harm  in  other  ways.  But  no  adequate 
explanation  has  been  given  of  the  difference  in 
this  respect  between  the  practice  of  this  and 
the  last  generation.  Purgatives  remain  as  a 
harmless,  unquestionable,  but  not  very  potent 
antiphlogistic  method. 

In  the  general  treatment  of  chronic  inflamma- 
tions we  have  more  satisfactory  principles.  It 
is  in  cachectic  persons,  or  persons  with  an  in- 
nerited  proclivity  (perhaps  not  yet  manifest) 
to  cachectic  diseases,  that  inflammations  most 
tend  to  become  chronic.  Hence,  the  first  rule 
is  to  improve  the  nutrition.  Many  patients  with 
chronic  inflammations  get  well  at  once  when 
placed  in  good  quarters,  and  on  good  food.  Next 
in  importance  come  nutrient  tonics,  of  which  cod- 
liver  oil  is  the  chief.  There  are  few  chronic  in- 
flammations in  which  it  does  not  do  good.  Iron 
is  very  often  valuable  ; and,  if  it  fail  or  is  con- 
tra-indicated, arsenic  may  be  employed.  In 
chronic  inflammations  of  fibrous  tissues,  iodide 
of  potassium  has  a real  value,  not  easily  ex- 
plained. In  treating  other  inflammations,  either 
acute  or  chronic,  there  are  many  specific  remedies, 
but  these  are  remedies  for  the  disease,  not  for 
its  inflammatory  features  only.  For  this  reason, 
we  do  not  here  speak  of  mercury,  colehicum, 
salicylate  of  soda,  and  other  agents. 

Finally  a most  important  means  of  treating 
indirectly  accessible  inflammations  must  be  men- 
tioned, namely  that  by  counter-irritants,  or  setting 
up  a rival  inflammation.  In  order  to  relieve  an 
inflammation,  for  instance,  of  the  knee-joint,  we 
produce  a superficial  inflammation  cf  the  skin. 
This  is  most  used  in  chronic,  but  applies  to  some 
'cute  inflammations  also.  Various  explanations 
lave  been  given  of  the  undoubted  efficacy  of  this 
reatment.  Some  believe  the  action  is  trans- 
nitted  through  the  nerves  ; others  that  blood  is 
Irawn  away  ; others  that  the  lymphatics  are 
timulated.  The  writer’s  belief  is  that  in  the  most 
45 


INFLUENZA.  706 

marked  cases  of  benefit  from  counter-irritation, 
there  is  a continuity  of  tissue  between  the  in- 
flamed organ  and  the  part  where  the  counter-ir- 
ritant is  applied,  and  that  the  action  may  some- 
times consist  in  drawing  away  blood;  but  gene- 
rally this  is  not  possible,  and  the  benefit  results 
from  setting  up  currents  of  plasma  through  the 
lymphatics  and  the  connective-tissue  spaces.  It 
should  be  noted  that  in  some  inflammations, where 
oedema  is  a marked  feature,  simple  puncture  has 
an  unquestionable  efficacy  which  may  perhaps  be 
explained  in  the  same  way.  The  substances  used 
for  counter-irritation  are  either  vesicants,  such 
as  cantharides  or  ammonia;  or  rubefacients,  as 
mustard  and  iodino.  Dry  heat  at  different  tem- 
peratures mayproduce  the  effect  of  either  of  these 
classes.  When  redness  is  produced  on  the  skin, 
it  does  not  follow  that  hypersemia  alone  result-. 
In  fact  the  desquamation  often  shows  that  a low 
form  of  inflammation  has  been  established.  We 
have  here  endeavoured  to  give  the  principles  onlv 
of  the  treatment  of  inflammation.  For  the  treat- 
ment of  inflammations  of  special  parts,  the  ar- 
ticles on  these  subjects,  as  well  as  the  article? 
on  Blood,  Abstraction  of ; Counter-irritation  ; 
and  Heat,  Therapeutics  of,  must  be  consulted. 

J.  F.  Payne. 

INFLATION  ( inflo , I blow  into). — A term 
applied,  therapeutically,  to  the  method  of  blowing 
air  or  gas  into  any  hollow  space.  It  is  employed 
particularly  in  connection  with  the  lungs  in  the 
process  of  artificial  respiration  {sec  Artificial 
Respiration).  It  is  also  used  for  the  purpose  of 
dilating  the  bowel  in  cases  of  obstruction  {see 
Intestinal  Obstruction).  The  term  inflation 
was  formerly  used,  pathologically,  as  a synonym 
for  emphysema  of  the  lungs,  but  is  now  moro 
strictly  limited  to  the  condition  in  which  the 
alveoli  are  temporarily  distended  with  air,  from 
any  obstruction  in  the  air-passages.  See  Lungs, 
Emphysema  of. 

INFLUENZA. — Synon.  : Epidemic  Catarrh ; 
F’r.  Grippe  ; Ger.  Influenza  ; Epidemischer 
Scknupfenfieber. 

The  term  Influenza  is  said  to  have  been  first 
introduced  in  1711,  when  the  disease  was  pre- 
vailing in  the  North  of  Italy,  and  it  has  been 
generally  adopted  in  this  country ; though  the 
more  scientific  term — Epidemic  Catarrhal  Fever 
— is  often  used  in  systematic  works. 

Df.finition. — This  disease  is  not  to  be  re- 
garded as  simply  an  unusually  prevalent  common 
catarrh,  but  must  be  considered  as  a specific 
affection,  which  appears  occasionally  over  wide 
districts,  and  at  or  about  the  same  time ; is 
characterised  by  marked  febrile  symptoms ; is 
often  attended  by  serious  complications ; and 
causes  great  and  prolonged  prostration  of 
strength. 

Occurrence. — Various  epidemics  of  influenza 
are  on  record  from  the  middle  ages  down  to 
more  recent  times,  and  those  which  have  oc- 
curred in  the  last  and  present  centuries  have 
been  fully  described.  The  disease  is  reported 
to  have  prevailed  in  1729,  1732-33,  1737,  1742 
1758,  1762,  1767,  1775,  and  1782,  and  iu  1803, 
1833,  1837,  and  1847.  The  following  account  is 
chiefly  founded  upon  the  disease  as  it  prevailed 


INFLUENZA. 


roe 

in  1847,  but  the  description  given  of  its  pecu- 
liarities corresponds  with  the  accounts  of  previous 
epidemics. 

The  disease  may  be  described  as  assuming 
three  distinct  forms: — 

1st.  That  in  which  it  is  simple,  or  unattended 
with  any  serious  complication. 

2nd.  When  it  is  complicated  by  serious  affec- 
tion of  the  aiirial  mucous  membrane,  and  espe- 
cially with  bronchitis  and  pneumonia  ; and 

3rd.  When  the  disorder  of  the  digestive  organs , 
which  generally  exists  to  some  degree  in  the 
disease,  becomes  a more  prominent  character  • 
while  there  are  marked  rheumatic  symptoms,  and 
a tendency  to  assume  a remittent  form. 

The  description  would  also  be  imperfect  without 
reference  being  made  to  the  modifying  influence 
which  the  epidemic  exerts  over  other  diseases 
prevailing  at  the  same  time,  and  especially  over 
the  specific  fevers. 

1.  Simple  Catarrhal  Fewer. — Symptoms. — 
In  this  form  of  the  disease  the  attack  is  most  com- 
monly sudden.  The  patient  experiences  a sense  of 
cold  down  the  back  and  between  the  shoulders, 
lapsing  into  general  chilliness  or  complete  rigors, 
and  succeeded  by  flushes  of  heat  and  dryness  of 
the  skin,  pain  in  the  head,  chest,  and  extremities, 
find  prostration  of  strength.  Generally  these 
symptoms  follow  some  exposure  to  cold  and 
damp,  but  occasionally  they  appear  without  being 
traceable  to  any  immediately  exciting  cause,  and 
more  rarely  the  attack  comps  on  gradually,  with 
a general  feeling  of  indisposition  of  two  or  three 
days’  duration. 

At  first  there  is  dryness  of  the  nostrils  and 
soreness  of  the  throat,  wfith  a sense  of  tightness 
or  constriction  of  the  chest,  and  a dry,  hard 
cough.  As  the  disease  advances,  copious  de- 
fluxioc  from  the  nostrils  takes  place;  the  throat 
is  often  seriously  affected  ; and  the  cough  is  more 
frequent.  The  expectoration  is  at  first  scanty, 
and  consists  of  a pale  glairy  fluid  ; but  at  a later 
period  there  is  more  copious  discharge  of  opaque 
mucus.  At  the  same  time  some  degree  of  diffi- 
culty of  breathing  and  soreness  at  the  chest  are 
experienced.  The  respiration  is  in  most  in- 
stances accelerated  ; and,  on  auscultation,  the 
inspiratory  sounds  are  dry  and  harsh,  especially 
in  the  posterior  and  inferior  parts  of  the  chest, 
and  sibilant  and  sonorous  rhonchi  may  be 
audible  on  forced  inspiration.  In  some  cases 
no  marked  sounds  are  heard,  but  the  vesicular 
murmur  is  very  indistinct.  A sense  of  chilli- 
ness. alternating  with  flushes  of  hea.t,  is  a general 
symptom  throughout  the  progress  of  the  attack ; 
and  there  is  distressing  headache,  particularly  in 
the  forehead,  across  one  or  both  eyebrows,  as  well 
as  pain  in  the  balls  of  the  eyes.  These  symp- 
toms often  undergo  considerable  remission  during 
the  day,  and  become  much  increased  in  severity 
towards  night.  There  is  also  commonly  much 
mental  depression,  listlessness,  inability  for  in- 
tellectual exertion,  and  nocturnal  restlessness. 
The  tongue  is  usually  moist,  and  covered  with  a 
white  creamy  fur;  but  occasionally  it  is  mor- 
bidly red  at  the  tip  and  edges,  and  thickly  coated 
with  a whity-brown  fur  towards  the  centre  and 
root ; more  rarely,  and  especially  in  the  morning, 
it  is  dry.  In  the  greater  number  of  cases,  entire 
loss  of  appetite,  with  some  nausea,  and  a confined 


state  of  the  bowels,  are  present  from  the  com- 
mencement; but  occasionally  diarrhoea  is  observed 
at  an  early  period,  and  not  unfrequently  it  comes 
on  during  the  progress  of  the  disease.  Sense  of 
weight,  tenderness,  and  pain  in  the  right  hypo- 
chondrium  are  frequently  experienced;  and  there 
is  often  some  icteroid  tinging  of  the  conjunctiva 
or  of  the  general  complexion.  The  urine  ij 
scanty  and  high-coloured  at  first,  but  subse- 
quently becomes  more  free,  and  deposits  some 
sediment. 

Prostration  of  strength  is  throughout  one  of 
the  most  marked  and  distressing  features  of  ike 
complaint,  and  there  is  a general  feeling  cl 
soreness,  with  dull  aching  pains  in  the  chest, 
back,  and  limbs.  The  pulse  is  but  little  varied 
in  frequency,  generally  ranging  from  eighty  to 
ninety,  and  rarely  exceeding  a hundrel  beats  in 
the  minute.  Though  occasionally  full,  it  is  uni- 
formly very  compressible,  and,  after  the  first 
day  or  two,  feeble.  The  skin  is  seldom  hot  or 
very  dry,  or,  if  so,  it  is  only  at  the  commence- 
ment of  the  attack,  and  it  soon  becomes  cool  and 
moist ; the  complaint  usually  subsides  with  free 
perspiration. 

The  ordinary  duration  of  the  indisposition  in 
this  form  of  the  epidemic  may  be  stated  at 
from  three  to  five  days  in  the  milder  cases, 
tind  from  seven  to  ten  in  those  of  a more  severe 
description.  The  disease,  however,  on  its  sub- 
sidence usually  leaves  the  patient  for  some  time 
much  prostrated,  and  suffering  from  loss  of  appe- 
tite, inaptitude  for  bodily  or  mental  exertion, 
and  a troublesome  cough.  There  is  a great 
tendency  to  relapse. 

Not  unfrequently  towards  the  termination  of 
the  attack  the  transient  pains,  which  are  trouble- 
some during  its  course,  increase  in  severity,  and 
rheumatic  affections  of  an  obstinate  and  painful 
character  supervene.  These  often  assume  a re- 
mittent or  intermittent  form,  returning  regularly 
at  the  same  hour  for  several  days  in  succession, 
and  not  unfrequently  affecting  one  side  of  the 
head,  or  one  eyebrow  or  eyeball,  and  occasionally 
the  intercostal  muscles  of  one  side  of  the  chest. 

2.  Epidemic  Catarrhal  Fever  with  pre- 
dominant Pulmonary  Affection. — Symptoms. 
It  has  already  been  noticed  that  some  amount 
of  soreness  of  the  throat,  and  uneasiness  or  pain 
in  the  chest,  with  cough  and  expectoration  and 
slight  bronchitic  signs,  are  observed  in  the  cases 
of  the  epidemic  which  might  be  considered  as 
assuming  the  simple  form.  Not  unfrequently. 
however,  the  symptoms  of  affection  of  the  aerial 
mucous  membrane  are  more  marked,  there  being 
decided  quinsy,  laryngeal  symptoms,  croup, 
bronchitis,  or  pneumonia.  Of  these,  however, 
the  most  frequent  and  important  are  the  bron- 
chitic and  pneumonic  complications. 

The  bronchitis  has  especially  the  tendency  to 
assume  the  acute  capillary  form.  In  cases  of 
acute  capillary  bronchitis  occurring  as  a compli- 
cation of  influenza,  there  is  usually  in  the  early 
stage  increased  frequency  and  some  difficulty  ot 
breathing,  constriction  of  the  chest,  and  sore- 
ness or  stiffness  of  the  throat.  The  cough, 
though  slight,  is  troublesome  from  its  frequency. 
The  expectoration,  if  there  be  any,  is  scanty  and 
of  a glairv  character.  The  tongue  is  usually  red 
at  the  tip  and  edges,  and  covered  at  the  Jersnn 


INFLUENZA. 


with  a creamy  mucus  or  with  a whity-brown  fur  ; 
occasionally  it  is  morbidly  red  throughout.  The 
pulse  is  accelerated,  heating  generally  110  to  112 
or  1 1 G in  the  minute,  and  occasionally  more. 
The  skin  is  not  usually  hot,  except  it  be  at  the 
commencement  of  the  attack,  and  if  so  it  usually 
becomes  cooler  in  two  or  three  days.  With  these 
symptoms  there  are  the  marked  prostration  of 
strength,  the  severe  frontal  headache,  the  general 
soreness  of  the  body,  and  the  pain  in  the  back 
and  limbs,  which  characterise  the  ordinary  cases 
.f  influenza. 

When  the  chest  is  examined  in  this  stage 
if  the  disease,  the  only  morbid  signs  detected 
are  a roughness  of  the  inspiratory  sound,  par- 
ticularly when  a forced  inspiration  is  drawn ; 
some  slight  crepitation,  audible  more  especially 
towards  the  lower  part  of  each  dorsal  region; 
feebleness  of  the  vesicular  murmur;  and  per- 
haps slight  sibilant  rhonehus  in  front.  The 
respiration  is,  however,  quicker  and  shorter  than 
natural,  averaging  28,  32,  or  40  in  the  minute  ; 
the  dvspnoea  is  greater  than  is  explained  by  the 
obvious  physical  signs  ; and  most  generally  there 
is  some  lividity  of  the  face. 

In  the  second  stage  all  these  symptoms  are 
much  aggravated.  The  respiratory  acts  are  per- 
formed quickly  and  imperfectly,  the  respirations 
in  the  minute  varying  from  30  to  40  or  50.  The 
cheeks  are  much  flushed,  and  the  lips  of  a 
somewhat  purple  colour.  Generally  there  is  not 
acute  pain  in  the  chest,  but  rather  a sense  of 
constriction  and  soreness ; the  cough,  though 
frequent  and  occurring  in  paroxysms,  is  not 
usually  severe.  The  expectoration  still  con- 
tinues scanty,  and  consists  of  small  yellowish- 
white  pellets,  forming  tenacious  masses  of  a 
peculiar  nodulated  orbotryoidal  form,  very  much 
resembling,  when  floating  in  water,  fragments  of 
•some  of  the  large  oolitic  limestones.  The  tongue 
is  mostly  covered  with  a thick  whity-brown  fur, 
i and  somewhat  dry  and  often  red  at  the  tip  and 
i edges  ; or  morbidly  red  and  glazed.  The  pulse 
is  much  accelerated,  beating  120,  130,  or  140 
times  in  the  minute,  but  it  is  generally  small 
and  very  compressible.  In  some  instances,  after 
being  low  and  feeble  at  the  outset  of  the  disease, 
it  acquires  a more  sthenic  character  in  the 
second  stage.  The  skin  is  rarely  dry,  or  much 
above  the  natural  temperature  ; and  the  hands 
and  feet  are  generally  cool.  The  skin  of  the 
extremities  is  also  much  congested,  so  that  when 
blanched  by  pressure,  the  colour  does  not  readily 
return.  The  prostration  of  strength  also  be- 
comes greater  ; and  there  is  much  headache,  and 
often  transient  delirium,  especially  during  the 
night.  On  percussion,  the  chest  does  not  present 
any  marked  alteration  of  resonance,  unless  there 
exists  some  other  disease  of  the  lung;  and  on 
lauscultation,  crepitation  of  a more  or  less  fine 
character  is  audible  with  the  inspiration,  first  in 
the  inferior  part  of  one  or  both  dorsal  regions, 
then  spreading  rapidly  higher  up  in  the  back  and 
toward  the  bases  of  the  lungs  in  front,  whilst 
ubilant  rhonehus  is  heard  in  other  parts  of -the 
■hest. 

The  third  stage  of  the  disease  is  marked  by 
he  dyspnoea  becoming  so  severe  that  the  patients 
re  compelled  to  sit  constantly  upright  inhed.or  to 
jean  forwards,  resting  on  their  arms  and  elbows  ; 


707 

whilst  at  intervals  the  respiration  becomes  very 
laborious.  The  lividity  of  the  cheeks,  lips,  and 
hands  is  increased;  the  eyes  become  prominent ; 
and  the  expression  of  countenance  is  extremely 
anxious.  The  cough  is  frequent,  and  of  a short 
abortive  character,  giving  the  impression  of 
viscid  secretion  in  the  lung,  which  the  patient 
has  not  power  to  expectorate  ; whilst  it  is  aggra- 
vated by  paroxysms,  which  cause  pain  in  the 
head,  and  increased  lividity.  The  sputum  now 
becomes  large  in  quantity;  it  is  of  a greenish- 
yellow  colour,  very  viscid,  contains  little  air,  and 
is  occasionally  streaked  with  blood.  The  re- 
spirations are  very  frequent,  50  to  60,  or  even 
more  ; and  expiration  is  very  laboured  and  pro- 
longed. The  pulse  is  very  feeble,  and  either 
extremely  quick — 140,  150,  or  160  in  the  minute 
— or  intermittent,  so  as  to  number  only  100  or 
1 20  beats.  The  tongue  is  covered  with  a thick 
yellowish-white  or  brown  fur,  and  is  generally 
dry ; sordes  also  form  upon  the  teeth.  Tho 
general  surface  of  the  body  becomes  cool  and 
bathed  in  perspiration  ; and  the  hands  and  feet 
decidedly  cold.  The  delirium  is  more  constant ; 
with  the  decaying  strength  the  cough  declines; 
the  expectoration  ceases  or  becomes  slight;  and 
the  patient  sinks. 

With  the  progress  of  the  disease  the  physical 
signs  change.  The  chest  in  front  yields  a uni- 
formly clear  sound  on  permission,  while  behind 
there  is  a general  impairment  of  the  resonance. 
The  crepitation  gradually  extends  over  larger 
portions  of  the  lungs,  being  of  a finer  character 
in  the  parts  more  recently  involved ; giving 
place  to  subcrepitant  and  mucous  rhonehi  in  the 
situation  in  which  it  was  first  heard;  and  finally 
becoming  of  a gurgling  character  in  the  neigh- 
bourhood of  the  larger  bronchial  tubes.  The 
subcrepitant  rhonehus  also  towards  the  end  ot 
the  attack  is  heard  with  the  expiration  as  well 
as  with  the  inspiration;  and  if  there  is  some 
local  condensation,  bronchial  respiration  may  be 
developed. 

Tn  the  cases  which  terminate  favourably,  the 
amendment  is  marked  by  the  respiration  becom- 
ing less  hurried  and  laborious ; by  the  expression 
of  countenance  being  less  anxious,  and  the  face 
less  livid;  and  by  the  prostration  of  strength  de- 
creasing. The  pulse  becomes  less  frequent,  the 
cough  less  severe,  and  the  sputum  less  viscid 
- — more  of  a muco-purulent  character  with  a ten- 
dency to  form  a homogeneous  mass,  containing 
large  air-bells.  At  a later  period  it  becomes 
thinner,  and  declines  in  amount.  The  mucous 
and  subcrepitant  rhonehi  are  replaced  by  finer 
sounds,  and  the  space  over  which  the  morbid 
signs  are  heard  diminishes— these  disappearing 
first  in  the  upper  part  of  the  chest,  then  at  the 
front  and  sides,  and  lastly  in  the  dorsal  regions. 
The  clearness  of  the  sound  on  percussion  on  the 
front  of  the  chest  also  passes  away,  and  is  often 
succeeded  by  a somewhat  dull  sound  ; and  tho 
respirator)’  sounds  become  indistinct.  The  con- 
valescence is,  however,  generally  protracted ; 
the  patient  is  liable  to  returns  of  dyspnoea  at 
intervals;  and  the  cough  continues  troublesome. 
After  the  subsidence  of  the  pulmonary  symptoms, 
the  rheumatic  pains,  if  previously  present,  may 
become  aggravated,  or  may  then  first  appear  and 
become  troublesome,  affecting  the  head,  face,  or 


INFLUENZA. 


708 

intercostal  muscles,  and  being  aggravated  to- 
wards night. 

Anatomical  Characters. — On  examination 
after  death,  one  of  the  peculiar  features  of  this 
form  of  disease  is  the  extremely  inflated  con- 
dition of  the  lungs,  which  in  lieu  of  collapsing 
when  the  chest  is  laid  open,  in  some  cases 
protrude  from  the  cavity.  This  condition  is  not 
limited  to  certain  parts  in  which  there  are 
larger  or  smaller  bullse,  but  consists  in  a gene- 
ral inflation  of  large  portions  of  the  lung.  The 
mucous  membrane  of  the  bronchi  is  reddened, 
and  the  injection  increases  towards  the  smaller 
tubes,  where  the  membrane  may  be  intensely 
red  and  have  a villous  appearance.  The  lung- 
tissue  in  the  cases  proving  fatal  at  an  early 
period  has  a peculiar  dry  appearance,  but  in  the 
later  stages  it  is  oedematous.  There  is  also 
more  or  less  lobular  condensation,  the  condensed 
parts  being  depressed  below  the  adjacent  inflated 
tissue,  and  having  a deep  purple  colour.  At  a 
later  period  the  condensed  tissue  may  soften 
from  the  presence  of  pus,  and  small  cavities 
may  be  formed  in  this  manner.  The  bronchial 
glands  are  enlarged  and  softened.  The  cavities 
of  the  heart,  especially  on  the  right  side,  are 
distended  with  firm  and  more  or  less  decolorised 
coagula. 

Prognosis  and  DURATION. — The  cases  of  in- 
fluenza complicated  by  acute  capillary  bronchi- 
tis are  always  very  serious  in  their  character; 
and  when  the  disease  occurs  in  persons  who 
have  before  been  out  of  health,  and  especially 
if  there  be  any  previous  disease  of  the  lungs  or 
heart,  or  if  the  subjects  be  very  young  or  elderly, 
they  prove  fatal  in  a large  proportion  of  cases. 
The  duration  of  the  disease  in  the  cases  which 
prove  fatal  is  from  about  ten  to  fourteon  days ; 
and  when  recovery  occurs,  the  patient  is  ill  from 
a fortnight  to  three  weeks,  or  longer. 

Pneumonia. — In  the  cases  of  pneumonia  which 
were  seen  during  the  prevalence  of  the  last 
epidemic  of  influenza,  the  disease  was  very 
generally  combined  with  bronchitis,  either  af- 
fecting the  larger  or  smaller  tubes,  yet  the  cases 
were  less  serious  than  those  in  which  the  disease 
assumed  the  form  of  acute  capillary  bronchitis 
alone.  This  is  the  more  remarkable  as  they 
were  more  frequently  combined  with  serious 
disorder  of  the  abdominal  organs,  and  with 
rheumatic  symptoms,  and  were  attended  with 
great  prostration  of  strength.  Of  the  symptoms 
in  these  cases,  cough  is  one  of  the  most  trouble- 
some ; the  expectoration  is  peculiar,  partaking 
both  of  the  glassy,  transparent,  or  opaque  charac- 
ter of  the  sputum  of  bronchitis,  and  of  the 
brownish  viscid  expectoration  of  pneumonia,  with 
the  usual  small  air-bells.  In  some  cases,  how- 
ever, when  there  is  great  prostration,  there  may 
be  no  expectoration.  Pain  in  the  chest  is  gene- 
rally experienced  at  the  invasion  of  the  disease, 
of  a more  or  less  severe  character,  but  after- 
wards it  is  not  present  to  any  marked  extent, 
or  is  only  experienced  when  the  patient  has 
a severe  paroxysm  of  coughing.  The  dyspnoea 
also  is  not  severe,  and  there  is  not  much  lividity 
of  the  face,  unless  in  cases  in  which  there  is 
also  considerable  bronchitis.  The  breathing  is 
not  usually  very  rapid,  the  respirations  not  ex- 
ceeding 28  or  32  in  the  minute.  The  pulse  also 


is  comparatively  quiet,  -beating  80,  90,  or  100, 
and  it  is  usually  soft  and  compressible,  or  de- 
cidedly small  and  weak.  The  skin,  as  in  the 
other  forms  of  influenza,  is  not  generally  hot 
or  dry  ; or,  if  so  at  the  commencement  of  the 
attack,  it  soon  becomes  cool  and  moist.  The 
tongue  has  usually  the  whitv-brown  covering 
which  has  before  been  described,  and  is  not  dry: 
but  sometimes  it  does  become  dry  and  brown. 
There  is  often  very  marked  disorder  of  the  diges- 
tive organs — sickness  and  vomiting  and  diarrhea; 
and  usually  some  slight  jaundiced  tinge  of  the 
skin  is  observed.  There  is  also  not  unfrequently 
some  delirium  and  stupor  of  mind ; and  the  pros- 
tration of  strength  is  often  extreme.  On  ex- 
amining the  chest,  in  addition  to  the  signs  of 
bronchitis,  which  are  always  present  to  a greater 
or  less  degree,  there  are  the  usual  indications  of 
pneumonia.  At  first  fine  crepitation  is  perceived 
in  the  seat  of  the  disease ; to  this  moro  or  less 
marked  dulness  on  percussion,  bronchial  respi- 
ration, and  increased  resonance  of  the  voice  and 
cough  succeed  ; and  these  signs,  though  gene- 
rally found  in  one  or  both  dorsal  regions,  may 
be  more  widely  diffused.  Notwithstanding,  how- 
ever, the  threatening  character  of  the  symptoms, 
it  was  observed  in  the  epidemic  of  1847  that 
the  disease  was  not  very  fatal,  and  the  signs  of 
consolidation  disappeared  more  readily  than  in 
most  ordinary  cases  of  pneumonia.  The  reso- 
lution was  shown  by  the  return  of  crepitation, 
though  of  a coarser  character,  in  the  seat  of 
consolidation;  and  by  the  gradual  diminution  of 
the  bronchial  respiration,  and  of  the  dulness  on 
percussion.  After  a time  the  natural  vesicular 
breathing  again  became  audible.  The  duration 
of  the  disease  was  very  similar  to  that  in  the 
cases  of  acute  capillary  bronchitis.  In  this,  as  ia 
the  other  forms  of  influenza,  the  convalescence 
was  often  very  protracted;  there  was  the  same 
tendency  to  recurrence  of  the  symptoms  on  any 
slight  exciting  cause ; and  the  rheumatic  pains 
often  long  continued  to  distress  the  patient. 

3.  Catarrhal  Fever,  complicated  with  gastro- 
intestinal affections  and  rheumatism,  and  of 
a remittent  character. 

It  has  already  been  stated  that  in  the  last 
epidemic  of  influenza,  there  were  very  generally 
present  more  or  less  marked  symptoms  of  gastro- 
intestinal and  hepatic  disorder;  and  that  rheu- 
matic pains,  having  a more  or  less  decidedly 
remittent  character,  were  very  usually  observed. 
It  has  further  been  said  that  in  the  cases  in 
which  the  pulmonary  complication  assumed  the 
pneumonic  form,  these  symptoms  were  generally 
more  marked  than  in  the  cases  of  acute  capillary 
bronchitis. 

In  some  cases,  however,  the  latter  symptoms 
were,  throughout,  the  predominant  feature ; and 
as  similar  observations  have  been  made  as  to 
former  epidemics,  cases  of  this  kind  may  fairly 
be  regarded  as  constituting  a special  form  of  the 
disease. 

In  this  form  of  the  epidemic,  nausea  and  sick- 
ness generally  occurred  at  an  early  period  of  the 
attack,  and  often  became  very  urgent  symptoms. 
The  matters  vomited  often  had  a bilious  tinge ; 
and  there  was  generally  a marked  bilious  tinge 
of  the  conjunctive  and  general  surface  of  the 
body,  amounting  in  some  cases  to  decided  jauc 


INFLUENZA. 


dice.  There  was  often  diarrhoea ; and  sometimes 
blend  was  passed  in  the  stools.  The  pains  in 
the  head,  back,  loins,  aud  extremities,  which  are 
present  with  more  or  less  severity  in  all  forms  of 
influenza,  wero  from  the  first  of  a severe  charac- 
ter, or  increased  with  the  progress  of  the  disease 
till  they  constituted  a predominant  feature.  The 
pain  was  usually  most  distressing  in  the  head, 
especially  in  the  forehead,  and  in  some  cases  was 
limited  to  one  temple,  one  eyebrow,  or  one  eye- 
ball. This  was  generally  of  an  intermittent  or  re- 
mittent character,  coming  on  at  night  after  more 
or  less  distinct  remission  during  the  day ; and 
was  attended  with  singing  in  the  ears,  distress- 
ing restlessness,  agitation,  and  inability  to  sleep, 
whilst  delirium  generally  increased  during  the 
exacerbation.  In  some  cases  it  only  amounted 
to  a little  excitement  and  incoherence,  but  in 
ethers  it  was  so  urgent  as  to  require  the  employ- 
ment of  restraint  to  retain  the  patient  in  bed, 
and  sometimes  it  continued  without  intermission 
for  some  hours.  It  was,  however,  remarkable 
how  completely  it  subsided,  as  a rule,  in  the 
morniDg.  With  these  symptoms  there  was 
usually  much  tremor  of  the  extremities ; and  the 
eye  was  pale  and  glassy,  though  the  pupil  was 
frequently  contracted. 

Early  in  the  attack  the  pulse  was  quick  and 
feeble,  and  of  a peculiarly'  vibratory  character, 
though  sometimes  it  was  but  little  accelerated. 
At  a later  period  it  often  became  very  rapid 
and  feeble,  or  fell  below  the  natural  standard 
cf  frequency,  being  very  soft  and  compressible, 
and  occasionally  intermittent.  The  tongue 
was  at  first  moist,  covered  with  the  usual 
wkltv-brown  fur,  and  red  at  the  tip ; subse- 
quently it  hid  a tendency  to  become  dry.  The 
breath  had  a peculiar,  offensive,  acid  odour. 
Epistaxis  occasionally  occurred,  and  sometimes 
to  an  alarming  amount.  The  skin  was  generally 
moist;  and  the  perspiration  had  tho  usual  sour 
, rheumatic  smell.  The  urine  was  at  first  scanty, 
but  afterwards  increased  in  quantity,  and  de- 
posited much  sediment  of  urates.  Occasionally' 
it  was  slightly  albuminous. 

With  these  symptoms  there  were  evidences  of 
some  pulmonary  disorder — bronchitis  or  pneu- 
monia ; and  very  frequently  murmurs  were  heard 
at  the  heart,  which  were  not,  however,  generally 
persistent. 

After  the  exacerbations  the  sweating  was 
often  very  profuse,  so  that  in  the  morning  the 
patient  was  found  completely  bathed  in  it,  and 
the  bedclothes  were  quite  wet.  The  prostration 
of  strength  also  was  often  extreme,  so  that  the 
hands  and  feet  became  livid  and  cold,  and  the 
patient  resembled  a person  in  the  algide  stage  of 
rholera. 

Notwithstanding  their  severity,  the  cases  of 
'his  third  form  of  influenza  generally  did  well, 
hough  the  patients  long  sufferod  from  the  rheu- 
matic symptoms,  and  only  very  slowly  recovered 
heir  strength.  As  seen  from  the  Kegistrar- 
leneral's  reports,  there  was  a great  increase  in 
he  deaths  from  ‘ rheumatism’  during  the  pre- 
alenco  of  the  epidemic,  which  probably  referred 
o cases  of  this  kind. 

I.  Modifying  Influence  of  the  Presence 
fi  Influenza  on  other  Diseases. — In  allvisit- 
tions  of  influenza  of  which  we  have  detailed 


709 

accounts,  the  epidemic  has  been  attended  by  an 
unusual  prevalence  of  other  forms  of  disease,  and 
especially  of  the  specific  fevers — and  the  features 
of  such  diseases  have  been  much  modified  by  the 
epidemic  influenza.  To  this  rule  the  influenza  of 
1817  affords  no  exception.  As  shown  by  the  re- 
ports of  the  deaths  in  London  and  the  country 
generally,  there  was  a great  increase  in  the  total 
mortality;  this  especially  showed  itself  in  tho 
zymotic  class  of  diseases,  but  obtained  also  as 
to  diseases  of  the  heart,  brain,  and  digestive 
organs.  An  unusual  number  of  deaths  were  re- 
corded from  ‘ typhus,’  under  which  head  were 
then  included  the  fevers  which  we  now  discrimi- 
nate into  typhus,  typhoid,  and  relapsing  fever. 
Of  all  these  forms  of  disease,  cases  occurred 
during  tho  time,  though  the  chief  prevalence 
was  apparently  of  typhoid  and  relapsing  fever. 
Tho  features  of  these  diseases  were  generally 
so  much  modified  by  the  epidemic  influence,  and 
they  were  so  constantly  attended  by  pulmonary 
complications,  that  it  was  often  difficult  to  de- 
cide whether  any  given  case  was  to  he  regarded 
as  a case  of  specific  fever  or  of  influenza. 
Various  forms  of  local  disease  were  also  preva- 
lent at  the  time,  both  as  distinct  affections,  and 
as  complications  of  specific  fever,  such  as  diph- 
theria, parotitis,  otitis,  stomatitis,  and  quinsy, 
with  erysipelas,  abscesses,  &e. ; and  these  were 
often  attended  by  great  prostration  of  strength, 
and  added  greatly  to  the  danger  of  the  various 
other  forms  of  disease  with  which  they  were 
combined. 

Pathology. — Every  phenomenon  of  influenza 
points  conclusively  to  the  influence  of  some 
powerful  depressing  agent,  operating  on  the 
nervous  system,  or  entering  the  blood.  The 
sudden  seizure  of  a large  proportion  of  cases  ; 
the  extreme  prostration  of  strength  from  the 
commencement,  and  to  a degree  disproportionod 
to  the  amount  of  local  disturbance ; the  symptoms 
of  disorder  of  all  organs,  and  especially  of  the 
cerebro-spinal  system  ; and  the  debility  which  so 
often  succeeds  even  simple  cases  of  the  disease, 
can  on  no  other  supposition  be  explained.  It 
seems  probable  also  that  the  affection  of  the 
respiratory  mucous  membrane  may  be  due  to 
the  morbific  influence,  whatever  it  may  be,  ope- 
rating more  specifically  upon  it ; but  it  is  ex- 
tremely difficult  to  offer  even  a probable  sugges- 
tion as  to  the  naturo  of  that  influence.  The  almost 
simultaneous  outbreak  of  the  epidemic  in  places 
widely  apart ; the  seizure  of  a large  proportion  of 
the  population  of  a town  or  district  within  the 
course  of  a few  hours  ; and  the  sudden  illness  of  in- 
dividuals or  bodies  of  men  visiting  a locality  where 
influenza  is,  or  has  very  recently  been,  prevailing, 
and  previous  to  direct  intercourse  with  any  per- 
sons actually  suffering — are  all  circumstances  op- 
posed to  the  notion  of  the  disease  being  dependent 
on  infection  in  the  ordinarily  understood  sense; 
and  might  seem  to  point  to  the  operation  of 
atmospheric  influence  as  the  cause.  The  con- 
ditions, however,  under  which  the  disease  has 
presented  itself  in  different  epidemics,  render 
such  an  explanation  impossible.  It  has  travelled 
over  districts  without  reference  to  season  or 
climate,  and  has  prevailed  in  the  same  locality 
in  all  seasons  and  in  almost  every  variety  of 
weather.  It  is  true  that  it  has  often  broken  out 


?10  INFLUENZA, 

after  great  meteorological  changes,  as  in  the  last 
two  epidemics  after  sudden  and  remarkable 
falls  from  a comparatively  high  to  a very  low 
temperature;  but,  on  the  other  hand,  epidemics 
have  arisen  under  other  circumstances,  and  such 
alternations  of  temperature  frequently  occur 
without  the  occurrence  of  an  epidemic  of  influ- 
enza. The  disease  has  also  broken  out  at  the 
same  time  at  different  places  in  which  the  same 
atmospheric  conditions  did  not  exist,  so  that  the 
operation  of  the  sudden  change  can  scarcely  be 
regarded  as  acting  even  as  an  exciting  cause. 
There  can,  however,  be  no  doubt  that  the  more 
common  predisponants  to  disease,  such  as  de- 
fective drainage,  overcrowding,  impure  air,  de- 
ficient clothing,  and  insufficient  or  unsuitable 
food,  powerfully  conduce  to  the  prevalence  and 
fatality  of  the  epidemic. 

Treatment. — Of  the  treatment  of  the  simpler 
forms  of  influenza  it  is  not  necessary  to  say 
much.  The  patient  should  be  confined  to  bed; 
have  a footbath;  take  some  form  of  diaphoretic 
medicine;  and  be  allowed  a mild,  unstimulating 
diet.  If  the  cough  becomes  troublesome,  or  if 
there  bo  pains  in  the  chest,  sinapisms  may  bo 
applied,  and  some  anodyne  may  be  added  to  the 
medicine;  and  for  the  relief  of  the  subsequent 
debility,  stimulants,  tonics, and  a nutritious  diet 
may  be  enjoined.  In  the  cases  complicated 
with  pulmonary  affections,  the  same  measures 
may  bo  used,  in  combination  with  expectorants 
and  anodynes;  and  more  decided  counter-irrita- 
tion maybe  applied  to  the  chpst.  When  there 
is  very  copious  secretion,  and  the  patient  cannot 
expectorate  froely,  the  greatest  benefit  is  often 
derived  from  the  use  of  emetics,  and  they  may 
be  employed  with  advantage  in  cases  in  which 
the  patient’s  strength  is  too  much  depressed  to 
allow  of  nauseating  doses  of  medicine  being 
given.  To  the  use  of  emetics,  the  stimulating 
expectorants  — squills,  ammonia,  &c.  — should 
succeed.  For  the  relief  of  the  cases  :n  which 
there  is  nausea  and  sickness  or  vomiting,  effer- 
vescents  with  morphia,  or  hydrocyanic  acid, 
may  be  given.  WThen  there  is  more  or  less  jaun- 
dice, small  doses  of  calomel  or  grey  powder,  in 
combination  with  Dover’s  powder,  are  very  bene- 
ficial ; and  when  there  is  diarrhoea  the  Dover's 
powder  or  decided  astringents — such  as  acetate  of 
lead,  or  lannic  acid — may  be  employed.  When 
(he  rheumatic  symptoms  are  severe,  the  greatest 
relief  is  obtained  by  the  administration  of  small 
doses  of  eolehieum  with  carbonate  of  potash  and 
opiates;  and  when  the  prostration  of  strength 
is  great,  ammonia,  in  combination  with  bark, 
should  be  given.  In  the  cases  in  which  there  is 
a decided  tendency  to  remissions  and  exacer- 
bations, bark  also  may  be  prescribed,  or,  in  the 
more  severe  cases,  quinine;  and  quinine  and 
other  tonics  should  be  freely  given  during  con- 
valescence. 

In  all  cases  of  influenza  all  depressing  treat- 
ment should  he  avoided.  The  cases  do  not 
require  it,  and  the  patients  are  too  much  pros- 
trated to  admit  of  its  employment.  In  all  the  dif- 
ferent forms  of  influenza  it  is  necessary  to  admin- 
ister support  very  freely,  and  sooner  or  later 
to  exhibit  stimulants.  In  the  cases  in  which 
there  is  pulmonary  or  othor  local  complication, 
the  strength  becomes  more  rapidly  and  more 


INHALATIONS,  THERAPEUTIC  USES  Of. 
seriously  depressed,  and  stimulants  and  support 
are  still  more  urgently  needed  ; and  indeed  it  is 
necessary  to  have  recourse  to  them  at  an  earlier 
period,  to  exhibit  them  more  f-eely,  and  toper- 
severe  in  their  use  for  a longer  period  in  such 
affections,  when  occurring  during  an  attack  of  in- 
fluenza than  when  arising  as  idiopathic  diseases. 
In  the  management  also  of  the  other  forms  of 
febrile  affections  which  are  seen  during  an  epi- 
demic of  influenza,  a more  restorative  and  stimu- 
lating treatment  is  required  than  under  ordinaiy 
circumstances,  for  all  such  diseases  partake  of 
the  peculiarly  asthenic  type  of  the  epidemic. 

• Thomas  B.  Peacock. 

INHALATION,  lEtiology  of. — See  Dis- 
ease, Causes  of. 

INHALATIONS,  Therapeutic  Uses  of 

( inhalo , I breathe  in). — Inhalation  is  a method 
of  applying  remedial  agents  to  the  respiratory 
tract,  whereby  these  substances  in  a gaseous  or 
atomized  form  are  brought  into  contact  with  tbe 
mucous  membrane  of  the  nos?,  mouth,  pharynx, 
larynx,  and  bronchi,  and  may  even  penetrate  to 
the  epithelium  of  the  air-cells.  Inhalation  dates 
from  the  days  of  Hippocrates  and  Galen,  and  has 
been  more  or  less  in  vogue  in  all  ages  ; but  onlv 
lately  has  it  been  proved  that  theinhaled  material 
passed  through  the  finest  ramifications  of  the 
bronchi  into  the  pulmonary  alveoli  and  in  some 
instances  became  absorbed  by  the  capillaries,  thus 
entering  the  general  circulation.  The  examina- 
tion of  the  lungs  of  colliers,  grinders,  and  others 
engaged  in  dusty  occupations  has  shown  that  the 
inhaled  dust  can  be  detected  in  the  lung-tissue, 
where  it  induces  chronic  pneumonia.  The  ex- 
periments at  the  Academie  de  Medeeine  proved 
that  medical  sprays  are  equally  penetratitg. 

Methods. — The  modes  of  inhalation  vary  with 
the  drug  used,  depending  mainly  on  the  tempera- 
ture at  which  ic  volatilizes,  and  also  on  the 
medicinal  effects  aimed  at. 

Chloroform,  ether,  bichloride  of  methylene,  and 
nitrite  of  amyl  evaporate  at  ordinary  tempera- 
tures, and  only  need  to  be  diluted  with  air  to  be 
safely  inhaled.  Calomel  and  sulphur  are  sub- 
limed at  high  temperatures  in  special  appara- 
tuses ; but  the  majority  of  drugs  are  best  vapo- 
rized through  the  medium  of  hot  water  or  steam, 
or  reduced  to  fine  spray  by  passing  compressed 
air  through  their  solutions. 

Many  forms  of  inhaler  are  in  use,  but  in  select- 
ing one  for  warm  inhalations  the  requisites  are:— 

(1)  that  it  can  be  used  without  difficulty  by  the 
patient;  (2) that  a temperature  of  1 3l)r  V'  15IFF. 
can  be  steadily  maintained ; (3)  that  the  steam 
bo  thoroughly  impregnated  with  the  medicament: 
and  (4)  that  the  inhaling  tube  be  fitted  to  the 
nostrils  as  well  as  to  the  mouth,  so  as  to  ensure 
a sufficient  supply  of  the  inhaled  vapour.  When 
no  inhaler  is  at  hand,  a jug  with  a wide  mouth 
and  half  filled  with  hot  water  may  be  used,  a 
towel  being  placed  round  between  the  mouth  and 
nose  of  the  patient  and  the  opening  of  the  jug,  to 
prevent  the  escape  of  the  vapour  into  the  air. 

Varieties  and  Uses. — Inhalations  are  em- 
ployed chiefly  in  diseases  of  the  pharynx,  larynx, 
and  air-passages,  and  may  be  classed  as  sedative, 
stimulant , and  antiseptic. 

Sedative.  —Steam  is  soothing  to  the  throat 


INHALATIONS,  THERAPEUTIC  USES  OF. 
when  this  part  is  dry,  inflamed,  or  irritable.  In 
incipient  laryngitis  and  croup,  as  well  as  in  irri- 
table bronchitis,  the  inspiration  of  steam  from 
specially  arranged  kettles  is  very  grateful,  the 
moist  vapour  promoting  secretion  and  expecto- 
ration. 

Jets  of  steam  are  used  in  hospitals  and  bath 
establishments  as  vehicles  for  the  inhaled  drugs, 
and  are  directed  into  the  patient's  mouth. 

As  sedatives  the  vapor  conii  and  the  vapor 
acidi  hydrocyanici  are  recommended  in  cases  of 
laryngeal  or  pulmonary  irritation  A sedative 
inhalation  made  of  equal  parts  of  chloroform 
and  rectified  spirit — of  which  one  teaspoonful  may 
be  added  to  a pint  of  water,  at  60°  to  100D  F. — 
is  much  commended  in  hay-fever  and  laryngeal 
spasm.  A combination  of  chloroform  and  conium, 
in  the  proportion  of  15  minims  of  the  former  to 
1 drachm  of  the  succus  conii,  in  half  a pint  of 
boiling  water,  is  useful  in  phthisis  and  some 
forms  of  asthma. 

Stimulant.  — Stimulating  moist  inhalations 
can  be  prepared  with  various  volatile  oils.  Oils 
of  pine  and  of  cubebs  are  useful  stimulants  in 
cases  where  there  is  much  secretion  from  the 
throat  and  air-tubes.  Thus  2 drachms  of  oil  of 
pine  or  oil  of  cubebs  may  bo  mixed  with  60  grains 
of  light  carbonate  of  magnesia  in  3 ounces  of 
water ; and  of  this  mixture  1 drachm  may  be 
used  in  a pint  of  water  at  each  inhalation.  One 
drachm  of  the  compound  tincture  of  benzoin,  in 
half  a pint  of  hot  water,  is  often  useful  in  chronic 
bronchitis  and  laryngitis.  Oil  of  turpentine  or 
of  pinus  silvestris  (1  drachm  to  the  half- pint  of 
hot  water)  makes  excellent  stimulant  inhalations 
in  cases  of  dilated  bronchi. 

Antiseptic. — Antiseptic  inhalations  are  used 
where  the  object  is  to  correct  a feetid  secretion, 
as  well  as  to  stimulate  the  secreting  membrane 
to  fresh  action.  In  foetid  bronchorrhoea,  in  gan- 
grene of  the  lung,  in  feetid  abscess,  and  in  pyo- 
pneumothorax, benefit  is  derived  from  the  vapor 
creasoti,  the  vapor  iodi,  or  from  glycerine  of  car- 
bolic acid  (from  2 to  3 drachms  to  the  pint  of 
boiling  water),  or  again  from  oil  of  thymol,  pre- 
pared like  the  other  essential  oil  vapours,  with 
light  magnesia  and  hot  water  (10  grains  to  the  3 
ounces).  The  fumes  of  nitre  paper  are  employed 
as  inhalations  in  cases  of  pure  spasmodic  asthma 
uncomplicated  with  bronchitis.  The  paper — pre- 
paredly soaking  white  blotting-paper  in  solution 
of  nitrate  of  potash — is  sometimes  washed  over 
with  tincture  of  benzoin,  and  this,  in  certain 
cases,  may  be  an  improvement ; but  in  ordinary 
forms  of  asthma  the  nitre  paper  (30  or  40 
grains  of  nitrate  of  potash  to  1 ounce  of  water 
to  form  the  solution  for  soaking  the  paper)  burnt 
till  the  patient  is  enveloped  in  smoke,  will  usually 
relieve  the  asthmatic  paroxysm.  The  fume  of  a 
grain  of  powdered  opium  volatilised  on  hot  metal 
has  been  praised  as  a remedy  to  cut  short  nasal 
catarrh ; as  well  as  smoking  solid  opium  in  the 
Chinese  fashion  through  a pipe,  in  spasmodic 
asthma.  Cigarettes  and  pastilles  containing  stra- 
monium and  other  antispasmodics,  are  sometimes 
i used  with  benefit. 

Atomised  inhalations  of  spray  havo  of  late 
I years  come  into  deserved  repute  as  valuable  aids 
to  the  treatment  of  chronic  diseases  of  the  throat 
end  lungs.  The  principle  of  the  hand-ball  and 


INJECTION.  71 1 

steam-spray  atomisers  is,  that  if  two  capillary 
tubes  are  placed  at  a certain  angle  to  each  other, 
one  dipping  into  a fluid,  while  through  the  other  a 
stream  of  air  is  driven  by  heat  or  compression,  a 
vacuum  is  formed  in  the  first,  causing  the  liquid 
to  pass  out  in  the  form  of  fine  spray.  In  using 
tlieso  instruments,  the  operator  should  seek  to 
blow  the  spray  into  the  patient’s  throat  at  the 
time  when  an  inspiration  is  being  taken,  as  thus 
the  spray  will  obtain  a free  entrance  through 
the  larynx  into  the  trachea.  It  is  doubtful  if 
much  spray  enters  the  air-tubes ; some  certainly 
does,  as  has  been  stated  above,  but  the  cold 
sprays  do  not  appear  to  afford  so  much  relief  to 
affections  of  the  lungs  as  the  warm  inhalations. 
In  cases  of  tumidity  of  the  larynx,  a spray 
containing  10  grains  of  alum  to  1 ounco  of 
distilled  water  may  be  used.  In  place  of  alum, 
2 grains  of  sulphate  of  iron,  5 grains  of  sulphate 
of  zinc,  or  5 grains  of  dry  chloride  of  iron,  in  1 
ounce  of  water,  may  be  employed.  For  antiseptic 
purposes,  5 minims  of  sulphurous  acid,  or  1 
minim  of  carbolic  acid,  to  1 ounce  of  water,  or  a 
like  quantity  of  liquor  iodi  may  be  used.  In  putrid 
sore-throat  and  diphtheria  the  writer  has  seen 
excellent  results  from  iodine,  either  inhaled  in 
vapour  or  applied  in  solution.  Three  and  a half 
drachms  of  lactic  acid  in  10  ounces  of  water  form 
a solution  which,  thrown  as  spray  into  the  throat, 
is  of  use  in  diphtheria ; it  seems  to  dissolve 
the  exudation.  As  a styptic  and  hremostatic 
spray  50  to  200  grains  of  tannic  acid  are  em- 
ployed, dissolved  in  10  ounces  of  water,  but  for 
relaxed  throat  a weaker  solution  is  useful.  For 
sedative  purposes  a solution  of  bromide  of  am- 
monium, or  one  containing  half  a grain  of  acetate 
of  morphia  to  1 ounce  of  water,  may  be  employed. 
Diluted  ipecacuanha  wine  spray  is  said  to  be 
very  efficacious  in  relieving  the  dyspnoea  of 
chronic  bronchitis  and  emphysema.  This  spray 
in  a few  instances  may  induce  vomiting,  but  this 
accident  may  be  obviated  by  diluting  the  wine 
with  a considerable  proportion  of  water.  At  the 
Continental  spas  it  is  usual  to  medicate  large 
chambers  by  means  of  sprays  and  vapours,  in 
which  patients  can  sit  for  hours  breathing  the 
artificial  atmospheres;  and  in  this  way  various 
mineral  waters,  such  as  those  of  La  Bourboule, 
Aix-les-Bainc,  and  Cauterets  arc  locally  applied. 

John  C.  Thorowgood. 

IHJECTION  ( injicio , I throw  in). — Synon.  : 
Fr.  Injection;  Ger.  Einspritzung. 

Definition. — Injection  is  the  act  of  introduc- 
ing a fluid  into  any  part  of  the  body,  by  means  of 
a syringe  or  similar  apparatus.  The  word  is  also 
employed  to  designate  the  fluid  so  introduced. 

Varieties. — Injections  are  chiefly  used  in  the 
treatment  of  disease;  but  reference  must  also 
be  made  to  the  method  as  it  is  practised  by 
anatomists  for  the  preservation  of  ‘ subjects’  for 
dissection;  and  for  the  purpose  of  filling  the 
blood-vessels,  lymphatics,  duets,  cavities,  spaces, 
&c.,  preparatory  to  microscopical  examination. 

The  therapeutical  application  of  injections 
comprehends  the  following  measures : — 

1.  Hypodermic  or  subcutaneous  injection,  in 
which  the  fluid  is  injected  under  the  skin.  See 
Hypodermic  Injection. 

2.  Injections  into  the  natural  canals  or  open 


712  INJECTION. 

cavities  of  tho  body ; for  example,  the  external 
ear,  the  Eustachian  tube,  the  nose,  the  nasal 
duct,  the  stomach,  the  rectum  (see  Enema).  the 
urethra,  the  bladder,  and  tho  vagina  and  uterus. 
The  various  forms  of  injections  just  indicated 
will  be  found  fully  discussed  under  the  diseases 
of  the  several  organs. 

3.  Injections  intosA«i  sacs,  normal  or  morbid  ; 
such  as  the  tunica  vaginalis,  the  serous  cavities, 
the  synovial  cavities,  the  sheaths  of  tendons,  and 
jysts  and  chronic  abscesses.  Tho  fluids  used  in 
this  class  of  injections  are  generally  stimulant, 
such  as  a solution  of  iodine.  See  Hydrocele. 

4.  Intravenous  injections,  the  fluid  introduced 

into  the  circulation  being  either  blood  (trans- 
fusion), milk,  or  some  kind  of  nutritive  solution. 
See  Transfusion.  J.  Mitchell  Bruce. 

INOCULATION  ( in. , into,  and  oculus,  a 
bud,  a graft). — As  usually  understood,  inocula- 
tion is  either  an  operative  procedure  or  an  acci- 
dental occurrence,  by  means  of  which  morbid 
materials  are  brought  into  direct  contact  witli 
the  minute  vessels  of  the  skin  or  of  a mucous 
membrane,  or  with  those  of  the  subcutaneous 
or  submucous  tissue,  so  that  they  are  readily 
and  speedily  absorbed,  the  result  being  that 
they  originate  certain  definite  and  specific 
diseases,  varying  with  tho  nature  of  the  mate- 
rial employed.  In  short,  inoculation,  as  com- 
monly practised  or  observed,  is  a mode  by  which 
the  contagia  of  certain  specific  diseases  are  con- 
veyed from  one  animal  or  individual  to  another; 
and  some  of  these  affections  can  only  be  thus 
transmitted,  while  others  are  capable  of  being 
communicated  in  other  ways,  but  in  th»j  way 
most  effectually  and  with  the  greatest  degree  of 
certainty.  The  most  familiar  examples  of  dis- 
eases thus  transmitted  are  vaccinia,  small-pox. 
syphilis,  and  hydrophobia.  It  need  hardly  be 
mentioned  that  vaccinia  can  only  be  conveyed  by 
inoculation,  and  it  is  for  the  purpose  of  inducing 
this  disease  that  the  method  is  ordinarily  inten- 
tionally practised,  so  that  the  terms  vaccination 
and  inoculation  have  come  to  be  popularly  re- 
garded as  synonymous  (sec  Vaccination).  Under 
certain  exceptional  circumstances  inoculation  of 
tho  contagious  matter  of  syphilis,  small-pox,  or 
anthrax  is  employed,  with  the  deliberate  pur- 
pose of  originating  these  affections  ( see  Small- 
pox ; Syphilis  ; and  Pustule,  Malignant).  This 
plan  has  also  been  practised  of  late  years  in  ex- 
perimental pathology,  by  which  the  effects  of 
the  inoculation  of  septic  liquids  upon  the  system 
have  been  demonstrated;  while  it  has  also  been 
shown  that  the  introduction  of  certain  solid 
morbid  products  iu  this  way  may  orkinate  an 
infective  process,  leading  to  definite  pathological 
results.  See  Contagion. 

With  regard  to  the  modes  by  which  inoculation 
is  effected,  it  need  only  he  said  hero  that  when 
it  is  practised  as  an  operation,  the  material  is 
usually  introduced  into  the  subcutaneous  or 
submucous  tissue,  by  means  of  a lancet  or  other 
pointed  instrument.  Sometimes  the  surface  of 
the  skin  is  merely  scarified,  so  that  the  epi- 
dermis is  more  or  less  destroyed;  or  this  is 
removed  by  somo  blistering  agent,  and  the  con- 
tagious substance  then  applied  to  the  exposed 
antis.  Accidental  inoculation  may  take  place  in 


INSANITY. 

connection  with  any  abrasion,  wounl,  or  ulcer 
on  the  skin  or  on  a mucous  surface ; or  by  tho 
bites  of  animals,  as  in  the  case  of  hydrophobia. 

Frederick  T.  Roberts. 

INSANITY.  - Synon.:  Fr.  Folk ; Gcr. 
Geisteskrankheit ; Geistesstoruiig. 

Insanity  is  popularly  known  as  disorder  of 
mind  : as  physicians,  we  know  it  to  be  disorder 
of  the  highest  organs  of  the  nervous  system 
which  unite  in  the  performance  of  that  function 
recognised  and  spoken  of  as  mind.  There  can 
be  no  disorder  of  mind  without  disorder  of 
braiu  : as  physiologists  and  pathologists  we  have 
to  study  and  treat  the  latter,  and  for  this  reason 
the  legislature  enacts  that  certificates  of  insanity 
shall  be  given  by  medical  men,  and  by  them 
alone,  and  that  to  their  care  shall  be  committed 
those  who  are  insane. 

As  a preparation,  then,  for  the  study  of  insane 
mind,  the  learner  ought  to  acquire  a knowledge 
of  healthy  mind — the  healthy  function  of  a healthy 
brain.  Ho  must  know  what  are  the  structures 
which  combine  to  make  up  that  which  we  call 
the  cerebrum,  and  contribute  to  its  healthy  work- 
ing, and  must  trace  the  growth  and  development 
of  this  working  from  the  earliest  days  of  infancy 
to  the  time  of  adult  life.  He  will  perceive  that 
the  growth  of  mental  function  is  as  gradual  as 
that  of  bodily  power;  that  in  some  it  may  be 
more  rapid  than  in  others,  like  that  of  the  body; 
that  it  may  be  arrested  in  its  development,  or 
stunted  and  deformed;  and  that  it  may  by 
imperfection  of  the  organs,  as  blindness  or  deaf- 
ness, be  impeded  or  stopped.  In  all  particulars 
it  will  be  found  subject  to  the  laws  which  regu- 
late the  growth  of  the  body  generally. 

Before  examining  brain-function,  it  will  be 
necessary  to  become  acquainted  with  the  various 
structures  which  form  the  cerebrum.  The  brain 
of  man,  and  indeed  of  all  vertebrates,  is  made  up 
of  nerve-cells  and  nerve-fibres  ; of  a substance  or 
stroma  in  which  the  cells  are  imbedded,  called 
neuroglia  ; and  of  blood-vessels  and  lymphatics. 
The  nerve-cells  are  gathered  into  convolutions  or 
centres  ; and  by  means  of  the  nerve-fibres  com- 
municate with  the  organs  of  special  sense,  with 
the  sensory  ganglia  and  spinal  cord,  with  each 
other,  and  with  the  convolutions  of  the  other 
hemisphere.  Modern  science  is  endeavouring  to 
throw  light  upon  tho  nature  and  uses  of  these 
convolutions.  The  seats  of  the  highest  intelli- 
gence, they  at  the  same  time  appear  to  he  cen- 
tres of  voluntary  motion,  and  of  the  outward 
manifestation  of  intellectual  action. 

Concerning  the  physiology  of  the  blood-supply 
of  the  brain  there  is  still  great  doubt  and  con- 
troversy. Anatomically  we  know  that  from  the 
internal  carotid  and  vertebral  arteries,  combining 
in  the  circle  of  Willis,  there  pass  to  the  brain-sub- 
stance the  anterior,  middle,  and  posterior  cere- 
bral arteries.  The  terminations  of  these  ramify 
in  the  pia  mater,  and  thence  send  many  small 
vessels  to  the  grey  matter,  and  fewer,  but  larger 
ones  to  the  white,  the  supply  of  blood  to  the 
former  being  much  the  more  plentiful.  That, 
however,  which  chiefly  concerns  the  student  of 
insanity  is  the  vaso-motor  system  of  nerves 
which  controls  and  regulates  the  blood-supply. 
Modern  research  appears  to  render  it  more  and 


INSANITY. 


more  certain  that  the  condition  of  insanity,  at 
any  rate  in  its  early  and  acute  stage,  is  mainly 
one  of  increased  blood-supply.  On  what  does 
this  depend  ? To  this  question  no  precise  an- 
swer can  as  yet  be  given.  Investigations  are 
still  being  made  as  to  the  nerves  which  dilate 
and  contract  the  vessels ; but  with  regard  to  this 
subject,  and  the  so-called  inhibition  of  nervous 
influence,  much  more  must  be  ascertained  before 
the  pathology  of  insanity  can  be  definitely  fixed. 
The  lymphatics  of  the  brain  are  also,  according 
to  some  observers,  largely  concerned  with  the 
disturbance  of  mental  function,  if  it  should  hap- 
pen that  by  being  blocked  up  or  impeded  they 
fail  to  carry  off  the  waste  products  of  the  organ. 
They  are  contained  in  perivascular  lymph-spaces, 
lying  between  the  outer  fibrous  coat  of  the  blood- 
vessels and  a hyaline  membrane  or  sheath  of 
pia  mater  which  separates  them  from  the  brain- 
Bubstance.1 

Even  concerning  the  neuroglia,  controversy 
exists.  Is  it  merely  connective-tissue,  or  is  it 
nerve-structure  ? Authorities  lean  to  the  former 
view,  and  the  increase  of  it  in  diseased  brains 
seems  to  point  to  a growth  of  lower  structure  at 
the  oxpense  of  higher. 

Passing  to  the  functions  of  the  brain,  the 
phenomena  comprised  under  this  name  are  of 
two  kinds.  There  are  the  various  movements 
excited  by  the  stimulation  of  the  different  brain- 
centres,  on  which  the  experiments  of  Dr.  Ferrier 
have  thrown  new  and  interesting  light.  But 
these  are  not  the  phenomena  of  mind.  The 
latter  can  only  be  studied  by  observation  of  a 
totally  different  character.  For  mind  implies 
sensation,  feeling,  consciousness ; and  as  we 
have  no  consciousness  of  any  feelings  but  our 
own,  it  is  evident  that  here  objective  observation 
is  insufficient,  however  unwilling  physiologists 
may  be  to  admit  it.  Yet  the  subjective  exami- 
nation of  ourselves  is  as  inadequate  by  itself  to 
explain  the  phenomena  of  diseased  mind,  as  ob- 
jective observation  is  to  make  known  the  nature 
of  mind  in  general.  We  must  use  the  subjective 
method  as  our  key,  and  by  means  of  it  open  up 
and  interpret  the  phenomena  of  mind  : we  may 
then  objectively  examine  the  mental  characteris- 
tics, the  growth  and  development,  the  diseases 
and  decay  of  mind  in  all  human  beings,  children 
or  adults,  idiots  or  insane,  and  by  tracing  thus 
the  effects  of  injuries  and  disease,  we  arrive  at  a 
knowledge  of  the  differences  between  sound  and 
unsound  mind. 

By  observation  of  the  movements  brought 
about  by  nerve-function,  we  perceive  that  they 
follow  the  application  of  a stimulus,  and  that 
many  actions  take  place  in  response  to  stimuli 
which  we  call  reflex,  instinctive,  or  automatic, 
before  those  begin  that  are  the  product  of  - mind 
in  its  highest  sense.  For  mind  grows  slowly 
| and  gradually.  The  first  movements  of  the 
child,  reflex  or  instinctive,  are  the  result  of  sti- 
mulation of  nerve-centres,  but  are  only  slightly, 
if  at  all,  attended  by  consciousness.  This  be- 
! comes  appreciable  later,  and  with  it  the  com- 
mencement of  memory  and  ideas,  as  the  feelings 
roused  by  stimulation  are  stored  away  in  the 
nimd,  to  be  reproduced  as  some  new  stimulus  is 

1 Dr.  Batty  Tuke.  Morisonian  Lectures.  Edinb.  Med. 
fount.,  Dec.  1874. 


713 

presented  to  them,  The  various  brain-centres 
are  in  this  manner  stored  with  ideas,  the  result 
of  experiences  derived  from  without,  and  by 
means  of  the  nerve-fibres  they  are  united  in 
groups  till  a most  complex  system  is  evolved. 
The  sensations  are  developed  into  more  and 
more  complex  feelings,  till  the  highest  emotions 
of  civilised  man  are  reached ; and  in  a similar 
manner  the  intellectual  processes  grow  from 
mere  perceptions  and  cognitions  to  the  highest 
trains  of  thought.  Mind  may  be  said  to  be  made 
up  of  feelings  and  the  relations  between  feelings, 
for  the  intellectual  element  of  mind  is  the  rela- 
tional element,  and  it  will  be  found  that  we  can- 
not locate  in  two  parts  of  the  brain  the  emotions 
and  the  intellect,  as  some  physiologists  have 
proposed;  for  no  kind  of  feeling,  sensational  or 
emotional,  can  be  wholly  free  from  the  intellec- 
tual element;  and  on  the  other  hand  ic  very 
rarely  happens  that  any  act  of  cognition  can  bo 
absolutely  free  from  emotion.2 

For  the  growth  of  healthy  brain  and  mind  all 
the  conditions  of  physical  health  are  necessary. 
If  at  birth  there  is  inherited  defector  accidental 
injury,  or  if  at  any  subsequent  period  develop 
ment  is  arrested  or  perverted,  idiocy  or  imbecility 
is  the  result.  There  will  be  an  imperfect  re- 
cording of  the  experiences  of  life,  an  inability  to 
learn,  and  a deficient  power  of  bringing  into  re- 
lation one  with  another  the  various  groups  of 
nerve-centres  which  make  up  the  brain,  and  are 
the  seat  of  mind. 

If,  however,  growth  and  development  have 
proceeded  normally,  and  normal  mind  is  the  re- 
sult, what  are  the  conditions  of  insanity,  or  dis- 
order of  mind  ? What  are  the  conditions  of  heal- 
thy and  unhealthy  brain-function  ? 

I.  We  know  by  experiment  on  nerves  and 
nerve-centres,  and  by  observation  of  the  objec- 
tive phenomena  of  motion,  that  a discharge  of 
nerve-force  or  nervous  fluid — call  it  what  W6 
will — is  liberated  when  a centre  is  stimulated, 
and  that  this  ramifies  according  to  its  quantity 
in  various  directions  throughout  the  system. 
When  there  is  health  and  vigour  the  supply  will 
be  large,  and  every  channel  both  in  the  brain 
and  body  will  be  duly  supplied.  But  in  the 
healthiest  nervous  system  there  must  in  time  be 
a cessation  of  this  discharge,  for  in  time  the  sup- 
ply will  be  exhausted,  and  repair  and  replenish- 
ing must  take  place.  And  unless  this  is  done, 
nerve-function  will  be  impaired  or  cease.  For 
the  repair  of  the  higher  nerve-centres  sleep  is 
necessary,  for  only  during  sleep  is  the  repair  of 
the  waste  effected,  and  we  commonly,  nay,  con- 
stantly find,  that  mental  disturbance  is  preceded 
by  loss  of  sleep. 

In  some  cases  want  of  sleep  may  depend  on 
the  actual  time  allowed  for  it  being  insufficient. 
Though  not  a very  common  cause  of  insanity, 
yet  it  sometimes  is  found  in  persons  who  aro 
very  hard-worked,  or  who,  by  religious  exercises 
and  services,  deprive  themselves  of  sleep.  In 
tho  great  majority,  however,  want  of  sleep  is 
the  result  of  a pathological  condition  of  the 
brain,  a condition  which  by  appropriate  treat- 
ment the  physician  seeks  to  remedy  as  the  first 
step  towards  the  cure  of  the  insanity. 

2 Herbert  Spencer,  Principles  of  Psychology,  vol.  i.  pi 


INSANITY. 


714 

Not  only  may  there  bo  a want  of  repair  and 
replenishing  of  the  nerve-force  expended,  but 
there  may  be  also  a defective  generation  and 
supply  of  it.  Through  anaemia  or  exhaustion 
from  acute  diseases  or  long-continued  illness,  the 
nerve-centres  fail  to  generate  from  the  blood  the 
power  necessary  fur  their  due  operation.  The 
discharge  liberated  does  not  ramify  throughout 
the  nervous  system,  calling  into  action  every 
part  of  the  brain,  and  penetrating  to  every  por- 
tion of  the  muscular  structures  ; thus  the  tailing 
supply  is  manifested  in  the  gloom  of  melancholia 
and  the  slow  and  torpid  movements  which  ac- 
company it;  and  when  it  is  reduced  to  a still 
lower  ebb,  there  may  be  not  enough  to  carry  on 
oven  the  semblance  of  mind ; the  patient  pre- 
sents the  appearance  of  utter  fatuity  seen  in  de- 
mentia., whether  primary  or  secondary,  and  either 
sits  motionless  and  lost  in  the  condition  termed 
melancholia  cum  stupors  [Fr.  melancolic  avec  stn- 
pear  ; Ger.  Schwcrmuth  mit  Stumpfsinn]  or  exe- 
cutes the  purposeless  and  automatic  movements 
of  acute  dementia  [Fr.  Demence  aigue\. 

The  defect  of  nerve-force  may  bring  about  in- 
sanity in  more  than  one  way.  A sudden  strain 
or  shock  may  make  an  unwonted  demand  upon 
the  nervous  supply.  Incessant  thought,  especi- 
ally of  a painful  kind,  may  use  up  the  reserve 
of  force : this  is  not  renewed,  and  insanity  is 
the  result,  the  increased  moleeular  discharge  not 
being  duly  compensated  by  an  increased  supply 
from  the  nutritive  sources.  Secondly,  the  sup- 
ply may  fall  so  far  below  the  standard  that  it  is 
not  sufficient  for  the  ordinary  demands  of  every- 
day life,  and  so,  without  any  mental  cause,  but 
simply  from  nerve-inanition,  the  stage  of  depres- 
sion appears.  In  both  of  these  cases,  however, 
as  in  all  recent,  insanity,  the  brain  is  in  a state 
of  hyperuemia,  as  evidenced  by  heat  of  head, 
want  of  sleep,  and  often  pain  and  congested 
appearance  of  face.  The  hyperemia  impedes 
healthy  nutrition  and  causes  sleep  to  be  absent, 
but  it  is  erroneous  to  say  that  the  brain  irr  such 
patients  is  in  a state  of  anaemia,  even  if  the 
general  bodily  condition  deserves  that  name. 

II.  It  may  be,  however,  that  there  is  not  so 
much  a defect  of  nerve-force,  as  an  unstable  con- 
dition of  the  cerebral  centres,  which  is  mani- 
fested by  a rapid  and  continuous  discharge. 
Such  a discharge  in  a more  sudden  and  violent 
form  we  are  familiar  with  in  the  phenomena  of 
epilepsy.  In  insanity  it  may  vary  from  undue 
hilarity  and  excitement  up  to  the  incessant  move- 
ments and  vociferation  of  acute  delirium  ; and 
tike  epilepsy  it  may  terminate  in  exhaustion, 
coma,  and  death.  The  supply  of  nerve-force  in 
such  cases  is  often  abundant.  The  patient  goes 
without  sleep  for  days  and  nights,  and  yet  re- 
covers. The  higher  brain-centres  lose  the  power 
of  control,  owing  to  the  violence  of  the  dis- 
charge, and  the  lower  and  more  automatic  cen- 
tres thus  liberated  are  stimulated  to  overaction, 
which  is  manifested  in  noisy  and  violent  delu- 
sions, and  so  on  to  mere  delirious  incoherence. 
And  after  the  discharge  has  ceased,  there  may 
be  a period  of  dementia  and  complete  obliteration 
cf  mind,  before  the  exhausted  brain  begins  to 
recover.  Persons  who  are  in  this  condition  of  un- 
stable nerve- equilibrium  may  be  thrown  off  their 
balance  by  mental  causes — by  shock,  or  grief, 


or  losses.  Their  brain  may  also  be  affected  by 
disorder  of  the  other  organs  of  the  body  sympa- 
thetically. In  all  such  patients  there  is  a predispo- 
sition, often  inherited,  to  nervous  instability  and 
rapid  discharge,  and  such  ‘ causes  ’ as  puberty, 
pregnancy,  or  child-birth  bring  about  an  explo 
sion.  Here,  too,  there  is  marked  cerebral  hy- 
peremia, producing  an  abnormal  nutrition  and 
corresponding  abnormal  function. 

III.  Disturbance  6v  defect  of  mind  may  bn 
caused  by  incomplete  development  of  any  part 
concerned  in  mental  action,  or  by  the  presence 
of  anything  within  the  cranium  which  interferes 
with  the  healthy  life  of  the  various  organs, 
There  may  be  tumours  of  different  kinds,  or  ab- 
scess. Insanity  also  follows  blows  oa  the  head; 
and  deterioration  of  brain  is  frequently  caused 
by  the  action  of  alcohol  and  other  poisons.  In 
all  these  cases  we  have  not  a functional  disturb- 
ance which  may  suddenly  arise  and  as  suddenly 
pass  away,  but  a gradually  organized  lesion 
which  usually  advances,  producing  serious  and 
permanent  results.  The  degeneration  of  the 
organ  and  tissues  through  age  will  also  produce 
corresponding  results. 

Symptoms. — What  are  the  symptoms  of  in- 
sanity, and  how  far  do  they  correspond  to  the 
pathology  of  brain-disturbance  as  set  forth  in 
the  above  remarks? 

The  first  symptom  usually  noticed  in  a per- 
son becoming  insane  is  an  alteration  in  his 
emotional  condition.  Either  he  is  more  quiet 
and  dull  than  usual,  or,  on  the  contrary,  more 
restless,  irritable,  excitable,  or  hilarious.  The 
dulness  may  vary  from  a mere  disposition  to  sit 
still,  and  neglect  his  work  or  amusements,  to 
actual  gloom  and  despondency.  The  restlessness 
and  excitement  may  also  vary  in  degree,  and  be 
accompanied  by  gaiety  or  outbursts  of  anger 
and  violence.  The  change  may  be  more  or  less 
concealed,  according  as  the  patient  can  or  can- 
not control  himself.  Those  of  his  own  family  or 
people  about  him  may  notice  it  long  before 
others,  and  this  stage  will  vary  in  duration, 
often  lasting  some  time  before  delusions  or  other 
marked  symptoms  are  discoverable. 

The  acts  of  the  patient  will  correspond  to  his 
altered  feelings.  His  relations  towards  the  outer 
world  will  be  altered.  In  bis  torpor  or  gloom 
he  will  look  on  everything  despondingly ; will 
be  unable  to  perform  his  duties,  will  not  care 
for  amusements,  will  sit  at  home  inactive,  or 
take  up  morbid  fancies  about  his  health.  Con- 
versely, he  will  act  rashly  iu  matters  of  busi- 
ness, embark  in  foolish  speculations,  take  no 
heed  of  time  or  appointments,  spend  money 
recklessly,  indulge  in  debauchery  or  frivolous 
pursuits,  show  causeless  anger  to  those  about 
him,  or  exhibit  silly'  and  childish  hilarity  when 
matters  of  grave  moment  are  pending. 

Here  we  have  a slight  insanity.  The  higher 
brain-centres  are  but  slightly  disturbed,  and  stiil 
exercise  a considerable  amount  of  control  oTer 
the  lower  and  less  specialised  centres.  It  may 
be  difficult  to  say  that  any  one  act  or  feeling  is 
of  itself  indicative  of  insanity,  but  the  patient 
is  a changed  man,  and  the  term  moral  insanity 
is  specially  applicable  to  this  condition. 

Such  an  insanity  may  remain  and  l e perma 
nent : more  frequently,  however,  it  either  passes 


INSANITY. 


off,  tho  patient  recovering,  or  advances  in  one 
or  other  of  the  directions  already  indicated. 
The  gloom  will  increase ; corresponding  delusions 
will  present  themselves  with  appropriate  acts 
and  conduct;  and  the  patient  will  drift  into 
melancholia.  Or  he  will  become  more  and  more 
hilarious,  angry,  excited,  or  suspicious,  and  a 
state  will  arise  to  which  for  want  of  a better' 
wo  give  the  name  of  mania.  Though  delusions 
are  not  usually  found  in  the  stage  of  alteration, 
they  are  seldom  absent  in  the  second  and  more 
advanced  period,  and  generally  correspond  to 
the  feeling  of  the  sufferer,  so  much  so  that  the 
appearance  and  humour  frequently  enable  us, 
without  previous  information,  to  arrive  at  the  de- 
lusions under  which  he  is  labouring.  This  stage 
is  often  called  intellectual  insanity , or  insanity 
with  delusions.  Patients  labouring  under  one 
or  other  of  these  forms  vary  in  the  degree  of 
insanity,  from  a condition  in  which  they  are  able 
to  talk  coherently  on  many  topics  to  one  of 
complete  incoherence  or  delirium.  To  the  former 
the  name  of  partial  insanity  is  often  applied. 

Another  condition  is  ths.t  of  fatuity  or  child- 
ishness in  various  degrees.  It  may  come  on 
rapidly,  the  patient  passing  at  once  into  this 
state,  which  is  then  called  acute  or  primary 
dementia-,  or  it  may  be  the  result  of  years  of 
insanity  or  brain-disease,  and  is  termed  chronic 
or  secondary  dementia.  In  such  people  we  find 
loss  of  memory,  inability  to  revive  the  relations 
of  feelings  and  ideas — not  emotional  disturbance, 
but  rather  an  absence  of  all  emotion. 

As  regards  the  bodily  symptoms,  almost  every 
variety  of  insanity  is  ushered  in  by  sleeplessness, 
sleep  being  deficient  or  altogether  absent,  per- 
haps for  days,  according  to  the  acuteness  of  the 
attack.  This  indicates  a disturbance  of  the  brain- 
circulation,  which  is  also  shown  by  heat  and  pain 
of  head,  injection  of  the  eonjunctivse,  and  throb- 
bing of  the  carotids.  There  may  be  excessive 
vascular  action  even  when  the  insanity  is  the 
reverse  of  what  is  sometimes  termed  sthenic,’ 
and  the  general  condition  of  the  patient  is  one 
of  anaemia  rather  than  hyperemia. 

It  has  been  said  that  the  mental  symptoms  of 
insanity  are  accidental,  that  they  do  not  indicate 
the  pathological  conditions,  but  depend  on  the 
state  of  the  body,  and  that  no  classification  of 
the  forms  of  the  disorder  ought  to  be  based  on 
them.  But  it  is  perfectly  certain  that  the  brain 
of  a man  suffering  from  melancholia  differs  alto- 
gether from  that  of  one  in  acute  mania.  In  the 
former  there  is  a scanty  generation  of  nerve- 
force,  which  is  insufficient  to  reach  the  remote 
channels  and  plexuses  of  the  brain.  There  is 
not  a general  incoherence  and  confusion  of  ideas, 
and  the  patient  can  converse  rationally  on  many 
topics.  His  feelings  are  those  of  pain  and  not  of 
pleasure,  because  pains  in  general  are  more  in- 
tense than  pleasures  in  general,1  and  the  former 
are  evoked  into  consciousness  by  the  feeble 
nerve-currents,  while  the  latter  are  not.  In 
what  is  termed  mania  we  may  have  every  shade 
of  feeling  displayed,  from  gloomy  and  suspicious 
irascibility  to  great  hilarity.  Heelings  of  anger 
and  resentment  are  called  up  without  the  con- 
trolling power  of  reflection  and  judgment,  such 

1 See  Herbert  Spencer,  Principles  of  Psychology,  vol. 

L p.  602. 


715 

as  would  prevail  were  the  whole  brain  at  work, 
and  tho  higher  faculties  and  feelings  co-opera- 
ting and  in  relation  with  the  lower.  This,  again, 
may  be  due  to  a want  of  nerve-force,  or  more 
frequently  to  an  undue  expenditure  of  it,  as  may 
be  seen  in  the  irritability  of  an  over-tired  child. 
What  we  may  call  the  more  automatic  and  less 
complex  feelings  of  fear  and  self-love  are  evoked, 
while  there  is  not  force  aud  pressure  enough  to 
supply  the  rarer  and  more  remote  qualities  of 
comparison  and  reasoning  which  require  the 
combination  and  union  of  the  highest  portions 
of  the  brain.  If  there  is  an  increased  and 
accelerated  blood-tlow,  great  hilarity  and  self- 
satisfaction  may  be  the  result,  yet  with  perfect 
incoherence  of  ideas,  owing  to  all  the  rela- 
tions of  the  brain-plexuses  being  interrupted  by 
the  tumultuous  or  impeded  circulation,  and  the 
excessive  nervous  discharge.  And  in  dementia 
the  very  opposite  may  be  witnessed.  The  supply 
of  force  is  reduced  so  low  that,  there  is  an  ab- 
sence of  all  ideas  ; memory,  at  any  rate  of  re- 
cent events,  is  lost,  and  only  the  well-marked 
occurrences  of  earlier  life  are  recalled. 

That  the  mental  symptoms  are  to  be  by  the 
pathologist  altogether  disregarded,  and  that  they 
are  of  no  assistance  in  the  -appreciation  of  the 
pathological  condition,  seems  a most  extraordi- 
nary assertion.  These  symptoms  do  not  depend 
on  the  state  of  the  body  generally,  but  on  that 
of  the  brain,  and  as  accurately  indicate  the  con- 
dition of  the  latter  as  the  breathing  indicates 
that  of  a lung.  The  brain  in  insanity  is  the 
2>ars  affecta,  the  insanity  is  the  symptom,  and 
when  we  see  in  the  same  individual  at  one  time 
mania  and  at  another  melancholia,  we  may  be 
sure  that  the  condition  of  brain  at  the  one 
period  is  not  the  same  as  at  the  other,  though 
originally  one  cause  may  have  lighted  up  the 
malady. 

Diagnosis. — Accuracy  of  diagnosis  is  specially 
important  in  insanity,  owing  to  the  legal  and 
social  results  which  flow  from  it,  and  because 
the  restrictions  on  liberty  which  may  be  neces- 
sary for  proper  treatment  cannot  be  resorted 
to  until  a diagnosis  has  been  conclusively  estab- 
lished. The  direction  of  the  investigation  will 
be  different,  according  as  the  condition  may  be 
the  result  either  cf  incomplete  development,  or 
of  disablement  or  perversion  by  disease.  Where 
imbecility  is  in  question,  it  may  often  he  neces- 
sary to  take  several  opportunities  of  examin- 
ing the  patient.  This  condition  always  implies 
intellectual  defect,  though  great  moral  depra- 
vity is  often  the  predominant  symptom.  It 
is  therefore  necessary  to  ascertain  whether  any 
or  what  kind  of  occupation  has  been  attempted, 
and  what  amount  of  incapacity  has  been  shown, 
and  whether  the  individual  has  proved  capa- 
ble of  profiting  by  such  education  as  he  has 
received.  Adults  in  ordinary  circumstances 
ought  at  least  to  be  able  to  read,  write,  an  l 
count.  The  decision  rests  on  whether  such 
capacity  has  been  shown  as  is  required  in  the 
ordinary  conduct  of  life.  To  form  a correct 
opinion  in  cases  of  acquired  insanity  is  often  a 
very  difficult  matter.  The  relatives  of  the 
patient  often  obstruct  rather  than  aid  the  en- 
quiry. They  are  generally  divided  in  opinion, 
and  this  may  be  partly  an  aid  and  partly  au 


INSANITY. 


716 

obstruction  ; but  great  care  is  required  to  avoid 
taking  part  at  first  with  either  side.  Before 
seeing  the  patient  it  is  proper  to  make  what 
inquiry  is  possible  into  the  hereditary  history 
of  the  family,  the  nature  of  the  diseases  or  in- 
juries from  which  the  patient  may  have  suffered, 
including  any  previous  attacks  of  insanity.  The 
ordinary  habits,  disposition,  tastes,  and  occupa- 
tions must  be  ascertained,  and  also  the  present 
habits,  disposition,  tastes,  occupations,  amount 
of  sleep,  and  general  bodily  health.  The  mental 
symptoms,  such  as  suspicions,  delusions,  or  loss 
of  memory,  which  have  suggested  the  allegation 
of  insanity,  must  also  be  inquired  into ; and 
special  attention  must  be  paid  to  any  indication 
of  the  change  of  conduct  or  disposition  which  is 
so  characteristic  of  the  advent  of  mental  disease. 
A reference  to  the  articles  descriptive  of  the 
forms  of  insanity  will  show  the  importance  of 
all  these  points.  In  the  whole  investigation 
care  must  he  taken  to  avoid  accepting  mere 
ex  parte  statements,  and  as  much  information  as 
possible  should  be  obtained  by  the  inspection  of 
letters  or  other  documents  written  by  the  patient. 
Sometimes  the  conduct  of  the  patient  renders  it 
difficult  to  obtain  an  interview',  and  care  must 
be  taken  not  to  overstep  legal  limits  in  the 
attempt.  If  the  physician  has  to  see  the  patient 
in  the  presence  of  other  persons,  it  is  a necessary 
procaution  to  make  certain  that  he  clearly  under- 
stands whom  he  is  to  examine.  In  obtaining  the 
interview  a certain  amount  of  stratagem  may 
sometimes  be  resorted  to  ; but  it  is  best  that  the 
physician  should  be  introduced  by  a friend  in 
his  true  character  as  a doctor,  and  on  no  account 
should,  any  false  statement  be  made.  As  a mere 
matter  of  expediency  it  will  be  found  that  any 
deviation  from  this  produces  more  evil  than 
good.  If  the  interview  takes  place  in  the  pa- 
tient's home,  valuable  information  may  fre- 
quently be  obtained  by  observation  of  the  order 
or  disorder  which  prevails.  The  condition  of 
the  furniture,  the  state  of  the  patient’s  clothing, 
the  manner  of  the  patient  towards  the  rest  of 
the  household  and  their  hearing  towards  the 
patient,  ought  to  be  noted.  The  patient’s 
physiognomy,  the  condition  of  the  pupils,  and 
any  gesticulations  or  convulsive  or  tremulous 
movements,  must  he  observed.  In  conversation 
it  is  well  to  get  as  soon  as  possible  to  the  sub- 
ject of  the  patient’s  health,  as  it  relieves  many 
necessary  questions  of  their  offensive  character. 
Eccentric  ideas  ought  not  to  be  combated  more 
than  may  aid  in  making  the  patient  disclose 
them  fully;  and  everything  tending  to  show  the 
presence  or  absence  of  delusions,  irrational  sus- 
picions, or  loss  of  memory,  ought  to  be  elicited. 
Many  other  points  will  probably  be  suggested  by 
the  course  of  each  inquiry;  and  the  importance 
to  be  attached  to  them,  as  well  as  to  those  just 
mentioned,  must  be  decided  by  a careful  study  of 
how  far  they  are  included  or  excluded  by  the  known 
symptoms  of  any  cf  the  various  forms  of  insanity. 

-33tiolosy. — We  now  pass  to  the  causes  of 
insanity,  which  are  usually  spoken  of  as  pre- 
disposing or  exciting:  in  many  cases  both  com- 
bino  in  the  causation  of  the  disorder. 

The  great  predisposing  cause  is  an  inherited 
disposition  to  neurotic  disorder— one  difficult  to 
estimate  and,  indeed,  to  discover,  owing  to  the 


care  with  which  it  is  concealed,  but  the  impor- 
tance of  which  cannot  be  questioned.  It  has 
been  adverted  to  in  the  second  section  of  the 
pathological  conditions,  and  will  again  be  noticed. 
See  Insanity,  Varieties  of. 

When  we  speak  of  such  predisposing  causes 
as  sex,  age,  and  condition  of  life,  it  is  evident 
'that  they  can  only  be  called  causes  in  the  sense 
of  being  concurrent  conditions,  in  some  of  which 
a man  or  woman  is  more  likely  to  become  insane 
than  in  others. 

Has  sex  anything  to  do  with  insanity?  Re- 
ferring to  statistical  tables  we  find  that  in  the 
Report  of  the  English  Commissioners  in  Lunacy 
for  theyear  1871  there  were  under  treatment  in 
asylums  at  the  end  of  theyear  1873, 18,872males 
and  20,74-1  females.  There  were  admitted  during 
the  year  (not  reckoning  re-admissions  or  trans- 
fers) 6,261  males  and  6,317  females,  while  in 
the  same  period  there  died  2,288  males  and 
1,705  females.  The  preponderating  number 
of  females  under  treatment  is  probably  due  to 
the  fact  that  the  mortality  among  them  is  far 
less  than  among  males,  and  consequently  they 
accumulate  in  asylums.  The  difference  in  the 
number  of  the  two  sexes  who  become  insane  is 
probably  not  material,  but  it  seems  that  tho 
males  are  the  larger  number,  or,  looking  at  the 
difference  in  the  mortality,  they  would  fall  below 
the  number  of  the  females  further  than  they  do. 

With  regard  to  age,  we  find  that  the  tendency 
to  insanity  increases  with  the  development  of 
brain  and  mind.  In  the  first  decade  of  life  it  is 
rare.  In  the  second,  which  includes  the  period 
of  puberty,  it  is  more  common,  but  not  so  much 
so  as  in  the  next.  The  period  between  25  and 
40  years  is  that  in  which  the  greatest  number 
of  cases  arises,  and  is  that  of  the  highest  de- 
velopment and  working  power.  After  this  the 
number  declines  in  each  decade,  as  before  it 
rose.  With  the  age  the  character  of  the  insanity 
varies.  In  youth  it  is  displayed  in  violent  and 
paroxysmal  mania,  sometimes  in  acute  de- 
mentia, and  cataleptoid  states.  There  is  great 
motor  disturbance  and  emotional  rather  than 
intellectual  aberration.  Rarely  are  the  young 
melancholic.  In  the  prime  of  life  there  is  active 
mania  with  delusions  and  intellectual  insanity, 
and  at  this  period  we  meet  with  the  most  acute 
forms.  Later,  melancholia  prevails ; while  in 
old  age  weakness  of  mind,  passing  into  fatuity 
and  second  childhood,  indicates  the  general 
decay  of  the  brain  and  nervous  system. 

As  to  the  condition  of  life  in  which  insanity 
is  most  frequently  found,  there  is  not  much  to 
be  said.  That  it  occurs  more  frequently  in 
civilised  than  in  barbarous  countries  may  be 
assumed  without  recourse  to  figures,  because  in 
the  former  mind  and  brain  are  more  complex, 
and  therefore  more  prone  to  disorder.  It  is, 
however,  the  failures  and  vices  of  civilisation 
that  bring  about  the  great  mass  of  insanity. 
And  of  these  the  chief  is  poverty,  with  all  its 
attendant  physical  evils  of  insufficient  food  and 
wretched  dwellings,  and  moral  evils  of  anxie'y 
and  degradation.  Next  to  poverty,  and  closely 
bound  up  with  it,  is  drinKing,  which  among  tho 
working  classes  plays  a fearful  part  in  the 
causation  of  the  disease.  Among  the  predispos- 
ing causes  of  insanity  included  by  the  Interna- 


INSANITY. 


tional  Congress  of  alienist  physicians  in  1867 
arc,  besides  those  already  enumerated,  consan- 
guinity ; great  difference  in  the  age  of  the 
parents ; influence  of  the  soil  and  surroundings  ; 
convulsions  or  emotions  of  tne  mother  during 
gestation ; epilepsy  and  other  nervous  affections ; 
pregnancy,  lactation,  menstrual  periods,  critical 
age,  puberty,  venereal  excess,  or  onanism.  We 
may  add  to  these,  damage  received  at  birth 
owing  to  difficult  parturition. 

The  exciting  causes  of  insanity  are  usually 
divided  into  moral  and  physical.  Among  tne 
former  vve  may  reckon  domestic  trouble  and 
anxiety,  mental  shock,  overwork,  religious  ex- 
citement, political  excitement  and  war,  and  disap- 
pointment. Concerning  such  little  need  be  said. 
They  may  vary  in  duration,  some  quickly  bring- 
ing about  insanity,  others  persisting  for  years 
before  that  result  is  reached.  For  the  most  part 
those  who  are  affected  by  such  causes  are  already 
predisposed  by  hereditary  taint,  by  a neurotic 
temperament,  or  by  being  at  one  or  other  of  the 
critical  periods  of  life. 

Among  the  physical  exciting  causes  are  some 
which  are  both  exciting  and  predisposing — for 
example,  intemperance  and  epilepsy.  These  may 
be  the  immediate  precursors  of  an  attack ; as  well 
as  agents  causing  a predisposition  to  the  disorder, 
by  being  repeated  through  a series  of  years. 
Other  physical  causes  are  parturition,  menor- 
rhagia, amenorrhcea,  and  various  other  ovarian 
and  uterine  ailments;  diseases  and  injuries  of 
the  head ; acute  febrile  diseases  and  chronic 
illness,  producing  exhaustion ; constitutional  dis- 
eases, as  gout,  ague,  or  syphilis ; disease  of 
heart  and  vessels  ; exposure  to  great  heat  or 
cold ; lead  and  other  poisons  ; anaemia ; blows  on 
the  head,  and  organic  affections  of  the  bones  of 
the  cranium,  or  the  various  parts  contained 
therein. 

Classification. — Almost  every  writer  on  in- 
sanity has  suggested  a special  classification  of  its 
forms,  andthe  majority  have  founded  their  sugges- 
i tions  either  on  the  aetiology  or  symptomatology  of 
the  disease.  Of  those  based  on  symptoms  none  is 
simpler  than  Griesinger’s : — (1)  states  of  mental 
depression-,  (2)  states  of  mental  exaltation ; (3) 
j states  of  mental  weakness.  He  placed  general 
paralysis  and  epilepsy  apart  as  mere  complica- 
tions of  insanity.  His  groups,  therefore,  corre- 
spond broadly  with  the  old  divisions  of  Melan- 
cholia, Mania,  and  Dementia.  The  aetiological 
classification  most  widely  known  is  that  of  Morel. 
He  divides  the  forms  into  six: — (1)  Hereditary 
insanity,  including  congenital  nervous  tempera- 
ment, moral  and  impulsive  insanitjq  imbecility, 
and  idiocy;  (2)  Toxic  insanity,  including  con- 
ditions caused  by  insufficient  or  injurious  food, 
poisons,  or  noxious  air  or  water ; (3)  Hyste- 
| rical,  epileptic,  and  hypochondriacal  insanity ; 
(4)  Idiopathic  insanity,  dependent  on  disease 
of  the  brain  or  its  membranes ; (5)  Sympa- 
thetic insanity ; and  (6)  Dementia,  or  the  condition 
' °f  terminative  enfeeblement.  For  any  systematic 
study  of  the  subject,  it  is  obvious  that  some 
Bymptomatological  grouping,  based  on  the  cha- 
racters of  the  mental  manifestations,  must  be 
necessary.  It  has,  however,  been  maintained 
that  it  is  impossible,  either  on  this  cr  on  a purely 
•etiological  basis,  to  found  groups  which  have 


717 

more  than  an  artificial  relationship  to  one  another. 
And  there  is  some  truth  in  this  criticism.  Hut, 
though  the  ties  which  bind  the  psychological 
groups  together  may  be  in  a sense  regarded  as 
artificial,  it  is  found  in  practice  that  the  asso 
ciated  conditions  exhibit  a considerable  amount 
of  intimate  natural  connection. 

At  the  International  Congress  of  Alienists  in 
1867  the  following  classification  was  laid  down, 
intended  to  combine  the  setiological  and  symp- 
tomatological  methods: — 1.  Simple  Insanity, 
comprehending  mania,  melancholia,  monomania, 
circular  insanity,  moral  insanity,  and  the  demen- 
tia following  these  forms.  2.  Epileptic  Insanity. 
3.  Paralytic  Insanity.  4.  Senile  Dementia.  5. 
Organic  Dementia.  6.  Idiocy.  7.  Cretinism. 

The  first  class,  it  will  be  observed,  comprises 
all  the  varieties  which  may  be  regarded  as  merely 
functional ; the  others  are  mostly  associated  with 
permanent  structural  lesions. 

No  classification  which  has  been  proposed  can 
be  regarded  as  altogether  satisfactory.  This  is 
partly  owing  to  the  fact  that  the  true  nature  and 
limits  of  insanity  itself  have  been  very  imper- 
fectly recognised.  The  essence  of  the  condition 
is,  of  course,  the  manifestation  of  disease  through 
some  deviation  from  the  healthy  standard  of 
mental  action.  It  is  a condition  of  mental  uu- 
health  analogous  to  bodily  unhealth.  Hut  we 
must  not  allow  ourselves  to  imagine  that  there 
is  a class  of  morbid  mental  manifestations  which 
are  independent  of  the  condition  of  the  physical 
frame.  The  truth  is  that  there  is  no  pathological 
condition  of  the  individual  in  which  both  mind 
and  body  are  not  affected  ; but  in  some  diseases 
the  mental  symptoms  come  into  prominence,  in 
others  the  physical.  The  notion,  not  yet  alto- 
gether exploded,  that  there  is  something  in  in- 
sanity altogether  distinct  from  bodily  disease, 
arose  from  the  belief  so  long  prevalent  that 
mental  action  is  independent  of  physical  condi- 
tions, and  from  the  fact  that  the  study  of  insanity 
has  been  and  still  is  too  much  dissociated  from 
the  study  of  the  rest  of  cerebral  pathology. 
Acting  upon  the  broader  and  truer  views,  at- 
tempts have  been  made  by  Schroeder  van  der 
Hoik,  and  others,  to  introduce  a more  natural 
system  of  classification.  Such  attempts  have 
proceeded  on  the  recognition  of  all  mental  symp- 
toms as  phenomena  whose  nature  cannot  be 
ascertained  without  a full  consideration  of  the 
physical  symptoms  of  disease  by  which  they  may 
he  accompanied.  Dr.  Slcae  proposed  a clas-ifi- 
cation  based  on  the  belief  that  every  mental  dis- 
order bears  a relation  to  some  bodily  disease — 
acuto  or  chronic — analogous  to  what  the  delirium 
of  fever  does  to  the  fever  in  whose  course  it  is 
manifested.  The  detailed  list  which  he  offered 
was,  however,  admittedly  imperfect;  and  it  is 
likely  that  any  satisfactory  classification  on  this 
principle  will  only  be  arrived  at  after  a much 
closer  study  of  the  mental  symptoms  of  disease 
than  has  yet  been  given  to  them.  But  Skae  de- 
serves the  credit  of  having  given  the  most  power- 
ful impulse  to  the  purely  medical,  as  opposed 
to  the  metaphysical,  mode  of  studying  insanity. 
In  furtherance  of  this,  some  progress  has  been 
made  by  Clouston,  Batty  Tuke,  and  others,  who 
have  published  careful  monographs  of  some  of 
the  more  prominent  forms.  If  by  such  means  we 


INSANITY. 


718 

can  group  together  conditions  which  are  similar, 
not  only  in  their  mental  but  also  in  their  physi- 
cal characters,  we  obtain  units  which  may  ulti- 
mately contribute  to  the  building  up  of  a more 
perfect  system,  and  which  can  never  be  altogether 
disregarded  by  classifiers  in  future.  Most  of 
the  attempts  which  have  been  made  to  describe 
such  groups  must  at  present  be  regarded  rather 
as  valuable  suggestions  than  as  well-established 
clinical  and  pathological  species.  For  the  pur- 
poses of  this  work  it  has  been  considered  best  to 
describe  in  the  present  article,  the  various  phases 
of  insanity  which  have  been  regarded  as  of 
special  importance,  without  regard  to  the  prin- 
ciples which  underlie  their  conception;  and 
afterwards  to  discuss  the  various  well-marked 
forms  of  the  disease  under  their  several  heads, 
alphabetically  arranged. 

Prognosis. — The  general  prognosis  of  in- 
sanity will  depend  (1)  on  the  duration  of  the 
existing  disorder.  Perhaps  the  best  established 
fact  of  all  is,  that  the  chances  of  recovery 
diminish  in  direct  proportion  to  the  duration  of 
the  malady,  and  that  it  is  consequently  of  the 
utmost  importance  to  place  a patient  early  under 
adequate  and  appropriate  treatment.  If  a twelve- 
month elapses  without  appreciable  improvement, 
the  chances  are  decidedly  unfavourable.  If  de- 
lusions or  hallucinations  remain  fixed  and  un- 
changed at  the  end  of  a year,  especially  if  there 
he  hallucinations  of  hearing,  the  prognosis  is 
bad.  The  chiof  exception  is  where  there  is 
marked  melancholia.  Patients  will  recover  from 
this  after  long  periods  ; whereas  such  recoveries 
are  seldom  found  in  insanity  when  depression  is 
absent.  (2)  When  the  cause  of  the  insanity  has 
been  of  long  duration,  the  prognosis  is  less  fa- 
vourable than  when  it  is  a passing  or  accidental 
cause.  (3)  Is  the  prognosis  unfavourable  in 
hereditary  insanity  ? So  much  of  the  so-called 
simple  insanity  is  hereditary,  that  we  must  admit 
that  recoveries  from  it  are  not  infrequent,  for  it 
is  from  this  simple  insanity  that  recoveries 
chiefly  take  place.  Hereditary  insanity  is  brought 
about  by  very  slight  exciting  causes,  and  thus 
the  prognosis  is  often  favourable,  and  recovery 
takes  place  ; but  relapse  is  to  be  feared,  and 
the  prognosis  in  a second  or  third  attack  is  not 
nearly  so  good.  In  this  hereditary  insanity,  too, 
we  frequently  meet  with  the  cases  of  recurring 
and  ‘ circular  ’ insanity,  the  progress  of  which  is 
most  unfavourable.  Both  Kay  and  Griesinger 
have  remarked  that  the  prognosis  in  hereditary 
insanity  is  favourable  only  where  the  individual 
has  previously  been  of  normal  mind.  When  he 
has  always  been  eccentric  or  semi-insana,  and 
undoubted  insanity  at  last  manifests  itself,  the 
prognosis  is  very  bad.  (4)  The  more  acute  the 
symptoms,  the  greater  the  cerebral  disturbance 
and  insomnia,  the  more  favourable  is  the  pro- 
gnosis, if  the  case  is  recent.  Conversely,  the 
prognosis  is  bad  when  there  is  little  bodily  dis- 
turbance, where  sleep  is  present,  the  appetite 
normal,  and  the  secretions  unaffected,  especially 
if  persistent  delusions  or  an  entire  moral  change 
are  found.  (5)  As  all  deviation  from  the  ordi- 
nary mental  state  and  disposition  is  indicative 
of  insanity,  so  any  return  to  it  is  a favourable 
sign,  however  trifling  the  circumstances  may  be. 
(6)  Improvement,  however  slow,  is  a good  sign 


if  it  he  progressive.  So  long  as  this  goes  on. 
recovery  may  take  place  ; but  many  patients 
improve  up  to  a certain  point,  and  then  go  no 
farther.  (7)  The  age  of  the  patient  must  be 
considered.  Young  people  recover  in  greater 
numbers  than  those  advanced  in  life.  The  latter 
recover  if  their  insanity  be  melancholia  ; but,  if 
it  be  mania,  with  hallucinations  and  delusions, 
and  obscene  conduct  and  ideas,  recovery  is  rare, 
especially  if  the  memory  is  impaired,  and  signs 
of  approaching  dementia  are  present.  (8)  All 
periodicity  in  the  disease,  such  as  exacerbations 
and  remissions  on  alternate  days,  is  unfavour- 
able. 

Treatment.- — Only  a few  general  remarks  on 
treatment  will  be  offered  here.  Our  objects 
should  be  to  restore  to  health  the  disordered 
brain,  to  cause  the  incessant  waste  to  cease,  to 
promote  a storing  and  not  an  expenditure  of 
nerve-force.  The  brain  must  be  nourished  by 
healthy  blood.  The  quantity  of  the  latter  when 
in  defect  must  be  increased;  when  its  quality  is 
in  fault  it  must  he  improved  ; and  when  the 
blood-flow  is  in  excess  it  must  be  checked; 
while  all  causes  of  disturbance  reacting  upon 
the  brain  from  other  organs  of  the  body  must 
bo  removed. 

It  is  not  to  be  forgotten  that  powerful  effects 
are  produced  throughout  the  nervous  system, 
both  in  the  lower  and  higher  centres,  bv  what 
has  been  termed  ‘ inhibition.’  By  the  diversion 
of  nervous  action  from  one  channel  to  another, 
considerable  influence  may  be  exercised.1  Emo- 
tional excitement  may  be  diverted  into  motor 
or  intellectual  channels ; or,  by  other  emotional 
stimuli,  may  be  counteracted  or  arrested.  Intel- 
lectual or  ideational  troubles  may  be  diverted  by 
emotional  longings,  or  by  counteracting  intellec- 
tual pursuits.  And  for  all  this  certain  adjuncts 
are  necessary.  Painful  emotional  distress,  with 
the  idea  of  impending  ruin,  is  perpetually  fos- 
tered by  the  sight  of  the  loved  faces  of  wife  and 
children  : the  patient  must  therefore  he  removed 
from  them.  Outbursts  of  anger  are  constantly 
directed  against  those  most  familiar,  and  delu- 
sions correspond.  These  must  be  abolished  by 
his  being  placed  among  strangers.  Great  as  is 
the  need  in  many  cases  of  medicinal  treatment, 
it  is  not  so  universally  demanded  as  is  the  re- 
moval of  the  sufferer  to  fresh  surroundings.  W e 
try  agtiin  and  again,  in  apparently  the  most  pro- 
mising cases,  to  effect  a cure  at  home,  and  we 
fail.  The  necessity  for  early  treatment  in  in- 
sanity is  dwelt  upon  by  every  writer  ; and  the 
treatment,  when  insanity  is  once  fairlv  estab- 
lished, only  begins  after  the  patient  is  removed. 

The  first  questions  to  be  solved  are  how  the 
removal  is  to  be  effected  ; and  to  what  place  the 
patient  is  to  be  removed.  In  the  majority  of 
cases,  especially  in  the  case  of  the  urban  poor,  no 
doubt  cau  arise — an  asylum  is  the  only  place 
open  to  them,  because  either  the  friends  are 
poor  and  cannot  afford  any  other  plan  of  treat- 
ment, or  are  compelled  to  have  recourse  to  the 
public  asylums  of  the  land.  For  many  an  asylum 
is  necessary  because  the  patient  is  danger-  us  to 
himself  or  others,  or  would  incessantly  struggle 
to  escape  from  a less  guarded  dwelling.  But 

1 Dr.  Lauder  Brunton,  on  Inhibition.  RidW 

Reports , iv.  179. 


INSANITY. 

there  are  some  patients  who  may  be  cured  out 
of  an  asylum.  Some  recover  from  acute  but 
transitory  attacks  of  delirious  mania  very  rapidly, 
much  as  do  the  sufferers  from  delirium  tremens, 
and,  if  measures  of  safety  can  be  taken,  we  may 
watch  such  for  a few  days  and  perchance  they 
may  recover  without  removal.  Many  persons 
at  the  very  outset  of  insanity  may  by  removal 
and  judicious  treatment  be  cured,  if  their 
friends  will  only  'pen  their  eyes  and  acknow- 
ledge the  threatening  evil,  and  not  wait,  as  they 
so  often  do,  till  compelled  by  circumstances  to 
interfere.  Such  patients  must  not  be  sent 
abroad  or  out  of  reach,  must  not  go  alone,  or 
without  able  or  skilled  companions.  They  may 
go  from  place  to  place,  or  to  a friend’s  or 
medical  man’s  house.  Fresh  scenes  and  faces, 
and  the  cessation  cf  work  or  wcrry,  will  often 
effect  a cure.  But  they  must  be  people  able 
to  walk  out  in  public  thoroughfares,  and  to  live 
in  houses  under  ordinary  precautions.  Where 
they  cannot  walk  in  public,  and  cannot  live 
in  a house  without  its  being  converted  into  a 
prison,  they  ought  to  go  to  an  asylum,  where 
there  are  grounds  for  exercise,  and  where  facili- 
ties for  escape  are  not  always  suggesting  attempts. 
Patients'  friends  constantly  make  a mistake : 
they  keep  the  patient  out  of  an  asylum  at  the 
time  asylum  treatment  would  cure  him,  and  send 
him  there  when  all  hope  of  cure  is  over,  and 
when,  as  a chronic  lunatic,  he  would  be  just  as 
well  off  out  of  one. 

With  regard  to  medicinal  treatment  little  need 
here  be  said.  The  drugs  chiefly  used  in  insanity 
nre  sedatives  and  narcotics.  The  writer  ha3 
little  faith  in  these,  except  for  the  purpose  of 
obtaining  sleep,  and  gives  them  only  at  night, 
except  in  the  happily  rare  cases  where  life  is  in 
danger  from  want  of  sleep.  To  procure  sleep 
no  drug  iu  his  experience  approaches  chloral  in 
value  ; and  few  are  the  cases  where  it  is  totally 
■ inefficacious.  He  has  failed  to  observe  the  per- 
nicious effects  attributed  to  it  by  some  writers, 
and  the  results  both  in  severe  and  slight  cases 
have  been  most  satisfactory.  In  the  melancholic 
and  non-exeited  cases  the  preparations  of  opium 
are  of  great  service,  alone,  or  in  combination 
with  chloral.  Iu  excitement,  bromide  of  potas- 
sium is  valuable,  alone,  or  in  combination  with 
chloral,  Indian  hemp,  or  henbane.  Digitalis, 
alone,  or  with  morphia,  is  highly  spoken  of  by 
Drs.  Robertson  and  Williams.  Ergot,  of  rye  is 
efficacious,  according  to  Dr.  Crichton  Browne,  in 
recurrent  and  chronic  mania  ; and  the  same 
physician  extols  the  virtues  of  calabar  bean  in 
general  paralysis. 

Good  and  abundant  food  is  an  essential  in  the 
treatment  of  the  insane:  stimulants  are  re- 
quired in  many  cases,  particularly  the  depressed 
and  anaemic  forms,  but  in  the  opposite,  though 
often  useful,  they  in  some  cases  produce  or  in- 
crease excitement,  especially  in  the  early  stage. 
With  the  food  tonics  should  be  given,  and  those 
best  suited  are,  in  the  writer's  experience,  the 
mineral  rather  than  the  vegetable,  and  chief  of 
all  the  preparations  of  iron. 

G.  F.  Blaxdford. 

INSANITY,  Morbid  Histology  of. — Up 
to  the  present  time  do  definite  and  distinct 


INSANITY,  MORBID  HISTOLOGY  OF'.  719 
lesion  has  been  shown  to  accompany  invariably 
any  definite  and  distinct  form  of  insanity,  with 
the  exception  of  general  paralysis ; it  may,  how- 
ever, be  considered  an  established  fact  that  in 
every  case,  whether  recent  or  chronic,  a marked 
departure,  or  departures,  from  healthy  condi- 
tions may  be  observed  if  properly  sought  for ; 
but  in  what  manner  these  lesions  have  influenced 
the  character  of  the  case  in  respect  of  its  leading 
symptoms,  mania,  melancholia,  or  dementia, 
little  as  yet  has  been  elucidated.  Nevertheless, 
the  nature  of  the  morbid  appearances  is  sufficient 
to  account  for  perversion  of  functional  activity, 
although  we  are  unable  to  account  for  the  pecu- 
liar nature  of  the  perversion. 

One  great  difficulty  which  presents  itself  to 
the  mind  of  the  cerebral  pathologist  is  to  deter- 
mine whether  the  morbidities  which  are  apparent 
on  microscopic  examination  are  of  a primary  or  se- 
condary nature,  whether  they  have  been  efficient 
causes  of  insanity,  or  whether  they  are  mcrely 
the  results  of  mail-nutrition  of  the  brain,  and  as 
such  efficient  causes  of  chronic  lunacy.  There 
exists  an  undetermined  point  in  anatomy  which, 
until  settled,  must  leave  the  question  to  a cer- 
tain extent  open — that  point  is  the  presence  or 
absence  of  cerebral  lymphatics.  When  it  is 
considered  that  the  brain  is  an  exceedingly  active 
organ,  performing  many  and  various  functions, 
and  when  it  is  further  considered  that  it  can 
obtain  no  vicarious  aid  in  the  performance  of 
those  functions —that  it  cannot,  like  the  lungs, 
seek  assistance  from  other  systems — it  must  be 
at  once  apparent  that  the  question  of  its  posses- 
sion of  an  overflow  for  getting  rid  of  super- 
fluous plasm  and  waste  products  is  of  paramount 
importance.  Fohmann  and  Arnold  demonstrated 
to  their  own  satisfaction  the  existence  of  a sys- 
tem of  lymphatics  in  the  pia  mater;  and  His, 
Obersteiner.  and  Boll  believe  that  the  pia-rratral 
envelope  of  the  cerebral  arteries  (hyaline  mem- 
brane) exercises  the  function  of  a lymphatic 
duct.  The  very  existence  of  such  a sheath  or 
envelope  has  been  called  in  qrrestion,  hut,  com- 
paratively slight  study  is  needed  to  make  its 
demonstration  certain.  Although  differences  of 
opinion  exist  as  to  its  relations  and  manner  of 
debouchement,  we  believe  that  it  terminates  by 
funnel-shaped  openings  into  the  spaces  which 
exist  over  the  sulei  between  the  pia  mater  and 
the  so-called  arachnoid  membrane.  Kolliker1 
has  pointed  out  that  the  connection  between  the 
pia  mater  and  the  arachnoid  over  the  convolu- 
tions is  so  complete  and  perfect  that  only  at 
parts,  namely  over  the  sulci,  a distinct  space  can 
be  shown  to  exist.  It  is  questionable  whether 
the  arachnoid  should  not  he  considered  to  he 
merely  the  outer  layer  of  the  pia  mater.  The 
bearings  of  this  point  on  pathological  histology 
will  be  considered  under  the  head  of  cerebral 
congestion  ; it  would  not  have  been  alluded  to 
were  it  not  that  it  assists  somewhat  in  the  dif- 
ferentiation between  primary  and  secondary 
lesions  of  the  cerebral  tissues. 

In  prosecuting  the  study  of  the  morbid  histo- 
logy of  the  brain  and  spinal  cord,  two  methods  of 
investigation  should  be  adopted: — I The  exami- 
nation of  the  tissues  in  the  fresh  state ; 2.  The 
examination  of  the  parts  in  situ  by  means  of 

’ Kolliker’?  Histology,  Old  Syd.  See.  vol.  i j . lie. 


INSANITY,  MORBID  HISTOLOGY  OF. 


720 

sections  made  after  submission  of  portions  of 
nervous  tissue  to  hardening  agents.  The  con- 
dition of  the  constituents  of  the  recent  brain 
can  best  be  observed  by  colouring  small  speci- 
mens with  rosaniline.  The  modern  method  of 
freezing,  and  section  by  means  of  the  microtome 
designed  by  Mr.  Reran  Lewis,  has  rendered  the 
investigation  of  histological  brain-chaDges  a 
comparatively  easy  task. 

The  Membranes. — The  dura  mater  is,  com- 
paratively rarely,  thickened  by  proliferation  of 
its  elements ; the  vessels  are  foun  1 to  be  irre- 
gularly dilated  and  tortuous,  with  thickening  of 
their  walls. 

The  arachnoid  and  pia  mater  are  in  such  close 
anatomical  relation  on  the  convexity  of  the  hemi- 
spheres, that  they  can  be  best  described  to- 
gether. Between  them,  supported  by  a delicate 
connective  tissue,  lie  the  blood-vessels  which  dip 
into  the  sulci,  carrying  with  them  an  investment 
of  pia  mater,  which  gives  prolongations  to  ac- 
company them  when  they  pierce  the  cerebral 
substance,  and  forms  the  so-called  hyaline  mem- 
brane. Over  the  sulci  are  the  spaces  usually 
termed  sub-arachnoid,  which  communicate  with 
one  another  by  conduits  accompanying  the  ves- 
sels. The  microscopic  appearances  of  ‘ milky 
arachnoid’  have  not  beeu  thoroughly  described; 
both  membranes  are  often  thickened,  presenting 
a laminated  appearance,  and  the  connective  tis- 
sue supporting  the  blood-vessels  is  considerably 
increased,  as  well  as  the  pia-matral  prolonga- 
tions accompanying  the  blood-vessels  into  the 
cerebral  substance,  which  loses  its  hyaline  cha- 
racter, and  becomes  distinctly  fibrous.  Exten- 
sive but  thin  blood-clots  are  occasionally  found 
between  the  arachnoid  and  pia  mater,  while 
more  rarely  extravasations  of  blood  ar-e  found 
between  the  pia  mater  and  the  cerebral  sub- 
stance. Deposits  of  hsematoidiu  often  surround 
the  vessels,  and  their  coats  are  frequently  hyper- 
trophied. Crystals  of  triple  phosphate  have  been 
seen  on  the  visceral  surface  of  the  pia  mater. 
Lymph  has  been  found  between  tho  pia  mater 
and  the  spinal  cord ; the  membrane  was  thick- 
ened, and  internal  to  it  were  numerous  distinct 
laminae  of  a finely  fibrillated  material,  in  some 
places  of  an  inch  in  breadth.  In  one  case 
there  was  long-standing  epilepsy,  in  the  other 
chorea,  both  being  complicated  by  insanity. 

The  Epithelium.  — The  ground-glass  ap- 
pearance frequently  seen  in  the  ependyma  of 
the  ventricles  is  due  to  three  different  morbid 
conditions,  which  are,  in  the  order  of  their  fre- 
quency, proliferated  epithelium,  lymph-exuda- 
tions, and  crystalline  deposits. 

When  change  in  the  epithelium  is  the  cause 
of  the  granulations,  a vertical  section  shows 
simply  a proliferation  of  cells  projecting  into  the 
ventricle,  like  villi. 

When  lymph-exudations  have  pushed  the 
ependyma  upwards,  it  presents  the  appearance 
of  rough,  irregular,  bullse-like  nodules,  consist- 
ing of  the  layer  of  proliferated  epithelial  cells, 
and  a greenish  homogeneous  stroma,  which  to- 
gether overlie  the  pia  mater ; the  same  ma- 
terial can  be  frequently  seen  infiltrating  the 
subjacent  cerebral  tissues.  Deposits  of  phos- 
phate of  lime  have  been  recorded  as  occurring 
beneath  the  ependyma  of  the  lateral  ventricles 


in  general  paralysis,  and  Bergmann  discovered 
a formation  of  pretty  large  crystals  of  ‘ double 
phosphate  ’ in  both  plexus  choroidei  in  a case 
of  ‘mania  with  mental  weakness*  (Griesinger, 
New  Syd.  Soc.  Trans.,  p.  429). 

A proliferation  of  the  columnar  epithelium  of 
the  central  canal  of  the  medulla  oblongata  is 
not  unfrequent,  causing  its  occlusion. 

The  Nerve-cells. — The  changes  in  the  nerve- 
cells  are  most  marked  in  the  anterior  two-thirds 
and  superior  parts  of  the  hemispheres,  as  in  this 
situation  they  are  usually  most  numerous  and 
large  in  size.  In  the  depending  portions  of  the 
hemispheres  and  the  occipital  lobe  few,  if  any, 
changes  have  been  noticed. 

The  special  morbid  conditions  of  the  neive- 
cells  are  : — a.  Atrophy  ; or  pigmentary,  granu- 
lar, or  fuscous  degeneration.  £.  Hypertrophy. 
y.  Calcification. 

Pigmentary,  fuscous,  or  granular  degeneration 
is  a very  common  condition  in  many  forms  of 
insanity,  particularly  senile  insanity  and  general 
paralysis,  and  is  probably  to  some  extent  a nor- 
mal senile  change.  Dr.  Major  distinguishes 
three  stages  : — 1st.  The  cells  lose  their  sharply 
defined  triangular  contour,  and  become  swollen 
or  inflated  in  appearance  ; the  process  running 
towards  the  periphery  of  the  convolution  usually 
remains  distinct,  but  the  other  processes  dis- 
appear, and  the  cell  becomes  rounded  off;  the 
nucleus  becomes  swollen  and  more  or  less  round 
or  oval,  and  the  nucleoli  are  seen  with  great  dis- 
tinctness. 2nd.  A deposit  of  granules  takes 
place,  either  external  to  the  cell  and  pressing 
upon  it,  or  in  its  interior,  until  it  becomes  more 
and  more  yellow  and  opaque  ; or  both  these  con- 
ditions may  occur  together.  3rd.  The  cell  goes 
on  to  destruction,  breaking  down  and  shrink'ng, 
leaving  the  nucleus  surrounded  only  by  a mass 
of  granules,  and  forming  a gap  in  the  cerebral 
tissue  formerly  occupied  by  the  swollen  cell ; still 
later  tho  granules  entirely  disappear,  leaving  the 
nucleus  free.  He  has  not  observed  the  nucleus 
actually  undergoing  disintegration,  but  often  no 
trace  of  it  is  to  be  found  in  the  mass  of  granules 
left  by  the  degenerated  cell. 

Hypertrophy  of  the  large  pyramidal  cells  of 
the  inner  layers  has  been  observed  in  senile 
atrophy  and  general  paralysis : as  the  name 
implies,  they  are  large,  abnormally  distinct  and 
swollen  in  apperance,  often  presenting  granular 
masses  in  their  interior ; the  processes  are  in- 
creased both  in  size  and  number;  and  the  angles 
of  the.  cells  may  be  greatly  prolonged  or  swollen 
and  stunted. 

Calcification  of  the  cells  by  the  deposit  of 
phosphate  of  lime  within  their  walls  has  been 
observed,  according  to  Blandford. 

The  Nerve-fibres. — The  chief  changes  in 
nerve-fibres,  apart  from  their  disintegration  l y 
apoplexies,  softenings,  &e.,  are  coarseness,  irre- 
gularity and  twisting  of  outline,  and  their  power 
in  the  fresh  state  of  resisting  pressure  under  a 
covering  glass,  some  becoming  readily  ampul- 
lated.  They  may  be  affected  by  a pigmentary 
degeneration  similar  to  that  occurring  in  the 
cells  ; and  finally  they  may  present  fusiform  or 
oval  swellings,  which  tint  strongly  with  car- 
mine, and  give  rise  to  the  appearances  knowr 
as  amyloid  bodies. 


INSANITY,  NI0RI3ID  HISTOLOGY  OF.  721 


Special  Morbid  Conditions  of  the  Grey 
Mattel’. — In  many  subjects  when  the  pia  mater 
is  thickened  and  hyperaemic,  a condition  of  the 
grey  matter  closely  resembling  grey  degeneration 
in  the  whito  matter  is  often  found;  it  differs 
from  the  latter  by  the  absence  of  proliferated 
nuclei,  and  is  strongly  suggestive  of  lymph-infil- 
tration, which  has  gradually  caused  atrophy  and 
absorption  of  the  normal  structures.  Circum- 
scribed spots  of  yellow  softening  show  under 
the  microscope  ragged  fibres,  colloid  bodies,  and 
granular  corpuscles  at  the  base  of  the  diseased 
tract. 

Local  atrophies  of  the  convolutions  are  pretty 
common  ; under  the  microscope  a thin  layer  of 
indurated  grey  matter,  presenting  no  trace  of 
normal  structure,  may  be  found  ; in  other  cases 
there  is  simple  absence  of  the  grey  matter,  the 
white  matter  in  both  being  unaffected. 

The  Neuroglia. — This  substance  undergoes 
inflammatory  changes  of  a sub-acute  or  chronic 
nature,  with  the  results  of  which  we  are  fami- 
liar as  more  or  less  diffused  sclerosis.  Together 
with  the  other  elements  of  the  cerebral  tissues, 
it  undergoes  atrophy  in  the  brain-wasting  of 
senility,  and  especially  of  senile  dementia  ; it  is 
also  liable  to  special  forms  of  degeneration, 
which  have  been  called  miliary  sclerosis  and 
colloid  degeneration,  though  those  terms  are 
somewhat  misleading,  as  the  changes  in  question 
differ  entirely  from  those  generally  described  by 
these  names. 

General  sclerosis  has  only  been  observed  in 
one  case,  which  is  fully  detailed  in  the  Journal 
of  Anatomy  and  Physiology,  May,  1873.  In  a hy- 
drocephalic epileptic  idiot  (whose  brain  weighed 
sixty  ounces)  the  hemispheres  varied  in  weight; 
the  left  being  23J  ounces,  the  right  30J  ounces. 
In  the  heavier  or  hypertrophied  side,  the  nerve- 
fibres  were  found  lying  in  fasciculi  consisting  of 
from  four  to  six  strands  ; these  fasciculi  were 
separated  from  one  another  by  a clear,  finely- 
fibrillar  plasm  in  which  nuclei  existed,  somewhat 
larger  than  normal. 

j.  Disseminated  or  •partied  sclerosis,  or  grey 
degeneration,  is  a lesion  frequently  met  with 
in  the  brains  of  old-standing  cases  of  insanity, 
especially  in  general  paralysis.  Its  most  fre- 
quent seat  is  the  white  matter  of  the  motor 
tract ; less  frequently  it  is  met  with  in  the 
hemispheres.  In  the  pons  varolii,  medulla 
iblongata,  and  spinal  cord  of  epileptics,  patches 
>f  this  disease  are  of  common  occurrence  and 
n an  extrome  degree.  When  a fino  section  of 
lerve-tissue  affected  by  this  disease  is  examined 
|’V  the  naked  eye,  circumscribed  opaque  patches 
an  be  seen ; in  coloured  sections  these  tracts 
re  strongly  tinted;  as  a rule,  they  are  found 
ontiguous  to  a vessel  whose  nuclei  are  much  pro- 
ferated,  and  around  which  considerable  prolifer- 
don  of  the  nuclei  of  the  neuroglia  exists, 
nder  the  microscope,  the  nerve-fibres,  are  seen 
1 be  partially  or  completely  atrophied;  the 
vis-cylinders  and  sheaths  are  destroyed ; and 
ie  field  is  occupied  by  a finely  molecular  and 
orillated  material,  imbedded  in  a cloudy  homo- 
rneous  plasm.  In  this  matrix  the  proliferated 
iclei  exist,  somewhat  enlarged,  sometimes 
Shjty granular  in  appearance  ; but  around  the 
mlicated  spot  they  are  to  be  seen  in  much 

46 


greater  quantity,  and  not  actively  diseased.  The 
atrophied  nerve-fibres  occasionally  project  rag 
gedly  into  the  grey  matter,  where  they  are  lost 
Rokitansky  believes  this  to  be  essentially  a pri- 
mary increase  of  the  neuroglia.  Leyden  thinks 
it  occurs  secondarily  to  the  atrophy  of  nerve- 
fibres  ; while  Rindfleisch  and  others  are  of 
opinion  that  the  first  stage  is  marked  by  pro- 
liferation of  the  nuclei  of  the  vessels,  which  i» 
followed  by  an  increase  of  the  neuroglia,  and 
the  development  of  a morbid  plasm,  which  is,  in 
all  probability,  modified  neuroglia. 

Miliary  sclerosis. — For  the  full  details  of  t hi- 
remarkable  lesion  the  reader  is  referred  to  the 
Edinburgh  Medical  Journal  for  September,  1863. 
and  to  the  British  and  Foreign  Medico- Chirm- 
gical  Review,  July,  1873.  The  following  is  1 
short  account  of  its  principrd  features.  It  is  not 
confined  to  any  one  class  of  mental  disease,  but 
has  been  found  best  marked  in  cases  accompanied 
by  paralysis  or  epilepsy.  It  differs  from  a 1 
other  lesions  termed  sclerosis  in  not  being  pre- 
ceded, attended,  or  followed  by  proliferation  of 
the  nuclei;  it  is  a circumscribed  lesion,  occurring 
in  patches  from  M to  of  an  inch  in  length, 
not  involving  surrounding  tissues,  except  by  dis- 
placement, diffusing  no  morbid  plasm  beyond  its 
own  area,  and  not  connected  with  the  blood- 
vessels. It  is  essentially  a disease  of  the  nuclei 
of  the  neuroglia,  and  its  progress  is  marked  by 
three  stages : — 1st.  A nucleus  becomes  enlarged, 
and  throws  out  a homogeneous  plasm,  of  a milky 
colour  and  apparently  of  a highly  viscid  con- 
sistence, forming  a semi-opaque  oval  spot,  usually 
unilocular  ; but  by  aggregation  the  spots  may  be 
bilocular,  or,  more  rarely,  multilocular.  In  the 
centre  of  these  spots  a cell-like  body  containing 
a nucleus  is  discernible — the  original  dilated 
nucleus  of  the  neuroglia.  2nd.  The  morbid 
plasm  becomes  distinctly  molecular,  and  per- 
meated by  fine  fibrils  ; as  it  advances,  the  plasm 
round  the  periphery  of  the  spot  becomes  more 
dense,  and  a degree  of  absorption  of  the  nerve- 
fibres  around  it  takes  place.  3rd.  The  molecu- 
lar matter  contracts  on  itself,  becomes  more 
opaque,  and  .often  falls  out  of  the  section,  leaving 
ragged  holes. 

Colloid  degeneration  may  be  either  a primary 
or  a secondary  product,  that  is  to  say,  there  i? 
reason  for  believing  that  in  certain  forms  of  in- 
sanity it  is  the  primary  pathological  change,  and 
that  it  is  also  to  be  met  with  in  the  brains  of 
chronic  cases  as  a result  of  long-continued  per- 
verted vascular  action.  It  has  been  produced  arti- 
ficially in  the  brains  of  pigeons  by  incising  them 
and  allowing  the  wound  to  heal.  This  degener- 
ation should  be  searched  for  in  recent  specimens. 
It  consists  of  round  or  oval  bodies,  from  to 
of  an  inch  in  diameter,  bounded  by  a distinct 
wall  containing  a homogeneous,  transparent,  and 
colourless  plasm ; sometimes  it  is  somewhat 
granular.  The  general  appearance  of  a section 
may  be  compared  to  a slice  of  cold  sago-pudding; 
it  cannot  be  coloured  by  carmine.  The  condition 
may  be  regarded  as  a degeneration  of  the  nuclei 
of  the  neuroglia,  and  is  found  in  both  grey  aD'i 
white  matter. 

The  Blood-vessels. — When  we  examine  an 
injected  preparation  of  the  substance  of  a cere- 
bral convolution,  and  witness  the  perfection  and 


l 


,'22  INS  ATS  IT  Y,  MORBID  HISTOLOGY  OF:  AND  VARIETIES  OF. 


delicacy  of  its  circulatory  apparatus  ; and  when 
we  reflect  on  the  results  of  the  phenomena  of  con- 
gestion, stasis,  and  anaemia  on  the  functions  of 
other  organs;  we  have  little  difficulty  in  compre- 
hending the  influence  such  conditions  must  have 
upon  the  highly  complex  elements  which  make 
up  the  organ  of  the  mind.  It  is  certain  that  in 
most  cases  of  recent  insanity,  disturbance  of  the 
cerebral  circulation  is  one,  if  not  the  essential, 
pathological  factor  ; and  if  such  disturbance  is 
of  long  continuance,  permanent  lesions  of  cells, 
fibres,  and  nuclei,  and,  as  a consequence, 
chronic  insanity  in  some  form,  must  result.  The 
examination  therefore  of  the  cerebral  vessels  is 
of  primary  importance. 

The  following  is  the  method  of  examination 
adopted  by  the  writers; — After  noting  the  degree 
of  engorgement  or  anaemia  in  the  centrum  ovale, 
and  whether  on  section  the  vessels  are  dragged 
out  by  the  knife,  vessels  of  moderato  size  should 
be  dissected  out  and  carefully  washed  with 
camel’s-hair  brushes,  and  then  submitted  to  the 
microscope.  By  this  mode  of  procedure  the  fol- 
lowing changes  may  be  discovered — (a)  Thick- 
ening or  degeneration  of  one  or  other  of  the 
coats.  ( b ) Thickening  of  the  sheath  or  hyaline 
membrane,  (c)  Deposits  between  the  adventitia 
and  the  sheath,  (d)  Proliferation  of  the  nuclei. 

(a)  Thickening  nr  degeneration  of  the  coats. — 
The  inner  fibrous  coat  has  been  found  thickened 
and  more  fibrous  than  in  health.  The  muscular 
coat  is  often  hypertrophied,  especially  the  circu- 
lar fibres;  it  is  best;  marked  in  general  paralysis 
and  epilepsy.  The  adventitia  is  occasionally 
thickened.  The  whole  of  the  coats  sometimes 
undergo  a hyaloid  or  vitreous  change,  which  is 
probably  allied  to  lardaceous  disease. 

( b ) The  hyaline  membrane  or  sheath  is  ofton 
thickened  and  fibroid,  enveloping  the  artery  in  a 
loosely  sacculated  manner. 

(c)  Deposits  between  the  adventitia  and  the 
sheath  are  of  t wo  kinds ; but  neither  is  peculiar  to 
insanity,  being  found  in  the  brains  of  persons  who 
have  died  offerer  or  Bright’s  disease  with  cerebral 
symptoms.  The  first  is  a finely  molecular  material 
of  a pale  yellow  tint,  or  more  often  colourless, 
closely  resembling  in  appearance  the  spores  of 
the  Favus  fungus,  and  refracting  light  highly ; it 
undergoes  no  change  when  treated  with  the  ordi- 
nary oil-tests,  and  is  found  on  the  smallest  capil- 
laries. The  particles  vary  in  size  from  to  T 

of  an  inch.  The  second  form  of  deposit  consists 
of  irregular  crystals  of  haematoidin  distributed 
pretty  equally  over  the  vessels,  except  at  the 
bifurcations,  where  they  are  aggregated. 

( d ) Proliferation  of  the  nuclei  usually  accom 
pauies  proliferation  of  the  nuclei  of  the  neuro- 
glia ; they  do  not  seem  to  increase  to  the  same 
size,  as  those  of  the  neuroglia,  but  become  oval  or 
irregular  in  shape. 

Fine  sections  of  hardened  tissues  are  necessary 
for  the  demonstration  of  the  following  vascular 
changes: — (c)  Abnormalities  in  direction.  (/) 
Dilatation,  microscopic  aneurisms,  and  apo- 
plexies. (g ) Perivascular  spaces.  (A)  Syphi- 
loma. 

(e)  Abnormalities  in  direction  may  take  the  form 
of  extremo  tortuosity  or  actual  thickening;  these 
are  usually  evidences  of  congestion,  but  may  under 
certain  circumstances  be  produced  artificially. 


(/)  Dilatation , microscopic  aneurisms,  and  apo- 
plexies.— Ecker,  Romaer,  and  Major  have  found 
a general  dilatation  of  the  small  vessels  in  mama 
and  ‘brain-wasting.’  MM.  Bouchard  and  Charcot 
have  carefully  described  the  appearances  of  mi- 
croscopic aneurisms ; they  are  usually  fusiform, 
more  rarely  sacculated,  measuring  Y to  Y of  aD 
inch  in  length,  their  breadth  being  one- fourth 
of  their  length.  These  authors  describe  a thick- 
ening of  the  fibrous  coats,  with  proliferation  of 
the  nuclei,  and  atrophy  of  the  transverse  mus- 
cular striae.  Drs.  Bastian  and  Blandford  have 
described  a thrombosis  of  the  minute  vessels 
by  masses  of  white  corpuscles  occurring  in  maria 
and  delirium. 

(g)  Perivascular  spaces. — In  subjects  who  have 
been  liable  to  cerebral  congestion  the  vascular 
canals  are  often  distinctly  dilated,  to  an  extent 
several  times  the  calibre  of  the  vessels;  the  brain- 
substance  bounding  them  is  condensed. 

(A)  Syphiloma  of  the  cerebral  arterioles  is  cha- 
racterised by  the  formation  of  a plastic  deposit 
around  their  walls,  which  becomes  converted 
into  fibrous  tissue,  and  gives  to  their  transverse 
sections  an  enormously  hypertrophied  and  con- 
centric appearance,  going  on  to  almost  complete 
occlusion  of  the  canals. 

Tumours. — Tumours  have  been  met  with  in 
some  cases  of  insanity,  but  as  no  growth  pecu- 
liar to  insanity  has  been  described,  it  is  unneces- 
sary to  enter  into  their  description. 

The  Spinal  Cord. — Microscopic  examination 
of  the  spinal  cord  has  not  revealed  any  lesion 
peculiar  to  the  various  forms  of  insanity,  except- 
ing general  paralysis.  Drs.  Westphal,  Meredith 
Clymer,  Boyd,  and  others  are  of  opinion  that 
in  this  disease  well-marked  departures  from 
health  are  to  be  found.  The  first-named  patholo- 
gist describes  an  atrophied  condition  of  the  cells 
of  the  posterior  columns,  with  increase  of  their 
connective  tissue,  commencing  externally  and 
extending  inwards  ; he  also  believes  in  a chronic 
myelitis  affecting  the  posterior  columns  and  the 
posterior  sections  of  the  lateral  columns.  As  for 
as  the  writers  have  been  able  to  observe,  this  is 
by  no  means  an  invariable  accompaniment  of  this 
disease,  although  in  one  case  it  was  undoubtedly 
present.  The  cells  of  the  cord  were  in  most 
instances  undergoing  fuscous  granular  degenera- 
tion, like  these  of  the  hemispheres. 

The  Sympathetic  System. — The  sympa- 
thetic ganglia  undergo  a pigmentary  degenera- 
tion in  various  forms  of  cerebral  disease. 

J.  Batty  Tcke. 

Robert  Saundbt. 

INSANITY,  Varieties  of.— Iu  this  article 
various  forms  of  insanity  will  be  described  under 
separate  heads.  Dkmextia,  General  Paralysis 
of  the  Insane,  Mania,  and  Melancholia  will 
be  found  in  other  parts  of  the  work. 

1.  Alcoholic  Insanity. — The  conditions  in- 
cluded under  this  head  must  not  he  confounded 
with  what  is  called  dipsomania.  In  the  latter 
affection  the  indulgence  in  alcohol  is  asvmptom. 
and  not  necessarily  a cause  ; while  here  the  in- 
sanity is  always  a direct  result  of  some  form  of 
alcoholic  poisoning.  It  is  met  with  in  three 
forms,  namely,  acute  alcoholic  insanity.  chre.'UC 
alcoholic  insanity,  and  delirium  tremens. 


INSANITY,  Y; 

Acute  alcoholic  insanity  seldom  occurs  except 
when  there  is  a strong  hereditary  tendency  to 
mental  disturbance,  or  when  the  cerebral  ener- 
gies have  been  notably  impaired  by  excesses  or 
overwork.  Where  all  these  predisposing  causes 
exist,  it  may  not  require  a large  dose  of  alcohol 
to  bring  on  an  attack.  The  most  frequent  form 
of  the  affection  is  violent  maniacal  delirium, 
known  as  mania  a potu,  with  a tendency  to  homi- 
cidal acts.  In  some  cases  the  mental  disorder 
takes  the  melancholic  form,  and  it  becomes  neces- 
sary to  guard  specially  against  the  strong  sui- 
cidal tendency  which  generally  characterises  it. 
Unless  the  brain  has  been  weakened  by  repeated 
attacks,  both  forms  are  curable  and  generally  of 
short  duration.  The  treatment  is  the  nourish- 
ing, non-stimulating  regimen  detailed  in  the 
articles  on  Mania  and  Melancholia. 

Chronic  alcoholic  insanity  is  one  of  the  results 
of  chronic  alcoholism,  and  there  is  no  condition 
which  better  illustrates  the  ‘solidarity  of  the 
psychical  and  somatic  functions  of  the  nervous 
system’  and  the  interdependence  of  their  morbid 
manifestations.  The  physical  symptoms  are  fully 
described  in  the  article  on  Alcoholism;  the 
mental  symptoms  are  generally  present  from  the 
beginning,  though  not  always  prominent  enough 
to  attract  special  attention.  The  sleeplessness, 
so  characteristic  of  commencing  mental  disorder, 
is  an  early  symptom ; then  restlessness  and 
depression,  with  suicidal  tendency,  sometimes 
passing  rapidly  into  complete  dementia,  but 
generally  passing  gradually  through  a course  of 
moral  and  mental  degradation,  which  progresses 
step  by  step  with  tile  symptoms  of  failure  of 
physical  nervous  power.  The  affection  presents 
many  points  of  resemblance  to  general  paralysis 
of  the  insane,  and  is  in  some  cases  only  to  be 
distinguished  from  it  by  obtaining  evidence  of 
alcoholic  poisoning,  and  by  the  persistence  of  the 
mental  depression,  which  is  seldom  more  than  a 
transitory  symptom  in  the  general  paralytic. 

Delirium  tremens  is  described  fully  under  the 
. .leading  of  Alcoholism;  but  it  is  proper  to 
note  here  that  after  the  acute  symptoms  of  that 
disease  have  passed  away,  there  is  sometimes 
. left  behind  a state  of  subacute  insanity  of  a 
' characteristic  nature.  At  first  suicidal  symp- 
toms are  apt  to  appear.  Suspicions  of  poisoning, 
fear  of  impending  evil,  and  hallucinations  of 
hearing  are  also  frequent.  The  treatment  re- 
quired is  constant  companionship  of  a trust- 
worthy attendant,  exercise,  fresh  air,  and  change 
of  scene,  with  attention  to  every  ordinary  means 
of  restoring  the  functions  to  a healthy  stato. 
Under  proper  treatment  the  prognosis  is  favour- 
able. John  Sibbaid. 

2.  Amenorrb.ee al  Insanity.  — Mental  de- 
rangement is  often  accompanied  in  females  by  sup- 
ires.-ion  of  the  menses.  Butin  many  such  cases 
he  insanity  cannot  be  called  amenorrheeal,  as 
he  cerebral  and  uterine  disorders  may  only  be 
i ssociated  as  both  symptomatic  of  some  debili- 
atiug  cause  affecting  the  whole  system.  Then 
lie  mental  condition  is  usually  the  depression 
1 reduced  by  amemia.  But  there  is  a mental  de- 
^ mgement  directly  resulting  from  sudden  suppres- 
on  of  the  catamenia,  to  which  this  distinctive 
lme  is  not  inaptly  applied.  Here  the  insanity 


ARIETIE3  OF.  72S 

takes  the  maniacal  form.  It  is  sometimes  ushered 
in  with  urgent  febrile  symptoms,  in  which  case 
the  mania  assumes  the  acutely  delirious  charac- 
ter. Where  general  febrile  disturbance  is  not 
prominent,  the  mental  condition  is  more  simply 
maniacal,  and  sometimes  does  not  get  beyond 
mere  irritability  with  delusions.  The  patholo* 
gical  condition  must  in  either  case  be  regarded 
as  mainly  a hyperaemia  of  the  brain. 

Treatment. — This  must  be  directed  towards 
the  restoration  of  the  arrested  discharge.  If 
the  patient  be  seen  at  the  commencement  of 
the  attack,  the  hip-bath  and  a gentle  purgative 
may  recall  it.  If  the  menstrual  period  has 
passed,  the  attention  of  the  practitioner  must  bo 
devoted  to  the  relief  of  the  more  urgent  symp- 
toms. If  the  symptoms  of  cerebral  congestion 
are  distinct,  leeches  will  probably  be  found  use- 
ful. Regular  action  of  the  bowels  should  be 
secured,  but  active  purgation  should  be  avoided. 
The  food  ought  to  bo  easy  of  digestion,  and  caro 
should  be  taken  not  to  let  it  be  deficient  in  quan- 
tity. If  the  mental  excitement  is  great  and  long- 
continued,  it  will  necessarily  produce  consider- 
able exhaustion,  and  the  condition  of  the  patient 
after  recovery  from  the  mental  excitement  will 
depend  very  much  on  the  extent  to  which  the 
strength  has  been  supported  during  the  continu- 
ance of  this  strain.  The  re-appearance  of  the 
catamenia  generally  implies  recovery  of  mental 
health;  but  cases  occur  where  prolonged  amenor 
rhcea  leads  to  a chronic  maniacal  condition, 
ultimately  passing  into  hopeless  dementia. 

John  Sibbald. 

3.  Choreic  Insanity. — There  appears  to  bo 
an  intimate  connection  between  the  pathological 
basis  of  chorea  and  a certain  disturbance  of  tlm 
mental  functions.  The  physical  and  the  merit;. I 
symptoms  however  do  not  necessarily  correspond 
in  intensity.  Sometimes  where  the  convulsive 
symptoms  are  very  severe,  the  mental  condition 
is  merely  one  of  dulness,  apathy,  or  irritability. 
In  children  it  shows  itself  generally  in  a mania 
cal  restlessness,  accompanied  by  delirium  of  a 
peculiarly  automatic  character.  It  is  frequently 
associated  at  all  periods  of  life  with  the  rheu- 
matic condition,  and  hence  it  has  by  some  author." 
been  called  rheumatic  insanity.  It  generally 
commences  with  sleeplessness  and  delirious  ex 
citement  of  a remittent  character,  which  is  some- 
times accompanied  by  violent  convulsive  effoit. 
As  the  excitement  passes  off,  delusions  of  sus- 
picion are  apt  to  arise,  and  these  are  strangely 
associated  with  an  apathetic  mental  condition. 
In  the  acute  form  the  prognosis  is  favourable, 
recovery  generally  taking  place  in  from  four  to 
eight  weeks.  The  chronic  form  is  apt  to  pass 
into  dementia.  John  Sibbald. 

I.  Epileptic  Insanity.  See  Epileptic  In- 
sanity. 

5.  Feigned  Insanity. — Insanity  may  bo 
feigned  in  order  to  escape  the  obligation  of  duty, 
or  the  consequences  of  crime.  If  manifested  at  a 
time  when  its  recognition  might  be  a benefit  to  the 
individual,  it  becomes  necessary  to  test  i ts  real!  ty. 
It  must  not  be  rashly  inferred  in  any  case  thai 
insanity  is  feigned;  for  it  sometimes  results  from 
the  excitement  consequent  on  a sense  of  guilt  oi 


INSANITY,  VARIETIES  OF. 


m 

the  shock  of  a false  aecusation ; cr  it  may  arise 
roineidontly  but  independently  of  such  conditions. 
The  best  preparation  for  making  a satisfactory 
examination  in  such  a case  is  a familiar  acquaint- 
ance with  the  appearance  and  conduct  of  persons 
undoubtedly  insane.  A person  feigning  insanity 
must,  to  be  successful,  simulate  some  known 
form  of  the  disease ; and  as  each  form  presents 
a more  or  less  definite  group  of  symptoms,  an 
impostor  is  apt  to  reveal  the  truth  by  omissions 
or  by  additions  inconsistent  with  the  part  that 
he  attempts  to  play  ; but  the  mistake  generally 
made  by  the  impostor  is  to  over-act  the  part. 
The  inquiry  may,  of  course,  assume  various  as- 
pects. A person  may  pretend  to  have  been  insane 
at  the  time  a certain  act  was  committed.  Here 
it  is  to  be  remembered  that  the  insanity,  if  real, 
would  not  probably  have  been  confined  to  the  time 
of  the  commission  of  the  crime ; and  some  evi- 
dence of  premonitory  symptoms  previous  to  the 
act  would  probably  be  found.  In  such  cases  it  is 
proper  to  regard  want  of  motive  as  so  far  an  in- 
dication of  insanity ; but  when  the  supposition 
of  a sudden  mental  perturbation  is  put  forward, 
some  reason  would  have  to  be  shown  for  its  oc- 
currence ; and  some  history  of  the  occurrence  of 
cerebral  injury,  or  of  previous  attacks  of  insanity, 
epilepsy,  or  other  cerebral  affection  ought  to  be 
forthcoming.  A person  feigning  to  be  insane  at 
the  time  he- is  examined  must  endeavour  to  present 
symptoms  of  either  mania,  melancholia,  mono- 
mania, dementia,  or  imbecility.  When  the  symp- 
toms arise  suddenly,  simulation  of  the  maniacal 
condition  is  generally  attempted.  The  exertion 
which  this  entails  will,  however,  generally  com- 
pel an  impostor  to  exhibit  symptoms  of  fatigue, 
and  even  to  sleep,  when  the  true  maniac  would 
exhibit  persistent  excitement.  The  raving  also 
when  feigned  may  be  recognised  as  hesitating  and 
premeditated.  Forgetfulness,  which  is  generally 
assumed  by  the  impostor,  is  an  unfrequent  symp- 
tom of  mania,  except  when  it  occurs  in  the  course 
of  general  paralysis,  and  this  is  a disease  whose 
other  symptoms  could  scarcely  be  simulated.  If 
melancholia  or  monomania  be  feigned,  the  chief 
facts  to  be  borne  in  mind  are  that  such  con- 
ditions, when  real,  are  very  unlikely  to  arise 
suddenly  where  there  are  no  symptoms  of  bodily 
disease  to  account  for  them  ; and  that  they  are 
usually  characterised  by  a tendency  to  conceal 
peculiarities,  or  at  least  not  to  push  them  osten- 
tatiously forward.  Dementia  never  occurs  sud- 
denly without  evident  cause.  A class  of  cases 
occur  in  which  insanity  is  only  partially  feigned. 
Young  criminals  frequently  try  to  exaggerate  the 
signs  of  the  intellectual  weakness  which  is  so 
generally  mingled  with  their  moral  depravity,  in 
hopes  of  obtaining  a relaxation  of  discipline,  or 
a transference  from  a prison  to  an  asylum.  Such 
cases  are  often  full  of  difficulty.  The  principle 
which  ought  to  regjdate  our  action  is  to  avoid 
the  continuance  of  punishment  when  disease  or 
deficiency  renders  it  useless.  Before  deciding 
upon  the  reality  of  any  doubtful  case  of  insanity, 
all  the  physical  conditions  of  the  individual,  such 
as  the  amount  of  sleep,  the  state  of  the  pulse, 
skin,  tongue,  and  digestive  system  generally,  the 
conduct  and  the  state  of  health  immediately  pre- 
ceding the  signs  of  insanity,  should  be  ascertained. 
The  effect  of  remarks  made  within  hoaring  of  the 


suspected  person  should  be  observed ; one  who 
proclaims  his  own  insanity  should  be  distrusted. 
And  the  medical  history  of  the  family  and  of  the 
individual  should  be  inquired  into,  with  a view 
to  disclose  anything  which  might  have  caused 
insanity  or  predisposed  to  it. 

Joint  SlBBALD. 

6.  Gastro-Enterio  Insanity. — The  emo 

tional  condition  is  well  known  to  be  to  an  appre- 
ciable extent  dependent  on  the  state  of  the  'prime 
vice  ; and  where  the  nervous  system  is  predisposi-d 
to  derangement,  certain  affections  of  the  stomach 
and  bowels  seem  sufficient  to  produce  insanitv. 
and  to  stamp  it  with  a special  melancholic 
character.  In  addition  to  the  mere  depression 
caused  by  anaemia,  there  is  associated  with  such 
affections  a peculiar  anguish  of  mind,  and  ten- 
dency to  self-accusation,  which  is  often  of  the 
most  distressing  nature.  Refusal  of  food  is  fre- 
quently a prominent  symptom.  The  intellectual 
perversion  is  often  slight,  and  seldom  so  promi- 
nent. as  in  other  acute  insanities.  Relief  of  the 
bodily  symptoms  is  generally  accompanied  by  a 
return  to  sanity.  The  affections  which  have 
been  most  frequently  observed  to  produce  this 
form  of  melancholia,  are  irritation  and  catarrh 
of  the  mucous  membrane,  constipation,  stricture 
or  other  causes  of  distension  of  the  viscera,  ami 
pressure  upon  the  stomach  or  intestines  bv 
tumours  in  the  epigastric  region.  Schroeder  van 
der  Kolk  described  the  mental  symptoms  as 
being  always  due  to  affections  of  the  colon; 
but  disease  of  other  portions  of  the  canal — as 
the  rectum  and  anus— seems  also  to  produce 
them.  John  Sibbald. 

7.  Hereditary  Insanity. — Srxox. : Fr.  Folic 
hereditaire ; Ger.  ErblicheGeisteskrankheit. — This 
implies  insanity  symptomatic  of  hereditary  weak- 
ness of  the  nervous  system,  generally  coming  on 
without  the  intervention  of  appreciable  exciting 
cause. 

The  nervous  system  seems  to  be  peculiarly 
liable  to  be  involved  in  the  effects  of  heredi- 
tary degeneracy,  and  this  is  frequently  evinced 
by  the  occurrence  of  mental  symptoms.  The 
ages  at  which  these  are  developed,  and  the 
character  which  they  exhibit,  depend  both  on 
the  nature  and  on  the  strength  of  the  hereditary 
disposition.  The  forms  of  insanity,  however, 
which  seem  to  be  most  directly  the  result  ot 
hereditary  influence,  generally  make  their  ap- 
pearance at  those  periods  of  life  when  either 
rapid  structural  development  takes  place,  special 
functional  activity  is  first  exhibited  or  is  ulti- 
mately arrested,  or  upon  the  advent  of  senile 
decay.  The  ordinary  exciting  causes  of  insanitv 
may  also  affect  persons  at  these  periods,  and  in 
such  cases  the  resulting  disorder  will  be  stampel 
more  or  less  distinctly  with  the  impress  of  it* 
origin.  But  where  these  forces  do  not  come 
powerfully  into  play,  it  is  found  that  hereditary 
insanity  exhibits  a special  character  according  to 
the  period  at  which  it  is  developed.  We  have 
thus  an  insanity  of  pubescence,  a climacteric 
insanity,  and  a senile  insanity.  Idiocy  and  im- 
becility (which  will  be  found  discussed  under  their 
respective  heads)  are  also  frequent  results  of 
hereditary  weakness,  showing  itself  during  foetal 
life,  or  during  the  period  of  dentition;  and  the 


INSANITY,  VARIETIES  OF.  725 


mental  derangements  which  often  affect  women 
at  parturition,  and  during  the  processes  which 
precede  or  follow  it,  seem  to  occupy  a position  in 
the  pathological  scale  intermediate  between  the 
hereditary  and  the  accidental  form  of  insanity. 

Insanity  of  pubescence  is  a condition  not  un- 
frequently  met  with,  and  one  which  it  is  very 
important  to  recognise  early  in  its  true  character. 
Much  unintentional  injury  is  frequently  done 
by  the  patient  being  at  first  regarded  as  a de- 
linquent and  treated  accordingly,  instead  of  re- 
ceiving the  careful  management  suitable  to  the 
disease.  The  affection  is  characterised  by  great 
disorder  of  the  emotional  and  moral  nature,  which 
is  evinced  by  restless  though  seldom  violent 
excitement,  eroticism,  acts  of  purposeless  mis- 
chief, and  exhibitions  of  inordinate  vanity.  Any 
marked  changeof  disposition  during  the  passage 
from  youth  to  adult  life  ought  to  be  regarded  as 
probably  pathological  in  its  nature,  and  must  be 
carefully  watched.  Persistent  sleeplessness  at 
such  a time  must  also  be  regarded  as  significant 
of  danger  to  the  mental  functions.  The  physical 
condition  is  indicated  by  capricious  appetite, 
and  symptoms  of  anaemia.  The  treatment 
required  is  rest  to  the  mind,  both  in  its  intel- 
lectual and  emotional  energies,  with  cultiva- 
tion of  everything  likely  to  develop  physical 
vigour.  If  the  hereditary  tendency  is  not  ex- 
ceptionally strong,  or  aggravated  by  accidental 
causes,  the  prognosis  is  not  unfavourable. 

Climacteric  insanity  occurs  in  males  between 
the  ages  of  fifty  and  sixty,  and  in  females  be- 
tween forty  and  fifty'.  Its  general  character  is 
a form  of  melancholia,  gradual  in  its  develop- 
ment, manifesting  itself  in  loss  of  sleep,  fear 
of  undefined  evil,  religious  despondency,  hal- 
lucinations of  the  senses,  refusal  of  food,  and 
frequently  in  a suicidal  tendency.  Excitement 
and  exaltation  occur  rarely',  and  are  generally  off 
short  duration.  The  mental  disorder  is  fre- 
quently accompanied  by  very  marked  emaciation, 
ind  the  t endency  is  always  to  anaemia.  The  treat- 
ment required  at  the  commencement  is  cessation 
of  mental  labour  and  change  of  scene.  During 
the  whole  progress  of  the  disease  the  diet  should 
bo  full  and  nourishing,  and  the  digestive  func- 
tions often  require  to  be  stimulated  to  healthy 
action.  In  the  majority  of  cases  the  prognosis  is 
unfavourable,  and  where  recovery  does  not  take 
place  within  one  or  at  most  two  years  the  course 
is  generally  towards  dementia. 

Senile  insanity  is  essentially  a form  of  de- 
mentia, which  comes  on  gradually  in  persons 
who  have  passed  through  the  earlier  periods  of 
life  without  disturbance  of  their  mental  health, 
but  who  break  down  in  old  age.  Its  principal 
features  are  loss  of  memory,  slight  excite- 
ments, whimsical  likings  and  dislikings,  queru- 
lousness, and  a gradual  decadence  into  fatuity. 
It  is  subject  to  occasional  remissions,  which  are 
sometimes  very  short,  as  when  caused  by  the 
stimulus  of  acute  febrile  conditions.  But  they 
are  sometimes  so  prolonged  as  to  amount  prac- 
tically to  recovery.  Not  infrequently  the  break- 
down of  the  nervous  system  pursues  a rapid 
, course,  aud  in  such  cases  there  is  often  a marked 
similarity  in  the  symptoms  to  those  of  general 
paralysis.  Both  mental  and  physical  conditions 
m the  advanced  stages  of  each  are  sometimes 


practically  indistinguishable.  The  diagnosis  will 
depend  on  whether  the  characteristic  first  stage 
of  general  paralysis  has  been  observed  at  the 
commencement,  or  only  a gradual  loss  of  physical 
and  mental  power.  Paralytics,  moreover,  are 
seldom  of  advanced  age. 

John  Sibbaxd. 

8.  Impulsive  Insanity. — Violent  acts  are 
committed  under  an  insane  impulse  by  numerous 
patients  whose  insanity  is  plain  and  acknow- 
ledged. They  may  be  done  under  the  influence 
of  delusions  or  hallucinations,  but  the  term  im- 
pulsive insanity  is  commonly  applied  to  a dis- 
order manifested,  not  by  delusions  and  similar 
symptoms,  but  by  acts  of  violence  to  which  a 
patient  is  driven  by  blind,  uncontrollable,  and 
morbid  impulse,  whereby  the  will  and  the  reason 
are  overpowered  for  a longer  or  shorter  time. 
These  are  for  the  most  part  acts  of  suicide  or 
homicide ; and  in  connection  with  the  latter,  great 
controversy  has  arisen  as  to  the  responsibility 
of  persons  committing  them.  Here,  as  in  moral 
insanity,  there  are  no  delusions  ; frequently  no 
change  will  have  been  detected  in  the  individual 
prior  to  tho  act,  nor  will  there  be  observers  of  it. 
And  it  is  a fact  that  the  impulse  may  be  satisfied 
and  exploded  in  the  act,  and  having  thus  found  a 
vent  may  be  felt  no  longer,  at  any  rate  for  a time. 
It  may  be  as  sudden  as  an  epileptic  fit,  and 
may,  like  the  latter,  bring  relief  to  the  brain. 
Indeed,  there  is  a strong  connection  as  well  as 
analogy  between  the  two  disorders,  and,  as  Dr. 
Maudsley  says,  instead  of  a convulsive  movement 
there  is  a convulsive  idea. 

In  estimating  such  acts  as  these  we  must  not 
only  consider  the  act  itself  and  the  manner  of  its 
performance,  but  must  also  closely  inquire  into 
the  past  history  of  the  perpetrator  and  his  pro- 
genitors. For  all  this  we  may  or  may  not  have  op- 
portunity. If  the  act  is  one  of  attempted  suicide, 
and  the  individual  is  kept  under  observation,  we 
may  have  no  difficulty  in  diagnosing  insanity. 
If  it  is  one  of  homicide,  and  the  criminal  is 
in  prison  for,  perhaps,  only  a week  or  two,  op- 
portunity of  ascertaining  the  history  of  his 
family  may  fail,  nor  will  he  himself  be  under 
skilled  observation.  Moreover  the  period  just 
after  the  committal  of  an  impulsive  homicide 
will  very  probably  be  the  one  in  which  fewest 
symptoms  of  insanity  will  be  noticeable.  The 
period  immediately  preceding  it  will  be  that  which 
most  closely  demands  a scrutiny,  but  we  may  be 
able  to  get  no  information  if  the  accused  has 
been  moving  from  place  to  place,  has  been  among 
strangers,  or  has  had  those  about  him  who  were 
obtuse  and  unobservant.  Many  an  act  of  sui- 
cide and  homicide  would  be  prevented  if  the 
friends  would  not  shut  their  eyes  with  such  per- 
tinacity to  the  strange  and  altered  looks  and  con- 
duct of  the  patient.  But  in  this  impulsive  form, 
although  there  may  not  have  been  enough  to 
warn  those  about  a man  to  restrain  him,  there 
may  have  been  symptoms  which  are  sufficient 
subsequently  to  indicate  to  a physician  the 
presence  of  mental  disorder.  There  may  have 
been  attacks  of  grand  mal  or  petit  mal : there 
may  have  been  former  attacks  of  insanity,  periods 
of,  it  may  be,  slight  depression,  which,  though 
they  may  have  attracted  little  notice  at  the  timev 


INSANITY,  VARIETIES  OF. 


126 

may  indicate  an  insane  diathesis.  The  sufferer 
may  hare  been  sleeping  badly  or  hare  taken  less 
nourishment  than  usual. 

The  medical  witness  will,  in  the  case  of  homi- 
cide, carefully  examine  and  pay  special  attention 
to  the  following  points  : — 

(a)  The  nature  and  character  of  the  act  must 
be  noted.  The  presence  or  absence  of  motive 
may  often  assist  us.  When  the  victim  is  near 
of  kin  and  dearly  loved,  suspicion  of  insanity 
will  at  once  arise.  AVhen,  on  the  other  hand,  it 
is  a perfect  stranger,  never  before  seen,  where 
there  has  been  no  previous  meeting  or  quarrel, 
the  same  suspicion  will  arise.  The  method  of 
the  act  may  guide  us  somewhat,  but  not  so 
much.  There  may  be  premeditation,  though 
generally  there  is  not. 

( b ) The  demeanour  of  the  prisoner  after  the 
act  may  assist  us.  Were  there,  or  were  there  not, 
attempts  to  conceal  it,  or  to  escape  detection  and 
arrest?  What  was  said  in  explanation?  It 
sometimes  happens  that  there  is  complete  un- 
consciousness or  forgetfulness  of  what  has  oc- 
curred, and  we  may  then  strongly  suspect  the 
presence  of  epilepsy. 

(o)  We  must  closely  inquire  into  the  family 
history,  and  shall  often  find  that  in  cases  of  im- 
pulsive homicide,  the  family  of  the  accused  is 
saturated  with  insanity.  And  where  this  is  so, 
we  may  also  find  that  from  youth  the  accused  has 
been  deficient  and  weak  in  intellect,  or  odd  and 
eccentric.  The  weak-minded,  in  fact,  may  be 
grouped  in  a special  class  of  homicides.  As 
there  is  a weak-minded  moral  insanity,  so  there 
is  a weak-minded  impulsive  homicidal  insanity 
the  sufferers  from  which  have  not  unfrequently 
been  hanged,  their  insanity  not  having  been 
sufficiently  marked  to  absolve  them  from  legal 
responsibility.  Fits  in  childhood  may  contribute 
to  this  state.  And  throughout,  at  the  age  of 
ppberty,  or  ;n  adult  life,  there  may  be  slight 
but  sure  indications  of  the  insane  blood  that  has 
been  inherited,  which  are  displayed  in  an  im- 
pulse to  homicide  or  suicide,  even  as  in  others 
the  tendency  is  shown  in  ordinary  attacks  of 
insanity. 

(d)  We  must  look  very  closely  for  symptoms 
or  a history  of  epilepsy.  Such  indications  as 
nocturnal  micturition  or  a bitten  tongue  may 
guide  us  to  the  truth,  while  in  acknowledged 
epileptics  it  may  happen  that  the  homicidal  at- 
tack takes  the  place  of  the  ordinary  convulsion, 
and  without  the  occurrence  of  the  latter  there 
may  be  a period  of  unconsciousness  and  uncon- 
scious action  lasting,  perhaps,  for  days.  See 
Epileptic  Insanity. 

The  occurrence  of  one  homicidal  attack  of  a 
strange  or  anomalous  character  may  make  us  fear 
its  recurrence,  and  when  we  have  to  examine  a 
criminal  who  has  committed  one  act  of  this  kind, 
it  is  important  to  inquire  whether  he  has  ever  at 
any  former  time  done  any  sudden  act  of  violence 
of  a similar  description.  For  this  reason  such 
patients  should  not  be  released  from  an  asylum, 
except  under  great  and  special  precautions. 

G.  F.  JIlandfoed. 

9.  Legal  Insanity. — Lawyers  regard  insanity 
from  a different  point  of  view  from  medical  men. 
A medical  man  applies  his  mind  to  its  study  so 


as  to  ascertain  how  far  he  may  infer  from  the 
evidences  of  mental  action  the  existence  of  mor- 
bid conditions  which  he  may  hope  to  alleviate  or 
remove.  It  is  therefore  hisduty  to  be  acquainted 
with  such  symptoms  as  give  the  earliest  indica- 
tion of  the  approach  or  development  of  these 
morbid  processes.  For  it  is  during  their  initia- 
tory stages  that  he  may  most  successfully  inter- 
vene with  the  resources  of  his  art,  to  check 
their  progress  or  to  ward  them  off.  He  there- 
fore identifies  with  the  existence  of  disease, 
every  deviation  from  the  healthy  mental  standard 
which  indicates  the  necessity  for  medical  treat- 
ment or  advice.  A lawyer,  on  the  other  hand, 
takes  note  of  insanity  only  in  so  far  as  it  affects 
the  safety  of  person  or  the  preservation  of  pro- 
perty. The  question  which  he  seeks  to  deter- 
mine is  whether  a person  is  justly  responsible 
for  certain  acts  which  he  has  committed,  or  is 
competent  to  perform  certain  acts  which  he  mav 
be  called  on  to  perform.  It  is  evident,  therefore, 
that  the  legal  view  of  insanity  must  naturally  be 
much  more  limited  than  the  medical.  ■ A lawyer, 
when  speaking  of  insanity,’  says  Mr.  Justice 
Stephen,  ‘ means  conduct  of  a certaiu  character; 
a physician  means  a certain  disease  one  of  the 
effects  of  which  is  to  produce  such  conduce ; ' an  t 
though  this  has  been  adversely  criticised  it  seems 
to  show  correctly  the  directions  in  which  the  two 
views  diverge.  They  might  perhaps  be  as  fairly 
indicated  in  other  words  ifwe  say  that  the  lawyer 
has  to  deal  with  the  naturo  or  quality  of  certain 
acts,  while  the  physician  has  to  deal  with  the 
condition  of  certain  persons.  No  satisfactory 
general  definition  of  legal  insanity  has  been  given. 
In  the  earlier  ages  of  our  legal  system  none  but 
the  most  outrageous  cases  of  insanity  were  recog- 
nised. Bracton  in  the  thirteenth  century  defined 
a madman  as  ‘one  who  does  not  understand  what 
he  is  doing,  and,  wanting  mind  and  reason,  differs 
little  from  brutes.’  Sir  Edward  Coke,  though 
he  recognises  different  classes,  according  as  the 
insanity  is  congenital,  permanent,  or  temporary, 
only  admits  that  a person  is  insane  when  he  is 
non  compos  mentis,  or  has  wholly  lost  his  memory 
and  understanding.  Sir  Matthew  Hale,  in  the 
seventeenth  century,  was  the  first  to  recognise 
the  existence  of  less  extreme  forms  of  insanity. 

‘ Some  persons,’  he  said,  * that  have  a competent 
use  of  reason  in  respect  of  some  subjects,  are 
yet  under  a particular  dementia  in  respect  of 
some  particular  discourses,  subjects,  or  applica- 
tions; or  else  it  is  partial  in  respect  of  degrees, 
and  does  not  excuse  persons  who  commit  capital 
acts  in  this  state.’  He  also  said  that  it  is  ‘very 
difficult  to  define  the  invisible  line  that  divides 
perfect  and  partial  insanity,’  and  ‘ that  most 
persons  that  are  felons,  of  themselves  or  others, 
are  under  a degree  of  partial  insanity  when  they 
commit  these  offences.’  The  recognition  of  these 
gradations,  reaching  even  to  the  mutual  overlap- 
ping of  crime  and  insanity,  indicates  as  much 
breadth  of  view  as  could  be  expected  at  a time 
when  the  very  judge  who  recognises  them  passed 
sentence  of  death  on  persons  convicted  of  witch- 
craft. Wo  cannot  doubt,  indeed,  that  at  that 
period  the  ignorance  of  the  nature  of  insanity 
was  such  that  many  lunatics  were  executed  for 
this  offence.  The  recognition  of  the  necessity  of 
takiug  legal  account  of  minor  degrees  of  insanitv 


INSANITY,  VARIETIES  OE.  727 


than  ‘ furious  madness  ’ or  idiocy  may  be  said  to 
commence  at  the  beginning  of  the  present  cen- 
tury. The  mode  in  which  unsoundness  of  mind 
comes  into  relation  with  law  at  present,  may  be 
looked  at  most  conveniently  from  three  points 
of  view: — 1.  Where  a person  suffers  from  such 
unsoundness  of  mind  that  it  is  necessary  for 
his  welfare,  or  the  safety  of  the  public,  that  his 
liberty  should  be  restricted  by  his  being  placed 
in  an  asylum  or  subjected  to  similar  restraint. 
2.  Where  a person  suffers  from  such  unsound- 
ness of  mind  that  he  is  incapable  of  managing 
himself  or  Ins  affairs.  3.  Where  irresponsibility 
for  crime,  on  account  of  insanity,  is  pleaded  in  a 
court  of  law.  It  will  be  found  more  convenient 
to  consider  these  three  relations  of  insanity  and 
jurisprudence  separately.  The  reader  is  conse- 
quently referred  to  the  articles  specially  devoted 
to  them,  which  will  be  found  under  the  heads  of 
Lunacy,  Law  of ; Civil  Incapacity  ; and  Cri- 
minal Ihresponsibility. 

John  Sibbald. 

10.  Moral  Insanity. — Synon.:  Fr.  Manie 
sans  dilire  ; Folie  raisonnantc ; Monomanic  affec- 
tive-, Ger.  Gcmuthsxvaknsmn. 

Under  the  names  of  moral  insanity , emo- 
tional insanity,  impulsive  insanity,  affective 
insanity,  has  been  described  the  disorder 
of  certain  patients,  which  is  manifested  by 
insane  actions  and  conduct  rather  than  by  in- 
sane ideas,  delusions,  or  hallucinations.  Such 
persons  are  sometimes  said  to  be  of  whole  and 
perfect  intellect,  though  unsound  in  the  moral 
and  emotional  part  of  their  brain.  They  come 
under  the  notice  of  medical  men,  not  so  much  for 
purposesof  treatmentasfordiagnosis.  Their  con- 
duct being  chiefly  displayed  in  foolish  or  violent 
acts,  they  require  to  bo  restrained,  and  the  ques- 
tion arises  : Is  this  conduct  badness  or  madness? 
are  they  responsible  for  it  or  not  ? 

Dr.  Maudsley  gives  moral  insanity  and  impul- 
sive insanity  as  two  subdivisions  of  emotional 
or  affective  insanity ; and,  as  the  symptoms  are 
certainly  different,  wo  cannot  do  better  than  con- 
sider them  under  separate  heads.  But  certain 
observations  are  applicable  to  both.  In  neither 
will  there  be  found  delusions,  and  as  delusions 
are,  in  the  opinion  of  some,  especially  lawyers, 
necessary  to  the  establishment  of  legal  insanity 
and  irresponsibility,  these  patients  are  notlegally 
insane.  Another  remark  is  that  this  moral  or 
impulsive  insanity  does  not  constitute  a definite 
and  well-marked  disease,  like  acute  delirium  or 
general  paralysis.  Every  patient  may  at  one 
time  or  other  bo  ‘morally  insane,’  that  is,  may 
not  have  reached  the  stage  of  delusions,  or  may 
have  recovered  from  it,  and  every  patient  may 
commit  ‘ impulsive  ’ acts  of  violence,  whether  his 
insanity  is  displayed  in  other  ways  or  not. 

By  moral  insanity  is  to  be  understood  a dis- 
order of  mind  shown  by  an  entire  change  of 
character  and  habits,  by  extraordinary  acts  and 
conduct,  extravagance  or  parsimony,  false  asser- 
tions and  false  views  concerning  those  nearest 
and  dearest,  but  without  absolute  delusion. 
Such  a change  may  be  noticed  after  any  of  the 
ordinary  causes  of  insanity.  It  may  follow  epilep- 
tic or  apoplectic  seizures,  or  may  be  seen  after  a 
poriod  of  drinking.  Its  approach  is  gradual,  as 


a rule,  rather  than  sudden,  and  the  extraordinary 
character  of  the  acts  may  not  at  first  be  so 
marked  as  subsequently.  Friends  wonder  that 
a man  should  say  this  or  that,  or  should  do 
things  so  foreign  to  his  nature  and  habits,  but 
some  time  may  elapse  before  they  can  convince 
themselves  that  such  conduct  is  the  result  of 
disease,  and  the  acts  may  be  such  that  many 
will  look  upon  them  even  to  the  last  as  signs 
merely  of  depravity.  Such  insanity  of  course 
varies  in  degree.  When  it  is  well  marked,  and 
the  conduct  is  outrageous,  there  will  be  no  diffi- 
culty in  the  diagnosis.  But  it  may  be  loss 
marked  ; it  may  consist  of  false  and  malevolent 
assertions  concerning  people,  even  the  nearest, 
of  little  plots  and  traps  to  annoy  others,  in  which 
great  ingenuity  and  cunning  may  be  displayed. 
And  there  will  be  the  greatest  plausibility  in  the 
story  by  which  all  such  acts  and  all  other  acts 
will  be  explained  away  and  excused.  It  would 
seem  sometimes  as  if  a universal  badness  had 
taken  possession  of  the  individual,  yet  a badness 
so  inexplicable  that  it  can  only  be  looked  upon 
as  madness.  Where  we  can  ascertain  that  this 
condition  of  things  is  something  which  has  come 
over  the  patient,  being  formerly  absent,  and  that 
he  is  altogether  changed,  we  may  suspect  insanity. 
But  much  examination  and  opportunity  for  ex- 
amination may  be  needful  before  wo  can  sign  a 
certificate,  for  such  people  are  often  very  acute, 
and  quite  on  the  alert.  They  have  no  scruples 
about  falsehood,  and  will  deny  or  justify  every- 
thing with  which  they  are  taxed  ; and  where  the 
insanity  is  manifested  in  conduct,  the  medical 
man  may  never  be  a witness  of  it,  and  is  obliged 
to  receive  on  hearsay  that  which  the  patient 
strenuously  denies.  Careful  inquiry,  however, 
will  probably  reveal  the  origin  and  cause  of  the 
change  ; there  may  have  been  a period,  though 
short,  of  acute  insanity — as  acute  mania  or  me- 
lancholia— which  passed  away  and  left  this  as  a 
permanent  condition;  or  it  maybe  the  precursor 
of  a more  advanced  stage  of  the  disorder,  one 
marked  by  the  ordinary  symptoms,  as  delusions 
and  hallucinations.  If  the  change  has  been 
rapid  and  progressive,  if  the  sufferer  has  become 
more  and  more  outrageous  and  eccentric,  it  is 
likely  that  in  a short  time  unmistakable  in- 
sanity will  be  displayed ; but  some  cases  pro- 
gress slowly,  and  steps  for  restraint  have  to 
be  taken  before  anything  like  delusion  is  to 
be  found.  It  may  be  necessary  to  prevent 
a man  from  squandering  all  his  property 
— a common  symptom  in  this  variety — or  from 
wandering  from  home  and  absenting  himseif 
no  one  knows  where,  or  keeping  low  company. 
And  when  a man  previously  quite  sober  suddenly 
takes  to  drinking,  the  question  may  arise  whether 
this  is  not  the  effect  of  insanity.  Great  diffi- 
culty may  be  found  in  proving  the  latter,  but 
unquestionably  it  is  often  the  case.  Here,  how- 
ever, if  the  habit  is  indulged  in,  the  patient  will 
most  likely  get  rapidly  worse,  and  then  restraint 
will  be  more  easily  enforced. 

Moral  insanity  may  be  the  precursor  of  general 
paralysis  ; it  may  also  be  the  sequel  and  result  of 
a more  severe  insanity  ; it  may  be  the  outcome 
of  apoplexy,  or  of  a blow  or  other  damage  to  the 
brain.  It  may  be  one  of  the  alternating  states 
of  the  6o-called  Folie  circulaire.  Here  a period 


INSANITY,  VARIETIES  OF. 


,728 

>f  depression  alternates  with  one  of  excitement, 
gaiety,  self-glorification,  ot  irascibility,  and  the 
latter  may  be  one  closely  resembling  that  usually 
called  moral  insanity,  and  evidenced  by  exag- 
gerated conduct  and  absurd  acts.  It  may  follow 
a simple  attack  of  epilepsy,  or  may  be  the  pre- 
cursor of  such  attacks,  being  a part  of  that  epi- 
leptic condition  known  as  masked  epilepsy.  See 
Epileptic  Insanity. 

The  one  constant  and  marked  feature  of  this 
insanity  is  the  absence  of  delusion ; but  we  are 
not  on  this  account  to  argue  that  the  intellect 
is  sound.  There  is  often  great  acuteness  and 
cunning  displayed  by  such  patients,  yet  along 
with  the  cunning  there  may  be  the  most  silly 
and  foolish  conduct.  Often  there  is  great  acute- 
ness shown  by  those  who  have  delusions,  but 
because  of  the  latter  we  say  their  intellect  is 
disordered.  Yet  it  is  proof  of  disorder  of  the 
intellect  if  a patient  spends  his  capital  as  though 
it  were  income,  defends  and  justifies  the  most 
outrageous  acts,  and  cannot  be  made  to  see  that 
they  are  outrageous.  Close  examination  will 
probably  reveal  the  fact  that  there  is  very  con- 
siderable intellectual  lesion  in  these  cases.  There 
is  a want  of  the  power  of  attention  and  concen- 
tration of  ideas  on  a subject.  A patient  com- 
mences a story  of  his  grievances,  and  in  two 
minutes  is  far  away  from  his  theme,  and  is  boast- 
ing of  his  virtues  or  conduct,  and  no  amount  of 
bringing  back  will  enable  him  to  give  a definite 
and  succinct  account  of  what  he  has  to  complain 
of.  Such  rambling  is  a marked  symptom  of  this 
insanity,  and  a strong  indication  of  a weakened 
intellect. 

There  is  one  more  form  of  moral  insanity 
which  is,  perhaps,  the  hardest  of  all  to  diagnose 
and  estimate.  It  is  the  congenital  moral  defect 
occasionally  met  with  in  persons  who  have  been 
from  birth  odd  and  peculiar,  and  incapable  of 
acting  and  behaving  like  other  people.  They  can 
hardly  be  called  idiots  or  imbeciles,  for  they  may 
exhibit  a considerable  amount  of  intellect  and 
even  genius  in  certain  special  directions.  We 
shall  generally  find  that  they  are  the  offspring 
of  parents  strongly  tainted  with  insanity,  epi- 
lepsy, or  alcoholism,  and  many  in  childhood  are 
tire  subject  of  fits,  chorea,  or  other  neuroses. 
They  are  incapable  of  being  instructed  like  other 
boys  aud  girls,  are  often  frightfully  cruel  towards 
animals  or  their  brothers  and  sisters,  and  seem 
utterly  incapable  of  telling  the  truth  or  under- 
standing why  they  should  do  so.  Here  there  is 
no  change  ; we  cannot  compare  the  individual’s 
condition  with  a former  one,  but  we  can  only 
estimate  him  by  the  average  of  mankind.  These 
are  the  persons  who  commit  crimes  and  become 
the  chronic  inmates  of  prisons,  and  it  is  most 
difficultboth  for  medical  and  otherprison-officials 
to  say  how  far  they  are  responsible,  and  how  far 
not.  Careful  and  special  education  is  needful  for 
them,  and  this  they  may  obtain  if  they  are  born 
of  well-to-do  parents,  but  a vast  number  are  to 
be  found  amongst  the  ranks  of  the  lower  classes; 
the  offspring  of  intemperance  and  poverty,  they 
swell  the  numbers  of  the  criminal  classes  in  no 
inconsiderable  degree. 

G.  F.  Biandfobd. 

1 1.  Pellagrous  Insanity. — This  is  a form  of 


insanity  associated  with  pellagra,  and  not  n:e( 
with  in  Britain.  It  is  characterised  by  mental 
symptoms  usually  indicative  of  anaemia — great 
depression,  frequently  with  tendency  to  suicide, 
passing  on  to  chronic  dementia.  It  is  most  fre- 
quently met  with  in  Italy. 

12.  Phthisical  Insanity. — It  has  been  gene- 
rally observed  that  there  is  a special  mental  cha- 
racter associated  with  pulmonary  tuberculosis. 
This  consists  frequently  in  a peculiar  cheerful 
hopefulness,  which  has  received  the  name  of  spet 
phthisica,  and  which  seems  strangely  out  of  har- 
mony with  the  unmistakable  signs  of  an  inevit- 
able doom  by  which  it  is  accompanied.  But 
there  is  also  a state  of  mental  depression  which 
has  been  observed  in  intimate  association  with 
the  disease.  Tho  peculiar  hopefulness  is  most 
frequently  met  with  in  the  acute  and  active  f orms 
of  phthisis,  and  it  is  often  so  irrational  and  per- 
sistent us  to  amount  to  an  insane  delusion,  grow- 
ing as  it  does  in  strength  while  the  evidences  of 
its  baselessness  accumulate.  In  the  last  stages  of 
the  malady  the  religious  and  general  emotional 
exaltation  is  often  extreme,  and  actual  delirium 
is  not  infrequent.  An  opposite  mental  condition 
is  met  with  in  chronic  phthisis,  more  especially 
in  that  form  of  it  which  has  been  called  latent. 
All  through  the  course  of  the  disease  there  is  a 
prevailing  depression  and  distrustfulness,  though 
the  physical  symptoms  are  neither  so  distressing 
nor  so  obvious  as  in  the  acuter  forms.  The  men- 
tal symptoms  sometimes  precede  the  physical. 
Languor  and  depression,  mingled  with  wayward- 
ness. are  characteristic  of  the  initial  stage.  This 
is  usually  accompanied  by  general  functional 
debility,  which  is  often  attributed  to  mere  dis- 
turbance of  digestion  and  nutrition.  The  skin  is 
habitually  pale,  and  the  circulation  feeble.  In 
many  cases  the  physical  signs  of  pulmonary  dis- 
ease when  present  are  apt  to  be  overlooked,  and 
occasionally  they  escape  observation  for  years. 
Where  the  mind  is  much  affected  the  ordinary 
symptomatic  cough,  expectoration,  and  dyspnoea 
are  often  absent ; and  this  is  the  case  sometimes 
where  physical  exploration  reveals  the  existence 
of  extensive  vomicae  and  other  characteristics  of 
advanced  disease.  The  mental  condition  as  the 
further  stages  are  reached  becomes  less  one  of 
depression  and  more  one  of  distinct  enfeeble- 
ment.  Occasional  fits  of  considerable  irritability 
and  excitement  occur.  Dr.  Clonston,  who  first 
drew  special  attention  to  this  condition,  says  of 
the  patients  that  ‘ there  is  a want  of  fixity  in 
their  mental  condition.  There  is  a disinclination 
to  enter  into  any  kind  of  amusement  or  con- 
tinuous work;  and  if  this  is  overcome  there  is 
no  interest  manifested  in  the  employment.  It 
might  be  called  a mixture  of  subacute  mania 
and  dementia,  being  sometimes  the  one  and 
sometimes  the  other.  As  the  case  advances,  the 
symptoms  of  dementia  come  to  predominate ; hut 
it  is  seldom  of  that  kind  in  which  the  mental 
faculties  are  entirely  obscured,  with  no  gleam  of 
intelligence  or  any  tendency  to  excitement.  If 
there  is  any  tendency  to  periodicity  in  the  symp- 
toms at  all,  the  remissions  are  not  so  regular, 
nor  so  complete,  nor  so  long  as  in  ordinary 
periodical  insanity.  If  there  is  depression  it  is 
accompanied  with  irritability  and  the  want  oi 


INSANITY,  VARIETIES  OF. 


an}'  fixed  depressing  idea  or  delusion.  If  there 
is  any  single  tendency  that  characterises  these 
eases,  ir.  is  to  be  suspicious.’  Where  any  chronic 
form  of  insanity  is  associated  with  phthisis  the 
chance  of  complete  restoration  to  sanity  is  very 
small.  In  the  affection  distinguished  by  emo- 
tional exaltation  no  special  treatment  is  called 
for.  The  only  indication  of  treatment  in  the 
other  type  of  disease  is  the  necessity  of  keeping 
up  a full  supply  of  nourishment  to  the  brain  ; 
and  this  sometimes  requires  that  forcible  feeding 
should  be  resorted  to.  Where  the  mental  con- 
dition is  much  disturbed,  a trustworthy  attend- 
ant ought  to  be  employed,  and  the  general  treat- 
ment should  always  be  tonic  and  stimulating. 
Removal  to  an  asylum  ought  in  most  cases  to  be 
avoided.  John  Sibbald. 

13.  Puerperal  Insanity. — Synon.  : Insania 
gravidarum;  Insania  puerperarum ; Insania  lac- 
tantium ; Fr.  Folie  puerperale ; Ger.  Puerperal- 
manie. 

Definition. — Insanity  developed  during  preg- 
nancy, parturition,  or  lactation. 

It  has  been  the  custom  of  authors,  till  a recent 
period,  to  include  under  this  heading  the  forms 
of  insanity  which  occur  in  females  during  the 
periods  of  utero-gestation,  the  puerperal  state, 
and  lactation.  It  is  now  frequent  to  find  the 
term  ‘ puerperal’  restricted  to  the  derangements 
which  come  on  at  the  time  of  delivery,  or  within 
a short  period  thereafter.  Whatever  names  we 
adopt,  it  is  impossible  to  consider  the  insanity 
occurring  at  these  different  periods  quite  inde- 
pendently. The  condition  of  the  woman  during 
tlie  whole  process,  from  the  time  of  conception 
till  the  child  is  weaned,  represents  one  of  those 
physiological  crises  during  which  congenital  or 
acquired  weakness  of  constitution  tends  to  show 
itself. 

The  insanity  of  pregnancy  generally  takes 
the  melancholic  form,  and  seems  to  be  due  in 
some  cases  chiefly  to  a gradually  developed 
anaemia,  and  in  others  to  disturbance  of  the 
abdominal  viscera,  both  of  which  conditions  are 
frequently  associated  with  mental  depression. 
The  delusions  which  characterise  the  disorder 
are  generally  exaggerations  of  the  anxieties  and 
, whims  so  frequent  in  pregnancy.  In  the  severer 
■ forms  the  suicidal  impulse  is  frequently  developed. 

; The  prognosis  is  generally  favourable;  but  re- 
covery seldom  occurs  till  the  termination  of  the 
gestation.  It  may  sometimes  be  expedient  to 
resort  to  the  induction  of  premature  labour.  In 
all  cases  a torpid  condition  of  the  digestive  func- 
tions should  be  carefully  corrected. 

Puerperal  insanity  in  its  more  restricted  mean- 
ng  is  frequently  understood  to  include  all  de- 
rangements occurring  at  parturition,  or  within 
six  or  eight  weeks  after  it.  Rut  it  is  better  to 
imit  the  term  to  what  occurs  during  the  first 
hree  weeks,  as  the  form  of  disorder  which  com- 
nences  after  that  period  is  generally  different  in 
haracter. 

■(Etiology. — Prominent  among  the  causes  of 
merperal  mania  are  all  states  of  debility,  either 
nduced  before  parturition  by  want,  intemperance, 
isorders  of  nutrition,  or  rapid  succession  of  preg- 
ancies,  especially  if  lactations  and  pregnancies 
le  carried  on  simultaneously  ; or  it  may  be  the 


723 

result  of  weakness  induced  during  parturition 
by  hsmorrhage  or  exhaustion.  It  is  liable  to 
occur  in  primipar®,  when  the  subjects  are  either 
exceptionally  young  or  exceptionally  advanced 
in  life.  Irritation  arising  in  the  pelvic  organs, 
intestines,  or  mammae  also  tends  to  produce  it. 
Any  inordinate  mental  excitement  or  depression 
is  apt  to  bring  it  on.  Where  any  of  these  causes 
are  superimposed  on  hereditary  tendency,  the 
danger  is  of  course  greatly  augmented. 

Symptoms. — Attacks  of  maniacal  excitement 
sometimes  occur  during  actual  parturition.  They 
are  usually  of  very  short  duration,  and  seem  to 
be  directly  dependent  on  the  intense  suffering 
which  may  accompany  the  pains.  The  most  fre- 
quent period  of  their  occurrence  is  when  the  head 
of  the  child  is  passing  either  the  os  internum  or 
externum.  The  more  serious  phase  of  the  dis- 
order is  in  its  acute  stage  a variety  of  acute 
maniacal  delirium.  It  usually  commences  with- 
in a week  or  ten  days  after  delivery.  Gen- 
erally it  is  preceded  by  sleeplessness,  and  the 
patient  manifests  more  or  less  apprehension  of 
coming  evil.  Sometimes,  however,  she  awakes 
delirious  from  what  had  been  regarded  as  a 
healthy  slumber.  When  the  attack  has  com- 
menced, sleep  is  always  either  very  imperfectly 
obtained,  or  is  altogether  absent.  The  pulse  is 
quick ; the  skin  often,  but  not  always,  dry  and  hot ; 
and  the  head  throbbing.  The  eyes  are  bright, 
and  the  face  generally  pale,  with  occasional 
flushing.  The  expression  is  generally  indicative 
of  alarm  or  suspicion  on  the  part  of  the  patient. 
The  tongue  is  dry  and  furred,  and  the  secretions 
of  milk  and  lochia  are  either  suppressed  or 
diminished.  The  bowels  are  sometimes  loose, 
but  constipation  is  the  usual  condition.  The 
appetite  is  uncertain ; sometimes  it  is  impaired, 
but  more  frequently  it  is  abnormally  large.  Not 
infrequently  the  sense  of  taste  is  perverted,  and 
the  patient  suspects  the  presence  of  poison  in 
her  food,  and  persistently  refuses  it.  The  breath 
is  often  offensive  in  odour.  Sometimes  the  men- 
tal excitement  does  not  reveal  itself  in  language, 
and  the  patient  may  be  obstinately  taciturn  from 
the  commencement.  But  there  is  usually  a great 
increase  of  loquacity,  gradually  increasing  from 
the  beginning,  and  passing  into  incoherent 
raving.  Sudden  impulsive  acts  of  violence  fre- 
quently manifest  themselves  in  this  disorder,  and 
in  these  the  patient  often  attempts  to  destroy 
herself,  her  child,  or  persons  for  whom  she 
has  usually  the  most  affectionate  regard.  She 
generally  appears  to  be  dissatisfied  with  those  in 
attendance  on  her,  and  often  entertains  delusions 
as  to  their  identity.  In  many  cases  the  mental 
condition  bears  a strong  resemblance  to  that  of 
delirium  tremens,  especially  when  the  patient 
has  undergone  privations,  or  has  been  intem- 
perate during  pregnancy. 

Diagnosis. — The  only  conditions  for  which 
puerperal  insanity  may  be  mistaken  are  the 
typhoid  delirium  of  puerperal  fever  or  pyaemia ; 
and  the  violent  excitement  frequently  sympto- 
matic of  meningitis.  In  these  cases  the  febrile 
condition  precedes  the  development  of  the  deli- 
rium, while  in  puerperal  mania  the  mental 
symptoms  show  themselves  from  the  first.  In 
meningitis  the  pupils  are  generally  contracted, 
] and  the  headache  is  peculiarly  intense;  ■while  in 


730  INSANITY,  1 

puerperal  mania  the  pupils  are  usually  dilated, 
and  the  h eadache  i s n ot  a very  prominent  symptom. 

Pkoqnosis. — According  to  the  published  sta- 
tistics of  this  disease,  recovery  may  he  expected 
in  about  70  per  cent,  cf  the  cases,  and  a fatal 
termination  need  not  be  anticipated  in  more 
than  5 per  cent.  But  as  these  figures  are  in  a 
great  measure  obtained  from  asylum  statistics, 
and  other  sources  in  which  only  the  severer  and 
more  persistent  forms  have  been  taken  into 
account,  it  may  be  fairly  assumed  that  the  true 
estimate  would  be  much  more  favourable.  The 
duration  of  the  insanity  may  vary  from  a few 
days  to  a year,  after  which  time  the  proportion  of 
recoveries  becomes  extrenjely  small.  The  great 
proportion  of  recoveries  takes  place  during  the 
first  six  months.  The  most  favourable  symp- 
toms, in  addition  to  amelioration  of  the  mental 
symptoms,  are  increase  of  bodily  weight,  and  re- 
storation of  the  catamenia. 

Treatment. — The  transitory  mania  which 
sometimes  accompanies  tho  severer  pains  of 
labour  does  not  require  special  treatment ; but 
anaesthetics  may  be  given  as  a preventive  measure 
in  cases  where  there  is  a known  liability  to  such 
excitement.  Special  care  ought  also  to  be  taken 
after  such  attacks,  until  the  strength  is  fully 
restored,  to  avoid  injury  by  premature  bodily 
exertion,  unnecessary  social  intercourse,  disquiet- 
ing news,  or  any  kind  of  mental  or  moral  strain. 
In  the  treatment  of  the  graver  form  of  puerperal 
mania,  the  chief  objects  are  to  remove  all  sources 
of  irritation,  to  restore  the  patient’s  strength,  and 
to  obtain  repose.  If  there  is  any  accumulation 
of  faeces,  a smart  purgative  should  he  at  once  ad- 
ministered. If  the  locbial  discharge  is  scanty, 
an  injection  of  warm  water,  containing  carbolic 
acid  or  some  other  antiseptic  remedy,  should  be 
given  per  vaginam.  The  condition  of  the  bladder 
should  be  ascertained,  and  this  organ  should  he 
relieved,  if  necessary ; care  should  also  bo  taken 
not  to  allow  the  breasts  to  be  over-distended.  In 
those  cases  in  which  violent  excitement  does  not 
come  on  suddenly,  an  attack  may  sometimes  be 
warded  off  or  cut  short  by  relieving  the  sleepless- 
ness which  is  one  of  the  early  symptoms.  As  a 
hypnotic  about  thirty  grains  of  chloral  is  the 
best.  Opium  ought  to  be  avoided,  and  hyoscya- 
mus  and  belladonna  cannot  be  relied  on.  In 
every  case  the  patient  should  receive  from  the 
first  as  much  light  and  nourishing  food  as  her 
digestive  powers  can  properly  hear  ; for  it  must 
always  be  remembered  that  we  have  to  deal 
with  a condition  of  ansemia.  Both  in  the  first 
stage,  and  when  the  disease  is  more  advanced, 
everything  must  be  done  to  promote  tranquil- 
lity. The  room  should  he  darkened,  and  still- 
ness maintained  as'  far  as  possible,  for  the  at- 
tention of  the  patient  is  very  easily  excited, 
and  both  vision  and  hearing  are  preternatu- 
rally  acute.  Constant  supervision  is  necessary, 
however,  on  account  of  the  tendency  to  sudden 
impulsive  violence ; and  the  patient  should  see 
her  infant  as  seldom  as  possible.  After  the 
maniacal  condition  has  fairly  declared  itself,  the 
child  should  be  removed  altogether,  as  its  pre- 
sence is  sometimes  productive  of  great  excite- 
ment in  the  patient,  and  must  always  be  regarded 
as  attended  with  risk  to  itself.  In  cases  where 
the  excitement  is  somewhat  of  a hysterical 


VARIETIES  OF. 

character,  bromide  of  potassium,  given  in  twenty, 
grain  doses  at  intervals  of  four  Lours,  may  pro- 
duce good  results.  Cooling  applications  to  the 
bead  sometimes  soothe  irritation,  and  induce 
sleep.  Digitalis  in  small  doses,  and  warm  baths, 
have  proved  useful.  Alcoholic  stimulauts  should 
generally  be  given  with  the  food ; their  effects 
being  carefully  watched,  and  the  quantity  varied 
accordingly.  Bleeding  and  every  kind  of  deple- 
tion should  be  avoided.  The  nursing  and 
attendance  should,  if  possible,  be  entirely  en- 
trusted to  strangers,  and  the  patient  should  not 
be  permitted  to  see  any  members  of  her  family. 
It  will  sometimes  be  necessary,  especially  in  the 
case  of  poor  persons,  to  resort  to  asylum  treat- 
ment ; but  this  ought  not  to  be  done  if  it  can  be 
avoided  ; and  with  patients  in  good  circumstances 
it  ought  never  to  be  necessary  in  the  acute  stage 
of  the  disease.  When  the  disease  becomes 
chronic,  tonics,  such  as  quinine  and  iron,  ought 
to  be  given,  and  a plentiful  supply  of  nourish- 
ment should  then,  as  all  through  the  illness,  b» 
carefully  administered.  Patients  liable  to  this 
disorder  should  not  be  allowed  without  consider- 
ation to  nurse  their  children. 

The  insanity  of  lactation  is  symptomatic  of 
causes  which  come  into  play  after  the  puerperal 
period,  and  it  ought  perhaps  to  be  looked  on  as 
symptomatic  merely’ of  prolonged  ansemia.  Acute 
maniacal  symptoms  of  short  duration  may  occur; 
but  the  characteristic  condition  is  melancholia, 
ushered  in  by  headache,  tinnitus  aurium,  flashes 
of  light  before  the  eyes,  and  other  signs  of 
debility.  A suicidal  tendency  sometimes  appears. 
The  treatment  required  is  to  wean  the  child,  and 
generally  to  save  and  increase  the  strength  of  the 
patient.  The  prognosis  is  favourable  in  the 
majority  of  eases.  John  Si.ibald. 

14.  Syphilitic  Insanity. — Amonsthe  results 
of  constitutional  syphilis,  affections  of  the  nervous 
system  are  not  uncommon ; and  when  the  disease 
affects  the  brain,  the  mental  symptoms  that  arise 
are  found  in  the  majority  of  cases  to  present  a 
marked  similarity  in  their  character.  In  such 
cases  the  mental  disorder  is  generally  preceded, 
as  in  so  many  forms  of  insanity,  by  distressing 
sleeplessness.  This  is  followed  gradually  by  in- 
creasing depression  of  mind.  Religious  anxiety 
of  a peculiarly  hopeless  character  frequently 
shows  itself.  Exaggerated  self-accusings  are 
earnestly  uttered  by  those  who  have  previously 
been  unusually  callous  as  to  the  results  of  their 
actions.  Hypochondriacal  delusions  are  not  un- 
common, and  are  frequently  associated,  in  the 
mind  of  the  patient,  with  the  fact  of  the  syphi- 
litic infection.  The  feeling  of  alarm  which  ac- 
companies these  symptoms  sometimes  developes 
into  a violent  excitement,  which  may  be  called 
maniacal.  If  the  symptoms  he  associated  with 
any  of  the  ordinary  signs  of  syphilitic  poisoning 
— the  dry,  scaly  skin,  and  the  sallow  lean  face ; 
and  especially  if  any  of  tho  characteristic  erup- 
tions are  present,  the  mental  disease  may.  he 
expected  to  yield  to  treatment  by  mercurials 
and  iodide  of  potassium.  The  mental  symptoms 
which  have  been  here  described  seem  to  occur 
without  the  existence  of  any  important  structural 
lesions  in  the  encephalon.  The  development  oi 
gummy  products  within  the  cranium  is  frequently 


INSANITY,  VARIETIES  OF. 

evinced  by  symptoms  similar  to  those  of  general 
paralysis.  Headache  of  very  persistent  character, 
giddiness,  vertigo,  and  epileptoid  fits  occur, 
accompanied  at  first  with  mental  depression. 
During  the  progress  of  the  disease  attacks  of 
acute  delirium  are  not  unusual.  Sometimes 
extravagant  delusions,  such  as  are  frequent  in 
general  paralysis,  are  exhibited ; but  generally 
the  progress  of  the  disease  is  characterised  by 
a gradual  falling  into  dementia.  The  prognosis 
in  such  cases  must  be  regarded  as  unfavourable, 
but  considerable  improvement  frequently  follows 
the  administration  of  antisypliilitic  remedies. 

John  Sibbald. 

INSECT  PARASITES. — Insect  parasites 
are  of  two  kinds,  external  and  internal.  The 
former  are  described  under  several  affections  of 
the  skin  (see  Pediculi  ; Scabies  ; &e.) ; the 
latter  are  classed  with  the  entozoa.  See  (Estrus  ; 
Chigoe  ; and  Demodex. 

INSENSIBILITY  (in,  not,  and  sentio,  I 
perceive). — This  word  signifies  either  loss  of  con- 
sciousness ; or  merely  loss  of  sensation  in  a part. 
See  Consciousness,  Disorders  of;  and  Sensation, 
Disorders  of. 

INSOL ATIO  (in,  in,  and  sol,  the  sun). — A 
synonym  for  sunstroke  (see  Sunstroke).  Inso- 
lation is  also  used  to  designate  a method  of  treat- 
ment, which  consists  in  exposing  the  patient  to 
the  rays  of  the  sun. 

INSOMNIA  (in,  not,  and  somnus,  sleep). 
Want  of  sleep,  or  sleeplessness.  See  Sleep, 
Disorders  of. 

INSPECTION  (inspicio,  I look  upon).— The 
technical  name  for  the  examination  of  a patient 
by  the  sense  of  sight.  See  Physical  Examina- 
tion. 

INSTILLATION  (in,  into,  and  stilla,  a 
drop). — The  method  of  applying  remedies  to  a 
part  in  the  form  of  drops.  Instillation  is  chiefly 
employed  in  connection  with  the  eye. 

INSUFFICIENCY  (in,  not,  and  sufficio, 

I am  sufficient). — A synonym  for  incompetence. 
See  Incompetence. 

INSUFFLATION  (in,  into,  and  sufflo,  I 
bloiv). — This  term  is  used  in  the  same  sense  as 
inflation  (see  Inflation).  It  is  also  a name  given 
to  a method  of  applying  remedies  in  the  form 
of  powder  to  the  throat  and  respiratory  passages, 
by  blowing  them  through  a tube  into  these  parts. 
See  Inhalations,  Therapeutic  Uses  of. 

INTEGUMENTS,  Diseases  of.  See  Skin, 

Diseases  of. 

INTELLECTUAL  INSANITY.  See  In- 
sanity. 

INTEMPERANCE,  Effects  of.  See  Al- 
coholism ; and  Disease,  Causes  of. 

INTERCOSTAL  NEURALGIA. —Any 
of  the  dorsal  nerves  may  be  the  seat  of  neuralgia, 
not  differing  materially  in  its  symptoms  from 
neuralgia  affecting  other  mixed  nerves,  but  espe- 
cially important  from  a diagnostic  point  of  view. 
The  pains  are  paroxysmal ; usually  affect  the 
region  of  distribution  of  the  anterior  division  of  , 


INTERCOSTAL  NEURALGIA.  731 

one  or  two  of  the  dorsal  nerves ; and  are  confined 
to  one  side,  most  frequently  the  left. 

^Etiology. — The  female  sex,  neurotic  heri- 
tage, and  weak  general  health  predispose  to  in- 
tercostal neuralgia.  As  determining  causes  may 
be  mentioned  blows ; the  action  of  cold ; local 
injury  to  the  nerves  from  the  growtli  of  thoracic 
aneurism ; and  disease  of  the  vertebrse.  Ex- 
haustion from  oversuckling,  menorrhagia,  or 
leucorrhcea;  irritation  from  cracked  nipples;  and 
pregnancy  are  all  occasional  but.imporlant  causes 
of  this  form  of  neuralgia.  The  pain  met  with 
in  the  chest  in  early  cases  of  phthisis  is  not  un- 
frequently  due  to  intercostal  neuralgia. 

Symptoms. — Pain  is  complained  of  at  some 
part  of  one  side  of.the  thorax  or  abdomen,  most 
often  in  the  region  innervated  by  the  sixth, 
seventh,  eighth,  or  ninth  intercostal  nerves,  and 
much  more  frequently  in  the  front  or  side  than 
behind.  It  is  occasionally  found  in  the  axilla 
and  inner  side  of  the  arm.  The  pain  may  be 
intermittent,  occurring  in  paroxysms,  varying  in 
number  from  a recurrence  every  few  minutos  to 
only  two  or  three  such  during  the  twenty-four 
hours  ; or  there  may  be  persistent  pain  of  a dull 
character,  interrupted  at  varying  intervals  by 
darts  of  a very  sharp  kind,  which  may  sometimes 
be'referred  with  precision  to  the  course  of  the 
neighbouring  nerve.  The  pain  is  described  as 
‘tearing,’  or  resembling  such  injuries  as  a ‘stab 
of  a knife,’  or  ‘ boring  with  a red-hot  iron.’  The 
acts  of  coughing  or  sneezing,  as  well  as  any 
rapid  movements  of  the  body,  are  apt  to  increase 
the  distress,  but  the  pain  is  also  independent  of 
these  disturbances,  and  will  attack  without  any 
such  provocation.  The  pain  is  sometimes  more 
of  a wearing  than  acute  character,  and  tho  rest 
will  often  be  destroyed  by  it.  Painful  points 
are  sometimes  to  be  discovered  in  the  following 
situations: — 1.  Over  a spinous  process  corre- 
sponding to  the  emergence  of  the  affected  dorsal 
nerve  from  the  intervertebral  foramen.  2.  At 
the  side  of  the  chest  or  abdomen,  where  the  lateral 
branch  becomes  subcutaneous.  3.  Near  the 
sternum  or  at  the  margin  of  the  rectus  abdo- 
minalis  muscle,  at  any  part  down  to  the  pubes, 
where  the  termination  of  tho  nerve  supplies  the 
skin.  The  skin  in  the  neighbourhood  of  the 
tender  points  is  sometimes  so  hyperaesthesie  that 
the  pressure  of  the  clothes  is  painful.  In  epileptics 
and  other  highly  neurotic  patients,  intercostal 
neuralgia  is  often  associated  with  palpitation  of 
the  heart,  and  the  pain  is  usually  referred  in  a 
vague  manner  to  that  organ.  Close  examination 
will  show  that  it  is  in  the  chest-wall,  and  tender 
points  may  generally  be  discovered.  The  affec- 
tion is  not  accompanied  by  fever.  Tho  paroxysms 
of  pain  may  produce  fainting  and  vomiting.  They 
often  cause  dyspnoea,  ■with  an  anxious  expression 
of  face,  from  the  inability  to  draw  a full  breath 
without  starting  the  pain. 

Complications. — Intercostal  neuralgia  is  some- 
times accompanied  by  herpes  zoster.  The  pain 
usually  precedes  the  appearance  of  the  eruption, 
but  it  is  occasionally  coincident  only,  and  some- 
times comes  after  it ; more  often  than  not  it  out- 
lasts the  eruption,  it  may  be  for  a long  period. 
In  certain  cases  actual  pain  lasts  but  a few  days, 
but  is  succeeded  by  an  intolerable  itching,  which 
is  described  as  being  under,  not  in  the  skin.  This 


132  INTERCOSTAL  NEURALGIA, 
sensation  is  said  to  be  felt  less  in  walking  than 
when  at  rest. 

Not  unfrequentlv  neuralgia  of  some  other 
nerves,  either  at  a distance,  as  the  fifth,  or  ana- 
tomically near,  as  the  brachial  plexus,  occurs  as 
a complication  of  intercostal  neuralgia.  This  is 
especially  likely  in  cases  happening  in  the  period 
of  bodily  decay.  It  is  then  too,  that  the  affection 
may  occasionally  be  accompanied  by  attacks  of 
angina  pectoris. 

Diagnosis. — Absence  of  pyrexia,  as  shown  by 
the  use  of  the  thermometer ; the  intermittence  of 
pain,  and  its  occurrence  irrespective  of  respira- 
tory movements,  although  liable  to  be  precipi- 
tated by  them ; and  the  results  of  physical 
examination,  serve  to  distinguish  intercostal  neu- 
ralgia from  pleurisy,  a condition  with  which,  on 
account  of  resemblance  in  the  stabbing  character 
of  the  pain,  it  is  very  apt  to  be  confounded. 

from  muscular  rheumatism  it  maybe  discrimi- 
nated by  the  presence  of  the  small  and  charac- 
teristic tender  points ; tenderness  of  the  spinous 
processes  on  pressure  ; and  by  the  pain  being 
found  to  be  not  dependent  upon  movements. 
The  same  features  serve  to  distinguish  it  from 
myalgia,  especially  that  form  which  often  comes 
from  long-continued  use  in  an  unaccustomed 
manner  of  some  muscle  attached  to  the  ribs,  as 
when  a person  unused  to  carpentering  handles 
i he  saw  energetically  for  a loug  time. 

Physical  examination  and  the  presence  of  py- 
rexia, will  preserve  from  the  error  of  confounding 
the  dull  pain  often  noted  in  pneumonia  with  that 
of  intercostal  neuralgia. 

Pains  of  a stabbing,  plunging,  or  electric- 
shock-like  character  are  often  experienced  in 
the  intercostal  spaces  in  the  course  of  locomotor 
ataxia,  and  it  is  important  not  to  confound  this 
disease  with  a simple  attack  of  intercostal  neu- 
ralgia. The  distinguishing  points  are  the  occur- 
rence of  similar  pains  coincidently  or  alternately 
in  other  parts  of  the  body,  especially  in  the  lower 
extremities;  the  absence  of  patellar  tendon  re- 
flex ; and  the  characteristic  gait  (if  present) 
— all  which  mark  locomotor  ataxia. 

Prognosis. — As  in  the  case  of  other  forms  of 
neuralgia,  thatof  the  intercostal  nerve  can  hardly 
be  said  to  be  attended  with  danger,  though  it 
must  be  allowed  that  in  some  very  rare  instances 
the  severity  of  the  pain  appears  to  have  actually 
destroyed  life.  It  is  apt,  however,  to  be  of  trouble- 
some duration,  lasting  for  periods  of  weeks  or 
months,  and  liable  to  recurrence. 

Treatment.— Search  should  be  made  in  other 
branches  of  the  same  nerve,  and  in  the  distribu- 
tion of  neighbouring  nerves,  for  any  source  of 
irritation  which  it  is  possible  to  remove.  Consti- 
pation of  the  bowels  should  be  treated  by  3 grains 
of  pilula  hydrargyri,  followed  by  some  Fried- 
richshall  or  Hunyadi  Janos  water,  repeated  for 
two  or  three  days.  Quinine  should  be  given  in 
doses  of  from  five  to  ten  grains  twice  a day ; and 
if  there  should  be  a state  of  antemia,  steel  should 
be  added.  Exposure  to  cold  and  damp  must  be 
avoided;  whilst  the  surroundings  generally  should 
be  favourable  to  improving  the  nutrition  and 
tone.  If  the  pain  be  very  acute,  and  sleep  pre- 
vented, morphia  may  be  injected  hypodermically 
in  the  neighbourhood  of  the  affected  nerve,  com- 
mencing with  a dose  of  an  eighth  of  a grain,  and  in- 


INTERMITTENT  FEVER. 

creasing  this,  if  necessary,  to  a quarter  of  a grain 
in  the  twenty-four  hours.  This  dose  should  not 
be  repeated,  however  ; and  it  is  better  to  be 
satisfied  with  a repetition  of  the  smaller  dose,  if 
required.  Small  blisters  (size  of  half-a-erown) 
may  be  applied  to  the  neighbourhood  of  the 
spinal  column,  near  the  point  of  emergence  of  the 
affected  nerve,  one  succeeding  another  as  it  heals. 
The  continuous  voltaic  current,  from  about  10 
to  20  cells,  Leelanche  or  Stohrer,  may  be  ap- 
plied, one  sponge  on  the  spine  and  the  other 
upon  the  painful  points,  in  turn.  There  is  no 
better  application  than  collodion  flexile  for  the 
herpes  zoster  which  sometimes  complicates  in- 
tercostal neuralgia.  See  Neuralgia. 

T.  Buzzard. 

INTERLOB  U LAK  (inter,  between,  and 
lobulus,  a little  lobe). — Situated  in  the  tissue 
between  the  lobules  of  any  organ.  A good  illus- 
tration is  interlobular  emphysema,  in  which  air 
occupies  the  parts  between  the  lobules  of  the 

luDgs. 

INTERMITTENT  ( intermitto , I leave  off 
for  a time). — A temporary  cessation  or  sus- 
pension. either  of  a function,  for  example,  of 
the  action  of  the  heart,  when  the  pulse  is  said 
to  intermit ; or  of  a disease,  such  as  neuralgia 
or  ague,  when  the  symptoms  cease  for  a certain 
time.  See  Pulse  ; and  Intermittent  Fever. 

INTERMITTENT  FEVER.  — Synos.  : 

Ague ; Fr.  Fievrc  Intermitiente ; Ger.  Katies 
Ficber. 

Definition. — A fever  of  malarial  origin,  cha- 
racterised by  the  sudden  rise  of  temperature 
during  the  paroxysm  ; by  the  equally  sudden  fall 
at  its  termination  ; and  by  the  regularity  of  the 
times  of  accession  and  apyrexia. 

.Etiology. — Intermittent  fever  belongs  to  the 
class  of  malarial  or  paroxysmal  fevers.  It  is  the 
most  typical,  and  the  most  common  of  the  class. 
The  human  system  once  subjected  to  the  pheno- 
mena of  a regular  attack  of  ague  in  any  of  its 
forms,  is  for  the  remainder  of  the  life  of  the  per- 
son so  affected  liable  to  a repetition  of  the  attack, 
without  his  necessarily  having  been  exposed 
afresh  to  the  action  of  its  cause.  This  tendency 
is  very  commonly  shown  in  those  who,  after  long 
residence  in  hot  and  malarial  climates,  are  ex- 
posed to  the  influence  of  cold,  and  especially 
easterly'  winds,  on  their  return  to  temperate  cli- 
mates in  the  spring  time  of  the  year.  The  more 
the  person  has  suffered  from  tlie  blood-changer 
and  visceral  degenerations  described  in  the  ar 
tide  Malaria,  the  more  prone  is  he  to  such 
recurring  attacks. 

Anatomical  Characters.  — In  the  article 
Malaria  the  pathology  of  intermittent  fever  is 
fully  discussed,  including  its  probable  depen- 
dence on  the  presence  of  the  liacillus  malaria 
in  the  body.  The  spleen  is  enlarged,  and 
in  pernicious  agues  proving  rapidly  fatal,  it 
is  found  in  a state  of  softening,  often  reduced 
to  a state  of  deeply  pigmented  pulp.  Death 
is  common  in  malarious  countries  from  rupture 
of  the  spleen,  the  result  of  blows  or  kicks,  ofte.i 
of  no  great  severity.  The  liver  is  usually  lounJ 
somewhat  congested  aud  pigmented,  and  in  cases 
of  long  standing  it  enlarges  like  the  spleen,  with 


INTERMITTENT  FEVER. 


the  same  increase  in  the  connective  tissue.  In 
the  algide  cases  hereafter  described,  when  blood 
is  driven  in  large  quantity  into  the  abdominal 
viscera,  the  digestive  mucous  membrane  of  the 
stomach  and  duodenum  is  congested  and  softened. 
The  heart  is  invariably  soft  and  flaccid,  pale, 
sometimes  of  a dirty  yellowish  colour— degenera- 
tive changes  induced  by  the  combined  action  of 
diseased  blood  and  high  temperature. 

Blood-changes. — Blood-changes  sometimes  take 
place  both  in  intermittent  and  remittent  fevers 
with  astonishing  rapidity.  Army  medical  officers 
serving  in  the  Mauritius  during  tho  epidemics 
of  malarial  fever  which  prevailed  there  some 
years  ago.  noted  that  the  sufferers  were  often 
reduced  to  a state  of  complete  anoemia  in  a 
few  hours ; the  same  is  tho  case  in  Algeria  {see 
Malaria).  In  such  cases  dropsical  affections 
supervene,  often  rapidly,  and  military  medical 
officers  there  record  cases  1 proving  suddenly  fatal 
from  oedema  of  the  glottis.’  The  blood  is  changed 
before  any  of  the  usual  symptoms  of  an  attack 
are  present— it  becomes  dark  in  colour;  the  serum 
which  separates  has  a dark  brown  colour ; and 
when  exposed  to  the  air,  the  coagulum,  which  is 
large  and  loose,  does  not  assume  its  usual  bright- 
red  colour.  The  white  corpuscles  are  immensely 
increased  in  number  ; and  tho  red  corpuscles  do 
not  evince  their  usual  tendency  to  run  together 
in  rouleaux. 

State  of  the  urine. — The  urine  contains  a large 
amount  of  free  acid,  and  retains  a highly  acid 
reaction  for  many  days  in  the  hottest  weather. 
In  tile  intervals  it  is  often  alkaline.  When  the 
paroxysms  cease,  the  watery  part  of  the  urine 
diminishes ; and  it  assumes  a deep  orange  colour, 
depositing  also  an  abundant  sediment  of  urate 
of  ammonia.  This  change  is  often  observed  by 
intelligent  patients,  who  learn  to  appreciate  its 
favourable  significance.  The  late  Dr.  Parkes  has 
shown  that  at  the  first  elevation  of  temperature 
the  urea  increases  ; this  lasts  during  the  cold  and 
hot  stages ; then  it  decreases,  falling  below  the 
healthy  average.  Colin  and  other  French  authors 
note  the  enormous  excretion  of  urea  in  malarial 
fevers  both  in  Italy  and  Algeria. 

Symptoms. — Three  forms  of  ague  have  long 
been  recognised,  namely,  the  quotidian,  which  re- 
curs in  twenty -four  hours ; the  tertian  in  forty- 
eight  hours  ; and  the  quartan  in  seventy  hours. 
The  term  double  tertian  is  used  when  the  paroxysm 
recurs  regularly  on  alternate  days,  the  attacks 
being  alike  in  severity  and  duration.  Other  more 
rare  forms  of  the  irregular  type  have  been  de- 
scribed, as  the  triple  tertian,  with  two  paroxysms 
in  one  day,  and  one  the  next;  the  double  quartan, 
with  a regular  fit  one  day,  a slight  one  the  next, 
and  a complete  intermission  on  the  third  day. 
The  quotidian  is  the  most  common  ; the  quartan 
the  rarest  of  all — a rule  which  seems  to  hold  good 
wherever  malarial  fevers  prevail.  The  quartan 
type  has  been  noted  from  early  times  for  the  te- 
nacity with  which  it  clings  to  its  victims. 

Premonitory  symptoms. — These  are  much  the 
same  as  in  all  febrile  disorders,  namely  pain  in 
the  back  and  lower  extremities,  languor,  lassitude, 
gastric  irritation,  loss  of  appetite,  nausea,  and 
Bometimes  vomiting ; with  occasionally  frequent 
calls  to  micturate,  tho  urine  being  pale  and 
highly  acid.  Then  follow  in  succession  the  three 


733 

stages,  the  cold,  the  hot,  and  the  sweating ; 
succeeded  by  what  is  technically  known  as  the 
interval  or  apyrexial  period,  which  lasts  i'or  a 
number  of  hours,  varying  according  to  the  typo 
of  the  disease. 

Cold  stage. — Tho  patient  experiences  a sense 
of  coldness  in  the  back;  then  rigors  set  in,  at  first 
faintly,  becoming  quickly  more  distinct,  until  tho 
teeth  chatter,  and  the  patient  feels  cold  all  over, 
and  demands  to  have  clothes  heaped  on  him ; the 
skin  shrivels,  the  nails  become  blue,  and  ho  ex- 
periences a sensation  of  intense  discomfort.  This 
feeling  of  cold  is,  however,  only  a ‘subjective 
symptom,’  for  if  a clinical  thermometer  be  placed 
in  the  mouth  or  rectum,  even  beforo  distinct 
rigors  set  in,  it  will  indicate  a rise  in  the  tem- 
perature of  from  two  to  three  degrees.  The  skin, 
from  contraction  of  the  superficial  vessels,  is  in- 
deed colder  than  natural,  but  from  the  first  tho 
temperature  of  the  blood  is  above  the  normal. 
The  phenomena  of  the  cold  stage  are  gastric  irri- 
tation, a foul  tongue,  a rapid  pulse,  and  quickened 
respiration,  with  a feeling  of  coldness  not  cou 
firmed  by  the  thermometer. 

Hot  stage. — As  this  sets  in,  the  patient  grow' 
warm  all  over,  the  face  flushes,  the  pulse  rises  in 
frequency  and  volume,  the  skin  grows  hot,  and 
the  patient  becomes  restless,  seeking  ease  to  hie 
aching  head,  back,  and  limbs  in  frequent  change 
of  posture.  The  tongue  in  this  stago  is  usuallj 
dry,  often  bilo-tinted;  and  the  bowels  are  consti- 
pated. 

Sweating  stage. — At  first  beads  of  perspira- 
tion appear  on  tho  brow  and  face,  and  the  hands 
become  moist;  and  soon,  to  the  immense  relief 
of  the  patient,  his  whole  body  sweats  freely,  the 
temperature  begins  to  decline,  and  the  paroxysm 
is  at  an  end.  The  average  duration  of  the  parox- 
ysm is  from  five  to  six  hours,  but  in  severe  cases 
it  may  last  for  twelve  hours.  When  sufferers  have 
been  exposed  to  malaria  in  such  places  as  the 
mangrove  swamps  of  Africa,  ‘ they  will  be  re- 
minded of  what  their  systems  have  imbibed  in  the 
way  of  surroundings  by  the  sickly  scent  of  the 
swamps  thrown  off  in  the  secretion  through  the 
skin.’  (Waller.)  Both  officers  and  soldiers  who 
came  under  the  care  of  the  writer  on  their 
return  from  the  late  expedition  to  the  Gold 
Coast,  observed  tho  same  fact  in  their  own 
persons  ; some  were  severely  nauseated  by  the 
unpleasant  smell,  recalling  the  stench  of  the 
places  where  the  poison  was  probably  taken 
into  their  systems. 

Temperature. — The  rapidity  with  which  the 
temperaturo  in  ague  rises  to  105°,  106°,  and 
sometimes  107°  Fahr.,  and  the  equally  sudden 
manner  in  which  it  falls  when  the  sweating  stage 
begins,  is  a very  notable  and  characteristic  fact 
of  great  diagnostic  value.  According  to  Wunder- 
lich, nothing  like  this  is  to  be  seen  in.any  other 
disease,  with  the  exception  of  cases  of  relapse 
in  typhoid,  the  febrile  paroxysms  in  acute  tuber- 
culosis, and  pyremia.  As  soon  as  the  sweating 
stage  begins,  the  temperature  declines,  at  first 
slowly,  then  as  rapidly  as  it  rose ; when  the  de- 
fervescence is  complete,  it  will  be  found  one  or 
two  points  of  a degree  below  the  normal,  where 
it  remains  during  the  period  of  apyrexia.  If  tho 
paroxysms  he  cut  short  by  quinine,  wo  may  still 
I detect  at  the  hour  of  expected  attack  a distinct 


INTERMITTENT  FEVER. 


1 34 

rise  in  the  temperature,  although  none  of  the 
other  symptoms  of  a paroxysm  may  occur,  and 
the  patient  may  be  hardly  sensible  of  it. 

Pernicious  agues.  - — This  term  is  much  used 
both  by  French  and  Italian  authors,  who  apply 
it  to  cases  both  of  intermittent  and  remittent 
fevers,  in  which  certain  symptoms  are  developed, 
such  as  delirium,  coma,  an  algide  condition  ; in 
a word,  any  serious  complication  placing  the 
life  of  the  patient  in  peril.  So  far  at  least  as 
intermittent  fever  is  concerned,  this  pernicious 
form  appears  to  bo  more  common  in  the  intensely 
malarious  regions  of  Italy  than  in  India.  Such 
was  the  experience  of  the  writer,  in  whose  large 
sphere  of  observation  such  grave  complications 
were  almost  entirely  confined  to  the  worst  forms 
of  remittent  fever,  contracted  in  places  notori- 
ously dangerous.  The  writer  is  strongly  im- 
pressed with  the  belief  that  the  ‘ pernicious  ’ 
symptoms,  the  mental  incoherence'  and  delirium, 
the  coma,  and  the  ‘algide  condition’  so  much 
dwelt  on  by  some  Italian  physicians  of  the  old 
school,  were  often  the  result,  not  so  much  of  the 
disease,  as  of  the  lowering  treatment  to  which 
they  subjected  their  patients. 

The  algide  form  of  ‘pernicious’  intermittent 
is  sometimes  described  by  writers  on  the  diseases 
of  India  as  ‘ ague  of  adynamic  type,’  and  it  was 
frequently  seen  and  well  described  by  the  French 
military  surgeons  both  in  Algeria  and  in  Rome, 
during  the  long  occupation  of  that  city  by  the 
French  army.  The  surface  is  cold,  but,  unlike 
the  cold  stage  of  an  ordinary  ague,  the  patient  is 
unconscious  of  the  low  temperature  of  the  surface. 
The  internal  temperature  is  high,  and  of  this  lie 
is  aware.  There  is  an  immense  accumulation  cf 
blood  in  the  abdominal  viscera,  with  great  thirst. 
Hie  expression  of  the  patient  is  tranquil,  and  his 
intelligence  is  intact.  ‘ II  se  sent  mourir,’  says 
Maillot,  ‘et  l’abattement  est  tel  qu’il  se  complait 
dans  cet  etat  de  repos  ; son  physionomie  est  sans 
mobility  ; Impassibility  la  plus  grande  estpeinte 
sur  la  visage.’  (Maillot,  Coliu.) 

Complications. — Intermittents  may  be  compli- 
cated by  attacks  of  various  diseases  of  greater 
or  less  severity — attacks  often  governed  by  cli- 
matic causes,  by  the  habits  of  the  individual 
patient,  or  by  the  fact  that  he  has  suffered  from 
one  orotlierof  such  diseases  on  previous  occasions, 
such  as  pneumonia,  bronchitis,  asthma,  dysen- 
tery, diarrhoea,  or  epilepsy.  It  is  an  old  observa- 
tion that  the  last-named  disease,  even  in  so-called 
‘confirmed  epileptics,’  sometimes  disappears  when 
the  victim  becomes  the  subject  of  an  attack  of 
ague.  One  very  striking  examplo  of  this  kind 
the  writer  has  seen. 

Pneumonia  is  certainly  the  most  formidable 
complication  met  with  in  intermittent  fever.  In- 
valids returning  from  India  or  from  other  hot 
and  malarial  climates  to  high  latitudes,  unless 
they  are  carefully  protected  by  suitable  clothing, 
are  prone  to  suffer  from  this  disease.  The  ra- 
pidity with  which  consolidation  of  the  lungs 
takes  place  in  such  cases  is  very  remarkable.  It 
is  not  an  uncommon  thing  to  see  five  or  six  cases 
of  this  kind  out  of  one  party  of  invalids  landed 
at  Netley  from  India,  if,  on  entering  the  Chan- 
nel, they  have  been  exposed  to  cold  weather. 
The  pneumonia  is  generally  double,  and  recovery 
is  rare.  the  patients  either  sinking  at  once,  or 


dying  after  a longer  or  shorter  illness  from  pneu- 
monic phthisis.  Pneumonia  of  this  type  is  a 
common  and  fatal  disease  among  the  malaria- 
poisoned  civil  population  of  Rome  during  the 
winter  months;  and  the  French  military  surgeons 
record  its  prevalence  in  the  French  garrison  there 
at  the  same  season,  and  also  among  malarial  in- 
valids sent  back  to  France  both  from  Algeria  and 
Rome  ( Recueil  des  Memoir es  Med.  MU.  t.  ii.  2* 
Sirie,  p.  268).  "When  pneumonia  occurs  as  a com 
plication  of  any  form  of  malarial  fever,  it  is  one 
of  the  gravest  import.  There  is  no  difficulty  in 
making  the  diagnosis  by  the  ordinary  means. 

Diagnosis. — An  ordinary  intermittent  presents 
no  difficulties.  The  well-marked  nature  of  the 
paroxysms ; the  sudden  rise  of  temperature  and  its 
equally  sudden  decline;  the  splenic  enlargement ; 
the  discolouration  of  the  skin;  the  urinary  changes 
described  above ; together  with  considerations  re- 
lating to  the  place  where  the  disease  was  con- 
tracted ; and,  above  all,  the  therapeutic  test,  that 
is,  the  power  of  quinine  in  preventing  the  recur- 
rence of  the  attacks,  ought  to  clear  up  all  doubts. 

Prognosis. — This,  in  ordinary  agues,  so  far  as 
immediate  danger  is  concerned,  is  highly  favour- 
able; death  from  uncomplicated  ague  is  very 
rare.  The  direct  mortality  from  ague,  at  all 
events  among  the  European  races  affected  by  it. 
is  small;  the  indirect  mortality' from  the  malarial 
cachexia,  occurring  either  per  se  or  as  a com- 
plication of  other  diseases,  is  very  great.  In 
complicated  or  so-called  pernicious  agues,  the 
prognosis  will  depend  on  the  extent  to  which 
important  organs  are  involved — cerebral,  pul- 
monary, or  gastric ; much  on  the  stage  the  dis- 
ease has  reached  before  the  patient  comes  under 
treatment ; and  much,  very  much,  on  the  nature 
of  that  treatment. 

Treatment. — Keeping  in  view  the  fact  that 
every’  paroxysm  of  intermittent  fever,  particu- 
larly in  a hot  climate,  is  a step,  however  short, 
on  the  road  to  the  cachectic  condition  described 
above  and  in  the  article  on  Malaria,  the  impor- 
tance of  breaking  the  recurrence  of  the  paroxysms 
will  be  apparent.  This,  then,  is  the  first  indication 
of  treatment ; the  second  is  hardly  less  important, 
namely,  to  improve  the  condition  tf  the  blood, 
and  by  judicious  treatment. — therapeutic,  dietetic, 
and  climatic — to  prevent  further  degeneration  of 
organs,  and,  so  far  as  may  be,  to  restore  affected 
tissues  to  their  normal  condition. 

If.  as  the  writer  firmly  believes,  there  be  such 
a thing  as  a specific  disease,  intermittent  fever  is 
specific.  Like  all  such,  it  has  a certain  definite 
series  of  phenomena  to  pass  through,  which  we 
may  assume  to  be  needful  for  the  purpose  of 
destroying,  altering,  or  in  some  way  expelling 
the  poison,  or  at  least  such  portion  of  it  as  may 
at  the  time  be  acting  on  the  system.  There  is  no 
drug  known  to  science  capable  of  arresting  tho 
stages  of  a true  malarial  fever  once  it  has  entered 
on  the  first  or  cold  stage.  This  doctrine,  as  Sir 
William  Jenner  has  admirably  stated  it  in  bis 
Address  on  the  JEtiology  o f Acute  Spccifi  ■ Diseases, 
has  been  taught  by  the  wri’er.  as  regards  malarial 
fevers  and  cholera,  in  liislectures  at  Netley  for  the 
last  twenty  years.  There  is  little,  therefore,  to 
be  said  as  to  the  treatment  of  the  stages  of 
ague  ; they  must  take  their  course,  the  only  in- 
terference being  to  supply  the  patient  with  the 


INTERMITTENT  FEVER. 


warm  covering  so  much  desired  during  the  cold 
stage  : if  this  be  protracted  unduly,  to  giro  him 
draughts  of  warm  tea;  and  should  symptoms  of 
collapse  appear  in  any  of  the  more  ‘pernicious’ 
forms  at  the  end  of  the  hot  stage,  to  administer 
such  restoratives  and  stimulants  as  the  case 
may  demand.  Excepting  in  cases  where  the 
stomach  is  oppressed  by  a recently  taken  meal, 
the  time-honoured  practice  of  administering  an 
emetic  may  be  safely  omitted.  The  lamented 
traveller  Livingstone,  whose  experience  of  mala- 
rial fevers  was  immense,  began  the  treatment  of 
rearly  all  cases  with  the  following  combination  : 
Resin  of  jalap  and  of  rhubarb,  from  6 to  8 grains, 
with  4 grains  of  calomel  and  a like  quantity  of 
ciuinine.  According  to  the  great  traveller  and 
his  hardly  less  experienced  companion,  the  Rev. 
Horace  AValler,  this  combination  was  found  very 
efficacious  as  the  commencement  of  treatment 
both  in  intermittent  and  remittent  fever.  In 
Livingstone’s  camp  his  pills  were  known  as 
‘ rousers,’  and  as  such  were  at  once  administered 
to  men  who,  ‘ from  premonitory  symptoms,  be- 
came idle  and  lethargic.’  In  about  five  hours 
copious  dark  coloured  motions  followed ; if  these 
were  delayed,  recourse  was  had  to  a brisk  pur- 
gative enema.  Quinine  was  then  given  in  4-grain 
doses  every  four  hours,  until  twelve  grains  were 
administered  in  the  twelve  hours  succeeding  the 
purgative  medicine.  Livingstone  and  his  followers 
deemed  any  other  mode  of  dealing  with  the  fevers 
of  Africa  to  be  ‘ mere  trifling.’  Common  sense 
points  to  the  necessity  of  caution  in  the  use  of 
such  active  purging  in  men  much  debilitated  by 
disease  or  climate,  or  both,  or  when  the  patients 
are  delicate  women,  or  Asiatics,  often  calling  for 
as  delicate  handling.  It  is  hardly  necessary  to 
add  that  this  sharp  treatment  is  notapplicable  to 
those  who  are  labouring,  or  have  previously  la- 
boured under  dysentery,  or  any  other  form  of 
bowel-complaint. 

In  the  ‘ interval,’  energetic  efforts  must  be 
made  to  bring  the  patient  under  the  influence  of 
quinine.  At  once  the  most  effective  and  the  most 
economical  plan  is  to  administer  quinine,  ia  solu- 
tion, in  a ten-grain  dose  at  the  end  of  the  sweat- 
ing stage,  and  to  repeat  it  in  from  four  to  six 
hours.  At  least  a scruple  of  the  remedy  should 
be  given  during  the  interval.  If  obstinate 
vomiting  interferes  wi:h  the  retention  of  the 
quinine,  which  will  rarely  happen  if  the  bowels 
have  been  well  relieved,  the  quinine  must  be  ad- 
ministered either  by  enema  or  by  the  hypodermic 
method.  The  first  plan  is  very  efficacious,  and 
is  safe  ; ihe  latter  is  the  most  effective,  but  is  not 
without  risk  of  inconvenience  from  troublesome 
ulceration  round  the  site  of  injection,  if  a mineral 
acid  has  been  used  to  dissolve  the  quinine ; 
this  in  urgent  circumstances,  such  as  in  per- 
, nicions  agues  dangerous  to  life,  or  in  remittents 
| (as  will  be  explained  under  the  head  of  that  type 
j rf  fever),  might  be  disregarded  were  it  not  that 
tetanus  followed  the  operation  in  five  cases  in 
one  year  in  the  Bengal  Presidency,  all  of  them 
proving  fatal.  In  the  face  of  such  a fact,  this 
operation,  trivial  as  it  seems,  should  not  be  per- 
. formed  on  light  grounds.  The  neutral  sulphate 
of  quinine,  which  dissolves  freely  in  water  at  a 
temperature  of  99°  F.,  does  not,  so  far  as  the 
writer's  experience  goes,  cause  ulceration.  The 


736 

syringe  used  for  this  purpose  should  be  a little 
larger  than  that  for  operations  with  morphia, 
and  should  have  a platinum  hollow  needle. 

Quinine,  in  one  or  other  of  the  methods  advised, 
should  be  used  until  the  paroxysms  are  broken. 
The  remedy  should  be  continued  da:ly,  so  long 
as  the  clinical  thermometer  indicates  a rise  in 
temperature  at  the  time  of  expected  attack,  even 
if  there  be  no  sign  of  a regular  cold  stage ; and 
within  a lunar  month  from  the  time  of  first 
attack,  the  patient  should  be  again  brought  under 
the  influence  of  quinine  for  some  days.  In  per- 
nicious agues,  or  in  cases  where  complications 
arise,  it  is  in  a high  degree  dangerous  to  pause 
in  the  administration  of  quinine. to  use  remedies 
of  a depressing  kind  for  this  or  that  set  of  symp- 
toms. Those  who  so  act  will  have  little  success 
in  practice  until  taught  by  bitter  experience 
the  daDger  of  departing  from  the  golden  rule  of 
trusting  to  quinine.  In  this  way,  epi'epsy,  pneu- 
monia. asthma,  bronchitis  may  liavo  to  be  met, 
aided  by  stimulation  of  the  skin,  support  from 
proper  food,  and  stimulants  when  called  for.  For 
many  years  the  writer  has  urged  this  doctrine  on 
the  attention  of  young  practitioners,  and  lie  is 
glad  to  see  that  it  is  even  more  strongly  insisted 
on  by  Trousseau  in  his  well-known  lectures. 

It  is  in  such  cases,  and  in  grave  remittents,  that 
the  Tinctura  Warburgi  has  been  found  so  useful 
as  to  warrant  a strong  recommendation.  The 
active  ingredient  in  this  febrifuge  is  quinine,  in 
combination  with  a variety  of  aromatic  drugs, 
which  either  are  now,  or  were  formerly  officinal. 
It  is  the  most  powerful  sudorific  known,  and  has 
been  found  in  the  writer’s  hands,  and  in  the 
practice  of  many  medical  officers  in  Southern 
India,  a remedy  of  great  power  in  all  malarial 
fevers.  After  opening  the  bowels,  half  an  ounce 
of  tincture  is  administered,  undiluted,  all  drink 
being  withheld  ; a second  dose  is  given  in  three 
hours.  It  soon  produces  free  action  of  the  skm, 
the  perspiration  often  having  an  aromatic  odour. 
It  is  rare  to  see  another  paroxysm  follow  the  use 
of  the  tincture.  In  adynamic  cases  it  should  be 
used  in  smaller  doses,  and  with  some  caution, 
lest  its  excessive  sudorific  action  should  be  too 
depressing.1 

Substitutes  for  quinine. — The  officers  in  charge 
of  the  Government  cinchona  plantations  in  India 
now  prepare  from  the  red  cinchona  bark,  by  a 
very  simple  and  economical  process,  a preparation 
known  as  ‘cinchona  alkaloid,’  which,  in  some- 
what larger  doses  than  quinine,  is  found  to  be 
effectual  in  checking  malarial  fever,  but  this  pre- 
paration, although  very  cheap,  has  fallen  into 
disrepute  from  the  distressing  nausea,  and  even 
vomiting,  it  often  causes. 

Salicylic  acid  is  now  largely  used  as  an  anti- 
pyretic. 

1 Dr.  Warburg  has  communicated  to  the  wrEer  the 
formula  for  the  preparation  of  this  tincture,  which  at 
Dr.  Warburg's  des  re  was  publishidin  the  Lancet,  and 
Medical  Times  and  Gazelle.  (See  Medical  Times  and  Gazette , 
1875,  vol.  ii.  page  540  ) As  stated  in  the  text,  quinine 
proved  to  be  the  active  ingredient,  in  combination  with  a 
number  of  aromatic  drugs  common  to  ancient  and  mo- 
dern pharmacy.  It  is  consistent,  with  the  writer's  know- 
ledge that  this  tincture  has  maintained  its  high  reputa- 
tion in  the  treatment  of  malarial  fevers  of  the  most 
danererous  type,  in  the  hands  of  Colonel  Gordon,  in  the 
pestilential  regions  traversed  by  him  and  his  cfSor.n, 
while  carrying  out  the  policy  of  the  Khedive  of  "Egypt 
along  the  head-waters  of  the  hide. 


7Sfi  INTERMITTENT  FEVER. 

Arsenic  has  been  used  for  ages,  particularly  in 
the  East,  in  the  treatment  of  agues.  There  is  no 
doubt  that  it  possesses  considerable  power  as  a so- 
called  antiperiodic.  TheFrenehmilitary surgeons, 
who  are  obliged  to  study  economy,  use  it  largely, 
and  in  doses  much  larger  than  are  commonly  given 
by  British. practitioners.  They  seek,  as  Boudin 
expresses  it,  to  oppose  an  arsenical  to  a malarial 
diathesis.  In  the  brow-aches  and  other  neuralgic 
sequels  of  malarial  fever  it  is  an  effective  remedy, 
either  alone  or  in  combination  with  quinine.  The 
alkaline  sulphites,  so  much  lauded  by  Professor 
Polli.  have  hitherto  disappointed  the  expectations 
of  British  medical  officers  who  have  fried  them. 
In  the  late  epidemic  outbreak  of  malarial  fever 
in  the  Mauritius  they  were  found  useless.  The 
sulphate  of  cinchonine  in  scruple  doses  is  much 
praised  by  Dr.  Paul  Turner.  Biberine  was  largely 
tried  by  the  writer  in  India,  and  found  to  be 
inert.  Of  late,  various  preparations  of  Eucalyptus 
globulus,  the  blue  gum  tree  of  Australia,  have 
been  much  praised  in  the  cure  of  ague,  and  more 
particularly  in  the  treatment  of  its  sequels. 
The  writer  is  inclined  to  fear  that  this  remedy, 
like  many  others,  has  been  unduly  vaunted.  It 
certainly  is  often  useful  in  the  malarial  cachexia, 
with  occasional  attacks  of  ague,  but  in  the  acute 
forms  of  the  disease  it  is,  in  the  experience  of  the 
writer,  far  below  quinine.  The  best  form  is  that 
of  tincture.  Both  in  France  and  Germany  it  is 
much  used  for  the  reduction  of  enlarged  spleens. 

Diet. — This  should  be  nutritious  and  easy  of 
digestion.  Dr.  Cornish  has  pointed  out  how 
much  the  mortality  from  malarial  fevers  is  in- 
creased amongst  the  natives  of  India  by  ‘starva- 
tion treatment.’ 

Treatment  of  malarial  cachexia. — On  the  first 
signs  of  this  condition  appearing,  the  sufferer 
should  be  sent  to  a non-malarial  climate.  If  by 
sea- voyage,  care  must  be  taken  so  to  regulate  the 
diet  as  to  avoid  the  risk  of  ingrafting  the  scor- 
butic on  the  malarial  cachexia.  Remembering 
also  the  danger  of  exposure  to  cold  insisted  on  al- 
ready, scrupulous  attention  to  clothing  is  a point 
of  cardinal  importance.  According  to  the  writer’s 
experience,  one  of  the  most  effective  means  of 
reviving  the  action  of  the  skin,  improving  the 
condition  of  the  blood,  and  restoring  the  spleen 
and  liver  to  a more  healthy  condition,  is  to  send 
those  whose  circumstances  admit  of  it  to  Carls- 
bad or  Homburg,  where,  under  proper  local 
medical  advice,  they  may  drink  the  waters  and  use 
the  baths.  The  good  effects  of  this  treatment  are 
often  very  marked  and  lasting.  It  should  be 
supplemented  by  a course  of  the  syrup  of  the 
triple  phosphates  of  iron,  quinine,  and  strychnia, 
in  half-drachm  doses  three  times  a day;  which 
after  a time  should  give  way  to  iron  in  some 
more  direct  form.  The  Carlsbad  water,  in  com- 
bination with  that  of  Friedriehshall,  if  con- 
tinued for  a sufficient  length  of  time,  is  often  most 
useful  in  improving  the  condition  of  the  abdo- 
minal organs,  even  when  the  patient  can  only 
use  them  in  this  country;  and  the  action  of  the 
skin  may  be  stimulated  with  profit  by  the  occa- 
sional use  of  a Turkish  bath,  or  by  a wet  sheet 
packing.  The  writer  has  long  used  the  ointment 
of  the  biniodide  of  mercury  in  reducing  enlarged 
spleens,  and  often  with  great  success.  The 
strength  of  the  ointment  is  13  grains  to  an  ounce 


INTERTRIGO. 

of  lard.  Of  this  a piece  as  large  as  a walnut  is 
to  be  well  rubbed  in  before  a good  fire.  The  pro- 
cess is  repeated  on  the  afternoon  of  the  samedav_ 
and  again,  if  need  be,  in  a fortnight.  If  ordinary 
care  be  taken  to  watch  the  effects,  and  not  to  use 
the  remedy  too  often,  no  ill  consequences  need  be 
feared.  The  writer  has  in  this  way  again  and 
again  reduced  spleens,  extending  even  into  the 
pelvis,  to  almost  normal  dimensions,  without  pro- 
ducing any  of  the  inconveniences  either  of  the 
mercurial  or  iodine  ingredients  of  the  ointment. 

It  is  a point  of  great  importance  that  patients 
should  be  placed  under  the  most  favourable 
hygienic  conditions,  and  breathe  the  purest  air 
available.  W.  C.  Maclean. 

INTERNAL  EAR,  Diseases  of.  See 
Eab,  Diseases  of, 

INTERSTITIAL  (inter,  between,  and  sto, 
I stand).  — Relating  to  the  interstices  of  an 
organ.  The  term  is  applied  in  physiology  to  the 
tissue  which  exists  between  the  proper  elements 
of  any  structure,  namely,  some  form  of  connective 
tissue.  In  pathology  the  word  is  used  in  con- 
nection with  absorption,  when  a part  is  gradually 
removed  without  any  obvious  breaking  off;  and 
also  to  indicate  the  implication  of  the  interstitial 
tissues  in  morbid  processes,  or  their  infiltration 
with  morbid  products,  as  interstitial  pneumonia, 
interstitial  hepatitis,  &c. 

INTERTRIGO  (inter,  between,  and  tero,  I 
rub). — Definition'. — A slight  inflammation  of 
the  skin  occurring  in  the  hollows  of  folds  of  tho 
integument  or  joints,  where  two  surfaces  lie  in 
contact  with  each  other. 

Aetiology. — The  cause  of  intertrigo  is  not,  as 
might  be  implied  by  its  name,  friction  alone; 
but  rather  moisture  and  heat  associated  with 
contact  and  pressure,  acting  on  a sensitive  skin. 
In  certain  situations  the  amount  of  inflammation 
is  liable  to  be  aggravated  by  the  addition  ol 
irritant  discharges,  such  as  excessive  perspira- 
tion, urine,  and  faecal  matter. 

Intertrigo  is  common  in  infants,  in  whom  it  is 
favoured  by  abundance  of  integument,  and  sensi- 
tiveness of  skin.  For  a similar  reason  it  is  met 
with  in  corpulent  persons  ; but  it  is  not  wanting 
in  the  emaciated,  when  there  exists  a tendency 
to  eczema,  or  an  eczematous  diathesis.  In  in- 
fants it  is  seen  in  the  perineum,  extending  froir 
the  anal  fossa  behind  to  the  groins  in  front,  and 
likewise  in  any  other  of  the  deep  folds  of  the 
integument.  Among  adults,  in  addition  to  these 
situations  it  occurs  in  the  axillae,  in  the  groove  be- 
neath the  mammae,  and  in  the  flexures  of  joints. 

Description. — The  term  intertrigo  points  tu 
a rubbing  together  cr  chafing,  fretting,  or  gall- 
ing of  the  skin  by  friction,  and  no  doubt  friction 
may  have  some  share  in  producing  the  inflam- 
mation ; but  it  is  also  certain  that  intertrigo  re- 
sults most  frequently  from  irritation  caused  by 
the  heat  and  moisture  of  the  part.  Intertrigo 
has  been  adopted  as  an  erythema  under  the 
name  of  erythema  intertrigo,  but  it  very  rarely 
remains  at  the  erythematous  stage,  having  a 
natural  tendency  to  run  on  to  exudation  with 
the  discharge  of  a muco-purulent  fluid,  and  to  be 
further  complicated  with  excoriations  and  chaps. 

In  this  condition  it  becomes  an  eczema  and  i= 


INTERTRIGO. 

rery  properly  treated  as  such.  Indeed,  it  is 
more  consistent  with,  the  genius  of  modern  der- 
matology to  consider  it,  even  from  the  begin- 
ning, as  an  eczema,  under  the  name  of  eczema 
crythematosum. 

Prognosis. — The  prognosis  of  this  affection  is 
favourable  as  to  cure,  but  uncertain  as  to  time, 
and  in  adults  it  is  very  apt  to  degenerate  into 
chronic  eczema. 

Treatment. — The  removal  of  the  cause  is  the 
first  indication  to  be  attonded  to  in  the  treat- 
ment of  intertrigo.  This  may  be  effected  by 
careful  ablution  with  soap.  The  part  should 
then  be  kept  as  dry  and  cool  as  possible,  and 
dusted  with  fuller’s  earth,  or  any  unirritating 
desiccative  powder.  Where  powder  is  unsuitable, 
a lotion  of  lime-water  inspissated  with  oxide  of 
zinc  will  be  found  useful ; and  if  this  should  provo 
irritating,  zinc  ointment,  with  the  addition  of  a 
drachm  of  spirits  of  wine  to  the  ounce,  should  be 
kept  constantly  applied.  Where  there  is  much 
exudation,  it  is  desirable,  as  in  eczema,  to  avoid 
ablution,  and  confine  the  treatment  to  wiping 
with  a soft  cloth  previously  to  each  repetition 
of  the  zinc  ointment.  Constitutional  symptoms 
are  rarely  present  in  intertrigo,  but  should  such 
arise,  the  indications  to  be  considered  are  regu- 
lation of  the  digestive  organs  and  associated 
functions  ; a suitable  diet ; and  tonic  regimen. 

Erasmus  Wilson. 

INTESTINAL  OBSTRUCTION.  — Sy- 
non.  : Ileus  ; Er.  Occlusion  intestinalc  ; Ger. 
Darm  verschliessung. 

Definition. — Under  this  term  are  included 
all  those  cases  in  which  the  contents  of  the  in- 
testinal canal  are  obstructed  in  their  onward 
, passage,  by  causes  or  conditions  occurring  with- 
in the  abdomen  or  pelvis.  Cases  in  which  ob- 
struction is  due  to  causes  or  conditions  affecting 
protruding  or  protruded  bpwel  are  included 
| under  the  head  of  Hernia. 

General  Remarks. — The  subject  of  intestinal 
obstruction  will  be  best  treated  by  first  discuss- 
ing the  condition  in  general,  and  afterwards  re- 
ferring to  its  various  pathological  causes  under 
separate  and  distinct  heads. 

Frequency.—  The  comparative  frequency  with 
which  intestinal  obstruction  occurs  is  difficult 
to  estimate.  It  is  by  no  means  a common  affec- 
tion, though  less  rare,  perhaps,  than  is  sometimes 
supposed  or  asserted.  It  is  always  fraught  with 
clanger,  and  in  a very  large  proportion  of  cases 
more  or  less  speedily  proves  fatal.  Brinton  esti- 
mates 1 out  of  every  280  deaths  from  all  causes 
.0  be  due  to  some  form  or  other  of  intestinal 
ibstruction.  Leichtenstern  gives  1 out  of  every 
TOO  to  500.  Brinton’s  estimate,  founded  on  the 
■csults  of  12,000  post-mortem  examinations,  is 
probably  somewhat  too  high,  inasmuch  as  a larger 
Proportion  of  cases  of  intestinal  obstruction  are 
ikely  to  have  been  inspected  than  of  cases  of 
lore  common  and  less  obscure  affections. 
IEtiology  and  Pathology. — Most  forms  of 
atestinal  obstruction  are  more  often  met  with 
i the  male  than  iu  the  female  subject.  Out  of  a 
>tal  of  1,806  sufferers,  1,018  were  males  and  788 
males.  But  women  are  more  liable  than  men 
1 suffer  from  certain  forms,  as,  for  example, 
cose  which  depend  upon  impaction  of  gall- 

47 


INTESTINAL  OBSTRUCTION.  737 
stones  or  faecal  matter;  upon  compression  <■ 
the  intestine  by  tumours  or  displaced  viscera ; oi 
upon  constrictions  by  peritoneal  or  other  adhe- 
sions. Some  forms,  esjiecially  intussusception 
and  volvulus,  most  frequently  occur  during  in- 
fancy or  childhood ; others,  as  strictures,  at 
comparatively  advanced  periods  of  life. 

The  causes,  or  anatomico-pathological  condi- 
tions which  may  give  rise  to  intestinal  obstruc- 
tion, vary  in  nature,  in  mode  of  action,  ani  ir 
acuteness  and  severity  of  effect.  Some  are  Con 
genital,  depending  upon  developmental  abnor- 
malities ; others  are  Acquired,  resulting  from 
accident,  disease,  or  physiological  incapacity 
Some  act  by  compression  of  the  bowel  from  with- 
out; some  by  constriction  of  the  bowel  within 
and  others  by  blocking  its  canal.  Some  com. 
into  play  suddenly  or  almost  suddenly’,  am! 
without  warning,  and  at  once  lead  to  complett 
occlusion  ; the  symptoms  are  most  acute,  and  in 
the  absence  of  relief,  fatal  results  speedily  follow. 
Some  coming  into  play  with  almost  equal  sud- 
denness, and  accompanied  by  almost  equally 
severe  symptoms,  do  not,  however,  so  immediately 
lead  to  complete  occlusion  ; some  degree  of  per- 
meability remains  for  a time  ; and  the  chances 
of  relief  are  somewhat  better.  Other  causes, 
again,  seem  to  develop  slowly ; the  symptoms 
in  the  earlier  stages,  at  any  rate,  are  not  acute  ; 
the  malady  takes  a chronic  course  ; better  oppor- 
tunities for  consideration  and  treatment  are 
afforded;  and  fatal  results,  though  they  may 
ultimately  ensue,  can  be  longer  averted. 

The  causes  of  intestinal  obstruction  may  be 
enumerated  as  follows,  in  order  as  nearly  as 
possible  corresponding  to  the  acuteness  and 
urgency  of  the  symptoms,  and  the  imminence  of 
danger  to  life  to  which  they’  give  rise  ; and  the 
relative  frequency  with  which  they  occur  may  be 
approximate vely  estimated  by  the  numbers  ap- 
pended, representing  the  results  of  an  analysis 
of  1,839  fatal  eases  recorded  or  observed  : — 

1.  Congenital  malformations. 

2.  Internal  strangulation  (546). 

(«)  By  peritoneal  false  ligaments  or  bands, 
the  result  of  previous  inflammatory  mischief, 
either  under  such  bands,  or  by  loops  or  knots, 
or  in  button-hole  slits,  or  by  kinking  caused  by 
traction,  or  by  the  margins  of  slits  or  rings  pro 
duced  by  adhesions  of  parts  or  organs  to  one 
another,  or  to  some  part  of  the  parietes  (219). 

(6)  By  the  omentum  or  mesentery  (in  associa- 
tion with  some  abnormal  peculiarity)  by  bands 
or  in  slits  (65). 

(c)  By  diverticula  or  diverticular  appendages, 
as  the  obliterated  omphalo-mesenteric  vessels,  or 
by  diverticular  knots  (To). 

(d)  By  the  appendix  vermiformis  (42). 

(e)  By  twisting  or  knotting  (volvulus)  and 
consequent  compression  of  the  bowel  by  itself,  or 
by  its  mesentery  (106). 

(f)  By  the  margins  of  peritoneal  pouches 
(retro-peritoneal  hernia,  hernia  through  foramen 
of  Winslow,  and  other  forms  of  internal  hernia) 
(39). 

3.  Impaction  of  gall-stones  (51). 

4.  Intussusception  or  invagination  (537). 

5.  Constriction  (511). 

(a)  By  cicatricial  contractions  of  the  ’>owel 
itself,  resulting  from  injury  or  ulcerative  disease. 


i 


INTESTINAL  OBSTRUCTION. 


738 

(i)  By  peritoneal  thickening  and  contraction, 
with  sometimes  matting  together  of  the  bowel, 
from  strumous  or  other  form  of  peritonitis(138). 

(c)  By  new  growths,  innocent  cr  malignant,  in 
the  bowel  itself  (373). 

6.  Compression. 

(<?)  By  displaced  (and  often  diseased)  viscera. 

(b)  By  new  growths,  innocent  or  malignant, 
hydatids,  &c.,  outside  the  bowel  (66). 

7.  Impaction  of  foreign  bodies  or  intes- 
tinal concretions  (78). 

8.  Impaction  of  fsecal  masses  .•  ‘ Physiolo- 
gical Incapacity’;  llius  Paralyticus ; Confirmed 
Constipation , habitual  or  accidental  (78). 

Seats. — Every  part  of  the  intestinal  tract  is 
liable  to  be  primarily  affected  by  one  or  other 
cause  of  obstruction.  But  some  parts  are  much 
more  frequently  than  others,  if  not  almost  exclu- 
sively, affected  by  certain  particular  causes ; and  in 
regard  to  treatment,  especially  so  far  as  operative 
measures  for  relief  are  concerned,  it  is  often  of 
very  great  importance  to  determine  not  only 
the  cause,  but  also  as  nearly  as  possible  the  seat 
of  the  obstruction.  Acute  internal  strangulation 
by  bands  most  frequently  affects  liio  small  in- 
testine, by  twisting  the  sigmoid  flexure.  Impac- 
tion of  gall-stones,  with  very  few  exceptions, 
occurs  in  the  jejunum  or  some  part  of  the  ileum. 
Compression  and  traction  especially  affect  the 
small  intestine.  Intussusception  most  frequently 
involves  the  caecum  and  colon,  and  next,  the 
ileum.  Constrictions  due  to  morbid  growths  are 
most  common  in  the  large  intestine,  especially  in 
the  lower  portion. 

Symptoms. — The  symptoms  and  physical  signs 
of  intestinal  obstruction  areas  a rule  sufficiently 
constant  and  characteristic  to  establish  the  gene- 
ral diagnosis.  But  though  they  vary  in  acute- 
ness, and  in  certain  other  respects,  with  the 
cause  and  seat  of  the  obstruction,  it  is  often  very 
difficult,  and  sometimes  impossible,  to  determine 
without  exploration  the  differential  diagnosis, 
however  important  it  may  he  to  do  so. 

The  symptoms  and  signs  commonly  presented, 
the  variations  met  with  in  different  cases,  and 
the  special  indications  afforded  by  such  varia- 
tions may  be  stated  as  follows — the  symptoms 
and  signs  especially  characteristic  of  each  form 
of  obstruction  being  summarily  repeated,  or 
further  discussed  in  subsequent  sections. 

1.  Pain. — In  a very  large  proportion  of  cases 
of  obstruction  depending  upon  most  causes 
pain  is  the  earliest,  or  one  of  the  earliest  sym- 
ptoms ; and  in  a greater  or  lesser  degree,  though 
it  may  change  in  character,  and  from  time  to 
time  remit  in  severity,  it  usually  persists  more 
or  less  continuously  and  constantly  very  nearly 
to  the  end.  The  impaction  of  a gall-stone  or 
foreign  body,  the  commencement  of  an  intussus- 
ception, or  the  strangulation  of  a portion  of 
bowel  occurring  suddenly,  is  usually  signalised 
by  an  access  of  acute,  indescribable  pain,  often 
‘ doubling  the  patient  up,’  and  sometimes  pro- 
ducing faintness,  and  even  collapse.  Stran- 
gulation by  bands  or  in  slits,  after  a period 
of  incarceration,  or  as  the  result  of  twists,  when 
the  bowel  is  not  suddenly  gripped  as  it  were, 
gives  rise  to  pain,  which,  though  supervening 
••utnewhat  gradually,  rapidly  becomes  almost 
e ually  sevore.  Strictures  of  the  bowel,  and  ob- 


structions due  to  the  pressure  of  tumours,  dis- 
placed viscera,  &e„  cause — at  any  rate  in  the 
earlier  stages — comparatively  little  pain.  Ob- 
struction of  the  large  intestine  by  impaction  of 
fames  is  attended  by  scarcely  any  actual  pain ; 
the  patient  as  a rule  complaining  simply  of  ful- 
ness, weight,  and  discomfort. 

The  pain  experienced  varies  in  its  cause  and 
character  in  different  stages.  At  the  onset  it 
is.  doubtless,  due  to  the  injury  immediately  in- 
dicted on  the  serous  or  mucous  coat  of  the  bowel; 
but  it  is  very  speedily  increased  and  maintained, 
and  sometimes  probably  is  started,  by  the 
effects  of  the  congestion  and  distension  of  the 
compressed  blood  vessels  on  their  accompany- 
ing nerves.  Somewhat  later  comes  the  pain  as- 
sociated with  distension  of  the  bowel  itself;  and 
this  is  increased,  at  more  or  less  frequent  inter- 
vals, by  paroxysmal  exacerbations  of  acute  suf- 
fering, which  accompany  the  futile  peristaltic 
efforts  of  the  intestine  to  move  on  the  solid, 
liquid,  or  gaseous  matters  accumulated  above 
the  obstruction.  Such  exacerbations  of  suffer- 
ing are  probably  due,  not  only  to  tension  of  the 
intestinal  walls  generally,  but  in  some  measure 
also  to  traction  upon  the  injured  parts.  At  a 
still  later  stage,  when  inflammation  is  established, 
the  pain  and  tenderness,  localised  or  diffused,  of 
enteritis  and  peritonitis  supervene. 

The  pain  in  the  early  stages  of  acute  strangu- 
lation, or  of  impaction  of  gall-stones  or  foreign 
bodies,  is  increased,  or  if  it  h ive  temporariiv 
subsided,  is  rekindled,  by  pressure  on  or  about 
the  spot  corresponding  to  the  seat  of  the  lesior  ; 
and  often  there  is  little  or  no  general  tenderness. 
In  intussusception  the  pain  is  often  relieved  to 
some  extent  by  moderate  pressure.  In  chronic 
obstruction  there  is  hut  little  pain  and  tender- 
ness on  pressure;  and  some  degree  of  relief  even 
may  sometimes  be  afforded  by  gentle,  supporting 
pressure,  diffused  over  one  portion  or  other  of 
the  distended  abdomen. 

Associated  with  the  actual  definite  pain,  are 
the  general  physical  anxiety  and  distress  always 
present  to  a greater  or  less  extent,  an  i in  expres- 
sion almost  characteristic  of  intestinal  obstruc- 
tion or  severe  intestinal  trouble. 

2.  Vomiting. — Vomiting  is  a very  constant 
symptom  of  intestinal  obstruction,  from  whatever 
cause.  It  may  commence  almost  simultaneously 
with  tho  occurrence  of  the  obstruction;  in  which 
case  it  may  be  regarded  as  sympathetic,  and  duo 
to  shock  associated  with  the  injury  inflicted.  Or 
it  may  come  on  somewhat  later;  in  which  case 
it  depends,  in  part,  upon  the  forcing  backwards 
into  the  stomach  of  the  accumulated  intestinal 
contents,  their  onward  progress  being  arrested 
by  the  obstruction,  and  in  part  upon  reflex  irri- 
tation associated  with  injury  or  inflammation  of 
tho  peritoneum.  At  whatever  perio  1 it  may 
have  commenced,  the  vomiting  recurs  with 
greater  or  less  severity  at  more  or  less  frequent 
intervals  until  the  termination  of  the  malady, 
although  sometimes  comparatively  long  inter- 
missions occur.  As  a general  rule,  the  nearer 
the  seat  of  obstruction  is  to  the  stomach,  and  | 
the  more  acute  the  cause,  the  earlier  does  vomit- 
ing come  on,  the  more  severe  is  it,  and  the 
more  frequently'  does  it  recur.  Early,  severe,  and 
frequently  repeated  v uniting  indicates  obstruc 


INTESTINAL  OBSTRUCTION. 


lion  of  the  small,  rather  than  of  the  large  in- 
testine. When  the  obstruction  is  high  up  in 
the  small  intestine,  but  belotv  the  opening  of  the 
ductus  communis  cboledochus,  the  vomit  usu- 
ally contains  an  admixture  of  bile,  more  or  less 
altered  it  may  he,  and  is  but  little  offensive. 
When  the  obstruction  is  below  the  middle  of  the 
small  intestine,  the  vomit  is  commonly  ‘ fecalnid  ’ 
in  appearance  and  odour.  When  the  obstruction 
is  in  the  colon,  or  even  the  lowest  part  of  the 
ileum,  the  vomit  is  more  or  less  decidedly  fecu- 
lent  in  character,  and  sometimes  contains  distinct 
fiscal  masses.  It  appears  to  be  clearly  established 
that  greit  distension  of  the  intestine  may  render 
the  ileo-esecai  valve  inefficient,  to  such  an  extent 
as  to  permit  regurgitation  from  the  large  into 
.he  small  intestine. 

The  occurrence  of  feculent  or  stercoraceous 
vomit  was  formerly  ascribed  to  reversed  or  anti- 
peristaltic  action  of  the  bowel.  The  possibility 
of  such  reversed  peristalsis  has,  however,  been 
disputed,  and  the  matter  may  be  regarded  as  at 
present  undecided.  Practically,  it  is  ob-ious 
that  contraction  of  the  bowel  on  its  contents 
must  press  them  in  the  direction  in  which  they 
can  most  easily  go  ; and  if  they  cannot  pass  on- 
wards, in  consequence  of  obstruction  in  front, 
they  must  pass  backwards  in  the  direction  in 
which  the  wav  is  open. 

3.  Constipation. — Constipation  is  of  necessity 
a constant  symptom  of  intestinal  obstruction. 
It  may  be  absolute  from  the  first,  or  may  be- 
come absolute  after  a variable  period  during 
which  more  or  less  scanty  faecal  evacuations  may 
,be  passed.  It  must  be  borne  in  mind  that  even 
after  complete  occlusion  has  occurred,  there  may 
remain  in  the  bowel  below  the  seat,  of  obstruc- 
tion some  portion  of  its  contents ; and  the 
secretions  and  excretions  of  the  mucous  mem- 
brane being  added,  the  evacuation  of  these  by 
natural  effort,  or  by  aid  of  enenwta,  may  give 
rise  to  the  false  idea  that  the  occlusion  is  not 
|iomplet«,  or  that  relief  has  been  obtained. 
)ften.  however,  the  bowel  below  the  obstruction 
J.t  once  ceasps  to  act,  and  after  death  may  be 
ound  to  contain  feces,  although  the  constipation 
as  been  absolute.  This  is  more  likely  to  cccur 
‘/hen  the  seat  of  the  obstruction  is  high  up.  In 
htussusceptions,  especially  in  the  more  chronic 
jises,  the  bowel  is  rarely  altogether  imperme- 
able from  the  first,  though  later  it  becomes  so, 
pm  the  effects  of  inflammatory  swelling.  In 
ich  cases,  sudden  constipation  is  often  followed 
;/  a period  during  which  small  quantities  of 
ical  matter,  mixed  with  blood  and  mucus,  are 
lissed,  and  this  is  succeeded  by  absolute  con- 
lipation  so  far  as  fecal  matters  are  concerned, 
jood  and  mucus  only  being  passed.  In  stric- 
jres  of  the  bowel,  either  simple  or  fr  m morbid 
pwths,  or  in  compression  by  tumours,  &c., 
jnstfpation  comes  about  comparatively  slowly, 

d is  often  only  rendered  absolute  by  a twist 
kink  of  the  bowel,  or  by  impaction  rf  some 

rtion  of  its  contents.  A very  constricted  con- 
“ ion  of  the  canal,  especially  of  the  small 
jestine,  in  the  absence  of  accidental  plugging, 
tfices  to  permit  the  onward  passage  of  its 
ij’tnal  contents. 

. Abdominal  distension  and.  swelling : Me- 
i ism. — The  occurrence  of  obstruction,  from 


739 

whatever  cause,  is  followed  by  distension  of  the 
intestine  above  the  seat  of  obstruction,  from 
accumulation  of  its  contents.  But  the  degree 
of  distension,  and  the  rapidity  with  which  it 
comes  on,  vary  with  the  cause  and  seat  of  the 
obstruction.  In  acute  internal  strangulation 
distenston  comes  on  rapidly  and  severely ; in 
chronic  obstruction  it  comes  on  gradually;  in 
intussusception  it  rarely  occurs,  at  any  rite 
during  the  early  stages.  The  portion  of  bowel 
immediately  above  the  sout  of  occlusion  is  first 
affected,  and  sometimes  its  position  can  be  re- 
cognised by  the  ‘slight  fulness  to  palpation,’ 
and  the  ‘ much  more  definite  dulness  to  percus- 
sion.’ presented  ‘ where  many  of  the  other  indi- 
cations of  obstruction  are  scarcely  perceptible, 
or  even  absent’  (Brinton.)  More  or  less  speedily 
the  distension  increases,  and  the  whole  extent 
of  bowel  above  the  obstruction  becomes  affected. 
The  more  rapidly  distension  takes  place,  ami 
the  greater  its  degree,  the  more  serious  as  a 
general  rule  is  the  aspect  of  the  case,  and  the 
sooner  is  a fatal  result  likely  to  ensue.  In  the 
earlier  stages,  when  the  seat  of  obstruction  is  in 
the  duodenum  or  high  up  in  the  jejunum,  the 
distension  is  limited  to  the  epigastrium  or  upper 
part  of  the  abdomen,  the  lower  parts  appearing 
sometimes  sunken.  When  the  obstruction  is 
below  the  middle  of  the  small  intestine  or  in 
the  csecum,  the  distension  occupies  principally 
the  middle  region  of  the  abdomen  at  first,  but 
gradually  extends  over  into  the  flanks,  the  small 
intestines  passing  into  the  regions  of  the  colon. 
When  the  hepatic  flexure  or  the  first  part  of 
the  transverse  colon  is  affected,  distension  ap- 
pears at  first  in  the  right  flank.  When  the 
obstruction  is  in  the  sigmoid  flexure  or  tho 
rectum,  more  or  less  speedily  after  distinct 
fulness  of  the  left  flank  the  whole  region  of 
the  colon  becomes  distended,  and  the  trans- 
verse colon  often  becomes  especially  prominent, 
leaving  the  mid-region  of  the  abdomen  below 
comparatively  sunken.  But  very  soon,  either  by 
implication  of  the  small  intestine  from  accumu- 
lation of  contents,  or  from  insufficiency  of  the 
ileo-csecal  valve — or  more  usually,  perhaps,  from 
extension  of  the  sigmoid  flexure  over  the  front 
of  the  abdomen,  and  doubling  down  of  the  trans- 
verse colon — the  distension  becomes  general.  ! I 
must  be  borne  in  mind  that  the  colon  may  U 
so  distended  and  displaced,  as  to  completi  ly 
cover  in,  and  conceal  from  examination,  t <■ 
small  intestines.  The  abdominal  distension 
occurring  during  the  earlier  stages  of  obstruction 
is  characterised  by  tympanites,  and  more  or 
less  tension  of  the  abdominal  walls,  with  but 
little  tenderness  on  pressure — sometimes,  indeed, 
moderate  pressure  affords  a sen-m  of  relief. 
Fluctuation  is  rarely  obvious.  The  distended 
portions  of  bowel,  as  already  indicated,  can  often 
be  made  out,  and  in  many  cases  the  peristaltic 
efforts  and  movements  of  the  small  intestines 
can  be  clearly  recognised  from  time  to  time, 
through  the  abdominal  wall,  by  sight  and  touch 
One  coil  of  intestine  can  be  perceived  rising  up 
and  becoming  prominent,  and  then  sinking 
down  and  giving  place  to  another;  and  some' 
times  waves  of  action,  as  it  were,  seem  to  pass 
along  a considerable  length  of  bowel.  fc)  ich 
movements  recur  at.  irregular  intervals,  and 


INTESTINAL  OBSTRUCTION. 


no 

accompanied  by  gurgling  noises  and  sensations 
(borborygmi),  and  by  exacerbation  of  suffering. 
They  are  most  frequently  met  'with,  in  cases  in 
which  the  obstruction  is  of  a chronic  character, 
and  is  seated  in  the  cmcum  or  first  part  of  the 
colon.  They  are  less  commonly  recognised  when 
the  obstruction  is  low  down  in  the  colon,  the 
sigmoid  flexure,  or  the  rectum  ; and  they  do  not 
as  a rule  occur  in  cases  of  acute  internal  strangu- 
lation, or  in  intussusception.  They  cease  when 
the  bowel  has  become  paralysed  by  continued 
distension ; or  when  peritonitis  has  supervened, 
or  rupture  has  occurred. 

Apart  from  such  distension  from  accumulation 
of  intestinal  contents  as  has  been  discussed,  cer- 
tain localised  swellings  in  the  abdomen,  which 
can  often  be  recognised  on  examination,  are 
liable  to  occur  in  connection  with  some  forms  of 
obstruction.  Thus,  intussusception  commonly 
gives  rise  to  an  elongated,  sausage-like  swelling. 
Tumours  of  various  kinds ; misplaced  viscera 
compressing  the  bowel ; growths  occupying  the 
bowel  itself,  especially  the  rectum ; and.  foreign 
bodies,  intestinal  concretions,  and,  though  very 
rarely,  gall-stones — all  of  these  may  cause  swell- 
ings perceptible  to  the  eye,  or  appreciable  on 
digital  examination,  either  of  the  external  sur- 
face, or  by  the  rectum  or  vagina. 

5.  Derangement  of  the  urinary  excretion. — In 
occlusion  of  the  intestine  occurring  high  up, 
especially  in  cases  of  acute  strangulation,  the 
excretion  of  urine  is  usually  diminished  to  a 
great  extent,  and  sometimes  is  almost  or  entirely 
Suppressed.  This  maybe  due  in  part  to  the  per- 
sistent vomiting,  and  consequent  diminution  of 
fluid  for  absorption  (Barlow) ; in. part  to  some 
vicarious  secretion  into  the  bowel  (Brinton)  ; 
and  in  part  to  some  reflex  inhibitory  influence, 
exerted  through  the  sympathetic  nervous  system 
upon  the  excreting  function  of  the  kidneys 
(Sedgwick,  Fagge).  When  the  obstruction  is 
low  down,  affecting  the  lower  part  of  the  colon 
or  the  rectum,  there  is  no  marked  diminution  in 
quantity ; there  may  even  bo  an  excess  of 
limpid  urine  excreted,  with  sometimes,  however, 
a difficulty  in  voiding  it. 

6.  General  aspect,  signs,  and  symptoms. — In 
cases  of  acute  obstruction  from  the  first,  and  in 
the  later  stages  of  chronic  obstruction,  the 
general  aspect  of  the  patient  is  more  or  less 
characteristic.  The  countenance  is  expressive 
of  physical  anxiety  and  distress : the  eyes  are 
sunken,  the  nose  pinched,  the  cheeks  hollow,  the 
lips  pale  or  purplish,  and  the  complexion  faintly 
livid;  the  general  surface  is  pale,  cool  or  cold, 
and  either  dry  or  covered  by  profuse  clammy 
perspiration  ; and  although  the  mental  faculties 
are  as  a rule  undisturbed,  there  is  a,  disposition 
to  torpor,  from  which  the  sufferer  is  from  time 
to  time  aroused  by  exacerbations  of  pain,  or  re- 
currence of  vomiting.  The  pulse  is  small  and 
thin,  and  towards  the  end  becomes  thready. 
Usually  it  is  increased,  but  sometimes  (for  a 
time  at  any  rate)  it  may  be  diminished  in  rapidity. 
The  temperature  is  often  lowered  to  a very 
marked  extent,  but  rises  if  peritonitis  sets  in. 
Sometimes  there  is  more  or  less  dyspnoea,  due 
either  to  reflex  nervous  influence,  or  to  pressure 
upwards  of  the  diaphragm  by  the  distended 
l.owcl  below,  and  the  latter  cause  also  often 


gives  rise  to  distressing  hiccough.  The  voice  is 
altered  in  character,  and  towards  the  end  is 
almost  or  entirely  lost.  The  tongue  is  red ; dry 
and  pointed ; or  dirty  brown  and  covered  by 
thick  tenacious  mucus,  coloured  by  vomited 
material.  The  patient  suffers  from  severe  and 
constant  thirst,  which  often  he  fears  to  assuage, 
lest  vomiting  should  be  provoked.  In  some  ex- 
ceptional cases  death  has  been  preceded  by  sub- 
delirium  and  coma;  and  in  others,  still  more 
exceptional,  by  violent  delirium  and  convulsions. 
In  children  convulsions  occasionally  occur  at  the 
commencement  or  during  the  early  stages  of 
intussusception,  as  well  as  towards  the  end,  and 
probably  arise  from  reflex  nervous  disturbance. 
The  torpor  commonly  noticed  may  depend  not 
only  on  general  depression,  but  also  in  great 
measure  upon  imperfect  aeration  of  the  blood, 
from  interference  with  respiration  ; and  the  coma, 
convulsions,  and  other  nervous  symptoms  which 
occur  in  rare  cases,  have  been  attributed  to 
uraemic  poisoning  from  suppression  of  urine. 

7.  Collapse. — Collapse  may  occur  at  the  com- 
mencement of  an  acute,  or  may  immediately 
precede  the  fatal  termination  of  a more  chronic 
case  of  intestinal  obstruction.  When  it  occurs 
at  the  commencement,  as  in  acute  strangulation, 
acute  intussusception,  or  sudden  impaction  of  a 
gall-stone  or  foreign  body,  it  is  due  to  the  shock 
of  the  injury  at  the  moment  inflicted ; when  it. 
occurs  after  a more  or  less  considerable  interval, 
whether  in  an  acute  or  in  a chronic  case,  it  is 
usually  associated  with  rupture  of  the  intestine, 
and  extravasation  of  its  contents  into  the  peri 
toneum. 

Diagnosis. — The  general  diagnosis  of  intes- 
tinal obstruction  rests  on  the  history  of  the 
case ; and  on  the  recognition  and  due  apprecia 
tion  of  the  symptoms  and  signs  above  discussed 
In  order  to  arrive  at  a right  conclusion,  not  only 
must  all  the  symptoms  be  fully  considered,  but 
careful  and  thorough  examination  of  the  abdo 
men  must  be  made,  by  palpation  and  percussion 
of  the  external  surface,  and  by  exploration  of 
the  rectum  and  vagina.  Such  thorough  examina- 
tion should  be  instituted,  and  the  differential  as 
well  as  the  general  diagnosis  made  out  as  clearly 
as  possible  at  the  earliest  practicable  period, 
before  general  abdominal  distension  or  the  super- 
vention of  complications  can  have  obscured  tho 
indications  first  presented.  In  some  cases  it 
may  be  desirable  to  administer  ether  or  chloro- 
form, in  order  to  facilitate  the  examination  by 
relaxing  the  abdominal  muscles,  and  to  save  the 
patient  from  needless  increase  of  pain.  In  all 
cases  in  which  the  symptoms  indicate  acute 
strangulation,  the  rings  and  openings  of  the 
abdominal  walls  must  be  carefiilly  examined, 
and  the  previous  or  actual  existence  of  an  cx 
ternal  hernia  inquired  into.  In  cases  of  chronic 
obstruction  in  which  occlusion  has  come  about 
gradually,  or  is  even  yet  incomplete,  it  is  espe 
cially  necessary  to  explore  the  rectum  as 
thoroughly'  as  possible,  by’  the  introduction  of 
the  finger,  or  even  ot  the  whole  hand.  In  the 
female,  exploration  per  vagina m is  often  no  less 
needful. 

Various  morbid  conditions  may  give  rise  to 
symptoms — pain,  vomiting,  constipation —more 
or  less  closely  resembling  or  simulating  those  of 


INTESTINAL  OBSTRUCTION. 


intestinal  obstruction.  Among  such  may  be 
mentioned  certain  forms  of  colic,  such  as  hepatic 
colic  or  renal  colic ; ulcerative  enteritis,  especially 
of  the  csecum  and  appendix  cseci ; perityphlitis ; 
and  intense  peritonitis,  such  as  follows  perfo- 
ration. In  tbese  conditions  there  is  arrest  of 
action,  but  not  mechanical  obstruction  of  the 
intestine  ; a distinction  which  it  is  important 
to  bear  in  mind.  The  history  and  progress  of 
tbe  case,  together  with  due  recognition  of  the 
more  distinctive  concomitant  signs  and  symp- 
toms usually  presented  by  each  of  such  con- 
ditions, serve  as  a rule  to  establish  the  diagnosis, 
though  it  may  be  often  difficult,  and  sometimes 
may  even  remain  doubtful. 

Course,  Complications,  and  Terminations. — 
The  tendency  of  intestinal  obstruction,  from 
whatever  cause,  is  towards  a fatal  termination, 
at  au  earlier  or  later  period  according  to  cir- 
cumstances, and  with  or  without  the  superven- 
tion of  more  or  less  obvious  and  extensive 
implications.  But  in  respect  to  the  more  acute 
urms,  there  are  scarcely  any  in  which  relief  may 
:.ot  be  afforded,  sometimes  coming  about  sponta- 
neously as  it  were,  almost  as  suddenly  and  unex- 
pectedly as  the  lesion  has  occurred,  sometimes 
resulting  after  an  extended  period  of  suffering, 
and  sometimes  consequent  on  the  treatment 
adopted.  In  the  more  chronic  forms,  with  the 
exception  of  those  depending  upon  impaction 
of  faeces,  and  some  others  perhaps  (as  chronic 
intussusception),  complete  and  permanent  relief 
'.s  less  likely  to  be  obtained ; and  death,  though 
considerably  longer  delayed,  is  almost  more  cer- 
tain to  ensue  sooner  or  later,  in  spite  of  tem- 
; porary  relief  afforded  by  operative  measures  or 
in  other  ways. 

The  complications  and  accidents  that  are 
1 1 .-.bl  3 to  occur  and  to  conduce  to  the  fatal  result 
«re: — peritonitis  starting  from  the  seat  of  the 
| lesion,  and  more  or  less  rapidly  spreading  and  be- 
i coming  general.;  enteritis ; ulceration  and  perfora- 
tion of  the  bowel ; sloughing  of  the  strangulated 
or intussuscepted  portions;  hiemorrhage  into  the 
peritoneum  or  into  the  bowel;  pneumonia,  due 
to  the  entrance  of  vomit  into  the  air-passages,  or 
to  pyaemia  from  absorption  of  decomposing  and 
(poisonous  material ; gradual  asphyxia  from  in- 
erference  with  respiration  by  abdominal  disten- 
tion ; uraemia ; coma  ; and  syncope  from  cardiac 
lepression  and  cerebral  anaemia. 

In  cases  of  acute  strangulation,  and  others  in 
' which  the  occlusion  has  been  sudden  and  com- 
pete from  the  first,  and  in  which  timely  relief 
tas  not  been  obtained,  tbe  average  duration  has 
■een  found  to  be  from  five  to  six  days.  But 
eath  may  occur  within  a few  hours,  or  not 
ntil  after  the  lapse  of  ten  days  or  a fortnight, 
n cases  of  constriction  or  compression,  in  which 
pmplete  occlusion  has  come  about  gradually,  or 
wen  has  not  been  finally  established,  the  dura- 
on  of  life  varies  greatly  according  to  circum- 
anees  and  the  complications  which  arise,  and 
may  be  prolonged  for  weeks,  months,  or  even 
j tars. 

Treatment. — The  treatment  of  intestinal  ob- 
1 ruction  must,  necessarily  be  determined  by  the 
use  and  the  circumstances  and  conditions  of 
e particular  case  with  which  we  may  have  to 
1 — and  therefore  can  be  more  specially  indi- 


741 

eated  and  discussed  In  tbe  subsequent  considera- 
tion of  the  several  forms  of  obstruction.  BuS 
some  general  statement  of  methods  of  treatment 
may  he  not  inappropriately  given  at  once,  inas- 
much as  tentative  measures  for  relief  are  often 
called  for  before  any  definite  conclusion  as  to  the 
precise  cause  of  the  trouble  can  be  arrived  at. 

1.  Purgatives. — Asa  rule,  when  the  existence 
of  obstruction  is  established,  and  emphatically 
in  all  acute  cases,  violent  purgatives  are  to  be 
avoided.  They  tend  to  increase  rather  than  to 
relieve  the  mischief.  The  object  should  be  in 
the  first  place  to  soothe,  and  not  to  irritate  and 
excite  the  suffering  part.  In  eases  in  which  it  may 
have  bpen  deemed  right  to  administer  a strong 
purgative  in  the  first  instance,  (and  this  is  often 
done  before  the  physician  or  surgeon  is  called  in) 
failure  of  effect  decidedly  contraindicates  the 
repetition  of  any  similar  dose.  When  all  urgent 
symptoms  have  subsided,  however,  and  in  tho 
more  chronic  cases,  mild  laxatives  (especially 
some  salines)  often  prove  of  great  value — but 
caution  in  their  administration  is  necessary. 

2.  Sedatives.— In  almost  all  cases  of  intes- 
tinal obstruction  sedatives  and  antispasmodics 
are  demanded  ; and  opium  and  belladonna,  con- 
joined or  separately,  are  the  most  useful  and 
reliable  medicines  we  possess.  They  should  be 
given  freely,  but  with  judgment,  according  to 
the  effect  produced.  They  may  be  administered 
by  the  mouth ; or,  if  the  vomiting  is  severe  and 
frequent,  by  the  rectum,  or  by  subcutaneous  in- 
jection, in  the  form  of  morphia  and  atropine.  In 
very  acute  cases  the  inhalation  of  chloroform 
or  ether  may  sometimes  be  desirable,  and  may 
prove  at  any  rate  temporarily  efficacious  in  re- 
lieving urgent  suffering. 

3.  Enemata. — Injections  more  or  less  copious 
of  simple  gruel,  soap  and  water,  with  or  without 
the  addition  of  oil,  castor  oil,  turpentine,  or 
ether,  or  of  pure  olive  oil  in  quantity,  are  con- 
stantly of  great  service  in  cases  of  intestinal  ob- 
struction, not  only  in  establishing  the  diagnosis, 
but  also  in  affording  relief  to  a more  or  less 
complete  extent.  In  many  cases  it  is  advantage- 
ous to  administer  the  enemata  with  the  body 
inverted,  or  at  any  rate  with  the  lower  part  well 
raised,  and  at  the  same  time  to  manipulate  the 
abdomen  ( massage — abdominal  taxis),  but  this 
must  be  done  with  caution.  When  very  copious 
enemata  are  deemed  desirable,  they  may  be  ad- 
ministered more  gradually,  and  probably  more 
safely,  by  the  syphon  and  hydraulic  pressuro 
than  by  means  of  the  syringe.  It  has  been 
sought  to  estimate  the  seat  of  the  obstruction  by 
the  quantity  of  fluid  that  can  be  thrown  into  the 
rectum ; but  as  a general  rule  no  satisfactory 
conclusion  can  be  thus  arrived  at. 

4.  Insufflation. — In  cases  of  intussusception, 
insufflation  of  air  by  means  of  bellows  has  some- 
times proved  efficacious  in  affording  relief ; but 
in  almost  all  other  forms  of  obstruction  ihis 
method  of  treatment  lias  rather  added  to  the 
distress  of  the  sufferer. 

5.  Local  applications. — Hot  fomentations  and 
poultices,  especially  with  the  free  application  of 
local  anodynes  (solutions  of  opium,  belladonna, 
hemlock,  or  aconite),  often  materially  relieve  suf- 
fering, and  thus,  as  well  perhaps  as  by  causing 
determination  to  the  surface,  and  lessening  in- 


INTESTINAL  OBSTRUCTION. 


742 

ternal  congestion,  favour  recovery.  On  the  other 
hand,  the  application  of  ice-bags  to  the  surface  of 
the  abdomen  has  been  strongly -advocated,  and 
jn  some  cases  has  certainly  seemed  to  be  pro- 
ductive of  benefit.  Galvanism,  to  the  surface — or 
with  one  pole  introduced  into  the  rectum — with 
the  view  of  stimulating  the  peristaltic  action  of 
the  bowel,  has  also  been  advocated. 

6.  Abdominal  taxis  (Hutchinson)  ; massage. — 
Careful  manipulation  of  the  abdomen,  with  move- 
ment of  the  body  from  one  position  to  another, 
has  in  some  cases  proved  successful  in  bringing 
about  relief  of  intestinal  obstruction. 

7.  Surgical  operations. — In  mauy  eases  opera- 
tive measures  of  one  kind  or  other  are  urgently 
demanded,  and  seem  to  afford  the  only  chance  of 
rescue  from  impending  death,  orfrom  more  or  less 
prolonged  suffering.  And  although  the  statistical 
results  hitherto  may  not  seem  very  encouraging, 
yet  careful  consideration  of  the  causes  of  failure 
in  the  past,  and  due  regard  to  receDt  advances 
ill  surgical  treatment  and  appliances  generally, 
warrant  the  belief  that  such  measures  will  be 
adopted  more  frequently,  under  more  favour- 
able circumstances,  and  more  successfully  in  the 
future.  The  surgical  operations  demanded  in 
intestinal  obstruction  may  be  divided  into  those 
which  have  for  their  object  the  removal  of  the 
cause  of  the  obstruction,  and  those  which  aim 
solely  at  affording  relief  by  establishing  an  open- 
ing above  the  seat  of  obstruction.  The  various 
methods  will  be  best  discussed  in  connection  with 
those  forms  of  obstruction  in  which  they  are 
respectively  indicated. 

Varieties. — The  several  varieties  of  intestinal 
obstruction,  according  to  the  pathological  cause 
of  the  condition,  wall  now  be  discussed. 

I.  Obstruction  from  Congenital  Malfor- 
mation.— Arrest  or  modification  of  the  normal 
process  of  development,  or  the  occurrence  of 
peritonitis  during  intra-uterine  life,  may  give 
rise  to  congenital  constriction,  or  to  defective 
continuity  of  the  intestinal  canal,  resulting  in 
more  or  less  absolute  occlusion. 

Constriction  or  occlusion  of  such  kind  is  occa- 
sionally, but  very  rarely,  met  with  in  the  duo- 
denum at  or  about  the  entrance  of  the  common 
duct,  or  about  the  junction  of  the  duodenum 
with  the  jejunum;  and  in  some  cases  has  ap- 
peared to  depend  upon  valve-like  folds  of  mucous 
membrane,  somewhat  resembling  enlarged  or 
confluent  valvulse  conniventes.  The  lower  por- 
tion of  the  ileum,  near  the  ileo-caecal  valve,  or 
about  the  point  of  junction  with  the  omphalo- 
mesenteric duct,  where  a bend  or  twist  takes 
place,  appears  more  liable  to  be  so  affected,  and 
instances  have  been  from  time  to  time  re- 
corded. The  colon,  and  almost  exclusively  the 
sigmoid  flexure,  is  the  part  of  the  bowel  most 
frequently  constricted  by  the  effects  of  intra- 
uterine peritonitis  and  consecutive  twisting  ; but 
instances  are  comparatively  rare. 

All  such  classes  of  cases  are  of  pathological 
inlerest,  rather  than  of  practical  importance. 
Vomiting  of  meconium,  absence  of  proper  eva- 
cuation, straining,  convulsions,  aud  evidences  of 
more  or  less  severe  suffering,  are  followed  by 
spoedy  death,  though  in  some  rare  instances  life 
has  been  prolonged  for  weeks  or  even  months. 
No  treatment  can  be  of  avail ; and  surgical  opera- 


tion can  only  hasten  death,  or  at  best  succeed  in 
pro'onging  misery. 

Very  much  more  common,  and  somewhat  moro 
hopeful,  are  those  cases  in  wit  ch  there  is  con- 
genital defect  of  the  lower  part  of  the  rectum, 
or  of  the  anus.  They  may  be  dividt-d  into— (lj 
Those  in  which  there  is  simply  imperforate  anus, 
the  bowel  being  closed  by  a membranous  or 
more  or  less  thick  layer  of  tissue,  and  forming 
a distended  cul  dc  sac  above  the  floor  of  the 
perineum-  (2)  Those  in  which  the  anus  is 
formed  and  leads  into  a cul  dc  sac,  which  ap- 
proaches more  or  less  closely  to  the  cul  de  sac 
of  the  portion  of  rectum  above:  (3)  Those  in 
which  the  lower  end  of  the  rectum  opens  into 
the  bladder,  urethra,  or  vagina. 

Symptoms.  — Retention  of  meconium,  with 
persistent  straining  and  sometimes  vomiting, 
or  the  scanty  escape  of  meconium  by  the  vagina, 
serve  to  suggest  the  probable  existence  of  some 
such  defect,  the  more  precise  nature  of  which 
can  generally  be  readily  ascertained  0:1  examina- 
tion or  exploration. 

Treatment. — Immediate  relief  may  often  be 
afforded  by  surgical  operation,  and  in  some  in- 
stances more  or  less  permanent  good  results 
have  been  obtained,  and  by  persevering  manage- 
ment maintained;  but  survival  to  adolescence 
or  adult  age  bas  seldom  ensued.  See  Rectum, 
Diseases  of. 

II.  Obstruction  from  Internal  Strangu- 
lation. - — - The  various  anatomico-pathological 
conditions  which  may  conduce  to  internal  stran- 
gulation have  been  already  enumerated  or  indi- 
cated. Of  these,  some  depend  upon  abnormalities 
or  peculiarities  for  the  most  part  developmental 
in  origin,  the  existence  of  which — previous  to 
exploration  or  post-mortem  examination — can- 
not he  predicated  or  ascertained  ; others,  how- 
ever, depend  upon  the  results  of  previous 
inflammatory  mischief  or  accidents.  In  every 
case,  therefore,  it  is  important  to  inquire 
minutely  into  the  early  history  of  the  patient; 
as  well  as  into  the  circumstances  immediately 
preceding  the  strangulation.  No  better  illus- 
tration of  this  can  be  quoted  than  that  afforded 
by  cases  in  which  strangulation  has  been  caused 
by  omentum  adherent  to  the  sac  of  an  old  re- 
ducible hernia. 

The  small  intestines  are  especially  liable  to 
become  strangulated  by  bands  or  adhesions 
(peritoneal  false  ligaments),  they  having  been 
found  to  be  so  affected  in  upwards  of  90  per 
cent,  of  such  cases.  Rands,  sometimes  rounded 
and  thread-  or  cord-like,  sometimes  broader  and 
flattened,  are  met  with  from  time  to  time, 
stretching  from  one  part  of  the  mesentery  or 
omentum  to  another ; but  oftener  attached  by 
one  extremity  to  mesentery  or  omentum,  and 
by  the  other  to  some  portion  of  bowel  (com- 
paratively rarely  to  the  large  intestine),  or  to 
the  abdominal  wall.  Very  rarely  indeed  are 
they  found  passing  from  one  portion  of  bowel  to 
another.  The  bowel  may  become  incarcerated 
under  or  behind  such  hands  (not  in  front  be-  . 
tween  them  and  the  yielding  anterior  abdominal 
wall),  or  it  may  he  encircled  by  them,  and  they 
may  be  looped  or  even  knotted  or  twisted  round 
it ; or,  again,  the  bowel  may  become  so  kinkec 
by  the  traction  of  a band  adherent  to  one  point,  j 


INTESTINAL  OBSTRUCTION. 


ns  to  lead  to  its  practical  occlusion.  The 
broader  adhesions  sometimes  present  slits,  in 
which  portions  of  bowel  may  be  caught.  Simi- 
larly, ruptures  or  slits  may  occur  in  the  omentum 
or  mesentery,  or  even  in  very  rare  instances 
in  the  suspensory  ligament  of  the  liver  or 
broad  ligament  of  the  uterus  ; and  these  struc- 
tures, especially  the  omentum,  by  adhesions  may 
constitute  broad  or  narrow  bands,  under  which 
incarceration  may  take  place,  or  by  which  portions 
of  bowel  may  be  surrounded  and  strangulated. 
Diverticula,  and  diverticular  appendages  (the 
obliterated  omphalo-mesentcric  vesels,  &c.),  by 
adhesion  or  by  looping,  and  the  appendix  cseci, 
either  adherent,  usually  by  its  extremity,  or 
spirally  elongated  and  twisted,  may  lead  to  a like 
result.  It  is  worthy  of  note  that  by  these,  as 
by  the  foregoing  conditions,  the  small  intestine 
is  most  frequently  affected.  So  also  in  the 
various  forms  of  internal  hernia  (hernia  into  the 
foramen  of  Winslow,  into  peritoneal  pouches, 
mesocolic,  duodeno-jejunal,  retro-peritoneal  her- 
nia, &c.,  all  of  which  are  very  rare),  it  is  still  the 
small  intestine  that  is  most  frequently  involved. 

Internal  strangulation  of  the  small  intestine, 
depending  on  the  several  causes  thus  indicated, 
is  most  commonly  met  with  during  early  adult 
life,  the  average  age  being  about  twenty-two 
years  ; and  one  sex  does  not  appear  to  be  much 
more  liable  to  suffer  than  the  other,  except  in 
the  case  of  strangulation  by  diverticula,  which 
has  been  observed  about  twice  as  frequently  in 
the  male  as  in  the  female  subject. 

The  large  intestine,  as  might  be  expected,  is 
much  more  liable  to  become -strangrdated  by 
torsion  or  twists  than  the  small,  and  the  sigmoid 
flexure  is  the  part  most  frequently  affected. 
Out  of  106  eases,  in  65  the  large  intestine  (in  60 
of  these  the  sigmoid  flexure)  and  in  41  the 
small  intestine  was  found  involved.  The  in- 
testine may  be  twisted  about  its  mesocolic  or 
mesenterial  axis,  or  one  loop  of  intestine  may 
be  intertwined  with  another.  In  conjunction 
with  the  twisting  there  may  be  falling  over,  as 
it  were,  and  dragging  down,  due  to  the  weight 
of  the  intestinal  contents.  Twists  of  the  intes- 
tine occur  most  frequently'  during  the  later 
periods  of  middle,  or  during  advanced  life.  Their 
occurrence  is  favoured  by  original  peculiarities 
in  the  length  and  disposition  of  the  peritoneal 
folds,  or  by  corresponding  peculiarities  acquired 
&s  the  result  of  the  stretching  and  relaxation 
which  accompany  the  changing  condition  of  parts 
at  different  periods  of  life. 

Tho  occurrence  of  internal  strangulation  is 
determined  by  the  entrance  of  a portion  of 
bowel  into  some  such  dangerous  position  as  has 
been  indicated,  and  its  retention  there.  This 
may  be  due  to  a relaxed  condition  of  the  bowel — 
it  may  be  after  diarrhoea — and  pressure  upon  it 
by  the  action  of  the  abdominal  muscles  during 
some  strain  or  twist  of  the  body  ; to  undue 
and  irregular  movement  of  tho  bowel  itself;  to 
the  weight  and  dragging  of  fecal  matter  accu- 
mulated at  one  part,  and  the  futile  effort  of  the 
; bowel  above  to  move  it  onward ; or  to  some 
accidental  circumstance  that  can  neither  be 
I ascertained  nor  defined.  Absolute  strangulation 
1 may  occur  suddenly  and  at  once ; or  may  be 
brought  about  only  after  an  appreciable  period, 


74S 

by  the  consecutive  swelling  of  the  inetreeratod 
or  twisted  bowel. 

Symptoms. — The  symptoms  of  internal  stran- 
gulation closely  resemble  those  of  strangulation 
of  external  hernia;  but  often  they  are  more 
acute,  and  unless  relief  is  obtained,  lead  more 
speedily  to  a fatal  result. 

Intense  abdominal  pain,  generally  in  the  mid- 
region ; not  infrequently  accompanied  by  collapse, 
either  at  the  very  commencement  or  very  early 
supervening;  severe  and  frequent  vomiting,  soon 
becoming  more  or  less  distinctly  feculent ; 
abdominal  distension,  at  first  locp.lised,  rapidly 
becoming  nutre  or  less  general ; constipation,  with 
urgent  desire  and  vain  effort  to  evacuate  the 
bowel — all  coming  on  without  warning  in  an  ap- 
parently healthy  subject,  constitute  a group  of 
symptoms  sufficiently  characteristic.  As  the 
case  progresses,  these  symptoms  persist,  in- 
creasing, or,  in  some  respects,  intermitting  or 
decreasing  in  severity  according  to  circum- 
stances, and  becoming  more  or  less  masked, 
modified,  or  added  to  by  the  symptoms  of  the 
complications  already  indicated  as  likely  to  arise, 
until  either  relief  is  obtained,  or  death  ensues. 

Cases  have  occurred  from  time  to  time  in 
which  all,  even  the  most  severe,  symptoms  of 
internal  strangulation  have  been  present,  but  in 
which  relief  has  come  about  almost  as  suddenly 
as  the  distress  has  arisen ; and  it  would  seem 
that  in  such  cases,  after  a period  of  rest,  either 
by  the  aid  of  treatment  or  otherwise,  the  stran- 
gulated bowel  has,  as  it  were,  recovered  itself, 
and  released  itself  from  its  entanglement,  or 
reversed  its  twist.  But  such  cases  are  rare,  and 
very  much  more  frequently  it  happens  that 
death  results,  either  very  quickly  from  shock,  or 
within  four  or  five  days  from  intense  peritonitis, 
following,  or  without  rupture  of  the  bowel. 

Treatment. — Tho  treatment  of  a case  pre- 
senting the  above  symptoms  resolves  itself  into 
the  question  as  to  whether  mere  palliative 
measures  should  be  perseveringly  adopted,  and 
the  patient  allowed  to  take  his  chance;  or 
whether  an  attempt  should  be  made  by  surgical 
operation  to  release  the  bowel,  and  thus  afford 
opportunity  for  recovery  (laparotomy),  or  to 
give  relief  by  opening  the  bowel  above  the  seat 
of  obstruction  (enterotomy). 

During  the  earliest  periods,  and  before  the 
nature  of  the  case  is  fully  pronounced,  there 
can  be  no  doubt  but  that  palliative  measures 
alone  should  bo  adopted.  Such  measures  consist 
in  perfect  rest ; relaxation  of  the  abdominal 
pariotes  by  position ; the  application  of  either 
ice  or  a hot  anodyne  fomentation  (each  having 
its  respective  merits)  over  the  especially  suf- 
feringpart;  and  the  administration  (after  collapse 
has  passed)  of  opiates  and  belladonna — by  the 
mouth,  subcutaneously,  or  by  suppository,  or  of 
chloroform  or  ether  by  inhalation,  as  circum- 
stances may  indicate.  If  the  physician  do  not 
venture  to  advise,  or  the  surgeon  be  not  bold 
enough  to  adopt  operative  interference,  similar 
measures  maybe  pursued  still  further, inasmuch 
as  they  tend  to  relieve  suffering,  and  to  lengthen 
the  time  during  which  relief  may  possibly  come 
about.  Enemata  may  be  used,  but  strong  pur- 
gatives can  only  add  to  the  distress,  and  increase 
the  danger  of  the  patient.  A little  ice  may.V.e 


INTESTINAL  OBSTRUCTION. 


>744 

sucked  with  advantage  from  time  to  time;  but 
it  is  worse  than  useless  to  attempt  to  introduce 
food  or  medicine  in  bulk  into  the  stomach,  only 
to  be  again  speedily  vomited. 

Abdominal  taxis. — After  one,  two,  or  at  most 
perhaps  three  days  (according  to  the  circum- 
stances and  conditions  of  the  particular  case)  have 
elapsed,  without  abatement,  or  with  probable  in- 
crease in  the  severity  of  the  symptoms,  when  the 
nature  of  the  case  is  clearly  pronounced,  and  espe- 
cially if  the  seat  and  cause  of  the  obstruction 
are  indicated,  surgical  operation  appears  to  the 
writer  imperative  ; and  the  earlier  this  is  done, 
the  better  is  the  chance  of  success.  “ The  writer 
cannot  forbear  expressing  in  this  place  the  strong 
feeling  and  conviction,  after  long  consideration 
and  some  experience,  that  he  entertains  on  this 
matter.  Before  proceeding,  however,  to  the  use 
of  the  knife,  it  may  be  well  under  chloroform  to 
try  the  effect  of  changes  in  the  position  of  the 
body,  and  of  ‘ abdominal  taxis  ’ by  gentle,  firm, 
unstained  manual  compression  of  the  part  of 
bowel  presumably  strangulated  and  distended, 
and  by  attempts  at  movement  in  one  direction 
or  another.  The  good  effects  of  sustained 
compression,  with  the  view  of  emptying  the 
distended  bowel  of  its  contents,  rather  than 
of  pushing  it  back,  in  the  reduction  of  external 
hernia,  are  not  sufficiently  generally  appreciated 
and  systematically  attempted.  And  further, 
every  surgeon  of  experience  has  met  with  cases 
of  external  hernia  in  which  the  movements  or 
joltings  of  a journey  to  the  hospital  have  re- 
sulted in  reduction.  So  it  may  bo  with  some 
rases  of  internal  strangulation. 

Abdominal  section. — If  such  attempts  fail,  an 
incision  should  be  made  in  the  middle  line  down- 
wards or  upwards  (as  the  indication  may  be)  from 
the  umbilicus  into  the  abdomen,  of  sufficient  ex- 
tent to  permit  the  introduction  of  the  fingers,  and 
the  seat  and  cause  of  the  obstruction  sought  for. 
As  a rule,  it  may  be  better  to  extend  the  incision 
so  far  as  to  afford  a clear  view  of  the  strangulated 
bowel ; but  it  must  be  borne  in  mind  that  the 
longer  the  incision  the  more,  probably,  will 
the  distended  bowels  protrude,  and  the  greater 
will  be  the  difficulty  in  replacing  and  retaining 
them.  Any  constricting  band  that  may  be  dis- 
covered may  then  be  divided,  and  the  bowel  re- 
leased, or  a twisted  portion  may  be  restored  to 
position.  The  chief  difficulties  likely  to  occur 
arise  from  the  protrusion  of  distended  bowel, 
which  is  apt  to  hinder  proceedings.  Punctures 
may  be  made  by  a fine  trocar  and  canula;  but 
all  such  punctures  should  be  carefully  closed  by 
ligature  or  suture.  The  chief  immediate  danger 
is  that  of  giving  way  of  the  bowel  at  the  seat  of 
strangulation  at  the  momentof  release,  and  extra- 
vasation of  its  contents;  but  in  cases  in  which 
this  happens,  it  is  almost  certain  that  similar 
rupture  would  have  speedily  occurred  if  matters 
had  been  allowed  to  take  their  course.  Any 
such  opening  in  the  bowel  should  be  at  once 
closed  by  suture,  and  every  effort  made  to  pre- 
vent extravasation  into  the  peritoneal  cavity. 
It  has  sometimes  been  found  desirable  to  attach 
the  edges  of  the  ruptured  portion  to  the  abdo- 
minal pariotes,  with  the  view  of  establishing  an 
artificial  opening. 

In  cases  in  which  there  has  been  an  external 


hernia,  it  maybe  preferable  to  make  the  incision 
in  the  groin,  and  to  extend  it  upwards  as  far  as 
may  be  needful.  In  several  such  cases  (four 
in  the  writer’s  own  experience)  the  cause  of 
strangulation  has  been  found  to  be  omentum 
adherent  to  the  sac  of  the  old  hernia,  division 
of  which  up  in  the  abdomen  has  resulted  in 
release  of  the  strangulated  bowel.  After  the 
operation  the  abdominal  incision  should  be  care- 
fully closed,  and  the  patient  kept  for  sometime 
thoroughly  under  the  influence  of  opium. 

It  must  be  admitted  that  the  statistics  of 
operations  for  internal  strangulation  do  not 
seem  encouraging.  In  61  out  of  95  recorded 
or  observed  cases  death  followed  more  or  less 
speedily,  and  in  34  only  did  recovery  take 
place.  But  the  causes  of  failure  are  obvious. 
In  most  cases  there  has  been  either  some  error 
in  diagnosis,  or  the  operation  has  been  per- 
formed too  late,  and  at  a period  when  recovery 
under  any  circumstances  would  have  been  hope- 
less. Increased  accuracy  in  diagnosis ; earlier 
resort  to  operation  ; and  the  adoption  of  im- 
proved surgical  methods,  among  which  must  t*“ 
especially  urged  the  use  of  antiseptic  precautions, 
may  be  confidently  expected  to  yield  better  re- 
sults in  the  future. 

Colotomy. — In  cases  in  which  it  appears  that 
the  lower  part  of  the  colon  or  sigmoid  flexure  i= 
strangulated  by  twisting  or  doubling  over,  and 
in  which  it  is  deemed  inexpedient  to  perform 
abdominal  section,  temporary  relief  at  any  rate 
may  be  afforded  by  lumbar  colotomy — right  or 
left.  Or  simple  puncture  of  the  colon  by  a fine 
trocar  and  canula  may  give  relief,  temporary 
or  permanent,  by  affording  escape  for  the  flatus. 

Enterotomy. — -The  operation  of  enterotomy  is 
applicable  to  cases  of  chronic,  rather  than  of 
acute  strangulation,  and  will  be  subsequently 
referred  to. 

III.  Obstruction  from  Impaction  of  Gall- 
stones.— Gall-stones  may  enter  the  intestine, 
either  after  passing  down  the  gradually  dilated 
duct,  or  after  a process  of  inflammatory  adhe- 
sion and  ulceration  between  the  gall-bladder  and 
the  duodenum  or  colon.  It  is  in  this  latter  way 
probably  that  gall-stones  large  enough  to  block 
its  canal  get  into  the  bowel ; and  hence  in  such 
cases,  though  there  is  usually  a previous  history 
of  more  or  less  suffering  in  the  hypochondriac 
region  (which  may  assist  the  diagnosis),  yet 
those  paroxysms  of  pain  and  the  jaundice  which 
accompany  the  passage  of  gall-stones  down  the 
duct  have  not  been  experienced.  Having  entered 
the  intestine,  gull-stones  may  either  pass  along 
until  they  escape  by  the  anus — sometimes  giving 
but  little  trouble  during  their  passage,  sometime- 
being  temporarily  arrested,  or  damaging  the 
bowel  at  one  point  or  other,  and  giving  rise  to 
pain,  vomiting,  deranged  action  of  the  bowels. 
&c. ; or  they  may  become  firmly  impacted,  and 
completely-  obstruct  the  intestinal  canal.  Ob- 
struction from  such  cause,  however,  is  com- 
paratively rare,  occurring  in  only  about  8 per 
cent,  of  the  cases  of  acute  obstruction.  It  is 
met  with  about  four  times  as  often  in  the  female 
as  in  the  male  subject ; and  almost  without 
exception,  or  with  very  few-  exceptions,  after 
late  middle  life — most  frequently  after  the  age 
of  sixty. 


INTESTINAL  OBSTRUCTION. 


745 


The  gall-stones  which  have  been  found  to 
;ause  obstruction  have  been  from  one  to  two 
inches  or  more  in  longest  diameter.  As  a rule 
they  have  been  single,  in  some  instances  con- 
glomerate. In  a large  proportion  of  cases  they 
have  been  impacted  in  the  duodenum  or  upper- 
part  of  the  jejunum;  in  some  few  instances 
about  the  middle  of  the  ileum  ; and,  again,  in 
somewhat  more  cases,  in  the  ileum  near  the 
ilco-csecal  valve.  Impaction  in  the  large  intes- 
tine very  rarely  occurs,  and  has  scarcely  ever 
led  to  a fatal  result,  but  in  some  instances  it  has 
been  attended  by  very  severe  symptoms. 

Impaction  is  favoured  by  natural  or  accidental 
narrowing  of  the  bowel,  and  doubtless  is  aided 
or  maintained  by  swelling  of  the  mucous  mem- 
brane and  spasmodic  contraction  round  the  stone, 
as  well  as  by  a more  or  less  persistently  con- 
tracted condition  of  the  bowel  beyond  it. 

Symptoms. — The  symptoms  following  impac- 
tion  often  come  on  suddenly,  and  are  usually 
very  acute  ; and  death,  preceded  by  all  the  in- 
dications of  intense  enteritis  conjoined  with  those 
j of  acute  obstruction,  as  a rule  occurs  in  five  or 
i 6ix  days,  if  it  have  not  occurred  earlier  as  the 
result  of  shock.  Recovery  rarely  takes  place. 
In  some  few  exceptional  cases,  however,  relief 
has  come  about  even  after  periods  of  severest 
suffering,  by  the  release  and  onward  passage  of 
the  stone;  in  some,  the  bowel  has  become 
stretched  into  a kind  of  diverticulum,  in  which 
the  stone  has  remained  lodged,  a way  by  it 
beingleft;  in  some,  after  adhesion  and  ulceration, 
an  opening  has  been  formed  between  the  small 
intestine  and  the  neighbouring  part  of  the  colon 
1 through  which  the  stone  has  escaped;  and  in 
some,  again,  after  similar  processes  between  the 
bowel  and  abdominal  wall,  the  stone  has  escaped 
externally,  or  has  been  removed  by  operation. 

Diagnosis. — The  diagnosis  of  obstruction  by 
gall-stone  is  aided  by  consideration  of  the  age, 
sex,  and  previous  history  of  the  patient ; the 
character  and  acuteness  of  the  symptoms  ; the 
localisation  of  the  earliest  pain  ; and  sometimes 
I by  the  recognition  on  examination  of  a more  or 
less  distinct  hard  lump,  corresponding  to  the 
obstructing  gall-stone. 

- Treatment. — None  other  than  palliative 

^measures  can  as  a rule  be  recommended;  but 
having  regard  to  the  extreme  danger  of  the  con- 
dition, and  the  severe  suffering  of  the  patient, 
the  operation  of  enterotomy  would  seem  to  the 
writer  to  be  justifiable. 

IV.  Intussusception  or  Invagination. — 
By  intussusception  or  invagination  is  understood 
the  passage  of  one  portion  of  intestine  into  the 
immediately  adjoining  portion. 

Intussusceptions  that  have  given  rise  to  no 
symptoms  during  life  are  not  infrequently  found 
pn  post  mortem  examination,  especially  of  the 
bodies  of  children,  and  those  who  have  died  of 
irain-disease.  Such  intussusceptions  occur  in 
'’.rticulo  mortis , or  immediately  after  death ; 
hey  are  easily  reduced,  are  almost  equally 
. asily  reproduced  or  imitated,  and  are  accom- 
'anied  by  no  sign  of  inflammation.  They  are 
f no  practical  import.  But  their  possible 
ccurrcnce  should  be  borne  in  mind,  lest,  when 
let  with,  they  should  lead  to  false  conclusions 
S to  the  cause  of  death  or  previous  suffering. 


.(Etiology. — Intussusceptions  occurring  dur- 
ing life,  and  causing  intestinal  obstruction,  are 
most  frequently  met  with  during  infancy  or 
early  childhood.  About  one  fourth  of  the  cases 
on  record  have  occurred  during  the  first  year, 
and  more  than  one  half  during  the  first  seven 
years  of  life.  The  male  subject  appears  to  be 
more  liable  than  the  female,  in  the  proportion  of 
about  two  to  one. 

The  occurrence  of  intussusception  w-ould  appear 
to  be  brought  about,  in  the  first  place,  by  some 
irregular  or  disorderly  peristaltic  action  of  one 
portion  of  bowel,  conjoined  with  inaction  or 
paresis  of  another,  dependent  upon  some  ill- 
defined  or  unaseertainable  cause  or  other  of 
derangement.  Sometimes  it  follows  diarrhoea 
or  violent  straining  ; sometimes  it  is  associated 
with  the  presence  of  worms,  or  of  masses  of 
imperfectly  digested  food  ; and  sometimes  with 
the  pressure  or  dragging  of  some  new  growth. 
Having  once  commenced,  the  intussusception 
goes  on  increasing,  more  or  less  continuously, 
as  the  result  of  peristaltic  action.  The  portion 
of  bowel  first  invaginated,  as  a rule,  advances 
at  the  expense  of  the  receiving  portion,  which 
turns  in  to  form  the  middle  layer.  The  length 
of  bowel  involved  varies  greatly  in  different 
cases,  as  a matter  of  course.  But  the  process  may 
go  on  until  the  portions  first  involved,  having 
traversed  the  whole  length  of  the  colon,  may 
reach,  or  even  protrude  or  be  expelled  from  the 
anus. 

Anatomical  Characters. — As  a rule,  with 
but  very  few  exceptions,  it  is  the  upper  portion 
of  the  bowel  that  passes  into  the  lower.  In 
ordinary  cases  the  intussusception  is  complete 
and  single,  and  thus  a transverse  section  shows 
three  rings  of  bowel ; a longitudinal  section, 
three  layers  of  bowel  on  each  side;  the  outer 
and  middlo  layers  having  mucous  surfaces  in 
mutual  contact,  and  the  middle  and  inner  hav- 
ing serous  surfaces  in  mutual  contact.  In  some 
rare  cases,  however,  the  intussusception  is  said 
to  be  incomplete-,  in  such  a funnel-shaped  pro- 
cess is  drawn  down,  usually  by  the  dragging  of 
a pedunculated  tumour,  from  some  part  of  the 
intestinal  wall  into  the  canal.  In  some  casos, 
again  also  rare,  the  intussusception  is  double, 
the  whole  intussusception-mass  being  received 
into  another  portion  of  bowel;  under  such  cir- 
cumstances four  rings  or  layers  are  shown  on 
section. 

Between  the  middle  and  inner  layers  the 
mesentery,  or  mesocolon,  or  both,  as  the  case 
may  be,  are  also  received,  and  these  determine, 
from  the  first,  peculiarities  in  the  conformation 
of  the  intussusception ; and  the  consequent  com- 
pression of  their  vessels,  and  arrest  of  the  cir- 
culation through  them,  bring  about  complications 
and  more  or  less  characteristic  effects,  such  as 
congestion  and  swelling,  ecchymosis,  and  even 
considerable  haemorrhage. 

Almost  any  part  of  the  intestinal  tract  may 
be  involved,  but  some  parts  are  involved  much 
more  frequently  than  others.  Thus  in  upwards 
of  50  per  cent,  of  the  cases,  the  ileum  and  caecum 
have  been  found  passing  into  the  colon  ( Intus ■ 
susccptio  ileo-ccecalis) ; in  about  30  per  cent,  the 
small  intestine  has  alone  been  involved — the 
ileum  in  most  of  those  (J.  ilcalis),  the  jejunum 


INTESTINAL  OBSTRUCTION. 


Ji  8 

iu  a few  (/.  jejanaUs),  the  duodenum  in  still 
fewer  (/.  duodeualis).  In  some  a portion  of 
iloum  invaginated  in  another  portion  has  passed 
on  through  the  ileo-eaecal  valve  into  the  colon 
(/.  ileo-colica).  In  about  12  per  cent,  of  the 
cases  the  colon  only  has  been  involved  (/.  colica ). 
The  rectum,  though  it  constantly  forms  the 
receiving  layer  of  an  extended  intussusception, 
is  very  seldom  primarily  affected,  except  as  the 
result  of  the  dragging  of,  or  pressure  upon  some 
new  growth. 

Symptoms. — The  symptoms  of  intussusception 
usually  appear  suddenly  and  are  very  severe. 
First,  there  is  pain,  often  most  intense  and 
agonising,  sometimes  like  that  of  colic,  some- 
times ‘straining  and  tearing’  in  character,  felt 
most  distinctly  at  a spot  corresponding  to  the 
commencing  lesion.  In  children  convulsions 
sometimes  occur.  Vomiting  speedily  super- 
venes, and  the  vomited  material  is  often 
streaked  or  mixed  with  blood,  and,  sooner  or 
later,  usually  becomes  fseeulent.  Diarrhoea 
soon  sets  in,  and,  accompanied  by  severe  strain- 
ing and  tenesmus,  recurs  at  frequent  intervals. 
The  evacuations,  at  first  fsecal,  very  early  are 
ptaioecl  with  blood,  and  soon  consist  of  little 
more  than  blood  and  mucus,  with  only  a slight 
admixture  of  faecal  matter,  or  none  at  all.  The 
occlusion  of  the  bowel  is  often  not  complete  at 
first,  but  it  speedily  becomes  so  from  congestion 
and  swelling.  After  a variable  period,  some  re- 
mission in  the  severity  of  the  symptoms  takes 
place,  to  be  again  followed  by  paroxysmal  exa- 
cerbation. 

On  examination  of  the  abdomen,  a firm, 
cylindrical,  ‘sausage-like’  swelling,  of  greater 
or  less  length,  can  be  distinctly  felt,  and  recog- 
nised as  the  intussusception-mass,  in  almost  all 
cases  of  ileo-caecal  or  colic  invagination.  In 
eases  in  which  the  small  intestine  alone  is  'in- 
volved, such  swelling  is  much  less  distinct  and 
smaller,  and  often  cannot  he  made  out  at  all. 
When  the  intussusception  has  reached  the  lower 
part  of  the  rectum,  which  it  may  do  even  by  the 
second  day,  it  can  be  readily  felt,  and  its  cha- 
racter can  often  be  determined  on  examination 
per  anum. 

Diagnosis. — The  diagnosis  of  intussusception 
of  the  intestine  is  generally  established  without 
difficulty,  by  the  recognition  of  the  signs  and 
symptoms  thus  indicated,  at  any  rate  during 
childhood,  and  in  the  more  acute  cases.  In 
some  of  the  more  chronic  cases  occurring  in 
adult  life,  however,  it  is  not  always  easy. 

Course  and  Progress. — The  course  and  pro- 
gress of  a case  of  intussusception  may  he  (1) 
acute.  Unless  relief  is  obtained,  the  case  will  then 
terminate  fatally,  either  speedily  from  shock,  or 
within  four  or  five  days- in  children,  or  within  a 
week  or  ten  days  iii  the  adult  from  peritonitis 
or  exhaustion.  Or  (2)  the  case  maybe  sub-acute ; 
death  occurring  within  three  or  four  weeks.  Or 
(3)  the  case  may  become,  or  may  be  from  the 
first,  more  or  less  chronic , and  terminate  in 
death  only  after  a period  of  weeks  or  months, 
from  peritonitis,  or  enteritis,  followed  or  not 
by  perforation ; or  from  wasting  and  exhaustion. 
Lastly,  recovery  may  take  place  after  sloughing, 
separation,  and  evacuation  of  the  invaginated 
bowel.  The  last  event,  which  is  of  great  interest, 


and,  in  regard  to  prognosis,  of  great  importance, 
very  rarely  takes  place  during  childhood.  It 
follows  peritonitic  adhesion  between  the  invagi- 
nated and  receiving  portions  of  bowel,  and  death 
of  more  or  less  of  the  former  from  deprivation  of 
blood-supply.  Numerous  cases  of  this  nature 
are  on  record,  varying  in  detail.  In  most  of  them 
it  has  been  some  portion  or  other  of  small  in- 
testine that  has  come  away.  In  some,  how- 
ever, the  caecum  with  its  appendix  and  portions 
of  the  colon  have  been  found.  Sometimes  the 
sloughed  intestine  is  evacuated  in  shreds  or  frag- 
ments, sometimes  in  its  entirety.  Such  separa- 
tion and  evacuation  take  place,  as  a rule,  in  from 
eleven  or  twelve  days  to  three  or  four  weeks, 
and  much  earlier  in  the  case  of  the  small  than 
of  the  large  intestine.  In  some  instances  the 
adhesions  have  giveaway  at  or  immediately  after 
the  separation  of  the  slough,  and  fatal  extrava- 
sation of  faeces  has  occurred ; and  in  some  a 
permanent  stricture  has  resulted  after  fair  pros- 
pect of  recovery  had  been  afforded. 

Treatment. — Acute  intussusception,  espe- 
cially in  the  child  or  infant,  demands  prompt 
and  active  measures  for  its  relief.  Purgatives 
can  only  increase  the  mischief ; palliatives  are, 
as  a rule,  of  little  or  no  permanent  avail,  though 
opium  and  belladonna  may  sometimes  do  good 
by  relieving  pain,  checking  undue  peristaltic 
action,  and  thus  hindering  the  progress  of  the 
lesion,  and  affording  a possible  chance  of  re- 
covery, or,  at  least,  by  rendering  the  remaining 
hours  of  life  comparatively  free  from  suffering. 

When  once  the  diagnosis  is  established,  resort 
should  be  had  without  delay  to  mechanical  or 
operative  treatment,  for  in  such  measures,  accord- 
ing to  the  results  of  experience,  lie  the  best  pros- 
pects of  complete  and  permanent  relief,  first, 
a copious  enema  of  oil,  or  oil  and  thin  gruel, 
should  be  gently  and  slowly  injected,  the  body 
being  inverted,  and  moved  from  one  position 
to  another,  abdominal  taxis  and  manipulation 
being,  meanwhile,  carefully  and  systematically 
carried  out;  or,  in  place  of  liquid  injection, 
insufflation  of  air  by  means  of  bellows  may  he 
employed.  If  the  intussusception  have  pro- 
truded from  the  anus,  it  should,  of  course,  be 
first  replaced,  and  if  felt  in  the  rectum  pushed 
up  as  high  as  may  be  practicable.  Numerous 
cases  are  on  record  in  w hich  such  means  haTe 
been  attended  by  success.  But  should  they  fail 
after  full  and  fair  trial — and  more  than  three  or 
four  attempts  should  not  be  made  unless  signs  of 
improvement  in  the  condition  are  manifest ; then 
surgical  operation — laparotomy — becomes  justi- 
fiable, and  increasing  experience  encourages  its 
adoption.  Laparotomy  should  be  undertaken  be- 
fore there  has  been  time  for  the  formation  of  adhe- 
sions, or  the  supervention  of  general  peritonitis. 
The  abdomen  having  been  opened,  with  all  due 
precaution,  by  median  incision  of  requisite  ex- 
tent, the  intussusception  is  usually  found  with- 
out difficulty,  and  may  he  traced  upward  and 
downward.  Reduction  may  generally  be  effected 
with  comparative  ease  by  gentle  traction  upon 
the  upper  part  of  the  invaginated  portion,  com- 
bined with  gradual  working  up  of  the  lower 
part  by  manipulative  pressure  from  below  up- 
wards upon  the  receiving  portion  (Hutchinson). 
After  the  operation,  the  wound  must  be  carefull* 


INTESTINAL  OBSTRUCTION. 


closed,  an  abdominal  bandage  applied,  perfect 
rest  secured,  and  after-treatment  on  general 
principles  carried  out. 

In  15  out  of  58  recorded  cases  this  opera- 
tion has  resulted  in  recovery;  in  43  it  has 
been  followed  by  death,  although  in  most  of 
these  reduction  was  effected.  It  is  probable, 
however,  that  a much  larger  proportion  of  suc- 
cessful than  of  unsuccessful  cases  have  been 
published,  and  the  figures  must  therefore  be 
taken  for  what  they  may  be  worth  ; they  suffice, 
however,  to  justify  the  more  frequent  and 
earlier  adoption  of  such  means  of  relief,  espe- 
cially under  the  protection  of  antiseptic  pre- 
cautions. 

In  the  more  chronic  forms  of  intussusception, 
and  especially  in  the  adult,  resort  to  operation 
is  not  so  urgently  called  for.  Palliative  measures, 
and  particularly  the  administration  of  opium  and 
belladonna,  with  enemata  from  time  to  time,  are 
often  of  the  greatest  service ; and,  as  already 
indicated,  recovery  after  sloughing  of  the  intus- 
suscepted  bowel,  or  portions  of  it,  not  infre- 
quently takes  place,  although  consecutive  and 
dangerous  complications  may  sooner  or  later 
arise. 

V.  Obstruction  from  Constrictions. — The 
anatomico-pathological  conditions  involving  some 
portion  or  other  of  the  intestinal  wall,  which 
may  give  rise  to  obstruction,  have  been  already 
enumerated  or  indicated.  Regarding  them  the 
following  further  statements  may  bo  made. 

1.  Simple  cicatricial  stenoses  may  result  from 
the  effects  of  in  juries  inflicted  by  caustic  poisons 
or  foreign  bodies ; such  are  most  likely  to  ho 
found  in  the  upper  part  of  the  small  intestine  ; 
they  are,  however,  very  rare.  Similar  stenoses 
may  follow  the  sloughing  of  intussusceptions  ; or 
the  ulceration  produced  by  temporarily  impacted 
gall-stones,  fecal  masses,  or  foreign  bodies ; or 
dysenteric,  tubercular,  or  syphilitic  ulceration  of 
considerable  extent  and  long  standing.  The 
dysenteric  stenoses  are  most  frequently  found 
about  the  flexures  of  the  colon  ; the  tubercular 
in  the  lower  part  of  the  ileum  or  caecum ; and 
the  syphilitic  in  the  rectum  or  lower  part  of  the 
colon.  Typhoid  ulceration  is  very  rarely  fol- 
lowed by  stenosis. 

2.  Peritonitic  thickening  and  contraction , with 
more  or  less  matting  together  and  constriction 
of  the  bowel,  most  frequently  involves  the  small 
intestine  or  the  flexures  of  the  colon. 

3.  New  growths  of  innocent  character — fibro- 
mata, myomata,  lipomata,  and  papillomata 
(benign  villous  growths) — are  from  time  to  time 
met  with,  connected  with  some  part  or  other  of 
the  intestinal  wall,  anil  causing  more  or  less 
obstruction,  either  by  themselves  blocking  the 
canal,  or  by  leading  to  dragging  down  of  the 
part  to  which  they  are  attached.  Such  growths 

1 often  become  polypoid.  They  are  (with  the  ex- 
ception of  myomata  and  lipomata)  most  fre- 
quently met  with  in  the  rectum,  sometimes  in 
other  parts  of  the  large  intestine,  very  rarely  in 
the  small  intestine. 

4.  New  growths  of -malignant  character — fibrous 

I cancer,  forming  hard,  narrow  constrictions,  slow 

to  ulcerate,  scirrhus,  encephaloma,  colloid  can- 
cer, epithelioma,  cylindroma,  and  sarcoma— are 
much  more  common;  and  from  the  readiness  with 


which  they  involve  the  whole  circumference  of 
the  bowel,  much  more  rapidly  load  to  serious  ob- 
struction than  do  those  of  au  innocent  character 
In  about  80  per  cent,  of  the  eases  such  growths 
have  been  found  affecting  the  rectum  ; in  about 
15  per  cent,  the  colon  and  caecum;  and  in  only 
about  5 per  cent,  some  part  or  other  of  the  small 
intestine. 

Symptoms. — The  various  conditions  thus  de- 
scribed, develop  more  or  less  gradually;  and  tho 
symptoms  to  which  they  give  rise  are  chronic 
in  character,  and  in  their  earlier  stages  by  no 
means  well  marked.  Disordered,  irregular,  and 
imperfect  action  of  the  bowels,  and  general  dis- 
comfort occurring  from  time  to  time,  with  inter- 
vals of  comparative  ease,  constitute  the  earliest 
indications.  Later,  and  after  a very  variable 
period,  as  the  constriction  increases,  the  trouble 
becomes  greater  and  more  constant,  and  the 
symptoms  of  obstruction  become  more  pronounced. 
In  most  cases  abdominal  distension  (meteorism) — 
localised  or  general,  and  accompanied  by  sensa- 
tions of  fulness,  feetid  eructations,  shortness  of 
breath,  and  pains  in  the  back,  varying  in  degree 
from  time  to  time — comes  on  sooner  or  later ; 
and  except  when  the  seat  of  obstruction  is  in  the 
rectum,  the  peristaltic  movements  of  the  intes- 
tines at  intervals  become  very  manifest  through 
the  abdominal  wall.  The  pain  experienced  is  very 
variable  in  character  and  severity,  and  is  often 
paroxysmal,  with  periods  of  complete  intermis- 
sion. As  the  case  progresses  towards  a fatal  ter- 
mination, the  distress  becomes  extreme.  Absolute 
occlusion,  as  a rule,  comes  about  slowly.  In  some 
cases  it  is  never  completely  established ; hut  in 
other  cases  it  occurs  suddenly,  from  impaction 
of  hardened  feces  or  undigested  food,  or  from 
other  cause  ; and  in  such  tho  symptoms  at  once 
correspondingly  increase  in  severity.  It  is 
worthy  of  note  that  even  in  cases  in  which  tho 
seat  of  constriction  is  in  the  sigmoid  flexure  or 
rectum,  the  greatest  fecal  accumulation  and 
corresponding  discomfort  are  observed  in  the 
caecum. 

Diagnosis. — The  general  diagnosis  of  obstruc- 
tion from  constriction,  as  a rule,  is  not  difficult ; 
hut  the  differential  diagnosis  as  to  the.  precise 
nature  of  the  constriction  is  often  very  obscure, 
except  in  those  cases  (the  large  majority)  in 
which  a stricture,  or  the  presence  of  some  new- 
growth,  can  be  discovered  on  examination  per 
anuin.  The  previous  history  often  supplies 
important  indications,  and  should  therefore  bo 
thoroughly  investigated. 

Course  and  Terminations. — The  course  of 
all  such  cases,  though  very  variable  in  duration, 
is  progressively  unfavourable,  and  sooner  or  later 
death  supervenes,  usually  from  peritonitis  with 
or  without  perforatiou,  or  from  exhaustion  from 
prolonged  suffering. 

Treatment. — The  treatment  must  ho  deter- 
mined and  varied  in  accordance  with  the  symp- 
toms and  indications  presented  from  time  to  time. 
In  the  earlier  stages,  soothing  and  palliative 
measures  should  be  adopted  during  periods  of 
exacerbation  of  suffering;  and  during  periods  of 
comparative  relief  laxatives  may  often  be  given 
with  great  advantage.  In  all  cases  in  which  there 
is  reason  to  suspect  the  existence  of  some  causa 
of  constriction,  the  most  careful  attention  to  diet. 


INTESTINAL  OBSTRUCTION. 


148 

and  the  administration  from  time  to  time  of  such 
medicines  as  favour  a soft,  semi-solid  condition 
of  the  faeces,  should  be  insisted  upon. 

Operation.— In  the  later  stages  resort  must 
be  had  to  surgical  operation,  and  the  greatest 
relief  may  often  be  afforded,  and  life  prolonged, 
by  the  establishment  of  an  artificial  anus  by 
opening  the  bowel  above  the  seat  of  constriction, 
either  by  incision  through  the  peritoneum— 
enterotomy ; or  by  post-peritoneal  incision — 
lumbar  colotomy,  right  or  left.  Laparotomy  is 
altogether  out  ot'  the  question. 

In  cases  in  which  there  is  reason  to  believe  that 
the  constriction  affects  the  small  intestines , en- 
terotomy should  be  adopted.  An  oblique  incision 
in  the  right  iliac  region,  more  or  less  parallel  with 
and  above  Poupart’s  ligament,  having  been  made 
and  cautiously  carried  down  through  the  various 
structures,  the  peritoneum  is  to  be  opened  to  a 
limited  extent,  and  the  first  protruding  portion 
of  distended  small  intestine  is  to  be  seized,  and 
being  well  pulled  out,  opened  by  very  limited 
incision.  In  the  case  of  the  small  intestine,  it  is 
needless,  on  account  of  the  semi-fluid  nature  of 
the  contents,  to  make  a large  opening,  and  it  is 
obviously  disadvantageous  to  do  so.  The  mar- 
gins of  the  opening  in  the  intestine  are  then 
to  be  sutured  to  the  margins  of  the  external 
wound.  This  operation,  especially  advocated  by 
Nelaton,  has  proved  successful  in  affording  relief 
and  prolonging  life  in  a considerable  number  of 
cases  (10  out  of  16).  One  great  drawback  to  it, 
in  the  event  of  prolongation  of  life,  lies  in  the 
extreme  inconvenience  and  annoyance  the  patient 
suffers  from  the  continual  escape  of  liquid  faeces 
in  the  part  of  the  body  operated  upon — an  escape 
which  there  is  the  greatest  practical  difficulty  in 
restraining. 

In  cases  in  which  the  seat  of  constriction  is  in 
the  colon  or  rectum,  lumbar  colotomy  (post- 
peritoneal  enterotomy)  is  to  be  performed,  on  the 
right  or  left  side  according  to  the  indications 
afforded.  The  merits  of  this  operation  in  reliev- 
ing suffering  and  prolonging  life  in  such  cases, 
can  scarcely  be  esteemed  too  highly. 

After  the  establishment  of  an  artificial  anus, 
and  the  rest  from  constant  irritation  thereby 
afforded,  the  constricted  bowel  may  recover  to  a 
certain  extent  its  permeability. 

VI.  Obstruction  from  Compression  from 
without. — Various  viscera,  enlarged  and  dis- 
placed as  the  result  of  disease — especially  the 
uterus  and  ovaries,  and  in  rare  instances  the 
6pleen,  the  pancreas,  and  even  the  kidney ; tuber- 
cular or  cancerous  glands ; tumours  of  the  omen- 
tum or  other  parts  of  the  peritoneum  ; tumours 
growing  from  one  part  or  other  of  the  abdominal 
or  pelvic  parietes,  or  from  the  contained  viscera  ; 
hydatid  cysts,  &c.,  may  so  compress  a neigh- 
bouring portion  of  bowel  as  to  lead  to  obstruc- 
tion, which  either  may  be  brought  about  gra- 
dually, or  from  some  accidental  cause  may  be 
suddenly  determined. 

Symptoms. — The  symptoms  more  or  less  closety 
resemble  those  of  obstruction,  chronic  or  acute, 
arising  from  other  causes. 

Diagnosis. — Careful  examination  of  the  abdo- 
men, including  thorough  examination  per  vagi- 
nam  and  per  anum  (sometimes  the  introduction 
uf  the  whole  hand  into  the  rectum  is  especially 


likely  to  be  useful),  together  with  the  history  or 
the  case,  and  the  consideration  of  the  collateral 
signs  and  symptoms,  will  generally  suffice  to 
establish,  approximafively  at  any  rate,  the 
diagnosis  of  obstruction  of  the  bowel  from  ex- 
ternal compression. 

Treatment. — The  treatment  of  this  condition 
consists,  first,  in  the  removal  of  the  cause,  if 
practicable ; secondly,  if  this  should  be  imprac- 
ticable, in  relieving  the  obstruction.  By  altering 
the  position  oi  the  body,  the  displaced  viscera 
may  sometimes  be  so  moved  as  to  cease  to  com- 
press tho  bowel;  tumours,  uterine  and  ovarian 
especially,  may  be  taken  away  by  operation; 
hydatid  cysts  may  be  tapped;  and  thus  relief 
may  be  afforded.  Or  again,  by  manipulation  or 
by  the  effects  of  copious  enemata,  the  bowel  itself 
may  be  so  moved  as  to  be  no  longer  compressed ; 
or  after  a period  of  rest,  under  the  influence  of 
sedatives,  it  may  release  itself.  But  if  none  of 
these  measures  should  be  applicable  or  successful, 
and  if  the  symptoms  of  obstruction  be  severe, 
resort  to  one  or  other  of  the  operations  (la farce 
tomy,  enterotomy.  or  colotomy)  already  discussed, 
may  become  needful.  In  some  cases,  of  this  class 
especially,  relief  lias  been  afforded,  and  the 
bowel  has  recovered  itself,  after  puncture  by  fine 
trocar  and  canula  and  aspiration.  The  ultimate 
prospects  must  depend  upon  how  far  the  com- 
pressing cause  can  be  removed. 

VII.  Obstruction  from  Impaction  of  Fo- 
reign Bodies,  Intestinal  Concretions  (Ente- 
roliths) &c. 

a.  Foreign  bodies  in  bull-,  such  as  bones,  coins, 
buttons,  knives,  forks,  pins,  needles,  &c.,  acciden- 
tally or  intentionally  swallowed,  occasionally  find 
their  way  on  from  the  stomach  into  the  intes- 
tines. In  a considerable  proportion  of  cases  they 
pass  on,  and  are  evacuated  per  anum  without 
very  much  inconvenience ; in  some  cases  they 
give  rise  to  enteritis  and  various  other  intestinal 
troubles ; in  some  rare  cases  they  lead  to  more 
or  less  complete  occlusion,  with  acute  or  sub- 
acute symptoms. 

Symptoms. — The  symptoms  of  impaction  of 
foreign  bodies  in  the  bowels  vary  with  the  ex- 
tent of  injury  inflicted,  and  the  degree  of  obstruc- 
tion occasioned. 

Diagnosis. — The  diagnosis  of  such  cases  rests 
on  the  history,  and  on  the  recognition  of  the 
presence  of  the  foreign  body  on  palpation  of  the 
abdomen,  or  examination  per  rectum. 

Treatment. — The  treatment  of  this  condition 
must  be  determined  by  the  general  circum- 
stances and  urgency  of  the  case.  As  a rule, 
purgatives  can  only  do  mischief.  Soothing  re- 
medies give  temporary  relief,  and  favour  the 
gradual  onward  passage  and  ultimate  expulsion 
of  the  foreign  body.  If  absolute  impaction  has 
clearly  taken  place,  and  the  symptoms  are 
urgent,  enterotomy  and  extraction  may  be  justi- 
fiable, or  even  imperative.  The  wound  in  the 
intestine  may  either  be  carefully  closed  by 
suture,  and  the  bowel  returned  ; or  its  edg-s 
may  be  attached  to  those  of  the  external  wound, 
and  an  artificial  anus  temporarily  established. 

In  some  instances,  such  procedures  have  been 
encouraged  and  favoured  by  the  previous  for- 
mation of  inflammatory  adhesions  between  the 
bowel  and  the  parietes. 


INTESTINAL  OBSTRUCTION. 

b.  Foreign  bodies — as  hair,  &c. ; indigestible 
constituents  of  the  food— as  the  skins,  seeds,  and 
stones  of  fruit  (the  husks  of  cereals,  and.  oats 
especially),  orange-pulp,  and  the  curd  of  milk  in 
young  children ; and  some  medicinal  substances 
us  macnesia,  chalk,  oxide  of  iron,  Ac.,  swal- 
lowed bit  by  bit  from  time  to  time,  may  accu- 
mulate in  some  part  or  other  of  the  bowel.  Be- 
coming matted  or  felted  together,  and  aggluti- 
nated by  the  intestinal  mucus  and  other  secre- 
tions. these  bodies  may  form  rounded  masses, 
which  sooner  or  later  may  give  rise  to  more  or 
less  complete  obstruction.  Such  masses  consti- 
tute the  large  proportion  of  the  so-called  ‘ intes- 
tinal concretions’  in  the  human  subject. 

c.  In  some  rare  instances,  however,  hard  stony 
concretions  ( enteroliths ),  consisting  for  the  most 
part  of  phosphates  of  lime  and  magnesia  with 
organic  material,  and  resembling  those  not  in- 
frequently found  in  some  of  the  lower  animals, 
have  been  met  with.  These  usually  have  as  a 
nucleus  some  foreign  body,  or  portion  of  har- 
dened altered  faeces. 

Intestinal  concretions  are  almost  invariably 
found  either  in  the  caecum  or  in  the  rectum. 
Their  presence  may  commonly  be  recognised  on 
examination.  They  are,  as  a rule,  slowly  formed, 
and  only  give  rise  to  complete  occlusion  after  a 
considerable  period,  during  which  repeated  at- 
tacks of  more  or  less  persistent  abdominal  dis- 
comfort and  distress  have  occurred.  Death  may 
be  brought  about  by  gradual  exhaustion,  or  by 
the  effects  of  inflammation  with  or  without  per- 
foration ; or  recovery  may  follow  the  evacuation 
of  the  concretion,  either  per  vias  naturales,  or 
through  an  ulcerated  or  artificial  opening. 

Foreign  bodies  introduced  into  the  rectum,  or 
which  have  passed  down  and  there  become  im- 
pacted, and  concretions  similarly  situated,  may 
be  removed  per  anum. 

VIII.  Obstruction  from  Impaction  of 
Faces. — Habitual  or  accidentally  prolonged 
constipation  may  lead  to  definitive  obstruction 
by  impaction  of  faecal  masses,  conjoined  with 
paralysis  and  inaction  of  the  bowel  from  disten- 
sion, and  contraction  of  the  empty  portion  below. 
Sometimes  the  occlusion  is  rendered  more  abso- 
lute and  irremediable  by  the  doubling  or  dragging 
clown  of  the  bowel  by  the  weight  of  its  contents. 
The  seat  of  the  obstructing  faecal  mass  is  usually 
the  sigmoid  flexure  or  the  rectum,  but  corre- 
sponding accumulation  is  at  the  same  time  often 
found  in  the  caecum.  This  cause  of  obstruction 
is  most  frequently  met  with  in  advanced  life,  and 
especially  among  lunatics  or  idiots. 

Symptoms. — The  symptoms  of  faecal  impac- 
tion are  characterised  by  their  chronicity;  and 
complete  occlusion  as  a rule  comes  about  slowl  v. 
There  is  little  or  no  actual  pain  during  the 
early  stages,  and  even  during  the  later  stages,  in 
the  absence  of  complications,  it  rarely  becomes 
acute.  Vomiting  is  altogether  absent  at  first,  or 
slight  and  rare ; towards  the  end,  however,  there 
may  be  faecal  vomiting.  Abdominal  distension 
only  comes  about  gradually.  Absolute  constipa- 
tion is  only  slowly  established,  and  somotimes  is 
preceded  by  more  or  less  frequent  scanty  diar- 
rhoea-like evacuations.  The  faecal  mass  can 
sometimes  be  felt  on  abdominal  examination,  and 
tench  more  often  on  rectal  exploration,  which  in 


INTESTINES,  DISEASES  OF.  749 
such  cases  should  always  be  thoroughly  carried 
out. 

Diagnosis. — The  diagnosis  of  such  cases  is 
determined  generally  without  difficulty  by  the 
history ; by  the  absence  of  acute  symptoms  ; by 
the  process  of  exclusion  of  other  causes  of  ob- 
struction ; and  by  the  aid  afforded  by  physical 
examination. 

Course. — In  a considerable  proportion  of  case* 
of  this  kind  relief  may  be  afforded  by  appro- 
priate treatment.  In  some  cases,  however,  death 
ensues  from  gradual  exhaustion  ; in  others  from 
chronic  peritonitis  ; and  in  others  from  ulcera- 
tion of  the  bowel,  followed  or  not  by  perforation 
and  acute  peritonitis. 

Treatment. — In  this  form  of  obstruction  of 
the  bowels,  very  copious  enemata,  administered 
through  a long,  soft  tube,  carefully  introduced 
and  insinuated  onwards  as  far  as  practicable, 
are  especially  useful.  Such  enemata— consisting 
of  thin  gruel,  soap  and  water,  oil,  with  or  with- 
out turpentine,  to  the  extent  of  two  or  three 
pints  or  more,  should  be  given  and  repeated  at 
intervals  as  indicated.  Or  a stream  of  warm 
water  from  a vessel  raised  to  a height,  through  a 
long  tube,  may  be  advantageously  made  to  play 
upon  and  wash  away,  portion  by  portion,  the 
faecal  mass  (Gay).  Sometimes  the  mass  may  be 
cleared  out  of  the  rectum  by  the  finger  or  a 
spoon.  In  some  cases  galvanism  to  the  abdo- 
minal wall,  in  some  t.he  application  of  an  ice- 
bag,  in  others  hot  fomentations  or  immersion  in 
the  hot  bath,  may  bo  useful. 

In  the  earlier  stages,  laxatives  or  even  purga- 
tives, as  calomel  in  a full  dose,  or  castor  oil, 
may  often  be  given  with  safety  and  advantage. 
A teaspoonful  of  Rochelle  salts  in  a cupful  of 
mutton  broth,  is  an  old  but  often  efficacious  re- 
medy. In  the  later  stages,  and  when  purgatives 
have  been  found  to  fail  or  to  increase  distross, 
opiates  are  indicated  ; and  belladonna  in  large 
doses  seems  often  to  exert  a peculiar  and  bene- 
ficial influence. 

When  relief  has  been  obtained,  the  greatest 
care  as  to  diet  and  after-management  is  neces- 
sary, in  order  to  prevent  that  recurrence  of 
trouble  to  which  the  patient  remains  liable.  Sec 
Constipation.  Arthur  E.  Durham. 

INTESTINAL  WORMS.— This  combined 
term  was  formerly  much  employed  in  medical 
literature,  as  an  equivalent  for  the  simpler  ex- 
pression entozoa , which  latter  title  is  far  better, 
more  comprehensive,  and  now  in  general  use.  To 
be  sure,  nearly  all  the  internal  parasites  of  mac, 
at  some  time  or  other  during  the  course  of  their 
development,  play  the  part  of  intestinal  worms, 
within  either  the  human  or  animal  host ; but 
since  this  particular  residence  frequently  consti- 
tutes neither  the  only  locality  they  occupy,  nor 
the  principal  feature  of  their  life-record,  it  is  well 
that  the  use  of  these  possibly  misleading  words 
should  be  discontinued.  See  Entozoa;  Para- 
sites; Worms;  and  Vermes. 

T.  S.  CoBBOi.n. 

INTESTINES,  Diseases  of. — General 

Rejiarks. — Morbid  affections  of  the  intestinal 
tract  are  of  very  frequent  occurrence  at  all 
ages ; some  being  limited  to  certain  periods  of 
life,  others  presenting  no  such  restriction. 


75 0 INTESTINES.  DISEASES  OF. 


The  direct  exposure  that  the  canal  offers  to 
external  influences,  in  the  form  of  ingesta,  will 
account  for  the  causes  of  a large  proportion  of 
cases.  So  many  irritants  to  disease  have  thus 
the  opportunity  to  exert  their  immediate  in- 
fluence, and  produce  what  may  be  termed 
■primary  affections  of  the  canal.  On  the  other 
hand,  since  much  of  the  normal  physiological 
work  of  the  tract  depends  for  its  performance 
on  a healthy  condition  of  other  functions,  espe- 
cially of  the  blood-circulation  and  nervous  sys- 
tem, any  disturbances  of  these  processes  will 
tend  to  influence  injuriously  intestinal  digestion, 
and  thus  give  rise  to  secondary  diseases  of  the 
bowel.  And  it  is  evident  that  an  improper 
preparation  of  the  food  in  the  intestine  must  in 
its  turn  affect  the  nutrition  of  the  tissues  gene- 
rally, and  among  others  those  of  the  canal  itself. 
In  no  case  is  the  interdependence  of  the  functions 
on  one  another  seen  more  completely  than  in  af- 
fections of  the  digestive  apparatus. 

For  this  same  reason  it  is  that  the  symptoms 
essentially  due  to  any  disease  of  the  intestines 
may  be  considerably  masked  by  more  prominent 
signs  of  mischief  elsewhere,  though  secondary  to 
the  intestinal  affection  ; whilst  in  other  cases 
the  disease  we  may  be  called  upon  to  treat  is 
but  an  expression  on  the  part  of  the  bowels  of 
a morbid  state,  primarily  connected  with  some 
other  organ. 

Besides  the  direct  nutritive  disturbance  of  all 
organs  and  tissues  of  the  body  that  must  ob- 
viously follow  any  morbid  condition  of  the  intes- 
tinal function,  there  is  a most  close  sympathy 
between  the  processes  of  digestion  and  the  ner- 
vous system ; or,  in  other  words,  a dyspepsia  which 
may  be  so  slight  as  practically  to  produce  no  ap- 
parent alteration  in  the  general  state  of  the  body, 
may  yet  distinctly  affect  the  mental  condition,  and 
all  degrees  of  disturbance, from  a mere  irritability 
of  temper  to  a complete  hypochondriasis,  may 
result.  The  frequent  association  of  headache 
with  dyspeptic  symptoms  is  a further  illustration 
of  the  connection ; in  reference  to  which  we  can- 
not avoid  noticing  the  very  extensive  nervous 
supply  that  is  provided  by  the  sympathetic  sys- 
tem to  the  chylopoietie  viscera. 

Although  structurally  continuous  with  the 
stomach,  and  closely  associated  with  it  in  its 
working,  the  intestine  nevertheless  is  exceed- 
ingly prone  to  be  diseased  independently  of  that 
organ,  while  at  other  times  both  suffer  together. 
Certain  spots  in  the  course  of  the  tract  favour 
the  development  of  certain  diseased  states,  and 
it  is  rare  to  find  the  entire  length  of  the  canal 
involved  ; whilst  one  portion  of  the  tube,  the 
jejunum,  is  probably  less  liable  to  disease  than 
any  other  organ  of  the  body. 

The  indications  of  intestinal  disease  are  fre- 
quently extremely  vague  and  uncertain.  The 
subjective  symptoms,  such  as  pain,  may  be  com- 
pletely wanting  in  some  of  the  most  serious 
condi  :ions,  or  out  of  all  proportion  to  the 
severity  of  the  case.  An  ulcer  may  proceed  to 
perforation,  and  a fatal  result  happen,  with  but 
a minimum  of  discomfort,  whilst  an  attack  of 
simple  colic  may  be  agonising.  Nor  is  physical 
examination  so  fruitful  in  its  results  in  the  case 
of  intestinal  disease  as  it  is  in  the  affections  of 
many  other  organs,  the  ugh  perhaps  in  no  other 


region  is  the  tactus  cniditus  so  valuable.  Many 
ot'  the  states  to  be  considered  below  undoubt- 
edly pass  through  their  whole  course  without 
giving  the  slightest  indication  of  their  exist- 
ence that  can  be  recognised  by  physical  exami- 
nation. An  investigation  of  the  evacuations 
at  present  furnishes  information  within  the 
narrowest  limits.  From  all  these  circumstances, 
a diagnosis  of  many  diseases  of  the  intestines  is 
almost  a matter  of  pure  inference  and  conjecture, 
based  upon  a careful  consideration  of  all  cir- 
cumstances, with  due  regard  to  the  value  of  ex- 
perience. 

In  respect  to  treatment,  very  much  may  be 
done  with  the  means  at  our  command.  The  re- 
moval of  causes  is  in  a large  proportion  of  cases 
easy,  and  a complete  cure  may  bo  effected.  .And 
whilst  some  of  the  remaining  cases  admit  of 
little  or  nothing  being  done  for  them,  a greater 
number  can  be  partially  relieved  by  palliative 
remedies. 

The  several  diseased  conditions  of  the  intes- 
tines may  now  be  discussed,  for  the  sake  of  con 
venience,  in  alphabetical  order. 

1.  Intestines,  Abscess  in  "Walls  of. — In 
the  course  of  severe  cases  of  enteritis — phleg- 
monous— where  the  inflammatory  process  affects 
all  the  coats  of  the  bowel,  and  the  products  in- 
filtrate the  different  tissues,  collections  of  pyoid 
cells  may  be  met  with,  but  with  no  well-defined 
limit,  which  may  be  regarded  as  abscesses.  Such 
bodies  may  burst  into  the  intestine,  leaving  small 
ulcers  ; or  through  the  peritoneal  coat,  and  so 
conceivably  cause  perforation. 

In  the  chronic  enteritis  so  often  met  with  in 
scrofulous  subjects,  the  solitary  and  agminated 
glands  may  undergo  slow  suppuration,  and  form 
abscesses  which  end  by  bursting  into  the  lumen 
of  the  gut. 

Such  morbid  products  are  rather  of  post-mor- 
tem interest,  since  they  give  rise  to  no  sym- 
ptoms during  life  which  will  permit  of  their 
formation  being  diagnosed,  apart  from  the  gene- 
ral existing  enteritis,  and  are  practically  inca- 
pable of  treatment. 

2.  Intestines.  Albuminoid  disease  of.— 

The  intestines  appear  to  be  affected  with  albu- 
minoid disease  next  in  frequency  to  the  spleen, 
liver,  kidneys,  and  lymphatic  glands,  and  it  is 
rare  for  the  alimentary  canal  to  show  si;:ns  of 
this  degeneration  until  it  has  become  far  ad- 
vanced in  the  above-named  organs.  It  is  stated 
that  the  intestines  are  affected  in  42  per  cent,  of 
all  cases  (Habershon). 

Anatomical  Characters. — As  in  other  or- 
gans, the  inner  coat  of  the  arteries,  particularly 
of  those  surrounding  the  solitary  and  agminated 
glands,  appears  to  be  the  starting  point  of  the 
albuminoid  change,  from  which  it  gradually  ex- 
tends to  adjacent  tissues,  until  the  whole  thick- 
ness of  the  bowel  may  be  replaced  by  this  ma- 
terial. In  milder  cases  it  is  limited  to  the  mueons 
and  submucous  coats,  which  in  all  cases  are  the 
first  to  suffer.  Considering  the  exceeding  prone- 
ness of  tho  Malpighian  corpuscles  of  the  spleen 
to  undergo  this  change,  it  is  noticeable  that  the 
solitary  and  agminated  glands  of  the  intestine, 
which  are  of  similar  structure,  should  long  resis1 


INTESTINES,  DISEASES  OF. 


tho  degeneration,  and  in  many  cases  may  be 
quite  unaffected.  Sooner  or  later,  however,  the 
albuminoid  granules  appear  in  these  structures, 
until  the  whole  gland  is  involved.  The  mesen- 
teric lymphatic  glands  are  usually  implicated ; 
and  in  severe  cases  the  mesenteric  and  peri- 
toneal vessels,  and  even  the  appendices  epiploic® 
(Hayem). 

The  naked-eye  appearance  of  the  mucous 
membrane  is  that  of  a pale,  thickened,  leathery- 
layer,  often  of  a ‘peculiar  glistening  aspect’ 
(Friedreich).  The  pallor  is  very  striking.  When 
the  degenerative  process  has  become  extreme, 
the  surface  is  ulcerated,  especially  over  the  fol- 
licles, from  fatty  degeneration  and  breaking 
down  of  the  new  material,  the  diminished  blood- 
supply  by  the  constricted  vessels  leading  to  this 
result. 

The  small  intestine,  and  particularly  the  lower 
part  of  the  ileum,  is  the  favourite  seat  of  the  dis- 
ease, which  sometimes  extends  upwards  to  the 
duodenum  and  stomach  ; the  colon  is  sometimes 
affected. 

Symptoms. — The  most  prominent  symptoms 
which  this  condition  gives  rise  to,  so  far  as  the 
alimentary  canal  is  concerned,  are  diarrhoea  and 
hmmorrhage.  Since  the  other  important  viscera 
are  always  simultaneously  affected,  other  symp- 
toms coexist. 

The  diarrhoea  is  rather  characterised  by  fluid- 
ity than  undue  frequency  of  the  stools,  though 
the  latter  does  occur:  the  evacuations'are  often 
greenish  from  altered  blood.  It  is  rare  to  find 
either  pain  or  tenderness  ; and  the  diarrhoea  when 
once  established  rarely  ceases. 

Dr.  Grainger  Stewart  has  shown  that  h®mor- 
rhage  from  the  surface  of  the  mucous  membrane, 
independently  of  any  ulceration,  is  of  frequent 
occurrence,  and  he  considers  it  as  due  to  rup- 
ture of  the  diseased  vessels. 

Treatment. — Enemata  of  starch  and  opium 
are  the  most  efficacious,  though  their  effect  is 
at  best  but  temporary.  The  writer,  however, 
has  seen  a case,  where  extreme  degeneration  of  all 
the  abdominal  viscera  was  present,  almost  com- 
pletely recover  on  removal  of  the  cause,  namely, 
a suppurating  joint. 

3.  Intestines,  Atrophy  of. — A general 
atrophy  of  the  intestines  accompanies  a wasting 
of  the  entire  body  from  any  serious  cause  of 
malnutrition,  such  as  starvation,  where  the  or- 
gans are  estimated  in  fatal  cases  to  lose  42  per 
cent,  of  their  weight,  becoming  extremely  thin 
and  transparent. 

Intestinal  catarrh,  particularly  in  children, 
may  lead  to  atrophy  of  the  bowels,  even  to  an 
extreme  degree. 

Wasting  of  parts  of  the  canal  are  of  more 
frequent  occurrence  from  disease.  This  is  well 
seen  in  cases  where  an  artificial  anus  has  been 
made,  the  gut  below  the  opening  becoming  thin 
and  shrivelled.  In  all  cases  where  any  consider- 
able stricture  of  the  intestine  exists,  the  portion 
beyond  the  obstruction  atrophies  more  or  less. 
This  subject  will  be  found  fully  discussed  by 
Nothnagel,  in  the  Zeitschrift  f.  Klin.  Medicin, 
IV.,  1832,  p.  422. 

4.  Intestines,  Catarrh  of. — This  is  a mild 
' form  of  iutestiual  inflammation  in  which,  how- 


751 

ever,  the  essentials  of  that  morbid  process  aro 
present,  though  in  a slight  degree  ( see  Intes- 
tines, Inflammation  of). 

5.  Intestines,  Contraction  of. — The  calibre 
of  the  intestinal  canal  may  be  diminished  by 
the  pressure  of  tumours;  by  structural  changes 
in  the  walls  ; or  by  displacements  of  portions  of 
the  bowels  in  invagination,  &c.  Such  causes  of 
stricture  are  more  properly  described  under  in- 
testinal obstructions.  See  Intestinal  Odstnuo 
tion. 

The  term  contraction  may  be  applied  to  that 
state  of  shrinking  which  the  gut  is  liable  to  pre- 
sent below  the  seat  of  any  permanent  stricture, 
whatever  its  nature,  just  as  the  portion  of  the 
canal  above  the  obstruction  tends  to  dilate.  It 
is  a condition  that  calls  for  no  interference, 
being  of  no  practical  importance. 

A spurious  contraction  of  part  of  the  intes- 
tines may  be  occasionally  seen  post  mortem , 
due  to  extreme  spasm  of  the  muscular  coat. 
Congenital  malformations,  producing  contraction 
of  the  canal,  may  be  met  with. 

6.  Intestines,  Dilatation  of. — The  normal 
diameter  of  the  small  intestine  may  be  taken  as 
1 i inch  throughout  ; and  that  of  the  large  in- 
testine as  gradually  diminishing  from  2.1  inches 
at  the  emeum.  to  11  inches  at  the  upper  part  of 
the  rectum.  But  the  canal  is  evidently  capable 
of  distension  much  beyond  these  limits,  as  may 
be  recognised  when  large  accumulations  of  flatus 
exist.  Such  conditions,  however,  may  disappear 
after  death,  the  bowel  returning  to  its  proper 
capacity.  These  dilatations,  therefore,  may  be 
regarded  as  temporary,  and  it  is  impossible  to 
say  what  may  he  the  extreme  limit  reached  and 
recovered  from. 

Other  forms  of  distension  of  a more  perma- 
nent nature  are  frequently  observed. 

Cases  have  been  placed  on  record  by  Peacock, 
Crisp,  and  others  (see  Path.  Soc.  Trans.)  where 
extreme  distension  occurred  without  an-  obvious 
cause,  but  associated  with  marked  constipation. 
In  one  case  the  colon  was  uniformly  distended 
to  a diameter  of  six  to  eight  inches  ; and  in  an- 
other the  average  diameter  of  the  small  intestine 
was  twice  the  normal.  In  this  case  the  stomach 
shared  in  the  distension:  and  the  person  had 
been  a large  eater,  and  extremely  fat. 

In  the  greater  number  of  cases  the  dilatation 
is  attributable  to  the  existence  of  some  stricture 
in  the  course  of  the  canal.  It  is  rare  for  any 
distension  tr  follow'  an  acute  obstruction,  though 
it  is  not  absolutely  unknown  ; but  a chronic 
stricture  is  almost  invariably  associated  with 
more  or  less  dilatation  of  the  tube  immediately 
above.  The  length  to  which  this  may  extend  is 
largely  dependent  on  the  duration  of  the  case; 
and  inasmuch  as  a persistent  obstruction  is 
usually  located  somewhere  in  the  large  intestine, 
it  is  the  colon  that  is  most  frequently  distended, 
and  this  may  be  so  excessive  as  practically  to 
obliterate  the  ileo-cmcal  valve.  The  mere  accu- 
mulation of  the  contents  above  the  obstruction 
is  doubtless  one  factor  in  causingthe  di-tension  . 
but  a diminished  resisting  power  on  the  part  of 
the  gut  probably  co-exists,  brought  about  by 
malnutrition  of  its  textures.  The  muscular  coi>t 
of  the  dilated  portions  is  usually  hypertrophied. 


INTESTINES,  DISEASES  OF. 


752 

while  the  mucous  membrane  is  thinned  and 
peculiarly  liable  to  ulceration,  the  decomposing 
contents  furnishing  an  exciting  cause  for  this 
result. 

The  existence  of  any  extreme  dilatation 
may  be  recognised  by  mspection  or  manipula- 
tion of  the  abdomen,  especially  if  the  parietes 
be  thin  and  wasted,  as  they  frequently  are  in 
such  cases.  Faecal  vomiting  may  of  course 
occur  in  connection  with  the  existence  of  a 
dilated  intestine,  but  this  is  rather  to  be  attri- 
buted to  the  primary  obstructing  cause,  in  the 
symptoms  of  which  the  few  indications  peculiar 
to  this  condition  are  merged. 

Paralysis  of  the  muscular  coats,  by  diminishing 
the  resistance  of  the  bowel,  allows  of  its  disten- 
sion. This  is  well  exemplified  in  the  extreme 
dilatation  from  flatus  which  so  frequently  accom- 
panies acute  peritonitis. 

7.  Intestines,  Gangrene  of. 

iETionoGY. — The  immediate  cause  of  the  com- 
plete death  of  a portion  of  the  intestine  is  the 
complete  arrest  of  the  flow  of  blood  through  the 
part  affected.  This  obstruction  may  be  produced 
by  : — 

(i.)  Embolus  of  the  superior  mesenteric  artery. 
Several  cases  of  this  condition  have  been  re- 
corded, the  emboli  originating  from  the  heart. 

(ii.)  Thrombus  of  the  mesenteric  veins.  The 
perfect  stasis  induced  by  this  cause  is  of  very 
rare  occurrence,  but  it  has  been  seen  to  fol- 
low invasion  of  the  portal  vein  by  malignant 
disease. 

(iii.)  Local  constrictions  of  the  bowel.  This 
is  by  far  the  commonest  cause  of  gangrene,  and 
is  the  probable  sequence  of  an  invagination  or 
ileus.  In  these  states  the  vessels  are  pressed 
upon  by  the  altered  position  of  the  gut,  which, 
with  the  continuously  increasing  pressure  of  the 
oedema  that  follows  the  venous  obstruction,  leads 
to  complete  stasis. 

(iv.)  The  more  gradual  obstruction  to  the 
blood-flow,  from  constriction  of  the  vessels  by 
diseases  of  their  walls,  leads  to  sloughing,  which 
frequently  tends  to  occur  in  albuminoid  disease 
of  the  intestines. 

(v.)  Sloughing  also  occurs  as  a sequence  of  the 
inflammatory  state,  when  the  process  is  of  such 
intensity  that  complete  cessation  of  the  circu- 
lation takes  place  in  localised  spots,  usually 
affecting  the  mucous  membrane  only,  though 
occasionally  penetrating  deeper,  ulcers  remaining 
after  separation  of  the  sloughs. 

Anatomical  Characters. — From  the  nature 
of  the  constructive  tissues  of  the  intestine,  the- 
gangrene  which  is  met  with  is  of  the  moist 
variety.  The  portion  of  bowel  which  is  affected 
is  at  first  of  an  intense  red  colour,  gradually 
increasing,  and  becoming  purple,  even  to  black. 
The  extreme  congestion  of  the  vessels  leads  to 
effusion  of  blood  into  the  tissues,  which,  however, 
are  uniformly  coloured ; decomposition  rapidly 
takes  place  in  the  stagnant  blood,  and  the  pro- 
ducts acted  on  by  the  sulphuretted  hydrogen  of 
the  intestines  become  black,  all  traces  of  red 
colour  being  soon  lost.  Meanwhile  the  mucous 
membrane  and  muscular  coats  are  swollen  and 
soddened  by  the  serum  and  blood  with  which 
they  are  infiltrated,  and  a dark-black  to  ash- 


grey,  soft,  pulpy  mass  is  finally  thrown  off  from 
the  healthy  tissue. 

The  extent  of  substance  which  may  under"o 
this  necrosis  and  be  separated  is  extremely 
variable,  from  a mere  slough  of  half  an  inch  in 
diameter  or  smaller,  to  portions  of  bowel  several 
feet  in  length.  Dr.  Peacock  records  a case  where 
12  feet  were  passed  in  eight  portions  during  a 
period  of  three  years. 

Symptoms.  — The  occurrence  of  symptoms 
whereby  mortification  of  the  bowels  can  le  diag- 
nosed is  not  to  be  expected.  The  signs  resolve 
themselves  into  those  of  the  existing  inflamma- 
tory state.  It  is  not  until  the  sphacelus  has  been 
passed,  or  that  signs  of  ulceration  are  manifest, 
that  the  existence  of  gangrene  can  be  ascer- 
tained. A very  few  hours  suffice  to  produce  this 
condition  when  once  the  causo  is  established,  and 
it  cannot  be  either  arrested  or  cured;  the  sepa- 
ration of  the  slough  is  to  be  desired,  though 
fatal  haemorrhage  may  be  associated  with  this 
process.  The  circumstances  of  this  state  pre- 
clude any  treatment  being  specially  directed  to- 
wards it. 

8.  Intestines,  Haemorrhage  from. — An  es- 
cape of  blood  from  the  intestines  is  a sign  of 
certain  morbid  conditions  rather  than  an  actual 
disease  itself,  hence  the  cause  of  the  haemorrhage 
must  be  sought  for. 

./Etiology. — The  causes  of  intestinal  haemor- 
rhage may  be  thus  indicated  : — 
o.  Increased  blood-pressure. 

Intense  hyperaemia  or  extreme  congestion. 
/3.  Affections  of  the  intestinal  walls. 

1.  Injuries  of  the  bowels. 

2.  Ulceration. 

3.  Vascular  growths,  haemorrhoids. 

4.  Amyloid  disease  of  the  walls. 
y.  Primarily  altered  blood-states — 

1.  Purpura  haemorrhagica. 

2.  Leucoeythaemia. 

3.  Yellow  fever  and  severe  intermittent 

fever. 

8.  Occasional  causes— 

Kupture  of  aneurism  into  intestine. 

Vicarious  menstruation. 

The  mere  enumeration  of  the  causes  must  here 
suffice.  It  is  obvious  that  the  relative  frequency 
of  these  conditions  differs  considerably,  and  in 
many  cases  the  cause  is  at  once  apparent,  whilst 
occasionally  the  source  of  the  blood  may  be  more 
obscure.  It  would  seem  from  statistics  that  in- 
testinal hsemorrhage  is  of  more  frequent  occur- 
rence in  males,  as  gastric  haemorrhage  is  more 
common  in  -women ; the  latter  fact  being  ex- 
plained by  the  greater  liability  of  females  to 
ulcer  of  the  stomach,  as  the  former  appears  to  he 
by  the  preponderance  of  males  suffering  from  the 
determining  causes  of  haemorrhage,  and  not  that 
the  sex  per  sc  predisposes  to  such  a result. 
Symptoms. — Associated  with  the  symptoms 
special  to  the  loss  of  blood,  and  which  are  in  the 
main  similar  to  bleeding  from  any  other  organ, 
there  are  the  signs  and  symptoms  of  the  causal 
disease.  The  extent  of  the  haemorrhage  will 
necessarily  largely  determine  the  symptoms,  many 
bleedings  being  so  trivial  as  to  give  rise  to  no 
appreciable  effects,  and  in  extreme  cases  the  loss 
being  so  great  and  sudden  as  to  lead  to  rapid 


INTESTINES,  DISEASES  OF. 


collapse  and  death.  Between  these  extremes  all 
degrees  of  anaemia,  faintness,  pallor,  giddiness, 
and.  failing  pulse  may  be  observed.  A sensation 
as  of  a warm  fluid  flowing  into  the  abdomen  is 
occasionally  complained  of,  but  otherwise  haemor- 
rhage in  this  situation  is  possessed  of  no  charac- 
teristic feature.  The  occurrence  of  the  above- 
mentioned  indications  in  the  course  of  a disease 
liable  to  lead  to  this  condition,  would  point  to 
hc'emorrhage,  especially  if  there  be  a fall  in  tem- 
perature from  a previous  pyrexial  state. 

Occasionally  the  escape  of  blood  is  beneficial. 
This  is  particularly  the  case  where  the  cause  is  a 
congestion  of  the  intestinal  tract,  with  or  without 
haemorrhoids.  Thereby  the  fulness  of  the  bowels 
is  relieved,  and  a more  equable  circulation  is 
established.  In  some  cases  ot  typhoid  fever, 
contrary  to  what  might  be  supposed,  improvement 
has  been  noticed  to  follow  a moderate  loss  of 
blood.  (Trousseau.) 

Except  in  such  cases  as  when  the  effusion  of 
blood  is  so  excessive  that  death  takes  place  be- 
fore any  escapes  from  the  bowel,  intestinal 
haemorrhage  reveals  itself  sooner  dr  later  in  the 
character  of  the  evacuations.  Unless  the  cause 
be  such  as  an  ulceration  immediately  within  the 
anus,  or  that  the  blood  be  sufficient  in  amount  to 
escape  alteration,  when  the  bright  red  colour  is 
retained,  the  fluid  is  always  altered  in  appearance. 
The  haematin  is  readily  affected  by  the  sulphur- 
etted hydrogen  in  the  canal,  and  converted  into  a 
blackened  material,  sulphide  of  iron  being  formed, 
which  stains  the  feces ; or  a black  tarry  substance 
is  evacuated,  being  the  altered  clotted  blood 
(see  Melina).  As  a rule,  when  the  blood  has 
undergone  this  change,  the  source  of  it  is  in  the 
small  intestine  ; blood  from  the  colon — where  it 
is  usually  due  to  ulceration — being  passed  ad- 
herent to  the  feces.  The  height  of  the  source,  and 
the  duration  of  its  stay  in  the  canal,  largely  de- 
termine the  extent  of  alteration  in  the  effusion. 

Diagnosis. — The  history  of  the  case  ; the  con- 
dition of  the  patient ; and  the  character  of  the 
oided  blood,  are  the  points  upon  which  a dia- 
rnosis  of  the  cause  of  intestiual  haemorrhage  is 
o be  based. 

Prognosis. — The  amount  of  blood  evacuated 
■5  not  a sure  guide  to  forming  an  opinion  of  the 
asult.  It  is  difficult  to  estimate  the  actual 
uantity  lost,  since  much  may  be  retained  in  the 
owel.  The  general  condition  of  the  patient, 
specially  the  state  of  the  pulse,  is  of  far  more 
nportance  ; whilst  allowance  must  he  made  for 
ae  nature  of  the  cause,  not  forgetting  the  oeca- 
onal  favourable  import  of  a flux. 

Treatment. — In  a certain  number  of  cases 
'ceding  from  the  bowel  is  quite  uncontrollable  ; 
others  it  is  capable  of  cure  ; whilst  in  a third 
■oup  it  is  rather  to  be  encouraged.  When  arrest 
the  htemorrhage  is  desired,  rest,  both  general 
‘id  local,  is  essential ; the  patient  should  be  kept 
the  recumbent  position,  as  thereby  the  liability 
syncope  is  averted ; and  the  canal  is  to  be  kept 
jijet  by  abstinence  from  food,  and  the  use  of 
ium,  to  prevent  peristalsis. 

The  active  treatment  is  to  be  directed  to  with- 
jawing  the  blood  as  much  as  possible  from  the 
ectedregion,  by  means  of  heat,  sinapisms,  dry- 
oping,  &c.,  to  other  parts  of  the  body  ; and  to 
) application  of  styptics  to  the  bleeding  surfaces, 
48 


or  the  administration  of  such  remedies  as  arrest 
bleeding  after  their  absorption  into  the  blood. 
Among  the  agents  which,  administered  by  the 
mouth  or  rectum,  act  locally,  may  be  mentioned 
turpentine  in  30  to  GO  minim  doses,  with  two  or 
three  ounces  of  starch  as  an  enema.  Injections 
of  equal  parts  of  tincture  of  perchloride  of  iron 
and  water  may  be  given ; or  acetate  of  lead  in 
combination  with  opium.  Tannic  acid  and  the 
vegetable  astringents  are  usually  too  slow  in 
their  effects  to  be  of  much  avail.  Probably  the 
most  effective  remedy  is  ergotin,  administered 
subcutaneously  in  2-grain  doses  dissolved  in  gly- 
cerine, and  repeated  if  necessary.  This  acts  not 
only  by  constricting  the  vessels,  but  by  dimi- 
nishing the  blood-pressure.  Bi  tartrate  of  potash 
in  doses  of  two  drachms,  and  the  local  applica- 
tion of  a saturated  solution  of  perchloride  of  iron 
in  glycerine,  are  of  great  benefit  in  arresting  the 
bleeding  of  piles;  for  wliich  purpose  also,  as  well 
as  for  vicarious  hemorrhage  from  the  lower 
bowel,  the  writer  has  found  frequently  repeated 
doses  (.n\v.  to  viii.)  of  tincture  of  hamamelis  of 
much  advantage. 

When  the  haemorrhage  is  d stinetly  the  result 
of  engorged  vessels,  its  occurrence  should  not  be 
checked,  provided  it  be  not  excessive.  Sulphate 
of  magnesia  in  full  doses,  with  a few  minims  of 
dilute  sulphuric  acid,  is  then  of  great  service  ; 
by  determining  an  effusion  of  the  watery  part  of 
the  blood,  the  congestion  is  relieved  and  the 
htemorrhage  is  arrested,  the  patient  meanwhile 
refraining  as  far  as  possible  from  taking  fluids. 

The  giving  of  stimulants  is  a procedure  that 
involves  careful  judgment.  Whilst  undoubtedly 
the  tendency  of  loss  of  blood  is  to  produce  death 
by  .syncope,  it  is  also  true  that  faintness  itself 
favours  the  cessation  of  the  bleeding,  and,  so  far 
as  a general  direction  can  he  given,  stimulants 
should  be  avoided,  unless  there  be  reason  to  fear, 
from  the  condition  of  the  patient,  character  of  the 
pulse,  &c.,  that  the  syncope  is  excessive.  Short 
of  that,  alcohol,  by  temporarily  increasing  the 
heart’s  power,  increases  the  bleeding. 

Transfusion  of  blood,  when  practicable,  should 
be  resorted  to  in  extreme  cases. 

9.  Intestines,  Hyperasmia  and  Congestion 
of. — The  former  term  is  here  applied  to  those 
conditions  of  vascular  engorgement  where  the 
excess  of  blood  is,  primarily  at  least,  on  the  ar- 
terial side  of  the  capillaries  (active  congestion, 
fluxion,  determination  of  blood);  whilst  the  latter 
term  is  restricted  to  cases  where  the  fulness  is 
caused  by  some  obstruction  to  the  venous  flow 
(passive  congestion).  Doubtless  cither  of  these 
conditions  may  lead  to  the  establishment  of  the 
other,  hut  it  is  desirable  to  consider  them  sepa- 
rately, not  so  much  for  the  difference  in  the 
causes  producing  them,  as  for  the  great  differ- 
ence in  their  results. 

It  should  be  remembered  that  even  within  the 
limits  of  health  a considerable  variation  is  met 
with  in  the  degree  of  vascularity  of  the  alimen- 
tary canal.  The  fluctuating  periods  of  rest  and 
activity  undergone  by  the  tube  are  associated  of 
necessity  with  alternations  of  comparative  hyper- 
semia  and  ansemia,  as  during  the  digestion  of  a 
meal  or  during  fasting.  It  is  impossible,  there- 
fore, to  draw  any  line  beyond  which  the  vascu 


INTESTINES,  DISEASES  OF. 


T54 

lar  fulness  can  be  said  to  be  abnormal ; as  it  is 
equally  impossible  to  say  exactly  where  hyper- 
aemia and  normal  gland-change  end,  and  catarrh 
begins. 

Anatomical  Characters. — The  appearances 
seen  post  mortem  are  far  from  being  always  in- 
dicative of  what  existed  during  life.  For  an  ex- 
treme arterial  fulness  may  completely  disappear 
after  death,  from  contraction  of  the  vessels ; 
whilst  venous  engorgement  more  or  less  com- 
pletely remains. 

^Etiology. — The  causes  of  intestinal  hyperse- 
mia  are  as  follows : — (a)  Mechanical  and  chemical 
irritants,  foreign  bodies,  and  poisonous  drugs. 
Spices  and  highly  seasoned  food,  and  alcohol  ; 
any  substance,  in  fact,  which  may  be  swallowed, 
and  at  all  exceeds  the  blandest  nature,  may  bring 
about  an  abnormal  degree  of  hyperaemia  of  the 
whole  or  part  of  the  canal.  These  causes  act 
locally  and  directly  upon  the  vessels. 

(/3)  Vnso-motor  paralysis  of  tho  splanchnic 
area.  If  from  any  cause  the  normal  tone  of  the 
mesenteric  vessels  is  diminished,  by  inhibition 
or  removal  of  the  tonic  influence  excited  by  the 
sympathetic,  tho  vessels  dilate  and  hyperaemia 
ensues.  It  isin  this  way  that  diarrhoea  following 
certain  emotional  states  is  to  he  explained.  Tho 
intimate  relation  which  has  been  shown  experi- 
mentally to  exist  between  the  splanchnic  nerves 
and  the  vaso  motor  system  generally,  but  especi- 
ally with  the  cardiac  innervation  by  means  of  the 
‘depressor  nerve,’  whereby  any  considerable  peri- 
pheral resistance  in  the  systemic  capillary  area 
which  impedes  tho  action  of  the  heart  is  com- 
pensated for  by  a dilatation  of  the  mesenteric 
vessels,  renders  it  probable  that  an  undue  hy- 
peraemia of  the  intestines  is  of  very  frequent 
occurrence. 

(7)  Collateral  hyperaemia,  or  the  fulness  of 
tho  vessels  of  one  region  caused  by  contraction  of 
the  vessels  of  another,  as  in  the  shrinking  of  tho 
cutaneous  vessels  from  cold,  extensive  burns,  &e. 
In  such  cases  the  blood,  remaining  constant  in 
amount,  must  distend  other  vessels : and  those  of 
tho  abdominal  viscera,  including  the  intestines, 
are  peculiarly  liable  to  become  engorged,  as  ex- 
plained by  what  may  be  called  their  compen- 
sating paralysis. 

The  causes  of  passive  congestion  are  the  fol- 
lowing':— (a)  A general  congestion  of  the  entire 
intestinal  tract  will  bo  produced  by  any  of  those 
causes  which  lead  to  universal  congestion  of  the 
tissues,  as  dilatation  of  the  right  heart  from  lung- 
disease.  Pressure  by  tumours  or  othor  conditions 
on  the  inferior  vena  cava  above  the  liver,  or  on 
the  portal  vein,  will  bring  about  the  same  result. 
So  also  will  any  obstruction  to  the  portal  circula- 
tion in  the  liver.  This  is  by  far  the  commonest 
cause  of  intestinal  congestion,  since  cirrhosis 
of  tho  liver,  however  produced,  directly  tends 
to  it. 

(A)  A congestion  of  a portion  of  the  tube 
occurs  when  any  obstruction  exists  to  the  venous 
flow  of  that  part,  as  is  marked  in  cases  of  in- 
vagination and  strangulation  of  the  bowel.  The 
rarer  conditions  of  embolism  of  branches  of  the 
mesenteric  arteries,  or  thrombosis  of  the  veins, 
will  induce  intense  congestion.  This  state  also 
forma  a part  of  the  vascular  changes  undergone 
by  any  inflamed  part. 


Symptoms  and  Effects.  — These  conditions 
may  of  themselves  give  no  evidence  of  their  ex- 
istence. But  tho  following  results  may  ensue: 

From  hyperaemia,  an  increased  secretion  of 
mucus  and  other  intestinal  fluids,  often  more 
watery  than  normal,  which  with  an  increased 
peristalsis,  induced  by  the  same  irritant  that  led 
to  hyperaemia,  produces  a diarrhoea.  Provided 
this  over-functional  activity  be  limited  to  the 
production  of  the  normal  secretions  of  the  part, 
and  increased  healthy  action  only,  the  condition  of 
hyperaemia  is  not  exceeded ; hut.  the  passage  into 
catarrh  is  easy,  and  persistently  sustained  ar- 
terial fulness  will  sooner  or  later  pass  into  that 
state. 

The  increased  blood-pressure  maybe  sufficient 
to  induce  diapedcsis  of  the  red  corpuscles,  or 
rupture  of  the  capillaries,  leading  to  capillary 
haemorrhage,  submucous  petechia-,  &c. 

As  regards  congestion,  the  more  complete  the 
obstruction  to  the  flow,  the  greater  vail  he  the 
pressure  in  the  veins,  whose  thin  walls  favour 
the  transudation  of  the  serous  part  of  the  blood, 
and  so  produce  an  oedema  of  the  mucous  mem- 
brane and  entire  thickness  of  the  bowel,  with  a 
transudation  onhoth  surfaces,  into  the  canal  itself 
and  info  the  peritoneal  cavity,  the  latter  being 
more  marked.  The  fluid  ethision  in  this  ease 
is  dependent  entirely  on  mechanical  conditions, 
whilst  the  flow  in  hyperaemia  is  mainly  the  result 
of  increased  secreting  activity.  Ibemorrhago 
from  rupture  of  the  smaller  vessels  is  of  frequent 
occurrence,  and  may  ho  very  considerable. 

A prolonged  stateof  congestion — and  asa  rule 
the  cause  is  such  as  to  determine  a permanent 
state — leads  to  certain  structural  alterations  in 
the  tissues  of  the  bowel,  from  the  imperfect 
nutrition  that  a chronic  venous  fulness  permits 
of.  The  nature  of  the  change  is  chiefly  the  infil- 
tration of  tho  mucous  and  submucous  coats  with 
an  imperfectly  formed  connective  tissue,  which 
causes  a thickening  and  toughness  of  the  bowels, 
almost  identical  with  the  results  of  chronic  in- 
flammation. 

Treatment. — It  is  seldom  that  these  con- 
ditions are  such  as  call  for  treatment.  The 
hyperaemia  is  usually  of  a transient  nature;  and 
the  cause  of  congestion  is  generally  irremovable. 
Aperients,  such  as  jalap,  gamboge.  &c..  are  some- 
times beneficial,  by  inducing  watery  evacuations 
and  so  relieving  the  vessels,  but  they  demand 
constant  repetition. 

The  treatment  of  haemorrhage  has  been  con- 
sidered ; but  this  and  diarrhoea,  when  due  to 
congestion,  are,  unless  excessive,  often  benefi 
cial,  and  are  not  to  he  checked. 

10.  Intestines,  Hypertrophy  of. — This  is 
always  of  local  occurrence,  a general  hypertrophy, 
involving  the  entire  length  of  the  bowel,  being 
practically  unknown. 

In  chronic  enteritis  the  mucous,  submucous, 
and  even  muscular  coats  are  apt  to  become' much 
thickened,  and  though  this  is  partly  due  to  an 
excessive  formation  of  connective  tissue,  there 
is  also  some  actual  hyperplasia  of  the  normal 
textures. 

In  portions  of  the  intestines  above  an  1 bstruc- 
tion.  a true  hypertrophy  of  the  gut,  parthulsrly 
of  the  muscular  layers,  is  to  be  found  ; uu*..  as 


INTESTINES.  DISEASES  OF.  756 


already  said,  this  is  usually  associated  with  dila- 
tatiou  of  the  tube. 

It  is  rare  for  this  condition  to  he  other  than 
inferred  during  life ; it  gives  rise  to  no  symptoms 
and  calls  for  no  treatment ; and  when  established 
is  rather  of  the  nature  of  a compensatory  lesion. 

11.  Intestines,  Inflammation  of.—  Synon.  : 
Enteritis ; Fr.  Enter  it e ; Ger.  Darmentzundung. 

Under  this  term  are  included  all  those  struc- 
tural changes  in  the  mucous  membrane  of  the 
intestinal  tract  which  primarily  follow  the  ap- 
plication of  an  abnormal  irritant,  provided  that 
the  irritant  be  not  of  sufficient  intensity  to  pro- 
duce absolute  destruction  of  tissue.  Such  changes 
will  involve  more  or  less  all  the  tissue-elements 
of  the  mucous  membrane,  and  may  extend  to  the 
muscular,  or  even  the  peritoneal  coat.  They  are 
essentially  characterised  by  productive,  coinci- 
dent with  destructive  features,  the  former  leading 
to  the  formation  of  new  material,  as  pus  or  con- 
nective tissue,  the  latter  to  ulceration  or  gangrene. 
The  inflammatory  process  may  present  consider- 
able variety  in  type.  The  simplest  form,  to 
which  the  term  ‘ catarrh  ’ may  be  applied,  passes, 
by  almost  insensible  gradations,  from  the  tissue- 
changes  met  with  in  the  course  of  normal  diges- 
tion, to  a distinct  condition  of  disease.  Or  it 
may  be  that,  superadded  to  the  above-named 
, characters  of  inflammation,  are  certain  specifle 
. characters  due  either  to  the  nature  of  the  cause, 
or  to  t he  predisposition  of  the  tissue  affected, 
or  to  both,  which  determine  the  conditions  known 
ifts  diphtheritic,  phlegmonous,  dysenteric,  &c. 

There  are  thus  differences  in  the  severity 
with  which  enteritis  may  occur,  both  as  regards 
the  extent  of  departure  from  normal  structure, 
,and  in  respect  to  the  symptoms  which  arise. 
But  in  all  cases  the  essential  characters  of  in- 
flammation are  present,  which  may  be  regarded 
as  the  results  of  the  irritant,  phis  the  efforts 
at  repair  on  the  part  of  the  affected  tissue. 

The  morbid  process  may  affect  the  intestine 
throughout  ils  entire  length,  either  in  common 
with  or  independently  of  the  stomach — general 
enteritis ; or  it  may  be  distinctly  limited  to  cer- 
tain parts  of  the  canal — local  enteritis,  including 
duodenitis,  ileitis,  typhlitis,  colitis,  proctitis.  As 
i rule  the  term  enteritis  is  restricted  to  inflam- 
mation of  the  small  intestines. 

In  respect  to  duration  and  intensity,  enteritis 
nay  be  acute  or  chronic. 

(4)  Acute  Enteritis.  — Acute  enteritis  is 
lometimes  culled  gastric  remittent,  or  infantile 
;emittcnt  fever — terms  it  is  advisable  to  discard 
ntirely,  since  they  are  frequently  applied  to 
ery  different  diseases.  Acute  enteritis  is  meant 
r include  all  those  cases  where  the  essential  fea- 
i.ires  of  an  inflammation  are  present,  varying  in 
^verity  from  a simple  catarrh  or  muco-enteritis, 
p those  severer  forms  possessed  of  special  fea- 
iires,  such  as  phlegmonous  or  diphtheritic.  The 
tore  severe  cases,  especially  in  children,  are 
imetimes  called  simple  or  English  cholera,  or 
flora  infantum. 

AStioi.ooy. — It  is  doubtful  whether  an  idio- 
ithic  enteritis  is  ever  met  with;  some  cause  is 
'nerally  to  be  found. 

1 Predisposing  causes. — (a)  The  exposed  situa- 
m of  the  intestinal  tract  to  irritating  sub- 


stances swallowed,  causes  this  disease  to  be  one 
of  frequent  occurrence. 

(/3)  The  structure  of  the  intestinal  mucous 
membrane,  with  its  delicate  and  susceptible  epi- 
thelial cells,  and  slightly  protected  blood-capil- 
laries, favours  the  occurrence  of  those  changes 
which  constitute  inflammation. 

(y)  Age  especially7  predisposes  to  enteritis.  Foi 
although  itmay  occur  at  any  period  of  life,  infante 
and  children  during  the  period  of  dentition  are 
peculiarly  susceptible.  A moderate  intestinal 
catarrh  may  almost  be  regarded  as  a normal  ac- 
companiment of  dentition,  like  to  the  increased 
activity  of  the  salivary  and  other  glands  at  that 
period.  From  the  moderate  it  may  easily  pass 
into  the  serious  or  even  fatal  degree. 

(5)  The  season  of  the  year  appears  to  exercise 
an  influence,  for  during  the  summer  this  disease 
is  certainly  much  more  frequent;  and  particularly 
so  when  there  is  extreme  difference  between  day 
and  night  temperatures,  or  when  the  heat  is  as- 
sociated with  much  moisture. 

(e)  Occasionally  this  malady  would  appear  to 
be  epidemic. 

Exciting  causes. — These,  whatever  their  nature, 
would  appear  to  act  by  inducing  a hyperaemia  of 
the  tissues,  which  thence  pass  into  a state  of  in- 
flammation. 

1.  Irritating  ingesta  of  the  most  varied  kind, 
such  as  abnormal,  ilL-cooked,  or  improperly  di- 
gested food,  and  irritant  drugs  or  poisons,  often 
cause  enteritis.  Of  these,  improper  food  is  by 
far  the  most  common,  especially  during  the  first 
year  of  life.  Cow’s  milk  alone  may  be  at  that 
time  sufficient  to  produce  it,  and  it  is  rare  for 
infants  to  escape  an  attack.  An  excessive  flow 
of  bile  into  the  intestine  is  an  occasional  cause. 

i.  Exposure  to  cold  may  be  followed  by  in- 
flammation of  the  intestines,  as  it  may  be  by 
inflammation  of  the  lungs,  kidneys,  or  pleura; 
the  factor  which  determines  the  particular  organ 
involved  is  unknown.  There  would  seem  to  be 
some  other  factor  than  the  mere  determination  to 
the  viscera  of  an  excess  of  cooled  blood  from  the 
contracted  cutaneous  capillaries,  which  probably 
affects  the  nutrition  of  the  tissue-elements  via 
the  nervous  system. 

The  occurrence  of  inflammation  and  ulceration 
of  the  duodenum  which  follows  extensive  super- 
ficial burns,  cannot  bo  altogether  explained  by 
the  hyperaemia  of  the  intestines,  which  is  said  to 
follow  the  superficial  injury. 

3.  Wounds,  new-growths,  and  the  mechanical 
results  of  intussusception,  hernia,  impaction  of 
faeces,  gall-stones,  parasites,  and  other  condi- 
tions, will  lead  to  enteritis. 

4.  Inflammation  of  neighbouring  parts  may 
involve  the  intestines  by  extension,  as  from  the 
stomach,  peritoneum,  or  bile-ducts. 

5.  The  specifle  poison  of  diphtheria  not  in- 
frequently leads  to  enteritis  of  a characteristic 
nature.  An  inflammatory  state  of  the  intes- 
tinal mucous  membrane  is  said  to  accompany  or 
follow  the  exanthemata,  and  more  especially 
s< arlet  fever;  and  it  sometimes  complicates  sep- 
ticaemia, particularly  when  this  is  of  puerperal 
origin.  In  such  cases  the  disease  would  seem  to 
be  set  up,  at  least  sometimes,  by  extension  from 
the  uterus  along  the  peritoneum. 

Anatomical  Cuabacters. — It  probably  novel 


INTESTINES,  DISEASES  OF. 


f56 

occurs  that  the  whole  length  of  intestine  is  the 
seat  of  inflammation,  and  it  is  not  often  that 
even  the  entire  small  intestine  is  so  affected.  It  is 
far  more  frequent  to  find  certain  tracts,  of  a 
few  inches  or  a few  feet,  involved.  Speaking 
generally,  the  colon,  caecum,  rectum,  duodenum, 
ileum,  and  jejunum  are  affected,  as  regards  fre- 
quency, in  that  order.  In  some  situations  special 
features  are  present,  but  the  essential  characters 
of  inflammation  always  exist,  whatever  be  the 
site. 

Owing  to  the  physical  properties  of  the  in- 
testinal tissues,  tlie  appearances  seen  after  death 
by  no  means  necessarily  correspond  to  what 
actually  exists  during  life.  Thus,  the  hyper- 
cemic  state  of  the  mucous  membrane,  with  the 
increased  redness,  varying  from  a more  intense 
pink  than  normal  up  to  a deep  dark  red,  may 
leave  but  a trace  ‘post  mortem , the  vessels 
having  become  considerably  emptied  from  the 
constriction  of  the  vessels  in  rigor  mortis.  An 
increased  vascularity,  however,  is  one  of  the  im- 
portant features  of  the  state  under  consider- 
ation, and  it  may  sometimes  be  so  intense  as  to 
lead  to  capillary  rupture  and  formation  of  pe- 
techise  in  the  mucous  membrane.  The  tissue- 
elements  of  the  gut,  as  a result  of  the  irritant 
causing  the  inflammation,  and  with  the  accom- 
paniment of  an  increased  vascular  supply,  under- 
go changes  in  their  appearance  and  behaviour. 
Thus  the  epithelial  cells  are  in  a state  of  cloudy 
swelling  and  increased  activity  in  multiplica- 
tion, each  successive  progeny  approaching  nearer 
and  nearer  to  the  embryonic  type ; the  connec- 
tive-tissue elements  are  similarly  affected,  and 
leucocytes  transude  into  the  tissues  from  the 
vessels.  These  new-formed  cells  constitute  pus- 
corpuseles,  which  are  thrown  off  from  the  surface 
of  the  mucous  membrane,  and  crowd  to  a vari- 
able depth  the  tissues  of  the  different  coats.  If 
the  primary  irritant  to  the  inflammation  be  of  a 
specific  character,  such  as  the  poison  of  diphthe- 
ria, or  of  an  extremely  severe  nature,  such  as  an 
intussusception  or  hernia,  then  the  new'-formed 
cells  become  entangled  in  a fibrinous  coagulable 
exudation  from  the  blood,  and  form  patches  of 
membrane  more  or  less  adherent  to  the  surface 
of  the  bowel,  depending  on  the  depth  of  tissue 
involved.  In  all  cases  there  is  some  cedema  of 
the  intestinal  walls  from  serous  effusion,  and  the 
free  surface  of  the  membrane  is  covered  with  a 
glairy  mucus,  containing  pus-cells,  and  frequently 
crystals  of  triple  phosphates. 

The  epithelium  of  the  follicles  of  Lieberkiihn 
becomes  extremely  granular,  and  proliferates 
extensively,  with  the  frequent  result  of  blocking 
up  the  lumen  of  the  gland,  which  thus  becomes 
very  prominent.  The  solitary  and  agminated 
glands  are  invariably  much  swollen,  and  very 
often  the  process  of  inflammation  is  most  in- 
tense in  their  vicinity.  Occasionally  the  mesen- 
teric glands  are  similarly  affected. 

How  this  inflammation  may  terminate  very 
much  depends  on  the  course  ; it  may  subside,  and 
the  bowel  gradually  assume  its  normal  characters 
with  no  impairment  of  function  ; it  may  lapse 
into  a chronic  state;  or  it  may  pass  on  into 
ulceration,  or  even  sloughing  and  gangrene. 

To  these  various  degrees  of  the  inflammatory 
state  different  terms  have  been  applied  in  no 


very  definite  way.  Thus,  when  the  mucous 
membrane  alone  is  affected,  a catarrh  or  muco- 
enteritis  is  said  to  exist ; whilst  the  severer  form, 
affecting  all  the  coats,  and  attended  with  sup- 
puration, such  as  occurs  in  the  neighbourhood 
of  an  intussusception,  is  known  as  phlegmonous. 
When  a membranous  exudation  is  found  in  asso- 
ciation with  diphtheria,  we  have  a true  diph- 
theritic enteritis ; and  the  expression  pellicular 
may  be  more  fitly  applied  to  those  cases  where 
a similar  membrane  is  formed,  though  not  in 
connection  with  the  diphtheria  poison.  Such  a 
state  is  of  not  infrequent  occurrence  on  the 
prominent  edges  of  the  valvul®  conniventes,  and 
still  oftener  of  the  saccules  of  the  colon,  due 
to  the  presence  of  hardened  faeces  or  impacted 
calculi.  Both  these  latter  forms  are  invariably 
associated  with  ulceration.  The  term  dysenteric 
is  very  indifferently  applied  to  more  than  one 
form  of  enteritis  or  colitis : the  writer  thinks  it 
better  limited  to  that  form  of  inflammation  due 
to  the  specific  poison  of  dysentery,  although  the 
morbid  appearances  of  such  cases  are  almost  or 
quite  identical  with  some  of  the  varieties  enume- 
rated above,  the  differences  in  the  cases  being 
dependent  on  their  clinical  history. 

An  enteritis  associated  with  aphthae  is  of 
common  occurrence  in  children. 

Symptoms. — That  a considerable  variation  is 
met  with  in  the  kind  and  severity  of  the  symp- 
toms presented  in  cases  of  enteritis,  is  only  to  be 
expected  when  the  great  difference  in  degree  and 
extent  of  morbid  change  that  is  met  with  is  re- 
membered. “Whilst  the  pathological  changes  that 
take  place  in  a limited  part  of  the  canal  are  iden- 
tical with  those  that  may  be  found  in  another,  to 
a very  large  extent  the  symptoms  that  arise  in  the 
two  cases  may  be  widely'  different.  For  whereas 
one  patient  may  suffer  from  an  attack  of  intes- 
tinal catarrh,  with  but  a trifling  array  of  symp- 
toms, another  may  succumb  within  a few  days. 
There  is  no  one  symptom  or  even  group  of 
symptoms  that  is  absolutely'  characteristic  of 
the  disease ; even  the  general  condition  of  the 
patient  is  not  constant.  In  the  milder  forms  of 
intestinal  catarrh  there  may  be  slight  pyrexia 
with  thirst  and  quickened  pulse,  but  these  symp- 
toms may'  bo  scarcely  noticeable  ; while,  on  tha 
other  hand,  in  the  severe  phlegmonous  enteritis 
they  are  extreme,  and  the  patient  is  in  a stats 
of  considerable  prostration.  I 

The  following  symptoms,  more  or  less  marked 
occur  in  different  cases.  ; 

Stools.— Diarrhoea  is  in  some  respects  th 
most  constant  symptom,  though,  when  the  affec 
tion  is  limited  to  the  higher  part  of  the  cam 
and  space  is  given  for  the  reabsorption  of  th 
excessive  exudation,  it  may'  not  only  be  wantin; 
but  there  may  be  actual  constipation.  The  lowi 
down  the  gut  is  inflamed,  the  greater  theliab 
lity  to  diarrhoea,  which  hence  becomes  a markf 
character  of  colitis  and  proctitis.  In  the  seve 
forms  of  the  affection  a more  or  less  comple 
constipation  may  be  due  to  the  paralysis  of  t 
inflamed  bowel,  arresting  the  peristalsis,  a 
allowing  of  the  accumulation  of  the  intestir 
contents  above  the  lesion ; this  is  obviou: 
more  complete  when  the  enteritis  is  associate 
with  any  state  producing  mechanical  obstructi 
such  as  intussusception,  or  ileus. 


INTESTINES.  DISEASES  OF.  757 


The  character  of  the  evacuations  is  very  vari- 
able. As  a rule  they  are  semi-fluid  when  diar- 
rhoea exists ; or  they  may  consist  chiefly  of  a 
liquid  with  a few  feculent  flakes  ; but,  when  time 
has  permitted  a partial  re-absorption  of  the  fluid 
part,  the  stools  become  more  consistent,  and  in 
cases  of  enteritis  which  are  chiefly  duo  to  faecal 
accumulation,  solid,  hard  masses  are  passed. 

Mucus,  in  greater  or  less  quantity,  is  con- 
stantly present — being  especially  abundant  in 
affections  of  the  large  intestine  and  rectum,  when 
it  is  often  discharged  as  complete  tubular  casts 
of  the  bowel. 

Flood  is  not  usual  except  in  proctitis,  or  un- 
less there  be  ulceration  or  haemorrhoids;  and 
pus  is  seldom  noticed  unless  the  rectum  be  in- 
flamed. 

Owing  to  the  imperfect  performance  of  diges- 
tion or  absorption,  the  motions  are  liable  to  con- 
tain many  abnormal  constituents — as  fat,  when 
the  duodenum  and  upper  part  of  the  jejunum  are 
involved,  or  even  masses  of  food  scarcely  changed ; 
and  the  altered  character  of  the  intestinal  con- 
tents, with  the  products  of  decomposition,  are  in 
themselves  important  features  in  maintaining  a 
diarrhoea.  As  a rule,  the  discharges  are  paler 
than  normal,  or  may  be  even  colourless  ; the 
greenish  tint  so  often  seen  in  the  enteritis  of 
children  is  due  to  altered  bile  or  blood-pigment. 
The  odour  is  usually  extremely  offensive  or  even 
putrid;  though  sometimes,  when  the  evacuations 
vre  very  liquid  and  colourless,  smell  may  be  alto- 
gether absent. 

Owing  to  a large  production  of  gases,  discharges 
if  flatus  are  of  very  frequent  occurrence. 

Vomiting,  except  in  the  severe  forms,  is  not  a 
.:ommon  symptom  of  enteritis,  unless  the  stomach 
tie  involved.  In  phlegmonous  enteritis,  however, 
■omiting  may  be  persistent,  and  even  stercora- 
eous;  and  it  is  relatively  more  frequent  in  chil- 
ren  than  in  adults.  Short  of  actual  vomiting, 
nausea  is  frequently  complained  of. 

Pain  and  tenderness. — Pain  in  itself  is  a most 
neertain  symptom,  perhaps  being  scarcely  no- 
iceable  in  the  milder  forms  of  catarrh  ; whilst  in 
plitis,  the  colicky,  griping  pains,  which  may  or 
lay  not  be  relieved  by  pressure,  are  character- 
tic.  Still  more  is  this  the  case  when  the  rectum 
affected,  when  the  straining  and  tenesmus  con- 
itute  one  of  the  most  distressing  symptoms  of 
le  malady.  When  the  peritoneum  is  involved, 
lie  pain  and  tenderness  are  marked  and  charac- 
ristic.  Both  may  be  generally  diffused  over 
ue  abdomen,  or  may  be  local  in  character,  as  over 
.e  caecum  ; in  a large  number  of  cases  the  pain 
referred  to  the  umbilical  region. 

General  symptoms. — Among  the  more  general 
mptoms,  or  those  associated  with  inflammation 
special  regions,  are  the  phenomena  of  the  fe- 
i he  state  in  a more  or  less  marked  degree.  The 
aperature  may  reach  104°  F.,  or  even  higher; 

1 in  some  cases  it  may  be  scarcely  elevated.  The 
j petite  may  be  unaffected,  especially  if  the  upper 
jrt  of  the  tract  be  free  from  the  disease;  whilst 
hromay  be  complete  anorexia  when  the  reverse 
-he  case.  Thirst  is  of  usual  occurrence,  and  it 
homes  very  marked  when  the  evacuations  are 
i andant  and  fluid.  The  tongue  indicates  rather 
’ general  state  of  the  patient,  and  is  a less  re- 
ble  index  of  the  actual  state  of  the  intestinal 


mucous  membrane,  than  in  corresponding  affec- 
tions of  the  stomach.  It  may  be  red,  irritable, 
and  glazed ; or  coated  with  a thick  fur,  witn  the 
edges  and  papillae  bright  and  prominent ; in 
milder  cases  it  can  often  scarcely  be  said  to  be 
affected. 

The  character  of  the  pulse  varies  with  the 
general  state.  Provided  that  the  pyrexia  be 
extreme,  there  is  the  usual  dry  skin  and  con- 
centrated urine,  with  a tendency  towards  the 
production  of  the  typhoid  state,  which  usually  is 
reached  in  fatal  cases.  In  many  cases  the  pros- 
tration is  excessive,  though  the  mind  is  usually 
unaffected  to  the  end,  and  in  a large  number 
of  cases  there  is  a very  marked  irritability 
of  temper.  Notwithstanding  the  intimate  sym- 
pathy between  the  alimentary  tract  and  the  brain, 
headache  is  of  rare  occurrence  in  enteritis.  A 
persistent  hiccough,  presumably  of  nervous  origin, 
is  met  with  sometimes.  In  children  the  disease 
readily  leads  to  a condition  of  collapse.  The 
child  lies  in  a languid,  almost  torpid,  state  ; with 
the  skin  of  the  abdomen  intensely  hot  and  dry ; 
whilst  the  extremities  are  cold  and  blue,  the 
face  is  pinched,  and  the  body  generally  appears 
shrunken.  Frequently  this  state  is  interrupted 
by  attacks  of  convulsions,  especially  if  dentition 
be  in  progress.  The  child,  too,  is  usually  ex- 
tremely fretful,  and  maintains  an  almost  con- 
stant, short,  feeble  cry,  evidently  accompanied 
with  pain. 

When  the  disease  affects  the  duodenum,  jaun- 
dice, due  to  closure  of  the  bile-duct,  very  often 
occurs.  The  intimate  nervous  relation  between 
the  rectum  and  base  of  the  bladder  explains  tho 
frequency  of  micturition,  so  commonly  associated 
with  proctitis. 

Diagnosis. — The  variability  and  oftentimes 
vagueness  of  the  symptoms  frequently  admits 
of  a diagnosis  of  enteritis  being  made  only  by  a 
process  of  exclusion.  The  history  of  improper 
feeding,  whether  temporary  or  prolonged,  often 
indicates  the  nature  of  the  disease  ; though  it 
cannot  be  denied  that  all  rules  of  a rational 
dietary  are  frequently  violated,  both  by  children 
and  adults,  with  apparent  impunity. 

Diarrhoea  alone  can  by  no  means  be  taken  to 
indicate  the  existoneeof  intestinal  inflammation, 
it  being  due  to  many  causes  which  leave  the  in- 
testines unaffected ; and  the  same  may  be  said 
of  constipation,  pain,  vomiting,  and  other  symp- 
toms. It  is  rather  to  a group  of  symptoms,  with 
the  previous  history,  that  the  observer  must  look. 
The  character  of  the  stools,  as  already  described, 
often  indicates  the  region  of  gut  affected ; and  tho 
existence  of  extreme  tenderness  and  pain,  with  a 
hard,  quick  pulse,  and  the  abdominal  decubitus 
together,  point  to  the  involvement  of  the  peri- 
toneum, which  an  exacerbation  of  temperature 
tends  to  confirm.  The  distinctive  features  of 
typhlitis,  colitis,  and  proctitis  have  been  already 
described  sufficiently  to  form  material  for  dia- 
gnosis in  most  cases.  To  distinguish  between  in- 
flammation of  the  jejunum  and  ileum  is  usually 
impossible,  nor,  practically,  is  it  a matter  of  im- 
portance. The  history  of  the  case,  the  course  of 
the  temperature,  and  the  characteristic  rash  and 
headache,  should  serve  to  separate  acute  enteritin 
from  typhoid  fever,  for  which  it  is  sometimes 
mistaken. 


INTESTINES,  DISEASES  01' 


758 

Prognosis. — This -will  clearly  depend  on  the 
degree  of  severity  of  the  affection,  no  less  than 
on  its  seat  and  extent.  Best,  which  is  of  prime 
necessity  to  an  inflamed  organ,  is  almost  incom- 
patible with  maintaining  the  due  nutrition  of  the 
patient,  and  this  fact  renders  the  prognosis  very 
uncertain. 

A simple  intestinal  catarrh  occurring  in  a 
healthy  subject  certainly  tends,  after  a few  days, 
to  complete  cure;  but  occurring,  as  it  frequently 
does,  in  persons  in  ill-health,  it  is  far  more 
liable  to  pass  into  an  obstinate  chronic  condition. 
In  children,  the  opinion  should  be  very  guarded  ; 
for  whilst  in  a large  number  of  cases  perfect  re- 
covery follows  removal  of  cause  and  suitable 
treatment,  others,  for  no  very  apparent  reason, 
will,  in  spite  of  everything,  progress  to  a fatal 
termination ; and  this  is,  of  course,  more  likely 
to  be  the  case  where  a strumous  or  tubercular 
diathesis  exists.  Enteritis  in  different  degrees 
of  severity  constitutes  one  of  the  most,  if  not  the 
most,  important  cause  of  infantile  mortality. 

In  the  severer  forms,  as  they  affect  adults, 
opinion  must  be  guided  by  the  nature  of  the 
cause,  and  the  general  state  of  the  patient.  Re- 
cognising that  the  unfavourable  tendencies  of  the 
patient  are  towards  extreme  prostration,  to  per- 
foration with  fatal  collapse,  or  to  chronic  ulcer- 
ation— according  as  these  conditions  are  threat- 
ened, so  may  the  prognosis  be  fairly  made.  The 
duration  of  extreme  cases  rarely  extends  beyond 
a few  days,  when,  if  death  do  not  occur,  the 
symptoms  abate,  and  recovery,  with  oftentimes  a 
tedious  convalescence,  follows,  or  a chronic  con- 
dition of  disease  is  established. 

Treatment. — Although  great  variety  exists  in 
the  degree  of  severity  of  the  symptoms  of  acute 
enteritis,  and  a corresponding  difference  obtains 
in  the  treatment  to  be  pursued,  yet  certain  gene- 
ral principles  may  be  first  laid  down,  and  the 
more  special  details  adapted  to  certain  condi- 
tions afterwards  indicated.  Inasmuch  as  tho 
disease  is  one  of  a febrile  nature,  where,  among 
other  things,  the  tissue-waste  is  out  of  propor- 
tion to  the  repair,  and  at  the  same  time  the  or- 
gans concerned  with  the  preparation  of  the  food 
are  those  mainly  at  fault,  every  effort  should  be 
made  to  minimise  the  bodily  waste.  This  is  best 
attained  by  keeping  the  patient  in  bed,  which 
also  offers  tho  additional  advantage  of  providing 
a uniform  warmth. 

As  regards  diet,  in  the  greater  number  of 
cases  of  acute  intestinal  inflammation,  the  appe- 
tite is  much  impaired,  even  to  complete  anorexia. 
Providing  the  person  attacked  have  been  pre- 
viously in  good  health,  no  harm  is  done  by  com- 
plete abstinencefrom  food  for  twenty -four  or  even 
forty-eight  hours.  This  gives  a much  better 
chance  of  rest  to  the  intestine,  and  abetter  oppor- 
tunity for  the  removal  of  any  irritant  ingesta 
which  may  have  been  the  cause  of  the  inflamma- 
tion. The  thirst  during  this  period  may  be  re- 
lieved by  ice-cold  water,  with  or  without  a little 
lemon-juice.  It  must  not  be  forgotten  that,  with 
the  mucous  membrane  and  its  glands  inflamed, 
the  conditions  of  normal  digestion  and  absorption 
are  materially  interfered  with,  and  articles  of  diet 
that  ordinarily  are  most  nutritious  and  easily 
digested,  may  and  do  become,  under  these  altered 
circumstances,  positively  harmful.  The  aim  in 


feeding  the  patient  should  be  to  give  those 
materials  which  are  most  quickly  absorbed,  and 
leave  the  smallest  amount  of  indigestible  resi- 
due. Provided  that  the  stomach  be  implicated 

and  it  is  rare  that  it  is  not  so.  either  directly  or 
indirectly — meat  foods  are  badly  borne ; instead 
of  the  proteid  constituents  being  digested  in  the 
stomach,  they  remain  there  and  undergo  putre- 
factive decomposition,  and  thus  a ‘d  fresh  irri- 
tants to  the  canal  lower  down.  If.  however,  as 
is  largely  shown  by  the  state  of  the  tongue,  the 
stomach  be  tolerably  free,  then  meat  essences, 
made  thin  and  allowed  to  stand  till  cold,  may  be 
given.  The  nausea  or  vomiting  which  is  usually 
present  is  more  easily  overcome  by  giving  the 
nourishment  cold ; and  a few  drops  of  lemon- 
juice  are  of  great  service  if  added  to  the  beef-tea. 
Milk  is  very  uncertain  in  the  way  it  is  tolerated 
by  such  patients.  Ocasionally  it  is  impossible  to 
give  it,  tho  vomiting  or  diarrhoea  being  increased 
by  it ; but  equal  parts  of  milk  and  soda-water  may 
constitute  sufficient  nourishment  to  last  for  seve- 
ral days  in  extreme  cases,  and  may  be  well  borne. 
Lime-water  maybe  substituted  for  the  soda-water, 
but,  as  a rule,  effervescing  fluids  are  more  grate- 
ful. The  milk  should  be  as  free  as  possible  from 
cream,  for  fats  in  all  forms  are  to  be  avoided, 
since  the  products  of  their  decomposition  are 
extremely  irritating.  A similar  objection,  though 
not  to  such  an  extent,  may  be  made  to  farina- 
ceous foods,  for  the  lactic  and  butyric  acids  to 
which  they  give  rise  in  the  process  of  pancreatic 
digestion  will  further  increase  any  existing  in- 
flammation. If  given  at  all,  it  should  be  only 
in  small  quantities  at  a time;  a remark  which 
equally  applies  to  all  other  food.  Nutrient  ene- 
mata  may  be  of  much  use  in  some  cases. 

A very  great  deal  may  be  done  for  the  patient  J 
with  drugs,  both  in  the  relief  of  symptoms,  and 
in  aiding  the  cure. 

It  is  seldom  advisable  to  check  the  diarrhoea  in 
acute  enteritis;  and  an  aperient  to  begin  with.ei- 
cept  evidence  exist  of  there  being  any  peritonitis,  i 
or  that  the  caecum  be  impacted  with  faeces,  is  a 
rational  treatment.  Thereby  the  irritant,  what- 
ever it  may  be,  is  removed,  and  a better  chance 
for  recovery  is  given.  Improper  food  is  so  com- 
monly the  cause,  that  the  majority  of  cases  are 
benefited  by  a preliminary  purgation.  This  it’ 
may  be  necessary  to  repeat,  especially  if  irrita- 
ting results  follow  the  nourishment  that  is  given. 
Probably  the  best  aperient  in  this  case  is  calomel, 
in  doses  of  two  to  four  grains,  given  as  powder. 
This  undoubtedly  cleans  out  the  upper  pint  of 
the  small  intestine,  and  it  will  be  necessary  ml 
follow  it  up  after  a few  hours  with  a quickly 
acting  aperient  of  a saline  character,  or,  better 
still,  senna,  if  the  latter  can  be  borne.  If  the 
inflammation  be  confined  to  the  colon,  where,  as 
already  said,  accumulations  of  feces  are  the 
common  cause,  copious  simple  enemata,  repeated 
every  six  or  eight  hours,  are  of  great  advantage 

and  this  plan  may  be  pursued  in  comunction  wit! 

the  aperient  given  by  the  mouth.  The  object  ha 
been  to  clear  out  the  alimentary  canal,  ant 
provided  that  this  has  been  done,  abstinent 
from  food  for  twelve  hours,  and  some  bismuth  r 
an  effervescing  form,  are  frequently  sufficient  i. 
milder  cases  to  put  the  attack  on  the  road  i 
cure.  The  writer  places  great  reliance  on  bismut. 


INTESTINES,  DISEASES  OF.  7W 


eilher  in  the  form  of  solution  with  an  effervescing 
cicrate  of  potash,  and  tlireo  or  four  minims  of 
diluto  hydrocyanic  acid;  or  granular  effervescing 
lime-juice  and  bismuth.  The  nausea  or  vomiting 
are  best  relieved  by  this  treatment.  Pain  is  of 
course  a pressing  symptom.  Besides  external 
applications  of  poultices  or  poppy-head  fomen- 
tations, the  internal  administration  of  opium  is 
very  effective — five  or  ten  drops  of  t-he  tincture 
everv  four  hours : the  opium  in  these  cases  does 
not  seem  to  interfere  with  the  action  of  the  aperi- 
ents. Should  there  be  peritonitis  the  opium  must 
be  increased  in  amount,  to  the  end  of  giving 
complete  rest  to  the  gut.  Several  leeches  applied 
to  the  anus,  with  the  view  of  relieving  the  hy- 
peremia of  the  intestinal  tract,  are  occasionally 
necessary  in  extreme  cases.  When  the  attack  is 
distinctly  attributable  to  cold,  a profuse  sweating 
induced  by  hot  baths,  and  ten  grains  of  Dover’s 
powder,  is  often  of  great  benefit.  In  those  cases 
■where,  from  the  duration,  character  of  stools,  and 
previous  treatment,  there  is  reason  to  believe  that 
the  irritating  causes  are  got  rid  of,  the  diarrhoea 
may  then  require  special  treatment,  especially 
when  the  patient  has  been  in  ill-health,  or  is 
constitutionally  debilitated,  in  which  cases  an 
ulceration  of  the  bowel  is  more  likely  to  follow. 
In  such  cases  a powder,  consisting  of  Dover's 
powder,  5 grains,  and  carbonate  of  bismuth,  10 
grains,  given  every  six  hours,  is  very  efficacious. 
Sulphate  of  copper,  nitrate  of  silver,  and  vege- 
table astringents,  are  frequently  used  for  the 
same  purpose. 

So  soon  as  the  more  acute  symptoms  have 
subsided,  the  bismuth  may  he  still  continued  and 
gradually  given  with  a vegetable  bitter,  such  as 
calumba.  But  ten  to  fifteen  minims  of  the  dilute 
hydrochloric  acid  in  an  ounce  of  water  is  almost 
an  essential  to  the  recovery  of  the  digestive 
power  of  the  stomach. 

Inconsequence  of  the  great  liability  to  a second 
attack  which  this  disease  engenders,  avoidance 
of  well-known  harmful  articles  of  diet,  and  the 
use  of  warm  clothing  or  flannel  belts,  arc  de- 
manded as  a prophylaxis. 

In  infants  and  ,'ottng  children  the  great  lia- 
bility to  collapse,  often  rapidly  fata],  must  be 
borne  in  mind.  Stimulants  in  some  form  are 
almost  a necessity.  The  following  prescription 
is  usually  used  by  the  writer: — Liquoris  Bis- 
ranthi  wij-iij,  Spiritus  Ammcniae  Aromatici 
"l'j-v,  Tincture  Cardamomi  Composite  in i j- v ; 
Aquae  Jj-Jij  according  to  age.  Brandy  in  small 
quantities  is  often  the  means  of  saving  life  in 
these  cases.  When  the  collapse  is  not  threaten- 
ing, two  or  three  drops  of  solution  of  corrosive 
sublimate,  with  syrup,  ”ss.  and  water,  5iss., 
every  two  or  three  hours,  is  of  great  service.  It 
is  a more  convenient  mode  of  giving  mercury 
than  in  the  form  of  grey  powder.  But  in  one 
form  or  another  the  writer  believes  mercury  to 
bo  of  prime  necessity.  Corrections  of  diet  on  the 
lines  indicated  above  are  of  course  essential. 
Hot  baths  and  other  means  to  keep  the  child 
Warm  must  be  followed. 

In  the  severer  cases,  which  are  lapsing  into  the 
■yphoid  state,  the  general  principles  for  that 
londition  must  be  followed ; but,  except  in  srrch 
k state,  alcoholic  stimulants  are  rarely  called 

or. 


(A)  Chronic  Enteritis. 

^Etiology. — 1.  A certain  proportion  c.f  trv 
acute  cases  lapse  into  chronic  when  the  original 
cause  persists  ; or  when  the  structural  changes 
resulting  from  an  acute  attack  are  permanent. 

2.  Those  conditions  which  lead  to  a chronic 
state  of  congestion  of  the  intestinal  tract  will 
thereby  so  affect  the  constitution  of  the  tissues, 
with  a consequent  disturbance  of  function,  as  to 
constitute  a chronic  inflammation.  The  most 
important  of  these  conditions  is  obstruction, 
either  at  the  right  side  of  the  heart,  or  affecting 
the  portal  circulation  in  the  liver. 

3.  Chronic  enteritis  is  the  occasional  accom- 
paniment of  some  general  chronic  disease,  such 
as  Bright’s  disease,  when  the  altered  nature  of 
the  arterioles,  and  circulation  of  a deteriorated 
blood,  may  readily  be  regarded  as  leading  to  a 
chronic  inflammation. 

4.  Residence  in  tropical  climates  is  a not  in- 
frequent cause  of  inflammatory  disease  of  the 
bowels. 

Anatomical  Chakactees.  — The  intestinal 
mucous  membrane,  when  it  has  been  the  seat  of 
inflammation  for  any  prolonged  time,  is  thick- 
ened, tough,  and  of  a grey  or  almost  black  colour, 
from  a deposition  of  pigment,  due  to  the  chronic 
congestion.  The  epithelial  cells  are  cloudy  and 
ill-defined,  and  there  is  an  infiltration  of  the  mu- 
cous and  submucous  layers  with  new  round-celled 
tissue,  passing  into  the  stage  of  connective  tissue ; 
hence  the  thickness  and  toughness.  The  lymph- 
oid follicles  are  prominent  and  hard,  and  the 
intestinal  glands  are  frequently  blocked  with 
cells  and  secretion,  and  form  minute  solid,  though 
perceptible  masses.  The  surface  of  the  mem- 
brane will  be  more  or  less  covered  with  a viscid 
glairy  mucus,  containing  pus  and  imperfectly- 
formed  epithelial  cells  ; not  unfrequentlv  such 
mucus  may  bo  voided  in  the  form  of  complete 
casts  of  the  tube,  and  this  is  particularly  the 
case  in  the  pellicular  form  of  colitis.  Sometimes 
the  muscular  coat  is  thickened  from  connective- 
tissue  formation.  As  a rule,  therefore,  the 
bowel  is  increased  in  thickness  ; but  in  children 
it  net  unfrequently  happens  that  a chronic  en- 
teritis is  associated  with  an  atrophy  of  all  the 
coats  and  the  contained  glands.  It  is  unusual 
for  a chronic  inflammation  of  the  intestine  to 
exist  in  adults  without  coincident  ulceration; 
but  in  children  the  disease  may  proceed  to  a 
fatal  termination,  and  show  no  such  condition 
after  death. 

Symptoms. — Whilst  many  cases  with  a persis- 
tent cause  may  be  said  to  be  chronic  from  their 
outset,  it  is  not  always  easy  to  say  exactly  when 
an  acute  case  has  lapsed  into  a chronic  state, 
very  much  the  same  symptoms  being  continued. 
In  such  affections  of  the  small  intestine,  the 
diarrhoea  may  be  wholly  wanting,  and  the  bowels 
may  be  very  confined.  This  is  due  to  the  dimi- 
nished peristalsis,  from  cedema  of  the  muscular 
coat  and  impaired  irritability.  “When,  however, 
ulceration  is  extreme,  and  especially  if  it  be  the 
coion  or  rectum  that  is  mainly  affected,  chronic 
diarrhoea  is  an  invariable  symptom.  The  re- 
marks made  on  the  character  of  the  stools  in 
acute  enteritis  are  equally  applicable  to  the 
chronic  state,  with  the  addition,  that  solid  and 
liquid  evacuations  frequently  alternate.  Lasting 


INTESTINES,  DISEASES  OF. 


J 60 

is  the  disease  does  often  for  many  months  or 
even  years,  a general  impairment  of  nutrition 
results;  the  function  concerned  in  the  elaboration 
of  the  food,  as  -well  as  that  by  which  the  digested 
products  are  absorbed,  are  necessarily  perverted, 
from  the  structural  alteration  of  the  organs  con- 
cerned in  their  performance ; and  as  a result  the 
entire  body  suffers.  The  marasmus  is  speedily 
noticed  in  infants  and  children,  whose  growing 
tissues  the  less  readily  withstand  malnutrition. 
Apart  from  the  general  ill-health  produced,  there 
would  seem  to  be  a special  inclination  for  the 
mental  qualities  to  become  affected,  so  that  the 
intellect  may  become  dulled  and  sluggish,  the 
temper  irritable,  and  the  patient  may  fall  into  a 
condition  of  marked  hypochondriasis ; this  is 
particularly  liable  to  be  the  case  when  the  colon 
s the  seat  of  the  disease.  The  emaciated  appear- 
mce;  the  dirty,  muddy  complexion;  complicated 
>ften  with  a short,  dry  cough,  dependent  on  reflex 
i uuses  from  the  stomach,  frequently  lead  a su- 
perficial observer  to  suspect  the  existence  of 
phthisis. 

Diagnosis. — The  grounds  on  which  a dia- 
gnosis can  be  made  are  sufficiently  obvious  from 
a consideration  of  the  foregoing  remarks. 

Prognosis. — Chronic  enteritis  almost  invari- 
ably tends  towards  a fatal  termination,  though 
this  may  be  long  delayed.  As  already  said,  it  is, 
at  least  in  adults,  the  colon  that  is  chiefly  the 
seat  of  this  malady,  and  where  it  is  almost 
always  associated  with  ulceration,  obstinately  re- 
sisting all  treatment,  which  at  best  is  only  pal- 
liative; the  general  nutrition  is  more  and  more 
deranged;  and  death  from  inanition  finally  ter- 
minates an  existence  of  prolonged  suffering  and 
discomfort. 

Treatment. — Owing  to  the  unfavourable  ten- 
dency of  this  disease,  the  treatment  can  be 
rarely  more  than  palliative.  The  debilitating 
and  wearying  character  of  the  malady  emphati- 
cally calls  for  good  feeding.  The  diet  should  he 
abundant,  no  less  than  nutritious.  When  the 
disease  affects  the  large  intestine,  the  ordinary 
digestive  changes  in  the  food  have  taken  place, 
and  the  contents  of  the  canal  reach  the  colon  in 
the  normal  semi-fluid  condition ; in  this  state 
they  may  be  passed ; but  owing  to  the  impaired 
movements  of  the  affected  bowel  the  feeces  are 
apt  to  accumulate,  and  constipation  results. 
This  should  be  guarded  against  by  simple  ene- 
mata,  and  the  soothing  effect  of  injection  of 
warm  water  only  is  often  very  marked.  In 
those  cases  where  the  enteritis  is  a sequence  of 
a congestion  of  the  intestine,  the  treatment  must 
be  directed  to  i-elievo  if  possible  the  cause  of  that 
congestion.  Since  this  is  usually  some  such  in- 
tractable condition  as  Bright’s  disease,  cardiac 
dilatation,  or  cirrhosis  of  the  liver,  it  is  not 
very  much  that  can  be  done. 

Tonics — such  as  quinine,  iron,  bark,  with  sea 
nir — are  of  undoubted  benefit ; and,  so  far  as  pos- 
sible, causes  of  mental  worry  should  be  removed. 

12.  Intestines,  Malformations  of. — These 
may  be  {a)  congenital ; or  ( h ) acquired. 

(a)  Congenital. — Though  seldom  of  much  cli- 
nical importance,  congenital  malformations  of 
the  intestines  are  often  of  great  interest  from  a 
developmental  point  of  view.  The  malformation 


may  be  of  the  nature  of  an  excessive  develop- 
ment. Thus  certain  parts  of  the  canal — duo- 
denum, colon,  and  appendix  vermiformis — have 
very  rarely  been  found  double.  The  commonest 
of  all  these  malformations  are  certain  diverticula 
of  the  ileum,  which  may  be  found  protruding  from 
the  free  margin  of  the  ileum  anywhere  within  ten 
inches  above  the  ileo-cfecal  valve.  The  eaecal  ex- 
tremities of  such  processes  may  be  connected  with 
the  umbilicus  by  thin  fibrous  cords,  showing 
them  to  be  unobliterated  portions  of  the  vitelline 
duct.  They  vary  in  length  from  half  an  inch  to  six 
inches,  or  even  more  ; their  structure  is  exactly 
that  of  the  ileum  ; and  they  have  been  found  the 
seat  of  typhoid  ulcerat  ion,  or  of  perforation  from 
the  irritation  of  foreign  bodies  that  have  become 
lodged  in  them.  The  vermiform  appendix  may 
vary  from  half  to  twice  the  natural  size. 

Deficiencies  of  development  may  affect  the 
whole  alimentary  canal,  or  only  certain  parte. 
Andral  records  a case  where  only  a straight  tube 
joined  the  rectum  and  (Esophagus.  The  ileum 
may  open  upon  an  ectopic  bladder.  The  lower 
extremity  of  the  canal  is  frequently  imperforate. 
Thus  the  rectum  may  end  in  a cloaca  common  to 
the  urino-genital  organs ; or  the  bowel  may  ter- 
minate in  a closed  extremity  anywhere  between 
the  brim  of  the  pelvis  and  immediately  beneath 
the  skin  ; the  anal  pouch,  which  develops  from 
without  inwards,  is  in  the  latter  case  absolutely 
wanting ; and  all  degrees  between  this  and  a 
pouch  that  has  just  failed  to  establish  a junction 
with  the  rectum  maybe  met  with,  producing  the 
lesion  known  as  imper  forate  anus.  The  valvulte 
conniventes  are  sometimes  wanting,  or  very  im- 
perfect, over  varying  areas  of  the  small  intestines. 
Congenital  constrictions  of  different  parts  of  the 
canal  are  occasionally  met  with — in  the  duodenum, 
either  close  to  the  opening  of  the  common  bile- 
duct  or  at  the  junction  with  the  jejunum;  in 
the  lower  end  of  the  ileum,  where  some  abnor- 
mality in  the  closure  of  the  vitelline  duct  ap- 
pears to  be  the  cause  ; or  in  the  sigmoid  flexure. 
Such  constrictions  maybe  multiple,  of  very  short 
extent,  the  canal  being  much  dilated  above,  and 
extremely  narrowed  and  shrunken  below.  The 
ileo-csecal  orifice  has  been  seen  contracted  to  the 
diameter  of  a small  cedar  pencil.  The  cause  of 
these  lesions  is  very  obscure,  but  at  present  they 
are  ascribed  to  a prenatal  peritonitis  or  enteritis, 
though  they  may  be  occasionally  accounted  for 
by  the  existence  of  prominent  valve-like  folds  of 
the  mucous  membrane. 

Hernial  protrusions  of  the  mucous  membrane 
through  the  other  coats,  often  very  numerous,  and 
varying  in  size  from  a pin  to  a walnut,  have 
been  seen  in  the  colon,  sometimes  extending 
into  the  appendices  epiploic®.  They  are  very 
liable  to  become  developed  in  cases  of  long- 
standing constipation. 

( b ) Acquired.  — The  acquired  malformations 
include  the  dilatations  and  contractions  that  are 
associated  with  stenosis  ; and  the  adhesions  and 
abnormal  communications  established  by  ulcera- 
tion and  peritonitis,  which  have  been  already  re- 
ferred to. 

When  any  symptoms  are  produced  by  malfor 
motion  of  the  intestines  they  are  usually  those 
of  obstruction  ; and  the  only  condition  that  mar 
be  amenable  to  treatment  is  imperforate  anas. 


INTESTINES, 

13.  Intestines,  Malignant  Disease  of. 
Tho  new  growths  which  are  met  with  in  con- 
nection with  the  intestine  may,  for  the  present 
purpose,  most  conveniently  be  divided  into  malig- 
nant and  non-maliqnant — a clinical  distinction 
irrespective  of  their  minute  structure.  We  will 
here  discuss  the  former  class,  in  which  there  are 
included  those  neoplasms  which  tend  to  produce 
a fatal  result,  as  a rule,  rapidly ; and  that  are 
accompanied  with  a marked  general  perversion 
of  nutrition. 

^Etiology. — Malignant  growths  of  the  intes- 
tine, as  in  other  situations,  whilst  not  wholly 
unknown  in  the  earlier  periods  of  life,  are  rarely 
met  with  before  the  age  of  forty. 

From  an  examination  of  9,000  fatal  cases  of 
cancer,  the  relative  frequency  of  intestinal  cancer 
to  that  of  other  organs  was  found  to  be  as  1 to 
£G  (Tanchou). 

Cancer  of  the  intestine  is  nearly  always 
primary,  and  very  frequently  runs  its  course 
without  any  secondary  formations  elsewhere. 
Occasionally  the  bowels  are  affected  by  exten- 
sion from  neighbouring  parts,  and  this  is  espe- 
cially liable  to  be  the  case  in  the  rectum,  when 
the  uterus  or  vagina  are  the  seat  of  tho  disease, 
and  in  the  duodenum,  which  may  become  in- 
volved in  an  extension  from  the  pancreas,  liver, 
or  stomach.  Primary  cancer  of  the  duodenum 
is  very  uncommon.  Very  rarely  small  nodules 
are  found  in  tho  solitary  and  agminated  glands 
secondary  to  carcinoma  existing  elsewhere. 

Anatomical  Characters. — Malignant  disease 
may  occur  at  any  spot  throughout  the  entire 
length  of  both  small  and  large  intestine,  but  is 
infinitely  more  often  to  be  met  with  at  certain 
special  parts,  notably  the  rectum,  sigmoid  flexure, 
caecum,  colon  generally,  and  duodenum;  the  jeju- 
num and  ileum  being  rarely  affected.  There  is 
undoubtedly  a predilection  for  those  spots  where 
any  delay  may  occur  in  the  passage  of  the  in- 
testinal contents,  such  as  the  flexures  of  the  large 
intestine ; and  this  favours  the  idea  that  me- 
chanical irritation  is  largely  concerned  in  the 
causation  of  malignant  growths. 

The  greater  number  of  the  growths  included 
in  the  category  of  malignant  are  comprised  in  the 
group  of  carcinomata,  and  present  the  following 
varieties  : — Schirrus,  encephaloid,  scirrho-ence- 
phaloid,  and  colloid.  Others  belong  to  the  epi- 
theliomata,  and  not  a few  to  the  adenomata  and 
lymphadenomata.  The  former  are  perverted 
growths  of  the  epithelial  tissue;  but  sometimes  tu- 
mours of  the  sarcomatousorconnective-tissuetype 
are  met  with,  following  a malignant  course,  and 
presenting  many  points  of  similarity  to  encepha- 
loid. The  microscopic  characters  of  these  new 
growths  present  no  special  features.  See  Can- 
cer; and  Tumours. 

As  a rule,  malignant  growths  would  appear  to 
commence  in  the  mucous  and  submucous  coats  of 
the  bowel,  and  then  gradually  involve  the  other 
issues;  but  the  colloid  form  usually  begins  in 
the  peritoneum,  and  extends  inwards. 

I The  mesenteric  glands  are  invariably  affected, 
.lid  may  come  to  form  large  tumours. 

Following  the  general  course  of  these  neo- 
ilasms  when  found  elsewhere,  they  may  undergo 
egeneration  and  ulceration,  thus  suffering  a 
iminution  in  bulk  at  one  spot  whil-t  they  extend 


DISEASES  OF.  • 7(51 

in  other  directions,  and  this  is  especially  the  case 
in  the  more  rapidly  growing  varieties,  as  the 
encephaloid,  adenoid,  and  malignant  sarcomata. 
In  tho  course  of  their  development  they  may  set 
up  adhesions  between  the  bowel  and  other  parts, 
as  the  abdominal  wall  or  uterus,  and  two  or  more 
coils  of  intestine  may  be  thus  involved. 

The  new-formed  tissue  may  constitute  an  irre- 
gular mass  of  a very  variable  size  and  extent,  of 
a nodulated  or  of  a villous  appearance,  perhaps 
partially  ulcerated,  and  extending  into  tho 
passage  of  the  canal,  producing  an  obstruction. 
The  scirrlius  and  encephaloid  growths  are  liable 
to  develop  in  an  annular  manner,  involving  the 
whole  circumference  of  the  bowel ; the  obstruct  ion 
produced  in  such  circumstances  may  be  extreme, 
even  to  narrowing  the  lumen  of  the  tube  to 
barely  the  size  of  a probe.  Occasionally,  how- 
ever, annular  encephaloid  growths  occur  with 
no  stenosis,  but  rather  a dilatation  of  the  canal. 
The  extent  of  obstruction  may  be  altered  by 
partial  destruction  of  the  new  growth  by  slough- 
ing, though  the  subsequent  cicatrices  that  may 
result,  will  again  constrict  the  gut. 

Symptoms. — For  a varying  time  beforo  this 
disease  definitely  and  unmistakably  asserts  itself, 
the  patient  complains  of  vague  dyspeptic  symp- 
toms ; a sense  of  uneasiness  in  the  abdomen,  not 
amounting  to  pain,  and  usually  increased  after 
meals ; and  marked  irregularity  in  the  action  of 
the  bowels,  with  or  without  flatulent  distension. 
The  persistent  and  gradual  increase  of  these 
symptoms,  especially  if  there  be  any  loss  of  flesh, 
is  very  significant,  and  should  excite  suspicion. 

Sooner  or  later,  according  to  the  duration  of 
the  case,  the  usual  cachexia  is  established;  and 
in  the  greater  number  of  cases  the  patient  rapidly 
emaciates,  especially  towards  the  end,  though  in 
cases  of  very  short  duration  the  wasting  may  not 
be  so  excessive.  The  emaciation  depends  not  only 
on  the  general  perversion  of  nutrition  caused  by 
the  development  of  the  cancer,  but  also  on  the 
direct  influence  it  exerts  on  organs  concerned  in 
the  digestion  of  nutriment. 

The  local  signs  and  symptoms  referable  to  the 
new  growth  itself  are  very  variable  in  their  occur- 
rence, and  often  aro  singularly  slight  in  comparison 
with  the  gravity  of  the  cause.  Thus  pain  may 
bo  completely  wanting,  and  perhaps  there  is  but 
little  tenderness  on  pressure;  when  present  the 
pain  is  usually  of  a dull  character,  and  quite 
localised.  When  the  rectum  is  affected,  the  pain 
is  apt  to  be  rather  of  a burning  character,  and  to- 
radiate  into  neighbouring  parts ; not  infrequently 
in  this  situation  the  pain  may  be  extreme,  and 
with  tenesmus  may  amount  to  a degree  of  suffer- 
ing which  is  very  rarely  the  case  elsewhere. 

The  indications  of  the  tumour  produced  by  the 
new  growth  are  very  uncertain,  being  often  little 
more  than  an  ill-defined  fulness  in  one  region ; 
at  other  times  presenting  a distinct  hard  irregu- 
lar mass,  of  variable  size,  this  last  quality  being 
partly  dependent  on  faeces.  Should  the  growth 
happen  to  be  situated  on  the  aorta  or  iliac  arteries, 
an  indistinct  pulsation  may  be  communicated  to 
it.  The  percussion-note  over  the  tumour  is  usually 
imperfectly  tympanitic,  from  the  existence  of 
coils  of  intestines  between  it  and  the  abdominal 
wall,  the  thickness  of  which  will  of  necessity 
considerably  modify  the  signs  of  the  existence  of 


762  INTESTINES, 

tho  growth.  The  mass  may  present  all  degrees 
from  free  mobility  to  complete  fixity,  dependent 
on  the  nature  of  its  sea.t,  and  also  on  the  exist- 
ence of  adhesions1  to  neighbouring  parts. 

Symptoms  of  intestinal  obstruction  are  rarely 
wanting ; though,  as  already  said,  in  exceptional 
cases  the  bowels  may  be  dilated  at  the  seat  of 
the  growth.  Vomiting,  constipation  of  increas- 
ing severity,  with  signs  of  intestinal  distension 
above  the  lesion,  are  among  the  most  constant ; 
occasional  diarrhoea,  determined  by  the  chronic 
enteritis  which  exists,  may  alternate  with  the 
constipation  ; and  rupture  of  the  intestines  has 
been  met  with.  Sec  Intestinal  Obstruction. 

The  stools  are  usually  characteristic  of  the 
obstruction,  consisting  of  small  separate  masses, 
frequently  hard  and  round,  and  often  mixed  with 
sloughed-off  portions  of  the  new-growth,  or  with 
blood,  that  has  escaped  from  the  ulcerated  surface. 
The  nearer  to  the  anus  the  growth  is  situated, 
the  less  change  will  there  be  in  the  blood,  which 
sometimes  maybe  considerable  in  amount. 

If  the  peritoneum  be  involved,  peritonitis  is 
likely  to  arise  ; and  ascites,  often  considerable,  is 
usually  developed  with  colloid  cancer.  Super- 
added  to  these  symptoms  will  be  those  caused  by 
tho  morbid  condition  of  any  other  organ  that  may 
be  affected,  such  as  the  liver,  bladder,  or  uterus. 

Course  and  Terminations. — Malignant  dis- 
ease of  the  intestines  in  the  majority  of  cases 
progresses  continuously  from  its  commencement 
to  a fatal  ending.  It  is  difficult  to  state  even  an 
average  duration,  owing  to  the  insidious  onset 
and  vagueness  of  the  first  symptoms;  but  the 
greater  number  of  cases  rarely  go  beyond  twelve 
to  eighteen  months  from  the  time  when  the  dis- 
ease is  clearly  established,  whilst  some  may  be 
fatal  in  a few  weeks,  and  a few  may  last  for 
years. 

Death  may  result  as  the  direct  consequence 
of  tliecachexia ; or  from  haemorrhage,  peritonitis, 
or  other  effects  of  the  growth. 

Diagnosis. — An  exact  diagnosis  is  often  not 
to  be  made,  and  the  nature  of  the  case  remains 
throughout  uncertain,  if  not  actually  as  to  the 
existence  of  a malignant  growth,  at  least  as  to 
che  seat  of  it.  The  insidious  and  ill-defined 
character  of  the  earliest  symptoms  presents 
nothing  diagnostic,  though  their  progressive 
character  and  resistance  to  treatment  would  cause 
a suspicion,  especially  in  a person  over  middle 
age,  and  in  whom  a gradual  even  though  slight 
loss  of  weight  is  noticed.  Even  in  the  later  stages, 
the  symptoms  are  almost  identical  with  those  of 
chronic  enteritis,  which  really  co-exists  with  the 
new-growth  to  a greater  or  less  extent ; and  in 
the  not  unfrequent  cases  in  which  a tumour  is 
not  to  be  felt,  or  is  uncertain  in  its  indications, 
the  diagnosis  becomes  extremely  difficult.  Some 
cases  also  in  which  the  new-growth  is  unrecogni- 
sable to  palpation,  and  at  the  same  time  causes 
little  or  no  obstruction,  closely  simulate  in  their 
course  diseases  of  the  supra-renal  capsule ; for 
the  latter  are  not  invariably  accompanied  by 
cutaneous  pigmentation,  and  the  rapid  and  pro- 
gressive emaciation,  with  more  or  less  persistent 
vomiting,  may  be  common  to  both.  It  is  true 
that  the  malignant  cachexia  is  frequently  pro- 
ductive of  a characteristic, facies,  but  this  would 
equally  occur  in  cancer  of  the  capsules. 


DISEASES  OF. 

Supposing  that  the  existence  of  an  abdominal 
tumour  be  clearly  ascertained,  it  is  not  always 
easy  to  determine  its  connection  with  the 
intestine,  since  the  variability  in  position,  in 
mobility,  and  in  size  (due  to  tho  accumulation, 
or  the  reverse,  of  feces),  precludes  any  diagnostic 
sign,  although  this  very  variability  is  regarded  bv 
some  as  almost  indicative  of  intestinal  cancer,  lii 
distinguishing  between  an  intestinal  tumour  and 
one  connected  with  the  liver,  pancreas,  kidney, 
mesenteric  glands,  uterus,  abdominal  wall,  or  the 
inflammatory  new-growths  following  a perityph- 
litis, an  aneurism,  or  a simple  fecal  accumula- 
tion, the  history  of  the  case,  age,  progressive  na- 
ture of  the  condition,  existence  of  tumour,  signs 
of  obstruction,  and  character  of  the  stools,  are 
the  points  to  be  considered  in  forming  a diagno- 
sis. Any  one  or  even  two  of  these  points  might 
equally  indicate  other  lesions,  but  taken  collec- 
tively, they  will  usually  justify  the  formation  of 
an  opinion.  A rectal  cancer,  that  is  accessible  to 
the  touch  or  oven  to  inspection,  need  offer  no 
difficulty,  but  it  is  otherwise  where  it  comes  to 
distinguishing  a duodenal  growth  from  one 
strictly  limited  to  the  pylorus.  The  vomiting  in 
the  latter  case  is  more  persistent  than  in  the 
former,  and  there  is  a greater  liability  to  hsema- 
temesis  ; but  these  are  most  uncertain  signs,  as 
also  is  the  existence  of  jattndice,  which  oftener 
complicates  the  duodenal  affection,  from  the 
greater  chance  of  involving  or  pressing  on  the 
bile-duct ; but  jaundice  is  not  a necessary  ac- 
companiment. A firm  epigastric  tumour,  felt 
close  )o  the  margin  of  the  thorax,  and  associated 
with  distinct  dyspeptic  symptoms,  may  also  be 
due  to  primary  cancer  of  the  head  of  the  pan- 
creas. The  symptoms  of  obstruction  are  less 
marked  at  first,  but  the  growth  will  probably 
involve  the  gut  in  its  progress,  and  cause  more 
complete  stenosis.  Owing  to  the  destruction  of 
the  gland-tissue,  the  pancreatic  juice  is  not  se- 
creted, and  undigested  fat  may  be  found  in  the 
stools. 

Similar  difficulties  may  surround  the  investi- 
gation o!  a tumour  situated  in  the  right  iliac 
fossa.  Emaciation,  constipation,  and  melana 
might  equally  indicate  a scirrho-cncephaloid  tu- 
mour of  the  caecum,  or  the  remains  of  a chronic 
perityphlitis.  The  history  may  help  a little,  but 
frequently  the  case  remains  throughout  in  doubt. 

Treatment. — The  extremely  rare  cases  of  re- 
puted natural  cure  of  malignant  disease  of  the 
intestines,  brought  about  by  sloughing  of  the 
growth  and  subsequent  cicatrisation  of  its  site, 
afford  no  hope  of  our  being  able  to  artificially 
imitate  the  process,  and  the  treatment  remains 
at  the  best  symptomatic  and  palliative. 

The  diet  should  be  so  arranged  as  to  contain 
the  minimum  of  indigestible  residue,  and  permit 
the  chief  digestion  and  absorption  in  the  stomach, 
if  it  be  the  upper  part  of  the  tube  that  is 
affected.  But  in  the  majority  of  such  cases  the 
utmost  disinclination  for  food  exists,  even  apart 
from  any  vomiting  or  pain  its  ingestion  may 
produce,  and  hence,  whatever  the  directions,  the 
patient  in  the  later  stages  practically  takes 
nothing.  The  anorexia  is  frequently  as  marked 
even  when  the  mischief  is  seated  in  the  colon, 
and  the  area  for  digestion  and  absorption  is  un- 
it) terfered  with. 


INTESTINES, 

In  the  earlier  stages  it  may  be  advisable  to 
insist  upon  as  much  nutritious  food  as  possible 
by  the  mouth  or  in  the  form  of  enema,  so  as  to 
offer  the  most  prolonged  resistance  to  the  inevit- 
able end  ; but  at  the  same  time  there  is  no 
slight  cause  for  thinking  that  the  same  course 
favours  the  speedier  development  of  the  new- 
growth.  Preparations  of  iron  may  be  given  with 
the  same  view. 

The  symptoms  dependent  upon  the  obstruction 
we  can  do  next  to  nothing  to  relieve  ; only  the 
mildest  aperients  are  permissible,  to  combat  the 
constipation  ; while  the  vomiting  is  as  a rule 
uncontrollable,  and,  indeed,  is  often  a relief. 

Hannorrhage  may  require  special  attention, 
and  the  pain  may  be  so  severe  as  to  necessitate 
free  administration  of  morphia  subcutaneously ; 
in  other  cases  belladonna  is  of  value  in  alleviat- 
ing the  local  discomfort,  and  acts  favourably 
by  allaying  any  spasm.  But  our  best  remedies 
offer  no  resistance  to  the  progress  of  the  disease, 
and  but  too  often  very  little  relief. 

The  special  characteristics  of  cancer  of  the 
rectum,  sigmoid  flexure,  or  caecum  occasionally 
permit  of  operative  interference — such  as  co- 
lotomy.  See  Intestinal  Obstruction;  and 
Rectum,  Diseases  of. 

14.  Intestines,  Malpositions  of.- — ’Dis- 
placements of  the  intestines,  like  malformations, 
are  both  congenital  and  acquired. 

Among  the  former  may  be  mentioned  complete 
transposition  of  the  viscera,  the  ciecum  and  as- 
cending colon  being  on  the  left  side,  and  the 
sigmoid  flexure  and  descending  colon  on  the 
right,  the  liver,  spleen,  stomach,  &c..  sharing 
in  the  change.  Certain  parts  only  of  the  intes- 
tinal canal  may  occupy  an  abnormal  situation, 
as  seen  in  the  various  congenital  herni®  ; or  the 
displacement  may  be  due  to  unusual  length  of 
the  mesenteries,  the  caecum  and  sigmoid  flexure 
being  the  parts  that  present  the  most  usual 
alteration  from  this  cause.  Thus  the  caecum 
may  occupy  the  left  hypochondrium  or  left  iliac 
fossa,  or  be  found  in  the  pelvic  cavity,  and,  of 
course,  other  parts  of  the  canal  must  correspond 
to  these  malpositions.  The  sigmoid  flexure 
has  been  seen  lying  to  the  right  side  of  the 
left  kidney,  which  was  situated  immediately 
below  the  bifurcation  of  the  aorta.  Similar 
displacements  are  referable  to  adhesions,  de- 
termined by  intra-uterine  peritonitis,  which  is 
frequently  associated  with  syphilis. 

The  malpositions  which  the  intestines  may 
come  to  present  from  changes  set  up  after 
birth  are  so  variable  as  scarcely  to  admit  of 
classification.  Hernia,  both  external  and  in- 
ternal, volvulus,  and  intussusception  are  among 
the  well-recognised  displacements ; but  there  is 
scarcely  any  limit  to  the  changes  in  position 
which  the  traction  and  pressure  of  tumours  and 
the  effects  of  peritonitis  may  produce. 

Many  of  these  conditions  give  rise  to  no 
symptoms,  and  may  even  fail  to  be  recognised 
during  life.  The  acquired  malpositions  lead  to 
obstruction  in  varying  degrees.  Nee  Intestinal 
Obstruction  ; and  Hf.rnia. 

15.  Intestines,  Morbid  Growths  of. — 
Owing  to  the  variety  of  tissues  that  enter  into 


DISEASES  OF,  768 

the  formation  of  the  intestine,  no  less  than  to  the 
origin  of  these  tissues  from  two  of  the  three  pri- 
mary layers  of  the  blastoderm,  the  new-growths 
that  may  develop  are  exceedingly  numerous. 

It  will  be  most  convenient  here  to  consider 
them  from  their  clinical  rather  than  from  their 
genetic  or  histological  point  of  view,  and  to  di- 
vide them  into  malignant  and  non-malignant 
growths.  The  former  have  already  been  treatod 
of,  and  the  special  neoplasms  of  tubercular  and 
syphilitic  origin  are  more  conveniently  referred 
to  separately. 

Varieties. — 1.  Filrromata.  These  growths, 
which  are  developed  from  the  connective  tissue  of 
the  submucous  coat,  are  usually  of  small  size,  fre- 
quently pedunculated,  though  sometimes  appear- 
ing as  sessile,  flattened  nodules,  of  half  the  siso 
of  a pea  projecting  into  the  canal.  The  smaller 
ones  may  be  scattered  throughout  the  length  of 
the  bowel,  whilst  the  larger  ones  (up  to  the  size 
of  a walnut)  are  fewer  in  number  or  single,  and 
are  usually  found  in  the  rectum.  They  present 
the  ordinary  microscopic  characters  of  fibrous 
tissue. 

2 . Lipomata. — Polypoid  growths  of  adipose 
tissue,  springing  from  the  submucous  coat,  are 
not  of  uncommon  occurrence  in  any  part  of  the 
intestines.  Less  often  they  are  sessile  and  of 
small  size. 

3.  Myomata. — Very  rarely  small  growths  are 
met  with,  chiefly  composed  of  contractile  fibre- 
cells,  with  a variable  amount  of  connective  tissue. 

4.  Vascular  tumours — Angiomata.  — Besides 
hoemorrhoids,  other  vascular  growths  are  some- 
times found,  of  an  erectile  character,  similar  to 
naevi  of  the  skin. 

5.  Mucous. — It  is  to  these  growths  that  the 
term  polypi  is  oftenest  applied.  They  essentially 
consist  of  all  tho  tissues  of  the  mucous  membrane, 
though  differing  in  their  vascularity,  and  also  in 
their  glandular  elements.  When  these  latter  are 
excessive  in  amount,  they  are  liable  to  present 
characters  which  connect  them  with  malignant 
forms  of  new-growth,  especially  if  their  surface 
assume  a villous  character.  Polypi  are  not  limited 
to  any  one  part  of  the  canal,  though  undoubtedly 
they  are  most  common  in  the  rectum.  Sometimes 
they  are  distinctively  pigmented.  They  are  oc- 
casionally multiple ; and  have  been  met  with  at 
all  ages. 

6.  Lymphoid  growths  — Lymph  adenomata. — 
Neoplasms  whose  structures  correspond  to  that  of 
the  solitary  or  agminated  glands,  or  of  the  lym- 
phoid layer  of  the  submucosa,  are  met  with  in 
association  with  theso  normal  constituents  of  the 
intestinal  wall,  and  quite  independently  of  any 
leucoeythmmia. 

7.  Cysts. — These  have  been  rarely  met  with, 
and  the  contrast  to  their  comparative  frequency 
in  the  uterine  mucous  membrane  is  remarkable. 
Dr.  Dickinson  (TV.  Path.  See.  vol.  xii.  p.  138)  re- 
cords the  occurrence  of  a colloid  cyst  of  the  size 
of  an  orange,  between  the  muscular  and  mucous 
coats  of  the  c®cum  in  a patient  aged  75,  so  placed 
as  to  give  rise  to  no  obstruction  or  other  symp- 
toms. The  contents  were  gelatinous  and  oily, 
and  there  were  no  cysts  elsewhere. 

Effects  and  Symptoms.  — As  a rule,  tho 
growths  mentioned  above  present  very  little  in- 
terest, unless  they  be  situated  just  within  the 


764  INTESTINES, 

rectum,  and  accessible  to  digital  examination. 
They  cannot  be  diagnosed,  though  they  may 
give  rise  to  certain  symptoms,  as,  for  instance, 
haemorrhage  from  the  vascular  polypi  and  erec- 
tile tumours,  or  partial  obstruction  if  they  attain 
any  size  ; but  such  symptoms  are  not  diagnostic. 
One  of  their  most  interesting  effects  appears  to 
be  the  liability  that  the  polypoid  forms,  occur- 
ring in  the  small  intestine,  have  of  inducing  in- 
tussusception, from  interfering  with  the  due  pro- 
gress of  peristalsis.  Prolapse  of  the  rectum  is 
similarly  found  to  be  occasionally  due  to  polypi. 

Treatment. — No  treatment  can  be  attempted, 
beyond  that  of  the  symptoms  which  may  arise;  or 
the  removal  of  growths  within  reach  of  the  anus. 

16.  Intestines,  Paralysis  of.  — The  peris- 
talsis of  the  intestinal  tube  is  normally  depen- 
dent on  automatic  nerve-impulses,  originating 
in  the  intrinsic  ganglia  of  the  canal,  controlled 
by  both  reflex  and  direct  impressions  from  the 
cerebro-spinal  and  sympathetic  systems,  the 
former  acting  via  the  vagus  in  an  accelerating 
manner,  the  latter  via  the  splanchnics  in  an  in- 
hibitory direction.  The  integrity  of  the  involun- 
tary muscular  fibre  is  assumed. 

^Etiology  and  Pathology. — A paresis  of  the 
intestinal  movements  may  be  brought  about  by 

( 1 ) causes  acting  through  the  nervous  system ; or 

(2)  through  imperfection  of  the  muscular  tissue. 

(1)  Nervous.— Whilst  it  is  possible  that  the 
intrinsic  ganglia  and  nerves  of  the  intestinal  mus- 
cular coat  may  be  the  seat  of  degeneration,  no 
known  observations  are  recorded.  Certain  lesions 
of  the  brain  are  accompanied  by  symptoms  of 
intestinal  paralysis,  but  with  no  hitherto  recog- 
nised regularity,  and  it  is  assumed  that  such 
lesions  act  by  interfering  with  the  function  of 
the  vagi.  It  is  doubtful  how  far  disease  of  the 
spinal  cord  produces  actual  paralysis  of  the  in- 
testines, though  constipation  may  result,  a cir- 
cumstance that  may  be  explained  by  assuming 
an  interference  with  the  centre  that  controls  de- 
fecation. See  Pieces,  Retention  of. 

(2)  Muscular. — The  irritability  of  the  mus- 
cular tissue  may  be  much  weakened  by  degene- 
ration (cloudy,  fatty,  or  amyloid).  Inflammation 
of  the  mucous  or  serous  coat,  especially  the  latter, 
is  liable  to  determine  granular  change  in  the 
muscular  fibres,  which,  aided  by  a coexistent 
oedema,  largely  impairs  the  contractile  power  of 
the  tissue.  The  irritability  is  also  liable  to  suffer 
from  the  over-stimulation  of  too  powerful  and  too 
frequent  purgative  medicines  ; and  the  muscular 
fibres  of  a much  dilated  portion  of  the  bowel  are 
apt  to  become  paralysed  from  distension  and 
stretching.  The  general  want  of  tone  that  the 
muscular  and  nervous  systems  manifest  subse- 
quent to  debilitating  diseases,  want  of  food,  hy- 
steria, and  other  conditions,  also  finds  expression 
in  the  alimentary  canal,  in  diminished  peristaltic 
action. 

The  modus  opcrandi  of  certain  astringent 
drugs  upon  the  bowel  is  quite  unknown,  possibly 
through  the  nervous  system,  as  appears  to  be 
Hie  case  with  opium,  and  perhaps  by  affecting 
t he  muscular  fibres  or  nerve-terminals.  Lead, 
which  would  seem  to  cause  both  paralysis  and 
spasm  of  the  muscular  coat,  may  act  in  this 
way. 


DISEASES  OF. 

Symptoms. — The  prominent  symptom  of  ictea- 
tinal  paralysis  is  constipation,  though  other  signs 
of  obstruction,  such  as  vomiting,  meteorisra.  &c„ 
may  be  superadded.  See  Constipation;  and 
Intestinal  Obstruction. 

Treatment. — As  a rule  this  is  directed  to  the 
primary  cause,  but  great  benefit  has  undoubtedly 
followed  the  special  application  of  electricity  to 
the  abdominal  parietes.  Friction  applied  on 
systematic  principles  is  of  undoubted  service. 

17.  Intestines,  Perforation  and  Rupture 
of.  — Aetiology.  — The  causes  of  perforation 
or  rupture  of  the  intestines  may  be  arranged 
thus : — 1.  External  injuries,  such  as  blows,  being 
run  over,  &c.,  though  more  liable  to  rupture 
the  solid  abdominal  viscera,  frequently  cause 
the  intestines  to  burst,  especially  the  ileum  or 
jejunum. 

2.  Corrosive  poisons,  when  swallowed  in  any 
considerable  amount,  may  destroy  not  only  the 
walls  of  the  stomach,  but  also  of  the  upper  part 
of  the  intestines. 

3.  Extreme  distension  byjlaius  above  the  site 
of  a constriction  may  cause  the  bowel  to  burst. 

4.  Ulcerations,  pre-eminently  the  so-called 
peptic  ulceration,  and  less  commonly  typhoid  and 
catarrhal  ulceration,  are  liable  to  lead  to  perfora- 
tion. 

5.  Perforations  may  be  produced  ab  extra,  by 
the  bursting  of  abscesses  or  aneurisms  into  the 
canal. 

Symptoms. — The  most  striking  symptom  which 
perforation  of  the  bowel  presents  is  collapse, 
and  it  is  a noticeable  fact  that  rupture  of  the 
hollow  abdominal  viscera  is  more  liable  to  induce 
this  condition  than  a similar  lesion  of  such  organs 
as  the  liver  or  spleen.  The  exact  explanation  of 
this  collapse  is  not  apparent. 

Should  the  patient  live  twenty-four  hours  after 
the  establishment  of  a perforation,  signs  of  peri- 
tonitis will  assert  themselves — severe  abdominal 
pain  and  tenderness,  pyrexia,  vomiting,  and  other 
symptoms.  Supposing  that  the  perforation  follow 
an  ulceration  in  the  course  of  a previously  high 
temperature,  such  as  enteric  fever,  there  will  be  a 
sudden  and  usually  considerable  fall  in  the  body- 
heat  ; this  may  be  the  first  indication  that  per- 
foration has  taken  place. 

Perforation  or  rupture  of  the  intestines  usually 
proves  fatal  within  forty-eight  hours  of  its  oc- 
currence, although  cases  are  recorded  which  have 
lasted  for  weeks  ; very  rarely  recovery  has  taken 
place. 

There  are  no  reliable  signs  whereby  rupture 
of  the  stomach  may  be  distinguished  from  that 
of  the  intestines,  nor  is  it  of  any  practical  im- 
portance. But  the  collapse  and  fall  in  tempera- 
ture, with  the  history  of  the  case,  are  quite  suf- 
ficient to  warrant  the  diagnosis  of  perforation  of 
some  part  of  the  canal. 

Treatment. — Rest  is  of  primary  importance, 
both  in  regard  to  the  whole  body,  and  the  bowels 
themselves.  This  object  is  best  attained  by  flic 
free  use  of  opium,  commencing  with  a grain,  and 
repeating  it  in  a few  hours  until  its  influence  is 
fully  established.  It  is  also  desirable  to  cut  off 
all  food,  except  an  occasional  teaspoonful  of  meat 
essence;  to  give  ice  to  suck;  to  administer  nu- 
trient enemata,  and  brandy  and  ether  if  the  col- 


INTESTINES,  DISEASES  OF. 


lapse  be  profound  ; and  to  apply  warmth  to  the 
extremities. 

18.  Intestines,  Spasm  of. — The  irregular 
and  forcible  movements  of  the  bowels,  usually 
accompanied  with  pain,  are  known  as  colic. 
Under  ordinary  circumstances  we  are  uncon- 
scious of  the  peristaltic  action,  but  when  the 
contractions  of  the  muscular  coats  bfcome  violent, 
more  or  less  pain  is  likely  to  occur. 

JEtiology.' — The  determining  causes  of  intes- 
tinal spasm  are : — 

1.  The  direct  irritation  of  indigestible  ingesta. 
2.  Exposure  to  cold.  3.  Certain  poisons— lead, 
strychnia,  &c. — which  probably  affect  the  mus- 
cular fibres  through  the  nervous  system. 

It  is  difficult  to  ascertain  the  exact  condition 
of  the  contracted  bowel,  since  the  appearances 
seen  after  death  are  not  an  index  of  what  existed 
during  life  ; but  it  would  seem  that  the  spasm 
may  start  from  several  points  in  the  course  of  the 
canal,  and,  after  persisting  for  a variable  time, 
either  yield  or  travel  on  as  a wave  of  spasmodic 
contraction.  For  how  long  a portion  of  bowel  may 
remain  contracted  is  quite  conjectural. 

Symptoms. — The  existence  of  a painless  spasm 
of  the  intestines  is  very  doubtful;  as  a rule  it  is 
the  pain  which  indicates  this  condition,  and  ex- 
cept the  contraction  be  maintained,  no  further 
symptoms  may  occur.  Constipation,  vomiting, 
meteorism,  may  all  be  present  in  varying  degrees, 
dependent  upon  the  extent  of  obstruction  which 
is  produced.  Not  infrequently  fever,  collapse, 
and  prostration  may  co-exist,  leading  to  the  belief 
that  a more  serious  condition  is  calling  for  treat- 
ment. 

The  specially  painful  spasm  of  the  anal  sphinc- 
ters and  lower  portion  of  the  rectum  termed 
tenesmus,  is  associated  with  gouty  congestion, 
with  ulceration,  and  with  most  other  lesions  in 
that  locality. 

Treatment. — The  external  application  of  moist 
heat  in  the  form  of  poultices  or  fomentations, 
preferably  of  poppy-head  or  other  opiates,  is  of 
great  value,  for  relaxing  the  spasm  or  removing 
the  pain.  Since  an  irritant  is  so  frequently  the 
cause,  an  aperient,  such  as  castor  oil  or  calomel, 
combined  with  opium,  is  essential.  The  collapse 
may  be  so  severe  as  to  call  for  energetic  stimula- 
tion by  brandy,  ammonia,  or  ether. 

19.  Intestines,  Syphilitic  Disease  of. — 

The  intestinal  canal  is  rarely  the  seat  of  the 
specific  lesions  of  syphilis,  except  at  the  lower 
end  of  the  rectum,  and  margin  of  the  anus.  Small 
gummata  have  been  found  in  the  submucous  tissue 
of  various  parts  of  the  bowel,  but  more  often  the 
ulcers  to  which  these  growths  give  rise  by  their 
degeneration  and  breaking  down ; radiating 
fibrous  cicatrices  of  the  mucous  membrane  have 
also  been  seen,  produced  by  these  syphilomata. 
It  is  doubtful  whether  there  be  any  specific  ulcer- 
ation of  the  intestine  which  is  not  preceded  by 
gummata,  although  small  ulcers  do  occur  in  new- 
born children,  the  subjects  of  congenital  syphilis. 

Syphilitic  ulceration  and  stricture  of  the  rec- 
tum is  not  of  infrequent  occurrence.  See  .Rectum, 
Diseases  of. 

20.  Intestines,  Tubercular  Disease  of. — 
The  specific  lesions  cf  the  tubercular  diathesis, 


765 

namely,  grey  granulations  or  miliary  tubercles, 
are  of  frequent  occurrence  throughout  the  intes- 
tinal canal.  Regarding  them  as  local  developments 
of  lymphoid  tissue,  the  opportunity  for  their  for- 
mation is  most  favourable,  owing  to  the  extensive 
distribution  of  this  tissue  throughout  the  sub- 
mucous coat,  and  the  special  aggregations  of  it 
which  form  the  solitary  and  agminated  glands. 
The  abundant  supply  of  lymphatic  vessels  in  the 
thickness  of  the  walls  of  the  canal,  and  the  close 
connection  of  the  serous  surface  with  the  lym- 
phatic system,  all  predispose  to  the  development, 
and  spread  of  a tubercular  growth  which  may 
have  become  established  in  a subject  of  the 
diathesis. 

jEtiology, — As  a primary  growth  tubercle 
very  rarely  attacks  the  intestines  in  adults, 
though  it  is  of  very  frequent  occurrence  in  chil- 
dren as  piart  of  a general  tuberculosis.  In  adults, 
on  the  contrary,  tubercular  disease  of  the  intes- 
tines is  very  commonly  developed  secondary  to  a 
similar  affection  of  the  lungs. 

Anatomical  Characters.  — The  submucous 
layer  and  the  peritoneal  coat  are  the  structures 
in  which  the  tubercle  originates;  in  the  former 
situation  it  especially  favours  the  ileum  and  cse- 
cum,  although  it  may  develop  throughout  the 
entire  length  of  the  tube,  whilst  the  peritoneal 
tubercle  is  about  equally  distributed.  The  me- 
senteric glands  are  always  considerably  involved. 
The  rareness  with  which  the  stomach  is  affected 
by  tubercle  is  in  marked  contrast  to  the  fre- 
quency of  the  intestinal  lesion. 

In  extreme  cases  of  tuberculosis  in  children, 
death  may  take  place  before  any  changes  in  the  tu- 
berculous formation  have  taken  place,  and  count- 
less grey  granulations,  from  the  size  of  a pin's 
head  to  bodies  microscopic,  are  to  be  found  in 
the  submucosa,  and  in  the  solitary  and  agminated 
glands.  Later  on,  however,  these  non-vascular 
new-growths  coalesce,  and  form  distinct  masses, 
which  from  lack  of  nutrition  undergo  caseous 
degeneration  and  break  down,  thus  forming  the 
tubercular  ulcers.  The  ulcers  tend  to  spread, 
and  rarely  to  heal,  and  whilst  they  may  be  at 
first  limited  to  the  glands,  they  invade  the  ad- 
jacent mucous  membrane,  especially  in  a direc- 
tion round  the  bowel,  their  extension  being 
preceded  by  the  development  of  fresh  tubercles, 
to  the  progressive  formation  and  destruction 
of  which  the  spread  of  the  ulcer  is  really  due. 
Large  masses  of  the  mucous  surface  may  be  thus 
destroyed,  leaving  a ragged,  flocculent  surface, 
formed  of  the  muscular  fibres,  or  even  of  deeper 
structures,  which  lesions  rarely  proceed  to  per- 
foration into  the  peritoneal  cavity,  adhesive  peri- 
tonitis having  established  attachments  to  adja- 
cent parts.  The  thickened,  congested,  irregular 
edges  of  the  ulcers,  with  miliary  tubercles  close 
to  the  margin,  are  very  distinctive  ; apart  from 
the  granulations,  the  ulcers  themselves  are  not 
unlike  those  of  dysenteric  origin,  or  chronic  fol- 
licular ulceration. 

Symptoms. — Until  ulceration  be  established, 
there  will  be  no  symptoms  of  tubercular  disease 
referable  to  the  intestinal  canal,  and  even  when 
this  stage  is  reached,  there  is  nothing  to  distin- 
guish it  from  ulceration  due  to  other  causes. 
There  is  the  same  pain  and  tenderness,  often  but 
little  marked ; usually  an  obstinate  diarrhoea, 


766  INTESTINES, 

characteristic  stools  -with  occasional  blood  ; and 
progressive  emaciation.  Added  to  these  are  the 
symptoms  due  to  implication  of  other  organs — 
lungs,  brain,  &c. — since  tubercular  ulceration  of 
the  bowels  scarcely  ever  occurs  alone. 

Treatment. — Little  can  be  done  for  intestinal 
tuberculosis.  The  course  of  the  disease  is  almost 
invariably  to  a fatal  end,  and  it  is  very  rare  for 
healing  and  cicatrisation  to  take  place.  The 
necessity  for  feeding  the  patient  is  almost  contra- 
indicated by  the  existence  of  a destroyed  digesting 
and  absorbent  surface,  whereby  the  food  becomes 
a positive  irritant.  Such  nourishment  as  is  taken 
should  therefore  he  in  the  most  digestible  and 
concentrated  form,  that  as  much  as  possible  may 
be  taken  up  from  the  stomach.  Starch  and  opium 
enemata  may  do  a little  to  check  the  diarrhoea, 
but  their  efficacy  is  soon  lost.  Hemorrhage, 
should  it  set  in,  is  scarcely  amenable  to  treatment, 
though  astringent  enemata  may  be  of  some  use, 
combined  with  the  internal  administration  of  ace- 
tate of  lead  and  opium.  No  treatment,  has  as  yet 
been  effectual  in  arresting  the  spread  of  t.uborcle, 
and  until  that  be  gained,  there  is  nothing  we  can 
do  that  will  permanently  benefit  the  affected 
intestines;  even  .palliative  measures  afford  but 
little  relief, 

21.  Intestines,  Ulceration  of.  — - Ulcera- 
tion of  the  intestinal  wall,  from  one  cause  or 
another,  is  of  extremely  common  occurrence.  The 
morbid  processes  involved  in  the  production  of 
the  ulcers  are  in  all  cases  essentially  the  same, 
namely,  a molecular  death  and  disintegration  of 
the  tissue,  leaving  a solution  in  continuity,  of 
varying  extent.  The  severe  disturbance  of  tissue- 
nutrition  which  leads  to  ulceration,  may  he  one  of 
the  later  stages  of  inflammation: — (1),  affecting 
previously  healthy  tissues  ; or  (2),  as  a means 
for  the  removal  of  necrosed  tissue  ; or  (3),  de- 
veloped in  new-growths. 

Varieties:  1.  Primary  inflammatory  ulcers.— 
Any  enteritis,  whether  of  the  mildest  character, 
or  of  a specific  type  such  as  diphtheritic,  may 
lead  to  ulceration  of  the  bewols.  As  a rule, 
the  more  severe  the  cause  of  the  inflammation, 
the  greater  the  liability  to  this  complication ; 
and  the  same  holds  in  respect  of  any  intestinal 
catarrh,  developed  in  the  course  of  any  serious 
state,  such  as  typhus  fever  or  Bright’s  disease. 
The  ulcer  may  appear  either  as  a small  abrasion 
of  the  epithelial  layer,  which  gradually  extends 
and  deepens  until  the  whole  mucous  coat  is 
involved ; or  the  first  indication  may  be  a thin 
glairy  pellicle,  adherent  to  the  mucous  membrane, 
which  in  time  is  thrown  off,  leaving  a breach 
in  the  subjacent  tissue.  In  other  cases  the 
destructive  process  commences  in  the  thickness 
of  the  bowel,  either  from  the  rupture  of  small 
collections  of  inflammatory  products,  resulting 
from  an  enteritis,  or  from  inflammation  of  the 
Soilicles.  The  escape  of  these  products  into  the 
tube  leaves  behind  an  ulcer. 

These  lesions  may  be  found  anywhere  through- 
out the  bowels,  although  they  are  much  more 
frequent  in  the  large  than  in  the  small  in- 
testine, and  one  form  of  follicular  ulceration, 
associated  with  the  specific  poison  of  dysentery,  is 
practically  limited  to  the  latter  situation.  At 
those  places  where  any  delay  is  likely  to  arise  in 


DISEASES  OF. 

the  passage  of  the  feces — the  caecum,  sigmoid 
flexure,  and  rectum — and  at  those  spots  which  are 
most  prominent,  such  as  the  edges  of  the  valvulae 
eonniventes,  and  the  sacculus  of  the  colon,  where 
an  enteritis  is  most  likely  to  he  produced,  there 
will  be  the  probable  site  of  these  inflammatory 
ulcers. 

2.  Ulcers  resulting  from  the  separation  oj 
necrosed  tissue. — The  process  of  molecular  dis- 
integration which  takes  place  in  the  adjacent 
bodies  of  living  and  dead  tissue,  resulting  in  the 
separation  of  a slough  and  the  leaving  of  an 
ulcer,  takes  place  in  the  intestines  as  elsewhere. 
The  causes  leading  to  the  death  of  circumscribed 
areas  cf  tissue  are  various.  Sometimes  the 
vitality  of  a portion  of  the  mucous  membrane  is 
destroyed  by  degeneration,  such  as  amyloid,  and 
an  ulcer  marks  the  spot  of  the  removed  patch. 
More  frequently  the  local  death  is  induced  by 
cessation  of  blood-flowthrough  a limited  area; 
the  cause  of  this  stasis  is  not  very  apparent, 
though  believed  to  be  due  to  emboli.  Under 
such  circumstances  the  solvent  power  of  the 
digestive  juices  may  be  exerted  on  the  non-living 
tissues,  which  are  thus  removed,  and  an  ulcer  is 
left.  To  such  ulcers  the  term  peptic  has  been 
applied,  and  identical  lesions  are  met  with  in 
the  stomach.  They  almost  invariably  occur  in 
the  first  part  of  the  duodenum,  above  the  point  of 
entrance  of  the  alkaline  bile  and  pancreatic  juices, 
although  very  rarely  they  have  been  seen  in  the 
jejunum.  Ulcers  of  this  character  appear  to  be 
connected  with  large  superficial  burns,  but  how 
the  relationship  is  established  is  not  known.  It 
is  a singular  fact  in  regard  to  them,  that  they 
are  ten  times  more  common  in  men  than  in 
women,  which  is  quite  the  reverse  of  what 
obtains  in  the  stomach,  although  the  relative 
frequency  of  gastric  and  duodenal  ulcers  is 
estimated  as  thirty  to  one.  Both  the  ileum  and 
colon  have  been  found  ulcerated  in  amyloid 
degeneration. 

3.  Ulceration  of  new-growths. — Almost  any 
neoplasm  of  the  intestinal  wall  may  ulcerate, 
though  as  a rule  the  more  rapidly  developed 
forms  are  more  liable.  Tubercular  and  typhoid 
growths  primarily  connected  with  the  solitary 
and  agminated  glands,  invariably  end  in  this  man- 
ner. Syphilitic  gummata  and  malignant  growths 
are  especially  prone  to  ulceration. 

Characters.— The  appearances  presented  by 
the  various  ulcers  differ  with  the  cause  and  the 
duration. 

They  may  he  single,  as  is  generally  the  case 
with  the  duodenal  ulcers  ; or  innumerable,  as 
the  follicular  ulcers  of  the  colon.  Typhoid  and 
tubercular  ulcers  are  as  a rule  multiple,  and  are 
most  numerous  at  the  lower  end  of  the  ileum, 
where  the  agminated  glands  are  most  abundant. 
Occasionally  large  surfaces  of  the  mucous 
membrane  are  destroyed,  with  here  and  there 
small  isolated  spots  of  the  membrane  left,  due  to 
the  spread  and  coalescence  of  many  separately 
arising  ulcers.  In  dysentery  and  chronic  tuber- 
cular ulceration  this  is  especially  liable  to  happen. 
Many  of  the  catarrhal  and  follicular  ulcers  are 
extremely  small,  not  more  than  a line  in  di  tmeter. 

The  peptic  ulcers  are  distinguished  by  their 
very  definite,  ‘clean-punched’  appearance ; the 
edges  are  slightly  sloping,  and  but  very  little, 


INTESTINES,  DISEASES  OF.  7C7 


if  at  all,  thickened  ; whilst  the  mucous  membrane 
immediately  adjacent  has  a perfectly  healthy 
appearance.  In  most  of  the  other  varieties  the 
edges  are  thickened,  irregular,  and  shaggy,  fre- 
quently excavated  and  overhanging  the  base ; 
the  ulcerative  process  extending  beneath  the 
mucous  membrane,  which  gradually  dies  and 
sloughs  away  as  its  nutrition  is  cut  off.  De- 
pendent upon  the  depth  and  course  of  the  ulcer 
will  be  the  nature  of  its  base,  which  may  be 
formed  of  the  muscular  coat,  of  the  peritoneum 
much  thickened,  or  of  adjacent  structures  with 
which  adhesion  has  been  established,  such  as 
the  liver  or  abdominal  wall.  The  floor  of  the 
ulcerated  tubercular  and  malignant  new-growths 
usually  presents  small  nodules  of  the  neoplasm, 
which  are  being  developed  coincidently  with  the 
ulceration.  The  buif  or  ash-grey  pigmented 
sloughs,  partially  separated,  give  a characteristic 
appearance  to  the  old-standing  ulcers  of  dysentery 
and  tubercle.  The  tubercular  and  typhoid  ulcers 
of  Peyer's  patches  present  a certain  difference  in 
the  direction  in  which  they  extend ; whilst  at 
first  both  are  limited  to  the  patch,  the  former 
tend  to  spread  in  an  annular  manner,  whilst  the 
latter  have  usually  their  long  axis  correspond- 
ing to  the  length  of  the  bowel.  This  difference 
depends  rather  on  the  duration  of  the  ulcer,  than 
on  any  specific  distinction  due  to  the  two  diseases ; 
for  the  more  acute  enteric  lesion  rarely  spreads 
much  beyond  the  area  of  the  patch,  which  is  in 
the  long  axis  of  the  bowel,  whilst  the  chronic 
tubercular  ulcer  follows  the  distribution  of  the 
lymphoid  tissue  outside  the  patches,  and  par- 
ticularly along  the  course  of  the  blood-vessels 
and  lymphatics. 

Couese. — The  course  of  an  intestinal  ulcer 
may  be  acute  or  chronic,  lasting  a few  days  or 
for  years.  Some  of  the  simple  ulcers  of  an  acute 
intestinal  catarrh  belong  to  the  former  group  ; 
whilst  the  ulceration  that  accompanies  chronic 
enteritis  may  be  of  indefinite  duration. 

The  acute  forms  may  either  heal  or  go  on  to 
perforation ; in  the  former  case  their  existence  can 
only  be  inferred,  and  catarrhal  and  follicular 
and  enteric  ulcers  belong  to  this  category.  The 
peptic  and  typhoid  tilcers  are  those  most  liable 
to  perforate  the  gut,  their  duration  being  too 
short  to  allow  of  the  formation  of  adhesions  to 
neighbouring  structures,  as  is  very  apt  to  be 
the  case  in  the  more  chronic  forms.  Occasion- 
ally the  perforation  may  lead  to  communication 
between  one  coil  of  intestine  and  another,  be- 
tween the  duodenum  and  stomach,  or  between 
the  bowel  and  bladder,  without  any  rupture 
into  the  peritoneal  cavity,  which  is  the  com- 
monest end  of  a perforating  typhoid  ulcer.  In 
chronic  ulcers,  where  no  adhesion  or  communi- 
cation takes  place,  the  base  is  thickened  by  a new- 
I formed  connective  tissue,  which  is  developed  as 
fast  as  or  even  faster  than  the  destructive  process 
proceeds,  and  hence  the  intestinal  wall  adjacent 
to,  and  involved  in  such  ulcers,  is  usually  much 
I thickened  and  indurated.  Short  of  actual  per- 
foration or  adhesion  to  other  parts,  the  site  of 
the  ulceration  most  frequently  is  marked  on  the 
external  surface  of  the  bowel  by  a sub-acute 
peritonitis,  which  may  produce  a partial  matting 
together  of  the  intestines. 

In  the  course  of  the  healing  of  the  larger 


ulcers,  by  the  formation  of  a contracting 
cicatricial  tissue,  the  gut  may  be  considerably 
constricted,  and  a most  formidable  obstruction 
may  be  established.  But  this  does  not  neces- 
sarily follow  even  large  ulcers,  such  as  those 
of  typhoid  fever;  and  the  extent  of  depth  of 
the  destruction  would  seem  to  influence  this 
result;  when  the  superficial  portion  of  the  mu- 
cous membrane  only  is  destroyed  very  little 
contraction  follows,  but  when  the  deeper  parts 
of  the  wall  are  involved  the  subsequently  de- 
veloped cicatrix  tends  to  shrink  considerably. 
Similar  differences  are  seen  in  destructions  of 
the  skin  and  subcutaneous  tissues. 

Sy.mptosis. — The  greatest  diversity  is  met  with 
in  the  symptoms  of  intestinal  ulceration,  and  few, 
if  any,  can  be  regarded  as  characteristic.  Inas- 
much as  the  lesion  may  occur  without  producing 
any  symptoms ; or  those  that  do  exist  may  be 
determined  by  the  course  of,  or  by  the  conditions 
associated  with  the  ulceration ; or  lastly,  the  re- 
sults of  this  condition,  such  as  perforation,  may 
entirely  obscure  the  actual  ulceration  itself : it 
frequently  happens  that  the  existence  of  an  ulcer 
is  not  recognised.  Nor  may  the  severity  of  the 
symptoms  be  taken  as  a measure  of  the  extent  of 
the  ulceration,  for  the  most  marked  pain,  tender- 
ness, diarrhoea,  and  other  symptoms  may  be  pro- 
duced by  an  area  of  typhoid  ulceration  that  heals; 
whilst  a perforating  duodenal  ulcer  may’  give 
scarcely  any  indication  of  its  existence,  until 
within  a few  hours  of  a fatal  ending.  This  course 
appears  to  be  very  characteristic  of  duodenal 
ulcers  ; and  the  writer  has  recorded  a case  of  a 
young  man  who  was  suddenly  attacked  with  all 
the  symptoms  of  apparently  intestinal  colic,  after 
constipation  of  a week’s  duration,  no  vomiting  and 
no  tenderness,  the  pain  beingrelieved  by  pressure 
on  the  abdomen.  Collapse  set  in,  and  death  re- 
sulted in  less  than  twenty-four  hours  from  the 
commencement  of  the  attack.  The  autopsy  showed 
a perforating  duodenal  ulcer.  Such  a case  is  not 
singular,  and  may  be  preceded,  as  this  case  was 
by  nothing  beyond  an  occasional  feeling  of  dis- 
comfort at  the  epigastrium,  not  serious  enough  to 
call  for  advice  or  treatment. 

Such  symptoms  as  diarrhoea,  vomiting,  pain, 
tenderness,  and  pyrexia  are  as  much  dependent 
on  a co-existent  enteritis  or  r.ew-growth,  as  they 
are  upon  the  ulcer.  Doubtless  the  exposed 
surface  of  an  ulcer  offers  the  opportunity  for 
increased  peristalsis  being  induced,  but  this  is 
not  of  necessity',  for  constipation  may  be  present. 
AVhere  the  area  of  ulceration  is  extensive,  the 
absorbing  surface  is  by  so  much  diminished, 
and  thus  while  the  general  nutrition  suffers,  the 
unabsorbed  products  of  d'gestion  are  liable  to 
decompose  and  induce  diarrhoea.  Vomiting  may 
arise  from  a duodenal  ulcer,  but  not  always, 
and  when  present  it  may'  be  due  to  perito- 
nitis; icterus  may  also  complicate  an  ulcer  in 
this  situation,  by  involving  the  opening  of  the 
bile-duct,  or  by  extension  of  the  duodenal  ca- 
tarrh. Pain  may  be  quite  absent  or  quite 
insignificant,  unless  the  rectum  be  the  seat  oi 
the  disease,  when  the  pain  and  tenesmus  are 
excruciating. 

The  passage  of  blood  in  the  stools,  especially 
if  bright,  is  probably  a most  characteristic 
indication  of  ulceration,  but  it  does  not  always 


768  INTESTINES,  DISEASES  OF. 
occur,  and  it  may  be  due  to  general  venous 
congestion  from  partial  obstruction.  See  Stools. 

The  symptoms  due  to  perforation  have  been 
already  described.  See  Intestines,  Perforation 
and  Bupture  of. 

Diagnosis. — From  what  has  been  said,  the 
formation  of  a diagnosis  of  intestinal  ulceration 
is  frequently  impossible,  and  an  ulcer  is  assumed 
rather  than  proved  to  exist.  In  enteric  fever 
ulcerat  ion  is  taken  for  granted  as  existing,  though 
no  special  symptoms  may  indicate  its  presence. 
But  if  a severe  and  persistent  diarrhoea,  with 
liquid  stools  and  shreds  of  mucus,  and  much  pain 
and  tenderness  over  the  abdomen,  supervene  in  a 
case  of  tubercular  phthisis,  it  is  a fair  inference  to 
assume  ulceration  of  the  intestines.  In  dysentery, 
like  enteric  fever,  the  ulceration  is  a specific  part 
of  the  disease,  and  the  diarrhoea,  pain,  and  cha- 
racteristic stools  are  in  this  case  directly  de- 
pendent upon  the  ulceration.  Since  there  are  no 
constant  distinctive  symptoms  of  ulceration,  the 
ground  for  a diagnosis  must  remain  uncertain. 

Prognosis. — This  largely  depends  upon  the 
cause.  Except  through  perforation  or  fatal 
haemorrhage  by  erosion  of  vessels,  death  does  not 
take  place  from  the  ulceration  itself.  But  a 
tubercular  ulceration  is  not  to  bo  expected  to 
heal,  and  it  may  by  its  development  hasten 
the  end  of  a phthisical  patient.  The  prognosis 
in  typhoid  ulceration  will  almost  entirely  be 
founded  on  the  general  state  of  the  patient,  since 
the  indications  of  the  ulceration  itself  may  be  so 
slight.  The  ulceration  of  malignant  new-growtlis 
may  be  of  actual  benefit,  by  removing  portions 
of  the  mass,  and  so  diminishing  obstruction.  In 
all  cases  the  liability  to  stenosis  must  be  remem- 
bered; and  the  impaired  health  of  body  and  mind 
in  chronic  ulceration  may  continue  throughout  life. 

Treatment. — Since  ulcers  of  the  intestine  are 
inaccessible  to  direct  treatment,  little  can  be  done 
for  them  apart  from  the  general  conditions  which 
they  may  complicate, or  the  treatment  of  the  symp- 
toms to  which  they  may  give  rise. 

Becognising  that  an  ulcer,  when  it  exists,  may 
lead  to  perforation,  the  object  will  be  to  avoid 
all  undue  movements  of  the  intestines,  and  hence 
aperients  are  forbidden,  and  opiates  are  indicated. 
The  astringents  that  are  likely  to  bo  used  for  the 
diarrhoea  or  haemorrhage  may  exert  a local  action 
on  the  lesion,  and  for  that  purpose  bismuth,  sul- 
phate of  copper,  and  similar  agents,  are  recom- 
mended. But  rest  is  probably  the  only  element 
of  treatment  that  can  affect  the  ulcerative  process 
directly ; whilst  any  improvement  of  the  general 
condition  will  necessarily  favour  the  healing — 
objects  which  can  he  best  accomplished  by  the 
use  of  diet  of  the  most  bland  description,  or  of 
nutrient  enemata. 

In  the  preceding  article  the  diseases  to  which 
the  intestines  are 'liable  have  been  treated  of  as 
affecting  the  canal  as  a whole : but  it  will  be  ob- 
served that  when  the  structure  and  functions  of 
particular  regions  of  the  bowel  modify  the  cha- 
racter of  the  disease,  special  reference  is  made 
thereto  ; and,  further,  that  when  the  affections 
of  any  portion  require  detailed  description — as 
of  the  caecum  or  rectum,  the  reader  is  referred 
to  articles  under  those  headings. 

"William  Henry  Allchin. 


INUNCTION. 

INTRA-THORACIC  TUMOURS.— Un- 
der this  general  term  are  included  all  growdia 
and  diseases  within  the  chest,  which  give  rise  to 
tumours  or  swellings,  offering  more  or  less  me- 
chanical interference  with  the  functions  of  the 
thoracic  organs,  and  for  the  most  part  manifest- 
ing themselves  by  external  swellings.  Aneur- 
isms would  thus  be  comprised  in  this  general 
definition.  The  general  features  and  pathology 
of  aneurismal  tumours  are,  however,  so  distinct  as 
to  require  separate  consideration  ( see  Thoracic 
Aneurism).  Other  intra-thoraeic  tumours  will 
be  found  described  under  the  headings  Lung, 
Malignant  Disease  of ; and  Mediastinum,  Dis- 
eases of.  J.  Bisdon  Bennett. 

INTUSSUSCEPTION  ( intus , within,  and 
suscipio,  I receive).—  Aform  of  intestinal  obstruc- 
tion, in  which  one  portion  of  the  bowel  passes  infi. 
another  portion.  Sec  Intestinal  Obstruction. 

INUNCTION  (ill,  on.  and  unrjuo.  I anoint). 
Synon.  : Anointing. — This  is  a method  of  ap- 
plying certain  substances  to  the  cutaneous  sur- 
face, the  object  being  to  promote  their  absorption, 
either  for  the  purpose  of  producing  local  effects, 
or  of  influencing  the  system  generally.  Inunc- 
tion implies  more  or  less  friction,  the  substance 
employed  being  rubbed  with  the  hand  into  some 
part  of  the  skin.  When  used  for  local  purposes, 
the  part  to  be  anointed  must  be  chosen  accord- 
ingly; but  if  it  is  intended  to  affect  the  system, 
a region  must  be  selected  where  the  cutaneous 
tissues  are  thin,  such  as  the  inside  of  the  thighs, 
or  the  axillae,  so  that  absorption  may  take  place 
more  rapidly  and  easily.  The  rubbing  must  be 
carried  on  gently,  and  for  a variable  time  accor- 
ding to  circumstances;  it  may  be  aided  by  heat, 
being  performed  before  the  fire,  or  the  part  mav 
be  previously  fomented. 

Application  and  Uses. — The  pharmaceutical 
preparations  which  are  employed  for  inunction 
include  glycerines,  liniments,  oils,  ointments, 
oleates,  and  compounds  made  with  vaseline,  ozo- 
kerine,  and  other  materials  of  a like  nature  re- 
cently introduced.  If  these  are  used  for  local 
purposes,  they  may  be  employed  simply  on  ac- 
count of  the  oleaginous  ingredients,  or  to  allow 
friction  to  be  more  easily  carried  on ; but  active 
ingredients  are  often  combined  in  the  preparations 
mentioned  above,  varying  according  to  the  object 
sought  to  he  obtained,  such  as  to  produce  a stimu- 
lant or  an  anodyne  effect.  Inunction  for  procuring 
absorption  in  order  to  affect  the  system,  is  almost 
entirely  confined  to  the  use  of  mercury,  and  on 
this  subject  the  following  observations  were  writ- 
ten for  this  work  by  the  late  Mr.  Gascoyen:— 

‘ Inunction  is  an  old  but  very  effectual  plan 
of  introducing  mercury  into  the  system  by  the 
skin.  Although  objected  to  as  a dirty  method, 
and  therefore  less  practised  than  fumigation,  it 
is  often  much  more  convenient,  and  can  be  used 
in  many  eases  where  the  mercurial  bath  is  im- 
practicable. 

‘From  half  a drachm  to  one  drachm  of  strong 
mercurial  ointment,  mixed  with  an  equal  quan- 
tity of  lard,  should  be  rubbed  into  the  skin  on 
the  inside  of  the  thighs,  legs,  and  arms,  before 
a fire  at  bedtime,  using  the  different  limbs  on 
successive  nights.  The  friction  should  be  gent  A 


INUNCTION. 

and  continued  for  a quarter  of  an  hour  to  half 
an  hour,  -when  most  of  the  ointment  Trill  have 
disappeared;  the  surface  must  not  be  washed, 
and  the  patient  should  wear  the  same  flannel 
under-clothing  night  and  day.  The  ointment 
may  be  used  every  night  until  the  gums  give 
evidence  of  its  action,  when  the  quantity  and 
frequency  of  application  must  be  diminished. 
Sometimes  it  will  produce  an  irritation  of  the 
skin,  especially  in  fair  or  hairy  persons.  If  this 
occur,  the  surface  must  be  washed  clean,  and  the 
rubbing  discontinued. 

‘ Inunction  is  a most  convenient  way  of  treat- 
ing syphilis  in  young  children.  The  ointment 
should  be  spread  upon  a flannel  roller,  and  the 
body  of  the  child  swathed  therein  ; occasionally 
the  skin  should  be  washed,  and  fresh  ointment 
applied. 

‘Although  but  little  practised  now  in  this 
country,  inunction  is  still  largely  employed  on 
the  Continent,  and  pu'ticularlv  in  conjunction 
with  the  natural  sulpbur  waters,  for  cases  of  old- 
standing  syphilis.’  Frederick  T.  Roberts. 

INVAGINATION"  (in,  in,  and  vagina,  a 
sheath). — A synonym  for  intussusception.  See 
Intussusception  ; and  Intestinal  Obstruction. 

INVASION,  Modes  of. — This  expression 
oignifios  the  manner  in  which  a disease  sets  in 
or  commences,  and  the  mode  of  onset  of  an  ill- 
ness is  frequently  an  important  factor  in  forming 
a diagnosis  as  to  the  nature  of  the  complaint. 
The  following  are  the  variations  noticed  in  this 
respect: — 1.  The  invasion  may  be  absolutely  or 
almost  sudden,  although  slight  symptoms  may 
have  been  previously  observed,  indicating  the 
presence  of  some  morbid  condition,  but  not  suf- 
Sciently  marked  to  attract  attention.  Or  there 
nay  be  distinct  indications  of  some  disease,  but 
l secondary  lesion  suddenly  occurs  in  its  course, 
[“his  mode  of  onset  is  exemplified  by  the  im- 
aediate  effects  of  injuries,  apoplexy,  syncope, 
upture  of  the  heart,  cholera,  many  cases  of 
aemorrhage,  and  most  forms  of  colic.  Certain 
iseases  of  a paroxysmal  type  are  also  charac- 
arised  by  the  occurrence  of  attacks,  which  come 
i more  or  less  suddenly,  such  as  asthma,  ague, 
nd  epilepsy.  Some  cases  of  fevers,  especially 
’phus  and  relapsing  fever,  as  W'ell  as  of  in- 
immatory  diseases,  begin  in  a sudden  manner. 
Frequently  the  onset  is  acute,  the  symptoms 
ming  on  rapidly,  and  becoming  speedily  severe, 
ough  often  preceded  for  a variable  time  by  pre- 
onitory  symptoms.  This  is  illustrated  by  most 
ses  of  the  various  fevers,  and  the  different  forms 
acute  inflammation.  3.  A subacute  mode  of 
vasion  is  not  uncommonly  noticed,  this  being 
;s  rapid,  and  the  symptoms  less  marked  than 
here  it  is  acute.  4.  Most  affections  are  chronic 
■ their  onset,  setting  in  gradually,  and  often 
perceptibly,  so  that  it  may  be  a long  time 
ore  the  patient  is  aware  that  there  is  any  de- 
tion  from  health.  Frederick  T.  Roberts. 

ODISM. — Definition. — Iodism  is  the  term 
hin  which  we  include  a variety  of  painful 
‘ inconvenient  effects,  following,  under  certain 
t i circumstances,  the  administration  of  iodine 
a its  salts,  but  more  especially  the  iodide  of 
P issium. 

49 


IODISM.  7(5!) 

Description.— Iodide  of  potassium  being  in 
part,  at  least,  decomposed  in  the  presence  of 
ozone  by  the  acids  of  the  b:ood,  we  shall  en- 
deavour, in  considering  the  symptoms  of  iodism 
to  determine  which  are  due  to  the  iodine,  nn-l 
for  which,  the  potash  must  be  held  responsible. 
The  physiological  action  of  iodine  is  mainly  di- 
rected to  the  nutritive  and  glandular  functions, 
to  the  skin  and  mucous  membranes  ; whilst  tilt- 
salts  of  potash  are  not  only  diuretic  and  purga 
tive,  but,  experimentally  at  least,  powerfully  de 
press  the  heart  and  spinal  cord. 

Killiet,  the  most  exhaustive  writer  on  th» 
subject,  makes  three  forms  of  iodic  intoxica- 
tion : the  first  consisting  of  gastric  irritation  : 
the  second,  where  nervous  troubles  come  ir.t- 
more  special  prominence:  whilst  cachexia  and 
rapid  emaciation  characterise  the.  third.  But  the 
most  orderly  and  convenient  plan  to  pursue,  will 
be  to  take  into  consideration,  in  regular  order, 
the  effects  produced  by  iodine  salts  on  the  va- 
rious organs  and  functions  of  the  body,  under 
various  conditions  of  idiosyncrasy  or  retarded 
elimination. 

1.  On  the  nervous  system. — Mental  depression 
and  diminution  of  muscular  energy  are  not  in- 
frequently noted  in  patients  taking  iodide  of 
potassium ; whilst  neuralgia,  tinnitus  aurium, 
and  convulsive  movements  have  also  been  de- 
scribed. It  is  probable  that  the  potash  is  here 
the  active  agent. 

2.  On  mucous  membranes. — Much  mucous  irri- 
tation is  occasionally  observed;  conjunctivitis, 
lachrymation,  sneezing  and  running  from  the  nose, 
frontal  headache,  and  puffy  swelling  of  the  oye- 
lids,  closely  simulating  coryza,  being  the  most 
common  symptoms  of  iodism,  and  sometimes 
following  a single  small  or  moderate  dose. 
Pharyngeal  congestion,  and  irritable  redness  of 
gums  and  tongue,  have  also  been  described. 
These  symptoms  are  doubtless  due  to  the  iodine. 

3.  On  the  skin. — The  eruptions  produced  by 
iodide  of  potassium  have  recently  attracted  much 
attention,  and  they  appear  under  several  forms. 
Erythema  has  been  observed ; and  most  practi- 
tioners of  experience  must  have  seen  the  small 
round  petechial  spots,  situated  between  the  knees 
and  ankles.  These  do  not  as  a rule  cause  any 
inconvenience,  and  are  usually  accidentally  dis- 
covered; but  Dr.  Stephen  Mackenzie  records  the 
case  of  an  infant  of  five  months  old,  suffering 
from  hereditary  syphilis,  who  died  of  purpura 
after  taking  two  and  a half  grains  of  iodide  of 
potassium  in  a single  dose.  Some  further  points 
of  interest,  in  connection  with  a case  of  this 
kind,  reported  by  Dr.  G.  F.  Duffey,  will  be  found 
in  the  British  Medical  Journal,  1880,  vol.  i. 
p.  626. 

A papular  and  pustular  eruption  resembling 
acne,  and  occasionally  appearing  in  so  great  pro- 
fusion as  to  excite  the  suspicion  of  small-pox. 
is  not  very  uncommon.  The  late  Dr.  Tilbury 
Fox  has  noted  ‘a  quasi-bullous  disease,’  sum- 
ming up  the  description  of  his  cases  as  follows : 
‘In  some  parts  they  resembled  acne  simplex ; in 
others  they  vesiculated  and  subsequently  simu- 
lated variolous  pustules ; at  a later  stage  ecthy- 
ma ; finally  bullae  filled  with  milky  contents,  or 
discharging  smegma;  and  these  bullae  possessed 
I peculiar  solid  bases  wholly  unlike  true  bullsp, 


770  IODISM. 

aud  answering  rather  to  large  molluscum  eonta- 
giosum  tumours  with  semi-fluid  instead  of  more 
solid  contents.  ’ 

Dr.  Fox  believed  this  condition  to  be  essenti- 
ally distinct  from  hydroa,  but  Mr.  Hutchinson  has 
brought  forward  good  evidence  to  show  that  the 
rare  skin-affection  going  under  that  name  must 
usually  be  looked  upon  as  one  of  the  symptoms 
of  iodism.  The  same  author  mentions  a case  of 
deep  and  unhealthy  ulceration  of  the  legs  follow- 
ing the  prolonged  use  of  iodide  of  potassium.  It 
seems  probable  that  the  iodine  rather  than  the 
potash  must  be  held  responsible  for  these  symp- 
toms. tiea  Archives  of  Dermatology,  1880. 

4.  On  the  nutritive  and  glandular  systems. — 
Patients  taking  iodide  of  potassium  sometimes 
complain  of  nausea,  anorexia,  and  a bitter  taste 
in  the  mouth ; but  where  cachectic  symptoms 
supervene,  indicated  by  rapid  emaciation,  nervous 
palpitation,  insommia,  and  hypochondriasis,  a ra- 
venous desire  for  food  has  been  observed.  Vo- 
miting, diarrhoea,  and  diuresis  have  also  been 
described.  Salivation  is  not  an  uncommon  symp- 
tom. A time-honoured  accusation  against  iodine 
is  its  supposed  tendency  to  cause  atrophy  of  the 
mammae  and  testicles  ; of  this,  fortunately,  there 
is  no  real  proof,  the  disappearance  of  the  testicle, 
which  occasionally  accompanies  the  absorption  of 
inflammatory  products  in  its  substance,  being 
sometimes  unjustly  attributed  to  the  treatment 
pursued. 

Pathology. — The  only  reason  for  the  occur- 
rence of  many  cases  of  iodism  seems  to  be  an  in- 
dividual peculiarity  on  the  part  of  the  patient,  or 
iu  other  words,  that  idiosyncrasy  which  so  fre- 
quently interferes  with  our  efforts  for  the  treat- 
ment of  disease.  But  now  and  then  a more  plausible 
explanation  may  be  given,  when  we  find  cardiac 
or  renal  disease  coinciding  with  the  pustular  rash 
of  iodide  of  potassium.  Retarded  capillary  cir- 
culation would  naturally  detain  the  drug  within  i 
the  blood  ; whilst  the  blocking  of  its  usual  means 
of  exit  from  the  system  might  be  supposed  to 
throw  the  onus  of  elimination  on  the  glandular 
structures  of  the  skin.  Hence  has  been  derived 
the  plausible  theory  that  iodine-acne  is  produced 
by  direct  local  stimulation  of  the  sebaceous 
structures;  but,  however  true  this  may  be  in  the 
slighter  cases,  Dr.  Thin’s  careful  examination 
of  the  skin  of  a. patient  suffering  from  a bullous 
rash,  has  shown  the  true  pathological  condition 
to  be  one  of  rupture  of  blood-vessels  at  certain 
localised  points,  with  blocking  by  coagula,  and 
escape  of  some  of  the  constituents  of  the  blood 
into  the  sui'rounding  tissues.  The  sebaceous  ele- 
ments and  sweat-glands  were  quite  unaffected, 
and  he  believes  the  iodic  papule,  the  so-called 
acne,  the  bulla,  and  the  purpuric  spot,  to  repre- 
sent different  stages  of  vascular  injury.  Drs. 
Duckworth  and  Vineent-Harris  were  unable  in 
their  observations  to  detect  any  rupture  of  ves- 
sels, but  confirm  Dr.  Thin's  report  in  all  other 
essential  respects. 

Diagnosis.  — Coryza,  or  any  skin-eruption, 
suddenly  occurring  in  a patient  taking  iodide  of 
potassium,  ought  to  be  looked  upon  with  sus- 
picion, and  treated  by  the  immediate  suspension 
of  the  drug.  The  slighter  varieties  of  iodism 
are  by  no  means  uncommon,  and  may  appear  after 
a single  small  dose ; but  although  ammonia  has 


IRRITATIVE  FEVER. 

been  confidently  vaunted  as  a specific  against 
such  irregular  manifestations  of  physiological 
activity,  experience  has  been  unableto  confirm 
this,  and  we  should  place  more  faith  in  encourag- 
ing prompt  elimination  by  very  free  dilution  of 
the  remedy. 

Fortunately,  the  graver  symptoms  of  iodism 
are  decidedly  rare,  and  we  may  all  the  more  con- 
gratulate ourselves  on  this,  when  we  remember 
how  powerless  we  are  to  recognise  the  idiosyn- 
crasy on  which  they  depend.  Trousseau,  how- 
ever, pointed  out  that  iodine  is  always  badly 
borne  in  exophthalmic  goitre;  and  Dr." Stephen 
Mackenzie  is  inclined  to  credit  syphilis  with 
some  share  in  producing  the  purpura  which 
proved  fatal  to  his  patient. 

Robert  Fauqvhabson. 

IRELAND,  South,  of.  See  Queenstown. 
Glengariff  is  also  deserving  of  notice. 

IRITIS.~-Inflammation  of  the  iris.  See 
Eye  and  its  Appendages,  Diseases  of. 

IRREGULAR. — This  term  is  applied  to 
cases  of  disease  which  do  not  run  their  regular 
or  typical  course,  such  as  gout  (see  Gout);  or 
to  functions  when  they  are  disturbed  with  respect 
to  time  or  rhythm— as  the  pulse,  the  bowels,  or 
menstruation. 

IRRIGATION  ( irrigo , I water). — A method 
of  applying  cold  water  as  a therapeutical  agent, 
which  consists  in  causing  it  to  fall  drop  by  drop 
on  one  spot.  See  Cold,  Therapeutics  of. 

IRRITABILITY  ( irrito , I provoke).-In 
physiology  this  word  signifies  the  power  of  re- 
sponding to  a stimulus,  as  exemplified  by  the 
contractility  of  muscular  tissue.  In  medicine 
irritability  implies  an  undue  excitability  of  an 
organ  or  tissue,  from  disease  or  disorder,  sucli 
I as  of  the  brain,  spinal  cord,  stomach,  eye,  or 
bladder. 

IRRITATIVE  FEVER.  — The  nervous 

disturbance  consequent  upon  fretting  of  the  sys- 
tem byr  various  sources  of  irritation,  gives  rise  > 
to  a pyrexia  which  is  often  called  ' Irritative 
fever.’  The  febrile  excitement  so  familiar  to 
the  surgeon  as  a consequence  of  wounds  and  in- 
juries may  be  classed  under  this  head.  It  may, 
however,  be  provoked  by  any  kind  of  irritation, 
especially  irritation  applied  to  the  mucous 
membrane  of  the  aliment  ary  canal.  The  rise  of 
tempei’ature  which  often  accompanies  irritation 
of  the  bowels  by  scybalse  or  acrid  secretions, 
aud  the  febrile  phenomena  attendant  upon  den- 
tition, may  be  quoted  as  familiar  examples 
of  irritative  fever  which  must  be  within  the 
experience  of  all. 

The  readiness  with  which  pyrexia  can  be  , 
induced  by  these  and  similar  causes  must  vary 
according  to  the  intensity  of  the  irritant,  and  the 
constitutional  peculiarities  of  the  individual 
upon  whom  it  operates.  As  a rule,  men  are  less 
susceptible  than  women,  and  women  than  chil- 
dren. In  children,  indeed,  with  their  exalted 
nervous  sensibility,  feverishness  from  thiscausc 
is  a common  symptom.  In  young  subjects 
mental  emotion  alone  will  often  produce  a rise 
of  temperature,  which  may  be  a source  of  per- 
plexity. In  children's  hoq  itals  it  is  a common 


IRRITATIVE  FEVER. 

observation  that  the  bodily  temperature  on  the 
night  of  admission  is  high,  even  although  the 
illness  affecting  the -child  is  one  not  in  itself 
usually  accompanied  by  fever. 

Dentition  in  young  children  is  so  frequent  a 
cause  of  pyrexia,  that  the  state  of  the  gums 
should  never  be  overlooked  in  any  case  where 
feverishness  is  a prominent  symptom.  Neglect 
of  this  precaution  may  cause  some  obscurity  in 
the  diagnosis.  Thus,  if  a child,  while  cutting  a 
tooth,  have  an  attack  of  pulmonary  catarrh,  the 
temperature  will  almost  certainly  be  high.  In 
such  a case  the  cough,  combined  with  fever, 
rapid  breathing,  and  a quick  pulse,  might  natu- 
rally suggest  the  presence  of  pneumonia.  On 
examination,  however,  it  will  be  found  that  the 
pulse-respiration  ratio  is  little  perverted,  the 
cough  is  loose  and  not  hacking,  and  the  history 
of  the  attack  is  not  the  history  of  pneumonia. 
On  searching  further  for  a cause  of  the  pyrexia, 
tension  and  swelling  of  the  gums  will  be  noticed, 
and  the  difficulty  will  be  at  once  explained. 

Irritation  of  the  stomach  and  bowels  by 
icrid  secretions  or  indigestible  food  is  another 
common  cause  of  irritative  fever  in  children. 
The  intense  nervous  disturbance  excited  in 
young  babies  by  an  improper  meal  induces  a 
rapid  rise  of  temperature,  and  may  culminate  in 
an  attack  of  convulsions.  Fsecal  accumulation, 
or  the  irritation  of  worms  in  the  bowels,  may 
also,  in  children  and  delicate  women,  produce 
sufficient  disturbance  to  give  rise  to  fever. 

In  children  the  sensitiveness  of  the  system  to 
irritants  varies  according  to  the  age  of  the  child, 
according  to  the  natural  impressionability  of  its 
nervous  system,  and  also  according  to  the  state 
of  its  general  health.  Thus,  as  a rule,  the 
younger  the  child,  the  more  sensitive  is  its  ner- 
vous system;  but  even  in  young  babies  differ- 
ences will  be  found  in  this  respect,  some  being 
affected  much  less  easily  than  others  by  reflex 
stimuli.  In  all,  however,  slow  reduction  of  the 
strength,  such  as  is  produced  by  progressive 
ichronie  disease,  gradually  reduces  nervous  sen- 
jhibility  ; and  a child,  enfeebled  by  an  illness  of 
ong  standing,  may  show  a complete  insensi- 
nlity  to  all  nervous  impressions.  In  voung  sub- 


JAUNDICE.  771 

jects  irritative  fever,  like  other  forms  of  pyrexia, 
is  usually  remittent;  but  its  remissions  are  not 
always  found  at  the  same  period  of  the  twenty  - 
j four  hours.  There  is  not,  for  instance,  always  a 
fall  of  temperature  in  the  morning  and  a rise  at 
night.  One  of  the  peculiarities  of  this  form  of 
febrile  disturbance  is  the  irregularity  of  the 
fever.  A high  morning  temperature  in  a young- 
child  should  always  suggest  a reflex  cause  for  the 
pyrexia. 

Treatment. — The  treatment  of  irritative  fever 
must  be  directed  to  the  relief  or  to  the  removal 
of  the  irritating  source  from  which  the  fever  pro- 
ceeds. The  use  of  febrifuge  remedies  may  be  also 
called  for,  if  constitutional  symptoms  be  marked 
or  persistent.  Eustace  Smith. 

ISCHEMIA  (iVxw,  I restrain,  and  aT,ua,  tho 
blood). — Deficiency  of  blood  in  a part,  short  ol 
complete  cessation  of  tho  circulation : partial 
anaemia.  See  Circulation,  Disorders  of. 

ISCHIALGIA  ( l(rx'‘ov , the  haunch,  and 
pain). — A synonym  for  sciatica.  See 
Sciatica. 

ISCHL,  in  the  Saltzkammergut,  Austria. 
A sheltered,  bracing,  mild,  rather  moist  cli- 
mate. Altitude  1,560  feet.  Thermal  common 
saline  baths.  See  Climate,  Treatment  of  Disease- 
by  ; and  Mineral  Waters. 

ISCHURIA  (lex",  I restrain,  and  oOpov,  t in 
urine). — This  word  properly  signifies  the  arrest 
of  the  secretion  of  urine  (see  Urine,  Suppres- 
sion of).  It  is  also  applied  to  mere  retention  ot 
urine. 

ISSUES.  See  Counter-irritation. 

ITALY.  See  Climate,  Treatment  of  Dis- 
ease by;  and  Naples,  Pisa,  Rome,  and  San  Remo. 

ITCH.  A popular  name  for  scabies.  See 
Scabies. 

ITCHING.  See  Pruritus. 

-ITIS.  A terminal  syllable  used  to  indicate 
an  inflammatory  disease  of  a tissue,  or  organ  ; for 
example,  Pleuritis,  Hepatitis,  or  Cystitis. 


J 


JACTATIOHh  or  JACTITATION  (jae- 
,tio,  a tossing  about  of  the  body,  or  marked 
btlessuess). — This  is  a condition  mostly  asso- 
ited  with  certain  severe  febrile  diseases,  but 
so  with  some  nervous  affections,  with  severe 
ii-iearditis,  or  as  a sequence  of  copious  uterine 
other  haemorrhages.  A restlessness  amounting 
jactation  may  likewise  be  met  with  in  some 
1 tents,  when  suffering  from  severe  or  long- 
' tinned  pain.  It  must  not  be  confounded 
' h certain  forms  of  chorea,  in  which  a some- 
Vit  similar  tossing  about  of  the  body  may  be 
< ountered.  The  absence  of  pain  and  of  marked 


febrile  disturbance,  together  with  the  history  of 
the  patient,  will,  even  in  the  cases  where  the 
general  resemblance  is  closest,  speedily  enable 
the  latter  condition  to  be  recognised. 

JAUNDICE. — Syxox. : Icterus;  Morbus 

regius ; Morbus  arquatus  (Celsus)  ; Pr.  Ictere  ; 
Jaunisse ; Ger.  Gelbsuclit. 

Definition. — Jaundice  may  be  defined  as  a 
yellowness  of  the  integuments  and  conjunetivae, 
and  of  the  tissues  and  secretions  generally,  from 
impregnation  with  bile-pigment. 

vEtioi.ogy  and  Pathology. — All  cases  -># 


JAUNDICE. 


772 

jaundiee  may  be  referred  to  one  of  two 
classes : — 

1.  Cases  in  which  there  is  a mechanical  im- 
pediment to  the  flow  of  bile  into  the  duodenum, 
and  where  the  bile  is  in  consequence  retained  in 
the  biliary  passages,  and  thence  absorbed  into 
the  blood. 

2.  Cases  in  which  there  is  no  impediment  to 
the  flow  of  bile  from  the  liver  into  the  bowel. 

These  two  forms  of  jaundice  have  long  been 
recognised ; but  there  is  much  difference  of 
opinion  as  to  the  mode  of  production  of  the  jaun- 
dice in  the  second  class  of  cases,  although  these 
are,  perhaps,  the  most  common  in  practice. 

When  there  is  any  obstruction  to  the  flow  of 
bile  through  the  hepatic  or  common  duct,  the 
way  in  which  jaundice  arises  is  sufficiently  clear. 
The  bile-ducts  and  the  gall-bladder  become  dis- 
tended with  bile,  which  is  absorbed  into  the 
blood  by  the  lymphatics  and  the  veins.  If  the 
hepatic  duct  of  a dog  be  ligatured,  and  the  animal 
killed  after  two  hours,  the  lymphatics  in  the  walls 
of  the  bile-ducts  are  seen  to  be  distended  with 
yellow  fluid;  the  fluid  in  the  thoracic  duct  is 
also  yellow,  and  so  likewise  are  the  intervening 
lymphatic  glands.  In  patients  also  who  die  of 
obstruction  of  the  bile-duct,  the  lymphatics  of 
the  liver  are  often  found  to  contain  bile.  On 
the  other  hand,  two  hours  after  ligature  of  the 
common  duct,  the  serum  of  blood  taken  from  the 
hepatic  vein  contains  much  more  bile-pigment 
than  that  of  blood  taken  from  the  jugular  vein, 
which  shows  that  in  cases  of  obstruction  of  the 
bile-duct,  bile  is  also  directly  absorbed  by  the 
veins. 

But  in  a large  proportion  of  cases  there  is  no 
mechanical  impediment  to  the  escape  of  bile  from 
the  liver,  and  then  an  explanation  of  the  jaundice 
is  less  obvious.  Boerhaave  and  Morgagni  long 
ago  suggested  that  the  jaundice  in  these  cases 
was  the  result  of  a suspended  secretion.  They 
taught  that  the  function  of  the  liver  was  merely 
to  separate  the  elements  of  bile  which  were 
already  formed  in  the  blood,  and  that  when 
anything  interfered  with  the  function  of  the  liver, 
the  elements  of  bile  accumulated  in  the  blood, 
and  the  result  was  jaundice  of  the  skin  and  other 
tissues.  Although  this  view  has  been  strenuously 
opposed  by  several  excellent  authorities,  it  is,  in 
this  country  at  all  events,  still  generally  accepted. 
It  is  advocated,  for  example,  by  Dr.  George 
Budd,  in  his  valuable  treatise  on  diseases  of  the 
liver,  although  it  is  but  right  to  add  that  Dr. 
Budd  makes  a special  exception  with  regard  to 
the  biliary  acids.  ‘ The  most  skilful  chemists,’ 
he  says,  ‘ who  have  recently  analysed  the  portal 
blood,  have  failed  to  detect  the  biliary  acids  in 
it,  and  have  come  to  the  conclusion  that  these 
at  least  are  formed  in  the  liver.’  This  opinion, 
that  the  liver  manufactures  the  bile-acids,  while 
it  merely  excretes  the  bile-pigment,  was  adopted 
by  Dr.  G.  Harley,  in  his  essay  on  jaundice. 

There  are,  however,  weighty  objections  to  this 
view,  some  of  which  may  bo  mentioned. 

1.  Although  bile-pigment  appears  to  be  de- 
rived from  the  colouring  matter  of  the  blood,  it 
has  not  yet  been  satisfactorily  shown  that  bile- 
pigment,  as  such,  exists  ready  formed  in  the 
blood  of  persons  who  have  not  jaundice.  Frerichs 
denies  that  it  ever  has.  Lehmann,  who  has  in- 


vestigated with  great  care  the  changes  which  the 
blood  undergoes  in  passing  through  the  liver, 
has  never  been  able  to  detect  tho  colouring 
matter  of  bile  in  portal  blood,  and  infers  that 
this,  as  well  as  the  bile-acids,  must  be  formed  in 
the  liver  itself.  The  blood  of  the  hepatic  artery 
has  been  examined  with  a like  result.  It  is 
obvious  that  if  bile-pigment  exists  in  healthy 
blood  at  all,  its  quantity  must  be  very  minute ; 
and  when  we  consider  that  the  quantity  of  bile 
secreted  by  the  human  liver  daiiy  is  about  two 
pints,  and  yet  that  jaundice  is  not  a normal 
condition,  it  seems  impossible  that  all  the  bile- 
pigment  secreted  by  the  liver  can  be  formed  in 
the  blood,  and  it  is  not  probable  that  part  is 
formed  in  the  blood  and  part  in  the  liver.  The 
discovery  by  a few  observers  of  a small  quantity 
of  bile-pigment  in  what  appeared  normal  blood 
does  not  prove  that  it  was  formed  in  the  blood. 
It  is  quite  conceivable  that  it  may  have  been 
formed  in  the  liver,  and  have  become  subse- 
quently absorbed. 

2.  The  secreting  tissue  of  the  liver  is  often 
for  the  most  part  or  entirely  destroyed,  so  that 
bile  is  no  longer  secreted,  and  yet  no  jaundice 
results.  If  bile-pigment  be  formed  in  the  circu- 
lating blood,  it  is  difficult  to  explain  what  be- 
comes of  it  in  these  cases. 

3.  If  the  constituents  of  bile  are  formed  in  tho 
blood,  intense  jaundice  ought  at  once  to  follow 
the  extirpation  of  the  liver  in  any  of  the  lower 
animals,  in  like  manner  as  urea  accumulates  in 
the  blood  after  removal  of  tho  kidneys.  But 
Muller,  Kunde,  Lehmann,  and  Moleschott  have 
repeatedly  extirpated  the  liver  of  frogs,  and  haTe 
invariably  failed  to  find  a trace  of  the  biliary 
acids,  or  of  bile-pigment,  in  the  blood,  the  urine, 
or  the  muscular  tissue. 

These  and  other  considerations  make  it  very 
doubtful  if  any  case  of  jaundice  can  with  pro- 
priety be  attributed  to  a suppression  of  the 
hepatic  functions ; and  it  is  therefore  necessary 
to  seek  for  some  other  explanation  of  those  cases 
of  jaundice  in  which  there  is  no  obstruction  in 
the  bile-duct. 

A solution  of  tho  difficulty  has  been  proposed 
by  Professor  Frerichs,  of  Berlin.  According  to 
this  distinguished  observer,  a large  proportion  of 
the  colourless  bile-acids  found  in  the  liver  is 
either  directly  taken  up  by  the  blood  in  the 
hepatic  vein,  or  is  absorbed  from  the  bowel. 
Under  ordinary  circumstances,  these  bile-acids 
become  oxydised  and  assist  in  forming  tho 
large  quantity  of  taurin  found  in  healthy  lung 
and  the  pigments  voided  in  the  urine;  but  it 
these  normal  metamorphoses  are  interrupted  by 
nervous  agencies,  or  by  poisons  in  the  blood,  the 
bile-acids,  not  being  sufficiently  oxydised,  are 
converted  into  bile-pigment  in  the  blood,  an! 
the  result  is  jaundice.  This  view  has  been  sup- 
ported by  two  experiments  intended  to  show 
first,  that  bile-pigment  can  be  produced  artifi- 
cially from  the  bile-acids,  by  the  action  of  con- 
centrated sulphuric  acid ; and,  secondly,  that 
colourless  biliary  acids,  whon  injected  into  the 
veins  of  dogs,  are  converted  in  the  blood  of  theso 
animals  into  bile-pigment.  There  is,  however 
far  from  being  unanimity  among  different  obser- 
vers as  to  the  results  of  these  experiments;  ana 
a decision  of  the  points  at  issue  does  not  appear 


JAUNDICE. 


(obe  of  material  importance  for  explaining  those 
eases  of  jaundice  in  which  there  is  no  obstruc- 
tion of  the  bile-duct,  inasmuch  as  there  are  good 
grounds  for  believing  that  not  only  in  jaundice, 
but  in  health,  a portion  of  the  bile-pigment,  as 
well  as  of  the  bile-acids,  formed  in  the  liver,  is 
absorbed  into  the  blood. 

Although  the  amount  of  bile  secreted  daily 
must  vary  in  different  persons,  and  in  the  same 
person  under  different  circumstances,  being  modi- 
fied by  the  quantity  and  quality  of  the  food,  the 
activity  of  respiration,  and  other  conditions,  there 
can  be  little  doubt  that  but  a small  portion  of 
that  which  is  ordinarily  secreted  is  discharged 
from  the  bowel.  Observations  on  the  lower 
animals  and  on  man  himself  have  shown  that 
the  quantity  of  bile  secreted  by  the  liver  of  a 
nealtby  adult  averages  forty  ounces.  It  is  gener- 
ally admitted  that  the  faeces  contain  but  a frac- 
tion of  the  bile-acids  (altered)  corresponding  to 
this  quantity  of  bile,  and  it  seems  equally  clear 
that  much  of  the  bile-pigment  must  also  dis- 
lppear  in  the  bowel.  There  are  grounds  for 
relieving  that  the  bile-pigment  which  so  dis- 
appears goes  to  form  urinary  pigment ; while 
the  fact  familiar  to  all  clinical  observers,  that 
'.he  bile-pigment  discharged  from  the  bowel  is 
greatly  increased  by  calomel  and  other  purga- 
tives, without  any  corresponding  increase  of 
secretion  of  bile  by  the  liver,  seems  to  show  that 
under  ordinary  circumstances  much  of  the  "bile— 

|i  pigment  secreted  by  the  liver  is  not  discharged 
with  the  faeces.  It  may  bo  added  that  in  carni- 
vorous animals  and  in  snakes,  although  bile- 
pigment  is  secreted  in  abundance  by  the  liver, 
the  quantity  discharged  with  the  feces  is  even 
relatively  less  than  in  man. 

The  question  as  to  what  becomes  of  the  bile 
which  is  not  discharged  from  the  bowel  has  an 
important  bearing  on  the  pathology  of  the  cases 
of  jaundice  now  under  consideration.  A large 
proportion  of  it  is  again  absorbed,  either  by  the 
biliary  passages,  or  by  the  mucous  membrane  of 
the  bowel.  From  what  is  now  known  of  the  dif- 
fusibility  of  fluids  through  animal  membranes, 
it  is  impossible  to  conceive  bile  long  in  contact 
with  the  lining  membrane  of  the  gall-bladder, 
bile-ducts,  and  intestine,  without  a large  portion 
of  it  passing  into  the  circulating  blood.  The 
constant  secretion  and  roabsorption  of  bile  is, 
in  fact,  merely  part  of  that  osmotic  circulation 
constantly  taking  place  between  the  fluid  con- 
ents  of  the  bowel  and  the  blood,  the  existence 
if  which  is  too  little  heeded  in  our  pathological 
peculations  and  in  therapeutics.  The  quantity 
'f  fluid  which  is  being  thus  constantly  poured 
ut  from  the  gastric  and  intestinal  glands,  the 
iver,  pancreas,  &e.,  and  then  reabsorbed  is 
normous  ; in  twenty-four  hours  it  probably  far 
jxceeds  tho  whole  amount  of  blood  and  fluid  in 
lie  body.  The  effect  of  this  continual  outpour- 
ig  is  supposed  to  be  to  aid  metamorphosis ; the 
ime  substance,  more  or  less  changed,  seems  to 
e thrown  out  and  reabsorbed,  until  it  is  adapted 
>r  the  repair  of  tissue  or  becomes  effete.  How 
I'any  times  this  cycle  of  movement  is  repeated, 
cfore  the  bile  is  extruded  from  the  system,  we 
ive  no  means  of  knowing;  but  in  the  course  of 
['is  osmotic  circulation,  much  of  the  bile  appears 
become  transformed  into  products  which  are 


773 

eliminated  by  tho  lungs  and  kidneys,  while 
at  the  same  time  this  circulation  assists  in  the 
assimilation  of  the  nutritive  materials  derived 
from  the  food. 

Here,  then,  we  have  an  explanation  of  those 
cases  of  jaundice  where  there  is  no  impediment 
to  the  flow  of  bile  from  the  liver.  Under  nor- 
mal conditions,  the  whole  of  the  bile  that  is  ab- 
sorbed is  at  once  transformed,  so  that  neither 
bile-acids  nor  bile-pigment  can  be  discovered  in 
the  blood  or  in  the  urine,  and  there  is  no  jaun 
dice.  But  in  certain  morbid  states,  the  absorbed 
bile  does  not  undergo  tho  normal  metamorphoses  ; 
it  circulates  in  the  blood  and  stains  the  skin  and 
other  tissues,  and  in  this  way  we  have  jaundice 
without  any  obstruction  of  the  bile-duct.  The 
morbid  states  which,  so  far  as  we  know,  conduce 
mainly  to  this  result  are,  for  the  most  part,  pre- 
cisely those  in  which  we  might  expect  abnormal 
blood-metamorphoses,  namely:— 

1.  Certain  poisons,  such  as  those  of  yellow- 
fever,  relapsing  fever,  pyaemia,  and  more  rarely 
those  of  remittent  fever,  typhus,  and  scarlatina; 
also  snake-poison,  chloroform,  &c. 

2.  Nervous  influences,  such  as  a sudden  fright, 
violent  rage,  great  or  protracted  anxiety,  and 
concussion  of  the  brain. 

3.  A deficient  supply  of  oxygen,  as  happens 
in  certain  cases  of  pneumonia,  or  in  persons 
living  in  confined  and  crowded  dwellings. 

4.  An  excessive  secretion  of  bile,  especially 
when  conjoined  with  constipation.  In  this  case, 
unless  the  bile  he  removed  by  purging,  tho 
quantity  absorbed  may  be  too  great  to  undergo 
the  normal  metamorphoses,  and  tho  presence  in 
the  blood  of  the  untransformed  bile  causes 
jaundice. 

According  to  this  view,  the  only  pathological 
difference  between  jaundice  from  obstruction 
and  jaundice  independent  of  obstruction  of  tho 
common  bile-duct  is  that,  in  the  former  case, 
little  or  none  of  the  bile  secreted  by  the  liver 
can  escape  from  the  body  with  the  feces,  and  con- 
sequently all  that  is  secreted  is  absorbed  into 
the  blood,  and  the  quantity  thus  absorbed  is  far 
too  great  to  undergo  the  normal  metamorphoses ; 
while,  in  the  latter  case,  bile  passes  into,  and  is 
discharged  from  the  bowel,  as  usual,  but  that 
which  is  absorbed,  which  in  quantity  may  not 
exceed  what  is  absorbed  in  health,  remains  un- 
changed in  the  blood.  As  might  be  expected, 
the  jaundice  in  the  former  case  is  usually  much 
more  intense  than  in  tho  latter,  although,  when 
an  obstruction  of  the  bile-duct  has  lasted  long, 
the  jaundice  often  becomes  paler,  not  from  any 
diminution  of  the  obstruction,  but  from  the 
secreting  tissue  of  the  liver  becoming  destroyed, 
and  comparatively  little  bile  being  secreted ; 
while  in  cases  where  there  is  no  obstruction  of 
the  bile-duct,  the  intensity  of  the  jaundice  will 
vary  according  to  the  amount  of  bile  which  ie 
absorbed,  and  the  degree  of  derangement  of  the 
blood-metamorphosis. 

With  these  preliminary  remarks  on  the  pa- 
thology of  jaundice,  we  may  now  proceed  to 
enumerate  its  different  causes,  which  may  ho 
classified  according  to  the  following  tabular 
form  :— 

A.  Jaundice  from  Mechanical  Obstruction 

of  the  Bile-duct. 


JAUNDICE. 


774 

I.  Obstruction  by  foreign  bodies  within  the 
luct. 

1.  Gall-stones  and  inspissated  bile. 

2.  Hydatids  and  distomata. 

S.  Foreign  bodies  from  the  intestines. 

II.  Obstruction  by  inflammatory  tumefaction 
if  the  duodenum,  or  of  the  lining  membrane  of  the 
duct,  with  exudation  into  its  interior. 

III.  Obstruction  by  stricture  or  obliteration  of 
'hr  duct. 

1 . Congenital  deficiency  of  the  duct. 

2.  Stricture  from  perihepatitis. 

3.  Closure  of  orifice  of  duct  in  consequence  of 
an  ulcer  in  the  duodenum. 

4.  Stricture  from  cicatrization  of  ulcers  in  the 
bile-ducts. 

5.  Spasmodic  stricture. 

IV.  Obstruction  by  tumours  closing  the  orifice 
of  the  duct,  or  growing  in  its  interior. 

V.  Obstruction  by  pressure  on  the  duct  from 
without,  by : — 

1.  Tumours  projecting  from  the  liver  itself. 

2.  Enlarged  glands  in  the  fissure  of  the  liver. 

3.  Tumour  of  the  stomach. 

4.  Tumour  of  duodenum  or  pancreas. 

5.  Tumour  of  the  kidney. 

6.  Post-peritoneal,  or  omental  tumour. 

7.  An  abdominal  aneurism. 

8.  Accumulation  of  fasces  in  the  bowels. 

9.  A pregnant  uterus. 

10.  Ovarian  and  uterine  tumours. 

B.  Jaundice  independent  of  Mechanical 
Obstruction  of  the  Bile-duct. 

I.  Poisons  in  the  blood  interfering  with  the 
normal  metamorphosis  of  bile. 

1.  The  poisons  of  the  various  specific  fevers. 

a.  Yellow  fever.  b.  Remittent  and  inter- 
mittent fevers,  c.  Relapsing  fever,  d.  Typhus. 
e.  Enteric  fever,  f.  Scarlatina,  g.  Epidemic 
Jaundice. 

2.  Animal  poisons,  a.  Pyaemia,  b.  Snake- 
poi  son. 

3.  Mineral  poisons,  a.  Phosphorus,  b.  Mer- 
cury. c.  Copper,  d.  Antimony. 

4.  Chloroform  and  ether. 

5.  Acute  atrophy  of  the  liver  ? 

11.  Impaired  or  deranged  innervation  interfer- 
ing with  the  normal  metamorphosis  of  bile. 

'1 . Severe  mental  emotions,  fright,  anxiety,  & c. 

2.  Concussion  of  the  brain. 

III.  Deficient  oxygenation  of  the  blood,  inter- 
fering with  the  normal  metamorphosis  of  bile. 

IV.  Excessive  secretion  of  bile,  more  of  which 
is  absorbed  than  can  undergo  the  normal  metamor- 
phosis. 

1.  Congestion  of  the  liver,  a.  Mechanical,  b. 
Active,  c.  Passive. 

V.  Undue  absorption  of  bile  into  the  blood,  from 
habitual  or  protracted  constipation. 

Symptoms. — Prom  what  has  been  stated  in  the 
preceding  section,  it  is  obvious  that  jaundice  is 
not  a disease,  hut  is  a sj'mptom  of  many  different 
diseases.  This  view  of  the  matter  cannot  he 
too  strongly  impressed  upon  the  student  and 
practitioner,  whose  efforts  must  in  every  case 
be  directed  to  discover  the  fundamental  malady. 
There  are,  however,  certain  phenomena  con- 
nected with  jaundice,  independent  of  its  cause, 
which  deserve  to  be  mentioned. 

1 . Intensity  of  the  jaundice.  Next  to  the 


liver  itself,  the  skin  is  the  tissue  of  the  body 
which  becomes  most  deeply  jaunliced:  but 
before  it  becomes  affected  a yellow  tint  is  usually 
observed  in  the  conjunctiva.  There  must  be  a 
certain  concentration  of  bile-pigment  to  produce 
a yellow  colour  of  the  skin  ; in  the  slighter  and 
more  temporary  cases,  the  conjunctiva  only  mav 
bo  affected.  Although  after  ligature  of  the  com- 
mon bile-duct  in  the  lower  animals  it  has  been 
sometimes  found  that  even  the  conjunctiva  do 
not  become  jaundiced  for  two  or  three  days;  ic 
the  human  subject  jaundice  of  both  skin  and 
conjunctive  is  usually  observed  within  twenty 
four  hours  of  closure  of  the  duct. 

The  colour  of  the  skin  varies  from  a pile  sul- 
phur or  lemon-yellow,  through  a citron  yellow,  to 
a deep  olive  or  bronzed  hue.  The  tint  varies 
according  to  the  cause  and  its  duration.  When 
the  cause  is  obstruction  of  the  bile-duct,  it  is 
light  at  first,  and  increases  in  depth  the  longer 
the  disease  lasts;  although  in  advanced  cases, 
as  already  stated,  the  colour  sometimes  becomes 
paler,  not  from  the  obstruction  yielding,  but 
from  the  tissue  of  the  liver  becoming  destroyed, 
and  very  little  bile  being  secreted.  Iu  jaundice 
from  obstruction  also,  the  depth  of  tint  often 
varies  from  day  to  day,  not  from  any  variation  in 
the  degree  of  obstruction,  hut  according  to  the 
amount  of  bile  secreted  by  the  liver,  and  the 
eliminative  activity  of  the  kidneys.  It  iswellto 
remember  that  what  is  called  ‘ black  jaundice  ’ 
may  result  from  any  cause  of  obstruction — from 
gall-stone  as  well  as  from  cancer.  In  these  cases 
the  greenish  or  almost  black  hue  is  due  to  the 
absorbed  bile-pigment  being  vitiated  and  dark, 
or  to  the  visage  being  also  d arkened  from  imper- 
fect arterialization  of  the  blood,  the  dark  colour 
resulting  from  a mimrling  of  the  lividity  with 
the  colour  of  bile.  When  the  jaundice  is  inde- 
pendent of  obstruction  to  the  flow  of  bile,  the 
colour  is  rarely  very  deep,  and  yet  these  are  often 
the  most  serious  cases.  The  colour  also  varies 
with  the  age,  the  natural  complexion,  and  the 
amount  of  fat  in  the  individual.  It  is  deeper  in 
the  old,  the  wrinkled,  and  the  dark-complexioned 
than  in  young  persons  of  fair  complexion,  and 
with  plenty  of  fat.  Lastly,  it  is  important  to 
remember  that  the  colour  often  remains  in  the 
skin  for  some  time  after  the  cause  of  the  jaundice 
has  been  removed,  and  that  then  its  departure 
may  be  expedited  by  diaphoretics  and  warm 
baths. 

2.  The  secretions  are  tinged  with  bile-pigment, 
but  some  much  more  so  than  others.  This  is 
notably  the  case  with  the  urine,  by  which  the 
greater  part  of  the  bile-pigment  is  eliminated 
from  the  body,  aud  which  acquires  a saffron- 
yellow,  greenish-brown.  or  brownish-black  hue, 
according  to  the  amount  of  pigment  which  it 
contains.  The  urine  usually  becomes  yellow 
before  the  skin,  or  even  the  conjunctivas;  and 
when  the  cause  of  the  jaundice  is  transient,  it  j 
may  happen  that  the  whole  of  the  pigment  is 
eliminated  by  the  urine,  without  any  jaundice 
appearing  in  the  skin.  On  the  other  hand,  when 
once  the  skin  has  become  yellow,  it  may  remain 
so  for  some  time  after  bile-pigment  has  quite  or 
nearly  disappeared  from  the  urine. 

Other  secretions  may  contain  bile-pigment 
well  as  the  urine.  The  cutaneous  glands  some- 


.JAUNDICE. 


tiines  eliminate  it  in  such  quantity  as  to  stain 
the  linen  yellow,  but  the  amount  discharged  in 
this  way  is  never  great.  Instances  have  been 
recorded  where  the  secretion  of  the  mammary 
glands  has  been  tinged  with  bile-pigment,  but 
they  are  not  very  common.  Still  rarer  instances 
have  been  noticed  where  the  saliva  or  the  tears 
have  been  tinged.  It  is  not  a little  remarkable 
that  bile-pigment  is  not  eliminated  in  cases  of 
jaundice  by  the  mucous  membrane  of  the  respi- 
ratory passages,  or  of  the  digestive  tube.  This  is 
a matter  of  some  practical  importance,  for,  were 
it  otherwise,  the  stools  might  contain  bile-pig- 
ment even  when  theie  was  complete  obstruction 
of  the  gall-duct.  Still,  when  either  of  these 
mucous  membranes  is  inflamed,  and  throws  off 
an  albuminous  or  fibrinous  exudation,  the  altered 
secretions  may  contain  bile-pigment.  Thus, 
when  pneumonia  coexists  with  jaundice,  there  is 
often  bile-pigment  in  the  sputa,  which  may  be 
distinguished  by  the  nitric-acid  test  from  the 
greenish  or  yellow  colour  often  presented  by 
pneumonic  sputa,  owing  to  changes  in  the  blood- 
pigment  independent  of  bile.  Indeed,  in  cases 
of  jaundice  bile-pigment  may  be  detected  in 
inflammatory  exudations,  as  in  the  serum  of  a 
blister,  before  it  appears  in  either  the  skin  or 
even  in  the  urine.  It  is  probable  that  those  rare 
cases  where  the  saliva  lias  been  noticed  to  be 
yellow  admit  of  a similar  explanation;  in  many 
of  them  there  has  been  mercurial  salivation,  a 
condition  in  which  the  saliva  is  not  normal,  but 
contains  much  albumen. 

3.  A bitter  taste  is  notnnfrequently  complained 
of  by  persons  who  are  the  subjects  of  jaundice. 
It  may  denote  the  presence  in  the  blood  of  the 
biliary  acids,  for  taurocholie  acid  is  intensely 
bitter.  It  is  at  all  events  not  due  to  bile-pig- 
ments, which  are  tasteless.  Moreover  it  is  a 
common  symptom  in  biliary  derangements  where 
there  is  no  jaundice. 

f.  Dercaigements  of  digestion,  such  as  flatu- 
lence, constipation,  and  an  altered  character  of 
the  motions,  may  be  due  to  the  absence  of  bile 
from  the  motions.  Bile  is  an  antiseptic,  and 
when  it  is  absent  the  intestinal  contents  undergo 
fermentation,  gases  accumulate  in  the  bowels, 
the  motions  become  putrid,  and  from  the  absence 
of  bile  they  present  a pale-drab  or  clay  colour. 
Bile  is  also  the  natural  stimulant  of  the  peri- 
staltic action  of  the  gut,  and  consequently  when 
the  supply  is  cut  off,  the  bowels  are  usually 
constipated ; but  in  some  cases  the  putrid  faeces 
act  as  an  irritant  and  excite  diarrhoea.  In  those 
casps  of  jaundice  where  there  is  no  obstruction 
if  the  common  bile-duct,  the  motions  may  be  but 
ittle  altered. 

When  bile  does  not  enter  the  bowel,  the  diges- 
ion  of  fat  is  interfered  with.  Jaundiced  patients 
dislike  fat,  and  do  not  assimilate  it,  and  the  fatty 
natter  in  the  ingesta  may  sometimes  be  detected 
n the  stools.  Hence,  whatever  be  the  cause  of 
ibstruetion  of  the  bile-duct,  the  nutrition  of  the 
>ody  suffers : the  emaciation  may  be  slow,  but  it 
[s  progressive,  until  all  the  fat  disappears,  and 
hen  the  weight  of  the  body  may  remain  station- 
ry  for  many  months.  "With  the  emaciation 
bore  is  always  more  or  less  muscular  debility. 

5 .  Tneritus,  without  any  eruption,  is  a very 
betinate  and  distressing  symptom  in  many  cases 


of  jaundice.  It  is  usually  worse  at  night,  and 
by  preventing  sleep,  may  wear  out  the  patient. 
It  is  chiefly  observed  in  cases  of  jaundice  due  to 
obstruction  of  the  bile-duct.  It  is  not  due  to 
the  presence  of  bile-pigment  in  the  blood,  for  in 
some  cases  it  precedes  the  jaundice,  and  in  others 
it  comes  and  goes  during  the  persistence  of  the 
jaundice.  Moreover,  in  many  cases  of  jaundice 
it  is  absent  throughout,  while  it  is  not  uncom- 
mon in  biliary  derangements  where  there  is  no- 
jaundice. 

6.  Cutaneous  eruptions.  Urticaria,  lichen, 
beds,  or  carbuncles  are  occasionally  observed  in 
connection  with  jaundice;  and  likewise  that  re- 
markable affection  of  the  skin  known  as  Xanthe- 
lasma or  Vitiligoidea,  the  more  severe  forms  of 
which  are  in  fact  almost  invariably  associated 
with  persistent  jaundice. 

7.  The  temperature  is  not  altered  in  jaundice, 
except  when  this  occurs  as  a complication  of 
some  acute  febrile  disease,  or  when  there  is  in- 
flammatory action  in  the  liver  itself. 

8.  Slowness  of  pulse.  A common  result  of 
non-febrile  jaundice  is  retardation  of  the  heart's 
action,  and  diminution  of  arterial  tension.  The 
pulse  may  fall  to  50,  40,  or  even  20,  and  some- 
times it  is  also  irregular.  This  slowness  of  pulse 
is  particularly  noticeable  when  the  patient  is 
recumbent.  When  there  has  been  antecedent 
pyrexia,  the  pulse  usually  falls  on  the  superven- 
tion of  jaundice.  Siowness  and  irregularity  of 
the  pulse  are  chiefly  observed  in  jaundice  from 
obstruction  of  the  bile-duct,  and  particularly  in 
those  common  cases  known  as  catarrhal  jaundice; 
and  accordingly  they  are  not  unfavourable  symp- 
toms, as  might  have  been  supposed.  So  far  as 
the  writer's  experience  goes,  patients  with  this 
symptom  invariably  recover.  It  has  not  yet 
been  explained  why  this  condition  of  circulation 
should  be  present  in  some  cases  of  jaundice,  and 
absent  in  others.  The  natural  explanation  would 
be  that  it  is  due  to  some  ingredient  of  the  bile, 
which  does  not  exist  in  the  blood  in  all  cases  of 
jaundice.  Some  experiments  of  Eohrig  have 
shown  that  the  biliary  acid  salts  paralyse  the 
heart,  and  retard  its  action,  while  bile-pigment 
has  no  such  effect.  Slowness  of  the  pulse,  there- 
fore, in  jaundice  may  indicate  the  presence  in 
the  blood  of  unchanged  biliary  acids ; but  so  far 
there  are  no  observations  to  show  that  bile-acidy 
are  present  in  the  urine  in  these  more  than  in 
other  cases  of  jaundice. 

9.  Hemorrhages. — In  many  cases  of  jaundice 
the  blood  seems  to  become  impoverished,  by  a 
diminution  in  the  proportion  of  red  corpuscles 
and  fibrine ; and  haemorrhages  take  place  from 
the  various  mucous  membranes,  and  into  the  sub- 
stance of  the  skin.  This  haemorrhagic  tendency 
is  particularly  observed  in  conjunction  with 
cerebral  sj'mptoms  in  cases  of  jaundice,  where 
there  is  no  obstruction  of  the  bile-duct,  but  it 
also  occurs  in  cases  of  mechanical  jaundice  of 
loDg  standing,  from  any  cause,  when  the  secreting 
tissue  of  the  liver  has  in  a great  measure  disap- 
peared. 

10.  Xanthopsy  or  Yellow  Vision. — In  rare 
cases  of  jaundice,  all  white  objects  appear  to  the 
patient  yellow.  The  administration  of  santonin 
internally  has  also  sometimes  been  followed  by 
yellow  vision,  which  has  ceased  as  soon  eu  tlui 


JAUNDICE. 


776 

lolouring  matter  has  been  eliminated  by  the  kid- 
neys. This  fact,  as  well  as  the  observation  that 
in  several  cases  of  jaundice,  with  xanthopsy, 
the  conjunctival  vessels  have  been  pretematu- 
rally  distended  with  blood,  has  led  to  the  belief 
that  the  symptom  is  due  to  a tinging  -with  bile- 
igment  of  the  humours  of  the  eye.  On  the  other 
and,  the  circumstances  that  the  xanthopsy  may 
intermit,  without  any  change  in  the  jaundice ; 
that  it  is  usually  absent  when  there  is  intense 
jaundice  of  the  cornea  and  other  tissues  of  the 
eye;  and  the  statement  that  it  may  occur  in  ty- 
phus fever  and  in  certain  derangements  of  vision, 
such  as  night-blindness,  when  there  is  no  jaun- 
dice, have  led  some  authorities  to  regard  it  as  a 
purely  nervous  symptom. 

11.  Cerebral  symptoms,  and  the  Typhoid,  state. 
Patients  with  jaundice  are  often  irritable  in 
their  temper  and  hypochondriacal ; aud  occasion- 
ally they  are  attacked  with  acute  deliri-um, 
stupor,  coma,  convulsions,  muscular  tremors, 
subsultus,  carphology,  paralysis  of  the  sphinc- 
ters, a dry  and  brown  tongue,  and  other  indica- 
tions of  the  typhoid  state.  These  symptoms  are 
most  common  in  cases  where  there  is  no  obstruc- 
tion of  the  ducts,  but  they  also  occur  in  cases  of 
obstruction,  usually  of  long  standing,  where  all  or 
the  greater  part  of  the  secreting  tissue  of  the 
liver  has  been  destroyed.  Different  opinions  are 
held  as  to  their  cause.  After  death  no  lesion  is 
found  of  the  brain  or  its  membranes,  and  they 
are,  therefore,  most  probably  due  to  somo  alter- 
ation of  the  blood.  They  are  commonly  attri- 
buted to  poisoning  of  the  blood  with  bile,  either 
from  suppression  or  re-absorption  of  the  secre- 
tion. But  the  assumption  that  the  elements  of 
the  bile  are  preformed  in  the  blood  has  been  al- 
ready shown  to  be  probably  erroneous : and  there 
is  equally  little  evidence  that  bile  is  possessed 
of  poisonous  qualities,  or  that  its  presence  in  the 
blood,  even  to  saturation,  will  give  rise  to  cere- 
bral symptoms.  Many  experiments  have  been 
performed  on  animals  to  show  that  bile  is  a 
deadly  poison  ; but,  there  is  reason  for  believing 
that  the  bad  results  observed  have  been  due  to 
the  injection  into  the  areolar  tissue  of  decom- 
posing mucus  contained  in  the  bile.  Bile,  from 
which  the  mucus  has  been  removed,  has  been 
repeatedly  injected  by  Frerichs  and  other  obser- 
vers into  the  largo  veins  of  dogs,  without  cere- 
bral symptoms  or  any  bad  results  ensuing,  ex- 
cept that  death  has  in  some  instances  been  caused 
by  the  entrance  of  air  into  the  veins.  But  it  is 
scarcely  necessary  to  turn  to  experimental  en- 
quiries on  the  lower  animals  for  ovidence  on  the 
matter,  and  in  all  these  experiments  there  are 
sources  of  fallacy.  There  is  ample  proof  that 
the  blood  of  the  human  subject  may  be  satu- 
rated with  bile  for  months,  or  even  years,  with- 
out any  cerebral  symptoms  resulting.  Dr.  Aus- 
tin Flint,  jun.,  is  of  opinion  that  the  cerebral 
symptoms  of  jaundice  are  due  to  the  retention  of 
cholesterine  in  the  blood,  or  to  what  he  has 
designated  Cholcstcrcemia.  Cholesterine  is  one 
of  the  constituents  of  bile,  and  Dr.  Flint  regards 
it  as  an  excrementitious  product  of  nervous  tis- 
sue. the  elimination  of  which  from  the  body  is 
one  of  the  functions  of  the  liver,  and  the  reten- 
tion of  which  in  the  blood  he  believes  to  act  as 
a poison  like  urea.  But  if  the  non-excretion  of 


all  the  elements  of  bile  docs  not  give  rise  to 
cerebral  symptoms,  it  is  difficult  to  understand 
how  they  can  result  from  the  retention  of  choles- 
terine alone.  In  eases,  for  instance,  of  perma- 
nent closure  of  tho  bile-duct,  cholesterine  is  not 
discharged  from  the  liver  into  the  bowel,  nor 
does  it  accumulate  in  the  biliary  passages,  and 
yet,  if  it  be  retained  in  the  blood,  cerebral  symp- 
toms rarely  occur. 

The  cerebral  symptoms  in  jaundice  are  often 
most  severe  when  the  jaundice  is  slight,  and  they 
may  occur  in  diseases  of  the  liver  when  there  is 
no  jaundice.  They  aro  best  explained  by  the 
knowledge  which  we  now  possess  of  the  function 
performed  by  the  liver  in  disintegrating  albumi- 
nous matter  into  less  complex  substances,  such 
as  urea  and  uric  acid,  which  are  eliminated  by 
the  kidneys.  When  this  function  of  the  liver  is 
arrested  or  seriously  impaired,  urea  is  no  longer 
eliminated  in  sufficient  quantity  by  the  kidneys ; 
lithic  acid  and  deleterious  products  of  disintegra- 
ting albumen  even  less  oxydised,  such  as  lencin 
and  tyrosin,  and  perhaps  others  with  which  we 
are  as  yet  imperfectly  acquainted,  accumulate  it 
the  blood  and  tissues  ; the  result  is  the  develop- 
ment of  symptoms  of  blood-poisoning  similar  to 
those  which  arise  when  the  kidneys  are  unable 
to  eliminate  the  products  of  albumen-disintc 
gration,  owing  to  disease  of  their  own  structure, 
or  to  an  excessive  formation  of  urea  and  other 
products,  as  happens  in  many  febrile  diseases. 
In  acute  atrophy,  for  example,  the  structure  of 
the  liver  is  destroyed,  and  its  functions  are 
arrested ; leucin  and  tyrosin  take  the  place  of 
urea  in  the  urine,  and  are  also  found  in  large 
quantity  in  the  liver,  spleen,  and  kidnevs;  while 
cerebral  symptoms  and  the  typhoid  state  are 
prominent  features  of  the  disease. 

Diagnosis. — There  is  rarely  much  difficulty  in 
the  diagnosis  of  jaundice,  but  it  is  well  to  re- 
member that  certain  conditions  are  sometimes 
mistaken  for  it,  such  as  chlorosis;  the  anaemic 
aspect  resulting  from  organic  visceral  disease 
(and  particularly  from  contracted  kidneys), from 
cancer,  from  exposure  to  malaria,  from  Addison's 
disease,  or  from  lead-poisoning;  an  undue  amount 
of  sub-eonjunctival  fat;  or  an  unusually  dark 
colour  of  the  ordinary  urinary  pigment,  or  the 
presence  in  the  urine  of  abnormal  pigments,  such 
as  those  of  santonin,  turmeric,  rhubarb,  Ac. 
In  ever}-  case  where  there  is  the  slightest  doubt, 
it  will  be  removed  by  resorting  to  the  nitric  acid 
test  for  bile-pigment  in  the  urine.  If  this  gives 
no  result,  the  case  is  not  one  of  jaundice. 

But  it  is  a more  difficult  matter  to  determine 
the  cause  of  the  jaundice,  and  yet  this  should  in- 
variably be  the  aim  of  the  medical  attendant, 
before  forming  a prognosis  or  proceeding  to  treat- 
ment. The  scope  of  this  article  does  not  per- 
mit a lengthened  analysis  of  the  characters 
distinguishing  the  different  forms  of  jaundice 
according  to  its  cause,  but  the  following  remarks 
may  be  of  some  service. 

1 . In  the  first  place  it  is  always  well  to  deter- 
mine whether  or  not  the  jaundice  be  due  to  ob- 
struction of  the  bile-duct.  According  to  Dr.  G. 
Harley  this  can  be  done  by  determining  the  pre- 
sence or  absence  of  bile-acids  in  the  urine.  Adop- 
ting the  view  that  bile-acids  are  f rmed  by  the 
1 liver,  while  bile-pigment  isprefbrmcd  in  tho  blond 


JAUNDICE. 


JOINTS,  DISEASES  OF.  777 


he  contends  that  in  jaundice  from  ‘ suppression  ’ 
(or  independent  of  obstruction)  the  liver  does 
not  secrete  bile,  and  consequently  no  bile-acids 
heiuo’  formed,  none  can  enter  the  circulation  or  be 
detected  in  the  urine;  -whereas  in  jaundice  from 
obstruction,, bile  is  secreted  and  absorbed  into 
the  blood,  and  a portion  of  the  bile-acids  not 
transformed  in  the  circulation  appears  in  the 
urine.  But  in  addition  to  the  strong  improba- 
bility already  urged  that  any  form  of  jaundice 
is  due  to  a suppressed  secretion  of  bile,  clinical 
experience  is  entirely  opposed  to  the  practical 
value  of  the  test  in  question  for  throwing  light 
on  the  cause  ot'  jaundice.  Bile-acids  have  been 
found  in  the  urine  in  cases  of  acute  atrophy  of 
the  liver,  where  there  is  no  obstruction  of  the  bile- 
duct,  and  in  very  many  cases  of  mechanical  jaun- 
dice they  are  certainly  absent.  A more  reliable 
indication  of  obstruction  of  the  common  bile-duct 
is  furnished  by  the  stools.  When  there  is  no 
obstruction,  the,  stools  almost  invariably  contain 
bile ; but  when  the  duct  is  obstructed,  they  are 
clay-coloured.  The  rule  is  not  without  excep- 
tions, and  there  are  several  sources  of  fallacy. 
The  jaundice  usually  persists  for  sometime  after 
the  duct  has  become  pervious,  and  thus  bilious 
motions  may  co-exist  with  jaundice  which  has 
resulted  from  obstruction ; or,  if  the  motions  be 
thin  and  watery,  they  may  appear  to  contain 
bile  from  the  admixture  of  jaundiced  urine  ; or, 
not  unfrequently,  when  the  bile-duct  is  quite 
impervious,  the  motions  are  of  a brownish  tinge, 
owing  to  the  presence  of  altered  blood,  which 
may  closely  resemble  dark  bile.  A tumour 
corresponding  to  the  region  of  the  gall-bladder 
will  favour  the  view  that  jaundice  is  due  to 
obstruction  of  the  bile-duct.  Lastly,  jaundice 
which  persists  and  is  yet  slight,  is  most  probably 
independent  of  obstruction,  for  jaundice  from 
persistent  obstruction  speedily  becomes  intense. 

2.  It  is  always  important  to  note  the  mode  of 
commencement  of  jaundice.  That  which  appears 
suddenly  in  a person  whose  previous  health  has 
been  good,  is  most  probably  the  result  of  obstruc- 
tion of  the  duct  by  a foreign  body,  or  it  has  a 
nervous  origin.  The  former  cause  will  be  dis- 
tinguished by  biliary  colic,  vomiting,  and  clav- 
’.oloured  stools.  On  the  other  hand  jaundice 
toming  on  slowly,  but  ultimately  becoming  in- 
ense,  with  clay-coloured  stools,  points  to  pres- 
ure  on  the  duct  from  without,  or  to  a growth  in 
ts  interior. 


3.  A history  of  previous  attacks  of  jaundice 
if  a similar  nature  is  in  favour  of  a catarrhal 
rigin  or  of  gall-stones. 

4.  Pain  in  severe  paroxysms  concurring  with 
inndice  points  generally  to  gall-stones  or  can- 
er;  more  rarely  to  hydatids,  or  to  an  aneurism 
f the  hepatic  artery.  Cancer  is  distinguished 
j.-om  gall-stones  by  there  being  usually  a history 
f failing  health  and  emaciation  before  either  the 
; ain  or  the  jaundice. 

5.  Jaundice  concurring  with  enlargement  of 
ie  liver  is  most  probably  due  to  cancer  or  cir- 
;iosis;  more  rarely  to'pysemic  abscesses,  or  to 

axv  liver,  with  large  glands  in  the  portal 
ssure. 

C.  Jaundice  concurring  with  ascites  points  to 
mcer  or  cirrhosis.  The  diagnosis  of  the  latter 
ill  usually  be  assisted  by  the  physiognomy,  the 


slightness  of  the  jaundice,  the  previous  habits, 
and  a history  of  alcoholic  dyspepsia ; while  in 
cancer  there  are  often  darting  pains,  and  the 
jaundice  is  usually-  intense. 

7.  Jaundice  concurring  with  pyrexia  is  either 
secondary  to  some  acute  febrile  disease  ; or  is  due 
to  suppurative  pylephlebitis,  a suppurating  hy- 
datid tumour  opening  into  a bile-duct,  or  inflam- 
mation of  the  bile-ducts.  Temporary  pyrexia 
may  also  occur  during  the  passage  of  a gall- 
stone. 

8.  Cerebral  symptoms  associated  with  jaun- 
dice suggest  acute  atrophy  of  the  liver,  poisoning 
by-  phosphorus,  some  specific  fever,  pneumonia, 
or  nervous  shock. 

9.  Jaundice  in  a young  person,  preceded  by 
symptoms  of  gastric  catarrh,  is  most  probably 
catarrhal. 

Treatment. — There  is  no  special  treatment  for 
jaundice  ; in  all  cases  the  treatment  must  have 
reference  to  what  is  believed  to  be  its  cause. 
The  appropriate  treatment  will  therefore  be  dis- 
cussed under  the  head  of  the  several  diseases 
which  give  rise  to  it.  Here  it  is  only  necessary 
to  observe,  that  in  all  cases  of  jaundice  from  ob- 
struction it  is  important  to  maintain  the  action 
of  the  kidneys,  which  are  the  main  channel  for 
the  elimination  of  the  bile ; while  portal  conges- 
tion is  obviated  by  appropriate  purgatives.  The 
part  which  the  bile  plays  in  assisting  assimila- 
tion of  nutriment  may  to  some  extent  be  sup- 
plied by  ox-gall;  and  creasote  will  often  check 
the  diarrhcea  excited  by  the  putrefying  feces. 
Patients  suffering  from  jaundice  ought  also  to 
partake  sparingly  of  fatty  or  saccharine  food,  or 
of  alcoholic  drinks. 

Charles  Murchison. 

JEJUNUM,  Diseases  of.  See  Intestines, 

Diseases  of. 

JIGGER. — A popular  term  employed  to 
designate  the  sand-worm  or  sand-flea.  See 
Chigoe. 

JOINTS,  Diseases  of. — Diseases  of  the 
joints  are  classified  according  to  the  structure 
primarily  or  chiefly  involved.  They  may  com- 
mence in  the  synovial  membrane,  in  the  bone, 
or  in  the  cartilage.  Primary  disease  of  the  liga- 
ments is  rare,  and  is  not  clinically  demonstrable. 
No  form  of  joint-disease  remains  long  confined 
to  one  tissue,  so  that  when  the  disease  is  of  some 
duration  it  will  be  found  to  implicate,  more  or 
less,  every  element  of  the  joint-apparatus.  In 
this  article  the  diseases  of  joints  will  first  be 
generally  discussed ; and  tho  individual  diseases 
will  then  be  considered  separately. 

.(Etiology  and  Pathology. — The  larger  arti- 
culations, those  in  constant  use,  and  more  espe- 
cially the  joints  of  the  lower  extremity,  are  the 
most  frequently  diseased.  Thus  the  knee  is 
more  often  the  seat  of  disease  than  any  other 
joint;  the  hip-joint  comes  next  in  order;  and 
then  the  ankle  and  elbow.  All  kinds  of  joint- 
diseases  are  frequent  in  children  and  young 
persons.  The  first  year  of  life  appears,  how- 
ever, to  be  nearly  exempt  from  these  affections, 
and  during  the  second  year  they  are  compa- 
ratively rare,  perhaps  because  movement  and 
risk  of  injury  are  at  that  period  at  a minimum. 


JOINTS,  DISEASES  OF. 


778 

Acute  arthritis,  however,  is  occasionally  wit- 
nessed during  the  first  year  of  life — during  even 
the  first  six  months.  It  is  unconnected  with 
syphilis  or  injury;  very  sudden  in  its  appear- 
ance, and  rapid  in  course  ; dangerous  to  life ; 
and  destructive  to  the  articular  ends  of  the 
hones  by  suppurative  disorganisation.  The 
causes  of  joint-disease  in  general  are  connected 
either  with  disordered  nutrition,  in  which  case  it 
usually  assumes  an  inflammatory  type ; or  with 
disordered  function.  The  latter  may  depend  on 
the  former,  or  be  unconnected  with  it.  Again, 
the  cause  may  be  local  in  its  origin,  or  arise 
from  some  constitutional  defect.  AmoDgst  the 
exciting  causes,  injury  is  liy  far  the  most  fre- 
quent. This  being  often  slight,  and  not  followed 
by  any  immediate  consequences,  the  connec- 
tion is  frequently  overlooked.  A blow,  or  a fall 
against  the  edge  of  a table  or  down  stairs,  may 
readily  bruise  the  synovial  membrane,  in  such 
exposed  joints  as  the  knee  or  elbow,  without 
causing  any  external  sign.  A slight  haemorrhage 
takes  place  into  the  synovial  cavity  or  the  sub- 
synovial  areolar  tissue,  and  serous  effusion  may 
speedily  supervene  ; in  this  manner  a common 
variety  of  acute  or  traumatic  serous  synovitis  is 
produced.  But  although  injury  is  the  most  fer- 
tile cause  of  joint-disease,  the  articulations  may 
sustain  most  severe  injury  without  becoming 
inflamed.  It  is  rare  to  find  any  serious  conse- 
quences result  from  dislocation;  the  joint  usu- 
ally perfectly  recovering  itself.  Penetrating 
wounds  of  the  joints  are  always  serious  injuries ; 
they  often  occasion  acute  synovitis,  and  if  septic 
changes  occur,  are  followed  inevitably  by  suppu- 
ration in  the  articulation,  and  danger  both  to  the 
limb  and  life  of  the  individual.  Fractures  often 
implicate  the  joint-surfaces,  and  prove  a fre- 
quent source  of  stiff-joint.  Plastic  synovitis 
may  be  thus  set  up,  causing  adhesions ; or  sup- 
puration takes  place  ; or  the  callus  formed  for 
the  repair  of  the  fracture  may  interfere  with  the 
joint  motion.  Gunshot  wounds  often  produce 
the  severest  form  of  inflammation  of  joints,  sup- 
puration being  the  usual  result.  When  joint- 
disease  follows  an  injury  it  is  usually  confined  to 
one  joint ; but  when  joint  disease  originates  from 
constitutional  causes,  more  than  one  joint  is 
often  affected  ; or  when  only  one,  the  constitu- 
tional nature  of  the  cause  is  manifested  in  dis- 
eased conditions  present  elsewhere,  or  by  traces 
of  inflammation  in  other  joints,  due  to  the  same 
cause.  The  deposit  of  tubercle  in  the  synovial 
membrane  and  hone  is  a frequent  cause  of 
chronic  joinl>disease. 

Joint-inflammations  are  of  common  occur- 
rence in  all  kinds  of  fever ; and  also  as  se- 
quelae of  the  exanthemata.  The  great  frequency 
of  polyarticular  serous  synovitis  in  acute  rheu- 
matism is  well  known,  as  also  in  purpura  and 
haemophilia,  wrhere  it  is  complicated  with  blood- 
extravasations.  In  pyaemia  the  joints  are  fre- 
quently the  seat  of  sero-purulent  and  purulent 
effusions  ; as  they  also  occasionally  are  in  scar- 
latina. Puerperal  synovitis  is  a variety  of  the 
pyaemic.  In  typhus  monarticular  arthritis  is 
frequently  met  with,  and  the  hip  is  the  joint 
oftenest  affected.  Endocarditis  and  polyarth- 
ritis are  very  often  associated  together,  and 
the  endocarditis  may  precede  and  give  rise  to 


the  joint-disorder  by  embolism.  The  fact  that 
multiple  joint-affections  are  met  with  both  in 
pyaemia  and  in  rheumatism  suggests  a connec- 
tion, but  what  its  nature  may  be  is  not  clear. 
Although  in  articular  rheumatism  p s-formation 
is  rare,  we  sometimes  witness  joint-suppuration 
in  such  cases  ; whilst  pyaemia  and  metastatic 
abscess  may  originate  from  ulcerative  endocar- 
ditis. In  chronic  synovitis,  affecting  two  or 
more  joints,  the  heart  should  always  he  ex- 
amined, for  traces  of  endocarditis  will  sometimes 
he  found.  In  the  exanthemata,  typhus,  and 
diphtheria,  metastases  in  the  shape  of  joint-in- 
flammations more  or  less  frequently  take  place. 
Joint-inflammation  is  of  frequent  occurrence  in 
dysentery.  With  gonorrhoea  a form  of  arthritis 
is  associated  which  is  called  ‘ gonorrhoeal.’ 
Syphilis  in  the  later  stages  frequently  attacks  a 
joint,  the  knee  by  preference,  syphilitic  deposits 
taking  place  in  the  bone  or  the  subsynovial  con- 
nective tissue,  but  synovial  effusion  is  not  com- 
mon. A suppurative  inflammation  of  the  ends 
of  the  bone  is  not  rare  in  children  the  subjects 
of  inherited  syphilis.  In  gout  the  joint-struc- 
tures are  affected ; as  a rule  the  perisynovial 
tissue  becomes  inflamed  owing  to  deposits  of 
urates.  Similar  deposits  even  occur  in  cartilages 
of  encrustation.  The  great  toe  is  most  often 
affected,  but  the  other  tarsal,  digital,  and  larger 
joints  are  frequently  diseased. 

Some  ilL-understood  form  of  vaso-motor  or 
trophic  irritation  appears  to  occasion  arthritis, 
in  locomotor  ataxy.  Effusion  into  the  joint  is 
preceded  by  pain,  and  the  knee  and  shoulder 
joints  are  those  generally  affected.  In  some 
cases  of  the  disease  changes  similar  to  those  in 
rheumatoid  arthritis  have  been  observed,  gene- 
rally in  the  knee,  shoulder,  elbow,  or  hip.  They 
occur  early  in  the  disease ; arise  suddenly ; aro 
often  monarticular;  and  not  rarely  give  rise  to 
dislocation,  especially  in  the  shoulder.  These 
characters  distinguish  the  disease  from  ordinary 
rheumatoid  arthritis.  Severe  inflammation  of 
the  joints  of  the  paralysed  limbs  has  been  ob- 
served in  cases  of  hemiplegia.  The  occurrence  of 
joint-disorder,  usually  synovial  inflammation,  is 
frequent  in  chronic  disease  of  the  spine ; and  it 
also  occasionally  happens  in  acute  myelitis,  in 
the  form  of  suppurative  arthritis.  In  both  cases 
the  knee  is  most  frequently  affected. 

Axatoxiicai,  Characters. — Joint-disease  may 
begin  as  an  inflammation  of  the  synovial  mem- 
brane, of  the  bone,  or  of  the  cartilage.  Fibrous 
tissue  having  but  slight  tendency  to  inflame,  it 
is  improbable  that  primary  disease  affecting  the 
ligaments  can  be  otherwise  than  most  excep- 
tional ; but  these  textures  very  soon  become 
secondarily  affected,  from  their  intimate  connec- 
tion with  the  synovial  membrane.  The  synovia' 
membrane  is  perhaps  more  ready’  to  inflame  than 
any  other  tissue  in  the  body,  and  in  many  joints 
it  is  much  exposed  to  injury  from  without,  while 
excessive  joint-movement  alone  is  sometimes 
sufficient  to  excite  synovitis.  Primary  disease 
of  the  hone  comes  next  in  order  of  frequency. 
Cartilage  is  least  likely  to  take  on  primary  u •- 
ease.  Each  of  these  tissues,  however,  becom.  - 
speedily  affected  by  disease  which  has  invaded 
or  commenced  in  the  other. 

SnrPTOMS  and  Diagnosis. — The  local  syrnp 


JOINTS.  DISEASES  OF. 


toms  of  joint-disease  have  reference  to  impair- 
ment of  function,  and  change  in  form-,  together 
with  pain,  both  local  and  sympathetic  ; and  cer- 
tain physical  signs. 

Impaired  function. — Usually  this  is  great  in 
proportion  to  the  natural  mobility  aud  import- 
ance of  the  joint,  and  most  evident  in  the  ex- 
I remities.  The  earliest  symptom  in  hip-joint- 
disease  is  a slight  limp  or  halt,  whilst  in  other 
joints  mere  stiffness  occurs;  the  full  range  of 
movement  is  simply  curtailed,  before  actual  pain 
or  swelling  takes  place.  The  position  of  maxi- 
mum relaxation,  namely,  that  intermediate  be- 
tween flexion  and  extension,  is  commonly  as- 
sumed by  diseased  joints.  Even  in  the  earliest 
Btages  of  disease,  the  interference  with  move- 
ment is  often  very  great,  amounting  to  a sort  of 
vital  anchylosis,  produced  by  the  action  of  the 
muscles,  whoso  tension  prevents  the  joint-sur- 
faces movingupon  each  other — an  effort  to  avert 
pain.  This  form  of  anchylosis  disappears  during 
narcosis.  Muscular  or  vital  anchylosis  must  be 
distinguished  from  the  rigidity  produced  by 
structural  changes.  Both  synovial  effusion  and 
peri-synovial  infiltration  mechanically  hinder 
free  joint-movement. 

Changes  in  form. — Changes  in  form  are  due 
to  the  alterations  in  shape  and  texture  of  the 
joint>structures,  and  to  effusions  within  its  ca- 
vity. These  changes  may  be  best  appreciated  by 
careful  measurements,  and  a comparison  with 
the  opposite  joint.  No  true  estimate  of  the 
amount  of  departure  from  the  normal  is  other- 
wise possible.  The  practitioner  is  thus  better  able 
to  diagnose  the  special  character  of  the  swelling, 
whether  it  be  due  to  synovial  effusion,  and  con- 
fined to  the  limits  of  the  capsule,  causing  it  to 
bulge  at  the  least  protected  parts  ; or  to  chronic 
thickening  of  the  synovial  membrane,  recognised 
on  palpation  by  its  elasticity  and  general  diffu- 
sion; or  to  disease  of  the  bone  and  periosteum, 
when  the  swelling  is  deep-seated  and  hard.  By 
accurate  comparison  a fluid  collection  outside 
the  joint,  either  an  abscess  or  a bursal  tumour, 
may  be  distinguished  from  intra-articular  swell- 
ing. 

Pain. — The  character  of  the  pain  is  an  im- 
portant symptom  in  diseases  of  the  joints.  In 
.acute  synovitis  it  is  severe  and  lancinating.  In 
bone-inflammation  it  is  a dull  aching  pain,  with 
marked  local  tenderness,  liable  to  periodic  exa- 
cerbations of  an  intense  kind.  Often  the  pain  is 
of  a shooting,  starting  character,  wakening  the 
sufferer  from  sleep.  The  pain  is  of  this  charac- 
ter and  most  severe  in  subarticular  ostitis. 
Pytemic  suppuration  and  chronic  synovitis  are 
‘generally  painless. 

Physical  signs. — "When  one  band  is  laid  flat 
upon  a diseased  joint  while  the  other  moves  it, 
certain  sensations  or  sounds  are  often  distin- 
guishable. A peculiar  soft  crepitation  due  to  the 
presence  of  blood-clot,  must  not  be  mistaken  for 
he  rougher  sensations  which  adhesions  afford, 
he  friction-sounds  of  movable  joint-bodies,  or 
he  grating  of  exposed  bone.  The  rubbing  of  one 
ganulation-surface  upon  another  may  be  likened 
o that  of  two  pieces  of  velvet.  Abnormal  move- 
nts, such  as  lateral  motion  in  a ginglymoid 
oint,  usually  imply  extensive  joint-disorder, 
lisplaeement  or  partial  dislocation,  and  altera- 


tion in  form  of  the  joint-surfaces  occur  as  the 
disease  progresses.  A notable  increase  of  local 
heat  may  be  felt  in  all  inflamed  joints.  When 
fistulous  tracks  exist  around  a diseased  joint, 
they  do  not  often  afford  direct  evidence  on  being 
probed  of  the  condition  of  the  joint,  but  they 
generally  prove  the  existence  of  articular  sup- 
puration, and  disease  of  the  bone. 

With  respect  to  the  general  symptoms  of  dis- 
eases of  the  joints,  it  need  only  be  said  here 
that  the  amount  of  pain  or  constitutional  dis- 
turbance in  acute  cases  varies  according  to  the 
extent  and  acuteness  of  the  disease,  and  the  pre- 
sence and  amount  of  suppuration.  In  chronic 
disorders  the  associated  constitutional  condition 
should  be  investigated. 

Complication's  aud  Sequel®. — The  complica- 
tions which  occur  in  joint-disease  are  generally 
connected  with  long-continued  suppuration. 
Amyloid  degeneration  of  the  viscera  is  pretty 
certain  to  be  present  when  suppuration  has 
existed  for  a year  or  more  in  young  people  ; less 
certainly  in  adults.  Hectic  fever,  tuberculosis, 
or  pyaemia  may  occur  at  any  period.  In  the  ab- 
sence or  failure  of  treatment,  the  patient,  should 
he  survive,  will  suffer  from  contraction,  defor- 
mity-, and  imperfect  growth  of  the  limb,  together 
with  more  or  less  complete  loss  of  function. 

Prognosis. — The  prognosis  in  diseases  of  the 
joints  will  depend  on  many  circumstances,  and 
must  be  considered  both  as  regards  life  and  as 
regards  function.  First,  with  respect  to  life, 
the  gravity  of  joint-diseases  increases  with  the 
size  of  the  joint  affected.  They  are  more  serious 
in  the  lower  than  in  the  upper  limb.  Pyaemia  is 
comparatively  rare  in  acute  joint-suppurations — 
why,  it  is  impossible  to  say.  When  pus  escapes 
from  the  interior  of  a joint  into  the  surrounding 
tissues,  pyaemia  may  occur.  A continuous  high 
temperature,  or  a large  evening  increase  asso- 
ciated with  hectic,  are  bad  signs';  the  exhaus- 
tion, which  depends  on  profuse  suppuration 
with  its  attendant  hectic  fever,  amyloid  degene- 
ration, and  tuberculosis,  being  the  most  frequent 
causes  of  death  in  joint-disease.  The  prognosis 
as  regards  function  is  often  difficult  to  determine. 
After  an  attack  of  simple  acute  or  subacute 
serous  synovitis,  recovery  is  generally  complete. 
Joint-function  is  usually  completely  lost  after 
suppuration  of  traumatic  origin,  recovery  being 
quite  exceptional.  When  the  suppuration  is  of  a 
pyaemic  nature,  and  the  patient  survives,  the  effu- 
sion may  become  absorbed,  and  the  joint-motion 
bo  preserved.  Chronic  synovitis  with  thickening 
of  the  subsynovial  tissue,  due  to  infiltration  with 
granulation-material,  can  seldom  he  cured  except 
by  operation,  especially  after  suppuration  has 
taken  place.  If  recovery  should  ensue,  the  joint- 
function  is  lost,  and  deformity  is  always  present. 
Increased  mobility — ‘ flail  joint’ — is  a very  rare 
sequence  of  joint-disease.  It  is  occasionally  seen 
in  the  shoulder,  and  also  in  the  knee. 

Treatment. — The  treatment  of  diseases  of  the 
joints  must  be  directed  to  preserve  the  life  of  the 
individual ; and,  as  far  as  possible,  the  functions 
of  the  limb.  Of  the  first  and  greatest  impor- 
tance among  remedial  measures  is  rest,  which  is 
best  secured  by  fixation  of  the  joint  and  limb  in 
an  appropriate  apparatus.  This  is  of  cardinal 
importance  to  a diseased  articulation,  just  a» 


JOINTS,  DISEASES  OF. 


160 

motion  is  a necessity  for  a healthy  one.  Immo- 
bilisation should  not  be  continued  longer  than 
necessary  ; it  "will  sometimes  seriously  damage 
even  a previously  healthy  joint,  immobilised  on 
account  of  fracture  of  the  limb ; and  a continu- 
ance of  rest  after  all  diseased  action  has  sub- 
sided often  exerts  a very  prejudicial  influence. 
Best,  however,  should  be  continued  so  long  as 
pain  and  increased  temperature  persist. 

Position. — The  same  means  adopted  to  secure 
immobility  must  be  utilised  to  obtain  the  best 
available  position  for  the  future  function  of  the 
part,  should  anchylosis  become  inevitable.  In 
the  ankle  the  foot  should  be  maintained  at  a 
right  angle ; the  hip  and  knee  must  be  extended 
in  the  axis  of  the  body  ; the  elbow  is  generally 
flexed  to  a right  angle,  the  position  in  which  the 
limb  is  most  useful.  Splints  of  various  forms  are 
used,  and  we  possess  in  plaster-of-Paris  and 
starch  ready  and  invaluable  means  of  producing 
an  apparatus,  which  gives  uniform  and  equable 
support  of  a simple  and  very  perfect  kind. 

Extension  exerts  a beneficial  influence,  as  well 
by  immobilising  the  joint,  as  by  its  power  to 
remove  contraction  and  deformity.  It  relieves 
pain  and  abates  the  symptoms  rather  by  keeping 
the  joint  at  rest,  and  changing  the  surfaces  of 
contact,  than  by  any  actual  distraction  of  the 
joint-surfaces.  A much  greater  weight  than  a 
patient  could  tolerate  must  be  used  before  any 
such  separation  could  occur.  Extension  often 
even  increases  the  intra-articular  pressure.  By 
straightening  the  limb  it  removes  the  joint  from 
its  position  of  maximum  relaxation,  and  puts 
the  skin  and  tendons  on  the  flexor  aspect  on  the 
stretch,  and  alters  the  mutual  accommodation  of 
the  joint-surfaces. 

As  there  is  almost  invariably  an  increase  of 
temperature  in  the  affected  joint,  the  application 
of  coll,  by  means  of  ice-bags  or  coils  of  cold 
water  tubing,  is  indicated.  Cold  acts  most  bene- 
ficially in  all  acute,  and  many  subacute  inflam- 
mations. Even  in  deep-seated  joints  like  the 
hip,  it  will  often  soothe  the  pain  and  abate  the 
symptoms,  but  it  is  more  applicable  to  the 
superficial  joints.  Cold  is  both  anaesthetic  and 
prophylactic  in  its  action.  The  sensations  of  the 
patient  in  respect  of  the  continuance  of  cold 
applications  must  be  consulted.  In  most  cases 
they  are  grateful.  In  chronic  joint-affections 
when  an  acute  attack  supervenes,  threatening 
suppuration,  cold  should  also  be  applied.  Cold 
applications  may  in  some  cases  be  continued  for 
weeks  or  months  with  advantage.  When  the 
acute  symptoms  have  passed  off,  and  it  is  de- 
sirable ” to  encourage  lymphatic  activity  and 
absorption,  the  cold  must  be  discontinued,  and 
compression,  together  with  friction  and  warmth, 
substituted.  Cold  is  not  applicable  to  purely 
chronic  cases  without  much  pain  or  tenderness. 

In  some  instances  of  acute  and  subacute  ar- 
thritis local  depletion  by  means  of  leeches  or 
scarification  is  very  useful,  and  this  may  be 
combined  with  hot  fomentations  in  cases  where 
cold  is  not  well  borne.  In  chronic  inflammation  of 
the  bone  the  actual  cautery  sometimes  procures 
.mmediate  abatement  of  the  pain,  and,  after  a 
time,  the  subsidence  of  the  inflammation.  The 
Dutton  cautery  may  be  used,  or,  still  better, 
linear  cauterisation,  over  the  most  sensitive 


points.  Or  an  issue  may  be  employed  in- 
stead. 

Compression  by  strapping,  or  with  a thick 
layer  of  cotton-wool  and  a tightly  applied  ban- 
dage over  it,  is  applicable  to  the  chronic  stages 
of  joint-disease.  It  must  be  discontinued  if  it 
occasion  pain.  It  is  better  calculated  to  remove 
fluid  effusions  than  the  plastic  material  poured 
out  into  the  perisynovial  tissue.  For  these  cases 
the  more  continuous  compression  of  a properly 
applied  elastic  bandage  will  prove  more  efficient; 
or  the  strapping  known  as  ‘ Scott’s  dressing.’ 

Massage  is  a most  valuable  local  means  for 
the  dispersion  of  chronic  swellings  of  joints.  It 
both  removes  the  results  of  diseased  action  in 
the  joint,  and  helps  to  restore  its  function.  It 
is  well  suited  to  disperse  serous  effusions  when 
the  acute  stage  is  over  ; for  cases  of  plastic  sy- 
novitis it  is  also  useful,  but  not  for  cases  of 
the  type  known  as  tumor  albus.  It  produces  a 
diminution  of  the  sensibility  of  the  part,  and  a 
local  increase  of  temperature,  and  the  lymphatics 
are  stimulated  to  increased  activity.  There  are 
several  modes  of  employing  massage.  The  first 
is  centripetal  stroking  with  the  palm  of  the 
hand  from  the  periphery  of  the  affected  part  to 
wards  the  centre  of  the  body,  called  effkurage, 
one  hand  following  the  other  in  immediate  suc- 
cession. The  amount  of  pressure  varies  with  the 
circumstances  of  the  case.  This  will  readily  dis- 
perse fluid  effusions  both  of  blood  and  serum. 
Friction-massage  is  another  useful  method,  and 
is  practised  by  pressing  the  palm  firmly  upon 
the  surface,  and  then  rotating  it.  This  plan  may 
be  combined  alternately  with  the  last  method, 
massage  proper — petrissage — which  is  done  by 
raising  up  the  soft  parts  vertically  from  the  bone 
with  both  hands,  and  compressing  them,  always 
in  a centripetal  direction. 

Forcible  movements.  — Forcible  movements, 
which  break-down  adhesions,  are  often  most  use- 
ful in  cases  of  stiff  joint  arising  after  protracted 
immobilisation,  after  fracture  in  the  vicinity  of 
a joint,  or  after  a severe  sprain.  Pain  will  be 
relieved  in  this  way,  and  mobility  restored  in 
some  instances,  in  a degree  quite  remarkable. 

Constitutional  treatment. — Where  any  general 
taint  exists,  this  must  be  treated  at  the  same 
time.  A tendency  to  tubercle  must  be  met  by 
iron,  tonics,  good  food,  and  fresh  pure  air. 
Gout,  syphilis,  or  rheumatism  must,  when  pre- 
sent as  a diathesis,  be  appropriately  treated. 

Operative  treatment. — Puncture  alone,  or  com- 
bined with  antiseptic  washing-out  of  the  articu- 
lation, may  often  be  performed  with  advantage, 
to  evacuate  the  fluid  in  a distended  joint  or  to 
diagnose  the  presence  of  pus  and  evacuate  it 
when  suppuration  has  taken  place.  Sufficiently 
free  incisions,  however,  and  the  insertion  of 
drainage  tubes  are  generally  to  be  preferred  m 
cases  of  joint-suppuration  ; and  with  these  should 
be  combined  the  washing-out  the  joint-cavity  with 
a three-  or  five-per-cent,  solution  of  carbolic  acid, 
or  other  adequate  antiseptic.  It  has  been,  pro- 
posed to  substitute  free  incisions  and  drainage 
for  excision  of  the  joint,  in  certain  chrome  forms 
of  disease,  such  as  white-swelling,  but  excision 
is  probably  in  most  respects  preferable.  Ex- 
cision is  practised  for  chronic  joint-disease  not 
amenable  to  other  means  ; it  is  not  a substitute 


JOINTS,  DISEASES  OF. 


for  amputation,  but  is  intended  to  obviate  its 
necessity.  Subperiosteal  resection,  where  practic- 
able, possesses  many  advantages,  especially  in 
cases  of  traumatic  origin.  The  attachments  of 
the  muscles  and  tendons,  and  the  cellular  inter- 
faces between  them,  are  thus  left  undisturbed. 
The  chances  of  perisynovial  suppuration  are 
diminished,  and  the  bleeding  is  reduced  to  a 
minimum.  There  is  more  complete  bony  repro- 
duction of  the  joinGsurfaees,  and  in  young  per- 
sons a new  joint  very  similar  to  the  normal  is  in 
some  instances  formed,  while  in  all  cases  there  is 
a probability  of  better  subsequent  function  and 
position.  The  operation  thus  performed  requires 
time  and  skill.  It  is  scarcely  applicable  to  the 
knee  or  even  the  hip,  and  is  unstated  for  cases  of 
chronic  synovial  disease,  where  it  is  of  the  last 
importance  to  excise  all  the  diseased  granula- 
tion-material. The  after-treatment  of  excisions 
is  of  great  importance.  Plaster-of-Paris  ban- 
dages supply  one  of  the  most  useful  means  of 
immobilisation,  especially  in  those  cases  where 
anchylosis  is  sought  for,  as  in  the  knee  ; and  the 
splint  should  be  unchanged,  if  possible,  fcr  four 
or  five  weeks.  In  the  elbow,  shoulder,  and  wrist, 
where  mobility  is  the  end  aimed  at,  passive 
movement  should  be  commenced  as  soon  as  the 
i condition  of  the  wound  admits  of  it,  namely  in 
about  a week  or  ten  days.  Galvanism  must  be 
used  at  a later  period  to  restore  the  wasted  mus- 
cular apparatus. 

Amputation  is  only  performed  as  a last  resort. 
It  is  very  rarely  needed  for  joint-diseases  in  the 
upper  limb,  except  perhaps  the  wrist,  when  the 
hand  is  permanently  crippled.  In  the  lower 
limb,  amputation  must  be  performed  in  those 
cases  in  which  the  patient  has  lost  all  strength 
and  healing  power,  from  the  drain  of  a long- 
1 continued  discharge.  It  is  advisable  where 
amyloid  degeneration  or  incipient  tuberculosis 
exists,  or  in  any  case,  in  short,  in  which  the 
power  of  the  patient  is  inadequate  to  furnish  the 
amount  of  repair  required  in  the  expectant  form 
of  treatment,  or  in  case  of  excision,  always  a 
more  serious  operation  than  mere  amputation. 
Amputation  should  also  be  adopted  in  those 
eases  in  which  the  local  disease,  especially  of  the 
bone,  is  too  extensive  to  admit  of  a good  func- 
'tional  result  after  excision.  In  the  very  young 
excision  is  very  undesirable,  since  the  epiphysis 
is  almost  of  necessity  sacrificed,  and  the  growth 
of  the  limb  checked.  Resection  in  some  joints  is 
practised  to  avert  anchylosis,  or  to  restore  the 
lost  function  of  the  joint,  as  in  the  shoulder, 
slbow,  and  wrist.  Various  congenital  and  other 
deformities  of  the  joints  may  be  removed  by 
osteotomy  of  the  bones  concerned. 

The  chief  diseases  of  joints  will  now  be  sepa- 
rately considered  in  alphabetical  order  as  fol- 
ows  : — ] . Cartilages,  Diseases  of ; 2.  Congenital 
Dislocation  ; 3.  Immobility  ; 4.  Inflammation, 
Vcute,  of  the  Synovial  Membrane  : 5.  Inflamma- 
ion,  Chronic,  of  the  same ; 6.  Gonorrhoeal  In- 
lammation ; 7.  Gouty  Inflammation  ; 8.  Stru- 
ious  Inflammation ; 9.  Loose  Cartilages  in 
oints;  10.  Nervous  Affections;  11.  Bheumatic 
arthritis,  Chronic;  12.  Serous  Effnsions;  and 
3.  Syphilitic  Disease.  Rheumatism  in  its 
svarai  forms  will  be  considered  separately. 


781 

1.  Joints,  Cartilages  of,  Diseases  of. — 
Primary  chondritis  as  a form  of  joint-disease  is 
neither  clinically  nor  pathologically  established. 
The  cartilage  has  little  tendency  to  active  in- 
flammation ; it  is  not  sensitive  to  pain;  chronic 
changes  take  place  in  it  as  the  result  of  impaired 
nutrition,  rather  than  inflammation.  The  car- 
tilages of  encrustation  are  the  residue,  which 
does  not  ossify,  of  the  mass  of  fcetal  cartilage 
forming  the  bone-ends.  We  meet  in  the  joints 
of  the  aged  with  depressions  and  fibrous  scars, 
caused  by  partial  atrophy  of  the  cartilage ; these 
changes  do  not  occasion  symptoms  during  life, 
beyond  sensations  of  creaking  and  roughness  in 
the  joint  when  moved. 

Almost  all  the  changes  which  occur  in  the 
articular  cartilages  are  secondary  to  synovitis 
and  ostitis,  and  more  or  less  passive.  In  serous 
synovitis  the  cartilage  is  softened  and  swollen, 
and  becomes  to  a certain  extent  cedematous.  In 
suppurative  synovitis  it  becomes  rough,  sodden, 
and  yellow ; its  cells  burst ; the  intercellular 
substance  fibrillates  ; and  portions  may  necrose. 
The  cartilage-changes  in  chronic  synovitis  have 
been  already  discussed,  and  others  will  be  re- 
ferred to  later. 

Young  growing  bones,  like  the  periosteum 
covering  them,  readily  inflame ; and  as  soon 
as  the  inflammation  invades  the  articular  surface 
of  the  bone,  the  cartilage  becomes  loosened  and 
necrosed,  or  invaded  by  the  granulation-tissue 
springing  from  the  bone.  The  cartilage  is  soft- 
ened ; its  capsules  burst ; fibrillation  occurs ; 
and  at  different  places  it  becomes  thinned.  Per- 
forations occur  in  it,  leading  to  the  bone,  giving 
it  a sieve-liko  appearance.  Where  the  inflam- 
matory process  is  more  acute,  the  whole  of  tLe 
encrusting  cartilage  may  become  .at  once  de- 
tached from  the  bone  beneath. 

In  these  cases  the  pain,  especially  at  night,  is 
very  severe.  Involuntary  starting  of  the  limb 
causes  intense  suffering,  wakening  the  patient 
from  sleep  with  a scream.  This  symptom  was 
formerly  considered  distinctive  of  ulceration  of 
cartilage,  a process  which  is  wholly  painless 
when  it  occurs  without  other  disease  in  the 
joint,  but  it  is  probable  the  pain  is  due  to  pres- 
sure upon  the  inflamed  bone,  and  it  will  some- 
times greatly  abate  when  the  cartilage  wholly 
disappears.  Disease  commencing  near  the  epi- 
physeal cartilage  often  extends  to  the  adjacent 
joint.  Those  joints  in  which  the  epiphyseal 
junction  is  within  the  capsule,  as,  for  instance, 
the  hip,  run  a double  risk  from  bone-inflamma- 
tion. 

2.  Joints,  Congenital  Dislocation  of.— 
Description. — This  is  a curious  and  ill-under- 
stood affection  of  the  joints.  It  is  almost  exclu- 
sively confined  to  the  female  sex.  The  liip-joint 
is  nearly  always  the  one  affected,  and  the  dis- 
placement is  generally  double.  It  has  often 
been  erroneously  mistaken  for  morbus  coxae,  and 
treated  accordingly. 

It  probably  occurs  in  early  fcetal  life  from 
defective  formation  of  the  joint-surfaces.  It  is 
not  discovered  until  the  child  begins  to  walk, 
which  it  generally  only  commences  to  do  at  a 
late  period.  When  the  hips  are  affected,  the  gait 
is  accompanied  by  a most  ungainly  swaying  ul 


JOINTS,  DISEASES  OF. 


?&2 

the  body  from  side  to  side  like  the  waddling  of  a 
duck.  All  that  can  be  done  is  to  supply  a 'well- 
contrived  artificial  support  to  the  pelvis  and 
limbs. 

Genu  valgum  and  genu  varum  (knock-knee  and 
bow-knee)  are  two  forms  of  disabling  and  un- 
sightly deformity  of  the  lower  limbs.  They  are 
often  due  to  an  abnormal  development  of  the 
condyles  or  shaft  of  the  femur,  or  the  tuberosities 
of  the  tibia,  and  to  changes  of  a rickety  character 
at  the  epiphyseal  junction.  In  extreme  eases 
progression  is  greatly  interfered  with.  The 
symptoms  are  painfully  obvious. 

Treatment.  — Treatment  of  the  limb  by 
splints  and  apparatus  and  forcible  straightening 
in  plaster- of-l’aris  bandages  succeeds  in  the 
milder  cases,  but  in  those  of  a severe  type,  or 
in  persons  of  ten  years  or  upwards,  this  plan  is 
most  tedious,  and  is  usually  attended  by  com- 
plete failure.  The  subcutaneous  division  of  the 
internal  or  external  condyle,  according  to  the 
nature  of  the  deformity,  restores  the  joint-sur- 
faces of  the  femur  to  their  normal  level,  and  is 
attended  by  the  happiest  results  both  to  the 
form  and  function  of  the  limb  and  joint.  It  is 
an  easier  and  in  many  ways  a more  successful 
operation  to  divide  the  shaft  of  the  bone  with  a 
chisel  near  its  articular  extremity,  and  thus 
procure  the  rectification  of  the  limb. 

3.  Joints,  Immobility  of. — Synon.  : Anchy- 
losis ; Fr.  AnJcylose ; G-er.  Gelenkverwachsung. 

.ZEtiology. — This  condition  may  be  due  to 
changes  in  the  structures  of  the  articulation — 
true  anchylosis  ; or  in  those  surrounding  the 
joint — false  anchylosis.  It  may  be  fibrous  and 
incomplete,  or  bony  and  complete.  False  or 
spurious  anchylosis — extra-articular — may  de- 
pend on  muscular  spasm  or  rigidity;  on  cicatri- 
cial contractions ; on  paralytic  or  spasmodic 
affections;  or  upon  prolonged  disuse  of  the 
ioint.  It  is  often  difficult,  even  under  chloro- 
*form,  to  distinguish  the  presence  of  absolute 
bony  anchylosis,  as  the  fibrous  form  may  be  so 
strong  and  extensive  as  almost  wholly  to  prevent 
movement.  The  two  varieties  are  but  degrees 
of  the  same  process.  Both  may  result  from  pre- 
vious inflammatory  changes  in  the  joint,  either 
of  the  nature  of  plastic  synovitis,  or  of  granu- 
lations springing  from  the  bone  and  other  joint- 
tissues,  becoming  further  organised.  Fibro-car- 
tilaginous  anchylosis  is  a common  form  in  young 
persons.  In  time  it  usually  becomes  converted 
into  true  bony  anchylosis. 

The  marked  anchylosis  which  tonic  spasm 
and  rigidity  of  the  muscles  produce  in  the  early 
stages  of  some  joint-diseases,  as  in  the  hip-joint 
and  knee,  may  be  called  vital  or  physiological.  It 
is  induced  by  an  effort  to  avert  pain ; it  disap- 
Dears  entirely  during  narcosis.  A joint  may  be- 
come stiff  and  anehylosed  by  long  fixation  on 
account  of  some  injury  or  disease  elsewhere,  es- 
pecially if  it  be  retained  in  a flexed  position,  as 
the  muscles  of  the  flexor  side  actually  shorten 
when  their  points  of  origin  and  insertion  per- 
manently approach  one  another.  The  same  thing 
may  also  happen  in  the  myogenic  affections  due 
to  paralysis  : in  which  the  cartilages  and  bones 
atrophy  at  the  san  e time. 

Treatment. — The  treatment  of  diseases  of 


joints  should,  in  all  cases  where  it  is  possible,  bo 
prophylactic  against  the  occurrence  of  anchy- 
losis. When  this  has  taken  place  in  an  incomplete 
degree,  an  attempt  to  restore  the  function  of  the 
limb  must  be  made  by  breaking  down  the  adhe- 
sions by  forcible  or  gradual  extension,  by  pas- 
sive motion,  by  massage,  and  by  tenotomy  of  the 
tense  tendons.  Excision  is  indicated  to  restore 
motion  in  complete  anchylosis  of  such  joints 
as  the  wrist,  the  elbow,  and  the  shoulder.  In 
other  cases  of  complete  anchylosis,  especially 
in  the  lower  limb,  surgical  interference  should 
be  confined  to  an  attempt  to  rectify  a faulty 
position  either  by  tenotomy,  extension,  forcible 
straightening,  excision,  or  osteotomy.  Amputa- 
tion can  only  be  needed  in  extreme  and  other- 
wise irremediable  deformity. 

4.  Joints,  Inflammation,  Acute,  of  the 
Synovial  Membrane  of. — Synox.  : Acute  Sy- 
novitis ; Fr.  Synovite ; Ger.  Synovitis. 

This  i3  one  of  the  most  common  of  all  joint- 
affections.  Probably  in  half  the  total  number  of 
chronic  joint-diseases  the  synovial  membrane  is 
first  affected.  The  synovial  membrane  is  very 
rich  in  vessels  and  cells ; and  much  exposed  to 
injury,  and  to  the  effects  of  joint-movement.  Au 
inflammation  beginning  at  one  point  soon 
spreads  over  the  whole  synovial  sac. 

Description. — Acute  synovitis  is  a Tery  com- 
mon Tesult  of  injury;  it  also  occurs  in  rheu- 
matism, gout,  pyaemia,  and  other  diseases.  It 
may  be  serous,  sero-fibrinous,  or  purulent.  Se- 
rous synovitis  is  the  simplest  and  most  common 
variety.  Even  a slight  external  injury’  is  often 
sufficient  to  produce  it;  a sprain  of  the  joint,  or 
even  excessive  movement,  may  cause  it,  as  well 
as  the  constitutional  disorders  already  men- 
tioned. The  knee  is  very  often  affected,  from 
its  exposed  position  and  the  large  area  of  the 
serous  membrane  lining  it.  The  synovial  mem- 
brane becomes  injected  and  thickened,  with 
oedema  of  the  subsynovial  tissue.  The  natural 
secretion  is  increased  in  quantity,  and  many 
cells  are  shed  into  the  joint  cavity,  the  capsule 
becoming  swollen,  tense,  fluctuating,  or  elas- 
tic. The  least  protected  parts  bulge,  from  the 
pressure  of  the  effused  fluid,  and  the  normal 
contour  of  the  joint  is  lost.  It  is  usually  semi- 
flexed.  A severe  burning,  cutting  pain  is  ex- 
perienced in  it.  It  is  exceedingly  sensitive  to 
pressure,  and  painful  on  the  slightest  movement. 
There  is  usually  considerable  fever.  When  the 
inflammation  is  more  intense,  the  synovitis  be- 
comes sero-fibrinous.  Flakes  of  lymph  are  min- 
gled with  the  synovia ; layers  of  false  membrane 
cover  the  synovial  membrane,  which  is  consider- 
ably thickened  and  dull  red  in  colour  ; and  the 
constitutional  disturbance  is  greater.  Finally,  it 
is  but  a short  step  from  this  to  suppurative  sy- 
novitis. If  the  irritant  cause  continue  its  action, 
the  leucocytes  filling  the  meshes  of  the  synovial 
membrane  are  shed  in  larger  quantity  ; the  fluid 
becomes  turbid  and  puriform  ; the  fever  and  local 
symptoms  increase  very  much  in  severity;  the 
external  parts  become  implicated  in  the  inflam- 
mation within;  and  joint-suppuration  or  abscess 
is  the  result. 

Treatment. — The  treatment  of  the  first  two 
stages  of  synovitis  is  directed  primarily  to  check 


JOINTS,  DISEASES  OF. 


783 


I 

| 

i 


the  progress  of  the  inflammation ; and  then  to 
procure  resolution,  and  absorption  of  the  effused 
fluid.  Fortunately  the  synovial  membrane  pos- 
sesses very  active  absorbent  powers  ; and  early 
and  efficient  treatment,  conjoined  with  removal 
of  the  source  of  irritation,  will  generally  ensure 
a cure,  with  complete  restoration  of  function. 
The  chief  means  are  cold  applications ; immobili- 
sation till  the  acute  stage  is  over;  and  then  com- 
pression and  friction,  or  in  suitable  cases  counter- 
irritation. Gout,  rheumatism,  or  other  diathesis, 
must  be  appropriately  treated  at  the  same 
time. 

In  those  cases  in  which  the  inflammation  has 
persisted  for  some  time,  and  plastic  effusion  has 
taken  place  on  the  surface  and  in  the  substance 
of  the  synovial  tissue,  the  joint  will  remain  for 
a long  time  stiff  and  thickened,  and  its  function 
impaired,  after  all  acute  symptoms  have  sub- 
sided ; whilst  in  those  cases  where  the  inflamma- 
tion has  continued  long  enough  to  invade  the 
other  joint-structures,  a perfect  cure  may  not  be 
possible. 

When  suppuration  occurs,  the  joint  must  be 
deait  with  as  any  other  abscess-cavity.  Free 
incisions  must  be  made  into  it,  and  it  should  be 
thoroughly  washed  out  with  some  antiseptic 
solution,  free  subsequent  drainage  being  pro- 
vided for.  In  tho  more  favourable  cases,  an- 
chylosis in  a convenient  position  will  be  obtained. 
Recovery  of  function  is  very  rare.  In  other 
cases  the  suppuration  continues ; the  cartilages 
of  encrustation  become  necrosed  and  detached  ; 
the  bone  becomes  exposed  and  carious  ; and  either 
excision  or  amputation  must  be  performed  to 
save  the  patient's  life  or  limb. 


5.  Joints,  Inflammation,  Chronic,  of  the 
Synovial  Membrane  of.  — - Synon.  : Chronic 
Synovitis. 

Chronic  synovitis  may  arise  as  the  sequel  of 
the  acute  disease  ; or,  as  is  more  frequent,  it 
may  depend  on  some  constitutional  dyscrasia,  or 
at  least  some  continuously  acting  irritant,  al- 
though in  the  first  instance  it  is  generally  ex- 
cited by  an  accidental  injury. 

Vabieties. — There  are  three  chief  varieties  of 
this  disease  which  are  often  co-existent,  namely  : 
—Pannus  Synovitis,  Granulation  Synovitis,  and 
Pa-pillomatous  Synovitis. 

a.  Pannus  Synovitis. — In  this  variety  a deli- 
cate membrane  will  be  found,  stretching  from 
the  inflamed  and  thickened  synovial  margins 
more  or  less  over  the  surface  of  the  cartilage, 
to  which  it  may  be  in  whole  or  in  part  ad- 
herent. 

b.  Granulation  Synovitis. — Tho  second,  or 
granulation-form,  is  a more  advanced  stage  of 
the  disease.  In  it  the  synovial  membrane  is 
often  completely  replaced  by  granulation-mate- 
' rial,  which  encroaches  on  the  margins  of  the 
cartilages,  and,  as  the  disease  progresses,  in- 
vades them,  and  coalesces  after  a time  with 
granulations  springing  from  the  inflamed  bone. 
These  granulations  are  pink  or  greyish-red,  not 
10  vascular  as  those  in  an  ordinary  wound. 
They  have  little  tendency  to  cicatricial  change, 
md  are  prone  to  soften  down  and  form  abscesses. 

The  synovial  membrane  often  becomes  enor- 
uously  thickened  from  the  granulation-material 


accumulated  in  it,  and  this  form  of  disease  is 
frequently  associated  with  the  tuberculous  dia- 
thesis. Bodies  identical  with  miliary  tubercles 
are  very  often  found  in  the  semi -gelatinous  or 
pulpy  synovial  membrane  ; the  whole  constitut- 
ing what  is  known  as  tumor  a/bus,  or  ‘ white- 
swelling.’ 

SvrMProMS.  — The  more  prominent  symptom 
associated  with  the  form  of  chronic  synovitis 
just  described  is  the  presence  of  a uniform 
semi-elastic  swelling,  caused  by  the  sero-fibri- 
nous  infiltration  of  the  synovial  membrane.  The 
skin  is  whitish,  tense  and  smooth,  whence  the 
name  tumor  albus.  The  amount  of- synovial  effu- 
sion into  the  joint  is  usually  limited;  the  pain 
is  seldom  severe ; the  amount  of  joint-movement 
is  diminished  ; and  there  is  usually  contraction 
of  the  limb,  and  sometimes  partial  dislocation. 
When  suppuration  occurs,  there  is  more  pain 
and  fever.  The  progress  of  the  disease  is  gene- 
rally very  chronic,  extending  over  months  or 
years,  and  allowing  the  patient  at  intervals  to 
take  moderate  exerei-e.  Exacerbations  take 
place,  however,  from  slight  causes,  or  without 
cause  ; attacks  of  subacute  or  acute  inflammation 
supervene  ; and  sooner  or  later  abscesses  form, 
communicating  both  with  the  cavity  of  the  joint, 
which  becomes  totally  disorganised,  and  with 
the  surface. 

Brodie’s  ‘pulpy  disease  of  the  synovial  mem- 
brane ’ is  simply  an  exaggerated  degree  of  gra- 
nulation synovitis,  in  which  the  subsynovial 
tissue  becomes  enormously  thickened  by  succes- 
sive attacks  cf  inflammation, 

Treatment. — The  disease  is  most  rebellious 
to  treatment,  and  scarcely  curable  amongst  the 
poorer  classes  without  operation.  Sometimes 
the  diseased  tissue  is  got  rid  of  by  suppuration ; 
and,  if  the  patient’s  strength  suffice,  a cure  by 
anchylosis,  probably  accompanied  by  consider- 
able deformity,  will  ensue.  Generally,  however, 
the  symptoms  become  worse;  the  aeneral  health 
gives  way  from  the  drain  of  the  continuous  dis- 
charge ; or  amyloid  or  some  other  intt-reum-nt 
disease  kills  the  patient.  At  any  time,  as  in  a 
suppurating  wound,  pyaemic  symptoms  or  hectic 
may  set  in. 

c.  Papillomatous  Synovitis. — Synon.  : Fim- 
briated disease  of  the  synovial  membrane  ; Pa- 
pilloma, or  Papillary  Fibroma  of  the  synovial 
membrane ; Ger.  Gchnlrzottcn. 

This  is  a peculiar  form  of  joint-disease  depen- 
dent on  chronic  synovitis,  in  which  numerous 
pedunculated  bodies,  cylindrical  or  fusiform, 
varying  in  size  from  a pin’s-head  to  a large  pea, 
project  from  the  membrane,  generally  near  the 
cartilage  margins,  or  they  may  cover  the  entire 
surface.  They  are  identical  in  minute  structure 
with  the  synovial  fringes.  Some  become  de- 
tached, and  fall  into  the  cavity  of  the  joint.  The 
disease  is  essentially  a hyperplasia  of  the  sy- 
novial adventitia  ; and  there  may  be  dozens  or 
hundreds  of  these  bodies  present  in  one  joint. 
Occasionally  they  contain  cartilage-cells,  or 
osseous  particles.  The  joints  in  the  lower  limb 
are  most,  often  affected. 

Treatment. — The  disease  is  scarcely  reme- 
diable except  by  excision  of  the  joint,  which 
may  be  practised  in  those  cases  in  which  there 
is  serious  loss  of  function. 


784  JOINTS,  DISEASES  OF. 


6.  Joints,  Inflammation  of,  Gonorrhoeal. 
This  disease  is  often  called  ■'  gonorrhoeal  rheu- 
matism.’ It  is  almost  always  observed  in  the 
male,  very  rarely  affecting  the  female.  Generally 
one  joint,  usually  in  the  lower  limb,  is  involved, 
as  the  knee  or  the  ankle.  It  is  not  so  common  in 
the  upper  extremity.  It  may  affect  several  joints 
in  succession.  It  may  occur  at  any  period  of  a 
gonorrhoeal  or  even  a gleety  discharge,  of  which 
the  patient  himself  is  possibly  unaware.  The 
fibrous  tissues  of  the  joint  seem  to  be  primarily 
engaged.  Sclerotitis  and  inflammation  of  the 
internal  layer  of  the  cornea  often  coexist,  but 
never  either  endo-  or  pericarditis. 

Symptoms. — The  joint  affected  is  exquisitely 
tender  on  pressure  ; it  is  swollen  rather  from  sub- 
cutaneous oedema  than  by  intra-artieular  effu- 
sion, which  is  usually  inconsiderable ; and  one 
side  of  the  joint  is  often  more  affected  than  the 
other.  The  fever  is  not  in  proportion  to  the  in- 
tensity of  the  local  symptoms,  the  rise  of  tempe- 
rature being  slight.  The  course  of  the  disease 
is  sloyv  and  obstinate  ; but  when  cured  it  is  not 
liable  to  return,  except  with  a fresh  attack  of 
gonorrhoea.  These  characters  distinguish  it  from 
ordinary  rheumatism. 

Treatment. — Best,  cold  applications,  and  the 
internal  exhibition  of  iodide  of  potassium  consti- 
tute the  best  treatment  for  gonorrhoeal  inflam- 
mation of  joint.  See  Rheumatism,  Gonorrhoeal. 

7.  Joints,  Inflammation  of,  Gouty. — Gout 
frequently  occasions  synovitis,  by  the  deposit 
of  urate  of  soda  in  the  perisynovial  tissue,  which 
excites  a synovial  effusion.  The  attacks  are 
very  acute  and  painful ; and  as  they  recur,  the 
joint  becomes  more  and  more  disorganised,  horn 
permanent  deposits  of  urates  in  the  cartilages 
and  bone,  as  well  as  in  the  perisynovial  tissue. 
The  use  of  the  joint  is  lost;  and  the  ‘chalk- 
stone,’  as  it  is  called,  acting  as  a foreign  body, 
sometimes  produces  an  abscess,  or  an  ulceration 
very  troublesome  to  heal.  When  the  collection 
is  quite  superficial,  it  may  often  be  evacuated  by 
incision  with  great  relief.  See  Gout. 

8.  Joints,  Inflammation  of,  Strumous. — - 
Scrofula  and  tubercle  are  often  associated  with 
joint-diseases.  Scrofulous  or  strumous  inflam- 
mation of  a joint  is  a vague  term,  but  we  are 
without  a better.  It  is  a form  of  chronic  inflam- 
mation in  ill-nourished  persons — nearly  always 
children — who  live  under  had  hygienic  condi- 
tions, and  are  prone  to  deposits  of  tubercle.  It  is 
observed  most  frequently  in  the  knee-  and  hip- 
joints. 

Anatomicau  Characters.-— This  disease  gene- 
rally commences  in  the  synovial  membrane, 
which  becomes  thickened,  and  by  degrees  con- 
verted into  a semi-gelatinous  mass  of  granulation- 
tissue,  yellowish-white  or  pink  in  colour  ; or  the 
disease  may  originate  in  osteomyelitis  of  the  end 
of  the  bone.  After  it  has  existed  for  some  time, 
it  is  difficult  to  determine  in  what  tissue  it  may 
have  originated,  and  it  is  of  no  clinical  impor- 
tance to  do  so,  for  in  any  case  the  later  stages 
of  the  malady  present  similar  features.  The 
cartilages  are  encroached  upon  from  their  mar- 
gins and  from  their  deep  surfaces  by  the  gra- 
nulations, whilst  active  changes  occur  simul- 


taneously in  their  substance,  similar  to  those 
already  described.  The  ligaments  soften,  and  nil 
the  structures  of  the  joint  become  involved. 
Frequently  small  masses  of  necrosed  Lone  will 
be  found  in  the  cancellated  structure,  and  the 
granulations  have  a great  tendency  to  suppurate. 
In  the  thickened  synovial  membrane,  and  also  in 
the  ends  of  the  bones,  miliary  bodies,  identical 
with  tubercles,  may  very  frequently  be  detected. 

Symptoms. — In  strumous  inflammation  the 
joint  is  uniformly  swollen,  tense,  elastic,  with 
a white  glistening  surface,  and  enlarged  veins 
shining  through  the  skin.  The  patient  can 
usually  move  about  until  suppuration  has  taken 
place,  as  the  pain  is  never  very  severe  in  the 
intervals  of  the  acute  attacks  of  inflammation 
which  supervene  from  time  to  time.  Enlarge- 
ment of  the  lymphatic  glands,  or  marks  of 
strumous  ulceration  elsewhere  are  seldom  want- 
ing ; whilst  sooner  or  later  a large  proportion  of 
the  individuals  affected  by  this  form  of  joint-dis- 
ease show  signs  of  general  tuberculosis.  Some- 
times this  state  precedes,  but  generally  it  fol- 
lows, the  local  joint-affection.  Inherited  syphilis 
appears  to  be  a predisposing  cause  of  strumous 
arthritis. 

Treatment. — This  must  be  mainly  directed 
to  improving  the  patient's  general  condition.  A 
purely  local  treatment,  short  of  a complete  remo- 
val of  the  diseased  structures,  is  not  of  the  least 
use.  When  the  joint  has  become  disorganised,  as 
before  described,  excision  should  be  performed 
before  the  viscera  become  implicated.  If  other 
organs  be  involved,  or  the  local  disease  be  too 
extensive,  then  amputation  becomes  imperative. 
When  not  relieved,  fresh  foci  of  suppuration 
form  ; the  patient  becomes  more  and  more  ex- 
hausted ; or  some  intercurrent  disease  sets  in.  It 
is  rare  for  spontaneous  cure  to  happen. 

9.  Joints,  Loose  Cartilages  in. — Stxon.  : 

Fr.  Corps  flottunts  ariiculaires;  Ger.  Gclenk- 
maiise. 

Description.  — * Loose  cartilages  ’ in  joints 
may  originate  either  from  chronic  inflammation, 
or  from  traumatic  causes.  They  may  be  single 
or  multiple.  The  knee-joint  is  most  frequently 
affected,  and  in  it  the  most  serious  symptoms 
are  produced.  These  bodies  may  be  fibrous 
lipomatous,  chondromatous.  or  osteo-chondm 
matous.  They  may  be  produced  from  polypoid 
growths  springing  from  the  synovial  membrane 
in  certain  forms  of  chronic  synovitis,  and  in 
arthritis  deformans  ; and  they  are  then  usually 
of  the  fibrous  or  osteoid  variety.  Lipomatous 
free  bodies  are  rare,  and  are  derived  from  the  sub- 
synovial  fatty  tissue,  being  produced  in  a fashion 
analogous  to  the  appendiese  of  the  great  intestine. 

The  chondromatous  and  osteo-chondromatous 
are  the  largest  and  most  important  varieties  of 
these  bodies ; hence  the  common  term  ‘ loose  car- 
tilage.’ Portions  of  the  joint-surface  may  some- 
times become  detached,  as  the  consequence  of 
an  injury,  by  a process  of  quiet  necrosis.  They 
thus  become  loose  in  the  joint.  There  is  good 
reason  to  believe  that  some  of  these  bodies  may 
obtain  nourishment  from  the  surrounding  syno- 
vial fluid,  and  that  cartilage  and  even  bone  can 
be  developed  in  them  subsequently  to  their  do 
tachment. 


JOINTS,  DISEASES  OF. 


Symptoms  and  Diagnosis. — The  symptoms  of 
loose  cartilages  in  a joint  vary  very  much.  In 
some  instances  these  bodies  cause  no  inconveni- 
ence. In  others  they  produce  repeated  attacks 
of  excruciating  pain,  followed  by  synovitis,  lay- 
ing the  patient  up  for  weeks ; whilst  in  the  most 
severe  cases  the  limb  may  become  almost  use- 
less. When  the  knee  is  the  joint  alfected,  the 
patient  experiences  great  insecurity  in  walking, 
the  loose  body  from  time  to  time  becoming 
wedged  between  the  joint-surfaces.  The  joint  is 
thus  ‘ locked.’  The  patient  may  suddenly  fall,  or 
faint  with  pain ; an  attack  of  synovitis  follows  ; 
and  with  a frequent  repetition  of  this  process 
joint-disorganisation  may  finally  result.  The 
prognosis  as  regards  function  is  always  bad. 

Tbeatment. — The  treatment  of  loose  carti- 
lages may  be  either  palliative  or  radical.  The 
former  method  consists  in  applying  support  to 
the  joint;  limiting  its  movements  ; and  fixing  the 
loose  body  in  some  synovial  pouch  where  it  can- 
not interfere  with  the  articular  surfaces. 

The  radical  method  consists  in  excising  the 
body — an  operation,  with  few  exceptions,  almost 
exclusively  practised  upon  the  knee-joint.  The 
body  may  be  removed  by  a free  direct  incision 
into  the  joint,  and  squeezing  the  body  through 
the  wound  at  once.  Or  the  indirect  manner  of 
operating  may  be  adopted.  This  consists  in 
subcutaneously  incising  the  capsule  of  the  joint 
with  a long,  narrow- bladed  knife  introduced  at 
some  distance  from  the  articulation ; forcing 
the  body  through  this  incision  into  the  cellular 
tissue  outside  ; and  then  closing  the  small  ex- 
ternal puncture  in  the  skin.  Three  or  four 
weeks  later  the  ‘ cartilago  ’ may  be  removed  by 
a superficial  incision,  or  left  undisturbed,  when 
it  often  becomes  absorbed. 

In  appreciating  the  comparative  value  of  these 
-wo  plans,  it  may  be  said  that  the  former  has 
litherto  proved  more  uniformly  successful  quoad 
extracting  the  body,  but  that  it  has  been  more 
langerous  to  limb  and  life — a danger,  however, 
vhich  antiseptic  precautions  will  in  future  re- 
use to  a minimum.  The  indirect  method  has 
■een  attended  by  a considerable  number  of  fail- 
res  in  the  extraction  of  the  loose  cartilage, 
specially  if  it  be  pedunculated ; but  it  has 
jitherto  proved  a much  less  dangerous  opera- 
on.  The  extremity  should  be  immobilised 
fterwards  for  two  or  three  weeks. 

When  some  dozens  of  these  bodies  are  present 
. a joint,  many  of  them  free,  many  attached, 
icision  of  the  articulation  is  often  the  only 
medy.  This  is  a severe  measure,  and  not  to  be 
,;htly  undertaken,  in  the  joints  of  the  lower 
ib  at  all  events. 

10.  Joints,  Uervous  Affections  of. — 
‘Non.:  Hysterical  joint ; Neuralgia  of  Joints; 
•jthralgia;  Fr . Art.hralgie  hysterique-,  Ger.  Ge- 
i kneurose. 

Ieschiption.  — Hysterical  affections  present 
f lptoms  simulating  real  joint-disease  so  closely, 

I t the  strongest  therapeutic  measures  havo 
c n been  exerted,  though  in  vain,  for  thoir 
c P*  Prolonged  immobilisation,  blistering,  the 
Mai  cautery,  resection,  and  even  amputation, 
h 3 been  practised  upon  joints  in  which  there 
1*  not  a trace  of  organic  disease, 

50 


786 

The  existence  of  hysterical  affections  of  joints 
is  denied  by  some  ; but  assuredly  they  do  occur  . 
and  most  often  in  young  women,  well-to-do  in 
life,  with  disordered  catamenia.  The  same  thing 
occurs,  but  less  frequently,  in  young  men.  The 
disease  is  not  witnessed  under  the  age  of  pu- 
berty. The  hip  and  knee  are  the  joints  princi- 
pally complained  of — most  frequently  the  latter. 
An  all-important  feature  of  a hysterical  joint  is 
that,  while  the  local  symptoms  may  be  intense, 
the  general  symptoms  are  either  absent,  or  in  no 
sort  of  proportion  to  the  local. 

A special  character  of  this  disease  is  that 
deep  pressure  is  often  less  painful  than  super- 
ficial pressure;  and  that  the  pain  and  tenderness 
are  vague,  shift  from  one  point  to  another,  and 
will  disappear  at  a given  spot  when  the  patient's 
attention  is  directed  elsewhere.  There  is  pain  on 
movement,  but  of  an  indefinite  character,  and 
not  so  limited  or  localised  as  in  real  disease. 
Nocturnal  startings  do  not  occur  ; the  patient 
may  enjoy  uninterrupted  sleep  for  hours.  There 
is  never  a continuous  rise  of  temperature,  either 
general  or  local ; the  co-relation  of  the  symp- 
toms is  not  the  usual  one  ; the  function  of  the 
joint  is  much  more  interfered  with  than  the 
other  features  of  the  disease  present  would  ap- 
pear to  justify.  There  is  an  exaggerated  fear  of 
examination;  and  the  facies  hysterica  is  often 
well-marked.  There  may  be  thickening  around 
the  joint,  and  even  marked  synovial  effusion  into 
it;  but  these  conditions  are  passive  in  character, 
and  generally  due  to  the  treatment  employed. 
The  limb  is  wasted  and  consequently  weak,  but 
never  to  the  same  extent  as  in  real  joint-disease. 
Exacerbations  occur  at  the  menstrual  period.  A 
careful  inquiry  should  be  made  into  the  history 
and  antecedents  of  the  case.  An  examination 
under  chloroform  will  often  afford  important 
evidence ; and  the  patient’s  symptoms  will  be 
■ improved  afterwards  by  the  movements  then 
practised  on  the  joint. 

Neuralgic  pain  in  the  articulations  may  arise 
under  different  circumstances.  It  may  be  the 
referred  pain,  unattended  by  local  lesion,  which 
is  so  frequent  in  the  knee  in  cases  of  hip-joint 
disease.  Neuralgic  pains  in  various  joints  are 
observed  in  the  preliminary  or  early  stages  of 
chronic  myelitis.  In  the  first  stage  of  locomotor 
ataxy  the  knee  may  be  affected  by  severe  neu- 
ralgia when  the  disease  is  low  down  in  the  cord  ; 
or  the  shoulders  when  it  is  at  a higher  point. 
Lastly,  so  called  neuralgia  of  a joint  may  really 
indicate  some  obscure  lesion,  as  chronic  inflam- 
mation of  the  bones  entering  into  the  formation 
of  the  articulation. 

Treatment. — The  methodical  exercise  of  an 
hysterical  joint  is  as  plainly  indicated  as  rest  is 
imperative  in  a case  of  organic  disease.  Tilt- 
bowels  should  be  regulated,  as  also  the  men- 
strual flow.  Assafcetida,  iron,  and  quinine  are 
most  important  remedies;  and  healthy  mental 
and  moral  influences  are  valuable  adjuncts. 
‘Get  up  and  walk’  is  a good  prescription  in 
many  such  cases.  Very  careful  and  repeated  ex- 
amination should  always  bo  made,  to  exclude 
any  possible  form  of  chronic  inflammation,  before 
pronouncing  a joint  to  be  hysterical.  It  must 
not  be  forgotten,  however,  that  after  slight  in- 
juries which  produce  some  inflammatory  symp- 


786  JOINTS,  DISEASES  OF. 
toms,  those  of  hysterical  joint  may  supervene, 
and  persist  long  after  all  traces  of  organic  dis- 
ease have  disappeared. 

The  treatment  of  neuralgia  connected  with  a 
joint  will  necessarily  vary  with  its  cause.  See 
Neuralgia. 

11.  Joints,  Rheumatic  Arthritis  of. 
Chronic. — Synon.  : Osteoarthritis  ; T'r.  Arthrite 
avec  usvre  des  cartilages ; Artlirite  sechc ; Ger. 
Altersabschleifung. 

^Etiology  and  Pathology, — The  number  of 
names  that  have  been  applied  to  this  disease  be- 
trays the  obscurity  enveloping  its  pathology.  In 
nature  it  is,  however,  essentially  a senile  dege- 
neration, preceded  by  chronic  inflammation  ; and 
is,  in  part,  perhaps  the  result  of  wear  and  tear 
of  the  joint.  It  is  most  common  in  hard-work- 
ing people,  exposed  to  the  influence  of  wet  and 
cold,  and  in  the  aged.  One  or  many  joints  may 
be  affected ; generally  the  fingers,  the  toes,  the 
hip,  and  the  knee.  It  may  be  set  up  by  injury, 
such  as  a sprain,  dislocation,  or  fracture  ; or  it 
may  arise  without  known  cause.  It  is  difficult 
to  say  which  tissue  is  primarily  at  fault,  but 
sooner  or  later  all  become  involved.  The  syno- 
vial membrane  inflames ; papillary  outgrowths 
form  upon  it ; the  cartilage  swells  ; and  the  ends 
of  the  bones  enlarge.  After  atime  the  quantity  of 
synovial  fluid  diminishes;  the  joint-friction  in- 
creases; the  cartilages  are  rubbed  away  at  the 
surfaces  of  contact ; and  afterwards  the  bone  it- 
self, which  becomes  denser  by  interstitial  deposit, 
disappears.  The  surface  is  ebumated,  and 
marked  with  striae  produced  by  friction ; whilst 
deposits  of  new  bone,  which  may  often  be  felt 
externally,  form  around  the  margins  of  the 
joints,  so  that  the  area  of  its  surfaces  becomes 
greatly  increased. 

Symptoms. — The  symptoms  of  ohronic  rheu- 
matic arthritis  chiefly  consist  in  constant  pain, 
of  a dull  aching  character,  and  worse  at  night, 
Motion  becomes  more  and  more  difficult  and 
painful  as  the  disease  advances;  but  anchylosis 
uever  occurs.  Rough  crepitus  is  felt  both  by 
the  patient  and  the  surgeon  when  the  joint  is 
moved.  See  Rheumatic  Arthritis. 

Treatment. — The  treatment  of  rheumatic 
arthritis  can  only  be  palliative,  and  consists  in 
the  use  of  warm  douches  and  other  warm  appli- 


KKLOID. 

cations,  and  the  administration  of  iodide  of  po- 
tassium internally.  The  disease  is  incurable. 

12.  Joints,  Serous  Effusion  into. — Synon.  : 
Hydrops  articuli-,  Hydarthrosis\  I'r.  Hydarthrose1, 
Ger.  GelenJcwassersucht. 

This  is  a form  of  chronic  serous  synovitis,  in 
which  there  are  no  obvious  inflammatoiy  symp- 
toms. The  joint  sometimes  becomes  greatly 
distended : the  ligaments  are  stretched ; and  in 
consequence  there  is  a sensation  of  tension  and 
feebleness  in  the  articulation.  The  knee  and 
elbow  are  most  frequently  attacked ; and  the  dis- 
ease is  often  associated  with  a gouty  or  rheu- 
matic diathesis,  or  with  rheumatoid  arthritis.  It 
is  very  difficult  to  cure.  The  joint  may  be  punc- 
tured and  the  fluid  drawn  off,  or,  still  better,  it 
may  be  injected  and  thoroughly  washed  out  with 
iodine  (equal  parts  of  the  compound  tincture  and 
water)  or  a carbolic  acid  ( 2-t  to  5 per  cent.)  so 
lution ; but  relapses  are  common. 

13.  Joints,  Syphilitic  Disease  of. — This 

disease  majr  originate  in  children,  in  the  form  of 
a suppurative  ostitis  at  the  junction  of  the  epi- 
physis and  diaphysis.  Other  signs  of  congenital 
syphilis  will  help  to  establish  the  diagnosis. 
The  disease  runs  a rapid  course,  and  the  joint  is 
frequently  destroyed.  In  the  adult  a chronic 
plastic  synovitis,  due  to  gummatous  infiltration 
of  the  perisynovial  tissue,  or  of  the  bone  and 
periosteum,  is  the  more  common  form.  There  is 
very  little  fluid  effusion  within  the  joint,  but 
considerable  impairment  of  mobility  is  produced 
by  the  thickening  outside  it.  The  progress  of 
the  disease  is  slow  and  painless,  except  at  night 
or  on  motion.  The  history  of  the  case;  the 
presence  of  traces  of  syphilis  elsewhere;  and 
the  effects  of  treatment,  will  help  in  establishing 
the  diagnosis.  The  internal  administration  of 
mercury  and  iodide  of  potassium,  combined  with 
local  pressure  by  means  of  strapping  with  mer- 
curial  plaster,  speedily  effects  a marked  im- 
provement and  cure. 

"William  MacCormac, 

JUGULAR  VEINS,  Physical  Signs  in 
connexion  with.  — The  principal  physical 
signs  in  connexion  with  the  jugular  veins  are 
distension,  pulsation,  and  venous  hum.  See 
Physical  Examination. 


K 


KELOID. — Stnon.  : Fr.  Childide,  Keloide ; 
(tor.  Keloid .- — Keloid  and  cheloid  are  two  words 
reAAiabling  each  other  in  sound,  and  sometimes 
used  indiscriminately,  but  differing  altogether 
in  origin  and  signification.  Keloid  is  derived 
from  kt]\U,  a mark  or  blemish;  whilst  cheloid 
derives  its  origin  from  xv^-b,  a crab’s  claw.  The 
disease  which  we  now  recognise  as  cheloid  was 
first  described  by  Alibert  under  the  name  of 
he  Us,  with  the  synonyms,  cheloide  and  caneroidc, 
aud  is  therefore  sometimes  referred  to  as  the  * kelis 


of  Alibert  ’ (see  Cheloid).  The  term  keloid  ha*, 
however,  been  applied  by  Addison  to  a blemish 
of  the  skin,  resulting  from  a fibrous  degeneration 
of  the  derma  allied  with  scleriasis;  hence  the 
use  of  the  term  kelis  Addisonii.  Both  diseases 
are.  really  fibromata ; but  one,  namely  cheloid,  is 
a tumour,  while  the  other,  kelis,  is  flat,  and  offer 
resembles  a cicatrix.  There  is  another  obvious 
difference  between  them:  cheloid  is  restricted  ti 
the  derma,  whilst  kelis  follows  the  subeutaneom 
connective-tissue  to  the  deeper  parts  of  the  boat 


KELOID. 

The  early  dermatologists  described  kelis  under 
the  name  of  morphoea , and  by  that  name  it  is 
still  distinguished  by  some  modern  writers. 

Erasmus  Wilson. 

KERATITIS,  or  KERATODEITIS 
(nepas,  a horn,  the  cornea). — Inflammation  of  the 
cornea.  See  Eye  and  its  Appendages,  Diseases 
of. 

KERION  (xriptov,  a honeycomb). — A term 
applied  to  a pustular  folliculitis  of  the  scalp.  The 
inflamed  skin  occurs  in  the  form  of  one  or  several 
blotches  of  a deep  red  colour,  prominent,  and 
dotted  over  with  yellow  spots— the  apertures  of 
the  follicles,  from  which  the  hair  has  been  ex- 
pelled, and  which  exude  a copious  muco-purulent 
fluid.  The  yellow  spots  are  converted  into  hol- 
lows by  the  tumefaction  of  the  framework  of 
inflamed  skin,  and,  no  doubt,  thereby  suggested 
the  idea  of  a honeycomb,  whilst  the  muco- 
purulent secretion  might  in  like  manner  be 
compared  to  honey.  Another  feature  of  the 
disease  is  the  elimination  of  the  hair  from  the 
inflamed  follicles,  and  the  subsequent  baldness 
, of  the  affected  part.  Kerion  is  sometimes  as- 
sociated with  tinea  capitis.  See  Skin,  Diseases 
j of ; and  Tinea. 

Erasmus  Wilson. 

KIDNEYS,  Diseases  of. — Synon.  : Er. 

Maladies  des  Reins-,  Ger.  Mierenkrankhciten .— 
The  kidney  is  subject  to  a number  of  diseases, 
which  will  be  considered  in  the  following  pages 
in  alphabetical  order.  At  the  outset,  however, 
jt  will  be  convenient  to  present  an  outline  of  the 
abnormal  phenomena  to  which  these  affections 
nay  give  rise. 

Summary  of  Symptoms. — The  facts  upon 
which  the  diagnosis  in  diseases  of  the  kidneys  is 
ounded,  are  of  three  classes,  namely  A.  Ab- 
lormal  local  conditions  ; B.  Abnormalities 
f the  urinary  secretion ; C.  Abnormalities 
u other  parts  of  the  system,  secondary  to 
he  local  phenomena. 

A.  Abnormal  local  phenomena.  — These 
juiy  be : — 

a.  Subjective.  The  patient  may  experience 
ain  or  uneasiness  in  the  region  of  the  kidney, 
lone  or  both  sides;  and  abnormal  sensations 
ay  be  also  referred  to  the  ureter,  the  bladder, 

the  urethra.  The  pain  may  be  influenced  by 
titude  or  by  exertion ; and  be  either  constant, 
roxysmal,  or  periodic.  It  may  be  aggravated, 
lieved,  or  unaffected  by  pressure. 

b.  Objective.  Examination  of  the  abdomen  and 
jvis,  by  means  of  palpation  and  percussion, 
ly  reveal  the  presence  of  a tumour  connected 
th  the  kidney.  The  tumour  may  be  solid  or 
id;  uniform  or  lobulated.  Tumours  of  the 
Iney  may  generally  be  made  out  by  palpa- 
n,  and  especially  by  tilting  with  the  one 

■ id  the  mass  forwards  from  the  lumbar  region, 
■>n  the  fingers  of  the  other  hand  applied  iu 
tut.  In  some  cases  the  absence  of  the  kidney 
ijin  its  normal  position  may  be  ascertained  by 
1 cussion  in  the  lumbar  region.  By  careful  ob- 
i ration  of  the  relative  form  of  the  two  sides  at 
t back  and  in  front,  either  the  presence  of  tu- 
t tr,  orthe  absence  of  the  organ,  may  be  rendered 
I inct. 


KIDNEYS,  DISEASES  OF.  787 

B.  Abnormalities  of  the  urinary  secre- 
tion.— a.  The  urine  may  be  altered  iu  quantity. 
It  may  be  increased,  as  in  waxy  degeneration  of 
the  kidney,  or  in  advanced  stages  of  cirrhotic  and 
inflammatory  Bright’s  disease ; or  diminished, 
either  from  obstruction  to  its  escape,  or  from 
failure  of  secretion.  The  conditions  leading  to 
obstruction  to  outflow  are  certain  diseases  of  tho 
urethra,  prostate,  bladder,  or  ureters  : the  last- 
named  inducing  suppression  only  where  both 
the  ducts  are  simultaneously  occluded,  or  where 
one  kidney  having  been  previously  destroyed,  the 
ureter  of  the  other  side  subsequently  becomes 
affected.  The  impaction  of  calculi,  and  the  pres- 
sure of  new-formations  are  the  chief  causes  of 
these  obstructions.  The  conditions  leading  to 
diminution  or  failure  of  secretion  are  the  py- 
rexial  state  ; obstruction  of  uriniferous  tubules, 
as  by  inflammatory  products ; long-standing 
passive  congestion,  as  in  cardiac  disease ; and 
probabiy  some  forms  of  altered  innervation. 

b.  The  urine  may  be  altered  in  colour,  as  from 
the  presence  of  blood,  pus,  bile,  purpurin ; or  of 
substances  introduced  into  the  system,  such  as 
logwood,  rhubarb,  senna,  tar,  and  carbolic  acid. 

c.  The  specific  gravity  may  be  altered,  being 
much  raised  when  the  proportion  of  water  is 
small,  or  when  an  excessive  amount  of  sugar  or 
of  urea  is  being  eliminated,  or  when  a large  pro- 
portion of  blood  or  of  albumin  is  present.  It  is 
diminished  whenever  the  proportion  of  water  is 
excessive,  or  the  elimination  of  urea  diminished. 
It  is  thus  an  important  feature  of  renal  disease. 
In  determining  the  specific  gravity  it  is  impor- 
tant to  remember  that,  when  the  specimen  has 
stood  for  some  time,  it  may  vary  in  different 
parts  of  the  same  column  of  fluid  ; that  it  varies 
with  the  temperature,  being  lower  iu  warm  than 
in  cold  fluid;  and  further  that  it  varies  at  dif- 
ferent times  of  the  day,  in  relation  to  the  stale 
of  the  digestion. 

d.  The  reaction  of  urine  varies  from  the  slightly 
acid  standard  of  health,  by  being  either  too  acid 
or  alkaline.  The  acidity  may  be  excessive  when 
the  urine  is  passed,  or  may  become  increased 
after  it  has  been  voided,  in  consequence  of  the 
acid  fermentation.  It  may  be  alkaline  when 
passed,  from  the  presence  either  of  fixed  alkali 
or  of  ammonia.  The  ammonia  results  from  de- 
composition of  urea,  and  this  change  constantly 
occurs  in  urine  which  has  been  kept  and  allowed 
to  decompose. 

e.  Albumin  is  a common  morbid  constituent  ot 
urine,  either  temporary  or  permanent.  Tempo- 
rary albuminuria  may  be  artificially  produced  by 
the  ingestion  into  the  stomach,  or  by  subcutaneous 
injection,  of  raw  albumin  of  egg;  and  it  some- 
times results  from  derangement  of  the  digestion, 
due  to  the  use  of  indigestible  articles  of  food.  It 
occurs  iu  certain  blood-diseases,  such  as  scarlet 
fever,  erysipelas,  diphtheria,  and  acute  yellow 
atrophy  of  the  liver,  and  is  probably  due  to  the 
irritation  of  the  kidneys  by  the  poisons  proper  to 
these  maladies.  It  also  occurs  in  some  cases  where 
fever  is  high  and  persistent,  and  is  then  to  be 
explained  by  alteration  of  the  condition  either 
of  the  vascular  walls,  of  the  renal  cells,  or  of  the 
innervation  of  the  kidneys.  It  also  occasionally 
results  from  the  use  of  certain  drugs,  such  as 
turpentine  and  cantharides  ; certainly  sometimes 


KIDNEYS,  DISEASES  OF. 


788 

from  nervous  affections,  such  as  exophthalmic 
goitre,  epilepsy,  and  injuries  to  or  organic  dis- 
ease of  the  brain.  Permanent  albuminuria  is  met 
with  in  all  the  forms  of  Bright’s  disease ; most 
abundantly  in  the  inflammatory  form ; to  a less 
extent,  but  constantly,  in  the  albuminoid ; to  a 
still  less  extent,  and  sometimes  altogether 
abstnt,  in  the  cirrhotic  variety.  It  also  re- 
sults from  passive  congestion  of  the  kidneys,  due 
to  cardiac  disease  or  other  cause  ; as  well  as 
from  suppurative  nephritis  and  other  diseases  of 
the  kidney,  and  from  pyelitis.  The  ordinary  albu- 
min of  the  blood-serum  is  the  form  which  usually 
appears  in  the  urine.  Now  and  then  it  is  found, 
especially  in  the  course  of  or  after  acute  febrile 
diseases,  that  a variety  of  albumin  occurs  in  the 
urine  which  is  unaffected  by  heat  and  nitric 
acid,  but  which  becomes  coagulated  by  alcohol. 
This  may  either  be  from  alteration  of  the  sub- 
stance itself,  or  from  the  presence  of  some  mate- 
rial which  interferes  with  the  ordinary  chemical 
reaction.  See  Albuminueia. 

f.  Urea  is  diminished  in  quantity  wherever 
there  is  destruction  of  the  renal  epithelium,  as 
in  the  different  forms  of  Bright's  disease,  especi- 
ally the  cirrhotic  and  inflammatory  varieties. 

g.  The  physical  and  chemical  characters  of  the 
urine  are  often  much  modified  by  conditions 
other  than  diseases  of  the  kidneys  themselves, 
and  abnormal  ingredients  may  be  present,  such 
as  sugar  or  bile,  but  these  alterations  do  not 
come  within  the  scope  of  the  present  article. 

h.  Deposits  are  also  frequently  present  in  the 
urine,  which  are  due  to  various  causes  apart 
from  renal  disease,  namely,  urates  and  uric  acid, 
oxalate  of  lime,  phosphates,  cystine,  xanthine, 
tyrosine,  and  leucine.  Organic  deposits  are  im- 
portant in  many  affections  of  the  kidney  or  its 
pelvis.  In  the  first  place  the  epithelium  from  the 
latter  may  be  present  in  more  or  less  abundance. 
Pus  appears  as  a fine  granular  yellowish  de- 
posit, which  becomes  viscid  and  transparent  on 
the  addition  of  liquor  potass*.  In  ammoniacal 
urine  it  is  sometimes  found  that  the  pus-cells 
have  undergone  this  change  within  the  bladder. 
Pus  may  be  derived  from  the  pelvis  of  the  kidney, 
or  from  the  kidney-substance  itself.  Deposits 
very  similar  in  general  appearance  to  pus  are 
sometimes  seen  in  cases  of  scrofulous  kidney, 
but  the  microscopic  appearances  are  different, 
the  corpuscles  being  altered,  and  often  associated 
with  fibrous  tissue.  Cancerous  deposits,  showing 
distinct  cancer-cells,  are  also  sometimes  met  with. 
The  presence  of  blood  gives  the  urine  a smoky, 
pinkish,  or  actually  bloody  appearance.  See 
Hematuria. 

Tube-casts  are  sometimes  so  numerous  as  to 
constitute  a deposit  quite  visible  to  the  naked 
eye.  These  casts  are  solid  moulds  of  the  urini- 
ferous  tubules,  sometimes  formed  within  the  free 
lumen  of  the  tube,  but  far  more  frequently  with- 
in the  basement-membrane,  thus  including  the 
more  or  less  altered  epithelium.  The  simplest 
form  of  tube-cast  is  the  hyaline,  a clear  structure- 
less cast,  Blood-casts  are  common,  containing 
distinct  red  corpuscles.  Epithelial  and  desqua- 
mative casts  are  opaque  and  granular,  the  granu- 
larity being  due  for  the  most  part  to  the  abundance 
of  altered  epithelium  in  their  substance.  Fatty 
casts  are  those  which  exhibit  evidences  of  fatty 


degeneration  of  the  epithelium.  See  Bbight's 
Disease  ; Casts  ; and  Urine,  Morbid  Conditions  of. 

C.  Symptoms  occurring  in  other  parts  of 
the  body. — Very  important  symptoms  occur  in 
connection  with  renal  diseases,  affecting  the  or- 
gans of  circulation  and  of  digestion,  the  nervous 
system,  and  the  skin  ; but  these  are  for  the  most 
part  associated  with  Bright’s  disease.  Set 
Bright’s  Disease  ; and  Uraemia. 

The  several  diseases  of  the  kidney  will  now 
be  indicated,  and  those  will  be  discussed  which 
are  not  described  under  special  headings  in  other 
parts  of  the  work. 

1.  Kidney,  Abscess  of. — Synox.  : Benal  ab- 
scess.— This  is  often  used  as  a generic  term  in- 
cluding any  accumulation  of  pus  in  connection 
with  the  kidney,  whether  in  the  substance  of  the 
organ,  in  its  pelvis,  or  even  around  it.  Strictly, 
it  applies  only  to  a collection  of  matter  resulting 
from  suppuration  in  the  kidney-structure  itself. 
See  Kidney,  Inflammation  of  Pelvis  of;  Kidney, 
Suppurative  Inflammation  of;  Perinephritis ; 
and  Surgical  Kidney. 

2.  Kidney,  Acute  Atrophy  of. — Deftnition. 

This  is  a rare  disease  of  the  kidney,  consisting 
in  rapid  exudation  into  the  cells  of  the  organ, 
followed  by  fatty  degeneration  and  disinte- 
gration ; caused  by  unknown  conditions ; cha 
racterised  by  sudden  occurrence  of  copious 
albuminuria,  with  very  numerous  tube-casts, 
and  frequently  marked  uraemic  symptoms;  and 
resulting  apparently  invariably  in  death. 

./Etiology. — The  causes  of  this  affection  are 
unknown,  but  it  appears  probablo  that  it  depends 
upon  some  form  of  blood-poison,  the  disease 
being  frequently  associated  with  acute  atrophy  of 
the  liver.  In  most  cases  it  would  appear  to  fol- 
low the  hepatic  disease ; in  some  it  precedes  it. 
It  is  much  more  common  in  the  female  sex  than 
in  the  male;  and  is  most  frequent  during  preg- 
nancy and  after  childbirth. 

Anatomical  Characters.  — There  are  two 
stages  in  the  progress  of  this  disease,  namely, 
(1)  that  of  exudative  infiltration  and  enlarge- 
ment ; (21  that  of  disintegration  and  atrophy. 
In  the  first  stage  the  organ  is  enlarged,  not 
markedly  congested,  the  capsule  strips  off 
readily,  the  substance  is  flaccid,  the  cortical 
substance  is  swollen,  the  individual  tubules  are 
enlarged  and  white.  On  section  the  vessels  are 
found  mostly  empty  of  blood,  being  compressed 
by  the  diseased  tubules.  The  tubules  are  oceu 
pied  by  dense  opaque  material ; and  the  individual 
cells  are  swollen  and  granular,  their  nuclei  being 
hidden  by  molecular  cell-contents.  The  tubules 
of  the  cones,  as  well  as  those  of  the  cortical 
substance,  are  frequently  affected.  Many  of  the 
cells  also  are  in  a state  of  fatty  degeneration,  or 
broken  down  even  at  this  stage.  In  the  more 
advanced  stage  the  organ  is  smaller  than  natu- 
ral, and  its  capsule  appears  wrinkled.  The  kid- 
dey  is  pale  and  flaccid.  When  cut  into  there 
escapes  a quantity  of  debris,  often  containing  oil- 
globules,  quite  visible  to  the  naked  eye.  The 
stroma  is  intact,  and  sections  can  easily  be  made 
with  a Valentin’s  knife.  The  sections  show 
that  many  of  the  tubules  are  denuded  of  epithe- 
lium, and  that  the  shrinking  of  the  organ  result* 


KIDNEYS,  DISEASES  OF.  789 


from  this  disintegration.  It  is  easy  to  find  dif- 
ferent tubules  and  cells  in  various  stages  of 
transformation,  some  showing  the  early  stage  of 
cloudy  swelling,  others  the  stage  of  fatty  trans- 
formation, and  others  the  disintegrating,  almost 
deliquescent  condition.  The  friability  of  the 
cells  is  quite  extraordinary,  the  weight  of  a thin 
covering  glass  often  sufficing  to  reduce  them  to 
molecular  debris. 

It  will  be  observed  that  the  changes,  both  in 
the  organ  and  the  individual  cells,  exactly  cor- 
respond to  those  met  with  in  acute  atrophy  of 
the  liver. 

Symptoms. — The  symptoms  characterising  this 
affection  have  not  yet  been  very  fully  studied. 
Diminution  of  urine,  copious  albuminuria,  with 
deposit  of  casts  corresponding  to  the  changes  in 
the  kidney,  are  probably  the  chief  renal  symp- 
toms. A tendency  to  haemorrhages,  jaundice, 
and  uraemic  nervous  affections,  and  the  series  of 
symptoms  proper  to  acute  atrophy  of  tho  liver, 
ire  also  observed. 

Diagnosis. — There  is  probably  no  disease  with 
which  this  is  very  liable  to  be  confounded. 

Prognosis  and  Treatment. — The  prognosis 
must  be  unfavourable ; and  no  treatment  can  be 
of  any  avail. 

3.  Kidney,  Albuminoid  Disease  of.  See 
Bright’s  Disease. 

4.  Kidney,  Anomalies  of. — The  kidneys 
may  present  three  kinds  of  anomaly,  namely: — 
1.  In  number.  2.  In  form.  3.  In  situation. 
Only  the  first  of  these  will  be  referred  to  here. 

Anomalies  in  Number. — Sometimes  one  kid- 
ney, with  the  corresponding  ureter,  is  entirely 
rbsent.  In  such  cases  the  organ  which  is  present 
is  muchabove  the  normal  size.  There  is  generally 
jno  symptom  present  during  life,  but  diseases  of 
he  pelvis  of  the  kidney  or  the  ureter  are  made 
nore  formidable  in  persons  so  affected,  than  in 
hose  normally  developed.  Occasionally  one  or 
nore  supernumerary  kidneys  are  present.  See 
fidney,  Malformation  of ; and  Kidney,  Malposi- 
ions  of. 

5.  Kidney,  Calculus  in.  See  Renal  Cal- 

DI.US. 

6.  Kidney,  Cancerous  Disease  of.  See 
lidney,  Malignant  Disease  of. 

7.  Kidney,  Chronic  Atrophy  of.— This  con- 
ition  of  the  kidney  arises  under  a variety  of 
rcumstances,  hut  specially  as  a consequence  of 
ydronephrosis,  and  of  the  different  forms  of 
right’s  disease.  In  hydronephrosis  the  atrophy 
immences  in  the  cones,  and  spreads  to  the  cor- 
ral substance.  In  all  the  forms  of  Bright’s  dis- 
use it  commences  at  the  surface  and  spreads  in- 
Ards.  In  hydronephrosis  atrophy  is  a result  of 
;e  pressure  of  the  renal  secretion,  as  it  aecumu- 
tes  in  the  dilated  pelvis  and  within  the  tu- 
lles. In  inflammatory  Bright’s  disease  it  is  due 

interstitial  changes,  and  the  gradual  absorp- 
m of  the  contents  of  the  occluded  uriniferous 
bules.  In  cirrhotic  Bright’s  disease  it  is  a con- 
duce of  the  contraction  of  the  hypertrophied 
rous  stroma,  and  the  consequent  destruction 
vessels  and  secreting  structures.  In  the  waxy 
albuminoid  form  it  is  due  to  the  molecu- 


lar absorption  of  the  hyaline  material  and  al- 
tered cells  which  occupy  the  uriniferous  tubules, 
as  a consequence  of  the  degeneration  proper  to 
the  vessels. 

Anatomical  Characters. — Although  really 
atrophied,  the  hydronephrotic  kidney  appears 
large,  and  may  form  a mass  several  times  the 
size  of  the  normal  kidney.  It  is  lobulated  on 
the  surface,  and  may  often  be  seen  to  be  little 
more  than  a group  of  cysts  containing  watery 
fluid.  In  the  earlier  stages  no  change  is  ob- 
served, except  flattening  of  the  cones ; in  the 
later  the  cortical  substance  also  is  more  or  less 
wasted.  This  condition  is  usually  seen  only  on 
one  side,  the  other  kidney  being  natural,  or  some- 
what hypertrophied. 

Atrophy  from  inflammatory  Bright’s  disease 
is  rarely  far  advanced  when  tho  fatal  result 
occurs.  Both  kidneys  are  affected,  and  usually 
to  the  same  extent.  The  capsule  strips  off  readily. 
The  surface  presents  a finely  granular  appear- 
ance. On  section,  the  cortical  substance  is  found 
relatively  diminished.  Many  of  the  tubules  are 
occupied  by  sebaceous-looking  material.  Many 
of  them  are  diminished  in  size,  and  irregular  in 
outline  from  absorption  of  their  contents.  The 
stroma  is  relatively  increased;  the  vessels  are 
little  altered. 

In  the  cirrhotic  form  the  atrophy  is  often  more 
advanced,  and  is  commonly  equal,  or  nearly  so, 
on  the  two  sides.  The  capsule  is  adherent,  the 
surface  granular  and  uneven.  On  section,  the 
cortical  substance  is  diminished,  and  it  often 
contains  many  cysts.  On  microscopic  examina- 
tion the  fibrous  stroma  is  found  markedly  in- 
creased, many  of  tho  tubules  and  vessels  arc 
destroyed,  while  the  smaller  arteries  are  thick- 
ened. 

In  the  albuminoid  form  the  kidneys  have 
in  some  cases  been  found  greatly  and  nearly 
equally  diminished  in  size.  The  capsule  strips  oft 
readily;  the  surface  is  finely  granular.  On  sec- 
tion the  cortical  substance  is  found  diminished, 
the  degenerated  Malpighian  bodies  remaining  sin- 
gularly prominent,  especially  towards  the  sur- 
face, the  stroma  appearing  relatively  somewhat 
increased,  and  the  hyaline  contents  of  the  tubules 
in  process  of  absorption. 

Symptoms. — No  definite  group  of  symptoms 
indicate  the  existence  of  atrophy.  Those  met 
with  in  the  atrophic  stages  of  tho  different 
affections  are  described  under  each  disease. 

Partial  Atrophy  of  the  Kidney  results 
from  embolism,  new-formations,  and  other  like 
causes;  and  is  in  many  instances  unattended  by 
symptoms. 

8.  Kidney,  Cirrhotic.  See  Bright’s  Disease. 

9.  Kidney,  Congestion  of.  See  Kidney, 
Hyper*  mia  of. 

10.  Kidney,  Cystic  Disease  of. — Defini- 
tion.— A chronic  morbid  state  of  the  kidney, 
caused  by  conditions  not  fully  ascertained ; cha- 
racterised in  some  cases  by  no  symptoms,  in 
others  by  the  presence  of  tumours,  and  by  symp- 
toms resembling  those  of  the  cirrhotic  form 
of  Bright’s  disease ; resulting  in  permanent 
change;  and  not  amenable  to  treatment.  The 
formation  of  cysts  in  the  kidney  may  he  unim- 


KIDNEYS,  DISEASES  OF. 


790 

portant,  either  from  the  small  number  of  cysts, 
or  from  the  co-existence  of  much  graver  disease 
of  the  kidney ; but  it  may  constitute  a serious 
disease. 

-ZEtiolosy. — Nothing  is  known  as  to  the 
causes  of  cystic  degeneration.  It  may  be  con- 
genital, or  may  come  on  during  adult  life.  The 
mode  of  origin  of  the  cysts  appears  to  be  from 
the  dilatation  above  obstructed  points  in  the 
course  of  uriniferous  tubules,  or  at  their  points 
of  origin  in  the  Malpighian  bodies.  Sometimes 
the  cysts  are  new  formations  in  connection  with 
epithelium ; and  sometimes  they  arise  from  the 
fibrous  stroma  of  the  organ. 

Anatomical  Characters. — Renal  cysts  vary 
greatly  in  size,  from  minute,  almost  microscopic, 
cavities,  to  spaces  capable  of  holding  several 
pints  of  fluid.  The  true  cystic  kidney  is  large ; 
its  surface  is  uneven,  and  in  colour  resembles  a 
piece  of  conglomerate.  The  capsule  strips  off, 
but  often  with  some  difficulty.  On  section  its 
substance  is  found  replaced  by  multitudes  of 
cysts,  scarcely  any  proper  tissues  remaining. 
The  contents  are  sometimes  watery,  sometimes 
contain  urinary  constituents,  sometimes  are 
tinged  with  blood,  and  sometimes  are  gelatinous 
or  colloid. 

Symptoms. — In  many  cases  cystic  disease  of 
the  kidneys  is  unattended  by  any  symptoms ; 
and  even  when  thedisease  is  extensive  and  severe 
there  are,  as  a rule,  no  constitutional  symptoms 
until  the  case  draws  near  its  termination.  Among 
local  signs  the  most  important  is  enlargement 
of  the  organs,  which  may  sometimes  be  made 
out  by  means  of  palpation  and  percussion,  in 
cases  which  are  advanced,  and  in  emaciated  sub- 
jects. Both  organs  are  generally  equally  enlarged. 
The  urine  is  secreted  in  natural  or  in  excessive 
quantity  ; its  specific  gravity  is  low  ; and  it  con- 
tains albumin,  and  sometimes  blood.  The  ter- 
mination of  these  cases  is  not  unfrequently 
abrupt,  with  uraemic  convulsions  and  coma. 

Diagnosis. — The  points  which  are  of  impor- 
tance are  the  presence  of  bilateral  tumour;  with 
copious  discharge  of  urine  of  low  specific  gravity, 
or  containing  albumin. 

Prognosis. — The  prognosis  is  always  un- 
favourable. 

Treatment. — Treatment  can  be  directed  only 
to  the  relief  of  symptoms. 

11.  Kidney,  Dropsy  of. — This  is  a synonym 
for  hydronephrosis,  in  which  urine,  more  or  less 
altered,  accumulates  in  the  renal  pelvis,  as  the 
result  of  obstruction  of  the  ureter.  See  Hydro- 
nephrosis. 

12.  Kidney,  Embolism  of. — The  impaction 
of  emboli  in  the  branches  of  the  renal  arteries 
gives  rise  to  various  lesions,  of  which  the  most 
common  is  the  haemorrhagic  infarction  ; next  to 
this  inflammation  and  secondary  abscesses  ; and 
more  rarely  gangrenous  inflammation.  These 
affections  often  do  not  manifest  themselves  dur- 
ing life  by  any  distinct,  symptoms ; or  their  exist- 
ence may  be  revealed  by  sudden  albuminuria  and 
hoematuria,  and  sometimes  by  general  constitu- 
tional disturbance  and  local  pain. 

JEtiolooy. — The  chief  cause  of  reual  embo- 
lism is  disease  of  the  valves  of  the  heart.  The 
emboli  may  be  composed  of  coagulated  fibrin  ; 


or  of  fragments  of  the  tissue  of  the  valve,  which 
have  been  separated  by  ulceration.  More  rarely 
embolism  is  caused  by  fibrin  which  has  coagu- 
lated between  the  meshes  of  the  fleshy  columns 
of  the  heart,  or  by  coagula  which  have  formed 
on  the  roughened  inner  coat  of  arteries.  Among 
the  remoter  causes  are  those  of  endocarditis  and 
endarteritis.  This,  in  so  far,  vindicates  the  name 
which  Ray er  applied  to  these  infarctions — ‘rheu- 
matismal  nephritis.’ 

Anatomical  Characters. — 1.  Of  hemorrhagic 
infarction. — This  may,  for  convenience,  he  de- 
scribed as  passing  through  three  stages: — (1) 
that  of  red  consolidation;  (2)  that  of  fawn- 
coloured  transformation  ; and  (3)  that  of  absorp- 
tion or  atrophy.  The  form  of  the  masses  is 
usually  conical,  or,  as  seen  on  section,  wedge- 
shaped,  the  base  being  towards  the  surface.  At 
first  a patch  is  deeply  congested,  and  presents  a 
dark  red  colour.  On  microscopic  examination 
the  vessels  are  found  congested,  many  ruptured; 
and  blood  is  extravasated  into  the  tubules.  In 
the  second  stage  this  redness  has  passed  away; 
a buff  or  fawn-coloured  mass  represents  the  red 
patch  of  the  earlier  stage.  On  microscopic 
examination  the  cells  of  the  tubules  are  found  to 
be  destroyed,  and  within  them,  as  well  as  in  the 
stroma,  blood-pigment  may  he  found.  In  the 
third  stage  there  is  commonly  a depression  of 
the  surface  of  the  organ  ; and,  on  section,  what 
had  been  the  conical  patch  is  represented  by  a 
fibrous  cicatrix. 

2.  Of  the  abscesses. — In  certain  cases,  espe- 
cially in  the  course  of  pyaemia,  emboli  lead  to 
abscesses.  Throughout  the  organ  such  abscesses 
exist,  and  may  be  traced  in  various  stages, 
which  might  be  described  as  those  of  red  con 
solidation,  of  ashy-gray  consolidation,  and  of  sup- 
puration. In  this  condition  the  clot  is  not  to  he 
found  at  the  apex  of  the  cone  of  disease,  but 
imbedded  within  it.  Between  the  simple  infarc- 
tion and  the  abscess  there  is  an  intermediate 
form — a certain  degree  of  suppuration  occurring 
at  tho  margin  of  the  affected  area. 

3.  Of  gangrenous  patches. — Very  rarely  it  ap- 
pears that,  in  consequence  of  the  impaction  of  an 
embolus,  gangrene  of  the  affected  district  occurs, 
with  more  or  less  suppuration. 

Symptoms. — The  symptoms  of  the  embolic 
infarction  are  often  very  indistinct,  hut  the  con- 
dition may  sometimes  be  diagnosed.  When 
valvular  disease  of  the  heart  or  extensive  cal- 
careous affection  of  the  arteries  exists,  and  when 
in  addition  to  this  sudden  albuminuria  or  hsemu- 
turia  appears,  with  some  degree  of  fever,  and 
pain  in  the  region  of  the  kidneys,  there  is  every 
reason  to  conclude  that  an  embolus  has  been  ini 
pacted.  This  condition  is  rarely  one  of  impor 
tance  in  the  case,  for  much  graver  maladies  co- 
exist with  it.  The  occurrence  of  abscess  in  the 
kidney'  may  sometimes  be  surmised  when  sudden 
albuminuria  or  haematuria  becomes  superadded 
to  the  other  symptoms  of  pyaemia.  Gangrene  ot 
the  kidney  or  a portion  of  it  is  not  likely  to  he, 
capable  of  diagnosis  during  life. 

Diagnosis. — The  diagnosis  of  renal  infarction 
turns  upon  the  points  above  referred  to.  _ It  is 
important  to  distinguish  it  from  Brialit  s dis- 
ease, and  from  passive  congestion.  From  t ie 
former  it  is  distinguished  by  tho  suddenness  o 


KIDNEYS,  DISEASES  OF. 


the  onset,  the  shortness  of  its  duration,  the  ab- 
jouee  of  dropsy,  and  tho  presence  of  cardiac  or 
vascular  disease ; from  the  latter  by  the  sudden- 
ness of  its  development,  and  by  the  absence  of 
signs  of  stasis  in  other  organs. 

Pbognosis. — The  prognosis  in  cases  of  infarc- 
tion is  favourable  so  far  as  the  kidneys  and  their 
functions  are  concerned,  but  unfavourable  in  this 
respect  that  there  is  a tendency  to  the  impaction 
of  emboli  in  other  more  important  parts,  par- 
ticularly in  the  brain. 

Treatment. — No  special  or  particular  treat- 
ment can  be  directed  in  this  condition. 

13.  Kidney,  Fatty  Disease  of. — Definition. 
A chronic  affection  of  the  kidney,  consisting  in 
simple  fatty  degeneration  of,  or  infiltration  into, 
the  renal  epithelium,  without  inflammation ; 
characterised  by  no  symptoms  as  yet  clearly 
ascertained. 

^Etiology. — Fatty  kidney  results  in  some 
cases  from  long-continued  exhausting  disorders ; 
from  senile  marasmus ; from  starvation ; from 
poisoning  with  phosphorus  ; and  perhaps  from 
excessive  indulgence  in  fatty  food. 

Anatomical  Characters.—1 The  organs  are  of 
about  the  natural  size,  their  surface  is  smooth, 
and  the  capsule  strips  off  readily.  There  is  no 
congestion,  and  scarcely  any  stellate  veins  are 
visible.  The  organ  is  more  soft  and  flexible  than 
natural,  and  the  surface  is  mottled  with  numer- 
ous deposits  of  sebaceous-looking  material.  On 
section  the  relative  size  of  the  cortical  substance 
and  the  cones  is  seen  to  be  preserved ; and  be- 
yond a general  pallor  there  is  no  change  except 
the  abundant  deposition  of  sebaceous-looking 
material,  mostly  in  the  tubules  of  the  cortical 
substance,  but  also  in  those  of  the  cones. 

On  examining  a section  with  a low  power  of 
the  microscope,  the  characteristic  fatty  opacity 
is  well-marked,  and  by  careful  scrutiny  it  may  be 
generally  made  out  that  the  fatty  material  is 
not  in  the  canal  of  the  tubule,  but  within  the 
epithelial  cells.  The  Malpighian  bodies,  the  ves- 
sels, and  the  stroma,  under  a higher  power,  appear 
natural ; and  in  transverse  section  of  the  tubules, 
a clear  lumen  may  be  made  out.  It  will  thus  be 
observed  that  there  is  no  inflammatory  desqua- 
mation of  the, cells,  nor  exudation  filling  up  the 
lumen  of  the  tube. 

Symptoms. — Little  is  known  of  the  clinical 
features  of  this  affection.  But  the  quantity  of 
the  urine  appears  to  be  diminished.  There  is  cer- 
tainly no  albuminuria,  and  apparently  no  other 
important  change  in  its  composition.  Dr.  Lang, 
of  Dorpat,  has  shown  that  a little  free  oil  is 
sometimes  found  in  the  urine. 

Diagnosis. — It  is  scarcely  possible  to  diagnose 
this  affection  with  certainty;  but  diminution  of 
.he  urine,  without  albuminuria,  and  with  the  pre- 
sence of  oil  in  the  urine,  especially  if  associated 
vith  the  signs  of  fatty  liver,  and  with  any  of  the 
mown  causes  of  fatty  degeneration,  may  lead  to 
he  establishment  of  the  diagnosis. 

Prognosis. — The  renal  affection  is  not  gener- 
■lly  an  important  element  in  the  prognosis,  other 
ouditions  of  more  importance  being  present. 

Treatment. — General  tonic  treatment,  and 
he  removal  of  the  cause  when  known,  are  the 
nly  indications. 


791 

14.  Kidney,  Gouty. — This  is  a form  of  con- 
tracted granular  kidney,  occurring  in  gouty  sub. 
jeets,  and  attended  with  the  deposit  of  urates  in 
the  renal  tubules.  See  Bright's  Disease;  and 
Gout. 

15.  Kidney,  Granular. — A synonym  for  a 
chronic  form  of  Bright's  disease,  where  the 
kidney  presents  a granular  appearance.  See 
Bright’s  Disease. 

16.  Kidney,  Haemorrhage  in  connection 
with. — Blood  may  escape  into  the  substance  of 
the  kidney,  as  the  result  of  embolism  or  injury ; 
into  the  tubules,  giving  rise  to  blood-casts;  or 
into  the  renal  pelvis,  especially  from  injury  to 
the  mucous  lining  by  calculi.  The  only  diag- 
nostic indication  of  this  event  is  the  presence 
of  blood  in  the  urine,  intimately  mixed  with  it, 
or  sometimes  in  clots.  A coagulum  of  blood 
may  block  up  the  ureter.  See  H-Hhatinuria  , 
Paroxysmal  ; and  Hematuria. 

17.  Kidney,  Hydatid  Disease  of. — Defi- 
nition. — A chronic  parasitic  disease  of  the 
kidney,  caused  by  the  reception  into  the  system 
of  the  ova  of  the  Tsenia  echinococcus,  and  the 
development  in  the  kidney  of  the  corresponding 
cystic  form  ; consisting  in  the  formation  of  hy- 
datid cysts — ‘ echinococcus  hominis  ’ — in  the  sub- 
stance of  the  organ ; characterised  in  some  cases 
by  no  symptoms,  in  others  by  renal  tumour,  or 
by  the  discharge  of  cysts  with  the  urine,  after 
symptoms  resembling  those  of  renal  calculus ; 
and  resulting  sometimes  in  recovery,  sometimes 
in  death,  either  by  perforation  into  the  lung,  in- 
testine, or  other  part,  or  by  suppuration. 

PEtiology. — 'The  tape-worm  form  is  the  Tsenia 
echinococcus,  which  inhabits  the  intestine  of  the 
dog.  The  frequency  of  hydatid-disease  is  deter- 
mined by  the  frequency  of  the  occurrence  of  the 
tape-worm  in  the  dogs,  and  by  the  habits  of  the 
people.  It  is  common  in  Iceland,  in  Egypt  and 
in  South  Australia.  In  England  it  is  not  com- 
mon; in  Scotland  it  is  very  rare.  See  Hydatids. 

Anatomical  Characters. — The  affected  organ 
is  enlarged,  sometimes  greatly.  It  is  often  con- 
nected by  adhesions  to  neighbouring  parts.  A 
globular  tumour  projects  from  the  surface,  and 
extends  into  the  substance  of  the  kidney,  in- 
ducing corresponding  atrophy.  The  cyst  has 
an  outer  covering  of  fibrous  tissue  derived  from 
the  organ ; and  an  inner  coat — the  cyst  proper, 
which  may  be  barren,  that  is,  devoid  of  daugh- 
ter-cysts, or  may  contain  within  it  numerous 
smaller  cj-sts  and  processes  growing  inwards 
from  the  walls,  containing  scolices  which  may 
give  origin  to  the  corresponding  tape-worm.  In 
either  case  the  cyst-wall  is  somewhat  tensely 
expanded  by  a clear  liquid,  rich  in  chloride  of 
sodium.  Tho  cyst  enlarges  gradually,  and  may 
burst  in  various  directions,  but  most  frequently 
into  the  pelvis  of  the  kidney,  or  into  the  lungs 
and  bronchi.  Sometimes  suppuration  of  the  cyst 
occurs,  and  accordingly  one  finds  on  post-mortem 
examination  the  remains  of  a shrivelled  and 
sunken  cyst,  with  caseated  contents,  in  which 
are  imbedded  remains  of  daughter-cysts  and 
hooklets  from  the  scolices. 

Symptoms. — The  course  of  hydatid-disease  cl 
the  kidney  is  always  chronic.  It  may  be  pro- 


KIDNEYS,  DISEASES  OF. 


792 

longed  for  many  years.  The  advance  is  insidious. 
Attention  is  sometimes  drawn,  first  to  the  pre- 
sence of  a tumour,  sometimes  to  the  evidences 
of  its  rupture.  When  rupture  takes  place  into 
the  pelvis  of  the  kidney,  daughter-cysts  passing 
along  the  ureter  give  rise  to  symptoms  resem- 
bling those  of  renal  colic  ; but  the  discharge  of 
the  cysts,  and  the  results  of  the  microscopic 
examination,  reveal  the  true  cause  of  the  irrita- 
tion. After  such  a discharge  the  cyst  may 
atrophy ; sometimes  it  happens  that  a second 
or  even  a third  discharge  occurs  after  a shorter 
or  longer  interval.  When  the  discharge  is  by 
the  lung,  pain  and  cough  occur,  due  to  irritation 
of  the  pleura.  Then  the  expulsion  of  the 
hydatids  takes  place  ; sometimes  this  also  results 
quite  favourably.  The  special  features  of  a 
hydatid  tumour  are  its  globular  form  and  its 
elasticity.  When  suppuration  occurs,  fever  super- 
venes, attended  with  local  pain. 

Diagnosis. — The  diagnosis  of  hydatid  of  the 
kidney  depends  upon  the  presence  of  a tumour 
of  a special  kind;  and  is  made  certain  by  the 
discharge  of  cysts  or  booklets. 

Prognosis. — -The  prognosis  is  always  doubtful. 

Treatment. — Medicine  is  of  no  avail.  The 
best  treatment  is  the  removal  of  the  fluid  con- 
tents of  the  cyst  by  aspiration.  When  such  re- 
moval is  effected  the  parasites  die,  and  the  cyst 
shrivels  up. 

18.  Kidney,  Hyperaemia  of — Definition. 
An  acute  or  chronic  affection  of  the  kidney, 
consisting  in  active  or  passive  congestion  of  its 
vessels,  with  secondary  changes  ; characterised 
bv  the  appearance  of  albumin,  and  sometimes  of 
blood  and  of  hyaline  tube-casts  in  the  urine,  the 
quantity  of  urine  being  generally  diminished, 
and  its  specific  gravity  natural ; resulting  in  re- 
covery if  the  cause  be  removed,  but  in  the  passive 
form  commonly  continuing  or  recurring  till  the 
fatal  result  is  induced,  partly  by  the  original, 
and  partly  by  other  causes. 

TEtiolosy. — Active  congestion,  that  is  conges- 
tion due  to  increased  influx  of  arterial  blood, 
may  be  caused  by  inflammation;  by  various  blood- 
poisons,  such  as  those  of  scarlet  fever,  measles, 
typhus  ; and  by  some  medicinal  substances,  such 
as  cantharides,  turpentine,  cubebs  ; also  probably 
by  agencies  which  paralyse  the  muscular  fibres 
of  the  small  arteries — as  is  sometimes  seen  ip  the 
course  of  exophthalmic  goitre — or  which  increase 
the  blood-pressure  in  the  renal  arteries.  Pas- 
sive congestion,  which  implies  congestion  due  to 
hindrance  to  the  efflux  of  venous  blood  from  the 
organ,  may  be  caused  by  any  obstruction  to  the 
circulation.  It  is  most  commonly  met  with  in 
cases  of  cardiac  disease,  where  the  right  chambers 
of  the  heart  are  dilated.  It  also  results  from 
such  diseases  of  the  lungs  as  are  followed  by 
dilatation  of  the  right  side  of  the  _ heart— for 
example,  emphysema.  It  also  sometimes  arises, 
though  much  more  rarely,  from  obstruction  in 
the  course  of  the  inferior  vena  cava,  or  in  the 
renal  veins,  as  from  pressure  of  aneurismal 
or  other  tumours,  or  from  the  formation  of  a 
thrombus. 

Anatomical  Characters. — Iu  the  active  form 
of  renal  hyperaemia,  the  anatomical  changes  are 
probably  less  marked  after  death  than  during 


life.  The  kidneys  are  generally  of  fully  the  nor. 
mal  size  ; the  capsule  strips  off  readily ; and  the 
surface  is  smooth.  On  section  tiie  vessels  are 
found  congested;  the  Malpighian  bodies  fre- 
quently standing  out  prominently,  being  dis- 
tended with  blood.  The  vessels  of  the  cones  are 
also  overfilled.  More  or  less  evidence  of  inflam- 
matory change  is  to  be  found  in  the  tubules,  the 
epithelium  being  granular  and  opaque,  and  the 
lumen  of  the  tubules,  especially  those  of  the 
coues,  being  filled  up  with  coagulated  fibrin. 
Blood  is  sometimes  found  extra vasated  into  the 
convoluted  tubules.  The  stroma  is  unaltered. 
Sometimes  there  is  congestion  of,  or  even  extra- 
vasation into  the  mucous  membrane  of  the  pelvis 
of  the  kidney  and  of  the  ureter.  In  passive 
congestion  the  anatomical  changes  are  more 
marked,  and  vary  with  the  duration  and  inten- 
sity of  the  affection.  In  the  slighter  forms, 
or  in  those  of  short  continuance,  the  kidney  is 
of  fully  the  natural  size  ; its  capsule  strips  off 
readily ; the  surface  of  the  organ  is  smooth ; 
and  there  is  evidence  of  congestion.  On  section, 
the  congestion  is  seen  to  occupy  the  veins  and 
the  Malpighian  bodies  ; sometimes  there  lire  evi- 
dences of  extravasation  of  blood  ; and  sometimes 
fibrinous  coagula  are  found  in  the  tubules. 

Iu  the  more  chronic  forms,  although  the  cap- 
sule strips  off  readily,  the  surface  is  somewhat 
uneven  ; congestion  is  still  marked  on  the  sur- 
face, but  scarccdy  so  distinctly  as  in  the  earlier 
stage.  On  section  the  organ  feels  firmer  than 
natural ; it  is  in  a condition  which  may  be  best 
described  by  the  term  induration.  Its  small 
veins  and  Malpighian  bodies  are  dilated  and  full 
of  blood ; the  fibrous  stroma  is  relatively  increased, 
especially  towards  the  surface  of  the  organ ; 
some  of  the  tubules  are  wasted,  some  are  blocked 
up  with  exuded  material,  and  some  exhibit  evi- 
dence of  disintegration  and  fatty  degeneration 
of  the  epithelium.  The  condition  of  the  stroma 
thus  approaches  that  of  cirrhosis  of  the  kidney ; 
the  condition  of  the  tubules  approaches  that  of 
inflammation.  There  is  no  definite  boundary  line 
between  the  conditions  anatomically;  still  the 
combination  of  the  changes  confirms  the  infer- 
ence which  must  be  drawn  from  the  study  of  the 
clinical  history,  that  these  hypersemic  changes, 
though  approaching  to,  are  not  identical  with 
the  processes  properly  included  under  the  term 
• Bright’s  disease.’ 

Symptoms. — The  symptoms  of  active  conges- 
tion are  the  presence  of  albumin  in  the  urine, 
occasionally  accompanied  by  hyaline  tube-easts, 
and  sometimes  by  blood  in  greater  or  less 
quantity.  It  occurs  commonly  as  a transient,  or 
occasionally,  as  a recurring  condition,  and  unless 
when  it  betokens  a commencing  inflammatory 
action,  is  rarely  of  much  practical  importance. 

In  passive  congestion  albuminuria  is  again  the 
leading  symptom ; the  urine  is  generally  some- 
what reduced  in  quantity,  of  about  normal  spe- 
cific gravity,  often  of  acid  reaction,  depositing 
urates.  The  amount  of  urea  is  little  below  the 
normal.  Tube-casts  are  usually  scanty,  and  may 
be  wanting ; when  present  they  are  hyaline 
or  sometimes  bloody,  and  occasionally  contain 
altered  epithelium.  The  other  symptoms  are 
those  of  obstruction  to  the  circulation ; occlu- 
sion of,  or  pressure  on,  the  veins  ; disease  of  the 


KIDNEYS,  DISEASES  OF. 


heart;  emphysema  of  the  lungs;  and  general 
dropsy. 

Diagnosis. — The  question  relating  to  diagno- 
sis, -which  is  of  most  practical  importance,  lies 
between  hypersemia  and  inflammatory  Bright’s 
disease.  In  making  this  distinction,  the  points 
to  which  we  havo  to  attend  are  the  general  con- 
dition of  the  patient,  in  respect  to  the  possible 
causes  of  such  an  affection,  the  presence  of  car- 
diac or  pulmonary  disease,  or  of  venous  obstruc- 
tion. Incongestive  affections  the  urine  is  scanty, 
as  it  often  is  in  Bright’s  disease,  but  it  is  of 
high  colour,  of  natural  specific  gravity,  and 
rarely  deposits  blood,  renal  epithelium,  or  tube- 
casts. 

Prognosis. — The  prognosis  depends  entirely 
upon  the  conditions  inducing  the  congestion.  In 
the  active  form  it  usually  rapidly  subsides  ; in 
the  passive  form,  it  is  persistent,  or  at  best,  if 
temporarily  got  rid  of,  is  almost  sure  to  recur. 

Treatment. — When  the  renal  congestion  is 
very  intense,  dry  cupping,  local  blood-letting, 
the  hot  air  or  the  warm  vapour  bath,  or  warm 
applications  over  the  kidneys,  may  be  indicated ; 
but  the  treatment  is  mostly  that  of  the  diseases 
which  are  inducing  the  congestion.  Thus,  in  the 
case  of  cardiac  disease  digitalis  and  iron,  in  the 
case  of  pulmonary  disease  digitalis  with  squill, 
and  if  necessary,  a little  blue  pill  or  carbonate 
of  ammonia,  are  indicated.  The  general  manage- 
ment should  be  that  proper  to  the  obstructive 
disease  which  has  induced  the  congestion. 

19.  Kidney,  Hypertrophy  of. — True  hyper- 
trophy, that  is  to  say,  increase  of  all  the  elements, 
or  of  the  essential  elements  of  the  kidney,  occurs 
only  in  one  organ  as  a rule,  and  that  by  way  of 
compensation  for  atrophy  of  the  other. 

Simple  increase  of  bulk  of  the  kidneys  often 
results  to  a certain  extent  from  congestion,  inflam- 
mation, the  various  forms  of  Bright’s  disease, 
new  formations,  and  accumulation  of  the  secre- 
tion. 

Anatomical  Characters. — These  present  no 
peculiarity  beyond  the  enlargement,  the  organ 
weighing  sometimes  eight  or  nine  ounces,  the 
renal  artery  and  vein  being  proportionately  en- 
larged, with  a corresponding  coarseness  of  struc- 
ture. 

Symptoms. — Hypertrophy  of  the  kidney  is 
without  symptoms,  but  it  might  so  happen  that 
the  enlargement  of  the  organ  could  be  detected 
on  physical  examination. 

20.  Kidney,  Infarction  in.  — See  Kidney, 
Embolism  of. 

21.  Kidney,  Inflammations  of.- — Inflam- 
nation  of  the  kidneys  and  their  pelves  presents 
aany  varieties.  The  kidneys  themselves  exhibit, 
; irst,  tubular  inflammation,  acute  or  chronic ; 
econd,  inflammation  of  the  stroma,  acute  or 
nronie  ; third,  suppurative  inflammation  of  the 
ubstance  of  the  organ,  septic  or  non-septie.  The 
;nal  pelvis  is  also  liable  to  acute  or  chronic 
iflammation.  It  will  serve  no  useful  purpose  to 
iscuss  these  in  a general  article,  and  therefore 
le  reader  is  referred  to  the  several  special  arti- 
es.  See  Bright’s  Disease  ; Kidney,  Suppura- 
ve  Inflammation  of;  and  Kidney,  Inflammation 
' Pelvis  of. 


793 

22.  Kidney,  Inflammation  of  Pelvis  of. 

Synon.  : Pyelitis;  Fr.  Fyelite ; Ger.  Nieren- 
bcckenentzundung . 

Definition. — An  acute  or  chronic  disease  of 
the  pelvis  of  the  kidney,  caused  by  extension  of 
inflammation  or  of  irritation  from  the  neigh- 
bouring parts,  by  renal  calculus,  by  cold,  or  by 
blood-poisoning;  consisting  in  inflammation  of 
the  mucous  membrane,  frequently  associated 
with  changes  in  the  other  coats  and  in  neigh- 
bouring parts  ; characterised  by  the  presence  of 
mucus  or  pus  in  the  secretion,  with  local  pain, 
and  more  or  less  constitutional  disturbance ; 
sometimes  resulting  in  recovery,  sometimes  in 
long-continued  illness,  and  occasionally  in  death. 

.-Etiology. — -Pyelitis  is  caused  by: — (1)  ex- 
tension of  inflammation  from  neighbouring  parts 
of  the  urinary  tract  sometimes  from  the  kid- 
neys, sometimes  from  the  bladder  ; (2)  stagna- 
tion and  decomposition  of  the  urine  in  the  renal 
pelvis;  (3)  mechanical  irritation,  as  from  calculi 
and  gravel;  (4)  exposure  to  cold;  (5)  certain 
blood-poisons,  such  as  those  of  pyaemia,  diph- 
theria, and  typhus ; (6)  the  action  of  certain 
other  poisons. 

Anatomical  Characters. — • Three  typps  of 
pyelitis  may  bo  recognised,  namely: — (1)  the 
acute-,  (2)  the  chronic ; and  (3)  the  calculous. 

(1)  Acute. — The  mucous  membrane  is  con- 
gested, and  its  surface  coated  with  mucus,  some- 
times with  a bloody,  sometimes  with  a diph- 
theritic layer.  The  membrane  itself  may  be 
more  or  less  extensively  destroyed  ; and  the  cha- 
racteristic tailed  cells  of  the  pelvis  of  the  kidney 
may  be  thrown  off  in  excessive  quantity.  Be- 
sides these  cells,  the  cavity  contains  mucus  or 
muco-purulent  material  in  quantity. 

(2)  Chronic.— In  this  condition  the  mneoua 
membrane  is  much  thickened,  ofren  of  a slate- 
grey  colour,  with  ecchymoses,  and  sometimes 
with  ulcerative  abrasions  of  the  surface.  The 
other  coats  of  the  pelvis  and  ureter  may  also  be 
distinctly  thickened,  and  the  lumen  of  the  ureter 
may  be  more  or  less  narrowed,  The  cavity  con- 
tains purulent  material,  with  debris  of  broken- 
down  mucous  membrane;  and  sometimes,  the 
ureter  being  obstructed,  great  accumulation  of 
pus  takes  place,  so  as  to  expand  the  pelvis  and 
lead  to  partial  atrophy  of  the  kidney  ( pyo- 
nephrosis). 

(3)  Calculous. — In  this  form  the  mucous 
membrane  may  present  either  of  the  conditions 
above  described,  but  one  always  finds  mingled 
with  the  other  materials  calculi  of  greater  or 
less  size. 

Symptoms. — The  symptoms  of  acute  pyelitis 
may  be  either  well-defined,  or  masked.  There 
may  bo  uneasiness  or  acute  pain  in  the  loins  and 
along  the  line  of  the  ureter  ; sometimes  distinct 
rigors,  with  other  febrile  symptoms,  occur  ; and 
the  urine  is  cloudy,  depositing  mucus  or  muco- 
purulent material,  or  sometimes  blood.  The 
most  characteristic  feature  is  the  presence  in  the 
urine  of  the  angular  tailed  cells  which  line  the 
pelvis  of  the  kidney.  The  condition  may  gradu- 
ally subside,  or  may  become  chronic ; or  in  rare 
cases,  and  where  important  complications  exist, 
it  may  prove  fatal. 

In  chronic  pyelitis  there  is  often  an  aching 
feeling,  or  well-defined  pain  in  the  region  of  the 


KIDNEYS,  DISEASES  OF. 


794 

ureters.  There  is  constitutional  disturbance, 
debility,  fever,  hectic  ; the  urine  is  opaque,  and 
deposits  pus — generally  grey,  sometimes  tinged 
with  blood.  This  condition  may  go  on  for  long 
periods,  sometimes  terminating  in  recovery,  but 
often  persisting  and  proving  fatal  by  exhaustion, 
by  extension  to  the  kidney-substance  or  to  the 
cellular  tissue,  or  by  concomitant  complications. 

The  calculous  form  differs  from  the  others  in 
respect  of  its  cause  ; and  in  being  attended  by 
more  pain,  by  more  tendency  to  haemorrhage, 
and  sometimes  by  thepresence  of  crystals,  gravel, 
or  calculi  in  the  deposit. 

If  the  escape  of  the  pus  should  be  prevented 
in  any  of  the  three  forms  of  pyelitis,  owing  to 
obstruction  of  the  ureter,  and  pyonephrosis 
result,  a fulness  or  fluctuating  tumour  may  be 
detected  in  the  renal  region,  and  this  in  some  ' 
instances  subsides  at  intervals,  with  a copious 
discharge  of  pus  in  the  urine. 

Diagnosis. — From  cystitis,  pyelitis  is  distin- 
guished by  the  absence  of  vesical  pain,  and  of 
frequent  calls  to  micturition;  and  by  the  pres- 
ence of  the  lumbar  uneasiness,  and  the  more  in- 
timate admixture  of  the  foreign  materials  with 
the  secretion.  From  renal  inflammation  it  is 
distinguished  by  the  absence  of  tube-casts;  the 
seat  of  the  pain  ; and  the  presence  of  the  charac- 
teristic cells  of  the  renal  pelvis.  From  strumous 
kidney  it  is  sometimes  almost  impossible  to  dif- 
ferentiate simple  pyelitis.  Indeed  the  two  con- 
ditions are  not  unfrequently  associated  together, 
but  the  presence  of  other  evidences  of  strumous 
disease,  the  enlargement  of  one  or  both  kidneys, 
and  the  presence  of  copious  debris,  in  addition  to 
the  pus,  often  suffice  to  distinguish  the  one  from 
the  other. 

Prognosis. — In  the  slighter  and  acute  forms 
of  pyelitis,  the  prognosis  is  generally  favour- 
able. In  the  chronic  variety7  it  must  always  be 
guarded,  the  amount  of  danger  being  determined 
in  some  measure  by  the  cause,  the  constitutional 
conditions,  and  the  complications. 

Treatment. — Tho  first  essential  is  that  the 
patient  shou'd  have  rest,  and  that  the  urinary 
secretion  should  be  copious  and  bland.  In  order 
to  secure  this  a diet  largely  composed  of  milk 
and  simple  diluents,  or  in  some  cases  exclusively 
of  milk,  and  the  avoidance  of  stimulating  foods 
and  drinks,  are  to  be  insisted  on.  As  to  medi- 
cine, if  the  urine  be  excessively  acid,  alkalies 
should  be  administered  ; if  it  be  alkaline,  mine- 
ral acids  should  be  given.  Various  remedies 
which  appear  to  diminish  irritation,  such  as  tho 
uva  ursi,  pareira  brava,  buchu,  triticum  repens, 
copaiva,  aud  sandal-wood  oil,  ought  to  be  em- 
ployed. In  the  acuter  cases  the  application  of 
poultices  to  the  loins,  and  the  internal  administra- 
tion of  henbane  or  opium,  are  to  be  recommended. 

In  the  chronic  forms  of  pyelitis  a similar  lino 
of  treatment  should  be  perseveringly  followed ; 
and  in  cases  which  owe  their  origin  to  the  pres- 
ence of  calculi,  the  remedies  appropriate  to  the 
diathetic  condition  should  be  employed.  Astrin- 
gents may  possibly  be  useful  in  checking  too 
copious  a discharge  of  pus, 

23.  Kidney,  Malformations  of.  — The 
commonest  malformation  of  the  kidneys  is  lobu- 
lation, which  is  a relic  of  the  fcetal  condition. 


Next  comes  the  undue  development  of  one 
organ.  Sometimes  there  are  two  pelves  belonging 
to  each  kidney,  or  two  ureters.  A not  very  rare 
anomaly  is  the  horseshoe  kidney,  which  consists 
simply  in  the  union  of  the  two  kidneys,  by  a 
band  of  renal  tissue,  at  either  end,  usually  the 
lower.  This  abnormality  is  often  attended  bv 
anomalies  in  the  arrangement  of  the  ureters  anil 
vessels.  A very  rare  condition  is  that  in  which 
there  is  a central  union  between  the  two  organs, 
owing  to  the  development  of  supplementary 
renal  structure  opposite  their  pelves.  None  cf 
these  malformations  lead  to  any  important 
symptoms,  except  by  pressure  upon  the  i.uct  or 
vessels,  under  superadded  abnormal  conditions  of 
the  organs  themselves,  or  of  neighbouring  parts. 

24.  Kidney,  Malignant  Disease  of— De- 
finition.— A chronic  disease  of  the  kidney, 
caused  by  the  circumstances  which  induce  cancer 
elsewhere ; consisting  in  the  formation  of  no- 
dules of  cancer,  or  the  infiltration  of  the  organ 
with  the  new  formation ; characterised  by  a 
renal  tumour,  cachexia,  and  frequently  by  altera- 
tion of  the  urine  ; and  resulting  in  death. 

tEtiology. — Primary  renal  cancer  arises  from 
causes  not  yet  ascertained.  It  occurs  at  two 
epochs  of  life,  namely,  in  early  childhood  and  in 
adult  age.  Children  under  four  years  appear 
specially  liable.  The  male  sex  is  more  fre- 
quently affected  than  the  female ; the  right 
kidney7  more  commonly  than  the  left. 

Secondary  cancer  of  the  kidney  is  most  fre- 
quently associated  with  carcinoma  of  the  liver, 
the  stomach,  the  mamma,  the  testicle,  or  the 
uterus ; sometimes  of  the  supra-renal  bodies,  or 
the  mesenteric  glands. 

Anatomical  Characters. — All  the  varieties 
of  cancer  have  been  met  with  in  the  kidney,  but 
the  medullary  is  by  far  the  most  common.  It  is 
sometimes  primary,  sometimes  secondary.  The 
primary  affects  usually  one  kidney,  most  com- 
monly the  right;  the  organ  is  often  much  en- 
larged, weighing  sometimes  as  much  as  sixteen 
or  seventeen  pounds,  and  this  even  in  young  chil- 
dren. In  ten  children  Dr.  Eoberts  found  the  aver 
age  weight  8f  lbs. : in  ten  adults  hefound  it  9|  lbs. 
Such  large  tumours  occupy  a great  part  of  the 
abdomen,  and  push  the  colon  forward.  The 
cancer  is  in  some  cases  scattered  in  separate 
nodules  ; in  others  it  is  infiltrated  through  the 
mass.  It  commences  always  in  the  cortical  sub- 
stance, and  is  developed  from  the  fibrous  stroma. 
In  the  scattered  cases  the  remaining  portions  oi 
the  kidney7  are  quite  sound.  The  cancer  may 
involve  the  sub-mucous  tissue  of  the  mucous 
membrane  of  the  pelvis,  the  ureters,  and  tho 
veins.  The  lymphatic  vessels  and  glands  also 
become  secondarily  affected.  Sometimes  it  at- 
fects  the  peritoneum,  colon,  and  it  has  even 
involved  the  skin. 

When  the  renal  affection  is  secondary,  it  con- 
stantly affects  both  organs,  and  rarely  leads  to 
such  enlargement  as  is  seen  in  the  primary  dis- 
ease. It  occurs  in  the  form  of  numerous  nodules, 
developed  in  the  stroma  or  along  the  vessels. 
The  remaining  renal  tissue  is  commonly  healthy, 
but  it  may  be  inflamed  or  otherwise  altered. 

Symptoms. — The  symptoms  of  primary  cancer 
generally  become  quite  distinct  when  the  disease 


KIDNEYS,  DISEASES  OF. 


advances,  but  in  the  earlier  stages  they  are  very 
indistinct.  The  urine  itself  is,  as  a rule,  natural 
in  quantity,  of  acid  reaction,  normal  specific 
gravity  and  colour;  but  from  time  to  time  blood 
appears,  its  amount  varying  from  a mere  trace 
to  a very  serious  haemorrhage.  Sometimes  the 
blood  is  in  clots,  and  this  bleeding  may  be  the 
earliestsymptom;  and  it  occasionally  happens  that 
carcinomatous  elements  may  be  discovered  in  the 
urinary  deposit,  but  it  is  very  difficult  to  be 
sure  of  their  presence. 

Examination  of  the  abdomen  reveals  the  pre- 
sence of  a tumour,  occupying  and  extending 
from  the  region  of  the  kidney.  The  tumour  is 
generally  nodulated,  of  tolerably  firm  consist- 
ence, and  dull  on  percussion.  The  colon  lies  in 
front  of  the  mass,  which  is  capable  of  being  tilted 
forward  by  pressure  on  the  renal  region.  When 
the  left  kidney  is  affected,  the  spleen  is  displaced 
upwards.  As  a rule,  there  is  persistent  consti- 
pation, and  some  pain,  together  with  the  general 
symptoms  of  the  carcinomatous  cachexia. 

Diagnosis. — Carcinoma  of  the  left  kidney  may 
be  confounded  with  enlargement  of  the  spleen ; 
with  perinephric  abscess ; perhaps  sometimes 
with  disease  of  the  mesenteric  glands  ; or  with 
obstruction  of  the  colon,  and  retention  of  feces. 

From  splenic  tumour  it  is  distinguished  by  its 
lower  position,  and  the  absence  of  the  splenic 
notch  ; the  normal  condition  of  the  blood  ; and 
the  presence  of  blood  in  the  urine  ; also  by  the 
nodulated  character  of  the  tumour  itself,  and  by 
the  position  of  the  colon. 

From  perinephric  abscess  it  is  distinguished  by 
the  absence  of  fever,  and  of  fluctuation  ; as  well 
as  by  the  less  rapid  advance  of  the  disease. 

From  tumours  of  the  mesenteric  glands  renal 
cancer  is  distinguished  by  its  situation,  being 
more  towards  the  side  and  the  lumbar  region. 
The  mass  also  is  less  nodular  than  in  mesenteric 
growths,  which  are  composed  of  groups  of  glands. 

From  carcinoma  of  the  intestine,  with  accumu- 
lation of  faeces  above  it,  it  is  distinguished  by 
the  position  of  the  mass,  and  by  its  characters 
on  palpation;  as  well  as  by  absence  of  the  signs 
proper  to  the  intestinal  disease. 

Carcinoma  of  the  right  kidney  may  be  con- 
founded witli  tumour  of  the  liver,  especially  in 
children ; but  the  presence  of  a space  of  clear  per- 
cussion, more  or  less  extended  between  the  liver 
and  the  tumour,  should  remove  all  doubt.  If 
the  diseased  kidney  touches  the  liver,  reliance 
must  be  placed  on  the  symptoms  proper  to  renal 
or  to  hepatic  disease. 

Cancer  of  the  kidney  is  to  be  distinguished 
from  tumour  of  the  ovary,  by  its  more  fixed  con- . 
dition,  and  the  h'story  of  its  growth. 

Prognosis. — The  prognosis  is  in  all  cases 
unfavourable ; the  duration  varies  with  the  form 
of  cancer.  Dr.  Walshe  thinks  eight  months  tho 
average,  but  that  probably  is  too  short. 

Treatment. — Treatment  is,  of  course,  merely 
palliative — morphia,  belladonna,  henbane,  applied 
externally  or  injected  subcutaneously  to  relieve 
pain  ; ergotine  and  other  preparations  of  ergot, 
jeetste  ot  lead,  and  gallic  acid  to  check  haemor- 
rhage ; and  iron  as  an  astringent  and  blood-tonic. 
Hie  bowels  require  careful  attention;  and  some- 
imes  there  may  be  so  much  ascites  as  to  warrant 
apping. 


795 

25.  Kidney,  Malpositions  of. — The  kidney 
may  be  congenitally  displaced,  but  the  impor- 
tant anomaly  coming  under  this  head  is  the 
movable  kidney,  which  demands  special  consider- 
ation. 

Definition.— The  movable  kidney  is  a con- 
dition especially  affecting  women;  consisting  in 
the  undue  mobility  of  one,  or  rarely  of  both  kid- 
neys ; characterised  in  some  cases  by  no  symp- 
toms, in  others  by  uneasiness  or  pain  and  general 
nervous  disturbance,  and  by  the  presence  of  a 
tender  reniform  tumour,  with  clear  note  on  per- 
cussion in  the  renal  region  of  the  affected  side  ; 
resulting,  as  a rule,  in  frequent  recurrence  of 
the  symptoms  without  danger  to  life. 

^Etiology. — Movable  kidney  is  more  common 
in  the  female  sex,  and  especially  in  those  who 
have  passed  through  many  pregnancies,  but  it  is 
not  exclusively  associated  with  women,  for  it, 
occurs  (although  rarely)  in  males,  and  also  in 
children.  The  right  kidney  is  much  more  fre- 
quently affected — 65  out  of  91  cases  (Ebstein). 
Its  occurrence  is  probably  mainly  due  to  laxity 
of  the  abdominal  parietes,  and  utfusual  length, 
or  irregular  distribution,  of  the  renal  vessels. 

Anatomical  Characters. — The  kidney  is  not 
necessarily  changed  in  its  structure,  but  its  posi- 
tion may  be  altered  in  any  direction. 

Symptoms. — In  many  cases  no  symptoms  oc- 
cur in  movable  kidney.  But  in  some,  whenever 
the  displacement  occurs,  much  uneasiness  or 
even  considerable  pain  is  experienced.  Tho 
writer  has  known  a man  unable  to  work  in  con- 
sequence of  the  pain  induced  by  the  displace- 
ment, and  losing  a day’s  work  regularly  once  a 
week  or  once  a fortnight.  The  sensations  are 
generally  rather  of  the  nature  of  vague  uneasi- 
ness than  of  actual  pain,  except  when  tho  organ 
is  touched,  and  then  there  is  pain  of  a peculiar 
and  sickening  kind.  On  percussion  over  the  renal 
region  posteriorly  a clear  note  may  be  elicited 
on  the  affected  side,  and  sometimes  a flattening 
may  be  made  out  at  the  part.  The  urine  some- 
times becomes  altered  during  the  attacks,  de- 
positing mucus  and  in  one  case  in  the  writer’s 
practice  a little  blood.  Careful  palpation  re- 
veals a tumour,  of  characteristic  renal  form  ; and 
now  and  then  pulsation  of  the  renal  artery  may 
be  felt.  The  morbid  condition  may  recur  at 
intervals  during  many  years,  and  is  in  some 
cases  apparent  for  a time,  and  then  absent  fur 
a very  long  period.  It  is  liable  to  be  brought  on 
by  effort,  but  often  appears  without  discoverable 
cause.  Occasionally  it  is  found  that  the  dis- 
placed kidney  owes  its  position  to  the  existence 
of  carcinoma  or  other  disease  of  the  organ. 

Diagnosis. — The  malady  may  be  confounded 
with  tumour  of  a malignant  nature,  originating 
either  in  the  abdomen  or  the  pelvis.  The  diag- 
nostic points  are,  the  fever ; the  peculiar  tender- 
ness ; the  mobility  ; the  occasional  disappear- 
ance ; the  unchanging  character  of  the  tumour  ; 
and  the  occurrence  of  a clear  percussion-note  and 
flattening  in  the  renal  region  of  the  affected  side. 

Prognosis. — The  prognosis  is  favourable. 

Treatment. — The  treatment  should  be  by 
means  of  bandages  or  trusses,  to  support  the  ab- 
dominal walls,  and  keep  up  a pressure  upon  tho 
kidney,  so  as  to  retain  it  in  its  normal  situation. 
In  the  case  of  the  working  man  above  referred 


/90  KIDNEYS,  DISEASES  OF. 


to,  complete  immunity  from  the  displacement 
was  obtained  by  the  use  of  a bandage  with  a pad 
bo  arranged  as  to  keep  up  a pressure  upon  the 
organ. 

26.  Kidney,  Morbid  Growths  of.  — The 
only  really  important  morbid  growths  of  the 
kidney  are  cancer  and  tubercle.  Syphilitic  new 
formations  occasionally  occur,  but  give  rise  to  no 
characteristic  symptoms.  Growths  of  fibrous, 
fatty,  bony,  muscular,  and  glandular  tissue  have 
all  been  met  with  in  a few  cases.  Hydatid 
disease  may  also  be  mentioned. 

27.  Kidney,  Parasites  of. — The  parasites 
which  have  been  described  as  existing  in  the 
human  kidneys  are  Hydatids,  Strongylus  gigas, 
Pentastoma  denticulatum,  and  Bilharzia  hsema- 
tobia. 

The  Strongylus  gigas  is  a large  nematode 
worm,  and  is  extremely  rare  in  man.  The  Pen- 
tastoma denticulatum  is  the  larval  form  of  P. 
tsenioides,  one  of  the  Arachnida.  It  was  found 
in  one  case  by  AVagner.  Bilharzia  liaematobia  is 
a trematode  worm,  about  three  or  four  lines  in 
leDgth ; and  inhabits  the  branches  of  the  portal 
system,  and  the  minute  veins  of  the  pelvis  of 
the  kidney,  ureter,  and  bladder.  The  parasite 
also  affects  these  structures  themselves.  So  com- 
mon is  it  in  Egypt,  that  out  of  363  post-mortem 
examinations,  Griesinger  found  it  117  times. 

Symptoms. — Hydatid-disease  gives  rise  to  a 
tumour.  The  symptoms  produced  by  the  pres- 
ence of  Bilharzia  in  the  kidney  are  hsematuria, 
with  irritation  of  the  urinary  tract.  This  para- 
site is  the  cause  of  the  endemic  hmmaturia  of 
certain  regions.  The  other  parasites  do  not 
originate  any  definite  symptoms. 

Treatment. — In  the  treatment  of  patients 
affected  with  Bilharzia  haematobia,  the  internal 
use  of  oil  of  turpentine,  and  of  the  extract  of  the 
male  shield  fern,  is  recommended.  It  is  stated 
that  when  the  bladder  is  affected,  injections  of 
iodide  of  potassium,  twenty  or  thirty  grains  dis- 
solved in  tepid  water,  repeated  every  second  or 
third  day,  have  been  found  useful.  Sec  Kidney, 
Hydatid  Disease  of;  Strongylus  gigas,  &c. 

28.  Kidney,  Suppurative  Inflammation 
of. — Definition*. — An  acute  or  sub-acute  disease 
of  the  kidneys  ; caused  by  injuries,  extension  of 
disease  from  the  bladder,  and  perhaps  exposure  ; 
consisting  in  inflammation  and  suppuration  in 
the  kidney  ; characterised  by  constitutional  dis- 
turbance, with  local  pain  or  tenderness,  and  va- 
rious alterations  of  secretion ; and  usually  result- 
ing in  death. 

-Etiology. — The  commonest  causes  of  this 
disease  are  renal  calculus,  leading  to  inflamma- 
tion of  the  pelvis  of  the  kidney;  or  inflamma- 
tion of  this  part,  propagated  upwards  from  the 
bladder  or  urethra.  Next  in  frequency  is  pyse- 
mia,  which  induces  metastatic  abscesses.  Com- 
paratively rarely  the  inflammation  is  a result  of 
embolism  of  the  renal  arteries  ; of  injuries  ; and 
perhaps  of  exposure  to  cold. 

Anatomical  Characters. — The  affected  or- 
gans are  generally  above  the  natural  size.  The 
capsule  may  strip  off  readily,  but  often,  as  it  is 
being  stripped,  leads  to  tearing  of  the  substance, 
and  liberation  of  pus.  The  surface  is  frequently 


discoloured  in  patches.  The  abscesses  mav 
be  described  as  passing  through  several  stages. 
There  is  first  the  stage  of  congestion,  with  exu- 
dation into  the  stroma  of  the  organ ; secondly, 
the  stage  of  grey  consolidation ; and  thirdly  that 
cf  suppuration.  Occasionally  sloughing  occurs. 
Sometimes  perinephric  abscess  results,  from 
perforation  of  the  capsule.  Drying  up  of  the 
pus,  with  shrivelling  of  the  affected  area,  is  some- 
times met  with. 

Microscopic  examination  reveals  in  some  cases 
at  an  early  stage  the  presence  of  colonies  of  bac- 
teria in  certain  districts  within  the  tubules, 
causing  irritation  first  in  them,  then  in  the 
stroma,  and  thus  inducing  suppuration. 

Stmttoms. — The  most  important  clinical  fea- 
tures of  suppurative  nephritis  are  the  constitu- 
tional disturbance,  accompanied  by  pain  in  the 
region  of  the  kidneys,  and  tenderness  on  pres- 
sure, with  scantiness  of  secretion ; the  urine  being 
albuminous  or  bloody,  or  sometimes  purulent, 
and  depositing  tube-casts. 

Diagnosis. — From  pyelitis,  suppurative  in- 
flammation of  the  kidneys  is  distinguished  by 
the  presence  of  tube-casts,  and  the  absence  of  the 
characteristic  angular  cells  of  the  calices  of  the 
pelvis.  From  perinephritis,  it  is  diagnosed  by 
the  absence  of  distinct  tumour,  and  by  the  his- 
tory of  the  case. 

Prognosis. — The  prognosis  is  generally  grave. 

Treatment. — The  strength  should  be  sup- 
ported by  suitable  food,  by  tonics,  and  stimu- 
lants when  necessary ; and  in  some  cases  benefit 
may  be  derived  from  poulticing,  fomentation,  or 
from  the  application  of  leeches.  Under  suitable 
conditions  it  might  be  desirable  to  open  a renai 
abscess,  and  evacuate  the  pus. 

29.  Kidney,  Syphilitio  Disease  of. — Sy- 
philis may  produce  in  the  kidney,  as  in  other 
organs,  congestion,  inflammation — either  simple 
or  gummatous,  with  the  cicatrices  and  nodules 
resulting  therefrom,  and  waxy  or  amyloid  de- 
generation. 

-Etiology. — Nothing  is  known  as  to  the  con- 
ditions which  determine  the  action  of  the  syphi- 
litic poison  upon  the  kidney. 

Anatomical  Characters. — There  is  scarcely 
ever  an  opportunity  of  studying  the  appearances 
of  the  kidney  in  cases  of  congestion — probably 
over-filling  of  the  vessels,  with  slight  inflamma- 
tory conditions  of  the  tubules,  is  all  that  would 
be  found.  The  simple  interstitial  inflammation 
is  characterised  by  thickening  and  swelling  of 
the  fibrous  stroma,  in  patches  here  and  there. 
Gummatous  inflammation  is  rare,  but  when  it 
does  occur,  it  forms  masses  of  the  ordinary 
gummy  character.  Either  of  these  conditions 
may  lead  to  the  formation  of  syphilitic  cicatrices, 
which  may  appear  on  the  surface  of  the  orcan. 
or  be  imbedded  in  the  cortical  substance.  Their 
formation  is  attended  by  the  destruction  of 
tubules  in  the  affected  parts. 

Stmttoms. — Albuminuria,  slight  in  amount 
and  of  temporary  duration,  occurring  along  wi:h 
other  syphilitic  congestive  affections,  has  ap- 
peared to  the  writer  to  indicate  renal  conges- 
tion. Various  slight  cases  of  inflammatory 
Bright’s  disease,  have  appeared  to  be  due  to  the 
syphilitic  poison.  The  symptoms  of  the  inter- 


KIDNEYS,  DISEASES  OF. 

stitiiil  and  gummy  inflammations  are  not  ascer- 
tained, although  probably  albuminuria  attends 
them  also.  The  symptoms  of  waxy  degenera- 
tion are  described  under  Bright’s  Disease. 

Diagnosis. — The  diagnosis  of  syphilitic  dis- 
ease of  the  kidney  depends  upon  the  co-existence 
of  renal  symptoms  with  evidences  of  syphilis, 
while  other  diseases  of  the  kidney  are  excluded. 

Prognosis. — This  is  favourable  so  far  as  dan- 
ger is  concerned,  except  in  the  case  of  severe 
waxy  degeneration. 

Treatment. — Iodide  of  potassium  has  been 
found  to  be  useful  in  this  as  in  other  syphilitic 
affections,  at  least  in  the  congestive  and  inflam- 
matory conditions.  Should  it  fail  to  give  relief, 
the  bichloride  of  mercury  may  be  given  in 
moderate  doses,  and  continued  cautiously  even 
when  albuminuria  is  present. 

30.  Kidney,  Tuberculosis  of. — Definition. 
A chronic  disease  of  the  kidneys  and  ureters  ; 
caused  ,by  tubercular  infection,  or  by  strumous 
inflammation  of  the  structures  involved;  con- 
sisting in  the  formation  of  nodules  of  tubercle, 
or  in  strumous  inflammation  of  the  substance  of 
the  gland,  and  of  the  mucous  membrane ; charac- 
terised by  some  constitutional  disturbance,  some- 
times by  renal  tumour,  and  by  various  alterations 
of  the  urine,  particularly  deposit  of  caseous  puru- 
lent debris-  and  resulting  usually  in  death. 

JEtiology. — The  direct  causes  of  tubercular 
disease  of  the  kidney  are  unknown.  It  is  more 
common  in  children  and  young  people  than  in 
those  more  advanced  in  life,  but  it — especially 
the  scrofulous  form — may  occur  later  on.  Men 
are  decidedly  more  frequently  affected  than 
women.  The  kidneys  are  rarely  equally  involved ; 
the  right  is  commonly  worse  than  the  left.  One 
organ  may  be  quite  free  from  disease. 

Anatomical  Characters. — Under  this  term 
are  included  both  tubercle  proper,  and  strumous 
inflammation.  Tubercle  proper  occurs  in  the  form 
of  minute  miliary  nodules  scattered  throughout 
the  substance  of  the  organ,  as  a local  manifes- 
tation of  a general  true  tuberculosis.  Strumous 
inflammation  leads  to  the  formation  of  larger 
masses,  involving  either  the  mucous  membrane 
of  the  pelvis  of  the  kidney,  or  the  cortical  sub- 
stance. When  the  former  is  its  seat,  it  leads  to  a 
thickening  of  the  mucous  membrane,  commenc- 
ing in  patches  which  gradually  extend,  and  ulti- 
mately undergo  ulceration.  When  the  cortical 
substance  is  affected,  the  organ  becomes  en- 
'arged ; presents  a markedly  lobulated  surface  ; 
md  on  section  conical  masses  of  altered  tissue 
ire  found  to  correspond  to  the  prominences  of 
he  lobules.  Some  of  them  are  solid  and  cheesy  ; 
ithers  are  softened  in  the  centre ; while  others 
ire  completely  softened,  so  that  on  section  a 
mantity  of  puriform  debris  flows  out,  leaving  a 
avity  with  white  walls,  rendered  shaggy  by  the 
hreds  of  fibrous  tissue  which  project  from 
hem.  Sometimes  scarcely  any  renal  struc- 
ure  is  loft.  Occasionally  what  remains  shows 
lie  characters  of  waxy  degeneration.  The  dis- 
use commences  in  the  stroma  of  the  organ  ; the 
! ibules  are  compressed,  but  are  rarely  the  seat 
f inflammatory  changes.  ’When  uie  mucous 
lembrane  of  the  pelvis  of  the  kidney  and  the 

retor  is  affected,  the  membrane  is  thickened  at 

■ 


IUE3TINE.  707 

certain  parts,  and  afterwards  becomes  ulcerated  ; 
and  the  lumen  is  diminished,  or  completely  choked 
up  by  granular  debris.  Frequently  both  the  mu- 
cous membrane  and  the  substance  of  the  kidney 
are  affected.  It  occasionally  happens,  when  one 
kidney  is  exclusively  affected,  that  shrinking  of 
the  gland  takes  place;  and  a putty-like  material, 
rich  in  cholesterine,  or  perhaps  even  calcareous 
nodules  are  found,  occupying  the  smooth-walled 
cavities  produced  by  the  disease.  Tuberculosis 
of  the  ureters,  prostate,  vesiculoe  seminales,  blad- 
der, and  testicle  not  unfrequently  co-exists. 

Symptoms. — When  tubercle  occurs  in  small  no- 
dules it  produces  no  symptoms,  and  even  in  the 
inflammatory  form  the  constitutional  symptoms 
are,  in  the  earlier  stages,  not  very  well-marked  ; 
but  as  the  disease  advances,  fever,  passing  gra 
dually  into  the  hectic  type,  is  developed.  The 
local  symptoms  may  be  negative,  but  there  is 
frequently  pain  in  the  affected  organ,  with 
tenderness  on  pressure ; and  in  some  cases  a 
tumour  may  be  felt  in  front,  or  percussion  may 
reveal  an  increased  area  of  dulness  in  one  or 
both  renal  regions.  The  secretion  may  be  nor 
mal,  or  even  sometimes  excessive  in  quantity, 
when  the  disease  is  not  far  advanced.  It  may  bo 
acid  or  alkaline,  of  fair  specific  gravity,  albumi- 
nous, and  sometimes  bloody.  It  often  contains 
a puriform  material,  with  debris  of  renal  tissue. 
Sometimes  there  are  masses  of  cheesy  material, 
which  are  eminently  characteristic,  occurring  in 
no  other  form  of  disease  of  the  urinary  tract. 
Occasionally  the  urine  becomes  suppressed,  and 
symptoms  of  uraemia  precede  the  fatal  termina- 
tion. Sometimes  a tumour  may  bo  felt ; and  on 
percussion  behind,  it  may  be  found  that  the 
renal  dulness  is  more  extensive  on  one  side  than 
the  other. 

Diagnosis. — The  evidences  on  which  we  rely 
in  the  diagnosis  of  tubercular  disease  of  the  kid- 
ney aro  the  presence  of  pyelitis,  combined  with 
those  of  tubercular  disease  in  other  parts,  and 
above  all  the  deposit  in  the  urine  of  the  character- 
istic fragments  of  cheesy  tissuo  above  described. 

Prognosis. — The  prognosis  is  very  unfavour- 
able, on  account  both  of  the  local  and  of  the 
constitutional  conditions. 

Treatment. — The  treatment  is  merely  pallia- 
tive, to  relieve  pain  or  uneasiness  ; and  to  seek 
to  improve  the  general  health,  by  administering 
remedies  which  are  useful  in  strumous  affections. 

31.  Kidney,  Tumour  of.— Any  enlargement 
connected  with  the  kidney,  which  reveals  itself 
on  clinical  examination,  is  regarded  as  a renal 
tumour.  This  may  be  due  to  mere  hypertrophy 
of  the  organ  ; any  form  of  cystic  disease ; accu- 
mulation of  any  fluid  in  the  renal  pelvis,  or  in 
the  kidney  itself;  or  a solid  new-growth,  espe- 
cially malignant  disease.  For  a description  of 
the  signs  of  these  several  conditions,  the  reader 
is  referred  to  their  respective  headings  in  this 
article. 

T.  Grainger  Stewart. 

KIESTINE  (kvid,  I am  pregnant ; and 
a pellicle). — Synon.  : Fr.  Kyestiine\  Ger. 
Kyestein. — -This  substance  was  formerly  be- 
lieved to  be  peculiar  to,  and  always  present  in, 
the  urine  of  women  in  pregnancy,  and  it  was 
held,  therefore,  to  be  significant  of  that  condition. 


198  KIESTINE. 

Recent  investigations  show  that  it  may  be  absent 
all  through  pregnancy,  or  present  only  during 
certain  months,  usually  from  the  second  to  the 
seventh  ; that  it  may  be  present  in  the  urine  of 
anaemic  persons,  male  as  well  as  female ; and 
therefore  that  it  has  not  the  diagnostic  value 
which  was  formerly  attached  to  it. 

Kiestine  is  a nitrogenised  body  allied  to  caseine ; 
and,  according  to  Dr.  Braxton  Hicks,  the  amount 
deposited  from  urine  containing  it  can  be  aug- 
mented by  the  addition  of  rennet.  Chemically  and 
microscopically  it  is  a variable  body.  Fat,  mucus, 
crystals  of  the  phosphates,  infusoria,  and  granu- 
lar matter  have  been  found  in  it.  If  urine  capable 
of  yielding  kiestine  be  set  aside  in  a tall  glass,  a 
cloud,  apparently  of  mucus,  becomes  visible  in 
the  middle  of  it  on  the  second  or  third  day.  This 
soon  rises  to  the  top,  and  an  iridescent  pellicle 
is  seen  forming  on  the  surface.  When  this  has 
fully  formed,  it  begins  to  fall  through  the  fluid  in 
the  form  of  flocculi,  until  the  whole  is  deposited 
at  the  bottom  in  a whitish  layer.  Another  pellicle 
containing  triple  phosphates  succeeds  this,  and 
putrefaetivo  changes  proceed. 

No  reliance  can  be  placed  upon  the  presence 
of  kiestine  as  a proof  of  pregnancy. 

Alfred  Wii.tshire. 

KINAESTHESIS  (tcivtu,  I move,  and 
al(rdT]7Ls,  sensation). — The  sense  of  movement. 

In  view  of  the  conclusion  that  the  term  ‘ mus- 
cular sense  ’ ought  to  be  abolished,  as  being  in 
several  respects  misleading,  when  applied,  as 
it  often  is  (see  Muscular  Sense)  by  diflferent 
writers  with  totally  different  significations, 
partly  referring  to  some  and  partly  to  all  the 
impressions  which  we  derive  from  our  moving 
members,  or  from  movements  generally,  the 
writer  (The  Brain  as  an  Organ  of  Mind,  p.  543,  : 
and  Appendix ) has  proposed  to  employ  the  above 
term  as  the  designation  of  an  important  but 
confessedly  complex  sense-endowment.  He  re- 
gards it  as  a form  of  sense,  ‘ whereby  we  are  made 
acquainted  with  the  position  and  movements  of 
our  limbs,  whereby  we  judge  of  “ weight”  and 
“ resistance,”  and  by  means  of  which  the  brain 
also  derives  much  unconscious  guidance  in  the 
performance  of  movements  generally,  but  espe- 
cially in  those  of  the  automatic  type.’  In  re- 
gard t o the  various  components  of  this  endow- 
ment he  adds: — ‘ Impressions  of  various  kinds 
combine  fur  the  perfection  of  this  “sense  of 
movement,”  and  in  part  its  cerebral  seat  or  area 
coincides  with  that  of  the  sense  of  touch.  There 
are  included  under  it,  as  its  several  components, 
cutaneous  impressions,  impressions  from  mus- 
cles and  other  deep  textures  of  the  Jimbs  (such 
as  fasciae,  tendons,  and  articular  surfaces),  all  of 
which  yield  conscious  impressions  of  different 
degrees  of  definiteness  ; and  in  addition  there 


KYPHOSIS. 

seems  to  be  a highly  important  set  of  “unfelt” 
impressions,  which  guide  the  motor  activity  of 
the  brain  by  automatically  bringing  it  into  rela- 
tion with  the  different  degrees  of  contraction  of 
all  muscles  that  may  be  in  a state  of  action.’ 

Kinsesthetic  centres  or  mechanisms  would, 
therefore,  in  accordance  with  this  view,  exist  in 
the  brain,  just  as  visual  or  auditory  centres  also 
exist.  The  cerebral  seat  or  locus  pertaining  to 
the  movement-sense  would  perhaps  be  more  dif- 
fused, though  it  would  otherwise  hold  much  th6 
same  relative  rank  as  the  several  cortical  me- 
chanisms for  the  more  special  senses. 

Disorders  of  Kinjesthesis.— In  certain  cere- 
bral and  spinal  diseases  the  sense  of  movement 
is  known  to  be  blunted,  or  actually  abolished, 
in  some  parts  of  the  body ; and  that  in  regard 
either  to  the  whole,  or  only  to  some  of  its  com- 
ponent impressions.  Concerning  perversions  or 
exaltations  of  this  endowment,  however,  we  as 
yet  know  almost  nothing. 

Total  abolition  of  the  endowment  in  the  limbs, 
on  one  side  of  the  body,  exists  in  certain  rare 
cases  of  hemianssthesia,  where  there  is  also 
complete  loss  of  tactile  sensibility.  On  the 
other  hand,  it  is  partially  impaired  in  both 
lower  extremities,  not  unfrequently,  in  cases  of 
locomotor  ataxy ; whilst  in  another  class  of 
cases,  without  coexisting  anaesthesia,  there 
would  seem  to  be  an  absence  of  the  ordinary 
unconscious  impressions  emanating  from  muscles 
in  action,  and  as  a consequence  motor  defects  of 
an  ataxic  order,  so  long  as  the  movements  at- 
tempted are  not  guided  by  sight  impressions. 
Incoordinate  movements  pertaining  to  this  latter 
category  are  decidedly  rare,  and  stand  in  need 
of  further  investigation. 

H.  Charlton  Bastian. 

KIN-COUGH  (Dutch,  Kienhhoef).  Also 
Chin-cough,  Both  of  these  words  are  synonyms 
for  whooping  cough.  See  Whooping  Cough. 

KING’S  EVIL.  — A popular  name  for 
scrofula,  originating  in  an  idea  formerly  held 
that  the  disease  could  be  cured  by  the  king’s 
touch.  See  Scrofula. 

KISSINGEN,  in  Bavaria.— Common  salt 
waters.  Sec  Mineral  Waters. 

KLEPTOMANIA. — Insanity  characterised 
by  an  irresistible  impulse  to  steal.  See  Insanity, 
Legal ; and  Criminal  Irresponsibility. 

KRETZNAC5,  in  Germany. — Common 

salt  waters  containing  Iodine.  See  Mineral 
Waters. 

KYPHOSIS  (Ku<j>hs,  bent). — A synonym  lor 
angular  deformity  of  the  spine.  See  St ine. 
Diseases  of. 


L 


LABIO  GLOSS 0-LAET5TGEAL  PA- 

RALYSIS ( labium , a lip  ; y\w<rcra,  the  tongue ; 
and  \dpuyi,  the  throat).— There  are  two  forms 
of  this  disease,  which  have  to  he  considered 
separately,  namely,  (A)  the  chronic  form;  and 
(li)  the  acute  form.  It  will  he  aonvenient  to 
discuss  the  chronic  form  first. 

(A)  Chronic  Labio- Glosso  - Laryngeal 
Paralysis. — Synon.  ; Fr.  Paralysic  glosso-lalno- 
laryngee  (Trousseau) ; Ger.  Progressive  Bulbar- 
parnlysie  (Wachsmuth). 

Definition. — A progressive  symmetrical  pa- 
ralysis of  the  lips  and  adjacent  facial  muscles, 
of  the  tongue,  pharynx,  and  sometimes  also  of  the 
larynx  ; with  or  without  conspicuous  wasting ; 
and  often  associated  with  muscular  atrophy 
elsewhere. 

History. — First  described  by  Dumesnil,  in 
1857,  and  by  Duchenne  in  1860,  the  disease  was 
made  generally  known  by  Trousseau’s  lecture, 
published  in  1863.  By  the  latter  writer  it  was 
termed  ‘ labio-glosso-laryngeal  paralysis.’  The 
awkwardness  of  the  German  version  of  the  term 
led  Wachsmuth,  in  1864,  to  designate  it ‘pro- 
gressive bulbar  paralysis,’  and  German  literature 
1 has  given  wide  currency  to  the  term,  which  is, 
however,  open  to  the  objection  that  the  term 
‘ bulbar  paralysis  ’ has  been  applied  to  all  para- 
l lyses  of  the  nerves  arising  from  the  medulla 
; oblongata. 

jEtiolouy. — Of  the  causes  of  the  affection 
little  is  known.  It  is  a disease  of  later  life, 
being  almost  unknown  under  forty.  Males  are 
affected  more  frequently  than  females.  The  dis- 
ease, as  such,  does  not  appear  to  be  inherited, 

I but  in  many  cases  there  is  a family  history  of 
other  affections  of  the  central  nervous  system. 
Of  immediate  causes,  exposure  to  cold,  mental 
anxiety,  and  imperfect  nourishment  have  been 
supposed  to  exert  an  influence  in  some  cases. 

Anatomical  Characters. — The  tissue  of  the 
affected  muscles  is  pale;  fatty  tissue  may  be 
in  excess;  and  the  muscular  fibres  often,  but  not 
always,  preseat  granular  degeneration.  They  are 
frequently  narrowed  ; whilst  the  tissue  between 
them  may  be  increased  in  quantity,  and  may 
contain  pigmentary  products  of  degeneration. 
The  motor  nerve-fibres  to  the  muscles  are  grey, 
translucent,  and  under  the  microscope,  dege- 
nerated. Their  nuclei  of  origin  in  the  medulla 
oblongata  are  also  diseased.  The  motor  cells  are 
shrunken  and  atrophied;  their  processes  are  lost; 
and  the  intermediate  tissue  is  degenerated.  The 
hypog)  jssal  nucleus  is  examined  most  readily, 
and  the  change  in  it  is  striking,  as  well  as  in 
the  nucleus  of  the  spinal  accessory  (larynx).  The 
anatomical  change  which  underlies  the  affection 
of  the  lips  has  not  yet  been  detected.  There  is 
some  uncertainty  of  the  precise  origin  of  this  part 
of  the  facial  nerve.  Guided  by  Duchenne's  clinical 
ibservat  ion  and  conclusion  that  these  fibres,  from 
heir  affection  with  those  of  the  hypoglossal,  must 
lirise  near  the  nucleus  of  the  latter,  Lockhart 
1 Ilarke  believed  he  had  traced  the m to  a group  of 


cells  close  to  the  hypoglossal  nucleus.  Later 
researches,  especially  those  of  Pierret  andMcy- 
nert,  have  rendered  this  conclusion  doubtful.  It 
is  certain,  however,  that  a large  number  of  the 
fibres  of  the  facial  descend  to  the  level  of  the 
hypoglossal  nucleus.  They  diverge  from  the  mid- 
dle line,  close  to  which  the  hypoglossal  nucleus 
is  situated,  and  some  at  least  pass  towards  the 
lower  part  of  the  column  of  cells,  which,  above, 
gives  origin  to  the  motor  fibres  of  the  fifth  nerve. 
But  the  physiological  association  of  the  move- 
ment of  the  tongue  and  lips  is  most  close.  We 
cannot  narrow  the  tongue  without  contracting 
the  orbicularis.  Hence  it  is  certain  that  the 
low'er  facial  nucleus  and  the  hypoglossal  nucleus, 
whether  cont  iguous  or  not,  are  closely  connected ; 
and  that  this  connected  part  of  the  facial  suffers, 
in  this  disease,  in  the  same  manner  as  the  hypo- 
glossal. The  same  fact  is  almost  certain  of  the 
motor  nucleus  of  the  glosso- pharyngeal.  When 
there  is  muscular  atrophy  in  the  limbs,  a cor- 
responding degeneration  may  be  found  in  the 
anterior  cornua  of  the  spinal  cord,  often  conjoined 
with  sclerosis  in  the  lateral  columns,  and  in  the 
anterior  pyramids  in  the  medulla.  There  is 
every  reason  to  believe  that,  in  the  chronic  form, 
the  atrophic  changes  in  the  nerve-elements  are 
the  primary  alteration. 

Symptoms. — The  symptoms  have  the  distribu- 
tion indicated  by  the  name  given  to  the  disease 
by  Trousseau,  the  affected  parts  being  the  lips, 
tongue,  throat,  and  larynx.  They  are,  so  to 
speak,  arranged  about  the  tongue  as  a centre. 
It  is  in  this  organ  that  the  earliest  symptoms 
commonly  present  themselves,  a*  a trifling  indis- 
tinctness of  speech,  due  to  an  imperfect  articula- 
tion of  those  sounds  in  which  the  tongue  is  most 
concerned — dental  and  palatine  sounds.  The 
tongue  can  be  still  protruded,  although  perhaps 
not  quite  so  far  as  normal.  The  lips  then 
become  weak,  and  sounds  in  which  the  lips 
are  concerned  are  imperfectly  articulated.  The 
vowels  o and  oo,  in  the  pronunciation  of  which 
the  orbicularis  contracts,  cannot  he  well  sounded. 
The  lips  are  not  brought  together  so  perfectly, 
or  separated  so  promptly,  as  in  health,  and  the 
labial  explosives,  b and p,  become/.  Whistling 
is  impossible.  The  lower  part  of  the  face  loses 
its  expression,  the  lips  are  habitually  separated, 
and  the  saliva  cannot  be  perfectly  retained.  The 
difficulty  in  articulation  is  soon  increased  by  the 
weakness  of  the  palate,  which  ceases  to  shut  off 
the  nasal  cavity,  so  that  a nasal  resonance  ac- 
companies sounds  from  which  it  should  be  absent. 
The  paralysis  of  the  tongue  increases  until  the 
organ  can  no  longer  be  protruded.  Deglutition 
becomes  impaired, partly  (accordingto Duchenne, 
wholly)  from  the  weakness  of  the  tongue,  but 
probably  in  part  also  from  that  of  the  constric- 
tors of  the  pharynx.  The  soft  palate  ultimately 
hangs  motionless,  and,  during  the  act  of  swallow- 
ing, does  not  close  the  posterior  nares,  so  that 
liquids  regurgitato  into  the  nose.  Food  is  apt 
to  lodge  in  the  upper  part  of  the  pharynx,  and 


800 


LABIO-GLOSSO-LARYNGEAL  PARALYSIS. 


crumbs  or  liquid  to  get  into  the  larynx.  The 
laryngeal  muscles  subsequently  become  ■weak, 
and  the  glottis  cannot  be  closed.  Coughing  is, 
therefore,  imperfect ; air  is  driven  through  the 
larynx,  but  there  is  no  sudden  opening  of  a pre- 
viously closed  glottis,  and  hence  no  explosive 
cough.  In  proportion  as  the  glottis  is  paralysed, 
phonation  is  interfered  with,  but  is  rarely 
altogether  lost.  As  the  disease  progresses  the 
speech  becomes  almost  unintelligible,  being 
reduced  to  unarticulated  vocal  sounds.  It  is  to 
be  noted,  however,  that  the  habitual  articulation 
is  rarely  the  best  possible.  Words  can  be  dis- 
tinctly articulated  by  a deliberate  effort  which 
are  scarcely  at  all  articulated  in  ordinary  speech. 
The  saliva  can  neither  be  swallowed  nor  retained 
within  tho  mouth,  and  is  constantly  dribbling 
over  the  lower  lip,  below  which  the  patient  has 
to  hold  a handkerchief  continually.  It  has  been 
thought  that  the  quantity  of  saliva  is  increased, 
but  the  evidence  of  this  is  insufficient.  The 
condition  of  the  tongue  varies  much  in  different 
cases.  In  some  it  is,  throughout,  large,  broad, 
flabby,  and  soft  to  the  touch.  In  others  it  is 
conspicuously  wasted,  and  covered  with  wrinkles 
and  furrows  from  the  shrinking.  In  some  cases 
the  lips  retain  their  normal  size ; in  others  they 
are  distinctly  thinner  than  natural.  This  strik- 
ing contrast  between  different  cases  ledDuchenne 
to  distinguish  two  varieties,  the  atrophic  and  the 
paralytic.  Most  later  writers  have,  however, 
rejected  this  distinction,  on  the  ground  that, 
post  mortem,  muscular  wasting  has  always  been 
found,  whether  the  tongue  was  large  or  shrunken. 
In  tho  former  condition  fatty  tissue  prevents  the 
wasting  fi’ombeing conspicuous  duringlife.  There 
is  certainly,  however,  a marked  contrast  between 
the  appearance  of  the  tongue  in  the  two  cases. 
In  the  affected  muscles  the  electrical  irritability 
is  usually  little  changed;  they  still  contract  to 
the  faradaic  current,  even  when  the  atrophy  is 
conspicuous.  Erb  found,  however,  in  one  case,  in- 
dication of  the  reaction  of  degeneration,  in  undue 
readiness  of  contraction  to  the  anodal  (positive) 
closure.  Other  muscles  of  tho  head  are  rarely 
affected.  Those  in  the  upper  part  of  the  face 
always  escape.  But  in  many  cases  muscular 
atrophy  in  tire  limbs,  in  greater  or  less  degree, 
is  associated,  with  or  without  ‘contracture.’  So, 
too,  in  eases  of  ordinary  muscular  atrophy,  com- 
mencing in  the  limbs,  the  lips,  tongue,  and  throat 
are  often  affected  towards  the  end  of  the  case,  in 
the  same  manner  as  in  the  disease  now  under  con- 
sideration. Death,  in  labio-glossal  paralysis,  is 
usually  the  result  of  asthenia,  due,  in  part,  to  the 
difficulty  in  deglutition.  Sometimes  the  patient 
dies  in  a paroxysm  of  coughing,  occasioned  by  an 
ineffectual  attempt  to  swallow  liquids  or  saliva. 

Diagnosis. — Before  labio-glossal  paralysis  was 
well  known,  the  difficulty  in  swallowing  was 
ascribed  to  a chronic  inflammation  of  the  fauces, 
but  this,  mistake  is  now  scarcely  possible.  The 
symptoms  have  to  be  distinguished  from  those 
due  to  other  diseases  of  the  medulla,  and  to  dis- 
ease elsewhere.  Many  acute  lesions,  in  the  region 
affected  in  this  disease,  may  cause  similar  symp- 
toms, but  these  are  distinguished  by  their  sudden 
onset.  Compression  of  the  medulla  may  also  give 
rise  to  symptoms  of  similar  distribution, butthese 
are  commonly  unilateral,  and  often  accompanied 


by  a preponderant  affection  of  the  muscular  part 
of  the  spinal  accessory,  and  by  great  weakness, 
without  wasting,  in  the  limbs.  Occasionally 
movements  of  the  tongue  are  impaired  by  disease 
of  the  cerebral  hemispheres.  The  movements  of 
the  tongue  are  especially  represented  in  the  lower 
part  of  each  ascending  frontal  convolution.  WheE 
this  is  diseased  on  one  side,  the  iossis  soon  com- 
pensated for  by  the  centre  in  the  opposite  hemi- 
sphere, but  a symmetrical  bilateral  lesion  in  this 
situation  may  cause  complete  paralysis  of  the 
tongue,  as  in  a case  recorded  by  Dr.  Barlow. 
Such  paralysis  also  is  acute  in  onset. 

Prognosis. — The  prognosis  is  most  grave.  The 
disease  consists  in  a slow  degeneration  of  the 
nerve-elements,  and  although,  in  some  cases,  a 
temporary  arrest  may  be  obtained,  it  is  doubtful 
whether,  in  any  instance  of  this  form,  consider- 
able improvement  has  occurred. 

Treatment. — The  degenerative  tendency  of 
chronic  labio-glosso-laryngeal  paralysis  is  usu- 
ally beyond  the  reach  of  remedies.  Therapeu- 
tical efforts  must  be  directed  to  the  endeavour 
to  retard  it  by  nervine  tonics,  quinine,  strych- 
nine, arsenic,  nitrate  of  silver,  and  the  like.  The 
writer  is  unable  to  agree  with  Erb’s  condem- 
nation of  strychnia  as  harmful  in  these  cases, 
although  he  has  seen  little  benefit  from  its  use. 
Electricity  may  be  tried,  although  too  often  it 
is  unsuccessful.  Faradisation  should  be  applied 
to  the  affected  muscles,  if  they  still  react  to  it. 
Erb  strongly  recommends  the  application  of  the 
voltaic  current  through  the  throat,  the  positive 
electrode  being  placed  on  the  back  of  the  neck, 
the  negative  stroked  down  the  side  of  the 
pharynx  externally',  and  such  a strength  being 
employed  as  shall  produce  reflex  movements  of 
deglutition.  Change  of  air  is  desirable  in  the 
early  stage,  and  rest  is  imperative.  Food  must 
be  carefully  regulated ; easily  digestible  varieties 
being  reduced  to  a semi-solid  condition.  In  the 
later  stages,  should  swallowing  be  impossible, 
nourishment  must  be  administered  by  an  oesopha- 
geal tube,  or,  what  is  better,  by  a catheter  in- 
troduced through  the  nose.  Belladonna  or  atro- 
pine may,  to  some  extent,  check  the  troublesome 
flow  of  saliva. 

(B)  Acute  Labio-Glosso-Laryngeal  Pa- 
ralysis.— Synon. ; Acuto  bulbar  paralysis; 

Myelitis  bulbi. 

Definition. — Paralysis  of  similar  distribution 
to  that  of  the  chronic  form,  with  or  without  con- 
spicuous wasting,  of  sudden  onset,  and  due  to  an 
acute  process. 

.ZEtiology. — The  causes  of  this  affection  are  for 
the  most  part  those  which  lead  to  acute  lesions 
elsewhere  in  the  brain,  especially  degeneration 
of  vessels,  syphilitic  disease,  and  injuries.  It 
is  a disease  chiefly  of  late  life. 

Anatomical  Characters. — Little  is  known  of 
the  exact  condition  in  cases  of  acute  onset  which 
have  recovered  with  persistent  labio-glossal  pa- 
ralysis. In  cases  which  have  died  rapidly,  foci 
of  softening  in  the  medulla  have  been  found;  and 
there  is  reason  to  believe  that  such  softening, 
from  vascular  occlusion,  is  tho  most  common 
cause  of  the  condition.  Probably  a small  h senior 
rhage  may  also  give  rise  to  it.  Tho  symmetry 
of  the  symptoms  in  the  ncute  form,  and  their 


XxABlO-G  LOSSO-LARYNGEAL  PARALYSIS, 
limitation  to  the  parts  tvhich  are  affected  in  the 
cnrouic  disease,  show  the  close  relation  of  the 
central  structures,  so  that  they  are  all  affected 
by  the  one  lesion.  The  wasting  in  some  of  the 
cases  of  this  variety  is  very  much  slower  than 
that  which  follows  an  acute  lesion  of  motor  grey 
matter  elsewhere.  It  is  possible  that  the  as- 
cending fibres  from  the  nuclei  concerned  may 
pass  up  closeto  the  middle  line,  in  a situation  in 
which  all  may  be  damaged  by  a single  lesion. 

Symptoms. — The  onset  is  sudden,  often  with 
headache  and  giddiness,  rarely  with  loss  of  con- 
sciousness. The  patient  suddenly  finds  a diffi- 
culty in  swallowing  and  in  articulation,  with 
inability  to  protrude  the  tongue.  Respiratory 
disturbances — cough,  dyspncea,  and  hiccough — ■ 
may  be  present.  There  may  be  convulsions  and 
weakness  in  the  limbs,  sometimes  with  tingling, 
but  very  rarely  with  loss  of  sensibility.  Many 
cases  which  present  these  symptoms  die  rapidly 
in  the  course  of  a few  hours  or  days.  In  those 
which  recover,  a paralysis  cf  the  tongue,  lips, 
throat,  and  larynx  may  remain,  identical  in  all 
respects  with  that  which  characterises  the  chronic 
form,  and  there  may  or  may  not  be  conspicuous 
wasting.  The  course  is,  however,  not  progressive. 
The  patient  may  remain  in  the  same  condition 
; for  a considerable  time,  and  even  exhibit  marked 
improvement. 

Diagnosis. — The  diagnosis  of  the  acute  form 
of  labio-glossc-iaryngeal  paralysis  calls  for  little 
remark.  It  must  be  remembered  that  the  symp- 
toms may  deviate  from  the  type  more  than  in 
the  chronic  variety,  as  the  lesion  sometimes 
iproduces  irregular  effects.  It  is  chiefly  liable 
|;o  be  confounded  with  the  impairment  of  move- 
uents  of  the  palate  and  toDgue  sometimes  left 
ifter double  hemiplegia,  from  which  the  history 
ufflces  to  distinguish  it,  the  two  attacks  of 
lemiplegia  usually  occurring  at  different  times, 
the  rare  symmetrical  affection  of  the  surface- 
entres  for  the  tongue,  mentioned  above,  is  also 
ot  simultaneous  on  the  two  sides,  and  it  is 
ssociated  with  at  least  transient  hemiplegic 
•eakness. 

Prognosis. — If  the  patient  recover  from  the 
nmediate  effects  of  the  lesion,  the  prognosis  of 
|e  paralysis  of  the  lips,  tongue,  and  other  parts 
better  than  in  the  chronic  form,  inasmuch  as 
■covery  of  slightly  damaged  structures  may  lead 
a considerable  degree  of  restoration  of  power, 
te  prognosis  is  also  better  if  there  is  any  reason 
ascribe  the  mischief  to  syphilitic  disease 
-wertheless,  in  some  acute  cases  the  paralysis 
■nams  absolute,  although  even  in  these  there 
not  the  tendency  to  increase  which  is  seen  in 
p chronic  variety. 

Treatment. — Any  causal  indication  must  be 
■efully  sought  for  in  acute  labio-glosso-laryn- 
l.vl  paralysis,  and  treated,  especially  evidence 
Jsyphilis.  In  other  conditions  the  treatment  is 
t ,t  for  the  lesion  which  is  supposed  to  exist. 
1 -ctrical  treatment  of  the  muscles  is  of  great 
i|'ortance,  in  order  to  prevent,  as  far  as  pos- 
s.e,  secondary  degenerations,  which  are  apt 
t- occur  before  the  partially  damaged  struc- 
t ;s  have  recovered.  The  remarks  regarding 
ing  in  the  chronic  form  are  equally  applicable 
he  acute  variety. 

W.  R.  Gowers. 

51 


LACHRYMAL  APPARATUS.  80! 

LACHRYMAL  APPARATUS,  Diseases 
of  (AdKpvfia,  a tear). 

The  lachrymal  apparatus  consists  of  the  gland, 
with  its  excretory  ducts  ; and  of  thepuncta,  the 
canaliculi,  the  lachrymal  sac,  and  the  nasal  duct, 
through  which  superfluous  tears  are  conveyed 
into  the  nose.  The  diseases  of  this  apparatus  are 
almost  limited,  with  the  exception  of  growth* 
affecting  the  gland  itself  (see  Orbit,  Diseases  of) 
to  the  excessive  secretion  of  tears,  and  to  impedi 
ments  to  their  escape  into  the  nose.  To  excessiu 
secretion,  or  to  impeded  outflow,  the  common 
term  epiphora  has  been  applied;  - but  the  great 
majority  of  cases  of  epiphora  are  due  to  the  latter 
of  the  two  causes. 

Epiphora.  - — Excessive  secretion  of  tears  i.- 
described  by  authors  as  an  affection  for  which 
it  is  not  always  possible  to  discover  an  adequate 
cause,  and  it  may  perhaps  be  sometimes  due  t" 
the  prolonged  operation  of  emotional  influences. 
In  most  instances,  however,  it  is  associated 
with  some  kind  or  degree  of  conjunctival  irri- 
tation, and  is  to  be  regarded  only  as  a reflex 
phenomenon  hence  arising.  It  is  well  known  that, 
any  temporary  or  accidental  irritation,  such  as 
may  arise  from  the  intrusion  of  a foreign  body 
into  the  conjunctival  sac,  is  apt  to  be  followed  by 
a copious  secretion  of  tears,  which  assist  in  dis- 
lodging the  offender;  and  irritations  of  a more 
chronic  kind,  produced  by  congestion  or  irregu- 
larity of  the  lining  membrane  of  the  lids,  may- 
have  a similar  effect. 

Impediments  to  the  escape  of  the  tears,  causing 
them  to  collect  in  the  conjunctival  sac,  or  even 
to  flow  over  the  cheek,  may  depend  upon  dis- 
placement of  the  pun  eta,  so  that  these  apertures 
are  no  longer  applied  to  the  conjunctival  surface, 
from  which  they  normally  remove  superabundant 
moisture  by  capillary  attraction.  Such  displace- 
ments affect  chiefly  the  punctum  of  the  lower  lid ; 
and  may  be  consequent  either  upon  conjunctiva! 
swelling,  by  which  the  lid  is  pushed  away  from 
the  eye,  or  upon  paralysis  or  -weakness  of  the 
orbicularis  muscle,  which  allows  the  lid  to  fall 
by  the  action  of  gravity.  In  some  cases  epiphora 
will  depend  upon  obliteration  or  occlusion  of  the 
puncta.  The  former  condition  is  incurable  ; the 
latter  may  be  produced  by  plugs  of  inspissated 
mucus,  which  may  be  removed  by  the  careful  em- 
ployment of  a probe. 

But  the  most  ordinary  cause  of  obstruction  is 
stricture  of  the  nasal  duct ; in  which  condition 
the  tears  are  arrested  a little  below  the  sac,  and 
the  sac  consequently  becomes  over-distended. 
In  this  condition,  the  sac  can  be  seen  and  felt  as  a 
small  lump,  situated  just  beneath  the  tendo  oculi 
When  pressure  is  made  upon  this  lump,  a fluid, 
consisting  of  tears  mixed  with  more  or  less 
mucus  or  muco-pus,  will  regurgitate  into  tin 
eye,  and  the  lump  itself  will  disappear.  The 
danger  in  such  cases  is  that  the  continued  dis 
tension  of  the  sac  will  in  time  excite  inflamma 
tion  of  its  lining  membrane,  leading  to  the  for- 
mation of  pus,  and  this  to  an  opening  upon  the 
cheek,  producing  what  is  called  a lachrymal 
fistula . Such  an  opening  never  heals  until  the 
duct  is  again  pervious,  and  it  is  liable  to  under- 
go periodic  attacks  of  unsightly  inflammation. 

Treatment. — In  all  cases  of  lachrymal  hyper- 
secretion, the  first  thing  to  be  done  is  to  search 


302  LACHRYMAL  APPARATUS. 

under  the  lids  for  any  concealed  foreign  body 
which  may  be  lurking  there.  If  none  be  detected, 
examination  must  be  made  for  conditions  likely 
to  be  irritating ; and  they  are  to  be  treated,  if 
they  exist,  by  mild  astringent  or  other  suitable 
local  applications.  There  is  probably  no  medicine 
which  can  be  said  to  exert  any  positive  effect  in 
diminishing  the  amount  of  the  lachrymal  secre- 
tion. 

If  the  displacement  of  the  lid  can  be  cured  by 
treatment  addressed  to  its  causes,  the  tears  will 
usually  return  to  their  accustomed  channel.  If 
the  displacement  be  incurable,  as  happens  in  some 
cases  of  paralysis  of  th eportio  dura,  or  of  chronic 
ectropion,  the  patient  may  often  be  relieved  by 
slitting  open  the  canaliculus  as  far  as  the  caruncle, 
so  as  to  carry  back  the  aperture  to  the  secretion 
which  it  is  designed  to  remove. 

The  treatment  of  stricture  of  the  nasal  duct 
can  often  be  only  palliative.  The  patient  should 
acquire  the  habit  of  emptying  the  distended 
sac  by  finger-pressure  many  times  a day,  and 
of  wiping  away  the  fluid  ; while,  to  diminish 
the  irritation  of  the  mucous  membrane,  a drop 
nf  any  mild  astringent  lotion  may  be  applied  to 
the  inner  corner  of  the  conjunctiva  two  or  three 
times  a day,  immediately  after  such  pressure  has 
I ecu  made.  Perhaps  the  lotion  most  generally 
suitable  for  this  purpose  is  a solution  of  acetate 
hi  le id  in  distilled  water,  of  a strength  not  ex- 
ceeding three  grains  to  the  ounce. 

When  a radical  cure  is  desired,  the  canaliculus 
must  be  slit  up,  and  the  patency  of  the  duct  re- 
stored by  the  passage  of  probes  through  the 
si  ricture.  If  fistula  has  already  formed,  or  even 
if  the  sac  is  the  seat  of  an  abscess,  no  other  plan 
is  available  ; but  for  the  necessary  details  the 
ro  tder  is  referred  to  works  on  ophthalmic  surgery. 

R.  Brudeneix  Carter. 

LACTATION",  Disorders  of. — The  dis- 
orders of  lactation  are  numerous.  Sometimes 
the  quantity  of  the  lacteal  secretion  is  exces- 
sively small  and  quite  inadequate  for  the  support 
of  the  child.  At  other  times  it  is  so  abundant 
that  the  milk  will  flow  from  one  nipple  as  the 
infant  is  sucking  the  other ; and  when  the  child 
is  removed  from  the  breast.,  the  secretion  con- 
ti lines  from  both  sides.  The  term  agalactia  is 
applied  to  the  former,  and  galactorrhoea  to  the 
latter  condition. 

1.  Agalactia  signifies  either  a total  suppres- 
sion of  the  mammary  secretion,  or  a very  scanty 
supply.  It  results  generally  from  anaemia. 

The  treatment  should  be  directed  towards  im- 
proving the  health  of  the  patient  as  much  as 
possible,  by  a generous  diet,  and  tonics,  particu- 
larly those  containing  iron.  Certain  drugs  have 
been  employed  as  galactagogues,  and,  it  has  been 
said,  with  benefit.  The  leaves  of  the  castor-oil 
plant,  boiled,  have  been  used  as  a local  application 
— the  liquid  for  fomentation,  and  the  leaves  as  a 
poultice ; and  a strong  decoction  of  the  same  plant 
has  been  given  as  a drink.  It  is  doubtful,  how- 
ever, whether  such  remedies  are  efficacious.  See 
Galactag  ogtjes. 

2.  Galactorrhoea  occurs  in  two  forms.  In 
nc  the  composition  of  the  milk  is  normal,  but 

the  quantity  excessive ; in  the  other  form  the  in- 


LAGOPHTHALMOS. 

crease  in  the  bulk  of  the  secretion  is  due  tn  a 
preponderance  of  the  watery  part  of  the  fluid. 

Remedies  employed  to  reduce  the  amount  of  the 
mammary  secretion  are  termed  galadophyga,  and 
the  chief  of  these  are  belladonna  and  iodide  of 
potassium.  Belladonna  is  employed  as  an  out- 
ward application,  as  well  as  adm  nistered  inter- 
nally. The  extract  rubbed  up  with  glycerine  mat- 
te spread  on  lint,  and  thus  applied  to  the  breasts, 
or  the  emplastrum  belladonnas  may  be  used. 
The  child  should  not  he  put  to  the  breast  too 
frequently.  If  the  excessive  secretion  continue 
for  any  length  of  time,  great  emaciation  mat- 
res  tilt ; and  to  this  condition  the  term  mammaro 
diabetes  has  been  applied.  Under  such  circum- 
stances lactation  should  he  entirely  stopped  as 
soon  as  possible.  Strapping  the  breasts  tightly 
immediately  after  they  have  been  emptied  is  of 
use.  Every  care  must  be  taken  to  avoid  the  for- 
mation of  a mammary  abscess ; and  if  the  breasts 
get  hard  and  knotty  a breast-pump  should  be 
employed  to  free  the  tubes. 

3.  Depressed  nipples  are  generally  produced 
by  the  pressure  of  stays.  If  this  condition  be 
observed  during  pregnancy,  periodic  attempts 
should  be  made  to  draw  the  nipples  out  by  means 
of  a glass  nipple-shield,  to  which  an  india-rubber 
tube  and  teat  is  attached. 

4.  Fissures  and  excoriations  of  the  nipples 
often  lead  to  abscess,  and  it  is  said  that  it  may 
sometimes  lead  to  malignant  disease.  To  avoid 
the  occurrence  of  these,  astringents  should  be 
applied  to  the  nipples  during  pregnancy,  in  order 
to  harden  them.  Eau-de- cologne  and  water, 
brandy  and  water,  or  a weak  solution  of  tannir. 
may  he  employed  for  this  purpose. 

Sometimes  an  abrasion  on  the  surface  form' 
an  ulcer  or  a crack  at  some  part  of  the  nipple, 
most  frequently  at  its  base,  which  gives  rise  to 
great  pain  during  suckling.  The  remedies  for 
these  cracks  are  astringent  applications,  such  as 
tannin,  flexible  collodion,  or  a weak  solution  of 
nitrate  of  silver.  Care  should  be  taken  td 
sponge  these  away  before  the  infant  is  again 
put  to  the  breast;  and  a nipple-shield  with  ait 
india-rubber  teat  will  be  found  of  great  service 

For  abscess  and  other  morbid  cotulitions  of  the 
mammary  gland  supervening  during  lactatioi 
see  Breast,  Diseases  of;  Milk  Fever;  anc 
Nipple,  Diseases  of.  Clement  Godson. 

LACTEAL  VESSELS  and  GLANDS 

Diseases  of.  Sec  Mesenteric  Glands,  Dis 
eases  of. 

LAGOPHTHALMOS  (A aybs,  a hare;  c£ 

6a\p6s,  the  eye). — This  term  is  derived  from  a 
old  supposition  that  the  hare  sleeps  with  its  eye 
open ; and  is  applied  to  a condition  in  which  tliei 
is  inability  to  clcse  one  or  both  eyes.  Lagopl 
thalmos  may  be  due  to  paralysis  of  the  orbici 
laris,  in  which  case  it  will  be  attended  by fallia 
of  the  lower  lid,  and  will  generally  be  assoc 
ated  with  paralysis  of  other  muscles  supplied  1 
the  portio  dura  (sec  Facial  Paralysis)  ; to  tl 
contraction  of  cicatrices;  to  spasm  of  theuppe 
eyelid  ( sec  Third  Nerve,  Diseases  of);  or  p> 
sibly  to  congenital  malformation  of  die  lies.  J 
paralytic  lagophthalmos,  the  treatment  is. it. 
of  facial  paralysis.  Where  there  is  contra,  t 


LAGOPHTHALMOS. 

Or  deformity,  each  case  must  be  considered  on  its 
own  merits,  with  regard  to  the  possibility  of 
obtaining  relief  from  a surgical  operation. 

R.  Brudeneix  Carter. 

LARDACEOUS  DISEASE  ( lardum , ba- 
con).— A synonym  for  albuminoid  disease,  which 
is  so  called  from  the  resemblance  of  the  cut 
surface  of  an  affected  organ  to  raw  bacon.  See 
Albuminoid  Disease. 

LARVALIS  (larva,  a mask).  — A term 
usually  associated  with  porrigo.  The  thick  in- 
crustation which  is  sometimes  seen  covering  the 
face  of  children  affected  with  eczema,  and  con- 
stituting a hideous  mask  to  the  features,  is  an 
example  of  porrigo  larvalis,  or  rather  eczema  lar- 
> >alc , as  likewise  is  ordinary  milk-crust. 

LARVATED  (larva,  a mask). — A term  ap- 
plied to  certain  diseases,  when  their  ordinary 
characters  are  masked  or  concealed ; as,  for  ex- 
ample, typhoid  fever.  See  Typhoid  Fever. 

LARYNGEAL  PHTHISIS.  — A morbid 
condition  of  the  larynx,  supposed  to  be  of  a 
i tubercular  nature,  and  either  associated  or  not 
! with  pulmonary  phthisis.  See  Larynx,  Diseases 
of ; and  Phthisis. 

LARYNGISMUS  STRIDULUS  (larynx, 
fthe  windpipe;  stridor,  a noise). — A form  of 
obstructed  breathing,  attended  with  a peculiar 
stridor  or  crowdng  sound  during  inspiration,  and 
.dependent  on  spasm  of  the  muscles  of  the  glottis. 
See  Larynx,  Diseases  of ; 9.  Spasm. 

LARYNGITIS. — Inflammation  of  the  la- 
ynx.  See  Larynx,  Diseases  of ; 3.  Inflammation. 

LARYNGOSCOPE,  The.  (AdpiryL  the 
arynx,  and  okow4w,  I look.) — Definition. — An 
nstrument-  for  illuminating  the  interior  of  the 
arynx  and  trachea,  and  reflecting  those  parts 
o as  to  present  their  image  to  the  eye  of  the 
bserver. 

Description.—  The  apparatus  for  laryngoscopy 
onsist  of  a small  round  plane  mirror,  set  on  a 
letal  stem  and  fixed  in  a wooden  handle,  for 
itroduction  into  the  throat;  and,  for  concen- 
■atingand  reflecting  the  light  into  the  throat,  a 
incave  reflector  to  be  worn  in  front  of  the  fore- 
iiad,  or  perforated  for  wearing  in  front  of  the 
re  of  the  observer.  With  this  throat-mirror  and 
Hector,  any  lamp,  or  even  a candle,  is  available.; 
it  brilliant  illumination  contributes  so  much 
the  distinctness  of  the  image  that  some  appa- 
tus  to  condense  the  light  is  also  desirable. 

: tiler  a special  apparatus  with  a bull’s-eye  lens, 
a globe  of  water,  such  as  a plain  round  de- 
bater, forms  a powerful  condenser,  and  with  it 
j?  concave  reflector  may  be  dispensed  with,  the 
lit  be  ng  concentrated  directly  by  the  globe  of 
ter  on  the  tbroat  of  the  patient. 

Appl  ication. — In  practising  laryngoscopy,  the 
>t  object  is  to  throw  a brilliant  light  into  the 
i irynx.  Sunlight  falling  directly,  or  reflected 
-in  an  ordinary  looking-glass,  through  the 
' uth  into  the  throat  of  the  patient ; bright 
((’light;  or  the  concentrated  light,  of  a lamp 
^candle,  are  each  of  them  available  for  this 
I pose. 

'he  patient  being  placed  beside  and  a little 


LARYNGOSCOPE.  803 

in  front  of  the  lamp,  when  the  reflector  is  used; 
or  opposite  the  window,  or  lamp  and  concen- 
trator, if  direct  light  is  employed,  the  operator 
seats  himself  opposite  him,  and  adjusts  the  re- 
flector which  he  is  wearing,  or  the  concentrator 
in  front  of  the  lamp,  so  that  wheu  the  patient 
sits  upright,  with  his  head  inclined  slightly  back, 
his  mouth  widely  open,  and  the  tongue  put  out, 
the  light  shall  be  concentrated  on  the  back  ol 
the  pharynx  and  velum  palati. 

The  first  object  being  thus  attained,  the  nexi 
is  to  throw  the  light  into  the  larynx.  While  the 
patient  breathes  deeply  and  quietly,  his  pro- 
truded tongue,  protected  by  a napkin  or  hand- 
kerchief to  prevent  its  slipping,  is  held  steadily 
but  gently  forward,  either  by  his  own  hand,  or 
by  the  disengaged  hand  of  the  operator ; and  the 
throat-mirror,  previously  warmed  to  prevent  the 
condensation  of  moisture  on  its  surface,  held  like 
a pen,  is  passed  into  the  patient’s  throat,  and  held 
with  its  back  steadily  pressing  against  and  rais- 
ing the  soft  palate  and  uvula  at  such  an  angle 
that  it  throws  the  light  into  the  larynx.  This 
angle  will  vary  according  to  the  position  of  the 
patient  and  the  part  of  the  larynx  which  we  wish 
especially  to  examine  ; and  the  inclination  of 
the  mirror  must  be  altered,  it  must  be  raised  or 
lowered,  brought  forward  or  advanced  further 
in  the  pharynx,  as  may  be  necessary  ; the  operator 
observing  what  part  is  reflected  in  the  mirror, 
and  in  moving  it  being  guided  by  his  knowledge 
of  the  relation  of  the  various  parts  of  the  larynx 
to  each  other.  Unless  the  tonsils  are  enlarged, 
no  part  of  the  fauces  or  pharynx,  except  the  soft 
palate  and  uvula,  should  be  touched  ; and  the 
operator  must  be  specially  careful  that  the  lower 
edge  of  the  mirror  does  not  come  in  contact  with 
the  back  of  the  pharynx.  He  must  remember 
also  that,  while  steady  pressure  can  be  borne, 
titillation  of  any  part  of  the  fauces  will  induce 
retching.  If  a patient’s  nervousness  induces 
retching,  or  if  a spasmodic  action  of  the  muscles 
of  the  tongue  makes  it  rise,  his  nervousness  must 
be  calmed,  he  must  be  induced  to  take  a deep 
inspiration  through  the  mouth,  to  accomplish 
which  he  will  raise  the  soft  palate  and  depress 
the  tongue,  the  traction  on  which  must  also  lie 
slackened.  Enlarged  tonsils  may  present  an  in- 
superable obstacle  to  successful  examination  ; in 
slighter  cases  either  a very  large  round  mirror 
which  presses  the  tonsils  on  one  side,  or  a small 
ovate  mirror,  should  then  be  used.  More  fre- 
quently a pendulous  epiglottis  banging  back  over 
the  upper  part  of  the  larynx  impedes  the  view  ; 
in  such  a case  the  patient  must  utter,  or  try  to 
utter,  in  a high  falsetto  tone,  a prolonged  ‘eh,’ 
or  he  must  force  a laugh  or  a cough,  and  the 
mirror  must  bo  held  lower  in  the  pharynx,  in  a 
more  vertical  position. 

For  the  topical  treatment  of  laryngeal  diseases, 
in  addition  to  the  laryngoscope  the  practitioner 
requires  a laryngeal  probe  or  sound,  brushes  on 
whalebone  or  stout  wire  handles,  curved  at  a 
suitable  angle,  for  applying  solutions  ; a caustic- 
holder,  similarly  curved,  for  applying  solid  sub- 
stances; an  injector  to  apply  a shower  of  fluid 
or  spray;  and  a scarifying  instrument.  For  tilt 
operative  treatment  of  polypus,  &c.,  a set  oi 
special  forceps,  a laryngeal  ecraseur,  special 
knives,  and  other  instruments  are  necessary  ■ 


304  LARYNGOSCOPE. 

while,  for  use  by  the  patient,  a spray-producer 

ur  atomiser,  and  a simple  inhaler  will  be  required. 

Thomas  James  Walker. 

LARYNX,  Diseases  of.  — The  functions 
and  peculiar  anatomical  position  of  the  larynx 
give  to  its  diseases  a special  importance  ; and  in 
addition  to  such  objective  and  subjective  symp- 
toms  as  are  common  to  affections  of  other  organs, 
we  find  here  modifications  of  respiration,  vocali- 
sation, and  deglutition. 

The  principal  diseases  and  disorders  which 
affect  the  larynx  may  be  conveniently  enume- 
rated and  described  in  the  following  order: — - 

1.  Aphonia;  2.  Disorders  of  circulation;  3.  In- 
flammation ; 4.  Lepra ; 5.  Lupus ; 6.  Malignant 
disease  ; 7.  Paralysis  ; 8.  Polypus ; 9.  Spasm ; 
and  10.  Syphilitic  disease.  See  also  Croup  ; 
Diphtheria  ; and  Trachea,  Diseases  of. 

1.  Aphonia.  — Synon.  : Fr.  Aphonic;  Ger. 
Stimmlosiglceit. 

Definition.— Speaking  in  a whisper,  the  sound 
being  produced  without  closure  of  the  vocal 
cords. 

Various  modifications  of  the  note,  tone,  and 
quality  of  the  laryngeal  voice  result  from 
changes  in  the  larynx  ; and  if  no  air  passes 
through  the  larynx  or  mouth,  as  when  a patient 
breathing  through  a tracheotomy  tube  attempts 
to  speak,  all  sound  is  abolished,  the  movements 
of  the  lips  alone  being  used  in  the  endeavour 
to  form  words.  Aphonia  is  the  term  applied  to 
the  voice  produced  in  the  mouth  when  the  laryn- 
geal note  is  withdrawn  from  it;  and  this 
symptom  occurs  not  only  as  a result  of  disease, 
but  as  a common  functional  disorder  constitut- 
ing functional  hysterical  aphonia.  In  these  cases 
there  is  no  morbid  change  in  the  larynx,  no 
affection  of  its  nerves  or  muscles.  The  word 
paralysis  should  never  be  applied  to  this  or  other 
similar  affections  without  the  prefix  simulated ; 
the  power  to  exercise  the  voice  exists,  but  the 
patient  holds  it  in  abeyance.  The  affection  is 
much  more  frequent  in  women  than  in  men.  It 
commonly  originates  • in  an  attack  of  catarrh, 
when,  owing  to  the  relaxation  and  congestion  of 
the  laryngeal  mucous  membrane,  vocalisation  is 
inconvenient  and  requires  an  effort,  and  the 
patient  whispers  to  rest  his  voice,  precisely  as  an 
exhausted  phthisical  patient  does,  even  when 
there  is  no  laryngeal  complication.  The  habit 
thus  originated  is  maintained  for  months  or  years, 
as  long  as  t.he  unhealthy  mental,  emotional,  and 
physical  condition  which  we  term  hysteria  lasts ; 
and  this  may  be  the  only  phenomenon  of  that 
condition.  Like  other  nervous  and  hysterical 
symptoms,  nervous  aphonia  may  lead  us  to  sup- 
pose the  existence  of  more  serious  disease;  but 
the  patient  suffering  from  nervous  aphonia  fre- 
quently closes  the  vocal  cords  in  laughing  and 
coughing,  while  in  speaking  she  never  emits  even 
a husky  uncertain  laryngeal  sound.  The  laryn- 
goscope is  of  the  greatest  value  for  the  diag- 
nosis. The  interior  of  the  larynx  is  seen  to  bo 
free  from  disease;  the  vocal  cords  move  during 
respiration ; but  when  the  patient  is  asked  to  say 
Ah  or  Eh,  they  remain  apart,  or  are  brought  to- 
gether for  an  instant  (showing  that  there  is  no 
loss  of  power)  and  again  separated  and  allowed 


LARYNX,  DISEASES  OF. 

to  remain  open,  while  an  apparent  effort  is  made 
to  utter  the  sound.  Sec  Voice,  Disorders  of. 

Treatment. — Well-regulated  and  interesting 
employment,  or  amusement  and  remedies  adapted 
to  the  general  condition  of  the  patient,  must  be 
employed;  and  the  patient  must  be  convinced 
that  she  has  the  power  to  speak,  a power  which 
she  does  not  exercise,  usually  under  the  belief  that 
she  has  it  not.  The  mere  expression  of  aconfident 
opinion,  or  fhe  promise  of  a successful  result  to 
some  system  of  using  the  voice  may  suffice;  but 
usually  some  measure  directed  to  the  part  is 
necessary  to  induce  the  patient  to  exercise  her 
will  upon  the  laryngeal  muscles,  and  to  speak,  and 
of  those  which  may  be  used  none  is  so  effective  as, 
or  more  innocent  than,  electricity,  especially  when 
applied  to  the  interior  of  the  larynx.  Frequently 
one  application  of  electricity,  particularly  when 
accompanied  by  the  circumstance  of  a laryngo- 
sccpic  examination  in  a dark  chamber,  makes  a 
sufficiently  profound  impression  on  the  mind  of 
the  patient  to  restore  the  voice ; the  slight  pain  of 
the  operation  occasionally  inducing  her  to  ex- 
claim Oh!  while  her  attention  is  diverted  from 
her  supposed  inability  to  speak.  In  using  this 
remedy  in  these  cases,  no  practitioner  can  de- 
ceive himself  into  the  belief  that  he  is  restoring 
power  to  a paralysed  part  and  it  is  to  be  re- 
gretted that,  in  describing  the  treatment  of  theso 
cases,  this  belief  should  be  implied,  and  should 
have  led  to  a distrust  of  those  who  merit  the 
confidence  of  the  public  and  the  profession,  from 
their  special  skill  in  the  diagnosis  and  treatment 
of  laryngeal  diseases. 

2.  Larynx,  Disorders  of  Circulation  of.— 

Ancemia  of  the  larynx  does  not  exist  as  a separate 
disease.  Like  the  pallor  of  the  gums,  it  is  <v- 
scribed  as  one  of  the  symptoms  of  incipient 
phthisis. 

Congestion  of  the  larynx  requires  a passing 
notice.  Hyperaemia  of  some  portion  of  the 
mucous  lining  of  tho  larynx  results  from  over 
exertion  of  the  voice,  exposure  to  cold,  the 
action  of  irritants,  or  any  cause  obstructing  the 
circulation  through  the  larynx;  and  it  may  be 
consecutive  to  laryngitis.  It  causes  more  or  less 
persistent  hoarseness,  and  a sense  of  discomfort 
in  the  throat ; and  it  excites  what  is  commonly 
called  a ‘ tickling  cough.’  The  absence  of  any 
more  serious  source  of  these  symptoms  is  proved 
by  the  laryngoscope. 

Treatment. — Treatment  of  congestion  of  the 
larynx  is  unnecessary,  beyond  resting  the  voice, 
if  the  congestion  is  merely  temporary.  If  mor-' 
persistent,  at  the  same  time  that  the  voice  i; 
rested,  and  attention  paid  to  any  general  causi 
of  the  congestion  which  may  exist,  such  as  dis 
ordered  digestion,  astringents  should  be  applied 
locally.  The  larynx  may  be  brushed  out  daily 
with  a solution  of  two  scruples  of  sulphate  of 
zinc,  or  of  chloride  of  aluminum,  in  the  ounce  o!  i 
water;  or  a solution  of  nitrate  of  silver,  ten 
grains  to  the  ounce,  may  be  used;  while  tin* 
patient  should  inhale  three  or  four  times  a day 
the  spray  of  a solution  of  alum  or  tannic  acid,  of 
a strength  of  eight  grains  to  the  ounce. 

3.  Larynx,  Inflammation  of. — The  several 
varieties  of  laryngitis  will  be  treated  of  undei 


LARYNX.  DISEASES  OF.  805 


the  following  headings : — (a)  Acute ; (4) 
Chronic  ; (c)  Tubercular ; ( d ) Spasmodic ; 
'«)  (Edematous. 

(a)  Acute  Laryngitis. — Synon.  : Laryngitis 
catarrhalis,  Angina  intern <f,  Cynanehe  laryngea ; 
Fr.  Laryngite  aigue  catarrhale-,  Ger.  Kehlkopf- 
tntzundung. 

Definition. — Inflammation  of  the  mucous 
mombrane,  or  of  the  mucous  lining  and  subja- 
cent cellular  tissue  of  the  larynx ; acute  in  its 
onset ; rapid  in  its  course  ; disturbing  the  func- 
tions of  respiration,  vocalisation  and  deglutition  ; 
and  accompanied  by  inflammatory  fever. 

.Etiology. — Like  all  laryngeal  diseases,  laryn- 
gitis is  more  common  among  males  than  females, 
and  among  children  than  adults.  Gout,  syphilis, 
and  anything  which  depresses  the  constitution, 
may  be  regarded  as  predisposing  causes.  The 
most  frequent  exciting  cause  is  exposure  to  cold; 
laryngitis  is,  indeed,  one  of  the  regular  sequences 
of  catarrh.  It  occurs  as  a complication  of  exan- 
thematous fevers — in  measles,  usually  of  the 
simple  catarrhal  or  stridulous  variety ; in  scar- 
latina, of  an  erysipelatous  or  cedematous  cha- 
racter; in  small-pox,  variolous  pustules  being 
found  in  the  larynx ; and  in  enteric  fever  and 
typhus,  the  consecutive  laryngitis  being  of  a 
destructive  type,  and  leading  to  rapid  ulceration. 
A very  bad  form  of  erysipelatous  inflammation 
of  the  larynx  occurs  as  a rare  complication  of 
erysipelas ; and  the  cedematous  variety  may  result 
from  an  extension  of  diffuse  inflammation  of  the 
cellular  tissue  of  the  neck.  Traumatic  laryngitis 
follows  scalds,  the  application  of  irritants  to,  and 
wouuds  of  the  larynx. 

Anatomical  Characters. — In  acute  laryn- 
gitis the  blood-vessels  are  dilated ; the  mucous 
;membrane  is  swollen,  and  its  consistency  altered ; 
its  cells  are  infiltrated  by  the  fluid  exuded  from 
c iie  blood;  and  its  surface  possibly  eroded,  even 
ui  the  mildest  eases.  In  the  more  severe 
iparcnchymateuse ) form  of  laryngitis,  the  cellular 
issue  is  similarly  involved ; the  exudation  is 
•xtensive ; and  the  functions  of  the  muscles  being 
-eriously  interfered  with,  the  movements  of  the 
rytaenoid  cartilages  and  vocal  cords  are  greatly 
mpeded. 

Symptoms. — When  laryngitis  supervenes  on 
■itarrh,  the  patient  feels  and  shows  that  there  is 
■iiore  serious  illness.  He  is  restless  and  anxious ; 
xperienees  a feeling  of  constriction  about  the 
ima ; complains  of  sore-throat  in  swallowing  ; 
nd  points  to  the  larynx  as  the  seat  of  pain, 
’lie  breathing  is  altered,  having  more  or  less  the 
haraeteristics  of  laryngeal  obstruction,  namely, 
he  long-drawn  hissing  inspiration,  prolonged 
xpiration  of  the  same  character,  but  with  less  of 
le  sibilant  sound,  and  diminution  or  complete 
Volition  of  any  pause  between  each  respiratory 
fort.  The  voice  also  is  altered,  becoming 
usky  and  uncertain,  deeper  in  tone,  and  eroak- 
|ig in  quality.  The  patient  likewise  suffers  from 
juigh,  of  the  same  character  as  the  voice;  from 
he  imperfect  closure  of  the  vocal  cords  it  wants 
larpness,  is  husky,  and  sometimes  is  accom- 
mied  by  a hollow,  clanging  sound,  eonsti- 
ting  what  is  commonly  called  the  croupy 
ugh.  The  expectoration  varies  according  as 
e inflammation  involves  the  larynx  alone,  or 


extends  to  the  trachea  and  bronchi.  In  the 
former  case  it  is  usually  clear,  thin,  tenacious 
mucus,  which  is  hatched,  rather  than  coughed 
up,  mixed  with  the  saliva,  which  is  freely  secreted 
but  not  swallowed.  Sometimes  the  expectora- 
tion contains  harder  pellets,  secreted  in  the 
ventricles  of  the  larynx ; whilst,  if  the  trachea 
and  bronchi  are  involved,  the  usual  thick  ex- 
pectoration of  bronchitis  is  also  coughed  up. 
Deglutition  is  painful  and  difficult;  while,  on 
inspection,  the  throat  shows  only  a little  red- 
ness, quite  inadequate  to  account  for  the  dys- 
phagia. Accompanying  these  symptoms  there 
is  a rapid  pulse,  and  slight  rise  of  temperature, 
though  the  tongue  may  be  moist,  and  other 
indications  of  inflammatory  fever  slight. 

With  the  laryngoscope  the  whole  interior  of 
the  larynx  is  seen  to  be  of  a bright  red  colour, 
the  vocal  cords  alone  usually  retaining  their 
white  appearance,  but  with  bright  vascular 
patches  ; in  severer  cases  the  swelling,  caused 
by  the  infiltration  of  the  mucous  membrane  and 
subjacent  cellular  tissue,  is  also  perceptible. 

If  the  case  progress  untowardly.  the  restless- 
ness and  anxiety  increase ; suffocative  paroxysms 
occur,  and  recur  with  increasing  frequency  ; the 
patient's  whole  attention  appears  concentrated 
on  the  effort  of  breathing ; he  dreads  to  speak 
or  swallow,  and  if  obliged  to  say  anything,  ho 
takes  first  a laboured  inspiration,  and  then  with 
a straining  effort,  painful  to  witness,  brings  out 
what  little  voice  is  left.  Gradually,  as  the  aera- 
tion of  the  blood  becomes  more  imperfect,  drowsi- 
ness comes  on ; the  eyes,  staring  in  the  previous 
stage,  are  half  closed  by  the  drooping  lids  ; the 
face,  bathed  in  perspiration,  becomes  livid ; and 
death  occurs,  probably  in  a paroxysm  of  suffoca- 
tive dyspneea. 

Complications  and  Sequelje. — The  compli- 
cation of  laryngitis  with  other  inflammatory 
diseases  of  the  respiratory  system  will  be  referred 
to  immediately,  but  there  are  two  symptoms, 
namely,  oedema  and  spasm,  which  complicate 
laryngitis,  and  by  their  prominence  give  a dis- 
tinctive character  to  the  disease.  See  (Edema- 
tous Laryngitis. 

Diagnosis.— Acute  laryngitis,  whether  simple, 
stridulous,  or  cedematous,  is  apt  to  be  con- 
founded with  that  form  of  inflammation  which  is 
characterised  by  the  formation  of  a false  mem- 
brane in  the  larynx,  namely,  croup  or  laryngeal 
diphtheria.  If  practicable,  a laryngoscopic  ex- 
amination, showing  the  absence  of  false  mem- 
brane, is  the  most  certain  means  of  diagnosing 
simple  from  pseudo-membranous  laryngitis ; but 
even  where  perfect  casts  of  the  trachea,  bronchi, 
and  primary  bronchia  were  expectorated,  tho 
writer  has  seen  the  larynx  absolutely  free  from 
false  membrane,  and  simply  inflamed.  The  ab- 
sence of  diphtheritic  membrane  in  the  fauces,  of 
acrid  excoriating  discharge  from  the  nostrils, 
and  of  glandular  swellings,  as  well  as  the  mode 
of  accession  of  the  symptoms,  would  lead  us  to 
regard  the  case  as  simple  laryngitis;  while  tho 
presence  of  any  of  these  symptoms,  or  the  preva- 
lence of  an  epidemic  of  diphtheria,  would  lead 
us  to  suspect  false  membrane.  Even  after  duo 
consideration  of  these  points,  and  of  the  cha- 
racter of  the  voice,  cough,  &c.,  in  certain  eases 
we  are  unable  to  say  whether  we  have  to  de&! 


LARYNX.  DISEASES  OF. 


306 

with  simple,  or  with  pseuclo-membranous  laryn- 
gitis. The  stridulous  laryngitis  or  false  croup 
of  children  is  further  distinguished  from  true 
croup,  by  the  sudden  accession  of  the  symptoms 
at  night ; by  the  noisy  clanging  character  of  the 
cough,  as  distinguished  from  the  husky , sup- 
pressed, though  possibly  clanging  cough  of  croup ; 
by  the  similar  absence  of  huskiness  in  the  voice  ; 
and  by  the  progress  of  the  case,  true  croup  or 
diphtheria  increasing  in  intensity,  while,  from 
the  first  sudden  onset  of  the  symptoms,  false 
croup  diminishes,  unless  complicated  with  lobu- 
lar pneumonia  or  other  severe  disease.  From 
laryngismus  stridulus  acute  laryngitis  is  distin- 
gui  shed  by  the  presence  of  slight  pyrexia,  and  other 
indications  of  primary  inflammatory  affection  of 
the  larynx  and  air-passages ; by  the  absence  of 
indications  of  any  other  affection  of  the  nervous 
system,  or  of  a tendency  to  convulsions  ; by  the 
usual  occurrence  of  the  attack  in  the  night 
only  ; by  the  slighter  affection  of  the  breathing ; 
and  by  the  frequent  croupy  cough,  which  is  the 
prominent  symptom,  and  which  is  wanting  in 
laryngismus. 

Prognosis. — In  mild  attacks  of  laryngitis  all 
the  symptoms  exist  only  in  a slight  degree,  and 
disappear  in  a few  days  under  simple  treatment. 
Such  is  the  ordinary  course  of  the  false  croup 
of  children.  In  adults  laryngitis  may  occur  in 
any  degree  between  the  milde3t  form  and  that 
in  which,  the  symptoms  being  all  most  intense, 
it  may  prove  fatal  in  a day  or  two,  or  even  in  a 
few  hours.  The  danger  depends  in  great  measure 
on  the  amount  of  oedema  present,  and  this  on 
the  extent  to  which  the  submucous  tissue  is  in- 
volved. Those  cases  which  are  consecutive  to 
diffuse  cellular  inflammation  of  the  neck,  or  to 
scarlatina  or  erysipelas,  are  most  unfavourable  ; 
so  also  are  those  in  which  there  is  renal  disease. 
Laryngo-typhus  is  especially  fatal,  as  is  also  the 
oedematous  laryngitis  resulting  from  scald  in 
children.  Although  mild  laryngitis  usually  ter- 
minates favourably  in  a few  dayrs,  it  is  necessary 
that  every  case  should  bo  sedulously  watched,  as 
at  any  period  dangerous  symptoms  may  set  in 
and  prove  rapidly  fatal.  The  disease  is  most 
deadly  in  the  young.  Acute  may  pass  on  to 
chronic  laryngitis,  and  occasionally,  but  rarely, 
may  cause  chronic  ulceration. 

Treatment. — As  soon  as  the  first  indications 
of  even  slight  laryngitis  are  observed,  the  patient 
should  be  confined  to  a warm  room ; poultices 
should  be  applied  to  his  throat;  he  should  inhale 
the  steam  of  either  plain  water,  or  of  water  con- 
taining a few  drops  of  iodine;  and  small  doses  of 
liquor  morphi®  hydrochloratis  and  liquor  ammo- 
ni®  acetatis  should  be  given  every  three  or  four 
hours,  4 or  5 minims  of  antimonial  wine  being 
added  if  secretion  seem  deficient.  Should  the 
symptoms  increase  in  intensity  emetics  may  be 
administered,  and  a blister  should  be  applied  on 
each  side  of  the  thyroid  cartilage.  The  diet  should 
be  chiefly  liquid  ; and,  as  a rule,  no  stimulants 
are  required.  Should  the  dyspnoea  become 
urgent,  tracheotomy  must  be  performed ; and 
this  may  be  called  for  so  suddenly,  that  as  soon 
as  a case  of  laryngitis  comes  under  his  care,  the 
practitioner  should  be  ready  for  the  operation. 
After  the  trachea  has  been  opened,  the  patient 
is  to  be  kept  with  the  same  care  in  a warm 


moist  atmosphere;  a sponge  continually  changed 
and  wrung  out  of  hot  water  containing  a little 
tincture  of  iodine  should  be  kept  in  front  of  the 
tube ; and  the  airshould  be  warmed  and  moistened 
as  it  is  drawn  through  the  sponge,  which  also 
catches  the  secretions  coughed  through  the  tube. 
With  due  care  in  the  performance  of  the  operation 
and  after-treatment  of  the  patient,  in  cases  of 
simple  laryngitis,  tracheotomy  is  almost  always 
successful,  but  it  should  not  be  resorted  to  unless 
the  case  is  urgent.  Laryngoscopic  examination 
will  materially  help  the  practitioner,  who  may 
live  at  a distance  from  his  patient,  as  to  the 
safety  of  leaving  him  without  a tube  in  his 
throat.  Circumstances  may  lead  to  the  post- 
ponement of  the  operation  until  the  patient  is  in 
extremis , but  even  then  it  should  be  resorted  to. 
The  writer  has  twice  operate  1 upon  patientswiio 
were  believed  to  have  just  died,  with  the  effect  of 
restoring  them  to  life  for  some  days,  although  in 
neither  case  was  the  result  ultimately  successful, 
both  being  cases  of  diphtheria,  which  killed  the 
patients,  notwithstanding  i lie  relief  to  the  laryn- 
geal obstruction. 

Simple  cases  of  false  croup  in  children  are 
usually  relieved  by  warm  poultices  to  the  throat, 
or  by  an  emetic,  the  last  remedy  being  very 
effectual.  Where  cedema  complicates  laryngitis, 
very  active  treatment  is  required  In  the  slighter 
cases,  the  spray  of  a solution  of  8 or  10  grains 
of  tannic  acid  in  an  ounce  of  water,  or  of  alum, 
10  grains  to  the  ounce,  or  of  a saturated  solution 
of  chlorate  of  potash,  should  be  inhaled;  if  the 
case  is  more  severe,  scarification  by  a long  curved 
bistoury,  with  a cutting  edge  only  at  the  point, 
will  in  most  instances  give  relief.  If  by  the 
laryngoscope  the  oedema  has  been  proved  to 
be  infraglottic,  scarification  is  not  practicable. 
Should  the  syrmptoms  become  urgent,  tracheotomy 
must  be  performed  in  such  a case ; and  in  any 
case  o;  oedema,  the  urgency  of  the  symptoms 
may  decide  the  practitioner  to  prefer  it  to  scari- 
fication. The  treatment  of  traumatic  oedema,  the 
result  of  scald  of  the  throat,  is  usually  unsatis- 
factory ; it  must  be  surgical,  by  scarification  or 
tracheotomy'.  Scarification  is  sometimes  followed 
by  severe  haemorrhage,  and  the  surgeon  who  un- 
dertakes either  this  operation  or  tracheotomy, 
must  be  prepared  to  meet  any  emergency  that 
may  arise. 

(4)  Chronic  Laryngitis. —Definition. — 
Low  persistent  inflammation  of  the  mucous  mem- 
brane and  subjacent  tissue  of  the  larynx,  occasion- 
ally confined  to  the  glandular  structures  only. 

-Etiology. — Specific  forms  of  chronic  laryn- 
gitis, to  be  separately  considered,  result  from 
tubercle,  syphilis,  &e.  The  simple  form  almost 
always  depends  on  exposure  to  cold,  and  the  too 
early  and  frequent  use  of  the  voico,  or  other 
want  of  care,  after  acute  laryngitis ; it  is  also  a 
definite  result,  according  to  Cohen  and  others, of 
over-feeding.  The  variety  called  ' follicular  or 
‘glandular’  laryngitis  depends  on  habitual  over- 
exerlion  of  the  voice,  not  unfrequently  coupled 
with  excessive  use  of  alcohol  or  tobacco;  it  a 
complaint  of  public  speakers  and  singers. 

Anatomical  Characters. — The  mucous  meni- 
brane  of  the  larynx  is  swollen  aud  h.vpenemic ; 
the  vessels  are  dilated,  usually  iu  patches ; the 


LAIIYXX,  DISEASES  OF 


vocal  cords  are  usually  least  affected,  though 
they  may  present  streaks  of  congestion ; ulcera- 
tion is  rare  in  simple  chronic  laryngitis,  hut 
there  may  be  abrasions  of  the  surface.  In  glan- 
dular or*  follicular  laryngitis,  sometimes  called 
1 clergyman  s sore-throat,’  the  mucous  membrane 
generally  is  hut  little  thickened;  but  in  the 
parts  richest  in  glands,  that  is  over  the  arytaenoid 
cartilages,  at  the  base  of  the  epiglottis  and  parts 
of  the  ventricular  bands,  the  racemose  glands 
are  hypertrophied  ; the  surrounding  vessels  di- 
lated; the  ducts  and  cul-de-sacs  enlarged,  and 
their  orifices  closed,  so  that  the  secretions  accu- 
mulate and  sometimes  escape  by  ulceration. 
Usually  a similar  condition  of  the  follicles  of 
the  pharynx  accompanies  this  form  of  chronic 
laryngitis. 

Symptoms. — The  symptoms  of  chronic  laryn- 
gitis are  hoarseness  and  aphonia  after  slight 
exertion  of  the  voice  ; a hacking  cough,  with 
Out  little  of  the  brassy,  laryngeal  character ; 
either  no  expectoration,  or  only  a little  tenacious 
mucus;  a sense  of  dryness,  with  slight  pain  in 
the  throat ; and  occasionally  dyspnoea  on  unusual 
exertion. 

Complications  and  Sequel.®. — Very  rarely 
ulceration  may  take  place  ; or  a sudden  accession 
of  acute  symptoms  with  oedema  may  occur,  and 
this  may  be  followed  by  suppuration  and  necro- 
sis of  the  cartilages. 

Diagnosis. — In  cases  of  chronic  disease  of  the 
larynx  a laryngoscopic  examination  is  almost 
always  practicable ; without  the  laryngoscope, 
diagnosis  and  treatment  can  he  only  guess- 
work ; with  it  the  appearances  described  above 
are  clearly  recognised. 

Prognosis. — Chronic  catarrhal  laryngitis  may 
subside  spontaneously,  hut  is  usually  persistent 
unless  properly  treated.  It  may  lead  to  perma- 
nent hypertrophy  of  the  mucous  membrane  and 
thickening  of  t he  cellular  tissue,  and  this  may 
be  general,  or  limited  so  as  to  resemble  a tumour. 
It  sometimes  gives  rise  to  warty  growths. 
Glandular  laryngitis  is  very  obstinate.  Neither 
form  of  non-specific  chronic  laryngitis  is  in  it- 
self dangerous  to  life. 

Treatment. — Any  imprudence  in  diet  or 
hygiene  must  he  corrected,  and  the  voice  rested 
as  much  as  possible.  About  every  other  day  the 
larynx  should  be  brushed  out  with  a solution  of 
nitrate  of  silver,  40  grains  to  the  ounce  of  water : 
and  the  spray  of  a solution  of  tannic  acid  and 
alum,  or  the  steam  of  boiling  water  containing 
a drachm  of  tincture  of  iodine,  or  about  10  drops 
of  fir-wool  oil,  dissolved  in  spirit,  in  the  pint  of 
water,  should  be  inhaled  three  or  four  times  a 
day.  In  obstinate  cases,  inhalations  of  the  tere- 
| binthinate  balsams,  mixed  with  two  or  three 
times  their  bulk  of  ether,  as  recommended  by 
Dr.  Symonds,  may  he  used,  the  warmth  of  the 
- hand  being  sufficient  to  volatilise  such  solutions 
prepared  according  to  his  formulae.  Attention 
must  bo  paid  to  the  general  health,  and  to  the 
state  of  the  digestive  organs. 

(e)  Tubercular  Laryngitis, — Syxon.  : La- 
ryngeal Phthisis ; Er.  Phthisic  Laryngec ; Ger. 
KcM/iopftuherculose. 

Definition, — A specific  inflammation  of  the 
•arynx,  depending  on  the  presence  of  tubercle  ; 


sal 

accompanying,  and  sometimes  preceding,  tuber- 
cle of  the  lungs;  and  leading  to  destructive 
ulceration  of  the  soft  parts,  and  to  caries  and 
necrosis  of  the  cartilages  of  the  larynx. 

.ZEtiology. — Pulmonary  consumption  may  be 
complicated  by  simple  laryngitis,  hut  the  disease 
specified  above  is  itself  tuberculous,  its  predis- 
posing causes  being  those  which  favour  the  deve- 
lopment of  tubercle  in  persons  of  scrofulous  con- 
stitution, and  the  exciting  causes  the  same  as 
those  of  simple  laryngitis. 

Anatomical  Characters. — The  majority  of 
pathologists  are  agreed  that,  even  in  the  earliest 
stages  of  tubercular  laryngitis,  minute  deposits 
of  miliary  tubercle  will  be  found ; and  these  may 
generally  be  seen  causing  slight  eminences,  dif- 
fering from  the  follicles  in  glandular  laryngitis, 
in  that  from  the  first  they  become  centres  of 
ulceration  of  the  mucous  membrane.  This  de 
structive  process  extends  to  the  deeper  parts, 
involving  the  fibrous  tissues  ; the  articulations 
suppurate,  and  the  ligaments  and  cartilages  are 
destroyed;  and  prominent  granulations  and  fun- 
gous growths  occasionally  spring  from  the  ulcers 
near  the  vocal  cords.  The  epiglottis  is  usually 
the  first  cartilage  attacked,  then  the  arytaen'oids 
and  the  cricoid,  tho  last  being  the  most  liable  to 
necrosis.  Occasionally  abscesses  form,  the  ne- 
crosed cartilage  being  included  in  them ; and 
ultimately  every  tissue  of  the  larynx  becomes 
involved. 

Symptoms.  — In  tubercular  laryngitis  the 
symptoms  specially  dependent  on  the  condition 
of  the  larnyx  are  hoarseness  and  weakness  of 
the  voice;  cough,  at  first  frequent  and  tickling, 
later  huskyr,  laboured,  and  ineffectual ; difficulty 
in  swallowing,  often  distressing,  from  the  early 
affection  of  the  epiglottis  ancl  upper  parts  of  the 
larynx;  expectoration,  varying  according  to  the 
extent  to  which  the  lungs  are  affected,  and 
sometimes,  in  the  later  stages,  including  portions 
of  cartilage  ; little  difficulty  of  breathing  at  first, 
but  later,  from  oedema,  spasm,  or  great  destruc- 
tion of  tissue,  urgent  dyspnoea,  which  may  neces- 
sitate tracheotomy.  To  these  symptoms,  sooner 
or  later,  are  usually  added  those  of  advancing 
pulmonary  phthisis.  A pale  oedematous  condition 
of  tho  aryepiglottidean  folds  is  usually  the  first 
indication  of  laryngeal  phthisis  observed  with 
the  laryngoscope ; then  swelling  and  ulceration 
of  the  epiglottis,  followed  by  ulcers  about  the 
arytaenoid  cartilages.  The  view  of  the  disease, 
as  it  extends  lower,  is  usually  prevented  by  tho 
secretions,  and  the  swollen  condition  of  the 
epiglottis  and  upper  parts  of  the  larynx. 

Complications  and  Sequel.®. — These  have 
been  sufficiently  indicated  in  the  description  of 
the  pathology  and  symptoms  of  the  disease. 

Diagnosis. — Tubercular  must  be  diagnosed 
from  simple  chronic  laryngitis  by  the  early  occur- 
rence of  oedema  and  ulceration ; and  from  acute 
oedema  by  the  mode  of  onset  of  the  symptoms 
Erom  syphilitic  disease  the  diagnosis  is  more 
difficult:  there  is  no  distinction  in  the  appear- 
ance of  the  ulcers,  hut  in  syphilis  there  is  less 
oedema,  and  the  ulcers  may  heal,  and  present 
cicatrices.  The  detection  of  tubercle  in  the 
lungs,  or  other  indications  of  the  tubercular 
diathesis,  will  help  to  determine  our  opinitn. 

Prognosis. — Tubercular  laryngitis  is 


LARYNX,  DISEASES  OF. 


SOS 

cured ; but  the  rapidity  of  its  progress  may  some 
times  be  checked.  If  it  precede  the  deposit  of 
tubercle  in  the  lungs  it  may  last  in  its  early 
stage  for  years  : if  it  supervenes  on  pulmonary 
consumption  the  downward  progress  is  very  rapid. 

Treatment. — This  must  have  reference  to  the 
diathesis  on  which  the  disease  depends,  and  to 
its  local  manifestation.  The  constitutional  treat- 
ment is  fully  discussed  in  the  articles  Phthisis, 
and  Scrofula.  The  local  treatment  must  be 
directed  to  mitigate  the  severe  pain,  and  if  pos- 
sible to  the  cure  of  the  disease.  Pest  must  be 
obtained  for  the  vocal  organs,  whilst  the  food 
should  be  such  as  to  cause  little  inconvenience 
or  pain  in  swallowing.  Artificial  feeding  by 
enemata  or  even  by  the  oesophagus  tube  may  be 
needed.  Soothing  applications  include  ice  and 
iced  water;  demulcent  gargles  {see  Gargles)  ; the 
insufflation  of  a powder  composed  of  3 grains  of 
starch  to  1 -6th  grain  or  more  of  morphia ; or  the 
application  by  the  brush  of  a mixture  of  bis- 
muth, gum,  and  1-Gth  grain  of  morphia.  Sooth- 
ing inhalations  of  conium,  benzoin,  chloroform, 
or  hops  may  also  be  used  {see  Inhalations). 
Occasionally,  to  promote  the  healing  of  ulcers, 
mild  solutions  of  perchloride  of  iron,  nitrate 
of  silver,  or  sulphate  of  copper,  may  be 
tried.  A leech  or  two  over  the  larynx,  fol- 
lowed by  a poultice,  may  prove  useful  in  some 
cases. 


(d)  Spasmodic  Laryngitis. — Synon.  : False 
Croup;  Croup.  Fr. Laryngitc  ou  Angine  stridu- 
leuse ; Ger.  Pseudo-croup. 

Definition. — A mild  degree  of  inflammation 
of  the  larnyx  and  air-passages ; occurring  chiefly 
in  young  children;  accompanied  by  attacks  of. 
laryngeal  spasmodic  cough  and  breathing,  which 
come  on  usually  at  night ; and  commonly  termi- 
nating favourably  in  a few  days. 

Spasm  of  the  glottis  occurs  as  a purely  ner- 
vous affection,  as  in  laryngismus  stridulus, 
but  the  complaint  defined  above  is  a variety  of 
laryngitis  ; it  is  one  about  which  practitioners  are 
continually  consulted,  and  is  what  mothers  mean 
when  they  talk  of  a child  being  liable  to  croup. 

AStiology. — Any  of  the  ordinary  causes  of 
catarrh  -will,  in  a child  with  a tendency  to  this 
affection,  induce  an  attack.  The  age  of  the  child 
is  material  in  producing  this  tendency,  as  is  also 
family  proclivity;  false  croup  occurring  usually 
in  children  of  from  two  to  six  or  seven  years 
old.  It  occasionally  complicates  the  eruptive 
fevers,  and  especially  measles. 

Symptoms  and  Treatment.-  -A  child,  haring 
previously  shown  signs  of  catarrh  or  slight  bron- 
chitis, and  having  probably  been  a little  hoarse, 
wakes  up  suddenly  from  sleep  with  a clauging, 
spasmodic,  not-  husky,  cough,  and  with  dyspnoea, 
characterised  by  the  cooing  sound  with  each  in- 
spiration which  indicates  spasmodic  closing  of  the 
larynx,  or  by  a complete  spasm  with  convulsive 
movements  of  inspiration,  lasting  for  a few 
seconds.  Tho  voice  is  not  affected,  or  if  altered 
it  is  not  husky,  but  is  simply  emitted  with 
difficulty,  from  tho  difficulty  in  regulating  the 
action  of  tho  vocal  cords.  There  is  not  more  py-  ! 
l exia  than  generally  accompanies  a severe  cold.  I 
Under  simple  treatment  the  attack  usually  sub-  | 


sides,  and  the  child  drops  asleep.  The  attack 
may  be  repeated  on  one  or  two  following  nights; 
but  the  first  is  usually  tho  most  violent,  and  that 
which  most  alarms  the  little  patient  and  those 
around  him.  These  are  the  symptoms  of  an  or- 
dinary attack  of  false  croup,  but  its  essential 
cause  being  some  degree  of  inflammation  of  the 
air-passages,  it  is  clear  that  this  may  go  on  to  a 
severer  form,  and  the  child,  first  attended  for 
false  croup,  may  die  from  pneumonia  nr  other 
inflammatory  affection  of  the  respiratory  system, 
the  symptoms  produced  by  the  severer  affection 
of  the  lung  combining  with  and  complicating 
those  dependent  on  the  larynx.  The  persistent 
dyspnoea,  and  other  symptoms,  must  in  such  a 
case  be  traced  by  the  practitioner  to  their  proper 
sources,  or  he  may  erroneously  suspect  and 
adopt  treatment  for  graver  laryngeal  disease 
than  actually  exists. 

(e)  (Edematous  Laryn  gitis.— Synon.: 

(Edema  glottidis ; CEdema  of  the  Larynx ; Fr. 
Laryngite  ceiemateuse',  Ger.  Keklkopfocdem. 

Definition. — Inflammatory  exudation  into 
the  submucous  areolar  tissue  of  the  larynx,  of 
serous,  sero-purulent,  or  sero-gclatinous  fluid. 

The  exudation  usually  attacks  first  the  ary- 
epiglottic  folds  and  the  epiglottis,  and  it  may 
extend  thence  to  the  ventricles  and  other  parts 
of  the  larnyx,  the  vocal  cords  themselves  being 
seldom  affected.  The  submucous  tissue  below  the 
vocal  cords,  lining  the  cricoid  cartilage,  may  be 
the  sole  seat  of  the  exudation  ; a form  of  oedema 
which  has  been  attributed  usually  to  a gouty 
constitution.  Whether  occurring  in  the  course 
of  acute  laryngitis,  or,  as  is  more  frequently  the 
case,  supervening  on  chronic  laryngitis,  oedema 
of  the  larynx  is  of  the  greatest  importance,  being 
least  fatal  when  an  accident  of  chronic  disease. 
(Edema  complicates  laryngitis  of  an  asthenic 
type,  such  as  eases  consecutive  to  the  exanthe- 
mata, and  is  always  present  in  the  cases  due  to 
scalds  from  driuking  boiling  fluids.  It  is  this 
form  of  laryngitis  which  occurs  in  persons  labour- 
ing under  Bright’s  disease,  the  oedema  in  these 
cases  not  being  passive  dropsy,  but  the  result  of 
inflammation. 

Anatomical  Characters. — The  mucous  mem- 
brane in  cedematous  laryngitis  is  rather  attenu- 
ated than  thickened,  and  but  little  injected, 
unless  it  occurs  as  a complication  of  the  super- 
ficial form  of  inflammation.  Especially  in  scalds 
there  is  but  little  hypenemia ; but  there  is  death 
and  vesication  of  the  mucous  membrane  with  ex- 
cessive oedema. 

Symptoms. — The  symptoms  indicative  of 
laryngitis  exist  in  an  increased  degree  when  this 
is  complicated  with  oedema,  the  swelling  of  the 
epiglottis  interfering  especially  with  deglutition, 
and  that  of  the  aryepiglottic  and  ventricular 
bands  causing  very  dangerous  dyspnoea.  By 
examination  with  the  finger,  and  far  better  by 
the  laryngoscope,  we  observe  further  the  physical 
condition  caused  by  the  swelling.  The  epiglottis 
is  felt,  or  seen,  misshapen,  rounded  like  a chest- 
nut, or  its  two  sides  swollen  so  as  to  resemble 
two  mucous  Ldadders  pressed  together  in  the 
middle  line;  and,  unless  this  bides  the  rest  ot 
the  larynx,  the  aryepiglnttie  folds  will  be  recog 
nised  as  two  long  roumied  swellings,  passing 


LARYNX.  DISEASES  OF.  800 


from  before  back,  and  nearly  meeting  in  the 
centre,  the  swollen  ventricular  bands  being 
visible  only  when  there  is  little  oedema  above. 

Treatment. — The  treatment  of  cedematous 
laryngitis  has  already  been  described  under  the 
head  of  acute  laryngitis. 

i.  Larynx,  Lepra  of.— Definition  : A spe- 
cific affection  of  the  larynx,  met  with  only  in  cases 
of  lepra  of  long  standing,  and  associated  with  a 
similar  affection  of  the  buccal  mucous  membrane, 
the  tongue,  and  the  palate. 

JEtiologt. — The  causes  are  identical  with 
those  of  lepra  in  other  situations. 

Anatomical  Characters.  — _ The  _ disease 
spreads  from  the  mouth  to  the  epiglottis,  which 
becomes  thickened,  and  is  fixed  from  the  infiltra- 
tion of  its  mucous  membrane.  Other  parts  of 
the  larynx  afterwards  present  the  same  anato- 
mical changes.  The  tubercles  may  ulcerate  and 
cicatrize. 

Symptoms,  Complications,  and  Diagnosis. — 
The  symptoms  of  laryngeal  lepra  are  those  of 
chronic  inflammation  ; and  if  the  tubercles  ulce- 
rate, the  ulceration  is  very  slow,  and  not  of  the 
destructive  character  of  syphilis.  As  lepra  of 
the  larynx  occurs  only  when  the  disease  of  the 
skin  has  been  long  established,  its  diagnosis  is 
clear.  It  usually  exists  for  a long  time,  even 
years,  before  it  ulcerates,  and  even  after  this  it 
is  very  slow  in  its  progress,  and  not  fatal. 

Treatment. — As  in  other  forms  of  lepra, 
treatment  is  almost  useless  ; the  fissures  and 
ulcers  are  said  to  be  relieved  by  touching  with 
solid  lunar  caustic.  See  Lepra. 

5.  Larynx,  Lupus  of.— Definition  : A rare 
specific  form  of  inflammation  and  ulceration  of 
the  mucous  membrane  of  the  larynx,  always 
associated  with  lupus  of  the  skin. 

jEtiot.ogy. — The  causes  of  this  disease,  and 
of  lupus  of  the  skin,  are  identical. 

Anatomical  Characters. — In  lupus  of  the 
larynx  great  numbers  of  small  red  round  papules 
are  first  formed.  These  become  abraded ; and 
the  abrasions  gradually  form  ulcers,  which  pene- 
trate deeply  into  the  substance  of  the  epiglottis, 
being  triangular  in  form,  with  the  apex  directed 
forwards.  Similar  ulcers  are  found  at  a later 
stage  in  other  parts  of  the  larynx. 

Symptoms,  Complications,  and  Diagnosis. — ■ 
The  symptoms  of  lupus  of  the  larynx  are  those 
of  chronic  inflammation  ; hut  there  appears  to 
be  no  tendency  to  oedema  or  to  those  affoctions 
of  the  cartilages  which  occur  in  syphilitic  and 
tubercular  laryngitis,  from  which  the  disease  is 
further  distinguished  by  the  peculiar  form  of  the 
ulcers  and  the  papules,  and  the  presence  of  lupus 
of  the  skin.  It  lasts  for  many  years. 

Treatment. — Lupus  of  the  larynx  must  be 
treated  locally  by  caustics  or  the  galvanic 
[cautery  ; and'  constitutionally  in  the  same  way 
is  other  forms  of  lupus.  See  Lupus. 

6.  Larynx,  Malignant  Disease  of. — The 
arynx  is  rarely  the  primary  seat  of  cancer  (ex- 
iept  in  the  form  of  epithelioma),  although  it  is 

requently  involved  by  the  spread  of  the  disease 
rom  the  oesophagus,  pharynx,  and  neighbouring 
«rts.  The  disease  occurs  usually  as  a general 
diltration  of  the  tissues,  and  does  not  form  a 


polypoid  tumour.  It  gives  rise  to  symptoms  of 
dysphagia,  and  of  laryngeal  obstruction,  added 
to  those  of  malignant  disease  in  other  situations. 
The  symptoms  only  occur  when  the  larynx  is 
either  attacked  primarily,  or  invaded  second- 
arily, by  the  disease ; mere  mechanical  pressuro 
by  growths  external  to  it  not  interfering  with 
its  functions,  although  they  may  displace  the 
organ  to  a very  great  extent. 

Treatment. — The  obstruction  to  respiration 
may  demand  the  performance  of  tracheotomy ; 
and  if  the  lower  part  of  the  trachea  is  free  from 
disease,  the  operation  will  prolong  life.  If  the 
trachea  itself  is  extensively  affected,  the  inser- 
tion of  the  tube  may  increase  rather  than  relievo 
the  dyspnoea.  Removal  of  a cancerous  larynx 
was  first  practised  by  Billroth,  and  has  since 
been  performed  by  several  Continental  surgeons. 
The  results  of  the  operation  have,  however,  been 
so  unfavourable  that  it  cannot  be  recommended 
in  this  form  of  diseaso. 

7.  Larynx,  Paralysis  of. — Definition  : Loss 
of  power  in  the  laryngeal  muscles,  occurring  in 
connection  with  disease  or  poisoning  of  the  ner- 
vous centres,  or  with  pressure  upon  or  disease 
of  the  laryngeal  nerves,  caused  by  aneurism, 
enlarged  cervical  or  bi-onchial  glands,  or  other 
intrathoracic  tumours. 

Varieties  and  Treatment. — The  commonest 
effect  of  disease  of  or  pressure  upon  the  re- 
current laryngeal  or  motor  nerve  of  the  larynx 
is  paralysis  of  the  rtMuctors,  causing  the  vocal 
cords  to  approximate  in  the  middle  line,  in 
a relaxed  state.  They  are  not  tense  even  when 
an  attempt  is  made  to  speak;  and  during  re- 
spiration a narrow  chink  is  left,  with  relaxed 
edges,  causing  very  stridnlous  breathing  and, 
possibly,  fatal  asphyxia.  Paralysis  of  the  ad- 
ductors, unilateral  or  bilateral,  when  one  or  both 
vocal  cords  are  seen  at  all  times  relaxed  and 
drawn  aside,  is  a consequence  of  disease  of  the 
superior  laryngeal  nerve,  which  supplies  tho  cri- 
cothyroid and  arytsenoid  muscles.  These  varieties 
of  paralysis  are  readily  recognised  by  the  laryn- 
goscope; and  they  usually  cause  aphonia,  without 
necessarily  dyspnoea.  When  these  cases  are  of 
long  standing,  the  muscles  become  atrophied  as  in 
other  paralysed  parts.  The  condition  usually  de- 
pending on  serious  disease  without  the  larynx, 
treatment  can  be  of  little  avail.  Tracheotomy 
may  be  called  for  to  avert  asphyxia.  Cases  are  re- 
corded where  the  local  use  of  electricity  has  cured 
paralysis,  but  these  were  probably  cases  like  those 
previously  described,  where  paralysis  of  the  ad- 
ductors is  simulated.  See  1.  Aphonia ; Pneumo- 
gastric  Nerve,  Diseases  of ; and  Appendix. 

8.  Larynx,  Polypus  of. — Synon.:  Growths 
of  the  Larynx;  Fr.  Tumeurs,  Kystes,  et  Polypes 
dll  Larynx  ; Ger.  Kehlkopf polypen. 

Definition. — A morbid  growth  attached  to 
the  walls  of  the  larynx,  and  projecting  into  its 
cavity,  in  the  form  of  a tumour. 

^Etiology. — The  invention  and  use  of  the 
laryngoscope,  leading  to  accurate  diagnosis,  has 
established  the  fact  that  tumours  of  the  larynx 
are  of  much  more  frequent  occurrence  than  was 
formerly  supposed.  They  are  most  common  in 
adult  males  who  habitually  over-exert  the  voice; 


LARYNX,  DISEASES  OF. 


S10 

hut  they  occur  in  either  sex,  and  at  any  age, 
from  infancy  upwards.  Inflammatory  attacks, 
syphilis,  and  anything  leading  to  habitual  con- 
gestion of  the  larynx,  favour  their  development. 

Anatomical  Characters. — Growths  of  various 
kinds  occur  in  the  larynx.  ( a ) Papilloma , or 
warty  growth,  having  a base  of  connective 
tissue,  and  coated  with  epithelium,  may  occur 
either  as  a solitary  separate  filament,  or  a group 
of  filaments,  or  as  an  agglomeration  of  little 
rounded  eminences,  the  whole  forming  a per- 
fectly defined  tumour.  It  is  frequently  multiple  ; 
increases  rapidly;  has  a tendency  to  recur  when 
removed  ; and  is  of  friable  texture.  It  is  most 
common  at  the  anterior  commissure  of  the  vocal 
cords,  but  these  growths  may  be  attached  all 
over  the  larynx. 

(b)  Fibroma  is  usually  solitary,  its  size  vary- 
ing from  that  of  a grape-seed  to  that  of  a 
pigeon’s  egg  or  more,  either  sessile  or  peduncu- 
lated. with  a bright  smooth  surface,  becoming 
tabulated  as  the  tumour  increases. 

(c)  Mixed  fibrous  and  fibro-cellidar  tumours, 
sarcoma,  and  mixed  Upoma  and  fibroma,  exter- 
nally resemble  fibroma,  their  nature  not  being 
recognisable  until  after  removal. 

(d)  Adenoma,  or  glandular  tumour,  is  described 
by  Tiirck  as  distinguishable  from  fibroma  by  its 
swelling,  and  altering  in  colour.  It  increases 
rapidly,  and  is  of  a dark  pink  colour  at  first, 
becoming  whitish  as  it  increases. 

(e)  Myxoma,  or  mucous  polypus,  is  rare.  It 
presents  a smooth,  moist-looking,  semi-translu- 
cent, rounded  surface  ; and,  according  to  Bruns, 
consists  of  a slimy  matrix,  with  intersecting 
fibrillae,  inclosed  in  the  altered  mucous  mem- 
brane. 

( f)  Cystic  polypus  is  usually  the  result  of  a 
change  in  some  other  tumour.  It  may,  however, 
occur  as  a primary  growth;  and  a case  is  re- 
corded where  such  a growth  caused  the  death  of 
an  infant,  thirty-six  hours  after  birth. 

( g ) Epithelioma  is  not  uncommon,  presenting 
the  usual  structure  and  appearance  of  epithe- 
lioma elsewhere. 

Symptoms. — Polypus  may  cause  absolutely  no 
inconvenience.  The  most  constant  symptom  is 
a modification  of  the  voice.  It  usually  excites 
dry  cough,  often  spasmodic  and  croupy.  The 
breathing  is  but  little  affected  until  the  growth 
attains  some  size,  when  dyspnoea  will  set  in,  at 
first  only  on  exertion,  occasionally  spasmodic  ; 
as  the  growth  increases,  it  becomes  constant, 
and  at  last  fatal  if  the  disease  is  unrelieved. 
Tumours  attached  below  the  vocal  cords  are 
rare ; when  they  exist,  and  are  large  enough  to 
interfere  with  the  breathing,  expiration  is  as 
noisy  and  difficult  as  inspiration.  These  growths 
are  usually  painless  ; they  may  be  so  situated 
as  to  interfere  with  swallowing,  but  this  is  not 
usual.  In  addition  to  these  symptoms,  the  growth 
can  be  seen  with  the  aid  of  the  laryngoscope, 
and  felt  with  the  laryngeal  probe  or  sound,  and 
sometimes  with  the  finger.  Occasionally  portions 
of  a papilloma  are  expelled  by  coughing. 

Diagnosis. — A certain  diagnosis  can  only  bo 
arrived  at  by  a physical  examination,  unless, 
indeed,  portions  of  the  growth  are  expectorated. 
Most  forms  of  growth  may  be  diagnosed  by  their 
appearance  in  the  laryngoscope.  The  point  and 


extent  of  attachment  may  be  determined  by  the 
skilful  use  of  a laryngeal  sound  or  probe. 

PnoGNOsis. — The  importance  of  these  growths 
varies  with  their  situation  and  rate  of  increase. 
A few  months  have  sufficed  for  the  growth  ot 
tumours,  from  their  origin  to  their  attaining  a 
size  sufficient  to  threaten  suffocation;  in  other 
cases  they  may  exist  for  years  without  giving 
riseto  any  symptombeyonddysphoniaoraphonia. 
As  soon  as  a polypus  causes  dyspnoea,  it  has 
become  dangerous.  Although  a polypus  under 
observation  for  some  time  has  been  seen  to  grow 
smaller,  and  cases  occasionally  occur  where  the 
more  friable  variety  is  spontaneously  expelled, 
the  disease  must  practically  be  regarded  as  in- 
curable, except  by  operation  or  other  local  treat- 
ment. 

Treatment. — A small  stationary  fibroma  or 
other  tumour,  giving  rise  to  but  little  incon- 
venience, requires  no  treatment.  Small  papilli- 
form growths  are  amenable  to  treatment  by 
strong  caustic  solutions.  Almost  all  other 
tumours  must  be  removed  by  operation.  Re- 
moval may  be  effected  by  instruments  introduced 
into  the  larynx  from  above  with  the  aid  of  the 
laryngoscope ; or,  where  the  disease  is  very  ex- 
tensive, an  artificial  opening  into  the  larynx 
(thyrotomy  or  division  of  both  thyroid  and  cri- 
coid) may  be  necessary,  the  growth  or  growths 
being  removed  through  this  opening.  If  the 
growth  is  removed  per  vias  naturalcs,  it  may  be 
crushed  through  at  its  base  by  a properly  con- 
structed dcraseur;  it  may  be  seized  and  torn  off 
by  forceps ; or  it  may  be  cut  off  by  knives  or 
scissors.  The  particular  operation,  and  the  in- 
struments to  be  used,  must  be  determined  by  the 
circumstances  of  the  case.  Tracheotomy  mav 
be  necessary  as  a palliative  measure,  where,  for 
some  reason,  a curative  operation  cannot  be 
adopted  ; or  it  may  be  required  as  a preliminary 
to  the  radical  operation.  Where  the  choice  lies 
between  tracheotomy  and  an  operation  for  re- 
moval of  the  tumour,  the  latter  must  always  be 
selected.  Removal  of  the  larynx  for  recurrent 
sarcoma  has  been  successfully  practised  in  this 
country  by  the  late  Dr.  Eoulis  : and  the  opera- 
tion is  available  where  milder  measures  for  the 
cure  of  these  growths  prove  ineffectual.  After 
extirpation  the  voice  can  be  restored  by  the  in- 
sertion of  an  artificial  glottis. 

9.  Larynx,  Spasm  of. — In  the  description  of 
other  diseases  of  the  larynx,  this  has  been  re- 
ferred to  as  a frequent  and  often  fatal  complica- 
tion. Spasm  is  a most  urgent  symptom  when  the 
larynx  is  irritated  by  the  lodgment  of  a foreign 
body-  or  other  irritant.  It  may  result  from  pres- 
sure on,  or  disease  of  the  pneumogastric  nerve ; 
from  hysteria  ; and  as  a manifestation  of  a more 
general  affection  of  the  nervous  system,  in  which 
case  it  constitutes  the  following  special  malady. 

Laryngismus  stridulus. — Svnon.  : Child-crow- 
ing; Spasmodic  croup ; False  croup;  Fr.  Spasms 
ds  la  glotte ; Pseudo-croup  nerveux ; Ger . Kchl- 
Jcopfkrampf. 

Definition. — Short  or  more  prolonged  acces- 
sions of  suffocation  ; depending  on  tonic  spasm  of 
the  adductor  muscles  of  the  larynx,  aud  usually 
of  the  diaphragm  and  other  respiratory  muscles; 
causing  closure  of  the  glottis,  and  a sudden  arrest 


LARYNX.  DISEASES  OF.  811 


of  inspiration ; and  ending  in  a shrill  crowing 
Bound,  as  the  inspiratory  act  is  resumed  and  con- 
cluded. It  is  unaccompanied  by  any  inflamma- 
tory affection  of  the  larynx  or  air-passages  ; and 
is  often  associated  xvith  other  convulsive  affec- 
tions. 

^Etiology. — Anything  causing  excessive  reflex 
irritability,  rachitis,  chronic  hydrocephalus,  and 
other  organic  affections  of  the  brain  or  medulla 
oblongata,  predispose  to  this  convulsive  affec- 
tion. It  is  undoubtedly  sometimes  associated 
with  chronic  enlargement  of  the  thymus ; and 
with  the  irritation  of  teething.  A sudden  fright, 
irritation  of  the  larynx  by  the  accidental  en- 
trance of  food,  or  some  such  slight  agitation  as 
that  caused  by  a child  being  tossed  in  the  air, 
may  excite  the  attack. 

Anatomical  Characters. — This  is  purely  a 
nervous  disease,  and  there  is  no  anatomical 
change  in  the  larynx. 

Symptoms. — With  or  without  premonitory  in- 
dications of  a tendency  to  convulsive  affection, 
such  as  drawing  in  of  the  thumbs  and  great  toes, 
or  clenching  of  the  hands ; often  during  sleep, 
and  with  no  evident  exciting  cause,  or  at  any 
time  in  the  day  ; a child  is  suddenly  attacked 
with  difficult  breathing,  inspiration  being  accom- 
panied by  the  crowing  sound  characteristic  of  la- 
ryngeal spasm.  This  may  continue  for  some  time, 
and  then  gradually  subside.  The  spasm  may  be 
short,  or  it  may  be  longer  and  more  intense,  in- 
spiration being  proportionately  difficult.  It  may 
be  complete,  and  the  act  of  inspiration  cease 
entirely,  until  just  as  death  seems  imminent,  the 
spasm  relaxes,  and  with  a crowing  inspiration 
breathing  is  re-established.  In  the  worst  cases, 
and  sometimes  in  the  first  attack,  death  does 
actually  occur. 

Diagnosis. — The  diagnosis  of  this  disease 
from  stridulous  laryngitis  orreal  false  croup,  with 
which  it  is  in  this  country  frequently  confounded, 
and  that  even  by  l-pcent  authors,  is  considered 
under  3.  a,  Acute  Laryngitis.  The  symptoms 
caused  by  a foreign  body  lodged  in  the  larynx 
closely  simulate  laryngismus  stridulus.  The 
nature  of  the  ease  is  decided  by  its  history ; and, 
unless  the  age  of  the  patient  precludes  it,  by  a 
laryngoscopie  examination. 

Prognosis. — The  milder  forms  of  this  malady 
yield  to  suitable  treatment,  and  disappear  as 
improvement  takes  place  in  the  condition  indu- 
cing the  attack.  Severer  forms,  if  not  fatal  in 
a first,  may  be  so  in  a subsequent  attack.  When 
the  spasm  depends  on  some  incurable  organic 
change  in  the  nervous  system,  the  case  is  of 
course  hopeless  from  the  first. 

Treatment. — Attention  to  the  diet  and  general 
management  of  the  child,  regular  bathing,  and 
the  administration  of  remedies  suitable  to  cor- 
rect faults  of  digestion,  are  necessary.  The 
persevering  use  of  bromide  of  potassium  has 
been  found  beneficial  by  the  writer  ; and  chloral 
hydrate  is  of  undoubted  value.  For  the  imme- 
diate treatment  of  the  spasmodic  attack,  prompt 
immersion  in  a warm  bath,  the  administration 
of  an  emetic,  or  the  use  of  an  anaesthetic  vapour 
may  be  resorted  to ; and  should  breathing  not 
be  re-established  as  the  spasm  ceases,  dashing 
cold  water  on  the  face  and  chest,  friction,  appli- 
cation of  strong  ammonia  and  vinegar  to  the 


nostrils,  and  especially  artificial  respiration, 
must  be  adopted,  with  the  object  of  restoring 
the  function.  Tracheotomy  may  be  requisite,  but 
the  practitioner  is,  unfortunately,  seldom  present 
when  the  indications  for  the  operation  arise. 

10.  Larnyx,  Syphilitic  Disease  of. — Syphilis 
affects  the  larynx  differently  according  to  the 
stage  of  the  disease  at  which  the  organ  is  at- 
tacked. Erythematous  maculse,  raised  mucous 
patches  or  condylomata,  and  superficial  ulceration, 
like  that  seen  in  the  fauces  and  pharynx,  may 
occur  as  secondary  symptoms  ; but  the  larynx  is 
more  commonly  and  more  seriously  affected  in 
advanced  stages  of  syphilis.  It  may  then  be  the 
seat  of  small  tubercles,  varying  from  the  size  of 
a millet-seed  to  that  of  a pea ; or  ulceration  may 
occur,  following  upon  an  eruption  or  upon  gum- 
mata.  The  ulcers  are  usually  multiple,  deep, 
and  sharp-edged,  presenting  much  the  appear- 
ance of  tubercular  ulcers  ; and  the  cartilages  are 
frequently  necrosed.  Sometimes  the  disease  begins 
with  perichondritis,  leading  to  suppuration  and 
subsequent  caries  and  necrosis  of  the  cartilages, 
external  fistul*  occasionally  communicating  with 
the  diseased  larynx. 

Symptoms. — Secondary  syphilitic  affections 
cause  hoarseness  and  sometimes  loss  of  voice, 
with  some  harshness  of  breathing,  but  there  is 
usually  neither  pain,  cough,  fever,  nor  much  dys- 
pnoea. The  more  serious  tertiary  affections  may 
give  rise  to  all  the  symptoms  caused  by  tuber- 
cular ulceration,  but  the  constitutional  symp- 
toms are  those  of  syphilis,  as  distinguished  from 
consumption. 

Complications  and  Sequelie. — Although 
amenable  to  treatment,  and  therefore  curable, 
syphilis  is  more  liable  than  any  other  affection 
of  the  larynx  to  leave  serious  consequences.  Not 
only  are  the  cicatrices  of  the  healing  ulcers 
liable  to  contract  the  opening  of  the  larynx,  and 
to  cause  adhesions  which  may  permanently  ob- 
struct respiration,  but  the  specific  deposits  occa- 
sionally occur  in  such  a form,  that  even  without 
ulceration,  they  produce  stenosis  or  contraction 
of  the  larynx  or  trachea.  Tumours  of  the 
larynx  appear  sometimes  to  result  indirectly 
from  syphilis  ; and,  as  just  mentioned,  aerial 
fistulae  may  be  left  after  necrosis  of  the  carti- 
lages. 

Diagnosis. — The  secondary  affections  of  the 
larynx  are  easily  recognised  in  the  laryngoscope, 
and  there  are  usually  other  indications  of  the 
constitutional  taint.  Syphilitic  must  be  distin- 
guished from  tuberculous  ulceration  by  the  con- 
comitant symptoms  of  the  disease,  the  presence 
of  gummatous  tumours,  and  the  occurrence  of 
cicatrisation  of  the  ulcers ; the  oedema  and 
general  thickening  are  also  less  than  in  tuber- 
cle. From  ulcerated  epithelioma  it  may  be  distin- 
guished by  the  history ; by  the  fact  that  the  can- 
croid growths  usually  extend  from  the  pharynx 
and  oesophagus  to  the  larynx ; by  the  cancroid 
ulcer  being  solitary,  while  syphilitic  ulcers  are 
usually  multiple;  and  by  the  appearances  of  the 
sores  and  their  base.  Frequently  in  these  cases 
the  amount  of  secretion  prevents  a satisfactory 
view  of  the  parts,  and  our  diagnosis  must  then 
he  arrived  at  without  the  aid  of  the  laryngoscope. 

Prognosis. — The  prognosis  in  cases  of  laryn- 


SI 2 LARYNX,  DISEASES  OF. 

geal  syphilis  must  vary  according  to  its  form,  but 
unless  the  case  is  complicated  by  some  other 
vice  in  the  system,  wo  may  hope  to  cure  it  by 
appropriate  treatment.  If  left  to  itself,  the  ter- 
tiary form  of  the  disease  will  probably  ulti- 
mately destroy  the  patient.  Where  it  occurs  in  a 
person  of  scrofulous  constitution,  the  prognosis 
will  be  less  favourable ; and  if  to  this  be  added 
abuse  of  alcohol,  and  irregular  living,  the  chances 
of  recovery  arc  small.  At  any  period  of  this,  as 
of  other  laryngeal  disease,  sudden  urgent  symp- 
toms are  liable  to  arise,  resulting  in  a fatal  ter- 
mination, a consideration  which  must  induce  us 
always  to  give  a guarded  opinion. 

Treatment. — Local  treatment  is  seldom  neces- 
sary for  the  secondary  syphilitic  affections  of  the 
larynx,  and  we  must  trust  to  mercurial  inunction 
and  other  constitutional  remedies.  Should  a mu- 
cous condyloma,  from  its  situation,  affect  the  voice 
or  breathing  in  a very  grave  degree,  a solution  of 
bichloride  of  mercury,  one  grain  dissolved  in  a 
drachm  of  weak  spirit,  may  be  carefully  applied 
with  a brush.  Syphilitic  ulceration  of  the 
1 irynx  requires  persevering  treatment  by  iodide 
of  potassium ; and  where  if.  does  not  yield  to  this 
remedy,  appropriately  combined  with  quinine, 
cod-liver  oil,  &c,  mercury  must  be  employed, 
che  best  method  being  by  mercurial  inunction, 
or  the  hypodermic  injection  of  tho  bichloride. 
A prolonged  course  of  the  drug  being  necessary, 
the  patient  must  pay  great  attention  to  his 
mouth,  sucking  alum  frequently,  so  as  to  avoid 
ptyalism.  The  local  application  of  a solution  of 
10  grains  of  sulphate  of  copper  to  the  ounce, 
and  touching  isolated  ulcers  with  solid  nitrate  of 
silver  or  sulphate  of  copper,  will  be  beneficial ; 
astringent,  sedative,  or  other  medicated,  and 
especially  iodine,  inhalations  should  also  be  em- 
ployed. In  old  cases  of  syphilis,  warty  growths 
ere  sometimes  seen  in  the  larynx,  which  maj'  be 
cured  by  frequent  topical  applications,  com- 
bined with  constitutional  treatment.  When  the 
dyspnoea  is  dangerous,  tracheotomy  must  not 
be  delayed.  It  will  usually  prove  successful, 
although  the  destruction  of  tissue  and  cicatrisa- 
tion may  be  such  as  to  necessitate  the  permanent 
wearing  of  the  tube.  Operations  for  the  division 
of  cicatricial  bands  and  adhesions  may  be  re- 
quired. They  should  be  undertaken  only  by  a 
skilful  and  practised  laryngeal  operator.  Tw'o 
or  three  cases  have  been  operated  upon  suc- 
cessfully, where  the  vocal  cords  were  united  in 
their  whole  length  by  a web  of  adhesions.  Heine 
has  removed  the  larynx  for  stenosis  resulting 
from  syphilis  ; but  extirpation  must  not  be 
adopted  where  tracheotomy  is  available. 

Thomas  Jambs  Wai.keu. 

LATENT  ( latco , I lie  hid). — This  word  is 
applied  to  cases  of  certain  diseases  in  which 
their  usual  characteristic  features  are  obscured 
and  concealed ; for  example,  latent  pleurisy, 
latent  scarlatina.  Symptoms  are  also  said  to  be 
latent  when  they  do  not  occur  under  circum- 
stances in  which  they  ought  to  appear.  For  in- 
stance, cough  may  be  latent  in  certain  cases  of 
phthisis. 

LEAD,  Poisoning  by. — Synox.  : Plumbism; 
Fr.  Intoxication  saturnine ; Ger.  Bleivergiftung. 


LEAD,  POISONING  BY. 

Pure  metallic  lead  has  probably  no  injurious 
action  on  the  system  ; but  owing  to  the  ease  with 
which  it  oxidises  and  forms  salts,  all  of  which 
are  poisonous,  lead-poisoning  is  of  common  occur- 
rence amongst  all  persons  whose  occupation 
brings  them  much  in  contact  with  metallic  lead 
and  its  alloys ; among  those  engaged  in  indus- 
tries in  which  lead-salts  are  manufactured  or 
largely  employed ; as  well  as  from  contamina- 
tion, accidental  or  otherwise,  of  articles  of  food, 
drink,  or  luxury,  with  lead  or  its  compounds. 

Acute  poisoning  with  lead  is  not  common,  nor 
are  any  of  the  lead  salts  actively  poisonous.  The 
acetate  or  sugar  of  lead  is  popularly  believed  to 
be  a virulent  poison,  but  it  is  by  no  means  so. 
There  are  very  few  fatal  cases  on  record,  even 
from  swallowing  quantities  amounting  to  an 
ounce  cf  the  acetate  or  its  equivalent.  The 
symptoms  are  in  the  main  those  of  irritant 
poisoning,  the  chief  difference  being  that  consti- 
pation is  the  rule,  and  diarrhoea  tho  exception. 

The  chronic  form  of  poisoning  by  lead  is  of  in- 
finitely more  importance  and  prevalence.  Tho 
sources  of  it  are  extremely  numerous  and  varied, 
and  it  is  almost  impossible  to  specify  all  indi- 
vidually. The  following  are  among  the  chief, 
classified  according  to  the  primary  form  of  the 
poison. 

1.  Metallic  Lead,  Poisoning  by. — Lead- 
poisoning occurs  among  lead-miners,  metallur- 
gists, and  workers  in  lead  or  its  alloys,  such 
as  plumbers,  solderers,  type-founders,  composi- 
tors, and  manufacturers  of  lead  toys  (toy-soldiers). 
It  has  been  observed  also  among  fishmongers, 
from  using  lead  counters;  in  pot-boys;  as  the 
result  of  packing  articles  of  food  or  luxury  in 
lead-foil ; aDd  from  contamination  of  articles  of 
drink  by  shot  used  for  cleaning  bottles,  siphon 
soda-water  bottles,  &c. 

Under  this  head  may  also  be  included  the  very 
frequent  contamination  of  drinking  water  by  lead 
pipes  and  cisterns.  Pure  water,  freed  from  gases 
and  excluded  from  contact  with  air,  does  not  act 
upon  lead,  but  in  presence  of  air  the  lead  be- 
comes speedily  acted  on,  and  the  water  contami- 
nated. An  oxide  of  lead  is  formed,  which  being 
partially  soluble  in  water,  allows  the  action  to 
go  on.  From  its  solution  the  oxide  is  in  great 
measure  precipitated  bv  carbonic  acid,  which  is 
absorbed.  The  lead  falls  as  an  oxycarbonate, 
though  the  presence  of  carbonic  acid  in  the  water 
keeps  a certain  quantity  in  solution.  The  purer 
the  water  the  more  rapid  the  action.  The  pre- 
sence of  certain  salts  in  the  water  considerably 
modifies  its  action  on  lead.  Thus  the  nitrates, 
nitrites,  and  chlorides,  by  forming  soluble  com- 
pounds with  lead,  increase  the  solvent  action  of 
the  water ; and  as  these  salts  usually  result  from 
sewage-contamination,  such  water  is  rendered 
still  more  dangerous  by  passing  through  lead 
pipes.  Other  salts,  usually  found  in  spring  and 
river  waters,  act  as  protectives  by  forming  in- 
soluble lead-compounds,  which  being  deposited 
as  a crust  in  the  interior  of  the  pipe  or  cistern, 
prevent  further  action.  Of  this  class  are  the 
sulphates,  phosphates,  and  carbonates.  Hence 
waters,  unless  containing  much  less  than  the 
average  proportion  of  lime-salts,  after  a time 
cease  to  be  contaminated  to  any  great  extent, 
though  the  presence  of  carbonic  acid  in  the  water 


LEAD,  POISONING  BY. 


renders  a solution  of  the  crust  possible  in  some 
measure.  Waters  so  deficient  in  lime-salts  as  the 
Loch  Katrine  water  supplied  to  Glasgow  cannot 
safely  be  conveyed  in  lead  pipes.  Galvanised 
iron,  earthenware,  or  slate  may  in  many  cases  be 
advantageously  substituted  for  lead,  if  not  pos- 
cible  in  all.  "Lead  covers  to  cisterns  are  very 
objectionable,  as  the  water  which  rises  by  evapo- 
ration condenses  and  drops  back  contaminated. 
The  electrolytic  action  of  solders  also  helps  to 
contaminate  water  with  lead. 

2.  Oxides  of  Lead,  Poisoning  by— The 
most  important  oxide  of  lead  in  this  reration  is 
litharge  or  plumbic  oxide  (Massicot),  which  is 
largely  used  in  making  glass  and  glazes  for 
earthenware  and  iron.  Those  engaged  in  glass- 
making and  grinding,  glazing,  pottery,  &c., 
suffer.  Owing  to  the  solubility  of  lead-glazes, 
articles  of  food  if  acid  may  bo  contaminated. 
Litharge  is  also  used  for  hair-dyes,  japanning, 
&c.,  whence  poisoning  may  result. 

The  ‘red  lead,’  which  is  a mixture  of  lead 
oxides,  has  caused  poisoning,  by  being  used  to 
colour  wafers,  adulterate  snuff,  and  make  putty 
or  cement  for  tanks,  &c. 

3.  Lead  Salts,  Poisoning  by. — Of  these  the 
most  important  in  this  relation  is  the  carbonate, 
or  ‘ white  lead.’  Those  engaged  in  the  manu- 
facture, grinding,  and  packing  of  white  lead  are 
the  most  frequent  sufferers,  and  also  those  who 
largely  use  it,  such  as  painters,  glaziers,  plumb- 
ers, glazed  card  manufacturers,  lacquerers,  lace 
manufacturers,  and  those  who  apply  it  as  a cos- 
metic (clowns,  &c.).  The  acetate  of  lead  has 
been  used  for  correcting  the  acidity  of  wine  and 
cider,  and  has  been  a frequent  source  of  lead- 
poisoning. Poisoning  hss  also  occurred  among 
seamstresses  from  using  silk  thread  adulterated 
with  it ; in  dye-works,  where  it  is  largely  used ; 
from  using  it  as  a hair-dye  ; and  from  long-con- 
tinued medicinal  administration.  Lead  colours, 
chromates,  &c.,  have  also  caused  poisoning,  by 
being  used  to  colour  confectionery.  From  these 
and  similar  sources  lead  may  be  introduced  into 
the  system  by  inhalation,  ingestion  into  the 
stomach,  and  apparently  also  by  cutaneous  ab- 
sorption. 

Symptoms. — The  affections  caused  by  lead  are 
frequently  termed  saturnine,  owing  to  lead  being 
the  symbol  of  Saturn,  the  malign  planet  of  the 
astrologers.  They  are  of  a manifold  character, 
and  do  not  always  occur  in  regular  order  or 
sequence. 

Saturnine  cachexia. — As  a rule,  after  long- 
continued  introduction  of  lead  into  the  system, 
a saturnine  cachexia  is  developed,  characterised 
by  anaemia,  an  earthy  or  dull  hue  of  the  skin, 
digestive  derangement,  dryness  of  the  mouth, 
frequently  a styptic  or  sweetish  astringent  taste, 
mated  tongue,  and  fetid  breath.  The  teeth  are 
discoloured,  and  frequently  appear  elongated  from 
retraction  of  the  gums.  At  the  margin  of  the 
;eeth  and  the  gums  a bluish  or  violet  line  is  de- 
veloped. This,  which  is  regarded  as  the  specially 
liagnostic  indication  of  lead-poisoning,  was 
irst  described  by  Burton,  and  is  shown  to  be 
due  to  the  formation  of  a lead  sulphide  in  the 
>arts. 

Lead  Colic. — Synon.  : Colica  Saturnina ; Fr. 
Udiquede  Plomb;  Ger.  ISleikoUk. — Following  the 


813 

symptoms  just  described,  but  sometimes  without 
marked  prodromata,  a very  characteristic  affec- 
tion occurs,  namely,  lead  colic.  This  is  known 
by  many  other  synonyms,  of  which  the  more  com- 
mon are  Painter's  colic,  Devonshire  colic,  Colica 
Pictonum,  the  last  being  derived  from  the  inhabi- 
tants of  Poictou,  among  whom  in  modern  times  it 
was  first  extensively  prevalent,  owing  to  adulter  ■ 
ation  of  wine  with  lead-salts. 

Patients  affected  with  lead  colic  oxhibit  a 
cachectic  look,  earthy  hue,  blue  line  on  the  gums, 
coated  tongue,  and  fetid  breath  ; and  suffer  from 
nausea  and,  occasionally,  vomiting.  The  bowels 
are  obstinately  confined,  cr  scanty  hard  motions 
are  passed  with  difficulty.  Paroxysms  of  excru- 
ciating pain  occur  in  the  abdomen,  which  feels 
hard,  and  is  retracted  in  tho  region  of  the  um- 
bilicus. The  pain  is  of  a truly  colicky  nature, 
and  is  relieved  by  pressure.  The  countenance  is 
anxious,  and  the  skin  is  covered  with  cold  per- 
spiration. The  respiration  is  shallow,  and  the 
pulse  generally  slow  and  hard,  though  this  is  not 
always  tho  case.  The  urine  is  not  unfrequently 
almost  or  entirely  suppressed. 

Lead  Palsy. — Synon.  : Fr.  Paralysie  satur- 
nine ; Ger.  Bleildhmung.  After  repeated  attacks 
of  lead  colic,  or  it  may  be  after  one,  and  some- 
times without  antecedent  colic,  various  other 
affections  occur.  One  of  the  most  common  of 
these  is  a form  of  paralysis  termed  lead  palsy, 
or,  from  its  special  features,  ‘dropped  wrist.’ 
The  paralysis  shows  itself  more  particularly  in 
the  extensor  muscles  of  tho  forearm,  or  region  of 
distribution  of  the  musculo-spiral  nerve ; and  in 
consequence,  when  the  arm  is  raised,  the  hand 
drops  by  its  own  weight.  The  paralysis  generally 
commences  in  the  extensor  digitorum  communis, 
and  gradually  extends  to  the  other  muscles  sup- 
plied by  the  musculo-spiral,  with  the  remarkable 
exception  of  the  supinator  longus.  The  paralysis 
does  not  necessarily  confine  itselfto  the  forearm, 
for  in  advanced  cases  it  may  attack  other  muscles 
in  the  arm,  the  muscles  of  the  leg,  and  the  dorsal 
muscles ; showing  itself  by  preference  in  the  ex- 
tensor muscles  of  the  body,  and  giving  rise  to  a 
peculiar  stooping,  tottering  gait.  Aphonia  occa- 
sionally results.  The  paralysed  muscles  undergo 
atrophy,  and  ultimately  cease  to  react  to  fara- 
disation or  galvanisation,  the  faradic  excitability 
being  lost  before  the  galvanic,  as  in  peripheral 
paralysis  generally. 

Other  'phenomena. — Tendinous  swellings  of  an 
oval  or  elongated  shape  frequently  form  on  the 
tendons  at  the  back  of  the  wrist,  and  contrast 
prominently  with  the  atrophied  muscles.  Neu- 
ralgic pains  in  the  muscles  and  joints  are 
often  complained  of.  In  the  more  advanced 
cases  various  forms  of  encephalopathies  occur. 
Epileptiform  convulsions  are  common ; and 
psychical  affections  are  not  unfrequent,  in  the 
form  of  delirium,  mania,  or  melancholia.  Appa- 
rently in  causal  relation  with  lead-poisoning,  dis- 
ease of  the  kidneys  and  albuminuria  may  occur ; 
and  gout  is  frequently  seen  among  those  who  work 
in  lead.  Abortion  occurs  to  a large  extent  among 
women  employed  at  white-lead  works  ; according 
to  Paul,  in  the  proportion  of  sixty  per  cent,  of 
those  so  employed. 

The  tendency  is  to  recovery,  if  the  cause  of  the 
symptoms  is  removed;  but  if  not,  the  paralytic 


S 1 4 LEAD,  POISONING  BY. 

and  other  affections  become  incurable,  and  death 

occurs  in  a miserable  state  of  cachexia. 

Anatomical  Characters. — There  are  no  very 
characteristic  appearances  of  chroniclead-poison- 
ing.  Lead  is  found  in  almost  every  organ  and 
tissue  in  the  body,  the  greatest  quantity,  accord- 
ing to  Heubel,  being  found  in  the  bones ; next  in 
the  kidneys,  liver,  brain,  and  spinal  cord ; and  to 
a less  extent  in  the  muscles. 

Among  the  appearances  which  nave  been  de- 
scribed are  constriction  and  apparent  thickening 
of  the  muscular  coats  of  the  large  intestine ; and  an 
atrophic  condition  of  the  intestinal  mucous  mem- 
brane has  been  found  by  some  authors  (Kussmaul 
and  Maier).  These  authors  have  also  found  an 
increase  of  the  connective  tissue,  and  atrophy  of 
the  nervous  tissue  in  the  abdominal  ganglia  of 
the  sympathetic.  The  paralysed  muscles  exhibit 
atrophic  degeneration,  with  hyperplasia  of  the 
connective  tissue,  and  disappearance  of  the  striie, 
and  the  nerve-trunks  likewise  exhibit  various 
stages  of  atrophy.  We  possess,  as  yet,  no  very 
reliable  knowledge  of  the  condition  of  the  nerve- 
centres.  The  subject  is  one  still  requiring  much 
investigation. 

Pathology. — The  mode  of  action  of  lead,  and 
the  causation  of  its  characteristic  symptoms  are 
subjects  still  under  discussion.  Henleis  of  opinion 
that  lead  acts  primarily  on  the  non-voluntary 
muscular  fibres  throughout  the  body , while  Heubel 
thinks  that  the  primary  action  is  on  the  nerve- 
centres.  From  this,  as  secondary  consequences, 
are  deduced  the  colic,  due  to  irritation  by  com- 
pression of  the  intestinal  nerves,  and  the  consti- 
pation from  cessation  of  the  intestinal  secretion 
by  contraction  of  the  blood-vessels.  To  the  arterial 
ischaemia  so  produced  the  paralysis  is  attributed 
(BUrwinkel).  Hitzig  thinks  that  the  paralysis  of 
the  extensors  is  due  to  a peculiar  disposition  of 
the  veins,  which  favours  the  deposition  of  lead 
there.  This  is  a mechanical  theory  which  has 
little  to  support  it  except  a dilated-condition  of 
the  veins,  and  is  utterly  insufficient  to  account 
for  the  occurrence  of  paralysis  in  other  regions, 
besides  being  in  contradiction  to  the  fact  that 
lead  is  not  specially  deposited  in  the  muscles,  as 
this  theory  would  necessitate.  That  the  paralysis 
is  due  to  degeneration  of  the  nerves  is  in  harmony 
with  the  symptoms  and  electrical  reactions  of  the 
muscles,  and  is  supported  by  the  post-mortem 
appearances  ; but  whether  the  peripheral  degene- 
ration is  primary,  or  secondary  to  central  de- 
generation in  the  anterior  horns  of  the  spinal 
cord,  is  not  as  yet  satisfactorily  determined. 

Treatment.  — In  acute  lead-poisoning  from 
any  cause  the  stomach  must  be  emptied  by  the 
stomach-pump,  or  by  emetics — of  which  sulphate 
of  zinc  is  to  be  preferred.  Solutions  of  the  alka- 
line or  earthy  sulphates — of  which  the  best  is 
sulphate  of  magnesia — are  indicated,  with  the 
view  of  forming  the  comparatively  insoluble  sul- 
phateof  lead, and  expelling  it  from  the  intestines. 

As  regards  chronic  poisoning  by  lead,  prophy- 
laxis is  the  most  important  consideration.  The 
great  principles  in  lead-works  are  the  inculcation 
of  cleanliness  ; avoiding  eating  with  unwashed 
hands,  or  in  working  clothes,  or  in  workshops; 
moist  grinding ; free  ventilation  ; precautions 
against  dust  rising,  or  wearing  of  flannel  respi- 
rators where  it  is  unavoidable ; and  occasional 


LEPEA. 

doses  of  sulphate  of  magnesia,  acidulated  with 
sulphuric  acid.  Sulphuric  acid  lemonade  has 
been  recommended  as  a drink. 

Workmen  who  begin  to  show  signs  of  lead- 
poisoning  should  at  once  give  up  the  work,  and 
take  to  some  other  employment.  As  regards 
water-contamination,  what  has  already  been  said 
on  this  subject  will  suffice  to  indicate  the  pro- 
phylactic measures. 

In  the  treatment  of  lead  colic,  purgatives  are 
indicated,  and  opium  may  be  necessary  to  allay 
the  excruciating  pain.  The  sulphate  of  magnesia 
is  the  best  purgative.  Iodide  of  potassium  is 
generally  given  with  the  object  of  removing  the 
lead  from  the  system,  and  is  on  the  whole  satis- 
factory in  its  results.  A combination  of  the  iodide 
with  sulphate  of  magnesia  is  very  beneficial.  Sul- 
phur baths  are  also  recommended. 

The  local  paralytic  affections  require  local,  in 
addition  to  the  general  treatment..  Unless  the 
muscles  are  in  an  advanced  state  of  atrophy,  and 
give  no  response  to  electrical  stimulation,  good 
results  may  be  obtained  by  the  use  of  the  galvanic 
current  applied  to  the  muscles  and  to  the  mus- 
culo-spiral  nerve.  Faradisation  has  also  been 
found  beneficial,  and  is  recommended  by  Dn- 
chenne,  but  the  preference  is  to  be  given  to  the 
continuous  cuiTent,  D.  Fere;  an. 

LEAMINGTON,  in  Warwickshire. — Sul- 

phated  common  salt  waters.  See  Mineuai. 
Waters. 

LEECHING.  — The  local  abstraction  of 
blood,  by  means  of  leeches.  See  Blood,  Abstrac- 
tion of. 

LENS,  Diseases  of.  See  Cataract. 

LENTIGO. — A synonym  for  freckle.  See 
Freckles. 

LEPIDOSIS  (Xeirls  or  Aeaos,  a scale). — A 
term  adopted  by  Mason  Good  to  distinguish 
the  group  of  squamous  affections  of  the  skin ; 
amongst  which  is  included  lepra  vulgaris  or 
lepriasis.  The  term  is  now  obsolete. 

LEPOTHRIX  (Acaly  or  AeVos,  a scale,  and 
Splf,  a hair). — Definition. — A term  applied  to 
a hair  in  which  there  is  loosening  and  partial 
detachment  of  the  overlapping  edges  of  the 
scales  cf  its  cuticle. 

Such  hairs  are  usually  met  with  in  the  axilla, 
and  their  peculiar  conformation  is  attributable 
to  the  heat  and  dampuess  of  that  region,  which 
causes  maceration  of  the  hair,  particularly  when 
it  is  of  feeble  structure.  Sometimes  the  scales 
completely  surround  the  hair ; very  commonly 
one  side  of  the  shaft  is  more  affected  than  the 
rest,  and  presents  the  appearance  of  a fringe; 
and  not  uufrequently  the  scales  are  roughened 
with  earthy  and  saline  crusts  deposited  by  the 
sweat. 

Treatment. — The  treatment  most  suitable 
for  this  evil  is  saponaceous  ablution,  followed  by 
the  use  cf  a lotion  compose!  of  two  to  four 
drachms  of  oxide  of  zinc  to  half  a pint  of  lime- 
water.  Eeasmcs  Wilson. 

LEPRA  ( Aeirls  or  XeVoy.  a scale). — The  term 
lepra  was  used  in  the  plural,  \cvpai,  by  Hippo- 
crates, to  imply  its  constitution  of  mmtiplc 


LEPEA. 

patches.  ’Willan  adopted  the  term  as  significative 
of  a squamous  eruption,  and  in  this  sense  it  has 
been  regarded  as  the  lepra  Gnecorum.  The  foreign 
schools,  however,  prefer  to  name  it  psoriasis,  a 
term  now  commonly  associated  with  it  in  Great 
Britain  ; whilst  they  assign  the  word  ‘ lepra  ’ to 
the  elephantiasis  of  the  Greeks,  the  so-called 
• true  leprosy.’  Hence  whilst  the  operation  of 
time  has  transferred  the  word  ‘ psoriasis  ’ to  the 
lepra  of  tho  Greeks,  :t  has  conveyed  the  term 
‘elephantiasis’  of  the  Greeks  to  the  lepra  of  the 
Arabs ; and  common  consent  reserves  the  word 
lepra  or  leprosy  for  the  elephantiasis  of  the 
Greeks.  Thus,  the  terms,  lepra,  psoriasis,  ele- 
phantiasis graecorum,  and  leprosy  are  somewhat 
confusedly  intermingled,  and  cne  mode  of  extri- 
cation from  the  dilemma  would  appear  to  be  to 
consider  lepra  as  synonymous  with  leprosy,  and  to 
abandon  its  upe  in  connexion  with  the  lepra  of 
the  Greeks,  now  termed  psoriasis;  although  the 
adoption  of  Mason  Good’s  term  ‘ lepriasis  ’ would 
no  doubt  be  the  better  alternative.  For  himself, 
however,  the  writer  prefers  the  more  classical 
courso  of  retaining  the  term  ‘lepra,’  the  type  of 
roughness,  for  the  lepra  Grsecorum  and  the  lepra 
vulgaris  of  Willan.;  giving  to  genuine  leprosy, 
the  great  disease,  its  Greek  designation,  elephan- 
tiasis ; and  attaching  psoriasis  to  squamous 
eczema,  the  ‘psora’  of  the  ancients,  to  which  it 
properly  belongs.  The  elephantiasis  Arabum  or 
‘elephant  leg,’  must  be  left  out  of  consideration, 
as  being  an  error  of  nomenclature,  taking  its 
origin  in  a blunder  of  translation  of  the  Greek 
writings  by  the  Arabian  authors.  See  Elephan- 
tiasis Arabum.  Erasmus  Wilson. 

LEPROSY  (Xeirpbs,  rough).  — Derivation 
and  Synonyms. — The  term  leprosy  had  its  origin 
at  a time  when  diseases  of  ‘roughness’  compre- 
hended a large  majority  of  affections  of  the 
skin;  and  it  was,  in  fact,  a generic  name  for 
‘skin  diseases.’  Hence  the  indefiniteness  of 
the  word  as  we  meet  with  it  in  the  Bible, 
where  ‘leprosy’  in  one  connexion  represents 
a trivial  disorder,  and  in  another  a serious  dis- 
ease ; and  in  a similar  sense,  a leper,  in  many 
instances,  was  nothing  more  than  a person 
afflicted  with  a cutaneous  complaint.  In  mo- 
dern times  leprosy  has  been  found  a convenient 
designation  for  that  terrible  disease  described 
by  the  Greek  fathers  of  medicine  as  elephan- 
tiasis— a disease  widely  spread  over  the  world, 
j and,  according  to  the  saying  of  Aretteus,  so 
much  greater  than  tho  rest  of  diseases  as  the 
elephant  is  bigger  than  ail  other  animals — a 
I disease  which  is  universal  in  its  diffusion  through 
the  frame,  and  in  which  all  the  tissues  of  the 
Body  are  implicated  to  a greater  or  less  extent. 
The  terms  leprosy  and  lepra  are  consequently 
.quite  distinct  from  each  other;  leprosy  and  ele- 
phantiasis being  synonymous  ; whereas  the  term 
lepra,  or  rather  \ewpal,  in  tho  plural,  was  ap- 
plied by  the  Greeks  to  scaly  white  spots  of  the 
skin,  a disease  of  roughness  as  in  elephantiasis, 
although  a disease  of  roughness  in  a very  dif- 
ferent sense.  But  the  analogy  of  the  two  words, 
both  in  derivation  and  sound,  has  given  rise  to 
some  confusion,  and  the  contusion  is  increased 
by  a misapplieaticn  of  the  term  elephantiasis, 
l’hus  we  find  that  whilst  the  elephantiasis  of  the 


LEPEOSY.  815 

Greeks  has  the  signification  of  leprosy,  the  lepra 
of  the  Greeks  is  a trivial  affection,  sometimes 
styled  lepra  vulgaris,  and  very  commonly, 
although  erroneously,  ps  riasis.  The  word 
elephantiasis  has  aiso  been  applied  to  a local 
disease  of  hypertrophic  growth  known  as  ele- 
phantiasis Arabum  , whilst  the  Arabians,  amongst 
whom  leprosy  is  also  found,  call  that  disease 
lepra.  It  therefore  follows  that  leprosy,  ele- 
phantiasis Graecorum,  and  lepra  Arabum  are 
synonymous  terms. 

The  synonyms  of  leprosy  are  numerous,  as 
may  be  inferred  from  the  extensive  distribution 
of  the  disease  throughout  the  world,  and  its 
identification  in  different  countries  by  different 
names.  Amongst  the  most  important  of  its  syno- 
ny^msare: — Elephantiasis ; Lepra;  Lepraelephan- 
tia  ; Black  Leprosy;  Bed  Leprosy ; Elephantiasis 
tuberosa,  ancesthetica,  nodosa,  mutilans,  leontina, 
satyria;  Joint-evil;  the  Myckle  Ail  or  Great 
Disease,  its  English  name  in  ancient  times  ; la 
Lepre  in  France;  dcr  Aussatz  in  Germany; 
Spedalskshcd,  throughout  Scandinavia;  Lik.pra 
in  Norway  ; and  so  forth. 

Geographical  Distribution.— The  countries 
in  which  leprosy  prevails  most  extensively 
are:  — Hindostan,  China,  the  islands  ot'  the 
Indian  Ocean,  some  of  the  Polynesian  Islands, 
Madagascar,  Africa,  the  West  Indies,  parts  of 
South  America,  Norway,  Sweden,  and  parts  of 
Canada.  Therefore,  although  most  abundant 
in  hot  climates,  it  is  likewise  frequently  met 
with  in  the  North.  For  thirteen  centuries  it  was 
endemic  in  Great  Britain  ; the  last  case  still  lin- 
gered on  the  borders  of  Scotland  so  late  as  the 
beginning  of  the  nineteenth  century  ; now  an 
indigenous  example  is  nowhere  to  be  found  in 
the  British  Islands. 

^Etiology'. — The  cause  of  leprosy  is  endemic. 
The  disease  has  been  mi  t with  from  time  imme- 
morial in  certain  countries  and  localities;  there- 
fore the  cause  must  be  one  which  will  be  capable 
of  abiding  in  different  countries  and  in  different 
climates — climates  as  various  in  character  us 
the  northern  regions  and  the  tropics.  Time  was 
when  leprosy  prevailed  in  Great  Britain,  and  it 
took  up  its  abode  there  for  thirteen  centuries ; 
but  the  disease  has  gone,  and  therefore  we  may 
presume  that  the  cause  lias  ceased.  Whether  it 
has  ceased  in  consequence  of  drainage  and  more 
general  cultivation  of  the  soil,  is  a question  to 
be  carefully  considered.  Hitherto  indigenous 
leprosy  has  been  unknown  in  the  Australian 
colonies;  but  a well-marked  ease  of  elephantia- 
sis tuberosa  has  recently  come  under  the  wri- 
ter's attention,  having  its  origin  in  New  Zealand. 
The  patient  was  a man  of  distinguished  note  in 
Australia;  he  had  been  draining  very  extensively 
in  New  Zealand,  and  he  had  lived  for  several 
years  amidst  the  exhalations  of  the  fresh-opened 
soil  of  the  marshes.  The  example  is  not  soli- 
tary. An  English  lad  was  born  and  brought  up 
on  the  verge  of  a marsh  in  the  West  Indies.  He 
was  sent  to  Lond-m  on  account  of  debility ; tho 
diagnosis  was  elephantiasis.  A few  years  after- 
wards, his  father,  an  officer  of  police,  followed 
him  home,  a victim  of  the  same  disease,  which 
had  become  developed  since  the  departure  of  Iris 
son.  The  writer  could  multiply  cases  of  this 
kind  considerably,  and  has  had  the  conviction 


LEPROSV 


816 

forcibly  borne  in  upon  him,  that  the  cause  of 
leprosy  is  miasma.  No  other  cause  is  of  such 
general  distribution,  suiting  every  climate  and 
every  part  of  the  world,  uuless  it  be  such  coun- 
tries as  have  been  relieved  of  the  cause  by  land- 
culture  and  improvement.  Leprosy  has  been  as- 
sumed to  be  caused  by  bad  food,  and  by  a fish  diet. 
There  can  be  no  doubt  that  an  improper  diet  may 
be  quite  equal  to  the  production  of  debility  and 
disease,  and  might  predispose,  like  aDy  other 
lowering  course,  to  the  invasion  of  a miasma  ; but 
the  disease  prevails  amongst  the  well-nourished 
as  well  as  amongst  the  ill-nourished,  and  in 
countries  where  fish  is  rarely  or  never  eaten ; 
whilst  fish  in  moderation  must  be  regarded  as  a 
most  healthful  and  nutritious  article  of  diet. 
Leprosy  is  now  believed  to  be  hereditary,  and  it 
has  the  character  of  being  non-contagious. 
Nevertheless  there  are  some  curious  histories 
on  record  of  the  first  appearance  of  leprosy  in  a 
population  after  the  immigration  of  foreigners 
from  a leprous  country,  as  in  the  example  of 
the  importation  of  negroes  into  the  district  of 
Surinam  in  South  America,  and  the  origin  and 
spread  of  the  disease  among  the  Sandwich 
Islanders  after  an  immigration  of  the  Chinese. 
This  and  other  questions  of  cause  must  still 
remain  unsettled  until  further  information  is 
obtainable.  A specific  form  of  bacillus  has  re- 
cently been  found  in  leprosy,  the  lymphatics 
being  believed  to  be  the  channels  of  infection. 
See  Lancet,  July  30,  1881. 

Axatomicai.  Characters. — The  morbid  ana- 
tomy of  leprosy  centres  chiefly  in  the  integument 
and  in  the  nervous  system.  Danielssen  and 
Boeck  found  the  sheaths  of  the  cutaneous  nerves 
thickened  and  distended  with  exudative  deposits, 
and  similar  changes  were  seen  in  the  spinal  cord. 
They  also  discovered  tubercular  matter  in  seve- 
ral of  the  internal  organs,  glands,  and  viscera. 
Virchow  is  of  opinion  that  the  pathological  ele- 
ment of  elephantiasis  differs  in  no  essential  re- 
spect from  that  of  the  gummata  of  syphilis,  nor 
indeed  from  that  of  lupus  and  glanders.  Granu- 
lation-tissue is  the  characteristic  element  of  all 
the  three;  the  granulation  tumour  of  elephan- 
tiasis is,  however,  more  permanent  than  others 
of  the  same  class,  and  tends  in  a less  degree 
to  degeneration  and  softening.  Dr.  Moxon,  in 
a well-marked  case  of  elephantiasis  tuberosa 
that  fell  under  his  examination  in  Guy’s  Hos- 
pital, regarded  the  pathology  of  the  disease  as 
especially  evinced  by  the  integument,  which  he 
found  atrophic  and  disorganised,  the  nerves 
apparently  healthy,  but  the  cutaneous  nerves 
and  veins  alike  involved  in  dyscrasic  degenera- 
tion. ‘ We  are  struck,’  he  observes,  ‘with  the 
small  amount  of  morbid  change  proper  to  ele- 
phantiasis. The  immediate  cause  of  death  was 
amvloid  or  lardaceous  disease  of  the  alimentary 
canal,  liver,  kidneys,  and  spleen,  with  marasmus 
in  the  most  extreme  degree.  The  amyloid 
change  occurs  in  the  same  places  as  in  other 
lingering  but  not  otherwise  mortal  maladies.’ 

Symptoms. — Leprosy  makes  its  beginning  so 
lightly  and  so  unobtrusively,  that  it  is  perhaps 
rarely  detected  in  its  earliest  stage.  At  that 
period  there  might,  after  close  examination,  be 
discovered  a few  symptoms  of  debility,  such  as 
weariness,  chilliness,  failure  of  appetite,  sleepi- 


ness, and  lassitude.  But  these  symptoms 
subside  after  a while,  and  the  patient  "recovers 
his  wonted  energy  and  power ; some  months  later 
similar  symptoms  return,  but  somewhat  inten- 
sified ; and  several  such  recurrences  may  be 
experienced  before  any  more  obvious  symptoms 
are  made  evident.  The  symptoms  resemble 
those  produced  by  malarious  poison,  and  may 
be  regarded  as  indicating  the  incubation  of  the 
leprous  virus. 

These  premonitory  symptoms  of  leprosy  ac- 
quire force  after  repeated  recurrence ; and  then 
two  other  symptoms  make  their,  appearance, 
namely,  a hyperaemia  of  the  skin,  and  a defective 
sensibility  of  the  peripheral  branches  of  the 
spinal  nerves.  The  hyperaemia  of  the  skin  ge- 
nerally assumes  the  form  of  circular  spots,  some- 
times of  uniform  size,  at  other  times  of  blotches 
of  irregular  shape  and  varied  extent.  The  iso- 
lated spots  appear  commonly  on  the  trunk  of 
the  body  and  fleshy  parts  of  the  limbs,  whilst 
on  the  face  and  neck,  and  on  the  hands  and  feet 
there  is  an  uniformly  diffused  redness.  What 
has  already  been  said  with  regard  to  the  pro- 
gressive development  of  the  constitutional  symp- 
toms must  be  repeated  with  respect  to  the  local 
signs  of  the  disease.  At  first  only  the  face, 
hands,  and  feet  may  he  congested,  with  a few 
spots  on  the  trunk  of  the  body.  Then  the 
hyperaemic  congestion  will  subside  and  remain 
quiescent  until  another  exacerbation  of  the  lep- 
rous fever  is  imminent,  when  the  spots  will  be 
increased  in  number  and  deepened  in  colour. 

The  redness  of  leprosy  is  dull  coppery  or 
purplish  in  tint ; as  it  subsides  it  leaves  on  the 
skin  a pigmentary  stain;  the  affected  integument 
is  puffy  with  serous  infiltration;  the  pores  are 
dilated  as  if  from  hypertrophy  of  the  follicles  ; 
and  in  general  appearance  the  skin  resembles  the 
rind  of  an  orange.  At  a more  advanced  stage  of 
the  cutaneous  disorder  the  hyperaemic  congestion 
becomes  centrifugal,  and  the  circular  spot  is 
developed  into  a ring  ; even  the  pigment  d;s- 
appears  from  the  centre  of  the  blotch,  leaving 
a bleached  centre  surrounded  by  a belt  which  is 
slightly  tumid,  of  a dull  red  hue,  and  deeply  pig- 
mented. Eventually  the  whole  of  the  affected 
part  may  be  represented  ljy  a white  blotch. 
Blotches  of  all  the  three  kinds  may  be  seen  at 
the  same  time  dispersed  over  the  body,  some 
being  red  only,  some  melasmic,  some  leucasmic, 
according  to  their  age ; and  others  of  irregular 
figure,  arising  from  the  blending  of  the  circular 
spots,  or  spread  out  into  rings  of  various  extent. 

The  distribution  of  the  maculse  or  blotches  of 
leprosy  on  the  surface  of  the  body  corresponds 
with  the  nerve-territories  of  the  integument,  and 
the  same  may  be  said  with  regard  to  the  face, 
and  the  extremities  below  the  elbows  and  knees. 
On  the  face  the  parts  specially  affected  are  the 
superciliary  regions,  the  nose,  and  the  ears ; and 
on  the  arms  the  territory  of  the  ulnar  nerve. 
In  all  these  regions  the  blotches  soon  become 
blended ; and  the  redness,  pigmentation,  and  infil- 
tration are  more  general  than  elsewhere.  The 
suffused  redness  of  the  skin  has  suggested  the 
term  elephantiasis  erythematosa  ; and  tins  state 
of  congestion  is  frequently  accompanied  by  pro- 
minence of  the  follicles,  and  more  or  less  des- 
quamation and  exfoliation  of  cuticle.  In  some 


LEPROSY. 


aituations  the  hypereemic  blotches  are  moistened 
by  a greasy  exudation ; in  others  they  are  dry, 
parched,  and  rough. 

In  all  the  affected  parts  of  the  skin  there 
exists  a certain  degree  of  numbness  or  anaes- 
thesia. In  the  early  stages  of  the  disease  there 
is  scarcely  any  pain  ; nevertheless,  if  the  ulnar 
i nerre  be  pressed  against  the  inner  condyle,  the 
pain  is  frequently  acute,  and  the  same  occurs 
trom  pressure  on  the  peroneal  nerve.  As  a con- 
sequence of  imperfect  innervation,  the  fingers 
are  frequently  slender  and  benumbed  ; they  are 
brown  from  pigmentation  ; and  the  metacarpal 
space  between  the  forefinger  and  thumb  is  hol- 
lowed, from  defective  nutrition  of  the  abductor 
muscle. 

Varieties. — Starting  with  one  uniform  series 
of  premonitory  symptoms,  leprosy  after  a while 
evinces  a remarkable  tendency  to  pursue  an 
[elective  course.  In  the  great  majority  of  cases 
die  prime  seat  of  manifestation  of  the  disease  is 
lie  integument  and  mucous  membrane;  this 
constitutes  the  form  of  the  disease  known  as 
•lephantiasis  tuberosa.  In  a smaller  number  of 
uses  the  affection  of  the  nervous  system,  and 
lartieularly  loss  of  sensation,  are  most  conspi- 
uous ; and  this  constitutes  the  group  called  ele- 
ihantiasis  anasthetica:  whilst  a sub-group  of 
lephantiasis  anasthetica  is  remarkable  for  dis- 
ocation  and  amputation  of  the  members  at  the 
lints;  constituting  elephantiasis  nodosa,  juint- 
vil,  or  elephantiasis  mutilans. 

In  the  tegumentary  or  tuberous  group,  the 
inspicuous  symptom  is  the  development  and 
radual  growth  of  solid  papules  or  tubercles  in 
le  skin.  These  originate  in  the  centre  of  the 
(•persemic  spots  already  mentioned,  and  do  not 
ake  their  appearance  until  after  the  disease  has 
fisted  for  several  months.  At  first  they  are 
ddish  in  colour  ; afterwards  they  differ  little 
tint  from  the  surrounding  skin.  They  range  in 
:efrom  two  lines  to  half  an  inch  in  diameter; 
d are  slightly  convex  at  the  summit,  and  hard 
the  touch.  Their  development  follows  the 
igressive  exacerbations  of  the  leprous  fever  ; 
;y  grow  while  the  febrile  process  continues, 

• i become  stationary  when  it  abates  ; each 
ucerbation,  however,  adds  to  their  bulk,  and 
ices  them  on  to  maturity.  Having  reached 
I mature  stage,  they  soften  and  break  up  ; an 
1 8r  is  formed,  which  discharges  for  a while ; 
c l then  the  ulcer  heals.  A common  seat  of  the 
t ercles  is  the  region  of  the  eyebrows,  which 
t y denude  of  hair  ; they  also  give  a frowning 
a set  to  the  countenance,  and  when  of  large  size 
a a leonine  fierceness  to  the  expression,  which 
h suggested  the  term  elephantiasis  leontina. 
S ilar  phenomena  to  those  already  described 
ifest  themselves  in  the  fauces,  the  nasal 
c.  ties,  and  the  larynx — at  first  hypersmic 
®ul»,  then  tuberous  prominences,  and  next 
ul  ration,  so  that  the  symptoms  in  this  region 
81  usually  severe.  The  voice  is  hoarse ; the 
ml  passages  are  clogged;  occasionally  the 
se  un  ulcerates ; and  sometimes  the  nasal  bones 
H n.  Tubercles  likewise  form  along  the  edges 
°l  e eyelids  ; the  conjunctiva  is  inflamed  and 
th  ened;  the  cornea  becomes  opaque;  and 
80i  times  the  eyeball  is  destroyed.  The  lips 
art  andered  protuberant  by  the  tubercles,  and 

52 


817 

ulcerate  like  the  rest.  The  external  ear  is  like- 
wise enlarged  and  studded  with  tubercles,  and 
the  lobule  of  the  pinna  is  remarkably  elongated, 
suggesting,  with  the  large  tubercles  on  the  fore- 
head, the  features  of  the  typical  satyr.  Finally, 
the  leprous  congestion  extends  to  the  scalp ; the 
hair  falls  off,  as  it  does  on  the  eyebrows ; and 
the  term  elephantiasis  alopcciata  receives  some 
corroboration.  On  the  trunk  of  the  body  the 
ulcers  are  frequently  of  considerable  extent ; and 
occasionally  the  limbs  have  the  appearance  ol 
being  stripped  of  integument  from  the  shoulders 
to  the  hands. 

The  ulceration  of  elephantiasis  is  not,  how- 
ever, restricted  to  the  softening  of  tubercles ; in- 
stead of,  as  in  this  instance,  beginning  from 
without, it  starts  inits  most  extensive formsfrom 
within.  There  is  at  first  a general  swelling  of  a 
part,  such  as  the  heel  or  the  joint  of  a great-toe ; 
a blister  is  raised  on  the  skin  covering  the  swell- 
ing; the  cuticle  is  rubbed  off;  and  an  ulcer  is 
quickly  established.  All  this  may  occur  with- 
out pain  and  almost  without  the  knowledge 
of  the  patient.  A large  quantity  of  a glairy, 
colourless  fluid  is  poured  out  by  the  ulcer ; the 
sore  is  asthenic  and  sluggish  ; in  the  case  of  a 
joint  the  bone  may  be  exposed,  and  very  pro- 
bably the  end  of  a phalanx  will  be  forced  through 
the  opening,  to  be  followed  in  due  time  by  the 
rest  of  the  bone  ; then  the  ulcer  contracts  ; the 
cavity  closes  up ; and  the  integument  heals. 
After  a time  a similar  process  commences  in  tho 
great>toe  of  the  opposite  foot,  or  in  the  joint  of 
a thumb,  and  runs  the  same  course — either  tho 
extrusion  of  a bone  or  the  healing  up  of  an 
asthenic  sore,  after  a continuance  of  several 
weeks  or  months.  The  joints  of  the  phalanges 
of  the  feet  and  hands  are  similarly  attacked 
from  time  to  time,  and  a considerable  amount  of 
deformity  of  these  members  results.  But  it  is 
worthy  of  note  that  while  these  morbid  processes 
are  all  of  them  subject  to  the  periodical  canon  of 
the  disease,  they  alternate  in  their  occurrence ; 
and  it  is  to  be  further  noted  that  an  excessive 
discharge  from  one  of  these  ulcers  has  a deriva- 
tive influence,  and  communicates  a sense  of  re- 
lief to  the  whole  system. 

Elephantiasis  ansstlietica  differs  from  ele- 
phantiasis tuberosa  in  the  more  decided  mani- 
festation of  disorder  of  the  nervous  system. 
There  are  the  same  premonitory  symptoms,  the 
same  hyperaemic  spots  and  blotches  on  the  skin, 
the  same  pigmentary  maculae ; but  there  is  an 
absence  of  tubercles  and  ulceration,  the  numb- 
ness and  anmsthesia  are  more  decided,  a general 
state  of  atrophy  creeps  through  the  system, 
and  the  sufferer  is  prostrated  by  exhaustion. 
Neuralgic  pains,  which  are  not  wholly  absent  in 
elephantiasis  tuberosa,  are  more  obtrusive  in  ele- 
phantiasis anaesthetics.  A sense  of  dulness  and 
heat  pervades  the  surface;  and  there  are  sensations 
of  tingling  and  prickling,  and  of  burning  heat. 
Whilst  the  integument  is  insensible,  there  are 
deep-seated  burning  pains,  sometimes  of  a bone 
or  joint,  and  sometimes  of  the  vertebral  column. 
These  pains  are  greatest  at  night ; they  prevent 
sleep,  and  give  rise  to  restlessness  and  frightful 
dreams.  Moreover,  the  skin,  robbed  of  its  sensa- 
tion, is  prone  to  vesication  and  excoriation,  and 
the  latter  frequently  ends  in  ulceration.  The 


LEPROSY. 


SIS 

anaesthesia  is  often  so  great  that  the  contact  of  fire 
or  of  the  severest  caustics  occasions  no  sensation. 

Elephantiasis  mutilans  is  more  local  in  its 
characters  than  either  of  the  preceding;  it  is 
wanting  in  the  tegumentary  manifestations  of 
elephantiasis  tuberosa,  and  although  essentially 
anaesthetic  in  its  nature,  the  anaesthesia  is  local, 
and  affects  chiefly  the  limbs.  In  this  form  of  the 
disease  loss  of  the  bones  of  the  hands  and  feet  is 
a conspicuous  symptom  ; and  not  unfrequently 
the  limb  is  lopped  off  painlessly  at  the  ankle  or 
knee,  or  at  the  wrist  or  elbow.  When  the  pha- 
langes and  metacarpal  or  metatarsal  bones  are 
alone  attacked,  the  last  phalanx,  probably  from 
its  higher  vascular  organisation,  is  generally 
spared  ; this  may  be  the  case  even  when  the 
bones  of  the  wrist  are  eliminated ; ’and  the 
hand  or  foot  in  this  case  is  crumpled  up,  re- 
sembling a confused  bunch  of  tips  of  fingers  or 
toes.  Often  the  bones  are  ejected;  in  these  cases 
the  integument  heals  in  the  most  complete  man- 
ner, and  it  is  in  similar  cases,  where  consider- 
able reparative  power  is  obviously  present,  that 
spontaneous  cure  is  most  likoly  to  occur.  In 
elephantiasis  anaesthetics  the  nervous  system  is 
too  deeply  and  seriously  implicated  to  admit  of 
spontaneous  cure  ; and  in  elephantiasis  tuberosa 
the  tegumentary  system,  both  cutaneous  and 
mucous,  is  likewise  too  extensively  damaged  to 
render  cure  a rational  expectancy. 

Prognosis. — The  prognosis  of  leprosy  is 
essentially  unfavourable.  A disease  which  tends 
to  the  continuous  degeneration  of  the  skin  and 
mucous  membrane,  with  general  dyscrasia  of 
the  entire  organism  ; which  is  impelled  onwards 
by  a law  of  periodic  progression  ; and  which  has 
no  tendency  to  spontaneous  resolution,  must 
necessarily  be  fatal,  the  only  question  being 
one  of  duration.  A very  few  instances  are  on 
record  in  which  individuals  afflicted  with  this 
disease  have  survived,  and  these  principally 
from  amongst  the  cases  of  elephantiasis  muti- 
lans; hut  such  instances  must  be  regarded  as  the 
rare  exception, rather  than  the  rule.  The  tuberous 
form  of  the  disease  is  more  rapid  in  its  termina- 
tion than  the  anaesthetic  form ; and  the  duration  of 
life  in  both  ranges  from  about  ten  to  twenty  years. 

Treatment. — The  treatment  of  leprosy  re- 
solves itself  into,  first,  the  employment  of  means 
intended  to  promote  improvement  in  the  general 
health;  and,  secondly,  the  adoption  of  such  em- 
pirical remedies  as  have  acquired  a favourable 
reputation  for  the  cure  of  the  disease.  In  the 
first  category  we  must  place  the  removal  of  the 
patient  from  the  locality  wherein  the  disease 
has  been  engendered,  and  possibly  to  one  where 
the  disease  is  unknown.  Next  would  follow  a 
liberal  and  generous  diet,  such  as  animal  food 
nnd  beer;  with  active  exercise.  Thirdly,  tonic 
mid  nutritive  remedies,  such  as  cod-liver  oil, 
iron,  quinine,  strychnine,  bitters,  and  phos- 
phates, should  he  given.  Nitric  acid  has  been 
praised  by  one  physician,  and  acetic  acid  in  com- 
bination with  carbolic  acid  by  another.  There 
can  be  no  doubt  that  under  a generous  regimen 
the  patient  will  improve  in  health  and  strength; 
the  periodical  exacerbations  of  fever  will  be  less 
frequent,  and  hope  will  gleam  in  the  mind,  both 
of  the  physician  and  the  patient;  but  cure, 
alas!  is  as  distant  as  ever. 


Specific  alteratives  hare  been  exhausted  with 
equal  want  of  success.  Iodine  has  failed.  Daniels- 
sen  and  Boeck  administered  arsenic  largely; 
and  the  perchloride  of  mercury  has  been  exten- 
sively used  by  Beauperthuy.  When  these  and 
other  remedies  are  employed  judiciously,  in  com- 
bination with  a generous  diet,  moderate  exerdre, 
and  thorough  stimulation  and  inunction  cf  the 
skin,  the  symptoms  invariably  improve  for  a 
time  ; but  the  disease  as  certainly  falls  back  into 
chronic  sluggishness  and  smouldering  inactivity 
when  they  are  relinquished  or  neglected. 

The  principal  empirical  remedies  which  have 
been  recommended  in  this  disease  are; — tLo 
asclepias  gigantea;  hydrocotyle  asiatica;  ve- 
ronica quinquefolia ; cliaoulmoogra  oil,  and 
gurjun  balsam.  The  asclepias  or  rumex  gi- 
gantea, the  mudar  of  Hindostan,  has  received 
the  name  of  vegetable  mercury.  The  part  of 
the  plant  employed  medicinally  is  the  root-bark, 
reduced  to  powder  ; and  the  dose  of  the  latter  is 
half  a drachm  daily.  The  hydrocotyle  asiatica. 
in  the  form  of  powder  of  t he  dried  plant,  is  given 
in  doses  ranging  between  one  and  six  grains 
daily,  and  is  also  administered  as  an  infusion,  a 
syrup,  and  an  extract;  its  active  principle  is 
vellarine.  The  medicinal  part  of  the  veronica 
quinquefolia  is  its  root,  and  ten  ounces  of  the 
root  has  been  menlioned  as  a quantity  sufficient  | 
to  cure  a leprosy.  The  cliaoulmoogra  oil  is! 
procured  from  the  seed  of  an  Indian  tree,  the 
chaoul  moogra  or  gynoeardia  odorata.  It  is  ad- 
ministered both  internally  and  externally,  the 
dose  for  the  former  purpose  being  six  to  twelve 
minims,  three  times  a day.  A tincture  of  the 
plumbago  rosea  has  also  been  found  serviceable! 
in  cases  of  anaesthetic  leprosy;  the  dose  being 
one  drachm  three  times  a day. 

More  recently  Dr.  Joseph  Dougall  lias  recom- 
mended gurjun  balsam  or  wood  oil  ai  a very 
promising  and  successful  remedy.  It  is  ail 
oleo-resin,  obtained  from  one  of  the  species  "t 
the  dipterocarpus  tree  of  India ; and  is  given  in 
the  form  of  an  emulsion,  in  combination  with  ar 
equal  proportion  of  lime-water,  the  dose  of  the 
emulsion  ranging  between  two  and  four  drachm: 
twice  a day.  Or  it  may  very  conveniently  be  adj 
ministered  in  capsules,  each  containing  a drachm 

The  local  treatment  of  leprosy  consists  1 
stimulation  of  the  skin  by  means  of  hot-ail 
baths,  followed  by  frictions  and  inunction  witj 
bland  and  stimulating  oils.  Ointments  and  hnj 
ments  of  the  specific  remedies  already  mentioned 
namely',  mudar,  hydrocoty'le,  and  gurjun,  hav 
been  used  for  this  purpose,  as  well  as  for  dres: 
ing  the  ulcers.  Danielssen  and  Boeck  employe 
counter-irritants  in  the  course  of  nerves  pr 
sunied  to  be  affected,  with  cupping  and  mox 
to  the  spine  in  anaesthetic  leprosy;  whilst  t!» 
treated  the  tubercles  of  tubercular  leprosy  wi 
the  acid  nitrate  of  mercury,  and  with  a strongs 
lution  of  potassa  fusa.  Beauperthuy  found  bene 
result  from  the  acrid  irritating  oil  of  the  shell 
the  cashew  nut  ( Anacardium  orientate)  used  a; 
blister  to  the  tuberous  skin ; a copious  exudati 
followed  the  application,  and  relieved  both  || 
local  and  the  constitutional  symptoms.  Thegnrj 
treatment  is  accompanied  by  energetic  trie:. 
with  a liniment  composed  of  equal  parts  oi  • 

I a satu  and  lime-water,  the  same  as  the  emuisi 


LEPROSY. 

taken  internally ; and  asthenic  ulcers  are  pen-  | 
cilled  with  a solution  of  chloride  of  zinc. 

A review  of  these  various  methods  of  treat- 
ment, and  a consideration  of  the  personal  atten- 
tion required  by  the  patient  suffering  under  this 
terrible  disease,  are  suggestive  of  the  observation 
that  it  can  only  be  effectually  treated  in  an  in- 
stitution devoted  especially  to  the  purpose. 

Eras u us  Wilson. 

LEPTOMENINGITIS  (Aejr rbs,  delicate 
; or  thin,  and  meningitis). — A term  signifying  in- 
flammation of  the  pia  mater.  By  its  use,  in 
association-  with  arachnitis  and  pachymeningitis, 
we  are  enabled  accurately  to  indicate  the  precise 
teat  of  inflammation  involving  the  meninges  of 
the  brain  or  spinal  cord.  There  is  a practical 
convenience,  warranted  by  pathological  facts,  in 
retaining  the  term  arachnitis,  although  anato- 
mists are  not  now  disposed,  as  they  were  for- 
merly, to  believe  in  the  existence  of  an  arach- 
noid membrane,  distinct,  externally  from  the 
dura  mater,  and  internally  from  the  pia  mater. 
'iee  Meninges,  Diseases  of. 

LEPTOTHRIX.  (AeirrAs,  delicate  or  slender, 
.nid  a filament  or  hair). — Lcptothrix  buccalis 
is  a name  assigned  by  Robin  to  certain  vege- 
table parasites  or  minute  filaments,  which  can  be 
recognised  by  means  of  the  microscope,  amongst 
the  epithelial  scales  of  the  tongue  or  other  parts 
of  the  mouth ; and  especially  between  the  teeth, 
or  in  the  hollows  of  decayed  teeth.  They  occur  in 
healthy  persons,  as  well  as  in  the  sick,  and  have  in 
this  situation  really  no  pathological  signification. 
Organisms  of  the  same  kind  are,  however,  now 
'Commonly  named  bacilli,  and  have  during  the 
fast  two  or  three  years  been  recognised  as  ex  - 
j’eedingly  common  in  many  organic  solutions, 
ind  also  within  the  blood  and  tissues  of  animals 
and  of  man  suffering  from  splenic  fever  ( see  Pus- 
fULH,  Malignant).  Some  regard  them  as  con 
tituting  a distinct  genus,  whilst  others  believe 
'hem  to  be  only  one  of  the  multitudinous  forms 
.hat  may  be  assumed  by  bacteria,  when  growing 
a certain  kinds  of  media.  See  Bacteria  ; and 
Ticrococci. 

Dermatologists  also  employ  the  term  lepto- 
ihrix  to  indicate  a morbid  thinness  and  weak- 
ess  of  the  hair. 

LESION  ( ledo , I hurt.) — This  word  ori- 
inally  signified  a hurt  or  an  injury ; but  its  use 
now  extended  to  comprehend  all  organic 
langes  of  a morbid  character,  affecting  an 
■gan  or  tissue. 

LETHARGY  (Ai j(b),  oblivion,  and  apyla, 
Teness). — A disorder  of  consciousness,  which 
nsists  of  prolonged  and  profound  sleep,  from 
i'aich  the  patient  may  be  momentarily  aroused, 
it  into  which  he  falls  off  again  immediately, 
j e Consciousness,  Disorders  of ; and  Trance. 
LEUCE  (Afu/cbs;  white). — This  term  has  been 
i plied  to  blotches  in  the  skin  of  a white  colour; 

1 hence  it  has  alternately  been  confounded  with 
lira  alphoides,  with  vitiligo,  and  with  the  leuco- 
Irmic  blotches  of  leprosy.  It  seems,  however, 
are  than  probable  that  the  pathological  eon- 
i m intended  to  be  signified  by  this  word,  is  a 
jcumscribed  scleriasis,  namely,  that  which  we 
■ present  term  morphea  alba.  See  Morphcea. 

Erasmus  Wilson. 


LEUCOCYTHzEMIA.  313 

LEUCIN  (\evichs,  white). — Leucin,  the  che- 
mical composition  of  which  is  C12Hl3NO',  is  a 
product  of  decomposition  of  albuminous  bodies. 
It  may  be  obtained  from  them  by  the  action  of 
caustic  alkalies,  or  by  long  boiling  with  sul- 
phuric acid.  It  is  found  in  the  secretion  and 
substance  of  the  pancreas,  in  the  spleen,  thy- 
mus, thyroid,  suprarenal  bodies,  lymphatic 
glands,  salivary  glands,  liver,  kidneys,  and  brain. 
It  is  also  found  in  old  scales  of  the  epidermis, 
and  in  ichthyosis,  old  toe-nails,  and  sebaceous 
cysts.  Pathologically  it  occurs  in  abundance  in 
the  urine  and  liver  of  those  who  die  of  acuic 
yellow  atrophy;  and,  it  is  said,  in  the  urine  of 
those  suffering  from  severe  typhoid  and  variola, 
although  thereisno  chemical  proof  of  this.  Leucin 
is  thought  by  some  physiologists  to  be  a stage 
in  the  decomposition  of  albuminous  matters  into 
urea.  Under  the  microscope  it  is  seen  as  round 
balls,  having  some  resemblance  to  drops  of  oil, 
sometimes  hyaline,  sometimes  with  radiating 
marks,  sometimes  with  concentric  rings.  The  test 
for  leucin  with  the  microscope  is  very  untrust- 
worthy taken  alone.  Nearly  every  urine  can  be 
made  to  give  this  evidence.  If  leucin  is  to  be 
looked  for,  it  must  be  separated  by  the  following 
process.  The  urine  is  precipitated  with  acetate 
of  lead,  filtered,  and  the  excess  of  lead  removed 
from  the  filtrate  with  sulphuretted  hydrogen.  The 
filtrate  must  bo  next  evaporated  to  dryness ; the 
residue  extracted  with  boiling  alcohol  and  fil- 
tered ; and  the  filtrate  evaporated  to  a syrup.  If 
leucin  be  present,  it  separates  in  the  form  of  the 
crystals  described  above.  Chemical  tests  must 
now  be  applied  to  the  crystals.  A small  portion 
is  evaporated  to  dryness  in  a platinum  crucible 
with  nitric  acid ; and  if  leucin  be  present,  a 
colourless,  almost  invisible,  residue  is  left, 
which  becomes  yellow  or  brown  when  warmed 
with  a few  drops  of  soda  solution.  Leucin  is 
almost  always  found  associated  with  tyrosin.  See 
Tyrosin.  J.  Wickham  Legg. 

LEUCOCYTHAEMIA  (Aewc&j,  white,  Kbros, 
a cell,  and  ol/ict,  blood). — Synon.  ; Leukemia 
(Virchow) ; Splenopathia  leucocythemia  (Huss) ; 
Er.  Leucocythemie ; Diatfiese  lymphogene  a forme 
leucemique  (Jaccoud  );  Ger.  Lcucocythamie. 

Definition. — A chronic  disease,  in  which  there 
is  a considerable  and  permanent  increase  in  the 
number  of  the  pale  blood-corpuscles ; usually 
associated  with  enlargement  of  the  spleen,  some- 
times also  with  that  of  the  lymphatic  glands, 
and  with  disease  of  the  medulla  of  bone. 

The  term  leucocythaemia  proposed  by  the  late 
Dr.  Hughes  Bennett  is  a convenient  and  signifi- 
cant designation,  the  essential  feature  of  the  dis- 
ease being  the  excessive  proportion  of  leucocytes 
in  the  blood.  The  term  leukemia,  proposed  by 
Virchow,  is  less  obviously  accurate,  since  the 
blood  (as  Parkes  urged)  although  appreciably 
paler  than  normal,  is  not  white. 

Excess  of  leucocytes  in  the  blood,  slight  or 
transient,  is  known  as  leucocytosis,  and  is  met  with 
in  many  morbid  states.  Permanent  excess,  some- 
times considerable,  but  rarely  very  great,  also 
occurs,  associated  with  a primary  enlargement 
of  the  lymphatic  glands — ‘lymphatic  leucocy- 
thaemia.’ These  cases  differ  in  many  important 
respects  from  the  cases  of  leucocythaemia  a3St> 


LEUCOCYTILEMIA. 


820 

mated  with  primary  enlargement  of  the  spleen  ; 
so  that  it  is  most  convenient  to  describe  them  in 
connection  with  lymphadenoma,  and  to  consider 
here  only  cases  of  splenic  leucocythaemia.  See 
Lymphadenoma. 

History. — Pallor  of  the  blood,  as  if  pus  were 
mixed  with  it,  was  noted  by  Bichat  in  the  be- 
ginning of  this  century ; and  the  combination  of 
this  appearance  with  enlargement  of  the  spleen, 
was  observed  by  Velpeau  in  1827.  The  de- 
pendence of  this  alteration  in  the  blood  on  an 
excess  of  pale  corpuscles  was  described  by 
Donn6  iD  1844,  and  interpreted  by  him  as  due 
to  imperfect  transformation  of  white  into  red 
corpuscles.  In  1845,  two  cases  of  the  disease 
were  published  together,  the  one  by  Dr.  Craigie, 
the  other  by  Dr.  Hughes  Bennett ; and  to  the 
latter  appears  to  belong  the  credit  of  recognising 
the  salient  features  of  the  affection  as  a distinct 
malady.  A month  later,  however,  Virchow  pub- 
lished another  case,  independently  and  admirably 
worked  out.  In  all  these  cases  the  change  in 
the  blood  was  only  recognised  after  death.  It 
was  first  observed  during  life  in  1846,  by  Dr.  H. 
W.  Fuller,  and  subsequently  by  Dr.  Walshe.  In 
Germany  the  first  case  was  diagnosed  during  life, 
by  Vogel,  in  1848.  Since  then  numerous  cases 
and  descriptions  of  the  disease  have  been  pub- 
lished, of  which  the  more  important  are  those  of 
Virchow,  Hughes  Bennett,  Vidal,  Huss,  Ehrlich, 
and  Mosler. 

.Etiology. — In  only  a small  proportion  of  cases 
of  leueocythmmia  can  any  causation  be  traced. 
Race,  as  such,  seems  to  be  without  influence. 
Heredity  has  only  been  traced,  as  a history  of 
splenic  disease  in  ancestors  or  collaterals,  in  one 
or  two  isolated  instances.  The  disease  is  twice  as 
frequent  in  men  as  in  women.  It  may  oecur  at  all 
ages.  It  is  very  rare  under  the  age  of  ten,  and 
the  numbers  gradually  rise,  taking  both  sexes,  to 
the  decade  between  thirty  and  forty,  when  nearly 
one-third  of  the  total  occur  (46  out  of  154  cases). 
After  forty  they  fall  in  each  decennial  period.  In 
females,  however,  the  maximum  is  reached  in  the 
period  between  forty  and  fifty ; and  of  eleven  cases 
over  sixty  collected  by  the  writer,  only  one  was 
in  a woman.  Position  in  life  appears  to  exercise 
no  influence  on  the  occurrence  of  the  disease. 
Depressing  influences,  inanition,  over-exertion, 
and  especially  depressing  mental  emotion,  are 
antecedents  which  have  been  occasionally  noted. 
Sexual  processes,  in  women,  appear  to  have  a dis  - 
tinct influence.  The  disease  has  been  seen  to 
be  most  frequent,  in  them,  during  the  climac- 
teric decade,  and  practically  to  cease  when 
the  menstrual  epoch  is  over.  In  some  cases 
the  disease  has  commenced  during  pregnancy ; in 
a larger  number  it  has  succeeded  parturition. 
Injury  to  the  spleen  seemed,  in  one  or  two 
recorded  cases,  to  be  the  cause  of  the  disease. 
Small-pox,  typhoid  fever,  acute  rheumatism, 
pneumonia,  and  syphilis,  have  been  supposed  to 
be  causes  of  the  affection,  but  the  aetiological  re- 
lation is  doubtful.  Of  all  antecedent  conditions, 
intermittent  fever  is  incomparably  the  most 
frequent.  In  one-fourth  of  the  total  num- 
ber of  cases  (150)  analysed  by  the  writer,  there 
was  a history  either  of  ague  or  of  residence  in 
an  aguo  district.  The  interval  between  the 
malarial  affections  and  the  disease  varied  from  a 


few  months  to  thirty  years.  The  fact  that,  in 
many  cases,  a long  period  elapses,  and  that  the 
attacks  of  ague,  in  some  instances,  were  trifling 
makes  it  probable  that,  in  the  cases  in  which  th» 
patients  had  merely  lived  in  an  ague  district, 
the  malarial  influence,  which  did  not  cause  ague 
led  to  morbid  changes  which  eventuated  in  the 
leucocythaemia.  One  patient  under  the  writer’s 
care,  amiddle-aged  woman,  had  lived  in  amalarial 
district  only  during  the  first  few  years  of  her  life, 
but,  shortly  before  her  birth,  her  mother  had 
suffered  from  an  attack  of  ague. 

Anatomical  Characters.  — Blood.  — The 
blood,  as  seen  after  death  or  during  life,  is  paler 
than  normal,  and  may  even  be  greyish-red  in 
colour.  In  extreme  cases  coagulation  is  imper- 
fect ; a grumous  chocolate-brown  mass  results. 
After  defibrination  three  layers  form — red  cor- 
puscles, pale  corpuscles,  and  liquor  sanguinis. 
Under  the  microscope  the  pale  corpuscles  are 
seen  to  he  in  great  excess : instead  of  two  or  three 
per  field,  as  in  the  normal,  there  may  be  several 
hundreds.  Enumeration  (see  H hemacytometer) 
shows  that  not  only  are  the  white  corpuscles  in- 
creased, but  the  red  are  lessened  out  of  propor- 
tion to  the  increase  in  the  white,  so  that  the  total 
number  of  corpuscles  is  always  diminished.  In- 
stead of  the  normal  5,000,000  per  cubic  milli- 
metre, there  may  be  only  2,500,000  or  even 
1,150,000  (50  and  23  per  cent,  of  the  normal). 
The  proportion  between  the  white  and  red  varies, 
being  1-20,  1-10,  1-5,  1-2,  or  1-1;  or  the 
white  may  be  the  more  numerous.  The  apparent 
is  greater  than  the  real  excess  of  white,  in  con- 
sequence of  the  closer  contact  of  the  red.  It  was 
proposed  by  Magnus  Huss  to  regard  as  leuco- 
cythaemia only'  those  cases  in  which  the  propor- 
tion is  greater  than  1 to  20,  and  the  rule  has 
been  largely  followed  ; but  it  must  be  remem- 
bered that  in  commencing  cases  the  proportion 
may  be  smaller  than  this.  The  greatest  change 
hitherto  recorded  was  a reduction  of  the  red 
from  5,000,000  to  470,000  per  cubic  millimetre 
(9  per  cent,  of  the  normal),  and  an  increase  or 
the  white  to  680,000  per  cubic  millimetre  in- 
stead of  15,000,  the  normal  average.  The  pale 
corpuscles  may  be  of  normal  size ; but  usually 
some  are  large  ; and  often  many  are  smaller 
than  normal  (the  globulins  of  Donne),  especially 
when  the  lymphatic  glands  are  affected.  Re- 
agents bring  into  view  one  to  four  nuclei.  Some 
of  the  corpuscles  present  obvious  fatty  degenera- 
tion. The  red  corpuscles  are  usually  normal  in 
appearance,  sometimes  unduly  pale.  Nucleated 
coloured  corpuscles  have  been  seen  in  a few 
cases,  believed  to  be  intermediate  forms  between 
the  white  and  red  corpuscles.  The  specific 
gravity  of  the  blood  is  lessened  from  1,055,  the 
mean  in  health,  to  an  average  of  1,042  ; the 
change  being  due  to  an  increased  proportion  of 
water,  from  790  parts  per  1.000  in  health,  to 
840  in  leucocythaemia.  The  fat  and  fibrin  are 
increased,  and  the  latter  sometimes  presents  a pe- 
culiar granularappearance.  The  iron  is  lessened. 
Abnormal  constituents  have  also  been  found  in 
the  blood,  such  as  the  albukalin  of  Reichardt, 
mucin,  a substance  analagous  to  glutin,  hypo- 
xanthin,  lactic  and  formic  acids.  Minute  octa- 
hedral crystals  have  been  found  in  the  blood  ana 
in  many  organs  after  death,  about  '016  mm.  in 


length.  Their  nature  is  uncertain.  _ 
have  been  found  only  after  death,  it  is  conjec- 
tured that  the  substance  of  which  they  consist  is 
held  dissolved  during  life.  They  are  not  pecu- 
liar to  this  disease. 

Organs.— The.spleen  is  always  enlarged,  some- 
times extremely.  Its  weight  varies  from  twice 
to  fifty  times  the  normal — 1 lb.  to  18  lbs.  The 
average  of  72  cases  analysed  was  about  6 lbs. 
The  average  length  is  nearly  12  inches.  The  en- 
largement is  commonly  uniform;  the  shape  of  the 
or<mn  being  preserved.  The  surface  is  smooth, 
but  often  presents  traces  of  local  peritonitis,  in 
the  form  of  yellowish  opaque  patches.  It  is 
frequently  adherent  to  the  diaphragm,  omentum, 
abdominal  wall,  intestines,  or  liver.  _ Its  con- 
sistence is  usually  increased,  rarely  diminished. 
The  cut  surface  is  smooth,  and  yields  compa- 
ratively little  blood  ; it  is  brownish-red,  or  even 
brownish-yellow,  marbled  with  paler  lines,  due 
to  thickened  trabeculae.  The  Malpighian  fol- 
licles are  not  usually  conspicuous.  In  cases  which 
begin  with  enlargement  of  the  lymphatic  glands, 
and  which  are  really  cases  of  primary  lympha- 
denoma,  the  Malpighian  follicles  may  be  so 
t enlarged  as  to  constitute  small  growths.  There 
,s  rarely  an  area  of  distinct  softening.  Wedge- 
shaped,  yellowish-white,  caseous  portions  are 
frequent,  and  are  evidently  infarcts;  when  recent 
they  are  deep  red.  The  histological  change  in 
the  organ  is  an  overgrowth  of  the  splenic  pulp  ; 
the  trabecular  tissue  is  increased  ; and  so  also  is 
the  retiform  tissue  of  nucleated  fibres  and  cells, 
among  which  the  lymphoid  corpuscles  lie.  The 
Malpighian  bodies  may  not  be  discoverable  wdth 
the  microscope,  or  they  may  be  found  to  have 
undergone  fatty  or  lardaceous  degeneration.  The 
infarct-like  masses  present  the  splenic  tissue- 
elements  in  a state  of  fatty  degeneration.  In 
many  cases  the  crystals,  already  described,  have 
been  found  in  the  spleen  in  great  abundance. 
This  organ  has  been  found  by  analysis  to  contain 
glutin,  glycocoll,  hypoxanthin,  xanthin,  leucin, 
and  tyrosin. 

The  lymphatic  glands,  some  or  many,  are  en- 
arged  in  one-third  of  the  cases  of  primarily 
splenic  leucocythcemia  (51  out  of  157  cases). 
The  order  in  which  the  several  groups  are  af- 
ected  is,  beginning  with  the  most  frequent,  the 
nesenteric,  cervical,  inguinal,  axillary,  retro- 
peritoneal, thoracic,  portal,  and-  iliac.  In  only 
live  cases  was  the  change  universal.  The  en- 
irgement  is  not  considerable,  the  individual 
lands  rarely  attaining  the  size  of  a walnut, 
'hey  are  usually  smooth,  soft,  grey,  or  reddish- 
I'hite  on  section ; rarely  caseating  or  suppura- 
ng;  sometimes  presenting  haemorrhagic  extra- 
ctions. Their  minute  structure  differs  little 
om  the  normal.  Lymphoid  corpuscles  lie  in  an 
lenoid  reticulum,  which  is  rarely  increased,  as 
is  in  lymphadenoma. 

With  respect  to  the  alimentary  canal,  the 
lms  are  occasionally  swollen  and  ulcerated,  the 
veiling  being  due  to  infiltration  of  the  gum 
|ith  leucocytes,  or  to  an  actual  lymphoid 
owth.  The  tonsils  and  follicles  of  the  tongue 
e sometimes  enlarged  by  lymphoid  growth ; 
d there  may  be  a similar  change,  usually  slight, 
the  lymphoid  tissue  of  the  wall  of  the 
imach,  and  much  more  considerable  in  the 


82 1 

solitary  and  ngminated  glands  of  the  small  in- 
testine. These  growths  frequently  ulcerate. 
Similar  changes  are  also  found  in  the  large 
intestine.  The  peritoneum  sometimes  presents 
similar  growths.  The  liver  is  enlarged  in  at 
least  two-thirds  of  the  cases,  varying  in  weight 
from  5 lbs.  to  14  lbs.  In  some  cases  of  slight 
enlargement  no  structural  change  beyoDd  con- 
gestion has  been  found ; frequently,  however, 
there  are  disseminated  lymphoid  growths,  minute, 
greyish-white,  commonly  interlobular  in  position, 
often  surrounding  branches  of  the  portal  vein. 
The  capillaries  are  always  distended  with  pale 
corpuscles.  Fatty  degeneration  of  the  liver-cells 
is  also  common.  The  kidneys  are  abnormal  in  at 
least  one-half  of  the  cases.  They  may  be  simply 
pale  from  anaemia ; pale  and  enlarged,  from 
granular  degeneration  of  the  cells,  and  disten- 
sion of  the  capillaries  with  leucocytes ; or  they 
may  present  minute  growths  similar  to  those  in 
the  liver,  and  situated  between  the  tubuli  of  the 
cortex,  especially  near  the  glomeruli.  Marked 
fatty  degeneration  of  the  kidney  has  also  been 
found.  The  suprarenal  bodies  have  been  found 
diseased  in  several  cases,  and  in  one  or  two  there 
was  bronzing  of  the  skin.  The  thymus  and  thy- 
roid glands  have  also  been  found  enlarged.  The 
heart,  as  in  other  cases  of  intense  anaemia,  may 
present  granular  and  fatty  degeneration.  Ex- 
travasations of  blood  have  been  found  beneath 
the  endo-  and  pericardium.  Its  capillaries 
are  often  distended  with  leucocytes.  Pericar- 
dial effusion  is  common.  The  lungs  may  pre- 
sent simply  distension  of  capillaries,  or  haemor- 
rhagic infarcts,  or  actual  growths,  similar  in  struc- 
ture to  those  found  elsewhere.  These  commence 
at  the  bronchi  and  infiltrate  adjacent  tissues. 
Earely  they  may  break  down  and  form  cavities. 
Pleural  effusion  is  very  common,  and  lymphoid 
growths  have  been  found  on  the  membrane. 
In  the  brain,  haemorrhages,  usually  multiple, 
constitute  the  most  frequent  change.  Minute 
growths  in  the  membranes,  distension  of  the 
meningeal  vessels  with  pale  blood,  and  their  ob- 
struction by  masses  of  leucocytes  (Bastian),  have 
also  been  recorded.  The  skin  is,  in  rare  cases, 
the  seat  of  growths.  The  bones  have  lately 
been  found  diseased  in  many  cases  (Eanvier, 
Neumann,  &c.).  The  marrow  is  grey  or  reddish- 
grey,  diffluent,  and  presents  lymphoid  cells  and 
blood-corpuscles.  Sometimes  cells  intermediate 
between  white  and  red  corpuscles  have  been 
found  in  it.  The  vessels  are  fewer  than  normal. 
The  change  may  be  found  in  all  the  bones,  most 
marked  in  those  which  possess  most  spongy 
tissue,  as  the  ribs  and  vertebrae,  but  also  con- 
siderable in  the  long  bones.  Externally  the 
bones  may  be  normal  or  enlarged.  The  compact 
substance  may  be  reduced  in  thickness,  and  even 
perforated  (Mosler).  The  retina  is  frequently 
diseased.  Haemorrhages  may  be  found,  especially 
in  the  nerve-fibre  layers,  and  adjacent  to  them 
the  retinal  elements  may  be  degenerated.  The 
capillary  vessels  are  filled  with  pale  corpuscles, 
and  actual  lymphoid  growths  have  also  been 
found. 

Symptoms. — Of  the  early  symptoms  of  leuco- 
cythaemia,  the  most  frequent  are  those  due  to  the 
splenic  enlargement,  namely,  abdominal  fulness, 
pain,  or  an  actual  tumour.  Next  in  frequency  is 


LEU  COC  YTHiEMIA. 
Since  they 


LEU  COCYTH^EMIA. 


822 

weakness.  Haemorrhage,  especially  epistaxis,  often 
occurs  early,  but  rarely  before  othor  indications 
of  ill-health.  The  change  in  the  blood  causes  pal- 
Lor  of  skin  and  mucous  membranes,  shortness  of 
breath,  and  all  the  indications  of  anaemia.  To  its 
defect  a large  number  of  the  symptoms  to  be 
described  are  due.  The  altered  characters  of  the 
blood,  readily  observable  during  life,  have  been 
alreadydescribed.  The  temperature  isfrequently, 
but  not  invariably,  raised.  It  is  commonly  higher 
in  the  evening  than  in  the  morning;  the  evening 
rise  usually  reaching  101°-104°.  The  morning 
fall  may  be  considerable  or  slight.  Sometimes 
periods  of  considerable  pyrexia  alternate  with 
others  in  which  there  is  little  fever.  The  cases 
in  which  there  is  most  pyrexia  are  usually,  but 
not  always,  those  of  most  rapid  course.  The 
enlargement  of  the  spleen  presents  the  typical 
characters  of  a splenic  tumour.  It  may  occupy 
the  whole  left  half  of  the  abdomen,  extend  even 
beyond  the  middle  lino,  descend  into  the  iliac 
fossa,  and  even  into  the  pelvis,  so  as  to  be  per- 
ceptible by  vaginal  examination  (Spencer  Wells). 
It  may  vary  in  size  from  time  to  time.  Friction 
may  sometimes,  and  a bruit  da  souffle  rarely,  be 
heard  over  it.  It  usually  causes  an  unpleasant 
sense  of  distension,  is  often  tender,  and  sometimes 
is  the  seat  of  spontaneous  pain.  By  its  pressure  it 
may  raise  the  heart,  cause  considerable  dy.spncea, 
and  interfere  greatly  with  the  functions  of  the 
stomach.  The  distension  of  the  abdominal  wall 
may  cause  lines,  similar  to  those  of  pregnancy, 
to  appear  over  the  spleen,  and  their  position  is 
sometimes  distinctly  determined  by  the  couree  of 
vessels.  The  enlargement  of  the  glands  is  rarely 
sufficient  to  give  rise  to  other  symptoms  than  the 
obtrusive  evidence  of  their  presence.  The  glands 
1 hus  present,  in  this  disease,  a marked  contrast 
to  their  condition  in  lymphadenoma.  They  often 
lessen  in  size  before  death.  The  alteration  in  the 
bones  is  usually  unattended  by  symptoms.  Barely 
they  become  distinctly  enlarged  and  tender. 
Tile  action  of  the  heart  is  disturbed  by  both  the 
anaemia  and  the  displacement.  The  pulse  is 
frequent ; and  palpitation  is  common.  The  cir- 
culation is  impeded ; effusion  of  serum  into  the 
cellular  tissue  of  the  body  is  almost  invariable 
in  the  later  stages  of  the  disease.  Slight  ascites 
is  frequent,  and  great  effusion  is  sometimes  duo 
to  the  pressure  of  enlarged  glands  on  the  portal 
vein.  Hydrothorax  is  also  common.  The  most 
striking  circulatory  symptom  is  haemorrhage, 
which  occurs  in  a large  proportion  of  cases,  most 
frequently  from  the  nose,  and  less  frequently  from 
the  bowels,  stomach,  lungs,  uterus,  into  the  skin, 
brain,  joints,  cellular  tissue,  or  peritoneum.  The 
haemorrhagic  tendency  is  so  great  that  slight 
injuries  may  give  rise  to  serious  loss  of  blood  ; 
the  extraction  of  a tooth,  or  the  puncture  for 
paracentesis,  has  thus  led  to  death;  while  most 
cases  in  which  excision  of  the  spleen  has  been 
attempted  have  been  fatal  from  the  same  cause. 
The  respiration  is  usually  interfered  with,  partly 
from  the  splenic  enlargement,  and  partly  from 
the  anaemia  ; that  due  to  the  former  is  increased 
by  the  recumbent  posture.  The  anaemic  dyspnoea 
may  be  unnoticed  when  the  patient  is  at  rest, 
although  any  considerable  movement  causes  an 
agony  of  breathlessness.  The  dyspnoea  is  also  in- 
creased by  changes  in  the  lung,  bronchial  catarrh,  1 


and  the  frequent  pleural  effusion  in  the  later 
stages.  Cough  is  frequent,  and  may  be  an  early 
symptom  of  the  disease.  The  change  in  the  gums, 
already  described,  may  lead  to  ulceration— the 
‘ leuktemic  stomatitis  ’ of  Mosler;  but  it  is  more 
rare  in  this  disease  than  in  lymphadenoma.  The 
gastric  functions  are  chiefly  interfered  with  bv 
the  pressure  of  the  spleen,  which  causes  dyspep- 
sia, and  often  vomiting.  Diarrhoea  is  extremely 
common,  and  may  be  accompanied  by  haemor- 
rhage. The  enlargement  of  the  liver  may  be 
recognised  during  life,  but  rarely  gives  rise  to 
subj  ecti  ve  symptoms.  Jaundice  only  results  from 
compression  of  the  bile-ducts  by  enlarged  glands. 
A yellowish  tint  of  skin  is,  it  may  be  remarked, 
frequent,  apart  from  true  jaundice — the  ‘ icterus 
lienalis’;  it  probably  results  from  the  ansmia, 
the  altered  blood  being  unable  to  destroy  the  bile- 
pigment  absorbed  into  it  from  the  intestine.  The 
urine  varies  in  amount,  but  is  usually  strongly 
acid,  and  of  high  specific  gravity.  The  amount 
of  -urea  is  unaltered,  that  of  uric  acid  is  increased. 
Hypoxanthin,  lactic  acid,  and  formic  acid  hare 
been  found  in  it.  Albumin  is  rare,  apart  from 
structural  changes  in  the  kidneys.  Menstruation 
is  usually  arrested.  Thefunctions  of  the  nervous 
system  tire  disturbed  by  the  altered  blood;  lan- 
guor, tinnitus,  and  vertigo  are  frequent;  and 
slight  mental  failure,  delirium,  and  coma  are 
occasionally  met  with.  The  graver  symptoms 
are  probably  due  to  capillary  obstruction  bv 
masses  of  leucocytes,  or  to  small  haemorrhages. 
Besides  the  noises  in  the  cars,  deafness  is  com- 
mon, especially  towards  the  end.  I11  the  fundus 
oculi,  changes  may  usually  he  seen  with  the 
ophthalmoscope.  The  pallor  of  the  blood  in 
the  retinal  and  choroidal  vessels  is  conspicuous. 
The  retinal  veins  become  very  broad,  and  are 
often  tortuous.  Extravasations  of  blood  are  al- 
most invariable  at  some  period,  usually  striated, 
sometimes  rounded.  Yellowish  or  white  spots 
are  sometimes  seen,  due  to  the  collodions  of 
lymphoid  cells  already  described.  Occasionally 
the  retina  is  irregularly  thickened,  so  that  the  , 
vessels  present  conspicuous  antero-posterior 
curves.  Those  changes  constitute  the  ‘ leukamic 
retinitis’  of  Liebreich.  The  extent  to  which 
sight  is  interfered  with  depends  on  the  degree  to 
which  the  neighbourhood  of  the  macula  lutea  is 
involved.  The  skin  is  strikingly  pale,  or  some- 
times, as  already  stated,  greenish  yellow.  Occa- 
sionally a peculiar  dark  pigmentation  is  present. 
Sweating  is  common. 

Complications. — The  most  frequent  compli- 
cations of  leucoeythaemia  are  pleural  effusion, 
cedema  of  the  lungs,  lobar  pneumonia,  bronchial 
catarrh,  pericardial  effusion,  dilatation  of  the 
heart,  venous  thrombosis,  cerebral  haemorrhage, 
and  fatty  degenerations  ; and  the  more  rare  sie 
cirrhosis  of  the  liver  ; parenchymatous  degener- 
ation of  the  kidneys,  giving  rise  to  the  symptoms 
of  subacute  Bright’s  disease  ; renal  calculi ; per- 
sistent or  intermittent  erection  of  the  penis,  the | 
former  probably  due  to  thrombosis  in  the  cor- 
pora cavernosa;  oedema  of  depending  parts; 
ascites;  furuncles;  and  erysipelas.  The  various 
haemorrhages  are  rather  to  be  regarded  as  symp- 
toms of  the  disease  than  us  complications. 

Duration. — Cases  of  splenic  leucoeytlisemis 
vary  in  duration  from  six  months  to  seven  yeais. 


LEUCOCY 

One  or  two  recorded  cases  ran  their  course  in  less 
than  six  months.  The  average  duration  of  sixty- 
three  cases  was  two  years.  The  actual  duration 
of  the  affection  is  probably  longer  than  this,  be- 
cause the  disease  has  often  reached  a consider- 
■ able  degree  before  the  symptoms  became  trouble- 
some. 

Causes  of  Death.— The  most  common  causes 
of  death  in  leucocythaemia  are  loss  of  blood, 
asthenia,  diarrhoea,  cerebral  hemorrhage,  pneu- 
monia, and  pleurisy.  In  asthenia  the  actual  end 
is -often  duo  to  cardiac  failure.  The  haemorrhage 
most  frequently  fatal  is  from  the  nose,  the  next 
most  frequent  from  the  bowels. 

Pathology. — The  pathology  of  leucocythaemia 
is  still  involved  in  obscurity.  We  are  imper- 
fectly acquainted  with  the  normal  life-history  of 
the  blood-corpuscles.  For  a full  discussion  of 
the  facts  which  have  been  ascertained,  and  the 
theories  built  upon  them,  the  reader  is  referred 
to  the  writer  s article  on  the  disease  in  Reynolds’ 
System  of  Medicine,  Vol.  v.  It  is  only  pos- 
sible here  to  give  a brief  outline  of  the  patho- 
logy of  the  disease  which  these  facts  and  theories 
suggest.  Recent  researches  make  it  probable 
that  the  red  corpuscles  arise  from  a transforma- 
tion of  the  smaller  lymphoid  cells — globulins  of 
Donne,  hsematoblasts  of  Hayem — and  that  this 
transformation  takes  place  to  a large  extent  in 
the  splenic  pulp  and  in  the  marrow  of  hones, 
(tissues  which  have  many  histological  characters 
in  common.  If  these  tissues  are  diseased,  the 
i transformation  may  not  take  place,  and  the 
unchanged  lymphoid  cells  may  develop  into  the 
.ordinary  leucocytes,  which  are  either  retained  in 
these  tissues,  increasing  their  hulk  and  changing 
their  structure  still  further,  or  pass  into  the 
blood.  Both  results  probably  occur.  Hence  we 
assume  a primary  change  of  the  splenic  pulp, 
which  is  increased  further  by  the  retained  leu- 
tocytes.  Where  the  hsematoblasts  arise,  is  still 
.mcertain — they  are  probably  in  part  developed 
n the  splenic  pulp  and  marrow  of  bones,  from 
ire-existing  cells,  and  from  the  protoplasmic 
rahecul®  of  the  tissues  (Klein) ; probably  in  part 
hey  come  from  the  true  lymphatic  structures, 
:he  glands,  Malpighian  follicles  of  the  spleen,  &c. 
-’rimary  disease  of  these  lymphatic  structures 
(institutes  lymphadenoma  ; and  the  splenic  pulp 
nay  he  normal,  and  the  leucocytes  are  only  in 
■light  excess,  or  are  not  more  numerous  than 
hey  should  he.  In  true  splenic  leucocythaemia 
he  glands  and  Malpighian  follicles  are  not  pri- 
larily  diseased,  hut  they  may  suffer  secondarily, 
hen  lymphatic  growths  arise  in  organs  ; and 
tis  secondary  affection  is  in  part  the  result  of 
lie  accumulation  of  leucocytes.  That  the  en- 
irgement  of  the  spleen  is  not,  as  has  been 
tought,  merely  the  result  of  the  accumulation 
,i  it  of  pale  corpuscles  from  primarily  diseased 
lood,  is  shown  by  the  increased  consistence  of 
le  organ,  and  by  the  fact  that  the  splenic  tu- 
our  precedes  the  change  in  the  blood.  There  is 
>me  reason  to  believe,  that  as  the  spleen  alone 
ay  be  diseased,  so,  in  some  rare  cases,  the 
arrow  of  bones  may  alone  be  diseased,  and 
jay  give  rise  to  a primary  ‘ myelogenic  leuco- 
j'thsemia,’  but  this  is  not  yet  proved.  That 
e disease  may  be  primary  in  both  the  marrow 
'.dthe  spleen,  is  highly  probable,  from  recorded 


TIIjEMIA  . 823 

facts.  It  is  certain,  however,  that  the  marrow 
is,  in  most  cases,  not  affected  primarily,  and  may 
bo  unaffected  throughout,  or  may  suffer  second- 
arily, as  do  the  glands.  The  same  is  true  of 
the  collections  of  lymphatic  tissue  elsewhere  in 
•the  body.  The  cases  in  which  the  lymphatic 
glands  enlarge  early — ‘ lymphatico-splenic  leuco- 
cythsemia’—  are,  for  the  most  part,  if  not  entirely, 
cases  of  composite  nature.  The  spleen  presents 
a double  change — growths  in  the  follicles,  such 
as  are  associated  with  the  glandular  growths  in 
lymphadenoma  (Hodgkins’  disease),  and  increase 
in  the  splenic  pulp,  as  in  pure  splenic  leucoey- 
thaimia.  In  such  cases  there  may  be  a large 
increase  in  the  pale  corpuscles  of  the  blood. 

Diagnosis. — The  diagnosis  of  leucocythaemia 
rests  on  the  existence  of  enlargement  of  the  spleen, 
and  a considerable  excess  of  leucocytes  in  the 
blood.  In  all  cases  of  splenic  tumour,  the  blood 
should  he  examined ; if  the  proportion  of  white 
corpuscles  to  the  red  is  greater  than  1 to  20,  the 
case  is  certainly  one  of  leucoeythsemia.  But  if 
the  proportion  is  less  than  this,  leucocythaemia 
cannot  with  certainty  be  excluded,  because  it 
is  probable  that,  in  all  cases,  the  splenic  tumour 
and  anremia  precede  the  leucocytal  excess,  and 
the  latter  may  he  in  process  of  development. 
To  ascertain  the  actual  state  of  the  blood,  it  is 
always  desirable  to  enumerate  the  corpuscles 
with  the  hsemaeytometer.  Repeated  examina- 
tion, to  ascertain  that  the  proportion  of  pale  cor- 
puscles is  not  increasing,  is  necessary  before 
impending  leucoeythsemia  can  he  excluded.  In 
cases  in  which  the  lymphatic  glands  enlarge 
early,  the  question  arises  whether  the  case  is 
one  of  splenic  leucoeythsemia,  or  of  Hodgkins' 
disease.  In  the  latter,  as  just  stated,  the  enlarge- 
ment of  the  spleen  depends,  not  on  an  increase 
of  the  splenic  pulp,  hut  on  overgrowth  of  the  Mal- 
pighian follicles;  the  splenic  enlargement  is  less 
than  in  leucocythaemia,  and  is  less  uniform.  In 
the  composite  cases  alluded  to  above,  in  which, 
witli  enlargement  of  the  glands  and  splenic 
follicles  (lymphadenoma),  there  exists  also  over- 
growth of  the  splenic  pulp,  and  a considerable 
leucocytal  excess  in  the  blood,  the  two  morbid 
processes  are  conjoined,  and  the  affection  may- 
be termed  lymphadeno-splenic  leucocythaemia. 
These  cases  are  distinguished  from  the  simple 
splenic  affection  by  the  early  enlargement  and 
firmness  cf  the  glands.  In  simple-  splenic  leueo- 
cythaemia  the  affection  of  the  glands  is  usually 
late,  and  rarely  considerable.  The  diagnosis  of 
the  disease  from  conditions  in  which  a consider- 
able excess  of  pale  corpuscles  exists,  without 
enlargement  of  the  spleen,  is  usually  easy,  be- 
cause such  excess  is  transient,  soon  passes  away, 
and  is  not  associated  with  a splenic  tumour. 

Prognosis. — The  prognosis  of  a disease  which 
depends  on  a primary  affection  of  theblood-form- 
ingorgnnsis  necessarily  most  grave.  No  means  of 
arresting  the  progress  of  the  developed  disease  has 
yet  been  discovered.  The  immediate  prognosis 
is  less  serious  in  proportion  as  the  evidence  of 
organic  changes  in  the  blood-forming  organs  is 
slight,  and  in  proportion  to  the  early  stage  of 
the  disease.  Neither  age,  sex,  nor  causation 
affords  prognostic  information.  The  greater  the 
number  of  white  corpuscles  and  the  deficiency 
of  red,  as  ascertained  by  counting,  the  worse  the 


324  LEU  COC  YTHiEMI  A. 

prognosis.  The  size  of  the  spleen,  alone,  affords 
little  information.  Hemorrhages  are  of  grave 
augury,  but  epistaxis  least  so. 

Treatment. — The  knowledge  of  the  causes  of 
leueocythasmia,  slight  though  it  is,  suggests  im- 
portant prophylactic  measures — the  prevention 
of  ague,  and  the  careful  treatment  of  all  who 
have  been  exposed  to  malarial  influences.  Splenic 
tumours  resulting  from  such  exposure  should  be 
systematically  treated ; the  subjects  of  them 
should  exercise  great  care  to  avoid  exposure  to 
cold,  injuries,  and  all  causes  of  portal  congestion. 
These  precautions  are  especially  necessary  in 
women  at  the  menstrual  periods ; and  if  such 
women  bear  children,  their  state  during  preg- 
nancy and  after  parturition  should  be  carefully 
supervised,  and  lactation  prohibited.  Whether 
there  is  simple  anaemia  or  leucocythcemia,  every 
effort  should  be  made  to  reduce  the  size  of  the 
splenic  tumour,  by  quinine,  cold  affusion,  ergo- 
tine,  and  especially  by  voltaic  electricity,  a most 
powerful  agent.  By  obtaining  contraction  of  the 
spleen,  expelling  retained  leucocytes,  and  per- 
haps stimulating  directly  its  functional  action, 
we  render  its  condition  less  abnormal.  In  a caso 
of  anaemia  splenica  no  remedies  improved  the 
blood-state  till  the  spleen  was  galvanised,  when 
the  red  corpuscles  at  once  began  to  increase. 
Remedies  which  do  good  in  ordinary  anaemia 
have  slight  influence  in  this  disease.  Iron  is 
almost  useless;  cod-liver  oil,  however,  has  seemed 
to  do  some  good.  Arsenic  has  been  largely  tried, 
but  without  benefit  in  pronounced  cases.  Its 
undoubted  value  in  lymphadenoma  suggests  its 
further  trial  in  early  cases  ; it  should  be  given 
in  tho  largest  doses  that  can  be  borne.  Phos- 
phorus has  been  recommended,  but  in  almost 
every  case  of  pronounced  leueocythaemia  it  has 
been  powerless  for  good.  Nevertheless,  its  in- 
fluence in  improving  the  blood-state  in  lympha- 
denoma warrants  further  trial  in  the  early  stage 
of  the  disease.  Iodides,  bromides,  and  mercury 
are  useless.  Change  of  air  may  slightly  improve 
the  patient’s  state,  but  has  no  influence  on  the 
disease.  Transfusion  has  been  tried,  but  the 
results  are  not  encouraging.  Excision  of  the 
spleen  has  been  suggested.  The  operation  has 
been  performed  with  success  in  cases  of  anaemia 
splenica,  but  in  actual  leueocythaemia  the  opera- 
tion has  been  invariably  fatal— in  most  cases 
from  uncontrollable  loss  of  blood,  the  result  of 
the  haemorrhagic  tendency.  Further  trial  of  it, 
in  such  cases,  is  not  justifiable.  In  early  cases, 
where  there  is  no  considerable  excess  of  pale 
corpuscles,  and  the  red  are  not  reduced  below 
sixty  per  cent,  of  the  normal,  it  might  be  suc- 
cessful; but  it  is  questionable  whether,  in  such 
cases,  the  ultimate  issue  without  interference  is 
sufficiently  certain  to  justify  the  performance  of 
so  grave  an  operation.  Special  symptoms  may 
require  treatment.  Haemorrhage  must  be  checked 
by  the  usual  methods,  and  crystals  of  perchloride 
of  iron  may  be  applied  to  accessible  places  (Jon- 
ner).  For  vomiting,  a posture  which  will  relieve 
the  stomach  from  pressure,  and  counter-irrita- 
tion, are  usoful.  Aperients  should  be  employed 
with  caution  ; and  under  no  circumstances  should 
the  yellow  tint  of  the  skin  lead  to  the  use  of 
mercurials.  For  the  oedema,  digitalis  and  other 
diuretics  are  best.  For  the  splenic  pain,  counter  i 


LEUCORRHCEA. 

irritation,  sedative  liniments,  and  hypodermic 
injections  of  morphia  may  be  used.  In  propor- 
tion to  the  anaemia,  physical  rest  is  important 
that  the  diminished  supply  of  oxygen  may  not  be 
rendered  inadequate  for  the  need  of  the  tissues, 
by  muscular  exertion.  W.  R.  Gowers. 

LEUCOCVTOSIS  (Aeiocis,  white,  andici/Toi, 
a cell). — A condition  of  the  blood,  in  which  the 
white  corpuscles  are  appreciably  but  mode- 
rately increased.  See  Blood,  Morbid  Condi- 
tions of. 

LEUCODEEMA  (A.eu/d>s,  white,  and  5q>/±o, 
the  skin). — White  or  aehromatous  integument. 
See  Pigmentary  Skin-Diseases. 

LEUCOMA  (\evubs,  white) A white  opa- 

city of  the  cornea,  generally  referable  to  in- 
flammation or  ulceration  of  that  structure.  Set 
Eye  and  its  Appendages,  Diseases  of. 

LEUCOPATHIA  (\evKbs,  white,  and  vd&n 
a disease). — Synon.  : Albinism,  Achroma,  Leni-o- 
derma,  Leuce,  Leucasmus. 

This  disease  is  sometimes  general,  but  fre- 
quently  partial ; in  the  latter  form  constituting 
cutis  variegata  and  ‘ piebald  skin.’  The  -white- 
ness is  referable  to  absence  of  pigment,  which 
may  be  simply  due  to  an  arrest  of  function  of 
tho  rete  mucosum,  or  to  an  organic  alteration  of 
the  integument.  See  Pigmentary  Skin-Dis- 
eases. 

LETTCO-PHLEGMATIC  TEMPERA- 
MENT. See  Temperament. 

LEtTCORRHCEA  (Aeuxos,  white,  and  |Ss»,  I 
flow). — Synon.:  Fr.  Leucorrhee;  Ger.  Weisser 
Flues;  Lat.  Fluor  All/us;  Pop.  ‘ The  'Whites ’ ; 

‘ White  Discharge.’ 

Definition. — A non-hsmorrhagic  discharge, 
of  pale  colour,  escaping  from  the  female  genital 
fissure. 

-Etiology. — Leucorrhcea  is  a symptom  rather 
than  a distinct  disease  ; and  is  found  resulting 
from  all  the  morbid  processes  that  lead  to  hy- 
per-secretion from  the  genital  mucous  surfaces, 
or  from  the  glands  opening  upon  them,  whether 
tho  mucous  membranes  be  injured  or  entire.  It 
is,  however,  a source  of  much  discomfort  and 
deterioration  of  health,  and  so  demands  special 
treatment. 

Symptoms. — Leucorrhcea  presents  several  dis- 
tinct varieties  according  to  the  seat  of  its  cause ; 
and  the  symptoms  of  each  variety  require  sepa- 
rate consideration. 

1.  Vulvar  Leucorrhcea. — In  this  variety  a 
glairy  viscid  secretion  is  found  bathing  the  ap- 
posed surfaces  of  the  pudenda,  stiffening  into  a 
crust  on  the  surface  of  the  labia  majors  or  on 
the  insides  of  the  thighs,  and  sometimes  glueing 
the  lips  more  or  less  firmly  together  at  their 
margins.  It  is  usually  derived  from  the  mnei 
parous  glands  covering  the  internal  surfaces  of 
the  labia  majora  and  the  nymphs  ; but  in  cases 
of  special  eruptions  and  general  vulvitis  it  m37 
come  from  the  vestibular  surface ; and  in  still 
rarer  cases  it  is  poured  out  from  the  glands  of 
Bartholin.  Vulvar  leucorrhcea  is  met  with  al 
any  period  of  life,  hut  is  most  common  in  the 
young,  infantile  leucorrhcea  almost  always  being 
of  this  variety.  In  cases  of  gonorrhoeal  infection 


LEUCORRHCEA. 


in  the  female,  the  vulva  is  usually  the  seat  of  a 
profuse  discharge  that  is  apt  to  become  puru- 
lent, but  it  is  rarely  confined  to  this  situation, 
spreading  both  into  the  urethra,  and  upwards 
into  the  higher  spheres  of  the  genital  mucosa. 

2.  Vaginal  Leucorrhcea. — The  discharge  in 
cases  of  vaginal  leucorrhcea  is  most  frequently 
white  in  appearance,  of  acid  reaction,  and  due 
to  a secretion  from  the  general  surface  of  the 
vaginal  mucous  membrane.  Its  whiteness,  on 
microscopic  examination,  is  found  to  be  owing  to 
the  presence  of  quantities  of  scaly  epithelial 
cells,  many  of  which  are  crowded  with  fatty  par- 
ticles, whilst  others  have  been  quite  dissolved  in 
consequence  of  the  fatty  degeneration.  Some- 
times the  discharge  has  a more  yellowish  tint, and 
then  it  is  found  to  contain  quantities  of  pus-cells 
among  the  epithelial  scales.  In  the  former  group 
of  cases  we  have  to  do  with  a simple  catarrhal 
condition  of  the  vaginal  mucosa  ; in  the  latter 
there  are  red  granulation-like  spots  scattered 
over  the  membrane,  which  has  here  lest  its  epi- 
thelial covering.  Vaginal  leucorrhcea  is  a com- 
plaint to  which  women  are  specially  liable  during 
their  reproductive  life.  The  catarrhal  form  is 
extremely  common  in  young  married  females  ; 
whilst  the  other  form  occurs  rather  about  the 
menopause,  or.  if  occurring  earlier,  is  complicated 
with  some  of  the  other  varieties  of  leucorrhoea. 
Apart  from  specific  causes,  it  may  be  brought 
on  by  sexual  excesses ; by  the  presence  of  a 
foreign  body,  such  as  a pessary ; by  a displaced 
uterus;  by  a chill;  or  by  any  condition  that 
interferes  with  the  circulation  in  the  pelvis.  In 
a large  proportion  of  cases  it  is  secondary  to  the 
next  variety  of  leucorrhcea. 

3.  Cervical  Leucorrhoea.  — The  discharge 
that  comes  from  the  canal  of  the  cervix  uteri  is 
transparent,  like  unboiled  white  of  egg,  very 
tenacious,  and  of  alkaline  reaction.  It  may  still 
present  these  characters  as  it  escapes  from  the 
pudenda ; but  it  generally  becomes  somewhat 
clouded  as  it  passes  through  the  vaginal  canal, 

. and  gets  acted  upon  by  the  acid  secretion  from  the 
vaginal  walls.  Independently  of  this  change  in 
the  vagina,  it  is  sometimes  found  already  more 
or  less  opaque  as  it  lies  within  the  cervical  canal, 
and  may  he  seen  of  a yellowish  or  greenish  or 
reddish  tint  in  various  cases.  The  clear  cervical 
leucorrhoea  is  seen  under  the  microscope  to  be 
made  up  of  a viscid  magma,  having  entangled 
jin  it  large  numbers  of  columnar  epithelial  cells, 
which  have  a tendency  to  arrange  themselves  in 
tows.  These  are  easily  seen  to  be  the  ciliated 
ipithclial  cells  that  cover  the  normal  mucous 
uembrane,  but  deprived  for  the  most  part  of 
heir  cilia.  They  are  accompanied  by  smaller 
ounded  cells  like  mucous  corpuscles  or  wander- 
ng  cells,  partly  derived  from  the  interior  of  the 
;rypts,  and  partly  shed  from  the  general  surface 
rom  which  the  epithelium  has  been  removed, 
n almost  all  cases  some  of  the  epithelial  cells 
nd  mucous  corpuscles  are  charged  with  fatty 
articles,  and  surrounded  with  granules,  resulting 
•om  the  breaking  down  of  some  of  their  number, 
he  more  turbid  the  fluid,  the  more  the  cells 
re  found  to  have  undergone  such  degeneration  ; 
id  where  the  discharge  is  profuse,  fluid,  and  of 
dlowish  colour,  it  has  more  the  characters  of  a 
indent  fluid  in  which  the  relatively  few  cylin- 


825 

drical  cells  are  changed  in  form,  becoming  oval  or 
rounded,  and  nearly  all  reduced  to  a compound 
granular  mass.  The  more  deeply  tinted  dis- 
charges owe  their  discoloration  to  the  admix- 
ture of  blood,  the  rod  corpuscles  of  which  can 
easily  be  recognised.  Apart  from  the  leucorrhceas 
of  specific  origin,  this  is  the  commonest  of  all 
the  varieties.  It  maybe  found  in  females  of  any 
age,  but  specially  affects  women  during  their 
reproductive  history,  and  more  especially  those 
who  have  been  mothers.  We  can  understand  the 
special  liability  of  the  cervix  to  catarrhal  affec- 
tions, when  we  remember  that  all  intra-uterine 
discharges  pass  through  and  may  irritate  it ; that 
it  is  exposed  to  damage  during  the  transit  of  the 
foetus  in  parturition;  thatvaginalaffeetionseasily 
pass  into  it  by  continuity  of  structure  ; and  that 
it  may  readily  be  injured  by  foreign  bodies  in  the 
vaginal  canal,  or  even  by  fretting  of  its  orifice 
against  the  vaginal  wall  in  cases  of  displacement 
or  excessive  mobility. 

4.  Intra-uterine  Leucorrhoea. — Here  also 
the  discharge  is  transparent,  like  white  of  egg, 
and  alkaline  in  its  reaction,  but  it  is  more  fluid 
than  the  secretion  from  the  cervical  canal,  and 
may  escape  as  a clear  liquid  from  the  genital 
fissure.  In  cases  of  long  standing,  more  particu- 
larly where  there  exists  some  organic  disease  in 
the  uterine  parietes,  the  fluid  becomes  turbid, 
purulent,  and  more  frequently  than  in  any  other 
variety  of  leucorrhcea  tinged  with  blood,  even 
alternating  with  irregular  discharges  of  blood. 
Under  the  microscope  we  see  many  cylindrical 
epithelial  cells,  not  infrequently  ciliated;  along 
with  groups  of  smaller  cells,  partly  cylindrical, 
partly  rounded,  that  have  been  discharged  from 
the  uterine  follicles ; all  imbedded  in  a mucous 
fluid.  Where  the  discharge  is  more  turbid,  tho 
epithelial  cells  are  seen  to  be  undergoing  fatty 
degeneration,  and  to  be  accompanied  with  wan- 
dering cells,  pus-globules,  and  crowds  of  free 
fatty  particles.  This  uterine  leucorrhoea  may  be 
found  at  any  period  of  life,  but  as  an  indepen- 
dent affection  it  is  found  almost  exclusively  in 
virgins  or  your.g  married  women,  or  in  women 
who  are  ceasing,  or  have  ceased,  to  menstruate. 
In  the  last-named  class  of  cases  the  cervix  is 
often  atrophied,  and  its  orifices  narrowed ; and 
tho  intra-utorine  secretion  may  accumulate  for 
a time,  and  be  expelled  with  some  degree  of  suf- 
fering. Most  frequently  it  is  found  associated 
with  cervical  leucorrhoea,  the  endo-cervical  affec- 
tion having  passed  up  to  the  endometrium,  or, 
more  rarely,  vice  versa.  Perhaps  the  most  fre- 
quent form  of  it  is  found  in  women  who  are 
subject  to  a leucorrhoeal  discharge  before  or 
after  the  menstrual  periods ; and  in  the  cases  of 
amenorrhea  where  a pale  discharge  escapes  at 
the  usual  menstrual  periods,  this  has  its  source 
in  the  interior  of  the  uterus  proper. 

o.  Tubal  Leucorrhoea. — ■ Doubtless  some 
small  portion  of  the  fluid  that  escapes  in  certain 
eases  of  leucorrhcea  is  furnished  by  the  Fallopian 
tubes ; but  despite  the  elaborate  attempts  of  Hen- 
nig  and  others  to  establish  a distinction  between 
it  and  the  other  varieties,  it  remains  rather  as  a 
subject  of  pathological  interest  than  of  clinical 
importance,  and  need  not  occupy  us  further  here. 

Diagnosis. — The  statements  of  a patient  in 
regard  to  a lencorrhosal  discharge  cannot  be  re« 


R23  L E U CORRHQE  A. 

lied  on  in  establishing  a diagnosis  as  to  its  source. 
If  it  be  white  and  flaky  we  may  judge  that  it  is 
vaginal ; if  more  transparent,  and  escaping  in  half- 
coagulated  flocculi,  we  may  conclude  that  it  is 
cervical ; whilst  a clear  and  more  continuous  and 
fluid  discharge  would  be  more  justly  referred  to 
the  uterus  proper.  But  it  is  never  safe  to  trust 
merely  to  the  appearance  of  the  discharge  as  it 
escapes  from  the  vulva,  for  it  may  have  become 
modified  as  it  lay  in  or  traversed  some  part  of 
the  canal,  or  may  be  compounded  of  fluids  derived 
from  different  surfaces.  The  seat  of  the  dis- 
charge must  therefore  be  exposed.  In  the  vul- 
var variety  it  suffices  to  separate  the  labia  and 
occasionally  to  expose  the  navicular  fossa  and 
the  orifices  of  the  Bartholinian ducts,  bypassing 
the  finger  into  the  anus.  The  vaginal  form  of 
leucorrhcea  requires  for  its  detection  the  use  of  a 
speculum,  duck-bill  or  tubular  ; and  the  cervical, 
one  of  these  or  a bi-valve  speculum.  For  the 
diagnosis  of  intra-uterine  leucorrhcea  it  is  some- 
times helpful  to  remove  some  of  the  fluid  for 
microscopic  examination  by  means  of  a fine 
syringe.  Unless  a clear  history  of  infection  can  be 
obtained,  it  is  almost  impossible  to  establish  a 
distinction  between  a gonorrheal  discharge  and 
the  simpler  catarrhal  leucorrhoea.  In  the  former 
there  is  a very  notable  tendency  to  spread  through 
all  the  contiguous  mucous  surfaces,  though  the 
vulva  may  he  predominantly  affected.  In  chil- 
dren suffering  from  the  infectious  discharge, 
traces  of  the  injuries  that  are  usually  inflicted 
at  the  period  of  infection  should  be  sought  for. 

Treatment. — In  instituting  our  treatment  of 
leucorrhoea  it  is  of  the  first  importance  to  have  in 
view  the  constitutional  condition  of  the  patient  ; 
to  use  means  to  counteract  any  diathetic  ten- 
dency— tuberculous,  strumous,  or  syphilitic; 
and  to  raise  as  far  as  possible  the  general  stan- 
dard of  the  patient's  health,  by  tho  administra- 
tion of  tonics,  and  the  enforcement  of  a suitable 
diet  and  regimen.  It  is  partly  in  this  way  that 
a change  of  residence  is  often  useful;  and  in 
making  a change,  it  is  well  for  the  patient  to  go 
to  some  of  tho  spas,  such  as  Ems  or  Kissingen, 
the  waters  of  which  are  helpful  in  reducing  con- 
gestions and  catarrhs  of  the  pelvic  viscera.  In 
young  women  of  relaxed  habit  of  body,  it  mav  be 
enough  to  prescribe  quinine  and  iron  or  arsenic, 
and  the  daily  use  of  a cold  sponge  bath;  and  in 
infantile  leucorrhcea,  cod-liver  oil  aud  iodide  of 
iron  should  be  administered. 

In  the  great  majority  of  cases  of  leucorrhoea, 
6ome  kind  of  local  treatment  becomes  an  absolute 
necessity.  Sometimes  it  is  enough  to  pay  strict 
attention  to  cleanliness,  washing  the  pudendal 
surfaces  with  a soft  sponge,  or  syringing  the  va- 
ginal canal  with  tepid  water;  and  even  when  as- 
tringent applications  are  to  be  made,  the  surfaces 
should  first  be  subjected  to  a detergent  stream 
of  water.  Where  there  is  marked  congestion  of 
tho  uterus  it  is  best  to  make  the  injections  with 
hot  water,  and  to  keep  the  stream  passing  through 
the  vagina  for  at  least  five  minutes  at  a time  ; 
the  immediate  relaxation  of  the  blood-vessels 
and  hyperaemia  being  followed  by  contraction  of 
their  walls,  which  favours  the  cessation  of  the  dis- 
charge. The  astringents  most  serviceable  for 
checkinguidiwmnd leucorrhceas  are  alum, 
Illuminated  iron,  acetate  of  lead,  sulphate  of  cop-  I 


LICHEN. 

per,  sulphate  of  zinc,  borax,  and  infcsiont  of 
oak-bark,  matico,  and  other  vegetables  charged 
with  tannin.  They  are  best  applied  in  the 
form  of  an  injection  with  a Higginson’s  tyringe. 
having  a vaginal  nozzle  attached  to  it ; or  of  a 
douche  through  a long  india-rubber  tube,  with  a 
stop-cock  for  regulating  the  flow  fitted  clos« 
to  the  vaginal  nozzle,  and  the  other  extremiw 
opening  into  a wide  receptacle,  or  fitted  to  a 
filler  into  which  the  fluid  is  poured.  Where  there 
is  a difficulty  in  using  the  injection,  and  where 
it  is  desirable  to  keep  np  a more  prolonged  ap- 
plicationof  the  medicament,  it  maybe  introduced 
into  the  vagina  in  the  form  of  pessaries  made 
with  cacao-butter  or  with  gelatine.  Topical  appli- 
cations to  tne  canal  of  the  cervix  and  cavity  of 
the  uterus  ought  always  to  be  made  tlirough  the 
speculum,  and  without  such  applications  it  is  a 
hopeless  task  to  undertake  the  cure  of  cervical 
leucorrhcea.  Here,  more  concentrated  or  more 
powerful  astringents  or  escharotics  become 
necessary.  Nitrate  of  silver  in  the  form  of  a 
stick  of  caustic  is  easily  applied,  but  its  repeated 
application  may  lead  to  mischief.  Zinc-alum, 
dried  sulphate  of  zinc,  sulphate  of  copper,  per- 
chloride  of  iron,  or  tannin  may  be  introduced  in 
the  form  of  rods  or  arrows  made  with  starch  and 
giun.  If  a uterine  sound  or  stiletto  be  dipped 
in  water  and  a thin  film  of  cotton  wadding 
wrapped  round  the  point  to  the  length  of  about 
two  inches,  the  adherent  mucus  can  be  cleared 
away,  and  the  same  or  another  sound  mounted 
with  wadding  can  be  charged  with  fuming  nitric 
acid,  or  the  acid  nitrate  of  mercury,  or  strong 
carbolic  acid,  or  a solution  of  perchloride  of 
iron,  or  tincture  of  iodine,  and  carried  through 
the  speculum  along  the  cervical  canal.  In  intra- 
uterine leucorrhoea  it  becomes  necessary  to  carry 
the  application  right  up  in  the  same  way  to  the 
interior  of  the  uterus.  It  is  usually  best  to  be- 
gin with  one  of  the  stronger  liquids,  apply  it 
a few  days  after  a menstrual  period,  and  folio" 
it  up  with  applications  of  iodine.  So  long  as  the 
stiletteor  sound  with  the  dry  waddingpasses  easily 
through  the  os  internum,  it  is  usually  necessary 
to  continue  from  time  to  time  the  intra-nterine 
application. 

Alexander  Bussell  Simpson. 

LEUKAEMIA.  See  Leccoctthxmia. 

LEUTERBAD  (Locite),  in  Switzerland. 
Thermal  earthy  waters.  See  Mineral  Waters. 

LICE,  Diseases  due  to.  See  Pedicclus. 

LICHEN  (AeixV,  an  eruption). — This  term 
was  originally  assigned  to  lichens  of  the  vege- 
table kingdom  from  the  idea,  which  is  by  them 
suggested,  of  adhesion  to  the  bark  of  a tree. 
Subsequently  the  term  became  transferred  to  a 
diseased  state  of  the  skin,  but  the  precise  nature 
of  that  disease  is  unknown  at  the  present  day. 
The  affection  which  most  nearly  realises  the 
signification  of  the  term  is  lepra  vulgaris,  r'~ 
possibly  a centrifugal  cluster  of  papulae.  In  the 
latter  sense  the  term  was  adopted  by  Willan,  and 
since  his  time  it  has  been  generally  accepted  ns 
the  type  of  a papular  eruption  of  the  skin.  TVitl 
this  acceptation  lichen  is  a folliculitis  attended 
with  prominence  in  the  form  of  a minute  pimple 
and  may  be  associated  with  eczema — as  in  ibi 


LICHENS 

instance  of  lichen  simplex,  lichen  circumscriptus, 
lichen  agrius,  and  lichen  tropicus  ; or  with  urti- 
caria— as  in  lichen  urticatus.  It  may,  however, 
be  independent  of  these,  as  in  lichen  pilaris, 
lichen  planus,  and  the  eruption  described  by 
Hebra,  under  the  name  of  lichen  scrofulosorum. 
See  Appendix.  Erasmus  Wilson. 

LIENTERIC  (\e~Los,  smooth,  and  tvr epov, 
the  intestine). — A form  of  diarrhoea  in  which 
the  stools  contain  much  undigested  food,  in  con- 
sequence of  its  having  passed  rapidly  along  the 
alimentary  canal.  See  Diarrhcea  ; and  Stools. 

LIGHTNING,  Effects  of. — The  effects 
produced  by  lightning  differ  only  in  degree  from 
those  produced  by  the  discharge  of  static  electri- 
city, generated  in  the  laboratory.  With  a Leyden 
jar  of  sufficient  size  a small  animal  may  be  killed, 
and  in  larger  animals  the  effects  of  shock  and 
local  injury  may  be  produced.  By  lightning  a 
person  may  be  killed  outright,  and  a post-mortem 
examination  may  reveal  no  lesion  whatever.  The 
mode  of  death  in  these  eases  seems  to  be  by  the 
shock  to  the  brain  and  nervous  system  generally. 
Effects  not  distinguishable  from  ordinary  con- 
cussion of  the  brain  may  be  observed,  and  the 
person  struck  may  remain  insensible,  with  slow 
respiration,  scarcely  pereeptible  pulse,  and  dilated 
pupils,  for  periods  varying  from  a few  minutes  to 
more  than  an  hour.  This  may  be  followed  by 
complete  recovery;  or  there  may  remain  paralysis 
of  the  limbs,  usually  the  lower,  or  occasionally 
derangements  of  the  special  senses — blindness,  a 
metallic  taste  in  the  mouth,  noises  in  the  ears, 
and  an  odour  in  the  nose.  The  brain  may  be  more 
or  less  permanently  affected,  and  we  read  of 
delirium,  mania,  and  loss  of  memory  as  results 
of  the  lightning-stroke.  Various  objective  phe- 
nomena have  also  been  observed.  The  electricity 
.on  its  way  through  the  body  may  produce  a 
number  of  mechanical  effects.  Wounds  like  those 
produced  by  a blunt  stabbing  instrument  may 
nark  the  points  of  entry  and  of  exit ; bones  have 
oven  been  broken,  the  membrana  tympani  has 
been  ruptured,  and  internal  viscera  have  suffered 
n a similar  way.  Patches  of  erythema,  urticaria, 
'mperficial  ecehymoses,  and  scorchings  of  the 
urface  having  a curious  tree-like  and  branched 
.rrangement,  have  all  been  described ; and  this 
ast  phenomenon  has  apparently  given  rise  to  the 
ssertion  that  delineations  of  trees  standing  in 
he  neighbourhood  of  the  accident  have  been 
.raced  photographically  on  the  body  of  the  vic- 
im.  Lightning  is  apt  to  be  attracted  by  any 
betal  w orn  about  the  body.  Watch-chains  are 
■equently  broken  and  fused,  and  by  the  intense 
eating  of  these  metallic  conductors  the  clothing 
.as  been  set  on  fire.  Watches  have  been  broken 
'ad  partially  fused,  and  have  forcibly  burst 
trough  the  pockets  in  which  they  were  con- 
ined.  Steel  articles,  such  as  pocket-knives,  have 
ten  rendered  magnetic.  The  clothing  is  some- 
mes  burnt  and  torn  to  a great  extent,  and  strong 
tots  have  been  found  burst  open,  or  thrown  off 
e feet  to  a distance,  or  nails  in  the  soles  have 
en  driven  out  of  them.  The  remote  effects  of 
;htning  are  due  to  the  mechanical  injuries  pro- 
ved by  it:  permanent  paralyses  may  result 
>m  injury  to  the  nerves,  and  inflammatory 


LITHONTRIPTICS.  827 

action  may  be  set  up  by  the  injury  inflicted  on 
internal  or  external  parts.  One  ease  is  recorded 
in  which  the  whole  of  the  hair  on  the  head  and 
body,  as  well  as  the  nails  of  both  hands,  came 
off  after  a lightning  stroke.  It  has  been  asserted 
that  rigor  mortis  does  not  occur  in  persons  killed 
by  lightning,  and  that  the  blood  remains  fluid 
for  a very  long  time  after  death,  but  neither  of 
these  facts  has  been  substantiated. 

Treatment. — The  treatment  of  those  who  have 
been  struck  by  lightning  consists  in  first  rousing 
and  keeping  up  the  respiration  and  circulation. 
The  cold  douche  is  often  of  great  value,  and  this, 
combined  with  friction  of  the  limbs,  warmth  to 
the  extremities,  and  the  administration  of  stimu- 
lants, either  by  the  mouth  or  in  the  form  of 
enemata,  would  seem  to  be  the  measures  best 
calculated  to  restore  the  suspended  animation. 
Secondly,  special  injuries  must  be  subsequently 
treated  according  to  their  nature. 

G.  V.  Poore. 

LINE^l  ATROPHIC2E  (Lat.  Atrophic 
lines). — A form  of  scleroderma.  See  SCLERO- 
DERMA. 

LIPOMA  (Aliros,  fat).  — A fatty  tumour. 
See  Tumours. 

LIPPSPRINGE,  in  Germany. — Earthy 
waters.  See  Mineral  Waters. 

LISBON,  West  Coast  of  Portugal.  — - 
Warm,  moist  climate,  with  very  variable  tem- 
perature. Mean  temperature  in  winter.  51°  Fahr. 
Prevailing  winds,  N.E.-S.E.  in  spring;  S.W, 
rainy.  See  Climate,  Treatment  of  Disease  by. 

LISDOONVARNA.  in  Ireland.— Sulphur 

waters.  See  Mineral  Waters. 

LITHIASIS.  LITHIC  ACID  DIA- 
THESIS (\ldcs,  a stone).  See  Gout  ; and  Uric 
Acid  Calculus  and  Diathesis. 

LITHONTRIPTICS  (\l0os,  a stone,  and 
Tpiipis,  friction). — Synon.  : Fr.  Lithontriptiques ; 
Ger.  Steinaufloscnde  Mittel. 

Definition. — Lithontriptics  are  therapeutical 
measures  used  for  the  purpose  of  dissolving  cal- 
culi in  the  urinary  tract. 

Enumeration. — The  chief  lithontriptics  are  : 
Water,  Potash,  Lithia,  Borax,  Phosphate  of  Soda, 
Soap,  Lime-water,  Nitric  Acid,  Phosphoric  Acid, 
Hydrochloric  Acid,  Sulphuric  Acid,  and  Mineral 
Waters,  such  as  those  of  Wildungen. 

Action.  - — • Lithontriptics  dissolve  stone  in 
various  ways.  Some  of  them  possess  a simple 
solvent  action,  as  in  the  case  of  water.  Others 
unite  with  the  calculi  so  as  to  form  a more 
soluble  compound,  as  in  the  case  of  the  union  of 
potash  or  lithia  with  the  uric  acid  of  a calculus, 
producing  urate  of  potash  or  lithia,  which  is 
more  soluble  than  uric  acid  itself.  In  the  case 
of  phosphatie  calculi  dilute  nitric  acid  combines 
with  the  bases  of  which  they  are  composed  to 
form  a more  soluble  compound. 

Uses. — Lithontriptics  may  be  employed  for 
tlio  purpose  of  dissolving  calculi  either  in  the 
kidney  or  in  the  bladder.  They  may  either  be 
taken  internally,  so  as  to  act  upon  the  calculi 
through  the  medium  of  the  urine  ; or  be  injected 
directly  into  the  bladder.  This  latter  treatment 
can  only  be  adopted  in  the  case  of  a vesical  cal- 


828  LITHONTEIPTICS. 

cuius,  and  is  inapplicable  in  the  case  of  a renal 
calculus.  The  most  useful  of  all  lithontriptics  is 
water,  and  especially  distilled  water.  When 
this  is  taken  in  large  quantities,  the  urine  be- 
comes very  dilute^  and  small  calculi  may  be 
partially  dissolved,  so  as  to  be  reduced  in  size 
and  ejected  through  the  natural  passages.  If  the 
calculus  is  composed  of  uric  acid,  potash  or 
lithia  is  the  best  remedy  for  internal  adminis- 
tration, the  urates  of  these  bases  being  mere 
soluble  than  the  urate  of  soda.  In  the  case  of 
phosphatic  calculi,  acid  remedies  are  employed 
instead  of  alkaline;  but  it  is  exceedingly  difficult 
to  render  the  urine  acid  by  means  of  acids  given 
by  the  mouth,  unless  they  are  administered  in 
quantities  likely  to  derange  the  digestion.  In 
place  of  mineral  acids,  benzoic  acid  and  benzoate 
of  ammonia  have  been  employed,  as  benzoic  acid 
passes  out  of  the  body  in  the  form  of  hippuric 
acid,  giving  an  acid  reaction  to  the  urine.  On 
account  of  this  difficulty,  acids  have  been  di- 
rectly injected  into  the  bladder,  in  order  to  act 
directly  upon  the  stone;  for  which  purpose  nitric 
acid,  largely  diluted,  is  the  one  which  has  been 
most  generally  employed.  This  procedure,  how- 
ever, is  now  rarely  had  recourse  to,  as  it  is  much 
easier  to  crush  the  stone  by  mechanical  means. 

T.  Laud sr  Brunton. 

LITH  UKIA  (\i6os,  a stone,  and  olpov,  the 
urine). — A condition  in  which  a deposit  of  uric 
acid  or  urates  takes  place  in  the  urine.  See 
Uric  Acid  Calculus  and  Diathesis  ; and  Urine, 
Morbid  Conditions  of. 

LIVEE,  Diseases  of. — Synon.  : Fr.  Mala- 
dies dn  Foie ; Ger.  Krankhcitcn  Fr  Leber. 

The  liver  is  an  organ  which  has  always  occu- 
pied a prominent  place,  both  with  the  pro- 
fession and  the  public,  as  being  the  seat  of 
important  diseases,  as  well  as  the  origin  and 
source  of  numerous  symptoms  and  ailments.  Not 
only  is  it  concerned  in  the  formation  of  one 
of  the  principal  secretions,  namely,  the  bile, 
but,  according  to  most  physiologists,  it  has  a 
peculiar  glycogenic  function ; and  some  autho- 
rities now  maintain  that  it  is  in  this  organ  that 
urea  is  formed.  Moreover,  a large  quantity  of 
blood  passes  through  it,  in  connection  with  the 
portal  circulation,  by  means  of  which  the  blood 
returning  from  the  stomach,  intestines,  pancreas, 
and  spleen  is  distributed  throughout  the  liver, 
and  thence  conveyed  to  the  inferior  vena  cava. 
Hence,  hepatic  affections,  by  interfering  more  or 
less  with  the  physiological  functions  or  anato- 
mical arrangements  of  the  organ,  may  give  rise 
to  diverse  phenomena,  not  only  of  a local  cha- 
racter, but  associated  also  with  the  general 
system. 

Summary  of  Diseases. — The  individual  affec- 
tions of  the  liver  will  be  treated  of  separately, 
in  alphabetical  order,  but  it  may  be  well  to  in- 
dicate here  beforehand  their  general  nature.  The 
first  great  division  is  that  into  functional  and  or- 
ganic. Functional  hepatic  disorders  are  regarded 
by  many  eminent  physicians  as  being  of  peculiar 
significance,  and  as  demanding  special  attention, 
particularly  with  reference  to  those  disorders 
which  influence  the  secretion  of  the  bile.  The 
main  organic  diseases  of  the  liver,  in  which  there 
is  some  more  or  less  obvious  anatomical  change, 


LIVEE,  DISEASES  OF. 

may  be  summarised  thus ; — 1 . Congestion,  either 
active  or  mechanical.  2.  Hemorrhage  into  the 
organ,  or  so-called  apoplexy.  3.  Acute  inflam 
motion,  usually  terminating  in  abscess,  rarely  in 
actual  gangrene.  4.  Chronic  inflammation,  end- 
ing in  the  condition  termed  cirrhosis . in  which 
the  liver  is  hardened,  granular,  and  usually 
contracted.  5.  Hypertrophy.  6.  Atrophy,  either 
acute — which  is  a very  fatal  disease  ; or  chronic, 
the  latter  being  of  different  kinds.  7.  Biliary 
accumidation.  8.  Malpositions  and  uialfo*ma 
tions.  9.  Infiltrations,  including  fatty  and  al- 
buminoid disease.  10.  Few  growths,  especially 
hydatids,  syphilitic  formations,  and  cancer. 
Tubercle  is  occasionally  found  in  the  liver. 

^Etiology  and  Pathology.  — Taking  a gen- 
eral survey  of  the  causes  which  originate  hepatic 
diseases,  and  of  the  circumstances  under  which 
they  arise,  the  most  important  may  be  indicated 
thus: — 1.  An  affection  of  the  liver  may  be 
merely  a local  manifestation  of  some  constitu- 
tional or  general  malady,  as  in  the  case  of  cancer, 
tubercle,  syphilis,  or  albuminoid  disease.  The 
last-mentioned  is  remotely  due  to  causes  which 
need  not  be  discussed  here  ; but  it  may  be  men- 
tioned that  the  liver  is  an  organ  very  liable  to 
suffer  from  albuminoid  change.  2.  Some  local 
injury  or  irritation  may  originate  hepatic  dis- 
ease, either  from  without,  as  a blow  or  stab; 
or  from  within,  as  sometimes  happens  in  the 
case  of  biliary  calculi.  3.  Certain  animal 
parasites  entering  the  body  are  prone  to  lodge 
in  the  liver.  This  applies  especially  to  hydatids, 
originatingfrom  the  Tania  echinococcus.  4.  From 
the  intimate  connection  of  the  liver  with  the 
alimentary  canal,  and  the  existence  of  the  por- 
tal circulation,  hepatic  disorders  are  very  liable 
to  arise  from  improper  diet,  as  well  as  from 
digestive  derangements  in  the  stomach  and 
bowels,  and  constipation.  5.  Abuse  of  alcohol, 
and  especially  indulgence  in  ardent  spirits,  oc- 
cupies an  important  position  in  the  aetiology  of 
disorders  and  certain  diseases  of  the  liver.  Un- 
due use  of  hot  condiments  is  also  regarded  as  an 
element  of  some  consequence.  6.  Long-continued 
•exposure  to  a high  temperature  in  tropical  cli- 
mates is  a powerful  cause  of  hepatic  derange- 
ment and  disease,  particularly  if  accompanied 
with  too  free  indulgence  in  alcoholic  stimulants. 
7.  Diseases  of  the  liver  may  arise  by  extension 
from  neighbouring  structures  ; or  by  the  convec- 
tion of  morbid  materials  from  more  or  less  dis- 
tant parts.  The  latter  may  be  best  illustrated 
by  pyaemia;  and  secondary  affections  of  this 
kind  aro  believed  to  be  particularly  frequent  in 
the  liver,  when  the  morbid  products  are  conveyed 
directly  from  the  alimentary  tube,  in  conse- 
quence of  some  disease  of  its  walls,  such  as 
ulceration.  8.  Obstruction  to  the  circulation, 
due  to  certain  forms  of  cardiac  disease,  is  an 
important  cause  of  some  hepatic  affections.  9. 
Disorders  of  the  liver  are  often  attributed  to 
various  hygienic  errors,  exposure  to  cold,  and 
other  causes,  but  how  far  this  conclusion  is  jus- 
tified in  particular  cases  is  a matter  of  question. 

Clinical  Signs. — So  far  as  the  actual  diseases.'! 
the  liver  are  concerned,  it  is  unnecessary  here  la 
regard  any  symptoms  resulting  from  disturbance 
of  the  glycogenic  functions,  as  these  belong  to  a 
difforent  category.  The  clinical  phenomena  to 


LIVER,  ABSCESS  OF.  829 


be  looked  for  lie  -within  a limited  range,  and 
may  he  grouped  under  the  following  heads : — 
X.  Morbid  sensations,  referred  to  the  hepatic 
region,  or  to  the  shoulder,  such  as  pain  of  various 
kinds,  tenderness,  sense  of  weight,  throbbing. 
2.  Symptoms  due  to  interference  with  the  biliary 
functions,  particularly  jaundice  and  Its  accom- 
panying phenomena.  3.  Symptoms  resulting  from 
more  or  less  obstruction  to  the  portal  circulation. 
These  include  digestive  disorders,  due  to  con- 
gestion or  catarrh  of  the  mucous  membrane 
lining  the  stomach  and  intestines  ; hemorrhage 
from  this  membrane  in  some  cases ; ascites, 
which  is  a most  important  symptom  ; enlarge- 
ment of  the  spleen  ; congestion  of  the  womb  in 
women ; haemorrhoids ; and,  in  certain  condi- 
tions, dilatation  of  the  veins  of  the  abdominal 
wall.  4.  Symptoms  produced  by  the  pressure,  or 
interference  with  neighbouring  structures,  of  an 
. enlarged  liver.  Thus,  it  not  uncommonly  ex- 
tends upwards,  checking  the  movements  of  the 
diaphragm,  and  pressing  upon  the  lung,  hence 
causing  dyspnoea.  Or  it  may  compress  vessels 
and  olher  structures  ; or  in  some  cases  it  even 

■ interferes  with  the  heart’s  movement.  5.  Phy- 
i sical  signs. — These  indicate  enlargement  or  con- 
traction of  the  liver;  changes  in  situation  or 
isliape;  or  changes  in  physical  characters.  6. 

General  symptoms.  These  maybe  more  or  less 

■ independent  of  the  hepatic  disease,  this  being 
merely  a part  of  a general  malady ; or  the  liver- 
■affeetion  may  give  rise  to  pyrexia,  wasting,  and 
other  symptoms.  Hepatic  derangements  are  sup- 
posed to  originate  many  general  symptoms,  not 
obviously  connected  with  this  organ;  and  they 
have  even  been  made  accountable  for  the  goaty 
;tate. 

The  individual  diseases  of  the  liver  will  now 
oe  discussed  in  alphabetical  order. 

Frederick  T.  Roberts. 

LIVER,  Abscess  of.  — Synon.  ; Hepatic 
.bscess ; Fr.  Abces  du  Foie-,  Her.  Leberabscess. 
Though  of  such  importance  as  to  require  a 
eparate  notice,  abscess  of  the  liver  is  not  an 
ndependent  affection,  but  is  only  the  consequence 
f inflammatory  action  set  up  in  that  organ. 
.Etiology. — As  abscess  of  the  liver  is  com- 
aratively  rare  in  temperate  climates  and  fre- 
dent  among  Europeans  in  tropical  ones,  it  has 
aturally  been  attributed  to  the  effects  of  heat,  or 
' alternations  of  heat  and  cold.  Being  occasion- 
lly  associated  with  malarious  fever,  and  fre- 
lently  with  dysentery,  it  is  supposed  that  it  may 
s induced  by  the  same  causes  as  those  diseases, 
he  opinion  has  been  often  advanced  that  ab- 
ess  of  the  liver  is  always  secondary  to  dysen- 
ry,  or  to  ulceration  of  the  bowels.  That  it  may 
easionally  be  so  it  would  be  difficult  to  deny, 
th  reference  to  what  is  known  of  its  occasional 
usal  connection  with  operations  on  the  rectum, 
it  although  dysentery  and  hepatic  abscess  are 
iquently  associated,  this  association  is  very 
re  except  in  the  tropics ; nor  is  it  there  very 
istant.  Thus  dysentery  is  extremely  common 
children,  while  abscess  of  the  liver  is  equally 
•e  among  them ; indeed,  abscess  of  the  liver  is 
ry  unusual  under  the  age  of  twenty,  and  is 
re  common  after  the  age  of  twenty-five  than 
ow  it.  The  proportion  of  cases  in  which 


liver-abscess  and  dysentery  are  associated  is 
extremely  variable ; it  is  more  frequent  in  one 
year  than  in  another,  and  also  at  one  period  of 
the  year  than  at  another.  Although  dysen- 
tery is  the  commoner  affection,  yet  occasionally 
the  number  of  cases  of  hepatitis,  with  a certain 
proportion  of  deaths  from  abscess,  may  greatly 
exceed  the  number  of  cases  of  dysentery.  There 
are  many  fatal  cases  of  abscess  in  which  the 
towels  have  been  found  perfectly  healthy ; ab- 
scess of  the  liver,  on  the  other  hand,  can  scarcely 
be  considered  to  be  very  frequent  in  dysentery. 
Yet  dysentery  and  abscess  of  the  liver  seem  to 
arise  in  the  tropics  from  very  much  the  same 
causes ; and  something  is  there  impressed  on  the 
constitution  which  seems  to  render  the  system, 
even  for  some  years  after  a return  to  Europe, 
somewhat  inclined  to  liver-abscess. 

Abscess  of  the  liver  is  an  occasional  result  of 
pytemia,  and  connected  at  times  with  surgical 
operations,  especially  with  those  performed  on 
the  rectum.  It  has  been  induced  by  falls  or  by 
direct  violence ; or  by  the  impaction  of  a gall- 
stone, especially  where  it  has  been  rough  and 
spicular. 

The  predisposing  causes  are  the  same  as  those 
of  hepatitis — drinking,  irregular  life,  exposure, 
and  residence  in  the  tropics. 

Anatomical  Characters. — The  course  of  for- 
mation of  hepatic  abscess  seems  to  be  the  follow- 
ing ; — The  liver  is  first  loaded  in  some  portion 
or  portions  with  an  excess  of  blood ; then  fol- 
lows exudation  of  lymph  and  pus,  forming 
small  deposits,  of  which  two  or  throe  coa- 
lesce, while  the  liver-substance  breaks  down. 
The  abscess  extends  in  this  mode.  It  is  usually 
lined  by  a membranous  cyst,  which  is  very  thin 
when  the  formation  of  the  abscess  has  been 
rapid,  and  of  greater  consistence  when  the  abscess 
is  old.  The  abscess  may  be  of  almost  any  size, 
from  that  of  a small  orange  up  to  a huge  cyst 
containing  ten  or  twelve  pints  of  pus.  Six 
hundred  ounces  of  pus  have  been  withdrawn 
from  an  abscess  in  five  months.  Most  commonly 
the  abscess  is  single,  but  frequently  there  are 
several  abscesses.  They  are  most  common  in  the 
right  lobe.  They  may  have  reached  the  surface 
or  havo  burst,  or  they  may  be  only  discoverable 
on  making  an  incision  into  the  organ  after  death. 
In  the  great  majority  of  cases,  if  the  abscess  has 
not  been  exposed  to  the  air,  its  contents  are  laud- 
able or  healthy,  inodorous  pus.  In  some  cases 
the  pus  is  of  the  colour  of  chocolate.  It  is  said 
that  streaks  of  bile  have  sometimes  been  ob- 
served. Slight  pinkish  streaks  are  not  so  rare. 
An  abscess  may  open  through  various  channels. 
Sometimes  it  finds  its  way  to  the  surface,  and 
discharges  itself  through  the  skin.  This  usually 
happens  lower  down  than  tho  ribs.  The  abscess 
may  open  into  the  peritoneal  cavity,  and  has 
done  so  into  the  pericardium.  In  such  cases  the 
result  is  fatal.  It  passes  occasionally  into  some 
portion  of  the  bowels,  and  as  this  causes  the 
least  constitutional  disturbance,  it  is  a favourable 
mode  of  discharge.  Very  frequently,  when  the 
abscess  is  near  the  convex  side  of  the  liver,  the 
diaphragm  and  the  surface  of  the  liver  become 
adherent— as  in  this  case  the  abscess  has  not 
usually  been  very  deep-seated — and  the  abscess 
opens  itself  through  the  lung.  This  offers  a fair 


LIVER,  AESCESS  OF. 


830 

chance  of  recovery.  There  are  still  other  possible 
points  of  exit,  but  these  are  chiefly  matters  of 
curiosity. 

When  the  abscess  has  burst,  cicatrisation 
commences,  and  has  sometimes  been  traced 
when  the  case  has  terminated  fatally.  But  it  is 
remarkable  that  well-marked  cases  of  complete 
cicatrisation  have  not  often  been  recorded— 
various  membranous  formations  and  slight  de- 
pressions in  the  liver  being  new  considered  to 
be  the  results  of  syphilitic  hepatitis.  There  is 
a strong  presumption  that  liver-abscess  is  occa- 
sionally absorbed  without  having  ruptured,  and 
also  that  it  may  remain  latent  for  a long  period. 
In  cases  where  the  abscess  has  been  partially 
absorbed,  a white  fibrous  sac  has  been  found, 
containing  a little  pus  and  sometimes  cheesy 
matter ; and  in  some  cases  in  which  there  has 
been  strong  presumption  that  the  abscess  had 
existed  for  four  or  five  years,  the  walls  of  the 
abscess  have  been  found  much  thickened,  and 
almost  cretaceous.  Although  a portion  of 
the  liver  has  been  converted  into  abscess,  the 
remaining  portion  of  it  may  be  healthy,  or  some- 
what indurated  from  former  attacks  of  con- 
gestion ; and  it  is  wonderful  how  in  favourable 
cases,  where  the  contents  of  an  abscess  have  been 
absorbed  or  evacuated,  the  remaining  healthy 
portion  of  the  liver  executes  its  work. 

In  addition  to  the  formation  of  ordinary  he- 
patic abscesses,  suppuration  may  take  place  ex- 
tensively throughout  the  liver,  after  lobular 
hepatitis,  as  in  a case  recorded  by  Dr.  Quain 
(Path.  See.  Trans.  1853) ; and  also  in  the  portal 
canals,  or  beneath  the  investing  capsule  of  the 
liver. 

Symptoms. — These  are  more  urgent  when  acute 
hepatitis  runs  into  abscess,  than  when  abscess  is 
the  consequence  of  repeated  attacks  of  illness,  as 
Is  most  commonly  the  case.  The  general  symp- 
toms are  a pale,  muddy  complexion ; a look  of 
anxiety,  and  a state  of  low,  irregular  feverish- 
ness, the  pulse  being  generally  about  100,  and 
the  temperature  increased  by  a degree  or  two. 
There  may  be  one  or  two  shivering  fits,  or  accesses 
of  fever  simulating  ague.  The  appetite  is  im- 
paired,- there  is  vomiting,  with  irritability  of 
the  stomach  ; the  tongue  has  generally  a white 
coating,  but  in  some  cases  is  almost  clean.  The 
throbbing  pain  which  usually  accompanies  the 
formation  of  pus  is  scarcely  ever  present.  There 
is  occasionally  pain  in  the  shoulder  or  shoulder- 
blade,  but  this  is  uncertain.  A certain  amount 
of  pain,  usually  dull,  is  felt  in  the  liver,  often  in- 
creased on  pressure ; attended  with  more  or  less, 
and  sometimes  with  very  considerable,  enlarge- 
ment of  the  organ.  There  is  also  fulness  or  bulg- 
ing of  the  right  side;  and  at  the  last,  possibly, 
fluctuation.  If  abscess  form  on  the  upper  side 
of  the  liver,  there  is  more  or  less  pressure  on  the 
diaphragm,  causing  shortness  of  breath,  and  occa- 
sionally leading  to  local  inflammation,  attended 
with  acute  pain.  But  such  symptoms,  which 
are  more  valuable  taken  collectively  than  indi- 
vidually, may  not  be  present  in  a marked  degree. 
The  state  of  the  biliary  secretion  is  very  often 
normal,  or  nearly  so ; and  the  condition  of  the 
urine  offers  no  certain  indication,  although  bile- 
pigment  is  sometimes  present  in  it..  Jaundice 
is  comparatively  rare.  In  some  of  its  more  in- 


sidious forms,  hepatic  abscess  may  come  on  with- 
out being  preceded  by  fever  or  ushered  in  by 
sbiverings;  but  even  in  such  cases  a general 
falling  off  of  the  health  is  always  observable. 

As  has  been  already  pointed  out.  the  abscess 
may  burst  in  various  directions;  or  it  maybe 
opened  by  a surgical  operation.  As  a general 
rule  the  result  is  more  favourable — probablv 
because  the  opening  being  small  the  pus  escapes 
gradually — when  the  abscess  finds  an  opening 
for  itself,  than  when  it  is  evacuated  artificially. 
In  the  latter  case  the  discharge  usually  la-ts  for 
some  months — nay,  for  more  than  a year  in 
some  instances  ; and  although  the  patient  im- 
proves up  to  a certain  point,  he  is  very  likely  to 
sink  in  the  end.  When  the  patient  sinks,  it  is 
usually  from  general  exhaustion  of  the  system. 
Pyaemia  is  of  extremely  rare  occurrence. 

Complications. — Abscess  of  the  liver  is  often 
complicated  with  dysentery,  or  with  diarrhoea : 
and  less  frequently  with  malarious  fever.  Some- 
times there  is  a certain  amount  of  pleurisy  or 
pneumonia.  This  is  more  frequent  in  acute  cases 
than  when  the  formation  of  abscess  has  been 
slow. 

Diagnosis. — A positive  diagnosis  is  difficult 
to  make  in  the  early,  and  sometimes  in  the  later, 
stages  of  hepatic  abscess.  The  writer  has  known 
an  iron-worker  burst  an  abscess  through  his 
lungs  when  at  work,  the  presence  of  which 
was  not  suspected;  also  a medical  man  sub- 
mit his  side  to  examination  by  several  of  his 
brethren,  bear  any  amount  of  pressure,  and  yet 
die  two  days  after  choked  by  the  bursting  of  an 
abscess.  Nevertheless,  an  experienced  physician 
will  from  the  symptoms  be  able  to  guess  the  pre- 
sence of  abscess  of  the  liver  before  any  palpable  , 
signs  appear.  These  are,  first,  the  general  aspect 
of  the  patient ; then  the  enlargement  of  the  side. 
It  is  only  in  a more  advanced  stage  that  fluctua- 
tion can  he  made  out.  As  to  the  diagnosis  after 
the  abscess  has  burst,  if  it  breaks  through  the  lung 
the  peculiar  chocolate- colour  expec'oration  is  at 
once  characteristic.  If  the  absepss  bursts  into 
the  pleura  or  peritoneum,  the  diagnosis  is  not  so 
positive,  but  the  sudden  collapse  usually  shows 
what  has  happened.  When  the  abscess  bursts 
through  the  bowels,  especially  in  small  amounts 
at  a time,  the  fact  is  rarely  recognisable,  except 
by  the  gradual  improvement  of  the  patient.  It 
seems  to  be  certain  that  hepatic  abscess  has 
sometimes  been  confounded  with  a distended 
gall-bladder ; with  care,  however,  such  a mistake 
can  scarcely  happen.  It  may  be  confounded 
with  cancer  or  with  hydatids  of  the  liver-  but  in 
these  affections — and  particularly  in  the  last — 
there  is  very  little  constitutional  disturbance, 
and  in  cancer  a nodular  protuberance  may  very 
generally  be  recognised.  The  only  other  mistake 
that  is  occasionally-  made  is,  that  of  confounding 
abscess  and  the  effects  consequent  on  its  pre- 
sence, when  it  points  upwards,  with  pneumonia 
or  pleurisy  near  the  baso  of  the  raht  lung;  but 
with  careful  auscultation  the  affection  of  the 
lung  or  pleura  ought  to  be  made  out  by  then 
physical  signs. 

Prognosis. — This  is  generally  very  unfavour 
able.  Yet  there  is  always  a char.ce  of  recover 
if  the  pus  finds  for  itself  an  exit,  as  throughthi 
bowels  or  lungs,  or  even  if  exit  to  it  is  fT1'reJ 


LIVER,  ALBUMINOID  DISEASE  OF. 


artificially.  The  statistics  of  the  results  of  mak- 
ing artificial  openings  are  not  very  encouraging. 
The  operation,  however,  frequently  appears  to 
prolonglife.  The  most  favourable  mode  of  exit 
is  through  the  lungs.  The  discharge  of  pus 
may  continue  for  six  months,  and  yet  recovery 
take  place.  Absorption  of  the  abscess  probably 
sometimes  occurs,  though  this  is  a very  rare 
termination.  Such  absorption  is,  obviously, 
chiefly  a matter  of  inference.  If  a patient  re- 
covers from  an  attack  of  liver-abscess,  his  health 
may  return  to  its  usual  standard.  There  is 
reason  to  believe  that  individuals  have  lived  thirty 
or  forty  years  after  the  occurrence  of  abscess  ; 
and  the  writer  knew  a man  of  7*,  who  had  had 
abscess  forty-five  years  before. 

Treatment. — To  avert  the  formation  of  ab- 
scess. the  ordinary  treatment  for  hepatitis  is  the 
only  one  that  can  be  adopted.  When  abscess 
has"  once  formed,  or  evenwhekevcr  there  is  good 
ground  for  suspecting  this,  the  time  for  all 
active  treatment  has  gone  by.  The  patient  must 
have  his  strength  supported  by  mild  nutritious 
diet  and  wine.  He  must  be  treated  symptoma- 
tically. Usually  it  is  sufficient  to  secure  regular 
action  of  the  bowels,  and  thus  help  the  sound 
remaining  portion  of  the  liver  to  perform  its 
function.  Mineral  acids,  quinine,  and  other 
tonics,  may  all  be  useful.  Counter-irritation 
over  the  liver  is  often  tried,  but  it  may  be  doubted 
whether  in  this  condition  of  things  it  is  a mea- 
sure of  any  importance,  although  some  think 
that  it  may  help  to  limit  the  extent  of  the  ab- 
scess. The  course  of  the  disease  must  be  watched. 
The  only  mode  of  interference  that,  we  can  pursue 
is  that  of  helping  to  give  exit  to  the  contents  of 
the  abscess.  Towards  expediting  this  little  can 
be  done  until  fluctuation  becomes  evident,  and 
then  interference  is  to  be  delayed  as  long  as 
possible,  as  nature  will  probably  select  the  most 
convenient  spot  for  the  exit  of  the  pus,  and,  after 
all,  the  presence  of  other  undetected  abscesses  in 
the  liver  may  make  operative  procedure  useless. 
The  abscess  may  point  in  an  intercostal  space, 
below  the  edee  of  the  ribs,  at  the  epigastrium, 
and  even  as  low  down  as  the  umbilicus.  A great 
deal  has  been  written  about  modes  of  opening 
the  abscess,  and  of  ascertaining  first  whether  it 
has  formed  adhesions,  and  various  modes  have 
been  suggested  for  ensuring  adhesions.  However 
these  are  not  matters  of  much  practical  impor- 
tance. It  is  usual  to  make  an  opening  whenever 
there  is  distinct  bulging  between  the  ribs;  but 
it  is  better,  when  it  is  at  all  possible,  to  wait 
and  operate,  if  it  can  be  managed,  below  the  ribs. 
However  near  the  surface  the  abscess  may  appear 
to  be,  a lancet  is  seldom  sufficient,  and  a good- 
sized  trochar  and'  canula  should  be  employed. 
The  aspirator,  and  everything  that  will  help  to 
; prevent  the  introduction  of  air,  should  be  taken 
advantage  of.  and  the  precautions  of  the  anti- 
septic method  most  strictly  observed.  For  there 
is  always  a chance  of  gangrene  after  a time 
supervening  round  the  opening,  and  the  risk 
of  this  seems  to  be  greater  the  higher  up  the 
opening  is  made.  The  evacuation  of  an  abscess 
i usually  produces  amelioration  of  the  general 
condition,  whether  it  be  permanent  or  not. 

Change  of  climate  may  operate  favourably 
when  the  patient  is  suffering  from  the  long- 


831 

continued  drain  of  an  open  abscess;  and  if  we 
are  to  .judge  by  the  number  of  patients  suspected 
of  having  liver-abscess  who  have  been  sent  to 
sea  and  who  have  arrived  in  Europe  with  their 
symptoms  relieved,  we  may  almost  venture  to 
say  that  a long  sea-voyage  under  favourable 
circumstances  assists  absorption.  In  favourable 
cases  the  sequelae  of  liver-abscess  must  be  treated 
like  those  of  hepatitis.  J.  Macphebson. 

LIVER,  Albuminoid  Disease  of. — Stnon.  : 

Fr.  Degencrcsccnce  amylo'ide  da  Foie;  Ger.  Amy- 
loide  Kntartung  der  Leber. 

Definition. — A disease  characterised  by  pain- 
less, more  or  less  considerable,  enlargement  of 
the  liver ; due  to  the  existence  in  i*s  structure 
of  a peculiar  homogeneous  substance,  the  exact 
nature  of  which  is  not  known,  but  which  has  a 
marked  relation  to  certain  cachexias  and  consti- 
tutional maladies. 

./Etiology. — Albuminoid  disease  of  the  liver 
occurs  in  association  with  certain  cachexias, 
especially  those  of  constitutional  syphilis,  scro- 
fula, rickets,  scrofulous  diseases  of  bones  and 
joints,  and  other  diseases  attended  with  pro- 
tracted suppuration.  It  has  been  noticed  in 
connection  with  chronic  dysentery,  but  the  re- 
cords of  the  Seamen’s  Hospital  do  not  confirm 
such  association.  In  many  cases  of  chronic 
ague,  with  marked  cachexia,  which  have  been 
admitted  into  the  hospital  just  named,  there 
was  an  enlarged,  hard  liver,  pointing  to  albu- 
minoid change;  but  there  was  probably  in 
these  cases  the  superaddition  of  syphilitic  taint. 
Rokitansky  speaks  of  the  disease  as  congenital 
in  children  born  of  syphilitic  parents. 

Anatomical  Characters. — The  liver  has  its 
normal  shape;  is  more  or  less  enlarged,  some- 
times to  such  an  extent  as  to  fill  the  greater  part 
of  the  abdominal  cavity;  and  is  hard,  resistant, 
and  inelastic,  with  a smooth  glistening  surface. 
The  organ  cuts  like  bacon,  hence  the  name  ‘ larda- 
ceous.’  The  cut  surface  is  grey,  or  fawn-colour, 
or  pale  red;  but  sometimes  it  is  yellowish,  and 
this  appearance,  in  conjunction  with  the  con- 
sistence of  the  organ,  has  led  to  the  name 
‘ waxy.’  From  the  incised  veins  a little  pale 
blood  usually  oozes.  The  application  of  solution 
of  iodine  to  the  cut.  surface  causes  change  of 
colour,  which  has  been  described  as  blood-red, 
reddish-brown,  mahogany  brown,  walnut,  by 
different  observers.  The  addition  of  sulphuric 
acid  induces  a blue  colour,  best  seen  in  a deli- 
cate section  placed  under  the  microscope.  Sup- 
posing a lobule  of  the  liver  to  be  divided  into 
three  zones,  the  characteristic  iodine  stain  will 
be  seen,  in  less  advanced  stages  of  the  disease, 
to  be  limited  to  the  middle  zone,  where  the 
hepatic  artery  is  distributed;  the  vessels  and 
cells  here  being  filled  with  the  new  material, 
which  afterwards  may  extend  so  as  to  implicate 
the  entire  lobule.  The  structures  invaded  by 
the  new  material  have,  in  a section  examined 
microscopically,  a lustrous,  transparent,  and 
somewhat  swollen  appearance.  "When  the  entire 
lobule  is  affected,  the  aspect  is  homogeneous. 
The  appearance  of  an  albuminoid  liver  may  be 
modified  by  the  co-existence  of  fatty  change,  or 
cirrhosis,  or  syphilitic  disease.  The  spleen  is 
generally,  and  the  kidneys  are  occasionally.  in>- 


LIVEE,  ACUTE  YELLOW  ATROPHY  OF. 


832 

plicated.  Corral  has  used  some  new  colouring 
matters,  namely,  two  methyl-anilin  violets,  dis- 
covered by  Lauth,  and  a violet  discovered  by 
Hoffman,  as  tests  of  albuminoid  degeneration. 
The  normal  tissues  of  the  liver  and  other  organs 
do  not  decompose  the  violets,  but  when  amy- 
loid degeneration  is  present,  the  affected  parts 
become  of  a violet-red,  the  normal  structures 
assuming  a violet-blue  tint.  In  the  examinations 
of  specimens  by  Cornil  the  hepatic  cells  were 
unaffected,  a result  in  opposition  to  generally 
received  views,  as  just  stated,  and  to  his  own 
previous  investigations.  In  all  cases  the  walls 
of  the  capillaries,  or  of  the  hepatic  arteries  and 
veins,  were  affected.  Methyl-green  has  been 
more  recently  used  for  the  same  purpose. 

Symptoms. — Palpation,  in  marked  cases  of 
albuminoid  disease  of  the  liver,  will  readily 
detect  a large,  hard,  resistant  tumour,  having 
the  normal  outlines  of  the  liver ; the  smoothness 
of  its  surface;  and  the  extent  to  which  it  en- 
croaches upon  the  abdominal  cavity.  Pressure 
doesnot  elicit  any  tenderness,  nor  is  there  usually 
any  pain ; at  most,  in  advanced  cases,  there  isonly 
a sense  of  tension  and  fulness,  as  in  other  hepatic 
enlargements.  The  painless  nature  of  the  tumour 
is  distinctive.  The  disease  does  not  interfere 
with  the  portal  circulation,  and  does  not  there- 
fore directly  cause  ascites.  When  this  occurs  it 
is  the  result  of  general  cachexia,  induced  by  the 
constitutional  malady,  and  perhaps  by  associated 
ronal  complication.  The  dropsy  generally  affects 
the  legs  in  the  first  instance,  and  afterwards  the 
serous  cavities,  and  is  not  a prominent  symptom 
unless  the  kidneys  are  implicated.  In  this  case 
the  urine  is  usually  of  low  specific  gravity  and 
albuminous,  and  the  anaemia  very  marked.  The 
system  of  bile-ducts  not  being  obstructed  by  the 
disease,  there  is  no  jaundice;  or  if  this  occur, 
which  is  a rare  event,  it  is  from  pressure  on  the 
duct  externally  by  enlarged  lymphatic  glands. 
The  evacuations  are,  however,  frequently  ot  a pale 
yellow,  and  at  times  of  a clayey,  colour,  which 
may  be  accounted  for  by  the  extensive  impair- 
ment of  secreting  structure,  and  the  consequent 
secretion  of  a poor,  colourless  bile.  A lardaceous 
state  of  the  spleen  is  a frequent  accompaniment 
of  the  liver  affection,  and  gives  rise  to  increased 
volume  and  hardness  of  the  organ,  which  may 
be  detected  by  palpation  in  the  left  jhypochon- 
drium.  Vomiting,  without  the  usual  indications 
of  gastric  derangement,  as  furred  tongue,  &c., 
and  diarrhoea,  are  symptoms  not  uncommon  in  ad- 
vanced cases,  and  are  due,  according  to  Frerichs, 
to  the  implication  in  the  disease  of  the  vessels 
and  villi  of  the  stomach  and  intestines. 

Diagnosis. — The  peculiar  features  of  the  en- 
largement, its  painless  character,  the  concurrence 
of  the  constitutional  maladies  already  noticed, 
especially  if  with  implication  of  spleen  and  kid- 
neys, will  distinguish  this  from  othei  hepatic 
enlargements.  If  there  be  associated  cirrhosis 
or  syphilitic  disease,  the  diagnosis  will  be  diffi- 
cult ; but,  as  Bamberger  remarks,  an  error  will 
not  be  of  moment  as  regards  prognosis  and 
treatment. 

Prognosis  and  Duration. — The  disease  may 
run  on  for  months  or  even  years,  but  it 
generally  proves  fatal,  either  by  intercurrent 
affections,  or  by  ansemia,  general  dropsy,  and 


exhaustion,  such  result  being  more  rapidly  deter- 
mined when  the  kidneys  are  involved,  In  the 
early  stage  of  the  malady  an  arrest  of  mischief, 
if  not  a cure,  may  possibly  be  effected. 

Treatment. — It  is  only  in  the  earlier  stages 
of  albuminoid  disease  of  the  liver  that  treat- 
ment can  avail,  and  then  it  must  be  directed 
especially  to  the  associated  cachexia.  Whether 
this  be  syphilitic  or  strumous,  the  preparations 
of  iodine  are  indicated  ; the  iodide  of  potassium, 
the  tincture  of  iodine,  or,  where  the  ansemia  is 
marked,  iodine  in  combination  with  iron.  The 
syrup  of  iodide  of  iron  in  drachm  doses,  three 
times  a day,  has  proved  useful,  if  not  in  reducing 
the  tumour,  at  least  in  improving  the  general 
condition  of  the  patient.  The  iodine  mineral 
springs,  as  Woodhall  Spa,  Kreuznach,  Adelheids- 
quelle,  &c.,  are  indicated,  although  they  contain 
but  infinitesimal  doses  of  iodine  and  bromine. 
The  baths  of  Aix-la-Chapelle,  Ems,  and  Weil- 
bach  have  each  had  their  supporters  in  the 
treatment  of  this  malady.  Hydrochlorate  of 
ammonia,  in  ten  to  twenty  grain  doses,  three 
times  a day,  continued  for  some  time,  has  been 
found  to  be  efficacious  in  reducing  large,  hard 
livers  (Budd,  Begbie).  The  general  therapeutical 
indications  are  pure  air ; plain,  nourishing  diet; 
the  regulated  use  of  alcoholic  stimulants ; and 
adequate  protection  of  the  skin  by  warm  clothing 
and  other  measures.  Stephen  H.  Ward. 

LIVER,  Apoplexy  of. — By  this  is  meant 
haemorrhage  in  the  liver,  in  the  form  either  of 
isolated  patches  of  extravasation  or  of  general 
effusion,  the  whole  of  the  hepatic  parenchyma  be- 
ing converted  into  a dark-red  pulpy  mass.  This 
affection  is  rarely  met  with  in  this  country,  but 
has  been  often  observed  abroad  in  warm  climates 
and  malarious  districts,  as  a result  of  disease  of 
the  liver,  or  prolonged  and  intense  congestion 
It  occurs  also  in  some  cases  of  scurvy.  Aber- 
crombie believed  that  the  puerperal  condition 
predisposed  to  hepatic  apoplexy.  It  has  been 
observed  also,  according  to  Frerichs,  in  some 
Dew-born  infants  after  loDg  labours,  and  in 
cases  of  this  kind  it  is  usually  associated  with 
pulmonary  atelectasis.  A rapidly  fatal  case  of 
hepatic  apoplexy  was  reported  by  Andral,  in 
which  there  were  no  indications  of  any  efficient 
cause  of  the  haemorrhage.  (Clin.  Med.,  3 ed., 
t.  ii.,  p.  259.)  Extravasation  of  blood  into  the 
substance  of  the  liver,  together  with  a pulpy 
condition  of  more  or  less  of  the  parenchyma, 
may  he  produced  by  the  application  of  violence 
to  the  hepatic  region. 

Symptoms. — The  symptoms  that  have  been 
observed  in  cases  of  hepatic  apoplexy  are  pain 
in  the  right  hypochondriac  region,  and  excessive 
tenderness;  jaundice  ; bilious  vomiting;  melanin; 
a cold  and  bloodless  condition  of  the  skin  of  i he 
face  and  limbs ; and  in  some  cases  syncope. 

This  affection  is  almost  invariably  fatal  when 
due  to  prevailing  disease  of  the  liver,  or  to  ex- 
tensive laceration.  W.  Johnson  Smith. 

LIVER,  Atrophy  of,  Acuta  Yellow.— Sv 

non.:  Fr.  Atrophie  jaune  aigue  du  Fcic ; Ict'crt 
grave ; Ger.  Acute  Atrophie  dcr  Leber. 

Definition, — This  is  a general  disease,  iikened 
by  Trousseau  to  a pyrexia.  The  jaundice,  bcinc 


LIVER.  BILIARY 

prominent  a symptom,  formerly  drew  attention 
too  exclusively  to  the  liver ; but  the  same  de- 
generation which  seizes  upon  the  liver,  likewise 
attacks  all  the  glandular  and  muscular  organs  of 
the  body.  The  morbid  change  is  a parenchy- 
matous degeneration,  called  by  Virchow  and  his 
schoola  parenchymatous  inflammation.  It  con- 
sists in  a filling  of  the  cells  of  a gland  with  albu- 
minous granules,  iu  such  numbers  as  altogether 
to  hide  the  nucleus ; the  albuminous  granules 
are  quickly  followed  by  oily  particles  and  drops. 
In  the  muscular  tissue,  the  striation  is  lost,  and 
its  place  taken  by  granules,  placed  irregularly 
or  running  lengthwise.  These  morbid  appear- 
ances are  found  in  poisoning  by  phosphorus, 
arsenic,  antimony,  alcohol,  and  other  agents,  and 
in  all  fevers,  though  in  a less  degree  than  in 
acute  yellow  atrophy.  Buhl  was  the  first  to 
point  out  that  the  pyrexial  changes  were  the  be- 
ginuings  of  acute  yellow  atrophy. 

.Etiology. — Acute  yellow  atrophy  is  perhaps 
the  rarest  of  all  the  diseases  common  to  this  cli- 
mate. Of  its  causes,  next  to  nothing  is  known. 
It  seems  to  be  more  common  in  women  than  in 
men;  and  in  pregnant  women  than  iu  others. 

It  has  been  shown  that  in  pregnant  and  suck- 
ling quadrupeds  and  laying  hens,  the  liver  and 
kidneys  often  show  cells  infiltrated  with  fat,  a 
fact  which  may  throw  some  light  on  the  dispo- 
sition of  pregnant  women  to  acute  yellow  atro- 
phy. Emotional  disturbances,  such  as  grief  and 
;roublo,  and  bad  hygienic  conditions,  have  been 
bought  by  some  to  predispose  to  this  disease. 
Dthers  believe  that  all  cases  may  be  traced  to 
I'hosphorus-poisoning. 

Anatomical  Characters. — After  death  it  is 
tot  uncommon  to  find  the  liver  of  natural  size, 
r even  enlarged,  in  the  early  stages  of  acute 
trophy.  Later  on  the  organ  shrinks,  so  that  in 
xtreme  cases  it  may'  weigh  as  little  as  nineteen 
unces.  It  decreases  in  all  diameters,  but  the 
;ft  lobe  is  especially  shrunken.  The  capsule  is 
ften  wrinkled.  On  section,  there  is  no  longer 
ny  appearance  of  lobules,  but  an  ochre-coloured 
irface  without  definite  structure,  but  often 
iddened.  Under  the  microscope,  the  liver-cells 
•e  found,  in  the  early  stages,  to  be  filled  with 
•anules,  so  as  completely  to  hide  the  nucleus ; 
vrt  of  these  granules  are  soluble  in  acetic  acid, 
hers  are  not.  Later  on,  all  trace  of  liver-cells 
ay  be  lost,  nothing  but  a granular  and  oily  de- 
itus  and  pigment  being  seen  under  the  miero- 
jpe.  If  the  organ  be  set  aside,  it  often  he- 
mes covered  with  crystals,  stated  by  Frerichs 
consist  of  leucin  and  tyrosin. 

The  spleen  is  enlarged  and  soft  in  the  great 
i jority  of  cases.  The  stomach  and  alimentary 
ual  are  filled  with  dark-red  or  tarry  contents, 
t • outcome  of  haemorrhage  ; the  tubular  glands 
i the  stomach  are  filled  with  fattily  degene- 
tsd  epithelium.  The  muscular  tissue  of  the 
1 rt  shows  likewise  fatty  degeneration  ; and 
t tubules  of  the  kidneys  are  filled  with  epithe- 
1 n in  various  stages  of  fatty  degeneration. 

tmptoms. — Acute  yellow  atrophy  is  com- 
u fly  preceded  for  some  days  or  weeks  by  a 
s pie  jaundice,  in  which  nothing  peculiar  can 
b nade  out.  Delirium  and  convulsions  then 
ti  lenly  set  in,  followed  by  deep  coma,  sterto- 
n i breathing,  and  dilated  pupils.  During  the 

53 


ACCUMULATION  IN.  833 

first  part  of  the  disease  the  pulse  is  natural  in 
frequency,  but  with  the  appearance  of  the  con 
vulsions  and  delirium  it  rises  to  120  or  130.  The 
skin  is  always  yellow,  rarely  deeply  coloured. 
The  urine  is  natural  in  quantity,  bilious,  contain- 
ing leucin  and  tyrosin,  and  towards  the  end  of 
the  disorder,  containing  no  urea,  chlorides,  or 
phosphatic  earthy  salts;  a kind  of  peptone  is 
present.  There  is  almost  always  constipation  ; 
the  stools  being  at  first  pale,  afterwards  black 
from  admixture  of  blood.  Vomiting  is  very  con- 
stantly present ; at  the  end  of  the  disease,  of  a 
black  coffee-ground  matter.  The  right  hypo- 
chondriac and  epigastric  regions  are  painful 
and  tender.  The  liver,  at  first  natural  in  6ize, 
or  even  largor  than  natural,  decreases  daily  in 
dimensions,  so  that  at  last  percussion  may  give 
no  liver-dulness  at  all.  With  the  decrease  of  the 
liver,  the  spleen  increases  in  size.  A hmmor- 
rhagic  diathesis  likewise  sets  in,  as  shown  by 
petechise  on  the  skin,  epistaxis,  haematemesis, 
and  melaena.  The  temperature  is  commonly 
low,  until  just  before  death. 

Diagnosis. — The  diagnosis  is  beset  with  diffi- 
culties, and  may  remain  -doubtful  even  after 
death.  Poisoning  by  phosphorus  can  hardly  be 
distinguished  from  acute  yellow  atrophy,  unless 
the  patient  own  to  having  taken  the  drug.  The 
prodromal  stage  cannot  be  distinguished  from 
simple  jaundice. 

Prognosis. — The  prognosis  is  extremely  bad : 
only  a very  few  suspected  cases  are  known  to 
have  recovered. 

Treatment. — The  treatment  must  be  con- 
ducted upon  general  principles.  A few  eases,  in 
which  the  diagnosis  of  acute  yellow  atrophy  has 
been  thought  justifiable,  have  recovered,  and 
these  have  been  treated  with  the  mineral  acids 
and  purgatives,  aconite,  quinine,  and  camphor. 
These  are  therefore  the  remedies  which  may  be 
recommended  to  be  used.  Local  symptoms,  such 
as  vomiting  or  bleeding,  must  be  treated  as  in 
other  diseases.  J.  Wickham  Legg. 

LIVER,  Atrophy  of,  Chronic. — Chronic 
atrophy  of  the  liver  is  seen  in  many  wasting 
diseases,  and  in  old  age  ; the  liver  then  often 
shrinks,  becoming  tougher  in  consistence,  but 
rarely  granular  on  the  surface.  The  cut  surface 
is  dark  red  or  pale  brown  ; the  acini  are  either 
invisible,  or  else  smaller  than  natural.  Frerichs 
thinks  that  the  blood-vessels  are  all  dilated. 
The  increased  toughness  seems  due  to  the  atrophy 
of  the  liver-cells,  the  meshes  of  the  connective- 
tissue  network  being  thus  brought  nearer  to 
each  other. 

The  symptoms  of  chronic  atrophy  are  merged 
in  those  of  the  primary  disease,  against  which 
all  treatment  must  be  directed. 

J.  Wickham  Legg. 

LIVER,  Biliary  Accumulation  in.  — 
Anatomical  Characters. — When  a permanent 
obstruction  to  the  flow  of  bile  into  the  duodenum 
has  been  set  up,  serious  changes  take  place  in 
the  gall-ducts  and  the  liver  itself  (see  Gall- 
Bladder  and  Gall-Ducts,  Diseases  of).  At  first 
the  liver  swells,  apparently  from  the  pent-up 
secretion.  It  becomes  of  a deep  bilious  or  olive- 
green  colour,  tne  central  parts  of  the  acini  being 
the  deeper  coloured ; on  section  the  dilated 


LIVER,  CIRRHOSIS  OF. 


S34 

ducts  are  seen,  and  bile  or  a colourless  fluid 
wells  out  of  them.  Increase  in  the  consistence 
of  the  liver  commences ; and  if  the  obstruction 
continue,  the  organ  wastes,  becomes  much  tougher, 
and  shows  a granular  surface.  This  increase  in 
consistence  is  due  to  an  overgrowth  of  the  con- 
nective-tissue of  the  liver,  as  in  cirrhosis,  only  to 
a less  degree.  The  amount  of  over-growth  de- 
pends upon  the  kind  of  obstruction.  It  is  greater 
when  a rough  angular  gall-stone  is  the  cause, 
than  when  an  hydatid  tumour  with  its  smooth 
walls  presses  upon  the  gall-ducts.  This  over- 
growth springs  at  first  from  the  gall-ducts, 
which  are  greatly  thickened,  and  thence  spreads 
over  the  connective  tissue  of  the  portal 
canals. 

The  liver-cells  atrophy,  as  in  cirrhosis.  They 
vary  much  in  size.  Their  contents  seem  to  be 
chiefly  fat  and  pigment-granules,  though  neither 
is  of  very  great  amount  as  a rule.  The  arrange- 
ment in  rays  around  the  hepatic  venule  is  quite 
lost.  One  of  the  most  important  functions  of 
the  liver  is  the  preparation  of  glycogen,  and  this 
function  seems  to  be  abolished  in  long-continued 
jaundice.  In  animals  whose  bile-ducts  were 
tied,  the  writer  found  the  glycogen  to  disappear 
not  many  hours  after  the  ligature  was  applied ; 
and  after  puncture  of  the  fourth  ventricle,  no 
sugar  appeared  in  the  urine. 

In  some  cases  of  complete  obstruction  to  the 
bile-ducts,  the  liver-cells  have  been  found  alto- 
gether destroyed,  nothing  hut  a fatty  detritus 
being  seen  under  the  microscope.  This  is  not 
owing  simply  to  post-morton,  changes  in  the 
liver ; but  is  possibly  due  to  the  long-continued 
action  of  the  bile-acids  circulating  in  the  blood 
upon  the  liver-cells  themselves,  as  Leyden  has 
pointed  out.  It  is  not  owing  to  the  simple  solu- 
tion of  the  liver, -cells  in  the  bile,  for  the  bile  has 
not  the  power  of  dissolving  these  cells,  as  Th.  von 
Duscii  has  asserted. 

Symptoms. — As  regards  the  clinical  pheno- 
mena of  biliary  accumulation  in  the  liver,  theie 
are,  of  course,  all  the  symptoms  of  jaundice 
and  of  the  disease  which  leads  to  it.  In  ad- 
dition, the  liver  at  first  swells,  and  may  be 
detected  bolow  the  ribs  for  two  or  three  fingers’ 
breadth,  but  rarely  more;  it  is  often  painful  on 
palpation.  Later  on,  the  liver  retreats  within 
the  boundaries  of  the  chest.  Ascites  often  shows 
itself,  owing  to  the  disturbance  of  the  circula- 
tion in  the  liver;  and  the  spleen  often  swells. 
All  these  symptoms  are,  however,  liable  to  be 
interfered  with  by  the  primary  disease. 

Treatment. — The  treatment  must  be  directed 
to  the  cause  of  the  obstruction  of  the  ducts. 

J.  Wickham  Legg. 

LIVER,  Cirrhosis  of. — Synon.  : Granular 
liver  ; Hobnailed  liver ; Gin-drinker's  liver  ; In- 
terstitial hepatitis;  Fr.  Cirrhose  du  Foie;  Ger. 
Girrhose  der  Leber. 

Definition. — A chronic  disease  of  the  liver, 
in  which  the  organ  becomes  hardened,  and  usu- 
ally more  or  less  diminished  in  size,  at  the 
same  time  assuming  a granular  or  hob-nailed 
appeannee  ; these  changes  resulting  from  an  in- 
crease in  the  connective-tissue,  usually  caused 
by  ab'-.se  of  spirituous  liquors.  The  name  cir- 
rhosti  was  first  given  by  Laennec  to  the  hardened 


and  shrunken  liver,  on  account  of  the  yellow 
colour  of  the  granulations  in  this  disease. 

-ZEtiology. — The  most  common  cause  of  cir- 
rhosis is,  undoubtedly,  the  abuse  of  spirituous 
liquors.  Spirits,  unmixed  with  water,  seem  to 
be  more  potent  in  causing  cirrhosis  than  wine  or 
malt  liquors.  Next  after  these,  but  at  a great 
distance,  come  syphilis,  aud  the  immoderate  use, 
it  is  said,  of  spices — such  as  curry,  or  of  coffee. 
In  some  rare  cases  no  cause  is  apparent.  The 
disease  is  far  more  common  among  men  than 
women  ; it  is  very  rare  indeed  amongst  children. 
In  one  of  these  cases,  the  child  asked  the  nurse 
for  gin  soon  after  admission  into  the  hospital. 
Cirrhosis  has  also  been  seen  among  the  lower 
animals,  a proof  that  alcohol  is  not  the  sole 
cause. 

Anatomical  Characters. — The  seat  of  the 
disease  in  cirrhosis  is  the  capsule  of  Glisson. 
The  connective-tissue,  which  accompanies  the 
vessels  entering  at  the  portal  fissure,  and  which 
forms  a covering  for  the  liver  beneath  the 
peritoneum,  takes  on  a very  active  overgrowth. 
One  result  of  this  overgrowth  is  a compression  and 
atrophy  of  the  secreting  cells  of  the  liver.  Another 
is  a hindrance  to  the  flow  of  blood  through  the 
liver ; for,  although  new  vessels  do  indeed  form 
in  the  new  connective-tissue,  yet  these  are  by  no 
mea-us  enough  to  carry  on  the  circulation,  in  the 
place  of  those  obliterated  or  destroyed  by  ihe 
advancing  overgrowth  of  connective-tissue. 

There  are  several  varieties  of  cirrhosis.  In  the 
first — that  which  is  most  common — the  liver  is 
shrunken,  it  may  be  to  one-half  or  one-third  i.f 
its  natural  size.  This  shrinking  is  often  greatest 
in  the  left  lobe,  so  that  th:s  may  become  a mere 
appendage  to  the  right.  At  the  sharp  edge  < t 
the  liver,  there  is  often  nothing  left  but  a semi- 
transparent tissue,  containing  noneof  theelemen.'s 
of  the  gland.  False  membranes  often  join  the  I 
surface  of  the  liver  with  the  diaphragm  or  other 
neighbouring  parts.  The  surface  itself  is  greatly 
roughened.  It  shows  numberless  granulations, 
varying  in  size  from  a poppy-seed  to  a hazel-nut. 
The  fibrous  investment  of  the  liver  is  greatly ! 
thickened;  and  the  peritoneum  tears  off  either  in  I 
layers,  or  leaving  a granular  surface  bi  hind.  The 
liver  is  exceedingly  hard  and  tough;  and  on 
section,  the  cut  surface  is  seen  to  be  made  up  of  I 
yellow  islets,  imbedded  in  a white  translucent 
tissue.  These  yellow  bodies  are  the  representa- 
tives of  the  granulations  seen  on  the  outer  surface, 
and  they  are  the  remains  of  the  natural  liver- 
tissue,  separated  from  one  another  by  the  new 
white  connective-tissue.  This  is  by  far  the  com- 
monest variety  of  cirrhosis,  but  there  are  others. 
One  form  is  hypertrophous  cirrhosis,  in  which 
the  liver  is  greatly  increased  in  size,  sometimes 
more  than  double  its  natural  weight;  but  tin 
surface  is  smooth,  and  the  capsule,  though  thick 
ened,  leaves  a smooth  surface  when  torn  oft 
There  is  toughening  of  the  liver,  though  not  ti 
so  great  a degree,  and  the  same  appearance  o 
the  cut  surface  as  in  ordinary  cirrhosis.  In  an 
other  variety  the  organ  is  shrunken,  but  thesur 
face  is  smooth,  and  or.  section  are  seen  or.l 
pins'-points  of  yellow  tissue  in  the  white  trait 
lucent  overgrowth.  Whether  the  hypertrophou 
variety  ever  becomes  shrunken  is  still  undecid.ec 
A third  variety  is  fatty  irrhosis,  which  may  V 


LIVER,  CIRRHOSIS  OF. 


mistaken  at  first  sight  for  fatty  liver,  but  the 
touch  shows  how  tough  it  is.  It  sometimes 
floats  in  water.  There  is  no  everted  edge,  and  on 
section  no  acini  are  to  be  made  out;  but  the  cut 
surface  is  indistinct,  pale,  and  yellow.  The  sur- 
face of  the  liver  is  smooth. 

Under  the  microscope,  using  a low  power,  the 
tissue  of  the  cirrhosed  liver  is  seen  to  be  broken 
np  into  islets,  separated  by  broad  bands  of  what 
looks  like  a highly  nucleated  connective-tissue. 
The  separation  between  the  two  appears  sharply 
defined.  In  some  cases  the  liver-cells  may  be 
| seen  infiltrated  with  fat.  With  higher  powers, 
the  most  striking  object  in  the  field  is  the  great 
abundance  of  what  were  once  called  nuclei,  but 
now  lymphatic  corpuscles,  in  the  new-formed 
connective-tissue:  these  vary  little  in  size  or 
shape,  being  nearly  all  round  or  roundish.  The 
prevailing  opinion  now  is  that  they  are  emi- 
grated leucocytes.  They  are  arranged  sometimes 
in  clusters,  sometimes  in  lines,  and  sometimes 
indefinitely.  The  origin  of  the  clusters  is  uncer- 
tain ; but  it  sepms  tolerably  clear  that  the  linear 
disposition  arises  from  the  obliteration  of  vessels 
carrying  bile  or  blood.  The  connective-tissue 
itself  is  highly  fibrous ; sometimes  homogeneous 
or  granular.  The  liver-cells  themselves  undergo 
great  changes.  They  lose  their  natural  polyhe- 
dral shape,  and  become  oblong,  oval,  or  spindle- 
■ shaped.  Between  them  the  new  connective- 
tissue  gradually  insinuates  itself,  and  the  cells 
-become  lost  in  the  advancing  overgrowth.  These 
changes  in  the  liver-cells  are  of  course  best  seen 
at  the  spot  where  the  liver-tissue  and  the  con- 
-neetive-tissue  join. 

Symptoms. — The  first  approaches  of  cirrhosis 
are  commonly  very  insidious.  Often  one  of  the 
first  symptoms  is  a dull  pain  in  the  neighbour- 
hood of  the  liver.  This  is  accompanied  by  signs 
if  a chronic  gastric  catarrh,  of  which  morning 
tickness  is,  for  the  diagnosis  of  intemperance,  of 
lie  greatest  importance.  The  patients  are  com- 
nonly  of  a sallow,  often  almost  jaundiced,  com- 
ilaxion.  They  grow  thinner,  and  their  strength 
Jails.  Some  patients  suffer  from  piles : in  others 
.iarrhasa  occurs.  Later  on  the  belly  begins  to 
well,  and  ascites  appears;  the  legs  may  become 
idematous.  from  the  pressure  of  the  fluid  in  the 
felly  on  the  anterior  wall  of  the  inferior  vena 
java.  The  urine  is  high-coloured  ; of-  en  deposits 
rates;  and  sometimes  contains  albumin  from 
mtr, acted  kidneys. 

An  important  point  in  the  diagnosis  is  to 
-termine  whether  the  liver  is  of  small  size, 
lid  growing  smaller.  This  is  often  difficult,  on 
count  of  the  ascites;  the  difficulty  may  some- 
nes  be  overcome  by  laying  the  patient  on  his 
:t  side.  In  the  earlier  stages  the  hard  edge  of 
je  liver  may  at  times  he  felt,  and  even  though 
,e  ascites  be  great,  by  suddenly  depressing  the 
P 11s  of  the  belly  with  the  fingers.  The  percus- 
n-dulness  of  t he  liver  in  the  nipple  line  may  be 
luced  to  two  inches  or  even  one  inch  in  height. 
[Although  in  the  new-formed  connective-tissue 
' cirrhosis  fresh  vessels  form  to  take  the  place 
1 hose  obliterated,  yet  these  by  no  means  suffice 
1 carry  on  the  circulation  through  the  liver, 
■tal  obstruction  therefore  arises,  which  relieves 
1 If  in  various  ways  ; most  commonly  fluid  is 
bred  out  into  the  cavity  of  the  peritoneum, 


835 

causing  an  ascites,  or  into  tlio  cavity  cf  the  in- 
testines, causing  a diarrhoea,  which  should  not 
be  lightly  checked.  In  other  cases  it  is  relieved 
by  hsmatemesis,  or  by  hasmorrhoidal  discharge. 
That  which  is  most  fortunate  for  the  patient  ia 
the  formation  of  a varicose  communication  be- 
tween some  radicles  of  the  portal  system  and  the 
general  veins ; as  between  the  htemorrhoidal 
and  the  hypogastric,  the  veins  of  the  stomach 
and  the  oesophageal.  Most  important  of  all, 
however,  is  a vein  discovered  by  Sappey.  It 
arises  from  the  left  branch  of  the  portal  vein, 
and  passes  up  the  falciform  ligament  close  to  tho 
ligamentum  teres  to  join  the  epigastric  and  in- 
ternal mammary  veins.  It  is  by  no  means  tho 
same  as.  the  old  obliterated  umbilical  vein, 
although  so  near  to  it.  The  vein  just  mentioned 
will  often  be  found  dilated  after  death. 

As  a rule  the  spleen  is  enlarged  in  cirrhosis. 
The  enlargement  may  be  very  great,  but  tho 
organ  is  commonly  about  twice  or  three  times 
the  natural  size.  After  death  the  spleen  is  found 
of  softer  consistence  than  natural,  sometimes 
pulpy.  Tho  cause  is  obscure ; the  reason  com- 
monly civen  is  the  hindrance  to  the  flow  of 
blood  through  the  liver  acting  on  the  splenic 
vein.  The  spleen,  however,  does  not  always 
swell  when  there  is  obstruction  to  the  portal  cir- 
culation, for  example,  in  nutmeg-liver. 

Ascries  is  a symptom  which  sooner  or  later  is 
sure  to  come  on.  It  appears  to  arise  from  the 
venous  stasis  in  the  subperitoneal  tissues. 
Fluctuation,  and  the  movement  of  the  fluid  on 
change  of  posture  are  very  clear.  The  fluid,  like 
all  other  dropsical  effusions,  contains  albr.miD, 
salts,  sometimes  urea,  sometimes  sugar ; and  in 
jaundice  bile-pigment.  After  the  ascites  has  set 
in,  the  feet  may  begin  to  swell,  from  the  pressure 
of  the  fluid  on  the  vena  cava.  The  upper  limbs 
and  face  are  free  from  oedema.  In  some  cases 
albumin  is  present  in  the  urine,  from  coincident 
Bright’s  disease. 

The  patients  often  complain  greatly  of  flatu- 
lence, which  adds  much  to  their  distress,  and 
dyspnoea.  Haematemesis  and  piles  are  of  fre- 
quent occurrence.  Diarrhoea  when  it  comes  is, 
as  above  mentioned,  salutary,  and  should  not  be 
checked  unless  extreme.  The  urine  is  scanty  and 
high-co'oured  ; often  turbid  from  urates  ; and 
bile-pigment  is  present  when  jaundice  sets  in. 
Jaundice  may  or  may  not  be  seen,  according  as 
the  pressure  of  the  new  connective-tissue  does  or 
does  not  involve  the  bile-ducts. 

Diagnosis. — The  diagnosis  depends  upon  tho 
history  of  intemperance ; the  size  and  consist- 
ence of  the  liver;  the  size  of  the  spleen;  and 
the  appearance  of  ascites  and  other  dropsies.  Of 
importance  also  is  the  peculiar  sallow  earthy 
complexion  ; and  the  occurrence  of  haemorrhages 
from  the  stomach  or  intestines  The  diagnosis 
is  often  easy ; while  at  other  times  it  is  very 
hard  or  well-nigh  impossible  to  make.  Cirrhosis 
may  be  confounded  with  portal  thrombosis  ; ob- 
literation of  the  hepatic  duct;  nutmeg-liver, 
syphilitic  disease,  cancer,  or  hydatids  of  thp 
liver;  and  chronic  peritonitis. 

Phognosis. — It  is  rare  for  a patient  suffering 
from  cirrhosis  of  the  liver  to  live  longer  than  a 
twelvemonth  after  the  symptoms  have  become 
so  pronounced  as  t<  allow  a diagnosis  to  bo  marie 


LIVER,  ENLARGEMENTS  OF. 


i3G 

Death  is  in  nearly  all  cases  the  end  of  the  dis- 
ease. 

. Treatment. — In  the  early  stages  of  cirrhosis 
it  is  most  important  to  induce  the  patient  to 
give  up  his  habits  of  intemperance,  for  without 
this,  treatment  will  be  of  little  avail.  Next  the 
use  of  alkaline  purgatives,  with  or  without  vege- 
table bitters,  such  as  chiretta  or  calumba.  will 
be  very  useful.  A course  of  the  waters  of  Carls- 
bad is  often  most  useful,  or  other  alkaline  or 
iodised  waters.  The  diet  must  be  mild ; and 
exercise  on  horseback  or  on  foot  should  be  re- 
commended. 

In  the  later  stages  of  the  disease  the  great 
object  will  be  to  keep  up  the  strength  of  the 
patient.  For  the  ascites,  which  often  becomes 
the  patient’s  great  trouble,  diuretics,  especially 
copaiba,  and  mercurial  alteratives  may  be  em- 
ployed. Paracentesis  should  be  put  off  as  long 
as  possible,  as  the  end  of  the  disease  often 
arrives  soon  after  the  tapping,  though  in  some 
cases  the  ascites  is  cured  by  this  operation.  The 
flatulence  should  be  combated  by  regulation  of 
diet,  charcoal,  small  doses  of  hydrochloric  acid, 
and  carminatives.  The  bowels  must  be  kept 
open,  but  not  severely  acted  on. 

J.  Wickham  Leoq. 

LIVER,  Congestion  of.  Sea  Liver,  Hy- 
persemia  of. 

LIVER,  Contraction  of. — -A  .small  liver  is 
met  with  in  cirrhosis,  in  nutmeg-liver,  and  in 
long-continued  obstruction  to  the  gall-ducts,  in 
all  of  which  an  over-growth  of  the  connective- 
tissue  of  the  capsule  of  Glisson  is  seen.  Any 
kind  of  pressure  on  the  liver  from  neighbouring 
organs  will  likewise  beget  wasting.  A small 
liver  is  seen  in  old  age,  and  in  the  marasmus  of 
wasting  diseases.  The  liver  likewise  wastes  if 
the  portal  vein  be  obstructed,  or  the  capillaries 
in  the  liver  be  obstructed,  as  in  pigmented  liver. 
A shrunken  liver  cannot  be  looked  upon  as  a 
disease  by  itself.  J.  Wickham  Legg. 

LIVER,  Enlargements  of. — Anatomical 
Relations. — In  proceeding  to  determine  ■whether 
the  liver  is  enlarged  or  not,  the  following  points 
must  be  remembered.  Normally,  the  dull  sound 
yielded  by  percussion  extends  upwards  in  front, 
in  a line  drawn  towards  the  nipple,  to  about  the 
sixth  rib  ; laterally,  in  the  axillary  region,  to 
the  eighth  rib ; and  by  the  side  of  the  spine,  to 
the  eleventh  rib.  The  lower  border  of  the  liver 
corresponds  in  front  and  at  the  side  to  the  lower 
border  of  the  ribs;  and  the  dulness  behind 
merges  into  that  caused  by  the  right  kidney. 
The  left  lobe  of  the  liver  extends  across  the 
epigastrium  to  the  left  of  the  mesial  line;  the 
dull  sound  caused  by  its  upper  border  merging 
in  that  produced  by  the  heart.  The  upper  part 
of  the  convexity  of  the  liver  rises  to  a little 
more  than  an  inch  above  the  sixth  rib,  the  lung 
dipping  down  in  front,  and  giving  rise  to  a modi- 
fied percussion  sound;  but  for  practical  clinical 
investigation  it  is  better  to  take  the  line  of  abso- 
lute dulness.  The  extent  of  the  dull  sound  from 
above  downwards  in  the  right  mammary  line  is 
nearly  four  inches,  and  at  the  side  about  four 
inches  and  a half.  In  the  middle  line  in  front  it 
extends  from  the  base  of  the  ensiform  cartilage 


to  about  two  fingers’  breadth  below  its  point. 
It  should  be  remembered  that  the  limits  of  the 
liver  present,  compatibly  with  health,  consider- 
able variation ; that  the  organ  is  relatively  larger 
in  early  than  in  adult  life ; that  it  is  depressed 
in  inspiration,  and  ascends  in  expiration ; that  it 
is  somewhat  lower  down  in  the  erect  than  in  the 
recumbent  position  ; and  that  there  is  temporary 
distension  during  digestion. 

Diagnosis. — There  are  various  sources  of  fal- 
lacy which  may  lead  to  an  erroneous  conclusion 
as  to  the  size  of  the  organ.  Thus,  an  intestine 
distended  with  flatus  may  get  in  front  of  the 
anterior  border  of  the  organ,  and  lead  to  the 
supposition  that  there  is  contraction,  when  the 
contrary  is  the  case.  When  there  is  ascites  to 
any  extent,  it  is  difficult  to  make  out  the  boun- 
daries of  the  liver.  In  this  case,  however,  by 
placing  the  patient  on  the  left  side,  so  as  to  let 
the  fluid  gravitate  in  this  direction,  a diagnosis 
may  often  be  effected ; also,  by  suddenly  pressing 
the  finger  down  below  the  ribs,  and  thus  dis- 
placing the  fluid,  one  may  sometimes  detect  the 
enlarged  organ.  A rigid  right  rectus  muscle  is 
liable  to  be  taken  for  a tumour ; to  obviate  this 
source  of  fallacy,  the  patient  should  lie  on 
his  back  with  his  thighs  drawn  up,  and  his 
attention  should  be  diverted  by  conversation 
whilst  the  examination  is  being  made.  Sources 
of  fallacy  may  exist  in  the  liver  itself,  as  in 
malformations  or  malpositions  of  the  organ ; or 
they  maybe  outside  it,  either  in  the  abdomen  or 
chest.  Malignant  disease  of  the  stomach,  omen- 
tum, or  pancreas  ; a kidney  greatly  enlarged  by 
cancerous  deposit : or  faecal  accumulations  in  the 
colon,  maybe  mistaken  for  hepatic  enlargement. 
The  following  considerations  will  assist  in  arriv- 
ing at  a correct  diagnosis — (a)  enlargements  of| 
the  liver,  however  much  they  may  extend  beyond,: 
generally  occupy  the  normal  site  of  the  organ, 
and  however  irregular  the  surface,  the  usual 
outline  may  be  traced ; (6)  such  enlargements 
usually  follow  the  movements  of  the  diaphragm 
in  full  respiration.  Effusion  into  the  right  pleura 
may  be  mistaken  for  enlarged  liver,  especially  a: 
this  organ  may  be  depressed  by  it,  and  so  appea. 
to  extend  beyond  its  limits  in  the  downward  a 
well  as  in  the  upward  direction.  In  pleuritic  effu 
sion,  however,  the  dulness  on  percussion  will  var 
with  the  position  of  the  patient,  and  the  upper  lin 
of  dulness  will  in'  effusion  be  straight,  in  hepati 
enlargement  convex.  Pleuritic  effusion  and  hep;: 
tie  enlargement  may,  however,  co-exist.  Pnei 
mothorax,  emphysema  of  the  right  lung,  thorac 
tumours,  and  even  extreme  pericardial  effus-o 
may  depress  the  liver,  and  affect  the  diagnosis. 

Enumeration.-  -Dr.  Bright  arranged  enlarg 
ments  of  liver  under  two  heads,  according  to  t 
surface  of  the  organ,  namely,  smooth  and  irreg 
lar.  Dr.  Murchison  considered  this  elassificati 
open  to  the  objection  that  an  enlargement usua. 
smooth  is  at  times  irregular,  and  vice  versa,  a 
he  proposed  the  division  into  painless  and  pa 
ful  enlargements  ; but  to  this  similar  object 
may  be  taken.  The  principal  enlargements- 
the  liver  are  associated  with  the  following  d 
eases  of  the  organ.  | 

1.  Hypcra-mia  or  Congestion. — The  enlar- 
ment  is  not  usually,  particularly  in  aente  cas- 
very  great ; but  in  chronic  cases,  and  in  cong 


LIVER,  FATTY  DISEASE  OF. 


non  from  obstruction  to  the  circulation,  it  is 
often  considerable,  the  organ  extending  down- 
wards nearly  to  the  umbilicus,  and  across  into 
the  left  bypochondrium.  The  normal  contour  of 
the  liver  is  preserved  ; the  surface  is  smooth ; and 
the  resistance  is  increased.  Pain  and  tenderness 
are  often  present,  especially  in  acute  congestion. 

2.  Obstruction  of  the  bile-ducts. — Obstruction 
of  the  bile-ducts,  whether  temporary  from  in- 
flammation or  impaction  of  gall-stones,  or  per- 
sistent, will  be  attended  with  some  enlargement, 

' smooth  and  normal  in  shape,  of  the  liver  ; with, 
perhaps,  also,  distension  of  the  gall-bladder, 
causing  a pyriform  tumour,  which  projects  down- 
wards from  the  anterior  border  of  the  liver,  and 

. is,  in!  some  cases,  of  considerable  size. 

3.  Abscess. — The  presence  of  numerous  pysemic 
abscesses  in  the  liver  will  give  rise  to  an  en- 
largement of  the  organ,  with  tenderness  on  pres- 
sure over  the  right  hypochondrium.  Tropical 
abscess,  when  deep-seated,  may  give  rise  to  like 
results ; but  when  large  and  near  the  surface 
will,  if  under  the  ribs,  cause  prominence  of 
the  right  hypochondrium,  with  obliteration  of 
the  intercostal  spaces;  or  when  pointing  below 
or  to  the  left  of  the  ribs,  will  present  an  elastic, 
fluctuating  tumour,  with,  perhaps,  redness  of 
surface. 

4.  Hydatid  disease. — Hydatid  of  the  liver  is 
marked  by  nearly  the  same  physical  signs  as 
abscess ; a large  hydatid  cyst  causing,  according 

o its  site,  cither  bulging  of  the  right  hypo- 
hondrium,  or  an  elastic  tumour  either  below  or 
o the  left  of  the  right  lower  ribs.  The  tumour 
n some  cases  gives  a sense  of  fluctuation,  and 
ho  peculiar  vibratory  tremor  known  as  hydatid- 
i-emitus.  A hydatid  cyst  may  attain  much 
Teater  magnitude  than  is  ever  reached  by  ab- 
eess,  and  may  occupy  the  greater  part  of  the 
j Women.  Unlike  abscess,  hydatid  disease,  un- 
less the  cyst  is  suppurating,  is  unattended  by 
lain  or  constitutional  disturbance. 

5.  Simple  hypertrophy. — Simple  hypertrophy 
f the  liver,  resulting  from  an  increase  of  the 
ize  or  number  of  the  secreting  cells,  causes  a 
ainless  enlargement,  having  the  normal  shape 
f the  organ,  but  attaining  at  times  to  twice  its 
ormal  size. 

6.  Hatty  degeneration. — This  morbid  condition 
" the  liver  causes  a painless  enlargement,  not 
sually  very  great ; with  preservation  of  the  nor- 
; al  outline  and  smooth  surface  of  liver ; but  with 

minished  resistance. 

7.  Albuminoid  degeneration.  — In  albuminoid 
sease  the  liver  preserves  its  shape ; is  large ; 
ually  has  a quite  smooth  surface  ; and  is  hard 
d resistant  to  the  touch.  Enlargement  from 
is  cause  is  sometimes  very  great,  and  second 
ly  to  that  which  results  from  malignant 
;sease.  The  surface  in  albuminoid  disease  is 
metimes  irregular,  from  co-existence  of  cir- 
osis  or  syphilitic  cicatrices.  The  spleen  is 
ually  enlarged. 

8.  Malignant  disease.—  In  malignant  disease 
j liver  is  not  always  enlarged;  and  in  the 
iltrated  form,  the  surface  may  be  smooth, 
ually,  however,  especially  when  the  disease  is 
ranced,  there  is  enlargement,  with  loss  of  nor- 
1 shape  ; and  the  surface  is  hard  and  resist- 
. and  coverel  with  nodules,  or  large  knobs 


837 

and  protuberances.  The  greatest  enlargement — 
sometimes  such  as  to  occupy  the  greater  part  of 
the  abdominal  cavity,  is  attained  in  this  disease. 
Pain,  varying  in  character  and  intensity,  seated 
in  the  liver  or  distal,  is  also  generally  present. 

9.  Cirrhosis. — In  some  cases  of  cirrhosis  the 
liver  may  be  found  enlarged,  as  in  the  so-called 
‘ hvpertrophous  ’ form.  See  Liver,  Cirrhosis  of. 

Stephen  H.  Wabd. 

LIVER,  Eatty  Disease  of. — Definition. 
A disease  attended  with  painless  enlargement 
and  diminished  consistence  of  the  liver  ; due  to 
the  presence  of  a large  quantity  of  fat  or  oil  in  the 
secreting  structure  ; and  occurring  in  connection 
with  phthisis  and  other  wasting  diseases,  or  in 
persons  of  luxurious  and  indolent  habits,  in 
whom  there  is  usually  an  abundant  development 
of  fat  in  the  tissues  and  other  organs. 

^Etiology. — Fatty  liver  may  either  be  due 
to  degeneration  of  cell-structure  through  faulty 
nutrition,  or  it  may  result  from  infiltration  of 
the  cells  with  fat,  transmitted  through  the  portal 
vessels  from  without  (fatty  infiltration.)  Fatty 
degeneration  is  met  with  in  association  with 
other  hepatic  diseases,  as  albuminoid  disease 
and  cancer.  The  fatty  liver  which  results  from 
poisoning  by  phosphorus  would,  according  to 
the  experiments  of  Voit  and  Bauer,  appear  to 
be  due  to  degeneration,  as  the  dogs  upon  which 
they  experimented  had  been  kept  without  food 
previously,  and  were  starved  during  the  time 
phosphorus  was  administered  ; showing  that  tho 
fat  could  not  have  come  from  other  parts  of  tho 
body,  or  been  introduced  in  food,  but  must  havo 
resulted  from  the  metamorphosis  of  tissue-ma- 
terial. It  is  with  fatty  infiltration  that  we  are 
more  particularly  concerned.  The  fat  may  come 
either  from  within  or  from  without  the  body. 
The  former  case  is  illustrated  when  the  greater 
part  of  the  fat  of  the  tissues  and  organs  is  ab- 
sorbed, as  in  the  emaciation  of  advanced  phthisis. 
Louis,  who  first  established  the  association  of 
fatty  liver  with  phthisis,  found  it  to.  exist  in 
about  one-third  of  the  cases  of  this  disease,  and 
met  with  it  much  more  frequently  in  phthisical 
females  than  in  males.  His  observations  have 
been  amply  confirmed  by  subsequent  observers. 
Fatty  infiltration  of  the  liver  also  occurs  in  con- 
nection with  other  wasting  diseases,  and  is  not 
infrequent  in  patients  who  have  been  long  bed- 
ridden. From  a therapeutical  point  of  view,  the 
medical  practitioner  is  more  interested  in  tho 
disease  under  consideration,  when  fat  is  intro- 
duced from  without  the  body.  The  affection  of 
the  liver  is  then  associated  with  development  of 
fat  in  other  organs  and  in  the  tissues  generally. 
Persons  thus  affected  are  usually  given  to  undue 
indulgence  in  eating  and  drinking;  to  eating  not 
only  too  much  food,  but  food  rich  in  oil  and  fat, 
and  drinking  beer,  but  especially  spirits  to  excess. 
Want  of  exercise  of  mind  and  body,  a heated 
atmosphere,  and  general  luxurious  habits,  mate- 
rially assist  in  determining  the  affection.  In 
illustration  of  this  cause  may  be  adduced  tho 
oft-cited  experiments  of  Magendie,  who  induced 
very  fatty  livers  in  dogs  by  feeding  them  exclu- 
sively on  butter;  and  also  in  the  production  of 
the  foie  gras  in  geese,  by  penning  them  up  in  a 
heated  atmosphere  and  cramming  them. 


LIVER,  FUNCTIONAL  DISORDERS  OF. 


538 

Anatomical  Characters. — In  fatty  disease 
the  liver  is  more  or  less  enlarged,  but  seldom  to 
any  great  extent;  the  surface  is  smooth;  the 
borders  are  rounded  ; the  substance  pits  on  pres- 
sure ; and  the  organ  is  either  of  pale  yellow  or 
drab  colour,  or,  when  partially  affected,  has  a 
mottled  appearance.  A portion  placed  in  water 
floats,  showing  a diminished  specific  gravity.  On 
cutting  into  the  organ,  the  knife  is  greased  ; and 
a greasy  stain  is  imparted  to  blotting  paper 
applied  to  the  cut  surface.  A portion  when  held 
in  the  flame  of  a lamp  or  candle,  will,  when  the 
water  is  driven  off,  burn.  It  is,  however,  as 
Frerichs  remarks,  only  by  the  microscope  that 
the  degree  to  which  the  liver  is  implicated  can 
be  determined.  In  slighter  grades,  fat-granules 
and  globules  are  seen  to  be  limited  to  the  outer 
zone  of  the  lobules  in  the  vicinity  of  the  portal 
vessels  ; but  in  advanced  cases  the  whole  of 
the  cells  will  be  found  to  be  filled  either  with 
separate  globules,  or  with  a single  large  drop 
of  fat.  In  less  extensive  infiltration  the  liver 
may  be  marked  by  red  spots,  corresponding  to 
the  hepatic  veins.  Fat  in  limited  quantity  is 
always  present  in  the  human  liver,  so  that  the 
term  fatty  can  only  be  applied  when  it  is  in 
excess. 

Symptoms.—  In  the  lessei  grades  of  the  disease, 
there  are  scarcely  any  distinctive  symptoms, 
either  objective  or  subjective.  When  the  affec- 
tion is  more  pironounced,  percussion  will  indicate 
more  or  less  enlargement,  usually  in  the  down- 
ward direction ; and  palpation  may  detect  a 
rounded  border  and  diminished  consistence,  and 
will,  at  any  rate,  determine  that  the  organ  is  not 
unduly  hard,  has  no  irregularity  of  surface,  and 
does  not  differ  materially  in  shape  from  the 
healthy  liver.  There  is  seldom,  if  ever,  any 
pain ; at  most,  in  marked  cases,  a sense  of  tension 
and  of  uneasiness  on  lying  on  tne  leftside.  Jaun- 
dice is  a rare  event;  and  ascites  and  enlarge- 
ment of  the  spleen  cannot  be  classed  as  symptoms 
of  the  disease.  In  cases  of  fatty  infiltration,  de- 
pendent on  luxurious  habits,  as  regards  diet,  &c., 
there  is  usually  more  or  less  development  of  fat  in 
other  organs,  as  well  as  in  the  omentum  and  sub- 
cutaneous cellular  tissue.  There  is  also  a greasy 
condition  of  skin,  with  peculiar  odour,  resulting 
from  abnormal  oily  secretion  from  the  sebaceous 
follicles.  Dr.  Addison  considered  a peculiar  con- 
dition of  the  skin — presenting  to  the  eye  a blood- 
less, almost  semi-transparent,  and  waxy  appear- 
ance, and  to  the  touch  a feeling  of  smoothness, 
looseness,  and  flabbiness — as  indicative,  if  not 
pathognomonic,  of  fatty  degeneration  of  the 
liver.  In  cases  where  the  liver  is  much  enlarged, 
and  there  is  much  abdominal  fat,  the  upward 
pressure  may  interfere  with  the  action  of  the 
diaphragm,  and  cause,  especially  after  meals, 
embarrassment  of  breathing.  The  functional 
symptoms  likely  to  be  present  in  advanced  cases 
are  irregularity,  generally  sluggishness,  of  the 
bowels  ; more  or  less  dyspepsia  ; and,  perhaps, 
loss  of  appetite.  In  some  cases  a weak  or  irre- 
gular, or  intermitting  action  of  the  heart,  with 
tendency  to  faintness  or  giddiness,  points  to  impli- 
cation of  this  organ,  and  is  indicative  of  possible 
fatal  consequences. 

Diagnosis. — The  enlargement  of  the  liver,  with 
preservation  of  its  normal  shape,  without  hard- 


ness or  irregularity ; the  absence  of  pain,  jatm. 
dice,  ascites,  or  enlargement  of  the  splewi;  and 
its  association  either  with  the  emaciation  of 
phthisis  or  other  wasting  diseases,  or  with  the 
habits  of  the  gourmand  and  general  development 
of  fat  in  the  body,  will  usually  enable  us  to  dis- 
tinguish fatty  from  other  hepatic  enlargements. 

Prognosis. — The  prognosis  of  fatty  disease  of 
the  liver  is  affected  by  the  associated  general 
condition  of  the  patient,  and  will,  of  course,  le 
unfavourable  in  phthisis. 

Treatment. — The  general  therapeutical  indi- 
cations in  fatty  liver  resulting  from  luxurious 
habits  of  living,  point  to  reform  in  the  direction 
of  diet,  air,  exercise,  &c.  Rich,  oily,  and  fatty 
articles  of  food  are  to  be  avoided  ; whilst  sugar 
and  starch  should  be  taken  in  moderation.  Beer, 
in  all  forms,  is  objectionable,  and  so  also  is 
alcohol,  unless  well-diluted,  and  taken  only  at 
meals.  Champagne  is  objectionable,  hut  other 
light  French  wines  are  admissible.  Exercise, 
either  on  foot  or  horseback,  should  be  had 
recourse  to  daily,  but  must  be  regulated  accord- 
ing to  the  soundness  of  the  heart  and  cir- 
culation. Free  exposure  to  pure  air,  and  avoid- 
ance of  heated  rooms,  are  desirable.  The  func- 
tions of  the  skin  must  be  promoted  by  adequate 
clothing,  and  by  the  use  of  the  hath,  or  by 
sponging  with  soap  and  warm  water.  The 
bowels  must  be  attended  to,  and  dyspepsia 
met  by  antacids  and  vegetable  bitters.  The 
Carlsbad  waters — the  warm  Sprudel  especially — 
are  indicated,  being  supposed  to  act  upon  the 
redundant  fat.  Stephen  H.  Ward. 

LIVER,  Functional  Disorders  of.— In- 
troductory Remarks. — The  late  Dr.  Copland,  in 
his  Dictionary  of  Practical  Medicine,  arranged 
these  disorders  under  three  heads,  according  to; 
the  nature  of  the  biliary  secretion.  1.  Diminished; 
secretion  of  bile;  2.  Excessive  secretion  of 
bile;  and  3.  Vitiated  biliary  secretion.  Dr.Budd, 
whilst  recognising  the  functions  of  the  liver  ail 
threefold,  namely,  as  to  changes  effected  in  the 
blood,  the  formation  of  sugar,  and  the  seere 
tion  of  bile,  almost  restricts  what  he  says  upon 
the  subject  of  functional  disorders  to  abnormal 
conditions  of  the  secretion — excessive,  defective 
or  unhealthy  bile.  The  late  Dr.  Murchison,  in 
his  lectures  on  P'unctional  Derange  nents  of  tin. 
Liver,  showed  that  the  classification  lieretofon 
adopted,  does  not  represent  the  present  state  oi 
knowledge  of  the  functions  of  the  organ.  Hi 
summarises  these  functions  under  three  heads 
1.  The  formation  of  glycogen,  which  contribute 
to  the  maintenauee  of  animal  heat,  and  to  U 
nutrition  of  the  blood  and  tissues.  2.  The  de 
structive  metamorpdiosis  of  albuminoid  mattei 
and  the  formation  of  urea  and  other  nitrq 
genous  products,  which  are  subsequently  elimi 
nated  by  the  kidneys ; these  changes  also  main 
taining  the  animal  heat.  3.  The  secretion  <j 
bile,  a large  portion  of  which  is  reabsorbed 
assisting  iu  the  assimilation  of  fat,  and  otlie 
elements ; whilst  a part,  passing  downward, 
stimulates  the  peristaltic  action  of  the  intestine 
and  arrests  decomposition.  The  author  juj 
cited  arranged  the  phenomena  of  tunction 
derangements  of  the  liver  under  nine  heads. 
Abnormal  nutrition.  2.  Abnormal  eliminatic 


830 


LIVER,  FUNCTIONAL  DISORDERS  OF. 


3.  Abnormal  disintegration.  4.  Derangements  of 
the  organs  of  digestion.  5.  Derangements  of  the 
nervous  system.  6.  Derangements  of  the  organs 
of  circulation.  7.  Derangements  of  the  organs 
of  respiration.  8.  Derangements  of  the  urinary 
organs.  9.  Abnormal  conditions  of  the  skin. 
The  above  heads,  however,  represent  for  the  most 
part  functional  and  general  symptoms  resulting 
from  functional  hepatic  disorders,  rather  than 
these  disorders  themselves.  The  arrangement 
under  three  heads,  representing  the  three  prin- 
cipal functions  of  the  organ,  is  that  which  the 
writer  proposes  to  adopt. 

iErcoLOGT. — It  is  scarcely  necessary  to  remark 
that  functional  disorders  of  the  liver  are  often 
secondary  to  structural  diseases  of  the  organ,  or 
to  diseases  of  the  thoracic  and  abdominal  viscera, 
febrile  affections,  malaria,  and  other  causes.  It 
is  with  the  causes  which  induce  these  disorders 
when  primary,  that  we  are  here  concerned.  Pro- 
minent among  such  causes  are  errors  in  diet,  and 
the  undue  use  of  alcoholic  liquors.  Habitual 
over-eating,  and  especially  indulgence  in  rich, 
fatty  articles  of  food,  such  as  rich  soups,  entrees, 
and  pastry;  and  the  undue  use  of  sugar,  fish  or 
flesh  containing  much  oily  matter,  are  very  apt 
, to  disturb  the  function  of  the  liver.  Excess  in 
the  use  of  alcoholic  drinks  is  another  cause,  in 
this  country,  in  frequent  operation.  The  combi- 
nation of  sugar  with  alcohol  much  enhances  the 
mischief.  Hot,  sweetened  grog ; sweet  new  wines, 
as  champagne,  unless  dry ; Madeira,  and  sweet 
sherries  ; port-wine  ; liqueurs  ; and  malt  liquors, 
particularly  mild  ales  and  stout,  are  ready  causes 
of  hepatic  derangement.  "Want  cf  exercise, 
whether  the  result  of  necessity  or  of  indolent 
habits,  is  another  common  exciting  cause  of 
hepatic  functional  disorders;  and  its  effect  is 
enhanced  when  it  is  associated  with  errors  in 
diet.  Living  habitually  in  a high  temperature, 
whether  in  a warm  climate  or  in  over-heated 
rooms,  is  another  cause,  and  is  intensified  when 
associated  with  the  causes  already  alluded  to. 
Depressing  nervous  and  emotional  influences 
must  not  be  forgotten  in  considering  the  aetiology 
tf  the  subject. 

Symptoms. — The  phenomena  which  are  ob- 
served in  functional  derangements  of  the  liver 
bay  now  be  briefly  indicated,  according  to  the 
'articular  hepatic  function  which  is  disor- 
dered. 

1.  Disorders  of  the  Glycogenic  Func- 
ion. — Disorders  relating  to  the  glycogenic 
unction  fall  under  tho  subject  of  diabetes,  and 
eed  here  only  be  alluded  to.  See  Diabetes. 

2.  Disorders  of  the  Metabolic  Function, 
n reference  to  derangements  from  faulty  func- 
on  connected  with  albuminoid  disintegration, 
:c.,  the  writer  quite  concurs  with,  and  will  con- 
sely  state  the  views  advanced  by  Dr.  Murehi- 
m.  One  of  the  immediate  results  of  such  faulty 
inction  is  the  non-conversion  of  nitrogenous 
attersinto  urea,  and  the  production  of  lithates 
id  lithic  acid,  inducing  a condition  of  blood 
■ which  this  authority  fitly  applied  the  term 
‘hamia.  This  lithsemia  may  be  relieved  for 
'.time  by  elimination  by  the  kidneys,  showing 
pelf  in  deposits  in  the  urine,  on  cooling,  of  lithic 
id,  lithates,  and  pigmentary  matter.  These 
posits  are  not  unfrequent  in  persons  in  good 


health,  especially  after  any  excess  or  error  in 
diet;  and  they  are  more  or  less  constant  in 
subjects  of  gouty  habit  of  body,  and  in  those 
who  are  predisposed  to  hepatic  derangement,  or 
who  induce  it  by  habitual  over-stimulatiDg  diet. 
These  deposits  may  exist  for  years  without 
causing  much  discomfort ; but  after  a time,  the 
excessive  quantity  of  lithic  acid  and  lithates  can- 
not be  eliminated  by  the  kidneys ; and  they  accu- 
mulate, causing  disturbances  in  different  parts  of 
the  organism,  and  giving  rise  to  various  more  or 
less  distressing  symptoms.  Of  these  symptoms 
the  more  prominent,  are ; — epigastric  oppres- 
sion, flatulent  distension  of  stomach  and  bowelz, 
heartburn,  acid  eructations,  sense  of  weariness 
and  tendency  to  sleep  after  meals,  furred  tongue, 
unpleasant  taste  in  the  mouth,  especially  in  tli? 
morning,  appetite  often  good,  sometimes  the 
contrary,  an  excessive  secretion  of  viscid  mucus 
in  the  fauces  and  back  of  the  nose,  constipation 
and  vitiated  secretions.  Palpitation,  irregular 
or  intermitting  pulse,  frontal  headache,  vertigo, 
noises  in  the  ears,  restlessness  at  night,  irrita- 
bility of  temper,  and  hypochondriasis,  are  other 
symptoms  that  are  not  unfrequently  present. 

Gout,  whether  openly  expressed,  latent,  or 
irregular,  is  associated  with  tho  symptoms  just 
mentioned,  and  is  one  of  the  results  of  lithaemia, 
and  of  faulty  hepatic  function. 

Urinary  calculi  are  another  result  of  lithaemia, 
at  all  events,  those  which  consist  of  lithic  acid 
or  its  salts,  and  which  arc  the  most  frequent. 
Sir  H.  Thompson  confirms  this  view,  and  shows 
that  the  formation  of  these  calculi  is  to  be  pre- 
vented by  remedies  and  a regime  directed  to  the 
liver  rather  than  to  the  kidneys. 

Biliary  calculi  are  also  a result  of  functional 
hepatic  derangement,  and  are  frequently  associated 
with  a gouty  habit  of  body,  and  with  lithic  acid 
deposits  and  calculi. 

Lithaemia  predisposes  to  local  inflammations. 
Individuals  who  are  subject  to  deposits  of  lithic 
acid  and  lithates  are  more  liable  than  others  to 
severe  local  inflammations  ; and  in  reference  to 
this  fact,  Dr.  Murchison  made  the  practical 
observation  that  in  such  persons  the  lithates 
cease  to  be  eliminated  on  the  advent  of  a local 
iufiammation  or  ordinary  febrile  catarrh,  to  be 
again  discharged  freely  on  the  subsidence  of  the 
pyrexia.  In  such  eases,  he  added,  the  retention 
of  lithates  in  the  system  has  probably  deter- 
mined the  attack. 

Some  diseases  of  the  skin,  as  eczema,  psoriasis, 
lichen,  and  urticaria,  are  unquestionably  often 
induced  and  maintained  by  lithaemia  and  the 
hepatic  derangement  from  which  it  results. 

To  conclude  this  portion  of  the  subject,  tho 
functional  derangement  under  consideration,  as 
Dr.  Murchison  remarked,  ‘ by  the  production  of 
peccant  substances  which  are  not  readily  elimi- 
nated, and  which,  therefore,  accumulate  in  the 
system,  may  in  the  long  run  lead  to  many  of  the 
most  serious  maladies,  both  acute  and  chronic,  to 
which  our  race  is  subject.’ 

3.  Disorders  of  the  Biliary  Function. 
Disorders  referable  to  faulty  biliary’  secretion 
may’  be  divided  into  (a)  those  due  to  excessive 
secretion  ; and  (A)  those  due  to  deficient  secretion. 
It  is  scarcely  necessary  to  arrange  those  due  tc 
vitiated  bile  under  a separate  head,  as  the  secre- 


LIVER,  FUNCTIONAL  DISORDERS  OF. 


840 

tion  may  be  vitiated,  whether  it  be  redundant  or 
deficient. 

(а)  Excessive  secretion  of  bile  is  characterised 
by  bilious  diarrhoea — copious,  fluid,  bilious  eva- 
cuations, nausea,  or  not  unfrequently  vomiting ; 
twisting,  griping  pains  in  the  abdomen ; and 
perhaps  some  febrile  symptoms.  The  bile  in 
some  cases  seems  to  be  peculiarly  acrid,  and 
causes  much  smarting  when  it  is  voided.  The 
urine  is  generally  high-coloured,  and  loaded 
with  lithates.  There  is  frequently  headache, 
and  either  irritability  of  temper  or  depression  of 
spirits.  Disturbances  of  circulation,  in  the  form 
of  irregularity  of  pulse,  and  palpitation  of  the 
heart,  are  also  occasionally  present.  As  has  been 
stated  under  the  article  Liver,  Hyperaemia  of, 
this  excessive  secretion  of  bile,  with  the  attend- 
ant symptoms,  is  usually  the  result  of  congestion 
of  the  liver. 

(б)  Deficient  secretion  of  bile  is  characterised 
by  dyspeptic  symptoms,  such  as  furred  tongue, 
unpleasant  taste  in  the  mouth,  loss  of  appe- 
tite, and  flatulence.  The  action  of  the  bowels 
may  be  irregular,  but  is  usually  costive ; and  the 
evacuations  are  of  a pale  yellow,  or  drab,  or 
whitish  colour,  and  often  of  offensive  odour.  The 
complexion  is  usually  sallow  and  anaemic,  not  often 
jaundiced.  Disturbances  of  the  circulation,  in 
the  form  of  languid  or  irregular  pulse,  and  of  the 
nervous  system,  as  headache,  languor,  drowsiness, 
and  hypochondriasis,  are  frequent  concomitants. 
The  urine  is  generally  dark-coloured,  turbid,  and 
loaded  with  lithates.  There  is  also,  in  cases  of 
long  standing,  loss  of  flesh.  Indeed,  the  func- 
tions of  the  bile  in  promoting  the  assimilation 
of  fat,  in  stimulating  the  peristaltic  action  of 
the  intestines,  and  as  an  antiseptic,  are  well  illus- 
trated in  the  symptoms  which  attend  protracted 
deficiency  of  the  secretion. 

Treatment. — Among  the  remedies  which  pro- 
mote the  expulsion,  if  not  the  secretion  of  bile, 
mercury  and  its  preparations  hold  a promi- 
nent place.  For  notwithstanding  the  results 
of  experiments  upon  animals,  few  practitioners 
will  be  content  to  give  up  the  advantage  which 
their  clinical  experience  has  taught  them  is  to 
be  derived  from  the  judicious  use  of  mercury'. 
It  is  possible  that  the  drug  merely  effects  the 
expulsion  of  the  bile ; the  result,  however,  is 
unquestionable.  In  excessive  secretion  of  bile 
a single  full  dose  of  calomel,  followed  in  a 
few  hours  by  a saline  draught,  will  cause  a free 
downward  discharge ; and  in  the  lithaemic  con- 
dition of  system,  indicated  by  turbid  urine  con- 
taining copious  lithates,  the  same  treatment  will 
afford  ready  relief.  In  smaller  doses,  repeated 
at  intervals,  and  combined  with  other  aperients, 
as  coloeyntli,  or  rhubarb,  mercury  will  be  fol- 
lowed by  beneficial  results  in  less  active  func- 
tional derangement.  In  some  cases  mercury  is 
inadmissible,  or  disagrees,  and,  in  any'  case,  it  is 
well  not  to  repeat  it  too  frequently,  or  to  con- 
tinue it  for  too  long  a time,  as  its  protracted  use 
is  apt  to  impair  digestion  and  nutrition,  and 
weaken  the  function  of  the  organ  which  it  at  first 
relieves.  Of  late  years  a valuable  addition  to  the 
list  of  cholagogues  has  been  made  in  podophyllin. 
A quarter  of  a grain  to  a grain  of  the  resin 
may  be  given  for  a dose,  combined  with  a little 
ryoscyamus  or  half  a grain  of  extract  of  canna- 


bis indica  to  prevent  griping,  and  a grain  or 
two  of  rhubarb  or  watery  extract  of  aloes,  or,  if 
it  is  desirable  to  quicken  the  action,  with  some 
extract  of  colocynth,  or  it  may  be  given  in  solu- 
tion as  a tincture.  When  the  drug  acts  fa- 
vourably it  produces  one  or  two  bulky  evacua- 
tions, with  copious  excretion  of  bile,  followed 
by  a feeling  on  the  part  of  the  patient  that  the 
bowels  have  been  thoroughly  emptied.  Its  ac- 
tion, however,  is  at  times  neither  satisfactory 
nor  certain,  and  it  causes  occasionally  much 
griping,  irritation,  and  tenesmus,  and  subse- 
quent depression.  Taraxacum  is  useful  as  an 
aperient,  and  probably  alterative,  in  functional 
hepatic  disorders,  and  may  be  given  in  cases 
where  the  gouty  or  lithic  acid  diathesis  exists, 
in  combination  with  alkalies,  especially  the 
bicarbonate  of  potash.  The  fresh  extract,  in 
ten  to  fifteen-grain  doses,  acts  better  than  the 
juice.  Nitro-muriatic  acid  is  indicated  in  cases 
of  torpid  liver  associated  with  oxaluria  (set 
Liver,  Hyperaemia  of).  The  saline  aperient 
draught  has  of  late  been  in  a great  degree 
superseded  by  one  or  other  of  the  apenent 
mineral  waters,  the  Friedrichshall,  Pullna,  Huu- 
yadi,  &c.  These  should  be  taken  in  the  morn- 
ing, fasting,  and  their  effect  is  quickened  by  the 
addition  of  some  warm  water.  The  action  of 
these  waters,  as  of  the  saline  purgative,  is  to 
cause  a drain  from  the  intestinal  vessels,  and 
thus  to  relieve  the  congested  hepatic  portal  sys- 
tem. The  waters  of  Carlsbad,  Marienbad,  and 
other  similar  springs  contain  no  sulphate  of 
magnesia,  and  owe  their  aperient  effect  to  the 
sulphate  of  soda  which  is  the  preponderating 
ingredient.  This  drug  does  not  act  by  stimu- 
lating intestinal  secretion,  but,  according  to 
Buckheim,  by  retaining  the  water  in  which  it  is 
dissolved  and  that  which  it  meets  with  in  the 
bowel,  and  so  constituting  a solvent  which  loos- 
ens and  softens  and  carries  down  dried  faecal 
masses,  and  tenacious  mucus.  The  amount  of 
carbonate  of  soda  associated  with  the  Glauber's 
salt  in  these  waters  renders  them  antacid,  and 
assists  in  determining  a diuretic  as  well  as 
aperient  action.  The  mineral  waters,  or  the  salts 
obtained  from  them  by  evaporation,  may  be 
taken  at  home  in  the  morning,  in  conjunction 
with  sufficient  warm  water.  For  those  indivi- 
duals especially  who  are  suffering  from  hepatic 
congestion  or  merely  functional  disorder,  espe- 
cially if  the  result  of  irregular  habits  in  eating 
and  drinking,  a visit  to  and  course  of  waters  at 
one  of  the  spas  will,  if  means  permit,  be  de- 
sirable. Change  of  scene,  regularity  in  diet,  and 
absence  from  mental  harass,  are,  of  course,  im- 
portant elements  in  the  success  of  a more  or  less 
protracted  stay  at  such  places;  and  it  is  remark- 
able how  readily  many  individuals,  who  are 
quite  unmanageable  at  home,  submit  to  strict 
hygienic  arrangements  under  fresh  influences. 
Cheltenham,  Leamington,  and  Scarborough  in 
this  country,  and  in  addition  to  those  already 
named,  Homburg  and  Kissengen  on  the  Conti- 
nent, are  amongst  the  spas  which  enjoy  special 
renown  in  the  treatment  of  liver-affections.  See 
Mineral  Waters. 

In  no  class  of  disorders  do  general  remedial 
or  hygienic  agents  act  more  beneficially  than  in 
functional  derangements  of  the  liver.  Pure  air 


LIVEE.  HYDATID  DISEASE  OF.  841 


exercise,  strict  attention  to  the  functions  of  the 
stin,  and  suitable  diet,  are  the  curative  means 
on  which  we  must  mainly  rely.  In  all  cases  it  is 
of  moment  to  promote  t he  healthy  action  of  the 
skin  and  lungs.  This  is  to  be  done  by  exercise 
on  foot  or  horseback.  The  latter  is  peculiarly  ad- 
vantageous, as  it  stimulates  directly,  by  a series 
of  succussions,  and  by  contraction  of  the  abdo- 
minal muscles,  the  liver  and  intestines,  and 
may  be  had  recourse  to,  in  moderation,  by  those 
who  are  not  very  vigorous.  Walking  promotes 
the  general  circulation,  excites  the  action  of  the 
skin,  increases  the  frequency  and  fulness  of  the 
respirations,  and  indirectly  tends  materially  to 
relieve  a congested  or  indolent  state  of  liver.  The 
action  of  the  skin  must  also  be  maintained  by 
adequate  clothing  in  all  seasons  of  the  year,  and 
by  daily  use  of  the  sponge-bath,  followed  by 
active  friction  of  the  entire  surface  of  the  body. 

The  diet  should  be  of  a light  nourishing  cha- 
racter; and  rich  gravies,  made  dishes,  soups, 
sauces,  pastry,  raw  vegetables,  and  such  articles, 
should  be  carefully  avoided.  The  nitrogenous 
foods  suit  best,  especially  where  there  is  asso- 
ciated lithsemia ; starchy  and  saccharine  articles 
beirig  objectionable.  The  stronger  spirituous 
! drinks  are  to  be  entirely  avoided  ; but  the  lighter 
wines,  as  claret,  hock,  and  light  dry  sherry,  may 
be  taken  at  meals  in  moderation. 

S.  H.  Ward. 

LIVES,  Gangrene  of.  Sec  Liver,  Abscess 
of;  and  Inflammation,  Acute,  of. 

LIVES,  Hydatid  Disease  of. — Synon.  : 
Echinococci  of  Liver. 

Anatomical  Characters. — The  liver  is  the 
organ  most  frequently  affected  with  hydatid  dis- 
ease. There  is  usually  but  one  cyst,  but  there 
may  be  two,  three,  or  more ; and  the  size  of  the 
cyst  may  vary  from  that  of  a pea  to  that  of  a 
child’s  head.  The  cysts  may  exist  in  either  lobe 
of  the  liver,  hut  they  are  more  frequent  in  the 
right ; and  they  may  be  attached  to  the  upper  or 
under  surface,  or  project  from  the  border,  or  lie 
buried  in  the  substance  of  the  gland.  This  is 
more  or  less  modified  in  form,  and  increased  in 
size,  according  to  the  magnitude  and  site  of  the 
cyst.  When  the  cyst  is  small  and  deep-seated, 
there  will  be  no  appreciable  change  in  the  liver, 
and  the  disease  may  be  latent  for  years.  When, 
however,  the  cyst  is  very  large,  it,  with  the 
liver,  may  constitute  a tumour,  which  may  en- 
croach upon  the  thorax,  and  also  fill  a great  part 
jf  the  abdomen.  Pressure  of  the  cyst  may  in- 
luce  atrophy  of  a portion  of  the  liver,  but,  at 
imes,  hypertrophy  is  the  result.  The  bile-ducts 
lave  occasionally  been  found  to  be  obliterated, 
>r  a communication  to  have  been  effected  be- 
ween  them  and  the  cysts.  When  at  the  surface 
j'f  the  organ,  the  cysts  as  they  enlaree  may 
nduce  inflammation  and  thickening  of  the  peri- 
;oneum,  and  adhesion  to  neighbouring  struc- 
ures. 

Symptoms. — A hydatid  cyst,  when  sufficiently 
irge  and  near  the  surface,  generally  exhibits 
•self  as  a tumour  of  variable  size,  situated  either 
i the  right  hypochondrium  or  in  the  epigastric 
igion ; evenly  globular  in  its  early  stages ; 
cm,  resisting,  yet  elastic,  and,  at  times,  with  a 
■nsation  of  fluctuation.  Briancon  and  Piorry 


noticed  a vibration  or  trembling — hydatid  fremi- 
tus— which  is  felt  when  the  surface  is  compressed 
gently  by  three  fingers  of  the  left  hand,  and 
sharp  percussion  made  with  the  right  hand  over 
the  middle  finger.  Prerichs  does  not  consider  this 
sign  of  much  importance,  it  having  been  present 
in  only  one-half  of  his  cases.  If  the  tumour  is 
situated  behind  the  liver,  it  will,  as  it  develops, 
push  this  organ  forwards,  flatten  it,  and  increase 
the  area  of  dulness.  The  tumour  may  last  for  a 
considerable  time,  and  go  on  increasing  to  some 
extent,  and  yet  the  patient  remain  free  from 
constitutional  disturbance,  perform  all  his 
functions  well,  and  keep  in  good  condition  as 
regards  flesh  and  strength.  When,  however,  it 
has  attained  a very  large  size,  it  will  give  rise  to 
various  symptoms  ; to  a feeling  of  tightness  and 
distension  ; if  it  press  upwards,  to  embarrassed 
breathing,  cough,  and  palpitation ; if  upon  the 
abdominal  viscera,  to  interference  with  their 
functions.  Pain  is  not  generally  present,  but 
in  some  cases  there  is  a gnawing  pain,  either  at 
the  epigastrium,  or  extending  forwards  from  the 
lumbar  region.  (Edema  of  the  lower  extremities 
may  occur  when  the  tumour  presses  upon  the 
inferior  cava. 

Diagnosis. — Hydatid  tumour  of  the  liver  is 
not  always  easily  diagnosed  ; but  the  charac- 
teristic features  already  noticed,  and  its  com- 
patibility (in  many  cases  up  to  an  advanced 
stage)  with  a good  state  of  health,  will  generally 
point  to  its  nature.  Abscess  of  the  liver  will  he 
distinguished  by  local  and  remote  pain  ; the  fre- 
quent antecedence  or  co-existenee  of  dysentery; 
and  severe  constitutionalsymptoms.suchasheetic 
fever,  rigors,  &c.  It  must,  however,  be  remem- 
bered that  hydatid  cysts  are  liable  to  become 
inflamed  and  to  suppurate,  when  the  diagnosia 
will  not  be  so  readily  made.  Cancer  of  the  liver 
will  generally  he  marked  by  irregularity  of  sur- 
face ; the  presence  of  pain  ; the  cachectic  aspect ; 
and  the  rapidity  of  progress.  Aneurism  of  the 
abdominal  aorta  may  form  an  epigastric  tumour, 
of  even,  spherical  shape;  hut  the  pulsations, 
frequently  very  forcible,  coupled,  probably,  with 
bruit,  audible  along  the  course  of  the  vessel 
before  and  behind,  will  determine  the  diagnosis. 
The  site,  the  pyriform  shape  and  uniform  size, 
and  the  usual  accompaniment  of  jaundice,  will 
distinguish  from  hydatid  disease  the  tumour 
caused  by  a distended  gall-bladder.  Prerichs 
thinks  that  hydatid  disease  of  the  liver  is  more 
frequently  confounded  with  localised  pleuritic 
effusion  at  the  base  of  the  chest  than  with  any 
other  affection.  He  remarks  that  the  same 
signs — dulness  on  percussion,  absence  of  vocal 
thrill,  intercostal  fluctuation — would  be  present 
in  both  cases.  He  rests  the  diagnosis  on  the 
fact  that  the  line  of  dulness  would  present  a 
curve  which  would  look  upwards  in  the  one  case, 
downwards  in  the  other. 

Prognosis  and  Terminations.  — Hydatid 
tumour  of  the  liver  may  last  for  years,  and  he 
compatible  with  an  average  state  of  health;  or 
at  an  early  or  advanced  period  of  its  existence, 
it  may  terminate  in  one  of  the  following  ways ; — 
1.  It  may,  from  its  bulk  and  position,  press  upon 
and  interfere  with  the  functions  of  different 
organs.  Pressuro  on  the  large  venous  trunks 
may  induce  ascites  and  dropsy  of  the  lower  ex- 


342  LIVER.  HYPEREMIA  OF. 


tremities  ; pressure  upon  the  stomach  and  intes- 
tinal canal  may  obstruct  functions  connected  with 
the  assimilation  of  food,  and  induce  failure  of 
flesh  and  strength,  and  ultimately  death  from 
exhaustion.  2.  The  tumour  may  contract  ad- 
hesions with  the  diaphragm ; ulcerative  action 
through  this  may  be  set  up,  and  either  (a)  dis- 
charge of  the  contents  of  the  sac  may  take  place 
into  the  pleura,  and  fatal  pleuritis  result ; or  ( b ) 
further  adhesions  and  ulceration  may  effect  com- 
munication with  the  lung,  pneumonic  symptoms 
ensue,  and  the  contents  of  the  sac,  mixed  with 
the  products  of  inflammation,  be  expectorated. 
3.  A rare  result  is  adhesion  to,  and  ulceration 
into  the  pericardium,  with  escape  of  contents, 
and  rapidly  fatal  results.  4.  Adhesion  may  be 
effected  with  some  part  of  the  alimentary  canal, 
and  the  contents  of  the  sac  be  discharged  by 
vomiting  or  by  stool.  5.  Rupture  of  the  sac 
may  be  caused  by  a blow  or  otherwise  ; the  con- 
tents be  discharged  into  the  peritoneum  ; and 
fatal  peritonitis  result.  6.  The  tumour  may 
contract  adhesions  with  the  parietes ; point  ex- 
ternally ; and  be  opened  or  effect  an  opening 
by  natural  process,  inflammation  and  suppuration 
having  been  previously  set  up  in  the  sac.  7. 
Budd  and  Ererichs  notice  a possible  cure  from 
the  obliteration  of  the  sac  by  the  formation 
within  it  of  a putty-like  matter,  which  involves 
or  perhaps  results  from  destruction  of  the  cysts. 
8.  Communication  may  be  effected  between  a 
cyst  and  one  of  the  bile-ducts,  and  then  the  result 
will  usually  be  fatal,  although  there  are  one 
or  two  cases  recorded  of  recovery.  9.  Similar 
cysts  may  be  formed  in  other  parts  or  organs  of 
the  body.  10.  As  a possible  rare  event  may  be 
mentioned  communication  of  the  sac  with  the 
ascending  vena  cava,  escape  of  the  contents  into 
this,  transfer  of  the  contents  to  the  right  side  of 
the  heart,  impaction  in  the  pulmonary  artery, 
and  fatal  asphyxia. 

Treatment. — So  long  as  a hydatid  tumour 
induces  no  distressing  symptoms,  and  does  not 
affect  the  functions  of  any  organs,  there  is  no 
pressing  cause  for  interference.  When,  how- 
ever, it  is  rapidly  increasing,  is  accompanied 
with  pain  or  distressing  distension,  and  espe- 
cially if  by  upward  pressure  it  is  causing  diffi- 
culty of  breathing,  and  other  symptoms,  it  will 
be  well  to  have  recourse  to  tapping.  If  there  be 
any  doubt  about  the  nature  of  the  tumour,  the 
exploratory  needle  may  be  first  introduced,  and 
should  a clear  fluid,  free  from  albumen,  escape, 
the  case  may  be  fairly  pronounced  to  be  one  of 
hydatid  disease.  It  is  now,  indeed,  considered 
the  best  treatment  not  to  wait  for  urgent  symp- 
toms : but  when  the  disease  is  well  developed, 
the  cyst  yet  perhaps  single,  and  the  walls 
elastic,  to  let  out  the  contents.  This  is  best  and 
most  safely  effected  by  puncturing  with  a fine 
trochar  or  with  an  aspirator.  Certain  precau- 
tionary measures  must,  however,  be  attended  to. 
Prior  to  tapping,  a broad  flannel  roller  should  be 
firmly  applied  round  the  abdomen,  commencing 
from  below  and  carrying  the  bandage  np  to  the 
tumour,  so  as  to  assist  in  fixing  this.  It  is  con- 
sidered desirable  not  to  quite  empty-  the  cyst,  as 
by  doing  so  the  chance  of  air  entering  the  cyst 
is  increased.  This  result  may  also  be  further 
prevented,  and  adhesion  of  the  cyst  to  the 


parietes  promoted,  by  applying  a compress  of 
lint  over  the  wound  and  fixing  it  firmly  with 
the  remainder  of  the  bandage  which  has  been 
already  partially  applied.  The  patient  should 
be  kept  quiet  in  bed  for  a day  or  two,  and  rest 
should  be  further  ensured  by  the  administration 
of  morphia.  Tho  late  Hr.  Murchison  discoun- 
tenanced the  use  of  chloroform  for  this  operation, 
as  the  pain  is  but  trifling,  and  the  chloroform 
may  induce  vomiting,  which  would  interfere  with 
the  subsequent  rest  of  parts,  so  desirable  to 
ensure  a successful  result.  It  is  not  necessarv 
to  wait  for  the  adhesion  of  the  cyst'  to  the 
parietes  before  puncturing,  as  the  use  of  a fino 
trochar  diminishes  the  risk  of  escape  of  the  con- 
tents of  the  sac  into  the  peritoneum ; and,  more- 
over, the  escape  of  a certain  amount  of  fluid  will 
not  usually  induce  peritonitis.  A large  propor- 
tion of  cases  thus  treated  have  been  successful 
"When  a hydatid  cyst  has  suppurated,  it  should 
be  opened  with  a large  trochar  or  a bistoury,  and 
kept  open.  Puncture  and  subsequent  injection 
of  the  cyst  with  some  stimulating  fluid ; gradual 
opening  of  the  cyst  by  applications  of  caustic 
potash,  so  as  to  ensure  adhesion  with  the  pa- 
rietes ; and  a large  incision  with  a view  to  effective 
removal  of  contents,  are  methods  of  treatment 
which  have  been  practised,  but  cannot  be  re- 
commended in  comparison  with  simple  puncture 
with  a fine  trochar.  Dr.  Ililton  Eagge  and  Mr. 
Durham  treated  several  cases  successfully  by 
acupuncture,  and  by  passing  a galvanic  current 
through  the  contents  of  the  cyst ; hut  it  seemed 
probable  that  the  result  was  due  to  the  acu- 
puncture, and  not  to  the  galvanic  influence. 
Treatment  by  special  medicinal  agents,  adminis- 
tered internally,  has  been  fairly  tried.  Of  these, 
common  salt  and  iodide  of  potassium  in  large 
doses  may  he  mentioned.  They  have,  however, 
proved  useless.  Stephen  II.  "Ward. 

LIVER,  Hypersemia  of. — Synon.  : Conges- 
tion of  the  Liver. 

Definition. — Uniform  enlargement  of  the 
liver,  with  preservation  of  its  normal  shape; 
caused  by  over-distension  with  blood,  the  result 
of  mechanical  obstruction  to  the  return  of  bicod 
to  the  heart,  or  of  direct  afflux  of  blood  through 
the  portal  vessels  ; attended  with  a sense  of  ful- 
ness and  oppression  in  the  right  hypochondrium 
and  in  the  epigastric  region,  a dusky  and  some- 
times jaundiced  complexion ; and  terminating,  if 
not  relieved,  in  organic  changes  in  the  hepitio 
parenchyma. 

JEtiology. — Congestion  of  the  liver  may  he  | 
either  active  or  passive.  Niemeyer  limits  tho  | 
term  ‘ congestion  ’ to  the  latter,  and  applies  the1 
term  ‘ fluxion’  to  the  former.  Active  hyperamiaA 
or  congestion,  results  from — 1.  Excess  iu  eat- 
ing and  drinking,  especially  in  persons  efse’en- 
tarv  and  indolent  habits.  Determination  <i 
blood  to  the  liver  occurs,  to  some  extent,  in  the 
process  of  digestion  in  connection  with  ordinary 
meals,  and  if  these  consist  of  rich  and  irritating! 
materials,  and  are  repeated  too  often,  or  if  tliri 
liver  is  stimulated  between  meals  by  the  imbibi- 
tion of  spirituous  liquors  the  hypermmia  may 
become  excessive  and  continuous.  2.  Long  ex- 
posure to  a tropical  or  sub-tropical  temperature 
will,  perhaps,  induce  hepatic  congestion,  but 


LIVER,  HYPEREMIA  OF.  8-13 


such  influence  may  be  long  resisted  by  per- 
sons of  temperate  habits ; and  it  is  probable  that 
the  association  of  irregularities  in  eating  and 
drinking  mainly  contributes  to  the  result.  3.  A 
chill,  after  exposure  to  heat,  may  induce  active 
hepatic  congestion,  which,  in  hot  climates,  may 
result  in  suppurative  hepatitis.  4.  It  maybe 
excited  by  injuries  to  the  liver— such  as  contu- 
sions or  wounds.  5.  It  occurs  in  connection  with 
suppressed  menstruation,  especially  in  women  of 
full  habit  of  body,  and  who  are  approaching  the 
period  of  1 change  of  life.’  6.  Hyperaemia  of  the 
liver  with  enlargement  occurs  in  connection  with 
typhus  fever,  the  acute  exanthemata,  puerperal 
lever,  scurvy,  &c.  It  is  also  a result  of  pro- 
longed exposure  to  malaria,  with  or  without 
attacks  of  pronounced  ague.  This  influence  is 
the  main  cause  of  the  enlarged  livers  with  which 
‘old  Indians’  return  to  this  country.  Passive 
hyperemia,  to  which  the  term  mechanical  is 
applied  by  some  authors,  is  due  to  interference 
with  the  return  of  blood  from  the  liver  through 
the  hepatic  vein  and  inferior  cava  to  the  heart. 
Such  interference  may  be  due  immediately  to 
dilatation  of  the  right  heart,  with  affection' of 
the  tricuspid  valve ; to  obstruction  to  the  cir- 
culation in  the  course  of  the  pulmonary  arteries, 
caused  by  different  diseases  of  the  lungs;  or 
farther  on,  in  the  line  of  the  circulation,  to 
disease  of  the  mitral  or  aortic  valves.  The  affec- 
tions of  the  lungs  which  interfere  with  the  pul- 
monary circulation  are  either  acute,  as  pneu- 
monia, and  then  the  hepatic  hyperaemia  may 
pass  off  with  the  disease;  or  they  are  chronic, 
as  emphysema,  and  fibroid  disease,  and  then  the 
hyperaemia  will  persist.  Mechanical  congestion 
of  the  liver  may  result  from  direct  obstruction 
to  the  flow  of  blood  by  the  pressure  on  the  vena 
cava  of  aneurismal  or  other  tumours.  Mere 
weakness  of  the  heart’s  action  often  keeps  up  a 
certain  amount  of  passive  congestion. 

Anatomical  Characters. — A hypersonic  liver 
is  increased  in  size  about  equally  in  all  direc- 
tions ; its  resistance  is  also  increased ; its  peri- 
toneal investment  appears  distended  and  shin- 
ing. On  making  an  incision  blood  oozes  out 
freely,  and  the  cut  surface  is  dark  red,  either 
uniformly  so,  or  spotted  with  intervening  lighter 
spaces.  In  the  active  form  of  congestion  there 
is  engorgement  of  the  portal  vessels  at  the  peri- 
phery of  the  lobules ; in  the  passive  or  mechani- 
cal form,  the  central  vessels  of  the  lobules — the 
hepatic  veins — are  engorged.  In  the  latter  form, 
when  it  is  due  to  a persistent  cause,  as  disease 
of  the  mitral  valve,  and  has  lasted  some  time, 
the  cut  surface  gives  the  characteristic  appear- 
ance to  which  the  term  nutmeg-liver  has  been 
applied.  The  dark  centres  contrast  with  the 
pale  circumference  of  the  lobules,  the  light 
I and  dark  parts  are  clearly  defined,  varying  ac- 
' cording  to  the  section ; the  surface  gives  an 
appearance  which  resembles  closely  that  of  a cut 
nutmeg.  The  central  dark  spots  result  from 
distension  of  the  hepatic  veins,  and  deposition  of 
bile-pigment  in  the  adjacent  hepatic  cells,  which 
are  more  or  less  atrophied  by  pressure  ; the 
.ighter  spaces  correspond  to  the  interlobular 
terns,  the  light  colour  being  due,  according  to 
nost  pathologists,  to  the  presence  of  fat  in  the 
ells  at  the  circumference.  Dr.  Wickham  Legg, 


however,  states,  as  the  result  of  an  examination 
of  twenty  cases  of  nutmeg-liver,  that  the  fat 
was  not  in  excess  in  the  majority  of  them.  In 
addition  to  the  atrophy  of  the  cells  by  pressure 
of  dilated  hepatic  veins,  there  is  hypertrophy  of 
the  interlobular  hepatic  tissue,  with  lymphoid 
bodies  scattered  through  it  and,  in  later  stages, 
through  the  liver  generally,  and  it  is  on  this 
latter  cause,  as  in  cirrhosis,  that  the  shrinking 
of  the  liver  in  advanced  cases  depends.  The 
term  ‘ red  atrophy  ’ has  been  applied  to  this 
advanced  stage  of  nutmeg-liver,  but,  as  Dr. 
Legg  remarks,  it  is  objectionable,  as  having 
been  previously  used  by  Virchow  to  designate  a 
state  of  liver  met  with  in  wasting  diseases,  such 
as  typhoid  fever.  The  term  ‘ atrophic  nutmeg- 
liver  ’ answers  well.  ‘ Varicose  atrophy,’  used 
by  some  writers,  is  based  upon  the  dilated  con- 
dition of  the  central  vessels  and  their  radicles. 

Symptoms  and  Sequels. — In  slight  cases  of 
hyperaemia  the  liver  does  not  extend  much  be- 
yond its  normal  limits,  but  it  may  perhaps  be 
felt  below  the  borders  of  the  ribs  and  across  the 
epigastrium.  In  severe  cases,  and  especially  in 
passive  hyperaemia  from  obstructed  circulation, 
the  organ  often  attains  a considerable  size,  and 
is  found,  on  percussion,  to  extend  upwards  into 
the  mammary  region,  downwards  nearly  to  the 
umbilicus,  and  across  into  the  left  hypochon- 
drium.  Its  resistance  is  generally  increased, 
and,  in  old-standing  cases  resulting  from  malaria 
and  hot  climate,  it  has  an  amount  of  hardness 
which  characterises,  and  probably  indicates,  al- 
buminoid degeneration.  There  is  often,  espe- 
cially in  acute  cases,  tenderness  on  pressure. 
The  patients  do  not  exactly  speak  of  pain, 
but  of  a sense  of  oppression  and  fulness  in  the 
right  hypochondriac  and  in  the  egigastric  re- 
gions, and  of  uneasiness  from  the  pressure  ol 
clothes,  or  on  lying  on  the  left  side.  In  most 
acute  cases  there  is  marked  functional  and  gene- 
ral disturbance  ; a furred  tongue,  nausea,  vomit- 
ing at  times  of  bile,  bilious  diarrhoea,  sallowness 
of  complexion,  or  some  amount  of  jaundice.  In 
some  cases  the  bile  seems  to  be  peculiarly  acrid, 
and  causes  much  griping  and  distress  as  it 
passes  downwards,  and  smarting  as  it  is  voided. 
The  urine  is  high-coloured,  and  loaded  with 
lithates.  The  patients  often  complain  of  head- 
ache, are  irritable,  depressed  in  spirits,  and  feel 
languid  and  drowsy.  Disturbances  of  circulation 
are  indicated,  in  severe  attacks,  by  irregularity 
of  the  pulse,  and  palpitation  of  the  heart.  When 
jaundice,  in  any  marked  degree,  is  present,  there 
is  probably  catarrh  of  the  bile-ducts,  and  tran- 
sient obstruction  of  these  ducts,  and  then  the  eva- 
cuations are  devoid  of  bile.  The  hyperaemic  con- 
dition of  liver  induced  in  India  or  other  tropical 
regions,  as  the  result  of  high  temperature  and 
malarious  influence,  may  terminate  in  chronic  en- 
largement, and  possibly  in  damaged  structure  of 
the  organ.  The  symptoms  which  mark  this  are 
cachexia  and  anaemia,  with  sallowness  of  com- 
plexion ; a weak  circulation,  indicated  by  great 
susceptibility  to  changes  of  temperature,  by 
chilliness  and  coldness  of  the  lower  extremi- 
ties ; disturbances  of  nervous  system,  shown  by 
irritability,  depression  of  spirits,  disinclination 
for  effort  of  any  kind,  headache,  giddiness ; 
and  other  symptoms.  Dyspeptic  symptoms  are 


844  LIVER.  HYPEREMIA  OF. 


present.  The  bowels  are  either  constipated 
or  relaxed ; the  stools  in  either  case  showing  a 
deficient  or  vitiated  secretion  of  bilo.  The  urine 
sometimes  contains  bile,  frequently  oxalate  of 
Jime,  and  excess  of  urea.  The  skin  is  dry  and 
harsh.  Individuals  with  such  a condition  of  liver 
may  prolong  their  existence  for  years;  or  the 
serious  interference  with  nutrition  may  induce 
increasing  loss  of  flesh  and  strength,  and.  prema- 
ture death. 

In  the  mechanical  form  of  hypersemia  there 
are,  in  addition  to  special  gastric  and  hepatic 
symptoms,  other  symptoms  indicative  of  the 
pulmonary  or  cardiac  affection  on  which  it  de- 
pends. The  complexion  is  more  or  less  dusky, 
and  there  is  a certain  amount  of  lividity  mixed 
with  the  jaundiced  hue.  The  liver,  which  may 
have  become  much  enlarged,  will,  if  observed 
carefully  in  any  protracted  case,  often  be  found 
again  to  diminish  as  the  atrophic  change 
takes  place.  Ascites  may  now  become  a promi- 
nent symptom,  whilst,  as  Niemeyer  remarks,  the 
general  dropsy  resulting  from  associated  heart- 
affection  may  be  yielding  to  treatment. 

Diagnosis. — Hyperaemia  of  the  liver,  when  it 
is  the  result  of  obstruction  to  the  circulation 
caused  by  diseases  in  the  chest,  is  easily  recog- 
nised. Also,  when  of  the  active  kind  and  acute, 
it  is  not  likely  to  bo  mistaken  for  any  other 
cause  of  enlargement.  It  is  only  when  the  con- 
gestion is  chronic,  and  the  liver  hard  and  resis- 
tant, that  an  erroneous  diagnosis  may  be  made, 
but  the  previous  history  of  the  ease,  and  asso- 
ciated general  symptoms,  will  lead  to  a right 
conclusion.  It  might  be  mistaken  for  albuminoid 
disease,  but  then  it  may  be  really  undergoing 
this  degeneration. 

Prognosis. — Active  liypersemia  of  the  liver 
usually  ends  favourably  on  removal  of  the  excit- 
ing cause,  and  under  appropriate  treatment. 
The  following  considerations  will,  however,  in- 
fluence the  prognosis.  1.  An  attack  of  hyper- 
semia  in  an  individual  of  intemperate  habits 
may  be  but  the  early  stage  of  cirrhosis.  2.  A 
similar  attack,  occurring  in  India,  may,  as  Dr. 
Maclean  remarks,  be  but  tho  commencement  of 
acute  hepatitis,  which  may  end  in  suppuration. 
3.  The  prognosis  in  the  mechanical  congestion, 
dependent  upon  disease  in  the  chest,  will  be  in- 
fluenced by  the  nature  and  stage  of  such  disease. 

Treatment. — An  attack  of  acute  hyperaemia 
of  the  liver  will  usually  be  relieved  quickly  by 
rest;  by  restriction  to  a bland,  fluid  diet;  and  by 
ensuring  free  action  of  the  bowels  by  a dose  of 
calomel,  followed  after  a few  hours  by  a saline 
aperient,  either  in  the  form  of  a draught,  or  of 
one  of  the  more  active  mineral  waters.  A single 
sufficient  dose  of  calomel,  four  or  five  grains, 
will  often  rapidly  relieve  attendant  gastric  irri- 
tation and  vomiting,  and  ensure  a free  downward 
discharge  of  bile.  Should  there  be  much  ten- 
derness on  pressure  over  the  liver,  the  applica- 
tion of  sinapisms  or  turpentine  stupes,  followed 
by  hot  poultices,  will  be  beneficial.  So  long  as 
any  acute  symptoms  continue,  the  patient  should 
be  kept  quiet  in  bed ; the  diet  should  be  light  and 
fluid ; and  stimulants  should  be  rigorously  ex- 
cluded. The  portal  system  must  be  kept  re- 
lieved by  a dose  of  Pullna  or  Friedrichshall 
water,  or  a saline  draught,  every  or  every  other 


morning,  preceded  the  previous  night  by  some 
mercurial  preparation,  if  the  secretion  seem  to 
require  this.  Podophyllin  may  be  advantageously 
substituted  for  mercury,  in  some  cases, "but  it 
is  uncertain  in  its  action.  Its  griping  effect  is 
counteracted  by  the  addition  of  a little  extract 
of  liyoscyamus  or  half  a grain  of  extract  of 
cannabis  indiea,  and  its  action  will  be  quickened 
by  adding  a little  compound  colocynth  pill. 
When  the  acute  stage  of  hyperaemia  is  passed, 
taraxacum  often  acts  well  as  a purgative  and 
alterative  ; combined,  in  subjects  of  gouty  habit, 
whose  urine  is  more  or  less  charged  with  lithates! 
with  bicarbonate  of  potash,  or,  in  other  cases,  with 
nitro-muriatic  acid.  This  acid,  in  torpidity  and 
chronic  enlargement  of  the  liver,  is  one  of  our 
most  effective  remedies.  It  acts  by  alteringand 
promoting  the  biliary  secretion,  and  by  improving 
the  tone  of  the  digestive  organs.  In  the  chronic 
enlargement  of  liver  of  ‘ old  Indians,’  and  in  that 
which  results  from  malarious  poison,  and  also 
in  other  forms  of  chronic  congestion,  it  often 
acts  very  beneficially.  It  may  be  used  both  in- 
ternally and  externally.  Ten  to  twentv  drops 
of  the  dilute  acid  of  the  pharmacopoeia  may  be 
given  two  or  three  times  daily,  combined  "with 
taraxacum,  quinine,  or  other  drug,  according  to 
indications.  The  external  use  of  the  acid  has  been 
advantageously  had  recourse  to  at  the  Seamen's 
Hospital  for  years,  either  in  the  form  of  com- 
press over  the  abdomen,  or  by  sponging  the  sur- 
face of  the  body,  or  by  the  use  of  baths  to  tho 
lower  extremities.  The  fluid  for  the  bath  or 
compress  is  prepared  by  adding  eight  ounces  of 
the  dilute  acid  of  the  pharmacopoeia  to  a gallon 
of  water  of  about  98°  Fahr.  The  compress  may 
be  applied  by  soakingaflannelrollerof  sufficient 
length,  about  a foot  in  width,  in  the  prepared 
acid,  and  wringing  it  so  that  it  merely  remains 
damp.  The  roller  should  be  then  applied  round 
the  body,  covered  with  a piece  of  oiled  silk, 
and  worn  constantly — subject,  however,  to  re- 
newal of  acid  night  and  morning ; or  the  lower 
extremities  may  be  immersed  in  the  fluid  for 
about  twenty  minutes,  night  and  morning,  and  the 
inner  sides  of  the  thighs  and  tho  body  be  sponged 
at  the  same  time.  Earthenware  or  wooden  baths 
should  be  used ; and  the  sponges  and  towels  after 
each  bath  must  be  well  washed  in  cold  water,  or 
they  will  be  destroyed  by  the  acid.  At.  times  the 
external  use  of  the  acid  causes  purging;  and  in 
several  cases,  at  the  Seamen’s  Hospital,  severe 
irritation  of  the  skin,  with  copious  papular 
eruption,  resulted,  and  the  remedy  had  to  be 
discontinued. 

Chloride  of  ammonium  and  iodide  of  potas- 
sium must  be  mentioned  as  drugs  that  have  been 
found  serviceable  in  reducing  livers  enlarged 
by  chronic  congestion.  In  the  hyperaemia  re- 
sulting from  disease  of  the  mitral  or  aortic 
valves,  or  from  chronic  lung-changes,  it  is  suffi- 
cient to  remark  that  the  chest-symptoms  will 
often  be  most  effectually  relieved  by  treatment 
directed  especially  to  the  liver. 

Much  benefit  will  result  in  many  eases  of 
liypersemia  by  a course  of  mineral  waters  at  one 
of  the  German  or  English  spas.  Marienbad,  tho 
cool  springs  of  Carlsbad,  rather  than  the  Sprudel. 
Kissingen,  Cheltenham,  Harrogate,  Ac.,  are  in- 
dicated in  active  hyponemia ; the  more  tome 


LIVER.  ACUTE  INFLAMMATION  OF.  845 


waters  in  the  more  chronic  forms  of  congestion. 
A more  detailed  notice  of  the  different  spas  and 
vraters  in  relation  to  liver-affections  is  given  at 
the  end  of  the  article  on  Functional  Disorders  of 
the  Liver.  See  Minebal  Waters. 

Stephen  H.  Ward. 

LIVER,  Hypertrophy  of. — In  true  hyper- 
trophy of  the  liver,  the  increase  in  the  size  of 
the  organ  is  due  to  enlargement  and  multipli- 
cation of  the  secreting  cells,  without  any  morbid 
change  having  taken  place  in  these,  and  with- 
out the  deposit  around  them  of  any  morbid 
material.  The  parenchyma  of  an  hypertrophied 
liver  is  generally  firm  and  vascular,  in  some  few 
instances  pale  and  flabby.  The  hypertrophy 
may  be  partial  or  general.  Partial  hypertrophy 
may  either  result  from  localised  irritation  of  the 
liver,  as  in  tight-lacing;  or  it  may  compensate 
for  some  other  portion  of  the  organ  reduced  or 
entirely  destroyed  by  disease,  as  in  the  large 
irregular  lobules  of  hepatic  tissue  formed  in 
advanced  cases  of  syphilitic  hepatitis.  General 
hypertrophy  has  been  found  in  some  cases  of 
diabetes  mellitus;  in  leukaemia;  and,  according 
to  Dr.  Jules  Simon,  in  a certain  cachectic  con- 
dition produced  under  the  combined  influences 
of  deprivation,  scrofula,  and  residence  in  a damp 
locality.  Whether  true  hepatic  hypertrophy  can 
be  caused  by  residence  in  hot  climates,  or  by 
prolonged  exposure  to  malaria,  seems,  according 
to  Frerichs,  to  be  open  to  doubt.  It  is  probably 
due  in  some  instances  to  prolonged  congestion 
of  the  liver,  and  as  a result  of  such  a condition 
may  occasionally  be  met  with  in  drinkers  and 
free  livers,  and  in  the  subjects  of  pulmonary  and 
cardiac  diseases.  W.  Johnson  Smith. 

LIVER,  Induration  of. — The  liver  is  com- 
monly hardened  whenever  it  is  small.  Simple 
induration  is  a state  in  which  new  connective- 
tissue  seems  to  replace  the  proper  hepatic  tissue 
throughout  large  tracts  of  the  liver.  Often  the 
organ  becomes  small  and  lobulated ; at  other 
times  it  is  increased  in  size,  and  a case  has  been 
known  in  which  it  weighed  eight  pounds,  consti- 
tuting a connective-tissue  hypertrophy  of  the 
liver.  The  diseased  part  presents  the  appearance 
of  a completely  homogeneous,  whitish-yellow, 
firm,  hard  mass;  which  under  the  microscope 
( is  seen  to  he  made  up  of  connective-tissue,  in 
which  no,  or  very  few,  elements  of  liver-sub- 
stauce  can  be  made  out. 

J.  Wickham  Lego. 

LIVER,  Inflammation  of,  Acute. — Sr- 
non.  : Acute  Hepatitis  ; Fr.  Hepatite  aigue ; Ger. 
Acute  Lebcrentziindung. 

It  is  usual  to  divide  acute  inflammation  of  the 
liver  into  perihepatitis,  involving  tho  investing 
membrane  of  the  liver  and  Glisson’s  capsule; 
wd  hepatitis,  iu  which  the  parenchyma  of  the 
liver  is  engaged — in  other  words,  into  superficial 
wd  deep-seated  ; but,  practically  speaking,  peri- 
lepatitis  is  rarely  more  than  an  accompaniment 
if  hepatitis,  of  peritonitis,  or  of  an  acute  attack 
if  a neighbouring  organ.  We  shall  not  treat  of 
he  two  separately,  as  they  are  constantly  asso- 
ciated with  each  other. 

JEtiology. — Acute  hepatitis  is  by  no  means 
' common  affection  in  Europe,  and  even  in  the 


tropics  congestion  is  far  more  frequent  than  acute 
inflammation.  The  chief  causes  of  hepatitis  are 
exposure  to  heat,  and  to  changes  of  temperature 
— both  of  which  have  a large  share  in  what  is 
called  tropical  influence — irregular  habits  of  life, 
and  spirit-drinking.  Irregular  action  of  the 
liver  and  of  the  bowels  predisposes  to  it.  Men  in 
the  tropics  are  far  more  subject  to  the  disease 
than  women  or  children — in  fact  acute  hepatitis 
is  exceedingly  rare  in  children.  The  disease  is 
uncommon  in  men  under  the  age  of  twenty,  and 
appears  to  be  most  frequent  between  the  ages  of 
twenty-five  and  thirty-five.  Independently  of  the 
cases  in  which  it  appears  to  be  connected  with 
dysentery,  many  authors  believe  hepatitis  to  ho 
induced  by  the  same  causes  as  those  which  pro- 
duce tropical  dysentery  and  tropical  fever — in 
other  words,  by  malarious  influences.  Hepatitis 
or  perihepatitis  are  sometimes  occasioned  by 
falls,  or  by  external  violence,  which  may  operate 
in  producing  them  either  directly  or  secondarily. 

Anatomical  Characters.—' The  liver  when  in- 
flamed is  usually  represented  as  softened  and  con- 
gested, sometimes  having  a granular  appearance. 
When  cut  into,  more  blood  flows  from  it  than 
usual.  It  is  sometimes  infiltrated  with  serous 
fluid,  with  lymph,  or  occasionally  with  small 
spots  of  pus.  While  portions  of  the  liver  are 
involved  in  inflammation,  other  portions  may  he 
unaltered;  but  most  generally  it  is  inflamed  or 
congested  throughout,  in  some  parts  in  red 
patches,  while  in  other  parts  there  are  patches 
of  a yellowish  colour.  These  may  be  traced  in 
their  changes  until  they  are  converted  into  ab- 
scesses, which  may  be  single,  or  less  frequently 
multiple ; usually  these  are  enclosed  in  a cyst, 
which  varies  from  the  thinnest  half-formed  mem- 
brane to  a tolerably  tough  one.  If  there  has 
been  much  perihepatitis,  the  liver  is  very  com- 
monly adherent  to  the  diaphragm  or  to  the  neigh- 
bouring viscera  by  organised  lymph,  and  its 
capsule  is  thickened. 

With  reference  to  the  distribution  of  dts  blood- 
vessels, it  has  been  presumed  that  congestion  of 
the  liver  is  mainly  caused  by  obstruction  to  the 
hepatic  veins,  consequent  on  affections  of  the 
heart  or  lungs,  or  by  some  obstruction  of  the 
vena  port®,  or  morbid  alteration  of  the  blood 
which  it  conveys.  In  inflammation,  again,  the 
capillaries  of  tile  hepatic  artery  are  believed  to 
be  primarily  engorged.  But  these  matters  are 
not  very  certain  As  regards  suppurative  in- 
flammation, Budd  maintains  that  it  is  the  result 
of  purulent  matter  taken  up  from  ulcerating  sur- 
faces of  the  bowel,  and  conveyed  to  the  liver  by 
the  vena  port®. 

Symptoms. — These  vary  much  iu  their  degree 
of  acuteness.  There  is  frequently  in  the  com- 
mencement chilliness,  or  even  some  shivering, 
followed  by  fever.  The  appetite  is  impaired, 
and  t here  may  bo  loathing  of  food.  The  tongue 
is  white,  and  usually  has  a thick  white  coat. 
The  bowels  are  sometimes  constipated;  more 
frequently  there  is  diarrhoea.  Sometimes  there 
is  great  thirst,  along  with  irritability  of  tho 
stomach,  with  bilious  vomiting.  A certain  de- 
gree of  jaundice  has  been  often  set  down  as  a 
symptom  of  hepatitis,  but  it  is  very  unusual. 
There  is  frequently  pain  in  the  right  shoulder, 
but  by  no  means  always.  There  is  often  a short 


346  LIVER,  ACUTE 

dry  cough.  There  is  generally  some  fever;  the 
pulse  is  usually  from  100  to  110,  and  the  tem- 
perature of  the  body  is  increased  two  or  three 
degrees ; but  there  is  seldom  present  that  amount 
of  irritation  which  one  would  expect  to  find, 
when  inflammation  is  so  acute  that  it  may  end 
in  suppuration.  In  the  region  of  the  liver  the 
symptoms  are  various.  Sometimes  there  is  sharp 
lancinating  pain,  especially  when  the  convex  sur- 
face is  most  affected ; more  frequently  there  is 
a dull,  heavy  pain,  which  is  increased  when  the 
patient  endeavours  to  lie  on  his  left  side.  There 
is  generally  pain  in  the  liver  on  pressure.  On 
careful  examination  the  viscus  will  often  be 
found  to  be  increased  in  bulk,  but  by  no  means 
always  so.  It  may  be  enlarged  upwards  and 
backwards,  or  below  the  edge  of  the  ribs,  or 
towards  the  epigastrium.  If  the  inflammation  is 
at  all  acute,  or  if  there  bo  perihepatitis,  wdiich 
may  involve  the  lower  surface  of  the  diaphragm, 
there  may  be  shortness  of  breathing,  which  is 
often  very  distressing.  The  acuteness  of  suffer- 
ing depends  very  much  on  whether  the  surface 
or  the  deeper  portion  of  the  organ  is  most  in- 
volved in  the  inflammation.  The  urine  is  com- 
monly high-coloured,  and  contains  an  excess  of 
bile-pigment.  Sometimes  albumin  is  present, 
but  on  the  whole  nothing  very  definite  is  known 
on  this  point. 

As  regards  the  duration  of  the  symptoms,  if 
there  only  be  perihepatitis,  they  will  probably 
subside  in  three  or  four  days.  Deep-seated  hepa- 
titis may  end  in  about  ten  days  in  resolution,  or 
in  the  formation  of  abscess  (see  Liver,  Abscess 
of) ; or  the  disease  may  be  protracted  in  a 
less  acute  form  for  weeks  or  mouths,  producing 
enlargement  or  partial  induration  of  the  liver. 
In  such  cases,  and  indeed  in  the  less  acute 
form  of  hepatitis,  it  is  often  difficult  to  draw 
a distinction  between  chronic  congestion  and 
chronic  inflammation. 

Diagnosis. — Hepatitis  is  not  very  likely  to  he 
confounded  with  other  affections.  If  the  sur- 
face is  particularly  involved,  when  there  is  much 
shortness  of  brea:  h,  and  the  pains  are  lancinating, 
it  may  be  confounded  with  local  pleurisy  or 
pneumonia.  The  auscultatory  sounds,  as  also 
the  position  of  the  patient,  will  show  whether 
the  lungs  are  affected — for  with  pneumonia,  with 
intercostal  neuralgia,  with  inflammation  of  the 
stomach,  or  with  the  passage  of  gall-stones,  he 
will  not  lie  on  the  affected  side',  as  in  hepatitis  ; 
nor  is  there  in  these  diseases  the  excessive  irri- 
tability of  stomach  that  fhere  is  in  inflam- 
mation of  the  liver.  The  pain  of  gall-stones 
comes  on  more  suddenly,  is  more  acute,  and  dis- 
appears more  rapidly.  Sometimes  hepatitis  has 
been  confounded  with  enlargement  of  the  gall- 
bladder, but  usually  the  pyriform  shape  and  pro- 
minence of  that  organ  when  over-filled  should  be 
enough  to  distinguish  it.  As  for  the  diagnosis 
between  hepatitis  and  perihepatitis,  it  is  chiefly 
of  importance  as  regards  the  prognosis.  The  pain 
in  the  latter  is  usually  more  acute,  less  of  a dull 
pain,  and  is  less  persistent.  The  parenchyma 
of  the  viscus  is  less  sensitive  than  its  surface,  as 
has  appeared  to  the  writer,  on  handling  and  cut- 
ting off  two  or  three  inches  of  liver  which  had 
protruded  through  a wound. 

Prognosis.  — The  prognosis  of  hepatitis  is 


INFLAMMATION  OF. 

grave,  hut  its  termination  is  generally  favourable 
intemperate  climates,  especially  when  the  case  is 
one  rather  of  perihepatitis  than  of  hepatitis.  In 
the  tropics  the  disease  is  much  more  f ormidable. 
There  is  always  the  risk  of  its  running  into  ab- 
scess ; or,  if  that  be  avoided,  of  a state  of  chronic 
hyperaemia  of  the  organ,  with  enlargement  and 
constant  tendency  to  relapse  supervening.  The 
complication  with  dysentery  or  chronic  diarrhoea 
is  frequent  and  unfavourable.  The  ratio  of 
mortality  differs  much  in  different  places,  and 
in  the  same  place  in  different  seasons ; and  it  is 
difficult  to  ascertain  the  absolute  mortality  of 
hepatitis,  as  long  as  congestion  and  inflammation 
of  the  liver  are  not  distinguished  in  statistical 
returns.  However,  hepatitis  (if  cholera  be  ex- 
cluded) has  long  been,  and  continues  to  be 
steadily,  the  greatest  source  of  mortality  among 
our  soldiers  in  India.  The  French  found  it  a 
very  fatal  disease  in  Algiers,  and  it  has  always 
been  one  of  tho  most  serious  diseases  of  hot 
countries. 

Treatment.— The  activity  of  treatment  must 
he  regulated  by  the  acuteness  of  the  case,  and  by 
the  presence  or  absence  of  complications,  such  as 
dysentery.  In  former  days  repeated  venesection 
used  to  be  employed.  We  now  find  leeches 
applied  over  the  liver  or  to  the  anus  at  least  as 
effectual.  Emollient  cataplasms  are  to  he  kept 
constantly  applied  to  the  side.  The  bowels 
should  be  freely  acted  on  with  the  neutral  salts. 
The  action  of  ipecacuanha  in  large  doses  is  very 
useful,  whether  it  produces  nausea  or  operates 
on  the  bowels.  It  is  particularly  indicated  where 
there  is  dysenteric  complication.  The  general 
feeling  is  that  the  induction  of  vomiting  operates 
unfavourably,  hut  in  the  early  stage  of  the  dis- 
ease wo  do  not  think  a certain  amount  of  it  in- 
jurious. It  seems  to  relieve  the  liver  to  some 
extent.  Calomel  and  opium,  and  the  exhi- 
bition of  calomel  in  small  doses,  to  touch  the 
gums,  was  the  old  treatment  in  India:  wliilo 
tho  French  trusted  mainly  to  the  exhibition  of 
calomel,  ipecacuanha,  and  opium.  Both  modes 
of  treatment  were  believed  to  yield  satisfactory 
results.  The  popular  idea  that  if  the  patient 
was  once  salivated  he  was  secure  from  the  forma- 
tion of  abscess  had  no  foundation  in  fact.  If 
there  is  much  general  fever,  the  use  of  an 
ordinary  diaphoretic  mixture,  with  a larger  pro- 
portion of  tartar  emetic,  will  be  found  useful; 
if  nausea  is  produced,  so  milch  the  better.  When 
the  symptoms  become  less  acute,  the  steady  use 
of  m>  derate  saline  aperients,  or  of  iodide  of 
potassium — in  short,  the  ordinary  treatment  for 
congested  liver,  should  be  adopted.  Counter- 
irritants  and  blistering,  or  the  application  of 
tincture  of  iodine  over  the  liver,  aro  of  more  use 
in  this  than  in  the  earlier  stages.  The  nitro- 
muriatic  acid  bath  has  long  been  a popular  re- 
medy in  the  chronic  stage  of  hepatitis.  The 
body  may  be  immersed,  but  a bath  for  the  feet, 
or  sponging  the  side  with  a solution  of  the  acid, 
will  usually  he  found  as  efficacious.  The  in- 
ternal use  of  the  mineral  acids  the  writer  believes 
to  be  more  effective.  Change  of  climate  exer- 
cises a singularly  beneficial  effect ; especially 
that  obtained  by  a sea -voyage.  Sudden  exposure 
to  cold,  however,  after  a return  from  a "arm 
climate,  must  be  particularly  guarded  against 


LIVER.  MALIGNANT  DISEASE  OF.  847 


The  treatment  of  the  sequelae  of  hepatitis  be- 
comes practically  that  of  congestion  of  the  liver. 
The  steady  use  of  saline  aperients,  or  a resort 
to  the  saline-alkaline,  or  to  alkaline  baths,  as 
Carlsbad,  Marienbad,  Elster,  Vichy  and  others, 
will  be  found  beneficial.  Jn  the  acute  stage  the 
diet  must  be  low,  and  limited  chiefly  to  fluids. 
Great  attention  must  be  paid  to  diet  during  con- 
valescence also ; attention  to  this  will  help  mate- 
rially in  preventing  the  disease  from  becoming 
chronic;  and,  indeed,  there  is  no  better  prophy- 
lactic against  hepatitis  than  a carefully  regu- 
lated diet,  with  abstinence  from  spirituous 
dTinks.  J.  Macpherson. 

LIVER,  Inflammation  of,  Chronic. — This 
is  usually  only  another  name  for  cirrhosis.  Some- 
times the  name  is  given  to  a perihepatitis,  a 
thickening  and  opacity  of  the  capsule  enclosing 
the  liver,  and  beneath  which  the  liver-substance 
is  found  hardened  and  tough,  due  to  an  over- 
growth of  the  connective  tissue  from  the  capsule. 
Most  pathologists,  however,  look  upon  cirrhosis  as 
a chronic  inflammation  of  the  liver,  and  the  name 
is  usually  restricted  to  this  state.  Sec  Liver, 
Cirrhosis  of.  J.  AVickham  Lecg. 

LIVER,  Malformations  of. — Abnormali- 
ties in  the  form  of  the  liver  are  not  common, 
and  are  more  often  acquired  than  congenital. 
The  following  are  some  of  the  most  frequently 
observed  malformations  that  are  congenital , and 
due  to  some  original  defect : — A more  or  less 
quadrangular  liver ; a rounded  liver ; reduced 
( proportions  or  total  absence  of  left  lobe  ; pro- 
longation of  the  left  lobe  in  the  form  of  a narrow 
tongue-like  process  towards  the  region  of  the 
spleen ; abnormal  grooving  of  the  surfaces  of  the 
liver;  extremo  depth  of  normal  fissures.  Another 
occasional  variety  of  hepatic  malformation  con- 
sists in  extensive  lobulation,  and  tho  existence 
of  one  or  more  additional  small  lobes — a con- 
dition met  with  in  the  livers  of  rodent  animals. 
An  extreme  instance  of  this  extensive  lobulation 
was  observed  by  Dr.  Dickinson,  and  is  recorded 
in  the  Transactions  of  the  Pathological  Society 
(vol.  xvii.,p.  160).  Acquired  malformation  may 
be  due  to  hepatic  abscess ; to  hydatids  of  the 
diver;  to  new-growths;  to  some  form  of  chronic 
nflammation  (cirrhosis,  syphilitic  disease) ; or, 
inallv,  to  compression  of  the  organ  by  tight- 
acing  and  other  means. 

AV.  Johnson  Smith. 

LIVER,  Malignant  Disease  of. — Defini- 
ion. — Development  in  the  liver  of  cancerous  or 
arcomatous  growths,  either  primary,  or  secondary 
i similar  growths  elsewhere  ; causing,  generally, 
nlargemeut  of  the  organ,  with  irregularity  of  its 
urface;  attended  with  pain,  often  with  jaundice 
;ud  ascites,  with  marked  cachexia  and  progressive 
naciation  ; and  having  usually  a rapidly  fatal 
■rmination. 

AiTtOLOGT. — Sex  has  no  influence  in  the  cau- 
ition  of  hepatic  cancer;  the  disease  occurs  as 
i ten  in  males  as  in  females.  It  is  very  rare 
early  life,  but  cases  are  recorded.  Of  eighty- 
ree  cases  analysed  by  I'rerichs,  forty-one  were 
tween  forty  and  sixty  years  of  age,  and  the 
mainder  in  nearly  equal  proportions  above  and 
low  that  period.  Climate,  habits  of  life,  over- 


indulgence  in  the  use  of  spirituous  liquors,  do 
not  seem  to  play  any  part  in  determining  the 
malady.  The  influence  of  hereditary  tendency  to 
cancer  must  not,  however,  be  overlooked. 

Anatomical  Characters.  - — The  malignant 
growths  which  affect  the  liver  are  usually  the 
carcinomata — the  true  cancers;  and  of  these,  in 
nearly  all  cases,  tho  sehirrous  and  medullary  or 
encephaloid  forms ; the  colloid  being  rarely  met 
with,  and  then  only  as  a secondary  deposit.  Of 
the  sarcomata,  the  melanotic  and  round-celled  or 
medullary  sarcomata  are  met  with  occasionally. 
Cancer  may  occur  as  an  infiltration  of  the  liver- 
tissue,  when  large  masses  of  the  liver  are  uni- 
formly affected,  and  little  or  no  irregularity  of 
surface  results.  It  usually,  however,  occurs  in 
circumscribed  masses,  smaller  nodules  or  larger 
protuberances,  varying  in  size,  to  use  a familiar 
comparison,  from  that  of  a pea  to  that  of  achild's 
head.  These  masses  are  more  or  less  numerous, 
and  usually  distinct;  or  they  may  encroach  upon 
one  another,  and  give  an  appearance  of  coales- 
cence. AVhen  near  the  surface,  they  give  rise 
to  the  marked  irregularity  which  is  very  charac- 
teristic of  the  disease ; and  when  lar-re  and 
numerous,  cause  considerable  increase  in  the 
size  of  the  liver.  The  masses  on  the  surface 
are  sometimes  flattened,  arid  have  a central 
depression  which  has  been  designated  as  ‘ cancer 
navel.’  The  growths  may  be  firm  and  of  brawny 
or  even  cartilaginous  consistence,  as  when 
scirrhus  prevails  ; or  thpy  may  be  of  medullary 
softness,  when  an  incision  will  yield  freely  the 
so-called  cancer-juice.  The  cut  surface  is  either 
white,  or  reddish-white,  or  darker  red  when 
blood  has  been  recently  extra  vasated,  or  of  vary- 
ing colour,  from  altered  blood-p>igment,  when 
the  extravasation  of  blood  has  been  of  longer 
date.  The  portal  ard  hepatic  veins  are  some- 
times invaded  by  the  cancer,  and  a clot  is  formed 
in  them,  which  becomes  cancerous.  Colloid 
cancer  of  the  liver  occurs  rarely  as  a secondary 
invasion  from  the  stomach  or  peritoneum.  Me- 
lanotic sarcoma  or  melanosis  exists  occasionally 
in  conjunction  with  the  disease  in  other  parts 
of  the  body.  Malignant  disease  of  the  liver  is 
primary  in  about  one-fourth  of  all  eases ; se- 
condary in  the  remainder  ; and  in  about  onp-half 
of  the  cases  in  which  it  is  so,  the  primary 
disease  has  been  seated  in  structures  connected 
with  the  portal  system. 

Symptoms.--Li  the  earlier  stage  of  this  disease, 
the  symptoms  may  be  merely  subjective,  and 
then  diagnosis  will  be  difficult.  AVhen  the  dis- 
ease, however,  is  far  advanced,  a prominent 
irregular  swelling  may  be  seen,  raising  tho  ab- 
dominal parietes,  and  occupying  often  a lartre 
portion  of  the  abdominal  cavity.  Lesser  grades 
of  the  disease  may  be  detected  by  palpation  and 
percussion.  The  liver  will  be  found  to  extend 
more  or  less  beyond  its  normal  limits  ; to  be  hard 
and  resisting  ; and,  in  a uirge  proportion  of  eases, 
irregular,  in  a few  cases,  however,  when  tho 
disease  is  infiltrated,  the  surface  will  perhaps 
be  smooth  throughout.  At  times  there  is  no 
enlargement  of  the  organ,  and  the  portion  af 
fected  lies  under  (he  ribs,  so  that  physical  exa- 
mination does  not  help  us.  There  is  often 
tenderness  on  pressure,  especial'y  when  the  peri- 
toneal coat  is  inflamed.  Usually,  hut  not  always, 


848  LIVER.  MALIGNANT  DISEASE  OF. 


there  is  pain  in  the  liver  itself;  sometimes 
merely  a feeling  of  tightness  and  fulness  ; at 
other  times  a gnawing,  aching  pain;  and  some 
patients  have  described  the  pain  as  ‘ burning.’ 
There  is  frequently  also  pain  shooting  back  to 
the  spine,  over  the  sacrum,  or  about  the  angle 
of  the  right  scapula.  A sensation  as  of  a cord 
drawn  round  the  right  hypochondrium  has  been 
complained  of.  There  is  sometimes  pain  radia- 
ting down  to  the  lower  part  of  the  abdomen  ; and 
occasionally  wandering  pains  in  the  extremities 
and  body  generally  are  complained  of.  When  the 
stomach  is  intact,  there  may  be  no  material  dis- 
turbance of  its  functions,  but  usually  derangement 
is  manifested  by  loss  of  appetite,  nausea,  vomit- 
ing, and  other  symptoms,  which  will  be  intensi- 
fied if  the  stomach  is  implicated  in  the  disease. 
The  bowels  are,  as  a rule,  constipated  in  the 
earlier  stage,  but  towards  the  close  there  is  often 
dysenteric  diarrhoea.  Jaundice  occurs  in  nearly 
one-half  of  the  cases  of  malignant  disease  of  the 
liver,  and  is  due  to  compression  of  the  bile-ducts 
by  cancerous  masses  within  the  organ,  or  by  an 
enlarged  lymphatic  gland  in  the  portal  fissure. 
When  once  established  it  is  permanent,  and  the 
colour  of  the  patient  varies,  being  pale  yellow,  or 
deep  olive-yellow,  or  greenish,  or  sometimes  of 
the  dark  hue  which  has  given  rise  to  the  term 
‘black  jaundice.’  The  stools  in  such  cases  are 
white  or  clayey  in  appearance;  and  the  urine 
deep-coloured  from  bile-pigment.  The  condition 
of  urine,  when  there  is  no  jaundice,  is  variable  ; 
in  the  earlier  stages  of  the  disease  it  is  generally 
scanty  and  pigmented,  and  loaded  with  lithates; 
in  the  last  stage,  according  to  Dr.  Parkes,  copi- 
ous, pale,  and  deficient  in  urea.  This  condition 
he  attributes  to  the  utter  failure  of  digestive 
and  nutritive  power.  Ascites  is  present  in  more 
than  half  of  the  cases,  and  is  due  either  to  com- 
pression of  the  portal  vessels,  or  to  inflamma- 
tion of  the  peritoneum.  Sometimes  the  large 
size  of  the  tumour,  especially  if  ascites  to  any 
extent  be  present,  may  cause  much  pressure  up- 
wards, and  give  rise  to  distressing  chest-symp- 
toms, such  as  embarrassed  breathing,  or  palpi- 
tation. Haemorrhage  not  unfrequently  occurs  in 
advanced  cases.  The  blood  may  come  from  the 
stomach  or  bowels,  and  be  duo  to  portal  obstruc- 
tion ; or  may  be  of  passive  character,  as  in  scurvy 
or  purpura ; and  the  bleeding  may  take  place 
beneath  the  skin,  or  come  from  the  stomach  or 
bowels.  In  the  latter  case  the  haemorrhage  is 
accompanied,  according  to  Frerichs’  experience, 
by  intense  jaundice,  and  usually  by  somnolence 
and  delirium.  The  complexion  of  patients  suffer- 
ing from  the  disease  under  consideration,  when 
there  is  no  jaundice,  is  usually  sallow,  anaemic, 
earth-coloured.  There  is,  in  a large  majority  of 
cases,  progressive,  and  towards  the  close,  often 
extreme  emaciation.  Generally  there  is  no  fever, 
but  a sort  of  hectic  may  occur  when  the  can- 
cerous development  goes  on  rapidly,  and  involves 
several  organs.  When  the  disease  of  the  liver 
is  secondary  to,  and  complicated  with  cancerous 
affections  of  other  organs,  as  the  stomach — which 
occurs  in  a considerable  proportion  of  cases — 
pancreas,  uterus,  or  mammary  gland,  symptoms 
will  exist  indicating  such  complications,  but  need 
not  be  specially  dealt  with  here. 

Diagnosis.-  -When  hepatic  cancer  is  somewhat 


advanced,  and  the  liver  large  and  irregular  ou 
its  surface,  the  diagnosis  will  be  easily  effecied. 
In  the  early  stage,  on  the  contrary,  and  in  cases 
in  which,  throughout,  the  liver  is  not  perceptibly 
enlarged,  one  must  be  cautious  in  giving  a hasty 
or  too  decided  opinion.  Inherited  tendency  to 
cancer;  the  age  of  the  patient;  in  women  the 
period  of  ‘change  of  life;’  a sallow,  earthy 
aspect;  progressive  emaciation  ; and  pain  in  the 
right  hypochondrium,  point  with  fair  probability 
to  the  disease.  But  nearly  the  same  conditions 
and  symptoms  maybe  associated  with  aggravated 
hypochondriasis,  or  chronic  tendency  to  gall- 
stones ; and  in  the  latter  case,  the  difficulty  of 
diagnosis  is  increased,  as  gall-stones  are  often 
associated  with  cancer.  Permanent  closure  of 
the  bile-duct  from  other  causes  gives  rise  to 
persistent  jaundice  and  other  symptoms,  as  in 
the  case  of  closure  by  pressure  from  a cancerous 
mass.  Enlargement  of  the  liver  from  malignant 
disease  may  be  confounded  with  the  following 
hepatic  enlargements  and  malignant  tumours 
1.  Albuminoid  or  lardaeeous  disease.  In  this 
affection  the  hard,  perfectly  smooth  surface,  with 
preservation  of  normal  shape  of  the  liver,  absence 
of  pain  in  the  tumour,  and  of  jaundice,  will  lit 
sufficiently  distinctive,  unless  the  liver  is  ren- 
dered nomewhat  uneven  by  other  associated 
affections.  2.  In  a not  very  advanced  stage  of 
cirrhosis,  as  also  of  malignant  disease,  the  liver 
may  be  enlarged,  and  its  surface  uneven,  and  in 
both  diseases  there  is  great  resemblance  in  the 
aspect  and  general  cachectic  state  of  the  patient, 
and  similar  disturbance  of  gastric  and  hepatic 
function.  In  cancer,  however,  the  ascites  is 
generally  but  slight,  and  the  liver,  instead  of 
contracting,  as  it  usually  does  in  cirrhosis  as  the 
disease  progresses,  continues  to  increase,  and  is 
marked  by  large  nodules  and  protuberances, which 
contrast  with  the  smaller  elevations  in  cirrhosis. 
In  cancer  the  skin  is  often  perspiring  ; in  cirrhosis 
it  is  harsh  and  dry.  Intemperance  is  not  an 
element  in  the  aetiology  of  cancer,  as  it  is  in 
cirrhosis.  In  the  latter  disease,  as  also  in  lar- 
daceous  liver,  the  spleen  is  frequently  enlarged. 
3.  Hydatid  tumour  is  to  be  distinguished  from 
a localised  cancerous  mass  by  the  presence  of 
more  or  less  distinct  fluctuation ; and  the  absence 
of  pain,  and  of  serious  functional  and  constitu- 
tional symptoms.  4.  A tumour  caused  by  hepa- 
tic abscess  would  probably  give  evidence  of 
fluctuation ; be  associated  with  or  consecutive  j 
upon  dysentery ; and  often  attended  by  rigors, 
hectic  fever,  and  characteristic  shoulder-tip  pam. 
o.  Malformations  and  malpositions  of  the  liver 
have  been  mistaken  for  cancerous  enlargement, 
especially  in  females  about  the  period  of 
‘ change  of  life.’  6.  A highly-distended  gall- 
bladder has  been  mistaken  for  a cancerous  pro- 
jection from  the  liver;  but  the  smooth,  oval 
swelling,  and  the  site  of  the  enlargement,  arc 
distinctive,  and,  as  Frerichs  says,  a practitioner 
who  made  an  erroneous  diagnosis  in  such  case 
would  be  wanting  in  the  tactus  cruditus.  7 . Cancer 
of  the  omentum  would  present  a movable  tumour, 
separable,  probably,  from  the  liver  by  a slight 
area  of  tympanitic  resonance.  S.  Cancerous  de- 
posits in  the  left  lobe  of  the  liver  may  be  readdv 
mistaken  for  cancerous  affections  of  the  stomach 
Tha  following  points  will  assist  in  diagnosis:- 


LIVER,  MORBID  GROWTHS  05. 


84'/ 


' a ) Percussion  in  the  greatest  thickening  of  the 
stomach-walls  gives  a tolerably  clear,  tympa- 
nitic sound;  m cancer  of  the  leftlobe  of  the  liver, 
the  sound  is  much  more  deadened,  and  is  only 
somewhat  tympanitic  on  stronger  percussion 
stroke  ; (4)  careful  examination  of  the  liver,  and 
of  the  stomach,  when  full  and  when  empty,  will 
also  lead  to  a correct  conclusion  ; (e)  even  when 
the  liver  and  stomach  are  both  affected,  careful 
examination  may  often  make  out  the  boundaries 
of  disease  in  each.  9.  Malignant  tumour  of 
the  right  lobe  may  be  mistaken  for  malignant 
enlargement  of  the  right  kidney.  Percussion 
will  generally  give  a tympanitic  sound,  from  the 
presence  of  intestine  between  the  kidney  and 
liver.  The  hepatic  tumour  is  also  distinguished 
from  this  and  other  abdominal  tumours  by  its 
following  the  movements  of  the  diaphragm  in 
respiration.  But  when  the  renal  enlargement  is 
very  great,  diagnosis  is  not  easy.  Three  or  four 
years  ago  a sailor  was  brought  into  the  Seamen’s 
Hospital  with  an  immense  tumour  occupying 
the  greater  part  of  the  abdomen.  This  was 
diagnosed  by  all  who  saw  it  as  malignant  disease 
of  the  liver.  After  death,  however,  it  was  found 
that  the  liver  was  quite  healthy,  much  com- 
. pressed  and  narrowed,  and  spread  out  over  the 
upper  part  of  an  enormous,  cancerous  kidney. 
10.  Malignant  disease  of  the  ascending  or  trans- 
verse colon  will  constitute  a movable,  and  gene- 
rally somewhat  tympanitic  swelling;  and  faecal 
accumulations  in  the  colon  may  be  removed,  but 
not  always  readily,  by  aperients  and  injections. 
Percussion,  too,  will  often  elicit  a resonant  space 
between  the  enlarged  intestine  and  the  liver. 

Proonosis. — The  prognosis  is  always  unfa- 
vourable. The  disease  when  once  fully  pro- 
lounced  runs  its  course  rapidly,  the  fatal  ter- 
nination  being  seldom  deferred  beyond  a year, 
ichirrus  has  usually  a longer  duration  than 
nedullary  cancer. 

Treatment. — This  can  be  but  palliative,  and 
irected  to  rendering  the  inevitably  fatal  course 
s smooth  as  possible,  by'  relieving  distressing 
ymptoms.  Remedies  which  in  other  hepatic 
Sections  are  valuable,  such  as  cholagogues,  or 
lineral  waters,  are  here  useless,  if  not  worse, 
he  diet  should  be  plain  and  nourishing ; and 
te  moderate  use  of  wine  and  alcohol  is  not  con- 
j'a-indicated,  as  in  other  disorders  of  the  liver, 
trious  gastric  and  other  derangements  must  be 
et  by  appropriate  remedies;  it  being  always 
irne  in  mind  that  we  have  to  soothe  the  patient, 
id  not  add  to  his  distress  by  the  exhibition  of 
.useous  drugs.  For  the  relief  of  pain,  the  various 
eparations  of  opium  are  indicated,  and,  as  a 
le,  morphia  acts  the  best.  It  may  be  adminis- 
ted  either  internally,  or  by  the  hypodermic 
:thod,and  must  be  repeated  when  pain  demands 
Local  applications  over  the  liver,  as  poul- 
es,  spongio-piline,  &c.,  with  solution  of  opium 
•inkled  over  the  surface,  are  useful,  especially 
en  the  peritoneal  coat  is  inflamed.  Tapping 
mid  not  be  had  recourse  to  for  the  relief  of 
: ites,  unless  this  becomes  so  great  as  to  inter- 
• e by  upward  pressure  with  the  functions  of 

I ^ lungs  or  heart.  The  fluid  soon  reaccumulates, 

I I the  effect  of  the  operation  is  to  hasten  the 
1 d termination. 

Stephen  H.  Ward. 


LIVEK,  Malpositions  of.  —Abnormalities 
in  the  position  of  the  liver  are  much  less  rare 
than  abnormalities  in  its  form.  The  more  fre- 
quent forms  of  congenital  displacement  are  these : 
Lateral  transposition,  the  liver  being  found  on  the 
left  instead  of  the  right  side  of  the  abdomen ; 
eventration,  the  organ  being  exposed  in  front  of 
the  abdomen  of  a fcetus  ; the  presence  of  more 
or  less  of  the  liver  in  the  chest,  through  con- 
genital deficiency  of  the  diaphragm.  In  acquired 
displacement  the  liver  may  be  either  depressed 
or  elevated,  some  rotation  of  the  organ  on  ils 
transverse  axis  taking  place  in  an  opposite  direc 
tion  in  each  case.  Depression  may  be  caused  by 
pressure  from  above,  as  by  effusion  in  the  right 
pleural  cavity,  and  probably  to  some  slight  ex- 
tent by  considerable  pericardial  effusion,  or  car- 
diac hypertrophy.  Elevation  of  the  liver,  which 
takes  place  more  frequently,  may  be  due  to  preg- 
nancy, ascites,  or  the  presence  of  some  large  ab- 
dominal tumour.  Curvature  of  the  spine,  whether 
lateral  or  angular,  usually  gives  rise  to  some 
change  in  the  position  of  the  liver.  In  Potts’ 
disease  the  organ  is  often  forced  downwards 
towards  the  crest  of  the  right  ilium. 

By  tight-lacing  both  the  position  and  the 
form  of  the  liver  may  he  altered.  The  organ 
may  be  forced  downwards,  and  at  the  same 
time  so  twisted  on  its  transverse  axis  that  its 
convex  surface  looks  directly  forwards,  and  its 
concave  surface  directly  backwards.  When 
tightly  compressed  the  upper  surface  of  the  right 
lobe  becomes  marked  by'  the  ribs,  and  presents 
transverse  puckerings.  At  the  same  time  tho 
right  lobe  is  bent  upon  itself,  the  concavity  of 
its  lower  surface  beiDg  much  increased.  The 
hepatic  tissue  corresponding  to  the  summit  of 
the  arch  thus  formed  gradually  wastes,  until 
at  last  the  lobe  is  divided  into  two  portions  by 
a deep  transverse  groove,  which  portions  are 
connected  merely  by  a membranous  band,  com- 
posed of  thickened  serous  membrane,  and  the 
corresponding  portion  of  the  hepatic  capsule. 

AV.  Johnson  Smith. 

LIVER,  Morbid  Growths  of. — Several 
morbid  growths  have  been  met  with  in  the  liver, 
of  which  the  following  are  the  most  import- 
ant t 

1.  Simple  Cysts.  — These  formations  are 
not  often  met  with  in  the  liver.  There  may  be  a 
single  cyst,  which  is  usually  large ; or  a number 
of  small  cysts  scattered  throughout  the  organ. 
In  tho  latter  case  the  condition  is  analogous  to 
that  of  the  so-called  cystic  disease  of  the  kidney, 
and  indeed  is  sometimes  associated  with  this 
affection.  The  cyst-wall  consists  of  a fibrous 
membrane  projecting  in  folds  into  the  cavity  of 
the  sac,  and  lined  on  its  inner  surface  by  pave- 
ment-epithelium. The  cyst  almost  always  con- 
tains thin  clear  fluid,  and  is  net  connected  with 
any  bile-duct  or  vessel. 

2.  Dermoid  Cysts. — Mr.  Hulke  has  recorded 
an  instance  in  which  several  dermoid  cysts  in  a 
withered  condition  were  found  attached  to  the 
surface  of  the  liver. 

3.  Erectile  Tumours. — An  hepatic  erectile 
or  cavernous  tumour  consists  of  it  small  red  or 
bluish-red  formation,  of  a more  or  less  globular 
shape,  of  reticulated  structure,  and  containing 


54 


350  LIVER,  PIGMENTATION  OF. 


fluid  blood  or  soft  coagula.  Growths  of  this 
nature  are  often  multiple,  and  each  of  about 
the  size  of  a filbert ; they  are  usually  found 
either  along  the  anterior  margin  of  the  liver, 
or  on  the  upper  surface  of  the  organ,  near  the 
attachment  of  the  suspensory  ligament.  Each 
tumour  is  enclosed  in  a capsule  of  delicate  con- 
nective-tissue. Though  seated  at  the  periphery 
of  the  liver,  an  erectile  tumour  seldom  projects 
beyond  the  surface  of  the  organ.  Much  remains 
to  be  made  out  as  to  the  pathological  signifi- 
cance of  these  tumours,  especially  with  regard 
to  their  relation  to  malignant  disease.  There  is 
some  difference  of  opinion  as  to  their  connection 
w ith  the  hepatic  vascular  system.  Virchow  and 
Wilks  hold  that  they  are  in  communication  with 
minute  branches  of  the  hepatic  artery ; whilst 
Frerichs  states  that  they  cannot  be  injected 
through  this  vessel  or  through  the  hepatic  veins, 
but  only  through  branches  of  the  portal  vein. 

4.  Lymphatic  Formations. — The  liver  is 
sometimes  found  studded  in  all  parts  with 
minute  patches  of  tissue  of  soft  consistence, 
each  patch  being  made  up  of  an  aggregation  of 
lymphoid  cells  disposed  in  the  meshes  of  a deli- 
cate reticulum.  These  patches  of  tissue  are  in 
close  connection  with  small  vessels,  from  the 
walls  of  which,  according  to  Frerichs,  they  are 
developed.  This  condition  is  associated  with 
leukaemia. 

5.  Tubercle. — Tubercle,  as  met  with  in  the 
liver,  occurs  only  in  the  form  of  minute  miliary 
granulations,  scattered  throughout  the  whole 
organ,  but  accumulated  more  especially  on  the 
surface.  These  growths  have  been  rarely 
observed  in  the  liver,  and  in  most  of  the  in- 
stances in  association  with  acute  general  tu- 
berculosis. 

6.  Cancer. — Different  forms  of  cancer  are 
liable  to  affect  the  liver ; but  this  class  of 
diseases  is  so  important  that  they  require  sepa- 
rate consideration.  See  Liver,  Malignant  Dis- 
ease of. 

7.  Hydatids. — This  is  an  important  disease 
affecting  the  liver,  -which  demands  notice  in  this 
connection,  but  it  is  discussed  in  a separate 
article.  See  Liver,  Hydatids  of. 

8.  Benign  Growths. —Fibrous  and  other 

growths  have  been  iu  rare  instances  found  in 
the  liver,  but  they  do  not  give  rise  to  any 
clinical  signs.  W.  Johnson  Smith. 

LIVES,  Nutmeg. — Sr  non.  : Fr.  Foie  noix 
da  muscade ; Ger.  Mascatnussleber. — N utmeg-li  ver 
consists  in  a chronic  passive  congestion  of  the 
organ,  a state  which  may  always  be  brought  about 
when  there  exists  any  impediment  to  the  circu- 
lation of  the  blood  through  the  heart  or  lungs. 
The  radicles  of  the  hepatic  vein  become  filled  with 
blood,  and  thus  the  centre  of  each  acinus  shows 
a deep  red,  while  the  outer  parts  are  either 
yellow  or  of  natural  tint.  A nutmeg  appearance 
is  thus  given  to  the  liver,  which  is  often  shrunken 
and  tough,  with  adherent  capsule,  and  granular 
surface.  Under  the  microscope  the  centre  of  the 
acinus  is  seen  to  be  filled  with  dilated  blood- 
vessels, which,  pressing  on  the  liver-cells,  cause 
them  to  atrophy,  so  that  in  advanced  stages  of 
the  disease  they  disappear  altogether,  and  the 
centre  of  t ho  acinus  is  made  up  of  blood-vessels 


only,  but  there  is  no  increase  of  the  connective 
tissue  in  the  same  situation.  The  capsule  of 
Glisson  now  and  then  takes  on  an  overgrowth, 
just  as  in  cirrhosis  ; and  the  connective  tissue 
between  the  lobule  and  around  the  vessels  is 
considerably  increased.  It  is  to  this  overgrowth 
of  the  connective  tissue  that  the  shrinking  and 
hardening  of  the  liver  are  due. 

Symptoms. — The  liver  may  sometimes  be  felt 
during  life  under  the  ribs,  more  often  net.  Slight 
jaundice  is  often  present.  The  spleen  is  not  en- 
larged, hut  is  small — the  opposite  condition  to 
that  found  in  cirrhosis. 

Treatment.— This  must  be  directed  to  the 
condition  of  the  heart  or  lung  upon  which  the 
obstruction  to  the  circulation  depends.  Nutmeg- 
liver  may  always  be  suspected  when  there  exists 
any  impediment  to  the  return  of  blood  from  the 
hepatic  veins.  J.  Wickham  Lego. 

LIVEK,  Pigmentation  of. — In  subjects  who 
have  succumbed  to  intense  malarious  fever,  and 
in  some  who  during  life  had  suffered  from  fre- 
quent attacks  of  intermittent  or  remittent  fever 
in  hot  climates,  the  liver  may  he  found  to  be 
stained  by  pigment,  either  diffused  throughout 
the  whole  organ,  or  dispersed  here  and  there 
in  irregular  patches.  This  pigmentation  of  the 
liver  is  always  associated  with  a similar  condi- 
tion of  the  spleen,  and  frequently  with  staining 
of  the  nervous  centres,  the  lungs,  the  kidneys, 
and  the  lymph-glands.  Hepatic  pigmentation  is 
one  of  the  chief  post-mortem  phenomena  of  the 
condition  known  as  ‘ melanaemia,’  in  which  the 
blood,  especially  that  of  the  portal  system,  is  per- 
vaded by  granules  of  pigment  of  a black  or  deep- 
brown  colour,  some  of  which  are  free  and  isolated, 
some  held  together  in  irregular  masses  by  a pale 
jelly,  and  others  enclosed  in  cells.  In  the  pig- 
mented liver  these  granules  are  to  bo  found  in 
the  portal  blood,  in  the  walls  of  the  capillaries, 
and  outside  the  vessels,  scattered  amongst  the 
hepatic  cells,  but  not  within  these  cells.  In  an 
early  stage  of  the  hepatic  pigmentation  the  stain- 
ing affects  only  the  periphery  of  each  lobule, 
hut,  as  the  disease  progresses,  the  deposit  gra- 
dually extends  to  the  centre  of  the  lobules,  and 
attacks  the  hepatic  venous  system.  The  arterial 
capillaries  also  contain  similar  pigment-granules. 

Symptoms.- — The  size  of  the  affected  livci 
varies  in  different  cases,  and  according  to  the 
severity  and  the  stage  of  the  disease.  Th( 
organ  is.  sometimes  congested  and  swoHen:  i 
often  remains  of  normal  size ; in  some  fev 
instances  it  finally  becomes  atrophied.  Tli 
main  symptoms  of  this  condition  of  the  live 
are  occasional  intestinal  haemorrhage,  diarrhtE.- 
and  ascites.  These  symptoms  in  well-marke 
cases  of  melanaemia  are  usually  associated  wit 
albuminuria,  due  to  pigmentary  affection  of  tl 
kidneys,  and  with  more  severe  symptoms  due  t 
cerebral  complications,  such  as  delirium,  com 
and  paralysis.  Melanaemia  has  been  met  wit 
mostly  in  warm  climates,  and  occasionally  dmur 
severe  epidemics  of  intermittent  and  remitte: 
fever  in  some  parts  of  the  North  of  Europe.  . 
this  country  it  lias  been  very  rarely  observe 
See  Blood,  Morbid  Conditions  of. 

W.  Johnson  Smith. 

LIVES.  Syphilitic  Disease  of.— The  liv 


LIVER,  SYPHILITIC  DISEASE  OF. 


occasionally  becomes  diseased  during  the  tertiary 
fctao-e  of  syphilis,  or  the  period  of  gummy  deposits, 
the  hepatic  affection  being  associated  at  some 
period  with  osseous  and  cutaneous  lesions,  and 
with  syphilitic  cachexia. 

Anatomical  Characters. — Syphilitic  hepatitis 
may  attack  both  the  capsule  ( perihepatitis ) and 
the  internal  prolongations  or  septa  of  the  capsule 
( parenchymatous  hepatitis,  syphilitic  cirrhosis). 
In  some  cases  a small  portion,  in  others  a greater 
part  or  the  whole  of  the  organ,  is  affected.  In 
the  milder  form  and  less  adranced  stages  of  the 
disease  the  capsule  is  slightly  thickened,  and 
marked  by  a few  isolated  white  patches,  while 
the  surface  of  the  liver  is  here  and  there  slightly 
grooved  and  indented.  After  prolonged  inflam- 
matory action  the  liver  becomes  much  deformed, 
and  is  made  up  of  a number  of  small  lobes 
oounded  by  deep  depressions,  the  parenchyma  on 
section  beingfound  to  be  traversed  by  well-marked 
bands  of  tough  and  retractile  connective-tissue. 
The  secretory  structures  of  the  liver  do  not  under- 
go very  much  change  in  this  disease,  and  notwith- 
standing the  retractile  properties  of  the  fibrous 
tissue  forming  the  white  bands,  the  vessels  and 
facts  usually  remain  permeable.  The  liver-cells 
occasionally  become  loaded  with  fatty  elements, 
and  in  some  rare  instances  undergo  albuminoid 
degeneration.  In  cases  of  syphilitic  hepatitis,  the 
liver  is  almost  always  bound  to  the  diaphragm, 
and  sometimes  to  the  adjacent  viscera,  by  firm 
adhesions. 

Deposition  of  gummy  tummirs — ‘ the  encysted 
knotty  tumours  of  the  liver,’  as  they  were 
named  by  Dr.  Budd—  occurs  more  frequently 
than  syphilitic  hepatitis,  with  which  condition, 
however,  it  is  often  associated.  In  this  form 
of  syphilitic  disease,  the  liver  presents  on  sec- 
tion, especially  in  its  deoper  parts,  a number  of 
globular  growths,  more  or  less  firm  in  consist- 
ence, of  a yellowish-white  colour,  and  varying 
from  the  size  of  a pin's  head  to  that  of  a large 
walnut.  A large  deposit  of  this  kind  is  usu- 
ally soft  or  cheesy  at  its  centre,  and  becomes 
more  and  more  firm  towards  its  periphery, 
where  it  is  surrounded  by  a greyish  and  trans- 
lucent zone  of  incipient  connective-tissue,  which 
passes  gradually  into  apparently  healthy  paren- 
chyma. A full  description  of  the  minute  struc- 
ure  of  these  hepatic  gummy  tumours  will  be 
bund  in  a report  by  Dr.  Payne  on  three  speci- 
nens  shown  before  the  Pathological  Society  in 
870  ( Transactions  of  the  Pathological  Society , 
'ol.  xxi.  p.  207).  In  each  tumour  it  was  found 
hat  the  soft  central  portion  was  composed  of 
ranular  and  almost  amorphous  material,  in 
■hich  were  imbedded  certain  round  or  irregular 
ranslueent  bodies  of  large  size,  which  probably 
^presented  collections  of  degenerated  liver-cells, 
i lie  soft  central  portion  passed  imperceptibly 
ito  fibro-nueleated  structure.  The  surrounding 
|brous  zone  was  found  to  be  composed  of  dense 
innective-tissue,  in  crescentic  and  irregularly- 
jtaped  interspaces,  containing  masses  of  fatty 
obules  or  granular  matter.  This  fibrous  struc- 
re  was  not  strictly  defined  fromthe  structure  of 
e mure  central  parts  of  the  tumour,  and  on  the 
tsivle  passed  into  the  interstitial  connective- 
's™ of  the  liver,  and  became  converted  into 
isses  of  nucleated  tissue,  each  of  which  masses 


851 

appeared  to  be  formed  around  a small  branch  of 
the  portal  vein  or  hepatic  artery.  Dr.  Payne 
supports  the  view  held  by  Virchow  concerning 
the  pathogenesis  of  hepatic  gummy  tumours,  and 
holds  that  the  amorphous  central  portion  is  to  bo 
regarded,  not  as  a deposit  of  tissue  lowly  organised 
from  the  first,  but  as  fibrous  tissue  in  a more  or 
less  advanced  stage  of  involution  and  decay. 

Whether  true  hepatic  cirrhosis  may  be  caused 
by  syphilis  is  open  to  doubt,  since  in  most  cases 
supposed  to  be  of  syphilitic  origin  it  has  been 
found  impossible  to  exclude  with  confidence  the 
idea  of  a probable  alcoholic  origin. 

Albuminoid  degeneration  of  the  liver  has  not 
unfrequently  been  observed  in  the  subjects  both 
of  acquired  and  of  inherited  syphilis,  and  very 
often  in  syphilitic  subjects  who  had  not  been  pre- 
viously affected  with  caries  or  necrosis  of  bone, 
with  cutaneons  ulceration,  or  with  profound  or 
prolonged  suppuration.  This  condition  of  the 
liver,  when  associated  with  syphilis,  is  probably 
due  rather  to  cachexia  and  debility,  than  to  any 
essentially  syphilitic  influences.  The  almost  if 
not  quite  obsolete  views  that  the  amyloid  dis- 
ease is  to  be  attributed  to  the  action  of  mercury, 
or  to  the  combined  action  of  this  medicinal 
agent  and  syphilis,  are  opposed  by  the  facts  that 
this  condition  of  the  liver  has  often  been  ob- 
served in  a syphilitic  foetus,  and  also  in  adults 
who  had  not  previously  been  treated  with  mercury, 
and  never  in  non-syphilitic  subjects  of  mercurial 
poisoning. 

Symptoms.— The  symptoms  of  syphilitic  hepa- 
titis and  gummy  tumours  in  the  liver  are  in  most 
instances  obscure,  so  that  these  complications  of 
advanced  syphilis  are  often  overlooked.  The  liver 
in  some  cases  is  enlarged,  in  other  cases  reduced 
in  size.  In  the  former  instance  it  will  often  bo 
found  on  abdominal  percussion  that  the  relative 
proportions  of  the  right  and  left  lobes  have  been 
much  altered,  and  that  there  » considerablo 
deformity  of  the  whole  organ.  Firm  globular 
elevations  on  the  surface  of  the  liver  may  some- 
times be  felt  through  the  anterior  abdominal 
wall.  Advanced  syphilitic  hepatitis  is  usually 
associated  with  slight  and  slowly  increasing 
ascites,  and  sometimes  with  oedema  of  the  lower 
extremities.  There  is  seldom  any  well-marked 
jaundice.  The  patient  often  complains  of  a sense 
of  weight  and  uneasiness  in  the  right  hypo- 
ehondrium,  or,  in  some  few  cases,  of  severe 
pain.  In  almost  all  cases  there  is  some  hepatic 
tenderness.  The  most  constant  symptoms  are 
of  a dyspeptic  character  ; the  abdomen  often  be- 
comes painful  and  distended  ; and  there  is  very 
often,  at  an  advanced  stage  of  the  disease,  obsti- 
nate and  profuse  diarrhoea. 

Diagnosis. — The  slow  progress  of  the  disease : 
the  absence  of  any  severe  pain  in  the  region  of  the 
liver  ; aclear  history  of  syphilis,  and  the  presence 
of  syphilitic  lesions  at  some  part  of  the  body;  no 
history  of  cancer ; and  the  absence  of  any  indica- 
tions of  malignant  disease,  whether  on  the  surface 
of  the  body  or  in  the  abdominal  cavity,  all  serve  to 
support  the  diagnosis  of  syphilitic,  as  opposed 
to  cancerous  disease  -of  the  liver.  In  ordinary 
cirrhosis  of  the  liver  the  progress  of  the  disease 
is  more  rapid ; the  dyspeptic  symptoms  more 
severe;  the  ascites  more  abundant;  and  the  indi- 
cations of  alcoholism  are  generally  well  marked 


352  LIVER,  TUBERCULAR  DISEASE  OF. 

Treatment. — The  treatment  of  syphilitic 
disease  of  the  liver  is  that  usually  carried  out 
in  cases  of  tertiary  syphilis. 

W.  Johnson  Smith. 

LIVER,  Tubercular  Disease  of.  See 

Liver,  Morbid  Growths  of. 

LIVER-FLUKE. — A common  name  for  the 
Fasciola.  See  Distoma. 

LLANDRINDOD,  in  Radnorshire,  South 
Wales.  — Saline,  sulphated,  and  chalybeate 
waters.  See  Mineral  Waters. 

LOBULAR  ( lobulus , a little  lobe). — Of  or 
belonging  to  a lobule.  A term  generally  ap- 
plied to  morbid  conditions  affecting  indivi- 
dual lobules  of  organs  which  are  thus  constituted, 
euch  as  lobular  pneumonia,  lobular  pulmonary 
collapse,  and  lobular  hepatitis. 

LOCAL. — This  term  is  used  in  contradistinc- 
tion to  the  word  general.  Thus,  in  connection  with 
morbid  conditions,  it  is  applied  to  those  which 
are  confined  to,  or  seem  specially  to  affect,  a par- 
ticular part.  Again,  local  causes  are  such  as  act 
upon  a limited  portion  only  of  the  body,  such  as 
a blow  or  a burn.  Local  treatment  implies  the 
application  of  remedies  in  the  same  sense. 

LOCK-JAW. — A popular  synonym  for  teta- 
nus. See  Tetanus. 

LOCOMOTOR  ATAXY  (locus,  a place,  and 
moto,  I move ; a,  priv.  and  ra(ts,  order). — Synon.  : 
Tabes  dorsalis  ; Fr.  Ataxie  locomotrice  ; Ger. 
Graue  Degeneration  der  Hinterstrange  des  Ruck- 
enmarJcs. 

Definition. — A disease  of  the  spinal  cord, 
characterised  by  a peculiar  unsteadiness  in  the 
performance  of  voluntary  movements ; or  a loss, 
to  a greater  or  less  extent,  of  the  power  to  control 
and  co-ordinate  the  action  of  muscles  necessary’ 
for  the  steady  performance  of  these  movements. 

Aetiology. — The  causes  of  locomotor  ataxy  are 
so  various,  that  in  persons  who  are  predisposed 
to  it,  almost  anything  that  seriously  depresses 
the  nervous  power,  especially  of  the  spinal  cord, 
will  become  an  exciting  cause.  Such  are  cold,  wet, 
excessivefatigue,  bad  or  insufficient  diet,  depress- 
ing emotions  of  the  mind,  and,  as  the  writer 
thinks,  onanism,  or  the  long  continuance  of  other 
forms  of  sexual  excess.  Suppression  of  habitual 
perspirations,  particularly  of  the  feet,  and  the 
removal  of  haemorrhoids,  have  in  many  instances 
immediately  preceded  the  disease.  But  pro- 
longed exposure  to  cold  and  wet  appears  to  be 
one  of  its  most  common  causes.  Syphilis  is 
regarded  by  some  as  the  chief  predisposing 
cause ; and  the  disease  is  certainly  very  much 
more  frequent  in  males  than  in  females. 

Anatomical  Characters. — The  spinal  cord  is 
invariably  altered  in  structure.  Generally,  the 
membranes  are  much  congested,  and  the  writer 
has  often  found  them  thickened  posteriorly  by 
exudations,  and  adherent  to  each  other  and  to 
the  posterior  columns.  The  posterior  columns, 
especially  in  their  outer  regions,  and  the  nerve- 
roots  are  the  parts  that  are  chiefly  affected.  The 
morbid  change  consists  of  atrophy  and  disinte- 
gration of  the  nerve-fibres,  to  a variable  extent ; 
with  hypertrophy  of  the  connective  tissue.  Oil- 


LOCOMOTOR  ATAXY, 
globules  surround  many  of  the  blood-vessels 
The  posterior  nerve-roots  undergo  the  same  kind 
of  degeneration,  which  sometimes  extends  to  the 
surfaces  of  the  lateral  columns,  and  even  along 
the  edges  of  the  anterior.  Sometimes  the  write  t 
has  found  the  extremities  of  the  posterior  cornua, 
and  even  the  central  grey  substance,  more  or  less 
damaged  by  disintegration.1  The  pathological 
change  seems  to  travel  from  the  centre  to  the 
periphery— from  the  spinal  cord  to  the  posterior 
roots.  In  the  cerebral  nerves,  however,  the  mor- 
bid change  takes  an  opposite  direction— from 
the  periphery  towards  the  centres.  Sometimes 
it  extends  as  far  as  the  corpora  geniculata,  hut 
seldom  as  far  as  the  corpora  quadrigemina. 

Symptoms. — In  most  cases  the  unsteadiness 
begins  in  the  lower  extremities ; hut  generally — 
after  a certain  bnt  variable  time — it  involves  the 
upper  extremities,  the  hands  and  arms  being  the 
parts  most  affected. 

As  the  writer  has  pointed  out,  this  un- 
steadiness, or  muscular  inco-ordination,  occurs 
under  two  consecutive  forms.  It  first  makes  its 
appearance  as  a simple  unsteadiness  of  gait;  the 
patient  walks  like  a person  partially  intoxicated. 
He  likewise  frequently  complains  of  heaviness  in 
his  logs ; and  of  fatigue  after  walking  or  after 
standing.  With  his  legs  close  together,  and  his 
eyes  shut,  he  sways  about  and  would  fall  if  not 
supported.  Later  on  he  finds  that  he  cannot 
walk  without  looking  at  his  feet.  When  the 
upper  extremities  become  affected,  the  patient 
is  unable  to  dress  himself,  to  button  his  clothes, 
to  write,  or  to  pick  up  a pin. 

After  a time  a second  kind  of  disorderly  move- 
ment supervenes.  This  arises  from  a spasmodic 
and  jerking  action  of  the  muscles,  which  the  will 
quits  in  motion,  but  is  unable  to  control;  the 
patient  cannot  regulate  the  degree  of  their  con- 
traction. When  put  in  motion  the  muscles  con- 
tract beyond  the  degree  intended,  and  flex  or 
extend  the  limb  with  an  uncontrollable  jerk. 
All  the  voluntary  movements  are  hurried  and 
precipitate.  The  patient  seems  to  be  walking 
upon  springs ; he  proceeds  with  a kind  of  pranc- 
ing gait,  and  brings  his  heels  to  the  ground  with 
a kind  of  kick.  If  he  attempts  to  take  hold  of 
an  object  he  probably  will  thrust  it  from  him  by 
a spasmodic  jerk  of  his  arm.  The  disease  is 
progressive.  At  ail  advanced  stage  the  patient 
cannot  walk  or  stand  -without  assistance,  and  even 
then,  if  he  attempts  to  advance,  he  jerks  his  legs 
about  in  the  most  disorderly  manner. 

The  ataxy  or  disorderly  movement  is  accom- 
panied by  some  of  the  following  symptoms, 
namely : — Strabismus,  diplopia,  amblyopia,  am- 
aurosis, ptosis,  contraction  of  both  pupils  or  only 
of  one ; shifting  pains  in  different  parts  of  the 
body,  but  chiefly  in  the  extremities ; cutaneous 
and  muscular  anaesthesia,  and  loss  of  the  sense 
of  temperature;  incontinence  of  urine,  and  dy- 
suria;  loss  of  electro-muscular  contractility,  in 
a variable  degree  ; abolition  of  the  patellar-ten- 
don reflex  ; spermatorrhoea,  with  loss  of  sexual 
power  and  desire ; occasionally,  hut  not  often 
paralysis  of  the  first,  fifth,  seventh,  eight,  ant 
ninth  cerebral  nerves;  (edematous  swelling  o 
the  joints,  chiefly  of  the  knees;  and  cardiac  ar.i 
gastric  disturbance. 

* See  Lancet,  June  10, 1SG5. 


LOCOMOTOR  ATAXY. 


All  these  symptoms  are  never  found  together 
in  any  one  case  of  locomotor  ataxy,  but  occur  in 
different  groups  in  different  cases,  as  the  follow- 
ing examples  will  show.  The  symptoms  made 
their  appearance  in  the  order  of  time  in  which 
they  are  mentioned. 

Case  1.— Strabismus  and  diplopia;  pains  in 
the  legs,  with  numbness  of  toes  ; ataxy,  or  un- 
steadiness of  gait;  numbness  of  fingers,  followed 
by  pains  in  the  arms,  with  unsteadiness  of  mus- 
cular movements;  incontinence  of  urine;  both 
pupils  contracted  to  the  size  of  pins’-heads. 

Case  2—  Darting  and  shifting  pains  in  legs, 
with  numbness  and  heaviness;  pains  in  abdo- 
men and  chest ; ataxy ; pains  and  numbness  in 
hands  and  arms,  followed  by  ataxy ; analgesia  ; 
incontinence  of  urine,  alternating  with  dysuria ; 
haemorrhoids ; loss  of  sexual  power. 

Very  frequently  the  pains  in  the  limbs  are, 
for  a variable  period,  the  only  precursors  of  the 
other  symptoms.  They  are  of  two  kinds — the 
irst  is  of  an  aching,  gnawing  character,  and  is 
often  mistaken  by  the  patient  for  rheumatism. 
The  other  kinds  of  pains  are  acute  and  lancinat- 
ing, like  electric  shocks,  shifting  from  one  part  of 
the  body  to  another.  They  recur  in  paroxysms, 
lasting  for  a few  hours  or  a few  days,  and  suddenly 
disappear  for  a variable  period. 

In  other  cases  the  ocular  disturbances  are  the 
first  symptoms  that  make  their  appearance. 
They  consist  of  strabismus,  or  amblyopia,  ending 
frequently  in  amaurosis.  In  a large  proportion 
of  cases,  paralysis  of  either  the  third  or  the  sixth 
cerebral  nerve,  with  diplopia,  is  found  during  the 
first  stage  of  the  disease.  The  peculiarity  of 
this  paralysis  is  its  periodicity.  It  may  last  for 
a few  days,  or  a few  weeks  or  months,  and  then 
iisappear  as  suddenly  as  it  came  ; or  it  may  con- 
tinue uninterruptedly  throughout  the  disease. 
Sometimes  the  strabismus  is  double,  but  more 
frequently  it  is  limited  to  one  eye.  Even  when 
there  is  no  perceptible  strabismus,  there  is  some- 
times double  vision,  when  the  patient  turns  his 
ayes  in  a particular  direction.  Ptosis  and  dila- 
.ation  of  the  pupil  are  also  frequently  present. 
In  some  cases  one  pupil  is  dilated,  while  the 
>tker  is  contracted.  Amblyopia  sometimes  ap- 
pears at  a very  early  period,  and  increases  till  it 
erminates  in  amaurosis. 

Cutaneous  anaesthesia  usually  accompanies  the 
■taxy,  and  affects  chiefly  the  arms,  fingers,  legs, 
nd  toes.  The  patient  says  that  he  seems  to  be 
talking  on  something  soft,  and  does  not  feel  the 
Tound  properly ; unless  he  looks  at  his  feet,  he 
careely  knows  that  they  have  reached  it.  Some- 
mes  he  feels  as  if  he  were  ‘ walking  on  air,’  on 
is  ankle-joints,  or  on  his  hip-joints,  when  the 
umbness  extends  up  the  legs  and  thighs.  Anal- 
Issia,  or  loss  of  sensibility  to  pain,  in  a greater 
t less  degree,  is  very  common;  or  painful  im- 
tessions  are  felt  with  unusual  slowness.  The 
riter  has  known  cases  in  which  several  minutes 
ive  elapsed  before  the  prick  of  a needle  has 
^en  felt. 

Disorders  of  the  urinary  organs  are  generally 
termittent  in  their  attacks.  Usually  the 
suria  and  incontinence  recur  alternately  in 
e same  stage  of  the  disease.  Spermatorrhoea 
commonly  one  of  the  early  symptoms  in 
■omotor  ataxy.  It  is  followed  by  loss  of 


853 

sexual  power,  with  or  without  loss  of  sexual 
desire. 

Affection  of  the  joints  in  locomotor  ataxy  was 
first  described  by  M.  Charcot,  of  Paris.  The  knee- 
joint  is  almost  always  the  seat  of  the  disease, 
which  appears  suddenly  as  an  elastic  oedematous 
swelling.  Like  the  diplopia,  strabismus,  and 
urinary  troubles,  it  may  be  intermittent — may 
remain  only  for  a short  time,  or  continue  unin- 
terruptedly and  result  in  permanent  deformities, 
with  disease  of  the  bones  and  cartilages  of  the 
joint. 

The  strabismus,  amblyopia,  and  shifting  in- 
termittent pains  were  considered  by  Duchenne 
as  the  first  stage  of  ataxy,  which  may  last  for 
months  or  years.  The  next  stage  is  when  the 
ataxy  or  unsteadiness  of  gait  makes  its  appear- 
ance, either  accompanied  with  or  soon  followed 
by  anaesthesia  or  analgesia,  generally  in  the 
lower  extremities.  In  the  third  stage  many  of 
the  symptoms  become  more  marked  and  more 
general,  the  ataxy  or  muscular  inco-ordination 
extending  to  the  upper  extremities.  This  divi- 
sion into  three  distinct  stages  does  not,  however, 
apply  to  all  cases. 

Diagnosis. — In  the  early  stages  of  the  disease, 
especially  before  the  muscular  ataxy  has  made  its 
appearance,  and  when  only  two  or  three  other 
symptoms  are  present,  the  diagnosis  is  extremely 
difficult,  even  to  those  who  have  great  practical 
experience  of  the  disease.  Several  of  the  symp- 
toms, such  as  strabismus,  amblyopia,  anaesthesia, 
and  the  so-called  ‘ rheumatic  ’ pains,  which  precede 
frequently  for  a long  time  the  motor  ataxy,  may 
be  found  in  other  disorders  which  differ  essen- 
tially from  this  malady.  But  there  is  often  in 
some  of  these  symptoms  a certain  peculiarity 
which  may  assist  us  in  the  diagnosis.  For 
instance,  in  a great  many  cases  the  strabismus 
is  accompanied  by  amblyopia ; and  when  it  is 
single,  the  amblyopia  is  on  the  corresponding 
side.  Moreover,  the  sudden  attacks  and  equally 
sudden  cessation  of  the  pains,  their  rapid  shifting 
from  one  place  to  another,  or  their  remarkable 
proneness  to  fix,  sometimes  for  hours,  on  some 
particular  spot,  are  not  without  their  signifi- 
cance. 

Prognosis  and  Treatment. — The  prognosis 
is  generally  very  unfavourable.  An  early  diag- 
nosis is  of  the  greatest  importance,  as  it  is  chiefly 
at  the  first  invasion  of  the  disease  that  the  patient 
is  most  benefited  by  treatment.  An  important 
object  is  to  protect  the  patient  from  cold  and  wet, 
and  keep  him  in  an  equable  temperature.  The 
whole  of  the  body  should  therefore  be  enveloped 
in  flannel.  A good  and  generous  diet,  with  11106 
or  beer,  seems  best  suited  for  the  patient.  Of  the 
different  medicines  that  have  been  used,  nitrate  of 
silver  seems  to  have  the  most  specific  influence  on 
locomotor  ataxy.  One-eighth  of  a grain  gradually 
increased  to  one  grain  three  times  a day,  after 
meals,  is  the  best  mode  of  exhibition.  If  it 
should  irritate  the  bowels  or  the  bladder,  it  may 
be  combined  with  morphia,  cannabis  indica,  or 
belladonna.  The  oxide  of  silver  is  a useful 
substitute  for  the  nitrate,  when  the  latter  dis- 
agrees. Dry-cupping  along  the  spine  has  been 
found  useful.  For  the  relief  of  the  severe  limb- 
pains  there  is  nothing  so  efficacious  as  the  sub- 
cutaneous injection  of  morphia.  The  writer  haa 


854  LOCOMOTOR  ATAXY. 

always  found  that  constipation  aggravates  the 
pains.  Sulphur  baths  have  been  used  with  some 
relief.  Cod-liver  oil  and  phosphorus  may  also 
be  prescribed.  Rest  has  been  strongly  recom- 
mended ; and  the  constant  galvanic  current  is 
certainly  sometimes  beneficial. 

J.  Lockhart  Clarkk. 

LORDOSIS  ( \opS'os , bent). — A term  ap- 
plied to  abnormal  curvature  of  the  spine  for- 
wards. See  Spine,  Diseases  of. 

LUCID  INTERVALS.— No  better  defini- 
tion of  this  state  has  been  given  than  that  of  Lord 
Thurlotv,  who  calls  it  ‘ an  interval  in  which  the 
mind  having  thrown  off  the  disease  had  recovered 
its  general  habit.’  It  must  be  regarded  as  ex- 
tremely unlikely  that  a perfect  restoration  to 
reason  can  take  place  in  the  course  of  any  long- 
continued  insanity,  without  full  opportunity 
having  been  afforded  of  testing  its  nature.  The 
law  more  readily  recognises  the  restoration  of 
the  mind  to  a state  of  civil  capacity  such  as  will 
render  testamentary  acts  valid,  than  such  tem- 
porary recovery  as  would  restore  responsibility 
for  crime.  If  a civil  act  be  rationally  performed, 
the  law  accepts  that  as  vrimd-facie  proof  of  the 
capacity  of  the  agent;  but  juries  very  seldom 
convict  the  accused  of  a crime  if  insanity  is  proved 
to  have  existed  within  a short  period  of  its  com- 
mission. John  Sibb.ald. 

LUHATSCHOWITZ,  in  Moravia— Mu- 

riated  alkaline  waters.  See  Mineral  Waters. 

LUMBAGO  ( lumbi , the  loins). — Synon.  : 
Fr.  Lumbago ; Ger.  Lcndcnweh. — Muscular  rheu- 
matism, affecting  the  muscles  and  fasciae  of  the 
lumbar  region.  Sec  Rheumatism,  Muscular. 

LUMBAR  ABSCESS. —Definition. — A 
variety  of  spinal  abscess,  usually  due  to  caries 
of  the  upper  lumbar  or  lower  dorsal  vertebrae  ; 
in  which  the  pus,  instead  of  taking  the  course 
followed  in  psoas  abscess,  becomes  envelopied  by 
the  muscles  and  fasciae  of  the  lumbar  region,  and 
usually  points  in  this  situation  ; or  by  infiltrating 
the  cellular  interspaces  of  the  abdominal  muscles, 
gains  the  front  of  the  abdomen,  and  descends 
above  Poupart’s  ligament.  The  last-named  feature 
is  a diagnostic  point  of  some  moment,  since  psoas 
abscess,  although  commencing  in  the  same  man- 
ner, is  usually  characterised  by  making  its  way 
below  Poupart’s  ligament. 

JEtiology.— The  origin  of  lumbar  abscess  is 
often  ascribed  by  the  patient  to  a wrench  or  a 
blow — statements  which  must  be  taken  with 
some  caution,  since  it  will  be  noticed  that  the 
patient  rarely  remembers  any  injury  having  hap- 
pened, until  long  after  well-marked  symptoms 
have  arisen.  Curvature  of  the  spine  is  almost 
invariably  present.  In  children  it  is  almost 
always  the  result  of  scrofulous  osteitis  ; and  it 
has  been  by  some  ascribed,  in  adults,  to  sexual 
excesses. 

Description. — Lumbar  abscess  may  commence 
in  the  soft  parts,  but  when  dependent  on  spinal 
caries  is  preceded  by  the  usual  symptoms  of 
Rotts’  disease,  which  have  been  coming  on 
slowly  and  insidiously  for  a period  varying  from 
three  to  six  months. 

Owing  to  the  numerous  tendinous  expansions, 


LUMBAR  REGION. 

and  dense  aponeurotic  structures  and  fasciae  of 
the  lumbar  region,  the  pus,  which  has  formed  in 
connection  with  the  spine,  meets  with  many  ob- 
structions, resulting  in  singular  deflections,  before 
it  gains  the  surface  (see  Lumbar  Region).  Most 
frequently  it  perforates  the  quadratus  lumbornm 
muscle,  and  points  at  the  edge  of  the  sacro- 
lumbalis.  Here  it  shows  itself  as  a broad,  flat, 
slightly  elevated,  fluctuating  tumour;  bavin*' a 
somewhat  irregular  surface,  owing  to  the  tendi- 
nous structures  which  traverse  its  cavity.  Occa- 
sionally the  pus  of  a lumbar  abscess  makes  its  way 
downwards  and  forwards  above  Poupart’s  liga- 
ment, or  between  the  abdominal  muscles,  and 
points  at  the  outer  edge  of  the  rectus  abdominis 
muscle;  and  indeed  there  would  seem  to  be  no 
intermuscular  or  interaponeurotic  space  which  it 
may  not  permeate.  In  other  instances,  it  may 
be  first  observed  by  palpation  of  the  abdominal 
walls  ; may  simulate  caecal  abscess,  a malignant 
growth,  an  intestinal  collection,  an  aneurysm,  or 
other  abdominal  tumour ; or  may  burst  into  the 
cellular  tissue  of  the  abdominal  cavity.  In  chil- 
dren, owing  to  the  relatively  small  size  of  the 
pelvis,  there  is  a chance  of  the  pus  mounting  over 
the  iliac  crest,  or  sidewaysover  the  glutsi  muscles. 

Prognosis. — The  prognosis  is  precisely  the 
same  as  that  mentioned  in  the  article  on  psoas 
abscess.  See  Psoas  Abscess. 

Treatment. — The  treatment  is  the  same  as 
that  indicated  in  psoas  abscess,  namely,  free  an- 
tiseptic incision.  There  are,  however,  cases  where 
spontaneous  evacuation  of  the  pus,  and  treat- 
ment by  the  prone  couch  have  led  to  good  re- 
sults ; and,  moreover,  there  are  casts  of  spon- 
taneous cure.  Edward  Bellamy. 

LUMBAR  REGION.  — This  rogion,  to 
which  it  is  somewhat,  difficult  to  assign  precise 
limits,  may  conveniently  be  described,  for  practical 
purposes,  as  bounded(with  reference  to  the  surface 
of  the  body)  superiorly  by  the  last  rib,  below  by 
the  posterior  half  of  the  upper  edge  of  the  crest 
of  the  ilium,  and  externally  by  the  posterior 
margin  of  the  external  oblique  muscle.  The 
series  of  lumbar  spines  would  thus  superficially 
separate  the  right  from  the  left  lumbar  region. 
All  the  structures  lying  between  the  skin  and 
such  abdominal  viscera  as  are  in  relation  with 
the  parietes,  enter  into  the  formation  of  the  lum- 
bar region,  the  symmetry’  of  the  two  sides  being 
broken  by  the  fact  that  the  right  kidney  lies 
lower  than  the  left.  These  structures  are  met 
with  in  the  following  order  from  the  surface: — 

1.  the  skin;  2.  the  cellular  tissue ; 3.  the  lum- 
bar aponeurosis ; 4.  the  museulo-aponeurotic 
layer;  5.  the  bones;  and  6.  tbe  visceral  layer. 
The  blood-vessels  and  nerves  are  distributed 
amongst  these  tissues. 

1.  The  s/cin. — The  skin  of  the  lumbar  region 
is  remarkable  for  its  extreme  thickness,  and 
want  of  sensibility  and  mobility,  being  firmly 
fixed  to  the  spines  of  the  vertebrae. 

2.  The  cellular  tissue. — The  cellular  tissue 
consists  of  two  laminae,  a superficial  and  a deep 
the  former  very’  adherent  to  the  skin,  whilst  tbe 
deepor  is  strengthened  by  several  processes,  do 
rived  from  the  aponeurotic  layer. 

3.  The  lumbar  aponeurosis. — The  lumbar  apo 
neurosis,  the  strongest  in  the  whole  body,  deier 


LUMBAR  REGION. 

mines  in  a gieat  measure  the  form  of  the  region.  | 
It  is  attached  firmly'  to  the  spinous  process  of 
the  lumbar  vertebrae,  and  its  anterior  surface 
gives  origin  to,  and  binds  down  the  erectores 
spiD®  muscles.  The  aponeurosis  of  the  transver- 
' salis  is  here  divisible  into  three  vertical  laminae, 
namely,  the  posterior,  which  assists  in  the  for- 
mation of  the  lumbar  aponeurosis ; the  middle 
lamina,  attached  to  the  tips  of  the  transverse 
processes  of  the  lumbar  vertebrae,  and  forming 
with  the  preceding  a sheath  for  the  erectores 
spin®;  and  the  anterior,  attached  to  the  bases 
of  the  transverse  processes  of  the  vertebrae,  and 
forming,  with  the  middle  lamina,  the  sheath  of 
the  quadrates  lumborum.  The  aponeurosis  is 
limited  by  the  posterior  border  of  the  external 
oblique  muscle. 

4.  The  musculo-aponeurotic  layer. — The  mus- 
culo-aponeurotic  layer  consists,  on  either  side  of 
the  mesial  line,  of  the  mass  of  the  erector  spin® 
muscle  and  the  transverso-spinales  internal  to 
and  below  it;  whilst  between  these  muscles  are 
the  branches  of  the  lumbar  vessels  and  nerves. 
Beneath  these  lie  the  transverse  processes  of  the 
lumbar  vertebr®,  the  inter-transversales  mus- 
cles, the  lamins  of  the  vertebrae,  with  the  liga- 
menta  subflava  ; and,  in  a plane  anterior,  the 
quadrati  lumborum,  and  ilio-lumbar  ligaments. 
The  psoas  muscle  enters  the  lumbar  region. 

5.  The  bones. — These  consist  of  the  lumbar 
vertebr®,  with  the  inter-vertebral  discs  and  liga- 
ments, enclosing  the  cauda  equina  with  its  in- 
vestments. 

6.  Visceral  layer. — In  front  of  the  bones  lie  the 
pillars  of  the  diaphragm  ; the  inferior  vena  cava 
to  the  left,  and  the  aorta  to  the  right ; on  either 
side,  the  chain  of  the  sympathetic,  the  lumbar 
glands,  and  the  receptaculum  chyli,  and  the 
commencement  of  the  thoracic  duet ; and  the 
commencement  of  the  azygos  major  vein. 

In  front  of  the  quadratus  is  a space  occupied 
in  its  superior  third  by  the  kidney,  and  its  lower 
two-thirds  by  the  colon.  About  half  the  kidney 
lies  in  this  space,  of  which  the  right  is  rather 
the  lower  of  the  two.  The  right  colon  is  entirely 
enclosed  in  the  peritoneum,  whilst  the  left  has 
only  apartial  investment  of  that  membrane.  The 
kidney  lies  external  to  the  psoas,  and  upon  the 
quadratus,  corresponding  with  the  outer  side  of 
die  sacro-lumbar  muscular  mass.  Certain  anom- 
ilies  in  the  relation  of  die  kidneys  are  sometimes 
net  with : they  occasionally  descend  into  the  iliac 
’osss,  or  they  may  float,  owing  to  extreme  length 
if  the  blood-vessels,  which  penetrate  the  hilum, 
nd  may  then  be  felt  loosely  situated  amongst 
he  other  abdominal  viscera.  On  the  psoas  lie 
:-the  ureter  internally  ; obliquely  the  spermatic 
r ovarian  vessels,  and  the  sympathetic  ; and 
xternally  the  genito-crural  nerve. 

Blood-vessels. — The  arteries  which  perforate 
nd  supply  this  region  are  the  lumbar  arteries, 
'he  veins  correspond  with  the  arteries ; they 
aastomose,  however,  with  the  renal  veins. 

Berves. — The  nerves  of  the  region  are  derived 
om  the  lumbar  plexus,  formed  by  the  five  lum- 
ir  nerves  and  last  dorsal ; whilst  the  sympa- 
etic  system  is  derived  from  the  solar,  renal, 
’■pogastric,  and  lumbo-aortic  plexuses. 
Pathological  and  Clinical  Relations. — The 
mbar  region  is  of  great  surgical  importance, 


LUNACY,  LAW  OF.  855 

from  the  relation  to  its  anterior  aspect  of  certain 
abdominal  viscera  ; from  the  numerous  fasci® 
which  enter  into  its  formation,  and  their  relatior 
to  abscesses,  growths,  and  bloody  or  urinary 
effusions ; and  from  the  fact  that  the  operations 
of  colotomy,  nephrotomy,  nephrectomy,  and  ths 
opening  of  perinephritic  abscesses  are  performed 
within  its  boundaries.  Spina  bifida  has  a great 
predilection  for  this  region.  Penetrating  wounds 
in  the  lumbar  region  are  liable  to  involve  the 
cauda  equina,  owing  to  the  wide  separation  which 
exists  between  the  lamin®  of  the  lumbar  verte- 
br®. ‘With  regard  to  abscesses,  connected  with 
caries  of  the  lumbar  vertebr®,  their  situation  is 
generally  determined  by  their  origin.  When  the 
posterior  portion  of  the  bodies  or  spines  are  af- 
fected, the  pus  is  conducted  backwards,  beingcon- 
fined  by  the  fascia  lumborum.  If  the  transverse 
processes  or  the  anterior  portion  of  the  bones  be 
the  seat  of  disease,  the  pus  will  point  anteriorly 
on  the  abdominal  wall,  being  either  bound  down 
by  the  fascia  transversalis,  or  conducted  forwards 
between  the  abdominal  muscles,  in  which  case 
the  pointing  always  takes  place  above  Poupart’s 
ligament.  Renal  or  perinephritic  abscesses  often 
point  at  the  border  of  the  quadratus  lumborum 
muscle,  and  may  there  be  opened.  Lumbar 
hernia  protrudes  at  the  so-called  * triangle  of 
Petit.  ’ The  operations  practised  in  the  lumbar 
region  are  lumbar  colotomy,  Dephrotomy,  and 
nephrectomy.  Of  lumbar  colotomy  there  are 
several  modifications,  but  it  is  generally  per- 
formed in  the  descending  colon,  which  is  usually 
uncovered  by  peritoneum  posteriorly. 

Other  pathological  andclinical  relations  of  this 
region,  which  have  many  points  in  common  with 
those  of  the  iliac  region,  are  referred  to  under 
that  heading.  Edward  Bellamy. 

LUMBRICUS. — By  many  practitioners  this 
term  is  still  employed  to  designate  the  large 
round-worm  ( Ascaris  lumbricoides ).  The  title  is 
entirely  a misnomer,  having  originated  with 
Tyson  (Phil.  Trans.  1683)  who  called  the  com- 
mon species  Lumbricus  teres  liominis.  All  the 
larger  round- worms  infesting  man  and  animals 
are  apt  to  be  called  lumbricoids.  Notwithstand- 
ing their  general  resemblance  to  ordinary  earth- 
worms, their  organisation  is  totally  different. 
Occasionally,  in  practice,  patients  seek  to  deceive 
the  medical  attendant,  by  placing  one  or  more 
earth-worms  in  the  night-stool  or  chamber-pot. 
Quite  recently  the  writer  encountered  an  instance 
where  a large  garden  lobworm  (L.  terrestris ), 
about  a foot  in  length,  had  been  carefully  selected 
for  this  purpose.  The  practitioner  should  not 
only  be  familiar  with  the  differences  of  character 
presented  by  true  and  false  worms  of  this  kind, 
but  should  bear  in  mind  that  earth-worms  can- 
not live  in  the  human  bladder  and  intestines. 
See  Ascarides;  and  Round- worms. 

T S.  Cobbold. 

LUNACY,  Law  of. — The  medical  practi- 
tioner is  frequently  required  to  perform  duties  in 
connexion  with  lunacy,  the  satisfactory  discharge 
of  which  requires  that  he  should  have  somo 
acquaintance  with  the  legal  enactments  by  which 
they  are  regulated.  Tbo  statutes  differ  slightly 
in  the  three  divisions  of  the  kingdom.  It  will 
therefore  be  necessary,  after  describing  what  is 


LUNACY,  LAW  OF. 


566 

required  under  the  law  in  England,  to  show 
where  its  requirements  differ  from  those  which 
exist  in  Scotland  and  Ireland.  The  details  to  be 
given  here  will  only  include  what  is  necessary 
for  the  information  of  the  general  practitioner. 
Anyone  who  intends  to  devote  himself  specially 
to  the  treatment  of  the  insane,  or  to  receive  one 
or  more  persons  of  unsound  mind  into  his  house, 
must  comply  with  regulations  which  we  cannot 
here  set  forth,  but  which  are  fully  described  in 
works  upon  the  subject.  When  a person  living 
in  his  own  homo  is  under  treatment  for  insanity, 
t he  medical  attendant  is  justified  by  the  common 
law,  in  adopting  any  measures  of  restraint  which 
may  be  necessary  for  safety  or  the  proper  treat- 
ment of  the  malady.  This  has  been  decided  by 
the  courts  of  law  in  recent  cases.  If,  however, 
it  is  proposed  to  place  the  patient  in  an  asylum, 
or  to  remove  him  to  the  charge  of  any  person 
who  is  to  derive  profit  either  directly  or  indi- 
rectly from  the  proceeding,  it  is  necessary  that 
certain  forms  should  be  carefully  observed. 

In  the  case  of  a Chancery  lunatic,  an  order  by 
the  ‘ Committee  of  the  Person,’  having  annexed 
to  it  an  office  copy  of  the  appointment  of  the 
Committee,  is  sufficient  authority  for  the  recep- 
tion of  the  lunatic  either  into  an  asylum  ora  pri- 
vate house.  In  the  case  of  other  private  patients, 
it  is  necessary  to  have  what  is  called  an  ‘ order’ 
and  two  medical  certificates,  as  in  the  annexed 
form.1  The  order  may  be  signed  by  anyone 
having  a reasonable  right  to  interfere,  provided 
he  is  neither  of  the  medical  men  signing  the 

i MEDICAL  CERTIFICATE. 

Sched.  (A.)  No.  2,  Sects.  4,  5,  8,  10,  11,  12,  13. 

/,  the  undersigned,  William  Haney , being  a (*)  Mem- 
ber of  the  Royal  College  of  Physicians  of  London,  and  being 
in  actual  practice  as  a ('>)  Physician,  hereby  certify,  that 
I,  on  the  third  day  of  March  1875,  at  (c)  number  8 Kent 
Street,  Norwich,  in  tbe  county  of  Norfolk,  separately  from 
any  other  Medical  practitioner  personally  examined 
Edward  Harris  of  (d)  number  8,  Kent  Street , Norwich, 
Grocer,  aud  that  the  said  Edward  Hands  is  a (e)  person 
of  unsound  mind  and  a proper  person  to  be  taken  charge 
of  and  detained  under  Care  and  Treatment,  and  that  I 
have  formed  this  opinion  upon  the  following  grounds ; 
viz. 

1.  Facts  indicating  Insanity  observed  by  myself  tf) 
He  states  that  his  daughter,  who  has  lived  in  his  house  for 
years,  is  a person  unknown  to  him,  who  has  been  placed  in 
the  house  as  a spy,  and  made  to  look  like  his  daughter.  He 
states  also  that  he  believes  Parliament  intends  to  ruin  him. 

2.  Other  facts  (if  any)  indicating  Insanity  communi- 
cated to  me  by  others  (e)  If  is  daughter,  Mary  Harris, 
informs  me  that  he  has  been  sleepless  and  restless  and  much 
depressed  in  mind  for  the  last  week,  and  that  he  has  on  that 
account  been  unable  to  attend  to  his  business. 

Signed,  N ame,  William  Harvey 

Place  of  abode,  31.  Chapel  Street,  Norwich. 

Haled  this  third  day  of  March  One  Thousand  Eight 
Hundred  and  Eighty. 


(“)  Here  set  forth  the  qualification  entitling  the  person 
certif  ying  to  practise  as  a physician,  surgeon,  or  apothecary, 
for  example:— Fellow'  of  the  Royal  College  of  Physicians 
of  London,  Member  of  the  Royal  College  of  Surgeons  of 
England,  Licentiate  of  the  Apothecaries’  Society,  or  as 
the  case  may  be. 

(b)  Physician,  surgeon,  or  apothecary,  as  the  case  may 
be. 

(')  Here  insert  the  street  and  number  of  the  house  (if  any) 
or  other  like  particulars. 

(d)  Insert  tvsidence  and  profession,  or  occupation  (if  any) 
of  the  patient. 

(•)  Lunatic,  or  an  idiot,  or  a person  of  unsound  mind. 

< f)  Here  state  the  facts. 

fs)  Here  state  the  information,  and  from  whom. 


certificates,  nor  father,  son,  brother,  partner,  or 
assistant  to  either  of  them,  nor  professionally  or 
pecuniarily  connected,  or  to  be  connected  in  anv 
way,  with  the  person  under  whose  charge  the 
patient  is  to  be  placed.  The  person  signing  the 
order  must  have  seen  the  patient  within  a month 
of  the  date  of  the  order ; and  the  order  con- 
tinues available  for  one  month  from  the  day  of 
its  date. 

The  medical  certificates  must  be  signed  by 
registered  practitioners  in  actual  practice  in 
England.  They  must  have  no  interest,  directly 
or  indirectly,  in  the  patient,  in  the  establishment 
or  house  to  which  he  is  to  be  sent,  or  in  his 
subsequent  treatment ; and  they  must  not  be  in 
partnership  with  one  another,  nor  otherwise  pro- 
fessionally connected.  A certificate  when  granted 
remains  valid  for  seven  days  from  the  date  of 
examination.  The  necessary  form  is  here  given. 
The  words  in  italics  describe  a supposititious 
case,  and  are  introduced  merely  to  illustrate  the 
manner  in  which  the  blanks  must  be  filled  up. 

This  document  may  he  altogether  in  writing; 
but  it  is  both  desirable  and  convenient  for  all 
concerned  that  the  regular  printed  forms  should 
be  used.1 

Great  care  must  he  taken  to  have  every  detail 
of  these  documents  complete  and  accurate ; for 
it  frequently  happens  that  what  may  appear  to 
many  a trifling  error  renders  a certificate  invalid, 
and  thus  entails  much  inconvenience  and  some- 
times distress.  The  foot  notes  attached  to  the 
certificate  will  be  found  sufficient  as  guides  in  the 
more  important  details,  but  the  following  hints 
will  also  be  found  useful : — 1.  The  medical  quali- 
fication must  he  given  in  full ; 2.  The  house  at 
which  the  examination  was  made  must  he  accu- 
rately named,  giving  the  name  of  the  street,  if 
there  be  any,  and  the  number  of  the  house ; 3. 
The  residence  of  the  patient  must  be  described 
with  similar  precision ; and  4,  The  name  of  the 
person  must  be  given,  from  whom  the  ‘other 
facts  ’ are  obtained.  The  opinions  at  which  the 
medical  man  must  arrive  before  signing  a certi- 
ficate are  two,  and  they  are  quite  distinct.  He 
has  first  to  determine  whether  the  patient  is  of 
unsound  mind,  and  next  whether  it  would  be 
proper  to  place  him  under  restraint.  The  deter- 
mination that  a person  is  insane  does  net  neces- 
sarily imply  that  it  is  proper  to  place  him  under 
restraint.  In  stating  the  facts  upon  which  the 
certificates  are  founded  it  must  he  borne  in  mind 
that' they  must  be  such  as  will  appear  to  the 
Commissioners  in  Lunacy  to  be  sufficient  evi- 
dence of  insanity  ; and  great  care  must  be  taken 
to  state  them  both  intelligibly  and  accurately. 
There  must  be  sufficient  in  the  facts  observed  by 
the  medical  man  himself  to  justify  the  opinion 
to  which  he  certifies,  the  facts  communicated  by 
others  being  only  accepted  in  corroboration  of 
it;  these  may  indeed  he  altogether  omitted  with- 
out invalidating  the  document.  On  this  point 
tho  Commissioners  have  laid  it  down  that  the 
Legislature  has  been  careful  to  guard  against 
the  facts  communicated  by  ethers  exercising 

1 These  forms  can  he  obtained  at.  the  law-stationers. 
As  they  are  frequently  wanted  with  the  least  possible 
delay,  we  mention  the  names  of  Messrs.  Shaw  and  Sons, 
Fetter  Lane,  and  of  Messrs.  Knight  and  Co.,  90  Fieri 
Street,  as  fir-ms  in  the  habit  of  supplying  them. 


LUNACY,  LAW  OF. 

undue  influence  upon  the  mind  of  the  medical 
man  in  granting  his  certificate,  ‘ by  requiring 
that  this  certificate  shall  be  directly  dedncible 
from  examination  on  a particular  day  and  at  a 
specified  place,  and  that  the  opinion  expressed 
therein  as  having  been  formed  on  such  particular 
day  shall  be  set  forth  as  the  result  of  his  having 
observed  at  that  time  in  the  person  under  ex- 
amination some  specific  fact  indicating  insanity.’ 
In  the  statement  of  the  facts  observed,  it  is 
therefore  necessary  that  at  least  one  such  fact  or 
combination  of  facts,  should  be  mentioned  as 
could  not  be  affirmed  of  a person  of  sound  mind. 
A frequent  error  is  the  stating  of  facts  in  such 
an  imperfect  manner  that,  though  they  may  have 
been  real  indications  of  insanity  as  observed,  the 
manner  in  ■which  they  are  recorded  makes  them 
appear  insufficient.  It  is  sometimes  stated,  for 
example,  that  a patient  ‘ believes  himself  to  be 
possessed  of  great  wealth;’  but  it  is  necessary 
that  we  should  also  state  whether  this  is  or  is 
not  a well-founded  belief.  And  it  is  not  infre- 
quent to  find  this  necessary  adjunct  absent  from 
the  statement.  One  actual  statement  of  facts, 
for  instance,  was  1 his  appearance,  manner,  mode 
of  speaking,  as  well  as  his  conduct,’  a detail  of 
circumstances  which  had  probably  proved  con- 
clusively enough  to  the  writer  that  the  patient 
was  insane,  but  which  afforded  no  substantial 
information  to  those  who  merely  read  the  state- 
ment. When  the  case  is  urgent,  and  it  is  found 
impracticable  to  obtain  certificates  from  two 
medical  men,  the  patient  may  be  received  into 
he  asylum  or  house  upon  a single  certificate. 
But  this  entails  the  necessity  of  obtaining  two 
ldditional  certificates  from  ether  medical  men 
vithin  three  clear  days  after  the  reception  of  the 
jatient. 

A private  patient  may  be  discharged  from  the 
sylum  or  house  in  which  he  has  been  detained, 
■a  the  written  authority  of  the  person  who 
igned  the  order  for  his  admission.  If  a patient 
herald  die  while  under  detention  it  is  necessary 
3 give  notice  of  the  death  to  the  Coroner  and  to 
le  Commissioners  in  Lunacy. 

In  the  case  of  pauper  lunatics  the  procedure 
i somewhat  different  from  what  is  required  for 
rivate  patients.  Anyone  aware  of  the  exist- 
■ice  of  an  insane  pauper  in  a parish,  ought,  if 
lie  case  is  a proper  one  for  asylum  treatment, 
i give  notice  to  the  relieving  officer  or  the 
■erseer.  When  a district  medical  officer  under 
e poor  law  becomes  aware  of  such  a circum- 
ance  it  becomes  his  statutory  duty  to  give  this 
'ticein  writing  within  three  days  after  obtaining 
i ch  knowledge.  The  relieving  officer  or  over- 
ir  may  then  place  the  patient  in  an  asylum  upon 
e medical  certificate,  accompanied  either  by 
e order  of  a justice  of  the  peace,  or  by  an  order 
i;ued  conjointly  by  himself  and  an  officiating 
Tgyman  of  the  parish. 

In  order  to  place  a patient  in  an  asylum  in 
utland,  a petition  accompanied  by  a statement 
|1  two  medical  certificates  has  to  be  presented 
the  sheriff,1  In  the  case  of  a private  patient 
■ person  signing  the  petition  must  state  the 
;ree  of  kinship  or  other  relation  in  which  he 

The  regular  printed  forms  for  Scotland  may  be  ob- 
Gft  from  Messrs.  T.  and  A.  Constable,  11  Thistle 
' iet,  Edinburgh. 


LUNATIC.  857 

stands  to  the  patient.  In  the  case  of  a pauper 
the  petition  must  be  signed  by  the  inspector  of  the 
poor.  In  either  case,  if  there  be  reasonable  ground 
for  so  doing,  the  patient  may  be  placed  in  the 
asylum  on  what  is  called  a ‘ certificate  of  emer- 
gency,’ signed  by  one  medical  man.  If,  however, 
the  order  of  the  sheriff  is  not  obtained  within 
three  days  thereafter,  the  patient  must  be  dis- 
charged. In  the  case  of  a patient  placed  for  profit 
in  a private  house  in  Scotland,  the  fact  must  be 
reported  to  the  General  Board  of  Lunacy  for 
Scotland,  and  the  sanction  of  the  Board  obtained. 

The  procedure  required  for  placing  a patient 
in  an  asylum  in  Ireland  is  generally  similar  to 
what  is  required  in  England.  For  admission  to 
a private  asylum,  an  order  and  two  medical  cer- 
tificates must  be  filled  up  and  signed,  subject  to 
regulations  resembling  those  already  described 
as  enforced  in  England  ; but  the  facts  indicating 
insanity  do  not  require  to  be  stated  in  the  certi- 
ficates. Pauper  patients  are  placed  in  district 
asylums,  and  are  admitted  to  these  institutions 
on  application  being  made  at  the  asylum  of  the 
district  in  which  the  patient  resides.  The  neces- 
sary form  is  obtained  at  the  asylum.  It  consists 
of  (1)  a declaration  to  be  made  before  a magis- 
trate, that  the  patient  is  insane  and  destitute, 
and  has  no  friend  able  or  willing  to  pay  for  his 
board  in  an  asylum  ; and  to  this  is  annexed  a 
statement  descriptive  of  the  patient ; (2),  a 
certificate  by  a magistrate,  and  a clergyman  or 
poor  law  guardian,  in  corroboration  of  the 
declaration ; and  (3),  a medical  certificate  of 
insanity.  When  these  forms  have  been  filled  up, 
it  is  necessary  to  wait  until  it  is  notified  to  some 
of  the  friends  of  the  lunatic  that  there  is  room 
for  him  at  the  asylum.  The  procedure  specially 
designed  for  the  committal  of  dangerous  luna- 
tics is,  however,  frequently  adopted  in  placing 
paupers  in  asylums.  As  this  necessitates  the 
lodgment  of  the  patient  in  an  ordinary  prison, 
it  is  evidently  a course  which  ought  to  he 
avoided,  and  which  the  medical  practitioner 
ought  specially  to  discourage.  According  to 
this  procedure  the  patient  requires  to  be  appre- 
hended by  the  police,  and  brought  before  two 
justices  of  the  peace.  They  call  to  their  aid  the 
medical  officer  of  the  Dispensary  District,  and 
either  discharge  the  patient  or  order  his  removal 
to  the  asylum.  Patients  who  are  not  destitute, 
but  whose  friends  are  unable  to  pay  the  rate3  of 
board  charged  in  private  asylums,  are  received 
into  district  asylums  at  low  rates,  upon  appli- 
cation being  made  at  the  asylum  in  a similar 
manner  to  that  already  described  for  paupers. 
The  chief  difference  between  the  two  forms  is 
that  in  the  case  of  patients  not  destitute,  the 
medical  certificate  requires  to  be  signed  by  two 
medical  men  instead  of  only  by  one. 

John  Sibbai.d. 

LUNATIC  (tuna,  the  moon). — Synon.  : Fr. 
Lunatique  ; Ger.  Mondsiichtig. — A designation 
given  to  persons  suffering  from  mental  disorder, 
because  such  subjects  were  formerly  believed  to 
be  peculiarly  affected  by  lunar  influences.  The 
term  is  used  popularly  as  synonymous  with  in- 
sane. In  medical  literature  it  is  seldom  em- 
ployed, but  the  legal  relations  of  the  word  are 
important.  The  adjective  lunatic  is  also  used 


858  LUNATIC, 

to  signify  that  the  object  with  which  it  is  asso- 
ciated is  connected  with  insanity,  as  lunatic  asy- 
lum. See  Insanity. 

LUNGS,  Diseases  of. — Synon.  : Fr.  Mala- 
dies du  Ponrnon ; Ger.  Krankheiten  dcr  Lungen. 
Under  this  title  there  will  be  described  in  the 
following  pages,  with  certain  exceptions,  the 
various  morbid  conditions  which  affect  the  pul- 
monary organs.  Pulmonary  phthisis  is  so  com- 
mon a disease,  so  complex  and  variable  in  its 
pathology,  and  so  closely  associated  in  its  aetio- 
logy and  symptoms  with  the  entire  organism, 
that  it  will,  be  most  conveniently  described 
apart  from  tho  other  diseases  of  the  lungs  (see 
Phthisis).  Certain  other  diseases  which  in- 
volve the  lungs,  if  not  the  lung-tissue  proper, 
and  which  in  some  nosological  systems  are  de- 
scribed as  pulmonary  diseases — namely,  asthma, 
diseases  of  the  bronchi,  and  diseases  of  the 
pleura,  will  also  be  found  described  apart  from 
the  present  connection,  and  under  their  several 
headings.  Again,  disorders  of  respiration,  such 
as  dyspnoea,  orthopnoea,  and  ‘ Cheyne-Stokes  re- 
spiration,’ although  frequently  associated  with 
diseases  of  the  lungs,  are  in  other  instances 
referable  to  some  morbid  condition  of  other  parts, 
such  as  the  blood,  the  heart  and  circulation,  or 
the  nervous  apparatus  of  breathing,  and  they 
will  therefore  be  discussed  in  a distinct  article 
( see  Respiration,  Disorders  of).  The  more  im- 
portant special  clinical  phenomena  of  disease  of 
the  lungs — namely,  cough,  expectoration,  haemop- 
tysis, and  the  various  physical  signs,  also  de- 
mand more  detailed  and  complete  consideration 
than  can  be  devoted  to  them  in  connection  with 
the  various  pathological  conditions  to  which 
they  are  due.  See  Cough  ; Expectoration  ; 
Haemoptysis  ; and  Physical  Examination. 

After  the  separation  of  these  subjects  from 
that  of  diseases  of  the  lungs,  there  remain  for 
consideration  under  this  head  a large  number  of 
morbid  conditions,  which  rank  of  the  very  first 
importance  in  practical  medicine,  and  which  will 
now  be  enumerated.  The  morbid  processes  which 
affect  the  lungs  may  be  readily  divided  into  two 
great  groups — namely,  first,  those  which  are 
not  essentially  different  from  similar  processes 
in  other  parts  of  the  body ; and,  secondly,  those 
which  arc  quite  peculiar  to  these  organs. 

First,  -with  respect  to  the  former  group,  the 
lungs,  like  the  other  great  viscera,  may  present 
any  of  the  ordinary  morbid  conditions,  which 
affect  either  entire  organs,  or  the  several  tissues 
of  which  they  are  composed.  Thus  the  lungs 
maybe  the  subject  of  various  injuries,  leading  to 
perforation  or  rupture,  and  may  present  certain 
malformations  and  misplacements.  They  may 
undergo  such  alterations  of  nutrition  as  end  iu 
atrophy,  hypertrophy,  or  certain  degenerations. 
Disturbances  of  circulation  give  rise  to  well- 
defined  pathological  conditions,  such  as  anosmia, 
congestion,  hyperemia,  ‘ apoplexy embolism,  in- 
farction, oedema,  and  hesmorrhage.  The  inflam- 
matory process  leads  to  a greater  variety  of 
pathological  changes  in  the  lungs  than  in  per- 
haps any  other  organ,  and  which  are  known  as 
catarrhal,  croupous,  and  chronic  pneumomia, 
abscess,  cirrhosis,  gangrene,  and  some  forms  of 
phthisis.  Morbid  growths  of  all  kinds,  including 


LUNGS,  AUS CESS  OF. 

malignant  disease,  may  involve  the  lurgs,  whether 
primarily  or  secondarily.  Syphilis,  besides  actu- 
ally involving  the  lungs,  occasionally  determines 
or  modifies  the  occurrence  of  other  pathological 
processes  within  them.  Various  parasites,  espe- 
cially hydatids , are  occasionally  tenants  of  the 
pulmonary  organs. 

Secondly,  the  morbid  conditions  which  are 
peculiar  to  the  lungs  are  such  as  depend  upon 
their  special  structure,  relations,  and  functions. 
Thus  the  relation  between  the  pulmonary  tissue 
and  the  pressure  within  and  around  the  lungs 
may  he  so  disturbed  as  to  lead,  on  the  one  hand 
to  collapse  or  compression,  or  on  the  other  hand 
to  emphysema.  Their  communication  with  the 
atmosphere,  and  the  constant  interchange  that 
is  going  on  between  the  contents  of  the  lungs 
and  the  external  air,  have  an  important  influ- 
ence upon  the  origin,  distribution,  progress,  and 
treatment  of  many  of  the  diseases  which  affect 
them  ; whilst  the  length  and  complexity  of  the 
respiratory  passages  and  their  liability  to  dis- 
ease, lead  to  many  disturbances  of  the  pres- 
sure, the  circulation,  and  the  nutrition  within 
the  lungs,  and  thus  to  collapse,  hypenemia, 
inflammation,  and  even  destructive  disease.  The 
relation  of  tho  lungs  to  the  circulation  has 
an  equally  important  influence  upon  them  from 
a pathological  point  of  view.  Constituting  as 
they  do  the  channel  of  communication  between 
the  right  and  the  left  sides  of  the  heart,  the 
pulmonary’  vessels  are  involved  in  all  the  dis- 
turbances which  affect  the  cardiac  circulation, 
whether  due  to  actual  disease  of  the  valves  or  of 
the  walls,  or  to  simple  functional  derangement 
of  that  organ.  Congestion,  oedema,  embolism, 
infarction,  htemorrhage,  and  some  forms  of  in- 
flammation of  the  lungs,  are  the  ordinary  results 
of  such  circulatory  disturbance  of  a temporary 
kind ; and  when  it  is  more  protracted,  brown 
induration,  as  well  as  diseases  of  the  bronchi 
and  pleura,  are  likely  to  result. 

Such  are  the  principal  conditions  which  deter- 
mine and  influence  diseases  of  the  lungs;  and  wo 
shall  here  enumerate  these  in  the  alphabetical 
order  in  which  they  will  be  found  referred  to  in 
the  following  pages  ; — 1.  Abscess.  2.  Albu- 
minoid Disease.  3.  Anaemia.  4.  Apoplexy.  5. 
Atrophy.  6.  Brown  Induration.  7.  Cancer.  8. 
Cirrhosis.  9.  Collapse.  10.  Compression.  11. 
Congestion.  12.  Consumption.  13.  Degenera- 
tions. 14.  Embolism.  15.  Emphysema.  16. 
Gangrene.  17.  Haemorrhage.  18.  Hydatids. 
19.  Hyperemia.  20.  Hypertrophy.  21.  Indura- 
tion. 22.  Infarction.  23.  Infiltrations.  24.  In- 
flammation— Croupous,  Secondary,  Catarrhal 
and  Chronic.  25.  Inflation.  26.  Malformations 
27.  Malignant  Diseases.  28.  Malpositions.  29 
Morbid  Growths.  30.  Gxdema.  31.  Perforation 
32.  Rupture.  33.  Syphilitic  Disease  ; and  34 
Tuberculosis. 

LUNGS,  Abscess  of.— Synon.  : Fr.  Abet 
du  Poumon  ; Ger.  Lungenabscess. 

Definition. — Circumscribed  suppuration  c 
the  pulmonary  tissues. 

-Etiology  and  Pathology. — An  acute  pri 
mary  inflammation  of  the  lungs  may  oecasior 
ally  lead  to  the  formation  of  abscess.  Muej 
more  commonly,  however,  pulmonarr  abseesst 


LUNGS,  ABSCESS  OF. 

are  the  result  of  secondary  or  infective  inflam- 
mations, and  they  are  then,  for  the  most  part, 
associated  with  pyaemia. 

Of  acute  primary  inflammations  of  the  lung, 
as  causes  of  abscess,  we  have  to  csnsider  those 
due  to  mechanical  injuries,  and  those  associated 
with  acute  pneumonia  and  with  gangrene. 
With  regard  to  the  former  it  is  only  neces- 
sary to  remark  that  mechanical  injuries,  as  frac- 
tured ribs,  penetrating  wounds  of  the  thorax, 
the  lodgment  of  foreign  bodies,  &e.,  may  cause 
suppuration,  and  so  occasionally  lead  to  the  for- 
mation of  abscess.  That  acute  pneumonia  may, 
in  rare  cases,  terminate  in  abscess  of  the  lung, 
has  already  been  stated.  Such  a result  appears 
to  be  favoured  by  a bad  constitution,  and  by  any 
circumstances  which  tend  to  impair  the  general 
health,  either  before  or  during  the  disease.  The 
' abscess  is  more  common  in  the  upper  than  in 
the  lower  lobes.  Lastly,  circumscribed  gangrene 
of  the  lung  occasionally  terminates  in  abscess. 
This  takes  place  by  the  evacuation  of  the  ne- 
, erotic  tissue  through  the  bronchi,  and  the  for- 
mation of  a pyogenic  membrane  from  the  walls 
of  the  cavity,  which  generates  pus.  The  cavity 
may  ultimately  close  by  granulation  and  cicatri- 
sation. Abscesses  of  primary  origin  are  usually 
single. 

Secondary  or  infective  abscesses  of  the  lung 
owe  their  origin  to  the  dissemination  of  infective 
substances,  derived  from  some  focus  of  primary 
inflammation,  by  means  of  the  blood-vessels  or 
lymphatics.  They  are  usually  due  to  a general 
pyaemie  process ; and  consequently  the  blood- 
vessels are  the  channels  by  means  of  which  the 
■ufective  substances  are  conveyed  to  the  lungs. 
These  substances  are  sometimes  sufficiently 
arge  to  block  the  pulmonary  vessels,  the  for- 
nation  of  the  abscess  being  preceded  by  a pro- 
’ess  of  haemorrhagic  infarction.  In  other  cases 
he  suppuration  occurs  without  any  evidence  of 
I'.ueh  infarction  taking  place.  These  abscesses 
re  almost  invariably  multiple.  They  vary  in 
ize  from  a pin’s  head  to  a walnut,  and  are 
sually  most  abundant  near  the  surface.  They'  are 
ommonly  surrounded  by  a thin  zone  of  dark  red 
onsolidation ; and  when  adjacent  to  the  pleura, 
his  membrane  over  them  is  always  inflamed. 
Symptoms  and  Physical  Signs. — The  forma- 
ion  of  abscess  in  the  lung  is  rarely  attended  by 
ny  marked  clinical  phenomena,  the  symptoms 
f the  disease,  in  the  course  of  which  the  localised 
ippuration  takes  place  being,  for  the  most  part, 
ut  little  modified  by  its  occurrence. 

When  acute  pneumonia  terminates  in  abscess, 
ther  the  rapid  fall  of  the  temperature  which 
'institutes  crisis  does  not  occur,  or,  what  is  more 
mmon,  its  occurrence  is  followed  by  pyrexia 
an  irregular  type.  The  physical  signs  of 
msolidation  also  persist,  and  there  is  usually 
'eat  prostration.  Sometimes,  owing  to  the 
s ening  of  the  abscess  into  a bronchus,  pus  is 
ughed  up ; and  then,  if  the  communication 
th  the  bronchus  remain  free,  signs  of  cavity 
3 discoverable.  Before  such  partial  evacuation 
its  contents,  the  detection  of  the  abscess  by 
ysical  examination  is  usually  impossible.  The 
'Peetoration  of  sputa  containing  large  quan- 
ta of  pus,  and  often  a little  blood,  may  con- 
ue  for  some  weeks  ; the  signs  of  prostration 


LUNGS,  ANiEMLh  OF.  859 
may  gradually  increase ; and  death  may  ensue  in 
the  course  of  from  two  to  three  months,  and  often 
earlier.  Partial  or  complete  recovery  may,  how- 
ever, take  place,  the  cavity  becoming  quiescent 
and  secreting  only  small  quantities  of  pus  ; and 
complete  cicatrisation  may  ultimately  occur.  In 
exceptional  cases  the  abscess  opens  into  the 
pleural  cavity. 

Abscesses  of  the  lungs  occurring  in  the  course 
of  pyaemia  rarely  give  rise  to  any  special  symp- 
toms or  physical  signs.  They  are  usually  much 
smaller  than  primary  abscesses ; and  death  com- 
monly ensues  before  any  of  them  have  attained 
sufficient  magnitude  to  influence  the  general 
phenomena  of  the  disease. 

Diagnosis. — The  diagnosis  of  abscess,  occur- 
ring in  the  course  of  pneumonia,  rests  mainly 
upon  the  persistence  and  characters  of  the 
pyrexia  ; upon  the  physical  signs  of  excavation 
supervening  on  those  of  pulmonary  consolidation; 
and  upon  the  expectoration  of  sputa  containing 
pus.  Pyaemie  abscesses  rarely  admit  of  diagnosis. 
Their  existence  may  be  suspected  if,  in  cases  of 
pyaemia,  pleural  friction-sounds  are  audible  over 
different  portions  of  the  chest. 

Prognosis. — Abscess  resulting  from  pneu- 
monia very  commonly  proves  fatal  in  from  one  to 
three  months  ; it  may,  however,  as  already  stated, 
ultimatelyterminate  in  partial  or  even  complete 
recovery.  The  development  of  abscesses  in  the 
lungs  in  the  course  of  pyaemia  does  not  appear 
to  influence  the  general  prognosis. 

Treatment. — Abscesses  of  the  lungs  rarely 
admit  of  any  special  treatment.  Their  occur- 
rence, however,  indicates  the  importance  of 
doing  all  that  is  possible  to  maintain  the  strength 
of  the  patient.  T.  Henry  Green. 

LUNGS,  Albuminoid  Disease  of. — In 
advanced  eases  of  albuminoid  disease,  the  lung- 
tissues  may  present  more  or  less  of  this  morbid 
change;  but  it  is  of  no  practical  importance,  for 
it  does  not  give  rise  to  any  evident  symptoms, 
nor  does  it  have  any  specially  injurious  effect 
upon  the  patient. 

LTJN GS,  Anaemia  of. — Synon.  ; Pr.  Animie 
du  poumon  ; Ger.  Lungenanamie. 

Definition.  — A deficiency  of  blood  in  the 
lungs. 

Anaemia  of  the  lung  may  be  general  or  local. 

IEtiology.  — Besides  haemorrhage  and  the 
other  causes  of  general  bloodlessness,  there  are 
certain  local  causes  which  produce  amentia  of  the 
lung.  In  senile  atrophy,  and  in  pulmonary  vesi- 
cular emphysema,  anaemia  is  associated  with 
destruction  of  capillaries.  Local  or  partial 
anaemia  of  the  lung  is  the  immediate  result  of 
embolism  of  the  branches  of  the  pulmonary 
artery.  It  rarely  happens  that  the  main  vessel 
is  entirely  obstructed  by  an  embolus  ; but  it,  or 
more  commonly  one  of  its  main  divisions,  may 
be  compressed  or  obliterated  by  the  invasion 
of  a malignant  growth  or  aneurism.  Aneurism 
of  a branch  of  the  pulmonary  artery  within  the 
luns  usually  causes  anaemia  of  the  portion  to 
which  the  vessel  is  distributed. 

Anatomical  Characters. — In  extreme  anae- 
mia, as  after  death  from  haemorrhage,  the  lungs 
and  the  bronchial  mucous  membrane  are  ex- 


SCO  LUNGS.  ANAEMIA  OF. 
coedingly  pale  from  absence  of  blood.  They 
are  of  coarse  lighter  in  weight  than  natural,  but 
in  other  respects  unchanged.  In  the  general 
disease  known  as  anaemia,  the  lung  partakes  with 
other  organs  of  the  general  deficiency  of  red  blood ; 
but  in  this  condition,  it  being  not  so  much  in  bulk 
as  in  quality  that  the  blood  is  deficient,  the  lungs 
are  of  normal  weight,  but  paler  and  more  moist 
than  natural,  sometimes  slightly  (edematous. 

Effects. — The  consequences  of  pulmonary 
anaemia,  when  long-continued,  are  atrophy  of  its 
texture,  as  in  senile  atrophy  and  vesicular  em- 
physema, and  in  local  deficiency  of  blood  from 
partial  obstruction  of  a large  branch  of  the 
pulmonary  artery.  In  complete  obstruction  of 
vessels  from  embolism,  death  and  sloughing  of 
the  deprived  area  of  lung  is  the  consequence. 
The  . sudden  arrest  of  circulation  through  a 
limited  portion  of  the  lung,  gives  rise  to  stress 
on  the  collateral  circulation,  the  result  of  which 
is  often  haemorrhage. 

Symptoms. — The  dyspnoea  and  palpitation 
observed  in  anaemia  are  traceable  to  the  anaemic 
condition  of  the  lungs,  and  have  their  rationale 
in  the  necessity  for  an  increased  diligence  of 
respiration,  to  enable  the  diluted  blood  to  gather 
sufficient  oxygen  for  carrying  on  the  various 
combustion-processes  of  life.  The  remarkable 
gasping  and  restlessness  seen  in  cases  of  fatal 
haemorrhage,  are  really  the  signs  of  asphyxia 
from  pulmonary  deprivation  of  blood.  The 
symptoms  of  general  or  local  pulmonary  anaemia 
dependent  upon  emphysema,  embolism,  &c.,  are 
lost  in  those  of  the  more  important  diseases. 

Treatment. — There  is  no  special  treatment  for 
pulmonary  anaemia.  B.  Douglas  Powell. 

LUNGS,  Apoplexy  of. — A synonym  for 
extravasation  of  blood  into  the  lungs.  See 
Lungs,  Haemorrhage  into. 

LUNGS,  Atrophy  of. — Synon.  : Senile  em- 
physema; Fr.  Atrophie  du  Poumon ; Ger . Lun- 
genatrophie. 

Definition. — A wasting  of  the  constituent 
elements  of  the  lungs,  from  defective  nutrition. 

Varieties. — Atrophy  of  the  lung  may  be : — (a) 
general,  in  which  all  the  tissues  of  the  whole  of 
both  lungs  are  wasted,  as  in  senile  atrophy ; or 
it  may  he  ( h ) local,  in  which  all  the  tissues  of  a 
portion  of  the  lung  are  wasted,  as  in  the  atrophy 
that  results  from  a local  diminution  of  blood- 
supply;  or  (c)  it  may  be  partial,  in  which  some 
of  the  tissues  are  atrophied  coincidently  with 
increased  growth  of  other  tissues,  as  in  some 
cases  of  so-called  ‘ hypertrophous  emphysema,’ 
and  in  ‘cirrhosis’  of  the  lung. 

.Etiology. — The  cause  of  simple  atrophy  of 
the  lungs  is  that  general  failure  of  nutrition 
which  is  natural  to  advanced  age.  Hereditary 
predisposition  may  determine  an  earlier  failure 
of  nutritive  change  in  the  lungs.  The  strongly- 
marked  tendoney  of  vesicular  emphysema  to  re- 
cur in  successive  generations  is  certainly  in  favour 
of  such  a tendency  to  premature  impairment  of 
tissue  being  inherited. 

Over-stretching  of  the  walls  of  the  air-cells  in 
emphysema,  with  the  consequent  impediment  to 
circulation,  is  an  important  cause  of  subsequent 
atrophy  in  this  disease.  Collapse  and  anaemia 


LUNGS,  ATEOPHY  OF. 

of  lung  from  pressure  from  without,  or  from  the 
pressure  of  a growth  or  aneurism  upon  one  of 
the  pulmonary  vessels,  cutting  off  the  blood- 
supply,  or  on  a large  bronchus,  diminishing  the 
respiratory  function,  may  cause  atrophy  of  the 
whole  or  of  a part  of  ono  lung. 

Anatomical  Characters. — The  appearance  of 
an  atrophied  lung  may  be  best  seen  in  a case  of 
natural  or  senile  atrophy.  The  lung  is  small, 
light,  anaemic,  more  or  less  deeply  pigmented, 
drier  in  texture  and  less  firm  and  resisting  than 
natural,  pitting  on  pressure  from  want  of  elastic 
resilience,  and  capable  of  being  squeezed  into  a 
very  small  compass.  The  air-cells  appear  to  be 
increased  in  size;  and  at  some  portions,  if  the 
lung  be  inflated  and  dried,  large  cells  may  be 
seen,  evidently  resulting  from  the  coalescence  of 
two  or  moro  infundibula.  Across  such  cells  fila- 
ments, the  remnants  of  small  bronchi  and  blood- 
vessels, may  extend.  The  pulmonary  arterv  and 
its  branches  are  diminishedin  size,  and  the  bron- 
chial tubes  are  also  thinned. 

Microscopical  characters.  — The  atrophic  pro- 
cess commences  at  the  vesicular  septa,  which 
project  inwards  to  subdivide  the  infundibula,  or 
alveolar  spaces  of  the  lung,  into  true  air-cells,  or 
alveoli.  The  process  is  one  of  simple  withering 
and  obliteration  of  capillaries,  dependent  on  di- 
minished respiratory  function  and  blood-volume. 
The  septa  dwindle  down  to  mere  ridees  upon 
the  infundibular  walls;  and  these  walls  in  their 
turn  become  thinned  even  to  perforation  and 
coalescence  of  several  air-spaces.  Thus,  without 
any  corresponding  enlargement  of  lung,  there  is 
an  apparent  enlargement  of  air-cells  from  the 
simplification  of  structure.  A certain  degree  of 
fatty  degeneration,  affecting  especially  the  mi- 
nute vessels  and  the  nuclear  remains  of  the  pul- 
monary epithelium,  is  associated  with  this  simple 
atrophy,  as  with  all  other  atrophic  processes. 

When  atrophy  of  the  lung  is  associated  with, 
or  the  result  of,  other  diseases,  as  emphysema  or 
forcible  collapse,  the  process  is  essentially  the 
same,  but  is  combined  in  the  former  case  with 
over-stretching  of  the  air-cells,  and  more  or  less 
thickening  of  the  fibrous  tissues  derived  from 
the  bronchial  and  perivascular  sheaths,  from  re- 
peated congestions.  Thus  we  have  a larger  and 
heavier  lung;  and,  in  the  later  stages,  more 
marked  fatty  degeneration  of  its  fibrous  texture. 

In  cases  of  atrophy  from  the  long-continued 
pressure  of  fluid  in  the  pleura,  the  pleura  is 
always  thickened  from  the  original  inflammation, 
and  fibrous  processes  are  directed  inwards  from 
it  between  the  lobules,  so  as  to  render  difficult 
any  subsequent  expansion  of  the  lung. 

In  the  case  of  atrophy  from  compression  of  the 
lung  by  fibrous  growth  or  fluid  effusion,  we  have 
again  often  a heavier  lung  from  increase  o; 
fibrous  tissue.  It  is  obvious  that  the  increast 
in  weight  must  always  be  due  to  attendant 
often  determining,  disease. 

Effects  and  Symptoms. — The  consequence 
of  the  partial  atrophy  of  lung  which  aceom 
panies  the  ‘ large-lunged’  emphysema  of  advancr< 
middle  life  are  very  grave.  Extensive  obliter.i 
tion  of  tlie  pulmonary  capillaries,  without 
corresponding  diminution  in  the  blood-volum( 
induces  a stress  of  circulation,  a mechanics 
congestion,  which  ultimately  tells  back  throng 


LUNGS,  ATROPHY  OF. 

the  right  heart  upon  the  whole  venous  system. 
The  damaged  elasticity  of  the  lung  impairs  the 
mechanism,  as  the  atrophy  of  the  alveoli  impairs 
the  function  of  respiration.  In  senile  emphy- 
sema, however,  the  lung-atrophy,  being  but  a 
part  of  a general  atrophy  of  all  the  tissues  and 
of  the  blood,  causes  no  discomfort,  provided  no 
extra  effort  is  attempted  and  no  bronchitis  super- 
vene. Local  atrophy  of  the  lung  has  its  symp- 
toms merged  in  those  of  the  predominant  disease. 

Physical  signs. — In  senile  atrophy  of  the  lungs 
the  chest-capacity  is  diminished  in  all  directions 
to  accommodate  the  small  lungs.  The  lower  ribs 
are  approximated  and  their  obliquity  greatly 
increased  ; the  upper  intercostal  spaces  aro  de- 
pressed. The  chest-movements  are  very  limited. 
The  percussion  resonance  is  generally  increased 
over  the  chest,  except  over  the  prsecordial  re- 
gion, which  is  less  covered  by  lung  than  natural. 
The  respiratory  murmurs  are  simply  enfeebled, 
not  altered,  unless  there  be  some  bronchitis  pre- 
sent. It  has  been  said  that  there  may  be  some 
effusion  into  the  pleura  in  atrophy  of  the  lung,  to 
fill  up  the  space  vacated  by  the  shrunken  organ, 
fhe  mechanism  of  such  an  effusion  is,  how- 
ever, quite  inconceivable. 

Complications. — There  are  no  complications 
necessarily  incident  to  senile  atrophy  of  the 
ung.  Bronchitis  not  uncommonly,  however, 
supervenes,  and  proves  fatal  to  the  patient. 

Treatment. — The  treatment  of  senile  atrophy 
if  the  lungs  simply  consists  in  shielding  the  aged 
lerson  from  the  causes  of  bronchitis. 

R.  Douglas  Powell, 

LUNGS,  Brown  Induration  of. — The 

ondition  recognised  by  this  name  by  Virchow 
Ind  Laennec,  is  one  which  is  sometimes  ob- 
erved  after  prolonged  congestion  of  the  lungs, 
■articularly  that  which  results  from  disease  con- 
ected  with  the  mitral  orifice.  The  morbid  change 
insists  mainly  in  excessive  pigmentation,  the  pig- 
lent  accumulating  not  only  in  the  interlobular 
ssue,  but  also  in  the  alveoli  and  minute  bronchi, 
here  it  is  enclosed  in  enlarged  epithelial  and 
.ranular  cells.  At  the  same  time  the  capil- 
iries  are  dilated,  the  interstitial  tissue  is 
iicreased,  and  probably  the  alveolar  walls  are 
lickened.  The  pigment  is  granular,  and  of  a 
bllowish  colour;  it  is  derived  from  the  blood; 
id  seems  to  be  of  the  nature  of  haematoidin. 

. may  become  brownish,  reddish,  or  even  black ; 
id  ultimately  may  bo  found  free.  The  extent 
id  degree  of  brown  induration  vary  much  in 
fferent  cases.  When  the  change  is  marked, 
e lungs  are  enlarged,  heavy,  firm,  incompres- 
jhle,  and  inelastic,  not  collapsing  on  exposure, 
ley  present  various  tints,  from  yellowish  to 
■ ddish-brown.  This  alteration  in  colour  is  also 
; ident  on  section,  and  red  spots  are  often  seen, 
ading  into  black,  while  a brownish  fluid  may 
expressed.  Brown  induration  is  associated 
th  congestion  of  other  parts  of  the  lungs,  and 
en  with  infarctions.  It  cannot  be  clinically 
cognised  apart  from  these  conditions,  unless 
i affected  organs  should  present  physical  signs 
consolidation  in  cases  of  known  pulmonary 
igestion  from  mitral  disease.  No  special  treat- 
'Dt  is  called  for. 

Frederick  T.  Roberts. 


LUNGS,  COLLAPSE  OF.  861 

LUNGS,  Cancer  of. — See  Lungs,  Malignant 
Disease  of. 

LUNGS,  Cirrhosis  of. — A synonym  for 
chronic  pneumonia,  See  Lungs,  Inflammation  of. 

LUN GS,  Collapse  of. — Synon.  : Apneuma- 
tosis;  Fr.  Affaissenient pulmonaire;  Ger.  Lungcn- 
collapsus. 

Definition. — Simple  diminution  in  size  of  the 
whole  or  of  a part  of  a lung,  with  reduction  of 
the  volume  of  the  contained  air,  and  caused  by 
interference  with  its  free  entrance  in  inspiration. 

-Dtiology. — -The  causes  of  collapse  of  the 
lung  are  either  intrinsic  or  extrinsic ; and  fre- 
quently the  two  classes  of  causes  are  combined. 
The  intrinsic  causes  present  actual  obstruction 
of  the  respiratory  passages,  and  include  all 
diseases  of  the  larynx,  trachea,  and  bronchi, 
attended  with  inspiratory  dyspnoea,  whether 
due  to  the  pressure  of  external  tumours,  to  af- 
fections of  the  passages  themselves,  or  to  the 
presence  of  inflammatory  products,  blood,  and 
foreign  bodies  within  them.  To  this  class  of 
cases  belongs  the  collapse  of  the  lung  which  is 
apt  to  follow  infantile  bronchitis,  when  the  tubes 
become  obstructed,  and  there  is  no  power  to  ex- 
pectorate. All  causes  that  interfere  with  respi- 
ratory efficiency  favour  the  occurrence  of  the 
condition  named.  A plug  of  mucus  may  be 
drawn,  in  inspiration,  deeper  and  deeper  into 
the  bronchial  tubes,  which  it  obstructs,  and  act- 
inglike a ‘ ball  plug,’  allows  the  expulsion  of  air 
in  expiration,  but  interferes  with  inspiration  ; 
the  air  not  being  replaced,  apneumatosis  is  de- 
veloped; and  as  there  is  no  air  behind  the  plug 
of  mucus,  cough  is  powerless  to  expel  it.  In 
children,  bronchial  inflammation  is  exceedingly 
common,  and  the  smaller  tubes  being  propor- 
tionately smaller  in  the  child  than  in  the  adult, 
the  danger  of  collapse  is  increased.  When  chil- 
dren under  five  years  of  age  die  of  bronchitis  and 
allied  affections,  apneumatosis  is  almost  invari- 
ably present ; and  2opercent.  of  the  total  mortality 
of  infants  may  be  safely  set  down  to  this  cause. 
Partial  collapse  of  the  lung  from  pressure  on 
the  respiratory  passages  will  be  found  described 
in  the  article  Mediastinum,  Diseases  of.  The 
extrinsic  causes  of  pulmonary  collapse  are  cer- 
tain conditions  of  the  walls  of  the  chest,  which 
diminish  the  force  of  the  inspiratory  act,  such  as 
paralysis  or  debility  of  the  inspiratory  muscles, 
and  softness  of  their  bony  attachments.  Muscular 
paralysis  is  seen  in  injuries  to  the  cord.  Debility 
of  the  respiratory  muscles  may  often  be  observed 
before  death.  Collapse  of  the  lung  is  sometimes, 
although  rarely,  met  with  in  adult  life,  when  great 
prostration  occurs  in  the  course  of  fever,  and 
respiration  is  impeded  by  pulmonary  congestion. 
Asssociated  as  it  is  with  softness  and  weakness 
of  the  ribs,  rickets  is  one  of  the  most  frequent 
causes  of  collapse  of  the  lungs.  The  action  of 
the  inspiratory  muscles  may  be  still  further 
interfered  with  by  abdominal  distension,  or  by 
the  binding  up  of  the  abdomen  of  the  infant 
with  tight  bandages.  The  danger  of  collapse  is 
lessened  when  the  ribs  have  gained  firmness 
and  fixity,  and  when,  raised  by  the  respiratory 
muscles,  the  thoracic  cavity  is  enlarged,  and  the 
lungs  are  consequently  expanded. 


362  LUNGS,  COLLAPSE  OF. 

Anatomical  Characters. — The  whole  of  one 
lung  or  of  one  lobe  may  be  affected,  but  a lobule 
or  a part  only  of  the  lung  is  usually  involved, 
the  affected  lobules  being  abruptly  separated 
from  those  adjoining.  As  a rule  several  patches 
of  collapse  occur  in  each  lung,  having  a darker 
colour  and  more  depressed  surface  than  the 
healthy  parts.  The  lower  margins  of  the  left 
lower  lobe  are  most  frequently  affected.  The 
collapsed  portions  of  lung  are  similar  to  the 
liver  in  consistence ; they  resist  pressure,  are 
non-crepitant,  are  smooth  on  section,  and  sink  in 
water.  The  bronchi  are  filled  with  mucous  fluid ; 
there  is  an  entire  absence  of  air  in  the  collapsed 
parts.  On  inflation  the  affected  portion  assumes 
a natural  appearance,  unless  considerable  con- 
gestion exists  ; whereas  in  pneumonia  inflation 
cannot  restore  the  lung  to  its  natural  appearance. 
In  pneumonia  pleurisy  is  rarely  absent ; but  in 
collapse,  uncomplicated  with  diathetic  disease, 
the  pleura  is  invariably  healthy. 

Symptoms. — The  symptoms  of  collapse  of  the 
lung  vary  greatly  with  the  cause,  rapidity,  and 
extent  of  the  morbid  condition.  In  severe  cases, 
for  example,  in  the  collapse  that  follows  bron- 
chitis in  very  young  subjects,  the  symptoms 
are  peculiar.  There  is  great  prostration,  debi- 
lity, restlessness,  and  sleeplessness.  The  tem- 
perature falls ; the  surface  becomes  cold,  blue, 
or  dusky ; the  eyes  become  shrunken ; and  the 
pulse  is  quick  and  small.  There  is  a constant 
feeble  whining  cry.  Respiration  is  very  quick 
and  shallow,  as  high  as  70  to  80  or  even  100  per 
minute.  The  rhythm  is  changed,  the  interval 
being  between  inspiration  and  expiration,  in- 
stead of  after  expiration.  There  is  no  pain  as  in 
pleurisy.  The  cough  is  constant  and  impotent ; 
is  often  followed  by  a cry  of  impatience;  and 
differs  much  from  the  suffocative  cough  of  bron- 
chitis. 

On  examining  the  chest,  the  lower  part  is 
found  retracted  and  diminished  in  diameter. 
The  intercostal  spaces  sink  in  inspiration,  and 
move  outwards  slightly  in  expiration.  When 
the  collapse  is  extensive  the  percussion  is  dull 
and  resistant,  unless  the  affected  lobules  are  in- 
terspersed among  the  healthy  ones.  The  respi- 
ratory murmur  is  lost  over  the  affected  parts, 
though  conducted  breath-sounds,  of  a bronchial 
character,  and  rhonehi  are  generally  audible 
almost  universally.  In  the  simpler  cases  of  col- 
lapse of  the  lungs,  such  as  occur  in  pertussis 
during  the  severe  fits  of  coughing,  some  of  these 
symptoms  and  signs  may  be  suddenly  developed, 
and  again  speedily  disappear. 

Diagnosis. — -Apneumatosis  may  be  distin- 
guished from  croupous  pneumonia  by  the  com- 
parative rarity  of  the  latter  disease  in  infancy ; 
and  by  absence  of  the  great  heat  of  skin,  and  of 
fine  crepitation  on  auscultation.  From  extensive 
miliary  tuberculosis  it  is  diagnosed  by  the  ab- 
sence of  advancing  symptoms  of  constitutional 
disorder,  though  the  two  conditions  may  co-exist. 
In  pleurisy  the  dulness  on  percussion,  and  the 
absence  of  respiratory  sounds  at  the  base,  are 
much  more  marked  than  in  apneumatosis.  Con- 
genital collapse  or  atelectasis,  is  a condition 
which  has  to  be  diagnosed  from  infantile  collapse 
or  apneumatosis.  Readily  separable  by  symptoms, 
these  two  conditions  may  be  indistinguishable  by 


LUNGS,  COMPRESSION  OF. 
physical  signs.  In  atelectasis  the  lung  retains, 
in  whole  or  in  part,  its  foetal  condition,  nature 
having  failed  to  establish  respiration  and  fit  the 
child  for  its  new  mode  of  existence.  In  apneu- 
matosis the  once  permeable  lungs  cease  to  admit 
air,  and  thus  death  from  apncea  occurs  without 
any  apparent  structural  change  being  discover- 
able, save  that  the  respiratory  organs  bear  the 
appearance  of  foetal,  unexpanded  lungs. 

Prognosis.  — The  prognosis  in  collapse  of 
the  lung  is  favourable  if  the  affection  is  recent, 
and  the  child  healthy,  with  fair  muscular  power, 
and  under  favourable  hygienic  conditions.  On 
the  contrary,  the  disease  is  generally  fatal 
if  it  involve  a considerable  extent  of  lung,  es- 
pecially if  it  supervene  on  atelectasis.  Death 
usually  occurs  from  slow  asphyxia,  the  effect 
being  the  same  as  if  the  size  of  the  lung  were 
reduced  by  the  removal  of  the  affected  parts.  As 
much  as  half  of  the  entire  lungs  has  been  found 
involved,  thus  fully  accounting  for  the  quickened 
respiration,  the  distress,  and  the  dyspncea,  andfor 
the  bloodlessness  and  extreme  pallor,  with  cold, 
blue  extremities.  The  fatality  of  whooping-cough 
in  infants  is  mainly  due  to  the  ready  collapse  of 
the  lungs,  specially  when  the  child  is  badly 
nourished  and  breathing  impure  air.  The  natu- 
ral course  of  the  disease  is  from  bad  to  worse ; 
more  lung  is  involved  each  day;  and  death 
occurs  after  two  or  three  weeks  from  slow  as- 
phyxia. If  collapse  follows  acute  bronchitis 
death  often  ensues  rapidly,  but  if  recovery  takes 
place  the  lungs  are  slow  to  regain  activity,  and 
the  seeds  of  future  mischief  remain.  After  an 
attack  of  pneumonia  complete  absence  of  breath- 
sounds  may  exist  for  a time,  and  then  suddenly 
— after  a blow,  shock,  or  violent  cough — air  en- 
ters the  collapsed  portion  of  lung,  and  the  respi- 
rator}' sounds  assume  a normal  character. 

Treatment. — When  this  affection  was  looked 
upon  as  a form  of  pneumonia  it  was  treated  by 
depletion.  Now  that  we  realise  that  it  is  not  of 
an  inflammatory  character,  our  object  must  he 
not  to  lower  vitality  but  to  diminish  excessive 
secretion.  Slight  counter-irritation,  by  means 
of  stimulating  embrocations,  is  useful.  An 
emetic  of  ipecacuanha  will  help  to  remove  accu- 
mulation if  the  patient  is  not  too  weak.  Expec- 
toration may  be  promoted  by  small  doses  of  the 
same  drug.  When  the  lungs  are  extensively  in- 
volved, vital  power  must  be  kept  up  by  the  help 
of  ammonia,  steel,  phosphates  of  iron,  port  wine, 
and  beef-tea  ; and  the  food  must  he  so  designed 
as  to  be  digestible  by  the  stomach  of  the  in 
fant.  E.  Symes  Thompson. 

LUNGS,  Compression  of. — Synon.  : Fr. 

Compression  dn  l’oumon ; Ger.  Lunyencom- 
pression. 

Definition. — Diminution  in  size  of  the  whoh 
or  of  a part  of  a lung,  associated  with  reduetioi 
of  the  volume  of  the  contained  air,  and  causes 
by  pressure  on  the  pleural  surface. 

^Etiology. — Compression  of  the  lung  roa; 
arise  in  the  course  of  numerous  diseases  or  in 
juries  affecting  the  chest,  the  compiressing  in 
fluence  being  either  gaseous,  liquid,  or  solid. 

First,  the  admission  of  air  to  the  pleura  fron 
without,  through  a perforating  wound,  as  from  : 
sword  or  bayonet  thrust ; or  from  withm,  as  b 


LUNGS,  COMPRESSION  OF. 

rupture  of  an  air-cell,  or  the  extension  of  pulmo- 
nary ulceration  through  the  pleura,  produces  in 
either  case  compression.  If  no  previous  pleu- 
risy has  existed  the  compression  is  complete  ; 
hut  if,  on  the  other  hand,  long-standing  pleurisy 
has  caused  udhesion,  compression  cannot  take 
place,  or  will  be  but  partial.  Pneumothorax 
arising  without  perforation  may  be  due  to  the 
evolution  of  gas  from  gangrene,  or  to  the  decom- 
position of  pleuritic  fluid ; or  the  gas  may  be 
directly  secreted  within  the  pleura,  taking  the 
place  of  serum  absorbed  after  pleuritic  effusion. 
Resides  the  causes  named,  perforation  may  arise 
from  fractured  ribs  with  pulmonary  laceration, 
or  from  contusion  of  the  lung  without  frac- 
ture; from  ulcerative  perforation  of  lunar,  either 
tuberculous  or  gangrenous  ; from  pulmonary 
apoplexv,  hydatids,  cancer,  empysema,  abscess  ; 
from  rupture  of  the  lung  in  whooping-cough ; 
from  perforation  of  the  lung  from  without,  by 
diseased  and  suppurating  bronchial  glands  open- 
ing into  the  pleura  and  bronchi ; and  from  rup- 
ture or  ulceration  bf  the  oesophagus,  opening 
into  the  pleura.  Of  this  long  list,  omitting  the 
surgical  cases,  nine  out  of  ten  aro  due  to 
phthisis. 

Secondly,  compression  may  arise  from  the 
presence  of  fluid,  such  as  pleuritic  effusion,  acute 
or  chronic;  passive,  non-inflammatory  effusion, 
as  in  hydrothorax ; or  blood,  as  in  hsemato- 
thorax. 

Thirdly,  compression  of  the  lung  by  solids  is 
teen  in  the  case  of  various  tumours  of  the- chest, 
whether  originating  in  the  mediastinal  struc- 
ures,  in  the  lungs,  or  in  the  thoracic  parietes. 

In  a fourth  class  of  cases  compression  of  the 
ung  is  the  result  of  the  enlargement  of  neigh- 
bouring parts,  other  than  the  thoracic  viscera  ; 
md  especially  of  the  abdomen,  as  in  ascites,  and 
umours  of  the  liver,  spleen,  or  ovaries. 

Anatomical  Characters.  — Compression  of 
ho  lung  may  he  either  general  or  local,  eom- 
lete  or  partial.  A lung  compressed  by  pleuritic 
ffusion  is  found  to  be  reduced  in  volume,  non- 
repitant.  dense,  and  quite  insusceptible  of  in- 
jation.  The  blood  is  coagulated  in  the  affected 
jibes,  the  clot  being  often  decolourised  and  ad- 
ierent  to  the  walls  of  the  vessels,  many  of 
Rich  are  impervious,  or  altogether  obliterated  ; 
jhile  the  pervious  vessels  and  the  air-cells  of 
le  adjacent  parts  are  distended,  and  eniphy- 
■ma  is  produced.  In  other  cases,  the  compressed 
ng  proves  to  be  anaemic,  tough,  and  dry. 

In  cases  of  slow  recovery  from  chronic  em- 
■a?ma  the  lung  is  often  found  bound  down  and 
Tokened,  having  very  little  normal  pulmonary 
istie  remaining.  The  thoracic  cavity  vacated 
the  shrunken  lung  is  occupied  by  the  dis- 
iced  heart,  and  sometimes  by  the  extension  of 
b sound  lung  across  the  middle  line. 

When  perforation  occurs  with  admission  of 
from  the  bronchi  to  the  pleural  cavity,  the 
nospheric  pressure  distends  the  pleura,  and 
ds  to  displace  the  mediastinum  and  the  other 
g.  The  heart,  too,  being  unsupported,  is 
; ssed  against  the  healthy  lung,  and  may  he 
i placed  to  a very  considerable  extent. 

Symptoms  and  Phvsicai.  Signs. — The  symp- 
l.is  of  compression  of  the  lung  vary  greatly  in 
'•  .irdance  with  its  causes,  the  rapidity  of  onset, 


LUNGS,  DEGENERATIONS  OF.  863 

and  the  extent  and  degree  of  compression.  If 
pleuritic  effusion  be  very  rapid,  the  dyspnoea 
may  be  exceedingly  urgent.  After  perforation 
of  the  pleura  with  sudden  collapse  of  the  lung, 
there  also  occur  acute  pain,  dry  cough,  and 
painful  spasms  of  the  intercostal  muscles.  The 
pulse  is  frequent,  feeble,  and  often  irregular. 
Symptoms,  more  or  less  acute,  of  inflammation 
may  follow.  In  other  instances  the  symptoms 
are  those  of  hydrothorax,  or  of  intrathoracic 
tumour. 

The  physical  signs  of  compression  of  the  lung 
are  chiefly  those  of  the  associated  cause,  such  as 
pmeumothorax,  pleurisy,  hydrothorax,  or  intra- 
thoracic tumour ; and  part  y certain  phenomena 
characteristic  of  the  physical  condition  of  the 
lung  itseif.  The  latter  vary  considerably  with 
the  degree  and  extent  of  compression,  but  they 
may  be  described  in  general  terms  as  follows: 
— Either  increased  clearness  of  the  percussion 
sound  over  the  area  of  compressed  lung,  with 
tubular  or  rarely  even  tympanitic  quality,  espe- 
cially in  children,  or  in  extreme  eases  of  com- 
pression complete  loss  of  resonance  ; indefinite, 
weak,  but  occasionally  rather  blowing  or  tubular 
respiratory  sound,  sometimes  mixed  with  scanty, 
dry,  subcrepit.ant  rhonchus  ; and  exaggerated 
loudness  and  ringing  quality  of  vocal  resonance. 
A further  description  of  these  symptoms  and  signs 
will  be  found  under  the  headings  of  the  various 
causes  of  compression  referred  to. 

Diagnosis. — The  diagnosis  of  compression  of 
the  lung  is  in  general  simply  the  diagnosis  of 
the  condition  on  which  it  depends. 

Prognosis. — The  prognosis  depends  on  the 
cause  of  the  compression.  Thus  in  pneumothorax 
it  is  unfavourable,  though  recovery  may  take 
place.  In  liydrothi >rax  the  prognosis  is  unfavour- 
able, as  it  is  usually  an  evidence  of  formidable, 
if  not  incurable,  organic  disease.  In  pleurisy,  if 
the  effusion  has  been  rapid,  met  by  prompt  treat- 
ment, and  uncomplicated  with  hectic,  complete 
recovery  may  take  place  without  much  compres- 
sion of  lung  or  distortion  of  chest;  but  incom- 
pletely-cured pleurisy  is  too  frequently  the  first 
incident  in  the  history  of  phthisical  disease.  In 
empysema  the  prognosis  is  more  favourable  than 
in  pneumothorax  or  hydrothorax. 

Treatment. — Little  need  be  said  as  to  the 
treatment  of  lung-compression.  It  resolves  it- 
self into  that  of  the  intercurrent  or  causative 
diseases.  Bearing  in  mind  the  injury  done  to 
the  lung  by  compression,  eff >rts  should  be  made 
to  relieve  the  lung  before  it  has  been  irremediably 
bound  down.  The  early  adoption  of  paracentesis 
thoracis  is  the  most  practical  means  of  gaining 
this  end  in  pleuritic  effusion.  Remedies  calcu- 
lated to  remove  effusion  and  thus  relieve  the 
lung  should  be  given,  remembering  that  the 
more  speedy  the  relief  given  to  the  lung  the  more 
complete  will  be  the  cure.  Suitable  movements 
of  the  chest  might  bp  ordered  subsequently,  with 
the  view  of  promoting  expansion  of  its  walls 
and  of  the  lung.  E.  Symes  Thompson. 

LUNGS,  Congestion  of. — See  Lungs,  Ily- 

peraemia  of. 

LUNGS,  Consumption  of. — See  PnTHisis. 

LUNGS,  Degenerations  of. — Changes  of 


8G4  LUNGS,  DEGENERATIONS  OF. 
a degenerative  cliaracter  in  connection  with  the 
lungs  constitute  an  important  element  in  some 
pulmonary  diseases,  or  they  may  he  the  sole 
morbid  condition  present.  They  are  of  the  fol- 
lowing nature  : — 

1.  Albuminoid. — This  is  only  occasionally 
noticed,  in  marked  cases  of  general  albuminoid 
disease. 

2.  Fibroid.- — Changes  leading  to  a more  or  less 
fibroid  condition  of  the  pulmonary  tissue  are  of 
common  occurrence,  but  it  is  not  always  easy 
to  determine  whether  they  should  be  regarded 
as  due  to  a chronic  inflammatory  process,  or  to 
degeneration,  and  pathologists  differ  in  their 
views  on  this  point.  As  a degeneration,  the 
fibroid  change  may  bo  considered  as  most  im- 
portant in  connection  with  emphysema,  and  it  is 
regarded  by  some  authorities  as  an  element  of 
much  consequence  in  the  causation  of  many  cases 
of  this  disease.  It  also  follows  long-continued 
congestion,  and  collapse  or  compression  of  the 
lung  from  any  cause.  Of  course  much  fibroid 
or  fibrous  tissue  is  found  in  the  lungs  in  many 
cases  of  phthisis,  and  in  connection  with  pleu- 
ritic adhesions  and  other  conditions,  but  this  state 
must  be  looked  upon  mainly  as  of  inflammatory 
origin.  The  effects  of  these  changes  are  to  make 
the  lung-tissue  firmer  and  tougher,  but  at  the 
same  time  to  diminish  or  destroy  its  elasticity, 
the  elastic  tissue  being  more  or  less  displaced. 
Hence,  if  the  lungs  be  exposed  to  any  distend- 
ing force,  they  cannot  recover  themselves  pro- 
perly, and  the  air-vesicles  remain  more  or  less 
permanently  dilated. 

3.  Fatty. — This  degeneration  is  also  regarded 
by  some  pathologists  as  one  of  the  main  ele- 
ments in  originating  many  cases  of  emphysema 
of  the  lungs,  and  also  as  one  of  the  actual  con- 
ditions in  this  disease.  Here,  again,  the  lung- 
tissue  is  impaired  in  its  elasticity  and  resisting 
power  to  distension,  but  it  is  not  tough.  Granu- 
lar fat  may  be  visible  under  the  microscope. 

4.  Figmentary. — The  lungs  become  the  seat 
of  more  or  less  pigmentation  with  increasing 
age.  They  are  also  markedly  affected  in  certain 
occupations  in  which  carbonaceous  matters  are 
inhaled.  In  so-called  brown  induration  of  the 
lungs  there  is  an  abundance  of  pigment. 

5.  Senile. — The  lung-tissue  undergoes  atrophy, 
with  more  or  less  less  of  elasticity,  owing  to 
wasting  of  the  elastic  tissue  with  increasing  age, 
and  even  a fatty  degeneration  may  take  place. 
Hence,  in  such  subjects  emphysema  is  readily 
set  up  by  causes  which  would  have  no  effect  on 
younger  persons. 

6.  Secondary. — Under  this  head  may  be  in- 
cluded those  degenerative  changes  which  take 
place  in  morbid  formations  in  the  lungs,  such  as 
inflammatory  deposits,  tubercle,  or  cancer.  These 
belong  mainly  to  the  fatty  or  caseous  variety  of 
degeneration,  but  calcification  may  also  occur. 

Frederick  T.  Roberts. 

LUNGS,  Embolism  of.  — See  Lungs, 
Anmmia  of ; and  Lungs,  Haemorrhage  into. 

LUNGS,  Emphysema  of.  — Synon.  : Fr. 
Emphyseme  du  poumon ; Ger.  Lungencmphyscm. 

Definition. — An  excess  of  air  in  the  lungs, 
whether  due  to  a dilated  condition  of  the  air- 


LUNGS,  EMPHYSEMA  OF. 

sacs,  or  to  the  presence  of  air  in  the  interlobular 
tissue. 

Varieties. — There  are  two  kinds  of  empty 
sema  of  the  lungs,  namely  : — 

A.  Vesicular  Emphysema. 

B.  Interlobular  Emphysema. 

A.  Vesicular  Emphysema. — Pulmonary  ve- 
sicular emphysema  exists  in  three  forms,  namely, 
1.  partial  lobular  ; 2.  lobular;  and  3.  lobar.  The 
last  form  involves  the  whole  of  a lobe,  or  the 
whole  of  one  or  both  lungs.  The  first  form  is 
rarely  seen  alone,  butis  generally  associated  with 
the  second  form,  which  is  very  common,  and  is 
found  in  connection  with  diseases,  such  as  bron- 
chitis, which  are  attended  with  violent  or  long- 
standing cough.  The  third  form  is  by  far  the 
most  important,  and  will  be  more  especially  re- 
ferred to  in  the  present  article.  It  more  fre- 
quently attacks  both  lungs  than  one,  and  the 
lower  as  well  as  the  upper  lobes.  It  is  a serious 
malady,  and  sometimes  destroys  life  at  an  early 
period.  Its  features  are  characteristic : the  lung- 
substance  has  a peculiar  deughy  feel;  pits  on 
pressure  ; is  wanting  in  healthy  crepitation ; and 
has  a colour  very  closely  resembling  that  of  a 
calf’s  lung.  It  has  been  described  as  ‘large- 
lunged  vesicular  emphysema.’ 

.-Etiology. — Determining  causes  and  mechan- 
ism.— With  reference  to  the  determining  causes 
of  emphysema  there  are  two  theories,  namely, 
the  inspiratory  theory,  and  the  expiratory 
theory.  On  the  first  view  the  dilatation  and  rup- 
ture of  the  air-sacs  are  accounted  for  by  the 
over-distension  of  the  lungs  in  inspiration.  On 
the  second  view  these  changes  are  considered  to  | 
be  caused  by  the  strain  to  which  the  lung-tissue 
is  subjected  in  violent  expiratory  efforts,  espe- 
cially the  act  of  coughing.  It  has  been  thought 
by  others  that  emphysema  must  be  looked  upon  i 
as  a eomplemental  lesion,  arising  in  consequence 
of  the  over-distension  to  which  the  healthy  por- 
tions of  the  lungs  are  subjected  in  cases  of  pul- 
monary collapse.  Without  entering  into  any 
critical  examination  of  the  theories  as  to  the 
mechanical  causes  of  emphysema,  it  may  per- 
haps be  sufficient  to  say-  that  there  can  be  little, 
if  any,  doubt  that  the  lobular  forms  of  the  dis- 
ease are  mainly  produced  bv  expiratory  efforts.; 
such  as  violent  cough,  or  blowing  wind  instru- 
ments. They  have  their  seat  in  those  parts  of 
the  lungs  which  become  most  distended  by  such 
acts.  With  regard  to  the  lobar  form  of  the  dis- 
ease, however,  this  explanation  cf  its  mechanism 
does  not  suffice.  In  this  affection  the  inspiratory 
power  is  that  which  distends  the  lungs.  The 
pulmonary  tissue  has  lost  a portion  of  its  elasti 
cityr,  it  yields  to  distension,  and  no  longer  re-act; 
perfectly  when  the  distending  power  ceases 
Further  distension  follows ; reaction  diminWic 
still  more  ; until  at  length  in  some  instances  th 
lungs  become  greatly  enlarged. 

In  senile  cases  the  loss  of  elasticity  of  th 
chest-walls  aids  in  preventing  the  pulmonary  re 
action. 

Anatomical  Characters  and  Pathology.-I 
In  the  early  stages  of  emphysema  there  is  siir 
ply  a dilatation  of  the  air-sacs ; an  increase  i 
the  size  of  the  alveoli;  and  a diminution  in  tlj 
height  of  the  alveolar  walls,  which  yieldir 
with  the  distending  cavities,  become  partial 


LUNGS,  EMPHYSEMA  OF. 


obliterated.  As  the  disease  progresses  the  air- 
bucs  become  more  distended,  and  the  -walls  of 
the  alveoli  sometimos  completely  obliterated,  so 
that  the  air-sacs  are  quite  smooth,  instead  of 
honeycombed.  Then  follows  perforation  of  the 
air-sacs— at  . first  slight,  here  and  there  an  oval 
opening  being  discoverable ; afterwards  the 
openings  become  more  numerous  and  larger. 
The  subsequent  progress  of  the  disease  is  attended 
with  further  distension  of  the  air-sacs,  and  rup- 
ture of  the  fibres  of  their  walls.  The  openings 
thus  caused  coalesce,  until  at  length  the  walls 
are  simply  represented  by  membranous  shreds, 
and  even  large  vesicles  may  form.  These 
changes,  varying  in  degree,  characterise  all  the 
forms  of  emphysema.  In  the  lobar  form,  however, 
perforation  takes  place  to  a much  greater  extent 
quoad  the  amount  of  dilatation,  than  in  the  lo- 
bular or  partial  lobular  form. 

The  emphysematous  lung  is  ansemic,  its  blood- 
vessels become  widely  separated,  and  often  rup- 
tured and  atrophied.  The  bronchial  tubes  are 
sometimes  dilated, -especially  in  old-standing 
cases,  and  in  these  there  is  frequently  found  an 
increased  development  of  the  circular  muscular 
fibres. 

The  pathology  of  emphysema  involves  some 
important  points  for  consideration.  The  great 
question  is  whether  there  is  any  degeneration 
of  tissue  preceding  or  attending  the  affection. 
When  the  disease  is  partial,  and  has  followed  or 
s attended  by  bronchitis,  or  some  other  affec- 
ion  in  which  there  has  been  violent  or  long- 
itanding  cough,  the  emphysema  may  be  the  re- 
ult  of  mechanical  violence,  without  pre-existing 
.egeneration  of  the  lung-tissue.  When,  however, 
t is  of  the  lobar  form,  degeneration  is  probably 
he  primary  step  in  the  affection.  The  facts 
dlieh  tend  to  confirm  this  view  are: — (1)  the 
isidious  manner  in  which  the  disease  sometimes 
tines  on,  and  the  development  which  it  attains, 
''ithout  any  previous  history  of  violent  or  long- 
anding  cough  ; (2)  the  frequency  with  which 
attacks  the  whole  of  both  lungs;  and  (3)  its 
jreditary  character.  The  exact  nature  of  the 
generation  has  not  been  satisfactorily  made 
jit.  Fatty  matter  has  been  found  in  a few  in- 
ances,  but  not  in  all  cases.  The  degeneration 
probably  one  primarily  involving  the  elastic 
'res  and  other  structures  of  the  walls  of  the 
'-sacs.  Whatever  be  the  nature  of  the  degene- 
ion,  there  can  be  no  doubt  that  lobar  emphy- 
na  is  a malady  resulting  from  some  form  of 
1-nutrition  of  the  lung-tissue.  There  is  reason 
believe  too  that  this  form  of  emphysema  is 
netimes  associated  with  gout. 

There  is  a form  of  lobar  emphysema  which  is 
■ t with  in  old  age,  and  which  differs  in  some 
i pects  from  that  already  described.  The  lungs 
not  so  large ; they  are  universally  distended, 

1 rever,  to  a greater  or  less  extent;  and  they 
I sent  a somewhat  atrophied  appearance.  The 
t rations,  of  which  they  are  the  seat,  are  pro- 
1 ly  the  result  of  those  changes  which  age  pro- 
i es  in  the  chest- walls,  impairing  their  elasti- 
c . This  loss  of  elasticity  may  also  affect  the 
1 ;-tissue.  See  Lungs,  Atrophy  of. 

knowledge  of  the  changes  produced  by  em- 
P sema  affords  an  explanation  of  the  peculiar 
C,  'acter  of  the  respiratory  movements  and 

55 


860 

sounds,  as  well  as  of  the  other  pnysical  signs 
and  symptoms  of  the  disease.  The  lungs  being 
the  seat  of  general  expansion,  the  thorax  is  kept 
abnormally  distended.  Thus  it  can  undergo  but 
little  enlargement  at  each  inspiration.  As  there 
is  no  impediment  to  the  passage  of  air  to  the 
air-sacs,  inspiration  is  accomplished  rapidly. 
Not  so,  however,  with  expiration.  The  lung- 
tissue  has  in  great  measure  lost  its  elasticity, 
and  reacts  slowly  after  distension ; and  this 
results  in  laboured,  slow,  and  ineffectual  efforts 
to  expel  the  air.  Further,  as  the  lungs  art- 
more  or  less  riddled  with  perforations,  their 
aerating  surface  is  diminished,  and  this  neces- 
sarily causes  dyspncea,  whenever  any  increased 
demand  is  made  on  the  respiratory  function 
The  quantity  of  blood  circulating  through  the 
lungs,  even  from  the  earliest  stages  of  the  af- 
fection, is  also  diminished ; and  the  destruction 
of  the  capillary  vessels,  which  ensues  when  the 
disease  is  more  developed,  further  decreases  the 
vascularity  of  the  pulmonary  tissue.  Hence  its 
pale,  anaemic  appearance  after  death,  a circum- 
stance which  serves  to  explain  how  rarely  it  is 
the  seat  of  pneumonic  inflammation. 

Symptoms. — A constant  and  generally  gradu- 
ally increasing  dyspnoea  is  one  of  the  most  im- 
portantand  most  frequent  of  the  symptomsof  em- 
physema. Cough  with  expectoration  is  generally 
more  or  less  present.  Haemoptysis  is  rare,  and 
when  it  does  occur,  is  slight.  The  patient  usually 
complainsof  no  pain,  butof  afeeling  of  oppression, 
or  a 1 smothering  in  the  chest.’  In  severe  cases 
of  lobar  emphysema  this  last  symptom  and  the 
dyspnoea  are  often  the  only  circumstances  which 
attract  the  attention  of  the  sufferer  to  his  malady. 
In  other  instances,  however,  and  especially  when 
the  disease  is  only  partial,  a close  examination 
will  elicit  the  fact  that  there  have  been  bronchitic 
symptoms.  Few  cases  of  emphysema  exist  for 
any  length  of  time  without  the  occurrence  of 
asthmatic  seizures.  In  advanced  cases  the  aspect 
is  peculiar.  The  countenance  is  dusky,  leaden, 
and  puffy.  The  nostrils  are  dilated,  and  expand 
widely  on  inspiration,  whilst  the  angles  of  the 
mouth  are  drawn  down.  The  voice  is  feeble. 
The  whole  body  has  a cachectic  appearance,  and 
is  sometimes  much  wasted.  General  dropsy 
often  ensues. 

Physical  Signs. — Amongst  the  most  important 
of  the  physical  signs  of  emphysema  are  the  fol- 
lowing The  upper  part  of  the  chest  and  the 
clavicles  are  prominent ; the  neck  seems  short- 
ened ; the  fosste  above  the  clavicles  are  deepened  ; 
there  is  increased  curvature  of  the  dorsal  spine  • 
and  the  sternum  is  arched.  The  gait  is  stooping: 
the  ribs  are  prominent;  and  the  intercostal 
spaces  are  depressed.  There  is  indeed  a general 
increase  in  the  size  of  the  chest,  usually  most 
marked  at  the  upper  part.  These  are  the  fea- 
tures of  the  disease  when  it  is  extensive.  If  par- 
tial, or  confined  to  one  lung  or  part  of  a lung, 
the  prominence  of  the  chest  exists  on  one  side 
only,  and  the  other  symptoms  and  signs  are  less 
marked.  The  movements  of  the  chest  in  respi- 
ration are  peculiar.  The  breathing  is  for  the 
most  part  superior  thoracic,  but  the  chest  is  not 
much  expanded  on  inspiration,  for  the  lungs  are 
already  inordinately  distended.  The  lower  end 
I of  the  sternum  and  the  lower  ribs  are  drawn  ir 


566 


LUNG3,  EMPHYSEMA  OF. 


luring  inspiration.  In  some  cases  during  in- 
spiration there  is  marked  protrusion  of  the 
abdomen.  The  respiration  presents  other  fea- 
tures. The  inspiration  is  short  and  quick,  and 
is  followed  by  a prolonged  and  often  wheezing 
expiration.  Coughing  is  performed  feebly,  and 
expectoration  is  attended  with  difficulty.  Per- 
cussion and  auscultation  elicit  important  diag- 
nostic marks  of  the  disease.  When  it  is  gene- 
ral there  is  increased,  and  in  some  instances 
almost  tympanitic,  resonance  over  the  whole 
of  the  chest,  most  marked  towards  the  apices 
of  the  lungs,  and  along  their  anterior  borders ; 
and  in  partial  cases  almost  confined  to  these 
spots,  or  to  one  side.  The  prsecordial  region  is 
generally  resonant,  owing  to  the  distended  lungs 
coming  between  the  heart  and  the  wall  of  the 
chest;  and  the  cardiac  impulse  can  often  be 
felt  beneath  the  lower  end  of  the  sternum.  The 
respiratory  murmur  is  faint,  and  characterised 
by  peculiarities  which  a knowledge  of  the 
anatomical  condition  of  the  lungs  and  of  the 
chest-walls  enables  us  to  explain.  The  in- 
spiratory murmur  is  short,  and  is  followed  by 
a prolonged  expiratory  murmur.  This  latter  is 
unlike  the  sound  heard  in  any  other  affection, 
and  is,  in  fact,  pathognomonic  of  emphysema.  In 
some  advanced  cases  the  respiratory  sounds  are 
scarcely  audible,  if  the  bronchial  tubes  are  free 
from  mucus,  and  no  spasm  exist.  Laennec  de- 
scribed a rale  which  he  thought  was  peculiar  to 
emphysema.  He  called  it  ‘ rale  crepitant  sec  a 
grosses  bulles.’  A rale  such  as  Laennec  described 
is  often  heard  in  emphysema,  but  it  is  not  a dry 
rdle.  It  is  probably  produced  in  the  finest 
bronchial  tubes,  and  is  a modification  of  the  sub- 
crepitant rale  of  bronchitis.  Although  valuable 
in  aiding  diagnosis  when  present,  yet  from  its 
frequent  absence  and  the  difficulty  of  distinguish- 
ing it  from  the  ordinary  sup-crepitant  rale , it 
loses  much  of  its  diagnostic  import. 

Complications  and  Sequels:. — Bronchitis  is 
one  of  the  most  frequent  of  the  diseases  asso- 
ciated with  emphysema  of  the  lungs.  It  is  rare 
for  the  latter  affection  to  exist  for  any  length  of 
time  without  the  supervention  of  the  former. 
Bronchitis  presents  some  peculiarities  when  it 
affects  an  emphysematous  lung.  It  is  rather  the 
result  of  congestion  than  of  inflammation.  It 
often  attacks  the  finer  bronchial  tubes  ; and  when 
severe,  is  attended  with  profuse  secretion;  a 
circumstance  which,  coupled  with  the  fact  that 
expectoration  is  less  easily  accomplished  than 
when  the  lungs  are  healthy,  seriously  compli- 
cates the  affection,  and  increases  the  danger  of 
death  from  apnoea.  The  inflammation  some- 
times runs  on  very  rapidly,  and  copious  puru- 
lent or  purit'orm  expectoration  occurs.  Even 
when  this  is  the  case,  an  examination  of  the 
tubes  after  death  may  reveal  but  little  vascularity 
of  the  mucous  membrane.  These  severe  bron- 
chitic attacks  are  very  apt  to  be  attended  by  the 
formation  of  fibrinous  clots  in  the  heart  and  the 
large  vessels  arising  therefrom.  Bronchitis,  in  a 
sub-acute  or  chronic  form,  is  a very  constant  cause 
of  winter  cough  in  emphysematous  patients. 

Asthma,  occurring  with  greater  or  less  seve- 
rity, is  a frequent  attendant  on  emphysema.  The 
attacks  come  on  for  the  most  part  during  the 
night,  and  may  possibly  be  due  to  the  congestion 


of  the  lungs  which  takes  place  during  sleep,  or 
when  the  body  is  long  in  the  recumbent  posture. 
This  congestion  probably  sets  up  an  irritation, 
which  gives  rise  to  reflex  spasm  of  the  bronchial 
muscular  fibres. 

Secondary  affections  of  the  heart  are  constantly 
met  with  in  advanced  cases  of  emphysema.  Many 
pathologists  have  believed  that  the  right  cavities 
alone  become  affected ; but  more  recent  obser- 
vations have  shown  that  the  cardiac  disease  is 
not  confined  to  one  side.  There  is,  in  exten- 
sive emphysema,  a general  hypertrophy  of  the 
heart,  with  dilatation  of  all  the  cavities,  especially 
of  the  ventricles.  But  hypertrophy  is  not  the 
only  change  which  takes  place;  valvular  dis- 
ease is  frequently  found.  The  deposits  and 
thickening  which  occur  about  the  valves  are  no 
doubt  secondary  to  the  changes  in  the  muscular 
walls,  and  must  be  attributed  to  the  general 
mal-nutrition  produced  by  the  disease.  It  is  not 
difficult  to  understand  how  it  happens  that  in 
emphysema  there  is  general  cardiac  hypertro- 
phy. The  impediment  which  exists  to  the  cir- 
culation of  the  blood  through  the  lungs  neces- 
sarily gives  rise  to  an  overloaded  state  of  the 
right  side  of  the  heart ; hence  results  increased 
action  of  the  right  cavities,  and  hypertrophy  of 
their  walls.  Again,  the  overloaded  state  of  the 
venous  system,  and  the  consequent  impediment 
to  the  capillary  and  arterial  circula'ion.  call  for 
increased  action  of  the  left  ventricle  ; and  this  is 
followed  bv  its  dilatation  and  thickening.  There 
exists  also  another  cause,  which  probably  has 
some  influence  in  producing  this  cardiac  hyper- 
trophy, namely’,  the  altered  position  of  the  heart. 
This  organ  is  pushed  downwards  and  towards 
the  median  line,  and  its  impulse  is  often  felt 
strongly’  in  the  epigastrium.  The  position  of '.1  e 
ventricles  is  therefore  changed,  and  the  direction 
of  the  axis  of  their  cavities  is  altered  with  re- 
ference to  that  of  their  great  vessels  This  must 
lead  to  embarrassment  of  the  circulation. 

As  a consequence  of  the  changes  in  the  heart 
and  venous  system  in  emphysema,  dropsy  often 
results.  Many’  cases  go  on  for  a long  time  with- 
out any  dropsical  symptoms,  whilst  in  others 
there  is  only  slight  oedema  of  the  legs.  In 
advanced  cases,  however,  there  is  frequently 
general  dropsy. 

General  emphysema  is  attended  in  its  progress 
with  symptoms  of  cachexia  and  antemia.  It 
some  cases  there  is  much  wasting  of  the  mus- 
cular system,  even  before  dropsic.il  effusion: 
occur.  Further,  the  patients  often  have  a sallov 
and  anaemic  appearance,  not  unlike  that  me 
with  in  renal  and  other  serious  organic  disease^ 
There  has  been  an  impression  that  emphysem 
and  phthisis  are  incompatible  diseases,  bn 
recent  researches  have  shown  that  this  view  ; 
not  correct.  Indeed,  in  a large  proportion  d 
cases  of  death  from  phthisis,  patches  of  emphy 
sema,  lobular  or  partial  lobular,  are  met  with 
and  doubtless  have  been  produced  by  the  fits  < 
coughing  so  common  in  the  disease.  But  tl 
great  question  is  whether  tubercular  depos 
ever  takes  place  in  lungs  which  are  the  seat 
lobar  emphysema ; and  this  question  must  1 
answered  in  the  affirmative,  although  the  co 
currence  of  the  two  diseases  is  rare.  Tne 
monic  consolidation  is  'cry  uncommon  in  ■' 


LUNGS,  GANGRENE  OF, 


emphysematous  lung,  and  probably  acute  so- 
1 called  sthenic  pneumonia  never  attacks  the  organ 
in  such  a condition. 

Pleurisy  not  unfrequently  exists  in  connection 
with  emphysema ; pleuritic  adhesions  being 
often  found  after  death.  The  occurrence  of 
pleurisy  must,  however,  be  considered  as  an 
accidental  circumstance.  In  the  most  extensive 
cases  of  emphysema  pleuritic  adhesions  may  not 
lie  found. 

Treatment. — This  must  be  referred  to  under 
two  heads,  namely  (1)  the  treatment  of  the  dis- 
ease : and  (2)  that  of  the  secondary  affections, 
which  follow  or  are  associated  with  it. 

(1)  Treatment  of  the  disease. — Too  little  at- 
tention has  been  paid  to  emphysema  of  the  lungs 
as  a substantive  disease.  Considered  in  the 
main  as  the  result  of  bronchitic  affections,  the 
treatment  has  been  chiefly  directed  to  the  con- 
trol of  these  attacks;  and  in  regard  to  the 
partial  forms  of  emphysema,  this  is  a most  im- 
portant object.  But  in  reference  to  lobar  em- 
physema, if  we  recognise  the  fact  that  it  is  pri- 
marily due  to  some  degeneration  of  tissue,  it  is 
ihvious  that  the  treatment  should  be  directed  to 
check,  if  possible,  this  process.  It  can  scarcely 
be  expected  that  when  once  perforation  and  rup- 
ture of  the  air-sacs  have  taken  place,  the  normal 
condition  of  the  lung  can  be  restored.  But 
whilst  we  admit  this,  it  is  by  no  means  implied 
that  the  disease  is  beyond  control.  That  condi- 
tion of  lung-tissue  which  precedes  the  perfora- 
tions— the  simple  distension  of  the  air-sacs — 
admits  of  great  amelioration,  and  further  dege- 
nerative changes  may  be,  if  not  prevented,  at 
east  much  retarded. 

The  main  principles  of  treatment  should  be 
•uch  as  guide  us  in  the  management  of  other 
iionstitutional  diseases  attended  with  degenera- 
ion.  All  measures  which  tend  to  invigorate 
,he  system,  to  give  tone  to  the  heart,  and  im- 
prove the  condition  of  the  blood,  should  be 
esorted  to.  Amongst  the  remedies  for  internal 
administration  the  most  useful  is  iron.  It  should 
e given  in  small  and  continued  doses.  Quinine 
!>  valuable,  as  are  also  the  various  bitters  and 
, flier  reme  lies  for  dyspepsia,  from  which  emphy- 
:matous  patients  often  suffer.  Cod-liver  oil  is 
jery  useful  in  some  cases.  Strychnia  has  been 
'commended  with  the  view  of  improving  the 
■ne  of  the  muscular  fibres  of  the  bronchial 
tbes.  It  has  not  been  found  useful  in  this  re- 
ject ; nor  need  we  wonder  at  this,  for  tile  disease 
one  primarily  of  the  air-sacs,  and  not  of  the 
'/onch.al  tubes,  and  if  the  muscles  of  the  latter 
<e  secondaiily  affected,  it  is  rather  with  spasm 
an  paralysis.  Small  doses  of  strychnia  given 
Jr  dyspeptic  symptoms  may  be  useful. 

Breathing  condensed  air  has  been  strongly  ad- 
■ rated,  and  no  doubt  it  has  afforded  in  some 
yes  decided  temporary  relief,  but  no  perma- 
itly  good  effects  have  apparently  ever  followed 
use.  See  Air,  Therapeutics  of. 

The  regulation  of  the  diet,  and  the  general 
nagement  are  most  important.  The  diet 
iuld  be  nourishing,  and  a moderate  amount  of 
inulants  should  be  allowed.  The  food  should 
easy  of  digestion,  and  nutritious  in  propor- 
1 1 to  its  bulk.  The  stomach  should  never  be 
t|r loaded,  as  that  condition  will  give  rise  to 


867 

dyspnoea.  Errors  of  diet  must  be  avoided,  and 
the  functions  of  the  bowels  shc  ald  be  carefully 
regulated.  Another  point  is  to  give  the  lungs 
as  little  work  as  possible,  and  to  let  the  patient 
breathe  a pure  air.  All  violent  exercise,  or 
physical  exertion  of  any  kind,  must  be  strictly 
prohibited;  moderate  exercise  is,  however,  to 
be  recommended.  Moderate  walking,  yachting, 
carriage  exercise,  riding  at  a quiet  pace,  and  on  ah 
easy  horse,  are  important  adjuvants  in  the  gene- 
ral treatment  of  emphysema.  The  condition  of 
the  skin  should  be  carefully  looked  to  ; warm 
clothing  should  be  constantly  worn ; and  the 
greatest  care  should  be  taken  to  ward  off  bron- 
chial inflammation.  Residence  during  the  winter 
in  a warm  and  dry  climate  is  to  be  recommended. 

2.  Treatment  of  secondary  affections. — Amongst 
the  most  important  of  the  affections  secondary 
to  emphysema  is  bronchitis.  No  depressing 
measures  should  be  used  in  this  disease,  but  such 
as  will  promote  expectoration,  and  check  the  se- 
cretion of  the  bronchial  tubes,  if,  as  is  very 
frequently  the  case,  this  be  excessive.  Ammonia, 
the  various  stimulatingexpectorants,  and  iron  are 
the  most  valuable  remedies,  together  with  mode- 
rate counter-irritation  (see  Bronchi,  Diseases  of). 
The  dyspnoea  attendant  on  emphysema  admits 
only  of  palliative  treatment,  but  is  often  greatly 
improved  by  the  observance  of  the  rules  laid 
down  for  the  general  management  of  the  dis- 
ease. The  dyspnoea  is  always  increased  by 
the  presence  of  bronchitis ; by  the  stomach  or 
bowels  being  overloaded;  and  by  the  general 
over-distension  of  the  venous  system,  which 
necessarily  ensues  as  a consequence  of  the  impe- 
diment to  the  flow  of  blood  through  the  lungs. 
Care  should  be  taken  to  prevent  any  flatulent 
distension  of  the  stomach  or  intestines,  and  to 
.keep  up  a good  action  of  the  bowels,  liver,  and 
lcidneys.  Fur  the  relief  of  the  asthma  which 
frequently  exists  in  connection  with  emphysema, 
full  doses  of  iodide  of  potassium  are  often  useful. 
Stramonium  may  also  be  smoked,  and  other 
measures  beneficial  in  ordinary  spasmodic 
asthma  may  be  tried  ( see  Asthma).  In  reference 
to  the  treatment  of  the  dropsical  symptoms, 
which  follow  as  a secondary  consequence  of 
emphysema,  the  reader  is  referred  to  the  article 
Dropsy. 

B.  Interlobular  Emphysema. — This  con- 
dition, in  which  the  excess  of  air  in  the  lungs  is 
contained  not  in  the  alveoli  but  in  the  connec- 
tive tissue  between  the  lobules,  is  described 
under  the  head  of  Emphysema,  Subcutaneous. 

A.  T.  H.  Waters. 

LUNGS,  Gangrene  of. — Synon.  ; Fr.  Gaik 

gr'ene  du  Poumon  ; Ger.  Lungenbrand. 

Definition. — Death  of  a portion  of  the  sub- 
stance of  the  lungs. 

Gangrene  of  the  lungs  is  of  two  kinds,  namely  : 
(1)  diffused,  in  which  the  whole  of  one  lobe 
or  lung  is  affected ; and  (2)  circumscribed,  in 
which  a portion  only  of  a lobe  undergoes  gan- 
grenous change. 

.•Etiology. — -Gangrene  is  sometimes  a resit! 
of  acute  pneumonia.  It  has  been  known  to  fo’. 
low  the  inhalation  of  noxious  gases.  When  it 
occurs  independently  of  these  causes,  it  is  at 
evidence  either  of  extreme  constitutional  depren 


LUNGS,  HEMORRHAGE  INTO. 


S68 

sion,  or  of  pressure  interfering  with  the  circula- 
tion and  nutrition  of  the  lung.  An  aneurism  or 
mediastinal  growth,  pressing  upon  the  main  ar- 
terial, venous,  and  nervous  trunks  at  the  root  of 
the  lung,  is  perhaps  the  most  common  cause  of 
diffused  gangrene ; whereas  the  more  circum- 
scribed form  of  the  disease  is  a sequela  of  acute 
and  limited  pneumonia,  cancer,  or  rapid  phthisis 
in  a debilitated  subject.  In  pulmonary  apoplexy 
gangrenous  change  sometimes  occurs,  the  gan- 
grene being  limited  to  the  portion  of  lung  in- 
volved in  the  originating  extravasation  of  blood. 
Pneumonia  caused  by  a foreign  body  in  the  air- 
passages  is  apt  to  run  on  to  gangrene.  The 
diffused  gangrene  that  occurs  in  drunkards  and 
lunatics,  in  asthenic  fever,  measles,  small-pox, 
and  typhus,  evidences  excessive  nerve-prostra- 
tion and  loss  of  nutritive  power.  In  children 
gangrene  of  lung  sometimes  follows  cancrum 
oris,  as  well  as  the  eruptive  fevers. 

Anatomical  Characters. — The  colour  of  a 
gangrenous  lung  is  dark,  dirty  olive,  or  greenish 
brown.  It  is  moist  or  wet;  and  either  of  the 
consistence  of  engorged  lung,  or  softer  and  more 
diffluent.  The  odour  is  that  of  external  gan- 
grene or  decomposed  flesh,  and  is  distinctive 
during  life,  rendering  the  room  in  which  the 
patient  lies  horribly  offensive.  When  scattered 
patches  of  gangrene  occur,  there  is  often  in  one 
part  a solid  mass  of  greenish  lung-tissue,  and  in 
another  a central  sloughy  or  gangrenous  cavity, 
surrounded  by  a broad  rim  of  soft,  infiltrated 
lung.  The  seat  of  circumscribed  gangrene  is 
usually  the  periphery  of  the  lung,  and  the  lower 
lobes.  If  a bronchus  open  into  the  gangrenous 
patch,  inflammation  of  the  bronchial  membrane 
is  set  up.  In  rare  cases  the  pleura  is  involved, 
and  pyo-pneumothorax  induced.  Sometimes  the 
pulmonary  arteries  are  found  plugged,  and  more 
often  the  bronchial  arteries.  In  those  rare  cases 
in  which  recovery  takes  place  interstitial  pneu- 
monia is  set  up,  leading  to  encapsulation  of  the 
gangrenous  spot;  the  sloughs  are  ejected;  and 
cicatrisation  follows,  as  in  pulmonary  abscess. 

In  diffuse  gangrene  the  whole  of  one  lung  is 
sometimes  involved.  The  pulmonary  tissue  is 
then  converted  into  a black,  putrid  substance, 
saturated  with  blackish  purulent  fluid ; or  the 
gangrenous  part  merges  gradually  into  cedema- 
tous  or  hepatised  tissue. 

Embolism,  arising  from  the  introduction  of 
putrid  matter  into  the  veins,  and  leading  to 
abscess  in  various  organs,  may  follow  either 
form  of  gangrene.  Secondary  gangrenous  change 
is  frequently  met  with  in  other  parts  of  the  same 
or  of  the  opposite  lung. 

Symptoms. — It  is  seldom  possible  to  diagnose 
gangrene  of  the  lung  until  the  purulent  discharge 
reaches  a bronchus  and  is  ejected.  Then  the 
sputa  are  found  to  soon  separate  into  layers — 
a frothy  superficial  one,  a liquid  middle,  and  a 
lower  sediment.  The  smell  of  the  sputa  and 
breath  is  pathognomonic.  The  dyspntea  and 
prostration  are  usually  great.  The  physical 
signs  are  those  of  softening  and  excavation,  per- 
cussion being  either  dull  or  tympanitic,  and  loose 
crepitation  being  soon  replaced  by  gurgling  and 
perhaps  amphoric  breathing.  The  passage  of 
the  circumscribed  into  the  diffused  form  may  be 
traced  by  watching  the  physical  signs. 


Diagnosis.  — Suppurative  ulceration  of  the 
bronchial  cartilages  gives  rise  to  great  feetor  of 
breath.  Sometimes  a gangrenous  odour  in  the 
breath  occurs  when  the  putrefactive  change  is 
limited  to  the  secretions,  the  lungs  being  free ; 
and  it  is  present  also  in  pyo-pneumothorax  witli 
internal  fistula.  These  several  diseases  must  be 
excluded  by  a careful  estimation  of  the  history 
and  the  physical  signs. 

Prognosis.  • — The  prognosis  of  pulmonary 
gangrene  is  hopeless  in  the  diffused  form ; and 
should  be  made  very  cautiously,  even  when  the 
symptoms  or  signs  point  to  a limitation  of  the 
mischief. 

Treatment. — Besides  the  general  treatment 
which  co-existing  disease  may  require,  special 
attention  must  be  given  to  the  removal  of  the 
gangrenous  odour  from  the  atmosphere  of  the 
room,  from  the  sputa,  and  from  the  patient, 
who  is  apt  to  exhale  from  the  skin  a similar 
odour  to  that  given  off  in  the  breath.  Sul- 
phurous acid,  carbolic  acid,  or  chloride  of  lime 
fulfil  the  first  indication ; Condy’s  fluid  the  se- 
cond ; and  this  may-  also,  when  diluted,  form  a 
useful  wash,  gargle,  or  drink.  The  sulpho-carbo- 
lates,  when  administered  freely,  have  a distinct 
value  in  removing  the  feetor  from  the  skin,  and 
making  the  patient  less  unapproachable. 

When  a gangrenous  abscess  of  the  lung  ex- 
ists, and  it  is  evident  that  the  passage  of  foetid 
matters  through  the  bronchi  is  settingup  danger- 
ous irritation,  leading  to  exhausting  discharge, 
or  threatening  to  poison  the  system,  the  ques- 
tion of  tapping  the  gangrenous  cavity  should  be 
entertained.  The  introduction  of  a drainage- 
tube  sometimes  affords  immediate  relief  in  such 
cases  ; the  feetor  of  breath  ceases ; the  offensive 
secretions,  being  no  longer  locked  up  in  the 
lung,  lose  their  putrescent  character;  and  the 
relief  to  the  constitution  is  great.  An  accurate) 
diagnosis  is  in  such  cases  essential,  the  danger 
of  the  operation  being  greatly  enhanced  if  the 
abscess  is  at  a distance  from  the  chest -wall,  and 
if  the  lung  is  not  adherent  to  the  costal  pleura. 
The  operation  should  only  be  performed  when 
there  is  but  little  prospect  of  recovery  without  it 
but  must  not  be  delayed  until  the  vital  powers  ar. 
too  reduced  to  allow  of  ultimate  convalescence. 

Every  attempt  must  be  made  to  support  thi 
strength  by  nourishing  food  and  stimulants 
bark  and  ammonia,  quinine  and  acids,  iron  au< 
cod-liver  oil  being  indicated.  The  inhalation  c 
creasote  or  carbolic  acid  in  spray  may  he  trietj 
or  of  turpentine  given  off  from  hot  water. 

E.  Symes  Thompson 

IiUNGS,  Hsemorrhage  into. — Stnon.:  E: 
travasation  of  blood  into  the  lungs  ; Pulmonai 
apoplexy;  Er.  Hemorrhagic  du  poinnon ; Ge 
Lujigenblutung. 

Etiology  and  Pathology. — In  the  artic 
Hemoptysis  will  be  found  enumerated  t 
causes  which  lead  to  pulmonary  hsemorrhage. 
the  present  article  only  those  extrarasations 
blood  into  the  lungs  ate  included  which  do  r 
depend  upon  direct  injury  to  the  organ,  or  up 
exposure  and  rupture  of  vessels  in  the  com 
of  destructive  disease  affecting  it.  Hsemorrla- 
into  the  substance  of  the  lungs  may  be  difi- 
punctform,  or  circumscribed. 


LUNGS,  HYDATIDS  OF.  860 


(1)  Diffuse  pulmonary  apoplexy. — The  diffuse 
extravasation  of  blood  into  the  lungs  is  an 
extremely  rare  condition.  Some  cases  have  been 
recorded,  however,  in  which  it  has  arisen  from 
primary  disease  of  a branch  of  the  pulmonary 
artery.  The  lung-tissue  is  broken  down  by  the 
htemorrhage  into  it;  and  the  patient  soon  suc- 
cumbs. 

(2)  Punetiform  hemorrhage,  and  (3)  circum- 
scribed or  nodular  pulmonary  apoplexy , are  not  of 
uncommon  occurrence,  and  are  attendant  upon 
the  same  morbid  conditions  of  the  lung.  Mitral 
disease  of  the  heart,  mitral  stenosis  especially, 
but  also  mitral  regurgitation,  are  the  chief  re- 
mote causes  of  these  two  forms  of  pulmonary 
apoplexy. 

In  certain  purpuric  states  of  system,  which  we 
need  not  here  specify,  punetiform  heemorrhage  in 
the  lungs  is  possible  ; the  purpura  much  more 
frequently  affects,  however,  the  pleural  surface 
or  bronchial  mucous  membrane.  Mechanical 
congestion  of  the  lungs  from  the  above-mentioned 
forms  of  heart-disease  is  by  far  the  most  common 
condition  upon  which  this  minute  and  interstitial 
form  of  haemorrhage  supervenes,  giving  rise  to 
no  additional  symptoms,  but  causing  considerable 
and  peculiar  pigmentation  of  the  lung.  The  in- 
terstitially  thickened  lungs  acquire  a brownish 
tint,  from  the  absorption  of  the  blood-spots,  leav- 
ing htematin  behind,  and  the  appearance  has 
given  rise  to  the  term  brown  induration  of  the 
lungs.  See  Lungs,  Brown  Induration  of. 

Nodular  or  circumscribed  pulmonary  apoplexy 
is  aften  associated  with  thepetechial  haemorrhage 
;ust  described,  and  like  it  mostly  supervenes 
upon  the  mechanical  congestion  of  the  lungs 
arising  from  heart-disease.  There  are  two  ways 
in  which  this  form  of  haemorrhage  may  be  pro- 
duced. The  first  way  is  by  rupture  of  capil- 
laries or  small  veins  under  the  heightened  pres- 
sure of  the  pulmonary  circulation.  An  effusion 
of  blood  thus  occurs,  which  fills  up  one  or  more 
lobules,  and  coagulates  to  form  the  dark  firm 
consolidations  so  characteristic  of  the  lesion. 
Or  a branch  of  the  pulmonary  artery  becomes 
obstructed  by  an  embolus,  for  instance,  by  a 
fragment  of  coagulum  conveyed  from  the  right 
auricle,  or  from  one  of  the  systemic  veins  ; and 
ts  territory  becomes  at  once  filled  with  blood,  in 
..he  following  manner.  The  pulmonary 'arterial 
vessels  do  not  communicate  with  one  another, 
;ach  branching  separately  to  its  capillary  distri- 
bution ; the  pulmonary  veins,  on  the  contrary, 
nosculate  freely,  and,  moreover,  are  not  pro- 
dded with  valves.  Thus  when  the  onflow  of 
lood  is  arrested  through  the  obstructed  branch, 
enous  regurgitation  through  the  capillaries 
rom  collateral  pressure  fills  up  the  precluded 
aseular  area  with  stagnating  blood,  and  the 
itra-alveolar  tissues  become  speedily  occupied 
' ith  its  effused  corpuscles.  In  some  cases  the 
?ssel  may  not  at  first  be  accurately  closed  by 
le  embolus;  the  onward  current  is  then  re- 
rded  instead  of  being  quite  arrested ; the 
echanism  is,  however,  practically  the  same. 
Anatomical  Chaeacters. — A lung,  the  seat 
this  form  of  haemorrhage,  is  usually  tough- 
ed and  heavy.  Some  hard,  and  more  or  less 
ut,re,  flat  surfaces  may  be  felt  and  seen 
ised  above  the  general  surface  of  the  lung. 


which  has  shrunk  below  their  level.  The 
pleura  covering  such  patches  is  darkened  in 
colour,  and  presents  flakes  or  granulations  of 
lymph,  impairing  its  translucency  and  smooth- 
ness. On  making  a vertical  section  through  one 
of  the  surfaces,  it  is  found  to  form  the  base  of 
a more  or  less  conical  mass,  which  has  a firm 
damson-ehecse-like  section,  andis  sharply  defined 
from  the  surrounding  tissue.  In  its  axis  is  seen 
a branch  of  the  pulmonary  artery,  occupied  by 
partially  altered  clot.  There  is  usually  some 
staining  of  the  pulmonary  tissue  immediately 
surrounding  the  apoplectic  nodule,  from  imbibi- 
tion. Such  haemorrhagic  nodules  vary  greatly 
in  number  and  size  ; there  are  usually  several  in 
each  lung,  of  about  the  size  of  a walnut ; but  one 
may  occupy  a whole  lobe.  They  also  vary  in 
appearance  according  to  the  date  of  their  occur- 
rence; their  colour,  at  first  that  of  dark  blood- 
clot,  passes  through  pale  chocolate  or  catechu 
tint  to  yellowish  red  or  pale  yellow,  as  the 
colouring  matter  becomes  gradually  absorbed. 
The  whole  extravasation  may  be  gradually  and 
completely  absorbed,  leaving  the  restored  lung 
but  little  damaged ; or  a shrunken  fibrinous  de- 
position or  blood-cyst,  with  surrounding  indur- 
ation, may  mark  the  site  of  former  haemorrhage. 
It  should  be  added  that  these  extrasavations^ 
although  generally  near  the  pleural  surface  of 
the  lung,  are  not  always  so,  but  may  occur  deeply 
in  its  substance. 

Symptoms. — Amidst  the  distressing  symptoms 
which  are  attendant  upon  the  conditions  leading 
to  pulmonary  apoplexy,  it  would  be  difficult  to 
single  out  any  diagnostic  of  this  special  lesion. 
An  exacerbation  of  dyspnoea  already  terrible 
enough,  or  a sudden  failure  of  pulse,  may  perhaps 
be  noted.  Dark  scanty  lisemopitysis  is,  however, 
the  pathognomonic  sign,  the  frothy  mucous  ex- 
pectoration containing  some  streaks,  or  small  clots 
of  dark  coagulated  blood.  Some  circumscribed 
patches  of  dulness,  with  bronchial  breathing 
and  neighbouring  crepitation,  may  be  made  out, 
especially  in  the  mammary  and  mid-axillary 
regions. 

Prognosis  and  Treatment. — These  lesions 
are  among  those  which  close  the  scene  in  the 
heart-disease  to  which  they  are  accessory ; they 
are  therefore  irremediable.  Sometimes  when, 
from  any  cause,  their  occurrence  appears  to  have 
been  hurried  forward ; when  the  lividity  is  great, 
the  dyspnoea  urgent,  and  yet  the  disease  is  not 
of  long  duration  ; wet-cupping  or  bleeding  from 
the  arm  will  certainly  give  great  temporary  relief, 
and  perhaps  avert  immediate  danger. 

B.  Douglas  Powell. 

LUNGS,  Hydatids  of. — Synon.:  Fr.  Kystes 

hydatiques  du  poumon  ; Ger.  Lungenecliinococcus. 

Definition. — A disease  due  to  the  presence  of 
hydatids  in  the  lungs. 

.(Etiology. — Hydatid  cysts  in  the  lungs  rarely 
occur  in  this  country  as  a primary  disease  of  the 
lung,  but  they  are  not  unfrequently  met  with  as 
an  extension  of  disease  from  the  liver. 

The  general  causes  of  hydatid  disease  are 
elsewhere  discussed,  but  the  circumstances 
which  determine  the  localisation  of  the  hydatid 
are  not  clearly  ascertained.  In  Australia,  where 
the  affection  is  very  common,  it  is  met  with 


LUIS  us,  HYPEREMIA  OF. 


370 

sometimes  in  the  lung  without  any  other  organs 
being  affected ; although  in  many  cases  in  which 
the  iungs  are  diseased,  evidence  of  the  existence 
of  the  same  disorder  elsewhere  is  not  wanting. 
In  100  cases,  the  liver  was  the  organ  affected  in 
70,  the,  lung  in  12.  The  great  prevalence  of  the 
disease  in  Melbourne  is  said  to  be  due  to  drink- 
ing from  water-holes  frequented  by  sheep,  and 
from  eating  watercress  or  uncooked  salads  con- 
taining the  ova  of  tho  parasite. 

Anatomical  Characters. — The  general  ana- 
tomy of  hydatid  disease  will  be  found  in  the 
article  describing  this  parasite  (sec  Hydatids). 
Single  sacs  of  acephaloeysts  are  by  far  most 
usual,  varying  in  size  from  a pigeon’s  egg  to  a 
man’s  fist.  Sometimes  the  upper,  and  sometimes 
the  lower  lobes  are  the  seat  of  the  cysts.  They 
are  developed  in  the  interstitial  pulmonary 
tissue;  as  growth  proceeds,  the  neighbouring 
parenchyma  is  converted  into  fibro-eellular  tis- 
sue, and  undergoes  obsolescence.  The  parent  sac, 
containing  the  echinococci,  is  adherent  to  the 
surrounding  tissue. 

If  the  parent  sac  be  destroyed  by  inflammation 
and  consequent  suppuration,  a communication  is 
established  between  the  cavity  and  the  bronchi, 
through  which  the  daughter-cysts  may  be 
ejected  ; just  as  in  more  common  instances  they 
may  escape  from  the  liver  after  perforating 
the  diaphragm  and  lung.  Not  unfrequently  the 
pulmonary  sac  communicates  with  a similar  sac 
in  the  liver.  It  is  natural  to  infer  in  such  cases 
that  the  disease  originated  in  the  liver.  Indeed, 
it  has  been  stated  that  primary  hydatid  of  tho 
lung  is  unknown. 

Symptoms  and  Physical  Signs. — Hydatids 
may  exist  in  the  lung  for  a considerable  time 
without  giving  rise  to  any  noticeable  symptoms ; 
but  as  the  tumour  enlarges,  and  presses  upon  the 
surrounding  tissues,  haemoptysis  occurs,  as  also 
bronchitis,  pneumonia,  or  even  gangrene.  Some- 
times the  cysts  perforate  the  pleura  and  cause 
pneumothorax,  or  make  their  way  through  the 
diaphragm  into  the  abdominal  cavity.  The  more 
usual  course  is  the  converse  of  this,  namely7,  that 
a hydatid  of  the  liver  exists  perhaps  for  years. 
causes  abdominal  distension,  and  eventually7  dis- 
charges its  contents  through  the  diaphragm  into 
a bronchus  ; then  expectoration  of  blood  occurs, 
with  gooseberry-like  skins,  varying  in  size  from 
a nut  (in  which  case  the  cyrst  may  be  expelled 
w'hole)  to  an  orange  (in  which  case  the  sacs  are 
shrivelled  and  empty),  causing  strangling  and 
suffocating  cough  during  expulsion. 

If  the  site  of  the  tumour  be  superficial,  altered 
breath-sounds  and  percussion-note  may  be  ob- 
served, but  if  it  be  deeply  seated,  the  physical 
signs  may  escape  detection.  If  bronchitis  or 
pneumonia  be  set  up,  the  signs  and  symptoms 
of  these  disorders  mask  those  of  the  originating 
disease.  Often  the  symptoms  are  like  those  of 
rapid  phthisis,  namely,  cough,  muco-purulent  ex- 
pectoration, haemoptysis,  night-sweats,  and  ema- 
ciation. The  meaning  of  these  symptoms  is  ap- 
parently confirmed  by  the  physical  signs,  namely, 
dulness  on  percussion ; absence  of  breath-sounds, 
or  prolonged  expiratory  murmur  ; and,  when  the 
cysts  burst,  gurgling  and  pectoriloquy.  Unless 
the  daughter-cysts  or  hooklets  are  expectorated, 
there  is  nothing  to  point  unmistakeably  to  the  ] 


nature  of  the  disease.  "When  perforation  of  the 
diaphragm  occurs,  hepatic  symptoms  or  ‘hose 
of  pleurisy  occur.  The  patient  looks  anxious; 
the  features  are  collapsed;  the  skin  is  clammy 
and  livid ; the  extremities  are  co.d ; incessant 
paroxysmal  cough  occurs,  with  vomiting;  and 
by  degrees  6allowness  and  jaundice  make  their 
appearance.  Symptoms  of  acute  pneumonia  may 
occur — of  consolidation,  followed  by  excavation  ; 
the  expectoration  being  at  first  rusty,  then  bile- 
tinged,  muco-purulent,  and  foetid,  and  containing, 
besides  shreds  of  lung-tissue,  entire  cysts  or 
portions  of  them. 

Diagnosis. — It  may  be  difficult  to  distinguish 
a large  hydatid  cyst  from  pleuritic  effusion,  as 
the  lung  may  be  displaced,  the  chest  bulges, 
and  the  intercostal  spaces  become  prominent  and 
fluctuating.  The  rounded  outline  of  the  dull 
space,  the  absence  of  acute  symptoms,  the  his- 
tory of  gradual  onset,  the  absence  of  a-gophonv, 
and  of  alteration  of  physical  signs  on  change 
of  posture,  will  guide  the  decision  ; and  an  ex- 
ploratory puncture,  which  gives  exit  to  a clear 
saline,  non-albuminous  fluid,  containing  possibly 
hooklets  or  fragments  of  cysts,  will  confirm  the 
diagnosis.  The  conduction  of  the  heart-sounds 
and  impulse,  and  the  tense  unyielding  condition 
of  the  bulged  side  on  palpation,  may  lead  to 
the  suspicion  of  mediastinal  tumour;  but  in  the 
case  of  hydatids  there  is  seldom  any  visible 
venous  engorgement,  or  laryngeal  or  oesophageal 
pressure-sign,  as  in  aneurismal  or  other  media- 
stinal growths.  There  is,  moreover,  generally  a 
freedom  from  cachexia  or  constitution  1 disturb- 
ance, In  circumscribed  abscess  the  neighbouring 
lung  is  rarely  so  free  from  disease  as  in  hydatid. 

Prognosis. — Although  the  symptoms  may  bo 
so  severe  as  to  threaten  immediate  death  from 
suffocation,  recovery  occurs  in  at  least  half  the 
cases  in  which  hydatid  disease  begins  in  tho 
lung,  and  one-third  of  those  in  which  it  spreads 
from  tho  liver,  If  the  cyst  is  allowed  to  burst  of 
itself,  recovery  takes  place  in  from  30  to  40  per 
cent,  of  cases.  But  the  mortality  is  greatly  re- 
duced by  early  tapping. 

Treatment. — Palliative  treatment  must  bo 
directed  mainly  to  the  mitigation  of  pain,  and! 
other  urgent  symptoms.  Curative  treatment 
consists  in  destroying  the  vitality  of  the  cyst. 
If  the  fluid  contents  are  drawn  off,  or  allowed 
to  escape,  the  death  of  the  hydatid  may  occur, 
or  inflammatory  action,  leading  to  suppuration. 
If  the  fluid  re-collect  and  pressure-signs  recur, 
iodine  or  other  stimulating  fluid  may  be  in- 
jected. The  iodide  or  bromide  of  potassium 
with  kainela  have  gained  among  Australian  pliyj 
sicians  reputation  in  these  cases,  especially  wher 
combined  with  the  use  of  the  trochar. 

E.  Symes  Thompson. 

LUNGS,  Hypersemia  of— Synon.  : Conges 
tion  of  the  Lungs  ; Pr.  Hypcremic  du  poumun 
Gor.  Lungcnhypcramie. 

Definition. — Excess  of  blood  in  the  lungs 
whether  local  or  general. 

Varieties. — Pulmonary  hypersemia  may  b 
active,  passive,  or  obstructive. 

The  morbid  appearances  and  symptoms  ar 
different  in  these  three  kinds  of  hypersemia,  an 
they  may,  therefore,  be  best  considered  separate!’ 


LUNGS,  IIYPERiEJIIA  OF. 


A.  Active  Hyperemia  of  the  Lungs. — 
3ynon. : Active  congestion  ; active  affiuxion. 
Definition. — A determination  of  blood  to  the 

lungs. 

Anatomical  Characters. — Active  hyperemia 
or  congestion  may  affect  any  portion  of  the  lung, 
which  remains  crepitant  and  little  changed,  save 
that  it  is  more  crimson  in  colour,  and  contains 
slightly  more  blood  than  natural.  The  condition 
is  indeed  rather  a vital  or  physiological  one  ; and, 
as  in  active  hyperemia  of  the  skin,  may  present 
no  fost-mortem,  appearances.  On  section,  how- 
ever, the  lung  usually  exudes  some  frothy  serum, 
tinged  with  blood;  and  sometimes,  especially 
when  the  hyperemia  is  local  and  arises  from 
collateral  stress  of  circulation,  there  is  found 
haemorrhage  into  the  lung.  The  mucous  mem- 
brane of  the  bronchial  tubes  is  minutely  injected, 
or  it  may  be  quite  natural  in  appearance. 

.Etiology. — The  causes  which  produce  in- 
flammation of  the  lung  will  also  produce  active 
hyperemia,  namely,  cold,  irritation,  adjacent  in- 
flammation, &c.  Increased  action  of  the  heart 
during  violent  effort  or  excitement,  whether 
from  mental  emotion  or  from  drink,  will  produce 
the  same  effect.  It  is  said  that  the  pressure  of 
blood  in  the  pulmonary  artery  increases  more 
rapidly  than  that  in  the  aorta  during  exertion 
(Colin).  Hsemoptysis  from  pulmonary  hyper- 
amia  is  commonly  produced  by  the  excessive 
imbibition  of  stimulants.  Predisposition,  either 
hereditary  or  in  consequence  of  present  disease, 
renders  these  last-named  causes  much  more 
readily  operative.  Obstruction  to  the  passage 
of  blood  through  one  portion  of  the  pulmonary 
system  of  vessels,  for  example,  by  embolism,  or 
by  destruction  of  capillaries,  will  cause  increased 
collateral  activity  of  circulation.  Sudden  sup- 
pression of  menstruation  may  cause  active  deter- 
mination of  blood  to  the  lungs.  Sudden  diminu- 
tion of  the  atmospheric  pressure  within  the 
chest,  as  during  violent  inspiratory  effort,  whilst 
the  trachea  is  closed,  for  instance,  in  croup, 
laryngismus,  or  whooping-cough,  may  cause  ac- 
tive determination  of  blood  to  the  lungs. 

Effects. — Several  important  effects  may  be 
produced  by  active  hyperemia  of  the  lungs. 
Haemorrhage  is  rarely  extensive,  unless  there  be 
attendant  organic  lesion  present.  Active  hyper- 
emia of  the  lung  constitutes  the  first  stage  of 
exudative  or  croupous  pneumonia,  with  fibrinous 
ixudation  into  the  air-cells.  Pulmonary  oedema 
nay  result  from  the  excessive  blood-pressure, 
he  serum  exuded  being  frothy  and  blood-tinged, 
vesicular  catarrh  is  not  so  distinctly  a cuuse- 
uence  of  hyperemia,  with  which,  however,  it  is 
ften  associated. 

Symptoms. — The  symptoms  of  active  pulmo- 
^7  hyperemia  are  dyspnoea ; more  or  less  py- 
exia;  cough;  and  sometimes  copious  haemopty- 
■is,  in  which  case  precedent  organic  disease  must 
e suspected.  The  rusty  sputa  of  the  first  stage 
f pneumonia  is  that  most  typical  of  pulmonary 
yperemia. 

Diagnosis. — The  diagnosis  would  rest  mainly 
pon  the  suddenness  of  attack,  and  the  evidence 
a sufficient  determining  cause,  with  or  with- 
it  predisposition. 

Pbognosis. — Active  hyperemia,  save  in  some 
■ses  of  aollateral  afflux,  is  necessarily  a tran- 


87X 

sient  affection,  subsiding  in  a few  hours,  or  pass- 
ing on  to  inflammation. 

Treatment. — The  first  point  in  the  treatment 
of  this  condition  is  to  secure  absolute  rest  in 
bed,  -with  silence,  and  removal  of  all  causes  of 
excitement.  Derivatives ; mustard  or  linseed 
poultices  to  the  chest;  perhaps  cupping,  or  eveu 
blood-letting  ; warmth  to  the  extremities  ; sa- 
line purgatives  ; and  a low  diet,  without  stimu- 
lants, may  all  be  employed.  The  special  cause  of 
the  hyperemia  should  be  treated.  As  a rule  as- 
tringent medicines  should  be  avoided.  Digitalis 
is  useful  to  calm  the  circulation,  especiaUy  after 
excitement  from  alcohol.  If  the  pyrexia  be  very 
marked,  pneumonia  may  be  expected,  and  saline 
diaphoretics  are  especially  indicated. 

B.  Passive  Hyperemia  of  the  Lungs. — 

Synon.  : Passive  or  hypostatic  congestion. 

Definition.  — An  incomplete  stagnation  of 
blood  in  the  lungs. 

./Etiology. — Passive  or  hypostatic  congestion 
of  the  lung  is  a condition  of  hyperemia  affecting 
by  preference  the  most  depending  parts  of  the 
lung.  Failure  of  heart-power,  an  inability  to 
propel  the  blood  clear  through  the  pulmonary 
capillaries,  is  the  chief  cause  of  this  condition. 
In  states  of  exhaustion  from  low  fevers,  espe- 
cially typhus  and  typhoid  ; after  severe  surgical 
operations  ; in  extreme  old  age  ; or  towards  the 
end  of  prostrating  illness,  this  failure  of  heart- 
pow'er,  and  consequent  stagnation  of  blood  in  the 
lower  parts  of  the  lung,  usually  t.ie  bas»s,  is  apt 
to  supervene,  and  is  one  of  the  common  modes 
of  death.  An  altered  condition  of  the  blood, 
so  as  to  render  its  passage  through  the  capillaries 
more  difficult,  is  also  stated  to  be  a cause  of  this 
form  of  congestion  of  the  lungs  and  of  other 
organs.  In  uremic  and  icteric  conditions,  and 
in  the  febrile  state,  the  blood  does  not  pass 
through  the  capillaries  with  the  same  facility  as 
in  health,  and  hypostatic  congestions  are  more 
apt  to  occur.  Finally,  when  the  vessels  have  lost 
their  tone,  and  the  heart  fails  in  power,  gravita- 
tion exercises  its  influence  in  attracting  the 
blood  to  the  most  dependent  parts. 

Anatomical  Chabactees. — Passive  hyper- 
semia  almost  always  affects  the  bases  of  both 
lungs,  although  often  not  in  an  equal  degree,  the 
difference  depending  mainly  upon  the  position  of 
the  patient  during  the  last  days  of  life.  The 
affected  lung  is  dark-coloured,  and  engorged  with 
dark  blood.  Its  tissue  is  more  or  less  deeply 
stained  with  bloyilv  and  is  less  crepitant  than 
natural,  yielding  iifeo  more  readily  than  natural 
under  the  pressure  of  the  finger.  If  thoroughly 
washed,  however,  in  a gentle  stream  of  water, 
the  lung-texture  will  be  found  to  be  but  little 
altered.  This  condition  very  readily  passes  into 
a low  form  of  pneumonia,  and  thus  portions  of 
the  lung  may  be  found  consolidated,  having 
much  the  appearance  and  consistence  on  section 
of  a congested  spleen  (splenifieation,  hypostatic 
pneumonia).  The  bronchial  tubes  and  pleura  axe 
affected  by  post-mortem  staining. 

Symptoms. — The  symptoms  of  this  form  of 
congestion  of  the  lungs  are  lividity,  especially  of 
the  lips  and  extremities ; and  quickened,  shallow 
breathing ; superadded  to  those  of  extreme  pros- 
I tration.  Dulness  on  percussion,  with  enfeebled 


172  LUNGS,  HYPEREMIA  OF. 


breathing  and  moist  crepitant  rale,  are  found 
over  the  bases  of  both  lungs,  but  in  greatest 
extent  on  that  side  to  which  the  patient  has  been 
inclining. 

Treatment. — Passive  hyperaemia  of  the  lungs 
being  never  the  primary  affection,  and  always 
being  a sign  of  failing  power,  its  treatment  con- 
sists in  vigorously  supporting  the  patient  by 
alcoholic  stimulants  frequently  administered, 
with  nutritious  food.  Nutritive  enemata  are  often 
of  great  value.  In  all  exhausting  diseases  this 
condition  should  be  anticipated,  and  warded  oft' 
if  possible  by  timely  support  and  stimulants, 
and  above  all  by  frequently  turning  the  patient 
from  one  side  to  the  other,  thus  calling  in  the 
aid,  rather  than  permitting  the  hindrance,  of 
gravitation  to  the  circulation  through  the  lungs. 
Of  medicines,  ammonia,  ether,  bark  and  quinine 
are  of  the  greatest  value ; and  musk,  sumbul, 
and  lavender  may  be  useful  adjuncts. 

C.  Obstructive  Hyperaemia  of  the  Lungs. 
Synon.  : Mechanical  congestion. 

Definition. — Hyperaemia  from  obstruction  to 
the  escape  of  blood  from  the  lungs.  Mechanical 
congestion  of  the  lungs  is  a condition  differing 
essentially  from  either  of  the  two  preceding. 

Etiology.- — The  origin  of  this  form  of  hyper- 
semia  is  purely  secondary  and  mechanical,  and  is 
included  in  that  of  the  primary  disease.  The 
obstruction  may  be  at  the  mitral  valve,  as  in 
mitral  stenosis  or  regurgitation  ; or,  again,  the 
obstruction  may  be  at  the  left  ventricle,  when  this 
cavity  is  dilated  and  imperfectly  emptied,  as  in 
the  advanced  stages  of  constrictive  or  regurgi- 
tant aortic  disease.  Whether  there  be  an  abso- 
lute narrowing  of  the  blood-channel  between  the 
pulmonary  and  systemic  circulations,  that  is,  at 
the  mitral  orifice  or  at  the  commencement  of  the 
aorta  ; or  whether,  from  enlargement  of  the  mi- 
tral orifice  or  from  disease  or  injury  of  its  valve, 
regurgitation  he  permitted,  so  that  each  contrac- 
tion of  the  right  ventricle  is  met  and  opposed, 
more  or  less,  by  a counter  rush  of  blood  from 
the  left  ventricle — in  any  case,  and  still  more  in 
the  combination  of  two  or  more  of  these  causes, 
it  is  clear  that  the  pulmonary  circulation  can 
only  go  on  at  an  increased  pressure  by  the  con- 
traction of  the  right  ventricle  becoming  more 
vigorous  ; and  that  hyperiemia  must  result  from 
the  damming  back  of  the  blood  through  the 
pulmonary  veins. 

Of  the  causes  named,  mitral  constriction  is 
that  which  leads  most  simply  to  obstructive 
hyperaemia  of  the  lungs. 

Anatomical  Characters. — It  is  obvious  that 
obstructive  hyperaemia  is  of  general  distribution, 
affecting  the  whole  of  both  lungs.  The  result 
of  the  heightened  blood-pressure  from  increased 
force  of  injection  into  the  lungs,  to  overcome  an 
impediment  to  the  escape  of  blood  from  them,  is 
most  felt  in  the  pulmonary  capillaries.  These 
capillaries  gradually  become  lengthened,  tor- 
tuous, and  dilated  even  to  three  times  their 
normal  dimensions  (Rindfleisch).  From  chronic 
engorgement  of  the  lungs,  the  nuclei  of  the  in- 
terlobular areolar  tissue  and  of  the  connective 
tissue  surrounding  the  minute  vessels  and  bronchi, 
and  pervading  the  parenchyma,  proliferate.  The 
' hickened  and  tortuous  capillaries  intrude  upon 


the  air-spaces;  and  tho  elasticity  of  the  lungs 
being  also  impaired,  their  vital  capacity  is 
diminished.  It  is  stated  that  the  muscular 
fibres,  which  proceed  from  the  bronchial  termi- 
nations to  form  loops  upon  and  encircle  the 
infundibula,  become  hypertrophied  (Rindfleisch'). 
thus,  perhaps,  compensating  for  a diminution 
in  the  more  mechanical  elastic  property  of  the 
lung.  Sometimes  minute  haemorrhages  take 
place  into  the  parenchyma  of  the  lung;  some- 
times larger  escapes  of  blood  fill  the  alveoli  of 
circumscribed  patches  (pulmonary  apoplexy.) 
Tho  total  result  of  tho  intimate  changes  de- 
scribed, is  an  uniform  increase  in  the  size  and 
weight  of  the  lungs,  with  an  increased  density 
and  toughness.  On  section  the  lungs  are  found 
to  be  more  pigmented  and  solid-looking  than 
natural,  sometimes  of  a brownish  hue  (brown 
induration) ; they  are,  however,  crepitant 
throughout,  excepo  here  and  there,  where  they 
may  present  the  firm,  dark,  damson-cheese-like 
section,  fading  to  brown-red,  of  recent  pulmo- 
nary apoplexy.  There  may  be  some  cedema  pre- 
sent. The  pulmonary  arteries  and  veins  are  en- 
larged and  congested ; and  the  bronchial  mucous 
membrano  is  usually  the  seat  of  chronic  catarrh. 
Patches  of  atheroma  are  frequently  to  be  seen  in 
the  larger  branches  of  the  pulmonary'  artery. 

Symptoms. — Dyspnoea  and  cough,  both  brought 
on  or  increased  by'  effort,  with  palpitation,  and 
oppression  or  tightness,  usually  referred  to  the 
epigastrium,  are  the  most  constant  symptoms  of 
obstructive  hyperaemia  of  the  lungs.  Patients 
suffering  from  this  condition  have  repeated  at 
tacks  of  bronchial  catarrh,  and  haemoptysis  is 
of  common  occurrence.  The  haemoptysis  may 
be  considerable,  but  usually  the  expectoration 
is  streaked  with  blood  or  contains  small  dark 
coagula. 

This  form  of  hyperaemia  commonly  occurs 
before  middle  life,  during  the  usual  period  of 
mitral  heart-disease.  The  signs  of  heart-dis- 
ease, and  most  often  of  constriction  of  the  mitral 
valve,  are  present.  Tho  subjects  of  this  disease 
are  often  undersized  and  badly  nourished ; the 
pigeon-breasted  type  of  chest  being  common  es- 
pecially in  those  cases  in  which  the  disease 
manifests  itself  early  in  life.  Small,  frequent 
pulse;  more  or  less  lividity  of  lips;  and  other 
signs  and  symptoms  of  the  cardiac  disease,  of 
which  the  pulmonary  condition  is  the  conse- 
quence, are  to  be  observed.  A fine  inspiratory 
crepitant  rale  over  the  lungs  may  be  heard. 
During  the  repeated  bronchial  catarrhs,  with 
increased  pulmonary  hyperaemia,  to  which  such 
patients  are  especially  prone,  all  symptoms  are 
much  aggravated. 

Diagnosis.  — The  existence  of  obstructive 
heart-disease  suggests  the  presence  of  corre- 
sponding hyperaemia  of  the  lungs.  The  fine  cre- 
pitant rale  and  the  haemorrhagic  symptoms  and 
signs  more  positively  point  in  the  same  direction. 

Prognosis. — The  prognosis  rests  chiefly  upon 
the  heart-condition  present.  Increasing  fre- 
quency of  catarrhal  complications,  and  especially 
of  haemoptysis,  shows  the  turning  of  the  balance 
against  the  patient.  The  condition  may  ;u 
favourable  eases  continue  for  years,  especially 
when  dependent  upon  simple  constriction  of  tb» 
mitral  valve. 


LUNGS,  HYPERTROPHY  OF. 


Treatment.- — The  treatment  is  essentially  that 
of  the  heart-disease;  with  the  avoidance  of  all 
causes  which  hasten  respiration,  and  which  tend 
to  produce  catarrhs,  to  which  these  patients  are 
bo  especially  prone.  R.  Douglas  Powell. 

LUNGS,  Hypertrophy  of. — Definition. — 
Enlargement  of  the  lungs,  with  increased  func- 
tional power.  A condition  only  clinically  met 
with  as  a compensatory  affection  of  one  lung,  or 
of  a portion  of  one  lung,  to  make  up  for  more  or 
less  loss  of  pulmonary  tissue  by  disease. 

.Etiology  and  Pathology. — The  process  by 
which  hypertrophy  of  the  lung  comes  about  is 
almost  a mechanical  one.  Destructive  disease 
having  removed  a large  portion  of  one  lung,  or 
ermanent  collapse  or  blocking  of  such  portion 
aving  occurred  from  any  cause,  the  diminished 
power  of  the  affected  lung  to  occupy  its  ap- 
portioned space  in  the  chest-cavity  during  in- 
spiration, is  compensated  for  by  an  increased 
expansion  of  the  healthy  lung,  together  with  a 
certain  recession  of  the  softer  parts  of  the  chest- 
wall  on  the  affected  side.  The  increased  ex- 
pansion of  the  healthy  lung  encourages  an 
increased  afflux  of  blood,  which  is  at  the  same 
time  determined  through  it  by  the  partial  ob- 
struction to  circulation  through  the  diseased  lung. 
These  changes  taking  place  gradually,  the  in- 
creased function  and  increased  afflux  of  blood 
are,  in  accordance  with  our  experience  of  similar 
conditions  in  other  parts,  attended  with  increased 
nutrition  of  the  lung,  and  its  true  hypertrophy 
is  thus  little  by  little  established. 

Hypertrophy  of  the  lung,  therefore,  is  not  a 
liseased  condition,  but  an  excessivo  develop- 
nent  in  consequence  of  injury  to  some  other  por- 
ion  of  the  same  or  of  the  opposite  lung.  Its 
iccurrence  may  be  best  noted  during  the  gradual 
ibsorption  or  removal  of  a pleural  effusion,  which 
las  long  compressed  the  opposite  lung.  Any 
lisease,  however,  which,  after  destroying  or 
lacing  in  abeyance  a certain  proportion  of  one 
ung,  becomes  arrested,  tends  to  cause  hyper- 
rophous  development  of  the  remaining  lung. 
Jhronic  pneumonia,  cirrhosis,  arrested  phthisis, 
nd  atelectasis  in  the  child,  are  the  chief  diseases 
f the  kind.  While  disease  is  actively  progressive 
pe  conditions  present — namely,  fever,  anorexia, 
nd  pleuritic  pains,  are  unfavourable  to  the 
vtra  development  of  the  sound  lung,  but  when 
leseunfavourable  conditions  subside,  the  liyper- 
•ophy  proceeds  with  great  rapidity,  and  may  be 
itablished  in  a very  few  months.  The  effect 
the  rarefied  air  of  mountainous  regions  is 
1 develop  the  natural  capacity  and  function  of 
e lungs. 

Anatomical  Chaeacters. — An  hypertrophied 
ng  is  larger  and  heavier  than  natural ; and 
> anterior  and  inferior  margins  are  thick  and 
unded,  and  are  found  to  extend  beyond  their 
rmal  thoracic  limits  both  laterally  and  infe- 
irly.  The  texture  of  the  lung  is  firmer  and 
ire  resilient  than  usual;  and  it  is  plentifully 
pplied  with  blood.  The  air-cells  are  slightly 
larged,  but  not  obviously  dilated  ; and  on  mi- 
pscopic  examination  the  nutrition  of  the  alve- 
r walls  and  capillaries  is  found  to  be  perfect; 
■re  being  neither  the  thinning  of  the  alveoli, 
" tile  excessive  growth  of  fibrous  tissue  met 


873 

with  at  different  stages  of  so-called  ‘ hypertro- 
phous  emphysema.’  Nor  are  the  capillaries 
tortuous  and  dilated  as  in  the  indurative 
‘ hypertrophy  ’ of  the  lung  from  heart-disease. 

Extent  of  lung  affected. — W e have  considered, 
for  the  sake  of  simplicity  of  description,  those  cases 
in  which  the  whole  of  one  lung  is  hypertrophied, 
and  such  cases  are  very  common.  Hut  a single 
lobe  of  a lung  may  become  hypertrophied,  the 
seat  of  the  hypertrophy  depending  upon  the 
seat  of  the  disease  to  which  it  is  compensatory. 
But,  except  when  the  pulmonary  destruction  is 
limitedand  circumscribed,  other  conditions  come 
into  play,  and  we  are  more  apt  to  get  em- 
physema than  hypertrophy.  It  may  be  said 
then  that  hypertrophy  of  the  lung  is  (at  least 
so  far  as  we  can  appreciate  it  clinically)  a one- 
sided affection,  except  in  those  cases  in  which  it 
has  been  occasioned  by  some  general  external 
cause,  as  rarefied  air. 

Physical  Signs. — The  side  on  which  is  the 
hypertrophied  lung  is  expanded,  both  relatively 
(tho  opposite  side  being  usually  flattened  and 
contracted)  and  absolutely.  The  nipple-level 
is  raised.  There  is  increased  percussion-reso- 
nance over  the  side,  extending  across  the  median 
line,  so  that  sometimes  the  line  of  resonance 
indicating  the  inner  margin  of  the  enlarged  lung 
will  reach  the  mid-clavicular  vertical  line  of  the 
opposite  side.  The  lower  limits  of  resonance 
are  also  extended  in  front  and  behind.  The 
respiratory  murmur  has  that  peculiar  coarse 
vesicular  character,  with  somewhat  prolonged 
expiration,  which  is  known  as  ‘puerile’  or 
‘ exaggerated  ’ respiration.  The  heart  is  more 
or  less  displaced  towards  the  contracted  side, 
and  tho  displacement  is  often  apparently  in- 
creased by  the  heart  becoming  on  the  one  side 
covered  by  the  expanded  lung,  and  on  the  other 
side  unduly  exposed  by  the  recession  of  the 
diseased  lung.  This  is  especially  the  case  when 
the  hypertrophy  affects  the  left  lung.  There  are 
no  morbid  sounds  heard  over  the  enlarged  lung 
unless  (as  in  many  cases  of  phthisis)  it  becomes 
or  has  been  affected  by  disease.  With  the  ex- 
pansion of  the  lung  the  general  symptoms  im- 
prove, and  the  dyspnoea  lessens. 

Diagnosis. — The  diagnosis  lias  to  be  made 
between  hypertrophy  of  the  lung;  hypertro- 
phous  emphysema ; and  mere  dilatation.  The 
unilateralness  of  the  hypertrophy ; its  arising 
secondarily  to  some  disablement  of  the  opposite 
lung ; the  absence  of  precedent  or  present  general 
bronchitis  or  asthma;  together  with  the  observa- 
tion of  its  occurrence  being  commensurate  with 
improvement  in  the  condition  of  the  patient, 
are  the  main  features  distinguishing  it  from 
large-lunged  or  hypertrophous  emphysema.  Nor 
could  the  puerile  breathing  of  hypertrophy 
be  easily  confounded  with  the  short,  weak,  or 
inaudible  inspiration,  and  wheezy  prolonged 
expiration  of  emphysema.  In  persons  of  broken 
constitution,  with  contractile  disease  of  one  lung, 
tho  opposite  lung  may  become  dilated  and  assume 
the  shape  and  dimensions  of  hypertrophy  ; but 
the  breathing  of  the  patient  does  not  improve, 
the  respiratory  sounds  are  enfeebled,  and  it  is 
clear  that  the  condition  present  is  one  of  em- 
physema rather  than  true  hypertrophy. 

Prognosis. — The  prognosis  is  always  prt 


LUNGS,  INFLAMMATION  OF. 


174 

tanto  favourable  to  the  patient,  the  hypertrophy 
beingan  important  element  of  his  recovery. 

Treatment. — (Compensatory  hypertrophy  of 
the  lung  is  a condition  carefully  to  be  encouraged, 
when  all  active  symptoms  attendant  upon  the 
original  disease  are  past.  Mild  courses  of 
calisthenics,  and  a temporary  sojourn  at  some 
elevated  health-resort  during  the  warm  season, 
are  most  valuable,  if  not  attempted  too  soon. 
Abundanco  of  fresh  air  throughout  the  year, 
with  the  careful  avoidance  of  fresh  catarrhs, 
such  as  may  be  obtained  by  spending  a winter  and 
spring  or  two  seasons  at  the  South  of  France,  in 
Italy,  or  at  Madeira;  or  a well-planned  sea-voy- 
age to  Australia,  are  excellent  ways  of  spending 
months  of  convalescence.  A generous  unstimula- 
ting diet  is  indicated,  and  tonic  remedies  and  cod- 
liver  oil  are  useful,  more  especially  in  the  early 
stages  of  the  wished-for  hypertrophic  develop- 
ment. E.  Douglas  Powell. 

LUNGS,  Induration  of. — See  Lungs,  In- 
flammation of. 

LUNGS,  Infarction  of. — See  Lungs,  Hre- 
morrhage  into. 

LUNGS,  Infiltrations  of. — Certain  morbid 
formations  in  the  luog  assume  the  arrangement 
of  an  infiltration,  the  tissues,  especially  the  in- 
terlobular cellular  tissue,  being  permeated  with 
the  morbid  material.  In  some  instances  itinvolves 
even  the  epithelial  cells.  The  best  examples  of 
this  arrangement  are  observed  in  connection  with 
certain  cases  of  the  fibroid  change;  iu  infiltrated 
cancer ; and  in  those  forms  of  pulmonary  disease 
where  the  lung-tissue  is  the  seat  of  a deposit  of 
substances  introduced  from  without,  being  in- 
haled in  various  occupations,  such  as  particles 
of  carbonaceous  matter  and  cnal-dust,  stone-grit, 
iron-filings,  particles  of  cotton  or  wool,  and  other 
materials.  Albuminoid  disease,  and  some  forms 
of  pigmentary  change  also  present  a kind  of  in- 
filtrated arrangement.  These  conditions  need 
not  be  further  considered  here,  as  they  are  dis- 
cussed it  their  several  appropriate  articles. 

Frederick  T.  Koberts. 

LUNGS,  Inflammation  of.— Synon.  : Pneu- 
monia; Fr.  Pneumonie',  Gar,  Lung  client ziindung. 

Definition. — The  tern: 1 pneumonia  ’ has  been 
employed  simply  to  designate  inflammation  of  the 
lung-tissue.  Inflammatory  processes  in  the  lungs, 
however,  occur  under  such  diverse  circumstances, 
and  are  accompanied  by  such  diverse  clinical 
phenomena  and  histological  changes,  that  ‘ pneu- 
monia’ used  in  this  sense  includes  widely  differ- 
ent diseases. 

Varieties. — Pneumonias  are  divisible  into  the 
following  varieties; — A.  Acute  Pneumonia; 
B.  Secondary  Pneumonias ; C.  Broncho, 
Catarrhal,  or  Lobular  Pneumonia;  and  D. 
Chronic  or  Interstitial  Pneumonia.  In  addi- 
tion to  these  there  are  those  intense  and  concen- 
trated forms  of  pulmonary  inflammation  which 
lead  to  the  formation  of  abscess. 

There  are  certain  other  forms  of  lung-consolida- 
tion which  have  sometimes  been  described  as 
pneumonic,  but  which  are  really,  for  the  most 
part,  non-inflammatory  in  their  nature,  arid  will, 
therefore,  be  only  briefly  alluded  to  in  the  present 


article.  These  are: — (1)  tlat  condition  rf  col- 
lapse and  hypersemia,  mainly  due  to  weak  inspi- 
ratory power,  feeble  circulation,  and  gravita- 
tion, which  is  so  common  in  the  more  dependent 
portion  of  the  lungs  in  many  acute  and  chronic 
diseases  {see  Hypostasis).  (2)  Consolidations 
of  the  lung  resulting  from  mechanical  congestion 
and  embolism,  such  as  are  met  with  in  certain 
diseases  of  the  heart,  &c.  See  Lungs,  Hyper- 
aemia  of. 

The  several  varieties  of  pulmonary  inflamma- 
tion must  now  be  considered  separately  in  tha 
order  just  indicated. 

A.  Acute  Pneumonia. — Synon.  : Fr.  Pueu. 

monie  aigue  ; Ger.  Croupose  Pneumonie. — This  is 
pneumonia  par  excellence.  It  is  the  disease  to 
which  some  would  be  inclined  to  restrict  the  ap- 
plication of  the  term.  It  is  often  termed  croupous 
pneumonia,  from  the  supposed  resemblance  of  the 
histological  process  to  that  of  croup.  It  is  also 
known  as  lobar  pneumonia,  inasmuch  as  a large 
area  of  the  lung  is  usually  involved  in  the  inflam- 
mation. 

Definition. — Pneumonia  may  be  described 
generally  as  an  acute  disease,  characterised 
clinically  by  sudden  onset,  severe  febrile  symp- 
toms, cough,  expectoration,  and  dyspnoea;  by 
the  physical  signs  of  pulmonary  consolidation ; 
and  by  a rapid  abatement  of  the  eeneral  symp- 
toms between  the  fourth  and  teDth  days. 
Anatomically  it  is  characterised  by  an  acute 
inflammation  of  the  lung-tissue,  and  by  the 
accumulation  of  the  inflammatory  products 
within  the  alveoli,  which  products  consist  in  the 
main,  of  a fibrinous  exudation  and  leucocytes. 

.Etiology. — Atmospheric  influences.  — Condi- 
tions of  weather  and  climate  are  probably  the 
most  important  of  all  known  agencies  in  the 
causation  of  pneumonia.  The  influence  of  cold 
and  damp  in  increasing  the  liability  to  acute  in- 
flammatory diseases  of  the  chest  is  well  known. 
This  influence  is  marked  in  pneumonia,  although 
to  a much  less  extent  than  in  bronchitis.  Pneu- 
monia is  more  common  in  temperate  climates 
than  in  those  regions  which  are  characterised  by 
great  heat  or  extreme  cold.  Climates  and  sea- 
sons which  are  liable  to  sudden  changes  of  tem- 
perature, and  winds  from  the  north  and  north- 
east, appear  to  be  especially  favourable  to  this 
disease. 

Age. — Acute  pneumonia  is  met  with  betweer 
the  ages  of  one  and  five  years.  Here,  however 
it  is  liable  to  be  confounded  with  broncho-pncu 
monia  and  with  collapse  of  the  lung,  so  that  the 
results  of  statistics  are  less  reliable  at  this  that 
in  the  subsequent  periods  of  life.  It  may  b 
stated  notwithstanding,  that  acute  pneumonia  i 
less  common  during  infancy  than  has  been  gene 
rally  supposed,  and  that  amongst  the  pneu 
monias  which  are  so  frequent  during  this  pen.1 
of  life  the  broncho-catarrhal  forms  preponderate 
After  the  age  of  five  years  the  liability  to  pnev 
monia  diminishes,  but  it  again  becomes  exceet 
ingly  frequent  between  the  ages  of  twenty  an 
forty',  during  which  period  the  liability  to  tl 
disease  reaches  its  maximum.  It  is  also  qui 
common  in  old  age. 

Sex.  — In  adults  more  males  than  feraal 
suffer.  This  is  probably  owing  to  the  foim 


LUNGS.  INFLAMMATION  OF.  875 


being  more  exposed  to  atmospheric  influences. 
In  early  life  this  difference  does  not  obtain. 

Social  position,  §c. — Pneumonia  is  more  com- 
mon amongst  the  poor  and  badly  fed,  and  amongst 
those  whose  occupation  necessitates  an  irregular 
mode  of  life  and  great  exposure,  than  amongst 
the  upper  classes  of  society. 

Constitution,  and  health.  — Those  who  arc 

■ constitutionally  weak,  and  those  whose  general 
health  has  been  impaired  by  some  temporary 
cause,  are  more  prone  to  the  disease  than  the 
strong  and  vigorous. 

) Previous  diseases.  — True  pneumonia,  as  is 
well  known,  sometimes  occurs  in  those  who  are 
the  subjects  of  other  disease.  It  is  impossible 
to  speak  with  certainty  as  to  the  relation  which 
subsists  between  the  pneumonia  and  the  disease 
in  the  course  of  which  it  supervenes.  In  some 
cases  it  may  be  merely  an  accidental  complica- 
tion; whilst  in  others  the  previous  disease  may 
exercise  more  or  less  influence  in  the  causation 
of  the  pneumonia.  Most  of  the  pulmonary  con- 
solidations, however,  which  occur  in  the  course 
of  other  diseases  do  not  belong  to  the  category 
of  true  pneumonia,  but  are  either  local  inflam- 
mations, caused  by  some  abnormal  state  which  the 
pre-existing  disease  has  induced  ; or  conditions 
of  hyperaemia  and  collapse,  in  which  an  inflam- 
matory process  plays  but  little  part. 

Exciting  causes. — In  many  cases  of  acute 
(pneumonia  evidence  of  the  existence  of  any  ex- 
isting cause  is  ent  irely  wanting.  Of  discoverable 
causes,  that  which  is  most  common  is  a sudden 
chill,  or  less  frequently,  more  prolonged  exposure 
to  cold  and  damp.  Excluding  cold,  no  conditions 
can  be  mentioned  which  have  any  marked  in- 
lluenee  in  determining  the  disease. 

Anatomical  Characters. — The  changes  oc- 
curring in  the  lungs  in  acute  pneumonia  are 
tommonly  described  under  the  three  following 
heads  : — 

1.  Stage  of  engorgement. — This  is  the  stage 
if  inflammatory  hyperaemia  and  oedema,  and  it  is 
characterised  microscopically  by  overfulness  and 
flight  tortuosity  of  the  pulmonary  capillaries, 
and  by  swelling  of  the  alveolar  epithelium.  The 
ung  is  of  a dark  red  colour  ; it  is  heavier  and 
ess  crepitant  than  natural ; it  pits  on  pressure; 
•ndits  cut  surface  y ields  a reddish,  frothy,  tena- 
ious  liquid. 

2.  Red  hepa/isation. — Here  there  is  an  exu- 
ation  of  liquor  sanguinis  and  blood-corpuscles, 
he  exuded  liquids  coagulate  within  the  alveoli 
nd  terminal  bronchioles,  the  coagulum  enclosing 
umerous  white  and  a few  red  blood-corpuscles, 
'he  alveolar  epithelium  is  swollen  and  granu- 
ir.  It  is  stated  by  some  German  patholo- 
ists  that  the  coagulum  is  in  part  produced  by 
langes  in  the  epithelium.  The  lung  is  now 
jiueh  heavier  than  in  the  preceding  stage,  and  is 
icreasod  in  size,  so  ns  to  be  often  marked  by 
is  ribs.  It  is  quite  solid  ; sinks  in  water  ; and 
mnotbe  artificially  inflated.  It  is  remarkably 
iable,  breaking  down  with  a soft  granular  frac- 
. re.  The  cut  surface  has  a markedly  granular 
ipearance,  seen  especially  when  the  tissue  is 
rn,  and  due  to  the  plugs  of  coagulated  exuda- 
}n  matter  which  fill  the  alveoli.  The  colour  is 

a dark  reddish-brown,  often  hero  and  there 
ssing  into  grey.  This  admixture  with  grey 


sometimes  gives  a marb’ed  appearance.  The 
pleura  covering  the  solid  lung  always  partici- 
pates more  or  less  in  the  inflammatory  process. 
It  is  opaque,  hypersemic,  and  coated  w ith  lymph. 

3.  Grey  kepatisation. — This  stage  is  charac- 
terised by  a continuance  of  the  process  of  inflam- 
matory cell-emigration,  and  by  cell-proliferation. 
The  white  blood-corpuscles  continue  to  escape 
from  the  vessels,  and  the  alveolar  epithelium 
multiplies.  The  alveoli  thus  become  more  com- 
pletely filled  with  young  cell-forms,  so  that  the 
fibrinous  exudation  is  no  longer  visible  as  an  in- 
dependent material.  Many  of  these  cells,  espe- 
cially those  in  the  vicinity  of  the  alveolar  walls, 
are  larger  than  leucocytes  and  nucleated.  These 
are  evidently  the  offspring  of  the  alveolar  epi- 
thelium. The  fibrinous  exudation  now  disinte- 
grates, and  the  young  cells  rapidly  undergo  fatty 
metamorphosis.  The  alveolar  walls  themselves, 
with  few  exceptions,  remain  throughout  the  pro- 
cess unaltered;  although  very  occasionally,  when 
this  stage  is  untisually  advanced,  they  may  be 
found  here  and  there  partially  destroyed.  Owing 
to  these  changes,  the  reddish-brown  colour  of 
the  lung  becomes  altered  to  a greyish  or  yel- 
lowish white.  The  granular  appearance  is  much 
less  marked ; the  solid  tissue  is  much  softer  and 
more  pulpy  in  consistence;  and  a puriform  liquid 
exudes  from  the  cut  surface  of  the  organ.  This 
stage,  when  advanced,  has  been  termed  ‘suppu- 
ration ’ of  the  lung. 

Although  these  three  stages  of  the  pneumonic 
process  have  been  described  as  succeeding  one 
another  in  orderly  succession,  it  must  be  remem- 
bered that  each  stage  does  not  occur  simul- 
taneously throughout  the  whole  of  the  affected 
area  of  the  lung.  The  changes  advance  unequally, 
so  that  whilst  one  portion  of  the  lung  is  in  the 
stage  of  red  hepatisation,  another  may  be  in  the 
grey  stage — hence  the  mottled,  marble  appear- 
anceof  the  consolidation.  Therapidity  with  which 
the  several  stages  succeed  one  another  is  also 
subject  to  marked  variations.  In  some  cases  the 
pneumonic  consolidation  very  rapidly  becomes 
grey,  whilst  in  others  the  time  occupied  in  the 
transition  is  much  longer.  These  differences 
will  be  again  alluded  to  when  considering  the 
clinical  history  of  the  disease. 

Resolution. — The  natural  and  almost  invari- 
able termination  of  the  histological  process  is  in 
resolution — the  lung  gradually  returning  to  its 
normal  condition.  This  is  effected  by  the  fatty  and 
mucoid  degeneration,  and  consequent  liquefac- 
tion, of  the  inflammatory  products  which  have  ac- 
cumulated within  the  alveoli.  As  the  liquefac- 
tion proceeds,  the  circulation  in  the  alveolar  walls 
is  gradually  restored ; the  softened  products  are 
removed  by  absorption,  and  to  a much  less  extent 
by  expectoration ; and  the  lung  ultimately  re- 
gains its  normal  characters.  The  other  excep- 
tional modes  of  termination  in  gangrene,  abscess, 
and  chronic  pneumonia  will  be  alluded  to  subse- 
quently. 

Site. — The  local  lesion  in  acute  pneumonia  is 
in  the  majority  of  cases  limited  to  one  lung. 
When  double,  one  lung  is  usually  involved  before 
the  other.  The  right  lung  is  more  commonly  af- 
fected than  the  left.  The  part  of  the  lung  usually 
involved  is  the  lower  lobe  (about  75  per  cent.)  Tho 
consolidation  may  extend  upwards  and  implicat* 


LUNGS,  INFLAMMATION  OF. 


376 

the  -whole  lung.  Pneumonia  of  the  upper  lobes  is 
more  frequently  double  than  basic  disease.  It 
is  quite  rare  for  the  pneumonic  process  to  com- 
mence in  two  different  portions  of  the  lung.  When 
the  consolidation  is  met  with  in  both  lungs,  or 
commencing  in  the  upper  and  middle  lobes,  the 
pneumonia  is  often  either  a secondary  affection, 
and  has  supervened  in  one  whose  health  has 
been  previously  injured,  as  by  alcohol ; and  such 
distributions  of  the  local  lesion  should  always 
make  the  physician  look  carefully  for  evidence  of 
some  pre-existing  disease. 

Pathology.— Acute  pneumonia  is  undoubtedly 
to  be  regarded  as  a general  disease,  of  which  the 
pulmonary  inflammation  is  the  prominent  local 
lesion.  The  view  that  it  is  a strictly  local  affec- 
tion of  the  lung,  to  which  the  pyrexia  and  other 
symptoms  are  secondary,  is  altogether  untenable. 
The  truth  of  this  statement  becomes  obvious 
from  a study  of  its  natural  history.  The  disease, 
as  will  be  seen  subsequently,  runs  a typical 
course.  The  pyrexia  bears  no  definite  relation 
to  the  lung-affection.  It  frequently  precedes  it 
by  a considerable  interval,  and  commonly  disap- 
pears suddenly,  and  long  before  the  resolution  of 
the  pulmonary  consolidation. 

Respecting  the  exact  nature  of  the  disease, 
however,  we  are  at  present  unable  to  speak 
definitely.  It  is  maintained  by  some  observers 
that,  like  tho  specific  fevers,  it  is  due  to  a 
specific  cause.  Pneumonia,  whilst  differing  from 
these  fevers  in  not  being  contagious,  resembles 
them  in  the  typieal  character  of  its  clinical 
phenomena,  and  to  a less  extent,  of  its  local 
lesion.  The  changes  in  the  lung  occurring  in 
pneumonia  cannot  be  induced  by  artificial  in- 
jury of  the  organ,  and  it  must  therefore  be  ad- 
mitted that  there  is  something  special  in  the 
inflammatory  process.  Pneumonia  appears  to 
be  most  closely  allied  to  tonsillitis  and  acute 
rheumatism,  and  like  these  diseases  the  circum- 
stances under  which  it  originates  are  certainly 
exceedingly  diverse. 

Symptoms. — The  onset  of  acute  pneumonia  is 
in  the  majority  of  cases  sudden,  not  being  ac- 
companied by  any  premonitory  symptoms.  Much 
less  frequently  certain  premonitory  symptoms 
precede  the  more  severe  phenomena  which 
characterise  the  invasion  of  the  disease.  These 
symptoms  include  general  malaise,  headache, 
chilliness,  pains  in  the  back,  and  loss  of  appetite. 

Invasion. — The  invasion  in  adults  is,  in  almost 
all  cases,  announced  by  a rigor.  This  rigor  is 
more  marked  in  pneumonia  than  in  almost  any 
other  disease.  The  rigor  is  usually  single,  and  is 
»*cely  repeated,  either  at  the  commencement  or  in 
*hecourseof  the  illness.  In  very  old  subjects  the 
i gor  is  very  frequently  absent,  and  in  children 
il  s place  is  often  taken  by  convulsions  or  vomit- 
ing. The  rigors  or  other  phenomena  marking 
the  invasion  of  the  disease,  together  with  the 
attendant  pyrexia,  are  usually  quickly  followed 
by  symptoms  pointing  to  the  lung-affection. 
These  symptoms  commonly  supervene  in  the 
course  of  from  twelve  to  twenty-four  hours,  al- 
though in  exceptional  cases  not  until  after  the 
lapse  of  two  or  three  days.  The  earliest  of  them 
are  pain  in  the  side,  dyspnoea,  and  cough.  These 
more  local  symptoms,  together  with  the  pyrexia, 
acceleration  of  pulse,  thirst,  and  prostration, 


gradually  develop  up  to  tho  second  day  of  the  dis- 
ease, by  which  time  (and  sometimes  before  this) 
the  pulmonary  lesion  is  usually  sufficiently  far 
advanced  to  yield  unequivocal  physical  signs. 
The  general  aspect  and  symptoms  of  the  patient 
are  now  tolerably  characteristic.  The  flushed  and 
sometimesdusky  face,  anxious  expression,  hurried 
breathing,  hot  skin,  rapid  pulse,  short  frequent 
cough,  and  marked  prostration,  supervening 
quickly  upon  the  well-marked  initial  rigor,  indi- 
cate pretty  clearly  the  nature  of  the  disease. 

Pain. — The  pain  in  the  side,  which  is  increased 
by  deep  inspiration  and  by  cough,  usually  corre- 
sponds in  situation  with  that  of  the  affected  lung, 
although  it  is  occasionally  experienced  in  other 
parts.  This  symptom  may  occur  coincidently 
with,  although  it  more  commonly  succeeds,  the 
rigor.  In  quite  exceptional  cases  it  precedes  it, 
being  the  first  symptom  noticed.  Respecting  its 
cause — it  is  probably  due  to  the  implication  of 
the  pleura  in  the  inflammatory  process. 

Respiratory  phenomena. — Increased  frequency 
of  respiration,  dyspnoea,  and  cough,  are  early 
and  prominent  symptoms.  The  respiration— 
usually  regular — ranges  from  30  to  60,  and  in 
children  reaches  even  to  70,  whilst  the  pulse 
may  be  only  from  90  to  120.  This  perversion 
in  the  pulse-respiration  ratio  is  important  in 
diagnosis.  The  breathing  is  shallow;  inspira- 
tion is  abrupt;  and  when  the  pain  in  the  side 
is  severe,  respiration  is  sometimes  irregular. 
The  accelerated  respiration  is  accompanied  by 
marked  expansion  of  the  alee  nasi,  and  by  more 
or  less  dyspnoea.  There  is.  however,  no  definite 
relation  between  the  last-named  symptom  and 
the  frequency  of  the  respiratory  act.  Owing  to 
the  pain,  and  to  the  frequency  and  difficulty  of 
breathing,  speech  is  interfered  with  and  often 
rendered  exceedingly  difficult.  Cough  is  an 
almost  constant  symptom,  except  in  the  very 
old.  It  is  short  and  hacking,  rarely  paroxysmal 
like  that  of  bronchitis.  It  is  usually  in  the 
early  stages  attended  with  severe  pain  iu  the 
side,  so  that  the  patient  endeavours  to  repress 
it.  The  cough,  except  in  children,  and  often  in 
the  old,  is  attended  by  expectoration.  The 
sputa  of  pneumonia  are  very  characteristic.  They 
are  viscid,  glairy,  and  remarkably  tenacious,  so 
that  they  cling  to  the  mouth  of  the  patient,  and 
adhere  closely  to  the  sides  of  the  vessel  contain- 
ing them.  In  colour,  they  present  various 
shades  of  red,  brown,  and  yellow,  owing  to  the 
admixture  of  blood.  The  appearance  so  well 
known  ns  ‘rusty,’  is  that  most  commonly  met 
with.  Sometimes  they  are  much  more  diffluent, 
and  of  a dark  purple  colour,  somewhat  resem- 
bling prune-juice.  The  characteristic  sputa  are 
usually  met  with  on  the  first  or  second  day 
of  the  disease,  but  their  appearance  is  otren 
preceded  by  a frothy  aerated  expectoration  like 
that  of  bronchitis.  The  amount  expectorated  is 
small,  and  sometimes  the  pneumonic  is  asso- 
ciated with  more  or  less  of  the  frothy  catarrha, 
sputa  throughout  the  whole  of  the  disease 
During  the  period  of  resolution  the  sputa  bi 
come  less  viscid  and  more  catarrhal  in  diameter 
and  they  usually  contain  small  particles  of  hlac* 
pigment.  The  histological  elements  met  wit! 
in  the  sputa  are  leucocytes,  red  blood-cells,  an( 
altered  epithelium  from  the  alveoli  and  air-pas 


LUNGS,  INFLAMMATION  OF. 


Bages ; and  towards  the  decline  of  the  disease,  I 
fat-grannies,  pigment,  and  occasionally  fibrinous 
masses,  which  are  casts  of  the  alveoli  and  ter- 
minal bronchioles. 

Pulse. — The  pulse  m adults  usually  ranges 
from  90  to  1 20,  and  it  may  be  even  more  frequent. 
It  is  commonly  much  more  rapid  in  children,  and 
less  so  in  the  old.  In  the  early  stage  of  the  disease 
it  is  often  full  and  strong,  but  it  soon  becomes 
smaller  and  easily  compressible.  It  may  be  irre- 
gular, intermittent,  or  diehrotous.  The  small- 
ness of  the  pulse  is  probably  due  partly  to 
diminished  cardiac  power,  and  partly  to  the 
diminished  amount  of  blood  which  is  propelled 
from  the  left  ventricle,  owing  to  the  overloading 
of  the  right  cardiac  cavities  which  results  from 
the  obstructed  circulation  in  the  lungs. 

Pyrexia. — The  pyrexia  of  pneumonia  is  con- 
tinuous, with  slight  morning  remissions  and  even- 
ing exacerbations.  The  temperature  rises  very 
suddenly  with  the  invasion  of  the  disease,  to  from 
102°  to  105°  Fahr. ; and  this  high  temperature 
is  maintained  until  the  period  of  crisis.  This 
sudden  rise  and  maintenance  of  a high  tempera- 
ture is  very  characteristic.  The  amount  of 
elevation  varies  in  different  cases.  As  a rule  it 
does  not  exceed  about  1 01° or  1 05°  Fahr.,  but  tem- 
peratures of  107°  have  been  known  to  terminate 
favourably.  In  fatal  cases  it  may  reach  109° 
shortly  before  death.  The  maximum  tempera- 
ture is  usually  met  with  on  the  second  or  third 
lay  of  the  disease,  but  it  occasionally  occurs 
mmediately  before  the  crisis.  The  daily  varia- 
ions  are  usually  as  follows  : — The  temperature 
,s  lowest  about  7 or  S a.m.  In  the  forenoon, 
>r  somewhat  later,  it  commences  to  rise,  and 
attains  its  maximum  in  the  early  evening.  It 
, hen  falls,  but  a slight  exacerbation  occasionally 
iccurs  again  at  midnight,  after  which  it  gradually 
alls.  The  difference  between  the  highest  and 
owest  temperatures  is  usually  not  more  than 
0 Fahr.  The  pyrexia  runs,  for  the  most  part, 
uniform  course  until  the  period  of  crisis,  when 
he  temperature  falls  rapidly,  in  the  manner  to 
■a  hereafter  described. 

Nervous  system. — Headache,  restlessness,  and 
leeplessness  are  almost  always  prominent 
ymptoms.  Slight  delirium  is  also  common, 
'specially  towards  evening,  when  the  pyrexia  is 
t its  maximum.  Sometimes  the  delirium  is 
tore  marked  and  violent.  It  constitutes  a 
tore  prominent  symptom  in  the  old,  and  in  the 
lebilitated  and  intemperate.  In  drunkards  it 
■ constantly  present,  and  here  it  often  assumes 
ue  character  of  delirium  tremens.  Convulsions 
[•e  common  in  children,  especially  at  the  period 
invasion.  They  are  rare  in  the  adult.  These 
■rvous  symptoms  are  sometimes  so  prominent 
; to  mask  the  nature  of  the  disease. 

Digestive  organs.  — The  symptoms  of  acute 
jieumonia  referable  to  the  digestive  system  are 
nilar  to  those  met  with  in  other  severe  febrile 
seases.  There  is  loss  of  appetite  and  thirst. 
le  tongue  is  more  or  less  thickly  coated  with 
white  fur,  and  it  tends  in  severe  cases  to 
oomc  dry  and  brown.  Herpes  often  appear 
lout  the  lips,  and  sometimes  on  other  parts  of 
8 face,  about  the  third  or  fourth  day  of  the 
lease.  \ omiting,  which  is  a common  symptom 
invasion  in  the  child,  is  an  occasional  compli- 


877 

cation,  as  is  also  diarrhoea;  constipation,  how- 
ever, is  the  rule. 

Urine. — The  quantity  of  urine  is  considerably 
diminished,  and  its  specific  gravity  increased, 
so  that  abundant  urates  are  deposited.  The 
excretion  of  urea  is  greatly  increased,  and  it 
may  amount  to  as  much  as  seventy-five  grammes 
in  the  twenty-four  hours.  The  uric  acid  is 
likewise  augmented.  The  chloride  of  sodium 
is  much  diminished,  and  during  the  height  of 
the  disease  it  may  entirely  disappear.  Slight 
temporary  albuminuria  is  perhaps  more  common 
in  pneumonia  than  in  almost  any  other  acuto 
febrile  affection.  The  amount  is  usually  in 
direct  proportion  to  the  severity  of  the  disease. 
Bile-pigment  is  occasionally  met  with. 

Course  and  Terminations. — The  symptoms 
which  have  been  described  continue  with  often 
increasing  severity  up  to  about  theendof  the  first- 
week  of  the  disease,  sometimes  longer,  when  an 
improvement  usually  occurs.  This  improvement 
may  tqke  place  quite  suddenly,  and  the  disease 
rapidly  terminate  in  health — termination  by 
crisis  ; or  the  recovery  may  be  more  gradual — 
termination  by  lysis.  In  other  cases  death 
occurs  either  before  or  after  the  crisis.  The 
disease  may  also  terminate  in  gangrene  of  the 
lung ; in  pulmonary  abscess ; or  in  chronic 
pneumonia.  These  several  modes  of  termination 
must  be  considered  separately. 

Complete  recovery. — This  is  the  most  common 
termination  of  acute  pneumonia  in  young  and 
healthy  adults,  and  the  improvement  usually 
occurs  quite  suddenly — by  crisis.  The  time  at 
which  this  crisis  takes  place,  as  indicated  by  the 
sadden  fall  of  temperature,  varies  from  the 
third  to  the  twelfth  day.  In  the  majority  of 
cases  it  is  on  the  fifth,  sixth,  or  seventh  day;  it 
is  occasionally  as  early  as  the  third  day ; and 
sometimes  it  is  prolonged  into  the  middle  of  the 
second  week.  The  old  doctrine  that  the  crisis 
always  occurs  on  the  odd  days  is  untenable. 

The  supervention  of  the  crisis  is  sometimes 
indicated  by  a change  in  the  pulse,  which  be- 
comes softer,  and  somewhat  irregular  in  force 
and  rhythm.  The  most  marked  phenomenon 
attending  it  is  the  abrupt  fall  of  the  bodily 
temperature.  This  fall  may  commence  either 
during  the  morning  remission  or  the  afternoon 
exacerbation.  It  appears  to  be  most  eommor 
late  in  the  afternoon.  The  temperature  very 
often  reaches  the  normal  standard  in  from  six- 
teen to  twenty-four  hours,  usually  within  forty- 
eight  hours  ; the  morning  remission  and  evening 
exacerbation  occurring  during  the  period  of  de- 
fervescence. The  temperature  not  unfrequent ly 
falls  to  1°  or  2°  Fahr.  below  normal,  and  may 
remain  so  for  two  or  three  days.  Occasionally 
a marked  increase  in  the  pyrexia  is  observed 
immediately  before  the  commencement  of  defer- 
vescence. 

With  the  fall  of  temperature  all  the  symp- 
toms rapidly  improve.  The  skin  becomes  moist 
and  often  perspires  profusely.  The  amount  of 
urine  increases.  The  respiration  falls  in  fre- 
quency; and,  to  a less  extent,  the  pulse.  The 
cough  becomes  looser,  and  the  expectoration 
more  copious  ; the  sputa  gradually  losing  their 
tenacity  and  rusty  colour,  and  becoming  more 
bronchitic  in  character.  They  are  now  usually 


878  LUNGS,  INFLAMMATION  OF. 


mingled  with  more  or  less  black  pigment.  An 
improvement  in  the  physical  signs  is  sometimes 
observed  at  the  same  time ; more  commonly, 
However,  this  does  not  take  place  till  one  or  two 
days  later.  The  patient  often  falls  into  a deep 
sleep,  and  on  waking,  with  the  exception  of  great 
weakness,  declares  himself  pretty  well  and  be- 
gins to  ask  for  food.  In  some  cases,  however, 
the  amount  of  prostration  following  the  crisis  is 
so  great  that  the  return  to  health  is  more  gra- 
dual, and  a condition  of  collapse  may  ensue 
which  may  even  terminate  in  death. 

Iu  the  majority  of  cases  acute  pneumonia 
terminates  abruptly  in  the  manner  above  de- 
scribed. Sometimes,  however,  recovery  is  more 
protracted,  and  defervescence  may  not  be  com- 
plete till  the  end  of  the  second  week,  the  tem- 
perature falling  more  gradually — by  lysis.  The 
critical  fall  of  temperature  is  occasionally  in- 
terrupted by  more  or  less  marked  exacerbations, 
due  either  to  the  implication  of  fresh  portions 
of  the  lung,  or  to  the  supervention  of  one  of 
the  complications  to  bo  hereafter  alluded  to. 
In  some  cases,  again,  after  the  occurrence  of 
the  crisis,  the  temperature  assumes  a hectic 
type,  and  does  not  quite  reach  the  normal  stan- 
dard for  perhaps  two  or  three  weeks : the  irregu- 
lar fever  being  due  probably  to  the  contamina- 
tion of  the  blood  by  the  absorbed  pneumonic 
products  (Parkes).  Lastly,  a distinct  relapse 
may  occur  after  the  completion  of  crisis ; but 
the  relapse  is  in  most  cases  shorter  and  less 
severe  than  the  primary  attack. 

Death. — When  pneumonia  terminates  fatally, 
it  usually  does  so  towards  the  end  of  the  first, 
or  quite  at  the  beginning  of  the  second  week. 
Death  is  commonly  due  partly  to  failure  of 
cardiac  power,  and  partly  to  apncea.  Apnoea 
is  the  least  important  element  in  the  causation 
of  dissolution.  The  danger  from  it  increases 
with  the  extent  of  lung  involved,  and  it  is 
consequently  usually  greater  in  double  than  in 
unilateral  disease.  Failure  of  cardiac  power  is 
undoubtedly  the  most  important  means  by  which 
pneumonia  destroys  life  (Juergensen).  There 
are  several  conditions  in  the  disease  which  tend 
to  damage  the  contractile  power  of  the  heart. 
First,  and  foremost  of  these  is  the  pyrexia. 
The  severe  pyrexia  of  pneumonia,  like  that  cf 
other  acute  febrile  diseases,  produces  more  or 
less  granular  degeneration  of  the  cardiac 
muscular  fibres.  It  also  necessitates  increased 
frequency  of  the  cardiac  contractions,  in  order 
to  supply  the  increas-  l demand  for  oxygen,  and 
to  remove  the  excess  of  carbonic  acid.  Owing  to 
this  increased  frequency,  the  length  of  diastole — 
the  period  during  which  the  heart  rests  and  is 
nourished — is  shortened.  The  condition  of  the 
lung  itself  constitutes  another  important  ele- 
ment tending  to  damage  the  contractile  power 
of  the  heart,  and  especially  of  the  right 
ventricle  (Juergensen).  The  lung-consolidation 
not  only  presents  more  or  less  obstruction  to  the 
pulmonary  circulation,  and  hence  necessitates 
increased  action  on  the  part  of  the  right  ven- 
tricle ; but  owing  to  the  diminished  respiratory 
surface,  this  ventricle  is  obliged  to  do  more 
work  in  order  that  the  proper  interchange  of 
gases  may  be  effected  in  the  lungs. 

Such  being  the  modes  by  which  pneumonia 


tends  to  destroy  life,  it  will  he  readily  understood 
that  the  earliest  and  most  important  signs  of 
unfavourable  augury  are  on  the  6ide  of  the 
circulation.  The  pulse  becomes  more  frequent, 
small,  irregular,  and  often  dichrotous.  The 
frequency  of  the  respiration,  the  dyspnoea,  and 
the  cyanosis  increase.  The  cough  becomes  feeble 
and  ineffectual.  Owing  to  the  engorgement  and 
failure  of  power  of  the  right  ventricle  general 
pulmonary  cedema  usually  supervenes,  so  that 
moist  rales  are  audible  at  both  bases.  The  ex- 
tremities become  cold,  and  there  is  often  profuse 
perspiration.  The  mind  wanders,  and  a condi- 
tion of  partial  coma  supervenes  before  the  close. 
In  some  cases  a rapid  rise  of  temperature  takes 
place  before  the  fatal  termination,  whilst  in 
others  there  may  he  a considerable  fall  in  the 
thermometer. 

Pneumonia  may  also  terminate  fatally  from 
the  state  of  collapse  which  follows  the  crisis. 
Lastly,  in  those  exceptional  eases  in  which  the 
pneumonia  tends  to  become  more  or  less  chronic, 
death  may  occur  during  the  third  or  fourth 
week.  Death  may  also  result  from  the  com- 
plications. 

Gangrene. — This  is  quite  rare.  It  is  most 
common  in  chronic  drunkards,  and  in  those  of  de- 
bilitated constitution.  Its  occurrence  appears  to 
he  due  partly  to  blocking  of  vessels,  and  partly  to 
the  septic  influence  of  altered  inflammatory  pro- 
ducts. It  is  usually  limited  to  a small  area  of 
the  pneumonic  lung ; and  is  either  diffuse,  or 
becomes  limited  by  a zone  of  inflamed  tissue. 
It  commonly’  supervenes  late  in  the  disease;  and 
the  most  reliable  signs  of  its  occurrence  are 
marked  feetor  of  the  expectoration,  and  great 
prostration.  Portions  of  lung-tissue  are  occa- 
sionally found  in  the  sputa.  It  is  almost  invaria- 
bly, hut  not  necessarily,  fatal. 

Abscess. — This  is  somewhat  more  common 
than  the  preceding.  See  Lungs,  Abscess  of. 

Chronic  pneumonia.— Acute  pneumonia  in  very 
exceptional  cases  becomes  chronic,  and  leads  to 
induration  of  the  lung.  See  D.  Chronic  Pneu- 
monia. 

Physical  Sign’s. — The  earliest  physical  signs 
of  acute  pneumonia  are  usually  discoverable 
within  forty-eight  hours  of  the  invasion  cf  the 
disease.  They  often  appear  within  twelve  or 
twenty-four  hours  ; hut  occasionally,  when  the 
local  lesion  is  deeply  seated,  nothing  abnormal  is 
to  be  detected  until  the  third  or  fourth  day.  It 
will  be  well  to  describe  them  in  the  order  in 
which  they  commonly  make  their  appearance. 
The  time  occupied  in  their  evolution  will  vary 
according  to  the  rapidity  with  which  the  several 
stages  of  the  pneumonic  process  succeed  one 
another.  _ 

The  earliest  abnormal  physical  signs  are  due 
to  the  pain  caused  by  the  movement  of  the 
affected  side  ; to  the  hypersemia  of  the  pulmo- 
nary capillaries;  and  to  the  commencing  exu- 
dation into  the  air-vesicles.  The  respiratory 
movements  of  the  side  are  more  or  less  im- 
paired. This  is  partly’  owing  to  pain,  and  partly 
to  diminished  elasticity  of  the  lung-tissue.  The 
breath-sounds  are  usually  somewhat  weak  an 
harsh,  but  not  distant;  although,  an  stated  by 
Stokes,  they  are  occasionally  in  the  earnest 
stage  harsher  and  louder  than  natural.  Pei^ 


LUNGS,  INFLAMMATION  OF. 


mission  during  this  stage  is  usually  not  mark- 
edly altered.  The  resonance,  however,  is  some- 
times quite  appreciably  tympanitic,  but  as  the 
disease  progresses  the  tone  becomes  impaired. 
The  tympanitic  quality  of  the  resonance  is 
caused  by  the  diminished  elasticity  of  the  still 
air-containing  lung.  The  vocal  fremitus  is  in- 
creased. The  most  important  sign,  however,  of 
th^  congestive  stage  is  fine  crepitation.  This 
rale  consists  of  a number  of  fine,  dry,  crackling 
sounds,  following  one  another  in  rapid  succession, 
which  have  been  aptly  compared  by  Dr.  C.  J.  B. 
Williams  to  the  sounds  produced  by  rubbing 
the  hair  between  the  fingers  close  to  the  ear.  It 
occurs  during  the  later  period  cf  this  stage,  when 
the  process  of  exudation  from  the  pulmonary 
capillaries  is  commencing  to  take  place.  Its 
production  is  probably  due  to  the  partial  agglu- 
tination of  the  walls  of  the  air-vesicles  and 
their  forcible  separation  during  the  inspiratory 
act.  The  rale  is  almost  exclusively  limited  to 
inspiration.  It  is  intensified  by  deep  inspira- 
tion and  also  by  cough,  and  it  is  sometimes 
necessary  to  make  the  patient  cough  in  order 
that  it  may  be  produced.  A precisely  similar 
j rale  is  often  heard  with  deep  inspiration  in 
portions  of  the  lung  which  have  been  imper- 
fectly expanded.  Such  imperfect  expansion  is 
common  in  the  posterior  parts  of  the  lungs  of 
patients  who  have  been  confined  to  bed  from 
.acute  or  chronic  disease,  and  in  whom,  owing  to 
muscular  weakness,  inspiration  is  incompletely 
.performed.  The  rale  produced  under  these 
circumstances  is  distinguished  from  pneumonic 
crepitation  inasmuch  as  it  completely  disappears 
After  a few  deep  inspirations,  whereas  the  pneu- 
monic rale  when  once  established  persists  until 
the  consolidation  of  the  lung  is  tolerably  com- 
plete. 

The  physical  signs  of  the  stage  of  hepatisa- 
ion  are  due  to  the  more  or  less  complete  eon- 
■olidation  of  the  lung.  The  fine  crepitation 
which  characterised  the  later  periods  of  the 
■receding  stage  continues  during  the  process 
f consolidation,  but  ceases  as  the  filling  of 
he  air-vesieles  becomes  complete  ; although  it 
tay  often  still  be  heard  at  the  confines  of  the 
■ore  firmly  consolidated  lung.  It  occasion- 
tly  happens,  however,  when  the  consolidation 
very  rapidly  induced,  that  no  crepitation  is 
eard  throughout  the  course  of  the  disease  until 
le  period  of  resolution.  When  the  lung  has 
;icome  consolidated,  the  expansivo  movement 
' the  corresponding  portion  of  the  chest,  which 
as  before  diminished,  ceases.  The  intercos- 
1 spaces,  although  sometimes  slightly  more 
•ominent  than  in  the  healthy  side,  are  still 
pressed  and  not  obliterated  as  in  pleural  effu- 
>n.  AVhen  the  amount  of  exudation  is  very 
insiderable,  slight  enlargement  of  the  side  is 
‘cessarily  produced.  The  situation  of  the  car- 
te impulse  is  not  altered.  The  vocal  fre- 
!'tus  is  usually  increased.  To  this  general  rule, 
wever,  there  are  exceptions,  and  it  not  un- 
quently  happens  that  it  is  unaltered,  and  it 
•y  even  be  completely  absent,.  This  diminu- 
,n  in  the  vocal  fremitus  is  sometimes  due  to 
* blocking  of  the  smaller  bronchi  with  the 
lammatory  exudation,  but  more  frequently 
i appears  to  result  from  an  accumulation  of 


879 

mucus.  In  the  latter  case  it  may  sometimes 
be  restored  by  cough.  Coincidently  with  the 
increase  of  vocal  fremitus  there  is  usually  in- 
creased vocal  resonance,  and  sometimes  whisper- 
ing pectoriloquy  (Walshe  and  AVilson  Fox).  The 
percussion-sound  now  is  much  more  deficient  iD 
tone,  and  it  is  often  more  or  less  amphoric. 
This  amphoric  quality  is  probably  obtained  from 
the  columns  of  air  in  the  larger  bronchi  and 
trachea.  There  is  also  a great  increase  in  the 
sense  of  resistance,  but  neither  the  dulness  nor 
the  resistance  are  so  marked  as  in  pleural 
effusion.  In  basic  disease  percussion  under  the 
clavicle  often  yields  a distinctly  amphoric  note, 
whilst  the  lower  portions  of  the  chest  may  be 
almost  absolutely  dull.  The  auscultatory  sign 
of  this  stage  is  bronchial  breathing  This  is 
usually  remarkably  superficial,  high-pitched,  and 
metallic  in  quality  (tubular  breathing).  Some- 
times, however,  it  is  less  metallic  and  softer 
(diffused  blowing — AValshe).  These- respiratory 
phenomena,  like  the  vocal  resonance  and  fremi- 
tus, may  be  ab-ent  over  larger  or  smaller  areas 
of  the  consolidated  lung,  owing  to  the  obstruction 
of  the  bronchi  by  catarrhal  secretion.  The 
slight  pleurisy  which  constantly  accompanies 
the  pneumonia  is  rarely  susceptible  of  physical 
demonstration  during  this  stage.  This  is  prob- 
ably owing  to  the  immobility  of  the  solid  lung. 
During  the  period  of  resolution,  as  expansive 
power  returns,  friction-sounds  are  occasionally 
audible. 

Resolution  usually  commences  in  those  por- 
tions of  the  lung  which  were  the  last  to  become 
consolidated.  The  most  important  and  the 
earliest  of  the  signs  of  resolution  is  the  return 
of  crepitation.  The  crepitation,  however,  differs 
from  that  met  with  in  the  earlier  stages  of  the 
disease.  It  is  larger,  coarser,  and  more  liquid  in 
character — redux  crepitation  ; audits  liquid  cha- 
racter gradually  increases  until  it  may  become 
distinctly  bubbling.  AVhen  resolution  is  very 
rapid,  redux  crepitation  may  be  absent  (Wilson 
Fox).  The  bronchial  breathing  now  loses  its 
metallic  ringing  quality  ; the  pcrcussion-dulness 
gradually  disappears ; and  the  respiration  regains 
to  a great  extent  its  normal  characters. 

The  commencement  of  resolution  and  of  the 
improvement  in  the  physical  signs  occasionally 
takes  place,  as  already  stated,  coincidently  with 
the  establishment  of  crisis  ; but  more  commonly 
it  is  not  observed  until  from  twenty-lour  to 
forty-eight  hours  after  the  temperature  has 
reached  the  normal  standard.  The  time  occu- 
pied in  the  completion  of  resolution  varies. 
Sometimes  all  physical  signs  almost  completely 
disappear  in  twenty-four  hours.  L'sually,  how- 
ever, resolution  is  less  rapid,  and  marked  signs 
of  consolidation  remain  for  periods  varying  from 
two  or  three  days  to  two  weeks.  A slight 
amount  of  dulness  and  some  weakness  of  respira- 
tion often  persist  at  the  posterior  and  inferior 
portions  of  the  lung  for  even  still  longer  periods. 
This  is  especially  the  case  if  the  pneumonia  is 
complicated  with  pleurisy.  AAThen  marked  signs 
of  consolidation  exist  after  the  third  week, 
there  always  exists  more  or  less  probability 
that  the  pneumonic  process  may  become  chronic. 

A'ahieties.  — The  three  following  varieties 
of  pneumonia  present  clinical  phenomena  some- 


880  LUNGS,  INFL, 

what  different  from  those  which  have  been  de- 
scribed. 

a.  Latent  •pneumonia . — Pneumonia  has  been 
termed  latent  when  the  characteristic  symptoms 
of  the  disease  are  absent,  or  but  little  pro- 
nounced ; or  when  they  are  masked  by  some 
other  clinical  phenomena.  It  is  in  the  pneu- 
monia of  the  aged  that  marked  latency  is  so 
often  observed.  Here  invasion  may  be  unat- 
tended by  rigor  or  other  prominent  symptoms. 
Cough,  expectoration,  pain,  and  dyspnoea  may 
be  completely  wanting.  If  cough  be  present 
the  sputa  often  do  not  present  the  rusty  tinge, 
but  are  simply  transparent  or  muco-purulent. 
Pyrexia,  some  increased  frequency  of  breathing, 
great  prostration,  and  mote  or  less  muttering 
delirium,  are  the  principal  symptoms.  The  fever, 
however,  is  usually  much  less  than  in  adults. 
This  latent  course  of  pneumonia  it  is  important 
to  bear  in  mind,  as  it  indicates  the  necessity  of 
making  a most  careful  physical  examination  of 
the  chest  in  all  severo  acute  illnesses  of  the  aged. 
In  the  pneumonia  of  drunkards  and  of  young 
children,  also,  the  accompanying  nervous  pheno- 
mena may  be  so  prominent  as  to  mask  the 
nature  of  the  disease. 

b.  Asthenic  ( typhoid ) pneumonia.  — When 
pneumonia  occurs  in  those  who  are  debilitated 
by  previous  disease,  by  the  abuse  of  alcohol,  by 
age,  by  privation,  or  other  causes,  the  pheno- 
mena of  invasion  are  usually  not  pronounced, 
and  symptoms  of  intense  prostration  occur  early. 
In  many  respects  the  course  of  the  disease 
closely  resembles  that  which  has  been  just  de- 
scribed as  so  common  in  the  aged.  The  initial 
rigor  and  pain  in  the  side  are  often  observed;  but 
cough  is  slight ; and  the  expectoration,  instead 
of  the  rusty-brown  tint,  may  present  a dirty 
brown  or  prune-juice  appearance.  Various 
symptoms  of  an  asthenic  type  soon  become  pro- 
minent ; the  most  important  of  which  are  low 
delirium,  alternating  with  stupor;  tremors  ; and 
paralysis  of  the  sphincters.  The  tongue  is 
brown  and  dry  ; sordes  form  ou  the  teeth ; the 
pulse  is  exceedingly  rapid  and  feeble ; and  there 
is  often  slight  jaundice  and  albuminuria.  Death 
usually  supervenes  some  time  during  the  second 
week  of  the  disease.  After  death  the  lung  is 
usually  found  to  be  less  firmly  consolidated  and 
less  granular  than  in  sthenic  forms  of  pneu- 
monia. The  stage  of  grey  hepatisation  in  some 
cases  is  exceedingly  advanced,  constituting 
what  has  been  termed  ‘suppuration’  of  the  lung 
(Sturges). 

c.  Intermittent  pneumonia. — An  intermittent 
variety  of  pneumonia  is  sometimes  met  with  in 
malarial  districts,  which  appears  to  be  one  of 
the  results  of  malarial  infection.  According  to 
Grisolle  it  occurs  in  intermittent  and  remittent 
forms.  The  former  is  characterised  mainly  by 
the  complete  intermissions  which  occur  in  the 
pyrexia.  The  temperature  falls  suddenly  at  the 
end  of  twenty-four  hours  ; profuse  sweating  oc- 
curs ; and  the  physical  signs  of  the  pneumonia 
almost  entirely  disappear.  A return  of  the 
pyrexia  and  physical  signs  takes  place  at  the 
expiration  of  twenty-four  or  forty-eight  hours, 
followed  by  another  intermission,  and  this  by  a 
third  or  fourth,  the  disease  presenting  either 
a quotidian  or  a tertian  type.  Both  lungs  are 


MMATION  OF. 

liable  to  be  involved.  In  tne  remittent  form 
there  is  a much  less  complete  disappearance  of 
the  physical  signs  during  the  remission. 

Complications. — Pleurisy.  —Pleurisy  of  slight 
intensity  and  unaccompanied  by  effusion  is,  as 
already  stated,  almost  invariably  met  with  in 
acute  pneumonia  over  those  portions  of  the  lun» 
which  are  consolidated.  This  is  natural  to  the 
disease,  and  cannot  he  regarded  as  a complicaticr. 
Pleurisy  of  greater  intensity,  and  atten  !ed*'l,y 
effusion,  occurs  in  from  five  to  fifteen  per  cent, 
of  the  cases.  Signs  of  effusion  are  not  usually 
discoverable  before  the  third  or  fourth  day  of 
the  disease.  The  amount  of  liquid  varies  xvith 
the  extent  of  the  lung-consolidation.  When  this 
is  considerable,  involving  nearly  the  whole  lung, 
there  is  but  little  room  for  effusion.  The  super' 
vention  of  pleurisy  does  not  commonly  mate 
rially  modify  the  course  of  the  disease.  It  may, 
however,  protract  the  period  of  defervescence.' 
Its  influence  in  interfering  with  the  disappear- 
ance of  the  physical  signs  has  been  already 
alluded  to.  When  pleurisy  occurs  on  the  side 
opposite  to  the  pneumonia  it  constitutes  a more 
dangorous  complication. 

Bronchitis. — This  is  also  a common  complica- 
tion, especially  in  the  aged  and  in  young  chil- 
dren. Many  cases,  however,  which  have  been 
described  as  acute  pneumonia  associated  with 
bronchitis,  have  doubtless  been  eases  of  broncho- 
pneumonia. The  bronchitis  almost  invariably 
affects  both  lungs.  Its  supervention  is  attended 
by  an  increase  in  the  cough  and  in  the  amount  of 
expectoration.  When  it  involves  the  smaller 
tubes  generally,  it  constitutes  a serious  compli- 
cation. 

Pericarditis. — This  is  less  frequent.  It  may 
result  from  the  direct  extension  of  the  inflam- 
matory process  from  the  pleura,  or  it  may  be 
a part  ot  the  general  disease.  It  is  a grave  com- 
plication, and  greatly  increases  the  mortality. 

Jaundice. — A slight  yellowish  tinge  of  the 
conjunctiva,  and  even  of  the  skin,  is  not  unfre- 
quent in  pneumonia,  and  has  no  clinical  signi- 
ficance. It  is  probably  in  most  eases  owing  to 
the  congestion  of  the  liver  which  results  from 
the  impeded  pulmonary  circulation — the  dis- 
tended portal  veins  pressing  upon  the  bile-duets. 
Much  more  extensive  jaundice  is  also  occasionally 
met  with,  which  appears  usually  to  be  due  tc 
duodenal  catarrh,  and  is  attended  by  gastru 
symptoms.  In  other  cases,  especially  in  asthenii 
forms  of  the  disease,  a non-obstructive  jaundici 
sometimes  occurs,  resulting  from  changes  in  th< 
red  blood-corpuscles.  This  is  commonly  asso 
dated  with  nervous  symptoms,  such  as  stupor 
delirium,  and  a tendency  to  collapse,  which  ar 
of  grave  prognostic  import. 

Parotitis. — This  is  a very  rare  and  exceeding! 
serious  complication.  According  to  Grisolh 
it  is  usually  unilateral ; the  inflammatory  pr 
cess  is  very  acute  ; and  commonly  leads  to  suj 
puration  or  gangrene. 

Diagnosis. — The  diagnosis  of  acute  pneum' 
nia,  although  usually  easy,  is  sometimes  attend; 
with  difficulty.  It  cannot  be  made  with  abs 
lute  certainty  before  the  appearance  of  tl 
physical  signs  of  pulmonary  consolidate, 
although  some  of  the  phenomena  of  invasion  a 
so  characteristic,  that  the  nature  of  the  disea 


LUNGS,  INFLAMMATION  OF. 


851 


# often  tolerably  evident  before  abnormal  phy- 
sical signs  are  discoverable.  The  phenomena 
which  are  of  the  most  diagnostic  value  at  this 
early  stage  of  the  disease  are  the  pyrexia,  the 
altered  pulse-respiration  ratio,  the  pain  in  the 
side,  and  the  cough.  The  sudden  and  rapid  rise 
of  the  bodily  temperature,  which  usually  reaches 
its  maximum  in  forty-eight  hours,  is  very  cha- 
.racteristic;  such  a rapid  attainment  and  main- 
tenance of  a high  temperature  being  perhaps 
more  common  in  pneumonia  than  in  any  other 
disease  (Wilson  Fox).  Of  the  other  symptoms, 
the  increased  frequency  of  respiration,  and  espe- 
cially the  alteration  in  the  pulse-respiration 
ratio,  are  of  the  most  valuable  diagnostic  import 
AValshe).  When  physical  signs  of  pulmonary 
lonsolidation  are  discoverable,  which  they  usually 
ire  within  forty-eight  hours,  the  diagnosis  be- 
•omes  certain. 

Difficulties  in  diagnosis  may  arise  in  those 
■ases  in  which  the  local  process  in  its  earlier 
tages  is  deeply  seated.  Here,  characteristic 
ihysical  signs  may  be  wanting  for  four  or  five 
lays,  during  which  time  some  doubt  may  exist 
s to  the  nature  of  the  disease.  Then,  again, 
n those  latent  forms  of  pneumonia  which  have 
een  already  described  the  disease  may  be  easily 
verlooked,  unless  a careful  examination  be  made 
f the  chest. 

The  diagnosis  of  pneumonia  from  other  dis- 
uses of  the  lungs  is  rarely  difficult.  The 
isease  with  which  it  is  most  liable  to  be  con- 
iiinded  is  pleurisy.  In  pleurisy,  however,  there 
not,  as  a rule,  such  a sudden  aud  rapid  attain- 
ent  of  a high  temperature  as  in  acute  pneu- 
onia ; and  when  effusion  has  taken  place,  the 
lysical  signs  are  in  most  cases  sufficiently 
stinctive.  In  pleural  effusion  the  bulging  of 
e side;  the  obliteration  of  the  intercostal 
aces ; the  displacement  of  the  heart ; the  abso- 
tedulness  and  sense  of  resistance  on  percussion; 
'e  weak  and  distant  character  of  the  respiration ; 
d the  diminished  vocal  fremitus  and  resonance, 
ntrast  with  the  signs  of  pulmonary  consola- 
tion. 

Another  disease  with  which  pneumonia  may 
confounded  is  that  somewhat  rare  form  of  very 
■ ite  phthisis,  in  which  a large  area  of  the  lung 
1 tomes  rapidiy  consolidated — the  consolidation 
1 ug  often  in  the  main  indistinguishable  histo- 
1 ically  from  that  met  with  in  acute  pneu- 
r ha.  Here,  however,  although  the  whole  lung 
r ; be  involved,  the  disease  usually  commences 
n;he  upper  lobes,  so  that  abnormal  physical 
8 .s  are  more  marked  at  the  apex.  The  onset 
o he  disease  also  is  commonly  much  less  sud- 
d and  its  course  is  more  protracted.  Then, 
n>  the  rapid  consolidation  of  the  lower  por- 
t>  > of  the  lungs  which  sometimes  supervenes 
ii pore  chronic  forms  of  phthisis,  might  be  mis- 
ta  n for  the  consolidation  of  acute  pneumonia  ; 
b'  the  history  of  the  case,  a careful  examina- 
j"  of  the  upper  lobes  of  the  lungs,  the  irregu- 
jf  'ourse  of  the  pyrexia,  and  the  protracted 
notion  of  the  disease,  will  easily  serve  to  dis- 
!u  'sh  them.  It  may  be  stated  generally  that, 
ln  1 acute  consolidations  of  the  lung,  a pro- 
tn  3d  course  of  the  pyrexia,  and  the  occur- 
18'  of  marked  exacerbations  and  of  remissions 
°t  3 fever  at  irregular  intervals,  afford  grounds 

56 


for  the  supposition  that  the  consolidation  is 
phthisical. 

The  diagnosis  of  acute  pneumonia  from 
broncho-pneumonia  and  collapse  of  the  lung,  will 
be  considered  when  treating  of  broncho-pneu- 
monia. See  Broncho-Pneumonia. 

Prognosis. — The  mortality  from  acute  pneu- 
monia varies  at  different  periods,  the  diseasa 
being  more  fatal  in  some  years  than  in  others. 
This  is  probably  partly  owing  to  variations  ir 
what  is  called  ‘ epidemic  influence.’ 

Of  all  the  circumstances  which  influence  the 
prognosis  of  pneumonia,  that  which  is  perhaps 
the  most  important  is  the  state  of  the  general 
health.  In  weakly  subjects,  and  in  those  whose 
constitutions  have  been  damaged  by  previous 
disease,  by  privation,  or  by  their  mode  of  life, 
acute  pneumonia  is  exceedingly  dangerous.  The 
prognosis  is,  however,  especially  grave  in  those 
injured  by  the  long-continued  abuse  of  alcohol, 
the  mortality  being,  according  to  Huss,  from  20 
to  25  per  cent. 

In  healthy  children  the  mortality  from  pneu- 
monia is  comparatively  small.  The  fatality  for- 
merly ascribed  to  the  disease  at  this  period  of 
life  was  probably  owing  in  great  measure  to 
the  inclusion  of  cases  of  collapse  and  broncho- 
pneumonia in  the  statistics ; the  latter  disease 
being  exceedingly  fatal.  Healthy  young  adults 
rarely  die  ; after  the  age  of  thirty  the  mortality 
increases  considerably ; and  in  the  old  pneu- 
monia is  an  exceedingly  fatal  disease. 

Pneumonia  is  more  fatal  in  females  than 
males,  the  mortality  being  in  the  proportion  of 
three  to  two.  Pregnancy  renders  the  disease 
more  dangerous. 

The  danger  of  pneumonia  increases  somewhat 
with  the  extent  of  lung  implicated.  It  is,  how- 
ever, the  implication  of  both  lungs  which  ren- 
ders the  prognosis  especially  grave.  With  re- 
gard to  the  situation  of  the  consolidation  it 
may,  perhaps,  be  stated  generally  that  pneu- 
monias commencing  in  the  upper  lobes  are 
rather  more  serious  than  basic  disease.  The  gra- 
dual extension  of  the  consolidation  late  in  the 
disease,  and  the  spreading  of  the  inflammatory 
process  from  one  centre  to  another,  constitute 
elements  of  gravity.  When  resolution  is  much 
protracted,  the  fact  that  the  disease  in  very  ex- 
ceptional cases  terminates  in  an  indurative  con- 
solidation of  the  lung  is  not  to  be  forgotten. 

The  mortality  of  pneumonia  is  greatly  in- 
creased by  the  existence  of  complications.  The 
prognostic  importance  of  these  has  already  been 
considered. 

Of  individual  symptoms  the  pulse  is  of  chief 
importance.  A pulse  which  in  the  adult  is 
persistently  over  120,  and  in  the  child  over  140. 
is  of  grave  significance.  Marked  irregularity 
in  force  and  rhythm  is  also  unfavourable,  es- 
pecially in  the  young.  Dichrotism  may  occur 
temporarily  in  quite  favourable  cases,  but  if  it 
persists  it  indicates  danger.  The  variations  in 
respiration  are  of  less  import.  An  extreme 
quickness  of  breathing,  marked  dyspnoea,  and 
cyanosis  are  not  uncommon  in  cases  which  ter- 
minate in  recovery;  at  the  same  time  such 
symptoms  must  have  more  or  less  unfavourable 
significance.  Sputa  of  a dark  prune-juice  colour 
are  of  somewhat  evil  augury;  as  is  also  ac 


LUNGS,  INFLAMMATION  OF. 


iH‘2 

Abundant  liquid  puriform  expectoration.  The 
indications  from  the  pyrexia  are  of  less  prognos- 
tic value  in  pneumonia  than  in  most  other  acute 
diseases.  A temperature  of  105°  or  106°  Fahr. 
does  not  in  itself  indicate  danger.  Greater  eleva- 
tion is  grave.  In  many  fatal  cases  the  tempera- 
ture never  attains  102°.  The  significance  of  a 
protracted  defervescence  has  already  been  al- 
luded to.  On  the  side  of  the  nervous  system,  it 
is  to  be  remembered  that  slight  delirium  is  not 
uncommon ; but  when  it  is  marked,  and  espe- 
cially when  it  occurs  late  in  the  disease,  it  is 
most  grave.  It  is  of  greater  significance  in 
adults  than  in  children.  Tremors  and  a ten- 
dency to  coma  are  also  unfavourable.  A dry, 
brown  tongue  is  unfavourable,  especially  when 
associated  with  only  a moderate  degree  of  py- 
rexia. Gastric  catarrh  and  diarrhoea  add  to  the 
danger.  A slight  amount  of  jaundice  is  not  of 
bad  impoTt.  The  existence  of  albuminuria,  or 
the  appearance  of  albumen  in  the  urine  early  in 
the  disease,  is  unfavourable. 

Tkkatment. — In  considering  the  treatment  of 
acute  pneumonia,  it  is  of  the  utmost  importance 
to  bear  in  mind  the  true  nature  of  the  disease. 
All  rational  and  successful  therapeutics  must  be 
based  upon  the  recognition  of  the  fact,  that  it  is 
a general,  and  not  a local,  affection  which  we 
wish  to  influence.  The  ‘heroic’  methods  of 
treatment  by  venesection,  tartar  emetic,  &c.,  so 
much  in  vogue  in  the  past,  had  for  their  object 
the  controlling  or  cutting  short  of  a local  affec- 
tion of  the  lung  ; hence  the  unfavourable  results 
which  attended  them.  As  these  methods  have 
been  abandoned,  and  there  has  existed  a more 
correct  appreciation  of  the  pathology  of  the 
disease,  the  mortality  attending  it  has  dimi- 
nished. 

■When  discussing  the  pathology  of  pneumonia, 
reasons  were  adduced  for  the  belief  that  it  owes 
its  origin  to  a specific  cause.  Whether  this  be 
so  or  no,  the  disease  is  so  closely  allied  to  the 
specific  fevers,  that  in  attempting  to  influence  its 
course  by  treatment,  we  must  be  guided  by  the 
same  general  principles.  As  in  these  fevers,  our 
object  must  be  to  endeavour  to  conduct  the 
pneumonia  to  a favourable  termination.  We 
cannot  arrest  its  progress,  but  we  can  often  do 
very  much  both  to  maintain  the  strength  of  the 
patient,  and  to  modify  those  elements  in  the 
disease  which  tend  to  destroy  life. 

The  modes  by  which  pneumonia  tends  to 
destroy  life  have  been  already  considered. 
Failure  of  cardiac  power  is  the.  great  source  of 
danger.  The  causes  of  this  failure  it  is  impor- 
tant to  bear  in  mind  when  treating  the  disease, 
and  the  reader  is  referred  to  what  has  been 
already  stated  respecting  it.  The  natural  course 
of  the  disease  is  also  to  be  remembered.  In  the 
strong  and  robust  pneumonia  usually  terminates 
in  health.  It  is  in  those  who  are  debilitated  by 
age,  privation,  mode  of  life,  the  abuse  of  alcohol, 
or  pre-existing  disease,  that  such  great  morta- 
lity attends  it.  It  is  a question  of  the  intensity  of 
the  disease  on  the  one  hand,  and  of  the  resisting 
power  of  the  individual  on  the  other.  Such  con- 
siderations as  these  not  only  indicate  the  impor- 
tance of  doing  all  that  is  possible  to  husband 
and  support  the  strength  of  the  patient,  but  also  | 
af  not  interfering  too  actively  with  the  disease,  1 


unless  circumstances  arise  which,  if  uninfluenced 
by  treatment,  would  tend  to  rapidly  prove  latil. 

Such  being  the  general  principles  which  should 
guide  the  practitioner  in  the  treatment  of  acute 
pneumonia,  the  manner  in  which  they  are  to  be 
best  carried  out  may  now  he  indicated. 

The  patient  should  he  kept  in  bed.  The  room 
should  be  large  and  airy ; and  the  temperature 
about  60°  to  62°  Fahr.  It  should  be  well-ven- 
tilated : a plentiful  supply  of  fresh  air  is  most 
important,  and  although  due  care  should  be  ex- 
ercised in  the  ventilation,  there  is  not  the  same 
necessity  to  keep  the  patient  scrupulously  pro- 
tected from  draughts,  as  in  the  treatment  of 
acute  bronchitis. 

The  diet  should  he  carefully  regulated,  nutri- 
tious, and  easily  digestible,  consisting  of  milk, 
milk  with  the  white  of  egg,  beef-tea,  meat  es- 
sence, and  such-like  articles,  given  in  varying 
quantities  and  at  varying  intervals,  according 
to  the  condition  of  the  patient.  With  the  object 
of  promoting  the  appetite,  it  is  well  to  keep 
the  mouth  cleansed  with  glycerine  and  lemon- 
juice.  Small  quantities  of  wine,  as  hock,  dry 
sherry,  champagne,  or  burgundy,  given  occa- 
sionally with  food,  are  often  useful  as  stimu- 
lants to  the  appetite  and  digestive  process. 
Some  acid  and  bitter,  as  hydrochloric  acid  and 
orange-peel,  may  also  he  prescribed  for  the  same 
purpose.  If  in  the  early  stage  of  the  disease 
there  is  great  constipation,  loaded  tongue 
nausea,  or  other  gastric  symptoms,  the  adminis- 
tration of  a small  dose  of  calomel,  or  of  blue 
pill  and  colocynth,  is  often  followed  by  marke' 
improvement,  both  in  the  power  to  take  food,  anc 
in  the  general  condition  of  the  patient.  Tin 
exhibition  of  purgatives,  however,  requires  grea 
care,  as  they  occasionally  set  up  a catarrhs 
condition  of  the  intestine,  and  consequent  diar 
rhcea,  which  may  prove  more  or  less  persistent 
It  is  important,  therefore,  except  in  such  case 
as  those  above  indicated,  to  procure  all  neeessar 
evacuation  of  the  bowels  either  by  a small  dos 
of  castor  oil,  or  of  colocynth  and  hyoscyamus,  c 
by  simple  enemata. 

Everything  should  he  done  to  husband  ti 
strength  of  the  patient,  and  the  services  of  s 
efficient  nurse  will  often  do  very  much  towar; 
the  attainment  of  this  object.  Perfect  rest  mu 
be  enjoined,  and  all  unnecessary  speaking  1 
forbidden.  There  are  two  circumstances  whi> 
often  tend  greatly  to  interfere  with  rest— tl 
pain  in  the  side,  and  the  cough.  The  former 
these  may  usually  be  relieved  by  the  appliq 
tion  of  large  hot  linseed  poultices,  or  of  b 
fomentations  to  the  side.  These  must  be  f> 
quently  changed,  and  great  care  should 
exercised  in  their  renewal  not  to  disturb  or  : 
convenience  the  patient.  If  these  means  do  i 
succeed,  from  one-eighth  to  one-sixth  grain 
acetate  of  morphia  may  be  administered  hy] 
dermicallv ; or  a small  blister  or  three  or  fc 
leeches  may  be  applied  to  the  seat  of  the  pa 
and  the  hot  applications  then  renewed.  Cou. 
is  not  usually  a troublesome  symptom,  and 
less  it  greatly  disturbs  the  patient,  it  is  bet? 
not  to  interfere  with  it.  If  necessary,  a linet, 
containing  from  two  to  four  minims  of  liq- 
morphi*  hydrochloratis  and  a similar  quanta 
of  vinum  ipecacuanhas,  given  occasionally^ 


! 


LUNGS,  INFLAMMATION  OF. 


88S 


often  beneficial.  By  means  of  the  treatment 
above  indicated,  and  by  keeping  the  room  quiet 
and  darkened,  the  patient  will  often  procure  a 
sufficient  amount  of  sleep.  This  can  very 
frequently  be  promoted  by  carefully  sponging 
the  whole  surface  of  the  body,  a portion  at  a 
time,  with  tepid  water,  the  last  thing  at  night. 
Should  it  be  necessary,  some  narcotic  must  also 
be  administered,  but  with  great  caution,  so  as 
not  to  interfere  with  freedom  of  expectoration ; 
and  it  should  only  be  had  recourse  to  when  other 
means  have  failed,  and  in  the  absence  of  contra- 
indications. Hyoscyamus  and  bromide  of  potas- 
sium may  be  safely  used  for  this  purpose  ; and 
should  these  fail,  opium  may  also  be  given.  This 
should  be  prescribed  in  a sufficiently  large  dose 
to  ensure  sleep,  and  is  perhaps  best  administered 
hypodermically,  as  acetate  of  morphia.  Chloral 
is  usually  contraindicated,  on  account  of  its  de- 
nressing  effect  upon  the  circulation. 

A very  large  number  of  cases  of  pneumonia 
erminate  in  health  without  the  necessity  of  any 
further  interference  on  the  part  of  the  physician 
i ban  has  been  described.  Frequently,  on  the 
ither  hand,  circumstances  arise  indicative  of 
'.anger,  which  require  to  be  met  by  more  active 
treatment.  The  chief  source  of  danger,  as  al- 
ready stated,  is  failure  of  cardiac  power,  and 
onsequently  all  symptoms  of  such  failure  must 
Jo  carefully  watched  for.  Apncea  is  less  impor- 
tant, excnpt  in  those  cases  where  both  lungs  are 
xtensively  involved. 

Any  sign  of  cardiac  failure  will  in  the  first 
lace  suggest  the  advisability  of  administering 
Icohol.  The  exhibition  of  small  quantities  of 
;ine  with  food  has  been  already  recommended 
•>  sometimes  useful  in  stimulating  the  appe- 
|te  and  assisting  digestion,  in  cases  where  there 
■e  no  symptoms  of  asthenia;  but  when  such 
■mptoms  arise,  alcohol  must  be  employed  in 
rger  quantities.  It  may  be  stated  generally 
at  a pulse  of  over  120  or  130  calls  for  the 
lployment  of  stimulants.  Brandy  appears  in 
}st  cases  to  answer  best.  The  amount  admin- 
ered  must  depend  upon  its  effects  ; and  al- 
Dtigh  in  most  cases  from  four  to  eight  ounces 
the  twenty-four  hours  will  be  sufficient,  if  the 
licnia  persist  it  must  be  given  in  very  much 
■ ger  quantities.  Baik  and  camphor  have  also 
jin  employed  as  stimulants,  and  in  some  cases 
<y  are  useful  in  addition  to  the  alcohol, 
n the  treatment  of  failure  of  cardiac  power, 
livever,  it  is  important  to  attempt  to  modify, 
(far  as  possible,  those  conditions  upon  which 
£ih  failure  principally  depends.  The  most  im- 
Ijtant  of  these  conditions  is  the  pjmexia  (Juer- 
ffsen).  Various  remedies  have  been  employed 
vp  the  object  of  diminishing  pyrexia.  Of  these 
a lite,  tartar  emetic,  and  veratrum,  although 
f ' all  have  more  or  less  effect  in  relieving 
b i the  frequency  of  the  pulse  and  the  tempe- 
r:  re,  tend  to  weaken  the  heart,  and  are  conse- 
R illy  contraindicated  in  pneumonia.  Digitalis 
ay  erhaps  less  objectionable,  but  its  liability, 
ltie  large  doses  in  which  it  must  be  adminis- 
fil,  to  depress  the  circulation,  renders  its  ex- 
N ion  somewhat  dangerous. 

lie  two  romed’vs  which  appear  to  be  of  most 
tali  in  reducing  the  pyrexia  of  pneumonia  are 


F 


ne,  and  the  external  application  of  cold. 


Quinine  has  been  used  moro  largely  in  Germany 
than  in  this  country.  It  must  be  given  in  large 
doses— -thirty  grains  or  more,  it  is  usually 
best  to  administer  one  dose  early  in  the  evening, 
and  not  to  repeat  this  until  after  an  interval  of 
twenty-four  hours  ; and  it  is  often  well  at  the 
same  time  to  give  a full  dose  of  alcohol  (brandy, 
an  ounce  to  an  ounce  and  a half).  Quinine  thus 
given  undoubtedly  in  many,  although  not  in  all, 
cases  produces  a marked  reduction  in  the  tem- 
perature, and  it  is  desirable  to  employ  it  when 
such  a reduction  is  indicated. 

A much  more  efficient  agent  in  diminishing 
the  pyrexia  than  quinine  is  the  external  ap- 
plication of  cold.  This  mode  of  treatment  also 
has  been  much  more  largely  employed  abroad 
than  in  this  country,  and  here  it  is  only  in  quite 
exceptional  cases,  where  the  temperature  ranges 
very  high  (106°  or  107°  Fahr.)  that  its  employ- 
ment would  be  considered  justifiable.  The  fol- 
lowing is  the  method  of  procedure  recommended 
by  Professor  Juergensen  : — When  the  tempera- 
ture reaches  104°  Fahr.  the  patient  should  be 
placed  in  a bath  at  a temperature  of  603  Fahr., 
and  be  kept  there  from  seven  to  twenty-five 
minutes — according  to  the  effect  on  the  tempera- 
ture. The  pulse  must  be  carefully  watched,  and 
stimulants  be  administered  both  before,  during, 
and  after  the  bath.  If  necessary  the  tempera- 
ture of  the  water  must  be  gradually  reduced  to 
42°  Fahr.  The  cooling  process  usually  continues 
for  about  a quarter  of  an  hour  after  removal 
from  the  bath.  The  bath  must  be  repeated  when 
the  temperature  again  rises  to  104°  Fahr.  Juer- 
gensen recommends  this  treatment  before  the 
supervention  of  symptoms  of  cardiac  failure, 
with  the  object  of  diminishing  the  injury  to 
the  heart  caused  by  the  pyrexia.  When  there 
is  marked  asthenia,  and  the  heart's  action  is 
already  much  enfeebled,  such  treatment  requires 
to  be  employed  with  great  caution,  owing  to  the 
temporary  depression  caused  by  the  cold,  and 
the  increased  work  at  first  thrown  on  the  heart, 
from  the  contraction  of  the  peripheral  blood- 
vessels. Under  these  circumstances  the  propric-tv 
of  employing  it  is  probably  doubtful. 

There  are  other  methods  by  which  cold  may  be 
applied  externally  with  the  object  of  reducing 
temperature,  namely,  by  packing  the  patient  in  a 
wet  sheet;  by  the  application  of  ice-bags  to  tin 
spine ; and  by  sponging  the  surface  of  the  bod  \ 
with  cold  water.  These,  however,  are  les.- 
effeetual  than  the  bath,  and  they  often  cause 
more  distress  to  the  patient.  The  effect  of  such 
treatment  is  not  only  to  reduce  the  bodily  tem- 
perature, but  also  the  frequency  of  the  pulse  and 
respirations,  and  it  often  induces  quiet  sleep. 

Although  failure  of  cardiac  power  is  the  chid 
source  of  danger  in  pneumonia,  dyspnoea  is  occa- 
sionally a most  grave  symptom,  especially  in 
th'  se  cases  in  which  both  lungs  become  in- 
volved. This  dyspnoea  is  due  partly  to  the  lung- 
consolidation,  and  partly  to  the  pyrexia;  hence 
it  will  be  only  partially  relieved  by  anything 
which  reduces  the  temperature.  It  has  long- 
been  known  that  the  dyspnoea  of  pneumonia  > 
diminished  temporarily  by  venesection,  and  at 
the  present  day  this  is  probably  the  only  symp- 
tom for  the  relief  of  which  the  practice  of  bleed- 
ing would  be  considered  at  all  justifiable.  In 


S84  LUNGS,  INFLAMMATION  OF. 


considering  the  advisability  of  removing  blood 
in  those  cases  in  which  dyspnoea  constitutes  an 
urgent  symptom,  it  must,  however,  be  borne  in 
mind  not  only  that  the  relief  is  merely  temporary, 
but  that  the  loss  of  blood  must  tend  more  or  less 
to  weaken  the  patient,  and  hence  to  favour  that 
condition  of  asthenia  which  is  of  all  things  the 
most  to  be  feared.  Bleeding  is  certainly  only  to 
be  thought  of  when  the  dyspnoea  threatens  life, 
and  when  at  the  same  time  the  strength,  as  in- 
dicated by  the  pulse,  is  good ; and  it  should  not 
exceed  the  removal  of  eight  or  ten  ounces  of 
blood.  Such  cases  are  certainly  not  common; 
and  when  they  do  occur,  it  is  a question  whether 
i t would  not  be  safer  practice  to  endeavour  to 
relieve  the  dyspnoea  by  reducing  the  tempera- 
ture (either  by  the  cautious  application  of  cold 
or  by  quinine),  than  to  have  recourse  to  the 
lancet. 

Of  the  complications  delirium  sometimes  calls 
for  treatment.  Active  delirium  is  not  com- 
mon in  pneumonia,  except  in  those  who  have 
been  intemperate.  When  marked  it  is  always 
indicative  of  danger.  In  its  management  the 
practitioner  must  be  guided  by  the  general  con- 
dition of  the  patient.  It  is  usually  accompanied 
by  asthenia,  and  hence  calls  for  the  exhibition 
of  stimulants.  The  influence  of  an  experienced 
nurse  is  most  important.  If  the  pyrexia  is  con- 
siderable, the  advisability  of  wet  packing  or  of 
the  cold  bath  should  be  considered.  In  many 
cases  simply  sponging  the  surface  of  the  body 
with  cold  water  produces  a soothing  effect.  The 
application  of  ice  to  the  head  for  a short  time 
may  also  be  tried.  If  these  means  fail  in  quiet- 
ing the  patient,  and  the  delirium  is  very  violent 
and  prevents  sleep,  it  may  in  some  cases  be  ad- 
visable to  administer  an  opiate.  This  should 
only  be  done,  however,  as  a last  resource,  and 
when  there  is  marked  asthenia  it  is  quite  unad- 
visable.  The  opiate  should  be  given  in  one  full 
dose  sufficient  to  procure  sleep.  Morphia  admi- 
nistered hypodermically,  or  given  with  ammonia 
or  brandy  by  the  mouth,  is  perhaps  the  best 
form  of  exhibiting  it. 

Of  the  management  of  other  complications 
occurring  in  the  course  of  pneumonia  there  is 
nothing  special  to  be  remarked;  they  must  be 
treated  on  general  principles.  The  existence  of 
bronchial  catarrh  often  requires  small  doses  of 
ipecacuanha,  ammonia,  and.  salines.  Diarrhoea 
and  gastric  symptoms  are  to  be  met  by  careful 
dieting,  chalk,  bismuth,  and,  if  necessary,  other 
astringent  remedies.  In  pneumonia,  as  in  other 
acute  diseases,  the  administration  of  an  opiate 
enema  is  an  efficient  and  safe  means  of  checking 
diarrhoea.  Pericarditis  rarely  admits  of  any 
special  interference. 

Convalescence.— During  the  period  which  im- 
mediately succeeds  the  crisis,  the  utmost  care  is 
required  to  support  the  patient,  and  to  prevent  any 
serious  amount  of  prostration,  which  at  this  time 
sometimes  supervenes.  Stimulants  are  usually 
required  for  some  days  after  the  temperature  has 
attained  the  normal  standard.  Convalescence  in 
most  cases  is  quickly  established.  Solid  diet  is 
soon  desired,  and  may  be  safely  given.  Tonics 
— such  as  quinine,  iron,  and  cod-liver  oil — and 
change  of  air  are  useful  in  assisting  the  restora- 
tion to  health. 


B.  Secondary  Pneumonia. — DErurmos.— 

Secondary  pneumonia  is  a local  affection,  not  a 
general  disease.  It  is  an  inflammation  of  the 
lung  occurring  in  those  who  are  the  subjects  of 
some  other  disease ; the  pneumonic  process 
standing  in  more  or  less  causal  relation  to  the 
disease  in  the  course  of  which  it  supervenes. 

Intercurrent  Pneumonia. — Before  proceeding 
to  consider  secondary  pneumonia  as  thus  defined, 
it  is  to  be  remarked  that  the  general  disease- 
acute  pneumonia — occasionally  occurs  in  the 
course  of  other  diseases  as  an  accidental  com- 
plication, its  occurrence  not  being  influenced  Lv 
the  pre-existingcondition.  Such  pneumonias  may 
be  termed  intercurrent , and  they  are  to  be  dis- 
tinguished from  the  local  secondary  affections. 
They  often  closely  resemble,  in  their  clinical 
features,  the  acute  disease  as  it  has  been  already 
described  ; although  in  some  cases  they  arc  more 
or  less  modified  by  the  disease  in  the  course  of 
which  they  occur. 

Hypostatic  Pneumonia. — There  is  also  a class 
of  consolidations  of  the  lung  very  common  in 
those  who  are  the  subjects  of  other  diseases, 
which  are  often  described  as  secondary'  pneu- 
monias, but  which  are  really  for  the  most 
part  non-inflammatory  in  their  nature;  and 
will,  therefore,  be  very  briefly  alluded  to  in 
the  present  article.  These  are  those  consolida- 
tions so  often  met  with  at  the  bases  and  more 
dependent  portions  of  the  lungs,  in  the  course  of 
both  chronic  and  acute  diseases,  and  also  in  the 
aged  and  cachectic.  They  have  been  termed 
hypostatic  pneumonias,  and  consist,  in  the  main, 
of  collapse,  hyperoemia,  andeedemaof  the  lung- 
tissue,  resulting  from  weak  inspiratory  power, 
feeble  circulation,  and  gravitation.  The  con- 
solidation thus  mechanically  induced  is  in- 
creased by  more  or  less  exudation  of  liquor 
sanguinis  and  blood-corpuscles  into  the  alveoli : 
which  exudation  is  due  to  the  damage  to  the 
walls  of  the  capillaries  caused  by  the  blood- 
stasis  (Cohnheim).  There  is  also  some  swelling 
and  proliferation  of  the  alveolar  epithelium.  The 
frequent  occurrence  of  this  epithelial  activity  in 
collapsed  and  oedematons  lung-tissue  is  discussed 
at  greater  length  under  the  head  of  broncho- 
pneumonia. 

-ZEtiologt. — Secondary  pneumonias,  as  already 
stated,  bear  a causal  relation  to  the  disease  it 
the  course  of  which  they  supervene.  Theywoulc 
seem  to  owe  their  origin  almost  exclusively  t< 
some  abnormal  condition  which  the  pre-existin: 
disease  has  induced.  They  occur  in  the  cours 
of  many  diseases,  and  sometimes  appear  to  cop 
stitute  the  acute  affection  which  determines  dis 
solution.  There  is  one  disease  in  which  sue 
pneumonias  are  especially  frequent  — namel; 
Bright’s  disease.  Pneumonia  occurring  in  tfc 
course  of  Bright's  disease,  however,  sometime 
closely  resembles  the  acute  primary  affectio. 
and  the  Bright's  disease  is  probably  merely  oi 
of  the  elements  concerned  in  its  causation  : b 
more  frequently  it  is  simply  the  local  affeeti 
about  to  be  described. 

Anatomical  Characters. — The  changes  c 
curring  in  the  lung  in  secondary  pneumon 
are,  for  the  most  part,  precisely  similar  to  tho 
of  the  acute  primary  disease.  In  many  caS' 
however,  the  consolidation  is  less  dense;  a 


LUNGS,  INFLAMMATION  OF. 


epithelial  activity  sometimes  constitutes  a more 
orominent  feature  in  its  production.  The  pleura 
is  usually  implicated,  but  not  so  invariably  so  as 
in  primary  pneumonia.  When  associated  with 
Bright's  disease,  the  consolidation  often  passes 
rapidly  into  the  stage  of  grey  hepatisation.  With 
regard  to  the  situation  of  the  consolidation,  it 
:'s  more  frequently  situated  in  the  upper  and 
middle  lobes,  and  is  more  often  double,  than  is 
that  of  the  primary  disease. 

Symptoms.  — - The  clinical  phenomena  of 
secondary  pneumonia  differ  from  those  of  the 
acute  primary  disease,  the  symptoms  so  charac- 
teristic of  the  latter  being  almost  entirely  want- 
ing. The  symptoms  which  do  exist  are  often 
but  little  pronounced,  and  the  disease  may  even 
run  an  almost  latent  course.  This  latency  of 
symptoms  is  often  partly  due  to  their  being 
masked  and  modified  by  those  of  the  disease  to 
which  the  pneumonia  is  secondary. 

The  onset  of  the  pneumonic  process  is  usually 
unattended  by  rigors  or  other  marked  pheno- 
mena. Cough,  expectoration,  pain,  and  dyspncea 
are  often  slight,  and  they  may  even  escape  obser- 
vation. If  cough  be  present,  the  sputa  may  be 
free  from  blood,  and  simply  watery  or  muco- 
purulent. The  pjmexia  is  moderate,  the  tempe- 
rature often  not  being  more  than  100°  Fahr. 
Not  unfrequently  slightly  increased  frequency  of 
:he  respiration,  with  occasional  cough,  and  symp- 
toms of  increased  illness,  are  all  that  exist  to  in- 
dicate that  pneumonia  has  supervened. 

Diagnosis. — Owing  to  the  frequent  latency  of 
he  symptoms  of  secondary  pneumonia,  the 
liagnosis  often  rests,  for  the  most  part,  upon 
lie  existence  of  physical  signs  of  pulmonary 
onsolidation.  When  the  consolidation  occupies 
he  posterior  and  inferior  portions  of  the  lung, 
t may  be  impossible  to  distinguish  it  from 
iraple  hypostasis.  See  Hypostasis. 

PnoGNosis. — The  supervention  of  pneumonia 
n the  course  of  a chronic  disease  usually,  but 
y no  means  invariably,  indicates  that  the 
isease  will  shortly  terminate  in  death.  The 
nlmonary  inflammation  appears  to  determine 
issolution.  Pneumonia  occurring  in  acute 
iseases  materially  increases  the  gravity  of  the 
rognosis. 

Treatment. — The  treatment  of  secondary 
leumonia  usually  resolves  itself  into  that  of 
,ie  disease  in  the  course  of  which  it  occurs, 
'arm  applications  to  the  chest,  small  doses  of 
nmonia,  and  alcoholic  stimulants  may  some- 
mes  favourably  influence  the  pneumonic 
ocess. 

C.  Broncho-Pneumonia. — Synox.  : Catar- 
al  inflammation  of  the  lungs  ; Lobular  pneu- 
i>nia;  Fr.  Pneunionie  lobulaire ; Broncho-jmeu- 
\nie ; Ger.  Bronchopneumonie. 

Definition. — Broncho-,  catarrhal,  or  lobular 
’eumonia  is  inflammation  of  the  lung-tissue 
iociated  with,  and  usually  secondary  to,  in- 
timation of  the  bronchial  mucous  membrane. 

■ the  earlier  stage  the  pulmonary  inflammation 
commonly  limited  to  scattered  groups  of  air- 
icles,  hence  the  term  lobular  which  is  applied 
'bis  form cf  pneumonia.  As  the  process  ad- 
1 ices,  the  inflammatory  nodules  may  gradually 
i lesce  so  as  to  produce  larger  tracts  of  consoli- 


883 

dation.  The  inflammatory  products  which  fill 
the  alveoli  consist  principally  of  cells,  derived 
from  the  epithelium  of  the  alveoli,  and  from 
the  bronchial  mucous  membrane ; exudation  and 
emigration  play  a much  less  prominent  part  in 
the  process  than  they  do  in  acute  pneumonia. 
Owing  to  this  preponderance  of  epithelial  pro- 
ducts, and  to  the  association  of  the  pulmonary 
with  the  bronchial  inflammation,  the  process  is 
also  known  as  catarrhal-  pneumonia. 

-(Etiology. — Broncho-pneumonia,  as  already 
stated,  is  invariably  associated  with  bronchial 
catarrh.  In  some  eases  it  would  appear  that  the 
injury  which  produces  the  bronchial  inflamma- 
tion produces  at  the  same  time  inflammation  of 
the  alveolar  walls,  but  much  more  frequently  the 
bronchitis  precedes  the  pneumonia,  and  gives 
rise  to  it  in  a manner  to  be  hereafter  described. 
Whatever  causes  inflammation  of  the  bronchial 
mucous  membrane  may  thus  be  a cause  of 
broncho-pneumonia. 

Bronchitis  is  frequently  followed  by  broncho- 
pneumonia, especially  in  childhood  and  in  old 
age.  All  those  conditions  which  favour  the 
occurrence  of  bronchitis  must  therefore  he 
enumerated  amongst  the  causes  of  this  form  of 
pneumonia.  Of  these  conditions  it  will  be  suf- 
ficient to  mention  here  the  marked  influence  of 
cold  and  damp,  and,  to  a less  extent,  of  heart- 
disease  and  emphysema ; also  the  inhalation  of 
irritating  gases,  and  of  an  atmosphere  contain- 
ing irritating  particles  of  solid  matter. 

It  is  the  bronchitis  associated  with  certain 
infectious  diseases  which  is  most  liable  to  he 
followed  by  broncho-pneumonia.  This  is  espe- 
cially the  case  with  that  accompanying  measles 
and  whooping-cough.  In  both  these  diseases  this 
form  of  lung-complication  is  exceedingly  fre- 
quent. It  also  sometimes  occurs  in  connexion 
with  the  bronchial  catarrh  of  influenza  and  diph- 
theria. 

All  conditions  which  tend  to  impair  the  gene- 
ral health  favour  the  occurrence  of  broncho- 
pneumonia. The  weakly  and  debilitated  suffer 
most.  Bad  air  and  insufficient  food  are  most 
important  predisposing  causes.  A state  of  mal- 
nutrition not  only  renders  the  bronchial  mucous 
membrane  abnormally  liable  to  become  inflamed, 
but  also  diminishes  the  power  of  the  respiratory 
muscles,  and  thus  aids  in  the  production  of  pul- 
monary collapse,  a condition  which,  as  will  ho 
seen  presently,  is  especially  favourable  to  the 
pneumonic  process.  Owing  to  the  general  debi- 
lity and  weakness  of  the  thoracic  parietes  in 
rickets,  bronchitis  in  the  subjects  of  this  disease 
is  exceedingly  liable  to  be  followed  by  broncho- 
pneumonia. 

Broncho-pneumonia  is  most  common  during 
the  first  four  years  of  life — the  period  when 
bronchial  catarrh,  measles,  and  whooping-cough 
are  so  frequent.  It  is  also  common  in  old  age. 
In  young  adults  it  is  comparatively  rare.  Sex 
has  no  influence. 

Anatomical  Characters. — The  appearances 
presented  by  the  lungs  after  death  vary.  The 
bronchi  always  exhibit  signs  of  more  or  less 
bronchial  catarrh.  This  may  involve  the  whole 
of  the  bronchial  mucous  membrane,  but  it  is 
usually  most  marked  in  the  smaller  tubes.  These 
are  found  containing  a thick,  tenacious,  and  often 


*86 


LUNGS,  INFLAMMATION  OF. 


puriform  secretion,  ■which  is  occasionally  here 
and  there  drier  or  inspissated.  The  mucous  mem- 
brane of  these  tubes  is  more  or  less  softened, 
swollen,  red,  and  thickened,  and  often  presents 
irregular  superficial  erosions.  Owing  to  this  in- 
flammatory swelling  the  tubes  stand  out  pro- 
minently on  section  of  the  lung.  Cylindrical 
dilatations  of  the  tubes  are  also  frequently  met 
jrth. 

The  lung-tissue  itself  exhibits,  associated  in 
various  degrees,  collapse,  congestion,  oedema, 
emphysema,  and  pneumonic  consolidation.  The 
bluish,  non-crepitant,  depressed  portions  of  col- 
lapse, which  become  darker  and  more  friable 
with  age,  are  usually  most  abundant  in  the  lower 
lobes  and  margins  of  the  lungs.  The  collapse 
sometimes  involves  the  whole  of  one  lobe,  but 
more  commonly  it  is  limited  to  much  smaller 
areas  of  the  lung.  When  scattered  and  limited 
in  its  distribution,  there  is  usually  more  or  less 
emphysema  of  the  intervening  portions  of  the 
lung  ; when  very  extensive  in  the  lower  lobes, 
the  emphysema  is  most  marked  in  the  upper. 

Those  portions  of  the  lung  in  which  the  pneu- 
monic process  has  supervened  most  commonly 
appear  as  scattered  nodules  of  consolidation, 
varying  in  size  from  a small  pea  to  a hazel  nut. 
These  are  ill-defined  and  pass  insensibly  into  the 
surrounding  tissue,  which  is  variously  altered 
by  congestion,  collapse,  and  emphysema.  They 
are  of  a reddish-grey  colour,  slightly  elevated, 
smooth,  or  very  faintly  granular,  and  soft  and 
friable  in  consistence.  As  they  increase  in  size 
they  may  become  confluent,  and  thus  are  pro- 
duced larger  tracts  of  consolidation.  In  a more 
advanced  stage,  the  nodular  and  more  diffuso 
consolidation  becomes  palor,  firmer,  and  drier, 
and  somewhat  resembles  in  colour  the  greyish- 
yellow  hepatisation  of  acute  pneumonia.  The 
cut  ends  of  dilated  bronchi,  filled  with  pus,  are 
occasionally  seen  in  the  centres  of  the  pneumonic 
nodules. 

Microscopical  characters.  — When  examined 
microscopically  this  consolidation  is  seen  to  con- 
sist of  an  accumulation  within  the  alveoli  of 
a gelatinous  mucoid-looking  substance,  small 
cells  resembling  leucocytes,  and  epithelial  ele- 
ments. In  many  cases  much  of  this  accumu- 
lation is  precisely  similar  to  that  contained  in 
the  smaller  bronchi ; aud  it  is  evidently  the 
inflammatory  and  richly  cellular  bronchial  se- 
cretion which  has  been  inhaled.  At  the  same 
time  it  is  in  the  highest  degree  probable  that 
it  is  partly  the  result  of  exudation  and  emi- 
gration from  the  pulmonary  capillaries ; such 
exudation  and  emigration,  however,  do  not  play 
nearly  such  a prominent  part  in  the  process  as 
they  do  in  acute  pneumonia,  and  a fibrinous 
coagulum  is  rarely  met  with.  Associated  with 
this  material  are  large  epithelial  elements,  pro- 
bably the  offspring  of  the  alveolar  epithelium. 
These  vary  considerably  in  number.  In  some 
portions  of  the  consolidation  they  may  be  very 
few,  whilst  in  others  they  may  constitute  the 
predominant  change.  These  differences  probably 
depend  upon  how  far  the  inhalation  of  the  bron- 
chial secretion  constitutes  a part  of  the  process. 
The  epithelium  covering  the  alveolar  walls  is  more 
or  less  swollen  and  granular,  and  is  often  loosened 
from  its  attachment.  - 


Many  of  the  nodules  of  consolidation  met  witli 
in  the  lungs  after  death  from  bronchopneu- 
monia, differ  somewhat  from  those  which  have 
been  described.  They  are  smaller  and  softer, 
cf  a more  yellow  colour,  les3  prominent,  and  less 
granular;  and  on  scraping,  a puriform  liquid  is 
obtained  from  them.  These  consist  almost  ex- 
clusively of  puriform  secretion  inhaled  from  the 
bronchi ; and  there  is  an  almost  complete  absence 
of  epithelial  elements,  and  of  other  evidence  of 
alveolar  inflammation.  Some  of  these  nodules 
are  merely  the  cut  ends  of  dilated  bronchi  tilled 
with  pus. 

The  pleura  is  usually  more  or  less  injected, 
and  a little  lymph  with  small  ceehymoses  aro 
commonly  met  with.  These  appearances  are 
most  marked  in  the  vicinity  of  the  sub-pleural 
pneumonic  nodules. 

The  subsequent  changes  which  take  place  in 
the  lungs  vary.  When  the  disease  dots  not  end  in 
death,  resolution  is  the  most  common  termina- 
tion. The  contents  of  the  alveoli  undergo  fatty 
degeneration,  and  are  removed  by  expectoration 
and  absorption,  the  lung  gradually  regaining  its 
normal  characters.  This  process,  however,  is  less 
readily  effected  than  in  the  consolidation  of 
acute  pneumonia ; and  it  often  occupies  such  a 
lengthened  period  that  some  thickening  of  the 
bronchial  aud  alveolar  walls,  and  dilatation  of  I 
the  smaller  bronchi  remain.  In  still  more 
chronic  cases  the  fibroid  thickening  is  much 
more  marked,  and  considerable  irregularly-dis- 
tributed pigmented  induration  and  bronchial  j 
dilatation  may  be  produced  (see  Chronic  Pneu- 
monia). In  these  chronic  forms  the  contents  of 
the  alveoli  sometimes  caseate,  and  the  caseous 
products  and  thickened  alveoli  may,  in  excep- 
tional cases,  disintegrate,  and  thus  lead  to  the 
destruction  of  the  lung.  Such  a result  comes 
under  the  category  of  phthisis,  and  will  there- 
fore not  be  described  in  the  present  article. 

Pathology. — The  inflammation  of  the  bron- 
chial mucous  membrane,  which  is  invariablyasso- 
ciated  with  broncho-pneumonia,  in  the  great  ma 
joritv  of  cases  precedes  and  is  the  principal  caus* 
of  the  pneumonic  process.  In  exceptional  case 
it.  would  appear  probable  that  the  same  injur; 
which  produces  the  bronchial  inflammation  pro 
duces  at  tho  same  time  the  inflammation  of  th 
air-vesicles.  Inflammation  of  the  bronchial  mu 
cous  membrane  may  give  rise  to  broncho-pneu 
monia  in  two  ways  — ( 1 ) By  causing,  in  the  firs 
place,  collapse  of  the  lung-tissue ; and  (2)  by  th 
direct  extension  of  the  inflammation  from  th 
bronchi  to  the  air-vesicles.  The  pneumonic  pr< 
cess  being  the  result  of  the  bronchitis  almo: 
invariably  involves  simultaneously  both  lungs. 

1.  Broncho-pneumonia  consecutive  to  collajt 
Collapse  cf  the  lung-tissue  greatly  favours  tl 
occurrence  of  broncho-pneumonia,  and  usual 
tho  pneumonic  process  is  principally  confined 
those  portions  of  the  lung  in  which  collapse  h 
taken  place.  This  is  particularly  the  case 
young  children.  Although  it  would  be  beyo 
the  scope  of  the  piresent  article  to  discuss 
length  the  relation  which  subsists  betwe 
bronchial  catarrh  and  pulmonary  collapse,  t 
mode  of  production  of  the  latter  may  be  brie 
indicated.  There  tire  two  circumstances  prin 
pally  concerned  in  the  production  of  the  collap 


LUNGS,  INFLAMMATION  OF. 


which  is  consecutivo  to  bronchitis— the  narrow- 
ing of  the  bronchial  tubes,  and  the  weakness  of 
the  inspiratory  power.  The  mucous  membrane 
of  the  bronchi  becomes  considerably  swollen  as 
the  result  of  the  inflammatory  process,  often 
being  thrown  into  folds ; and  its  surface  is  covered 
with  thick  tenacious  mucus.  These  conditions 
may  cause  so  much  narrowing  of  the  smaller 
tubes  as  to  render  the  entrance  of  air  exceedingly 
difficult,  and  they  may  even  completelyprevent  it. 
In  addition  to  the  bronchial  narrowing  the  power 
of  inflating  the  lungs  is  usually  diminished.  This 
is  due  partly  to  tne  general  debility  which  so 
often  exists  prior  to  the  bronchitis,  and  partly 
to  the  damage  to  the  respiratory  muscles  caused 
by  the  febrile  process.  The  superficial  charac- 
ter of  the  respiration  due  to  the  fever  also  aids 
in  the  production  of  the  collapse,  as  does  also 
any  weakness  of  the  osseous  structures  of  the 
thorax,  such  as  exists  in  rickets.  The  collapse 
thus  induced  is  especially  frequent  in  the  pos- 
terior and  inferior  portions  of  the  lungs — those 
portions  in  which  normally  the  inflation  of  the 
lung  is  the  least  complete.  Commencing  here 
the  process  may  gradually  extend  upwards  till 
large  areas  of  both  lungs  become  involved.  In 
Other  cases,  owing  to  a more  irregular  distribu- 
tion of  the  bronchial  obstruction,  the  collapse  is 
limited  to  small  isolated  portions  of  the  lung. 
These  portions  vary  in  size  from  a hemp-seed  to 
i walnut.  They  are  commonly  more  or  less 
wedge-shaped,  with  their  apices  towards  the 
jronchus  leading  to  the  group  of  collapsed 
obules ; and  the  lung-tissue  around  them  usually 
Presents  various  degrees  of  congestion  and  em- 
thysema. 

The  tendency  of  the  pneumonic  process  to 
iccur  in  the  collapsed  portions  of  the  lung  is 
lue  partly  to  the  hypersemia  which  is  induced 
>y  the  collapse,  and  partly  to  the  irritation  of 
nhaled  bronchial  secretion.  Collapse  of  the 
ung-tissue  invariably  induces  more  or  less  con- 
estion.  This  is  owing  to  the  absence  of  the  ex- 
ansion  and  contraction  of  the  air-vesicles,  which 
ormallyaid  the  pulmonary  circulation,  and  also 
3 the  impediment  to  the  blood-flow  resulting 
■om  imperfect  aeration.  This  congestion  is 
uickly  followed  by  oedema,  and  the  bluish- 
urple  collapsed  portions  of  the  lung  become 
eeper  in  colour,  less  resistant,  and  more  friable 
i consistence.  In  lung-tissue  thus  altered  an 
iflammatory  process,  characterised  partly  by 
nidation  and  partly  by  epithelial  activity,  is 
•one  to  supervene. 

Another  circumstance  which  often  appears  to 
ay  a prominent  part  in  the  causation  of  the 
leumonie  process,  is  the  presence  within  the 
reoli  of  the  inflammatory  products  cf  the 
onehial  mucous  membrane.  Such  products  are 
| squently  found  in  the  lungs  in  cases  of  broncho- 
eumonia.  They  occur  in  scattered  groups  of 
■-vesicles,  and  are  evidently  inhaled.  They  are 
ind  both  in  the  air-containing  and  in  the  coi- 
ned portions  of  the  lung,  but  especially  in  the 
ter,  the  presence  of  collapse  necessarily  inter- 
ing  with  their  removal  by  expectoration  or  ab- 
ption.  These  inhaled  products  are  often  found 
ing  small  groups  of  alveoli  without  any  evi- 
' ice  of  sv.bsiquent  inflammation,  and  there  can 
1 no  doubt  that  many  of  the  patches  of  consoli- 


887 

dation  which  are  usually  described  as  pneumonic 
are  in  reality  non-inflammatory  in  their  nature, 
and  are  thus  produced.  At  the  same  time,  owing 
to  the  irritation  of  the  inhaled  secretion,  it 
tends  to  induce  inflammatory  changes  within  the 
alveoli,  and  these  changes  are  frequently  largely 
owing  to  its  presence.  Juergensen  accounts  for 
the  pneumonic  process  occurring  in  isolated  spots 
in  the  collapsed  lung  by  regarding  the  inflam- 
mation as  being  determined  by  the  inhaled  bron- 
chial secretion. 

2.  Broncho-pneumonia  independent  of  collapse . 
Although  the  pneumonic  process  is  usually  con- 
secutive to  collapse  it  may  occur  independently. 
This  maybe  owing  either  to  the  direct  extension 
of  the  inflammation  from  the  bronchi  to  the  air- 
vesicles,  or  to  the  influence  of  inflammatory  pro- 
ducts inhaled  from  the  bronchi.  In  other  cases 
it  is  possible  that  the  injury  which  causes  the 
bronchitis  causes  at  the  same  time  the  inflam- 
mation of  the  pulmonary  alveoli. 

Symptoms. — The  symptoms  of  broncho-pueu 
monia  are,  to  a great  extent,  those  of  capillary 
bronchitis.  They  vary  according  to  the  severity 
of  the  bronchitis,  aod  according  as  this  is  asso- 
ciated or  not  with  other  disease.  In  the  severe 
forms  of  capillary  bronchitis  of  childhood,  and 
in  that  associated  with  measles,  the  implication 
of  the  lung  usually  gives  rise  to  early  and 
marked  symptoms,  and  the  disease  runs  a 
comparatively  acute  course.  In  the  less  severe 
forms  of  bronchial  catarrh,  on  the  other  hand, 
and  in  that  associated  with  whooping-cougli,  the 
supervention  of  a pneumonic  process  commonly 
occurs  later;  the  symptoms  are  less  pronounced; 
ami  the  course  of  the  disease  is  much  more 
chronic.  Although  various  gradations  are  met 
with  between  these  more  acute  and  the  chronic 
forms,  it  will  be  advisable,  for  the  sake  of  de- 
scription, to  consider  them  separately. 

Acute  hroncho-pncumonia — The  more  acute 
forms  of  broncho-pneumonia  occur  especially 
as  a complication  of  measles,  and  in  the  simple 
capillary  bronchitis  of  childhood.  In  measles 
the  pneumonic  process  commonly  supervenes 
towards  the  end  of  the  first,  or  beginning  of  the 
second  week,  but  it  may  be  much  later. 

The  early  symptoms  are  those  of  severe 
catarrh  of  the  smaller  bronchi — pyrexia,  fre- 
quent cough,  accelerated  respiration,  slight 
action  of  the  nares,  &c.  Such  symptoms  precede, 
for  a varying  length  of  time,  those  clue  to  the 
implication  of  the  lung-tissue.  The  earliest 
symptoms  of  the  pneumonic  process  are  by  no 
means  well-defined,  and  consequently  the  time 
at  which  the  lung  becomes  involved  cannot  be 
fixed  with  certainty.  Rigors  and  vomiting  are 
but  rarely  observed. 

Usually  an  increase  in  the  acceleration  of  the 
respiration,  or  in  the  dyspnoea,  are  the  first  signs 
of  the  pulmonary  implication.  The  breathing 
becomes  very  rapid,  and  commonly  causes  much 
distress,  the  child  tossing  about  and  being  ex- 
ceedingly restless.  This  dyspnoea  is  more 
marked  at  some  times  than  at  others,  and  is 
occasionally  more  or  less  distinctly  paroxysmal. 
The  respiration  is  superficial,  inspiration  being 
short,  and  the  expansion  of  the  thorax  imper- 
fect. There  is  marked  action  of  the  accessory 
respiratory  muscles,  and  the  upper  portions  ri 


388 


LUNGS,  INFLAMMATION  OF. 


the  thorax  are  raised,  whilst  the  lower  are 
retracted  during  the  inspiratory  act ; the  action 
of  the  nares  is  very  pronounced. 

An  increase  in  the  pyrexia  which  attended 
the  pre-existing  bronchitis  is,  with  few  excep- 
tions, observed  as  the  lungs  become  involved, 
and  such  increase  is  to  he  regarded  as  one  of  the 
most  valuable  indications  of  the  existence  of  a 
pneumonic  process.  The  maximum  temperature 
af  acute  simple  bronchitis  is  seldom  higher 
than  102°Fahr.,  whereas  that  of  the  secondary 
pneumonic  process  is  often  10f°  or  105°.  This 
i ncrease  usually  occurs  more  or  less  gradually ; 
— there  is  rarely  the  sudden  rise  of  temperature 
met  with  in  acute  pneumonia.  Unlike  the 
temperature  of  this  disease  also,  the  fever  of 
broncho-pneumonia  runs  no  definite  course.  It 
varies  with  the  extent  of  the  lung-implication, 
and  with  the  rapidity  with  which  this  implication 
is  effected.  There  is  no  regular  diurnal  variation; 
the  remissions  and  exacerbations  are  often  con- 
siderable ; and  they  occur  at  irregular  times, 
the  temperature  being  sometimes  higher  in  the 
morning  than  at  night.  The  cough,  which  beforo 
the  implication  of  the  lung  was  paroxysmal  in 
character,  gradually  becomes  less  and  less  so, 
and  it  now  often  causes  much  pain  to  the  pa- 
tient. The  sputa  are  bronchitic  in  character, 
usually  very  tenacious,  and  occasionally  streaked 
with  blood;  as,  however,  expectoration  rarely 
occurs  in  the  child,  they  are  not  often  seen.  The 
pulse  is  much  increased  in  frequency,  in  children 
under  five  years  often  being  150.  It  may  in  the 
earliest  stage  of  the  disease  be  moderately  full 
and  strong,  but  it  quickly  becomes  soft,  small, 
and  feeble.  In  addition  to  the  above,  there  are 
often  symptoms  referable  to  the  digestive  organs. 
Of  these  diarrhoea  is  the  most  important.  This 
is  quite  frequent,  especially  when  the  disease 
follows  measles.  It  is  very  readily  induced  by 
medicines  and  by  improper  feeding;  and  as  it 
greatly  weakens  the  patient,  it  is  important  that 
this  liability  to  it  should  be  kept  in  mind. 
Vomiting,  as  already  stated,  is  very  rare  as  an 
initial  symptom ; it  is,  however,  common  in  the 
course  of  the  disease,  especially  as  a result  of 
cough,  the  bronchial  secretion,  together  with  the 
contents  of  the  stomach,  often  being  expelled. 

As  the  implication  of  the  lungs  increases,  the 
breathing  becomes  still  more  rapid  and  super- 
ficial ; the  dyspnoea  is  more  marked  ; the  expres- 
sion is  auxious  ; the  face  is  pale ; and  symptoms 
of  carbonic-acid-poisoning  become  evident. 
Strength  now  fails;  the  face  and  lips  become 
cyanotic;  and  the  extreme  restlessness  ' gives 
place  to  apathy  and  a semi-comatose  condition, 
which  is  interrupted  from  time  to  time  by  in- 
effectual efforts  to  cough.  With  the  rapid 
failure  of  strength  and  increasing  cyanosis, 
cough  almost  ceases  ; the  pulse  becomes  exceed- 
ingly  feeble;  and  the  child,  often  extremely 
emaciated,  may  die  exhausted,  and  in  a condition 
of  more  or  less  profound  coma.  Sometimes  death 
occurs  suddenly  during  a paroxysm  of  cough,  or 
with  convulsions. 

Chronic  broncho-pneumonia. — The  symptoms 
of  the  more  chronic  forms  of  broncho-pneu- 
monia,  such  as  occur  especially  after  whooping- 
cough,  and  also  after  bronchial  catarrh  of  mo- 
derate severity,  differ  somewhat  from  those  of 


the  acute  disease.  The  pneumonic  process  com- 
monly supervenes  later,  and  the  course  of  the 
disease  is  much  more  protracted.  As  in  the 
acute  forms,  pyrexia  and  increased  frequency  of 
respiration  are  the  earliest  indications  of" the 
pulmonary  implication.  In  these  cases,  how- 
ever, there  is  usually  but  little  if  aDy  fever  prior 
to  the  pneumonia  ; it  comes  on  very  gradually ; 
and  the  maximum  temperature  is  much  lower 
than  iu  the  more  acute  forms,  commonly  not 
being  more  than  102°Fahr.  The  course  oftho 
pyrexia  also  is  still  more  irregular,  lengthened 
periods  of  very  slight  fever  being  interrupted 
from  time  to  time  by  slight  exacerbations.  Loss 
of  appetite,  great  emaciation,  increasing  diffi- 
culty of  breathing,  and  loss  of  strength,  charac- 
terise the  disease.  Such  symptoms  may  con- 
tinue for  months,  and  the  child  ultimately  die 
or  recover  with  more  or  less  damaged  lungs. 

AVhen  broncho-pneumonia  occurs  in  adults 
and  in  the  aged,  the  symptoms  are  for  the  most 
part  much  less  pronounced  than  in  the  child. 
In  strong  adults  the  disease  is  perhaps  most 
common  after  diphtheria,  and  here  the  pulmonary 
symptoms  may  be  well-marked ; but  in  the  debili- 
tated, and  especially  in  the  old,  the  course  of  the 
disease  is  much  more  latent,  very  slight  pyrexia 
(100°  Fahr.),  slight  cough  and  dyspnoea,  and 
marked  debility  being  the  principal  symptoms 
observable. 

In  the  aged  and  feeble,  broncho-pneumonia  is 
very  frequently  associated  with  that  form  of 
lung-consolidation  which  results  from  weak  in- 
spiratory power,  feeble  circulation,  and  gravita- 
tion (hypostatic  pneumonia).  It  has  already 
been  stated  that  this  consolidation,  which  con- 
sists mainly  of  collapse,  hyperaemia,  and  oedema 
of  the  lung-tissue,  favours  a catarrhal  swelling 
and  proliferation  of  the  alveolar  epithelium. 
Hypostatic  consolidation  may  exist  quite  inde- 
pendently of  bronchial  catarrh  ; but  when  such 
catarrh  occurs  in  the  aged  and  feeble,  gravita- 
tion often  determines  the  supervention  of  tile 
pneumonic  process,  which  under  such  circum- 
stances is  consequently  not  infrequently  unila- 
teral. 

When  the  more  acute  varieties  of  broncho- 
pneumonia terminate  fatally,  they  usually  do 
go  from  the  tenth  to  the  fourteenth  day  of 
the  disease.  Death,  unlike  that  from  acute 
pneumonia,  is  mainly  due  to  the  interference 
with  the  respiratory  function  and,  to  a much 
less  extent,  to  failure  of  cardiac  power  (Juergen- 
sen).  The  interference  with  the  respiration  if 
much  greater  than  in  acute  pneumonia,  for,  in 
addition  to  the  diminution  of  the  respirator! 
area,  due  to  the  pulmonary  consolidation  anc 
collapse,  there  is  the  much  more  -importan 
cause  of  interference — namely,  the  impedimen 
to  the  entrance  of  air,  caused  by  the  swelling  o 
the  bronchial  mucous  membrane,  and  the  aceu 
mulation  of  secretion  in  the  bronchial  tubes 
These  interferences  with  respiration  necessitat 
increased  action  of  the  respiratory  muscles;  bu 
with  the  progress  of  the  disease  these  muscle 
become  weakened,  partly  by  the  fever,  and  parti 
from  the  imperfect  supply  of  oxygen.  With  thi 
failure  of  respiratory  power  the  incompletencs 
of  oxygenation  necessarily  increases,  until  th 
supply  of  oxygen  may  become  so  small  as  te  lea 


LUNGS.  INFLAMMATION  OF. 


to  complete  muscular  paralysis.  The  damage 
to  the  heart,  as  in  acute  pneumonia,  is  due  partly 
to  the  diminished  respiratory  area,  and  partly  to 
the  fever;  but  this  damage  is  a much  less  im- 
portant element  in  the  causation  of  dissolution 
m broncho-pneumonia,  than  it  is  in  the  general 
disease.  (Juergensen).  In  chronic  broncho- 
pneumonia death  may  not  occur  for  some  months, 
and  then  it  results  as  much  from  general  failure 
of  strength  as  from  interference  with  the  respi- 
ratory function. 

When  the  disease  does  not  terminate  in  death, 
improvement  in  the  symptoms  is  always  gra- 
dual. The  temperature  falls  slowly,  several 
days,  and  occasionally  some  weeks,  being  occu- 
pied in  the  completion  of  defervescence;  and 
this  gradual  decline  is  usually  interrupted  by 
more  or  less  marked  and  frequent  exacerba- 
tions and  remissions  of  the  fever.  The  cough 
and  dyspnoea  diminish,  and  the  appotite  gradu- 
ally returns ; but  restoration  to  health  is  always 
protracted  ; and  the  child  remains  for  some  time 
especially  liable  to  repetition  of  the  bronchial 
symptoms. 

Sometimes  recovery  from  the  broncho-pneumo- 
Jnia  is  not  complete,  andthe  disease  leads  to  indu- 
ration of  the  lung,  dilatation  of  the  bronchi,  &c. 
?(see  Chronic  Pneumonia).  Emphysema  and  acute 
tuberculosis  are  occasional  sequelae.  That  the 
disease  sometimes  terminates  in  phthisis,  espe- 
cially in  children  and  in  those  who  inherit  weak 
ungs, appears  to  the  writer  to  be  indisputable. 

Physical  signs. — The  physical  signs  of  broncho- 
ineumonia  are  in  the  main  those  of  capillary 
bronchitis.  Imperfect  expansion  of  the  thorax, 
deration  of  the  upper  portions,  and  recession 
if  the  lower,  during  the  inspiratory  act ; moist 
jiud  dry  rales,  audible  over  both  sides ; and  the 
ibsence  of  any  marked  alterations  in  perctission- 
esonance,  are  the  principal  signs  observable,  not 
nly  in  the  earlier  stages,  but  throughout  the 
(thole  course  of  the  disease.  The  recession  of 
he  chest-walls  is  increased  by  collapse.  The 
iaporvention  of  the  pulmonary  implication  is 
lidicated  rather  by  the  symptoms — increase  in 
te  pyrexia  and  in  the  dyspnoea — than  by  any 
larked  alteration  in  tho  physical  signs.  The 
iffieulty  of  detecting  the  lung-consolidation  is 
ne  to  its  usually  being  limited,  in  the  earlier 
ages,  at  all  events,  to  small  areas,  which  are 
irrounded  by  healthy  or  emphysematous  lung, 

' that  resonance  on  percussion  is  but  little  im- 
lired.  It  is  only  when  these  small  areas  have 
lalesced  into  larger  areas  of  consolidation,  that 
y marked  alterations  in  percussion-resonance 
ie  discoverable.  The  impaired  resonance  due  to 
lapse  is  not  to  be  distinguished  from  that  duo 
pneumonic  consolidation ; and,  inasmuch  as  the 
llapse  is  so  often  symmetrical,  involving  both 
;=>es  posteriorly,  the  difficulty  of  appreciating 
is  increased.  Much  more  valuable  aid  in 
ysical  diagnosis  is  in  most  cases  to  be  ob- 
ned  from  auscultation.  Over  those  portions 
the  lung  where  consolidation  has  taken  place 
' moist  bronchitic  rules  tend  to  assume  a some- 
at  metallic  quality;  they  also  becomo  finer, 
mgh  not  so  fine  as  true  pneumonic  crepitation ; 

1 1 they  are  more  superficial.  The  detection  of 
1 so  superficial,  somewhat  metallic  fine  moist 
1 heard  with  inspiration,  and  often  with 


889 

expiration,  over  small  areas  of  the  lungs,  is  a 
most  valuable  and  often  the  only  physical  sign 
of  the  pulmonary  implication.  If  large  areas 
become  consolidated,  there  is,  in  addition  to  this, 
some  impairment  of  rosonance  on  percussion. 

Complications. — These  are  few.  It  is  scarcely 
necessary  again  to  state  that  bronchial  catarrh 
is  always  present.  Pleurisy  is  less  common  than 
in  acute  pneumonia.  Slight  inflammation  of  the 
pleura  is,  however,  usually  found  post  mortem , 
over  those  portions  of  the  lung  which  are  con- 
solidated. Pleuritic  effusion  is  rare.  Intestinal 
catarrh  is  a very  important  and  common  com- 
plication. Tho  liability  to  this  in  the  child,  and 
the  mechanical  congestion  resulting  from  tho  ob- 
structed pulmonary  circulation,  must  be  borne 
in  mind  in  explaining  its  frequency. 

Convulsions  occasionally  occur,  and  are  of  un- 
favourable augury.  The  nervous  phenomena  in 
some  few  cases  have  been  described  as  simulating 
those  of  tubercular  meningitis.  Catarrhal  laryn- 
gitis, associated  with  much  spasm  and  laryngeal 
stenosis,  is  sometimes  observed,  especially  after 
measles. 

Diagnosis. — The  diagnosis  of  broncho-pneu- 
monia is  occasionally  difficult.  This  difficulty 
is  mainly  owing  to  the  co-existence  of  capil- 
lary bronchitis.  The  recognition  of  the  pulmo- 
nary implication  in  its  earlier  stages  is  often 
impossible.  The  increase  in  the  pyrexia,  and  in 
the  frequency  of  respiration,  are  the  symptoms  of 
the  most  diagnostic  value.  Owing  to  the  small 
areas  of  lung  involved,  any  alteration  in  the 
physical  signs  of  tho  capillary  bronchitis  may 
be  entirely  wanting.  The  occurrence  of  exten- 
sive collapse  in  the  earlier  stages  gives  more 
marked  physical  signs  of  consolidation,  and  hence 
renders  the  diagnosis  more  easy.  It  is  almost 
impossible  to  diagnose  certainly,  either  by  symp- 
toms or  by  physical  signs,  between  the  collapse 
and  the  pneumonic  consolidation.  This,  how- 
ever, is  of  but  little  practical  importance,  inas- 
much as  the  collapse  is  usually  associated  with, 
and  often  the  immediate  precursor  of,  the  pneu- 
monic process. 

The  diagnosis  of  broncho-pneumonia  from  the 
pulmonary  consolidation  of  acute  pneumonia 
may  occasionally  be  difficult  in  the  later  stages 
of  the  former,  when  an  extensive  area  of  the  lung 
has  become  consolidated.  The  history  of  the 
case,  and  especially  the  course  of  the  pyrexia, 
will  usually  suffice  to  distinguish  them. 

The  distinction  from  acute  tuberculosis  some- 
times presents  much  difficulty,  as  does  also  the 
recognition  of  tuborculosis  and  phthisis  as  an 
occasional  result  of  the  disease.  A careful  con- 
sideration of  the  earlier  symptoms,  and  the  ex- 
istence or  not  of  marked  predisposition,  are  here 
most  important.  Slight  and  irregular  pyrexia, 
existing  before  the  supervention  of  lung-symp- 
toms, is  greatly  in  favour  of  tuberculosis.  In 
some  cases,  however,  tbe  phenomena  of  these 
diseases  are  so  analogous  that  a certain  diagnosis 
is  impossible. 

Prognosis. — Broncho-pneumonia  is  much  more 
dangerous  than  the  acute  primary  disease,  and 
the  mortality  from  it  is  much  greater.  The 
more  chronic  forms  are  more  fatal  than  the 
acute.  Tho  two  circumstances  which  have  an 
especial  influence  upon  prognosis  are  the  age  oi 


390  LUNGS,  INFLAMMATION  OF. 


the  patient,  and  the  general  health.  Before 
puberty,  the  younger  the  patient  the  graver  the 
prognosis.  In  children  under  five  years,  the 
mortality  is  exeeedintrly  great  (probably  about 
20  per  cent.)  I'he  disease  is  also  especially  fatal 
in  weakly  children,  and  in  all  those  who  are 
constitutionally  feeble,  or  debilitated  by  previous 
illness.  The  existence  of  rickets  materially  in- 
creases the  gravity  of  prognosis.  The  daDger 
also  increases  greatly  with  the  extent  of  lung 
involved,  much  more  so  than  is  the  case  in  acute 
pneumonia  Of  the  value  of  the  several  symp- 
toms as  influencing  prognosis,  alter  the  descrip- 
tion which  has  been  given  of  the  disease  and  of 
the  modes  in  which  it  tends  to  cause  death,  it 
is  hardly  necessary  to  speak  further.  Symptoms 
of  imperfect  aeration  of  the  blood  are  those  most 
to  be  feared. 

Treatment. — In  the  treatment  of  broncho- 
pneumonia, it  is  important  to  bear  in  mind: — 
1st,  that  the  disease  is  invariably  associated 
with,  and  is  in  the  main  induced  by  bronchial 
catarrh,  and  by  its  so  frequently  attendant  col- 
lapse ; 2ndly,  that  its  occurrence  is  especially 
favoured  by  everything  that  weakens  the  patient ; 
and  3riily,  that  it  tends  to  destroy  life  prin- 
cipally by  interfering  with  the  function  of  respi- 
ration, which  interference  necessarily  increases 
with  the  consequent  weakening  of  the  respira- 
tory power.  Such  being  the  facts,  it  is  obvious 
that  the  main  object  of  treatment  will  be,  first, 
to  control  bronchial  catarrh,  and  endeavour  so 
to  modify  it  as  to  prevent  the  occurrence  of 
collapse;  and,  secondly,  to  support  as  much  as 
possible  tho  strength  of  the  patient,  with  the 
object  of  preventing  not  only  collapse,  but  also 
that  increased  interference  with  the  function  of 
respiration  which  results  from  weakening  of  the 
respiratoiv  muscles. 

It  wonfd  be  out  of  place  in  the  present  ar- 
ticle to  enter  into  a detailed  description  of  the 
management  of  acute  bronchitis  (stc  Bronchi, 
Diseases  of).  It  will  be  sufficient  to  indicate 
the  more  important  means  of  controlling  the  dis- 
ease, with  especial  reference  to  the  prevention  of 
the  so  frequently  attendant  collapse. 

The  patient  should  be  kept  in  a warm  room, 
the  temperature  of  which  should  never  be 
allowed  to  fall  below  60°  Falir.  The  room 
should  be  well,  but  carefully  ventilated ; and 
protection  from  draughts  is  important,  much 
more  so  than  in  the  treatment  of  aeuto  pneu- 
monia. It  is  also  advisable  to  keep  the  air  moist 
by  means  of  a steam  kettle,  as  the  exhalation 
of  water  from  the  lungs  is  thus  diminished, 
and  the  bronchial  secretion  consequently  ren- 
dered less  tenacious,  and  more  easily  removed 
by  cough.  The  diet,  which  must  be  regulated 
according  to  the  age  of  the  patient,  should  be 
nutritious  and  easily  digestible,  the  importance 
of  supporting  the  strength  being  kept  in  mind. 
When  the  disease  follows  measles,  the  liabi- 
lity to  gastro-intostinal  catarrh  must  not  be  for- 
gotten. Small  doses  of  ipecacuanha  with  salines 
should  be  administered  frequently.  The  chest 
should  be  enveloped  in  lightly  made  linseed 
and  mustard  poultices  ; or,  what  in  the  case  of 
very  young  children  answers  better,  it  should 
be  rubbed  three  or  four  times  daily  with  some 
Stimulating  liniment,  and  kept  wrapped  in  cotton- 


wool covered  with  oil-silk.  When  the  secretion 
in  the  tubes  is  abundant,  its  removal  may  be 
much  aided  by  small  doees  of  carbonate  of 
ammonia.  This  may  be  either  combined  with 
the  ipecacuanha  and  saline  mixture,  or  given 
separately  in  a little  milk.  Sen  ga,  as  an  in- 
fusion, and  chloride  of  ammonium  may  also  be 
given  with  the  same  object.  The  last-named 
drug  appears  to  have  the  effect  Dot  only  of 
rendering  the  secretion  less  tenacious  and  more 
easily  removable,  but  also  of  diminishing  its 
formation.  An  occasional  emetic  dose  of  ipeca- 
cuanha often  materially  relieves  the  patient, 
when  numerous  rales  audible  over  the  chest, 
and  increased  dyspnoea,  indicate  an  accumula- 
tion of  the  secretion.  This,  however,  must  not 
be  given  when  there  is  marked  exhaustion 
present.  The  exhibition  of  opiates  is  as  a rule 
contraindicated.  When  the  cough  is  feeble,  and 
the  secretion  abundant,  they  do  much  harm.  In 
the  more  chronic  forms  of  the  disease,  however, 
and  especially  when  following  whooping-cough, 
where  the  cough  is  often  violent,  and  there  is 
but  little  bronchial  secretion,  opiates  may  he 
cautiously  given  with  advantage,  as  may  alto 
bromide  of  ammonium. 

With  the  object  of  reducing  the  temperature, 
and  also  of  increasing  the  expansion  of  the 
lungs,  much  may  be  done  by  the  external  applica- 
tion of  cold.  This  method  of  treatment  appears 
to  be  especially  valuable  in  increasing  the  depth 
and  force  of  respiration,  and  thus  in  preventing 
the  occurrence  of  collapse.  Its  utility  has  been 
strongly  advocated  by  both  Bartels  and  Ziemssee. 
The  method  recommended  by  these  physicians 
consists  in  the  application  of  cold  wet  compresses 
round  the  chest,  which  treatment  may  he  con- 
tinued from  half  to  three  or  four  hours.  It  is 
often  necessary  to  repeat  the  application  at 
intervals  for  some  days,  as  the  beneficial  effect 
is  only  temporary.  This  treatment  produces 
a marked  reduction  of  the  temperature,  and 
also  a diminution  in  the  frequency,  but  an  in- 
crease in  the  depth,  of  the  respirations;  the 
distress  being  thus  considerably  relieved,  and 
the  patient  often  falling  into  a sound  sleep. 
Owing  to  the  depression  produced  by  the  cold 
if  too  long  continued,  its  effects  require  to  be 
watched,  and  when  symptoms  of  exhaustion 
appear,  the  cold  should  be  discontinued,  to  be 
renewed  again  subsequently. 

Another  method  of  treatment  by  cold  is  that 
recommended  by  Juergenscn,  and  considered  by 
him  very  preferable  to  the  preceding,  as  being 
more  effectual  and  causing  less  discomfort. 
This  is  a treatment  by  baths  and  cold  affusion. 
The  child  is  first  placed  in  a bath  at  a tem- 
perature of  from  77°  to  SO0  Falir.  for  twenty 
minutes;  and  then  from  10  to  20  quarts  of 
water  at  36°  Fahr.  are  to  he  quickly  thrown 
over  the  hack  and  chest.  This  causes  severed 
deep  respirations,  and  thus  is  valuable  in  pre- 
venting collapse ; hut  it  appears  to  have  less 
effect  in  reducing  temperature  than  the  treat- 
ment by  cold  compresses. 

Whilst  these  various  means  are  being  em 
ployed,  it  is  all-important  to  support  tin 
strength  of  the  patient.  Brandy  is  here  mos 
valuable,  and  it  is  to  he  remembered  tha: 
children  hear  stimulation  well.  The  brandy  if 


LUNGS,  INFLAMMATION  OF. 


test  given  in  milk,  the  quantity  being  pro- 
portioned to  the  age  of  the  patient.  An  infant 
may  begin  with  from  five  to  ten  drops  every  two 
or  three  hours.  Under  its  influence  the  pulse 
usually  improves,  the  respirations  become  less 
frequent,  and  the  distress  and  cyanosis  diminish. 
The  administration  of  brandy  is  usually  advis- 
able before  and  during  the  treatment  by  cold. 
When  prostration  is  extreme,  or  deglutition 
difficult,  both  the  brandy  and  other  nutriment 
may  be  administered  by  the  rectum. 

In  the  chronic  forms  of  broncho-pneumonia 
these  more  active  methods  of  treatment  are  but 
rarely  called  for.  Here  attention  to  nutrition 
is  most  important,  and  small  doses  of  cod-liver 
oil  in  the  later  stages,  even  before  the  complete 
disappearance  of  the  pyrexia,  are  often  useful. 
When  the  disease  leads  to  induration  of  the  lungs 
and  dilatation  of  the  bronchi,  the  treatment  re- 
solves itself  into  that  of  chronic  pneumonia. 

Convalescence,  it  must  be  remembered,  is  al- 
ways slow,  and  there  is  a tendency  to  relapse. 
Great  care  is  consequently  requisite  during  this 
period.  All  causes  of  catarrh  must  be  carefully 
guarded  against ; and  the  restoration  to  health 
assisted  by  nutritious  diet,  cod-liver  oil,  and 
iron.  A change  of  air  is  especially  valuable. 

D.  Chronic  Pneumonia.— Synon.  : Chronic 
Inflammation  of  the  Lungs  ; Cirrhosis  of  the 
Lung;  Fr.  Pneumonic  interstitielle ; Ger.  Lun- 
jencirrhose. 

Definition.— Chronic  pneumonia  is  a compa- 
ratively rare  disease,  characterised  by  a gradual 
increase  in  the  connective  tissue  of  the  lung, 
which  leads  to  an  induration  of  the  pulmonary 
texture,  and  to  progressive  obliteration  of  the 
alveolar  cavities.  It  is  commonly  associated 
with  catarrh  and  dilatation  of  the  bronchi,  and 
often  with  ulceration  of  the  bronchial  walls,  and 
excavation  of  the  indurated  lung.  Cough,  ex- 
pectoration— often  abundant,  but  varying  with 
the  bronchial  catarrh — -dyspnoea,  gradual  impair- 
ment of  nutrition,  and  occasional  accessions  of 
slight  pyrexia,  are  the  most  prominent  clinical 
phenomena  accompanying  the  disease,  which 
runs  an  exceedingly  chronic  course,  often  subject 
to  long  periods  of  quiescence,  but  tending  to 
terminate  fatally  in  from  five  to  fifteen  years. 

Chronic  pneumonia  is  also  known  as  intersti- 
tial pneumonia.  In  its  most  marked  form  it 
constitutes  the  disease  which  received  from  Cor- 
rigan the  name  of  cirrhosis.  The  term  ‘ fibroid 
phthisis,’  which  is  sometimes  applied  to  it,  is 
iltogether  inapplicable. 

./Etiology  and  Pathology.  — It  is  exceed- 
ngly  doubtful  if  chronic  pneumonia  is  ever  a 
irimary  aud  independent  disease.  It  probably 
n all  cases  owes  its  origin  to  some  antecedent 
nflammation  of  the  pulmonary  or  bronchial 
extures,  or  of  the  pleura.  It  may  be  stated 
generally  that  all  inflammatory  processes  in  the 
ungs,  as  in  other  organs,  which  become  chronic, 
cad  to  an  increase  of  the  connective-tissue  ele- 
ments, and  consequently  to  fibroid  induration 
f the  organ.  In  the  lungs  by  far  the  most 
. ommon  cause  of  such  induration  is  pulmonary 
hthisis.  In  all  cases  of  phthisis,  excepting 
hose  which  are  the  most  acute,  there  is  more 
r less  fibroid  growth;  and  the  extent  of  this 


891 

growth  is,  for  the  most  part,  in  direct  propor- 
tion to  the  ehronicity  of  the  disease.  Those 
forms  of  phthisis  which  are  the  most  chronic, 
and  in  which  the  fibrosis  reaches  its  maximum, 
have  been  termed  ‘fibroid  phthisis.’  The  most 
chronic  cases  of  phthisis  are,  it  must  be  ad- 
mitted, somewhat  closely  allied  to  some  forms 
of  chronic  pneumonia.  The  two  diseases,  how- 
ever, differ  pathologically  in  this  respect — that 
whereas  much  of  the  pulmonary  consolidation 
of  phthisis  tends  to  undergo  molecular  death 
and  disintegration,  that  of  chronic  pneumonia 
exhibits  no  such  tendency  ; but  any  destruction 
and  excavation  of  the  indurated  lung  which  may 
take  place,  is  due  to  secondaiy  inflammation  and 
ulceration  commencing  in  the  bronchial  walls. 
In  considering  the  pathology  of  chronic  pneu- 
monia, therefore,  it  is  necessary  to  exclude  in  the 
first  place  the  pulmonary  induration  of  phthisis. 
Chronic  pneumonia  must  also  be  separated  from 
that  form  of  pulmonary  induration  which  is 
produced  by  long-continued  mechanical  conges- 
tion, namely,  brown  induration;  and  from  those 
more  localised  indurations  due  to  bronchitis, 
peri-bronchitis,  old  infarctions,  and  syphilis. 

There  appear  to  be  four  conditions  which  may 
give  rise  to  chronic  pneumonia,  namely:  — 1. 
Acute  pneumonia.  2.  Broncho-pneumonia.  3. 
Pleurisy.  4.  The  inhalation  of  irritating  par- 
ticles of  solid  matter.  Each  of  these  must  be 
considered  separately. 

1.  Acute  pneumonia. — Chronic  pneumonia  is 
an  occasional,  though  quite  rare,  result  of  the 
acute  primary  disease.  The  pulmonary  consoli 
dation  of  acute  pneumonia  almost  invariably 
undergoes  complete  resolution.  This  resolution 
is  usually  effected  rapidly,  in  from  seven  to 
fourteen  days.  Occasionally,  however,  the  course 
of  the  disease  is  more  protracted,  and  the  con- 
solidation persists  beyond  the  third  week.  When 
thus  protracted,  the  hepatissd  lung  tends  to  be- 
come slightly  indurated,  owing  mainly  to  thick- 
ening of  the  walls  of  the  alveoli.  This  indurated 
hepatisation  differs  but  little  in  its  physical  cha- 
racters from  ordinary  red  and  grey  hepatisation  ; 
it  is  simply  somewhat  firmer  and  more  resistant. 
In  very  exceptional  cases  this  small  amount  of 
induration  commencing  in  the  alveolar  walls  may 
gradually  increase,  so  as  ultimately  to  give  rise 
to  that  extensive  fibrosis  of  the  lung  which  con- 
stitutes what  is  known  as  chronic  pneumonia. 

2.  Brmicho-pneumonia.  — Broncho-pneumonia 
appears  to  be  a somewhat  more  frequent  cause 
of  the  disease  than  the  preceding  (Wilson  Fox). 
The  greater  liability  of  this  form  of  pneumonia 
to  lead  to  pulmonary  induration  is  to  ho  ac- 
counted for  partly  by  its  longer  duration  and 
greater  tendency  to  become  chronic,  and  partly 
by  the  existence  of  bronchial  dilatation  with 
which  it  is  so  frequently  associated.  That 
bronchial  dilatation  is  favourable  to  an  in- 
durative pneumonic  process  has  been  espe- 
cially insisted  upon  by  Dr.  Wilson  Fox.  Dila- 
tation of  the  bronchi  is  exceed  ugly  common  in 
the  simple  bronchitis  of  childhood,  and  espe- 
cially in  that  associated  with  whcoping-cough 
and  measles  ; it  is  also  a direct  result  of  pul- 
monary fibrosis.  In  whatever  way  originating, 
its  existence  favours  the  persistence  of  tha 
catarrhal  and  pneumonic  processes.  The  removal 


LUNGS,  INFLAMMATION  OF. 


S92 

of  secretion  is  rendered  more  difficult ; the 
retained  secretion  tends  to  increase  and  keep 
up  the  irritative  process,  both  in  the  dilated 
bronchi  and  also  in  the  pulmonary  alveoli ; and 
this  persistence  of  the  bronchial  and  pulmonary 
inflammation  leads  to  fibroid  thickening  of  the 
bronchial  and  alveolar  walls.  In  this  way  more 
or  less  disseminated  patches  of  indurative  con- 
solidation are  produced,  which  as  the  process 
proceeds  gradually  increase,  so  that  ultimately 
they  may  involve  large  areas  of  the  lung.  The 
progressive  tendency  of  the  process  is  probably 
partly  to  be  explained  by  the  fact,  already 
stated,  that  pulmonary  fibrosis  is  a cause  of 
bronchial  dilatation,  so  that  fibrosis  once  esta- 
blished, by  inducing  further  dilatation  of  the 
bronchi,  favours  the  extension  of  the  bronchial 
and  pulmonary  inflammation. 

3.  Pleurisy. — Pleurisy  in  very  exceptional 
cases  leads  to  the  development  of  a chronic 
pneumonia.  It  appears  to  be  in  those  cases  of 
pleurisy  which  are  more  or  less  chronic,  and  in 
which  the  lung  remains  long  collapsed  from  the 
effusion,  that  such  a result  is  most  liable  to  oc- 
cur. The  induration  of  the  lung  thus  induced 
is  often,  however,  exceedingly  partial,  consist- 
ing merely  in  some  increase  of  the  interlobular 
connective  tissue  originating  and  extending  in- 
wards as  dense  bands  from  the  thickened  vis- 
ceral pleura.  In  other  cases  pleurisy  probably 
gives  rise  to  a much  more  general  fibrosis. 

-1.  Inhalation. — The  inhalation  of  irritating 
particles,  such  as  occurs  in  the  trades  of  miners, 
potters,  stone-masons,  grinders,  &e.,  is  the  cause 
of  the  fibrosis  of  the  lungs  common  amongst 
persons  so  employed.  The  continuous  irritation 
of  the  inhaled  particles  induces  a bronchial 
and  alveolar  inflammation,  and  ultimately  fibrous 
growth  in  the  bronchial  and  alveolar  walls, 
which,  gradually  extending,  may  involve  large 
areas  or  even  the  whole  of  the  lungs. 

Anatomical  CiiAHACTEns. — The  histological 
changes  met  with  in  the  lungs  in  chronic  pneu- 
monia may  be  described  generally  as  consisting 
in  the  development  of  a fibro-nucleated  tissue 
from  the  walls  of  the  alveoli,  from  those  of  the 
bronchi,  and  from  the  interlobular  connective 
tissue ; which  new  growth,  as  it  increases,  and 
from  its  tendency  to  contract,  gradually  replaces 
and  obliterates  the  alveolar  structure.  The 
character  of  these  changes,  however,  varies 
somewhat  according  to  the  inflammatory  ante- 
cedents in  which  they  originate.  When  chronic 
pneumonia  is  the  result  of  acute  pneumonia,  the 
principal  change  takes  place  in  the  walls  of  the 
alveoli.  These  become  thickened  by  the  growth 
of  a small-celled  tissue,  in  which,  associated 
with  the  spheroidal  cellular  elements,  there  are 
sometimes  elongated  fusiform  cells,  such  as  are 
found  in  embryonic  tissue  which  is  in  process  of 
forming  a fibrous  structure.  This  new  growth, 
in  its  earlier  stages,  usually  contains  new  blood- 
vessels ; but  later  the  tissue  contracts,  and  the 
vessels  become  to  a great  extent  obliterated. 
The  growth  differs  from  the  non- vascular  growth 
rf  phthisis,  inasmuch  as  it  has  but  little  ten- 
iency  to  undergo  molecular  death  and  disin- 
tegration. The  alveolar  cavities,  where  not 
obliterated,  are  either  empty,  or  contain  exuda- 
li on-products  and  a few  epithelial  cells. 


When  secondary  to  ordinary  broncho-pneu. 
monia,  or  to  that  induced  by  the  inhalation  of 
irritating  particles,  the  new  fibroid  growth  also 
originates  principally  from  the  alveolar  walk. 
Here,  however,  the  growth  in  the  earlier  stages 
is  less  uniform,  and  the  peri-bronchial  and  inter- 
lobular connective  tissues  play  a more  promi- 
nent part  in  the  process.  The  new  peri-bronchial 
tissue  invades  the  walls  of  the  adjacent  alveoli, 
and  materially  increases  the  fibrosis. 

In  the  chronic  pneumonia  resulting  from 
pleurisy,  the  change,  as  already  stated, Is  often 
more  localised,  consisting  in  the  development  of 
dense  fibreus  bands  passing  inwards  from  the 
thickened  pleura.  Those  are  developed  from  the 
interlobular  tissue.  In  other  cases  the  fibrosis 
is  more  general. 

In  whichever  of  the  pulmonary  structures 
the  new  fibroid  growth  originates,  as  it  increases, 
all  the  connective  tissue  of  the  lung  may  become 
involved,  and  the  alveolar  cavities  be  completely 
obliterated.  The  new  growth,  like  that  met  with 
in  the  inflammatory  indurations  of  other  organs, 
although  in  the  earlier  stages  of  its  develop- 
ment it  may  be  richly  cellular  and  contain  new 
blood-vessels,  tends  gradually  to  become  less 
cellular,  denser,  and  more  contractile.  In  its 
more  advanced  state  it  often  consists  either  of 
closely  packed  wavy  fibres,  or  more  frequently 
of  a dense  homogeneous  or  obscurely  fibrillated 
material,  associated  with  which  are  a few  small 
round  or  fusiform  cells.  Sometimes  the  new 
growth  is  found  richly  cellular,  even  in  the 
most  advanced  stages  of  the  disease. 

The  macroscopical  appearances  of  the  lung 
vary  with  the  extent  of  the  fibroid  change.  In 
the  earliest  stages  of  the  induration  resulting 
from  acute  pneumonia,  where  there  is  merely  a 
slight  thickening  of  the  walls  of  the  alveoli,  the 
consolidation  very  much  resembles  that  of  red 
or  grey  hepatisation.  It  differs  in  being  firmer 
and  less  friable  in  consistence,  and  is  somewhat 
less  granular.  In  the  later  stages,  and  in  all 
cases  where  the  fibrosis  is  extensive  and  general, 
the  lung  is  diminished  in  size,  den-e.  firm,  fibrous, 
and  even  cartilaginous  in  consistence.  The  cut 
surface  is  smooth ; and  the  large  amount  of 
irregularly  distributed  black-pigment  usually 
present,  gives  to  it  a peculiar  grey,  marbled 
appearance.  Numerous  dilated  bronchi  traverse 
it  in  all  directions. 

When  the  disease  is  secondary  to  broncho- 
pneumonia the  fibrosis  in  the  earlier  stages  is 
much  less  general,  as  it  usually  is  also  when  the 
result  of  pleurisy.  Sometimes  dense  tracts  of 
fibrous  tissue  are  found  intersecting  the  lung  in 
various  directions.  As  the  disease  advances, 
however,  a large  area,  or  even  the  whole  lung, 
may  become  involved. 

The  bronchi  are  almost  invariably  found 
dilated  in  those  portions  of  the  lung  where  the 
induration  is  advanced.  In  some  cases  some 
dilatation  of  the  tubes  is  observed  in  parts 
which  are  not  involved  in  the  induration.  This 
dilatation  is  often  very  considerable,  and  the 
dilated  tubes  sometimes  form  large  cavities, 
which  may  occupy  a large  portion  of  the  indu- 
rated lung.  The  walls  of  the  tubes  are  much 
thickened,  and  the  mucous  membrane  is  olten 
ulcerated.  This  secondary  inflammation  and 


LUNGS,  INFLAMMATION  OF. 


olceration  of  the  bronchi  occurs  especially  in 
the  dilated  portions,  and  it  appears  here  to  be 
induced  by  the  irritation  of  the  retained  and 
putrid  secretion.  It  may  extend  into  and  in- 
volve the  indurated  lung,  and  so  lead  to  more  or 
less  excavation.  The  mucous  membrane  some- 
times sloughs,  and  the  gangrenous  process  may 
involve  ths  lung.  The  large  cavities  so  common 
in  these  lungs  are  in  the  main,  however,  dilated 
bronchi.  See  Bronchi,  Diseases  of. 

The  pleura  of  the  affected  lung,  except  in  the 
earliest  stages  of  the  disease,  is  much  thickened 
and  adherent. 

Site. — Chronic  pneumonia  is  in  the  majority 
of  cases  unilateral.  The  whole  lung  may  be 
involved  or  only  a portion.  In  the  latter  case 
the  base  is  much  more  commonly  affected  than 
the  apex.  When  due  to  the  inhalation  of  irri- 
tating solid  particles,  both  lungs  are  usually  im- 
plicated. 

Symptoms. — In  the  earlier  stages  of  chronic 
pneumonia  the  symptoms  are  often  very  obscure, 
and  it  is  not  uncommon  to  meet  with  advanced 
aud  extensive  fibrosis  in  which  the  lung-affection 
must  presumably  have  been  of  much  longer 
duration  than  the  symptoms  accompanying  it. 
In  some  cases  the  symptoms  are  directly  con- 
tinuous with  those  of  some  more  acute  pulmo- 
nary inflammation — an  acute  or  a broncho- 
pneumonia. Under  these  circumstances  a pro- 
longation of  some  of  the  phenomena  of  the 
original  disease  indicates  the  supervention  of 
the  pulmonary  fibrosis.  The  pyrexia  does  not 
entirely  disappear.  There  may  be  merely 
slight  elevation  of  temperature  towards  evening, 
or  the  course  of  the  fever  may  be  very  irregular. 
The  cough  usually  persists,  as  does  also  some 
increase  in  tho  frequency  of  the  respiration  and 
pulse;  and  the  patient,  instead  of  improving, 
gradually  loses  strength  and  flesh.  At  the 
same  time  the  physical  signs  of  the  pulmonary 
consolidation  remain,  and  gradually  give  place 
to  those  of  pulmonary  induration.  Where 
thronic  pneumonia  is  secondary  to  pleurisy,  a 
;ontinuous  sequence  in  the  symptoms  is  less 
commonly  observed.  When  the  result  of  the 
nhalation  of  irritating  solid  particles,  thesymp- 
■oms  of  bronchial  catarrh  are  predominant. 

When  the  fibrosis  is  fully  established  the 
ymptoms  are  usually  more  pronounced.  They 
•ary  considerably,  however,  according  to  the 
xtent  of  the  lung  involved,  the  quiescence  or 
ctivity  of  the  indurating  process,  and  the  pre- 
ence  or  absence  of  bronchial  catarrh.  When 
ronchial  catarrh  is  absent,  and  the  disease  is 
erfectly  quiescent,  a considerable  area,  or  even 
he  whole  of  the  lung,  may  be  involved  without 
roducing  any  marked  pulmonary  symptoms, 
ad  slight  dyspnoea,  with  some  general  impair- 
ment of  nutrition  and  failure  of  strength,  may  be 
most  the  only  phenomena  present.  Such  qui- 
cence  and  immunity  from  symptoms,  however, 
though  common  in  the  course  of  the  disease, 
rarely  observed  over  very  lengthened  periods. 
With  the  existence  of  catarrh  of  the  bronchi, 
ueh  more  marked  symptoms  are  observable, 
fiammation  of  the  bronchi  is  especially  fa- 
ured  by  the  dilatation  of  the  tubes,  and  it  is 
Most  invariably  present,  to  a greater  or  less 
tent,  during  the  course  of  the  disease ; with  it 


S93 

is  usually  associated  activity  of  the  indurating 
process.  The  dilatation  of  the  bronchi  and 
secondary  ulceration  of  their  walls,  which  are 
so  frequent,  are  also  most  important  factors  in 
accounting  for  the  symptoms.  The  courso  of 
the  disease  now  often  simulates  that  of  chronic 
phthisis,  but  it  is  for  the  most  part  more  chronic, 
less  regularly  progressive,  aud  more  frequently 
interrupted  by  periods  of  quiescence.  The 
dyspnoea  is  now  more  marked,  and  cough  be- 
comes a troublesome  symptom.  The  cough  may 
be  more  or  less  constant,  and  it  is  usually  at- 
tended by  expectoration.  Its  characters  vary, 
however,  according  to  the  extent  of  bronchial 
dilatation  and  excavation.  Wlien  there  are 
numerous  dilated  bronchi  in  the  lower  portions 
of  the  lung,  the  secretion  accumulates  within 
them,  and  its  removal  by  expectoration  becomes 
exceedingly  difficult.  Under  these  circumstances 
the  cough  is  violent  and  paroxysmal.  The 
patient  may  remain  for  several  hours  with  but 
little  or  no  cough,  and  then  occurs  a violent 
paroxysm,  which  results  in  the  expectoration  of 
large  quantities  of  muco-purulent  secretion.  This 
violent  paroxysmal  cough  and  copious  expectora- 
tion, occurring  at  long  intervals,  are  exceedingly 
characteristic  of  bronchial  dilatation  in  the  lower 
portion  of  a lung.  According  to  Niemeyer,  the 
paroxysm  occurs  when  the  secretion  which  accu- 
mulates in  the  lower  portions  of  the  lung  reaches 
and  irritates  the  more  healthy  bronchi  which 
retain  their  sensibility,  the  dilated  tubes  being 
so  altered  as  to  be  completely  insensible.  The 
sputum  may  be  simply  puriform,  but  when  there 
is  much  bronchial  dilatation,  owing  to  its  accu- 
mulation and  retention  in  the  tubes,  it  usually 
undergoes  putrefaction.  It  then  often  has  a 
greyish  or  greenish-black  colour,  and  is  usually 
more  or  less  feetid.  This  feetor  exists  quite 
independently  of  gangrene,  although  it  is  more 
marked  when  gangrene  is  present.  Haemoptysis 
is  not  unfrequent,  but  it  is  usually  small  in 
quantity.  It  is  probably  in  most  cases  due  to 
ulceration  of  the  bronchial  walls. 

Pyrexia  is  usually  present  to  a greater  or  less 
extent  in  the  course  of  the  disease.  The  fever, 
however,  is  exceedingly  irregular,  and  there  are 
often  long  periods  of  perfect  immunity.  During 
the  pyrexial  periods  the  maximum  evening  tem- 
perature is  rarely  more  than  101°  or  102°  Fahr., 
and  it  may  be  only  100°.  The  morning  tempe- 
rature is  often  normal.  The  pyrexia  appears  in 
most  cases  to  be  due  to  inflammation  and  ulcera- 
tion of  the  bronchi,  and  to  the  activity  of  the 
indurating  process. 

With  the  progress  of  the  disease  the  patient 
gradually  emaciates.  The  digestion  becomes 
impaired,  and  diarrhoea  is  often  present.  Dropsy 
is  a common  symptom,  although  it  is  rarely  ex- 
tensive, and  is,  for  the  most  part,  confined  to  the 
lower  extremities.  It  appears  in  most  cases  to  be 
due  to  the  anaemia  and  impeded  pulmonary  cir- 
culation. The  pulmonary  obstruction  may  also 
give  rise  to  some  enlargement  of  the  right  side 
of  the  heart,  and  cyanosis.  Lardaeeous  disease 
of  the  viscera  is  occasionally  met  with.  Death 
usually  results  from  the  general  failure  of 
strength,  or  from  some  intercurrent  affection  nf 
the  opposite  lung. 

Physical  signs.  — In  the  earliest  stage  of 


304  LUNGS.  INFLAMMATION  OF. 


chronic  pneumonia,  when  it  is  the  result  of  a 
more  acute  pneumonic  process,  the  physical 
signs  are,  in  the  main,  those  met  with  during 
the  acute  consolidation.  It  is  the  persistence  of 
the  signs  of  the  pulmonary  consolidation  after 
the  acute  attack  which  indicates  the  possibility 
that  the  disease  may  become  chronic.  Dulness 
on  percussion  ; increased  vocal  fremitus ; bron- 
chial breathing;  and  the  existence  of  rales, 
which  are  larger,  moister,  and  more  metallic  in 
quality  than  those  of  fine  crepitation,  are  ob- 
servable during  this  stage.  When  the  induration 
is  fully  established,  the  physical  signs  are  those 
of  contraction  and  consolidation,  with  usually 
those  of  more  or  less  dilatation  of  the  bronchi, 
of  a whole  or  a portion  of  the  lung.  The  re- 
traction is  well-marked,  and  commonly  affects 
the  whole  side,  although  when  the  lung  is  not 
universally  involved  it  may  be  more  limited. 
Expansion  is  exceedingly  deficient,  or  com- 
pletely absent.  The  heart  is  much  displaced 
towards  the  affected  side ; the  diaphragm  and 
the  abdominal  viscera  are  drawn  up ; and  the 
opposite  lung  encroaches  considerably  across 
the  middle  line  in  front.  Percussion  is  hard, 
wooden,  and  high-pitched,  sometimes  more  or 
less  amphoric.  The  vocal  fremitus  is  usually 
increased  ; and  there  is  often  bronchophony  or 
pectoriloquy.  The  respiratory  sounds  will  vary 
according  to  the  extent  of  the  bronchial  dilata- 
tion and  excavation,  and  the  amount  of  secretion. 
They  are  for  the  most  part  bronchial;  usually 
large  and  loud  ; and  often  distinctly  cavernous. 
When  there  is  much  secretion  in  the  dilated 
bronchi,  high-pitched  bubbling  rales  are  heard, 
which  are  often  amphoric  and  cavernous.  These 
may  be  audible  only  after  cough.  The  opposite 
lung  is  usually  hyper-resonant,  and  the  respira- 
tion exaggerated. 

Diagnosis. — The  diagnosis  of  chronic  pneu- 
monia rests  mainly  on  the  physical  signs.  The 
diseases  with  which  it  is  most  liable  to  be  con- 
founded are  chronic  phthisis,  and  retraction 
from  pleurisy.  In  the  most  chronic  forms  of 
phthisis,  where  the  fibrosis  of  the  lung  is  con- 
siderable, the  diagnosis  from  non-phthisical 
consolidation  may  present  some  difficulty.  This 
difficulty,  however,  rarely  exists  except  in  those 
eases  in  which  the  chronic  pneumonia  involves 
only  the  upper  portions  of  the  lung.  Here  the 
situation  of  the  consolidation  is  very  greatly 
in  favour  of  its  phthisical  nature.  This  proba- 
bility is  infinitely  increased  if  the  other  lung 
be  affected.  In  unilateral  basic  disease,  and  in 
induration  of  the  whole  of  one  lung,  the  other 
lung  being  healthy,  the  question  of  phthisis  can 
rarely  present  itself.  Disease  of  the  larynx  is 
in  favour  of  the  phthisical,  fostidity  of  the  sputa 
of  the  non-phthisical  nature  of  the  consolidation. 

The  retraction  resulting  from  pleurisy  with 
effusion  may  also  be  occasionally  confounded 
with  chronic  pneumonia.  Here,  however,  there 
are  rarely  the  physical  signs  of  dilatation  of  the 
bronchi,  and  the  vocal  fremitus  is  more  commonly 
diminished.  The  presence  of  abundant  foetid 
sputa,  of  pyrexia,  emaciation,  &c.,  in  chronic 
pneumonia  will  also  in  most  cases  render  the 
diagnosis  easy. 

Prognosis. — Chronic  pneumonia,  when  it  in- 
volves a considerable  area  of  the  lung,  usually 


tends  ultimately  to  terminate  in  death,  although 
under  favourable  circumstances  life  may  be  pro- 
longed for  many  years.  When  the  induration  is 
more  limited,  and  remains  quiescent,  the  general 
health  and  duration  of  life  may  sometimes  be 
but  little  affected.  The  most  important  element 
in  the  prognosis  is  the  condition  of  the  bronchi. 
The  existence  of  bronchial  inflammation,  as  evi- 
denced by  profuse  expectoration,  is  always  un- 
favourable, as  it  not  only  weakens  the  patient, 
but  is  usually  attended  by  extension  of  the  in- 
duration, and  ultimately  leads,  in  the  dilated 
tubes,  to  ulceration  of  the  bronchial  walls  and 
surrounding  tissue,  and  occasionally  to  gangrene. 
Pyrexia,  as  another  evidence  of  inflammation  of 
the  bronchi  and  indurated  lung,  is  likewise  un- 
favourable, as  is  also  haemoptysis.  The  latter 
indicates  deep  ulceration,  and  it  may  in  excep- 
tional cases  endanger  life.  The  general  condition 
of  the  patient  must  also  be  taken  into  account 
in  making  a prognosis.  Failure  of  strength  and 
of  digestive  power,  diarrhoea,  and  dropsy,  are 
all  of  unfavourable  augury. 

Treatment. — In  considering  the  treatment  of 
chronic  pneumonia,  it  is  in  the  first  place  im- 
portant to  bear  in  mind  that  the  usual  origin 
of  the  disease  is  some  more  acute  pulmonary 
inflammation.  Hence  the  necessity  for  the  most 
careful  management  and  supervision  of  such  in- 
flammations in  their  later  stages,  with  the  object 
of  procuring  a complete  resolution  of  the  pneu- 
monic products. 

When  the  fibrosis  of  the  lung  is  established, 
it  is  hardly  necessary  to  remark  that  the  new 
growth  is  incapable  of  removal,  and  by  treat- 
ment we  can  only  hope  to  influence  the  extension 
of  the  disease,  and  control  the  bronchial  catarrh 
with  which  it  is  so  frequently  associated.  The 
frequency  and  gravity  of  bronchial  catarrh  has 
been  already  insisted  upon,  and  its  management, 
in  the  majority  of  cases,  constitutes  the  most 
important  element  in  the  treatment.  In  that 
class  of  cases  in  which  the  disease  owes  its 
origin  to  the  inhalation  of  irritating  particles 
of  solid  matter,  the  removal  of  the  patient 
from  the  source  of  irritation  is  obviously  called 
for. 

In  the  attempt  to  prevent  and  control  bron- 
chial catarrh,  the  question  of  climate  must  ne- 
cessarily present  itself,  an4  very  much  may 
usually  be  done  by  residence  at  some  suitable 
station.  One  not  subject  to  vicissitudes  of  tem- 
perature, and  at  the  same  time  dry  and  mode- 
rately bracing,  is  most  likely  to  be  beneficial. 
The  patient  should  he  warmly  clad,  and  every- 
thing should  be  done,  by  means  of  diet  and 
medicine,  to  improve  the  general  health,  inas- 
much as  the  better  the  state  of  nutrition,  the 
less  is  the  liability  to  bronchial  inflammation. 
Cod-liver  oil  and  iron  are  often  useful  for  this 
purpose.  If  an  attack  of  acute  bronchial  catarrh 
supervenes  it  should  be  treated  at  once,  and  the 
importance  of  quickly  controlling  it  should  not 
be  forgotten.  In  the  medicinal  treatment  of  the 
more  chronic  catarrhal  process,  which  is  so  often 
associated  with  profuse  secretion,  much  may 
usually  be  gained  by  the  use  of  inhalations,  o 
which  turpentine,  creosote,  iodine,  and  carbolu 
acid  are,  perhaps,  the  most  generally  useful 
These  not  only  tend  to  diminish  the  amount  o 


LUNGS.  MALIGNANT  DISEASE  OF.  895 


socrefion.  bat  induce  coughing,  and  so  assist  in 
its  evacuation.  They  also  materially  lessen 
fcetor.  Turpentine  may  be  administered  inter- 
nally with  the  same  object.  When  the  cough 
is  excessive  and  prevents  sleep,  opium  and 
chloral  are  most  valuable.  Counter-irritation, 
especially  inunctions  with  iodine,  appear  some- 
times to  be  serviceable.  Gastric  disturbance, 
diarrhoea,  haemoptysis,  &e.,  must  be  treated,  as 
they  arise,  on  general  principles. 

T.  Henry  Green. 

LUNGS,  Inflation  of. — This  term  is  used 
somewhat  ambiguously.  It  is  sometimes  em- 
ployed as  synonymous  with  emphysema  in  its 
general  sense.  More  correctly  it  has  been 
limited  to  that  condition  in  which  the  lungs  are 
acutely  and  temporarily  distended  more  or  le>s 
with  air  from  various  causes,  such  as  plugging 
of  the  bronchial  tubes,  a condition  which  is 
usually  called  ‘acute  emphysema.’  It  cannot  be 
said  to  give  rise  in  itself -to  any  definite  symp- 
toms ; but  it  can  be  made  out  by  physical  ex- 
amination, the  signs  being  those  indicating 
excess  of  air  in  the  lungs. 

When  this  condition  exists,  the  aim  in  treat- 
ment should  be  to  get  rid  of  any  obstruction 
leading  to  the  imprisonment  of  the  air,  and  to 
help  the  lungs  in  expelling  it.  It  must  be 
remembered  that,  even  after  a considerable 
degree  of  distension,  the  lungs  may  return  to 
their  normal  dimensions. 

Inflation  is  also  a term  applied  to  that  expan- 
sion of  the  lungs  with  air,  which  is  aimed  at  in 
the  practice  of  artificial  respiration. 

Frederick  T.  Roberts. 

LUNGS,  Malformations  of. — There  are  no 
malformations  of  the  lungs  which  can  1 e re- 
garded as  of  much  importance  from  a clinical 
point  of  view.  As  anatomical  peculiarities,  the 
shape  of  these  organs,  or  the  arrangement  of 
their  lobes,  may  be  abnormal.  In  a case  which 
came  under  the  notice  of  tho  writer,  one  of  the 
lungs  was  improperly  developed  and  unexpanded, 
in  connection  with  the  almost  complete  absence 
of  one  of  the  divisions  of  the  pulmonarj-  artery. 
The  form  of  the  lungs  is  frequently  more  or  less 
altered,  as  the  result  of  various  organic  diseases 
if  these  organs.  Frederick  T.  Koberts. 

LUNGS,  Malignant  Disease  of. — Synon.  : 
i'r.  Carcinome  du  Poumon ; Ger.  Lungenkrebs. 

Definition. — Malignant  disease  affecting  the 
mlmonary  tissues. 

.(Etiology. — Malignant  disease  of  the  lungs  is 
jf  more  frequent  occurrence  than  was  at  one 
ime  supposed.  But  there  are  not  sufficient 
rustworthy  statistics  to  enable  us  to  determine 
s relative  frequency  to  other  forms  of  thoracic 
jrganic  disease.  It  has  been  met  with  in  per- 
ms of  all  ages,  from  childhood  to  extreme  old 
;e;  but  the  middle  periods  of  life,  from  ‘20 
i 60,  are  the  most  liable;  and  the  two  sexes 
■e  about  equally  obnoxious  to  the  disease.  As 
primary  disease,  originating  in  the  lungs,  can- 
r is  undoubtedly  rare,  though  much  less  rare 
first  manifesting  its  presence  in  those  organs, 
jlhsr  by  local  or  general  symptoms.  In  by  far 
c larger  number  of  eases  the  disease  in  the 
lgs  is  a secondary  affection,  consequent  on  the 


transmission  of  cancer-cells,  or  blastema,  from 
other  parts  ; and  in  this  way.  with  the  exception 
of  the  liver,  the  lungs  are  more  frequently  im- 
plicated than  any  other  internal  organ.  Thus, 
after  the  removal  of  an  external  cancer,  pulmo- 
nary symptoms  are  among  the  most  frequent 
and  earliest  indicate  ns  that  the  disease  has  in- 
vaded internal  organs. 

Anatomical  Characters. — The  right  lung 
has  been  considered  to  be  more  frequently 
affected  with  malignant  disease  than  the  left. 
This,  however,  does  not  accord  with  the  writer’s 
experience.  Of  thirty-nine  cases  tabulated  by 
him,  the  left  lung  was  the  principal  seat  in  four- 
teen, and  the  right  in  nine  only,  whilst  of  the 
remainder  either  both  lungs  were  affected,  or 
the  disease  was  confined  to  the  mediastinum.  Of 
the  several  varieties  of  cancer  encephaloid  is  by 
far  the  most  common  in  the  lungs  ; colloid  and 
epithelioma  are  the  rarest  ; and  scirrhus  holds 
a middle  place.  The  intermediate  varieties  of 
these  leading  forms  are  also  occasionally  seen. 

Symptoms  and  Diagnosis. — In  proceeding 
now  to  describe  the  various  aspects  under 
which  these  several  varieties  are  presented  to 
the  clinical  observer,  their  natural  history  and 
diagnosis,  it  is  not  pr<  posed  to  maintain  any 
precise  distinction  between  primary  and  secon- 
dary forms,  nor  to  discuss  the  minute  anatomy 
or  general  pathology  of  the  several  species,  such 
questions  h iving  been  considered  in  other  parts 
of  this  work.  The  object  of  the  writer  is  to  treat 
the  subject  from  a clinical  p nnt  of  view.  It  is 
important,  however,  to  observe,  in  limine,  that 
cancer  may  either  commence  in,  or  eventually 
implicate  any  or  all  i f the  pulmonary  textures; 
although  undoubtedly  both  the  primary  localisa- 
tion and  the  spread  of  the  disease  are  influenced 
by  the  particular  species.  Both  the  early  symp- 
toms and  the  subsequent  progress  of  the  case 
will  often  be  materially  nr  dified  bv  the  parlieular 
tissue  that  is  mainly  implicated.  If  the  disease 
first  manifests  itself  in  ihe  form  of  sui>-p!cural 
growths,  both  tho  early  symptoms  and  the  sub- 
sequent phenomena  will  differ  from  those  which 
present  themselves  when  the  disease  commences 
in  the  deeper  tissues  of  the  lungs.  And  it  is 
observable,  that  when  the  disease  commences  as 
disseminated  deposits  in  the  lungs,  these  depo- 
sits are  frequently  most  numerous  in  the  vicinity 
of  the  pleura,  so  that  this  membrane  is  very 
early  implicated,  in  many  cases,  when  it  is  net 
the  primary  seat  of  disease. 

For  clinical  purposes  we  cannot  do  better  than 
divide  intra-thoracic  cancerous  growths  into 
three  groups.  1.  Where  the  disease  is  dissemi- 
nated through  the  lungs,  either  in  the  form  of 
isolated  scattered  nodules  of  varying  magnitude, 
or  as  spreading  along  the  mucous  membrane  and 
sides  of  the  bronchial  rubes  and  vessels,  through 
a greater  or  less  extent  of  the  lung.  2.  Cases 
where  the  growth  is  more  localised,  occurring, 
tor  the  most  part,  in  large  masses.  3.  Medias- 
tinal tumours  involving  the  various  stru  turesat 
the  root  of  the  lungs,  and  eventually  giving  rise 
to  symptoms  of  pressure  and  distress  of  a moro 
or  less  seiious  character. 

1.  Disseminated  Malignant  Disease. — In 
the  disseminated  form  of  pulmonary  cancer  the 
symptoms  vary  considerably,  according  to  the 


896  LUNGS,  MALIGNANT  DISEASE  OF. 


seat  of  the  growths.  When  the  pleural  sur- 
face is  chiefly  implicated,  both  the  symptoms 
and  the  physical  signs  are  essentially  those 
of  pleurisy,  though  the  degree  of  febrile  dis- 
turbance is  usually  very  slight,  and  but  little 
or  perhaps  no  false  membrane  may  be  effused. 
The  exudation  is  generally  clear  serum,  or  serum 
mixed  ■with  blood;  and  it  may  have  a greenish 
or  brown  colour,  but  is  rarely  purulent  or  even 
semi-purulent.  As  the  effusion  increases  in 
amount,  the  ordinary  consequences  of  compres- 
sion of  the  lung  ensue,  but  dilatation  of  the  side 
is  generally  much  less  marked  than  in  simple 
pleurisy  with  effusion,  in  consequence  of  there 
being  less  giving  way  of  the  intercostals.  The 
fluid  generally  returns  speedily  after  paracen- 
tesis. 

When  the  mucous  and  submucous  membranes 
of  the  bronchi  and  the  surrounding  connective 
tissue  are  the  chief  seats  of  the  disease,  the 
physical  signs  are  those  of  bronchial  irritation 
and  emphysema,  which,  however,  may,  for  some 
time,  be  quite  disproportionate  to  the  dyspnoea 
and  other  symptoms  of  ordinary  bronchitis.  The 
expectoration  is,  for  the  most  part,  scanty,  and 
either  simply  mucous  or  mixed  with  blood ; or 
small  bronchial  casts  may  be  expectorated. 
Examination  with  the  microscope  vyill  occasion- 
ally reveal  characteristic  cancer-cells.  The 
resonance  of  the  chest  may  remain  normal,  when 
auscultation  proves  that  there  is  a diminution 
of  air  entering  the  lung.  But  there  will  not  be 
the  hyper-resonance  of  emphysema.  AVheezing 
and  dry  and  moist  sounds  vary  much  with  the 
amount  of  constriction  of  the  tubes,  and  the 
amount  and  character  of  the  secretion.  But  in 
advanced  cases  of  this  kind,  by  the  spread  of  the 
disease  along  the  interlobular  septa  and  through 
the  lung,  its  condition  becomes  similar  to  that  of 
a cirrhotic  lung,  and  the  clinical  aspects  of  the 
case  may  be  greatly  altered.  Perhaps  the  most 
characteristic  symptom  of  this  class  of  cases 
is  dyspncea  insidiously  increasing,  especially  on 
exertion,  without  corresponding  symptoms  of 
either  congestion  of  lung  or  compression.  Of 
the  general  symptoms  the  most  characteristic 
is  that  of  steadily-advancing  debility,  which  is 
common  to  other  forms  of  cancer.  And  it  is 
from  asthenia,  or  from  general  cachexia,  that 
the  patient  usually  dies,  before  much  or  any 
disintegration  of  tissue  takes  place.  It  is  the 
scirrhous  variety  of  cancer  which  most  often 
Ihus  follows  and  implicates  the  bronchi. 

In  the  distributive  form,  characterized  by  nu- 
merous masses,  varying  from  the  size  of  a millet- 
seed  to  that  of  a pea,  scattered  throughout  the 
lungs,  the  clinical  phenomena,  both  local  and 
general,  may  very  closely  simulate  those  of 
tubercle,  with  recurrent  attacks  of  bronchial 
irritation  and  congestion,  and  febrile  disturb- 
ance. But  as  a rule,  to  which,  however,  some 
remarkable  exceptions  have  been  met  with, 
there  is  little  if  any  increase  of  temperature, 
nor  is  there  the  quickened  breath  and  frequent 
dry  cough  of  tubercle.  The  dyspncea  is  chiefly 
on  exertion,  and  seems  more  due  to  feeble  circula- 
tion and  general  debility  than  to  either  pulmon- 
ary disease  or  febrile  disturbance.  Indeed  the 
absence  of  local  signs  of  inflammation,  or  symp- 
toms of  functional  disturbance,  are  frequently 


remarkable.  Signs  of  bronchial  irritation  in 
some  of  these  cases  have  been  early  noted  and 
prominent  symptoms ; in  others  they  have  been 
slight  and  variable.  The  apices  of  the  lungs, 
though  often  implicated,  are  not  specially  and 
early  invaded  as  in  tubercle,  but  rather  the 
bases.  If  the  cancerous  growths  are  TaDidly 
developed  and  extensively  distributed  through 
the  lungs,  both  the  signs  and  general  symptoms 
become  greatly  modified,  and  the  case  proves 
speedily  fatal.  The  similarity  to  acute  tuber- 
culosis is  sometimes  very  close,  especially  in 
those  instances  in  which  there  is  marked  febrile 
disturbance,  and  recurring  slight  haemoptysis. 

2.  Localised  Malignant  Disease.  — The 
second  class  of  cases  of  malignant  disease  of  the 
lungs,  in  which  the  disease  manifests  itself  in 
the  form  of  isolated  masses  of  larger  size,  is  the 
most  common.  There  may  be  one  such  tumour 
or  several,  at  first  assuming  a rounded  form, 
but  as  they  gradually  invade  the  luDg,  acquiring 
an  indefinite  shape,  and  involving  a large  portion 
or  even  the  whole  of  the  lung.  Such  tumours, 
being  most  frequently  of  the  encephaloid  varie 
ties  of  malignant  disease,  often  grow  rapidly, 
and  as  rapidly  disintegrate,  giving  rise  to  haemor 
rhage  and  destruction,  not  only  of  the  mass  itself, 
but  also  of  the  surrounding  tissues.  In  this  way 
vomicae  may  be  formed,  or  portions  of  lung  may 
become  gangrenous.  The  symptoms  and  progress 
of  these  cases  necessarily  vary  much.  If  the 
growth  or  growths  have  attained  any  considerable 
size,  there  is  dulness  on  percussion,  and  an  absence 
of  respiratory  murmur  over  the  affected  portion 
of  lung.  The  presence  and  character  of  other 
physical  signs  depend  very  much  on  the  patency 
or  occlusion  of  the  bronchi.  When,  as  is  often 
the  case,  these  are  completely  occluded,  nothing 
whatever  may  be  detected  on  auscultation,  aud 
all  vocal  fremitus  may  be  absent ; the  implicated 
portion  being  completely  shut  off  from  the  rest 
of  the  lung,  and  from  all  communication  with  the 
trachea.  If,  however,  the  bronchi  remain  patent, 
or— as  the  result  of  breaking  down  of  the  cancer- 
ous mass — if  communication  with  the  larger 
bronchi  lias  been  re-established,  we  have  evi- 
dence of  abundant  secretion,  and  the  ordinary 
phenomena  associated  with  a cavity.  In  such 
circumstances  microscopic  examination  of  the 
expectorated  matters  may  give  decisive  evidence 
of  the  nature  of  the  case.  On  the  other  hand, 
before  any  such  consequences  have  arisen,  we 
may  have  in  the  case  of  a large  tumour  involv- 
ing the  whole  or  the  greater  part  of  one  lung, 
auscultatory  signs  which  are  witli  difficulty  dis- 
tinguishable from  those  of  extensive  pleuritic 
effusion.  In  other  instances,  where  the  portion 
of  lung  implicated  in  the  cancerous  growth  is; 
limited  and  well-defined,  the  physical  signs  may 
so  closely  resemble  those  of  phthisis  as  to  lead 
astray  the  most  expert.  Thus  we  may  have 
limited  dulness  on  percussion,  with  absence  of 
respiration ; followed  by  signs  of  surrounding 
irritation,  slight  haemoptysis,  cough,  expecto- 
ration, and  indications  of  a cavity.  In  some 
rare  instances  there  have  been  limited  flattening 
and  altered  form  of  the  chest-walls,  such  a; 
characterise  chronic  phthisis.  Copious  haemop- 
tysis, except  in  connection  with  extorsive  ><e 
struction  of  lung-tissue,  is  not  common  iu  ra  ice 


LUNGS.  MORBID 

of  the  lung.  The  diagnosis  in  these  instances, 
where  the  local  signs  so  closely  resemble  phthisis, 
must  be  based  mainly  on  the  constitutional  symp- 
toms, and  the  history  of  the  case.  There  is 
considerable  difference  as  to  the  progress  and 
modo  of  termination  in  the  whole  of  the  class 
of  cases  now  under  consideration.  Long  before 
the  local  changes  have  advanced  far  enough  to 
admit  of  a decisive  diagnosis,  the  patient  may 
die  from  rapidly-increasing  debility  and  emacia- 
tion, with  more  or  less  of  hectic  fever,  and  even 
typhoid  phenomena ; or  he  may  be  carried  off 
by  rapidly-occurring  pleuritic  effusion.  In  other 
instances  cancer  developing  in  other  organs  is  the 
cause  of  death.  Indeed,  in  a large  proportion 
of  cases  the  manifestation  of  malignant  growths 
in  the  neck,  the  axilla,  or  other  parts,  places 
beyond  question  the  nature  of  the  case.  So  long 
as  the  growth  is  confined  to  the  substance  of  the 
lung,  and  does  not  implicate  the  nerve-trunks 
and  larger  vessels,  there  is  usually  little  pain, 
paroxysmal  dyspnoea,  or  disturbance  of  the  heart’s 
action,  excepting  such  as  may  be  due  to  feeble- 
ness of  muscular  power.  Nor  is  there  generally 
any  external  cedema,  or  distension  of  the  super- 
ficial veins.  The  reverse  of  all  this  characterises 
the  cases  in  which  the  mediastinum  and  the  roots 
of  the  lungs  become  involved. 

3.  Mediastinal  Tumours. — This  form  of  ma- 
lignant disease  of  the  lungs  is  described  under  a 
separate  heading.  See  Mediastinum,  Diseases  of. 

Peoqnosis  and  Treatment. — The  subject  of 
the  prognosis  and  treatment  of  malignant  disease 
of  the  lungs  in  its  various  forms,  will  be  more 
conveniently  discussed  in  the  article  Medias- 
tinum, Diseases  of. 

J.  Risdon  Bennett. 

LUNGS,  Malpositions  of. — Among  mal- 
positions may  be  regarded  those  conditions  in 
which  the  lung  is  contracted  more  or  less 
within  its  normal  limits  ; or,  on  the  other  hand, 
distended  so  as  to  pass  beyond  its  usual  bounda- 
•ies,  One  or  both  organs  may  be  thus  affected, 
these  alterations  may  result  either  from  more 
>r  less  diminution  of  the  amount  of  air  in  the 
ungs,  as  in  cases  of  compression  or  collapso ; 
rom  excess  of  the  same,  as  in  emphysema  and 
ypertrophy;  or  from  diseases  which  affect  their 
tructure.  The  lung  may  also  be  displaced 
y the  pressure  of  tumours,  in  addition  to  being 
impressed.  The  most  important  malposition 
c the  lung,  however,  is  that  known  as  hernia, 
which  a portion  of  the  organ  projects  into  the 
;ck,  or  through  some  part  of  the  chest-walls, 
through  the  diaphragm  into  the  abdominal 
vity.  If  the  hernia  passes  towards  the  surface 
the  body,  it  may  be  made  out  clinically,  being 
licated  by  a soft  and  compressible  swelling, 
:alised,  resonant  on  percussion,  and  rendered 
>re  prominent  by  a cough.  Pulmonary  symp- 
qs  might  possibly  be  present.  It  is  imprac- 
iblo  to  detect  a hernia  of  the  lungs  through 
diaphragm.  Frederick  T.  Roberts. 

TONGS,  Morbid  Growths  in. — The  for- 
i dons  in  the  lungs  which  belong  to  the  class 
< morbid  growths  may  be  thus  enumerated, 
l the  order  of  their  importance  : — 1.  Tubercle. 
* Cancer.  3.  Syphilitic  gummata.  4.  Hydatids, 
t Hare  formations,  such  as  sarcoma,  enchon- 

57 


GROWTHS  IN.  , 897 

droma,  osteoid  and  myeloid  growths,  haema- 
toma,  lymphatic  formations.  &c.  Most  cf  these 
are  discussed  under  their  appropriate  heading.-, 
and  it  is  unnecessary  to  allude  to  them  any 
further  here.  Those  belonging  to  the  last  group 
are  usually  rather  of  pathological  interesi 
than  of  clinical  importance,  as  they  rarely  give 
rise  to  any  local  symptoms  or  physical  signs 
during  life,  and  are  merely  discovered,  as  a rule, 
at  the  post-mortem  examination.  It  is  a questiot 
how  far  some  of  these  growths  are  to  be  re- 
garded as  being  of  a malignant  nature.  In  some 
cases  they  are  secondary  to  similar  growths  else- 
where, or  the  lung  may  be  involved  by  extensi  i. 
Lymphatic  formations  in  the  lungs  are  sum 
times  observed  in  cases  of  Hodgkin's  disease. 

Effects. — It  maybe  useful  to  indicato  i he 
effects,  if  any,  which  morbid  growths  may  p o- 
duce  in  connection  with  the  lungs.  1.  l ilt 
lung-tissues  may  merely  be  more  or  less  d s- 
placed  ana  compressed;  or,  in  course  of  time 
become  absorbed  or  atrophied,  in  proportior 
as  the  growth  progresses.  2.  The  distribu- 
tion of  air  in  the  lungs  may  be  modified  by  the 
mere  presence  of  a growth,  so  that  in  one  pail 
it  is  in  excess,  and  in  another  part  deficient.  3. 
Similarly,  the  circulation  of  blood  may  be  dis- 
turbed, leading  to  congestion  in  one  part,  and 
anaemia  in  another.  4.  Morbid  formations  are 
very  liable  to  cause  local  irritation.  Hence 
they  may  induce  bronchial  congestion  and  ca 
tarrh,  localised  acute  pneumonia  and  its  con- 
sequences, or  chronic  interstitial  pneumonic, 
which  may  lead  to  the  formation  of  a fibrou: 
capsule  around  a growth.  5.  Certain  formations 
are  liable  to  undergo  degenerative  and  destruc- 
tive processes,  either  in  themselves,  or  along 
with  the  pulmonary  tissues.  In  this  way  they 
originate  ulcerations  or  cavities,  and  may  give 
rise  to  products,  which  are  not  only  injurious  to 
the  lungs,  but  also  infect  distant  parts  to  which 
they  may  be  conveyed.  After  destruction  re- 
parative processes  not  unfrequently  take  plac-v 
with  loss,  however,  of  the  involved  portions  oi 
the  lung-structures.  It  must  be  remarked  here 
that  some  morbid  growths  seem  to  become  in- 
filtrated through  the  pulmonary  tissues  without 
destroying  them ; and  under  appropriate  treat- 
ment the  growth  is  absorbed,  leaving  the  in- 
volved portion  of  the  lung  intact.  This  applies, 
for  instance,  to  some  cases  of  syphilitic  infil- 
tration. 6.  Growths  in  the  lungs  sometimes 
extend  beyond  these  organs,  so  as  to  interfere 
with  neighbouring  structures,  causing  irritation, 
pressure,  or  destructive  effects.  Thus,  local 
pleurisy,  pressuro  on  vessels  or  nerves,  destruc- 
tion of  bones,  and  other  consequences  may  ensue. 
In  short,  the  growths  become  then  practically  in- 
tro-thoracic tumours,  and  produce  similar  effects 
Symptoms. — What  has  been  stated  as  to  the 
effects  of  morbid  growths  in  theluDgs  will  readily 
explain  the  clinical  signs  which  they  tend  te 
originate.  They  may  be  of  such  little  conse- 
quence that  they  produce  no  sign  whatever 
during  life,  not  interfering  in  any  way  with  the 
respiratory  functions,  or  being  themselves  in  in- 
sufficient amount  to  be  discoverable  by  physical 
examination.  Indeed,  some  formations  may  in- 
vade the  lungs  to  a considerable  extent  so  insi- 
diously that  no  evident  symptoms  are  induced. 


898 


LUNGS,  (EDEMA  OF. 


The  writer  has  known  cases  in  which  the  lungs 
were  extensively  implicated  in  secondary  cancer 
without  any  symptoms,  except  some  feeling 
of  shortness  of  breath  on  exertion.  Usually, 
however,  various  degrees  and  combinations  of  the 
ordinary  pulmonary  symptoms  may  be  antici- 
pated—namely,  pain  in  some  part  of  the  chest, 
cough,  expectoration,  the  sputum  sometimes 
containing  fragments  of  the  growth,  haemoptysis, 
and  dyspooea.  Pressure-symptoms  in  connection 
with  other  structures  are  induced  in  some  cases. 
Physical  examination  may  detect  the  disease 
when  there  are  no  symptoms  ; or  these  may  co- 
exist with  physical  signs,  which  either  reveal 
the  presence  of  the  morbid  formation  itself — 
such  as  alteration  in  the  shape  and  size  of  the 
chest,  deficient  expansion,  dulness,  bronchial  or 
other  abnormal  breath-sounds,  modified  vocal 
fremitus  and  resonance;  of  its  effects  on  the 
lungs;  of  the  formation  of  cavities;  or  of  its 
effects  on  neighbouring  parts.  The  particulars 
relating  to  these  points  are  discussed  in  other 
articles.  Definite  general  symptoms  are  asso- 
ciated with  many  forms  of  morbid  growth  in  the 
lungs. 

Treatment The  principles  of  treatment  of 

morbid  growths  in  the  lungs  are,  first,  to  get  rid 
of  them,  if  possible,  by  medicinal  means,  as  in 
the  case  of  syphilis  ; secondly,  to  treat  their 
effects  ; thirdly',  to  treat  local  symptoms  which 
may  arise  ; and  fourthly,  to  treat  the  general 
sj'mptoms.  Frederick  T.  Roberts. 

LUNGS,  (Edema  of. — Synon.  ; Fr.  (Edeme 
du  Poumon ; Ger.  Lungenbdem. 

Definition. — Infiltration  of  the  pulmonary 
tissue  with  serous  fluid. 

The  serous  fluid  is  effused  from  the  pulmonary 
capillaries  into  the  pulmonary  textures,  and  into 
the  alveolar  and  bronchial  spaces. 

JEtiology. — The  causes  of  this  exudation  are 
manifold,  but  of  two  sorts  : — ( a ) Disordered  cir- 
culation:— 1.  active  congestion,  attendant  upon 
inflammatory  conditions  of  the  lungs  and  bron- 
chi ; 2.  passive  congestion ; 3.  mechanical  con- 
gestion— in  heart-diseases,  emphysema,  or  pres- 
sure upon  the  pulmonary  veins ; 4.  want  of 
tone  of  vessels  after  inflammatory'  conditions,  as 
pneumonia  or  bronchitis,  or  pressure  upon  the 
vagus  nerve  or  pulmonary  plexus  ; 5.  afflux  of 
blood  to  the  lungs  in  croup,  and  during  the 
asthmatic  paroxysms  determined  by  the  ineffec- 
tual efforts  at  inspiration.  ( b ) Morbid  conditions 
of  the  blood'. — in  albuminuria,  and  to  a less  de- 
gree in  other  diseases  in  which  the  condition  of 
the  blood  is  altered  or  impaired — for  example, 
scurvy,  purpura,  ansemia,  hydraemia — the  lungs 
partaking  of  the  general  disposition  to  dropsy. 

Anatomical  Characthrs. — In  cases  of  oedema 
pulmonum,  the  lungs  are  usually  large,  filling 
the  thoracic  cavity,  and  sometimes  indented  by' 
the  ribs.  They  are  heavy;  their  pleural  sur- 
faces are  wet;  and  the  pleural  cavities  contain 
an  excess  of  serum.  Both  lungs  are  as  a rule 
affected,  their  lower  and  most  dependent  por- 
tions chiefly;  and  one  lung,  on  the  side  to  which 
the  patient  has  last  inclined,  is  more  highly 
[edematous  than  the  other.  The  higher  the 
legi'ee  of  oedema,  the  lees  crepitant  the  lung 
icd  tbe  more  distinctly  the  surface  pits  on  pres- 


sure. A portion  cut  from  a simply  oedematoag 
lung  will,  however,  almost  always  float  in  water; 
but  at  the  base  of  the  lung  there  is  usually  some 
collapse  iu  addition  to  the  oedema,  and  a por- 
tion removed  therefrom  sinks.  On  section  the 
lung  exudes  abundant  thin  serum,  and  more 
or  less  frothy  fluid,  with  which  the  bronchial 
tubes  are  also  occupied.  On  first  making  a 
section,  the  succulent  tissue  will  break  down 
easily  under  the  finger;  but,  after  the  excess 
of  fluid  has  been  squeezed  out,  the  lung  feels 
toughened.  (Edema  may  be  found  at  any  por- 
tion of  the  lung — at  the  apex,  for  instance, 
determined  there  by  the  inflammatory  process. 
The  transition  between  oedema  and  inflammatory 
consolidation  is  very  gradual  (Edema  is  also 
very  apt  to  pass  into,  or  to  be  complicated  with, 
a certain  degree  of  inflammation.  The  degree  of 
friability',  and  of  compressibility,  and  the  applica- 
tion of  the  water  test,  are  the  readiest  methods 
of  distinguishing  between  the  two.  If  a por- 
tion of  cedematous  lung  be  examined  under  the 
microscope,  tbe  alveoli  are  found  to  contain 
more  or  less  numerous  large  gTanular  cells,  but 
these  are  never  so  numerous  as  to  occupy 
entirely  the  alveoli. 

Symptoms. — The  symptoms  of  oedema  of  the 
lungs  are — in  addition  to  those  of  the  disease 
which  has  produced  it  — dyspnoea,  which  may 
amount  to  orthopnoea ; troublesome  • retching’ 
cough;  and  difficult,  yet  tolerably  abundant, 
frothy,  serous  expectoration.  The  percussion  note 
is  deadened  at  both  bases,  although  the  dulness 
is  usually  more  extensive  at  one  base  than  the 
other  ; the  vocal  fremitus  is  diminished;  the  re- 
spiratory murmur  is  enfeebled  or  lost;  and  a fin* 
bubbling  crepitation  is  heard. 

Diagnosis. — The  diagnosis  of  pulmonary  aide 
ma  is  not  usually  difficult.  The  absence  of  pleuri 
tic  pains  and  offerer,  and  the  double-sidednes 
of  the  disease,  together  with  the  absence  of  an; 
true  bronchial  breathing  or  aegophonv,  will  ex 
elude  pneumonia  or  pleurisy.  The  presence  c 
dulness  will  also  distinguish  the  condition  froi 
simple  capillary  bronchitis,  with  a certain  dt 
gree  of  which,  however,  it  is  often  combine! 
The  general  condition  of  the  patient,  and  tf 
presence  or  absence  of  those  diseases  or  circun 
stances  which  are  known  to  produce  oedema 
the  lungs,  must  be  carefully  taken  into  conside 
ation.  If,  for  instance,  after  an  asthmatic  p 
roxysm  we  hear  some  fine  bubbling  rales  oter  tl 
bases  of  the  lungs,  and  find  tho  patient  expect 
rating  an  unusual  quantity  of  frothy  serous  flui 
we  may  suspect  pulmonary  oedema  rather  th; 


bronchitis. 

Prognosis.— The  prognosis  in  oedema  of  t 
lungs  depends  mainly  upon  the  general  or  lo- 
conditions  with  which  it  is  associated.  It  is 
very  grave  purport  in  chronic  Bright  s disease, 
in  heart-disease.  It  is  also  a grave  complieati 
in  chronic  bronchitis,  showing  failure  of  hen- 
power.  It  is,  however,  often  a transient  h 
unimportant  affection  when  it  succeeds  to  act 
chest-affections,  as  pneumonia  or  bronchitis.' 
to  asthma.  As  a complication  of  acute  che- 
affectiuns.  it  is  rarely  recognised  clinicallv. 

Treatment. — The  treatment  of  pulmonj 
cedema  is,  in  all  important  cases,  derivat* 
Poultices  are  to  be  applied  to  the  chest, 


LUNGS,  PERFORATION  OF. 


899 


rofficient  mustard  to  produce  redness.  Dry- 
cupping will  often  give  great  relief.  Blisters 
should  be  avoided.  Watery  purgatives  should 
be  administered,  according  to  the  strength  o‘ 
the  patient.  Diuretics  are  useful  in  some  eases, 
especially  the  vegetable  diuretics,  such  as  digi- 
talis. juniper,  and  scoparium,  as  also  nitric 
ether:  and  the  same  is  to  be  said  of  diaphor- 
etics, fur  example,  acetate  of  ammonia,  -warmth, 
air  baths.  Moderate  stimulation  and  support 
must  b“  kept  up.  Kidney  or  heart-disease  if 
. present  will  mainly  determine  the  exact  treat- 
ment. If  there  be  failure  of  cardiac  power, 
sether,  ammonia,  and  alcoholic  stimulants  are 
required;  and  if  the  heart’s  action  continues 
hurried  or  irregular,  digitalis  is  especially  in- 
dicated. When  we  suspect  a loss  of  tone  of 
vessels,  as  after  bronchitis  or  pneumonia  and 
n anaemic  states,  perchloride  of  iron  with  some 
mineral  acid  is  to  be  recommended. 

In  all  cases  rest  in  bed  or  on  a couch  is  neces- 
sary. R.  Douglas  Powell. 

LUNG,  Perforation  of.— Synon.  : The  term 
pneumothorax  is  almost  equivalent. 

Definition. — The  formation  of  an  opening 
through  the  pulmonary  pleura,  communicating 
with  the  interior  of  the  lung. 

.Etiology.—  Perforation  of  the  lung  may 
irise  in  many  ways.  Its  causes  may  be  classified 
inder  the  three  following  headings : — 

1.  Penetrating  wounds;  for  example,  gunshot 
round,  punctured  wound,  or  laceration  by  a 
iroken  rib. 

2.  Dis  uses  affecting  the  pleural  cavity  or 
e:gkhouring  organs-,  such  as  empyema,  hepatic 
bscess  nr  hydatid,  or  suppuration  of  the  bron- 
hial  glands. 

3.  Disease  affecting  the  lung  itself ; for  in- 
:ance,  phthisis,  emphysema,  gangrene,  hydatids, 
r cancer. 

Of  all  the  causes  of  perforation  of  the  lung, 
hthisis  is  infinitely  the  most  common.  It  is 
te  rule  in  phthisis  for  pleuritic  adhesions  to 
rm  part  passu  with  the  pulmonary  lesion,  and 
aese  adhesions  are  usually  very  firm  and  diffi- 
lt  to  break  down.  In  neither  respect,  how- 
er,  does  this  rule  always  hold  good.  In  some 
re  cases  in  the  earliest  stage  of  the  disease  a 
lall  tubercular  nodule  situated  immediately 
der  the  pleura  softens,  and  the  pleura  gives 
y.  Again,  at  any  stage  of  the  disease  an  out- 
ng  tubercular  mass,  situated  below  the  point 
which  the  pleural  adhesions  have  extended, 
y soften  and  rupture  into  the  pleural  cavity. 
In  the  more  acute  pneumonic  varieties  of 
; :hisis  there  is  often  a singular  indisposition 
' the  formation  of  pleural  adhesions.  The 
] mcnary  pleura  in  such  cases  becomes  covered 
ha  thin,  smooth,  translucent  layer  of  lymph, 
t ning  through  which  can  be  seen  at  several 
Ints  opaqne  yellow  spots.  These  spots  are 
1 id  to  correspond  with  underlying  masses  of 
6 ened  cheesy  material,  by  which  the  pleura 

I been  undermined  and  deprived  of  its  vascular 
* ply.  Pneumothorax  has  its  most  frequent 
o in  in  rupture  of  the  pleura  at  one  of  these 
r ow  points. 

mally,  sinuses  are  sometimes  found  leading 

I I old  cavities  within  the  lung  to  the  pleural 


surface.  Occasionally  these  sinuses,  the  pleura 
being  adherent,  penetrate  through  the  thoracic 
wall  and  point  externally.  In  other  cases,  of 
which  the  writer  has  seen  two  examples,  they 
may  open  into  the  opposite  pleural  cavity. 

Anatomical  Characters. — The  affected  lung 
is  in  all  cases  collapsed,  and  in  cases  of  old 
standing  may  be  so  completely  so,  and  covered  by 
such  thick  layers  of  lymph,  as  to  be  found  only 
with  difficulty.  The  opening  may  have  closed. 
It  is  sometimes  difficult  to  discern.  It  may 
consist  of  a small  slit,  communicating  with  a 
cavity  by  a slanting  sinus,  so  as  to  form  a com- 
plete valve ; or  it  may  be  of  considerable  size, 
and  communicate  widely  with  a cavity  or  bron- 
chus. All  degrees  of  patency  between  these 
two  extremes  occur.  The  position  of  the  open- 
ing is  very  variable ; it  is  most  commonly  situa- 
ted somewhere  on  the  lateral  or  convex  side  ef 
the  lung.  The  rupture  is  almost  always  into 
the  pleural  cavity  on  the  same  side.  It  may, 
however,  take  place  into  the  opposite  pleural 
cavity,  through  the  mediastinal  fold  of  pleura. 
The  pleura  is  inflamed,  and  covered  with  lymph; 
and  its  cavity  contains  air,  and  a greater  or  less 
quantity  of  purulent  fluid.  The  heart  is  dis- 
placed, unless  in  some  rare  ease  it  be  held  by  a 
strong  adhesion.  Someyears  ago  the  writer  tested 
the  degree  of  air-pressure  present  in  ten  eases 
of  pneumothorax  by  means  of  a water-pressure 
gauge.  In  two  eases  it  was  nil;  in  one  case  it 
was  equal  to  125  inch;  in  two  cases  2 inches;  in 
one  case  3'75  inches  ; in  two  cases  4 inches ; in 
one  case  5'3  inches;  and  in  a double  case  il 
equalled  3’5  inches  in  one  pleura,  and  2'7  in  the 
other.  The  gas  effused  approximates  in  com- 
position to  that  of  expired  air,  containing  frem 
8 to  16  per  cent,  of  carbonic  acid.  Sometimes 
sulphuretted  hydrogen  also  is  found  in  fetid  cases. 

Symptoms  and  Signs. — The  symptoms  and 
signs  of  perforation  of  the  pleura  are  those  of 
pneumothorax  and  of  hydro-pneumothorax.  At 
the  moment  of  attack  sudden  acute  pain  is  felt 
in  the  chest,  at  the  seat  of  rupture,  and  is  im- 
mediately followed  by  great  dyspnoea  and  shock. 
In  a well-marked  case  the  expression  of  face  is 
peculiarly  agonized  and  terror-stricken;  the  ex- 
tremities are  cold  ; damp  sweats  break  out , the 
pulse  is  quick  and  small ; and  the  respirations  are 
exceedingly  rapid.  The  position  of  the  patieDt  is 
that  of  orthopnoea.  with  an  inclination  forwards, 
and  to  the  sound  side ; it  is,  however,  frequently 
changed  in  the  endeavour  to  gain  breath.  The 
voice  is  feeble  and  whispering.  The  urgency  of 
the  shock  and  dyspnoea  depends  upon  the  amount 
of  useful  lung  suddenly  disabled.  If  the  patient 
survive  the  attack,  after  two  or  three  days  fever 
of  a hectic  ebara  ter,  with  sweats,  supervenes. 
In  some  cases,  however,  the  symptoms  of  pneu- 
mothorax come  on  very  insidiously. 

Physical  signs.  - The  physical  signs  are  very 
characteristic.  There  is  enlargement  of  the  side 
affected,  and  effacement  or  bulging  of  the  inter- 
costal spaces.  The  heart  is  displaced  towards 
the  s und  side.  The  percussion-note  is  hyper- 
resonant  or  tympanitic  over  the  siae  affected, 
except  where  i at  the  apex)  the  lung  may  perhaps 
be  still  adherent;  and  on  auscultation  either 
r.o  respiration  at  all  is  audible,  or  amphoric 
breathing  of  a peculiar  character  may  be  hear,: 


930 


LUNGS,  SYPHILITIC  DISEASE  OF. 


at  one  or  more  points,  sometimes  accompanied 
with  the  characteristic  metallic  tinkle.  A pecu- 
liar metallic  echo  is  heard  if  the  patient  coughs. 
If,  whilst  the  ear  is  applied,  a coin  placed  on 
the  diseased  side  is  struck  with  another  coin,  a 
characteristic  bell-note  is  heard.  The  vocal  fremi- 
tus is  diminished  or  lost.  At  a later  stage,  when 
more  or  less  effusion  has  taken  place,  the  signs  of 
hydro-pneumothorax  present  themselves,  namely, 
dulness  below  and  liyper-resonance  above — in 
varying  proportions  and  shifting  in  relative  posi- 
tion with  the  posture  of  the  patient.  If  the 
amount  of  fluid  be  moderate,  a splash  or  succus- 
sion-sound  may  be  elicited.  This  sound  may  be 
audible  to  the  ear  applied  to  the  chest,  or  to 
bystanders.  If  the  fluid  effusion  be  consider- 
able, intercostal  fluctuation  may  be  felt ; and  this 
fluctuation  gives  to  the  finger,  on  percussion  at 
the  level  of  junction  of.  air  and  fluid,  a peculiar 
sensation  of  thrill.  The  position  usually  assumed 
by  the  patient  now  is  with  the  head  raised,  and 
leaning  towards  the  diseased  side. 

Diagnosis. — The  diagnosis  of  perforation  of 
the  lung  is  to  be  made  from  other  diseases; 
and  also  with  respect  to  the  probable  nature 
of  the  opening,  and  the  degree  of  pressure  pre- 
sent. If  the  three  essential  signs  of  pneu- 
mothorax be  remembered,  namely,  displacement 
of  heart,  tympanitie  percussion-note,  and  either 
absence  of  respiration  or  amphoric  breathing, 
there  can  scarcely  be  any  difficulty  in  mak- 
ing the  diagnosis.  It  cannot  be  confounded  with 
a.  bilateral  disease  like  emphysema.  The  shift- 
ing resonance  and  dulness,  the  succussiou-splash, 
with1  perhaps  metallic  tinkle  and  amphoric 
breath-sound,  are  signs  abundantly  sufficient  to 
distinguish  hydro-pneumothorax  from  ordinary 
empyema.  Respecting  the  nature  of  the  opening 
—whether  valvular  or  free,  careful  auscultation 
will  usually  gain  the  desired  information.  If 
amphoric  breathing  be  well-marked,  it  may  be 
assumed  that  the  opening  is  a free  and  tolerably 
direct  one ; if,  on  the  other  hand,  no  respiratory 
sound  be  audible,  the  communication  with  the 
pleura  is  indirect  and  more  or  less  completely 
valvular.  In  the  latter  case  the  pressure-symp- 
toms become  more  urgent. 

Prognosis. — Of  course  the  prognosis  in  every 
case  of  tubercular  pneumothorax  is  necessarily 
very  grave,  but  by  no  means  equally  .grave  in  all 
cases.  The  following  considerations  will  guide 
to  a correct  prognosis,  (a)  Nature  of  opening.  If 
the  communication  with  the  pleura  be  valvular, 
signified  by  the  entire  absence  of  breath-sound, 
and  the  increasing  urgency  of  dyspnoea,  the 
patient  will  die  in  a few  hours,  unless  relieved 
by  paracentesis.  ( b ) State  of  the  opposite  lung. 
If  the  effusion  of  air  have"  occurred  on  the  side 
least  affected  by  previous  disease,  the  case  is 
correspondingly  hopeless.  If,  on  the  other 
hand,  we  know  that  the  lung  now  collapsed  was 
previously  much  diseased,  and  if  the  other  lung 
be  but  little  affected,  the  duration  of  life  may 
not  be  greatly  shortened  by  the  accident.  Life 
is  then  gradually  extinguished  bjr  hectic  fever, 
and  progressive  disease  in  the  opposite  lung.  It 
is  by  no  means  impossible,  and  probably  hap- 
pens more  frequently  than  is  supposed,  that  the 
opening  in  the  pleura  may  close,  the  air  become 
absorbed,  and  the  case  converted  into  one  of 


simple  empyema.  In  pneumothorax  arisingfrom 
accidental  wound  or  injury  to  the  lung,  the  prog- 
nosis depends  upon  the  visceral  injury.  Theair  in 
the  pleura  is  absorbedwith  considerablereadiness. 

Treatment. — In  all  cases  in  which  death  ia 
threatened  by  asphyxia,  in  consequence  of  air 
accumulating  in  the  pleura,  paracentesis  with  a 
fine  trochar  must  be  performed.  This  will  Id 
such  cases  give  great  relief,  and  may  be  repeated 
if  necessary.  There  is  a tendency  for  an  opin- 
ing at  first  completely  valvular  to  become  at  a 
later  period  more  patent  or  possibly  to  close  so 
that  it  is  better  to  operate  when  necessary  with 
a fine  trochar  than  to  make  a permanent  open- 
ing. Rest  to  the  affected  side  should  be  secured, 
as  far  as  possible,  by  the  application  of  a broad 
piece  of  strapping  extending  round  the  side  to 
beyond  the  middle  line  in  front  and  behind. 
The  shock  and  dyspnoea  are  best  treated  by 
opium  in  repeated  small  doses.  Stimulants  may 
also  be  necessary,  but  opium  is  far  more  useful. 

R.  Douglas  Powell. 

LUNG,  Rupture  of.— Rupture  of  the  lung 
is  an  extremely  rare  occurrence.  Cases  of  so- 
called  rupture  of  the  lung  from  external  violence 
are,  for  the  most  part,  really  produced  by  per- 
foration or  laceration  of  the  pleura  by  a fractured 
rib.  It  is  said  that  rupture  of  the  lung  may 
occur  in  whooping-cough. 

LUNGS,  Syphilitic  Disease  of. — There  is 
still  much  uncertainty  as  to  the  effects  which 
syphilis  may  produce  in  connection  with  the 
lungs,  but  there  can  be  no  doubt  that  it  does 
sometimes  originate  specific  lesions  in  these 
organs,  though  much  less  frequently  than  in 
most  of  the  other  viscera.  They  are  generally 
only  met  with  in  advanced  cases  of  acquired 
syphilis,  when  the  signs  of  the  disease  are 
markedly  developed  in  other  parts.  Occasion- 
ally the  lungs  are  involved  in  congenital  syphilis. 
The.  presence  of  a tubercular  or  scrofulous  dia- 
thesis has  been  supposed  to  predispose  to  the 
implication  of  the  lungs  in  syphilitic  disease. 

Anatomical  Characters. — Gummata  consti- 
tute the  most  certain  and  unquestionable  lesioDs 
of  a syphilitic  nature  in  the  lungs,  but  they 
are  rare.  When  present,  they  vary  in  number 
from  one  to  many.  In  the  latter  case  they  an 
disseminated,  but  are  stated  to  have  a predi 
lection  for  the  deeper  parts  of  the  organs.  Ii 
size  these  growths  usually  vary  from  a pea  t< 
a walnut,  but  may  reach  the  dimensions  of  ; 
large  egg.  Thoy  are  generally  well-defined 
rounded  in  shape,  and  often  surrounded  wit' 
a fibrous  capsule.  In  their  early  condition  gum 
mata  in  the  lungs  appear  on  section  greyis 
or  brownish-red,  homogeneous,  firm,  and  dryis 
in  consistence.  Subsequently  they  tend  to  do 
generate,  becoming  more  or  less  caseous,  ye: 
low,  and  less  consistent;  and  they  may  eve 
break  down  in  the  centre,  so  as  to  form  cavitie 
The  structure  of  these  gummata  is  found  c 
microscopical  examination  to  be  made  up  of  nj 
perfect  fibres,  abortive  nuclei,  and  a few  fibr 
cells,  infiltrating  the  pulmonary  tissues,  ai 
thickening  the  alveoli.  Afterwards  these  a 
mixed  with  granular  matter  and  other  produc 
of  degeneration  and  disintegration. 

There  has  been  much  discussion  regarding  t 


LUNGS,  SYPHILITIC  DISEASE  OF. 

relation  of  syphilis  to  another  form  of  lesion 
affecting  the  lung-tissues,  namely,  a variety  of 
chronic  interstitial  pneumonia.  There  seems 
every  reason  to  believe  that  this  morbid  condition 
is  in  some  instances  due  to  syphilis.  The  result 
is  a fibroid  infiltration  of  the  pulmonary  tissue, 
which  in  its  general  and  microscopic  characters 
cannot  be  distinguished  from  a similar  condition 
due  to  interstitial  pneumonia  from  other  causes, 
but  the  new  tissue  is  said  to  be  more  vascular 
in  its  early  stages.  The  affected  parts  are 
much  indurated ; and  any  bronchi  which  are  im- 
plicated tend  to  become  more  or  less  dilated. 
The  morbid  condition  may  be  distributed  in 
various  parts  of  the  lungs,  but  appears  to  have 
a preference  for  their  bases  and  the  vicinity  of 
their  roots.  It  frequently  originates  at  the  sur- 
face, and  penetrates  thence  into  the  interior  of 
the  lungs  in  the  form  of  fibrous  bands,  the  pleura 
being  generally  thickened  or  adherent,  and  super- 
ficial puckerings  and  depressions  being  visible. 
In  other  instances  the  new  growth  commences 
around  gummata;  or  from  a chronic  contracting 
peri-bronchitis,  associated  with  ulcerative  inflam- 
mation (Pye-Smith).  Dr.  Green  states  that  it 
originates  mainly  around  the  small  interlobular 
blood-vessels.  Syphilitic  fibroid  infiltration  has 
10  tendency  to  caseation ; but  it  may  become  the 
seat  of  ulceration  or  gangrene. 

In  connection  with  congenital  syphilis,  a pecu- 
liar condition  has  been  described  as  affecting  the 
ungs  in  new-born  or  very  young  infants,  under 
carious  names,  such  as  syphilitic  pneumonia, 
white  hepatization,  and  epithelioma  of  the  lungs, 
t assumes  a more  or  less  diffuse  or  infiltrated 
.rrangement,  but  is  of  variable  extent,  and  may 
ivolve  one  or  both  organs.  One  lung  may  be 
ffected  throughout,  while  the  other  is  quite  free 
:om  disease.  The  more  obvious  characters  are 
s follows : — The  pleura  is  usually  unaffected, 
he  lung  is  enlarged,  and  may  be  in  a state  of 
ill  expansion,  so  that  its  surface  is  marked  by 
te  ribs ; it  feels  remarkably  heavy ; and  at  the 
;at  of  the  disease  is  dense,  firm,  hard,  and 
,ually  resistant,  not  breaking  down  under  pres- 
re.  On  section  it  presents  a white  or  yellow- 
h-white  colour,  being  more  or  less  bloodless  ; 
uniform  and  smooth;  and  little  or  no  fluid  can 
expressed  or  scraped  from  the  cut  surface, 
refill  examination  reveals  minute  bands  of 
rous  tissue  running  in  all  directions.  Miero- 
ipically  the  change  seems  to  consist  mainly  in 
ickening  of  the  alveolar  walls  and  minute 
inchi,  due  to  an  imperfectly  fibrillated  and 
fieated  tissue,  which  undergoes  degenerative 
1 inges.  Most  observers  further  describe  an 
i rease  in  the  epithelial  cells,  which  fill  the 
: -vesicles  and  minute  air-tubes,  but  Wagner 
i ies  this.  The  vessels  also  become  thickened 
! . ultimately  obliterated. 

t maybe  remarked  that  the  bronchial  tubes 
o-heir  divisions  may  be  affected  with  syphi- 
1 ‘ disease,  their  submucuous  tissue,  or  occa- 
6 'ally  their  deeper  structures,  becoming  in- 
fi  ated  with  a fibro-nuclear  growth.  Ulceration 
n ' take  place,  followed  by  cicatrization,  and 
h ing  to  thickening  of  their  walls,  and  narrow- 
u or  even  complete  closure  of  their  channel. 

tstPTOMS.— In  the  present  state  of  knowledge 
■t  mpossibleto  write  with  anything  like  definite- 


LUNGS,  TUBERCULOSIS  OF.  901 
ness  respecting  the  clinical  history  of  syphilitic 
disease  of  the  lungs.  As  a matter  of  fact,  in 
the  majority  of  cases  the  lesions  have  only  been 
discovered  after  death,  no  symptoms  having 
occurred  during  life  pointing  to  the  lungs  ; or, 
these  having  been  obscured  by  symptoms  affect- 
ing other  parts.  In  a case  of  recognised  consti- 
tutional syphilis,  attention  should  be  paid  to  the 
lungs  as  well  as  to  other  organs,  and  it  would  be 
advisable  to  examine  them  from  time  to  time,  as 
physical  signs  might  occur  without  any  obvious 
symptoms  to  attract  the  patient's  attention.  If 
pulmonary  symptoms  should  arise  in  a person 
undoubtedly  syphilitic,  or  who  had  had  syphilis, 
the  possibility  of  the  lungs  being  affected  should 
specially  be  borne  in  mind.  Among  these  symp- 
toms haemoptysis  at  an  early  period  is  said  to 
be  important.  Physical  examination  might  pos- 
sibly reveal  the  presence  of  gummata,  as  evi- 
denced by  localised  dulness,  bronchial  breath- 
ing, increased  vocal  fremitus  and  resonance,  and 
other  signs  of  consolidation.  The  most  signifi- 
cant signs,  however,  are  those  indicating  marked 
induration  of  the  lung  from  fibroid  infiltration, 
especially  if  unilateral,  and  confined  to  the  base 
or  middle  portion  of  the  organ.  In  course  of 
time  signs  of  cavities  might  become  evident, 
due  to  breaking-down  of  gummata,  or  to  dilated 
bronchi.  The  general  symptoms  are  those  of 
constitutional  syphilis,  combined  with  those  of 
phthisis.  There  is  but  little  or  no  pyrexia 
accompanying  the  pulmonary  lesions ; and  the 
progress  of  the  case  is  essentially  chronic.  The 
effects  of  treatment  may  be  of  peculiar  signi- 
ficance in  the  diagnosis  of  syphilitic  disease  of 
the  lungs.  If  such  symptoms  and  physical  signs 
connected  with  these  organs  as  have  been  in- 
dicated above  should  disappear  under  the  use 
of  anti-syphilitic  remedies,  a diagnosis  of  this 
disease  might  fairly  be  made.  Indeed  some  ob- 
servers think  that  they  frequently  discover  and 
cure  it,  but  this  is  somewhat  doubtful. 

Treatment.—  If  syphilitic  disease  of  the 
lungs  be  recognised  or  suspected,  the  appropriate 
treatment  in  most  cases  is  to  administer  iodide 
of  potassium  freely  and  continuously.  In  some 
cases  a mercurial  course  of  treatment  answers 
best ; or  perchloride  of  mercury  might  be  com- 
bined with  the  iodide.  It  may  be  necessary  to 
employ  internal  remedies  or  local  applications 
for  the  relief  cf  pulmonary  symptoms.  Cod- 
liver  oil  and  tonics  may  be  given  with  advantage 
for  the  amelioration  of  the  general  condition,  in 
cases  where  such  medicines  are  needed. 

Frederick  T.  Roberts. 

LUNGS,  Tuberculosis  of. — Tubercle  is  the 
most  important  morbid  growth  affecting  the  lung, 
but  it  is  by  no  means  a settled  point  what  should 
be  included  under  this  term.  Many  pathologists 
only  recognise  as  tubercle  the  so-called  grey  gra- 
nulations ; others  regard  the  various  masses  and 
infiltrations  noticed  in  cases  of  phthisis  as  of  this 
nature,  and  they  look  upon  tubercle  in  these  or- 
gans as  divisible  into  grey  and  yellow  varieties, 
and  arranged  either  in  granules  or  as  an  infil- 
tration. It  is  unnecessary  in  this  place  to  discuss 
this  subject  further,  as  it  is  considered  fully  in 
other  appropriate  articles.  See  Phthisis  ; and 
Tuberculosis.  Frederick  T.  Roberts. 


002  LUPUS  ERYTHEMATOSUS. 

LUPUS  ERYTHEMATOSUS  {lupus,  a 
wolf,  or  a rodent  disease;  and  erythematosus,  re- 
lated to  erythema). — Synon. : Seborrhasa,  con - 

<j  estiva. 

Definition. — A chronic  hyperaemia  of  the  skin, 
attended  by  a new  cell-growth,  followed  by  in- 
terstitial absorption,  and  ending  in  scar. 

^Etiology. — Women  are  more  liable  to  lupus 
erythematosus  than  men,  in  the  proportion  of  8 or 
10  to  1.  It  is  rare  before  puberty,  and  most  often 
begins  between  the  ages  of  20  and  30  years ; but 
no  age  of  adult  life  up  to  60  or  70  is  exempt. 
Weakly  persons  are  thought  by  some  to  be  most 
liable,  but  it  may  attack  perfectly  healthy  people 
— at  any  rate  there  is  no  intimate  connection 
with  any  other  special  disease.  This  affection  is 
not  hereditary.  It  attacks  ail  classes  of  society. 

Anatomical  Characters. — The  capillaries  of 
the  cutis  are  dilated,  and  a small-celled  new- 
growth  develops  in  it,  close  under  the  epider- 
mis, around  the  orifices  of  the  sebaceous  and 
hair-follicles  and  the  sweat-ducts.  There  is  an 
increased  secretion  of  sebum ; and  crusts  of 
epidermis  and  fatty  matter  form.  The  terminal 
scar  is  due  to  destruction  of  normal  tissue  by 
the  new-growth ; partial  fatty  degeneration  and 
absorption  of  the  latter;  and  conversion  of  the 
remainder  into  permanent  connective-tissue. 

Stmptoms. — Lupus  erythematosus  most  often 
attacks  the  face  Small  patches  of  well-defined 
crimson  or  purplish  redness  form  on  the  skin 
of  the  cheeks  or  nose,  and  remain  for  a long 
period  unaltered ; they  then  become  covered  in 
parts  with  thin,  firmly  adherent,  dirty-looking 
crusts,  which  if  removed  are  found  to  send  pro- 
cesses into  the  dilated  mouths  of  the  sebaceous 
glands.  In  the  final  stage,  the  redness  gives  place 
to  a very  superficial  whitish  scar.  Confluence 
of  several  small  patches  gives  rise  to  irregular 
patterns.  When  both  cheeks  are  attacked  at 
once,  the  patches  tend  to  unite  across  the  nose 
in  the  shape  of  a bat's  wing  or  butterfly.  The 
scalp  often  suffers,  and  there  is  permanent  loss 
of  hair.  Other  seats  of  lupus  erythematosus  are 
the  ears,  eyelids,  lips,  and  backs  of  the  hands; 
but  it  may  exceptionally  occur  on  the  arms  and 
legs,  on  the  trunk,  and  on  several  parts  at  one 
time.  There  is  no  pain,  or  ulceration,  but  some- 
times slight  itching.  Exposure  to  cold  winds  or 
to  great  heat  aggravates  the  disease.  In  Germany 
an  acute  form  has  been  observed,  in  which  the 
eruption  quickly  covers  a large  part  of  the  body; 
is  attended  with  fever  and  prostration ; and  may 
end  in  death.  The  writer  has  seen  such  a case. 

Complications.  — Recurrent  erysipelas  has 
been  noticed  more  often  in  lupus  erythematosus 
than  in  lupus  vulgaris.  These  two  forms  of  lupus 
may  occur  in  the  same  individual. 

Diagnosis. — This  disease  is  to  be  diagnosed 
from  lupus  vulgaris,  by  its  commencement  after 
puberty  ; by  its  very  superficial  character ; and 
by  the  sebaceous  crusts.  From  eczema,  which  it 
sometimes  resembles  at  first  sight,  lupus  erythe- 
matosus may  be  distinguished  by  the  history, 
chronicity,  trifling  itching,  and  the  presence  of 
scars.  For  its  diagnosis  from  acne  rosacea  see 
Acne. 

Prognosis. — This  disease  is  very  chronic,  and 
may  last  for  years.  Permanent  cure  is  very 
doubtful,  on  account  of  the  tendency  to  relapse. 


LUPUS  VULGARIS. 

Except  in  the  acute  form,  which  is  rare,  then 
is  no  danger  to  life. 

Treatment.  — In  the  treatment  of  lupus 
erythematosus  the  first  indication  is  to  rectify 
any  derangement  of  the  general  health.  There  is 
no  specific  internal  remedy.  Arsenic  and  mercurr 
are  not  indicated  ; milk  and  cod-liver  oil  improve 
the  nutrition.  Externally,  mild  caustics  sui'  best. 
Emplastrum  hydrargyri  should  always  be  tried, 
spread  thickly  on  linen,  with  enough  oleum 
terebinthinae  to  make  it  soft,  and  applied  every 
night  for  a long  period.  The  liniment  or  tincture 
of  iodine  can  be  painted  on  until  slight  inflam- 
mation is  set  up,  and  repeated  after  an  interval ; 
or  spirit  of  soap  (1$,  saponis  mollis  5j,  spiritus 
rini  yss-3j)  may  be  rubbed  in  in  the  same  way, 
and  let  dry  on.  Stronger  caustics,  such  as  the 
solution  of  caustic  potash,  require  great  taution 
in  their  use  ( see  Lupus  Vulgaris).  Some  cases 
do  best  with  soothing  remedies — such  as  unguen- 
tum  zinci  benzoati,  or  a lead  lotion  ( liquoris 
plumbi  subacetatis  yj,  glycerini,  yij)  applied 
warm  after  the  crusts  are  removed ; and  the  lat- 
ter are  always  of  service  in  the  intervals  between 
the  caustics.  Edward  I.  Spares. 

LUPUS  VULGARIS  {lupus,  a wolf,  or  a 

rodent  disease ; and  vutgans,  common). — Synon.  ; 
Fr.  Scrofulide  maligne ; Dartre  rongeanie ; Ger. 
Lupus ; Fressende  Flcchte. 

Definition. — A very  chronic  non-contagious 
disease  of  the  skin  and  mucous  membranes; 
chiefly  due  to  an  infiltration  of  small  round 
cells  into  their  substance  ; attended  either  with 
epidermic  exfoliation,  interstitial  absorption,  or 
destiuetive  ulceration. 

Aetiology. — The  aetiology  of  lupus  vulgaris 
is  unknown.  Some  cases  occur  in  scrofulous  per- 
sons with  enlarged  or  suppurating  lymphatic 
glands,  diseases  of  the  bones  and  joints,  &e.,  or  in 
the  children  of  consumptive  parents,*  but  in  the 
larger  number  lupus  affects  perfectly  healthy 
people.  Most  cases  begin  very  early  in  life, 
from  the  second  or  third  year  up  to  puberty. 
The  ulcerative  form — lupus  exedem — may  begin 
still  later,  but  it  is  very  rare  for  it  to  do  so  after 
the  thirtieth  year.  Women  are  somewhat  more 
liable  to  lupus  than  men,  and  country  people 
than  townspeople.  It  is  in  no  way  due  to  syphilis, 
either  hereditary  or  acquired ; and  instances 
in  which  two  members  of  the  same  family  ari 
attacked  are  rare. 

Anatomical  Characters. — The  cutis  in  lupus 
is  infiltrated  with  vast  numbers  of  small  rounc 
cells  of  about  0001  mm.  in  diameter,  which  en 
croach  on  and  gradually  destroy  its  proper  tis 
sues.  The  new-growth  has  a certain  resemblanc 
to  granulation-tissue  (Virchow).  It  is  highl 
vascular,  and  contains  new-formed  capillar 
vessels.  Nodules  bare  been  described,  dissem 
nated  through  the  cutis,  each  consisting  of  cnec 
more  eeutral  multinuclear  giant-cells,  surronnde 
by  bands  of  smaller  cells  which  shade  off  int 
the  granulation-tissue.  These  nodules  exact; 
resemble  grey  tubercle  (Friedlander).  some  ai 
thorities  regard  these  giant-cells  as  retrograc 
products,  due  to  central  fusion  of  the  en.lotheli 
cells  of  sweat-ducts,  blood-vessels,  and  lymph 
tics,  with  persistence  of  their  nuclei  (Lang 
The  epidermis  covering  the  lupus-tissue  is  this 


LUPUS  VULGARIS. 


mod;  the  lower  cells  of  tho  rete  mucosum  are 
fattily  degenerated,  and  contain  reddish  pigment. 
Lnpus-tissue  is  very  persistent.  It  may  either 
undergo  fatty  degeneration  and  subsequent  ab- 
sorption, without  lesion  of  the  epidermis;  or 
else  the  latter  breaks  down  too,  and  ulceration 
is  the  result. 

Symptoms. — Lupus  usually  begins  as  one  or 
more  small,  smooth,  reddish-brown,  or  reddish- 
yellow  blotches,  from  the  size  of  a pin’s  head  to 
s split  pea,  which  may  be  level  with  the  skin, 
or  else  raised  in  the  form  of  small  tubercles. 
Several  of  these  are  generally  aggregated  into  a 
patch,  and  a number  of  them  may  coalesce,  so 
as  to  cover  extensive  surfaces  of  skin  ; but  this 
is  the  exception  rather  than  the  rule.  Any 
change  that  occurs  is  always  slow,  and  a patch 
the  size  of  a shilling  or  a florin  may  take  years 
to  form.  In  the  non-ulcerative  variety,  thin, 
epidermic  scales  are  continually  thrown  otffrom 
the  surface  of  the  tubercles — lupus  cxfolia- 
tivus.  After  a while,  interstitial  absorption  of 
the  lupus-cells  begins  in  the  older  tubercles, 
and  a bluish-white  papery  scar  is  left.  In  other 
cases  the  tubercles  soften,  ulcerate,  and  become 
covered  with  greenish-yellow  adherent  scabs, 
beneath  which  the  ulcer  extends.  The  surround- 
ing parts  are  swollen,  and  the  edge  of  the  ulcer 
is  pinkish.  Removal  of  the  scab  exposes  a 
loss  of  substance,  with  sharp-cut  edges,  and  a 
granulating  base  covered  with  purulent  secre- 
tion. The  ulceration  may  attack  structures 
deeper  than  the  skin,  and  destroy  cartilage, 
fibrous  tissues,  muscle,  and  even  bone.  The 
nucous  membranes  are  not  often  primarily 
flfected  by  lupus,  though  it  often  extends  to 
,hem  from  the  skin  ; instances  are,  however,  re- 
jorded  in  which  the  larynx  has  been  attacked, 
lausing  ulceration,  partial  destruction  of  the 
ipiglottis,  and  warty  outgrowths  on  the  pos- 
erior  wall. 

Lupus  may  occur  on  any  part  of  the  body  or 
imbs,  but  it  has  a special  preference  for  the  skin 
>f  the  face.  The  non-ulcerative  form  chiefly 
elects  the  cheeks,  and  afterwards,  in  order  of 
requeney,  the  nose,  ears,  legs,  arms,  and  trunk, 
'he  ulcerative  form  — lupus  exedens  — begins 
lmost  exclusively  on  the  nose,  attacking  chiefly 
is  anterior  portion,  either  the  tip  or  the  odges 
f the  alae.  Sometimes  it  begins  within  the 
ostril.  Unless  proper  treatment  is  at  hand  the 
ose  may  be  entirely  destroyed,  and  severe  in- 
mds  made  into  the  tissues  of  the  cheeks,  lips, 
ad  other  neighbouring  parts. 

Complications  and  Seqtjeuj. — Lupus  may 
i-exist  with  enlarged  and  suppurating  glands 
the  neck  and  elsewhere;  with  various  scrofu- 
us  affections;  with  phthisis;  and  with  chronic 
right’s  disease.  Great  deformity  may  result 
em  tho  coutraction  of  the  scars  which  it  leaves, 
r example,  ectropion,  stricture  of  the  nares, 
d distortion  of  the  mouth.  About  a dozen 
ses  have  been  recorded  in  which  epithelioma 
veloped  on  a patch  of  lupus  of  many  years’ 
mding,  or  on  a lupus  scar.  We  may  regard 
-h  cases  as  arising  from  the  stimulus  of  the 
aliferative  processes  in  the  cutis  on  the  neigh- 
aring  epithelium. 

Diagnosis. — Theduration  and  position  of  lupus 
garis,  and  the  absence  of  thick  scaliness  and 


903 

itching,  will  generally  render  it  easy  to  distin- 
guish this  disease  from  circumscribed  forms  of 
psoriasis  and  eczema ; and  its  commencement  in 
early  life  will  clearly  separate  it  from  epitheliul 
cancer  and  rodent  ulcer.  It  is  with  syphilis  that 
it  is  most  apt  to  be  confounded,  and  the  diagnosis 
between  lupus  exedens  on  the  nose,  and  an  ulce- 
rating 6yphilide,  is  sometimes  extremely  diffi- 
cult, or  at  first  sight  impossible.  In  these  cases, 
after  carefully  considering  the  history,  we  must 
examine  other  parts  of  the  body  for  traces  cf 
syphilis,  and  an  inspection  of  the  mouth  and 
pharynx  will  often  materially  assist  us  ; and 
lastly,  the  greater  chronicity  and  slower  exten- 
sion of  lupus,  as  well  as  its  resistance  to  specific 
treatment,  will  generally  lead  to  a correct 
opinion.  Indolence  is  a character  of  special 
value  in  deciding  between  lupus  and  syphilis, 
particularly  as  affecting  the  mucous  membranes. 
Syphilis  has  also  more  tendency  to  suppuration 
than  lupus. 

Prognosis.— Lupus  is  never  fatal  per  se,  but 
it  can  never  be  looked  on  in  a favourable  light, 
owing  to  its  tendency  to  relapse  under  treat- 
ment, and  its  invariable  termination  in  a con- 
tracting cicatrix. 

Treatment — Internal.— Internal  treatment  is 
only  of  use  in  lupus  vulgaris  where  the  patient's 
general  health  is  bad,  or  where  well-marked 
symptoms  of  scrofula  are  present.  In  these 
cases  great  benefit  may  be  derived  from  tonics, 
especially  the  iodide  of  iron,  and  from  cod-liver 
oil  in  as  large  doses  as  can  be  tolerated.  Nu- 
tritious food  should  be  freely  given ; and  the 
patient  should  take  plenty  of  outdoor  exercise  in 
a bracing  climate. 

External. — The  real  cure  for  all  forms  of 
lupus  must  always  consist  in  the  destruction  of 
tho  new  tissue  forming  it,  by  caustic  agents  of 
various  strengths.  A number  of  such  remedies 
have  been  proposed,  but  the  successful  applica- 
tion of  each  seems  often  to  depend  more  on 
individual  experience  of  its  use,  than  on  the 
superiority  of  any  one  caustic  over  the  rest. 
The  caustics  most  generally  used  are  caustic 
potash,  nitrate  of  silver,  and  acid  nitrate  of 
mercury.  Equal  parts  of  caustic  potash  and  dis- 
tilled water  may  be  applied  with  a tiny  piece  of 
sponge,  so  as  to  limit  the  action  as  much  as  pos- 
sible. The  pain  which  follows  is  not  of  long 
duration — a point  of  much  importance  where  a 
caustic  must  be  repeatedly  used.  Solid  nitrate 
of  silver  should  be  bored  freely  into  all  ulcerated 
parts  or  soft  tubercles.  The  lupus-tissue  offers 
but  slight  resistance  to  it,  whereas  it  will  not 
penetrate  or  injure  healthy  parts.  Acid  nitrate 
of  mercury  may  be  painted  on  with  a glass 
brush.  The  crusts  which  form  after  any  of  these 
agents,  fall  off  in  ten  days  or  a fortnight,  and 
it  is  not  advisable  to  repeat  the  application  at 
shorter  intervals.  As  a rule  no  dressing  except 
zinc  ointment  is  required.  Some  authorities 
prefer  the  actual  or  else  the  galvanic  cautery, 
but  both  these  measures  have  the  disadvantage 
of  disfiguring  the  parts,  so  that  it  is  difficult  to 
determine  when  healthy  tissues  are  reached. 
Others  advise  multiple  scarification,  with  one 
or  more  fine-bladed  knives,  so  as  to  obliterate 
blood-vessels,  and  produce  absorption  by  starv- 
ing the  lupus  tissue  and  exciting  inflammation 


904  LUPUS  VULGARIS. 

(Volkmann,  Veiel).  For  a more  detailed  descrip- 
tion of  the  mechanical  methods  of  treatment, 
including  that  by  ‘ scraping,’  see  Appendix.  In 
the  treatment  of  the  superficial  patches  of 
lupus  non-exedens,  the  repeated  application  of 
mercurial  plaster  during  several  months  has 
sometimes  been  followed  by  absorption  of  the 
growth.  Pyrogallic  acid  ointment  (1  to  10)  has 
been  used  by  Hebra  and  others  with  much  suc- 
cess. In  other  cases  painting  with  tincture  or 
liniment  of  iodine,  and  coating  with  gutta-percha 
foil,  produces  slow  improvement ; and  where  no 
uleoration  exists,  demanding  active  interference, 
these  milder  remedies  deserve  a trial.  See  Ap- 
pendix. Edward  I.  Sparks. 

LYMPH  (rvfitpTi,  a nymph,  water). — Physio- 
logically, lymph  signifies  the  fluid  which  circu- 
lates in  the  lymphatic  system.  Pathologically, 
the  term  is  applied  to  the  coagulable  exudation 
which  escapes  from  the  vessels  in  inflammation. 
The  name  ‘ vaccine  lymph,’  or  ‘ lymph,’  is  also 
given  to  the  fluid  contained  in  the  vaccine- 
vesicle.  See  Inflammation  ; and  Vaccinia. 

LYMPHADENITIS  ( lympha , lymph,  and 
adenitis,  inflammation  of  a gland). — Inflamma- 
tion of  lymphatic  glands.  See  Lymphatic  System, 
Diseases  of. 

LYMPH  ADENOMA.— Synon.  : Hodgkin's 
Disease  ; Antenna  Lymphatica  (Wilks) ; Fr.  Ade- 
nie  (Trousseau) ; Lymphadenic  (Ranvier)  ; Ger. 
Pseudoleukdmie  (W underlich). 

Definition. — A disease  characterised  by  more 
or  less  widely-spread  enlargement  of  the  lymph- 
atic glands,  accompanied  frequently  by  enlarge- 
ment of  the  spleen,  and  by  progressive  anaemia. 

History. — Cases  of  coincident  enlargement  of 
the  lymphatic  glands  and  spleen  were  noted 
by  Malpighi  (1669)  and  Morgagni  (1752).  The 
nature  of  the  glandular  change  was  first  care- 
fully described  by  Craigie,  (1828);  and  the  gen- 
eral clinical  history  of  the  affection  was  pointed 
out  by  Hodgkin  (1832),  and  by  Wilks  (1856). 
The  most  important  subsequent  observations  are 
those  of  Virchow  (1864),  Wilks  (1865),  Trousseau 
(1865),  Wunderlich  (1858  and  1866),  and  Mur- 
chison (1870). 

Nature. — The  enlargement  of  the  lymphatic 
glands,  which  consists  at  first  of  mere  hyper- 
plasia, and  subsequently  of  fibroid  induration, 
varies  much  in  its  extent.  A few  glands  only 
may  suffer,  or  every  gland  in  the  body  may  be 
enlarged.  The  former  cases  have  the  characters 
of  a local  growth ; the  latter  is  distinctly  a 
general  disease,  for  which  the  term  lymphade- 
nosis seems  the  most  exact.  The  glands  vary  in 
consistence  : when  soft  there  may  a considerable 
excess  of  leucocytes  in  the  blood ; when  hard 
there  may  be  simple  anaemia.  This  difference 
does  not  afford  sufficient  ground  for  separation. 
The  enlargement  of  the  spleen  is  usually  due  to 
disseminated  growths,  arising  in  the  Malpighian 
bodies  : sometimes  there  is  also  hyperplasia  of 
the  splenic  pulp,  as  in  splenic  leueocythoemia. 

^Etiology. — In  two-thirds  of  the  cases  of 
lymphadenoma,  no  cause  can  be  traced,  and  the 
ascertainable  antecedents  of  the  disease,  in  most 
of  the  remaining  cases,  evidently  constitute  oniy 
a small  part  of  the  influences  tc  which  it  is  duo. 
Hereditary  transmission  has  not  been  distinctly 


LYMPHADEN  OMA. 

proved.  The  disease  is  three  times  as  frequent 
in  males  as  in  females.  It  is  met  with  at  all  ages, 
but  is  most  frequent  in  early  and  late  adult  life! 
1 1 occurs,  but  is  not  specially  frequent,  in  chil- 
dren under  ten  years,  and,  having  regard  to  the 
numbers  living,  it  is  least  frequent  between  the 
ages  of  forty  and  fifty  years.  Intemperance, 
mental  depression,  insufficient  food,  and  over-' 
exertion  have  been  noted,  in  rare  cases,  as  ante- 
cedents. Exposure  to  cold,  in  several  instances, 
has  appeared  to  be  the  exciting  cause  of  tho 
affection.  It  is  doubtful  whether  the  disease 
has  any  relation  to  constitutional  syphilis.  In 
several  cases  the  symptoms  have  first  appeared 
after  child-birth.  Various  febrile  affections  have, 
in  a few  instances,  preceded  the  affection.  The 
exciting  cause  which  has  been  noted  most  fre- 
quently is  some  local  irritation,  as  of  a decayed 
tooth,  discharge  from  the  ear,  sore-throat,  in- 
flammation of  the  lachrymal  sac,  or  eczema.  In 
these  cases  the  glands  nearest  the  source  of  irri- 
tation first  enlarged,  and  then  more  distant  oDes 
became  affected. 

Anatomical  Characters.-—  The  several  groups 
of  glands  are  affected  in  the  following  order  of 
frequency,  beginning  with  those  most  commonly 
diseased:  cervical,  axillary,  inguinal,  retro-peri- 
toneal, bronchial,  mediastinal,  mesenteric.  Sub- 
sidiary adjacent  glands  are  often  enlarged 
together  with  the  chief  groups,  and  nodular 
growths,  similar  to  enlarged  glands,  arise  in 
the  course  of  the  lymphatics  in  places  in  which 
the  existence  of  glands  is  not  usually  recognised, 
so  that  continuous  chains  of  nodules  connect  the 
various  groups.  The  size  attained  by  the  glands 
i n lymphadeuoma  varies  from  that  of  a bean  to 
that  of  a hen’s  egg.  At  first  the  individual  glands 
are  separate  and  movable  one  on  another.  Ulti- 
mately they  often  unite  to  form  a conglomerate 
mass,  in  consequence,  in  most  cases,  of  the  per- 
foration of  tho  capsules  of  the  glands  by  growth, 
which  may  also  invade  adjacent  parts.  The 
cervical  glands  are  usually  enlarged  iu  both 
the  anterior  aud  posterior  triangle.;  and  the  sub- 
maxillary  glands  may  encircle  tho  neck  beneath 
the  lower  jaw.  They  may  press  on  the  trachea  or 
larynx,  displace  the  latter,  compress  the  internal 
jugular  vein,  and  cause  paralysis  of  the  recur- 
rent laryngeal  uerve.  The  occipital  glands  are 
usually  also  enlarged.  The  axillary  glands 
often  form  a mass  of  rery  large  size,  and  pro- 
longations may  extend  beneath  the  pectoral 
muscle.  The  glands  in  the  anterior  mediasti- 
num frequently  suffer,  and  the  growth  may 
extend  to  adjacent  structures,  such  as  the  peri- 
cardium, which  may  be  perforated.  The  thymus 
may  be  involved,  secondarily  or  primarily,  or 
may  escape.  The  bronchial  glands  are  diseased 
more  frequently  than  the  cardiac  glands,  and 
the  trachea  and  bronchi  may  be  pressed  upon, 
or  the  lung  invaded.  The  retro-peritoneal 
glands  often  form  a mass  of  large  size,  which 
may  surround  and  compress  the  solar  plexus 
causing  symptoms  similar  to  those  of  Addison"; 
disease.  Enlargement  of  the  mesenteric  gland; 
is  neither  common  nor  considerable.  The  in 
guinal  group  is  frequently  diseased,  and  tin 
femoral  vessels  and  craral  nerves  may  be  th-rc- 
by  compressed.  The  consistence  ofthoenlar®* 
glands  maybe  either  soft  or  very  hard.  Usually 


LYMPHADENOMA. 


the  longer  the  enlargement  has  existed,  the 
firmer  are  the  glands.  Their  section  is  more  uni- 
form than  in  health.  The  colour  is  yellowish  or 
whitish-grey.  In  the  firmer  glands  dense  tracts 
of  fibrous  tissue  are  seen  to  pass  in  different 
directions.  Barely  the  follicles  have  a dif- 
ferent appearance,  being  opaque  and  yellowish 
from  fatty  degeneration,  whilst  the  septa  are 
white  and  conspicuous,  from  fibroid  thickening. 

( hiseation  is,  however,  rare,  and  when  it  occurs 
is  commonly  confined  to  one  or  two  glands. 
When  caseation  is  general,  the  cases  are  of  a 
form  intermediate  between  lymphadenoma  and 
scrofula.  The  softer  glands  yield  a juice  on 
scraping;  the  firmer  glands  yield  no  juice. 
In  the  former,  the  only  histological  change  is 
an  enormous  increase  in  the  cellular  elements — 
the  lymph-corpuscles  of  the  reticulum ; but  the 
relations  of  the  septa  and  follicles  often  remain 
normal.  Sometimes  the  cell-growth  invades  the 
septa,  which  become  split  up  and  disappear ; 
and  it  may  even,  in  a similar  manner,  perforate 
the  capsule.  The  firmer  glands  present  much 
fibrous  tissue,  which  may  be  confined  to  the 
; septa,  or  invade  also  the  delicate  network  in 
the  substance  of  the  gland  ; and  then  the  cells 
gradually  disappear,  and  the  whole  substance 
of  the  gland  may  be  transformed  into  a fibrous 
mass.  The  tracts  of  fibrous  tissue  may  have 
under  the  microscope  a peculiar  vitreous  aspect, 
especially  around  the  arteries. 

The  spleen  is  diseased  in  at  least  four-fifths 
of  the  cases,  usually  in  consequence  of  disse- 
minated growths,  often  irregular  in  shape, 
arising  from  the  Malpighian  corpuscles,  yellow- 
ishor  greyish  white,  rarely  caseating.  and  usually 
corresponding  in  consistence,  and  resembling  in 
structure,  the  glands  in  the  same  case.  The 
splenic  pulp  may  be  normal  in  quantity,  or 
nay  be  compressed  and  atrophied.  In  some 
cases  it  is  also  increased  in  quantity,  and  this 
• ncrease  may  even  be  the  sole  change.  In  such 
ases  the  morbid  changes  of  lymphadenoma  and 
plenic  leucocythasmia  coexist,  and  there  is 
■ften  a much  greater  increase  in  the  white 
orpuscles  of  the  blood,  than  when  the  spleen 
s the  seat  of  simple  growths.  The  size  at- 
uued,  in  the  cases  of  nodular  growths,  is  not 
reat,  the  weight  being  from  ten  to  thirty  ounces, 
/hen  the  splenic  pulp  is  increased,  the  size 
stained  is  rather  greater.  In  the  latter  case 
le  enlargement  is  uniform,  while  it  may  be 
regular  when  there  are  growths.  The  medulla 
' bones  has  been  found,  in  rare  cases,  to  pre- 
nt  a change  similar  to  that  met  with  in  splenic 
acocythsmia  and  pernicious  anaemia.  Col- 
htions  of  adenoid  tissue  elsewhere  often  under- 
changes similar  to  that  of  the  lymphatic 
inds.  The  tonsils,  the  mucous  membrane  of 
,e  pharynx,  the  oesophagus,  the  stomach,  and 
3 large  and  small  intestines,  may  all  be  the 
•t  of  growths,  originating  in  the  follicular 
nds,  and  sometimes  ulcerating.  The  liver  is 
en  the  seat  of  scattered  lymphoid  growths, 
lally  minute,  varying  in  size  from  a small  pea 
! a pin’s-head.  They  occupy  the  interlobular 
1 ces.  Barely  larger  nodular  growths  are 
I nd.  In  other  cases  the  liver  is  simply 
fgested.  Similar  minute  growths  are  often 
l ad  in  the  kidneys,  chiefly  in  the  cortex ; and 


90.3 

these  organs  may  also  be  the  seat  of  parenchy- 
matous degeneration.  The  peritoneum  may  he 
inflamed  over  enlarged  glands,  or  may  be  the 
seat  of  growths.  Growths  have  also  been  found 
in  the  testicles  ; and  frequently  in  the  lungs, 
where  they  may  break  down  and  form  cavities. 

SrarpTOirs. — The  most  important  symptoms  of 
lymphadenoma  are  due  to  the  altered  blood-state, 
and  to  the  enlarged  glands.  The  latter  .cause 
the  earliest  symptoms,  and  the  cervical  glands 
are  commonly  the  first  to  enlarge.  When  the 
internal  glands  are  primarily  affected,  pain  and 
pressure-signs  may  precede  other  symptoms. 
Occasionally  the  signs  of  anoemia  precede  those 
of  the  local  change;  and,  in  rare  instances,  irre- 
gular febrile  disturbance  may  occur  before  the 
glandular  enlargement.  The  affected  glands  are 
smooth,  and  present,  at  first,  a peculiar  mobility, 
which  may  disappear  when  they  become  adher- 
ent, and  constitute  an  irregular  lobular  tumour 
of  some  size.  They  are  usually  painless,  except 
during  periods  of  rapid  growth.  A diminution  in 
size  has  been  observed  before  death.  The  enlarge- 
ment of  the  cervical  glands  may  cause  the  neck 
to  equal,  or  even  exceed,  the  head  in  circum- 
ference. The  pressure  on  the  veins  may  cause 
■ symptoms  of  passive  cerebral  congestion.  The 
larynx  may  be  displaced ; and  the  movements  of 
the  lower  jaw  may  be  interfered  with.  Pressure 
on  the  trachea,  by  the  glands  in  the  neck  and  in 
the  posterior  mediastinum,  may  cause  dyspnera 
and  even  death  by  suffocation.  That  on  the 
pharynx  and  oesophagus  may  obstruct  deglu- 
tition, and  cause  death  by  starvation.  The 
enlargement  of  the  axillary  and  inguinal  glands 
may  interfere  with  the  movement  of  the  limbs, 
and  impede  the  circulation.  Various  and  serious 
pressure-effects  result  from  the  enlargement  of 
the  thoracic  and  abdominal  glands,  obstruction 
in  veins,  pressure  on  nerves,  &c.  The  enlarge- 
ment of  the  spleen  can  usually  readily  be  felt, 
but  does  not  commonly  give  rise  to  symp- 
toms. Anaemia  is  one  of  the  conspicuous  symp- 
toms, and  may  precede,  or  succeed,  obtrusive 
affection  of  the  glands.  The  red  corpuscles 
may  be  reduced  to  fifty,  thirty,  and  even 
twenty-five  per  cent,  of  the  normal.  In  mest 
cases  there  is  no  marked  excess  of  white  cor- 
puscles, but  occasionally  they  are  much  more 
numerous  than  normal.  In  almost  all  cases  in 
which  their  excess  is  comparable  to  that  met 
with  in  splenic  leucocythaemia,  the  splenic  pulp 
is  increased  in  quantity,  and  the  lesions  of 
splenic  leucocythaemia  and  of  lymphadenoma  are 
conjoined.  The  liver  may  he  enlarged  from 
the  disseminated  growths,  and  from  congestion. 
Jaundice  only  occurs  from  the  pressure  of  en- 
larged portal  glands  upon  the  bile-ducts.  Ascites 
may  he  due  to  similar  pressure,  or  to  the  blood- 
state,  being  then  part  of  general  dropsy.  The 
function  of  the  kidneys  is  rarely  affected.  Sto- 
matitis, sometimes  ulcerating,  results  from  the 
lymphoid  growth  in  the  mucous  membrane;  and  a 
similar  change  in  the  stomach  causes  interference 
with  digestion  and  vomiting — symptoms  which 
are  increased  by  the  ansemia.  Slight  dyspnoea 
results  from  the  blood-state,  while  intense  diffi- 
culty of  breathing,  and  even  actual  suffocation, 
may  occur  from  the  pressure  of  enlarged  glands 
on  the  trachea  or  bronchi.  The  functions  of  ths 


LYMPHADENOMA. 


JOG 

nervous  system  are  variously  deranged  Ly  the 
ill-nourished  blood.  Towards  the  end  there 
may  be  convulsions,  delirium,  and  coma.  Pyrexia 
is  a frequent,  but  not  invariable  symptom.  It 
is  almost  always  present  in  early  life,  much  less 
common  at  advanced  ages.  The  temperature 
may  be  considerably  raised,  even  when  the 
glandular  enlargement  is  slight ; the  elevation 
varies  from  two  to  six  degrees,  and  may  be 
continuous,  or  with  daily  remissions,  or  periods 
of  considerable  elevation  may  alternate  with 
periods  in  which  it  is  only  slightly  raised. 

Complications. — The  pressure-effects  of  the 
enlarged  glands,  already  mentioned,  are  some- 
times so  considerable  as  to  give  rise  to  com- 
plications, as  thrombosis  in  vessels,  pleural 
and  pericardial  effusions,  and  bronzing  of  the 
skin  from  disease  of  the  solar  plexus.  Inter- 
current affections,  occasionally  met  with,  are 
Bright’s  disease,  pneumonia,  fatty  degeneration 
of  the  heart  and  liver,  erysipelas,  pemphigus, 
boils,  and  other  effects. 

. Course  and  Duration. — The  disease  may 
remain  local  for  a long  time,  even  years,  affect- 
ing one  group  of  glands  only,  and  subsequently 
slowly  becoming  general.  When  the  general 
enlargement  of  glands  is  established,  the  disease 
rarely  lasts  more  than  two  years.  It  usually 
terminates  fatally  by  asthenia  ; but  not  rarely 
by  some  secondary  effect  of  the  morbid  process, 
ns  asphyxia,  starvation,  diarrhoea ; or  by  a com- 
plication, especially  by  pneumonia. 

Pathology. — The  changes  in  the  glands  in 
lymphadenoma  resemble,  in  the  early  stage,  those 
which  result  from  simple  irritation;  and,  as  has 
been  seen,  the  first  enlargement  often  appears  to 
be  excited  by  local  irritation.  Clinically,  how- 
ever, the  disease  has  a semi-malignant  aspect. 
Dr.  Wilks  therefore  assigned  to  it  a position  be- 
tween cancer  and  tubercle.  Its  history  suggests 
that  it  is  due  to  both  constitutional  and  local 
causes,  and  that  the  extent  of  these  two  elements 
varies  in  different  cases.  The  constitutional 
predisposition  apparently  affects  chiefly  the 
Lymphatic  structures.  The  assumption  of  such 
a predisposition  is  necessary  to  explain  the 
general  affection  of  the  glands  which  charac- 
terises some  cases  in  the  beginning,  and  also  the 
persistence  of  the  affection  when  it  begins  locally, 
as  well  as  its  subsequent  extension.  In  the 
hitter  easo,  however,  a process  of  secondary 
infection  may  be  at  work,  the  lymphatic  tissues, 
already  predisposed,  becoming  affected  by  the 
circulation  in  the  blood  of  a matcries  morbi 
derived  from  the  structures  first  diseased.  Some 
cases  present  characters  intermediate  between 
lymphadenoma  and  scrofula — the  low  tissue- 
vitality  of  the  latter  leading  to  wide  fatty 
degeneration  and  caseation  of  the  new  growth, 
instead  of  its  fibroid  transformation.  The  ex- 
istence of  an  excess  of  white  corpuscles  in  the 
blood  does  not  present  valid  ground  for  separa- 
ting certain  cases  from  the  rest,  and  calling 
them  ‘ lymphatic  leucocythaemia.’  Most  of  such 
cases  are,  as  has  been  said,  forms  of  mixed 
disease.  In  simple  lymphadenosis  the  Mal- 
pighian follicles  of  the  spleen  are  diseased,  and 
when  there  is  a considerable  excess  of  leu- 
cocytes in  the  blood,  the  splenic  pulp  is  usually 
also  increased  in  quantity.  The  anatomical 


lesions  of  splenic  leucocythaemia  and  lymphade- 
nosis are  conjoined,  and  to  the  increase  in  th« 
pulp  the  leucocytal  excess  is  due.  Occasionally, 
however,  when  the  diseased  glands  are  soft, 
lymphoid  corpuscles,  changed  in  character,  pass 
from  them  into  the  blood,  and  persist  there, 
leading  to  an  excess  of  the  pale  cells.  When 
the  glands  are  hard,  the  production  of  lymphoid 
cells,  and  their  passage  into  the  blood,  seem  in- 
terfered with,  and  thus  simple  anaemia results. 

Diagnosis. — Local  glandular  growths  cannot 
he  sharply  separated  from  cases  of  generalised 
lymphadenoma,  although  they  may  be  clinically 
distinguished.  Generalisation  may  ultimately 
occur,  even  though  one  group  of  glands  hai 
alone  been  diseased  for  many  years.  In  splenic 
leucocythaemia  the  glands  are  only  affected  late 
in  the  disease,  after  considerable  enlargement 
of  the  spleen  has  existed  alone  for  a long  time. 
When  the  spleen  presents  great  enlargement, 
and  the  glands  are  affected  early,  the  case  is 
usually  of  the  mixed  form  above  described,  both 
splenic  pulp  and  follicles  being  diseased.  In 
scrofulous  enlargement  of  the  glands,  the  diaeaso 
is  commonly  confined  to  a single  group  of  glands 
which  have  been  subjected  to  local  irritation ; 
some  of  the  glands  often  soften  and  suppurate ; 
the  affection  occurs  chiefly  in  early  life  ; and  the 
other  constitutional  signs  of  scrofula  are  present 
Cancer  of  tho  glands  differs  widely  in  its  micro- 
scopical characters  from  lymphadenoma,  but 
clinically  the  distinction  from  a local  lymphoma 
may  be  difficult,  and  turns  chiefly  on  the  slow 
extension  of  cancer  to  neighbouring  glands,  and 
in  its  subsequent  localisation  in  organs  rather 
than  in  lymphatic  structures. 

Prognosis. — When  the  disease  is  widely 
spread,  or  the  local  growths  considerable  in 
size,  a fatal  termination  is  almost  certain.  The 
duration,  however,  in  each  case,  varies  much. 
Tho  younger  the  patient,  tho  better  the  pre- 
ceding health,  the  longer  is  the  duration  of  the 
disease.  The  consistence  of  the  glands  has  little 
prognostic  value.  The  softer  they  are,  the  more 
rapid  is  the  course  of  the  disease;  but.  on  the 
other  hand,  if  it  is  influenced  by  remedial  agents, 
the  soft  glands  can  be  restored  to  a better  func- 
tional condition  than  the  hard.  The  prognosis  is 
worse  the  more  profound  the  ansemia.  Eleva- 
tion of  temperature  as  a rule  indicates  a rapid 
course,  but  to  this  there  are  some  striking  ex 
ceptions,  as  in  one  ease  under  the  writer's  care 
in  which  the  glandular  enlargement  continue! 
slight,  although  the  temperature  for  twelve 
months  was  always  above  the  normal. 

Treatment. — The  possibly  infecting  influene 
of  the  primary  glandular  enlargements  has  let 
to  their  extirpation.  Where  other  glands,  o 
the  spleen,  has  been  enlarged,  the  operatio 
has  done  no  good  ; and,  in  such  cases,  surgiaj 
interference  is  only  justified  by  impending  deat 
from  the  local  pressure.  But  where  the  affectio 
has  been  confined  to  one  group  of  glands,  tb 
progress  of  the  disease  has  been  retarded  h 
their  removal,  and  in  some  cases,  the  malad 
has  even  been  cured.  The  degree  of  ansemia 
of  great  importance  as  influencing  the  prospe 
of  benefit,  and  even  of  survival  from  the  oper 
tion,  and  the  actual  proportion  of  corpusd 
should,  in  all  cases,  be  estimated  by  the  haemac 


LYMPHADENOMA. 

tometer.  An  operation  should  never  be  per- 
formed if  the  proportion  of  red  corpuscles  is 
less  than  60  per  cent,  of  the  normal.  A slight 
excess  of  white  corpuscles  does  not  militate 
against  the  success  of  an  operation.  Other 
methods  of  local  treatment  have  been  employed, 
with  some  benefit,  especially  rubbing  and  sham- 
pooing, the  alternate  application  of  heat  and 
cold,  compression,  and  blistering.  Galvano- 
puncture  is  useless.  Various  substances  have 
been  injected  into  the  glands— iodine,  nitrate  of 
silver,  carbolic  acid,  arsenic.  The  last  has  alone 
appeared  useful  (Winiwarter),  but  it  was,  in  all 
cases,  given  internally  at  the  same  time.  Of 
internal  remedies  arsenic  is  incomparably  the 
most  potent.  It  should  be  pushed  to  the  largest 
doses  the  patient  can  bear,  as  n\.xv.  of  liquor 
arsenicalis  three  times  daily.  It  often  causes 
some  pain  in  the  glands,  followed  by  their 
diminution  in  size,  and  even,  in  a few  re- 
corded cases,  by  their  complete  disappearance. 
Although  such  a favourable  result  has  not  come 
under  the  writer's  personal  observation,  he  has 
seen  a marked  diminution  obtained  in  the  size  of 
glands  which  were  before  steadily  enlarging,  a 
diminution  which  has  been  maintained  for  years. 
Phosphorus  has  been  given  in  the  disease  (first 
by  Verneuil),  but  it  is  far  less  useful  than 
arsenic.  Iodine  and  iodide  of  potassium  are 
of  littlo  service.  Cod-liver  oil  is  useful  when 
there  is  any  indication  of  a scrofulous  diathesis. 
Mercury  and  carbolic  acid  have  been  given  in- 
ternally without  success.  Iron,  useless  alone, 
has  sometimes  appeared  to  do  good  when  given 
in  conjunction  with  other  remedies.  Change  of 
air,  general  tonics,  and  careful  diet  are  often  of 
considerable  sendee,  especially  when  employed 
along  with  other  measures.  W.  R.  Gowers. 

LYMPHAH GEITIS  ( vvfjupr j,  water,  or 
lymph,  and  iyyuov,  a vessel). — Inflammation  of 
lymphatic  vessels.  See  Lymphatic  System,  Dis- 
eases of. 

LYMPH  AN  GIECT  ASIS  ( lympha , lymph, 
md  angiectasis,  vascular  dilatation). — Lymph- 
itic  varix,  or  varicose  dilatation  of  lymphatic 
-essels.  See  Lymphatic  System,  Diseases  of. 

LYMPHATIC  SYSTEM,  Diseases  of.— 

Iynon.  : I'r.  Maladies  du  Systems  Lymphatique ; 
ler.  Krankheiten  dcs  Lymphsy stems. 

There  is  no  essential  difference  between  the 
emphatic  and  lacteal  systems,  which  together 
onstitute  the  absorbent  system.  In  this  article 
ttention  will  be  briefly  directed  to  those  diseases 
f the  lymphatic  vessels  and  glands  which  are 
lore  or  less  of  a local  nature  ; and  what  is 
ated  with  regard  to  the  former  will  apply 
merally  to  the  lacteals,  but  attention  will  be 
rected  to  any  points  connected  with  these 
issels  calling  for  special  notice.  Some  of  the 
lections  involving  these  structures  are  con- 
lered  in  separate  articles,  and  need,  therefore, 
erely  be  mentioned  here ; while  the  mesen- 
■ric  glands  are  discussed  independently  (sec 
esenteric  Glands,  Diseases  of).  It  may  be 
marked  that  recent  pathological  investigations 
mt  to  the  existence  of  important  relations 
tween  the  absorbent  system  and  certain  dis- 
ses,  namely,  some  of  those  belonging  to  the 
nolle  class,  and  those  depending  upon  septic 


Ll'MPHATIC  SYSTEM.  901 

conditions,  such  as  plague,  typhus  and  typhoid 
fever,  diphtheria,  erysipelas,  glanders,  malignant 
pustule,  snake-bite,  dissection  or  post-mortem 
wounds,  and  certain  forms  of  serous  inflara 
mation,  such  as  puerperal  peritonitis.  Moreover, 
the  lymphatic  vessels  seem  to  bo  materially 
affected  in  some  skin-diseases,  such  as  erythema 
and  elephantiasis ; while  there  are  structures 
which  consist  mainly  of  lymphatic  follicles,  and 
their  diseases  principally  affect  these  follicles. 
The  absorbent  system  is  also  concerned  in  an 
important  degree  in  conveying  morbid  products 
from  one  part  of  the  body  to  another,  such  as 
cancerous  elements,  tubercle,  or  the  syphilitic 
poison,  and  thus  of  disseminating  these  diseases 
through  the  system.  These  points  are  more  fully 
dwelt  upon  in  their  appropriate  articles,  and  now 
the  individual  diseases  of  the  lymphatic  system 
will  be  discussed  in  their  appropriate  order. 

1.  Acute  Inflammation. — According  to  the 
structures  involved,  acute  inflammation,  con- 
nected with  the  lymphatic  system,  presents  threo 
varieties,  namely : — (a)  where  the  vessels  are 
alone  affected — lymphangeitis  or  angcioleucitis ; 

( 'b ) where  the  condition  is  limited  to  the  glands 
— adenitis ; or  (c)  where  both  vessels  and  glands 
are  involved.  It  will  be  convenient  to  consider 
these  varieties  together.  As  a rule  the  disease 
is  localized,  but  under  certain  circumstances  the 
lymphatic  system  is  more  or  less  widely  im- 
plicated, especially  if  the  inflammation  is  of  a 
septic  character.  It  may  be  set  up  and  extend 
with  great  rapidity. 

.(Etiology  and  Pathology. — The  causes  of 
acute  inflammation  of  the  lymphatic  vessels  or 
glands  may  be  thus  indicated; — 1.  Traumatic, 
including  such  injuries  as  wounds,  contusions, 
or  a severe  strain.  2.  Irritation  from  without. 
Strong  heat,  as  that  of  the  sun,  may  set  up 
inflammation  of  the  superficial  lymphatics. 
Pressure  or  friction  may  also  produce  this 
effect  upon  the  vessels  or  glands.  It  is  not  an 
uncommon  practice  to  excite  inflammation  arti- 
ficially in  the  glands,  for  the  cure  of  certain  of 
their  diseases,  by  injecting  irritants  into  their 
substance.  3.  Irritation  from  within.  This  may 
be  due  to  inflammation  in  the  vicinity,  sup- 
puration, ulcerat  ion,  diseases  of  joints  or  bones, 
and  other  causes.  In  medical  practice  the  im- 
plication of  the  glands  under  the  jaw,  in  cases  of 
diphtheria  and  scarlatina,  is  a familiar  illustra- 
tion of  this  class  of  cases  ; or  the  inflammation 
of  the  glands  behind  the  ear  in  cases  of  im- 
petigo of  the  head.  It  may  also  be  noticed  here 
that  the  lymphatic  vessels  are  more  or  less  in- 
volved in  phlegmasia  dolens.  4.  Specific  irrita- 
tions. These  deserve  separate  recognition,  and 
include  syphilis,  gonorrhoea,  and  various  septic 
poisons,  which  frequently  affect  the  lymphatic 
structures.  Inflammation  of  the  absorbent  glands 
is  also  an  important  feature  in  plague,  glanders, 
and  other  diseases. 

With  regard  to  the  modes  in  which  the  inflam- 
mation is  set  up,  this  may  happen  in  several 
ways.  In  the  first  place,  the  cause  may  act 
directly  upon  the  lymphatic  vessels  or  glands, 
as  in  the  case  of  injury.  Secondly,  these  struc- 
tures may  be  involved  by  extension  from  neigh- 
bouring parts.  Glands  are  frequently  affected 
in  this  way ; and  lymphatic  vessels  may  be 


908  LYMPHATIC  SYSTEM.  DISEASES  OF. 


involved  by  continuous  extension  of  irritation 
from  inflamed  organs,  serous  membranes,  or 
other  structures  with  which  they  are  connected. 
Thirdly,  the  cause  of  the  inflammation  is  often 
more  or  less  remote  from  the  situation  in  which 
'it  appears,  especially  in  the  case  of  the  glands. 
This  may  arise  from  the  condition  passing  con- 
tinuously along  the  vessels  from  some  seat  of 
irritation  to  the  glands  in  their  course;  or  mor- 
bid products  may  be  carried  by  the  current  of 
lymph  to  the  glands,  the  vessels  themselves  be- 
ing unaffected,  when  the  inflammation  thus  set 
up  is  said  to  bo  sympathetic.  In  other  instances 
pus  has  been  found  within  the  lymphatic  vessels, 
having  made  its  way  from  some  seat  of  inflam- 
mation. It  may  also  be  mentioned  that  lymphatic 
inflammation  may  originate  a similar  condition 
in  other  structures,  such  as  the  joints,  and  this 
may  be  of  a purulent  character. 

' Inflammation  is  much  more  readily  excited  in 
the  lymphatic  structures  in  some  persons  than 
in  others,  and  especially  in  those  who  are  of  a 
strumous  habit.  The  glands  are  more  liable  to 
■be  affected  in  the  early  periods  of  life.  A low 
state  of  the  general  health  may  predispose  to 
inflammation  of  these  structures  from  slight 
causes.  Glands  which  are  chronically  enlarged, 
as  the  result  of  inflammation,  are  very  liable  to 
become  the  seat  of  acute  inflammation  from 
slight  causes. 

Anatomical  Chakacters. — Inflammation  af- 
fecting the  lymphatic  vessels  presents  two  forms, 
but  they  may  be  met  with  together.  When  the 
minute  capillary  network  is  involved,  the  con- 
dition is  termed  reticular  lymphangeitis ; the 
skin  and  its  capillaries  are  generally  affocted  at 
the  same  time,  so  that  there  is  more  or  less 
diffused  redness,  but  it  may  present  a reticulated 
arrangement.  Tubular  lymphangeitis  signifies 
that  the  main  vessels  are  implicated.  They  are 
visible  on  the  surface  as  red  lines,  straight  or 
wavy,  passing  to  the  gftnds.  They  become 
dilated,  and  their  walls  thickened.  Their  in- 
ternal coat  is  opaque  and  uneven,  and  the 
endothelium  often  disappears.  Coagulation  of 
the  lymph  within  the  vessels  takes  place,  closing 
tip  their  channel.  The  coagulum  may  become 
organised,  so  that  they  are  permanently  ob- 
literated; or  it  may  soften  and  even  suppurate 
at  the  centre,  and  the  products  may  enter  into 
the  general  circulation,  and  thus  cause  septi- 
caemia or  pytemia.  The  inflammation  is  liable  to 
extend  to  the  surrounding  cellular  tissue,  leading 
to  exudation,  hyperplasia  of  cells,  and  consequent 
swelling  and  thickening. 

Inflammation  of  lymphatic  glands  is  charac- 
terised in  the  early  stage  by  swelling,  congestion, 
and  increased  firmness.  The  lymph  accumu- 
lates, exudation  takes  place,  and  abundant  cells 
are  present.  The  inflammatory  process  may 
soon  subside,  terminating  in  resolution.  In  many 
cases,  however,  suppuration  ensues,  especially 
in  certain  forms  of  inflammation,  this  com- 
mencing in  the  centre  of  the  glands,  the  cavities 
of  which  become  more  or  less  speedily  filled 
with  pus.  The  inflammation  spreads  to  the 
surrounding  cellular  tissue,  and,  an  abscess  be- 
ing formed,  the  pus  makes  its  way  to  the  sur- 
face. If  the  glands  are  internal,  they  may  burst, 
there,  and  lead  to  serious  consequences;  or  by 


merely  setting  up  irritation  in  adjacent  struc- 
tures, they  may  produce  similar  results.  Some- 
times the  glands  remain  permanently  enlarged 
and  indurated,  especially  after  repeated  attacks  of 
inflammation ; and  they  may  become  adherent 
to  the  parts  around.  A single  gland  may  be  in- 
flamed, but  it  is  common  for  a cluster  or  a chain 
of  glands  to  be  involved.  In  some  cases  the  in- 
flammation assumes  a more  or  less  sub-acute 
character,  and  the  progress  of  events  is  slower. 

Symptoms. — These  are  local  and  general.  The 
local  phenomena  consist  of  subjective  sensations, 
and  objective  signs.  Pain  is  felt  at  the  seat  of 
inflammation,  which  may  be  very  severe,  often 
accompanied  with  a sense  of  heat  or  burning, 
and  stiffness  or  tension.  There  is  usually 
marked  tenderness,  and  this  may  be  present 
when  little  or  no  spontaneous  pain  is  complained 
of,  while  it  is  often  remarkably  limited  to  the 
line  of  an  affected  lymphatic  vessel.  Movement 
also  increases  the  pain.  The  subjective  sensa- 
tions are  more  severe  as  a rule  when  the  glands 
are  involved.  When  suppuration  takes  place, 
the  pain  tends  to  assume  a shooting  and  throb- 
bing character.  As  regards  objective  signs, 
inflamed  lymphatic  vessels,  if  superficial,  are 
usually  visible  as  red  lines,  either  straight  or 
wavy,  running  in  the  direction  of  the  glands; 
or  there  may  be  separate  red  patches.  Should 
they  be  deeply  situated,  however,  the  vessels 
cannot  be  seen.  The  larger  trunks  may  be  felt 
by  the  fingers,  being  cord-like,  firm,  and  knotted. 
The  surrounding  tissues  are  seen  and  felt  to  be 
more  or  less  swollen  and  indurated.  If  the  cir- 
culation of  the  lymph  is  much  interfered  with,  a 
limb  may  be  considerably  enlarged,  and  presents 
a feeling  of  firmness  and  solidity,  owing  to  the 
occurrence  of  lymphatic  oedema. 

When  the  lymphatic  glands  become  inflamed 
their  enlargement  can  be  detected,  and  the  sur- 
rounding tissues  may  also  be  swollen.  At  first 
they  feel  firm,  but  if  suppuration  takes  place 
they  become  more  and  more  soft,  and  at  last 
present  a sensation  of  fluctuation.  The  over- 
lying  skin  is  markedly  red,  and  there  is  often 
subcutaneous  cedema.  Suppurative  inflammation 
of  tymphatic  glands  constitutes  the  condition 
known  as  ‘ bubo.’  If  not  opened  artificially, 
the  abscess  ultimately  bursts  externally,  but  it 
may  burrow  considerably  before  doing  so,  and 
the  opening  is  often  imperfect.  Sec  Bubo. 

The  general  symptoms  accompanying  inflam- 
mation of  the  lymphatic  structures  vary  in  their 
intensity  in  different  cases,  according  to  its  seve- 
rity, extent,  and  results.  In  the  slighter  cases 
there  is  no  obvious  constitutional  disturbance. 
As  a rule,  however,  more  or  less  fever,  with 
its  accompanying  symptoms,  sets  in,  preceded 
often  by  shivering  or  even  distinct  rigors.  II 
suppuration  occurs  the  rigors  may  he  repeated ; 
the  pyrexia  increases;  and  more  or  less  wasting 
follows,  if  there  should  be  prolonged  discharge 
of  pus.  Where  the  inflammation  is  of  a septic 
character  from  the  first,  or  when  septic  matters 
are  conveyed  into  the  circulation,  the  genera, 
symptoms  are  exceedingly  grave,  being  similar  tc 
those  indicative  of  septicaemia  from  other  causes 
such  as  repeated  rigors,  high  and  erratic  fever 
great  weakness  and  prostration,  low  nervna 
symptoms,  weak  and  rapid  cardiac  action  asx 


LYMPHATIC  SYSTEM,  DISEASES  OF.  »09 


pulse,  and  other  typhoid  phenomena.  The  ter- 
mination is  then  usually  fatal. 

Treatment. — In  the  management  of  any  acute 
inflammation  affecting  the  lymphatic  vessels  or 
■ glands,  the  first  indication  is  to  get  rid  of  its 
cause,  if  this  be  practicable.  In  the  next  place 
rest  is  of  essential  importance,  and  the  affected 
part  should  be  so  placed  as  to  avoid  all  pressure 
er  tension.  As  regards  local  treatment,  the  ap- 
plication of  heat  and  moisture,  by  means  of 
fomentations  and  poultices,  usually  answers  best. 
To  these  anodynes  may  be  added,  if  necessary, 
especially  belladonna;  and  the  latter  may  be 
often  applied  with  advantage  in  the  form  of  ex- 
tract, mixed  with  glycerine.  Itis  not  uncommonly 
advisable  to  take  away  blood  locally  from  the 
neighbourhood  of  inflamed  glands,  by  means  of 
leeches.  Some  authorities  maintain  that  sup- 
juration  may  sometimes  be  prevented  by  counter- 
rritation  around  the  glands,  effected  by  applying 
jlistering-fluid  or  strong  iodine.  If  suppuration 
take  place,  the  progress  of  the  pus  towards  the 
mrface  must  be  encouraged  by  the  usual  means, 
md  the  abscess  opened  at  the  appropriate  time. 
Should  general  treatment  be  required,  at  first  it 
s usually  necessary  to  keep  the  patient  on  low 
diet,  to  open  the  bowels  well,  and  perhaps  to 
.dminister  some  simple  saline  mixture.  When 
uppuration  occurs,  a more  or  less  supporting 
onic  and  stimulant  treatment  is  called  for.  In 
eptie  cases  the  free  use  of  alcoholic  stimu- 
ints,  with  the  administration  of  full  doses  of 
uinine  or  salicine,  constitutes  the  appropriate 
treatment. 

2.  Chronic  Inflammation. — It  is  only  the 
mphatic  glands  which  can  be  said  to  be  liable 
< this  affection — chronic  adenitis.  They  may 
main  in  a condition  of  chronic  inflammation 
'ter  one  or  more  acute  or  sub-acute  attacks ; or 
iis  is  set  up  as  a chronic  affection  from  some 
■ntinued  or  repeated  irritation.  Formerly  a 
W form  of  chronic  inflammation  was  regarded 
the  primary  lesion  in  scrofulous  or  tubercular 
inds,  and  some  pathologists  still  hold  this  view, 
le  affected  glands  are  enlarged  and  firm,  and 
uallv  somewhat  painful  and  tender.  These 
anges  may  be  due  partly  to  a hyperplasia  of 
le  gland-structures,  partly  to  an  exudation  into 
rir  midst.  Frequently  they  continue  in  this 
idition  for  a long  time,  without  undergoing 
y obvious  change,  hut  they  are  liable  to  acute 
icerbations  from  slight  causes.  They  may  ulti- 
tely  become  the  seat  of  caseous  degeneration, 
-pf  suppuration,  even  though  there  is  no  evident 
i ofulous  diathesis.  The  circulation  of  the  lymph 
t ough  the  involved  glands  is  prevented  to  a 
later  or  less  degree.  Usually  there  is  no  con- 
* utional  disturbance,  unless  a considerable 
tuber  of  glauds  are  implicated,  or  they  dege- 
tate  or  suppurate. 

Treatment. — It  is  not  desirable  to  allow 
t onic  adenitis  to  continue,  as  unpleasant  or 
c n serious  consequences  may  ensue,  and  there- 

I ■ it  should  be  subjected  to  proper  treatment 
v rout  delay.  Any  source  of  irritation  must  be 
tjoved  at  the  outset.  Gentle  friction  over  the 
e irged  glands,  with  some  simple  oleaginous 
o reasy  material,  may  be  effectual  in  reducing 
t n,  or  ;t  may  be  necessary  to  rub  in  weak 

II  ne  ointment,  or  to  paint  the  surface  with 


tincture  of  iodine.  Counter-irritation  by  blisters 
may  be  sometimes  useful.  Internally  cod-liver 
oil  and  quinine  are  frequently  of  much  value  ; 
preparations  of  iron  are  also  often  very  service- 
able, especially  the  syrup  of  the  iodide. 

3.  Scrofulous  or  Tubercular  Disease. — 
The  morbid  condition  of  the  lymphatic  glands 
thus  named  may  be  conveniently  discussed  here, 
as  the  ultimate  effects  produced  are  very  similar 
to  those  which  result  from  chronic  inflammatiol 
in  certain  cases.  This  affection,  however,  is  sup- 
posed to  be  one  of  the  manifestations  of  a par- 
ticular diathesis — the  scrofulous  or  tubercular — 
in  which  the  absorbent  glands  are  very  prom1 
to  become  the  seat  of  certain  changes  of  a de- 
structive character.  It  will  be  discussed  at  greater 
length  in  other  articles,  and  here  it  will  suffice 
to  offer  a few  general  remarks  on  the  subject. 

HStiologv. — Scrofulous  disease  of  the  glands 
often  occurs  in  those  who  present  obvious  cha- 
racteristics of  the  diathesis ; but  this  is  by  no 
means  always  the  case,  for  the  subjects  of  the 
glandular  affection  may  be  apparently  strong  and 
healthy.  Children  and  young  persons  are  by  far 
most  frequently  affected.  The  glandular  change 
may  originally  be  set  up  by  some  irritation,  which 
seems  to  give  it  a start,  but  in  many  instances 
there  is  no  such  obvious  cause,  and  it  appears 
to  cco-nmence  spontaneously.  Once  an  absorbent 
gland  becomes  the  seat  of  scrofulous  changes, 
others  in  connection  with  it,  or  even  at  a distance, 
are  very  liable  to  become  secondarily  implicated. 

Anatomical  Characters. — Scrofulous  disease 
may  involve  the  lacteal  as  well  as  the  lymphatic 
glands,  and  of  the  latter  those  within  the  body 
may  be  affected,  as  well  as  those  which  are 
external.  This  disease  of  the  lacteal  glands 
is  separately  discussed  (see  Mesentejhc  Glands, 
Diseases  of);  and  also  that  of  certain  lymphatic 
glands  within  the  chest  (see  Bronchial  Glands, 
Diseases  of).  Of  the  external  glands,  those 
in  the  neck  and  under  the  jaw  are  most  com- 
monly involved.  The  changes  always  go  through 
a more  or  less  chronic  course.  At  first  the 
glands  become  enlarged  and  firm,  and,  accord- 
ing to  most  observers,  this  seems  to  be  merely 
due  to  a hyperplasia  of  the  lymphatic  elements. 
These,  however,  possess  but  a very  low  de- 
gree of  vitality,  and  have  a marked  tendency 
to  degenerate  and  disintegrate,  so  that  the  tissues 
become  destroyed.  Ordinarily  caseation  takes 
place,  the  substance  of  the  glands  becoming  yel- 
low and  softened ; then  a slow  process  of  un- 
healthy suppuration  generally  ensues,  leading  to 
the  formation  of  chronic  abscesses.  The  skiD 
over  them  presents  a congested  appearance,  and 
is  often  undermined  for  some  distance,  the  sub- 
cutaneous tissues  being  involved  in  the  suppura- 
tive process.  If  the  abscesses  are  not  properly 
opened,  they  are  liable  to  cause  much  destruction 
of  the  skin,  and  to  leave  unhealthy  sinuses  and 
ulcers  when  they  burst  of  their  own  accord.  If 
they  subsequently  heal,  this  is  often  attended  by 
extensive  scarring,  and  the  scars  are  permanent, 
but  become  less  marked  in  course  of  time.  In 
some  cases  the  glands  do  not  suppurate,  but. 
after  caseation  they  become  calcified  and  inert; 
it  appears  that  this  result  may  take  place  even 
after  the  formation  of  pus,  which  then  becomes  in- 
spissated, and  mixed  up  with  calcareous  matter. 


LYMPHATIC  SYSTEM,  DISEASES  OF. 


010 

Symptoms. — In  the  case  of  the  external  glands, 
with  which  we  are  now  concerned,  the  changes 
above  described  can  be  observed  clinically.  They 
are  attended  with  little  or  no  pain,  but  there  is 
usually  more  or  less  tenderLess.  Constitutional 
symptoms  are  usually  prominent,  when  the  glands 
become  to  any  extent  the  seat  of  scrofulous 
disease.  There  may  bo  the  symptoms  of  the 
diathesis ; but  the  glandular  affection  Itself  also 
tends  to  produce  wasting,  anaemia,  general  weak- 
ness, and  more  or  less  pyrexia,  which,  if  there 
should  be  abundant  suppuration,  is  apt  tc  assume 
a hectic  type.  If  the  glandular  disease  is  limited, 
however,  the  system  may  suffer  but  little  or  not 
at  all ; and  even  alter  it  has  been  extensive  and 
severe,  so  as  to  lower  the  patient  very  much, 
recovery  may  take  place  under  appropriate  treat- 
ment, the  patient  ultimately  becoming  strong  and 
robust.  When  the  internal  glands  are  affected, 
they  may  give  rise  to  symptoms  from  their  mere 
mechanical  presence,  such  as  those  indicative  of 
pressure  or  irritation ; and  if  destructive  changes 
occur  in  them,  very  serious  results  are  liable  to 
be  produced.  The  general  symptoms  are  also 
usually  more  marked  in  these  cases,  and  may 
become  extreme  in  degree.  It  must  be  remarked 
that  it  is  highly  probable  that  phthisis  may  be 
set  up  by  an  infective  process,  in  connection  with 
suppurating  or  caseous  scrofulous  glands. 

Tkeatme.nt. — General  treatment  is  of  essen- 
tial consequence  in  the  treatment  of  scrofulous 
disease  of  glands.  The  patient  should  be  placod 
under  the  most  satisfactory  sanitary  conditions 
that  can  be  obtained ; but  in  many  cases  this  is 
a very  difficult  matter,  and  it  is  of  great  im- 
portance, if  possible,  to  remove  from  their  un- 
healthy and  often  wretched  homes  those  suffer- 
ing from  this  affection,  and  to  treat  them  in 
suitable  sanatoriums  or  hospitals.  They  should 
be  as  much  as  possible  in  the  open  air,  and  a 
change  of  air  will  often  prove  of  decided  benefit 
to  those  suffering  from  scrofulous  glands.  Resi- 
dence at  the  seaside,  with  sea-bathing,  is  also  of 
much  service,  or  a sea  voyage  may  be  desirable. 
The  digestive  functions  require  careful  attention 
and  regulation  ; and  the  food  must  be  nutritious, 
including  abundance  of  good  milk,  fresh  eggs, 
and  such  articles  of  diet.  As  regards  medicines, 
those  which  are  usually  indicated  are  cod-liver 
oil,  quinine,  and  preparations  of  iron,  especially 
the  syrup  of  the  iodide,  steel-wine,  or  Parrish’s 
syrup.  Where  there  is  much  suppuration,  marked 
benefit  has  been  found  to  result  from  the  adminis- 
tration of  minute  doses  of  sulphide  of  calcium, 
and  from  chloride  of  calcium. 

Local  treatment  is  usually  called  for.  In  the 
early  stages  attempts  may  be  made  to  cause  ab- 
sorption of  the  enlarged  glands,  but  these  must 
be  cautiously  conducted.  Gentle  friction,  the 
application  of  preparations  containing  iodine  or 
certain  iodides,  and  the  use  of  poultices  or  fo- 
mentation of  sea-weeds,  arc  the  measures  usually 
adopted.  In  some  cases  it  certainly  seems  the 
best  plan  of  treatment  to  try  to  encourage  sup- 
puration in  glands  which  are  in  a torpid  state, 
and  which  cannot  be  absorbed.  For  this  purpose 
they  have  been  injected  with  irritants.  Suppura- 
tion ant  its  consequences  must  be  treated  on 
ordinary  principles ; but  it  should  be  remarked 
that  abscesses  should  not  be  allowed  to  burst  of 


their  own  accord,  but  need  surgical  interference, 
as  otherwise  they  may  lead  to  much  destruction 
of  the  skin  and  subcutaneous  tissues. 

4.  Hypertrophy  and  Atrophy  of  Glands. 
The  lymphatic  glands  become  hypertrophied  un- 
der different  circumstances.  In  some  cases  there 
is  a mere  local  hypertrophy,  which  shows  no 
tendency  to  progress  towards  other  parts,  and 
which  may  be  due  to  some  obvious  irritation,  or 
independent  of  any  known  cause.  As  has  been 
already  pointed  out,  hypertrophy  is  the  earlv 
condition  of  scrofulous  glands.  This  morbid 
change  is  most  important,  however,  in  connec- 
tion with  the  disease  termed  lymphadenoma,  or 
Hodgkin’s  disease,  in  which  there  is  a progres- 
sive enlargement  of  the  lymphatic  glands ; and 
with  one  form  of  leucocythimia.  These  affec- 
tions are  discussed  in  separate  articles.  Without 
entering  upon  any  lengthy  description,  therefore, 
it  will  suffice  to  remark  that  in  these  affections 
the  enlargement  varies  much  in  degree  and  ex- 
tent in  different  cases ; that  it  is  due  simply  to 
an  increase  of  the  normal  lymphatic  structures; 
and  that  the  glands  usually  show  no  tendency 
towards  any  degenerati  ve  or  destructive  change. 
Clinically  they  are  recognised  by  their  obvious 
physical  characters  when  superficial;  or  by  phy- 
sical signs  when  situated  in  internal  cavities. 
As  a rule  they  are  painless  ; but  may  give  rise 
to  various  symptoms  by  their  mechanical  pres- 
sure, irritation,  or  destructive  effects.  In  many 
cases  more  or  less  severe  general  symptoms  are 
present.  See  Leucocyth.emia;  and  Lymphadb- 
noma. 

Atrophy  of  lymphatic  glands  may  occur  after 
inflammation;  as  a senile  change;  after  the  re- 
moval of  a limb,  or  its  long-continued  want  of 
use ; or  from  other  causes.  No  definite  effects 
can  be  referred  to  this  condition,  but  if  there 
should  be  extensive  glandular  atrophy  it  might 
obviously  interfere  with  the  due  nutrition  of  the 
blood  and  general  system. 

6.  Morbid  Formations  and  Deposits  in 
Glands. — Under  this  heading  the  following  may 
be  considered : — 

a.  Caitccr. — The  various  forms  of  malignant 
growth  frequently  involve  lymphatic  glands.  In 
most  cases  the  disease  is  secondary  to  cancer  in 
some  neighbouring  part,  and  the  glands  are  very 
prone  to  become  involved,  owing  to  the  cancer- 
elements  being  directly  conveyed  to  them  by 
the  lymphatics.  This  is  well  exemplified  by 
the  implication  of  the  axillary  glands  when  the 
breast  is  the  seat  of  cancer.  Not  uncommonly, 
however,  the  formation  is  primary  in  the  glands, 
and  then  involves  other  structures  by  direct  ex- 
tension or  convection.  All  forms  of  malignanl 
disease  are  met  with,  but  the  encephaloid  variety 
is  most  common.  When  secondary,  however,  i> 
generally  approximates  in  characters  to  tlu 
primary  formation,  and  hence  may  be  of  a scir 
rhous  or  melanotic  nature.  It  may  also  be  men 
tioned  here  that  secondary  sarcoma  occurs  ii 
the  lymphatic  glands.  The  growth  may  attain  i 
considerable  size,  and  it  is  more  or  less  node 
lated.  The  consistence  will  depend  on  th 
variety  of  the  cancer ; often  it  is  soft,  and 
milky  juice  escapes  on  pressure.  If  eancerou 
glands  aro  external,  they  can  be  recognised  o 
examination,  and  are  usually  painful  and  tende 


LYMPHATIC  SYSTEM,  DISEASES  OF. 


911 


■When  situated  internally  they  give  rise  to  physi- 
cal signs  of  their  presence,  either  in  the  chest 
or  the  abdomen;  and  to  more  or  less  pressure- 
symptoms  ; -which  may  be  combined  with  the  con- 
stitutional symptoms  of  malignant  disease.  It 
may  be  very  difficult  to  distinguish  clinically 
between  cancerous  glands  and  lymphadenoma- 
tous  growths  situated  internally. 

b.  Albuminoid,  disease. — The  glands  are  liable 
to  be  involved  in  conditions  which  give  rise  to 
albuminoid  degeneration.  On  section  they  pre- 
sent the  peculiar  waxy,  pale,  translucent,  homo- 
geneous appearance  characteristic  of  tissues 
which  are  the  seat  of  this  change.  The  glands 
may  be  enlarged;  but  when  they  attain  a consi- 
derable size,  this  is  partly  due  to  hypertrophy. 
In  other  cases  they  are  small  and  firm.  This 
condition  may  give  rise  to  symptoms  by  pres- 
sure, as  sometimes  happens  in  the  case  of  albu- 
minoid glands  in  the  portal  fissure,  which  may 
cause  ascites  or  jaundice. 

c.  Pigmentation. — The  bronchial  glands  may 
be  the  seat  of  a deposit  of  black  particles  in 
cases  where  the  lungs  are  thus  affected,  as  in 
miners,  colliers,  &c.  They  are  enlarged  to  some 
extent,  and  black ; and  a black  liquid  escapes 
on  pressure.  This  condition  does  not  give  rise 
to  any  obvious  symptoms.  More  or  less  pigmen- 
tation of  these  glands  is  often  observed  with 
advancing  age. 

d.  Syphilitic  growths. — The  glands  in  the  groin 
are  affected  from  the  irritation  of  the  primary 
syphilitic  sore,  and  others  are  often  involved  in 
connection  with  its  secondary  and  tertiary  effects ; 
but  no  doubt  they  are  also  liable  to  become  the 
seat  of  special  syphilitic  formations. 

e.  Tubercle. — The  condition  of  glands  usually 
termed  ‘tuberculous’  has  been  already  con- 
sidered, but  sometimes  distinct  grey  granulations 
ure  found  in  connection  with  acute  tuberculosis. 
They  originate  in  the  follicles  of  the  glands. 

Treatment. — Practically  the  treatment  of  the 
morbid  formations  in  glands  just  considered,  if 
iny  be  called  for,  consists  in  measures  directed 
igainst  the  constitutional  condition  of  which  they 
ire  a manifestation.  In  the  case  of  cancer,  opera- 
ive  interference  may  be  demanded.  Symptoms, 
specially  those  resulting  from  pressure,  may 
Iso  require  special  treatment. 

6.  Chronic  Changes  affecting  Lympha- 
ic8. — The  lymphatic  vessels  are  subject  to  two 
rincipal  classes  of  chronic  changes,  namely  (a) 
dilatation  and  hypertrophy  ; and  ( b ) Obstruc- 
on. 

a.  Dilatation  and  hypertrophy — Lymphangiec- 
sis. — Leaving  out  of  consideration  the  thoracic 
ict  and  receptaculum  chyli,  the  lymphatics, 
'.her  superficial  or  deep,  and  also  the  lacteals, 
ly  become  more  or  less  dilated  and  hypertro- 
ied.  Even  the  vessels  of  internal  mucous  or 
•ous  membranes  may  be  thus  affected.  In  most 
les  the  larger  trunks  are  implicated,  but  the 
Hilary  plexuses  are  sometimes  chiefly  or  alone 
•olved.  With  regard  to  the  causes  of  this  con- 
' ion,  it  is  often  congenital,  and  has  then  been 
i ributedto  a want  of  specialisation  in  the  lvm- 
1 itic  system  of  certain  parts.  In  other  cases  it 
1 vidently  due  to  some  obstruction  to  the  circu- 
1 on  of  the  lymph,  and  consequent,  enlargement 
0 ho  vessels  behind  the  impediment.  Such  ob- 


struction may  be  seated  in  the  glands  or  vessels, 
and  in  the  latter  case  may  be  due  to  internal  plug- 
ging or  to  external  pressure.  In  some  instances 
the  enlargement  of  the  lymphatics  partakes  of 
the  character  of  a primary  hypertrophy,  either 
alone,  or  along  with  other  tissues,  as  in  connec- 
tion with  elephantiasis  and  other  growths,  of 
which  enlarged  lymphatics  constitute  an  im- 
portant element.  Dilatation  has  been  also  attri- 
buted to  a supposed  paralysis  of  the  muscular 
coat  of  the  lymphatic  vessels.  Lymphangiectasia 
is  most  common  in  warm  and  moist  climates. 

There,  are  various  forms  which  enlarged  lym- 
phatics assume.  Thus,  there  may  be  simply  a 
localised  dilatation  of  the  capillaries,  consti- 
tuting a visible  freely-anastomosing  reticulum 
or  network.  More  commonly  the  trunks  are 
enlarged,  assuming  a tubular,  fusiform,  vari- 
cose, saecnlar,  or  cirsoid  form.  Or  a distinct 
growth  may  be  produced,  which  has  been  speci- 
ally termed  lymphangiectasis,  and  has  been  divi- 
ded by  Wagner  into  three  varieties — (i.)  simple  ; 
(ii.)  cavernous  ; (iii.)  cystoid  — names  which 
sufficiently  indicate  their  several  peculiarities. 
The  walls  of  the  vessels  are  often  more  or  less 
thickened  from  hypertrophy.  Dilated  lymphatics 
are  liable  ultimately  to  give  way,  with  conse- 
quent escape  of  the  lymph. 

Clinically  the  conditions  now  under  considera- 
tion are  visible  when  superficial,  or  when  occur- 
ring on  a surface  which  can  be  inspected.  The 
appearances  will  differ  according  to  the  par- 
ticular morbid  chaDge  present.  There  nmy  lie  a 
distinct  tumour;  or  the  enlarged  lymphatic-  may 
only'  form  one  element  in  certain  growths.  Cystic 
formations  originating  in  the  lymphatic  system 
are  said  to  be  most  common  in  connection  with 
the  upper  lip,  tongue,  and  neck.  I is  beyond 
the  province  of  this  article  to  describe  these 
conditions  in  anv  detail.  Enlargement  of  the 
superficial  lymphatics  is  chiefly  observed  pn 
the  inner  side  of  the  thigh,  the  sides  of  the  ab- 
domen, and  the  scrotum  and  penis;  they  appear 
in  the  form  of  vesicles  like  grains  of  sago,  grouped 
regularly  or  irregularly  Sometimes  only  am- 
pullse  are  formed,  which  are  generally  soft  and 
painless.  These  conditions  have  been  mistaken 
for  hernia,  abscess,  scro  ulous  glands,  and  other 
diseases.  Should  the  dilated  lymphatics  rup- 
ture subeutane  usly,  vesicles  containing  a clear 
or  milky  fluid  appear.  They  may  rupture  on 
the  surface  of  the  skin,  the  lymph  being  dis- 
charged externally,  which  is  an  important  ele- 
ment in  the  diagnosis  of  doubtful  cases.  When 
dilated  absorbents  are  situated  internally,  they 
cannot  be  recognised  unless  they  should  happen 
to  runture,  with  the  escape  of  their  contents  by 
some  outlet  This  applies  mainly  to  the  lacteals, 
the  contents  of  which  may  pass  out  with  the 
stools,  and  to  the  urinary  mucous  membrane,  it 
being  supposed  by  some  pathologists  that  the 
condition  termed  shyluria  is  merely  due  to  the 
rupture  of  dilated  lymphatic  vessels  in  this 
membrane. 

b.  Obstruction. — As  in  the  case  of  dilatation, 
the  capillary  plexuses  or  larger  lymphatics  may 
be  obstructed.  This  may  arise  chiefly  from 
pluggingof  their  channels  by  coagulated  lymph; 
inflammation  of  the  vessels:  pressure  by  enlargod 
glands,  aneurisms,  or  other  tumours,  or  tnoruly 


912  LYMPHATIC  SYSTEM. 

as  a result  of  inflammation  of  the  cellular  tissue 
around  the  vessels.  It  may  he  remarked  here 
that  lymphatic  tissues,  similar  to  those  observed 
in  the  glands,  sometimes  form  here  and  there  in 
the  course  of  the  lymphatics  in  cases  of  lympha- 
denoma.  The  lymphatics  of  the  urinary  mucous 
membrane  are  also  supposed  by  some  pathologists 
to  become  the  seat  of  aggregation  of  the  animal 
parasites  named  filaria,  and  they  consider  that 
this  is  the  cause  of  chyluria. 

The  effects  liable  to  be  produced  by  obstruc- 
tion of  lymphatic  vessels  are  swelling,  from  so- 
called  lymphatic  oedema ; and  dilatation  of  the 
vessels  behind  the  obstruction,  which  may  lead 
to  their  rupture.  It  is  by  these  effects  alone 
that  this  condition  can  be  recognised  clinically. 

Treatment. — But  little  can  be  done  for  the 
chronic  changes  now  under  consideration  affect- 
ing lymphatic  vessels.  Proper  bandaging,  or  the 
use  of  some  elastic  support,  may  be  of  use  in 
treating  dilated  vessels,  if  they  happen  to  be  con- 
veniently situated.  Friction  and  kneading  may 
assist  in  removing  lymphatic  oedema  due  to  ob- 
struction. Growths  come  under  the  treatment 
of  the  surgeon,  and  do  not  call  for  any  special 
remark  here.  Frederick  T.  Roberts. 

LYMPHATIC  TEMPERAMENT.  Sec 

Temperament. 

LYMPHOMA. — A synonym  for  lymphade- 
noma.  See  Ly.mphadenoma. 

LYMPHORRHAGIA  or  LYMPHOR- 
RHCEA  ( lympha , lymph,  from  vvfitprj,  water  ; 
and  frfiyvv/xt,  I burst  forth,  or  pea,  I flow). 

Definition. — These  terms  literally  signify  a 
flow  of  lymph,  but  they  are  used  to  indicate  an 
abnormal  discharge  from  any  part  of  the  ab- 
sorbent system,  whether  it  be  of  lymph  or  of 
chyle. 

.Ft  10 logy  and  Pathoeosy. — Lymphorrhagia 
may  take  place  from  the  lymphatic  capillaries 
or  trunks;  from  the  lacteals  ; from  the  absorbent 
glands;  or  from  the  receptaculum  chyli  or  tho- 
racic duct.  Cases  in  which  this  condition  occurs 
are  usually  divided  into  traumatic  and  idiopathic , 
according  to  their  apparent  causation.  In  the 
former  the  cause  is  a wound,  which  generally 
affects  either  the  thoracic  duct,  the  larger  ly7m- 
phatic  trunks,  or  the  glands.  A discharge  of 
lymph  has  in  rare  instances  followed  even  a slight 
wound,  particularly  in  the  neighbourhood  of 
joints,  and  this  was  attributed  by  the  late  Mr. 
Messenger  Bradley  to  a constitutional  defect — 
a lymphorrhagic  diathesis,  corresponding  to  the 
haemorrhagic  diathesis.  Idiopathic  lymphorrhrea 
is  almost  always  the  result  of  dilatation  of  a ves- 
sel or  vessels,  which  ultimately  rupture.  They 
lire  often  greatly  distended  before  they  give  way. 
Allusion  may  again  be  made  here  to  the  supposed 
relation  of  chyluria  to  the  presence  of  filaria  in 
the  lymphatic  vessels  of  the  urinary  organs,  these  1 


LYSIS. 

parasites  causing  them  to  rupture,  and  the  lymph 
consequently  being  discharged  with  the  urine. 

Symptoms  and  Effects. — Should  an  escape  of 
lymph  take  place  upon  any  part  of  the  surface 
of  the  body,  it  differs  much  in  its  quantity  and 
characters  in  different  cases.  It  may  be  less 
than  an  ounce,  or  amount  to  five  and  even  ten 
pounds  within  the  twenty-four  hours;  while  in 
the  same  case  its  quantity  is  liable  to  variation 
from  time  to  time,  and  the  flow  has  even  been 
known  to  assume  a periodic  character,  increasing 
during  the  period  of  digestion.  In  traumatic 
cases  the  discharge  either  presents  the  ordinary 
appearance  of  lymph,  being  clear  and  limpid,  or 
it  is  mixed  more  or  less  with  blood  or  with  in- 
flammatory products.  'When  rupture  takes  place 
spontaneously  after  dilatation  of  the  vessels,  the 
fluid  is  more  like  chyle,  being  more  or  less  milky 
and  white,  from  the  presence  of  particles  of  fat, 
but  its  characters  are  liable  to  alter  from  time  to 
time.  It  contains  a variable  quantity  of  fibrino- 
genous  elements,  and  is  proportionately  disposed 
to  coagulate  spontaneously7.  Internal  lymphor- 
rhagia causes  different  results.  In  the  case  of 
the  intestines  and  urinary7  organs,  the  fluid  is 
discharged  with  the  feces  and  urine  respectively, 
in  the  former  case  being  supposed  to  give  rise  to 
fatty  stools,  and  in  the  latter  to  chyluria.  The 
late  Mr.  Bradley  attributed  some  cases  of  effusion 
into  serous  cavities,  such  as  certain  forms  of 
hydrocele,  hydrocephalus,  pleuritic  effusion,  and 
ascites,  to  a lymphorrhagia  into  the  respective 
cavities ; and  the  writer  has  met  with  a case  of 
ascites  which  seemed  to  support  this  view.  Fatal 
peritonitis  has  resulted  from  the  entrance  of  chyle 
into  the  peritoneum,  owing  to  the  rupture  of  a 
dilated  receptaculum  chyli.  The  escape  of  lymph 
or  chyle  out  of  the  system  tends  to  affect  the 
general  health,  and  if  it  is  in  large  amount,  this 
is  likely  to  lead  to  marked  emaciation,  debility, 
and  anaemia. 

Treatment. — In  external  lymphorrhagia  all 
that  can  be  done  is  to  check  the  flow  of  lymph 
by  pressure  of  bandages,  and  the  application  of 
astringents.  In  cases  where  it  takes  place  into 
internal  passages,  tincture  of  iron  in  full  doses 
may  be  of  service.  The  general  condition  must 
be  attended  to,  and  improved  by  nutrients  and 
tonics,  if  required. 

Frederick  T.  Roberts. 

LYPEMANIA  (Aihnj,  grief,  and  panto,  mad- 
ness).— The  name  applied  by  Esquirol  to  the 
form  of  insanity  characterised  by  mental  depres- 
sion, usually7  called  melancholia.  See  Melax 
cholia. 

LYSIS  (\0w,  I dissolve).— This  word  hai 
formerly  various  significations,  but  is  now  ge 
nerally  applied  to  the  gradual  decline  of  an 
disease  or  pathological  process,  especially  fevei 
I See  Fever. 


M 


MACUTjJE  ( macula , a spot  or  stain). — 
Synon.:  Fr.  Macules ; Ger.  FlecTce. 

Description. — Willan’s  definition  of  macula 
is  ‘a  permanent  discoloration  of  some  portion  of 
the  skin;’  and  that  author  adopted  the  term  as 
the  title  of  his, eighth  ordor  of  cutaneous  affec- 
tions, including  sunburn,  naevus,  and  spilus.  The 
term  macula  is  likewise  applied  to  a hyperaemic 
Btate  of  the  skin,  which  may  be  simply  chronic 
without  being  permanent,  such  as  those  which 
hare  received  the  name  of  macula  syphilitica. 
Maculs,  therefore,  may  be  merely  pigmentary, 
and  located  in  the  rete  mucosum  alone  ; or  they 
may  be  haemostatic  or  haemorrhagic,  and  be 
seated  in  the  derma  and  subcutaneous  tissues. 
Sunburn,  freckles,  liver-spot,  bronzed  and  melas- 
mic  spots,  and  the  stains  left  on  the  skin  after 
the  dispersion  of  certain  cutaneous  eruptions, 
such  as  lepra  vulgaris,  acne,  lichen  planus, 
syphilis,  and  elephantiasis,  are  examples  of  pig- 
mentary maculae,  whilst  leucosmic  spots  and 
blotches  represent  an  absence  of  pigment.  The 
maculae  resulting  from  a permanent  hyperaemia 
>f  the  blood-vessels  of  the  skin,  such  as  flat  vas- 
mlar  naeviand  the  claret-stain  naevus,  are  haemo- 
static and  disappear  under  pressure;  whilst  the 
lsemorrhagic  maculae  are  represented  by  the 
scape  of  the  red  corpuscles  of  the  blood  from  the 
•essels,  and  their  diffusion  in  the  connective  tis- 
ues,  such  as  occurs  in  purpura  and  in  bruises. 
Treatment. — The  therapeutics  of  maculae  will 
e found  treated  of  under  the  heads  of  pigmen- 
iry  affections  of  the  skin,  and  of  the  respective 
iseases  with  which  they  are  associated. 

Erasmus  Wilson. 

MADEIRA ; North  Atlantic  Ocean. — 
foist,  mild,  equable,  relaxing  climate.  Mean 
imperature  in  winter,  60’6°  Fahr.  Prevailing 
indN.E.  See  Climate,  Treatment  of  Disease  by. 
MADNESS.  See  Insanity. 

MADURA-POOT. — A synonym  forfungus- 
ot  of  India.  See  Fungus-Disease  cf  India. 

MAGGOTS. — A popular  term  for  tho  para- 
de larvae  of  various  insects,  including  hots.  See 
Istrus. 

MAGNETISM,  ANIMAL.— This  name 
is  formerly  applied  to  the  imaginary  new  force 
principle,  supposed  to  be  akin  to  magnetism, 
d to  be  in  operation  when  individuals  were 
esmerised.’  This  hypothetical  new  force  was 
'might  to  be  called  into  play  by  the  mesme- 
er ; and  it  was  deemed  to  be  by  virtue  of  its 
luence  that  the  will,  thoughts,  and  actions  of 
' ( ‘medium,’  or  person  mesmerised,  are  capable 
‘ being  influenced  in  the  so-called  mesmeric 
1 nee  or  sleep.  This  view  as  to  the  nature  of 
1 causal  conditions  is  now  regarded  as  alto- 
[ her  erroneous,  although  certain  remarkable 
< cts  appear  to  have  been  produced  on  many 
1 sons  by  so-called  ‘ mesmeric  passes,’  or  other 

58 


means,  owing  to  the  induction  in  such  persons 
under  physiological  conditions,  of  some  at  pre- 
sent impprfeetly  understood  state  or  modification 
of  cerebral  activity  (sea  Mesmerism).  This  state 
is  now  generally  spoken  of  as  the  ‘ hypnotic 
condition.’  1 hypnotic  sleep,’ or  ‘hypnotism’;  or 
more  rarely  as  ‘ induced  somnambulism.’  On  the 
other  hand,  when  such  a state  is  induced,  as  a 
therapeutic  means  or  agency,  it  has  been  spoken 
of  as  ‘ Braidism.’  See  Braidism. 

H.  Charlton  Bastian. 

MALACOSIS  (y-aXaubs,  soft).- — A term  for 
the  morbid  softening  ofstructures.  See  Softening. 

MALACOSTEONf/uaAasbs,  soft,  and  omlov, 
a bone). — A peculiar  disease  of  bone,  charac- 
terised by  softening.  See  Mollities  Ossium. 

MALAGA,  in  South  of  Spain. — Dry,  mild, 
bracing,  equable  climate.  Mean  temperature 
in  winter,  55°  Fahr.  Winds;  N.W.  ( Tcrral),  dry 
and  dusty;  E.  (Lcvante),  cold  and  damp.  Draw- 
backs : bad  drainage  and  cookery.  See  Climate, 
Treatment  of  Disease  by. 

MALAISE  (Fr.) — Synon.  : Indisposition; 
Ger.  Missbefinden. — In  cases  of  simple  digestive 
derangement,  in  ague,  and  in  the  stage  of  inva- 
sion of  many  acute  diseases,  the  patient  very 
commonly  first  becomes  aware  that  his  health  is 
disturbed  by  a feeling  of  general  illness,  which 
is  known  as  malaise. 

Description. — Under  tho  circumstances  just 
mentioned,  the  ordinarily  unconscious  feeling 
of  being  well,  or  bien-etre , which  accompanies 
perfect  health,  is  replaced  by  a painful  and 
depressing  feeling,  which  the  patient  probably 
cannot  describe  otherwise  than  as  a sense  of 
being  weak,  languid,  listless,  and  disinclined  to 
bodily  or  mental  exertion.  Malaise  is  commonly 
associated  with  bodily  debility,  chilliness  or 
actual  rigors,  moderate  pyrexia,  general  pains 
or  aches,  giddiness,  headache,  and  anorexia.  In 
the  course  of  the  more  serious  diseases  in  which 
it  occurs,  malaise  either  passes  off  or  soon  gives 
place  to  more  urgent  symptoms — such  as  depres- 
sion, apathy,  delirium,  or  stupor  ; but  in  other 
instances  it  persists,  and  constitutes  the  chief 
subjective  phenomenon  of  the  disease,  as  in  some 
cases  of  typhoid  fever. 

Treatment. — The  treatment  of  malaise  will 
depend  upon  the  nature  of  the  cause  of  the  feel- 
ings just  described,  and  should  be  directed  to  its 
removal  or  remedy.  J.  Mitchell  Bruce. 

MALARIA  (Itah). — Synon.:  Marsh  Miasm. ; 
Fr.  Mauvais  Air;  Intoxication  dcs  Marais;  In- 
toxication Tellurique ; Ger.  Malaria. 

Definition. — An  earthborn  poison,  generated 
in  soils  the  energies  of  which  are  not  expended 
in  the  growth  and  sustenance  of  healthy  vegeta- 
tion. By  almost  universal  consent  this  poison  is 
the  cause  of  all  the  types  of  intermittent  and 


MALARIA. 


)14 

remittent  fevers,  commonly  called  malarial,  and 
of  the  degeneration  of  the  blood  and  tissues  re- 
sulting from  long  residence  in  places  where  this 
poison  is  generated. 

The  Italian  word  malaria  is  now  employed  to 
convey  the  meaning  expressed  in  the  above  defi- 
nition. It  is  certainly  preferable  to  the  term 
marsh  miasm,  which  implies  that  marshes  are  the 
sole  source  of  the  poison.  M.  L6on  Colin,  Pro- 
fessor of  Military  Medicine  in  the  Val-de-Grace, 
who  has  written  an  instructive  work  on  malarial 
lovers,  does  not  use  the  term  malaria  to  distin- 
guish the  agent  that  causes  them ; he  prefers  the 
term  telluric  poison,  intoxication  tellurique,  pro- 
ceeding from  the  energy  of  the  soil,  when  that 
energy  is  not  absorbed  by  its  natural  consumers, 
crops  or  plants — in  a word,  healthy  vegetation. 
This  telluric  influence  or  poison  is,  however, 
after  all,  a malaria,  a bad  or  poisonous  air  under 
another  name. 

Essential  Nature. — Chemists  have  not  been 
ablo  to  demonstrate  the  presence  of  a malaria — 
a fever-generating  agent — in  the  air  of  marshes, 
any  more  than  they  have  been  able  so  to  do  in 
other  places  where  the  same  fevers  prevail.  Much 
light  has.  however,  been  thrown  upon  the  intimate 
nature  of  the  malarial  poison,  by  the  researches 
of  Professors  Tommasi  Crudeli,  of  Rome,  and 
Elebs,  of  Prague,  who  made  the  physical  cause  or 
poison  t.o  which  malarial  fevers  are  due  the  sub- 
jectof  careful  investigation  in  the  Agro  Romaiw, 
in  the  spring  season  of  1879.  They  examined 
minutely  the  lower  strata  of  the  atmosphere  of 
the  district  in  question,  as  well  as  its  soil  and 
stagnant  waters;  and  in  the  two  former  they 
discovered  ‘ a microscopic  fungus,  consisting  of 
numerous  movable  shining  spores,  of  a longish 
oval  shape,  and  nine  micromillimetres  in  diameter. 
This  fungus  was  afterwards  artificially  generated 
in  various  kinds  of  soil;  the  fluid  matter  thus 
obtained  was  filtered,  and  repeatedly  washed; 
and  the  residuum  left  after  filtration  was  intro- 
duced under  the  skin  of  healthy  dogs.  The  same 
iliing  was  done  with  the  microscopical  particles 
obtained  by  washing  large  quantities  of  the  sur- 
face soil.  All  the  animals  experimented  upon  had 
the  fever,  with  the  regular  typical  course,  show- 
ing free  intervals,  lasting  various  lengths  of  time 
up  to  sixty  hours,  and  an  increase  of  thetempera- 
turo  of  the  blood  during  the  shivering  fits  up  to 
nearly  42°  C.;  the  normal  temperature  in  healthy 
dogs  beingfrom38°to393  centigrade.  The  animals 
affected  by  intermittent  fever  showed  precisely 
the  same  acute  enlargementof  the  spleen  ashuman 
patients  who  had  caught  the  disease  in  the  usual 
way;  and  in  the  spleens  of  these  animals  a large 
quantity  of  the  characteristic  form  of  fungus  was 
present.’  Tommasi  Crudeli  andKlebs  have  given 
to  this  organism  the  name  of  Bacillus  mnlarue. 

Doctors  Marchiafava  and  Valenti,  of  Rome,  af- 
firm that  they  have  detected  the  Bacillus  mala- 
ria in  human  patients,  in  a more  advanced  stage 
than  in  the  animals  operated  upon  by  Crudeli  and 
Klebs.  Dr.  Crudeli  still  more  recently  states, 
as  the  result  of  further  pathological  investiga- 
tions, that  the  bacilli  may  always  be  found  in  the 
blood  during  the  period  of  i vasion  of  the  fever; 
hut  that  during  the  acme  they  disappear,  and 
spores  only  can  he  discovered.  The  bacilli  have 
been  found  chiefly  in  the  spleen  of  the  human 


subject ; and  in  the  marrow  of  bones  in  animate 
experimented  on.  The  bacillus  has  not  yet  been 
found  in  Bengal.  According  to  the  researches  of 
Laveran,  extended  and  corrected  by  Richard,  the 
blood  in  malarial  fever  contai ns,  duri  ng  the  acces- 
sion, spherical  organisms,  developed  in  connexion 
with  the  red  corpuscles,  and  furnished  with  fila- 
ments; also  certain  curved  and  pointed  bodies, 
w-hich  are  only  infected  and  deformed  corpuscles. 
The  pigment  granules  of  malarial  blood  are  pro- 
duced in  the  red  corpuscles  during  the  growth  of 
the  organisms.  Lancet,  1882,  vol.  i.  p.  993.  Should 
future  investigations  by  independent  observers  in 
other  malarial  regions  confirm  these  conclusions, 
it  would  be  difficult  to  overrate  their  importance. 

Genetic  Relations. — When  we  consider  that 
in  many  regions  of  the  globe  two-thirds  of  the 
mortality  is  caused  by  the  fevers,  and  their 
sequels,  to  which  this  poison  gives  rise,  we  can 
understand  why  all  that  relates  to  malaria  is 
important  to  the  statesman,  the  soldier,  the  sani- 
tarian, and  the  physician.  ‘Fevers,’  savs  Dr. 
Cornish,  the  Sanitary  Commissioner  of  Madras, 
‘one  year  with  another  destroy  twice  as  many 
people  in  India  as  small-pox,  cholera,  and  ail 
other  epidemic  causes  put  together.’  Dr.  Partes 
has  well  said  ‘that  when  a climate  is  called 
“unhealthy,”  it  is  simply  meant  that  it  is  mala- 
rious.’ This  remark  is  especially  true  of  tropical 
climates.  Malaria  has  generally  been  said  to 
be  the  product  of  heat,  moisture,  and  vegetable 
decomposition.  The  terms  marsh  miasm,  and 
paludal  fevers,  long  employed  to  distinguish  the 
poison  and  the  fevers  to  which  it  gives  rise,  mark 
the  almost  universal  belief  that  the  air  of  marshes 
alone  is  endowed  with  the  power  of  generating 
them.  That  low,  moist,  and  warm  localities  are 
generally  noted  as  malarious  is  indisputable. 
Marshes  are  not,  as  a rule,  dangerous  when 
abundantly  covered  with  water;  it  is  when  the 
water  level  is  lowered,  and  the  saturated  soil  is 
exposed  to  the  drying  influence  of  a high  tem- 
perature and  the  direct  rays  of  the  sun,  that 
this  poison  is  evolved  in  abundance.  The  pro- 
duction of  malaria  on  a great  scale  in  this  way 
was  seen  in  the  district  of  Burdwan,  in  Bengal 
The  soil  is  alluvial,  but  dry ; and,  until  withii 
the  last  few  years,  Burdwan  was  more  salubriom 
than  the  central  or  eastern  districts  of  the  Lowe 
Gangetic  delta.  The  drainage  of  the  district  be 
came  obstructed  bythe  silting  up  of  its  naturalam 
artificial  outlets,  the  result  being  a waterloggw 
condition  of  the  soil,  the  development  of  malaria 
and  an  alarming  increase  in  the  death-rate. 

Malaria  is,  however,  generated  under  condition 
apparently  widely  different,  from  the  above.  Whe 
the  British  Army  under  Wellington  was  operat 
ing  in  Estremadura,  the  country  was  so  arid  an 
dry  far  want  of  rain,  that  the  rivers  and  sma 
streams  were  reduced  to  mere  lines  of  widely  d( 
tached  pools  ; yet  it  was  assailed  by  a remitter 
fever  of  such  destructive  malignity  ‘ that,’  say 
Ferguson,  who  records  the  fact.  ‘ the  enemy  an 
all  Europe  believed  that  the  British  host  was  e: 
tirpated.’  A fever  of  like  malignity  scourged  tl 
same  army  in  the  bare  open  country  by  whic 
Ciudad  Rodrigo  is  approached  from  the  side  • 
Portugal,  at  a time  when,  says  the  same  autho 
‘ the  vegetation  was  so  burned  up  that  tl 
whole  country  resembled  a brick-ground- 


MALARIA. 


must,  however,  be  kept  in  mind  that  both  dis- 
tricts are  in  the  rainy  season  flooded  with  water, 
at  which  time  they  are  healthy,  until  the  drying 
process  begins  under  the  action  of  a powerful  sun. 

Malaria  is  notoriously  rife  in  soils  the  upper 
strata  of  which  are  rich  in  organic  matter,  and 
are  from  any  cause  left  to  nature  and  the  influ- 
ence of  the  sun.  The  Roman  Campagna 1 is  a 
well-known  example  of  this  kind.  M.  Leon  Co- 
lin lias  explored  this  tract  of  country  in  search 
of  rhe  commonly  recognised  sources  of  malaria, 
arid  reports  it  everywhere  dry  and  free  from 
stagnant  water.  But  the  cultivating  hand  of 
man  has  long  been  withdrawn  from  this  once  fer- 
tile region,  and  the  energies  of  its  rich  soil,  in- 
stead of  being  directed  to  food-producing  ends, 
are  wholly  given  up  to  the  development  of  mala- 
ria, for  which  it  is  notorious. 

It  is  well  known  that  so-called  malarial  fevers 
prevail  in  some  of  the  most  sterile  regions  of  the 
earth.  Here,  it  is  often  said,  ‘ there  is  no  or- 
ganic matter,  no  vegetative  energy  running  waste, 
on  which  to  fall  back  for  an  explanation.’  Yet 
many  of  those  desert  places,  to  all  appearance 
mder  the  curse  of  perpetual  barrenness,  do  con- 
tain organic  matter,  and  are  in  reality  so  full  of 
vegetative  energy,  that  water  only  is  wanted  to 
fit  them  for  the  productive  labour  of  the  husband- 
man. There  are  millions  of  acres  in  India,  now 
supplying  abundant  harvests,  which,  if  water  was 
withdrawn,  and  the  cultivating  hand  of  man 
withheld,  would  quickly  relapse  into  deserts 
ruitful  only  in  malaria. 

We  need  not  go  to  tropical  countries  in  search 
>f  examples  of  this  kind : our  own  country  can 
'urnish  them  in  abundance.  So  late  as  the 
•eign  of  the  sister  of  Elizabeth,  * to  whose  name 
. horrible  epithet  adheres,’  large  tracts  of  country 
him  political  causes  fell  out  of  cereal  cultivation, 
ml  forthwith  malarial  fevers  became  epidemic, 
itended  with  a heavy  mortality. 

The  disturbance  of  soil  that  has  long  been  fal- 
low is  often  followed,  both  in  hot  and  temperate 
limatos,  by  the  evolution  of  malaria.  A familiar 
sample  was  the  prevalence  of  intermittent  fever 
1 Paris  during  the  construction  of  the  Canal 
t.  Martin  ; also  during  the  excavations  for  tho 
unifications  of  the  same  city,  in  the  reign  of 
ouis  Philippe  ; and  on  a larger  scale  in  dif- 
uent  parts  of  France  when  tho  railways  were 
i process  of  construction. 

Malaria  is  freely  generated  at  the  bases  of 
ountain  ranges  in  tropical  climates.  The  strip 
land  extending  along  the  base  of  the  Himalaya, 
lied  the  terrai,  is  a notable  example  of  this 
nd.  The  soil  of  this  region  is  immensely  rich, 
ill  supplied  with  water,  and  covered  with  dense 
rests,  which  with  the  vast  mountain  range 
■ikes  free  perflation  of  air  impossible.  At 
.rticular  seasons  of  the  year  it  is  almost  certain 
ath  to  enter  this  region. 

Some  rocks  in  a state  of  disintegration,  when 
icly  exposed  to  the  drying  action  of  the  sun 
d air,  are  in  tropical  countries  often  highly 
ilarious,  and  give  rise  to  severe  forms  of  fever. 

1 Every  sanitarian  must  wish  success  to  the  gigantic 
ernes  suggested  by  Garibaldi  to  make  Rome  fit  in  a 
itary  point  of  view  for  the  capital  of  Italy,  and  to 
ffy  the  pestilential  Agro  Romano.  In  the  present 
te  of  matters  Rome  is  unsuitable  for  a capital,  except 
reasons  purely  sentimental. 


91A 

The  example  most  familiar  to  the  writer  from 
personal  knowledge  is  the  island  of  IIong-Kong. 
The  soil,  according  to  Dr.  Parkes,  contains  only 
about  2 per  cent,  of  organic  matter ; but  like  all 
granitic  rocks  it  is  highly  absorbent  of  water ; and 
Friedell,  quoted  by  the  same  authority,  affirms 
that  it  is  permeated  by  fungi.  The  writer  was 
encamped  on  this  island  before  it  was  ceded  to 
the  British  Government.  At  this  time  the  soil 
was  but  little  disturbed,  and  the  troops  did  not 
suffer.  But  when  excavations  were  made  at  a 
subsequent  time,  for  the  construction  of  the  city 
of  Victoria,  on  the  side  of  the  island  facing  the 
harbour,  a fatal  form  of  remittent  fever  appeared, 
which  caused  great  mortality  among  both  tho 
civil  and  the  military  population. 

Parkes  (Practical  Hygiene)  thus  sums  up  his 
account  of  the  soils  with  the  largest  organic 
emanations:  ‘1.  Alluvial  soils,  old  estuaries, 
deltas.  Peaty  soils  are  much  less  malarious. 
Marshes  overflowed  regularly  by  the  sea  are 
often  healthy,  while  the  occasional  admixture 
of  salt  water  increases  the  emanations.  2.  Sands, 
if  there  is  an  impermiahle  clay  or  marly  subsoil. 
Old  watercourses.  3.  The  lower  parts  of  tho 
chalk,  where  there  is  a subsoil  of  ganlt  or  clay. 
4.  Weathered  granitic  or  trap  rocks,  if  vegetable 
matter  has  become  intermixed ; such  soils  absorb 
both  heat  and  water.  5.  Rich  vegetable  soils  at 
the  foot  of  hills.’ 

When  malarial  fevers  appear  in  ships  return- 
ing from  unhealthy  climates,  tho  explanation  is 
to  be  looked  for  under  one  or  other  of  the  follow- 
ing causes  : — (a)  the  sufferers  may  have  had  their 
systems  charged  with  malaria  before  embarka- 
tion, as  is  constantly  seen  in  the  case  of  invalids 
returning  from  India  ; (b)  they  may  have  used 
water  on  board  drawn  from  a malarious  locality ; 
(c)  tho  source  of  tho  malaria  may  ho  in  the  ship, 
from  decayed  vegetable  matter  mingling  with 
the  bilge  water,  in  ships  under  a bad  sanitary 
regime ; 1 or  (d)  it  may  be  derived  from  mala- 
rious mud,  as  in  the  case  of  H.M.  ship  ‘ Power- 
ful,’ returning  from  India,  when  a severe  out- 
break of  fever  was  traced  to  this  cause.  There 
is,  however,  reason  to  believe  that  when  fever 
has  been  observed  to  follow  the  consumption  of 
unwholesome  water  at  sea,  it  has  sometimes  been 
not  malarial  but  enteric,  from  the  unsuspected 
presence  in  it  of  the  specific  germs  of  that  disease. 

Instances  are  also  recorded,  in  which  symp- 
toms having  aperiodic  character,  and  yielding  to 
the  treatment  which  is  effective  in  malarial  dis- 
eases, have  resulted  from  exposure  to  decaying 
vegetable  matter,  a connection  of  which  with  a 
special  marsh  poison  could  not  well  be  traced. 

Attributes.  — Malaria,  however  generated, 
possesses  certain  properties  well  known  to  those 
who  live  in  malarial  localities.  Temperature 
exercises  great  influence  over  its  development 
and  activity ; many  places  can  be  visited  with 
impunity  in  winter  which  are  dangerous  in 
summer  and  autumn.  Wenzel  made  observations 
on  the  effect  of  temperature  in  the  development 

1 The  writer  is  indebted  to  the  late  Dr.  Mansfield,  R.N., 
for  an  instructive  example  of  a fatal  form  of  yellow  ma- 
larial  fever  on  board  H.M.  ship  ‘ Egmont,’  long  used  as  a 
storeship  at  Rio.  The  ship  was  found  to  be  in  a stato 
of  decay ; the  timbers  were  permeated  by  fungi  of  a 
white  or  cream  colour,  giving  otf  a sickening  and  o fta»* 
sive  odour. 


MALARIA. 


J16 

of  malaria  during  the  construction  of  the  fortified 
port  of  Jahde ; he  observed  that  the  increase  of 
attacks  of  malarial  fever  was  coincident  with  a 
rise  in  the  temperature.  In  the  charts  con- 
structed by  him  to  illustrate  the  point,  a constant 
precedence  of  the  temperature  curve  by  twenty  or 
twenty-five  days  of  the  sickness  curve  of  attacks 
is  to  be  seen ; so  that  in  a temperate  climate  like 
that  of  Jahde,  threo  weeks  of  increased  tempera- 
ture appeared  to  be  necessary  for  the  genesis  of 
the  malarial  poison,  and  the  outbreak  of  sick- 
ness. When  in  any  year  the  medium  summer 
temperature  did  not  reach  12°  R.  (59°  F.)  the 
sickness  remained  at  its  minimum. 

Malaria  drifts  along  plains  to  a considerable 
distance  from  its  source,  when  aided  by  winds 
sufficiently  strong  to  propel,  but  not  to  dispel  it. 
Under  the  influence  of  currents  of  heated  air  it 
can  ascend,  in  dangerous  concentration,  far  above 
its  source,  and  buildings  elevated  some  hundreds 
of  feet  above  a malarious  plain  are  often  more 
under  its  influence  than  those  on  the  plain  itself. 
When  favoured  by  ravines  and  currents  of  heated 
air,  it  can  scale  mountains  to  a height  which 
appears  to  differ  in  different  climates,  varying 
from  four  or  five  hundred  to  two  or  three 
thousand  feet.  It  is  unsafe  to  place  human 
habitations  on  the  edge  of  such  ravines  on  moun- 
tain tracts  generally  considered  above  ‘ fever- 
range.’  A belt  of  forest,  interposed  between  any 
malarial  place  and  human  habitations  affords 
considerable  protection,  and  a sheet  of  water 
similarly  placed  exercises  an  absorbing  power — 
facts  long  familiar  to  sanitarians.  Soils  protected 
from  the  sun’s  rays  by  forest  trees  are  generally 
healthy  ; but  when  exposed  to  the  sun  after  the 
forests  have  been  cleared  away,  malaria  is  evolved 
until  the  land  is  brought  under  cultivation.1 

Pathological  Relations.  —The  physician  can 
demonstrate  the  existence  of  malaria  by  the  best 
of  all  tests,  namely,  its  pathological  action.  This 
action  has  been  recognised  for  ages  in  the  pro- 
perty it  possesses  of  producing  a class  of  fevers 
distinct  from  all  others  in  their  symptoms  and 
sequels,  to  which  the  name  of  malarial  or  pa- 
roxysmal has  been  given  ; the  latter  term  from 
the  almost  clock-like  regularity  of  the  periods  of 
apyrexia  and  recurrence.  Pathologists  have  also 
recognised  its  power  of  impressing  on  other  dis- 
orders, in  a lesser  degree,  the  same  stamp  of 
periodicity,  and  its  more  insidious  but  not  less 
dangerous  endowment  of  inducing  that  ‘slow 
blight  of  the  constitutional  powers’  to  which  the 
term  malarial  cachexia  is  now  applied.  The 
most  striking  features  of  this  condition  are  easily 
recognised.  The  sufferers  appear  much  older 
than  they  are;  the  6kin  assumes  a brownish 

‘ A popular  belief  has  arisen  that  the  blue  gum  tree 
of  Australia,  Eucalyptus  Globulus,  is  particularly  effica- 
cious in  this  way.  This  tree  is  now  popularly  known  as 
the  ‘ fever  tree,’  and  is  being  extensively  planted  for  pro- 
tective purposes  in  the  malarious  parts  of  Italy.  Its 
supposed  virtues  are  said  to  be  due  to  the  camphoracious 
constitution  of  the  leaves  of  this  •■cnie,  gigantic,  and 
rapidly-growing  tree.  It  is  a notable  fact  that  the  ex- 
tensive pasture  lands  of  Australia  are  very  free  from 
malaria,  and  the  fact  is  there  attributed  to  the  existence 
of  vast  forests  of  the  blue  gum  tree. 

All  the  species  of  eucalyptus  grow  with  amazing  ra- 
pidity ; wherever  they  are  planted  they  are  great  con- 
sumers of  moisture,  and  thus  exercise  a drying  influence  on 
the  subsoil,  which  must  have  a considerable  effect  on  the 
climate  where  they  exist  in  large  numbers. 


yellow  tint,  of  various  shades,  according  to  the 
natural  complexion  of  the  person  and  length  of 
residence  in  an  unhealthy  climate.  Thi-y  become 
anaemic,  with  an  immense  increase  in  the  white 
corpuscles  of  tlio  blood.  The  rapidity  with  which 
this  ansemia  is  developed  is  surprising.  Pro- 
fessor Kelsch  has  shown  by  carefully  conducted 
observations  made  by  Malassez’s  method,  that 
in  twenty-four  hours  a man  affected  with  in- 
termittent fever  lost  more  than  a million  of 
globules  per  millimetre  cube.  This  condition 
of  the  blood  often  gives  rise  to  murmurs,  not 
confined  to  the  cardiac  region,  but  heard  also 
in  the  large  vessels,  misleading  unwafy  observers 
into  a false  diagnosis  of  organic  disease.  Persons 
whose  blood  is  thus  so  affected  are  prone  to 
attacks  of  a f,-.tal  form  of  pneumonia,  if  exposed 
to  cold  when  not  protected  by  sufficiently  warm 
clothing.  Their  digestive  and  h at-generating 
powers  are  impaired,  and  they  are  liable  to 
diarrhoea  from  slight  causes,  often  of  an  intrac- 
table kind.  The  liver  is  generally  enlarged,  bat 
the  most  characteristic  lesion  is  enlargement  of 
the  spleen,  which  often  attains  such  a size  aj 
to  occupy  a large  part  of  the  abdominal  cavity. 
There  is  in  the  pathological  museum  at  Netley 
a preparation  of  the  section  of  a spleen  taken 
from  the  body  of  a small  drummer  bov,  who  had 
been  under  the  caro  of  the  writer.  This  lad  had 
spent  some  years  of  his  brief  life  in  the  Pesliawnr 
Valley.  The  weight  of  the  spleen  was  10  lbs. 
15  oz.,  that  of  the  liver  9 lbs.  10  ozs.  The  con- 
dition was  alike  in  both  organs,  an  immense  de- 
velopment of  connective  tissue  having  taken  place. 
These  two  organs  made  up  one  quarter  of  the  total 
body-weight  of  the  boy.  Roth  spleen  and  liver, 
and  sometimes  even  the  brain  and  spinal  card,  are 
deeply  pigmented.  The  urine  is  sometimes  albu- 
minous, with  oedema  of  the  lower  extremities— 
symptoms  suggestive  of  Bright’s  disease,  leading 
to  a grave  prognosis,  often  ill-founded,  as  the 
above  symptoms  usually’  disappear  under  good 
climatic  and  therapeutic  means. 

Neuralgic  affections,  varied  and  numerous,  are 
common  sequels  of  malarial  poisoning;  ‘brow 
ache  ’ is  a familiar  example.  To  the  above  may 
be  added  palpitation  of  the  heart,  rheumatic 
pains  in  limbs  and  joints,  and  amenorrhoea ; and 
if,  as  often  happens,  scurvy  be  engra'ted  on  the 
malarial  cachexia,  such  of  the  above  affectionsas 
may  be  present  are  at  once  seriously  aggravated. 

Tropical  dysentery  prevails  in  its  worst  forms 
in  malarial  localities  ; the  same  is  true  ot  sup- 
purative inflammation  of  the  liver.  It  seems 
probable  that  when  malaria  acts  as  a predisposing 
cause  of  dy’sentery,  it  is  taken  into  the  system 
through  the  medium  of  water.  It  is  a significam 
fact,  elsewhere  insisted  on  by  the  writer,  tha- 
exactly  in  proportion  as  we  have  banished  ma 
laria  from  the  soil  of  the  British  Islands,  so  ha 
dysentery  disappeared  as  an  endemic  disease. 

The  late  Dr.  Cutchliffe,  of  the  Bengal  annv 
noticed  that  in  some  very  malarious  districts  h 
the  Bengal  Presidency,  large  numbers  of  male 
were  impotent,  the  women  proving  fruitful  wit 
males  from  other  non-malarious  regions.  I 
such  localities,  also,  the  children  of  those  affee.e 
are  often  born,  not  only  with  the  external  signs  c 
the  malarial  cachexia,  but  also  with  the  viscen 
changes  and  pigmented  organs  described  above 


MALARIA. 

Since  we  cannot  yet  affirm  that  the  essential  | 
nature  of  the  malarial  poison  has  been  discovered, 
we  may  notice  two  other  theories  that  have  j 
oeen  advanced.  It  need  only  be  said  of  the 
few  who  maintain  that  the  grave  pathological 
changes  attributed  to  malaria  are  ail  explicable 
either  on  the  hypothesis  of  ‘ chill,’  according  to 
Dr.  Oldham.  or  ‘certain  electrical  conditions,’ 
according  to  Dr.  Munro,  that  they  have  a difficult 
thesis  to  support.  If  ‘chill’  will  account  for 
the  loss  of  10,000  men  at  Walcheren,  for  the 
frightful  disaster  of  a like  kind  at  Carthagena, 
for  the  terrible  visitation  of  paroxysmal  fevers  in 
the  Mauritius,  and  countless  examples  of  the  same 
kind,  and  for  the  yearly  loss  of  life  in  India  from 
fevers— the  country  in  which  Dr.  Oldham  serves, 
why,  seeing  that  mankind  are  exposed  to  ‘chill’ 
everywhere,  are  not  such  fevers  with  their  sequels 
universal  in  their  prevalence,  instead  of  being 
. unfilled  to  places  under  one  or  other  of  the  con- 
ditions described  in  this  article  ? Why,  above 
all,  in  a country  like  Great  Britain,  where  vast 
nultitudes  of  the  population  are  hourly  exposed 
‘.o  every  variety  of  atmospheric  change,  have 
paroxysmal  fevers,  once  endemic  there,  disap- 
peared, save  in  such  exceptional  places  as  are 
j still  under  one  or  other  of  the  conditions  de- 
scribed above?  No  satisfactory  answer  has  been 
given  to  this  question.  As  for  the  ‘ electrical 
mnditions  ’ of  the  other  hypothesis,  when  its 
author  can  explain  what  these  conditions  are, 
and  why  they  no  longer  exist  in  the  British 
Islands,  or  do  not  produce  their  usual  effects, 
we  shall  be  prepared  to  discuss  their  value  from 
a pathological  point  of  view. 

W.  C.  Maclean. 

MALARIAL.— Pertaining  to  or  connected 
withmalariajfor  example,  malarial fever , malarial 
region,  malarial  poison.  See  Malaria. 

MALFORMATIONS  (male,  amiss,  and 
formo,  I fashion). — Synon.:  Fr.  Malformations- 
Ger.  Nisshildungen. 

Definition.  — Deviations  from  the  normal 
standard,  in  the  size,  form,  number,  or  situation 
if  any  part  or  organ  of  the  body. 

Varieties  and  ^Etiology. — The  malforma- 
ions  of  the  human  body  may  be  conveniently 
■onsidered  under  two  distinct  heads,  namely — 
A)  Acquired  malformations,  more  commonly 
ailed  deformities ; and  (B)  Congenital  mal- 
ormations. 

A.  Acquired  Deformities. — Acquired  deformi- 
ies  may  be  the  result  of  disease,  affecting,  for 
istance,  the  spine,  which  may  become  curved,  or 
le  joints,  or  the  tendons.  Similarly,  the  bones 
my  tie  the  seat  of  deformity,  as  in  rickets,  mol- 
ties  ossium,  or  osteitis.  Certain  injuries  and 
■‘cidents,  such  as  burns,  scalds,  fractures,  and 
islocations,  lead  also  to  a great  number  and 
ir.ety  of  deformities.  Various  habits,  customs, 
id  occupations,  by  giving  rise  to  pressure  on 
rtain  parts  of  the  body,  by  altering  the  amount 
blood  circulating  through  them,  or  by  inter- 
ring with  their  due  innervation,  bring  about 
inges  in  the  relative  size  and  shape  of  the  bony 
1 soft  textures,  and  so  lead  to  malformations, 
is  thus  that  the  brow  is  flattened  by  certain 
bes  of  American  Indians ; the  waist  deformed, 
d the  corresponding  viscera  compressed  and 


MALFORMATIONS.  917 

dislocated,  by  means  of  the  tight-lacing  practised 
by  more  civilized  peoples ; and  the  feet  dis- 
torted by  many  nations,  especially  the  Chinese. 
Not  only  is  such  a striking  example  as  the  com- 
mon depression  of  the  lower  part  of  the  sternum 
in  shoemakers  a deformity,  but  the  huge  develop- 
ment of  certain  groups  of  muscles  at  the  expense 
of  others  induced  by  some  occupations,  must  bo 
looked  upon  in  the  same  light,  lor  these,  too,  aro 
deviations  from  the  normal  outline  of  the  hu- 
man figure.  Besides  these  cases,  which  may  bo 
termed  primary  malformations,  many  others  ol 
a secondary  character,  that  is,  dependent  on  somo 
antecedent  change  or  lesion,  are  frequently  seen. 
These  may  occur  in  organs  correlated  in  growth, 
as  the  absence  of  hair  on  the  face  and  pubes, 
and  the  increase  of  subcutaneous  fat,  if  from  any 
cause  the  testicles  waste,  or  if  they  are  removed 
before  puberty.  Absence  of,  or  disease  in,  any 
part  which  causes  the  disuse  of  other  parts,  also 
induces  a secondary  deformity,  as  the  atrophy 
and  degeneration  of  a group  of  muscles,  or  ol  a 
limb,  when  the  nervous  supply  is  in  any  way 
interrupted  either  at  the  centre  or  the  periphery. 
The  brief  reference  which  has  been  made  to  these 
acquired  malformations  will  suffice,  and  this  arti- 
cle will  be  devoted  to  a consideration  of  the  largo 
class  of  congenital  deformities,  and  of  these  to 
such  only  as  are  of  a general  character  Special 
malformations  of  organs  will  be  noticed  with  the 
diseases  of  those  organs,  such  as  the  brain,  heart, 
and  liver.  Deformities  of  the  chest,  which  are 
a subject  of  the  greatest  interest  to  the  practi- 
tioner, are  also  separately  discussed.  See  Defou- 
MITIES  OF  THE  CHEST. 

B.  Congenital  Malformations. — Since  the  ap- 
pearance of  the  classic  work  of  Bid.  Gcoffroy 
St.  Hilaire,  congenital  malformations  have  been 
grouped  and  classified,  and  their  causes  deter- 
mined with  such  approximate  accuracy,  that,  in 
place  of  the  superstitious  beliefs  and  incredible 
absurdities  which  formerly  prevailed,  a distinct 
branch  of  pathological  anatomy  has  been  estab- 
lished, namely,  that  of  Teratology.  Instead  of 
considering  a monstrosity  as  a presaee  of  somo 
misfortune,  a proof  of  divino  vengeance,  an  effect 
of  witchcraft,  the  result  of  intercourse  with  the 
lower  animals,  with  demons,  or  even  with  women 
during  menstruation  or  pregnancy,  we  now  trace 
it  either  to  a malformation  of  the  original  germ, 
or  to  somo  cause  interfering  with  its  development, 
and  inducing  either  an  excess  or  a deficiency  of 
parts  or  organs.  Starting  from  the  normal  stan- 
dard, we  find  varieties  in  development  of  all  kinds 
in  two  complete  series,  namely, an  ascending  series, 
from  a mere  supernumerary  digit  to  double  or 
even  triple  monsters  ; and  a descending  series, 
from  the  mere  default  of  a digit  or  organ,  or  the 
union  of  digits,  to  monsters  with  scarcely  a traco 
of  human  structure,  forming  an  almost  shape- 
less mass  Besides  these,  we  may  have  excess  or 
defect  in  the  size  and  development  of  various 
organs  and  parts,  or  of  the  body  cn  masse,  lead- 
ing to  the  formation  of  giants  and  of  dwarfs.  In 
other  cases,  development  and  size  are  normal, 
but  the  viscera  are  transposed,  and  this,  too, 
may  be  either  general  or  partial.  From  the 
moment  of  fecundation  the  ovum  is  exposed  to 
various  influences,  which  may  alter  its  normal 
development ; and  it  depends  on  whether  it  i ? 


MALFORMATIONS. 


P18 

subjected  to  these  /it  an  early  or  a late  stage,  as 
to  whether  complex  or  simple  anomalies  result. 

1.  Malformations  by  Excess. — Reference 
will  first  be  made  to  the  formation  of  mon- 
sters by  excess.  Two  ova  may  be  formed  in 
one  Graafian  vesicle,  for  double-yelked  eggs  are 
well  known  ; but  there  is  no  evidence  to  show 
that  these  would  form  a double  monster.  In- 
deed, Professor  Allen  Thomson  found  on  incu- 
bating a dozen  of  such  eggs,  that  not  one  pro- 
duced a double  embryo ; whilst  Wolff  observed 
two  completely  separate  foetuses  developed  upon 
a single  yelk.  The  arrival  of  two  impregnated 
ova  in  the  uterus  at  the  same  time  will  probably 
give  rise,  not  to  double  monsters,  but  to  twins, 
and  their  fusion  seems  almost  impossible.  We 
are  thus  led  to  the  opinion  that  monsters  by 
excess  depend  on  an  error  of  development  taking 
place  in  a single  germ ; and  this  idea  is  more 
readily  tenable  since  Allen  Thomson  has  shown 
that,  in  birds,  two  primitive  grooves  may  be 
formed  on  one  yelk  and  in  one  area  germina- 
tiva,  for  in  this  way  the  most  complete  cases  of 
double  monstrosity  can  be  explained.  In  con- 
firmation of  this  theory,  the  researches  of  Le- 
reboullet  may  be  quoted.  This  observer  has 
seen,  instead  of  the  single  budding  of  the  blas- 
toderma,  which  is  ordinarily  developed  into  the 
embryo  of  the  fish,  two  or  even  three  buds 
marked  off;  and  these,  during  the  process  of 
development  would  meet  at  some  point,  and  in 
this  manner  produce  parts  of  distinct  embryos 
where  they  are  separate,  whilst  a corresponding 
region  . of  a single  organism  only  would  be 
formed  at  the  point  of  junction.  According  to 
the  mode  and  extent  of  the  junction  of  the  blas- 
todermic buds,  the  monsters  would  vary ; and 
so  would  be  derived  all  the  different  varieties, 
from  a duplicity  of  the  face  or  head,  the  upper 
or  lower  extremities,  to  such  extreme  cases  as 
the  Hungarian  sisters,  and  the  Siamese  twins, 
who  were  joined  by  the  xiphoid  cartilage  only, 
and  the  twin  negresses  (Millie  and  Christine) 
who  are  united  by  their  lower  lumbar  vertebrae, 
sacrum  and  coccyx.  In  these  cases  all  the  viscera 
are  not  completely  isolated  and  double,  for  in 
the  Siamese  twins  three  peritoneal  prolongations 
were  found  in  the  connecting  band,  and  there 
was  a vascular  communication  between  their  two 
livers.  In  the  case  of  Millie  and  Christine, 
there  is  a single  anus  and  a single  vulva,  but 
two  hymens,  two  clitorides,  and  very  probably 
two  vaginae  and  uteri.  The  Hungarian  sisters, 
Helen  and  Judith,  had  but  one  vaginal  orifice, 
although  the  upper  part  of  that  organ  was 
divided  into  two,  and  the  two  intestines  met  in 
a single  anus,  placed  between  the  four  thighs. 
The  Bohemian  sisters  Rosalie  and  Josepha,  more 
recently  exhibited,  in  whom  there  is  a junction 
of  the  posterior  wall  of  the  pelvis,  present  ap- 
parently a single  urethra  and  a single  anus,  but 
a double  vagina.  Still  more  curious  are  the  mon- 
strosities which  are  only  united  by  their  vertex, 
as  the  cephalopages.  where  the  two  foetuses  are 
placed  end  to  end ; and  the  metopages,  where  they 
are  placed  parallel,  face  to  face,  and  sternum  to 
Sternum.  In  one  of  these  cases,  two  normal  brains, 
Completely  separated  by  their  membranes,  were 
found  on  dissection.  These  compound  monsters 
always  have  a single  chorion,  a single  amnion, 


and  a single  placenta,  though  the  umbilical cori 
may  be  double.  They  are  always  of  the  same  sex, 
and  their  capability  of  living  depends  on  tlieir 
having  an  almost  completely  double  organisation, 
or  on  one  individual  being  reduced  to  such  a 
state  of  atrophy  as  to  be  a mere  appendage  to 
the  other,  who  is  almost  normal  in  other  ro- 
spects.  The  condition  of  the  brain  and  of  the 
heart  are  the  most  important  factors  with  re- 
gard to  their  viability.  They  have  never  trans- 
mitted their  peculiarities  to  their  offspring. 

2.  Parasitic  Monsters. — The  parasitic  fa- 
mily of  monsters  are  characterised  by  a more  or 
less  rudimentary  individual  being  implanted  on, 
and  growing  at  the  expense  of,  another  who  is 
fully  formed.  This  parasite  may  either  exist  as  a 
supernumerary  head,  or  limbs,  or  may  be  almost 
complete ; it  may  grow  from  the  head,  maxillae, 
or  lower  part  of  the  trunk ; and  when  the  genitals 
exist,  it  is  found  to  be  of  the  6ame  sex  as  the 
chief  individual.  Some  of  these  cases  attain  to 
adult  life,  and  if  they  have  any  children,  these 
are  well-formed.  From  such  instances  the  transi- 
tion is  easy  to  those  monsters  in  which  the  para- 
site is  either  included  under  the  skin,  or  even, 
during  the  approximation  of  the  visceral  laminae, 
becomes  implanted  inside  the  abdominal  cavity, 
as  is  well  seen  in  a specimen  in  the  Hunterian 
Museum  of  the  College  of  Surgeons.  In  these  an 
arm,  a leg,  or  a hand  may  be  found;  fragments 
of  bone  are  common  ; and  even  nervous,  muscu- 
lar, or  glandular  structures  may  occur.  A fibrous 
capsule  is  formed  around  these  vestiges,  and  if 
they  are  sufficiently  nourished  from  without, 
they  may  live  a kind  of  vegetative  life ; but  more 
frequently  they  degenerate  or  decompose  by 
contact  with  the  air,  and  so  causo  the  death 
of  their  host. 

3.  Malformations  by  Deficiency. — In  the 

case  of  monstrosities  by  deficiency,  we  again 
have  every  grade,  from  those  almost  without 
human  form,  to  the  simplest  malformation  due 
to  a non-development  or  defective  union  of  some 
parts  of  the  embryo.  The  acardiac  monsters 
are  always  products  of  a twin  conception;  and 
the  amount  of  their  development  depends  on 
the  period  of  its  arrest,  and  on  the  degreo  of 
anastomosis  between  their  umbilical  vessels  and 
those  of  the  normal  foetus.  Slighter  malforma- 
tions are  caused  by  physical  or  mechanical  influ- 
ences acting  on  a single  individual,  or  by  some 
pathological  lesion.  Panum  and  Dareste,  by 
experiments  on  this  subject,  have  shown  that 
different  degrees  of  heat,  and  mechanical  shocks 
always  lead  to  some  malformation,  and  that  the 
same  agency  always  produces  the  same  malfor- 
mation. Lesions  of  the  amnion  and  placenta, 
and  twisting  of  the  funis  around  the  foetus,  are 
fertile  causes  of  deformity.  On  dissection  a 
large  number  of  deviations  are  found  to  bo 
dependent  on  inflammatory  processes,  causing 
morbid  adhesions  and  serous  effusions.  These 
interfere  with  nutrition,  and  so  lead  to  an  arrest 
of  development.  Again,  as  in  after-life  so  in 
the  embryo,  a primary  lesion  may  induce  a 
secondary  one,  as  when  club-feet  are  caused  bv 
a defect  in  the  nervous  centres.  In  the  produc- 
tion of  malformations,  causes  of  a general  nature 
affecting  the  parents  must  not  be  left  out  o! 
consideration;  for  syphilis,  chronic  nlcohdism 


MALFORMATIONS. 

and  hereditary  influences  are  undoubtedly  very 
potent  factors.  The  writer  attaches  but  very 
little  importance  to  Demeaux’s  suggestion — un- 
supported as  it  is  by  any  valid  evidence — that 
copulation  in  a state  of  drunkenness  may  en- 
gender malformations ; but  he  is  inclined  to 
give  more  credit  to  maternal  impressions  during 
pregnancy  as  an  agent  in  some  of  these  cases. 
Many  examples  which  are  ascribed  to  such 
influences  are  undoubtedly  due  to  other  causes  ; 
but  the  numerous  well-attested  instances  in 
physiological  treatises,  which  prove  the  effects 
of  "both  prolonged,  and  sudden,  but  intense, 
emotion  on  the  process  of  secretion,  must  make 
one  pause  before  dogmatically  asserting  that  the 
nutrition  and  development  of  the  embryo  cannot 
be  interfered  with  in  a similar  manner. 

4.  Transpositions. — Transposition  may  af- 
fect the  entire  organism  in  some  of  the  lower 
classes  of  animals,  as  in  certain  fishes  and  mol- 
luscs, but  in  man  this  is  limited  to  the  tho- 
racic and  abdominal  viscera.  The  organs  nor- 
mally situated  on  the  right  side  are  placed 
on  the  left,  and  vice  versa;  whilst  those  which 
occupy  the  median  plane  are  so  rotated  that 
the  parts  which  should  be  found  on  one  side 
of  the  mesial  line  are  displaced  to  the  other. 
Such  transposition  varies  in  degree  in  different 
cases,  sometimes  affecting  all  the  viscera,  at 
ether  times  merely  one  or  two  organs.  The 
■more  general  cases  are  stated  by  Dareste  to  be 
lue  to  the  embryo-heart  taking  a turn  in  its 
sarly  development  to  the  left  instead  of  to  the 
•ight,  which  is  its  normal  change.  lie  has  arti- 
icially  produced  similar  deformities  by  incuba- 
ingeggs  placed  obliquely,  so  as  to  subject  their 
xtremities  to  unequal  degrees  cf  heat,  and 
ause  an  excess  of  development  on  one  side, 
lischoff,  however,  attributes  them  to  an  altera- 
ion  in  the  normal  position  of  the  umbilical 
esicle  and  allantois,  so  that  the  former  turns 
e the  left  and  the  latter  to  the  right,  and 
uggests  that  this  might  possibly  influence  the 
te  of  the  internal  organs. 

A variety  of  malformations,  such  as  hare-lip, 
.eft palate,  imperforate  anus  or  vagina,  club-foot, 
id  webbed  fingers,  are  subjects  which  belong 
i surgery,  and  do  not  require  further  notice  here. 
Tbbatment. — Many  malformations,  especially 
ich  as  belong  to  the  ciass  of  acquired  deformi- 
bs,  admit  of  benefit  by  treatment,  but  as  such 
Batment  is  of  a purely  surgical  kind,  it  does 
j't  require  to  be  discussed  in  the  present  work. 

John  Curnow. 

MALIGNANT  CHOLERA.  A synonym 
’ Asiatic  cholera.  See  Cholera. 

MALIGNANT  DISEASES.— This  term  is 
plied  to  certain  diseases  or  types  of  a disease 
ich  tend  towards  a fatal  issue.  First,  it  is  ap- 
ed to  such  diseases  as  cancer,  which  essentially 
dto  the  destruction  of  life  ; and  secondly,  to 
i tain  varieties  of  fevers  and  other  acute  affec- 
’ as,  such  as  typhoid  fever,  scarlet  fever,  small- 
1 :,  and  cholera,  which  present  peculiarly  grave 
v aggravated  symptoms,  and  generally  end  in 
t th.  See  Cancer;  Smallpox;  &c. 

IALIGNANT  PUSTULE.  See  Pustcle, 

1 UQNANT. 


.MALINGERING.  91i> 

MALINGERING.  — Malingering,  in  the 
sense  of  an  elaborate  and  carefully-planned 
attempt  to  deceive  the  medical  man,  is  not  very 
frequently  met  with  in  private  practice  ; and 
although  the  simulation  of  various  morbid  con- 
ditions is  a common  complication  of  hysteria,  the 
consideration  of  this  branch  of  the  subject  w:L 
find  its  more  natural  place  under  the  heading  of 
Feigned  Diseases.  The  army  or  prison  surgeon 
however,  must  be  on  his  guard  against  imposture 
and  must  exercise  all  his  diagnostic  skill.  For  his 
guidance  many  elaborate  works  have  been  written 
and  much  information  collected  regarding  th. 
nefarious  way  in  which  soldiers  have  often  oiu 
witted  their  medical  attendants.  In  our  ou  • 
country,  under  the  present  conditions  of  voli  i 
tary  service,  the  men  seldom  attempt  to  do  mot\ 
than  plead  the  excuse  of  some  slight  and  tem- 
porary ailment  to  obtain  remission  from  guard, 
or  drills.  Headaches,  rheumatism,  colic,  diar- 
rhoea, and  other  affections  of  a more  or  less 
‘subjective’  order,  are  naturally  difficult  of  de- 
tection ; but  the  surgeon  learns  gradually  by 
experience,  and  seldom  fails  to  acquire  a pret  t \ 
shrewd  knowledgeof  the  habitual  schemer’s  some 
what  narrow  range  of  imposture ; and  hence  it  is 
that,  with  all  its  faults,  the  regimental  system 
of  military  practice  has  always  worked  well, 
and  enabled  a sharp  look-out  to  be  kept  on  tht 
troublesome  malingerer,  whose  ingenuity  is  so 
unprofitably  expended  on  attempts  to  shirk  his 
own  duties  at  the  expense  of  his  more  indus- 
trious comrades.  Occasionally,  however,  when 
the  soldier  urgently  wishes  his  discharge,  he  is 
induced  to  lay  hisplans  with  greater  decision,  ami 
to  resort  either  to  mutilation  or  to  the  imitation 
of  chronic  disease,  and  in  Continental  armies  in- 
stances of  this  sort  are  comparatively  common. 
To  avoid  the  grievous  burden  of  conscription,  aD 
infinite  variety  of  artifices  have  been  employed 
with  greater  or  less  success,  and  the  ample  lite- 
rature of  the  subject  bears  amusing  record  to  the 
ingenuity  with  which  these  inventions  have  been 
carried  out.  In  dealing,  however,  with  the  minor 
degrees  of  malingering  met  with  at  home,  we  must 
be  very  careful  not  to  be  over-suspicious,  and  not 
to  do  injustice  to  a real  sufferer  whose  symptoms 
seem  somewhat  vague  and  incomprehensible. 
Numerous  eases  are  on  record  in  which  the 
mystery  surrounding  a fixed  and  obstinate  pain 
in  the  back  has  been  cleared  up  by  the  rupture 
of  an  abdominal  aneurism ; and  Dr.  Spry  records, 
in  the  nineteenth  volume  of  the  Pathological  So- 
ciety's Transactions,  a most  instructive  case  in 
point,  A typically  healthy  trooper  of  the  Second 
Life  Guards  presented  himself  at  hospital,  com- 
plaining of  very  uncomfortable  sensations  in  the 
oesophagus  and  stomach,  following  the  swallowing 
of  a bone.  Some  suspicion  of  malingering  was 
entertained  at  the  time  ; but  Dr.  Spry,  impressed 
by  a certain  anxiety  of  aspect,  retained  the  man 
under  treatment,  and  three  days  later  death  sud- 
denly ensued,  and  the  post-mortem  examination 
revealed  perforation  of  the  aorta,  caused  by  a 
small  spiculum  of  beef-bone.  Facts  like  this  are 
abundantly  suggestive  of  caution,  and  of  the 
happy  medium  between  excessive  sharpness  and 
undue  credulity,  which  a wide  and  intelligently 
used  experience  can  alone  confer.  Far  better  ia 
it  for  us  to  be  deceived  twenty  times,  than  foi 


020  MALINGERING-, 

unjust  suspicion  to  be  directed  to  the  victim  of 
some  painful  and  depressing  disease,  -whose  only 
fault  may  consist  in  his  inability  to  supply  a 
sufficiently  clear  and  convincing  scheme  of  suffer- 
ings which  may  be  only  too  real. 

Robert  Farqtjharson. 

MALPOSITION  OF  ORGANS.  See 

Organs,  Displacement  of. 

MALTA. — Warm,  rather  moist,  and  very 
variable  winter  climate.  See  Climate,  Treat- 
ment of  Disease  by. 

MAMMARY  GLAND,  Diseases  of.  See 

Breast,  Diseases  of. 

MANIA  (/xavla,  fury,  madness). — Synon.  : 
Fr . Manie  suraigue  ; Dclire  aic/ue  ; Fiuretor  ; Ger. 
Tobsucht ; Wuth. 

Under  the  term  mania,  very  distinet  disorders 
or  degrees  of  disorder  have  been  described, 
which  we  shall  speak  of  as  Acute  Delirious 
Mania  ; Acute  Mania ; and  Mania. 

I.  Acute  Delirious  Mania. — Acute  delirious 
mania,  or  maniacal  delirium — whichever  we  pre- 
fer to  call  it — is  something  quite  distinct  from 
that  ordinarily  known  as  acute  mania.  The 
symptoms  are  much  graver,  the  course  is  briefer 
and  more  defined,  and  the  treatment  of  the 
one  would  be  quite  inappropriate  to  the  other. 
An  outburst  of  delirious  mania  may  take  place 
after  very  few  and  very  short  premonitory 
symptoms.  Quite  suddenly,  after  a few  days 
or  even  hours,  the  patient  will  display  the  most 
violent  excitement,  whieh  may  as  suddenly 
subside,  or  rnn  a well-marked  course  of  a few 
weeks  ; and  if  it  does  not  terminate  fatally  will 
gradually  'decline,  recovery  usually  taking  place. 
Such  an  attack  may  have  its  origin  in  some 
sudden  mental  shock,  as  the  death  ©f  a friend, 
a violent  quarrel,  a disappointment  or  -suddenly 
announced  misfortune ; or  it  may  arise  in  the 
course  or  decline  of  an  acute  disease,  as  pneu- 
monia or  measles.  It  may  also  come  on  during 
rheumatism  ; or  after  great  fatigue,  an  epileptic 
seizure,  or  child-birth. 

We  cannot  tell  at  first  whether  theattack  will  j 
be  transient  or  prolonged.  We  may  try  to  cut 
it  short  by  a brisk  purgative,  and  by  such 
medicines  as  chloral  and  bromide  of  potassium, 
and  these  not  unfrequontly  answer  the  purpose. 
Sleep  i s procured,  and  perfect  recovery  may  take 
place  in  a few  days.  There  are  patients  whose 
organisation  is  so  unstable  that  it  is  thrown  off 
its  balance  by  a eause  perhaps  trifling,  but  which 
produces  a tremendous  nerve-discharge,  a com- 
plete disturbance  of  the  whole  mental  functions. 
But  so  transient  may  this  be,  that  one  sleep 
restores  the  normal  equilibrium, and  the  patient 
is  cured.  This  condition  in  females  is  often 
called  hysterical — hysterical  mania.  There  is  no 
special  connection  between  it  and  the  uterine 
functions,  and  it  is  better  to  retain  the  name 
hysterical  mania  for  a variety  to  which  it  may 
be  more  appropriately  given. 

The  delirium,  however,  does  not  always  ter- 
minate quickly.  If  sleep  becomes  less  and  less, 
the  mind  more  and  more  confused,  and  quiet 
and  lucid  intervals  rarer  and  rarer,  we  may  be  > 
sure  that  the  attack  will  be  serious  and  pro- 
longed, and  that  careful  and  efficient  nursing  | 


MANIA. 

for  some  time  will  be  necessary.  Where  a quiet 
and  airy  room  can  be  provided,  and  where  a 
patient’s  means  are  sufficient  to  allow  him  an 
adequate  staff  of  attendants,  an  asylum  is  not 
indispensable.  He  will  not  require  to  take 
exercise  in  a garden  ; he  will  not  be  dangerous, 
as  some  are,  to  himself  or  others,  though  he 
may  be  violent  and  excited.  He  may  be  noisy, 
and  therefore  may  not  be  able  to  remain  unless 
the  house  is  detached.  The  room  should  be 
lofty  and  cool,  the  windows  protected  and 
darkened;  all  furniture  must  be  removed,  aud 
the  bed  made  on  mattresses  placed  on  the  floor, 
for  he  will  not  lie  on  a bedstead,  and  attempts 
to  keep  him  there  will  end  in  bruises  or  more 
6erious  injury.  Clothes  will  be  torn  off ; but  if 
the  weather  is  very  hot,  as  is  so  often  the  case 
during  these  attacks,  this  will  be  of  little  con- 
sequence. If  it  is  cold,  a strong  suit  laced  up 
the  back  may  be  put  on,  and  underneath  it 
the  requisite  body-clothes ; or  a blanket  may  be 
placed  round  the  patient,  and  fastened  up  the 
back. 

These  patients  are  in  incessant  motion,  singing, 
shouting,  and  talking  in  a string  of  incoherent 
utterances,  often  repeating  the  same  sentence 
again  and  again,  or  a snatch  of  a song  or  text, 
or  a rhyme  of  their  own  composition.  As  a rale 
they  are  not  violent,  and  do  not  attack  those 
about  them,  though  they  may  resist  that  which 
is  done  for  them.  They  may  be  hilarious  and 
full  of  glee  and  mischief,  which  is  a good  sign ; 
or  terror  - stricken,  with  visions  of  horrible 
objects,  which  is  unfavourable.  They  are  wet 
and  dirty ; and  the  urine  will  be  high-coloured, 
and  often  retained  for  a long  period.  We  shall 
derive  valuable  information  if  we  are  able  t" 
take  the  temperature,  but  often  that  is  a diffi- 
cult task.  A high  temperature  is  a bad  sign: 
and  so  is  a rapid  pulse,  if  it  continues  persis- 
tently' when  the  patient  has  not  been  using 
violent  exertion  for  some  time.  The  tongue  will 
often  become  thickly  coated,  dry,  and  brown.  If 
it  does  not,  but  remains  moist  and  comparatively 
clean,  this  is  of  good  omen. 

Prognosis. — The  prognosis  in  these  cases  is 
upon  the  whole  favourable.  The  terminations  are 
almost  always  either  recovery  or  death.  The 
patients  are  mostly  young  persons,  who  recover 
unless  weakened  by  previous  attacks,  other 
disease,  or  child-birth.  Many  of  the  fatal  cases, 
in  the  writer's  experience,  have  been  com- 
plicated by  tuberculosis. 

Treatment. — Sleep  in  such  attacks  is  gener- 
ally absent,  sometimes  for  many  days.  M omen 
can  last  longer  without  sleep  than  men,  and 
die  much  less  frequently  in  acute  delirium.  If 
sleep  does  not  come  the  patient  dies,  and  our 
great  effort  must  be  to  promote  sleep  by  various 
methods.  The  first  question  will  be  whether  we 
are  to  give  drugs  to  accomplish  this ; and  it 
so,  what  drugs  ? Opium  must  not  be  given ; it 
will  not  procure  sleep,  whether  given  by  the 
mouth  or  subcutaneously'.  It  may  produce  a 
slight  narcotism  for  half-an-hour  or  so,  and  if 
we  increase  the  dose,  will  cause  narcotic  poison- 
ing and  death  ; but  in  the  height  of  the  attack 
it  will  not  procure  sleep.  Chloral  we  may  try 
in  combination  with  bromide  of  potassium,  giving 
balf-drachm  doses  of  each  and  watching  tbi 


MANIA. 


92  i 


effect.  In  all  bat  the  most  acute  cases,  sleep 
of  longer  or  shorter  duration  will  be  caused  by 
these  drugs  ; and  although  it  may  be  short,  it 
may  bo  sufficient  to  save  the  patient’s  life,  and 
enable  him  to  battle  successfully  with  the  dis- 
order. In  the  writer’s  experience,  many  more 
of  these  acutely  delirious  patients  died  before 
the  introduction  of  chloral  than  have  done  since. 
Yet  it  must  not  be  given  in  enormous  or 
repeated  doses,  and  a considerable  interval 
should  elapse  between  them.  It  may  be  ad- 
ministered easily  in  stout  or  ale,  and  often  in 
wine. 

Next  to  sleep,  the  most  important  matter  is 
food.  To  enable  the  sufferer  to  withstand  the 
exhaustion,  which  is  the  cause  of  death  when 
a case  ends  fatally,  he  must  be  fed  frequently 
and  liberally.  These  patients  rarely  refuse  food, 
but  require  careful  coaxing  and  feeding ; and  a 
skilful  attendant  will  give  something  every  two 
or  three  hours — minced  meat  and  vegetables, 
or  bread  and  milk,  beef-tea,  eggs,  and  the  like. 
Brandy  often  produces  great  excitement  at  the 
onset  and  height  of  an  attack,  and  stout  or  ale 
s more  suitable,  and  more  likely  to  bring  about 
sleep.  We  may  give  also  plenty  of  lemonade, 
oarley-water,  and  such  drinks,  if  there  be  great 
leat  and  thirst. 

Although  this  unconscious  or  semi-conscious 
leliriuni  may  continue  for  many  days,  yet  in 
ihnost  every  case  the  violence  and  excitement 
re  paroxysmal,  with  intervals  of  comparative 
■aim,  even  if  there  be  no  sleep.  Judicious 
.ttendants  will  avail  themselves  of  these  quiet 
Intervals  to  administer  food,  and  to  keep  the 
atient  in  the  recumbent  posture,  thus  ensuring 
est,  instead  of  letting  him  be  continually  on 
is  legs  wandering  about  the  room,  and  so  ex- 
austing  his  strength.  And  when  held  down  in 
his  way,  with  cold  cloths  applied  to  the  head, 
r his  face  fanned  by  the  nurse,  he  is  not 
n'ikely  to  drop  off  to  sleep. 

Can  sleep  be  procured  by  other  means  ? The 
'rench  have  advocated  prolonged  hot  baths, 
ut  they  are  attended  with  considerable  danger, 
/e  may  try  a bath  of  half-an-hour  at  GO1  or 
1°,  allowing  it  to  become  cooler,  but  it  is  of 
) use  attempting  this  unless  the  patient  sub- 
mits to  it  without  a desperate  struggle.  Cold 
> the  head  may  be  applied,  because  it  is  sooth- 
|.g  and  grateful  to  the  sufferer,  though  it  is  a 
testion  whether  the  circulation  in  the  brain  is 
uch  affected  thereby. 

The  bowels  maybe  kept  open  by  a few  grains 
calomel  administered  in  the  food,  or  half- 
grain  of  podophyllin.  Active  purgation  is 
admissible  except  at  the  very  outset,  and 
emata  cannot  easily  be  given  in  the  violent 
ages.  It  is  somewhat  the  fashion  to  apply 

l.sters  to  the  nape  or  calves.  This  is  most 
idvisable,  for  such  parts  may  become  very 
re.  owing  to  the  restlessness  of  the  patient, 
d thus  deprive  him  of  sleep.  Neither  is  it 
itessary  to  cut  all  the  hair  off,  which  in  the 
je  of  a lady  may  be  a very  grievous  matter, 
very  long,  it  may  he  shortened  without  being 
close  to  the  head. 

II.  Acute  Mania. — Quite  different  from  the 


Conscious  raving  of  maniacal  delirium  is  the 
1 scions  but  violent  excitement  to  which  we 


give  the  name  of  acute  mania.  The  former  is  a 
disorder  dangerous  to  life,  running  a rapid  course 
to  death  or  amendment  in  a week  or  two.  The 
latter  may  goon  for  weeks  or  months  with  little 
danger  to  life,  but  with  excitement  so  trouble 
some  that  the  sufferers  require  the  restraint  and 
discipline  of  an  asylum.  Though  most  insane, 
full  of  delusions  and  insane  habits  of  every  kind, 
they  know  what  they  are  about,  and  are  all  the 
more  mischievous  in  consequence.  They  can 
take  every  advantage  of  an  opportunity,  and 
know  how  to  exasperate  those  about  them.  They 
generally  eat  well,  and  sleep  ii, differently,  but. 
sufficiently  to  support  life;  and  their  bodily 
health  often  remains  wonderfully  good  consider- 
ing what  they  go  through.  They  will  destroy 
clothes,  windows,  bedding,  and  deny  or  justify 
all  they  have  done.  The  termination  is  n<t  usu- 
ally fatal,  unless  the  health  gives  way  through 
some  other  disease.  The  patients  generally  re- 
cover gradually,  or  sink  into  chronic  mania  or 
dementia. 

Prognosis. — The  prognosis  in  cases  of  acute 
mania  will  depend  upon  circumstances.  (1)  The 
number  and  duration  of  the  attacks  are  important. 
In  a first  attack  the  prognosis  is  favourable.  If 
recent,  we  may  have  hopes,  even  if  there  have 
been  preceding  attacks  of  a like  character. 
(2)  If  the  patient  is  not  of  advanced  age  or  of 
broken  health,  the  prognosis  is  favourable.  (3)  If 
the  mania  consists  of  violent,  turbulent  conduct 
rather  than  of  fixed  delusions,  as  is  frequently 
the  ease,  there  is  more  hope.  If  the  patient 
hears  voices,  the  prognosis  is  bad.  If  there 
are  delusions  which  impel  him  to  refuse  food, 
and  lie  does  so  persistently  and  violently,  it  may 
be  difficult  to  give  sufficient  nourishment,  and  he 
may  sink  from  exhaustion,  or  become  a chronic 
maniac. 

Treatment.  — Patients  sufferin';  from  this 
form  of  mania  do  not  require,  like  the  last,  to 
be  kept  in  one  room;  on  the  c ntrary,  they 
should  take  plenty  of  exercise  in  the  open  nir. 
This  will  promote  sleep  more  than  drugs,  though 
we  may  give  an  occasional  dose  of  chloral,  or 
bromide  of  potassium,  or  the  latter  with  chloral 
or  with  Indian  hemp.  Such  medicines,  however, 
should  be  given  only  to  procure  sli-ep,  not  to 
allay  excitement.  Plenty  of  food  is  required,  for 
the  waste  is  great. 

Such  patients  are  not  to  be  cured  or  even 
kept  without  discipline  and  moral  treatment; 
and  great  tact,  firmness,  and  patience  are  re- 
quired for  their  management.  They  may  be 
very  dangerous  and  spiteful,  will  know  how  to 
provoke  attendants,  and  how  to  take  them  un- 
awares if  off  their  guard.  Such  mural  treat- 
ment will  be  far  more  efficacious  than  drugs, 
but  it  can  only  be  carried  out  in  an  asylum. 
Patients  in  this  condition,  if  kept  in  private 
houses,  must  be  rendered  quiet  by  drugs  ; but 
there  is  great  fear  lest  bv  this  the  disease,  in- 
tend of  being  cured,  may  be  converted  into  a 
chronic  and  incurable  mania. 

III.  Mania. — A great  variety  of  cases  are 
grouped  under  this  name,  arising  from  various 
causes,  but  alike  in  the  fact  that  they  are  marked 
by  excitement  rather  than  depression,  by  exalla- 
tion  or  wrath,  but  not  by  gloom.  Excitement, 
and  aoisy  and  irrational  conduct,  characterise 


m MANIA. 

gome,  but  most  patients  present  delusions  co- 
inciding ■with  their  temper  and  bodily  condition. 
Almost  always  this  form  of  insanity  is  marked 
by  delusions,  if  it  lasts  long  enough  ; but  some- 
times a short  burst  of  excitement — a transitory 
mania — may  pass  away  without  the  stage  of 
delusion  being  reached. 

The  diagnosis  of  an  ordinary  case  of  mania  is 
not  difficult.  The  prognosis  must  depend  on  the 
cause ; the  age  of  the  patient ; the  character  of 
the  delusions,  if  there  be  any ; the  occurrence 
or  non-occurrence  of  previous  attacks  ; and  their 
history.  Attacks  of  mania  are  frequently  recur- 
rent, and  may  recur  again  and  again  through  a 
long  life ; recovery  may  take  place  on  each  occa- 
sion, or  the  disorder  may  at  last  turn  into  chronic 
mania  or  dementia.  The  period  of  excitement 
in  many  cases  is  followed  by  one  of  depression, 
and  these  may  alternate  with  great  regularity 
for  twenty  or  thirty  years  ; and  even  when  the 
patient  is  sunk  into  hopeless  dementia,  the  period 
of  excitement  may  occur  as  regularly  as  before 
the  mental  powers  had  given  way. 

Treatment.— Of  the  treatment  of  these  cases 
little  can  be  said.  The  majority  will  need  the 
care  of  an  asylum,  at  any  rate  during  the  excited 
stage.  The  intervening  or  rational  period  will 
often  be  prolonged  by  removal  from  the  asylum, 
and  when  this  is  the  case  there  is  frequently 
less  reluctance  to  return  to  it  when  the  neces- 
sity arises,  and  instances  are  not  uncommon  of 
patients  themselves  seeking  its  shelter. 

G.  F.  Blandford. 

MANIPULATION  (mantis,  the  hand). — A 
mode  of  investigating  and  also  of  treating  diseases 
by  the  use  of  the  hands.  See  Physical  Examina- 
tion ; Friction  ; and  Shampooing. 

MABA8MTS  (papaivoi,  I grow  lean). — A 
synonym  for  general  wasting.  See  Atrophy, 
General. 

MARIENBAD,  in  Bohemia. — Alkaline 
sulphated  waters.  See  Mineral  Waters. 

MARSH  FEVER. — A synonym  for  inter- 
mittent fever.  See  Intermittent  Fever. 

MASKED.  A synonym  for  larvated.  See 
Larvated. 

MASSAGE  (French). — A synonym  for  sham- 
pooing. See  Shampooing. 

the  breast,  and 

&K yos,  or  obvrrj,  pain). — Pain  in  the  mammary 
gland.  See  Breast,  Diseases  of. 

MASTICATION,  Disorders  of. — In  the 

mouth  the  food  is  submitted  to  the  action  of 
the  jaws,  carrying  the  teeth;  is  moved  about 
by  the  tongue:  and  is  kept  between  the  teeth  by 
the  lips,  cheeks,  and  tongue.  The  muscles  which 
perform  the  complicated  and  nicely-adjusted 
movements  of  mastication,  are  supplied  by  the 
trifacial,  facial,  and  hypoglossal  nerves — that  is, 
the  v.,  vii.,  and  xii.  pairs  of  cranial  nerves  re- 
spectively. These  movements  are  essentially 
voluntary,  the  stimuli  which  determine  them  being 
central  in  origin,  and  passing  to  the  muscles  by 
the  above-mentioned  nerves ; but  at  the  same 
time,  the  mere  contact  of  the  buccal  mucous 


MASTICATION. 

membrane  with  food,  aids  in  determining'  the 
movements,  its  impressions  travelling  to  the  train 
by  the  fifth  pair  of  nerves. 

Mastication  is  liable  to  be  disordered  from 
various  causes. 

1.  Muscular  Para! ys'is. — Imperfect  perform 
anee  of  mastication  is  frequently  the  result  of 
cerebral  lesions,  such  as  haemorrhage  or  tumours. 
Dependent  on  the  seat  and  extent  of  these  will 
he  the  extent  of  the  paralysis,  which  may  vary 
from  an  impaired  movement  of  one  cheek,  thus 
permitting  the  food  to  collect  between  it  and  th- 
gum,  to  an  absolute  loss  of  power  of  swallow- 
ing. Sometimes  the  purely  reflex  portion  of 
this  act  may  be  retained,  mastication  being  im- 
possible ; or  it  may  be  that  the  tongue  alone  is 
affected,  from  injury  to  the  nucleus  of  origin  of 
the  hypoglossal  nerve.  In  those  cases  whore 
the  trifacial  alone  is  affected,  mastication  is 
rendered  difficult,  by  the  absence  of  the  con- 
tact-sensations which  aid  in  determining  norma, 
movements. 

There  are  several  special  forms  of  paralysis 
in  which  these  movements  are  affected,  either 
alone  or  in  common  with  other  muscles  of  the 
body. 

(a)  Labio-glosxo-laryngcal  paralysis,  due  to 
certain  morbid  conditions  of  the  medulla,  affect- 
ing the  glosso-pharyngeal,  hypoglossal,  and  spi- 
nal accessory  nerves,  is  especially  characterised 
by  the  impairment  of  mastication  and  deglutition, 
which  progresses  from  a mere  escape  of  saliva, 
due  to  paralysis  of  the  orbicularis  oris,  to  ab- 
solute inability  to  perform  either  act.  Of  the 
masticatory  muscles,  it  is  those  of  the  tongue 
and  cheek  which  are  mainly  affected,  the  eleva- 
tors and  depressors  of  the  jaw  usually  escaping. 
The  patient  thrusts  his  food  to  the  very  back  of 
the  mouth  ; and  even  then,  when  in  the  grasp  of 
the  constrictors  of  the  pharynx,  it  is  swallowed 
with  difficulty ; often  being  ejected  through  the 
nose,  or  getting  into  the  trachea  through  the 
imperfectly  closed  glottis.  As  the  disease  pro- 
gresses to  its  invariably  fatal  end,  the  palsy 
increases  in  completeness. 

( b ) The  loss  of  power  in  the  muscles  of  raus 
tication  and  deglutition,  so  frequently  associated 
with  diphtheria,  is  doubtless  dependent  on  some 
central  changes,  since  it  is  only  one  of  the  many 
forms  of  paralysis  that  may  complicate  this  dis- 
ease. At  the  same  time  it  has  been  in  part 
ascribed  to  degeneration  of  the  muscular  tissue 

2.  Muscular  Spasm. — Trismus,  or  tonic  spasm 
of  the  muscles  of  mastication  supplied  by  tlx 
motor  branch  of  the  fifth  nerve,  is  rarely  nni 
lateral.  The  jaws  are  usually  completely  locked 
and  incapable  of  separation,  thus  renderin. 
mastication  impossible.  The  trismus  may  be  ; 
part  of  a general  condition  of  tetanus,  or  n.n 
be  the  sole  indication  of  spasm ; and  in  the  latte 
case  is  usually  reflex  in  origin,  being  determine 
by  such  causes  as  dental  irritation,  or  facia 
neuralgia,  or,  more  rarely,  by  distant  wounds  o 
intestinal  worms.  | 

Irregular  clonic  spasms  of  the  muscles  of  tn 
jaws,  such  as  are  frequently  seen  in  epilepsy  an 
hysteria,  and  are  evidenced  by  chattering  an 
grinding  of  the  teeth,  will  offer  some  difficult 
to  the  proper  performance  of  mastication. 

Spasm,  whether  tonic  or  clonic,  when  limite 


MASTICATION. 

) the  facial  muscles  supplied  by  the  seventh 
air,  -will  interfere  but  slightly  avith  mastication, 
y preventing  the  action  of  the  lips  and  cheeks, 
ie  food  will  not  bo  so  easily  kept  betwoen  the 
-eth,  and  the  saliva  will  dribble  from  the  un- 
.osed  mouth.  Nor  are  the  impulsive  spasmodic 
tovements  of  the  tongue,  as  seen  in  chorea,  im- 
ortant  as  impairing  the  proper  mastication  and 
vallowing  of  the  food. 

3.  Affections  of  the  Temporo-maxillary  Articu- 
tion. — Chronic  arthritis  may  lead  to  such  se- 
ous  disorganisation  of  the  joint  as  to  impair  its 
ovemonts,  anchylosis  occasionally  occurring. 

4.  Tumours. — Enlargements  of  the  salivary  or 
mphatic  glands,  tumours  of  the  thyroid  body, 
)ulis,  and  new  growths  of  the  tongue,  may 
terfere  with  mastication. 

. 5.  Morbid  Conditions  of  the  Mouth. — Inflam- 
ation  of  the  month  or  tongue,  and  disorders  of 
e teeth,  render  mastication  difficult. 

The  several  subjects  here  referred  to  are 
eated  of  under  separate  headings. 

Effects. — Portions  of  food  imperfectly  mas- 
jated  may  produce  suffocation,  by  blocking  up 
e entrance  of  the  glottis,  or  lodging  in  the 
llet.  Imperfectly  masticated  food,  when  swal- 
sved,  is  a well-recognised  cause  of  dyspepsia 
id  its  many  inconveniences. 

Teeathent. — The  treatment  of  disorders  of 
.istication  naturally  consists  in  the  removal  of 
eir  cause,  when  possible.  The  reader  is  referred 
the  articles  in  which  the  several  conditions 
: fully  discussed.  W.  II.  Allchin. 

MASTURBATION  ( manus , the  hand,  and 
. ■pro,  I ravish).— Synon.  : Fr.  Masturbation ; 

1 r.  Selbstbejlcckung. 

Definition. — The  production  of  the  sexual 
i;asm  by  unnatural  means. 

.Etiology. — This  practice  is  found  to  occur 
1 ier  a variety  of  circumstances.  First,  in  very 
; mg  children,  local  irritation,  situated  beneath 
ii  prepuce  in  males,  or  within  the  vulva  in 
Hales,  leads  to  manipulation  of  the  parts,  and 
1 consequent  pleasurable  excitement,  which  is 
ustantly  renewed,  with  an  entire  unconscious- 
ns  of  the  meaning  of  the  practice.  As  an 

i lance,  not  long  since  the  writer  was  consulted 
1 a mother  about  the  extreme  delicacy  of  her 
1;,  then  little  over  four  years  of  age.  No  tan- 
ple  disease  being  evident,  the  little  fellow  was 
f pped,  with  the  view  to  a more  complete  ex- 
a nation.  Whilst  this  was  being  made,  the  child 
vi  seen  to  rub  his  penis  with  the  hand  in  the 
n it  careless  manner,  causing  thereby  an  erec- 
t an  observation  which  explained  the  cause 
c he  ill-health. 

’he  second  class  includes  cases  which  are  of 
a ery  different  character.  The  individuals  in 
t , class  have  reached  or  are  near  the  age  of 
p.  erty,  and  have  either  accidentally  learned,  or 
hi  taught,  this  pernicious  habit.  Pruritus 
i’  ’c,  due  to  diabetes  or  other  causes,  may,  for 

ii  mce,  lead  to  it  in  the  female.  A third  class 
o uses  may  be  mentioned,  in  which  the  practice 
h a central  origin,  in  certain  forms  of  brain- 
d ase  or  cerebral  deficiency,  as  is  seen  in  some 
ft  is  of  insanity  and  in  idiocy. 

1 1 the  last  two  classes  of  cases  it  may  be 
m that  there  is  often  more  or  less  perversion 


MASTURBATION.  023 

or  loss  of  the  higher  moral  feelings,  if  not  entire 
degradation  of  the  moral  sense. 

Effects  and  Symptoms. — There  is  no  doubt 
that  the  excitement  incident  to  the  habitual 
and  frequent  indulgence  in  the  unnatural  prac- 
tice of  masturbation  leads  to  the  most  serious 
constitutional  effects.  These  effects  are  more 
especially  manifested  in  the  nervous  system,  the 
functions  of  which  are  perverted.  The  mental 
faculties  become  more  or  less  affected;  and  often 
great  despondency,  loss  of  memory,  irritability, 
prostration  of  strength,  headache,  and  neuralgic 
pains  ensue.  Anaemia  occurs,  and  the  functions 
of  the  heart  and  other  organs  of  circulation  are 
disturbed.  Digestion  is  disordered.  There  is 
general  loss  of  health  and  strength  ; and  chronic 
hypochondriacal  invalidism,  if  not  worse,  is  set 
up.  In  certain  cases  the  urinary  organs  are 
affected  ; and  the  writer  has  observed  in  several 
instances  the  presence  of  albumin  in  the  urine, 
which  would  seem  to  be  the  result  of  some 
reflex  action  on  the  nerves  and  vessels  of  tho 
kidney.  The  effects  on  the  male  genital  organs 
themselves  are  marked.  There  is  extreme  irri- 
tability of  the  neck  of  the  bladder  and  adjoining 
parts,  accompanied  by  discharge  of  mucus  and. 
of  prostatic  secretion,  often  mistaken  for  semen. 
At  the  same  time  seminal  emissions  are  prone 
to  occur  on  the  least  sexual  excitement,  either 
by  day  or  during  sleep ; and  in  extreme  cases 
there  is  impotence.  In  tho  female  the  natural 
feelings  are  often  lost. 

Diagnosis. — In  many  cases  of  masturbation 
in  young  men  the  diagnosis  is  sufficiently  easy  ; 
for  such  persons,  alarmed  by  reading  the  adver- 
tisements and  books  written  specially  to  excite 
feelings  of  shame  and  fear,  and  to  bring  the 
subjects  of  them  within  the  nets  spread  abroad 
by  quacks,  are  sufficiently  ready  to  declare  the 
cause  of  their  distress.  In  other  cases,  in  which 
the  practice  is  concealed  from  fear  of  the  con- 
sequences, or  from  innocent  unconsciousness  of 
its  nature — and  this  is  more  especially  the  case 
in  females,  the  diagnosis  is  often  very  difficult. 
When,  however,  the  symptoms  just  described 
are  present,  in  the  absence  of  any  cause  to 
account  for  them,  the  practitioner  may  entertain 
a reasonable  suspicion  of  the  existence  of  this 
habit,  although  it  may  be  difficult  in  many 
cases  to  carry  his  impression  beyond  the  sus- 
picion. 

Teeatjtent.—  In  the  first  class  of  cases  above 
mentioned — that  is,  in  very  young  persons,  in 
whom  some  local  irritation  exists — the  source  of 
this  irritation  must  be  found  and  removed.  Some- 
times it  may  be  an  elongated  prepuce,  with  irri- 
tating matter  beneath  it ; in  such  cases  circum- 
cision may  be  required.  In  females  cleanliness 
and  simple  lotions  may  suffice ; or  irritation 
caused  by  the  wandering  of  thread-worms  or 
otherwise  may  require  to  be  treated.  In  these 
cases  attention  to  the  general  health,  to  the 
state  of  the  digestion,  to  the  urinary  secretion, 
and  to  the  bowels  should  not  be  neglected. 
Diabetes  must  be  searched  for,  and  treated  if 
present.  Extreme  watchfulness  by  the  nurse  is 
necessary,  and  at  night  it  may  be  even  necessary 
to  secure  the  hands  by  muffling  or  tying  them 
behind  the  back. 

In  young  adults  the  moral  sense  must  Is 


024  MASTURBATION. 

kCted  upon.  It  has  been  suggested,  by  way  of 
prevention,  that  judicious  and  kind  advice  may 
with  advantage  be  given  before  even  a know- 
ledge of  the  habit  is  acquired,  whilst  too  much 
vigilance  cannot  be  exercised  by  those  who  di- 
rect and  assist  in  the  management  of  schools. 

In  the  actual  treatment  of  the  disease,  that 
is,  the  effects  established  by  masturbation,  it  is 
of  the  highest  importance  to  improve  the  health, 
both  mentally  and  bodily.  Early  rising  and 
healthful  exercise,  with  careful  diet,  and  travel, 
if  practicable,  should  be  recommended.  Reme- 
dies directed  to  the  treatment  of  symptoms 
connected  with  the  nervous,  circulatory,  and 
digestive  systems  will  be  required.  Of  course 
the  habit  must  be  entirely  surrendered,  and  all 
thoughts  of  a loose  or  libidinous  character  must 
be  avoided.  The  bromides,  especially  the  bro- 
mides of  potassium  and  ammonium,  are  very 
useful  for  lessening  sexual  excitability ; and  in 
the  case  of  females,  these  may  be  more  espe- 
cially needed  at  the  close  of  or  just  after  the 
catamenial  periods.  In  certain  cases  where  these 
remedies,  together  with  steel,  and  other  appro- 
priate drugs,  have  failed  to  diminish  the  fre- 
quency of  the  seminal  emissions  which  are  com- 
mon in  males,  caustics  may  be  applied  to  the 
neck  of  the  bladder.  See  Spermatorrhcea. 

MAW-WORMS. — A synonym  for  thread- 
worms. See  Thread-Worms. 

MEASLE. — In  helminthology  this  term  is 
frequently  employed  as  a synonym  of  cysticcrcus. 
Thus,  we  have  pork,  beef,  and  mutton  measles, 
each  entozoon  being  a distinct  form  cf  bladder- 
worm,  and  therefore,  at  the  same  time,  the  larval 
representative  of  an  equally  distinct  species  of 
tape-worm.  The  human  measle  is  a variety  only 
of  the  pork  measle,  both  forms  constituting 
what  is  sometimes  called  the  scolex-condition  of 
the  Tania  solium.  Most  kinds  of  flesh  ordina- 
rily consumed  as  food  are  liable  to  become 
' measled,’  but  no  such  parasites  have  hitherto 
been  detected  in  the  muscles  of  the  horse.  This 
fact  supplies  an  argument  in  favour  of  hippo- 
phagy.  For  detailed  information  respecting  all 
the  known  forms  of  human  and  animal  measles 
and  bladder- worms  the  reader  is  referred  to  Dr. 
R.  Moniez’  Essai  Monographique  sur  les  Cysti- 
cerques,  forming  the  first  part  of  the  third  vo- 
lume of  the  Travaux  de  I'Institut  Zoologique  dc 
Lille,  1880.  See  Bladder-worms;  and  Cysti- 
CERCCS.  T.  S.  CoBBOLD. 

MEASLES. — Symon.  : Morbilli;  Rubeola-, 
Fr.  Rougeole ; G*r.  Maseru. 

Definition. — An  infectious  specific  fever;  -with 
an  eruptiou,  on  the  fourth  day  after  catarrhal 
symptoms,  of  a deep-red  spotted  rash ; this  is  at 
first  slightly  raised,  and  is  distributed  in  cres- 
centic groups,  which  soon  extend  over  all  parts 
of  the  surface ; it  persists  as  a general  mottling 
after  the  subsidence  of  the  fever,  and  where 
intense  may  cause  a fine  desquamation.  The 
disease  prevails  as  an  epidemic;  and  it  very 
rarely,  if  ever,  attacks  the  same  person  more 
than  onee. 

AEtioloot. — Contagion  is  the  cause  of  measles 
wherever  it  is  now  met  with.  In  large  towns, 
phere  sources  of  infection  always  exist,  epi- 


MEASLES. 

demies  recur  about  every  four  years,  chiefly 
among  children,  as  fresh  series  of  the  suscep- 
tible become  exposed.  Few  adults  suffer;  most 
of  them  having  been  attacked  in  childhood. 
Among  scattered  populations  long  periods  may 
elapse  without  infection  reaching  them;  when 
it  does,  neither  age  nor  sex  influences  directly 
either  the  liability  to  attacks,  or  their  severity. 

The  essential  characters  of  the  disease  are 
everywhere  the  same.  The  fatality  is  increased 
by  extremes  of  heat  in  hot  countries  and  seasons, 
and  by  extremes  of  cold  in  cold  climates;  by 
malarial  soil,  vitiated  air,  or  crowded  dwellings: 
by  defective  diet ; and  by  scurvy. 

The  annual  mortality  from  measles  in  London 
is  nearly  five  per  ten  thousand.  The  deaths 
from  measles  are  about  one  per  cent,  of  all 
deaths  in  England  and  Wales,  and  nearly  two  pei 
cent,  in  large  towns ; this  is  higher  during  epi- 
demics, but  has  not  reached  much  beyond  2 7 ii 
London.  The  proportion  of  deaths  to  attacks 
varies  from  twenty  to  thirty  per  cent,  in  crowdec 
wards,  to  one  or  two  percent,  in  healthy  houses 
the  mortality  of  ten  or  twelve  per  cent,  is  ; 
common  estimate. 

The  contagium  of  measles,  except  in  the  catar 
rhal  stage,  is  not  far  diffusible  in  the  air,  bu 
clings  to  surfaces,  and  may  so  be  carried  fron 
place  to  place.  Children  with  full  eruption  havi 
been  brought  into  a house  among  others,  am 
nursed  in  a room  apart,  without  any  extensioi 
of  the  disease  even  to  the  most  susceptible 
When  young  infants  are  said  to  escape  infection! 
it  is  where  the  family  is  small,  and  they  an 
less  exposed.  Among  young  children  the  death 
are  in  equal  proportion  to  the  numbers  of  th 
two  sexes  living.  With  us  more  than  half  o 
the  whole  number  of  deaths  from  measles  ar 
of  children  under  two  years  of  age;  the  pro 
portion  thence  progressively  diminishes.  Thi 
differs  from  what  is  observed  in  scarlet  fere 
and  diphtheria ; moreover,  the  proportion3t 
fatality  of  these  latter  diseases  in  the  two  sexe 
is  greater  for  girls. 

Measles  in  a school  or  family  is  sure  t 
spread  ; the  catarrhal  stage,  infectious  through 
out.  is  mistaken  for  a common  cold,  and  notimel 
separation  is  attempted.  The  cough  is  an  impoi 
tant  means  of  conveying  infection  at  this  time 
The  period  of  incubation  is  ten  to  twelve  day 
rarely  a day  or  two  more.  During  the  latent  stag 
of  this  long  incubation,  those  who  have  been  er 
posed  to  infection  are  thought  to  have  escape! 
and  are  sent  to  begin  the  same  round  elsewher 
The  disease  may  be  conveyed  by  fomites.  Infe< 
tion  begins  before  the  rash  appears  and  thecoi 
tsgium  may  be  given  off  by  the  third  day.  nin: 
probably  during  the  greater  part  of  the  incub; 
tion-period.  The  contagium  principle  develop! 
only  in  the  bodies  of  the  sick,  is  found  during  tl 
height,  of  the  disease  in  the  tissues,  the  seen 
tions,  the  blood,  and  the  breath.  Inoculation  : 
this  stage  either  with  the  blood  or  serum,  1 
Home,  Cullen,  and  others,  reproduced  measl 
without  modification  ; the  primary  fever  th( 
appearing  on  the  seventh  day.  and  the  ernpti; 
on  the  ninth  and  tenth.  Mayr.  of  Leipzig,  twn 
conveyed  the  disease  by  means  of  nasal  n ucr 
Catarrh  began  on  the  eighth  and  ninth  day 
rash  on  the  tenth  and  eleventh.  AfteranatUr 


923 


MEASLES. 


If  measles  personal  infection  is  probably  over 
ij  the  end  of  a month ; it  may  persist  longer, 
r be  conveyed  somehow  by  convalescents  for 
nother  month.  How  long  infection  may  cling 
o articles  of  clothing,  or  linger  in  closed  rooms, 
3 uncertain.  After  two  years  of  age  the  mor- 
ality is  not  greater  in  proportion  to  the  number 
f attacks  than  at  other  periods  of  life ; and  there 
3 some  advantage  in  contracting  this  disease  at 
time  when  careful  nursing  and  individual  at- 
ention  can  be  secured.  Those  who  escape  measles 
uring  childhood  are  very  likely  to  be  seized  on 
aking  their  part  in  mixed  communities. 
Pathology. — Measles  is  the  type  of  a zymotic 
isease.  An  organised  ferment,  bacterium  or 
mila,  in  a suitable  medium,  at  first  increases 
lowly,  with  barely  noticeable  changes ; then 
omes  a more  violent  disturbance ; after  which 
he  zymotic  organism  ceases  to  develop,  and  the 
leaium  can  no  more  sustain  a similar  action, 
iter  experimental  zymosis  the  fluid  medium 
lears,  and  the  organisms  accumulate  at  some 
art  of  the  containing  vessel.  Several  years  ago 
>r.  Ransome,  of  Manchester,  obtained  particles 
■•om  the  breath  of  two  persons  suffering  from 
leasles.  Drs.  Braidwood  and  Vacher  have  since 
imfirmtd  this  observation.  Glycerine,  on  which 
lildren  with  measles  respired  during  any  of  the 
ciptive  days,  exhibited  numerous  highly  refrac- 
le  bodies,  larger  than  those  seen  in  vaccine- 
mph ; others  wero  elongated,  with  sharp-cut 
uls,  sparkling  and  colourless  ; they  were  most 
mndant  in  the  two  days  of  greatest  eruption  ; 
icy  were  not  found  in  the  breath  during 
jalth,  nor  in  the  course  of  scarlet  fever  and 
phus.  After  death  from  measles,  on  the 
ghth  day,  they  were  found  in  the  true  skin  in 
•oups  below  the  rete  mucosum,  by  the  lymph- 
iaces  and  sweat-ducts,  but  not  deeper  than 
e level  of  these  glands ; sparkling,  spindle- 
aped,  rod-like,  or  canoe-shaped  bodies  were 
so  seen,  which  did  not  take  the  carmine  tinge, 
lese  bodies  were  not  seen  in  the  lymph-spaces, 
r in  the  sweat-ducts  and  glands,  nor  in  the 
■ir-follicles.  In  the  lung  both  forms  were  found 
some  exudation  filling  the  alveoli.  The  sphe- 
■al  forms  have  a dark,  smooth  outline,  and 
not  readily  take  the  carmine  stain.  Near 
ese  were  rod-like,  fusiform,  or  ovate  bodies, 
ghtly  tinged  with  carmine.  These  are  quite 
itinguishable  from  the  particles  seen  in  other 
ms  of  pneumonia.  With  a high  power,  similar 
firkling,  staff-shaped  bodies  were  seen  scattered 
: md  the  bile-ducts.  None  were  found  in  the 
* ineys,  spleen,  or  mesenteric  glands. 

;.n  the  blood  some  increase  of  white  and  a 
( at  decrease  of  red  corpuscles  occur  during  the 
1 er.  Numerous  moving  microzymes  have  been 
i n during  the  eruption,  decreasing  rapidly, 
i.l  disappearing  in  three  weeks  ; but  temoo- 
J ily  reappearing  with  any  febrile  disturbance. 
Ixatomical  Characters. — The  mucous  mem- 
1 ne  of  the  larynx  and  trachea  is  always  red 
> measles,  often  with  punctiform  congeries  of 
' 3els;  and  not  unfrequently  thin  films  of  lymph 
8 found  loosely  adherent.  The  bronchi  are  con- 
ned, sometimes  with  exudation  on  the  lining 
t nbrane,  more  frequently  covered  with  muco- 
1 or  plugged  with  catarrhal  mucus ; capillary 
ichitis  with  broncho-pneumonia  is  frequent. 


Lobules  of  the  lung  are  often  collapsed  or  in- 
flamed : the  pneumonic  exudation,  whether  the 
result  of  occluded  bronchioles,  or  of  direct  conges- 
tion, fills  or  breaks  down  the  alveoli,  and  invades 
the  parenchyma.  Lobar  pneumonia,  if  extend- 
ing to  the  surface,  is  accompanied  by  pleurisy, 
often  limited  to  the  part  of  the  lung  affected. 
Fluid  may  be  found  effused  into  the  pleura  or 
pericardium,  without  any  traces  of  inflamma- 
tion. Petechia  are  often  found  on  the  pleural 
surfaces.  Any  inflammatory  signs,  either  cardiac 
or  articular,  in  the  serous  membranes  are  so  rare 
as  to  be  quite  exceptional.  Dark,  soft  coagula 
are  found  in  the  right  side  of  the  heart,  in  the 
venae  cavae,  and  in  the  cranial  venous  sinuses. 
The  meninges  are  congested;  there  is  injection 
and  hypersemia  of  the  brain-substance,  and  in- 
creased fluid  in  the  ventricles  and  subarachnoid 
space  ; more  rarely  recent  lymph  is  seen  on  the 
surface  of  the  hemispheres  ; deposits  at  the  base 
belong  to  later  consequences  of  the  disease. 
Congestion  of  the  digestive  tract  is  most  marked 
near  the  ileum  and  colon ; externally  the  distended 
veins  of  the  submucous  coat  are  seen  ; internally 
there  is  deep  redness  of  the  surface,  the  solitary 
glands  are  distended  and  elevated,  the  agmi- 
nated  to  a less  degree,  but  there  is  little  or 
no  enlargement  of  the  mesenteric  glands ; the 
follicles  of  Lieberkiihn  and  the  tubular  glands 
of  the  large  intestine  are  more  distinct  than 
usual ; a chronic  ileo-colitis  may  result.  The 
liver  is  mottled  ; both  the  portal  and  hepatic 
veins  are  full;  and  the  lobules  are  ill-detined 
and  granular  in  appearance,  with  fatty  particles 
interspersed.  The  bronchial  glands  are  often 
enlarged,  and  sometimes  softened  ; suppuration 
from  them  extended  up  behind  the  (Esophagus 
in  one  instance.  The  lymphatic  glands  of  the 
neck  are  always  congested  and  enlarged,  and 
often  those  elsewhere,  as  in  the  axilla  or  groin. 
The  spleen  is  swollen  and  friable,  or  very  little 
altered.  The  kidneys  show  no  distinctive  changes; 
they  are  hyperaemic  in  the  earlier  stages  of  the 
disease,  and  the  tubules  may  then  be  full  of 
epithelium  and  cell-debris  ; the  degree  of  after- 
congestion depends  much  on  the  degree  of  pul- 
monary obstruction,  or  on  early  exposure  to  cold 
or  fatigue ; no  albumen  or  casts  of  renal  tubes 
are  found  in  the  urine,  unless  a secondary  nephri- 
tis have  been  thus  occasioned. 

Symptoms. — The  symptoms  of  measles  seldom 
occur  until  eight  days  after  exposure  to  infection. 
They  may  begin  suddenly,  with  high  fever,  aching 
pains,  and  vomiting,  the  initial  fever  subsiding 
next  day,  but  not  completely,  when  there  may  be 
little  feeling  of  illness,  but  some  signs  of  coryza, 
cough  and  sneezing,  with  enlargement  of  the 
lymphatic  glands  in  the  neck.  On  the  third  day 
the  coryza  is  more  marked,  the  cough  often  very 
troublesome,  and  the  fever  increased.  Some  few 
spots  of  eruption  are  now  visible  on  the  forehead 
and  sides  of  the  face.  The  conjunctivas  are  in- 
jected, thetonsils  full  and  smooth,  the  soft  palate 
mottled,  the  tongue  furred,  the  pulse  quickened. 
On  the  fourth  day  the  eruption  appears  more 
fully,  with  rapid  pulse  and  sudden  elevation  of 
temperature,  often  to  104°  by  night,  with  de- 
lirium. On  the  fifth  day,  with  full  rash,  there 
is  marked  alleviation  of  all  the  symptoms : the 
cough  is  quiet ; the  pulse  is  less  full  and  fre- 


MEASLES. 


326 

quent;  the  tongue  cleans;  and  the  temperature, 
already  fallen  by  3°  or  even  4°,  often  reaches  the 
normal  by  the  sixth  day,  leaving  the  skin  still 
deeply  stained  by  the  fading  rash,  and  the  patient 
■weak.  Luring  the  next  week  or  ten  days  there 
is  a tendency,  not  only  to  depression,  but  to  sud- 
den rises  of  temperature,  with  various  complica- 
tions that  retard  or  endanger  convalescence.  We 
notice  three  stages  : — the  ingress ; the  eruption , 
and  the  decline. 

The  ingress. — The  ingress  of  measles  is  not 
always  with  marked  initial  fever.  Coryza  and 
spots  of  the  rash  may  be  observed  before  illness 
is  complained  of,  though  some  elevation  of  tempe- 
rature can  be  traced  by  the  thermometer  for 
three  days  before  the  full  eruption.  This  febrile 
movement  has  been  preceded  in  some  cases,  where 
thermometric  observations  were  made  throughout 
tlie  period  of  incubation,  by  a well-marked  de- 
pression of  short  duration.  Before  this,  fatigue, 
headache,  vertigo,  chorea,  and  other  irregular 
symptoms  may  occur.  Often  some  slight  dis- 
turbances of  health,  and  even  cough,  have  been 
observed  all  through  the  incubation-period  ; 
sometimes  an  intercurrent  disease  has  delayed 
the  regular  march  of  the  invasion  to  seven  or 
eight  days,  or  the  latent  stage  has  been  prolonged 
to  ten  or  twelve  days ; more  frequently  this  is 
reduced  to  three  days,  and  even  these  days  may 
In-  febrile  from  a concurrent  influenza  or  herpetic 
catarrh.  The  eruptive  fever  always  occupies  four 
days.  As  this  approaches  the  crisis,  many  symp- 
toms are  aggravated.  Incessant  cough  occurs, 
often  in  children  with  croup  of  the  catarrhal 
kind;  bronchial  irritation  with  rales  and  rhon- 
chal  fremitus,  or  possibly  submucous  rhonchus, 
may  be  heard  at  the  pulmonary  bases ; the  re- 
spirations, hurried  and  shallow,  are  30  to  40  in 
tlie  minute  ; the  pulse  is  quickened  to  130  or  140. 
Both  the  respiration  and  the  pulse,  especially  the 
former,  are  more  accelerated  in  young  children  ; 
and  with  them  convulsions  may  at  this  period 
retard  the  eruption  or  prove  fatal.  Death  before 
the  rash  is  thrown  out,  though  rare,  has  also  hap- 
pened in  adults.-  The  urine  is  scanty,  yellow  or 
dark-coloured,  and  deposits  lithates  ; in  extreme 
cases  it  has  been  suppressed.  Abdominal  pain  or 
diarrhoea  may  occur,  and  the  latter  may  become 
a serious  symptom.  Thirst  is  great;  the  bps  are 
dry;  the  tongue  is  moist, with  red  papillae  show- 
ing through  a thick  white  fur;  the  palate  and 
fauces  are  red,  from  many  punctiform  congeries 
of  vessels;  the  deep  injection  and  swelling  of  the 
pharynx  may  extend  to  the  Eustachian  orifices, 
and  cause  deafness ; deglutition  is  painful,  and 
sometimes  difficult,  from  the  imperfect  closing  of 
the  turgid  epiglottis,  as  well  as  from  fulness  of 
the  tonsils.  With  these  throat-symptoms  the 
gland  at  the  angle  of  the  jaw  is  somewhat  en- 
larged and  tender  ; but  there  is  not  much  swell- 
ing or  oedema  of  the  overlying  integument. 
The  lymphatic  glands  of  the  neck  are  palpably 
enlarged  before  there  is  much  or  any  rash  on  the 
skin,  those  of  the  axilla  and  groin  afterwards. 
Kpistaxis  is  not  rare.  The  eyelids  are  swollen, 
tlie  conjunctiva  being  inflamed  and  purulent ; 
there  is  intolerance  of  light;  there  is  fear  of 
the  eye  being  permanently  injured.  The  noc- 
turnal delirium  and  most  of  the  other  symptoms 
abate  when  the  eruption  is  complete. 


The  rash. — The  rash  first  shows  itself  in  dis- 
tinct, red,  and  nearly  circular  spots,  much  scat- 
tered; fresh  spots  soon  show  in  the  clear  skin. 
They  begin  as  red  points,  which  are  raised,  and 
feel  rough  or  ‘ shotty,’  especially  on  the  face,  and 
early  in  the  eruption;  they  then  form  crescentic 
groups,  which  coalesce  into  patches  of  irregular 
outline  on  the  body.  The  face,  disfigured  by  the 
swelbng,  is  first  covered;  then  the  neck  and  chest. 
The  rash  is  also  well-marked  in  the  scapular 
region,  extending  to  the  rest  of  the  trunk  and 
to  the  extremities  on  the  second  day,  becoming 
more  sparse  as  it  descends.  A peculiar  and 
offensive  odour  from  the  sick  is  recognisable 
during  the  whole  eruptive  period.  The  rash  de- 
clines in  the  order  of  its  invasion.  Within  twenty- 
four  hours  the  swelling  of  the  face  subsides ; the 
red  spots,  no  longer  raised,  become  pale  under 
pressure,  and  leave  a yellowish  discolouration. or 
on  the  shoulders  marks  of  a dusky  red.  Conside- 
rable irritation  attends  tlie  rash,  con  tinning  win 
it  to  the  third  day  or  longer.  At  this  time  fine 
desquamation  is  noticed  on  the  face;  small  scales 
of  cuticle  are  detached  from  the  top  of  the 
enlarged  papillae,  so  that  most  of  the  surface  is 
furfuraceous  ; this  disappears  with  the  irritation 
by  the  second  week,  or  may  persist  a week 
longer  ; it  does  not  occur  when  the  eruption  has 
been  slight,  hardly  ever  on  the  fingers  and  feet, 
and  never  in  large  shreds.  A coppery,  mottled 
discolouration  remains  on  the  more  vascular 
parts  of  the  skin,  or  where  the  rash  has  been 
most  marked,  for  eight  or  ten  days,  and  some- 
times continues  visible  three  weeks  from  the 
commencement  of  the  illness.  The  eruption  may 
begin  on  other  parts  of  the  body  than  the  face,  as 
at  the  seat  of  any  injury  to  the  skin.  The  disease 
may  run  its  course  safely  with  very  little,  possibly 
without  any  eruption.  An  imperfectly  developed 
dusky  or  livid  rash  is  met  with  in  severe  cases. 
With  serious  lung-complication  a full  rash  may 
recede.  Petechial  specks  may  accompany  a mode- 
rate eruption,  or  haemorrhagic  spots  complicate  the 
irregular  forms.  Some  of  the  earlier  spots  may 
not  only  be  raised  and  acuminate,  but  minutely 
vesicular  at  their  apices.  In  the  dark  races  the 
erupt  ion  is  yellowish,  raised  above,  but  somewhat 
lighter  in  colour  than  the  surrounding  integu- 
ment ; in  the  mulatto  it  varies  from  a yellowisi 
to  a dusky  brown ; but  all  other  signs  cf  thi 
eruptive  period  are  well  marked. 

The  decline.  Complications  and  sequela.— 
The  pulmonary  lesions  of  the  febrile  stage, 
capillary  bronchitis  or  broncho-pneumonia,  may 
delay  defervescence,  or  rapidly  prove  fatal.  Witt 
moderate  lung-mischief  the  fall  of  temperature 
following  the  rash  is  often  very  marked,  and 
with  extrema  depression  further  congestion  c: 
the  lung  will  occur.  The  liability  to  depression  o: 
temperature  which  follows  many  acute  fevers,  ii 
specially  marked  in  this  one,  and  requires  to  be 
guarded  against.  A tendency  to  sudden  eleva 
tions  of  temperature  is  also  noticeable  for  ten  o 
twelve  days  after  the  eruptive  fever  subsides 
rarely  this  has  been  accompanied  by  a recrudes 
cenee  and  reappearance  of  the  rash,  someumc- 
by  no  definite  changes,  possibly  by  some  tha 
are  obscure,  of  the  nervous  centres.  The  commo 
accidents  of  this  period  are — first,  3 return  c 
cough  in  children  ; this  may  becroupy,  beginnm 


MEASLES. 


the  very  day  of  the  first  decline  of  temperature. 
The  temperature  again  rises  suddenly,  perhaps  to 
103°,  with  greatly  excited  pulse  and  respiration. 
Next  day  there  is  tracheal  rhonchus,  but  no  in- 
creased size  of  the  cervical  glands.  The  cough 
then  becomes  looser,  and  thin  shreds  of  false 
membrane  are  expelled.  This  form  of  membra- 
nous croup  is  as  common  from  three  to  six  days 
ifter  the  rash,  as  catarrhal  croup  is  the  day  before 
he  rash.  It  rarely  attacks  more  than  one  child 
r.  a family ; this  is  sometimes  the  same  child  who 
pad  laryngeal  symptoms  in  the  catarrhal  period, 
in  some  epidemics  laryngitis  and  subsequent 
loarseness  have  often  followed.  More  frequently 
i return  of  cough  indicates  the  commencement  of 
.ironchitis  or  ot  broncho-pneumonia.  In  the  lat- 
er a sharp  elevation  of  the  temperature  of  no 
oug  duration  occurs.  Lobar  pneumonia,  less  fre- 
;uent,  maintains  a higher  range  of  temperature  ; 
t may  be  mistaken  for  meningitis.  Pleurisy, 
xcept  in  connection  with  lobar  pneumonia,  is 
are.  Otitis  may  cause  a high  temperature  of 
hort  duration.  Three  or  four  such  inter- 
uptions  may  happen  in  a single  convalescence, 
erious  complications,  not  attended  with  much 
emperature-disturbance,  are  found  in  diarrhoea, 
yseutery,  and  passive  haemorrhages.  Enteritis, 
nth  diarrhoea  and  dysentery,  is  as  fatal  and 
'equent  a complication  of  this  disease  in  hot 
imates  as  are  pulmonary  affections  with  us.  In 
mvalescence,  after  a critical  increase  ot  urine, 
■ie  kidneys  act  more  freely ; if  during  pulmonary 
^struction  the  chlorides  were  diminished,  they 
m reappear,  the  excretion  of  urea  is  increased, 
id  uric  acid  may  be  eliminated  in  excess.  Al- 
lminuria,  unless  determined  by  extreme  neglect 
id  exposure,  is  not  a consequence  of  measles. 
Impairment  of  health  results  as  often  from 
is  as  from  other  specific  fevors.  Nerve-waste 
ay  lead  to  imbecility  and  dementia.  Acute 
berculosis  is  started,  or  tubercular  deposits 
gin  after  measles.  The  strumous  diathesis 
evoked,  and  may  set  up  a troublesome  oph- 
almia,  with  danger  to  the  cornea;  or  a fatal 
torative  stomatitis.  Abrasions  of  the  nares  or 
s may  persist  or  extend,  eczema  or  ecthyma 
pear,  and  glandular  enlargements  increase  or 
:ome  chronic.  Even  in  the.  robust  acute  pul- 
inary  disease  is  readily  induced  by  exposure 
want  of  care  during  convalescence ; a liabi- 
. r to  this,  to  pustular  eruptions,  and  to  irre- 
( lar  febrile  disturbance,  may  persist  for  three 
' eks.  It  has  happened  that  some  nervous  dis- 
fciers,  such  as  chorea  or  mania,  have  been 
nested  during  an  attack  of  measles,  even  with 
] manent  benefit.  Measles  not  infrequently 
( sxists  with  mumps  and  with  whooping-cough, 
i re  rarely  with  varicella  and  vaccinia.  Either 
t hese,  taken  with  measles,  is  delayed  or  inter- 
tted,  resuming  its  course  when  the  eruption 
c ueasles  is  over.  Whooping-cough,  established 
1 trehand,  is  temporarily  interrupted  by  an 
a ,ck  of  measles.  Scarlet  fever  may  complicate 
n ,sles,  also  erysipelas ; or  measles  may  be 
e racted  in  the  course  of  typhoid  fever.  Diph- 
tl  ‘ia  is  not  so  frequent  a complication  of  measles 
a it  is  of  scarlet  fever.  After  any  of  these 
d ases  the  liability  to  suffer  infoction  from  the 
o rs  seems  to  be  increased.  The  exemption 
ft,  l a second  attack  of  measles  is  not  universal, 


927 

but  the  exceptions  to  the  rule  are  so  few  as  to  be 
rarely  observed.  In  two  instances  observed  by 
the  writer,  at  intervals  of  fifteen  and  twenty-five 
years  respectively  from  the  primary  attack,  the 
rash  was  preceded  by  the  usual  catarrhal  fever, 
and  was  but  slightly,  if  at  all,  modified.  Out  of 
numberless  mistaken  eases,  no  other  has  come  un- 
der his  notice.  An  allied  form  of  rubeola  {sine  ca- 
tarrho ),  essentially  distinct,  iscommonly  mistaken 
for  measles  ; hence  the  belief  in  second  measles. 

Diagnosis. — The  first  spots  of  measles,  if 
scattered,  raised,  and  hard,  may  be  mistaken  for 
those  of  small-pox;  or  the  small-pox  eruption 
may  begin  with  some  measles-like  roseola.  The 
temperature  curve  for  the  two  diseases  is  similar. 
In  the  small-pox  curve  a sudden  rise  begins  only 
two  days  before  the  eruption,  whilst  in  measles 
there  is  a gradual  rise  for  three  or  four  days  ; 
this  iu  small-pox  is  evidenced  by  a history  of 
sudden  and  severe  illness  only  on  the  day  but 
one  before  the  eruption,  whilst  in  measles  there  is 
no  such  symptom  on  that  day,  the  illness  dating 
from  a day  or  two  earlier,  usually  with  distinc 
tive  catarrhal  symptoms. 

The  declining  rash  of  measles  leaves  a mot 
tling  of  the  skin,  not  unliko  the  mulberry  eruption 
of  typhus ; the  latter  seldom  appears  before  the 
fifth  day  of  the  disease,  the  fever  continuing  high 
for  several  days  after.  In  measles,  at  this  stage  of 
the  rash,  the  fever  has  already  begun  to  decline, 
the  temperature  falling  suddenly,  often  to  below 
the  normal.  The  rash  of  rubeola  sine  catarrho, 
Eotheln,  or  rubella,  closety  resembles  the  erup- 
tion of  measles  ; the  spots,  brighter  in  colour  and 
even  more  discrete,  are  preceded  by  only  one  day 
of  headache  or  slight  sore-throat.  The  incuba- 
tion-period generally  is  longer  than  in  measles. 
In  scarlet  fever  the  ingress  is  sudden  ; there  is 
the  characteristic  sore-throat ; and  there  is  the 
early  appearance  on  many  parts  of  the  body  of 
the  finely  diffused,  comparatively  smooth,  bright 
scarlet  redness  of  the  rash.  The  incubation-period 
has  been  short.  In  erysipelas  the  redness  appears 
at  one  part  only,  and  extends  from  that,  whether 
it  be  the  face  or  other  parts  of  the  body.  Roseola 
from  irritating  articles  of  food  has  very  little 
fever,  and  no  enlargement  of  the  cervical  glands, 
otherwise  it  might  look  like  measles.  Urticaria 
and  erythema,  with  differing  aspect,  cause  hut 
slight  thermometric  disturbance. 

Prognosis. — This  is  mostly  favourable  in 
measles  ; the  tendency  of  the  febrile  action  is  to 
recovery.  Favourable  progress  may  be  endan- 
gered by — 1.  The  bad  health  of  the  sufferer.  2. 
Wantofcare.  3.  Insanitary  surroundings.  Under 
either  of  these  conditions  the  simplest  kind  of 
measles  in  a healthy  subject  may  give  rise  to  the 
worst  forms  of  the  disease.  Morbilli  mitiores  and 
graviores  are  not  essentially  distinct.  High  fever 
with  the  eruption  is  not  in  itself  unfavourable  ; 
at  this  time  a temperature  of  105°  in  children, 
and  104°  in  adults,  or  half  a degree  beyond, 
is  safely  reached ; with  precautions  at  its  sud- 
den decline,  the  progress  afterwards  is  most 
satisfactory.  High  temperature  during  the  after- 
course is  a sign  of  greater  import ; it  guides  to 
various  complications,  and  subsides  as  they  are 
relieved  ; occurring  irregularly  it  is  a cause  for 
anxiety;  if  steadily  maintained,  or  recurring 
regularly  at  short  intervals,  with  wasting  ns  a 


MEASLES. 


928 

result,  there  is  little  hope  of  recovery,  and  none  if 
acute  tuberculosis  of  lung  or  of  brain  is  evidenced. 
The  latter  danger  makes  convulsions  of  worse 
augury  in  the  decline  than  during  the  ingress  of 
measles  in  young  children ; convulsions,  taking 
the  place  of  delirium  in  older  persons,  cease  after 
the  eruption.  Recession  of  the  rash  is  not  alarm- 
ing when  the  attack  is  slight,  or  the  temperature 
is  low  at  the  crisis;  when  there  i3  pulmonary  or 
other  local  congestion,  and  at  the  same  time  sud- 
den depression,  it  becomes  an  additional  sign  of 
danger.  A dark  rash,  interspersed  with  fine  red 
specks,  may  occur  early  in  cases  of  moderate 
seventy  ; a dusky  or  livid  colour  subsequently 
marks  cases  of  considerable  intensity  ; petechial 
or  haemorrhagic  blotches  at  this  time  are  of 
grave  import,  as  indicative  of  scorbutus,  which 
state  ranks  next  to  impaired  nutrition  in  infants, 
as  the  most  unfavourable  concomitant  of  measles. 
Black  or  haemorrhagic  measles,  without  scor- 
butus, is  more  rare  than  is  haemorrhagic  or 
black  small-pox.  Some  dangerous  haemorrhages 
may  follow  measles  where  no  scorbutic  condition 
exists.  Among  insanitary  conditions,  though 
the  presence  of  sewer-gas  has  in  isolated  in- 
stances determined  a fatal  result,  the  most  dis- 
astrous is  overcrowding.  The  great  mortality 
from  measles  is  due  to  lung-disease,  not  at  the 
height  of  the  fever,  but  in  the  second  week ; the 
frequency  and  severity  of  pulmonary  complica- 
tions being  less  a direct  effect  of  low  temperature 
than  of  tainted  air  in  which  the  poor  are  pent 
up  for  the  sake  of  warmth.  During  the  ingress 
of  measles  exposure  to  cold  may  occasion  a 
highly  dangerous  suffocative  catarrh,  with  capil- 
lary bronchitis  ; after  or  during  the  rash  a chill 
is  as  likely  to  conduce  to  serious  diarrhcea  as  to 
pulmonary  congestion,  especially  in  hot  weather. 
Equally  depressing  in  their  effects,  these  are 
direct  results  of  the  disease  independently  of 
weather  or  season.  Measles  contracted  during 
acute  or  prolonged  illness  is  a grave  addition  to 
the  danger.  In  the  puerperal  state  infinitely  less 
mischief  is  produced  by  this  disease  than  by  scar- 
let fever;  delivery  has  been  hastened  without 
mischance,  or  abortion  has  resulted,  not  without 
risk  of  fatal  results;  there  are  times  when  young 
married  women  who  have  not  had  measles  should 
Keep  from  risk  of  infection.  It  would  seem  that 
the  child  can  go  through  the  disease  in  ittsro, 
with  after-immunity.  There  is  an  instance  on  re- 
cord of  a mother  with  measles  giving  birth  to  a 
child  ‘full  of  measles,’  both  doing  well;  others 
of  infants  having  the  rash  three,  five,  and  eight 
days  after  birth,  when  the  mother  was  herself 
ill.  Infants  escape  measles  while  suckling,  in- 
somuch as  they  are  less  exposed  to  infection ; 
they  suffer  no  less  severely  than  others.  In 
adolescence  a body-heat  of  107°  has  been  safely 
passed,  during  the  decline  of  measles,  with  no 
marked  complication.  In  children  of  all  ages 
a warning  is  given  of  some  danger  closely  fol- 
lowing the  eruption,  when  the  normal  fall 
of  temperature  at  the  crisis  is  delayed  or  pre- 
vented. In  advanced  convalescence  sudden  rise 
of  temperature,  with  delirium,  often  marks  an 
attack  of  pneumonia  ; this,  if  of  limited  extent, 
may  be  hoped  to  end  favourably  in  a week  by 
resolution,  without  much  cough,  but  with  steady 
high  temperature  till  near  the  end. 


Treatment. — Rest,  pure  air,  equable  warmth, 
diluents,  and  nourishment,  are  tUo  chief  requi- 
sites in  the  treatment  of  measles. 

All  risks  from  exposure  or  fatigue  should  b« 
avoided  while  the  disease  may  be  only  latent 
The  first  catarrhal  signs  demand  confinement  to 
the  room ; the  initial  fever,  rest  in  bed.  The  usual 
meals,  moderate  in  quantity,  can  be  taken;  if 
not,  milk,  broth,  or  meat-jelly  will  be  require!. 
Extra  liquids,  as  barley-water,  lem  onade,  or  even 
cold  water,  and  small  pieces  of  ice,  are  pleasant 
and  necessary.  Simple  salines,  as  potash  in  the 
lemonade,  or  citrate  of  ammonia,  are  useful; 
dilute  acetate  of  ammonia,  coloured  with  syrupus 
croci,  is  an  old  and  good  form ; to  this  a few 
drops  of  ipecacuanha  wine  may  be  added,  bat 
neither  expectorants  nor  diaphoretics  have  any 
influence  on  the  cough  until  after  the  eruption. 
The  bowels  must  be  gently  regulated;  a furred 
tongue  is  not  a reason  for  giving  purgative  me- 
dicine. No  diminution  of  the  expected  critical 
fever,  if  this  were  desirable,  will  be  brought 
about  by  the  action  of  emetics  and  aperients; 
where  either  of  such  evacuations  have  troubled 
the  ingress,  the  eruption  is  delayed  with  no  after- 
benefit.  The  froe  use  of  cold,  so  speedy  and 
potent  an  antipyretic  in  scarlet  and  other  fevers, 
is  not  required  in  the  early  stages  of  measles, 
and  would  be  injurious  until  after  the  eruption 
is  out.  In  the  fever  of  measles  a certain  pro- 
gressive rise  of  temperature  is  necessary  to  its 
favourable  termination ; where  this  is  inter- 
rupted, as  by  debility  or  chill,  sometimes  by 
convulsions  in  infants,  the  warm  bath  is  to  bt 
used.  At  this  stage  of  the  disease  wine  is  rarely 
necessary ; it  may  be  required  after  epistaxis  o 
for  sudden  depression,  where  food  has  not  beei 
taken.  The  room  should  bo  kept  quiet,  ant 
perhaps  dark,  so  that  sleep  may  be  favoured 
Tepid  sponging  of  the  surface,  part  at  a time 
relieves  the  feeling  of  heat  and  tension ; irri 
tation  is  soothed  by  applying  cold  cream  to  tk 
face,  and  carbolated  oil  to  the  body,  or  by  rut 
bing  with  snot  in  some  places.  The  bed-clotke 
should  not  be  too  heavy.  An  attendant  may  b 
required  during  the  night.  Good  ventilatio 
admits  fresh  air  without  draught  or  chill  to  tfc 
patient.  A spray  of  ozonised  water  or  aromat 
vinegar  freshens  the  air  of  the  room.  In  thiswa; 
with  previous  good  health,  the  danger  of  pulmi 
nary  complications  is  lessened.  AYhen  sever 
cases  have  to  be  treated  in  a ward,  each  patiei 
should  have  a space  screened  off  from  draught 
and  kept  sweet.  Directly  the  rash  is  out,  tl 
fever  falls,  the  tongue  cleans,  the  appetite  r 
turns,  and  the  patient  seems  cheerful  and  we! 
ordinary  food  can  again  be  taken,  sleep  rcturr 
and  no  alcoholic  stimulant  is  required.  On  t 
other  hand,  with  dislike  of  food,  languor,  or  ret 
lessness  at  nights,  stimulants  should  be  givt 
before  the  dry  tongue,  small  and  rapid  puli 
receding  rash,  or  signs  of  pulmonary  congestu 
render  free  and  frequent  stimulation  indispt 
sable.  There  is,  perhaps,  no  condition  wh< 
wine  produces  such  marked  and  immediate  her 
fit  as  in  the  depression  following  upon  the  cri 
of  measles ; it  seems  to  give  life,  certainly 
is  a direct  means  of  saving  it.  enabling  st 
nourishment  to  be  taken  as  will  soon  sup 
altogether  the  needed  support.  Sedative*  i’ 


MEASLES. 

not  often  required ; a small  dose  of  Dover’s 
powder  moderates  any  tendency  to  diarrhoea; 
this  is  always  to  be  guarded  against,  and  never 
provoked.  Where,  without  complication,  the  fe- 
brile crisis  is  delayed,  a dose  of  quinine  with 
Dover’s  powder  at  night  has  been  useful.  After 
the  crisis  cold  bathing,  with  great  precaution, 
aids  sleep,  and  gives  tone  to  the  cutaneous,  bron- 
chial, and  pulmonary  circulations ; cold  affusions 
may  be  necessary  for  hyperpyrexia  at  a later 
stage,  when,  if  head-symptoms  threaten,  ice  should 
be  applied  to  the  head.  Croupy  symptoms  and 
bronchial  catarrh  in  children  after  the  eruption, 
ire  to  be  treated  on  general  principles,  as  de- 
scribed in  the  articles  having  reference  to  these 
liseases.  Diarrhoea  at  the  close  of  measles  may 
ake  the  place  of  pneumonic  symptoms,  and  need 
jot  be  suddenly  checked.  Best  in  bed,  carefully 
’egulated  diet,  and  stimulants,  with  opiate  epi- 
hems,  or  an  opiate  enema,  will  generally  relieve, 
the  mineral  acids,  with  or  without  a bitter,  aid 
igestion,  and  can  either  be  given  very  dilute  as  a 
rink  at  any  time,  or  in  a definite  dose  with  food, 
'or  the  irregular  febrile  disturbance  noticed  in 
le  weakly,  they  are  useful  adjuncts  to  the  quinine 
■ cod-liver  oil  that  are  then  essential.  Some 
cal  troubles  must  he  treated;  earache  needs  a 
)se  of  croton-chloral,  or  a warm  poultice  with 
little  opium  in  the  ear  gives  relief ; otorrhcea 
quires  tepid  syringing ; for  ophthalmia,  lead 
cion,  and  the  topical  use  of  belladonua  or  atro- 
,i  if  there  be  photophobia,  a7e  necessary;  the 
'cllen  eyelids  should  be  raised  to  sea  that  no 
ury  to  the  eye  occurs  while  other  severe  symp- 
us  may  be  attracting  most  attention.  Ulcers  in 
i ) mouth  or  elsewhere  may  have  to  be  touched 
Ah  nitrate  of  silver  or  boracic  acid,  where 
; ringent  washes  are  ineffective.  After-treat- 
intis  always  important  and  necessary.  For  the 
f smia  which  attends  convalescence  some  form 
c ron  is  to  be  taken  with  meals  two  or  three 
t es  a day.  Cod-liver  oil  should  be  given  an 
1 r after  meals,  at  least  twice  a day,  to  the 
s imous  or  delicate.  Often  the  mineral  acids 
" i a hitter  are  of  service,  especially  when  the 
r l has  been  livid  or  petechial.  The  clothing 
6l  ild  be  warm,  with  flannel  next  the  skin.  Cold 
baling  rapidly  performed,  or  with  salt-water, 
» ) £*e  recommended ; and  when  the  weather 
is  ne  the  patient  should  go  out  of  doors  once 
or  vice  a day,  avoiding  chill  or  fatigue.  Chil- 
dr  are  the  better  for  an  afternoon  sleep ; adults 
sh  Id  avoid  full  work,  or  exposure  at  night,  for 
on  >r  two  months  after  measles.  Convalescents 
*h' d have  a change  of  room  in  the  second  week 
of  le  illness  ; means  should  then  be  taken  to 
po  v and  disinfect  the  sick  chamber,  as  by 
hui  ng  sulphur  or  the  bisulphide  of  carbon  in  it 
donning  ; this  does  not  interfere  with 
oft  rooms  in  the  house  to  which  convalescents 
are  moved.  Change  of  air  or  place  is  not  so 
nee  ary  ns  is  often  supposed.  Homo  is  the  best 
k.  ^or  cure,  not  only  until  all  danger  of  infec- 
j>or  i passed,  but  that  the  dangers  of  conva- 
lesc  ee  and  the  possible  development  of  any 
coni  utional  defect  may  be  watched,  and  receive 
■he  diest  and  best  attention. 

William  Squire. 

^ MS  U KEMEKT. — A method  of  physical 

59 


MEDIASTINUM,  DISEASES  OF.  92P 
examination,  in  which  tape-measures  and  othei 
instruments  are  used  to  ascertain  accurately  the 
shape,  dimensions,  and  movements  of  different 
parts  of  the  body.  See  Physical  Examination. 

MEDIASTINUM,  Diseases  of. — Synon.  : 

Fr.  Maladies  du  Mediastin  ; Ger.  Krankheitcn 
des  Mediastinum. — The  principal  morbid  condi- 
tions which  occur  in  connection  with  that  regior 
of  the  chest  which  is  known  as  the  mediastinum, 
are  (1)  aneurism  of  the  thoracic  aorta ; (2)  in 
flammation  of  the  tissues  or  textures  within  the 
cavity ; and  (3)  new  growths  involving  the  same 
space.  Of  theso  conditions,  aortic  aneurism  is 
by  far  the  most  common  ; hut  it  possesses  so 
many  special  features  that  it  will  be  described 
separately  in  this  work  ( see  Aorta,  Diseases  of 
and  Thoracic  Aneurism).  The  remaining  pa- 
thological conditions  involving  the  mediastinum 
will  be  discussed  in  the  following  pages. 

1.  Mediastinum,  Inflammation  of. — Sy- 
non.; Mediastinisis  ; Fr.  Mediastinite ; Ger. 
Mediastinitis. 

Definition. — This  term  has  been  employed  by 
writers  to  denote  inflammation  ofihe  serous  sur 
face  of  the  duplicature  of  the  pleura  separating 
the  pleural  from  the  mediastinal  cavity,  and  also: 
inflammation  originating  in  the  cellular  tissue 
or  other  tbxtures  of  the  mediastinal  space.  In 
the  former  sense  mediastinitis  is  but  a variety  of 
pleurisy,  which,  though  it  may  he  characterised  by 
special  symptoms,  must  be  very  difficult,  if  not 
impossible,  to  diagnose  during  life.  We  confine 
our  attention  here  to  inflammation  and  its  result  s 
in  the  mediastinal  cavity. 

^Etiology  and  Anatomical  Characters. — 
There  are  very  few  trustworthy  observations  or 
record  of  simple  acute  inflammation  of  the  me- 
diastinum, terminating  either  in  resolution  or  in 
effusion  of  plastic  lymph.  An  example  of  the 
latter  detailed  by  Wildemann  is  probably  unique. 
In  this  instance  the  anterior  mediastinum  was 
filled  with  layers  of  solid  exudation ; the  peri- 
cardium inflamed;  and  its  cavity  distended  by 
six  ounces  of  pus.  The  mediastinal  effusion 
appeared  to  have  been  occasioned  by  long-con- 
tinued pressure  on  the  sternal  region.  On  the 
other  hand,  we  have  numerous  examples  re- 
corded, in  which  mediastinal  abscesses  have  re 
suited  both  from  primary  or  idiopathic,  and  froir 
secondary  or  symptomatic  inflammation.  Primary 
abscess,  thongh  rare,  is  occasionally  met  with 
produced  either  by  local  injury  or  simply  cold 
Gunther  (in  Oesterreich . Zeitschr.  f.  prak.  Heilk 
1859,)  and  others  have  recorded  cases  of  medias 
tinal  abscess  originating  simply  in  cold.  It  may 
however,  be  suspected  that  some  forgotten  pliy 
sical  injury  had  in  some  of  these  cases  been 
received,  as  in  the  only  case  of  the  kind  that  has 
fallen  under  the  writer’s  notice.  Dr.  Goodhart 
in  the  Pathological  Transactions,  vol.  xxviii.,  re- 
cords a case  of  acute  mediastinal  abscess,  result- 
ing apparently  from  injury  produced  by  tin. 
sticking  of  a piece  of  meat  in  the  oesophagus. 
But  by  far  the  most  frequent  cause  is  suppura- 
tion of  the  lymphatic  glands  in  scrofulous  sub- 
jects,  as  in  a remarkable  instance  recorded  by 
Dr.  Bristowe,  in  the  Pathological  Transactions, 
vol.  ix.  p.  46.  Secondary  or  symptomatic  ab- 


M EDIASTINTJM,  DISEASES  OF. 


930 

scesses,  in  the  form  of  purulent  depots , are  not 
infrequently  met  with  in  the  anterior  medias- 
tinum, either  in  connection  with  operations,  such 
as  tracheotomy,  or  as  the  result  of  general  py- 
aemia. 

Symptoms.- — The  only  instance  of  primary  ab- 
scess of  the  anterior  mediastinum  that  has  fallen 
under  the  writer's  observation  presented  the 
following  symptoms : — A middle-aged  lady,  pre- 
viously in  good  health,  fell  on  going  up-stairs  and 
struck  the  sternum  against  the  stone  edge  of  the 
stairs.  A few  weeks  afterwards  she  complained 
of  uneasiness  about  the  chest,  and  of  pains  in 
the  left  shoulder  and  about  the  scapula  and  neck. 
They  were  not  severe,  and  had  more  the  charac- 
ter of  neuralgia  or  rheumatism  than  of  anything 
more  serious.  After  a time  there  was  some  general 
derangement  of  the  health,  attended  by  dyspeptic 
symptoms,  a certain  degree  of  febrile  disturb- 
ance, some  dyspnoea,  and  inability  to  lie  down 
except  in  certain  positions.  Two  months  after  the 
accident,  which  had  been  forgotten,  there  was  a 
distinct  prominence  over  the  upper  part  of  the 
sternum  of  an  oval  shape,  and  rather  less  in  cir- 
cumference than  the  palm  of  the  hand,  not  red, 
but  tender  on  pressure,  and  to  which  was  referred 
a sense  of  uneasiness  and  pressure.  The  aspect 
of  the  patient  was  indicative  of  some  anxiety,  but 
not  distress.  The  breathing  was  quiet;  the 
pulse  was  quickened  ; but  there  was  little  or  no 
febrile  heat.  There  was  some  cough,  attended 
by  mucous  expectoration  sometimes  streaked 
with  bl<x)d.  She  complained  of  soreness  and 
irritation  of  the  larynx  and  fauces.  The  ac- 
tion anl  situation  of  the  heart  were  normal. 
There  was  dulness  on  percussion  over  the  whole 
of  the  prominence  of  the  sternum,  and  no- 
where else  throughout  the  chest,  but  neither 
pulsation  nor  fluctuation  could  be  detected  in 
the  tumour.  There  was  no  physical  evidence  of 
pressure  either  on  the  trachea  or  bronchi,  al- 
though the  patient  admitted  a feeling  of  weight 
or  pressure,  as  well  as  of  dull  uneasiness ; but 
there  had  been  no  sense  of  throbbing.  There 
was  no  enlargement  of  the  jugulars  or  superficial 
veins,  nor  any  tumefaction  of  the  base  of  the 
nock.  Careful  physical  examination  of  the  whole 
chest  revealed  nothing  beyond  a few  loose  mucous 
r&lcs.  Local  sedative  applications  and  the  use  of 
bromide  of  potassium  gave  some  relief  to  the  pain 
and  local  tenderness,  but  the  cough  and  laryngeal 
irritation  continued.  After  a few  days  about  a 
teaspoonful  of  bright  fluid  blood  was  coughed  up, 
and  the  day  following  a little  more,  without  ef- 
fort. The  next  day  there  was  suddenly  brought 
up  from  two  to  three  ounces  of  purulent  matter, 
followed  by  a sense  of  great  relief.  A micro- 
scopical examination  of  this  matter  revealed 
nothing  more  than  pus  and  mucus  mixed  with  an 
unusually  large  number  of  squamous  epithelial 
cells,  but  not  a trace  of  elastic  tissue,  or  anything 
to  indicate  disorganising  changes  in  the  lung. 
The  purulent  expectoration  continued,  but  in 
steadily  decreasing  amount,  for  about  five  weeks, 
the  sternal  swelling  subsiding  pari  passu.  Ulti- 
mately the  sternal  region  was  of  normal  aspect, 
and  the  general  health  was  completely'  restored, 
though  for  some  time  there  was  occasional  slight 
oppression  of  the  breathing. 

The  above  example  1ms  been  recited  because 


the  symptoms  correspond  very  closely  with 
those  which  have  generally  characterised  such 
eases.  In  some  instances,  however,  there  has 
been  more  distinct  evidence  of  phlcgmoD,  and  a 
greater  amount  of  febrile  disturbance  and  dis- 
tress. Unless  the  abscess  be  large,  or  associated 
with  glandular  or  other  organic  disease,  symp- 
toms of  compression,  either  of  the  bronchi  ot 
large  vessels,  are  not  usually  observed.  But  in 
the  latter  case  there  may  be  not  only  symp- 
toms of  venous  and  bronchial  obstruction,  but 
even  serious  laryngeal  symptoms  and  paroxysms 
of  severe  dyspnoea.  The  abscess  may  open  either 
into  the  trachea,  bronchi,  or  pleural  cavity,  if  no 
external  outlet  is  obtained.  Spontaneous  exter- 
nal opening  is  said  to  occur  most  frequently  on 
a level  with  the  second  rib,  to  the  left  of  the 
sternum. 

Phogkosis. — The  prognosis  of  mediastinal  in- 
flammation should,  in  view  of  its  possible  termi- 
nations, be  guarded. 

Treatment. — Unless  the  acute  symptoms  of 
phlegmonous  inflammation  should  be  well 
marked,  but  little  can  be  done  in  the  way  of 
treatment,  beyond  allaying  pain,  and  the  use  of 
local  soothing  applications.  Strict  rest  should 
be  enjoined,  and  an  external  opening  should  be 
made  for  the  outlet  of  matter,  so  soon  as  dis- 
tinct indications  are  presented  of  its  presence. 
It  should  also  be  borne  in  mind  that  the  inflam- 
matory action  is  liable  to  spread,  and  to  invoke 
either  the  lungs  or  the  pericardium. 

2.  Mediastinum,  Morbid  Growths  con- 
nected with. — By  far  the  larger  pr  portion  of 
intrathoraeic  growths  originate  in  the  medias- 
tinum, and  for  the  most  part  in  the  lymphatic 
glands.  Others,  which  may  commence  in  the 
lungs  or  pleura,  involve,  sooner  or  later,  the 
mediastinal  spaces.  In  treating,  therefore,  ot 
mediastinal  tumours,  from  a clini  al  point  o' 
view,  it  is  of  less  importance  to  determine  thei: 
precise  origin  than  to  ascertain  the  genera 
character  of  the  growth,  its  modes  of  develop 
ment,  and  the  effects  likely  to  lie  produced  oi 
the  surrounding  textures.  It  is  manifest,  how 
ever,  that  the  particular  site  of  the  growt 
must  exercise  an  important  influence,  both  o 
the  early  symptoms,  and  the  subsequent  feature 
of  the  case.  It  is  necessary,  therefore,  to  re 
member,  when  forming  a diagnosis  in  cast 
necessarily  very  obscure  in  their  early  stage 
how  very  various  are  the  situations  and  rel 
tions  of  the  growths.  Thus  either  function 
derangements  of  the  heart,  neuralgic  pains 
the  muscles,  dysphagia,  spasmodic  affections 
the  larynx,  bronchial  irritation,  or  limit- 
pleuritic  symptoms,  may  be  the  earliest  iia 
cations. 

Varieties  and  Symptoms. — Almost  eve 
form  of  morbid  growth  has  been  met  with  in  t 
mediastina  : cancer  in  all  its  varieties;  sareou 
tons,  osteosarcomatous,  enchondromatous,  a 
fibrous  tumours ; lymphadenoma:  and  lardaceo, 
steatomatous.  and  tubercular  masses.  The  p 
gress  and  duration  of  the  disease  will  differ  nwr 
rially,  according  to  the  natural  history  of  th-‘ 
several  formations.  The  growth  of  sure  is  my 
I more  rapid  than  that  of  others.  By  some  ‘ 
l adjacent  textures  are  much  more  readily  ibyh- 1 


MEDIASTINUM,  DISEASES  OF. 


931 


than  by  others.  Constitutional  symptoms  and 
impairment  of  the  general  health  are  much  more 
pronounced  in  some  than  in  others.  Apart,  there- 
fore, from  the  special  features  given  to  each  case 
by  the  particular  locality  of  the  disease,  there 
■will  be  very  great  differences  in  its  general  aspect 
and  progress.  And  were  it  only  in  reference  to 
prognosis,  irrespective  of  treatment,  it  would  be 
very  desirable  to  determine  the  nature  as  well  as 
the  existence  of  the  growth.  This,  unfortunately, 
.n  many  instances,  cannot  be  done  ; but  in  others 
we  may  form  an  opinion  with  considerable  confi- 
dence. The  development  of  the  malignant  growths 
is  generally  much  more  rapid  than  that  of  the 
more  innocent,  and  the  duration  much  shorter. 
It  is  seldom  that  the  duration  of  an  intra-tlioracic 
growth  of  a malignant  character  extends  beyond 
a year.  Those  having  the  character  of  lympha- 
ienoma  or  lymphosarcoma  are  sometimes  of  much 
ongcr  duration.  These  in  a large  proportion 
>f  cases  commence  in  tlie  lymphatic  glands  of 
he  posterior  mediastinum,  or  in  the  anterior 
nediastinum,  from,  as  some  believe,  remains  of 
he  thymus  gland.  They  sometimes  attain  to 
in  enormous  size,  and  may  ultimately  involve 
.11  the  structures  within  the  thorax,  including 
he  heart  and  pericardium.  In  other  instances, 
ommencing  probably  in  the  connective  tissue, 
be  disease  spreads  along  the  roots  of  the  lungs 
nd  sides  of  the  bronchi,  extensively  involving 
le  adjacent  tissues  and  the  lungs  themselves, 
ithout,  for  a long  time,  giving  rise  to  any  con- 
derable  tumour.  In  other  cases  several  distinct 
imours  are  developed  at  some  distance  apart, 
he  period  at  which  pleuritic  effusion,  or  oedema 
1 tho  external  parts  occurs,  also  varies  greatly, 
bus,  too,  it  happens  that  alterations  in  the  ex- 
rnal  form  of  the  chest  are  early  manifest  in 
me  cases,  and  not  till  later  in  others.  In  some 
stances  these  alterations  of  form  are  limited,  in 
,hers  they  implicate  the  whole  of  one  side,  or 
en  the  whole  contour  of  the  thorax.  In  not 
few  instances,  whilst  the  growth  is  still  of 
lited  extent,  and  confined  to  the  posterior  me- 
jistinum,  the  symptoms  so  closely  resemble  those 
aneurism  as  to  make  the  diagnosis  extremely 
■iScult  and  uncertain.  The  more  prominent 
inptoms  are  indeed  in  some  instances,  and 
i a long  time,  mainly  cardiac.  In  the  most 
i lignant  types  of  disease,  and  where,  as  in  far 
t greater  number  of  instances  is  the  case,  the 
1 iphatic  glands  of  the  thorax  have  become 
i >licated  by  extension  of  disease  from  other 
o ms,  the  local  thoracic  symptoms  are  from  the 
f ; assoc.ated  with  those  general  symptoms 
Well  are  characteristic  of  malignant  disease, 
a pass  under  the  term  of  cancerous  cachexia. 
S omatous  tumours,  on  tho  other  hand,  at- 
h a considerable  size  without  constitutional 
syptoms  of  any  special  character.  As  a rule 
ithay  he  said  that  all  intra-thoracic  growths 
te  to  develop  inwards  rather  than  outwards; 
ar  thus  often  overlap  the  limgs  and  heart, 
P8)  along  the  great  vessels  and  nerves,  and 
Pr  i on  those  parts  that  offer-  least  resistance. 
It  only  in  very  rare  instances  that  the  chest- 
Wi  1 become  eroded  by  the  outward  pressure  of 
th  umour,  as  in  so  many  cases  of  aneurism. 
T1  is  the  more  remarkable  because  in  many  in- 
stsies  the  presence  of  the  growth  is  distinctly  in- 


dicated by  external  tumour,  arising  from  outward 
pressure  of  portions  of  the  chest-wal Is.  Thisis 
of  course  especially  the  case  when  the  growth 
is  in  immediate  proximity  to  the  walls  of  the 
chest.  In  the  case  of  large  tumours  the  external 
form  of  the  chest  may  be  rendered  unsymmetrical 
by  displacement  of  the  heart,  and  downward  pres- 
sure on  the  diaphragm  and  liver.  There  is,  how- 
ever, another  and  very  distinct  mode  by  which 
the  symmetry  of  the  chest  is  affected,  and  that  is 
by  collapse  of  the  lung  and  sinking  of  the  chest- 
wall,  in  consequence  of  the  pressure  exercised  on 
the  root  of  the  lung,  by  the  progressive  advance 
of  the  tumour.  The  effect  of  this  is  sometimes 
rendered  still  more  apparent  by  the  corresponding 
expansion  of  the  opposite  lung,  either  from  con- 
gestion or  induced  emphysema.  The  deformity 
of  the  chest  attains  its  maximum  in  many  cases 
by  the  outgrowth  of  tumours  above  the  clavicle 
and  along  the  neck.  It  may  be  well,  however, 
at  the  risk  of  some  repetition,  to  classify,  under 
different  heads,  the  most  characteristic  of  the 
multifarious  phenomena  that  have  been  observed 
in  connection  with  the  different  varieties  of 
mediastinal  growths. 

Derangements  of  tlie  circulation. — Derange- 
ments of  the  circulation,  which  are  necessarily 
induced,  in  all  cases,  to  a greater  or  less  degree, 
give  rise  to  phenomena  which  are  of  special  dia- 
gnostic importance  in  mediastinal  tumours.  The 
return  of  blood  through  the  vena  cava  superior 
and  its  affluents  is  early  impeded,  more  or  less,  in 
the  majority  of  cases,  and  sometimes  to  such  n.n 
extent  as  to  give  a special  aspect  to  the  case  It 
is  not,  however,  simply  by  pressure  on  the  venous 
trunks  that  the  indications  of  pulmonary  conges- 
tion, oedema,  and  cyanosis  areinduced.  In  many 
cases  the  veins  themselves,  although  seldom  the 
arteries,  are  involved  in  the  cancerous  disease : 
and  when  this  is  not  the  case,  there  is  often  a 
special  tendency  to  thrombosis  and  obliteration 
both  of  the  large  veins  and  of  their  radicles. 
Cancerous  deposit  has,  in  some  cases,  been  traced 
into  the  jugular  and  subclavian  veins,  entirely 
occluding  them;  in  other  cases  these  vessels 
have  been  enormously  distended.  Thus  we  h ive 
in  many  instances  great  tumefaction  of  the  face- 
neck,  and  upper  extremities,  from  oedema  and 
general  serous  infiltration.  In  like  manner  the 
circulation  through  certain  portions  of  the  lungs 
may  give  rise  either  to  haemorrhage  in  the  form 
of  haemoptysis,  or  to  sanguineous  effusion  into  tile 
plpura,  or  to  large  apoplectic  clots,  that  is,  infarcts. 
In  this  latter  way  the  physical  signs  of  consolida- 
tion are  sometimes  suddenly  induced,  or  increased.; 
and  after  death  the  pleural  cavity  has  been  found 
occupied  by  large  protuberances  from  the  pleura, 
consisting  simply  of  blood-tumours,  due  to  extra- 
vasation into  the  pulmonary  tissues.  Although 
the  arteries  are  much  less  liable  to  become  im- 
plicated in  cancerous  disease  than  the  veins,  they 
are  subject,  like  all  the  other  contents  of  the 
thorax,  to  pressure.  The  force  of  the  current  o' 
blood  through  them  may  thus  be  diminished,  ami 
there  may  be  a marked  difference  in  the  radial 
and  carotid  arteries  of  the  two  sides,  just  as  tiler 
is  in  aneurism  of  the  aorta.  It  is  needless  t 
say  that  the  symptoms  arising  from  mechanical 
influences  acting  on  the  heart  must  be  ver 
various.  This  organ  may  either  be  dragged  fro  c 


MEDIASTINUM,  DISEASES  OF. 


032 

its  natural  situation,  or  surrounded,  more  or 
less  completely,  by  the  advancing  disease,  and  its 
situation  and  action  concealed  from  all  observa- 
tion ; or  its  very  substance  may  become  involved 
in  the  spread  of  the  disease,  and  the  pericardium 
may  be  largely  distended  by  serous  and  bloody 
effusion.  Apart  from  those  disturbances  of  the 
heart’s  action  arising  from  interrupted  circula- 
tion through  the  lungs,  its  innervation  may  be 
seriously  affected,  as  will  be  subsequently  noted. 
And  it  is  evident  that  the  sounds,  rhythm,  and 
impulse  will  be  affected  in  more  ways  than  one ; 
even  when  neither  the  valvular  apparatus  nor 
any  other  structure  is  the  actual  seat  of  disease. 
In  the  malignant  forms  of  disease  the  muscular 
power  of  the  heart  is  generally  impaired,  and 
there  is  a consequent  tendency  to  palpitation  and 
faintness,  often  associated  with  nausea  and  vomit- 
ing. Such  symptoms  have  been  observed  in  rare 
cases,  where  the  heart  has  become  implicated  by 
disease  extending  from  the  mamma  through  the 
thoracic  walls. 

Febrile  symptoms. — Mediastinal  tumours  are 
not  as  a rule  characterised  by  febrile  disturbance, 
at  any  period  of  their  course.  Several  examples 
of  tumours  having  the  character  of  lympha- 
denoma  have,  however,  exhibited  striking  excep- 
tions to  this  rule.  The  writer  has  recorded  a re- 
markable instance,  and  others  have  been  recorded 
by  the  late  Dr.  Murchison  and  Dr.  Church,  in 
which  there  was  persistent  elevation  of  tempera- 
ture, and  rapidity  of  pulse  and  respiration,  but 
with  daily  alternations  of  rise  and  fall.  And  in 
these  instances  it  is  remarkable  that  the  pyrexia 
declined  with  the  advance  of  the  disease  to  its 
fatal  termination.  Intercurrent  inflammatory 
affections,  whether  of  the  pulmonary  tissue  or  of 
the  pleura,  may  in  any  case  occasion  correspond- 
ing symptoms  of  fever.  These,  however,  are 
seldom  very  pronounced. 

Disturbances  of  innervation. — Disturbances  of 
innervation  occur  at  all  stages,  and  in  connection 
with  every  variety  of  growth.  They  vary,  how- 
ever, greatly  in  their  character  and  severity. 
Although  pain  may  be  said  to  be  present  in  most 
instances,  it  is  often,  all  through  the  case,  by  no 
means  a prominent  symptom.  The  patient’s  dis- 
tress, often  very  great,  is  more  frequently  due  to 
dyspncea  and  interrupted  circulation,  than  to 
direct  implication  of  the  nerves.  Nevertheless 
neuralgic  pains  are  among  the  most  frequent 
of  the  early  subjective  symptoms,  and  are  some- 
times severe  in  the  later  stages.  When  from  the 
situation  of  the  growth  the  recurrent  laryngeal 
nerve  is  early  implicated,  we  sometimes  get 
paralysis  of  the  vocal  cords  and  aphonia,  at  other 
times  spasmodic  paroxysms  of  dyspncea,  and  ur- 
gent laryngeal  symptoms.  In  rare  cases  cancerous 
disease  of  the  posterior  mediastinum  has  invaded 
the  spine,  and  given  rise  to  paralysis  of  the  limbs 
and  trunk.  The  cough,  which  is  generally  due 
to  more  or  less  bronchial  irritation  and  secretion, 
sometimes  arises  from  purely  nervous  reflex  ir- 
ritation, and  may  occur  in  paroxysms  like  those 
of  whooping  cough.  The  innervation  of  the 
heart  may  be  so  disturbed  as  to  occasion  symp- 
toms of  angina,  as  well  as  various  irregularities  of 
action  and  tendency  to  fainting.  The  immediate 
cause  of  death  is  not  infrequently  to  be  attributed 
to  sudden  interruption  of  the  heart’s  action. 


Bespiratory  phenomena. — The  respiratory  phe 
nomena,  although  presenting  the  utmost  diver- 
sities,  have  nevertheless  certain  special  charac- 
teristics. When  the  patient  is  at  rest,  there  is 
often  nothing  to  denote  any  impediment  to  the 
respiratory  function — no  quickened  movement,  nc 
alteration  of  aspect,  no  expression  of  anxiety; 
but  on  the  least  exertion,  dyspncea  is  at  once 
manifested.  Mere  change  of  position  may  induce 
a paroxysm  of  dyspncea.  With  advancing  dis- 
ease implicating  at  length  the  contents  of  the 
thorax  to  a great  extent,  there  may  be  no  corre- 
sponding increase  of  dyspnoea,  especially  if  the 
progress  be  slow.  In  other  cases,  with  physical 
signs  of  a very  questionable  and  limited  charac- 
ter, there  may  be  great  distress  in  breathing. 
Absence  of  apparent  dyspnoea  is  sometimes  the 
more  remarkable  from  the  manifestly  diminished 
movement  of  the  chest-walls,  or  even  com- 
plete immobility  perhaps  of  one  side.  Nor  in 
many  cases  does  the  dyspnoea  correspond  with  the 
evidence  of  pressure,  and  the  absence  of  respira- 
tory sounds  on  auscultation.  The  want  of  cor- 
respondence between  the  physical  signs  and  the 
functional  symptoms  is  indeed  often  most  striking. 
In  one  case  there  will  be  persistent  difficulty  of 
breathing,  amounting  to  orthopnoea  of  the  most 
urgent  character,  in  another  merely  a little  quick- 
ened respiration  — lividity  and  turgescence  of 
features  in  one  case,  in  another  an  anaemic  aspect. 

Physical  signs. — So  long  as  a mediastinal  tu- 
mour remains  of  but  small  size,  it  will,  of  course, 
not  be  recognisable  by  external  physical  signs, 
except  such  as  are  due  to  mechanical  derange- 
ments of  the  circulation,  generally  denoted  by 
enlargement  of  the  external  superficial  veins. 
Comparatively  small  tumours  will,  however, 
sometimes  manifest  themselves  by  circumscribed 
alterations  in  the  external  aspect  of  the  chest. 
This  of  course  will  depend  much  on  the  site  of 
the  tumour.  Tumours  of  the  anterior  medias- 
tinum may  very  early  manifest  themselves,  bv 
throwing  forward  the  sternum  and  the  sternal 
attachments  of  one  or  more  of  the  ribs,  and  ulti- 
mately rendering  the  two  sides  of  the  chest 
asymmetrical.  It  is  in  these  cases,  when,  with 
the  growth  of  the  tumour,  the  heart  and  aorta 
become  overlapped  and  pressed  on,  that  we  have 
evidence  of  pulsation  and  vibration,  simulating 
closely  the  signs  of  aneurism,  and  sometimes 
attended  by  a cardiac  bruit.  In  other  cases  the 
growth,  extending  upwards,  shows  itself  by  tu- 
mefaction and  swelling  above  the  sternum  and 
clavicles,  being  then  often  attended  by  signs  or 
pressure  on  the  trachea  or  bronchi.  When  the 
posterior  mediastinum  is  the  chief  seat  of  dis- 
ease, this  may  attain  to  very  considerable  deve- 
lopment before  any  very  decided  alteration  is 
seen  in  the  form  of  the  chest,  unless  one  or  other 
pleura  have  become  distended  by  fluid  effusion. 
The  diagnosis  of  these  latter  cases  often  present- 
the  utmost  difficulty,  the  physical  signs  being 
simply  those  of  pleuritic  effusion,  and  the  symp- 
toms such  only  as  may  be  fairly  referred  to 
mechanical  effects  of  fluid  pressure.  When  tie 
tumour  is  of  any  considerable  size,  the  motion- 
of  those  parts  of  the  chest-walls  which  are  m 
immediate  proximity  to  the  growth  are  almo 
always  impeded,  and  there  is  evidence  of  dimiu 
ished  expansion.  This  is  also  the  case  when  t 


MEDIASTINUM,  DISEASES  OP.  933 


pleura  ia  occupied  by  secondary  growths,  when 
there  may  he  obliteration  of  the  intercostal 
spaces,  as  in  pleurisy.  But  as  collapse  of  the 
lung  sometimes  takes  place  with  little  or  no 
pleuritic  effusion,  there  may  be  falling  in  of  one 
side  of  the  chest,  appreciable  by  the  eye,  as  well 
as  by  measurement.  As,  however,  the  tumour 
usually  extends  more  to  one  side  than  the  other, 
the  measurements  of  the  two  sides  will  generally 
differ,  from  this  cause  alone.  By  percussion  and 
palpation  the  ordinary  signs  of  solidification  will 
of  course  be  detected,  whenever  the  tumour  ap- 
proaches the  chest-walls  and  attains  to  any  size, 
or  whenever  any  considerable  portion  of  the  lung 
has  been  rendered  solid,  either  by  invasion  of  the 
growth,  by  pneumonic  consolidation,  or  by  hae- 
moptic  engorgement.  Signs  of  displacement  are 
often  manifest  comparatively  early,  and  later  on 
may  be  of  the  most  unmistakable  character.  The 
heart  may  be  dragged  away  from  its  natural 
situation  in  various  directions ; the  diaphragm 
thrust  down ; the  lower  ribs  thrown  out ; and  the 
leformity  of  the  anterior  part  of  the  chest,  and 
.lie  physical  signs  on  auscultation  and  percussion, 
may  be  greatly  modified,  by  distension  of  the 
pericardium  from  effusion.  It  will  at  once, 
therefore,  be  seen  that  the  cardiac  signs  will  be 
of  very  variable  and  diverse  character — so  much 
so  that  any  detailed  description  would  be  of 
little  practical  use.  It  should  also  always  be 
remembered,  that  the  lung  undergoes  very 
various  and  opposite  changes  as  the  result  simply 
of  pressure  on  the  bronchi,  and  interruption  to 
the  entrance  and  egress  of  air  from  the  air-cells. 
Thus  in  the  early  stages  there  may  be  more  or 
less  of  emphysema,  and  corresponding  physical 
signs  on  the  affected  side;  and  in  more  advanced 
cases  a certain  amount  of  emphysema  of  the 
opposite  side.  As  the  bronchi  become  occluded, 
we  have  at  first  the  stethoscopic  signs  of  accumu- 
lation of  secretion,  soon  to  be  followed  by  signs 
of  consolidation  and  absence  of  respiration,  when 
the  lung  is  undergoing  those  destructive  changes 
by  which  it  becomes  converted  into  a solid  mass 
broken  up  by  irregular  abscesses  or  pockets  of  pus, 
produced  in  part  by  actual  pulmonary  disinte- 
gration, and  partly  by  dilatation  of  the  bronchi. 
In  the  latter  condition  there  may  be  enlargement 
of  the  lung  and  distension  of  the  side,  rather  than 
collapse.  Hyper-resonance  from  emphysema, 
followed  by  signs  of  consolidation  and  absence 
, of  all  respiratory  phenomena,  associated  with  or 
preceded  by  other  indications  of  pressure,  would 
be  tolerably  decisive  of  the  existence  of  a me- 
diastinal tumour,  but  whether  aneurismal  or 
some  form  of  malignant  disease  might  still  be  a 
question. 

Diagnosis. — From  the  preceding  remarks  it 
will  be  evident  that  there  are  no  symptoms  or 
physical  signs,  nor  any  precise  order  of  pheno- 
mena, that  can  be  said  to  be  peculiar  to,  or 
diagnostic  of,  an  intra-thoracie  growth.  No  two 
leases  will  he  found  to  be  precisely  alike.  Never- 
theless, the  want  of  correspondence  with  the 
irdinary  forms  of  thoracic  disease;  the  very 
general  presence  of  signs  of  pressure  and  me- 
■haoical  derangement ; and  the  varying  aspects 
f these  signs  are,  in  the  majority  of  cases,  when 
onsi  lered  in  conjunction  with  the  history  of  the 
ase,  sufficient  to  lead,  if  not  to  a positive,  at 


least  to  a probable  diagnosis.  In  the  early 
stages  of  a mediastinal  tumour,  when  the  growth 
is  still  small,  it  will  be  easily  seen,  if  we  reflect 
on  the  anatomical  relations  of  the  mediastinum, 
that  an  accurate  diagnosis  must  often  be  impos- 
sible. And  even  when  formidable  symptoms  arise 
from  the  peculiar  relations  of  a small  growth,  it 
must  often  be  extremely  difficult  to  avoid  error. 
Both  retro-  and  antero-stemal  nodes  will  some- 
times closely  resemble  both  aneurism  on  the  one 
side,  and  mediastinal  tumours  on  the  other.  For 
further  remarks  on  the  physical  diagnosis,  the 
reader  is  referred  to  the  articles  Lungs,  Malig- 
nant Disease  of ; Mediastinum,  Inflammation 
of ; and  Thoracic  Aneurism. 

Treatment. — There  is  but  little  that  can  he 
said  as  to  the  treatment  of  mediastinal  tumours, 
except  as  regards  the  palliation  of  urgent  symp- 
toms, or  the  relief  of  some  of  the  chief  secondary 
effects  of  the  original  diseases.  All  forms  of 
intra-thoracic  growths  of  a malignant  character 
are  steadily  progressive  to  their  fatal  termina- 
tion. Some  of  the  less  malignant  in  character — 
for  example,  lymphadenomatous  tumours — may 
last  a long  time,  and  appear  for  a while  to  be 
stationary,  and  unattended  by  any  serious  im- 
pairment of  the  general  health.  Even  these,  how- 
ever, are  exceptional  cases.  Bodily  rest,  freedom 
from  causes  of  moral  disturbance,  maintenance  of 
the  general  nutrition,  change  of  air,  and  every 
available  hygienic  means,  are  essential  in  all 
cases.  Chalybeates  and  other  tonics  may  be  of 
more  or  less  service.  Special  symptoms  often 
admit  of  considerable  relief;  for  instance,  local 
pains  by  external  soothing  applications,  or 
counter-irritants,  such  as  sinapisms  and  small 
blisters.  The  latter  are  often  of  signal  benefit. 
Pain,  sleeplessness,  and  harassing  unrelieving 
cough  may  all  he  alleviated  by  opium  and  other 
narcotics,  such  as  chloral  or  bromide  of  potas- 
sium, and  sometimes  by  minute  doses  of  anti- 
mony. For  the  distressing  paroxysmal  attacks 
of  (^jspncea  and  laryngeal  spasm,  opium  and  its 
preparations  require  to  he  given  with  caution ; 
but  chlorodyne,  Hoffman’s  ether,  and  the  in- 
halation of  chloroform  are  often  useful.  The 
distress  arising  from  dyspnoea  and  inability  to 
lie  down  will  often  tax  the  resources  of  the 
physician  to  the  utmost,  depending  as  they  do 
on  a variety  of  complex  causes.  When  they  ap- 
pear to  be  mainly  referrible  to  accumulation  of 
fluid  in  the  pleura,  paracentesis  must  he  resorted 
to.  and  will  often  be  followed  by  great  temporary 
relief.  At  one  time  the  writer  was  averse  to 
this  procedure,  but  further  experience  has  led 
him  to  believe  that  it  is  productive  of  little  if  any 
mischief,  and  that  life  may  sometimes  be  much 
prolonged  by  even  repeated  evacuation  of  the 
pleural  effusion.  In  proportion  as  symptoms  of 
pleurisy,  bronchitis,  or  pneumonia  predominate, 
they  must  be  met  by  the  ordinary  therapeutic 
resources.  It  remains  to  be  seen  whether  our 
further  knowledge  of  the  natural  history  of  lym- 
phadenoma  may  advance  our  therapeutic  re- 
sources. Certainly  the  slower  progress  of  such 
cases  affords  more  time  for  the  trial  of  iodine, 
chalybeates,  or  other  constitutional  remedies.  It 
should  ever  be  borne  in  mind  that  severe  attacks 
of  dyspncea,  with  stridulous  breathing  and  other 
indications  of  intra-thoracic  pressure,  may  all 


334  MEDIASTINUM,  DISEASES  OF. 
be  due  to  nerve-irritation  alone,  and  often  be 
greatly  alleviated  by  small  doses  of  morphia 
combined  -with  antispasmodics. 

J.  Risdon  Bennett. 

MEDIATE  (medius,  a means). — -A  term  ap- 
plied to  auscultation  and  percussion,  when  some 
medium  is  interposed  between  the  surface  of 
the  body  of  the  patient  and  the  ear  or  finger 
of  the  physician,  such  as  the  stethoscope  in  the 
one  case,  or  a pleximeter  in  the  other.  See 
Physical  Examination. 

MEDITERRANEAN,  The.— Moderately 
dry  and  warm,  and  very  sunny  winter  climate. 
See  Algiers;  Cannes;  Hyeres;  Nice;  Men- 
tone ; Malaga  ; San  Remo,  &c.  ; and  Climate, 
Treatment  of  Disease  by. 

MEDULLA  OBLONGATA,  Lesions  of. 

Synon.  ; Fr.  Maladies  de  la  Moelle  allongee ; 
Ger.  Krankkeiten  des  verldngerten  Marks. 

Introduction. — The  pathology  of  the  medulla 
oblongata  is  more  than  usually  complex.  Not 
merely  is  it  liable  to  injuries,  and  diseases  such 
as  haemorrhages,  softenings — necrobiotic  and  in- 
flammatory, tumours,  &c.,  having  their  primary 
seat  here,  as  in  other  nerve-centres;  hut  also, 
and  more  frequently,  the  medulla  is  implicated 
in  diseases  of  the  pons  and  cerebellum,  and 
affected  indirectly  by  intracranial  diseases  in 
general.  Being  the  connecting  link  between  the 
brain  and  spinal  cord,  it  is  subject  to  ascending 
or  descending  degenerative  processes,  secondary 
to  lesions  in  the  cerebral  or  spinal  sensory  and 
motor  tracts.  Further,  it  is  the  seat  of  a special 
form  of  degeneration,  characterised  by  a very 
doflnite  group  of  symptoms,  differentiated  under 
the  term  bulbar  or  labio-glosso-laryngeal  para- 
lysis. 

With  the  indirect  affections  of  the  medulla 
oblongata,  in  connection  with  the  various  forms 
of  intracranial  disease,  degenerations  of  the 
sensory  or  motor  tracts  secondary  to  cerebral 
or  spinal  disease,  or  the  pathology  and  symptom- 
atology of  bulbar  paralysis,  this  article  does 
not  profess  to  deal,  as  these  subjects  will  be 
found  fully  discussed  under  other  headings. 
Attention  will  be  directed  mainly  to  the  data 
which  serve  to  establish,  so  far  as  this  is 
possible,  the  regional  diagnosis  of  medullary 
lesions. 

Summary  op  Pathological  Conditions. — 
Traumatic  lesions. — Injuries  of  the  medulla  ob- 
longata are  not  uncommon  in  consequence  of 
fracture  or  dislocation  of  the  atlas  and  axis,  as  in 
falls,  hanging,  twisting  of  the  neck,  or  as  the  re- 
sult of  diseased  vertebra.  In  such  cases  death 
is  instantaneous,  owiug  to  the  sudden  cessation 
of  the  circulation  and  respiration,  from  lesion  of 
the  centres  of  these  vital  functions,  which  are 
situated  in  the  medulla  (Flourens’  ncetid  vital). 

To  commotion  or  contusion,  with  punctiform 
extravasations  in  the  medullary  centres  (Duret, 
Sur  les  Traumatismes  Cerchraux,  187S),  is  also 
to  be  attributed  sudden  death  from  blows  on 
the  head.  Not  unfrequently  lesions  of  the 
fourth  ventricle,  the  result  of  cranial  injuries, 
not  proving  fatal,  give  rise  to  diabetes  mellitus 
or  insipidus,  along  with  other  symptoms  indica- 
tive of  chronic  lesion  of  the  pons  or  medulla. 


MEDULLA  OBLONGATA,  LESION'S  OK. 

Effusions  of  blood  into  the  fourth  ventricle, 
whether  arising  from  the  medulla  itself,  the  pons, 
or  the  cerebellum,  or  gaining  access  from  the  la- 
teral ventricles  by  the  aqueduct  of  Sylvius,  are, 
as  a rule,  suddenly  fatal  from  paralysis  of  the 
circulation  and  respiration.  Death  may  occur 
with  or  without  convulsions. 

Tumours. — Tumours  implicating  the  medulla 
oblongata  may  have  their  seat  primarily  in  tiie 
medulla ; but  more  commonly  the  tumours  are 
situated  at  the  base  of  the  skull,  in  the  cerebellum 
or  pons,  and  invade  the  medulla  in  their  growth. 
Apart  from  the  general  symptoms  of  cerebral 
tumour — headache,  sickness,  optic  neuritis,  &c., 
the  special  indications  of  implication  of  the  me- 
dulla oblongata  are  one  or  more  of  the  symptoms 
mentioned  below.  Here  also,  however,  some 
remarkable  cases  have  been  put  on  record,  in 
which,  notwithstanding  the  existence  of  tumours 
actually  in  the  substance  of  the  medulla  itself, 
the  symptoms  during  life  have  presented  nothing 
striking  or  characteristic.  (See  a case  by  Dr. 
Wiiks,  Diseases  of  the  Nervous  System,  1878.) 

Hemorrhage. — Haemorrhage  into  the  substance 
of  the  medulla  oblongata,  and  limited  to  this,  is 
comparatively  rare.  More  commonly  the  pons 
and  medulla  are  affected  together.  Hemorrhages 
here  of  any  extent  are  very  rapidly  fatal.  Insome 
cases  death  is  instantaneous.  In  others  a few  hours 
may  elapse,  death  occurring  in  profound  coma 
with  stertorous  respiration,  and  occasionally  con- 
vulsions. Whether  the  haemorrhage  is  primarily 
in  the  medulla  or  in  the  pons  cannot  be  diagnosed 
with  certainty.  The  other  causes  of  sudden 
death,  such  as  affections  of  the  heart,  must  be 
excluded  before  haemorrhage  into  the  medulla 
can  be  diagnosed,  and  this  is  in  many  circum- 
stances obviously  impossible. 

Haemorrhage  into  the  medulla  oblongata  is 
usually  fatal,  and  rarely  gives  rise  to  ehronie 
stationary  lesions.  These  are  usually  the  result 
of  thrombosis  or  embolism,  or,  more  rarely,  acute 
myelitis. 

Thrombosis. — Thrombosis  of  the  vertebral 
arteries  is  the  most  common  origin  of  softening 
limited  to  the  medulla  oblongata.  The  onset  is 
frequently  sudden,  as  in  haemorrhage,  but  the 
course  is  more  slow.  The  more  chronic  nature  of 
the  affection  is  an  important  diagnostic  featuro 
of  softening.  The  symptoms  of  softening  of  the 
medulla  thus  arising  are  in  many  respects  like 
those  of  progressive  bulbar  paralysis,  but  there 
are  also  important  differences.  They  are  some- 
times generalised  under  the  head  of  ‘acute’  or 
‘ apoplectiform  ’ bulbar  paralysis,  in  contra- 
distinction to  the  classic  form  of  this  affection 
described  by  Duchcnne.  See  Labio-Glosso- 
Laryngeal  Paralysis. 

Localising  Phenomena. — The  symptoms  met 
with  in  the  affection  just  named  are  the  most 
reliable  clinical  data  on  which  to  found  a 
regional  diagnosis  of  lesions  of  the  medulla 
oblongata.  The  characteristic  symptoms  are  a 
conjoint  affection  of  the  extremities  and  one  or 
more  of  the  bulbar  cranial  nerves,  with  im- 
pairment of  speech  and  deglutition,  and  cardio- 
respiratory disturbances.  Sometimes  all  foul 
extremities  are  paretic  or  paralysed;  some- 
times the  lower  extremities  alone;  anJ  occa- 
sionally the  paralysis  is  of  the  hemiplegic  order 


MEGRIM. 


93a 


MEDULLA  OBLONGATA,  LESIONS  OE. 

[t  the  paralysis  affects  only  the  extremities, 
n thout  implication  of  the  bulbar  nerves,  as 
' sometimes  occurs  a diagnosis  of  the  medullary 
I -eat  of  the  lesion  cannot  be  made  with  certainty. 
Anaesthesia  has  not  been  recorded,  but  occa- 
sionally paraesthesiae  have  been  observed.  Ataxic 
affections  of  the  extremities  have  also  been  met 
jvith  by  Leyden  and  Prevost. 

Of  the  cranial  nerves  the  hypoglossal  is  most 
commonly  involved.  The  symptoms  are  im- 
paired mobility  of  the  tongue,  with  more  or  less 
pronounced  dysarthria.  This  is  not  absolutely 
characteristic  of  bulbar  disease,  however,  as  a 
similar  affection  of  the  hypoglossal  may  occur 
in  disease  of  the  pons.  The  tongue  and  speech 
are  rarely,  if  ever,  so  affected  as  iu  the  classic 
or  progressive  bulbar  paralysis,  nor  has  the 
atrophy  of  the  muscles  of  the  tongue,  with 
altered  electrical  reactions,  been  noted. 

Of  more  importance  as  a diagnostic  mark  is 
dysphagia,  or  paralysis  of  deglutition.  This,  in 
the  absence  of  general  cerebral  symptoms,  points 
to  affection  of  the  medulla.  Paralysis  of  the 
soft  palate,  on  one  or  both  sides,  is  also  a fre- 
quent, if  not  constant,  symptom.  Occasionally 
also  aphonia  occurs,  and,  taken  with  the  other 
eymptoms.  points  conclusively  to  affection  of  the 
medulla  oblongata. 

Irregularity  of  the  heart ; acceleration  or  re- 
tardation of  the  pulse ; and  sighing  and  laboured 
respiration,  often  amounting  to  orthopncea,  in 
the  absence  of  general  cerebral  symptoms,  are 
also  important  indications  of  disease  of  the  me- 
dulla oblongata.  Among  other  symptoms  have 
been  noted  coughing,  and  vomiting,  explicable 
by  affection  of  the  respiratory  centres.  Trismus 
has  been  mentioned  by  Joffroy  as  a charac- 
teristic symptom  of  acute  bulbar  paralysis,  but 
Nothnagel,  on  good  grounds,  disputes  the  accu- 
racy of  this  statement. 

Albuminuria  and  glycosuria  have  also  been 
observed  in  connection  with  bulbar  lesions,  the 
latter  more  particularly  after  injuries  affecting 
the  floor  of  the  fourth  ventricle;  but  the 
occurrence  of  these  symptoms  in  connection 
with  acute  bulbar  paralysis  requires  further 
investigation,  as  they  cannot  as  yet  be  regarded 
as  constant. 

An  affection  simulating  disease  of  the  medulla 
oblongata  results  from  bilateral  lesion  of  the  an- 
terior third  of  the  internal  capsule  (Lepine),  or  of 
the  cortex  in  the  region  of  the  lower  extremity 
of  the  ascending  frontal  and  posterior  extremity 
of  the  third  frontal  convolution  (Barlow).  Such 
a bilateral  lesion  causes  paralysis  of  articulation, 
and  also  true  aphasia  if  the  lesion  is  cortical, 
along  with  a greater  or  less  degree  of  double 
• hemiplegia.  The  diagnosis  must  depend  on  the 
truly  volitional  character  of  tho  paralysis  in  such 
cases,  the  reflex  mechanism  of  deglutition  being 
unimpaired.  There  will  also  be  absence  of  af- 
fection of  sensibility  and  of  trophic  degeneration 
of  the  muscles,  and  absence  also  of  disturbances 
of  the  cardiac  and  respiratory  rhythm.  Defective 
comprehension  of  speech,  and  obvious  aphasia — - 
the  movements  of  articulation  not  being  abso- 
lutely paralysed,  and  also  agraphia — the  hand 
not  being  completely  powerless — will  differen- 
tiate cerebral  from  bulbar  paralysis. 

D.  Fkekier. 


MEDULLA  OP  BONES,  Diseases  of.— 
Sy.nox.  : Fr.  Maladies  de  la  Moelle  cks  Os ; 
Ger.  Krankheiten  des  Knochenmarks. — The  mor- 
bid conditions  of  the  medulla  of  bones  are  most 
conveniently  described  under  the  head  of  the 
several  diseases  of  which  they  almost  invariably 
form  but  a part.  Thus,  injuries,  acute  and 
chronic  inflammation  or  osteomyelitis,  and  the 
majority  of  new  growths  involving  the  marrow, 
affect  the  bone  as  a whole,  and  are  accordingly 
discussed  in  the  article  upon  these  subjects  (sc« 
Bonk,  Diseases  of).  Myeloid  tumour,  which  is 
peculiarly  connected  with  the  medulla,  is  also 
described  and  figured  in  the  article  on  Tumours. 

The  medulla  of  bones  is  also  the  seat 
of  important  pathological  changes  in  several 
chronic  constitutional  diseases.  For  instance,  ii 
is  affected  in  some  cases  of  leucocythsemia,  and 
of  lymphadenoma ; in  mollities  ossium  ; and  in 
rickets.  The  reader  is  referred  to  the  descrip- 
tion of  the  anatomical  characters  of  these  con- 
ditions in  the  articles  bearing  their  several 
names. 

MEDULLA  SPINALIS,  Diseases  of.  See 

Spinal  Cord,  Diseases  of. 

MEDULLARY  CANCEB.-A  synonym 
for  encephaloid  cancer.  See  Cancer. 

MEGBIM. — Synon.  : Migraine;  Sick  Head- 
ache ; Nervous  Headache  ; Hemicrania ; Fr. 
Migraine ; Ger.  Migr'dne. 

Definition. — Headache  of  a periodical  cha- 
racter; generally  ushered  in  by  some  piremoni- 
tory  symptoms  ; more  or  less  unilateral ; and 
frequently  associated  with  nausea  and  bilious 
vomiting. 

fEnoLonY. — The  chief  predisposing  causes  of 
attacks  of  migraine  are  hereditary  tendency; 
anaemia  ; a general  want  of  tone  in  the  system  ; 
and  the  nervous  temperament  Among  tho  ex- 
citing causes  may  be  included  all  those  of  a 
depressing  or  exhausting  nature,  whether  physical 
or  mental,  such  as  prolonged  mental  work,  men- 
tal excitement,  grief,  anxiety,  bodily  fatigue,  late 
hours,  sexual  excesses,  breathing  the  impure  aii 
of  a crowded  room,  and  improper  food. 

Symptoms. — This  complaint  seems  to  have 
two  more  or  less  well-defined  stages,  the  head- 
ache being  preceded  for  a variable  period  by 
certain  disorders  of  sensation.  In  some  persons 
the  malady  stops  short  here,  and  is  not  followed 
by  headache;  in  others  the  headache  appears  to 
be  developed  without  any  premonitory  symptoms, 
until  careful  inquiry  reveals  the  contrary'.  The 
two  stages  therefore  are,  first,  the  stage  of  dis- 
ordered sensation  ; second,  the  stage  of  head- 
ache, with  other  symptoms. 

The  most  striking  of  the  disordered  sensa- 
tions is  a transient  disturbance  of  vision  which 
sometimes  takes  place.  It  commences  with  a 
wavy  glimmering  near  the  outside  corner  of  the 
field  of  vision,  and  spreads  all  over  the  visual 
area  with  a zigzag  outline,  in  a straight-lined 
angular  pattern,  and  with  or  without  lines  of 
colour  between  the  darker  lines.  Or  it  may 
commence  by  the  appearance  of  a blind  spot 
close  to  the  centre  of  vision,  which  soon  begins  to 
spread,  showing  a serrated  margin,  and  present- 
ing a tremor  or  wavy  glimmering  in  its  interior 


MEGRIM. 


)30 

This  condition  is  often  associated  with  a feeling, 
of  chilliness,  coldness  of  the  hands  and  feet,  or 
other  symptoms  ; it  may  last  from  five  to  thirty 
minutes  or  longer,  and  then  be  succeeded  by  the 
stage  of  headache. 

On  the  other  hand,  the  headache  may  be,  and 
in  many  individuals  always  is,  developed  without 
the  ocular  disturbance,  but  other  sensations  are 
substituted  for  it.  The  patient  has  a feeling  of 
chilliness,  and  the  feet  are  cold.  There  is  mental 
depression,  with  a dread  of  impending  evil ; the 
patient  is  restless  and  uneasy;  ‘cannot  quite 
tell,’  as  he  says,  ‘ what  he  would  be  at ; ’ and 
has  what  is  expressively  called  ‘ the  fidgets.’ 
This  condition  may  continue  half  an  hour  cr 
more,  and  then  the  slight  boring  pierciDg  pain 
is  felt  in  the  head,  with  which  the  aching  begins; 
and  the  disorder  runs  its  course,  as  will  ho 
presently  described.  In  other  cases,  this  feeling 
of  depression  or  uneasiness  lasts  for  several 
hours,  the  patient  goes  to  bed,  and  in  the  early 
morning  wakes  with  the  headache'  fully  deve- 
loped. 

The  headache,  when  preceded  by  ocular  distur- 
bance, shows  itself  as  follows : — When  the  vibra- 
tory movement  is  at  its  height,  a little  aching  is 
felt  in  the  head,  on  the  side  opposite  to  that  on 
which  the  glimmering  first  appeared : it  is  slight 
at  first,  but  gradually  increases  in  intensity. 
Some  persons  have  said  that  the  sensation  was 
as  though  a point  in  the  temple  were  being  bored 
with  a gimlet,  and  the  gimlet  slowly  increasing 
in  size.  The  pain  gradually  spreads  from  this 
point,  which  may  be  covered  with  the  finger,  and 
pressure  upon  which  affords  relief,  first  over  one 
side  of  the  head ; and  then,  but  not  always,  it  ex- 
tends to  the  other.  As  the  headache  increases, 
the  ocular  disturbance  declines ; nausea  is  felt, 
which  increases  with  the  headache  ; retch- 
ing and  vomiting  occur,  the  latter  sometimes, 
though  rarely,  giving  relief;  the  head  throbs; 
the  slightest  movement  increases  the  pain,  and 
any  attempt  to  move  from  the  recumbent  posture 
increases  the  gastric  uneasiness  ; the  mouth  feels 
clammy ; the  eyeballs  ache,  and  are  tender  on 
pressure,  one  more  so  than  the  other ; the  pupils 
are  rather  contracted,  and  generally  unequally  so ; 
and  the  patient  lies  apparently  more  dead  than 
alive,  his  face  pale,  and  the  head  hot.  After  a 
varying  number  of  hourslie  is  somewhat  relieved 
bv  troubled  sleep  ; he  wakes  up  next  morning 
free  perhaps  from  headache  ; but  he  is  listless ; 
his  brain  is  weary;  and  he  feels  as  if  he  had 
undergone  a hard  mental  struggle.  There  may 
be  now  an  interval  of  a few  days,  weeks,  or 
years,  before  the  disorder  again  shows  itself. 

The  headache  varies  much  in  character,  degree, 
and  duration.  In  some  persons  the  pain  is  not 
localised  in  any  particular  spot,  but  seems 
generally  diffused  over  the  head ; others  have 
not  noticed  that  there  is  more  pain  on  one  side 
of  the  head  than  the  other,  or  that  the  aching 
radiates  from  one  painful  spot,  until  their 
attention  has  been  directed  to  the  fact,  and  then 
I hey  distinctly  recognise  it ; others,  again,  have 
neither  vomiting  nor  nausea  ; and  lastly,  the 
duration  of  the  headache  may  be  very  short,  or 
not  extend  over  more  than  two  or  three  hours, 
or  this  symptom  may  be  entirely  absent.  The 
disorder  may  even  stop  short  at  the  vibratory 


stage,  the  vision  be  restored,  and  no  farther 
inconvenience  felt. 

In  a certain  proportion  of  cases  during  the 
vibratory  stage  a tingling  is  felt  in  some"  por- 
tion of  the  body — the  partis  ‘asleep.’  Sometimes 
it  is  felt  in  one  arm  or  in  the  side  of  the  toDgne, 
or  on  the  side  of  the  face,  and  it  is  on  the  same 
side  as  that  on  which  the  glimmering  in  the 
eye  begins.  Sometimes  the  hearing,  speech,  or 
memory  is  affected. 

The  age  at  which  the  attacks  generally  com- 
mence is  from  twelve  to  twenty-five.  Females 
are  more  liable  to  them  than  males.  After  a cer- 
tain period,  with  advancing  age  the  attacks,  as  s 
rule,  are  less  easily  developed,  and  become  much 
less  frequent.  They  cease  generally  after  fifty 
or  sixty,  and  in  women  not  uncommonly  at  the 
change  of  life. 

Pathology. — Considerable  diversity  of  opinion 
exists  as  to  the  nature  of  megrim.  Formerly 
it  was  regarded  as ' being  dependent  upon  gas- 
tric or  hepatic  derangement,  a view,  howerer. 
which  now  finds  few  supporters.  Some  patho- 
logists hold  it  to  he  a form  of  neuralgia;  but 
though  it  has  a great  resemblance  to  neuralgia, 
it  ‘causes  much  greater  disturbance  of  the  sen- 
sorium,  it  spreads  much  more  generally  over  the 
head,  and  is  not  unfrequently  accompanied  with 
nausea  and  vomiting.  After  the  attack  there 
may  be  an  intermission  of  weeks  or  months,  and 
the  attack  itself  runs  a more  uniform  or  con- 
tinuous course  ’ (Lebert).  The  view  which  the 
writer  has  advanced  is  that  the  affection  is  to 
be  referred  to  the  sympathetic  nervous  system. 
If  by  fatigue,  anxiety,  or  other  depressing  cause, 
the  general  tone  of  the  body  be  lowered,  and 
with  it  the  regulating  or  inhibitory  power  of 
the  cerehro-spinal  over  the  sympathetic  ner- 
vous system  impaired,  then  uncontrolled  action 
or  excitement  of  one  or  more  portions  of  the 
latter  takes  place,  causing  contraction  of  the 
blood-vessels  under  the  influence  of  the  affected 
portions,  and  so  producing  the  disorders  of  sen- 
sation which  precede  the  headache;  this  excite- 
ment is  followed  by  exhaustion  or  paralysis  of 
the  sympathetic,  and  is  associated  (just  as  would 
be  the  case  after  section  of  the  nerve)  with 
dilatation  of  the  vessels,  and  with  headache.  Dr. 
Edward  Liveing,  in  his  classical  and  exhaustive 
work  on  megrim,  combats  this  view,  and  main- 
tains that  the  phenomena  are  those  of  ‘a  nerve- 
storm  traversing  more  or  less  of  the  sensory 
tract  from  the  optic  thalami  to  the  ganglia  of  the 
vagus,  or  else  radiating  in  the  same  tract  from 
a focus  in  the  neighbourhood  of  the  quadriga- 
minal  bodies.’ 

Treatment. — By  careful  management  very 
great  relief  can  be  afforded  to  the  sufferers  from  , 
this  malady,  not  only  by  diminishing  the  inten- 
sity of  the  attacks,  but  also  by  considerably 
lengthening  the  intervals  between  them.  Me 
may  consider  separately  the  remedial  measures 
to  be  employed  (1)  during  the  intervals  between 
the  attacks;  (2)  during  the  premonitory  stage  or 
stage  of  disordered  sensation ; and  (3)  during  the 
stage  of  headache. 

1.  During  the  intervals  between  the  attacks.— 

It  is  to  the  treatment  during  this  period  that 
the  greatest  consideration  must  be  given.  The 
cause,  if  possible,  must  l»-  discovered,  and  in  a 


MEGRIM.  937 


very  large  majority  of  eases,  careful  inquiry  -will 
reveal  the  fact  that  a distinct  cause  does  exist. 
Overwork,  prolonged  anxiety,  over-fatigue,  dis- 
appointed hopes  or  affections,  sexual  irregulari- 
ties, and  impoverished  nutrition  of  the  body, 
are  among  the  chief  causes ; and  while  these 
are  in  operation  medicine  will  prove  of  little 
avail.  Remove  the  causo,  and  then  endeavour  to 
brace  up  the  bodily  and  nervous  systems.  The 
chief  remedies  for  this  purpose  are  the  vegetable 
bitters,  iron,  strychnine,  and  cod-liver  oil.  But 
the  success  following  their  use  very  much  de- 
pends upon  the  way  in  which  they  are  adminis- 
tered. For  a day  or  two  after  a headache  the 
6tomaeh  and  bowels  may  possibly  be  disordered, 
and  not  in  a fit  state  to  tolerate  iron  or  cod-liver 
oil.  This  condition  must  be  corrected,  and  for 
this  purpose  the  simple  vegetable  bitters,  such 
as  gentian  with  small  doses  of  henbane  and  some 
aromatic,  may  be  of  service ; and  if  necessary 
one  or  two  grains  of  blue  pill,  with  four  or  five 
of  compound  rhubarb  pill,  may  be  given  at  night, 
but  strong  purgation  must  be  avoided.  Iron  may 
then  be  given,  either  in  the  form  of  the  ammonio- 
citrate  alone,  or  combined  with  two  or  three  grains 
of  iodide  of  potassium  ; and  according  to  circum- 
stances fifteen  or  twenty  minims  of  tincture  of 
henbane,  or  twenty  or  thirty  minims  of  aromatic 
spirit  of  ammonia,  may  be  added  to  each  dose. 
Or  the  iron  may  be  given  in  the  form  of  the 
mistnra  ferri  composita  of  the  Pharmacopccia  ; 
the  mixture  answering  better,  however,  in  some 
cases  without  the  myrrh.  Strychnine  is,  in  the 
writer's  opinion,  a very  important  remedial  agent 
n many  forms  of  this  disorder,  and  may  be  given 
with  the  remedies  previously  mentioned  in  the 
form  of  liquor  strychnine  or  tinctura  nucis 
romicse,  or  may  be  combined  with  infusion  of 
•luassia  or  ealumba.  Where  iron  is  contra-in- 
jicatedfrom  any  cause,  or  when  it  is  not  readily 
■"roe,  the  administration  of  nux  vomica  with 
quassia  has  seemed  to  act  beneficially.  In 
'eniales  with  a distinct  hysterical  temperament 
iux  vomica  does  not  answer  so  well,  and  better 
■esults  will  be  obtained  by  giving  the  vegetable 
litters  with  ten-grain  doses  of  bromide  of  potas- 
ium,  and  fifteen  or  twenty  of  tincture  of  henbane, 
wice  or  three  times  a day.  As  a rule,  however, 
he  bromide  is  of  more  use  administered  during 
he  headache  than  in  the  intervals.  Cod-liver 
il  often  acts  beneficially,  especially  when  there 
i much  nervous  exhaustion.  It  may  be  given 
■nee  a day  immediately  after  breakfast,  beginning 
ith  a small  teaspoonful,  and  gradually  increasing 
le  quantity  to  a tablespoonful,  but  not  beyond, 
nless  in  exceptional  cases.  Ifthe  bowels  are  con- 
dpated,  five  grains  or  so  of  the  socotrine  aloes 
ill  may  be  given  at  night ; or  ifthe  constipation 
3 habitual,  five  grains  of  the  aloes-and-iron  pill, 
ven  twice  a day  before  meals,  will  generally 
duce  greater  regularity  in  the  action  of  the 
)wels. 

Other  remedies  have  been  recommended,  and 
a sometimes  of  service,  especially  arsenic  and 
unine. 

In  persons  of  feeble  bodily  power,  rest  is  of 
e greatest  importance,  and  it  is  often  advisable 
at  such  patients  should  remain  in  bed  at  least 
■ elve  hours  out  of  the  twenty-four,  and  take 
cir  breakfast  an  hour  and  a half  or  two  hours 


before  rising  in  the  morning.  Whenever  the 
headaches  recur  frequently,  this  rule  should  be 
enforced.  In  many  cases  a tumblorful  of  new 
milk,  to  which  two  teaspoonfuls  of  brandy,  rum, 
or  whisky  have  been  added,  may  be  taken  with 
advantage  before  breakfast,  directly  on  waking 
in  the  morning. 

The  diet  should  be  liberal ; the  food  plain  and 
easily  digestible  ; and  two  or  three  glasses  of 
wine,  beer,  or  porter  per  diem,  may  generally  be 
taken  with  benefit.  The  more  exercise  the  patient 
can  take  in  the  open  air,  without  fatigue,  the 
better. 

2.  During  the  'premonitory  stage,  or  stage  of 
disturbed  sensation. — In  the  forms  attended  by 
disturbance  of  vision,  the  longer  this  lasts  the 
greater  will  be  the  headache,  and  we  must  en- 
deavour therefore  to  shorten  this  stage  as  much 
as  possible.  Directly  the  glimmering  appears 
the  patient  should  lie  down,  with  the  head  low ; 
and  if  the  glimmering  be  on  the  right  or 
left  of  the  field  of  vision,  he  should  lie  on  the 
opposite  side.  Let  him  take  at  once  some  alco- 
holic stimulant,  a full-sized  glass  of  sherry,  a 
large  tablespoonful  of  brandy  diluted,  or  a glass 
of  champagne.  If  alcoholic  stimulants  be  ob- 
jected to,  or  if  it  be  not  advisable  to  recommend 
them,  then  a teaspoonful  of  sal  volatile  in  water 
may  be  prescribed  instead.  If  the  patient  be 
chilly,  or  his  feet  cold,  the  couch  should  be  drawn 
near  the  fire,  and  a hot  bottle  applied  to  the  feet 
By  these  means  the  heart  is  enabled  to  drive 
the  blood  with  greater  force  to  the  brain,  and  the 
duration  of  the  vibratory  movement  is  thereby 
materially  lessened.  After  the  glimmering  has 
passed  off,  the  patient  should  lie  still  for  a time, 
so  that  it  may  not  return.  This  injunction  will 
only  be  necessary  when  the  headache  is  slight ; 
if  it  be  severe,  attended  with  much  nausea  or 
vomiting,  the  patient  will  be  little  disposed,  or 
little  able,  to  leave  the  recumbent  position. 

If,  instead  of  the  disturbance  of  vision  pre- 
ceding the  headache,  there  be  a feeling  of 
depression  or  irritability,  fidgets,  and  similar 
phenomena,  the  administration  of  such  cerebro- 
spinal stimulants  as  henbane,  valerian,  assa- 
foetida,  spirit  of  chloroform,  or  ether,  will  often 
cut  short  the  attack.  Fifteen  or  twenty  drops 
of  the  tincture  of  henbane,  with  the  same  quan- 
tity of  spirit  of  chloroform,  will  soothe  the 
nervous  irritability  in  the  slighter  forms,  and 
may  be  repeated  in  three  or  four  hours  if  neces- 
sary. If  there  be  great  mental  depression,  then 
valerian  or  assafoetida  should  be  tried.  Half  a 
drachm  to  a drachm  of  the  ammoniated  tincture 
of  valerian,  or  the  same  quantity  of  the  fetid 
spirit  of  ammonia  may  be  given.  As  a rule,  in 
such  cases  as  these,  alcoholic  stimulants  are  not 
advisable  at  this  stage.  A small  quantity  will 
cause  flushing,  heaviness,  and  slight  confusion 
of  thought,  without  relieving  the  depression  ; 
and  though  the  severe  headache  may  be  averted, 
alcoholic  stimulants  do  not  answer  so  well  as  the 
remedies  previously  mentioned. 

3.  During  the  stage  of  headache. — If  the  head- 
ache be  slight,  and  the  patient  soon  able  to  sit 
up,  there  is  little  to  be  done.  A cup  of  coffee  or 
tea,  cheerful  conversation,  a walk,  drive,  or  ride, 
may  often  help  to  remove  the  pain.  If,  how- 
ever. the  symptoms  be  severe,  then  the  ad  minis- 


93S  MEGRIM, 

tration  of  fu>ther  remedies  is  called  for.  The 
patient  should  keep  perfectly  still  and  quiet, 
■with  the  room  darkened ; for  every  sound  or 
sight  causes  pain,  and  the  slightest  movement  is 
sufficient  to  produce  gastric  uneasiness.  Some- 
times free  evacuation  of  the  contents  of  the 
stomach,  especially  if  it  contain  undigested  food, 
is  followed  by  relief;  but,  as  a rule,  it  is  better 
to  try  to  relieve  and  check  the  vomiting.  Iced 
soda-water,  with  or  without  two  or  three  drops  of 
dilute  hydrocyanic  acid  or  spirit  of  chloroform  ; 
cold  tea  ; or  the  effervescing  citrate  of  potash 
with  hydrocyanic  acid,  may  often  afford  marked 
relief.  The  headache  may  be  lessened  byapplying 
cloths  dipped  in  cold  water  or  evaporating  lotions 
to  the  head.  If  the  extremities  be  cold,  and  the 
headache  severe,  a warm  stimulating  foot-bath 
can  be  tried,  so  soon  as  the  nausea  will  allow  the 
patient  to  sit  up.  If  the  attacks  occur  in  the  early 
part  of  the  day,  as  soon  as  the  pain  has  subsided 
it  is  generally  better  for  the  patient  to  sit  up  or 
move  about,  or  even  to  take  exercise  in  the  open 
air.  During  the  attack  the  appetite  is  diminished, 
the  idea  even  of  taking  food  provoking  disgust. 
Still,  after  the  nausea  has  passed  away,  a plate 
of  soup,  or  some  easily  digested  food,  will  often 
have  a good  effect  in  equalising  the  cerebral  cir- 
culation, and  in  relieving  the  headache.  If  the 
headache  be  severe,  bromide  of  potassium  is  a 
remedy  which  will  often  prove  of  great  service. 
It  may  be  given  in  doses  of  fifteen  or  twenty 
grains,  with  fifteen  or  twenty  minims  of  tincture 
of  henbane,  and  to  these  may  be  added  thirty  or 
forty  minims  of  the  aromatic  spirit  of  ammonia, 
in  some  cases  with  advantage.  If  necessary,  the 
dose  may  be  repeated  after  an  interval  of  two 
hours  or  so.  In  other  cases  chloride  of  ammonium 
in  doses  of  fifteen  grains  produces  marked  relief, 
and  may  be  sometimes  advantageously  combined 
with  spirit  of  chloroform  and  compound  tincture 
of  lavender.  Guarana  powder  is  a remedy  which 
is  used,  often  with  happy  results.  The  sick- 
headaches  which  it  seems  te  reLeve  are  those 
in  which  distinct  premonitory  symptoms  usher 
in  the  attack,  and  particularly  those  preceded 
by  disturbance  of  vision.  It  may  be  given  in 
such  cases  in  doses  of  fifteen  grains,  with  the 
same  quantity  of  sugar,  and  repeated  in  from 
half  an  hour  to  two  hours.  In  those  individuals, 
however,  in  whom  the  headache  is  developed 
suddenly,  where  the  attacks  come  on  without 
any  or  with  very  indefinite  premonitory  symp- 
toms, guarana  appears  to  have  little  effect. 

As  a rule,  the  use  of  purgatives  in  this  stage 
is  decidedly  objectionable,  but  occasionally  a 
saline  purgative  at  the  commencement  of  an 
attack  is  indicated,  and  is  of  service. 

P.  W.  Latham. 

MELJ3NA  (/xe'Aas,  black). — Syxox. : Dysen- 
teria  splenica-,  Fr.  Milena;  Ger.  Schwarze  Ruhr. 

This  term  is  used  to  denote  black  tar-like 
evacuations  that  are  passed  from  the  bowel. 
The  colour  and  appearance  are  due  to  altered 
blood,  and  the  expression  is  not  properly  appli- 
cable to  simple  haemorrhage  from  the  alimentary 
canal,  when  blood  of  a normal  appearance  is 
voided. 

In  order  that  the  blood  should  have  undergone 
the  change  which  produces  the  characteristic 


MELANCHOLIA. 

evacuations,  it  must  have  been  effused  high  up 
in  the  canal,  and  in  some  quantity.  When 
haemorrhage  takes  place  in  the  lower  part  of  the 
small  intestine,  or  in  the  colon  or  rectum,  ths 
blood  is  passed  in  a scarcely  altered  state,  or  at 
most  renders  the  faeces  dark,  without  producing 
the  black,  viscid  motions  now  referred  to. 

Blood  that  is  passed  into  the  stomach,  from 
any  cause,  is  subjected  to  the  action  of  the  gastric 
juice,  and  undergoes  a partial  digestion.  The 
acid  of  the  secretion  converts  the  htemoglobin 
into  haematin,  a blackish-brown  substance,  and 
the  exposure  of  this  to  the  sulphuretted  hydro --ea 
produced  in  the  lower  part  of  the  intestine  con- 
verts the  iron  it  contains  into  a black  sulphide. 
The  tar-like  consistency  is  due  to  the  serum, 
digested  clot,  and  mucus ; and  the  discharged 
material  is  usually  free  from  remains  of  food, 
being  simply  altered  blood.  When  the  haemor- 
rhage takes  place  into  the  upper  part  of  the 
intestine,  the  change  is  not  so  completely 
effected.  In  place  of  being  submitted  to  pro- 
longed action  of  an  acid  secretion,  with  consider- 
able power  of  digesting,  the  blood  is  acted  upon 
by  alkaline  secretions,  the  officacv  of  which  is  les6, 
unless  the  ingesta  have  been  previously  affected 
by  the  gastric  juice.  The  result  is  that,  although 
the  blood  is  to  a great  extent  altered,  and  the 
same  black  sulphide  of  iron  is  formed,  it  be- 
comes more  or  less  mixed  with  the  contents  of 
the  tube,  and  is  not  voided  in  lumpy  clots,  but 
almost  uniformly  incorporated  with  the  faeces, 
which  may  be  solid,  semi-solid,  or  fluid.  The 
faeces  may  be  blackened  by  iron,  bismuth,  and 
other  agents,  taken  as  drugs,  but  they  do  not  pro- 
duce the  viscid  matter  like  semi- digested  blood. 

Melsena  is  the  mere  expression  of  a condition 
brought  about  by  many  causes,  and  these  have 
to  be  sought  for  and  treated.  See  F.eces,  Exa- 
mination of ; ILhmatemesis  ; Intestines,  Hae- 
morrhage from ; and  Stools. 

W.  H.  Allchin. 

MELAN^IMIA  (geAas,  black,  and  cl/m,  the 
blood). — A morbid  condition  of  the  blood,  in  which 
it  contains  black  and  brown  pigment-particles. 
See  Blood,  Morbid  Conditions  of. 

MELANCHOLIA  (jueAos,  black;  and  xoAlj, 
bile). — Stxon.  : Fr.  Lypemanie  ; Melancolie ; 
Ger.  Sckwcrmuth ; Melancholic. — This  name  is 
now  usuaUy  applied  to  a form  of  insanity 
characterised  by  great  mental  depression,  but 
formerly  it  was  U6ed  by  writers  to  denote  par- 
tial insanity,  or  monomania.  The  sufferer  in  this 
disorder  feels  his  whole  existence,  mental  and 
bodily,  overwhelmed  and  oppressed  by  gloom, 
anxiety,  and  foreboding.  At  first  it  may  be 
only  a feeling  which  takes  no  definite  shape,  and 
there  may  be  no  delusions.  Sometimes,  though 
rarely,  there  are  none  throughout;  the  morbid 
feeling  constitutes  the  disorder,  which  in  this 
form  has  been  called  simple  melancholia.  Its 
access  is  almost  always  gradual,  and  though 
we  may  attribute  it  to  grief,  overwork,  or  worry 
it  often  happens  that  no  mental  or  moral  cause 
can  be  found,  and  we  are  obliged  to  set  it  dowi 
to  inherited  predisposition,  to  some  debilitating 
illness,  to  declining  strength,  or  to  advancing 
age.  Some  are  aware  that  there  is  no  real  grounc 


MELANCHOLIA. 


for  their  sorrow  and  sadness,  and  are  able  to  look 
on  it  as  an  illness;  others  feel  that  there  must 
be  some  real  cause  for  their  despondency,  that 
something  terrible  is  impending,  though  they 
know  not  what.  The  majority  can  argue  and 
■converse  rationally  on  subjects  unconnected  with 
their  feeling  of  misery. 

The  bodily  health,  even  if  at  first  it  appears 
good,  soon  participates  in  the  disturbance.  The 
digestion  is  disordered,  the  urine  loaded  with 
lithates,  the  skin  dry,  the  bowels  are  constipated, 
the  pulse  is  slow  rather  than  quick,  the  conjunc- 
tiva dull  and  yellow.  The  patient  will  complain 
of  various  uneasy  feelings  in  the  prsecordial  or 
epigasciie  region,  and  this,  with  the  state  of  the 
excretions,  will  confirm  the  notion,  so  prevalent 
amongst  many,  that  the  whole  misehiof  is  in  the 
liver.  Such  simple  depression  may  continue  for 
a longer  or  shorter  space  of  time.  It  may  pass 
away  suddenly  or  gradually,  or  the  individual 
will  grow  worse  in  one  of  two  ways.  The  depres- 
sion becomes  greater,  and  delusions  of  various 
kinds  present  themselves  ; or  it  is  replaced  by 
the  excitement  of  mania. 

Melancholia  with  delusions  is  far  more  common 
than  simple  melancholia , and  is  that  which  most 
frequently  we  are  called  upon  to  treat.  The 
patient  feels  utterly  changed,  and  attributes  it.  to 
carious  causes,  and.  deduces  various  results  from 
;t.  He  has  all  manner  of  diseases— syphilis, 
‘eprosy,  lice ; his  stomach  is  gone,  and  therefore 
ae  cannot  eat.  He  cannot  attend  to  business, 
tnd  therefore  is  ruined.  He  is  so  wretched  that 
■ie  must  have  committed  sins  unpardonable  in 
his  world  or  the  next.  The  bodily  symptoms, 
ike  the  mental,  are  aggravated.  Sleep  is  absent 
ir  scanty,  and  there  is  rapid  wasting.  The  bowels 
re  loaded,  and  resist  strong  purgatives ; the 
ongue  is  white  and  furred;  the  breath  offensive. 
Ihe  patients  are  for  the  most  part  elderly ; 
limacteric  insanity  is  almost  always  melancholia. 
)f  338  melancholic  patients  admitted  into  St. 
rake’s  Hospital  only  9 were  below  the  age  of 
wen  t v. 

| It  cannot  be  too  strongly  impressed  upon 
tedical  men  that  all  melancholic  patients, 
ven  those  whose  disorder  seems  simple  and 
light,  are,  especially  in  the  early  stage,  vpry  apt 
) commit  suicide.  We  read  accounts  almost 
laily  in  the  newspapers  of  suicides  committed  by 
Lis  class  of  persons,  and  most  lamentable  they 
re,  for  it  is  a class  which  above  all  others  is 
menable  to  treatment. 

An  asylum  is  not  absolutely  requisite  for 
ach,  if  their  means  allow  of  proper  companions, 
'ouse,  and  exercise.  They  must  not  be  left  alone 
y night  or  day;  must  not  he  left  to  attendants 
aly;  and  must  have  some  amusement  or  diver- 
on.  If  all  this  cannot  be  provided,  to  an  asy- 
im  they  must  go  ; for  if  they  are  resolutely  and 
instantly  bent  on  suicide,  it  is  most  difficult  to 
uard  against  it  in  an  ordinary  house. 

Whether  they  are  sent  to  an  asylum  or  not,  it 
found  to  be  almost  invariably  necessary  to  re- 
ove  them  from.  home.  We  may  think  the  case 
slight  one,  and  may  hope  that  amusement 
id  cessation  from  work,  with  medical  treatment 
id  good  living,  will  remove  the  depression, 
gain  and  again  we  are  disappointed.  The  sight 
- home  ar.d  home  scenes,  of  family  and  friends, 


939 

and  the  contrast  between  past  happiness  and 
present  gloom,  perpetuate  the  melancholy  and 
prevent  its  dispersion.  After  valuable  time  is 
lost,  we  are  compelled  to  send  away  the  patient 
to  an  asylum  or  quasi-asylum. 

Prognosis. — The  prognosis  in  cases  of  melan- 
cholia is  favourable,  and  patients  get  well  in 
great  numbers,  even  at  an  advanced  age.  It  is 
also  important  to  remember  that  recovery  may 
take  place  from  this  form  of  insanity  after  con- 
siderable periods  of  time.  The  writer  has  in  the 
second  volume  of  the  St.  George  s Hospital  Reports 
recorded  three  cases  of  melancholia  in  which 
recovery  took  place  after  five,  six,  and  seven 
years’  residence  in  an  asylum  ; and  he  has  since 
treated  a lady  who  recovered  from  a most  suicidal 
attack  of  the  disorder  after  nine  years.  In  deal- 
ing with  property  it  is  often  necessary  to  con- 
sider the  question  of  probable  recovery,  and  it 
is  well  to  keep  in  view  the  chance  of  it  here, 
although  in  perhaps  every  other  form  of  insanity 
recovery  after  such  periods  would  be  out  of  the 
question. 

Treatment.— On  examination  of  a melan- 
cholic patient,  it  is  generally  found  that  there  has 
been  a considerable  loss  of  flesh.  This  may  be 
due  to  the  mental  care  and  sorrow,  but  it  is  often 
caused  by  an  insufficient  quantity  of  food,  which 
has  been  scanty,  either  because  all  appetite  has 
been  lost  owing  to  the  prevailing  wretchedness,  or 
because,  from  various  delusions,  there  has  been 
an  unwillingness  to  take  food.  Moreover,  there 
is  almost  always  considerable  disorder  of  the 
digestive  apparatus,  the  result  and  not  the  cause 
of  the  depressed  nervous  condition.  Tho  first 
thing  to  be  done  is  to  correct  this  disorder ; and 
then  to  restore  the  defective  nutrition  of  the 
brain. 

One  symptom  is  obstinate  constipation.  It 
may  be  necessary  in  the  first  instance  to  relieve 
the  loaded  and  obstructed  bowel  by  means  of 
turpentine  enemata;  after  which  it  will  be  of 
advantage  to  give  a daily  dinner  pill  of  the  ex- 
tracts of  aloes  and  nux  vomica,  or  a daily  tea- 
Bpoonful  of  castor-oil,  following  it  up  if  necessary 
by  an  enema,  but  ensuring  an  action  every,  or 
every  other  day,  and  so  habituating  the  bowels 
to  act.  Many  of  these  patients,  especially 
women,  will  be  found  to  be  persons  who  have 
been  accustomed  to  go  for  long  periods  without 
the  bowels  acting,  or  who  never  had  relief  with 
out  medicine.  Food  must  be  given  to  melan- 
cholic patients  in  large  quantities.  It  constantly 
happens  that  it  is  withheld  from  them  under  the 
impression  that  their  malady  is  essentially  dys- 
pepsia, and  that  the  stomach  must  not  be  allied 
upon  for  much  exertion.  Many,  as  has  been 
said,  refuse  it  for  one  reason  or  other.  In  either 
case  the  melancholia  increases,  and  the  patient 
gets  thinner  and  weaker.  Food  must  be  given 
with  no  sparing  hand,  not  merely  beef-tea  and 
invalid  diet,  but  solid  food,  bread,  meat,  and  eggs, 
with  a liberal  allowance  of  wine  or  malt  liquor. 
Some  may  require  forcible  feeding,  and  this  can 
hardly  be  carried  out  except  in  an  asylum,  but 
many  by  coaxing  or  threats  will  take  what  is 
given  to  them  with  a spoon,  and  they  must  be 
fed _ frequently  till  they  will  take  the  meals  of 
their  own  accord.  Under  this  augmented  diet 
the  tongue  will  become  clean,  the  bowels  will  ad 


940  M ELANOHOLIA. 

without/  physic,  and  the  patient’s  appearance  ■will 

soon  testify  to  the  efficacy  of  the  treatment. 

Sleep,  though  not  entirely  absent  here,  trill  be 
in  defect.  To  procure  it  opium  has  teen  long 
looked  upon  as  of  the  greatest  value.  In  melan- 
cholia, of  all  the  various  forms  of  insanity,  this 
drug  is  most  useful,  and  its  benefit  consists  not 
merely  in  the  procuring  of  sleep,  but  in  alleviating 
the  feeling  of  wretchedness.  It  may  be  given 
ei  tlier  by  the  mouth  or  by  subcutaneous  injection. 
It  is  of  importance  that  we  do  not  give  a prepa- 
ration which  shall  cause  sickness  or  constipation : 
the  ordinary  preparations  of  morphia,  the  acetate 
and  hydroclilorate,  are  apt  to  do  this  if  given  in 
full  doses,  and  it  is  better  to  substitute  the 
liquor  morphiae  bimoconatis,  Dover's  powder, 
Battley’s  solution,  or  solid  opium,  if  we  can  be 
sure  that  pills  will  be  swallowed.  Chloral  will 
procure  sleep  here  as  in  other  cases,  and  may  be 
combined  with  opium  to  bring  about  more  speedy 
action  of  the  latter,  but  chloral  has  not  such  a 
lasting  influence  on  the  malady;  when  its  sleep- 
producing  effect  has  passed  away,  the  patient 
does  not  feel  any  benefit  from  the  medicine. 
When  the  secretions  have  been  corrected,  and 
digestion  is  re-established,  tonics  may  be  useful, 
especially  the  preparations  of  iron. 

G.  F.  Blandford. 

MELANCHOLIA,  Varieties  of.— 1.  Me- 
lancholia, Acute. — Although  the  prognosis  in 
simple  melancholia, and  that  which  may  be  called 
sub-acute,  is  so  favourable,  there  is  an  advanced 
stage  which  truly  merits  the  name  of  acute, 
and  generally  terminates  fatally.  The  patients 
are  not  silent,  gloomy,  and  depressed,  but  panic- 
stricken;  and  in  violent  frenzy  and  terror  they 
try  to  escape  from  those  about  them,  to  tear  off 
their  clothes,  gouge  out  their  eyes,  and  injure 
themselves  in  overy  way.  They  will  not  lie  on 
a bed  unless  forced  to  do  so,  but  will  prefer  the 
floor,  or  incessantly  pace  the  room.  Food  they 
resist  with  all  their  power,  thinking  that  it  is 
poisoned,  or  that  they  will  be  punished  for  taking 
it.  Such  patients  must  be  fed  by  force,  and  fed 
early,  but  it  often  happens  that  our  feeding  here 
is  of  no  avail,  and  they  sink  from  the  exhaustion 
of  this  acute  disorder.  For  it  is  constantly  found 
in  those  who  are  already  broken  and  debilitated 
in  health,  and  it  is  but  the  last  stage  of  a series  of 
disorders.  The  incessant  agitation,  violence,  and 
sleeplessness  produce  rapid  wasting  and  sinking; 
the  food  administered  is  not  assimilated,  and 
fails  to  restore  the  wasted  force.  This  form 
runs  a rapid  course,  in  contradistinction  to  the 
last,  which  is  tedious,  hut  nevertheless  tends  to 
recovery  in  the  majority  of  cases.  We  may  ad- 
minister opium  here  with  or  without  chloral; 
other  drugs  are  of  little  use.  Cod-liver  oil  may 
be  added  to  the  food.  Warmth  and  stimulants 
are  demanded  ; and  clothes  must  be  kept  on  by 
means  of  a strong  suit  which  cannot  be  removed 
by  the  patient. 

2.  Melancolie  aveo  Stupeur  (Fr.)  Synox.  : 
Her.  Schwermuth  mit  Stumpfsinn. — A more  ex- 
treme form  of  melancholia  is  thus  named,  where 
the  patient  sits  or  stands,  speechless  and  motion- 
less, and  requires  to  be  fed,  washed,  and  dressed. 
Though  such  a one  will  not  speak  or  do  anything 
for  himself,  he  may  bo  watching  every  opportunity 


MEMORY,  DEFECTS  OF. 

of  committing  suicide,  and  refusu  food  with  the 
same  motive.  The  vital  powers  in  these  persona 
are  greatly  depressed,  and  they  require  much  food 
and  stimulant.  This  form  has  been  confounded 
by  some  with  that  variety  of  insanity  termed 
acute  dementia  (see  Dementia)  ; but  the  latter 
occurs  only  in  young  people,  whereas  melancholia 
as  a rule  does  not;  and  the  early  symptoms  are 
quite  different,  acutedemeutia coming  on  rapidly, 
and  without  the  depression  and  gloomy  delusions 
which  mark  the  other  complaint. 

G.  F.  Blandford, 

MELANOMA  (jtteAas,  black). — Any  morbid 
growth  in  which  the  presence  of  black  pigment 
is  a leading  character.  See  Tumours. 

MELANOPATHIA  (geAar,  black,  and 
ndeos,  a disease). — An  excess  of  black  pigment 
in  the  skin,  due  to  abnormal  function  of  the  rete 
mucosum.  Melanopathia  is  rarely  general,  more 
frequently  partial.  In  certain  instances,  as  in  the 
‘bronzed  skin  ’ of  Addison’s  disease,  it  is  asso- 
ciated with  anaemia.  See  Pigmentary  Sein- 
Diseases. 

MELANOSIS  (yueAas,  black). — A ecording  to 
the  present  doctrines  of  pathology,  melanosis 
signifies  the  condition  of  system  associated  with 
the  presence  of  pigmented  tumours.  See  Canceb  ; 
and  Tumours. 

MELASMA  (fit\as,  black). — A term  usually 
applied  to  excess  of  pigment  in  the  skin,  from 
abnormal  function  of  the  rete  mucosum.  See 
Pigmentary  Skin-Diseases. 

MELLITURIA  (jue'Ai,  honey,  and  oupov, 
urine). — A synonym  for  saccharine  urine.  See 
Diabetes. 

MEMBEANA  TYMPANI,  Diseases  of. 

See  Ear,  Diseases  of. 

MEMBRANES  OP  BRAIN  AND 
CORD,  Diseases  of.  Meninges, Diseases  of. 

MEMORY,  Defects  of. — There  are  so  many 
different  kinds  of  memory,  and  so  many  different 
degrees  of  excellence  of  each  variety  in  different 
individuals  in  health,  that  it  is  not  always  easy 
to  say  in  regard  to  any  particular  person  how 
far  his  memory  is  defective.  In  other  cases  the 
degree  of  impairment  is  so  great  as  to  make  its 
existence  perfectly  obvious.  Between  such  ex- 
tremes, all  intermediate  grades  of  defect  m3v  at 
times  be  met  -with.  The  nature  and  causes  of 
the  various  defects  of  memory  cannot  possibly 
he  set  forth  withont  giving  some  account  of  the 
different  physiological  processes  involved  in  its 
exercise ; and  also  of  the  several  fundamental 
modes  in  which  this  is  brought  about. 

The  Component  Processes  in  Memort.  — 
What  is  commonly  known  as  ‘memory’  is  de- 
pendent upon  two  kinds  of  processes.  The  first 
of  these  is  a vital,  molecular,  or  organic  process 
of  some  kind,  taking  place  in  various  parts  of  the 
brain  simultaneously,  on  the  occurrence  of  some 
‘ perceptive  act  ’ or  thought-process.  In  a healthy 
and  properly-nourished  brain  certain  neural  pro- 
cesses, in  different  regions  of  the  organ,  are  sup- 
posed to  coincide  with  each  act  of  perception  and 
apprehension.  Similarly,  in  ‘ ideation’  or  reflec- 
tion, molecular  processes  of  a closely -related  kind 
are  presumed  to  take  place,  partly  in  the  arene 


MEMORY,  DEFECTS  OF. 


f the  brain  concerned  witn  perceptions  and 
ortlyin  other  regions,  and  these  several  changes 
ave  the  same  kind  of  relation  to  our  thoughts 
hat  the  others  have  to  our  perceptions ; in  eacli 
ase  they,  in  fact,  constitute  the  organic  basis  of 
he  respective  processes.  These  initial  organic 
hanges  of  all  kinds  -were  referred  to  by  Lay- 
ock,  and  comprised  under  the  name  ‘ synesis.’ 
ihe  first  essential,  therefore,  for  the  exercise  of 
lemory  is  that  these  synetic  processes  should 
ave  been  properly  accomplished.  If  they  have 
■eeu  imperfectly  performed,  memory  will  be 
ither  defective  or  non-existent. 

Yet  these  processes  constitute  the  foundations 
or  memory,  rather  than  memory  itself. 

Memory  essentially  consists  in  a repetition  or 
reak  revival  of  such  molecular  movements  and 
processes  in  nerve-tissues,  and  of  the  conscious 
tates  associated  with  them.  They  are  similar 
a kind,  and  take  place  in  all  such  parts  of  the 
rain  as  were  concerned  with  the  original  con- 
cious  realisation  of  the  objects,  relations,  or 
recesses  which  now  recur  as  ‘remembered’  im- 
ressions  or  thoughts.  This,  therefore,  is  the 
tcond  of  the  processes  above  referred  to,  as 
ssential  to  the  exercise  of  memory. 

Modes  of  Exercise  of  Memory. — The  repe- 
tion  or  weak  revival  of  foregone  processes,  and 
f their  associated  conscious  states,  is  brought 
■bout  in  three  modes  fairly  distinct  from  one 
nother.  The  first  mode  of  exercise  of  memory 
i ) is  found  in  acts  of  perception,  when,  on  the 
resentation  of  some  object  to  the  sense  of 
!ght,  hearing,  toueh,  smell,  or  taste,  or  to  any 
,vo  of  them,  the  remaining  qualities  of  this 
bject  become  nascent  or  revived  in  memory,  so 
rat  the  object  itself  is  perceived  or  recognised 
j being  of  such  and  such  a nature. 

This  kind  of  process  is  only  impaired  where 
id  nutrition  of  the  brain  as  a whole  is  gravely 
iterfered  with.  Special  parts  of  such  a process 
re,  however,  not  unfrequently  interfered  with 
y local  brain-disease,  as  when,  for  instance, 
le  sight  of  a written  or  printed  word  does  not 
mse  its  appropriate  related  memories;  or  when 
spoken  word  remains  unrealised  or  unappre- 
;nded,  because  its  mere  sound  does  not  excite 
1 the  memories  which  should  cluster  round 
; in  the  one  case  we  have  what  has  been 
.ther  inappropriately  termed  ‘ word-blindness,’ 
id  in  the  other  ‘ word-deafness.’  The  one  set 
persons  exhibiting  such  defects  may  be  per- 
ctly  well  able  to  recognise  natural  objects  or 
rsons  by  sight;  just  as  the  others  maybe  able 
appreciate  different  kinds  of  natural  sounds, 
differences  in  emotional  intonations  of  the 
ice,  although  particular  words  may  not  call  to 
eir  mind  any  distinct  apprehension  of  the 
ing,  idea,  or  relation  which  they  are  usually 
iployed  to  designate. 

The  second,  or  most  common  mode  in  which 
smory  is  exercised  is  ( b ) during  the  ordinary 
irse  of  thought,  when  by  natural  processes  of 
;3sociation’  the  ideas  of  objects,  of  persons,  of 
ents.  and  of  their  relations  one  with  another 
i with  ideas,  recur  to  consciousness,  with  or 
shout  a simultaneous  full  realisation  of  the 
rds  suitable  for  the  expression  of  all  these 
ises  of  our  thoughts — according  as  we  are 
rely  thinking  to  ourselves,  or  as  we  at  the 


94) 

same  time  give  expression  to  our  thoughts 
whilst  conversing  with  another  person.  These, 
together  with  the  kinds  of  exercise  first  referred 
to,  constitute  by  far  the  most  frequent  modes 
in  which  memory  is  called  into  play.  It  here 
manifests  itself  in  a purely  automatic  manner, 
without  sense  of  effort  on  our  part  (other  than 
that  which  is  concerned  with  the  direction  of 
our  thoughts),  owing  to  the  fact  that  present 
cerebral  activities  tend  to  recur  in  the  manner 
and  order  which  have  been  most  frequently  re- 
peated in  the  race  and  in  the  individual— such 
manner  and  order  necessarily  varying  according 
to  the  particular  direction  and  nature  of  their 
or  his  education,  natural  or  acquired.  The  study 
of  this  order  corresponds  with  the  study  of  the 
order  of  mental  phenomena,  and  has  resulted  in 
the  establishment  of  certain  so-called  Taws  of 
association.’ 

The  process  by  which  language  incorporates 
itself  with  all  our  perceptions  and  thoughts  is 
not  different  from  that  which  associates  percep- 
tions and  thoughts  among  themselves.  It  is, 
however,  a more  special  association;  and  con- 
sequently a weak  or  failing  memory — whether 
resulting  from  old  age,  brain-shock,  or  malnu- 
trition— is  peculiarly  apt  to  show  itself  in  this 
direction,  and  that  more  especially  by'  an  ina- 
bility to  revive  the  cerebral  processes  conneeced 
with  the  names  of  persons,  places,  or  things  ( see 
Aphasia).  But  this  kind  of  defect  has  to  be  dis- 
tinguished from  the  inability  to  utter  or  to  write 
words  which  are  nevertheless  remembered,  that 
is,  where  the  cerebral  processes  associated  with 
the  word  as  a mental  symbol  may  be  revived,  in 
the  main,  in  some  portions  of  the  brain  con- 
cerned with  the  reception  of  auditory  impres- 
sions, though  incitations  may  not  be  able  to 
pass  over  from  these  centres  so  as  to  revive 
nerve-processes  in  other  centres  of  the  motor 
type,  by  which  the  word  is  either  spoken  or 
written,  according  as  the  one  or  other  effect  is 
desired  ( see  Aphasia).  The  loss  of  verbal  me- 
mory is  in  these  latter  cases  not  so  real  as  it 
seems  to  be,  and  such  defects  may,  moreover,  be 
induced  by  quite  limited  cerebral  lesions. 

In  the  third  mode  of  exercise  of  memory  (c) 
there  is  no  longer  the  easy  flowing  mechanical 
revival  of  foregone  processes,  together  with  the 
simultaneous  recurrence  of  copies  of  foregone 
phases  of  consciousness,  which  should  charac- 
terise the  modes  of  exercise  above  alluded  to. 
Now  there  is  a delay  in  the  process  of  automatic 
revival ; a vague  sense  of  effort  intervenes  at 
some  stage  of  the  thought-processes,  similar  to 
that  of  which  we  are  conscious  when  we  attempt 
to  ‘guide  our  thoughts’  into  particular  chan- 
nels ; we  strive  ‘ by  way  of  association  ’ to  find 
some  new  molecular  channel  by  means  of  which 
the  cerebral  processes  concerned  with  the  for- 
gotten name,  event,  idea,  or  relation,  may  be 
roused  anew,  in  order  that  we  may  ‘ recollect,’  or 
recall  by  voluntary  effort,  what  may  be  needful 
for  the  continued  expression  of  our  thoughts. 

This  latter  process  of  ‘recollection  ’ is,  there- 
fore, that  which  is  rendered  necessary  by  the 
first  stage  of  faultiness  of  memory,  a condition 
which  may  obviously  be  brought  about  in  alto- 
gether different  modes,  to  some  of  which  w:  are 
now  about  to  refer. 


242  MEMORY,  DEFECTS  OF. 

./Etiology  of  Defective  Memory. — It  seems 
clear,  on  the  one  hand,  that  for  memory  to  be 
good  (cr)  the  preliminary  process  of  synesis  must 
have  been  well  accomplished.  Yet  this  first  and 
essential  condition  may  be  defective  from  va- 
rious causes.  (1)  The  original  plasticity  or  re- 
ceptive potency  of  the  nerve-tissue  may  have 
been  inferior  from  birth;  or  it  may  have  been 
temporarily  lowered  by  conditions  of  mal-nurri- 
tion,  such  as  are  not  unfrequently  met  with  in 
porsons  who  have  suffered  from  severe  fevers  or 
from  other  exhausting  diseases.  On  the  other 
hand,  the  potency  of  the  nerve-tissue  may  be 
good,  and  yet  the  processes  of  synesis  may  have 
been  badly  effected,  owing  (2)  to  the  individual  s 
lack  of  attention  at  the  time  when  what  is  now 
to  be  remembered  originally  engaged  his  con- 
sciousness ; for  no  truth  is  more  obvious  in 
regard  to  memory  than  that  of  its  dependence 
upon  the  degree  of  attention  bestowed  upon  the 
original  impressions  or  ideas.  Those  which  have 
been  vividly  attended  to  at  the  time,  from  what- 
ever cause,  tend  to  become  indelibly  ‘stamped 
upon  the  memory,’  and  all  the  more  so  because 
such  impressions  or  ideas  are  prone  to  be  often 
thought  of,  and  thereby  strengthened  by  each 
revival  of  the  cerebral  process;  whilst  those  that 
have  slightly  engage.d  our  attention  are  apt  not 
to  be  revived,  and  to  be  after  a time  effaced, 
though  it  is  in  this  respect  especially  that  so 
much  of  individual  difference  is  met  with.  Greatly 
diminished  power  of  attention  is,  moreover,  com- 
monly met  with  in  exhausting  diseases,  and  in 
multitudinous  brain-affections. 

Rut,  on  the  other  hand,  however  well  the  pro- 
cess of  synesis  may  have  been  accomplished 
originally,  this  will  be  altogether  unavailing  if 
(i)  the  avenues  are  damaged  or  impaired  by 
which  associated  processes  transmit  their  sti- 
muli. The  automatic  excitation  of  memory  is 
then  hindered.  Thus,  to  take  only  one  ex- 
amplj,  if  certain  commissural  connections  be 
severed  between  what  we  may  term  the  visual 
and  the  auditory  word-centres,  a person  may  be 
able  to  read  so  as  to  understand  the  words  which 
he  sees,  and  yet  not  be  able  to  pronounce  one  of 
them,  because  the  associational  stimulus  cannot 
pass  to  the  corresponding  part  of  the  auditory 
word-centre,  so  as  to  rouse  this  particular 
memory  or  idea  of  the  word,  from  the  molecular 
processes  concerned  with  which  the  motor  stimuli 
issue  for  its  pronunciation.  (See  Brain  as  an 
Organ  of  Mind,  p.  640.) 

Again,  however  well  the  process  of  synesis  may 
have  been  originally  performed,  if  (c)  the  whole 
nutrition  of  the  brain  becomes  lowered  by  ex- 
hausting disease  or  old  age,  failure  of  memory 
may  present  itself  because  attention  cannot  be 
adequately  roused,  and  the  cerebral  processes 
generally  are  too  feeble  to  propagate  them- 
selves, as  they  would  have  done  formerly,  into 
the  various  collateral  channels  or  molecular 
paths,  so  as  to  rouse  the  activity  of  all  such 
previously  associated  brain-regions  as  are  neces- 
sary for  the  full  realisation  of  the  thoughts  of 
the  moment. 

From  what  has  been  already  said,  it  will  be 
boeu  taat  defects  of  memory  may  result  from 
very  various  causes,  acting  as  an  impediment  to 
one  or  other  of  the  successive  processes  upon 


MENINGES,  DISEASES  OF. 
which  memory  depends — namely,  either  (a)  from 
synetic  defects;  (6)  from  associational  defects;  or 
(c)  from  expressional  defects. 

Pathology. — In  all  those  cases  in  which  we 
may  presume  that  synesis  is  impaired,  we  may 
expect  also  to  find  evidence  of  a greatly  weak- 
ened power  of  attention,  and  there  may  in  addi- 
tion be  an  impaired  perceptive  power.  Such 
defects  are  mostly  dependent  upon  general  causes 
affecting  the  nutrition  of  the  brain  as  a whole. 
A condition  of  this  kind  may  be  only  temporary, 
and  then,  whilst  recent  events  are  speedily  for- 
gotten, it  may  happen  that  the  memory  of  old 
impressions  remains  fairly  good,  or  may  even  be 
marvellously  intensified,  so  that  long-forgotten 
occurrences  or  knowledge  become  revived.  At 
other  times  the  patient's  mind  may  for  a time  be 
reduced  to  a perfect  blank,  old  and  recent  know- 
ledge, familiar  and  unfamiliar,  is  alike  blotted 
out ; though  after  a time  recovery  of  memory 
may  take  place,  either  slowly  or  with  compara- 
tive suddenness.  In  cases  of  epileptic  mania, 
and  in  many  instances  of  brain-shock  from  blows 
upon  the  head,  the  patient  may  lose  all  memory 
of  immediately  preceding  events. 

Where  the  secondary  process  of  revival  is  that 
which  is  interfered  with,  the  loss  of  memory  is 
generally  most  manifest  in  regard  to  words.  The 
processes  of  association  by  which  these  are  re- 
called to  memory,  are  either  impaired  or  dis- 
turbed, so  that  we  get  one  or  other  variety  of 
amnesia  induced,  either  of  tho  paralytic,  or  of 
the  incoordinate  type  ( see  Aphasia).  Such  de- 
fects are,  in  the  opinion  of  the  writer,  specially 
prone  to  be  induced  by  lesions  of  the  convolu- 
tions contiguous  to  the  posterior  extremity  of 
the  Sylvian  fissure.  (See  Brain  as  an  Organ  cf 
Mind,  pp.  682-7.) 

Where  there  is  mere  loss  of  power  to  express 
thoughts,  the  loss  of  memory  is  often  more  appa- 
rent than  real,  and  is  due  to  a mere  paralysis 
affecting  speech  and  writing  as  motor  acts  ( set 
Aphasia).  And  these  conditions,  either  singly 
or  in  combination,  are  also  apt  to  be  induced  by 
lesions  in  the  third  left  frontal  convolution,  or 
of  regions  between  this  gyrus  and  those  bordering 
upon  the  posterior  extremity  of  the  Sylvian 
fissure. 

T rkatment. — The  treatment  of  these  various 
defects  of  memory,  so  far  as  they  are  amenable 
to  therapeutic  influence,  naturally  resolves  itself 
into  the  treatment  of  tho  various  general  or 
local  merbid  conditions  upon  which  they  depend. 
In  some  cases  we  can  do  little  or  nothing ; but 
in  other  instances  much  good  may  be  effected 
under  the  influence  of  a tonic  and  restorative 
regimen,  ai  led  by  stimulant,  sedative,  or  hypno- 
tic remedies.  H.  Chaei.ton  Bastian. 

MENIDROSIS  (mV,  a month,  and  iSpusJ 
sweat). — A term  applied  to  vicarious  menstrua- 
tion by  the  skin.  Set  Perspiration,  Disorders  of 

MEBTIERE’S  DISEASE.  Ses  Vertigo. 

MENINGES,  Diseases  of.— The  treatmeD1 
of  this  subject  is  naturally  divisible  into  two  mail 
heads.  We  have  to  consider  (1)  the  morbid  cun 
ditions  resulting  from  disease  of  tile  Cerebra 
Meninges;  (2)  those  of  the  Spinal  Meninges 
Though  most  frequently  affected  separately 


meninges,  diseases  of. 

etill  it  happens  on  some  occasions  that  these 
two  main  divisions  of  the  membranes  surround- 
ing the  great  nerve-centres  are  simultaneously 
diseased.^  This  is  the  case,  for  instance,  in 
Epidemic  Cercbro- Spinal  Meningitis , an  impor- 
tant general  disease,  which  is  considered  in  a 
i Beparate  article  (see  Epidemic  Cerebro-Spinal 
Meningitis).  A similar  diffusion  of  inflammation 
also  occurs,  but  more  rarely,  in  cases  of  Sporadic 
Cerebro-Spinal  Meningitis,  which  may  be  some- 
times • simple,’  and  sometimes  of  the  1 tuber- 
cular’ order.  In  the  articles  that  follow,  the 
several  diseases  of  the  Cerebral  Meninge3  and  of 
the  Spinal  Meninges  will  be  separately  discussed. 

MENINGES,  CEHEBEAL,  Diseases 

of. — Synon.  : Fr.  Maladies  des  Meninges  Cere- 
drrales ; Ger.  Krankkeiten  der  Himhdute. — The 
following  morbid  conditions,  and  varieties  of 
such  conditions,  have  to  be  considered  under  this 
heading : — 

1.  Inflammation — of  several  varieties. 

2.  Hemorrhage  into. 

3.  Hematoma  of. 

4.  New  growths  and  Adventitious  products. — 
Under  this  head  are  included,  besides  the 
different  kind  of  tumours  originating  in  the 
meninges,  other  bodies  of  quasi-accidental  origin, 
which  may  be  met  with  in  the  cavity  of  the 
arachnoid,  in  the  meshes  of  the  pia  mater,  or  in 
connection  with  the  vessels  of  these  parts. 

■5.  Malformations.  See  Brain,  Malforma- 
tions of. 

Inflammation  of  the  cerebral  meninges  occurs 
’rom  various  causes,  and  also  affects  various 
jarts  of  the  membranes,  so  that  the  subjoined 
•arieties  of  the  disease  will  have  to  be  separately 
icnsidered : — 

, ,,  . ...  f a.  Idiopathic. 

”■  Simple  Meningitis 

h.  Tubercular  Meningitis. 

The  simple  meningitis  of  traumatic  origin 
iccurs  under  three  pretty  distinct  forms,  aecord- 
ng  as  it  affects  the  dura  mater — Pachymenin- 
gitis; the  surfaces  of  the  arachnoid — Arachnitis  ; 
r the  meshes  of  the  pia  mater  beneath  this 
oembrane — Leptomeningitis.  Both  the  idiopathic 
imple  meningitis  and  tubercular  meningitis  are 
orms  ot'  leptomeningitis.  All  are  acute  diseases. 

Concerning  chronic  meningitis  we  have  more 
f pathological  than  of  clinical  knowledge,  though 
ren  as  regards  the  former  side  we  are  bound 
'i  say  that  much  of  the  thickening  and  opacity 
f the  arachnoid,  formerly  regarded  as  duo  to 
ihronic  inflammation,’  is  rather  a mere  result  of 
egenerative  overgrowth — partly  brought  about 
5 an  appanage  of  advancing  age,  and  partly  as  a 
^sequence  of  frequent  or  long-continued  eon- 
jjstions.  Still,  such  conditions  may  at  times  be 
iiupled  with  more  distinctive  evidences  of  actual 
ironic  inflammation,  for  example,  in  some  cases 
: chronic  mania,  and  also  iu  general  paralysis 
the  insane. 

. Good  reasons,  moreover,  exist  for  believing  in 
te  frequent  clinical  existence  of  local  chronic 
flammation  of  the  meninges,  as  evidenced  by 
e presence  more  especially  of  localised  pain 
id  of  tenderness  on  slight  percussion,  coupled 
th  other  head-symptoms.  Fortunately  for 
e patient,  however,  we  have  often  no  oppor- 


MENINGES,  INFLAMMATION  OF.  943 
tunity  of  verifying  this  diagnosis,  because  such 
a condition  is  of  itself  not  likely  to  lead  to  fatal 
results.  It  may  follow  a blow ; it  may  occur 
as  one  of  the  consequences  of  constitutional 
svphilis,  or  it  may  manifest  itself  independently 
of  either  of  these  causes.  Chronic  syphilitic 
meningitis  is  the  best  known  of  these  varieties. 
Its  associated  morbid  conditions  are,  however, 
most  closely  related  to  another  set  of  changes, 
which  will  be  described,  and  in  which  wo  have 
to  do  with  new  growths  or  ‘ gummata.’ 

Two  other  varieties  of  meningitis  are  occa- 
sionally met  with  as  rare  events ; first,  an  in- 
flammation limited  to  the  envelopes  of  the 
cerebellum,  or  extending  from  it  only  to  the 
pons  varolii ; and,  secondly,  an  inflammatory 
condition  of  the  lining  membrane  of  the  lateral, 
and  .perhaps  the  third  ventricles.  The  natural 
history  of  these  states  is  at  present  so  little 
known  as  not  to  admit  of  systematic  treatment. 
Their  aetiology  and  symptomatology  have  still 
to  be  established.  H.  Charlton  Bastlan. 

MENINGES,  CEREBRAL,  Inflamma- 
tion of.  Simple  Idiopathic. — Synon.  : Simple 
Idiopathic  Cerebral  Leptomeningitis ; Lepto- 
meningitis infantum  (in  part).  Fr.  Meningite 
Simple ; Ger.  Acute  Himhautentcundung. 

Definition. — A simple  non-tubercular  inflam- 
mation of  the  cerebral  pia  mater,  which  may  be 
either  limited  to  the  convexiiy,  general,  or  con- 
fined to  the  base  of  the  brain.  It  is  associated 
with  very  variable  symptoms  in  different  cases  , 
and  is  probably  caused  in  many  different  ways. 

yEtiology  and  Pathology. — Our  knowledge 
of  the  aetiology  and  pathology  of  acute  idio- 
pathic cerebral  meningitis  is  only  vague  and  in- 
definite, so  that  little  but  unconnected  statements 
or  mere  suggestions  can  be  here  set  down. 

It  appears  that  sex  exercises  an  influence  in 
the  production  of  idiopathic  meningitis,  and 
that  the  disease  occurs  much  more  frequently 
in  males  than  in  females.  In  regard  to  age.  it 
is  met  with  almost  as  frequently  in  individuals 
from  ten  to  twenty  as  in  those  below  the  tenth 
year.  In  individuals  over  twenty  the  disease  is 
much  more  rare. 

Meningitis  is  apt  to  occur  during,  or  as  a 
sequence  of,  some  acute  febrile  disease,  such  as 
measles,  scarlet  fever,  small-pox.  and  rheumatic 
fever.  It  may  complicate  erysipelas  of  the  head 
and  face ; or  may  occur  in  the  course  of  pneumonia 
or  pleuro-pneumonia.  Sometimes  it  is  met  with 
in  miserably  cachectic  subjects,  who  have  not 
previously  been  suffering  from  any  acute  disease. 
It  has  been  known  to  follow  prolonged  exposure 
to  the  sun;  to  ensue  after  the  occurrence  of 
severe  moral  perturbations  ; and  likewise  to  fol- 
low a shock  or  blow,  even  when  this  has  not 
been  complicated  with  an  external  wound,  or 
with  a fracture  of  one  of  the  bones  of  the  skull. 

But  how  do  these  various  predisposing  or 
exciting  causes  operate,  so  as  actually  to  bring 
about  the  inflammation  ot  the  meninges,  with 
which  we  are  now  concerned?  Here  some  hints 
only  can  be  offered  by  way  of  explanation.  In 
part  the  problem  does  not  difier  from  that  as 
to  the  actual  cause  of  inflammation  in  other 
internal  parts  of  the  body.  Setting  aside 
ttaumatic  influences,  or  the  sudden  operation  of 


944  MENINGES,  CEREBRAL, 

excessive  heat  or  excessive  cold,  how  does  in- 
flammation start  from  mere  altered  nutritive 
processes  ? It  is  difficult  to  believe  in  a primary 
alteration  in  themode  of  activity  of  cell-elements 
originating  of  and  by  itself,  independently  of 
altered  nervous  or  of  altered  vascular  conditions 
within  the  texture.  Again,  altered  nervous  in- 
fluence (whether  vaso-motor  or  other)  may  be  a 
real  factor  in  the  initiation  of  a meningitis,  even 
though  we  know  nothing  of  it  as  a fact,  and 
consequently  can  say  nothing  as  to  the  kind  or 
cause  of  altered  nervous  influence  which  might 
be  operative.  We  are  thrown  back,  therefore, 
necessarily  upon  a consideration  of  those  altered 
influences  that  may  arise  in  or  upon  the  side  of 
the  vascular  system,  for  the  elucidation  of  the 
other  probable  cause  or  starting-point  of  the  in- 
flammation with  which  we  may  have  to  deal. 

We  shall  do  well  to  bear  in  mind,  also,  that 
tn  certain  states  of  the  system,  or  in  certain 
constitutions,  conditions  exist  (partly  febrile, 
partly  cachectic,  and  partly  of  the  nature  of 
blood-poisoning)  which  are  inimical  to  the 
localisation  of  an  inflammatory  process  (how- 
soever initiated),  and  just  as  favourable  to  its 
extension,  especially  in  a tissue  like  that  of  the 
pia  mater.  And  in  just  such  conditions  of  the 
system  we  should  also  find  that  some  simple 
accident  on  the  side  of  the  vascular  system,  such 
as  the  rupture  of  some  vessel  or  vessels  and  the 
occurrence  of  a slight  haemorrhage  into  the  tissue, 
or  the  occlusion  of  one  or  more  vessels  either  by 
embolism  or  thrombosis  (events  which  might  not 
on  other  occasions  lead  to  the  setting  up  of  any- 
thing like  inflammation),  may,  under  the  par- 
ticular constitutional  conditions  existing  in  the 
patient,  be  capable  of  exciting  an  inflammatory 
process. 

1.  In  the  acute  diseases,  or  during  convales- 
cence from  them,  as  well  as  in  extremely  cachectic 
subjects,  altered  blood-states  sometimes  exist 
favourable  to  the  occurrence  of  thrombosis ; and 
this  may  occur  either  in  one  of  the  veins  return- 
ing blood  to  the  longitudinal  sinus,  or  in  the 
sinus  itself.  The  condition  of  the  sinuses  should 
therefore  be  always  investigated  in  cases  of 
meningitis.  In  many  instances  hcemorrhages  have 
been  found  beneath  the  arachnoid  in  meningitis, 
and  these  may,  like  the  meningitis  itself,  have 
been  immediately  consequent  upon  thrombosis  in 
the  longitudinal  sinus,  although  this,  the  primary 
process,  has  escaped  observation. 

2.  In  erysipelas  of  the  head  and  face,  as  a 
cause,  we  have  the  type  of  a mode  of  origin  of 
meningitis  such  as  may  occur  also  in  other  cases 
— for  example,  in  some  of  those  instances  where, 
in  the  course  of  rheumatic  fever  symptoms  of 
meningitis  (other  than  those  which  are  occasioned 
by  hyperpyrexia)  set  in  with  great  severity,  and 
cause  the  death  of  the  patient  just  as  rapidly  as 
when  they  supervene  in  the  course  of  erysipelas 
of  the  head  and  face.  In  both  these  cases  no 
products  of  inflammation  may  be  met  with  in 
the  membranes  post  mortem , but  only  a very 
minute  injection  of  the  pia  mater  in  all  regions 
basal,  as  well  as  lateral,  or  vertical.  The  ten- 
dency here,  therefore,  is  to  set  up  a general  menin- 
gitis, just  as  in  the  previous  category  of  causes 
the  tendency  would  be  to  the  establishment  of  a 
meningitis  affecting  the  convexity.  On  micro- 


INELAMMATION  OE. 

scopical  examination,  in  one  such  case,  the  writer 
found  the  minute  vessels  blocked  with  concretions 
of  an  albuminoid  or  fibrinous  nature,  which  seem 
to  have  separated  from  the  blood.  (See  Path. 
Trans,  vol.  xx.  p.  8.) 

It  is  difficult  to  say  in  what  acute  conditions 
some  such  cause  as  this  may  not  have  been  opera- 
tive in  settingup  the  inflammation,  where  menin- 
gitis occurs  in  the  absence  of  other  easily  recog- 
nisable causes. 

3.  Multiple  embolisms  of  the  vessels  of  the 
pia  mater  in  certain  cases  of  endocarditis  are 
another  possible  initiating  cause  of  idiopathic 
meningitis — which,  moreover,  seemed  almost  cer- 
tainly to  have  been  the  actual  cause,  in  a case 
that  came  under  the  writer’s  observation  a few 
years  ago. 

4.  Meningitis  may  take  its  origin  in  a slight 
lacerating  lesion  of  the  surface  of  the  braiH  or  of 
its  membranes,  with  or  without  notable  extra- 
vasation of  blood,  as  a result  of  a fall  or  blow, 
even  in  cases  where  there  is  no  fracture  of  the 
skull  or  external  wound. 

5.  In  other  cases,  also,  a meningitis  really 
secondary  may  appear  to  be  primary  and  idio- 
pathic, as  when  (a)  it  extends  from  some  focus  of 
syphilitic  disease  of  the  meninges,  or  (b)  when  i; 
occurs  as  a sequence  of  some  unrecognised  chronic 
inflammation  involving  the  middle  ear  and  por- 
tions of  the  temporal  bone. 

Anatomical  Characters. — Simple  idiopathic 
inflammation  of  the  cerebral  meninges  is  a con- 
dition which  varies  much  in  severity  in  different 
cases.  In  its  earliest  or  initial  stage,  nothing 
more  than  a minute  and  more  or  less  uniform 
injection  of  small  vessels  and  capillaries  in  cer- 
tain regions  of  the  cortex  maybe  met  with.  Bat 
later  on,  definite  products  of  inflammation  are  to 
be  seen  ; these  are  for  the  most  part  situated 
beneath  the  arachnoid,  in  the  meshes  of  the  pia 
mater.  They  consist,  according  to  the  stage  of  the 
morbid  process,  either  of  a gelatinous  white  or 
yellow  lymph-like  matter,  of  actual  pus,  or  of 
more  coherent  yellow  lymph,  in  the  form  of  mem- 
branous layers.  In  regard  to  the  area  involved 
considerable  differences  also  exist.  The  inflam- 
mation— (1)  may  be  limited  to  the  convexity 
and  to  the  lateral  regions  of  both  hemispheres : 
(2)  it  may  be  general,  that  is.  involve  the  parts 
above-mentioned,  and  also  the  base;  cr  (3)  it 
may  be  limited  to  the  basal  regions  of  the 
brain.  In  both  the  latter  eases  the  ventricles 
are  apt  to  contain  fluid,  and  the  central  parts  of 
the  brain  to'be  softened,  as  they  are  in  tuber- 
cular meningitis,  which  also  affects  the  base  in 
a special  manner. 

Of  these  varieties  as  to  seat,  the  first,  in 
which  the  convexity  is  involved,  is  decidedly 
the  most  typical,  and  in  this  respect  simple 
idiopathic  meningitis  contrasts  in  a salient 
manner  with  tubercular  meningitis,  in  which 
the  tendency  is  no  less  marked  to  implicate  the 
base  of  the  brain.  In'  the  second  variety,  the 
inflammation  beginning  above  probably  extends 
to  the  base  by  mere  continuity,  in  eases  where 
the  condition  of  the  patient,  or  the  intensity 
of  the  inflammatory  process  itself,  favours  its 
spread  from  the  original  site;  or,  in  certain 
cases,  the  inflammation  may  be  from  the  first 
general  in  seat.  In  regard  to  the  third  variety 


MENINGES,  CEREBRAL,  INFLAMMATION  OF. 


much  doubt  may  be  said  to  exist.  It  is  by  no 
means  clearly  established  that  a simple  idio- 
pathic inflammation  ever  begins  to  manifest 
itself  at  the  base,  and  there  only — though  no 
good  reason  can  be  assigned  why  such  a distri- 
bution should  not  occasionally  exist,  except 
that  experience  shows  it  to  be  at  least  very 
rare.  If,  moreover,  such  an  inflammation  be 
not  of  unsuspected  traumatic  origin,  there  are 
still  two  other  modes  of  accounting  for  its  exist- 
'euce,  which  should  be  excluded  before  regard- 
ing it  as  an  idiopathic  cerebral  meningitis  of 
unusual  site.  Thus,  it  may  be  an  extension  up- 
wards from  the  spinal  meninges  of  an  inflamma- 
tion beginning  there — a case,  in  fact,  of  cerebro- 
spinal meningitis,  either  sporadic  or  epidemic. 
Or,  on  the  other  hand,  it  may  be  one  of  those 
cases  of  tubercular  meningitis  where  the  general 
disease  manifests  itself  on  tho  side  of  the  brain 
irst,  and  in  which  the  patient  dies  before  the 
ocal  process  is  at  all  fully  developed.  In  such 
i case  tho  inflammation  may  be  really  of  the 
ubercular  variety,  and  yet  to  superficial  obser- 
vation not  recognisable  as  such.  Although  not 
ikely  to  occur  often  when  the  autopsy  is  made 
>y  a competent  observer,  the  case  may  be  other- 
rise,  and  either  of  such  misapprehensions  as  to 
he  real  nature  of  the  affection  is  more  especially 
pt  to  occur  where  the  head  only  is  examined. 

In  all  these  cases,  too,  the  inflammation  may 
e limited  to  the  meninges  themselves,  or  the 
irface  of  the  brain  may  also  bo  manifestly 
lvolved  in  the  inflammatory  process,  so  that 
e then  have  to  do  with  a meningo-cercbritis  of 
drying  seat  and  extent. 

Symptoms. — In  no  disease  is  the  symptoma- 
>logy  more  various  than  it  is  in  acute  menin- 
tis— a fact  partly  due  to  the  varying  intensity 

the  inflammatory  process,  partly  dependent 
>onthe  process  being  localised  or  more  general, 
id  partly  according  as  there  is  or  is  not  the 
-existence  of  dropsy  of  the  ventricles  with 
flammation  of  their  walls.  Sometimes  the 
sease  is  almost  latent,  accompanied  only  with 
,ght  symptoms,  merging  into  stupor  and  coma 
lay  or  two  before  death.  Or  tho  symptoms 
iy  be  marked  and  quite  tragic  in  their  severity ; 
hered  in  either  by  frightful  pains  in  the  head, 
well-marked  delirium,  or  by  convulsions ; sub- 
ing  eventually  into  a condition  of  stupor  or 
na;  and  followed  by  death  within  eight  or 
1 days,  though  this  may  be  delayed  till  the 
i liration  of  three  weeks  or  a month.  Recovery, 

' ich  sometimes  occurs,  must  be  regarded  as  a 
i e event. 

nasmuch  as  it  is  not  practicable,  within  the 
1 its  of  this  article,  to  give  a detailed  account 
c :he  various  groupings  of  symptoms  that  may 
1 met  with  in  different  cases,  we  must  confine 
qselves  to  an  enumeration  of  the  symptoms 
t nselves,  most  apt  to  occur — (1)  in  the  early 
a ;es  of  the  disease,  and  (2)  in  its  later  phases. 

. Cephalalgia  of  an  intense  character,  either 
{ioral,  or  localised  in  some  particular  region  or 
r ons  of  the  head,  may  be  complained  of  again 
a again  where  the  patient  is  old  enough,  or, 
d e he  too  young,  is  indicated  by  cries,  by  ap- 
P ition  of  the  hands  to  the  head,  or  by  other 
81  s.  Sometimes,  however,  this  symptom  may  be 
«t  absent,  or  it  may  come  on  at  a later  date. 

60 


94£ 

Delirium,  occasionally  furious,  at  other  times 
more  quiet  and  of  a simply  loquacious  type,  i.- 
another  symptom;  or  extreme  restlessness.  Mere 
insomnia,  too,  sometimes  exists  from  the  com- 
mencement ; whilst  at  other  times  a semi-coma- 
tose condition,  gradually  deepening  into  actual 
coma,  may  exist  from  tho  first,  especially  in 
children,  or  it  may  succeed  a transitory  de- 
lirious condition.  Nausea  and  vomiting,  and 
also  convulsions,  either  local  or  general,  may 
be  met  with  in  the  early  stages  of  the  disease, 
and  sometimes  as  initial  symptoms.  With 
them  will  go  general  pyrexia  and  sometimes 
rigors  ; also  heat  of  head,  rapid  pulse,  a furre  i 
and  often  thickly-coated  tongue,  constipation, 
perhaps  some  intolerance  of  light  and  of  loud 
sounds,  together  with  an  easily  obtainable  tail" 
cerebrate. 

2.  As  later  symptoms  we  may  have  localised 
convulsions,  or  spasms,  often  of  the  tonic  order, 
affecting  perhaps  the  head  and  neck,  which  are 
frequently  drawn  backwards,  or  one  or  both 
arms ; or  a condition  of  trismus  may  exist.  Tho 
eyes,  too,  are  sometimes  drawn  upwards.  The 
pupils  may  be  at  first  contracted,  or  if  not. 
they  may  be  of  medium  size,  unequal  and  insen- 
sitive ; whilst  later  on  they  are  most  frequently 
widely  dilated  and  insensitive.  The  conjunctivee 
are  often  injected.  Paralysis  of  one  arm,  or 
sometimes  of  an  arm  and  a leg.  may  occur.  The 
sensibility  of  the  skin  may  be  either  exalted 
or  deadened.  The  abdomen  is  often  hollow  and 
boat-shaped.  The  tongue  becomes  thickly  coated, 
or  dry  and  brown.  Difficulty  of  deglutition  is 
frequently  well  marked  towards  the  end ; and 
there  is  incontinence  of  faeces  and  urine  as  soon 
as  the  stupor  becomes  marked.  Sometimes  the 
pulse  is  unnaturally  slow  and  infrequent  from 
the  first ; at  other  times,  and  especially  towards 
the  end,  it  is  very  frequent  and  irregular.  The 
respiration,  too,  becomes  much  disturbed,  being 
often  sighing  and  of  very  irregular  rhythm, 
tending  to  become  stertorous  at  last.  The  tem- 
perature is  frequently  high,  but  pursues  a mark- 
edly irregular  course.  Remissions  of  the  py- 
rexial  condition  may  take  place  from  time  to 
time.  The  skin  is  generally  hot  and  dry,  though 
occasionally  there  may  be  copious  sweats.  Stu- 
por and  coma  almost  invariably  occur  at  the  last, 
if  not  present  at  an  earlier  stage. 

Prognosis. — A large  number  of  deaths  take 
place  within  the  first  week  of  acute  meningitis ; 
a much  smaller  number  survive  till  the  end  of 
the  second  week ; fewer  still  reach  the  end  of 
the  third ; and  only  a very  few  survive  to  the 
fourth  week.  It  is  difficult  to  say  what  the 
percentage  of  recoveries  may  be ; but  probably 
less  than  ten  would  survive  out  of  a hundred 
cases  of  acute  idiopathic  cerebral  meningitis. 

Diagnosis. — The  diagnosis  of  idiopathic  me- 
ningitis involves  considerations  very  similar  to 
those  arising  in  the  diagnosis  of  tubercular 
meningitis,  and  need  not  therefore  now  be  dis- 
cussed. See  Meninges,  Cerebral,  Inflammation 
of,  Tubercular. 

The  diagnosis  of  simple  from  tubercular  menin- 
gitis must  oftentimes  be  a matter  of  extreme 
difficulty.  Whether  the  condition  of  the  blood, 
as  recognised  by  the  aid  of  the  microscope  is  the 
same  in  simple  meningitis  as  it  is  in  tubercular 


346 


MENINGES,  CEREBRAL,  INFLAMMATION  OF. 


meningitis  the  ■writer  is  unable  to  say.  Should 
it  not  be  so,  some  help  might  be  obtained  in  this 
direction.  The  conditions  under  whichthe  disease 
seems  to  develop  may  throw  some  light  upon 
the  problem.  In  regard  to  special  symptoms, 
the  possible  range  is  so  great  in  each  variety, 
that  it  becomes  difficult  to  fix  upon  any  that 
are  positively  distinctive  of  one  or  of  the  other. 
Delirium  is,  however,  rarely  so  violent  in  tuber- 
cular as  it  may  be  in  simple  meningitis.  Re- 
traction of  the  head  is  also  not  so  frequent  in  the 
tubercular  variety.  On  the  other  hand  the  tem- 
perature much  more  frequently  rises  over  101°  Fh. 
in  simple  than  it  does  in  tubercular  meningitis. 
Finally,  it  must  be  borne  in  mind  that  the 
former  is  an  extremely  rare  disease,  the  latter 
unfortunately  only  too  common  ; and  that  whilst 
in  tubercular  meningitis  the  two  sexes  fall  vic- 
tims with  about  equal  frequency7,  in  the  simple 
variety,  t-wo  out  of  three  are  likely  to  be  males. 

Treatment. — In  the  early  stages  of  acute 
simple  meningitis  aperients  may  be  freely  ad- 
ministered. A leech  or  two  might  be  applied  to 
the  temples,  in  cases  where  pain  is  greatly  com- 
plained of ; or  under  the  same  conditions  the 
head  may  be  shaved  and  an  ice-bag  applied, 
should  it  not  be  deemed  useless  on  account  of 
the  extreme  restlessness  of  the  patient.  The 
writer  believes  that  little  or  nothing  is  to  be 
expected  from  drug  treatment  towards  the  cure 
of  this  disease,  although  some  alleviation  of  the 
more  distressing  symptoms  may  at  times  be 
brought  about  by  special  attention  to  them.  The 
patient  requires  to  be  carefully  fed,  and  assidu- 
ously nursed  and  kept  quiet  throughout,  in  the 
hope  that  the  end  may  be  favourable. 

H.  Ch.vbi.ton  Bastian. 

MENTNC+ES,  CEREBRAL,  Inflam- 
mation of,  Simple  Traumatic. — Several  dis- 
tinct forms  of  meningitis,  of  traumatic  origin, 
have  to  be  carefully  distinguished  from  each 
other.  We  have  a meningitis  in  which  the 
outer  surface  of  the  dura  mater  is  the  part  chiefly 
affected — Pachymeningitis-,  one  in  which  the 
cavity  of  the  arachnoid  is  the  seat  of  the  effu- 
sion —Arachnitis ; and  one  in  which  both  these 
escape,  and  the  subarachnoid  spaces,  or,  it  may 
bo,  the  structure  of  the  pia  mater,  is  primarily 
iuvolved — Leptomeningitis  or  Subarachnoid  Me- 
ningitis. For  the  most  part,  it  is  possible  to  dis- 
tinguish these  forms  at  the  bedside,  as  well  as  in 
the  post-mortem  room.  Sometimes  the  case  is  of 
a mixed  form  ; especially  is  it  not  uncommon  for 
an  inflammation  which  had  begun  between  dura 
mater  and  bone  to  extend  through  the  fibrous 
membrane, and  involve  the  arachnoid  beneath  it; 
but  it  is  still  a remarkable  fact  in  pathology 
that  very  frequently  the  delicate  arachnoid  suf- 
fices to  restrict  an  extensive  inflammatory  pro- 
cess to  one  or  the  other  side  of  it. 

Of  the  inflammation  between  the  dura  mater 
and  bone  it  is  possibly  true  that  it  occurs  only 
in  association  with  disease  of  the  bone.  If  there 
be  any  exceptions  to  this  latter  statement  they 
occur  probably  in  connection  with  syphilis.  Oc- 
casionally cases  are  met  with  in  which  the  ar- 
achnoid cavity  itself  contains  puro-lymph,  the 
surface  of  one  hemisphere,  for  instance,  being 
covered,  and  yet  there  is  no  history  of  injury  or 


of  prior  inflammation  of  the  scalp  or  bone.  Such 
cases  are,  however,  rare,  and  their  possible  causes 
need  further  investigation. 

In  a general  way,  children  may  be  deemed 
more  liable  to  meningitis  after  injuries  than 
adults,  and  in  them  not  very  unfrequently  severe 
and  fatal  complications  ensue  after  injuries  not 
attended  by  fracture. 

1.  Pachymeningitis.  — Inflammation  of  the 
meninges  secondary  to  inflammation  of  the  bone 
is  one  of  the  commonest  of  the  dangers  which 
attach  to  injuries  to  the  head.  The  hone  is  con- 
tused, and  in  most  cases  there  is  some  stripping 
off  of  the  pericranium. 

Symptoms.  • — For  a week  or  ten  days  the 
patient  does  well ; and  then  he  begins  perhaps 
to  complain  of  headache,  feels  chilly  and  uncom- 
fortable, and  cannot  eat.  These  symptoms  in- 
crease, and  drowsiness  and  semi-stupor  mav 
come  on.  If  the  ophthalmoscope  be  used,  very 
possibly  at  this  stage  the  discs  may  be  found 
hazy  and  swollen ; aDd  this  may  occur  without  any 
evident  defect  of  sight,  or  with  but  little.  If  the  I 
trephine  be  now  used,  the  bone  will  be  found 
discoloured,  its  diploe  greenish,  and  beneath  it 
a collection  of  pus.  The  pus  is  rarely  in  large 
quantity,  and  is  usually  discoloured,  whilst  all 
around  the  collection  of  fluid  there  is  much  cohe- 
rent and  sticky  lymph,  which  loosens  the  mem- 
brane from  the  bone.  It  is  very  rare  to  find  ;:i 
large  abscess,  such  as  those  described  in  the  cele- 
brated cases  given  by  Pott.  Usually  the  termi- 
nation of  such  cases  is  that  the  substance  of  the 
dura  mater  inflames ; that  the  arachnoid  is  im- 
plicated ; and  that  a layer  of  puro-lymph  line: 
that  membrane,  and  coats  the  hemisphere.  With 
this  state  special  symptoms  are  associated,  th< 
most  noteworthy  being  hemiplegia  of  the  oppo 
site  side.  Very  commonly,  however,  anothe 
event  cuts  short  the  case.  In  mentioning  th 
early  symptoms  nothing  has  been  said  as  t 
rigors,  r.or  do  they,  as  a rule,  occur,  unless  th 
complication  just  hinted  at  is  developed.  Th;: 
complication  is  pyaemia.  This  pytemia  has  n 
essential  connection  with  the  meningitis.  1 
depends  upon  the  inflammation  of  bone,  whic 
is  the  common  cause  of  both,  and  which  may  V 
the  parent  of  either  singly,  or  of  the  two  as  twin 
With  the  gangrenous  osteitis  occurs  gangrenoi 
phlebitis  of  the  veins  of  the  diploe ; from  the; 
the  process  extends  to  the  proximal  sinus  of  t) 
brain  (more  commonly  the  superior  longitudinal 
infectivo  emboli  of  decomposing  material  ga 
access  to  the  circulation  ; aDd  all  thewell-knov 
phenomena  of  pyaemia  iollow.  It  is  most  it 
portant  to  distinguish  the  symptoms  whi; 
belong  to  the  pyaemia,  if  we  would  rightly  e-s 
mate  those  due  to  the  meningitis,  for  very  i? 
quently  they  are  met  with  together.  Especia 
must  we  remember  that  a severe  rigor  probat 
denotes  pyaemia;  and  that,  if  it  be  repeated,  t 
diagnosis  of  this  affection  is  almost  certain,  t 
is  the  almost  constant  complication  with  pl- 
bitic  pvaemia,  which  so  almost  invariably  dis- 
points  the  surgeon  of  any  benefit  from  the  nst t 
the  trephine  in  this  group  of  cases.  If  pvten 
does  not  occur,  then  probably  arachnitis  is  the, 
and  thus  it  conies  to  pass  that  a recovery  a i 
secondary  trephining  is  almost  unknown. 

Treatment. — But  little  is  to  be  doneS 


MENINGES,  CEREBRAL 

regards  treatment  for  this  form  of  osteitic  menin- 
gitis ; the  main  thing  is  to  adopt  measures  for 
its  prevention.  The  careful  management  of  the 
wound,  either  by  Lister’s  plan  or  by  the  constant 
use  of  the  lead  and  spirit  lotion,  and  the  exemp- 
tion of  the  patient  from  all  risk  of  contagion, 
are  the  matters  which  will  chiefly  claim  atten- 
tion. In  cases  of  depressed  compound  fracture 
without  symptoms,  one  of  the  objects  of  primary 
trephining  is  to  prevent  meningitis,  by  removing 
displaced  fragments,  and  by  affording  free  exit 
i for  secretions. 

2.  Arachnitis.  — The  form  of  meningitis  to 
which  the  term  arachnitis  is  applicable  is  a 
frequent  consequence  both  of  inflammation  of 
?ontused  bone  and  of  wounds  of  the  membranes. 

' Suough  has  already  been  said  as  to  the  circum- 
stances under  which  it  occurs  after  contusions  of 
bono,  and  we  have  chiefly  now  to  examine  its 
pathology  and  special  symptoms. 

Anatomical  Characters.  — In  the  post- 
mortem, room  arachnitis  may  be  easily  distin- 
guished from  inflammation  in  tho  subarachnoid 
spaces,  and  tho  distinction  ought  always  to  be 
'carefully  made.  In  arachnitis  tho  puro-lymph 
covers  the  cerebral  convolutions  in  an  even  layer, 
and  does  not  dip  into  the  sulci,  to  which,  indeed, 
it  has  no  access;  whereas  when  the  spaces  are 
affected,  the  sulci  are  filled,  and  the  convexities 
of  the  convolutions  remain  free.  In  the  latter 
Tone  of  the  effusion  can  be  peeled  or  sponged 
iway,  nor  does  any  adhere  to  the  parietal  arach- 
noid. In  true  arachnitis  both  the  parietal  and 
fiscerai  layers  are  smeared  over. 

Symptoms. — Many  cases  of  compound  fracture 
if  the  skull,  with  laceration  of  the  dura  mater, 

, fiord  us  good  opportunities  for  the  study  of  acute 
raumaticaraclmitis;  but, unfortunately,  in  many 
>f  these  cases  the  brain-substance  is  also  punc- 
tured, and  it  becomes  at  least  possible  that  the 
ondition  described  as  diffuse  encephalitis  may 
e present,  and  may  complicate  the  symptoms. 
Ve  are  helped,  however,  as  regards  the  avoid- 
nca  of  fallacious  inferences  by  the  other  set 
f arachnitis  cases,  in  which  the  arachnitis  is 
scondary  to  osteitis,  in  which,  there  having 
;en  no  injury  to  the  brain,  there  is  no  proba- 
lity  of  encephalitis.  Speaking,  then,  from 
|o  result  of  observation  of  both  classes,  it  may 
||)  stated  that  whenever  evidences  of  arachnitis 
e found  widely  spread  over  a whole  hemisphere, 
ere  has  been  during  life  hemiplegia  of  the  op- 
■ site  limbs.  Exceptions,  apparent  or  real,  occur 
this,  but  they  are  rare,  and  probably  most  of 
dm  are  apparent  and  not  real.  The  risk  of 
•or  lies  in  the  ease  in  which,  in  a patient  who 
j very  ill,  hemiplegia,  which  supervened  gra- 
ally  during  the  last  day  or  two  of  life,  may 
re  been  overlooked.  The  hemiplegia  is  rarely 
nplete,  and  unless  the  limbs  be  carefully 
I ced  at  each  visit,  both  patient  and  surgeon 
>y  be  unaware  of  its  presence.  Its  degree  is 
I portionate  to  the  extent  of  the  arachnitis; 

if  the  latter  pass  under  the  falx  and  involve 
t opposite  hemisphere  also,  there  may  be 
f cral  weakness  of  all  the  limbs,  which  may 
pin  to  some  extent  mask  tho  hemiplegia.  It 
1 Imost  certain  that  the  hemiplegia  has  little 
jj  nothing  to  do  with  pressure  from  effused 
" l l°r  the  latter  is  rarely  in  large  quantity. 


INFLAMMATION  OF.  947 

Its  immediate  cause  is,  indeed,  not  very  obvious, 
but  as  the  grey  matter  of  the  cortex  is  almost 
always  discoloured,  and  changed  from  a pink 
tint  to  a greenish-slate  hue,  it  may  be  conjectured 
that  this  in  some  way  has  to  do  with  tho 
symptoms.  The  other  symptoms  which  attend 
acute  diffuse  arachnitis  are — wandering  delirium, 
rarely  violent ; increased  temperature ; inconti- 
nence of  urine  and  faeces  (part  of  the  hemiplegia)  ; 
and  occasionally  unilateral  sweating.  It  should 
be  remarked  that  the  hemiplegia  involves  both 
sensation  and  motion.  As,  however,  it  is  in- 
complete, the  defect  in  sensation  is  almost  cer- 
tain to  escape  notice.  Patients  who  are  obliged 
to  admit  that  they  cannot  move  their  limbs 
forcibly,  will  deny  that  there  is  any  defect  in 
feeling,  and  it  is  often  impossible  to  confute 
them.  In  well-pronounced  cases,  however,  sen- 
sation always  fails  as  well  as  motion. 

Treatment. — It  is  doubtful  whether  recovery 
ever  takes  place  after  this  form  of  arachnitis  has 
become  well  established ; and  here,  again,  we 
have  to  think  rather  of  prevention  than  of  cure. 
Cold  to  the  head — spirit  lotions  being  the  most 
convenient  form — and  very  early  and  efficient 
resort  to  mercury,  are  the  chief  measures  where 
the  dura  mater  is  known  to  have  been  lacerated. 
Strong  spirit  lotions  should  be  used  from  the 
first,  and  mercury  also  given.  It  is  too  late  tu 
commence  the  exhibition  of  mercury  after  the 
symptoms  of  arachnitis  have  set  in.  Amongst 
the  measures  of  treatment  of  more  doubtful 
value  are  aconite,  in  small  doses  frequently  re- 
peated, leeches,  blisters,  and  fomentations.  If 
blisters  are  used,  they  should  be  applied  to  the 
neck,  or  back,  or  shoulder. 

3.  Leptomeningitis. — This  form  of  trau- 
matic meningitis,  which  occurs  in  the  sub- 
arachnoid spaces,  is  an  exceedingly  interesting 
malady. 

^Etiology. — Leptomeningitis  may  ho  encoun- 
tered after  any  form  of  injury  to  the  skull  in- 
volving laceration  or  puncture  of  the  visceral 
arachnoid,  but  its  most  typical  illustrations  arc 
witnessed  after  fracture  through  the  petrous 
portion  of  the  temporal  bone.  This  fracture 
although  usually  counting  as  a simple  one,  is  in 
reality  compound,  in  that  it  opens  up  access  to 
au  air-containing  cavity.  It  is  possible  that  air 
may  reach  the  injured  bone  either  through  the 
external  ear  or  the  Eustachian  tube. 

It  is  a matter  of  some  interest  to  determine 
whether  arachnitis  of  these  spaces  often,  if  ever 
results  from  severe  concussion  without  any  frac- 
ture, or  after  simple  fracture  without  any  pos- 
sibility of  admission  of  air.  It  is  impossible, 
however,  to  speak  clearly  on  this  point. 

Anatomical  Characters. — Results  which  are 
scarcely  ever  witnessed  after  simple  fractures  in 
other  regions  of  the  skull  may  occur  here,  a fact 
which  can  only  be  explained  on  the  supposition 
that  we  hive  to  encounter  tho  risks  incident 
to  compound  lesions.  Amongst  the  results  re- 
ferred to  is  the  frequent  development,  sonx- 
days  after  the  accident,  of  inflammation  in  the 
large  subarachnoid  spaces  at  t.he  base  of  the 
brain.  It  is  .probable  that  the  inflammatory 
process  travels  along  the  course  of  the  nerve- 
trunks  (seventh  nerve),  and  thus  gains  access  tu 
tho  spaces.  Affecting  first  the  parts  adjacent 


MENINGES,  CEREBRAL,  INFLAMMATION  OF. 


118 

to  the  roots  of  the  nerves,  the  inflammation 
may  spread  downwards  on  the  medulla  and 
eord,  or  upwards  through  the  posterior  fissures 
into  the  ventricles,  cr  C7er  the  surface  of  the 
hemispheres.  Usually  it  is  almost  confined  to 
the  base  of  the  brain  and  medulla  oblongata. 
These  parts  are  coated  with  serous  lymph,  which 
invests  them  closely  and  adheres  to  all  the 
nerve-roots  passing  from  them.  The  layers  of 
arachnoid  which  cover  in  and  confine  the  exu- 
dation remain  quite  transparent,  and  show  no 
traces  of  lym-ph  on  their  inner  surface.  It  is 
only  when  these  layers  are  cut  or  torn  that 
access  to  the  inflammatory  effusion  is  gained. 
In  performing  the  autopsy  it  is  needful  to  use 
care  lest  this  laceration  be  made  by  accident, 
and  the  characteristic  appearance  somewhat 
spoiled. 

Symptoms. — Patients  suffering  from  this  form 
of  basal  subarachnoid  inflammation  may  become 
delirious  and  die  very  quickly  in  the  first  access 
of  the  morbid  action;  but.,  on  the  other  hand, 
and  more  usually,  they  may  live  for  several 
days,  or  a week  or  two,  and  show  only  compara- 
tively mild  symptoms.  Absolute  sleeplessness, 
with  occasional  wandering,  but  without  any 
degree  of  paralysis,  was  the  most  prominent 
symptom  in  one  very  well-marked  caso.  It  is 
probable,  though  not  as  yet  established,  that 
optic  neuritis  often  attends  this  form  of  menin- 
gitis. Its  peculiarities  as  regards  increase  of 
temperature  have  not  as  yet  been  ascertained. 
That  the  subarachnoid  spaces  are  affected  may 
be  plausibly  suspected  whenever,  after  supposed 
injury  to  the  base  of  the  skull,  vague  cerebral 
symptoms,  unattended  by  definite  paralysis, 
supervene ; and  if  there  have  been  bleeding 
from  the  ear  and  deafness,  with  facial  paralysis 
in  the  first  instance — a triad  pathognomonic  of 
fractured  petrous  bone — then  this  is  the  form 
of  meningitis  certain  to  follow,  if  any. 

Prognosis. — As  regards  recovery  from  trau- 
matic meningitis  of  the  base,  what  has  been  said 
on  the  difficulties  in  forming  a confident  opinion 
as  to  its  presence  will  sufficiently  explain  the  im- 
possibility, in  any  given  ease  in  which  recovery 
has  resulted,  of  feeling  sure  that  the  inflammation 
in  question  had  really  existed.  Many  patients, 
however,  recover  more  or  less,  often  perfectly, 
after  prolonged  and  severe  symptoms  following 
fractured  base.  Some  of  these  are  doubtless 
recoveries  from  severe  contusion,  but  others,  espe- 
cially those  in  which  serous  fluid  has  drained 
away  from  the  ear,  may  be  plausibly  conjectured 
to  be  recoveries  from  meningitis  of  the  base. 

Treatment.  — The  measures  of  treatment 
likely  to  conduce  to  recovery  in  such  cases  are 
the  same  as  those  for  other  forms  of  meningitis. 
Mercury  to  ptyalism  is  the  chief  agent,  and  so 
impressed  has  the  writer  for  long  been  as  to  the 
danger  of  the  malady,  and  the  value  and  harm- 
lessness of  the  drug,  that  ho  has  been  in  the 
habit  of  giving  it  from  the  first  in  all  cases  in 
which  fracture  of  the  petrous  bone  has  been 
diagnosed.  Jonathan  Hutchinson. 

MENINGES,  CEREBRAL,  Inflam- 
mation of,  Tubercular. — Synon.  : Granular 
Meningitis  ; Acute  Hydrocephalus  ; Hydro- 
cephalus intemus ; Brain  Fever  (in  part) ; Tuber- 


cular Leptomeningitis  ; Fr.  Fie  ire  cerebrate, 
Meningite  granideuse ; Meningite  tubercukuu- 
Ger.  Tubercvlose  Hirnhoutentzundung. 

Definition. — An  acute  and  extremely  fatal 
febrile  disease,  with  a predominance  of  head- 
symptoms  ; terminating  in  stupor  and  coma,  with 
or  without  convulsions ; and  characterised  after 
death  by  a ‘ granular  ’ meningitis  affecting  the 
pia  mater  at  the  base  of  the  brain,  with  the 
frequent  accompaniment  of  dropsy  of  the  lateral 
ventricles,  and  softening  of  the  parts  around 
them.  The  inflammation  of  the  membranes  at 
the  base  of  the  brain  is  often  found  to  be  asso- 
ciated with  a spinal  meningitis. 

Tubercular  meningitis  is  not  an  independent 
affection;  it  constitutes  one  important  phase  of 
a maDy-sided  general  disease  commonly  known 
as  Acute  Tuberculosis,  and  marked  anatomically 
by  the  presence  of  ‘grey  granulations’  within 
the  thorax  and  abdomen,  as  well  as  in  the  mem- 
branes of  the  brain.  In  certain  rare  cases  death 
takes  place  from  granular  meningitis,  before  the 
anatomical  marks  of  the  general  disease  have 
had  time  to  develop  within  the  chest  Of  abdo- 
men. More  frequently,  however,  the  manifes- 
tations of  the  general  disease  are  already  well 
developed  in  one  or  other,  or  in  both,  of  these 
situations,  at  the  time  that  they  reveal  them- 
selves also  on  the  side  of  the  brain.  In  the 
latter,  and  by  far  the  most  common  class  of 
cases,  the  symptoms  met  with  will  he  in  part 
those  of  the  general  affection,  and  in  part  (but 
in  a predominant  degree)  those  due  to  that  im- 
plication of  the  brain  and  its  membranes  with 
which  we  are  now  specially  concerned.  See 
Tuberculosis,  Acute. 

.(Etiology. — The  aetiology  of  tubercular  men- 
ingitis of  course  resolves  itself  into  the  fetiolcgy 
of  the  general  disease,  acute  tuberculosis,  of 
which  it  forms  part. 

This  affection  is  one  which  occurs  with  special 
frequency  in  young  children,  between  two  and 
six  years  old,  though  it  is  also  met  with  in 
infants,  in  older  children,  in  young  adults,  and 
even  in  persons  beyond  middle  age.  In  adults 
it  is  most  apt  to  manifest  itself  as  an  occasional 
complication  in  the  course  of  chronic  phthisis. 
In  children  a proclivity  to  the  disease  seems 
often  to  he  inherited,  so  that  two  or  more 
in  the  samo  family  may  be  carried  off  by  it.  But 
in  what  proportion  of  cases  any  such  proclivity 
exists  can  scarcely  he  said  to  be  known. 

The  central  brain-changes — namely,  the  dropsy 
and  the  central  softening — are  not,  in  the  opin:o: 
of  the  writer,  necessary  accompaniments  of  tuber 
cular  meningitis,  although  they  most  frequentl. 
coexist — just  as  they  are  also  most  frequentl 
concomitants  of  simple  or  non-tubercular  mer 
ingitis  when  it  affects  the  base  of  the  braii 
These  central  brain-changes  were,  howeror,  th 
part  of  the  disease  that  first  attracted  tlj 
attention  of  physicians,  so  that  the  affectic 
with  which  we  are  now  concerned  was  knov 
as  Acute  Hydrocephalus  long  before  the  mo 
modern  designations  of  Granular  or  Tubercul 
Meningitis  came  into  use. 

Anatomical  Characters. — "When  the  calvar 
is  removed  the  dura  mater  is  found  to  be  tight 
stretched  over  the  brain.  On  stripping  hack  tl 
membrane,  the  arachnoid  presents  a dull  appet 


MENINGES,  CEREBRAL, 

ance,  and  it  is  slightly  sticky  when  touched. 
The  convolutions  of  the  vertex  and  lateral 
regions  of  the  brain  are  seen  to  be  more  or  less 
flattened  from  pressure,  and  the  sulci  are  cor- 
respondingly indistinct.  No  lymph  may  be  seen ; 
or  at  most  a small  quantity,  in  the  lower  parietal 
regions  along  some  of  the  branches  of  the  middle 
cerebral  arteries.  When  the  brain  is  removed, 
however,  and  its  under  surface  is  examined,  a 
more  or  less  opaque  white  or  a yellowish  lymph- 
like matter  may  be  seen  (beneath  the  arachnoid, 
in  the  meshes  of  the  pia  mater)  extending  from 
the  optic  commissure  backwards  over  the  central 
portions  of  the  base  and  onwards  over  the  pons. 
In  certain  cases  lymph  and  evidences  of  recent 
inflammation  are  found  round  the  medulla,  and 
even  along  the  whole  length  of  the  spinal  cord. 
More  or  less  lymph  also  extends  on  each  side 
into  the  sylvian  fissures.  A minute  inspection 
mil  likewise  show  that  the  tip  of  the  temporo- 
sphenoidal  lobe,  and  the  orbital  surface  of 
the  frontal  lobe,  are  flecked  with  a number  of 
translucent  granulations,  as  though  the  parts 
had  been  sprinkled  with  fine  sand ; and  on  open- 
ing up  the  Sylvian  fissure  on  each  side,  similar 
granulations,  with  others  more  opaque  and  of 
larger  size,  may  be  seen  amongst  the  lymph  in 
this  situation.  Translucent  granulations  also 
sometimes  exist,  scattered  more  sparingly  over 
the  lateral  aspects  of  the  hemispheres,  especially 
along  the  sides  of  the  vessels. 

Examination  with  the  microscope  shows  that 
the  granulations  are  composed  of  overgrowths 
of  tissue-elements  immediately  surrounding  the 
smaller  vessels,  and  within  their  perivascular 
sheaths.  In  these  situations  the  tissue  over- 
growths may  cause  a local  bulging  of  the  sheath, 
either  all  round,  or  merely  on  one  side  of  the 
vessel ; and  when  such  growths  become  opaque 
from  incipient  fatty  degeneration,  they  are  then 
more  easily  visible  as  minute  white  specks.  A 
close  examination  of  the  prolongations  of  the 
pia  mater  dipping  between  the  convolutions, 
with  the  aid  of  lens  or  microscope,  will  often 
show  minute  granulations  not  otherwise  recog- 
nisable— and  that,  too,  in  many  regions  of  the 
brain.  And  in  cases  of  incipient  tubercular 
meningitis,  where  the  amount  of  lymph  about 
lie  base  is  extremely  slight,  the  lens  or  micro- 
icope  may  show  the  presence  of  granulations, 
iot  otherwise  recognisable,  in  and  around  the 
ower  part  of  the  Sylvian  fissures — that  is  in  the 
■cgions  where  they  are  most  prone  first  to  mani- 
fest themselves. 

The  pia  mater  is  generally  unduly  adherent 
o the  surface  of  the  convolutions,  so  that  it 
an  only  be  removed  in  small  shreds,  and  then 
ot  without  tearing  the  superficial  grey  matter, 
'his  condition  of  things  is  the  very  opposite 
f what  may  be  met  with  in  some  cases  of 
imple  meningitis  affecting  the  vertex,  in  which 
he  thickened  pia  mater,  with  all  its  prolon- 
ations,  may  sometimes  be  easily  stripped  off 
;om  the  greater  portion  of  a hemisphere  in  one 
iece. 

The  substance  of  the  brain  is  commonly  much 
lore  vascular  than  natural.  The  lateral  ven- 
'icles  are  usually  moderately  dilated,  containing 
■om  2 to  4 or  6 ounces  of  not  very  clear  serum, 
he  veins  on  their  surface  are  then  engorged, 


,,  INFLAMMATION  OF.  949 

and  the  fornix  and  other  adjacent  parts  may  b© 
more  or  less  softened,  or  actually  diffluent.  Mi- 
croscopical examination  of  such  softened  tissue 
will  reveal  the  presence  of  an  abundance  of 
granulation-corpuscles;  and  its  specific  gravity, 
if  estimated,  will  be  found  to  be  diminished — 
both  these  characteristics  being  marks  of  a patho- 
logical softening  which  has  occurred  during  life, 
and  not  of  a softening  due  to  mere  post-mortem 
maceration.  Some  have  erroneously  supposed 
that  such  mere  maceration  would  be  adequate 
to  produce  the  softening. 

Sometimes  the  above-described  changes  aro 
more  fully  developed  in  one  than  in  the  other 
hemisphere ; and  occasionally  also  in  some  parts 
of  the  brain  small  nodular  growths  of  a ‘ tuber- 
cular’ nature  may  be  met  with,  varying  in  size 
from  a small  pea  to  an  almond.  These  growths 
are  most  apt  to  occur  in  the  substance  of  some 
of  the  cerebral  convolutions,  or  near  the  surface 
of  the  cerebellum,  or  even,  as  the  writer  has  seen, 
within  the  substance  of  the  corpus  striatum.  In 
many  such  cases  the  small  nodular  tumours  will 
be  found  to  be  in  intimate  relations  with  the 
vessels  of  the  part,  and,  in  fact,  to  be  composed 
of  a mere  aggregate  of  the  smaller  ‘granulations’ 
more  or  less  fused  into  a single  mass. 

Pathology. — The  granulations  begin  to  ap- 
pear first  in  the  meninges  of  the  base  under 
those  influences,  whatever  they  may  be,  that 
lead  to  the  development  of  similar  grey  granu- 
lations in  other  organs  of  the  body.  These 
primary  changes  excite  a common  inflammation 
of  the  membranes  around,  and  thus  entail  the 
production  of  the  lymph,  which  covers  the  base 
of  the  brain,  and  extends  on  either  side  into  the 
Sylvian  fissures.  Why  the  grey  granulations 
should  tend  to  develop  first,  and  specially  about 
the  vessels  at  the  base  of  the  brain,  cannot  at 
present  be  explained. 

This  inflammation  of  the  basal  meninges  also 
extends,  by  direct  continuity  of  tissue,  over  and 
around  the  cerebral  peduncles  to  the  velum  in- 
terpositum,  and  to  the  connective  tissue  at  the 
upper  and  anterior  extremity  of  the  middle  lobe 
of  the  cerebellum.  In  one  or  other,  and  often 
in  both,  situations  the  tissues  are  thickened  by 
lymph.  The  writer  has  seen  the  velum  inter- 
positum  thick  and  leather-like  in  consistence, 
and  the  vense  magn®  Galeni  which  run  through 
it  blocked  by  thrombosis;  and  this  he  believes 
to  be  an  occasional  cause  of  the  central  soften- 
ing and  dropsy,  previously  referred  to  as  com- 
ponent parts  of  the  disease  (see  Edinburgh 
Medical  Journal , April  1867).  In  other  cases, 
where  no  such  thickening  or  thrombosis  is  to  be 
detected,  there  is  great  swelling  of  the  connec- 
tive tissue,  from  development  of  lymph,  opposite 
the  termination  of  these  great  veins  which  re- 
turn the  blood  from  the  surface  of  the  ventricles 
and  from  the  central  parts  of  the  brain — at  the 
point,  that  is,  where  the  veins  of  Galen  empty 
themselves  into  the  straight  sinus. 

In  this  way  the  very  common  association  of 
the  central  ventricular  changes  with  the  basal 
meningitis  may  be  accounted  for,  and  also  the 
occasional  absence  of  such  changes,  in  instances 
where  the  inflammation,  apt  to  be  setup  through 
mere  continuity  of  tissue,  does  not  attain  sufficient 
proportions  to  interfere  with  the  return  of  blood, 


MENINGES,  CEREBRAL,  INFLAMMATION  OF. 


950 

either  through  the  veins  of  Galen,  or  from  them 
into  the  straight  sinus.  It  is  of  course  possible 
that  the  central  softening  may  also  be  favoured 
by  an  independent  affection  of  the  small  vessels 
situated  in  the  walls  of  tho  ventricles,  and  a de- 
velopment of  granulations  around  them — though 
this  has  not  hitherto  been  recognised.  It  is, 
however,  well  known  that  thrombosis  is  ex- 
tremely apt  to  occur  in  those  minute  vessels  in 
various  parts  of  the  brain  which  are  enveloped 
by  granulations — a fact  that  goes  far  to  account 
for  the  extreme  gravity  of  the  symptoms  in 
many  cases  of  tubercular  meningitis,  in  which 
naked-eye  changes  appear  to  be  slight  and  alto- 
gether disproportionate  in  amount. 

Symptoms. — The  symptoms  presented  in  dif- 
ferent cases  of  tubercular  meningitis  often  vary 
very  widely  from  one  another,  although  amongst 
them  all  there  is  an  underlying  bond  of  similarity. 
The  variation  may  be  easily  understood  from  a 
consideration  of  the  fact  that  such  symptoms 
form  part  of  those  pertaining  to  a febrile  affec- 
tion characterised  by  other  local  manifestations, 
of  varying  importance  in  different  cases  ; and 
also  from  the  fact  of  the  differences  constantly 
met  with  in  the  relative  and  absolute  develop- 
ment of  the  different  kinds  of  changes  encountered 
within  the  cranium  itself  in  this  disease — espe- 
cially in  regard  to  the  amount  of  ventricular 
effusion  and  central  softening  existing  in  con- 
junction with  the  meningeal  inflammation,  which 
itself  varies  much  in  intensity  and  in  regard  to 
the  area  involved  in  different  cases. 

It  is,  therefore,  usual  and  most  convenient  to 
enumerate  the  possible  signs  and  symptoms  of 
this  disease  as  they  occur  in  three  stages— 
artificial  and  often  ill-marked  from  one  another 
as  they  are — namely,  (1)  those  of  the  invasion 
stage ; (2)  those  of  the  developed  disease ; and 
(3)  those  of  its  closing  phases. 

(1)  Stage  of  Invasion. — Amongst  the  initial 
symptoms  of  tubercular  meningitis  may  be  men- 
tioned obstinate  and  recurrent  vomiting,  often 
associated  with  constipation ; coming  on  fre- 
quently after  a period  of  previous  malaise  ; and 
associated  with  fretfulness,  slight  wasting,  in- 
disposition to  play,  and  disturbed  sleep.  Soon 
after,  or  simultaneously,  there  may  be  more  or 
loss  marked  indications  of  cephalalgia.  Young 
children  who  cannot  speak  are  fretful  and  con- 
stantly cry ; they  often  also  put  their  hands 
to  their  head.  Such  children  start  and  cry 
out  in  their  sleep.  The  temperature  may  ba  as 
yet  scarcely,  if  at  all  elevated ; or  there  may 
be  rigors  from  time  to  time,  with  temporary 
feverishness,  recurring  daily  about  the  same 
hour.  The  child  often  cries  out  when  touched, 
and  a more  or  less  general  exalted  sensibility  to 
painful  impressions  seems  to  exist. 

(2)  Developed  Disease.— In  the  second  stage 
any  feverishness  that  may  have  existed  often 
itbates.  There  may  be  less  restlessness,  so  that 
tho  child  even  sleeps  more  than  natural.  Tho 
pupils  are  often  insensitive  to  light,  and  unequal. 
There  is  frequently  also  some  slight  or  perhaps 
marked  strabismus.  The  pulse  is  apt  to  be  much 
less  frequent  than  natural  (56-70  per  minute 
perhaps),  and  decidedly  irregular.  The  hyper- 
sensitiveness  of  skin  may  havo  disappeared,  but 
a peculiar  vaso-motor  irritability  exists,  bo  that 


when  the  nail  of  the  fore-finger  is  drawn  ones 
across  the  skin  of  the  abdomen  or  other  part,  a 
deep  red  linear  mark  comes  out  slowly,  and  per- 
sists a long  time.  This  so-called  ‘ tache  cere- 
brale,’  whilst  also  met  with  in  other  affections 

is,  as  Trousseau  rightly  enough  insists,  rarely 
absent  in  tubercular  meningitis.  Frequent  plain- 
tive cries  may  be  uttered,  though  the  child  is 
generally  more  quiet  and  drowsy  ; it  is  apathetic 
also  in  regard  to  food,  not  asking  or 'crying  for 

it,  but  still  talcing  it,  perhaps  well,  whenever  it 
is  administered.  Convulsions  may  occur  during 
this  stage,  or  weakness  of  one  or  more  limbs  may 
be  noticed,  especially  where  larger  tubercular 
nodules  occur  in  one  or  other  portion  of  the 
brain-substance.  Sometimes,  too,  the  paralysis 
is  of  a shifting  and  transitory  nature,  varying 
in  degree  or  even  in  situation  in  the  course  of  a 
few  days. 

(3)  Closing  Phases. — In  the  closing  stages  of  the 
disease  the  drowsiness  may  gradually  deepen  into 
stupor  or  actual  coma ; though  in  conditions  short 
of  the  latter,  the  child  may  still  more  or  less  fre- 
quently utter  plaintive  cries.  The  pulse,  instead 
of  being  less  frequent  than  natural,  now  becomes 
preternaturally  frequent;  whilst  the  respiration 
often  assumes  a slow,  sighing,  and  markedly 
irregular  type.  The  face,  frequently  pale  and 
clammy,  flushes  at  times.  The  head  is  hot,  and 
the  temperature  generally  raised,  though  often  not 
more  than  to  100°,  and  rarely  beyond  102°,  until 
quite  to  the  close  of  the  disease.  The  fontanelle 
is  raised,  and  there  may  be  unnatural  pulsation. 
The  eyes,  when  examined  with  the  ophthalmo- 
scope. may  show  evidences  of  grey  granulations 
in  the  choroid.  The  pupils  may  be  unequal, but 
are  generally  dilated  and  insensitive.  In  one 
remarkable  case  the  writer  has  seen  a rhyth- 
mical contraction  and  dilatation  go  on,  especially 
on  exposing  them  to  light.  In  this  stage,  when 
the  patient  is  sufficiently  conscious,  it  may  be 
found  thatsight  is  notably  impaired  oralmost  lost. 

The  patient  may  take  the  food  which  is  given, 
up  to  the  last;  though  at  other  times  there  seems 
to  be  an  actual  inability  to  swallow  it,  even  when 
it  is  placed  in  the  mouth,  owing  to  paralysis  of 
the  muscles  of  the  tongue  and  pharynx.  The 
abdomen  is  often  boat-shaped  and  retracted:  and 
an  obstinate  constipation  stiil  continues.  Even 
in  this  last  stage  of  the  disease  a temporary 
and  delusive  lull  may  take  place ; the  child  may 
seem  to  revive  a little,  but  only  too  soon  to  lapse 
again  into  a state  as  bad  as  or  even  worse  than 
before.  Frequent  and  long-continued  convulsive 
seizures  are  especially  apt  to  occur  during  this 
stage  of  the  disease  ; and  death  may  take  place 
during  or  immediately  after  one  of  these  attacks 
At  other  times  the  end  is  brought  about  more 
gradually,  through  progressing  failure  in  tin 
heart’s  action,  combined  with  disturbance  o 
respiration.  In  the  latter  class  of  cases  thi 
temperature  may  gradually  fall,  during  the  las 
few  hours  before  death  takes  place,  to  severs 
degrees  below  the  normal ; though  in  otherease 
of  tubercular  meningitis  there  is  a slow  an< 
steady  rise  of  temperature  up  to  105°,  or  eve 
106°,  before  the  patient  expires. 

Diagnosis. — -In  the  early  stages  the  diagnosi 
of  tubercular  meningitis  may  present  extsem 
difficulties.  "We  must  wait, before  expressing 


MENINGES,  CEREBRAL,  INFLAMMATION  OF. 


definite  opinion  in  one  of  these  doubtful  cases, 
till  the  patient  has  been  seen  and  examined  two 
or  three  times.  The  premonitory  symptoms  and 
those  of  the  first  stage  are  often  far  from  distinc- 
tive. They  may,  it  is  true,  represent  the  begin- 
ning of  tubercular  meningitis,  but,  on  the  other 
hand,  they  may  also  represent  something  less 
serious — for  instance,  a mere  failure  of  health 
from  various  causes,  complicated  by  some  gastro- 
intestinal irritation,  or  perhaps  the  commencing 
outbreak  of  some  one  or  other  of  the  specific 
fevers.  Details  as  to  the  child’s  condition  during 
the  last  two  or  three  weeks,  comprising  the  order 
of  evolution  of  the  several  symptoms,  may,  how- 
ever, throw  some  light  upon  the  real  nature  of 
the  case  at  an  early  stage  of  the  disease. 

A contributory  cause  of  the  difficulties  beset- 
ting the  early  diagnosis  of  tubercular  meningitis 
is  to  bo  found  in  the  fact  that  acute  tuberculosis 
is  itself  extremely  difficult  to  recognise.  We 
cannot,  therefore,  readily  fall  back  upon  a 
diagnosis  of  the  general  condition  in  order  to 
strengthen  our  diagnosis  of  tubercular  meningitis. 
As  a matter  of  fact  it  is  just  the  reverse.  Of  all 
the  local  manifestations  of  this  disease,  those 
within  the  head  produce  by  far  the  most  definite 
set  of  symptoms  ; so  that  we  can  always  most 
safely  infer  the  probable  existence  of  acute 
tuberculosis  with  grey  granulations  throughout 
the  body,  from  the  presence  of  the  developed 
symptoms  of  tubercular  meningitis.  The  symp- 
toms produced  by  grey  granulations  within  the 
thorax  or  within  tho  abdomen,  are 'far  less 
distinctive  or,  in  fact,  not  distinctive  at  all.  The 
existence  of  a particular  habit  or  build  of  body 
in  all  cases  of  acute  tuberculosis  to  any  ap- 
preciable extent,  or  certainly  to  such  an  extent 
as  to  make  it  possible  to  use  the  recognition  of 
it  as  an  aid  to  diagnosis  in  a case  otherwise 
obscure,  is  very  improbable.  Our  notions  as  to 
the  existence  and  nature  of  a tubercular  habit 
of  body  need  revision ; it  must  not  thoughtlessly 
be  confounded  with  the  mere  phthisical  habit  of 
body;  and  it  seems  probable,  from  more  than  one 
point  of  view,  that  acute  tuberculosis  is  a quasi- 
accidental disease,  occurring  at  times  in  in- 
dividuals of  any  build  of  body  whatsoever — with 
no  more  limitations,  that  is,  than  may  exist  in 
regard  to  the  incidence  upon  persons  of  different 
lodily  types  of  one  of  tho  common  acute  specific 
diseases. 

The  symptoms  of  the  established  disease  are 
therefore  alone  distinctive,  to  any  really  trust- 
worthy extent,  of  the  existence  of  tubercular 
meningitis,  and  through  it  of  the  presence  of  its 
general  underlying  condition.  We  may  have 
3ur  suspicions  before,  but  these  can  only  trans- 
form themselves  into  certainties  as  the  disease 
ictually  develops,  and  as  it  passes,  moreover, 
nto  the  incurable  stage. 

At  this  phasis  of  the  disease  the  alternative 
■onditions  to  be  thought  of  are  in  the  main 
hese — typhoid  fever  on  the  one  hand,  or  else 
iome  form  of  intracranial  disease  other  than 
ubercular  meningitis.  Here,  as  in  almost  all 
uses  of  brain-disease,  we  have  to  look  not  to  any 
me  or  two  signs  or  symptoms  which  can  be  re- 
:arded  as  pathognomonic,  but  ra  iher  to  the  sum 
otal  of  symptoms,  and  to  the  way  in  which  they 
ie  grouped.  With  the  possible  existence  of  some 


95 1 

or  all  of  the  premonitory  and  initial  symptoms 
already  enumerated,  if  the  patient  becomes  more 
somnolent;  if  the  pulse  falls  much  below  par  in 
frequency,  and  is  at  the  same  time  irregular;  if 
with  a condition  of  fever  still  existing,  the  child 
does  not  constantly  crave  for  drink ; and  especially 
if  there  is  also  the  combination  of  obstinate  con- 
stipation and  a retracted  abdomen,  together  with 
an  irregular  and  suspirious  form  of  respiration, 
we  may  feel  more  and  more  certain  that  we  have 
not  to  do  with  even  one  of  the  most  anomalous 
forms  of  typhoid  fever  associated  with  head- 
symptoms — or,  indeed,  with  any  form  of  intra- 
cranial disease  other  than  tubercular  meningitis. 
An  examination  of  the  temperature  chart  may 
considerably  aid  us  in  the  same  direction,  and 
so  also  may  a microscopical  examination  of  the 
blood. 

Some  years  ago,  tho  writer  made  observations 
upon  this  latter  point,  tending  to  show  that  ir 
tubercular  meningitis  there  are,  in  a large  pro- 
portion of  the  cases,  distinctive  alterations  in  the 
blood — as  drawn  by  a needle-prick  from  the  tip 
of  the  fore-finger  and  examined  at  once  upon  an 
ordinary  microscope-slide — capable  of  affording 
very  material  aid  in  the  diagnosis  of  tubercular 
meningitis  from  typhoid  fever,  as  well  as  from 
other  brain-affections  (such  as  a new-growth  im- 
plicating the  pons  and  contiguous  parts,  throm- 
bosis in  some  of  the  cranial  sinuses,  or  perhaps 
one  of  the  simple  forms  of  meningitis).  The 
characters  of  the  blood  met  with  in  tubercular 
meningitis  are  these ; — The  white  corpuscles 
are  decidedly  more  numerous  than  natural,  and 
speedily  (that  is,  within  ten  to  fifteen  minutes 
after  the  blood  has  been  drawn)  show  signs  of 
great  amoeboid  activity,  by  tbe  development  of 
vacuoles  within  them,  and  of  numerous  projec- 
tions from  their  outer  surface  ; groups  of  proto- 
plasmic particles  of  various  sizes  are  also  to  b® 
seen  interspersed  amongst  the  blood-corpuscles, 
as  well  as  here  and  there  a small  pigment-granule 
or  an  irregular  block  of  pigment  of  reddish  or 
reddish-black  colour.  Tho  red  corpuscles  usually 
run  together  into  irregular  masses,  rather  than 
into  definite  rouleaux,  though  they  present  ws 
very  distinctive  changes.  This  increase  in  num- 
ber with  exalted  amoeboid  activity  of  white 
corpuscles,  in  conjunction  with  the  other  blood- 
characters  above-mentioned,  are  not  met  with- 
in typhoid  fever,  or  in  the  great  majority,  at 
least,  of  other  cerebral  affections. 

F’or  the  diagnosis  of  tubercular  from  the  simple 
form  of  meningitis,  see  Meninges,  Cerebral, 
Inflammation  of,  Simple  Idiopathic. 

Prognosis. — Death  is  well-nigh  certain  within 
three  weeks,  or  at  most  a month,  from  the  date  of 
the  invasion-symptoms  of  tubercular  meningitis. 
When  the  disease  has  arrived  at  a stage  permit- 
ting of  pretty  certain  diagnosis,  hope  rather  than 
rational  expectation  may  still  hold  out  a chance 
of  recovery.  Although  instances  of  this  have 
occurred,  they  are  of  extreme  rarity.  If  the 
courso  of  the  disease  is  to  be  modified  by  treat- 
ment, it  must  be  during  those  early  stages  when 
we  are  capable  of  forming  only  a provisional  or 
tentative  diagnosis.  In  these  stages,  however, 
the  writer — and  many  good  observers  share  this 
opinion — is  inclined  to  think  that  under  judicious 
treatment  the  development  of  the  disease  mav 


MENINGES,  CEREBRAL,  H.EMOKRHAGE  INTO. 


96‘2 

be  arrested.  Still  this  view  may,  quite  possibly, 
be  an  erroneous  one.  Proof  of  such  a position, 
or  of  its  opposite,  is,  from  the  nature  of  the 
ease,  impossible. 

Treatment. — From  what  has  just  been  said, 
it  will  be  seen  that  anything  like  curative  treat- 
ment must  be  directed  to  the  early  or  premoni- 
tory symptoms  of  the  disease.  Here  the  writer 
thinks  he  has  seen  decidedly  good  results  from 
one  to  six  grains  of  iodide  of  potassium,  accord- 
ing to  the  'age  of  the  child,  administered  three 
times  a day,  with  small  doses  of  cod-liver  oil; 
at  the  same  time  attending  to  the  state  of  the 
bowels,  and  giving  suitable  doses  of  bromide  of 
potassium  at  night,  till  the  restless  condition 
with  disturbed  sleep  has  passed  away. 

When  the  disease  is  further  advanced,  we  may 
perhaps  be  able  to  diminish  pain  by  the  appli- 
cation of  cold  to  the  head  ; but  we  only  aggra- 
vate the  sufferings  of  the  patient  by  the  use  of 
blisters,  tartar  emetic  ointment,  or  other  irrita- 
ting applications.  Bromide  of  potassium  may 
do  something  to  keep  convulsions  in  check, 
though  at  other  times  it  seems  to  be  quite 
powerless.  Chloral  is  probably  a dangerous  drug 
for  a patient,  the  action  of  whose  heart  is  already 
so  seriously  interfered  with  ; though  chloroform 
inhalations  may  be  had  recourse  to  in  an  extreme 
case,  where  persistent  convulsions  cannot  other- 
wise be  checked.  Beyond  this,  the  child  needs 
the  most  careful  nursing,  and  to  be  well  sup- 
ported with  strong  beef-tea  and  milk,  and  occa- 
sionally with  stimulants,  so  long  as  it  is  capable 
of  taking  food,  whilst  attention  is  paid  to  the 
bowels.  In  this  way,  if  the  patient’s  case 
is  to  prove  one  of  those  rare  and  exceptional 
instances  in  which  recovery  is  possible,  we,  at 
all  events  do  nothing  to  thwart  the  course  of 
natural  processes  which  have  a chance,  however 
small,  of  terminating  in  recovery. 

H.  Charlton  Bastian. 

MENINGES,  CEREBRAL,  Haemor- 
rliago  into. — Synon.  ; Fr.  Apoplerie  meningee  \ 
Hemorrhagic  meningec ; Ger.  Hirnhautblutungen. 

' Definition. — Effusion  of  blood  in  one  or  other 
of  the  following  situations; — (1)  Between  the 
bone  and  the  dura  mater ; (2)  Between  the  dura 
mater  and  the  arachnoid  (into  the  so-called 
‘ arachnoid  sac  ’)  ; or  (3)  beneath  the  arachnoid 
and  into  the  meshes  of  the  pia  mater. 

■^Etiology. — The  first  of  these  varieties  of 
meningeal  haemorrhage  has  an  almost  exclusively 
traumatic  origin ; being  a result  of  falls  or 
blows  which  occasion  the  rupture  of  one  of  the 
meningeal  arteries,  lying  between  the  bone  and 
the  dura  mater.  Still,  caries  of  the  bone  may 
in  very  rare  cases  lead  to  such  a haemorrhage,  by 
causing  erosion  of  one  of  the  meningeal  arteries. 

The  other  two  varieties  are  not  so  distinctly 
separated  from  one  another,  since  a haemorrhage 
occurring  in  the  pia  mater,  if  large,  is  very  apt 
to  break  through  the  arachnoid,  and  thus  lead  to 
effusion  of  biood  into  the  ‘arachnoid  sac’;  and 
this  whether  t lie  primary  effusion  has  been  the 
result,  of  a traumatic  injury,  or  is  a sequela  of 
some  gclier.  1 or  local  disease.  Effusion  into  the 
arachnoid  may  also  occur  as  a result  of  rupture 
of  some  vessel  on  the  inner  surface  of  the  dura 
mater;  this  being  probably  a rare  consequence 


of  injury,  though  it  is  a frequent  result  of  disease 
in  this  situation  ( pachymeningitis  interna). 

Effusions  of  blood  are  occasionally  found  be- 
neath the  arachnoid  which  have  not  originate  i 
there,  but  which  have  come  to  the  surface,  hr 
laceration  of  brain-substance,  from  some  intra- 
cerebral haemorrhage ; or  they  may  have  been 
caused  by  intraventricular  haemorrhages,  finding 
their  way  into  the  fourth  ventricle,  and  thence 
into  the  sub-arachnoid  tissue. 

In  very  young  children,  whose  vessels  are 
presumably  healthy,  bleeding  into  the  arach- 
noid may  occur  from  any  unusual  amount  of 
strain.  This  occasionally  takes  place  at  the  time 
of  birth,  especially  during  prolonged  labours. 
Indeed,  according  to  Cruveilhier,  arachnoid 
haemorrhage  is  the  cause  of  the  death  of  about 
one-third  of  those  infants  who  die  almost  imme- 
diately after  birth.  A little  later  on  in  life,  a 
similar  accident  may  occur  during  paroxysms 
of  whooping-cough,  or  during  other  spasmodic 
respiratory  conditions,  in  which  the  return  of 
venous  blood  from  the  head  is  impeded.  Later 
still,  an  arachnoid  haemorrhage  not  unfrequently 
follows  a fall  or  blow  upon  the  head,  or  it  mav 
result  from  the  rupture  of  an  aneurism  on  one  of 
the  larger  vessels  about  the  base  of  the  brain — 
especially  the  basilar  or  one  of  the  middle  cere- 
brals. Small  subarachoid  haemorrhages,  often 
multiple,  are  not  unfrequently  produced  by  the 
occurrence  of  thrombosis  in  the  longitudinal 
sinus.  They  may  also  occur  in  persons  suffering 
from  scurvy  or  leucocythemia.  Lastly,  they 
may  be  met  with  as  ooe  out  of  the  many  forms 
of  lesion  occurring  in  men  suffering  from  general 
paralysis  of  the  insane. 

Meningeal  haemorrhages  are  decidedly  more 
common  in  males  than  in  females — in  the  pro- 
portion of  about  three  to  one.  They  do  not  like 
cerebral  haemorrhages,  occur  with  progressiro 
frequency  as  age  advances,  but  are  much  more 
uniformly  distributed  through  the  different  de- 
cades of  life. 

Anatomical  Characters. — When  death  takes 
place  soon  after  blood  has  been  effused  into 
the  arachnoid,  as  well  as  in  the  other  situations, 
it  is  found  in  an  easily  recognisable  condition. 
This  is  by  no  means  the  case,  however,  after  the 
lapse  of  montns  or  years  ; then,  in  the  case  of 
small  haemorrhages,  we  may  meet  with  mere 
yellowish  or  rust-coloured  stains ; whilst  where 
they  have  been  of  larger  size,  we  may  meet  with 
decolorised  cyst-like  bodies,  either  free  or  ad- 
herent— or  else  there  may  be  decolorised  mem- 
branous masses,  adhering  mostly  to  the  parietal 
arachnoid.  "Where  the  size  of  the  clot  has  been 
large,  the  surface  of  the  brain  is  more  or  less 
pressed  upon,  so  that  some  atrophy  of  its  sub- 
stance follows.  Many  of  these  latter  points  are 
well  exemplified  in  a case  recorded  by  Dr.  Quain 
in  the  Path.  Trans.,  vol.  vi.  page  8. 

Sometimes  the  layers  of  altered  blood  are  neithei 
adherent  to  the  arachnoid,  nor  do  they  lie  freeot 
its  surface ; they  may  be  attached  to  the  surfaci 
of  the  dura  mater,  or  lie  between  new  growth; 
arising  from  its  inner  layers,  and  thus  produci 
a condition  which  often  goes  by  the  name  o 
heematoma.  Prolonged  discussions  have  take! 
place  on  the  question  whether  these  change 
are  results  of  a primary  haemorrhage  oi  whethe 


MENINGES,  CEREBRAL,  HAEMORRHAGE  INTO:  AND  HEMATOMA  OF.  953 


we  have  not  rather  to  do  with  a ’pachymeningitis 
interna  hemorrhagica,  where  an  inflammation  is 
the  first  event,  during  which  effusion  of  blood 
takes  place  into  the  innermost  layers  of  the 
altered  and  inflamed  membrane.  See  Meninges, 
Cebebbal,  Haematoma  of. 

Simptoms. — The  symptoms  attendant  upon 
meningeal  haemorrhage  will  necessarily  vary  a 
i great  deal  in  severity,  according  to  the  amount 
and  suddenness  of  the  effusion.  These  symptoms 
are,  moreover,  in  the  great  majority  of  the 
traumatic  cases  obscured  by  those  depending 
.upon  the  mere  shock  and  concussion  of  the 
brain,  which  the  original  accident  or  blow  occa- 
sions. 

Where  subarachnoid  haemorrhages  occur  in  the 
course  of  thrombosis  of  the  longitudinal  sinus, 
no  distinctive  symptoms  are  as  a rule  produced ; 
and  those  of  the  primary  affection  are  them- 
iselves  only  too  variable,  and  difficult  of  recog- 
nition. Again,  where  subarachnoid  haemorrhages 
occur  in  the  course  of  purpura,  leukaemia,  or 
allied  affections,  the  amount  of  blood  effused  is 
usually  too  small  to  produce  definite  or  recog- 
nisable symptoms.  At  most,  the  abrupt  onset 
nfpainin  the  head,  vertigo,  or  mental  confusion, 
may  give  rise  to  a suspicion  that  such  an  event 
has  occurred. 

Where  a large  haemorrhage  takes  place  be- 
neath and  into  the  arachnoid  sac,  over  one  hemi- 
iphere,  or  over  both,  either  as  the  result  of  a 
all  or  blow,  or  from  the  bursting  of  an  aneurism 
in  one  of  the  large  arteries  at  the  base  of  the 
irain,  a profound  coma  is  produced  which  may 
irove  rapidly  fatal — that  is,  in  the  course  of  a 
'ew  minutes  or  a few  hours.  Where  the  amount 
if  blood  effused  is  less,  and  where  it  is  poured 
■ut  more  gradually  at  first,  there  may  be  pre- 
aonitory  symptoms,  in  the  form  of  sudden  head- 
cke,  vertigo,  mental  confusion,  vomiting,  or 
onvulsions,  rapidly  followed  by  unconsciousness, 
it  first  there  js  generally  complete  relaxation 
f all  the  limbs  ; but  later — after  some  hours  or 
ays — the  weakness  may  be  distinctly  unilateral, 
iat  is,  of  hemiplegic  type — though  sometimes 
•ith  very  slight  implication  of  the  face.  There 
iay  also  be  twitchings  or  rigidity  of  the  limbs 
a one  or  both  sides.  On  recovery  of  conscious- 
ess  there  may  be  no  distinct  loss  of  sensibility, 
fly  numbness,  in  the  limbs ; and  the  paralysis 
.ay  after  a time  grow  less  up  to  a certain  point, 

• gradually  disappear. 

Diagnosis. — In  many  of  the  slighter  forms  of 
emorrhage  into  the  cerebral  meninges  diagnosis 
for  the  reasons  specified,  almost  impossible. 

In  the  more  severe  cases  a sudden  apoplectic 
tack  is  produced,  agreeing  very  closely  with 
at  occasioned  by  some  of  the  most  serious 
'ms  of  intra-cerebral  haemorrhage.  Causal 
nditions,  especially  when  they  have  been  trau- 
itic,  together  with  the  possible  youth  of  the 
tient,  may  in  some  cases  help  us  to  diag- 
se  a large  arachnoid  haemorrhage,  from  a 
oious  bleeding  into  the  lateral  ventricles,  or 
■m  a sudden  haemorrhage  into  the  middle  of 
s pons  Varolii ; though  it  should  bo  borne  in 
ad  that  in  the  former  of  these  two  conditions 
pupils  are  almost  always  widely  dilated, 
list  in  the  latter  they  are  as  constantly  cou- 
rted and  insensitive,  whereas  they  are  likely, 


so  far  as  the  writer’s  observations  have  gone, 
to  be  in  a more  intermediate  condition  in  arach- 
noid haemorrhage. 

Prognosis. — In  the  case  of  arachnoid  haemor- 
rhages, whether  large  or  of  only  moderate  volume, 
should  the  patient  survive  the  first  effects  of 
the  effusion,  and,  it  may  be,  of  the  injury  which 
caused  it,  danger  to  life  is  no  longer  to  be  feared. 
The  only  question,  then,  is  as  to  the  amount  of 
paralysis,  mental  impairment,  or  of  irritability 
with  cephalalgia,  which  may  remain ; or  whether 
or  not  a tendency  to  convulsions  may  be  set 
up,  as  a consequence  of  the  original  injury  and 
lesion. 

Treatment. — The  treatment  of  a case  of 
meningeal  haemorrhage  does  not  differ  from  that 
appropriate  for  cerebral  haemorrhage.  Perfect 
rest  in  the  recumbent  position,  with  the  head 
slightly  raised,  is  essential.  Cold  to  the  head 
may  be  conjoined  with  hot  applications  and 
mustard  plasters  to  the  lower  extremities.  For 
other  indications  and  details  of  treatment  we 
must  be  guided  by  the  varying  conditions  of  the 
patient.  During  convalescence  in  the  more  fa- 
vourable cases  we  must  pay  great  attention  to 
the  general  health  of  the  patient,  and  above  all 
protect  him  from  overwork  or  excitement  of  any 
kind.  H.  Charlton  Bastian. 

MENINGES,  CEREBRAL,  Heematoma 

of. — Synon.  : Pachymeningitis  interna  hemor- 
rhagica-, Fr.  Pachymeningitc ; Ger.  Pachymenin- 
gitis. 

Definition. — Inflammation  of  the  inner  sur- 
face of  the  dura  mater,  attended  with  the  forma- 
tion of  a membranous  vascular  tissue,  into  which 
hcemorrhage  takes  place. 

.Etiology. — This  affection  is  met  with  at  all 
ages,  but  is  most  common  in  advanced  life  and 
early  childhood.  Males  are  said  to  suffer  more 
frequently  than  females.  It  is  rarely  primary ; 
most  of  the  recorded  cases  have  followed,  at  some 
interval,  an  injury,  or  occurred  in  the  subjects  of 
insanity,  or  chronic  alcoholism.  Other  cases  have 
appeared  consequent  on  acute  rheumatism  and 
other  pyrexial  affections,  especially  pneumonia 
and  small-pox. 

Anatomical  Characters. — According  to  Vir- 
chow, in  the  early  stage,  before  haemorrhage  has 
taken  place,  a delicate  reticulated  membrane 
exists  on  the  inner  surface  of  the  dura  mater  in 
one  or  many  layers — even  twenty.  It  varies  in 
consistence  according  to  its  age.  The  colour  is 
usually  reddish,  from  the  number  of  new-formed 
vessels ; but  it  is  often  rust-coloured  from  de- 
generated blood  extravasatedin  minute  quantity. 
The  position  of  the  membrane  is  always  over  the 
convexity,  commonly  near  the  middle  line;  and 
it  is  often  symmetrical  on  the  two  siRes.  In  the 
second  stage,  that  of  haemorrhage,  blood  in  con- 
siderable quantity  is  effused  between  the  layers 
in  one  or  several  places,  and  may  extend  as  far 
as  the  limits  of  the  false  membrane,  thus  con- 
stituting one  or  more  simple  or  loculated  cysts. 
These  cysts  are,  of  course,  adherent  externally 
to  the  dura  mater,  and  internally  rest  on  the 
arachnoid  membrane  and  convolutions,  which 
they  compress  and  even  depress.  Their  con- 
tents are  blood — liquid,  coagulated,  or  in  every 
stage  of  degener  ition.  Ultimately  only  coloured 


J54  MENINGES,  CEREBRAL,  NEW  GROWTHS  AXI)  PRODUCTS  IN. 


serositv  may  remain.  The  thin  delicate  wall  of 
the  cyst  was  formerly  regarded  as  organised 
fibrin  from  a blood-clot,  or  as  the  separated 
parietal  layer  of  the  arachnoid;  and  some  pa- 
thologists are  still  of  opinion  that  the  haemor- 
rhage precedes  the  formation  of  ihe  membrane. 
Sec  Meninges,  Cerebral,  Haemorrhage  into. 

Symptoms. — Two  periods  may  often  be  recog- 
nised, corresponding  to  the  anatomical  stages  of 
hsematoma  of  the  dura  mater  just  described.  In 
the  first,  circumscribed  headache  is  the  chief 
symptom,  often  felt  at  the  vertex.  It  may  be  asso- 
ciated with  giddiness,  uncertainty  of  movement, 
lowered  mental  power,  and  contraction  of  pupils. 
In  children,  in  whom  the  whole  disease  commonly 
lasts  only  a few  days,  there  is  often  fever.  In 
adults  this  stage  may  last  for  weeks  or  months. 
The  second  stage,  that,  of  blood-effusion,  is  at- 
tended by  an  increase  of  the  mental  dulness  to 
distinct  somnolence,  at  first  intermitting,  but 
deepening  to  actual  coma  with  a rapidity  that 
depends  on  the  rapidity  of  effusion.  The  pupils 
continue  contracted,  but  that  on  the  side  of  the 
mischief  may  become  the  smaller.  Hemiplegic 
paralysis  or  contraction  may  occur  when  the 
haematoma  is  unilateral.  In  children  convul- 
sions are  common.  The  duration  of  this  stage 
in  the  adult  may  be  weeks  or  months  ; and  death 
occurs  in  coma.  In  children  it  usually  lasts  only 
a few  days. 

Diagnosis. — The  diagnosis  of  haematoma  of 
the  dura  mater  is  often  difficult,  and  depends  on 
the  slow  onset  of  coma,  after  a period  of  liead- 
uche,  without  symptoms  to  indicate  a localised 
lesion  of  the  brain.  In  the  child  the  disease 
may  be  mistaken  for  tubercular  meningitis,  but 
the  course  of  infantile  haematoma  is  usually  more 
rapid,  vomiting  is  rare,  and  muscular  contractions 
and  convulsions  are  common. 

Prognosis. — The  prognosis  is  very  unfavour- 
able, but  not  absolutely  fatal  in  the  adult ; in 
several  cases  in  which  the  symptoms  of  hsema- 
toma  have  been  present,  recovery  has  taken 
place.  In  children  there  is  little  hope. 

Treatment. — In  the  child  one  or  two  leeches 
may  be  applied  behind  the  ears:  and  cold  to  the 
head,  and  counter-irritation  to  the  skin  of  the 
neck  and  limbs,  are  likely  to  be  useful. 

In  the  adult,  if  by  rest,  cold  to  the  head,  and 
counter-irritation  the  effusion  can  be  arrested, 
absorption  of  the  blood  will  slowly  take  place  ; 
and  this  may  be  furthered  by  moderate  purga- 
tion, by  diuresis,  as  well  as,  perhaps,  by  the 
administration  of  iodide  of  potassium. 

W.  R.  Gowers. 


MENINGES,  CEREBRAL,  New 
Growths  and  Adventitious  Products  in. — 

The  clinical  aspects  of  the  several  pathological 
conditions  composing  the  set  of  changes  included 
under  these  heads,  are  comparatively  meagre  and 
ill-defined,  as  compared  with  what  we  know  of 
them  pathologically.  For  this  various  reasons 
exist,  some  of  which  will  he  presently  in- 
dicated. 

Anatomical  Characters.  — In  the  present 
article  it  will  suffice  to  enumerate  the  new 
growths  and  adventitious  products  met  with  in 
the  cerebral  meninges,  referring  to  special  arti- 


cles on  the  several  bodies  for  a fuller  description 
of  them. 

Symptoms  and  Diagnosis. — Intracranial  new 
growths  or  adventitious  products  are,  as  a class, 
accompanied  by  the  most  diverse  sets  of  symp- 
toms. The  new  growths  or  products  vaiy  in  dif- 
ferent eases  within  very  wide  limits,  from  the 
point  of  view  of  the  suddenness  of  their  onset  or 
increase,  as  well  as  of  their  actual  bulk  or  num- 
ber, and  also  as  regards  the  particular  intra- 
cranial region  or  regions  which  they  implicate. 
We  may  therefore  in  some  measure  understand 
what  happens,  that  some  growths  or  products 
may  be  unaccompanied  by  appreciable  symptoms 
during  life  ; that  others  may  be  associated  only 
with  vague  symptoms  of  a general  order,  deno:’- 
ing  the  existence  of  some  kind  of  intracranial 
mischief ; whilst,  on  the  other  band,  some  may 
be  associated  with  such  comparatively  definite 
groups  of  symptoms  as  to  make  it  reasonably 
easy  to  arrive  at  a pretty  certain  diagrosis,  both 
as  to  the  situation  and  as  to  the  nature  of  the 
intracranial  growth  or  morbid  product. 

But,  it  may  be  said,  why  use  the  broader 
term  ‘ intracranial  ’ when  we  are  here  only  con- 
cerned with  morbid  conditions  of  the  meninges? 
This  brings  us  to  the  second  of  the  reasons 
above  referred  to,  namely,  that  it  is  often,  and, 
for  the  most  part,  impossible  to  distinguish  cli- 
nically between  mere  meningeal  new  growths  or 
products,  and  those  which  arise  from  or  within 
some  portions  of  the  encephalon.  The  reasons 
for  our  impotency  in  this  direction  are  also  not! 
difficult  to  find.  First,  wc  may  cite  the  general 
one,  of  the  frequent  vagueness  or  even  absence 
of  any  appreciable  symptoms  attendant  upoi 
intracranial  growths  or  products;  and,  secondly 
the  more  special  reason,  that  growtlis  starting 
from  the  meninges  will  often  press  upon  ant 
implicate  the  surface  of  the  brain  in  differen 
regions,  in  much  the  same  manner  as  if  the; 
sprang  from  the  surface  of  the  brain  itself  i' 
such  regions.  And.  thirdly,  there  is  the  furthe 
consideration  that  intracranial  growths  or  pre 
ducts  are  frequently  multiple  in  the  same  indi 
vidual,  and  then  may  partly  spring  from  th 
meninges,  and  partly  in  the  substance  of  tb 
brain  itself. 

Eor  these  various  reasons  it  happens  that 
the  diagnosis  of  a purely  meningeal  new  growt 
or  adventitious  product  could  ever  he  arrive 
at,  it  would  be  effected  through  the  medium  t 
a previous  pathological  diagnosis.  But  ho 
limited  are  the  possibilities  in  this  direction  mf 
be  gathered  from  the  following  consideration 
Certain  personal  or  family  characteristics  pr 
sented  by  a patient  may  make  it  highly  pr 
bable  that  syphilitic  intracranial  disease,  < 
that  scrofulous  intracranial  growths  exist.  St- 
more  rarely  the  signs  and  symptoms  may  i 
dicate  that  cancerous  intracranial  growths, 
that  growths  similar  to  some  multiple  tumou 
already  existing  in  other  parts  of  the  body,  mt 
be  the  causes  also  of  co-existing  head-symptotr 
Yet  these  are  almost  the  only  cases  in  which 
may  be  possible  for  us  to  arrive  at  anythit 
like  a positive  diagnosis  as  to  the  nature  of 
supposed  intracranial  growth  or  product.  At 
of  these  the  first  only,  namely,  syphilitic  d;sesj 
could  with  any  degree  of  certainty  be  diagnos 


MENINGES,  CEREBRAL,  NEW 

as  a change  limited  to  the  meninges ; the  others 
would  be  just  as  likely  to  take  origin  within  the 
cerebral  substance  as  from  the  meninges. 

For  these  reasons  no  good  purpose  would  be 
attained  by  enteringat.  length  into  the  groups  of 
symptoms  that  may  be  produced  by  meningeal 
growths  or  adventitious  products.  They  are  apt 
ciosely  to  resemble  some  of  those  co-existing 
with  growths  within  the  brain,  which  have  been 
already  considered.  See  Bbain,  Tumours  and 
New  Growths  of. 

A.  New  Growths  — (a)  Syphilitic  growths  or 
thickenings  of  the  meninges. — These  products 
are  met  with  principally  in  the  form  of  yellowish 
lymph-like  masses,  connecting  the  dura  mater  to 
the  arachnoid,  and  this  with  the  pia  mater  to  the 
surface  of  the  cerebral  hemispheres  in  some 
region  (often  the  parietal),  of  irregular  area  and 
variable  extent.  This  yellow  ‘ gummatous  ’ 
material  probably  takes  its  origin,  for  the  most 
part,  in  or  on  the  surface  of  the  dura  mater, 
while  it  may  extend  inwardly  so  as  to  infiltrate 
or  press  upon  the  surface  of  the  brain,  and  also 
outwardly,  so  as  to  cause  erosion  of  the  cranial 
bones.  The  membranes  around  may  be  thickened, 
or  more  or  less  obviously  inflamed.  This  form 
of  disease  does  not  occur  in  congenital  syphilis  ; 
when  it  exists,  therefore,  it  is  invariably  met 
with  in  persons  beyond  the  age  of  puberty. 
Similar  growths  taking  origin  completely  within 
the  brain-substance  are  extremely  rare. 

(h)  Scrofulous  tumours. — -These  are  often 
spoken  of  as  ‘tubercular’  growths.  They,  un- 
like the  last,  are  much  more  frequently  met 
with  in  children  than  in  adults,  and  especially 
in  young  children  between  the  ages  of  two  and 
seven  years.  They  are  yellowish  nodular  masses, 
'varying  in  size  from  a small  pea  to  a walnut. 
Whilst  some  of  them  may  obviously  spring  from 
,ke  pia  mater,  others  (and  this  much  more  fre- 
quently) are  met  with  within  the  substance  of 
some  portion  of  the  cerebrum  or  cerebellum, 
is  in  the  last  case,  these  growths  are  presumed 
:o  be  in  the  main  dependent  upon  the  existence 
)f  a special  constitutional  state — one  which  carries 
with  it  proclivities  to  certain  kinds  of  tissue 
iver-growth. 

(c)  Cancer.— Cancer  not  unfrequently  affects 
he  dura  mater,  wdience  it  may  extend  outwards 
■r  inwards,  and  thus  implicate  other  parts  second- 
■rily — either  eroding  and  perforating  the  bone, 
>r  greatly  depressing  the  surface  of  the  brain 
s it  grows  inwards.  Although  more  frequent 
n the  second  half  of  life,  meningeal  cancer  may 
ecur  also  in  youth,  or  even  in  childhood. 

(d)  Other  growths. — Other  growths  of  less  fre- 
uent  occurrence,  and  therefore  of  less  importance, 
iso  start  from  the  meninges.  We  may  havo  the 
showing  : — Sarcomata  ; Fibromata  ; Fibro-en- 
hondromata ; Stcatomatous  or  cholesteatoniatous 
rowths ; and  Structureless  or  wax-like  tumours, 
aving  the  so-called  ‘ amyloid  ’ reaction.  Such 
amours  as  these  may  give  rise  to  more  or  less 
efinite  head-symptoms  during  life.  They  spring, 
>r  the  most  part,  from  the  dura  mater  rather 
tan  from  the  arachnoid. 

Other  smaller,  and  mostly  rare,  growths  may 
a met  with  quite  unexpectedly  after  death,  be- 
mse  of  their  occurrence  in  the  form  of  flat  plates, 
hich  do  not  interfere  by  pressure  or  otherwise 


GROWTHS  AND  PRODUCTS  IN.  955 

with  the  subjacent  cerebral  substance,  and  there- 
fore give  rise  to  no  obvious  symptoms.  They 
are: — Osteomata,  which  occur  either  iu  the  falx, 
in  the  walls  of  the  lateral  sinuses,  or  much  more 
rarely  in  the  substance  of  the  arachnoid,  in  the 
form  of  osseous  plaques ; aud  Calcareous  deposi- 
tions (belonging,  perhaps,  more  strictly  to  the  next 
than  to  this  section)  which  vary  in  size  trom  a 
mustard  seed  to  a small  nut,  and  which  may  be 
found  in  or  beneath  the  arachnoid,  or  also  on 
the  inner  surface  of  the  dura  mater.  Sometimes 
a number  of  such  minute  concretions  miy  be 
met  with  in  connection  with  the  pia  mater  or 
arachnoid  (especially  when  these  membranes  are 
thickened  or  otherwise  diseased),  in  the  form  of 
minute  granules  closely  resembling  the  so-called 
‘brain  sand,’  each  of  which  may  present  traces 
of  several  concentric  layers. 

B.  Adventitious  Products. — (a)  Parasites. 
These  may  be  of  two  kinJs,  both  of  them  being 
larval  states  of  tape-worms. 

Cysticerci  are  larval  conditions  of  Tenia  solium, 
having  the  form  of  small  bladders,  which  vary 
in  size  from  that  of  a pea  to  a horse-bean.  They 
often  exist  in  large  numbers  in  the  meninges, 
and  within  the  brain  of  the  same  individual,  and 
are  very  rarely  solitary.  As  many  as  100  may 
be  found  within  the  cranium ; and  when  they  are 
thus  numerous  many  of  them  will  almost  certainly 
be  met  with  in  the  pia  mater,  merely  pressing 
upon  and  slightly  indenting  the  surface  of  the 
convolutions,  though  others  will  be  situated  within 
the  substance  of  both  cerebral  and  cerebellar 
convolutions.  They  are  not  confined  to  persons 
of  any  age  or  either  sex,  though  they  occur  rather 
more  frequently  in  those  representing  the  second 
than  the  first  half  of  life.  Infection  is  brought 
about  by  the  eating  of  raw,  or  insufficiently 
cooked  ‘ measly  ’ pork.  See  Cysticercus. 

Hydatids  are  larval  forms  of  Teenia  echinococ- 
cus, a very  small  four-jointed  tape-worm  com- 
monly infesting  the  alimentary  canal  of  the  dog. 
The  hydatids  met  with  in  the  brain  are  always 
barren  cysts  (aeephaloeysts),  and  the  outer  en- 
closing membrane  is  generally  very  thin.  They 
are  usually  solitary;  may  vary  in  size  from  that 
of  a marble  up  to  a large  orange;  are  rare  even  in 
the  brain-substance,  and  still  more  rare  in  th# 
pia  mater.  Sometimes  two,  three,  or  more  hy- 
datid cysts  exist  within  the  cranium  of  the  same 
individual,  but  they  are  then  usually  of  small 
size.  Davaine  refers  to  an  instance  in  which 
many  hydatids  were  found  in  the  meninges  and 
at  the  surface  of  the  brain,  as  well  as  within  its 
substance.  Out  of  twenty-fuur  recorded  cases, 
in  which  the  age  was  stated,  the  writer  has 
found  that  no  less  than  eighteen  of  them  were 
persons  between  the  ages  of  ten  and  thirty 
years,  three  of  the  remainder  being  above  and 
three  below  these  extremes.  Infection  may  well 
be  brought  about  by  means  of  the  dog’s  tongue, 
which  is  at  times  only  too  quickly  transferred  from 
parts  liable  to  be  contaminated  by  ova  of  its 
own  tape-worms,  to  the  hands  or  even  the  lips 
of  his  master  or  mistress.  Besides  this  more 
direct  method,  the  ova  of  the  Taenia  echinococcus 
voided  by  the  dog  may  be  blown  about,  or  other- 
wise get  by  accidencal  means  into  water  or  foo  1 
taken  by  man.  See  Hydatids. 

(4)  Aneurisms. — These,  situated  either  on  ona 


066  MENINGES,  CEREBRAL,  NEW  GROWTHS  AND  PRODUCTS  IN 


of  the  vessels  composing  the  circle  of  Willis,  or 
on  some  one  or  more  of  its  primary  branches, 
may  vary  in  size  from  a small  pea  to  that  of  a 
walnut.  Those  of  larger  size,  which  are  usually 
single,  may  give  rise  to  distinct  head-symptoms ; 
but  at  other  times,  and  especially  when  the 
aneurism  is  very  small,  there  may  have  been  no 
reason  to  suspect  its  existence,  or  that  of  any 
other  intracranial  disease,  till,  perhaps,  the  rup- 
ture of  such  an  aneurism  may  lead  to  the  super- 
vention of  serious  symptoms,  speedily  terminating 
in  death.  These  aneurisms  may  occur,  possibly 
as  a sequence  of  a previous  embolism  (Church), 
even  in  early  youth  as  in  adult  age. 

(c)  Thrombi  in  the  cerebral  sinuses. — The  process 
of  thrombosis  is  known  principally  as  it  occurs 
in  three  of  the  sinuses  contained  within  the  cere- 
bral meninges,  namely,  in  the  longitudinal  sinus, 
or  in  one  or  other  of  the  two  lateral  sinuses. 

(1)  The  formation  of  a thrombus  in  the  lon- 
gitudinal sinus  is  usually  a primary  phenomenon, 
dependent  in  the  main  upon  the  operation  of 
general  causes,  such  as  some  alteration  in  the 
quality  of  the  blood,  combined  with  slow,  feeble, 
and  irregular  action  of  the  heart.  The  opera- 
t ion  of  these  causes  has,  however,  been  known. 
In  have  been  favoured  in  certain  cases  by  local 
conditions,  such  as  the  great  development  of 
Pacchionian  bodies,  and  their  projection  into  the 
sinus — an  event  most  likely  to  occur  in  elderly 
persons.  Thrombosis  of  the  longitudinal  sinus 
may,  however,  be  met  with  also  in  the  early  as 
well  as  in  the  middle  periods  of  life.  The  ori- 
ginal thrombus  frequently  prolongs  itself  through 
the  straight  sinus  to  the  * torcular  Herophili,’ 
and  thence  on  either  side  into  the  lateral  sinuses. 
And  in  this  latter  class  of  cases  ventricular  effu- 
sions and  superficial  cerebral  softenings  are  apt 
to  be  associated  with  the  thrombosis.  The  soft- 
enings are  of  a peculiar  and  characteristic  kind, 
consisting  generally  of  a number  of  small  red 
patches,  occupying  principally  the  grey  matter 
on  each  side  of  the  upper  surface  of  the  brain. 
Occasionally  softening  of  a portion  of  brain  of 
considerable  extent  has  been  produced.  Besides 
the  ventricular  effusion,  there  may  also  be  an 
excess  of  serum  beneath  the  arachnoid,  or  more 
rarely  small  effusions  of  blood  in  these  situa- 
tions, together  with  minute  patches  of  haemor- 
rhage in  the  convolutional  grey  matter,  such  as 
havo  been  described  by  Cruveilhier  under  the 
name  of  apoplexie  capillaire.  The  actual  combi- 
nation of  these  conditions  will  depend  upon  tho 
seat  of  the  obstruction,  the  rapidity  with  which 
it  is  brought  about,  and  the  existence  or  not  of 
marked  pathological  conditions  of  the  vessels 
generally.  The  variation  in  the  symptomatology 
of  this  affection  in  different  cases  is,  therefore, 
also  extreme ; the  symptoms  are  sometimes  of  an 
excessively  grave  order,  and  sometimes  almost 
nil.  Strange  as  it  may  seem,  Dr.  Gee  says: — 

‘ I have  known  a decolorised  softening  thrombus 
to  occupy  the  whole  bore  of  the  upper  longitudinal 
sinus,  to  be  attended  by  large  sub-arachnoid 
haemorrhages,  and  to  have  caused  no  symptoms 
during  life.’ 

(2)  Just  as  frequent,  however,  as  the  event 
abovo  referred  to,  is  the  formation  of  a thrombus 
in  one  or  other  of  the  lateral  sinuses  ; only  then 
the  process  is  almost  invariably  secondary  to  in- 


flammation of  the  scalp  or  cranial  bones,  whethei 
induced  by  traumatic  conditions  or  by  disease. 
Caries  of  the  cranial  bones  is  the  principal  pre- 
disposing condition ; indeed,  in  three-fourths  of 
the  recorded  cases  the  temporal  bone  was  the 
part  affected,  and  that  as  a result  of  internal 
otitis.  In  these  cases  there  is  often  evidence  of 
a more  or  less  circumscribed  inflammation  of 
the  meninges,  but  cerebral  softenings  and  sub- 
arachnoid extravasations  of  blood  rarely  occur. 
This,  according  to  Yon  Dusch,  is  explicable  by 
the  fact  that  in  these  cases  the  thrombosis  starts 
from  tho  veins  in  communication  with  tho  in- 
flamed spot,  and  reaches  the  lateral  sinus  only 
after  the  collateral  circulation  has  had  time  to 
establish  itself ; instead  of  forming  primarily  in 
the  sinus,  and  before  a collateral  circulation  has 
been  set  up. 

(d)  Serum, — This  fluid  may  be  met  with  in 
excess  in  two  situations.  It  occurs  (1)  beneath 
the  arachnoid,  in  cases  in  which  one  or  both 
cerebral  hemispheres  have  become  wasted  or 
atrophied.  After  fifty  or  sixty  years  of  age, 
therefore,  it  is  common  to  find  an  excess  of  sub- 
arachnoid serum.  This  fluid  transudes  from  the 
vessels  as  pressure  outside  them  diminishes, 
owing  to  brain-atrophy.  It  is  absurd  to  suppose 
that  it  has  any  other,  or  at  least  any  important, 
pathological  significance.  To  speak,  as  some  do, 
of  ‘ serous  apoplexy  ’ as  a cause  of  death,  when 
no  very  obvious  reason  can  by  such  persons  he 
assigned  for  it,  is  a mischievous  assumption  of 
knowledge  where  aconfession  of  ignorance  would 
be  better.  But  serum  is  sometimes  found  in 
excess  (2)  within  the  cavity  of  the  arachnoid, 
when  it  constitutes  the  condition  occasionally 
spoken  of  as  ‘ external  hydrocephalus.'  It  seems 
probable  that  the  majority  of  such  cases  are  in- 
stances in  which  the  fluid  of  an  ordinary  internal 
hydrocephalus  has,  at  some  period  before  or  after 
death,  in  part  escaped  from  the  ventricles  into 
the  cavity  of  the  arachnoid  (see  Hydrocepha- 
lus, Chronic).  Still,  there  may  be  a narrow 
margin  of  cases  not  capable  of  being  thus  ac- 
counted for,  iu  which  the  cause  of  the  presence 
of  fluid  in  this  situation  is  very  uncertain,  when 
it  is  not,  as  it  may  be  sometimes,  an  appanage 
of  meningeal  inflammation. 

Prognosis. — Some  of  tho  smaller  and  more 
slowly  growing  tumours  may  give  rise  to  no 
symptoms  during  life,  and  may  not  appreciably! 
tend  to  shorten  its  duration.  The  accumu- 
lation of  serum  beneath  the  aiachnoid  is,  more- 
over, only  a non-disturbing  effect  of  other 
causes. 

The  case  is,  however,  of  much  graver  import 
whore  we  have  to  do  with  syphilitic,  scrofulous, 
cancerous,  or  other  growths  having  a tendency 
to  more  or  less  rapid  increase ; also  where  the 
patient  is  suffering  from  tho  existence  of  intra- 
cranial cysticerci  or  hydatids,  or  from  the  occur- 
rence of  thrombosis  in  the  longitudinal  or  lateral 
sinuses.  In  all  such  instances  we  may,  for  the 
most  part,  look  for  a steady  increase  in  the 
gravity  of  the  patient's  symptoms,  and,  except 
in  the  case  of  the  first  kind  of  growth  nndti 
the  influence  of  proper  treatment,  for  death  at 
no  very  distant  date. 

Treatment. — Drug  treatment  can  be  looiec 
forward  to  as  curative,  or  nearly  so,  in  only  out 


MENINGES.  SPINAL,  DISEASES  OF.  <J57 


of  these  various  maladies,  namely,  in  that  of 
syphilitic  origin — hence  the  great  importance  of 
a correct  diagnosis  where  this  condition  is  pre- 
sent. In  a large  number  of  cases,  symptoms 
of  the  gravest  character,  associated,  it  may  be, 
with  paralysis,  stupor,  severe  convulsions,  ex- 
cruciating cephalalgia,  and  even  incipient  in- 
sanity, one  or  more,  or  all,  will,  when  really 
ot  syphilitic  origin,  yield  in  a truly  marvel- 
lous manner  to  the  continued  and  steady  use 
of  iodide  of  potassium  in  doses  of  eight  grains, 
gradually  raised  to  twenty  or  thirty  grains, 
three  times  a day,  especially  when  given  in 
combination  with  Sjto  i of  a grain  of  bichloride 
of  mercury. 

Cod-liver  oil,  with  vinum  ferri  or  the  syrupus 
ferri  phosphatis,  together  with  good  food, 
quietude,  and  fresh  air,  may  also  do  something 
to  retard  or  even  stop  the  growth  of  scrofulous 
, tumours  iu  sickly  children. 

Beyond  this,  in  the  class  of  cases  which  we  have 
just  been  considering,  medicinal  treatment  can 
be  merely  palliative.  We  must  strive  to  relieve 
headache  and  secure  better  sleep ; to  mitigate 
the  severity  of  convulsive  attacks ; or,  if  pos- 
sible, to  lessen  the  marked  tendency  to  vomiting 
which  may  exist.  Mental  dulness  and  stupor, 
in  such  cases,  are  mostly  beyond  the  reach  of 
'relief  from  therapeutics  ; though  restlessness  and 
rritability  may  perhaps  be  mitigated,  by  the 
idministration  of  remedies  suitable  for  the  relief 
if  pain,  and  for  the  encouragement  of  sleep. 

H.  Charlton  Bastian. 

MENINGES,  SPINAL,  Diseases  of.— 

n this  place  we  shall  have  to  consider  the 
ollowing  conditions 
1.  Inflammation  of  several  varieties. 

1 2.  Hemorrhage  into. 

3.  New  growths  and  Adventitious  Products. 

4.  Malformations.  See  Spina  Bifida. 
Inflammation  affects  the  spinal  meninges  in 

everal  different  forms,  though  they  are  divisible 
ito  two  main  categories.  Thus  we  may  have  : — 
i)  Inflammation  of  the  spinal  meninges  of  trau- 
matic or  secondary  origin  ; and  affecting  either 
le  dura  mater  (spinal  pachymoningitis) ; or 
te  arachnoid  membrane  (spinal  arachnitis). 
■)  Inflammation  of  the  spinal  meninges  of  a 
mple  idiopathic,  or  of  a tubercular  nature,  and 
ith  of  them  affecting  the  pia  mater  (spinal 
ptomeningitis). 

These  different  forms  of  spinal  meningitis, 
hether  existing  alone  or  in  association  with  a 
milar  inflammation  of  the  cerebral  meninges, 
cur  as  acute  diseases.  Occasionally,  where 
.ch  diseases  do  not  terminate  fatally,  they 
ay  lapse  into  a sub-acute  or  chronic  condition, 
jid  thus  persist  for  a considerable  time.  In 
sociation  with  new  growths  or  with  adven- 
ious  products  iu  the  meninges  there  may  also 
ise  a sub-acute  or  chronic  localised  inflamma- 
n of  these  membranes  ; but  of  chronic  spinal 
uningitis  beginning  idiopathically  as  such, 
d pursuing  a course  chronic  from  the  first, 
r knowledge  is  at  present  extremely  slight, 
ronic  thickenings  of  the  spinal  membranes 
),  it  is  true,  met  with  from  time  to  time  post 
rtem,  which  are  by  some  deemed  to  have  had 
inflammatory  origin  independently  of  any 


acute  attack.  But  as  in  other  situations,  so 
here  considerable  thickenings  of  these  serous 
membranes  may  he  met  with  as  a result  of  de- 
generative rather  than  of  inflammatory  changes; 
and  such  conditions  may  give  rise  to  no  very 
appreciable  symptoms  during  life  till,  as  a 
sequence  of  their  thickening  and  undue  adhesion 
to  the  surface  of  the  spinal  cord,  a superficial 
or  annular  form  of  scelerosis  becomes  established 
in  this  organ,  either  limited  in  site  or  irregularly 
developed  in  different  regions. 

1.  Meninges,  Spinal,  Inflammation  of. 
Traumatic  and  Secondary. — aEtiology. — In 
the  case  of  the  cerebral  meninges,  inflammation 
as  a result  of  traumatic  injuries  is  more  common 
than  as  a phenomenon  secondary  to  disease  of  the 
bone  or  of  the  scalp.  The  proportional  frequency 
of  these  modes  of  causation  is,  however,  some- 
what reversed  in  the  case  of  the  spinal  meninges ; 
partly  because  the  head  is  more  liable  than  the 
spine  to  suffer  from  direct  injuries,  and  partly 
because  disease  of  the  spine  and  of  adjacent 
parts  occurs  with  considerable  frequency  in  such 
a manner  as  to  be  capable  of  exciting  a secondary 
inflammation  of  the  spinal  meninges.  Among 
the  various  efficient  traumatic  influences  may  be 
mentioned  fractures  and  dislocations  of  the  ver- 
tebra, and  stabs  or  other  penetrating  wounds 
implicating  the  contents  of  the  spinal  canal ; 
whilst  among  the  most  frequent  morbid  con- 
ditions, in  the  course  of  which  there  may  be 
a secondary  development  of  spinal  meningitis, 
we  must  cite  the  following : — caries  of  the  ver- 
tebra, deep  sloughing  bed-sores  in  the  sacral 
region  ; cancer  of  the  vertebra  ; and  inflamma- 
tion of  some  part  of  the  thoracic  or  abdominal 
parietes  contiguous  to  the  spinal  column,  and 
capable  of  spreading  to  the  spinal  canal  from 
within. 

Anatomical  Charactees. — In  all  these  cases 
the  signs  and  products  of  inflammation  may  be 
found  in  one  or  other,  or  in  both,  of  two  situa- 
tions ; that  is,  either  implicating  the  dura  mater, 
principally  on  its  external  surface,  when  we  have 
the  condition  commonly  known  as  spinal  pachy- 
meningitis ; or  affecting  the  surface  of  the  arach- 
noid so  as  to  produce  a spinal  arachnitis.  Thus 
the  same  kind  of  limitation  in  the  distribution  of 
the  inflammation  is  apt  to  occur  when  it  starts 
under  the  influence  of  such  causes,  as  is  found 
to  obtain  in  regard  to  the  traumatic  cr  secondary 
inflammations  of  the  cerebral  meninges.  Perhaps 
there  is  in  the  case  of  inflammation  of  the  spinal 
membranes,  however,  a rather  more  distinct  ten- 
dency for  such  inflammations  to  spread,  so  as  to 
involve  the  subjacent  pia  mater,  than  is  the  case 
in  the  paraUel  inflammations  of  the  cerebral 
meninges. 

In  spinal  pachymeningitis  the  dura  mater  itself 
is  thickened  and  more  vascular  than  natural, 
this  being  seen  more  especially  on  its  outer  sur- 
face ; and  both  it  and  the  surrounding  connective 
tissue  are  covered  or  infiltrated  either  with  yel- 
lowish lymph-like  matter,  or  with  actual  pus. 
The  internal  surface  of  the  dura  mater  may  also 
he  more  or  less  covered  with  inflammatory  pro- 
ducts. The  nerve-roots  passing  through  tbo 
membrane  are  likewise  generally  affected  by  the 
inflammatory  process,  and  they  may  show  signs 


J58  MENINGES,  SPINAL, 

of  compression  or  even  of  atrophy.  Such  in- 
Uammation  may  be  either  limited  to  the  region 
of  two  or  three  vertebrae,  or  it  may  affect  more 
or  less  the  whole  length  of  the  spinal  membranes. 

Another  more  idiopathic  and  also  more  chronic 
form  of  spinal  pachymeningitis  has  of  late  been 
observed  by  Charcot  and  others,  affecting  prin- 
cipally the  inner  layers  of  the  dura  mater  in 
the  cervical  region.  In  this  condition,  which  is 
described  by  the  author  above  named  as  pachj- 
miningite  cervicale  hypertrophique,  there  seems  to 
be  a considerable  hyperplasia  of  tissue-elements 
in  the  inner  layers  of  the  dura  mater,  which  is 
apt  to  develop  into  an  overgrowth  of  almost 
cicatricial  hardness,  often  made  up  of  concentric 
laminae.  These  are  frequently  adherent  to  the 
arachnoid  and  to  the  pia  mater,  which  also  be- 
come mere  or  less  thickened.  In  these  latter 
cases  especially,  not  only  are  the  spinal  nerve- 
roots  greatly  damaged,  but  the  spinal  cord  is 
itself  more  or  less  compressed  and  softened,  so 
that  distinct  paralytic  symptoms,  with  muscular 
atrophy,  are  apt  to  be  produced. 

Where  spinal  arachnitis  is  superadded,  or 
when  it  exists  alone,  we  find  that  pus  or  lymph 
is  situated  on  the  outer  surface  of  the  visceral 
arachnoid,  and  also  to  a less  extent  on  that 
lining  the  dura  mater.  The  combination  of  the 
two  conditions  is  rather  more  frequent  than  the 
existence  of  arachnitis  alone,  and  it  is  important 
to  remember  that  these  forms  of  inflammation 
are  very  rarely,  if  ever,  primary  and  idiopathic, 
with  the  exception  of  the  more  chronic  variety 
described  by  Charcot,  but  that  they  occur  as  con- 
sequences of  injury  or  of  certain  forms  of  disease 
adjacent  to  the  spinal  canal. 

Symptoms,  Prognosis,  and  Treatment. — As 
the  nerve-roots  are  affected  in  these  forms  of 
inflammation,  as  well  as  in  the  idiopathic  menin- 
gitis which  implicates  the  pia  mater  ( Spinal, 
leptomeningitis),  and  as  the  symptoms  of  both 
sots  of  affections  are  in  great  part  dependent  upon 
this,  and  are  therefore  in  many  respects  similar 
(and  by  no  means  always  capable  of  being 
accurately  discriminated  from  one  another),  it 
would  serve  no  useful  purpose  to  dwell  upon  the 
symptomatology  and  treatment  of  spinal  pachy- 
meningitis and  arachnitis  alone.  The  reader  is, 
therefore,  referred  to  the  corresponding  sections 
in  the  next  article. 

1a.  Meninges,  Spinal,  Inflammation  of. 
Simple  Idiopathic  and  Tubercular.—  Synon.: 

Simple  and  Tubercular  Spinal  Leptomeningitis. 

Simple  spinal  meningitis  of  idiopathic  origin, 
and  tubercular  spinal  meningitis,  are  affections 
so  closely  relat  ed  to  one  another,  both  in  their  cli- 
nical and  pathological  aspects,  that  no  advantage 
whatsoever  would  be  derived  from  considering 
them  separately.  In  each  case  we  have  to  do 
with  an  inflammation  involving  the  spinal  pia 
miter,  so  that  the  products  of  inflammation  are 
situated  beneath  the  arachnoid  membrane.  In 
order  to  distinguish  these  from  other  forms  of 
meningitis,  such  as  pachymeningitis  and  arach- 
nitis, it  is  desirable  that  we  should  use  some 
special  term,  such  as  leptomenitigitis,  which  has 
of  late  been  employed  as  a distinctive  appel- 
lation for  an  inflammation  affecting  the  pia  mater, 
whether  cerebral  cr  spinal. 


INFLAMMATION  OF. 

In  regard  to  the  extent  or  area  of  this  kind 
of  inflammation,  it  must  be  said  that  the  tuber- 
cular variety  always  involves  the  presence  of  a 
similar  inflammation  at  the  base  of  the  brain 
though  the  contrary  position  is  not  true— that 
is  to  say,  the  tubercular  inflammation  may  exist 
at  the  base  of  the  brain  alone,  without  involving 
the  spinal  meninges.  Of  the  mn-tubercular 
forms  of  spinal  lep  omeningitis,  there  are  two 
varieties,  and  of  these  one  form  always  involves 
the  membranes  at  the  base  of  the  brain  and  the 
spinal  meninges  simultaneous^.  This  is  the 
‘ epidemic  cerebro-spinal  meningitis,'  which  is 
described  in  a separate  article  ( see  Epidemic 
Cerebro-Spinal  Meningitis).  The  other  form 
may  or  may  not  simultaneously  involve  the  mem- 
branes at  the  base  of  the  brain,  so  that  we  have 
in  these  cases  either  a ‘simple  sporadic  cerebro- 
spinal meningitis,’  or  a ‘ simple  sp  nal  menin- 
gitis.’ 

Whenever  the  inflammation  has  a ‘ cerebro- 
spinal’ distribution,  no  confusion  is  involved  by 
retaining  the  use  of  the  simpler  term  meningitis, 
as  it  is  generally  understood  that  torms  of  in- 
flammation having  such  a distribution  involve 
the  pia  mater  especially.  Bat  in  place  of  the 
name  spinal  meningitis,  if  we  meaa  to  imply 
that  the  inflammation  affects  the  same  tissue,  it 
is  best  to  use  the  more  special  and  distinctive 
term  ‘spinal  leptomeningitis.’ 

From  what  has  been  said  above,  it  will  he 
understood  that  the  symptoms  resulting  from 
meningitis  involving  the  base  of  the  brain  alone, 
or  together  with  serous  effusion  and  softening 
of  the  walls  of  fho  ventricles  (which,  as  we  have 
seen,  so  frequently  co-exists  with  inflammation 
of  the  membranes  in  this  situation',  have  been 
principally  studied  in  the  purely  cerebral  forms 
of  tubercular  meningitis.  On  the  other  hand, 
the  symptoms  resulting  from  spinal  lepto- 
meningitis are  best  studied  in  the  simple  forms 
of  this  disease.  It  will  also  be  evident  that 
the  simple  and  the  tubercular  forms  "f  cerebro- 
spinal meningitis  are  likely  to  agree  to  some 
extent  in  their  symptomatology  with  that  oj 
the  disease  known  as  ‘ epidemic  cerebro-spina 
meningitis.’ 

^Etiology. — This  disease  is  most  prone  t< 
occur  in  children  and  in  young  persons;  and  ii 
more  frequent  in  males  than  in  females.  Person: 
who  are  badly  fed,  and  live  under  very  unfavour 
able  sanitary  conditions,  are  more  liable  to  bi 
attacked  than  those  who  are  healthy  and  snr 
rounded  by  opposite  conditions. 

For  the  tubercular  form  the  exciting  causo 
are  all  such  influences  or  conditions,  whateve 
they  may  be,  which  determine  the  outbreak  c 
acute  tuberculosis.  The  affection  of  the  spina 
meuinues  may  be  either  an  extension  of  the  in 
flammation  originally  existing  at  the  base  of  th 
brain  alone,  or  it  may  be  another  imlependen 
manifestation  of  the  general  disease  developtn 
within  the  spinal  canal  simultaneously  with  th 
cerebral  meningitis.  See  Meninges,  Cbukbra. 
Tubercular  Inflammation  of. 

For  the  simple  or  nou-tubercular  form,  th 
exciting  causes  are  various,  but  the  best  e: 
tablisbed  of  them  would  seem  to  be  these  :- 
exposure  to  cold,  or  cold  and  wet,  in  vanot 
forms  ; certain  acute  diseases,  or  the  period  < 


MENINGES.  SPINAL, 

convalescence  therefrom  : concussion  of  thespine, 
as  from  falling  down  stairs,  or  in  other  ways  ; 
wounds  affecting  the  spinal  cord  or  its  mem- 
branes. as  in  stabs  of  various  kinds  ; or  fracture 
and  dislocation  of  the  vertebrae. 

The  last  modes  of  causation  mentioned  are 
similar  to  those  which  obtain  for  spinal  pachy- 
meningitis and  arachnitis.  For,  although  these 
latter  conditions  may  be  excited  alone  under 
such  traumatic  influences,  they  may  also  in  cer- 
tain cases,  and  especially  arachnitis,  be  excited 
in  association  with  a spinal  leptomeningitis. 
Precisely  the  same  kind  of  thing  has  also  to  be 
said  in  regard  to  the  occasional  action  of  other 
.causes,  such  as  caries  of  the  vertebrae,  deep- 
sloughing  bed-sores  in  cases  of  paraplegia,  or 
other  instances  of  inflammatory  processes  con- 
tiguous to  the  spinal  canal.  Any  of  these  latter 
conditions  may  also  set  up  a leptomeningitis,  in 
association  with  one  of  the  other  forms  of  me- 
Dingeal  inflammation. 

A spinal  leptomeningitis  may  spread  so  as  to 
implicate  the  base  of  the  brain;  or  a cerebral 
basal  leptomeningitis  may  subsequently  impli- 
cate the  spinal  membranes  ; or,  lastly,  the  in- 
flammation may  appear  in  both  regions  simul- 
taneously, and  thus  be  from  the  first  cerebro- 
spinal in  seat.  The  writer  has  of  late  seen 
several  cases  of  the  tubercular  variety  belonging 
apparently  to  this  latter  category  ; but  until  the 
.spiual  canal  has  been  regularly  opened  for  some 
time  in  autopsies  of  persons  dying  from  this 
disease,  we  shall  be  unable  to  say  what  is  the 
exact  numerical  proportion  of  such  cases  as 
compared  with  those  which  are  simply  cerebral 
n type.  The  medulla  may  be  comparatively  free 
from  lymph,  and  yet  an  inflammation  of  the 
spinal  meninges  may  be  well-marked.  There 
must,  therefore,  be  a routine  opening  of  the 
spinal  canal  for  the  decision  of  this  question, 
ind  not  a mere  casual  inspection  of  its  upper 
:xtremity  through  the  foramen  magnum. 

Anatomical  Characters. — According  to  the 
stage  of  the  disease  at  which  death  takes  place, 
ve  may  meet  with  the  inflammatory  process  in 
me  or  other  of  three  different  stages  : — (1)  that 
f greatly  increased  vascularity  of  the  spinal 
■ia  mater ; (2)  one  in  which,  in  addition  to  the 
acroased  vascularity,  gelatinous  serum,  lymph, 
r pus  exists  in  the  meshes  of  the  pia  mater, 
nd  ofren  more  marked  in  amount  along  the 
osterior  columns.  This  latter  is  the  condition 
ammonly  met  with  ; but  in  rare  eases,  where 
Atients  have  survived  an  acute  attack,  we  may 
nd  (3)  certain  residuary  chronic  changes  in  the 
■rm  of  thickenings,  opacities,  and  undue  ad- 
,-sions  of  the  pia  and  arachnoid  to  the  spinal 
^rd,  which  perhaps  may  itself  show  a more  or 
:ss  marked  condition  of  peripheral  sclerosis. 

| In  the  tubercular  variety  we  frequently  have 
do  with  a mere  gelatinous  serum,  or  thin 
eenish-yellow  lymph  (similar  to  that  met  with 
the  base  of  the  brain)  rather  than  with  actual 
s in  the  meshes  of  the  pia  mater.  Careful 
•utiny  of  the  vessels  in  the  anterior  fissure 
d in  other  parts  may  also  show  the  character- 
ic  ‘ granulations,’  in  the  form  of  opalescent, 
litisli  or  yellowrish-white  specks. 

In  both  forms  of  the  disease  the  nerve-roots 
s implicated  in  various  ways.  They  are  usually 


INFLAMMATION  OF.  959 

involved  in  the  inflammatory  process,  and  may 
be  much  pressed  upon  by  lymph  and  other 
hyperplasic  products.  The  nutrition  of  the  cord 
itself  isprobably  profoundly  altered,  owing  to  the 
existence  of  an  inflammatory  process  affecting 
the  network  of  vessels  from  which  its  blood- 
supply  is  derived ; and,  moreover,  the  organic  con- 
tinuity existing  between  the  pia  mater  and  the 
off-shoots  of  connective  tissue  which  extend  into 
it  on  all  sides,  around  the  blood-vessels  that 
penetrate  its  substance,  makes  it  only  natural 
to  suppose  that  the  inflammatory  process  would 
more  or  less  invade  the  substance  of  the  cord 
itself.  And  this,  as  the  observations  of  F. 
Sehultze  have  shown  ( Berlin . Kim.  Wochen- 
schrift,  1876,  No.  1),  actually  does  occur.  But 
further  researches  are  needed  in  this  direction, 
in  order  that  we  may  know  the  frequency  with 
which  grave  changes  of  this  kind  are  produced. 

Symptoms. — General  listlessness  and  a sense 
of  chilliness  have  been  noticed  as  premonitory 
symptoms  in  some  cases  of  spiuai  meningitis. 
At  other  times  the  disease  has  been  observed  to 
commence  with  a more  marked  feeling  of  chil- 
liness, accompanied  or  quickly  followed  by  some 
febrile  elevation  of  temperature,  together  with 
a full,  rapid  pulse.  Soon  there  supervenes  a 
deep-seated,  boring  pain  in  the  back,  varying  in 
situation  according  to  the  degree  of  intensity 
of  the  inflammatory  process  at  different  levels. 
Pains  also  extend  round  the  body  in  girdle 
fashion,  and  likewise  into  the  limbs.  Whilst  the 
pains  in  the  back  are  more  or  less  continuous, 
though  greatly  aggravated  by  all  attempts  at 
movement,  those  felt  in  the  limbs  and  trunk  may 
be  only  experienced  when  attempts  to  move  are 
made.  Movement  excites  the  dorsal  pain  far 
more  than  pressure  upon  the  vertebral  spines, 
or  light  tapping  over  the  same  region. 

Rigidity  of  the  spine,  from  muscular  spasms, 
either  localised  or  general,  and  also  rigidity  of 
the  limbs,  or  even  of  special  muscles,  may  coexist 
with  the  pains  in  the  back  and  limbs.  There  is 
often  an  exaltation  of  reflex  movements  in  the 
early  stages  of  the  disease,  though  this  condition 
is  nothing  like  so  well  marked  as  it  is  in 
tetanus. 

At  the  same  time  marked  hypersesthesia  of 
the  skin  exists  over  considerable  regions  of  the 
trunk  and  extremities.  The  patient  cannut  bear 
to  be  touched,  however  lightly  ; and  still  less 
can  he  endure  to  be  moved.  He  is  irritable  or 
plaintive  if  these  proceedings  be  attempted. 
Owing  to  the  varying  nature  and  extent  of  the 
spasms,  and  the  different  amount  of  pain  endured, 
the  position  assumed  by  the  patient  is  very 
various  in  different  cases. 

Difficulty  in  defsecation  and  in  micturition 
often  exists,  especially  in  the  early  stages  of  the 
disease,  and  this  is  supposed  to  be  due  to  a spas- 
modic condition  of  the  sphincters.  The  respira- 
tion and  the  heart's  action  are  principal ly  inter- 
fered with  in  cases  where  the  cervical  meninges 
are  gravely  involved. 

The  temperature  seems  to  pursue  a somewhat 
irregular  course,  but  concerning  this  further  in- 
formation is  needed.  It  may  be  only  slightly 
above  the  normal;  and  may  not  rise  much  beyond 
102°,  even  in  fatal  cases,  till  near  the  end.  Then 
it  may  rise  considerably  in  the  course  of  a few 


960  MENINGES,  SPINAL, 

hours  ; whilst  in  other  cases  it  may  at  this  same 
period  become  depressed  below  the  normal. 

In  the  later  stages  of  the  disease  some  amount 
of  paresis,  or  actual  paralysis,  may  be  noted  in 
one  or  more  limbs  ; the  pains  on  movement  and 
the  skin-hyperaet.hesia  become  less,  or  may  in- 
deed be  intermixed  with  tracts  in  which  actual 
anaesthesia  exists.  The  bladder  may  at  last  be 
paralysed;  and  respiration  may  be  most  gravely 
interfered  with,  so  that  disturbance  of  this  func- 
tion, as  well  as  of  the  heart's  action,  may  be  the 
actual  cause  of  death. 

These  symptoms  are,  in  all  probability,  as 
Erb  maintains,  due  in  very  great  part  to  the 
inflammatory  and  other  changes  by  which  the 
anterior  and  posterior  nerve-roots  are  impli- 
cated. Others  may  be  due  to  extensions  of  the 
inflammatory  process  to  the  substance  of  the 
spinal  cord,  thus  leaving  a somewhat  uncertain 
minority  of  symptoms  to  be  accounted  for  by 
the  mere  implication  of  the  pia  mater  itself. 

The  grouping  of  symptoms  is  apt  to  vary 
much  in  different  cases,  according  as  there  is  or 
is  not  the  coexistence  of  a cerebral  meningitis  ; 
or,  in  the  absence  of  this  complication,  according 
us  the  inflammation  is  more  or  less  localised  in 
different  regions  of  the  cord,  or  general  in  its 
distribution.  Much  will  depend  also  upon  the 
severity  of  the  process,  and  upon  the  extent  to 
which  the  substance  of  the  spinal  cord  becomes 
involved  in  the  course  of  the  disease. 

Diagnosis. — Eever;  pains  in  the  back  and 
limbs,  greatly  aggravated  by  movement ; together 
with  stiffness  of  the  neck,  trunk,  or  limbs ; local 
muscular  spasms ; hypersesthesia  of  the  skin ; 
retention  of  feces  and  urine  ; dyspnoea ; with  a 
tendency  in  the  later  stages  to  the  superven- 
tion of  paresis,  or  actual  paralysis  of  limbs — 
these  are  the  symptoms,  the  combination  of 
which  to  a marked  extent  becomes  almost  typical 
of  spinal  meningitis. 

Its  complication  with  a basal  cerebral  menin- 
gitis is,  amongst  other  signs,  chiefly  indicated 
by  the  occurrence  of  vomiting,  headache,  slight 
delirium  or  stupor,  paralysis  of  ocular  muscles, 
difficulty  in  deglutition,  loss  of  speech,  or  convul- 
sions. The  presence  of  many  of  such  symptoms 
may,  from  their  great  importance,  tend  to  dwarf 
or  obscure  those  due  to  the  inflammation  of  the 
spinal  meninges  alone;  on  the  other  hand,  if  they 
are  absent  we  may  feel  assured  that  the  inflam- 
mation has  not  also  at  tacked  the  base  of  the  brain. 

The  fact  that  a meningitis  i3  spinal  in  seat, 
and  unaccompanied  with  cerebral  symptoms,  is 
of  itself  exceedingly  good  evidence  to  prove  that 
it  is  not  the  tubercular  form  of  the  affection. 

To  settle  the  question,  which  membranes  of 
the  cord  are  inflamed  in  any  given  case,  we  must 
bo  guided  much  by  what  we  can  learn  concern- 
ing the  causal  conditions  and  the  distribution  of 
the  inflammation,  rather  than  by  any  at  present 
known  differences  in  the  grouping  of  symptoms. 
Thus  inflammations  of  idiopathic  origin,  or 
those  which  are  cerebro-spinal  in  seat,  will 
almost  invariably  be  found  to  be  instances  of 
leptomeningitis  ; whilst  those  set  up  as  a result 
of  caries  of  the  vertebrae,  or  as  a sequence  of 
a sloughing  sacral  bed-sore,  are  certainly  much 
more  prone  to  take  the  form  of  pachymeningitis, 
or  of  this  in  combination  with  arachnitis. 


i,  INFLAMMATION  OF. 

In  reference  to  the  diagnosis  of  spinal  menin- 
gitis from  other  affections,  it  may  bo  said  that 
a very  slight  amount  of  attention  to  tbe  nature 
of  the  pains  and  attendant  conditions,  will 
suffice  to  avoid  the  mistake  of  supposing  them 
to  be  rheumatic  in  nature.  And,  similarly,  the 
absence  of  trismus  in  the  early  stages,  and  of 
any  extremely  well-marked  exaltation  of  reflex 
excitability,  together  with  the  presence  of  severe 
pains  in  the  back  and  limbs,  will  be  negative 
and  positive  characters  sufficient  for  distinguish 
ing  spinal  meningitis  from  tetanus. 

Another  disease  with  which  spinal  meningitis 
is  liable  to  be  confounded,  is  acute  softening 
of  the  spinal  cord.  But  the  distinction  should 
be  easy  in  the  early  stages  ; and  the  history  of 
the  course  of  the  affection  will  guide  us  later 
on,  when  symptoms  of  actual  paralysis  may  have 
become  developed.  Still,  in  certain  cases,  a 
spinal  meningitis  may  entail  a softening  of  the 
cord  to  a marked  extent,  and  then  the  symp- 
toms of  the  primary  affection  will  gradually  bo 
merged  in  those  of  the  other  which  it  induces. 

A very  rare  condition,  once  met  with  by  tbo 
present  writer,  is,  he  thinks,  almost  impossible  | 
to  bo  diagnosed  from  spinal  meningitis— that 
is,  where  a sarcomatous  or  carcinomatous  new 
growth  springs  up  rapidly  throughout  the 
spinal  pia  mater  in  the  situation  usually  occu- 
pied by  lymph  or  pus,  especially  when,  as  in  the 
instance  referred  to,  the  disease  seems  to  he  the 
direct  sequence  of  a fall  from  a height  or  over 
a flight  of  steps,  and  death  takes  place  within  a 
period  of  six  or  eight  weeks  (see  Lancet,  vol.  i. 
1880,  p.  988). 

Prognosis. — The  prognosis  of  spinal  menin- 
gitis depends  a good  deal  upon  the  nature  of  the 
primary  or  causal  conditions ; upon  the  question 
whether  the  disease  shows  a tendency  to  extend 
to  the  cerebral  meninges ; upon  the  severity  with 
which  it  implicates  the  cervical  region  of  the 
cord ; and  also  to  some  extent  upon  the  age  and 
general  state  of  health  of  the  person  attacked. 

It  is  a disease  which  proves  fatal  in  the  course 
of  a few  weeks  in  a very  large  percentage  o 
cases;  complete  recovery  is  certainly  a ran 
exception;  but  late  and  partial  recovery— tha 
is,  after  the  disease  has  lasted  long,  and  witl 
the  remainder  of  some  amount  of  muscula 
atrophy  or  incurable  paralysis — is  a little  mon 
frequent.  In  such  cases  the  disease  after  a tim 
lapses  into  a chronic  condition,  and  the  patien 
very  gradually  recovers,  except,  perhaps,  fo 
such  incurable  sequel®  as  are  above  mentionec 
But  even  in  these  cases  tending  towards  rc 
covery,  a relapse  is  most  easily  brought  abou 
owing  to  the  recommencement  of  the  disease  i 
an  acute  form. 

Where  spinal  meningitis  supervenes  upon 
sloughing  bed-sore  existing  in  a case  of  par 
plegia,  the  end  is  usually  not  far  distant.  Tli 
gravity  of  any  case  of  spinal  meningitis  is  als 
always  greatly  enhanced  when  the  di sea- 
spreads  to  the  cerebral  meninges.  And,  so  1; 
as  the  spinal  meninges  themselves  are  cot 
earned,  any  great  intensity  of  the  inflamm3tor 
process  in  the  cervical  region,  is  always  of  tb 
gravest  import,  because  of  the  liability  to  secoi 
dary  implication  of  the  cord  itself  in  these  r 
gions,  either  structurally  or  functionally  and  ti 


MENINGES.  SPINAL.  HAEMORRHAGE  INTO.  9 til 


bringing  about  from  this  cause  of  serious  inter- 
ference with  the  functions  of  respiration  and 
Scirculation.  A continuously  rising  temperature 
in  such  a case — to  103°  and  onwards — is  also  of 
fatal  import. 

Treatment. — The  severity  of  the  disease  is 
apt  to  prompt  to  the  use  of  active  measures  .of 
questionable  utility;  amongst  these  may  bo 
cited  free  local  blood-letting,  tho  free  application 
of  ice  to  the  spine,  and  active  purgation.  It 
is  difficult,  too,  to  say  on  what  principle  it  is 
thought  absolutely  necessary  to  apply  cold  when 
ive  have  to  do  with  an  inflammation  within  the 
jpinal  canal  or  within  the  cranium,  whilst  we 
almost  always  apply  heat  externally  in  the  case 
of  an  inflamed  pleura,  an  inflamed  peritoneum, 
ir  even  to  an  inflamed  skin-tract.  Probably  the 
ipplication  of  ice  in  such  cases  tends  to  alleviate 
lain,  so  that  where  this  is  great  its  use  may 
oriDg  much  relief  to  present  suffering,  when 
not  applications  would  only  aggravate  it.  But 
Vere  it  not  for  the  fact  that  in  meningeal 
inflammation  (whether  spinal  or  cerebral)  in- 
reased  fulness  of  vessels  around  sensitive  organs 
hut  in  by  unyielding  walls,  almost  necessarily 
ends  to  aggravation  of  pain,  the  application 
'f  heat  would  probably  be  more  beneficial  than 
hat  of  cold,  so  far  as  the  possible  resolution 
f the  inflammatory  condition  itself  is  con- 
erned. 

The  patient  should  certainly  be  kept  in  a 
ool,  quiet  room,  and  lying  either  on  his  side,  or, 

' possible,  on  his  face  on  a comfortable  bed. 
le  should  be  well  supplied  with  spoon  diet  of 
ae  most  nourishing  description,  together  with 
Jgs  and  a moderate  amount  of  stimulants, 
ccording  to  the  indications  presented  by  his 
'mptoms  and  general  condition. 

Blisters  may  be  applied  along  each  side  of 
ie  spine  alternately,  or  the  same  regions  may 
a painted  with  liquor  iodi.  Pain  should  also  be 
■ised  by  opium  or  morphia  ; in  fact,  an  opiate 
oatment  maybe  resorted  to  in  a large  proportion 
'the  eases.  When  opium  and  morphia  do  not 
;ree,  or  are  not  admissiblo,  Indian  hemp  would 
‘ worthy  of  trial  as  a mere  anodyne ; or  we 
just  fall  back  upon  bromide  of  potassium  and 
ioral,  though  the  latter  must  be  used  with 
ieat  caution  where  the  heart's  action  is  slow, 
■egular,  and  seriously  interfered  with.  Bella- 
,nna  and  ergot  have  also  been  recommended, 
somewhat  doubtful  grounds,  as  anti-inflam- 
jitory  remedies. 

We  ought,  in  fact,  to  endeavour  to  combat  the 
jj'St.  urgent  symptoms  as  much  as  possible, 
in  if  we  cannot,  by  counter-irritants  and  by 
> judicious  use  of  drugs,  modify  the  course  of 
' | inflammation.  Also  by  suitable  feeding  and 
i 'icious  nursing  we  should  endeavour  to  tide 
11  patient  through  the  disease.  And  if,  hap- 
ly, the  activity  of  the  inflammatory  process 
f isides,  the  most  unremitting  attention  will 
U be  required  to  protect  the  patient  against  a 
Apse.  Should  his  condition  otherwise  admit 
c it,  the  absorption  of  inflammatory  products 
' Adi  in  this  stage,  be  likely  to  be  promoted  by 
t use  of  a small  dose  of  bichloride  of  mercury 
( ih  as  one-sixteenth  of  a grain  for  an  adult), 

■ ombination  with  increasing  doses  of  iodidoof 
P issium.  At  the  same  time,  every  effort  must 

61 


be  made  to  restore  the  patient’s  general  health, 
and  to  combat  the  emaciation  which  the  disease 
itself  usually  involves. 

2.  Meninges,  Spinal,  Hsemorrhage  inti 
or  upon. — Synon.  ; H<emafo>-rac/iis;  Meningea 
Apoplexy  (Spinal). 

Effusions  of  blood  upon,  between  or  beneatl 
the  spinal  meninges  are  altogether  rare  events 
contrasting  notably  in  this  respect  with  the  com- 
parative frequency  of  parallel  conditions  on  th< 
side  of  the  cerebral  meninges. 

AEtiology. — Among  the  causes  of  meningea! 
haemorrhages,  stabs,  blows,  or  falls  will  hold  a 
first  rank.  After  these  causes  we  should  have 
to  cite  impediments  to  the  circulation  of  blood 
occasioned  by  various  respiratory  or  museulai 
spasms,  occurring  either  in  the  course  of  whoop- 
ing-cough, or  during  some  more  than  usually 
violent  convulsive  attack,  epileptic,  tetanic,  oi 
other.  The  lifting  of  heavy  weights,  or  other 
great  voluntary  muscular  exertions,  may  like- 
wise at  times  prove  causes  of  spinal  meningea] 
hiemorrhage.  Occasionally,  however,  it  occurs 
independently  of  any  such,  or  of  other  readily 
assignable  causes. 

Anatomical  Characters. — Fluid  blood  or 
blood-clots  may  exist  in  relation  with  the  spinal 
meninges  in  three  different  situations. 

The  most  frequent  site  of  such  hsmorrhago 
is  (1)  outside  the  dura  mater,  between  it  and 
the  vertebral  arches.  Here  large  clots  arc 
sometimes  found,  wholly,  or  more  frequently  in 
part,  surrounding  the  dura  mater  in  the  region 
in  which  tho  hsemorrhage  has  occurred.  Where 
the  effusion  is  large,  the  cord  itself  may  he  dis- 
tinctly compressed,  but  even  smaller  effusions 
may  produce  some  amount  of  compiession  of 
nerve-roots.  A clot  in  this  situation,  as  in  oilier 
sites,  will,  of  course,  become  much  modified  in 
appearance  with  age. 

Clots  and  more  or  less  fluid  blood  may  also, 
but  more  rarely,  be  met  with  (2)  inside  the 
dura  mater,  within  the  so-called  arachnoid  sac. 
This  occurs  perhaps  most  frequently  as  a mere 
sequence  of  a similar  hsemorrhage  taking  place 
in  the  cerebral  meninges,  the  blood  simply  gravi- 
tating into  the  spinal  canal.  Sometimes,  however, 
especially  in  cases  of  spinal  pachymeningitis, 
blood  is  actually  effused  in  this  situation — and 
that  where  the  internal  surface  of  the  dura  mater 
is  much  more  vascular  than  natural.  The  open- 
ing of  a thoracic  or  abdominal  aneurism  may  also 
occasionally  take  place  into  the  spinal  canal,  and 
thus  produce  sudden  and  grave  compression  of 
the  spinal  cord. 

Much  smaller  extravasations  of  blood  are  also 
met  with  (3)  beneath  the  arachnoid  and  within 
the  meshes  of  the  pia  mater,  over  areas  perhaps 
small  in  extent  longitudinally,  but  more  or  less 
embracing  the  cord  in  one  or  more  regions.  The 
cord  or  nerve-roots  may,  however,  he  decidedly 
compressed  by  such  haemorrhages,  even  when 
they  are  small  in  amount,  owing  to  the  space 
into  which  the  effusion  takes  place  being  com- 
paratively shallow. 

Symptoms. — The  symptoms  of  these  affections 
are  in  a large  proportion  of  the  cases  vague  and 
ill-defined.  They  may  be  much  obscured  by  the 
causal  conditions.  In  other  cases  they  will  vary 


362  MENINGES,  SPINAL,  NEW  GROWTHS  AND  PRODUCTS  OF. 


in  distinctness  according  to  the  amount  and 
abruptness  of  the  haemorrhage. 

As  a rule,  the  onset  of  symptoms  is  sudden. 
Pain  in  the  region  of  the  spine,  in  which  the 
haemorrhage  exists,  or  radiating  thence  along 
the  nerves  emanating  from  this  region,  may  be 
the  first  symptom.  More  rarely,  muscular 
twitchings  or  spasms  may  exist,  either  alone  or 
with  pains.  These  symptoms,  dependent  upon 
irritation  and  compression  of  sensory  and  motor 
nerve-roots,  are  at  other  times  almost  wholly' 
absent.  There  may  then  be  as  abiding  symptoms 
mere  numbness  or  tingling  in  the  parts  affected, 
together  with  a sense  of  weight  and  paresis  in 
the  limbs.  Actual  paralysis  is  rare  ; and  even 
when  it  is  present,  the  rectum  and  bladder 
mostly  escape. 

Where  pain  exists,  there  is  often  stiffness  of 
rhe  spine;  and  these  botli  together  greatly  inter- 
fere with  movement.  Febrile  reaction  is  usually 
absent  or  very  slight.  The  severity  of  the 
symptoms  may  abate  after  a day  or  two,  leaving 
only  more  or  less  paresis.  In  the  case  of  large 
haemorrhages,  however,  with  extensive  compres- 
sion of  the  spinal  cord,  death  may  bo  rapid, 
occurring  in  the  course  of  some  hours  or  of  a 
day  or  two. 

The  symptoms  will  vary  as  the  effused  blood 
presses  upon  the  cord  in  the  cervical,  the  dorsal, 
or  the  lumbar  region.  Where  the  effusion  is  in 
the  cervical  region  in  a traumatic  case,  in  which 
there  is  obvious  head-injury  with  a condition  of 
stupor,  it  is  almost  certain  not  to  be  diagnosed. 
The  patient  is  not  sensible  enough  to  complain 
of  pain ; and  the  irregular  respiration  and  small 
disordered  pulse,  with  slight  tremor  or  rigidity 
of  one  or  both  upper  extremities,  may  with 
more  probability  be  ascribed  to  multiple  head- 
lesions — as  actually  happened  in  a case  which 
recently  came  under  the  writer’s  notice. 

Diagnosis. — It  maybe  impossible  to  diagnose 
haemorrhage  into  the  spinal  meninges  in  cases 
where  it  occurs  as  a concomitant  of  other  grave 
diseases — such  as  tetanus,  eclampsia,  or  cerebral 
haemorrhage;  and  also  in  cases  where  it  merely 
complicates  a traumatic  injury  of  the  spinal 
cord  itself.  In  other  cases,  the  presence  of 
certain  causal  conditions,  together  with  the  ab- 
rupt commencement  of  spinal  symptoms  in  such 
combinations  as  have  been  above  referred  to, 
is  sufficient  to  enable  U9  to  diagnose  it  from 
haemorrhage  into  the  substance  of  the  cord,  as 
well  as  from  meningitis,  or  acute  softening  (see 
Spinal  Cord,  Diseases  of).  The  gradual  onset 
of  the  symptoms  arising  from  tumours  of  the 
spinal  cord,  or  of  the  spinal  meninges,  make  it 
more  easy  to  separate  theso  affections  from 
meningeal  haemorrhages. 

Prognosis. — Meningeal  haemorrhages  are  as 
a class  decidedly  less  grave  than  meningeal  tu- 
mours. They  are  unlike  the  latter,  moreover, 
inasmuch  as  the  worst  symptoms  attendant  upon 
them  are  produced  at  once,  instead  of  being  only 
very  slowly  evolved  ; so  that  after  a short  time, 
unless  the  blood  effused  happen  to  have  pro- 
duced a certain  amount  of  compression  of  the 
spinal  cord,  the  symptoms  gradually  diminish  in 
severity.  Large  extra-meningeal  haemorrhages, 
compressing  the  cervical  region  of  the  cord,  are 
by  far  tne  most  serious  forms  of  this  affection. 


Treatment. — In  the  treatment  of  spinal  me- 
ningeal haemorrhage  the  patient  must,  of  course, 
be  kept  perfectly  quiet  and  in  the  recumbent 
position.  Spoon  diet  should  be  administered  for 
a few  days ; and  vascular  sedatives,  such  as  aco- 
nite, may  be  given  with  advantage.  Some  re- 
commend active  purgation,  and  the  aDstraction 
of  blood  from  the  neighbourhood  of  the  spinal 
column  by  cupping  or  leeches.  These  measures, 
however,  are  of  questionable  utility,  and  the  fir- 
mer especially  might  easily  do  positive  ham. 


3.  Meninges,  Spinal,  New  Growths  and 
Adventitious  Products  of. — This  subject  re- 
quires no  very  lengthy  discussion.  As  was  said 
in  regard  to  such  growths  and  products  spring- 
ing from  or  connected  with  the  cerebral  menin- 
ges, the  symptoms  to  which  they  give  rise  are  in 
the  main  referable  to  irritation  and  pressure  upon 
adjacent  portions  of  the  nerve-centres  or  upon 
certain  nerve-roots.  The  symptoms,  therefore, 
of  meningeal  growths  or  adventitious  products 
are  almost,  if  not  quite,  indistinguishable  from 
those  produced  by  similar  bodies  in  the  spinal 
cord. 

The  sections  on  special  symptoms  and  diagnosis 
which  might  otherwise  have  appeared  here  maj 
be  suppressed;  and  the  reader  be  referred foi 
their  equivalents  to  what  he  will  find  under  the 
bead  of  Spinal  Cord,  Tumours  of. 

We  shall  now  merely  give  a few  details  con 
cerning  the  aetiology,  nature,  and  precise  sites  o. 
the  various  new  growths  and  adventitious  pro 
ducts  that  may  be  met  with  in  connection  with  th 
spinal  meninges,  and  shall  supplement  these  de 
tails  with  some  few  general  remarks  bearingupo; 
the  prognosis  and  treatment  of  such  affections. 

-Etiology. — In  accounting  for  certain  tu 
mours,  such  as  those  of  a syphilitic,  of  a sere 
fulous,  or  of  a cancerous  type,  we  may  fall  bae 
upon  the  existence  of  a general  ‘predisposition 
though  what  determines  the  appearance  of  sne 
tumours  in  this  or  that  particular  situatiq 
generally  remains  as  much  a matter  of  unce 
tainty  as  when  the  growths  are  solitary  or  < 
non-diathetic  origin.  Amongst  such  determinir 
or  exciting  causes  only  one  of  those  usually  cit< 
seems  to  be  of  real  potency,  namely,  the  occu 
rence  of  blows  or  injuries  of  various  kind 
Theso  certainly  appear  at  times  to  be — in  tl 
spinal  meninges  as  in  other  situations  — t 
immediately  exciting  causes  of  certain  nt 
growths. 

Parasites,  such  as  cystieerci  and  hydatic 
gain  entry  to  the  system  in  the  way  mention 
in  the  articles  on  these  subjects;  butsomethi 
so  indefinite  or  accidental  as  to  be  spoken  of 
us  as  ‘ chance,’ will  determine  their  appearance 
this  or  that  particular  tissue  or  organ. 

A.  New  Growths. — (a)  Cancer. — Cancer' 
curs  most  frequently  in  the  spinal  meninges,  i: 
as  a primary  affection,  but  by  extending  to  thi 
from  a previous  cancerous  growth  in  one  of  o 
adjacent  vertebrae.  The  space  within  the  spi  1 
canal  being  very  limited,  such  a tumour  s i 
begins  to  press  injuriously  upon  nerve-roots  u 
upon  the  cord  itself.  In  rare  cases,  howeve® 
cancerous  new  growth  may  start  from  the  sp  •* 
dura  mater. 

(A)  Scrofulous  growths. — These  masses  are  » 


meninges,  spinal. 

with  principally  incases  of  scrofulous  disease  of 
the  spinal  column,  and  especially  where  angular 
curvature  is  produced,  though  they  are  not  con- 
fined to  these  more  severe  forms  of  vertebral 
caries.  Caseating  growths  are  in  such  cases  apt 
to  extend  from  the  vertebrae,  so  as  to  infiltrate 
the  dura  mater,  and  then  produce  fungating  ex- 
crescences on  its  inner  surface.  Small  isolated 
scrofulous  tumours,  the  so-called  ‘ tubercular  ’ 
growths,  may  also  he  met  with,  though  more 
rarely  than  in  the  cerebrum,  springing  from  the 
[spinal  pia  mater,  and  more  or  less  imbedding 
themselves  in  the  substance  of  the  spinal  cord. 

(c)  Syphilomata. — Syphilitic  growths  are  also 
decidedly  less  frequent  in  connection  with  the 
spinal  than  with  the  cerebral  meninges.  Small 
tumours  may,  however,  spring  either  from  the 
dura  matcror  from  the  arachnoid  and  pia  mater. 
Or.  instead  of  well-defined  tumours,  there  may 
be  thickenings  of  the  membranes  in  some  part  of 
their  extent,  and  adhesions  between  one  another 
and  the  surface  of  the  cord,  by  means  of  opaque, 
yellowish-white,  gummatous  growths. 

(d)  Sarcomata. — Sarcomatous  tumours  of  all 
kinds  may  be  met  with  in  connection  with  the 
Spinal  meninges,  springing  occasionally  from  the 
iura  mater,  hut  more  commonly  from  the  arach- 
noid and  pia  mater.  Instead  of  being  distinctly 
circumscribed,  such  growths  may  exist  in  the 
!orm  of  diffuse  infiltrations,  invading  the  pia 
nater  all  round  the  cord  for  a variable  extent. 
In  one  remarkable  case  the  writer  met  with  a 
growth  of  this  kind  involving  the  pia  mater 
liroughout  the  whole  length  of  the  spinal  cord, 
rliich  was  most  developed  on  its  lateral  and 
tosterior  aspects.  Here  in  some  places  the  layer 
*f  new  growth  was  about  one-third  of  an  inch  in 
iepth,  and  the  cord  was  notably  compressed  in 
ts  postero-lateral  aspects  ( Lancet , June  26, 
880,  p.  988). 

j ( e ) Myxomata. — Myxomata  are  met  with  in 
he  form  of  small  circumscribed  tumours,  spring- 
ig  mostly  from  the  pia  mater.  The  writer  has 
Ten  one  about  the  size  of  a very  large  almond 
ituated  on,  and  greatly  compressing,  the  pos- 
hrior  columns  of  the  cord.  Its  presence  was 
ssociated  with  very  obscure  and  ill-defined 
.■mptoms  during  life. 

If)  Tubercle. — Tubercles  in  the  form  of  1 grey 
ranulations’  have  already  been  referred  to  in 
le  description  of  Spinal  Leptomeningitis. 

(y)  Fibromata,  ( h ) Lipomata,  and  (i)  Enckon- 
•omata. — These  various  kinds  of  new-growth 
ivebeen  met  with  occasionally,  but  principally 
connection  with  the  outer  aspect  of  the  dura 
ater. 

' (£')  Osteomata.—' These  formations  are  here  of 
1 clinical  significance,  though  they  are  much 
Jre  common  in  persons  of  all  ages  on  the  spinal 
an  on  the  cerebral  meninges.  They  are  apt 
occur  in  the  form  of  small  bony  plates  scat- 
red  over  the  surface  of  the  arachnoid.  Some- 
nes  a limited  ‘ ossification  ’ of  the  dura  mater 
also  met  with. 

B.  Advontitious  Products. — Parasites  The 
ne  two  kinds  of  parasites  may  he  found 
connection  with  the  spinal  meninges  as  we 
ve  already  had  to  refer  to  in  connection  with 
>se  of  the  cerebrum — namely,  the  small  and 
en  numerous  cysticerci,  as  well  as  the  more 


MENINGO-MYE  LITIS.  963 

solitary  and  larger  hydatids.  The  latter  may 
be  found  within  the  dura  mater,  but  they  have 
been  met  with  much  more  frequently  outside 
this  membrane,  often  forming  large  tumours  con- 
tiguous to  the  spinal  canal.  These  are  the  only 
adventitious  products  of  any  importance  which 
occur  in,  or  in  relation  with,  the  spinal  me- 
ninges. 

Prognosis. — As  a class  these  affections  are 
grave,  tending  to  produce,  with  some  exceptions, 
various  irregular  forms  of  paralysis,  and  ulti- 
mately death,  though  this  latter  may  take  place 
only  after  the  expiration  of  two,  three,  or  more 
years.  The  symptoms  produced  by  tumours 
and  parasites,  as  a rule,  go  on  increasing  in 
severity;  and  the  gravity  of  the  prognosis  will 
depend  much  upon  their  rapidity  of  growth,  as 
evidenced  by  the  increase  of  signs  of  severe 
compression  of  the  cord  or  of  its  nerve-roots,  in 
connexion  with  the  state  of  other  organs.  The 
supervention  of  obstinate  bed-sores,  and  para- 
lysis with  inflammation  of  the  bladder,  may  at 
List  greatly  hasten  the  fatal  termination. 

Treatment. — In  the  treatment  of  tumours  or 
parasites  within  the  spinal  canal,  our  efforts  must 
be  in  the  main  directed  to  restoring  or  improving 
the  general  health  of  the  patient,  and  to  com- 
bating the  more  urgent  symptoms  that  may 
arise— such  as  pain,  spasms,  paralysis,  sleepless- 
ness, bed-sores,  and  cystitis.  Where,  however, 
we  have  to  deal  with  growths  of  syphilitic 
origin,  we  can  attack  the  disease  itself  by  means 
of  drugs.  Under  the  influence  of  small  doses  of 
mercury  and  increasing  doses  of  iodide  of  potas- 
sium, the  patient's  condition  may  often  be  mar- 
vellously improved,  though  the  relief  is  perhaps 
not  so  striking  as  in  cases  where  syphilis  affects 
the  cerebral  meninges,  because  in  this  latter  dis- 
ease the  symptoms  are  more  varied  in  nature, 
and  more  dependent  upon  added  functional  com- 
plications. H.  Charlton'  Bastian. 

MENTNGOCELE. — See  Brain,  Malforma- 
tions of;  and  Skull,  Diseases  of. 

MENINGO  - CEREBRITIS.  — A name 
given  to  a pathological  condition  in  which  in- 
flammation of  the  pia  mater  extends  in  some 
regions  of  the  cerebrum  so  as  to  implicate  the 
subjacent  cortical  substance.  The  fact  of  such  an 
extension  is  much  less  capable  of  being  diagnosed 
during  life  than  of  being  discovered  after  death, 
but  it  may  then  be  recognised  by  the  existence  of 
superficial  softening  of  the  brain-substance,  to- 
gether with  a more  or  less  marked  increase  of 
vascularity.  This  condition  probably  always 
exists  to  a certain  extent  in  meningitis,  and 
might  reveal  itself  on  careful  microscopical  ex- 
amination— although  the  inflammatory  changes 
may  not  have  advanced  far  enough  to  produce 
an  easily  appreciable  amount  of  softening. 

MENIN GO-MYELITIS  is  a term  used  to 
indicate  a condition  in  which  inflammation  of  the 
spinal  meninges  has  extended  to  the  surface  of 
the  spinal  cord.  The  evidence  of  such  an  exten- 
sion has  usually  been  supposed  to  depend  upon 
the  existence  of  an  appreciable  amount  of  super- 
ficial softening.  But  minor  changes  of  an  in- 
flammatory type,  capable  of  recognition  by  the 


064  MENING  O-MYELITIS. 

microscope,  may  also  here  exist  -with  frequency, 
as  F.  Schultze  has  shown,  although  they  may  fall 
short  of  entailing  actual  softening. 

MENOPAUSE  {pyres,  the  menses,  and  i rav- 
en, a cessation). — The  natural  cessation  of  the 
menstrual  flow,  or  ‘ change  of  life  ’ in  the  female. 
See  Change  of  Life. 

MENORRHAGIA  (gyv,  a month,  and  pi j- 
■yvvfj.1,1  burst  forth). — Over-abundant  menstrua- 
tion, whether  due  to  excessive  quantity,  or  to 
undue  frequency.  See  Menses  or  Menstruation, 
Disorders  of. 

MENSES  or  MENSTRUATION,  Dis- 
orders of. — Synon.  : Fr.  Troubles  dc  la  Men- 
struation ; Ger.  Storungcn  des  Monatsflusses ; 
Storungen  der  Menstruation. 

Menstruation  is  the  periodic  discharge  of  a 
sanguineous  fluid  from  the  female  generative 
organs.  The  discharge  continues  each  time  for 
from  three  to  eight  days.  It  varies  in  quantity 
in  different  subjects.  The  estimation  of  this  is 
surrounded  by  great  difficulties ; usually,  how- 
ever, the  quantity  is  from  four  to  six  or  eight 
ounces.  It  takes  place  monthly;  that  is,  a period 
of  twenty-eight  days  intervenes  from  the  appear- 
ance of  one  flow  to  the  appearance  of  the  next 
following.  In  many  cases,  however,  this  interval 
is  less  than  twenty-eight,  and  may  be  as  short  as 
twenty-one  days ; on  the  other  hand,  it  may  he 
prolonged  to  thirty-one  days,  and  the  function  he 
still  performed  normally.  The  discharge  does  not 
appear  during  childhood  or  old  age.  It  usually 
appears  for  the  first  time  between'  the  twelfth 
and  fifteenth  years,  and  for  the  last  time  between 
the  forty-third  and  forty-eighth;  hut  it  may 
appear  as  early  as  the  ninth,  and  continue  to 
appear  regularly  afterwards  up  to  the  fifty-third 
or  fifty-fifth  year.  The  function  is  suspended 
during  pregnancy,  and,  as  a rule,  during  lacta- 
tion. The  source  of  the  discharge  is  the  body 
of  tho  uterus.  It  is  not  due  to  a congestion  or 
an  erection  of  that  organ,  as  has  been  supposed, 
hut  to  the  degeneration,  disintegration,  and 
removal  of  the  so-called  mucous  membrane  of 
the  uterus — the  decidua  menstrualis.  In  conse- 
quence of  this  degeneration  and  disintegration, 
the  vessels  on  the  inner  surface  of  the  uterus 
aro  opened,  and  haemorrhage  follows.  The 
ultimate  cause  of  the  discharge  is  said  to  be 
the  separation  of  ova  ; such,  however,  is  not 
the  case  in  every  instance,  for  menstruation  may 
take  place  without  the  discharge  of  an  ovum,  and, 
on  the  other  hand,  ova  may  be  separated  from 
the  ovary  without  the  occurrence  of  menstrua- 
tion. It  can  hardly  be  doubted,  however,  that 
the  function  is  in  some  manner  dependent  cn  the 
ovaries,  for  when  tho  latter  have  been  removed 
menstruation  ceases. 

The  fluid  is  not  in  all  eases  sanguineous  ; 
indeed  its  bloody  character  may  he  regarded  as 
accidental,  though  present  in  tho  infinite  majority 
of  cases.  It  may,  however,  be  easily  under- 
stood that  the  disintegration  and  removal  of  the 
‘ decidua  menstrualis,’  which  is  the  essential 
factor  in  menstruation,  may  be  effected  without 
the  occurrence  of  haemorrhage,  and  there  is 


MENSES,  DISORDERS  OF. 

reason  to  believe  that  in  so-called  ‘ white  met 
struation  ’ such  is  the  case. 

For  the  due  performance  of  the  function  two 
conditions  are  essential,  namely,  sound  general 
health,  and  normally  developed  organs  of  gene- 
ration. Disorders  of  the  menstrua)  process  mav 
be  brought  about  by  very  many  conditions.  These 
disorders  are  generally  divided  into : — 

I.  Amenorrhcea,  where  the  discharge  is  ab- 
sent, or  deficient  in  quantity. 

II.  Dysmenorrhoea,  where  the  function  is 
performed  with  difficulty  and  pain. 

III.  Menorrhagia,  where  the  discharge  is 
profuse. 

I.  Amenorrhcea. — Synon.:  Fr.  Amenorrhk; 
Ger.  Amenorrhoe. 

^Etiology  and  Symptoms. — Amenorrhcea  is 
dependent  either  on  general  states ; or  on  local 
pathological  conditions — that  is,  on  lesions  of 
the  uterus  and  ovaries. 

1.  All  conditions  or  influences  which  tend  to 
deteriorate  the  blood,  or  which  act  unfavourably 
on  nutrition,  may  be  causes  of  amenorrhoea.  The 
most  common  of  these  is  the  demand  made  on  the' 
system  in  the  development  of  the  aptitude  for! 
aonception,  the  growth  and  separation  of  ova,  and 

► tjie  performance  of  the  menstrual  function.  At 
this  time  the  breasts  develop,  the  ovaries  and 
uterus  enlarge,  the  pelvis  grows,  and  the  whole 
form  becomes  altered.  Many  women  who  dim 
ing  childhood  have  enjoyed  apparently  perfect 
health,  as  they  approach  puberty  become  gra- 
dually or  suddenly  anaemic  or  chlorotic,  without! 
any  assignable  cause  other  than  the  demand 
made  on  nutrition  by  the  process  of  develop- 
ment through  which  they  at  the  time  pass 
Nutrition  becomes  impaired,  tastes  perverted 
pains  of  a neuralgic  character  are  felt  in  variou; 
parts  of  the  body,  the  menstrual  discharge  does 
not  appear,  or  it  may  appear  once  scantily 
and  then  at  irregular  intervals,  or  it  may  disap 
pear  for  months  or  even  years.  All  the  symp 
toms  of  anaemia  are  present,  and  the  patient  i 
languid,  listless,  lacks  energy,  and  is  in  more  o 
less  constant  suffering.  The  above  may  tab 
place  in  cases  where  the  surroundings  may  b 
favourable  to  healthy  development.  Hygieni 
conditions,  however,  play  a most  important  par 
in  the  proper  development  of  the  female  func 
tions,  and  when  the  surroundings  are  unfavour 
able,  evil  is  sure  to  follow.  Want  of  food,  o 
improper  food,  want  of  fresh  air.  impure  ail 
want  of  exercise,  foul  gases,  malaria,  are  prolifi 
causes  of  failure  or  imperfection  in  the  growt 
and  development  of  the  young  girl,  and  at 
common  causes  of  amenorrhcea.  Disease  also  i 
a by  no  means  infrequent  cause  of  the  conditio: 
under  consideration,  as  phthisis, Bright's  diseas- 
diseases  of  tho  liver,  stomach,  and  nervous  sy: 
tern.  Emotion,  fright,  or  grief,  change  of  a 
and  food  (as  when  girls  go  from  the  country  1 
London),  and  cold,  may-  arrest  or  suspend  tl 
monthly  discharge. 

2.  But  amenorrhcea  may  he  due  to  local  coi 
ditions.  These  are  absence  cr  disease  of  tl 
ovaries,  of  the  uterus,  or  of  both;  and  imperfe< 
development  of  one  or  both  organs. 

In  cases  where  the  ovaries  are  absent,  tl 
change  in  form,  from  girl  io  woman,  which  tak 
place  at  puberty,  does  not  occur.  The  gi 


MENSES,  DISORDERS  OF. 


grows  but  does  not  develop.  A masculine  ap- 
pearance supervenes,  the  breasts  remain  small, 
the  pelvis  narrow,  the  voice  becomes  manly  and 
harsh,  a beard  may  grow  on  the  face,  sexual 
passion  is  absent,  and  the  health  remains  good. 

When  the  uterus  alone  is  wanting,  there  may 
he  no  indication  of  the  condition  in  the  state 
of  the  general  health  or  development,  and  local 
examination  is  necessary  in  order  to  detect  the 
circumstance.  In  theso  cases  the  vagina  termi- 
nates in  a cul  de  sac,  and  the  uterus  cannot 
be  felt  on  examination.  On  introducing  a 
finger  into  the  rectum  and  a sound  into  tho 
bladder,  it  is  found  that  the  two  organs  are  in 
i contact,  and  that  there  is  no  uterus  between 
them.  There  are,  however,  as  a rule,  one  or  two 
small  fibrous  masses  representing  the  uterus. 

Certain  diseases,  as  scrofulous  abscess  and 
atrophy,  which  involve  the  whole  substance  of 
the  ovaries,  and  also  atrophy  of  the  womb,  may 
tause  amenorrhcea. 

Amenorrhcea  from  retention. — In  these  cases  the 
sanguineous  discharge  is  separated,  but  does  not 
appear  externally,  owing  to  atresia  of  the  genital 
tanal.  The  closure  may  occur  at  any  point 
between  the  os  uteri  and  the  vaginal  orifice.  •A, 
membrane  may  close  the  os  tine®;  the  hymej 
may  be  imperforate ; the  vagina  may  be  absent, - 
or  its  walls  may  be  adherent  at  any  part  of  its 
course,  or  along  the  whole  of  it.  The  occlusion 
may  be  congenital,  or  may  arise  from  inflamma- 
tion during  childhood,  or  after  severe  labours. 
In  these  cases  the  menstrual  molimina  are 
periodically  present,  but  the  catamenia  do  not 
appear.  The  molimina  increase  in  severity 
from  month  to  month  ; the  patient  has  pain  in 
the  back,  a sense  of  weight  in  the  pelvis,  and 
becomes  pale  and  sallow ; the  abdomen  after  a 
;ime  begins  to  enlarge,  and  continues  to  increase. 
Dn  examination  a tumour  having  the  shape 
of  the  enlarged  uterus  maybe  felt  rising  from 
he  pelvis.  It  is  smooth,  elastic,  and  dull  on 
oercussion.  If  the  condition  be  not  discovered,  the 
intension  of  the  uterus  may  go  on  to  rupture, 
<r  its  contents  may  pass  along  the  Fallopian 
ubes  into  the  abdomen,  causing  peritonitis  and 
eath. 

Diagnosis. — Whenever  a patient  suffers  from 
menorrhffia,  pregnancy  must  be  thought  of.  If 
lis  state  can  be  excluded,  the  general  condition 
mst  be  investigated.  Anmniia  and  its  causes 
iould  be  sought  for.  The  chest,  heart,  and 
tine  must  be  examined.  If  thdre  be  no  general 
mdition  to  account  for  the  amenorrhcea,  the 
"actitioner  must  see  whether  the  breasts  and 
dvisare  developed,  and  examine  the  vulva  and 
gina  for  obstruction,  if  there  be  any  suspicion 
such  a condition.  Finally  it  may  be  necessary 
examine  the  uterus  and  ovaries. 

Treatment. — The  treatment  of  the  first  form 
amenorrhcea  is  the  treatment  of  the  general 
ite.  If  there  be  want  of  constitutional  vigour, 
inge  of  air,  exercise  in  the  open  air,  mental 
pupation,  but  not  severe,  and  nourishing  diet 
)uld  be  advised.  The  stomach  and  bowels 
ist  be  attended  to;  and  gentle  aperients  and 
ines  given  if  the  tongue  be  foul ; then  vege- 
>le  tonics,  iron,  iodine,  or  other  appropriate 
uedies.  No  efforts  should  be  made  to  act  es- 
| 'ally  upon  the  uterus,  and  this  is  particularly 


965 

binding  when  the  amenorrhcea  is  dependent  on 
phthisis,  Bright’s  disease,  or  such-like  conditions. 

The  second  form  is  often  incurable.  In  those 
cases  where  the  uterus  and  ovaries  are  absent, 
nothing  can  be  done.  If  the  uterus  be  present, 
but  imperfectly  developed,  means  should  be 
used  to  promote  its  growth.  With  this  view 
stem  pessaries,  galvanic  pessaries,  and  irritants 
have  been  advised.  Galvanism  will  probably 
prove  a useful  agent  in  these  cases.  It  should 
be  tried  first  externally,  one  pole  being  applied 
to  the  spine  and  one  over  the  uterus  and  ovaries. 
Should  this  fail,  one  pole  should  be  applied  to 
the  uterus  direct,  and  tho  other  above  the  pubes, 
and  to  the  ovarian  regions.  These  means,  which 
are  not  free  from  danger,  should,  however,  never 
be  tried  where  the  amenorrhoea  is  not  associated 
with  suffering  of  some  kind.  Indeed,  amenor- 
rhoea in  many  instances  requires  no  treatment 
at  all. 

In  cases  of  retention  from  atresia  of  the  genital 
canal,  an  outlet  must  be  made  for  the  flow.  If 
the  hymen  be  imperforate  it  should  be  divided, 
and  the  fluid  allowed  to  run  out.  In  cases  of 
. absence  of  the  vagina,  a canal  has  in  some  in- 
stances been  successfully  mado.  In  atresia  of 
the  os  uteri  the  offending  structure  should  be 
divided  by  the  trochar  or  knife.  These  opera- 
tions aro  accompanied  by  a considerable  amount 
of  danger.  Patients  not  infrequently  die  after 
them  from  peritonitis  or  shock.  It  should  not 
be  forgotten,  however,  that  it  is  imperative  to 
remove  the  menstrual  fluid  retained,  for  unless 
this  be  accomplished  death  is  inevitable. 

II.  Dysmenorrhcen. — Synon.  : Fr.  Dysme- 
norrhee ; Ger.  Dysmenorrhoii. 

In  dj'smenorrhoea,  menstruation  is  accompanied 
by  pain.  In  some  women  the  menstrual  function 
is  performed  without  pain  or  discomfort  of  any 
kind  ; as  a rule,  however,  they  suffer  more  or  less 
from  backache,  headache,  languor,  and  lassitude 
during  the  catamenial  flow.  When  the  dull 
aching  amounts  to  sharp  pain,  the  function  is 
performed  abnormally,  and  the  woman  is  said 
to  suffer  from  dysmenorrhoea. 

^Etiology  and  Symptoms. — -This  symptom 
has  been  referred  to  five  different  conditions, 
upon  one  or  more  of  which  it  is  supposed  to  de- 
pend, and  hence  there  are  five  kinds  of  dysme- 
norrhoea recognised,  namely: — - 

1 . Mechanical  or  obstructive. 

2.  Congestive  or  inflammatory. 

3.  Neuralgic,  sympathetic , or  spasmodic. 

4.  Membranous. 

5.  Ovarian. 

1.  Mechanical  dysmenorrhoea.  — Mechanical 
dysmenorrhoea  is  doubtless  the  most  common 
of  the  above  forms.  Indeed,  it  has  been  said 
that  dysmenorrhoea  cannot  exist  without  ob- 
struction to  the  flow  of  blood  from  the  uterus. 
Opinions,  however,  differ  greatly  with  regard  to 
the  seat  of  obstruction.  It  may  exist  in  the  vagina 
or  in  the  uterus.  Dr.  Robert  Barnes  believes  it 
to  be  usually  situated  at  the  os  tine®,  and  to  be 
frequently  accompanied  by  conical  cervix.  Dr. 
Marion  Sims  thinks  its  most  frequent  seat  is  the 
os  internum  uteri.  Dr.  Graily  Hewitt  refers  the 
obstruction  to  flexion  of  the  uterus  in  the  great 
majority  of  cases.  That  the  outer  orifice  of  the 
uterus  is  occasionally  so  small  as  to  cause  ob- 


MENSES,  DISORD  EES  OF. 


366 

Btruction  to  tho  catamenial  flow  has  been  proved 
beyond  question,  but  there  is  no  evidence  of  the 
great  frequency  of  this  condition.  Still  less  evi- 
dence is  found  of  the  existence  of  obstruction  at 
the  inner  orifico.  Flexions  ot  the  uterus  need 
be  acute  to  present  obstruction  to  the  flow  ; in 
such  cases,  at  the  point  of  flexion  the  canal  of 
the  uterus  is  flattened,  and  its  walls  are  not 
easily  separated.  Retroflexion  is  a more  fre- 
quent cause  of  dysmenorrhcea  than  antiflexion, 
because,  as  a rule,  the  aDgle  of  flexion  is  more 
acute  in  the  former  than  in  the  latter.  It  should, 
however,  be  borne  in  mind  that  a very  fine 
channel,  even  a pinhole  os,  may  suffice  to  permit 
a fatal  haemorrhage,  and  it  is  probable  that  a 
very  narrow  canal  would  prove  capable  of  the 
painless  passage  through  it  of  the  menstrual 
discharge  when  the  latter  is  in  a healthy  state — 
that  is,  when  it  contains  neither  clots  of  blood 
nor  fragments  of  membrane.  There  are  reasons 
for  believing  that  in  the  great  majority  of  cases 
of  painful  menstruation,  tho  cause  of  the  ob- 
struction does  not  lie  in  the  genital  passage,  but 
in  the  menstrual  fluid  itself,  because  the  latter, 
instead  of  being  a homogeneous  mixture  of  blood, 
mucus,  and  the  molecularly  disintegrated  deci- 
dua, contains  small  fragments  of  the  inner  sur- 
face of  the  uterus,  clots,  and  masses  of  viscid 
mucus ; and  that  while  the  orifices  of  the  uterus 
would  easily  permit  the  passage  of  healthy 
menses,  they  do  not  suffice  for  the  painless 
expulsion  of  such  particles  as  have  been  enume- 
rated. 

This  form  of  dysmenorrhcea  is  very  common. 
It  is  frequently  accompanied  by  inflammation  or 
congestion  of  the  body  of  the  uterus,  as  well 
as  by  inflammation  and  abrasion  of  the  lining 
membrane  of  the  cervix.  That  these  complica- 
tions contribute  to  enhance  the  pain  caused  by 
the  obstruction  present  during  menstruation 
cannot  be  doubted.  At  the  same  time  it  should 
be  borne  in  mind  that  the  complications  are 
probably  secondary.  Indeed,  primary  inflamma- 
tion of  the  unimpregnated  uterus  is  of  infinite 
rarity ; it  depends  on  the  obstruction  which  had 
been  at  work  for  years  before  the  inflammation 
set  in. 

The  symptom  of  this  variety  is  pain  of  vary- 
ing intensity;  in  some  cases  it  is  of  a very 
severe  character.  It  begins  in  the  pelvis,  and 
radiates  to  tho  groin,  sacrum,  and  thighs.  It  is 
often  said  to  be  all  round  the  pelvis  or  lower 
part  of  the  trunk.  It  may  come  on  a little 
before,  with,  or  a little  after  the  appearance  of 
the  discharge,  and  may  cease  with  or  soon  after 
the  same;  or  it  may  continue  more  or  less  severe, 
but  always  paroxysmal,  until  the  end  of  the 
flow.  There  is  often  tenderness  of  the  skin  of 
the  hypogastriura  and  groins ; vomiting,  hic- 
cough, headache,  hysteria,  and  even  delirium  may 
be  present.  The  flow  may  be  scanty  or  profuse, 
and  in  the  former  case  it  is  often  followed  by  an 
abundant  yellow  discharge  for  a few  days.  There 
may  be  leucorrhoea  throughout  the  inter-men- 
strual interval,  Micturition  is  often  painful. 

2.  Congestive  or  inflammatory. — This  name  has 
been  given  to  those  cases  of  painful  menstruation 
in  which  the  uterus  is  enlarged,  and  heavier  than 
natural.  It  is  met  with  in  the  married  and  in 
the  single ; but  it  is  probable  that  it  never  occurs 


as  a primary  affection,  but  is  the  result  of  obstruc- 
tion, abortion,  or  labour.  The  symptoms  are 
those  of  mechanical  dysmenorrhcea.  The  state 
of  enlargement  can  be  diagnosed  by  digital  ex- 
amination only. 

3.  Neuralgic. — This  variety  at  one  time  in- 
cluded a very  large  number  of  the  cases  of  painful 
menstruation  which  came  under  notice;  but  since 
more  efficient  means  have  been  employed  for 
learning  the  condition  of  the  uterus,  the  number 
of  cases  referred  to  this  category  has  greatly 
diminished.  At  present  it  is  limited  to  the  cases 
of  young  girls,  in  whom  it  is  not  desirable  to 
make  a vaginal  examination;  and  to  those  cases 
in  which  no  pelvic  lesion  can  be  found  to  account 
for  the  suffering.  It  cannot  be  said  that  neu- 
ralgia of  the  uterus  never  exists ; at  the  same 
time  it  is  of  such  rarity  that  it  should  be  diag- 
nosed with  the  greatest  hesitation. 

The  symptoms  are  similar  to  those  of  the  ob- 
structive variety. 

4.  Membranous. — In  this  form  a membranous 
sac,  having  the  shape  of  the  cavity  of  the  body 
of  the  uterus,  is  expelled  with  the  catamenia. 
The  sac  has  three  orifices,  corresponding  to  the 
orifices  of  tho  Fallopian  tubes,  and  the  inner 
orifice  of  the  neck  of  the  uterus.  It  has  an  inter- 
nal smooth,  punctated,  and  an  external  flocculent 
surface.  Occasionally  during  expulsion  the  sae 
is  turned  inside  out.  It  may  be  passed  with 
every,  or  with  every  other,  menstruation,  or  only 
occasionally.  Instead  of  being  passed  in  the  form 
of  a complete  sac,  the  membrane  may  be  broken 
up,  and  expelled  as  shreds  of  various  sizes.  Micro- 
scopic examination  shows  that  the  membrane 
possesses  a structure  identical  with  the  lining  of 
the  body  of  the  uterus.  It  contains  glands  and 
blood-vessels,  and  is,  in  fact,  the  decidua.  It  has 
been  said  that  it  is  always  the  result  of  concep- 
tion, but  ample  evidence  has  been  published  to 
refute  this  statement.  As  a rule  the  uterus  is 
enlarged ; this,  however,  is  not  always  the  case. 
The  enlargement  is  probably  a condition  secon- 
dary to  the  dysmenorrhtea,  or  to  previous  gesta- 
tion. There  is  commonly  tenderness  of  the  pelvic 
tissues  around  the  uterus,  probably  of  the  peri- 
toneum; ovaritis  is  frequently  present.  All  these 
conditions  are  probably  secondary. 

Displacement  of  the  uterus  is  also  not  an  un- 
common complication — an  anteflexion  or  retro- 
flexion : an  affection  of  another  mucous  mem- 
brane may  also  co-exist. 

The  symptoms  are  usually  very  severe,  the 
pain  being  most  intense,  of  a bearing-down  cha 
racter,  and  often  compared  to  labour-pains.  I 
reaches  its  acme  just  before  the  membrane  i. 
expelled.  If  the  membrane  be  passed  in  frag 
ments,  the  pain  recurs  with  the  passage  of  each 
The  pain  accompanying  the  expulsion  may  hi 
slight,  or  even  absent.  In  the  latter  case  the  uteru 
is  large,  and  the  os  patulous.  The  passage  of  thj 
membrane  takes  place  often  on  the  third  day  c 
menstruation,  but  may  occur  later;  frequentl 
shreds  are  passed  from  the  first  or  second  da 
at  intervals  to  the  end  of  the  flow.  With  tl: 
expulsion  of  the  membrane,  there  is  generally 
gush  of  blood,  after  which  the  flow  proceec 
normally.  The  catamenial  discharge  may  1 
normal  in  amount,  considerably  increased,  < 
even  scanty. 


MENSES,  DISORDERS  OF.  967 


The  pathology  of  this  affection  is  unknown. 
It  has  been  said,  to  be  the  result  of  conception. 
Cases  of  abortion  may  probably  hare  been  mis- 
taken for  this  affection,  but  that  it  occurs  inde- 
pendently of  sexual  connection  is  amply  proved. 
It  has  also  been  said  that  it  is  due  to  inflam- 
mation ; that  the  membrane  expelled  is  an  in- 
flammatory exudation.  The  evidence  in  favour 
of  this  view  is  very  scanty.  Inflammation  or 
congestion  of  the  uterus  is  frequently  met  with 
in  cases  of  membranous  dysmenorrhoea,  but  not 
(always.  Indeed,  cases  of  this  affection  occur  in 
which  no  trace  of  inflammation  of  the  uterus 
could  be  found  either  before  or  after  death.  More 
recently  it  has  been  stated  that  it  is  due  to 
amyloid  degeneration  of  the  lining  membrane 
of  the  uterus.  If  this  be  the  fact  in  some  cases, 
jt  certainly  is  not  in  all.  It  is  more  probably 
due  to  malnutrition,  which  in  some  cases  has 
oxisted  ah  initio.  It  has  been  met  with  also  in 
gouty  and  rheumatic  subjects,  but  what  rela- 
tion it  holds  to  these  diatheses  is  unknown. 

5.  Ovarian. — This  does  not  deserve  the  name 
of  dysmenorrhoea,  for  it  is  not  due  to  menstruation 
—that  is,  to  the  discharge  of  the  sanguineous 
fluid  from  the  uterus — but  to  the  growth  and 
rupture  of  the  Graafian  follicles.  The  Graafian 
'ollicles  develop  gradually,  and  take  a long  time 
o arrive  at  maturity.  It  is  not  a sudden  pro- 
:ess.  It  is,  however,  towards  the  end  of  their 
growth,  as  they  approach  the  time  of  rupture, 
hat  they  become  painful.  They  usually  burst 
ome  time  before  the  appearance  of  the  men- 
trual  flow,  but  this  may  happen  during  the 
atamenia,  or  after  their  cessation.  The  pain 
sually  comes  on  before  the  catamenia,  a few 
ays  or  a week,  an  1 may  cease  with  the  appear- 
nee  of  the  menses,  or  several  days  before  that 
vent.  The  suffering  may,  however,  come  on  at 
ny  time  during  the  flow  or  during  the  interval, 
is  situated  usually  in  the  left  ovarian  region, 
)r  the  left  ovary  is  more  frequently  affected 
lan  the  right.  The  pain  extends  down  the 
lighs,  and  to  the  sacro-iliac  joint  of  the  same 
de.  Not  infrequently  the  corresponding  kidney 
tender.  Pain  may  occur  in  the  left  and  right 
de  at.  alternate  periods,  or  a period  may  pass 
ithout  pain.  Vomiting  and  hysteria  are  often 
■esent.  There  is  superficial  and  deop  tender- 
ss  over  the  painful  part.  Patients  often  say 
at  they  have  a swelling  in  the  side,  and  on 
animation  a diffused  fulness  is  found  in  the 
arian  region,  which  is  tympanitic,  and  due 
idently  to  local  distension  of  the  intestine  by 
s.  Examination  per  vaginam  and  per  rectum 
11  often  detect  a small  tumour,  tender,  mov- 
ie in  the  early  periods,  later  on  fixed,  on  the 
e affected,  and  a little  behind  the  uterus, 
essure  on  the  tumour  calls  forth  severe  pain 
1 a feeling  of  sickness.  Later  on  the  uterus 
:omes  less  movable,  and  drawn  to  the  affected 
■ e.  This  is  doubtless  due  to  contraction  of 
> :ammatory  products,  and  not  to  distension  of 
i broad  ligaments,  for  it  occurs  in  long  stand  - 
i cases  only.  Micturition  is  frequent  and 
] nful. 

fhe  pathological  lesion  is  inflammation  of  the 

< lafian  follicles,  of  the  stroma,  or  surfaces 

< the  ovary,  extending  to  the  neighbouring  tis- 
f s.  This,  again,  is  rarely  primary.  In  women 


who  have  had  children,  it  is  often  due  to  par- 
turition and  abortion.  In  tho  unmarried  it  is 
the  result  of  long-standing  dysmenorrhoea.  In 
the  latter  cases  true  dysmenorrhoea  is  always 
primary,  and  ovaritis  secondary.  It  may,  how- 
ever, be  the  result  of  exposure  to  cold  during 
menstruation. 

Many  diseases  of  the  uterus,  as  fibroid  tumours, 
polypi,  cancer,  &c.,  cause  dysmenorrhoea. 

Treatment. — Dysmenorrhoea  is  often  very 
obstinate  under  treatment,  and  its  course  is  very 
protracted.  In  many  cases  much  may  be  done 
by  attention  to  the  general  health,  and  to  the 
stomach,  liver,  and  bowels. 

During  an  attack  rest  in  bed  should  be  en- 
joined, and  hot  baths,  anodynes — opium,  morphia, 
chloral,  or  chloroform — be  administered  for  the 
relief  of  the  pain.  Saline  aperients,  iron,  arsenic, 
and  bismuth,  are  of  service  during  the  intervals. 
If  there  be  a gouty  or  rheumatic  tendency,  this 
must  bo  treated.  But  recourse  must  be  had  in 
the  great  majority  of  cases  to  local  treatment, 
and  the  plan  adopted  will  depend  much  on  the 
view  taken,  not  of  the  individual  case,  but  of 
dysmenorrhoea  generally.  Should  displacement 
be  found,  it  should  be  corrected.  Frequently, 
however,  when  this  has  been  accomplished,  the 
suffering  continues.  Clots  are  commonly  found 
in  the  discharge,  and  the  cervical  canal  is  not 
capacious  enough  to  permit  their  passage.  In 
these  cases  the  channel  must  be  enlarged.  This 
may  bo  done  in  several  ways : — 

1.  By  graduated  bougies,  similar  to  those  in 
use  for  dilating  stricture  of  the  urethra.  One  or 
more  of  them  are  passed  at  intervals  of  several 
days,  until  the  necessary  dilatation  has  been 
accomplished. 

2.  A dilator,  such  as  Priestley’s  or  Ellinger’s, 
may  be  introduced  into  the  uterus,  and  the  ori- 
fices forcibly  and  suddenly  dilated. 

3.  Tents  of  compressed  sponge,  or  of  lami- 
naria digitate,  may  be  passed  into  the  canal,  and 
allowed  to  remain  there  for  six  or  ten  hours, 
until  it  has  been  well  dilated. 

These  means,  however,  are  unsatisfactory,  for 
the  orifices  regain  their  original  state — the  dila- 
tation is  not  permanent.  To  obviate  this  con- 
traction, recourse  has  been  had  to  incision  of 
tho  supposed  contracted  part.  The  best  method 
is  that  first  proposed  by  Dr.  Marion  Sims,  that 
is,  the  division  of  the  external  orifico  by  scissors, 
and  of  the  internal,  if  necessary,  by  means  of  a 
blunt  pointed  knife.  The  operation  is  performed 
as  follows  : — 

The  patient  is  placed  on  a table  on  the  left 
side,  with  the  knees  drawn  up.  Sims’s  duck-bill 
speculum  is  introduced,  so  as  to  bring  the  cervix 
uteri  to  view.  It  is  then  given  to  an  assistant 
to  maintain  it  in  position.  The  cervix  is  fixed 
by  a sharp  hook,  and  the  lips  of  the  uterus 
divided  laterally  by  scissors.  Sims’s  knife  is 
then  introduced  through  the  inner  orifice,  and 
as  it  is  withdrawn  is  made  to  incise  the  os  in- 
ternum as  well  as  the  angle  of  the  wound  made 
by  the  scissors  near  the  same  orifice;  the 
knife  is  again  introduced,  and  the  opposite  side 
incised  in  a similar  manner.  Marion  Sims  re- 
commends incision  of  the  inner  and  outer 
orifices  ; Dr.  Robert  Barnes  the  outer  orifice  only. 
When  the  cutting  is  completed,  a strip  of  lint, 


m MENSES,  DISORDERS  OF. 
moistened  in  a solution  of  perchloride  of  iron  in 
glycerine,  should  bo  introduced  into  the  wound, 
and  a plug  of  lint  into  the  vagina,  and  the  patient 
put  to  bed.  The  haemorrhage  accompanying  the 
operation  is  usually  slight ; sometimes,  however, 
it  is  profuse,  but  it  can  generally  be  controlled 
by  pressure  made  against  the  cervix  fixed  by 
a sharp  hcok,  by  means  of  sponge  probangs. 
Rest  in  bed  for  one  week  should  be  enjoined. 
The  vaginal  plug  should  be  renewed  every  day 
until  the  third  or  fourth  day,  when  the  intra- 
cervical  dressing  may  be  removed.  The  sound 
should  then  be  introduced  daily,  to  prevent  union 
of  the  edges  of  the  wound,  or  an  intra-uterine 
stem  may  be  worn  with  a similar  object.  Instru- 
ments called  hysterotomes  have  been  invented 
for  incising  the  orifices  of  the  uterus.  They  are 
single  or  doublo-bladed.  The  blade  or  blades 
are  concealed  in  a sheath  during  their  introduc- 
tion into  the  uterus ; when  this  has  been  done, 
the  blade  or  blades  are  made  to  spring  out  and 
incise  the  cervix  as  the  instrument  is  withdrawn. 
The  operation  is  better  performed  by  knife  or 
scissors. 

III.  Menorrhagia,  and  Metrorrhagia.— 
Syjsox. : Vulg.  Flooding;  Fr.  Menorrkagie ; 
Metrorrhagie ; Ger.  Mutterblutfluss. 

The  former  term  is  used  to  denote  profuse 
menstruation ; the  latter,  haemorrhage  from  the 
uterus  at  any  other  time  than  the  catamenial 
epoch.  The  two  symptoms  are  frequently  met 
with.  Menorrhagia  often  exists  alone.  When 
metrorrhagia  is  present  during  menstrual  life, 
the  ci.tamenia  are,  as  a rule,  also  profuse. 
These  haemorrhages  may  be  called  forth  by 
many  lesions.  Indeed,  they  may  accompany  the 
majority  of  the  pathological  conditions  to  which 
the  pelvic  organs  are  liable.  They  may  also 
arise  from  general  states — as  scurvy,  the  haemor- 
rhagic diathesis,  Bright’s  disease,  phthisis,  cir- 
rhosis of  the  liver,  and  the  acute  specific  diseases. . 
The  most  common  cases  are,  however,  met  with 
in  the  form  of  distinct  alterations  of  structure 
in  the  polvic  organs,  as  sub-involution  of  the 
uterus,  polypus,  fibroid  tumour,  cancer,  displace- 
ments, retained  portions  of  placenta,  moles — - 
fleshy  or  vesicular,  fungous  degeneration  of  the 
mucous  membrane  of  the  uterus,  mucous  polypi, 
ulcerations  of  the  cervix,  haematocele,  inversion 
of  the  uterus,  and  congestion  of  the  uterus,  duo 
to  obstruction  to  the  circulation  through  the 
heart  and  lungs  or  liver. 

Profuse  haemorrhages  of  an  irregular  character 
occur  also  in  young  girls  before  the  advent  of  re- 
gular menstruation.  This  form  of  uterine  haemor- 
rhage is  not  common,  hut  it  is  sometimes  of  very 
serious  import,  for  occasionally  it  has  proved 
fatal.  More  frequent  is  the  occurrence  of  irre- 
gular bleeding  from  the  uterus  during  the 
menopause.  The  causes  of  these  climacteric 
hsmorrhages  are  really  not  known.  They  have 
been  said  to  be  due  to  congestion,  but  on  in- 
sufficient evidence. 

Treatment. — The  treatment  of  haemorrhage 
from  the  uterus  resolves  itself  into  the  imme- 
diate treatment  of  the  attack,  and  the  treatment 
of  the  condition  leading  to  it.  The  treatment 
of  the  attack,  or  the  means  of  arresting  the 
bleeding,  consists  in  great  part  in  securing  abso- 
lute rest.  The  patient  should  remain  in  bed  in 


MENSURATION. 

the  recumbent  position,  and  avoid  all  exert, on 
mental  and  physical.  At  the  same  time,  internal 
remedies  which  tend  to  check  haemorrhage  should 
be  given.  Of  these,  those  most  commonly  used 
are  ergot  of  rye,  gallic  acid,  the  mineral'acids, 
and  acetate  of  lead.  Mineral  acids,  in  combi- 
nation with  sulphate  of  magnesia  or  soda,  often 
act  welL  Should  acetate  of  lead  be  adminis- 
tered, the  patient  should  be  carefully  watched, 
as  some  persons  are  very  sensitive  to  the  action 
of  the  drug,  and  manifest  symptoms  of  acute 
lead-poisoning  after  the  administration  of  a 
small  quantity  of  it.  Should  these  means  fail, 
recourse  should  be  had  to  plugging  the  vagina 
or  uterus.  The  vagina  is  plugged  in  the  follow- 
ing manner : — The  patient  is  placed  on  her  left 
side  and  a speculum  is  introduced,  and  the  canal 
is  firmly  packed  with  pledgets  of  cotton-wool  or 
strips  of  lint,  tied  on  a string  for  convenience 
of  removal.  This  will  arrest  the  haemorrhage 
for  a time,  hut  it  can  only  prove  a temporary 
expedient.  The  plug  is  liable  to  become  ex- 
tremely offensive,  from  decomposition  of  blood! 
and  of  the  secretions  in  the  vagina,  and  shonld 
consequently  he  changed  every  eight  or  twelve, 
hours.  A more  efficient  means  of  arresting 
haemorrhage  is  plugging  the  uterus  itself.  This 
is  done  by  means  of  tents  of  sponge  or  laminaria 
and  with  a twofold  object.  The  first  object  i.“ 
the  immediate  arrest  of  the  bleeding;  but  tilt 
chief  object  usually  is  to  dilate  the  canal  o 
the  uterus  so  as  to  permit  its  exploration  by 
the  finger,  and  the  discovery  of  the  cause  of  th> 
bleeding.  This  means  will  not  only  check  tin 
bleeding  temporarily,  but  will  in  many  case 
effect  a permanent  cure.  To  facilitate  the  intro 
duction  of  a tent  a Sims’s  speculum  should  b 
used,  and  the  cervix  of  the  uterus  should  be  fixe’ 
by  a sharp  hook.  In  many  cases,  however,  tent 
will  not  be  necessary.  The  hsmerrhage  wall  b 
controlled  by  the  other  means  enumerated,  c 
the  cause  of  the  haemorrhage  will  be  made  od 
without  the  use  of  tents.  In  all  cases,  howeve: 
in  which  the  haemorrhage  is  uncontrollable,  d 
so  profuse  as  to  threaten  life,  or  in  which  th 
cause  of  the  bleeding  is  obscure,  tents  shou! 
be  had  recourse  to,  both  to  check  the  flow  an 
complete  the  diagnosis.  When  the  cause  h; 
been  discovered,  it  should,  if  possible,  be  n 
moved. 

But  even  after  the  uterine  canal  has  bee 
dilated  no  definite  cause  may  be  found  for  tl 
bleeding.  In  these  cases,  styptics,  or  evf 
caustics,  may  be  applied  to  the  inner  surface 
the  organ.  Those  chiefly  used  are  nitric  aci 
chromic  acid,  carbolic  acid,  a solution  of  iodic 
or  a solution  of  perchloride  of  iron.  The 
are  best  applied  through  a uterine  speculr 
of  platinum  or  vulcanite,  on  a probe 
similar  material.  While  using  these  mea 
it  should  be  borne  in  mind  that  interi 
uterine  medication  is  not  free  from  gra 
danger. 

The  remainder  of  the  treatment  of  mem 
rhagia  consists  in  attention  to  the  gene 
state. 

MENSURATION  ( mensura , a measure) 

A synonym  for  measurement.  See  Measuj 
went  ; and  Physical  Examination. 


MENTAGRA. 

MENTAGRA  ( mentum , the  chin,  and  &ypa , 
in  attack).— A name  for  affections  of  the  chin, 
more  general  than  sycosis,  and  therefore  some- 
times convenient.  See  Skis,  Diseases  of ; and 

Sycosis. 

MEUTAGEOPHYTON  ( mentagra , and 
yirrov,  a plant).— The  fungus-plant  of  mentagra, 
in  reality  a trichophyton,  discovered  by.  Gruby 
in  the  hair-follicles  and  hair  in  sycosis.  See 
Epiphytic  Skin-Diseases;  Sycosis;  and  Tinea. 

MENTAL  DISORDERS.  See  Insanity. 
MENTIGO.  See  Mentagra. 

MENTONE,  on  extreme  east  of  French 
Riviera.— Moderately  warm,  bracing,  sheltered, 
and  dry  -winter  climate.  Mean  temperature  in 
winter,"  48°  Fahr.  Winds:  E.  SE.,  and  NW. 
Soil,  sandstone.  See  Climate,  Treatment  of 
Disease  by. 

MERCURY,  Diseases  arising  from. — 
Synon.  : Fr.  Hydrargyrie ; Intoxication  mercu- 
rielle;  Ger.  Quecksilbervergiftung . 

Though  considerable  discrepancies  of  opinion 
have  existed  as  to  the  poisonous  or  innocent 
properties  of  the  metal  mercury  itself  when 
■swallowed,  there  can  be  no  doubt  as  to  the 
poisonous  character  of  its  soluble  and  volatile 
compounds,  nor  even  as  to  the  insidious  nature 
of  the  vapours  of  metallic  mercury.  Metallic 
mercury  has  occasionally  been  administered  in 
enormous  quantities  without  producing  any  de- 
cided physiological  effects ; whilst  in  other  in- 
duces, salivation  and  other  specific  effects 
lave  resulted.  These  differences  are  doubtless 
lue  to  the  fact,  that  in  those  cases  where  effects 
fare  resulted  from  the  administration,  oxidation 
nd  solution  of  a portion  of  the  metal  had  taken 
dace. 

Mercurial  poisoning  may  be  either  (A)  acute, 
r (B)  chronic  ; the  former  resulting  from  the 
dministration  of  one  or  several  large  doses  at 
hort  intervals,  the  latter  form  of  mereurialism 
rising  from  the  repeated  exhibition  of  small 
oses  of  the  less  active  preparations  of  the 
letal.  There  is  also  a peculiar  form  of  mer- 
irialism,  which  is  the  effect  of  the  inhalation 
: the  vapours,  either  of  the  metal  or  of  its 
ilatile  compounds,  and  is  characterised  by 
iralysis. 

A.  Acute  mercurial  poisoning. — Descrip- 
on. — The  effects  produced  by  a considerable 
'se,  say  a drachm,  of  one  of  the  more  soluble 
mpounds  of  mercury,  such  as  corrosive  sub- 
aate,  or  the  nitrate,  are  those  of  a corro- 
"e  and  irritant  poison.  The  effects  are  im- 
idiate.  In  the  act  of  swallowing  an  intense 
rning  sensation  is  experienced  in  the  mouth 
I throat,  followed  by  excruciating  piain  in 
')  stomach,  and  extending  to  the  abdomen, 
ie  local  effects  of  the  poison  are  frequently 
;ible,  as  a whitening  of  the  tongue  and 
j.ces.  There  is  vomiting,  tenesmus,  and  pur- 
i g,  often  of  a bloody  character.  Colic  and 
I at  tenderness  and  swelling  of  the  abdomen, 
i also  symptomatic.  Not  unfrequently  there 
■ oppression  of  the  urine.  The  gustatory  sen- 
tion  is  perverted;  there  is  dryness  of  the 
' nth ; and  a brassy  or  metallic  taste  is  generally 


MERCURY,  DISEASES  FROM.  960 
experienced  after  the  first  local  corrosive  action 
of  the  poison  has  somewhat  abated.  The  coun- 
tenance is  anxious ; the  skin  is  pale,  cold,  and 
clammy ; and  the  pulse  is  small,  weak,  and 
rapid.  Salivation  may  supervene,  accompanied 
by  foetor  of  the  breath.  Should  recovery  not 
take  place,  death  may  occur  within  a few  hours, 
or  may  be  delayed  for  one  or  more  days  ; or  the 
patient  may  more  rarely  succumb  to  some  of  tho 
ordinary  sequelfe  of  corrosive  poisoning.  When 
death  supervenes  speedily  after  the  administra  - 
tion  of  the  poison,  the  fatal  result  is  usually 
due  to  collapse. 

Most  of  the  effects  of  acute  mercurial  poison- 
ing may  result  from  the  application  of  a concen- 
trated solution  of  corrosive  sublimate  to  the  un- 
broken skin. 

Anatomical  Charactf.rs. — The  -post-mortem 
appearances  seen  after  acute  mercurial  poison- 
ing are  inflammation,  and  even  erosion  of  the 
mucous  membrane  of  the  stomach,  and  extrava- 
sation of  blood  beneath  this  membrane.  Ulcera- 
tion is  rare.  The  intestinal  tract  also  exhibits 
signs  of  extensive  inflammation,  and  this  has 
been  noticed  especially  in  the  large  intestine. 
The  rectum  is  usually  much  inflamed,  and  its 
surface  covered  with  shreds  of  bloody  mucus.  A 
peculiar  slaty  appearance  of  the  mucous  mem- 
brane of  the  stomach  and  intestines,  where  not 
highly  inflamed,  has  been  thought  to  be  charac- 
teristic of  corrosive  sublimate  poisoning. 

Diagnosis.— Though  the  symptoms  of  poison- 
ing by  corrosive  sublimate,  and  other  corrosive 
preparations  of  mercury,  greatly  resemble  thos6 
produced  by  arsepic,  the  diagnosis  is  generally 
not  difficult.  The  effects  following  almost  imme- 
diately on  administration,  the  metallic  taste  in 
the  mouth,  and  the  greater  frequency  of  bloody 
stools  in  mercurial  poisoning,  serve  to  differen- 
tiate between  the  poisons.  Where  doubt  exists, 
an  analysis  of  the  secretions  may  be  made ; 
arsenic  is  most  readily  detected  in  the  urine,  and 
mercury  in  the  saliva.  The  existence  of  saliva- 
tion and  feetor  of  the  breath — though  not  always 
present — may  also  be  valuable  aids  in  completing 
the  diagnosis. 

Treatment. — In  acute  poisoning  by  corrosive 
sublimate,  the  best  antidote  is  albumen,  or  the 
albuminoids  in  any  soluble  form.  The  white  of 
one  or  more  eggs  should  be  beaten  up  with  water, 
and  swallowed  as  quickly  as  possible.  Failing 
an  egg,  flour  made  into  a thin  paste  may  be  ad- 
ministered. Albumen  combines  directly  with  cor- 
rosive sublimate  to  form  an  insoluble  compound. 
On  account  of  the  powerful  local  action  of  the 
poison  on  the  stomach,  the  use  of  the  stomach- 
pump  is  not  advisable  ; but  if  the  vomiting  be 
not  free,  emetics  of  as  simple  character  as  pos- 
sible may  be  administered.  The  rest  of  the 
treatment  consists  in  alleviating  pain  by  means 
of  opiates,  and  the  general  treatment  applicable 
for  irritant  poisons.  Thirst  must  be  alleviated 
by  demulcent  drinks.  For  this  purpose  milk, 
mixed  with  once  or  twice  its  bulk  of  lime-water, 
is  excellent ; the  casein  of  the  milk  and  the  lims 
both  tending  to  render  the  mercury  insoluble, 
and  so  to  act  as  antidotes. 

B.  Chronic  mercurial  poisoning.  Synon.  : 
Mereurialism. 

Description. — The  repeated  ingestion  of  small 


970  MERCURY,  DISEASES  FROM, 
doses  of  the  more  soluble  and  active  prepara- 
tions of  mercury,  such  as  the  bichloride  and  the 
bicyanide,  may  give  rise  to  chronic  symptoms ; 
but  these  more  frequently  result  from  the  ad- 
ministration of  one  or  more  doses  of  the  more 
insoluble  preparations  of  the  metal,  such  as 
calomel  or  the  oxides.  When  chronic  symptoms 
follow  the  administration  of  one  dose  of  a mer- 
curial preparation,  this  is  not  altogether  due 
to  the  peculiar  idiosyncrasy  of  the  patient,  but 
is  attributable  in  no  small  degree  to  the  slow- 
ness with  which  mercury  is  eliminated  from  the 
system.  There  appears  also  to  be  a remarkable 
difference,  not  altogether  dependent  upon  their 
differing  solubilities,  between  mercuric  or  per- 
salts,  and  mercurous  or  proto-salts,  in  respect  to 
their  toxic  properties.  Mercuric  compounds  are 
greatly  more  potent  than  mercurous  salts.  By 
far  the  most  common  result  of  the  continued  ad- 
ministration of  mercury  compounds  is  salivation. 
This  consists  in  a profuse  discharge  from  the 
salivary  glands  ; swelling  and  tenderness  of  the 
gums ; and  foetor  of  the  breath.  In  children, 
and  more  rarely  in  adults,  salivation  may  pass 
into  sloughing  and  gangrene  of  the  cheeks ; and 
a fatal  result  may  ensue.  Other  symptoms  are 
nausea,  colicky  pains,  depression,  and  those  ner- 
vous symptoms  to  which  the  term  ‘ mercurial 
palsy  ’ has  been  applied  ; but  this  last  group  of 
symptoms,  which  is  most  commonly  met  with 
after  inhalation  of  the  vapours  of  mercury,  must 
be  described  more  in  detail. 

Mercurial  Paralysis. — Workers  in  mercury, 
such  as  water-gilders,  looking-glass  makers,  and 
the  makers  of  barometers  'and  thermometers, 
are  apt  to  suffer  from  a peculiar  form  of  shaking 
palsy,  kr.own  either  as  ‘ the  trembles,’  mercurial 
tremors  or  metallic  tremors,  and  tremblemcnt 
metallique  by  the  French.  This  disease  affects 
those  who  handle  the  oxides  of  the  metal,  but 
more  frequently  those  who  aro  exposed  to  mercu- 
rial fumes.  Mercury  exhibits  a small  vapour- 
tension,  and  consequently  is  vapourisable  at  all 
ordinary  temperatures,  but  the  tension  of  it3 
vapour  below  60°  Fahr.  is  very  small.  The 
metallic  tremors  may  come  on  suddenly  or  gra- 
dually, and  they  may  be  unaccompanied  with 
salivation.  The  upper  Embs  are  first  affected, 
and  then  by  degrees  the  whole  muscular  system. 
The  patient  is  affected  with  tremors  when  an 
endeavour  is  made  to  exert  the  muscles,  so  that 
he  is  unable  to  guide,  for  instance,  a glass  of 
water  steadily  to  the  lips  ; he  cannot  put  his  feet 
steadily  to  the  ground ; and  when  he  tries  to 
walk  he  breaks  into  a dancing  trot.  The  muscles 
of  mastication  and  deglutition  are  affected  in 
advanced  cases.  Delirium,  mania,  and  idiocy 
have  occasionally  followed  the  continued  inhala- 
tion of  mercury  fumes. 

Diagnosis. — The  diagnosis  of  mercurial  tre- 
mors is  usually  not  difficult.  It  must  be  ad- 
mitted, however,  that  in  some  cases  the  tremors 
produced  by  mercury  are  in  no  way  distinguish- 
able from  those  due  to  the  now  well-recognised 
disease  known  as  disseminated,  multiple,  or  in- 
sular sclerosis.  The  former  are  less  readily 
confounded  with  ordinary  shaking  palsy  (para- 
lysis agitans)  and  the  convulsive  movements  of 
chorea.  The  history  of  exposure  to  mercury 
will  seldom  be  absent.  In  paralysis  agitans  the 


MESENTERIC  GLANDS, 
tremors  occur  when  the  patient  is  at  rest ; and 
the  peculiar  forward  gait,  as  if  the  patient 
were  endeavouring  to  pass  from  a walking  to 
a running  pace,  is  characteristic.  The  metallic 
tremors  come  on  only  when  the  muscles  are 
exerted,  and  usually  they  entirely  cease  when 
the  patient  is  lying  at  rest,  or  is  asleep.  The 
same  may  be  said  of  the  tremors  of  disseminated 
sclerosis ; but  here  we  have  the  peculiar  con- 
sensual rotation  of  the  eyes  known  as  nystag- 
mus. In  paralysis  agitans,  when  told  to  raioo 
the  affected  hand,  or  to  protrude  the  tongue, 
the  patient  performs  both  actions  steadily.  In 
mercurial  tremors,  and  in  disseminated  sclerosis, 
the  case  is  different — the  tongue  when  volun- 
tarily protruded  is  tremulous,  and  the  patient 
cannot  raise  his  hand  when  requested  to  do  60, 
without  shaking.  In  both  mercurial  tremors  and 
the  tremors  of  insular  sclerosis,  the  muscular 
agitation  ceases  for  the  most  part  during  sleep. 
In  one  form  of  metallic  tremors  the  movements 
approach  in  character  the  convulsive  movements 
of  chorea. 

Tbeatment. — In  chronic  mercurial  poisonine. 
it  is  obvious  that  the  patient  must  at  once  be 
removed  from  the  further  influence  of  the  metal. 
Masks  worn  over  the  mouth  aro  not  of  much  use. 
In  mercurial  tremors  cessation  from  working 
with  the  metal,  and  mild  tonics  of  iron,  usually 
suffice  for  the  speedy  restoration  to  health;  but 
the  shaking  occasionally  persists  throughout 
life.  For  salivation  and  the  more  formidable 
gangrene  of  the  mouth,  besides  cessation  of  the 
administration  of  the  metal,  and  the  exhibition 
of  tonics,  iodide  of  potassium  may  be  given. 
Astringent  gargles  and  active  local  treatment 
may  perhaps  be  necessary. 

Thomas  Stevenson, 

MESENTERIC  GLANDS,  Diseases  of. 

Of  the  lacteal  glands,  which  lie  in  the  folds  of 
the  peritoneum  connected  with  the  intestines, 
the  mesenteric — which  are  connected  with  the 
small  intestines — may  be  ranked  as  the  most 
important,  and  what  is  described  with  regard 
to  these  will  apply  to  the  rest  of  the  lacteal 
glands.  They  are  all  really  of  the  same  nature  as 
the  lymphatic  glands,  and  are  subject  to  similar 
diseases.  The  statements  made,  therefore,  with 
reference  to  these  structures,  will  also  apply  in 
the  main  to  the  lacteal  glands  (see  Lymphatic 
System,  Diseases  of) ; but  the  latter  are  likewise 
liable  to  certain  special  morbid  changes,  whilst 
these  changes  present  some  peculiarities  as  re- 
gards their  effects  and  symptoms.  Thus,  when  the 
lacteal  glands  are  diseased,  the  general  nutritior 
tends  to  bo  markedly  impaired,  owing  to  the  in- 
terference with  the  transmission  and  due  elabo 
ration  of  the  chyle,  and  if  they  are  extensive! 
involved  the  entire  system  suffers  gravely 
Owing  to  their  situation  and  anatomical  rela 
dons,  these  glands,  in  certain  forms  of  diseasf 
may  originate  secondary  effects  of  consider 
able  importance.  For  instance,  peritonitis  ma 
be  excited  by  their  irritation  or  rupture;  c 
by  their  pressure  on  vessels  or  other  structure1 
ascites  and  other  conditions  more  or  less  senou 
may  result.  The  enlarged  mesenteric  glands  ma 
be  felt,  in  certain  diseases,  through  the  abdomim 
walls.  With  these  preliminary  remarks,  the  pa 


MESENTElttC  GLANDS,  DISEASES  OF. 


icular  diseases  of  the  mesenteric  glands  will  now 
ie  considered,  so  far  as  they  may  require  special 
omment. 

1.  Acute  Congestion  and  Inflammation, 
'he  lacteal  glands  are  very  liable  to  become 
lore  or  less  congested  or  inflamed  in  connection 
nth  any  inflammatory  condition  affecting  the 
ntestinal  canal.  The  situation  and  number  of 
lands  implicated  will  correspond  mainly  with 
he  portion  of  bowel  involved.  They  become 
nlarged,  but  the  changes  are  seldom  such  as 

0 give  rise  to  any  evident  symptoms,  and  they 
ubside  as  the  cause  of  the  irritation  ceases  to 
perate.  In  rare  instances  the  inflammatory 
rocess  may  go  on  to  suppuration,  and  then  there 

1 great  danger  of  serious  consequences ; in  one 
ase  which  came  under  the  writer's  notice,  fatal 
eritonitis  appeared  to  have  been  set  up  by  the 
rotation  of  a suppurating  mesenteric  gland. 

Attention  may  be  directed  here  to  the  changes 
hich  o;cur  in  the  lacteal  glands  in  certain 
pecial  acute  diseases,  namely,  typhoid  fever  and 
ysentery.  In  typhoid  fever  the  mesenteric 
iands  are  usually  involved,  corresponding  with 
le  part  of  the  small  bowel  affected  in  this  dis- 
use; but  if  the  colon  is  implicated  themesocolic 
lands  also  suffer.  The  changes  in  the  glands 
innot  be  looked  upon  as  merely  secondary 
i>  intestinal  irritation,  for  they  commence  from 
ie  outset,  and  go  on  simultaneously  with  the 
rogress  of  the  intestinal  lesions.  The  glands 
ecome  enlarged,  from  a hyperplasia  of  their  lym- 
hatic  elements,  and  this  enlargement  increases 
util  from  about  the  tenth  to  the  fourteenth 
ly  of  the  disease.  They  are  of  a red  or  purplish 
ilour,  and  moderately  firm.  On  section  small, 
jaque,  pale-yellow,  friable  collections  are  some- 
mes  seen.  As  a rule  the  glands  subsequently 
icome  gradually  softer,  and  diminish  in  size, 
suming  in  favourable  cases  their  normal  con- 
tion;  not  uncommonly,  however,  they  become 
ore  or  less  shrivelled  and  contracted,  tough  and 
le,  or  of  a grey  or  bluish  colour,  and  they  may 
en  calcify.  In  exceptional  instances  the  glands 
pidly  soften  in  their  interior,  a purulent  fluid 
iug  formed,  mingled  with  sloughs  ; and  very 
cely  they  have  ruptured  into  the  peritoneum, 
us  setting  up  fatal  peritonitis.  It  cannot  be 
monstrated  how  far  the  implication  of  the 
sorbent  glands  accounts  for  the  symptoms  of 
phoid  fever,  but  it  is  highly  probable  that  they 
ye  more  or  less  influence  over  them. 

Dysentery  is  another  special  disease  in  which 
'■ \ lacteal  glands  are  involved,  but  the  changes 
i ’e  seem  to  be  merely  the  effects  of  irritation 
1 m the  intestinal  lesion.  The  mesocolic  glands 
; mainly  affected,  but  if  the  disease  implicates 
t small  intestines,  the  mesenteric  also  suffer. 

1 ;y  become  enlarged,  red,  and  softened;  and  if 
t dysentery  assumes  a chronic  form,  the  glands 
6 also  permanently  changed. 

. Scrofulous  or  Tubercular  Disease. — 

- ies  mcsenterica. — The  nature  of  this  affection 
1 been  already  discussed  in  relation  to  the 
s orbent  glands  generally  (see  Lymphatic 
1 tem,  Diseases  of),  and  it  will  suffice  to  indi- 
c i here  the  special  points  which  require  to  be 
r ced  in  connection  with  the  lacteal  glands. 

£ )fulous  or  tuberculous  disease  of  the  me- 
* glands  constitutes  a most  important 


971 

disease  in  children  and  your.g  persons.  It  may 
exist  independently,  but  is  usually  associated 
with  so-called  tubercular  ulceration  of  the  in- 
testines, to  which  it  is  then  probably  secondary. 
It  is  not  improbable  that  the  mesenteric  disease 
may  be  primarily  set  up  as  the  result  of  mere 
long-continued  chronic  intestinal  catarrh.  The 
patient  may  be  evidently  scrofulous  or  tuber- 
cular, but  this  is  by  no  means  constant,  and  there 
may'  be  no  signs  whatever  of  any  such  diathesie. 
The  disease  may  also  be  accompanied  with  pul- 
monary phthisis,  although  this  is  comparatively 
rare  in  children,  and  the  lung-affection  is  almost 
always  secondary.  In  adults,  on  the  other  hand, 
tuberculous  disease  of  the  lacteal  glands,  when 
it  does  occur,  is  in  tho  large  majority  of  cases  a 
complication  of  pulmonary  phthisis,  intestinal 
ulceration  being  present  at  the  same  time. 

The  changes  in  the  glands  are  similar  to  those 
characteristic  of  the  scrofulous  process  in  the 
lymphatic  glands,  namely,  a hyperplasia  of 
the  cellular  structures,  of  low  vitality,  followed 
by  caseation,  and  ultimately  by  calcification,  if 
tho  case  last  sufficiently  long ; and  it  is  usual  in 
fatal  cases  to  find  these  conditions  more  or  less 
combined  in  different  glands.  Should  recovery 
take  place,  all  the  involved  glands  may  be  con- 
verted into  inert,  chalky  masses,  in  which  con- 
dition they  remain  permanently.  A case  came 
under  the  writer's  notice  some  years  ago,  in  which 
the  patient  having  died  from  an  independent 
acute  illness,  the  mesenteric  glands  were  found  to 
be  universally  calcified,  this  being  associated  with 
scarring  of  the  external  glands,  and  other  signs 
of  past  scrofulous  disease,  from  which  the  patient 
had  quite  recovered ; the  condition  of  the  glandg 
was  unattended  with  any  symptoms  whatever. 
The  individual  glands  in  mesenteric  disease  may 
attain  a considerable  size,  and  when  they  aro 
agglomerated  a distinct  tumour  is  formed. 

Symptoms.  — It  is  frequently  impossible  to 
recognise  definitely  the  symptoms,  either  local 
or  general,  due  to  scrofulous  disease  of  the 
mesenteric  glands,  as  they  are  combined  with, 
and  masked  by  those  resulting  from  intestinal 
ulceration  and  catarrh,  or  from  the  implication  of 
other  structures.  The  digestive  organs  are  usu- 
ally disordered,  and,  even  if  there  should  Dot  be 
intestinal  ulceration,  children  who  suffer  from 
mesenteric  disease  are  very  liable  to  enteric 
catarrh.  Hence  diarrhoea,  with  unhealthy  stools, 
is  a common  symptom,  and  it  is  often  difficult  to 
check,  or  it  returns  from  very  slight  causes.  In 
other  cases  the  bowels  are  constipated.  Scrofu- 
lous mesenteric  glands  do  not  seem  to  be  painful 
in  themselves, but  colicky  pains  in  connection  with 
the  bowels  are  of  frequent  occurrence,  and  the 
diseases  of  the  glands  may  have  some  influence  in 
exciting  these.  The  abdomen  is  almost  always  dis- 
tended and  prominent,  owing  to  the  accumulation 
of  flatus,  and  it  may  be  distinctly  tympanitic. 
Hence,  even  when  the  glands  are  much  enlarged, 
it  is  often  impossible  to  feel  them,  but  they  may 
sometimes  be  made  out  by  deep  pressure  with 
the  fingers  over  the  abdomen.  In  some  instances 
the  abdomen  is  retracted,  and  then  the  glands 
may  be  more  readily  felt.  They  may  produce 
symptoms  by  their  mechanical  effects,  and  the 
writer  has  met  with  a case  in  which  extreme 
ascites  was  probably  due  to  tubercular  mesenteric 


972  MESENTERIC  GLANDS, 
lisease.  By  irritation  of  the  peritoneum,  or,  in 
rery  rare  instances,  fcy  the  glands  bursting  into 
its  cavity,  peritonitis  may  be  set  up.  The  general 
symptoms  are  usually  very  prominent,  as  evi- 
aenced  by  wasting,  which  may  reach  extreme 
emaciation,  anaemia, debility,  and  pyrexia,  marked 
heetic  fever  ultimately  supervening  in  some 
cases.  How  far,  however,  the  mesenteric  lesion 
originates  these  symptoms  is  a matter  of  doubt 
and  dispute,  but  it  is  highly  probable  that 
it  is  in  some  measure  accountable  for  them. 
Oases  in  which  mesenteric  glands  are  tho.  seat 
of  scrofulous  disease  differ  much  in  their  seve- 
rity, and  it  may  be  quite  impossible  to  make 
any  positive  diagnosis.  A large  number  of  cases 
prove  fatal,  but  it  mustbe  remembered  that  even 
after  severe  symptoms  recovery  may  take  place, 
the  glands  becoming  calcareous  and  harmless. 
When  the  glandular  affection  is  secondary  to 
pulmonary  phthisis,  it  helps  to  hasten  the  fatal 
termination. 

Treatment. — This  mainly  consists  in  the 
treatment  required  for  scrofulous  disease  in  gene- 
ral, such  as  the  administration  of  cod-liver  oil, 
preparations  of  iron,  quinine,  and  other  tonics ; 
favourable  hygienic  conditions  and  surroundings ; 
change  of  air,  especially  to  tho  country  or  to 
the  sea-side  ; and  other  appropriate  measures. 
The  diet  needs  particularly  careful  attention. 
It  should  be  nutritious  and  digestible,  but  has 
often  to  be  modified  so  as  to  render  it  suitable 
for  the  condition  of  the  alimentary  canal.  Re- 
medies directed  to  the  improvement  of  the  state 
of  this  canal,  or  to  the  relief  of  symptoms  con- 
nected with  it,  are  also  often  required.  No 
local  application  can  possibly  have  any  effect 
upon  scrofulous  mesenteric  glands ; but  symp- 
toms might  be  benefited  by  friction  with  some 
liniment,  the  application  of  a flannel  bandage, 
or  the  use  of  dry  heat,  fomentations,  or  poul- 
tices in  connection  with  the  abdomen,  should 
occasion  call  for  them.  Any  secondary  morbid 
conditions  which  may  arise  must  be  attended 
to.  In  the  case  already  alluded  to,  paracentesis 
was  urgently  demanded,  on  account  of  extreme 
ascites ; the  fluid  re-accumulated  almost  to  the 
same  amount,  but  it  afterwards  gradually  dis- 
appeared entirely  by  absorption,  and  the  patient 
recovered. 

3.  Hypertrophy. — It  will  merely  be  needful 
to  remark  under  this  head  that  the  lacteal  glands 
are  liable  to  be  more  or  less  hypertrophied  in 
cases  of  lymphadenoma,  and  in  the  form  of  len- 
cocythsemia  attended  with  glandular  enlargement. 
The  writer  has  met  with  instances  where  the 
growth  was  very  considerable.  They  might  pos- 
sibly be  detected  during  life  by  physical  exami- 
nation, or  they  might  cause  symptoms  by  their 
mechanical  effects  ; but,  as  a rule,  their  existence 
is  only  ascertained  at  the  post-mortevi  examina- 
tion. 

4.  Atrophy  and  Degeneration. — The  me- 
senteric glands  atrophy  in  old  age,  and  they  may 
also  become  wasted  and  withered  after  previous 
disease,  such  as  typhoid  fever.  The  caseous  and 
calcareous  changes  which  they  undergo  in  con- 
nection with  scrofulous  disease  have  been  already 
indicated.  It  may  happen  that  atrophic  or  de- 
generative changes  in  these  glands  affect  the 
general  condition  ; but  it  is  certain  that  they 


MESMERISM. 

may  be  extensively  calcified,  and  yet  the  patient 
remain  apparently  in  excellent  health. 

o.  Morbid  Formations. — The  mesenteric 
glands  may  be  the  seat  of  albuminoid  disease. 
It  is  said  that  they  can  then  be  felt  through  the 
abdominal  walls,  firm,  distinct,  and  easily  mov- 
able ; but  thi3  is  by  no  means  always  the  case. 
Cancer  is  chiefly  met  with  as  a secondary  de- 
posit, the  lacteal  glands  being  particularly  liable 
to  become  affected  if  the  intestine  is  the  seat  of 
malignant  disease,  and  the  localisation  being  de- 
termined by  that  of  the  intestinal  lesion.  It  may, 
occur,  however,  as  a primary  affection.  The  cancer 
is  usually  of  the  softer  variety,  but  it  will  de- 
pend to  some  extent  on  the  nature  of  any  primary 
deposit.  A considerable  tumour  may  be  formed, 
firm  and  nodulated ; or  the  glands  may  remain 
separate.  Physical  examination  often  revealsthe 
presence  of  the  disease ; and  this,  together  with 
localised  pain,  and  symptoms  due  to  pressure,! 
should  any  such  be  present,  as  well  as  signs  of 
the  cancerous  cachexia,  or  of  the  implication  oil 
other  organs,  especially  the  intestines,  constitute] 
the  clinical  phenomena  associated  with  malignant 
disease  of  the  lacteal  glands.  No  treatment  can 
be  of  any  service.  Frederick  T.  Roberts. 

MESENTERY,  Diseases  of.  See  Perito- 
neum, Diseases  of. 

MESMERISM  — Definition. — The  name  oi 
the  process  by  which,  rather  more  than  a century 
ago,  Anthony  Mesmer,  the  deluded  (or  at  all 
events  the  deluding)  promulgator  of  the  doctrine 
of  ‘animal  magnetism,’  induced  the  so-called 
mesmeric  trance  or  sleep.  See  Magnetism 
Animal. 

This  mesmeric  trance  is  identical  with  the 
condition  now  known  as  ‘ induced  somr.am 
bulistn,’  or  still  more  commonly  as  ‘ hypnotism 
or  the  ‘ hypnotic  state.’  The  condition  itsel 
is  one  which  presents  to  the  observer  many 
highly  interesting  phenomena,  and  it,  togethc; 
with  the  means  of  inducing  it,  were  first  investi 
gated  in  a full  and  scientific  manner  by  Jam*- 
Braid  of  Manchester  (1843). 

In  this  place  it  is  not  intended  to  speak  o 
the  subject  from  its  old  point  of  view.  Tin 
reader  who  desires  to  gain  some  notion  of  tht 
errors,  deceptions,  and  vain  pretensions  witl 
which  tho  whole  subject  was  enveloped  by  thos, 
who  have  been  content  to  style  themselvc] 
‘ mesmerists,’  may  with  advantage  consult  th 
article  on  ‘ Mesmensme,’  by  Deschambre  (Die' 
Ency.  dcs  Sc.  Med.,  tome  vii.),  at  the  close  o 
which  they  will  also  find  a valuable  bibliography 
Here  the  proceedings  of  Mesmer  and  his  fol 
lowers  in  France  are  fully  exposed. 

As  a sort  of  transition  between  this  old  statj 
of  things,  with  its  erroneous  theory  and  vai 
pretensions,  and  the  scientific  standpoint  take, 
by  Braid  in  regard  to  the  more  correct  linn 
tation  of  the  phenomena  observable  and  thei 
altogether  intrinsic  mode  of  production,  cam 
the  observations  of  Elliotson  in  London,  as  con 
ducted  in  the  years  1837-3S,  when  he  sought  t 
inform  himself  and  others  as  to  the  phenomen 
and  curative  virtues  of  mesmerism.  He  er 
countered  a storm  of  opposition,  principally  o 
account  of  his  mode  of  dealing  with  the  subjee 
He  was  unquestionably  honest  and  enthusiast! 


I 


MESMERISM. 

to  Iij3  search  for  what  he  believe'd  to  be  truth  ; 
,'but,  he  unfortunately  did  not,  as  Braid  by  his 
keener  insight  was  enabled  to  do,  reject  and 
otherwise  explain  the  so-called  phenomena  of 
clairvoyance,  of  transposition  of  the  senses,  and 
ot  prediction  or  prophecy.  It  is  to  be  regretted, 
however,  that  Braid  did  not  also  reject  all  the 
so-called  phenomena  of  phreno-hypnotism. 

An  independent  practical  study  of  the  subject 
jnd  of  its  therapeutic  applications  was  shortly 
after  the  date  of  Braid's  labours  commenced  by 
Esdaile  in  India  (1846),  as  well  as  by  J.  K. 
Mitchell  in  the  United  States.  They  have  more 
recently  been  succeeded  by  other  investigators, 
Lmongst  whom  may  be  mentioned  Girard  Teulon 
md  Demarquay  (1860);  Ch.  Richet  (1875); 
Charcot  (1878);  and  also  Weinhold,  Beard,  Pre- 
fer, Berger,  Griitzner,  and  Heidenhain  (1880). 

The  induction  of  the  hypnotic  state  or  sleep 
las  hitherto  been  possible  in  only  a certain,  but 
Variable  percentage  of  the  persons  with  whom 
rial  has  been  made,  though  a successful  result 
ias  been  much  more  frequent  with  women  than 
with  men.  According  to  Richet,  however,  the 
Operator  should  not  be  discouraged  by  the  failure 
>f  his  first  attempts  with  the  same  person ; as 
iersons  may  succumb  on  the  fourth  or  fifth 
rial,  and  subsequently  prove  thoroughly  good 
ubjects  for  experimentation.  Persons  who  have 
nee  been  hypnotised  can  in  general  be  again 
rought  with  comparative  ease  into  the  same 
ondition,  and  the  facility  of  hypnotising  such 
-ersons  goes  on  increasing  after  each  operation, 
wing  to  the  existence  of  a predisposing  mental 
Vate.  A condition  of  excited  expectancy  is  in- 
feed  a decidedly  favouring  mental  state,  though 
ne  which  is  not  essential,  since,  according  to 
'■raid,  Heidenhain,  and  others,  even  male  adults 
ho  have  heard  nothing  on  the  subject,  and  do 
jpt  know  for  what  purpose  they  are  being  ex- 
irimented  with,  can  often  be  hypnotised. 

In  persons  who  are  favourably  disposed  for 
issing  into  the  hypnotic  state,  the  condition  is 
sily  induced  by  weak,  long-continued,  and  uni- 
rm  stimulation,  either  of  the  nerves  of  sight, 
touch,  or  of  hearing.  This  state  is,  on  the 
utrary,  almost  always  easily  capable  of  being 
ruptly  terminated  by  some  strong  or  suddenly 
rying  stimulation  of  the  same  nerves. 

Many  of  the  lower  animals,  such  as  frogs  and 
.vis,  cau  be  thrown  into  an  extremely  similar 
iidition  as  a result  of  certain  sudden  and 
werful  sensorial  impressions.  Preyer  distin- 
ishes  the  state  into  which  they  are  thrown  by 
different  name,  namely,  ‘ cataplexy,’  because 
’ i mode,  or  physiological  process,  by  which  it 
induced,  seems  to  be  different  from  that  by 
’ ich  hypnotism  is  caused. 

Che  hypnotic  state  or  sleep  is  one  which 
Vies  much  in  intensity  in  different  persons, 
tin  the  same  person  at  different  times.  The 
ficipal  phenomena  that  are  exhibited  or 
t ;ch  can  be  detected  in  hypnotized  persons  are 
I.  following: — (1)  Imitation  movements;  (2) 
1 iltations  of  special  sense ; (3)  Illusions  and 
lilucinations ; (4)  Analgesia,  general  or  uni- 
1 ral,  or  even  a condition  of  hemianaesthesia, 
geral  and  special;  (5)  Increased  reflex  irrita- 
t l.y  and  tonic  spasms  of  the  voluntary  muscles ; 
ftj  (6)  Other  miscellaneous  phenomena,  such 


MESOLOGY.  973 

as  spasm  of  the  accommodation  apparatus  in  the 
eye,  dilatation  of  the  pupils,  increased  rapidity 
of  respiration  and  of  the  pulse,  together  with 
profuse  perspiration. 

A discussion  of  the  mode  of  production  of 
these  several  phenomena,  or  of  the  nature  of  the 
hypnotic  condition  itself,  would  lead  us  info 
details  too  purely  physiological  for  our  present 
purpose — suffice  it  to  say  that  the  hypnotic 
state,  in  one  or  other  of  its  stages,  seems  to  be 
akin  to  that  met  with  in  some  sleeping  persons, 
as  well  as  to  the  states  known  as  somnam- 
bulism and  catalepsy,  and  that  its  physiological 
cause  is  presumed  by  Heidenhain  to  be  some 
inhibitory  arrest  of  activity  of  the  ganglion-cells 
of  the  cerebral  cortex,  or,  as  the  writor  would 
rather  put  it,  of  certain  tracts  of  these  ganglion- 
cells.  (See  Animal  Magnetism:  Physiological 
Observations,  by  R.  Heidenhain,  1880.) 

The  scientific  study  of  the  phenomena  pre- 
sented by  hypnotized  persons  is  unquestionably 
of  great  interest  and  importance,  from  the  point 
of  view  of  the  higher  cerebral  physiology.  But 
whether  the  systematic  induction  of  such  a 
state  can  ever  be  used  as  a legitimate  or  potent 
means  for  curing  disease,  or  even  for  the  alle- 
viation of  certain  distressing  symptoms,  must 
be  left  for  the  future  to  decide.  The  good 
use  to  which  it  was  put  by  Esdaile  in  India, 
as  a means  of  inducing  insensibility  during  sur- 
gical operations  before  the  general  introduction 
of  chloroform,  ought,  however,  never  to  be  for- 
gotten. (See  his  Mesmerism  in  India,  and  its  Prac- 
tical Application  in  Surgery  and  Medicine.)  The 
whole  subject  is  one  of  great  interest  for  the 
practitioner  of  medicine,  now  that  the  absurd 
theories  have  been  got  rid  of.  We  must  be  care- 
ful, however,  to  pursue  the  study  of  the  con- 
dition itself  in  a strictly  scientific  manner,  and 
watch  lest  the  too-ready  adoption  of  hypnosis 
or  Braidism  as  a curative  agent  may  do  harm 
rather  than  good — and  that  not  to  the  patient 
only,  but  also  to  the  practitioner.  Tile  state- 
ments of  the  results  obtained  by  Braid  (see  his 
Neurypnology,  1843)  are  little  less  than  mar- 
vellous ; and  there  can  be.  no  doubt  that  the 
therapeutic  uses  of  hypnotism  ought  to  receive 
a new  and  thorough  investigation  by  some  in- 
structed and  well-trained  observers.  The  pit- 
falls  besetting  such  an  investigation  are  by  no 
means  few ; but,  on  the  other  hand,  the  gains 
to  the  science  of  medicine  and  to  therapeutics 
might  be  great.  See  Braidism. 

H.  Chaklton  Bastian. 

MESOLOGY  (jue'croj,  a medium;  aDd  Xiyos, 
a discourse). 

This  term,  recently  introduced  by  Bertillon, 
conveniently  expresses  the  investigation  of  the 
mutual  relationships  existing  between  liv:ng  be- 
ings and  their  surroundings. 

The  physiological  life  of  any  organism  may  be 
regarded  as  the  resultant  on  the  part  of  the 
tissues  of  two  sets  of  influences — intrinsic  or 
hereditary,  and  extrinsic.  To  the  former  are 
due  those  structural,  and  consequently  functional 
characteristics,  which  are  common  to  ancestors 
and  progeny  alike,  whilst  the  fluctuating  nature 
of  the  environment  determines  those  variation® 
which  distinguish  different  species.  Within  cer- 


074  MESOLOGY. 


MICRCCOCCI. 


tam  assumed  limits  these  stimuli  are  regarded 
as  normal,  and  the  resulting  manifestations  of 
the  tissues  aro  said  to  be  healthy;  -whilst  dis- 
turbances in  either  of  these  groups  of  influences 
constitute  the  causes  of  disease — that  is,  abnormal 
function  dependent  on  abnormal  structure,  which 
in  its  turn  has  been  brought  about  by  a change 
in  the  usual  conditions  under  which  it  exists. 

Mesology,  therefore,  may  be  looked  upon  in  a 
restricted  sense  as  a branch  of  setiology,  dealing, 
as  it  does,  with  such  factors  as  temperature, 
atmosphere,  climate,  locality,  food,  clothing,  and 
i ha  more  subtle  agencies  of  habit,  profession, 
domesticity,  mental  states  of  depression,  excite- 
ment, or  irritation;  in  short,  with  any  and  every 
circumstance,  whether  material  or  psychical, 
which  acts  upon  the  body.  W.  H.  Allchin. 

METALLIC. — A peculiar  quality  of  sound, 
which  the  name  suggests,  either  elicited  by  per- 
cussion or  heard  on  auscultation,  especially  in 
connection  with  certain  adventitious  sounds  in 
pulmonary  cavities.  See  Physical  Examination-. 

METaMORPHOSIS  (jueTci,  a particle  sig- 
nifying change,  and  p.ep<p6u,  I form). — In  a 
pathological  sense  this  word  signifies  a form  of 
degeneration,  in  which  one  tissue  or  substance 
becomes  chemically  changed  into  another,  as  for 
example,  albuminous  structures  into  fat.  See 
Degeneration. 


METASTASIS  1 
METASTATIC  / 


(/j.e6'uTTT]ni.  I change 


place). — These  terms  are  supposed  to  imply  the 
translation  of  a disease  from  one  part  of  the  body 
to  another,  such  as  seems  to  occur  occasionally 
in  gout,  rheumatism,  mumps,  and  certain  affec- 
tions of  the  skin  and  mucous  membranes.  Mo- 
dern pathology,  whilst  admitting  the  existence 
of  the  phenomena  to  which  the  term  metastasis 
has  been  applied,  refuses  to  accept  as  satisfac- 
tory the  explanation  of  the  fact  implied  in  the 
term. 


METEORISM  (p.eTeccpl(a,  I raise  up). — A 
synonym  for  tympanites.  See  Tympanites. 


METR  ALGIA  (u^rpa,  the  womb,  and  &\yos, 
pain). — Pain  in  the  womb.  See  Womb,  Dis- 
eases of. 


packed,  with  very  little  intercellular  substance. 
They  do  not  grow  into  rods  or  filaments,  thus 
being  distinguished  from  bacteria  proper  and 
bacilli ; and  they  have,  according  to  Cohn,  no 
power  of  independent  locomotive  movement 
differing  in  this  respect  from  common  bacteria, 
which  have  usually  alternate  stages  of  rest  and 
motion.  The  other  essential  generic  characters 
are  those  of  bacteria  in  general.  See  Bacteria. 

Description  and  Physical  Characters.— 
Micrococci  are  of  extreme  minuteness,  rarely 
exceeding  jL  of  an  inch  in  diameter,  and  often 
being  much  smaller  than  this.  As  seen  with 
the  microscope,  they  appear  as  minute  liighly- 
refraetile  dots ; and,  if  suspended  in  fluid,  are  in 
active  Brownian  movement.  When  single,  thev 
are  with  difficulty  to  be  distinguished  from 
minute  oil-globules  or  granules  of  protoplasm, 
but  they  are  usually  found  in  pairs  or  rows,  and 
are  then  more  easily  recognised.  As  they  mul- 
tiply by  transverse  fission  with  extraordinary 
rapidity,  they  are  usually  seen  in  this  dumb-bell 
shape,  and  moving  to  and  fro,  when  in  active 
growth.  If  growing  more  slowly  in  a quiescent 
medium,  they  form  chains,  composed  of  six 
eight,  or  more  members  linked  together.  And 
lastly,  under  favourable  conditions,  they  grow 
into  rounded  masses  consisting  of  an  agglomera- 
tion of  an  infinite  number  of  individuals,  unite! 
by  an  intercellular  substance,  the  so-callet 


Fia.  27.  a.  Single  and  doable  micrococci ; b.  groups 
four,  ‘ sarcina  ’ form  ; r.  chains  ; d.  zooglcea ; e.  sing 
and  double  micrococci,  more  highly  magnified,  showii 
process  of  division ; /.  a chain,  more  highly  magnified. 


METRITIS  (p.T)Tpa,  the  womb).  — Inflam- 
mation of  the  womb.  See  Womb,  Diseases  of. 

MIASM  (piaivo),  I pollute). — This  term  has 
been  used  very  vaguely  in  reference  to  poison- 
ous emanations  generally,  but  its  application 
ought  to  be  limited  to  the  malarial  poison.  See 
Malaria. 

MICROCOCCI  ( puicpbs , little  ; and  kukkos , a 
berry). — Synon.  : Spherical  or  sphaero-bacteria ; 
globular  bacteria  ; Microsporon  (Klebs);  Monas 
crepusculum  ; Ger.  Kugel-bacte  ricn. 

Some  of  these  names  are  also  used  by  different 
authors  in  a wider  sense ; and  some,  such  as 
microsporon,  have  only  been  applied  to  certain 
species. 

Definition. — Bacteria,  of  spherical  or  ovoid 
form,  which  multiply  like  other  bacteria  by 
transverse  fission  into  double  forms,  chains,  or 
clumps,  or  into  large  globular  masses  (zooglcea), 
in  which  the  individual  elements  are  densely 


zooglcea  (fig.  27,  d).  The  various  groupings  thi 
produced  have  been  described  under  varioi 
names  : dumb-bell  or  double  form,  when  two  i 
dividual  elements  are  incompletely  separati 
(Fig.  27,  a) ; chain  form  ( Kettcnform ),  rosa; 
form  (Rosenkranzform),  torula  form,  Icptothn 
mycothri-x,  streptococcus,  and  various  oth 
names,  when  in  rows  which  are  straight,  bei 
or  curved  (Fig.  27,  c).  Usually,  before  eomplei 
separation  of  any  two  elements  takes  plac 
the  fission  process  has  commenced  in  these  l 
dividuals,  and  thus  a chain  of  four  is  produce 
if,  as  is  usual,  the  fission  is  transverse;  wbe 
more  rarely,  it  is  longitudinal,  a group  of  four 
‘ sardna-form’ — is  produced  (Fig.  27,  b).  The 
names  are  unscientific,  and  should  be  discardi 
for  they  indicate  no  real  difference  in  natu 
but  merely  an  accidental  grouping. 

When  diffused  in  a clear  fluid,  micrococci  cai 
an  opalescence.  If,  however,  they  are  in  zoogl 
masses,  they  appear  to  the  naked  eye  as  opa^ 


MICROCOCCI. 


•ffhite  dots,  -which  may  be  as  large  as  a pin’s-head 
or  more ; or  they  may  be  tinged  by  colouring 
matters  absorbed  from  the  surrounding  medium. 

Micrococci  consist  of  protoplasm,  which,  like 
that  of  other  bacteria,  is  hignly  refractile,  re- 
sists the  action  of  alkalies  and  dilute  acids,  and 
is  strongly  coloured  by  various  reagents.  The 
protoplasm  is  believed  to  consist  of  an  outer 
envelope  and  cell-contents.  When  in  zoogloea 
masses,  micrococci  are  united  by  a small  quantity 
of  intercellular  substance,  which  may,  perhaps, 
be  produced  by  solution  of  their  outer  envelope. 
The  zoogloea  appears  under  the  microscope  as 
dense  granular  masses,  with  a finely  but  uni- 
formly punctated  surface. 

Life-history. — Micrococci  have  been  supposed 
by  some  to  originate  spontaneously  by  the  disin- 
tegration of  organised  albuminous  bodies  ; but 
this  mode  of  production  is  denied  by  other  ob- 
servers. In  their  free  growth  they  require  the 
presence  of  a pabulum  containing  nitrogen-  and 
carbon-compounds,  and  water,  together  with  a 
small  quantity  of  free  oxygen ; but  most  micro- 
cocci, if  not  all,  grow  freely  in  fluids  from  which 
the  free  access  of  air  is  excluded,  and  hence  they 
belong  to  Pasteur’s  class  of  anarobice.  The  growth 
|of  micrococci  is  largely  influenced  by  temperature, 
but  tho  degree  of  heat  most  favourable  to  their 
germination  probably  varies  with  the  different 
species. 

Micrococci  are  very  tenacious  of  life,  resisting 
;he  action  of  heat  to  a remarkable  degree.  The 
sxact  death-point  has  not  been  accurately  deter- 
nined.  They  appear  also  to  resist  the  so-called 
antiseptics’  much  more  than  other  bacteria. 

The  relation  of  micrococci  to  ordinary  rod- 
ihaped  bacteria  has  been  a matter  of  dispute, 
it  is  now  known  that  rod-bacteria,  when  culti- 
-ated,  may  produce  spores,  which  can  divide  and 
tub-divide  again,  and  which,  in  their  physical 
haracters,  are  undistinguishable  from  micrococci, 
io,  also,  bacilli  produce  spores,  which  may  sub- 
side, but  again  germinating  reproduce  the 
acillus  filaments.  The  question  has  therefore 
een  raised,  whether  these  micrococci  are  not 
'he  spores  of  bacteria,  which  have  assumed  an 
bortive  stable  form,  and  do  not  usually  produce 
jd-bacteria.  It  has  indeed  been  stated  that 
acteria  have  been  seen  to  divide  into  micrococci, 
■utthe  numerous  experiments  and  observations 
lade  with  the  object  of  reproducing  bacteria 
om  micrococci  have  hitherto  failed. 
Classification. — Thus  far  micrococci  have 
:en  treated  as  a class ; it  must  now  be  stated 
'.at  various  sub-genera  and  species  have  been 
iscribed. 

Micrococci  have  been  divided  by  Cohn  into 
ree  sub-orders,  namely — (1 ) ckromogenic,  those 
lich  produce  in  their  growth  soluble  or  in- 
luble  colouring  matters ; (2)  zymogenic , those 
acerned  in  special  forms  of  fermentation ; and 
) •pathogenic,  or  those  associated  with  disease, 
irments  of  contagion.’  It  is  the  pathogenic 
me  that  need  here  be  considered. 

Pathological  Relations  in  General. — Mi- 
icocci,  like  other  bacteria,  play  a certain  part 
putrefactive  and  fermentative  processes,  in 
ich  they  are  constantly  present ; and  pro- 
ilythev  are  also  in  someway  concerned  in 
' tain  of  the  processes  of  disease  in  animal 


97  A 

and  vegetable  organisms.  Although  the  exact 
part  which  bacteria  play  must  be  allowed  to  bo 
doubtful,  there  can  hardly  be  a question  of 
their  importance  in  relation  to  some  of  these 
processes.  In  face  of  the  various  opinions  now 
entertained  on  the  subject,  it  can  only  be  stated 
here  that  some  believe  them  to  be  the  active 
agents  of  these  processes,  and  as  a consequence 
that  the  bacterium  which  produces  each  pro- 
cess, whether  fermentative  or  morbific,  is  specific 
in  its  nature  ; whilst  others  believe  that  these 
processes  arise  independently,  that  the  bacteria 
are  merely  concomitants,  and  that  the  varie- 
ties in  mode  of  growth  and  in  outward  form  are 
merely  the  results  of  the  various  conditions 
under  which  they  grow.  But  there  is  much 
evidence,  both  from  the  study  of  processes  of 
fermentation,  and  of  the  diseases  of  vegetables 
and  animals,  to  show  that  the  various  forms  of 
micrococci,  as  of  other  bacteria,  are  more  or 
less  specific,  or  at  least  have  acquired  specific 
properties  and  powers. 

Micrococci  have  been  alleged  to  be  concerned 
in  the  production  of  a large  number  of  diseases, 
mainly  those  known  as  septic  and  contagious. 
Of  the  septic  diseases,  pyaemia,  septicaemia, 
and  puerperal  fever,  and  of  the  contagious 
specific  diseases,  diphtheria,  erysipelas,  gonor- 
rhoea, and  vaccinia,  are  those  in  which  micrococci 
are  asserted  to  play  an  important  part.  There 
can  be  no  doubt  that  they  are  frequently,  if  not 
constantly,  present  in  the  tissues  or  fluids  of  the 
body,  or  in  the  inflammatory  products,  in  some  of 
these  diseases,  but  their  significance  is  a matter 
of  dispute  (see  Bacteria).  It  may  be  observed 
that  the  question  of  their  action  in  pyaemia  and 
septicaemia  is  a very  different  one  from  that  of 
their  relation  to  the  specific  diseases,  such  as 
vaccinia,  and  these  two  classes  of  disease  may 
therefore  be  considered  separately. 

Special  pathology  in  relation  to  blood- 
poisoning. — With  regard  to  the  septic  diseases, 
especially  pyaemia,  the  evidence  of  the  action  of 
micrococci  is  partly  derived  from  general  consi- 
deration, partly  from  anatomical  observation,  and 
partly  from  experiments  on  the  lower  animals. 

Micrococci  are  known  to  be  present  in  nearly 
all  decomposing  animal  fluids,  and,  on  the  other 
hand,  the  experiments  of  Lister  and  others  tend 
to  show  that  if  precautions  are  taken  to  exclude 
bacteria,  especially  micrococci  and  bacterium 
termo,  putrescence  does  not  occur.  Micrococci 
are  hence  regarded  as  the  ferments  of  putre- 
faction, or,  rather,  of  one  form  of  putrefaction. 
Tho  evidence  that  pyaemia  is  produced  by  the 
inoculation  of  some  putrescent  animal  matter  is 
very  strong;  and  the  exclusion  of  the  ferment 
of  putrefaction  has  apparently  the  same  effect. 
Micrococci  are  also  found  in  the  pus  or  serum 
of  nearly  all  active  poisoned  wounds,  commonly 
so  called,  such  as  ‘ necrotic  warts,’  whitlows, 
&c.,  and  frequently  in  the  pus  of  acute  ab- 
scesses, (Birch-Hirsehfeld,  Alex.  Ogston,  and 
others);  and  there  is  much  evidence  to  show  that 
the  infective  property  of  the  pus  of  abscesses 
is  dependent  on,  or  co-existent  with,  their  pre- 
sence, inoculation  with  fresh  pus  containing  them 
producing  suppuration,  but  in  their  absence  no 
such  effect  being  observed.  When  artificially 
cultivated  in  nutrient  fluids  this  property  of 


MICROCOCCI. 


076 

©iusing  suppuration  may  be  lost,  especially  if 
there  is  free  access  of  air ; but  A.  Ogston  has 
succeeded  in  cultivating  them  in  eggs,  excluding 
the  air,  and  in  thus  multiplying  micrococci 
which  retain  their  power  of  causing  suppuration. 
This  is  also  in  accordance  with  numerous  expe- 
riments, which  have  proved  that  decomposed 
blood,  containing  abundant  micrococci,  may  be 
inoculated  with  impunity,  showing  that  either 
only  certain  kinds  of  micrococci  have  phlogogenic 
or  septic  properties,  or  that  certain  conditions  of 
growth  are  necessary  to  confer  or  maintain  those 
properties. 

Anatomical  observations  on  pyaemia,  both  in 
man  and  in  the  lower  animals,  have  shown  that 
micrococci  are  almost  constantly  present  in  the 
affected  parts.  The  first  observations  on  this 
point  are  probably  due  to  Klebs,  who  described 
the  microsporon  septieum  as  found  in  pyeemia, 
and  cultivated  it  outside  the  body.  Many  ob- 
servers have  since  confirmed  his  results,  with 
some  variations  in  detail.  Zooglcea  masses  of 
micrococci  are  found  in  the  capillaries,  and  capil- 
lary arterioles  and  venules,  the  latter  especially, 
of  various  organs — the  lung,  kidney,  heart,  liver, 
and  thymus  in  particular.  Moreover,  their  pre- 
sence in  these  viscera  usually  coincides  with  the 
presence  of  abscesses  in  course  of  formation  in 
these  situations.  They  are  also  found  in  the 
submucous  tissues,  and  the  serous  cavities,  lym- 
phatic glands,  &c.  In  pyeemia  in  the  lower 
animals,  micrococci  are  often  found  in  large 
numbers  in  the  blood.  Nor  is  it  only  in  pyaemia, 
commonly  so-called,  that  this  constant  presence 
of  micrococci  is  observed ; in  many  other  allied 
diseases  associated  with  blood-poisoning  simi- 
lar observations  have  been  made.  Thus,  in  puer- 
peral fever  (Heiberg),  hospital  gangrene,  ulce- 
rative endocarditis,  diphtheritic  endocarditis 
(Weigert),  &c.,  they  have  been  found,  both  in 
the  primary  lesion  and  in  the  secondary  ab- 
scesses. As  to  their  mode  of  action,  apart  from 
the  general  results  of  putrid  fermentation,  micro- 
cocci appear  in  some  cases  to  produce  local  effects, 
such  as  dilatation  of  the  walls  of  vessels,  or 
thrombosis  by  their  action  on  leucocytes,  and 
local  irritation  and  its  consequences.  Moreover, 
it  would  appear  from  the  researches  of  Koch, 
who  produced  various  forms  of  blood-poisoniDg 
and  gangrene  in  rodents,  that  micrococci  may 
have  different  actions  in  different  forms  of  these 
diseases,  and  that  in  their  physical  characters 
and  grouping,  as  well  as  in  their  local  action, 
these  micrococci  may  show  differences  sufficient 
to  constitute  distinct  species,  each  having  a 
specific  action,  and  producing  a special  form  of 
disease,  whether  pyaemia, septicaemia,  or  gangrene. 
By  many  other  observers,  however,  the  specific 
dintinctness  of  these  different  forms  is  alto- 
gether denied.  For  fuller  details  the  writings 
of  Hiller,  Klebs,  Billroth,  Pasteur,  Lister, 
Burdon-Sanderson,  Watson-Chcyne,  and  many 
others,  may  be  consulted. 

Against  these  observations  the  objection  has 
been  raised  that  micrococci  are  capable  of  de- 
velopment in  the  body  in  lowered  conditions  of 
vitality,  or  even  of  spontaneous  generation  from 
disintegrating  albuminous  substances,  both  after 
death  and  during  life  when  death  is  approach- 
ing ; and  that  they  aro  merely  evidonce  of  a 


change  allied  to  decomposition  intra  vitam. 
That  the  healthy  organism  has  a great  power  of 
resisting  their  entrance,  and  of  destroying  them 
when  artificially  introduced,  must  be  considered 
an  established  fact;  but  there  are  so  many 
channels  by  which  they  may  enter  if  the  power 
of  resistance  is  lowered,  that  a spontaneous  gene- 
ration must  not  be  assumed  too  readily  to  explain 
their  presence.  Experiments  made  by  feeding 
animals  with  phosphorus,  and  thus  lowering  thcii 
vitality,  clearly  show  that  micrococci  do  appear 
in  the  blood  under  these  conditions.  Many  expe- 
riments have  been  made  to  determine  whether 
micrococci  and  bacteria  exist  normally  in  the 
blood  and  tissues,  held  in  cheek  only  by  the 
vitality  of  the  organism,  so  that  after  death  thev 
germinate.  Recent  experiments,  notably  these  of 
Billroth,  Tiegel,  Burdon-Sanderson,  Chiene  and 
Ewart,  Nencki  and  Giacosa,  and  Watson-Cheyne, 
have  led  to  very  different  results,  partly  due  to 
differences  in  method  ; but  the  question  must  he 
considered  to  be  at  present  undecided. 

Special  pathology  in  relation  to  specific  con- 
tagious diseases. — The  subject  of  the  relation  | 
of  micrococci  to  specific  contagious  diseases, 
such  as  diphtheria  and  vaccinia,  is  too  wide  for 
complete  discussion  here.  By  some  each  of  these 
diseases  is  believed  to  he  dependent  on  the 
action  of  a particular  specific  micrococcus  con- 
stituting  its  contagium  and  virus;  and  by  the 
multiplication  of  these  micrococci,  and  the  patho- 
logical changes  consequent  thereon,  the  disease 
is  supposed  to  be  produced  and  propagated.  Of, 
the  ‘pathogenic’  micrococci  which  have  been 
described,  the  most  important  are  the  micro- 
coccus diphfheriticus  and  micrococcus  vaccine. ! 
The  micrococcus  of  diphtheria  has  been  described 
by  Eberth,  Nassilloff,  Weigert,  and  others,  and 
they  have  insisted  on  its  constancy  and  impor- 
tance. On  the  other  hand  many  good  observers 
have  failed  to  find  it  in  well-marked  cases;  and 
it  must  bo  allowed  that  micrococci  are  most 
abundant  in  the  tonsils  and  pharynx  and  other 
parts  most  prone  to  sloughing,  and  are  far  less 
constant  in  the  larynx  and  trachea.  Then 
presence  in  decomposing  false  membranes  u 
pirobably  of  no  significance.  The  micrococcus 
vaccina:  of  Cohn,  Burdon-Sanderson,  and  othen 
has  no  doubt  a real  existence — that  is,  micro, 
cocci  are  commonly  found  in  vaccine  lymph;  bn 
the  experimental  evidence  that  they  constitute 
the  contagium  is  negative. 

It  appears  unnecessary  to  refer  in  detail  t 
many  other  supposed  pathogenic  micrococci  whicl 
have  been  described  in  relation  to  small-pox 
horse-pox,  glanders,  gonorrhoea,  and  other  affeq 
tions,  for  the  evidence  upon  which  their  existeuq 
is  asserted  is,  to  say  the  least,  extremely  imperfec' 
All  that  can  safely  be  affirmed  is  that  micrococ< 
are  to  be  found  in  great  abundance  in  the  pathq 
logical  excretions  and  secretions  of  certain  con 
tagious  diseases,  especially  when,  as  in  diphther:; 
these  have  a tendency  to  become  putrid ; an 
that  they  are  usually  also  present  in  the  actn 
virus  of  inoculable  diseases,  for  example,  vs 
cinia ; but  whether  they  constitute  the  actu 
contagium,  or  by  their  action  produce  a local  co 
dition  which  is  favourable  to  the  absorption  at 
activity  of  the  virus,  is  at  present  uncertain. 

W.  S.  Gkeexfibtjx 


MICROSCOPE  IN  MEDICINE. 


MICROSCOPE  in  MEDICINE  — The 
exact  position  of  the  microscope  in  medicine 
has,  like  most  other  instruments  of  research,  not 
been  always  clearly  recognised.  Over-estimated 
in  its  value  by  the  enthusiast,  it  has  suffered 
from  an  undue  exaggeration  as  to  its  capabili- 
ties, second  only  to  that  unfair  depreciation  put 
forward  by  ignorance  of  its  use.  Whilst  perhaps 
! representatives  of  both  views  may  be  found  at 
the  present  day,  the  time  has  come,  after  nearly 
half  a century  of  experience,  to  define  with 
moderation  the  limits  of  its  application. 

It  must  at  the  outset  be  recognised  that  the 
microscope  is  but  an  aid  to  one  of  our  senses. 
It  merely  extends  our  means  of  observation,  of 
seeing  what  is.  The  range  of  our  vision  being 
{limited,  this  optical  arrangement  permits  a 
wider  field,  a greater  depth  of  perception.  Of 
itself  the  microscope  allows  the  hitherto  hidden, 
only  because  too  minute,  to  be  seen,  whilst  it 
discloses  nothing  that  does  not  already  exist ; it 
renders,  in  short,  the  eye  for  the  time  being  and 
n one  direction  more  perfect. 

The  formation  of  a diagnosis,  which  may  be 
•egarded  as  the  first  aim  of  practical  medicine, 
Is  the  result  of  a judgment  founded  upon  obser- 
•ation  of  the  case,  guided  by  experience  and 
vith  due  regard  to  external  circumstances.  Any 
gent  that  may  extend  the  means  of  observa- 
ion,  or  render  Such  more  accurate,  is  obviously 
great  gain  ; and  on  this  ground  the  microscope 
inks  with  the  stethoscope,  the  thermometer, 
nd  the  probe,  which  permit  a wider  application 
f the  senses  of  hearing  and  touch.  But  whilst 
Ifii'haps  it  may  be  conceded  that  the  microscope 
•r  daily  practice  is  not  of  such  necessity  as 
ther  of  those  instruments,  it  has  a further  and 
■eater  claim  on  the  consideration  of  the  medi- 
il  man,  for  what  it  has  done  and  is  doing  in 
ying  the  foundation  of  the  science  on  which  his 
•actice  depends. 

That  which  characterises  the  theories  of  pa- 
ology  at  the  present  day,  and  which  markedly 
stinguishes  them  from  any  and  all  hitherto 
ught,  is  the  recognition  of  the  association  and 
pendence  of  function  upon  structuro,  with  the 
bscquent  corollary  that  disease  is  hut  altered 
action  due  to  altered  structure.  Whilst  the 
owledge  of  the  structure  of  the  bodyr — ana- 
ny — was,  previous  to  the  present  century,  of 
> grossest  character,  the  theories  of  disease 
re  limited  only  by  fancy  and  empiricism. 
■It  as  the  great  truth  which  established  the 
1 nection  of  physiology,  and  hence  of  pathology, 
' h anatomy  came  more  and  more  to  be  recog- 
i ad,  the  principles  of  morbid  action,  the  ex- 
1 nation  of  symptoms,  and  the  suggestion  of 
r onal  treatment  followed  on  truly  scientific 
Kinds.  It  was  in  establishing,  and  is  now  in 
Retaining  and  following  this  truth,  that  the 
n loscope  ranks  highest  among  our  instru- 
m.its  of  research. 

as  Instrument.— In  face  of  the  many  and 
e .llent  instruments  that  are  offered,  it  would  be 
id  lious  to  recommend  any  particular  one  ; but 
‘bellowing  remarks  are  intended  to  be  a guide 
as  the  kind  of  microscope  that  is  sufficient  for 
th  irdinary  requirements  of  the  practitioner,  it 
M ; assumed  that  the  optical  principles  of  a 
>ouud  microscope  are  understood. 

62 


Obviously  the  first  point  to  keep  in  view  is 
the  magnifying  power,  inasmuch  as  it  is  to  bring 
within  the  rango  of  vision  invisible  objects  that 
the  instrument  is  valuable.  For  all  ordinary 
practical  purposes  a power  that  will  magnify 
300  to  400  diameters  is  sufficient ; higher  de- 
grees require  specially  skilled  manipulation,  and 
are  out  of  the  category  of  present  consideration. 
But  at  the  same  time  it  is  almost  an  essential 
that  a much  lower  power  be  available,  such  as 
one  of  60  diameters,  in  order  that  a more  general 
view  may  be  had  of  the  object  under  examina- 
tion, since  it  is  thus  that  an  idea  may  be  ob- 
tained of  the  plan  and  arrangement  of  the  object, 
the  details  of  which  are  resolved  by  the  higher 
power.  Scarcely  secondary  in  consideration  is 
the  ‘defining  power,’  by  which  ‘a  clear  and 
distinct  image  of  all  well-marked  features  of 
an  object,  especially  of  its  boundaries,’  is  ob- 
tained (Carpenter).  Subordinate  to  these  quali- 
fications, but  yet  of  great  importance,  are  ‘ flat- 
ness of  field,’  ‘achromatism,’  ‘penetration,’  and 
‘ sufficient  light.’  Excellence  in  these  various 
points  is  to  be  aimed  at  in  the  selection  of  a 
glass.  The  whole  field  of  vision  should  he 
flat,  that  is,  the  circumference  and  the  centre 
should  be  in  focus  at  the  same  time ; and  the 
margins  of  the  object  viewed  should  not  be 
fringed  with  coloured  bands.  Errors  in  these 
directions,  known  as  spherical  and  chromatic 
aberrations,  are  corrected  by  the  employment 
of  ‘combinations’  of  lenses,  of  varying  degrees 
of  convexity,  and  manufactured  of  different 
kinds  of  glass.  It  is  clearly  of  great  import- 
ance to  have  the  field  well  illuminated,  or  that 
there  be  as  much  light  as  possible,  but  it  is 
equally  obvious  that  this  necessarily  varies  with 
the  focal  length  of  the  object-glass — the  higher 
the  power  the  less  the  light  that  can  he  ad- 
mitted. Still,  however,  a considerable  difference 
exists  in  respect  to  the  illumination  among 
glasses  of  the  same  magnifying  power,  and  it  is 
highly  desirable  to  keep  this  point  in  view  in 
choosing  an  objective.  Certain  aids  to  this  end 
are  given  by  reflectors,  achromatic  condensers, 
&c.  With  the  degree  of  ‘ illuminating  power  ’ of 
the  glass  must  be  considered  its  ‘ penetrating 
power  or  focal  depth,  by  which  the  observer  is 
enabled  to  look  into  the  structure  of  objects’ 
(Carpenter).  The  latter  quality  is  of  the  utmost 
importance  in  the  microscope  of  the  medical 
practitioner  and  histologist,  as  by  it  a know- 
ledge is  afforded  of  the  relative  disposition  of 
the  constituent  parts  of  the  object  under  inves- 
tigation. All  these  properties  are  closely  asso- 
ciated with  what  is  known  as  the  * angular  aper- 
ture’ of  the  objective,  that  is,  ‘the  angle  formed 
between  the  most  external  rays  that  can  pene- 
trate the  entire  system  of  lenses  of  an  objective, 
from  a luminous  point  placed  in  the  focus.’  Now 
the  degree  of  angular  aperture  will  depend  on 
the  distance  of  the  object,  when  in  focus,  from 
the  front  lens  of  the  objective,  and  the  size  of 
the  ‘ actual  aperture,’  or  width  of  the  front  lens 
of  the  combination.  The  illumination  of  the 
object  must  be  directly  proportionate  to  the  latter, 
since  upon  the  actual  size  of  the  lens  must  depend 
the  amount  of  light  admitted  ; but  since  the  cir- 
cumferential and  central  rays  tend  to  come  to  a 
focus  at  different  points,  to  the  manifest  detri- 


MICROSCOPE  IN  MEDICINE. 


?78 

ment  of  the  distinctness  of  the  image,  the  defin- 
ing power  of  the  glass  will  be  improved  as  the 
outside  rays  are  cut  off  by  diminishing  the  field, 
or,  in  other  words,  by  diminishing  the  amount 
of  light.  Within  certain  limits,  therefore,  the 
definition  improves  in  inverse  proportion  to  the 
illumination,  always  assuming  a complete  correc- 
tion of  chromatic  and  spherical  aberration.  Now 
the  ‘ penetrating  power,’  within  certain  limits,  va- 
ries in  inverse  proportion  to  the  extent  of  angle 
of  aperture  of  the  objective,  which,  as  already 
said,  in  part  depends  on  the  size  of  the  actual 
aperture.  Hence  also  the  penetration  up  to  a 
certain  point  improves  in  inverse  proportion  to 
the  illumination.  Since  it  is  impossible  to  recon- 
cile these  very  opposite  qualities,  the  observer 
must  be  prepared  to  lose  somewhat  in  light  what 
he  gains  in  distinctness  and  depth  of  his  image; 
and,  as  a rule,  the  angular  aperture  of  the  J 
should  not  exceed  75°,  nor  of  the  Ath  or^th,  90°. 
The  so-called  ‘ resolving  power ' of  a glass,  ‘ by 
which  closely-approximated  markings  may  be 
distinguished,’  is  of  but  little  value  to  the  medi- 
cal practitioner. 

Keeping  in  mind  these  points,  it  is  possible  tc 
obtain  a microscope  for  a very  moderate  cost 
(£6  to  £7),  which  shall  fulfil  all  the  ordinary 
requirements  of  the  medical  man.  The  stand 
should  be  small  and  perfectly  steady,  on  the 
tripod  or  horseshoe  (Hartnack)  model.  The 
stage  should  be  tolerably  large  (a  common  fault 
is  its  small  size),  and  its  aperture  of  moderate  size 
and  provided  with  a wheel  of  diaphragms ; whilst 
the  addition  of  an  achromatic  condenser  is  most 
desirable.  The  mirror  itself  should  be  double, 
concave  on  one  side  and  flat  on  the  other,  attached 
to  the  body  by  a j ointed  arm,  and  not  too  small — 
another  fault  in  cheap  instruments.  The  body  of 
the  microscope  should  be  so  attached  to  the 
stand  as  to  permit  of  inclination  to  any  angle 
between  the  vertical  and  horizontal  positions, 
and  should  be  provided  with  a ‘draw  tube.’  In 
order  that  the  tube  carrying  the  optical  arrange- 
ments, eye-piece  and  objective,  may  he  brought 
into  proper  position  to  focus  the  object,  it  is 
usually  provided  with  ‘coarse’  and  ‘fine’  ad- 
justments, though  these  are  not  always  both 
present  in  the  cheaper  instruments,  and  are 
really  not  absolutely  necessary  for  the  powers 
here  recommended,  being  moreover  worse  than 
useless  unless  they  are  exceedingly  well  made, 
which  adds  considerably  to  the  expense,  whilst  a 
little  practice  will  render  the  observer  indepen- 
dent of  them  ; if  one  only  be  available,  the  finer 
should  be  preferred.  Lastly  with  respect  to  the 
glasses,  a great  diversity  of  opinion  exists,  very 
much  determined  by  what  the  individual  is  accus- 
tomed to  ; familiarity  with  a special  instrument 
and  its  parts  going  a great  way  to  ensure  success 
in  its  employment.  Whilst  probably  the  A ery  best 
glasses,  and  those  of  the  highest  power  (l-25th 
and  l-50th  inch)  are  made  in  England,  excellent 
objectives  are  made  in  Germany  and  France,  are 
amply  sufficient  for  medical  practice,  and  give  a 
nearly  equivalent  result  at  a much  lower  cost. 
The  cheapest  English  glasses  should  certainly 
be  avoided.  For  a low  power  a 1-inch  or  f-inch 
is  sufficient,  and  anything  lower  is  of  little  use  ; 
whilst  for  a high  power  opinions  differ  in  regard 
to  a J,  or  | (or  the  foreign  equivalents), 


depending  much  on  the  quality  and  maker  of  the 
glass.  The  writer  believes  that  for  all  ordinary 
purposes  the  English  J-incli  is  sufficient,  if  used 
with  a No.  2 or  B eye-piece,  giving  a magnifying 
power  of  about  32(1  diameters,  whilst  it  has  the 
great  advantage  of  permitting  considerable  illu- 
mination, the  want  of  which  is  especially  felt 
by  the  occasional  observer,  whilst  to  one  more 
familiar  with  the  instrument  the  loss  of  light  is 
hut  little  felt,  as  magnifying  power  and  defi- 
nition are  increased. 

For  testing  the  optical  properties  of  theglasses, 
nothing  is  better  than  a drop  of  fresh  blood  and 
a piece  of  muscular  fibre ; and  both  the  A and  B 
eye-pieces  should  be  tried  with  each  objective. 

Drawing. — It  is  frequently  necessary  that  an 
accurate  drawing  should  be  made  of  the  object 
seen,  and  this  may  be  doDe  by  means  of  the 
camera  lucida  prism,  attached  to  the  eye-piece  of 
the  microscope,  which  is  then  placed  horizontally. 
The  rays  of  light  proceeding  from  the  object 
along  the  tube  to  the  eye-piece  are  then  pro- 
jected downwards  by  the  prism,  on  to  the  paper 
beneath,  forming  an  image  which  may  be  traced 
over.  An  arrangement  with  a piece  of  neutra 
tint  glass  is  supplied,  which  answers  all  the  pur- 
poses of  a camera  lucida,  and  is  much  cheaper 
Considerable  practice  is,  however,  needed  in  the 
use  of  these  instruments. 

Measuring.— For  purposes  of  measuring  mi- 
croscopical objects  various  forms  of  micrometers 
are  employed.  One  kind  fits  into  the  eye-piece ; I 
and  another  consists  of  a ruled  glass  slip,  a 
drawing  of  the  lines  on  which  is  made  by  the  I 
aid  of  the  camera  lucida  with  each  objective- 
such  drawing  being  afterwards  used  as  a measure 
to  be  applied  to  the  outlines  previously  made  by 
the  prism. 

Binocular  Microscope. — The  binocular  ar- 
rangement of  the  microscope,  though  undoubtedly 
possessing  great  advantages  as  regards  pene- 
trating power,  is  not  of  such  value  for  ordinary 
clinical  purposes;  and,  necessitating  as  it  docs 
the  very  best  construction,  is  only  applicable  to 
the  larger  and  more  expensive  instruments.  A 
very  convenient  accessory  when  well  made  is 
the  ‘ nose-piece,’  which  carries  the  two  objectives 
and  thereby  saves  much  trouble.  For  power; 
higher  than  the  J,  it  is  not  satisfactory  with  th< 
smaller  microscopes. 

Apparatus  and  Reagents. — Bearing  in  mini 
that  it  is  for  tho  clinical  use  of  the  instrument 
rather  than  as  a means  of  histological  research 
that  the  microscope  is  here  considered,  the  ae 
tual  reagents  and  apparatus  required  are  ver 
few.  The  following  are  requisites: — A pair  c 
small  curved  scissors ; a pair  of  fine  pointed  foi 
ceps  ; a few  sharp  needles,  mounted  in  handle: 
those  with  cutting  edge  being  preferable  ; slid? 
and  cover-glasses,  which  latter  cannot  be  :c 
thin ; several  camel’s-hair  brushes ; one  or  t\v 
glass  rods ; and  pipettes.  Except  for  the  ex; 
ruination  of  tumours  and  new  growths,  whitj 
may  require  hardening  and  staining,  tho  medic, 
man  chiefly  wants  a microscope  to  ascertain  tl 
nature  of  various  secretions  and  discharge 
which  are  mostly  of  a fluid  nature,  and  do  a 
require  the  addition  of  any  medium ; but  shou 
any  such  be  needed,  it  is  desirable  that 
should  be  inert,  and  as  nearly  as  possible  of  t 


MICROSCOPE  IN  MEDICINE. 


979 


density  of  the  blood-serum  with  which  the  tis- 
sues are  normally  moistened.  For  that  purpose  a 
g or  4 per  cent,  solution  of  chloride  of  sodium, 
or  a 3 per  cent,  solution  of  glycerine  in  distilled 
water,  to  which  a few  crystals  of  carbolic  acid 
have  been  added  to  prevent  the  growth  of  fungi, 
is  most  convenient.  For  hardening  portions  of 
i tissue  to  allow  of  cutting  sections,  solutions  of 
iehromic  acid  (|  to  1 per  cent.) ; of  bichromate 
of  potash  of  the  same  strength ; of  chromic  acid 
Lid  spirit  (|  per  cent,  to  90  per  cent.),  dis- 
frilled  water  to  100  ; and  Muller’s  fluid — a solu- 
tion of  bichromate  of  potash  (2£),  sulphate  of 
Lda  (1),  distilled  water  (to  100);  are  the  most 
effective,  and  are  easily  made.  It  is  necessary  to 
(remember  that  a very  considerable  quantity  of 
Inch  fluid  is  required,  and  that  it  requires  re- 
aewing  daily  for  the  first  three  days.  For  a 
liece  of  tissue  of  tho  size  of  a filbert,  at  least 
'our  ounces  of  either  of  the  above  is  requisite. 
Jndcr  favourable  circumstances  the  hardening 
s complete  in  14  to  21  days.  By  means  of  the 
reezing  microtome  perfectly  fresh  tissue  may 
|e  cut  and  examined. 

Among  the  very  many  methods  recommended 
pr  hardening  and  staining  portions  of  tissue, 
jie  following  is  given  as  an  extremely  ready 
nd,  on  the  whole,  easy  plan.  Small  pieces  of 
tie  substance,  of  about  the  size  of  a large  pea, 
(re  placed  in  spirit  for  at  least  twelve  hours  to 
pt  rid  of  the  water ; they  are  then  transferred 
j>  a solution  of  magenta  in  oil  of  cloves,  to 
lain.  The  time  required  for  staining  varies 
jith  the  tissue,  the  size  of  the  piece,  and  the 
'rength  of  the  solution;  but  usually  twenty- 
fur  hours  is  sufficient.  The  pieces  are  then 
moved  to  a bottle  containing  melted  cocoa- 
.tter,  and  kept  there  for  twelve  hours.  The 
(at  of  the  chimney-piece  suffices  to  keep  the 
tter  melted.  One  of  the  portions  is  now  put 
the  end  of  a small  cork,  to  which  it  becomes 
ached  by  the  setting  of  the  cocoa-butter  in 
out  a couple  of  hours,  and  may  then  be  cut 
:h  a razor,  wetted  with  spirit  in  the  ordinary 
y.  The  sections  are  floated  on  to  a slide,  the 
i lerfluous  spirit  removed  by  blotting-paper ; and 
! rop  of  oil  of  cloves  let  fall  on  the  specimen  ; 
\ichis  covered  with  acovering-glass,  and  finally 
t tly  warmed  for  a minute  over  a spirit-lamp 
t|  lissolve  out  the  butter.  Such  a specimen  may 
tjbreserved  by  the  addition  of  a little  chloro- 
f n-balsam  to  the  edge  of  the  cover-glass. 

linical  Uses.— The  microscope  may  be  ap- 
p d to  the  investigation  of  the  various  dis- 
ci ’ges  and  secretions  from  the  body,  with  the 
Hit  of  obtaining  information,  which  though 
oli  of  but  imperfect  value,  may  on  other  oeca- 
6i  3 be  of  the  most  positive  and  precise  cha- 
raF,  determining  a diagnosis  which  without  it 
w id  be  uncertain. 

) Urine. — It  may  be  taken  as  a fundamen- 
ta  rinciple  that  perfectly  healthy,  fresh  urine 
6hld  have  no  visible  deposits.  A small 
(putity  of  flocculent  mucus,  entangling  a few 
eP  dial  cells,  is,  however,  of  such  frequent 
ociiTence  and  of  such  trifling  importance  as 
pn  ically  to  come  within  the  limits  of  health. 
Me  than  that  is  abnormal,  and  such  deposits 
je|nd  investigation.  It  may  he  that  they  are 
result  of  changes  in  the  urine  after  it  is 


passed,  or,  on  the  contrary,  they  may  have  been 
voided  as  such.  Occasionally  absolutely  clear- 
looking  urine  may  contain  tube-casts,  which  the 
microscope  only  can  detect. 

It  is  important,  therefore,  to  know  the  age  of 
any  sample  of  urine  that  is  examined,  and  when 
possible,  a portion  of  the  whole  twenty-four 
hours’  quantity  should  be  taken.  Where  this 
cannot  be  done,  what  is  passed  in  the  morning 
on  rising  should  be  chosen,  since  it  is  in  such  a 
specimen  that  certain  matters  are  most  likely  to 
be  present.  Frequently  an  examination  for  seve- 
ral successive  days  may  be  necessary,  for  there 
are  some  conditions  of  kidney-disease  in  which 
but  very  few  casts  are  passed,  and  would  most 
probably  escape  one  examination  of  a haphazard 
specimen.  The  urine  should  be  collected  in  coni- 
cal glasses,  holding  about  four  ounces,  which  must 
he  scrupulously  clean,  and,  if  in  frequent  use, 
are  best  kept  in  a closed  vessel  of  water,  since 
thereby  dust  is  prevented  from  accumulating  at 
the  bottom  ; and  it  is  well  to  pour  a little  strong 
nitric  acid  into  such  glasses  occasionally,  to 
effectually  remove  all  dust  and  deposits,  sub- 
sequently, of  course,  thoroughly  washing  them 
in  cold  water.  Tho  urine  should  be  allowed  to 
stand  six  or  eight  hours  at  least,  and  be  covered 
by  a plate  of  glass  ora  paper  cap,  to  prevent  the 
entrance  of  dust.  With  a clean  glass  pipette  a few 
drops  of  the  lowest  portion  of  the  fluid  may  he 
removed.  A collecting-glass  has  been  recently 
invented  whereby  the  lower  strata  of  urine  may- 
be drawn  off  from  the  bottom  by  a tap  ; but  a 
pipette  answers  all  ordinary  purposes.  It  is  con- 
venient to  have  the  glass  slide  to  which  tho 
drops  are  transferred  provided  with  a cell,  made 
by  a very  thin  circle  of  gold  size,  sinco  not  infre- 
quently large  casts  are  crushed  by  the  pressure 
of  the  cover-glass.  The  cell  also  answers  the. 
purpose  of  confining  the  fluid,  any  excess  of 
which  can  he  removed  with  blotting  paper.  Such 
an  arrangement  is  not  suitable  when  it  is  re- 
quired to  add  any  reagents  to  the  specimen. 

A preliminary  examination  with  the  lower 
power  is  occasionally  desirable,  but  it  is  with 
the  higher  power  that  a knowledge  of  the  nature 
of  any  deposit  that  may  be  present  is  obtained. 
The  following  objects  may  occur,  the  clinical 
significance  of  which  is  treated  of  elsewhere : — 

1.  Adventitious  matter,  dust,  — Even  with 

the  greatest  care  in  collecting  and  preparation, 
foreign  bodies  are  extremely  apt  to  be  met 
with,  the  commonest  of  which  are  hairs,  wool, 
cotton  and  flax  fibres,  minute  particles  of  wood, 
starch-granules,  sand,  and  oil-globules.  Besides 
these,  a number  of  extraneous  substances  may 
occur,  such  as  sputum  and  faeces,  the  source  of 
which  is  obvious,  whilst  occasionally  substances 
are  purposely  added  to  deceive  the  observer.  It 
is  absolutely  essential  that  an  acquaintance  with 
the  microscopic  appearance  of  all  such  objects 
be  possessed  by  the  medical  man. 

2.  Mums. — This  material  presents  itself  as 
finely  granular  streaks  and  smears  of  every 
variety7  of  size  and  shape,  often  mistaken  for 
casts,  and  occasionally  simulated  by  scratches  on 
the  slide  or  cover-glass. 

3.  Epithelial  cells. — These  may  be  derived 
from  all  parts  of  the  urinary  tract ; and  they 
include  glandular  spheroidal  or  polyhedral  Celia 


980  MICROSCOPE 

from  the  kidney,  especially  the  convoluted  tu- 
bules ; columnar  cells  from  the  ureter  and  the 
greater  portion  of  the  urethra ; and  flattened 
tesselated  scales  from  the  pelvis  of  the  kidneys, 
and  the  orifice  of  the  urethra.  Very  large  cells 
of  the  same  variety  come  from  the  vagina.  The 
vesical  epithelium  is  very  variable  in  appear- 
ance, but  is  generally  either  flattened  or  pyri- 
form, of  large  size,  and  not  always  to  be  distin- 
guished from  the  scales  from  other  parts. 

4.  Spermatozoa.  — Spermatozoa  occasionally 
occur  in  the  urine,  without  being  of  serious 
importance.  Their  characteristic  appearance  is 
not  easily  recognised  under  a magnifying  power 
of  less  than  300  diameters. 

5.  Blood.— Blood-corpuscles  in  the  urine  differ 
considerably  from  their  normal  biconcave  disc 
shape,  and  usually  shrink  into  irregularly-shaped 
particles,  but  they  may  swell  up  and  become 
globular  in  appearance,  these  changes  being  due 
to  alterations  in  the  density  of  the  fluid.  Under 
such  circumstances  the  corpuscles  are  not  very 
easy  of  detection,  and  if  but  very  few  in  number, 
may  not  always  bo  recognised  with  certainty, 
especially  as  there  are  many  other  objects,  such 
as  spores  of  fungi,  which  closely  resemble  them. 
If  the  blood  be  present  in  moderate  quantity,  it 
gives  a characteristic  colour  to  the  urine,  which 
suggests  the  presence  of  corpuscles.  The  discs 
more  rapidly  disappear  in  alkaline  than  acid 
urine,  remaining  in  the  latter  for  a considerable 
time. 

6.  Leucocytes. — Bodies  identical  with  white 
blood-corpuscles  are  sometimes  seen  entangled 
in  the  shreds  of  mucus  (mucous  corpuscles),  or 
may  be  derived  from  the  epithelial  surface ; 
and,  if  present  in  large  amount,  constitute  pus- 
corpuscles,  originating  from  pyelitis,  cystitis, 
urethritis,  leucorrboea,  rupture  of  an  abscess  into 
the  urinary  tract,  and  other  conditions. 

7.  Portions  of  new  growths. — Cells,  fibres,  and 
other  elements,  from  cancerous  and  other  neo- 
plasms of  the  urinary  organs  or  adjacent  struc- 
tures, such  as  the  uterus  and  the  rectum,  may 
be  detected  in  the  urine;  but  it  is  very  seldom 
that  the  diagnosis  of  the  existence  of  these  new 
growths  rests  upon  their  recognition  under  such 
circumstances.  . 

8.  Penal  tube-casts. — The  appearances,  nature, 
and  origin  of  these  bodies  have  been  fully  treated 
of  in  the  article  Casts. 

9.  Living  organisms. — The  urine  after  standing, 
at  the  onset  of  the  alkaline  fermentation,  con- 
tains bacteria  and  vibriones,  with  their  charac- 
teristic vibrating  movements ; sometimes,  also, 
various  forms  of  torula  and  even  sarcinre,  the 
former  often  in  association  with  diabetes  in  acid 
urine  ( Torula  ccrevisies  ; Penicillium  glaucum). 
Certain  entozoa  are  found  in  the  urine,  the  most 
important  of  which  is  the  Bilharzia  hcemotobia,  a 
trematode  worm,  which  causes  a peculiar  form  of 
endemic  haematuria.  The  ova  are  about  .tMM 
inch  in  length,  of  oval  form,  and  terminating  in 
a spine:  empty  egg-shells  and  flask-shaped  cili- 
ated embryos  are  present  in  large  quantities  in 
the  urine  of  patients  suffering  from  this  affec- 
tion, together  with  blood  and  pus.  Booklets  and 
fragments  of  echinococci  from  rupture  of  hydatid 
cysts  into  the  urinary  passages  may  sometimes 
be  detected  in  the  urine. 


IN  MEDICINE. 

10.  Fat. — In  the  condition  known  aschyluria, 
large  quantities  of  fat  in  a state  of  fine  mole- 
cules  and  minute  globules,  with  a few  leucocytes 
and  red  blood-corpuscles,  are  seen  by  the  aid  of 
the  microscope. 

11.  Salts — (a)  Amorphous. — During  the  so- 
called  ‘ acid  fermentation,’  which  takes  place 
within  a few  hours  after  the  passage  of  normal 
urine,  urates  of  soda,  potash , and  ammonia,  and 
occasionally  of  lime  and  magnesia,  are  thrown 
down  as  a granular  amorphous  deposit  of  a brick- 
dust  appearance  ; and  later,  during  the  ‘ alkaline 
fermentation,’  phosphate  of  lime  is  precipitated 
in  a similar  condition,  but  of  a white  colour. 
Microscopic  examination  is  useless  to  distinguish 
such  substances,  which  require  treatment  with 
heat  or  reagents  for  their  detection. 

(#)  Crystalline. — Uric  acid,  which  in  excess 
forms  the  cayenne-pepper-like  grains,  or  gravel, 
is  multiform  in  its  microscopic  appearances, 
presenting  as  it  does  typically  six-sided  plates, 
and  four-sided  rhombs,  but  often  ovoid,  barrel- 
or  comb-sbaped.  Owing,  to  the  affinity  of  the 
urinary  pigments  for  uric  acid  and  its  salts, 
such  crystals  are  usually  slightly  tinted— straw 
colour  to  pale  brown ; and  they  are  verv  fre- 
quently aggregated  into  masses,  and  of  the 
greatest  diversity  in  size. 

Oxalate  of  lime,  found  in  both  acid  and  alka- 
line urine,  especially  after  tho  ingestion  of 
rhubarb,  tomatoes,  and  certain  other  articles 
of  food,  occurs  as  octahedra,  or  more  rarely  as 
very  perfect  dumb-bells,  the  former  being  com- 
posed of  two  four-sided  pyramids  placed  base 
to  base,  appearing  when  seen  in  the  short  dia- 
meter as  a square  marked  by  two  bright  cross 
lines. 

Triple  or  ammonio-magnesian  phosphites  ar- 
deposited  in  alkaline  urine  as  triangular  prism: 
with  bevelled  ends,  and  differing  in  length;  whei 
very  short  simulating  the  oxalate  of  lime  octa 
hedra.  Stellate  crystals  of  the  same  substanc- 
have  been  seen. 

Phosphate  of  lime,  though  usually  amorphous 
occurs  sometimes  as  crystals  arranged  iu  ver 
characteristic  rosettes. 

Carbonate  of  lime,  of  very  rare  occurrenei 
appears  as  small  spheres. 

Lcucin  occurs  as  yellowish,  highly  refractia 
spheres,  almost  like  oil-globules,  and  as  needh 
like  scales.  Tyrosin  assumes  the  form  of  tuf 
of  very  fine  neodles.  Cystin  appears  as  reguh 
hexagonal  tablets  of  various  size,  frequently  la 
one  on  the  other.  Ha-matin,  derived  from  tl 
blood-pigment-,  has  been  found  in  minute  acic 
lar  crystals  in  the  urine  of  cases  of  hsmai 
nuria. 

For  the  simple  detection  of  most  of  the  abov 
mentioned  objects  no  reagents  are  necessary,  t 
urine  itself  being  sufficient ; but  the  more  trai 
parent  bodies,  such  as  casts  and  epithelial  cel 
are  often  rendered  easier  of  detection  by  sligh 
tinting  the  field  with  a drop  of  magenta  soluti- 
or  tincture  of  iodine.  The  crystalline  depos- 
may  be  preserved  by  mounting  in  Canada  b- 
Si'.m,  subsequent  to  washing  in  spirit  and  t- 
pentine  ; but  attempts  to  keep  for  any  tu 
casts,  or  epithelium,  are  usually  very  unsatisf- 
tory,  though  occasionally  successful  in  very  w 
glycerine  solution. 


M10K0SC0FE  IN  MEDICINE. 


(B)  Faeces. — It  is  not  often  that  the  matters 
passed  by  the  bowel  are  submitted  to  micro- 
scopic examination — not  so  often  perhaps  as  they 
should  be.  The  greater  part  of  the  motions  ap- 
jpears  to  consist  microscopically  of  amorphous 
granular  flakes  of  no  special  character ; these  are 
lor  the  most  part  the  degenerated  dead  epithelial 
cells  shed  from  the  mucous  membrane. 

Amongst  the  distinctly  recognisable  normal 
pbjects  are  starch-granules,  oil-globules,  shreds 
hid  fibres  cf  vegetable  tissue,  and  also  of  yellow 
dastie  tissue,  and  not  infrequently  leucin,  tyrosin, 
ind  eholesterine  crystals.  Various  fungi,  blood- 
,ind  pus-corpuscles,  crystals  of  triple  phosphates, 
nd  ova  of  entozoa,  are  among  the  most  impor- 
tant abnormal  objects  that  may  be  met  with. 

To  investigate  these  it  is  merely  sufficient  to 
fatten  out,  by  means  of  slight  pressure  on  the 
'over-glass,  a small  portion  of  the  motion,  in  a 
rop  of  dilute  glycerine.  Both  powers  should 
|e  employed,  since  many  of  the  fragments  are 
asily  recognised  when  magnified  sixty  or  eighty 
.iameters. 

(C)  Vomit. — This  should  be  examined  as  soon 
'is possible  after  expulsion,  and  the  liability  to  the 
■resenceof  all  kinds  of  extraneous  matter  should 
je  borno  in  mind.  Small  portions  may  be  spread 
iit  in  dilute  glycerine;  or  it  may  be  necessary 
i shake  up  the  matter  with  distilled  water,  and 
Ike  up  a few  drops  of  the  mixture  with  a pipette. 

It  is  impossible  to  give  any  accurate  descrip- 
pn  of  theappearaneesofthe  various  kinds  of  par- 
filly  digested  food;  hut  besides  the  characteristic 
arch-granules  and  the  gastric  epithelial  cells, 
ere  are  certain  bodies  which  it  is  often  of  im- 
rtance  to  be  able  to  recognise,  such  as  torulse 
d sarcinse,  blood-corpuscles,  and  cancer-cells. 

(D)  Sputum. — In  the  examination  of  the  ex- 
ctoration  the  microscope  is  often  of  great 
I ue,  as  thereby  the  exact  nature  of  the  con- 
ion  of  the  lungs  may  be  declared.  Small 
reds  of  the  sputum  should  he  separated  and 
read  out  on  the  slide,  and  covered  at  once ; 
netimes  a drop  of  dilute  glycerine  is  required. 

. is  obvious  that  the  expectoration  is  liable 

contain  all  kinds  of  objects  that  have  not 
ne  from  the  lungs — fragments  of  food,  epi- 
:lial  scales  from  the  tongue  and  mouth,  hairs, 

■ . — but,  excluding  all  such  bodies,  the  sputum 
lisists  of  a menstruum  of  viscid  mucus,  which 
. hardly  recognisable  under  the  microscope, 

■ '■ept  as  a very  finely  granular  film,  entangled 
if  which  are  innumerable  air-bubbles  of  all 
t is,  with  a few  leucocytes  (mucous  corpuscles), 

: i occasionally  a few  ciliated  epithelium-cells 
1 n the  air-passages.  If  a drop  of  acetic 
a 1 be  floated  in  beneath  the  cover-glass,  the 
mus  assumes  a finely  striated  appearance, 
it  the  nuclei  of  the  colls  are  rendered  very 
dlinct.  With  all  degrees  of  catarrh  and  in- 
timation of  the  mucous  tract  the  number  of 
h ocytes  becomes  more  and  more  abundant, 
"|i  occasional  red  blood-corpuscles  and  oil- 
gjiules,  the  latter  often  aggregated  into  sphe- 
re al  masses.  Black  particles,  due  to  inhaled 
ev,  or  coal  or  metallic  dust,  or  else  derived 
h i the  pigment  of  the  lung-tissue,  are  present 
st' trying  amounts.  When  the  lung  is  actually 
t»  king  down,  fragments  of  pulmonic  tissue 
uj  be  readily  recognised  under  the  microscope 


981 

by  the  characteristic  elastic  fibres,  which  are 
rendered  especially  distinct  by  the  addition  of 
acetic  acid,  or  by  previously  boiling  the  sputum 
with  solution  of  caustic  soda  (20  grains  to  the 
ounce),  which  clears  up  other  matter,  leaving 
the  elastic  tissue  untouched.  Vegetable  fibres 
derived  from  the  food,  and  which  also  resist  tho 
action  of  the  alkali,  must  not  be  mistaken  for 
the  lung-tissue. 

Among  other  objects  which  an  examination  of 
the  sputum  may  reveal  are  crystals  of  eholes- 
terine from  caseous  matter,  blood-crystals,  por- 
tions of  new  growths,  as  cancer-cells,  bacilli, 
and  hooklets  of  echinococcus. 

(E)  Blood. — By  an  examination  of  a drop  of 
blood  under  the  high  power,  the  relative  and 
actual  numbers  of  the  red  and  white  corpuscles, 
their  character,  and  the  presence  of  abnormal 
objects,  may  he  ascertained.  The  method  of 
estimating  the  number  of  corpuscles  is  fully 
detailed  under  the  heading  Hemacytometer. 
The  recognition  of  leucoeythtemia  to  a great 
extent  depends  upon  the  microscope,  by  which 
the  excess  of  white  corpuscles  is  at  once  mani 
fested. 

The  red  corpuscles  are  apt  to  undergo  altera- 
tion in  shape,  such  as  shrinking,  or  crenation, 
but  it  is  not  always  easy  to  determine  how  far 
such  may  be  the  result  of  the  preparation  of 
the  specimen. 

Living  organisms  are  occasionally  found  in 
the  blood— bacillus,  spirilla,  &c. — associated  with 
certain  septic  states,  such  as  malignant  pustule 
and  relapsing  fever.  For  their  detection  a higher 
power  is  needed,  and  no  satisfactory  investi- 
gation of  such  bodies  can  he  made  without  a 
power  of  700  diameters.  A small  nematoid 
worm,  the  Filaria  sanguinis-hominis,  about  yh 
inch  long  and  ^Jjg-inch  broad,  has  also  been 
found  in  the  blood.  See  Filaria  Sanguinis- 
Hominis. 

To  examine  the  blood  it  is  sufficient  to  prick 
the  finger,  apply  with  the  small  forceps  a clean, 
dry  cover-glass  to  the  wound,  and  gently  place  it 
on  the  slide,  interposing  a hair  at  the  edge  to 
prevent  the  corpuscles  from  being  crushed.  It  is 
necessary  to  have  enough  blood  to  form  a com- 
plete film,  as  otherwise  it  dries  very  quickly  and 
alters  in  appearance,  whilst  if  there  be  sufficient, 
the  edge  alone  will  dry,  and  prevent  the  central 
part  from  evaporating. 

(F)  Milk. — A drop  of  milk  placed  on  a slide 
and  covered  with  a thin  glass,  discloses  on  exa- 
mination fatty  granules  and  globules  of  all  sizes, 
with  sharply-defined  outlines,  and  kept  separate 
from  one  another  by  being  surrounded  by  invisi- 
ble films  of  transparent  casein.  In  the  milk 
secreted  immediately  after  delivery  will  he  seen 
colostrum  corpuscles. 

(G)  Morbid  Discharges. — The  microscope 
is  frequently  of  value  in  examining  discharges 
from  surfaces — for  instance,  in  leucorrhcea;  or 
from  abscesses  which  may  have  hurst.  In  the 
latter  cases,  besides  the  pus-cells,  fragments  of 
tissue  may  be  seen,  indicating  the  situation  of 
the  abscess  ; or  the  existence  of  a new  growth 
may  be  manifested  by  the  escape  of  small  por- 
tions in  the  discharge. 

(H)  Contents  of  Cysts. — These  are  for  the 
most  part  fluid  or  gelatinous,  and  leave  -cry 


082  MICROSCOPE  IN  MEDICINE. 

little  for  microscopic  examination.  Exception 
must  bo  made  to  the  echinococcus  hooklets  of 
hydatid  cysts,  the  fatty  matter  of  sebaceous 
cysts,  and  cholesterine  crystals,  so  commonly  met 
with  in  ovarian,  and  indeed  in  all  forms  of  cysts. 

(I)  Hew  Growths. — The  microscopical  cha- 
racters of  tumours  are  fully  described  under  the 
heads  of  Cancer  and  Tumours. 

(K)  Adulterations  of  Food,  Drugs,  &e. — 
By  means  of  the  microscope  many  impurities 
and  adulterations  may  be  discovered,  which 
would  otherwise  remain  unrecognised.  The  fol- 
lowing substances  which  are  extensively  used — 
namely,  starch  of  various  kinds,  improperly 
added  to  cocoa  and  mustard ; leaves  of  willow 
or  plum,  substituted  for  tea;  chicory,  a root  of 
a species  of  dandelion,  mixed  with  coffee ; sand 
with  sugar  ; red  lead  with  cayenne  pepper;  and 
many  pigments — indigo,  Venetian  red,  umber, 
turmeric ; as  well  as  different  salts,  sulphate 
and  carbonate  of  lime— are  at  once  detected 
under  the  microscope,  and  many  of  them  in  this 
way  only. 

(L)  Medico-Legal  Inquiries.  — Stains  of 
blood,  semen,  &c.,  on  clothing.  The  spots  should 
be  moistened  with  a few  drops  of  distilled  water, 
or,  better  still,  a per  cent,  solution  of  chloride 
of  sodium,  and  scraped  with  a sharp  knife  ; and 
the  fluid  then  transferred  to  a glass  slide,  and 
examined  in  the  usual  manner.  The  micro- 
scopical characters  of  spermatozoa  and  blood 
have  been  already  referred  to. 

(Consult  The  Microscope,  by  Dr.  Carpenter ; 
How  to  work  with  the  Microscope,  and  The  Micro- 
scope in  Clinical  Medicine,  by  Dr.  Beale ; Prac- 
tical Histology,  by  Professor  Rutherford ; and  A 
Course  of  Practical  Histology,  by  Professor 
Schitfer.) 

DESCRIPTION  OF  FIGURES. 

Fig.  28.— Bed  blood-corpuscles— human  : x 350. 

a.  Normal,  singly  and  in  rouleaux,  b.  Shrunk  from 
treatment  with  concentrated  fluid,  c.  Distended 
and  globular  from  absorption  of  water.  It  is  in  this 
condition  that  the  red  corpuscles  are  most  apt  to 
appear  when  mixed  with  various  fluids  of  the  body. 
Fig.  29.— Scaly  epithelial  cells  from  mouth,  vagina,  &c. 
x 200. 

Fig.  30. — Leucocytes.  Pus,  mucous  or  white  blood-cor- 
puscles. x 350. 

a.  Normal,  b.  After  treatment  with  acetic  acid; 
nuclei  very  apparent,  c.  Distended  and  rendered 
transparent  by  water. 

Fig.  31.— Ciliated  epithelial  cells  from  air-passages,  x 200. 
Fig.  32. — Cotton  fibres,  showing  characteristic  twist, 
x 100. 

Fig.  33.— Milk  showing  colostrum  corpuscles  and  oil-glo- 
bules, the  latter  very  variable  in  size,  and  with  a 
sharply  defined  outline,  x 200. 

Fig.  34. — Particles  of  vomited  matter,  x 250. 

a.  Starch  granules,  showing  characteristic  concentric 
lines,  b.  Fragments  of  partially  digested  muscular 
fibre. 

Fig.  35.— Epithelium  from  urinary  tracts,  x 200. 

a.  From  renal  tubules ; glandular,  b.  From  ureter 
and  urethra ; columnar,  c.  "Vesical. 

Fig.  36.— Spermatozoa  ; human,  x 350. 

Fig.  37.— Fragments  of  hair,  x 100. 

a.  Cortex,  b.  Epidermis,  c.  Medulla. 

Fig.  38.— Sarcina  ventriculi.  x 250. 

Fig.  39. — Hooklets  of  Echinococcus,  x 250. 

Fig.  40.— From  phthisical  sputum,  showing  elastic  fibres 
of  lung-tissue  and  leucooytes.  x 350. 

Fig  41.— Hsemin  crystals  from  old  blood-clot,  x 250. 
Pig,  42.— Cubes  of  chloride  of  sodium,  x 200. 

Fig.  43.— Leucin.  x 120. 

Fig.  44.— Tyrosiu.  x 120. 


MICTURITION,  DISORDERS  OF. 

Fig.  45. — Erie  acid,  various  forms,  x 120. 

Fig.  46.— Cholesterin  plates,  x 120. 

Fig.  47 — Cystin.  x 120. 

Fig.  48.— Oxalate  of  lime ; dumb-bells  and  oetahedii 
x 120. 

Fig.  49. — Triple  or  ammoniaco-magnesian  pliosnlate. 
x 120. 

Fig.  50.— Torula  cerevisim ; yeast  fungns.  x 350. 

Fig.  51. — Sputum  of  early  pneumonia,  showing  red  blood- 
corpuscles  and  leucocytes,  x 300. 

Fig.  52.— Shreds  of  elastic  tissue  in  sputum  of  phthhis 
x 300. 

Fig.  53. — Oidium  albicaus  ; thrush,  x 300. 

Fig.  54. — Penicilliiun  glaucum.  x 300. 

W.  H.  Allchw.  i 

MICRO  SPORON  ( ixiKpos , small,  and  avlpos, 
a spore). — The  fungus-plant  of  phytosis  or  tinea 
versicolor  ; also  named  epidermophyton.  Set 
Epiphytic  Skin-diseases;  and  Skin,  Diseases  of. : 

MICTURITION",  Disorders  of. — Under 
this  term  will  be  considered  those  conditions 
which  interfere  "with  the  normal  performance  of 
micturition,  regarded  as  a physical  act.  Thus 
suppression  of  urine  is  not  included  in  this  cate- 
gory, for  in  the  state  so  described,  the  urine  is 
not  secreted  by  the  kidney,  and  the  absence  of: 
the  secretion  is  not  due  to  any  physical  cause  in 
the  bladder  or  urethra.  The  following  will  he 
treated  of  as  disorders  of  micturition: — 

1.  Irritability  of  the  bladder  in  the  adult. 

2.  Diminished  size  of  stream. 

3.  Retention  of  urine,  partial  and  complete. 

4.  Urine  passing  by  an  abnormal  channel. 

5.  Incontinence  and  overflow  of  urine  in  the 
adult. 

6.  Incontinence  of  urine  in  the  child. 

1.  Irritability  of  the  bladder. — This  term  if 
never  to  be  employed  as  defining  any  morbic 
condition  of  the  bladder,  since  it  is  too  vague  t 
denote  anything  else  than  a symptom,  of  whicll 
the  practitioner  has  to  discover  the  cause.  It  il 
commonly  used  iu  widely  differing  senses,  and  con 
veys  therefore  no  definite  meaning  to  the  hearei 
As  denoting  a symptom,  it  may  be  held  to  impij 
the  simple  fact  of  unduly  frequent  micturition,  am 
should  never  be  used,  either  in  writing  or  other 
wise,  in  any  other  sense.  Whenever,  therefore,  tin 
phenomenon  is  present,  instead  of  regarding  : 
as  due  to  ‘ irritability  of  the  bladder  ’ as  so  fre 
quently  happens,  the  problem  to  be  solved  i 
what  is  the  cause  of  that  irritability  ? In  a! 
maladies  of  the  bladder,  and  in  most  that  affec 
the  kidney  also,  unnaturally  frequent  micturitio 
is  present.  It  may  vary  in  degree,  and  exi: 
alone  as  a single  symptom ; or  it  may,  as  is  mne 
more  usually  the  case,  be  accompanied  by  otke 
symptoms,  which  aid  the  diagnosis.  Thus  it 
present  in  all  the  inflammatory  conditions  of  tl 
bladder,  and  whenever  foreign  bodies  ortumou. 
exist  there.  Also  when  the  bladder  is  full,  a: 
either  habitually  does  not  empty  itself,  or  wh< 
absolute  retention  is  present,  in  either  ease  tl 
wants  to  pass  water  are  frequent  and  press  in 
It  is  often  present  in  stricture  of  the  urethr 
and  in  inflammations  of  that  passage ; also  j 
chronic  pyelitis,  simple  or  calculous,  in  chrou 
nephritis,  ,n  Bright's  disease,  and  in  diabet^ 
as  a result  of  the  increased  quantity  of  urn 
It  is  present  likewise  during  hysterical  stau 
and  under  emotional  excitements  iu  many  p>" 
sons  of  either  sex ; and  whenever  the  watery  t! 


( face  page  982. 


MICROSCOPE  IN'  MEDICINE. 


Drawings  Illustrating  Common  Objects  seen  with  the  Microscope  in  Medicme. 


MICTURITION, 
meats  of  the  urine  are  rapidly  and  abundantly 
eecreted. 

2.  Diminished  size  of  stream. — This  may  occur 
either  with  or  without  organic  obstruction  in  the 
passage.  It  is  always  present,  of  course,  in  con- 
genital narrowing  of  the  prepuce  or  of  the  exter- 
nal meatus ; in  organic  stricture  of  the  urethra  ; 
and  mostly  in  enlarged  prostate.  It  may  be 
occasioned  by  inflammation  of  the  urethra  and 
prostate;  and  by  impaired  power  in  the  bladder 
to  expel  its  contents,  from  partial  paralysis, 
atony,  or  other  cause.  Occasionally  the  channel 

1 is  narrowed  by  irregular  actions  of  the  sur- 
rounding muscles,  and  thus  ‘ spasmodic  stricture’ 
(not  a good  term)  is  spoken  of  as  producing  a 
diminution  of  the  stream. 

3.  Retention  of  urine. — Retention  of  urine, 
partial  or  complete,  is  not  to  be  confounded 
with  ‘suppression,’  the  latter  being  of  course 
defective  action  of  the  socreting  organ,  so  that 
no  urine  is  produced,  and  the  bladder  remains 
.empty.  Retention  is  the  product  in  almost  all 
cases  of  mechanical  obstruction,  such  as  enlarged 
prostate  from  hypertrophy,  tumour,  or  inflam- 
mation, or  stricture  of  the  urethra.  Impacted 
calculus  is  sometimes  the  cause ; sometimes  also, 
but  most  rarely,  the  spasmodic  action  referred 
to  above. 

Treatment. — As  the  cause  is  a purely  me- 
chanical one  in  the  great  majority  of  instances, 
the  remedy  which  should  be  applied  is  also  a 
nechanical  one,  namely,  a catheter  of  appro- 
priate size  and  kind.  The  instrument,  however, 
s not  always  at  hand,  and  medicinal  agents 
.ire  valuable  until  it  can  be  obtained.  At  the 
lead  of  these  no  doubt  is  opium,  which  allays 
nvoluntary  straining,  and  sometimes  thus  en- 
ibles  the  patient  to  relievo  himself  by  the 
latural  method,  at  all  events  to  some  extent.  It 
hould  be  given  in  full  doses,  for  the  purpose 
ither  of  relieving  the  patient’s  suffering  and 
.nxiety,  or  of  acting  favourably  on  the  func- 
ion;  and  the  error  in  practice  which  has  been 
nost  common  is  to  give  doses  of  10  to  15 
linims  of  laudanum  orliquor  opii,  when  30  to  40 
r more  were  necessary,  and  would  have  been 
ighly  useful.  Of  course  the  form  of  opiate  may 
e varied,  according  to  the  habits  of  the  patient, 
r the  views  of  the  attendant.  Simple  opium  is 
lerely  mentioned  here  as  the  type.  Local  bath- 
rig,  as  hot  as  it  can  bo  borne,  is  also  a valuable 
djunct.  Diuretics,  often  given,  are  for  the  most 
art  injurious  ; that  is  to  say,  when  the  cause  is 
mechanical  one ; the  same  must  bo  said,  in 
ich  circumstances,  of  the  tincture  of  the  per- 
iloriile  of  iron,  once  in  some  repute  in  retention 
’ urine.  As  a general  principle  also,  it  is  not  to 
i forgotten  that  purgation  commonly  promotes 
is  expulsive  action  of  the  bladder,  often  ma- 
rially  so,  and  tends  to  afford  relief. 

4.  Urine  passing  by  abnormal  passages. — The 
■ine  may  escape  by  abnormal  channels,  such 
fistul®.  This  condition  is  necessarily  named 
one  of  the  ‘ disorders  of  micturition,’  but  its 
'.ture  and  treatment  bring  it  solely  under  the 
.nds  of  the  surgeon. 

5.  Incontinence  and  overflow  of  urine  in  the 
'ult. — The  conditions  so  denoted  are  among 
ose  disorders  of  micturition  which  it  is  most 
iportant  to  understand.  Nothing  is  commoner 


DISORDERS  OF.  983 

than  to  find  a man,  probably  in  advanced  yearr, 
passing  urine  with  increased  frequency,  even 
sometimes  passing  it  without  his  will  or  know- 
ledge, during  sleep ; and  it  is  unfortunately  not 
uncommon  also,  that  he  is  told  that  this  is  a com- 
mon weakness  among  elderly  men,  inseparable 
from  the  fact  of  age,  and  either  not  amenable  to 
treatment,  or  not  worthy  of  serious  notice.  Many 
a life  has  been  endangered  most  certainly,  and 
some  even  lost  by  such  counsel.  This  condition  is 
often  loosely  spoken  of  as  ‘ incontinence  ’ of  urine ; 
of  which,  however,  it  is  not  only  not  an  example, 
but  on  the  contrary  indicates  a condition  of  a 
precisely  opposite  character.  The  confounding  of 
these  opposite  states  is  a matter  of  extreme  im- 
portance. AVhat  does  produce  frequent  micturi- 
tion and  so-called  incontinence,  is  a bladder  un- 
able to  empty  itself,  consequently  always  partially 
if  not  completely  filled,  from  which  the  surplus 
must  be  either  frequently  discharged,  or  runs  off 
‘ incontinently.’  The  important  point,  then,  is 
never  to  lose  sight  of  the  fact  that  frequent 
micturition,  and  above  all  urine  involuntarily 
passed  by  elderly  men,  in  nineteen  cases  out  of 
twenty  indicates  retention  (requiring  the  cathe- 
ter), and  not  incontinence. 

True  incontinence,  which  means  inability  to 
retain,  on  the  part  of  the  bladder,  is  a very  rare 
occurrence,  and  is  present  almost  invariably  only 
in  cases  of  disease  in  the  nervotfe  centres  pro- 
ducing paralysis  in  other  parts  of  the  body,  as 
well  as  the  bladder.  AVhen  the  bladder-symptoms 
alone  are  present,  and  no  signs  of  paralysis  else- 
where exist,  it  maybe  held  as  almost  absolutely 
certain  that  the  bladder  itself  is  not  paralysed. 
It  may  be  over-distended  with  fluid  from  en- 
larged prostate  ; or  its  coats  may  be  thinned  and 
atonied,  and  so  unable  to  contract  on  their  con- 
tents ; but  there  is  no  true  paralysis  of  the 
bladder  (commonly  as  that  term  is  often  em- 
ployed) without  central  lesions  of  the  kind  above 
referred  to,  and  affecting  other  functions  also 
besides  that  of  micturition. 

Treatment.— In  these  partial  retentions  of 
urine,  producing  its  overflow  and  involuntary 
discharge,  the  remedy  is  the  catheter,  and  the 
case  is  mainly  surgical.  There  are  some  in- 
stances in  which  restoration  of  the  power  of  tho 
bladder  may  be  attempted  by  medicinal  agents, 
such  as  strychnia,  iron,  and  electricity,  but  their 
effect  is  little  or  none,  apart  from  the  habitual 
emptying  of  the  organ  by  artificial  means.  In 
some  cases  perhaps  they  may  be  advantageously 
associated  with  the  surgical  treatment. 

6.  Juvenile  incontinence. — A brief  sketch  of 
this  common  and  well-known  affection  is  all 
that  our  limits  will  admit.  Nevertheless  it  is 
one  relative  to  which  much  might  be  written, 
without  exhausting  a subject  the  pathology  of 
which  has  wide  and  manifold  relations. 

In  the  earliest  periods  of  childhood  an  undue 
frequency  of  passing  water  is  often  to  be  observed 
among  individuals  of  both  sexes,  more  com- 
monly in  boys  than  in  girls.  As  age  advances  the 
infirmity  usually  lessens,  and  then  disappears; 
whilst  in  exceptional  instances  it  continues,  with- 
out change,  to  puberty,  and  even  for  some  years 
after  that  period  has  arrived.  But  the  pecu- 
liarity of  the  case  is  that  the  urine  is  passed 
unconsciously  during  sleep,  and  this  forms  thi 


9S1  MICTURITION.  DISORDERS  Or. 


most  serious  symptom.  In  spite  of  all  precau- 
tions a quantity  of  urine  is  discharged  every 
night  during  deep  sleep,  an  occurrence  of  which 
the  child  is  quite  unaware,  and  which  as  he 
advances  in  age  he  is  wholly  unable  to  control, 
however  strong  may  be  his  disposition  to  do  so. 
On  the  bladder  becoming  distended  reflex  action 
of  the  vesical  muscular  coats  takes  place,  and  the 
contents  are  discharged.  The  flow  of  urine  is  de- 
termined, as  it  would  appear,  not  by  inability  on 
the  part  of  the  bladder  to  retain  a small  quantity 
of  urine,  but  by  its  undue  excitability  or  readi- 
ness to  contract,  so  that  the  act  of  micturition 
can  be  exerted  while  the  will  is  in  abeyance 
through  sleep.  There  appears  to  be  something 
analogous  between  this  condition  and  that  which 
determines  in  after-life  seminal  emissions  under 
similar  circumstances.  In  a few  instances,  cer- 
tain aberrations  from  a good  standard  of 
health  seem  to  favour  the  production  of  these 
phenomena,  especially  sources  of  irritation  in  the 
rectum,  which  produce  activity  in  that  muscular 
apparatus,  involving  also  the  kindred  muscles 
of  the  bladder,  which  are  so  closely  associated. 
Thus  the  presence  of  ascaridos  or  other  foreign 
agents  may  suffice  to  occasion  expulsive  action  in 
the  bladder.  During  the  period  of  infancy  and 
early  childhood  the  nervous  system  is  highly 
impressionable,  and  the  habit  in  question  being 
accidentally  set  up,  its  persistence  may  result 
solely  from  repetition  through  the  force  of  cus- 
tom. long  after  ths  original  cause  has  disap- 
peared. 

Sometimes  slight  malformations  of  the  male 
organ  favour  the  occurrence  of  incontinence ; 
such  as  a narrow  meatus,  or  a long  prepuce 
which  is  never  retracted,  and  is  consequently  in 
an  unhealthy  state. 

Precocious  development,  and  extreme  activity 
of  the  mental  faculties,  producing  disturbed  sleep, 
seem  to  favour  the  occurrence  of  incontinence. 
On  the  other  hand,  it  is  sometimes  associated 
with  a morbid  deficiency  of  intelligence. 

Treatment.—1 The  treatment  ordinarily  neces- 
sary may  be  to  some  extent  inferred,  when  ex- 
amination of  the  patient  has  determined  the 
oresence  or  absence  of  the  conditions  named. 
This  done,  the  next  indication  is  to  subdue  the 
ictivity  of  the  expulsive  function  of  the  bladder 
by  some  agent  which  possesses  that  power.  The 
most  powerful  for  this  purpose  is  undoubtedly 
belladonna;  one  of  the  most  notable  qualities 
of  this  drug  is  its  temporary  influence  to  pro- 
duce a paralysed  condition  of  the  vesical  mus- 
cles. Thus,  if  administered  to  an  adult  whose 
powers  of  expelling  urine  are  feeble,  such,  for 
example,  as  are  commonly  met  with  in  ad- 
vancing years,  complete  retention  of  urine  is 
often  produced.  Of  this  the  writer  has  seen 
many  marked  illustrations.  Now,  as  has  already' 
been  observed,  in  not  a few  of  the  cases  of  so- 
ralled  ‘juvenile  incontinence,’  its  existence  is 
due  solely  to  persisting  habit  after  the  original 
occasion  of  it  has  long  ceased  ; and  these  are 
certainly  and  rapidly  cured  by  administering  the 
agent  in  question.  We  have  only  to  induce  a 
partial  paralysis  of  the  bladder  for  a week  or 
two,  or  for  a few  weeks  at  most,  and  by  this 
means  not  only  to  destroy  the  old  habit,  but  to 
develop  a new  one,  namely,  a habit  of  retention, 


and  the  annoyance  disappears  entirely  and  for 
ever.  On  meeting,  therefore,  with  a case,  whether 
in  childhood  or  youth,  the  first  indication  is  to 
correct  any7  manifest  deviation  from  the  ordi- 
nary standard  of  general  health;  and  secondly, 
to  administer  belladonna  persistently.  Small 
doses,  suited  to  the  age  of  the  patient,  suffice 
at  first,  and  may  be  given  every  afternoon  and 
evening  only — say  from  eight  to  fifteen  minims 
of  the  tincture  on  each  occasion  during  the  first 
week.  In  the  second  week  of  treatment,  the 
dose  may  be  augmented  one  half;  and  in  the 
third  week  the  original  dose  is  doubled ; meantime 
some  improvement  will  almost  certainly  now  he 
manifest.  Since  the  ability  to  bear  belladonna  in- 
creases rapidly  as  the  system  becomes  habituated 
to  it,  a large  dose  may  be  given  during  another 
term  of  three  successive  weeks,  by  which  time  the 
involuntary  discharge  of  urine  probably  ceases. 
After  this  the  dose  may  be  gradually  diminished, 
and  at  a rate  more  rapid  than  it  was  augmented: 
the  habit  of  retention  has  probably  been  formed 
by  this  time,  and  when  cessation  from  medicine 
takes  place,  no  recurrence  of  the  symptoms  will 
be  observed.  Such  is  the  writer's  experience  in 
a considerable  proportion  of  the  cases  which 
have  fallen  in  his  way.  But  it  must  be  confessed 
that  a troublesome  minority  is  met  with  in  which 
the  belladonna  has  had  little  or  no  useful  in- 
fluence. It  generally  exerts  some,  however,  and 
it  is  worth  while  to  be  careful  that  the  drug  has 
been  well  prepared.  Thus  the  writer  has  been 
successful  with  the  belladonna  of  one  chemist 
after  failure  with  that  of  another.  Now,  in  regard 
of  these  obstinate  and  exceptional  cases,  what 
remains  to  be  done  ? It  may  be  assumed  that 
an  exhaustive  observation  has  been  made  of  all 
the  functions,  especially  of  those  which  perform 
digestion,  and  that  it  is  unnecessary  to  insist 
further  on  this  score,  or  to  suggest  the  numerous 
details  which  such  consideration  gives  rise  to. 
All  this  done,  there  still  remain  modes  of  treat- 
ment of  a local  character,  which  ultimately 
almost  always  prove  successful  in  these  cases. 
These  do  not  include  blisters  on  ihe  sacrum: 
apparatus  to  prevent  the  patient  lying  on  his 
back,  when  asleep ; arrangements  to  arouse  him 
during  the  night  once  or  twice  to  pass  watei 
voluntarily,  and  such  measures — all  of  which 
are  palliative  means,  and  do  little  towards  a 
radical  cure,  and  which  constituted  the  chief 
agencies  employed  some  years  age. 

Superior  to  all  these  in  the  writer's  hands  ha: 
been  the  application  of  a solution  of  nitrate  o 
silver  to  the  urethra,  whether  in  the  male  o: 
female.  Even  the  use  of  a flexible  bougie,  smal 
of  course  for  children,  passed  daily,  and  removei 
in  the  course  of  a minute  or  so,  is  sometime' 
successful.  But  if  this  fails,  the  injection  bj 
means  of  a sufficiently  long  tube  of  the  solutio 
named  to  the  prostatic  portion  of  the  urethra  am 
neck  of  the  bladder,  is  a remedy  of  no  mean  value 
Eqr  young  women  up  to  the  age  of  eighteen  o 
twenty  in  whom  this  unfortunate  infirmity  stii 
exists,  the  writer  has  found  it  almost,  if  nc 
invariably,  successful.  It  should  be  apphe 
immediately  after  the  bladder  is  emptied.  ■ 
quantity,  say,  of  a drachm,  and  of  a minimui 
strength  of  ten  grains  to  the  ounce,  up  to  trebi 
that  strength  if  necessary  for  subsequent  appl 


MICTURITION,  DISORDERS  OR. 
cations.  Enough  should  be  employed  to  produce 
decided  smarting,  which  shall  continue  for  a day 
or  two.  A week  or  two  should  be  permitted 
to  elapse  between  each  application. 

It  would  not  be  right  to  omit  the  mention  of 
other  remedies  besides  belladonna,  which  may 
be  used  either  alone  or  in  combination  with  it. 
Such  are  the  tincture  of  the  perchloride  of  iron  ; 
strychnia ; tincture  of  cantharides ; and  bromide 
of  potassium.  The  latter,  given  at  night  only, 
has  sometimes  a manifestly  beneficial  effect. 

Henry  Thompson. 

MIGRAINE. — A synonym  for  megrim.  See 
Megrim. 

MIGRATION  OF  CORPUSCLES.— The 

iseape  of  blood-corpuscles  through  the  walls  of 
ninute  vessels,  and  their  passage  into  the  sur- 
rounding tissues.  The  process  is  chiefly  seen  in 
nflammation.  See  Inflammation. 

MILIARIA  ( milium , a grain). — Synon.  : 
iudatoria  ( sudamina ) ; Fr.  Miliaire  ; Ger. 
't'riesel. 

Definition. — A vesicular  eruption  of  the 
kin,  generally  associated  with  profuse  sweating, 
nd  sometimes  with  pyrexia. 

Description. — The  proximate  cause  of  milia- 
ia  is  reduction  of  the  vitality  of  the  skin,  under 
he  influence  of  extreme  heat  and  sweating, 
'he  vesicles  have  the  bulk  of  millet-seeds ; are 
eveloped  close  to  the  pores  of  the  skin ; are 
enerally  discrete  ; and  are  dispersed  irregularly 
ver  the  surface.  They  are  thin,  and  contain  at 
rst  a pellucid  serum,  which  by  magnifying  the 
ypewemic  base  on  which  they  are  developed, 
lives  them  a red  appearance — miliaria  rubra ; in 
more  advanced  stage  the  serum  becomes  milky 
id  opaque,  and  then  the  eruption  is  called 
Maria  alba.  When  left,  to  themselves  the 
isicles  subside  and  dry  up  into  an  extremely 
jlin  scale. 

Treatment. — The  treatment  of  miliaria  con- 
its in  subduing  whatever  feverish  symptoms 
ay  be  present;  in  lightening  the  clothing  and 
- verings ; in  the  use  of  tepid  baths  and  tepid 
onging;  and  after  the  bath,  dusting  the  skin 
th  some  absorbent  powder,  such  as  fuller's 
jrth.  Sponging  with  lime-water  is  also  use- 
1 ; and  the  use  of  a lotion  in  which  oxide  of 
ic  is  suspended  in  lime-water,  in  the  propor- 
® of  two  scruples  to  an  ounce.  This  should 
painted  on  the  affected  parts  of  the  skin,  and 
owed  to  dessicate  thereon. 

Erasmus  Wilson. 

MILIARY  ANEURISMS.— Minute  dila- 
tions in  connection  with  the  small  blood-ves- 
ts; especially  met  with  in  the  brain.  See 
■ ain,  Vessels  of,  Diseases  of. 

MILIARY  NEVER.- — A febrile  condition 
i ended  with  the  eruption  of  miliaria.  See 

1 MARIA. 

MILIARY  TUBERCLES.— True  tuber- 
jk  which  appear  in  the  form  of  minute  granu- 
i ons.  See  Tubercle. 

ULIUM  (Latin). — A term  suggestive  of 
- d size  and  roundness,  resembling  a millet- 
8 l ; a synonym  of  grutum.  See  Grutum. 


MINERAL  WATERS.  9S5 

MILK  FEVER. — Synon.:  Ephemeral  Fever; 
Fr.  Fievre  laiteuse-,  Ger.  Milchfieber. 

Definition. — A certain  amount  of  constitu- 
tional disturbance,  accompanying  the  flow  of 
milk  to  the  breasts,  on  the  second  or  third  day 
following  delivery. 

■/Etiology. — This  condition  appears  to  affect 
chiefly  those  who  are  in  a feeble  state,  from 
want  of  nourisnment,  loss  of  blood,  or  other 
cause  ; or  to  occur  when  the  child  has  not  been 
put  to  the  breasts  sufficiently  early  to  free  the 
milk-tubes. 

Symptoms. — The  symptoms  of  milk-fever  are 
sometimes  slight,  and  pass  off  very  quickly,  in 
which  case  the  term  ‘ ephemeral’  is  appropriate ; 
but  not  infrequently  the  fever  runs  high,  the 
temperature  reaching  beyond  102°  Fahr.,  and 
the  pulse  beating  140  in  the  minute,  from  which 
state  recovery  is  less  rapid.  The  patient  is 
generally  seized  suddenly  with  severe  rigors  ; 
her  teeth  chatter,  there  is  a sensation  of  cold 
water  running  down  her  spine,  and  she  calls  for 
blankets  and  hot-water  bottles.  At  this  time  the 
breasts  are  swollen  and  sensitive.  This  chill 
soon  gives  way  to  a hot  stage,  which  may  last 
from  two  to  twelve  hours  ; the  head  aches  fear- 
fully ; there  is  pain  in  the  limbs,  restlessness,  a 
dry  tongue,  thirst,  and  sometimes  delirium.  The 
breasts  now  become  hard  and  knotty,  and  very 
painful  when  touched.  Then  follows  the  sweat- 
ing stage,  from  which  great  relief  is  experienced ; 
as  a rule  the  breasts  become  softer,  and  milk 
commences  to  flow  from  the  nipples ; the  tem- 
perature falls;  and  all  the  symptoms  abate. 
Sometimes,  however,  the  breasts  remain  hard, 
and  an  abscess  forms  in  one  of  them,  in  which 
case  the  temperature  still  remains  high,  though 
the  other  feverish  symptoms  subside. 

Treatment. — During  the  cold  stage  the  desire 
of  the  patient  for  hot-water  bottles  and  blan- 
kets should  be  gratified ; and  care  should  be 
taken  not  to  diminish  the  amount  of  clothing 
too  rapidly  during  the  hot  stage.  The  bowels 
should  be  evacuated.  A diaphoretic  mixture 
should  be  administered  ; and  the  child  should 
be  put  to  the  breasts  as  soon  as  the  sweating 
stage  sets  in.  Clement  Godson. 

MILFHOSIS  (fii\<pw<ns,  falling  off  of  the 
hair). — Synon.  : Milkosis.— Falling  off  of  hair, 
especially  of  the  eyebrows ; an  obsolete  term. 

MIMOSIS  (fii/ilofiai,  I imitate). — Aterm  ap- 
plied to  the  phenomena  of  a disease,  which  re- 
semble or  imitate  those  of  another  disease. 

MIND,  Disorders  of.  Sec  Idiocy  ; and 
Insanity. 

MINERAL  WATERS.  — Definition. — 
Mineral  waters  is  the  name  given  to  those  waters 
which,  on  account  of  the  different  saline  or 
gaseous  substances  which  they  hold  in  solution, 
or  of  their  elevated  temperature,  are  used  in  the 
treatment  of  disease,  either  internally  or  in  the 
various  forms  of  baths. 

The  science  that  treats  of  the  effects  of  mine- 
ral waters  and  baths  on  a great  number  of 
chronic  maladies  is  called  balneotherapeutics.  Ir. 
a wider  sense  this  branch  of  medicine  comprises 
also  the  use  of  sea-baths  and  of  common  water,  but 
these  subjects  are  treated  in  separate  articles. 
See  11yd-  otiierafeutics  ; and  Sea  Air. 


3IINEKAL  WATEBS. 


Courses  of  mineral  waters  and  baths  are  to  he 
regarded  as  methods  of  treatment  analogous  to 
courses  of  other  remedies,  but  they  are  much 
more  complicated,  not  only  because  many  of  the 
mineral  waters  are  in  themselves  compound  re- 
medies, containing  several  active  substances  in 
combination,  but  also  because  in  most  courses 
of  waters  or  baths  the  invalid  is  influenced  by 
several  other  powerful  agents,  such  as  travel- 
ling, change  of  social  conditions,  of  occupation, 
scene,  and  diet,  change  of  climate,  and  increased 
exercise.  Each  of  these  influences  has  in  itself 
a powerful  action,  and  to  their  combination  wc 
must  often  ascribe  a great  part  of  the  curative 
effects  of  balneotherapeutic  courses;  they  ought 
therefore  to  be  carefully  considered  in  every 
individual  case  as  part  of  the  plan  prescribed. 
We  are  unable  in  this  article  fully  to  discuss 
these  important  concomitant  influences,  but  may 
refer  for  their  critical  estimation  to  Dr.  Braun’s 
treatise  On  the  curative  effects  of  Baths  and 
Waters  (Smith,  Elder,  and  Co.  1875),  and  other 
works. 

As  most  chronic  diseases  are  treated  by  other 
remedies  as  well  as  by  balneotherapeutic  courses, 
the  physician  must  in  every  case  consider  whether 
and  when  mineral  waters  are  to  be  used,  either 
instead  of  other  remedies,  or  in  combination,  or 
in  alternation  with  them. 

General  Composition  and  Classification. — 
The  principal  constituents  of  mineral  waters 
are : — water,  soda,  magnesia,  lime,  and  iron ; 
combined  with  hydrochloric,  sulphuric,  carbonic 
and  hydro-sulphuric  acids,  the  two  latter  exist- 
ing also  in  some  waters  ‘free,’  that  is,  uncom- 
bined with  bases.  Nitrogen  and  oxygen  are  like- 
wise present  in  most  mineral  waters  in  various 
proportions ; and  in  some  there  are  also  silica, 
arsenic,  bromine,  iodine,  Jithia,  manganese, 
potash,  organic  matters,  and  several  other  sub- 
stances in  small  quantities. 

The  substances  dissolved  in  mineral  waters 
are  derived  from  the  surface  soil  and  the  rocky 
strata  through  which  the  water  deposited  from 
the  atmosphere  passes.  The  dissolving  power 
of  this  water  is  much  increased  by  the  gases 
which  it  absorbs,  especially  carbonic  acid  and 
oxygen.  The  constitution  of  mineral  waters, 
therefore,  varies  according  to  the  nature  of  the 
strata  through  which  they  have  passed. 

The  different  mineral  waters  may  be  grouped 
in  various  ways,  as,  for  instance,  according  to 
their  chemical  constituents,  their  temperature, 
their  geological  origin  or  geographical  distri- 
bution, or  their  physiological  or  therapeutical 
actions. 

The  chemical  classification,  imperfect  though 
it  is,  offers  the  advantage,  that  it  directs  the 
attention  at  once  to  the  most  important  consti- 
tuents of  the  water.  Some  of  the  classes,  how- 
ever, are  not  named  according  to  the  substances 
contained  in  them  in  the  largest  quantity,  but 
according  to  those  considered  most  potent ; such 
as  the  iron  and  sulphur  waters.  Another  diffi- 
culty in  the  classification  is,  that  some  mineral 
waters  contain  several  active  substances  in 
sufficiently  large  proportions  to  allow  of  their 
being  placed  in  different  classes ; and,  again, 
that  some  springs  are  so  deficient  in  active 
principles  as  to  render  it  doubtful  where  to 


place  them.  Of  these  latter,  some  appear  to 
owe  their  virtues  to  the  water  alone,  and  its 
temperature,  aided  by  the  climate  in  which  they 
are  situated.  Beginning  with  the  latter  as  the 
most  simple,  we  may  group  the  mineral  waters 
in  the  following  principal  classes ; — 

I.  Simple  thermal  waters. 

II.  Common  salt  or  muriated  saline 
waters. 

III.  Alkaline  waters. 

IV.  Sulphated  saline  waters. 

V.  Iron  or  chalybeate  waters. 

VI.  Sulphur  waters. 

VII.  Earthy  and  calcareous  waters. 

Some  of  the  waters  are  chieflyusedforbathinz 
others  more  for  drinking,  the  majority  for  bot'r’ 
purposes.  In  the  consideration  of  the  uses  of 
the  different  spas,  it  is  important  to  distinguisi 
between  the  etfeets  produced  by  the  baths,  and 
those  caused  by  the  internal  use  of  the  waters 
and  in  larger  works  the  plan  followed  bv  Dr 
Braun,  namely,  to  devote  one  section  to  ‘bathing 
and  another  to  ‘ drinking  courses  of  miners 
waters,’  offers  advantages  to  the  student ; but  ii 
an  article  like  the  present  it  would  be  ineon 
venient,  as  frequent  repetitions  would  he  neces- 
sary. 

The  term  ‘ baths  ’ comprises  not  only  the  or 
dinary  tub  bath,  but  also  swimming  baths,  01 
piscines ; partial  baths  fortbe  feet,  the  hands, am 
other  parts ; douches  of  great  variety ; vapou 
baths;  and  mineral  mud  baths.  At  manvplace 
also  inhalations  of  vapour  and  pulverised  spra 
form  part  of  the  treatment. 

We  will  now  give  a short  account  of  thl 
different  classes. 

I.  Simple  thermal  waters. — The  simpl 
thermal  waters  are  characterised  by  poverty  ii 
solid  and  gaseous  substances,  and  hence  lo' 
specific  gravity;  by  perfect  transparency;  b 
great  softness ; and  by  elevated  temperature- 
varying  in  the  different  spas  from  about  80°  t 
over  150°  Fahr.  Some  of  them  contain  nitroge 
in  larger  proportions  than  the  gases  of  wate; 
usually  do,  others  oxygen.  They  are  often  calk 
indifferent  waters,  on  account  of  the  absence  < 
special  mineralization ; and  also  wild  baths  (Wilt 
bdder ),  on  account  of  their  being  usually  situate 
in  wild  mountainous  regions. 

Action. — The  water  of  this  class  of  spas  wht 
taken  internally  probably  acts  only  as  ordina 
very  pure  warm  water.  By  the  drinking  of  wap 
as  well  as  of  cold  water,  the  stomach  is  wash 
out;  the  secretion  of  bile,  saliva,  pancreatic  juit 
urine,  etc.  is  increased;  the  tissue-change  is  au 
mented,  and  the  removal  of  effete'  matters  fre 
the  tissues  and  blood  promoted ; and  by  t 
acceleration  of  the  retrogressive  tissue-chant 
the  progressive  tissue-change  becomes  facilitate 
As  differences  between  warm  water  and  et 
water,  we  may  mention  that  the  latter  acts  m< 
as  a local  excitant  on  the  stomach,  while  t 
former  is  more  easily  absorbed,  and  makes  1 
demands  on  the  powers  of  the  constitution, 
not  causing  any  expenditure  of  heat. 

The  simple  thermal  waters  are  much  mf 
used  for  bathing  than  for  drinking  courses:  at 
the  baths,  as  such,  have  probably  the  effects! 
ordinary  warm  baths,  varying  according  to  t* 


MINERAL  WATERS. 


temperature  of  the  Laths,  and  the  time  spent  in 
them. 

As  the  fundamental  effects  of  warm  baths, 
which  effects  form  part  of  the  action  of  all  kinds 
bf  -warm  baths,,  simple  as  well  as  mineralised,  we 
tnay  regard : — 

( 1 .)  That  they  soften  and  purify  the  skin  more 
rapidly  than  cold  baths,  and  prepare  it  for  per- 
spiration. 

(2.)  That  they  equalise  and  diminish  the  loss 
)f  heat,  and,  according  to  the  temperature  of  the 
bath,  lessen  and  prevent  it  altogether  ; and  that 
a the  hot  bath,  heat  is  even  added  to  the  body. 

(3.)  That  the  circulation  in  the  skin  is  accele- 
■ated. 

(4.)  That  the  organic  functions  and  the  tissue- 
:hange  are  slightly  stimulated,  or  rather  facili- 
ated,  without  any  strong  reaction  on  the  part  of 
he  organism. 

(5.)  That  the  nervous  system  and  muscular 
rritability  are  calmed. 

(6.)  That  the  absorption  of  exudations  is  pro- 
noted. 

These  effects,  as  already  mentioned,  vary  con- 
iderably  with  the  degree  of  heat.  In  the  tepid 
ath  (from  80°  to  95°  Fahr.)  the  central  nervous 
ystem  and  the  action  of  the  heart  are  but 
lightly  influenced;  in  the  viarm  bath  (from  £6° 
o 102°  or  103°)  the  heart’s  action  is  quickened, 
ut  the  respiration  is  generally  but  slightly  af- 
fected; in  the  hot  hath  (from  103°  to  110°  F.) 
lie  central  nervous  system  becomes  much  more 
-xcited;  not  only  is  the  heart’s  action  further 
iccelerated.but  therespirationbecomesrapid,  and 
pmetimes  irregular  ; and  the  hypertemia  of  the 
linleads  to  perspiration  on  removal  from  the  bath. 
Baths  of  a temperature  above  1 1 0°  are  scarcely 
>Ter  used,  and  only  for  a very  few  minutes.  The 
'Tacts  vary  also  considerably,  according  to  the 
uration  of  the  immersion. 

Uses. — The  drinking  courses  of  these  waters 
l‘.ay  assist  iu  the  treatment  of  irritable  forms  of 
factions  of  the  throat,  stomach,  and  intestines, 
ith  spasmodic  cough,  cardialgia,  constipation 
;om  sluggish  secretion  of  bile  and  intestinal 
dees ; and  by  increasing  the  tissue-change,  they 
•e  useful  in  chronic  rheumatism  and  gout. 

One  of  the  main  uses  of  the  simple  thermal 
iths  is  to  allay  over-excitability  and  hyper- 
nsibility  of  the  nervous  system  in  its  various 
iheres;  thus  they  often  act  beneficially  in 
ses  of  neuralgia,  hypercesthesia,  painful  men- 
ruation,  and  hysterical  tendency.  Their  re- 
lation in  painful  wounds  and  cicatrices  is 
statical.  In  these  cases,  as  well  as  in  chronic 
eumatism  in  its  various  forms,  and  sciatica, 
'e  hotter  are  more  useful  than  the  tepid  baths. 

! some  forms  of  paralysis  and  loss  of  muscular 
tver  depending  on  peripheral  changes,  such  as 
udations  on  nerve-sheaths,  good  effects  are 
oduced  ; but  if  they  are  caused  by  changes 
the  centres  of  the  nervous  system,  not  much 
to  be  expected.  In  gout  the  internal  use  of 
aer  mineral  waters  is  generally  required,  but 
second  courses  the  simple  thermal  waters  are 
en  useful ; and  in  many  delicate  gouty  per- 
is the  balneotherapeutic  treatment  ought  to 
restricted  to  courses  of  tepid  baths,  aided  by 
mata  and  diet.  Most  of  these  conditions  can 
also  treated  with  other  waters. 


987 

Enumeration',  and  Selection. — The  choice 
of  a simple  thermal  spa  is  to  be  guided,  not  by 
the  name  of  the  disease  alone,  but  also  by  the 
state  of  constitution,  and  many  concomitant  cir- 
cumstances. The  simple  thermal  waters  deserve, 
catcris  paribus,  the  preference,  when  gentle 
management  is  required — when  it  is  desirable 
to  make  as  slight  demands  as  possible  on  the 
powers  of  the  constitution.  Their  action  is  in 
this  respect  greatly  assisted  by  the  mountainous 
climate  enjoyed  by  the  majority  of  these  baths. 
The  selection  of  a special  spa  in  a given  case 
depends  on  the  nature  of  the  case  in  the  widest 
sense  ; on  the  degree  of  elevation  which  is  desi- 
rable ; on  the  means  of  treatment  obtainable  and 
customary  at  the  different  spas,  including  the 
most  important  agent — the  spa  physician  ; on  the 
accommodation,  the  food,  manner  of  living,  and 
social  conditions  ; on  the  distance  and  means  of 
reaching  the  spa;  and  on  many  other  circum- 
stances. Information  on  these  subjects  can  only 
be  obtained  by  the  study  of  larger  works  ( see 
the  English  edition  of  Braun's  Work  on  Baths, 
pp.  123  to  192),  and  by  personal  visits.  We  can 
give  here  only  the  names  of  the  principal  spas  of  thi  s 
class  arranged  according  to  their  elevation 


Elevation 

Tempera- 

Name. 

Country. 

(approxi- 

mative). 

Feet. 

lure  of 
springs 
Fahren 
heit. 

Panticosa 
Lenkerbad  ) 
(Loeche  j- 

Spain  (Pyrenees) 

5000 

77°-02° 

Switzerland 

4600 

102°-122° 

les  Bains)  ) 
Bormio 

Italy 

4300 

90°-104° 

Gastein 

Austrian  Alp3 

3300 

95°-114-8c 

Pfaffcrs 

Switzerland 

2115 

100  4° 

Jokannisbad 

Bohemia 

2000 

86° 

Bagneres  de  ) 
Bigorre  J 

France 

(PjTenees) 

1850 

90°-95° 

Ragatz 

Switzerland 

1570 

96° 

Badenweiler 

Baden 

1425 

8G°-90  5° 

Landeck 

Silesia  (Prussia) 

1400 

G<S°-84-2° 

Wild  bad 

Wurtemberg 

1323 

95°-9S'6° 

Plombi&res 

France 

1310 

66°-156° 

Luxeuil 

rFrance 

1300 

65°-lfi3° 

Neuhaus 

Styria  (Austria) 

1200 

95° 

Liebenzell 

Wurtemberg 

1113 

72°-82° 

"Warmbrunn 

Silesia  (Prussia 

1100 

96-8°-104° 

Buxton 

England 

i looo  l 

1 (nearly)  j 

82° 

Schlangenbad 

Nassau  (Prussia) 

,900 

Sl-5°-86° 

Neris 

France 

800 

114°-1253 

Rbmerbad  ) 
and  Tiiflcer  f 

Styria  (Austria) 

700-800 

93°-100° 

Teplitz 

Bohemia 

650 

95°-120° 

Lucua 

Italy 

500 

10o°-129° 

Bath 

England 

100 

100°-12C° 

Many  other  slightly  mineralised  warm  waters, 
whose  principal  action  is  to  be  referred  to  water 
and  heat,  might  be  mentioned  here,  while  several 
of  the  places  contained  in  the  list,  as  Leukerbad, 
Bormio,  Bagneres  de  Bigorre,  and  Bath,  might 
find  places  in  other  divisions. 

The  very  hot  Algerian  baths,  Hammam-Mes- 
koutin,  Biskra,  and  Hammam  R’Irha,  the  last 
beautifully  situated  some  sixty  miles  from  Al- 
giers, belong  likewise  to  this  class. 

Allied  in  their  action,  though  more  powerful 
in  their  demands  on  the  system,  and  in  their 
effects,  are  the  natural  hot  vapour  baths  in  the 
large  cave  of  Monsummano  in  Upper  Italy,  and 
in  the  smaller  excavation  in  the  rocks  of  Batta- 
glia in  the  Euganean  mountains. 


MINERAL  WATERS. 


988 

II.  Common  salt  or  muriated  saline 
waters.  — Composition. — Common  salt  or  chlo- 
ride of  sodium  is  the  principal  solid  constituent 
of  the  waters  of  this  class ; but  this  substance  is 
contained  also  in  many  other  mineral  waters, 
especially  in  some  alkaline,  in  some  sulphur,  and 
some  Glauber’s  salt  waters,  and  has  a consider- 
able share  in  the  effects  of  these  waters. 

Action. — In  order  to  appreciate  the  action  of 
the  common  salt  waters,  we  must  bear  in  mind 
that  common  salt  forms  part  of  all  the  tissues 
and  juices  of  the  body ; that  it  acts  as  a solvent 
in  the  stomach,  promoting  digestion;  that  it  is 
essential  to  the  formation  as  well  as  the  disinte- 
gration of  cells  and  tissues  ; that  it  stimulates 
not  only  the  retrogressive,  but  also  the  progres- 
sive tissue-change  or  nutrition  of  the  body ; and 
that  it  is  a great  agent  in  the  endosmotic  quali- 
ties of  the  blood  and  in  the  processes  of  secretion 
and  absorption.  Chloride  of  sodium  stimulates 
the  secreting  apparatus  of  the  stomach  and  in- 
testines, and  hence  the  action  of  the  bowels, 
and  the  circulation  of  the  portal  system,  and 
indirectly  the  general  circulation.  It  quickens 
the  tissue-change,  and  through  this,  as  well  as 
the  increased  circulation,  promotes  absorption  of 
pathological  products,  without  lowering  the  or- 
ganism. In  larger  doses,  however,  beyond  about 
five  drachms  per  diem,  irritation  of  the  mucous 
membrane  of  the  stomach  and  intestines  may  be 
produced.  The  action  of  the  common  salt  waters 
is  modified  by  their  accompanying  properties, 
especially  by  the  carbonic  acid  contained  in  them, 
by  their  temperature,  and  by  the  degree  of  their 
concentration. 

The  carbonic  acid  in  this  and  other  classes  of 
waters  quiets  the  sensitive  nerves  of  the  sto- 
mach; stimulates  the  secretion  and  peristaltic 
action  of  the  stomach  and  bowels  ; and  indi- 
rectly increases  the  secretion  of  the  kidneys.  In 
large  quantities,  however,  if  not  rapidly  ejected 
by  eructation,  it  may  produce,  by  being  absorbed, 
poisonous  effects  on  the  blood  and  nervous  sys- 
tem. The  presence  of  carbonic  acid  in  salt  waters 
increases  the  effects  of  chloride  of  sodium  on 
the  stomach  and  intestines,  and  by  accelerating 
the  passage  of  the  waters  from  the  stomach  into 
the  intestinal  canal,  promotes  the  action  of  the 
bowels. 

Elevation  of  the  temperature  of  the  water  pro- 
duces more  rapid  absorption,  and  thus  diminishes 
the  local,  and  increases  the  more  distant  and 
constitutional  effects. 

Concentration  increases  the  local  stimulation. 

As  to  the  action  of  these  waters  in  the  form  of 
baths,  the  chloride  of  sodium  and  other  chlorides 
(though  any  absorption  through  the  skin  of  these 
and  other  salts  contained  in  mineral  waters  is 
doubtful  or,  at  all  events,  forms  only  a small 
part  of  their  therapeutic  effects)  stimulate  the 
cutaneous  ends  of  the  nerves  and  the  capillaries, 
and  promote  through  this  the  nutrition  and  tone 
of  the  skin,  and  indirectly  the  tissue-change,  an 
action  which  is  heightened  by  the  presence  of 
carbonic  acid,  as  witnessed  at  the  gaseous  saline 
baths  of  Rehme  and  Nauheim. 

Uses. — Salt  waters  and  salt  baths  are  useful 
in  weakness  of  the  skin ; in  tendency  to  rheu 
matic  fever  or  bronchitis ; in  retarded  con- 
valescence from  acute  and  chronic  illness  • in 


enlargements  of  joints  from  preceding  inflate, 
mation ; in  scrofulous  complaints ; in  many  forms 
of  anaemia  and  chlorosis — especially  those  where 
iron  alone  is  not  borne  ; in  numerous  cases  of 
Indian  cachexia;  and  in  cases  of  sluggish  circula- 
tion in  the  portal  system,  which  leads  to  innu- 
merable varieties  of  digestive  troubles,  to  con- 
gestion of  the  liver,  and  of  the  pelvic  organs  in 
women,  and  to  piles. 

Enumeration,  and  Selection.  — The  same 
classes  of  cases,  as  far  as  the  name  goes,  are 
treated  also  by  alkaline  and  sulphated  waters. 
The  individual  conditions  must  guide  the  prac- 
titioner in  deciding  for  either  the  one  or  the 
other  kind  of  waters,  and  for  the  special  spa, 
according  to  the  strength  of  the  springs,  the 
amount  of  carbonic  acid,  and  concomitant  con- 
ditions. Spare  and  pale  persons,  we  may  men- 
tion, mostly  bear  the  common  salt  waters  better 
than  strongly  alkaline  and  sulphated  waters. 
Common  salt  waters  are  to  be  found  in  almost 
all  countries;  we  can  only  give  the  most  impor- 
tant or  best  known.  In  England Droitwich 
— perhaps  the  strongest  of  all  brmes,  with  good 
arrangements — Nantwich,  Middlewieh,  Wooc- 
hall,  and  Harrogate ; Leamington  and  Chelten- 
ham contain  likewise  much  common  salt,  in 
addition  to  sulphate  of  soda.  In  Germany-.— 
Kissingen,  Homburg,  Rehme-Oeynhausen,  Nau- 
heim, Kreuznach,  Soden,Pyrmont  (which  contains 
salt  as  well  as  iron  springs),  Wiesbaden,  Hall 
in  Austria,  Hall  in  the  Tyrol,  Hall  in  Wur- 
temberg,  Reichenhall,  Ischl,  Ivreuth.  Durkheim. 
SalzuDgen.  Canstatt,  Cronthal,  Baden-Baden, 
and  several  others.  In  France : — Bourbonne-les- 
Bains,  Lamotte-les-Bains,  Balaruc,  Salins.  Ir 
Italy-.— Ischia,  Castellamare,  Monte  Cat  tin  i.  La 
Porretta.  In  Switzerland : — Bex. 

III.  Alkaline  Waters. — Composition. — The 
alkaline  waters  contain  carbonate  of  soda  as  a 
prominent  constituent;  they  are  also  more  of 
less  rich  in  carbonic  acid ; and  some  are  distin 
guished  by  so  large  a proportion  of  chloride  o 
sodium  as  to  warrant  a sub-division  into— (1 
simple  alkaline  waters ; and  (2)  muriated  alkaliit 
waters. 

Action. — In  considering  the  dietetic  and  me 
dicinal  value  of  these  waters,  we  must  bear  i: 
mind  that  soda  in  combination  with  cartoni 
acid  is  a most  important  constituent  of  tk 
human  body.  Oxidation  and  tissue-change  seer 
to  be  greatly  influenced  by  the  presence  of  soda 
various  proteinaceous  bodies  seem  to  be  kept  i 
solution  by7  it;  it  has  a considerable  share  in  th 
secretion  of  saliva  and  bile,  and  in  the  digestiv 
processes  ; and,  according  to  Liebig,  it  acts  as 
vehicle  for  the  carbonic  acid  from  the  blood  t 
the  lungs. 

Carbonate  of  soda  may  be  considered  as  a 
antacid,  as  a diuretic,  as  a promoter  of  tissm 
ckaDge,  and  as  a solvent.  The  beneficial  effec 
of  alkalis  are  in  general  produced  only  by 
systematic  use  of  small  doses ; whilst  hr; 
quantities  cause,  by  their  excessive  solvent  eflfa 
emaciation,  and.  by  their  depressing  influence  < 
the  heart's  action,  diminish  the  tissue-chanc 
The  action  of  soda  differs  in  this  respect  ffi 
that  of  chloride  of  sodium,  which  even  in  co 
siderable  doses  increases  the  tissue-change,  ai 
does  not  so  easily  exercise  an  emaciating  effect 


MINERAL 

USES. — The  conditions  in  which  alkaline  wa- 
fers are  mostly  employed  are  certain  forms  of 
lyspepsia,  with  undue  acidity  of  the  stomach  ; 
:ongestive  conditions  of  the  liver  from  sluggish 
iortal  circulation ; tendency  to  gallstones  ; dia- 
>etes;  uric  acid  diathesis,  and  its  results  — 
rravel  and  litbiasis ; some  forms  of  gout ; and 
specially  chronic  catarrhal  affections  of  the  mil- 
ieus membranes  of  the  respiratory,  digestive, 
,nd  genital  organs. 

Enumeration,  and  Selection. — Where  it  ;s 
i.ecessary  to  improve  the  stato  of  the  blood,  or  to 
void  emaciation,  the  muriated  alkaline  are  pre- 
erahle  to  the  simple  alkaline  waters. 

1.  The  principal  spas  with  simple  olkaline 
haters  are:— a.  Hot: — Vichy,  Neuenahr,  Mont 
lore,  Chaudes  Aigues,  and  Neris,  the  three  last 
eing  feebly  minoralised ; b.  Cold: — Apollinaris, 
fals,  Salzbrunn.  le  Boulou,  Evian,  Bilin,  Facliin- 
len,  Geilnau,  Wilhelmsquelle,  Taunus,  Giess- 
iibel,  Soulzmatt,  and  Marcolo. 

2.  The  chief  muriated  alkaline  waters  are — 
i)  Ems,  Royat,  and  La  Bourboule,  which  repre- 
tntthe^of  springs;  whilst  ( b ) Luhatschowitz, 
alters,  Gleiehenberg,  Roisdorf,  Kosbach,  Vic- 
ar-Cere, and  Toennistein  are  cold. 

We  ought  to  remark  that  several  of  the  waters 
i this  class,  especially  la  Bourboule  and  Mont 
ore,  contain  arsenic  in  appreciable  quantities. 
IV.  Sulphated  waters. — Composition. — We 
elude  under  this  term  those  springs  which  are 
laracterised  by  a preponderating  amount  of  the 
dphates  of  soda  or  magnesia,  or  both  sulphates 
gether.  They  may  be  subdivided  into  (1) 
tuple  sulphated  waters  or  bitter  waters  ; and  (2) 
kaline  sulphated  waters , which  latter  contain 
so  carbonate  of  soda  and  chloride  of  sodium. 
Action. — The  bitter  salts  can  scarcely  be  said 
, be  constituents  of  the  organism  ; they  seem 
act  by  stimulating,  and  in  larger  doses  irrita- 
ig  the  mucous  membrane  of  the  stomach  and 
.mentary  canal,  causing  thin  watery  secretion, 
d in  large  doses  diarrhoea.  Sulphate  of  soda  is 
is  irritating  than  sulphate  of  magnesia.  The 
ristaltic  action  of  the  bowels  is  likewise  in- 
cased by  them.  Their  continued  employment 
apt  to  cause  emaciation.  By  the  presence  of 
rbonate  of  soda  and  chloride  of  sodium,  the 
bion  of  tho  bitter  salts  is  modified. 

Uses. — The  bitter  waters  are  useful  in  habits 
| constipation  with  sluggish  portal  circulation, 
hsmorrlioidal  tendencies,  in  congestion  and 
.argement  of  the  liver  and  spleen,  in  some 
,'ms  of  dyspepsia,  in  gallstones  and  allied  af- 
tions,  in  gouty  conditions,  lithiasis,  and  din- 
es ; and,  ceeteris  paribus,  have  in  stout  and  in 
i;  called  plethoric  persons,  the  preference  over 
' ! muriated  saline  waters. 

2numeeation,  and  Selection. — Where  pro- 
ged  courses  are  required  the  weaker  sulphated 
' ters,  and  especially  the  alkaline  sulphated 
’ cers,  are  to  be  preferred ; whilst  the  stronger 
Her  waters,  are  more  frequently  selected  for 
.asional  purging  doses.  1.  The  principal  sim- 
i sulphated  or  bitter  waters  are: — Galthof, 

- llna,  Saidschutz,  Sedlitz,  Birmensdorf,  Ivanda, 

1 nyadi  Janos  and  other  springs  near  Ofen, 
. 10m,  Aranjuez,  Friedrichshall,  and  Mergen- 
I im,  ths  two  latter  being  also  rich  in  chlo- 
1 58.  Weaker  springs  of  a similar  nature  are 


WATERS.  989 

at  Leamington  and  Cheltenham — both  with  a 
large  amount  of  common  salt,  at  Scarborough, 
and  at  the  Purton  Spa.  2.  The  principal  alka- 
line sulphated  waters  are  Carlsbad,  Marienbad, 
Tarasp-Schuls,  Franzensbad,  Elster,  and  Ber- 
trich.  The  constitution  and  the  action  of  the 
waters  of  Carlsbad  and  Bertrich  are  modified 
by  their  thermal  nature. 

. V.  Iron  or  chalybeate  waters. — Composi- 
tion.— Iron  is  contained  iu  the  majority  of 
mineral  waters ; hut  we  regard  as  iron  waters 
only  those  where  the  quantity  of  iron  is,  in  pro- 
portion to  the  other  constituents,  so  far  predo- 
minant as  to  give  a therapeutic  character  to  the 
springs. 

Action. — The  formation  of  blood-globules,  the 
contractility  of  the  blood-vessels,  the  oxidation 
and  the  production  of  heat,  and  the  general 
nutrition  of  tissues  seem  to  be  favoured  by  the 
use  of  iron  waters.  A small  quantity  only  of 
iron  seems  to  be  absorbed  by  the  stomach,  none 
through  the  skin  ; the  action  of  chalybeate  baths 
seemingly  being  due  to  the  influence  of  the  water 
and  carbonic  acid  only. 

TIses.  — The  conditions  most  benefited  by 
chalybeate  waters  are  the  various  forms  of  anae- 
mia, or  poverty  of  blood  and  particularly  of 
red  corpuscles,  especially  when  caused  by  actual 
loss  of  blood,  suppuration,  or  previous  acute  oi 
chronic  disease.  The  liver  and  digestive  organs, 
however,  must  be  in  healthy  working  order , 
whilst  in  cases  of  anaemia  accompanied  by  con- 
gestion of  the  liver  and  spleen,  chalybeates  alone 
are  rarely  useful,  but  must  be  preceded  or  modi- 
fied in  their  action  by  the  use  of  saline  waters  ; 
and  this  is  often  the  case  not  only  in  anaemia  ot 
Indian  and  malarious  cachexia,  hut  also  in  chlo- 
rosis. Neuralgia,  sterility  and  impoteney,  and 
general  debility  are  often  benefited  through  im- 
provement of  the  general  health.  Those  iron 
waters  are  most  useful  which  contain  the  iron  in 
the  form  of  the  bicarbonate  of  the  protoxide, 
kept  in  solution  by  free  carbonic  acid. 

Enumeration,  and  Selection. — Iron  springs 
are  (1)  comparatively  pure,  that  is  containing 
only  a few  grains  of  other  substances  in  16 
ounces  of  water : — Schwalbach,  Spa,  Briickenau, 
Schandau,  Liebwerda,  Flinsberg,  Freienwalde, 
Recoaro,  Koenigswarth,  Liebenstein,  Altwasser, 
Alexisbad,  Muskau,  Tunbridge  "Wells,  and  one 
spring  at  Harrogate  : (2)  compound  iron  springs, 
that  is,  which  contain,  in  addition  to  iron  and 
carbonic  acid,  a moderate  quantity  of  other  salts, 
especially  the  carbonates  of  soda,  lime,  and  mag- 
nesia, the  sulphates  of  soda,  magnesia,  and  lime, 
and  common  salt : — Aratapak,  Orezza,  Pyrmont, 
Driburg,  Rippoldsau,  Griesbach,  Antogast,  Pe- 
tersthal,  Booklet,  St.  Moritz,  Reinerz,  Godes- 
berg,  Cndowa,  Imnau,  and  Santa  Catarina. 

VI.  Sulphur  waters.  — Composition.  — 
Amongst  sulphur  waters  we  class  those  springs 
which  contain  either  sulphuret  of  hydrogen,  or 
the  sulphuret  of  sodium,  calcium,  potassium,  or 
magnesium,  in  an  appreciable  and  constant  pro- 
portion. They  are  partly  thermal,  partly  cold ; 
and  some  of  them,  especially  Aix-la-Chapelle, 
Uriage,  and  Baden  in  Switzerland,  contain  a 
considerable  proportion  of  common  salt  and  other 
solids,  which  are  to  be  taken  into  consideration 
in  the  appreciation  of  their  effects. 


990  MINERAL 

Action. — It  is  difficult  to  describe  the  physio- 
logical effects  of  the  sulphur  "waters,  as  far  as 
they  depend  on  such  minute  quantities  of  sul- 
phur as  are  contained  in  them.  Sulphur  "water 
baths  seem  to  act  in  the  same  manner  as  simple 
baths.  If  the  "waters  are  taken  internally,  some 
sulphuretted  hydrogen  is  probably  absorbed, 
entering  the  circulation  through  the  portal  vein. 
The  pure  sulphur  waters  exercise  a constipating 
rather  than  an  aperient  effect.  The  faeces  become 
mostly  blackened  from  sulphuret  of  iron.  The 
protracted  use  of  these  waters  is  apt  to  lead  to 
a certain  degree  of  anaemia,  possibly  from  the 
action  of  the  sulphur  on  the  iron  of  the  blood- 
globules. 

Uses. — Sulphur  waters  are  mostly  used  in 
combined  bathing  and  drinking  courses,  as  also 
by  inhalation,  in  cases  of  metallic  poisoning  ; in 
congestion  of  the  liver  ; piles ; bronchial,  laryn- 
geal and  pharyngeal  catarrh  ; in  early  chronic 
phthisis  ; in  numerous  cutaneous  affections,  espe- 
cially the  herpetic  dyscrasia  of  the  French  ; in 
rheumatism  and  gout ; and  in  constitutional 
syphilis. 

Enumeration,  and  Selection.  — The  best 
known  thermal  sulphur  waters  are : — Eaux 
Bonnes,  Eaux  Ohaudes,  Cauterets,  Saint  Sau- 
veup,  Bareges,  Bagneres  de  Luchon,  Ax,  Escal- 
des,  Lo  Vornet,  Amelie-les-Bains,  Ullage,  Alle- 
vurd,  Aix-les-Bains,  Aix-la-Chapelle,  Baden  in 
Austria,  Baden  in  Switzerland,  Lavey,  Schinz- 
nach,  Battaglia  and  Abano  in  the  Euganean 
Mountains;  Panticosa ; Mehadia,  and  other 
springs  in  Hungary  ; and  Helouan  or  Helwan, 
near  Cairo.  Gold  sulphur  springs  are : — Eilsen, 
Nenndorf,  Langenbriicken,  Weilbach,  Meinberg, 
Reutlingen,Enghien,Challes,  Stachelberg,  Heus- 
tri  cli,  Gurnigel,  some  Harrogate  springs,  Llan- 
drindod and  Builtli  in  Wales,  Moffat  andStrath- 
peffer  in  Scotland,  and  Lisdunvarna  in  Ireland. 

VII.  Earthy  and  calcareous  waters. — Com- 
position.— As  earthy  and  calcareous  waters  we 
designate  those  springs  in  which  the  earthy 
substances,  especially  carbonate  and  sulphate  of 
lime  and  carbonate  of  magnesia,  form  the  pro- 
minent constituents. 

Action.- — In  the  shape  of  baths,  the  earthy 
waters  act  almost  in  the  same  way  as  ordinary 
water  baths.  Internally  taken,  the  carbonate  of 
lime  exercises  an  antacid  and  a soothing  effect 
on  the  mucous  membrane  of  the  stomach  and 
intestines,  and  together  with  the  sulphate  of 
lime  is  slightly  astringent  and  constipating.  If 
lime  is  absorbed,  it  may  possibly  assist  in  the 
formation  of  cells  and  of  bone,  and  may  exercise 
also  a soothing  effect  on  other  mucous  mem- 
branes ; this  point,  however,  can  scarcely  bo 
regarded  as  settled. 

Uses. — These  waters,  according  to  their  com- 
position, are  useful  in  digestive  troubles  with 
tendency  to  acidity,  diarrhoea,  and  undue  irrita- 
bility of  the  mucous  membrane.  They  are  em- 
ployed also  in  osteomalacia,  rhachitis,  and  tuber- 
culosis ; and  further,  in  some  skin-diseases, 
especially  in  eczema  and  psoriasis,  where,  how- 
ever, the  long  continuation  of  the  warm  bath, 
that  is  the  soaking  of  the  skin,  is  of  more  impor- 
tance than  the  nature  of  the  solid  constituents 
contained  in  the  water.  Some  of  these  waters 
possess  a great  reputation  in  chronic  catarrh  of 


, WATERS. 

the  bladder,  and  in  tendency  to  gravel  and  stone ; 
but  probably  the  large  quantity  of  water  con- 
sumed,  as  for  instance,  at  Contrexeville,  and  the 
consequent  dilution  of  the  urine  and  the  washing 
out  of  renal  tubules,  are  here  to  be  regarded  as 
the  principal  causes  of  the  useful  effect.  The 
best  known  earthy  or  calcareous  waters  are 
Wildungen,  Lippspringe,  with  the  Inselbad, 
Weissenburg,  Contrexeville,  Bagnere-de-Bigorre, 
St.  Arnaud,  and  Cransac ; and  amongst  the  table 
waters : — Couzan,  St.  Galmier,  and  the  Taunts 
water. 

Many  of  the  waters  mentioned  in  other  classes 
might  also  be  mentioned  here,  such  as  Bormio, 
Leuk,  Bath,  and  Lucca,  named  under  the  simple 
thermal  waters  ; and  Baden  in  Austria,  Baden 
in  Switzerland,  Schinznach,  Battaglia,  Abano,  and 
others  enumerated  under  the  sulphur  waters. 

On  prescribing  mineral  waters  and  baths. 
In  every  case  we  must  first  settle  the  ques-- 
tion  whether  the  treatment  hy  mineral  waters 
and  baths  offers  advantages  over  ordinary  treat- 
ment. If  the  question  is  answered  in  the  affirm- 
ative, we  have  to  consider  not  only  the  nature 
of  the  disease,  but  quite  as  much  the  nature  of 

. the  individual  in  whom  it  occurs ; the  amount 
of  vital  forces  in  general ; the  power  of  reaction;! 
the  state  of  the  different  organs ; and  whether 
they  can  assist  in  relieving  the  diseased  parti 
of  the  organism,  or  whether  they  are  unable  to| 
respond  to  any  unusual  demand  made  on  them.. 
Thus  we  shall  be  enabled  to  decide  whether 
stronger  therapeutic  influences  can  be  employed; 
whether  longer  and  rougher  journeys  are  permit- 
ted, and  colder  climates  and  seasons  ; or  whether 
delicate  treatment  is  essential,  comprising  the; 
simple  thermal  baths,  summer  temperature,  moun- 
tain climates  of  moderate  elovation,  and  easyj 
journeys.  The  baths  and  waters  are  not  to  bq 
selected  according  to  the  chemical  constitution 
of  their  springs  alone,  but  the  means  and  appli- 
ances in  use,  and  the  accustomed  methods  of 
treatment  at  certain  places,  the  qualities  of  the 
local  physician,  the  accommodation,  the  fool 
the  cooking,  and  the  social  conditions,  the  faei 
lity  of  reaching  a place,  the  climate  and  othet 
elements  of  ‘ change,’  are  each  and  every  on 
to  be  taken  into  consideration.  It  must  he  evi- 
dent already  from  these  remarks,  that  the  same 
morbid  affection  can  occasionally  be  treated  wit. 
advantage  by  different  classes  of  mineral  waters 
and  at  different  spas,  and  that  apparently  widely 
different  diseases  may  be  benefited  by  the  sami 
spa  ; not  only  because  many  mineral  waters  an 
composed  of  different  active  elements,  but  alsc 
becausothe  internal  and  external  administratiot 
of  the  same  water  may  be  so  much  varied  as  ti 
produce  a great  variety  of  effects.  In  mam 
instances  the  disease  itself  cannot  be  directly 
attacked,  but  our  efforts  must  be  directed  to: 
wards  improving  the  general  constitution,  am 
through  this  influencing  the  diseased  portion  d 
the  organism. 

We  cannot  do  more  here  thau  give  some  hint 
regarding  the  groups  of  diseased  conditions  i 
which  mineral  waters  may  be  prescribed. 

1.  Anemia. — In  cases  of  anaemia  it  is  essenti; 
to  consider  whether  the  condition  is  caused,  fir; 

I bv  direct  loss  of  blood  and  its  component  part; 

I secondly,  indirectly  by  acuto  or  chronic  diseas 


MINERAL 

(sleeplessness,  neuralgia,  and  inability  to  take  up 
food;  thirdly,  by  congestion  of  the  pelvic  or- 
gans, with  loss  of  blood  and  albuminous  juices  ; 
or,  lastly,  by  lymphatic  diseases,  or  visceral 
affections  resulting  from  warm  climates.  The 
'more  the  first  cause  preponderates,  the  more 
we  may  expect  from  the  direct  use  of  iron  ; and 
v.'e  have  then  to  consider  whether  pharmaceutical 
preparations,  or  iron  waters  with  or  without 
chango  of  climate,  with  or  without  baths,  are  to 
bo  preferred,  or  whether  iron  springs  are  to  bo 
recommended.  In  the  indirect  forms  of  anaemia 
the  mildest  thermal  treatment,  with  mountainous 
idimates  of  moderate  elevation,  or  the  latter 
[alone,  are  often  the  only  beneficial  courses  in  de- 
licate constitutions ; whilst  in  others  somewhat 
less  feeble  according  to  individual  conditions, 
common  salt  waters  and  baths  with  or  without 
iron,  or  the  gaseous  tepid  salt  baths  of  Nauheim 
[and  Rehme,  or  the  much  stronger  influences  of 
jea  air  and  of  sea  baths,  are  useful.  In  the 
;hird  group  the  common  salt  waters  with  a certain 
jimount  of  iron,  and  occasionally  the  sulphated 
-aline  waters,  must  generally  precede  every  other 
lttempt  at  strengthening ; for  the  acceleration  of 
[he  portal  circulation,  the  regular  emptying  of 
he  different  branches  of  the  portal  vein,  and  the 
Increased  tissue-change  are  essential  to  the  im- 
provement of  the  nutrition  and  sanguification  ; 
;.nd  only  after  such  a preliminary  course  the 
purer  iron  waters  and  the  higher  alpine  air  are 
ikely  to  become  useful. 

2.  Sluggish  portal  circulation. — A sluggish 
tradition  of  the  portal  system  forms  a frequent 
implication,  not  only  of  anaemia,  but  of  a great 
fany  ailments  of  the  different  systems  of  the 
Body ; and  is  often  only  a part  of  a general  want 
,f  tone  in  the  organic  muscular  fibre,  especially 
if  the  right  ventricle  and  of  the  whole  venous 
’stem.  It  is  difficult  to  find  a name  for  these,  by 
p means,  rare  constitutional  defects,  which  form 
to  main  characteristics  of  what  the  old  German 
lysicians  called  ‘abdominal  plethora.’  If  we 
[lly  know  what  we  mean  by  the  terms,  we  may 
11  these  conditions  portal  venosity  and  general 
nosity  according  to  the  extent  of  the  defect, 
toy  form  tho  principal  complications  and  in 
any  cases  the  main  cause  of  the  most  varied 
[gestive  troubles,  as  aciditjq  sickness,  flatu- 
icy,  constipation,  and  intestinal  catarrh.  They 
lie  also  at  the  root  of  congestion  of  the  htemor- 
ioiaal  vessels  and  piles,  of  varicosity  of  the 
;s,  of  congestion  of  the  womb  and  ovaries  and 
rastrual  anomalies,  of  congestion  of  the  liver 
d imperfect  secretion  of  bile,  and  of  chronic 
rachial  catarrh,  with  dilatation  and  imperfect 
' ■ i traction  of  the  right  ventricle.  Gravel  and 
|ht  are  likewise  often  associated  with  slug- 
i;h  portal  circulation.  In  the  treatment  of 
jse  very  numerous  complaints,  widely  different 
tiugh  they  appear  to  be,  we  have  therefore 
• ’ays  to  ask  in  how  far  they  are  complicated 
[portal  venosity,  and  in  how  far  diet,  regimen, 
yirmaceutical  and  balneotherapeutic  treatment 
Gcted  against  this  venosity  may  relieve  the 
t cial  case  before  us.  If  this  portal  venosity 
jar  in  lean  and  delicate  persons,  the  common 
H -waters  as  Ivissingen,  Homburg,  Soden,  &e., 
[jell  increase  the  tissue-change  without  impair- 
1 the  nutrition,  internally  and  in  the  form  of 


WATERS.  SOI 

baths,  or  the  simple  thermal  baths  in  sub-alpina 
situations,  assisted  by  the  internal  use  of  salt 
waters,  are  often  useful.  If  the  individual  be 
stout  and  inclined  to  costiveness,  the  sulphated 
saline  waters  with  soda  and  common  salt,  such 
as  Carlsbad,  Marienbad,  Franzensbad.  Elster, 
and  Tarasp,  are  the  most  effective;  while  again 
in  others  of  this  class  the  simple  alkaline  waters, 
such  as  Vichy,  are  preferable.  In  all  these 
cases,  however,  the  treatment  by  waters  and 
baths  ought  to  be  assisted  by  regulation  of  diet 
and  exercise. 

3.  Gravel. — Gravel,  especially  uric  acid  gravel, 
is  usually  complicated  with  portal  venosity,  and 
is  to  be  treated  accordingly.  As  a symptom- 
atic treatment,  the  alkaline  mineral  waters  have 
a more  lasting  effect  than  the  administration 
of  pharmaceutical  preparations  ; but  more  effec- 
tive are  alkaline  waters  containing  sulphates, 
and  especially  the  less  concentrated  and  hot 
springs  of  Carlsbad.  Most  useful  of  all,  espe- 
cially for  home  treatment,  are  the  waters  of 
Luhatschowitz,  with  their  peculiar  combination 
of  carbonates  and  chlorides. 

4.  Gout. — Gout  is  likewise  often  complicated 
with  and  aggravated  by  portal  venosity,  and  we 
must  always  endeavour  to  facilitate  the  removal 
of  the  products  of  the  retrogressive  tissue- 
change  ; but  gout  occurs  in  the  most  widely  dif- 
ferent constitutions.  If  gout  and  its  allied  forms 
be  met  with  in  so-called  strong  constitutions, 
with  a good  primary  digestion,  ability  to  sustain 
a long  morning  fast,  accompanied  perhaps  by  a 
tendency  to  stoutness,  and  an  acid  urine  of  toler- 
ably high  specific  gravity,  becoming  iridescent 
with  nitric  acid,  the  alkaline  sulphated  waters 
of  Carlsbad,  and  sometimes  those  of  Marienbad. 
Franzensbad,  Elster,  and  Tarasp  are  most  useful, 
though  they  cannot  altogether  remove  the  gouty 
disposition.  If  the  time  be  short,  and  a long 
rest  after  the  course  not  permitted,  the  simple 
alkaline  waters  of  Vichy  may  be  selected,  and  in 
more  delicate  constitutions  the  muriated  alka- 
line waters  of  Royat,  Ems,  or  Baden-Baden.  In 
lean  and  decrepit  gouty  patients  the  common 
salt-waters  of  Homburg,  Kissingen,  Harrogate 
and  Leamington,  the  arsenical  salt-waters  of 
La  Bourboule,  tho  waters  of  "Wiesbaden,  the 
muriated  sulphur  waters  of  Aix-la-Chapelle, 
or,  again,  weak  muriated  alkaline  waters  like 
Baden-Baden,  deserve  a trial.  In  many  delicate 
persons  the  simple  thermal  waters  of  Buxton, 
Schlangenbad,  Wildbad,  Ragatz,  Gastein,  and 
Bath,  and  the  sulphur  waters  of  Aix-les-Bains 
and  Bagn&res-de-Luchon,  offer  great  advantages  ; 
but  numerous  cases  may  be  regarded  as  quite 
intractable  by  baths,  waters,  and  medicines,  and 
in  these  diet  and  climate  are  the  only  means  of 
management. 

5.  Chronic  Bheumatism. — In  chronic  rheuma- 
tism, associated  with  exudation  round  the  joints, 
the  hot  thermal  treatment,  either  at  the  hotter 
simple  thermal  spas,  as  Bath,  Teplitz,  the  Eiiga- 
nean  baths,  or  the  natural  vapour  baths  of  the 
cave  of  Monsummano,  at  the  weaker  hot  salt- 
waters of  Wiesbaden  and  Baden-Baden,  or  at 
the  thermal  sulphur  waters,  such  as  Aix-la-Cha- 
pelle, Aix-les-Bains,  Bareges,  Bagneres-de-Lu- 
chon,  Eaux  Chaudes,  &c.,  are  the  most  useful ; oi 
in  more  delicate  cases,  tho  gaseous  thermal  salt 


992  MINERAL  WATERS, 

waters  of  Rehme  and  Nauheim.  In  the  muscular 
varieties, -with  stiffness,  the  hotter  waters,  assisted 
by  douches  and  shampooing,  are  specially  indi- 
cated. In  many  instances,  however,  the  cause  of 
constantly  recurring  rheumatism  is  weakness  of 
the  skin,  and  here  the  tonic  forms  of  the  cold 
water-cure  and  sea-baths  promise  more  perma- 
nent good  than  hot  baths. 

It  is  impossible,  in  .a  short  treatise,  to  enter 
into  all  the  morbid  conditions  suitable  for  balneo- 
therapeutic treatment;  but  the  preceding  remarks 
may  show  that  the  physician,  in  prescribing 
waters,  ought  to  base  his  advice  on  the  teach- 
ings of  physiology,  pathology,  climatology,  and 
general  therapeutics,  in  the  widest  sense. 

We  might  be  expected  to  give  a few  hints  on 
diet,  during  mineral-water  courses,  but  no  general 
rules  can  be  laid  down.  Every  individual  re- 
quires rules  for  his  own  case,  and  rules  'which 
may  be  necessary  during  the  use  of  muriatie 
saline,  or  sulphated  saline  waters,  are  not  neces- 
sary in  other  courses— for  instance,  of  simple 
thermal  or  of  iron  waters. 

The  bath  physician  ought  to  guide  every  in- 
valid, according  to  his  or  her  individual  con- 
dition, as  well  with  regard  to  diet,  as  to  the 
internal  or  external  use  of  waters,  and  with 
regard  to  exercise  and  other  hygienic  and  thera- 
peutic aids.  The  result  of  a course  of  waters 
often  depends  entirely  on  this  guidance.  It  is 
important,  therefore,  to  supply  the  bath  physician 
with  a statement  as  to  the  ailments  and  tho  con- 
stitution of  the  invalid. 

Length  of  Treatment. — It  is  a general  belief 
that  three  or  four  weeks  is  the  term  for  a course 
of  waters  or  baths  ; but  it  is  impossible  to  fix  a 
definite  time.  As  courses  of  iodide  of  potassium, 
of  iron,  of  quinine,  or  of  mercury  must  be  of  dif- 
ferent duration  in  different  individuals,  exactly 
so  we  find  it  with  mineral  waters ; and  as  two 
or  three  courses  of  a remedy  may  have  to  be 
taken  in  the  same  year,  so  it  is  often  desirable 
to  give  two  or  three  courses  of  Vichy,  of  Carls- 
bad, or  of  Spa  waters,  in  one  year,  though  not 
all  of  them  need  be  taken  at  the  spring.  In 
many  cases  preparatory  courses  are  advisable, 
climatic,  medicinal,  and  balneotherapeutic,  and 
in  as  large  a number  secondary  courses.  Most 
invalids  would  do  well  not  to  return  imme- 
diately after  a course  of  baths  to  their  usual 
abodes  and  accustomed  ways  of  living.  In  many 
instances,  however,  it  is  imperatively  necessary  to 
abstain  from  work,  and  to  keep  to  a simple  diet  for 
about  a month  or  more  after  the  course  of  waters, 
and  this  is  especially  the  case  with  the  more 
powerful  waters  like  Carlsbad  and  Marienbad. 

Season. — As  to  tho  period  of  the  year,  there  is 
no  time  when  the  different  waters  might  not  he 
drunk,  if  it  were  necessary.  Most  spas  are  open 
only  from  May  till  October,  some  longer,  some 
only  from  June  till  September ; but  some  few 
localities  are  partially  open  also  during  winter, 
especially  Aix-la-Chapelle,  Aix-les -Bains,  Baden- 
Baden,  and  Wiesbaden.  Many  waters  can  be 
taken  at  home,  and  at  any  time  of  the  year  ; hut 
the  elements  of  change  are  wanting,  and  the 
strict  adherence  to  regimen  and  diet  is  often 
difficult.  During  the  summer  months  the  de- 
mands on  the  human  body  are  diminished,  by 
the  external  warmth  and  the  greater  equability 


MISCARRIAGE. 

of  the  meteorological  influences ; nature  is  more 
exhilarating,  and  invites  to  outdoor  life  and 
exercise,  without  much  risk  of  chills  and  their 
consequences ; and  delicate  persons,  therefore, 
ought  to  select  the  summer  months  for  courses 
at  the  spas.  The  later  parts  of  the  spring  and 
the  autumn,  however,  offer  advantages  to  the 
more  robust,  who  at  those  times  find  the  baths  and 
the  hotels  less  crowded,  and  who  can  then  receive 
more  attention  from  the  bath  physician.  And. 
besides,  those  who  are  unable  to  bear  heat  have 
in  the  earlier  and  later  parts  of  the  season  the 
benefit  of  cooler  air,  which  is  to  the  average 
visitor  a real  advantage  at  some  c.f  the  hotter 
localities,  like  Aix-les-Bains,  Aix-la-Chapelle, 
Ems,  Creuznach.  Soden,  Baden-Baden,  and  Ra- 
gatz.  Hermann  Webeu. 

MIS  CARE  IAGE. — Stxon.:  Abortion;  Pr. 

Avortcment;  Faussc  Couchc ; Ger.  Fehlgcburt. 

Definition. — Miscarriage  is  the  interruption 
of  gestation  before  the  foetus  has  become  viable. 

Frequency. — The  relative  frequency  of  mis- 
carriages, of  premature  labours  (between  th“ ! 
seventh  and  ninth  months),  and  of  full-time 1 
births,  cannot  be  very  closely  estimated.  Early 
abortions  are  often  unnoticed  or  forgotten.  The ' 
statement  of  Dr.  Whitehead  is  very  striking, 
that  of  sixty-four  women  who  had  lived  in  wed- 
lock till  the  menopause,  there  were  only  eighth 
who  had  not  at  some  time  had  a miscarriage. 
His  statistics  show  that  the  period  at  which 
abortions  most  frequently  occur  is  about  the 
third  month. 

.(Etiology. — The  causes  of  abortion  may  be 
found  either: — (1)  on  the  part  of  the  ovum  o: 
foetus  ; or  (2)  on  the  part  of  the  mother. 

1.  Foetal. — The  causes  of  miscarriage  on  the 
part  of  the  ovum  are  : — (a)  all  the  diseases  of 
the  feetus  itself  which  compromise  its  life,  surf 
as  acute  fevers  and  chronic  diseases — chiefly  of 
syphilitic  origin ; and  (6)  many  of  the  morbid 
changes  in  the  foetal  appendages.  Of  the  latte) 
the  most  noteworthy  are,  first,  diseases  of  th< 
chorion,  the  more  familiar  of  which  is  the  hyda 
tidiform  degeneration ; secondly,  abnormal  condi 
tions  of  the  umbilical  cord,  such  as  excessive  tor 
sion  with  constriction  of  the  vessels,  convolution! 
of  it  simultaneously  round  the  neck  and  lowe 
extremities,  and  the  formation  of  tight  knot 
upon  it ; and  thirdly,  abnormal  relations  am 
morbid  conditions  of  the  placenta.  Where  th 
placental  area,  for  example,  is  of  too  limited  ex 
tent,  the  ovum  easily  becomes  detached  from  th 
uterus ; where  it  is  too  large,  extravasations  c 
blood  easily  take  place  in  the  lobules.  Whe 
the  placenta  is  planted  low  down  in  the  cavit 
of  the  uterus,  it  is  liable  to  partial  detacl 
ments  ; and  thus  in  a great  many  cases  abortio 
takes  place  at  an  early  stage  in  patients  wh 
would  have  been  subject  to  the  greater  dange) 
of  unavoidable  hsemorrhage,  had  the  pregnane 
gone  on  towards  the  usual  term.  Again,  tl 
morbid  processes  which  occur  in  the  placent 
inflammatory, degenerative,  or  apoplectic, whethc 
duo  to  a syphilitic  taint,  or  to  other  cause 
lead  to  death  of  the  embryo  or  feetus,  and  th' 
in  many  instances  to  the  early  casting  of  t! 
ovum.  It  is  worth  while  to  note  that  death 
the  embryo,  and  morbid  changes  in  its  appe 


MISCARRIAGE. 


y 03 


Jages,  do  not  necessarily  at  once  cause  abortion. 
Three  or  four  weeks  usually  elapse  after  the 
'death  of  the  foetus  ero  its  expulsion  is  effected  ; 
the  decidual  membrane  having  in  the  interval 
indergone  retrogressive  changes.  It  is  only 
|vhen  such  an  extravasation  of  blood  takes  place 
is  leads  to  sudden  distension  of  the  uterus,  or 
vhen  the  membranes  burst  and  such  escape  of 
liquor  amnii  occurs  as  leads  to  its  sudden  col- 
lapse, that  the  organ  is  stimulated  to  the  im- 
mediate evacuation  of  its  contents.  Hence,  while 
lie  ultimate  cause  of  abortion  is  often  enough 
traceable  to  the  ovum,  the  immediate  occasion  is 
'tore  frequently  due  to  some  maternal  condition, 
2.  Maternal. — The  causes  of  miscarriage  on 
re  part  of  the  mother  are  either  («)  general ; or 
>)  local.  ( a ) Amongst  the  general  or  constitu- 
onal  conditions  that  favour  the  occurrence  of 
jortion  we  note,  first,  all  the  causes  that  lead 
) depression  of  a woman's  health.  Abortions 
re  frequent,  for  instance,  in  times  of  famine; 
nongst  women  who  yield  themselves  to  ex- 
sses ; in  anaemic  women ; and  in  those  tainted 
'tli  the  syphilitic  poison.  Often  enough,  espe- 
illy  in  the  last  class,  the  cause  of  the  abortion 
jn  be  traced  to  som#  morbid  change  in  the 
iternal  portion  of  the  placenta ; but  sometimes, 
seems  to  be  due  simply  to  the  impure  or 
poverished  condition  of  the  patient's  blood.* 
■ condly,  fevers,  such  as  the  zymotic  fevers,  and 
j'ute  inflammations,  more  particularly  of  impor- 
|t  viscera,  such  as  pneumonia,  occurring  in 
livid  women,  very  frequently  become  compli- 
(|ed  by  abortion.  Thirdly,  shock  may  bring  on 
tiscarriage,  whether  operating  simply  through 
It!  nervous  system,  of  which  we  meet  occa- 
taal  examples ; or,  as  is  more  frequently  the 
ee,  by  producing  a more  direct  physical  impres- 
6 1 upon  the  uterus,  as  in  cases  where  the  patient 
l'is  or  steps  suddenly  down  from  a height,  lifts 
weight,  stretches  her  arms  above  the  head,  or 
'■',‘xposed  to  any  sudden  jar  or  more  protracted 
j'ing.  Though  many  cases  of  abortion  are 
a ibuted  to  such  a cause,  it  is  always  to  be 
lie  in  mind  that  in  some  of  these,  at  least, 
t!  supposed  cause  would  not  have  led  to  the 
d ster  unloss  there  had  already  existed  a 
p lisposition  in  some  morbid  condition  of  the 
ufus  or  its  contents. 

mongst  ( b ) the  local  causes  we  find,  first,  and 
m . frequently,  diseased  conditions  of  the  deci- 
< l , Commonly  in  these  cases  the  patient  had 
Pfiously  been  the  subject  of  chronic  endome- 
trJ3  > though  occasionally  cases  are  met  with 
wl  ,0  there  have  been  no  marked  symptoms 
pt  lously,  and  the  degenerative  process  may 
a t either  the  vera  or  reflexa  or  serotina, 
se-  ately  or  simultaneously.  Second  in  fre- 

.y  under  this  head  we  have  the  abortions  due 
0 'placements  of  the  uterus,  these  being  com- 
mc  y either  descents  or  retroversions.  Thirdly, 
«e:  asms  of  the  uterus,  such  as  cancers  or  fib- 
toi  amours,  sometimes  permit  the  occurrence 
•'  .Qception,  but  prevent  gestation  running  to 
usjatural  term..  Fourthly,  the  presence  of 
w us  in  the  neighbouring  organs,  or  inflam- 
y adhesions  a,mong  them,  may  prevent  the 
nil  , rom  attfdning  its  full  growth,  and  com- 
P to  early  evacuation  of  its  contents. 

1 moms  and  Diagnosis.— In  dealing  with  a 

63 


case  of  suspected  miscarriage,  we  have  to  de- 
termine first  that  the  patient  is  pregnant.  This 
we  do  by  a careful  inquiry  into  the  patient's 
history,  and  a complete  physical  diagnosis. 
Supposing  that,  by  the  usual  investigation  into 
the  signs  and  symptoms  of  pregnancy,  we  are 
satisfied  that  gestation  had  begun,  we  have 
next  to  ascertain  whether  miscarriage  is  only 
threatening  to  come  on,  has  fairly  set  in,  or  has 
already  been  completed. 

The  symptom  that,  in  the  great  run  of  cases, 
first  attracts  attention,  which  usually  goes  on  till 
the  process  is  completed,  and  which  continues 
for  some  hours  or  days  subsequently,  is  haemor- 
rhage. The  amount  of  blood  lost  varies  indefi- 
nitely; and  so  does  the  manner  of  its  escape.  Ix 
certain  cases  the  onset  of  pelvic  pains,  with  the 
regular  intermissions  that  betray  their  origin  in 
the  muscular  contractions  of  the  uterine  walls, 
alarms  the  patient  and  attracts  her  attention 
before  any  escape  of  blood  has  taken  place. 
These  cases  are  exceptional.  Usually  the  haemor- 
rhage precedes — and  it  may  be  for  days  or  weeks 
— the  expulsive  action  of  the  uterus.  The  cases, 
however,  are  rare  unless  they  be  instances  of 
very  early  abortion,  where  the  process  is  com- 
pleted without  the  accession  of  appreciably  pain- 
ful contractions.  Occasionally  there  occur  dis- 
charges of  liquor  amnii  or  other  watery  fluid,  or 
of  fragments  of  the  degenerated  membranes,  or 
of  the  disintegrated  fcetus. 

These  symptoms  call  for  physical  exploration 
of  the  uterus.  If  we  find  the  uterus  gravid,  with 
the  os  undilated  and  tile  cervical  canal  above  it 
unexpanded,  the  haemorrhage  being  slight  and 
the  pains  controllable,  we  regard  and  treat  the 
case  as  one  simply  of  threatened  abortion.  But 
if  the  pains  are  persistent,  if  the  os  uteri  opens 
to  admit  the  finger,  or  the  canal  of  the  cervix 
above  it  is  becoming  expanded;  still  more,  if 
the  uterine  contents  are  being  pressed  down 
within  reach  of  the  exploring  finger,  we  have  to 
do  with  an  actual  abortion  which  it  is  useless  to 
seek  to  avert.  The  treatment  of  actual  abortion 
is  often  enough  called  for,  even  with  quiescent 
uterus  and  closed  canals,  when  the  haemorrhage 
is  profuse. 

In  trying  to  determine  whether  the  miscar- 
riage is  completed,  we  have  first  to  examine  the 
mole  or  mass  that  has  been  expelled.  This 
consists  sometimes  of  the  ovum  alone ; of  the 
ovum  and  decidua  reflexa  ; or  of  the  ovum  with 
all  the  uterine  deciduae.  Where  the  uterine 
contents  escape  in  broken-down  fragments,  and 
cannot  be  satisfactorily  pieced  together,  it  be- 
comes necessary  to  examine  the  uterus,  and  even 
to  explore  the  interior  of  that  organ  with  the 
finger  ; and  in  these  and  other  cases  where  the 
diagnosis  is  doubtful,  it  may  be  requisite  some- 
times to  dilate  the  cervix  with  a carbolized 
sponge-tent,  in  order  ta  get  full  access  to  the 
uterine  cavity. 

Treatment. — The  treatment  of  miscarriage 
varies  according  as  wo  have  to  do  with  a case  of 
(1)  threatening  abortion  ; or  (2)  abortion  in  ac- 
tual progress. 

Treatment  of  threatening  abortion. — The  treat- 
ment in  a case  where  abortion  is  merely  threat- 
ening is  largely  expectant.  The  patient  is  put  to 
bed  and  kept  at  rest  in  the  recumbent  position 


904  MISCARRIAGE. 

All  exercise  or  excitement,  physical  or  psychical, 
must  be  forbidden  A light,  non-stimulating 
diet,  with  fluids  for  the  most  part  cold,  is  to  be 
enjoined ; and  any  tendency  either  to  constipa- 
tion or  to  diarrhoea  is  to  be  combated.  Where 
the  haemorrhage  is  continuous  and  the  uterus 
atonic  or  flaccid,  small  doses  of  ergot — twenty 
drops,  every  six  or  eight  hours,  of  the  extractum 
ergotso  liquidum—  are  useful.  Dilute  sulphuric 
acid  or  gallic  acid,  either  alone  or  in  com- 
bination with  digitalis,  may  be  administered. 
Where  there  are  occasional  pains  accompanying 
the  discharge,  the  best  effects  are  obtained 
from  the  administration  of  opiates,  which  may 
be  prescribed  in  the  form  of  the  acetate  of  lead 
and  opium  pill.  Where  the  pains  constitute 
the  more  urgent  symptom,  and  the  haemorrhage 
is  less,  it  may  be  well  to  check  the  uterine 
action  at  once  by  the  use  of  an  anaesthetic  fol- 
lowed by  opiates,  or  the  administration  of  a dose 
of  chloral ; and  the  astringent  may  then  be  dis- 
pensed with.  The  opiates  in  such  eases  are  best 
administered  hypodermically  ox  per  rectum. 

Treatment  of  actual  abortion. — Where  the  stage 
of  expectancy  is  clearly  over,  and  the  patency  of 
the  os  internum,  the  persistence  of  the  pains,  or 
the  profusion  of  the  haemorrhage,  calls  for  active 
interference,  there  are  two  main  indications  to 
be  fulfilled,  namely,  to  restrain  the  haemorrhage  ; 
and  to  ensure  the  complete  evacuation  of  the 
uterus. 

To  restrain  the  haemorrhage  we  compel  the 
uterus  to  more  energetic  contraction,  first,  by 
the  administration  of  large  repeated  doses  of 
ergot.  A drachm  of  the  liquid  extract  may  bo 
given  every  three  or  four  hours  ; but  the  effect 
of  the  drug  can  be  most  speedily  and  safely 
ensured  by  the  hypodermic  injection  of  ergotin 
-according  to  some  such  a formula  as  this:  — ije 
Ergotin.  5ij  ; chloral  hydratis,  css  ; Aquae  destil- 
lataj,  5vi — 16  drops  to  be  injected  into  the  gluteal 
muscle.  The  dialysed  solution  of  ergotin  is  said 
to  produce  less  irritation.  Secondly,  the,  geni- 
tal canal  must  be  plugged.  Where  we  have  no 
other  means  at  command  of  checking  the  dis- 
charge, a carefully  applied  vaginal  tampon  may 
be  trusted ; or  the  vaginal  plug  may  be  used 
where  the  haemorrhage  is  going  on,  but  there  is 
still  some  hope  that  the  abortion  may  be  ar- 
rested. Where  the  indication  is  more  urgent, 
the  introduction  of  a sponge-tent  into  the  cer- 
vical canal  is  very  much  more  satisfactory,  and 
in  every  way  more  efficacious.  It  arrests  the 
hcemorrhage  immediately  and  inevitably;  it 
excites  the  uterus  to  more  energetic  action ; and 
it  at  the  same  time  expands  the  cervical  canal  in 
all  its  length. 

The  complete  evacuation  of  the  uterus  may 
take  place  by  the  unaided  efforts  of  its  muscu- 
lar walls.  On  visiting  a patient  in  the  morning, 
who  had  a sponge  tent  passed  into  the  cervix 
uteri,  and  a hypodermic  injection  of  ergotin 
over  night,  we  may  find  sponge  and  ovum  and 
all  expelled.  Where  the  ovum  is  still  in  utcro, 
if  it  be  loose  and  the  cervix  dilated,  compres- 
sion of  the  uterus  from  above  the  pubes  may 
suffice  to  make  it  expel  its  contents.  Usually, 
however,  it  becomes  necessary  to  get  at  the 
interior  of  the  uterine  cavity  with  a finger  or 
fingers  passed  through  the  vaginal  canal.  In 


MITRAL  VALVE. 

most  cases  it  greatly  facilitates  the  operation  to 
anaesthetize  the  patient,  and  in  some  cases  the 
previous  administration  of  chloroform  is  abso- 
lutely necessary.  To  render  the  uterus  accessible 
to  the  exploring  fingers,  it  must  either  be  pushed 
down  from  above  or  dragged  down  from  below. 
The  patient  lying  unconscious  on  her  back,  the 
fundus  uteri  may  be  depressed  by  the  left  hand 
pushed  firmly  and  steadily  down  through  the 
pelvic  brim.  The  depression  may  be  effected  by  I 
an  assistant,  but  never  so  satisfactorily  as  by 
the  operator  himself.  Not  less  than  two  fin^er- 
of  the  right  hand  should  be  used  for  the  intern:.! 
manipulation;  the  middle  finger  being  folded  i; 
the  fornix  vaginae,  whilst  the  index  passes  throuci 
the  os  to  the  fundus  uteri,  and  sweeps  round  tin 
entire  ovum,  detaching  it  at  any  adherent  points! 
Sometimes  the  middle  finger  more  convenient! 
enters  the  uterine  cavity ; and  in  most  cases  c 
miscarriage  in  the  fourth  month,  the  whole  ham. 
except  the  thumb,  may  require  to  be  passed  inti 
the  vagina,  and  two  or  more  fingers  into  the  util 
ri  n e cavity.  Even  where  the  vagi  nal  orifice  is  ntj 
at  first  very  wide,  if  the  hand  be  carefully  warms 
and  soaped,  and  the  interstices  of  the  finger 
filled  up  on  their  palmar  aspect  with  a quantity  - 
half-melted  soap,  sufficient  dilatation  is  speedi 
effected.  Occasionally  the  smaller  left  hand  mt 
'be  employed  for  internal  manipulation,  while  t! 
stronger  right  is  engaged  in  making  the  exte 
nal  pressure  on  the  fundus  uteri.  Access 
the  interior  of  the  uterus  may  in  most  cases 
gained  more  easily  by  dragging  the  uterus  doy 
from  below.  One  or  other  of  the  lips  of  t 
uterus — usually  the  anterior— is  seized  with! 
vulsellum,  double  or  triple  pronged,  and  sligh 
curved.  One  of  the  blades  grasps  the  vagi, 
aspect  of  the  front  lip  of  the  cervix  as  high  ap' 
the  roof  of  the  vagina,  the  other  at  a eorrespo  - 
ing  level  within  the  cervical  canal.  The  ute  : 
is  capable  of  being  drawn  far  down  without  : ' 
injury  to  its  ligaments,  or  aoy  laceration  by  ’ 
bite  of  the  vulsellum.  It  may  be  pulled  down  wi 
the  right  hand  and  kept  fixed  by  it,  whilst  h 
fingers  of  the  left  pass  into  the  cavity,  andexple 
and  evacuate  it.  Or  the  vulsellum  may  be  helm 
the  left  hand,  or  given  to  an  assistant,  to keepje 
uterus  depressed,  whilst  the  more  familiar  rig- 
hand  fingers  do  the  intra-uterine  work,  ie 
finger  or  fingers  that  have  detached  the  oyn 
commonly  succeed  in  extracting  it,  aided  sce- 
times  by  pressure  with  the  other  hand  fin 
without.  If  not,  there  is  no  objection  to  lajg 
hold  of  the  loosened  body  with  a pair  of  ;tg 
dressing  forceps,  or  a Lyon's  or  polypus  forws, 
and  so  withdrawing  it;  but  no  such  instruirit, 
even  though  it  bear  the  name  of  abortion» 
ceps,  ought  to  be  trusted  to  for  the  detachmt 
of  a retained  ovum  or  fragment  of  adherenta- 
qenta.  The  separation  should  always  be  effied 
by  the  direct  action  of  the  living  finger. 

After-treatment.  — The  uterus  having  pen 
completely  emptied,  the  patient  should  be  ep: 
at  absolute  rest  in  bed,  and  subjected  to  the  me 
treatment  as  an  ordinary  puerperal  female.; 

Alexander  Russell  Suits'. 

MITRAL  VALVE  AND  ORIFlE. 
Diseases  of.  See  Heaet,  I alves  0F,li* 
eases  of. 


MODIFIED. 

MODIFIED. — A term  applied  to  a disease, 
>r  to  any  of  the  phenomena  of  a disease,  such  as 
in  eruption,  when,  as  the  result  of  a recognised 
I’.ause,  they  present  unusual  characters,  or  run  an 
inusual  course.  Thus,  small-pox  is  modified  by 
Vaccination.  See  Small-pox. 


MOFFAT,  in  Scotland. — Sulphur  and  also 
jhalybeate  waters.  See  Mineral  Waters. 

MOGIGRAPHIA  {p-6-yis,  with  difficulty, 
nd  ypacpu,  I write).— A synonym  for  writer's 
ramp.  See  Writer’s  Cramp. 


MOLE.— MOLAR  PREGNANCY.— The 

Lies  that  are  met  with  in  obstetrical  practice 
lay  be  conveniently  divided  into  two  classes, 
ft)  the  false ; and  (B)  the  true  moles.  The  false 
;oles  maybe  briefly  dismissed,  but  it  is  desirable 
|at  they  should  be  discussed,  in  order  to  clear 
ie  ground  for  the  consideration  of  the  more 
iportant  variety. 

A.  False  moles. — False  moles  are  not  the  re- 
llt  of  conception.  Substances  discharged  from 
Ie  virgin  passages  are  occasionally  so  called ; 
r example,  shreds  of  vaginal  mucous  mem- 
;me,  which  the  microscope  should  recognise, 
fere  is  more  difficulty,  however,  with  the  mem- 
knes  of  membranous  dysmenorrhcea,  where 
|e  discharged  tissues  may  be  mistaken  for  true 
pidual  membranes.  The  circumstances  attend - 
t each  case  must  he  nicely  weighed,  such  as 
b history  of  previous  attacks,  the  absence  of 
| signs  or  symptoms  of  pregnancy,  and  so  on. 
fain,  if  the  discharged  membrane  happen  to 
I complete,  the  two  openings  of  the  Fallopian 
lies  and  that  of  the  cervix  will  be  found,  a con- 
ilion  which  does  not  obtain  in  true  deciduae, 
ilproscopieal  examination  will  also  aid  in  the 
clgnosis,  by  proving  the  presence  or  absence 
structures  belonging  to  the  fecundated  ovum, 
lod-clots,  variously  altered,  may  also  be  dis- 
crged  by  the  non-pregnant,  and  give  rise  to 
dbt  and  difficulty ; especially  those  partially 
dplourised  clots,  which  consist  mainly  of 
filin,  the  serum  and  red  blood-corpuscles  having 
t< . great  extent  escaped.  The  blood  is  probably 
hlierinotic  in  these  cases.  Careful  examina- 
ti  is  necessary  to  determine  the  true  nature 
ofthe  expelled  product.  Nothing  should  be 
pjkounced  to  bo  a true  mole  which  does  not 
pfent  structures  known  to  occur  only  in  the 
felndated  ovum.  Polypi  and  small  fibroid 
tinurs,  or  portions  of  large  ones,  are  not  diffi- 
cii  of  recognition  by  naked-eye  and  micro- 
scjical  examination. 


True  moles. — True  moles  are  always  the 
re  t of  impregnation.  The  embryo  may  speedily 
disipear  in  the  early  stages,  and  then  we  meet 
onjwith  the  membranes  or  appendages ; these, 
Mver,  are  characteristic. 

0 chief  varieties  of  true  mole  are  at  present 
rec  nised,  namely,  (1)  the  fleshy,  and  (2)  the 
vesldar  or  hydatidiform  mole. 

1 Fleshy  mole. — ^Etiology  and  Pathology. 
Ex  ivasation  of  blood  between  the  maternal 
andntal  structures  of  the  fecundated  ovum,  or 
inb  he  tissues  of  the  latter,  appears  to  be  the 
act  agent  in  the  production  of  the  fleshy  mole  ; 
“10|h  it  is  difficult  to  determine  the  agencies 
■*hi  by  this  condition  is  brought  about.  A 


MOLE— MOLAR  PREGNANCY.  995 
diseased  state  of  the  decidiue  may  doubtless  re- 
sult when  pregnancy  supervenes  upon  chronic 
endo-metritis  ; or  effusion  of  blood  into  the  ma- 
ternal structures  may  occur  from  cardiac  disease. 
Again,  syphilitic  and  other  hlood-dyscrasiae  ap- 
pear to  exert  an  influence;  and  perhaps  the  same 
may  be  said  of  acute  specific  diseases  when  they 
fail  to  excite  abortion.  It  seems  probable  that 
degeneration  of  the  embryonic  appendages  takes 
place  as  the  initial  lesion  in  some  cases,  it  may 
be  from  syphilis.  The  pathology  of  the  subject 
is  still,  however,  shrouded  in  considerable  ob- 
scurity. 

Description. — Whatever  may  be  the  excit- 
ing causes,  when  once  blood  has  been  effused 
into  or  between  the  foetal  and  maternal  struc- 
tures, the  vitality  of  the  embryo  is  speedily 
compromised.  The  common  result  of  this  is 
abortion  ; but  when  the  whole  ovum  is  not  thrown 
off,  growth  may  take  place  in  the  remaining  tis- 
sues, while  the  effused  blood  becomes  organised 
and  gives  bulk  to  the  mole.  Notunfrequently  a 
considerable  effusion  of  blood  takes  place  imme- 
diately beneath  the  amnion,  encroaching  greatly 
upon,  and  sometimes  rupturing,  the  amnionic 
sac.  The  inner  aspect  of  this  cavity  then  pre- 
sents an  irregularly  nodular  appearance,  and  is 
of  deep,  almost  black,  colour.  When  the  nodule* 
are  incised  they  are  seen  to  be  composed  of  firm 
blood-clot.  If  not  immediately  thrown  off,  growth 
may  continue  in  the  tissues,  and  a bulky,  fleshy 
mole  may  result.  The  connection  between  the 
ovum  and  the  womb  being  most  intimate  at  the 
placental  site,  changes  go  on  most  actively  at 
that  spot  ; and  when  blood  is  largely  effused  here 
it  constitutes  what  is  called  ‘apoplexy  of  the 
ovum.’  Examination  of  carneous  moles  seems 
to  show  that,  under  certain  circumstances,  the 
decidua  vera  is  the  chief  scat  of  degenerative 
changes  ; but  it  appears  that  in  all  cases  chorion 
villi  may  be  found,  though  much  altered  by  the 
presence  of  fatty  and  molecular  matter. 

The  growth  of  fleshy  moles  may  be  rapid,  but 
ordinarily  it  is  not  excessively  so;  such,  at  least,  is 
the  experience  of  the  writer.  Fatty  degeneration 
may  be  extremely  marked,  and  in  rare  cases  cal- 
careous degeneration  may  be  met  with,  forming 
what  the  Germans  call  the  Steinmole ; but  it 
must  never  be  forgotten  that  similar  degenera- 
tion of  other  uterine  bodies  may  occur,  for  ex- 
ample, of  fibroids,  so  that  calcareous  bodies  are 
not  to  be  looked  upon  as  true  moles  unless  other 
clear  evidence  exists  of  conception  having  taken 
place.  Blood-polypi  are  occasionally  met  with, 
arising  after  miscarriage  or  delivery  at  full 
term,  in  which,  organisation  having  taken  place, 
and  communication  being  established  between  the 
clot  and  the  uterus,  degenerative  changes  go  on 
to  the  extent  of  calcification,  whereby  a so-called 
Steinmole  may  be  produced. 

2.  Vesicular  mole. — The  vesicular,  hydatid,  or 
hydatidiform  is  the  better  understood,  if  not 
more  important,  variety  of  true  mole. 

Description. — It  is  necessary  to  state  at  the 
outset  that  the  name  ‘ hydatid  ’ mole  is  erroneous 
and  misleading.  There  are  no  true  hydatids  or 
ecchinococci  in  it.  The  physical  arrangement 
of  the  vesicles  is  different.  True  hydatids  are 
closed  sacs,  contained  one  within  another,  while 
the  vesicular  mole  is  formed  by  saccules  growing 


096  MOLE— MOLAR  PREGNANCY, 

from  one  another.  It  was  formerly  supposed 
that  they  grew  from  a common  stalk,  and  they 
were  likened  to  a hunch  of  grapes  or  currants  ; 
but,  for  the  reason  given  above,  that  simile  was 
imperfect.  The  vesicles  vary  in  size  from  a 
chestnut  to  a pin’s  head,  or  less ; usually  they  are 
about  the  size  of  small  currants  ; and  as  a few 
may  from  time  to  time  escape,  accompanied  by 
more  or  less  sanguineous  discharge,  Gooch’s 
simile  of  ‘ white  currants  floating  in  red-currant 
juice  ’ is  a very  apt  one. 

All  authorities  agree  that  the  vesicles  grow 
from  the  chorionic  villi.  There  is  no  new  for- 
mation, but  excessive  and  erratic  development. 
Mettenheimer,  Paget,  Barnes,  Virchow,  and 
others  concur  in  this  view.  Whether  the  chango 
is  the  cause  or  consequence  of  the  death  of  the 
embryo  is  unsettled.  Leishman  points  out  that 
the  period  within  which  degeneration  of  the 
chorionic  villi  may  originate  does  not  extend 
probably  beyond  the  tenth  week,  that  being  the 
period  of  greatest  activity  in  the  growth  and 
multiplication  of  the  villi.  Later  on,  when 
blood-vessels  have  occupied  the  bulk  of  the 
villi,  this  kind  of  degeneration  seems  incapable 
of  formation.  The  probabilities,  therefore,  are 
in  favour  of  the  formation  taking  place  in  the 
first  chorion,  or  vitelline  membrane.  In  re- 
ference to  this  portion  of  the  subject  it  may 
be  well  to  remark  that  recurrence  of  vesicular 
growths  has  occasionally,  though  rarely,  been 
met  with  after  apparent  removal  of  vesicular 
moles  from  the  uterus.  Probably  some  portion 
escaped  detection  in  those  cases,  and  growth 
went  on  therein.  Dr.  McClintock  mentioned 
this  many  years  ago,  and  several  cases  are  on 
record. 

The  connection  between  the  vesicular  mole 
and  the  uterus  may  be  extremely  intimate,  some 
vesicles  penetrating  the  uterine  wall  even  to  the 
peritoneum.  Barnes  states  this,  and  Schroeder 
refers  to  a case  by  Volkmann  and  oneby  Jarotsky 
and  Waldeyer,  in  which  it  occurred.  The  occa- 
sional recurrence  of  this  variety  of  mole  may 
be  explained  by  portions  imbedded  in  the  uterine 
wall  escaping  removal,  or  resisting  expulsion. 
The  penetration  of  the  uterine  parietes  may  also 
favour  rupture  of  the  organ  during  the  expulsion 
of  a vesicular  mole,  as  in  a case  recorded  by 
the  late  Dr.  Tyler-Smith. 

The  vesicular  mole  belongs  to  the  class  of 
pathological  products  known  as  myxomata. 
According  to  Gscheidlen  the  cyst-fluid  contains 
albumen,  mucin,  phosphates,  and  other  inorganic 
salts,  leuein  and  tyrosin  in  small  quantities,  but 
no  trace  of  fibrinogenous  substance,  paralbumen, 
cr  sugar. 

An  analogous  degeneration  of  the  placenta 
has  been  described  by  Virchow  and  Hildebrandt 
as  1 fibrous  myxoma’  of  the  placenta.  Schroeder 
quotes  cases  of  ‘ diffuse  myxoma  ’ of  the  placenta, 
by  Breslau  and  Ebertli,  and  Spaeth  and  Wedl. 
A case  of  myxoma,  or  hyperplasia  of  the  cho- 
rionic villi,  is  related  by  Dr.  Sinclair  in  vol.  i.  of 
the  Publications  of  the  Massachusetts  Medical 
Society. 

StmptOms. — The  symptoms  of  vesicular  molar 
pregnancy  are  at  first  usually  those  of  ordinary- 
pregnancy,  but  patients  often  complain  of  ma- 
laise. The  bulk  of  the  uterus  increases  with 


HOLIMEN. 

great  and  disproportionate  rapidity.  There  is  a 
tendency  to  the  loss  of  the  ovoid  form,  and  the 
assumption  of  the  globular  or  more  transversely 
wide  shape.  Generally  there  is  early  evidence  of 
the  presence  of  some  derangement,  hy  the  ap- 
pearance of  watery  and  sanguineous  disebarse. 
When  vesicles  come  away  the  diagnosis  is  clear : 
but  in  their  absence  the  practitioner  may  bej 
puzzled.  In  other  cases  there  may  be  high  tem 
perature,  quick  pulse,  an  icteric  tint  of  skin, arP 
a dry  or  glazed  tongue. 

Physical  examination  often  yields  important 
information.  Palpation  may  give,  as  Leishman 
remarks,  a significant  sensation  of  bogginess 
with  absence  of  the  irregular  foetal  hardness 
Hardening  under  manipulation  is  very  significan  | 
of  the  uterine  nature  of  the  tumour.  On  vaginv 
examination  a doughy  sensation  may  be  expe 
rienced  in  the  lower  segment  of  the  uterus1 
Should  the  os  be  open,  vesicles  may  be  felt.  T ! 
the  touch  they  somewhat  resemble  recent  blood) 
clots.  In  all  suspicious  cases  discharged  mate 
rials  should  be  carefully  examined. 

Treatment. — The  treatment  of  all  these  casej 
of  mole  pregnancy  consists  in  the  complete  ra 
moval,  whenever  practicable,  of  all  the  disease 
tissues.  Dilatation  of  the  uterus  may  be  nece.- 
sary  for  this  purpose,  either  by  the  fmger  or  b 
means  of  tents,  or  Barnes's  bags;  and  erect 
and  other  oxytocics  may  be  called  for  to  aid  i 
the  expulsion  of  the  offending  product  in  son 
cases. 

The  diseased  tissues  should,  if  possible,  1 
completely  removed.  Portions  may  beretaine 
after  the  bulk  has  been  removed  or  expelled,  at 
give  rise  to  grave  and  exhausting  discharges, 
to  recurrence,  as  has  been  mentioned  above, 
is  important  to  remember,  in  this  connection,  th| 
twin  pregnancies  may  occur  in  which  vesieul 
degeneration  affects  the  membranes  of  but  o 
ovum.  It  is  well,  therefore,  to  bear  in  mind  t 
possibility  of  this  ; and  that  the  sound  ovum  m 
proceed  to  full  development.  This  state  of  thi 
is  said  to  have  occurred  on  the  occasion  of 
birth  of  the  celebrated  anatomist  Bedard. 

Ai-fbf.d  Wiltshire 

MOLE,  in  Skin-Diseases  (A.S.  mal).- 
term  applied  to  certain  permanent  out-grows 
of  the  skin.  They  are  usually  congenital,  and.- 
termed  navi  or  ‘ mother-marks.’  When  coved 
with  hair  they  are  called  ‘ hairy  moles,’  or  n t 
pilosi ; and  when  of  a dark  colour,  ‘ pigmentk 
moles,’  navi  pigmentosi.  Another  synonynH 
the  pigmentary  mole  is  spiltis.  I 

Treatment. — The  most  convenient  modgt 
treatment  of  all  these  kinds  of  mole  is  the  c;  - 
ful  application  of  a strong  solution  of  pot;  a 
fusa,  two  parts  to  one  of  water.  They  are  tk>- 
by  converted,  in  the  course  of  a few  minutes,  - j 
a transparent  gelatinous  mass,  which  dritdp 
into  a black  scab ; and  they  are  rarely  rep- 
duced  when  removed  in  this  manner. 

Erasmus  Wilso 

MOLIMEN  ( molior , I move  or  stir).--1 
impulse  or  effort.  The  word  is  chiefly  use-;  - 
connection  with  menstruation,  to  indicated 
effort  which  appears  to  be  made  by  the  sy  n 
to  perform  this  function.  See  Menses,  oe  -*• 
steuation,  Disorders  of. 


MOLLITIES  OSSIUM.  . 
MOLLITIES  OSSIUM  (Lat.).— Synon.  : 

Isteomalacia  ; Malacosteon ; Fr.  RamoUissement 
L Os;  Ger.  Knochenerweichung. 

Definition. — A condition  in  which  the  bones 
' the  skeleton  become  by  degrees  decalcified,  so 
lat  they  can  no  longer  sustain  the  weight  of  the 
|dy,  but  bend  or  break  on  slight  provocation. 
[Mollities  ossium  has  been  called  an  excentrie 
rophy;  but  the  minute  changes  which  occur 
re  not  those  of  atrophy,  but  rather  of  active 
calcification  of  the  bone. 

/Etiology  and  Pathology. — The  causes  of 
Wlities  ossium  are  unknown.  It  affects  the 
jnale  sex  almost  exclusively ; only  occurs  in 
iults,  and  during  the  period  of  child-bearing. 
;iere  is  some  intimate  connection  between  the 
c'tbr'eak  of  mollities  ossium  and  the  gravid 
i.te;  and  repeated  pregnancies  appear  to  pre- 
,..pose  to  its  occurrence.  It  also,  but  very 
:-ely,  is  observed  in  the  male  sex.  The  disease 
t ms  to  occur  in  the  lower  classes  cf  the  people, 
are  exposed  to  hardship  and  have  inade- 
Jtte  food.  In  certain  localities  it  would  seem 
be  endemic.  It  has  been  ascribed  to  changes 
i the  nutrition  of  the  bone. ; to  a process  akin 
tjchronie  osteitis,  or  osteomyelitis  ; and  to  the 
p.'ion  of  an  excess  of  lactic  acid  in  the.  blood, 
jis  acid  is  said  to  have  been  found  in  the  bones 
si  urine  of  persons  affected  by  the  disease. 
Anatomical  Characters. — The  bone  in  mol- 
lies ossium  becomes  gradually  decalcified,  the 
amge  spreading  from  within  outwards,  until 
ipere  shell  of  external  compact  tissue  rs  left, 
it  this  cortical  layer  never  wholly  disappears. 
r-e  medullar}’  cavity  enlarges  in  all  directions, 

( upying  the  epiphysis,  and  invading  the  cor- 
til  substance,  until  the  interior  becomes  a 
pitiniform  mass,  enclosed  in  a periosteal  shell. 
jb  bone  can  be  cut  into  layers  with  a knife, 
(Indented  with  the  pressure  of  the  finger. 

n the  stage  of  acuta  progress  the  medulla  is 
vjy  vascular,  the  vessels  are  enlarged,  and  here 
a.  there  extravasations  of  blood  occur.  The 
r>  lullary  spaces  are  filled  with  nucleated  mar- 
r ’-corpuscles ; the  trabeculae  give  way;  the 
olous  particles  disappear;  the  fat-cells  dim- 
ii  h,  and  gradually  disappear ; and  finally  the 
wile  interior  is  filled  with  a pale  or  yellowish 
g.tinous  substance,  resembling  the  vitreous 
bijy.  In  extreme  cases  the  external  covering 
u be  solely  the  fibrous  periosteum,  with  a 
ft  plates  of  bone  in  its  interior. 

ntPTOMs. — One  of  the  earliest  symptoms 
iciollities  ossium  is  aching  rheumatoid  pains 
idlhe  affected  bones,  generally  aggravated  at 
n t.  The  vertebral  column,  the  ribs,  and 
tl  pelvis  are  the  parts  first  affected;  and  in 
tl  e serious  deformity  shortly  becomes  mani- 
fcj  The  weight  of  the  body  causes  extreme 
liyal  and  angular  curvatures.  The  ribs  are 
hi;  and  broken ; one  series  of  fractures  taking 
pie  in  the  axillary  line,  usually  directed 
inirds,  is  produced  by  external  pressure ; 
m st  a second  and  third  row  of  fractures  take 
pi  i by  more  indirect  force — the  one  near  the 
jjjjj  of  the  ribs,  the  other  outside  the  sternum. 
Ti  arms  often  lie  in  a trough-shaped  hollow  on 
tlij  ides  of  the  body.  The  sternum  gives  way 
njveral  places,  and.  is  displaced  forwards. 

I r,>|!gh  the  weight  of  the  body  acting  from 


MOLLUSCUM.  997 

above,  the  promontory  of  the  sacrum  is  projected 
forwards,  whilst  the  lateral  pressure  of  the  head 
of  the  femur,  against  the  acetabulum,  causes 
the  transverse  diameter  of  the  pelvic  outlet  to 
diminish.  It  thus  assumes  a trifoliate  shape, 
the  pubic  symphysis  often  projecting  forwards 
at  right  angles  to  its  normal  position,  with  its 
two  horizontal  rami  in  contact.  The  floor  of 
one  acetabulum  may  even  touch  the  other.  The 
bones  of  the  extremities  suffer  from  multiple 
fractures  and  bending  from  the  most  triflin'? 
causes ; and  these  are  very  imperfectly  repaired 
in  the  later  stages  of  the  disease,  although  in 
the  earlier  they  unite  readily  by  bony  callus.  As 
the  disease  progresses,  the  body  becomes  more 
and  more  misshapen  ; the  patient  more  perfectly 
helpless  and  bedridden ; and  death  usually  ensues 
from  exhaustion,  after  a more  or  less  protracted 
interval,  or  the  sufferer  is  carried  oft'  by  inter- 
current disease.  Female  subjects  frequently  die 
in  consequence  of  severe  instrumental  interference 
required  during  pregnancy.  There  is  no  consti- 
tutional cachexia. 

Diagnosis. — The  diagnosis  of  mollities  ossium 
is  at  first  very  obscure.  The  pains  resemble 
those  of  rheumatism.  The  character  of  the 
deformity  will,  however,  settle  any  doubts.  The 
disease  should  not  be  confounded  with  rickets, 
which  is  a disease  of  infancy  or  childhood,  due 
to  delayed  ossification,  and  producing  prominent 
curvatures  of  the  shafts  of  the  bone,  and  en- 
largements near  the  epiphyses,  very  distinct  in 
type  from  the  infractions  and  extravagant  dis- 
tortions of  the  osteomalacic  skeleton.  Nor  does 
mollities  resemble  the  fatty  atrophy  of  bones 
due  to  senile  changes,  in  which  condition,  though 
fracture  be  common,  there  is  no  general  de- 
formity involving  different  parts  of  the  skeleton. 

Prognosis. — The  prognosis  in  most  cases  is 
unfavourable.  In  some  well-marked  cases  of 
softening,  the  bones  appear  to  have  afterwards 
recovered  their  normal  consistence,  but  this  is 
very  unusual. 

Treatment. — No  remedial  measures,  as  yet 
discovered,  have  either  arrested  the  progress 
of  mollities  ossium  or  promoted  its  cure.  Women 
affected  in  this  way  should  be  restrained,  if 
possible,  from  further  childbearing,  not  only 
to  avert  increase  of  the  disease,  but  to  avoid 
the  dangers  attending  childbirth  in  cases  of  de- 
formed pelvis.  Otherwise,  an  ample  supply  of 
nourishing  food,  rest  in  the  recumbent  position, 
and  abundance  of  fresh  air,  are,  combined  with 
iron  and  quinine  internally,  the  principal  means 
of  treatment  at  our  disposal. 

Willi  am  Mac  Cormac. 

MOLLUSCUM  ( mollis , soft).  — Defini- 

tion.— A term  applied  to  soft  tumours  of  the  skin. 

Structurally,  molluscum  is  an  overgrowth  of 
the  connective  tissue,  and  therefore  a fibroma  ; 
hence  it  is  named  by  Virchow  fibroma  molluscum. 
But  there  is  another  tumour  of  small  size,  rarely 
larger  than  a pea,  which  has  been  described  as 
an  overgrowth  of  the  sebaceous  glands,  but  re- 
cently as  a specific  degeneration  of  the  cells  of 
the  reto  Malpighii.  In  England  observation 
proves  the  contagiousness  of  this  affection — 
molluscum  contagiosum. 

Description. — Pathologically  the  fibromatoue 


39U  MOLLUSCUM. 

molluscum  is  an  hypertrophy  of  the  connective 
tissue  of  the  superficial  stratum  of  the  inte- 
gument, infiltrated  "with  serum,  which  renders 
the  tumour  more  or  less  mdematous,  and  gives 
it  its  character  of  softness.  It  may  range 
in  size  from  that  of  a millet-seed  to  that  of  an 
oraDge  or  large  melon.  Occasionally  even,  as 
in  a remarkable  case  illustrated  by  Virchow, 
small  mollusea  were  protruded  from  the  surface 
of  one  of  very  large  size.  The  molluscum  will 
also  vary  in  density,  in  proportion  to  the  firmness 
or  relaxation  of  the  connective  tissue,  and  the 
quantity  of  fluid  contained  within  its  meshes. 

Sometimes  the  molluscous  growth  is  not  re- 
stricted to  the  form  of  a tumour,  but  occupies  a 
large  extent  of  the  integument,  such  as  the 
whole  cii’cumference  of  a limb,  and  gives  rise  to 
immense  folds  and  lobes  which  overhang  each 
other  in  festoons,  suggesting  the  term  ‘ derma- 
tolysis,’  applied  to  this  variety  by  Alibert.  At 
other  times  the  tumour  grows  in  length,  expand- 
ing as  it  proceeds,  until,  issuing  from  a narrow 
base,  it  develops  into  a mass  resembling  distended 
intestines. 

The  blood-vessels  of  molluscous  tumours  are 
always  large,  particularly  the  veins;  but  in  the 
exaggerated  forms  of  the  disease,  the  latter  are 
prodigious  in  size,  and  may  be  seen  through  the 
tikin  twining  around  the  base  of  the  lobes. 

Treatment. — The  treatment  of  molluscum 
consists  in  the  removal  of  the  tumour.  When 
the  latter  is  of  small  size  this  may  be  accomplished 
with  the  scissors,  hut  when  it  assumes  the  gigantic 
proportions  already  mentioned  the  operation  is  a 
serious  one.  Mr.  Pollock,  in  a case  of  this  kind, 
secured  the  large  vessels  by  means  of  a ligature 
before  proceeding  to  the  employment  of  the  knife. 
To  treat  molluscum  contagiosum  we  must  slightly 
enlarge  the  opening  with  a lancet,  and  press  out 
its  contents.  The  capsule  then  contracts  or  dies. 

Erasmus  Wilson. 

MONOMANIA. — Svnon.  : Fr.  Monomanic  ; 
Ger.  Wahnsinn. — This  term  is  falling  into  disuse 
on  account  of  its  vagueness,  and  because  it  has 
been  employed  by  various  writers  to  denote 
different  kinds  of  insanity.  Some  have  used  it 
to  denote  an  insanity  which  is  indicated  by 
some  one  particular  delusion,  the  mind  remain- 
ing clear  on  every  other  point.  Others  mean 
by  it  an  insanity  without  delusion,  an  affective 
or  impulsive  insanity,  the  essence  of  which  is 
the  absence  of  delusion,  and  the  so-called  in- 
tegrity of  tho  intellectual  portion  of  the  mind. 
Esquirol  thought  it  a disorder  of  the  faculties 
limited  to  a few  subjects,  with  excitement,  and 
gay  and  expensive  passion  ; while  according  to 
others,  melancholia  without  delusion  would  be 
an  instance  of  affective  monomania.  We  may 
take  it,  however,  that  all  authors  are  agreed  in 
using  the  term  monomania  to  indicate  a partial 
insanity,  which  enables  the  patient  to  converse 
and  act  rationally  to  a considerable  degree,  and 
therefore  renders  his  responsibility  a matter 
of  question.  Such  cases  form  the  grounds  of 
forensic  contests,  whether  criminal  or  civil;  but 
it  is  better  to  affix  to  them  some  more  precise 
term,  and  to  indicate  symptomatologically  and 
pathologically  the  exact  nature  of  the  mental 
and  bodily  condition  of  the  alleged  lunatic. 

G.  F.  Blanbford. 


MOKBIFIC. 

MONSUMM.ANA,  Cave  of;  in  Uppe 
Italy. — Natural  vapour  baths.  See  Mixeha 

Waters. 

MONT  DOEE,  in  France. — Simple  thei 

mal  water,  containing  arsenic  and  soda.  & 
Mineral  Waters. 

MONTPELLIER,  in  South  of  Franci 

Variable,  fairly  warm,  winter  climate.  Hie 
winds  from  N.E.  and  N.W.  See  Climate,  Trts 
ment  of  Disease  by. 

MORAL  INSANITY.  See  Insanity,  yJ 

rieties  of. 

MORBID  (morbus,  a disease). — This  won 
merely  signifies  diseased,  and  is  used,  in  its  sever 
applications,  as  a technical  or  scientific  term. : 
contradistinction  to  the  term  healthy.  Amoi 
the  most  common  examples  of  these  applicatio: 
may  be  mentioned  morbid  anatomy  and  histolcg 
which  imply  the  anatomy  and  histology  of  d: 
eased  conditions  ; morbid  sensations  or  fedim 
as  distinguished  from  healthy  sensations,  wheth 
connected  with  either  of  the  ordinary  senses, 
with  some  particular  organ,  such  as  appetit 
morbid  actions ; morbid  secretions  or  discharge 
and  morbid  growths.  The  word  is  employed  it 
somewhat  special  sense,  in  relation  to  individn: 
who  are  mentally  low  in  spirits  and  despondei 
without  any  obvious  cause  to  account  for  tH 
condition;  such  individuals  are  often  spoken! 
as  being  in  a morbid  state. 

MORBIDITY  ( morbus , a disease).  — II 
term,  which  is  of  recent  introduction,  is  ei 
ployed  to  denote  the  amount  of  illness  exist! 
in  a given  community;  and,  as  1 mortality ’ s! 
presses  the  death-rate,  so  ‘ morbidity’  indica; 
the  sick-rate,  whether  the  diseases  be  fatal  or  nl 

Since  health  is  an  extremely  ill-defined  sta- 
marked  out  by  no  absolute  boundaries,  and  sit 
many  people  suffer  from  diseases  that  are  e. 
cealed  intentionally  or  through  ignorance,  it 
comes  a matter  of  considerable  difficulty  to  ■ 
press  with  certainty  the  amount  of  illness  tk 
may  exist  at  any  time.  Some  information  m, 
however,  be  obtained  from  the  records  of  sit- 
clubs  and  benefit  societies,  on  which  statists 
may  he  based  of  the  average  time  their  s;- 
scribers  arc  ill  during  the  year,  in  relations 
employment,  age,  locality,  and  other  circc- 
stances.  _ 'Ll 

By  an  investigation  of  this  subject  the  rate.-f 
mortality  come  to  possess  an  extended  sigi|- 
cance,  for  they  thus  indicate  not  merely  the  p- 
portion  between  tho  living  and  tho  dead,  but  r 
tween  tho  latter  and  the  two  classes  of  the  liv;. 
namely,  the  healthy  and  the  diseased;  and-s 
a branch  of  State  medicine,  must  doubtless  cfe 
to  take  a prominent  place.  As  further  kn- 
ledge  provides  accurate  facts  and  figures,  >e 
subject  will  have  a distinct  practical  beariosn 
estimating  the  value  of  men  for  work,  if 
average  liabilitv  to  disease  and  the  total amc-.. 
of  illness  an  individual  may  expect  to  suffer-’ 
known  ; while  it  is  reasonable  to  believe  thais 
the  ‘ aptitudes  to  disease’  are  further  conditio- 
the  means  for  prevention  mav  be  extended. : 

W.  H.  Allchi: 

MORBIFIC  ( morbus , disease,  and  fan  1 
make). — This  word  is  properly  applied  toot 


MORBIFIC. 

juso  that  produces  a disease.  Such  a cause  is 
ften  spoken  of  as  a morbific  agent. 

MORBILLI  (dim.  of  morbus,  a disease). — A 
ynonym  for  measles.  See  Measles. 

MORBUS. — This  is  the  Latin  word  for 
isease.  Formerly  it  was  frequently  employed, 
■,ut  is  not  much  in  vogue  at  the  present  day. 
Vhen  applied  to  particular  diseases,  it  is  asso- 
rted with  some  qualifying  adjective  or  noun, 
idicating  the  nature  or  seat  of  such  disease, 
ome  peculiarity  by  which  it  is  characterised,  or 
te  name  of  some  renowned  authority  upon  it. 
|b  would  not  serve  any  useful  purpose  to  give  a 
st  of  the  diseases  with  which  the  word  is  con- 
ected,  and  it  will  sufiico  to  cite,  as  examples, 
ime  of  its  more  common  applications,  such  as 
'/>rbus  cordis,  disease  of  the  heart;  morbus 
■ixce  or  coxarius,  disease  of  the  hip-joint;  morbus 
rcalis,  ergotism ; morbus  Brightii,  Bright’s 
isease  ; morbus  cceruleus,  blue  disease. 

MOROCCO,  in.  North  Africa. — Warm, 
ealthy  winter  climate.  Tangiers  is  exposed  to 
lid,  damp  S.W.  winds  in  autumn  and  spring, 
!ad  to  E.  winds.  Living  superior  to  Malaga. 
,cc  Climate,  Treatment  of  Disease  by. 

MORPHIA,  Poisoning  by.  See  Opium, 
oisoning  by. 

MORPHCEA  ( morphcea , a blotch).- — This 
ord  has  been  used  at  various  times  as  a synonym 
' lepra  alphoides  or  alphos,  and  leuce,  and  is 
.Tied  in  meaning  with  vitiligo.  More  recently  it 
|s  served  to  distinguish  a circumscribed  form  of 
leroderma.  Four  varieties  of  morphcea  have 
■en  recognised — namely,  morphcea  o.lba,  nigra, 
berosa,  and  atrophica ; but  a better  knowledge 
the  pathology  of  the  disease  will  probably 
erge  the  whole  of  these  varieties  in  sclero- 
ma. See  ScLEKODEitMA.  Erasmus  Wilson. 

MORTALITY. — Synon.:  Ratcof  Mortality ; 
•wth-rate;  Fr.  Mortality ; Ger.  Sterblichkdt. 
Definition. — The  proportion  of  persons  dying 
those  surviving  under  given  circumstances  ; 
more  usually,  the  proportion  borneby  the  per- 
is who  die  to  the  whole  number  of  those  sub- 
, ted  to  the  given  circumstances. 

Thus  we  may  have  to  do  with  the  annual 
•.rtality  of  the  population  of  a country,  a dis- 
t it,  or  a city  ; or  of  a body  of  men  similarly 
< mmstanced,  as  of  clergymen  or  of  lead-miners ; 
( of  bodies  of  men  otherwise  alike,  but  sub- 
j ;ed  to  different  conditions  of  climate,  Sec.,  as 
t British  army  ; or  of  the  population,  or  any 
stion  of  the  population,  at  special  ages,  as  of 
ihnts  in  factory  towns. 

Or  we  may  be  concerned  with  the  propor- 
t is  of  deaths  to  survivors,  or  to  the  whole 
paher  of  entrants,  during  and  after  exposure 
t . special  cause  or  causes  of  death,  operating 
e ier  speedily  or  during  a protracted  period, 
b'eunder  come,  for  example,  the  mortality  sus- 
t .ed  by  the  population  of  Rio  Janeiro,  or  New 
leans,  during  an  epidemic  of  yellow  fever  ; or 
I ; suffered  by  a number  of  persons  in  passing 
t iugh  an  attack  of  enteric  fever  or  pneu- 
n,  ia. 

stdiation  of  Mortalitt. — The  annual  mor- 
■'  j of  a population  is  reckoned,  not  on  the 


MORTALITY.  999 

numbers  in  existence  at.  the  beginning  of  a year, 
but  on  the  average  number  in  existence  on  the 
several  days  of  the  year,  or,  what  is  nearly  the 
same  thing,  on  the  mean  population  of  the  year. 
The  necessity  of  this  becomes  evident.,  when  we 
consider  that  in  our  own  country  the  large  towns 
are  mostly  increasing  an  a very  rapid  rate,  while 
some  agricultural  parishes  and  unprosperous 
places  actually'  decline  in  population.  In  the 
towns,  therefore,  the  death-rate,  if  reckoned  oo 
the  last  census,  or  even  on  the  number  be- 
lieved or  estimated  to  exist  at  the  beginning  c: 
the  given  year,  would  come  out  higher  than  it 
ought  to  be,  while  in  declining  parishes  it  would 
be  somewhat  too  low.  Similarly  the  annual 
mortality  of  bodies  of  troops  is  calculated  on 
the  mean  strength. 

Two  formulae  are  in  use  for  specifying  death- 
rates.  In  the  first  the  proportion  of  deaths  is 
takenas  unity ; thus,  the  mortality  in  England  and 
Wales  in  1873  would  be  stated  as  1 in  46.  In 
the  second,  which  is  more  convenient  and  is 
now  generally  employed,  the  number  of  lives  at 
risk  is  taken  as  100  or  1,000  : thus  the  mortality 
of  1878  would  come  out  21;7.  Either  formula 
is  convertible  into  the  other  by  simplo  division: 
thus  1,000 -=-46  = 21-7  ; and  1,000^-21-7  = 46. 

The  death-rates  of  large  civilised  countries, 
in  which  registration  is  strictly  carried  out,  give 
a pretty  fair  representation  of  the  viability  of 
the  population.  So  much  may  he  said  for 
England,  Wales,  and  Scotland,  and  for  most  of 
the  European  States,  but  not,  unfortunately,  for 
Ireland,  where  the  weakness  of  the  registration 
laws  makes  the  record  defective. 

Mortality  of  Nations. — The  following  are 
the  death-rates  per  1,000  of  most  of  the  prin- 
cipal States  of  Europe  : — 


Norway 

Sweden 

Denmark 

England  and  Yales 

Scotland 

Belgium 

Switzerland 

France 

Or  excluding  two  years  of  war 

Netherlands 

Herman  Empire 

Italy 

Spain  

Austria 

Hungary 

Or  excluding  two  cholera  years 

The  death-rate  of  Russia,  except  in  the  ex- 
treme north,  is  high.  It  was  stated  at  35'9  ir 
1842.  That  of  Portugal  the  writer  has  not  been 
able  to  obtain.  Those  of  Turkey,  of  Ireland, 
and  of  Greece  are  unknown.  In  maDv  of  the 
British  colonies  it  is  lower  than  everf  in  Norway. 
Thus  the  average  mortality  during  the  ten  years, 
1866-75,  was  in  1 

Victoria,  15-8  | South  Australia,  13-3 

New  South  Yales,  15-3  Tasmania,  14-8 
Queensland,  17-7  | New  Zealand,  12-4 

Mortality  of  Cities. — The  mortality  of  cities 
is  in  this  country  almost  invariably  higher  than 
that  of  the.  open  country.  But  this  rule  does 
not  apply  to  all  other  countries  ; the  exceptions 
occur  mostly  where  endemic  fevers  are  prevalent 
1 Hayter,  Australian  Statistics. 


In  years. 

Per  1000 
living. 

1846-55 

..  17*9 

1869-78 

..  18*9 

,, 

..  19*2 

..  21*8 

„ 

. . 22*1 

. . 22*6 

1S70-78 

. . 23*5 

1869-78 

. . 24*3 

22*5 

1869-78 

. . 24*4 

1872-78 

. . 27*2 

1869-78 

. . 29*5 

1861-70 

..  29*7 

1869-73 

..  31-1 

1868-77 

. . 39*6 

. . 36*1 

MORTALITY. 


1000 

in  the  country.  Thus  the  mortality  rate  in  1878 
was  in  London,  23-o  ; in  Edinburgh,  22T,  and 
in  Dublin,  29  6 ; and  in  20  other  large  towns 
in  the  United  Kingdom  it  varied  between  19‘ 
in  Portsmouth,  and  29'4  in  Liverpool ; while  in 
50  towns  of  the  second  class  the  extremes  were 
16  2 at  Dover,  and  1ST  at  Rochester;  30’4  at 
Blackburn,  and  30'8  at  Preston ; the  average  of 
the  23  towns  being  24'4  per  1,000,  and  of  the 
50  towns  23'.  In  the  same  year  the  rural  dis- 
tricts and  small  towns  of  England  yielded  an 
average  rate  of  19'  only.  There  are  a consider- 
able number  of  districts,  almost  all  rural,  which 
year  after  year  fall  below  17  ; and  17  was  accord- 
ingly fixed  upon  by  the  late  registrar-general 
for  England  as  a kind  of  standard  to  be  aimed 
at  by  sanitarians.  And  there  are  districts  in 
England,  and  entire  small  counties  in  Scotland, 
where  the  rate  occasionally  falls  below  even  15. 

The  following  table  exhibits  the  death-rates 
experienced  in  1878  in  a number  of  foreign  and 


colonial  cities : — 
Calcutta 

37-7 

Paris  . 

24-6 

Madras 

48-8 

Brussels 

. 28-0 

Bombay 

41-8 

Amsterdam. 

. 24-4 

New  York  . 

24-8 

Rotterdam  . 

. 27-3 

Brooklyn  . 

20*1 

The  Hague  . 

. 26*4 

Philadelphia 

1 8-0 

Copenhagen 

. 22-0 

Montreal 

30-9 

Stockholm  . 

. 22-4 

Alexandria  . 

4o"4 

Christiania  . 

. 18-5 

Melbourne,  1873  and 

St.  Petersburg  . 

. 47-1 

1875. 

22*8 

Berlin  . 

. 29*9 

Borne  (1878) 

2.9-8 

Hamburg  . 

. 26*9 

Naples 

33-1 

Dresden 

. 24-7 

Turin  .... 

31*1 

Munich 

. 34-G 

Venice 

28-7 

Breslau 

. 29-9 

Trieste 

36-2 

Vienna 

. 29-G 

Geneva 

23-G 

Budapest  . 

. 40-3 

Analysis  of  Results. — -These  tables  awaken, 
by  the  enormous  differences  between  the  several 
cities  and  countries,  a curiosity  respecting  the 
causes  of  such  differences,  which,  however,  the 
figures  themselves  go  far  towards  satisfying.  It 
is  at  once  evident  that,  whatever  may  be  the 
case  in  the  open  country,  cities  suffer  to  a con- 
siderable extent  in  the  ratio  of  their  ignorance 
and  neglect  of  sanitary  laws,  and  of  the  poverty 
and  squalor,  or  barbarism  of  their  populations. 
Mark,  for  example,  the  contrast  between  Phila- 
delphia and  St.  Petersburg ! Cities  having  a 
steadily  warm  climate,  or  a climate  of  extremes, 
are  more  unhealthy  than  those  which  enjoy  a 
temperate  one.  By  this  consideration,  combined 
with  that  of  their  superior  civilisation,  may  be 
explained  the  favourable  position  of  the  cities  of 
"Western  as  compared  with  those  of  Eastern 
Europe.  The  short,  hot  summers  are  very  fatal 
in  the  latter  region,  and  even  in  Southern  Ger- 
many and  at  Stockholm ; while  in  Western 
Europe  generally,  and  especially  in  Scotland, 
winter  and  spring  are  the  deadly  seasons.  It  is 
noteworthy  that  in  most  of  the  large  cities  of 
Italy  the  short,  sharp,  and  changeable  winter  is 
not  less  deadly  than  the  hot  summer  and  mala- 
rious autumn;  in  fact  good  winter  climates  for 
poitrinairqs  are  exceptional  even  in  Italy. 

In  Great  Britain  the  inriuenee  of  climat  e per  se 
on  the  annual  mortality  of  the  several  cities  and 
districts  is  not  very  great ; and  its  effects  are 
obscured  by  those  of  other  agencies.  But  if  we 
confine  our  attention  to  the  rural  districts,  where 
the  disturbing  factors  are  less  important,  we 
shall  find  that  the  rates  of  mortality  are  on  the 


whole  slightly  more  favourable  in  the  north 
than  in  the  south.  Of  all  the  counties  in  Great 
Britain  Orkney-and-Shetland  stands  best,  with 
an  annual  mortality,  on  an  average  of  10  years,1 
of  15"  13  ; and  Shetland,  the  more  northern  divi- 
sion, stands  better  than  Orkney.  Great  Britain 
is,  therefore,  no  exception  to  tho  rule  that  in 
Europe  mortality  decreases  from  south  to  north. 
This  is  in  no  way  inconsistent  with  the  fact  that 
throughout  Great  Britain  winter  is  the  deadly 
season,  and  cold  is  more  fatal  than  heat,  thoracic 
than  abdominal  diseases. 

Influence  of  Seasons. — The  following  were 
the  death-rates  of  the  four  seasons  in  England 
and  Wales,  in  1868-77  : — 


Win- 

ter. 

Spring. 

Sum- 

mer. 

Au- 

tumn. 

Year. 

In  the  chief  towns  . 

25-8 

22-5 

23-1 

24-9 

23-7 

In  the  small  towns 

and  rural  districts 

21-7 

19*3 

17-2 

18-5 

19-0 

In  Scotland  the  seasonal  mortality,  owin2. 
doubtless,  to  the  less  intensity  of  the  summer 
heat,  follows  pretty  nearly  the  order  of  the 
English  small  towns  and  rural  districts.  Thus 
in  1878:  winter,  25'2;  spring,  23'2 ; summer 
19'8  ; autumn,  204  ; year,  22-3. 

It  would  seem,  however,  that  in  London,  ir 
the  early  part  of  the  seventeenth  century,  wher 
the  death-rate,  owing  to  the  closeness  anc 
filthiness  of  the  city,  was  fearfully  high,  tin 
maximum  was  attained  in  summer,  the  figure: 
standing  as  follows  in  1606-10,  during  whic! 
years  the  plague  was  absent.  Average  mortalit 
percent.: — winter  (J.  F.  M.),  1'4;  spring,  1'5 
summer,  2'7  ; autumn,  2’0 : — total,  7'0. 

Influence  of  Density  of  Population.— 1 
accordance  with  a principle  already  laid  dowr 
that  in  communities  sufficiently' advanced  to  fm 
nish  mortality  statistics,  the  death-rate  dim' 
nishes  with  the  progress  of  civilisation,  th 
mortality  of  London  has  since  the  seventect 
century'  gradually  and  greatly  diminished.  ^ 
the  beginning  of  this  nineteenth  century  it  ha 
sunk  to  29,  in  1840-49  it  was  25'3,  and  i 
1870-78  only  23. 

The  death-rate  is  also  diminishing  in  Franc 
Belgium,  the  Netherlands,  Sweden,  and  Ge 
many,  in  all  of  which  countries  the  populatic 
is  believed  to  be  advancing  in  comfort  and  gen 
ral  well-being,  but  in  southern  and  easte 
Europe,  where  comparatively  little  advance  h 
taken  place  in  these  respects,  no  such  diminuth 
can  be  demonstrated. 

Nor,  though  evident  in  London  and  in  sevei 
other  great  towns,  can  a diminution  of  t 
death-rate  be  positively  affirmed  of  Great  Brita 
generally.  In  Scotland,  indeed,  there  was  a c 
cided  increase  from  1S55  until  1S76,  when 
decline,  which  may'  prove  transient  only,  set 
And  in  England  no  improvement  could  he  she 
for  many  years  before  1S7L  since  which  ds> 
there  has  been  an  almost  unbroken  success: 
of  years  of  low  mortality,  concurring  with- 
generally  low  temperature  and  excessive  fill/ 
rain. 


1 1S66-76. 


MORTALITY. 


IO01 


The  great  antagonistic  influence  in  Great 
Britain  may  bo  found  in  Dr.  Farr’s  principle, 
That  mortality  increases  with  density  of  popu- 
lation.’ And  ‘urbanisation’  advances  so  rapidly 
in  Great  Britain,  that  all  the  efforts  and  de- 
vices of  sanitary  and  medical  science  are  scarcely 
lable  to  do  more  than  neutralise  its  evil 
effects. 

■ SotmcES  of  Fallacy. — It  may  he  as  well  to 
advert  to  some  of  the  principal  sources  of  fallacy, 
uhich  hamper  us  in  appreciating  national  and 
local  death-rates.  One  of  these  is  the  varying 
number  of  births.  This  ranges  in  the  Conti- 
nental States  of  Europe  from  about  40  in  Ger- 
nany  and  Austria,  and  even  more  in  Russia  and 
Hungary,  down  to  25  in  France;  and  in  Britain 
’rom  48  or  50  in  some  coal  and  iron  districts, 
jlown  to  22  in  the  county  of  Sutherland.  The 
ate  Dr.  Letheby  maintained  that  a high  birth- 
ate  was  a direct  cause  of  a high  death-rate, 
>wing  to  the  great  mortality  among  infants. 
This  was  an  error ; the  two  often  concur,  but 
he  former  is  not  a cause  of  the  latter,  unless 
vhere  the  infants  perish  in  enormous  propor- 
ion.  The  usual  result  in  this  country  of  a large 
,nd  especially  of  an  increasing  birth-rate,  is  to 
..ugment  in  the  community  the  proportion  of 
ihhdren  beyond  infancy,  and  of  young  persons, 
rho  ordinarily  suffer  a very  low  death-rate  as 
ompared  with  old  or  even  middle-aged  per- 
.ons.  The  favourable  rates  prevailing  among 
nese  young  persons  overpowering  the  unfavour- 
ite ones  of  the  infants,  and  of  the  comparatively 
nail  number  of  old  people,  the  apparent  death- 
ate  is  actually  diminished,  instead  of  being 
lereasedas  Letheby  supposed.  And  this  points 
) the  true  reason  why  the  death-rate  of  France 
; higher  than  that  of  England,  whereas  the  ex- 
'octatiou  of  life  in  the  two  countries  is  about 
le  same  at  most  ages,  the  birth-rate  of  France 
ling  exceedingly  low  (Bertillon).  The  lower 
\e  average  age  of  the  population  the  lower  the 
nth-rate. 

A considerable  amount  of  emigration  or  immi- 
•ation  affects  the  death-rate  in  proportion  to 
te  average  age  of  the  migrants.  Thus  the 
ortality  of  most  great  and  growing  towns 
ould  stand  worse  than  it  does,  were  it  not  for 
e large  numbers  of  young  and  healthy  persons 
im  the  country  who  settle  in  them.  Watering- 
ices  and  residential  towns  appear  somewhat 
althier  than  they  really  are,  by  reason  of  the 
.mbers  of  young  domestic  servants  who  form  a 
rge  portion  of  their  population.  But  it  is  in 
r colonies  that  the  effect  of  migration  on  the 
ath-rate  can  best  be  studied.  The  unexampled 
ith-rate  of  New  Zealand,  quoted  above,  is  the 
suit  of  two  kinds  of  causes,  one  set  of  which 
I1  may  call  real,  the  other  factitious  or  apparent, 
e former  are  the  cool,  equable  climate,  and  the 
lerly  and  prosperous  condition  of  the  popula- 
n ; the  latter  are  the  constant  stream  of 
■stly  youtliful  immigrants,  and  the  very  high 
th-rate. 

Influence  of  Age  and  Sex. — The  influence 
age  and  of  sex  on  the  mortality  in  England  and 
lies  may  be  best  shown  in  a tabular  form. 
Mortality  per  1,000  at  twelve  groups  of 
i’S  in  males  and  females  in  the  41  years 
IS— 78 : — 


All 

Ages 

0- 

5- 

10- 

15- 

20- 

25- 

^rales 

71 

3 

4 

G 

8 

9 

Females  .... 

21-2 

G2 

s 

4 

3 

9 

35- 

45- 

55— 

65- 

75— 

85- 

■Males 

23-3 

13 

IS 

32 

67 

147 

311 

Females  .... 

21-2 

12 

15 

2S 

53 

134 

287 

The  superiority  of  the  women  is  here  well- 
marked,  except  during  childhood  and  the  years 
of  early  married  life  and  much  child-bearing. 

Influence  of  Race. — The  influence  of  race  is 
usually  difficult  to  separate  from  that  of  habits 
of  life.  In  Europe  the  Jews  offer  the  most 
notable  example.  It  may  be  sufficient  to  quote 
from  Oesterlen  Neufville’s  statistics  of  Frank- 
fort-on-the-Maine,  who  found  that  there  the  aver- 
age age  of  Christians  at  death  was  36'9  years,  but 
that  of  Jews  was  48‘7  ; and  from  Hoffman,  the 
death-rate  of  the  Jews  of  Prussia,  which  was 
only  21'6  per  1,000,  against  29'G  among  the 
Christians. 

Influence  of  Station  and  Occupation. — 
The  influence  of  station  and  occupation  on  mor- 
tality is  very  great.  The  subject  has  been  care- 
fully handled  by  Dr.  Farr  in  the  Supplement  to 
the  Registrar-General  for  England's  thirty-fifth 
Report.  Briefly,  it  may  be  said  that  of  all  trades 
or  professions  that  can  be  isolated,  clergymen, 
barristers,  farmers,  agricultural  labourers,  game- 
keepers.  grocers,  seem  to  stand  best  in  this  re- 
spect. Booksellers,  paper-makers,  wheelwrights, 
and  carpenters  also  suffer  but  a small  mortality. 
Schoolmasters  and  teachers  go  on  well  up  to 
fifty-five.  Solicitors,  domestic  servants,  watch- 
makers, shoemakers,  blacksmiths,  range  not  far 
from  the  average  rates ; so  do  bakers  (though 
such  is  not  the  current  opinion),  and  the  whole 
tribe  of  weavers.  The  workers  in  iron,  as  a rule, 
experience  but  a low  mortality  in  early  life,  but 
a high  one  as  they  grow  older ; the  same  may 
be  said  of  millers,  and,  somewhat  strangely,  and 
no  doubt  for  very  different  reasons,  of  Roman 
Catholic  priests.  Tailors  begin  very  ill,  and  end 
fairly.  Medical  men,  alas  1 perish  frequently  in 
early  life,  and  only  attain  a respectable  position 
after  fifty-five.  Chemists,  too,  and  veterinary 
surgeons,  como  out  badly.  The  figures  for 
drapers  much  resemblo  those  for  medical  men. 
Those  for  miners,  naturally  enough,  are  not 
much  different  from  those  for  iron-workers, 
though  a little  worse.  Tobacconists,  as  might  be 
expected,  suffer  very  heavily  until  middle  life. 
Printers,  bookbinders,  clerks,  commercial  travel- 
lers, glass  manufacturers,  dock  labourers,  porters, 
railway  employes,  butchers,  fishmongers,  coach- 
men, draymen,  grooms,  all  suffer  a very  high  mor- 
tality. And  the  very  worst  positions  are  occupied 
by  the  dealers  in  alcohol  and  in  lead  (tl*e  painters), 
and  by  the  potters. 

These  facts  are  of  considerable  practical  in- 
terest in  relation  to  questions  of  life  insurance. 

Mortality  of  Diseases. — Some  acquaintance 
with  the  mortality  of  diseases,  and  the  extent 
to  which  it  is  influenced  by  age,  sex,  climate, 
I season,  &c.,  is  also  of  great  value  for  prognosis. 


1002  MOETALITY. 

Information  on  this  subject  will  be  found  under 
the  heads  of  the  several  diseases ; moreover  the 
limits  of  this  article  are  not  sufficient  to  admit 
of  much  discussion  cf  the  subject. 

A few  facts  respecting  the  acute  infectious 
diseases  will,  however,  be  of  interest — - 

1.  Typhoid  Fever. — The  average  death-rate  of 
enteric  fever  was  put  by  Murchison,  in  accord- 
ance with  British,  French,  and  German  hospital 
statistics,  at  17'4  per  cent.  There  is  a good 
deal  of  ground  for  putting  the  average  mortality 
of  children  and  youths  at  11  or  12,  but  it  is  pro- 
bable that  only  the  worst  cases  occurring  in 
children  find  their  way  to  hospitals.  Over  fifty 
years  of  age  somewhere  near  one-half  usually  die 
(Liebermeister). 

2.  Typhus. — In  typhus  the  mortality  varies 
extremely  in  different  epidemics,  sometimes  rising 
above  the  average  of  enteric  fever,  more  often, 
perhaps,  falling  below  it.  In  Ireland  it  is  usually 
low,  averaging  perhaps  9 or  10  per  cent.,  or  less. 
The  mortality  of  children  from  this  disease  is 
much  lower  than  from  enteric  fever  (Murchi- 
son, Lebert,  &e.).  The  number  of  deaths  as- 
cribed to  typhus  (that  is  continued  fever,  inclu- 
ding enteric)  in  the  register,  is,  however,  largest 
in  proportion  to  the  living  under  five  years;  is 
low  from  10  to  15,  and  again  from  25  to  35  ; and 
then  increases  gradually  up  to  extreme  old  age. 
One  cannot  help  suspecting  that  other  febrile 
affections  of  children  are  confounded  with  typhus 
and  enteric  fevers. 

3.  Measles. — The  mortality  from  epidemics 
of  this  disease  is  often  as  low  as  2 or  3 per  cent,, 
but  it  has  been  known  to  rise  to  30  per  cent, 
under  unfavourable  circumstances,  as  where  chil- 
dren, or  even  adults,  are  crowded  together  in  a 
hospital.  Among  ‘ virgin  ’ communities  (as  in  well- 
known  epidemics  in, Iceland,  Farce,  Madagascar, 
Fiji)  the  mortality  is  sometimes  frightfully  large. 
It  is  comparatively  small  in  summer;  and  de- 
cidedly small  among  the  comfortable  classes, 
owing  doubtless  to  the  exercise  of  greater  care. 
It  is  beyond  comparison  greatest  in  the  second 
year  of  life,  and  by  the  tenth  has  become  quite 
trifling ; but  adults  may  die  of  measles. 

4.  Scarlatina.— There  is  a prodigious  differ- 
ence in  the  deadliness  of  different  epidemics 
of  this  disease,  even  in  the  same  locality.  In 
Southern  Europe  it  is  comparatively  a mild  dis- 
ease; in  Britain  it  is  most  severe;  yet  even  here 
eighty  successive  cases  may  occur  without  a 
death.  But  a mortality  under  10  per  cent,  may 
be  considered  moderate  (Thomas,  in  Ziemssen ); 
it  is  often  much  higher.  It  is  at  its  maximum 
from  the  second  to  the  fourth  year,  but  continues 
very  deadly  up  to  ten  or  twelve ; by  fifteen  it 
has  almost  reached  a minimum,  but,  unlike 
measles,  continues  to  be  somewhat  formidable 
t hroughout  life,  especially  to  parturient  women. 
Season  and  station  in  life  make  little  difference 
in  its  deadliness. 

5.  Smallpox. — Smallpox  did  and  does,  in  un- 
vaccinated communities,  where  it  has  long  been 
at  home,  destroy  somewhere  about  10  per  cent, 
of  the  population  ; and  of  persons  unprotected  by 
vaccination,  who  are  attacked,  40  per  cent,  often 
perish.  Among  ‘virgin’  communities  it  is  still 
more  deadly.  Age  makes  comparatively  little 
difference  in  its  fatality. 


MOTILITY,  DISORDERS  OF. 

6.  Whooping  cough. — The  death-rate  of  this 
disease  is  very  Large  in  the  first  year  of  life,  de- 
clining afterwards  like  that  of  measles,  but  rather 
more  rapidly,  and  becoming  quite  insignificant 
before  the  tenth  year.  Whooping-cough  is  more 
fatal  in  winter  than  in  summer,  in  towns  than  in 
the  country,  among  the  poor  than  among  the  rich  ; 
but  these  differences,  except  the  first,  are  not 
very  well-marked.  John  Beddoe. 

MORTIFICATION  (mors,  death,  and /ado, 
I make). — A popular  name  for  gangrene.  S< 
Gangrene. 

MOTILITY,  Disorders  of. — The  power  of 
executing  movements  of  the  different  parts,  or 
of  the  body  as  a whole,  may  be  interfered  with 
in  various  ways ; and  as  such  disabilities  are 
generally  partial,  the  particular  movements  that 
happen  to  be  implicated  will  also  differ  amongst 
themselves  in  different  cases. 

The  disorders  of  movement  to  be  referred  to 
in  this  place  are  principally  those  in  which  mus- 
cles of  one  of  the  limbs,  or  of  other  external  parts 
of  the  body  are  concerned  — though  disorders 
of  the  same  kind,  and  also  of  different  degrees, 
are  likewise  frequent,  in  which  we  may  find  per- 
verted movements  of  viscera  and  their  ducts,  as 
well  as  of  blood-vessels:  in  other  words,  portions ! 
of  the  involuntary  muscular  system  are  apt  to 
have  their  functional  activity  deranged,  after 
some  of  the  same  inodes  as  piortions  of  the 
voluntary  muscular  system. 

In  such  cases,  almost  without  exception — and  ' 
to  whichever  class  the  defects  may  belong— the 
disordered  motility  is  due  primarily  to  some  de- 
fective or  abnormal  action  of  the  nerve-centres 
or  of  the  nerves  in  relation  with  tho  muscles  im- 
plicated, rather  than  to  any  primitive  disease  of 
the  muscles  themselves. 

Classification. — Disorders  of  motility  are 
divisible  into  three  primary  classes,  according 
as  they  show  themselves  (A)  in  response  to1 
voluntary  incitations ; (B)  in  response  to  mere 
‘reflex’  impressions;  or  (C)  spontaneously.  Thd 
particular  muscles  implicated  (or  the  mode  oi 
distribution  of  the  various  defects)  will  neces- 
sarily differ  much  according  to  the  extent  ant 
situation  of  the  disease  in  the  nerve-centres  o: 
in  the  nerve-trunks  to  which  the  defects  an 
due.  In  some  cases  particular  defects  of  motilit; 
can  be  confidently  referred  to  disease  of  th. 
brain,  and  even  of  particular  parts  thereof;  ii 
others  they  may  be  referred  to  disease  of  thi 
spinal  cord  in  particular  regions;  or,  in  othe 
cases  still,  they  may  be  as  clearly  due  to  som 
altered  condition  of  nerve-roots  or  of  nerve 
trunks  in  their  continuity. 

A.  Disorders  of  voluntary  movement: 
Under  this  head  are  to  be  included  different  varie 
ties  of  disordered  movement,  thus  divisible : — 

1.  Diminution  of  motor  power. — This  vaiie 
much  in  degree  in  difterent  cases.  There  ms 
be  mere  weakness  (paresis)  or  actual  loss  ( 
power  (paralysis)  of  one  or  more  limbs,  or  < 
particular  sets  of  muscles.  The  type  of  tl 
paralysis  will  vary  according  to  the  seat  ar 
extent  of  the  lesion ; thus  it  may  be  due  to; 
cerebral  lesion,  and  be  of  the  hemiplegic  tyj 
(see  Hemiplegia)  ; or  it  may  be  due  to  a spin 
lesion,  and  be  of  the  paraplegic  type  (see  Pab 


MOTILITY,  DISORDERS  OF. 


plegia)  ; or  the  loss  of  power  may  be  owing  to 
disease  or  injury  of  some  nerve-trunk,  and  then 
be  of  the  type  of  a peripheral  paralysis,  such  as 
we  get  in  facial  palsy. 

2.  Imperfect  coordination  of  movements. — Here 
the  several  muscles  concerned  with  the  produc- 
tion of  a given  movement  act  without  the  rela- 
tive subordination  and  gradation  of  force  needful 
for  its  proper  execution.  Some  muscles  contract 
too  powerfully  and  others  not  enough,  or  some 
contract  too  quickly  and  others  too  slowly,  with 
the  effect  of  producing  a spasmodic  or  otherwise 
disordered  movement  — one  by  which  the  end 
desired  is  not  readily  attained.  The  condition 
thus  produced  is  known  as  ‘ataxia.’  of  which 
there  are  two  principal  varieties — one  caused 
by  disease  of  the  posterior  columns  of  the  spinal 
cord  {see  Locomotor  Ataxy)  ; and  the  other  by 
disoase  of  the  cerebellum  (see  Cerebellum, 
Lesions  of).  Ataxia  is,  in  fact,  a condition  for 
the  most  part  caused  by  the  defects  described  in 
the  previous  category,  together  with  that  to  be 
mentioned  in  the  next,  the  two  states  co-existing 
(in  different  proportions  in  different  cases)  among 
muscles  called  into  simultaneous  or  successive 
activity  for  the  execution  of  various  complex 
movements.  A kind  of  ataxy  may  indeed  be 
induced  by  mere  paresis  in  some  muscles  of 
a physiological  group,  that  is  of  some  muscles 
whose  business  it  is  habitually  to  act  in  com- 
bination with  others. 

3.  Spasmodic  action  of  certain  muscles. — On 
volitional  incitations  reaching  the  spinal  cord 
iu  certain  states  of  disease,  some  of  the  muscles 
whose  contraction  is  to  be  brought  about  are 
thrown  into  a condition  of  over-action  or  tonic 
spasm,  whereby  the  performance  of  the  move- 
ment is  greatly  interfered  with.  In  such  cases 
there  is  almost  always  in  addition  increased 
reflex  excitability,  so  that  it  is  in  some  cases 
difficult  to  say  how  much  of  the  spasm  is  pri- 
marily due  to  the  volitional  incitation,  and  how 
much  to  reflex  spasms — caused  by  cutaneous  im- 
pressions consequent  upon  the  commencing  move- 

. ment.  These  conditions  are  especially  met  with 
in  cases  where  portions  of  the  cord  are  cut  oft’  from 
the  so-called  ‘inhibiting’  influence  of  the  brain, 
at  the  same  time  that  there  is  hyperaemia,  with 
increased  excitability  of  the  then  active  regions 
of  spinal  grey  matter.  This  state  of  things  is  par- 
ticularly frequent  in  ‘primary  sclerosis  of  the 
lateral  columns.’  On  the  other  hand,  the  initia- 
tion of  voluntary  movements  may,  in  other  cases, 
give  rise  to  clonic  spasms  in  the  parts  moved, 
especially  in  certain  cases  of  disseminated  or 
insular  sclerosis.  See  Spinal  Cord,  Diseases  of. 

i.  Tremors,  shapings,  or  choreic  movements. — 
Tremors  (tine  or  coarse)  and  shakings  are  really 
jftonic  spasms  of  limited  range ; and  all  gradations 
'may  at  times  be  met  with  between  these  several 
ypes  of  disordered  movement.  Such  morbid 
movements  of  one  or  other  grade,  even  if  they 
.ixist  more  or  less  continuously,  are  usually  in- 
creased by  volitional  incitations.  This  is  the 
’.ase,  for  instance,  in  paralysis  agitans;  in  the 
rembling  from  mercurial  poisoning  or  from 
hronic  alcoholism,  as  well  as  in  that  from 
■enile  changes ; in  the  shakings  met  with  in 
SisaemiDated  sclerosis  ; and  also  in  the  more 
rregular  movements,  often  of  wider  range,  met 


1003 

with  in  chorea.  See  Chorea  ; Spinal  Cord,  Die- 
eases  of ; and  Tremor. 

B.  Disorders  of  reflex  motility. — The  con- 
ditions on  which  disordered  movements,  due  to 
increase  of  reflex  excitability,  depend,  have  been 
above  referred  to.  The  withdrawal  of  brain- 
influence  from,  and  the  increased  hypercemia  of 
certain  tracts  of  spinal  grey  matter,  seem  co  be  the 
main  causes,  and  these  are  met  with  principally 
m certain  forms  of  paraplegia,  and  in  spasmodic 
spinal  paralysis,  or  primary  sclerosis  of  tho 
lateral  columns.  The  mere  weakening  of  cere- 
bral influence  will,  however,  lead  to  an  increased 
manifestation  of  reflex  movements,  as  may  be 
seen  in  certain  nervous  or  delicate  persons,  in 
infants,  or  in  young  children. 

Two  forms  of  reflex  actions  have  to  be  dis- 
criminated, namely,  those  excited  by  cutaneous 
impressions — skin  reflexes;  and  those  induced 
by  taps  or  slight  blows  upon  tendons — tendon 
reflexes.  Both  forms  are  often  unduly  exalted 
in  the  same  person,  though  sometimes  the  skin 
reflexes  may  be  normal,  whilst  the  tendon  re- 
flexes are  greatly  exaggerated. 

Reflex  movements  of  both  kinds  may  be 
diminished,  either  (1)  from  disease  of  afferent 
nerve-roots  outside  or  within  the  cord,  as  in 
locomotor  ataxy ; (2)  from  destructive  disease  of 
the  grey  matter  of  the  cord,  as  in  many  cases  of 
severe  paraplegia ; or  (3)  from  disease  of  the 
motor  roots  or  nerves  supplying  particular  groups 
of  muscles. 

An  increase  or  a diminution  of  reflex  excita- 
bility is  frequently  met  with,  and  is  often  of 
much  importance,  in  connection  with  one  or  ether 
of  the  viscera,  such  as  the  heart,  the  stomach, 
the  bladder,  or  the  intestines.  This  undue 
nervous  excitability  may  be  depend  upon  mor- 
bid conditions,  partly  of  the  medulla  or  spinal 
cord,  and  partly  of  portions  of  the  sympathetic 
system. 

As  possible  conditions  of  much  importance  in 
the  aetiology  of  many’ nervous  affections  we  may 
here  also  mention  disordered  activity  of  certain 
vaso-motor  centres,  which,  either  immediately 
or  remotely,  influence  the  calibre  of  the  blood- 
vessels supplying  certain  portions  of  the  brain 
or  cord.  In  this  manner  there  may  be  induced 
either  spasm  of  their  vessels,  with  greatly  lowered 
blood-supply;  or  paralysis  of  vessels,  with  con- 
sequenthyperaemia  in  such  nerve-centres.  These 
conditions  would  correspond  with  the  death-like 
pallors  or  the  flushings  occasionally  observable 
in  the  face,  or  other  tracts  of  skin.  The  doubt 
exists,  however,  as  to  how  long  such  mere 
reflex  pallors  or  flushings  may  persist  in  nerve- 
centres,  that  is,  when  they  are  simply  due  to 
functional  defects.  Are  they  al way’s  merely  tran- 
sient phenomena,  or  may  they  persist  for  days  or 
even  weeks,  as  some  have  supposed? 

C.  Spontaneous  movements. — The  move- 
ments which  are  manifested  ‘ spontaneously  ’ are 
various  in  nature  or  degree,  though  they  are  of 
kinds  similar  to  those  that  may  be  excited  by 
voluntary  incitations.  We  need  only  enumerate 
these  different  varieties  here,  and  briefly  indicate 

i either  the  diseases  in  which  they  are  encountered, 
or  the  conditions  on  which  they  depend.  («) 
Tremors,  such  as  present  themselves  in  paralysis 
agitans,  or  mercurial  poisoning ; ( b ) twitchings, 


1004  MOTILITY,  DISORDERS  OF. 

or  startings,  occurring  in  one  or  more  limbs, 
either  upper  or  lower,  in  some  cases  of  cerebral 
end  of  spinal  disease  ; the  more  irregular  but 
less  spasmodic  movements,  known  as  (c)  choreic, 
occurring  principally  in  the  disease  from  which 
they  derive  their  name  (being  sometimes  indefi- 
nite, and  at  others  distinctly  co-ordinated) ; ( d ) 
spasms,  which  may  be  either  co-ordinated,  as  in 
some  eases  of  chorea ; clonic,  as  in  epilepsy, 
eclampsia,  and  other  allied  affections ; or  tonic, 
as  in  tetany,  tetauus,  strychnia-poisoning,  and 
certain  spinal  affections,  as  well  as  in  some  cere- 
bral diseases. 

Conditions  of  rigidity  and  contraction,  due  to 
a more  or  less  permanent  tonic  spasm,  are 
scarcely  to  be  described  under  the  head  of  spon- 
taneous movements,  since  in  such  conditions, 
although  there  is  powerful  muscular  contraction, 
there  is  no  actual  movement;  and,  similarly,  the 
spontaneous  jlickerings  of  muscular  fibres,  seen 
in  so  many  cases  of  progressive  muscular  atrophy, 
deserve  to  be  mentioned  here,  even  though  no 
movements  are  produced,  owing  to  the  small 
number  of  muscular  fibres  involved  at  any  one 
time.  The  flickerings  themselves  are  really  clonic 
spasms,  involving  a few  fibres  simultaneously. 

Treatment. — The  treatment  of  these  different 
nervous  conditions  will  be  considered  fully 
under  the  various  special  articles  to  which  re- 
ference has  been  made. 

II.  Charlton  Bastiax. 

MOUTH,  Diseases  of. — The  principal  dis- 
eases of  the  mouth  may  be  thus  enumerated  in 
the  following  order; — 1.  Inflammation  and  itn 
results  ; 2.  Epulis  ; 3.  Gumboil ; 4.  Ranula  ; 
5.  Salivary  calculus;  and  6.  Salivary  fistula. 
Diseases  of  the  tongue  and  of  the  teeth  are 
treated  of  in  other  articles 

1.  Inflammation. — Synox.  ; Stomatitis ; Fr. 
Scomatite  ; Ger.  Mundschleimhautentzundung. — 
Inflammation  of  the  mouth  is  fully  described 
under  the  heading  Stomatitis.  See  also  Aphthje  ; 
and  Cancrum  Oris. 

2.  Epulis.  — Synox.  ; Fr.  Epulide  ; Ger. 
Epulis. 

Descriptiox. — Epulis  is  the  name  given  to  a 
tumour  which  springs  from  the  alveolar  processes 
and  from  the  periosteum  covering  them.  It  is 
more  often  seen  in  connection  with  the  inferior 
than  witli  the  superior  maxilla.  It  forms  a 
smooth,  rounded,  or  lobulated  tumour,  covered 
with  the  mucous  membrane  of  the  gum.  It  is 
firm  or  semi-elastic  to  the  touch.  As  it  grows, 
it  loosens  and  displaces  the  teeth.  Its  intimate 
structure  varies  considerably.  Sometimes  it  is 
a simple  fibrous  tumour;  sometimes  a round- 
celled  sarcoma  ; sometimes  a myeloid.  At  first 
it  is  benign  ; but  if  it  be  allowed  to  remain,  it 
is  apt  to  ulcerate,  and  exhibits  something  of  a 
malignant  aspect  and  character. 

Treatment. — The  tumour  should  be  removed, 
and  the  portion  of  the  alveolar  process  from 
which  it  springs  should  be  taken  away.  Unless 
this  be  done,  the  growth  is  almost  certain  to 
return. 

3.  Gumboil. — Synox.  : Parulis ; Fr.  Pandie ; 
G er.  Zahnfieischgeschwiir. 

Description. — A gumboil  is  a circumscribed 
inflammation  of  the  mucous  membrane,  or  of 


MOUTH,  DLSEASES  OF. 
the  periosteum  covering  the  alveolar  processes. 
It  is  usually  caused  by  the  irritation  of  a de- 
cayed tooth.  In  a severe  case  the  swelling,  pain, 
and  discomfort  are  great ; and  the  constitutional 
symptoms  often  run  high.  When  suppuration 
takes  place  the  boil  generally  breaks,  and  a 
speedy  cure  is  obtained.  If,  however,  the  pus 
cannot  find  a ready  exit,  it  may  burrow,  giving 
rise  to  necrosis  of  the  subjacent  bone,  or  it  mav 
form  sinuses  in  various  directions — for  mstance, 
on  the  cheek. 

Tbeatmext. — The  cheek  should  be  poulticed, 
and  the  old-fashioned  fig  poultice  is  often 
applied  to  the  gum  with  advantage.  The  month 
is  to  be  frequently  rinsed  with  hot  water.  The 
diet  should  consist  entirely  of  fluids.  An 
aperient  should  be  given  at  the  outset,  and  sub- 
sequently a suitable  stimulant,  such  as  ammonia 
and  bark.  As  soon  as  pus  can  be  detected,  the 
gum  should  bo  lanced.  When  the  acute  inflam- 
mation has  subsided,  the  source  of  irritation 
should  be  removed. 

4.  Banula. — Synox.  ; Fr.  Grcnouillcitc ; Ger. 
Ranula  ; Froschleingeschmilst. 

Definition. — Cystic  formations  in  the  mucous 
membrane  beneath  the  tongue,  which  take  their 
origin  sometimes  in  the  ducts  of  the  sublingual 
or  sub-maxillary  glands,  sometimes  in  the  areo- 
lar spaces,  and  possibly  also  in  the  bursa  be- 
tween the  genio-hyo-glossi  muscles. 

A.  Internal  Ranula. — Descriptiox. — The  ma- 
jority of  cases  of  ranula  are  unconnected  with 
the  salivary  glands ; and,  in  many  instances,  a 
probe  may  be  passed  along  the  ducts,  or  the 
saliva  may  be  noticed  flowing  from  them,  while 
the  ranula  remains  unaltered. 

Other  cases  belong  to  that  simple  variety 
which  depends  merely  upon  an  accumulation  of 
the  normal  secretions  in  a natural  cavitv.  such 
as  a duct,  which  has  become  temporarily  ob- 
structed. Such  obstruction  may  arise  from’ local 
inflammation,  from  inspissation  of  the  normal 
fluid,  or  from  the  impaction  of  a salivary  cal- 
culus, as  will  be  subsequently  described. 

Treatment. — The  majority  of  cysts  in  this 
situation  lie  just  beneath  the  mucous  membrane. 
They  are,  moreover,  always  small  at  their  com- 
mencement, so  that  if  the  attention  of  the  sur- 
geon is  called  to  them  early,  they  can  generally 
be  cured  by  taking  up  a piece  of  the  cyst-wall, 
and  cutting  it  off  with  scissors  ; or  a seton  mav 
be  passed  through  the  tumour  and  knotted,  when 
the  cyst  will  gradually  contract. 

B.  External  Ranida.  — Description. — These 
are  larger  tumours,  which  lie  between  the  tongue 
and  the  jaw.  and  become  prominent  at  the 
upper  part  of  the  neck.  Though  the  term 
ranida  is  applied  to  them,  they  are  of  a different 
eharacter,  and  analogous  to  the  sebaceous  tu- 
mours which  are  so  frequently  met  with  in  the 
skin,  containing,  like  them,  a thick,  gritty  sub- 
stance of  a fawn  colour,  often  very  offensive. 
This  material  is  made  up  chiefly  of  epithelium, 
plates  of  cholesterine,  and  oil. 

Sometimes  these  enlargements  advance  very 
slowly;  but  in  other  instances  their  progress  is 
extraordinarily'  rapid,  and  then  the  disease  is 
called  acute  ranida. 

Treatment. — The  cure  of  cases  of  this  class 
is  more  difficult  and  tedious.  The  cyst  should 


MOUTH,  DISEASES  OF. 
be  freely  opened  from  the  mouth ; the  contents 
Ecooped  out ; and  the  cavity  filled  with  lint. 
Sometimes  it  is  desirable  to  make  a counter- 
opening  in  the  neck,  and  to  treat  the  disease  as 
sn  ordinary  abscess.  Passing  a seton  may  be 
useful.  To  dissect  the  cyst  out  is  an  unneces- 
sary proceeding,  and  not  always  free  from 
danger. 

5.  Salivary  Calculus. — Synon.  : Fr.  Calcul 
salivaire-,  Ger.  Speichclstein. 

Description. — Concretions,  composed  chiefly 
of  phosphate  of  lime,  are  not  very  uncommon 
in  the  ducts  of  the  parotid,  sub-maxillary, 
and  sublingual  glands.  These  calculi  may  vaTy 
in  size  from  a pin’s  head  to  a filbert,  or  even 
larger.  Not  unfrequently  they  form  around  some 
small  foreign  body,  such  as  a seed  or  a morsel  of 
woodv  fibre,  which  has  made  its  way  into  the 
duct.  Occasionally  they  occupy  the  substance 
of  the  gland,  but  more  often  they  are  found  in 
the  duct.  Here  they  may  simply  obstruct  the 
outlet,  and  give  rise  to  an  accumulation  of  the 
secretion,  forming  a ranula,  and  inconveniencing 
the  patient  by  forcing  the  tongue  upward  and 
backward ; or  they  may  cause  a local  inflamma- 
tion which  terminates  in  an  abscess. 

Treatment. — If  a concretion  can  be  felt,  either 
with  a finger  or  with  a probe,  an  incision  should 
be  made  and  the  calculus  removed.  If  there  is 
local  inflammation,  it  should  be  fomented  or 
poulticed;  and,  if  an  abscess  forms,  it  should  be 
opened  and  then  treated  in  the  same  way. 

6.  Salivary  fistula. — Synon.  : Fr.  Fistule 
salivaire ; Ger.  Speichetfistd. 

Description. — Occasionally  the  duct  of  the 
parotid  gland  (Steno’s  duct)  is  wounded  or  in- 
volved in  an  ulceration,  or  an  abscess  forms  in 
its  track  and  bursts  externally.  In  such  cases  a 
salivary  fistula  is  likely  to  be  the  result.  The 
secretion  from  the  parotid,  instead  of  making  its 
wav  into  the  mouth,  dribbles  over  the  cheek. 

Treatment. — The  treatment  of  salivary  fis- 
tula consists,  first,  in  establishing  an  opening 
into  the  mouth  by  means  of  a few  threads  of  silk, 
a wire,  or  a piece  of  catgut,  passed  from  without 
inwards,  brought  out  at  the  mouth,  and  the 
ends  tied  together.  The  next  point  is  to  close 
the  skin  of  the  cheek  over  the  fistulous  opening. 
This  may  be  done  by  touching  tho  edges  with 
the  actual  cautery,  so  as  to  make  them  contract ; 
by  paring  the  edges,  and  bringing  them  accu- 
rately together  ; or  by  dissecting  the  skin  around 
the  wound,  sliding  it  along  so  as  to  cover  the 
opening,  and  securing  it  with  stitches.  But  the 
cure  of  salivary  fistula— a purely  surgical  pro- 
ceeding— is  always  difficult,  and  a more  or  less 
depressed  scar  is  sure  to  remain. 

W.  Fairlie  Clarke. 

MOVABLE  KID  MET.  See  Kidneys, 
Diseases  of. 

MOVEMENT,  Therapeutical  Uses  of. — 
Synon.  : Movement  Cure;  Kinesitherapeutics  ; 
■t'r.  (xymnastique  Suedoise ; Ger.  Kinesitherapie. 

Description. — The  method  of  treatment  of 
lisease  by  movement  appears  to  have  been  first 
lesigned  by  Ling,  a member  of  the  Koval 
iwedish  Academy,  about  the  beginning  of  the 
'resent  century.  The  movements  employed  are 
aid  to  be  of  three  classes,  namely : 1 . Active 


MUCOUS  MEMBRANES.  1005 
movements , executed  by  the  patient  himself,  or 
by  the  patient  aided  by  an  assistant ; 2.  Passive 
movements,  performed  by  the  assistant  on  the 
patient;  and  3.  Acts  of  resistance  to  movements, 
whether  executed  by  the  assistant  against  the 
patient,  or  by  the  patient  against  the  assistant. 

Uses. — The  several  classes  of  movements,  for 
which  mechanical  arrangements  are  also  con- 
trived, when  scientifically  employed,  are  used  in 
the  treatment  of  paralysis,  curvatures  of  the 
spine  or  limbs,  and  injuries  and  diseases  of  the 
joints.  Movements  of  the  nature  of  friction  or 
shampooing  are  also  employed  in  the  treatment 
of  certain  diseases  of  internal  organs,  and  will 
be  found  described  elsewhere  in  this  work.  See 
Friction  ; and  Shampooing. 

MOX2E  (Eastern). — A term  for  a form  of 
counter-irritation,  which  consists  in  producing  an 
eschar  by  burning  certain  materials  upon  the 
skin  of  a part.  Moxae  were  originally  prepared 
in  Eastern  countries  from  the  leaves  of  the  arte- 
misia  ; but  when  used  in  this  country,  cotton- 
wool and  other  substances  are  employed.  Sea 
Counter-Irritation. 

MUCOID  DEGENERATION.  — A form 

of  degeneration,  which  is  associated  with  the 
production  of  a mucus-like  substance.  See  Dege- 
neration. 

MUCOUS  MEMBRANES,  Diseases  of. 
This  class  of  membranes,  which  line  organs  and 
passages  communicating  with  the  exterior  of  the 
body,  though  presenting  modifications  as  to  their 
minute  structure  in  different  parts  of  the  body, 
exhibit  a general  resemblance  in  their  construc- 
tion, and  consist  essentially  of  sub-mucous  tis- 
sue; abasement-membrane;  epithelium  of  various 
kinds  covering  the  free  surface;  and  numerous 
glands  or  follicles,  differing  in  their  characters 
in  different  tracts.  They  are  highly  vascular 
as  a rule  ; and  many  of  them  are  richly  provided 
with  absorbent  vessels.  It  is  only  intended  in 
this  article  to  treat  briefly,  from  a general  point 
of  view,  the  morbid  conditions  to  which  mucous 
structures  as  a class  are  liable.  Those  connected 
with  the  several  mucous  tracts  are  discussed 
under  their  appropriate  headings. 

1.  Injury. — Most  of  the  mucous  surfaces  are 
exposed  to  injury  from  various  causes.  This  may 
come  from  without,  the  cause  being  either  me- 
chanical, chemical,  or  excessive  heat.  As  illus- 
trations may  he  mentioned  injury  to  the  mucous 
lining  of  the  alimentary  canal  or  air-passages  by 
foreign  bodies ; corrosion  from  swallowing  strong 
acids ; and  burning  or  scalding  of  the  mouth  or 
of  parts  lower  down,  in  consequence  of  inhaling 
a hot  blast  or  swallowing  boiling  water.  In  other 
cases  the  injury  may  originate  within  the  body, 
as  by  calculi  passing  along  tubes  or  lodged  in 
cavities ; hardened  faeces  in  the  intestines  ; para- 
sites ; or  the  rupture  of  enlarged  veins,  aneurisms, 
or  abscesses  opening  into  mucous  cavities. 

The  effects  of  an  injury  to  a mucous  surface 
differ  much  in  their  nature  and  extent,  accord- 
ing to  its  cause.  Thus  there  may  be  a mere 
contusion;  a superficial  erosion  or  abrasion;  a 
more  or  less  extensive  wound  or  rupture,  other 
structures  being  then  also  involved;  a burn  or 
scald ; or  actual  destruction  by  corrosives.  More 


1006  MUCOUS  MEMBRANES,  DISEASES  OF. 


or  less  inflammation  follows  injury  tc  a mucous 
surface.  Subsequently  ulcers  may  be  produced, 
which  by  their  cicatrization  may  give  rise  to  con- 
striction or  actual  obliteration  of  tubes,  and  other 
untoward  consequences. 

2.  Hypersemia  and  Anaemia. — The  mucous 
membranes  are  very  prone  to  become  the  seat 
of  congestion,  either  active,  mechanical,  or  pas- 
sive. Active  congestion  may  bo  a part  of  a 
physiological  process,  as  is  seen  in  the  gastric 
mucous  membrane  during  the  process  of  diges- 
tion. Any  slight  irritation  may  also  cause  it, 
and  it  is  scarcely  practicable  to  indicate  a dis- 
tinct line  of  demarcation  between  this  condition 
and  inflammation,  of  which  active  congestion 
constitutes  the  earliest  stage.  It  is  character- 
ised by  bright  redness,  new  vessels  frequently 
coming  to  view;  and  at  first  by  a tendency  to 
dryness  of  the  affected  membrane,  which  may 
be  followed  by  excessive  and  altered  secretion. 
Mechanical  congestion  is  often  an  important 
morbid  condition  in  connection  with  mucous 
structures,  giving  rise  to  troublesome  symptoms. 
For  instance,  in  cases  of  cardiac  disease  ob- 
structing the  pulmonary  circulation,  the  mucous 
lining  of  the  air-passages  becomes  more  or  less 
congested  permanently;  and  if  the  general 
venous  circulation  becomes  overloaded  from  a 
similar  cause,  other  mucous  tracts  suffer,  espe- 
cially that  of  the  alimentary  canal.  This  tract 
is  also  directly  involved  in  cases  of  portal 
obstruction.  Particular  portions  of  a mucous 
membrane  might  become  the  seat  of  mechanical 
congestion,  if  some  local  vein  should  become 
obstructed  from  any  cause.  The  effects  of  this 
condition  are  in  the  first  instance  to  make  the 
colour  deeper,  with  a more  orless venous  hue ; and 
at  last  the  small  veins  may  be  evidently  dilated 
and  varicose.  The  secretion  becomes  modified 
in  quantity  and  quality,  and  in  time  a permanent 
discharge  is  likely  to  be  established,  consisting 
of  an  unhealthy,  thick,  and  tenacious  mucus; 
while  the  proper  secretion  of  special  glands, 
such  as  the  gastric  juice,  is  interfered  with.  In 
some  instances  mechanical  congestion  gives  rise 
to  an  abundant  flow  of  a watery  mucus.  The 
membrane  itself  is  also  liable  to  become  altered, 
being  swollen  at  first ; and  ultimately  it  may 
become  permanently  thickened  ar.d  firmer  than 
normal,  owing  to  increase  of  connective  tissue, 
while  its  own  special  structures  degenerate. 
Passive  hyperamia  may  follow  inflammation  of 
a mucous  membrane  ; or  it  occurs  in  persons  of 
relaxed  and  feeble  habit ; or  follows  undue  use 
of  a part  covered  with  a mucous  membrane,  as 
in  the  case  of  the  throat. 

Aruemia  in  connection  with  a mucous  mem- 
brane is  important  only  when  this  is  a part  of 
general  anaemia  from  any  cause.  Those  mucous 
surfaces  which  are  visible,  such  as  the  conjunctive 
or  the  lining  of  the  mouth  and  lips,  give  the 
most  striking  evidence  of  this  condition,  as  indi- 
cated by  their  pallor  or  even  bloodlessness.  Ad 
anemic  condition  of  the  alimentary  canal  inter- 
feres in  an  important  degree  with  the  functions 
of  its  mucous  membrane,  and  with  the  formation 
of  the  secretions  which  it  normally  produces. 

3.  Inflammation. — -Various  forms  and  de- 
grees of  inflammation  are  of  very  common 
occurrence  in  connection  with  mucous  mem- 


branes, and  a large  number  of  cases  in  ordinary 
practice  belong  to  this  class.  Without  entering 
into  any  description,  it  will  suffice  to  state  here 
that  the  inflammation  may  be  acute,  sub-acute 
or  chronic ; and  either  catarrhal,  croupous,  or 
diphtheritic  in  character  (sea  Infi^mmation;. 
Different  tracts  of  membrane  present  different 
degrees  of  liability  to  these  several  forms  of  in- 
flammation ; and  the  catarrhal  form  not  only  has 
various  grades  of  intensity,  with  correspondin'* 
variety  in  its  products,  which  may  become  mue(> 
purulent  or  actually  purulent,  but  these  products 
also  differ  in  their  nature  in  connection  with  dif- 
ferent membranes  of  the  mucous  class.  Further 
inflammation  from  special  causes,  such  as  gonor- 
rhoea, is  characterised  by  running  a definite 
course,  and  forming  special  products.  When 
tho  inflammation  is  of  a severe  type,  it  may  end 
in  more  or  less  destruction  of  the  mucous  tissues, 
as  indicated  by  erosions,  ulcerations,  or  even 
gangrene.  Where  the  submucous  tissue  is  loose, 
oedema  is  liable  to  occur.  From  this  cause,  as 
well  as  from  thickening  of  the  mucous  membrane 
itself,  or  from  a croupous  or  other  deposit  on  its 
surface,  narrowing  or  oven  actual  closure  of  any 
tube  or  passage  lined  by  such  a membrane  is 
apt  to  be  produced.  Inflammation  may  also  give 
rise  to  sub-mucous  suppuration.  When  the  in- 
flammation is  chronic,  permanent  changes  ;irc 
set  up  in  mucous  tissues,  the  normal  elements 
being  altered  or  entirely  removed,  and  a fibroid 
material  being  formed  in  course  of  time,  so  that 
the  membrane  is  rendered  permanently  thickened 
and  tough.  The  cause  of  inflammation  of  a 
mucous  membrane  may  be  local,  includin':  in- 
jury. mechanical  or  chemical  irritation,  or  that 
resulting  from  undue  heat  or  cold,  morbid  pro- 
ducts or  growths ; or  general,  such  as  chilling  of 
the  body  from  ‘ a cold,’  blood-poisoning  in  con- 
nection with  fevers  and  other  conditions;  or 
the  inflammation  may  be  a part  of  some  specific 
disease — for  instance,  diphtheria  or  gonorrheea. 
Some  mucous  tracts  are  particularly  liable  to  be 
affected  under  certain  predisposing  conditions, 
and  at  certain  periods  of  life.  Thus,  bronchitis 
is  very  common  in  children  and  old  persons; 
while  the  former  are  exceedingly  subject  to 
catarrh  of  the  alimentary  mucous  lining. 

4.  Ulceration. —Ulcers  are  of  common  occur- 
rence on  mucous  surfaces.  They  usually  result 
from  injury  or  inflammation,  or  are  the  termina- 
tion of  certain  special  morbid  processes,  as  in 
the  case  of  typhoid  fever,  syphilis,  tubercular 
disease,  cancer,  dysentery,  or  diphtheria.  Ulcera- 
tion may  depend  upon  destruction  of  the  tissues 
by  parasitic  growths,  as  in  some  cases  of  thmsh. 
Some  pathologists  believe  that  ulceration  of  a 
mucous  membrane  occasionally  arises  from  plug- 
ging of  arteries,  and  consequent  death  of  a limited 
portion  of  this  membrane,  which  separates,  leav- 
ing an  ulcer.  In  the  case  of  the  stomach  it  has 
also  been  supposed  that  under  certain  circum- 
stances the  gastric  juice  may  so  act  upon  the 
mucous  lining  as  to  destroy  it.  A peculiarform 
of  ulcer  is  sometimes  observed  in  the  duodenum 
after  severe  burns.  Ulceration  often  begins  in 
connection  with  the  glandular  structures;  this 
may  he  due  in  the  first  instance  to  mere  block- 
ing up  of  their  orifices,  leading  to  accumulation 
of  their  products  and  subsequent  inflammation; 


MUCOUS  MEMBEANES,  DISEASES  OF. 


but  certain  special  mcrbid  processes  commence 
in  these  structures.  Inflammation  may  cause 
ulceration,  either  by  directly  destroying  the 
membrane  rapidly  or  gradually,  or  by  setting  up 
sub-mucous  suppuration.  Mucous  ulcers  differ 
much  in  their  seat,  extent,  depth,  shape,  and  other 
characters,  according  to  their  cause.  The  simple 
forms  are  either  mere  erosions  or  of  the  catarrhal 
or  follicular  varieties ; and  in  each  of  the  special 
diseases  already  mentioned  the  ulcers  present 
peculiar  characters.  Occasionally  they  assume 
a gangrenous  appearance.  If  they  extend  deeply, 
they  involve  other  tissues  besides  those  of  the 
mucous  membrane,  and  may  thus  lead  to  per- 
foration of  cavities  or  tubes,  and  other  untoward 
consequences.  Cicatrization  often  takes  place, 
and  this  may  lead  to  permanent  contraction, 

' stricture,  or  even  complete  closure  of  channels 
lined  by  mucous  membranes,  with  more  or  less 
thickening  and  induration.  Ulceration  fre- 
quently destroys  the  glandular  structures,  which 
are  not  afterwards  renewed. 

5.  Gangrene. — Occasionally  the  tissues  form- 
ing mucous  membrane  mortify,  as  the  result 
either  of  severe  injury,  corrosion,  inflammation, 
or  vascular  obstruction.  The  gangrene  is  of  the 
moist  kind,  and  the  dead  tissues  may  separate  in 
a mass  or  in  shreds.  Consequently  an  ulcer  is 
left ; or  actual  perforation  of  a tube  or  hollow 
organ  may  take  place. 

6.  Nutritive  Changes. — Hypertrophy  of 
mucous  tissues  is  sometimes  seen,  but  this  may 
appear  to  be  the  case  when  it  is  not  really  so, 
the  membrane  being  thickened  and  firm,  owing 
to  a chronic  inflammation,  and  the  formation  of 
tibrous  tissue.  Atrophy  is  not  uncommon,  espe- 
cially of  certain  of  the  elements  of  mucous  mem- 
jjbranes,  such  as  the  glands  or  epithelium.  De- 
generation is  also  often  observed,  affecting  these 

md  other  structures.  This  degeneration  may  be 
:f  a senile  character ; or  of  a special  kind,  such 
(is  albuminoid  or  mucous  degeneration.  Not  un- 
■ommonly  mucous  tissues  are  relaxed  and  de- 
icient  in  tone,  their  nutrition  being  impaired. 

7.  Deposits  and  Hew  Growths. — The  chief 
lew  formations  observed  in  connection  with 
aucous  membranes  are  polypi,  villous  growths, 
pithelioma,  and  tubercle.  Syphilitic  gummata 
hay  involve  these  membranes.  Cysts  also  ocea- 
ionally  form,  originating  from  the  glands  or 
epithelial  structures.  It  may  be  mentioned  here 
Jhat  certain  animal  or  vegetable  parasites  are 
jften  associated  with  mucous  membranes. 

8.  Special  Diseases. — It  will  suffice  to  re- 
lark  under  this  head  that  in  certain  diseases 
uucous  membranes  are  particularly  affected, 
Jich  as  typhoid  fever,  diphtheria,  and  dysentery. 

Symptoms. — The  symptoms  which  may  arise 
connection  with  one  or  other  of  the  diseases 
ifecting  mucous  membranes  just  indicated,  are 
the  following  nature 

1.  Morbid  sensations,  usually  of  a more  or 
jss  painful  character,  are  often  experienced, 
aese  will  vary  in  degree  and  kind,  not  only 
tk  the  nature  of  the  disease,  but  also  with  the 
rticular  mucous  surface  which  is  involved, 
ne  being  much  more  sensitive  than  others. 
1 inful  sensations  are  chiefly  met  with  in  con- 
ation with  injury,  inflammation,  or  ulceration, 
1 they  will  be  localised  in  accordance  with  the 

: 


1007 

seat  and  extent  of  the  mischief.  As  a general 
rule  it  may  be  stated  that  the  sensation  is  one  of 
burning,  rawness,  or  soreness  ; and  it  is  usually 
much  increased  by  any  irritation  of  the  affected 
part,  to  which  mucous  membranes,  from  their 
situation,  are  specially  exposed.  Sometimes 
the  morbid  sensation  consists  in  a feeling  of 
tickling,  itching,  or  undue  irritability  and  sensi- 
bility to  sensory  impressions.  It  must  be  borne 
in  mind  that  serious  lesions  of  mucous  surfaces, 
which,  as  a rule,  cause  marked  painful  sensa- 
tions, may  exist  withotit  any  such  effects. 

2.  Hcemorrhage  from  mucous  surfaces  is  of 
common  occurrence,  the  amount  of  blood  lost 
varying  from  a mere  trace  to  a quantity  sufficient 
to  cause  death.  The  bleeding  may  apparently 
take  place  quite  spontaneously,  and  without  any 
evident  cause,  as  in  some  cases  of  epistaxis ; or 
it  may  be  associated  with  congestion,  injury, 
inflammation,  ulceration,  gangrene,  new  growths, 
or  other  conditions. 

3.  Morbid  products  are  very  frequently  formed 
on  mucous  surfaces,  or  the  normal  secretions 
are  modified  in  quantity  or  quality.  Thus,  the 
mucus  may  bo  deficient  or  excessive  ; and  either 
thin  and  watery,  unduly  thick  and  adhesive, 
modified  in  its  reaction,  or  otherwise  altered.  A 
free  serous  flow  may  take  place  from  a mucous 
membrane,  as  the  result  of  congestion  or  catarrh. 
Muco-purulent  matter,  actual  pus,  and  croupous 
or  diphtheritic  substance,  are  among  the  chief 
morbid  products  formed  in  connection  withmucous 
surfaces.  Not  only  do  these  materials  reveal 
their  presence  by  being  discharged  externally 
in  various  ways,  but  they  may  themselves  cause 
other  symptoms,  by  affecting  substances  with 
which  they  come  into  contact.  For  instance,  in 
the  alimentary  canal  unhealthy  mucous  secretions 
often  lead  to  fermentation  and  decomposition  of 
food,  with  their  consequences  ; and  similar  effects 
are  produced  on  the  urine  by  morbid  materials 
formed  in  the  bladder.  Some  products  are  also 
in  themselves  irritating,  and  affect  injuriously  the 
surfaces  over  which  they  pass,  causing  pain,  or 
setting  up  secondary  inflammation.  Gangrenous 
tissues  may  also  be  discharged. 

4.  Expulsive  actions  of  different  kinds  are 
often  excited  by  morbid  conditions  connected 
with  mucous  surfaces  lining  passages  and  organs. 
These  may  he  illustrated  by  sneezing,  coughing, 
vomiting,  undue  action  of  the  bowels,  and  fre- 
quent micturition.  They  may  result  merely  from 
excessive  sensibility  of  the  membrane ; or  from 
the  presence  of  blood,  or  of  the  morbid  materials 
already  mentioned. 

5.  The  special  functions  of  certain  mucous 
membranes  are  very  liable  to  be  interfered  with 
when  they  are  affected  in  various  ways,  espe- 
cially in  consequence  of  changes  in  the  epithe- 
lium and  glandular  structures.  This  may  be 
best  illustrated  by  the  alimentary  canal,  where 
dyspeptic  symptoms  often  arise  from  changes 
of  this  character,  the  secretions  necessary  for  the 
process  of  digestion  not  being  properly  formed  ; 
and  absorption  by  the  intestinal  wall  is  also  liable 
to  be  interfered  with. 

6.  Obstruction  or  contraction  of  tubes  or 
orifices  lined  by  mucous  membranes  may  arise 
from  inflammatory  or  hypertrophic  thickening, 
submucous  cedema  or  suppuration,  thick  secre- 


1008  MUCOUS  MEMBRANES, 
t.ion,  cicatrization  of  ulcers,  or  some  forms  of 
new  growth.  The  consequent  symptoms  are 
similar  to  those  from  other  forms  of  obstruction, 
such  as  dysphagia  when  the  oesophagus  is  af- 
fected, dilatation  of  the  stomach  from  obstruc- 
tion of  the  pylorus,  retention  of  urine  when 
the  urethra  is  involved,  or  some  form  of  dyspnoea 
when  the  air-tubes  are  obstructed. 

7.  Physical  examination,  particularly  by  in- 
spection, at  once  reveals  the  condition  of  mucous 
surfaces  which  are  visible.  This  may  be  aided 
by  instruments  in  the  examination  of  parts  which 
are  situated  more  internally.  Special  modes  of 
examination  give  us  important  information  as  to 
the  diseases  of  certain  mucous  membranes,  such 
as  that  lining  the  air-tubes. 

8.  General  symptoms.  — Diseases  of  mucous 
membranes  are  often  accompanied  with  symp- 
toms affecting  the  general  system.  The  most' 
obvious  of  these  are  fever  and  wasting,  which 
may  arise  from  various  causes.  Pyrexia  is 
not  as  a rule  high  in  inflammation  of  mucous 
surfaces.  It  must  be  remembered  that  certain 
affections  of  this  class  of  membranes  are  but 
manifestations  of  some  general  or  constitutional 
disease,  which  presents  its  own  symptoms. 

Treatment. — The  general  principles  or  indi- 
cations in  the  treatment  of  diseases  of  mucous 
membranes  may  be  summed  up  as  follows : — 
1.  To  relieve  pain  and  other  sensations  by  ap- 
propriate means.  2.  To  check  haemorrhages,  if 
they  are  in  such  amount  as  to  need  interference. 
3.  To  subdue  inflammatory  action.  4.  To  brace 
up  and  give  tone  to  relaxed  tissues.  5.  To 
influence  secretions  and  morbid  products,  increas- 
ing or  diminishing  the  former,  checking  or 
modifying  discharges,  and  endeavouring  to  affect 
special  materials,  such  as  diphtheritic  deposits. 
G.  To  allay  undue  excitability,  causing  violent 
actions  ; or  to  aid  such  actions  as  may  be  neces- 
sary to  expel  excessive  secretions  or  morbid 
products ; or  in  other  ways  to  prevent  their 
accumulation.  7.  To  supply  the  place  of,  and 
prevent  the  symptoms  resulting  from  the  want 
of  secretions  necessary  for  special  purposes, 
which  are  formed  ’ by  certain  mucous  surfaces, 
such  as  the  gastric  juice.  8.  To  treat  particu- 
lar morbid  conditions,  such  as  ulcers,  gangrene, 
new  growths,  or  constriction,  with  the  view  of 
curing  them.  9.  To  treat  general  symptoms. 

Local  applications ; or  such  remedies  as  when 
administered  internally  come  into  contact  with 
the  affected  surface,  are  of  much  value  in  the 
treatment  of  diseased  mucous  membranes.  These 
may  be  anodyne,  sedative,  stimulating,  astrin- 
gent, demulcent,  or  of  other  kinds,  according 
to  the  action  required  ; and  they  are  often  ad- 
vantageously applied  in  special  ways.  Opera- 
tive procedures  are  not  unfrequently  required. 
General  treatment  is  often  of  the  greatest  ser- 
vice in  the  management  of  diseases  of  mucous 
membranes,  and  this  may  be  the  only  indication 
needing  attention.  Moreover,  it  must  be  borne 
in  mind  that  there  are  certain  diseases  in  which 
the  morbid  condition  of  the  mucous  membrane 
is  but  a part  of  the  general  malady,  and  calls 
for  no  special  treatment. 

1’rtEDF.nicK  T.  Roberts. 

MUCOUS  BALE. — An  adventitious  sound 


MUCOUS  TUBERCLES. 

heard  on  auscultating  the  chest  in  certain  forms 
of  disease,  and  due  to  the  passage  of  air  through 
viscid  fluid  in  the  bronchi.  See  Physical  Exa- 
mination. 

MUCOUS  SECRETION,  Disorders  of. 

See  Mucous  Membranes,  Diseases  of;  and 
Secretions,  Disorders  of. 

MUCOUS  TUBERCLES.— Synon.  ; Con- 

dylomata ; Er.  Plaques  muqueuses. 

Definition. — Flattened  raised  patches  upon 
the  soft  skin  and  mucous  surfaces  of  syphilitic 
persons.  See  Condyloma. 

.Etiology. — Mucous  tubercles  are  a certain 
evidence  of  syphilitic  contamination,  and  belong 
to  what  are  commonly  known  as  the  secondary 
manifestations ; they  may  appear  very  early  in 
that  stage  of  the  disease,  or  amongst  the  later 
symptoms.  They  are  often  present  in  hereditary 
syphilis.  Mucous  tubercles  are  much  more  fre- 
quent in  women  than  in  men ; in  fact  they  are 
sometimes  the  only  symptom  of  the  constitu- 
tional taint  in  females. 

Experimental  inoculation  of  the  discharge  from  j 
these  tubercles  shows  that  it  is  capable  of  pro- 1 
during  a hard  chancre  at  the  point  of  insertion, 
followed  by  general  syphilis ; and  from  clinical 
observation  it  would  appear  that  these  lesions 
are  highly  contagious,  and  a fertile  source  for 
spreading  disease. 

Description. — Mucous  tubercles  consist  of  a 
circumscribed  hypertrophy  of  the  skin  and  cuticle. 
They  appear  as  flat,  elevated  patches,  of  a round 
or  oval  shape,  with  a broad  base,  of  a reddish 
colour,  and  generally  covered  by  a thin  grey: 
pellicle.  When  in  close  proximity  they  coalesce, 
and  form  a dense  tnberculated  mass  of  irregular 
shape  and  size,  which  is  generally  fissured,  ulce- 
rated, and  encrusted  with  dried  secretion  from 
the  neighbouring  skin.  As  a rule  they  are  not1 
painful,  but  when  irritated  they  become  very 
sensitive.  When  situated  upon  a mucous  mem- 
brane they  are  less  raised,  patchy  in  appear- 
ance, and  whitish  in  colour.  This  is  especially 
the  case  in  the  throat,  where  they  have  been 
termed  plaques  opalines.  At  other  times  they 
may  form  superficial  ulcerations  with  inflamed; 
margins. 

The  favourite  locality  of  mucous  tubercles  is 
the  genital  organs,  the  anus,  and  the  moist  skin 
adjoining;  but  they  are  not  frequent  on  the 
penis.  They  may  also  be  found  at  the  umbilicus, 
axillie,  auditory  meatus,  alae  of  the  nose,  on  the 
lips  and  nipples,  and  between  the  toes.  The 
mucous  membranes  usually  affected  are  those  oj 
the  mouth,  tongue,  and  throat ; and  occasionally 
they  are  seen  in  the  vagina  or  on  the  os  uteri 
Want  of  cleanliness  favours  their  development 
as  does  irritation  from  any  cause ; and  in  stout 
persons  they  may  be  met  with  in  unusual  situa 
tions,  where  folds  of  skin  meet,  and  perspiratioi 
collects. 

In  young  children,  the  subjects  of  inher.te 
syphilis,  mucous  tubercles  are  generally  foun 
at  or  about  the  anus  or  organs  of  generation 
but  when  the  disease  has  been  communicated 
the  mouth  and  fauces  are  more  usually  affected 

Treatment. — The  local  treatment  of  syphiliti 
condylomata  is  cleanliness,  with  some  mercuna 
or  astringent  application  ; and  if  the  patches  b 


MUCOUS  TUBERCLES. 

'mall  and  few  in  number,  this  will  generally  be 
sufficient.  If  the  tubercles  be  large,  indurated, 
and  ulcerated,  or  if  they  be  very  chronic,  with 
little  disposition  to  subsido  under  the  above 
treatment,  an  occasional  pencilling  with  nitrate 
cf  silver  or  tincture  of  iodine  may  hasten  their 
removal.  General  mercurial  treatment  must  be 
combined  with  the  local  remedies.  Attention 
must  of  course  be  given  to  the  general  health. 

George  G.  Gascoyen. 

MULTILOCULAR,  (multi,  many,  and  lo- 
■ uli , small  spaces).— A term  applied  to  cysts 
md  other  forms  of  growths,  and  to  pulmonary 
laxities,  when  they  consist  of  many  small  spaces 
ir  loculi.  See  Cysts. 

MUMPS.  — Synon.  : Parotitis;  Cynanche 
Darotidea ; Pr.  Oreillon ; Ger.  Mumps. 

Definition. — An  acute,  febrile,  infectious 
isease;  attended  with  swelling  of  the  salivary 
lands,  mostly  of  the  parotids;  and  ending  in 
^solution. 

./Etiology.— This  is  an  affection  more  eom- 
tonly  seen  in  young  persons  —boys,  growing  girls, 
nd  young  men  ; but  it  may  occur  in  adults  of 
,ther  sex  who  are  much  with  the  sick,  and  have 
pt  bad  the  complaint  before.  Mumps  rarely 
tacks  the  same  person  twice.  It  occurs  as  an 
hlemic  in  large  institutions,  such  as  schools 
id  barracks.  It  is  conveyed  from  person  to 
rson  by  contagion— that  is,  by  infecting  par- 
ties reproduced  in  the  course  of  the  disease, 
d given  off  by  the  sick,  possibly  even  before 
8 glands  are  affected,  certainly  for  two  or 
Tee  weeks  afterwards.  It  has  an  incubation- 
riod  of  from  eight  days  to  three  weeks. 

Some  hygienic  defects  may  favour  the  spread 
mumps.  Whether  it  prevails  more  at  one 
i.son  than  another  is  uncertain. 

Anatomical  Characters.  — Not  many,  pro- 
My  no  cases  of  idiopathic  parotitis  afford  the 
1 hologist  an  opportunity  of  making  a post- 
'i  Hern  examination  into  the  nature  of  the  affec- 
1 1.  But  arguing  from  analogy,  some  maintain 
tit  here,  as  in  the  more  frequently  fatal  symp- 
tiiatic  parotitis,  the  inflammation  has  its  start- 

i -point  in  the  gland-tissue  proper,  or  in  a 
c irrh  of  its  duct.  Others  again  assert,  and 
ti  has  long  been  the  prevalent  opinion,  that  the 

ii  rstitial  and  the  connective  tissue  around  the 
g id  are  the  seat  of  the  mischief.  The  affection 
is  robably  both  parenchymatous  and  intersti- 
ti  But  wherever  the  inflammation  has  its 
oiiin,  certain  it  is  that  the  interstitial  and 
ce  lar  tissue  around  the  gland  are  the  parts 
w hgive  most  evidence  of  the  existence  of  the 
dbise.  They  become  kypereemic,  infiltrated 
wf  serous  fluid,  and  consequently  much  swollen. 
A;  this  (edematous  state  passes  to  structures 
head  those  pertaining  directly  to  the  parotid 
gl  l.  Seldom  does  there  appear  to  be  any 
fibrous  exudation  poured  out;  and  still  less 
fre.ently  do  the  tissues  exhibit  any  tendency' 
to  eak  down  and  to  suppurate.  The  swelling 
ctfletely  disappears  about  three  days  after 
the  ver.  On  the  subsidence  of  the  local  lesion 
a s ailed  metastasis  to  the  testicle  and  other 
gk.  ular  and  fibrous  structures  is  not  rare. 
Alt  itious  in  the  kidney  and  atrophy  of  the 
tea  .es  have  followed;  nor  have  the  investments 

64 


MUMPS.  1009 

of  the  nerves,  or  the  surfaces  of  the  heart,  always 
escaped. 

Symptoms  and  Diagnosis.  — Some  general 
symptoms  always  precede  the  local  manifes- 
tations of  mumps ; they  may  be  so  slight  as 
almost  to  escape  notice ; or  fatigue  in  the  day, 
restlessness  at  night,  chilliness,  or  vomiting  may 
mark  the  ingress.  These  initial  sy’mptoms  do 
not  occur  until  a week  after  exposure  to  in- 
fection, and  may  not  be  followed  at  once  by  the 
local  signs.  Mostly',  after  a week  of  malaise,  or 
only  a look  of  illness,  the  onset  of  mumps  is 
sudden,  with  chill,  rarely  rigor,  sometimes  vomit- 
ing, and  well-marked  fever ; often  only  a few 
hours  before  pain  and  swelling  begin  in  the 
parotid  or  sub-maxillary  glands. 

One  restless  night  follows,  either  from  pain, 
or  from  fever,  or  both.  Sometimes  the  pain  is 
severe,  and  the  temperature  only  elevated  by  one 
degree ; sometimes  the  fever  is  more  evident.  It 
generally  reaches  100°  or  101°,  and  frequently 
rises  to  103°  or  10-1°  ; at  this  point  ic  is  not 
long  maintained,  but  subsides  as  the  local  lesion 
is  established,  falling  to  the  normal,  or  even 
below  it,  on  the  third  or  fourth  day  of  the  disease. 
The  temperature  may  be  low  while  the  swelling 
is  still  marked  and  painful ; and  in  some  cases 
appetite  returns  before  eating  is  easy.  This 
happens  when  the  patient  is  kept  at  rest  in  bed. 
Without  such  precaution  sudden  and  great  ele- 
vations of  temperature  occur  at  the  end  of  the 
first  week,  either  without  serious  local  mischief, 
or  with  orchitis,  deafness,  tinnitus  of  one  ear, 
and  albuminuria,  not  always  transient;  rheu- 
matism, and  heart-affections,  leaving  traces  both 
of  pericardial  and  of  endocardial  inflammation, 
may  also  occur. 

From  face-ache  and  enlarged  lymphatic  glands, 
the  sudden  sensation  of  pain  or  stiffness  in  the 
parotid  or  submaxillary  gland,  following  on  the 
general  symptoms,  and  absence  of  any  such  local 
trouble  as  usually  affects  the  lymphatics,  together 
with  the  history  of  a possible  infection,  will  gene- 
rally suffice  for  the  diagnosis  of  mumps.  Fur- 
ther evidence  is  obtained  on  examining  the  spot, 
where,  besides  the  swelling  being  at  first  deeply 
seated,  some  degree  of  swelling  of  the  parts 
surrounding  the  gland  exists  near  the  lobe  of 
the  ear,  which  very  soon  thereafter  increases 
to  such  an  extent  as  to  involve  more  or  less  the 
whole  of  one  side  of  the  face,  and  passes  down 
on  to  the  neck.  Coincidently  with  the  appear- 
ance of  this  enlargement,  the  pyrexia  declines  in 
some  cases ; while  in  others  some  days  ela'pse 
before  the  subsidence  of  the  fever.  Pain  is  now 
complained  of,  and  the  patient  can  no,  longer 
open  his  mouth  to  the  usual  extent.  Yawning 
excites  severe  pain ; in  fact,  it  can  hardly  be 
effected.  The  yawn  is  aborted.  So  with  masti- 
cation and  speaking — they  are  greatly  impaired, 
and  the  sufferer  prefers  to  starve  and  to  remain 
silent  rather  than  endure  the  pain  involved  in 
the  effort  to  perform  either  act.  The  saliva  is 
either  largely  increased,  going  the  length  of 
salivation,  or  much  diminished  in  quantity.  If 
pressure  be  made  over  the  swelling,  the  patient 
quickly  indicates  the  unpleasantness  and  the  pain 
of  the  proceeding ; and  the  sensation  afforded  by 
manipulation  is  that  of  an  elastic  tumour,  with  a 
slightly  softer  feeling  in  the  centre.  The  skin 


1010  MUMPS. 


MUSCLE  VOLITANTES. 


over  the  swelling  may  be  slightly  reddened; 
often  there  is  no  deviation  from  the  normal 
colour.  In  many  cases  these  symptoms  are  not 
nearly  so  severe,  and  the  disproportion  between 
the  amount  of  distortion  of  the  countenance  and 
the  actual  suffering  is  sufficiently  astonishing,  as 
well  to  the  patient  as  to  the  sympathising  friends. 
Most  frequently  the  affection  is  limited  to  one 
side  of  the  face  ; but  as  the  swelling  of  the  one 
side  subsides,  the  other  seems  to  take  it  up,  and 
it  runs  through  the  same  series  of  events,  with, 
possibly,  an  interval  of  a few  days  between  them. 
Rarely  are  the  two  sides  simultaneously  affected; 
but  in  such  a case  the  uneasiness,  pain,  and  dis- 
comfort are  of  course  greatly  increased.  After 
the  continuance  of  these  symptoms  for  about  six 
or  eight  days,  they  begin  to  abate,  the  oedema 
lessens,  the  pain  is  lost,  the  stiffness  and  tension 
disappear,  and  in  a few  days  later  the  face 
acquires  its  usual  appearance.  Occasionally 
there  is  left.,  for  some  time  after  this,  a certain 
degree  of  hardness  in  the  neighbourhood  of  the 
parotid,  which  gives  no  uneasiness,  and  can 
rarely  be  mistaken  for  tumour.  In  like  manner 
the  history  of  the  case  will  disclose  the  nature  of 
other  local  pains,  or  of  orchitis. 

Not  uncommonly,  especially  in  young  subjects, 
a ‘metastasis’  takes  place  from  theparotid  gland 
to  the  testicle  in  boys,  and  to  the  mammse  or 
ovary  in  girls.  When  this  occurs,  and  it  may 
happen  at  any  period  of  the  disease,  an  exacer- 
bation of  the  fever  takes  place,  and  at  the  same 
time  pain  in  the  inguinal  region  is  complained  of. 
An  examination  of  the  parts  reveals  the  fact 
that  there  is  swelling  of  the  testicle,  an  orchitis, 
as  well  as  an  accompanying  oedema  of  the  scrotum. 
In  the  case  of  the  girl  the  vulva  becomes  the 
seat  of  the  oedema,  and  on  pressure  over  the 
region  of  the  ovary  pain  is  elicited.  The  meta- 
stasis may  take  place  before  the  inflammation  of 
the  parotid  has  entirely  subsided ; and  when  the 
orchitis  abates,  the  parotid  may  again  take  on 
the  inflammatory  condition.  Inflammation  of  the 
coverings  of  the  brain  is  to  be  feared  on  sudden 
subsidence  of  the  inflammation  of  the  parotid, 
if  no  orchitis  follows  the  disappearance  of  the 
original  affection. 

Prognosis. — This  is  almost  invariably  favour- 
able in  mumps,  unless  in  the  very  weakly  and  in 
the  tuberculous,  or  in  the  rare  event  of  meningitis 
being  developed.  It  may  be  said  to  be  always  a 
disease  of  a comparatively  trivial  nature,  pro- 
ducing considerable  pain  and  much  discomfort, 
but  not  endangering  the  life  of  the  sufferer.  In 
very  exceptional  instances  the  inflammation  of 
the  parotid  terminates  in  abscess.  The  indica- 
tions of  such  an  untoward  result  are  increased 
pain  in  the  centre  of  the  swelling,  hardness,  and 
dark  red  appearance  of  the  skin  over  the  spot. 
In  time  the  abscess  discharges  outwardly,  or  into 
the  external  auditory  meatus.  Atrophy  of  the 
testis  sometimes  follows  ‘metastatic’  orchitis. 

Treatment. — It  may  not,  in  every  case,  and 
at  all  seasons,  be  necessary  to  confine  a patient 
suffering  from  mumps  to  his  bed.  But  little 
treatment,  beyond  rest  and  care  for  the  week  or 
ten  days  this  disease  lasts,  is  required ; still  it  is 
more  prudent  for  the  first  few  days  to  enjoin  rest 
in  bed.  This  is  particularly  necessary  if  the  pa- 
tient be  young.  In  every  case  going  out  into  the 


open  air  should  be  forbidden,  and  the  patient 
recommended  to  keep  as  much  as  possible  to  one 
room.  Rise  of  temperature  means  increased  waste, 
and  this  is  cancelled  by  rest.  The  bowels  may 
require  relief,  as  constipation  keeps  up  distur- 
bance of  the  temperature.  All  active  evacuants 
should  be  avoided.  It  may  be  well  to  give  some 
simple  saline,  as  potash  with  lemon  juice,  and 
diluents  during  the  first  few  days;  ice  is  always 
grateful.  A dose  of  chloral  may  be  required  at 
night  (a  grain  for  each  year  of  the  patient’s  agf 
in  children)  if  there  he  any  restlessness. 

As  to  local  treatment,  not  much  is  required 
unless  the  pain  be  unusually  severe.  It  wil 
be  sufficient  in  most  cases  to  protect  the  par 
from  the  air  by  means  of  a light  handkerchief 
Should  more  active  interference  be  called  for 
some  anodyne  may  be  used,  or  soothing  embro 
cation,  such  as  the  soap  and  opium  liniment 
belladonna  liniment,  or  external  warmth;  dis 
cretiou  in  the  use  of  these  may  safely  enoug 
be  left  in  the  hands  of  the  patient  himself,  if  c 
mature  years.  If  there  be  the  slightest  tendene 
to  suppuration,  indicated  by  increase  of  fever  an 
tenderness  over  the  gland,  with  redness  of  tl 
overlying  skin,  poultices  must  be  had  recourse  ;< 
and  so  soon  as  distinct  fluctuation  is  discovert 
the  abscess  must  be  opened,  otherwise  the  glam 
tissue  becomes  still  further  disorganised,  tl 
lobules  become  softened  and  break  down,  and  tl 
gland  is  permanently  destroyed.  The  applicatie 
of  leeches  is  useless  in  reducing  the  inflammatio: 
or  in  staying  the  formation  of  the  abscess.  Tb 
may  be  of  service  in  lessening  the  pain  of  met 
static  orchitis  or  ovaritis ; but  these  are  w 
treated  by  the  same  gentle  means  employed  in  t 
case  of  the  parotid  itself.  It  is  almost  universal 
recommended  in  the  case  of  a metastasis  to  t 
to  induce  a return  of  the  inflammation  to 
original  source,  by  the  application  of  irritai 
to  the  parotid,  such  as  a mustard  poulti 
This  seems  unnecessary  in  the  majority  of 
stances,  as  the  inflammation  is  of  such  s m 
type ; besides  it  implies  a belief  in  the  dicti 
that  this  is  a true  metastasis,  and  not  men 
another  manifestation  of  the  same  morbid  con- 
tion  which  originally  gave  rise  to  theparoti- 
Tepid  sponging  is  of  use  during  the  course! 
the  disease,  and  a warm  bath,  or  a pediluvii. 
may  be  required  when  metastasis  threats. 
Sometimes  wine  or  brandy  is  required. 

Considerable  ansemia  and  much  debility  rf 
persist  even  when  mumps  has  been  mild  ins 
course,  especially  in  the  weakly  or  unhealf. 
so  that  tonics,  with  iron  and  cod-liver  oil,  iy 
have  to  be  continued  for  some  time. 

C.  Mcibheai 

MURMUR.— This  term,  as  used  in  ausem- 
tion.  was  originally  applied  to  the  natural  sods 
heard  over  the  iungs  in  respiration ; but  -s 
employment  has  since  been  extended  to  inefe 
a great  variety  of  auscultatory  sounds  conDe  c 
with  the  heart,  the  blood-vessels,  the  places, 
&c.  See  Physical  Examination. 

MU  SC-23  VOLITANTES  (musca,  a 
volitatis,  floating  about). — This  name  is  give") 
the  semi-translucent  threads,  spots,  circles.1 
filaments  that  may  be  seen,  subjectively,  to_at 
and  glide  about  over  the  field  of  vision.  A' 


MTJSC^:  VOLIT ANTES, 
form  the  spectrum  of  the  vitreous  humour,  and 
may  be  seen  by  every  eye.  They  are  stirred  up 
end  brought  into  view  whenever  the  eye  is 
suddenly  moved ; and  when  the  eye  is  fixed 
•they  continue  to  float  about  for  a time,  then 
gradually  subside,  and  seem  to  sink  down  below 
and  away  from  the  axis  of  vision.  True  muses 
volitantes  have  no  pathological  significance,  and 
Lrenot  visible  objectively.  They  are,  however, 
aot  unfrequently  associated  with  some  error  of 
refraction,  or  with  disturbed  states  of  cerebral 
■irculation.  See  Vision,  Disorders  of. 


MUSCLES,  Diseases  of.  — Synon\  : Fr. 

naladies  des  Muscles;  Ger.  Krankheiten  der 
ifuskil. 

In  describing  the  diseases  of  the  muscular 
issue  attention  will  be  confined  to  the  voluntary 
iuscles,  excluding  diseases  of  the  muscular 
pbstance  of  the  heart,  which  are  treated  of 
Isewhere.  Many  of  the  morbid  states  of  the 
pluntary  muscles  come  properly  under  the  con- 
deration  of  the  surgeon,  and  others  of  them  will 
e more  suitably  treated  of  in  special  articles  on 
jie  various  diseases  of  the  nervous  system  with 
jhieli  they  are  associated.  There  still  remain, 
owever.  some  special  diseases  of  muscles  to  be 
escribed. 

1.  Acute  Inflammation. — Stnon.  : Myo- 
:is. — Ordinary  inflammation  of  muscle,  lead- 
ig  to  exudation  and  suppuration,  arises  chiefly 
a result  of  injury,  rupture  of  a muscle,  or 
tension  of  inflammation  from  neighbouring 
seased  bones.  Inflammation  sometimes,  how- 
er,  arises  spontaneously,  particularly  in  the 
igue,  diaphragm,  and  psoas  muscle;  in  the 
ter  situation  forming  one  variety  of  psoas 
■iscess.  The  symptoms  are  pain,  tenderness, 
d swelling,  corresponding  to  the  seat  of  the 
: 'animation.  Exudation  of  serum  and  of  lymph 
lies  place,  and  subsequently  an  abscess  may 
f m ; occasionally  the  process  goes  on  to  gan- 
line. 

■Secondary  inflammations  and  formations  of 
1 are  of  more  frequent  occurrence  than  simple 
i animation  and  abscess.  They  arise  in  the 
c.rse  of  the  various  forms  of  pyaemia.  The 
(■sence  of  such  secondary  abscesses  in  muscles 
-specially  characteristic  of  glanders  and  farcy, 
^ re  inflammatory  infiltrations  of  various  sizes 
a :ar  in  many  of  the  muscles,  especially  those 
°|he  arm.  Disintegration  takes  place  in  their 
«,re,and  a collection  of  puriform  fluid  results. 

Chronic  Indurating  Inflammation. — 
i his  form  of  inflammation  there  is  prolife- 
rs n of  cells  in  the  interstitial  tissue,  causing 
th muscle  to  become  hard  and  painfiil.  The 
tv'e  muscle  may  be  attacked,  or  the  pro- 
cel  may  be  limited  to  one  or  more  portions. 
In1  its  are  often  attacked  by  chronic  inflamma- 
tiepf  the  sterno-mastoid  muscle.  The  whole 
mi|le  becomes  hard  and  painful,  but  rarely  sup- 
plies. The  disease  usually  yields  to  soothing 
oal  applications ; but  if  it  be  of  syphilitic 
on  i,  the  use  of  internal  antisyphilitie  remedies 
mijbe  required.  In  adults  chronic  indurative 
mjj  tis  of  a syphilitic  character  may  occur  in 
the  :erno-mastoid,  the  various  muscles  of  the 
log  d arm,  the  temporal  and  masseter  muscles, 


MTJSCLES,  DISEASES  OF.  1011 
the  tongue,  and  other  parts.  The  disease  may 
appear  either  as  a diffuse  inflammation,  with 
the  usual  signs  of  pain  on  movement,  tender- 
ness, and  some  swelling,  or  sometimes  a series 
of  beaded  swellings ; or  as  a circumscribed  in- 
flammation, with  an  abundant  infiltration  of 
nucleated  cells.  If  the  inflammation  does  not 
soon  subside,  the  cellular  exudation  becomes  or- 
ganised into  contracting  fibrous  tissue,  and  the 
compressed  muscular  fibres  atrophy.  In  diffused 
myositis  permanent  contraction  of  the  muscle 
may  result  from  this  cause ; in  circumscribed 
syphib’tic  myositis  a fibrous  tumour  in  the  in- 
terior of  the  muscle  may  result ; sometimes  a 
gummy  tumour  is  formed.  Syphilitic  tumours 
thus  formed  in  muscle  bear  a great  resemblance 
to  malignant  tumours.  Indeed  it  is  often  found 
that  the  only  means  of  distinguishing  the  two 
clinically  is  by  the  effect  of  iodide  of  potassium 
in  causing  the  disappearance  of  the  former. 

3.  Rheumatic  Inflammation. — The  morbid 
changes  in  this  form  of  inflammation  rarely  pass 
beyond  the  stage  of  congestion  and  serous  exu- 
dation, though  occasionally  proliferation  of  the 
interstitial  tissue  may  occur,  and  callosities  may 
be  formed.  See  Rheumatism:,  Muscular. 

4.  Haemorrhage. — Haemorrhage  takes  place 
in  muscle  not  only  from  injury,  but  frequently 
in  the  course  of  typhus  and  typhoid  fevers  and 
pyaemia. 

5.  Rupture. — Rupture  of  muscle  is  a subject 
which  falls  more  properly  into  the  domain  of  the 
surgeon,  but  the  accident  occurs  also  in  circum- 
stances which  may  bring  it  under  the  notice  of 
the  physician.  Violent  contraction  of  a muscle, 
without  external  injury,  may  lead  to  partial  rup- 
ture of  its  fibres,  for  example  the  gastrocnemius. 
The  violent  spasms  of  tetanus  occasionally  cause 
complete  rupture  of  a muscle,  particularly  of 
the  muscles  of  the  back,  the'  rectus  femoris,  and 
the  psoas.  Rupture  of  muscles  has  been  known 
to  occur  in  the  delirium  of  fever ; and  may  be 
the  cause  of  abscess  forming  in  muscle,  as  de- 
scribed above. 

Teeatment.  — The  treatment  of  ruptured 
muscle  consists  mainly  in  rest ; in  the  support 
of  the  muscle  by  uniform  bandaging;  and  in 
suitable  applications,  should  the  formation  of 
abscess  occur. 

6.  Lesions  of  Sensibility. — a.  Myalgia. — 
This  term  was  given  by  the  late  Dr.  Inman 
to  a painful  condition  of  the  muscles  arising 
in  those  who  are  in  feeble  health.  The  pain 
is  similar  to  that  which  is  present  in  a muscle 
after  long-continued  and  fatiguing  exertion— 
for  example,  in  the  limbs  after  a long  walk, 
or  in  the  diaphragm  and  intercostals  after 
violent  laughing.  In  persons  who  are  debili- 
tated, pain  may  arise  in  the  muscles  after  very 
slight  exertion,  and  this  constitutes  myalgia. 
It  is  often  accompanied  by  cramps  at  intervals. 
The  pain  is  most  commonly  felt  at  the  tendinous 
insertion  of  the  muscle.  The  abdominal  muscles 
are  frequently  the  seat  of  myalgia,  such  as  the 
costal  origin  of  the  external  oblique — causing, 
according  to  some  authorities,  that  pain  in  the 
side  which  is  so  common  in  women — and  the 
pubic  insertion  of  the  recti.  The  muscles  of  the 
back,  and  especially  the  trapezius,  also  suffer; 
the  muscles  of  the  limbs  much  less  frequently 


1012  MUSCLES,  DISEASES  OF. 

When  situated  in  the  trunk,  myalgia  is  often 
mistaken  for  some  congestive  or  inflammatory 
condition  of  the  liver,  spleen,  or  other  viseus 
lying  beneath.  The  pains  of  myalgia  are  dis- 
tinguished by  their  hot  and  burning  character. 
They  are  increased  by  exercise  of  the  affected 
muscle,  and  disappear  -when  it  is  relaxed  or 
artificially  supported.  However  severe  the  pain 
may  be,  the  pulse  remains  unaffected  ; but  it  is 
usually  uniformly  weak  and  fast. 

The  muscles  or  their  fibrous  connexions  are 
also  the  seat  of  pain  in  the  condition  known  as 
muscular  rheumatism. 

Treatment. — The  muscles  should  have  rest 
and  support  by  bandaging.  Tonic  treatment  is 
required.  Dr.  Inman  especially  recommended 
cod-liver  oil  and  tincture  of  perchloride  of  iron. 
Friction  and  counter-irritation  do  little  good. 
Exercise  is  of  no  use,  unless  combined  with  fresh 
air  and  good  diet. 

b.  Muscular  anesthesia. — This  term  is  given 
by  Dr.  Russell  Reynolds  to  a group  of  symptoms 
occasionally  met  with,  and  believed  by  him  to  be 
caused  by  loss  of  the  ‘ muscular  sense.’  See 
Muscular  Sense,  Disorders  of. 

7.  Atrophy  and  Degenerations. — a.  Sim- 
ple atrophy. — Simple  atrophy  of  the  substance  of 
muscular  fibres  arises  either  from  general  de- 
fective nutrition,  during  the  course  of  wasting 
diseases,  such  as  phthisis,  in  cachectic  conditions, 
or  after  severe  fevers;  or  as  a local  condition 
from  disuse  of  the  muscle.  The  muscles  become 
pale  and  flabby.  The  ultimate  fibres  are  re- 
duced in  volume,  but  preserve  their  anatomical 
characters,  still  showing  the  longitudinal  and 
transverse  striation.  The  atrophy  is  sometimes 
so  advanced  in  parts,  that  the  muscular  substance 
of  the  fibre  entirely  disappears,  and  nothing  is 
left  but  the  sheath  of  the  sarcolemma,  which 
appears  in  the  form  of  fibrous  bands  between  the 
remaining  muscular  fibres. 

As  a local  condition,  atrophy  is  most  fre- 
quently seen  in  muscles  in  the  neighbourhood  of 
a diseased  joint,  or  in  a paralysed  limb.  In 
these  cases  the  atrophy  is  usually  combined 
with  more  or  less  interstitial  deposit  of  fat 
between  the  ultimate  fibres,  constituting  fatty 
growth  on  or  infiltration  of  muscle.  Occasionally 
the  amount  of  fat,  is  so  great  as  to  cause  an  actual 
increase  in  bulk  of  the  muscle,  so  that  it  appears 
hypertrophied.  The  atrophic  and  other  changes 
arising  in  paralysed  muscles  are  considered  in 
their  appropriate  articles.  Fatty  infiltration  of 
muscles  may  also  arise  as  a primary  condition, 
when  there  is  an  excess  of  fat  in  the  blood,  and 
atrophy  of  the  muscular  substance  results  from  it. 

b.  Fatty  degeneration. — Here  the  fat  is  depo- 
sited, not  between  the  ultimate  fibres,  as  in  fatty 
infiltration  of  muscle,  but  in  their  interior.  Rows 
of  minute  granules  appear  in  the  longitudinal 
striee,  and  gradually  increase  until  the  whole 
breadth  of  the  fibre  is  occupied  by  them,  and 
nothing  is  left  but  the  sarcolemma.  When  the 
degeneration  reaches  this  extent,  it  is  of  course 
irrecoverable.  Muscles  affected  by  this  change 
become  very  soft  and  friable.  This  degeneration 
is  met  with  much  oftener  in  the  heart  than  in 
voluntary  muscles.  It  is  sometimes  associated 
with  atrophy  of  the  fibres  in  the  muscles  of 
limbs  attacked  by  certain  forms  of  paralysis. 


MUSCULAR  HYPERTROPHY. 

It  is  met  with  also  in  fever  and  phosphorus, 
poisoning,  granular  degeneration  being  the  first 
stage.  See  Fatty  Degeneration. 

c.  Granular  degeneration. — Granular  degene- 
ration of  muscles  occurs  in  fevers  and  acute 
diseases.  The  ultimate  fibres  become  swollen 
and  opaque,  being  filled  with  fine  grannies. 
These  clear  up  on  the  addition  of  acetic  acid ; 
this  test  distinguishing  granular  from  fatty  de- j 
generation.  The  muscles  which  are  affected  bv| 
it  are  soft  and  friable  and  easily  rupture.  The' 
fibres  no  doubt  ultimately  recover  their  natural 
appearances;  but  if  the  disease  be  severe  and 
long-continued,  granular  degeneration  advances 
to  fatty  degeneration,  as  is  seen  in  cases  of; 
phosphorus-poisoning. 

d.  W axy  degeneration ; Vitreous  degeneration 
Myositis  typhosa. — This  degeneration,  which  was 
discovered  by  Zenker,  is  believed  to  be  partly  a; 
post-mortem  change.  The  affected  fibres  swell  and 
lose  their  striation ; and  become  of  a homogene- 
ous translucent  aspect.  After  a time  transverst 
fractures  appear  in  each  fibre,  dividing  it  ink 
a series  of  short  cylinders.  The  nuclei  of  the 
sarcolemma  also  multiply.  The  change  doer] 
not  attack  all  the  muscular  fibres  of  a pari 
uniformly;  for  healthy  and  degenerated  fibre- 
are  seen  side  by  side.  It  is  observed  chiefly  ii 
typhoid  fever,  cholera,  and  other  acute  febril 
diseases,  being  often  associated  with  the  granula 
degeneration.  It  usually  attacks  the  adducto 
muscles  of  the  thigh,  the  abdominal  and  pectora 
muscles,  and  the  diaphragm ; appearing  i 
patches  of  one  or  more  square  inches,  whic 
gradually  become  softened  and  pulpy,  and  re 
semble  a muscular  abscess  (Wilks  and  Moxon 
See  Degeneration. 

e.  Fibroid  degeneration. — Fibroid  degeneratia 
of  muscle  has  already  been  referred  to  as  a resu 
of  myositis.  Chronic  or  repeated  inflammatio: 
of  a rheumatic  or  syphilitic  character,  leads 
the  formation  of  fibrous  tissue  in  muscle,  and  tl 
muscle  becomes  of  a tough  whitish  character. 

f.  Ossification.  — Ossification  of  muscle  is 
rare  result  of  chronic  inflammation  or  irritatic 
It  is  observed  to  occur  in  muscles  which  a 
subject  to  pressure,  as  the  deltoid  in  soldie 
and  the  adductors  in  riders.  In  a few  cases  os 
fication  of  a considerable  number  of  the  muse’ 
has  taken  place. 

8.  Tumours. — Besides  the  syphilitic,  fibro’ 
and  gummatous  tumours  already  referred 
muscle  is  subject  to  growths  of  a sarcomatc 
and  cancerous  nature.  Fatty,  cartilaginous,  v 
cular,  and  other  tumours,  are  also  met  with' 
this  tissue,  but  rarely. 

9.  Parasitic  Affections. — The  chief  disec 
of  muscles  belonging  to  this  group  is  that  <3 
to  the  presence  of  trichina  ( sec  Trichinos  . 

The  cysticcrcus  cellulose  is  also  sometimes  fold 
in  muscles.  See  also  Pelodeba. 

Alexander  Datidso: 

MUSCULAR  ATROPHY,  PROGBP 
SIVE.  See  Progressive  Muscular  Atrof' 

MUSCULAR  HYPERTROPHY.  — n 

increase  in  muscular  tissue,  affecting  either.e 
voluntary  muscles,  or  the  muscular  tissue)! 
special  organs,  such  as  the  heart,  the  inteste, 
or  the  bladder.  True  muscular  hypertrophy  b=i 


MUSCULAR  HYPERTROPHY. 

lot  be  confounded  'with  an  increase  in  the  res- 
ume of  muscular  structures  from  hyperplasia  of 
he  connective-tissue  elements.  See  Hypertro- 
phy; and  Pseudo-htpertrophic  Paralysis. 

MUSCULAR  RHEUMATISM.— A form 
if  rheumatism  affecting  the  muscles.  See  Rheu- 
iatism,  Muscular. 

MUSCULAR  SENSE,  Disorders  of. — 

ly  the  term  ‘ muscular  sense  ’ is  meant  the  sen- 
ation  by  which  we  are  aware  of  the  degree  of 
orce  exerted  by  contracting  muscles.  By  it  we 
.ecome  conscious  of  the  resistance  to  contraction, 
hat  is,  the  tension  of  the  fibres,  rather  than  of 
he  contraction  itself.  This  sense  must  be  dis- 
inguished  from  the  1 common  sensibility  ’ which 
luscles  possess,  and  by  which  we  feel — (1)  pain 
n firm  pressure ; and  (2)  pain  on  tetanic  con- 
'■action,  whether  spontaneous  (‘cramp’),  or  ex- 
:ted  by  faradisation,  independently  of  the  ex- 
itation  of  cutaneous  nerves,  as  when  the  skin  is 
isensitive  or  absent.  It  must  also  be  distin- 
nished  from  (3)  the  sense  of  muscular  fatigue, 
(he  muscular  sense  proper  has  been  referred  to 
sensation  in  the  joints,  skin,  and  other  parts, 
f the  position  of  the  limb,  but  it  may  be  un- 
upaired  when  this  sensation  is  lost  {see  Kin.es- 
^esis).  It  has  been  thought  to  be  merely  the 
msciousness  of  the  degree  of  the  out-going 
otor-impulse,  but  it  may  be  lost  when  motor 
fewer  is  normal,  as  in  a case  under  the  obser- 
ition  of  the  writer,  in  which  the  muscular 
nse  was  suddenly  lost  in  one  arm,  although 
e power  was  unimpaired.  A poker  did  not 
em  heavier  than  a feather.  The  sensibility 
•obably  depends  upon  afferent  fibres,  which 
ive  been  found  by  Tschiijew  to  terminate  be- 
een  the  fibril]®.  They  apparently  course  with 
e motor  fibres  in  the  mixed  nerves,  but  pass 
the  spinal  cord  in  the  posterior  roots.  From 
Je  fact  that  the  common  and  special  sensibility 
muscles  may  be  lost  in  different  degrees,  it 
s been  conjectured  that  in  the  cord  the  paths 
e not  quite  the  same. 

Hypermsthesia. — Increase  of  the  common 
isibility  of  muscles  is  not  unusual,  but  very 
tie  is  known  of  that  of  the  muscular  sense.  The 
isation  of  restlessness,  impelling  movement, 
s been  attributed  to  it,  but  without  sufficient 
ison.  An  increase  of  the  muscular  sense  has 
■o  been  supposed  to  exist  in  writer's  cramp 
1 chorea  (Eulenberg). 

Anaesthesia. — Diminution  of  common  sensa- 
n in  muscles  is  frequent,  with  or  without  loss 
voluntary  power.  Diminution  of  the  special 
; isibility,  muscular  anesthesia , or  muscular 
hlgesia,  is  occasionally  observed,  commonly  in 
1 isequenee  of  central  disease,  especially  of  the 
: Dal  cord,  and  is  usually  associated  with  a 
ciitution  of  other  forms  of  sensibility.  The 
\ eases  in  which  muscular  an»sthesia  is  com- 
i nly  observed  are  locomotor  ataxy  and  hys- 
ba.  In  the  former  it  is  common,  but  not  in- 
‘iable,  and  bears  no  necessary  relation  to  the 
1 nge  in  cutaneous  sensibility. 

Iyhptoms.- -In  muscular  an®sthesia  the  pa- 
id is  unaware  of  the  degree  of  force  exerted 
1 the  contracting  muscles,  and  is  dependent  for 
1 knowledge  of  the  position  of  his  limb,  and 
( its  movements  mainly  upon  cutaneous  im- 


MUSHROOMS,  POISONING  BY.  1013 
pressions.  Ignorance  of  the  degree  of  contraction 
interferes  with  muscular  coordination,  by  ren- 
dering this  dependent  on  cutaneous  and  ocular 
perceptions.  When  these  are  perfect,  the  amount 
of  incoordination  may  be  slight.  The  condition 
of  the  muscular  sense  is  ascertained  by  observing 
the  accuracy  of  movement  with  and  without  clo- 
sure of  the  eyes,  and  especially  by  ascertaining 
the  sensitiveness  to  movement  against  resistance 
so  applied  as  to  affect  the  cutaneous  nerves  as 
little  as  possible.  The  best  method  for  this  pur- 
pose is  to  suspend  a weight,  in  a bag  or  cloth,  to 
the  limb,  and  observe  (a)  the  minimum  which  can 
be  recognised;  and  ( b ) the  least  increase  in  a 
greater  weight  which  can  be  distinctly  perceived. 
The  sensibility  of  the  two  limbs  may  be  con- 
veniently compared.  In  each  of  these  points 
the  muscular  sense  may  present  a deviation  from 
the  normal,  and  the  change  in  the  two  is  not 
always  proportioned.  The  minimum  recognisable, 
and  the  minimum  difference  recognisable,  vary  in 
different  parts.  The  latter  amounts  in  the  case 
of  the  arm  in  health  to  a difference  of  ^th  in  a 
weight  of  three  or  four  pounds.  Balls  of  similar 
size  and  appearance,  but  of  different  weights, 
have  been  employed  for  the  same  purpose. 

Treatment. — Muscular  anmsthesia  usually 
occurs  as  part  of  a wider  affection,  as  in  hysteria 
and  ataxy,  and  rarely  requires  special  treatment. 
Sudden  local  loss  of  muscular  sense  commonly 
depends  on  an  acute,  localised  change  in  the  cord, 
and  requires  rest  and  counter-irritation.  In  one 
case  under  the  writer’s  care,  such  a condition  in 
the  arm  rapidly  passed  away  under  this  treat- 
ment. Faradisation  of  the  muscles  has  been 
suggested,  and  may  in  some  cases  be  useful. 

W.  R.  Gowers. 

MUSCULAR  SPASM.  See  Spasm. 

MUSCULAR  TIC. — A synonym  for  facial 
spasm.  <See  Facial  Spasm. 

MUSCULAR  TREMORS.  See  Tremors. 

MUSHROOMS,  Poisoning  by. — Syxon.  ; 
Fr.  Empoisonntment  par  les  Champignons  ; Ger. 
Pilzver gif tung. 

Poisoning  by  mushrooms  is  by  no  means  a 
common  occurrence.  Great  discrepancy  of  opi- 
nion has  existed  as  to  the  poisonous  or  harm- 
less nature  of  some  species  of  fungi.  We  are 
now,  however,  increasing  our  hitherto  limited 
knowledge  of  the  various  species  and  varieties 
of  mushrooms;  and  within  the  last  dozen  years 
the  researches  of  Schmiedeberg,  Poppe,  and 
others,  have  thrown  great  light  upon  the  active 
principle  of  at  least  one  mushroom — the  fly- 
fungus.  The  varied  toxic  symptoms  produced 
by  the  ingestion  of  mushrooms  become  more 
easily  explicable  when  we  bear  in  mind  that 
only  a few  fungi  are  apparently  poisonous  under 
all  conditions.  They  are  Amanita  muscaria, 
the  fly-fungus,  which  grows  not  very  plenti- 
fully in  this  country  ; Russula  Integra  seu 
enietica  ( Agaricus  integer  seu  emeticus ),  also  not 
very  common ; Boletus  luridvs  (B.  perniciosus , 
B.  hovinus ) ; and  Amanitaphalloid.es  (A.  balbusos, 
A.  venenosa,  A.  viridis),  to  which  belong  the 
varieties  termed  Agaricus  citrinus  and  Agaricus 
viresccns.  Other  fungi  are  poisonous  only  under 
special  conditions,  among  which  may  be  named 


1014  MUSHROOMS,  POISONING  BY. 
idiosyncrasy,  and  the  susceptibility  of  young 
children  to  the  toxic  effects  of  mushrooms.  The 
delicious  edible  morel  even  has  been  known  to 
produce  fatal  results.  It  must  not  be  forgotten 
that  gastro-intestinal  catarrh  of  a severe  charac- 
ter may  result  from  the  ingestion  of  a large 
quantity  of  iil-cookod  indigestible  fungus-tissue ; 
that  the  highly  nitrogenous  tissue  of  fungi  is 
peculiarly  prone  to  rapid  decomposition ; and 
that  fungi  as  a class  absorb  excretory  animal 
matters,  perhaps  unchanged.  These  circum- 
stances may  serve  to  explain  some  of  the  ap- 
parent anomalies  connected  with  mushroom-poi- 
soning. Some  kinds  of  poisonotis  mushrooms 
have  their  active  principle  either  dissipated  or 
destroyed  by  the  prolonged  heat  employed  in 
thorough  cooking. 

Anatomical  Characters. — Evidence  of  gas- 
tro-intestinal catarrh,  more  prominent  in  the 
stomach  than  in  the  intestines  ; signs  of  cardiac 
paralysis,  or  of  asphyxia ; occasionally  fatty 
degeneration  of  the  liver  and  other  viscera ; 
and  minute  sub-serous  extravasations  of  blood, 
have  all  been  noted  after  death  from  mushroom - 
poisoning. 

Symptoms. — The  symptoms  of  mushroom  poi- 
soning are  of  a twofold  character  : gastro-intes- 
tinal irritation,  and  a so-called  narcosis.  After 
partaking  of  a meal  of  poisonous  mushrooms, 
colic  sets  in,  followed  by  nausea  and  ropeated 
vomiting,  and  diarrhoea  eventually  supervenes. 
The  onset  of  symptoms  does  not  as  a rule  mani- 
fest itself  till  after  the  lapse  of  some  hours, 
six  or  eight  or  more,  after  partaking  of  the 
fungi.  But  this  period  is  liable  to  great  va- 
riation, and  may  be  much  shorter.  Fragments 
of  the  fungi  may  be  recognised  in  the  faeces ; and, 
indeed,  were  it  not  for  this,  and  the  history 
of  the  case,  a diagnosis  from  violent  ordinary 
gastro-intestinal  catarrh  would  often  be  im- 
possible. In  severe  and  fatal  cases  the  stools 
of  the  patient  may  become  rice-watery  in  cha- 
racter ; the  patient  becomes  algid,  collapsod,  and 
cyanosed,  with  muscular  contractions  ; and  in 
children  convulsions  are  not  rarely  met  with. 
The  sufferer  eventually  becomes  somnolent  and 
falls  into  a state  of  sopor ; but  this  is  perhaps 
not  due  to  a true  narcosis,  but  to  the  drain  of 
fluid  from  the  system,  and  carbonic  acid  poison- 
ing- . , , 

When  the  amanita  muscana  has  been  taken, 
cerebral  symptoms  are  more  prominent.  The 
patient  appears  to  be  in  a state  of  inebriation ; 
and  there  frequently  appears  to  be  a tendency 
to  dash  the  head  against  a wall  or  other  solid 
object.  These  symptoms,  are,  however,  not  ex- 
clusively met  with  in  muscarine  poisoning,  but 
may  be  observed  when  other  fungi  have  been 
eaten. 

Diagnosis. — The  history  of  the  case,  and  the 
detection  of  particles  of  the  fungi  in  the  feces, 
are  usually  sufficient;  but  in  the  absence  cf 
these  a diagnosis  from  natural  disease  is  per- 
haps impossible.  It  has  been  proposed  to  tost 
for  the  presence  of  muscarine,  the  active  alkaloid 
of  the  fly-fungus,  by  applying  a drop  of  the  con- 
centrated or  unconcentrated  urine  to  the  heart 
of  a frog.  Muscarine  causes  the  heart  of  the 
animal  to  stop  in  the  state  of  diastole. 

Prognosis. — The  patient  cannot  be  considered 


MYOCARDITIS. 

safe  for  at  least  three  days,  unless  the  mor 
prominent  symptoms  have  been  markedly  alle 
viated.  Death  may  occur  at  any  period  betwee 
six  and  seventy-two  hours.  Recovery  is  frei 
quent. 

Treatment.  — In  poisoning  by  mushroom 
emetics  should  be  promptly  administered,  to  eva 
cuate  the  stomach,  and  those  which  are  not  of 
depressing  nature  should  be  selected.  The  sto 
mach-pump  is  perhaps  of  little  service,  seein 
how  persistently  the  particles  of  fungi  adhere  t 
the  walls  of  the  gastro-intestinal  canal.  Oleagi 
nous  purgatives,  as,  for  example,  a spoonful  c 
castor  oil  in  olive  oil,  may  be  advantageous! 
administered.  Fortunately  the  action  of 
carine,  which  Schmiedeberg  and  Poppe  hav 
isolated  as  the  active  alkaloid  of  amanita  mut 
carina,  and  which,  is  probably  identical  wit! 
bulbosine,  stated  by  Letellier  and  Speneux  t 
be  the  active  principle  of  amanita  phalloides,  i 
pretty  well  known.  Amanitine,  an  alkaloid,  i 
said  to  be  an  active  principle  in  certain  fung 
and  is  perhaps  closely  allied  to  muscarine 
Atropine  appears  to  be  a direct  antidote  t 
muscarine;  and  digitalis  appears  to  be  so  in 
lesser  degree.  Atropine  should  therefore  b: 
given  in  small  doses  in  cases  of  poisoning  1 
amanita  muscarina ; and  failing  this  some  prepa 
ration  of  digitalis.  Should  atropine  be  admini; 
tered  it  would  be  well  to  avoid  the  use  of  opium 
but  if  atropine  be  not  administered  the  exhau; 
tive  diarrhoea  may  have  to  be  combated  by  tk 
use  of  opiates  combired  with  astringents. 

Thomas  Stevenson. 

MYALGIA  (/uOr,  a muscle,  and  aXyos,  pain 
A name  for  pain  in  a muscle.  See  Muscle 
Diseases  of ; and  Rheumatism,  Muscular. 

MYCETOMA  (jui {injj,  a mushroom). — 
synonym  for  fungus-foot  of  India.  See  Fungu 
Disease  of  India. 

MYCO DERMA  (ju jki\s,  a mushroom,  ar 
Sipfia,  the  skin). — Vegetable  organisms  ass- 
eiated  with  certain  diseases  of  the  skin.  5 
Epiphytic  Skin-diseases  ; and  Tinea. 

MYDRIASIS  (ua5p'td<ris). — This  word  w. 
used  by  Galen  and  other  writers  to  signify  an  n: 
due  enlargement-  of  the  pupil ; but  by  Aretsei 
(tt epl  yporiaw  ttclBuv.  I.  7)  to  mean  a shrinking 
contraction  of  the  pupil.  Aretreus  employs  tl 
word  er\aTVKopia  (ibid.)  to  express  dilatation 
the  pupil.  The  word  is  now  invariably  used 
mean  a preternatural  dilatation,  and  sluggiskne 
or  immobility  of  the  pupil.  It  is  the  opposite 
mvosis.  Sec  Pupil,  Disorders  of. 


MYELITIS  (uueAbs,  marrow). — Inflamm 
tion  of  the  spinal  cord.  A term  that  has  bej 
much  abused,  and  which  is  still  wrongly  appli 
to  many  mere  degenerative  softenings  of  tl 
organ.  See  Spinal  Cord,  Diseases  of. 


\ ( uve\bs , the  marrow).— 
MYELOMA  / v 

form  of  sarcoma,  characterised  by  the  presen 
of  giant  or  myeloid  cells.  See  T ruouRS. 

MYOCARDITIS  (,iu"s,  a muscle,  and napS 
the  heart). — Inflammation  of  the  walls  of  t 
heart.  See  Heart,  Inflammation  of. 


MYOPIA. 

MYOPIA  (m vanli ; from  piai,  I closo  or  blink, 
.n(l  sty,  the  eye). — Thatformof  ametropia,  orerror 
nf  refraction,  in  which, owing  toahigh  refractive 
■index  of  the  dioptric  media,  or  excessive  con- 
vexity of  the  refracting  surfaces,  or  abnormal 
elongation  of  the  antero-posterior  axis  of  the  eye- 
ball, parallel  rays  of  light  converge  to  a focus  in 
front  of  the  retina,  and  form,  therefore,  circles  of 
diffusion  upon  the  retina.  It  is  the  opposite 
;of  hypermetrnpia  (see  Hypermetropia),  and  is 
iiometimes  called  brachymetropia  (fipaxus,  short ; 
lirpov,  a measure;  and  ity,  the  eye),  or  hypome- 
| ropia  (viraperpos,  below  the  measure).  See 
Vision,  Disorders  of. 

MYOSIS  (mow,  I shut).— A pretornatural 
contraction  and  sluggishness  or  immobility  of 
ihe  pupil.  The  opposite  of  mydriasis.  See 
Pupil,  Disorders  of. 

MYOSITIS  (pvs,  a muscle). — Inflammation 
>f  a muscle.  See  Muscles,  Diseases  of. 

MYXCEDEMA  {pvt,a,  mucus,  and  otSuipa, 
, swelling). 

Definition.— A name  given  by  the  writer 
f this  article  to  a progressive  disease,  in  which 
(he  tissues  of  the  body  are  invaded  by  a jelly- 
ike  mucus-yielding  dropsy,  unaccompanied  by 
dbuminuria  or  other  signs  of  primary  affection 
f the  kidneys. 

^Etiology.  — Beyond  the  almost  invariable 
ssociation  of  this  disease  with  the  period  of 
dult  life  in  women,  no  indications  of  its  mode 
If  causation  have  been  recognised.  In  the  fif- 
teen or  sixteen  cases  so  far  fully  recorded,  alco- 
olism,  syphilis,  and  fevers,  are,  as  causes,  e Al- 
luded by  the  history.  More  married  than  single 
'omen  are  affected.  Pregnancy  has  in  one  or 
svo  cases  been  followod  by  the  first  appearance 
f the  change. 

Anatomical  Characters. — Hitherto  only  two 
odies  of  persons  dying  from  this  disease  have 
sen  examined.  The  results  were  identical  in 
lese  two.  A remarkable  overgrowth,  associated 
ith  a sort  of  retrograde  degeneration,  of  eon- 
Bctive  tissue  was  found  in  all  parts  of  the 
)dy.  The  fibrillar  element  of  ordinary  connec- 
ve  tissue  was  everywhere  increased,  and  its 
ements  unnaturally  defined  ; the  corpuscular 
ements  were  enlarged  and  multiplied;  the 
terstitial  cement  enormously  augmented.  In 
irmal  tissue  this  latter  element  yields  some 
'ucin.  The  skin  in  myxeedema  yields  many 
mdreds  of  times  as  much  mucin  as  ordinary  or 
asarcous  skin. 

To  such  amplification  and  mucous  infiltration 
e skin  owes  its  swelling,  its  translucency,  and 
) defect  of  secretion.  The  same  sort  of  inter- 
nal expansion  is  found  in  the  mucous  mem- 
janes,  in  glands  of  all  kinds,  in  muscles,  and  in 
e central  ganglia  of  the  nervous  system,  sub- 
ctingthe  proper  structural  elements  of  each  tis- 
e to  destructive  pressure.  It  is  most  developed 
all,  perhaps,  in  the  outer  coat  of  arteries.  The 
uinution  of  the  thyroid  is  associated  with  an 
nost  complete  annihilation  of  the  proper  gland- 
ucture  by  this  stuff ; and  the  late  occurrence 
albuminuria  marks  the  advanced  progress  of 
inroads  on  the  Malpighian  bodies  and  tubules, 
hether  the  mental  failure  of  the  last  stage  be 
0 to  the  operation  of  similar  changes  in  the 


MYXCEDEMA.  1015 

brain,  is  not  a matter  upon  which  a decision  is 
at  present  possible.  There  appears  to  be  a 
general  increase  of  neuroglia,  and  a very  con- 
siderable development  of  the  connective  tissue 
around  all  the  vessels.  On  the  other  hand,  the 
appearances  seen  in  sections  of  the  central  gan- 
glia are  not  those  of  disseminated  sclerosis. 

Symptoms. — Tho  subjects  of  myxeedema  are, 
some  doubtful  cases  excepted,  always  adult  fe- 
males, who  present  a very  characteristic  physio- 
gnomy. The  face  is  swollen  in  every  feature,  so 
as  to  suggest  the  existence  of  renal  disease.  But 
while  the  negative  results  of  a complete  exami- 
nation dispel  this  idea,  the  distribution  and 
quality  of  the  swelling  are  different  from  what  is 
observed  in  common  dropsy.  The  swollen  skin  i« 
singularly  waxy-loolcing  and  anaemic ; and  the 
swelling  affects  dependent  and  non-dependent 
features  equally.  Thus  the  upper  and  lower  eye- 
lids, and  the  upper  and  lower  lips  are  uniformly 
enlarged ; the  aim  nasi  are  thickened  and  broad- 
ened ; the  ridges  of  expression  are  blurred  and 
coarsened,  or  the  lines  obliterated.  The  oedema 
is  resilient;  does  not  pit  on  pressure  ; and  shows, 
as  the  foregoing  statement  indicates,  no  ten- 
dency to  shift  by  gravitation.  Tho  cheeks  are 
overspread  with  a dull  pink  flush,  abruptly 
limited  towards  tho  orbits,  and  standing  in  vivid 
contrast  with  the  anaemic  skin  around. 

The  conditions  observed  in  tho  face  prevail 
throughout  the  body.  The  skin  is  everywhere 
thickened,  translucent,  dry,  and  rough  to  the 
touch  ; perspiration  being  infrequent  or  absent. 
The  hands,  in  particular,  lose  all  shapeliness  and 
expression,  and  have  received  from  tSir  William 
Gull  the  appropriate  epithet,  ‘spade-like.’  All 
visible  and  tangible  mucous  membrane  is  simi- 
larly amplified.  Late  in  the  disease  ordinary 
anasarca  is  often  added  to  the  mucoid  oedema. 

Two  other  noteworthy  phenomena  are  met  with 
in  tho  external  examination  of  the  body  ; first,  a 
diminution,  sometimes  almost  a disappearance, 
of  the  thyroid  body ; and  secondly,  a correlated 
tumefaction,  with  marked  resilience  of  the  skin,  in 
the  lower  triangle  of  the  neck,  above  the  clavicle. 

An  affection  of  the  nervous  system  as  well 
marked  as  that  of  the  skin,  belongs  to  myx- 
eedema. In  the  earlier  stages  an  ever-increasing 
hebetude  involves  sensation,  voluntary  move- 
ment, and  intellect;  in  the  later,  aberration  of 
mind  often  supervenes.  The  face  wears  a fixed, 
heavy,  and  withal  most  sad  expression ; the 
speech  is  slow  and  laboured,  though  not  slurred 
or  slovenly ; the  voice  monotonous,  like  that  of 
an  automaton,  and  leathery  in  tone.  Sensation 
is  slow,  but  finally  sure.  The  movements  of 
the  limbs  are  slow  and  languid ; the  mainte- 
nance of  fixed  attitudes  requires  much  effort ; 
and  sudden  falls  are  not  infrequent.  It  ap- 
pears as  if  the  muscles  were  toneless  and  ex- 
cessively relaxed  during  rest,  so  that  a con- 
siderable initial  contraction  is  necessary  before 
they  bear  on  their  attachments  ; and  as  if  the 
muscular  sense  were  also  torpid.  The  result  is 
that  while  there  is  neither  jerking  nor  tremor  of 
the  legs  in  walking,  the  balance  of  the  body  is 
painfully  maintained,  as  the  weight  is  thrown  on 
each  leg  in  succession  ; and  a quiver  often  runs 
through  the  body  at  the  moment  of  raising  one 
foot  from  the  ground  and  balancing  tho  body  on 


1016  MYXtEDEMA. 

the  other.  This  tardiness  of  coordination  is 
altogether  different  from  the  vague  staggerings 
and  jerks  of  locomotor  ataxy,  and  from  the 
rhythmical  tremors  of  disseminated  sclerosis. 
And  it  must  be  remembered  that  there  is  no 
real  loss  of  muscular  power,  no  ■wasting  of  mus- 
cles, and  no  loss  of  sensation.  Laxity  of  muscles 
at  rest  gives  rise  to  drooping  of  the  head  on 
the  chest  in  some  cases  ; in  others  it  has  led  to 
fracture  of  the  patella,  by  allowing,  first,  a yield- 
ing of  the  extensors  of  the  leg,  and  then  a 
sudden  arrest  of  the  consequent  fall. 

In  the  operations  of  the  intellect,  thought  and 
volition  are  again  slow.  All  the  patients  ob- 
served have  complained  of  being  unable  to  per- 
form any  of  the  daily  actions  of  life  with  their 
natural  expedition.  Yet  all  that  they  actually 
do  is  well  done,  and  they  are  acutely  conscious 
of  their  shortcoming  in  activity.  In  conversa- 
tion ideas  come  deliberately,  and  are  tardily 
expressed.  To  write  a letter  occupies  an  hour 
where  it  would  before  have  taken  ten  minutes. 
Yet  the  language  is  correct,  and  the  caligrapby 
unchanged.  There  is,  in  fact,  an  unwieldy  state 
of  mind  as  of  body.  The  difficulty  of  collecting 
thoughts  gives  an  early  impression  of  loss  of 
memory.  This,  in  fact,  occurs  late  in  the  dis- 
ease, when  other  aberrations  are  developed. 

Two  affections  of  the  special  senses  apparently 
related  with  changes  of  the  periphery  are  often 
noticed— one  a persistent  unpleasant  taste,  some- 
times of  bitterness,  sometimes  of  sweetness,  &e. ; 
the  other  a persistent  unpleasant  smell.  Other- 
wise the  special  senses  show  no  defect  save  tar- 
diness. The  hair  is  often  scanty,  and  the  teeth 
decay  early — conditions  no  doubt  related  with 
the  changes  in  the  skin  and  mucous  membrane. 

The  heat  of  the  body  is  almost  always  lower 


NAILS,  DISEASES  OF. 

than  normal,  ranging  between  98’  and  94°  Fahr. 
or  even  less,  ilost  patients  complain  of  con- 
stant chilliness,  without  appearing  to  estimate 
at  all  readily  changes  of  external  temperature 
The  viscera  give  no  signs  of  organic  affection  in 
the  beginning  of  the  disease.  The  urine  is 
usually  increased  in  quantity;  lowered  in  spe. 
eific  gravity ; and  contains  no  albumin,  sugar,  oi 
casts.  The  uterine  functions  go  on  as  in  health 
As  the  affection  advances  various  indications 
of  damage  to  viscera  are  declared,  and  the  urine 
is  generally  albuminous  in  the  last  stage.  Then 
also,  together  with  all  the  indications  of  great 
general  debility,  the  mind  often  becomes  un- 
hinged. Lethargic  good  temper  is  exchanged 
for  moroseness,  fretfulness,  irritability;  delusions 
or  hallucinations  often  follow;  and  there  is  a 
speedy  lapse  into  coma.  Death  comes  either  bv 
coma,  or  with  the  signs  of  ura-mic  poisoning,  or 
by  inanition. 

Prognosis. — The  progress  of  the  disease  is  not 
readily  affected  by  any  remedy.  The  prognosis 
is  altogether  unfavourable ; the  duration  of  ob-i 
served  cases  has  been  from  six  years  upwards 

Treatment. — Something  may  be  done  by  keep- 
ing the  patient  carefully  sheltered  from  the  cold; 
something  by  tonics ; something  by  good  food 
Though  these  will  not  cure  they  will  at  least  help 
the  patient  to  bear  her  sufferings  better.  Of  lat 
the  writer  has  found  in  two  cases  benefit  from  th 
use  of  vapour  baths.  In  three  others  unde! 
the  prolonged  use  of  jaborandi  the  signs  of  myx 
cedema  have  almost  disappeared.  Ten  to  six:- 
minims  of  the  fluid  extract  may  be  given  fou 
times  daily.  Nitro-glycerinehas  benefited  one  case 
Dr.  Andrew  Clark  regards  the  disease  as  fairi- 
curable  by  careful  diet,  iron,  arsenic,  baths,  and 
assiduous  frictions.1  Wileiasi  M.  Onn. 


N 


N-ffiVUS.  See  Tumours. 

NAILS,  Diseases  of. — Synon.:  Fr.  Maladies 
des  Ongles ; Ger.  Krankheiten  der  Nagel. 

Onyehopathic  or  ungual  affections  admit  of  a 
division  into — (A.)  Diseases  of  the  nail  proper ; 
and  (B.)  Diseases  of  the  soft  parts  in  immediate 
relation  with  the  nail. 

Under  the  former  head  may  be  considered 
alterations  of  colour,  texture,  figure,  and  develop- 
ment ; and  under  the  latter,  affections  of  the 
walls  of  the  nails  and  inflammation. 

./Etiology. — The  nails,  in  consequence  of  their 
position,  are  more  than  usually  liable  to  injury 
from  undue  pressure,  from  blows,  and  from 
foreign  bodies  forced  beneath  them,  such  as 
splinters  of  wood,  pins,  and  nails.  The  great 
vascularity  and  sensitiveness  of  the  tip  of  the 
fingers  and  toes,  and  the  close  adhesion  of 
the  bed  of  the  nail  to  the  deeper  structures,  are 
at  the  same  time  predisposing  causes,  and  causes 
of  greater  intensity  of  result.  Syphilis,  struma, 
eczema,  psoriasis,  and  gout  are  also  causes  of 
onychia  and  paronychia. 

A.  Diseases  of  the  Nail  Proper. — 1.  Colour. 
In  colour,  the  nails,  which  are  naturally  clear 
and  translucent,  may  be  brownish  or  greyish. 


and  dirty  in  appearance  ; or  they  may  be  opaqr 
in  round  and  circumscribed  white  spots,  or  i 
patches  of  greater  extent.  The  small,  whit 
opaque  spots  are  termed  fores  unguium  or  mn 
dacia,  hut  when  of  greater  extent  and  producin 
a more  general  whiteness,  seiene  unguium.  Tb 
transparency  of  the  nails  admits  of  stains  in  tl 
derma  being  visible  through  them,  and  these  ai 
not  to  he  confounded  with  discolouration  of  ti 
nail  itself.  Stains  of  this  kind  result  from  tl 
development  of  psoriasis  or  of  syphilis  beneat 
the  nail,  as  also  the  diffusion  of  pus  and  bloo< 
the  latter  constituting  ccchyrnoma  unguium. 

1 Since  the  above  was  written,  many  cases  of  tb 
disease  have  been  described  by  observers  in  England  m 
France,  but  the  condition  appears  to  be  rare  in  German 
These  additions  to  our  knowledge  make  it  evident  tb 
more  men  are  affected  than  the  earlier  observations  i 
dicated.  Several  cases  of  a typical  kind  in  which  mal 
were  the  subjects  have  been  fully  described ; and  I 
Andrew  Clark  has  stated  that  in  his  experience  mal 
have  been  the  more  frequent  sufferers,  namely,  in  abo 
the  proportion  of  seven  to  three  females.  Recent  obst 
rations  again  bring  out  more  strongly  the  fact  that  t 
central  organs  of  the  nervous  system  are  affected, 
many  cases  to  a large  extent,  by  the  destructive  incros 
of  the  connective  tissue  element.  Marked  bulbar  paraly 
has  been  observed  in  two  cases.  Dr.  Mahomed  has  argu 
strongly  in  favour  of  the  identity  of  myxoedema  wt 
Bright’s  disease. 


NAILS,  DISEASES  OF. 


2.  Texture. — In  texture  the  nail-substance 
nay  be  hard  or  soft,  thick  or  thin,  brittle  or 
flexible,  uneven  and  rough,  or  fibrous.  Thick 
pail  may  be  the  simple  consequence  of  more 
ictive  production  of  nail-substance,  and  in  this 
■espect  may  be  contrasted  with  the  thin  nail ; or 
t may  result  from  interference  of  growth  in 
ength,  which  enforces  the  apposition  of  lamina 
ifter  lamina  to  its  under  surface,  until  a thick 
horizontal  mass  is  formed,  or,  if  it  be  lifted  from 
•ts  bed,  those  elongated,  horny,  and  twisted 
ylinders  which  resemble  horns  rather  than  . 
'ails.  A third  kind  of  thickening  of  the  nail  re- 
mits from  the  formation  in  excessive  quantity 
fa  coarse,  lamellated  cell-substance  on  the  bed 
f the  nail,  which  lifts  the  horny  plate  into 
a oblique  and  almost  perpendicular  position, 
nd  gives  it  the  appearance  of  a claw.  This 
tate  of  the  nail  is  termed  gryphosis  or  onyclio- 
ryphosis,  and  is  often  the  first  stage  of  the 
orn-like  nail. 

Hardness  of  texture  of  the  nail  may  retain  its 
uality  of  toughness,  but  is  more  frequently 
ssociatcd  with  brittleness  to  a greater  or  less 
stent.  In  the  latter  state  there  may  be  several 
mgitudinal  cracks  or  fissures  in  the  nail,  sink- 
ag  as  deeply  as  the  vascular  corium,  and  the 
mgitudinal  fragments  may  themselves  be  trans- 
ersely  fissured  and  broken. 

I Softness  of  the  nail  is  accompanied  with  flexi- 
lity ; and  the  degree  of  the  latter  quality  will 
3 governed  by  the  degree  of  density  of  the 
irny  plate.  In  some  instances  the  covering  oi 
'6  matrix  and  bed  of  the  nail  more  nearly 
sembles  epidermis  than  horn,  and  may  be  taken 
i represent  an  absence  of  the  nail,  or  alopecia 
igualis.  Usually  smooth  and  polished  on  its 
trface,  the  nail  may  be  rough , sometimes  appa- 
intly  fibrous,  sometimes  crossed  by  shallow 
•ooves  or  deep  fissures,  and  sometimes  fretted 

■ eroded  as  if  it  were  worm-eaten.  These 
irious  appearances  have  suggested  the  terms 
sura  and  tinea  unguium,  as  likewise,  scabrities, 
fadatio,  and  degeneratio. 

3.  Growth. — The  condition  of  the  nails  has  re- 
tion  to  the  state  of  the  system  generally,  as  it 
well  known  that  they  undergo  an  impairment 
growth  during  illnesses  which  affect  the  nutri- 
ye  function  of  the  organism.  In  the  case  of 
enail  this  is  exhibited  by  a deficient  formation 
horny  matter,  which  results  in  the  production 
a groove  across  the  nail ; and  it  has  been 
own  by  Dr.  Wilks  and  Dr.  Beau,  that  if  the 
to  of  growth  of  the  nails  be  ascertained,  the 
riod  and  duration  of  the  illness  may  be  deter- 
ned  by  the  position  and  breadth  of  the  groove. 

4.  Figure. — Aberrations  of  figure  of  the  nails 
5 exemplified  in  the  broad,  thin,  curved  nail 
dch  is  met  with  on  the  club-shaped  fingers  of 
'uina,  and  which  has  received  the  name  of 
guis  aduncus;  in  the  longitudinally  contracted 
I prominent  nail  termed  keel-shaped,  arctura 

■ guis  or  gryphosis ; and  in  the  depressed,  or 
h-shaped  nail,  which  looks  as  if  it  were  tied 
tvn  in  the  centre  and  forced  upwards  at  the 
cumference. 

5.  Development.  — Errors  of  development  of 
P na'h  giving  rise  to  supernumerary  nails, 

almost  entirely  restricted  to  tho  bifid  or 
ible  nail,  which  is  associated  with  a broaden- 


1017 

ing  and  tendency  to  bifurcation  of  the  last 
phalanx. 

6.  Parasitic  Affections.  See  Tinea. 

B.  Disorders  of  the  Connected  Soft 
Parts. — Disorders  of  the  soft  parts  connected 
with  the  nail,  assume  the  forms  of  errors  of 
growth,  and  inflammation. 

1.  Errors  of  Growth. — The  epidermis  which 
borders  the  posterior  wail  of  the  nail,  and  is  nor- 
mally adherent  to  its  surface,  is  apt  to  be  drawn 
forward  with  the  growth  of  the  nail,  and  become 
stretched  over  its  surface  as  a thin  film,  which 
has  been  likened  to  a wing,  and  has  received  the 
name  of  pterygium  unguis.  At  other  times  this 
border  of  cuticle  splits  up  into  narrow  shreds, 
some  of  which  separate  from  the  nail  and  curve 
backwards.  In  their  abnormal  position  they 
are  liable  to  become  torn  ; and  when  the  tear,  as 
is  usually  the  case,  extends  to  the  corium,  there 
is  bleeding  and  pain,  and  sometimes  inflamma- 
tion. This  is  the  affection  which  is  known  by 
the  term  agnail,  derived  from  the  ancient  Saxon 
word,  ange,  signifying  ‘ angry.’ 

2.  Onychia. — Inflammation  of  the  end  of  the 
finger,  involving  the  soft  parts  surrounding  and 
beneath  the  nail,  is  termed  onychia ; but  when 
the  inflammation  is  limited  to  one  or  other  of  the 
walls  of  the  nails,  the  case  is  one  of  paronychia. 

Onychia  presents  the  ordinary  characters  of 
inflammation,  modified  by  extent  and  degree ; 
by  the  anatomical  construction  of  the  p>art ; and 
especially  by  the  constitution  of  the  patient. 
Hence  we  distinguish  a common,  a strumous,  and 
a syphilitic  onychia ; the  first  probably  issuing  in 
suppuration  with  loss  of  the  nail,  the  second  ir. 
prolonged  ulceration  withfungous  vegetation,  and 
the  third  in  deep  ulceration.  Common  onychia 
is  intensely  painful,  and  more  rapid  in  its  course 
than  the  specific  kinds.  Sometimes  the  inflam- 
mation is  so  severe  as  to  destroy  the  vitality  of 
the  bone.  The  strumous  and  syphilitic  forms 
of  onychia  are  sometimes  associated  with  much 
swelling  and  congestion  of  the  finger-end  ; and 
have  probably  been  described  as  onychia  maligna. 

3.  Paronychia. — Paronychia,  or  inflammation 
of  the  walls  of  the  nails,  sometimes  presents 
itself  in  an  acute  form,  as  in  the  painful  abscess 
termed  panaris  or  whitlow ; sometimes  as  a 
chronic  inflammation  of  one  of  the  lateral  walls 
of  the  nail  due  to  pressure  against  the  border 
of  the  nail,  termed  ingrowing  nail ; and  some- 
times as  a chronic  thickening  of  the  posterior 
wall,  which,  becoming  everted  and  prominent,  is 
termed  ficus  ungualis. 

Tbeatjient.— A prophylactic  of  the  slighter 
forms  of  disorder  of  the  nails,  is  the  bestowal  of 
some  care  and  attention  on  their  culture,  to  pre- 
vent them  from  growing  too  long;  to  prevent  the 
epidermis  growing  forward  on  the  back  of  the 
nail ; and  at  the  same  time  to  avoid  the  loosening 
of  this  fold  and  pressing  it  back  too  forcibly. 

Onychia  and  paronychia  must  be  managed 
according  to  the  general  principles  of  treatment 
of  inflammation.  If  tho  cause  be  obvious,  such 
as  the  presence  of  a foreign  body  or  an  ingrow- 
ing nail,  these  irritants  must  be  removed.  In 
acute  idiopathic  onychia,  position,  pressure,  and 
cold  applications  are  appropriate  to  its  primary 
stage ; and  water-dressing  or  poultice  if  the  pain 
should  be  severe.  Where  the  issue  is  by  abscess, 


1018  NAILS,  DISEASES  OF. 
as  in  ■whitlow,  the  first  appearance  of  the  pale 
disk  which  represents  pus  should  be  looked  for, 
and  a puncture  made  to  give  it  exit;  whilst 
chronic  inflammation  and  ulceration  are  to  be 
treated  with  stimulant  applications,  the  former 
with  linimentum  iodi,  the  latter  with  the  com- 
pound tincture  of  benzoin  and  unguentum  resin® ; 
possibly  with  lunar  caustic. 

Where  an  ingrowing  nail  keeps  up  a parony- 
chial  inflammation,  the  body  of  the  nail  should 
be  thinned  by  scraping  to  diminish  the  force  of 
pressure ; and  by  a little  manoeuvring,  a director 
may  be  introduced,  beneath  tho  border  of  the 
nail,  and  the  edge  cut  away  with  a pair  of 
scissors.  A minute  compress  of  cotton-wool 
should  then  be  passed  beneath  the  adjoining 
part  of  the  nail,  so  as  to  direct  the  ingrowing 
point  upwards  and  outwards.  As  a last  resource, 
avulsion  or  some  other  surgical  procedure  may 
be  found  necessary. 

Its  appropriate  treatment  is  removal  of  the 
diseasednail,and  dressing  with  powdered  nitrate 
of  lead  or*a  lotion  of  liquor  arsenicalis. 

Syphilitic,  strumous,  eczematous,  leprous,  and 
gouty  onychia  and  paronychia,  besides  the  or- 
dinary treatment  applicable  to  inflammation  in 
general,  will  call  for  specific  constitutional  and 
local  treatment,  for  example,  iodide  of  potas- 
sium and  blackwash  for  syphilis ; cod-liver  oil, 
iron  tonics,  and  nitrate  of  silver  for  struma; 
arsenic  for  eczema  and  psoriasis;  and  colchicum, 
inter  alia , for  gout.  Erasmus  Wilson. 

NAPLES,  in  South  Italy. — Changeable 
climate.  Mean  temperature,  winter,  48°  Fahr. 
Cold  winds  in  spring.  Sec  Climate,  Treatment 
of  Disease  by. 

NARCOSIS  1 , , T1  , ... 

NARCOTISM  / {mpK6“'  1 become  torPld)' 
A condition  of  profound  insensibility,  due  to  the 
introduction  of  certain  poisons,  or  excessive 
doses  of  certain  drugs,  into  the  sj'stem,  such  as 
opium  or  alcohol ; or  to  the  retention  there  of 
certain  oxeretory  elements,  as  in  uraemia.  Sec 
Consciousness,  Disorders  of ; and  Narcotics. 

NARCOTICS  (vapKow,  I become  torpid). — - 
Synon.  : Fr.  Harcotiqucs  ; Ger.  Narcotische  Mit- 
tcl. — Definition. — Remedies  which  promote  or 
artificially  imitate  the  natural  physiological  pro- 
cesses of  sleep  ; but  which  in  large  quantity 
produce  complete  insensibility. 

Enumeration.- — A convenient  division  of  nar- 
cotics, in  the  limited  sense  of  hypnotics,  may  be 
made  into  (1)  indirect  narcotics,  which  include 
many  soothing  aud  hygienic  conditions,  Ano- 
dynes, Conium,  &c. ; and  (2),  direct  narcotics,  of 
which  Opium,  Chloral-hydrate,  Croton-chloral, 
Bromide  of  Potassium,  Hyoscyamus,  Stramonium, 
Belladonna.  Hop,  Indian  hemp,  Alcohol,  Digitalis, 
and  the  Anaesthetic  vapours  are  in  most  general 
use. 

Action. — The  indirect  class  of  narcotics  have 
no  primary  influence  over  tho  cerebral  circula- 
tion, but  act  either  by  supplying  warmth,  quiet, 
and  other  tranquillising  elements,  or  by  removing 
some  disturbing  cause  which  renders  sleep  im- 
possible. We  know  how  powerfully  sleep  is 
under  tho  influence  of  habit  and  regularity;  how 
an  excess  of  heat  or  cold,  an  inconveniently  placed 


NARCOTICS. 

pillow,  or  apenetrating  beam  of  morning  lightmav 
often  produce  more  or  less  restlessness ; and  the 
insomnia  of  feebleness  or  exhaustion  may  readily 
yield  to  a little  nourishment,  or  to  a well  timed 
dose  of  alcohol.  Rain,  again,  is  in  some  indi- 
viduals responsible  for  many  a wakeful  hour;  and! 
the  evacuation  of  deep-seated  pus,  the  extraction 
of  an  aching  tooth,  or  a dose  of  quinine  mav 
sometimes  prove  as  effectual  an  anodyne  as  the 
subcutaneous  injection  of  morphia,  ora  modemtei 
dose  of  opium,  which  stands  as  the  type  of  lliisl 
therapeutical  group. 

Conium  may  prove  narcotic,  by  stilling  the  dis- 
orderly movements  of  chorea  or  of  acute  mania. 

Direct  narcotics,  on  the  other  hand,  either  pro- 
duce some  specific  effect  upon  the  cerebral  grey 
matter,  or  have  a very  decided  action  on  the 
blood-supply  of  the  brain,  and  by  constricting 
its  vessels,  produce  that  degree  of  anamia  whiel 
more  or  less  suspends  its  functions,  and  cause: 
sleep.  In  larger  doses,  however,  an  oppositi 
effect  results,  and  we  then  see  the  cerebral  con 
gestion,  the  livicl  face,  and  the  gradually  deepen 
ing  coma,  which  too  surely  indicate  the  fata 
termination  of  opium-poisoning. 

Uses. — Enough  has  been  already  said  regard 
ing  the  general  principles  on  which  we  emplo; 
indirect  narcotics;  and  the  tact  and  ingenuit- 
of  the  physician  will  often  be  severely  taxed  t 
discover  the  precise  cause  on  which  the  want  o: 
sleep  depends.  When  remedies,  however,  of  th 
more  domestic  class  have  been  exhausted,  v 
must  have  recourse  to  drugs,  and  a brief  resm 
may  now  be  given  of  the  advantages  and  disad 
vantages  of  those  remedial  agentswhose  soporifi 
qualities  have  been  firmly  established  by  experl 
ment  and  experience. 

Opium  and  morphia  naturally  stand  first,  an 
still  hold  their  place  as  our  most  potent  and  r< 
liable  narcotics,  all  the  more  valuable  becansi 
almost  alone  in  their  class,  they  are  also  endowe 
with  powerful  anodyne  action,  in  virtue  of  vliic 
they  may  reliere  pain  without  causing  sleei 
Valuable  as  it  is  in  all  forms  of  insomnia,  opiui 
is  especially  indicated  in  typhus  fever  and  oth< 
acute  disorders,  when  delirium  and  prolong! 
wakefulness  seem  to  endanger  life.  The  princip; 
drawback  to  opium  is  the  digestive  disturbam 
following  its  use,  and  the  fact  that  as  toleratic 
is  very  rapidly  established,  gradually  increasii 
doses  are  needed  to  cheek  the  counteracting  ii 
fluence  of  habit. 

Chloral  is  less  to  be  recommended  in  acu 
diseases,  on  account  of  its  tendency  to  caul 
cardiac  failure,  but  it  is  of  essential  service 
simple  insomnia,  in  chronic  affections  where  t. 
prolonged  use  of  narcotics  is  required,  and 
delirium  tremens.  In  prescribing  it  we  mn 
not  forget  its  weakening  action  on  the  heart,  ai 
on  the  respiratory  centre,  or  the  petechial  a I 
other  skin-eruptions  which  have  been  describ 
as  following  its  use. 

Bromide  of  potassium  is  peculiarly  well  fitt 
to  soothe  the  brain  when  rendered  irritable 
over- work,  but  we  must  remember  that  it  is  re 
uncertain  as  a narcotic,  and  is  apt  to  produce 
eruption,  and  an  uncomfortable  degree  of  mi 
cular  weakness.  See  Beomism. 

Digitalis  is  of  use  when  flaccid  vessels  pern 
a free  flow  of  blood  to  the  brain,  thus  effectua 


NARCOTICS. 

preventing  sleep  when  the  patient  occupies  the 
•ecumbent  posture,  the  tonic  influence  of  tiie 
Irug  bracing  up  the  arterial  tissues,  and  ena- 
bling a due  amount  of  cerebral  anaemia  to  be 
obtained. 

The  other  narcotics  may  be  tried  when  the 
juore  potent  remedies  of  the  class  fail  or  lose 
heir  power  ; and  under  certain  circumstances  a 
ombination  may  succeed  better  than  simplicity. 
Chus  chloral  and  bromide  of  potassium  are  more 
•aluable  in  acute  mania  when  given  together 
Ilian  alone ; and  opium  and  tartar-emetic  are  well 
.nown  to  form  one  of  our  most  effectual  means 
if  dealing  with  some  of  those  very  intractable 
forms  of  sleeplessness  which  occur  in  the  course 
If  typhus.  Robert  Farquharson. 

NATAL,  in  South  Africa. — Warm,  but 
healthy  climate,  with  hot,  wet  summers,  and  dry, 
lear  winters.  High  winds  from  S.E.  andN.W. 
Soil,  sandstone  and  granite.  See  Climate, 
treatment  of  Disease  by. 

NAUHEIM:,  in  Germany. — Gaseous  ther- 
tal  salt  waters.  See  Mineral  Waters. 

NAUSEA  (rais,  a ship,  in  relation  to  sea- 
sickness).— A feeling  of  sickness  or  inclination 
id  vomit,  generally  accompanied  by  a sense  of 
isgust  or  loathing,  and  sometimes  by  a feeling 
|f  great  depression.  See  Sea-sickness  ; and 

'OMITING. 

NAUSEANTS  (rails,  a ship). — Definition. 
gents  which  produco  the  condition  of  nausea. 
Enumeration. — The  principal  nauseants  are 
Varm  water,  Tartar-emetic,  Ipecacuanha,  To- 
acco,  Squill,  and  Apomorphia. 

Action.- — These  substances  produce  irritation 
f the  stomach,  loss  of  appetite,  general  malaise, 
afeebled  circulation,  muscular  weakness,  and 
■equently  also  salivation  and  sweating. 

Uses. — Nauseants  have  been  employed  to  di- 
linish  appetite,  in  the  hope  of  causing  absorption 
■f  fatty  accumulations,  or  of  pathological  depo- 
ts. They  are  also  used  in  producing  relaxation 
f involuntary  muscular  fibre,  and  thus  accele- 
iting  the  passage  of  calculi  through  the  bile- 
get  or  the  ureters.  They  were  formerly  used 
■ produce  relaxation  of  voluntary  muscles,  in 
tderto  facilitate  the  reduction  of  dislocations,  or 
> subdue  the  paroxysms  of  delirium  or  mania, 
.or  such  purposes,  however,  they  are  now  re- 
aced  by  anaesthetics  or  other  sedative  measures, 
hey  are  still  used  to  excite  sweating.  See  Dia- 
ioretics  ; and  Emetics. 

T.  Lauder  Brunton. 

NEAR-SIGHTEDNESS.  See  Myopia;  and 
ision,  Disorders  of. 

NECRO-BIOSIS  (rcKpus,  a dead  body,  and 
os,  life). — Molecular  death  of  a tissue  without 
,ss  of  continuity',  especially  seen  in  the  various 
nnsof  atrophy  and  degeneration.  See  Atrophy  ; 
id  Degeneration. 

NECROPSY  (FtKp&s,  a dead  body  ; and 
c oiscw,  I inspect). — Synon.  : Fr.  Nccropsie  ; 
er.  hcichcnschau. 

Definition. — The  inspection  of  the  body  after 
lath. 


NECROPSY  1019 

Method. — After  making  a complete  external 
inspection  of  the  body,  and  noticing  the  general 
appearance,  rigor  mortis,  change  of  colour, 
whether  partial  or  general,  oedema,  marks  of 
injury,  and  other  points,  a post-mortem  examina- 
tion should  begin  with  the  head,  or,  if  the  spinal 
cord  is  to  be  examined,  with  the  spine. 

Head. — To  open  the  head,  make  an  incision 
down  to  the  hone,  across  the  vertex  from  the 
base  of  one  mastoid  process  to  the  other,  and 
reflect  the  scalp  backwards  and  forwards ; then 
divide  the  bone  all  round  with  the  saw,  beginning 
in  front  a little  above  the  level  of  the  super- 
ciliary ridge.  The  posterior  half  of  this  section 
should  make  an  angle  with  the  anterior  half  by 
being  brought  over  the  occipital  bone,  a little 
behind  the  apex  of  the  lambdoidal  suture.  By 
this  means  the  skull-cap  will,  when  replaced, 
rest  firmly  in  its  position  without  slipping  back 
and  so  causing  disfigurement  of  the  forehead.  In 
cases  of  fracture  of  the  skull  the  section  should 
be  completed  with  the  saw,  care  being  taken  not 
to  wound  the  dura  mater.  Under  other  circum- 
stances the  inner  table  may  be  conveniently 
divided  with  a chisel  and  mallet.  The  skull-cap 
must  now  he  forcibly  dragged  off;  if  very  ad- 
herent to  the  dura  mater,  a long  flexible  spatula 
may  be  introduced  between  them,  and  separation 
effected. 

In  young  subjects,  before  the  sutures  and 
fontanelles  are  united,  it  is  better  to  remove 
the  dura  mater  and  skull-cap  together,  by  divid- 
ing the  former  with  blunt-pointed  scissors  in 
a line  with  the  section  through  the  bone,  and 
then  cutting  through  the  falx  at  its  anterior 
and  posterior  attachments. 

The  longitudinal  sinus  may  now  be  opened 
and  examined.  The  dura  mater  should  next  be 
divided  on  each  side  with  blunt-pointed  scissors, 
or  on  the  level  of  the  section  through  the  bone,  and 
the  two  lateral  flaps  turned  up ; the  falx  should 
next  be  divided  near  its  anterior  attachment, 
and  the  whole  membrane  drawn  backwards  off 
the  hemispheres.  The  brain  must  now  be  re- 
moved ; a long  narrow  scalpel  being  used  to  cut 
through  the  nerves  and  vessels,  whilst  the  ten- 
torium is  most  safely  divided  with  blunt-pointed 
scissors.  The  spinal  cord  should  be  cut  as  low 
as  possible.  Any  fluid  present  at  the  base  of  the 
skull  should  be  drawn  off  with  a syringe  and 
measured. 

Brain. — After  examining  the  pia  mater,  it 
should  be  entirely  stripped  off,  and  the  surface 
of  the  brain  examined.  It  should  then  he  placed 
on  its  base,  and,  if  very  soft,  supported  by  a 
towel  wrapped  round  it.  A horizontal  incision 
should  theu  be  carried  through  each  cerebral 
hemisphere,  on  a level  with  the  upper  surface 
of  the  corpus  callosum,  from  within  outwards, 
not  quite  reaching  the  surface,  so  as  to  leave 
the  hemispheres  still  attached  to  the  rest  of  the 
brain.  These  should  be  turned  back,  and  nu- 
merous vertical  incisions  made  in  the  upturned 
surface.  Each  lateral  ventricle  should  then  be 
opened  by  a vertical  incision  through  its  roof, 
and  any  fluid  contents  withdrawn  by  a syringe. 
The  fornix  should  now  be  divided  in  front,  and 
with  the  septum  and  corpus  callosum  turned 
backwards.  The  velum  interpositum  and  cho- 
roid plexus  being  reflected  in  a similar  manner, 


NECROPSY. 


1020 

numerous  longitudinal  incisions  should  then  he 
made  in  the  corpora  striata  and  thalami  optici, 
and  in  the  corpora  quadrigemina.  An  incision 
should  now  be  made  through  the  superior  ver- 
miform process  of  the  cerebellum,  so  as  to  lay 
open  the  fourth  ventricle.  The  cerebellum  may 
he  examined  by  making  parallel  incisions  on 
each  side  through  its  lobes,  not  quite  detaching 
the  sections.  The  brain  may  now  be  folded  to- 
gether again,  and  the  under  surface  turned  up 
and  examined.  Incisions  should  be  made  into 
the  under  surface  of  the  cerebral  lobes,  and  into 
the  crura  and  pons ; and  the  medulla  divided 
transversely  at  different  levels.  Softened  por- 
tions should  be  tested  with  a stream  of  water ; 
and  parts  reserved  for  microscopical  examination 
at  once  placed  in  a hardening  solution,  such  as 
chromic  acid  1 per  cent. 

A method  of  examining  the  cerebrum  prefer- 
able to  the  above,  when  it  is  desired  to  deter- 
mine accurately  the  exact  seat  of  lesions,  is  the 
one  recommended  by  Dr.  Pitres. 

The  cerebral  hemispheres  having  been  sepa- 
rated and  stripped  of  their  pia  mater,  are 
divided  into  three  portions  by  two  transverse 
vertical  incisions,  the  first  passing  about  two 
inches  in  front  of  the  fissure  of  Rolando,  the 
second  a little  less  than  half  an  inch  in  front  of 
th-e  internal  perpendicular  fissure,  the  occipito- 
parietal fissure  of  Huxley,  which  divides  the 
parietal  from  the  occipital  lobe  of  the  cerebrum. 
The  cerebrum  will  thus  be  divided  into  three 
portions,  an  anterior  or  prefrontal,  a middle 
or  fronto-parietal,  and  a posterior  or  occipital. 
The  first  and  last  portions  correspond  to  the  non- 
excitable  parts  of  the  cerebrum,  lesions  of  which 
do  not  cause  either  motor  or  sensory  disturbances. 
The  middle  region,  on  the  contrary,  comprises 
the  corpus  striatum  and  optic  thalamus,  and  the 
cortical  motor  zone. 

This  central  portion  may  be  best  examined  by 
making  four  vertical  sections  by  incisions  parallel 
to  the  fissure  of  Rolando.  The  first,  or  pedicnlo- 
frontal  section  is  made  by  an  incision  about 
three-quarters  of  an  inch  in  front  of  the  fissure 
of  Rolando,  dividing  the  second  and  third 
frontal  convolutions  close  to  their  insertion  into 
the  ascending  frontal  convolution.  This  section 
will  especially  comprise  the  third  frontal  convolu- 
tion. On  its  surface  are  seen  sections  of  the  three 
frontal  convolutions,  the  anterior  extremity  of 
the  island  of  Reil,  the  posterior  extremity  of 
the  orbitar  convolutions,  the  caudate  and  len- 
ticular nuclei  of  the  corpus  striatum  separated 
by  the  internal  capsule. 

The  second,  or  frontal  section,  is  made  by  an 
incision  at  the  level  of  the  ascending  frontal 
convolution.  Its  surface  displays  a section  of 
the  ascending  frontal  convolution  in  all  its  ex- 
tent, the  convolutions  of  the  sphenoidal  lobe, 
the  island  of  Reil,  the  external  capsule  and  the 
claustrum,  the  caudate  nucleus,  the  lenticular 
nucleus  at  its  thickest  part,  and  the  optic  tha- 
lamus. 

The  third,  or  parietal  section,  is  made  by  an 
incision  carried  through  the  ascending  parietal 
convolution.  It  much  resembles  the  former, 
but  the  lenticular  nucleus  and  the  claustrum  are 
divided  where  they  are  smaller. 

The  fourth,  or  pediculo-par'etal  section,  is 


made  by  an  incision  about  an  inch  behind  the 
fissure  of  Rolando  at  the  level  of  the  foot  of  the 
parietal  lobules,  and  passes  through  the  pos- 
terior extremity  of  the  optic  thalamus.  The 
lenticular  ganglion  is  no  longer  visible;  the! 
corona  radiata  is  divided  in  the  region  where 
lesions  produce  hemianesthesia. 

By  means  of  these  sections  the  exact  relatione 
of  lesions  of  the  cerebrum  can  be  made  out! 
with  much  greater  accuracy  than  by  the  ordi- 
nary methods  of  examination. 

Base  of  Skull,  Orbit,  and  Internal  Ear. — The 
base  of  the  skull  and  its  sinuses  may  now  be  ex- 
amined. In  cases  of  fracture,  the  dura  matei 
should  be  carefully  stripped  off,  so  as  to  expose 
the  surface  of  the  bone.  The  contents  of  the 
orbit  may  be  examined  by  removing  its  roof 
The  tympanum  can  be  opened  by  cutting  through 
with  a chisel  the  plate  of  bone  forming  its  roof 
This  is  situated  on  the  anterior  surface  of  the 
petrous  bone,  just  in  front  of  the  eminence  o; 
the  superior  semicircular  canal.  To  examine  the 
internal  ear  the  petrous  bone  must  be  removed 
This  is  best  done  by  two  converging  incision; 
made  with  a saw,  and  then  separating  its  apex 
from  the  sphenoid  and  occipital  bones  with  the 
chisel. 

Spinal  Cord, — To  examine  the  spinal  cord  the 
body  must  be  turned  on  its  face,  with  the  head 
hanging  over  the  table,  and  a block  placed  undei 
the  chest.  An  incision  must  be  made  over  the 
vertebral  spines  from  the  top  of  the  sacrum  tc 
the  occiput,  and  the  vertebral  arches  kid  bare. 
These  are  best  divided  with  the  rachitome,  a 
double  semi-circular  saw,  in  the  absence  of  whicl 
a short  common  savmay  be  used,  ora  chisel  and 
mallet.  The  cord  should  be  removed  in  its  tube 
of  dura  mater,  the  latter  being  held  by  the  for- 
ceps, and  care  taken  not  to  bend  the  cord 
abruptly.  The  dura  mater  should  then  be  sli; 
open  with  blunt-pointed  scissors  along  its  an- 
terior and  posterior  surfaces,  and  the  core 
examined,  with  as  little  handling  as  possible,  by 
means  of  transverse  sections  made  with  a sharp 
scalpel.  Eor  microscopical  examination  the 
cord  may  be  placed  in  spirit  for  about  twenty- 
four  hours ; and  then,  after  removal  of  its  mem- 
branes, cut  into  lengths,  and  transferred  to  c 
one  per  cent,  solution  of  chromic  acid. 

A method  of  opening  the  spinal  canal  from, 
the  front,  preferable  in  many  respects  to  thi 
above,  is  practised  at  Vienna  and  many  place; 
on  the  Continent.  The  instruments  used  are  < 
strong  knife-shaped  chisel,  with  a cutting  beak 
and  a mallet.  After  the  removal  of  the  thoracii 
and  abdominal  viscera,  the  beak  of  the  chisel ): 
introduced  into  the  lowest  intervertebral  fora- 
men, and,  by  successive  blows  of  the  mallet,  the 
pedicles  of  the  vertebrae  are  cut  through  on  eael 
side  and  the  canal  exposed  by  removing  thi 
bodies.  In  this  way  great  disfigurement  of  thi 
body  and  soiling  of  the  table  and  linen  an 
avoided,  and  the  spinal  ganglia  are  more  easil; 
examined. 

Thorax  and  Abdomen. — The  thorax  and  abdo 
men  should  now  be  examined.  It  is  better  . 
lay  the  abdominal  cavity  fully  open  before  re 
moving  the  sternum,  in  cutting  through  th 
first  rib,  and  disarticulating  the  clavicle,  car 
I should  be  taken  not  to  wound  the  innominate  vein 


NECROPSY. 


• using  cutting  pliers,  which  should  be  directed 
as  to  cut  obliquely  through  the  rib  into  the 
ticulation,  all  danger  is  avoided. 

If  much  ascites  is  present,  the  belly  should 
tapped  before  laying  open  the  peritoneal 
vity.  So,  if  either  pleura  be  full  of  fluid, 
rich  will  be  shown  by  its  pouring  out  when 
[e  cartilages  of  the  ribs  are  cut  through,  suffi- 
»nt  should  be  drawn  off  with  a syringe  to 
■event  any  overflow  when  the  sternum  is  re- 
ovcd. 

The  lungs  should  now  be  drawn  out  of  the 
:est,  adhesions  separated,  and  their  posterior 
irfaces  examined.  The  contents  of  the  medias- 
imn  should  next  be  inspected,  and  the  pericar- 
um  opened.  If  the  case  be  one  of  thoracic 
leurism,  mediastinal  tumour,  or  malformation 

I the  heart  or  great  vessels,  the  heart  and  lungs 
tould  be  removed  together.  Otherwise,  the 
hart  may  be  first  removed  and  examined. 

Heart. — The  auricles  should  be  laid  freely 
oen  with  a pair  of  scissors,  by  an  incision  join- 
’g  the  mouths  of  the  great  veins  and  carried  to 
le  extremity  of  the  auricular  appendage.  The 
impetency  of  the  valves  may  then  be  tested. 

II  clots  must  first  be  removed,  the  heart  held 
: an  upright  position,  and  water  poured  into 
le  aorta  and  pulmonary  artery  successively,  the 
imiiunar  valves  being  held  back  with  the  handle 
ia  scalpel  to  allow  the  ventricle  to  become  filled ; 
t looking  into  the  auricles  the  competency  of 
te  auriculo-ventricular  valves  may  be  estimated. 

0 test  the  semilunar  valves  an  opening  must  be 
ade  into  each  ventricle;  the  pulmonary  artery 
id  aorta  cut  sufficiently  short  to  enable  the 
lives  to  be  clearly  seen ; and  then  water  poured 
to  these  two  vessels  successively,  and  the  valves 
oked  at  from  above.  The  right  ventricle  may 
,yw  be  opened.  The  left  forefinger  should  be 
troduced  through  the  pulmonary  artery,  and 
ie  anterior  wall  of  the  ventricle  divided  with 
unt-pointed  scissors  into  the  artery,  the  point 
: the  scissors  beiDg  guided  by  the  left  fore- 
ager  to  the  junction  of  the  valves.  The  pulmo- 
iry  artery  and  aorta  should  then  be  separated 

1 much  as  possible,  and  the  left  ventricle  opened 
a similar  manner  along  its  anterior  wall,  the 

ft  forefinger  as  before  guiding  the  scissors  to 
le  point  of  junction  of  the  semilunar  valves, 
he  incision  must  be  carried  close  to  the  ventri- 
ilar  septum,  and  the  septum  between  the  aorta 
id  pulmonary  artery,  but  without  cutting  the 
tter.  The  most  accurate  way  of  measuring  the 
paeity  of  the  orifices  is  to  pass  through  them 
■aduated  balls  fixed  on  rods,  in  default  of 
liich  the  fingers  may  be  used. 

Lungs. — To  remove  the  lungs,  the  trachea 
ust  be  cut  across  at  the  root  of  the  neck,  and 
ell  drawn  forwards  by  inserting  the  middle 
iger  into  the  lower  end,  and  the  other  fingers 
i each  side  behind  the  bifurcation,  care  being 
ken  not  to  cut  the  oesophagus. 

Larynx  and  Pharynx. — To  remove  the  larynx 
id  pharynx,  the  incision  in  the  neck  must  be 
rriecl  up  to  the  chin ; the  floor  of  the  mouth 
:iened  from  below;  the  left  forefinger  intro- 
iced,  and  used  to  depress  the  tongue ; a long 
srrow  scalpel  introduced  above  the  finger,  and 
rried  along  each  side  of  the  ramus  of  the  jaw ; 
e tongue  then  drawn  down  under  the  chin ; and 


1021 

the  soft  palate  and  pharynx  divided  transversely. 
The  pharynx  and  larynx  should  then  be  opened 
along  their  posterior  walls. 

Intestines. — In  examining  the  abdomen  it  is 
most  convenient  to  begin  with  the  intestines. 
The  largo  intestines  should  be  divided  between 
two  ligatures  below  the  sigmoid  flexure,  and 
drawn  out,  cutting  the  mesentery  close  to  the 
bowel.  This  process  should  be  continued  till  the 
duodenum  is  reached,  when  it  may  be  again  tied 
and  cut.  The  intestine  should  be  opeued  along 
the  line  of  attachment  of  the  mesentery. 

Spleen. — The  spleen  may  next  be  examined. 
It  should  be  drawn  forwards  out  of  the  abdomen, 
and  the  gastro-splenic  omentum  cut  through. 

Stomach.—' The  stomach  should  next  be  re- 
moved. A double  ligature  should  be  placed 
round  the  duodenum  about  two  inches  below  the 
pylorus,  and  another  one  round  the  lower  end  of 
the  oesophagus,  and  these  tubes  cut  through,  so 
as  to  remove  the  stomach  without  the  escape  of 
its  contents.  If  required  for  chemical  analysis, 
the  contents  should  be  emptied  into  a glass 
vessel,  by  removing  the  oesophageal  ligature. 

The  usual  practice  is  to  lay  open  the  stomach 
along  its  lesser  curvature,  from  the  oesophagus 
to  the  duodenum  ; but  in  many  cases  it  is  better 
to  carry  the  incision  along  the  greater  curvature, 
for,  as  ulcers  and  cancers  are  more  frequently 
situated  near  the  lesser  curvature,  this  incision 
is  more  likely  to  avoid  cutting  through  them. 

Unless  required  for  chemical  analysis,  the 
mucous  membrane  may  be  washed  by  a gentle 
stream  of  water  and  then  examined. 

Pancreas. — After  the  removal  of  the  stomach 
the  pancreas  may  be  conveniently  examined. 
Before  separating  it  from  the  duodenum  the  con- 
dition of  its  duct  should  be  ascertained. 

Liver. — In  all  cases  of  jaundice  the  liver  and 
duodenum  should  be  removed  together,  so  as  to 
obtain  the  bile-duct  intact.  In  removing  the 
liver  care  should  be  taken  not  to  injure  the  right 
suprarenal  capsule,  which  is  in  close  contact  and 
often  adherent.  In  testing  the  perviousness  of 
the  bile-ducts  it  is  better  not  to  squeeze  the  gall- 
bladder, as  this  will  often  overcome  an  obstruc- 
tion, but  to  open  the  duct  with  scissors,  aud 
observe  the  colour  of  the  lining  membrane 
below  an  obstruction.  This  will  be  found  un- 
stained by  bile. 

Supra-renal  Capsules. — In  cases  of  Addison’s 
disease  the  supra-renal  capsules  should  be  re- 
moved, united  with  the  semilunar  ganglia  and 
solar  plexus. 

Genito-urinary  Organs. — In  all  cases  of  uri- 
nary obstruction  the  kidney,  ureters,  and  bladder 
should  be  removed  in  connexion.  The  pelvic 
organs  may  be  removed  en  masse  by  carrying  a 
large  knife  all  round  the  pelvic  walls,  and  draw- 
ing the  viscera  upwards  and  backwards.  As 
much  of  the  urethra  as  may  be  required  can  be 
pulled  back  under  the  pubic  arch.  The  urethra 
and  bladder  should  be  opened  with  scissors  along 
their  upper  wall. 

The  uterus  may  be  examined  by  introducing 
one  blade  of  a pair  of  probe-pointed  scissors 
through  the  os  ; making  an  incision  through  the 
anterior  or  posterior  wall  to  the  fundus ; ar.d 
carrying  this  on  each  side  to  the  entrance  of  the 
Fallopian  tubes. 


1022  NECROPSY. 

The  kidney  may  be  bisected  by  an  incision 
through  it  from  the  convex  border  to  the  hilus ; 
the  capsules  should  then  be  stripped  off,  their 
thickness  and  degree  of  adhesion  being  noticed, 
and  the  state  of  the  surface  of  the  kidney,  both 
external  and  on  section,  carefully  observed. 

W.  Cayley. 

NECROSIS  0 expbs,  a dead  body).— The  ab- 
solute death  of  a circumscribed  portion  of  any 
tissue,  but  the  phrase  is  usually  associated  with 
death  of  bone.  See  Bone,  Diseases  of. 

NEOPLASMS  (veos,  new,  and  irXdo aw,  I 
mould). — A term  for  new  growths.  See  Tumours. 

NEPHRALGIA  (netppbs,  the  kidney,  and 
&X-yos,  pain). — Definition. — An  affection  of  the 
nerves  of  the  kidney,  unattended  by  any  evident 
anatomical  lesion;  characterised  by  tli6  occur- 
rence of  pain  in  the  region  of  the  kidney,  some- 
times periodic,  often  accompanying  exhaustion, 
but  without  any  morbid  changes  in  the  urine. 

.ZEtiology. — Exhaustion,  exposure  to  cold, 
malarious  poison,  and  the  nervous,  rheumatic, 
or  gouty  constitutions,  are  to  be  ranked  amongst 
the  chief  causes  of  nephralgia.  It  is  probable 
that  the  pains  in  the  kidney,  due  to  the  presence 
of  calculi  in  its  pelvis,  are  at  times  of  a purely 
neuralgic  character. 

Symptoms. — Neuralgic  pain  in  the  region  of 
the  kidney  is  sometimes  paroxysmal  and  very 
intense,  at  other  times  more  continued  and  less 
severe.  It  is  frequently  periodic,  and  is  apt  to 
occur  when  the  patient  is  exhausted,  or  in  a state 
of  nervous  depression.  It  is  unattended  by  any 
change  in  the  quantity  or  appearance  of  the 
urine,  and  the  pain  does  not  tend  to  dart  down 
in  the  direction  of  the  ureter,  while  tender  spots 
may  generally  be  discovered  in  the  neighbourhood 
of  the  spinal  column. 

Diagnosis. — The  disease  with  which  nephral- 
gia is  most  apt  to  be  confounded  is  renal  cal- 
culus. The  points  upon  which  reliance  is  to  be 
placed  in  making  the  diagnosis  are  the  exact 
seat  of  the  pain,  and  the  direction  in  which  it 
spreads  ; the  presence  or  absence  of  tender  spots 
in  the  lumbar  region  ; and  the  condition  of  the 
urine.  In  renal  calculus  the  urine  is  commonly 
bloody,  and  contains  crystals  or  groups  of  crys- 
tals, or  minute  calculi,  while  in  nephralgia  it  is 
natural. 

Prognosis. — The  prognosis  of  nephralgia  is 
favourable. 

Treatment. — The  severity  of  the  pain  may 
be  such  as  to  demand  subcutaneous  injection  of 
morphia.  The  most  valuable  remedy  for  cure  is 
quinine,  which  may  be  given  in  doses  of  five, 
ten,  or  even  twenty  grains  two  or  three  times  in 
the  course  of  the  day.  Iron,  arsenic,  chloride  of 
ammonium,  acupuncture,  or  Corrigan’s  cautery 
may  be  employed  in  suitable  cases,  if  the  quinine 
faiL  T.  Grainger  Stewart. 

NEPHRITIC  COLIC  (ve<t>pbs,  the  kidney). 
A synonym  for  renal  colic,  an  affection  which  is 
usually  due  to  the  presence  or  passage  of  a 
renal  calculus.  See  Renal  Calculus. 

NEPHRITIS  (vvppbs,  the  kidney). —A 
general  term  for  inflammation  of  the  kidney. 
See  Bright’s  Disease  ; and  Kidney,  Diseases  of. 


NERVES,  DISEASES  OF. 

| NERVES,  Diseases  of.  — Synon.  : Fi 

Maladies  des  Nerfs ; Ger.  Nervenkranleheiten.- 
Nerves,  in  their  origin,  course,  and  distributior 
are  connected  with  the  several  organs  and  tissue 
of  the  body,  and  are  consequently  affected  i 
various  ways  when  such  parts  are  disordered  o 
diseased.  But,  besides  such  secondary  derange 
ments,  nerves  are  subject  to  many  morbid  cor 
ditions  which  affect  them  ■primarily.  In  th 
case  of  certain  classes  of  nerves,  connected  wit 
special  functions,  the  effects  produced  by  diseas 
are  at  once  so  distinct  and  so  important,  tba 
they  require  separate  consideration.  Such,  fo 
example,  are  the  glosso-pharyngeal,  liypoglossa 
olfactory,  optic,  phrenic,  pneumogastric,  spina! 
accessory,  sixth  and  third  cranial  nerves,  th 
morbid  conditions  of  which  will  be  found  full 
discussed  under  their  respective  headings.  Agair 
certain  forms  of  congestion  or  inflammatio:. 
(whether  oceurringin  the  subjects  of  gout,  rhea 
matism,  malaria,  plumbism,  syphilis,  orinothe] 
states),  when  they  affect  important  nerves,  cans 
symptoms  of  a character  so  marked,  either  i. 
their  progress  or  distribution  or  by  their  severity 
as  to  deserve  a special  designation,  and  t 
demand  separate  description  (see  Intercosta 
Neuralgia;  Neuritis;  Sciatica;  and  Tic 
Douloureux).  In  these  and  in  other  allied  in 
stances  the  prominent  symptoms  are  referabl 
to  functional  disturbances  of  the  nerves.  Ii 
another  class  of  cases  similar  phenomen. 
originate  in  interference  with  the  genera 
nutrition,  in  disease  of  the  nervous  centres,  o' 
by  reflex  action ; and  these  phenomena  will  b 
found  discussed  in  the  articles  upon  Coxvci 
sions,  Neuralgia,  &c. 

In  this  place  there  remain  for  special  eon 
sideration  the  following  subjects  : — (1)  the  effect 
of  injuries  of  nerves ; (2)  the  most  commo 
morbid  growths  involving  nerves,  which  ar 
generally  known  as  neuromata-,  and  (3)  th 
effect  of  cutting  or  stretching  nerves  regarded  a 
a means  of  treatment. 

1.  Nerves,  Injuries  of. — Nerves  may  bl 
divided  accidentally  either  by  tearing  or  cutting 
or  surgically  during  an  operation,  or  for  th 
relief  of  pain  or  resection  of  tumours.  Th 
nerves  most  frequently  divided  accidentally  ar 
those  of  the  upper  extremity,  especially  th 
ulnar  as  it  passes  behind  the  inner  humeral  coe 
dyle,  or  as  it  lies  upon  the  anterior  annuls 
ligament.  The  median  and  musculo-spiral  nerre 
are  also  not  unfrequently  divided  by  deep  cut; 
on  the  fleshy  front  of  the  upper  fore-arm  o 
wrist. 

Sometimes,  besides  being  wholly  or  partiall 
divided,  nerves  may  be  bruised,  or  have  im 
bedded  in  their  substance  particles  of  friatl 
foreign  bodies,  such  as  glass  or  slate.  Fracture 
of  the  humerus  at  the  upper  or  lower  third,  ai 
not  uncommonly  complicated  by  laceration  of  th 
musculo-spiral  nerve,  by  the  sharp  edge  of  one  ( 
the  fragments ; for  the  nerve  passes  spirally  ronn 
and  in  close  contact  with  the  bone,  first  on  th 
inner,  then  on  the  hinder,  and  near  the  elbow  i 
the  outer  aspect  of  the  bone. 

Symptoms. — The  symptoms  of  the  division  i 
a nerve  are  loss  of  power  in  the  muscles,  and  < 
sensation  in  the  skin  supplied  by  the  offsets  ( 
the  injured  nerve,  as,  for  example,  the  radial  ar 


NERVES,  DISEASES  OF.  1026 


usterior  inter-osseous  branches  of  the  musculo- 
piral.  The  complete  or  the  partial  division 
oay  be  diagnosed  by  the  more  or  less  complete 
jterruption  of  their  functions. 

Nerves  unite,  if  the  cut  ends  are  placed  in 
pposition,  as  readily  as  other  structures ; but  it 
i usually  some  time  before  the  sensory  or 
rotor  functions  are  restored,  and  then  only  by 
low  degrees,  the  former  usually  taking  place 
ooner.  The  recovery  is  sometimes  delayed  by 
isplacement  or  error  in  the  co-aptation  of  the 
ut  fibrils,  and  then  the  brain  seems  to  require 
ime  education  and  training  to  correct  misplaced 
jnpressions,  which,  however,  is  in  most  cases 
ceomplished  ultimately  more  or  less  perfectly. 
Vlien  an  important  nerve,  such  as  the  great 
eiatic,  is  divided,  the  part  of  the  limb  supplied 
y it  suffers  in  its  nutrition,  and  is  apt  to  bc- 
iome  wasted,  and  if  the  patient  be  growing,  to 
ig  behind  its  fellow  in  development.  Sometimes 
he  muscles  may  become  atrophied ; and  if  the 
Jivision  is  not  united  in  due  time,  the  fibres  be- 
omo  subject  to  fatty  degeneration,  and  may  not 
tterwards  regain  their  power.  Other  tissues  be- 
ides  the  muscles  may  likewise  become  atrophied. 
,’hus  wasting  or  atrophy  of  the  fingers  may  re- 
mit from  injury  of  the  ulnar  or  median  nerve, 
ilhis  has  been  thought  to  be  in  some  degree  due 
i!o  the  interruption  of  innervation  in  certain  fibres, 
rhich  are  bound  up  in  the  spinal  as  well  as  in  the 
ympathetic  nervous  systems,  and  which  preside 
ver  and  control  the  nutrition  of  the  tissues,  the 
o-called  trophic  nerves.  The  parts  supplied  by 
hem  seem  to  be  more  liable  to  the  formation  of 
jloughing  sores,  as  is  illustrated  by  the  bed- 
ores  which  are  apt  to  follow  division  of  or 
ressure  upon  the  spinal  cord,  or  cauda,  equina 
la  fractures  of  the  spine.  Severe  contusions  of 
erves  will  sometimes  so  interrupt  their  fuuc- 
ional  power  as  to  produce  the  results  of  complete 
ivision. 

Treatment. — In  the  treatment  of  nerves  aeci- 
entally  divided  all  foreign  bodies  are,  in  thefirst 
lace,  to  be  carefully  removed  by  sponge  or  for- 
eps,  with  as  little  further  injury  to  the  nerve- 
issue  as  possible;  and  the  wound,  if  practicable, 

1 to  be  treated  antiseptically.  Then  the  limb 
hould  be  fixed  upon  splints  in  a position  which 
ill  bring  most  easily  and  closely  the  cut  ends  of 
ie  divided  nerve  into  apposition.  Carbolised 
itgut  ligature  may  be  applied  upon  the  nerve- 
leath  or  closely  adjacent  textures,  so  as  to  hold 
ie  cut  ends  evenly  together ; or  a thin  wire  may 

2 applied  to  the  neighbouring  tissues,  brought 
it  at  the  surface,  and  secured  over  shot  or  but- 
ms,  and  the  wound  treated  in  the  ordinary 
ay.  If  possible,  none  of  the  nerve-fibres  should 
e cut  away,  although  a slight  trimming  off  of 
gged  ends  may  be  advisable.  Passive  motion 
' the  paralysed  muscles  should  be  employed,  as 
>on  as  the  wound  is  united ; and  afterwards  weak 
radization  should  be  applied  to  the  limb,  to 
'omote  nutrition  and  stimulate  nerve-currents. 
2.  Nerves,  Tumours  of. — Synon.  : Kcuro- 
ata. 

The  tumours  which  affect  nerve-structure,  al- 
lough  no  doubt  varying  in  essential  character, 
they  do  in  other  parts  of  the  body,  have 
fially  been  grouped  indiscriminately  under  this 
■ad.  Surgically  they  may  be  classed  thus  : — 


(a)  constitutional,  which  affect  the  whole  of  a 
particular  group  or  groups  of  nerves,  and  are 
clearly  constitutional  in  their  origin ; and  ( h ) 
traumatic,  such  as  form  on  the  cut  ends  of  nerves 
after  amputation,  or  result  from  local  injury  of 
some  kind. 

(a)  Constitutional. — Numerous  cases  of  mul- 
tiple neuromata  are  on  record.  In  one  case, 
recorded  by  R.  W.  Smith,  upwards  of  2,000 
tumours  were  found.  In  most  instances  they  are 
confined  to  one  particular  set  of  nerves  and  their 
branches.  For  instance,  they  have  been  found 
in  the  posterior  tibial  and  plantar  nerves,  as 
in  a case  recorded  by  Van  der  Byl  ( Patho- 
logical Society's  Transactions,  vol.  vi.),  where 
the  growth  may  have  been  round-celled  sarcoma 
or  cancer.  In  another  remarkable  case  of  mul- 
tiple neuromata,  recorded  by  Dr.  Wilks  {op.  cit., 
vol.  x.),  perhaps  of  syphilitic  origin,  a simplo 
fibroid  deposit  was  found  within  the  neurilemma, 
causing  in  some  places  hardening  and  contrac- 
tion, and  in  others  neuromatous  tumours.  One 
of  these  had  formed  in  the  substance  of  the 
pneumogastric  nerve,  and  was  thought  by  Dr. 
Wilks  to  have  caused  the  disease  of  the  lung 
which  proved  fatal.  In  another  case,  recorded 
by  Mr.  F.  Smith,  multiple  tumours  affected  the 
internal  cutaneous  and  interosseous  nerves  of 
the  arm,  and  the  larger  tumours  were  found  to 
have  undergone  calcareous  degeneration  {op. 
cit.  vol.  xii.). 

A single  neuromatous  tumour  has  been  found 
on  the  auditory  nerve,  causing  deafness  (Toyn- 
bee, op.  cit.  vol.  iv.),  and  on  the  musculo-spirul 
nerve  in  several  recorded  cases  {op.  cit.  vol.  viii. ), 
by  Nunn  and  Barber.  In  one  of  these  cases 
acute  sensibility  and  intense  pain  in  the  course 
of  the  distribution  of  the  nerve  were  present. 
In  the  other  case,  no  pain  was  felt  unless  the 
tumour  was  pressed.  In  a tumour  upon  the 
same  nerve,  recorded  by  Shillitoe  {op.  cit.,  vol. 
x.),  of  the  size  of  a billiard  ball,  a blood-cvst 
containing  clot  and  serum  was  found  in  the  in- 
terior, surrounded  by  fibro-cellular  structure. 

1).  Traumatic. — Neuromatous  tumours  which 
form  on  the  cut  ends  of  nerves  after  amputation, 
are  rounded  or  oval  masses  placed  near,  but  not 
usually  quite  at,  the  extremity  of  the  cut  nerve. 
A small  portion  of  the  extreme  end  frequently 
forms  a sort  of  tapering  tail  to  the  tumour,  giving 
to  it  a resemblanco  to  a turnip-radish.  On  sec- 
tion the  tumour  is  found  to  consist  of  a fibroid 
substance,  hard,  resisting,  and  firm  to  the  touch, 
with  a somewhat  glistening  surface.  Under  the 
microscope  there  are  seen  the  same  general  charac- 
ters which  are  found  in  neuromata,  namely,  fib- 
roid elongated  or  spindle  cells  within  and  around 
the  neurilemma,  pressing  upon  and  displacing 
the  nerve-tubules,  which  are  seen  convoluted,  dis- 
torted, varicose,  or  lost  entirely  in  the  tumour- 
substance.  Some  few  may  be  traced  through  the 
tumour  itself  into  the  tail-like  termination,  but 
this  latter  usually  consists  of  fibrous  tissue  only. 
These  tumours  seem  to  occur  more  commonly  after 
amputation  of  the  upper  than  of  the  lower  ex- 
tremity. These  neuromata  are  not  uncommonly 
associated  with  pain,  more  or  less  acute  at  in- 
tervals. They  may  last  a long  time — in  some 
cases  during  the  whole  of  the  life  of  the  in- 
dividual. Sometimes  neuromata  give  riso  to 


1024  NERVES,  DISEASES  OF. 


acute  sensibility  or  tenderness  or  the  stump, 
and  more  rarely  to  spasmodic  twitchings  of  the 
muscles  or  even  epileptiform  convulsions. 

Tbeatment. — Neuromata  on  the  continuity  of 
a nerve,  if  painful  or  situated  so  as  to  be  easily 
accessible,  and  liable  to  injury, maybe  dissected 
out  carefully  and  with  antiseptic  precautions. 
Sometimes  it  will  be  found  that  the  tumour  can 
be  extirpated  without  taking  away  the  entire 
section  and  continuity  of  the  nerve,  which  when 
a large  one  (as  for  instance  the  great  sciatic)  it 
is  important  to  preserve.  In  case  this  cannot 
be  done,  the  whole  section  of  the  nerve-trunk 
may  be  taken  away,  and  the  smoothly  cut  ends 
brought  together  with  fine  catgut  sutures  put 
through  the  outer  nerve-sheath  only,  the  limb 
being  placed  in  a position  to  relax  the  nerve  and 
lessen  tension  to  the  utmost.  This  proceeding, 
as  before  remarked,  has  been  successful  in  uniting 
the  ends  of  nerves  accidentally  cut  through. 

In  cases  of  neuromata  in  stumps  the  same 
treatment  is  sometimes  available  and  effective. 
Opening  the  cicatrix  and  dissecting  out  the 
tumour  or  tumours  may  be  all  that  is  required. 
But  in  other  instances  the  pain  and  tenderness  are 
so  diffused,  and  the  growths  so  numerous,  that  re- 
amputation a few  inches  higher  up,  gives  more 
complete  and  satisfactory  results.  Yet  in  some 
patients  the  tendency  to  the  formation  of  these 
tumours  is  so  great  that  they  reappear,  even  after 
re-amputation,  and  the  prognosis  must  always  be 
guarded  on  this  point. 

3.  Nerves,  Surgical  Division  and 
Stretching  of. 

(a)  Nerve-scctilm.  Synonv  : Neurotomy. — 

Surgical  division  of  nerves  has  been  employed 
for  the  cure  of  painful  affections  such  as 
neuralgia,  and  for  tetanus  and  other  obstinate 
and  sustained  spasmodic  movements.  It  has 
been  usually  performed  subcutaneously,  and  most 
frequently  in  the  case  of  the  branches  of  the 
tri-facial  nerve,  at  their  exit  from  the  bony  fora- 
mina, such  as  the  supra-orbital,  the  infra-orbital, 
and  the  mental  branches.  The  division  should 
be  thoroughly  and  completely  done.  It  has  been 
found,  however,  that  in  a comparatively  short 
space  of  time,  the  operation,  though  perfectly  suc- 
cessful in  removing  the  pain  and  sensation  at 
the  peripheral  distribution  of  the  nerve,  is  of 
no  avail.  The  nerve,  after  simple  subcutaneous 
division,  unites  in  a few  weeks  or  months ; and 
first  sensation  and  then  pain  recur  in  the  part. 
In  cases  of  intracranial  disease  the  operation 
is  of  course  useless.  Efforts  have  been  directed 
to  prevent  this  union  of  the  cut  nerve,  by 
taking  away  a considerable  portion,  so  as  abso- 
lutely to  prevent  contact  of  the  ends ; and  the 
operation  then  must  necessarily  lose  its  subcuta- 
neous character.  When  the  nerve,  as  in  those 
nerves  above-named,  spreads  out  to  its  distribu- 
tion in  all  directions,  it  is  difficult  to  secure  this 
absolute  removal,  and  a good  deal  of  the  adja- 
cent soft  parts  must  be  excised  to  insure  its 
being  done  thoroughly.  In  a case  of  obstinate 
neuralgia  of  the  inferior  dental  nerve,  the  late 
Sir  William  Fergusson  gouged  away  the  outer 
wall  of  the  mental  foramen  for  the  space  of  an 
inch,  and  dissected  out  the  nerve  from  the  canal 
to  the  same  extent,  with  the  effect  of  curing  the 
disease. 


In  some  neuralgic  cases  the  cause  of  the  pa; 
lies  within  the  cranium  or  brain  itself,  as  aW 
mentioned,  and  is  of  course  not  to  be  reached  b 
surgical  operation. 

In  traumatic  tetanus  division  of  the  nerv 
going  to  the  wounded  part  has  been  practise! 
by  Hilton  ( Medical  Tones  and  Gazette , vol.  i 
1869),  and  by  Sir  Joseph  Fayrer  (Rankin'. 
Abstract , 1863,  vol.  ii.),  as  well  as  by  Nelatoi 
and  others.  The  results,  however,  do  not  seen 
to  be  as  favourable  as  in  the  more  recently  in 
troduced  treatment  of  nerve-stretching,  -whilst) 
the  injury  inflicted  on  the  structures  is  certainh 
greater,  and  the  disabling  results  are  more  ap" 
to  be  permanent. 

(b)Ncrve-stretching. — This  is  one  of  the  moden 
modes  of  the  treatment  of  disease,  which  has  so 
far  achieved  a certain  amount  of  success.  It  ha; 
been  practised  in  cases  in  which  section  of  the! 
nerve  may  be  considered  justifiable,  such  as  con- 
tinuedand  severe  pain  or  spasm,  acute  or  chronic' 
of  the  parts  supplied  by  a nerve,  which  has  re- 
sisted all  milder  treatment,  and  in  loeomotoi 
ataxy.  Cases  of  traumatic  tetanus  also  claim  ; 
trial  of  this  method  of  cure. 

Method.  — Nerve-stretching  is  effected  1)_\ 
cutting  down  upon  the  nerve-trunk,  detaching 
it  from  its  connections  for  the  space  of  a fei\ 
inches,  laying  hold  of  it  with  the  fingers,  forcibh 
stretching  the  whole  nerve  from  its  origin  t"c 
such  an  extent  as  to  affect  powerfully  its  func- 
tions, and  then  closing  up  the  wound.  In  some, 
instances  a certain  amount  of  loss  of  sensa- 
tion or  muscular  power  in  parts  to  which  the 
nerve  is  distributed  is  the  immediate  result1 
which,  however,  passes  away  after  a certain 
interval,  and  the  nerve-function  becomes  mort 
or  less  completely  restored. 

Application's. — A number  of  cases  have  beet 
recorded  within  the  last  few  years,  in  whicl 
nerve-stretehiDg  has  been  employed  with  con 
siderable  success.  Thus  in  a case  of  spastr 
affecting  the  whole  of  the  muscles  of  the  lef 
arm,  with  considerable  ana?sthesia,  Nussbanm 
of  Munich,  stretched  the  nerves  of  the  arm  it 
three  places — namely,  the  ulnar  nerve  at  thi 
elbow;  the  median,  musculo-spiral,  and  ulnar  it 
the  axilla  ; and  the  primary  trunks  of  the  thrv 
lower  cervical  nerves  above  the  clavicle.  Th; 
patient  recovered  in  eleven  weeks,  with  restore 
tion  of  the  healthy  action  of  i he  muscles  of  th 
limb. 

The  late  Mr.  Callender  has  described  th' 
case  of  a man  in  whom  re-amputation  of  th' 
stump  of  the  fore-arm  for  neuralgia  had  been  per 
formed,  and  which  he  operated  on  by  strctchin; 
the  median  nerve  for  three-fourths  of  an  inch 
There  was  no  return  of  the  pain,  and  the  nu 
trition  of  the  stump  and  arm,  which  had  wasted 
was  much  improved.  The  writer  lately  cut  dow: 
upon  and  stretched  the  external  popliteal  (perc 
neal)  nerve,  behind  the  biceps  cruris  tendon,  in 
case  of  painful  spasm  of  the  extensor  and  peronee 
muscles,  with  a success  which  was  permanen 
months  afterwards.  Still  more  recently  Mi 
Godlee  has  treated  two  cases  of  facial  spasm  c 
many  years''  standing,  by  stretching  the  porti 
dura  at  its  exit  from  the  stylo-mastoid  forame: 
one  with  complete  success. 

In  cases  of  traumatic  tetanus,  the  applicatio 


NERVES,  DISEASES  OF. 

f nerve-stretching  seems  sufficiently  appro- 
riate,  and  accordingly  it  has  not  failed  to  be 
•ied.  A striking  case  of  this  description  is 
icorded  in  the  Centralblatt  fur  Chirurgie , Oct.  7, 
376,  No.  10,  by  Vogt.  In  fifteen  cases  of  teta- 
us  collected  by  Johnstone  of  Kentucky,  seven  of 
hich  were  operated  on  in  late  stages  of  disease, 
is  stated  that  there  were  five  cases  of  re- 
ivery  from  this  fatal  disease — a much  greater 
•oportion  than  from  any  other  method  of  treat- 
ent.  The  results  in  cases  of  nerve-stretching 
r traumatic  tetanus,  practised  in  London  during 
je  last  few  years,  do  not  add  to  the  favourable 
ipression  that  the  preceding  cases  were  calcu- 
;ed  to  give  as  to  the  efficacy  of  this  operation, 
has  been  tried  in  various  hospitals,  lately  in 
ing's  College  Hospital,  without  success.  In 
|e  case  it  seemed  rather  to  hasten  the  fatal 
rmination,  And  it  can  scarcely  be  said  that 
e infliction  of  a further  injury  on  the  continuity 
the  nerves  of  the  affected  part,  with  a corre- 
onding  impression  upon  the  nerve-centres,  is, 
priori,  likelv  to  cure  the  consequences  of  a 
mary  injury,  which  has  already  so  powerfully 
.i  fatally  influenced  the  condition  of  these  same 
live- centres. 

Still  more  recently  nerve-stretching  has  been 
pctised  upon  the  nerves  of  the  limb  for  the 
fief  of  the  pains  cf  locomotor  ataxy.  The 
lults,  in  Some  instances,  appear  to  have  been 
icessful  even  beyond  expectation ; for  not 
c y have  the  pains  been  removed,  but  the 
tturbances  of  co-ordination  have  also  been 
minished,  though  to  a limited  extent. 
Principles. — A satisfactory  explanation  of 
ft  modus  operandi  of  n6rve-stretching  is  not 
eily  given.  Nussbaum  suggested  that  the  suc- 
c 5 may  be  owing  to  an  alteration  in  the  relations 
1 ween  the  nerve-fibres,  having  the  effect  of 
i iroving  their  nutrition ; whilst  Callender  attri- 
led  it  to  the  consequent  numbing  of  the  nerve, 
tit  is,  the  temporary  suspension  of  its  func- 
t is,  by  interfering  with  the  transit  of  painful 
a abnormal  impressions,  the  nerve-centres 
t ing  time  to  resume  their  normal  control. 
Vli  regard  to  this  explanation  it  may  be 
p ited  out,  however,  that  both  motion  and 
station  are  often  uninterruptedly  retained  after 
tl  successful  stretching  of  a large  nerve, 
ill  certain  eases  of  rheumatic  neuralgia  it  might 
Conjectured  that  a degree  of  contraction  may 
fi  iw  a rheumatic  or  gouty  deposit  in  the  nerve- 
el  tli,  and  thus  affect  the  nerve-current  in  the 
c ral  axis  of  the  fibre  ; and  that  this  may  be 
d rn  out,  overcome,  or  broken  by  the  nerve- 
st:ching,  the  normal  function  of  the  nerve- 
tvde  being  thus  restored  temporarily  or 
puanently.  Whether  a similar  explanation 
w suffice  for  the  recorded  cases  of  cure  of 
te-ius  may  be  more  than  doubtful,  and  we 
m t wait  for  further  evidence  of  fact  before 
wan  explain  the  phenomena  with  any  appear- 
ai,  of  probability.  Brown-Sequard  has  recom- 
nvied  exposure' of  the  nerve,  and  washing  it 
wr  ether,  to  effect  the  same  end. 

John  Wood. 


W|! 

Ti 


ERVI,  in  the  Eastern  Italian  Riviera, 
n,  moist,  winter  climate.  Seo  Climate, 
;ment  of  Disease  by. 


65 


NERVOUS  SYSTEM.  1025 

NERVOUS. — A term  used  variously  in  re- 
ference to  persons,  to  temperaments,  or  to  morbid 
conditions.  A person  is  said  to  be  nervous,  or 
of  a nervous  temperament,  who  seems  to  present 
a special  susceptibility  to  pain,  or  who  exhibits 
an  undue  mobility,  as  it  is  termed,  of  the  nervous 
system — that  is  to  say,  when  the  person  starts 
or  shakes  on  the  occasion  of  abrupt  or  intense 
sensorial  impressions,  or  when  he  exhibits  a 
proneness  to  convulsions  or  manifests  an  exalted 
emotional  susceptibility.  An  organisation  of 
this  kind  characterises  children  rather  than 
adults,  and,  amongst  the  latter,  females  more 
than  males.  Nevertheless,  in  persons  of  both 
sexes  such  a bodily  disposition  is  frequently  to 
be  met  with,  varying  not  only  in  degree,  but  also 
in  kind  or  type.  As  one  of  the  most  important 
of  these  varieties,  we  must  include  the  as  yet 
very  imperfectly  understood  condition  known 
as  hysteria  ( see  Hysteria).  A nervous  disposi- 
tion may  be  either  inherited,  or  acquired  during 
the  life  of  the  individual,  and  it  then  ensues  as 
a sequence  of  some  severe  illness,  of  some  gvuve 
anxiety,  or  of  some  physical  or  moral  shocK. 

In  reference  to  disease,  the  term  nervous 
is  used  with  different  significations  in  dilferent 
cases.  Sometimes  it  is  used  in  more  general 
terms  to  signify  that  the  disease  is  one  impli- 
cating the  nervous  system  rather  than  any  other 
part  of  the  body.  At  other  times  the  use  of  the 
term  is  very  variable.  Thus,  by  the  term 
‘nervous  aphonia’  we  imply  that  the  voiceless- 
ness is  due  to  some  functional  nervous  inhibition, 
rather  than  to  any  distinct  paralytic  condition 
caused  by  structural  disease  ; whilst,  by  the  term 
* nervous  deafness,’  we  should  imply  that  the 
deafness  is  due  to  disease,  functional  or  organic, 
of  the  auditory  nerve  or  its  centres,  rather  than 
to  an  inflammatory  or  other  affection  of  the 
middle  ear.  H.  Charlton  Bastlan. 

NERVOUSNESS. — A term  applied  to  the 
state  of,  or  to  the  conditions  manifested  by,  a 
person  coming  within  the  description  of  ‘ner- 
vous ’ as  above  defined.  Sec  Nervous. 

NERVOUS  SYSTEM,  Diseases  of. — 

The  complexity  of  the  nervous  system,  its 
manifold  functions,  and  its  extensive  distribu- 
tion, render  its  diseases  more  varied  than  thoso 
of  any. other  system  of  the  body. 

From  the  manner  in  which  the  nervous  and 
vascular  systems  interlock,  their  diseases  or  pa- 
thological conditions  are  to  some  extent  insepar- 
ably related  to  one  another.  The  modes  of  inter- 
ference with  the  functions  of  the  vascular  system 
through  altered  nervous  action  are  compara- 
tively few  and  simple.  The  heart  may,  under  the 
influence  of  modified  nervous  stimulation  depart 
from  its  customary  order  and  rate  of  contraction, 
or  in  extreme  cases  cease  to  beat ; the  smaller 
arteries  over  a greater  or  less  extent  of  the  body 
may  diminish  in  their  calibre,  or  become  dilated  ; 
but,  save  for  such  events  as  these  and  their 
direct  consequences,  the  work  of  the  vascular 
system  is  habitually  carried  on  without  variations 
impressed  upon  it  by  abnormal  states  of  the 
nervous  system. 

On  the  other  hand,  the  diseases  of  the  nervous 
system  which  may  be  induced  by  altered  quality 


NERVOUS  SYSTEM,  DISEASES  OF. 


i026 

A blood,  or  by  alteration  of  function  in  the 
heart  or  some  part  of  the  vascular  system,  are 
numerous  and  varied.  The  functional  activity 
of  the  system  as  a whole  may  be  degraded, 
owing  to  the  fact  of  its  receiving  an  inadequate 
amount  of  blood  from  a feeble  or  slowly  acting 
heart.  Ortho  functions  of  a part  of  the  system 
may  be  interfered  with  by  an  undue  contraction 
or  dilatation  in  its  small  arteries,  or  by  an 
impediment  to  the  outflow  of  blood,  inducing 
a mechanical  congestion.  Again  the  complete 
or  partial  arrest  of  the  blood-flow  in  the  vessels 
of  some  important  region  (owing  to  thrombosis 
or  embolism  therein),  or  the  rupture  of  one  of 
the  branchesof  such  a vessel,  with  extravasation 
of  blood  into  the  organ, — either  of  these  events 
may  impair  or  destroy  the  functions  of  that 
particular  part,  even  if  it  cause  no  more  general 
disturbance  of  nerve-function.  In  short,  both 
local  perversions  of  function  and  structural 
changes  in  the  nervous  system,  are  far  more  fre- 
quently initiated  by  altered  quality  of  blood,  or 
unnatural  phenomena  in  the  vessels  of  the  part, 
than  by  primary  morbid  changes  in  either  of  the 
other  two  components  of  nerve-tissue,  namely, 
the  nerve-elements  themselves,  or  their  interstitial 
connective  tissue. 

But,  as  already  intimated,  the  number  of 
different  nervous  diseases  is  referable  princi- 
pally to  the  great  complexity  of  this  system.  It 
is  now  a familiar  fact  that  the  same  kind  of 
morbid  change  existing  in  different  parts  of  the 
nervous  system  tends  to  give  rise  to  wholly  dis- 
similar groups  of  symptoms.  Hence  the  impor- 
tance, from  a clinical  point  of  view,  of  studying 
the  varied  functions  and  functional  relationships 
of  the  several  parts  of  the  nervous  system. 

The  most  practical  and  useful  classification 
of  the  principal  component  parts  of  the  nervous 
system  is  as  follows  r — 

1.  The  Cerebro-Spinal  Division  (or  Nervous 

system  of  animal  life). 

a.  The  Encephalon. 

b.  The  Spinal  Cord. 

c.  The  Encephalic  and  Spinal  Nerves. 

2.  The  Organic  Division  (or  Nervous  system 

of  vegetative  life). 

a.  The  Pneumogastric  or  Vagus  Nerves. 

b.  The  Great  Sympathetic  System  (with 

which  is  included  the  ‘Vaso-Mo- 
tor’  System  of  Nerves). 

This  classification,  though  in  part  natural, 
is  also  in  other  respects  purely  artificial.  The 
cerebro -spinal  and  the  organic  nerve-centres 
are  structurally  continuous  at  many  points.  The 
vagus  nerves,  and  the  vaso-motor  system  of 
fibres  In  part,  have  an  encephalic  origin,  though 
the  latter  are  distributed  almost  throughout 
with  the  sympathetic  system,  of  which  it  is  often 
supposed  to  constitute  the  most  important  part. 
This  sympathetic  system  is  connected  at  inter- 
vals with  the  whole  length  of  the  cerebro-spical 
system,  from  the  lumbar  enlargement  to  the 
base  of  the  brain,  chiefly  by  connecting  filaments 
passing  between  it  and  the  anterior  spinal  nerves. 
Some  of  these  connecting  filaments  are  afferent, 
Others  are  efferent.  The  brain  again  is  brought 
into  immediate  relation  with  the  sympathetic 
system  through  the  wide-spread  filaments  of  the 
pneumogastric  nerves,  which  mingle  with  almost 


all  the  visceral  plexuses  both  of  the  thorax  and 
of  the  abdomen.  The  spinal  accessories  seem 
to  be  the  motor  nerves  through  which  the  more  j 
direct  impressions  brought  to  the  medulla  by  the 
pneumogastrics  are  reflected  upon  some  of  the 
viscera ; and,  similarly,  the  tranference  of  motor- 
stimuli  direct  from  the  spinal  cord  to  the  viscera, 
in  response  to  afferent  impressions  conveyed  tc 
it  by  certain  nerves  of  the  sympathetic  system, 
takes  place  through  motor  fibrils  in  the  filament! 
connecting  the  anterior  spinal  nerves  with  thi- 
system.  The  sympathetic  system  also  possesse: 
its  own  intrinsic  motor  fibres  and  vaso-motoi 
centres.  Other  intrinsic  motor  centres  probabb 
exist  amongst  the  sympathetic  ganglia,  whicli' 
like  those  of  the  heart,  may  be  capable  of  bring 
ing  about  muscular  contractions  iu  the  parts  wit] 
which  they  are  severally  in  relation. 

The  direct  consequence  of  the  close  relation 
ship  between  the  viscera  and  the  fibres  of  th 
pneumogastric  and  spinal  accessory,  as  well  a 
between  the  spinal  motor  nerves,  and  thos 
emanating  from  the  central  connections  of  tb! 
vaso-motor  system,  is  that  we  find  lesions  <| 
some  portions  of  the  cerebro-spinal  system  fri 
quently  involving  altered  actions  in  parts  undi 
the  immediate  influence  of  the  nervous  syste 
of  organic  life — as  when  diseases  of  the  medull 
and  its  neighbourhood  disturb  the  action 
the  heart  or  the  respiratory  processes,  whc 
vomiting  is  produced  by  cerebral  or  spin 
disease,  when  diabetes  or  polyuria  are  indue 
by  irritations  of  the  fourth  ventricle.  Su 
effects,  again,  are  illustrated  by  the  flow  of  tea) 
under  the  influence  of  grief,  by  the  arrest  of  t 
salivary  secretion  under  the  influence  of  fear,' 
by  the  occasional  production  of  an  increased  fl 
of  the  same  fluid  at  the  thought  of  savoury  fo 
Or.  the  action  of  the  two  nervous  systems  upon 
another  may  take  place  in  an  opposite  directij 
as  when  in  a neurotic  subject  an  irritant  in 
intestine,  or  t he  passage  of  a renal  calculus  dot 
the  ureter,  gives  rise  to  convulsions ; when  foit- 
of  ‘ reflex  ’ paralysis  are  produced ; when  ■ 
‘spirits ’are  depressed  under  the  influence i 
visceral  disease,  sometimes  to  such  an  extents 
to  induce  melancholia;  or  when,  on  the  otr 
hand,  irritative  states  of  the  ovary  lead  to  tit 
form  of  insanity  known  as  nymphomania. 

Sympathetic  disturbances  are  also  apt  to  sly 
themselves  in  the  functions  of  certain  parts  cl- 
prised  within  the  sphere  of  the  cerebro-spd 
system  itself,  when  some  other  portion  of  itf- 
comes  the  seat  of  disease,  though  the  extend 
which  this  occurs  is  still  involved  in  much  do  t- 
Brown-Sequard  believed  that  hemiplegia  i|lf 
is  often  induced  by  an  ‘inhibitory’  influeo. 
emanating  from  some  morbid  portion  of 
brain  and  acting  upon  certain  motor-cell^ 
the  spinal  cord.  Similarly  we  find  an  irrita’n 
occurring  in  one  portion  of  the  organic  neris 
system  entailing  morbid  manifestations  in  s:e 
other  and  perhaps  distant  part  of  thissysu. 
as  when  the  early  stage  of  pregnancy  or  wn 
ovarian  or  uterine  disease  leads  to  vomit: . 
when  certain  irritations  of  the  stomach  ejte 
the  act  of  coughing;  or  when  irritatioij11 
the  bronchial  mucous  membrane  lead  to  rd  ■- 
ing.  Essentially  similar  phenomena  are  e. 
when  suprarenai-capsular  disease  leads  to  •» 


NERVOUS  SYSTEM,  DISEASES  OF.  1027 


isss ; or  when  a blow  on  the  epigastrium,  by  con- 
•yin'g  a shock  to  the  semilunar  ganglia,  causes 
i arrest  of  respiration  or  of  the  heart’s  action. 
'«  Sympathetic  System,  Disorders  of. 

This  tendency  to  the  establishment  of  sym- 
dhetie  or  related  disturbance  of  distant  parts 
local  diseases  of  the  nervous  system,  is  one 
the  principal  sources  of  the  great  complexity 
diagnosis  in  these  affections.  Thus,  though 
lesion  in  the  brain  may  give  rise  to  a certain 
; of  direct  effects,  the  consequences  of  the 
me  lesion  may  also,  and  mostly  do,  become 
dtiplied  by  a reverberation  of  impressions 
i’oughout  the  nervous  system.  In  this  way 
■ at  are  called  indirect  effects  are  produced. 
;fch  indirect  effects  may  show  themselves  either 
i the  direction  of  arrest  or  of  exaltation  of 
liction,  and  in  the  former  case  they  are  often 
Jd  to  be  brought  about  by  ‘ inhibition.’ 

The  proportion  between  the  direct  and  the 
i irect,  effects  resulting  from  an  injury  to  ner- 
t|s  tissue  varies  greatly  in  different  cases, 
fording  to  the  seat,  the  extent,  and  the  nature 
t|he  lesions,  as  well  as  according  to  the  age,  sex, 

: 1 general  health  of  the  patients.  Hence  it 
(In  happens  that  the  same  kind  of  lesion  seems 
mlifferent  times  to  give  rise  to  a different  set 
odinical  accompaniments. 

;n  regard  to  diseases  of  the  organic  nervous 
Am  our  knowledge  is  at  present  extremely 
djietive.  The  recognition  of  the  diseases  of 
til  s\stem— that  is,  as  diseases  having  such  or 
s;ia  pathological  starting-point — is  beset  with 
p tliar  difficulties.  This  is  in  part  attributable 
tlhe  free  connections  existing  between  the  or- 
gjic  and  the  cerebrospinal  nervous  system,  and 
t ; consequent  difficulty,  so  frequently  arising, 
well  opposes  itself  to  our  settlement  of  the 
q’ition,  as  to  whether  any  particular  group  of 
sjptoms,  possibly  due  to  some  primary  disease 
oil  portion  of  the  organic  nervous  system, 
rely  owns  such  a cause,  or  whether  it  is  rather 
d to  some  disordered  condition  of  the  cerebro- 
s|al  centres,  which  induces  indirect  effects  on 
traside  of  the  nervous  system  of  organic  life. 
Tin,  again,  in  other  cases,  disease  of  some 
pijion  of  the  organic  nervous  system  may 
rtfy  exist,  which,  by  reason  merely  of  our 
pi  ent  defective  physiological  and  pathological 
kiyledge,  remains  unsuspected  as  a disease 
tang  that  particular  nature  and  origin. 

he  nature  of  the  functions  performed  by  the 
otlnic  nervous  system  sufficiently  explains  this 
di'.ulty.  In  part  it  serves  to  link  the  func- 
ti  jil  activity  of  certain  viscera  with  sensory 
inf  essions  or  motor  acts  referable  to  the  cerebro- 
sfil  system,  as  in  the  processes  of  ordinary 
or'isturbed  respiration,  parturition,  &c. ; in 
pa;  also  it  brings  different  • organs  into  co- 
nr  j.ated  activity,  as  when  the  presence  of  food 
in  9 alimentary  canal  excites  the  simultaneous 
uejity  of  the  pancreas,  the  liver,  and  other 
glilular  organs.  And  how  well  such  functions 
nslose  last-named  are  performed  we  are  often 
(affable  to  estimate  vaguely,  if  at  all,  since  the 
is  of  those  portions  of  the  nervous  syrstem 
on' licit  they  depend  do  not  reveal  themselves 
oit : by  sensible  impressions,  or  by  movements 
of  Jets  of  which  we  are  conscious. 

ter  functions  of  the  1 sympathetic’  nervous 


system,  such  as  those  which  have  to  do  with  the 
maintenance  and  regulation  of  the  functional 
activity  of  the  blood-making  or  ductless  glands, 
namely,  the  liver,  the  spleen,  the  supra-renal 
capsules,  or  the  lymphatic  glands,  are  even  still 
further  beyond  the  pale  of  recognisable  pheno- 
mena. Yet  disturbances  of  these  purely  organic 
functions  may  give  rise  to  certain  general  affec- 
tions, which  we  are  unable  to  refer  to  morbid 
states  or  actions  of  this  portion  of  the  nervous 
system.  Suprarenal-capsular  disease,  leucocy- 
thaemia,  diabetes,  chlorosis,  various  forms  of 
anaemia  and  other  conditions  of  general  mal- 
nutrition, are  instances  of  diseases  possibly  due 
to  deficient  or  perverted  action  of  some  of  these 
blood-making  organs,  immediately  occasioned  by 
morbid  conditions  of  the  sympathetic  nerve- 
centres  in  relation  therewith.  And  it  may  be 
fairly  presumed  that  the  functional  activity  of 
these,  organs  is  influenced  by  the  nerves  and 
nerve-ceutres  with  which  they  are  in  connection 
— just  as  that  of  ordinary  secretory  glands  (such 
as  the  parotid  and  sub-maxillary)  is  known  to  bo 
under  the  influence  of  the  nerves  with  which 
they  are  supplied. 

The  true  pathology  of  such  general  diseases 
as  have  been  named,  we  may  hope  will  be 
ultimately  elucidated  by  the  application  of  the 
same  means  as  have  led  to  our  present  knowledge 
concerning  the  symptomatology  of  local  diseases 
in  the  cerebro-spinal  portion  of  the  nervous 
system.  This  means,  therefore,  would  consist 
in  a more  searching  and  habitual  examination  of 
the  several  parts  of  the  nervous  system  of  organic 
life,  so  as  to  endeavour  to  connect  morbid  appear- 
'ances  in  its  several  centres  with  appreciable 
pathological  states  of  ductless  and  other  organs, 
and  the  still  further  endeavour  to  colligate  these 
morbid  appearances  with  the  respective  states  of 
health  or  symptoms  exhibited  by  the  patients 
during  life.  Slow  and  difficult  as  this  method 
is,  it  is  the  only  one  (apart  from  the  experimental 
method  with  lower  animals,  which  is  here 
available  only  to  a very  limited  extent)  that 
would  appear  to  hold  out  any  probability  of 
ultimate  success. 

The  obscurity  prevailing  in  reference  to  dis- 
eases of  the  cercbro-spinal  nervous  system,  is  not 
to  be  compared  in  extent  with  that  relating  to 
the  nervous  system  of  organic  life.  The  reason 
of  this  is  obvious.  Deviations  front  its  proper 
functions  come  much  more  easily  under  the 
ken  of  the  physician  and  of  the  patient ; whilst, 
in  addition,  morbid  changes  in  this  part  are  a 
few  degrees  less  difficult  to  detect,  and  as  they 
are  situated  in  parts  which  are  also  much 
more  frequently  scrutinised  in  the  post-mortem 
room,  such  changes  are  in  reality  far  more 
frequently  recognized  than  when  they  occur  in 
one  or  other  of  the  more  scattered  centres  of  the 
nervous  system  of  organic  life. 

For  some  general  remarks  on  the  diseases  of 
the  cerebro-spinal  nervous  system,  the  reader  is 
referred  to  the  articles,  Brain,  Diseases  of;  and 
Spinal  Cord,  Diseases  of. 

./Etiology  and  Pathology. — The  proper  and 
well-balanced  working  of  the  nervous  system, 
as  a whole,  depends  upon  the  maintenance  oftho 
accustomed  degree  of  excitability  in  its  different 
nerve-centres ; and  the  proper  nutrition  of  such 


1028  NERVOUS  SYSTEM.  DISEASES  OF. 


centres,  upon  'which  their  normal  molecular  mobi- 
lity depends,  is  certainly  largely  dependent  upon 
their  habitually  receiving  a supply  of  blood  which 
is  definite  in  amount,  and  uniform  in  quality.  But 
the  amount  of  blood  going  to  any  tissue  or  part 
is  subject  to  the  regulating  influence  of  the  local 
vaso-motor  centre,  with  which  the  vaso-motor 
nerves  supplying  the  blood-vessels  in  question 
are  in  relation.  By  the  influence  of  other  parts 
of  the  nervous  system,  or  owing  to  the  condition 
of  these  vaso-motor  nerve-centres,  the  vessels 
dependent  upon  them  may  be  either  unduly  con- 
tracted, or  unduly  dilated.  Again,  the  proper 
quality  of  blood  is  subject  to  much  alteration  in 
different  diseases ; for  instance,  it  may  be  thin 
and  poor  in  anaemic  states,  it  may  contain  poison- 
ous ingredients  in  workers  with  lead  and  mercury, 
whilst  it  may  contain  varied  noxious  constituents 
in  those  suffering  from  grave  renal  disease,  from 
septicaemia,  and  from  the  acute  specific  fevers. 
In  this  latter  group  there  is,  however,  reason  to 
believe  that  some  of  the  abnormal  nervous  pheno- 
mena which  are  apt  to  manifest  themselves  may 
be  duet  not  so  much  to  the  direct  toxic  influence 
of  altered  blood,  as  to  the  fact  that  in  such  states 
of  the  system  the  blood  may  be,  at  times,  more 
prone  than  natural  to  coagulate  in  the  minute 
vessels  of  the  nervous  system.  Such  undue 
proneness  to  coagulate  sometimes  depends  upon 
the  existence  of  an  increased  number  of  white 
blood-corpuscles,  which,  either  from  the  state 
of  the  blood-plasma,  or  from  the  condition  of 
the  tissues  outside,  show  a more  than  usual 
amoeboid  activity.  Or  an  undue  proneness  of 
the  blood  to  coagulate  in  some  of  the  small  vessels 
of  the  nervous  system,  during  or  after  some  of 
the  acute  specific  diseases,  may  be  due  to  an 
unnatural  tendency  of  the  fibrin  to  separate 
from  such  altered  blood.  The  nutritive  changes 
taking  place  in  different  tissues  are  chemical 
changes,  differing  from  one  another  in  exact 
nature,  and  therefore  capable  of  reacting  dif- 
ferently upon  the  blood  circulating  through  such 
parts.  These  facts  suffice  to  show  how  difficult 
it  is  to  draw  the  line  between  what  are  probably 
mere  toxic  effects  of  an  altered  blood,  and  those 
which  are  due  in  the  main  to  minute  and  almost 
inappreciable  changes  in  the  condition  of  the 
smaller  blood-vessels  of  a nerve-centre. 

But  whenever  variations  take  place  in  the 
nutritive  condition  of  any  centre,  these  varia- 
tions are  apt  to  involve  not  only  an  altered 
action  in  that  particular  part,  but  a perverted 
functional  activity  of  other  related  parts.  It 
often  happens,,  therefore,  that  an  exaltation 
or  diminution  of  functional  activity  in  some  one 
part  of  the  nervous  system,  causes  a diminution, 
exaltation,  or  other  perverted  activity  in  distant 
parts  of  the  system.  Thus,  owing  to  the  many 
possible  permutations  and  combinations,  we 
may  get  the  most  varied  grouping  of  abnormal 
phenomena  traceable  to  altered  actions  in  the 
nervous  system,  and  having  for  a starting-point 
some  perverted  functioning  of  one  or  more 
nerve-centres.  We  have  here  the  mode  of  pro- 
duction of  what  are  commonly  called  functional 
diseases.  Diseases  of  this  type  are  specially 
apt  to  manifest  themselves  after  some  unusual 
strain  has  been  thrown  upon  the  nervous,  sys- 
tem, especially  if  the  general  health  was  at  the 


same  time  lowered.  The  strain  may  have  ariser 
from  prolonged  over-work  and  deficient  sleep 
or  from  some  sudden  mental  shock,  whethe; 
of  joy  or  terror,  but  more  especially  the  latter 
At  other  times  such  functional  diseases  appea: 
without  any  assignable  cause,  more  especial]} 
in  persons  of  a neurotic  habit  of  body.  G-rea 
differences  exist  amongst  different  individuals  ii 
this  respect,  that  is,  in  their  proclivity  to  disease 
of  the  nervous  system,  though  it  is  a matter  o 
common  observation  that  children  and  female 
are,  as  a rule,  much  more  prone  than  men  to  be! 
come  affected  by  nervous  diseases  of  this  type. 

It  is  now  a well-established  fact  that  person! 
who  are  endowed  with  a neurotic  habit  of  bodv 
very  frequently  transmit  a similar  tendency  t 
their  children.  It  is  not  a tendency  to  any  or 
particular  disease,  but  a vulnerability  of  th 
nervous  system  as  a whole  which  is  transmitted 
so  that  under  the  influence  of  even  a compar. 
tively  slight  strain,  this  weakness  may  manife: 
itself  in  one  or  other  of  various  ways.  It  ma 
reveal  itself  by  mere  general  nervousness  n 
tremors,  by  attacks  of  chorea,  by  epilepsy,  orl 
one  or  other  of  the  forms  of  insanity.  Vfh>- 
the  neurotic  habit  of  body  exists  to  a wel 
marked  extent — either  in  one  or  in  both  parent 
different  children  may  be  affected  in  several  ' 
these  modes ; yet  it  is  not  necessarily  so,  f 
the  inherent  vigour  of  some  of  their  progei 
may  cause  such  tendencies  to  be  dwarfed  af 
practically  blotted  out. 

Other  diseases  of  the  nervous  system  a 
induced  by  definite  and  easily  recognisab 
structural  changes  belonging  to  one  or  oth' 
of  the  following  varieties.  Rupture  of  bloc 
vessels  often  happens,  causing  hamorrho j 
either  into  or  upon  the  brain  or  spinal  cor; 
though  haemorrhage  into  the  latter  organ  is 
extremely  rare  event.  Or  changes  may  occur 
the  vessels  of  some  part  of  the  nervous  syste 
leading  to  their  narrowing  or  actual  occlusi; 
by  the  combined  influence  of  degenerations  aj 
thrombosis;  or  a similar  result  may  be  broug. 
about  by  the  lodgment  of  an  embolus,  and 
each  case  the  consequence,  if  the  patient  1 
long  enough,  is  the  establishment  of  a focus; 
softening  in  the  brain  or  spinal  cord.  In  addit . 
to  these  changes  we  have  others  of  an  irritat 
or  inflammatory  nature.  These  may  affect  1> 
surface  of  the  brain,  when  they  are  associail 
with  simple  or  with  tubercular  meningitis;: 
they  may  implicate  some  deeper  portion  of  ^ 
substance,  though  unfortunately  we  are  at  p- 
sent  only  very  imperfectly  able  to  separate  the 
inflammatory  affections  from  the  more  sime 
degenerative  softenings,  either  at  the  bedsider 
in  the  post-mortem  room.  If,  however,  the  - 
flammatory  focus  should  subsequently  beccte 
the  seat  of  an  abscess,  the  latter  difficulty  woi 
disappear.  In  the  nerve-trunks  an  inflammatv 
condition,  affecting  principally  their  connecti- 
tissue  envelopes,  is  not  unfrequently  met  w , 
and  goes  by  the  name  of  neuritis.  Again,  tumos 
may  be  found,  either  arising  in  or  pressing  uo 
some  portion  of  the  nervous  system.  Thesery 
have  been  produced  under  the  influence  of  scrc- 
losis  or  syphilis,  or  they  may  be  cancerous, r 
wholly  unrelated  to  any  general  diathetic  stA 
Accphalocysts  or  cysticcrci  are  also  occasion!? 


NERVOUS  SYSTEM. 

i':t  with  pressing  upon  the  surface,  or  within  the 
ibstance  cf  the  brain ; or  fluid  may  accumulate 
■thin  the  ventricles,  as  in  hydrocephalus.  But 
ifar  more  frequent  morbid  condition  consists 
i an  overgrowth  of  the  interstitial  connective 
■sue,  leading  to  the  formation  of  patches  or 
■lets  of  sclerosis  in  the  brain  and  spinal  cord. 

' is  change  constitutes  the  basis  of  several  well- 
lognised  morbid  conditions  of  a progressive 
oe.  Lastly  we  may  have  certain  special  forms- 
• atrophy  and  degeneration,  showing  themselves 
ore  especially  in  the  nerve-cells  of  various  parts 
the  brain,  spinal  cord,  or  sympathetic  ganglia. 
Treatment. — For  the  treatment  of  nervous 
ieases  we  have  at  our  disposal  a number 
■ invaluable  remedies,  whose  action  is  more 
less  special.  Thus,  wo  have  strychnine 
1 bromide  of  potassium,  possessing  the  oppo- 
le  properties  of  increasing  and  diminishing 
fe  reflex  excitability  of  the  nervous  system, 
addition  to  other  beneficial  modes  of  action, 
e have  chloral  and  morphia  acting  either 
,-ectly  or  indirectly  as  hypnotics,  and  thus 
lowing  the  curative  action  of  rest  to  como 

0 play.  We  have  opium  and  Indian  hemp, 
bcutaneous  injections  of  morphia,  and  the  con- 
mt  galvanic  current  as  pain-subduers.  We 
;ve  drugs  like  ergot  and  nitrite  of  amyl,  capable 
[influencing  the  calibre  of  the  smaller  arteries, 
e have  in  conium  and  chloroform  most  power- 

1 agents  for  relaxing  the  whole  muscular  system, 
e have  iodide  of  potassium,  which  in  syphilis 
d other  cachectic  states  of  the  system  seems 
ilact  as  a direct  antidote  for  the  dispersion  of 
inective-tissue  overgrowths.  Whilst  in  the 
rious  forms  of  electricity  we  have  special 
ents  of  the  highest  value,  not  only  for  mitiga- 
jg  pain,  but  for  allaying  spasm,  for  improving 
e nutrition  of  wasted  muscles,  and  for  facili- 
ing  the  bringing  of  them  again  under  the 
luence  of  the  will  in  cases  of  paralysis. 

The  above  are  only  some  of  the  chief  special 
nedies  which  we  employ  in  the  treatment  of 
:vous  diseases.  We  have,  as  more  general  re- 
dies—so-called  nervine  tonics — the  prepara- 
ns  of  zinc,  arsenic,  iron,  quinine,  phosphorus, 

1 1-liver  oil,  &c. ; whilst  we  have  also  frequent 
msion  to  call  to  our  aid  ordinary  tonics, 
;!rgatives,  emmenagogues,  anthelmintics,  and 
'inter-irritants,  together  with  cold  or  tepid 
itches  and  the  shampooing  of  paralysed  limbs. 
The  manifestations  of  nervous  disease  are  im- 
i nsely  influenced  by  the  general  state  of  health 
i the  patient,  and  this  not  only  in  so-called 
1 ctional,  but  even  in  the  gravest  of  structural 
i eases.  There  is  indeed  no  class  of  affections 
i which  more  good  may  result  from  a minute 
i ard  to  diet,  exercise,  amount  and  kind  of 
1 our,  and  that  general  attention  to  all  hygienic 
(jails  upon  which  those  most  skilled  in  the 
t itment  of  these  diseases  always  largely  rely. 
. ire  are  few  chronic  diseases  of  the  nervous 
(jtem,  even  of  the  most  obstinate  and  progres- 
■'3  type,  in  which  very  much  may  not  be  done 
tier  to  arrest  or  to  stay  their  progress,  by 
•pful  attention  to  such  hygienic  details,  by 
t judicious  administration  of  drugs,  and  by 
i ntaining  the  general  health  of  the  patient  at 
1 highest  possible  standard. 

H.  Charlton  Bastian. 


NEURALGIA.  1029 

NERVOUS  TEMPERAMENT.  See 

Temperament. 

NETTLE  RASH. — A popular  synonym  fo* 
urticaria.  See  Urticaria. 

NEUCLEUS. — Ste  Cell;  and  Appendix. 

NETJENAHR,  in  Germany. — Thermal  al- 
kaline waters.  See  Mineral  Waters. 

NEURALGIA  [vtvpov,  nerve,  and  i\yew,  I 
suffer  pain). — Synon.  : Fr.  Nevralgie ; Ger.  A’ew- 
ralgie. — This  is  a term  applied  to  a disease  of  the 
nervous  sensory  apparatus,  marked  by  paroxys- 
mal pain,  which  is  for  the  most  part  unilate- 
ral, and  in  the  course  of  nerves.  In  many 
cases  no  evidence  of  change  in  the  periphery 
of  the  nerve  is  discoverable,  and  to  these  the 
term  neuralgic  is  perhaps  most  properly  ap- 
plied ; in  others,  however,  there  is  reason  to 
think  that  inflammation  of  the  sheath  of  the 
nerve  is  at  least  the  starting-point  of  the  dis- 
order. The  diagnostic  points  are  as  yet  not 
sufficiently  certain  for  these  cases  of  peri-neuritis 
to  he  absolutely  separated  from  those  of  neu- 
ralgia, and  they  may  so  far  be  considered  to- 
gether. Relative  constancy  in  the  pain,  with 
paresis  and  atrophy  of  muscles  supplied  by  the 
affected  nerve,  and  swelling  of  the  nerve-trunk, 
point  to  peri-neuritis.  See  Neuritis. 

.(Etiology. — Neuralgia  is  prone  to  occur  in 
families  marked  by  neurosal  tendencies,  not 
necessarily  of  neuralgic  character,  but  which 
display  themselves  in  various  phases  of  psy- 
chical disturbance,  as  insanity,  hysteria,  hypo- 
chondriasis, or  in  the  shape  of  epilepsy  and 
chorea.  Rare  before  puberty,  that  crisis  has  a 
strong  predisposing  influence.  In  the  middle 
period  of  life,  though  first  attacks  are  not  very 
common,  revivals  of  old-standing  disease  are  apt 
to  occur,  as  a result  apparently  of  the  depression 
occasioned  by  the  cares  of  life.  Premature 
agedness  (marked  by  atheromatous  changes  in 
the  vessels,  arcus  senilis,  permanent  greyness 
of  hair,  bagging  of  the  cheeks,  pulmonary  em- 
physema) conduces  to  severe  and  intractable 
neuralgias.  Malaria  is  a potent  cause.  Amemia 
and  mal-nutrition  generally,  however  brought 
about,  play  an  important  part.  So  also  do 
sexual  excesses,  and  perhaps  likewise  a state  of 
celibacy.  Pregnancy,  over-lactation,  and  menor- 
rhagia are  each  predisposing  causes.  The  most 
frequent  exciting  causes  are  cold,  especially 
damp  cold ; injury  to  the  nerve  by  violence,  or  by 
the  encroachment  of  morbid  growths ; syphilis  ; 
gout ; and  the  presence  of  lead  or  mercury  in 
the  system.  Irritation  of  peripheric  organs  may 
excite  neuralgia  in  nerves  nearly  or  remotely 
associated.  So  dental  caries  may  induce  supra- 
orbital neuralgia ; uterine  disease  may  excite 
neuralgia  of  distant  nerve-trunks — as,  for  ex- 
ample, the  occipital ; and  the  presence  of  intes- 
tinal worms  may  explain  the  occurrence  of  neu- 
ralgia in  parts  quite  unconnected  with  the  bowels. 
Neuralgia  is  a common  sequel  of  relapsing  fever. 

Anatomical  Characters. — In  neuralgia  pro- 
per no  definite  lesions  are  discoverable  — at 
least,  none  that  arc  constant  enough  to  deserve 
the  place  of  necessary  accompaniments  or  factors 
of  the  disease.  As  a result  of  neuritis  or  peri- 


NEURALGIA. 


1030 

neuritis  the  nerve-trunk  is  sometimes  found 
swollen  and  hyperemic;  or,  in  a later  stage, 
it  may  be  atrophied  and  its  fibres  degenerated. 

Symptoms.  — After  some  little  preceding 
numbness,  cutaneous  anaesthesia,  or  other  ab- 
normality of  sensation,  the  import  of  which 
gets  to  be  well  understood  by  persons  liable  to 
neuralgia,  the  patient  is  seized  with  pain, 
which  at  first  is  not  severe,  and  ceases  quickly, 
but  returns  in  a few  seconds  or  minutes,  lasting 
for  a short  time,  and  then  remitting.  These 
darts  revive  with  shorter  and  shorter  intervals, 
so  that  in  a little  time  the  pain  appears  to  be 
almost  continuous,  or  interrupted  only  by  waves 
of  intensity,  and  it  will  last  for  some  seconds  or 
more  than  a minute  together.  Then  comes  a 
respite,  to  be  followed  by  recurrence,  and  these 
alternations  may  continue  for  a few  minutes  or 
as  many  hours.  In  attacks  of  long  duration 
where  no  treatment  is  applied,  the  pains  gradu- 
ally get  less  acute,  the  intermissions  longer,  and 
the  outbreak  slides  off  into  a confused  feeling 
of  discomfort  and  bruising  about  the  seat  of 
pain,  coupled  with  a sense  of  exhaustion  and 
desire  for  sleep.  The  character  of  the  pain 
varies;  it  is  described  as  darting  like  a knife 
or  like  lightning,  crushing,  hammering,  boring, 
and  sometimes  burning.  In  neuralgia  about 
the  head  the  patient  will  often  be  seen  to  cringe 
and  recede  before  the  plunges  of  pain,  as  though 
he  were  receiving  blows.  When  the  pain  is  at 
its  worst  there  is  often  a radiation  of  it  to 
other  nerves,  and  especially  to  those  placed 
symmetrically  with  the  one  affected  ; but  this 
secondary  pain  never  attains  anything  like  the 
severity  of  the  original.  Not  always,  but  very 
commonly,  certain  definite  points  where  pressure 
is  exceedingly  painful  may  be  found  by  palpa- 
tion. These,  the  ‘points  douloureux’  of  Val- 
leix,  have  a certain  diagnostic  importance. 
Rare  in  first  attacks,  they  are  much  more  com- 
mon in  patients  who  have  been  subject  to 
recurrences  during  many  years.  There  is  always 
a nerve-branch  under  the  skin  at  these  points, 
and  more  often  than  not  they  correspond  with 
the  point  of  emergence  of  a nerve  from  a bony 
groove  or  opening,  or  its  passage  through  a 
muscular  aponeurosis.  Pallor  of  the  skin,  fol- 
lowed by  intense  redness,  horripilation,  and 
other  evidences  of  vaso-motor  disturbance  are 
common.  In  the  case  of  nerves  being  attacked 
which  preside  over  glands  there  is  often  in- 
creased secretion.  The  tactile  sensibility  of 
the  skin  is  almost  always  diminished  after  a 
time  in  the  neighbourhood  of  the  affected  nerve, 
though  at  first,  there  is  some  bypertesthesia. 

Local  Varieties. — The  varieties  of  neuralgia 
are  divided  into  two  primary  groups,  namely, 
I.  Superficial ; and  II.  Vieoeral. 

I.  Superficial. — These  include  the  follow- 
ins:  : — 

(a)  Trigeminal  neuralgia.  See  Tic  Doulou- 
reux. 

(b)  Cervico-occipital  neuralgia. — The  poste- 
rior branches  of  the  first  four  pairs  of  spinal 
nerves  may  be  affected,  but  it  is  that  of  the 
second,  the  great  occipital,  which  is  most  im- 
portant, from  its  size,  and  the  frequency  with 
which  it  is  attacked.  Shooting  pains  start 
from  just  below  the  occiput,  and  run  over  the 


back  and  top  of  the  head,  sometimes  into  t] 
external  meatus,  and  often  to  the  front  of  t 
head  and  face.  Giddiness,  noise  in  the  ea 
and  some  confusion  of  ideas  are  often  associat ! 
and  frequently  cause  cervico-occipital  neural; 
to  be  mistaken  for  commencing  organic  diset 
of  the  brain.  It  may  begin  by  such  act 
tenderness  of  the  scalp  as  makes  it  an  agony ! 
brush  the  hair. 

(c)  Cervico-brachial  neuralgia. — The  nerves 
the  brachial  plexus  and  the  posterior  branch 
of  the  four  lower  cervical  nerves  are  here  a 
cerned.  The  pains  affect  the  neck  and  shoulde  j 
or  shoot  down  the  arm  to  the  hand,  in  the  com! 
of  one  or  more  of  the  nerve-trunks.  Pain: 
points  may  be  found  in  the  axilla,  over  t 
upper  part  of  the  deltoid,  at  the  bend  of  t 
elbow,  three  inches  above  it  externally, 
the  groove  between  the  inner  condyle  of  t 
humerus  and  the  olecranon,  at  the  ulnar  side 
the  annular  ligament,  and  where  the  rad 
nerve  becomes  superficial.  The  ulnar  nerve 
that  most  often  affected,  but  the  neuralgia  us 
ally  spreads  to  other  trunks.  This  form 
neuralgia  is  sometimes  associated  with  the  pi; 
sence  of  carious  teeth. 

(d)  Dorso-intercostal  neuralgia.  S:e  Lvri 
costal  Neuralgia. 

(e)  Lvmbo-aJjdominal  neuralgia. — Here  t1 
superficial  branches  of  the  lumbar  plexus  to  t 
abdominal  walls  are  affected.  It  is  less  comm 
than  intercostal  neuralgia,  but  resembles  i 
generally.  Tender  points  maybe  found  close  I 
the  spine,  at  the  middle  of  the  crest  of  the  ilia 
iu  the  hypogastric  region,  in  the  groin,  and ' 
the  scrotum.  The  female  sex  is  apt  to  be  m 
affected. 

(/)  Crural  neuralgia. — This  variety  is  aim 
always  met  with  as  a complication  of  sciati 
being  rare  by  itself.  Pain  occurs  in  the  front1 
the  thigh  and  knee,  and  inner  surface  of  the . 
and  foot.  The  long  saphenous  branch  of  i- 
anterior  crural  nerve  is  most  commonly  affect. 
This  form  of  neuralgia  is  not  unfrequent  in  h- 
joint  disease,  where  it  is  secondary  to  irritatl 
of  the  branches  of  the  obturator  nerve  supp- 
ing the  joint. 

(g)  Obturator  neuralgia  affects  the  inner  si 
of  the  thigh. 

( h ) Fcnioro-poplitral  neuralgia.  See  Sciati. 

(i)  Coccydynia. — Pain  in  the  neighbourly! 
of  the  coccyx,  more  properly  called  coccygodm, 
especially  apt  to  occur  in  women,  is  sometin, 
but  by  no  means  always,  due  to  neuralgia  of  e 
coccygeal  plexus.  The  pain  is  felt  particular 
in  sitting,  and  shocks  from  rapid  movemt 
or  jumping  will  cause  great  distress.  So  cp 
sometimes  the  act  of  delineation  may  be  so  pc- 
ful  as  to  suggest  the  presence  of  fissure  of  e 
anus.  More  often  than  not  the  affection  folks 
an  injury,  especially  a fall  in  the  sitting  p - 
tion,  and  happens  sometimes  aftor  difficult  p- 
turition. 

II.  Visceral. — (a)  Cardiac. — A certain  ] - 
tion  of  the  class  of  cases  called  angina  pectjs 
depends  upon  cardiac  neuralgia  (see  Atccfi 
Pectoris).  There  is  sudden  severe  pain  at  |0 
lower  end  of  the  sternum,  darting  to  the  b* 
and  down  the  left  arm,  or  it  may  be  diffi,j 
over  the  chest  and  affect  both  arms.  The  Ini 


EURALGIA. 


feals  as  though  it  were  grasped,  the  face  loses 
.colour,  the  pulse  becomes  altered  iu  character, 
there  is  cold  sweating,  and  generally  the  aspect 
and  feeling  of  approaching  death,  tiueh  attacks 
.may  be  confined  to  two  or  three  repetitions,  or 
there  may  be  a constant  tendency  to  their  recur- 
rence under  circumstances  of  fatigue  or  strong 
'emotion. 

(b)  Uterine  and  ovarian  neuralgia. — Pain  at- 
tendant upon  menstruation,  independent  of  any 
nechanical  difficulty,  is  thus  named.  It  may  he 
excited  by  such  sources  of  peripheral  irritation 
is  ascarides,  leueorrhcea,  renal  calculus,  pro- 
apsus  uteri,  tumours,  ulceration  of  the  cervix, 
ir  impaction  of  feces ; or  the  sources  may  he  in 
some  distant  part  of  tho  body.  Ovarian  neu- 
ralgia may  be  accompanied  by  congestion  of  the 
wary. 

(c)  The  urethra , bladder,  rectum,  lcidney,  and 
'testis  may  each  ho  affected  by  neuralgia.  The 
latter  may  result  from  self-abuse,  or  be  con- 
sequent upon  renal  concretion.  See  Nephralgia. 

(d)  Gastralgia. — Abdominal  neuralgia  is  eha- 
■acterised  by  intensity  of  colicky  pain,  occurring 
n paroxysms  in  circumstances  differing  from 
hose  which  induce  ordinary  dyspepsia.  There 
is  nearly  always  a history  of  neuralgia  in  some 
>ther  part  of  the  body.  Vomiting  sometimes, 
md  constipation  invariably,  accompanies  the 
ittacks.  See  Gastralgia. 

Complications  and  Sequel.®. — Neuralgia 
vhen  it  attacks  mixed  nerves  may  produce 
huscular  powerlessness,  which  is  not  merely  a 
hrinking  from  making  muscular  effort  because 
if  the  pain  attending  it,  but  a temporary  paraly- 
is.  Or  there  may  be  spasm  of  muscles.  Long- 
ontinued  neuralgia  is  attended  by  more  or  less 
trophy  of  the  muscles  supplied  by  the  affected 
erves,  which  may  be  temporary,  or,  in  cases 
there  frequent  recurrences  of  the  attack  take 
■lace,  may  be  permanent.  Certain  forms  of 
euralgia,  especially  that  of  the  first  division  of 
he  fifth,  intercostal,  and  sciatic  are  liable  to  be 
ccompanied  by  a herpetic  eruption  {see  Herpes). 
maesthesia  of  a portion  of  the  skin  will  often 
ersist,  though  the  pain  itself  may  be  absent. 
Diagnosis. — It  may  be  said  perhaps  that  for 
ain  to  be  strictly  accounted  neuralgic  there 
fould  be  no  obvious  cause  for  it,  such  as  local 
lfiammation,  tumour,  or  injury:  it  should  be 
jlitsSnittent,  or  at  least  liable  to  great  exacer- 
itions,  and  independent  of  movement  or  any  ex- 
Tnal  agency ; it  should  take  the  course  of  one  or 
lore  nerves  ; and  there  should  be  spots  painful 
1 pressure  in  some  of  the  localities  already  in- 
'eated.  Neuralgia  is  distinguished  from  mval- 
|a  by  tho  latter  involving  the  attachments  of  a 
uscle,  not  occurring  in  paroxysms,  but  depend- 
it  upon  movement ; from  aneurism  by  careful 
■ lysical  examination,  which  is  especially  neces- 
ry  when  the  pain  is  about  the  chest  and 
ins.  In  chronic  rheumatism  the  pain  is  dif- 
sed,  influenced  by  movement,  and  it  does  not 
‘feet  the  district  of  a particular  nerve.  Acute 
eumatism  is  accompanied  by  elevation  of 
mperature,  sweating  and  swelling  of  joints. 
ie  thermometer,  and  the  known  symptoms  and 
!;ns  of  the  several  diseases,  will  also  at  once 
elude  pleurisy,  pneumonia,  and  peritonitis, 
philitic  periostitis  is  evidenced  by  the  sight 


1031 

and  touch,  as  well  as  (if  it  occur  early  iu 
the  disease),  by  the  presence  of  febrile  move- 
ment. Where  pain  in  the  back  is  supposed 
to  be  of  neuralgic  origin  it  is  important  to  ex- 
clude the  presence  of  hernia.  Examination  should 
be  made  per  vaginam  to  exclude  flexions  or 
tumours  of  the  uterus,  and  per  anum  for  the 
presence  of  abscess  about  the  rectum  or  malignant 
disease.  Organic  disease  of  the  brain  must  be 
excluded  by  the  absence  of  local  palsy,  vomit  ing, 
intellectual  disturbance,  or  optic  neuritis.  The 
pains  of  Bright’s  disease  must  be  carefully  ex- 
cluded by  search  for  albumen,  signs  of  arterial 
thickening,  and  cardiac  hypertrophy.  Spinal 
irritation  is  accompanied  by  pains  which,  how- 
ever, fail  to  mark  the  district  of  particular 
nerves,  and  are  vague  and  shifting.  There  is 
hyperaesthesia  of  the  skin  over  some  of  the  verte- 
bral spines.  Locomotor  ataxy  is  characterised  by 
pains  of  lightning-like  rapidity,  and  neuralgic  in 
character ; but  they  shift,  are  often  accompanied 
by  a staggering  gait,  sometimes  by  diplopia. 
Absence  of  the  patellar  tendon  reflex  (the  quadri- 
ceps extensor  muscle  at  the  same  time  responding 
freely  to  faradization  and  blows)  is  a strong 
indication  of  locomotor  ataxy.  The  pains  of 
syphilis  in  its  second  stage  maybe  distinguished 
by  the  presence  of  fever,  usually  also  of  a rash, 
and  the  fact  that  they  affect  many  parts  at  once. 

Prognosis. — Youth,  the  absence  of  strongly- 
marked  history  of  hereditary  neurosis,  the  fact 
that  neuralgia  has  followed  exposures  to  unusual 
strain,  severe  weather,  or  passing  defects  of 
nutrition,  and  that  its  attacks  are  influenced 
readily  by  treatment,  afford  a favourable  prog- 
nosis. The  onset  of  the  disease  after  middle  life, 
and  its  concurrence  with  signs  of  arterial  degene- 
ration, are  unfavourable  as  regards  cure.  Neu- 
ralgia of  itself  can  scarcely  he  said  to  affect  the 
duration  of  life.  On  the  whole  neuralgia  of  tho 
fifth  nerve  is  the  most  persistent. 

Treatment. — In  patients  suffering  from  mal- 
nutrition the  diet  should  he  ample  and  nutri- 
tious, and  should  include  a fair  amount  of  the 
fatty  element,  in  the  form  of  cod-liver  oil,  butter, 
or  cream.  A little  stimulant  may  sometimes  he 
necessary,  enough  to  promote  primary  digestion, 
hut  no  attempt  should  he  made  to  relieve  pain 
by  its  direct  agency.  Rheumatism  should  be 
treated  by  salicylate  of  soda  in  20-grain  doses 
three  or  four  times  a day.  Two  or  three 
grains  of  iodide  of  potassium  with  fifteen  of  car- 
bonate of  soda  taken  every  four  hours  will  often 
remove  neuralgic  pain  connected  with  rheu- 
matism. When  malaria  is  suspected  it  is  well 
to  follow  up  this  treatment  by  quinine  in  doses 
of  from  five  to  ten  grains  twice  a day.  A 
mercurial  purgative  may  he  usefully  combined 
with  a dose  of  quinine.  If  there  be  syphilis, 
iodide  of  potassium  in  10-grain  doses  three  times 
a day  must  he  had  recourse  to;  if  gout,  the 
acetic  extract  of  colchicum  may  he  given  in 
one-grain  doses  twice  daily,  coupled  with  saline 
purgatives.  Even  where  there  is  no  history 
of  malaria  quinine  will  often  he  very  useful, 
especially  in  neuralgia  of  the  first  division  of  the 
fifth  ( see  Tic-Doulourf.ux).  Phosphorus  in  its 
free  state,  in  capsules  containing  gr.  twieo 
a day,  after  food,  is  sometimes  of  service.  Or 
the  hypophosphite  of  soda  or  potash  may  hi 


1032  NEURALGIA, 

given  in  doses  of  from  five  to  ten  grains.  Phos- 
phoric acid  is  not  of  value.  The  liquor  potass® 
arsenitis,  in  doses  of  iniij,  increased  cautiously 
to  inviij,  or  n\x,  and  the  tincture  of  steel, 
in  doses  of  raxxx,  largely  diluted  with  water, 
may  sometimes  be  used  with  advantage;  and 
the  latter  will  occasionally  succeed  even  when 
there  are  no  ordinary  signs  of  chlorosis.  As 
anaemia  may  exist  with  a well-coloured  face,  the 
state  of  the  gums  and  inner  surface  of  the  lower 
eyelid  should  be  examined  for  undue  pallor. 
Strychnia,  in  iniij  to  n\.v  doses  of  the  liquor  three 
or  four  times  daily,  is  especially  useful  in  gas- 
tralgia,  and  belladonna,  in  ^ gr.  doses  of  the  ex- 
tract or  inx  doses  of  the  tincture,  in  neuralgia  of 
the  pelvic  viscera.  Seclusion  from  irritation  of 
various  kinds — movement,  cold,  noise,  dazzling 
light,  worry — should  he  carefully  maintained  in 
cases  of  trigeminal  neuralgia.  All  sources  of  peri- 
pheral irritation,  of  which  decayed  teeth,  foreign 
bodies  under  the  skin,  intestinal  worms,  imper- 
fectly-fitting boots  are  examples,  should  he  care- 
fully searched  for,  and  where  practicable  re- 
moved. If  lead  be  suspected  the  drinking  water 
should  be  tested,  and  if  the  mineral  be  found 
iodide  of  potassium  may  be  administered.  Re- 
moval from  imperfectly  ventilated  rooms,  or 
from  exposure  to  noxious  gases,  is  essential.  A 
warm,  dry  climate,  such  as  Egypt  or  Algeria, 
will  often  cure  when  all  other  remedies  have 
failed.  Por  immediate  relief  morphia  may  be 
injected  hypodermically,  either  near  the  seat  of 
pain,  or  in  an  indifferent  part  of  the  body.  It  is 
best  used  pretty  freely  diluted,  iniij  of  a solution 
of  acetate  of  morphia,  1 to  30,  being  commenced 
with,  and  repeated,  if  necessary,  when  the  pain 
returns.  This  dose  may  be  gradually  increased 
to  one  of  in  xv,  but  an  effort  should  be  made  to 
do  with  as  little  as  possible  and  to  avoid  nar- 
cotic effects.  The  following  pill  is  often  useful : 

Quini®  gr.  j,  Eerri  Tartarati  gr.  ij,  Morphi® 
Acetatis  gr.  i,  repeated  every  hour  or  two  when 
the  onset  is  expected. 

Next  in  value  to  morphia  is  the  use  of  small 
blisters  (size  of  a florin),  applied  in  the  neigh- 
bourhood of  the  principal  focus  of  pain,  one 
following  another  at  intervals  of  two  days,  not 
on  but  near  the  already  blistered  surface.  The 
continuous  current,  derived  from  so  many  cells  of 
a battery  as  cause  a characteristic  feeling  of  burn- 
ing, may  be  so  applied  that  the  affected  nerve  is 
as  completely  as  possible  included  in  the  voltaic 
circuit.  Sponges  moistened  with  warm  salt 
water  should  convey  the  current,  and  be  kept 
firmly  pressed  upon  the  skin  for  about  ten 
minutes ; or,  whilst  one  is  still,  the  other  may 
be  slid  along  so  as  to  linger  in  turn  upon  each 
focus  of  pain.  To  avoid  shock  the  circuit  should 
cot  be  broken  by  the  lifting  of  a sponge  till 
the  battery  is  ‘letdown’  to  zero.  If  relief  be 
afforded  the  application  may  be  repeated  many 
times  a day.  No  notice  need  be  taken  of  the 
position  of  the  poles  ( + and  — ),  the  object  of  the 
proceeding  being  simply  to  alter  the  electric 
tension  of  the  tissues  which  are  made  to  form 
part  of  the  circuit. 

In  rare  instances,  but  especially  in  ovarian 
neuralgia,  the  hypodermic  injection  of  atropine 
er.  to  i gr.  of  the  sulphate)  may  prove 
serviceable.  Where  there  is  great  restlessness 


NEURITIS. 

and  irritability  of  the  nervous  system,  bromide 
of  potassium  in  30-grain  doses  two  or  three 
times  a day  should  be  used.  Relief,  in  slight1 
cases  of  neuralgia,  is  obtained  by  applying  to  the 
skin  such  liniments  as  the  following;  Chlo- 
roformi  :ss,  Tincturae  Opii  Jss,  Linimentum 
Belladonna  ad  yiij. ; or  Ijc  Spiritus  Ammonite 
aromatici,  JEtheris",  Tinctur®  Opii,  Spiritus 
Vini  rectificati  aa  51.  Aconite  and  veratria  be- 
numb the  sensory  nerves,  but  they  are  uncertain 
remedies  and  very  apt  to  cause  irritation. 

In  unusually  severe  cases,  which  have  lasted 
over  years,  a portion  of  the  nerve  may  he  ex- 
cised ; or,  what  is  better,  the  nerve,  which  has 
been  exposed  by  an  incision,  may  be  lifted  from 
its  bed  and  so  firmly  pulled  upon  as  to  be 
stretched  (see  Nebves,  Diseases  of).  Veiy  satis- 
factory results  have  followed  this  procedure 
In  a case,  treated  by  the  writer,  of  terribb 
severe  neuralgia  of  the  first  two  divisions  ol 
the  fifth  nerve,  the  operation  was  performed  on 
each  division  of  the  nerve  in  turn,  with  immediate 
and,  as  far  as  at  present  observed,  permanent 
relief  from  pain.  Some  time  after  the  enre  cl 
a neuralgia  there  may  be  threatenings  of  a 
revival  (dull  heaviness,  with  tenderness,  of  the 
part)  following  great  fatigue  or  worry,  but  not 
immediately  amounting  to  anything.  Sleep  is 
the  best  remedy  for  this  condition,  and  this,  i' 
necessary,  may  be  aided  by  giving  ten  grains; 
of  chloral  hydrate. 

Special  reference  must  be  made  to  the  treat- 
ment of  coccydynia.  This  consists  in  sub- 
cutaneous division  of  tho  muscles  and  fibrous 
structures  attached  to  the  coccyx  with  a teno 
tomy  knife.  In  very  troublesome  eases  tlx* 
coccyx  has  been  excised.  The  application  of  ; 
leech  or  small  flying  blisters  in  the  neighbour 
hood,  will  sometimes  relieve.  The  bowels  shoulc 
be  kept  rather  loose,  and  rest  enjoined.  In  ob 
stinate  cases,  where  it  seems  probable  that  loi 
irritation  exists,  the  above-mentioned  operation 
of  Sir  J.  Simpson  may  be  performed  with  ad 
vantage.  T.  Bczzabd. 

NEURITIS  (vevpov,  a nerve). — Definition 
Inflammation  of  a nerve. 

..Etiology. — This  process  occurs  sometime 
as  an  idiopathic  change,  whose  origin  is  alto 
gether  obscure,  as  where  it  implicates  some  c 
the  intercostal  or  other  spinal  nerves,  and  is  the 
often  associated  with  an  eruption  of  herpes  coste 
in  corresponding  regions  of  the  skin.  At  othe 
times,  as  in  some  of  the  cases  when  it  attack 
the  facial  especially,  or  the  sciatic  nerve,  neuriti 
seems  to  he  set  up  as  a result  of  local  exposur 
to  cold  (see  Facial  Neeve,  Paralysis  of;  an 
Sciatica).  Such  forms  of  neuritis  as  these  a: 
commonly  spoken  of  as  ‘ rheumatic  inflammt 
tions  ’ of  the  respective  nerves.  Sometimes  th 
appellation  may  be  distinctly  justified;  ht 
whether  such  changes  have  necessarily  to  d 
either  with  rheumatism  or  with  a rheumst 
predisposition— or,  indeed,  with  gout  — seen 
in  many  cases  fully  open  to  doubt.  A proce 
essentially  similar  does,  however,  unquestionab) 
occur  with  especial  frequency  in  connectic 
with  the  roots  of  cranial  or  spinal  nerves,  ; 
persons  affected  with  syphilis. 

At  other  times  neuritis  may  ho  of  tramnat 


! 


NEUKITIS. 

origin,  or  it  may  spread  along  the  nerves  leading 
from  some  -wound  or  sloughing  sore.  This  latter 
cndition  of  things  has  been  found  to  exist  in 
:ome  cases  of  traumatic  tetanus.  See  Tetanus. 

Anatomical  Characters.— Strictly  speaking, 
ve  have  to  do,  in  this  pathological  state,  with 
inflammation  of  the  sheath  of  the  nerve,  rather 
han  with  changes  in  the  nerve-fibres  them- 
;elves.  It  is  possible,  of  course,  that  the  nerye- 
ibres  in  this  condition  may  undergo  some  dis- 
inetive  pathological  changes,  but  what  is  at 
, resent  known  is,  that  the  neurilemma,  or  con- 
ective-tissue  sheath  of  the  nerve  (including  its 
ainute  prolongations  between  and  around  sepa- 
rate bundles  of  nerve-fibrils)  becomes  much  more 
kypersemic  than  natural,  and  that  on  microscopi- 
al  examination  there  is  to  he  found,  in  addition 
jo  the  increased  vascularity,  a multiplication  of 
ew  tissue-elements  and  the  presence  of  migrated 
leucocytes.  These  changes  may  cause  consider- 
ate swelling  of  the  nerve-sheath  and  of  its  pro- 
bations, and  thus  may  produce  either  mere 
:ritation  or  more  or  less  compression  of  the 
erve-tubules,  according  to  the  amount  of  new 
lements  which  accumulate  in  or  are  produced 
ithin  the  nerve-sheath. 

Symptoms. — The  symptoms  of  neuritis  will 
ecessarily  vary  much  according  to  the  functions 
ith  which  the  affected  nerve  is  concerned, 
'here  may  be  impairment  of  special  or  common 
visibility,  or  pain  may  exist  (referred  to  the 
eripheral  distribution  of  the  nerve),  with  more 
■c  less  distinct  tenderness  along  its  course.  In 
rese  cases  the  pain  is  generally  paroxysmal, 
id  possibly  a pustular  or  vesicular  skin-eruption 
ay  present  itself  along  the  course  of  the  nerve, 
ter  some  more  than  usually  severe  attack 
1 pain.  Where  a motor  nerve  is  implicated, 
lere  may  be  twitchings  of  the  muscles  to  which 
is  distributed,  followed,  perhaps,  by  more  or 
ss  distinct  paralysis.  In  the  case  of  a mixed 
are,  like  the  sciatic,  being  involved,  both 
□ds  of  symptoms  present  themselves— that  is, 
ore  or  less  severe  pains  and  tenderness,  to- 
|ther  with  a distinct  paresis  of  the  muscles  to 
lieh  the  nerve  is  distributed. 

Treatment. — The  treatment  of  neuritis  is 
tli  general  and  local.  The  general  treatment 
of  especial  importance  in  cases  where  the 
fldition  seems  attributable  to  the  influence  of 
jphilis,  and  then  the  administration  of  small 
ses  of  bichloride  of  mercury,  in  combination 
th  large  doses  of  iodide  of  potassium,  will 
en  produce  marvellously  beneficial  results, 
uller  doses  of  iodide  of  potassium  alone,  or 
:h  colchicum,  are  to  he  given  in  other  cases,  in 
' ich  rheumatism  or  gout  may  seem  to  be  one 
'the  factors  in  exciting  the  nerve-inflammation. 

• t in  these  cases,  and  also  in  thoso  which  are 
i lple  results  of  exposure  to  cold,  the  cure  may 
loften  expedited,  and  the  patient  also  tempo- 
i ily  relieved,  by  local  treatment,  such  as  the 
i plication  of  a leech  or  two  (especially  in  the 
' ly  stages),  hot  fomentations,  or  small  flying 
I iters. 

luring  the  course  of  the  treatment  special 
i lptoms  may  become  all-important ; thus,  pain 
•If  become  so  agonising  as  imperatively  to  de- 
[ id  measures  for  its  relief;  and,  where  paralysis 
1 ne  of  the  symptoms,  galvanism  must  he  em- 


NIGHTMARE.  1033 

ployed  daily,  or  two  or  three  times  a week,  in 
order  to  prevent  as  much  as  possible  the  muscles 
from  degenerating  whilst  the  pathological  condi- 
tion in  the  nerve  is  being  cured— that  is,  in  cases 
in  which  a cure  is  possible. 

H.  Charlton  Bastian. 

NEUROMA  ( vevpuv , a nerve). — A tumour 
connected  with  a nerve.  See  Nerves,  Diseases  of. 

NEUROSES  ( vevpoi' , a nerve). — Synon.  : 
Fr.  Neuroses  ; Ger.  Ncrvenleiden. 

Definition. — Affections  of  the  nervous  system 
occurring  without  any  material  agent  producing 
them,  without  inflammation  or  any  other  con- 
stant structural  change  which  can  he  detected  in 
the  nervous  centres  : in  other  words,  functional 
affections  of  the  nervous  system. 

Many  of  the  disorders  which  may  he  included 
here  are  characterised  by  symptoms  such  as  neu- 
ralgia, convulsions,  &c.,  which  also  accompany 
other  disorders  associated  with  morbid  changes. 
It  is  very  necessary,  therefore,  in  inquiring  into 
any  particular  case  not  to  rest  satisfied  with  the 
presumption  that  the  disorder  is  functional  until 
the  condition  of  the  nervous  centres  has  been 
investigated;  lest,  regarding  the  symptom  as  the 
disease,  the  central  mischief  to  which  it  is  due 
may  be  overlooked.  It  is  highly  probable,  more- 
over, that  many  of  what  we  now  regard  as  func- 
tional diseases  will,  on  further  investigation,  he 
found  to  depend  upon  some  corresponding  change 
in  the  organ  affected. 

Enumeration. — The  neuroses  may  he  classi- 
fied according  to  the  organs  or  functions  in- 
volved : — 

a.  Visceral  Neuroses,  namely,  those  of  the  re- 
spiratory, circulatory,  or  digestive  organs. 

b.  Localised  Paralyses-,  for  instance,  palsy  of 
the  facial  and  other  peripheral  nerves. 

c.  Localised  involuntary  or  reflex  movements, 
such  as  spasm  of  the  facial  nerve,  and  writer’s 
cramp. 

d.  Disorders  of  general  sensibility,  including 
the  various  forms  of  neuralgia — trigeminal, 
cervico-occipital,  sciatic,  crural,  &c. 

e.  General  Neuroses,  namely,  chorea,  tetanus, 
epilepsy,  catalepsy,  hysteria,  and  allied  affec- 
tions. 

f.  Disorders  of  the  mental  faculties — hj-pochon- 

driasis,  melancholia,  and  other  forms  of  mental 
derangement.  P.  W.  Latham. 

NICE,  on  the  Erench.  Riviera. — Fairly 
warm,  rather  variable  and  windy,  dry,  bracing 
winter  climate.  Mean  temperature,  winter, 
4S’33°  Fahr.  See  Climate,  Treatment  of 
Disease  by. 

NICTITATION  J (mc-tio>  I wlnk  often). 
A rapid  involuntary  winking  of  the  eyelids, 
usually  due  to  some  nervous  disturbance.  See 
Chorea  ; and  Facial  Spasm. 

NIGHT-BLINDNESS.  See  Nyctalopia. 

NIGHTMARE. — This  is  a condition  cha- 
racterised by  an  abiding  sense  of  discomfort  or 
extreme  uneasiness,  occurring  in  the  midst  of  a 
disturbed  sleep,  sometimes  associated  with  a 
feeling  of  weight  at  the  epigastrium,  in  conjimc* 


1034  NIGHTMARE, 

lion  with  more  or  less  definitely  oppressive 
dreams.  It  is  principally  associated  with  the 
taking  of  a heavy  meal  or  of  indigestible  food 
before  going  to  sleep  by  some  persons,  especially 
those  of  a nervous  temperament,  whose  diges- 
tion is  weak.  A closely  allied  condition  is, 
however,  apt  to  be  met  with  as  a consequence 
of  brain-exhaustion  and  chronic  disturbance  of- 
sleep  in  those  who  are  overworked,  either  by 
application  to  study,  business  details,  or  literary 
pursuits.  Such  a condition  also  has  its  affinities 
with  certain  forms  of  incipient  delirium,  occurring 
either  in  various  febrile  diseases  or  as  a result 
of  alcoholic  excesses.  Sec  Sleep,  Disorders  of. 

H.  Charles  Bastian. 

NIGHT-SIGHT.  See  Hemeralopia. 

NIGRITIES  ( niger , black).— Synon.  : Fr. 
Koirceur ; Ger.  Sckwcirzc. — Nigritics  cutis  sig- 
nifies blackness  of  the  skin.  It  may  be  of  various 
degrees  ; and  results  from  aberration  of  deposit 
of  pigment,  or,  more  exactly,  from  an  excess  of 
black  pigment  in  the  integument.  See  Melano- 

PATHIA. 

NILE,  The. — Very  dry  winter  climate.  Un- 
suitable for  cases  of  active  pulmonary  disease. 
Mean  temperature,  winter,  57°  Fahr.  See 
Climate,  Treatment  of  Disease  by. 

NIPPLE,  Diseases  of. — Synon.  : Fr.  Ma- 
ladies du  Mamelon ; Ger.  Krankhciten  dcr  Brust- 
warze. — Some  of  the  more  ordinary  affections  of 
the  nipple  will  be  found  described  under  Breast, 
Diseases  of,  and  Lactation,  Disorders  of.  Here 
it  is  proposed  to  treat  of  certain  graver  diseases, 
which  claim  a separate  consideration. 

Malignant  Disease. — The  nipple  may  be  the 
seat  of  epithelioma,  which  commonly  commences 
as  a crack  or  fissure,  with  an  indurated  base, 
often  in  the  areola  or  at  its  junction  with  the 
nipple.  It  presents  no  special  features  which 
distinguish  it  from  similar  disease  of  the  in- 
tegument of  adjoining  parts.  Hard  carcinoma 
too  may  attack  the  nipple,  involving  its  deeper 
structures  and  producing  general  induration  and 
enlargement,  so  that  the  diseased  mass  projects 
from  the  summit  of  the  breast  like  a knob  or 
large  nut.  The  disease  probably  originates  in 
the  epithelium  of  the  galactophorous  ducts,  or  in 
that  of  the  sebaceous  glands. 

Of  greater  interest  than  either  of  these  is  an 
affection  frequently  associated  with  malignant 
disease  of  the  breast,  to  which  Sir  James  Paget 
has  lately  drawn  attention — an  eczematous  con- 
dition of  the  nipple  and  areola.  It  may  occur  in 
the  form  of  a dry,  seal}',  or  bi'anny  eruption, 
affecting  the  entire  surface  of  the  areola  and 
nipple,  which  is  darker-coloured,  a little  firmer, 
and  less  pliant  and  elastic  than  its  fellow.  Or, 
with  more  characteristic  signs  of  inflammation, 
small  vesicles  or  pustules  may  form,  and,  break- 
ing or  being  rubbed  off,  may  leave  behind  them 
tiny  scabs  or  ulcers,  or  a surface  raw  and  red. 
Either  condition  may  exist  for  many  months  or 
even  years  with  little  alteration,  and  with  scarcely 
any  tendency  to  spread  beyond  the  margin  of 
the  areola.  But  the  second  form,  causing  more 
irritation  than  the  first,  is  often  subjected  to 
treatment,  and  being  very  difficult  to  cure,  is 
sometimes  so  severely  treated  with  caustics  that 


NOLI  ME  TANGERK. 
destruction  ensues,  not  of  the  disease,  but  of  tb 
nipple,  which  appears  to  have  been  gradual! 
eaten  away  by  the  eczematous  affection.  Bet 
forms  are  uncommon,  but  they  are  rare  befoi 
the  middle  age.  A study  of  their  clinical  an ! 
pathological  characters  leads  to  the  conclusioi 
that  they  are  due  to  inflammation.  The  diseas 
has  been  noticed  in  men  as  well  as  women. 

Treatment. — This  disease  may  be  treatc- 
by  protecting  the  parts  with  a carefully  acj 
justed,  ventilated  shield,  and  by  the  appl 
cation  of  vaseline,  or  liniment  of  lead  an 
oil,  or  similar  soothing  dressing.  But  it  is  vei 
intractable,  in  some  cases  apparently  incurahll 
It  might  seem  as  if  an  affection  so  trivial  w« 
not  worthy  of  so  much  attention ; but  unfa 
tunately  there  appears  the  strongest  reas 
to  believe  that  these  conditions  of  the  nipp 
and  areola  are  not  infrequently  the  precursors 
carcinoma  of  the  breast,  sometimes  by  only 
few  months,  sometimes  and  more  often,  by 
period  of  years.  It  is  probable,  too,  that  tl 
carcinoma  is  directly  due  to  the  eczematous  df 
ease;  for  it  induces  changes  in  the  epithelium 
the  ducts  which  can  be  traced  deeplv  into  tl 
substance  of  the  breast,  whose  acini  become 
length  distended  with  proliferating  epithelim. 
On  this  account  it  has  been  proposed,  when  a 
the  lesser  methods  of  treatment  have  been  us. 
in  vain,  to  remove  the  entire  breast.  Opinio 
which  are  divided  on  the  necessity  of  this  me 
sure,  so  severe,  are  united  in  its  favour  whe 
with  the  superficial  inflammation,  there  exists  .• 
appreciable  induration,  however  slight,  with 
the  breast.  Care  must  he  taken  not  to  confoti 
these  eczematous  affections  of  the  nipple  aj 
areola  with  those  more  widely  diffused  surfa 
inflammations  of  the  breast,  with  which  th 
have  little  in  common,  either  in  the  ohstina 
with  which  they  resist  treatment,  or  in  the  deep 
disease  to  which  they  may  give  rise. 

Henry  T.  Butlin. 

NOCTAMBULATION  {node,  in  the  nig 

and  ambulo,  I walk). — A term  for  sleep)- walkii 
See  Sleep,  Disorders  of. 

NOCTURNAL  EMISSIONS.— Invoh- 

tary  emissions  of  semen  occurring  during  sle. 
See  Sexual  Functions  in  tub  Male,  11- 
orders  of. 

NOCTURNAL  INCONTINENCE. — 

voluntary  escape  of  urine  during  sleep.  ‘ 
Micturition,  Disorders  of. 

NODE  {nodus,  a swelling). — A circumscrill 
swelling  on  the  surface  of  a bone,  connected  wi 
the  periosteum,  and  usually  due  to  syphilis.  ‘ 
Bone,  Diseases  of ; and  Syphilis. 

NODI  DIGITORUM  (Latin).— Swallip 
of  the  distal  phalanges  of  the  fingers,  usuff 
associated  with  gout.  See  Gout. 

NOLI  ME  TANGERE  (Hit.,  Touch-i- 
not). — A term  of  dread,  which  has  been  appU 
to  a state  of  severe  ulceration  of  the  nose.  ■ 
tended  with  fungous  growth  and  more  or  less  - 
formity.  The  phrase  is  subjective,  and  has  bn 
used  somewhat  indiscriminately  in  connectu 
with  lupus,  cancer,  and  syphilis.  It  has  & 
very  properly  fallen  into  disuse,  or,  when  • 


NOLI  ME  TANGERE. 
ployed,  is  restricted  to  lupus  exedensof  the  nose. 
See  Lupus  Vulgabis.  Erasmus  Wilson. 

NOMA  (ve/xu,  I devour;. — Synon.  : Fr. 

Rome;  Ger.  Wasserkrebs. — A synonym  for 
cancrum  oris.  See  Cancrum  Oris. 

NOSE,  Diseases  of. — Synon.  : Fr.  Mala- 
dies du  Nee:;  Ger.  Krankhciten  der  Nase. — The 
diseases  that  affect  the  nose  may  be  conveniently 
divided  into — (A.)  The  diseases  of  the  External 
Nose ; and  (B.)  the  diseases  of  the  Internal 
Nose. 

A.  Diseases  of  the  External  Nose. — 

1.  Acne  Hosacea. — Synon.:  Pop.  ‘Gin- 
drinker's  nose.’ — This  affection  of  the  nose  is 
generally  met  with  in  later  adult  age.  Not  un- 
frequently  the  cause  is  to  be  found  in  alcoholic 
indulgence.  In  other  cases  it  may  be  associated 
with  some  irregularities  of  menstruation. 

Description. — The  organ  is  swollen  and  red; 
its  surfaco  is  shiny  and.  greasy-looking ; the 
skin  is  highly  injected,  the  venules  particularly 
appearing  almost  varicose ; the  sebaceous  fol- 
licles are  enlarged,  though  not  invariably  ; and 
the  skin  is  hypertrophied,  the  whole  condition 
giving  rise  to  an  unnatural  protuberance.  At  a 
later  stage  of  the  disease  the  nose  appears  tuber- 
culated  and  blotched,  often  pustular,  and  covered 
with  crusts  and  scales  ( acne  hypertrophica).  The 
• blood  disappears  under  pressure,  and  increases 
under  mental  excitement. 

Treatment. — Mild  cases  are  "best  treated  by 
lead  lotion,  a weak  solution  of  tho  bichloride 
of  mercury,  or  zinc  ointment.  In  severe  cases 
the  subcutaneous  division  of  the  larger  vessels 
by  a fine  tenotomy  knife  causes  a rapid  shrink- 
ing and  improvement.  In  all  cases  of  acne  atten- 
tion must  be  paid  to  the  manner  of  living  and 
general  health  of  the  patient. 

2.  Boil,  or  Furuncular  Inflammation. — 
A very  painful  form  of  boil  is  liable  to  develop 
on  the  tip  or  aim  of  the  nose,  causing  great 
disfigurement  and  often  intense  suffering.  It 
commences  in  the  subcutaneous  cellular  tissue, 
or  beneath  the  perichondrium ; and  by  its  gradual 
increase  and  extension  to  skin  and  fibro-carti- 
lage,  causes  great  swelling,  tension,  and  throbbing 
pain,  owing  to  the  peculiar  toughness  of  the 
tissues  entering  into  the  formation  of  the  inte- 
gumentary structures. 

.Etiology. — This  affection  is  generally  met 
within  young  or  middle-aged  persons  of  intem- 
perate habits,  although  frequently  it  is  seen  in 
the  delicate  and  ancemic.  Elderly  persons,  high 
feeders,  who  do  not  attend  to  the  proper  condi- 
tion of  their  intestinal  canal,  are  also  liable  to  it. 

Treatment. — If  detected  early,  boil  of  the 
nose  may  be  treated  by  painting  with  strong 
lead  lotion,  or  just  touching  the  part  with  the 
acid  nitrate  of  mercury,  and  immediately'  rub- 
bing it  off.  If  very  severe,  and  in  order  to  avoid 
he  pit  or  scar  which  might  be  left  by  allowing 
■.he  disease  to  take  its  course,  a very  fine  teno- 
tomy knife  may  be  passed  through  the  nostril 
md  into  the  boil,  to  relieve  tension,  and  to  allow 
'f  the  escape  of  the  pus  into  the  nostril. 

3.  Deformities.  — (o)  Congenital  absence. — 
^ases  have  been  recorded  of  congenital  absence 
if  the  nose.  It  does  not  appear  that  this  con- 


NOSE,  DISEASES  OF.  1035 
dition  can  be  satisfactorily  assisted  by  surgical 
interference. 

(£)  Congenital  occlusion. — Congenital  occlu- 
sion of  one  or  both  nostrils  is  a very  rare  affec- 
tion, and  obviously'  must  interfere  seriously'with 
sucking  and  respiration.  It  is  either  the  result 
of  a continuation  of  the  integument,  or  is  formed 
of  fibrous  tissue.  The  treatment,  which  should 
be  undertaken  at  once,  consists  in  making  care- 
ful incisions  through  the  obstruction,  and  keeping 
the  nostril  dilated  with  a piece  of  gum  or  metal 
catheter  or  a bougie  for  some  weeks. 

(y)  Deviation  of  the  septum. — This  deformity 
usually  consists  of  a lateral  curvature  of  the 
septum,  and  generally  of  some  hypertrophy  of  its 
extremity,  causing  an  inclination  of  the  organ  to 
one  side  or  the  other.  As  a result  there  is  often 
great  disproportion  in  the  nasal  cavities  or 
nostrils,  in  some  instances  amounting  to  almost 
complete  occlusion  of  one  side  ; and  the  projec- 
tion of  the  inferior  turbinated  bone  of  one  side 
may  be  mistaken  for  a growth,  on  account  of  its 
protrusion.  The  treatment  consists  in  carefully' 
paring  away  the  thickened  septum,  and  subse- 
quent dilatation  of  the  nostril. 

4.  Expansion  of  the  Nose,  Morbid. — The 
tip  occasionally'  becomes  enormously  developed, 
all  the  tissues  being  involved.  This  condition 
may  require  the  removal  of  a wedge-shaped 
portion  of  the  extremity,  including  the  growth, 
and  the  subsequent  adaptation  of  the  parts. 

5.  Fracture. — In  fracture  of  the  nasal  bones 
the  displaced  bone  or  bones  should  be  raised,  by- 
introducing  a pair  of  stout  forceps  with  flat  blades 
into  the  nostrils,  guiding  them  up  to  the  nasal 
bones  by  means  of  the  septum,  and  then  forcibly 
elevating  them.  The  bones  should  be  retained 
in  position  by  plugs,  or  the  small  screw-clamp 
lately  introduced,  assisted  in  severe  cases  by 
some  such  mechanical  appliance  as  a screw  truss, 
passing  round  the  head,  and  exerting  pressure 
laterally  upon  the  displaced  bones.  In  cases 
of  fracture  of  the  septum  with  displacement, 
and  subsequent  deformity,  the  shape  of  the  nose 
may  be  restored  by  this  method,  great  attention 
being  paid  to  the  management  of  the  plugs  and 
clamp. 

6.  Hypertrophy  of  the  Integument. — 
Synon.  : Lipoma  Nasi. — This  consists  of  a hyper- 
trophied condition  of  the  integuments  and  of 
the  subcutaneous  adipose  tissue,  constituting 
irregular  fleshy  excrescences,  and  occurring  in 
cases  of  severe  and  old-standing  acne  rosacea. 

Description.  — The  term  ‘lipoma’  is  an  iu- 
• appropriate  one,  inasmuch  as  the  mass  consists 
of  hypertrophied  infiltrated  skin  and  cellular 
tissue,  with  enlarged  sebaceous  follicles,  which 
occasionally  become  developed  into  distinct  cysts 
and  dilated  veins.  The  growth  is  chronic  anu 
painless,  varying  very  much  in  the  degree  of  its 
development  aDd  appearance,  sometimes  scat- 
tered like  small  warts,  at  others  pedunculated 
and  lobulated,  and  often  attaining  an  enormous 
size.  It  does  not  affect  the  cartilages. 

Treatment. — The  only  treatment  is  removal 
by  the  knife,  dissecting  the  mass  carefully  off 
the  underlying  cartilages,  and  allowing  the  sur- 
face to  heal  by  granulation. 

7.  Lupus. — The  forms  of  lupus  attacking 
the  nose  are  fully'  considered  elsewhere  in  this 


1036  NOSE.  DISEASES  OF. 


work.  See  Lupus  Erythematosus  ; and  Lupus 
Vulgaris. 

8.  Malignant  Disease.— Epithelioma  is  a rare 
form  of  malignant  disease  in  the  nose.  It  com- 
mences with  the  characteristic  wart,  which  passes 
on  to  the  ulcerative  stage;  and  its  first  appearance 
is  either  at  the  junction  of  the  skin  and  mucous 
membrane,  or  in  the  membrane  itself.  It  may 
he  stationary  for  years,  but  ultimately  ends  in 
destruction  of  the  organ.  It  must  not  be  con- 
founded with  syphilis.  The  history  of  the  case 
is  often  enough  to  establish  the  diagnosis ; whilst 
'the  epithelial  patch  is  nearly  always  single,  and 
the  specific  multiple.  The  disease  affects  the 
glands  sooner  or  later. 

Schirrus  and  Encepkaloid  cancer  occasionally 
involve  the  nose,  generally  growing  from  within 
outwards.  These  growths  may  be  either  excised, 
or  destroyed  by  escharotics. 

9.  Nsevus. — Nsevus  may  exist  in  all  degrees 
in  the  external  nose,  from  the  merest  patch  to  a 
large  disfiguring  tumour.  If  very  small,  inocu- 
lation with  vaccine  matter  may  entirely  destroy 
it.  Ligatures  invariably,  if  the  growth  be  large, 
leave  a scar;  injection  with  perchloride  of  iron 
is  very  dangerous.  The  best  method  of  treat- 
ment is  the  galvanic  cautery;  or  in  some  in- 
stances the  entire  removal  of  the  growth  with 
the  knife. 

10.  Kodent  Ulcer. — Eodent  ulcer  is  occa- 
sionally met  with  in  the  nose.  It  somewhat  re- 
sembles lupus,  but  occurs  in  later  life.  The  ulcer 
spreads  gradually ; and  the  pain  is  described  as 
of  a severe  aching  character.  It  has  been  classed 
with  the  cancers,  but  it  lacks  several  of  the  cha- 
racteristics of  that  kind  of  growth.  There  is 
no  constitutional  infection;  and  it  has  been  abun- 
dantly proved  that,  if  entirely  eradicated  with  the 
knife,  it  need  not  return.  See  Rodent  Ulcer. 

11.  Sebaceous  Tumours. — Sebaceous  tu- 
mours are  occasionally  met  with  on  the  sides 
and  tip  of  the  nose,  and  require  removal. 

12.  Syphilitic  Disease. — Syphilitic  ulcers  of 
the  nose  are  of  special  interest  as  being  one  of 
the  causes  of  ozsena.  The  symptoms  and  treat- 
ment of  this  condition  are  fully  described  in  a 
separate  article.  See  Ozhsna. 

13.  Wounds. — -Wounds  of  the  integuments  or 
soft  parts  of  the  external  nose  require  the  neat- 
est coaptation,  by  the  use  of  very  fine  silver  wire 
sutures,  or  of  isinglass  plaster ; and  as  union  is 
generally  very  rapid,  owing  to  the  great  vascu- 
larity of  the  tissues,  unless  this  be  attended  to 
serious  deformity  may  result.  Any  tendency  to 
falling  in  of  the  nostril  must  be  counteracted,  by 
introducing  a roll  of  lint  or  piece  of  bougie.  It 
may  be  worth  mentioning  that  instances  have 
occurred  where  the  nose  has  reunited  after  its 
complete  removal  from  the  face. 

Plastic  Operations. — Plastic  operations  on 
the  nose,  for  the  restoration  of  lost  parts,  or  for 
the  improvement  of  deformities,  are  described  in 
works  on  operative  surgery. 

B.  Diseases  of  the  Internal  Nose. — 

1.  Anosmia.— Anosmia,  or  loss  of  the  sense 
of  smell,  when  of  traumatic  origin,  is  either  the 
result  of  injury,  such  as  blows  on  the  head,  or 
of  the  inhalation  of  noxious  vapour ; or  it  de- 
pends on  cerebral  disease.  In  the  former  case, 
a very  frequent  cause  is  a blow  on  the  head, 


probably  rupturing  some  filaments  of  the  olfac- 
tory nerves,  as  they  pass  through  the  cribriform 
plate  of  the  ethmoid  bone,  according  to  Offle 
(Med.  Chir.  Trans,  vol.  liii).  The  external  root 
only  of  the  olfactory  nerve  is  the  one  directly 
concerned  ;n  olfaction,  ‘and  it  depends  upon 
the  degree  to  which  this  root  or  its  central  ter- 
mination has  been  disorganised,  whether  the  loss 
of  smell  be  complete  or  partial.’  Anosmia  from 
other  causes  than  injury  is  described  elsewhere. 
See  Olfactory  Nerve,  Disorders  of;  and  Smell, 
Disorders  of. 

Treatment. — The  treatment  of  anosmia  is 
somewhat  unsatisfactory.  In  cases  where  it  de- 
pends on  cbvious  causes,  the  removal  of  these 
may  entirely  or  partially  restore  the  sense  of 
smell ; and  in  other  cases  the  excitation  of  the 
Schneiderian  membrane  of  the  nasal  cavitv,  by 
the  continuous  galvanic  current,  promises  better 
results  than  the  administration  of  medicine  or 
local  applications. 

2.  Blood  Clots. — As  a result  of  injury,  or 
of  very  violent  blowing  of  the  nose,  extrava- 
sations of  blood  may  take  place,  and  form 
masses  in  the  nostrils,  which  often  set  up  in- 
flammation, terminating  in  ozaena.  In  a case 
lately  under  the  writer's  care,  a large,  hardened 
blood-clot — which  had  been  originally’ diagnosed 
as  a morbid  growth,  and  given  rise  to  great 
inconvenience — was  detached  from  the  posterior 
nares,  by  the  repeated  use  of  the  nasal  douche. 

3.  Foreign  Bodies  in  the  Nasal  Pas- 
sages.— Peas,  cherry-stones,  and  the  like  are 
often  inserted  into  the  nostrils  by  children,  and: 
if  found  out  at  once  can  he,  generally  speaking, 
readily  removed.  When  a foreign  body  has 
remained  for  any  length  of  time  in  the  nasal 
fossae,  it  becomes  coated  with  calcareous  matter 
and  forms  a calculus,  setting  up  a most  offensive 
discharge,  ulceration  of  the  mucous  membrane, 
and  necrosis  of  the  cartilages  or  bones.  In  all 
cases  of  persistent  discharge  from  the  nostrils 
the  impaction  of  a foreign  body'  should  be  sus- 
pected, and  examination  made  by  gentle  pro- 
bing or  the  rhinoscope. 

Treatment. — In  attempting  to  remove  a 
foreign  body  from  the  nasal  passages,  it  is  as 
well  to  avoid  the  use  of  forceps,  as  the  blades  it 
attempting  to  catch  the  body,  are  liable  to  cause 
its  impaction.  A small  slender  hook  may  It 
passed  behind  the  body,  or  a very  fine  screu 
into  it,  and  so  it  can  be  withdrawn,  as  sug- 
gested by  Gross.  The  removal  of  masses  thai 
have  long  been  retained  in  the  nasal  passages  may 
sometimes  he  effected  by  the  nasal  douche,  usint 
a strong  stream  directed  into  the  sound  nostril 
or  by  means  of  curved  bougies  passed  from  be 
hind.  Pushing  the  impaction  backwards  inn 
the  pharynx  is  always  rather  hazardous,  as  : 
may  pass  into  the  larynx.  Occasionally  foreigi 
bodies  have  been  so  long  in  the  nose,  and  bej 
come  so  firmly  impacted,  that  external  incisic! 
has  to  he  made,  and  the  structures  tonning  th 
external  nose  freely  divided  in  order  to  rea  • 
them;  or  the  method  of  Pouge,  of  eperatn., 
through  the  month,  may  be  employed. 

Insects,  leeches,  or  intestinal  worms  may  g’- 
into  the  nasal  passages,  and  from  them  pass  int 
the  sinuses.  It  has  been  proposed  to  destro 
these  by  vapour  of  alcohol  or  turpentine. 


NOSE,  DISEASES  OF.  1037 


4.  inflammation  of  the  Septum  Marium.— 
icute  inflammation  of  the  septum  narium  is 
Venerally  a result  of  injury,  and  may  terminate 
a abscess,  the  diagnosis  of  'which  from  polypus 
s easy.  The  abscess  should  be  promptly  opened. 

In  chronic  inflammation  of  the  nasal  septum, 
which  is  very  frequently  the  result  of  syphilis  or 
.icrofula,  there  is  often  necrosis  of  the  cartilagi- 
nous septum,  resulting  in  perforation,  which  may 
dve  rise  to  great  deformity,  on  account  of  the 
depression  of  the  nose  following  it.  As  regards 
reatment,  in  some  instances,  perhaps,  the  per- 
sistent dilatation  of  the  nostril  may  be  useful ; 
md  should  there  be  a disposition  of  the  ulcerative 
process  to  spread,  the  edges  should  be  touched 
nth  either  a strong  solution  or  the  solid  stick 
if  nitrate  of  silver.  The  constitutional  treat- 
ment must,  of  course,  he  dependent  on  the  cause 
if  the  ulceration. 

5.  Khinolith.es,  or  Nasal  Calculi. — These 
basses  are  generally  the  result  of  the  impaction 
if  some  foreign  body,  around  which  the  inspis- 
;ated  mucous  and  purulent  secretion  of  the  nasal 
passages  has  formed,  retaining  it  as  a sort  of 
mcleus.  Or  they  may  occur  spontaneously ; and, 
.ceording  to  Demarquay,  consist  of  phosphates 
If  lime  and  magnesia,  and  carbonate  of  lime, 
aagnesia,  and  soda. 

Ehinolifhes  cause  symptoms  of  obstruction 
.nd  irritation,  and  sometimes  set  up  severe  in- 
jammation  and  discharge.  Before  attempting 
heir  extraction,  the  posterior  nasal  douche 
mould  be  employed  to  wash  away  the  accumu- 
ited  secretion,  and  to  assist  in  dislodging  the 
lass,  which  may  be  subsequently  crushed,  and 
emoved  piecemeal  or  entirely. 

6.  Submucous  Infiltration  of  the  Sides 
f the  Vomer. — -This  affection  has  been  called 
'ttention  to  by  Cohen,  and  ‘ consists  of  a puffy 
audition  of  the  mucous  membrane  over  the  vomer, 
inch,  by  giving  rise  to  symptoms  of  obstruction 
t the  posterior  part  of  the  nares,  has  been  mis- 
iken  for  polypus.  On  examination  with  the 
linoscope,  there  is  observed  on  each  side  of 
,ie  septum,  and  confined  to  its  posterior  portion, 

tumid  mass  of  whitish  colour,  markedly  dis- 
act  from  the  red  colour  of  the  adjacent  mucous 
jembrane.  The  affection  is  usually  symme- 
ical,  but  often  exists  to  a greater  extent  upon 
he  side  than  the  other.  The  masses  are  round- 
b,  with  very  convex  outlines,  and  sometimes 
fiend  half-way  across  the  fossae,  and  oeea- 
onally  very  close  to  the  outer  margin  of  the 
ares,  if  not  in  contact  with  them.  The  disease 
ipears  to  consist  in  an  cedematous  protrusion 
the  mucous  membrane,  from  an  accumulation 
meath  it  of  serum  or  serous  mucus/ 
Treatment. — The  treatment  consists  ‘of  tear- 
g away  portions  of  the  protrusions,  by  for- 
ps  carried  up  behind  the  palate  or  through 
e nostril,  and  subsequent  cauterisation  of  the 
■its.  The  affection  is  an  obstinate  one,  and 
ly  recur  again  and  again.’  In  the  cedematous 
.embrace,  removed  in  one  such  case,  there  was 
undant  evidence  of  mycelium  (Cohen,  Diseases 
the  Throat.) 

7.  Tumours. — a.  Cartilaginous  growths  have 
en  met  with  in  connection  with  the  septum. 

b.  Polypi  of  the  nasal  passages  are  fully  de- 
abed  elsewhere.  See  Polypi. 


c.  Neuromata  have  been  met  with  in  the  nos- 
tril, and  mistaken  for  polypus. 

d.  Adenoma  of  the  pituitary  glands  has  been 
recorded  ( Archives  generates,  Oct.  1876),  occupy- 
ing the  superior  and  anterior  portion  of  the 
nasal  fossae.  The  growth  was  removed  by  ex- 
ternal incision. 

e.  Adenoid  vegetatir/ns  in  the  naso-pharyngeal 
cavity  have  been  described  by  Meyer,  of  Copen- 
hagen (Trans.  Med.  Chir.  Soc.,  vol.  liii).  They 
may  spring  from  any  part  of  the  naso-pharyngeal 
cavity,  except  the  septum  ; and  the  most  pro- 
minent structural  character  of  the  growth  is 
adenoid.  They  vary  in  shape  according  to  the 
wall  from  which  they  spring,  being  sometimes 
cristate,  cylindrical,  or  flat;  and  they  are  in 
general  highly  vascular. 

Symptoms. — The  symptoms  of  such  vegeta- 
tions depend,  of  course,  on  their  number,  size, 
and  locality ; but  one  is  led  to  their  detection 
by  observing  that  the  patient  is  compelled  to 
keep  the  mouth  open,  on  account  of  the  closure 
or  partial  closure  of  the  air-passages  through 
the  nose  ; by  the  attenuation  of  the  external 
nose  ; and  by  the  voice  losing  its  resonance  in 
the  naso-pharyngeal  cavity,  which  causes  a pe- 
culiar ‘deadness’  of  the  pronunciation.  There 
may  he,  moreover,  a sensation  of  the  existenco 
of  a foreign  body,  from  the  involvement  of  tho 
Eustachian  orifice.  Meyer  lays  down  the  general 
rule  that  ‘ a deaf  patient  who  breathes  througli 
the  mouth,  and  has  a thin  compressed  nose,  is 
affected  with  vegetations  in  the  naso-pharyngeal 
cavity.’  The  detection  of  these  growths  is  often 
best  accomplished  by  the  finger  passed  up  be- 
hind the  velum,  when  they  may  be  felt  as  soft 
masses  yielding  to  the  finger,  and  giving  the 
sensation  of  a bunch  of  earth-worms.  Ilhino- 
scopic  examination  is  very  difficult  and,  as  a 
rule,  unsatisfactory  in  these  cases.  The  writer 
has  recently  met  with  a case  of  this  nature, 
which  was  readily  diagnosed  by  the  finger. 

Treatment. — The  treatment  consists  in  caute- 
risation, if  the  growths  are  soft  and  small,  and 
the  use,  by  means  of  the  nasal  douche,  of  a 
watery  solution  of  common  suit,  or  bicarbonate 
of  soda  (1  in  500),  which  washes  away  the 
mucus,  and  also  alters  the  condition  of  the  se- 
cretory surfaces.  When  larger  vegetations  exist, 
operative  methods,  such  as  crushing  or  scraping 
off  the  masses  as  near  their  bases  as  possible, 
must  be  resorted  to  through  the  nose,  or  the 
employment  of  the  galvano-  cautery. 

f.  Cancer  in  all  its  forms  may  involve  the 
nasal  fossae,  originating  most  often  in  the  an- 
trum ; epithelioma  usually  commencing  on  the 
outside,  or  edge  of  the  alas.  The  only  treatment 
is  obviously  prompt  removal  on  detection,  and 
even  then  the  prognosis  is  most  unfavourable. 

g.  Osseous  tumours  occur  frequently  in  the 
internal  nose.  Dr.  Olivier  (Sur  les  Tumeurs 
osseuses  de  Fosses  Nasales,et  dcs  Sinus  de  la  Face : 
Paris,  1869)  calls  attention  to  growths  of  this 
nature,  which  are  developed  either  in  the  nasal 
fossae,  or  in  the  tissues  connected  therewith,  and 
states  that  they  are  characterised  by  the  follow- 
ing conditions.  1.  That  they  contain  in  their 
anatomical  constitution  only  the  elements  of  os- 
seous tissue,  spongy  or  compact.  2.  That  they 
are  primarily  developed  in  the  fibro-mucous 


1038  NOSE,  DISEASES  OF. 
membrane  which  lines  the  cavities  of  the  nasal 
fossae  and  the  sinuses.  So  far  a3  they  involve 
the  nasal  cavities,  the  following  facts  present 
themselves.  The  tumour  is  generally  to  be  seen 
at  the  anterior  portion  of  the  nostrils.  If  the 
bony  tissue  be  still  covered  by  the  mucous  mem- 
brane, that  membrane  retains  its  usual  cha- 
racters ; but  if  the  growth  be  carious,  it  becomes 
of  a greyish  hue  ; and  in  the  event  of  ulceration, 
the  growth  can  be  readily  distinguished.  These 
osseous  tumours  of  the  nose  invariably  cause 
some  exophthalmos,  whilst  respiration  and  pho- 
nation  are  interfered  with. 

Treatment. — The  treatment  of  osseous  tu- 
mours of  the  internal  nose  consists  in  their  re- 
moval by  methods  which  must  be  obviously 
conducted  according  to  their  position,  size,  or 
nature.  Sometimes  they  are  so  enormously  hard 
that  no  instrument  will  touch  them,  and  some- 
times so  soft  and  friable  that  the  greatest  care 
is  necessary  to  remove  them  in  their  entirety ; 
and  indeed  it  has  been  suggested  by  Ollivier, 
in  the  instance  of  these  friable  growths,  to 
attempt  to  remove  them  in  fragments  before 
making  external  incisions,  which  will  expose  the 
growth  entirely.  In  a case  of  the  ivory  variety 
lately  under  the  writer’s  notice,  the  tumour 
sprang  from  the  frontal  sinus  and  extended 
along  the  infundibulum,  presenting  in  the  nose 
as  a large  round  nodule  about  the  size  of  a 
marble,  covered  with  mucous  membrane,  and  of 
stony  hardness ; there  was  little  if  any  dis- 
placement of  the  external  parts.  With  regard 
to  the  operative  proceedings  for  the  removal  of 
such  growths,  or  indeed  for  gaining  a thorough 
view  of  the  nasal  passages,  the  method  devised 
by  Kouge,  of  Lausanne,  is  by  far  the  most  effec- 
tive. It  consists  in  dividing  the  mucous  mem- 
brane of  the  upper  lip,  at  its  junction  with  the 
jaw,  freely,  into  the  base  of  the  anterior  nares; 
in  cutting  subsequently  through  the  nasal  car- 
tilages; and  in  turning  the  lip  and  external  nose 
upwards,  so  that  a complete  view  of  the  nasal 
cavities  is  thus  obtained  over  the  roof  of  the 
palate. 

Other  diseases  affecting  the  internal  nose  are 
discussed  in  separate  articles.  See  Cobyza; 
Epistaxjs  ; Influenza  ; and  Oz.exa. 

Edwabd  Bellamy. 

NOSOPHTTA  (v6oos,  a disease,  and  tpvrdv, 
a plant). — A term  employed  by  Gruby  to  desig- 
nate a group  of  cutaneous  affections,  in  which  a 
fungus-formation  constitutes  an  essential  part 
of  the  disease.  Naturalists  have  identified  this 
fungoid  growth  with  vegetable  fungi  in  general, 
and  have  noted  several  species.  Pursuing  the 
same  idea,  they  have  regarded  this  fungoid 
matter  as  real  fungi,  vegetating  in  the  skin, 
drawing  their  sustenance  from  the  juices  of  that 
tissue,  producing  sporules,  and  diffusing  those 
sporules,  after  the  manner  of  seeds,  as  the  means 
of  propagating  the  species,  and  consequently,  the 
disease. 

In  this  view  of  the  nature  of  the  fungoid  de- 
velopment, those  diseases  in  which  the  fungi 
are  found  are  termed  ‘ parasitic,’  and  the  con- 
tagious nature  of  such  affections  is  thence  in- 
ferred. One  additional  factor  becomes  necessary, 
namely,  that  the  skin  should  be  in  a condition 


NURSES,  TRAINING  OF. 
favourable  for  the  reception  and  development  of 
the  parasitic  plant.  The  precise  pathological 
state  constituting  the  disease  may  *be  denomi- 
nated ‘phytosis,’  whilst  the  seat  of  its  manifes- 
tation  is  the  epidermis,  the  rete  mucosum,  the 
epithelium  of  the  follicles,  the  nails,  and  the 
hair. 

One  of  the  most  important  of  the  cutaneous 
nosophyta  is  tinea,  or  ringworm ; hence  the  word 
tinea  is  employed  synonymously  with  phytosis; 
and  we  are  enabled  to  enumerate  as  examples 
of  the  disease: — Phytosis  scu  Tinea  tonsurans, 
circinata,  favosa,  and  versicolor ; whilst  we  also 
note  that  phytosis  is  present  in  certain  forms 
of  folliculitis,  for  example,  in  lichen  marginatus : 
and.  in  sycosis.  Phytosis,  moreover,  is  a con- 
comitant of  onychogryphosis.  See  Phytosis; 
Ringworm  ; and  Tinea. 

Erasmus  Wilson. 

NOSTALGIA  ( viScrros , return,  and  &\y os, 
sadness). — Synon.:  Fr.  Nostalgic,  Ger.  Heimweh. 
— A form  of  melancholia,  sometimes  occurring 
in  persons  who  have  left  their  homes.  The 
symptom  from  which  it  derives  its  name  is  aa 
intense  desire  to  return  home ; and  this  is  accom- 
panied by  great  mental  and  physical  depression, 
which  may  end  fatally.  See  -Melancholia. 

NUMMULATED  SPUTUM  ( numma , a 

coin). — A form  of  sputum  which,  when  spreading;1 
out  on  a surface,  resembles  a coin  in  shape.  Sec 
Expectoration. 

NURSES,  Training  of.  — Training  is  to 
teach  not  only  what  is  to  be  done,  but  how  to 
do  it.  The  physician  or  surgeon  orders  what  is 
to  be  done.  Training  has  to  teach  the  nurse  how 
to  do  it  to  his  order  ; and  to  teach,  not  only  how 
to  do  it,  but  why  such  and  such  a thing  is  done, 
and  not  such  and  such  another ; as  also  to  teach 
symptoms,  and  what  symptoms  indicate  what 
of  disease  or  change,  and  the  ‘ reason  why’  o> 
such  symptoms. 

Nearly  all  physicians’  orders  are  conditional; 
Telling  the  nurse  what  to  do  is  not  enough  and 
cannot  be  enough  to  perfect  her — whatever  heij 
surroundings.  The  trained  power  of  attending  td 
one’s  own  impressions  made  by  one's  own  senses 
so  that  these  should  tell  the  nurse  how  the  patient 
is,  is  the  sine  qua  non  of  being  a nurse  at  all.  Tin 
nurse’s  eye  and  ear  must  be  trained — smell  and 
touch  are  her  two  right  hands — and  her  taste  i; 
sometimes  as  necessary  to  the  nurse  as  her  head: 
Observation  may  always  be  improved  by  trainin' 
— will  indeed  seldom  be  found  without  training 
for  otherwise  the  nurse  does  not  know  what  to  lool 
for.  Merely  looking  at  the  sick  is  not  observing 
To  look  is  not  always  to  see.  It  needs  a higi 
degree  of  training  to  look,  so  that  looking  shal 
tell  the  nurse  aright,  so  that  she  may  tell  tli 
medical  officer  aright  what  has  happened  in  hi 
absence — a higher  degree  in  medical  than  i| 
surgical  cases,  because  the  wound  may  tell  it 
own  tale  in  some  respects  ; but  highest  of  a: 
of  course,  in  children's  cases,  because  the  chill 
cannot  tell  its  own  tale ; it  cannot  alway 
answer  questions.  A conscientious  nurse  is  nc 
necessarily  an  observing  nurse ; and  life  or  deat 
may  lie  with  the  good  observer.  Without  atraine 
power  of  observation,  no  nurse  can  be  of  any  us 


NURSES.  TRAINING  OF.  1030 


>3  reporting  to  tho  medical  attendant.  The  best 
ne  can  hope  for  is  that  ho  ivill  ho  clever  enough 
jot  to  mind  her,  as  is  so  often  the  case.  Without 
j:  trained  power  of  observation,  neither  can  the 
urse  obey  intelligently  his  directions.  It  is  most 
uportant to  observe  the  symptoms  of  illness;  it 
L if  possible,  more  important  still  to  observe 
he  symptoms  of  nursing  ; of  what  is  the  fault 
jot  of  the  illness  but  of  the  nursing.  Observation 
Ills  how  the  patient  is ; reflection  tells,  what  is 
in  be  done ; training  tells  how  it  is  to  be  done, 
framing  and  experience  are,  of  course,  necessary 
[jo  teach  us,  too,  how  to  observe,  what  to  observe, 
"ow  to  think,  what  to  think.  Observation  tells 
s the  fact;  reflection  the  meaning  of  the.  fact, 
lellection  needs  training,  as  much  as  observation. 
Itherwise  the  untrained  nurse,  like  other  people 
(idled  quacks,  easily  falls  into  the  confusion  of 
j on  account  of,'  because  ‘ after  ’ — the  blunder  of 
[he  ‘ throe  crows.’  The  nurse  is  told  by  the 
ledical  attendant,  ‘ If  such  or  such  a change 
ccur,  or  if  such  or  such  symptoms  appear,  you 
re  to  do  so  and  so,  or  to  vary  my  treatment  in 
iich  or  such  a manner ' In  no  case  is  the 
hysician  or  surgeon  always  there.  The  woman 
lust  have  trained  powers  of  observation  and 
feflection,  or  she  cannot  obey.  The  patient’s 
fe  is  lost  by  her  blunder,  or  ‘ sequelae  ’ of  in- 
arable  infirmity  make  after-life  a long  disease  ; 
lid  people  say,  ‘ The  doctor  is  to  blame  ; ’ or, 
orse  still,  they  talk  of  it  as  if  God  were  to 
lame — as  if  it  were  God’s  will.  God’s  will  is 
ht  that  we  should  leave  our  nurses,  in  whose 
lands  we  must  leave  issues  of  life  or  death, 
ithout  training  to  fulfil  the  responsibilities  of 
ich  momentous  issues. 

To  obey  is  to  understand  orders,  and  to  un- 
irstand  orders  really  is  to  obey.  A nurse  does 
at  know  how  to  do  what  she  is  told  without 
ich  ‘training’  as  enables  her  to  understand 
hat  she  is  told  ; or  without  such  moral  and 
sciplinary  ‘ training  ’ as  enables  her  to  give  her 
hole  self  to  obey.  A woman  cannot  be  a good 
id  intelligent  nurse  without  being  a good  and 
kelligent  woman.  Therefore,  what  ‘training’ 
gnifies  in  tho  wide  sense,  what  makes  a good 
fining-school,  what  moral  and  disciplinary 
paining’  means,  and  how  it  is  to  be  attained, 
e to  be  clearly  understood. 

I.  What  makes  a good  Training-school  for 

Sums  ? 

(1)  A year’s  practical  and  technical  training 
hospital  wards,  under  trained  head-nurses 
D-called  ‘sisters’  of  London  hospitals),  who 
emselves  have  been  trained  to  train. 

For  a district  nurse,  an  additional  three 
jnths’  training  in  nursing  by  the  poor  bedside, 
der  a trained  and  training  district  superin- 
ldent,  is  essential. 

The  training  of  probationers  should  be  as 
ich  a part  of  the  duty  of  the  head  nurse 
jiister, ’)  as  directing  the  under-nurses  or  seeing 
the  patients. 

To  tell  the  training,  you  require  weekly  re- 
'ds,  under  printed  heads  corresponding  wi:|i 
! ‘List  of  Duties,’  kept  by  the  head-nurses  of 
p progress  of  each  probationer  (pupii)  in  her 
rd-work,  and  in  the  moral  qualities  necessary 
(her  ward-work ; a monthly  record  by  the  ma- 
d cf  the  results  of  the  weekly  records ; and  a 


quarterly  statement  by  her  as  to  how  each  head- 
nurse  has  performed  her  duty  to  each  proba- 
tioner. The  whole  to  bo  examined  periodically 
by  the  governing  body. 

(2)  Clinical  lectures  from  the  hospital  pro- 
fessors; lectures  on  subjects  connected  with 
nurses’  special  duties,  such  as  elementary  in- 
struction in  chemistry,  with  reference  to  air, 
water,  food,  &c. ; physiology,  with  reference  to  a 
knowledge  of  the  leading  lunctions  of  the  body  ; 
and  general  instruction  on  medical  and  surgical 
topics  ; examinations,  written  and  oral,  at  least 
four  of  each  in  the  year,  all  adapted  to  nurses  ; 
as  also  lectures  and  demonstrations  with  ana- 
tomical, chemical,  and  otherillustrations,  adapted 
especially  to  nurses — all  in  the  presence  and 
under  the  care  of  the  matron  (Lady  Superin- 
tendent) and  mistress  of  probationer’s  (Class- 
mistress  and  ‘ Home  ’-sister) ; together  with  in- 
struction from  a medical  instructor,  one  of  tho 
hospital  professors  and  hospital  medical  staff, 
specially  selected  to  teach  the  nurses. 

A good  nurses’  library  of  professional  books, 
not  for  the  probationers  to  skip  and  dip  in  at 
random,  but  to  be  made  careful  use  of,  under 
the  medical  instructor  and  class-mistress. 

(3)  Classes  for  a competent  mistress  to 
drill  the  professorial  teaching  into  the  proba- 
tioners’ minds ; the  mistress  of  probationers  to 
be  above  alia  ‘ home ’-sister,  capable  of  making 
the  ‘home’  a real  home,  and  of  training  and  dis- 
ciplining the  probationers  there  in  all  good — in 
moral  qualities,  customs  and  habits,  and  man- 
ners, without  which  no  woman  can  be  a nurse, 
and  in  their  duty  and  feeling  to  God  as  well  as 
to  their  neighbour. 

(f)  Tho  authority  and  discipline  over  all  the 
women  of  a trained  lady-superintendent,  who  is 
also  matron  of  the  hospital,  and  who  is  herself 
the  best  nurse  in  the  hospital,  the  example  and 
leader  of  her  nurses  in  all  that  she  wishes  her 
nurses  to  be,  in  all  that  training  is  to  make  her 
nurses. 

(5)  An  organisation  not  only  to  give  this 
training  systematically,  and  to  test  it  by  current 
tests  and  examinations,  but  also  to  give  the  pro- 
bationers, by  proper  help  in  the  wards,  time  to 
do  their  work  as  pupils  as  well  as  assistant- 
nurses,  and  above  all  to  make  it  a real  moral  as 
well  as  nui’sing  probation—  for  nursing  is  a pro- 
bation as  well  as  a mission. 

(6)  Accommodation  for  sleeping,  classes,  and 
meals  ; arrangements  for  time  and  teaching  and 
work  ; surroundings  of  a moral  and  religious, 
and  hard-working  and  sober,  yet  cheerful  tone 
and  atmosphere,  such  as  to  make  the  training- 
school  and  hospital  a ‘ home  ’ which  no  good 
young  woman  of  any  class  need  fear  by  entering 
to  lose  anything  of  health  of  body  or  mind  ; with 
moral  and  spiritual  helps,  and  an  elevating  and 
motherly  influence  over  all,  such  as  to  make 
the  v hole  a place  which  will  train  really  good 
women,  who  can  withstand  temptation  and  do 
real  work,  and  ueither  be  1 romantic’  nor  ‘ menial,’ 
For,  make  a hospital  as  good  as  you  will,  hos- 
pital-nurses require  more  such  helps,  and  get 
less,  than  women  either  in  their  own  homes  or  iu 
domestic  service. 

Every  hospital  should  have  and  he  such  a 
school  for  training  nurses  for  itself  and  other 


1040  NURSES.  TRAINING  OF. 


institutions,  including  district  and  private 
nurses,  who  must  be  trained  in  hospitals,  and 
therefore  cannot  have  a training-school  of  their 
own.  Professors  and  medical  staff  cannot  be 
always,  or  indeed  ever  at  hospital  bedsides, 
showing  nurses  what  to  do.  Let  each  give  the 
pupil-nurses  a clinical  lecture  once  a week. 
Above  all,  this  is  necessary  for  those  who  are  to 
be  head-nurses,  matrons,  and  lady-superinten- 
dents. The  success  of  any  training-school  depends 
mainly  upon  having  trained  nurses  themselves 
capable  of  training  others — (a)  in  ward-nursing; 
and  (b)  in  cases,  so  as  to  be  able  to  understand 
what  physician  and  surgeon  order,  and  do  it. 

II.  Course  for  all  Probationers. 

(1)  To  do  duty  as  assistant  nurse  and  pro- 
bationer successively  in  one  or  more  wards  of 
each  of  the  hospital  divisions,  one  or  two  or 
three  months  in  each,  male  and  female  surgical, 
male  and  female  medical,  children's,  obstetric, 
ophthalmic,  Magdalen;  ending  her  course,  if 
possible,  in  the  medical-instructor’s  wards. 

The  course  should,  if  possible,  begin  in  the 
female  medical  wards.  No  two  fresh  proba- 
tioners to  be  in  the  same  ward.  One  nurse- 
probationer  and  one  lady-probationer  to  be  to- 
gether, where  possible. 

(2)  To  learn  ward-management  by  being  in 
charge  of  wards  during  the  head-nurse’s  dinner- 
hour,  and  during  nurses’  recreation  hours  ; to 
take,  when  sufficiently  advanced  in  the  year's 
training,  day  or  night  staff  duty  for  staff-nurses 
on  their  holidays ; to  have  at  least  one  month’s 
night  duty — a fortnight  at  a time — in  the  year’s 
training. 

(3)  To  take,  when  sufficiently  advanced, 
special  duty,  by  day  or  by  night,  upon  special 
cases,  such  as  ovariotomy,  lithotomy,  tracheo- 
tomy, typhoid,  &c.,  in  the  single-bed  wards. 

(4)  To  make  a set  of  all  the  different  band- 
ages required. 

(5)  To  learn  from  the  head-nurse  to  read  the 
* cards,’  or  patients’  bed-tickets,  especially  in 
the  medical  wards. 

(6)  To  keep  a diary  of  her  ward  duties. 

Besides  this  diary,  each  probationer  at  least 

once  a month  to  draw  up  a sketch  of  her  day’s 
work,  not  merely  as  a ward  assistant  or  assistant 
nurse,  but  as  a probationer  in  training,  namely, 
what  she  has  learnt  that  day  from  ward-sister 
and  staff  nurse,  what  she  has  observed  on  special 
cases  in  the  ward,  &c. 

Warning  is  given  outonly  after  the  day’swork, 
that  it  is  such  and  such  probationer's  day  to  write 
it  out. 

(7)  To  take  careful  notes  of  cases.  A case- 
paper  should  be  regularly  kept  by  every  proba- 
tioner of  cases  selected  by  the  medical  instructor. 

The  case-paper  to  have  printed  headings,  such 
as  ‘Temperature,’  ‘Pulse,’  ‘Respiration,’  to  be 
taken  morning  and  evening  [in  some  cases  the 
physician  will  require  the  ‘ temperature  ’ to  be 
taken  as  often  as  every  hour,  or  even  every 
quarter  of  an  hour] ; ‘ Sleep,’  ‘ Nourishment,’ 

‘ Urine,’  ‘ Stools,’  to  be  noted  every  twenty-four 
hours — in  each  case  character  as  well  as  quantity; 

‘ treatment,’  to  be  noted  daily,  in  English,  and 
not  copied  off  the  ‘ cards ; ’ and  other  such  heads ; 
preceded  by  a real  medical  history  of  the  case— 
of  the  causation  of  the  disease  ; for  example,  in 


typhoid  fever  and  other  dirt  diseases,  producer 
by  foul  air  and  foul  water.  This  is  followed  In 
remarks  on  the  termination  cf  the  case.  Thes’i 
case-papers  should  be  rigorously  overhauled  b> 
ward-sisters  and  the  class-mistress,  as  well  a: 
by  the  medical  instructor,  who  should  alsoathi: 
own  hospital-beds  check  the  case-taking. 

(8)  To  take  careful  notes  of  all  lectures,  als- 
overlooked  by  class-mistress  and  medical  in 
structor. 

(0)  To  read  and  be  shown  illustrations  of  th; 
cases  nursed  in  the  wards,  [the  keen  professions, 
interest  felt  by  a promising  probationer  in  find 
ing  her  own  cases  in  a book  must  be  encouraged. 

(10)  To  jot  down  afterwards,  but  while  stU' 
fresh  in  the  memory,  any  remarks  suitable  fo 
her  own  instruction  made  to  the  students  by  th 
hospital  physicians  and  surgeons  in  going  theij 
rounds,  and  to  write  out  her  jottings  in  th 
class-room  under  the  superintendence  of  th 

‘ home ’-sister. 

(11)  To  write  out  under  the  superintendent 
of  the  ‘ home ’-sister  what  has  been  learnt  bot 
from  ward-sisters  and  medical  instructor  as  t 
what  is  to  be  done  and  how  to  do  it  in  nursing 
as  to  why  it  is  done,  and  why  something  else  i 
not  done  ; as  to  symptoms  and  the  ‘ reason  why 
of  such  symptoms. 

Without  (a)  time  for  these  things,  averag 
nurse-probationers  degenerate  into  conceits 
ward-drudges.  Without  ( b ) a system  for  thes 
things,  they  potter  and  cobble  out  their  yet 
about  the  patients,  and  make  not  much  progrei 
in  real  nursing,  that  is,  in  obeying  the  ph’ 
sicians’  and  surgeons’  orders  intelligently  ar 
perfectly. 

III.  Training  to  Train. — To  enable  nurses  t 
train  nurses,  a special  training  is  required ; ai 
for  this  a longer  period  than  a year  in  the  ho 
pital  is  necessary.  To  train  to  train  needs 
system : — 

(1)  A systematic  course  of  reading,  laid  dov 
by  the  medical-instructor,  who  recommends  t; 
books  for  the  training-school  library.  Hours 
study,  say  two  afternoons  a week ; class-mistre 
(‘ home ’-sister)  to  lead  one  at  least  of  the 
afternoons. 

(2)  Regular  oral  examinations  by  medicr 
instructor ; each  training-nurse  must  acqui 
powers  of  expression  to  train  others.  He  mu 
cultivate  these  in  answering  him.  Some  syste 
of  mutual  examination. 

(3)  At  least  four  written  examinations  in  t 
year  on  written  questions,  by  the  medical  i 
structor.  Essays  to  be  written  on  given  subjet 
in  nursing. 

(4)  Pre-eminently  careful  notes  of  lecturi 
in  order  to  enable  nurses  in  future  to  drill oths 
in  understanding  the  professorial  lectures, 
they  have  themselves  been  drilled. 

(5)  Pre-eminently  careful  notes  of  cases 

the  touchstone  for  the  future  trainer.  If  £ 
cannot  observe  and  understand  her  own  cas 
how  can  she  teach  others  to  observe  and  undi_ 
stand  them?  If  she  never  learn  the  reason: 
what  is  done,  how  can  she  train  others  to  let' 
it  ? ‘ Reading  up  ’ her  own  cases. 

(6)  A current  constant  course  of  cure; 
learning  from  head-nurses  and  medical  instruct 
and  physicians  or  surgeons  in  wards  where  i 


NURSES,  TRAINING  OF. 


1041 


s probationer,  to  know  not  only  what  symptoms 
re  there,  and.  what  symptoms  are  to  be  expected 
a such  and  such  an  event,  but  also  the  meaning 
jf  such  symptoms — the  ‘ reason  why.’  To  know 
ot  only  when  a wound  or  surgical  injury  or 
peration  ‘looks  well  and  when  it  ‘looks  ill,’ 
;,ut  why  it  looks  well  or  ill ; and  to  be  able  to 
■11  others  why.  To  know  not  only  what  is  to 
[e  done,  and  how  i t is  to  be  done,  but  why  that 
done,  and  not  something  else. 

(7)  At  least  twice  in  the  year’s  training,  but 
pt  at  the  beginning,  to  have  a week  or  more  of 
ping  the  night-rounds  with  tho  night-superin- 
ndent  of  nurses,  which  is  equally  good  for 
ght-superintendent  and  for  probationer. 

(8)  To  spend  at  least  a week,  but  not  at  the 
ginning  of  her  year,  in  the  linenry. 

(9)  Tho  future  superintendent,  who  is  to  have 
training  school,  should  have  at  least  a fnrc- 
ght  in  the  year,  about  six  or  nine  months  on  in 
draining,  in  the  ‘ Home,’  if  possible,  taking  or 
listing  at  classes,  and  doing  all  but  the  ‘Home’ 
iter’s  secretarial  work. 

(10)  Taking  temporary  duty  of  ward-sisters 

their  holidays,  and — the  best — of  ‘ Home  ’ 

;ter  on  her  holiday.  Of  course  no  fresh  proba- 
|mer,  however  gifted,  would  be  put  on  such  duty. 

(11)  Being  relieved  of  the  more  menial  ward- 
■rk,  such  as  cleaning  lavatory  basins,  w.c.  pans, 
i?,.,  when  she  can  do  it  so  perfectly  of  herself 
thout  being  told,  that  she  can  teach  others  to 
( it.  This  will  scarcely  be,  for  all  kinds  of  this 
' rd-work,  before  she  is  a six  months’  old  pro- 
1 :ioner. 

12)  A second  year's  training  for  the  higher 
Its.  A future  matron  or  lady-suporintendent 
t have  had  experience  as  ward-sister,  and  to 
l 'e  had  at  least  one  year  as  assistant-super- 
undent and  as  night  superintendent,  in  some 
1 pital  under  a trained  lady-superintendent. 

13)  The  matron  must  give  future  matrons  or 
s erintendents  insight  into  her  duties.  There 
nst  be  an  examination  and  questions  given  on 
s erintendents’  work. 

V.  Current  tests,  current  records  of  progress, 
a examinations. 

0 The  candidate  should  fill  up  a form  of 
& lication,  answering  printed  questions.  Regu- 
hbns  of  training  printed  on  the  back. 

I1)  Should  enter  on  a month’s  trial.  She  re- 
cces the  time-table  and  the  list  of  duties. 

; the  candidate  is  accepted  after  the  month  as 
pliationer — 

1)  Each  ward  head-nurse  or  sister  keeps  a 
re  ed  of  each  probationer,  under  printed  heads 
cc  isponding  with  the  list  of  duties.  She  fills 
uijre  columns  with  suitable  marks  once  a week. 

1 matron,  after  examining  tho  ward-sister’s 
re  cts  with  ward-sister  and  ‘ home  ’-sister  pre- 
80,  and  questioning  each  ward-sister  on  each 
pr,ationer,  records  her  own  opinion  on  the 
sujr's  reports.  The  medical  instructor  once  a 
m<jh  should  examine  each  probationer  sepa- 
nty,  upon  the  duties  which  the  ward  head- 
!,uj>  (sister)  has  ‘recorded’  her  as  defective  in, 
m 3 presence  of  ward-sister,  ‘ home  ’-sister,  and 
rospn;  and  also  should  examine  each  ward- 
613j'  separately  upon  her  records  of  each  proba- 
tio'r  in  the  matron’s  presence,  but  not  in  the 
pri  .tioner’s. 


The  ‘home ’-sister  also  furnishes  a record  of 
each  probationer’s  conduct  at  the  classes  and  in 
the  home. 

(d)  A register  with  two  pages  for  each  proba- 
tioner should  be  kept  monthly  by  the  matron 
assisted  by  the  ‘ home  ’-sister.  It  corresponds 
with  the  ward-sister’s  book,  and  has  monthly 
entries  for  the  whole  year  of  training.  The 
accounts  in  these  books  must  tally  at  the  end  of 
the  year,  or  somebody  has  been  wanting  in  moral 
courage. 

(e)  While  the  ward-sisters  keep  a weekly  and 
tho  matron  a monthly  record  of  the  progress  of 
each  probationer,  she  is  required  to  keep  a diary 
of  her  ward  work,  to  keep  ‘ case-papers’  with  the 
daily  changes  in  case  and  treatment,  and  to  keep 
notes  of  lectures ; and  the  careful  examination 
of  these  aifor  ls  important  items  in  the  records 
of  results  of  training,  and  of  the  capabilities  of 
each  probationer.  The  medical  instructor  enters 
his  verdict  on  professional  points  in  the  monthly 
register. 

(/)  The  medical  instructor,  and  each  hospital 
professor  who  gives  lectures  to  the  probationers, 
examines  them  orally  in  tho  presence  of  matron 
and  home-sister.  He  examines  their  notes  of  the 
lectures  and  awards  marks.  It  is  communicated 
to  each  probationer  how  she  stands  as  to  marks. 

(g)  Written  questions  are  given  by  tho  medi- 
cal instructor  at  least  four  times  a year,  to  be 
answered  in  writing,  at  least  by  t.he  proba- 
tioners who  are  training  to  train  others.  Marks 
are  awarded,  and  the  number  of  marks  received 
communicated  to  each  probationer.  Possibly 
prizes  may  be  given  for  proficiency. 

These  are  some  of  the  current  tests  of  the 
results  or  non-results  of  training,  of  progress  or 
no  progress.  Without  some  regular  system  of 
this  kind,  there  can  be  no  real  organization  for 
training.  The  heads  of  the  trainingsehool  must 
‘take  stock’ and  know  where  each  probationer 
really  stands,  and  what  the  training  is  really 
doing,  and  must  let  each  probationer  know 
where  she  stands.  The  matron  must  be  one 
whose  desiro  is  that  the  probationers  shall 
learn  : a rarer  thing  than  is  usually  supposed.  But 
besides  this  there  is  a constant,  motherly,  intan- 
gible supervision  and  observation  to  be  exercised, 
for  there  are  qualities  which  no  written  tests  can 
touch  and  no  examinations  can  reach.  The  pro- 
bationers must  really  be  the  matron’s  children ; 
the  ‘ home  ’ sister  must  really  be  their  elder  sister. 

A training  school  without  a mother  is  worse 
than  children  without  parents.  And  in  disci- 
plinary matters  none  but  a woman  can  under- 
stand a woman. 

V.  Staff  of  Training  School : — 

1.  The  superintendent  of  the  training  school 
is  the  matron  of  the  hospital,  and  head  of  all 
the  women  in  the  hospital.  She  is  presentwhen 
possible  at  the  probationers’  lectures  and  demon- 
strations, and  oral  examinations,  with  the 1 home’ 
sister,  who  is  always  present.  The  night-super- 
intendent of  nurses  trains  the  probationers  told 
off  to  accompany  her  at  night. 

2.  The  trained  ‘ home  ’-sister  (class-mistress ; 
mistress  of  probationers)  resides  in  the  ‘ home  ’ ; 
is  in  charge  of  the  * home  ’ and  its  servants  and  of 
the  probationers.  She  gives  two  classes  a week 
at  least  to  the  senior  nurse-probationers  and  two 


66 


NURSES,  TRAINING  OF. 


1042 

to  the  juniors,  drilling  them  in  the  medical  in- 
structor’s lectures,  &e.  &c.  She  superintends  two 
afternoons  at  least  in  the  week  the  study  hours 
of  the  probationers  training  to  train  others, 
that  is,  all  who  are  to  be  in  future  in  charge 
of  nurses,  whether  as  ward-sisters,  matrons  or 
superintendents,  and  gives  direct  instruction  on 
one  at  least  of  these  afternoons.  She  gives 
singing  and  Bible  classes.  She  must  from  time 
to  time  communicate  with  the  ward-sisters  on 
the  defects  in  the  probationers’  work,  and  con- 
cerning probationers  about  whom  she  may  feel 
uneasy.  Cutting  off  communication  between 
hospital  and  ‘ home  ’-sister  is  very  objectionable ; 
the  hospital-sister  must  not  want  moral  courage 
to  let  the  probationers  know  any  unfavourable 
report  she  has  made  of  them  in  the  Sisters’ 
Records.  This  is  unfair  to  the  probationers. 
The  ‘ home  ’-sister  must  attend  all  clinical  and 
other  lectures,  demonstrations,  and  examinations. 

3.  Ward-Sisters  (Head-nurses,  Training- 
nurses). — The  ward-sister  must  train  the  proba- 
tioners in  all  the  duties  of  a nurse.  Nee  Nursing 
the  Sick;  and  above,  ‘II.  Course  for  Probationers.’ 

The  ward-sister,  or — instructed  by  her — the 
staff  nurse,  is  to  show  every  new  probationer 
how  to  do  her  work ; not  only  what  things  are  to 
be  done,  hut  how  she  is  to  guard  against  the  way 
they  are  not  to  be  done,  as  well  as  against  what  is 
not  to  be  done.  She  is  to  instruct  the  nurses  how 
to  instruct  prooationers.  As  it  is  impossible  for 
a ‘ sister  ’ with  a sister's  duty  in  a ‘ heavy’  ward 
always  to  have  time  to  show  all  needfuL  things 
herself  to  the  probationer ; the  sister  must  from 
time  to  time  question  her  to  see  if  she  has  been 
shown  her  duties  and  how  she  does  them,  re- 
membering that  it  is  of  use  to  the  probationers 
to  put  these  things  into  words ; and  for  this  pur- 
pose each  probationer  is  to  be  occasionally  taken 
by  the  sister  on  her  ward  rounds,  and  examined 
as  to  what  she  has  done  in  each  case  under  her 
charge,  whether  she  has  learnt  to  do  it  rightly 
and  knows  ‘ the  reason  why.’ 

The  ward-sister  must  also  train  the  proba- 
tioners in  alacrity  of  intelligent  obedience  to  her 
medical  authorities,  which  must  be  the  proba- 
tioner’s lesson  of  what  obedience  ought  to  be. 
She  must  regard  the  probationers  less  as  hos- 
pital servants,  than  as  pupils  to  he  trained  for 
hospital  ‘sisters’  and  nurses.  The  training- 
nurse  must  he  a bridge  for  the  pupil-nurses. 

‘ He  who  will  he  a chief,  let  him  be  a bridge.’ 
She  must  not  make  them  too  little  of  pupils,  too 
much  of  assistant-nurses — or,  rather,  they  can- 
not be  too  much  of  assistant-nurses,  hut  being 
too  little  of  pupils  makes  them  too  little  of  real 
assistants,  and  (for  all  their  future)  of  real 
nurses.  The  training-nurse  must  interest  the 
piupil-nurse  in  her  cases.  The  pupil  cannot  have 
a nurse's  interest  in  them  without  knowing  what 
they  are.  Cases  she  is  interested  in  she  nurses 
with  twice  the  efficiency. 

4.  Medical  Instructor. — The  medical  instruc- 
tor, one  of  the  hospital  staff  who  will  under- 
take the  duties,  gives  a lecture  once  a week  on 
medical  and  surgical  topics  specially  connected 
with  nursing  duties ; demonstrations  with  ana- 
tomical and  other  illustrations,  specially  adapted 
to  nurses ; lessons  on  the  elementary  know- 
ledge of  physiology,  anatomy,  the  situation  of  ; 


the  principal  arteries,  &c. ; lessons  on  ban- 
daging; lessons  in  hygiene,  both  of  wards  and 
patients ; lessons  on  the  causation  of  disease ; 
on  what  is  to  be  done  iD  emergencies;  on  howto 
make  beds  for  various  operations  and  diseases 
&c.,  &e.  He  is  to  lay  down  a systematic  coursf 
of  reading  for  the  probationers  who  are  to  trair' 
others;  to  examine  them  by  written  questions  all 
least  four  times  in  the  year ; to  give  them  sub 
jects  for  essays,  and  to  examine  these;  to  awar 
marks.  He  is  to  examine  all  the  probationer 
orally;  to  examine  their  notes  of  lectures,  ti 
award  marks ; to  examine  their  case-paper.1 
He  is  to  give  clinical  lectures  at  least  once 
week,  at  his  own  ‘ beds  ’ (it  would  be  desiratl 
if  each  probationer  could  end  her  course  of  ward 
in  the  medicalinstructor's  wards),  and  to  examiD 
‘ case-papers  ’ taken  of  his  own  cases ; to  teac 
symptoms,  and  what  symptoms  indicate,  and  wh 
such  or  such  a treatment;  and  what  shows  a cai 
to  be  ‘ doing  well  ’ and  what  ‘ ill  ’ ; and  to  teac 
the  probationers  so  that  they  can  teach  othi 
probationers  in  their  turn.  He  will  encourage ; 
every  way  the  professional  interest  of  the  nur 
in  the  cases  she  is  nursing ; he  will  point  o 
these  cases  in  medical  and  surgical  hooks.  On 
a month  he  will  examine  each  probationer  sep 
rately  upon  the  duties  she  is  defective  in;  ail 
each  ward-sister  separately  upon  her  record 
experience  of  each  probationer.  He  will  fill  • 
the  monthly  register  at  the  end  of  each  proa 
tioner's  year  of  training,  with  his  verdict  onl, 
capacities,  and  on  such  professional  results 
her  training.  He  will  make  up  the  purely  p: 
fessional  columns— such  as  ‘ observation,’  ‘ope: 
tions’ — every  month,  seeing  the  matron  andwai 
sisters  for  the  purpose.  The  medical  instruc 
should  be  one  of  mature  age  and  experien 
should  be  really  a father  to  the  pupil-nurses,  i 
oue  whom  the  matron  can  freely  consult  wi 
If  the  hospital  have  a permanent  resident  medi 
officer  fit  for  the  purpose,  he  should  be  the  ■ 
structor. 

5.  The  medical  instructor  also  gives  elem- 
tary  instruction  in  chemistry,  physiology,  a - 
tomy,  surgery,  medicine,  as  far  as  they  br 
upon  nurses’  duties. 

6.  Lady  Visitor. — The  lady  visitor  should  it 
be  resident  in  the  hospital,  but  should  her  f 
havo  been  a trained  nurse,  so  as  to  knowwt 
training  is.  She  will  be  an  essential  assistae 
to  the  matron,  in  infusing  spirit  from  witbt 
into  her  training  school,  and  in  saving  e 
matron  from  the  appearance  even  of  arbitry 
power. 

Training,  general  consideration  of- 

A year’s  training  is  simply  teaching  the  nue 
her  A B C — teaching  her  how  to  go  on  le3n_g 
for  herself,  learning  to  understand  her  docl  9 
orders  and  to  read  her  own  experience,  for  ife 
experience  may  only  teach  the  ‘ post  hoc,  W 
propter  hoc.’  A nurse  without  training  is  li  a 
man  who  has  never  learnt  his  alphabet,  whous 
learnt  experience  only  from  his  own  blunt's- 
Blunders  in  executing  physicians  or  surgu  = 
orders  upon  the  living  body  are  hazardous  th'.> 
and  may  kill  the  patient.  Training  is  ton- 
able  the  nurse  to  see  what  she  sees — facts,!1 
to  do  what  she  is  told  ; to  obey  orders,  not  v 
by  rule  of  thumb,  but  by  giving  her  a ra 


NURSES,  TRAINING  OF, 

i thought  or  observation.  Othenvise  she  finds 
out  her  own  mistakes  by  experience  acquired 
I out  of  death,  rather  than  life,  or  does  not  find 
.hem  out  at  all. 

Medicine,  surgery,  pathology,  and,  above  all, 

1 hygiene,  have  made  immense  strides,  partly  in 
consequence  of  improved  tools,  improved  instru- 
ments of  observation.  Nursing,  their  agent,  has 
to  be  trained  up  to  them.  A good  nurse  of 
twenty  years  ago  had  not  to  do  the  twentieth  part 
of  what  she  is  required  by  her  physician  or  sur- 
geon to  do  now.  And  every  five  or  ten  years  a 
'nurse  really  requires  a second  training  now-a- 
Idays.  Nursing  needs  its  instruments  nearly  as 
much  as  surgery,  and  yet  more  than  medicine. 
The  physician  prescribes  for  supplying  the  vital 
force — but  the  nurse  supplies  it.  Training  is  to 
each  the  nurse  how  God  makes  health  and  how 
tie  makes  disease.  Training  is  to  teach  a nurse  to 
enow  her  business,  that  is,  to  observe  exactly,  to 
mderstand,  to  know  exactly,  to  do,  to  tell  exactly, 
n such  stupendous  issues  as  life  and  death, 
lealth  and  disease.  Training  is  to  enable  the 
nirse  to  act  for  the  best  in  carrying  out  her 
Orders,  not  as  a machine  but  as  a nurse  ; not  like 
lornelius  Agrippa’s  broomstick  which  went  on 
'arrying  water,  but  like  an  intelligent  and  re- 
ponsible  being.  Training  has  to  make  her,  not 
errile,  but  loyal  to  medical  orders  and  authori- 
ties. True  loyalty  to  orders  cannot  be  without 
he  independent  sense  or  energy  of  responsibility, 
■hich  alone  secures  real  trustworthiness.  Train- 
hg  makes  the  difference  in  a nurse  that  is  made 
i a student  by  making  him  prepare  specimens 
;r  himself  instead  of  merely  looking  at  prepared 
becimens.  Training  is  to  teach  the  nurse  how 
i handle  the  agencies  within  our  control  which 
[store  health  and  life,  in  strict  obedience  to  the 
hysician’s  or  surgeon's  power  and  knowledge  — 
bw  to  keep  the  health-mechanism  prescribed  to 
;r  in  gear.  Training  must  show  her  how  the 
fects  on  life  of  nursing  may  be  calculated  with 
ce  precision — such  care  or  carelessness,  such  a 
:k-rate,  such  a duration  of  case,  such  a death- 
|te.  Flobence  Nightingale. 

NURSIN' G THE  SICK. — Nursing  proper, 
it  is,  nursing  the  sick  and  injured,  will  be  here 
fated  of,  and  not  Preventive  or  Sanitary  Nurs- 
t,  or  nursing  healthy  children. 

Nursing  is  performed  usually  by  women,  under 
entitle  heads — physicians  and  surgeons.  Nurs- 
; is  putting  us  in  the  best  possible  conditions 
Nature  to  restore  or  to  preserve  health — to 
' went  or  to  cure  disease  or  injury.  The  physician 
' surgeon  prescribes  these  conditions— the  nurse 
dries  them  out.  Health  is  not  only  to  be  well, 

; . to  be  able  to  use  well  every  power  we  have 
t].ise.  Sickness  or  disease  is  Nature's  way  of 
thing  Tid  of  the  effects  of  conditions  which 
t|-e  interfered  with  health.  It  is  Nature’s  at- 
t ipt  to  cure — we  have  to  help  her.  Partly,  per- 
il's mainly,  upon  nursing  must  depend  whether 
- ure  succeeds  or  fails  in  her  attempt  to  cure 
l sickness.  Nursing  is  therefore  to  help  the 
pient  to  live.  Training  is  to  teach  the  nurse 
taelp  the  patient  to  live.  Nursing  is  an  art, 
a!  an  art  requiring  an  organized  practical  and 
s ntific  training.  For  nursing  is  the  skilled 
f . ant  of  medicine,  surgery,  and  hygiene. 


NURSING  THE  SICK.  1013 

Nursing  may  be  divided  under  four  heads  : — 
(a)  Hospital  nursing.  (A)  Private  nursing : that 
is,  nursing  one  sick  or  injured  person  at  a time, 
at  home ; giving  the  whole  time  to  that  one 
patient,  generally  of  the  richer  classes,  (c)  Dis- 
trict nursing  : that  is,  nursing  the  sick  or  injured 
poor  at  home,  taking  as  many  cases  as  can  be 
well  attended  to  by  one  nurse.  District  nursing, 
or  nursing  the  sick  poor  at  home,  is  a branch  of 
nursing  of  the  highest  importance,  and  requires 
the  highest  qualifications,  because  the  district 
nurse  has  not,  like  the  hospital  nurse,  a medical 
and  surgical  staff  always  at  her  call,  and  never 
hospital  appliances  to  her  hand,  (rf)  Midwifery 
nursing  will  not  be  treated  of  here.  It  differs 
from  other  nursing  in  this — that  the  lying-in 
woman,  the  patient,  is  not,  or  ought  not  to  be, 
sick,  and  that  the  nursing  consists  in  a surgical 
operation  and  in  hygienic  precautions.  [Mid- 
wifery and  general  cases  should  never  be  attended 
by  the  same  nurse.  No  ordinary  precautions  will 
secure  the  lying-in  case  from  danger  arising  out 
of  this  practice.] 

(u)  Hospital  Nursing. — Nursing  proper  means, 
besides  giving  the  medicines,  and  stimulants 
prescribed,  or  applying  the  surgical  dressings 
and  other  remedies  ordered  : — 1.  The  providing, 
and  the  proper  use  of,  fresh  air.  especially  at 
night,  that  is  ventilation,  and  of  warmth  or  cool- 
ness. 2.  The  securing  the  health  of  the  sick- 
room or  ward,  which  includes  light,  cleanliness 
of  floors  and  walls,  of  bed,  bedding,  and  utensils. 
3.  Personal  cleanliness  of  patient  and  of  nurse, 
quiet,  variety,  and  cheerfulness.  4.  The  adminis- 
tering and  sometimes  preparation  of  diet  (food 
and  drink).  5.  The  application  of  remedies.  In 
other  words,  all  that  is  wanted  to  enable  Nature 
to  set  up  her  restorative  processes,  to  expel  the 
intruder  disturbing  her  rules  of  health  and  life. 
For  it  is  Nature  that  cures  : Dot  the  physician 
or  nurse.  "We  shall  now  discuss  these  duties  in 
succession. 

1.  Ventilation.  'Warmth  and  Coolness. — 

a.  Ventilation  is  the  removal  of  the  air  poisoned 
by  the  breath  and  other  human  emanations,  and 
supplying  its  place  with/rasA  air. 

The  very  first  canon  of  nursing  is  to  keep  the 
air  inside  as  fresh  as  the  air  outside,  by  night  as 
well  as  by  day,  without  chilling  the  patient. 
The  best  rule  of  ventilation  is  still:  Poke  the 
fire,  open  the  window,  but  at  the  top.  for  fresli 
air  coming  in  at  the  ceiling  permeates  the  whole 
room,  without  causing  draught,  and  foul  air 
escapes.  Air  coming  in  at  the  floor  or  at  the 
level  of  the  patient  remains  there  and  chills  him. 
and  foul  air  does  not  escape.  Always  air  from 
the  outside  air.  Windows  are  made  to  open  ; 
doors  are  made  to  shut.  If  the  nurse  ventilate 
the  patient’s  room  or  ward  through  the  door — 
that  is,  making  the  room  draw  the  foul  air  from 
the  rest  of  the  house  or  building — she  ventilates 
him  with  foul  not  fresh  air.  But  ventilation  is  im- 
possible without  sufficient  floor  and  cubic  space, 
and  unless  the  windows  open  near  the  ceiling. 
"Where  other  patients  want  air,  fever  patients, 
for  example,  want  wind ; where,  other  sick  want 
a well-aired  room,  without  draughts,  pysemic 
patients,  for  example,  want  the  freest  possible 
supply  of  air  about  their  beds. 

h.  Warmth,  or  coolness. — This  the  physician 


1044  NURSING 

aas  to  prescribe  the  nurse  has  to  see  to  it.  In 
fever,  for  instance,  the  physician  -will  require 
her  to  examine  the  patient’s  feet  and  legs,  at 
least  every  hour,  to  ascertain  whether  they  are 
chilled,  and  to  keep  the  extremities  warm,  even 
though  his  temperature  he  high,  whether  in 
summer  or  winter. 

In  bronchitis,  in  ovariotomy,  &c.,  an  even, 
high,  moist  temperature  may  be  necessary,  and  a 
steaming  kettle  may  be  required  on  the  fire  night 
and  day. 

But  ordinarily  it  is  not  advisable  to  keep  the 
sick-room  always  at  the  same  temperature.  A 
cooler  air  at  night  is  necessary.  But  whether 
cool  or  warm,  the  air  must  be  fresh.  Sick  chil- 
dren become  fretful  in  foul  air  at  night.  And 
young  as  well  as  old  night-nurses  require  train- 
ing to  see  that  the  physician’s  orders  are  obeyed 
as  to  keeping  the  air  of  the  ward  fresh  by  night, 
and  not  above  or  below  a certain  temperature. 

The  head  of  the  sick  should  never  be  higher 
than  the  throat  of  the  chimney,  which  ensures 
the  best  air.  And  the  chimney  should  never  be 
closed  with  a chimney-board. 

2.  Health  of  Sick-Room,  or  Ward. — 
This  might  be  called  ‘ nursing  the  room.’  The 
placing  the  sick-bed  in  the  best  position  to  secure 
air  without  draught,  light  without  glare,  quiet 
and  cleanliness — and  this  often  necessitates  re- 
arrangement of  the  furniture  of  the  whole  room — 
is  one  of  the  essential  arts  of  nursing.  In  district 
nursing  of  the  poor,  it  must  be  one  of  the  nurse’s 
first  duties  to  put  the  room  in  a state  so  that 
the  patient  can  recover.  So,  too,  must  the 
hospital  and  the  hospital-ward  be  built  so  that 
the  patient  shall  not  ‘ die  of  hospital.’  To  get 
rid  of  the  conditions  which  have  interfered  with 
health  is  of  course  the  first  nursing  step  in  help- 
ing Nature  to  get  rid  of  the  effects  of  those  con- 
ditions. 

a.  Light. — Second  only  to  air  is  light  as  an 
essential  for  growth,  health,  and  recovery  from 
sickness — not  only  daylight  but  sunlight — and 
indeed  fresh  air  must  be  sun- warmed,  sun-pene- 
trated air.  This  should  be  meant  to  include 
colour,  pleasant  and  pretty  sights  for  the  patient’s 
eyes  to  rest  on — variety  of  objects,  flowers,  pic- 
tures/ People  say  the  effect  is  on  the  mind.  So 
it  is  ; but  the  enlightened  physician  tells  us  it  is 
on  the  body  too.  The  sun  is  a sculptor  as  well 
as  a painter.  The  Greeks  were  right  as  to  their 
Apollo. 

b.  Cleanliness. — Cleanliness  and  fresh  air  do 
not  so  much  give  life  as  they  are  life  itself  to 
the  patient.  Cleanliness — clean  air,  clean  water, 
clean  surroundings,  and  a fresh  atmosphere  every- 
where are  the  true  safeguards  against  ‘ infection’ 
— not  segregation  — or  rather  segregation  by 
ample  floor  and  cubic  space,  ample  ramparts  of 
fresh  atmosphere  : not  segregation  by  walls  and 
divisions.  You  cannot  lock-in  or  lock-out  the 
infectious  poison  ; you  cannot  wall-out  infection. 
You  can  air  it  out,  diffuse  it,  and  clean  it 
away. 

‘ Infectious  Hospitals  ’ and  ‘ Wards,’  whether 
necessary  or  not,  are  not  a part  of  hygiene;  and 
the  doctrine  of  ‘ disease  germs,’  in  the  sense  in 
which  it  may  lead  to  considering ‘infection’ in- 
evitable, must  not  be  taught  as  a principle  of 
sanitary  nursing.  That  there  is  no  such  thing  as 


THE  SICK. 

‘inevitable’  infection,  is  the  first  axiom  of 
nursing. 

Cleanliness  of  floors,  ceilings,  walls,  bed,  bed- 
ding, and  utensils,  and  of  sinks  ; also  of  lockers, 
if  any,  but  there  should  be  none. 

Floors  and  walls. — Medical  men  forbid  scrub- 
bing in  the  sick-room.  No  sick-room  floor  ought 
ever  to  be  washed,  except  by  the  doctor’s  orders 
and  at  the  hour  he  orders. 

The  only  clean  floor  is  a floor  planed,  satu- 
rated with  ‘ drying’ linseed  oil,  well  rubbed-iu. 
stained  (for  appearance  sake),  not  too  dark,  so  as 
not  to  hide  the  dirt,  and  beeswaxed  with  tur- 
pentine and  polished.  The  floor  to  be  wipc-d 
with  a damp  cloth  and  dried  with  a floor-brush, 
or  cleaned  by  a brush  with  a cloth  tied  over  it. 
Anything  offensive  spilt  to  be  washed  off  at  once 
with  soap  and  water.  Hospital-ward  floors 
should  be  scraped  and  polished  every  fortnight 
by  a frotteur  and  dry-rubbed  by  a man  every 
day.  The  patients  should  be  provided  with 
slippers.  No  carpet,  of  course,  in  a sick-room, 
except  a piece  of  washing  drugget  by  the  bed- 
side. A dirty  carpet  literally  infects  the 
room. 

The  only  clean  wall  is  one  that  is  oil-painted. 
From  this  you  can  wash  the  animal  matters. 
These  are  what  make  a room  musty.  The  worst 
wall  is  the  papered  wall.  The  next  worst  is  the 
plastered  wall.  But  the  plaster  can  be  made 
safe  by  frequent  lime-washing  and  occasional 
scraping.  The  paper  requires  frequent  renewing. 
A glazed  paper  gets  rid  of  a good  deal  of  thel 
danger.  But  the  ordinary  bed-room  paper  is  all 
that  it  ought  not  to  be. 

Furniture — as  little  as  possible  in  the  sick 
room — should  all  be  of  polished  wood,  metal,  ot. 
marble,  kept  clean  by  being  wiped  with  a dot! 
wrung  out  of  hot  water. 

Air  can  be  soiled  just  like  water.  Airis  always 
soiled  where  walls  and  carpets  are  saturated  witl 
animal  exhalations.  Dust  consists  greatly  o 
organic  matter.  There  should  be  no  ledges  ou' 
of  reach  capable  of  holding  dust.  An  Amott’: 
ventilator  in  the  chimney  will  keep  an  ordinar 
paper  longer  clean,  showing  the  connection  o 
ventilation  and  cleanliness.  Inattention  to  thes 
essential  matters  all  but  foils  the  best  nurse 
best  efforts. 

How  to  chan. — Dust  is  the  harbourer  an 
harbinger  of  disease.  Dust  in  hospitals  ma 
contain  epithelial  scales  from  the  mouth,  skit 
epiderm,  pus-cells.  As  there  appears  no  lim 
to  the  reproduction  of  epiderm  or  epithelium,  s 
there  is  no  limit  but  excessive  cleanliness  to  ll 
deposit  in  dust  in  a hospital  ward,  ‘which,'  as 
great  surgeon  has  said,  ‘ never  rests  from  foulir 
itself.’ 

The  onlv  way  to  remove  dust  is  to  wipe  ever 
thing  with  a damp  cloth.  And  all  fumifu 
ought  to  be  so  made  that  it  may  be  wip( 
with  a damp  cloth  without  injury  to  itself,  at 
so  polished  or  glazed  that  it  may  he  damp' 
without  injury  to  us.  Flapping,  by  way  of  dus 
ing,  is  not  cleaning.  To  ‘ dust.'  as  now  practise 
merely  means  to  distribute  dust  more  equal 
over  a room.  To  ‘tidy’  a room,  or  ‘put  t 
room  to  rights,’  means  to  remove  a thing  fxe 
one  place  which  it  has  kept  clean  for  itself  on 
another  and  a dirtier  one. 


NURSING  THE  SICK. 


No  one  atom  of  dust  ever  actually  leaves  the 
oomunderthe  present  system  of ‘dusting.’  The 
treater  part  of  nursing  consists  in  keeping  clean, 
lo  ventilation  can  freshen  a sick  room  where 
lie  most  scrupulous  cleanliness  is  not  kept. 

Bed  and  bedding;  linen,  $c. — Feverishness 
: generally  supposed  to  be  a symptom  of  fever ; 
i nine  cases  out  of  ten  it  is  a symptom  of  bod- 
ing. The  patient  has  had  re-introduced  into 
is  system  the  diseased  emanations  from  himself, 
d eliminate  which  from  his  system  Nature  had 
ppointed  the  disease.  These,  day  after  day  and 
eek  after  week,  soak  into  his  unaired  bedding 
:om  below  as  well  as  from  within,  if  the  chamber- 
tensils  are  left,  as  is  too  often  the  case,  unemp- 
ed  and  without  a lid  under  the  bed.  Erysipelas 
nd  pyaemia  are  produced  by  an  uncleansed  state 
f bed  and  bedding.  Black  flock  is  sometimes 
sed  for  fracture  pillows.  This  gets  full  of  dust, 
nd  may  be  the  cause  of  erysipelas. 

The  most  dangerous  effluvia  we  know  are  from 
!he  excreta  of  the  sick;  these  are  placed,  at 
last  for  a time,  where  they  must  throw  their 
ffluvia  into  the  underside  of  the  bed,  and  the 
pace  under  the  bed  is  never  aired ; it  cannot  be 
•ith  our  arrangements — a valance  or  counter- 
ane  down  to  the  floor,  or  perhaps  the  quilt 
Ip  carefully  pinned  over  that  no  air  can  pass 
nder  the  mattress. 

An  adult  in  health  exhales  by  the  lungs  and 
tin  in  the  twenty-four  hours  three  pints  at  least 
f moisture,  loaded  with  matter  ready  to  pu- 
■efy;  in  sickness  the  quantity  is  often  greatly 
icreased,  the  quality  is  always  more  noxious, 
his  goes  chiefly  into  the  bedding  because  it 
mnot  go  anywhere  else : and  it  stays  there, 
icause,  except  perhaps  by  a weekly  or  bi-weekly 
lange  of  sheets,  scarcely  any  other  airing  is 
tempted.  A nurse  will  be  careful  to  fidget- 
ness  about  airing  the  clean  sheets  from  clean 
imp,  the  clean  night-gown  from  clean  damp,  the 
;w  mattress  from  clean  damp  ; but  airing  the 
rty  sheet*  from  dirty  damp,  the  dirty  night- 
wn  (which  she  is  goiDg  to  put  on  the  patient 
ter  washing  him)  from  dirty  damp,  never  so 
uch  as  occurs  to  her.  And  a mattress  is  sup- 
'sed  to  be  aired  by  somebody  else  sleeping  on 
and  saturating  it  with  his  own  damp  before 
e patient  comes  to  exhale  into  it  the  patient’s 
mp. 

The  bed  is  always  saturated  with  the  patient, 
d the  unfortunate  patient  who  lies  in  it  is 
ways  being  saturated  with  the  bed. 

The  ordinary  sick-bed  of  a private  patient  is 
nerally  exactly  what  it  ought  to  be  to  bring 
is  poisoning  process  to  perfection : a wooden 
rr-poster  with  curtains,  two  or  even  three 
stresses,  or  even  a feather-bed,  piled  up — • 
ihaps  to  a height  above  the  throat  of  the 
imney  or  above  the  lower  chink  of  the  sash- 
adow,  which  is  all  that  is  ever  opened;  the 
adow  not  opening  or  opened  at  the  top;  a 
(ance  fastened  to  the  frame.  Nothing  ever 
oroughly  dries  or  airs  such  a bed  and  bedding. 
The  best  bed  and  bedding  are:  An  iron  bed- 
ad  with  Rheocline  springs,  or  the  woven-wire 
ttress,  no  valance  and  no  curtains,  of  course  ; 
' thin  hair  mattress,  light  Witney  blankets, 
heavy  cotton  counterpane,  which  retains  per- 
ration ; no  blanket  under  the  patient,  which 


1045 

acts  like  a poultice  and  promotes  bed-sores — 
bed-sores  which  are,  all  but  always,  a symptom 
not  of  the  disease  but  of  the  nursing. 

The  patient  should,  if  possible,  be  able  to  see 
out  of  window  from  the  bed. 

Two  beds,  one  for  the  day  and  one  for  the 
night,  are  necessary  for  the  best  nursing  of  the 
patient.  A true  nurse  always  knows  how  to 
make  a bed,  and  always  makes  it  herself.  And 
bed-making  has  much  to  do  with  bed-sores.  She 
hangs  up  the  whole  of  the  bedding  to  air  for  a 
few  hours  whenever  possible.  Sho  makes  the 
changes  of  linen  and  bed-linen — sheets  and  draw- 
sheets — as  often  as  is  necessary,  which  is  a great 
deal  oftener  than  is  usually  done.  In  hospitals, 
she  sees  to  no  patient  using  his  neighbour's 
towel;  and  to  different  towels  being  used  for 
different  purposes.  She  sees  to  all  dirty  linen, 
and  especially  bandages,  being  instantly  removed, 
and,  after  a previous  careful  disinfection  by 
steeping  in  boiling-water  with  a proportion  of 
carbolic  acid,  1 to  100,  being  washed  at  a laundry 
separate  from  any  other  building — if  she  has  such 
a laundry.  No  disinfection  will  enable  dirty 
linen  to  be  kept  with  safety  a single  day  in  the 
same  building  with  the  sick.  It  is  cruel  to 
allow  dirty  linen  from  ‘ infectious  ’ patients  to  be 
taken  home  by  the  relatives  to  be  washed  in  the 
crowded  rooms  of  the  poor.  Dirty  linen  should 
be  removed  immediately  from  the  sick-room  and 
sent  to  the  laundry,  at  least  every  day.  If  we 
are  careful  to  take  away  and  empty  bed-pans 
directly,  surely  this  is  still  more  important  with 
soiled  sheets.  It  must  not  be  supposed  that 
even  a good  sprinkling  of  carbolic  powder  (which 
besides  injures  the  sheets)  over  the  dirty  linen 
lying  in  a basket,  will  at  all  obviate  the  neces- 
sity of  instant  removal.  Foul-linen  shoots,  with 
a receptacle  at  the  bottom  to  receive  the  linen  in 
preparation  for  instant  removal,  are  a necessity 
of  every  hospital. 

Bandages  with  pus  on  them  are  always  to 
be  burnt  at  once — to  be  carried  straight  to  the 
ward  fire,  or  to  a furnace.  The  best  economy  is 
to  burn  them ; but  one  must  make  up  the  fire 
so  that  the  burning  shall  not  smell.  Bandages 
used  for  fractures,  &c.,  are  the  only  bandages 
that  may  be  washed.  Soak  these  with  chlorinated 
soda,  a diluted  pint ; then  boil  them  all  night 
with  soft-soap,  soda,  and  chlorinated  soda — a 
quart  bottle  for  the  two.  The  bandages  are  then 
to  be  rinsed  in  a tub.  The  boiler  must,  of  course, 
only  be -emptied  in  a closet-sink.  But  this 
washing  of  bandages  ought  never  to  be  done 
inside  a dwelling-house  or  hospital. 

All  disinfectants  are  more  or  less  a 1 mystic 
rite,’  as  a great  surgeon  said.  Absolute  cleanli- 
ness is  the  true  disinfectant ; but  chlorinated 
soda,  if  disinfectants  are  to  be  used,  is  about  the 
best.  Always  have  chlorinated  soda  for  nurses 
to  wash  their  hands,  especially  after  dressing  or 
handling  a suspicious  case.  ‘It  may  destroy 
germs  at  the  expense  of  the  cuticle ; ’ but,  ‘ if 
it  takes  off  the  cuticle,  it  must  be  bad  for  the 
germs,’  said  the  same  surgeon.  Fire  is  the 
right  way,  if  a thing  is  so  bad  that  it  wants  a 
disinfectant.  Hair  (and  all  hospital  beds  should 
be  of  hair)  should  be  heated  -to  about  350°, 
teased,  and  exposed  to  air.  Boil,  wash,  scour 
with  much  soap  and  water  and,  say,  chloride  of 


1046  NURSING 

Lime  , then  dry  and  expose  to  air  all  bed-ticks, 
blankets,  coverlids,  &c. 

Utensils. — All  chamber-utensils  and  bed-pans 
should  be  of  white  glazed  earthenware,  with 
well-fitting  lids.  None  should  ever  be  left  under 
the  bed,  but  be  brought  to  the  room,  and,  when 
used,  carried  immediately  to  the  closet-sink, 
emptied,  and  rinsed  there.  No  zinc  pail,  or  pail 
without  a lid,  should  be  carried  through  a ward 
or  sick-room.  The  pail  should  be  of  glazed 
earthenware  with  a lid.  But  better  no  pail  at  all 
in  a sick-room.  Without  care  for  these  things, 
the  doctor  will  tell  us,  ‘ it  is  impossible  to  nurse.’ 
Excreta  have  often  to  be  put  by  for  medical  in- 
spection ; the  nurse  must  see  to  this  being  done 
properly  and  inoffensively,  in  a closed  vessel — 
never  in  the  patient’s  room  or  ward.  As  for  urine, 
if  it  has  to  be  measured  and  tested,  there  are 
glass-measures,  with  covers,  fit  for  the  purpose. 
Bed-pans  should  have  carbolic-powder  in  them 
lavishly.  All  bed-pans  should  have  lids.  Glass 
urinals,  with  wide  necks,  -washed  with  warm 
water  and  soda,  are  the  only  really  clean  ones  ; 
ziucand  white  earthenware,  with  long  necks,  are 
never  clean.  After  being  used,  they  should  be 
put  by  the  bedside,  not  under,  and  taken  away  and 
emptied  at  once.  Small  white  chamber-utensils 
are  useful,  and  district  nurses  may  find  old  jam- 
pots the  cleanest  thing  for  urinals.  Chamber- 
utensils  in  a hospital  should  be  ranged  on  their 
sides  in  a sort  of  hutch  open  to  the  outward  air 
through  perforated  zinc,  in  the  lavatory  or  other 
compartment.  If  in  alargehospital-ward  cham- 
ber-utensils must  unhappily  be  allowed  under  the 
beds  at  night,  they  should  all,  of  course,  have  lids. 
Two  glazed  earthenware  (not  zinc)  pails,  with 
lids,  may  then  be  carried  round  the  last  thing  at 
night  and  the  first  thing  in  the  morning:  one 
pail  to  empty  into,  with  some  carbolic-po-wder  in 
it;  one  pail  to  rinse  with,  with  soda  or  chlori- 
nated soda  in  it.  The  chamber-utensils  should 
be  then  carried  off  to  the  hutch  in  the  lavatory. 
But  this  is  only  a pis  allcr ; a slop-pail  should 
really  never  be  brought  into  a sick-room  or  ward 
at  all.  It  should  be  a rule,  invariable — rather 
more  important  in  the  privato  house  than  else- 
where—that  the  utensil  should  be  carried  directly 
l o the  water-closet,  emptied  there,  rinsed  there, 
and  not  brought  back  till  it  is  wanted. 

There  should  always  be  -water  and  a tap  in 
every  water-closet  for  rinsing. 

Towels  in  a hospital  should  be  kept  separate 
for  three  separate  uses,  changed  for  clean  ones 
as  often  as  possible,  and  marked  ‘ Hands,’  ‘ Bed- 
pans,’  and  ‘ Basins.’ 

A bottle  of  chlorinated  soda  and  a bottle  of 
glycerine  should  always  be  by,  to  wash  the  hands. 

A young  nurse,  dressing  an  ulcerated  leg,  has 
been  known  to  wipe  it  with  the  sheet,  and 
alleged  that  she  had  seen  it  done  elsewhere ! 
There  should  always  be  a special  towel  for  such 
cases.  Charcoal  may  be  employed  in  offensive 
cases ; it  may  be  placed  under  the  bed  in  pans, 
or  under  the  limb  (if  slung)  in  the  bed.  Car- 
bolic powder  may  be  placed  in  the  chamber- 
utensil  (clean),  if  under  the  bed,  or  little  bags 
of  carbolic  powder  in  the  bed.  Condy's  fluid 
is  sometimes  placed  in  saucers,  but  this  is  not 
of  much  use.  Carbolized  tow  may  be  used  for 
cancer  cases  to  lie  upon,  and  changed  frequently. 


THE  SICK. 

Wool,  with  salicylic  acid,  is  sometimes  used 
to  cover  the  dressing  of  an  offensive  wound 
or  salicylic  lotion  for  a warm  water  dressing 
Slop  sinks  may  be  sluiced  down  with  carbolic 
acid.  Water-closet  pans  should  be  scrubbed 
with  strong  nitric  acid,  if  they  have  been  allowed 
to  get  at  all  offensive.  Urinals,  if  allowed  to  be- 
come furred,  must  be  sluiced  out  with  boiling 
water,  and  then,  if  necessary,  scraped  withaknik 
all  round  and  inside  the  grating.  Also  water-1 
closet  slop  sinks.  These  all  should  be  scrubbed! 
with  sand  and  chlorinated  soda  at  least  twice  a 
-week.  In  hospitals  the  head-nurse  ought  to  mop" 
out  and  rinse-down  the  urinals  every  morning 
herself  with  a little  bed-pan  mop.  and  let  boiling' 
water  run  through  ; the  same  with  the  water 
closet  pans.  The  lavatory  basins,  when  used 
should  he  mopped-out  every  morning,  anc 
scrubbed  at  least  twice  a week  with  sancLTher! 
should  be  two  mops — one  new  one  for  Lavatory 
basins,  appropriated  when  a little  old  to  the  bed-' 
pans,  and  the  old  one  replaced  with  new : thenevj 
small  mop  to  hang  over  the  lavatory  basins,  tin 
old  one  to  hang  over  the  slop-sink  for  bed-pans 
an  old  bottle-brush  for  the  handles  of  bed-pans 
a new  bottle-brush,  kept  in  the  ward-kitchen,  fo 
bottles.  Ordinary  basins  should  be  washed  wit!! 
tow. 

3.  Precautions  against  finger-poisoning 
&c. — One  of  the  most  important  points  nurse 
have  to  be  taught  on  beginning  surgical  ward! 
work  (and,  indeed,  surgeons  also,)  is  how  not  t 
poison  their  fingers.  No  good  nurse  will  poiso 
her  own  fingers  any  more  than  her  patient’s. 

The  following  rules  should  be  strictly  oil 
served : — 

Pare  the  finger-nails  close ; keep  them,  as  we 
as  fingers  and  hands,  scrupulously  cleaned;  auj 
thing  which  has  soiled  the  fingers  is  a possibl 
source  of  contagion  to  others  and  to  yourself 
an  agnail,  or  crack,  or  scratch,  or  pin-punctur., 
is  as  likely  to  produce  a poison-nest  to  others  c 
to  yourself,  even  more  than  an  open  wound  i 
sore.  Such  poison-nests  must  be  made  harmle; 
by  first  washing -with  pure  water,  next  by  appb 
ing  styptic  colloid,  thirdly  by  putting  on  an  indi; 
rubber  finger-stall.  Immediately  before  begh 
ning  any  dressing,  and  in  every  case  after  toucl 
ing  the  patient,  whether  in  dressing  wound 
rubbing  in  applications,  administering  enemat, 
internal  syringing,  washing  out  eyes,  ears,  nos; 
mouth — dip  the  hands  into  watery  solution 
carbolic  acid,  1 to  80,  and  then  wash  han< 
and  nails  carefully  with  carbolic  soap.  1 Dres 
ing  forceps,’  or  syringe,  or  whatever  is  use 
to  be  dipped  in  solution  cf  carbolic  (1  to  S 
before  use  as  well  as  after.  The  teeth  and  join 
of  the  ‘dressing  forceps’  to  be  brushed  clea 
Remove  soiled  dressings  with  ‘ dressing  foreep 
and  not  with  the  fingers ; on  no  account  serat 
up  adhesive  plaster  or  other  adhering  dres 
ing  -with  the  nails.  Nurses  of  the  old  scha 
will  boast  that  they  are  not  afraid.  The  fe 
of  dirt  is  the  beginning  of  good  nursing.  W i 
all  internal  cases,  keep  the  nails  short,  fill  t 
same  with  carbolic  soap,  and  carefully  ano: 
the  fingers  you  are  about  to  use,  especially  t 
first  and  second  fingers  in  attending  on  vagii 
cases,  with  carbolic  oil  (1  in  20).  Oil  theta 
or  nozzle,  &c.,  to  be  used  for  any  internal  apt 


atioa,  with  carbolic  oil  (1  in  20). 
ie  appliance  used  might  convey 
“latter  from  one  patient  to  another, 
se  two  basins  in  washing  wounds,  so  as  not  to 
ip  the  fingers  in  dirty  water.  Catheters  must 
e cleansed  and  disinfected,  first  with  a stream 
f warm  water,  and  then  with  a stream  of 
atery  solution  of  carbolic  acid  (1  to  40}. 
atheters  of  other  material  than  silver  should 
ot  be  soaked  in  carbolic  acid  solutions,  as  the 
jid  injures  varnish  and  gum  Never  ‘blow  down  ’ 
iwards  the  eye  first  instead  of  last,  for  so  some 
idgment  will  always  be  effected  at  the  bottom. 
:ever  fail  to  take  your  own  carbolic  soap,  with 
hich  you  will  be  provided,  in  your  own  soap-tin, 
ito  the  ward  each  morning  and  evening  in  your 
octet.  But  take  it  out  before  beginning  ‘dress- 
igs,’as  otherwise  you  put  a dirty  hand  into  your 
octet.  Always  dry  your  cleaned  fingers  and 
mds  on  towels  not  used  for  any  other  purpose. 
!fter  offensive  cases,  blow  the  nose  and  expec- 
irate,  and  rinse  mouth  and  throat  with  Condy 
id  water,  or  with  permanganate  of  potash,  a 
w grains  in  water.  Cuffs  and  sleeves  and  stuff 
.•esses  are  possible  carriersof  contagious  matter, 
lways  change  the  apron  and  over-sleeves  which 
ou  have  worn  about  the  sick  before  eating  or 
•inking.  Report  immediately  any  scratch  or 
;nail  or  sore  you  may  have  to  the  ward- 
ster;  ask  immediate  advice  after  breathing  in 
fensive  air.  Never  go  on  duty  in  the  morning 
thout  having  taken  a meal. 

The  nurse  must  be  taught  the  nature  of  con- 
gion  and  infection,  and  the  distinctions  be- 
feen  deodorants,  disinfectants,  and  antiseptics. 
Mischief  done  by  students  and  dressers  might 
ve  been  saved,  and  valuable  lives  spared,  even 
tong  surgeons,  if  such  precautions  had  been  al- 
'.ys  scrupulously  observed  by  them. 

4.  Food  and  Drink  (Diet). — The  physician 
ll  tell  us  that,  to  give  food  and  stimulants  in 
'e  way,  at  the  time,  of  the  kind,  with  the  cook- 
; and  preparing,  that  will  best  enable  the  poor 
feebled.  digestion  to  assimilate  it,  is  one  of  the 
; ?at  nursing  arts.  No  chemical  rules  can  be 
(•  en  for  this  as  absolute.  The  patient’s  stomach 
i the  laboratory,  and  also  the  chemist.  It  is 
t sole  judge  of  whether  the  physician's  orders 
i right;  and  the  nurse  has  to  watch  and  tell 
1 1 what  the  patient's  stomach  says.  She  must 
Iff  course  trained  and  cultivated  to  understand 
' it  it  says. 

Ihe  patient's  stomach  sometimes  craves,  and 
a milates  too,  what  no  rules  would  have  pre- 
s bed  for  it.  The  nurse  must  ask  the  physician 
' :ther  she  may  gratify  these  cravings.  Sick- 
ckery  should  do  half  the  digestion's  work  ; 
a proper  variety  is  essential.  If  a patient  is 
s after  taking  food  or  drink,  or  feverish,  or 
1 1,  or  torpid,  it  is  often  a symptom  not  of  the 
d ase  but  of  the  nursing.  Indeed,  how  mucli 
o he  suffering  of  illness,  as  well  as  cf  its 
dj?er,  is  the  fault  not  of  the  illness  but  of  the 
n :ing,  is  well  known  to  the  skilful  physician 
6 surgeon. 

pe  nurse,  of  course,  has  nothing  to  do  with 
d prescribing  of  stimulants  any  more  than 
ledicines.  But  life  often  depends — especially 
it  vers  and  severe  surgical  injuries — upon  the 
me  knowing  howto  follow  the  indications  of 


104/ 

tfie  changes  to  be  looked  for  in  the  patient's 
state  given  her  by  the  physician,  and  to  change 
the  times  of  giving  the  stimulants  accordingly. 

The  nurse  must  know  how  to  make  gruel, 
arrowroot  puddings,  egg-flip,  drinks,  good  beef- 
tea,  and  other  kinds  of  sick  cookery,  so  as  to  pleus« 
the  patients’  taste  and  vary  their  diet.  People 
say  'fanciful  patients’  must  be  ‘humoured.’ 
So  they  must ; but  it  is  in  order  to  excite  the 
proper  secretions  of  saliva  and  gastric  juice 
necessary  for  digestion.  Nothing  should  ever  be 
cooked  in  the  ward  or  in  the  patient's  room. 

But  though 1 sweet  JackPalstaff’  says,  ‘A  nurse 
is  a cook,’  the  whole  of  the  cooking  must  not  be 
thrown  on  the  nurse,  if  she  is  to  nurse  ; and  above 
all,  if  she  is  to  eat,  she  must  not  be  expected  to 
cook  for  herself.  But  she  will  always  be  required 
not  only  to  see  that  the  patient's  food  and  drink 
be  as  prescribed,  but  that  it  be  well  cooked,  and 
punctually  and  well  served.  The  physician  con- 
siders that  upon  the  nurse's  power  to  give  weak 
patients  food  in  the  way  they  like  often  depends 
their  taking,  or  at  least  assimilating,  any  food 
at  all. 

She  has  also  to  feed,  for  example,  fever- cases  so 
that  they  can  eat.  The  mere  lifting-up  of  a patient 
in  bed  to  give  him  food  may  terminate  fatally 
a fever-case.  The  nourishment  or  stimulant 
ordered  may  have  to  be  put  into  his  mouth  per- 
haps every  half-hour — perhaps  every  five  minutes 
— even  during  sleep,  without  rousing  the  patient 
— the  test  of  a good  nurse.  The  physician  ex- 
pects the  nurse  to  be  able  intelligently  to  make 
the  variations  he  prescribes  in  giving  these  things, 
especially  during  the  night,  according  to  the  state 
of  pulse  and  other  symptoms,  which  she  must 
know  how  to  observe,  in  order  to  follow  his 
conditional  directions,  upon  which  hangs  the 
patient’s  life  from  hour  to  hour,  often  from 
minute  to  minute.  In  convalescence  from  typhoid 
fever,  one  single  false  indulgence  has  often  in- 
duced a relapse  and  terminated  a case  fatally. 

5.  Application  of  Remedies. — The  phy- 
sician or  surgeon  requires  the  nurse — 

To  be  able  to  apply  leeches,  externally  and. 
internally,  in  the  best  way;  to  dress  blisters, 
burns,  sores. 

To  administer  stimulants  and  medicines  as 
ordered,  enemas  and  injections  to  men  and  women, 
and  suppositories. 

To  manage  trusses,  appliances  in  uterine  com- 
plaints ; to  pass  the  catheter — at  least  for  women. 
The  district  nurse  is  often  now  required  to  pass 
the  speculum,  also  the  catheter  for  men,  because 
there  is  no  one  else  to  to  do  it. 

To  use  the  best  methods  of  friction  to  the 
body  and  extremities  ; to  make  and  apply  fomen- 
tations, poultices,  and  minor  dressings,  wet  and 
dry  and  greasy  ; to  syringe  wounds  ; to  syringe 
the  vagina. 

To  manage  helpless  patients — fever,  operation, 
and  surgical  cases — that  is  to  move,  to  change 
them,  to  keep  them  personally  clean,  warm  or  cool. 

The  medical  attendant  will  expect  the  nurse 
to  maintain  an  exquisite  cleanliness  of  the  pa- 
tient's whole  person  and  skin,  and,  as  in  fever — 
the  daughter  of  dirt — to  clean  herself  the  patient's 
teeth,  gums,  and  tongue,  with  lemon-juiec  or 
white-of-egg  beat  to  a froth.  A nurse  is  no 
nurse  who  cannot  wash  or  sponge  a patient's 


NURSING  THE  SICK. 

Otherwise 
contagious 
Always 


1048  NURSING 

whole  body  without  exposure  or  chill  to  any 
part.  In  typhoid  and  other  fevers,  this  is  now  an 
essential  part  of  the  treatment. 

To  give  food  and  stimulants  to  helpless  pa- 
tients— fever,  operation,  and  surgical  cases ; to 
manage  the  position  of  such  cases ; to  prevent 
or  to  dress  bed-sores. 

To  make  the  sick-bed,  and  especially  to  make 
the  bed  with  the  patient  in  it ; to  change  the 
under-sheet  without  moving  the  patient,  as  in 
fever  and  operation  cases.  The  ‘ best  way’  in- 
cludes, in  this  as  in  all  other  things,  the  doing 
them  at  the  least  expense  to  the  patient’s  vital 
powers. 

To  prepare  the  bed  for  fever,  for  accidents,  for 
ovariotomy,  and  various  kinds  of  operations ; to 
undress,  handle,  and  put  to  bed  accident  cases. 

To  attend  at  and  prepare  for  operations — in- 
cluding ovariotomy,  lithotomy,  hernia;  to  pre- 
pare patients  for  and  manage  them  after  opera- 
tions and  anaesthetics — and  all  this  with  the  least 
call  upon  their  small  strength. 

To  be  able  to  do  the  first  thing  in  case  of 
haemorrhage,  namely,  compression  by  hand,  by 
extemporary  tourniquet  and  plugging. 

To  bandage  all  the  various  parts  of  the  body, 
arm,  leg,  and  chest  (in  Paris  the  infirmiers  of 
military  hospitals  are  made  to  practise  all  this, 
till  not  only  it  is  done  perfectly,  but  in  a given 
number  of  minutes). 

To  make  bandages  of  the  various  kinds  used ; 
T-bandages,  double-headed,  compound,  4-  and 
6-tailed,  many-tailed,  finger,  ovariotomy,  trian- 
gular, perineal,  starched,  and  plaster-of-Paris, 
and  other  stiff  bandages. 

To  make  rollers,  to  line  and  pad  splints,  to 
make  gutta-percha  splints,  fracture  and  chaff 
pillows  (black  flock  fracture-pillows  harbour 
dust),  and  sand-bags. 

The  nur3e  is  sometimes  now  required  to  give 
abcutaneous  injections,  to  use  the  galvanic 
battery,  and  to  dry-  and  wet-cup. 

She  is  required  to  be  able  to  apply  dry  and 
moist  heat,  to  give  inhalations  and  use  the 
spray-disperser ; to  apply  cold,  with  the  use 
of  siphons  and  with  ice ; and  antiseptic  treat- 
ment. 

Observation  of  Patients. — The  physician 
and  surgeon  require  every  nurse  to  bo  able  to 
observe  correctly,  and  to  report  correctly,  on  the 
state  or  character  of  secretions,  expectoration, 
pulse,  skin,  appetite ; effect  of  diet,  of  stimu- 
lants, and  of  medicines  ; eruptions  ; the  forma- 
tion of  matter;  as  to  intelligence,  with  regard 
to  delirium,  stupor,  &c. ; as  to  breathing,  whether 
quick  or  slow,  regular  or  irregular,  difficult,  &e. ; 
as  to  sleep,  whether  sound,  starting,  heavy,  &c. ; 
and  as  to  the  state  of  wounds.  The  physician 
also  requi  res  the  nurse  to  be  able  to  ‘ take  ’ 
and  to  record  the  temperature,  sometimes  every 
quarter  of  an  hour  in  critical  cases — the  pulse, 
the  respiration ; to  measure  and  sometimes  to 
test  the  urine  for  him.  She  will  be  required 
to  make  these  observations — if  possible  still  more 
accurately— for  child-patients,  who  cannot  tell 
what  is  the  matter  with  them ; to  understand  the 
management  of  sick  children  and  children's 
wards,  which  need  a yet  more  exquisite  cleanli- 
ness. And  children  show  a much  more  rapid 
change  of  symptoms  for  life  or  for  death  gene-  I 


THE  SICK. 

rally  than  adults.  Children  are  the  best  air- 
test,  the  best  test  of  sanitary  conditions. 

VI.  Other  Duties. — She  must  understand 

the  management  of  convalescents — a whole  de- 
partment of  nursing  in  itself — and  the  sooner  a 
convalescent,  especially  a convalescent  child,  is 
removed  from  hospital  to  a country  ‘ home’  the 
better. 

She  mustba  competent  for  the  charge  of  linen 
— a mos  timportautitemofnursing,  when  we  con- 
sider that  on  extreme  cleanliness  of  bed  and  pa- 
tient's linen — in  other  words,  on  linen  and  nurse 
depends  the  not  re-introducing  disease  intc 
disease. 

The  physician  considers  that  fever,  above  al 
other  diseases,  tests  nursing  power,  and  depends 

upon  this  for  life  or  death.  ‘ Dr. ’ (of  St 

Thomas's  Hospital)  ‘ doesn't  think  much  of  the 
nurse  who  loses  a fever  patient,’  was  said  o 
that  wise  man. 

Night-nursing. — The  physician  or  surgeoi 
roquires  the  night-nurse  to  be  as  good  as  th' 
day-nurse,  or  even  better — for  the  most  critica 
times  of  fever  and  severe  surgical  injury  oftei 
occur  at  night,  or  in  the  very  early  morning 
But  quite  the  same  kind  of  business  capacity  i: 
not  required  in  the  night-nurse  as  in  the  nursi 
in  day  charge  of  wards.  Night-nurses,  to  d< 
their  work  well,  must  have  at  least  seven  o 
eight  hours  in  bed  where  they  can  sleep  undis 
turbed  bj' day ; (even  horses  in  the  NewYor 
‘ Horse  Hotel,’  which  work  by  night,  have 
separate  dormitory  to  sleep  undisturbed  by  day 
They  must  have  hotmeals  prepared  for  them  whe 
they  come  off  duty  in  the  morning,  and  befor 
they  go  on  duty  at  night ; besides  breakfast  a 
1 or  2 a.m.  They  must  have  one  and  a half  ( 
two  hours’  exercise.  In  a hospital  they  shorn' 
be  obliged  to  show  their  pass.  It  is  rather  mo) 
necessary  for  a night-nurse  to  be  regular  in  h 
habits,  if  she  is  to  be  well  and  efficient,  than 
a day-nurse.  And  there  appears  no  reason  wl 
nursing  by  night,  if  properly  managed,  should  ! 
more  trying  than  by  day.  But  regularity 
habits,  of  meals,  of  sleep,  of  exercise,  of  pe 
sonal  cleanliness,  is  the  sine  qua  non.  Occasion 
breaks  or  transfers  to  day  duty  may  be  nece 
sary  ; or  a night  or  two  in  bed  every  month  f 
a night  superintendent. 

Holidays.  — All  nurses,  especially  nigh 
nurses,  must  have  holidays.  A month  in  t. 
year  is  not  too  much.  Yet  more  do  matrons  a: 
superintendents  and  all  women  filling  nursi 
offices  of  great  responsibility  require  an  annn 
holiday  if  they  are  to  maintain  vigour  of  1» 
and  mind,  and  not  to  wear  out  prematurely,  i 
occasional  three  months’  holiday  besides  m;g 
be  great  economy. 

What  a Nurse  is  to  be. — A really  go 

nurse  must  needs  be  of  the  highest  class 
character.  It  need  hardly  be  said  that  she  mi 
be  (1)  Chaste,  in  the  sense  of  the  Sermon  on  t 
Mount ; a good  nurse  should  be  the  ‘ Sermon 
the  Mount  ’ in  herself.  It  should  naturally  se< 
impossible  to  the  most  unchaste  to  utter  ev 
an  immodest  jest  in  her  presence.  Rerneml' 
this  great  and  dangerous  peculiarity  of  nursi. 
and  especially  of  hospital-nursing,  namely,  th 
it  is  the  only  case,  queens  not  excepted,  when 
woman  is  really  in  charge  of  men.  (2)  Sob 


NURSING  THE  SICK. 

n spirit  as  well  as  in  drink,  and  temperate  in 
ill  things.  (3)  Honest,  not  accepting  the  most 
rifling  fee  or  bribe  from  patients  or  friends.  (4) 
Truthful — and  to  be  able  to  tell  the  truth  includes 
mention  and  observation,  to  observe  truly— me- 
nory,  to  remember  truly — power  of  expression, 
o tell  truly  what  one  has  observed  truly — as 
veil  as  intention  to  speak  the  truth,  the  whole 
ruth,  and  nothing  but  the  truth.  (51  Trust- 
rortky,  to  carry  out  directions  intelligently  and 
perfectly,  unseen  as  well  as  seen,  ‘ to  the  Lord  ’ 
s well  as  unto  men, — no  mere  eye-service.  (6) 
’unctual  to  a second,  and  orderly  to  a hair— 
laving  everything  ready  and  in  order  before  she 
logins  her  dressings  or  her  work  about  the 
■atient ; nothing  forgotten.  (7)  Quiet,  yet 
uick ; quick  without  hurry ; gentle  without 
lowness ; discreet  without  self-importance,  no 
ossip.  (8)  Cheerful,  hopeful ; not  allowing  her- 
lelf  to  be  discouraged  bv  unfavourable  symp- 
oms ; not  given  to  depress  the  patient  by  antL- 
ipations  of  an  unfavourable  result.  (9)  Cleanly 
) the  point  of  exquisiteness,  both  for  the  patient’s 
ike  and  her  own  ; neat  and  ready.  (10)  Think- 
ig  of  her  patient  and  not  of  herself ; 1 tender 
ver  his  occasions  ’ or  wants,  cheerful  and  kindly, 
'atient,  ingenious  and  feat.  The  best  definition 
jin  be  found,  as  always,  in  Shakespeare,  where 
e says  that  to  be  ‘ nurse-like  ’ is  to  be 

‘So  kind,  so  duteous,  diligent, 

So  tender  over  his  occasions,  true, 

So  feat.’ 

A patient  wants  according  to  his  wants,  and 
ot  according  to  any  nurse’s  theory  of  his  wants 
• 1 occasions.’  ‘ Tender  over  his  occasions  ’ she 
ust  be ; but  she  must  have  a rule  of  thought ; 
id  this  the  physician  or  surgeon  has  to  give 
fer  in  his  directions ; which  her  training  must 
ivo  fitted  her  to  obey  intelligently,  using  dis- 
ction.  The  nurse  must  have  simplicity  and 
single  eye  to  the  patient’s  good.  She  must 
ake  no  demand  upon  the  patient  for  reciproca- 
pn,  for  acknowledgment  or  even  perception  of 
■r  services ; since  the  best  service  a nurse  can 
!ve  is  that  the  patient  shall  scarcely  be  aware 
any— shall  perceive  her  presence  only  by  per- 
iving  that  he  has  no  wants.  The  nurse  must 
Ways  be  kind,  but  never  emotional.  The  patient 
ast  find  a real,  not  forced  or  ‘ put  on,’  centre  of 
lmness  in  his  nurse.  To  call  upon  a patient 
• emotion  for  emotion  is  the  most  cruel,  be- 
luse  useless,  demand  upon  his  strength.  It  is 
king  him  to  bear  your  troubles  and  your 
xiety  as  well  as  his  own.  Suppressed  emotion 
as  bad — it  makes  the  nurse  constrained.  It 
j exposing  the  patient  to  both  frost  and  fire, 
ilf  the  battle  ot'  nursing  is  to  relieve  your  sick 
tom  having  to  think  for  themselves  at  all — least 
all  for  their  own  nursing. 

Florence  Nightingale. 

MTTTBIEG-LIVEIt. — A form  of  disease  of 
i liver,  the  appearance  of  which  on  section 
newhat  resembles  that  of  the  cut  surface  of  a 
hneg.  See  Liver,  Nutiieg. 

NUTRITION,  Disorders  of. — The  nutri- 
a of  the  body,  by  which  we  understand  the 
; intenance  of  its  parts  in  a fit  state  to  perform 
ir  functions,  depends  on  three  main  factors — 


NUTRITION,  DISORDERS  OF.  1049 

the  supply  of  suitable  food  ; the  assimilation  of 
food;  and  the  prevention  or  control  of  waste. 
When  any  of  these  factors  arc  disturbed  disor- 
ders of  nutrition  result.  If  food  be  inadequate 
or  unsuitable,  other  things  being  normal,  gen- 
eral atrophy  will  be  the  consequence  ( see  Atro- 
pht,  General)  ; and  the  same  result  will  evi- 
dently follow  if  the  organs  of  assimilation  are  at 
fault,  or  if  waste  be  excessive,  even  though  food 
be  abundant.  Hence  cancer  of  the  stomach  on  the 
one  hand,  and  diabetes  on  the  other,  may  be  taken 
as  the  types  of  ‘ wasting  diseases.’  Increased 
supply  of  food,  on  the  other  hand,  does  not  im- 
prove the  nutrition  or  cause  hypertrophy  with 
the  same  certainty  as  want  causes  atrophy,  caus- 
ing increase  chiefly  of  a single  tissue,  as  shown 
in  the  articles  on  Hypertrophy  and  Obesity. 

Similar  principles  apply,  mutatis  mutandis , to 
local  nutrition  or  the  nutrition  of  parts  of  the 
body  ; in  which  the  three  factors  are — the  supply 
of  nutritive  material  by  the  blood  ; the  power  of 
assimilation  possessed  by  the  tissues,  depending 
on  the  condition  of  their  minute  elements  ; and 
the  amount  or  rapidity  of  waste.  Ilencc,  as 
shown  elsewhere,  local  atrophy  results  from  ob- 
struction in  the  blood-supply  to  a part ; or  from 
the  inability  of  the  part  to  appropriate  nourish- 
ment, either  through  faulty  innervation  or  the 
condition  of  the  tissue-elements.  In  some  cases 
excessive  use,  leading  to  waste,  is  also  a cause  of 
local  atrophy.  Increased  blood-supply  alone 
does  not,  on  the  other  hand,  by  itself  lead  to 
hypertrophy.  See  Atrophy,  Local. 

When  the  disturbance  of  nutrition,  however 
produced,  causes  a qualitative  rather  than  a 
quantitative  change  in  the  tissue  or  organ,  this 
change  receives  the  name  of  Degeneration,  of 
which  there  are  several  kinds  ( see  Degenera- 
tion). Besides  special  kinds  of  degeneration, 
there  is  one  general  change  which  often  results 
from  impaired  nutrition,  namely,  softening , but 
this  is  no  longer  regarded  as  a distinct  process, 
since  it  differs,  in  its  minute  characters,  accord- 
ing to  the  tissue  which  is  affected.  Induration, 
also,  once  regarded  as  among  the  general  conse- 
quences of  impaired  nutrition,  can  hardly  now 
be  regarded  as  a distinct  and  substantive  pro- 
cess ; but  may  be  understood  in  the  sense  of 
fibroid  degeneration.  In  this  place  we  can  only 
refer  to  some  instances  of  disordered  nutrition, 
which  are  not  precisely  cases  of  atrophy  or  hy- 
pertrophy, but  are  yet  dependent  on  disturbances 
of  some  of  the  factors  of  nutrition  spoken  of 
above.  In  these  cases,  where  the  blood-supply 
is  not  interfered  with,  the  assimilative  power  of 
the  tissues  must  be  in  fault,  and  this  will  depend 
upon  either  innervation  or  the  condition  of  the 
tissue-elements.  In  some  of  these  the  nutritive 
disturbance  leads  to  inflammation. 

There  arc  many  curious  instances  of  local 
changes  of  nutrition  in  which  the  blood-supply 
is  quite  unimpaired,  and  the  cause  has  to  be 
sought  in  some  other  disturbance,  more  espe- 
cially one  of  the  nervous  system.  Reasoning 
from  certain  well-marked  cases  of  disorders  of 
nutrition  originating  in  the  nerves,  it  may  be 
plausibly  conjectured  that  many  other  changes, 
and  particularly  many  ordinary  diseases,  which 
we  usually  regard  as  idiopathic,  may  be  simi- 
larly due  to  disturbance  of  nervous  influence. 


NUTRITION,  DISORDERS  OF. 


1050 

Again,  the  nutrition  of  a part  may  be  affected, 
not  by  direct  nervous  influence,  but  by  reflex 
innervation,  and  thus  depend  upon  the  condition 
of  some  other  organ.  A very  clear  instance  of 
a lesion  of  nutrition  depending  on  the  nerves  is 
seen  in  the  disease,  herpes  zoster,  and  in  some 
other  skin-diseases,  the  distribution  of  which  is 
obviously  regulated  by  the  distribution  of  certain 
nerves.  The  dependence  of  nutrition  upon  the 
nervous  system  is  also  seen  in  some  instances  of 
healing,  as  in  the  case  of  ulcers  of  the  leg, 
pointed  out  by  Mr.  Hilton,  where  rapid  healing 
follows  the  section  of  a nerve-branch  leading  to 
the  ulcerated  patch.  On  the  other  hand,  the.  loss 
of  vitality  dependent  on  nervous  disturbance  is 
seen  in  the  rapid  formation  of  bed-sores  on  the 
sacrum  in  cases  of  paraplegia.  The  same  con- 
clusion must  be  drawn  from  the  nutritive  dis- 
turbances, beside  the  ordinary  disturbance  of  the 
sensory  or  motor  function  of  the  nerves,  which 
sometimes  follow  injuries  to  nerves.  Thus 
injuries  of  the  brachial  plexus,  not  severe  enough 
to  cause  actual  paralysis  of  motion,  may  produce 
a state  of  swelling  and  hyperaemia  in  the  fingers 
— the  condition  called  ‘ glossy  fingers  ’ by  Paget. 
Similar  and  more  complicated  changes  have  been 
observed  as  the  consequence  of  gunshot  wounds 
affecting  the  nerves.  These  cases,  and  such  as 
these,  have  raised  the  question  whether  there 
are  ‘ trophic  nerves,’  that  is,  whether,  in  addition 
to  the  fibres  passing  to  the  muscles  and  to  the 
periphery,  which  are  concerned  in  motion  and 
sensation  respectively,  there  are  others  dis- 
tributed to  the  tissue-elements  themselves,  whose 
function  it  is  to  keep  theso  elements  in  a proper 
state  of  nutrition.  It  is  impossible  to  discuss 
this  theory  here ; but  we  can  only  say  that 
some  of  the  phenomena  which  are  thought  to 
make  necessary  the  theory  of  trophic  nerves 
appear  to  be  explicable  by  assuming  the  presence 
in  the  mixed  nerve-trunks  of  some  fibres  de- 
rived from  the  sympathetic  system.  The  con- 
nection of  the  sympathetic  nerve-fibres  with 
nutrition,  though  chiefly  displayed  through 
variations  in  the  circulation,  is  undoubted.  In 
the  rare  cases  which  have  been  observed  in 
the  human  subject  of  lesion  of  the  sympathetic 
nerve  in  the  neck,  a permanent  change  in  the 
nutrition  of  the  affected  part  is  observed  when 
the  well-known  vascular  changes  have  passed 
away  or  become  greatly  modified.  Lastly,  it 
should  be  pointed  out  that  in  certain  diseases  of 
the  spinal  cord,  for  example,  locomotor  ataxia, 
affections  of  the  joints,  resembling  chronic 
rheumatism,  have  been  observed,  which  may  be 
very  plausibly,  though  not  yet  with  certainty, 
ascribed  to  nervous  derangements.  On  the 
strength  of  these  cases  it  has,  been  supposed 
that  in  other  forms  of  rheumatic  and  rheuma- 
toid disease,  the  distribution  of  the  morbid 
changes  depends  upon  the  nervous  system  ; but 
this  must  be  regarded  ns  quite  theoretical. 
Still  more  uncertain  are  the  theories  which  have 
been  framed  to  explain  the  occurrence  of  in- 
ternal diseases,  such  as  inflammation  of  the 
lungs,  &c.,  us  a consequence  of  nerve-lesions. 

When  we  find  disorders  of  nutrition  neither 
caused  by  changes  in  the  distribution  of  the  blood, 
nor  connected  with  any  nervous  derangements,  I 
the  fundamental  change  must  be  referred  to  the 


tissue-elements  themselves ; and  it  is  probable 
that  the  number  of  disorders  depending  upon 
such  changes  in  the  minute  tissue-elements  is 
very  large ; and  the  field  of  ‘ elemental  pa- 
thology’ may  be  larger  even  than  that  of  nerve- 
pathology  or  blood-pathology.  Such  an  expla- 
nation is  particularly  reasonable  when  the 
changes  are  symmetrical  on  the  two  sides  of 
the  body,  and  when  they  are  connected  with 
advancing  age ; as,  for  instance,  fatty  degenera- 
tion of  the  cornea,  turning  grey  of  the  hair,  and 
primary  degeneration  of  the  walls  of  arteries. 
In  these  cases  it  seems  unnecessary  to  suppose 
any  implication  of  the  nervous  system,  and  dis- 
turbances of  the  circulation  plainly  do  not 
account  for  the  facts.  It  can  only  be  supposed 
that  the  tissue-elements,  like  the  organism  it-; 
self,  have  their  natural  term  'of  life,  and  that! 
this  term  varies  in  different  individuals,  in  whom, 
therefore,  these  failures  of  nutrition  are  merely 
the  expression  of  the,  more  or  less,  premature, 
old  age  of  certain  elements.  These  changes 
may  be,  and  often  are,  the  expression  of  the! 
general  condition  of  the  whole  body,  which  is 
more  obvious  in  some  parts  than  others,  simply 
because  the  tissue-elements  in  these  parts  are 
older  or  less  vigorous. 

Treatment. — Having  spoken  of  the  chiei 
causes  of  disorders  of  nutrition,  it  remains  tc 
consider  whether  there  is  any  general  treatmem 
applicable  to  such  disorders,  independent  of  the 
special  treatment  proper  to  many  of  them  ai 
special  diseases. 

With  regard  to  the  general  nutrition  of  th 
body,  we  can  only  refer  to  what  has  been  saio 
under  the  head  of  Ateopht,  General,  sine- 
hypertrophy  is  not  a condition  which  practi 
cally  requires  treatment,  unless  exceptionally 
as  hypertrophy  of  a special  tissue.  With  re 
gard  to  local  disorders  of  nutrition,  the  firs 
and  only  generally  applicable  rule  must  be  tore 
move,  if  possible,  the  local  cause.  If  the  cause  i 
obscure,  or,  when  discovered,  cannot  be  obviatec 
, the  treatment  must  be  guided  by  circumstance: 
but  will  usually  be  more  of  a general  characte: 
As  an  example  of  the  removal  of  the  cause  ( 
disordered  nutrition,  we  have  instances  in  whic 
the  phenomena  of  nerve-lesion  above  referre 
to  have  disappeared  entirely  on  removing 
fragment  of  lead  or  other  irritating  substanc 
from  the  nerve-trunk.  A more  familiar  instant 
is  where  the  lower  part  of  the  leg  is  in  a pe: 
manent  state  of  malnutrition  from  stagnatic 
of  blood  in  varicose  veins ; oedema,  eczema,  sal 
cutaneous  induration,  and  ulcers  may  resul 
If,  by  suitable  pressure  or  surgical  treatment  i 
the  diseased  veins,  the  circulation  is  rendere 
normal,  all  these  morbid  conditions  will  l 
healed.  On  the  other  hand,  certain  local  di 
orders  of  nutrition  can  only  bo  treated  by  in 
proving  the  nutrition  of  the  whole  body.  C 
chectic  children,  for  instance,  may  exhibit  chron 
conjunctivitis,  bronchial  catarrh,  eczema  of  t] 
flexures,  and  the  peculiar  sloughing  sores 
the  fingers  which  have  no  distinct  name,  but  a 
weU-known  indications  of  malnutrition.  If, 
place  of,  or  in  addition  to,  local  treatment,  v 
use  general  treatment,  directed  to  improve  t) 
nutrition  of  the  body,  all  these  local  disorde 
may  entirely  and  perhaps  simultaneously  g 


NYCTALOPIA. 

vJ,  as  they  depend  only  upon  the  deficient 
jver  of  resistance  possessed  bv  the  tissues  in 
Aeral.  J.  F.  Payne. 

NYCTALOPIA.  — Like  hemeralopia  this 
\<rd  has  been  used  in  two  opposite  and  contra- 
(jtory  senses ; one  signifying  night-sight  or 
(, /-blindness ; the  other  night-blindness  or  day- 
&it.  According  to  the  former,  the  etymology 
c the  word  is  vu£,  night,  and  tinp,  the  eye;  but 
wording  to  the  latter,  it  is  vvl-,  night,  and 
foui//,  blind-eyed,  which  in  its  turn  is  derived 
fen  aAabs,  blind,  and  tin p.  The  testimony  of 
jppocrates  is  cited  in  favour  of  the  former 
Lining;  but  it  should  be  remembered  that  the 
vrk  in  which  the  term  occurs  is  not  genuine, 
rd  there  is,  moreover,  some  warrant  for  the 
f umption  that  the  text  may  not  have  been  cor- 
rtly  copied.  Galon,  Aetius,  Paulus  AEgineta, 
]ny,  and  most  of  the  best  ancient  authors, 
eploy  the  word  as  meaning  night-blindness, 
cl  we  shall  use  it  in  this  sense  here.  Nycta- 
llia  may,  therefore,  be  defined  as  disorder  of 


OBESITY.  1051 

vision  in  which  objects  are  seen  well,  and  with- 
out pain  or  discomfort,  during  the  day,  or  by 
strong  artificial  light,  but  become  more  or  less 
invisible  in  a deep  shade,  or  by  twilight.  It  is 
the  opposite  of  hemeralopia.  See  Hemeralopia  ; 
and  Vision,  Disorders  of. 

NYMPHOMANIA  (vvgipi),  a woman,  and 
fiav fa,  madness).— A form  of  mental  derangement 
in  women,  characterised  by  an  insatiable  desire 
for  sexual  intercourse.  See  Sexual  Functions 
in  the  Female,  Disorders  of. 

NYSTAGMUS  (i ’varaygos,  from  vvarraCu, 
I nod). — An  involuntary  movement  of  the  eye- 
ball, due  to  clonic  spasm  of  the  muscles  of  the 
globe.  It  usually  affects  both  eyes.  The  move- 
ment is  generally  horizontal,  that  is  from  side  to 
side,  and  is  then  called  oscillatory ; but  it  may 
be  rotatory,  that  is,  round  the  optic  axis,  or 
oblique,  when  it  is  said  to  be  mixed.  It  may  be 
(a)  congenital  or  infantile  ; (4)  acquired ; or  (c) 
symptomatic  of  cerebral  or  spinal  disease. 


o 


DBERLAND,  the  Bernese. — Grindelwald, 
(rnigel,  Interlaken,  Mfirren,  &c.  Cool,  bracing, 
funtain  summer  climate.  See  Climate,  Treat- 
: nt  of  Disease  by. 

DBESITY  ( obesus , corpulent;  from  ob,  by 
fson  of,  and  cdo,  I eat). — Synon.  : Corpu- 
jce;  Polysarcia;  Fr.  Obesite;  Ger.  Fettsucht, 

. tleibigkeit. 

Definition. — This  term  is  applied  to  a 
}>ieral  state  of  disordered  nutrition  of  the  body, 
aracterised  by  an  excessive  development  of  the 
• pose  tissue,  more  especially  in  those  situa- 
|ns  where  it  is  normally  most  abundant, 
tnely,  the  subcutaneous,  subserous,  and  inter- 
i;scular  connective  tissue. 

Etiology, — a.  Predisposing  causes. — The 
i uence  of  heredity  in  transmitting  the  liability 
t obesity  is  undoubted,  and  is  a matter  of  com- 
i n knowledge.  Sex  and  Age. — That  excessive 
dpulence  is  more  common  among  women  than 
;]ong  men  is  also  well  known.  Several  circum- 
f.nces  have  been  suggested  to  account  for  this, 
f h as  the  menstrual  functions  of  women,  their 
1 5 muscular  activity  as  compared  with  men,  and 
t ir  frequently  diminished  oxidative  power,  due 
t ooverty  of  red  blood-corpuscles.  Age  appears 
tjhave  considerable  influence  in  determining 
t>  condition.  Under  a healthy  regimen  cliil-  j 
c,n  get  fat  from  birth,  notwithstanding  that  ■ 
t the  same  time  the  albuminoid  ingesta  must 
Largely  employed  in  the  construction  of  the 
l idly  growing  tissues;  and  hence,  at  this  period 
c life,  the  fat  and  amyloid  food-stuff’s  are  the 
v if  source  of  the  adipose  deposit.  How  fre- 
c ntly  are  seen  children  improperly  fed  on 
Loss  of  starchy  matter,  very  fat,  whilst  their 
| oral  nutrition  is  much  impaired.  A fat  child 
‘ from  necessarily  being  a healthy  one.  At 


I puberty  there  is  frequently  a diminution  in 
I weight,  Loth  relatively  to  the  height  and  abso- 
lutely' ; but  the  contrary  to  this  sometimes 
! accompanies  the  establishment  of  menstruation, 
especially  if  the  subject  be  very  chlorotic — that 
is,  with  au  enfeebled  oxygen-carrying  blood- 
power.  After  the  age  of  forty,  particularly  in 
women  at  the  chmacteric,  the  influence  of  age 
markedly  asserts  itself.  Even  the  manifestation 
of  the  hereditary  tendency  may  be  postponed 
until  that  period,  and  for  women  to  become  fat 
at  that  time  is  almost  the  rule.  The  perversion 
of  nutrition  now  under  consideration  is,  in  some 
unknown  way,  curiously  but  distinctly  associated 
with  the  degree  of  development  of  the  sexual 
functions,  and  in  an  inverse  direction.  This  is 
very  noticeable  in  eunuchs  and  animals  whoso 
generative  organs  have  been  removed,  and  tho 
part  played  by  the  cessation  of  ovulation  has 
been  already  mentioned.  Even  during  preg- 
nancy, when  ovulation  is  suspended,  it  is  no  un- 
common occurrence  for  the  subcutaneous  fat  to 
be  increased  in  amount.  Race.— Among  certain 
races  obesity'  appears  to  prevail,  as  for  instance 
the  Hottentots  ; and  whilst  amongst  some,  such 
as  certain  castes  of  Hindoos,  the  condition  has 
been  highly  estimated,  amongst  others,  as  the 
Greeks  and  Romans,  it  was  regarded  as  dis- 
graceful. Climate. — Although  very  fat  people 

are  met  with  in  all  climates,  there  appears  to  be 
a special  tendency  to  their  predominance  in  low- 
lying,  damp  countries,  whilst,  with  certain  ex- 
ceptions, they  are  less  often  seen  in  very  hot  and 
in  mountainous  districts. 

Nervous  Influence. — Since  the  nervous  system 
so  directly  influences  tissue-changes,  it  is  not  tc 
be  wondered  at  that  certain  nervous  states  favour 
obesity  ; it  is  common  in  idiots. 


1062  OBESITY. 


b.  Determining  causes.— Excess  of.  food  is 
the  first  of  these  to  be  mentioned.  Whilst  no  doubt 
a large  excess  of  food  may  lead  to  corpulency,  it 
.must  be  confessed  that  it  very  often  does  not  do 
so,  and  extremely  thin  men  are  often  large  eaters. 
And,  on  the  contrary,  many  women  who  become 
excessively  obese  have  poor  appetites.  Nor 
does  it  seem  in  these  different  classes  of  cases, 
that  the  kind  of  food  makes  much  difference. 
Some  get  fat,  eat  what  they  will ; others  do  not, 
whatever  the  diet.  Brink.  — It  is,  however, 
usually  the  case  that  very  fat  people  take  a large 
amount  of  fluid  food.  How  alcohol  acts  in  the 
production  of  fat  is  not  very  clear.  It  is  asserted 
that  it  does  so  by  diminishing  oxidation;  but 
this  is  not  the  entire  explanation,  for  the  extent 
of  obesity  is  far  from  being  proportionate  to  the 
amount  taken,  and  not  unfrequently  an  exces- 
sive ingestion  is  not  associated  with  corpulency. 
There  would  seem  also  to  be  something  due  to 
the  form  in  which  the  alcohol  is  taken.  Exercise. 
— Deficient  muscular  activity,  by  diminishing  the 
amount  of  oxidation  of  tissue,  favours  obesity ; 
and  since,  as  a rule,  the  stouter  the  person  the 
less  capable  is  he  of  exercise,  these  two  conditions 
react  one  upon  the  other,  to  the  advantage  of  fat- 
production.  Disease. — Exceptional  cases  of  cor- 
pulence have  followed  recovery  from  fever,  and 
extensive  bleedings,  even  when  there  had  been  no 
predisposition  ; and  a similar  result  has  been  met 
with  after  prolonged  administration  of  mercurials 
and  arsenic,  which  is  perhaps  to  be  explained  by 
the  deteriorating  influence  that  these  drugs  are 
said  to  possess  on  the  red-blood  corpuscles. 

Pathology. — Assuming  that  the  current  views 
on  lipogenesis  or  fat-formation  are  known  to  the 
reader,  it  is  sufficient  here  to  state  that  from 
whatever  source  the  fat  of  the  body  be  derived, 
whether  from  the  fatty,  the  amyloid,  or  albu- 
minoid elements  of  the  food,  or  from  all,  as  is 
most  probable,  the  fact  of  its  being  stored  up  as 
adipose  tissue  must  be  regarded  chemically  as 
an  expression  of  deficient  oxidation ; a process 
which,  if  it  had  been  more  complete,  would  have 
resulted  in  the  conversion  of  these  elements  into 
carbonic  acid  and  water,  to  which  the  fat  itself 
is  reduced  when  it  is  subsequently  used  up  in  the 
economy.  It  is  thus  that  the  corpulence  that 
frequently  attends  such  morbid  states  as  anaemia, 
chlorosis,  haemorrhage,  some  pulmonary  and  car- 
diac diseases,  and  alcoholism,  is  to  be  explained  ; 
since  in  all  these  diseases  the  oxygenising  power 
of  the  blood  is  deficient. 

The  fat  of  the  body  in  an  average  male  adult 
constitutes  about  one-twentieth,  and  in  the  female 
rather  more,  of  the  total  weight.  It  is  not  for 
months  after  the  commencement  of  develop- 
ment, that  the  adipose  tissue  is  sufficiently  dif- 
ferentiated to  be  distinguishable  ; it  gradually  in- 
creases in  amount  , being  considerable  at  birth  and 
up  to  puberty,  when  it  often  diminishes  slightly; 
during  maturity  it  increases,  or  the  reverse,  being 
very  variable  in  amount;  and  during  old  age  it 
decreases.  During  childhood  the  adipose  tissue 
is  more  evenly  distributed  in  the  subcutaneous 
tissue  than  in  later  life,  when  fat  tends  to 
diminish  on  the  surface  in  proportion  as  it  be- 
comes deeper-seated. 

In  the  three  situations  in  which  the  fat  is  chiefly 
deposited — namely,  tho  subcutaneous,  subserous, 


and  inter-muscular  connective  tissue — there  a 
certain  areas  which  are  preferred  by  it,  as  the 
are  others  which  escape.  Whilst  the  ’abdonw 
buttocks,  and  back  of  the  neck  are  especially  p; 
minent,  the  wrists,  ankles,  eyelids,  scrotum  Y 
penis  are  free  from  fat  Beneath  mucous  me 
branes  it  is  very  unequally  distributed.  Fat  i 
never  seen  beneath  tho  peritoneal  coat  of  t 
stomach  or  intestines,  the  parietal  pericardii 
or  the  visceral  pleura ; whilst  the  great  omenta  i 
which  usually  weighs  about  Mb.,  may  reach 
7 lbs.  or  8 lbs.,  or,  it  is  said,  even  30  lbs. ; a1 
under  the  synovial  membranes  fat  may  be  ( 
posited  to  such  an  extent  as  to  interfere  w 
the  movement  of  the  joints. 

The  ordinary  state  of  the  organs  found  in  v( 
corpulent  people  is,  that  the  lungs  are  sma 
the  heart  and  the  liver  large,  and  infiltraf 
with  fat;  the  gall-bladder  containing  only  a lit 
pale  bile  or  mucus ; the  stomach  large  and  mi 
cular,  but  well-developed  : the  kidneys  sma'. 
as  also  the  spleen  and  lymphatic  glands;  a 
the  pancreas  largely  developed. 

Like  many  other  conditions  of  disease,  it 
impossible  to  define  the  exact  line  at  which 
morbid  obesity  may  he  said  to  commence.  ;| 
degrees  of  corpulence,  indicated  by  such  terms 
‘stout,’  ‘embonpoint,’  &c.,  occur,  to  which  tl 
notion  of  disease  is  wholly  inapplicable.  N 
as  will  be  seen,  can  the  disturbance  of  funct? 
be  taken  in  all  eases  as  the  measure  of  a morl 
state,  since  the  impairment  of  function  is  ij 
always  proportionate  to  the  amount  of  fat. 

As  instances  of  extreme  corpulency  the  foiloi 
ing  may  be  quoted: — 

Daniel  Lambert,  who  at  twenty-three  ye; 
old  weighed  32  stone,  but  could  walk  frd 
Woolwich  to  London.  His  subsequent  maximi 
weight  reached  to  52  st.  11  lbs. 

Edward  Wright,  44  st. 

Dr.  Wardell  records  the  case  of  a you 
married  woman,  who,  at  eighteen  was  thin  a', 
delicate,  had  no  children,  and  lived  well;  s> 
died  at  the  ago  of  forty-one ; the  thickness  of  t> 
subcutaneous  fat  on  the  sternum  was  4 inch, 
and  midway  between  pelvis  and  umbilicus; 
inches.  The  heart  weighed  36  oz.,  the  li" 
118  oz.,and  there  were  prolongations  of  fatfri 
the  omentum  1 to  4 inches  long,  as  thick  at 
candle. 

As  illustrations  of  precocious  obesity,  caS 
are  on  record  of  a girl  weighing  13  st.  at  b 
age  of  twelve  years ; and  a boy  weighing  8 st.  1 2 1. 
at  three  years.  This  boy  had  three  teeth  at  bif, 
and  twenty -six  at  thirteen  months  old. 

Thus,  in  extreme  cases,  one-half,  or  foui-fil  5 
even,  of  the  body-weight  may  he  fat 

Symptoms. — The  general  appearance  ofi 
corpulent  person  scarcely  needs  descripti. 
The  condition  may  he  associated  either  wi 
a hypersemic  or  full-blooded,  or  with  an  anseic 
state  of  body,  and  it  is  desirable  to  recognise  ts 
in  view  of  treatment.  Owing  to  the  fatty  infilt- 
tion  of  the  muscular  tissues,  and  the  degenerata 
of  the  fibres,  the  muscular  energy  is  diminish, 
this  being  especially  noticeable  in  regard  to  e 
heart,  the  action  of  which  is  easily  disturbed,  ii 
palpitation  is  a frequent  symptom,  accompani 
by  dyspncea,  induced  by  slight  exertion.  s 
affection  of  the  voluntary  muscles  manifests- 


OBESITY.  iq£3 


s:  in  an  indisposition  to  active  exercise.  The 
destive  power  is  often  very  well  maintained,  and 
t;  notwithstanding  the  frequent  excess  both  in 
t quantity  and  in  the  quality  of  food  indulged 
i Periodical  impairments  are,  however,  fre- 
est, and  flatulence  and  constipation  are  often 
tublesome.  The  cardiac  sounds  are  usually 
fble  and  distant,  though  the  reverse  obtains 
ven  there  is  a hypertrophied  ventricle.  The 
j se  is  fall,  or  small  and  weak,  according  to 
t plethoric  or  feeble  state  of  the  individual. 
!e  mental  activity  is  variable,  and  many  ex- 
tnal  causes  tend  to  modify  it ; but  the  tempera- 
rnt  is  proverbially  ‘ easy-going,’  indolent,  and 
liargie,  especially  after  meals,  although  very 
fquently  interrupted  by  attacks  of  peevishness 
pi  irritability,  or  by  unusual  somnolence  and 
cet.  Examples,  however,  of  considerable  in- 
t.ectual  attainments  are  not  unknown  among 
t,  corpulent.  The  excretions  are  usually  copious, 
hfnse  sweating  is  induced  by  slight  exertion, 
pi  the  secretion  of  the  sebaceous  glands  is  abun- 
nt.  The  urine  generally  is  acid,  and  contains 
; excess  of  uric  acid.  Partly  from  chafing,  and 
; fly  from  the  excessive  cutaneous  secretions, 
i ertrigo  and  other  eruptions  are  apt  to  occur 
i the  folds  of  the  groin,  helow  the  mammse, 
pi  in  similar  parts.  The  vessels  share  in  the 
peral  malnutrition  of  the  tissues,  and  atheroma 
cthe  arteries  is  often  found,  whilst  the  veins 
home  distended  and  varicose,  forming  kaemor- 
i lids  and  varicocele.  Depending  upon  these 
vcular  changes  are  the  congested  and  bloated 
poearance  of  the  face,  and  the  liability  to  head- 
; ies,  vertigo,  and  giddiness.  The  sexual  appetite 
i rcquently  deficient  in  both  sexes,  and  sterility 
i common  in  women.  Disturbances  of  sight 
i t hearing  are  frequently  noticed  in  fat  people. 
The  condition  of  obesity,  like  other  general 
] 'versions  of  nutrition,  such  as  tuberculosis  and 
i kets,  most  distinctly  presents  other  character- 
i'.cs  than  the  mere  signs  and  symptoms  above 
umerated.  There  are  certain  tendencies  and 
i lilities  which  the  state  engenders ; and 
iercnrrent  maladies  come  to  possess  special 
i tures.  Periodically,  the  fat  man  ails  without 
jhaps  any  obvious  cause,  and  such  ailments 
i st  be  regarded  as  the  expression  of  malnutri- 
1 1 of  the  tissues  produced  by  the  excess  of  fat. 
. long  the  more  prominent  of  these  affections 
i i proneness  to  catarrh  of  the  respiratory  and 
pnentary  mucous  membranes,  and  periodical 
‘ Ids’  and  diarrhoeas  are  frequent.  This  is  in 
fiat  part  due  to  the  fact  that  the  power  of  self- 
t ulation  of  temperature,  which  the  body  pos- 
tses,  is  diminished  by  the  thick  layer  of  sub- 
c aneous  fat,  which  is  a bad  conductor  of  heat, 
e interferes  with  compensatory  radiation.  At 
t same  time  the  plethoric  condition,  the  hy- 
fiaemia,  and  the  enfeebled  circulation  due  to 
t weak  heart,  all  tend  to  the  same  end,  namely, 
f ability  to  congestion  of  the  ill-supported  tis- 
f s,  such  as  the  mucous  membranes,  with  the 

I ilts  of  such  congestion  in  excessive  secretion 
t other  derangements  of  function. 

he  obese  subject  is  quite  as  liable  to  the 
t te  diseases  as  is  the  thin  man ; and  these 
t adies  run  in  him  a singularly  unfavourable 
( rse.  The.  diminished  power  of  heat-radia- 

I I increases  the  pyrexia ; and  the  weak  heart 


favours  the  establishment  of  the  adynamic  state. 
Such  means  for  lowering  the  temperature  as  cold 
applications  have  but  little  effect  through  the 
thick  fat ; and  aconite  is  contra-indicated  by  the 
pulse.  But  since  the  oxidising  process  in  the 
corpulent  is  diminished,  the  temperature  in  the 
febrile  state  is  rarely  very  high,  and  at  the  same 
time  is  but  ill  resisted. 

The  effective  agent  in  lipogenesis,  namely, 
deficient  oxidation  of  the  ingesta,  especially  the 
albuminoids,  also  favours  the  formation  of  uric 
acid,  and  hence  the  fat  are  often  gouty.  Saccharine 
urine  (a  condition  which,  whatever  view  be  taken 
of  its  pathology,  is  manifestly  a state  of  defi- 
cient oxidation  of  certain  tissue-elements) — es- 
pecially that  form  which  is  met  with  in  those 
advanced  in  life — very  frequently  occurs  in  stout 
people.  In  32  of  140  cases  of  diabetes  observed 
by  Seegen,  obesity  preceded  the  glycosuria. 

Progress  and  Prognosis. — The  progress  of 
obesity  is  essentially  chronic,  and  rarely,  if  ever, 
tends  to  other  than  increase  of  this  state.  Ex- 
treme fatness  in  the  very  young,  as  said,  usuallv 
subsides  ; but  the  obesity  of  advanced  life  never 
does,  unless  any  exhaustive  disease  should  co- 
exist, such  as  cancer  or  diabetes ; and  the  latter 
by  no  means  produces  then  the  emaciation  that 
it  causes  in  young  people.  Obesity  should,  on 
the  whole,  be  regarded  as  a grave  matter,  since 
very  fat  people  rarely  reach  an  advanced  ase ; 
whilst  a decrease  of  fat  at  middle  age  in  a person 
hitherto  stout  should  be  regarded  with  suspicion. 

In  obesity  death  by  syncope  may  result  from 
an  extremely  fatty  heart ; from  apoplexy,  caused 
hy  rupture  of  an  atheromatous  vessel  in  the  brain ; 
or  from  bronchitis,  with  general  oedema  from 
cardiac  dilatation. 

Treatment.  — Limited  space  prevents  even 
an  enumeration  of  the  nostrums  that  a fanciful 
empiricism  has  suggested  for  the  prevention  or 
cure  of  obesity. 

Eecognising  that  accumulation  of  fat  is  a per- 
version of  nutrition,  which,  if  once  established, 
and  with  a strong  hereditary  predisposition,  can- 
not he  cured,  it  follows  that  we  should  endeavour 
to  prevent  as  far  as  possible  its  increase,  by 
avoidance  of  those  factors  which  pathology  tells 
us  are  favourable  to  its  development.  The  cardinal 
rule  in  any  procedure  that  maybe  adopted  is  to 
avoid  heroic  treatment,  for  though  thereby  the 
fat  may  be  diminished,  the  result  may  bo  attained 
by  establishing  a worse  state  of  the  body,  if  not 
oneleadingeven  to  a fatal  termination.  Theguides 
as  to  how  far  a given  plan  may  be  proceeded 
with  are,  first  of  all,  the  age  and  general  con- 
dition of  the  patient,  especially  as  regards  the 
heart's  power  ; and,  secondly,  the  feelings  and 
capability  of  the  patient  as  the  treatment  is  pur- 
sued. Each  case  must  be  treated  according  to  cir- 
cumstances, bearing  in  mind  that  the  objects  to  be 
aimed  at  are  to  diminish  the  sources  of  the  fat, 
and  to  increase  the  oxygen-carrying  power  of  the 
blood  and  oxidising  power  of  the  tissues. 

The  diet  must  be  regulated  in  quantity  and 
quality.  Since  a healthy  diet  should  consist  of 
certain  proportions  of  nitrogenous,  amyloid,  and 
fatty  principles,  and  since  from  all  these  three 
substances  fat  may  be  formed  in  the  body,  the 
question  arises  which  can  be  most  advantageously 
diminished.  Experience  supports  our  patho- 


1054  OBESITY, 

logical  knowledge  in  advocating  a withdrawal  as 
far  as  possible  of  fatty  and  starchy  food,  whilst 
at  the  same  time  a moderate  increase  in  albu- 
minoid matter  is  permitted  ; for  with  a fair 
quantity  of  the  other  food-staffs,  proteids  increase 
tissue-change.  It  is  on  this  principle  that  systems 
of  dietary  for  the  corpulent  are  founded,  the  best 
known  of  which  bears  the  name  of  Banting,  who 
for  a year  (1863)  successfully  followed  out  a plan 
laid  down  for  him  by  Dr.  Harvey,  with  the  result 
of  losing  44  lbs.  in  weight,  and  without  the  re- 
currence of  corpulence  when  ordinary  diet  was 
resumed.  There  are  many  other  cases  recorded. 
Dr.  Cheyne,  who  weighed  32  stone,  reduced 
himself  a third  in  weight,  and  lived  afterwards  in 
good  health  to  the  age  of  seventy-two  (Dr.  Wadd 
on  Corpulence,  1822).  Lean  meats,  sweetbreads, 
fish,  except  rich  kinds,  such  as  salmon  and  eels, 
clear  soups,  poultry,  game,  eggs,  cheese,  green 
vegetables,  toast,  gluten  bread,  fresh  fruit,  and 
pickles  are  allowable  articles  of  diet.  An  average 
diet  for  an  adult  would  be  12  oz.  lean  meat,  6 
oz.  rusks  or  gluten  bread,  4 oz.  green  vegetables, 
1 oz.  butter,  and  tea  f-pint.  Much  difference  of 
opinion  exists  as  to  how  far  water  should  or 
should  not  be  freely  allowed.  Alcohol  generally 
should  be  avoided,  but  especially  spirits  and  beer, 
which  must  be  absolutely  forbidden,  except  on 
emergency;  cider  or  the  light  dry  wines,  both 
white  and  red,  diluted  with  water,  are  less 
objectionable.  Tea  and  coffee  are  supposed  to 
interfere  with  tissue-change,  and  therefore  should 
be  taken  sparingly ; and  milk,  from  the  quan- 
tity of  fat  it  contains,  is  to  some  extent  inadmis- 
sible. 

Exercise,  within  the  limits  of  the  patient's 
powers,  such  as  riding,  walking,  rowing,  and 
gymnastics,  is  of  great  benefit,  by  directly  induc- 
ing an  increased  oxidation  of  tissue,  and  improv- 
ing the  quality  of  the  blood,  and  therefore  its 
oxygen-carrying  power.  Cold-bathing,  if  well 
borne,  is  of  advantage  on  similar  grounds,  but 
extreme  sweating  is  unadvisablc,  and  may  be 
dangerous.  Breathing  compressed  air,  with  the 
object  of  increasing  the  tissue-oxidation,  has  been 
recommended. 

It  is  in  carrying  out  a system  rather  than 
in  devising  one  that  the  difficulty  occurs.  The 
regularity  and  restraint  prove  irksome  to  the 
patient,  and  are  frequently  broken.  Hence  it  is 
that  the  regimen  and  spare  diet  of  the  various 
spas,  such  as  Carlsbad,  Marienbad,  Kissengen, 
and  Ems  have  great  advantages,  since  at  such 
places,  and  in  such  surroundings,  the  patient 
more  readily  and  willingly  pursues  a given  plan. 

In  the  treatment  of  intercurrent  diseases  it  is 
essential  to  remember  the  enfeebled  resisting 
power  of  the  patient,  and  the  necessity  for  stimu- 
lants. 

Among  the  many  drugs  that  have  been  used, 
may  be  mentioned  alkalies,  iron,  and  iodine. 
Soap  was  formerly  much  employed,  as  much 
as  three  ounces  being  given  daily  with  milk  and 
lime  water ; and  some  of  the  good  effects  of  the 
various  1 waters  ’ are  ascribed  to  their  alkaline 
properties,  especially  the  alkaline  aperients  of 
the  above-mentioned  spas.  Iron  is  an  essential 
in  those  forms  of  corpulence  associated  with 
anaemia,  and  most  satisfactory  results  follow  its 
administration,  as  the  health  improves  and  the  I 


OBSTRUCTION",  AND  OCCLUSION, 
fat  diminishes.  Young  chlorotic  subjects  ben. 
by  this  treatment,  which  may  be  advantageon 
carried  out  at  some  chalybeate  spring,  such  ‘ 
Tunbridge  W ells,  Harrogate,  or  Spa.  The  iodic ' 
such  as  those  of  potash  and  iron,  given  in  k 
doses,  undoubtedly  effect  a reduction  in  t 
amount  of  fat,  but  not  always  with  a correspoi 
ing  improvement  in  health.  So  long  as  this  dJ 
not  suffer  and  the  patient  improves,  the  drug  ji 
be  persevered  in,  but  it  is  frequently  very  ba. 
borne  when  taken  in  quantity.  The  preparatii 
of  fucus  vesiculosus,  the  basis  of  certain  qua 
remedies,  appear  to  depend  for  their  value  : 
the  iodine  contained  in  them. 

W.  H.  Aixchix. 

OBSOLESCENT,  ( obsolcsco , I grow  out 
use). — A term  applied  to  miliary  tubercle,  wt 
instead  of  undergoing  destructive  changes, 
becomes  dried  up,  shrunken,  and  hard,  and  tl 
remains  inert.  See  Tubercle. 

OBSTRUCTION,  and  OCCLUSION 

Obstruction  and  occlusion  of  the  different  tu! 
and  orifices  of  the  body  are  mainly  effected 
three  different  ways: — first,  by  blocking 
tube  by  its  contents ; secondly,  by  alteration 
its  walls ; thirdly,  by  pressure  from  without. 

1.  Blocking. — The  first  mode  of  obstruct 
is  met  with  in  most  of  the  tubes  of  the  body,  aj 
may  be  produced  in  various  ways.  The  o;c: 
ding  mass  may  be  composed  of  the  normal  c 
tents  of  the  tube ; of  these  contents  variou' 
altered  ; or,  lastly,  it  may  be  some  foreign  s- 
stance  introduced  from  without.  Examples  f 
the  first  of  these  modes  occur  in  the  intestine,, 
cases  of  impacted  faeces  or  intestinal concretio: 
in  the  biliary  and  urinary  passages  from  calci: 
in  the  ducts  of  glands  from  the  products! 
catarrh  or  inspissated  mucus ; and  in  the  bloj- 
vessels  from  deposits  of  fibrin.  Obstruction' 
foreign  bodies  may  of  course  occur  in  all  tw 
in  direct  communication  with  the  external  s- 
face,  but  even  internal  tubes  are  sometimes  - 
structed  in  this  manner.  As  examples  of  Is 
may  be  cited  the  occasional  obstruction  of  e 
bile-ducts  by  hydatid  cysts,  or  by  the  asci« 
lumbricoides  ; of  the  pulmonary  artery  by  hy- 
tids  ; of  capillaries  by  masses  of  bacteria ; d 
of  the  pulmonary  capillaries  by  air  sucked  iny 
a wounded  vein. 

2.  Parietal  Changes. — Obstruction  of  tus 
from  alteration  in  their  walls  is  the  most  e<- 
mon  cause  of  the  various  forms  of  pennant 
stricture,  and  may  arise  from  many  different  c- 
ditions.  First,  in  those  tubes  whose  walls  e 
muscular,  it  may  be  the  result  of  spasm.  Is 
form  of  obstruction  is  usually  only  of  tempoiy 
duration,  and  is  probably  not  of  very  freqrt 
occurrence.  It  is  supposed  to  take  place  in  a 
urethra  and  the  bile-duct,  but  the  most  imp 
tant  instances  of  it  are  met  with  in  the  resp  - 
tory  and  vascular  systems.  In  the  former  c 
have  examples  in  spasmodic  closure  of  theglois, 
and  also  in  the  narrowing  of  the  bronchial  tus 
in  spasmodic  asthma ; in  the  latter  in  the  In- 
struction by  spasm  of  the  small  arteries  of  .e 
base  of  the  brain,  to  which  the  initial  phenoma 
of  the  epileptic  seizure  are  ascribed.  ToasimJ 
spasmodic  occlusion  of  the  arterioles  of  e 
lungs  Dr.  George  Johnson  ascribes  many  of a 


OBSTRUCTION'  AN'D  OCCLUSION', 
ohenomena  of  cholera.  To  a more  prolonged 
3pasm  of  the  blood-vessels  the  gangrene  produced 
oy  ergot  has  been  attributed. 

Obstruction  from  more  permanent  alterations 
,n  the  vails  of  the  tubes  may  be  produced,  first, 
oy  acute  inflammatory  swelling  and  oedema, 
md  by  the  formation  of  false  membranes  ; and 
secondly,  by  chronic  inflammatory  thickeniugs 
ind  cicatricial  contractions.  These  form  the 
aon-malignaut  permanent  strictures,  as  of  the 
irethra,  ^oesophagus,  pylorus,  and  intestines. 
Thirdly,  the  growth  of  some  malignant  or  other 
umour  in  the  -walls  of  tubes  may  lead  to  the 
’same  result.  This  form  of  stricture  is  especially 
common  in  the  digestive  canal,  from  the  pharynx 
downwards. 

3.  External  Pressure. — Lastly,  obstruction 
ind  occlusion  are  often  the  result  of  pressure  from 
vithout.  This  pressure  may  be  exercised  by  a 
umour  of  some  kind,  or  by  enlargement  of  an 
>rgan,  as,  for  example,  the  obstruction  of  the 
raehoa  produced  by  an  enlarged  thyroid  body, 
dr  the  pressure  from  without  may  be  produced 
py  the  effects  of  inflammatory  processes  occur- 
■ing  in  the  surrounding  parts.  We  have  ex- 
tmples  of  this  in  occlusion  of  the  intestine  by 
jbrous  bands,  and  in  obstruction  of  the  tubuli 
iriniferi  of  the  kidney  by  the  cirrhotic  process. 
)ther  examples  of  pressure  from  without,  causing 
destruction,  occur  in  displacements  of  the  intes- 
ine  in  hernia,  with  which  may  be  classed  the 
■arious  forms  of  volvulus. 

Effects. — The  effects  of  obstruction  and  oc- 
lusion  differ,  of  course,  according  to  the  tube  or 
rifice  affected.  They  are  in  part  due  to  the  arrest 
f function  of  the  tube,  and  in  part  are  purely 
leehanieal.  The  most  general  mechanical  effect 
p dilatation  of  the  tube  behind  the  seat  of  the 
bstruction,  owing  to  the  accumulation  of  its 
patents  (see  Dilatation),  and  arrest  of  func- 
;.on  beyond  it.  When  these  contents  are  them- 
?lves  irritating,  or  when  the  disturbing  cause 
Iso  constricts  the  blood-vessels,  ulceration,  or 
angrene  and  perforation,  are  liable  to  occur. 
; he  other  effects  are  mainly  due  to  the  backward 
pessure  of  the  accumulation.  In  cases  where 
ie  tube  is  the  duct  of  a gland,  the  ultimate  effect 
to  arrest  the  secreting  function,  and  cause 
-rophy  of  the  gland.  This  is  attended  by  cessa- 
on  of  any  further  accumulation ; and  sometimes 
pmplete  absorption  of  the  previous  accumulation 
kes  place,  and  the  dilated  duct  shrinks  and  be- 
i mes  completely  atrophied.  Examples  of  this 
■ ries  of  changes  occur  not  infrequently  in  the 
eter  and  kidney.  W.  Cayley. 

OCCUPATION,  etiology  of. — See  Dis- 
se,  Causes  of ; and  Public  Health. 
(EDEMA  (olSea,  I swell). — Synon.  : Fr. 
I ’dime;  G-er.  GEdem. — A dropsical  effusion  in 
3 cellular  tissue,  whether  subcutaneous,  sub- 
: icons,  snbserons,  or  in  the  interstices  of  organs, 
s Dropsy. 

(ESOPHAGUS,  Diseases  of. — Synon.:  Fr. 
iladies  d (Esophage ; Ger.  Krankhedten  der 
eiserohre. — The  diseases  of  the  oesophagus  may 
considered  in  the  following  order  : — 

H.  (Esophagitis. — Inflammation  of  the  ceso- 
igus. 

Etiology. — Inflammation  of  the  oesophagus, 


(ESOPHAGUS,  DISEASES  OF.  10-to 
arising  in  its  structures  and  confined  to  it.  is  an 
affection  of  rare  occurrence  : or  it  may  bo  that 
it  offers  so  few  marked  symptoms  that  but  small 
attention  is  paid  to  ir,  and  it  never  comes  before 
the  physician.  But  by  no  means  uncommon  is 
the  extension  of  inflammation  to  the  (Esophagus 
from  neighbouring  structures.  Thus,  a catarrhal 
inflammation  of  the  throat  and  fauces  may  pass 
down  the  cesophagus.  In  cliildren  thrush  has 
been  seen  to  extend  into  the  gullet,  setting  up  a 
certain  amount  of  inflammation ; and  the  same 
holds  good  with  regard  to  diphtheria  and  croup. 
Where  organic  disease  of  this  organ  exists,  a 
certain  amount  of  inflammation  is  liable  to  be 
set  up.  But  by  far  the  most  common  causes  of 
acute  oesophagitis  are  the  ingestion  of  irritating 
or  corrosive  substances,  such  as  boiling  water, 
alkalies,  or  acids ; and  mechanical  injury  from 
the  introduction  of  foreign  bodies. 

Symptoms. — Somewhere  in  the  line  of  the 
(Esophagus  pain,  varying  in  intensity,  of  a burn- 
ing or  lancinating  character,  is  complained  of, 
at  times  so  severe  as  to  induce  vomiting.  This 
pain  is  rendered  intensely  acute  by  all  attempts 
at  swallowing.  Even  the  passage  of  the  saliva  is 
sufficient  to  set  it  up,  and  hence  it  is  that  this  fluid 
is  seen  dribbling  from  the  mouth  of  the  child  who 
is  the  subject  of  this  disorder.  Thirst  is  a usual 
accompaniment  of  cesophagitis ; hut  rather  than 
endure  the  agony  of  swallowing  fluids,  the  indi- 
vidual will  put  from  him  all  fluids,  however 
bland.  If  the  attendant  insist  upon  an  effort 
being  made  to  swallow  some  sustenance,  most 
usually  this  is  speedily  rejected,  accompanied 
with  much  viscid  mucus,  flaies  of  lymph,  mem- 
branous shreds,  and  sometimes  blood  or  pus.  The 
amount  of  fever  and  constitutional  disturbance  is 
in  proportion  to  the  intensity  of  the  inflammation. 

Peognosis. — If  simple,  acute  oesophagitis 
usually  terminates  in  resolution,  and  somewhat 
speedily.  If  it  he  due  to  the  passage  of  acrid 
or  hot  substances;  ulceration  of  the  (Esophagus 
may  result;  or  simply  a permanent  thickening 
of  the  coats  of  the  tube,  whereby  its  calibre  is 
reduced,  and  stricture  is  the  result. 

Treatment. — It  is  best  to  abstain  from  all 
attempts  to  give  nourishment  in  the  ordinary 
way,  and  to  rely  entirely  upon  nutritive  enemata 
till  the  acuteness  of  the  affection  has  passed.  Ice 
may,  however,  be  given  to  the  patient  to  suck,  if 
it  prove  agreeable  to  him.  For  the  relief  of  the 
pain  warm  poultices  may  be  applied  externally, 
or  opiate  fomentations.  Opium  may  he  adminis- 
tered either  by  enema,  or  subcutaneously.  The 
state  of  the  bowels  must  be  attended  to. 

2.  Ulceration. — TEtiology. — This  affection, 
as  we  have  already  seen,  may  arise  as  the  result 
of  the  passage  of  irritating  fluids  through  the 
cesophagus.  More  commonly  it  is  brought  about 
by  the  swallowing  of  certain  pointed  or  angular 
bodies  which  stick  in  the  gullet,  and  cannot  be 
dislodged,  or  before  their  removal  have  eroded 
the  mucous  membrane  and  produced  ulceration. 
Simple  ulcer  and  perforating  ulcer  of  the  oeso- 
phagus have  also  been  described;  they  are  similar 
to  those  which  are  observed  in  the  stomach,  but 
are  of  rare  occurrence. 

Symptoms. — These  are  similar  to  the  pheno- 
mena described  under  oesophagitis,  only  the  pain 
is  more  localised,  and  is  more  generally  referred 


L066  (ESOPHAGUS,  DISEASES  OF, 


to  a circumscribed  spot  between  tlie  scapulee  in 
the  back,  at  the  top  of  the  sternum,  or  in  the 
prsecordia.  The  same  difficulty  in  swallowing 
is  experienced,  and,  on  account  of  the  slowness 
of  the  ulcerated  surface  to  heal,  is  much  more 
protracted,  so  that  the  patient  emaciates  rapidly, 
and  death  from  starvation  has  even  been  known 
to  occur.  In  the  perforating  variety  a commu- 
nication may  be  established  between  the  (Eso- 
phagus and  one  of  the  bronchi — more  likely  the 
left,  the  pleura,  or  the  pericardium.  Ausculta- 
tion may  reveal  a change  of  tone  in  the  sound 
of  the  swallow,  it  being  more  dead  in  quality  than 
in  health.  The  bolus  swallowed  seems  also  as 
if  it  were  di  minished  in  bulk,  but  much  elongated, 
so  that  it  takes  longer  to  pass  the  ulcerated  spot 
than  it  does  at  any  other  portion  of  the  tube. 

Prognosis. — This  must  be  founded  on  the 
nature  of  the  ulcer,  but  it  is  always  serious. 

Treatment. — Not  much  reliance  is  to  be  placed 
upon  medicinal  treatment.  The  patient’s  strength 
must  be  sustained  by  the  liberal  use  of  generous 
diet  if  he  can  swallow,  or  by  nutrient  enemata. 
It  may  be  possible  to  pass  into  the  stomach  a 
small-sized  oesophageal  tube  (catheterNo.  15)  and, 
by  attaching  it  to  the  stomach-pump,  thereby 
introduce  plenty  of  nourishment.  Stimulants 
will  also  most  likely  be  called  for.  Ice  may  be 
freely  allowed.  Local  application  of  nitrate  of 
silver,  tannic  acid,  borax,  and  other  agents,  by 
means  of  bougies,  has  been  advised. 

3.  Dilatation. — Dilatation  may  affect  the 
oesophagus  in  its  entire  length,  but  more  com- 
monly involves  merely  a portion  of  the  tube,  as  is 
frequently  observed  in  cases  of  stricture  of  the 
oesophagus.  In  addition  to  this,  sacs  are  met 
with  in  the  walls  of  tho  canal,  which  commu- 
nicate with  it.  These  divertieuli  are  usually 
formed  by  the  distension  of  all  the  coats  of 
the  oesophagus,  but  sometimes  by  the  mucous 
membrane  alone  becoming  dilated,  and  pushod 
between  the  other  coats.  The  causes  which  give 
rise  to  this  condition,  in  addition  to  stricture,  are 
the  lodgment  of  some  foreign  body  in  the  walls 
of  the  oesophagus  (this  is  one  of  tho  most  fre- 
quent origins  of  the  diverticula),  and  paralysis 
of  the  walls  induced  by  chronic  catarrh. 

Symptoms. — These  are  not  marked.  If  the  dila- 
tation be  idiopathic,  and  involve  the  whole  length 
of  the  tube,  nothing  very  abnormal  will  be  present 
to  lead  to  the  discovery  of  this  condition.  If  it  be 
secondary,  dependent  upon  stricture,  then  in  ad- 
dition to  the  symptoms  described  under  that  head, 
it  will  be  observed  that  the  food,  after  it  has  been 
swallowed,  is  much  longer  retained  than  formerly. 
There  is  also  experienced  a sensation  of  fulness, 
which  may  sometimes  be  perceptible  to  vision, 
at  the  point  above  the  stricture,  and  this  is  ac- 
companied by  a desire  to  relieve  the  sensation 
by  vomiting,  which  sooner  or  later  occurs,  spon- 
taneously or  induced  by  the  patient  himself,  and 
affords  great  and  immediate  comfort.  In  the 
case  of  diverticula,  when  of  some  size,  the  symp- 
toms are  very  similar  to  those  above  described. 
In  addition,  it  may  be  noticed  that  a very  had 
odour  is  given  off  from  the  mouth  of  the  patient, 
due  to  the  retention  and  decomposition  of  the  food 
in  these  pouches.  According  to  their  site,  tumours, 
varying  in  size  as  the  individual  has  more  or  less 
lately  been  partaking  of  food,  may  be  observed. 


These  may  sometimes  interfere  with  respiratioi 
cr  circulation.  Auscultation  in  the  case  of  simple 
dilatation  indicates  that  no  obstruction  to  the 
passage  of  the  bolus  exists,  and  there  is  no  pro- 
longation of  the  time  it  takes  to  pass  into  the 
stomach.  But  an  alteration  in  the  vigour  of  the! 
peristaltic  action  is  observed.  There  is  a defi 
ciency  or  entire  loss  of  the  contraction  of  the 
muscles,  and  the  gradual  transmission  of  thij 
bolus  onwards  is  no  longer  heard,  but  it  appear: 
to  run  or  drop  at  once  into  the  stomach.  It  h 
generally  believed  that  men  are  more  subject  til 
this  affection  than  women ; and  it  is  met  with  irj 
the  decline  of  life. 

Treatment. — Treatment  is  of  no  avail  fo, 
dilatation  of  the  oesophagus,  except  so  far  a 
to  remove  the  cause,  if  possible,  and  to  trea 
symptoms. 

4.  Stricture. — This  affection  may  be  the  re 
suit  of  either  of  the  two  first-named,  disorders 
or  of  a changed  condition  of  the  walls  of  the  teso 
phagus,  brought  about  by  the  existence  of  som 
new  growth,  such  as  that  resulting  from  cancer  o. 
syphilis.  Further,  contraction  of  the  cesophagu 
may  be  due  to  the  presence  of  a tumour  or  othe.i 
growth  pressing  upon,  and  so  narrowing  it 
calibre.  Or,  finally,  it  may  be  simply  function!) 
in  its  nature,  giving  rise  to  temporary  obstruc 
tion.  known  as  spasm  ( oesophagismus ) and  fane 
tional  paralysis  of  the  oesophagus. 

Symptoms. — Organic  stricture  of  the  msopha! 
gus  may  have  existed  for  some  time  before  th 
patient  or  his  medical  attendant  realises  the  grn 
vity  of  the  complaint,  because  the  symptoms  dt! 
velop  themselves  only  very  gradually.  Themos 
noticeable  of  all  is  the  difficulty  in  swallowing 
At  first  this  may  be  merely  occasional,  an 
only  perceived  when  a tolerably  large  bolus  \ 
attempted  to  be  passed  down  the  gullet ; bn 
gradually  the  difficulty  increases,  and  it  is  no 
not  only  confined  to  the  attempt  to  swallo  . 
solids,  however  finely  masticated,  but  semi-solic 
give  rise  to  the  same  sensation  as  if  the  foo 
never  passed  a certain  point,  this  point  bein 
usually  referred  to  the  manubrium  stemi,  : 
the  upper  or  lower  portion,  wherever  the  stri 
ture  is  situated.  If  the  patient,  by  dint  of  gre; 
resolution  and  perseverance,  overcome  the  dill 
culty  to  such  an  extent  as  to  swallow  son 
food,  the  first  morsel  passed  being  always  tn 
greatest  trial,  it  may  be  retained  for  a time,  hi 
is  ultimately  rejected.  This  desire  to  get  r 
of  the  food  swallowed  increases  to  suchanexter 
that  all  aliment  is  regurgitated,  rather  thq 
vomited.  The  rejected  matter  consists  of  tl 
food,  but  little  altered,  largely  mixed  with  m 
cus,  or  sometimes  with  a little  blood  and  pn 
The  reaction  is  always  alkaline.  Finally  the  dy 
phagia  becomes  so  marked  that  even  theattem 
to  swallow  liquids  is  given  up  as  hopeless.  C 
incident  with  the  advance  of  this  dysphagia  do 
the  emaciation  progress;  the  abdomen  falls  n 
and  the  patient  dies  from  starvation.  The  passa 
of  a bougie  will  definitely  settle  any  doubt ^ 
to  the  existence  of  an  organic  stricture,  besia 
affording  information  as  to  its  site,  extent.,  a: 
form  ; but  the  operation  must  not  be  perform 
without  due  cousideration,  as  it  has  happen 
that  an  unrecognised  aneurism  has  been  open 
by  this  instrument.  Auscultation  will  also  aid 


(ESOPHAGUS,  DISEASES  OF. 

t diagnosis.  It  ■will  reveal  the  same  slowing 
o', fie  passage  of  the  bolus  already  referred  to, 
a the  same  elongation  of  it.  In  addition,  if  the 
fctuve  be  very  narrow,  then  the  food  will  be 
h(rd  to  pass  through  it  with  difficulty  and  with 
aTeaking  sound;  while  if  it  be  narrower  still, 
p ticiilarly  if  the  food  be  fluid  in  its  consistence, 

■ eddies  as  it  were  in  a funnel,  with  a prolonged 
renant  gurgle,’  as  described  by  Allbutt. 

pasmodic  stricture  of  the  oesophagus  differs 
fia  the  organic  form  in  the  suddenness  with 
weh  the  dysphagia  comes  on  ; its  paroxysmal 
ndre ; its  not  unfrequently  being  but  one  of  the 
nay  symptoms  of  hysteria ; its  occurrence  in 
vmg  anaemic  females,  or  hypochondriacal  men ; 
a:  though  dyspepsia  may  bo  complained  of,  and 
era  prove  an  exciting  cause,  still  emaciation 
del  not  exist.  The  point  where  the  impediment 
tc  he  passage  of  the  food  is  experienced  is 
ufilly  at  the  upper  part  of  the  oesophagus  or 
plrynx.  Occasionally  pain  is  complained  of 
oi  attempting  to  swallow,  and  food  taken  is 
scetimes  ejected.  But  the  spasm  soon  yields, 
a:  food  finds  its  way  into  the  stomach.  The 
di.culty  in  swallowing  is  much  increased  by 
tfc  attempt  being  witnessed  by  sympathising 
fr  ids,  and  a stern  command  to  cease  from  such 
fr  olous  efforts  often  succeeds,  to  a surprising 
de'ee,  in  overcoming  the  dysphagia.  On  in- 
trucing  a bougie,  it  will  of  course  be  stopped 
if  e spasm  exists  at  the  moment;  but  gentle, 
carful,  continuous  pressure  will  ultimately 
cafe  the  spasm  to  give  way,  and  thus  its  true 
nage  will  be  reveaied. 

iognosis. — The  prognosis  in  cases  of  real 
or  nic  stricture  cannot  be  otherwise  than  always 
gre.  If  it  be  due  to  cancerous  growth,  then 
it  11st  necessarily  be  most  unfavourable.  Spas- 
mfc  stricture  is  very  hopeful. 

ieatment. — The  treatment  appertains  more 
to  ie  domain  of  surgery  than  of  medicine.  In 
tli.ase  of  organic  stricture,  the  frequent  passage 
of  mgies  of  varying  size  often  proves  valuable, 
oxot  in  the  case  of  cancer,  when  it  should 
neir  he  attempted.  Diet  must  be  attended  to, 
tli  state  of  the  stomach  looked  to,  and  dys- 
pe  c indications  combated.  If  food  cannot  be 
sw  owed  a small  catheter  may  be  introduced 
thigh  this  stricture,  and  the  patient  fed  by 
tin  stomach-pump ; or  nutrient  enemata  may 
be  ministered.  Forthe  spasmodic  variety,  the 
gefl-al  system  must  be  braced,  tonics  prescribed, 
ani.he  usual  anti-liysterical  remedies  ordered. 

Morbid  Growths. — By  far  tile  most  com- 
mciorm  of  growth  in  the  oesophagus  is  cancer. 
Ociiionally  fibroid  tumours  are  seen,  either 
as  ch,  or  as  polypi,  situated  about  the  level  of 
tluricoid  cartilage.  When  carcinomatous,  the 
grcj.h  may  be  any  of  the  usual  varieties  of 
ou  r;  and  it  will  frequently  he  found  to  affect 
thepper  third,  more  commonly  the  lower  third, 
'ok  ery  rarely  the  middle  of  the  gullet.  It  com- 
mel;s  in  the  submucous  tissue,  speedily  involv- 
'ngiie  other  coats  of  the  tube.  From  this  it 
nia.xtend  to  otherorgaus,  and  perforation  of  the 
,ra;:a,  bronchi,  aorta,  or  pericardium  may  tako 
pin 

v iptoms. — Confining  the  attention  to  cancer 
of  I oesophagus,  this  disease  may  well  be  sus- 
Pec  l if,  in  an  individual  above  middle  age, 

67 


CESTEUS.  1057 

gradually  increasing  dysphagia  be  complained 
of ; if  symptoms  of  stricture  be  pronounced ; if 
pain  be  experienced,  especially  of  a lancinating 
character,  about  the  spine  and  shoulder-blades ; 
if  nausea  and  retelling  he  observed,  together 
with  irritating  cough,  and  occasional  hiccough  ; 
if  the  patient  continue  to  emaciate,  and  present 
the  dirty  greenish-yellow  complexion  common 
in  cancerous  cachexia,  together  with  enlargement 
of  lymphatic  glands  : and  most  certainly  shall 
wo  be  confirmed  in  our  diagnosis  if,  on  examina- 
tion of  the  vomited  matters,  cancer-cells  be  seen. 

Prognosis. — The  prognosis  is  of  the  worst 
description.  The  patient  gradually  becomes  ex- 
hausted, and  dies  of  inanition. 

Treatment. — Treatment  can  bo  merely  pal- 
liative. It  consists  in  relieving  the  pain  by  nar- 
cotics; and  endeavouring  to  sustain  the  patient’s 
strength  as  long  as  possible. 

Claud  Mcirhead. 

CESTEUS  ( olarpos , a gadfly). — Synon.  : Fr. 
Ocstrc ; Ger.  Bremse. — A genus  of  dipterous  in- 
sects, called  gadflies,  the  larvae  of  which,  vulgarly 
known  as  maggots  or  hots,  live  parasitically  in 
man  and  animals.  The  ordinary  human  bot, 
GEstrus  hominis,  is  of  rare  occurrence  in  England, 
but  is  not  unfrequently  met  with  in  warm  coun- 
tries, especially  in  South  America.  The  larva  of 
the  gadfly  of  the  ox,  (Estrtis  bovis,  also  occasionally 
attacks  man.  Dr.  J.  M.  Duncan  has  recorded 
an  interesting  case  of  the  latter  kind  [Edinburgh 
Monthly  Journal,  1854),  and  Bracey  Clark  long 
previously  noticed  a similar  instance.  Cases  of 
GEstrus  hominis  were  either  described  of  noticed 
by  many  earlier  observers,  amongst  whom  were 
Linnaeus,  Gmelin,  Endolpbi,  Olivier,  Gill,  How- 
ship,  and  Treherne.  The  writer  is  in  possession 
of  full  particulars  of  a case  forwarded  to  him. 
with  the  parasite,  by  Mr.  Higginson  of  Liver- 
pool. It  occurred  in  a boil  at  the  back  of  the 
thigh.  A third  species  of  human  bot,  (Estrus 
guildingii,  from  Trinidad,  is  described  by  Guild- 
ing ; besides  which,  nearly  a score  of  other 
similar  cases  have  been  placed  on  record  by 
various  authors  who  were  not  able  to  identify 
the  species. 

True  maggots  and  other  bot-like  larvae  are 
continually  encountered  in  medical  practice.  As 
a rule,  their  identification  as  species  can  only  be 
determined  by  skilled  entomologists.  Some  forty 
years  ago  Mr.  Hope  referred  the  forms  then 
known  to  upwards  of  twenty  separate  genera 
of  insects  ( London  Medical  Gazette , 1837-38). 
Amongst  cases  of  insect  larvae  possessing  more 
than  ordinary  interest  we  may  particularise  the 
following: — 1.  Several  cases  in  which  the  larvae 
of  the  coleopterous  insect  Blaps  (B.  mortisaga) 
passed  from  the  stomach  and  intestines.  In 
Pickell’s  celebrated  case  1.206  larvae  were  found, 
besides  several  of  the  full-grown  insects,  which 
are  popularly  known  as  the  churchyard  beetle. 
The  writer  recorded  a case  ( British  Med.  Jour., 
1877),  from  the  practice  of  Dr.  Horne,  of  Barn- 
sley, where  a living  larva  was  passed  by  an 
infant.  2.  Numerous  cases  of  the  larvae  of  An- 
ihomyia  canalicularis.  Several  of  these  have 
occurred  in  the  writer’s  practice.  3.  In  Hope’s 
list  ( loc . cit.)  nine  case?  of  mealworm  are  given 
( Tencbrio  molitorX  4.  Hie  occurrence  in  the 


1058  OESTRUS, 

human  body  of  the  maggots  of  various  species 
of  fly  has  frequently  been  noticed  ( Musca  dornes- 
tica,  M.  carnaria,  M.  sareopkaga,  M.  vomitoria, 
&c.).  5.  In  several  instances,  the  so-called  rat- 

tailed larvae  ( Helophilus ) have  been  passed  per 
axum.  One  such  case  was  brought  under  the 
notice  of  the  writer  by  Mr.  Hoot ; and  a more 
recent  instance  has  occurred  in  tbo  practice  of 
Dr.  W.  H.  S.  Westropp,  at  Lisdoonvarna,  Ire- 
land. The  writer  identified  the  parasite  in  both 
cases.  6.  The  late  Dr.  Livingstone,  when  in 
Africa,  was  attacked  in  the  leg  by  a small  bot- 
like  larva,  which  Dr.  Kirk  removed  by  incision. 
The  specimen  was  presented  to  the  writer,  and 
is  now  preserved  in  the  museum  of  the  Royal 
College  of  Surgeons  ( Catalogue  of  Entozoa, 
No.  196).  In  actual  practice  it  is  not  uncommon 
to  find  the  larvae  of  various  species  of  moths 
(. Noctuce ),  either  in  the  night-stool  or  chamber- 
utensil  ; these,  for  the  most  part,  being  acciden- 
tally introduced.  In  like  manner  the  maggots 
of  various  butterflies  and  other  insects,  are  often 
passed,  having  been  previously  swallowed  along 
with  food.  Lastly  (7),  we  may  refer  to  the 
horrible  habits  of  the  larvte  of  the  golden  fly 
{Lucilia  hominivorax).  This  insect,  according  to 
M.  Coquerel,  is  particularly  destructive  to  the 
convicts  of  Cayenne.  The  larvae,  hatched  from 
eggs  previously  deposited  in  the  mouth  and  nos- 
trils of  the  victim,  penetrate  and  devour  the 
living  tissues,  after  the  manner  of  ordinary 
maggots  in  putrid  flesh.  According  to  M.  Bouyer 
{Tour  du  Monde , 1866),  the  majority  of  the  cases 
prove  incurable.  Other  species  of  Lucilia  have 
the  habit  of  attacking  the  eyes,  mouth,  and 
nostrils  of  toads  and  frogs,  the  maggots  eating 
into  the  tissues  of  the  living  batrachians.  Dr. 
McMunn  (of  Wolverhampton)  and  the  writer 
have  seen  instances  of  this,  and  have  confirmed 
the  observations  of  Herr  Boie,  and  of  M.  Girard, 
M.  Moniez,  and  others. 

Treatment. — As  regards  the  treatment  of 
intestinal  insect-parasites,  ordinary  purgatives, 
salines,  and  vermifuges,  especially  turpentine,  will 
usually  dislodge  them ; whilst  for  those  that  occur 
in  wounds  or  ulcers  at  or  near  the  surface,  nothing 
is  better  than  the  application  of  carbolic  acid 
solution.  See  Extozoa.  T.  S.  Cobbold. 

OEYNHATJSEN,  or  EEHME,  in  Ger- 
many.— Gaseous  thermal  salt  waters.  See 
Mineral  Waters. 

OPEN,  in  Hungary. — Sulphated  waters. ' See 
Mineral  Waters. 

OIDITTM  ALBICANS. — A vegetable  para- 
site, associated  with  aphthae  or  thrush.  See 
A.PHTH.E. 

OINOMANIA  (oTvos,  wine,  and  pavla.,  mad- 
ness).— A synonym  for  dipsomania.’  See  Dipso- 
mania. 

OLD  AGE,  Signs  of.  See  Senility. 

OLFACTORY  NERVE,  Morbid  Con- 
ditions of. — Tho  principal  morbid  conditions 
that  occur  in  connexion  with  the  nerve  of  smell 
are  the  following : — • 

1.  Olfactory  HypersBSthesia.  Synon.  : 
Hyperosmia. 


OLFACTORY  NERVE. 

Definition. — -Increased  sensitiveness  of  thi 
olfactory  nerve. 

HJtiolooy  and  Symptoms. — This  condition  i 
seen  in  the  increased  nervous  sensibility  whiei 
results  Irom  chronic  debilitating  illnc-ss.  I 
occurs  also  in  hysteria,  in  which  remarkable^ 
almost  animal,  acuteness  of  the  sense  is  some 
times  present,  so  that  not  only  objects  but  per 
sons  have  been  discriminated  by  this  means.  I 
insanity  the  same  condition  is  sometimes  seer 
It  is  usually  associated  with,  and  lias  to  ll 
distinguished  from,  an  altered  appreciation  c 
odours,  shown  in  the  abnormal  enjoyment  of  y 
disgust  at  the  odours  which  are  recognised  wit 
natural  or  preternatural  acuteness. 

Treatment.— The  condition  rarely  calls  ft; 
special  treatment. 

2.  Subjective  Sensations  of  Smell. — Sul 
jective  sensations  of  smell  occur  from  centr 
disease,  or  from  irritation  of  the  nerve  of  sine 
In  the  insane  olfactory  hallucinations  occr 
though  less  commonly  than  those  of  the  opt 
or  auditory  nerve.  Sehlager  met  with  them 
five  cases  out  of  six  hundred.  In  epilepsv  sul 
jective  sensations  of  smell  occur  as  occasior 
prodromata  of  fits,  and  the  disease  in  these  cas 
probably  involves  the  olfactory  centre  in  t] 
anterior  part  of  the  temporo-sphenoidal  loli 
It  was  so  in  a case  of  tumour  recorded  by  Sand 
Irritation  of  the  nerve,  from  meningeal  dise; 
or  injury,  also,  in  rare  cases,  causes  olfacM 
hyperaestliesia.  Dr.  Quain  lias  recordod  an 
tercsting  case  of  perityphlitis,  in  which  an  apv 
rently  subjective  sensation  of  a foul  odour  v 
persistently  complained  of  by  the  patient,  ui 
evacuation  of  the  contents  of  the  abscess,  wh 
the  supposed  smell  completely  disappeared. 

3.  Perversion  of  tho  Sense  of  Smell- 
Synon.  : Parosmia. — This  is  a rare  condith 
which  occasionally  results  from  irritation  of  e 
nerve  or  central  organ.  In  a case  recorded  y 
Legg,  some  time  after  an  injury  to  the  hi 
all  substances  ‘ tasted  ’ of  gas  or  paraffine,  1 
thero  was  marked  diminution  in  the  acutenes.f 
the  sense  of  smell. 

4.  Olfactory  Anaesthesia.— Synon.  : Ai- 
mia. 

Definition. — Loss  or  diminution  of  the  soe 
of  smell. 

■/Etiology. — The  causes  may  be  local  chans 
in  the  organ  of  smell ; disease  of  the  nerve  ir 
disease  of  the  centre. 

a.  Among  local  causes  may  be  mentioned  ie 
following: — (1)  acute  and  chronic  catarrh  ofie 
olfactory  mucous  membrane,  the  latter  cauig 
thickening ; a condition  sometimes  produced? 
excessive  snuff-taking.  (2)  Dryness  of  pe 
mucous  membrane,  as  in  cases  of  destruction! 
the  external  nose  (Xotta),  or  in  paralysis  olie 
fifth  nerve.  (3)  Occlusion  of  the  passagin' 
polypus,  preventing  the  access  of  air  tohe 
olfactory  region.  (4)  Impaired  access  of-ir 
consequent  on  facial  paralysis.  The  loss  oihe 
power  of  dilating  and  keeping  expanded  he 
nostril  prevents  a due  quantity  of  air  log 
drawn  through  the  nasal  passage ; and,  n'e- 
over,  the  loss  of  power  of  compressing  the  i»- 
tril  in  ‘sniffing,’  prevents  the  air  being  dirted 
into  the  olfactory  region.  (5)  Iniare  casepss 
of  pigment  in  the  nose,  consequent  on  geM 


OLFACTORY  NERVE, 
oss  of  pigment,  has  appeared  the  cause  of  loss 
f smell. 

b.  Damage  to  the  olfactory  nerve  may  result 
rom  injury  or  disease.  It  is  not  an  uncommon 
fesult  of  blows  or  falls  upon  the  head,  and  it  is 
irobable  that  in  these  eases  the  delicate  olfac- 
ory  nerves  are  torn  from  the  bulb  (see  Nose, 
diseases  of).  The  bulb,  or  tract,  may  also  suffer 
h adjacent  disease,  as  tumour,  abscess,  caries 
f the  bone,  and  meniDgeal  changes,  especially 
yphilitic.  Spontaneous  atrophy  of  the  olfactory 
nibs  occasionally  occurs  in  old  age  (Prevost), 
ud  has  been  met  with  in  younger  persons  in  the 
essential  anosmia  ’ of  Notta. 

e.  In  cerebral  disease  the  sense  of  smell  is 
ometimes  lost.  It  may  be  impaired  in  so- 
tiled  functional  disease,  as  in  hysteria,  and  in 
“generative  disease,  as  paralytic  dementia.  It 
1 occasionally  lost  in  organic  disease  involving 
lie  roots  of  the  olfactory  nerve.  Unilateral 
nosmia  has  been  met  with  in  cases  of  aphasia 
dughlings  Jackson),  an  association  which  is 
tpkined  by  the  passage  of  the  external  root 
the  olfactory  nerve  past  the  island  of  Reil 
• the  anterior  part  of  the  temporo-sphenoidal 
ibe. 

It  is  to  be  remembered  that  the  olfactory 
rves  are  sometimes  congenitally  absent. 
Symptoms. — The  evidence  of  anosmia  is  the 
ss  of  the  perception  of  odours.  This  may  be 
Irtial  or  complete,  according  to  the  extent  of 
yolvement  of  the  nerves.  It  may  be  lost  on 
.tit  sides ; or  when  due  to  degenerative  changes, 

. one  side  only.  When  clue  to  organic  brain- 
sease  it  is  lost  on  the  side  on  which  the  cerebral 
ion  is  situated. 

Diagnosis. — The  diagnosis  presents  little 
jhculty.  The  affection  is  commonly  com- 
lined  of,  but  often  as  ‘ loss  of  taste,’  the 
uinished  perception  of  jlavotirs  being  more 
nous  to  the  patient  than  the  loss  of  smell, 
e sensations  included  under  the  term  ‘ flavour  ’ 

it  need  hardly  bo  said,  really  olfactory  and 
; gustatory.  In  examination,  care  must  be 
'ten  to  employ  only  substances— as  aromatic 
■i,  &c. — which  affect  the  olfactory  nerve,  and 
: : acrid  substances,  as  ammonia  and  acetic  acid, 

' ich  stimulate  also  the  fifth  nerve. 

Prognosis. — The  prognosis  in  anosmia  is 
fourable  when  due  to  a local  cause,  but  when 
'•  re  is  reason  to  suspect  injury  or  disease  of 
i olfactory  nerve  or  centre,  recovery  is  im- 
1,  bable. 

'reatment. — -Anosmia,  as  a symptom,  rarely 
c s for  treatment,  which  should  be  directed  to 
r cause.  Sometimes  local  stimulation  is  of 
t 'ice;  and  occasionally  counter-irritation,  by 
bters  to  the  neck,  has  appeared  to  assist  re- 
c tv.  In  hysterical  cases  faradisation  of  the 
niil  mucous  membrane  has  been  recommended; 

the  olfactory  nerve  itself  is  not  accessible 
toiectrical  stimulation.  W.  R.  Gowers. 

LIG-iEMIA  (o\iyos,  small,  and  al pa,  blood). 
I.cieney  of  the  total  amount  of  blood  in  the 
See  Blood,  Morbid  Conditions  of. 

MAGHA  (&yos,  the  shoulder,  and  &ypa,  a 
stiU'e). — Synon.:  Fr.  Omagre ; Ger.  Schulter- 
5'  ‘ — A name  for  gout  in  the  shoulder.  See 
ufr. 


OPHTHALMOSCOPE.  1050 

OMENTUM,  Diseases  of.  See  Perito- 
neum, Diseasos  cf. 

ONANISM  (Onan). — A synonym  for  mas- 
turbation. See  Masturbation. 

ONYCHIA  (ijw£,  the  nail). — An  inflamma"- 
torv  affection  of  the  matrix  of  the  nail.  See 
Nails,  Diseases  of. 

ONYCHOGK  YPHOSIS  (orv',  the  nail,  and 
■ypuirds,  curved). — This  term  is  applied  to  curva- 
ture of  the  nails  ; and,  more  particularly,  to  the 
oblique  elevation  of  the  nails  from  their  matrix 
by  the  accumulation  beneath  them  of  crude  cell- 
substance,  which  forms  a kind  of  wedge,  and 
crumbles  away  upon  desiccation.  See  Nails, 
Diseases  of. 

ONYCHOMYCOSIS  (Sm(,  the  nail,  and 
/mvktis,  a fungus).  — Parasitic  disease  of  the 
nails.  See  Epiphytic  Skin-diseases  ; and  Nails, 
Diseases  of. 

OPHIASIS  (o<pis,  a serpent). — A form  of 
alopecia  areata,  which  assumes  a serpentine 
figure,  either  by  creeping  onwards,  or  by  the 
blending  of  two  or  more  of  the  circular  discs. 
See  Baldness. 

OPHTHALMIA  (6<pOa\pbs,  the  eye). — 
Synon.  : Fr.  Ophthalmie ; Ger.  Ophthalmia. — 
A general  term  which  might  be  used  to  express 
any  morbid  condition  of  the  eye,  but  which  is 
restricted  by  custom  to  the  forms  of  inflamma- 
tion which  originate  in  the  superficial  structures 
of  the  organ,  such  as  the  varieties  of  conjunc- 
tivitis, or  the  phlyctenulae  which  sometimes 
appear  upon  the  cornea,  and  may  give  rise  to 
shallow  ulcers.  Thus  we  have  mention  by 
authors  of  infantile , catarrhal,  contagious,  puru- 
lent, and  strumous  or  phlyctenular,  ophthalmia. 
See  Eye  and  its  Appendages,  Diseases  of. 

OPHTHALMITIS  ( b<pea\ubs , the  eye).— 
Synon.  : Panophthalmitis ; Fr.  Ophthahnite ; 
Ger.  Augencntzundung. — A term  which  has  been 
used  to  express  inflammation  affecting  the  whole 
of  the  structures  of  the  eyeball,  superficial  as 
well  as  deep.  Such  a condition  is  most  fre- 
quently seen  after  operations  upon  the  eye,  and 
was  described  bythelate  Dr.  Jacob  as  cyebal  litisl 
See  Eye  and  its  Appendages,  Diseases  of. 

OPHTHALMOSCOPE  (o<p9a\fbs,  the  eye, 
and  (TK07rew,  I examine). — Synon.:  FT.  Ophthal- 
moscope ; Ger.  Ophthalmoskop. 

The  ophthalmoscope  is  an  instrument  for 
lighting  up  the  interior  of  the  eye,  in  such  a 
manner  as  to  render  the  contained  structures 
clearly  visible. 

Description. — The  first  ophthalmoscope  was 
invented  about  1847,  by  the  late  Mr.  Charles 
Babbage,  who  laid  it  aside  because  an  ophthalmic 
surgeon  to  whom  he  showed  it,  and  who  failed  to 
perceive  its  probable  utility,  afforded  him  no 
encouragement.  In  1851  another  form  of  the 
instrument  was  invented  by  Helmholtz;  but,  in 
1852,  Babbage’s  original  form  was  re-invented  by 
Ruete,  and  this,  with  a few  unimportant  modifi- 
cations, has  ever  since  held  its  ground  in  practice. 
It  consists,  essentially,  of  a slightly  concave 
mirror,  with  a small  central  perforation ; or,  if 
the  mirror  be  of  silvered  glass,  with  the  silvering 


OPHTHALMOSCOPE. 


1060 

removed  from  a small  circle  in  the  centre.  A 
mirror  the  size  of  a shilling  :3  large  enough  for 
all  practical  purposes,  and  a central  aperture  of 
not  more  than  2 or  3 millimfetres  in  diameter  is 
better  than  a larger  one.  The  mirror  may  be 
attached  to  a handle  of  any  proportions  pre- 
ferred by  the  owner,  or  may  be  left  without 
one  ; but  it  must  be  accompanied  by  certain 
auxiliary  convex  and  concave  lenses,  the  uses  of 
which  will  be  presently  explained.  The  focal 
length  of  the  mirror  is  usually  about  8 inches. 

Method  op  Use. — In  order  to  learn  the  use  of 
the  ophthalmoscope,  the  beginner  will  do  well  to 
avail  himself  of  a contrivance  called  Perrin’s  ar- 
tificial  eye,  or  of  the  more  elaborate  one  lately 
designed  by  Landolt.  The  former  consists  of  a 
small  hollow  sphere  of  metal,  to  represent  the  eye, 
closed  in  front  by  a lens,  which  can  be  changed  at 
pleasure,  and  behind  by  a door  for  the  insertion  of 
pictures  of  various  healthy  and  diseased  condi- 
tions of  the  retina.  When  an  artificial  eye  is  not 
available,  the  learner  should  take  the  patient  into 
an  obscurely  lighted  room,  and  should  stand  or 
sit  facing  him,  with  the  two  heads  upon  the  same 
level.  A gas  or  oil  flame — preferably,  from  its 
greater  steadiness  and  superior  illumination,  that 
of  an  argand  burner — is  then  placed  upon  the  same 
level  as  the  eye  which  is  to  be  examined,  on  the 
same  side  of  the-  head,  and  a little  behind  it,  so 
that  no  direct  light  shall  fall  upon  the  cornea. 
The  observer,  commencing  with  his  face  exactly 
opposite  that  of  the  patient,  and  about  eighteen 
inches  distant  from  it,  places  the  back  of  the 
ophthalmoscope  mirror  against  his  eye,  using 
preferably  that  which  is  opposite  to  the  eye  to 
be  examined,  the  right  eye  for  the  patient’s  left, 
and  vice  versa.  The  patient  is  directed  to  look 
as  if  at  a distant  object,  over  the  shoulder  of 
the  observer  which  is  most  remote  from  the  eye 
under  inspection,  thus  looking  over  the  observer’s 
left  shoulder  when  the  right  eye  is  being  ex- 
amined. In  this  position,  the  observed  eye  is 
turned  a little  towards  the  nose  ; and  the  optic 
nerve-entrance,  which  is  somewhat  on  the  nasal 
side  of  the  posterior  pole,  is  brought  opposite  to 
the  pupil.  Looking  through  the  mirror-aperture, 
the  observer  directs  the  light  of  the  flame,  re- 
flected from  the  polished  surface,  in  such  a 
manner  that  it  falls  into  the  pupil  of  the  ob- 
served eye ; and  this  light,  returning  from  the 
eye,  reaches  him  through  the  perforation.  It 
exhibits  the  cavity  of  the  eye  illuminated,  but, 
as  a rule,  shows  no  objects,  but  only  the  pupil 
as  a reddish  or  yellowish  circle.  In  order  to  see 
the  contained  structures,  two  methods  are  em- 
ployed, the  indirect  and  the  direct ; the  former 
of  which  gives  the  better  general  view  of  the 
fundus,  the  latter  the  greater  facilities  for  study- 
ing the  condition  of  single  points  on  the  nerve 
or  on  the  retinal  surface.  It  is  therefore  neces- 
sary to  be  conversant  with  both,  and  to  use  one 
or  both  as  circumstances  may  require. 

Indirect  Method. — In  using  the  indirect  me- 
thod, the  observer  takes  a biconvex  lens,  of  about 
two  inches  focal  length,  and  holds  it  with  his 
free  hand  in  the  track  of  the  returning  light,  and 
at  about  two  inches  from  the  eye  of  the  patient. 
The  rays  of  light,  thus  rendered  convergent,  be- 
come united  into  an  aerial  inverted  image  of  the 
fundus  of  the  eye,  which  image,  and  not  the  fundus 


itself,  will  be  the  object  of  vision  to  the  observer 
The  position  of  the  image  is  in  the  focal  plane  oi 
the  lens,  nearer  to  the  spectator ; and,  in  order  to  I 
see  it  clearly,  nothing  is  necessary  but  to  have 
the  observing  eye  in  the  track  of  the  returnin» 
rays,  and  at  the  right  distance  from  the  image' 
which,  it  must  be  remembered,  with  a two-inch 
lens,  will  be  four  inches  or  more  nearer  to  the 
observer  than  the  eye  of  the  patient.  The  whole 
art  of  using  the  ophthalmoscope  for  the  indirect 
method  may  be  said  to  consist  in  movin'*  the 
eye  to  and  fro  upon  the  line  of  sight  until  the 
right  distance  is  attained,  without  movin'*  it 
laterally  so  as  to  get  out  of  the  track  of 'tin- 
rays,  and  without  losing  the  illumination.  Ail 
soon  as  a vessel,  cr  any  other  defined  object,  id 
seen,  the  observer  knows  that  his  distance  id 
correct,  and  he  then  causes  the  patient  to  change] 
the  direction  of  his  eye  until  every  part  of  it;: 
fundus  has  come  successively  into  view.  The 
image,  it  must  be  remembered,  is  inverted  ii 
every  particular ; its  nasal  side  representing  th. 
temporal  side  of  the  retina,  and  its  upper  por 
tion  the  lower  portion  of  the  retina.  In  firs 
attempts  to  use  the  ophthalmoscope  it  is  desir 
able  to  have  the  pupil  of  the  observed  ey 
dilated  by  atropin  or  duboisin,  but,  after  de’x 
terity  has  been  attained,  the  dilatation  may  i: 
most  cases  be  omitted.  The  details  of  the' re: 
tinal  image  are  sometimes  more  or  less  obscure- 
by  an  image  or  images  of  the  lamp-flame;  c 
which  there  may  be  two,  one  formed  by  the  at 
terior  and  one  by  the  posterior  surface  of  th 
lens.  These  images  are  only  sources  of  embat 
rassment  when  the  lens  is  held  vertically,  an 
may  be  displaced  and  put  out  of  sight  by  givir 
it  a small  degree  of  obliquity.  A bright  imag 
of  the  mirror  itself  upon  the  return,  showing  tl 
central  perforation  as  a dark  spot,  is  sometinu 
troublesome  to  beginners;  and  it  is  said  th 
this  image  has  even  been  mistaken  for  that 
the  optic  nerve.  The  blackness  and  sharp  de 
nition  of  the  perforation  should  render  such 
mistake  impossible  ; and  the  image  may  readi 
be  displaced  by  a slight  alteration  of  the  ang 
at  which  the  mirror  is  held. 

In  order  to  magnify  the  inverted  image,  a: 
to  increase  its  brightness  by  bringing  the  miri 
nearer  to  the  eye  of  the  patient,  a convex  le 
may  be  placed  behind  the  mirror  for  the  c 
server  to  look  through.  Something  of  this  ki 
is  always  necessary  for  observers  who  ha 
reached  the  period  of  life  at  which  spectac- 
are  required  for  reading ; and  it  is  advantaged 
to  all  persons.  The  writer's  practice  is  to  use 
lens  of  about  seven  inches’  focal  length  in  t ■ 
manner ; and  there  is  thus  obtained  an  im" 
which  for  many  purposes  is  as  good  as  that  - 
forded  by  the  direct  method.  IVith  such  a le. 
the  eye  of  the  observer  can  he  only  seven  inefc 
from  the  image,  and,  as  this  will  be  formed  Iff 
inches  in  front  of  the  eye  of  the  patient,  it  follts 
that  the  two  faces  will  be  only  eleven  incs 
apart.  At  this  comparatively  small  distar, 
the  illumination  of  the  fundus  of  theobserl 
eye,  which  is  afforded  by  a good  mirror,  is  - 
ceedingly  satisfactory. 

Direct  Method. — In  the  direct  method,  the 
server  does  not  apply  any  intervening  glass  - 
tween  the  mirror  and"  the  eye  of  the  patient,  1 


OPHTHALMOSCOPE. 


lines  as  close  to  the  latter  as  possible,  and  looks, 
ot  at  an  aerial  optical  image,  bnt  at  the  actual 
indus  itself,  magnified  by  its  own  crystalline  lens, 
it  is  only  when  the  eyes  of  both  observer  and 
ktientare  of  normal  refraction,  or  emmetropic, 
fiat  this  can  be  done  without  the  aid  of  a lens, 
fliich  when  required  is  most  conveniently  placed 
ehind  the  mirror.  The  lens  employed  for  this 
ju.rpose  must  be  such  as  to  correct  the  sum  of 
L error  of  refraction  of  both  the  eyes  ; and 
mst  therefore  be  concave  when  this  error  is  on 
lie  side  of  myopia,  convex  when  it  is  on  the  side 
[f  hypermetropia.  An  observer  who  is  short- 
ghted  will  begin  his  investigation  with  a con- 
kve  lens  behind  his  mirror,  which  corrects  his 
{svn  short  sight ; and  he  will  add  to  or  diminish 
ie  power  of  this  lens  to  meet  any  degree  of 
ihetropia  which  the  observed  eye  may  present 
|i  addition  to,  or  in  diminution  of,  his  own.  In 
tder  to  facilitate  the  required  changes,  all  ne- 
■ssary  lenses  are  now  usually  mounted  upon  a 
Ivolving  disc  placed  behind  the  mirror,  and  so 
•ranged  that  each  one  of  them  can  be  brought 
turn  before  the  aperture.  In  one  of  the  best 
' the  modern  forms  of  instrument,  that  of  Dr. 
bring,  of  New  York,  the  mirror  itself  is  made 
turn  upon  pivots  in  a vertical  line  indepen- 
|ntly  of  the  disc  of  lenses,  so  that  the  correct- 
g lens  receives  no  obliquity  from  the  position 
the  mirror.  This  contrivance  is  valuable  in 
ine  cases,  especially  when  a correcting  lens  of 
gh  power  is  required,  because  such  a lens,  if 
lid  obliquely,  is  liable  to  produce  some  distor- 
pnof  the  objects  seen  through  it.  In  using 
e revolving  disc,  a normal- sighted  observer 
mmences  with  no  lens  behind  the  aperture; 
d,  if  he  then  obtains  clear  definition,  he  knows 
jat  the  eye  into  which  he  is  looking  is  normal- 
|hted  also,  or  at  most  is  only  in  a slight  de- 
fee hypermetropic.  If,  on  the  contrary,  he 
es  not  obtain  a clear  image,  he  knows  that 
p eye  into  which  he  is  looking,  unless  the 
msparency  of  its  media  be  impaired,  is  not 
anal-sighted,  but  that  it  is  either  myopic, 
hypermetropic  in  a somewhat  high  degree, 
leping  the  fundus  in  view,  he  causes  the  disc 
revolve,  until  a lens  comes  over  the  aperture 
ich  renders  the  picture  distinct ; and  he  has 
In  only  to  see  the  number  and  kind  of  the 
;S  in  order  to  know  the  degree  as  well  as  the 
: ure  of  the  defect  of  refraction.  In  many 
4es  it  is  even  possible  to  prescribe  spectacles, 
I the  result  of  such  an  examination,  with  a 
vy  fair  degree  of  correctness  and  success.  But 
t!  chief  use  of  the  direct  method,  especially  in 
ts  applications  of  the  ophthalmoscope  as  an 
ijtrument  of  diagnosis  in  general  medicine,  is 
tijicrutinise,  as  already  stated,  some  portion  of 
t fundus  of  the  eye  which  has  been  shown,  by 
tj  indirect  method,  to  require  more  minute 
t, ruination  than  that  method  will  itself  permit 
t observer  to  accomplish. 

•pthalmoscopic  Appeaeances. — In  order  to 
■ ferpret  ophthalmoscopic  appearances,  and  to 
I inguisli  physiological  variations  from  patho- 
1' cal  changes,  it  is  before  all  things  necessary 
t'i'ear  in  mind  the  anatomy  of  the  structures 
v;cli  are,  or  may  be,  rendered  visible,  and  the 
r tions  which  they  bear  to  one  another.  The 
fi  lus  of  the  eye  is  composed  of  several  layers, 


1061 

the  more  anterior  of  which  commonly  conceal 
the  posterior  ; and  conceal  them  i n such  a manner 
that,  when  the  former  are  rendered  more  trans- 
parent by  malformation  or  disease,  the  latter 
are  brought  into  view. 

1.  Sclerotic. — Commencing  with  the  posterior 
layer,  it  consists  of  the  inner  suriaceof  the  scle- 
rotic,a smooth  and  shiningwhite  surface,  which  is 
ordinarily  entirely  concealed  by  the  pigmentation 
of  the  choroid  and  of  the  posterior  or  epithelial 
layer  of  the  retina.  The  sclerotic  is  naturally 
visible,  as  a general  white  background  to  a vas- 
cular network,  in  cases  of  albinism,  in  which  the 
natural  pigment  of  the  eye  is  congenitally  absent; 
or  in  some  very  fair  persons,  who  are  not  albinos, 
but  whose  eyes  aro  very  sparingly  pigmented. 
It  is  rendered  visible  in  patches,  as  a result 
of  malformation  or  disease,  in  cases  in  which  it 
is  exposed  by  a fissure  through  the  choroid,  such 
as  generally  accompanies  coloboma  iridis ; in  cases 
in  which  the  choroid  has  suffered  atrophy  as  a 
result  of  antecedent  haemorrhage  or  inflamma- 
tion ; and  in  the  immediate  neighbourhood  of  the 
optic  discs,  in  the  so-called  crescents  of  choroidal 
atrophy  which  are  so  often  associated  with  high 
degrees  of  myopia.  The  whiteness  of  an  exposed 
sclerotic  may  be  distinguished  from  that  of  an 
opaque  white  deposit  in  the  choroid  or  in  the 
retina,  by  many  small  physical  characters,  such 
as  the  relation  of  the  borders  of  the  whiteness 
to  the  neighbouring  tissues  and  vessels,  which 
will  show  the  one  to  be  the  result  of  the  removal, 
the  other  of  the  addition,  of  material.  The  most 
conspicuous  white  deposits  are  those  associated 
with  albuminuria  or  diabetes,  with  syphilitic 
retinitis,  and  with  the  first  stages  of  retinal 
glioma.  In  all  these  the  deposits  manifestly 
covcrand  conceal  vessels,  which  may  be  seen  to 
emerge  from  beneath  them;  while  in  complete 
atrophy  of  portions  of  the  choroid,  it  is  not  un- 
common to  see  a few  remains  of  dwindled  vessels, 
and  other  shreds  of  choroidal  tissue,  rendered  un- 
usually conspicuous  by  their  white  background, 
and  manifestly  situated  in  a plane  anterior  to  it. 

2.  Choroid. — The  next  layer  from  behind  for- 
wards is  the  choroid,  which  is  essentially  a vas- 
cular network,  containing  more  or  less  pigment 
in  the  intervals  between  the  vessels.  In  very  fair 
eyes,  as  already  mentioned,  the  choroid  may  allow 
the  general  whiteness  of  the  sclerotic  to  shine 
through  ; but,  in  the  great  majority  of  cases,  it 
conceals  the  latter  entirely.  In  like  manner,  the 
actual  structure  of  the  choroid  is  itself  usually 
concealed  by  the  pigment  in  the  epithelial  layer  of 
the  retina ; and  the  choroid  generally  only  plays 
the  part  of  a red  background,  varying  up  to  dark 
chocolate  colour  in  very  dark  eyes,  and  exhibiting 
neither  structure  nor  vessels.  When  the  retinal 
epithelium  is  scantily  pigmented,  as  occurs  in  light 
eyes,  the  larger  choroidal  vessels  may  be  seen 
through  the  retina ; and  they  are  readily  dis- 
tinguished from  those  proper  to  this  structure 
by  their  different  arrangement;  the  vessels  of 
the  retina  being  arborescent,  whilst  those  of  the 
choroid  are  either  nearly  parallel  to  one  another, 
or  arranged  in  more  or  less  diamond-shaped  reti- 
culations. When  both  sets  are  visible  together, 
moreover,  the  vessels  of  the  retina  will  be  clearly 
seen  to  be  in  a plane  anterior  to  that  of  the 
vessels  of  the  choroid,  and  a variety  of  mivute 


OPHTHALMOSCOPE. 


1062 

differences  of  colour  and  aspect  will  suffice  to 
show  that  the  two  sets  form  parts  of  different 
circulatory  systems. 

3.  Retina.  — The  retina  itself  is  formed  of 
several  layers,  the  deepest  of  which  contains  the 
perceptive  elements,  or  the  rods  and  cones  of  the 
so-called  Jacob’s  membrane.  In  front  of  the  per- 
ceptive elements  there  are  ganglionic  and  granular 
layers,  subservient  to  the  functions  or  to  the  nutri- 
tion of  the  rods  and  cones ; and,  in  front  of  these 
again,  a layer  of  connective-tissue,  containing 
and  supporting  the  conducting  fibres  which  are 
ultimately  massed  together  in  the  trunk  of  the 
optic  nerve,  and  which  convey  impressions  from 
the  retina  to  the  brain.  The  fibre  layer  and  its 
connective  tissue  are  necessarily  thickest  in  the 
immediate  neighbourhood  of  the  opticnerve,  and 
they  thin  off  towards  the  peripheral  parts  of  the 
retina ; whilst  all  but  the  perceptive  elements  are 
wholly  wanting  over  a small  circle  or  depression 
at  the  posterior  axis  of  the  eyeball,  a little  to 
the  outer  side  of  the  nerve,  and  known  as  the 
‘yellow  spot,’  with  its  fovea  centralis.  The  cen- 
tral artery  of  the  retina  enters  the  eye  in  the 
trunk  of  the  optic  nerve,  and  the  central  vein 
emerges  in  the  same  manner,  the  circulation 
between  the  two  being  almost  a closed  one,  save 
for  a few  very  small  and  insignificant  anasto- 
moses of  the  terminal  vessels,  some  at  the  nerve- 
entrance  itself,  others  in  the  ciliary  region.  The 
retinal  blood-vessels  are  chiefly  lodged  in  the 
connective  tissue  of  the  fibre  layer,  and  only 
small  twigs  dip  down  into  the  deeper  retinal 
tissues.  The  arteries  and  arterioles  divide,  and 
the  veinlets  and  veins  unite,  in  an  arborescent 
fashion ; and  the  two  sets  of  vessels  are  readily 
distinguished  apart  by  the  larger  calibre  and 
deeper  colour  of  those  which  carry  venous  blood. 
At  the  nerve-entrauce,  both  sets  bend  at  a right 
aDgle  or  nearly  so,  in  order  to  pass  from  the  axis 
of  the  nerve -trunk  into  the  plane  of  the  retina, 
or  vice  versa. 

Between  the  rods  and  cones  of  Jacob’s  mem- 
brane, and  the  anterior  or  capillary  layer  of  the 
choroid,  there  is  a sheet  of  pavement-epithelium, 
the  cells  of  which  contain  a larger  or  smaller 
quantity  of  pigment.  This  epithelial  layer  was 
at  one  time  regarded  as  part  of  the  choroid, 
but  more  recent  histologists  refer  it  to  the  retina. 
When  full  of  pigment,  it  forms  an  opaque  screen, 
by  which  the  choroid  is  concealed  from  view,  and 
against  which  the  delicate  retinal  structures, 
especially  near  the  nerve,  may  become  apparent 
as  a thin,  almost  pellucid,  film,  in  which  blood- 
vessels ramify.  In  the  eyes  of  fair  people,  with 
only  scanty  pigmentation,  the  epithelium  neither 
completely  conceals  the  choroid,  nor  does  it  throw- 
up  the  retina  with  anything  like  the  same  dis- 
tinctness, so  that  the  retinal  blood-vessels  are 
clearly  seen,  but  not  the  structure  which  sup- 
ports them.  When  the  pavement-epithelium 
has  been  removed,  either  by  disease  or  by  senile 
changes,  the  choroidal  tissues  become  con- 
spicuous. 

4.  Optic  Nerve. — The  general  aspect  of  the 
optic  nerve  varies  greatly,  within  limits  defined 
by  differences  in  the  degree  of  its  capillary  vascu- 
larity, by  the  effects  of  contrast  arising  from  the 
degree  of  pigmentation  of  the  surrounding  parts, 
and  by  the  mechanical  arrangement  of  the  struc- 


tures of  which  it  is  composed.  The  aperture 
the  sclerotic,  by  which  the  nerve  enters  the  e- 
is  closed  by  a cribriform  plate  of  condensed  cc 
nective  tissue,  the  lamina  cribrosa;  and  the  fill  i 
normally  leave  their  sheaths  on  the  outer  side 
this  lamina,  only  the  axis-cylinders  pass: 
through  its  perforations.  The  combined  as 
cylinders  constitute  a mass  the  whiteness 
which  is  subdued  rather  than  glistening,  a 
which  derives  a certain  amount  of  reddish  ro. 
ate,  or  pink  colour  from  the  capillary  vessels 
which  it  is  permeated.  The  axis-cylinders,  ii 
the  vessels,  bend  round  as  they  pass  from  thJ 
original  direction  into  that  of  the  retinal  surfac 
and,  in  the  majority  of  instances,  they  leave 
central  depression  in  the  nerve-disc  as  th 
separate,  a depression  at  the  bottom  of  which  l| 
glistening  whiteness  of  the  lamina  cribrosa ! 
visible,  and  which  has  been  called  the  form  d 
ticas.  In  other  instances,  this  central  depr. 
sion  does  not  exist,  but  the  axis  cylinders  ; 
gathered  chiefly  towards  one  side  of  the  nerj 
entrance,  and  the  lamina  is  visible  laterallv  ] 
stead  of  centrally.  The  size  of  the  forus  <mii\ 
is  very  variable,  insomuch  that  sometimes,  wc 
it  constitutes  quite  a large  central  depression, 
is  described  as  congenital  or  physiological  ex 
ration  of  the  nerve.  This  congenital  excavation 
always  readily  distinguishable  from  the  exca-j 
tion  produced  by  the  pressure  consequent  upl 
excess  of  internal  tension;  because  the  forn 
never,  and  the  latter  always,  extends  to  the  o 
treme  margin  of  the  nerve.  In  other  words,  il 
congenital  excavation,  however  large  and  I- 
markable,  is  always  surrounded  by  a ring  ' 
nerve-tissue;  while  themorbid excavation alw. 
extends  to  the  margin  of  the  opening  in  the  sq 
rotic.  The  position  of  the  blood-vessels  in  a 
nerve-entrance  is  also  another  variable  fact', 
since  they  are  sometimes  nearly  central,  anlt 
others  are  seen  to  pass  into  or  ont  of  the  ner|- 
tissue  close  to  its  margin.  In  a few  cases,  mc- 
over,  the  axis-cylinders  at  some  portion  or  p- 
tions  of  the  circumference  carry  their  sheathsr 
a short  distance  into  the  retina ; and  the  nep 
is  then  surrounded  by  white  glistening  procesi, 
with  brush-like  terminations.  Sometimes,  ag^. 
the  margin  of  the  opening  in  the  choroid  isriov 
pigmented,  and  the  nerve  is  surrounded  trim 
ring,  or  bordered  by  a crescent,  of  chocolatejr 
black  colour. 

o.  Fundus  as  a Whole. — The  general  appff - 
ance  of  the  healthy  fundus  oeuli  maybe  sunnd 
up  somewhat  in  the  following  way:  the  bi- 
ground  seen  in  the  inverted  image  ranges: 
colour  from  an  almost  chocolate  tint  in  tv 
dark  people  or  in  the  dark  races,  to  a clo  V 
woven  reticulation  of  vessels  carrying  red  bill, 
and  affording  indications  of  the  white  scleric 
lying  behind  them.  In  light  eyes,  the  re  a 
itself  is  invisible ; but  in  dark  eyes  its  tht- 
est  portion  appears  as  a delicate  film,  wth 
has  been  compared  to  moistened  tissue-pa' 
over  the  portion  of  the  field  which  immediuy 
surrounds  the  optic  nerve.  Except  in  very  let 
eyes,  the  vessels  of  the  choroid  are  not  indivu- 
ally  visible,  being  concealed  by  the  pigmental 
of  the  pavement-epithelium;  and,  when  vis  e, 
they  are  distinguishable  by  their  parallel  dc- 
. tioD,  and  by  the  absence  of  branches.  The  ver-i 


OPHTHALMOSCOPE.  106J 


,t  the  retina  are  always  clearly  visible,  and  may 
ie  traced  along  their  numerous  arborescent  rami- 
Scations  to  twigs  of  extreme  fineness.  The  ar- 
eries  are  smaller  and  brighter  than  the  veins, 
nd  often  present  the  appearance  of  a white  line 
jmming  along  the  axis  of  the  vessel,  almost  as  if 
t were  a translucent  red  tube,  carrying  a white 
uid.  The  veins,  larger  and  darker  than  the 
L-teries,  seldom  display  the  white  line.  The 
,essels  pass  off  the  optic  disc  on  all  sides,  but 
lake  bold  curves  which  carry  them  clear  of  the 
jirion  of  the  yellow  spot.  In  the  close  vicinity 
f the  disc,  the  vessels  are  sometimes  attended 
y fine  white  threads,  pursuing  the  same  general 
nurse  with  them,  and  which  are  apparently 
parser  portions  of  the  connective  tissue  by  which 
■ley  are  sustained.  The  optic  disc,  or  termina- 
!on  of  the  optic  nerve  itself,  the  most  conspicu- 
as  object  in  the  ophthalmoscopic  image,  stands 
it  boldly  against  its  surroundings,  and  presents 
■general  colour-effect  which  depends  partly  upon 
L richness  of  its  capillary  blood-supply,  and 
artly  upon  the  greater  or  less  degree  of  pigmen- 
ition  of  the  tissues  around  it.  Over  part,  of  its 
irfaee,  generally  in  or  near  the  centre,  but 
imetimes  laterally,  it  displays  the  whiter  colour 
f the  lamina  cribrosa,  and  tho  mottling  of 
s perforations  for  the  passage  of  the  nerve- 
pres.  It  is  often  bordered,  either  entirely  or 
trtially,  by  a line  of  dark  pigment  situated 
, the  margin  of  the  choroidal  opening ; and  it 
ten  exhibits  also  a fine  white  line  at  its  margin, 
jhich  is  the  edge  of  the  opening  in  the  sclerotic, 
>en  through  the  semi-transparent  nerve-tissue, 
he  vessels  pass  over  its  margin  without  devia- 
pn  or  change  of  plane.  The  apparent  size  and 
iape  of  the  disc  depend  much  upon  the  refrac- 
on  of  tho  eye.  As  seen  in  the  inverted  image, 

■ appears  comparatively  small  in  a myopic  eye, 
id  largo  in  a hypermetropic;  while,  in  cases  of 
tigmatism,  it  is  distorted  into  the  appearance 
an  oval.  In  the  same  way,  the  refraction 
pdifies  the  apparent  actual,  but  not  the  rela- 
te calibre  of  the  vessels.  In  the  myopic  eye 

0 vessels  appear  of  small  diameter,  and  in  tho 

■ permotropic  they  appear  of  large  diameter ; 
that  no  conclusions  about  their  actual  size  can 
drawn  until  the  state  of  refraction  has  been 
ten  into  account.  The  fact  that  the  veins  are 
atively  larger  or  smaller  than  usual,  when 
npared  with  the  arteries,  is,  of  course,  not  in- 
duced by  refraction,  except  that,  in  a hyper- 
■tropic  eye,  such  a difference  would  be  more 

■ ispicuous  than  in  a myopic,  by  reason  of  the 
re  magnified  image  produced  by  the  optical 

■ iditions  of  the  media. 

i.  Circulation. — In  a general  way,  the  blood- 

1 'rents  in  the  vessels  of  the  retina  are  continuous 
tl  uninterrupted;  but  any  hindrance  to  tho 
< ranee  of  blood  may  be  attended  by  pulsa- 
1 1,  first  in  the  voins  and  subsequently  in  the 
fbries.  Such  hindrance  may  arise- from  dis- 
tered  action  of  the  heart,  as  in  cases  of  insuf- 
f|;ncy  of  the  aortic  valves ; from  disease  of  the 
Its  of  the  arteries;  or  from  increased  resist- 
ive on  the  part  of  the  fluids  already  occupying 
tj  cavity  of  the  eyeball.  The  venous  pulse  de- 
I ds  upon  an  arrest  of  the  outflow  through  the 
ys  by  the  pressure  of  the  entering  arterial 
Tent;  which,  at  the  acme  of  the  pulse- wave, 


has  force  enough  to  push  back  the  venous  current 
when  there  is  not  room  enough  for  both.  Hence, 
in  the  venous  pulse,  the  vessels  empty  them- 
selves in  a direction  from  the  centre  of  the  disc 
towards  its  periphery,  and  refill  in  the  opposite 
direction.  The  ordinary  cause  of  venous  pulse 
is  increased  tension  or  fulness  within  the  eyeball, 
so  that  it  is  among  the  early  symptoms  of  glau- 
coma ; but  it  is  also  to  be  seen  in  a small  propor- 
tion of  cases  in  which  no  excess  of  tension  is 
to  be  discovered  either  by  touch  or  by  symptoms, 
and  in  which  the  eyes  appear  to  be  healthy.  In 
the  arterial  pulse,  the  resistance  to  the  entrance 
of  blood,  or  rather  the  disturbance  of  the  balance 
between  the  propulsive  and  the  resisting  forces, 
must  be  considerable ; and  the  course  of  events 
is  that  the  arterial  current  can  only  make  its 
way  into  the  eye  at  the  acme  of  the  pulse-wave, 
during  which  the  arteries  fill  from  the  periphery 
of  the  disc  to  the  centre,  to  collapse  again  as 
soon  as  the  impulse  of  the  Systole  diminishes. 
In  such  a condition,  the  impediment  to  the  en- 
trance of  arterial  blood  is  sufficient  to  imperil 
the  nutrition  of  the  nerve-tissue ; and  the  writer 
has  seenat  least  one  case  of  partial  nerve-atrophy, 
attended  with  arterial  pulsation,  for  which  no 
other  cause  than  excessive  arterial  tension  could 
be  assigned.  Arterial  pulse  is  probably  always 
present  in  advanced  stages  of  glaucoma,  but  by 
the  time  it  is  produced  the  fuudus  is  usually  ob- 
scured or  rendered  invisible  by  other  changes. 
Apart  from  glaucoma,  its  most  frequent  cause  is 
aortic  regurgitation ; and  in  this  form  the  eye 
does  not  suffer,  except  together  with  other  parts 
of  the  organism. 

7.  Optic  Neuritis  and  Atrophy. — The  morbid 
appearances  seen  with  the  ophthalmoscope,  and 
interesting  to  the  physician,  are  chiefly  those 
which  point  to  the  existence  of  some  diathesis,  or 
to  the  presence-of  disease  in  other  organs.  Swell- 
ing of  the  infra-ocular  extremity  of  the  optic 
nerve,  with  obliteration  of  its  margins  and  ob- 
struction to  its  vessels,  occurs  in  many  forms  of 
intracranial  disease,  especially  in  connection  with 
intracranial  tumour,  and  is  often  followed  by  atro- 
phy and  blindness  when  life  is  sufficiently  pro- 
longed. The  most  interesting  characteristic  of 
these  cases  is  that,  since  the  swelling  affects  only 
the  connective-tissue  layer,  which  is  absent  over 
the  region  of  the  yellow  spot,  there  is  commonly  no 
diminution  of  the  acuteness  of  central  vision  until 
the  atrophic  changes  have  commenced  ; by  which 
time,  in  many  instances,  the  primary  swelling  has 
passed  away.  Hence,  for  many  years,  there  existed 
great  uncertainty  about  the  cause  of  the  atrophy, 
and  this  uncertainty  was  only  removed  when 
physicians  began  to  examine  the  fundus  oeuli  in 
all  cerebral  cases,  without  regard  to  the  state 
of  sight.  Prior  to  that  time,  the  intra-ocular 
changes  were  apt  to  remain  undiscovered  in  their 
primary  stage,  and  until  commencing  impair- 
ment of  vision  produced  resort  to  an  ophthal- 
mologist, followed  by  an  ophthalmoscopic  exa- 
mination in  due  course ; and  then  the  atrophy 
was  often  attributed  to  many  fanciful  causes, 
among  which  the  smoking  of  tobacco  held  a pro- 
minent place.  It  is  not  necessary  to  assume 
that  tobacco  is  never  injurious  to  the  optic 
nerves,  in  order  to  be  quite  sure  that  the  ma- 
jority of  the  instances  of  atrophy  once  attributed 


10C4  OPHTHALMOSCOPE, 

to  its  influence  were,  in  reality,  due  to  a totally 
different  cause.  The  changes  associated  with 
intracranial  diseases  will  be  found  described  in 
a special  article.  See  Ophthalmoscope  in 
Medicine. 

8.  ‘Albuminuric  Retinitis.’ — Very  frequently 
i n albuminuria,  and  occasionally  in  diabetes  mel- 
litus,  the  fundus  of  the  eye  becomes  studded  over 
with  spots  or  patches  of  a glistening  white  colour, 
which  are  probably  due  to  fatty  degeneration 
of  the  connective  tissue  of  the  retina,  and  which 
are  often  associated  with  scattered  haemorrhages. 
The  blood,  in  these  instances,  is  usually  effused 
into  the  fibre-layer,  and,  following  the  course  of 
the  fibres,  becomes  spread  out  into  somewhat 
striated  spots,  with  brush-like  terminations. 
Every  case  in  which  either  the  white  patches  or 
the  haemorrhages,  or  both,  are  detected  by  the 
ophthalmoscope,  whether  with  or  without  im- 
pairment of  sight,  calls  for  a careful  examination 
of  the  urine,  and  renders  it  proper  to  follow 
mainly  the  indications  of  treatment  which  such 
an  examination  may  afford. 

9.  Haemorrhages. — Without  the  white  patches, 
haemorrhages  may  occur  in  the  retina  under 
various  conditions.  Sometimes  they  are  distinctly 
arterial,  in  which  case  they  are  generally  small  in 
absolute  amount,  and  may  often  be  traced  to  some 
manifest  point  of  rupture  in  the  vessel  from  which 
they  have  occurred.  These  haemorrhages  seldom 
produce  extreme  impairment  of  vision,  although 
they  are  usually  discovered  on  account  of  some 
degree  of  impairment ; and  their  chief  i niportance 
is  derived  from  the  warning  they  may  give  of  a 
state  of  brittleness  of  the  arteries,  and  of  a con- 
sequent liability  to  similar  bleedings  elsewhere, 
as  in  the-  brain.  They  call  for  all  the  precautions 
which  such  a state  would  suggest,  as  for  the  con- 
sumption of  a diminished  quantity  of  fluid,  and  for 
the  avoidance  of  constipation  and  of  all  violent 
bodily  efforts. 

Haemorrhages  which  are  distinctly  venous  occur 
not  unfrequently  in  connection  with  the  dis- 
turbances of  circulation  which  are  incidental  to 
the  cessation  of  the  menstrual  function,  or  to 
the  irregularities  by  which  cessation  is  preceded. 
The  blood  may  proceed  from  comparatively  large 
veins,  in  which  case  it  often  forms  a layer  im- 
mediately beneath  the  membrana  limitans  of  the 
retina,  causing  great  temporary  impairment  of 
sight,  or  even  total  blindness  ; and  yet,  in  many 
cases,  being  quickly  absorbed  without  permanent 
injury.  In  other  instances  it  may  proceed  from 
smaller  and  deeper-lying  veinlets,  in  which  case 
che  effusion  will  usually  be  situated  in  the  fibre- 
layer,  and  will  be  moulded,  so  to  speak,  by  the 
fibres,  into  what  have  been  described  as  1 flame- 
shaped’ haemorrhages.  These  are  generally 
multiple,  and  usually  cause  an  impairment  of 
function,  which  is  decided  although  not  total, 
and  is  often  permanent.  The  flame-shaped 
haemorrhages  are  said  by  Mr.  Hutchinson  to 
occur  preferably  in  persons  of  gouty  diathesis, 
and  he  holds  the  same  doctrine  with  regard  to  a 
less  common  form,  of  which  some  remarkable 
examples  have  been  observed  by  himself,  and  by 
Mr.  Bales  of  Birmingham.  In  these  cases,  tho 
subjects  were  young  males,  of  constipated  habit, 
and  in  many  instances  of  gouty  family  history, 
rfco  bleedings  were  large  in  amount,  so  as  to 


OPHTHALMOSCOPE  IX  MEDICINE. 

penetrate  into  the  vitreous  body  and  to  cause  fc 
a time  total  loss  of  sight,  and  were  frequent! 
recurrent.  To  what  extent  they  were  due  t 
deficient  plasticity  of  the  blood,  to  abnorm; 
friability  of  the  vessels,  to  variations  in  vast 
motor  tension,  or  to  the  withdrawal  of  extern: 
support  from  the  vessels  by  diminished  tensio1 
within  the  eyeball  itself,  is  at  present  a matti 
of  conjecture.  It  is  obvious  that  the  treatment, 
such  cases,  and.of  retinal  haemorrhages  general! 
must  resolve  itself  into  that  of  the  consfin 
tional  conditions  with  which  they  are  associate! 
The  only  special  indications,  as  regards  the  eyl 
will  be  the  enforcement  of  functional  rest,  ar'- 
the  maintenance  cf  an  elevated  position  of  tl 
head  during  sleep.  In  cases  connected  with  til 
cessation  of  the  menstrual  function,  the  absor 
tion  of  the  effused  blood  often  appears  to  be  pr 
moted  by  the  careful  administration  of  iodic 
of  potassium,  which  should  usually  be  combine 
with  ammouio-citrate  of  iron,  or  with  some  oth1 
suitable,  tonic,  and  care  should  always  be  tab 
to  maintain  a moderately  relaxed  condition  of  tl 
bowels.  Even  apart  from  the  injurious  effec 
likely  to  be  produced  by  straining,  constipa:;. 
appears  to  predispose  to  haemorrhage. 

10.  Embolism  of  the  Central  Artery. — Sudd, 
loss  of  vision  is  sometimes  occasioned  by  fi 
plugging  of  the  central  retinal  artery  by  : 
embolus.  This  is  especially  to  be  suspected  • 
cases  of  known  valvular  disease  of  the  hea: 
and  the  condition  is  readily  recognisable  with  i 
ophthalmoscope.  The  retinal  veins  are  usna 
somewhat  dilated,  but  their  contained  blood 
broken  up  into  irregular  portions,  in  which  . 
uncertain  or  wavering  movement  may  sometin! 
be  detected.  The  arteries  are  either  obliterat 
or  so  dwindled  as  to  be  scarcely  visible.  I 
connective  tissue  of  the  retina  rapidly  becon 
cloudy  and  opaque,  so  that  the  general  surf 
of  the  fundus  is  milk}-  or  opalescent;  but  in  fi 
region  of  the  yellow  spot,  where  there  is  lit) 
or  no  connective  tissue,  this  opacity  cannot? 
produced,  and  the  red  colour  of  the  chor. 
shines  through,  producing  the  effect  of  a cher- 
red  spot  on  a white  ground.  After  a few  wen 
the  retina  regains  its  transparency,  but  the  op- 
nerve  Dasses  into  a state  of  absolute  atrophy. 

E.  Bbcdenell  Caeteb 

OPHTHALMOSCOPE  IN  MEDICIK. 

In  a large  number  of  diseases  which  come  un: 
the  care  of  the  physician — diseases  of  the  nervs 
system,  kidneys,  blood,  and  other  structure  - 
intra-ocular  changes  occur,  and  may  be  obser* 
with  the  ophthalmoscope.  Hence  this  inst- 
ment  is  highly  useful  to  the  physician.  By  s 
aid  we  can  observe,  magnified  about  twev 
diameters,  the  termination  of  an  artery,  ofa  v(. 
and  of  a nerve  ; a peculiar  vascular  struets 
(the  choroid) ; and  a peculiar  nervous  structe 
(the  retina).  Nowhere  else  are  nerve  and  V 
sels  exposed  to  direct  observation.  Many  chans 
affecting  these,  tissues  throughout  the  body  r.v 
be  first  and  best  detected  here,  and  in  s<e 
other  diseases  these  intra-ocular  structures  e 
affected  in  a special  manner.  _ 1 

The  chief  changes  in  the  fundus  oculi  win 
are  of  importance  to  the  physician  are  the  folk- 
ing: — (a)  In  the  retinal  vessels: — variationt*1 


OPHTHALMOSCOPE  IN  MEDICINE. 


■26  in  tlie  condition  of  their  walls,  the  exist- 
uce  of  aneurisms,  the  tint  of  the  blood,  the  occur- 
ence of  visible  pulsation  in  arteries  or  veins,  of 
temorrhages,  or  of  vascular  obstruction.  ( b ) In 
,ie  optic  nerve  or  papilla: — congestion,  neuritis 
r papillitis  ; atrophy,  simple,  consecutive  (after 
euritis)  or  choroiditic.  (c)  In  the  retina : — 
arious  inflammatory  or  degenerative  changes  or 
rowths.  (d)  In  ihe  choroid : — inflammatory 
sudations,  with  their  resulting  disturbance  of 
le  choroidal  pigment,  atrophy,  growths.  For 
description  of  these  various  changes  the  reader 
i referred  to  the  special  articles.  In  this  place 
is  only  possible  to  point  out  the  changes 
inch  present  themselves  in  the  various  special 
iseases  which  come  under  the  physician's  care. 

I.  Diseases  affecting  the  Nervous  System. 
— Brain. — Two  forms  of  ocular  changes  are 
et  with:  (1)  ‘associated,’  the  consequence  of  the 
mse  of  the  cerebral  disease  ; (2)  ‘ consecutive,’ 
tie  direct  result  of  the  cerebral  disease.  Ancemia 
ad  hypemmia  of  the  brain  are  not,  as  a rule, 
wealed,  by  any  corresponding  change  in  the 
itinal  circulation,  this  being  regulated  in  a 
aerial  manner  by  the  intra-ocular  tension.  Such 
langes,  when  affecting  the  whole  head  and  con- 
derable  in  degree,  are,  however,  shared  by  the 
Ainal  vessels.  Moreover,  acute  cerebral  hyper- 
mia  may,  after  a time,  lead  to  congestion 
the  optic  papilla.  Acute  general  cerebritis 
usually  accompanied  by  meningitis,  and  to 
e latter  the  ophthalmoscopic  changes  are  pro- 
ibly  in  part  due.  There  is  a form  of  chronic 
rebrilis  or  encephalitis , of  which  the  symptoms 
e somewhat  like  those  of  tumour,  but  the  only 
auges  to  be  found  after  death  are  microscopic, 
.this  condition  well-marked  neuritis  (papillitis) 
ay  be  present. 

In  cerebral  hemorrhage  consecutive  changes 
e extremely  rare,  and  are  almost  confined  to 
ses  of  meningeal  haemorrhage,  from  which 
ght  neuritis  may  result.  Of  associated  changes, 
eurisms  are  rare,  but  have  been  noted ; retinal 
?morrhages  are  not  unfrequent.  They  are  most 
jnificant  in  blood-states,  although  most  com- 
■>nin  renal  disease  associated  with  albuminuric 
:initis.  In  the  latter  they  indicate  vascular 
>ease,  but  not  necessarily  that  a cerebral  lesion 
haemorrhagic,  since  they  are  often  associated 
th  softening  of  the  brain. 

In  softening  from  embolism,  retinal  embolism 
ji'.y  be,  in  rare  cases,  associated.  In  ulcerative 
pocarditis  septic  haemorrhages  may  be  seen  in 
P retina.  Consecutive  changes  are,  as  a rule, 
sent;  occasionally  slight  optic  neuritis  is  de- 
:oped. 

In  softening  from  arterial  thrombosis,  when 
is  is  due  to  atheroma  of  the  vessels,  associated 
tinges  (haemorrhages,  or  renal  retinitis)  may 
found  in  the  retina,  but  there  are  usually  no 
> isecutive  changes.  The  latter  are  also  absent 
thrombosis  from  syphilitic  disease  of  arteries  ; 
associated  changes — the  various  ophthalmo- 
pic  manifestations  of  syphilis — are  common, 
: 1 are  often  of  the  highest  diagnostic  impor- 
l ce. 

n abscess  of  the  brain,  optic  neuritis  occurs 
; a considerable  number  of  cases,  although  not 
ill.  It  has  no  known  relation  to  the  position 
! the  abscess,  but  is  perhaps  most  frequent  in 


1065 

the  cases  in  which  the  abscess  results  from  an 
injury. 

Tumours  of  ihe  brain.— Associated  changes 
are  very  rare,  and  are  confined  to  the  cases  in 
which  a similar  growth  (glioma  or  tubercle) 
exists  within  the  eye.  Consecutive  changes  are 
more  common  than  in  any  other  cerebral  affection. 
Optic  neuritis  occurs  in  about  four-fifths  of  the 
cases.  On  what  its  occurrence  or  absence  de- 
pends we  do  not  know.  Neither  position,  size, 
nor  nature  of  growth  seems  to  influence  it  in  any 
considerable  degree.  It  does  not  depend  on  in- 
crease of  intracranial  pressure.  In  some  cases 
it  is  at  least  aided  by  the  occurrence  of  menin- 
gitis. In  many  eases  a slight  descending  inflam- 
mation maybe  traced  from  the  optic  tracts  down 
the  nerves  to  the  eyes,  and  this,  at  the  papilla, 
seems  to  excite  a more  intense  degree,  perhaps 
aided  by  mechanical  congestion  or  oedema  of  the 
sheath.  The  latter  is  commonly  found  after 
death,  but  probably  does  not  constitute  the  chief 
mechanism  by  which  neuritis  is  produced.  A 
tumour  may  exist  for  a long  time  without 
neuritis,  or  the  neuritis  may  be  present  as  soon 
as  the  symptoms  of  tumour  manifest  themselves. 
Often  the  neuritis  and  the  tumour  correspond  in 
their  course,  each  being  acute  or  chronic.  Both 
may  even  be  almost  stationary  for  years.  An 
acute  neuritis,  occurring  during  the.  course  of  a 
tumour  which  appeared  chronic,  usually  indi- 
cates an  increase  in  the  growth,  aud  is  of  bad 
prognostic  significance.  The  degree  of  neuritis 
varies ; it  is  least  in  the  tumours  of  most 
chronic  course,  and  greatest  in  the  rapid  growths. 
It  is  often  accompanied  by  hsemorrhages.  Com- 
monly bilateral,  it  is  in  rare  cases  unilateral, 
and  is  then  usually  in  the  eye  opposite  to  the 
seat  of  the  tumour.  It  may  exist  in  consider- 
able degree  without  impairing  sight.  Perception 
of  colour  may  be  affected  before  acuity  of  vision. 
If  the  tumour  be  arrested  by  treatment,  as  in 
syphilitic  and  tubercular  growths,  the  neuritis 
will  subside,  but  too  often,  before  this  result  is 
obtained,  sight  has  been  damaged  beyond  re- 
covery. Simple  atrophy  of  the  optic  nerves 
sometimes  results  from  tumours,  although  far 
less  commonly  than  ‘ consecutive  atrophy.’ 

Intra-cranial  aneurisms  are  rarely  accompanied 
by  intra-ocular  changes.  Now  aud  then,  an  aneu- 
rism of  the  internal  carotid  has  caused  atrophy 
by  pressure,  and  even  optic  neuritis,  single  or 
double. 

Internal  hydrocephalus  is  usually  accompanied 
by  no  other  ophthalmoscopic  changes  than 
slight  fulness  of  the  veins.  Occasionally  simple 
atrophy  occurs,  commonly  from  the  pressure  of 
the  distended  third  ventricle  on  the  optic 
chiasma. 

Meninges.— Growths  in  the  meninges  lead  to 
optic  neuritis,  just  as  do  tumours  in  the  cerebral 
substance.  The  effect  of  meningitis  varies 
according  to  its  form  and  seat.  Simple  meningitis 
of  the  convexity  is  rarely  attended  by  ocular 
changes.  It  is  very  different  with  basilar  tuber- 
cular meningitis.  Occasionally,  though  rarely, 
tubercles  of  the  choroid  may  be  seen.  In  a con- 
siderable number  of  cases  there  is  distinct  neuri- 
tis ; it  is  well-marked  in  at  least  half.  Usually 
too  late  to  be  of  diagnostic  importance,  it  is 
now  and  then  sufficiently  early  to  decide  th« 


OPHTHALMOSCOPE  IN  MEDICINE. 


1066 

nature  of  the  case.  A similar  change  is  common 
in  both  syphilitic  and  traumatic  meningitis,  hut 
is  very  rare  in  the  epidemic  cerehro-spinal  form. 

Diseases  of  the  cranial  bones. — Caries  of  the 
sphenoid  hone  may  cause  descending  neuritis  ; 
caries  elsewhere  usttally  only  affects  the  eye  by 
causing  meningitis  or  abscess.  Thickening  of 
the  cranial  hones  may  he  attended  by  well- 
marked,  sometimes  intense,  neuritis,  with  haemor- 
rhages. This  is  apparently  produced  by  the 
resulting  constriction  of  the  nerve  and  sheath 
at  the  optic  foramen.  Inflammatory  mischief,  or 
growths  in  the  orbit,  frequently  cause  neuritis 
or  atrophy,  the  optic  nerve-trunk  being  damaged 
directly.  In  these  cases  the  affection  is  unilate- 
ral, at  least  for  a long  time,  and  is  often  accom- 
panied by  prominence  of  the  eyeball,  and  tender- 
ness when  it  is  pushed  back. 

Injuries  to  the  head  may  affect  the  eye  in 
various  ways.  (1)  The  retina  may  suffer  in 
consequence  of  the  immediate  concussion.  (2) 
Optic  neuritis  may  come  on  after  a few  days, 
commonly  as  the  result  of  a traumatic  meningitis. 
(3)  Direct  injury  to  the  optic  nerves  may  cause 
loss  of  sight  and  simple  atrophy.  (4)  Optic 
neuritis  may  come  on  some  weeks  after  the  in- 
jury, and  is  usually  due  to  inflammatory  pro- 
cesses in  the  damaged  brain. 

2.  Spinal  cord  -Acute  myelitis  and  spinal  me- 
ningitis are  very  rarely  attended  by  eye-changes. 
In  one  or  two  cases  coincident  optic  neuritis  has 
been  observed.  The  connection  between  the  two  is 
obscure.  Sclerosis  of  the  posterior  columns  (loco- 
motor ataxy)  is  accompanied  by  atrophy  of  the 
optic  nerves  in  a considerable  number  of  cases,  al- 
though not  perhaps  in  more  than  fifteen  per  cent. 
When  it  does  occur  it  is  frequently  an  early  rather 
than  a late  symptom.  It  is  always  the  simple 
form  of  atrophy,  often  grey  with  unnarrowed 
vessels.  Sight  usually  suffers  gravely ; the  field 
of  vision  is  much  restricted;  and  perception  of 
colours  may  be  lost.  The  atrophy  is  not  the  re- 
sult of  any  extension  upwards  of  the  disease  in  the 

' posterior  columns.  It  may  occur  when  this  has 
scarcely  commenced,  and  even  years  before  the 
earliest  symptoms.  It  is  apparently  an  associated 
degeneration.  In  lateral  sclerosis  ocular  changes 
are  doubtful.  In  disseminated,  sclerosis,  optic 
nerve-atrophy  may  occur,  just  as  in  posterior 
sclerosis,  hut  less  frequently.  Damage  to  sight, 
without  opthalnroscopic  changes,  occasionally  re- 
sults from  the  sclerosis  invading  the  optic  com- 
missure or  nerves.  In  caries  of  the  spine  changes 
in  the  optic  disc  are  practically  unknown.  In 
very  rare  cases  of  injury  to  the  spine,  neuritis 
and  subsequent  atrophy  have  been  observed, 
but  these  results  are  so  rare  that  their  precise 
significance  is  doubtful. 

3.  Functional  Diseases. — In  exophthalmic 
goitre  the  only  ophthalmoscopic  change  is  in- 
creased size  of  the  retinal  arteries,  which  may 
pulsate  visibly.  In  chorea,  embolism  of  the 
central  artery  of  the  retina  has  been  once  or 
twice  observed ; and  so  also  has  optic  neuritis, 
slight  in  degree.  As  a rule,  however,  the  fundus 
is  normal.  With  neuralgia  of  the  fifth,  optic 
nerve  atrophy  has  been  observed ; the  nature 
of  the  association  is  doubtful.  In  idiopathic 
epilepsy  the  appearance  of  the  fundus  is,  as  a 
rule,  perfectly  normal.  Even  during  an  attack 


it  is  probable  that  the  only  change  is  venom 
distension  during  the  stage  of  cyanosis.  Bnl 
during  the  status  epilepticus,  when  attack: 
recur  with  great  severity  for  several  days,  a con 
dition  of  slight  neuritis  may  be  produced,  sub  ' 
siding  after  the  attacks  are  over.  In  cases  c I 
convulsions  from  organic  brain-disease,  it  mus 
he  remembered,  optic  neuritis  or  its  effects  ar 
often  met  with.  The  frequency  with  whid| 
morbid  appearances  are  to  he  seen  in  the  eye  if 
insanity  has  been  variously  stated,  and  by  som 
writers  unquestionably  exaggerated.  They  ar 
most  frequent  in  general  paralysis  of  the  insane 
Optic-nerve  atrophy  is  the  usual  change,  and  i 
sometimes  an  early  event,  just  as  in  locomotc! 
ataxy.  In  very  rare  cases  slight  neuritis  ha 
been  seen.  In  mania,  melancholia,  and  dementi 
it  is  probable  that  there  are  no  related  morbi 
appearances  in  the  eye. 

II.  Diseases  affectin'}  the  Umnae 
System 

1.  Bright’s  Disease. — Sight  may  he  impaire 
in  this  complaint  by  uraemic  poisoning,  or  b 
retinal  changes.  The  latter  may  occur,  even  i 
considerable  degree,  without  any  affection  cj 
vision.  The  arteries  may  occasionally  be  eoi 
spicuously  narrow  (contracted),  and  in  rail 
cases  may  present  sclerosis  of  the  outer  coat,  c 
minute  aneurisms.  Aneurismal  dilatations  c 
the  capillaries  may  often  he  found  post  morten 
in  association  with  other  degenerations,  and  pre 
bablv  lead  to  the  occurrence  of  a very  commc 
change  in  the  retina — haemorrhages.  These  a>, 
usually  striated,  situated  in  the  nerve-fibre  lave 
sometimes  they  are  irregular  in  shape,  ar 
situated  in  the  deeper  layers.  They  may  detac 
the  retina  from  the  choroid,  or  hurst  through  in 
the  vitreous.  Sometimes  they  exist  alone ; mo 
commonly  they  are  conjoined  with  other  change 
to  which  the  term  ‘albuminuric  retinitis  ’ is  give 
This  latter  change  may  occur  in  all  forms 
renal  disease,  hut  is  by  far  the  most  common 
the  granular  kidney.  It  is  alato  symptom, nev 
appearing  until  the  general  system  is  sufferiD 
The  disease  of  the  retina  presents  certain  elemen 
which  are  variously  combined  ia  different  cast 
1.  Diffuse  slight  opacity  and  swelling  of  t 
retina,  due  to  the  infiltration  of  its  substance 
an  albuminous  coagulable  liquid  (oedema). 
White  spots  and  patches  of  various  size  a 
distribution ; some  large  and  soft-edged ; othc 
minute,  and  of  pearly  whiteness.  They  are  d 
to  fatty  degeneration  of  the  retinal  elemenj 
or  to  granular  degeneration  of  albumino 
exudations.  The  small  white  spots  often  radia 
around  the  macula  lutea.  3.  Hoemorrhag; 

4.  Inflammation  of  the  optic  papilla — ‘ nenrit. 

5.  The  subsidence  of  the  inflammatory  chans 
may  be  attended  with  the  signs  of  atrophy 
the  optic  nerve  and  retina.  According  to  t 
predominant  character,  four  types  of  retii 
affection  may  be  distinguished : a degenerati , 
haemorrhagic,  inflammatory,  and  neuritic  for 
In  the  first  the  white  spots  predominate,  a 
there  are  usually  extravasations,  hut  there* 
little  diffuse  opacity.  In  the  second  t 
haemorrhages  are  so  abundant  as  to  be  1* 
chief  feature.  In  the  third  there  is  much  c- 
fuse  opacity  and  swelling  of  the  retina.  In  a 
fourth  the  optic  neuritis  is  in  excess  of  the  otr 


I 


OPHTHALMOSCOPE  IN  MEDICINE. 


dianges,  and  the  appearance  may  easily  he  as- 
cribed to  cerebral  disease — the  more  so  that  it 
s often  conjoined  with  headache,  and  other 
vidence  of  cerebral  disorder.  The  conspicuous 
'ombination  of  white  spots  and  hcemorrhages 
Isually  enables  the  retinal  affection  of  all'u- 
ninuria  to  be  recognised  without  difficulty.  It 
nay  be  confounded  with  the  degeneration  left 
|y  a previous  wide  neuro-retinitis,  but  in  such 
ases  the  signs  of  atrophy  will  be  conspicuous. 
The  course  of  the  affection  in  Bright’s  disease  is 
iften  progressive,  but  arrest  and  even  recovery 
hay  be  obtained  by  the  treatment  of  the  renal 
dsease.  When  extensive,  sight  is  usually  im- 
paired, but  is  rarely  completely  lost. 

2.  Diabetes.— In  diabetes,  in  rare  cases,  re- 
inal  changes  have  been  observed  exactly  similar 

0 those  of  the  degenerative  form  of  the  albumi- 
.uric  affection,  and  this  when  there  was  no  albu- 
nen  in  the  urine.  Miliary  aneurisms  have  been 
ound  post  mortem,.  A distinction  from  the  renal 
orm  is  the  frequency  with  which  there  are  opa- 
ities  in  the  vitreous,  due  probably  to  slight  ex- 
ravasations  of  blood. 

HI.  Diseases  of  the  Heart. — The  peculiar 
;onditions  of  the  intra-ocular  circulation  prevent 
oy  dynamical  changes  in  the  circulation, 
fenous  distension,  if  considerable,  may  be 
isible  in  the  eye,  especially  in  cyanosis.  When 
rterial  pulsation  is  strong  it  may  be  visible  in 
he  retinal  arteries,  as  in  exophthalmic  goitre 
nd  in  aortic  regurgitation.  In  these  cases  also 
he  arterial  pulsation  may  (probably  in  the 
Heretic  ring)  be  communicated  to  the  vein,  and 
iiis  also  may  pulsate.  Embolism  of  the  central 
rtery  of  the  retina  may  occur,  and,  like  embo- 
sm  elsewhere,  is  most  common  in  mitral  con- 
triction.  In  ulcerative  endocarditis,  aceom- 
anied  with  multiple  embolism,  retinal  hsemor- 
hages  occur,  for  the  most  part  round,  with  a 
ale  or  white  centre.  They  are  almost  pathog- 
;omonic. 

IV.  Diseases  of  the  Blood. — Acute  ancsmia 
i’om  haemorrhage  may  bo  followed  by  loss 
jf  sight,  slight  or  considerable,  transient  or 
ennanent.  The  accident  most  commonly' follows 
aematemesis,  uterine  haemorrhage,  or  venesec- 
on.  In  some  cases  no  ophthalmoscopic  changes 
Jive  been  fouud ; in  others  there  has  been  neuro- 
litinitis.  The  mechanism  of  the  affection  is  ob- 
jure. Simple  chronic  anaemia  is  accompanied 
f marked  pallor  of  the  veins,  sometimes  of  the 
uoroid  and  disc,  but  the  latter  is  always  within 
ae  physiological  variations  in  tint.  Occasionally 
chlorosis  optic  neuritis  is  met  with,  disappear- 

1 g rapidly  under  iron.  In  pernicious  ancemia  the 
jioroid  is  notably  pale,  the  arteries  small,  the 
jiins  very  broad  (atonic)  and  pale.  Hsemor- 
puges  are  frequent,  especially  around  the  optic 
|sc,  and  they  are  often  associated  with  white 
Ltches.  Some  extravasations  are  rounded,  with 

white  or  pale  centre.  Occasionally  there  is 
,arked  neuritis.  In  leucocythcemia.  the  pallor 
>d  width  of  the  veins  are  very  striking.  Extra- 
ctions are  almost  invariable  at  some  period : 
bite  spots  are  frequent,  some  degenerative, 
hers  due  to  aggregations  of  leucocytes.  Some 
e surrounded  by  a halo  of  extravasation.  There 
ay  also  be  considerable  general  swelling  of  the 
tina,  throwing  the  distended  veins  into  con- 


1067 

spicnous  antero-posterior  curves.  In  purpura 
and  scurvy  retinal  haemorrhages  also  occur.  In 
the  intense  forms  of  purpura,  indeed,  they  are 
probably  constant. 

In  rare  cases  of  menstrual  disorders,  and  still 
rarer  instances  of  intestinal  disturbance  (chronic 
diarrhoea)  optic  neuritis  has  been  observed. 
Suppression  of  the  menses  has  been  followed  by 
retinal  haemorrhages.  The  connection  between 
the  several  events  is  obscure. 

V.  Chronic  General  Diseases. — In  chronic 
general  diseases  ophthalmoscopic  changes  are  met 
with  occasionally.  In  tuberculosis,  tubercles  may 
form  in  the  choroid,  and  bo  recognisable  as  small, 
round,  yellowish-white  spots,  free  from  pigment. 
They  have  more  frequently  been  found  in  this 
situation  after  death  than  during  life,  perhaps  be- 
cause not  looked  for  with  sufficient  perseverance, 
since  they  may  form  rapidly.  In  syphilis  ocular 
changes  are,  as  is  well  known,  common,  but  they 
come  chiefly  underthe  care  of  the  surgeon.  Traces 
of  past  iritis,  or  of  choroiditis — areas  of  choroi- 
dal atrophy  with  irregular  accumulation  of  pig- 
ment, frequently  afford  the  physician  important 
evidence  of  the  previous  existence  of  syphilis, 
acquired  or  inherited.  In  the  latter  the  cho- 
roidal changes  are  of  especial  importance,  and 
may  be  confined  to  small  round  white  spots  with 
pigment  in  the  centre,  or  there  may  be  evidence 
of  more  extensive  choroiditis  or  merely  of  eho- 
roiditic  atrophy,  a yellowish  disc,  with  the  edge 
a little  blurred,  and  very  small  retinal  vessels. 
Gout  has  been  supposed  to  cause  retinal  haemor- 
rhage (Hutchinson),  but  its  connection  with  oph- 
thalmoscopic change  (except  through  the  me- 
dium of  kidney-disease)  is  not  well-established. 

In  lead-poisoning,  besides  the  amblyopia  which 
may  come  on  without  ophthalmoscopic  changes, 
atrophy  of  the  disc  is  occasionally  met  with,  pre- 
ceded, in  some  cases,  by  a stage  of  congestion,  a 
red  disc,  with  softened  edges,  without  swelling. 
A considerable  degree  of  neuritis,  double,  with 
swelling  and  haemorrhages,  occurs  occasionally, 
especially  in  connection  with  cerebral  symptoms,, 
but  without  any  coarse  lesion  of  the  brain.  In 
chronic  alcoholism,  optic-nerve  atrophy  has  been 
described,  and  also  a condition  of  congestion. 
The  amblyopia  w'hich  accompanies  the  atrophy 
is  said  by  Eorster  to  be  characterised  by  loss  of 
central  vision  for  colour.  The  same  fact  is  well 
established  with  regard  to  tobacco  amaurosis,  in 
which  similar  congestion  and  atrophy  may  occur. 

YI.  Acute  General  Diseases.  — In  acute 
general  diseases,  changes  in  the  fundus  arc  for 
the  most  part  rare.  After  typhus,  typhoid,  and 
scarlet  fevers,  optic  neuritis  has  been  occasionally 
observed,  apart  from  any  renal  or  cerebral  com- 
plication. The  kidney  sequelae  of  scarlet  fever 
may  of  course  lead  to  the  special  retinal  changes. 
Malarial  fevers,  ague,  &c.,  are  frequently  attended 
with  retinal  haemorrhages  (Poncet,  S.  Mackenzie). 
Sometimes  the  extravasations  have  paler  centres. 
Optic  neuritis  and  atrophy  have  also  been  ob- 
served. Erysipelas  of  the  face  has  been  accom- 
panied by  loss  of  sight,  and  foEowed  by  atrophy, 
probably  by  the  extension  of  the  inflammation 
to  the  orbit,  and  to  the  trunk  of  the  optic  nerve. 
Pycemia  anisepticamia  have  long  been  known  t-c 
be  occasionally  accompanied  by  metastatic  pan- 
ophthalmitis, and  recent  observation  has  shown 


1068  OPHTHALMOSCOPE  IN  MEDICINE, 
that  slighter  alterations  in  the  fundus  oculi  fre- 
quently accompany  the  severer  forms  of  these 
affections.  Of  these  the  most  important  are 
retinal  haemorrhages,  round  or  irregular,  some- 
times large,  and  often  with  pale  centres.  It  is 
probable  that  they  are  in  some  cases  due  to 
septic  embolism,  but  they  may  occur  without  en- 
docarditis, and  are  probably  due,  in  some  cases, 
to  chemical  changes  in  the  blood.  They  are  al- 
most invariable  in  puerperal  septictemlo,  (Litton), 
and  are  also  found  in  other  forms  of  ulcerative 
endocarditis.  Usually,  they  occur  only  a few 
days  before  death.  In  other  cases  a peculiar 
form  of  retinitis  has  been  observed,  with  white 
spots  about  the  papilla  and  macula  lutea  (Roth). 

Most  of  the  appearances  mentioned  above  will 
be  found  figured  in  the  writer’s  Manual  and 
Atlas  of  Medical  Ophthalmoscopy. 

W.  R.  Gowers. 

OPISTHOTONOS  (u7r«r0ej/,  backwards,  and 
tovos,  a stretching). — A tetanic  spasm,  in  which 
tho  body  is  arched  backwards,  so  that  it  rests 
on  the  head  and  heels.  See  Tetantjs. 

OPIUM,  Poisoning  by. — In  consequence  of 
the  extent  to  which  opium  and  its  preparations, 
including  morphia,  are  used  for  the  relief  of 
pain,  and  the  readiness  with  which  the  drug  is 
procurable,  poisoning  by  opium  is  of  frequent 
occurrence ; and  there  is  no  doubt  that  great 
numbers  of  infants  perish  every  year  in  this 
country  through  the  improper  use  of  quack 
remedies  containing  opium. 

So  far  as  toxicology  is  concerned,  the  effects 
of  opium  may  be  referred  exclusively  to  morphia; 
since  the  effects  of  the  other  active  constituents 
of  the  drug  are  overshadowed  by  those  of  the 
chief  alkaloid. 

Anatomical  Characters. — The  post-mortem 
appearances  after  opium-poisoning  may  be  al- 
most nil.  As  a rule  the  brain  is  congested,  the 
puncta  omenta  being  especially  marked;  and 
the  lungs  and  right  side  of  the  heart  may  exhibit 
an  engorgement,  as  if  from  a modified  asphyxia ; 
but,  this  condition  is  by  no  means  invariable. 

Symptoms. — The  first  effect  of  the  administra- 
tion of  a toxic  dose  of  opium — a stato  of  bien- 
faisance  or  exaltation— commonly  observed  also 
after  the  administration  of  a medicinal  dose, 
may  be  either  very  short  or  entirely  wanting ; 
and  this  is  commonly  the  case  when  morphia  is 
injected  hypodermically.  A second  stage,  in 
which  the  symptoms  closely  resemble  those  of 
congestion  of  the  brain,  soon  sets  in.  The  face  is 
either  suffused  or  cyanosed;  the  pupils  strongly 
contracted;  the  skin  dry  and  warm;  the  breath- 
ing slow,  deep,  and  becoming  stertorous.  The 
patient  is  apparently  unconscious,  but  may  be 
aroused  by  shaking,  or  shouting  in  the  ear ; and 
when  he  is  aroused,  the  respirations  become 
more  rapid,  and  the  skin  may  regain  its  normal 
colour.  The  symptoms  of  this  secondstage  may 
gradually  ameliorate  under  appropriate  treat- 
ment ; or  a third  stage— that  of  prostration— 
supervenes.  The  coma  is  now  profound,  and  it 
may  bo  impossible  to  arouse  the  patient.  . The 
pupils  are  contracted  to  tho  size  of  pin-points  ; 
or  towards  the  termination  of  life  may  be  widely 
dilated.  Respiration  is  now'  very  slow,  shal- 
low, with  gradually  increasing  intervals,  during 


OPIUM,  POISONING  BY. 

which  there  are  no  signs  of  breathing,  and  ti 
patient  lies  in  a death-like  calm.  The  face  ij 
at  once  pallid  and  cyanosed;  the  skin  is  hatha 
in  perspiration,  at  first  warm,  and  then  cold  an' 
clammy.  The  pulse  increases  in  rapidity,  wit) 
progressively  increasing  feebleness.  The  patien 
may  even  now  recover,  signs  of  life  returnini 
very  gradually ; or  death  may  occur  from  failur 
of  respiration,  the  other  functions  of  life  bccoin 
ing  also  gradually  extinguished. 

Unusual  symptoms  in  opium-poisoning  are  trie 
mus  and  convulsions.  In  children  toxic  dose 
may  produce  very  rapid  effects,  the  second  stag 
of  the  intoxication  being  wanting,  and  sever1 
collapse  and  complete  unconsciousness  rapid!; 
supervening. 

Diagnosis. — The  certain  diagnosis  of  opium 
poisoning  is  often  a matter  of  great  difficulty,  a: 
the  symptoms  may  differ  in  no  material  respec 
from  those  exhibited  in  congestion  of  the  brain 
however  produced,  apoplexy,  and  ursemia.  Th' 
case  may  also  be  confounded  with  profound  alcd 
holic  intoxication.  It  may  also  be  difficult  c 
impossible  to  diagnose  from  poisoning  by  ehlcrr 
hydrate — a matter  of  less  importance,  since  th 
treatment  of  the  two  cases  would  be  simila: 
The  differential  diagnosis  of  opium-poisonin 
rests  upon  the  equally  and  minutely  contracte’ 
state  of  the  pupils,  a condition  which  is  all  by 
universal  in  the  second  stage  of  opium- poisoning 
our  ability  to  arouse  the  patient  temporarih1 
the  rousing  being  followed  by  more  or  lesj 
complete  disappearance  of  the  cyanosis  of  th 
countenance,  and  by  increased  rapidity  of  re 
spiration ; and  the  profuse  warm  or  clamra 
perspiration.  An  examination  of  the  urine  ft; 
albumin,  which  may  have  to  be  drawn  off  bytl 
catheter,  should  always  be  made ; but  it  must! 
borne  in  mind  that  urtemia  and  opium-poisonin 
may  bo  co-existent. 

Prognosis. — This  is  at  all  times  doubtfn 
There  is  great  liability  to  relapse,  even  whentn 
patient  appears  to  be  doing  well. 

Treatment. — First,  evacuate  the  stomach  n 
means  of  the  stomach-pump,  or  failing  this,  b 
the  use  of  emetics.  These,  however,  act  wit 
difficulty  in  cases  of  opium-poisoning;  andthei 
is  a special  danger  in  the  use  of  depressin 
emetics,  as,  for  example,  tartar  emetic,  on  a- 
count  of  the  possible  retention  by  the  stomac 
of  a fatal  dose  of  the  emetic.  AVarm  mustai 
and  water,  and  carbonate  of  ammonia  are  tl 
best  emetics  to  administer.  Secondly,  the  p; 
tient  must  be  prevented  lapsing  into  a state  • 
somnolence  by  walking  him  about ; alterna 
warm  and  cold  applications  to  the  chest ; flicJdi 
the  feet  with  a damp  towel ; shouting  into  tl 
ear ; and  the  application  of  the  faradic  curret 
These  means  will  have  the  additional  advanta^ 
of  maintaining  the  flagging  respiration,  and  r 
storing  normal  breathing.  In  the  last  resoi 
artificial  respiration  must  be  freely  employe 
The  absorption  of  the  alkaloids  of  opium  m; 
be  delayed  by  the  freeadministrationot  soluiioi 
containing  tannin,  so  as  to  render  the  alkalot 
insoluble  ; and  among  the  best  media  contains 
tannin  are  strong  infusions  of  tea  and  cofit 
The  caffein  which  these  infusions  contain,  its< 
also  exerts  a powerful  remedial  influence  in  tl 
form  of  intoxication.  Atropin,  as  a respirsto 


OPPRESSION. 

imulant,  appears  also  to  be  serviceable  as  a 
jrect  antidote  to  morphia.  It  is  best  given  by 
bcutaneous  injection,  in  doses  of  Ath  grain, 
lcoholic  stimulants  should  be  freely  given. 

Thomas  Stevenson. 

OPPRESSION. — A term  applied  to  a sense 
weight  in  any  part  of  the  body,  but  more 
equently  used  in  connection  with  the  chest, 
he  expression  is  sometimes  also  employed  in 
ferenee  to  a general  feeling  of  the  system  being 
rer-loadcd  or  over-weighted,  which  is  felt  at 
e commencement  of  certain  acute  diseases. 

OPTIC  NERVE  and  TRACT,  Diseases 

, — The  optic  nerve  may  be  damaged  by  various 
tra-ocular  processes ; but  these,  and  also  its 
irnary  atrophy,  have  been  already  described 
is  Eve  and  its  Appendages,  Diseases  of ; 
■hthalmoscope  ; and  Ophthalmoscope  in 
edicine).  In  this  article  only  those  affections 
iiich  are  situated  behind  and  independent  of 
e eye  will  be  described. 

Passing  from  the  orbit  into  the  intracranial 
jrity  by  the  optic  foramina,  into  which  they 
jsely  fit,  the  optic  nerves  are  connected  at  the 
iasma,  where  an  approximate  semi-decussation 
tos  place.  In  spite  of  recent  assertions  of 
isiadecki  and  others,  the  existence  of  the 
mi-decussation  is  quite  beyond  doubt.  From 
p ehiasma  each  optic  tract,  containing  fibres 
>m  the  corresponding  halves  of  both  retinae, 
sses  backwards,  between  the  crus  cerebri  and 
e inner  edge  of  the  temporo-sphcnoidal  lobe, 
the  posterior  portion  of  the  optic  thalamus, 
here  it  becomes  connected  with  the  corpora 
niculata.  Fibres  pass  thence  in  three  direc- 
fns,  namely: — (a)  to  the  posterior  extremity 
ilvinar)  of  the  optic  thalamus  ; ( b ) to  the  cor- 
ra  quadrigemina,  especially  the  anterior  ; and 
( to  the  convolutions  (occipital  lobe  and  angu- 

i gyrus).  Experiments  on  monkeys  (Ferrier) 

■ nonstrate  that  these  convolutions  are  con- 
ned in  vision. 

Ktiology. — In  the  orbit  the  nerve  may  he 
■jnaged  by  inflammation ; such  as  orbital  cellu- 
. 3,  arising  by  the  extension  of  facial  erysipelas, 

1 produced  by  exposure  to  cold.  The  inflam- 
ition  rarely  invades  the  nerve,  on  account  of  the 
ickness  of  the  sheath  which  invests  it,  but 
1 : nerve  is  damaged  by  the  pressure  of  the  in- 
nmatory  products.  It  may  also  be  compressed 
an  aneurism  of  the  ophthalmic  artery  or  by 
d'ital  tumours;  or  may  be  itself  the  seat  of 
t riad  growths  or  of  hemorrhage.  At  the  optic 
1 amen  the  nerve  may  be  compressed  by  a nar- 
rting  of  the  foramen,  such  as  occurs  in  thicken- 

ii  of  the  cranial  bones, an  occasional  consequence 
(jiyphilis,  acquired  and  congenital.  Within  the 
t’dl,  the  nerve  in  front  of  the  ehiasma  may  be 
imaged  by  the  extension  of  inflammation  from 
l meninges.  The  optic  commissure  is  oeca- 
sially  involved  in  growths,  and  may  he  com- 
Jssed  by  growths  in,  or  great  distension  of, 

• third  ventricle.  The  nerves  in  front  of  the 
ijasma,  and  the  ehiasma  itself,  are  liable  to  be 
1 aaged  by  the  pressure  of  aneurisms  of  adja- 

* t arteries.  The  optic  tracts  may  be  involved 

’ hemorrhage  into,  or  softening  of,  the  crura 

< ibri ; but  the  most  frequent  cause  of  their 

1 aage  is  a tumour  arising  at  the  base  of  the 
° 1 


OPTIC  NERVE  AND  TRACT.  1069 

brain,  or  in  the  adjacent  part  of  the  temporo- 
sphenoidal  lobe.  The  central  connections  of  the 
optic  nerves,  the  corpora  geniculata,  optic  thala- 
mus, white  substance  outside  it,  and  convolu- 
tions, may  be  damaged  by  tumour,  softening,  or 
haemorrhage.  The  corpora  quadrigemina  are 
rarely  affected,  so  as  to  cause  ocular  symptoms, 
except  by  growths. 

Symptoms. — Damage  to  the  optic  nerve,  be- 
tween the  optic  commissure  and  the  eye,  is  evi- 
denced by  affection  of  sight  in  that  eye  only. 
There  may  be  either  a concentric  or  sector  defect 
in  the  field,  or  complete  blindness ; the  reflex 
action  of  the  pupil  is  impaired.  When  the  nerve 
is  slowly  compressed,  the  loss  of  sight  is  fol- 
lowed by  slow  atrophy  of  the  intra-ocular  ex- 
tremity. When  it  is  invaded  by  inflammation, 
this  usually  descends  to  the  eye,  and  is  visible  as 
intra-ocular  neuritis,  and  may  ascend  to  the  com- 
missure, so  that  the  sight  of  the  other  eye  may 
subsequently  suffer.  Inflammation  at  the  back 
of  the  orbit  usually  also  involves  the  motor 
nerves,  and  so  may  cause  paralysis  of  all  the 
ocular  muscles.  These  recover,  however,  much 
more  readily  than  does  the  optic  nerve.  When 
the  nerve  is  compressed  by  narrowing  of  the 
optic  foramen,  the  loss  of  sight  is  usually  accom- 
panied, sometimes  preceded,  by  intra-ocular 
neuritis.  This  is  also  present  in  most  cases  in 
which  inflammation  extends  from  the  meninges 
to  the  intra-ocular  part  of  the  optic  nerves,  the 
optic  ehiasma,  and  even  in  extension  to  the  optic 
tract.  Damage  to  the  ehiasma  usually  affects  the 
sight  of  both  eyes.  In  most  cases  the  decussating 
fibres  suffer  chiefly  or  alone,  and  consequently 
there  is  loss  of  function  of  the  inner  half  of  each 
retina,  and  loss  of  the  outer  half  of  each  field 
of  vision — temporal  hemiopia  or  hemianopsia. 
Damage  to  the  outer  part  of  the  commissure  on 
each  side  affects  the  fibres  which  do  not  decus- 
sate, and  so  causes  loss  of  function  of  tlic  outer 
half  of  each  retina,  and  so  loss  of  the  inner  half 
of  each  field — nasal  liemiopia.  This  is  very 
rare,  but  has  been  seen  from  disease  of  arterial 
trunks  on  each  side  (Knapp).  In  irregular 
damage  to  the  ehiasma  the  loss  of  vision  may  be 
irregularly  distributed  in  the  two  eyes. 

The  optic  tract  receives  fibres  from  the  half 
of  each  retina  on  the  same  side,  and  its  damage 
thus  causes  loss  of  sight  in  the  opposite  half  of 
each  field  of  vision — lateral  hemiopia  or  hemian- 
opsia. The  area  affected  is  often  rather  more 
extensive  in  the  eye  on  the  side  opposite  to  the 
lesion  than  in  the  eye  on  the  same  side.  Since 
the  motor  tract,  in  the  adjacent  crus  cerebri  and 
hemisphere,  has  decussated  at  the  medulla,  if 
it  is  also  involved  in  the  lesion,  there  is  hemi- 
plegia on  the  same  side  as  the  loss  in  the  field 
of  vision.  The  patient  is  unable  to  see  to  the 
side  on  which  he  cannot  move  the  limbs.  Thus 
the  writer  has  recorded  a case  in  which  a patient 
had,  first,  right  hemiopia,  and  afterwards  right 
hemiplegia.  Both  were  due  to  a small  tumour 
of  the  inner  part  of  the  temporo-sphenoidal  lobe, 
which  had  first  invaded  the  optic  tract  and  then 
the  crus. 

Disease  of  the  corpora  geniculata  also  causes 
hemiopia. 

Regarding  the  effect  of  lesions  of  the  fibres 
which  extend  from  the  corpora  geniculata  to 


1070  OPTIC  NERVE  AND  TRACT, 
the  posterior  part  of  the  optie  thalamus  and 
to  the  convolutions,  there  is  some  difference  of 
opinion.  It  has,  until  lately,  been  held,  -with 
Von  Graefe,  that  lesions  of  the  convolutions  to 
which  these  fibres  proceed,  or  of  the  fibres  them- 
selves, cause  hemiopia,  just  as  does  a lesion  of 
the  optic  tract.  But  Charcot  has  called  atten- 
tion to  the  fact  that  hysterical  hemianaesthesia, 
believed  to  be  due  to  a disturbance  of  the  sen- 
sory function  of  one  hemisphere,  is  commonly 
associated,  not  with  hemiopia,  but  with  ‘crossed 
amblyopia,’  that  is,  with  partial  loss  of  sight  of 
the  eye  on  the  anaesthetic  side,  diminished 
acuity  of  vision,  restricted  field,  and  the  fields 
for  colour- vision  are  also  lessened.  These  fields 
vary  normally,  in  extent,  for  the  several  colours, 
and  some  or  all  may  be  so  lessened  as  to  cause 
partial  or  complete  colour-blindness.  Similar 
crossed  amblyopia  has  also  been  observed  as  a 
consequence  of  organic  lesions  causing  hemian- 
aesthesia, and  therefore  probably  involving  the 
fibres  of  the  posterior  part  of  the  internal  cap- 
sule, outside  the  optic  thalamus.  Hence  Charcot 
has  put  forward  the  hypothesis  that  the  fibres 
which  pass  from  the  optic  tract  to  the  corpora 
quadrigemina  are  those  which  ha  ve  not  decussated 
at  the  chiasma,  and  that  in  the  corpora  quad- 
rigemina a complementary  decussation  takes 
place,  the  fibres  passing  to  the  other  side  and 
there  joining  the  fibres  which  decussated  at  the 
chiasma,  so  that  the  convolutions  of  each  hemi- 
sphere receive  the  fibres,  not  from  one  half  of 
each  retina,  but  from  the  whole  of  the  retina 
on  the  opposite  side,  and  so  the  association  of 
crossed  amblyopia  with  hemianaesthesia  is  in- 
telligible. Hemiopia,  Charcot  believes,  is  always 
due  to  damage  to  the  optic  tract,  and  diseases  of 
the  hemisphere  which  cause  hemiopia  only  do  so 
by  pressure  on  the  optic  tract.  The  facts  avail- 
able as  evidence  on  this  question  are  not  very 
numerous,  but  they  are  decidedly  opposed  to 
Charcot’s  theory.  Clinically,  hemiopia  is  not 
unfrequently  met  with  in  association  with  hemi- 
plegia, hemianaesthesia,  and  occasionally  with 
aphasia,  in  cases  in  which  there  is  no  reason  to 
believe  that  there  is  more  than  one  lesion,  or 
that  it  is  situated  elseu'here  than  in  the  hemi- 
sphere. Such  clinical  evidence  alone  is  of  little 
weight,  but  it  derives  significance  from  a few 
reliable  pathological  facts,  in  which  a lesion  near 
the  surface  of  the  brain,  such  as  a haemorrhage, 
the  size  of  a walnut,  beneath  the  occipital  convo- 
lutions (Baumgarten)  has  caused  hemiopia.  The 
symptom  has  been  due  to  tumours  in  this  situa- 
tion in  many  recorded  cases,  and  in  one  which 
has  come  under  the  writer’s  notice.  These  facts 
make  it  probable  that  when  crossed  amblyopia 
results  from  a unilateral  cerebral  lesion,  the 
effect  is  due  to  a reflex  rather  than  to  a direct 
influence.  The  direct  effect  cf  a unilateral  cere- 
bral lesion  is  to  cause  hemiopia.  The  same  symp- 
tom may  also  result  from  a lesion  of  the  posterior 
part  of  the  optic  thalamus.  Charcot  suggests 
that  this  always  results  from  tumour  or  haemor- 
rhage in  this  situation,  which  has  compressed 
thelract.  But  no  case  exists  which  affords  sup- 
port to  the  opinion  that  the  pressure  of  an  adja- 
cent haemorrhage  on  the  ‘ optic  tract  could  cause 
hemiopia,  and  two  cases  have  come  under  the 
writer's  notice — one  in  a patientof  Dr.  Hughlings 


ORBIT,  DISEASES  OF. 

Jackson,  who  has  published  the  case— in  whici 
hemiopia  resulted  from  a simple  softening  o 
the  pulvinar. 

Disease  of  the  corpora  quadrigemina  hag  use 
ally  caused  complete  loss  of  sight  in  both  eyes 
hut  in  almost  all  cases  the  lesion  has  been 
tumour,  which  may  have  compressed  the  adja  | 
cent  corpora  genieulata,  or  caused  optic  neal 
ritis.  If  Charcot’s  theory  were  correct,  a lesioJ 
here  should  cause  nasal  hemiopia,  hut  such  a: 
effect  has  never  been  observed. 

Diagnosis. — The  chief  points  which  are  ou; 
guides  in  determining  the  position  of  post-oculal 
disease,  causing  loss  of  sight,  have  been  ahead 
stated.  If  the  affection  of  sight  is  confined  t 
one  eye,  it  is  probably — and,  if  associated  wit 
unilateral  optic  neuritis,  it  is  almost  certainly-' 
due  to  disease  of  the  nerve  in  front  of  the  chias 
ma.  In  this  case  the  reaction  of  the  pupil  t 
light  is  impaired.  On  the  other  hand,  if  th 
unilateral  affection  of  sight  is  associated  wit 
hemiplegia,  and  especially  with  hemianaesthesia 
on  the  same  side,  it  is  probable  that  the  diseas 
is  in  the  hemisphere,  and  the  failure  of  sigh:  i 
produced  in  some  manner  at  present  unknown 
In  this  case  the  pupil  often  acts  well  to  light 
Lateral,  homologous,  hemiopia  indicates  diseas; 
of  the  tract,  posterior  part  of  the  thalamus,  c! 
white  substance  between  the  thalamus  and  th] 
occipital  and  angular  convolutions,  or  of  thesj 
convolutions  themselves.  In  which  of  thes! 
positions  it  is  must  he  determined  by  the  ind. 
cations  of  the  localisation  of  disease  of  the  brail 
( see  Convolutions  of  the  Brain  and  Cobte 
Cerebri,  Lesions  of).  Nasal  or  temporal  hem] 
opia  indicates  disease  of  the  optic  chiasma. 

Prognosis. — This  must  be  influenced  byt! 
position  of  the  disease,  and  by  its  nature.  IVhtj 
there  is  simple  pressure  on  the  optic  nerve,  suft 
cient  to  abolish  sight,  the  prognosis  is  very  ui 
favourable.  Damage  by  the  extension  of  i: 
flammation  often  lessens  considerably.  In  diseas 
of  the  optic  commissure  or  optic  tracts  theproe 
nosis  is  also  grave,  because  the  morbid  processc 
from  which  these  parts  suffer,  rarely  recede.  G 
the  other  hand,  in  disease  of  the  hemispher! 
considerable  improvement  often  takes  place,  juj 
as  it  does  in  other  symptoms.  Often,  howevel 
the  symptom  is  thought  to  have  disappears 
when  it  still  persists  in  a diminished  degree. 

Treatment. — The  treatment  is  essential 
that  of  the  disease  to  which  the  symptom 
due,  and  need  not  be  further  discussed  in  th 
place.  W.  R.  Gowebs. 

OPTIC  THALA.MUS,  Lesions  of.  $ 

Thalamus  Opticus,  Lesions  of. 

OHBIT,  Diseases  of. — Synon.  : Fr.  Mat 
dies  de  TOrbite-,  Ger.  Krankheiten  dcr  Augc\ 
hohlc. — The  diseases  of  the  orbit  are  notnumerot 
and  are  almost  exclusively  surgical  in  their  ch 
racter.  The  bony  walls  of  the  cavity  are  liab 
to  be  fractured  by  direct  injury,  which  genera: 
implicates  other  portions  of  the  skull ; the  co 
tained  tissues  are  liable  to  phlegmonous  or  suj 
purative  inflammation ; and  the  cavity  may  he  t 
seat  of  tumours  of  various  kinds,  arising  eith 
from  the  walls  or  from  some  portion  of  the  co 
tents. 

1.  Haemorrhage.  — Haemorrhages  into  t 


ORBIT,  DISEASES  OF. 
orbit,  excepting  as  results  of  injury  or  from  the 
rupture  of  aneurismal  tumours,  are  extremely 
rare ; and  the  few  cases  which  have  been  recorded 
have  nearly  all  occurred  in  persons  of  generally 
htemorrhagie  tendency,  as  one  local  manifestation 
among  others  of  a constitutional  malady. 

2.  Emphysema. — Emphysema  of  the  orbit 
[is  not  unknown,  and  the  writer  has  seen  a young 
man  who,  in  blowing  his  nose  violently,  must 
have  ruptured,  some  of  the  ethmoidal  cells,  for 
he  distended  his  left  orbit  with  air,  and,  in  his 
dwq  words,  blew  his  eye  nearly  out  of  his  head. 
The  distension  soon  subsided,  and  no  permanent 
injury  was  done. 

3.  Inflammation. — Inflammation  of  the  tis- 
sues within  the  orbit  is  not  a common  affection,  but 
t is  liable  to  occur  as  a complication  of  fevers 
md  other  debilitating  diseases,  and  especially  as 
i ccmnlication  of  erysipelas  of  the  head  and 
•ace.  It  is  marked  by  brawn y swelling  of  the 
syolids,  with  some  protrusion  of  the  eyeball  and 
i ome  limitation  of  its  movements,  the  symptoms 
.ppearing  too  suddenly  and  increasing  too  quickly 
o be  attributable  to  the  growth  of  a tumour, 
the  injection  of  the  conjunctiva  is  generally  less 
narked  than  that  of  the  lids,  and  sight  is  scarcely 
r not  at  all  impaired  as  long  as  the  swelling  is 
Jnly  moderate  in  amount.  When  the  injected 
onjunctiva  of  the  eyeball  becomes  cedematous, 
ndmore  especially  when  the  oedema  is  limited 
o one  sector  of  the  globe,  or  is  much  more  pro- 
ounced  over  one  sector  than  elsewhere,  it  is, 
a the  opinion  of  the  writer,  an  almost  patho- 
inomonic  sign  of  suppuration  ; and  the  localisa- 
ion  of  the  oedema  will  serve  as  a guide  to  the 
osition  in  which  pus  may  be  looked  for.  Other 
ymptoms  of  suppuration,  such  as  rigors,  must 
f course  be  taken  into  account. 

Treatment.— As  soon  as  pus  is  believed  to 
xist,  it  should  be  evacuated,  since  its  retention 
mong  the  orbital  tissues  may  be  productive  of 
prions  injury,  not  only  to  the  eye,  but  also  to 
he  ocular  muscles  and  to  the  nerves  which 
■averse  the  orbital  cavity.  The  evacuation  is 
sually  best  effected  by  introducing  a narrow 
Iraight  knife  through  the  skin,  near  the  margin 
: the  orbit  in  the  selected  position,  and  by 
irusting  it  carefully  onward  as  far  as  may  be 
hudent,  giving  the  blade  an  occasional  turn 
ion  its  axis,  to  allow  of  the  escape  of  pus  as 
on  as  it  is  reached.  The  direction  of  the  point 
ould  be  governed  by  complete  knowledge  of 
e anatomy  cf  the  parts;  and  it  is  better  to 
thdraw  the  blade  too  soon  than  to  incur  any 
hk  of  wounding  important  structures.  When 
is  withdrawn,  if  no  pus  follow,  the  puncture 
hy  be  carefully  deepened  or  extended  laterally 
a probe ; but  it  is  not  necessary  to  be  very 
■enuous  in  such  endeavours,  because  if  the 
i>und  through  the  skin  and  fascia  be  kept  from 
‘aling  by  the  introduction  of  a' strip  of  lint,  or 
a bit  of  drainage-tube,  the  pus  will  soon  find 
way  into  the  channel  of  escape  thus  provided 
■'  it.  The  cavity  of  the  abscess  should  be 
ringed  out  from  time  to  time,  according  to  the 
ount  of  discharge,  with  some  suitable  astrin- 
it  or  antiseptic  lotion ; and  care  must  be 
:en  that  a free  opening  is  maintained  as  long 
pus  continues  to  be  secreted, 
f Caries.— In  strumous  children,  caries  of 


ORGANS,  DISPLACEMENT  OF.  1071 
some  part  of  the  margin  of  the  orbit  is  not  un- 
common ; and,  after  the  diseased  bone  has  come 
away,  we  frequently  see  much  deformity  of  the 
lids  produced  by  adhesions  between  the  skin 
and  the  deeper  tissues,  or  by  the  contraction  of 
cicatrices.  Many  of  such  cases  l-equire  plastic 
operations  ; but  each  one,  before  any  operation 
is  undertaken,  must  be  carefully  studied  in  order 
to  discover  the  most  promising  method  of  pro- 
cedure. In  a lad  with  inherited  syphilis,  the 
writer  has  seen  very  extensive  necrosis  of  the 
orbital  margin,  subsequent  to  the  partial  re- 
moval, and  partial  absorption,  of  a large  gum- 
matous tumour  in  the  cavity. 

5.  Tumours. — Tumours  of  the  orbit  may  be 
cysts  (hydatid,  dermoid,  or  sebaceous) ; lipo- 
mata  ; gummata ; sarcomata,  originating  in  con- 
nective tissue,  and  presenting  the  characters  of 
myxoma,  or  of  the  sarcomatous  growths  distin- 
guished respectively  by  round  and  by  spindle- 
shaped  cells ; or  they  may  be  gliomata,  springing 
from  the  connective  tissue  of  the  optic  nerve.  In 
other  instances  they  may  commence  as  an  appa- 
rent hypertrophy  of  the  lachrymal  gland;  or 
they  may  be  cartilaginous,  or  osseous.  All  alike 
produce  protrusion  of  the  eyeball,  and  limitation 
of  its  movements,  together  with  an  amount  of 
disturbance  of  vision,  which  depends  upon  the 
degree  of  pressure  or  of  stretching  to  which 
the  optic  nerve  is  subjected,  or  upon  the  degree 
in  which  the  intra-ocular  circulation  is  im- 
peded. Many  of  the  forms  are  liable  to  recur- 
rence, and  may  thus  ultimately  destroy  life. 

Treatment. — All  tumours  of  the  orbit  alike 
require  removal,  if  possible,  without  sacrifice  of 
the  eyeball. 

R.  Brudenell  Carter. 

ORCHITIS  (opxis>  a testicle). — Inflamma- 
tion of  the  testis.  See  Testes,  Diseases  of. 

OREZZA,  in.  Corsica. — Iron  waters.  See 
Mineral  Waters. 

ORGANIC  DISEASE.— This  expression 
indicates  the  nature  of  a disease  in  which  there 
is  a structural  change  in  the  part  affected,  as 
distinguished  from  a merely  functional  disorder, 
in  which  there  is  no  evidence  of  such  change 
See  Disease. 

ORGANS,  Displacement  of.— The  special 
malpositions  of  the  chief  individual  organs 
are  considered  in  the  articles  which  are  respec- 
tively devoted  to  these  organs,  and  it  is  only 
intended  here  to  discuss  the  subject  from  a 
general  point  of  view.  A distinction  is  some- 
times made  between  malposition  and  displacement, 
the  former  including  all  changes  of  position, 
from  whatever  cause ; the  latter  implying  that 
the  organ  has  by  some  force  been  removed  from 
its  normal  situation  after  it  has  occupied  it;  and 
the  term  dislocation  has  also  been  used  in  the 
same  sense.  For  all  practical  purposes  they  may 
be  considered  together, 

./Etiology  and  Pathology. — The  circum- 
stances under  which  an  organ  comes  to  oc- 
cupy an  abnormal  position  may  be  thus  sum- 
marised : — 1.  The  condition  may  be  congenital,  the 
organ  never  having  been  in  its  proper  place.  In 
this  way  all  or  part  of  the  organs  occupying  the 
chest  and  abdomen  may  be  transposed  to  the 


1072  OKGANS.  DISPLACEMENT  OF. 


wrong  side  of  the  body  (see  Malformations).  In 
this  connection  may  also  be  mentioned  the  fact 
that  an  organ,  which  some  time  or  other  after 
birth  changes  its  place  in  the  ordinary  course 
of  development,  may  fail  to  do  so,  and  thus 
remain  in  a wrong  situation.  This  may  be 
illustrated  by  the  testis,  which  occasionally  is 
retained  in  the  cavity  of  the  abdomen  or  the 
inguinal  canal,  instead  of  descending  into  the 
scrotum.  2.  A violent  strain  or  effort  is  liable  to 
cause  displacement  of  an  organ,  especially  if 
repeated  several  times.  This  has  been  made  to 
account  for  some  cases  of  movable  kidney ; and 
hernia  may  certainly  arise  in  this  way.  3.  Mal- 
position may  depend  upon  imperfection  in  the 
attachments  of  an  organ.  This  may  be  conge- 
nital, the  attachments  being  unusually  long  or 
loose  ; or  they  may  become  repeatedly  stretched 
from  different  causes,  and  thus  rendered  in- 
efficient. The  kidney  will  again  afford  an 
illustration  of  this  cause  of  displacement,  and 
also  the  intestines,  certain  portions  of  which 
may  come  to  occupy  an  abnormal  position  owing 
to  the  unusual  length  of  their  peritoneal  attach- 
ment. 4.  Another  cause  of  displacement  of 
organs  is  to  be  referred  to  abnormal  condi- 
tions connected  with  orifices  or  canals,  which 
either  remain  patent  or  too  large,  when  the}’ 
ought  to  have  closed  or  contracted;  or  which 
have  been  artificially  formed,  as  the  result  of 
injury  or  other  causes.  Thus,  a large  inguinal 
canal  and  orifice,  or  non-closure  of  the  peritoneal 
prolongation,  may  account  for  inguinal  hernia ; 
or  a new  opening  may  be  produced  in  some  part 
of  the  muscular  or  tendinous  structures  of  the 
abdominal  wall,  leading  to  some  form  of  ventral 
hernia  ; or  an  opening  may  remain,  or  be  formed 
after  birth,  in  the  diaphragm,  and  hence  an 
organ  be  displaced  from  the  abdomen  into  the 
thorax,  or  vice  versa.  5.  Pressure  is  an  impor- 
tant cause  of  displacement  of  organs.  This  may 
come  from  without,  as  from  wearing  tight  stays 
or  a belt ; but  is  of  most  importance  in  connec- 
tion with  morbid  conditions  within  the  body. 
Accumulations  of  liquid,  gas,  or  solid,  whether 
the  last-mentioned  be  due  to  enlarged  organs 
or  separate  tumours,  are  frequent  causes  of 
malposition  of  organs,  either  temporary  or 
permanent.  This  is  well  illustrated  by  the 
effects  of  pneumothorax,  pleuritic  effusion,  or 
an  intra-thoracic  growth  upon  the  lungs  and 
heart,  or  even  upon  certain  abdominal  organs ; and 
the  same  thing  occurs  from  similar  conditions 
within  the  abdominal  cavity.  6.  Traction  is 
another  force  which  causes  displacement  of 
organs.  The  action  of  the  lung  free  to  ex- 
pand in  cases  of  unilateral  pleuritic  effusion  has 
been  supposed  to  aid  in  the  lateral  displacement 
of  the  heart,  by  exercising  a kind  of  elastic 
traction  upon  it ; but  this  cause  is  best  ex- 
emplified by  the  effects  of  the  contraction 
of  diseased  organs  upon  neighbouring  organs, 
to  which  they  have  become  adherent.  For 
instance,  the  heart  is  frequently  altered  in 
its  position  as  the  result  of  a contracted  cavity 
at  the  apex  of  the  lung,  in  cases  of  phthisis. 
The  contraction  of  adhesions  themselves  may 
assist  inforiginating  more  or  less  malposition, 
and  they  frequently  cause  the  altered  situation 
of  an  organ  to  be  permanent,  by  fixing  it  in 


its  new  position.  7.  Disease  in  an  organ  itself 
may  originate  its  own  displacement.  It  com- 
monly happens  that  such  disease  enlarges  or 
contracts  an  organ,  and  thus  causes  it  to  pass 
beyond  or  to  bo  drawn  within  its  normal  limits ; 
but  further,  an  organ  may  become  so  heavy  as 
the  result  of  disease,  that  by  its  own  weight  it 
displaces  itself.  8.  In  the  case  of  certain  mus- 
cular hollow  organs,  such  as  the  intestines,  ex- 
cessive or  irregular  action  of  the  muscular  coat 
may  lead  to  malposition.  In  this  way  hernia 
may  be  originated,  or  internal  strangulation  of 
the  intestine,  or  intussusception  of  one  part  of  the 
bowel  into  another.  In  this  connection  the  in- 
fluence of  straining  at  stool  in  causing  protrusion 
of  the  lower  part  of  the  rectum  may  be  alluded 
to.  9.  The  displacements  of  the  uterus  con- 
stitute a special  group,  the  causes  of  which  are 
much  discussed.  Probably  prolonged  standing 
is  one  element  in  the  causation  of  some  of  these 
displacements  in  certain  cases 

varieties. — The  principal  varieties  of  mal- 
position of  organs  have  been  casually  indicated 
in  the  preceding  remarks,  but  it  may  be  useful 
to  arrange  them  more  systematically.  1.  An 
organ  may  lie  in  a wrong  cavity  altogether;  for 
example,  the  stomach  or  liver  may  lie  in  the j 
chest,  or  partly  in  both  chest  and  abdomen. 

2.  There  may  be  a transposition  of  one  or  morel 
of  the  viscera  to  the  wrong  side  of  the  body. 

3.  An  organ  remains  in  its  proper  cavity,  but 
is  more  or  less  removed  from  its  normal 
position.  This  may  merely  be  a temporary 
change,  the  organ  returning  to  its  place  whem 
the  cause  of  the  displacement  is  got  rid  of 
or  it  is  a permanent  condition,  ’ the  orgar 
being  fixed  in  its  new  site.  4.  Instead  of  beinc 
fixed,  an  organ  may  be  more  or  less  freely  mov 
able,  so  that  its  situation  alters  with  change  o 
posture,  manipulation,  or  other  causes  of  move- 
ment. 5.  A portion  of  an  organ  may  pass  out  o.j 
its  cavity,  so  as  to  lie  under  the  skin  or  amongst 
the  muscles,  as  in  external  hernia ; or  it  ma; 
even  come  altogether  out  of  the  body,  as  hap 
pens  when  organs  are  protruded  in  consequenci 
of  injury,  with  an  external  wound.  The  dis- 
placements named  procidentia  and  prolapse 
may  also  be  mentioned  here.  6.  In  the  cas- 
of  the  intestine,  one  part  may  alter  in  its  rela 
tions  to  other  parts,  as  happens  in  the  case  o 
invagination.  Coils  of  the  bowel  also  occasion 
ally  find  their  way  into  curious  positions,  owin' 
to  the  presence  of  bands  of  adhesion,  opening 
in  the  mesentery,  and  other  abnormal  condition 
which  predispose  to  their  displacement.  7.  Tk 
uterus  presents  special  malpositions,  both  a 
a whole,  and  in  relation  to  its  different  parti 
which  need  not  be  discussed  here.  See  Mom 
Diseases  of. 

Effects  and  Stmptoms. — There  may  be  n 
manifest  results  whatever  of  the  displacemei 
of  an  organ,  or  at  least  such  as  can  be  regarde 
of  much  or  any  consequence.  On  the  othe 
hand,  this  condition  may,  if  brought  abot 
suddenly  or  acutely,  be  attended  with  immediat 
symptoms  of  a grave  nature.  For  instance,  in  tb 
case  of  the  intestine,  the  passage  of  its  content 
is  often  prevented,  and  other  serious  results  ensu 
familiar  enough  in  cases  of  hernia ; while  rapi 
displacement  of  the  heart  may  lead  to  grat 


ORGANS,  DISPLACEMENT  OF. 

embarrassment  of  its  action,  and  prevent  the 
passage  of  blood  into  the  arteries,  by  altering 
;he  relation  of  their  orifices  to  the  cardiac 
:avities.  In  chronic  cases  also  displacement 
of  an  organ  frequently  gives  rise  to  phenomena 
If  greater  or  less  importance.  Thus,  its  own 
.'unctions  are  not  uncommonly  disturbed,  and 
nay  be  seriously  interfered  with,  as  happened 
n a case  observed  by  the  writer,  where  the 
tomach  passed  through  the  diaphragm  into 
lie  thorax.  The  displaced  organ  may  also 
reduce  physical  effects,  such  as  irritation  or 
■ressure,  and  thus  give  rise  to  pain  or  other 
objective  sensations,  or  to  symptoms  obviously 
jnnected  with  other  structures  and  organs, 
jhysical  examination  often  reveals  malposition 
: an  orgaD,  and  this  is  one  of  the  conditions 
Inch  should  always  be  borne  in  mind  when 
;amining  either  of  the  more  important  viscera. 
I some  instances  it  assumes  the  characters  of 
tumour,  as  in  the  case  of  movable  kidney; 
id  this  may  prey  so  much  upon  the  mind  of 
,e  patient  as  to  lead  to  considerable  general 
sorder,  although  the  condition  may  really  not 
of  much  moment.  It  must  be  remembered 
it  an  organ  may  be  diseased  at  the  same  time 
iff  it  is  displaced,  and  then  the  symptoms  are 
1 ely  to  be  more  marked. 

Treatment. — When  an  organ  is  suddenly  or 
ntely  displaced,  and  the  displacement  is  at- 
tided  with  serious  symptoms,  the  first  aim  in 
t’atment  should  be  to  get  it  restored  to  its 
vimal  position  as  soon  as  possible.  This  maybe 
i stralod  by  the  treatment  of  hernia  and  other 
fins  of  intestinal  displacement,  or  of  protruded 
o ans,  as  the  result  of  injury ; and  by  the  re- 
ntal of  pleuritic  effusion,  by  means  of  aspiration, 
wn  it  gravely  impedes  the  cardiac  action  in 
^sequence  of  displacing  the  heart.  In  chronic 
Ciis  the  same  principle  should  be  kept  in  view 
lithe  first  instance.  For  this  purpose  any 
c;,es  of  displacement  should  be  removed,  and 
it  ay  be  necessary  to  employ  mechanical  means, 
oiven  to  adopt  operative  procedures,  to  pre- 
v<  a recurrence  of  the  malposition.  This  may 
a!  be  exemplified  by  the  treatment  of  hernia, 
at  of  displacement  of  tho  uterus.  In  many 
eas,  however,  the  restoration  of  an  organ  to  its 
Doiial  position  is  impracticable.  Under  these 
cii.mstances  no  particular  treatment  may  be 
reiired;  or  perhaps  any  ill- effects  resulting 
frc.  the  malposition  may  be  obviated  by  the  ap- 
tlition  of  a bandage  or  other  means  of  support, 
as  the  ease  of  movable  kidney.  Medicinal 
agvs  maybe  of  service  in  combating  symptoms, 
ant  n improving  the  general  condition,  if  re- 
qu;a.  When  a malposition  is  of  no  conse- 
quiie,  the  patient's  mind  should  bo  made  quite 
eas  on  the  point,  especially  if  any  notion  is 
entrained  of  the  existence  of  a tumour. 

Frederick.  T.  .Roberts. 

GTHOPNG3A  (op0bs,  erect,  and  ttveu,  I 
brehe).. — A form  of  difficult  breathing,  in  which 
thehtient  is  unable  to  lie  down,  and  is  com- 
Pjd  to  assume  tho  sitting  or  erect  posture. 
^ .inspiration,  Disorders  of. 

C THOTONOS  (opQbs,  straight,  and  tuvos, 
1 st  ching). — A form  of  tetanic  spasm,  in  which 
the  dy  is  rigidly  extended.  See  Tetanus. 

68 


OVARIES,  DISEASES  OF.  1075 

OSMIDROSIS  odour,  and  iSpSs, 

'sweat). — A condition  of  the  perspiration  in 
which  it  yields  an  unusually  strong  or  fetid 
smell.  See  Perspiration,  Disorders  of. 

OSSEOUS  DEGENERATION.— A kind 
of  degeneration,  in  which  the  affected  textures  as- 
sume the  characters  of  bone.  See  Degeneration. 

OSSEOUS  SYSTEM,  Diseases  of.  See 
Bone,  Diseases  of. 

OSTEITIS  (bareoy,  a bone). — A synonym 
for  inflammation  of  bone,  which  may  be  of  various 
kinds.  See  Bone,  Diseases  of. 

OSTEOCOPIC  PAINS  (oareov,  a bone,  and 
k<5ttos,  fatigue). — Aching  pains  in  bones.  See 
Syphilis. 

OSTEOID  CANCER. — This  term  has  been 
vaguely  employed,  as  implying  a cancer  includ- 
ing bony  structure,  or  with  reference  to  malig- 
nant disease  involving  a bone.  See  Bone,  Dis- 
eases of;  Cancer;  and  Tumours. 

OSTEO-MALACIA  (oareoy,  a bone,  and 
fia.Aa.Kbs,  soft). — A synonym  for  mollifies  ossium. 
See  Mollities  Ossium. 

OSTEO-MYELITIS  (bcrriov,  a bone,  and 
peveAbs,  the  marrow). — A name  for  inflamma- 
tion of  the  medulla  of  bone.  See  Bone,  Dis- 
eases of. 

OSTEO- SARCOMA  ( bariov , a bone,  and 
cropf,  flesh). — A sarcomatous  growth  in  connec- 
tion with  bone.  See  Bone,  Diseases  of ; and 
Tumours. 

OTALGIA  (o3 s,  Sires,  the  ear,  and  &Ay os, 
pain). — Pain  in  the  ear ; ear-ache.  See  Eab, 
Diseases  of. 

OTITIS  (oSs,  the  ear). — Inflammation  of  the 
ear.  See  Ear,  Diseases  of. 

OTORRHCEA  (oOs,  the  ear,  and  f>eu,  I flow). 
Discharge  from  the  ear,  usually  purulent.  See 
Ear,  Diseases  of. 

OVARIES,  Diseases  of. — Synon.  : Fr. 

Maladies  des  Ovaircs;  Ger.  Krankheiten  der 
Eicrstocke  : Krankheiten  der  Ovarian. 

In  the  article  Abdomen,  Diseases  of,  a section  is 
arranged  in  one  of  the  groups  for  diseases  of  the 
female  generative  organs,  including  the  uterus 
and  its  broad  ligament,  the  Fallopian  tubes,  and 
the  ovaries.  Under  the  heads  Menstruation, 
Disorders  of,  and  Hysteria,  much  information 
may  be  found  upon  subjects  which  might  be 
included  among  the  diseases  of  the  ovaries.  But 
there  remains  something  regarding  the  patho- 
logy, diagnosis,  and  treatment  of  ovarian  diseases 
interesting  to  the  physician,  without  entering 
upon  the  more  surgical  question  of  such  cysts 
and  tumours  of  the  ovaries  as  call  for  tapping 
or  ovariotomy. 

In  proceeding  to  estimate  the  frequency  and 
importance  of  the  diseases  of  the  ovaries,  we  have 
to  consider  the  wonderful  series  of  periodical 
processes  which  go  on  in  women  every  month  for 
some  thirty-five  years;  sometimes  without  any 
interruption  by  pregnancy,  sometimes  inter- 
rupted by  many  pregnancies;  some  carried  on 
to  the  full  period,  some  interrupted  at  different 
stages,  followed  by  lactation  for  periods  variously 


OVARIES,  DISEASES  OF. 


1074 

prolonged,  and  perhaps  suddenly  stopped  by  the 
death  of  the  child  or  by  another  pregnancy, 
attended  by  losses  of  blood  of  less  or  greater 
quantity,  and  ceasing  usually  from  forty-five 
to  fifty-five  years  of  age,  after  more  or  less  ir- 
regularity. We  have  to  remember  that  at  each 
menstrual  period  one  or  other  ovary  becomes 
swollen  ; that  one  or  more  of  its  ovisacs  en- 
larges, opens,  and  admits  of  the  escape  of  the 
ovum  it  contained  ; that  the  fimbrial  end  of  the 
Fallopian  tube  grasps  the  ovary,  receives  the 
ovum,  and  allows  of  its  passage  into  the  uterine 
cavity;  that  the  uterus  itself  receives  an  in- 
creased supply  of  blood ; and  that  its  mucous 
membrane  undergoes  a series  of  exfoliative 
changes.  We  must  consider,  farther,  how  these 
periodical  processes  are  associated  with  much 
that  is  of  supreme  importance  in  the  state  of 
the  nervous  centres,  and  in  the  mental  con- 
dition of  woman  ; that  the  normal  process,  in- 
stead of  recurring  at  regular  intervals,  and 
ceasing  in  a few  days,  may  be  abnormally  pro- 
longed, and  may  recur  at  most  uncertain  pe- 
riods; and  that  evolution  and  involution  may 
be  both  affected  by  pregnancy  and  lactation. 
When  we  bear  in  mind  all  these  highly  complex 
conditions,  processes,  and  relations,  the  wonder 
is,  not  that  ovarian  diseases  should  be  frequent, 
but  that  so  many  women  pass  through  life  with- 
out suffering  from  them.  If  an  ovary  become 
swollen  and  tender,  its  blood-vessels  overdis- 
tended, and  extravasation  (or  apoplexy  of  the 
proper  ovarian  tissue)  take  place ; or  if  blood 
escaping  into  the  peritoneal  cavity,  becomes  en- 
capsuled,  or  forms  a hasmatocele  of  the  loose 
cellular  tissue  between  the  layers  of  one  or  both 
of  the  broad  ligaments,  we  can  only  wonder 
that  such  an  accident  does  not  happen  more 
frequently,  and  be  prepared  to  recognise  the 
effects  of  repeated  slight  extravasations.  These 
are  uneasiness  in  the  abdomen,  increasing  to 
pain,  more  or  less  severe,  want  of  sleejo,  and 
raised  temperature,  preceding  discharge  of  blood 
from  the  uterus ; then  swelling  and  tenderness 
in  one  or  both  groins,  bearing  down,  like  la- 
bour-pains, recurring  at  intervals,  with  dis- 
charge of  fluid  or  clotted  blood  or  of  mem- 
branous shreds  ; extension  of  pain  to  the  loins, 
and  irregular  flow  of  urine — all  symptoms  so 
often  observed  as  to  be  almost  neglected.  And 
if  a vaginal  examination  is  made,  especially 
when  combined  with  examination  by  the  rec- 
tum, not  only  may  one  or  Loth  ovaries  be  felt 
larger  and  lower  down  than  they  ought  to  be, 
behind  and  on  either  side  of  the  uterus  ; but  they 
may  be  extremely  tender  on  pressure,  and  there 
may  be  more  or  less  evidence  of  peri-uterine  ex- 
travasation. After  repeated  attacks  of  this  na- 
ture, permanent  hardening  and  enlargement  of 
ovaries  and  uterus,  and  their  impaired  mobility, 
due  to  organisation  of  blood-clot  or  ot  plastic 
lymph,  are  among  the  most  frequent  pathologi- 
cal changes  which  the  practitioner  is  called  upon 
to  treat. 

The  diseases  of  the  ovaries,  which  will  he  spe- 
cially described  in  this  article,  are  as  follows : — • 

1.  Abormalities;  2.  Displacements;  3.  Disturb- 
ances of  Circulation  ; 4.  Acute  Inflammation  ; 
5.  Chronic  Inflammation  ; and  6.  Tumours,  in- 
cluding Cysts. 


1.  Abormalities. — Absence  of  the  ovanw 
or  their  imperfect  development,  may  occasional! 
be  inferred;  and  the  presence  of  a third  c 
accessory  ovary,  now  and  then  observed  in  th 
dissecting-room  and  on  the  operating  table,  ma 
probably  account  for  the  recurrence  of  regnla 
menstruation  in  spite  of  serious  disease  c 
both  ovaries,  or  after  the  removal  of  both  b 
ovariotomy. 

2.  Displacements. — Congenital  or  acquire 
displacements  are  also  observed,  as  hernia  int 
the  inguinal  canal,  or  prolapse  to  the  bottom  < 
Douglas's  pouch. 

3.  Disturbances  of  Circulation. — Hype: 
semia,  when  not  excessive,  may  be  considered ; 
an  essential  part  of  normal  menstruation, 
very  little  excess  may  lead  to  the  formation  < 
a large  clot  in  an  unbroken  ovisac,  or  extr 
vasation  into  the  stroma  of  the  ovary,  constit 
ting  apoplexy ; or  between  the  layers  of  tl 
broad  ligament,  or  into  the  peritoneal  cavit 
thus  forming  peri-uterine  or  pelvic  hsematoce) 
In  some  cases,  apoplexy  of  the  ovisacs  is  clear 
traceable  to  torsion  of  the  ovary  upon  its  n 
trient  blood-vessels. 

4.  Acute  Inflammation. — Acute  oophori! 
and  peri-oophoritis  are  probably  of  much  mo 
frequent  occurrence  than  acute  orchitis  in  t 
male.  The  testicles  are  far  more  liable  to  m 
chanieal  injuries,  but  are  probably  not  me 
liable  to  extension  of  the  poison  of  gonorrha 
or  its  sympathetic  effects,  and  they  are  free  fit 
theperiodical  hyperaemia  which  may  be  regard 
as  the  first  step  in  the  process  of  ovarian  infla 
mation.  This  periodical  hyperaemia,  influend 
by  accidental  sudden  suppression  of  discharge 
blood  from  the  uterus,  is  the  usual  history  of 
acute  attack  of  oophoritis. 

Symptoms. — The  symptoms  of  acute  infia 
mation  of  an  ovary  are  pain  over  the  pul 
tenderness  on  pressure  in  one  iliac  region, irri 
tion  of  the  bladder,  tenderness  of  the  vagi 
and  pain  on  moving  the  cervix  uteri,  and  on  pa 
ing  the  finger  behind  and  on  one  side  of  » 
cervix  towards  the  sacro-iliac  synchondrosis.  - 
patients  with  lax  tissues,  by  combined  red 
and  vaginal  examination,  the  swollen  ovary  n' 
very  often  be  felt.  If  one  ovary  can  be  s 
and  moved,  the  patient  at  once  complains! 
greatly  aggravated  pai n . 

Treatment. — The  treatment  should  consis  t 
absolute  rest  on  the  back,  with  the  hips  rail 
and  thighs  flexed  ; or  on  the  side  not  affect, 
if  dry-cupping  glasses  can  be  applied  over  e 
sacrum.  Mustard  poultices,  or  turpentine  .1 
chloroform  liniment,  may  also  be  applied  cr 
the  sacrum  and  on  the  iliac  region.  Thebovs 
should  be  well  cleared  out,  and  small  doses! 
blue  pill  and  Dover's  powder  given  frequetf, 
with  a sufficient  quantity  of  bromide  of  potassii- 
Leeching  the  cervix  uteri  has  been  reeommeaa ; 
but  the  local  disturbance  caused  by  it  usuj 
does  more  harm  than  the  loss  of  blood  can  nte 
up  for.  Sometimes  the  pain  is  so  very  set® 
that  it  may  be  necessary  to  give  chloroform 
same  other  anaesthetic,  and  repeat  it  more  t" 
once  before  the  pain  subsides. 

5.  Chronic  Inflammation. — Chronic  oo a* 
ritis,  distinguished  by  those  paroxysmal  attfes 
of  paiu  recurring  at  the  menstrual  periods.  (“* 


OVARIES,  DISEASES  OF.  1075 


iionly  known  as  ovarian  dysmenorrhoea,  is  a 
ouch  more  common  condition  than  the  acute 
enn  of  the  disease.  And  there  can  be  little 
loubt  that  both  amenorrhaea  and  menorrhagia 
pay  be  often  due  to  changes  in  the  ovaries, 
vhich  are  the  result  of  repeated  attacks  of  sub- 
cute  inflammation.  Some  turgescence  of  the 
mtcous  membrane  of  the  uterus  and  Fallopian 
Lbes  is  a condition  attendant  upon  ovulation ; 
ml  is  physiological  or  pathological  in  close  re- 
ttion  with  the  normal  or  abnormal  process  in 
[lie  ovary.  So  far  as  anatomical  examination 
Baches  us,  it  is  rare  to  find  much  change  in  the 
varies  alone,  without  proof  of  what  is  called 
eri-oophoritis ; adhesions  between  the  surface 
'(  the  ovary  and  the  fimbriae  of  the  Fallopian 
ibe  or  the  tube  itself ; adhesions  due  to  pelvic 
britonitis  ; hardening  and  enlargement  of  the 
,-ary  itself ; hard  clots  in  some  of  the  ovisacs ; 

\ on  the  other  hand,  a shrivelling,  or  contrac- 
pn,  or  atrophy  of  the  gland. 

Trkatmext. — Whether  the  chronic  form  of 
[e  disease  has  succeeded  an  acute  attack — non- 
lerperal  or  puerperal — or  one  or  more  attacks 
gonorrhoea,  or  repeated  abortions,  or  has 
erely  increased  in  intensity  or  duration  after 
peated  recurrence,  the  treatment  must  still 
the  same : namely,  avoidance  of  known  causes, 
iit,  attention  to  the  general  health,  counter- 
itation,  and  the  use  of  sedatives,  especially 
ilium  and  the  bromides.  In  cases  of  distinct 
{ling  downwards  of  one  or  both  ovaries,  an 
• Stic  ring  pessary,  worn  in  the  vagina  for  a 
ly  weeks,  is  sometimes  of  signal  service.  Hard 
psaries  are  not  well  borne.  When  all  other 
ikns  fail,  the  operation  of  extirpating  both 
tries — Battey’s  operation — must  be  seriously 
tsidered  in  consultation.  We  require  more 
fits,  accurately  observed  and  faithfully  re- 
eded, especially  as  to  the  mortality,  and  to 
t results  obtained  by  the  operation  when  it 
(2s  not  prove  fatal,  and  the  state  of  the 
pent’s  health  of  body  and  mind  for  some 
yjirs  afterwards,  before  the  true  value  of  the 
o ration  can  be  estimated.  But  enough  evi- 
dfce  has  been  already  collected  to  prove  that, 
ajr  ordinary  measures  have  failed,  and  morbid 
pjsieal  and  mental  conditions  are  clearly  de- 
pflent  on  abnormal  menstruation,  and  possibly 
u;  1 morbid  conditions  of  the  ovaries,  the  physi- 
ci  wouldbefullyjustified inadvisingthe patient 
oiler  friends  to  call  for  the  aid  of  surgery. 

Tumours. — Of  all  the  diseases  of  the 
ov  ies,  far  more  common  than  any  malforma- 
tio  or  displacement,  even  more  commonly  the 
cap  of  such  suffering  as  to  lead  a patient  to 
sei.  for  medical  advice  than  either  the  acute 
or  ironic  forms  of  ovarian  inflammation,  or 
th;;  the  ovaralgia  or  nervous  hysterical  form 
oh-arian  irritation  associated  with  dysmenor- 
rhr,  and  with  various  forms  of  eccentricity,  and 
popbly  of  hypochondriasis,  melancholia,  or  ma- 
nia! excitement — common  though  these  con- 
<>it  is  may  be — cysts  of  one  or  both  ovaries  are 
tkeaost  frequent  of  all  the  diseases  of  these 
orgis.  So  far  as  regards  their  pathological 
ana  my,  for  all  practical  purposes  of  diagnosis 
*sc  reatment,  they  may  he  divided  into  simple 
nr  ; ilecidar,  and  compound  or  multilocular — 
the  rmer  a dilated  dropsical  ovisac,  the  latter 


a proliferating  cystoma  or  a dermoid  cyst.  A still 
more  practical,  if  less  scientific,  division  might 
he  made  into  (1)  Cysts , and  (2)  Tumours  of  the 
ovaries,  including  in  the  former  division  such  sim- 
ple or  multiple  cysts  as  from  the  preponderance 
of  fluid  and  small  amount  of  cyst-wall,  may  pro- 
perly be  considered  as  ovarian  dropsy — hydrops 
ovarii,  or  hydrops  folliculorvm.  Graafii ; and  in 
the  latter  such  solid  or  semi-solid  tumours  as, 
under  a general  class  of  proliferating  cystomata, 
include  pseudo-colloid  tumours,  myxo-cystoma, 
cystoid  adenoma,  sarcoma,  fibroma,  papilloma, 
carcinoma,  and  (as  a separate  class)  dermoid 
cysts.  The  histogenesis  and  the  microscopic 
character  of  these  varied  forms  of  disease  must 
be  studied  by  the  aid  of  special  treatises  or  mono- 
graphs. Here  their  clinical  history  is  of  chief 
importance. 

Symptoms  and  Diagnosis.  — Clinically  the 
main  points  for  consideration  in  eases  of  fluctu- 
ating abdominal  tumours  are  whether  the  fluid 
is  contained  within  a cyst,  or  whether  it  is  in 
the  peritoneal  cavity,  either  free  or  limited  by 
visceral  adhesions.  In  solid  tumours  the  seat 
and  nature  of  the  tumour  must  be  investigated. 

The  diagnosis  between  fluid  in  an  abdominal 
cyst  and  in  the  peritoneal  cavity  has  been  laid 
down  in  the  article  Ascites.  Ilere  it  is  only 
necessary  to  add  that  the  limit  of  fluctuation  as 
recognised  by  palpation,  and  the  limit  of  d ill- 
ness as  ascertained  on  percussion,  exactly  cor- 
respond when  the  fluid  is  encysted.  The  wave 
of  fluid  cannot  be  made  to  pass  beyond  the  line  of 
dulness  on  percussion.  But,  when  the  fluid  is 
free,  the  resonant  intestines  are  float  ingin  it,  and 
fluctuation  may  bo  detected  where  percussion 
gives  a resonant  or  tympanitic  note.  The  wave 
of  fluid  is  not  stopped  by  any  cyst-wall. 

Chemical  and  Microscopical  Examination. — If 
tapping  have  been  resorted  to,  in  order  to  givo 
temporary  relief  to  urgent  symptoms,  or  to  com- 
plete a doubtful  diagnosis,  chemical  and  micro- 
scopical examination  of  the  fluid  affords  valu- 
able information.  The  albumen  in  the  serum 
secreted  by  the  peritoneum  is  ordinary  albumin, 
which  is  coagulated  by  heat,  and  will  not  redis- 
solve in  double  its  volume  of  strong  boiling  acetic 
acid.  The  albumen  secreted  by  the  epithelial 
layer  of  an  ovarian  cyst  is  that  secreted  rather 
by  mucous  than  by  serous  membranes,  known 
as  metalbumin  and  paralbumin,  which  (like  true 
albumin)  is  coagulated  by  heat,  but  (unlike  true 
albumin)  is  re-dissolved,  or  converted  into  a 
translucent  gelatiuiform  liquid,  after  having  been 
boiled  in  double  its  volume  of  strong  acetic  acid. 
Then  on  examining  the  deposit  which  subsides 
after  ovarian  fluid  has  been  at  rest  for  some  hours, 
there  may  be  found  in  the  field  of  the  micro- 
scope the  nuclei  of  the  epithelial  cells  which 
line  the  interior  of  the  cyst.  The  scales  are 
thrown  off,  the  eell-walls  break  down,  and  the 
nuclei  remain.  These  are  the  so-called  ‘ovarian 
granule-cells  ’ of  Nunn,  Bennett,  and  Drysdale, 
and  are  characteristic  of  innocent  growth.  In 
addition  to  these  there  are  found  in  malignant 
growths  characteristic  groups  of  cells  of  different 
sizes,  described  about  the  same  time  by  Foulis 
and  Thornton  as  large  pear-shaped  round  or  oval 
cells,  containing  a granular  material,  with  one  oi 
several  large  clear  nuclei,  with  nucleoli  and  a 


OVARIES,  DISEASES  OF. 


1076 

number  of  transparent  globules  or  vacuoles.  The 
great  variety  in  size  and  shape  of  the  cells  com- 
posing the  groups  is  the  characteristic  feature. 
When  these  large  groups  are  found  in  fluid  re- 
moved from  a cyst,  it  is  extremely  probable  that 
a malignant  growth  projects  into  the  cavity  of 
the  cyst.  When  the  groups  are  found  in  peritoneal 
fluid,  there  is  either  some  malignant  growth,  or 
an  ovarian  cyst  of  a malignant  character  has 
burst  into  the  peritoneal  cavity.  Some  of  the 
cells  have  planted  themselves  upon  the  surface 
of  the  peritoneum,  where  they  have  grown  and 
multiplied.  Some  observers  believe  that  when 
such  groups  of  cells  are  found  in  fluid  removed 
from  a cyst  or  from  the  peritoneal  cavity,  the 
evidence  of  the  malignant  nature  of  the  disease 
is  so  strong  that  no  other  than  palliative  treat- 
ment is  justifiable.  But  microscopic  knowledge 
lias  certainly  not  yet  reached  such  perfection  as 
to  justify  a surgeon  in  refusing  to  attempt  to 
save  life  by  removing  a tumour,  if  it  can  be  re- 
moved, even  if  it  be  characterised  by  the  forma- 
tion of  such  groups  of  cells  as  have  been  described. 
Several  such  ovarian  tumours  have  been  removed 
after  they  had  burst,  and  after  several  tappings 
of  the  peritoneal  cavity,  with  the  happy  result 
of  recovery  from  the  operation  and  subsequent 
good  health.  After  the  removal  of  a proliferating 
cystoma  recurrence  of  the  disease  has  been  ob- 
served, but  there  is  good  ground  for  believing 
that  recurrence  is  exceptional. 

Semi-solid  tumotirs. — Semi-solid  ovarian  tu- 
mours are  more  common  than  simple  cysts.  In- 
stead of  a smooth  uniform  surface,  irregularities 
may  he  felt,  due  to  cysts,  or  groups  of  cysts,  of 
different  shapes  and  sizes,  or  to  thickening  of  por- 
tions of  the  wall  of  the  main  cyst.  The  wave  of 
fluctuation  is  interrupted  by  septa  in  different 
directions  ; and  hard  nodules,  or  bone-like  pro- 
jections, may  perhaps  he  detected.  Occasionally 
a deep  sulcus  between  two  portions  of  a semi-solid 
tumour,  with  resonant  intestine  in  the  sulcus, 
may  lead  to  doubt  whether  both  ovaries  are  not 
affected. 

Solid  tumours. — Ovarian  tumours  which  are 
entirely  solid,  not  fluctuating  in  any  portion  of 
them,  are  very  rare,  but  still  are  occasionally  met 
with,  both  as  innocent  fibroma  and  as  true  cancer. 

Adhesions. — Any  ovarian  tumour — cystic,  solid, 
or  semi-solid — may  be  free  from  adhesion  to  the 
abdominal  wrall  or  to  the  omentum  or  viacera,  or 
may  be  adherent  anywhere  within  the  abdominal 
or  pelvic  cavities.  But  as  the  result  of  ovariotomy 
is  very  little  affected  by  the  presence  or  absence 
of  adhesions,  a very  minute  diagnosis  of  the  nature 
and  extent  of  adhesions  is  not  of  much  practical 
importance.  Still  if  there  are  firm  adhesions  low 
down  in  the  pelvis,  fixing  the  uterus,  rectum,  and 
bladder  together,  or  fusing  them,  as  it  were,  into 
one  mass  with  tbo  ovarian  growths,  ovariotomy 
should  not  he  performed,  or  only  after  a very 
guarded  prognosis. 

Inflammation,  haemorrhage,  and  gangrene. — 
Any  ovarian  cyst,  simple  or  compound,  may  he 
the  seat  of  inflammation  either  on  its  surface, 
when  the  symptoms  do  not  differ  from  those  of 
peritonitis,  or  in  the  cyst-wall  or  lining  mem- 
brane, when  (without  any  peritonitis)  there 
may  be  pain  and  considerable  fever,  sometimes 
followed  by  rigors  and  suppuration.  Haemor- 


rhage into  one  or  more  of  the  evst-eavities  mat 
lead  to  all  the  symptoms  and  effects  of  internal 
haemorrhage.  Ur  the  whole  or  portions  of  the 
tumour  may  become  gangrenous,  from  a twisting 
of  the  pedicle  obstructing  the  circulation  of  blood 
in  the  vessels  of  the  tumour.  In  some  cases 
twisting  of  the  pedicle  may  be  followed  by  a com- 
plete separation  of  the  tumour  from  its  ordinary 
supply  of  blood.  In  this  condition  the  tumour 
is  nourished  by  vessels  in  the  omentum,  abdo- 
minal wall,  or  some  other  structure  adherent  to 
the  peritoneal  coat  of  the  tumour,  if  the  woman's 
death  is  not  speedily  caused  by  gangrene  of  the 
growth. 

Other  abdominal  tumours.  — The  abdominal 
tumours  most  frequently  mistaken  for  ovarian 
tumours  are  fibroid  or  fibrocystic  tumours  of  the 
uterus,  and  tumours  or  cysts  of  the  spleen,  brer, 
or  kidney.  Pregnancy,  either  normal  or  extra- 
uterine,  m.-\y  also  be  mistaken  for  an  ovarian 
tumour,  or  may  be  present  at  the  same  time.  It 
is  not  rare  to  find  a woman  with  an  ovarian  or  a 
uterine  tumour  to  he  also  pregnant ; so  that  the 
ordinary  signs  of  pregnancy  must  be  borne  in 
mind  in  examining  any  woman  who  has  an  ab- 
dominal tumour.  And  the  frequency  of  fee?, 
accumulations,  or  of  tympanitic  distension  o: 
the  intestines,  with  thick  or  rigid  abdomina 
walls  and  a fat  omentum,  must  also  be  re 
membered  and  excluded,  as  well  as  fatty  o 
fibro-fatty  tumours  which  may  form  in  th<j 
omentum,  or  consist  of  hypertrophied appendice 
epiploicae,  and  fibro-plastic  growths,  from  an; 
part  of  the  peritoneum  or  sub-peritoneal  cel 
lular  tissue.  Peritoneal  hydatids,  or  hydati 
cysts  of  the  liver,  spleen,  or  omentum,  retro 
peritoneal  abscesses,  pelvic  cellulitis  followe 
by  abscess,  distended  bladder,  pelvic  hsematoceL 
enlarged  mesenteric  or  lumbar  glands,  aort; 
aneurism,  and  enchondroma,  are  all  condition 
which  must  be  borne  in  mind  in  eases  where  thl 
ordinary  signs  of  an  ovarian  cyst  or  tumour  ai 
not  sufficiently  characteristic  to  exclude  doubt. 

But  the  most  frequent  source  of  error  is  earn 
of  the  peritoneum,  not  necessarily  involving  tl 
ovaries,  although  these  organs  may  not  be  fn 
from  the  disease.  In  some  cases  the  uteru 
and  both  ovaries,  and  the  peritoneum  everywhe 
become  covered  or  infiltrated  with  cancerous  d 
posits  or  growths,  and  in  nearly  all  cases  the 
is  considerable  accumulation  of  fluid  in  the  pel 
toneal  cavity.  If  the  coats  of  the  small  inte 
tines  are  involved,  the  very  characteristic  sigj 
are  manifest  of  movable  tumours,  which  are  boj 
hard  and  resonant,  and  which  on  being  press 
or  kneaded  gurgle  under  the  fingers.  In  a 
case  of  abdominal  tumour,  with  or  without  pe 
toneal  fluid,  where  the  loss  of  flesh  and  streng 
is  rapid,  although  the  tumour  may  not  be  lar: 
where  there  is  much  pain,  and  the  patient; 
subject  to  vomiting  or  diarrhoea,  the  diagno 
of  intra-abdominal  cancer  generally  proves  t 
true.  _ I 

Prognosis  and  Treatment. — 1.  Medical- 
It  must  be  confessed  that  the  medical  treatan 
of  ovarian  cysts  and  tumours  in  a curative  ser 
is  quite  hopeless.  In  cases  of  supposed  siro: 
cysts,  where  powerful  purgatives  and  diuni' 
have  been  followed  by  disappearance  of  the  fa 
the  true  explanation  has  been  either  a u 


Ov  ABIES.  DISEASES  OF.  107 


ike  in  diagnosis,  or  an  accidental  rupture  of 
thin  cyst.  In  the  compound  cysts,  or  the 
lore  solid  tumours,  iodides,  bromides,  mer- 
urials,  and  every  other  remedy  that  has  been 
Vied,  has  proved  useless  at  the  best,  and  has 
(ten  injured  the  general  health  of  the  pa- 
lentiritliout  affecting  the  morbid  growth.  Be- 
'ond  attending  to  the  general  healthof  the  patient 
hd  palliating  any  urgent  symptom,  the  chief 
m of  the  physician  should  be  to  do  no  harm,  to 
icoutage  a cheerful  state  of  mind  in  his  patient 
jy  the  assurance  that  the  disease  is  curable,  and 
bile  postponing  surgical  treatment  so  long  as 
is  not  clearly  necessary,  not  allowing  a patient 
wait  so  long  that,  after  unnecessary  and  pro- 
nged suffering,  she  falls  into  a condition  un- 
vourable  for  the  result  of  an  operation. 

2.  Surgical. — If,  after  exposure  to  cold,  or  as 
e result  of  a blow  or  fall,  a patient  with  an  ova- 
an  tumour  presents  the  signs  and  symptoms  of 
flammatory  changes  in  the  tumour  or  in  the 
•ritoneum,  rest,  fomentations  or  poultices,  and 
nates  are  indicated.  If  very  severe  symptoms 
lint  to  haemorrhage  or  cyst-rupture,  immediate 
iariotomy  may  afford  the  only  hope  of  saving 
’e. 

In  considering  the  very  important  question 
w long  a patient  should  be  left  to  ordinary 
■gienic  or  medical  treatment  without  any  assist- 
ce  from  surgery,  it  may  be  said : ‘ So  long  as 
e patient  does  not  suffer  much  pain,  is  not 
noyed  by  her  size  and  appearance,  has  no  great 
■ficulty  in  locomotion,  does  not  suffer  from  in- 
yious  pressure  on  the  organs  of  the  chest,  abdo- 
.n,  or  pelvis,  and  so  long  as  the  heart  and  lungs, 
‘testive  organs,  kidneys,  bladder,  and  rectum 
rform  their  functions  tolerably  well,  surgical 
atment  is  seldom  called  for.  It  is  only  a pro- 
ofed marriage,  or  a necessary  voyage,  or  some 
i ll  family  circumstance,  that  may  justify  or 
hder  expedient  earlier  resort  to  surgical  aid. 
der  ordinary  circumstances  the  surgeon  would 
t ; interfere  until  an  ovarian  tumour  either  dis- 
t ssingly  deforms  a patient,  or  seriously  impedes 
i;  locomotion,  or  prevents  the  free  action  of 
1 rt  or  lungs,  or  obstructs  the  circulation  through 
t large  veins  of  the  abdomen,  or,  by  deranging 
t digestive  organs,  leads  to  emaciation  and 
ukness,  or  by  its  pressure  causes  pain,  loss 
crest,  or  mechanical  obstruction  to  bladder  or 
r :um.’  These  are  the  rules  laid  down  by  the 
vter  of  this  article  in  1872.  Subsequent  ex- 
F *ence  of  the  ill  effects  of  delay,  and  of  the 
finished  and  diminishing  mortality  of  ova- 
r omy,  lead  to  the  conclusion  that  these  rules 
Tier  err  on  the  side  of  over-caution  and  too- 
% delay ; and  that  the  welfare  of  most  pa- 
lls is  better  promoted  by  advising  an  earlier 
a otion  of  surgical  treatment,  and  probably  the 
rioval  of  an  ovarian  tumour,  as  soon  as  its 
U:U-e  and  connections  can  be  clearly  aseer- 
t;  ed,  and  it  is  beginning  in  any  way  physically 
orientally  to  do  harm. 

i cases  of  single  cysts  the  question  of  pallia- 
t'.  treatment  by  tapping,  or  the  radical  cure  by 
o'  iotomy,  must  be  seriously  considered.  And 
w, 1 a cyst  is  really  single,  the  removal  of  the 
5 not;  °nly  gives  great  relief  for  a considerable 
PW  but  in  some  cases  fluid  does  not  collect 
al  i for  several  years,  sometimes  never.  Even 


when  a cyst  is  not  absolutely  single,  but  contains 
one  cavity  so  large  that  smaller  cavities  are  prac- 
tically insignificant,  tapping  may  give  sufficient 
relief  to  warrant  its  recommendation  in  cases 
where  patients  desire  to  postpone  any  more 
hazardous  operation.  But  in  all  cases  it  should 
bs  done  with  the  strictest  antiseptic  precautions 
against  the  entrance  into  the  emptied  cyst- 
cavity  of  atmospheric  air,  containing  any  germ 
or  material  which  may  set  up  putrefactive  or 
infective  changes  within  the  body. 

Tapping  by  the  abdominal  wall,  vagina,  or 
rectum,  alone  or  followed  by  pressure,  by  drain- 
age, by  injection  of  iodine,  by  incision,  or  by  the 
formation  of  a permanent  communication  be- 
tween the  cyst-cavity  and  the  peritoneal  cavity, 
in  these  days  can  only  be  regarded  as  substitutes 
in  cases  where  ovariotomy  is  rejected  by  the 
patient,  or  where  the  surgeon  finds  that  the 
ovarian  tumour  cannot  be  removed.  In  a very 
large  majority  of  cases  the  only  hope  of  cure  is 
in  ovariotomy. 

Question  of  Ovariotomy. — "When  it  has  to  he 
considered  in  consultation  whether  a patient 
should  be  advised  to  submit  to  ovariotomy  or  not, 
the  chief  points  for  discussion  are: — 1.  How 
long  is  she  likely  to  live  if  left  alone,  or  re- 
lieved by  palliative  treatment  only — hygienic 
and  medical — or  by  tapping  ? 2.  What  is  the 
risk  of  ovariotomy  at  the  average  rate  of  mor- 
tality, and  how  far  is  the  risk  in  the  one 
patient  who  is  the  subject  of  consultation  likely 
to  be  above  or  below  the  general  average  ? 

In  reply  to  the  first  question,  it  is  believed 
that  after  an  ovarian  tumour  has  attained  such 
a size  as  to  inconvenience  a patient  she  rarely 
lives  four  years — even  if  relieved  by  occasional 
tapping — and  that,  with  due  allowance  for  a few 
exceptional  cases  of  many  years’  duration,  two 
years  would  be  the  full  average  expectation  of 
life.  Two  years  of  invalid  life  is  what  is  lost  if 
ovariotomy  is  done  and  the  patient's  death  is 
hastened  by  the  operation. 

The  average  risk  of  ovariotomy  in  a large 
number  of  cases,  including  the  most  and  the 
least  favourable,  has  been  diminishing  for  many 
years  past ; and  the  diminution  during  the  last 
two  or  three  years  has  been  much  greater  than 
before  the  adoption  of  antiseptie  precautions 
during  the  operation.  Before  1860  so  many  un- 
successful cases  were  concealed,  and  the  numbers 
who  died,  of  the  eases  reported,  were  so  great, 
that  the  calculated  mortality'  of  about  50  per 
cent.,  or  half  the  patients  operated  on,  is  pro- 
bably far  too  small,  and  it  would  be  more 
correctly  estimated  at  70  to  80  per  cent.  Since 
1860  it  has  been  gradually  diminishing  from  35 
to  15  per  cent;  and  since  1878,  when  anti- 
septics came  into  general  use  here  and  in  Ger- 
many, it  has  fallen  below  10  per  cent.,  whilst 
well-founded  hopes  are  entertained  of  a still 
smaller  mortality. 

Whether  any  one  patient  is  likely  to  have 
more  or  less  than  the  average  probability  of  ten 
to  one  in  her  favour  must  depend  upon  her 
general  health.  For  the  rule  holds  good,  that 
while  the  easy  removal  of  small  free  tumours 
from  women  with  a feeble  heart,  or  unsound  lungs, 
kidneys,  or  liver,  or  shattered  nervous  system, 
may  hasten  death ; so  may  very  large  adherent 


1078  OVARIES,  DISEASES  OF. 
tumours  be  removed  with  extreme  difficulty  from 
sound,  healthy  women,  and  complete  recovery 
may  fffllow,  without  fever  or  any  unpleasant 
symptoms ; and,  most  satisfactory  of  all,  perfect 
health  may  afterwards  be  enjoyed  for  many 
years,  the  operation  leading  to  no  appreciable 
modification  in  subsequent  pregnancy  or  parturi- 
t ion.  The  removal  of  one  ovary  does  not  appear 
to  affect  the  number  of  pregnancies,  nor  the  sex 
of  the  children,  nor  the  occurrence  of  twin 
pregnancy ; and  it  is  quite  exceptional  to  observe 
that  the  removal  of  both  ovaries  leads  to  obesity, 
or  any  other  mental  or  bodily  peculiarity. 

T.  Spencer  Wells. 

OVERLYING. — Overlying  is  an  accident 
which,  it  is  alleged,  not  unfrequently  happens 
to  young  children,  whereby  they  are  killed  by 
suffocation.  On  an  average  rather  more  than 
400  children  per  annum  are  registered  in  London 
as  dying  from  ‘overlying’  in  bed.  The  post- 
mortem signs  of  overlying  are  those  of  suffoca- 
tion. Evidence  that  a child  has  really  died  from 
this  cause  is  afforded  by  (1)  the  post-mortem 
appearances  of  death  from  asphyxia  ; (2)  the 
absence  of  any  other  mortal  disease;  (3)  the 
absence  of  evidence  of  any  cause  of  asphyxia 
other  than  overlying. 

The  statement  that  a child  has  been  overlain 
should  be  received  with  caution.  It  is  reasonable 
to  suppose  that  avigorous  child  would  escapefrom 
a suffocating  position  beneath  the  bed-clothes, 
or  the  body  of  its  nurse,  by  its  own  efforts;  or 
at  least  succeed,  by  its  crying  and  struggling, 
in  waking  its  nurse.  On  the  other  hand,  a very 
weakly  child,  whose  lungs  possibly  have  only 
partially  expanded,  might  be  killed  by  a very 
trifling  cause,  such  as  the  position  of  its  mouth 
and  nose  against  the  body  of  its  nurse,  or  the 
accidental  temporary  obstruction  of  its  air-pas- 
sages by  the  bed-clothes.  A medical  witness 
before  committing  himself  to  a theory  of  death 
from  overlying,  must  consider  all  the  points 
alluded  to  above,  and  must  take  care  not  to 
bring  a charge  of  almost  criminal  carelessness 
against  a careful  nurse,  or  allow  an  act  of  wilful 
murder  to  pass  under  the  guise  of  accidental 
death.  G.  V.  Poore. 

OXALIC  ACID  DIATHESIS — OXA- 
LTTRIA— OXALATE  OP  LIME  CAL- 
CULUS. 

1.  Oxalic  Acid  Diathesis. — Srsrosr. : Fr. 
Oxalurie ; Ger.  Oxalurie. 

/Etiology. — Oxalic  acid,  when  it  occurs  in 
the  urine,  may  be  derived  from  various  sources. 
1.  It  may  come  from  certain  articles  of  the 
vegetable  kingdom  taken  as  food.  2.  It  may  be 
derived  from  imperfect  metamorphosis  of  the 
waste  tissues  of  the  body.  3.  It  may  be  due  to 
the  conversion  of  urea  and  uric  acid  after  the 
secretion  or  the  emission  of  urine.  4.  It  seems 
to  have  been  proved  that  oxalic  acid  sometimes 
exists  in  the  blood,  and  may  then  simply  be  eli- 
minated by  the  kidneys. 

CHARACTERS  AND  COMPOSITION. Oxalic  add 

in  the  urine  is  always  found  combined  with  lime, 
and  is  recognised  thus: — 1.  As  minute  octohedral 
crystals  with  cross  markings.  These  crystals 
assume  apparently  different  shapes,  according  to 
their  varying  position  in  the  field  of  the  micro- 


OXALIC  ACID  DIATHESIS, 
scope.  2.  As  spheroidal,  ovoid,  or  dumb-bell  su' 
morphous  masses.  These  latter  may  be  mistab 
for  somewhat  similar  bodies  composed  of  lithatt 
but  the  colour  of  the  lithates,  and  the  almost  i I 
variably  concurrent  presence  of  the  octohedr' 
will  distinguish  them  ( see  Microscope  in  Met 
cine).  The  urine  containing  oxalate  of  linl 
is  always  acid,  generally  of  an  amber  tint,  ai 
contains  a faint  cloud  of  mucus.  This  clou 
however,  may  he  so  slight  as  to  be  uunotice 
and  then  the  presence  of  oxalates  is  apt  to  1 
overlooked. 

Symptoms. — However  derived,  the  presence 
oxalate  of  lime  in  the  urine  frequently,  or  in  ail 
considerable  amount,  cannot  but  arrest  attentu 
and  suggest  the  question : Is  there  any  sped 
condition  of  the  system  dependent  on  or  ass 
ciated  with  this  occurrence?  In  other  words: 
there  any  peculiar  habit  of  body  to  which  the  ter 
‘ oxalic  acid  diathesis  ’ can  he  rightly  applie; 
Prout,  and  especially  Golding  Bird,  so  folly  d 
scribed  the  symptoms  of  nervous  exhaustio> 
dyspepsia,  and  hypochondriasis,  which  aresaii 
characterise  this  so-called  diathesis,  and  so  foi 
impressed  the  professional  mind  with  the  clinic 
association  of  these  symptoms  with— if  not  the] 
actual  dependence  on — oxaluria,  that  the  mo 
accurate  and  recent  observations  of  Beale,  Bene! 
and  W.  Roberts,  have  scarcely  yet  succeeded  * 
dissipating  the  error.  These  observers  ha 
proved  that,  in  the  large  majority  of  casos 
which  the  characteristic  symptoms  are  preset 
no  oxalates  are  found  in  the  urine;  and  col 
versely,  where  oxaluria  is  most  pronounced,  t| 
symptoms  are  absent.  Oxalate  of  lime  in  t 
urine  is  often  found  in  persons  enjoying  go; 
health.  From  what  ha3  been  said  of  its  aetiolog 
its  presence  in  various  chronic  diseases,  such 
phthisis,  chronic  bronchitis,  cardiac  lesions,  & 
in  which  oxidation  is  retarded,  is  explain 
So,  too,  oxaluria  is  present  in  many  conditio 
of  deranged  digestion  and  mal-assimilation,  a 
in  diseases  which  lower  nervous  tone  and  pow 

Treatment. — It  will  be  gathered  from  t! 
foregoing  remarks,  that  oxaluria  demands 
direct  or  uniform  therapeutical  treatment.  T 
indications  are,  to  obtain  perfect  digestion 
selecting  a diet  not  too  rich  in  nitrogenous 
auimal  food,  and  by  prudence  as  regards  qua 
tity,  so  that  crude  or  imperfectly  assimilal 
matters  are  not  absorbed ; to  promote  the  heala 
action  of  the  skin  and  lungs  by  sponge 
shower-baths,  and  free  exercise  in  a hraci 
country  or  at  the  seaside ; and  by  tonic  remed' 
to  improve  digestion,  and  strengthen  the  nerve, 
system. 

2.  Oxalate  of  lime  calculus. — Desckipth 
Mulberry  or  oxalate  of  lime  calculus  is  usua' 
of  a dark  brown,  sometimes  almost  black  colon 
generally  ovoid  or  spheroidal  in  shape ; wit., 
rough  and  tuberculated  exterior ; and  of  a h;l 
compact  interior.  The  absolute  nucleus  is  cc 
posed  of  dumb-bell  crystals,  united  by  molecu.' 
coalescence  in,  and  through  the  medium  of,  so-' 
viscid  organic  matter.  The  influences  which  c - 
trol  this  deposition  and  growth  of  calculi  hi; 
been  much  elucidated  through  the  researched 
Dr.  Carter  aud  Dr.  Ord,  but  need  not  he  special 
described  here.  See  Calculus. 

The  great  insolubility  of  oxalate  of  In 


OXALIC  ACID  DIATHESIS. 

lavours  the  chances  of  its  deposition  in  the  renal 
ubules.  It  has  been  detected  in  the  kidneys  of 
ho  fcetus  ; it  is  especially  liable  to  occur  during 
hildhood;  and  this  liability  decreases  asage 
■dvances.  In  England  calculi  composed  entirely 
If  oxalate  of  lime  are  rare  in  the  adult,  but  in 
ndia  they  are  comparatively  frequent.  Mul- 
erry  calculus  in  the  young  causes  intense  Buf- 
ferin«’ ; but  in  the  adult,  notwithstanding  the 
unnidable  tubercles  and  rough  exterior,  the 
ymptoms  of  stone  are  often  mild ; not  impro- 
bably because  these  projections  become  entangled 
a the  muscular  columns  of  the  bladder,  and  the 
alculus  is  thereby  fixed  in  position.  The  symp- 
pms  of  renal  calculus  are  fully  described  in 
bother  article.  See  Kenal  Calculus. 
Treatment. — Microscopic  mulberry  calculi, 
ere  it  possible  to  detect  their  existence,  could 
robably  be  washed  away  and  carried  off  by 
iluents  and  diuretics  ; but  a palpable  stone  is 
subject  for  surgical  treatment  only. 

W.  Cadge. 

OXALIC  ACID,  Poisoning  by.  — See 

OIsOXS. 

OXYUHIS  (o| us,  sharp,  and  ovpa,  a tail). — 
ynon. : Er.  Oxyure  ; Ger.  Spitzschwanzwurm  ; 
\adcnwurm. — A genus  of  nematoid  parasites  of 
hich  the  little  threadworm  or  seatworm  forms 
le  best  known  type.  Most  English  practitioners 
ill  6peak  of  the  common  threadworm,  Oxyiiris 
trmicularis,  as  belonging  to  the  genus  Ascaris. 
1 nine  cases  out  of  ten,  when  children  are  said 
■be  suffering  from  ascarides,  it  is  meant  that 
ley  are  infested  with  oxyurides  or  thread- 
arms.  These  parasites  not  only  differ  from  the 
carides  proper  in  respect  of  size,  but  also  as 
gards  the  form  of  the  body,  which  is  more 
less  spindle-shaped,  the  tail  being  sharply 
■intod.  Hence  the  generic  title.  Oxyurides 
fest  animals  as  well  as  man,  the  large  species 
the  horse,  Oxyuris  curvula,  being  almost  as 
jurious  to  that  animal  as  the  little  threadworm 
to  ourselves.  See  Ascarides;  Seatworm;  and 
jlREADWOBM.  T.  S.  CoBBOLD. 

OZJENA  (2£b,  a foul  odour). — Synon.  : Er. 
'.naise ; Ozene ; Ger.  Stinknase. 

Definition. — Ozaena  is  generally  understood 
mean  a chronic,  highly  foetid  discharge  from 
a nose,  or  its  accessory  cavities.  This  dis- 
irge,  however,  and  its  characteristics,  are 
. Iter  to  be  regarded  as  symptomatic  of  disease, 
in  as  disease  itself,  and  is  a result  of  some 
healthy  ulceration  of  the  mucous  membrane. 
Etiology. — The  causes  of  ozaena  are  various, 

■ : most  common  being  syphilis,  struma,  lupous 
i.eration,  canes,  or  necrosis  of  the  bones  or 
c tilages,  although  these  may  themselves  be 
i lendent  upon  the  presence  of  some  foreign 
lly,  or  other  cause  of  occlusion  of  the  meatus. 
< ena  may  exist  in  an  idiopathic  form,  which  is 
i arded  by  some  authorities  as  depending  upon 
nbnormal  condition  of  the  nasal  secretion,  or 
i. analogous  to  the  offensive  odour  sometimes 
i j with  in  the  feet  or  axillae.  Ozaena  has  been 
l some  attributed  to  the  abuse  of  mercurials,  but 
t 'e  conclusive  evidence  on  this  point  is  wanting. 

ymptoms. — The  ulceration,  on  which  ozsena 
lends,  generally  commences  high  up  in  the 
t ),  though  it  may  be  first  noticeable  as  lew 


OZiENA.  1079 

down  as  the  inferior  turbinated  bono  or  septum. 
In  the  strumous  form  only  one  side  may  be 
affected,  whereas  in  the  syphilitic  variety  both 
are  generally  involved,  and  there  is  a greater 
derangement  of  health.  The  diagnosis,  however, 
is  rendered  the  more  difficult  in  children,  since 
it  frequently  occurs  that  the  two  conditions 
coexist. 

The  nature  of  the  discharge  varies  with  the 
case  and  with  its  progress,  whatever  may  have 
been  its  origin,  and  it  may  be  influenced  by  p. 
cold,  overwork,  or  the  approach  of  the  menstrual 
period.  It  may  be  either  profuse  or  scanty,  thick 
or  thin,  purulent  or  sanious,  almost  colourless 
or  greenish  yellow,  and  streaked  with  blood. 
It  often  forms  crusts,  or  masses  of  inspissated 
mucus,  which  may  accumulate  at  the  posterior 
nares,  being  discharged  from  the  nostril  as 
horribly  offensive  concretions,  every  few  days, 
and  quickly  reforming: 

The  complications  consist  in  the  implication 
of  the  bones  and  destruction  of  the  septum, 
most  frequently  occurring  in  the  strumous  or 
syphilitic  form,  so  that  the  nose  falls  in,  pro- 
ducing great  deformity. 

Diagnosis, — It  is  of  the  greatest  importance 
to  distinguish  between  ozsena  and  the  various 
forms  of  foetid  breath  consequent  on  bad  teeth, 
ulceration  of  the  mouth  and  fauces,  the  presence 
of  foreign  bodies  or  of  retarded  secretion,  or 
disturbance  of  the  general  health — a point  which 
may  be  readily  made  out  by  causing  the  patient 
to  close  the  mouth  and  nostrils  alternately,  or 
by  rhinoscopic  examination. 

Treatment. — The  treatment  of  ozsena  must  be 
both  local  and  constitutional,  and  obviously  di- 
rected to  the  exciting  cause.  Local  treatment 
consists  in  the  removal  of  all  sources  of  irrita- 
tion, by  washing  out  the  choanse,  and  by  the  in- 
sufflation of  powders,  although  this  latter  is  net 
so  frequently  resorted  to.  The  most  valuable, 
undoubtedly,  is  the  nasal  douche  of  Thudichum, 
the  action  of  which  is  dependent  upon  the  fact 
that,  while  the  mouth  is  kept  open,  the  nares 
can  be  thoroughly  washed  out,  and  no  fluid 
pass  into  the  mouth,  since  the  velum  pendulum 
palati  is  closely  forced  against  the  upper  portion 
of  the  pharynx.  The  instrument  itself  consists 
of  a tube  of  varying  length,  with  a perforated 
nozzle,  which  is  to  fit  accurately  to  the  nostril. 
This  tube  descends  from  a small  cistern,  placed 
at  such  an  elevation  that,  by  turning  a stopcock, 
a current  offluidis  injected  into  the  cavity.  The 
fluid  used  depends  on  the  nature  of  the  case,  but 
is  generally  some  saline  solution,  such  as  a w-eak 
one  of  common  salt,  or  salt  and  carbonate  or 
phosphate  of  soda;  a weak  solution  of  carbolic 
acid,  of  Condy’s  fluid,  or  of  chlorinated  soda;  or 
a mercurial  *n  some  cases.  An  ordinary  well 
made  syringe,  capable  of  supplying  a tolerably 
continuous  stream,  will  answer  very  well  in 
many  instances. 

Where  ulcerating  surfaces  can  be  seen  or 
reached,  they  should  be  touched  by  a sponge  or 
camel' s-hair  brush  steeped  in  a solution  of  ni 
trate  of  silver,  nitric  acid,  or  carbolic  acid,  and 
the  apposed  surfaces  kept  from  contact  by 
sponge  tents  or  laminaria.  The  great  pain  at- 
tendant on  idiopathic  ozaena  may  be  relieved,  by 
applying  to  the  frontal  region  an  ointment  con- 


1080  OZiENA. 

taining  about  2 or  3 grains  of  morphia  to  the 
ounce.  The  injection  of  glycerine  is  often  of 
great  use,  especially  in  strumous  ozsena,  and  it 
may  be  combined  with  a grain  of  iodine  to  every 
ounce  with  advantage. 

With  regard  to  insufflation,  or  the  snuffing  up 
or  administration  of  medicated  powders  by  an 
instrument,  benefit  is  obtained  in  some  instances 
from  the  use  of  sub-nitrate  of  bismuth  rubbed 
up  with  Venetian  chalk,  or  calomel  rubbed  up 
with  sugar,  in  the  proportion  of  a grain  to  an 
ounce.  Tannin,  camphor,  and  cubebs  have  all 
been  recommended.  The  principal  remedies 
used  in  the  form  of  vapour,  have  been  mer- 
curials, such  as  calomel  or  bisulphide  of  mer- 


PAIN. 

cury,  sublimated  by  a lamp  and  inhaled.  Th 
vapour  of  hvdrochlorate  of  ammonia  is  als 
useful  in  all  forms  of  ozaena. 

With  regard  to  the  constitutional  treatmeni 
in  the  strumous  variety,  cod-liver  oil,  quinim 
iodide  of  iron,  and  arsenic  seem  to  be  of  mos 
service. 

Those  cases  which  are  obviously  syphilitic  ar 
usually  more  tractable  than  either  the  stramou 
or  idiopathic  varieties,  under  the  influence  c 
bichloride  of  mercury  or  iodide  of  potassium. ; 
the  patient  be  robust.  In  cases  where  the  healt 
is  impaired,  generous  living,  with  quinine  an 
iron,  would  be  indicated  before  entering  upo 
specific  treatment.  Edwaed  Fellahy. 


P 


PACHYDERMIA  (-rraxv,  thick,  and  oipua, 
the  skin). — A state  of  thickening  and  conden- 
sation of  the  integument,  which  is  sometimes 
observed  in  the  lower  limbs,  associated  with  in- 
filtration and  induration.  In  chronic  cellulitis  a 
state  of  pachydermia  is  also  met  with ; and 
thickening  of  the  epidermis,  as  in  the  instance 
of  callosity,  has  received  a similar  name.  But 
the  term  is  wanting  in  the  scientific  precision 
necessary  for  its  adoption  in  pathology. 

Erasmus  Wilson. 

PACHYMENINGITIS  (iraxus,  thick,  and 
P-hviy^,  a membrane). — A synonym  for  inflamma- 
tion of  the  dura  mater.  See  Meninges,  Cere- 
bbal,  Diseases  of. 

PAIN. — Synon.  : Fr.  Doulcur ; Ger.  Schmcrz. 

Definition. — Pain  is  the  representation  in 
consciousness  of  a change  produced  in  a nerve- 
eentre  by  a certain  mode  of  excitation.  It  would 
seem  that  some  special  perturbation  of  nervous 
impulses,  and  not  a mere  exaltation  of  the 
normal  functioning  of  the  sensory  apparatus,  is 
necessary  to  the  production  of  pain.  For  it  will 
sometimes  happen,  in  disease,  that  whilst  the 
faculty  of  perceiving  painful  impressions  made 
upon  the  skin  is  wholly,  or  in  great  part,  lost, 
touch  is  felt  nearly  as  well  as  in  health.  On 
the  other  hand,  in  hypersesthesia  of  the  surface, 
where  the  slightest  impression  produces  exqui- 
site pain,  the  power  of  tactile  discrimination  is 
actually  diminished. 

.ZEtiology  and  Pathology. — Pain  is  excited 
by  many  agencies  applied  to  the  skin — mecha- 
nical, thermic,  chemical,  electric,  pathological. 
Of  these  it  is  probably  only  the  last  which  are 
able  to  produce  pain  when  applied  to  the  viscera, 
bones,  and  blood-vessels.  The  situation  of  the 
stimulus  exciting  pain  may  he  at  any  part  of  the 
sensory  apparatus,  from  the  end-organ  in  the  skin 
to  the  central  ganglion ; but  the  feeling  of  pain 
is  always  referred  to  the  periphery  of  the  sensory 
fibre,  no  matter  what  portion  of  the  sensory  tract 
has  received  the  irritation.  As  regards  pain, 
therefore,  which  is  referred  to  some  part  of  the 
interior  of  the  body,  it  must  be  icmembered  that 
thecause  (always  some  pathological  agency)  may 


be  operating  either  upon  the  termination  of 
nerve,  its  trunk,  or  upon  the  nervous  centre  i 
the  spinal  cord,  or  superior  ganglia.  There  ma 
be  encroachments  upon  the  structure  of  th 
nerve-fibre  or  ganglionic  centre,  arising  froil 
hyperaemia,  effusion,  or  growth  in  neighbourin 
tissues. 

Pathologically,  pain  is  of  at  least  twofold  in 
portance.  1.  It  causes  distress  and  exkaustio 
of  nervous  energy,  interferes  with  sleep,  inten 
rupts  the  appetite  and  digestion,  so  that  the  ni 
trition  of  the  body  is  damaged,  and  thus,  if  long! 
continued,  it  can  lead  to  changes  shortening  es 
istence  ; or  it  may  be  so  severe  as  of  itself  t 
occasion  death.  2.  Its  aid  in  diagnosis  is  frt 
quently  of  higher  value  than  that  of  any  othi 
single  symptom. 

Varieties  and  Diagnosis. — It  may  he  usefi 
to  refer  briefly  to  a few  examples  of  the  diat 
nostic  importance  of  pain. 

Pain  in  the  head. — When  of  a continuous,  dul 
aching  character,  pain  in  the  head  may  he  da 
to  rheumatism  of  the  scalp,  and  this  is  especiall 
likely  if  it  he  increased  by  bending  the  hea 
down.  A headache  of  similar  character,  an 
affecting  the  forehead,  may  be  dependent  upo 
gastric  derangement.  Fixed  in  one  spot,  eithe 
on  the  head  or  face,  and  darting  from  that  spo 
if  sharp  and  paroxysmal,  it  is  likely  to  be  net 
ralgic.  If,  in  addition,  it  bo  accompanied  b 
vomiting  and  giddiness,  it  may  indicate  migraim 
Now,  migraine  much  more  often  than  not,  ei 
dures  for  a day  only  at  a time,  or  a little  mor 
If,  therefore,  these  symptoms  be  continued  b( 
yond  this  period,  they  should  always  be  regarde 
with  anxiety,  as  probably  connected  with  brai; 
mischief.  The  use  of  the  ophthalmoscope  : 
most  important  here.  Should  pain  in  the  hea 
be  accompanied  not  only  by  vomiting  and  gidd 
ness,  but  by  squint,  or  some  other  evidence  of 
localised  paralysis  of  a cranial  nerve,  it  is  almo: 
certainly  due  to  intracranial  disease  of  a coan 
kind — tumour,  aneurism,  abscess,  hsemorrhag 
or  meningitis.  In  cases  of  more  or  less  comple 
hemiplegia  from  vascular  changes  and  thrombi 
sis,  after  the  apparent  recovery  of  the  patien 
more  or  less  fixed  pain  in  the  head  will  oftc 


PAIN. 


emain.  Whilst  this  persists,  a guarded  prog- 
iosis  is  essential,  for  much  more  often  than  not 
urther  mischief  -vs-ill  follow  before  long.  In  all 
■ases  of  persistent  pain  in  the  head,  the  urine 
hould  be  carefully  examined,  not  only  for  albu- 
men, but  also  for  sugar.  Pain  of  a severe  kind, 
specially  apt  to  attack  the  back  of  the  head,  is 
ften  found  in  the  course  of  Bright’s  disease.  It 
-ill  then  be  accompanied  by  albuminous  urine  ; 
nd  the  ophthalmoscope  will  very  likely  show 
lbuminurie  retinitis.  There  is  also  a form  of 
lore  or  less  continuous  headache,  with  occa- 
onal  violent  exacerbations,  which  accompanies 
lycosuria. 

A recurrent  pain  in  the  head,  of  excessive 
iolence,  and  described  as  a feeliDg  as  though 
le  bones  were  being  crushed,  whilst  it  may 
icasionally  be  due  to  rheumatism,  is  far  more 
’ten  dependent  upon  syphilis.  Generally  speak - 
iig,  persistent  pain  in  the  head,  in  a person  un- 
customed to  it,  is  a symptom  which  should 
ways  be  regarded  with  anxiety,  and  the  use  of 
16  test-tube  and  ophthalmoscope  should  never 
such  circumstances  be  omitted.  This  should 
pecially  be  insisted  upon  if  the  patient  be  a 
male,  and  certain  concomitant  symptoms  in- 
ine  the  observer  to  believe  the  affection  to  be 
■sterical. 

In  obscure  cases  the  possibility  of  the  toxic 
fluence  of  lead  in  causing  pain  in  tho  head 
■ould  not  be  forgotten. 

The  pain  in  the  head  which  accompanies  chlo- 
sis  is  often  fixed  in  one  spot,  and  described  by 
e patient  as  a feeling  of  a nail  being  driven 
■a  the  head.  This  symptom  not  unfrequently 
companies  hysterical  conditions.  The  pain  in 
ie  head  complained  of  by  school  children,  as 
tacking  them  in  their  studies,  is  very  often  due 
some  abnormality  of  refraction  or  weakness  of 
■tain  muscles  of  the  eye,  which  needs  the  help 
i an  ophthalmologist  to  investigate.  Pains  in 
v;  head  of  a darting,  shooting  character,  are 
••netimes  due  to  locomotor  ataxia. 

Vain  in  ilie  neck. — This  is  not  at  all  uncommon, 

1 1 is  usually  due  to  rheumatism  affecting  the 
1 'ous  covering  of  the  large  muscles.  It  is  pro- 
1 ole,  too,  that  in  many  cases  it  depends  upon 
i tation  of  the  loose  connective  tissue  which 
t;.bles  one  muscle  to  glide  over  another,  and 
' :ch  is  really  an  expansion  of  the  lymphatic 
E.tem.  Uric  acid,  or  some  equivalent,  becoming 
dosited  in  this  lymphatic  space,  will  excite 
:> : ttle  subacute  inflammation,  and  produce  a 
v,y  acute  pain.  The  diathesis  of  the  patient 
s uldbe  inquired  into,  his  urine  and  evacuations 
curved,  and  his  mode  of  living  investigated. 
1 re  may  be,  too,  sometimes  pain  in  the  neck 
f;  a neuralgia.  This  will  be  distinguished  by 
it  paroxysmal  character,  and  its  being  indepen- 
d i of  muscular  movement.  Neuralgic  pain  in 
tl  neck  is  usually  accompanied  by  pain  in  the 
djrict  of  one  or  other  of  the  divisions  of  the 
bj'hial  plexus  in  the  arm. 

■ ain  in  the  chest. — This  may  be  referred  to 
ti  chest-wall,  or  to  the  interior  of  the  cavity. 
Ii'he  former  case  it  is  Decessary  to  determine 
w dier  the  pain  be  due  to  muscular  rheumatism, 
Politic  periostitis,  intercostal  neuralgia,  or  the 
-i  oachment  of  an  aneurism  or'  a tumour.  Ab- 
5 of  febrile  movement,  as  shown  by  the  ther- 


1081 

mometer,  and  the  entire  dependence  of  the  pain 
upon  movement,  point  to  the  first  of  theso  causes. 
A node  perceived  by  the  finger  upon  the  sternum, 
clavicle,  or  ribs,  would  indicate  syphilitic  perios- 
titis. The  character  of  the  pain,  and  the  pre- 
sence of  tender  points,  coupled  very  probably 
with  a history  of  previous  neuralgic  attacks 
in  some  other  part  of  the  body,  suggest  intercostal 
neuralgia.  Physical  examination  will  detect  or 
exclude  aneurismal  tumour.  Pleurisy  causes  a 
pain  referred  to  the  chest-wall,  which,  as  it  is 
particularly  marked  when  the  patient  coughs,  may 
be  confounded  with  muscular  rheumatism  or 
intercostal  neuralgia.  The  elevation  of  tempe- 
rature by  which  pleurisy  is  accompanied,  will 
ordinarily  distinguish  it  without  difficulty,  even 
before  there  are  any  auscultatory  signs.  Con- 
tinued dull  pain  deep  in  the  chest  may  indicate 
an  intrathoracic  growth,  abscess,  or  aneurism. 
Careful  physical  examination  and  observation 
are  the  means  by  which  the  diagnosis  of  this 
condition  can  be  made. 

Pain  is  often  experienced  about  the  heart  more 
or  less  early  in  the  course  of  acute  rheumatism. 
It  may  be  dependent  upon  commencing  peri-  or 
endocarditis,  which  will  be  disclosed  by  tho 
stethoscope.  There  is  a dull,  more  or  less  con- 
stant pain  about  the  heart,  which  occurs  in  con- 
ditions of  nervous  debility,  and  is  not  connected 
with  organic  disease  of  the  organ.  There  is  also 
a rather  sharp  pain  just  under  the  mamma,  ac- 
companied by  cardiac  palpitation,  which  is  often 
complained  of  by  epileptics,  and  by  persons  af- 
fected with  hysteria.  It  is  not  accompanied  by 
any  evidence  of  organic  change  in  the  heart, 
and  its  origin  is  probably  in  the  central  nervous 
system.  Pain  in  the  heart,  of  an  extremely  sud- 
den character,  as  though  the  muscle  were  being 
grasped,  and  accompanied  by  intense  apprehen- 
sion of  death,  with  facial  pallor  and  some  dyspncea, 
points  to  angina  pectoris.  The  pain  is  not  con- 
fined to  the  heart,  but  extends  to  the  left  arm, 
and  to  various  parts  of  the  chest.  The  pains  in 
the  chest  which  accompany  various  diseases  of 
the  lungs  and  pulmonary  tubes  will  require  to  be 
investigated  with  reference  to  these  conditions. 

Pain,  in  the  spinal  column. — Acute  pain  and 
tenderness  of  any  of  the  vertebral  spines  is  a 
symptom,  not  of  disease  of  the  spinal  cord,  but 
of  a peculiar  state  of  nervous  exhaustion.  It  is 
common  in  hysterical  persons,  and  in  others  who 
have  from  any  cause  become  greatly  debilitated. 
As  a rule  there  is  very  little  pain  in  the  spine  in 
diseases  of  the  cord.  In  spinal  meningitis  the 
patient  only  complains  of  pain  on  movement, 
and  especially  if  he  endeavour  to  turn  over  in 
bed.  Pressure  upon  any  part  of  the  vertebral 
spines  usually  causes  no  complaint.  There  may 
be  a little  uneasiness  complained  of  when  they 
are  strongly  percussed.  Pain  of  an  encircling 
kind,  in  a sort  of  band  in  the  wall  of  the  chest 
or  abdomen,  accompanied  by  what  is  often  de- 
scribed as  a ‘ bloated  feeling,’  is  a serious  symp- 
tom, and  points  to  myelitis.  There  should  be, 
however,  some  other  confirmatory  symptoms,  ere 
this  view  is  decisively  fixed  upon.  In  such  a 
condition  there  would  probably  be  found  more 
or  less  weakness  of  the  lower  extremities,  with 
some  cutaneous  anaesthesia,  below  the  band  of 
pain.  It  may  happen  that  an  aneurism  encroachos 


PAIN. 


1082 

upon  the  spinal  vertebrae,  or  a malignant  growth 
invades  some  of  them.  In  such  conditions  there 
is  often  constant  and  excessive  pain,  with,  not 
uncommonly,  a good  deal  of  tenderness  of  the 
surface.  The  possibility  of  these  conditions 
should  always  be  borne  in  mind. 

In  commencing  caries  of  the  vertebrae  a 
1 stinging  ’ pain  is  often  complained  of  in  the 
chest-wall,  and  pain  may  also  be  complained  of 
on  pressing  somewhat  heavily  upon  a vertebral 
spine.  In  such  a case,  too,  the  act  of  stooping 
and  lifting  weights  is  apt  to  cause  complaint  of 
pain  in  the  spinal  column. 

Pain  in  the  abdomen. — This  may,  like  pain  in 
the  chest,  be  referred  either  to  the  abdominal 
wall  or  cavity.  There  may  be  inflammation  and 
abscess  of  the  abdominal  wall.  There  may  be 
neuralgia  of  tho  superficial  branches  of  the  lum- 
bar plexus,  in  which  case  the  pain  is  paroxysmal, 
sharp,  and  may  be  accompanied  by  herpes.  But 
pain  in  this  situation  is  more  often  myalgic,  and 
will  be  found  to  correspond  to  tho  insertion  of 
some  abdominal  muscle,  which  is  subject  to  over- 
strain or  fatigue. 

Acute  abdominal  pain  referred  to  the  contents 
of  the  belly,  may  be  dependent  upon  internal 
strangulation  of  the  bowel,  in  which  case  it  will 
be  accompanied  by  vomiting,  constipation,  and 
probably  by  abdominal  distension,  with  marked 
peristaltic  writhings  of  the  intestines.  Or  the 
cause  may  exist  in  a hernia  which  is  strangu- 
lated. The  symptoms  in  this  case  will  be  much 
like  those  above  described,  and  therefore  it  is  in 
all  cases  of  acute  abdominal  pain  with  constipa- 
tion absolutely  necessary  to  make,  first  of  all,  a 
thorough  examination,  to  ascertain  that  no  her- 
nial tumour  is  to  be  found.  If  pain  in  the  abdo- 
men be  accompanied  by  tenderness  on  pressure, 
and  be  increased  by  coughing,  there  is  probably 
peritonitis.  In  such  a case  the  pulse  will  be 
found  quick  and  small,  and  the  temperature 
somewhat,  but  not  necessarily,  much  raised. 
The  patient  will  prefer  to  lie  on  the  back  with 
the  knees  bent,  and  the  face  will  betray  anxiety. 
In  hysterical  women  great  abdominal  pain  and 
tenderness  is  often  complained  of,  and  it  is  some- 
times not  very  easy  to  distinguish  this  from  peri- 
tonitis. It  is  best  done  by  engaging  the  patient’s 
attention,  and  noting  that  there  is  then  no  evi- 
dence of  tenderness  at  a point  which  had  been 
previously  exceedingly  painful.  The  pain  and 
tenderness  may  be  due  to  enteritis  or  perity- 
phlitis, in  which  case  there  will  be  obstinate  con- 
stipation, a tympanitic  state  of  the  whole  intes- 
tine or  the  csecum,  and  most  probably  vomiting. 
Cancerous  tumours  of  various  abdominal  organs 
will  have  to  be  diagnosed  by  careful  palpation, 
and  discriminated  from  faecal  accumulation. 
Colic  due  to  the  poison  of  lead,  causing  violent 
abdominal  pain  without  rise  of  temperature,  re- 
quires to  be  distinguished  from  the  symptoms 
which  mark  the  passage  of  a biliary  calculus. 
Extreme  suddenness  and  severity  characterise 
the  latter,  and  there  is  usually  more  vomiting  in 
the  passing  of  a gall-stone  than  in  colic.  But 
the  history  will  have  to  bo  investigated,  and 
the  evacuations,  if  any  take  place,  should  be 
examined.  The  absence  of  a blue  line  on  the 
gums  should  be  ascertained  ere  the  possibility 
of  the  existence  of  lead  colic  is  abandoned. 


Pain  in  the  bins  and  back. — There  are  mat 
conditions  which  give  rise  to  pain  in  these  sittr 
tions,  and  which  require  to  be  borne  in  mind  i 
examining  a patient.  Congestion  of  the  kidney 
or  nephritis,  will  be  shown  by  the  scanty,  higl 
coloured  urine,  containing  albumen  and  probab 
blood.  Kenal  calculus  will  be  attended  t 
unilateral  pain  in  the  loin,  following  the  dire 
tion  of  the  ureter,  and  affecting  the  correspom 
ing  testicle.  It  is  paroxysmal  in  character,  at 
often  horribly  severe.  The  urine  will  conta 
blood,  and  possibly  pus,  and  will  be  passed  ve: 
frequently.  As  between  such  a condition  ai 
the  presence  of  an  abscess  or  morbid  grow! 
in  the  kidney,  the  points  of  diagnosis  are  a 
strongly  marked,  and  careful  observation  will  1 
requisite,  in  order  to  form  an  opinion.  The  pr 
sence  of  a bad  stricture  in  the  urethra,  by  causii 
retention  and  over-distension  of  the  bladder  wi 
urine,  will  cause  pain  referred  not  only  to  t! 
hypogastric  region,  but  also  to  the  back. 

Lumbago  is  characterised  especially  by  i 
ability  of  the  patient  to  rise  from  his  chair  wit 
out  the  greatest  distress,  and  only  slowly  ai 
with  difficulty.  It  may  depend  upon  rheumatis 
of  the  muscles,  or,  still  more  probably,  of  su 
acute  inflammation  of  the  connective  tiss 
between  the  muscles.  Or  it  may  be  neurak 
in  character,  in  which  case  it  will  be  acute 
stabbing,  paroxysmal,  and  independent  of  mi 
cular  movement. 

Pain  in  the  back  is  frequently  caused 
flatulent  distension  of  the  bowels,  and  by  acc 
mulation  of  retained  faeces.  It  may  be  depends 
upon  a tumour  connected  with  the  bowel  (esp 
daily  likely  in  the  sigmoid  flexure  and  rectur 
which  may  or  mayr  not  be  felt  by  external  p; 
pation,  or  reached  by  the  observer's  finger,  inn 
ducedprr  anum.  Nor  must  it  be  forgotten  tb 
an  abscess  in  the  wall  of  the  rectum  will  cat 
long-continued  and  severe  pain  in  the  back, 
is  well  to  remember  that  an  undiscovered  hen 
may  give  rise  to  little  or  no  inconvenience  e 
cept  pain  in  the  back.  So  likewise  flexions  a 
morbid  growths  of  the  uterus,  and  uleeratio 
about  the  cervix,  may  be  the  cause  of  pain, 
well  as  the  approach  of  the  catamenial  peric 
which  in  some  women  is  the  cause  of  great  ps 
in  the  back. 

Pains  in  the  extremities. — These  may  be  d 
to  neuralgia,  in  which  case  they  will  be  found 
occupy  the  district  of  one  or  more  branches 
nerves,  and  to  be  paroxysmal  in  character.  T 
pains  which  affect  the  extremities  and  the  trui 
but  especially  the  legs,  in  the  early  stage  of 
comotor  ataxy,  are  peculiar  in  this.  A patie 
who  has  little  complaint  to  make  of  his  heal 
will  every  now  and  then  be  kept  awake  all  nig 
and  incapacitated  in  the  day,  by  sudden,  sha 
lightning-like  pains  darting  through  one  or  nr 
limbs,  and  often  severe  enough  to  make  him  e. 
out.  They  will  occur  in  paroxysms,  lasting  hoc. 
days,  or,  less  often,  weeks ; and  will  subside' 
suddenly  as  they  began.  With  such  symptoms  i 
patellar  tendon  reflex  should  always  be  test- 
Other  pains  affecting  the  extremities  are  rh; 
matic ; or  of  tho  nature  of  the  gnawing  f; 
aching  pains  which  occupy  the  jo.nts  in  act 
inflammation  front  any  cause,  including  rheur 
tisni,  and  in  arthritis  deformans.  The  joints  n> 


PAIN. 

Iso  be  the  seat  of  pains  of  a neuralgic  cha- 
aeter. 

Treatment. — The  treatment  of  pain  is  so  in- 
olved  in  the  causation,  that  but  little  can  here 
,e  said  with  advantage  on  this  point.  It  may  be 
aid  generally,  that  pain  ought,  if  possible,  to  be 
elieved,  for  its  continuance  is  exhausting  and 
lischievous  to  the  nervous  system.  Rest  is,  as 
rule,  the  first  essential.  Local  applications,  in 
he  form  of  simple  poultices,  sinapisms,  and 
ounter-irritant  or  anodyne  liniments,  constitute 
iae  most  ready  means  of  relieving  pain  in  many 
uses.  Food  of  a suitable  kind  will  often  bo 
iae  best  means  of  relieving  pain,  and  where  the 
audition  of  the  stomach  prevents  its  being  swal- 
Vwed,  it  is  frequently  desirable  to  inject  susten- 
ance by  enemata  into  the  bowel.  Constipation 
f the  bowels,  when  accompanied  by  pain,  should 
ever  (except  perhaps  in  the  case  of  lead  colic) 
e treated  by  purgatives.  Belladonna,  aceom- 
anied  by  minute  doses  of  opium,  is  the  best 
ceatment.  The  drugs  which  have  the  greatest 
ifluence  as  anodynes  are,  doubtless,  opium  and 
oloroform,  but  belladonna  and  Indian  hemp 
re  often  used  with  advantage.  They  both 
equire  to  be  used  with  caution.  A habit  of 
rcreasing  the  dose  of  opium  (even  when  it  is 
rnployed  in  the  form  of  morphia  with  the  hy- 
odermic  syringe)  is  soon  acquired.  It  is  un- 
desirable to  allow  patients  to  inject  themselves. 
[>  is  well,  in  all  cases,  to  begin  with  a small 
ose,  say  gr.  i morph  ise — a dose  which  is  sti- 
ulant  and  not  narcotic.  It  is  the  narcotic  dose 
hich  apparently  is  followed  by  a sort  of  recoil, 
jhich  suggests  the  need  for  a repetition  and  in 
rger  quantity.  « T.  Buzzard. 

PAINTER’S  COLIC.  — Stnon.  : Coliea 
Uclonum  ; Lead  colic  ; Fr.  Colique  des  pcintres; 
or.  Malerkolik. — A form  of  intestinal  colic,  due 

■ the  presence  of  lead  in  the  system ; so  called 
a account  of  the  frequency  of  its  occurrence 
nongst  house-painters.  See  Colic,  Intes- 
xal  ; and  Lead,  Poisoning  by. 

PALATE,  Diseases  of. — 1.  Paralysis. — - 
ae  chief  causes  of  paralysis  of  the  palate  are 
phtheria  {see  Paralysis,  Diphtheritic) ; degene- 
tion  of  the  nuclei  of  the  medulla  oblongata  (see 
ujio-glosso- laryngeal  Paralysis)  ; growths 
the  basis  cranii ; and  pressure  on  the  nerves  of 
e medulla.  The  two  first  usually  cause  bi- 
;eral  paralysis.  Unilateral  paralysis  is  com- 
ply due  to  cue  of  the  two  last  causes.  Disease 
the  trunk  of  the  facial  nerve  is  commonly  re- 
rded  as  an  occasional  cause  of  paralysis  of  the 
late.  But  this  is  certainly  extremely  rare  in 
dal  paralysis,  and,  in  the  writer’s  opinion,  its 
lurrence  even  is  open  to  question. 

Symptoms. — In  bilateral  paralysis  the  palate 
ings  flaccid,  and  irritation  of  the  mucous  mem- 
me  excites  no  reflex  movements.  It  is  not 
sed  in  breathing  or  phonation  ; a convenient 
t is  to  make  the  patient  utter  the  sound  ‘ ah  ’ 
‘a  high  tone;  the  central  palate  should  be 
sed  by  the  levator.  Deglutition  is  interfered 
li,  the  soft  palate  being  do  longer  raised  so  as 
'jshut  off  the  posterior  nares ; and  liquids  are 
ced  up  into  the  nose  by  the  contraction  of 

■ pharyngeal  muscles.  Speech  is  also  affected  ; 

1 resonance  of  the  nasal  chambers  gives  to  it 


PALATE,  PARALYSIS  OF.  1083 
the  1 twang  ’ which  only  the  n and  ng  sounds 
should  possess.  The  explosive  consonants  can- 
not be  well  pronounced,  because  the  open  passage 
through  the  nose  prevents  the  air  being  suf- 
ficiently compressed  to  give  the  sudden  sound 
when  the  passage  between  the  lips  is  open. 
Hence  p and  b become  f and  v. 

Unilateral  paralysis  of  the  palate  causes  little 
interference  with  deglutition.  The  chief  muscles 
which  raise  the  palate  meet,  it  will  be  remem- 
bered, in  the  middle  line  of  the  soft  palate,  and 
for  this  reason  one  muscle  is  able  to  effect  suffi- 
cient elevation  of  the  whole  palate  to  prevent  the 
regurgitation  of  liquids.  The  voice  may  have  a 
slight  nasal  twang,  but  the  articulation  of  the 
labial  explosives  is  not  interfered  with.  When 
at  rest,  the  paralysed  half  is  usually  a little  lower 
than  the  other.  The  uvula  is  said  to  be  oblique, 
inclined  towards  the  opposite  side.  It  is,  how 
ever,  sometimes  straight  in  the  middle  line.  A 
change  in  form  when  the  azygos  contracts  may 
be  expected,  but  is  not  always  to  be  observed. 
The  chief  indication  of  the  paralysis  is  the  un- 
equal movement,  which  is  best  recognised  during 
the  utterance  of  the  sound  ‘ ah.’  The  elevation 
of  the  middle  part  being  confined  to  one  side,  the 
base  of  the  uvula  is  drawn  a little  towards  the 
non-paralysed  side,  and  a dimple  forms  above 
the  bas9  of  the  uvula  on  that  side  only.  By  fara- 
disation a difference  in  the  contractility  of  the 
muscles  may  be  recognised,  but  the  special  ap- 
paratus and  difficulties  of  application  render  this 
test  not  one  of  general  application.  Unilateral 
paralysis  of  the  palate  is  often  associated  with 
paralysis  of  the  vocal  cord  on  the  same  side,  and 
often  with  paralysis  and  wasting  of  the  same  side 
of  the  tongue.  This  combination  is  met  with  es- 
pecially when  there  is  pressure  on  the  nerves  at 
the  anterior  part  of  the  medulla.  The  paralysis 
of  the  tongue  is,  of  course,  due  to  disease  of  the 
roots  of  the  hypoglossal ; that  of  the  vocal  cord 
to  damage  to  the  highest  roots  of  the  spinal  ac- 
cessory nerve.  These  nerves-fibres  arise  in  prox- 
imity, and  the  association  of  these  three  paralyses 
(first  pointed  out  by  Dr.  Hughlings  Jackson)  con- 
stitutes strong  evidence  that  the  nerve-supply  to 
the  levator  palati  is  derived  from  one  of  these 
nerves. 

Diagnosis. — The  recognition  of  bilateral  para- 
lysis of  the  palate  depends  on  its  immobility  on 
voluntary  and  reflex  stimulation ; that  of  unilate- 
ral paralysis  essentially  on  the  inequality  of  move- 
ment in  the  utterance  of  certain  sounds.  Difficulty 
in  diagnosis  is  due  to  the  frequent  inequality  of  the 
arches,  and  obliquity  of  the  uvula.  The  latter  is 
so  common  undernormal  conditions  thatno  weight 
can  be  attached  to  it  as  an  indication  of  paralysis. 
The  opinion  that  the  palate  is  sometimes  para- 
lysed in  facial  paralysis  rests  apparently  upon 
the  uvula  being  found  to  be  oblique,  and  observ- 
ers have  been  strangely  puzzled  by  the  frequency 
with  which  the  uvula  deviates  to,  as  well  as 
from,  the  paralysed  side,  and  have  formed  various 
ingenious  theories  to  account  for  the  phenomenon. 
The  writer  has  never  observed  any  defective 
movement  of  the  palate  or  uvula  in  facial  para- 
lysis, although  he  has  looked  carefully  for  it  in 
scores  of  cases  of  various  kinds.  In  the  face  of 
the  strong  assertions  which  have  been  made,  hu 
does  not  venture  to  deny  its  occurrence,  but  ha 


1084  PALATE,  PARALYSIS  OF. 
is  convinced  that  most  of  tho  supposed  instances 
have  been  examples  of  natural  obliquity. 

Prognosis  and  Treatment. — The  prognosis 
and  treatment  of  paralysis  of  the  palate  are 
those  of  its  causes.  Locally  the  muscles  may  be 
galvanised  by  a long  electrode,  insulated  ex- 
cept at  its  extremity,  and  furnished  with  a con- 
tact key,  so  that  the  circuit  is  not  completed 
until  the  instrument  is  in  position.  The  difficulty 
of  applying  electricity  for  any  length  of  time 
lessens,  however,  its  practical  value  as  a means 
of  treatment.  Food  which  is  semi -solid  is  usually 
swallowed  better  than  liquids. 

2.  For  other  diseases  of  the  palate  see  Throat, 
Diseases  of.  W.  R.  Gowers. 

PALERMO,  in  Sicily.  — Moist,  warm, 
equable,  winter  climate.  Mean  temperature 
winter,  52'7°  Fahr.  Eighty  days’  rain.  Season, 
October  to  April.  See  Climate,  Treatment  of 
Disease  by. 

PALLIATIVE  {pallium , a cover). — A term 
u-ed  in  connection  with  the  treatment  of  dis- 
ease. when  it  is  directed  merely  to  the  relief  or 
mitigation  of  symptoms.  See  Disease,  Treat- 
ment of. 

PALLOR  (Lat.). — Stnon.  : Fr.  Palcur; 
Ger.  Bldsse. 

This  term,  which  signifies  whiteness  or  ab- 
sence of  colour,  is  generally  applied  in  descrip- 
tive  medicine  and  pathology  in  connection 
with  the  state  of  the  blood-supply  of  any  part 
or  organ.  Pallor  then  denotes  extreme  de- 
ficiency of  that  healthy  colour  of  the  tissues 
which  is  referable  to  the  presence  of  the  red- 
corpuscles  in  the  capillaries ; and  indicates 
anaemia,  whether  due  to  contraction  of  the 
blood-vessels,  diminution  in  the  quantity  of 
blood  generally,  reduction  in  the  number  of  red- 
corpuscles,  or  relative  deficiency  of  hsemaglobin 
in  the  individual  corpuscles.  In  clinical  medi- 
cine, pallor  is  most  frequently  associated  with 
the  visible  portions  of  the  surface,  especially  the 
face,  tho  lips,  and  the  conjunctivae  ; or  with  parts 
which  may  be  readily  seen  by  special  methods 
of  examination,  such  as  the  tongue,  fauces, 
larynx,  mucous  membrane  of  the  nose,  and  fundus 
of  the  eye.  Sec  Anaemia.  J.  Mitchell  Bruce. 

PALPATION  (palpo , I handle  gently). — A 
method  of  physical  examination,  in  which  the 
hands  are  employed  to  appreciate  certain  condi- 
tions perceptible  by  the  sense  of  touch.  See 
Physical  Examination. 

PALPITATION  ( palpito , I beat  or  throb). 
See  Heart,  Palpitation  of. 

PALSY.  — A popular  synonym  for  motor 
paralysis.  See  Paralysis. 

PALSY,  Shaking. — A synonym  for  paralysis 
agitans.  See  Paralysis  Agitans. 

PALUDAL  I , , , , n, 

PALUSTRAL  J (Palus>  a marsh).-Of  or 

belonging  to  a marsh.  A term  generally  used 
in  connection  with  malarial,  or  marsh  fevers,  on 
account  of  their  frequent  aetiologieal  association 
with  marshes.  See  Malaria. 

PANCREAS,  Diseases  of. — Synon.  : Er. 
Maladies  du  Pancreas ; Ger.  KrasiTcheitcn  der 
Panekspeicheldriise.  I 


PANCREAS,  DISEASES  OF. 

The  pancreas  is  an  organ  of  great  important 
in  the  animal  economy,  as  it  produces  a secre- 
tion of  essential  value  in  the  process  of  diges-1 
tion.  Nevertheless,  owing  to  the  eomparativt 
rarity  of  its  diseases,  their  frequent  associatio: 
with  other  lesions  when  they  do  exist,  the  posi- 
tion and  relations  of  the  organ  in  the  abdomen 
and  other  causes,  it  must  be  acknowledged  that 
perhaps  there  is  no  organ  in  the  body  diseasi 
of  which  it  is  more  difficult  to  recognise  during 
life,  at  least  with  anything  like  certainty.  Ai 
the  same  time,  it  may  be  remarked  that  if"  more 
attention  were  paid  to  the  pancreas  by  the  gene- 
ral body  of  medical  practitioners,  our  knowledge' 
concerning  its  morbid  states  would  probably! 
be  greatly  increased,  and  we  should  have  more 
definite  and  precise  data  upon  which  to  form  r 
diagnosis.  Many  seem  to  forget  entirely  thai 
there  is  such  an  organ,  and  even  when  symptoms 
or  signs  point  to  it  with  sufficient  clearness 
at  any  rate  as  being  the  possiblo  seat  of  mis- 
chief, they  ignore  it  altogether,  and  it  neve; 
seems  to  enter  into  their  calculatioa  The  writer'; 
experience  has  constrained  him  at  the  commenir- 
ment  of  this  article  to  offer  these  remarks;  but 
on  the  other  hand,  he  feels  it  his  duty  to  wan 
against  attaching  too  much  importance  to  the 
pancreas,  and  emphatically  to  express  his  dis- 
sension from  all  views  which  attribute  the  origin 
of  certain  special  diseases  to  functional  disorder; 
of  this  organ. 

Symptomatology. — Before  considering  the 
diseases  of  the  pancreas  individually,  it  will  be 
expedient  to  discuss  generally  the  clinical  phe- 
nomena which  may  arise  when  this  organ  is  in- 
volved. The  most  striking  of  these  are  due,  not 
so  much  to  the  implication  of  the  pancreas  it-! 
self,  as  to  its  effects  upon  other  structures  with 
which  it  is  anatomically  so  closely  related ; tc 
their  being  involved  in  the  morbid  condition 
or  to  the  intimate  relation  existing  between  its 
vessels  and  nerves,  and  those  of  other  organs. 

1.  Subjective  sensations. — Subjective  sen- 
sations cannot  be  said,  as  a rule,  to  be  of  much 
value  in  the  diagnosis  of  pancreatic  affections, 
They  are  often  absent,  even  when  there  is  grave 
disease ; and  when  present  are  in  many  cases  o. 
a very  indefinite  character.  As  regards  their  site 
the  localisation  of  morbid  sensations  deep  in  the 
abdomen,  in  the  region  of  the  pancreas,  a little 
abovo  the  umbilicus,  might  point  to  this  organ 
There  is  no  reliance  whatever  to  be  placed  upon 
the  influence  of  changes  of  posture  in  modifying 
them,  as  has  been  affirmed.  'With  respect  to  theii 
nature  and  causation,  it  may,  in  rare  instances 
happen  that  pain  is  felt  in  the  pancreas  itself 
or  there  may  be  merely  an  ill-defined  sense  cl 
uneasiness  and  discomfort,  or  of  weight  and  op- 
pression. Deep  pressure  may  then  bring  out 
more  pain  or  oppression,  or  these  feelings  may 
only  be  experienced  when  such  pressure  is  made 
More  commonly,  however,  pancreatic  disease 
gives  rise  to  subjective  sensations  by  its  effect; 
on  surrounding  structures.  It  may  cause  pan 
and  a more  superficial  tenderness  than  usual,  by 
irritating  the  overlying  peritoneum.  IN  hen  the 
organ  is  enlarged  and  heavy,  it  may  produce 
sensation  of  stretching  and  dragging,  amounting 
occasionally  to  actual  pain,  and  it  is  probable 
that  under  these  circumstances  different  postures 


PANCREAS,  DISEASES  OF. 


Kght  influence  the  sensation,  it  being  most  felt 
, the  erect  posture.  The  most  important  pain, 
iwever,  connected  frith  pancreatic  disease  is 
at  due  to  implication  of  the  solar  plexus  and 
s ganglia,  of  -which  the  writer  has  met  with 
L striking  examples.  Sometimes  acute  inflam- 
ation  occurs,  when  the  pain  is  of  an  acute  cha- 
rter; or  more  commonly  the  nerves  are  merely 
[citated,and  this  is  attended  with  paroxysms  of 
vere  neuralgia  pain  shooting  in  various  direc- 
ts, which  may  amount  to  extreme  agony.  In 
jtlier  case  there  is  a feeling  of  great  oppression, 
stlessness  and  anxiety,  with  a tendency  to 
intness,  or  actual  syncope  or  collapse.  The 
ifering  maybe  very  obvious  in  the  appearance 
the  patient.  In  one  case  the  pain  was  greatly 
lieved  by  pressure.  It  might  be  supposed  that 
paroxysmal  pain  would  be  associated  with  the 
ssage  of  pancreatic  calculi,  but  of  its  occur- 
,nce  there  is  no  adequate  proof.  It  might  happen 
at  a continuous  dull  pain  arises  from  erosion 
the  spine,  as  the  result  of  pancreatic  disease. 
,2.  Disorders  of  Secretion. — It  may  be  re- 
tried as  a settled  point  in  physiology  that  the 
ncreatic  secretion  is  concerned  in  the  digestion 
the  starchy,  albuminous,  and  fatty  elements  of 
pd;  and  that  it  not  only  forms  an  emulsion 
|th the  fat,  but  breaks  it  up  into  fatty  acids  and 
ycerine.  Hence  it  might  be  anticipated  that 
ry  obvious  and  definite  consequences  would 
iso  from  any  disorder  of  this  secretion,  whether 
acting  the  quantity  which  is  formed  or  which 
aches  the  intestine,  or  the  quality  and  com- 
isition  of  the  fluid.  Such  consequences  have 
en  attributed  to  pancreatic  diseases,  though 
air  connection  has  been  by  no  means  clearly 
oved. 

Hyper-secrction  has  been  supposed  to  give  rise 
a form  of  pyrosis,  the  pancreatic  juice  entering 
i stomach,  and  being  discharged  through  the 
utth  by  the  act  of  eructation,  as  a more  or 
s slimy  and  viscid  fluid ; or  there  being  a 
istant  spitting  of  a fluid  like  saliva.  This 
5 likewise  been  attributed  to  salivation,  the 
i.ivary  glands  secreting  unduly,  either  from 
mpathy  or  vicariously — but  this  is  a mere 
Viory.  A form  of  chronic  diarrhoea  has  also 
:n  attributed  to  excess  of  pancreatic  secretion, 

' ich  might  at  the  same  time  be  of  irritating 
ulity,  and  this  formerly  received  the  name  of 
'i  rrhoea  or  Jlitxus pancrcaticus,  and  was  supposed 
lj)e  characterised  by  the  discharge  in  the  stools 
i i quantity  of  viscid  or  tenacious  liquid.  That 
trie  is  any  such  special  form  of  diarrhoea  is, 
i:vever,  extremely  doubtful. 

\ deficiency  or  absence  of  pancreatic  juice  from 

I intestinal  canal,  or  an  abnormal  quality  of 
1 3 secretion,  may  be  attended  with  phenomena, 

II  bably  of  a more  reliable  character,  although 
He  again  caution  is  needed ; among  other 
i sons  because  it  must  be  remembered  that  the 
o irent  secretions  employed  in  digestion  tend  to 
t ce  up  for  each  other’s  deficiencies.  It  is  not 
tikely  that  these  disorders  may  assist  in  origi- 
r mg  symptoms  indicating  deranged  intestinal 
dpstion  as  well  as  constipation.  More  rmpor- 
t : and  definite  phenomena,  however,  have  been 
t rred  to  this  cause.  The  chief  of  these  is  the 
f sence  of  a quantity  of  free  fat  or  oily  matter 
» he  stools,  which  has  not  been  digested  and 


108.5 

absorbed,  owing  to  the  want  of  pancreatic  juice. 
By  some  writers  this  symptom  has  been  regarded 
under  certain  circumstances  as  pathognomonic 
of  pancreatic  disease.  It  has  been  found  in  a 
considerable  number  of  cases,  and  experimental 
investigations  lend  support  to  the  importance 
of  the  phenomenon.  On  the  other  hand,  it  has 
been  chiefly  noticed  where  the  entrance  of  bile 
into  the  intestine  was  at  the  same  time  inter- 
fered with,  and  sometimes  when  this  condition 
alone  was  present,  the  pancreas  being  healthy  ; 
while  it  certainly  is  not  always  observed  even 
:n  grave  organic  disease  of  the  pancreas,  as  the 
writer  can  testify.  The  amount  of  the  fat  has 
varied  much  in  different  cases,  and  also  its  cha- 
racter. It  has  come  away  like  oil,  with  scarcely 
any  fecal  matter ; or,  after  standing,  oil  has 
floated  on  the  surface  of  liquid  feces.  In  other 
instances  lumps  of  fat  have  been  discharged, 
white  or  pale  yellow  and  tallow-like,  and  the 
stools  have  even  consisted  almost  entirely  of 
these  lumps.  In  other  cases,  again,  it  has  been 
more  or  less  crystalline  ; or  an  oily  fluid  was 
discharged,  which  condensed  on  cooling,  either 
around  the  containing  vessel,  or  on  the  surface 
of  the  feces.  It  has  been  observed  occasionally 
that  the  fat  was  far  greater  in  quantity  than 
had  been  taken  as  food ; this  has  been  accounted 
for  by  the  absorption  of  fat  from  the  general 
system,  in  connection  with  wasting,  to  which  re- 
ference will  again  be  made,  and  its  escape  from 
the  vessels  into  the  intestinal  canal.  Another 
condition  of  the  stools  attributed  to  want  of  pan 
creatic  secretion  is  the  presence  of  an  abundance 
of  undigested  muscular  tissue  in  them  ; but  it  is 
obvious  that  this  can  in  no  respect  be  regarded 
as  a reliable  sign. 

It  will  not  be  out  of  place  to  refer  here  to 
the  proved  value  of  the  pancreas  itself,  or  of 
preparations  made  from  it  and  containing  the 
active  principles  of  its  secretion,  in  aiding 
digestion  in  many  cases,  or  in  digesting  certain 
foods  before  administering  them,  especially 
according  to  the  plan  so  admirably  worked  out 
by  Dr.  William  Roberts  ( see  Peptonized  Food). 
This  may  prove  of  some  consequence  in  relation 
to  the  diagnosis  of  pancreatic  diseases,  for  it 
has  been  suggested  that  if,  with  the  doily  ad- 
ministration of  calf's  pancreas,  the  conditions 
of  the  stools  above  described  disappear,  this  is 
an  additional  sign  of  the  existence  of  pancreatic 
disease. 

3.  Symptoms  from  physical  effects. — The 
intimate  relations  of  the  pancreas  to  important 
structures  in  its  vicinity  give  rise  to  some  of 
the  most  striking  symptoms  associated  with  its 
diseases,  apart  from  the  mere  subjective  sensa- 
tions already  referred  to.  Of  these,  one  of  the 
chief  is  permanent  jaundice,  which  often  be- 
comes extreme,  due  to  closure  of  the  bile-duct. 
In  the  writer’s  opinion  this  symptom  becomes 
under  certain  circumstances  a most  important 
evidence  of  pancreatic  disease.  The  pylorus  or 
duodenum  are  also  very  liable  to  be  obstructed, 
thus  leading  to  chronic  vomiting,  often  obstinate, 
with  signs  of  dilatation  of  the  stomach ; by  pres- 
sure on  the  body  of  this  organ  pancreatic  disease 
has  been  known  gravely  to  disturb  its  functions, 
and  even  to  obstruct  its  cavity ; or  it  has  ulcer- 
ated through  its  walls,  and  given  rise  to  gastric 


1080  PANCREAS, 

perforation  and  haematemesis.  The  vessels  in 
relation  to  the  pancreas  are  also  important,  as 
being  liable  to  be  obstructed,  and  thus  to  give 
rise  to  symptoms.  The  veins  are  especially  to  be 
remembered,  namely,  the  portal,  superior  and 
inferior  mesenteric,  and  splenic,  which  may  be 
pressed  upon  or  closed  by  thrombosis.  Henc6 
may  arise  ascites,  intestinal  haemorrhage,  en- 
larged spleen,  and  other  phenomena,  although  in 
the  writer’s  experience  they  have  been  absent. 
The  vena  cava  inferior  or  the  aorta  may  also 
he  more  or  less  compressed,  and  in  the  latter 
case  a pulsation  or  even  a murmur  may  be 
.ransmitted  through  the  pancreas,  simulating  an 
aneurism ; indeed  this  lesion  has  been  actually 
caused  by  tile  compression  of  the  aorta  by  an 
enlarged  pancreas.  By  the  extension  of  pan- 
creatic disease  other  structures  at  a more  or  less 
remote  distance  may  be  interfered  with;  thus 
the  ascending  colon  has  been  obstructed,  and 
also  the  ureter,  leading  to  hydronephrosis. 

4.  General  symptoms. — It  certainly  hap- 
pens that  pancreatic  disease  is  not  uncommonly 
attended  with  marked  general  symptoms,  in  the 
direction  of  wasting,  which  may  reach  extreme 
emaciation,  with  proportionate  debility  and 
anaemia.  There  are  strong  reasons  for  conclud- 
ing, however,  that  these  do  not  depend  merely 
on  the  want  of  pancreatic  secretion,  provided 
the  other  secretions  are  in  sufficient  quantity  to 
make  up  for  it.  In  those  cases  in  which  the 
general  symptoms  are  observed,  there  are  other 
causes  to  account  for  them,  such  as  absence  of 
bile  from  the  intostine  as  well  as  of  pancreatic 
juice,  the  nature  of  the  disease  itself,  interference 
with  the  passage  of  food  through  the  pylorus 
or  along  the  duodenum,  the  implication  of  other 
structures  besides  the  pancreas,  or  the  presence 
of  severe  pain,  causing  much  constitutional  dis- 
turbance. It  has  been  suggested  that  some 
cases  of  so-called  Addison’s  disease,  with  bronzed 
skin,  are  due  to  pancreatic  disease,  but  this  only 
occurs  when  the  solar  plexus  becomes  involved 
in  a certain  morbid  process.  Patients  suffering 
from  grave  pancreatic  disease  are  often  very  low- 
spirited  and  despondent.  This  may  be  easily 
accounted  for,  without  attributing  any  peculiar 
influence  to  the  pancreas  in  relation  to  melan- 
cholia and  hypochondriasis,  a notion  which  was 
at  one  time  advanced  and  entertained. 

5.  Changes  in  the  Urine. — In  exceptional 
cases  of  pancreatic  disease  it  has  been  affirmed 
that  fat  appeared  in  the  urine  as  well  as  in  the 
stools,  either  in  the  form  of  oil-globules,  or  of 
a greasy  substance,  becoming  like  butter  on 
cooling.  This  was  supposed  to  be  due  to  the 
absorption  of  fat  in  the  process  of  wasting,  but 
further  observations  are  needed  on  the  subject. 
More  important  is  the  fact  that  various  morbid 
conditions  of  the  pancreas  have  been  found  asso- 
ciated with  diabetes.  These  conditions  include 
chronic  inflammatory  enlargements,  atrophy, 
fatty  degeneration,  pancreatic  calculi,  and  cys- 
tic dilatation  of  the  ducts.  In  some  instances 
diabetes  follows  the  pancreatic  disease ; in 
others  it  precedes  it.  In  either  case  the  diabetic 
condition  probably  depends,  not  on  the  pancreas, 
but  on  the  implication  of  the  solar  and  cceliae 
plexuses  and  semi-lunar  ganglia,  which  un- 
doubtedly are  sometimes  concerned  in  the  de- 


DISEASES  OF. 

velopment  of  glycosuria.  A theory  has  beer 
advanced  to  account  for  the  presence  of  sugai 
in  the  urine,  founded  on  the  power  of  the  pan- 
creatic secretion  in  decomposing  fats  and  set 
ting  glycogen  free,  but  for  this  hypothesis  there 
is  no  foundation. 

6.  Physical  signs. — It  is  only  in  very  ran 
instances  that  physical  examination  can  de- 
tect the  pancreas  in  health,  and  most  of  its; 
diseases  do  not  alter  the  organ  in  such  a manner 
as  to  render  such  examination  of  any  value  in! 
diagnosis.  Moreover,  even  more  or  less  marked 
physical  changes  are  often  difficult  to  be  detected,; 
owing  to  the  situation  of  the  pancreas,  and  tc 
distension  of  the  stomach,  or  pushing  forward 
of  the  liver.  It  may  be  affirmed  that  palpation 
or  manipulation  is  really  the  only  practicable! 
mode  of  examination  in  the  investigation  oi 
pancreatic  diseases,  and  it  must  be  made  when 
the  stomach  and  transverse  colon  are  empty,  and 
the  abdominal  muscles  thoroughly  relaxed.  The 
patient  should  not  only  lie  on  his  back,  but  in 
some  cases  help  may  he  derived  from  placing 
him  on  his  elbows  and  knees;  and  pressure 
should  not  merely  be  made  deeply  from  before 
backwards,  but  with  both  hands  laterally  from 
the  hypochondriac  regions.  It  may  be  possible 
to  detect  a general  enlargement  of  the  pancreas, 
as  a slightly  movable  swelling,  lying  across  the 
abdomen  in  its  usual  position ; but  the  im- 
portant condition  to  be  looked  for  is  a tumour  of 
the  head  of  the  organ,  which  is  deeply  situated, 
always  of  small  dimensions,  rounded,  smooth  or 
nodular,  usually  very  firm  or  hard,  and  firmly 
fixed,  as  if  it  were  rooted  in  the  depths  of  the 
abdominal  cavity.  Even  if  such  a condition 
were  found,  however,  it  would  be  difficult  to 
associate  it  distinctly  -with  the  pancreas  alone, 
but  for  all  practical  purposes  it  would  be  suffi- 
cient for  diagnosis.  The  possibility  of  an  en- 
larged pancreas  being  the  means  of  communicat- 
ing a pulsation  or  murmur  from  the  abdominal 
aorta  has  been  previously  alluded  to. 

Special  Diseases. — Excluding  certain  condi- 
tions of  the  pancreas,  which  are  of  little  or  no 
practical  importance,  such  as  malformations, 
displacements,  and  certain  exceptional  cases  oi 
sudden  haemorrhage  into  its  substance,  the  in- 
dividual diseases  of  the  pancreas  may  be  con- 
veniently considered  under  two  main  groups, 
namely : — 

1.  Acute  Inflammation. 

2.  Chronic  Diseases. 

1.  Acute  Inflammation.  — Svxox. : -Acute 
Pancreatitis. — This  is  an  extremely  rare  disease 
and  it  is  one  which,  even  when  it  does  occur,  is 
with  great  difficulty  recognised  during  life.  The 
results  of  the  inflammatory  process  vary  under 
different  circumstances. 

^Etiology. — Acute  pancreatitis,  as  a primary 
affection,  might  possibly  arise  from  some  injury 
over  the  epigastrium,  and  it  has  occurred  under 
other  circumstances ; but  the  causes  to  which  it 
has  been  referred  are  extremely  doubtful,  and  it 
is  better  to  acknowledge  that  we  are  ignorant  as 
to  their  nature.  As  a secondary  affection,  it 
has  been  met  with  in  severe  cases  of  acute  i'ebj 
rile  diseases,  such  as  typhoid  fever  and.  acute 
tuberculosis ; and  also  inpytemie  and  septicamnc 
conditions  of  various  kinds.  It  has  been  atnrmec 


PANCREAS.  DISEASES  OF.  1087 


iat  pancreatitis  has  occurred  as  a metastatic 
iflammation,  in  connection  with  a like  eondi- 
on  affecting  the  salivary  glands  or  testicle ; but 
his  is  also  a very  questionable  statement. 
Anatomical  Characters. — These  differ  under 
ifferent  circumstances.  At  first  usually  the 
ancreas  becomes  injected  and  hypersemic,  en- 
,rged,  and  firmer  in  consistence ; and  probably, 

: some  instances,  the  changes  may  not  go 
irther,  the  gland  returning  to  its  normal  con- 
tion.  Small  haemorrhages  may  take  place 
.ito  its  cellular  tissue,  or  around  it,  or  these 
arts  may  become  the  seat  of  exudation.  Sub- 
iquently,  in  certain  forms  of  inflammation,  sup- 
..lration  is  liable  to  ensue,  either  in  the  form  of  a 
undent  infiltration,  or  of  one  or  more  abscesses, 
ginning  in  the  latter  case  as  separate  points 
1 suppuration,  which  afterwards  enlarge  and 
balesce.  It  is  a matter  of  dispute  whether  the 
fas  is  formed  within  the  ducts  and  acini,  or  in  the 
llular  tissue.  In  rare  instances  gangrene  has 
icurred,  and,  it  would  seem,  especially  where 
acre  have  been  haemorrhages.  From  mere  irri- 
tion,  or  the  bursting  of  an  abscess,  peritonitis 
ay  be  set  up.  In  the  form  of  pancreatitis  oc- 
irring  in  febrile  diseases,  the  inflammation 
.sumes  a parenchymatous  form,  other  organs 
:ing  similarly  affected,  a so-called  acute  paren- 
ymatous  degeneration  taking  place,  and  the 
and  becoming  filled  with  granular  and  turbid 
iterial,  of  an  albuminoid  nature. 

Symptoms  and  Diagnosis. — In  certain  cases 
Lite  pancreatitis  occurs  under  circumstances 
: which  no  clinical  indications  whatever  of 
eh  a disease  c in  be  expected,  or  at  least  any 
a definite  nature.  The  earlier  symptoms, 
lieh  might  lead  to  the  suspicion  of  pancreatitis, 
3 deep-seated  pain  in  the  epigastrium,  with 
stric  disturbance,  and  some  degree  of  pyrexia, 
ssibly  the  slighter  cases  may  subside  after 
s,  and  recovery  take  place.  In  those  cases, 
wev£r,  in  which  the  presence  of  the  disease 
. 5 been  verified,  tho  pain  has  speedily  become 
: ense  and  continuous,  and  either  of  a dull 
Mracter,  or  shooting  towards  the  back  or  shoul- 

0.  This  was  accompanied  with  deep  tender- 
hs,  and  tension  of  the  epigastrium,  preventing 
i imination  being  made.  The  gastric  symptoms 
1 ame  more  marked,  including  eructations,  nau- 

1 , and  vomiting  of  a thin  or  viscid  liquid,  ofren 
( taining  bile.  There  was  thirst,  and  the 
! vels  were  constipated.  Other  symptoms  in- 
< led  great  restlessness,  praecordial  anxiety, 
1 ried  breathing,  and  a tendency  to  syncope, 
i h weak  pulse.  In  fatal  cases  the  symptoms 
i idly  became  worse,  and  death  was  preceded 
l the  usual  signs  of  collapse.  Most  of  these 
I nomena  havo  been  attributed  to  implication 
c he  solar  plexus.  Signs  of  peritonitis  might 
a!  e.  The  diagnosis  of  acute  pancreatitis  must 
a ays  be  extremely  uncertain,  but  in  endeavour- 
i to  make  it,  it  is  important  to  try  to  exclude 
ap  gastritis  or  duodenitis,  and  conditions  con- 
ned with  the  liver  or  bile-ducts.  This  affee- 
t does  not  seem  ever  to  cause-jaundice. 

reatmext. — But  little  can  be  definitely  said 
o his  matter.  The  most  obvious  indications 
Q to  keep  the  patient  at  rest ; to  give  only 
6 11  quantities  of  liquid  food ; to  relieve  the 
P i and  gastric  symptoms  by  means  of  ice, 


effervescents,  with  hydrocyanic  aciu,  opium,  or 
morphia,  and  other  suitable  remedies ; to  open 
the  bowels ; and  to  give  stimulants  for  the 
support  of  the  patient,  when  these  seem  to  be 
called  for.  Ice,  or,  on  the  other  hand,  fomenta- 
tions or  poultices,  might  be  applied  with  ad- 
vantage over  the  epigastrium  in  different  cases  ; 
and  it  has  been  recommended  to  apply  a few 
leeches.  Peritonitis  must  be  treated  if  it  should 
be  set  up. 

2.  Chronic  Diseases. — It  will  be  most  con- 
venient to  indicate,  in  the  first  place,  the  nature 
and  origin  of  the  several  chronic  diseases  of  the 
pancreas  ; and  then  to  discuss  as  a whole  their 
clinical  relations  and  treatment. 

(a)  Changes  affecting  circulation. — Under  this 
head  it  will  only  be  necessary  to  mention  that, 
in  cases  of  general  anaemia,  the  pancreas  suffers 
along  with  other  organs ; that  in  ail  conditions 
which  impede  the  portal  circulation,  w’hether  in 
connection  with  the  liver,  or  with  the  heart  or 
lungs,  this  organ  becomes  the  seat  of  mechanical 
venous  congestion  and  its  consequences;  and 
amongst  the  latter  haemorrhage  is  to  be  noted, 
which  occurs  in  separate  points,  the  blood  sub- 
sequently undergoing  changes,  and  its  sites 
being  indicated  by  altered  pigment,  or  by  spaces 
containing  coloured  serum,  and  having  pigmented 
walls.  Considerable  haemorrhages,  leading  to  the 
formation  of  apoplectic  cysts,  may  take  place 
into  the  pancreas,  as  the  result  of  rupture  of  a 
diseased  artery.  A peculiar  form  of  haemorrhage 
has  been  observed  in  connection  with  this  organ, 
in  which  it  becomes  haemorrhagic  throughout, 
and  no  marked  change  can  be  found  in  its  sub- 
stance or  in  its  vessels.  Cases  of  this  kind  seem 
to  be  sudden  in  their  onset,  and  rapidly  prove 
fatal,  but  their  nature  and  the  real  cause  of  death 
are  undetermined. 

( h ) Changes  in  growth. — -Many  cases  of  either 
general  or  partial  hypertrophy  of  the  pancreas 
have  been  described;  but  some  writers  doubt  the 
reality  of  a true  hypertrophy  or  hyperplasia  of 
the  glandular  elements,  and  maintain  that  the 
increase  in  size  and  weight  of  the  organ  in  these 
cases  was  due  to  an  increase  in  the  interstitial 
tissue,  or  to  other  causes.  This  is  one  of  the  con- 
ditions said  to  have  been  observed  in  connection 
with  diabetes.  Atrophy  is  an  undoubted  morbid 
condition  to  which  tho  pancreas  is  liable.  It  has 
been  observed  as  the  result  of  old  age  ; in  cases 
of  general  wasting  from  various  causes ; in  con- 
nection with  diabetes,  where  it  may  become  ex- 
treme ; or  from  certain  local  causes,  namely,  pres- 
sure upon  the  gland  by  morbid  conditions  in  its 
vicinity,  or  by  diseases  within  the  organ  itself. 
The  degree  of  wasting  varies ; but  it  may  be  so 
considerable  that  nothing  is  left  except  a fibrous 
cord  indicating  the  former  site  of  the  pancreas. 
In  lesser  degrees  the  change  is  often  associated 
with  more  or  less  fatty  degeneration. 

(c)  Chronic  Inflammation. — That  the  pancreas 
is  subject  to  a chronic  inflammatory  process  can- 
not be  doubted,  but  it  is  by  no  means  clear  what 
should  be  included  under  this  term.  The  condi- 
tion usually  recognised,  and  which  is  most  com- 
mon, is  that  in  which  the  organ  becomes  more 
or  less  cirrhotic  or  fibroid,  either  throughout  its 
whole  extent  or  in  some  portions  of  it ; the  head 
is  very  liable  to  be  thus  affected.  The  changoa 


PANCREAS,  DISEASES  OF. 


1088 

essentially  consist  in  an  increase  of  the  interstitial 
connective  tissue,  with  wasting  of  the  glandular 
structures,  and  the  organ  becomes  proportionately 
indurated,  dense,  firm,  and  tough,  and  may  be 
granular  or  irregular.  Distinct  tracts  of  con- 
nective tissue  may  be  visible.  This  form  of 
chronic  pancreatitis  may  in  various  degrees  result 
from  prolonged  venous  congestion ; chronic  al- 
coholism, especially  indulgence  in  strong  spirits ; 
retention  of  the  pancreatic  secretion,  with  dila- 
tation of  the  ducts;  the  irritation  of  morbid 
growths,  such  as  cancerous  or  syphilitic  growths  ; 
or  neighbouring  disease,  which  affects  the  pan- 
creas either  by  directly  spreading  to  it,  or  by 
causing  pressure  or  irritation.  In  some  of  these 
cases  a chronic  parenchymatous  inflammation 
seems  also  to  be  going  on. 

Very  rarely  the  pancreas  becomes  the  seat  of 
chronic  suppurative  inflammation,  either  by  ex- 
tension from  parts  around,  or  from  conditions  in 
the  organ  itself,  such  as  the  presence  of  calculi  or 
the  formation  of  cysts.  The  pus  either  infiltrates 
or  collects  in  one  or  more  abscesses,  and  the  latter 
may  burst  into  the  abdominal  cavity  or  other 
parts,  or  dry  up  and  become  calcareous.  Caseous 
masses,  following  chronic  inflammation,  may  form 
in  the  pancreas,  associated  with  similar  products 
elsewhere,  in  cases  of  scrofulous  or  tubercular 
disease. 

(cf)  Degenerations. — The  pancreas  is  liable  to 
the  usual  two  forms  of  fatty  change,  namely,  a 
fatty  hypertrophy  or  infiltration,  associated  with 
obesity,  which,  though  affecting  the  interstitial 
tissue,  may  eventually  cause  complete  wasting  of 
the  glandular  structure  by  pressure  ; and  fatty 
degeneration,  which  affects  the  gland-cells  them- 
selves ; or  the  two  conditions  may  be  associated. 
In  simple  fatty  degeneration  the  organ  becomes 
gradually  smaller,  softened,  and  flaccid ; pale 
or  whitish-yellow  or  brownish ; but  its  acini  are 
distinct.  A fatty  emulsion  may  form  in  the  ducts. 
The  products  of  degeneration  are  absorbed  or 
discharged,  and  coincident  atrophy  takes  place, 
so  that  at  last  the  organ  may  entirely  disappear. 
This  degeneration  has  been  noticed  as  the  result 
of  alcoholism,  in  wasting  diseases,  and  in  cases 
of  diabetes. 

Amyloid  disease  may  affect  the  pancreas,  but 
it  cannot  be  said  to  be  of  any  practical  conse- 
quence. 

(e)  Morbid  Growths-  Cancer  is  the  most  impor- 
tant disease  affecting  the  pancreas.  The  growth 
is  usually  of  the  scirrhous  variety,  rarely  of  an 
encephaloid,  a melanotic,  or  a colloid  nature.  In 
most  cases  it  is  secondary,  the  organ  being  usually 
involved  by  extension  from  neighbouring  struc- 
tures, or  now  and  then  a distinct  growth  being 
formed ; but  it  also  occurs  as  a primary  affection. 
Pancreatic  cancer  is  decidedly  more  frequent  in 
males  than  females,  and  it  is  rare  under  forty 
years  of  age.  The  writer  has,  however,  known  it 
to  occur  in  a young  man  twenty-three  years  old. 
Primary  cancer  has  been  attributed  to  injury 
over  the  epigastrium.  As  a rule  the  head  is  first 
implicated,  rarely  the  body  or  tail ; often  the 
disease  remains  confined  to  the  head,  but  in  other 
instances  it  spreads,  so  as  finally  to  involve  the  en- 
tire organ,  or  separate  deposits  form.  V hen  the 
morbid  condition  is  confined  to  the  head,  it  pre- 
sents a more  or  less  rounded  tumour,  varying  in 


size,  but  never  attaining  large  dimensions ; somf 
what  irregular  or  nodular;  very  dense  and  hard  i 
consistence ; and  whitish  on  section.  If  the  entir 
gland  be  affected,  similar  appearances  are  evider 
throughout  its  whole  extent;  but,  if  not,  th 
unaffected  portion  may  be  the  seat  of  atrophj 
chronic  inflammation,  or  dilatation  of  the  duct! 
with  the  formation  of  calculi.  Distinct  sma 
tumours  are  found  in  some  instances.  If  th 
cancer  be  of  other  kinds  than  seirrhus,  it  will  pr; 
sent  the  characters  peculiar  to  each.  Usually  i 
exhibits  under  the  microscope  the  structure  ( 
scirrhous  cancer,  there  being  a large  amount  ( 
fibrous  stroma. 

Pancreatic  cancer  always  affects,  in  some  way  c 
other,  neighbouring  structures.  It  may  simpl 
press  upon  them ; or  it  causes  irritation,  and  tht 
sets  up  chronic  inflammation,  becoming  adherer 
to  various  parts  ; or  the  cancer  may  spread ; c, 
destruction  and  ulceration  take  place,  invoh! 
ing  the  duodenum,  stomach,  vessels,  peritonenn 
diaphragm,  vertebra,  or  other  structures;  bd 
not  uncommonly  the  parts  are  found  so  matte 
together  at  the  post-mortem  examination,  that 
is  impossible  to  separate  them,  or  to  say  whet 
the  disease  began.  The  consequences  of  the  s< 
condary  effects  of  pancreatic  disease  have  alread 
been  pointed  out,  and  need  not  be  further  di| 
cussed  here,  except  to  remark  that  the  obstrnctici 
of  the  bile-duct.,  which  is  a frequent  event,  seen 
to  be  due,  not  so  much  to  pressure  as  to  contra, 
tion  at  the  orifice  or  aloDg  the  course  of  the  due, 
the  result  of  chronic  inflammation. 

As  rare  morbid  growths  found  in  the  pancre.: 
it  will  suffice  to  mention  sarcoma ; tuberel! 
either  as  a caseous  nodule,  or  in  the  form 
granulations  ; and  syphilitic  formations,  whk 
may  be  of  the  nature  of  gummata,  or  of  a cic- 
tricial  tissue,  involving  the  gland  generally  • 
locally. 

(J)  Obstruction  and  Dilatation  of  the  Ducts- 
Cystic  formations. — The  main  duct  of  the  pi 
creas — canal  of  Wirsung — may  be  obstructed 
or  near  its  orifice ; or  some  of  its  divisions  m. 
be  thus  affected.  The  former  depends  either  upi 
conditions  outside  the  gland,  causing  pressur 
such  as  tumours  in  the  vicinity,  enlarged  gland 
a large  gall-stone  in  the  bile-duct,  or  thickenir 
and  adhesions  due  to  inflammation ; or  upon  ecr 
ditions  in  the  gland  or  duct  itself,  namely,  ma 
formations  causing  a bending  of  the  duct,  calcul 
new  growths,  chronic  interstitial  inflammation,  > 
catarrh  of  the  duct.  One  or  other  of  these  co 
ditions  also  accounts  for  any  localised  obstructio 
The  effects  of  the  obstruction  will  be  to  produi 
retention  of  the  secretion,  with  dilatation  of  tl 
main  duct  and  all  its  branches,  either  uniform 
unequal,  or  of  limited  portions  of  these,  accor 
ing  to  the  seat  of  the  impediment ; and  ultimate 
one  or  several  cysts  usually  become  develope 
which  may  attain  a considerable  size.  In  tl 
early  stage  the  contents  resemble  more  or  less  tl 
ordinary  pancreatic  secretion,  but  subsequent 
they  become  either  serous,  purulent,  hsme 
rhagic,  caseous,  or  cretaceous.  The  walls  of  t 
cysts  become  thickened  and  indurated,  and,  1 
encroaching  upon  the  substance  of  the  pancre.' 
at  the  same  time  setting  up  chronic  interstitial  i 
flammation,  they  may  ultimately  cause  comple 
destruction  of  the  organ.  These  conditions  ha 


PANCREAS 

ieen  occasionally  found  in  connection  with  dia- 
'stes.  In  rare  instances  pancreatic  cysts  have 
feen  known  to  rupture  into  the  stomach  or  duo- 
enuin.  They  have  originated,  in  exceptional 
isea.  from  haemorrhage  into  the  pancreas. 

‘(a)  Calculi  and  Parasites.- — Calculi  occasion- 
ally form  in  connection  with  the  pancreas,  either 
its  main  duet,  or,  less  frequently,  in  the  di- 
'sions,  or  in  both  places.  There  may  be  but  one, 
a large  number.  They  may  bo  very  minute,  or 
tain  the  size  of  a nut  or  walnut,  or  even  larger 
Intensions.  The  concretions  are  usually  white, 
greyish- white,  occasionally  dark  or  blackish, 
and  or  oval  in  shape,  rarely  branched,  and 
■\ooth  or  rough  on  the  surface.  As  a rule  they 
Isist  mainly  of  calcic  carbonate  or  phosphate, 

<! of  both  salts  ; very  rarely  of  solidified  protein 
nstances.  They  originate  from  the  pancreatic 
jce,  the  inorganic  constituents  of  which  are 
pcipitated,  usually  owing  to  its  retention  ; but 
i|s  supposed  that  the  products  of  catarrh  of  the 
cats,  or  an  abnormal  composition  of  the  secre- 
te, may  also  be  the  primary  cause  of  the  pre- 
e|itation  which  leads  to  the  formation  of  pan- 
(. atic  calculi.  Their  effects  have  been  already 
pnted  out  in  the  description  of  the  preceding 
chases,  and  it  will  suffice  to  mention  that  the 
picipai  conditions  they  are  liable  to  produce 
a:  dilatation  of  the  ducts  and  cysts  ; inflamma- 
f i leading  to  abscesses  ; chronic  interstitial  in- 
fiimation  and  its  consequences ; or  inflammation 
iilie  structures  around.  They  probably  escape 
home  instances  through  the  canal  of  Wirsung. 

is  regards  parasites,  it  will  be  enough  to  state 
till  roundworms  occasionally  find  their  way  into 
tlpancreatic  duct. 

mptoms. — It  will  be  easily  understood  that 
m t of  the  cases  of  chronic  disease  of  the  pan- 
els are  unattended  with  any  symptoms  draw- 
inattention  to  this  organ,  or  with  such  as  are 
at  1 characteristic,  while  a large  number  pre- 
set no  symptoms  whatever,  being  latent  from 
fir  to  last,  the  lesion  being  only  discovered  at  the 
po  mortem  examination.  Moreover,  in  the  case 
of  e affections  which  might  be  expected  to  origi- 
nal prominent  symptoms,  they  are  so  often 
as:  dated  with  morbid  conditions  of  one  or  more 
of  e other  organs  concerned  in  the  digestive 
pr ass,  or  of  other  structures,  that  it  frequently 
bejnes  most  difficult  or  impossible  to  assign  to 
eaoits  share  in  the  production  of  the  phenomena 
oMved.  Under  any  circumstances,  several  of 
thijhronic  pancreatic  diseases  which  have  been 
deshed  can  only  lead  to  more  or  less  derange- 
me,  affecting  the  formation  or  escape  of  the 
sec:  ion,  and  all  of  them  tend  to  produce  this 
res  , so  that  symptoms  might  be  expected  to 
ari,  from  this  cause,  but  those  which  are  re- 
fer d as  at  all  significant,  whether  of  excess  or 
(lefjincy  of  pancreatic  juice  in  the  intestines, 
are  dy  present  in  comparatively  few  instances, 
eve  if  those  complaints  which  are  of  a grave 
chatter. 

I. addition  to  what  has  just  been  stated,  it 
'vili  fly  be  necessary  further  briefly  to  allude 
to  Gir  points  in  the  symptomatology  of  those 
pan  atic  affections,  in  connection  with  which 
nioi.ivident  clinical  phenomena  might  be  anti- 
clPa  1 ; the  explanation  of  the  symptoms  has 
^r6W  been  sufficiently  discussed. 

69 


I,  DISEASES  OF.  108S 

Chronic  inflammation  may  be  attended  with 
deep-seated  epigastric  pain  and  tenderness,  con- 
stant or  increased  paroxysmally.  It  certainly 
tends  to  be  complicated  with  symptoms  due  to 
pressure  on  neighbouring  structures,  or  their 
implication  in  the  inflammatory  process,  such  as 
jaundice,  ascites,  or  signs  of  obstruction  of  the 
pylorus  or  duodenum;  and  glycosuria  might 
possibly  set  in.  It  very  rarely  happens  that  the 
enlarged  pancreas,  or  its  head,  can  be  detected 
on  physical  examination.  More  or  less  general 
wasting  might  be  present. 

Cancer  is  by  far  the  most  important  disease  of 
the  pancreas,  and  the  one  most  likely  to  give  rise  to 
symptoms  of  a somewhat  definite  character,  though 
even  here  there  is  often  much  uncertainty.  Deep- 
seated  epigastric  pain  is  a very  frequent  symp- 
tom, at  some  period  or  other  in  the  course  of  a case, 
and  it  has  been  regarded  as  of  much  importance  ; 
but  it  must  be  remembered  that  it  may  be  absent 
from  first  to  last,  or  may  only  come  on  late  ia 
the  progress  of  the  disease.  This  pain  is  also 
characterised  by  its  intensity,  and  the  difficulty 
experienced  in  relieving  it.  It  is  usually  more 
or  less  constant,  and  of  an  aching  or  gnawing 
character,  or  lancinating,  shooting  across  the 
epigastrium,  especially  towards  the  right,  or 
backwards  towards  the  shoulder,  or  all  over  the 
abdomen.  Sometimes  a sensation  of  burning,  or  of 
tightness  and  dragging  is  described.  An  impor- 
tant feature  often  observed  in  connection  with 
this  pain  is  that  it  tends  to  become  greatly  ag- 
gravated in  paroxysms,  of  which  the  writer  has 
seen  some  striking  examples,  where  the  attacks 
were  most  agonising  and  almost  unbearable.  It 
may  be  influenced  byfood,. coughing,  deep  breath- 
ing, movement,  or  posture.  It  is  in  some  in- 
stances decidedly  worse  in  the  erect  and  supine 
postures ; and  during  the  paroxysms  the  patient 
may  bend  forward,  and  press  upon  the  epi- 
gastrium, in  order  to  obtain  relief.  Gastric 
symptoms  are  usually  prominent  in  cases  of  pan- 
creatic cancer,  especially  nausea  and  vomiting, 
and  eructations,  much  importance  being  attached 
by  some  writers  to  the  occurrence  of  an  abun- 
dant watery  pyrosis.  The  tongue  frequently 
continues  clean  and  moist  throughout.  The 
bowels  are  constipated,  and  fatty  stools  may  be 
observed ; but  they  are  by  no  means  constant. 
Thirst  is  sometimes  a marked  symptom.  Jaun- 
dice and  other  phenomena  indicative  of  in- 
terference with  neighbouring  structures  are  of 
common  occurrence,  and  jaundice  may  be  the 
most  prominent  symptom  in  cases  of  cancer  of 
the  pancreas.  Physical  examination  is  of  essen- 
tial importance  in  the  detection  of  this  disease, 
and  it  should  be  made  again  and  again  in  doubt- 
ful cases,  under  the  most  favourable  conditions 
obtainable.  In  many  instances,  however,  nothing 
can  be  detected,  at  any  rate  of  a definite  cha- 
racter ; or  there  may  be  only  a sensation  of  undue 
firmness,  resistance,  or  induration.  Sometimes 
the  enlarged  organ  may  be  made  out;  or  a tu 
mour  of  the  head,  having  the  characters  already 
described.  The  general  symptoms  are  always  of 
a serious  character,  namely,  emaciation,  anaemia, 
weakness,  and  depression,  and  they  often  become 
extreme.  There  may  be  distiuct  signs  of  the 
cancerous  cachexia. 

Cysts  in  the  pancreas  in  rare  instances  attain 


1090  PANCREAS,  DISEASES  OF. 
such  a size  as  to  cause  an  enlargement  percep- 
tible on  examination,  in  the  form  of  a deep- 
seated  tumour,  rounded  and  smooth,  soft,  and 
perhaps  yielding  a sense  of  fluctuation.  Pressure- 
signs  might  be  present ; but  in  the  cases  observed 
there  has  been  little  or  no  pain,  and  general  symp- 
toms were  absent  or  slight. 

Calculi  in  connection  with  the  pancreas  are 
almost  always  latent,  but  they  may  produce  se- 
condary effects  causing  symptoms.  There  is  no 
authentic  history  of  any  case  of  colic  from  the 
passage  of  a pancreatic  calculus  into  the  duo- 
denum. 

Diagnosis. — Sufficient  has  been  said  in  discuss- 
ing the  symptoms  to  indicate  how  difficult  or  im- 
possible it  must  be  to  diagnose  positively,  in  the 
great  majority  of  cases,  the  existence  of  chronic 
disease  of  the  pancreas.  Cancer  is  the  affection 
most  likely  to  be  recognised  ; but  some  of  the 
others  might  be  suspected  under  certain  circum- 
stances. What  has  been  stated  will  explain  how 
they  are  to  be  distinguished  from  each  other,  but 
it  is  often  very  difficult  to  diagnose  between 
chronic  pancreatitis  and  cancer.  With  regard 
to  the  diagnosis  of  pancreatic  lesions  from  those 
affecting  some  neighbouring  structure,  it  must  be 
remembered  that  they  are  liable  to  be  involved 
together,  and  it  may  then  be  of  little  practical 
moment  to  determine  precisely  what  structures 
are  implicated.  It  is  necessary  to  be  particu- 
larly cautious  against  referring  symptoms  con- 
nected with  the  liver  or  stomach,  induced  by 
pancreatic  disease,  to  a morbid  condition  of  either 
of  these  organs  ; while  it  must  always  be  borne 
in  mind  that  enlargement  of  the  liver  may  result 
from  accumulation  of  bile,  due  to  obstruction  of 
the  hepatic  duct ; and  also  that  dilatation  of  the 
stomach  will  follow  narrowing  or  closure  of  the 
pylorus  or  duodenum.  It  may  be  stated  as  a 
general  rule  that  serious  disease  of  the  liver  or 
6tomach  will  probably  reveal  itself  by  obvious 
signs ; and  if  this  can  be  excluded  in  certain 
cases,  the  diagnosis  of  pancreatic  disease  will  be 
appreciably  aided.  The  painful  paroxysms  con- 
nected with  pancreatic  cancer  may  readily  be 
mistaken  for  the  passage  of  gall-stones,  if  jaun- 
dice should  be  present.  If  a tumour  should  be  felt, 
it  may  be  difficult  to  distinguish  it  from  an  omen- 
tal tumour.  When  distant  effects  are  produced, 
such  as  hydronephrosis,  the  diagnosis  becomes 
almost  impossible.  It  must  be  remembered  that 
a pancreatic  tumour  may  present  pulsation  and 
bruit,  conducted  from  the  aorta,  and  thus  simu- 
late aortic  aneurism.  In  conclusion,  the  writer 
would  insist  once  more,  as  bearing  upon  the 
iiagnosis  of  pancreatic  disease,  on  the  importance 
of  remembering  that  there  is  such  an  organ  as 
the  pancreas ; and  also  of  making  a thorough 
physical  examination,  again  and  again  if  re- 
quired, in  any  case  in  which  disease  of  this  organ 
is  suspected. 

Prognosis. — But  little  need  be  said  under  this 
head.  Even  if  certain  forms  of  pancreatic  disease 
should"  be  recognised,  they  may  not  affect  life,  but 
no  positive  opinion  can  be  given.  _ It  has  been  af- 
firmed that  chronic  pancreatitis  is  curable  in  the 
early  stage,  but  of  this  there  is  no  real  proof ; it 
probably  aids  in  bringing  about  a fatal  result 
looner  or  later  in  those  cases  in  which  it  exists. 
Pancreatic  cancer  is  necessarily  a fatal  disease, 


PAPULA. 

and  it  usually  terminates  in  death  within  a ye 
after  the  symptoms  have  become  prominent. 

Treatment. — The  indications  in  the  manaj 
ment  of  cases  of  chronic  disease  of  the  panert 
are  within  a very  limited  compass,  even  if 
should  be  recognised.  Rarely  can  there  be  a 
possibility  of  curative  treatment  being  effectn 
although  supposed  cures  of  chronic  inflammati 
have  been  brought  forward,  obtained  by  the  ; 
ministration  of  calomel,  to  act  upon  the  panere 
of  saline  purgatives,  or  of  mineral  waters  off 
class;  or,  when  there  has  been  a syphilitic b 
tory,  by  the  use  of  mercury  to  produce  its  c<! 
stitutional  effects,  or  of  iodide  of  potassium, 
many  cases  the  employment  of  saline  aperit 
would  be  beneficial,  to  keep  the  intestinal  cafi 
free,  and  to  unload  the  portal  circulation.  An 
casional  dose  of  calomel  or  blue  pill  might  also  I 
advantageous.  In  the  large  majority  of  eases 
pancreatic  disease  the  treatment  would  have 
be  chiefly  symptomatic,  directed  especially  to  i 
relief  of  pain,  to  the  symptoms  connected  w 
deranged  digestion,  and  to  the  state  of  gene 
wasting  and  debility.  Hence,  every  case  must 
treated  on  its  own  merits,  in  accordance  w 
well-understood  principles.  For  the  relief  of  i 
severe  paroxysms  of  pain  attending  pancrea 
cancer,  subcutaneous  injection  of  morphia  is' 
most  reliable  remedy.  The  use  of  digestar 
particularly  as  recommended  by  Dr.  Willi) 
Roberts,  would  probably  prove  of  considera' 
practical  value  in  the  treatment  of  cases 
chronic  pancreatic  disease.  Sweetbreads  ml 
be  employed  as  an  article  of  diet ; or  pancrer 
emulsion,  or  liquor  pancreaticus,  might  be  giv-; 
but  the  previous  digestion  of  the  food  by  me! 
of  Bcnger's  liquor  pancreatieus  is  the  plan  lik 
to  be  followed  by  most  benefit,  and  from  i: 
plan  great  advantage  might  be  anticipated  in  • 
propriate  cases.  Frederick  T.  Robeets 

PANDEMIC  DISEASES  (irav,  all,  :! 
Stj/j-os,  the  people). — Epidemic  diseases  whi 
affect  groups  of  several  countries  or  the  wcl 
generally.  See  Epidemic;  and  Periodicity i 
Disease. 

PANTICOSA,  in  the  Spanish  Pyrene. 

Thermal  Waters.  See  Mineral  Waters. 

PAPILLOMA  (papilla,  a nipple,  a wa . 
A tumour  composed  of  hypertrophied  papi , 
either  of  the  skin,  or  of  a mucous  or  a sers 
membrane.  See  Tumours. 

PAPULA  (Latin). — Synon.  ; Pimple ; 
Papule;  Ger.  Papel. 

Definition.  — A minute  prominence  of  the  s , 
for  the  most  part  conical,  but  often  round,  1 
sometimes  flat ; and  resulting  from  vasculare 
gestion,  hypertrophous  growth,  or  aceumnlaw 
of  secretions. 

A rude  kind  of  distinction  might  be  dna 
between  inflammatory  pimples  and  non-indy 
matory  pimples.  In  the  classification  of  :a 
diseases  adopted  by  Willan  the  term  papular- 
presents  a group  of  pimply  affections ; ande 
defines  the  word  papula  as  follows : ‘ A vj 
small  and  acuminated  elevation  with  am- 
flamed  base,  very  seldom  containing  a fluic' 
suppurating,  and  commonly  terminating  in  sc  :• 
He  thereby  gives  the  word  pimple  a sp<d 
signification,  which  is  highly  objectionable.  A 


PAPULA. 

jore  correct  view  of  pimples  would  be  to  regard 
em  in  their  several  relations  to  vascular  con- 
ation. abnormal  growth,  and  retained  cutaneous 
•oducts.  A typical  papula  is  presented  to  us 
, cutis  anserina,  where  the  pore  of  the  skin  or 
iierture  of  a follicle  is  projected  outwards,  in 
insequence  of  a certain  rigidity,  which  opposes 
e contraction  of  the  interporous  tissue.  This 
ay  be  considered  as  a physiological  papula ; 
it  the  pathological  papula  is  similarly  located 
i the  follicle  of  the  skin,  the  prominence  being 
oduced  by  congestion  of  the  vascular  coat  of 
e follicle,  with  more  or  less  exudation  into  its 
.pillary  network.  Sucli  is  the  precise  pathology 
.lichen ; and  this  condition,  with  accumulation 
follicular  contents,  constitutes  conical  acne. 

A papula  from  hypertrophy  of  tissue  may  be 
ustrated  by  acrochordon,  minute  verructe,  and 
:lium;  and  a papule  from  accumulation  of 
caneous  products,  by  acne  punctata  and  im- 
frforate  follicles.  Erasmus  Wilson. 

PARACENTESIS  (ira pc,  through,  and 
i/re a,  I prick). — Synon.:  Tapping;  Fr.  Para- 
i the ; Ger.  Paracentcae. 

Definition. — The  operation  of  tapping  any 
tfity,  to  draw  off  fluid  or  gas. 
jl’he  term  is  usually  confined  to  operations  on 
t»  peritoneum,  pleura,  pericardium  and  cranial 
c;ity ; the  tapping  of  cystic  tumours  not  being 
i'luded.  Most  of  these  are  now  performed  with 
t aspirator  (see  Aspibator.)  All  those  here 
cjcribed  are  performed  with  the  cannula  and 
trhar.  The  more  extensive  operations  on  the 
dura,  such  as  antiseptic  opening,  free  drainage, 
tphining  the  ribs,  &c.,  are  described  with  the 
:l|ases  which  necessitate  them.  See  Pleura, 
Teases  of. 

Instruments  and  Operation. — The  best  form 
oinstrument  for  tapping  the  pleura  or  peri- 
tfal  cavity  is  that  known  as  Thompson’s 
e;  ion  trochar.  In  this  the  cannula  is  fixed  to 
i handle,  and  has  a lateral  opening  about  its 
m.dle,  to  which  a long  india-rubber  tube  is 
atched.  The  trochar  is  continued  through 
tl  handle  of  the  instrument  and  terminates  in  a 
boon.  In  the  handle  the  stem  of  the  trochar 
isirrounded  by  air-tight  packing.  The  instru- 
m t is  inserted  in  the  ordinary  way ; the 
tnar  is  then  drawn  back  till  its  head  is  past 
thii  lateral  opening  in  the  cannula,  through 
wl  h the  fluid  will  then  flow.  The  india-rubber 
tu!  must  be  carried  into  a vessel  containing 
caulie  acid  solution  (1  to  40).  The  result  is 
th;  a syphon  action  is  established,  of  sufficient 
foil  to  exhaust  the  cavity  operated  on,  and  at 
thi.ame  time  the  accidental  entrance  of  air  is 
reared  impossible.  Should  the  instrument  de- 
scr  >d  not  be  at  hand,  the  followi  ng  simple  plan, 
suftsted  by  Reybard,  will  be  found  very  effi- 
cie  The  cannula  immediately  below  its  ex- 
ter1  extremity  is  surrounded  by  a linen  petti- 
coa  from  two  to  three  inches  in  length,  which 
■s'jl  soaked  in  carbolic  oil  (1  to  10)  before 
thejistrument  is  used.  On  withdrawing  the 
trolir  the  petticoat  hangs  down,  forming  a 
cha  el  through  which  fluids  readily  pass  out- 
wai.  but  which  collapses  instantaneously  if 
lae  is  any  tendency  to  the  entrance  of  air. 
Thi!is  especially  useful  in  tapping  the  pleura. 
The  ime  result  can  be  obtained  by  applying  a 


PARACENTESIS.  1091 

large  veil  of  lint  or  rag,  soaked  in  carbolic  oil, 
over  the  cannula  the  moment  the  trochar  is  with- 
drawn. In  tapping  the  cranial  cavity  or  the  peri- 
cardium very  fine  instruments,  usually  known  as 
exploring  trockars,  must  be  used.  In  some  cases, 
when  the  ribs  are  very  close  together,  a flat 
cannula  with  a lancet-shaped  trochar,  may  be 
useful.  Before  using  a trochar  it  should  be 
passed  between  the  finger  and  thumb  to  feel  if 
the  free  edge  of  the  cannula  is  perfectly  con- 
cealed by  the  wider  head  of  the  trochar.  This 
is  frequently  not  the  case  with  old  instruments, 
in  which  the  cannula  has  lost  the  spring  given 
to  it  by  the  two  slits  at  the  end.  If  the  can- 
nula project  it  may  push  the  pleura  before  it, 
the  head  of  the  trochar  only  entering  the  cavity. 
A cannula  and  trochar  should  be  always  kept 
separate  when  not  in  use,  to  prevent  rusting,  and 
the  head  of  the  trochar  should  be  well  pushed  in- 
to a soft  cork.  A blunt  or  rusty  trochar  doubles 
the  suffering  of  the  patient.  Immediately  be- 
fore use  the  two  parts  of  the  instrument  should 
be  separately  well  washed  with  carbolic  acid 
solution  (1  to  20),  or  with  some  other  power- 
ful antiseptic,  and  the  trochar  will  enter  more 
easily  if  it  is  greased  with  carbolic  oil  (1  to 
10).  These  precautions  are  of  the  utmost  im- 
portance. A dirty  instrument  has  often  caused 
the  death  of  the  patient,  by  exciting  decomposi- 
tion in  the  cavity  operated  on ; and  real  cleanli- 
ness can  only  be  ensured  by  dipping  the  instru- 
ment immediately  before  use  in  some  powerful 
antiseptic.  A perfectly  bright  and  apparently 
clean  instrument  may  be  in  reality  coated  within 
and  without  with  microscopic  dirt,  which  anti- 
septics alone  can  render  innocuous. 

In  using  a trochar  the  instrument  is  held 
under  the  hand  with  the  end  of  the  handle  in 
the  hollow  of  the  palm  ; the  thumb  is  placed 
upon  the  rim  of  the  shield  of  the  cannula,  ready 
to  push  it  off  without  necessitating  the  employ- 
ment of  the  other  hand,  and  the  forefinger  is 
firmly  pressed  against  the  side  of  the  cannula, 
at  the  point  to  which  it  is  intended  to  limit  the 
advance  of  the  instrument.  No  preliminary  in- 
cision is  required  if  the  instrument  is  in  good 
order.  It  will  only  double  the  patient's  pain 
and  increase  the  risk  of  non-union  of  the  wound. 
It  is  advisable  to  draw  the  skin  aside  from  its 
normal  position  before  introducing  the  trochar,  so 
that  the  superficial  and  deep  parts  of  the  punc- 
ture may  not  correspond  when  it  is  withdrawn. 
A valved  opening  is  thus  made,  which  can  hardly 
fail  to  close  readily. 

Precautions. — When  either  of  the  large  cavi- 
ties is  tapped,  if  a large  quantity  of  fluid  is 
rapidly  removed,  the  patient  is  apt  to  become 
faint.  These  operations  should,  therefore,  bo 
always  performed  in  the  recumbent  or  semi- 
recumbent  position,  and  stimulants  should  be 
at  hand,  the  patient  beiDg  carefully  watched. 
Should  faintness  occur  the  operation  must  be 
immediately  suspended.  If  the  patient  fears  the 
pain  of  the  puncture,  the  skin  may  be  frozen, 
either  by  the  ether-spray  apparatus,  or  by  the 
application  of  a piece  of  ice  dipped  in  salt. 

1.  Paracentesis  Abdominis.— This  term  is 
usually  applied  exclusively  to  the  operation  of 
tapping  the  peritoneal  cavity  for  ascites,  or,  in 
very  rare  cases,  for  free  gas.  When  the  trochar 


PARACENTESIS. 


1092 

’.s  used  for  tho  relief  of  a distended  bladder,  or  to 
empty  an  ovarian  cyst  or  a hydatid  of  the  liver,  the 
simpler  term  ‘ tapping’  is  invariably  used.  The 
operation  for  ascites  is  performed  in  the  follow- 
ing way: — the  patient  must  be  made  to  empty 
the  bladder  immediately  before  the  operation  ; if 
there  is  the  remotest  possibility  that  this  cannot 
be  done  perfectly  by  natural  means,  a catheter 
must  be  passed.  A strip  of  flannel  wide  enough 
to  reach  from  the  nipples  to  the  pubes,  and  long 
enough  to  go  two  and.  a half  times  round  the  ab- 
domen, must  be  in  readiness.  Each  end  is  to  be 
torn  into  four  or  five  tails.  The  middle  of  the 
flannel  is  then  to  be  applied  to  the  front  of  the 
abdomen,  and  the  tails  so  arranged  as  to  inter- 
digitate  with  each  other  opposite  the  spine.  By 
pulling  on  the  tails  on  each  side  a uniform  elas- 
tic pressure  is  maintained  over  the  abdomen 
during  the  operation,  which  facilitates  the  flow 
of  the  fluid,  and  diminishes  the  tendency  to  faint- 
ing. A circular  hole  is  cut  in  the  flannel  at  the 
point  at  which  the  puncture  is  to  be  made.  The 
patient  must  be  brought  to  the  edge  of  the  bed, 
and  placed  in  the  recumbent  position,  with  the 
head  low.  If  the  quantity  of  fluid  is  not  great, 
and  the  small  intestines  float  up  so  as  to  come 
in  contact  with  the  lower  part  of  the  abdominal 
wall,  it  may  bo  necessary  to  raise  the  patient 
into  a semi-recumbent  position,  in  which  the  in- 
testines will  float  to  the  epigastric  region.  Hav- 
ing put  the  patient  in  position,  the  operator  must 
himself  percuss  the  abdomen  between  the  pubes 
and  the  umbilicus  immediately  before  inserting 
the  trochar,  and.  he  will,  of  course,  not  proceed 
with  the  operation  unless  there  is  absolute  dul- 
ness.  Having  ascertained  that  everything  h in 
proper  order,  the  skin  is  drawn  a little  to  one 
side,  and  the  trochar  is  plunged  sharply  through 
the  abdominal  walls  in  the  linea  alba,  at  a point 
midway  between  the  umbilicus  and  pubes. 
Other  points  have  been  recommended,  as  the 
linea  semilunaris,  but  the  middle  line  is  now 
universally  preferred.  As  soon  as  the  trochar 
is  withdrawn,  the  assistants  pull  firmly  on  the 
tails  of  the  bandage,  and  continue  to  do  so  as 
long  as  any  fluid  flows.  As  soon  as  the  fluid 
ceases  to  flow,  the  cannula  is  withdrawn,  and  a 
piece  of  lint,  soaked  in  collodion,  is  applied  over 
the  puncture.  The  corresponding  tails  of  the 
flannel  bandage  are  then  firmly  tied  together 
over  the  middle  line  of  the  abdomen.  For  ordi- 
nary cases  the  aspirator  is  in  everyway  inferior 
to  the  syphon  trochar,  and  should  never  be  used. 
If  the  patient  should  become  faint  during  the 
operation  the  instrument  must  be  withdrawn, 
the  head  put  as  low  as  possible,  and  some  stimu- 
lant administered. 

Dr.  Reginald  Southey  has  recommended  a 
more  gradual  evacuation,  in  preference  to  the 
rapid  method  above  described.  He  employ's  a 
very  fine  cannula,  perforated  laterally  by  nume- 
rous openings,  and  provided  with  a bulb-head 
and  a shield.  To  the  bulb-head  is  attached  a long 
india-rubber  tube.  The  cannula  is  inserted  in 
the  middle  line,  and  fixed  in  position  by  strap- 
ping ; and  the  fluid  drains  slowly  awayT  at  the 
rate  of  about  one  pint  per  hour.  The  cannula 
may  be  allowed  to  remain  in  position,  if  neces- 
sary, for  about  twelve  to  twenty-four  hours.  Dr. 
Southey  claims  for  his  method  the  following 


advantages— simplicity;  freedom  from  pain ; al 
sence  of  any  tendency  to  syncope ; and  the  avoi: 
ance  of  the  necessity  for  bandaging  afterward 
Experience  has  shown  that  there  is  no  risk  > 
peritonitis. 

2.  Paracentesis  Thoracis. — Sykon.  : Thor 
centesis. — This  is  required  for  serous  fluid  d 
pus  in  the  pleura,  and  more  rarely  for  blood  < 
air.  Aspiration  should  always  be  preferred  • 
the  operation  by  the  cannula  and  trochar  (s 
Aspirator).  Should  the  aspirator  not  be  .■ 
hand,  the  syphon-trochar  should  be  used;  o 
failing  that,  one  of  the  plans  before  mention! 
must  be  adopted'  to  prevent  the  entrance  of  a| 
during  inspiration.  The  patient  must  be  brong' 
to  the  edge  of  the  bed,  and  placed  in  a sen 
recumbent  position,  well  supported  by  pillow 
The  spot  selected  for  puncture  varies  great! 
It  is  generally  agreed  that  the  trochar  shon 
never  be  introduced  below  the  tenth  rib  on  t 
left  side  and  the  ninth  on  the  right,  for  fear 
wounding  the  diaphragm.  The  point  mostcoi 
monly  chosen  is  above  the  sixth  or  seventh  r 
between  the  digitalions  of  the  serratus  magm 
which  can  usually  be  clearly  seen.  Should'D 
not  be  visible,  any  point  may  be  taken  in  t 
proper  intercostal  space  between  the  mid-axilki 
line  and  the  junction  of  the  posterior  and  midi 
thirds  of  the  lateral  aspect  of  the  chest.  T 
trochar  must  alway's  be  kept  close  to  the  upfl 
border  of  the  rib,  in  orcftr  to  avoid  the  inti 
costal  nerve  and  artery.  In  whatever  space  t 
operation  may  be  performed  the  lower  border 
the  rib  below  the  space  should  first  be  clea  ' 
felt;  the  skin  is  then  to  lie  drawn  upwards 
the  width  of  the  rib,  and  the  trochar  thr 
sharply  in  immediately  above  its  upper  bord1 
H the  instruments  are  in  good  order,  and  the  i 
can  be  clearly'  defined,  no  preliminary  incis. 
is  necessary.  If,  from  partial  absorption  of ) 
fluid,  without  corresponding  expansion  of 
lung,  the  ribs  have  fallen  very  closely  togeth 
it  may  be  necessary  to  use  a flat  trochar,  wit. 
lancet-shaped  head.  The  precautions  as  to  fai - 
ness  and  the  closure  of  the  wound  are  the  sa- 
as  in  paracentesis  abdominis. 

3.  Paracentesis  Pericardii.— This  ope- 
tion  is  now  invariably  performed  with  the  ae- 
rator, as  the  results  of  the  use  of  the  orcLim 
trochar  have  been  extremely'  unsatisfacttf. 
See  Aspirator. 

4.  Paracentesis  Capitis.— This  operation  J 
been  occasionally  performed  in  cases  of  chro: 
hydrocephalus,  but  without  any  very  marl 
benefit.  It  is  not  safe  to  use  the  aspirator.-' 
the  vacuum  might  do  unexpected  damage  tco 
soft  a structure  as  the  brain,  while  a srl 
trochar  may  be  passed  through  tho  expanl 
hemisphere  into  the  ventricle  without  risk,  ‘.e 
instrument  used  should  be  the  smallest  exp'- 
ing  trochar.  An  elastic  bandage  must  be  it 
applied,  so  as  to  exert  a very  gentle  pressure r 
the  head.  The  trochar  is  then  introduce:'! 
any  point  where  bone  is  wanting,  except  in  e 
situations  of  the  sinuses.  The  best  placo  i 
one  side  of  the  anterior  fontanelle.  The  mi  t= 
line  must  be  avoided,  not  only  because  ofw 
longitudinal  sinus,  hut  because  in  the  vast  i- 
jority  of  cases  the  fluid  is  contained  in  the  > 
tricles.  The  quantity  of  fluid  removed  sh « 


PARACENTESIS. 


PARALYSIS.  1093 


It  exceed  two  ounces.  The  elastic  pressure 
1st  be  maintained  after  the  operation,  which 
ijy  be  repeated  at  intervals  of  four  or  five  days. 

Marcus  Beck. 

PARESTHESIA  (tt apa,  a prefix  indicating 
iegularity,  and  cuad^ais,  sensation). — A term 
iplied  to  abnormal  sensations  experienced  by 
patient,  distinct  from  mere  excess  or  diminu- 
tb  of  feeling ; for  example,  tingling,  itching, 
jl  formication.  See  Sensation,  Disorders  of. 


PARALYSIS  (irapci,  beside,  and  A I 
. sen  or  relax). — Synon.  : Palsy ; Paresis  (incom- 
tte  paralysis);  Fr.  Paralysie  ; Ger.  Lcihmung. 
Definition. — Loss  of  the  power  of  voluntarily 
editing  the  contraction  of  one  or  more  muscles, 
i ho  essential  condition  met  with  in  all  forms 
caiotor  paralysis.  And  similarly,  a loss  of  the 
psibility  of  transmitting  impressions,  either  of 
t special  senses  or  of  common  sensibility  from 
lious  parts  of  the  body,  from  their  seats  of 
: ipheric  commencement  inwards  to  those  por- 
v os  of  the  brain  which  are  concerned  with 
t ir  realisation  in  consciousness,  is  what  is 
cjmonly  known  as  ‘ sensory  paralysis.’  These 
h er  defects  are,  however,  considered  under  the 
hd  of  Sensation,  Disorders  of.  Here  attention 
\d  be  confined  to  the  subject  of  motor  paralysis, 
t'vhicli,  indeed,  the  term  paralysis  ought  to  be 
lilted.  It  is  more  fitting  to  speak  of  loss  of 
station  than  of  paralysis  of  sensation. 

’aralysis  Motor. — Motor  paralysis  may,  in 
derent  cases,  be  occasioned  by  defects  in  va- 
rus parts  of  the  neuro-muscular  apparatus. 
C tain  primary  differences  of  kind  have  first  to 
liionsidered. 

A.)  Certain  muscles  may  not  contract  because 
Ir  customary  neural  incitations  are  impeded 
olbortive  at  their  source  in  the  cerebral  cortex 
-4>  in  certain  forms  of  hysterical  paralysis,  or 
s; , result  of  definite  lesions  in  some  portions  of 
tlbrain-region  above  mentioned. 

3)  Other  forms  of  paralysis  result  because 
v rntary  motor  incitations  are  impeded  in 
Dismission  during  some  part  of  their  course 
tl'iugh  the  nerve-centres,  but  below  the  corti- 
cijstratum  of  grey  matter  in  which  they  take 
o in,  Under  this  head  are  to  bo  included  by 
f.'fthe  larger  number  of  cases  of  paralysis  actu- 
al! met  with;  and  according  as  the  situation 
Wes  in  which  the  impediment  to  thetransmis- 
sij  of  motor  stimuli  exists,  so  do  we  get  the 
pd.lysis  occurring  in  different  forms,  that  is, 
•ifking  different  distinctive  groups  of  muscles, 
w ior  without  certain  characteristic  associations, 
m le  shape  of  sensory  paralysis  or  disturbance, 
ideations  in  the  temperature  of  the  skin  over 
(hearts  affected,  and,  after  a time,  alterations 
injie  nutrition  of  the  muscles  whose  functions 
at;  n abeyance.  These  very  numerous  forms  of 
psjysis  fall  into  different  classes,  according 
asje  disease  or  injury  preventing  the  proper 
tr, mission  of  motor  stimuli  occurs  (1)  in  some 
P'4  ons  of  their  cerebral  path ; (2)  in  some  por- 
ti<S  of  their  spinal  path;  or  (3)  in  their  pas- 
fa  through  some  of  the  peripheral  nerves — that 
)s|  any  part  of  their  passage  to  the  muscles 
f’i|de  the  medulla  or  spinal  cord. 

I ) Lastly,  though  voluntary  motor  ineita- 
tK"  may  be  normally  generated,  and  properly 


transmitted  through  the  nerve-centres  and  along 
the  peripheral  nerves,  an  incomplete  paralysis  of 
certain  muscles  may  still  result  if  such  stimuli, 
owing  to  degenerative  atrophy  in  the  muscles, 
are  incapable  of  evoking  their  contraction.  In 
these,  as  in  the  other  cases,  the  resulting  loss  of 
movement  (akinesis)  would  represent  a true  pa- 
ralysis. The  fact  that  such  forms  of  paralysis 
are  often  incomplete,  is  dependent  upon  the  pecu- 
liarity that  some  healthy  muscular  fibres  usually 
remain  in  muscles  which  are  the  seat  of  atrophic 
changes  (see  Progressive  Muscular  Atrophy). 
Whilst  conceding  the  possibility  or  the  existence 
of  a group  of  diseases  in  which  the  changes  in 
the  muscles  are  primary,  it  must  be  said  that 
modern  researches  have  tended  to  show  that  in 
a very  large  majority  of  the  cases  of  muscular 
atrophy  such  changes  are  sequential  to  previous 
minute  lesions  in  the  spinal  cord  or  nerves.  Sec 
Pseudo-Hypertrophic  Paralysis. 

The  Etiology  and  Pathology  of  the  various 
forms  of  paralysis  will  not  now  be  further  re- 
ferred to,  but  will  be  discussed  in  the  following 
articles.  Some  general  remarks  on  this  subject 
will  be  found  under  the  heads  of  Nervous  Sys- 
tem, Diseases  of;  Brain,  Diseases  of;  and 
Spinal  Cord,  Diseases  of.  Reference  may  also 
be  made  to  the  various  special  articles  dealing 
wTith  the  pathological  causes  of  brain-disease  and 
to  the  articles  on  the  diseases  of  the  different 
cranial  and  other  motor  nerves. 

Diagnosis. — The  diagnosis  or  recognition  of  the 
cause  or  nature  of  any  particular  case  of  paralysis 
is  always  a many-sided  problem.  Having  pre- 
viously satisfied  ourselves  that  it  is  a real  and 
not  a merely  apparent  case  of  paralysis  (due  per- 
haps to  some  arthritic  disease),  we  have  to  en- 
deavour to  make  out  to  which  of  the  foregoing 
divisions  or  subdivisions  the  instance  before  us 
happens  to  belong.  Paralysis  of  any  group  of 
muscles  (in  the  limbs  or  elsewhere,  and  howso- 
ever occasioned)  may,  of  course,  be  either  com- 
plete or  incomplete ; and  it  may  be  as  well  here 
to  add,  that  it  is  the  incomplete  forms  of  para- 
lysis in  the  limbs  (cases  of  1 paresis  ’ as  they 
are  often  termed)  which  are  most  apt  to  be 
confounded  witli  certain  weaknesses  or  motor 
defects  due  to  joint-disease. 

In  actual  practice  the  'primary  question  as  to 
the  nature  of  the  paralysis  may  be,  and  com- 
monly is,  somewhat  simplified,  inasmuch  as  the 
varieties  included  under  class  A may  be  well 
merged  in  the  first  instance  with  the  primary 
category  of  class  B,  just  as  those  of  class  C may 
be  included  under  the  second  and  third  cate- 
gories of  class  B.  Thus  the  recognition  of  the 
varieties  of  paralysis  included  under  classes  A 
and  C,  belong  to  the  secondary  or  more  special 
problems  connected  with  diagnosis.  The  so- 
called  ‘hysterical’  forms  of  paralysis,  for  in- 
stance, are  to  be  regarded  as  due  to  functional 
perversion  rather  than  to  actual  structural  dam- 
age in  certain  portions  of  the  nervous  system ; 
it  seems,  evident,  however,  that  in  the  first 
place  we  should  decide  whether  wo  have  to  do 
with  a disease  of  the  brain  or  of  the  spinal  cord, 
before  taking  up  the  secondary  question  as  to 
such  disease  being  of  the  merely  functional  or  of 
structural  type. 

Thus,  for  practical  purposes  the  several  kind3 


1094  PARALYSIS. 


of  paralysis  are  primarily  divisible  into  three 
distinct  categories,  based  upon  the  situation  of 
the  damage,  lesion,  or  defective  activity  by 'which 
they  are  occasioned.  We  have:  — 

1 . Paralyses  of  Encephalic  Origin  ; 

2.  Paralyses  of  Spinal  Origin; 

3.  Paralyses  of  Peripheric  Origin; 
according  as  the  cause  is  one  which  operates 
upon  or  within  some  part  of  the  great  centres 
within  the  cranium;  upon  or  within  some  part 
of  the  spinal  cord  ; or  upon  or  within  some  one 
or  more  of  the  nerve-trunks,  in  parts  situated 
either  inside  or  outside  the  cranium  or  the  spinal 
canal. 

It  will  easily  be  understood  that  each  of  these 
primary  groups  of  paralysis,  and  especially  the 
first,  includes  very  many  varieties,  and  that  the 
recognition  of  these  several  varieties  is  often  a 
matter  of  extreme  difficulty — only  to  be  achieved 
after  an  attentive  and  minute  study  of  ah  the 
details  of  a case  by  those  who  are  well  instructed 
as  totho  anatomy  and  physiology'  of  the  nervous 
system,  and  most  familiar  by  daily  practice  with 
the  estimation  of  the  import  of  the  variotis  signs 
and  symptoms  in  the  light  supplied  by  this  know- 
ledge. 

The  primary  diagnosis  should,  however,  in  the 
great  majority  of  cases,  be  capable  of  being  made 
by  the  practitioner  with  comparative  certainty. 
In  so  doing  he  will  be  guided  by  the  general 
agreement  as  to  signs  and  symptoms  presented 
by  the  case  before  him  with  one  or  other  of  the 
following  combinations  of  signs  and  symptoms. 

1.  Paralyses  of  Encephalic  Origin. — These 
may  or  may  not.  be  ushered  in  by  an  apoplectic 
attack,  or  by  an  epileptiform  fit,  or  a series  of 
them.  The  paralysis  is  usually  confined  to  one 
half  of  the  body,  though  only  certain  parts  of 
this  are  affected,  namely,  more  or  less  of  one  half 
of  the  face,  with  the  arm  and  the  leg  (either 
incompletely  or  completely)  on  the  same  side, 
whilst  the  muscles  of  the  trunk  are  compa- 
ratively little  affected.  Where  the  paralysis  is 
incomplete,  the  arm  is  commonly  more  affected 
than  the  leg.  Except  where  loss  or  impairment 
of  consciousness  still  exists,  or  where  both  sides 
of  the  brain  are  affected,  the  patient  almost 
invariably  retains  control  over  the  bladder  and 
rectum.  The  common  sensibility  of  the  same 
half  of  the  body  may  for  a shorter  or  longer  period 
from  the  commencement  of  the  disease  be  more 
or  less  diminished.  The  electrical  irritability  of 
the  paralysed  muscles  is  not  notably  altered. 
The  superficial  reflexes  may  be  diminished,  and 
the  deep  reflexos  may  be  exalted  on  the  paralysed 
side  of  the  body.  See  Spinal  Cord,  Diseases  of. 

These  are  the  general  characters  of  a form  of 
paralysis  commonly  known  as  Hemiplegia.  It  is 
met  with  almost  as  frequently  on  the  one  as  on 
the  other  side  of  the  body,  and  may  occasionally 
affect  both  sides  simultaneously. 

2.  Paralyses  of  Spinal  Origin. — These 
forms  of  paralysis  usually  commence  without  con- 
vulsions or  impairment  of  consciousness,  though, 
like  those  of  the  last  category,  they  may  be  either 
sudden  or  gradual  in  their  mode  of  onset.  They 
are,  however,  commonly  characterised  by  their 
implication,  to  a variable  extent,  of  both  sides  of 
the  body.  In  the  great  majority  of  cases  the 
lower  extremities,  either  alone  or  with  the  trunk- 


muscles  up  to  a certain  level  of  nerve-supply, 
the  parts  that  are  paralysed.  The  arms 
much  less  frequently  affected.  It  is  common 
control  over  the  bladder  and  rectum  (one  or  be 
to  be  more  or  less  lost.  The  motor  paralysis  n ; 
exist  with  little  or  no  impairment  of  sonsibili 
though  in  some  cases  sensation,  in  one  or  ot 
of  its  modes,  is  defective  in  the  paralysed  pa  l 
The  upper  limit  of  defective  or  altered  sen 
bility  is  often  marked  round  the  trunk  by  a se! 
of  constriction,  or  a feeling  as  if  a band  w 
tied  round  the  body  (‘  girdle  sensation’),  T 
electric  irritability  of  the  paralysed  muscles  ni 
be  either  little  altered,  or  it  may,  especially 
some  parts,  be  modified  in  the  manner  to 
described  in  the  next  section  as  characteristir 
the  1 reaction  of  degeneration  ’ — and  in  this  law 
ease  early  and  marked  atrophy  of  such  paralyi 
muscles  may  be  looked  for. 

These  are  forms  of  paralysis  commonly  knc( 
by  the  name  of  Paraplegia.  Both  sides? 
the  body  are  usually  affected — equally  or 
equally — because  of  the  frequency  with  wb 
the  lesion,  or  cause  of  the  disease,  involves  bl 
halves  of  the  spinal  cord.  Where  this  is  not  * 
case,  however,  and  the  injury  or  lesion  is  cf 
fined  to  one  half  of  the  cord,  in  one  or  other  • 
gion,  a condition  known  as  Hcmiparaplegia  : 
suits,  in  which,  in  addition  to  other  spt, 
characters,  there  is  an  absence  of  any  trace? 
facial  paralysis,  even  though  the  arm  and  legi 
one  side  of  the  body  (where  the  lesion  ex,; 
high  up  in  the  cervical  region  of  the  cord)  v 
be  implicated  in  much  the  same  manner  as  tlf 
are  in  hemiplegia.  Here,  however,  theparaly- 
of  motion  occurs  on  the  same  side  as  the  lesi 

3.  Paralyses  of  Peripheric  Origin. — 
majority  of  paralyses  resulting  from  disease^ 
injury  of  nerve-trunks  are  rendered  comps 
tively  easy  of  recognition  by  the  fact  that  • 
loss  of  power  is  in  each  case  limited  to  t 
muscles  supplied  by  particular  nerves.  This  c 
ciimscribed  nature  of  the  paralysis  is  a fact 
great  value  for  diagnostic  purposes — especi;. 
when  the  loss  of  power  is  complete  rather  t? 
partial,  because  it  is  in  these  cases  more  para 
larly  that  we  are  apt  to  get  another  character^ 
sign  of  peripheral  paralysis,  namely,  an  altei 
electrical  excitability  of  both  nerve  andmusd 
Wrhere  the  injury  to  or  disease  of  a nerve-tru: 
is  well-marked,  so  that  its  fibres  are  eitl’ 
severed  or  rendered  incapable  of  conducting  s 
muli  from  the  centres,  owing  to  pressure  or  otr 
causes,  it  is  found  that  within  a period  of  six 
fourteen  days  the  following  electrical  phenomt. 
may  be  dotected: — Loss  of  irritability  of  t 
affected  nerve-trunk  to  both  electric  curren 
loss  of  or  greatly  diminished  irritability  of  t 
affected  muscles  under  stimulation  by  the  Fa 
die  current,  together  with  an  increase  of  thf 
sensitiveness  to  the  Voltaic  or  continuous  curri 
— so  that  they  respond  to  the  latter  even  nr 
readily  than  the  corresponding  muscles  of  1 
opposite  side.  These  characteristics,  as  a who 
together  with  certain  minor  peculiarities,  « 
stitute  the  so-called  ‘ reaction  of  degenerate 
(see  Electricity).  To  these  characters  must  | 
added  the  further  peculiarity  that  the  muse1 
thus  affected  are  apt  speedily  (within  two 
three  weeks  from  the  onset  of  the  paialys 


1095 


PARALYSIS. 


show  a marked  amount  of  atrophy  — a change 
isily  to  he  appreciated  in  limb-muscles,  and  in 
*me  of  those  pertaining  to  the  trunk,  but  by 
> means  so  obvious  in  the  muscles  of  the 

CO. 

The  above  constitute  the  characters  which  are 
the  main  to  be  relied  on  for  the  diagnosis  of 
iralyses  of  peripheric  origin.  Still  it  must  not 
i forgotten  that  when  the  ganglion-cells  in  the 
edulla  or  spinal  cord,  which  constitute  the 
rve-nnelei  of  the  several  motor  nerves,  are 
.sensed,  we  may  have  almost  precisely  the  same 
fects  produced  as  if  the  nerve-trunks  had  been 
maged  in  some  part  of  their  course — that  is, 

(a  may  have  in  each  ease  the  electrical  ‘ reae- 
pn  of  degeneration’  followed  by  speedy  atrophy 
the  affected  muscles.  In  this  case,  indeed 
[here  we  hare  disease  of  an  atrophic  character 
nited  to  the  nerve-cells  composing  the  nucleus 
a motor  nerve  or  nerves,  we  should  have  a 
rm  of  paralysis,  tolerably  well  typified  by  ‘ labio- 
iosso-laryngeal  paralysis,’  which  might  almost 
ith  indifference  be  placed  either  in  the  eate- 
ry of  spinal  or  of  peripheric  nervous  diseases, 
'ley  wouldbe.it  is  true,  spinal  in  seat;  and 
t they  would  be  attended  by  all  the  clinical 
aracters  pertaining  to  disease  of  the  nerve- 
unks — and  this  naturally  enough,  seeing  that 
e disease  would  in  fact  simply  affect  the  proxi- 
ial  extremities  of  nerve-trunks. 

What  has  just  been  said  will  serve  to  explain 
w it  is  that  in  many  cases  of  paralysis  of  spinal 
igin,  that  is, due  to  large  * transverse’  lesions, 
riously  damaging  the  grey  matter  of  the  cord, 
i may  get,  together  with  the  wide  or  general 
stribution  of  such  a paralysis,  evidence  that 
some  of  the  muscles  the  electrical  ‘reaction  of 
generation  ’ may  be  detected  as  well  as  early 
isting.  These  characteristics  of  peripheral 
ralysis  will,  in  fact,  occur  in  muscles  where  the 
ey  matter  at  the  roots  of  their  nerves  has  been 
stroyed.  In  cases  of  paraplegia  due  to  large 
insverse  lesions  limited  to  the  cervical  or  to 
ie  upper  dorsal  region,  we  might,  therefore, 
l)k  for  and  find  the  ‘ reaction  of  degeneration,’ 
th  early  wasting  in  some  of  the  muscles  of  the 
per  extremities  or  of  the  trunk,  whilst  we 
.mid  not  find  these  characters,  nor  be  war- 
rted  in  looking  for  them,  in  the  muscles  of  the 
ually  paralysed  lower  extremities. 

Of  course,  in  most  cases  of  paralysis,  the  pa- 
int’s personal  and  family  history,  as  well  as  the 
: de  of  onset  of  the  disease,  will  help  to  throw 
Iht  upon  the  question  whether,  in  the  case  be- 
1 e us,  we  have  to  do  with  a paralysis  of  ence- 
) ilic,  of  spinal,  or  of  peripheric  origin. 

The  further  characters  of  paralyses  of  spinal 
<gin  (paraplegias  and  liemiparaplegias)  will  be 
lind  in  the  article  Spixal  Cord,  Diseases 
<!  whilst  those  of  the  paralyses  of  peripheric 
(jgin  will  be  found  in  the  various  articles  on 
wases  of  special  motor  nerves,  such  as  the 
flial,  the  sciatic,  &c.  Diphtheritic  paralysis  is 
in  an  obscure  affection  commonly  supposed  to 
Itain  to  this  class.  Sec  Pabai.vsis,  Diphthe- 
i e. 

!ut  the  type  of  those  diseases  included  under 
t|  head  of  Paralyses  of  Encephalic  Origin  will 
c ' be  more  particularly  described. 

'his  account  of  the  characters  pertaining  to 


an  ordinary  form  of  Hemiplegia  can  perlmt  ? 
best  be  given  by  detailing  the  combination  of  signs 
and  symptoms  produced  by  disease,  either  in  the 
form  of  hEemorrhage  or  of  softening,  in  one  of  the 
corpora  striata.  "We  may  suppose  such  disease 
to  be  situated  on  the  right  side  of  the  brain,  and 
then,  as  a consequence,  we  should  meet  with  a 
left  hemiplegia. 

Characters  of  left  hemiplegia  from  disease  in 
or  near  the  right  corpus  striatum. — Where  there 
is  a sudden  onset  of  the  disease  and  a large  lesion, 
such  as  may  occur  especially  in  some  instances 
of  hEemorrhage,  the  symptoms  may  be  ushered 
in  by  an  apoplectic  attack,  and  a condition  of 
unconsciousness  may  remain,  as  a result  of  gene- 
ral brain-shock,  for  minutes,  hours,  or  even  days. 
Convulsions  rarely  occur  in  such  a case.  Where 
the  hsemorrhage  is  slighter  in  amount,  or  where 
the  causes  of  softening,  in  the  form  of  vascular 
obstruction,  are  limited  in  seat  and  not  abruptly 
brought  about,  there  may  be  no  loss  of  con- 
sciousness whatever  at  the  onset,  nor  any  sen- 
sation referred  to  the  head.  The  patient  may 
perhaps  experience  a mere  momentary  vertigo  ; 
and  sensations  of  numbness  or  tingling  rather 
than  of  actual  pain  may  be  felt  for  a minute  or 
two  in  one  or  other,  or  perhaps  in  both  limbs, 
before  their  weakness  or  actual  paralysis  is  de- 
tected. 

In  a case  of  this  kind,  or  after  recovery  of 
consciousness  in  the  more  severe  form  of  the  dis- 
ease, the  patient  will  on  examination  be  found 
to  present  the  following  characteristics (1)  An 
absence  of  any  decided  mental  disturbance ; (2) 
slight  ‘thickness’  of  speech;  (3)  more  or  less 
deviation  of  the  tip  of  the  tongue  towards  the 
paralysed  side,  when  it  is  protruded  ; (4)  partial 
and  incomplete  paralysis  of  the  facial  muscles 
on  the  side  on  which  the  paralysis  of  the  limbs 
exists — the  angle  of  the  mouth  is  lower,  and  the 
naso-labial  fold  less  distinct  than  on  the  oppo- 
site side,  though  the  two  eyes  can  le  closed  almost 
equally  well ; (5)  more  or  less  complete  loss  of 
voluntary  power  over  the  left  arm  and  leg ; (6) 
a flaccid  state  of  the  muscles  cf  these  limbs, 
which  are  found  to  respond  naturally,  or  perhaps 
even  a little  too  readily,  both  to  theFaradic  and 
Voltaic  currents ; (7)  some  slight  loss  of  sen- 
sibility, as  well  as  a feeling  of  numbness,  on 
the  paralysed  half  of  the  body;  (8)  slight  ele- 
vation of  temperature  on  the  paralysed  as  com- 
pared with  the  non- paralysed  side  .of  the  body — 
the  difference  being  seldom  more  than  one  degree 
of  the  Fahrenheit  scale. 

Of  these  signs,  the  thickness  of  speech,  the 
deviation  of  the  tongue,  the  paralysis  of  the 
face,  and  the  diminished  sensibility,  soon  either 
grow  perceptibly  less  or  actually  disappear.  In 
the  slighter  cases,  after  some  days  or  a week  or 
two,  there  may  also  be  some  return  of  voluntary 
power  over  the  leg  and  the  arm;  but  in  the  more 
severe  forms  of  complete  hemiplegia,  not  proving 
fatal,  any  recovery  of  motor  power  in  the  limbs 
may  be  delayed  for  months  instead  of  weeks, 
and  then  perhaps  the  recovery  may  be  only 
very  slight.  In  all  eases,  however,  the  recovery 
of  power  usually  begins  to  show  itself  in  the 
leg  sooner  than  in  the  arm  ; and  the  muselea 
about  the  joints  nearer  the  body’  are  in  each  case 
capable  of  being  called  into  action  before  those 


I09G  PARALYSIS, 

moving  joints  which  are  more  remote.  Some- 
times in  the  early  stages  of  the  disease  some 
amount  of  rigidity  may  be  met  with  in  the 
arm  or  in  the  leg,  or  in  both  simultaneously, 
which  is  found  to  disappear  during  sleep — early 
rigidity’;  whilst  later  on  a more  permanent 
form  of  rigidity  associated  with  organic  changes 
in  the  muscles  and  tendons— ‘ late  rigidity’ — is 
apt  to  supervene.  See  the  writer's  Paralysis  from 
lirain-disease,  pp.  151-178. 

The  particular  combinations  of  symptoms  met 
with  in  different  cases  of  hemiplegia  vary  in  an 
almost  endless  manner,  as  the  situation  of  the 
brain-lesion  varies,  and  also  to  a less  marked 
extent  in  accordance  with  variations  in  its 
magnitude,  and  in  the  suddenness  with  which 
it  is  brought  about.  Thus,  in  regard  to  varia- 
tions in  the  extent  and  completeness  of  motor 
paralysis  alone,  we  may  have  merely  a slight 
facial  paralysis,  with  some  weakness  of  the  arm 
on  the  same  side,  and  none  of  the  leg ; or  the 
paralysis  of  arm  and  face  may  be  more  marked, 
together  with  slight  paralysis  of  the  leg ; or 
paralysis  may  be  pretty  complete  in  all  three 
situations.  More  rarely  the  leg  may  be  more 
completely  paralysed  than  the  arm  ; and  where 
lesions  exist  in  both  hemispheres  of  the  brain, 
or  in  the  pons  Varolii,  a double  hemiplegic  con- 
dition may  exist — either  complete  or  incom- 
plete, and  in  the  latter  case  probably  unequal 
in  degree  on  the  two  sides  of  the  body.  Similar 
variations  exist  .in  regard  to  many  of  the  other 
concomitants  of  the  hemiplegic  state;  for  example, 
as  regards  the  amount  of  mental  disturbance, 
the  kind  and  degree  of  impairment  of  speech, 
the  amount  of  paralysis  of  tongue  and  difficulty 
of  deglutition,  the  amount  of  paralysis  of  the  face 
and  of  implication  of  the  ocular  muscles,  the 
amount  of  impairment  of  common  sensibility  and 
of  the  special  senses,  the  amount  of  difference  in 
temperature  between  the  two  sides  of  the  body, 
and  the  amount  of  command  over  the  sphincters 
of  the  bladder  and  rectum.  Combined  in  differ- 
ent groups,  owing  to  the  different  relative  de- 
velopment of  these  or  those  particular  symptoms, 
we  get  all  the  different  grades  and  kinds  of 
hemiplegia  actually  met  with  in  practice. 

The  attempt  to  connect  this  difference  in 
grouping  of  the  signs  and  symptoms  with  differ- 
ences in  the  locality  of  the  lesion,  is  to  concern 
ourselves  with  the  secondary,  as  opposed  to 
what  has  been  previously  termed  the  primary, 
problem  of  diagnosis.  We  should  then  have  to 
consider  what  is  more  especially  termed  regional 
diagnosis,  which,  however,  can  only  be  attempted 
after  careful  study  has  been  given  to  the  several 
distinctive  effects  produced  by  disease  in  the 
different  regions  and  parts  of  the  encephalon. 

In  attempting  to  arrive  at  a pathological  dia- 
gnosis in  any  case  of  paralysis,  our  attention 
must  be  given  more  to  the  mode  of  onset  of  the 
affection,  and  to  the  state  of  other  organs  and 
parts  of  the  body,  than  to  the  signs  and  symp- 
toms of  the  established  disease,  though  we  are 
compelled  to  rely  most  upon  these  latter  for  the 
establishment  of  a regional  diagnosis.  Still  these 
two  sides  to  the  problem  of  diagnosis  are  often 
very  intimately  related  to  one  another,  so  that 
it  may  be  essential  to  consider  them  concurrently 
in  order  to  derive  from  each  side  of  the  problem 


PARALYSIS  AGITASS. 

all  the  light  that  may  be  possible  for  It 
elucidation  or  confirmation  of  the  other  ha 
of  it. 

The  questions  concerning  Prognosis  an 
Treatment  are  considered  separately  under  tl: 
head  of  the  special  forms  of  paralysis,  and  of  th 
diseases  giving  rise  to  the  different  kinds  c 
paralysis  of  encephalic,  of  spinal,  and  of  per 
pherie  origin.  II.  Charlton  Bastian. 

PARALYSIS  AGITAMS . — Synon, 

Shaking  Palsy;  Fr.  Paralysie  tremblarUt 
Ger.  Schiittellcihmung. 

Definition. — A disease  of  advanced  life;  prt 
gressive  in  its  course;  and  characterised  mainl 
by  tremors  of  the  limbs  occurring  independent! 
of  muscular  exertion,  rigidity'  of  muscles,  and 
tendency  in  walking  to  loss  of  equilibrium. 

^Etiology. — The  causes  of  paralysis  agitaD 
are  obscure.  It  is  rarely  met  with  prior  to  fort 
years  of  age,  but  becomes  more  and  more  fre 
,quent  as  life  advances.  It  affects  both  sexe: 
but  men  probably  more  frequently  than  womer 
There  is  little  reason  to  regard  it  as  hereditary 
It  has  been  attributed  to  violent  emotion,  to  ex 
cessive  bodily  fatigue,  and  to  exposure  to  col 
and  wet.  It  has  also  been  referred  to  wound 
or  injuries  involving  nerves.  In  many  cases  n 
cause  is  assigned  or  can  be  discovered. 

Anatomical  Characters. — The  disease,  n 
doubt,  is  one  of  the  nervous  centres.  But  n 
distinctive  lesion  has  yet  been  discovered  in  thes, 
parts.  Sclerotic  and  other  degenerative  change;1 
evidences  of  sanguineous  exudations  in  the  corns 
of  some  of  the  smaller  vessels,  diseased  arteries 
and  various  coarse  lesions,  have  not  infrequentl 
been  met  with  in  the  cord  and  brain ; but  th: 
morbid  changes  hitherto  observed  have  bee 
variable  in  seat  and  character,  and  such  only  a 
are  frequently  present  under  other  circumstance, 
in  persons  who  die  in  old  age. 

Symptoms. — Paraly'sis  agitans,  with  few  ex 
ceptions,  comes  on  insidiously.  The  patient  ; 
first  attacked  with  occasional  tremors  in  a hand 
a thumb,  or  a foot  These  attacks  come  o 
irregularly,  without  obvious  cause,  and  last  fo 
an  uncertain  period.  But  gradually  they  in 
crease  in  frequency,  duration,  and  severity,  an 
spread  from  the  part  first  involved,  until,  a 
length,  probably  all  the  limbs  become  implicate! 
In  most  cases  the  tremors,  commencing  in  a han 
or  foot,  by  slow  degrees  invade  the  rest  cf  th 
limb,  and  thence  6pread  in  hemiplegic  fashio 
to  tho  other  limb  of  the  same  side.  Less  com 
monly  the  affection  spreads  in  the  first  instanc 
from  one  leg  to  the  other.  And  very  rarely  d 
both  arms  suffer,  the  legs  remaining  free,  o 
does  the  affection  involve  the  limbs  diagonally 
Associated  with  the  tremors,  sometimes  pre 
ceding  them,  but  much  more  frequently  comic, 
on  at  a later  period  of  the  disease,  there  ma. 
always  be  observed  a peculiar  rigidity  of  th 
muscles.  This  is  often  attended  with  cramp 
like  pains,  and,  like  the  tremors,  is  liable  at  fir; 
to  more  or  less  obvious  and  prolonged  interims 
sions.  It  implicates  the  muscles  of  the  head  an 
neck  and  trunk,  as  well  as  those  of  the  extremi 
ties,  and  the  flexor  muscles  in  greater  degre 
than  their  opponents.  Another  remarkaU| 
characteristic  of  tho  disease,  always  develops 


PARALYSIS  AGITANS. 
honor  or  later,  is  an  inability  to  maintain  equi- 
brium  when  walking  is  attempted. 

When  the  disease  is  fully  developed,  and  the 
iveral  phenomena  above  enumerated  are  asso- 
'ated,  the  collective  symptoms  produce  a very 
imarkable  and  characteristic  picture.  The  tre- 
mors involve  the  arms  and  legs ; the  head  and 
jek  remaining,  as  a rule,  absolutely  free  from 
tem.  They  consist  of  fine  arid  rapid  oscillations, 
hich  are  more  or  less  constant,  but  liable  to  ex- 
cerbations  ; cease  during  sleep  ; can  occasionally 
jb  arrested  temporarily  by  voluntary  effort ; and 
’ten  occur  with  exceptional  violence  when  the  pa- 
tent is  otherwise  at  absoluterest.  The  movements 
’ the  hands  are  peculiar.  The  thumbs  are  usually 
itended,  and  the  fingers  flexed  upon  them  ; and 
•Uectively  they  move  as  though  the  patient  were 
lling  a pencil  or  crumbling  bread.  The  oseilla- 
ons,  however,  are  not  limited  to  the  hands,  but 
Jvolve  the  wrists  and  other  joints  of  the  upper 
-.tremities.  The  tremors  of  the  lower  limbs, 
peeially  when  the  patient  stands,  are  neces- 
rily  transmitted  to  the  rest  of  the  body.  Tho 
Lddity,  which  affects  in  a greater  or  less  degree 
| the  muscles,  imparts  a striking  character  to 
s attitude  and  aspect.  It  causes  the  arms  to 
ind  out  slightly  from  the  trunk ; the  elbow- 
d wrist-joints  to  be  slightly  flexed;  the  hands 
he  tilted  towards  the  ulnar  side,  and  to  rest 
front  of  trie  abdomen  at  or  near  the  waist ; 
d the  fingers  to  be  flexed  or  distorted  at  their 
reral  joints.  It  causes  the  trunk  to  incline 
■wards,  as  the  patient  stands  or  walks ; the 
nes  to  be  slightly  bent;  and  the  feet  to 
extended  at  the  ankles ; so  that  he  rests 
on  his  toes.  But,  above  all,  it  causes  the 
nd  and  neck  to  be  thrown  forwards,  and  to  be 
Lined  rigidly  in  that  position,  and  the  features 
lie  immobile  and  inexpressive.  This  peculiar 
ity  of  the  head  and  neck  and  face,  associated 
it  is  with  constant  tremors  in  the  limbs,  con- 
futes a very  striking  feature  of  the  disease, 
ie  difficulty  of  maintaining  equilibrium,  though 
| doubt  increased  largely  by  the  presence  of 
f.scular  tremors  and  rigidity,  is  not  wholly 
to  them,  for  it  may  be  well  developed  at  a 
"y  early  stage  of  tho  disease.  Moreover,  it 
liy  be  long  delayed.  When  thus  affected  the 
[ ient  has  some  difficulty  in  rising  from  his 
sflt,  and,  before  he  starts  off  walking,  probably 
litotes  a little,  as  though  for  the  purpose  of 
IJincing  himself.  Then,  with  his  body  bent 
tjvurds,  he  begins  to  walk,  perhaps  with  some 
but  soon  his  steps  become  rapid  and  short, 
iij  he  runs  forwards  in  spite  of  himself,  and  if 
ni  arrested  probably  falls.  Sometimes  the  ten- 
tljcy  of  the  patient  is  to  run  backwards,  even 
tjUgh  tho  body  incline  forwards.  Often  in 
tse  cases,  while  the  patient  is  being  propelled 
wards  apparently  in  spite  of  himself,  a sudden 
pjik  at  his  clothes  will  reverse  or  alter  the 
diction  of  his  accelerating  movement.  These 
piomena  are  not  attended  with  vertigo. 

llier  symptoms  less  striking  than  the  above, 
h,  of  more  or  less  importance,  are  usually 
P c.nt  in  shaking  palsy.  There  is  generally, 
e^.from  the  first,  a great  sense  of  weariness 
11  lie  affected  muscles,  especially  after  exertion 
01  n attack  of  tremors ; but,  contrary  to  what 
B it  be  supposed,  the  tremulous  and  rigid 


PARALYSIS,  DIPHTHERITIC.  1097 
muscles  are,  as  a rule,  markedly  stronger  than 
their  as  yet  unaffected  fellows.  The  patient, 
more  particularly  late  in  the  disease,  becomes 
excessively  irritable  and  fidgety,  so  that  at  night 
especially  he  finds  it  difficult  or  impossible  to 
place  himself  in  a comfortable  position;  he  is 
apt  also  to  suffer  from  a painful  sense  of  heat, 
mainly  referred  to  the  epigastrium  and  back. 
Speech  generally  becomes  markedly  affected,  not 
from  loss  of  language,  but  from  difficulty  of 
enunciation.  Words  are  uttered  slowly,  and 
with  manifest  effort.  Associated  with  this  there 
is  often  tremulousness  of  the  tongue.  But  the 
slowness  and  difficulty  of  utterance,  which  are 
often  associated  with  slowness  and  difficulty  of 
deglutition,  constitute  only  one  manifestation  of 
the  general  slowness  and  difficulty  of  movement 
which,  for  the  most  part,  characterise  the  disease. 
Sensation  is  not  impaired ; and  the  patient  re- 
tains his  mental  faculties,  and  control  over  the 
rectum  and  bladder. 

Diagnosis. — The  affections  with  which  para- 
lysis agitans  are  most  likely  to  be  confounded 
are  disseminated  sclerosis,  and  mercurial  tre- 
mors. But  in  the  former  of  these  the  tremors 
occur  only  when  the  muscles  are  in  use,  and  for 
the  most  part  involve  the  head ; the  limbs  early 
become  paralysed  ; the  patient  has  no  tendency 
to  run  forwards  or  backwards ; and  generally 
nystagmus  is  present.  In  the  latter  affection 
there  is  probably  a history  of  exposure  to 
the  fumes  of  mercury,  and  a blue  line  on  the 
gums;  the  tremors  involve  not  only  the  limbs, 
but  the  head  and  neck,  and  are  symmetrical ; 
and  there  is  an  absence  of  the' peculiar  gait  of 
paralysis  agitans. 

PnoGiiF,ss  and  Terminations. — The  disease  is 
one  of  slow  and  often  irregular  progress,  and 
usually  lasts  for  many  years ; indeed  it  may  be 
many  years  before  it  attains  its  full  development. 
In  rare  cases  it  is  recovered  from  in  the  early 
stage;  but  for  the  most  part  it  is  incurable.  In 
its  last  stage  the  patient  becomes  confined  to  his 
couch  or  bed ; the  muscles  waste ; the  tremors, 
though  generally  extreme  at  the  time,  occasion- 
ally cease ; the  mental  powers  fail ; bed-sores 
form  ; and  general  prostration  ensues.  Death  is 
due  either  to  asthenia,  or  to  some  intercurrent 
disorder,  more  especially  pneumonia. 

Treatment. — In  treating  shaking  palsy  it  is 
of  importance  to  give  careful  attention  to  all 
hygienic  measures,  and  to  promote  the  patient’s 
health,  if  need  be,  by  tonics.  Specific  treatment 
has  proved  of  little  or  no  service.  Nervine 
tonics  and  sedatives  have  been  largely  employed ; 
but  those  which  have  found  most  favour  pro- 
bably are  iron,  strychnia,  and  hyoscyamus.  The 
systematic  use  of  baths  has  occasionally  proved 
of  temporary  benefit.  The  persistent  application 
of  the  continuous  galvanic  current  seems  to  have 
been  serviceable  in  some  eases. 

J.  S.  Bkistowe. 

PARALYSIS,  Diphtheritic.  — Synon.  : 
Er.  Paralysie  dipktheritique;  Qev.BipMheritische 
L 'dhraung. — Paralytic  affections  are  so  frequently 
associated  with  diphtheria,  that  they  have  been 
generally,  though  perhaps  not  correctly,  regarded 
as  peculiar  in  their  origin,  and  as  constituting  a 
characteristic  part  of  the  disease.  This  question 


1098  PARALYSIS.  DIPHTHERITIC. 


is  too  extensive  for  discussion  here.  Still  it  is 
necessary  to  call  attention  to  the  fact  that  para- 
lysis, in  various  forms  and  degrees,  occurs  asso- 
ciated with,  or  as  a sequel  of,  typhoid  fever,  re- 
lapsing fever,  cholera,  dysentery,  small-pox,  and 
pneumonia;  and  that  in  all,  they  are  attributed 
by  Gubler  and  others  to  an  essentially  similar 
state  incident  to  most  fevers  and  acute  diseases. 
Though  their  course  and  phenomena  present 
points  of  difference,  they  have  common  funda- 
mental characteristics — namely,  they  seem  all 
to  be,  as  a rule,  of  peripheral  origin ; they  all 
manifest  a natural  tendency  to  recovery;  and 
when  they  become  protracted,  they  are  apt  to 
become  permanent  from  atrophy  of  the  muscles 
caused  by  long  disuse. 

Symptoms. — The  usual  period  of  the  first 
manifestations  of  diphtheritic  paralysis  is  from 
eight  to  twelve  days  after  an  apparently  complete 
recovery.  To  this  rule,  however,  there  are  ex- 
ceptions. Sometimes,  the  paralytic  affections  do 
not  occur  till  the  patient  lias  seemed  to  be  well 
for  more  than  a month ; and,  on  the  other  hand, 
they  sometimes  show  themselves  during  the 
acute  stages  of  the  disease,  as  early,  occasionally, 
as  the  second  or  third  day  from  its  explosion. 
When  they  do  not  occur  till  the  close  of  the 
convalescence,  or  till  an  interval  of  some  days  or 
longer  after  apparent  recovery,  they  are  usually 
much  more  severe,  more  protracted,  and  more 
generalised.  When  they  show  themselves  in  the 
course  of  the  acute  malady,  they  are  generally 
slight,  transitory,  and  limited,  being  then  con- 
fined for  the  most  part  to  the  veil  of  the  palate, 
the  pharynx,  and  (Esophagus.  In  many  cases,  the 
veil  of  the  palate  is  alone  affected 

Generally,  the  earliest  indication  of  a para- 
lytic affection  is  a slight  difficulty  in  swallowing 
liquids.  Sometimes,  the  paralysis  announces 
itself  by  a choking  cough  on  attempting  to  eat. 
The  cause  of  the  cough— sometimes  an  alarming 
and  dangerous  symptom — is  the  food  coming  in 
contact  with  the  mucous  membrane  of  the  upper 
part  of  the  larynx,  in  consequence  of  the  para- 
lysed state  of  the  veil  of  the  palate.  This  organ 
is  insensible,  as  may  readily  be  proved  by  the 
failure  to  excite  reflex  action  by  touching  it.  A 
striking  feature  usually  appears  in  tho  changed 
character  of  the.  voice — its  whispering  nasality. 
The  eyelids  droop  or  remain  half-closed;  the 
muscles  of  the  face  become  affected ; the  cheeks 
are  expressionless  and  flabby;  and  the  powerless, 
flaccid  lips  allow  the  saliva  to  dribble  from  the 
mouth,  giving  the  patient  an  idiotic  aspect, 
which  is  frequently  intensified  by  the  muscles  of 
the  neck  losing  the  faculty  of  supporting  the 
head.  The  speech  of  diphtheritic  patients  is 
variously  affected : it  is  often  more  or  less  slow, 
difficult,  thick,  and  stammering — manifestations 
due  to  different  degrees  and  different  combina- 
tions of  paralysis  of  the  veil  of  the  palate,  pha- 
rynx, tongue,  lips,  and  cheeks.  The  inferior 
extremities  are  generally  paralysed  before  the 
superior ; but  when  the  former  become  affected 
the  latter  seldom  escape.  In  rare  cases  the 
paralysis  begins  in  the  arms.  More  serious 
aggravatious  of  the  situation  may  be  added  ; 
or  they  may  arise  before  tho  limbs  have  be- 
come affected.  The  heart,  the  muscles  of  the 
chest,  and  the  diaphragm  may  one  or  all  be 


stricken,  gradually  or  suddenly,  by  loss  of  powei 
Paralysis  of  the  heart  is  a cause  of  patient 
dying  suddenly  from  cardiac  syncope,  when  n 
immediate  danger  has  been  apprehended.  Some 
times  this  cause  of  death  is  threatened  befoi 
it  occurs.  When  the  respirator}' muscles  are  ,n 
fected,  even  in  a moderate  degree,  the  conditio 
is  one  of  danger,  in  consequence  of  the  lurs 
becoming  congested  from  imperfect  expansion  c 
the  thoracic  parietes.  The  intestinal  canal  an 
the  bladder  are  often  paralysed.  There  may  t 
constipation  as  inveterate  and  painful  as  thatc 
lead  colic ; there  may  be  obstinate  constipatio 
without  pain ; or  the  faeces  may  he  passed  ir| 
voluntarily,  with  or  without  medicinal  inte; 
ference.  The  bladder,  though  at  first  on] 
moderately  sluggish,  will  probably  soon  becon 
absolutely  paralysed  from  over-distension,  tl 
existence  of  the  paralysis  beiDg  shown  by  a cor 
stant  dribbling  from  the  urethra.  The  intestin; 
canal  and  bladder — one  or  both — may  he  dii 
tressingly  stricken  when  other  paralyticaffectior 
are  almost  or  altogether  absent.  Recorded  case 
show  that  all  the  senses  are  liable  to  be  affected 
The  sense  of  sight  is  that,  however,  which  isl 
far  tho  most  frequently  implicated.  Squintinji 
imperfect  sight,  and  other  visual  disturbance 
arise  from  a loss  of  eo-ordinative  muscular  powe 
paralysis  of  particular  muscles,  dilatation  of  tl 
pupils,  and  insensibility  of  the  retina — fromthes 
causes  separately,  or  in  various  combination 
Amblyopia,  presbyopia,  myopia,  and  diplopi 
may  be  met  with  ; but  the  first  is  the  most  con 
mon.  Local  or  general  cutaneous  anaesthesia 
usually  associated  with  diphtheritic  paralvsi. 
In  cases  in  which  the  diphtheritic  pellicle  h; 
never  appeared  in  the  throat,  paralytic  affectiof 
may  be  met  with.  Sanne  states  that  he  has  set 
paralytic  affections  in  a child  in  which  the  fals' 
membrane  existed  only  on  the  skin  around  tl; 
navel,  and  also  in  another  in  whichitwas  limite 
to  one  ear.  Similar  exceptional  cases  have  bee 
observed  by  others. 

Course. — There  is  in  all  cases  of  diphtheric 
paralysis  a strong  natural  tendency  to  recover 
Under  certain  special  reservations,  therefor 
such  as  extreme  debility,  or  implication  of  tl) 
heart,  respiratory  muscles,  or  larynx,  the  pro; 
nosis  is  favourable.  The.  duration  of  the  paralvt 
affections  is  very  variable,  and  is  dependent  to) 
considerable  extent  upon  the  manner  in  whic 
the  function  of  nutrition  is  performed,  and  tl 
skill  and  vigilance  with  which  nature  is  assist! 
by  treatment.  The  duration  is  much  more  fr 
qucntly  weeks  than  months;  and  when  it  is  mo 
than  a year,  there  is  a great  probability  of  tl 
affection  becoming  permanent,  from  the  establis 
ment  of  one  or  more  secondary  conditions,  such 
atrophy  of  muscles,  and  the  ascent  of  themorl 
state  from  the  periphery  to  the  nervous  centrf 

Pathology. — There  is  no  proof  that  there 
a specific  cause  of  paralysis  in  diphtheria.  Du 
ing  the  course  of,  and  in  the  convalescence  from: 
other  acute  disease  are  asthenia  and  anaemia 
constant  and  so  profound  as  in  diphtheria;  ai 
in  no  other  disease  is  paralysis  so  frequei 
The  two  facts  probably  stand  to  each  other 
the  relation  of  cause  and  effect,  The  treatme 
for  asthenia  and  anaemia  is  the  treatment  f 
diphtheritic  paralysis.  The  affection  exten 


PARALYSIS,  DIPHTHERITIC. 

Iroiu  the  peripheries  of  the  nerves  upwards. 
When  the  nervous  centres  are  implicated,  their 
implication  is  secondary. 

Treatment. — In  principle  and  in  detail,  the 
vreatment  of  the  paralysis  of  diphtheria  is  to 
1 great  extent  a continuation  or  renewal  of  the 
treatment  of  convalescence  from  the  attack  of 
(he  disease  itself.  Every  available  means  must 
be  employed  to  promote  nutrition,  and  the 
aealthful  exercise  of  all  the  functions.  The 
cading  therapeutical  indications,  in  respect  to 
general  treatment,  are  fulfilled  by  giving  the 
batient  a pepsinated  diet,  a ferruginous  medica- 
tion, and  as  much  of  the  open  air  as  weather 
md  the  circumstances  of  the  case  permit.  The 
dietetic  and  medicinal  details  must  be  carefully 
regulated  and  modified,  in  accordance  with  the 
progress  of  the  patient,  and  tho  personal  pecu- 
liarities of  his  case. 

Orezza  water  is  a good  form  in  which  to  ad- 
ninister  iron  in  these  affections.  When  the 
latient  has  a repugnance  to  take  this  water  with 
lis  meals,  in  doses  of  from  an  ounce  to  six  ounces, 
t may  be  given  half  an  hour  or  an  hour  after  he 
ias  eaten.  Artificial  preparations  of  iron  may 
Iso  be  used  with  advantage,  such  as  the  liquor 
erri  perchloridi,  in  doses  of  from  five  to  thirty 
hinims  in  water  twice  or  thrice  a day.  The 
•arbonate  of  iron  pill,  in  doses  of  from  three  to 
»n  grains  twice  or  thrice  a day,  immediately  be- 
fore or  with  meals,  often  answers  remarkably 
veil.  Bitter  effervescing  iron-draughts  suit  some 
•atients. 

- When  amendment  is  slow  or  absent  under  the 
se  of  ordinary  doses  of  iron,  though  tho  anaemic 
ondition  of  the  patient  seems  strongly  to  pro- 
iaim  the  necessity  of  this  medicine  being  given, 
,s  use  must  not  be  hastily  abandoned,  but  it 
.iould.be  administered  in  very'  small  quantity, 
jad  largely  diluted.  Should  we  still  be  disap- 
pointed with  the  result,  it  will  be  well  to  try 
■on  in  combination  with  iodine  or  with  arsenic 
i suitable  forms. 

The  extract  of  nux  vomica,  or  the  liquor  strych- 
jiae,  in  small  doses  taken  daily  with  some  ordi  nary 
junbination  of  laxatives  in  pills,  should  constitute 
art  of  the  later  treatment  in  nearly  every  case. 
In  addition  to  the  general  treatment,  the 
iralysis  of  diphtheria  frequently  calls  for  other 
ensures  of  a special  character. 

Persistent  and  carefully  regulated  local  stimu- 
tion  may  be  required  to  restore  impaired  in- 
rvation,  and  to  secure  an  adequate  supply  of 
■terial  blood  to  the  wasting  muscles.  There  are 
) other  means  so  likely  to  arrest  and  prevent 
'generation  and  atrophy  of  the  muscles — morbid 
ranges,  which,  if  unchecked,  lead  inevitably  to 
e permanence  and  incurability  of  the  para- 
sis.  Local  stimulation  may  be  accomplished 
' blisters,  liniments,  pastes,  or  shampooing, 
he  or  other  of  these  means  may  be  employed 
her  separately,  or  in  conjunction  with  some  of 
is  others.  The  occasional  application  of  blisters 
! most  useful ; but  care  must  be  taken  not  to 
sicate  too  large  a continuous  surface,  so  as  to 
errupt  the  use  of  systematic  gentler  stimula- 
n by  liniments,  pastes,  and  shampooing.  Care 
istalso  be  taken  not  to  make  tkeskin  too  tender 
admit  of  the  muscles  being  exercised  from 
se  to  time  without  pain.  To  limit  the  blister  to 


PARAPLEGIA.  1099 

the  surface  intended,  securing  at  tho  same  time 
rapid  and  comparatively  painless  vesication,  the 
best  proceeding  is  to  paint  the  surface  which  it  is 
desired  to  vesicate  with  an  acetum  cantliaridis 
four  times  as  strong  as  the  acetum  of  the  British 
Pharmacopoeia.  The  liquor  epispasticus  is  an 
excellent  application  for  raising  an  immediate 
blister;  but  when  time  is  not  all-important,  it  is 
better  to  use  a strong  acetum  cantbaridis.  Lu- 
brication with  liniments  combining  anodyne  with 
stimulating  properties  is  particularly  suitable, 
in  conjunction  with  shampooing,  and  the  galva- 
nic excitement  of  contraction  of  the  paralysed 
muscles.  A good  application  of  this  description 
is  composed  of  one  part  of  tincture  of  cantharides, 
one  part  of  tincture  of  opium,  and  six  parts  of 
compound  camphor  liniment.  A good  stimulating 
paste  is  composed  of  six  drachms  of  powdered 
ginger,  and  two  drachms  of  English  mustard,  tho- 
roughly rubbed  up  with  just  a sufficient  quantity 
of  lard  to  make  a paste  of  suitable  consistence. 
Circular  bands  of  linen,  an  inch  in  breadth, 
smeared  with  this  stimulating  paste,  are  applied 
at  intervals  of  five  or  six  inches  to  the  whole 
length  of  a limb,  care  being  taken  to  change  the 
position  of  the  bands  once,  twice,  or  oftener,  in 
the  twenty-four  hours,  so  that,  whilst  the  sur- 
face is  kept  glowing  with  warmth  by  the  paste, 
its  topical  action  on  the  skin  is  not  allowed  to 
exceed  the  proper  limit.  When  the  warm  ting- 
ling sensations  caused  by  the  stimulating  bands 
induce  restlessness  and  prevent  sleep,  the  bands 
must  be  removed  for  eight  or  ten  hours  at  a time. 
In  paralysis  of  the  respiratory  muscles,  large 
sinapisms  applied  to  the  chest  are  of  much  use. 
In  cardiac  paralysis,  Duchenne  has  recommended 
faradisation  of  the  prsecordial  region.  Galvanic 
excitement  of  contraction  in  the  paralysed  mus- 
cles of  the  limbs  is  often  decidedly  useful ; but 
it  is  a measure  which  requires  to  he  employed 
with  moderation,  and  at  intervals  of  about 
twenty-four  hours.  If  resorted  to  too  early,  or 
too  freely,  it  exhausts  the  returning  power  of 
the  affected  muscles. 

When  the  paralytic  affections  become  general, 
or  the  improvement  is  imperceptible  or  very  slow, 
sea-air,  sea-baths,  and  hydrotherapeutics  deserve 
attention.  In  obstinate  and  protracted  cases — 
particularly  in  strumous  subjects — they  often 
prove  of  much  advantage  when  employed  together 
with,  or  apart  from,  other  measures. 

John  Rose  Cormack. 

PARALYSIS,  SENSORY.  See  Sensa- 
tion, Disorders  of. 

PARAMENIA  ( irapa , irregularly,  and^V.  a 
month). — A term  for  irregular  menses.  See 
Menstruation,  Disorders  of. 

PARAPHIMOSIS  (ir apa,  beside,  and  cpiy.6ui, 
I confine).— Synon  : Fr.  andGer.  Paraphimosis. 
A morbid  condition  of  the  penis,  in  which  the 
prepuce  having  been  drawn  or  forced  back  behind 
the  glans,  cannot  be  returned,  and  thus  gives  rise 
to  a condition  of  strangulation  of  the  parts  in 
front  of  it.  See  Penis,  Diseases  of. 

PARAPLEGIA  (xa pa,  incompletely,  and 
7rA7jcr<T“>  I strike).— Paralysis  of  the  lower  ex» 
tremities,  usually  associated  with  paralysis  of 
the  lower  part  of  the  trunk,  bladder,  and  rectum. 
See  Paralysis  ; and  Spinal  Cord,  Diseases  of. 


1100  PARASITES. 

PARASITES  (ir apa,  upon,  and  onlw,  I feed). 
Synon.  : Fr.  Parasite ; Ger.  Parasit. 

Definition. — This  term,  in  its  most  extended 
sense,  is  applied,  in  general  pathology,  to  those 
living  organisms  which  derive  their  nourishment 
wholly  or  in  part  from  other  living  organisms. 
Parasites  may  be  vegetable  or  animal— phyto- 
parasites  or  zoo-parasites ; may  live  upon  the 
surface  of,  or  in  the  textures  or  cavities  of,  the 
organisms  they  infest — ccto-parasites  or  ento- 
parasites ; and  may  pass  through  the  whole  cycle 
of  their  existence  in  the  parasitic  state,  or  only 
during  certain  stages  of  their  life. 

This  definition  will  include  those  organisms, 
such  as  tinea  and  trichina,  which  feed  upon 
the  living  tissues  of  the  hosts  they  infest ; those 
which  subsist  on  the  material  prepared  by  the 
host  for  its  own  nourishment — for  instance,  torula 
and  taenia;  and,  lastly,  those  which  only  tem- 
porarily sojourn  on  the  surface  of  the  body, 
for  the  purpose  of  obtaining  food,  and  do  not 
live,  for  any  period  of  their  existence,  upon  or 
within  their  entertainer — for  example,  fleas  and 
gnats. 

The  majority  of  these  parasites  may  be  re- 
garded as  direct  causes  of  disease,  the  pathology 
of  which  is  now  being  made  the  subject  of  accu- 
rate investigation,  and  will  be  found  described, 
so  far  as  is  known,  in  other  parts  of  this  work.  A 
few  only  of  the  fungi,  such  as  the  blue  moulds 
(penicillium  glaucum),  may  be  looked  upon  as 
a result  of  a morbid  condition,  being  occa- 
sionally met  with  on  the  surface  of  old  ulcers,  in 
old  cavities  of  the  lungs,  and  on  the  nails. 

Vegetable  parasites  and  animal  parasites  will 
be  separately  noticed  in  the  following  articles. 

PARASITES,  Vegetable. — Vegetable  pa- 
rasites are  included  under  the  general  term  of 
fungi.  More  accurately  they  are  to  be  referred  to 
the  classes  Sehizophyta  or  Protophyta,  and  Zygo- 
spore*, which  are  provisionally  the  lowest  divi- 
sions of  the  sub-kingdom  Thallophyta. 

To  the  order  Sehizomycetes  of  the  former 
class  belong  Micrococcus,  Bacterium,  Bacillus, 
Vibrio,  Spirillum,  &e. ; and  to  the  order  Saccha- 
romycetes  of  the  same  class,  the  various  Torulte 
or  Mycodermata,  and  Sarcina  ventrieuli. 

These  organisms  are  extremely  simple,  con- 
sisting of  minute  particles  of  living  matter — 
spherical,  cylindrical,  filiform,  curved,  straight, 
or  spiral.  They  occur  in  swarms,  which  are  either 
lree,  or  imbedded  in  a gelatinous  matrix — the 
zooglcea-stage.  They  contain  no  chlorophyl,  and 
a nucleus  is  often  wanting.  They  multiply'  by 
fission.  The  cells  of  theTorulse,  or  yeast-plants, 
are  frequently  aggregated  into  simple  or  branch- 
ing rows;  and  in  Sarcina  ventrieuli  the  cells  are 
arranged  ingroups  of  four,  sixteen,  or  thirty-two, 
presenting  a very  characteristic  appearance. 

The  numerous  forms  included  under  the  term 
Bacteria  are  met  with  normally  in  many'  situa- 
tions in  the  body;  for  example,  they  are  an  in- 
variable accompaniment  of  pancreatic  digestion. 
Pathologically,  they  are  of  frequent  occurrence 
in  the  blood,  urine,  and  other  fluids,  and  are  re- 
garded as  playing  an  important  share  in  many 
contagious  and  other  diseases  (see  Bacteria; 
Contagion;  Micrococcus;  and  Zyme).  The 
ferment-bodies — Torulse  and  Sareinae — are  also 


PAROXYSM. 

found  in  the  stomach  during  digestion,  and  the 
former  are  abundant  in  diabetic  urine. 

In  the  class  Zygospore*  are  comprised  the 
filamentous  varieties,  such  as  O'idium  albicans, 
and  the  various  parasites  to  which  the  term  Tinea 
is  applied  (Trychophyton  tonsurans,  AchorioD 
Schcenleinii,  Microsporon  furfur,  &c.). 

W.  H.  Aixchin. 

PARASITES,  Animal. — A strict  defini- 
tion of  the  term  animal  parasites,  in  the  writer’s 
view,  should  he  understood  to  include  ‘ all  those 
forms  of  creatures  which  in  a direct  manner, 
by  dwelling  in  or  upon  other  living  animals, 
or  by  merely  visiting  or  momentarily  aiignting 
on  the  surface  of  the  body,  are  thus  enabled 
to  acquire  means  of  subsistence.’  A definition 
of  this  comprehensive  character  not  only  em- 
braces a variety  of  creatures  rarely  spoker 
of  as  parasites,  such  as  bugs,  fleas,  flies,  mos- 
quitoes, and  so  forth,  but  it  appropriately  ex- 
cludes all  those  forms  of  animal  life  that  merely 
play  the  rule  of  fellow-boarders  ( commensals  ci 
messmates  of  Van  Beneden),  and  which,  never- 
theless, are  commonly  looked  upon  as  parasites 
Regarded  from  a purely  zoological  point  of  view 
the  classification  of  the  animal  parasites  is  a 
matter  of  great  difficulty ; but,  for  all  practical 
purposes  connected  with  medicine  and  hygiene 
it  is  sufficient  to  speak  of  the  intestinal  worms 
as  forming  three  well-marked  groups,  namely : 
— (1)  fluke-worms ; (2)  tape-worms,  including 
bladder-worms ; and  (3)  round-worms,  including 
thread-worms.  Under  the  heading  Entozoa 
will  be  found  a full  list  of  the  human  animal 
parasites.  For  an  explanation  of  various  terms 
employed  in  connection  with  the  study  of  animal 
parasites,  the  reader  should  consult  the  articles 
on  Intestinal  Worms;  Helminths;  A'eemes 
and  Worms.  The  insect  parasites  (bots,  maggots 
Sec.)  are  noticed  under  CEstrus. 

T.  S.  Cobbold. 

PARENCHYMATOUS  (vapa,  beside,  and 
(yx<u\  I pour  in). — The  word  parenchyma  was  for- 
merlyT  used  to  designate  the  connective  tissue  o: 
the  several  viscera ; but  it  is  now  applied  to  thg 
protoplasm,  or  active  elements,  of  a tissue  oi 
organ  ; and  morbid  processes  affecting  the  actual 
substance  of  an  organ  are  hence  called  paren- 
chymatous. 

PARESIS  (irapt-npu,  I relax). — A slight  oi 
imperfect  paralysis  of  motion.  Sec  Paralysis 

PARONYCHIA  (vapa.  beside,  and  otv(,  the 
nail). — Inflammation  in  close  proximity  to  s 
nail.  A synonym  for  whitlow.  See  Rails,  Dis 
eases  of;  and  Whitlow. 

PAROTID  GLANDS,  Diseases  of.  Sc, 
Mumps  ; and  Salivary  Glands,  Diseases  of. 

PAdROXYSM  ( iraph,  indicating  increase 
and  o^vvai,  I sharpen). — This  word  is  used  tc 
indicate  the  periodic  attacks  or  fits  which  cha- 
racterise certain  diseases,  whether  regular  n 
irregular,  such  as  ague,  gout,  and  asthma.  I’ 
is  also  used  to  designate  the  aggravation  ol 
certain  symptoms  from  time  to  time,  such  as 
neuralgic  pain,  colic,  and  dyspnoea.  Disease; 
characterised  by  these  phenomena  are  calico 
paroxysmal  diseases. 


PARTIAL. 

PARTIAL  (pars,  a part). — When  applied  to 
isease  this  term  may  refer  either  to  its  extent, 
•its  degree.  Thus  wespeakof  partial  paralysis-, 
id  partial  blindness,  deafness,  &e. 

PASSIVE. — This  epithet  is  used  hy  some 
ithologists  in  connection  -with  certain  morbid 
inditions,  such  as  congestion,  dropsy,  oedema, 
id  haemorrhage,  where  there  is  deficiency  of 
•tal  power,  either  general  or  local,  and  a want 
' reaction  or  resistance  in  the  tissues.  Some 
ithologists  employ  the  term  passive  congestion 
s synonymous  with  congestion  from  obstruction 
;ee  Ciecclation,  Disorders  of;  and  Hypostasis). 
assive  movements  of  any  part,  for  instance,  of  a 
iint,  are  movements  effected  by  some  agency 
eternal  to  the  limb,  such  as  the  hands  of  the 
petitioner  or  of  the  patient  himself,  in  con- 
■adistinction  to  movements  produced  by  the 
uscles  of  the  affected  parts,  which  are  called 
\tive  movements.  Sec  Movement,  Therapeuti- 
.1  Uses  of. 

PATENT  FORAMEN  OVALE  or 
EPTUM.  See  Heart,  Malformations  of. 
PATHOGENIC  (irddos,  disease,  and  yer- 
■u,  I give  rise  to). — A term  applied  to  the  pro- 
iction  of  a disease,  having  reference  to  the  mode 
which  the  several  causes  which  lead  to  it 
Wate  in  its  development. 
PATHOGNOMONIC  (nddos,  disease,  and 
yviicKu,  I recognise).  — This  word  is  asso- 
rted with  those  symptoms  and  signs  which  are 
•ecially  characteristic  of  a disease,  and  which 
jr  their  presence  render  its  diagnosis  certain, 
c Disease,  Diagnosis  of. 

PATHOLOGY  (irdOos,  disease,  and  \iyos, 
discourse). — Pathology  is  the  name  generally 
icepted  for  the  science  of  disease,  but  the  sub- 
mits which  it  may  include  cannot  be  exactly 
fined.  For,  ease  and  disease,  well  and  ill,  and 
1 their  synonyms  are  relative  terms  of  which 
•ne  can  be  defined  unconditionally.  If  there 
uli  he  a fixed  standard  of  health,  all  devia- 
>ns  from  it  might  be  called  diseases;  but  a 
lief  characteristic  of  living  bodies  is,  not  fixity, 
t variation  by  self-adjustment  to  a wide  range 
varying  circumstances,  and  among  such  self- 
justments  it  is  not  practicable  to  mark  a line 
Derating  those  which  may  reasonably  be  called 
althy  from  those  which  may  as  reasonably  be 
,led  disease. 

The  impossibility  of  marking  such  a line  may 
tested  during  changes  in  any  external  condi- 
ns  of  life,  for  instance,  in  the  adjustments  of 
Ja  skin  to  a widely  varying  range  of  external 
hperatures.  Where  and  when  in  the  changes 
skin  produced  hy  long  contact  with  water 
ing  from  20°  Fh.  to  200°  Fh.  would  health 
ise  and  disease  begin  ? Similarly,  in  the  con- 
i ;uences  of  mechanical  injuries.  The  complete 
iair  and  reproduction  of  injured  and  lost  parts 
in  excellent  instance  of  health ; and  in  many 
' nts  injuries  elicit  a greater  production  of 
dthy  structures  than  would  occur  in  their 
i egrity— as  in  the  leaf  of  a Begonia  or  a Car- 
>'  nine,  in  which  a fresh  shoot  may  grow  from 
1 h of  many  wounds.  But  while  these,  and 
t'lilar  adjustments  to  conditions  produced  by 
i lry,  may  be  deemed  results  and  signs  of  health, 


PATHOLOGT.  1101 

many  others,  such  as  those  which  may  follow 
severe  crushings  and  open  wounds  of  limbs,  must 
rather  be  called  processes  of  disease,  even  though 
they  may  end  in  some  repair  of  injury.  Among 
all  the  cases  intermediate  between  these  extreme 
groups  of  adjustment  to  consequences  of  injuries, 
it  is  not  possible  to  separate  the  healthy  and 
the  diseased. 

In  this  impossibility  of  scientific  definition 
the  range  of  pathology  is  vaguely  settled  by  a 
general  understanding  as  to  what  may  be  called 
disease,  and  in  this  settlement  are  included  all 
the  states  which  are  distant  from  health,  whether 
they  be  in  the  way  of  diverging  from  it  or  in 
that  of  returning  to  it,  as  in  convalescence.  And 
some  states  are  included  for  which  it  is  hard  to 
assign  a better  or  other  reason  than  that  they 
are  not  useful  to  us.  When  fruits  or  other  parts 
of  plants  or  animals,  which  have  been  made  use- 
ful by  cultivation,  revert  to  their  more  natural 
state  and  become  useless,  they  are  generally 
regarded  as  diseased. 

Moreover,  in  the  study  of  any  disease  its  pro- 
cesses are  found,  though  different,  yet  not  essen- 
tially distinct  or  separable  from  those  of  health. 
Even  in  the  instances  of  the  widest  deviations 
from  health,  as  in  the  diseases  called  specific  or 
malignant,  a considerable  part  of  the  phenomena 
are  due  to  processes  tending  towards  a reversion 
to  health,  and  even  the  changes  most  averse  from 
health  are  limited  within  certain  methods  not 
wholly  unlike  the  healthy  ones. 

In  this  view  pathology  may  be  regarded  as  an 
extension  of  physiology  into  the  study  of  living 
bodies  in  conditions  widely  unlike  those  of  their 
ordinary  life.  Pathology,  herein,  accepts  the 
conventional  limitation  of  physiology  to  the 
study  of  the  nature  of  living  things  ; but  the 
limitation  is  convenient  more  than  just.  It  is 
not  possible  to  give  a verbal  definition  of  the 
difference  between  the  study  of  crystals  de- 
formed or  repairing  after  injury,  and  that  of 
monstrosities  and  the  processes  of  repair  in 
plants  and  animals.  As  physiology  is  not  truly 
limitable  from  chemistry  and  physics,  so  in  patho- 
logy many  processes  are  illustrated  by  things 
abnormal  or  contrary  to  general  rule  in  dead 
matter. 

Pathology  finds  in  physiology  its  basis,  the 
varying  standards  of  healthy  structure  and 
function  with  which  its  subject-matters  are  in 
contrast,  and  the  models  and  methods  of  its 
study ; but  its  range  is  wider  than  that  of 
physiology,  inasmuch  as  the  conditions  giving 
rise  to  disease  are  much  more  numerous  and 
more  various  than  those  of  health.  Moreover, 
the  deviations  from  health  may  reach  so  far  and 
wide,  that  the  facts  and  general  principles  of 
physiology  can  only  with  extreme  caution  be 
applied  to  them.  For  instance,  the  greater  part 
of  what  may  he  called  personal  characteristics 
in  respect  of  health  can  only  he  observed  in 
phenomena  of  disease.  It  is  from  observation 
of  these  that  our  knowledge  is  derived  of  dia- 
theses or  constitutional  peculiarities,  and  of  con- 
ditions predisposing  to  overt  disease.  Of  them 
and  their  various  minglings  and  alterations  hy 
inheritance,  and  by  tendencies  to  reversion  to- 
wards health,  physiology  can  give  no  account  ; 
its  suggestions  cannot  be  safely  used  unless 


1102  PATHOLOGY. 

completely  subject  to  the  test  of  pathological 
inquiry. 

It  seems  certain  that  many  erroneous  and  too 
narrow  systems  of  pathology  have  been  dervied 
from  the  beliefs  of  pathologists  that  they  could 
safely,  from  the  general  truths  of  physiology  or 
even  from  some  section  of  them,  infer  what  must 
be  true  in  respect  of  disease.  Hence,  by  means 
of  inferences  from  the  parts  of  physiology  for 
the  time-being  most  studied,  ther6  have  arisen 
the  systems  of  vital  and  chemical,  of  humoral 
and  neural,  pathology,  all  containing  many 
truths,  but  none  of  them  able  to  stand  the  test, 
without  which  nothing  in  pathology  should  be 
deemed  true — the  test  of  a wide  and  direct 
study  of  diseases.  It  would  be  well  if  all  sys- 
tems of  pathology  which  can  be  thus  specially 
named  should  be  suspected  of  great  error.  The 
science  of  disease  should  not  be  divided  or 
specialised  on  any  other  groimd  than  physiology 
may  be,  as  by  the  names  of  general,  comparative, 
animal , vegetable,  and  the  like.  The  study  of 
any  one  of  these  divisions,  wide  as  it  may  be,  is 
not  safe  unless  with  frequent  reference  to  the 
others  for  their  aid  ; and  every  study  of  diseases 
of  one  part  or  of  one  kind  is  very  unsafe,  unless 
with  a constant  consciousness  cf  its  narrowness 
and  partiality.  Even  if  it  could  be  made  sure 
that  many  diseases  begin  in  morbid  states  of  the 
blood  or  nervous  system,  or  any  other  chief  con- 
stituent of  the  body,  it  would  be  nearly  as  sure 
that  within  a few  hours,  or  even  minutes,  of 
their  beginning  the  other  chief  constituents  would 
be  involved.  For  the  relations  of  the  several 
parts  are  so  intimate  and,  through  the  nervous 
system  and  the  circulating  blood,  their  means  of 
communication  are  so  swift,  that  if  one  be  diseased 
none  can  long  remain  healthy.  There  is  no  truth 
more  necessary  to  be  held  in  pathology,  and  in  its 
practical  applications,  than  that  the  health  of 
each  part  is  a necessary  condition  of  the  health 
of  all  the  rest.  James  Paget. 

PATJ,  in  western  district  of  South  of 
Prance. — Cool,  variable,  damp,  calm,  sedative, 
winter  climate.  Mean  temperature,  winter,  42° 
Fahr.  Much  rain  and  many  cloudy  days  in 
winter.  Soil,  gravel.  See  Climate,  Treatment 
of  Disease  by. 

PECTORILOQUY'  ( pectorc . fwm  the  chest, 
and  loquor,  I speak). — A physical  sign,  connected 
with  vocal  resonance,  heard  on  auscultation  in 
some  limited  parts  of  the  chest.  The  sounds  of 
the  voice  in  pectoriloquy  are  directly  conducted 
to  the  ear,  so  that  the  words  spoken  by  the 
patient  may  be  distinctly  recognised  by  the  ob- 
server, as  if  proceeding  from  within  the  chest. 
See  Physical  Examination. 

PECTORILOQUY,  WHISPERING. 

See  Whispering  Pectoriloquy  ; and  Physical 
Examination. 

PEDICULUS. — Three  species  of  lice  are 
parasitic  on  man: — (1)  Pediculus  capitis ; (2) 
Pediculus  veslimenti  vel  corporis ; and  (3)  Pedi- 
culus pubis. 

1.  Pediculus  capitis. — This  species  of  pedicu- 
lus infests  the  head,  especially  the  occiput,  and 
deposits  its  eggs  on  the  shaft  of  the  hair,  usually 
not  far  from  the  root.  The  ovum  is  a small, 


PELLAGRA. 

oval,  semi-transparent  body,  somewhat  cuppee 
at  its  free  extremity,  and  very  firmly  attache; 
by  a short  peduncle  to  the  hair.  The  youn|' 
are  hatched  in  about  five  days.  The  louse  whe; 
full-grown  is  about  a line  in  length,  the  femal 
being  larger  than  the  male.  The  head,  thorax 
and  abdomen,  which  is  oval,  are  distinct.  Th. 
head  is  furnished  with  two  short  antenme,  am 
large,  black,  prominent  eyes.  Springing  froD 
the  thorax  are  six  well- developed  legs,  arms 
with  strong  claws,  with  which  the  animal  grasa 
the  liair.  On  the  back  of  the  male  is  seen  .- 
conspicuous,  elongated,  conical  organ,  the  penis] 
The  animal  is  of  a semi-transparent,  dirty-whitj 
colour,  and  is  covered  with  short  scattered 
hairs. 

2.  Pediculus  vestimenti. — This  species  close! 
resembles  in  shape  and  general  appearance  th’! 
pediculus  capitis,  but  is  of  larger  size.  It  in 
fests  the  under-clothing,  with  a preference  fo: 
that  of  a woolly  kind,  and  it  attacks  and  irri 
rates  the  parts  of  the  skin  that  are  covered  tr 
clothes.  The  ova  are  deposited,  not  on  the  hai 
of  the  skin,  but  on  tho  wool  or  fibre  of  th 
clothing,  and  the  young  are  hatched  in  ahem 
five  or  six  days. 

3.  Pediculus  pubis. — This  is  much  smaller  aw, 
relatively  shorter  than  ei  th  er  of  the  other  species 
and  the  line  of  separation  between  abdomen  am 
thorax  is  less  marked.  The  abdomen  is  shor 
and  rounded,  which  gives  the  animal  a crab-lik 
shape.  Like  the  other  species,  it  has  six  legs, 
armed  with  strong  claws  for  grasping  the  hair! 
This  louse  infests  the  pubic  region,  and  occa! 
sionally  the  axilla  and  hairy  parts  of  the  facei 
The  ova  are  found  firmly  attached  to  the  hair 
near  the  roots. 

The  different  speciesof  pediculi  do  not  bite, a 
they  have  no  jaws ; but  they  pierce  the  skin  an; 
draw  blood  by  means  of  a sucking  apparatus  o 
kaustellum,  and  in  this  way  they  derive  thei 
sustenance  from  the  human  body.  Regarded  b 
a pathological  aspect,  the  presence  of  pediculi  i 
described  as  a disease  under  the  name  of  morbu: 
pedietdaris,  or  phthiriasis.  See  Phthiriasis. 

Robert  LrrEKe. 

PELLAGRA  ( pellis , the  skin,  and  Hype 
a seizure). — Synon.  : Fr.  Pellagrc ; Ger . Pd 
lagra. 

Definition. — An  erythema  of  the  skin,  Erg 
thema  pcllagrosum.  which  makes  its  appearanc 
on  the  parts  of  the  body  most  exposed  to  the  light 
especially  the  back  of  the  hands  and  neck  am 
the  breast. 

Pellagra  has  been  regarded  as  a local  coup  d 
soleil,  whence  it  is  likewise  called  mal  del  sole 
The  disease  being  indigenous  to  hot  countrie; 
and  common  among  the  picasants  in  Italy,  Spain 
and  the  South  of  France,  it  has  there  received  th 
names  of  mal  dc  padrone,  mal  de  misere,  caitio 
'male,  and  scorbuto  Alpino.  It  has  also  been  desig 
nated  by  authors  risipola  Lombards,  rasa ■ Asia 
riensis,  lepra  Asturicnsis,  elephantiasis  Italics 
and  elephantiasis  Asturicnsis.  These  several  name 
point  to  different  features  of  its  history,  some 
times  alluding  to  its  appearance  ; for  example 
the  ‘ red  disease,’  mal  dc  la  rosa  ; sometimes  t 
the  class  of  people  liable  to  its  attack,  namelj 
agricultural  labourers ; sometimes  to  its  ore 


PELLAGRA. 

roed  cause — the  sun,  misery,  and  unwholesome 
lize  ( raphania  maistica) ; and  sometimes  to 
'eoretical  analogies,  as  in  the  instance  of  scor- 
;tus,  lepra,  and  elephantiasis. 

AStroLOGY. — The  local  symptoms  of  pellagra 
epare  us  for  the  consideration  of  a neurosis, 
which  there  exists  undoubtedly  a predisposing 
use,  as  well  as  an  exciting  cause  and  subse- 
|ent  constitutional  disorder.  The  predisposing 
iusos  are  heredity,  which  is  unquestionable  ; 
iverty ; insufficient  and  improper  food  and 
lathing ; malaria : and  especially  unwholesome 
jiizc,  which  constitutes  the  staple  article  of 
let  in  some  of  the  countries  wherein  the  disease 
endemic.  A certain  fungus,  spnrisorium  may- 
L-,  has  been  accredited  with  being  a special 
juse  of  the  disease.  The  sun’s  rays  are  regarded 
\\  the  immediate  exciting  cause,  and  its  powrer 

I more  particularly  evinced  in  the  spring  of  the 
ar,  and  has  been  expressed  by  the  term  ‘ ver- 
1 insolation.’ 

Symptoms. — The  local  affection,  to  the  outward 
|e,  is  at  first  an  ordinary  erythema,  with  a ten- 
ncy  to  centrifugal  growth.  ■ In  the  beginning 
jis  of  a dark-red  colour,  without  swelling  ; then 
becomes  more  or  less  deeply  pigmented  in  the 
;ntre;  and  later  on,  the  area  becomes  bleached 
id  atrophic,  while  the  margin  still  remains 
tire.  In  its  early  stage  the  congestion  of  the 
jin  is  attended  with  tingling  and  prickling 
in;  subsequently  it  loses  its  sensibility,  and  is 
bre  or  less  completely  benumbed.  At  a later 
riod  of  the  local  disease  there  occur  desqua- 
ition,  chapping,  with  exudation  and  incrus- 
don,  and  sometimes  vesicles  and  pustules. 

The  constitutional  symptoms  of  pellagra  are 
jjh  as  point  to  a serious  injury  of  tho  nervous 
btem.  They  are : — nausea,  vertigo,  heat  of  epi- 
strium,  diarrhoea,  lassitude,  disturbed  vision, 
imp  and  neuralgic  pains;  the  pulse  being 
ble,  the  tongue  red,  and  the  appetite  vora- 
us.  These  symptoms  are  attended  with  pros- 
ition  of  strength  and  emaciation.  They  con- 
ue  for  a period  of  three  months,  and  aro 
ble  to  be  re-excited  by  every  exposure  to  the 
1.  The  following  spring  the  symptoms  re- 
■n  with  greater  intensity,  affecting  more  and 
ire  deeply  the  nervous  system  and  brain  ; and 
ally  the  patient  drifts  into  dementia,  melan- 
plia,  or  mania.  In  the  later  periods  of  the  dis- 
,ie  the  patient  is  extremely  emaciated  ; the  skin 
Uow  and  shrunken;  the  lips  pale;  the  pulse 
ak,  sixty  to  seventy  in  the  minute ; and  the 
iremities  cold  and  tremulous.  Serous  effusion 
' mrs  in  the  cavities  of  the  body,  cerebro-spinal 
|1  visceral ; and  the  sufferers  die  from  exhaus- 
' n,  sometimes  from  softening  of  the  brain  and 
Inal  cord,  sometimes  from  colliquative  diar- 
jea,  and  sometimes  from  typhoid  fever. 
Prognosis. — Pellagra  is  generally  fatal  after 
(jaw  years  when  left  to  take  its  course;  but 
';My  last  for  a period  ranging  between  one  and 
' ty  years.  It  is  curable,  when  properly  treated, 
die  proportion  of  78  per  cent. 
fjtEATMENT. — The  most  successful  treatment 
1 pellagra  is  that  which  may  be  reasonably  de- 
1 :ed  from  an  examination  of  tho  causes  of  the 
tease,  namely,  improved  hygienic  conditions; 
nound  diet  of  mixed  animal  and  vegetable 
■ d ; beer  or  wino ; and  tonic  medicines,  espe- 


PELODERA.  1103 

cially  quinine,  phosphates,  and  chalybeafes.  To 
this  general  plan  may  be  added,  a careful  avoid- 
ance of  exposure  to  the  sun,  and  the  particular 
treatment  needed  for  complications,  for  example 
the  nerve-symptoms  and  diarrhoea.  The  local 
treatment  should  consist  in  the  use  of  soothing 
and  protective  lotions  and  ointments,  such  as 
oxide  of  zinc  and  lime-water,  or  oxide  of  ziDC  oint- 
ment; and  pencilling  the  margin,  when  the  disease 
is  obstinate,  with  iodine  liniment.  In  cases  of  the 
disease  of  small  extent,  such  as  are  occasionally 
brought  to  this  country  from  tropical  climates, 
arsenic  likewise  will  be  found  to  be  a useful 
remedy.  Erasmus  "Wilson. 

PELODEEA. — The  Dame  of  a genus  of 
‘ free  nematoids,’  one  species  of  which  (P.  setigera, 
Bast.),  according  to  the  determination  of  the 
present  writer,  has  been  found  as  a parasite 
within  the  human  body,  under  the  following 
circumstances  ; — In  the  autumn  of  1879  a febrile 
epidemic  prevailed  amongst  the  boys  on  board 
the  reformatory-school  ship  ‘ Cornwall,’  which 
was  investigated,  and  reported  upon  by  Mr.  AV. 
II.  Power,  for  the  Local  Government  Board.  The 
symptoms  of  the  disease  were  in  several  respects 
related  to  those  of  typhoid  fever  ; in  others  to 
those  of  trichiniasis.  Two  months  after  burial, 
the  body  of  the  only  boy  who  had  died  was  ex- 
amined by  Mr.  Power  and  Dr.  Cory.  Erom  the 
absence  of  all  characteristic  lesions,  they  decided 
that  this  boy  had  certainly  not  died  from  enteric 
fever.  Mr.  Power  adds; — ‘ This  conclusion  was 
more  than  confirmed  by  the  results  of  micro- 
scopic investigation  conducted  with  reference  to 
trichiniasis.  In  the  very  first  specimen  exa- 
mined— a few  fibres  from  one  of  the  abdominal 
muscles — was  found  a wandering  and  living  tri- 
china; and  further  search  revealed  the  presence 
of  these  parasites  in  most  of  the  muscles  ex- 
amined. Although  tolerably  abundant,  in  none 
of  the  muscles  had  the  parasite  reached  the  stage 
of  encapsulation.’ 

Doubts  were  subsequently  expressed  in  some 
quarters,  as  to  whether  the  parasites  were 
trichinae ; and  it  was  suggested  that  they  were 
free  nematoids  belonging  to  the  genus  Rhahditis. 

All  the  existing  microscopical  specimens  were 
therefore  handed  over  to  the  present  writer.  The 
result  wept  to  show  that  the  creatures  found 
were  distinctly  different  from  trichinae.  They 
were  in  their  mature  state,  of  about  the  same 
size  as  embryo  or  muscle  trichinae,  and,  as  the 
drawings  furnished  by  the  writer  show,  they  ex- 
hibited altogether  different  anatomical  characters 
(see  Ninth  Report  Local  Government  Board,  for 
1879;  Appendix).  He  determined  that  the  organ- 
ism was  a previously  unknown  species  of  the  genus 
Pelodera,  to  which  he  gave  the  name  P.  setigera. 

In  relation  to  the  fact  that  the  members  of 
this  genus  of  free  nematoids  have  hitherto  been 
found  ‘ in  damp  earth  and  decaying  substances,’ 
and  especially  in  fragments  of  muscle  buried 
in  damp  earth,  it  is  of  importance  to  bear  in 
mind  that  these  particular  nematoids  were  found 
alive  in  a corpse  which  had  been  buried  for  a 
period  of  two  months.  The  facts  go  no  further 
than  this,  with  the  addition  that  the  boy  died 
from  the  effects  of  an  obscure  febrile  disease.  All 
intermediate  links  as  to  source  of  infection,  and  as 


1101  PELODERA. 

to  the  existence  of  the  parasites  in  the  body  dur- 
ing life,  or  even  shortly  after  death,  are  wanting. 

Should  subsequent  investigation  confirm  the 
view  that  the  ‘ Cornwall  ’ epidemic  was  occasioned 
by  tho  presence  of  the  nematoids  above  referred 
to,  then  we  should  have  to  admit  the  existence 
of  two  distinct  fleshworm  diseases  in  the  human 
subject,  the  one  caused  by  the  trichina  flesh- 
worm,  and  the  other  by  the  pelodera  flesh-worm. 
And,  just  as  the  one  affection  is  now  commonly 
known  as  ‘ triehiniasis,’  so  might  the  other  be 
designated  ‘ peloderiasis.’ 

H.  Charlton  Bastian. 

PELVIC  ABSCESS. — Definition.  — An 
abscess  situated  in  the  pelvis,  and  generally  con- 
nected with  some  uterine  affection. 

.ZEtioloqy. — The  causes  of  pelvic  abscess  are : 
1.  Breaking  down  of  tubercles;  2.  Suppu- 
rative action,  the  result  of  broken-down  haema- 
tocele  or  suppurating  ovarian  cyst ; 3.  Inflam- 
mation of  tho  pelvic  peritoneum ; and  4.  Inflam- 
mation of  the  cellular  tissue  in  connection  with 
the  uterine  ovaries,  broad  ligaments,  or  the 
general  cellular  tissue  of  the  pelvis. 

Pelvic  peritonitis  and  cellulitis  being  often 
combined,  pelvic  abscess  may  arise  from  the  joint 
action  of  these  causes ; and,  indeed,  after  an  ab- 
scess has  arisen,  it  is  very  difficult,  if  not  impos- 
sible, to  differentiate  as  to  its  primary  origin. 

Symptoms. — Pain  of  a shooting  character,  with 
increased  local  tenderness,  accompanied  by  rigors, 
sweating,  and  pyrexia,  supervening  upon  the 
symptoms  of  pelvic  cellulitis  or  of  pelvic  peri- 
tonitis, will  generally  indicate  the  onset  of  the 
affection.  See  Pelvic  Cellulitis;  and  Pelvic 
Peritonitis. 

An  abscess  having  arisen  in  the  pelvis,  it 
conforms  to  the  same  general  laws  as  abscesses 
in  other  parts,  its  direction  depending  upon 
the  tension  of  the  surrounding  tissues,  an 
abscess  generally  burrowing  in  the  direction  of 
least  resistance.  Thus  pelvic  abscess  may  open 
in  the  following  directions,  singly  or  combined : — 
1.  Through  the  abdominal  walls  and  saphenous 
openings.  2.  Into  the  pelvic  viscera,  as  the 
bladder,  rectum,  vagina,  or  urethra.  3.  Through 
the  floor  of  the  pelvis,  near  the  anus.  4.  Through 
the  pelvic  foramina,  either  obturator  or  sacro- 
ischiatic.  5.  Through  the  pelvic  roof  into  the 
peritoneal  cavity.  6.  Into  the  lumbar  region,  in 
the  position  of  tho  kidney. 

Such  are  the  many  and  various  courses  which 
an  abscess  originating  in  the  pelvis  may  take. 
Eortunately  some  of  those  enumerated  are  rare, 
such  as  opening  into  the  peritoneum.  No  doubt 
its  starting-point  has  much  to  do  with  its 
subsequent  course,  which  admits  of  explanation 
chiefly  on  anatomical  grounds.  Should  an  abscess 
open  into  the  peritoneum,  then  our  trouble  will 
no  longer  be  with  the  abscess,  hut  with  the  peri- 
tonitis that  ensues,  so  that  we  may  lose  sight  of 
the  primary  disease  in  the  gravity  of  the  secon- 
dary. 

Should  the  abscess  open  into  the  rectum,  we 
shall  have  a discharge  of  pus  and  fecal  matter, 
of  a most  fcetid  character,  by  the  bowel.  On  its 
opening  into  the  bladder  long-continued  cystitis 
may  supervene.  Should  a communication  become 
established  between  these  two  organs,  we  shall 


PELVIC  CELLULITIS. 

have  the  indication  of  fecal  matter  present  i: 
the  urine. 

Treatment. — Pelvic  abscess  must  he  treatec 
as  deep-seated  abscesses  in  other  parts  of  thi 
body  in  the  early  stages,  namely,  by  inducing 
pointing  by  hot  fomentations  or  poultices;  but 
when  matter  has  formed  the  treatment  will  van 
somewhat,  according  to  the  position  the  absces" 
takes: — 1.  When  the  abscess  is  threatening  t< 
point  above  Poupart’s  ligament,  it  is  general]; 
wisest  not  to  use  the  lancet  until  the  skin  is  seer 
to  be  definitely  implicated.  2.  When  the  matte: 
is  burrowing  down  the  leg,  or  away  from  th* 
pelvis,  beneath  the  fascise,  it  must  be  treated 
according  to  the  usual  rules  laid  down  in  surgen 
for  deep-seated  abscesses.  3.  Should  the  matter 
be  in  the  floor  of  the  pelvis,  bulging  into  the! 
vagina  and  rectum,  and  highly  irritative  symp- 
toms exist,  then  it  will  he  advisable  to  empty  L 
aspiration,  or  if  pus  be  clearly  observed,  to  opei 
with  full-sized  trochar  and  cannula.  When  th« 
fluid  is  evacuated,  it  is  well  to  pass  up  a drainagi 
tube,  carefully  withdrawing  the  cannula,  arc 
leaving  the  tube  in  position,  through  which  hi! 
cyst  should  be  washed  out  twice  daily  with  : 
disinfecting  fluid,  such  as  some  preparation  o! 
iodine;  the  tube  can  be  removed  when  thi 
discharge  ceases  to  flow.  Should  haemorrhage 
have  occurred  in  the  cyst,  the  difficulty  of  evacua 
tion  of  its  contents  will  be  great;  in  this  casei; 
has  been  recommended  to  lay  open  the  cyst  wi’J 
a bistoury. 

The  posture  the  patient  assumes  is  also  o: 
importance,  the  pus  should  gravitate  to  th. 
opening;  thus,  supposing  the  opening  in  thi 
rectum  or  bladder,  then  the  vertical  posture  nil 
expedite  the  cure.  In  the  same  way  any  othe: 
position  may  be  assumed  which  fulfils  this  end. 

The  general  health  must  always  he  kept  u] 
by  the  administration  of  tonics,  good  food,  am 
stimulants,  so  as  to  counteract  the  exliaustiw 
due  to  the  prolonged  suppuration. 

J.  Braxton  Hicks. 

PELVIC  CELLULITIS— Synon. : Para 
metritis  (Schroeder.  Virchow,  and  Matthew 
Duncan) ; Perimetritis. 

Definition. — An  inflammation  of  the  cellula 
tissue  surrounding  the  pelvic  organs, both  inti) 
male  and  female,  but  much  more  frequently  ii 
the  latter,  and  therefore  more  especially  of  th. 
areolar  tissue  in  connection  with  the  uterus  am 
its  appendages.  Various  views  have  been  heh 
with  respect  to  the  pathology  of  pelvic  cellulitis 
each  author  giving  a name  according  to  his  ide] 
of  its  origin  ; though,  indeed,  two  distinct  affee 
tions,  pelvic  cellulitis  and  pelvic  peritonitis,  ar. 
described  under  the  general  name  of  pelvic  cel 
lulitis. 

xEtiology. — The  causes  of  pelvic  cellulitis  ar 
many  and  various,  but  it  may  be  broadly  statec 
that  it  may  arise  from  any  irritation  to  th 
mucous  membrane,  either  of  the  uterus,  vagina 
or  rectum,  whether  septic  or  benign.  Of  thes 
the  principal  are  traumatic,  and  consequent!; 
most  cases  are  seen  in  connection  with  the  puer 
peral  state,  and  after  operations  connected  will 
the  female  genital  organs  ; but  in  some  persons 
due  no  doubt  to  some  remarkable  idiosyncras; 
of  the  patient,  the  passage  even  of  a sound,  or  tin 


PELVIC  CELLULITIS. 


itention  of  a pessary,  slight  cause  as  it  may 
letn,  is  in  itself  sufficient  to  excite  all  the  phe- 
Dme'na  of  pelvic  cellulitis.  Of  the  other  than 
Lunatic  causes  may  be  mentioned  dysmenor- 
icea,  suppression  of  the  menses,  and  gonorrhoea. 
Anatomical  Characters. — It  was  not  until 
(onat  and  Bernutz  began  to  study  the  subject  of 
■Iric  cellulitis  that  any  progress  can  be  said 
have  been  made  in  regard  to  its  pathology, 
onat  seems  to  have  considered  that  the  pelvic 
llular  tissue  was  chiefly  the  seat  of  this  affec- 
Ln  ; whilst  Bernutz,  writing  shortly  after- 
Lrds,  denied  that  the  cellular  tissue  was  in  any 
[y  affected,  and  described  it  as  an  affection  of 
je  pelvic  peritoneum  ; lienee  we  have  the  term 
■cri-uteri ne  phlegmon’  of  Nonat,  and  ‘ pelvi- 
ritonitis’  of  Bernutz.  Virchow,  and  Matthews 
mean,  following  his  suggestion,  have  used  the 
Has  ‘ para-metritis'  and  4 peri-metritis , ’ ‘ para-’ 
rmfying  an  inflammation  of  the  cellular  tissue, 
eri-’  an  inflammation  of  the  serous  membrane 
grounding  ihe  uterus.  Schroeder  uses  the 
■m  pelveo-peritonitis  in  much  the  same  way  as 
rnutz,  and  adopts  the  ‘ para-metritis  ’ of  Vir- 
tow.  Cruveilhier,  Champonierre,  and  Tilt  have 
Anted  out  the  share  which  they  believe  the 
ihphatics  play  in  this  disease,  and  to  this  they 
Jfe  the  name  of  lymphangitis.  The  terms  pelvic 
(jlulitis  and  pelvic  peritonitis  appear  in  the  no- 
l.nclature  of  the  College  of  Physicians,  and  we 
h no  good  reason  to  alter  the  names.  Patho- 
iically,  no  doubt,  the  distinction  can  be  made 
ijnost  cases,  but  clinically  some  difficulty  arises, 
b!  many  and  various  have  been  the  computa- 
tis  as  to  their  relative  frequency.  Schroeder 
[ uts  out  that,  even  pathologically,  the  false  cyst 
i oelvic  peritonitis  may  become  so  thickened  as 
t/esemble  that  of  pelvic  cellulitis,  and  as  the 
nSority  of  cases  tend  towards  resolution,  and 
a .here  is  a clinical  difficulty  as  to  diagnosis, 
e pled  with  their  frequent  coexistence,  there 
mt  always  be  some  diversity  of  opinion  as  to 
tl  r relative  frequency. 

jelvic  cellulitis  being  caused,  as  we  have  said, 
bisome  irritation  of  the  genital  organs,  the 
q ition  as  to  the  mode  of  its  production,  and 
tl  part  which  the  different  tissues  take  in  its 
ti  salutation,  has  been  frequently  discussed. 
Si  e,  after  the  suggestion  of  Dance,  supposed 
tb  the  venous  system  acted  the  part  of  the 
cajer  in  conveying  the  materies  morbi.  For  a 
lo^  time  the  profession  were  content  to  receive 
thus  an  explanation  of  the  phenomena,  until 
Civeilhier  and  Champonierre  showed  the  part 
'vl|h  the  lymphatics  played  in  this  disease. 
Btjles  this,  there  is  reason  to  believe  that,  in 
th  ; cases  where  the  passage  of  a sound  and 
bu; -like  simple  irritants  are  the  cause  of  pelvic 
cel  litis,  the  nerves  must  play  an  important 
pa!  to  account  for  such  a rapid  effusion  of  so 
nr  plastic  material. 

Ivic  cellulitis  begins  by  an  exudation  of 
anibuminous  nature  into  the  cellular  tissue. 
Thj  as  in  other  cellular  inflammations,  may 
bepie  absorbed,  the  fluid  portion  first,  and 
the  lore  solid  portion  at  a later  period  ; or, 
tns  .d  of  ending  in  resolution,  it  may  take  on  a 
ret  ;rnde  metamorphosis,  and  end  in  abscess. 

'• » exuded  material  thrown  out  in  pelvic 
«eh,itis,  follows  the  same  steps  wherever  it  may 

TO 


11G5 

be  situated  in  the  pelvis,  although  its  name 
and  clinical  symptoms  vary  according  to  its 
topographical  distribution.  But  inasmuch  as  the 
effused  material  is  thrown  out  into  the  cellular 
tissue  near  such  a sensitive  organ  as  the  peri- 
toneum, the  inflammation  is  liable  at  any  time 
to  spread  to  and  involve  this  membrane,  by 
reason  of  its  continuity.  The  peritonitis  may 
either  become  localised,  or  may  spread  and  in- 
volve the  whole  membrane,  giving  rise  to  general 
peritonitis  ; when  the  latter  result  occurs  it  is 
generally  due  to  a septic  cause,  frequently  spread- 
ing with  extreme  rapidity.  It  is  highly  probable 
that  lymphangeitis  plays  an  important  part  in 
cases  of  this  kind. 

Symptoms. — A small  amount  of  pelvic  cellu- 
litis may  in  itself  give  rise  to  very  slight  symp- 
toms, perhaps  merely  a sense  of  uneasiness  in 
the  lower  por  ion  of  the  abdomen.  This  is  often 
the  case  in  slow  recovery  from  the  lying-in  state, 
and  may  be  overlooked,  a vaginal  examination 
not  being  deemed  necessary,  the  symptoms  vary- 
ing much  according  to  the  rapidity  and  the 
quantity  of  the  exudation.  Should  a large  quan- 
tity be  exuded,  the  most  prominent  symptoms  will 
be  more  severe,  namely,  more  or  less  tenderness 
on  deep  pressure,  with  dull  aching  pain  in  the 
pelvis,  languor,  and  pyrexia  ; along  with  these 
there  may  be  obstinate  constipation  and  pain 
in  defaecation.  Dysuria  also  may  be  a pro- 
minent symptom.  The  presence  of  the  last  two 
symptoms  will  depend  upon  the  situation  of  the 
effusion,  and  its  pressure  on  the  rectum  and 
bladder. 

Physical  signs  per  vaginam. — -In  the  early 
stage,  there  being  only  an  effusion  of  fluid,  its 
detection  will  be  difficult ; but  as  the  matter 
becomes  more  solid,  we  shall  be  aware  of  a dense 
mass,  usually  limited  to  one  or  other  side  of  the 
uterus,  but  if  the  amount  be  large,  entirely  sur- 
rounding the  organ.  This  effusion  is  generally 
in  the  layers  of  the  broad  ligaments,  either  at- 
tached to  or  separate  from  the  uterus,  but  usually 
fixed  to  it ; and  when  the  effused  matter  has  had 
time  to  consolidate,  it  is  of  considerable  hard- 
ness, similar  to  that  of  a uterine  fibroid,  but 
generally  irregular  in  outline,  often  following  the 
form  of  the  roof  of  the  vagina.  A uterus  fixed 
by  hard,  irregular,  and  immovable  swelling  is 
considered  by  some  as  pathognomonic  of  pelvic 
cellulitis.  Pain  running  down  the  legs,  on  flexion 
and  abduction  of  the  thigh,  owing  to  implication 
of  the  lumbar  nerves,  simulating  hip-joint  disease, 
is  also  a valuable  diagnostic  sign  in  some  cases. 

At  the  onset  the  temperature  generally  rises 
in  the  evening  to  101°  or  102°,  rarely  higher,  and 
is  lower  in  the  morning. 

The  pulse,  according  to  Dr.  Galabin,  is  full  in 
the  benign  cases ; but  in  the  septic  form  it  is 
dicrotic,  and  towards  the  end  in  fatal  cases  be- 
comes extremely  so.  The  pulse  and  temperature 
form  a valuable  guide  as  to  the  state  of  the  case. 
Favourable  cases  may  recover  in  a few  days, 
but  generally  go  on  for  weeks  or  months, 
the  absorption  gradually  taking  place,  its  dura- 
tion depending  much  on  the  general  state  of 
the  patient  and  the  amount  effused.  But  should 
the  case  break  down  and  end  in  abscess,  the  pre- 
sence of  this  will  be  shown  by  increased  pyrexia, 
probably  rigors,  and  localised  pain  of  a shooting 


1106  PELVIC  CELLULITIS, 
character.  For  the  signs  of  inflammation  ex- 
tending to  the  peritoneum,  see  Pelvic  Peri- 
tonitis. 

Diagnosis. — The  diagnosis  of  pelvic  cellulitis 
from  the  diseases  with  which  it  may  be  most 
readily  confounded,  will  be  found  in  the  articles 
on  Pelvic  Hematocele,  and  Pelvic  Peritonitis. 

Treatment. — When  the  pathology  of  pelvic 
cellulitis  is  fully  considered,  it  will  be  seen  that 
the  treatment  must  depend  upon  the  stage  to 
which  it  lias  advanced.  In  the  acute  stage  we 
should  limit  ourselves  to  the  administration  of 
salines,  and  of  sedatives  for  the  relief  of  pain, 
opium  being  given  internally ; and  locally,  hot 
fomentations  applied  to  the  lower  part  of  the 
abdomen,  and  hot  injections  given  per  vaginam. 
Leeches  are  often  applied  with  much  benefit  to 
the  groin,  perineum,  or,  still  better,  to  the  os 
uteri — three  or  four  at  a time,  thereby  removing 
any  temporary  congestion  of  those  parts.  The 
bowels  are  better  moved  by  an  enema,  than  by 
purgatives  given  by  the  mouth,  which  if  active 
may  cause  extension  of  the  inflammation  to  the 
peritoneum.  When  the  inflammatory  action 
has  subsided,  the  re-absorption  of  the  plastic 
material  which  has  been  thrown  out  is  assisted 
by  the  administration  of  tonics,  as  iron  and 
quinine.  Iodide  of  potassium  is  much  relied  on 
by  some  practitioners,  and  may  be  given  with 
advantage  combined  with  tonics  ; but  probably 
the  best  means  of  promoting  absorption  is  by 
restoring  the  general  health  by  every  method 
possible.  The  Americans  and  Germans  recom- 
mend the  vaginal  douche  night  and  morning  for 
about  twenty  minutes  ; they  believe  that  it  acts 
as  an  absorbent  as  well  as  a sedative.  In  the 
septic  variety  much  success  has  attended  the 
exhibition  of  large  doses  of  quinine,  five  grains 
every  four  hours  having  been  given  with  advan- 
taue.  In  all  cases  rest  is  imperatively  called  for, 
even  after  the  inflammatory  stage  is  past. 

J.  Braxton  Hicks. 

PELVIC  HEMATOCELE. — Synon. : 
Peri-uterine  Hsematocele;  Retro-uterine  Haema- 
tocele ; Pelvic  Thrombus. 

Nature. — Nelaton  described  this  affection  as 
a tense  bloody  tumour  situated  in  Douglas’s 
cul-de-sac,  which  pushed  the  uterus  forward 
towards  the  symphysis  pubis.  Afterwards  every 
bloody  tumour  in  connection  with  the  pelvic 
organs  came  to  be  so  described  by  some  authors. 
Thus  Dr.  Barnes  classes  ruptured  uterus  with  an 
effusion  of  blood  into  the  peritoneal  cavity  as  an 
example  of  pelvic  luematocele. 

Any  effusion  of  blood  which  takes  place  either 
from  ruptured  uterus  or  from  other  organs  is  not 
by  most  authorities  now  considered  as  true  pelvic 
haematocele ; indeed,  blood  effused  from  the  liver, 
kidney,  or  other  organ  which  has  found  its  way 
into  Douglas's  pouch,  might  thus  be  included 
under  this  name.  Pelvic  hsematocele  consists 
of  two  varieties,  to  which  the  names  of  retro- 
uterine heematoede,  or  better,  intra-peritoneal 
heemaiocelc ; and  pelvic  thrombus,  have  been  given. 
The  first  of  these  affections  may  be  described 
as  an  effusion  of  blood  into  the  retro-uterine  sac, 
subsequently  shut  off  from  the  rest  of  the  peri- 
toneum by  an  effusion  of  plastic  material.  The 
second  variety,  pelvic  thrombus , is  an  effusion 


PELVIC  HiEHATOCELE. 
of  blood  into  the  cellular  tissue  of  the  pelv 
organs,  and  more  especially  of  that  in  connectic 
with  the  uterus.  Even  with  this  limitation  < 
applications,  the  frequency  of  pelvic  liaematoce 
has  been  variously  stated  by  different  author- 
thus  Scanzoni  and  Schroeder  reckon  it  a ra; 
disease,  whilst  Zeyfurt  reckons  it  as  oceurrii 
in  5 per  cent,  of  all  uterine  cases.  Inasmui 
as  most  cases  recover,  the  diagnosis  must  depei 
solely  on  a careful  analysis  of  the  clinic i 
history. 

It  is  well,  however,  that  we  should  distmgui: 
between  the  two  affections,  and  we  shall  employ  f 
term  t hrorabus as  applying  to  an  effusion  of  bloi| 
into  the  cellular  tissue  around  the  uterus,  ai 
the  term  retro-uterine  hamatoeele  to  blood  whi ! 
has  gravitated  into  the  peritoneal  pouch  betwei 
the  uterus  and  rectum.  These  distinctions  a 
important,  inasmuch  as  they  can  in  most  cas 
be  discovered  both  clinically  and  patholo; 
cally. 

A.  Retro-uterine  Heematocele. — .Etiolo 
— The  causes  of  retro-uterine  haematocele  are 
follows : — 1.  rupture  of  the  uterine  wall  from  a 
cause,  including  aneurisms  and  varices ; 2.  rapid 
of  the  Eallopian  tubes  (hsematometra)  from  exti 
uterine  feetation;  3.  ovulation  and  ovarian  tumoi 
and  4.  rupture  of  other  viscera  in  the  abdomii 
cavity. 

Symptoms. — -These  will  be  the  same  as  in  f 
rupture  of  any  viscus,  and  the  escape  of  blq 
into  the  peritoneal  cavity.  Thus,  there  will 
sudden  onset  of  pain ; prostration  and  collap. 
greater  than  can  be  accounted  for  by  l 
ansemia ; often  vomiting,  which  is  at  times 
cessively  severe.  Nothing  can  be  felt  at  fi 
on  physical  examination,  owing  to  the  liq 
state  of  the  blood ; but  as  the  blood  coagula: 
hardness  will  supervene,  displacing  the  uteru- 
the  amount  and  direction  of  the  displace®: 
depending  on  the  position  which  the  blood  ■ 
sumes.  This,  as  has  been  pointed  out,  is  ge- 
rally  to  be  found  posteriorly,  thus  pushing  1 
uterus  forward  towards  the  pubes.  In  a sbf 
time  inflammatory  action  may  be  set  up,  so  a:i 
limit  the  effusion,  and  in  this  case  will  not  bef 
a severe  peritonitic  type;  but,  on  the  otr 
hand,  general  peritonitis  may  be  establish, 
which  generally  ends  fatally  ; or,  again,  e 
inflammatory  process  having  become  limfl 
by  plastic  material,  it  may  follow  the  ud 
course  of  pelvic  abscess. 

B.  Pelvic  Thrombus.  — .Etiology. — a 
chief  causes  of  pelvic  thrombus  are  hsen^ 
rhage  arising  from  interruption  or  suppress 
of  the  menses,  or  from  sexual  excitement ; d 
haemorrhage  from  diminished  resisting  powert 
the  vessels,  in  the  haemorrhagic  diathesis,  sr- 
butus,  or  purpura. 

Haemorrhage  which  has  thus  arisen  mayfow 
the  usual  course  of  extravasated  blood,  nany. 
coagulation  and  absorption,  or  proceed  tom 
formation  of  an  abscess. 

Symptoms. — These  will  depend  on  the  amnt 
of  the  effusion  and  its  position.  In  general* 
quantity  will  be  less  than  in  retro-uterine  hai- 
tocele.  It  is  generally  greater  when  it  oers 
in  the  layers  of  the  broad  ligament,  which  it  0 
separate  to  a very  considerable  extent,  rea:  ls 
sometimes  to  the  level  of  the  umbilicus.  lr 


PELVIC  HEMATOCELE, 
ver,  blood  effused  into  the  cellular  tissue  is 
ecessarily  under  restraint,  though  the  pain  would 
|e  thereby  increased. 

In  this,  as  in  the  affection  just  described,  we 
aye  a sudden  onset  of  symptoms,  but  we  do  not 
lave  such  marked  anaemia,  for  the  amount  of 
he  effusion  is  hardly  .so  large.  And  we  miss 
Lose  symptoms  of  severe  collapse  which  depend 
;pon  an  effusion  of  blood  into  the  peritoneal 
ivity.  In  fact,  here  we  have  more  the  symptoms  . 
f haemorrhage  per  so,  as  in  any  other  case  of 
rtmorrhage,  the  effusion  being  situated  outside 
le  peritoneum.  We  seldom  have  symptoms  of 
Britonitis  supervening,  but  rather  those  due  to 
ie  displacement  which  the  mass  occasions.  The 
[fusion  may  either  be  absorbed,  or  it  may  end 
. abscess,  which  pursues  the  usual  course  of 
slvic  abscess.  Sec  Pelvic  Abscess. 

Diagnosis. — These  swellings,  produced  by  blood- 
fusion,  are  liable  to  be  confounded  with  many 
her  troubles  about  the  uterus.  The  most  fre- 
quent position  is  in  either  broad  ligament,  where 
iey  may  simulate  fibroma,  ovarian  tumour,  and 
Specially  cellulitis  of  the  same  part.  The  next 
psition  in  frequency  is  behind,  in  the  cellular 
ssue  between  the  uterus  and  rectum,  where  the 
iematocele  may  imitate  retroflected  uterus  or 
,mour  in  Douglas’s  pouch.  When  the  hoamor- 
iage  is  found  at  the  roof  of  the  vagina,  or 

I 'tween  the  bladder  and  uterus,  it  gives  the 
lysical  characters  of  a fibroma  in  the  anterior 
ill,  of  pregnancy,  or  of  cellulitis.  It  will  thus 
: seen  that  the  diagnosis  depends  much  on  a 
par  clinical  history,  either  from  the  patient  or 
t friends,  which  in  some  cases  is  difficult  to 
tain. 

; Treatment. — This  divides  itself  into  two 
,rts,  the  first  of  which  will  be  the  arrest  of  the 
Ismorrhage  (should  it  still  be  going  on) ; and 
e second,  the  application  of  such  means  as  tend 
resolution  and  absorption  of  the  coagulum. 
lie  first  indication  will  be  fulfilled  by  absolute 
Jit,  and  the  administration  of  haemostatics,  such 
gallic  acid,  lead,  turpentine,  and  other  like 
nedies  on  which  we  are  wont  to  place  reliance 
i1  internal  haemorrhage,  combined  with  opiates, 
it  inasmuch  as  vomiting  is  often  a severe  and 
[eminent  symptom,  and  medicines  are  with 
acuity  kept  down  a sufficient  time  to  he  of 
(vice,  the  opiates  may  have  to  be  given  by  the 

!tum  or  hypodermically'.  Ice-bags  or,  if  these 
not  at  hand,  cold  lotions,  should  also  be  ap- 
id  to  the  lower  part  of  the  abdomen,  or  even 
coduced  per  vaginam.  At  the  same  time  a 
-nle  ice  may  bo  given  to  suck.  Small  doses 
ojopium,  or  any  of  its  preparations,  repeated 
alintervals  if  they  can  be  retained,  tend  both 
tpiet  the  circulation  and  support  the  system 
ujinst  loss.  Stimulants,  however,  and  hot 
djiks  must  be  avoided.  If  rupture  of  an  extra- 
urine  cyst  be  supposed  the  cause,  or  rupture 
°i]-n  ovarian  varix,  it  may  be  advisable  to  per- 
fi;a  abdominal  section. 

Jhe  haemorrhage  having  ceased,  we  must  still 
e j'iu  rest  for  some  time,  to  prevent  its  recurrence, 
» to  admit  of  the  blood  being  absorbed. 

1 fulfilling  the  second  indication,  namely, 
tl  resolution  of  the  extravasation,  little  will  be 
rt  lired  beyond  keeping  the  system  in  good 
gt  ral  health  by  the  administration  of  tonics. 


PELVIC  PERITONITIS.  1107 

Iron  and  quinine  are  of  much  service.  Som« 

practitioners  rely  on  iodide  of  potassium  as  an 
absorbent ; it  may  be  given  combined  with 
quinine.  Should  a recurrence  of  the  haemorrhage 
take  place  at  different  periods,  the  bromides  and 
iodides  have  been  considered  of  some  value  in 
quieting  the  action  of  the  ovaries. 

If  the  case  unfortunately  end  in  abscess,  the 
proper  treatment  will  be  that  of  pelvic  abscess. 
Sea  Pelvic  Abscess.  J.  Braxton  Hicks. 

PELVIC  PERITONITIS. — Synon.  : Peri- 
metritis (Bernutz,  Virchow,  and  Matthews 
Duncan). 

Definition. — A local  inflammation  of  that 
portion  of  the  peritoneum  surrounding  the  pelvic 
organs,  and  especially  the  uterus  and  broad  liga- 
ments. See  Pelvic  Cellulitis. 

Etiology. — Pelvic  peritonitis  is  often  found 
as  an  extension  from  pelvic  cellulitis,  both  in 
the  puerperal  and  non-puerperal  state.  In  the 
non-puerperal  state  it  is  associated  with  uterine 
flexions  and  versions;  various  operations  on  the 
genital  organs  ; rupture  of  ovarian  cysts  ; absceso 
of  tho  ovary  ; escape  of  blood  from  the  Fallopian 
tube;  gonorrhoea;  malignant  disease;  carcinoma; 
and  tubercle. 

Anatomical  Characters. — Here,  as  in  cellu- 
litis, the  part  which  the  veins,  lymphatics,  and 
nerves  take  is  still  open  to  controversy;  but  the 
lymphatics,  no  doubt,  take  the  most  important 
part. 

Whatever  the  origin  of  the  peritonitis  we 
have,  in  the  first  place,  an  effusion  varying  in 
character — either  serous,  plastic,  or  purulent. 
The  serum  may  either  be  absorbed,  or  become 
encysted  by  plastic  material,  and  form  a false 
cyst,  -which,  in  an  unhealthy  condition,  may  be 
of  a pyoid  nature,  forming  an  abscess  having 
the  usual  characters  of  pelvic  abscess. 

But  there  is  this  difference  from  the  exudation 
of  pelvic  cellulitis  and  that  of  pelvic  peritonitis, 
namely,  that  in  cellulitis  the  exuded  material  may 
be  absorbed,  leaving  but  few,  if  any,  relics  of  the 
bygone  inflammation,  whilst  in  peritonitis  the 
fluid  portion  is  chiefly  absorbed,  leaving  very 
often  strings  or  bands  of  adhesions  matting 
together  the  various  organs.  A not  uncommon 
occurrence  is  for  the  uterus,  if  previously  retro- 
flected, to  be  bound  down  posteriorly  to  the 
sacrum,  but  it  may  be  equally  fixed  in  any  other 
direction  in  which  effusion  has  been  poured  out. 
The  effect  of  these  adhesions  is  curious,  for  the 
ovary  has  been  rent  from  its  attachment,  and 
fixed  to  the  pelvic  brim  posteriorly.  These  adhe- 
sions may  stretch  and  give  rise  to  no  permanent 
displacements,  but  at  other  times  they  are  irre- 
mediable. Pregnancy  seems  to  have  most  influ- 
ence in  their  removal;  and,  indeed,  this  has 
been  suggested  as  a method  of  cure.  In  the  same 
way  they  may  hinder  the  action  of  the  uterus  in 
labour,  and  cause  pain  by  their  rigidity,  though 
they  often  hinder  conception  or  give  rise  to  abor- 
tion, and  sometimes  to  severe  and  even  fatal 
obstruction  of  the  bowels.  The  influence  of 
adhesions  should  always  be  borne  in  mind  after 
any  case  of  pelvic  peritonitis. 

Should  the  case  end  in  abscess  it  may  open 
in  any  of  the  ways  given  under  the  head  of 
[ Pelvic  Abscess. 


PELVIC  PERITONITIS. 


U08 

Symptoms. — In  chronic  and  subacute  cases  of 
pelvic  peritonitis,  the  symptoms  are  usually  ob- 
scure, the  patient  (often  after  childbirth)  com- 
plaining only  of  a dragging  sensation  at  the 
lower  portion  of  the  abdomen.  These  cases  fre- 
quently pass  unnoticed,  rest  in  bed  and  other 
remedies  sufficing  to  effect  a cure. 

In  acute  cases,  the  symptoms  begin  with  com- 
plaint of  a severe  pain,  increased  by  pressure, 
with  fixedness  of  the  abdominal  muscles  in  the 
lower  portion  of  the  abdomen,  or  the  coils  of  the 
intestine  may  be  seen  mapped  out.  Along  with 
this  there  is  usually  a wiry  pulse;  but  if  the 
disease  be  of  septic  origin,  it  may  be  dicrotic. 
The  temperature  is  usually  above  102°,  but 
varying  night  and  morning.  We  may  also  notice 
a Hippocratic  expression  of  the  countenance. 
Should  this  become  marked  we  should  have 
reason  to  fear  an  extension  to  the  general  peri- 
toneum. At  the  same  time  we  may  have  consti- 
pation, and  generally  severe  vomiting ; and  by 
pressure  of  effused  material  on  the  bladder  and 
rectum,  there  may  also  arise  constipation  and 
dysuria.  Pervaginam , we  may  discover  a tumour 
laterally  high  up  in  the  pelvis,  and  not  easily  felt, 
both  on  account  of  the  distance  from  the  examin- 
ing hand,  and  from  the  severe  pain  to  which 
examination  gives  rise. 

But  again,  it  must  be  pointed  out  that  cases 
do  occur  in  which  nearly  all  the  symptoms  are 
wanting,  although  the  attack  may  be  of  a most 
malignant  type,  the  rapid  pulse  and  pyrexia, 
coupled  with  a peculiar  expression  of  the  coun- 
tenance, being  almost  our  only  guide.  A vaginal 
examination  fails  to  give  us  any  indication  as  to 
its  nature,  owing  to  the  matter  being  purulent 
and  fluid.  These  cases  are  almost  always  of  septic 
origin. 

Diagnosis.— Pelvic  peritonitis  may  be  dia- 
gnosed from  pelvic  cellulitis  by  the  following 
considerations : — 

Pelvic  Cellulitis. 

1.  Tumour  easily  reached;  generally  easily 
and  early  felt  in  neighbourhood  of  broad  liga- 
ment, and  above  pelvic  brim. 

2.  Abdominal  pain,  increased  by  deep  pres- 
sure. 

3.  Temperature  usuallynot  above  102°;  pulse 
full,  soft,  dicrotic  in  septic  form. 

4.  Retraction  of  thigh  with  abduction.  Pain 
down  leg. 

5.  Nausea ; vomiting,  not  excessive. 

6.  Not  accompanied  by  tympanites. 

7.  Marked  tendency  to  suppuration. 

Pelvic  Peritonitis. 

1.  Tumour  not  noticeable  for  some  days. 

2.  Abdominal  tenderness  of  an  acute  kind, 
quickly  increased  on  pressure.  Form  of  coils  of 
intestines  mapped  out  on  abdomen.  Fixation  of 
abdominal  muscles. 

3.  Temperature  above  102°  usually;  pulse 
wiry  in  benign,  dicrotic  in  septic  form. 

4.  Pain  down  leg  and  retraction  of  thigh  never 
present. 

5.  Nausea;  vomiting  excessive. 

6.  Tympanites  present  in  severe  cases. 

7.  Constipation,  often  marked. 

8.  Suppuration  not  often  present. 


Treatment. — In  all  cases  of  pelvic  peritonitis 
whether  acute  or  chronic,  our  chief  point  isresi 
and  this  cannot  be  too  rigidly  insisted  upon.  Th* 
stage  of  the  disease,  whether  chronic  or  acute 
will  indicate  the  amount.  Should  the  case  be  o 
a subacute  nature,  then  reclining  on  a couch  wil 
be  all  that  is  necessary;  but  should,  on  theothe 
hand,  the  case  be  acute,  however  limited  in  area 
then  it  is  essential  that  we  should  order  absolut 
rest  in  bed,  as  little  movement  as  possible  bein;. 
allowed.  In  chronic  cases  this  point  must  l 
left  to  the  discretion  of  the  physician ; it  will  b 1 
for  his  consideration  what  part  the  local  eon 
dition  bears  in  relation  to  the  general  health 
and  whether  continuance  of  the  local  troubl’ 
will  not  cease  on  restoration  of  the  genera 
health. 

The  next  point  to  be  considered — and  wekhot 
of  none  in  which  so  much  mischief  is  done  b 
want  of  appreciation  of  the  true  condition — i 
the  administration  of  purgatives  in  the  acut 
forms.  The  same  rule  holds  good  here  as  in  th 
treatment  after  an  operation  for  hernia,  name!} 
that  any  increased  peristaltic  movement  of  th 
intestines  is  liable  to  cause  an  extension  of  th 
peritoneal  complication.  We  must  bear  in  min 
that  what  the  inflamed  peritoneum  wants  is  rest 
to  lessen  the  friction  of  the  surfaces;  and  shod 
any  unhealthy  matter  be  present,  time  is  to 
gently  required  for  the  effhsion  of  a limitin, 
plastic  material,  to  shut  it  off  from  the  rest  c 
the  abdominal  cavity;  and  after  its  formatioii 
still  further  repose  is  necessary  to  prevent  it 
being  broken  down.  Thus  it  is  that  we  find  on 
sheet-anchor  lies  in  the  administration  of  fu 
doses  of  opium,  which  not  onlij  allays  the  sens 
tiveness  of  the  peritoneum,  but  limits  the  per 
staltic  movement  of  the  intestines.  If  thebowe 
are  unrelieved  for  fourteen  to  eighteen  days,  n 
harm  will  accrue.  A mild  enema  of  olive-oil  an 
gruel  will  be  the  best  measure  to  adopt  wher 
necessity  requires  relief. 

In  the  more  chronic  cases,  for  the  same  reasoi 
we  should  never  purge  our  patient,  for  there 
always  a risk  of  extending  the  inflammatory  ai 
tion  to  the  general  peritoneum ; a mild  lasativ 
daily,  or,  better,  an  enema,  will  answer  ever 
purpose. 

If,  from  the  severity  of  the  constitution; 
symptoms  and  the  absence  of  the  local,  we  hat 
reason  to  believe  that  we  have  a case  of  sept, 
origin  to  deal  with,  quinine  must  be  given  j 
large  doses,  say  five  grains  every  four  hoars,  i 
mouth,  by  the  bowel,  or  hypodermically.  Vei 
marked  results  have  attended  the  exhibition  < 
this  drug  in  cases  otherwise  almost  hopeles 
Sixty  grains  a day  have  been  given  without  i 
result  — indeed  with  the  cure  of  the  patien 
Should  the  peritonitis  appear  to  be  of  a pure, 
sthenic  form,  the  employment  of  the  old  remed 
mercury,  will  generally  he  found  to  be  a val' 
able  addition  to  that  of  the  opiates,  at  any  ra 
for  a short  time ; but  in  any  case  great  caution 
required  lest  diarrhoea  be  induced.  In  thisfor 
the  employment  of  leeches  to  the  abdomen  w 
also  assist  in  the  reduction  of  the  inflammatio 
Care,  however,  must  be  observed  not  to  debilita 
the  patient.  Hot  opiated  fomentations  to  tl 
lower  part  of  the  abdomen  in  all  cases  aft'o: 
great  relief.  Should  the  case  lapse  into  a chron 


PELVIC  PERITONITIS. 

ste,  iodide  of  potassium  may  be  of  some  service 
aiding  tlie  absorption  of  the  inflammatory  pro- 
mts. The  bromide  has  also  been  given  with 
,e  idea  of  lessening  congestion  and  quieting  the 
(tion  of  the  ovaries. 

At  a later  date  much  good  will  result  from  the 
(ministration  of  tonics,  and  from  change  of  air, 
,e  local  trouble  being  often  kept  up  by  the 
neral  condition. 

Such  are  the  chief  indications  of  treatment, 
uniting,  dysuria,  and  other  complications  must 
treated  on  general  principles. 

J.  Braxton  Hicks. 

PEMPHIGUS  (ireVifuf,  a bladder). — Saxon.  : 
impholyx ; Fr.  Pemphigus ; Ger.  Blasenkrank- 
\t. 

Definition. — A somewhat  rare  skin-disease, 

( indefinite  duration  ; in  which  blebs  or  bullae, 
Staining  serous  or  sero-purulent  fluid,  form  in 
^sater  or  less  numbers  on  various  parts  of  the 
jfly  and  limbs;  burst;  dry  up,  and  produce 
ists;  and  finally  disappear,  leaving  temporary 
.ins,  but  no  permanent  scars. 

.Etiology. — At  Vienna  Hebra  found  one  case 
.-  chronic  pemphigus  in  10,000  adult  persons. 
i 29,535  patients  with  skin-diseases  of  all  kinds, 
eluding  the  acute  exanthemata,  there  were  in 
trteen  years  66  cases — 16  in  men,  and  20  in 
imen.  At  Prague,  in  five  years,  out  of  38,546 
sc  children,  54  had  pemphigus,  24  being  boys 
ill  30  girls.  Pemphigus  is  much  more  frequent 
.children  than  in  adults,  and  most  frequent  in 
t,  first  eighteen  months  of  life.  At  Prague 
2of  54  cases  were  under  one  month  old.  In 
silts  all  ages  are  nearly  equally  disposed  to  it. 
in  childhood  females  seem  slightly  more 
eposed  than  males  ; in  adult  life  pemphigus 
tgaris  attacks  three  times  as  many  men  as 
men.  Pemphigus  foliaceus  is  more  frequent 
i women.  Neither  geographical  distribution, 
s.son  of  the  year,  nor  any  special  diet  or  habits 

c. life  seem  to  affect  the  development  of  the 
(ipase.  It  occurs  in  persons  of  all  tempera- 
rats,  and  in  the  healthy  as  well  as  in  the  deli- 
c ;.  No  definite  relation  can  be  traced  between 
(langements  of  the  kidneys  and  pemphigus,  or 
t ween  the  latter  and  the  gouty  or  rheumatic 

d,  dieses.  In  a few  instances  there  has  been 
aiistinct  relation  between  pregnancy  and  the 
ojireak  of  bull®.  Pemphigus  is  never  en- 
due. Various  epidemics,  chiefly  among  chil- 
d';i,  have  been  described  by  trustworthy  writers, 
o which  the  latest  occurred  in  1869  at  Halle, 
a in  1874  in  Paris,  both  in  new-born  infants, 
t>  it  seems  doubtful  whether  these  were  cases 
oi- , rue  pemphigus,  and  not  rather  allied  to 
vi  cella.  Outbreaks  of  pemphigus  have  ap- 
pj’edin  more  than  one  case  to  be  determined 
H local  injury,  such  as  a puncture  of  the  fin- 
gt  There  are  one  or  two  instances  known  in 
W 'h  the  disease  has  been  transmitted  heredi- 
ty. 

J few  cases  of  localised  outbreak  of  bullae — 
fojixample,  on  one  hand  and  arm — have  been 
re  rted  in  connection  with  injuries  of  peri- 
P1  si  spinal  nerves,  and  chronic  meningitis  and 
®1  itis  of  the  spinal  cord. 

-mphigus  is  a non-contagious  disease,  and 
dsttempts  to  transfer  it  from  one  person  to 


PEMPHIGUS.  1109 

another,  by  inoculating  the  contents  of  the 
bullse,  havd  failed. 

Anatomical  Characters. — In  pemphigus  the 
capillaries  of  a circumscribed  portion  of  skin  are 
dilated  with  blood,  and  this  hyperaemia  is  fol- 
lowed by  exudation  from  them  of  serous  fluid, 
which  infiltrates  the  papillae  and  the  cells  of  the 
rete  mucosum,  and  finally  makes  its  way  beneath, 
the  epidermis,  so  as  to  raise  and  separate  its 
uppermost  layers  from  the  parts  below,  thus 
forming  a bulla  or  bleb.  The  parts  of  the  epi- 
dermis which  are  connected  with  the  hair-folli- 
cles resist  the  pressure  longest,  but  at  length 
give  way,  and  their  remains  then  hang  from  the 
under  surface  of  the  covering  of  the  bullae  as 
small  threads  or  processes. 

The  contents  of  the  bullae  consist  at  first  of 
nearly  pure  serum,  which  gives  on  heating  a 
floceulent  deposit  of  albumen  ; later  on  the  fluid 
contains  numerous  pus-cells,  probably  due  partly 
to  migration  of  white  blood-corpuscles,  and 
partly  to  proliferation  of  the  rete  cells.  Occa- 
sionally it  contains  small  quantities  of  blood 
exuded  from  the  surface  of  the  cutis.  Bacteria 
were  found  in  one  case  during  life  (Sangster). 
The  reaction  is  at  first  neutral,  but  is  faintly 
alkaline  in  the  older  bullae.  Soda  salts  predo- 
minate over  potash  salts.  In  two  cases  Jarisch 
has  detected  urea.  No  light  has  been  thrown  on 
the  nature  of  the  disease  by  a chemical  exami- 
nation of  the  urine,  or  of  the  blood,  although 
Bamberger  believes  that  there  is  an  excess  of 
ammonia  in  the  latter. 

No  post-mortem  examination  has  as  yet  re- 
vealed any  constant  alteration  in  the  organs  or 
tissues  which  would  account  for  pemphigus. 
General  anaemia,  and  wasting  of  the  muscles  and 
other  parts,  have  been  found  in  uncomplicated 
cases,  while  some  patients  have  died  of  intercur- 
rent pneumonia  and  of  phthisis.  In  more  than 
one  instance  amyloid  degeneration  of  the  liver 
and  spleen  has  been  found,  just  as  in  other 
chronic  wasting  diseases. 

Description. — Pemphigus  may  occur  with- 
out apparent  assignable  cause  in  a previously 
healthy  child  or  adult.  The  bullse  may  form  on 
a perfectly  normal  skin,  or  else  a circumscribed 
portion  of  skin  becomes  hyperaemic,  and  the 
epidermis  over  it  is  raised  by  a rapid  effusion  of 
serum  into  a bulla,  which  enlarges  quickly,  so 
as  to  outstrip  and  cover  its  base.  The  bullae 
are  mostly  hemispherical  in  shape,  and  may 
reach  the  size  of  an  orange,  or  larger ; but,  as  a 
rule,  they  vary  from  that  of  a pea  to  that  of  a 
hazel-nut  or  wTalnut.  Their  contents  are  at  first 
clear  and  transparent,  but  in  a day  or  two  they 
become  milky  and  opaque,  and  finally  purulent. 
The  coverings,  previously  tensely  filled,  burst ; 
and  the  discharge  dries  into  flat  yellow-brown 
or  blackish  crusts.  The  bullie  tend  to  a sym- 
metrical distribution  on  the  two  sides  of  the 
body,  and  also  in  some  cases  to  an  arrangement 
in  circles  or  semicircles.  They  may  also  spread 
peripherically,  fresh  bullae  forming  at  the  edge 
of  the  crusts,  or  stains  of  old  ones.  There  is 
no  areola  or  swelling  around  the  bullse,  but  red 
lines  are  sometimes  noticed  running  outwards 
from  them,  probably  duo  to  inflamed  lymphatic 
vessels.  At  the  same  time  as  the  skin  is 
affected,  small  bullae  generally  form  on  the 


PEMPHIGUS. 


1110 

mucous  membrane  of  the  mouth,  nose,  and  pha- 
rynx ; and  they  have  been  seen  with  the  laryngo- 
scope cn  the  posterior  surface  of  the  epiglottis. 
They  have  also  been  found  post  mortem  on  the 
mucous  membrane  of  the  bronchi  and  of  the 
intestines,  and  are  probably  the  cause  of  the 
diarrhoea  and  bronchitis  from  which  pemphigus 
patients  sometimes  suffer.  Pemphigus  has  a 
marked  tendency  to  recur  at  longer  or  shorter 
i nter vals,  each  outbreak  being  made  up  of  a num- 
ber of  successive  crops  of  bullae.  A few  bull*  may 
in  no  way  affect  the  general  health,  but  if  they 
are  numerous  they  may  be  preceded  by  rigors 
and  fever — 102°  to  103°  Fahr. — and  even  by  deli- 
rium and  other  cerebral  symptoms  in  children. 
The  disease  may  terminate  after  one  or  two 
attacks,  or  may  recur  at  intervals  and  with  in- 
creasing severity  for  years,  until  the  patient  is 
reduced  in  health  and  strength,  and  finally  dies 
in  a marasmic  state,  or  of  some  intercurrent 
disorder. 

Classification. — We  may  divide  pemphigus 
into  three  main  varieties:—!.  P.  acutus ; 2.  P. 
chronieus ; and  3.  P.  foliaceus.  Other  varieties, 
such  as  P.  solitarius,  when  only  one  bulla  exists 
at  once  ; P.  gangrenosus,  where  ulcers  succeed 
the  bull*  ; and  P.  pruriginosus,  where  itching 
is  a conspicuous  symptom,  have  been  described, 
but  they  scarcely  merit  detailed  notice. 

1 . Pemphigus  acutus. — By  this  we  understand 
a bullous  eruption  which  occurs  only  once  in 
the  same  individual,  has  a short  duration  of 
from  three  to  six  weeks,  and  generally  terminates 
in  complete  recover}'.  The  existence  of  such 
cases,  which  was  at  one  time  doubted,  is  now 
certain.  In  its  general  symptoms  P.  acutus 
resembles  the  acute  specific  diseases.  There  is  a 
prodromal  stage,  a rigor,  great  prostration,  and 
albumin  may  appear  in  the  urine  (Senftlebon). 
Fatal  cases  have  occurred. 

2.  Pemphigus  chronieus  scu  vulgaris. — This, 
the  P.  diutinus  of  Willan.is  the  most  usual  form, 
and  the  one  to  which  the  above  description  cor- 
responds. This  form  may  assume  a malignant 
character  by  the  number  of  bull*  present  at  one 
time,  and  by  their  prolonged  duration  and  rapid 
recurrence,  so  that  tho  patient’s  health  is  under- 
mined. 

3.  P.  foliaceus  (Cazenave). — Under  this  name 
has  been  described  a form  of  pemphigus  of  a 
peculiarly  malignant  character.  The  bull®  are 
few  and  small  at  first,  and  they  are  never 
tensely  filled  with  fluid.  Other  bull*  form 
round  each  central  bulla,  or  else  the  latter 
spreads  peripherically  pci'  continuum , until  at 
last  nearly  the  whole  surface  of  the  body  is 
involved.  At  the  same  time  the  skin  does  not 
heal  over  the  situation  of  the  older  bull*,  but 
remains  moist  and  raw,  and  covered  either  with 
crusts  like  those  of  impetigo,  or  else  with  the 
loosened  coverings  of  the  bull*,  which  form 
large  lamell®  or  scales,  from  which  the  disease 
derives  its  name.  The  scales  have-  been  likened 
to  flaky  pastry.  This  form  is  happily  ex- 
tremely rare,  for  it  is  always  fatal. 

Complications.  — Pemphigus  has  been  seen 
occurring  simultaneously  with  small-pox,  and 
with  purpura.  Several  cases  have  been  reported 
in  which  a form  of  pemphigus  occurred  in  the 
serly  weeks  of  pregnancy,  and  continued  until 


delivery.  In  one  ease  the  disease  recarrec 
during  several  successive  pregnancies.  Pem- 
phigus pruriginosus  is  a name  which  has  ben 
given  in  cases  where  the  disease  has  been  accom 
panied  by  severe  pruritus. 

Diagnosis. — The  fully-developed  eruption  o 
pemphigus  is  too  characteristic  for  it  to  be  mb 
taken  for  any  other  disease.  The  diagnosis  mu' 
be  difficult  at  the  onset,  when  only  a few  bulla 
have  appeared,  or  else  towards  the  terminatiji 
of  an  attack,  when  only  scabs  or  stains  are  left  ' 
in  the  first  case  the  absence  of  cuniculi  willdisi 
tinguish  it  from  some  rare  cases  of  scabies  of 
purely  bullous  form.  At  the  outset  it  may  bi 
also  necessary  to  distinguish  its  bulla  fron 
those  occurring  in  erysipelas;  from  the  use  o 
artificial  vesicants ; from  burns ; and  from  th< 
friction  of  shoes,  clothes,  or  contiguous  portion: 
of  skin.  The  bull®  of  herpes  iris  invariabh 
commence  on  the  backs  of  the  hands  and  feet 
run  a rapid  course ; and  assume  a concentrl 
circular  character.  The  bull*  which  not  unhe 
quently  occur  in  anssthetic  leprosy  can  scarce! 
give  rise  to  difficulty,  when  taken  in  connection 
with  the  macul*  and  other  phenomena  attendin: 
it.  In  long-standing  cases  of  pemphigus,  por 
tions  of  skin  which  are  extensively  denuded  oi 
their  epidermis,  may  take  on  a considerable  re; 
semblance  to  eczema  rubrum ; but  the  history 
the  emaciation  and  weakness  of  the  patient,  th! 
dark  staining  of  the  skin,  with  absolute  absene| 
of  infiltration  and  only  slight  irritation,  wil, 
render  it  easy  to  form  a decided  opinion.  Sypbi 
li tic  pemphigus  is  distinguished  from  true  pem: 
phigus  by  occurring  only  in  new-born  children 
by  involving  principally',  though  not  exclusively 
the  palms  and  soles ; by  leaving  the  mucon 
membranes  unaffected;  and  lastly,  by  formin 
thick  crusts  when  the  bull®  burst,  under  wliici 
deep  ulcers  form. 

Prognosis.— This  is  favourable  in  the  earl 
attacks,  but  doubtful  as  to  the  ultimate  resuii 
since  it  is  impossible  to  say  whether  the  diseas 
may  end  with  a single  attack,  or  go  on  t 
gradual  exhaustion  of  the  patient’s  strength  i 
the  later  ones. 

Treatment. — No  specific  remedy  for  pempli! 
gus  has  as  yet  been  discovered;  the  neare; 
approach  to  one  is  arsenic,  which  in  some  case 
of  relapsing  pemphigus,  especially  in  early  lit 
exerts  a marvellous  action  on  the  disease,  no 
only'  removing  all  traces  of  it  for  the  time,  but  ra 
straining  its  further  invasion  during  longperioq 
(Hutchinson).  In  other  cases  all  drugs  ai 
equally  powerless.  The  treatment  which  find 
most  general  approval  consists  in  the  admini^ 
tration  of  tonics,  especially  quinine  or  bark  an 
iron,  and  in  supporting  the  strength  of  th 
patient  by  nourishing  food  and  wine.  Extern! 
treatment  consists  in  puncturing  the  fully-fonne 
bull®,  and  then  in  coating  the  parts  with  zin 
lead,  or  boracic  acid  ointment,  or  else  in  dus 
ing  them  with  starch  cr  oxide  of  zinc.  In  t. 
pruriginous  form,  preparations  of  tar  and  war 
baths  may  be  tried.  In  some  cases  bran  bath 
and  in  others  alkaline  baths,  have  been  four 
beneficial,  but  it  is  impossible  to  lay  down  ai 
line  of  treatment  suitable  to  all  cases. 

Edward  I.  Spares. 

1 Revised  by  Dr.  Alfred  Sangster. 


I’ENIS,  DISEASES  OF. 


PENIS,  Diseases  of. — Synon.  : Fr.  Maladies 
•la  Verge;  Krankheiten  der  Rathe. — Taken  in 
jeir  widest  sense,  the  diseases  of  the  penis  in- 
ude  a number  of  conditions  -which  are  separ- 
• ely  described  in  this  work,  such  as  diseases  of 
ae  urethra,  gonorrhoea,  balanitis,  gleet,  syphilis, 
id  priapism.  For  a discussion  of  these  subjects 
jie  reader  is  referred  to  the  articles  under  their 
iveral  names.  In  this  place  there  remain  for 
imsideration  the  following  morbid  states: — 1, 
ingenital  abnormalities ; 2,  Phimosis,  acquired ; 
Preputial  calculi ; 4,  Paraphimosis  ; 5,  Inflam- 
ation  ; 6,  Gangrene;  7,  Herpes  preputialis ; 8, 
,ew  growths;  9,  Cancer;  and,  10,  Elephantiasis. 

1.  Penis,  Congenital  Abnormalities  of. — 
Irious  abnormalities  are  from  time  to  time  met 
th  in  the  penis,  which  are  more  or  less  impor- 
|nt  according  to  the  difficulties  in  micturition 
sexual  intercourse  to  which  they  may  gire 
se,  and  the  consequent  ill  effects  upon  the  per- 
nal  comfort  and  general  health.  Among  such 
ay  be  mentioned  certain  rudimentary  conditions 
the  whole  organ,  associated  or  not  with  defec- 
ts development  of  other  parts  of  the  genito- 
iinary  apparatus — undue  smallness  or  even  de- 
iency;  disproportionate  largeness;  torsion  or 
feral  deviation  ; in  extremely  rare  cases,  mul- 
ilication  (double  or  triple  penis) ; abnor- 
ilities  in  excess  or  deficiency  of  particular  parts 
the  organ — epispadias  ; hypospadias  ; and 
imosis.  The  three  last  named  require  special 
lice. 

la)  Epispadias. — Definition. — A condition 
which,  from  arrest  or  defect  indevelopment,  the 
Iper  parts  of  the  urethra  and  corpus  spongio- 
m are  wanting,  and  the  corpora  cavernosa  are 
■t  properly  closed  together ; and  in  which,  con- 
luently,  the  penis  appears  more  or  less  com- 
itely  fissured  or  opened  along  its  dorsal  aspect, 
d the  fioor  of  the  urethra  is  exposed. 

.Symptoms  and  Effects. — This  condition  is 
ust  frequently  associated  with  ectopia  vesicas 
e Bladder,  Diseases  of) ; but  the  defect  may 
limited  to  the  penis.  In  most  instances  the 
hpuce  is  long  and  pendulous  below  the  glans  ; 
:1  this  is  important,  inasmuch  as  it  may  often 
advantageously  used  in  remedial  plastic 
'orations. 

The  attendant  inconveniences  and  discomforts, 
i h as  incontinence  of  urine  and  unfitness  for 
fjual  congress,  though  varying  somewhat  in 
u;ree  with  the  extent  of  the  defect,  are  so  great 
:jl  so  constant,  that  any  reasonable  attempt  at 
lhedy  by  plastic  operation  may  be  considered 
jjtifiable.  It  must  be  confessed  that  such  at- 
tjipts  have  hitherto  resulted  much  more  fre- 
rjmtly  in  failure  than  in  success.  In  some 
cjss,  however,  much  good  has  been  effected ; and 
'Others  the  patients  have  been  enabled  to  wear 
"’■aratus  by  which  their  discomfort  has  been 
i Serially  diminished.  F’or  a description  of  the 
vjious  methods  adopted,  reference  must  be  made 
tyorks  on  operative  surgery  and  special  trea- 
tk 

I1)  Hypospadias. — Definition. — A condition 
4-hich,  from  defective  development  of  the  ure- 
t i and  of  the  corpus  spongiosum,  the  urethra 
ojns  on  the  under  surface  of  the  penis,  at  a vari- 
1 distance  behind  the  glans;  and  in  which, 


111  1 

during  erection,  the  penis  arches  more  or  less 
downwards  and  backwards.  The  prepuce  usually 
forms  a kind  of  flap,  which  overhangs,  but  does 
not  surround  the  glans. 

Symptoms  and  Effects. — The  opening  of  the 
urethra,  which  is  often  very  small  and  slit- 
like, may  be  situated  either  immediately  behind 
the  glans,  at  any  point  in  the  under  surface 
of  the  body  of  the  penis,  or  just  in  front  of  the 
scrotum.  In  the  first  case— by  no  means  an 
uncommon  condition — no  material  inconvenience 
results;  micturition  and  sexual  intercourse  can, 
as  a rule,  be  fairly  well  accomplished ; and 
there  is  no  need  for  surgical  interference  be- 
yond the  enlargement,  if  needful,  of  the  ure- 
thral orifice.  But  in  cases  in  which  the  urethral 
orifice  is  far  back,  the  urine  passes  down  the 
thighs,  or  backwards ; complete  sexual  intercourse 
is  rendered  difficult,  painful,  or  altogether  im- 
possible; and  the  semen  cannot  be  properly  intro- 
mitted. Such  a state  of  things  often  occasions 
great  mental  distress,  and,  thereby,  impairment 
of  health;  and  it  may  become  justifiable  and  de- 
sirable to  attempt  to  remedy  to  some  extent  the 
defect  by  surgical  operation.  A great  variety  of 
methods  have  been  devised  and  practised,  the  de- 
tails of  which  will  be  found  in  surgical  treatises. 
Most  of  them  have  resulted  in  complete  failure. 
But  in  some  few  instances  very  considerable  im- 
provement has  been  effected.  As  a rule,  opera- 
tive measures  should  be  delayed  until  adult  life 
is  reached. 

(c)  Phimosis. — Definition. — -A  condition, 
often  hereditary,  in  which  the  orifice  of  the  pre- 
puce is  so  small  as  to  render  it  difficult  or  impossi- 
ble to  uncover  the  glans  properly  and  to  the  full 
extent.  In  some  cases  the  orifice  is  a mere  pinhole, 
or  even  scarcely  discoverable  ; in  others  more  or 
less  of  the  glans  may  bo  exposed  to  view.  Asso- 
ciated with  this  condition  there  is  often  elonga- 
tion of  the  prepuce,  usually  shortness  and  tight- 
ness of  the  frienum,  and  not  infrequently  undue 
smallness  of  the  urethral  orifice. 

It  is  highly  important  that  the  existence  of 
congenital  phimosis  should  not  be  overlooked  or 
ignored,  for  at  all  periods  of  life  more  or  less 
serious  troubles  may  arise  from  it ; and  acci- 
dental circumstances — injury,  inflammation,  ul- 
ceration, &c.— .may  easily  convert  a comparatively 
slight  congenital  phimosis  into  a severe  so-called 
acquired  phimosis.  At  all  ages  phimosis  is  lia- 
ble to  interfere  with  free  micturition — in  severe 
cases  from  mechanical  obstruction,  in  less  severe, 
or  even  comparatively  slight  cases,  from  reflex 
irritation  and  spasm.  The  bladder  consequently 
may  not  be  properly  evacuated,  and  gradually 
cumulative  mischief  may  result. 

Symptoms  and  Effects. — In  infancy  and 
childhood  frequent  attempts  to  pass  water,  ac- 
companied by  straining  and  sometimes  scream- 
ing, the  passage  of  a small  stream,  or  of  a small 
quantity  at  a time  followed  by  sudden  stoppage; 
dribbling  of  the  water;  irritation  and  inflamma- 
tion about  the  prepuce;  and  pulling  at  the  penis, 
are  signs  and  symptoms  accompanying,  and  sug- 
gestive of  phimosis  in  the  first  place,  however 
closely  they  may  simulate  the  indications  of  stone 
in  the  bladder.  General  irritability  and  deterio- 
ration of  health,  the  production  of  hernia  by 
frequent  straining,  balanitis,  the  acquirement  oi 


PENIS,  DISEASES  OF. 


1112 

the  habit  of  masturbation,  and  reflex  paralyses, 
are  among  the  evil  results  that  may  arise. 

In  adult  life  local  discomfort,  slowness  of 
micturition,  imperfect  evacuation  of  the  bladder, 
with  all  its  probable  consequences;  smallness 
(from  compression)  of  theglans;  difficulty,  want 
of  pleasure,  or  even  pain  in  sexual  intercourse  ; 
and  liability  to  infection  during  impure  inter- 
course, are  troubles  more  or  less  constantly  affect- 
ing the  subject  of  phimosis  ; and  to  these  may 
be  added,  in  more  advanced  life,  increased  lia- 
bility to  cancer  of  the  penis. 

Treatment. — In  comparatively  slight  cases  of 
phimosis  the  prepuce  may  be  gradually  stretched, 
and  i ts  orifice  dilated  to  the  needful  extent,  by  fre- 
quently repeated  gentle  efforts  at  withdrawing  it, 
and  by  inserting,  between  times,  strips  of  dry  or 
oiled  lint  between  it  and  the  glans.  In  the  more 
severe  cases  resort  to  operation  is  needful.  The 
methods  variously  adopted  are: — (1)  Forcible 
tearing ; (2)  linear  incision  to  greater  or  less  ex- 
tent; (3)  excision  of  a portion  of  the  prepuce; 
and  (4)  circumcision.  The  first  method  is  clumsy 
and  altogether  to  be  condemned  ; the  second  is 
easy  to  perform,  hut  often  leaves  the  part  in  an 
awkward  condition  ; the  third  is  incomplete,  and 
rarely  satisfactory  in  effect ; the  fourth,  if  care- 
fully and  skilfully  carried  out  is  uniformly  suc- 
cessful, yields  excellent  results,  and,  as  a rule,  is 
to  be  recommended. 

The  best  method  of  performing  circumcision 
consists  in  first  slitting  up  the  prepuce  along  the 
median  line  on  the  dorsal  aspect,  by  means  of  a 
bistoury  or  scissors,  guided  by  a director,  to  a 
point  on  a level  with  or  rather  behind  the  corona, 
and  in  then  starting  from  this  point,  and  with 
scissors  cutting  all  round,  dividing  skin  and 
mucous  membrane  evenly  together.  As  a rule 
the  frsenum  should  be  cut;  indeed,  in  most 
cases  it  is  better  to  excise  a portion.  In  the 
infant,  sutures  are  not  necessary;  but  in  the  adult 
it  is  better  to  stitch  the  skin  and  mucous  mem- 
brane together  by  very  fine  sutures  inserted  as 
close  to  the  edges  as  possible.  Inrolling  is  thus 
prevented,  and  if  the  sutures  are  tied  very  tightly 
they  will  ulcerate  out,  and  the  pain  and  trouble 
of  removing  them  will  be  avoided.  The  simplest 
dressing  only  is  requisite;  but  the  parts  must  be 
kept  scrupulously  clean,  and  free  . from  all  irri- 
tation. 

( d ) Adherent  Prepuce. — In  some  cases  of 
phimosis,  and  occasionally  iu  cases  in  which  the 
preputial  orifice  is  not  unduly  small,  the  mucous 
membrane  of  the  prepuce  adheres,  to  a greater 
or  less  extent,  to  that  of  the  glans.  The  smegma 
and  other  secretions  are  thus  confined;  and  con- 
siderable local  irritation,  accompanied  by  more 
or  less  severe  symptoms,  often  closely  simulating 
those  of  stone  in  the  bladder,  may  be  set  up. 

Treatment. — The  foreskin  must  he  drawn 
gradually  back,  the  adherent  surfaces  being  se- 
parated during  the  process  by  the  fiat  end  of  a 
probe  or  other  thin 'blunt  instrument;  the  con- 
fined secretions  must  be  removed ; the  parts 
washed ; the  prepuce  replaced,  unless  circumci- 
sion has  been  needful ; and  strict  cleanliness  en- 
joined. 

If  this  condition  be  overlooked  during  infancy, 
the  adhesions  become  firm  and  dense,  and  se- 
riously impede  the  growth  of  the  glans.  Their  | 


division  in  the  adult  may  require  the  use  of  ths 
knife  during  circumcision. 

2.  Phimosis,  Acquired.  — This  condition 
may  arise  as  a result  of  repeated  attacks  of  in- 
flammation, with  or  without  chancrous  ulcera- 
tion, followed  by  induration,  thickening  of  the 
prepuce,  and  contraction  of  its  orifice.  It  is 
most  frequent  in  those  who  have  had  slight  con- 
genital phimosis.  See  Venereal  Sock. 

Circumcision  is  the  proper  treatment. 

3.  Preputial  Calculi. — The  subpreputial 
secretions,  if  allowed  to  remain  and  accumulate, 
occasionally  undergo  changes,  and  become  formed 
into  hard  concretions,  which  give  rise  to  more  or 
less  serious  discomfort  and  inconvenience.  Such 
concretions  are  found  to  consist  mainly  of  phos- 
phate of  lime  and  ammonio-magnesian  phosphate, 
with  a variable  amount  of  organic  matter. 

4.  Paraphimosis. — Paraphimosis  is  a con- 
dition in  which  a tight  foreskin,  having  been 
forced  back,  during  coitus  or  otherwise,  has  led 
to  strangulation,  oedema,  and  inflammatory  swell- 
ing of  the  glans  and  a portion  of  its  own  mucous 
membrane.  The  appearance  presented  is  most 
characteristic. 

Treatment. — Reduction  must  be  effected  at; 
the  earliest  possible  moment.  If  the  case  be 
neglected  severe  inflammation,  ulceration,  and 
sloughing  to  greater  or  less  extent,  followed  by 
more  or  less  permanent  deformity,  are  liable  to 
ensue.  The  method  ordinarily  adopted  consists 
in  grasping  the  body  of  the  penis  between  the 
middle  and  forefingers  of  both  hands,  drawing 
the  foreskin  forwards,  and  at  the  same  time  com- 
pressing and  pushing  back  the  glans  by  both 
thumbs.  This  method  is  very  painful  and  not: 
always  readily  successful.  A better  method, 
which  very  rarely  fails,  consists  in  slowly  ban- 
daging the  glans  (beginning  at  the  extremity), 
and  all  the  swollen  parts,  with  a piece  of  narrow 
elastic  webbing,  the  effect  of  which  is  gradually 
to  empty  the  engorged  vessels  and  squeeze  out 
the  serum  from  the  swollen  parts.  On  the  re- 
moval of  the  bandage  after  a few  minutes,  reduc- 
tion is,  as  a rule,  very  easily  effected.  The  pro- 
cess may  be  facilitated  by  a few  needle  or  lancet- 
point  punctures,  made  before  the  application  oi 
the  bandage. 

In  some  neglected  cases  it  may  be  needful  toj 
divide  the  constricting  band  by  means  of  a bis- 
toury. In  attempting  this  it  must  be  borne  in 
mind  that  the  constriction  is  not  immediately 
behind  the  glans,  but  behind  the  swollen  portion 
of  the  preputial  mucous  membrane. 

After  reduction  cooling  and  soothing  applica- 
tions are  useful. 

5.  Penis,  Inflammation  of. — Sinon.  : Pe- 
nitis. — Inflammation  of  the  penis  in  its  totality 
is  very  rarely  met  with  except  as  the  result  oi 
injury,  or  in  association  with  severe  venerea, 
diseases.  In  some  rare  instances  it  is  said  tc 
have  been  induced  by  excessive  sexual  inter- 
course, and  in  other  instances  by  persisted 
masturbation.  Cases,  however,  are  on  record  ir 
which  it  has  occurred  during,  or  among  th< 
sequel*  of  exanthematous  fevers. 

The  treatment  must  be  conducted  on  genera 
principles,  due  regard  being  paid  to  the  cause  ui 


PENIS,  DISEASES  OF. 
pndition  in  connection  with  which  the  Mamma- 
on  has  arisen.  If  the  patient  survive,  the 
art  may  recover. 

6.  Penis,  Gangrene  of. — Gangrene  of  the 
icnis,  except  as  the  result  of  injury,  or  constric- 
|on  by  ligature,  rings.  &c.,  in  the  majority  of 
ises  has  followed  impure  sexual  congress  during 

depressed  general  condition.  In  some  cases 
has  occurred  in  association  with  small-pox, 
phus,  and  typhoid  fevers.  Death  has  been  the 
immou  result.  In  some  few  cases  life  has  been 
-eserved,  though  the  part  has  been  lost. 

7.  Herpes  Preputialis. — This  is  a vesicular 
uption,  occurring  on  the  cutaneous  or  mucous 
rface  of  the  prepuce,  running  its  course  in 
wut  a week,  but  liable  to  recur  at  irregular 
(tervals.  A similar  eruption  sometimes  occurs 

the  glans. 

The  due  recognition  of  this  affection  is  im- 
irtant,  becauso  its  appearance  after  doubtful 
tercourse  often  excites  alarm,  and  may  lead  to 
isehievous  treatment. 

Treatment. — The  simplest  treatment  only  is 
quisite.  The  avoidance  or  prevention  of  all 
•itation  by  the  clothes  or  otherwise,  and  some- 
nes  a little  sedative  lotion,  are,  as  a rule,  all 
at  is  needful. 

8.  Penis,  New  Growths  of. — Cystic,  vas- 
lar,  fibrous,  and  other  new  growths  of  benign 
aracter  are  occasionally  situated  on  the  penis, 
ley  may  be  left  uuinterfered  with,  or  may  be 
t rid  of  by  operation,  according  to  the  incon- 
nience  they  cause,  and  the  indications  afforded. 
my  formations  or  calcareous  deposits  in  the 
rous  sheaths  of  the  corpora  cavernosa  are  of 
re  occurrence.  The  discomfort  they  have  in 
ne  instances  caused  has  necessitated  their  re- 
oval  by  operation,  which  has  been  successfully 
lomplished.  Papillomata,  or  warty  growths, 
; not  infrequently  met  with  in  persons  of 
cleanly  habits.  In  the  majority  of  cases  they 

■ ) associated  with  venereal  disease;  but  they 
.y  arise  independently  of  such  association, 
ijiecially  if  the  prepuce  be  long,  and  due  regard 
not  paid  to  cleanliness.  They  may  be  few  and 
i.ttered,  or  many  and  massed  ‘cauliflowerlike’ 
('ether.  Sometimes  they  entirely  surround  the 
< ona,  and  sometimes  in  patches  or  continuously 
( rer  more  or  less  completely  the  mucous  sur- 
ges of  the  prepuce  and  glans.  In  some  in- 
s nces  the  diagnosis  between  such  growths  and 

I lillary  epithelioma  is  not  obvious  ; ulceration 
( surface  indicates  the  latter. 

Treatment. — Removal  by  curved  scissors,  or 
t sting  off  by  forceps,  is  the  most  speedily  effec- 

I I treatment  of  papillomata  of  the  penis.  But 
i he  warts  are  few  and  small,  they  may  be  made 
t shrivel  and  dry  up  and  disappear,  by  repeated 
sdications  of  oxide  of  zinc,  calomel,  tannic 
a 1,  or  burnt  alum,  and  the  pressure  of  dry  lint 
l ween  the  foreskin  and  glans.  Cleanliness  is 
thntial. 


s 

I 

c 

t! 

t! 


■ Penis,  Cancer  of. — Cancer  in  the  male 
ijeet  in  a considerable  proportion  of  cases 
narily  affects  the  penis.  By  far  the  most 
mon  form  is  epithelioma,  and  the  most  com- 
l seat  of  first  appearance  is  the  glans,  or 
part  of  tho  preputial  mucous  membrane 


PENTAST01TA.  1113 

nearly  or  immediately  adjoining.  In  compara- 
tively rare  cases  scirrhus  is  described  as  having 
commenced  ‘lumplike’  in  some  part  or  other  of 
the  body  of  the  organ.  In  still  more  rare 
cases,  soft  cancer  has  been  met  with  in  young 
subjects  after  injury,  and  the  diagnosis  from 
suppuration  in  the  corpus  cavernosum  has  at 
first  been  doubtful. 

Epithelioma  seldom  appears  in  the  penis  be- 
fore the  age  of  forty,  most  frequently  between 
the  fiftieth  and  sixtieth  years.  In  161  cases 
out  of  2i3  the  sufferers  had  been  the  subjects 
of  phimosis.  In  some  few  instances  the  ori- 
gin of  the  malady  has  been  attributed,  rightly 
or  wrongly,  to  marital  connection  with  wives 
suffering  from  cancer  of  the  uterus.  Epithelioma 
is  first  noticed  as  a small,  warty  outgrowth, 
early  ulcerated ; or  as  a flat,  excoriated  surface, 
with  slightly  indurated  base,  occasionally  dis- 
posed to  bleed,  and  sometimes  painful.  Scabs 
form  from  time  to  time,  which,  when  removed, 
leave  exposed  a gradually  extending  ulcerated 
surface.  The  malady  persists  and  progresses  in 
spite  of  treatment,  infiltrating  and  destroying. 
The  discharge  is  thin  and  sanious,  bloodstained 
and  offensive.  The  ulcer  is  irregular  in  outline, 
with  more  or  less  everted  hard  edges  ; and  the 
induration  extends  into  the  surrounding  parts. 
Sooner  or  later  the  inguinal  glands  become  in- 
fected, and  the  general  health  seriously  deterio- 
rates. 

Diagnosis. — The  diagnosis  of  cancer  of  the 
penis  from  any  form  of  venereal  ulceration  is,  as 
a rule,  sufficiently  easy.  Difficulty  can  scarcely 
arise,  except  in  tho  comparatively  rare  cases  in 
which  there  is  exuberant  warty  growth  before 
obvious  ulceration. 

Treatment. — The  only  treatment  worthy  of 
consideration  consists  in  amputation  of  the  penis, 
well  behind  the  point  to  which  the  disease  has 
extended.  If  the  inguinal  glands  have  become  in- 
fected, they  should  be  removed  at  the  same  time, 
if  practicable.  If  they  are  affected  to  such  an 
extent  as  to  render  their  removal  impracticable, 
amputation  of  the  penis  can  do  little,  if  any, 
lasting  good. 

10.  Penis,  Elephantiasis  of. — Elephantiasis 
of  the  penis  is  almost  .always  associated  with 
elephantiasis  of  the  scrotum,  and  may  demand 
simultaneous  treatment  by  operation. 

Arthur  E.  Durham. 

PENTASTOMA  (ireVre,  five,  and  err ipa,  a 
mouth). — A genus  of  entozoa  belonging  to  tho 
family  Acaridce.  They  are  sometimes  placed  in 
a separate  order  termed  Acanthotheca.  The 
species,  two  of  which  are  liable  to  infest  man, 
are  characterised  by  the  presence  of  a ringed 
or  segmented  body,  the  head  being  armed  with 
four  large  hooks  or  claws,  arranged  in  pairs 
on  either  side  of  the  mouth.  The  older  writers 
misunderstood  the  nature  of  these  cephalo- 
thoracic feet;  hence  the  generic  misnomer  which 
the  term  pentastome  implies.  The  so-called  Peiir- 
tastoma  denticulatum  infesting  the  liver,  although 
tolerably  frequent  in  various  parts  of  Europe, 
gives  rise  to  no  functional  disturbance,  and  is 
consequently  destitute  of  clinical  importance.  It 
is  the  larval  condition  of  a worm  that  infests  the 
nasal  cavities  of  the  dog,  Pentastoma  tcenioides. 


1114  PENTASTOMA. 

The  other  human  pentastome,  Pentastoma  con- 
tirictum,  infests  the  liver  and  luDgs,  and,  on 
account  of  its  comparatively  large  size,  is  capable 
of  giving  rise  to  serious  and  even  fatal  symp- 
toms. It  measures  from  half  an  inch  to  an  inch 
in  length;  being  also  easily  recognised  by  the 
presence  of  twenty-three  rings.  This  entozoon 
not  only  occurs  in  Africa,  but  also  in  the  West 
Indies,  where  European  residents  are  liable  to 
be  attacked  by  it.  The  museum  of  the  Army 
Medical  Department  at  Netley  contains  examples 
of  this  parasite,  from  a case  in  which  the  entozoon 
appears  to  have  proved  fatal.  The  history  of  the 
case,  originally  sent  by  Dr.  Kearney,  is  given  by 
Dr.  Aitken  in  the  later  editions  of  his  treatise 
On  the  Science  and  Practice  of  Medicine.  To 
this  work  the  reader  is  referred  for  other  par- 
ticulars of  clinical  interest. 

T,  S.  COBBOLI). 

PEPTIC  GLANDS,  Diseases  of.  See 

Stomach,  Diseases  of. 

PEPTONISED  POOD.—' This  term  may 
be  used  as  the  equivalent  of  the  phrase  ‘ artifi- 
cially digested  food.’  In  natural  digestion  albu- 
minoid substances  are  changed  into  peptones,  and 
starchy  matters  are  changed  into  dextrine  and 
sugar.  These  processes  are  of  a purely  chemical 
nature,  and  they  can  be  imitated  outside  the 
body  very  closely  by  means  of  artificially  pre- 
pared digestive  juices.  An  extract  of  the  stomach, 
or  of  the  pancreas,  in  water,  has  approxima- 
tive^ the  same  powers  as  the  natural  secre- 
tions of  those  organs.  Hence  it  is  possible 
for  us  to  subject  articles  of  food  beforehand  to 
complete  or  partial  digestion;  and  to  administer 
such  artificially  digested  food  to  our  patients. 
In  cases  where  the  natural  digestive  powers  are 
more  or  less  in  abeyance,  it  would  be  an  obvious 
advantage  if  we  had.  at  command  a supply  of  food 
thus  modified,  and  yet  not  so  changed  as  to  have 
lost  its  agreeable  appearance  and  flavour.  Nor  is 
there  anything  repugnant  to  physiological  science 
or  to  the  custom  of  mankind  in  such  a proposal. 
The  essential  acts  of  digestion  are  not  vital 
operations,  but  chemical  transmutations ; and  the 
theatre  of  these  operations  is  on  the  surface  of 
the  gastric  and  intestinal  membrane,  and  not  in 
the  true  interior  of  the  body.  In  the  practice  of 
itboking  wo  have,  as  it  were,  a foreshadowing  of 
the  art  of  artificial  digestion ; and  although  the 
latter  art  may  never  pass  beyond  the  needs  of 
the  sick  and  debilitated — may  never  serve  the 
healthy  and  robust — it  is  not  more  absolutely 
alien  from  the  life  of  animals  in  a state  of  nature 
than  is  the  art  of  cooking.  The  practice  of 
cooking  is  an  exclusively  human  practice,  and  it 
is  now  spread  among  all  the  races  of  mankind, 
whether  civilised  or  uncivilised  ; and  among  the 
higher  races  the  two  most  important  groups  of 
alimentary  substances — albuminoid  and  starchy 
matters — are  eaten  almost  exclusively  in  the 
cooked  condition. 

Now  the  changes  impressed  on  articles  of  food 
by  cooking  are  not  merely  mechanical ; nor  are 
they  confined  to  alterations  in  the  appearance  and 
savour  of  the  food.  By  far  the  most  important 
changes  produced  by  cooking  consist  of  certain 
chemical  transformations,  whereby  several  of  the 
chief  alimentary  principles  are  rendered  incom- 


PEPTONISED  FOOD. 

parably  more  amenable  to  the  action  of  tl 
digestive  juices  than  in  the  uncooked  state.  ] 
a sense  we  may  speak  of  cooked  food  as  foe! 
which  has  undergone  the  preliminary  stage  of  d| 
gestion.  This  preliminary  stage  is  accomplish! 
for  us  of  the  human  race  by  the  artificial  aid  . 
heat ; but  in  the  case  of  all  the  lower  animals 
has  to  be  accomplished  by  the  labour  of  their  on 
digestive  organs.  The  affinity  of  digestion  t 
the  process  of  cooking  goes  even  much  beyon 
this.  It  has  been  shown  experimentally  th: 
albumen,  when  subjected  to  the  prolonged  actio| 
of  superheated  steam,  yields  a substance  resenj 
bling  peptone,  and  that  starch  when  similar: 
treated  yields  dextrine  and  sugar.  So  that 
would  not  be  inappropriate  to  describe  digestio! 
as  the  process  of  cooking  carried  a step  further 

Methods  of  preparation. — Peptonised  < 
artificially  digested  food  may  be  prepared,  eith.1 
by  following  the  gastric  method  with  pepsin  arj 
hydrochloric  acid,  or  by  following  the  intestin  | 
method,  and  using  extract  of  pancreas.  Tl 
latter  method  yields  by  far  the  better  result 
The  pancreas  not  only  acts  upon  albumins 
substances,  but  also  upon  starch.  Pepsin,  on  tl 
other  hand,  is  quite  inert  in  regard  to  starcl 
Moreover,  the  products  of  artificial  digestion  wi 
pepsin  and  acid  are  much  less  agreeable  to  tl 
taste  and  smell  than  those  produced  by  pancreat; 
extract.  By  the  latter  method  articles  of  foa 
can  be  profoundly  peptonised  with  little  detj 
ri  oration  of  that  agreeable  savour  which  mat 
them  inviting  to  the  palate.  The  writer  vri 
therefore,  in  what  follows,  confine  himself  to  ti 
pancreatic  method,  and  describe  the  modes 
which  food  may  be  partially  digested  beforehan 
and  yet  constitute  an  acceptable  nourishme: 
for  invalids. 

The  first  necessity  is  to  procure  an  activ 
extract  of  the  pancreas.  Water  is  the  propj 
solvent  of  the  digestive  ferments ; but,  iu  order 
obtain  a stable  preparation,  some  preservati 
agent  must  be  added  to  prevent  decomposition 
After  a trial  of  various  media  the  writer  has  con 
to  the  conclusion  that,  on  the  whole,  the  be 
solvent  is  dilute  spirit.  A mixture  of  one  pa 
of  rectified  spirit  with  three  parts  of  W3t 
answers  every  purpose.  The  pancreas  of  the  p 
yields  the  most  active  preparation;  but  the  pa 
creas  of  the  ox  or  the  sheep  may  be  employed,, 
that  of  the  pig  is  not  obtainable.  The  pancre 
of  the  calf  also  yields  an  extract  which  is  acti 
on  albuminous  substances,  but  it  is  not  a cti 
on  starchy  materials.  In  procuring  a supply 
pancreas  from  the  butcher,  it  is  well  torememl 
that  the  word  ‘ sweet-bread,’ which  is  the  Engh 
vernacular  for  piancreas,  is  likewise  applied 
the  thymus  gland ; and  that  the  genuine  swe< 
bread  of  the  kitchen  is  the  thymus  of  the  ca 
Butchers  distinguish  the  true  pancreas  as  h 
‘liver  sweetbread,’  and  it  is  by  this  name,  alo 
that  the  pancreas  must  be  asked  for  in  t 
shambles. 

Mode  of  preparation  of  Extract  of  Pa 
creas  or  Liquor  Pancreaticus. — The panerc 
is  first  well  freed  from  fat,  and  cut  up  into  sm 
pieces  with  a knife  or  a pair  of  scissors.  It 
then  mixed  with  four  times  its  weight  ot  t 
dilute  spirit,  put  into  a well-corked  wide-mouth 
bottle,  and  sot  aside  for  a week.  The  mixtt 


' 

PEPTONISED  FOOD. 


lould  be  well  agitated  at  least  once  daily.  At 
■e  end  of  a week  the  mixture  is  strained  through 
tislin,  and  then  filtered  through  paper  until  it 
clear. 

A very  active  extract  of  pancreas  is  now  pre- 
fred  on  the  large  scale  by  Mr.  Benger,  under 
t name  of  Liquor  Pancreaticus,  and  sent  out 
! Mottershead  & Co.,  chemists,  Manchester.  As 
is  a troublesome  matter  to  get  a supply  of 
increas  from  the  butcher,  and  as  the  filtration 
the  product  is  a tedious  process,  it  will  be 
and  much  more  convenient  to  employ  Mr. 
Snger’s  preparation,  if  it  can  be  procured,  than 
rely  on  home  manufacture.  In  the  succeeding 
struetions  for  the  preparation  of  peptonised 
f>d  it  will,  therefore,  be  supposed  that  a supply 
Danger's  liquor  pancreaticus  is  available. 
Directions  for  the  preparation  of  various 
nds  of  peptonised  food. — The  articles  which 
'a  most  easily  prepared,  and  are  most  likely  to 
serviceable  to  invalids  are  the  following: — 
Peptonised  milk. — A pint  of  milk  is  diluted 
th  a quarter  of  a pint  of  water,  and  heated  to 
{temperature  of  about  140°  Fh.  Should  no 
srmometer  be  at  hand,  the  diluted  milk  may 
divided  into  two  equal  portions,  one  of  which 
.heated  to  the  boiling  point  and  added  to  the 
c.d  portion,  when  the  mixture  will  be  of  the 
quired  temperature.  Two  teaspoonfuls  of  the 
{nor  pancreaticus  and  ten  grains  of  bicarbonate 
■ soda  are  then  added  to  the  warm  milk.  The 
ixture  is  poured  into  a covered  jug,  and 
fejug  is  placed  in  a warm  situation  under  a 
‘osey,’  in  order  to  keep  up  the  heat.  At  the 
(H  (if  an  hour,  or  an  hour  and  a half,  the  pro- 
mt is  boiled  for  two  or  three  minutes.  It  can 
ten  be  used  like  ordinary  milk. 

The  object  of  diluting  the  milk  is  to  prevent 
t|i  curdling  which  would  otherwise  occur,  and 
flatly  delay  the  peptonising  process.  The  ad- 
cion  of  bicarbonate  of  soda  prevents  coagulation 
c;:ing  the  final  boiling,  and  also  hastens  the 
pcess.  The  purpose  of  the  final  boiling  is  to 
If,  a stop  to  the  ferment-action  when  this  has 

i dled  the  desired  degree,  and  thereby  to  pre- 
yt  certain  ulterior  changes  which  would  render 
t product  less  palatable.  The  degree  to  which 
t peptonising  change  has  advanced  is  best 
j ged  of  by  the  development  of  a peculiar  bitter 
f our,  which  is  always  associated  with  the 
a ficial  digestion  of  milk.  The  point  aimed  at 
i:  i carry  the  change  so  far  that  the  bitter  flavour 
fust  perceived,  but  is  not  unpleasantly  pro- 
r need.  As  it  is  impossible  to  obtain  pancre- 
a extract  of  absolutely  constant  strength,  the 
djictions  as  to  the  quantity  to  be  added  must 
Fmderstood  with  a certain  latitude.  The  ex- 
ti  of  the  peptonising  action  can  be  regulated, 
e'er  by  increasing  or  diminishing  the  dose  of  the 
lilor  pancreaticus,  or  by  increasing  or  diminish- 

ii  the  time  during  which  it  is  allowed  to  operate. 
Fikimming  the  milk  beforehand,  and  restoring 
ti  cream  after  the  final  boiling,  the  product  is 
ralered  more  palatable. 

eptonised  gruel. — Gruel  may  be  prepared 
t’i  l any  of  the  numerous  farinaceous  articles  in 
c mon  use — wheaten  flour,  oatmeal,  arrowroot, 
*4 i,  pearl-barley,  pea  or  lentil  flour.  The  gruel 
sljild  bn  well  boiled,  and  made  thick  and  strong. 
I then  poured  into  a covered  jug,  and  allowed 


1115 

to  cool  until  it  becomes  lukewarm.  Liquor 
pancreaticus  is  then  added,  in  the  proportion  of  a 
dessert-spoonful  to  the  pint  of  gruel,  and  the  jug 
is  kept  warm  under  a ‘cosey’  as  before.  At  the 
end  of  a couple  of  hours  the  product  is  boiled, 
and  strained.  Tho  action  of  pancreatic  extract 
on  gruel  is  twofold — the  starch  of  the  meal  is 
converted  into  dextrine  and  sugar,  and  the  albu- 
minoid matters  are  peptonised.  The  conversion 
of  the  starch  causes  the  gruel,  however  thick  it 
may  have  been  at  starting,  to  become  quite  thin 
and  watery.  The  bitter  flavour  does  not  appear 
to  be  developed  in  the  pancreatic  digestion  of 
vegetable  proteids,  and  peptonised  gruels  are 
quite  devoid  of  any  unpleasant  taste.  It  is  diffi- 
cult to  say  to  what  extent  the  proteids  of  the 
meal  are  peptonised  in  this  process.  The  pro- 
duct gives  an  abundant  reaction  of  peptone  ; 
but  there  is  a considerable  residuum  of  undis- 
solved material.  Most  of  this,  no  doubt,  consists 
of  insoluble  ligneous  tissue,  but  it  also  contains 
some  unliberated  starchy  and  albuminous  matter. 
Peptonised  gruel  is  not  generally,  by  itself,  an 
acceptable  food  for  invalids,  but  in  conjunction 
with  peptonised  milk  (peptonised  milk-gruel)  or 
as  a basis  for  peptonised  soups,  jellies,  and  blanc- 
manges, it  is  likely  to  prove  valuable. 

Peptonised  millc-gniel. — This  is  the  preparation 
of  which  the  writer  has  had  the  most  experience 
in  the  treatment  of  the  sick,  and  with  which  he 
has  obtained  the  most  satisfactory  results.  It 
may  be  regarded  as  an  artificially  digested  bread- 
and-milk,  and  as  forming  by  itself  a complete 
and  highly  nutritious  food  for  weak  digestions. 
It  is  very  readily  made,  and  does  not  require  the 
use  of  the  thermometer.  First,  a thick  gruel  is 
made  from  any  of  the  farinaceous  articles  above 
mentioned.  The  gruel,  while  still  boiling  hot, 
is  added  to  an  equal  quantity  of  cold  milk.  The 
mixture  will  havo  a temperature  of  about  125° 
Fh.  To  each  pint  of  this  mixture  two  or  three  tea- 
spoonfuls of  liquor  pancreaticus,  and  ten  grains 
of  bicarbonate  of  soda,  are  added.  It  is  kept 
warm  in  a covered  jug  under  a ‘cosey’  for  an 
hour  or  hour-and-balf,  and  then  boiled  for  two 
or  three  minutes,  and  strained,  If  the  product 
has  too  much  bitter  flavour,  a smaller  quantity  of 
the  liquor  pancreaticus  must  be  used  in  the  next 
operation.  Invalids  take  this  compound,  as  a rul,e, 
if  not  with  relish,  at  least  without  any  objec- 
tion. 

Peptonised  soups,  jellies,  and  blanc-mangcs. — 
The  writer  has  sought  to  give  variety  to  pepto- 
nised dishes  by  preparing  soups,  jellies,  and  blanc- 
manges containing  peptonised  aliment.  Soups 
maybe  prepared  in  two  ways.  The  first  way  is  to 
add  what  cooks  call  ‘stock’  to  an  equal  quantity 
of  peptonised  gruel  or  peptonised  milk-gruel.  A 
second  and  better  way  is  to  use  peptonised  gruel, 
which  is  quite  thin  and  watery,  instead  of  simple 
water,  for  the  purpose  of  extracting  the  soluble 
matters  of  shins  of  beef  and  other  materials  em 
ployed  in  the  preparation  of  soups.  Jellies  may 
be  prepared  by  simply  adding  the  due  quantity 
of  gelatine  or  isinglass  to  hot  peptonised  gruel, 
and  flavouring  the  mixture  according  to  taste. 
Blanc-manges  may  be  made  by  treating  pepto- 
nised milk  in  a similar  way,  and  then  adding 
cream.  In  preparing  all  these  dishes  it  is  abso- 
lutely necessary  to  complete  the  operation  of  pep- 


1116  PEPTONISED  FOOD. 

Ionising  the  gruel  or  the  milk,  even  to  the  final 
boiling,  before  adding  the  stiffening  ingredient. 
For  if  pancreatic  extract  be  allowed  to  act  on  the 
gelatine,  the  gelatine  itself  undergoes  a process 
of  digestion,  and  its  power  of  setting  on  cooling 
is  therefore  utterly  abolished. 

Peptonised  bef-tea. — A pound  cf  finely  minced 
lean  beef  is  mixed  with  a pint  of  water,  and  ten 
grains  of  bicarbonate  of  soda  are  added  thereto. 
The  mixture  is  then  simmered  for  an  hour  and  a 
half  in  a covered  saucepan.  The  resulting  beef- 
tea  is  decanted  off  into  a covered  jug.  The  un- 
dissolved beef-residue  is  then  beaten  up  with  a 
spoon  into  a pulp,  and  added  to  the  beef-tea  in 
tho  covered  jug.  When  the  mixture  has  cooled 
down  to  about  140°  F.  (or  when  it  is  cool  enough 
to  be  tolerated  in  the  mouth)  a table-spoonful  of 
the  liquor  pancreaticus  is  added,  and  the  whol3 
well  stirred  together.  The  covered  j ug  is  then 
kept  warm  under  a ‘ cosey’ for  two  hours,  and 
agitated  occasionally.  At  the  end  of  this  time, 
the  contents  of  the  jug  are  boiled  briskly  for  two 
or  three  minutes,  and  finally  strained.  The  pro- 
duct is  then  ready  for  use.  Beef-tea  prepared  in 
this  way  is  rich  in  peptone.  It  contains  about  4 
per  cent,  of  organic  residue,  of  which  more  than 
three-fourths  consists  of  peptone ; so  that  its 
nutritive  value  in  regard  to  nitrogenised  ma- 
terials is  nearly  equivalent  to  that  of  milk.  When 
seasoned  with  salt  it  is  scarcely,  if  at  all,  dis- 
tinguishable in  taste  from  ordinary  beef-tea. 

Peptonised  enemata. — Pancreatic  extract  is 
peculiarly  adapted  for  administration  with  nutri- 
tive enemata.  The  enema  may  be  prepared  in 
the  usual  way  with  a mixture  of  milk  and  gruel, 
or  milk,  gruel,  and  beef-tea.  A dessert-spoonful 
of  liquor  pancreaticus  is  added  to  it  just  before 
administration.  In  the  warm  temperature  of  the 
bowel  the  pancreatic  ferments  find  a favourable 
medium  for  their  action  on  the  nutritive  ingre- 
dients with  which  they  are  mixed ; and  there  is 
no  acid  secretion  (as  in  the  stomach)  to  interfere 
with  the  progress  and  completion  of  the  digestive 
transformation.  Experience  has  satisfied  the 
writer  that  this  method  of  administering  nutri- 
ment is  a valuable  resource  when  the  stomach  is 
obstinately  intolerant  of  food,  or  when  there  is 
obstruction  in  the  higher  portions  of  the  digestive 
tract. 

Uses  of  peptonised  food. — The  employment 
of  food  which  has  been  wholly  or  partially  pep- 
tonised  is  indicated  when  the  natural  digestive 
powers  are  from  any  cause  enfeebled  or  suspended. 
The  most  striking  benefits  have  been  observed 
in  cases  of  gastric  catarrh  with  pain  and  intoler- 
ance of  food ; in  gastric  ulcer ; in  the  anorexia 
and  dyspepsia  associated  with  valvular  heart- 
disease  ; and  in  the  various  forms  of  pyloric  and 
intestinal  obstruction.  Good  results  have  also 
been  obtained  in  cases  of  defective  nutrition  and 
intestinal  irritation  in  infants.  In  using  pepto- 
nised food  it  is  well  to  remember  that  it  does  not 
keep  well,  especially  in  warm  weather.  Accord- 
ingly it  should  either  he  prepared  twice  a day,  so 
that  it  may  he  never  more  than  twelve  hours  old  ; 
or,  if  a quantity  sufficient  for  the  twenty-four 
be  prepared  at  once,  the  portion  which  remains 
over  at  the  end  of  twelve  hours  should  be  re- 
boiled. 

Williaii  Kobests. 


PERFORATIONS  AND  RUPTURES. 

PERCUSSION  (percusso,  I strike). 

method  of  physical  examination,  performed 
striking  gently  some  part  of  the  body,  especial 
the  chest  or  abdomen,  for  the  purpose  of  pr 
ducing  certain  sounds  or  tactile  sensations, 
may  be  performed  either  by  the  finger  or  fingc 
of  one  hand  striking  the  surface  directly,  or  i 
directly— the  fingers  of  the  other  hand  being  i 
terposed;  or  by  means  of  a special  instrument 
instruments.  Percussion  has  been  recommend- 
by  Dr.  Mortimer  Granville  as  an  agent  in  the  tret 
ment  of  certain  nervous  diseases  (Brit.  Med.  Jci 
Pol.  I.  1882).  See  Physical  Examination. 

PERFORATIONS  AND  RUPTURE, 

It  will  be  convenient  to  discuss  these  lesioi 
together,  and  from  a general  point  of  view  only,  ti 
more  important  perforations  and  ruptures  eoi 
neeted  with  particular  organs  being  treated  of : 
their  appropriate  articles.  The  word  rupture 
used  here  in  its  true  significance,  and  not  in  tl 
popular  sense  as  applied  to  hernia.  See  IUttup. 

Definition. — Though  there  is  no  absolute  c!l 
tinction  between  perforations  and  ruptures,  the 
are  certain  differences  by  which  they  are  usual 
broadly  recognised. 

The  term  perforation  is  generally  only  applid 
to  an  artificial  opening  produced  in  a hollo! 
organ  or  tube ; seldom,  and  only  under  spec; 
circumstances,  to  a lesion  affecting  a solid  tissu 
Moreover,  it  implies  that  the  opening  is  a sma 
ono,  or,  at  any  rate,  does  not  reach  large  dunci 
sions.  Again,  the  mode  in  which  the  lesion  I 
produced  has,  in  some  instances,  to  do  with  tl; 
definition  of  a perforation.  Thus,  if  the  ope:; 
ing  results  from  injury  by  a pointed  iustrumeu 
or  by  any  other  agent  which  would  cause  more  ci 
less  of  a puncture,  such  as  a fractured  rib  pent 
trating  the  lung,  it  would  be  called  a perforatior 
and  in  this  case  the  term  would  apply  also  ; 
a solid  organ  or  tissue.  Finally,  the  slow  di 
straction  of  certain  structures  by  aneurisms  as 
other  tumours  often  terminates  in  an  apertur 
being  formed,  which  is  then  called  a perforation 
This  is  well  exemplified  by  the  opening  formed  i 
the  sternum  in  some  cases  of  aortic  aneurism. 

A rupture  may  be  associated  with  any  stmc 
ture,  and  often  involves  solid  organs  and  tissue; 
such  as  muscles.  It  implies  a lesion  of  sons 
size,  and  may  reach  any  dimensions,  being  mon 
of  a tear  or  rent  than  a puncture.  There  is  alsj 
associated  with  the  term  the  idea  of  spontnneon 
production,  or  of  the  lesion  originating  iron 
within,  or  from  the  effects  of  some  compressin 
or  lacerating  injury,  instead  of  a penetrating  one 

^Etiology  and  Pathology. — The  causes  c 
perforations  and  ruptures,  and  the  pathologic;! 
conditions  under  which  these  lesions  occur,  ma 
be  thus  summarised : — 

1.  Injury. — This  often  comes  from  withou: 
and  may  be  of  different  kinds.  The  forms  d 
injury  most  requisite  to  notice  are  perforate 
wounds ; severe  compression  of  the  body,  as  be 
tween  railway-buffers,  which  may  cause  extensiv 
rupture,  even  of  solid  organs,  without  any  ex 
ternal  mark  of  violence ; violent  concussion,  as ; 
the  case  of  the  brain  ; and  straining,  which  is  es 
pecially  liable  to  cause  rupture  of  muscles  or  at 
teries.  To  the  category  of  injuries  also  beloa; 
various  causes  of  perforation  or  rupture  comm. 


PERFORATIONS 
j'm  within,  such  as  corrosives  which  have  been 
Eillowed,  bones  and  other  foreign  bodies  simi- 
l'ly  introduced,  calculi,  hardened  fasces  in  the 
ijestines,  and  worms.  Cases  have  now  and  then 
c urred  in  which  important  internal  organs  have 
fen  penetrated  in  the  attempt  made  by  show- 
m to  swallow  swords  and  similar  instruments. 
^Violent  actions. — Voluntary  muscles  have  by 
t in  own  excessive  action  led  to  their  rupture, 
a'in  cases  of  tetanus.  The  uterus  has  been  known 
trupture  itself.  In  rare  instances  the  healthy 
l g has  given  way  from  violent  cough.  3.  Morbid 
Otr  notice  atuz  degenerative  processes. — These  are 
ioortant  causes  of  perforations  and  ruptures  of 
vious  kinds,  and  they  include  ulceration  or 
gigrene,  as  of  the  stomach  or  intestine ; sup- 
jjation,  leading  to  the  formation  of  an  abscess, 
eier  associated  or  not  with  an  organ,  and  which 
iiy  hurst  into  various  internal  parts,  or  exter- 
rily;  cancer;  acute  fatty  degeneration  and  soften- 
i.  of  organs ; and  chronic  fatty,  atheromatous, 
o'jalcareous  degeneration.  Some  of  the  condi- 
t is  mentioned  are  in  themselves  essentially  de- 
6 fetive ; others  produce  such  changes  that  they 
r Ter  a rupture  liable  to  occur  from  very  little 
e ra  force  or  pressure,  such  as  that  which  arises 
fun.  a slight  strain,  a cough,  or  the  act  of  vomit- 
i:  or  defaecation,  as  is  well  exemplified  by  the 
Wirt  and  arteries.  Even  in  the  ease  of  the  de- 
s ictive  processes,  some  exciting  cause  may  lead 
tilhe  actual  perforation  or  rupture,  such  as  one 
o the  acts  mentioned  above,  or,  in  the  case  of 
ti  alimentary  canal,  the  injudicious  administra- 
th  of  solid  food,  or  of  articles  which  give  rise  to 
tl  rlent  distension.  Moreover,  after  ulceration 
a Beatrix  may  be  left,  which  for  a time  is  very 
lijle  to  give  way  from  slight  causes,  as  some- 
lips  happens  in  connection  with  typhoid  fever. 
T,  perforation  of  the  lung  in  cases  of  phthisis 
is  good  illustration  of  the  effects  of  destructive 
clliges.  4.  Gaseous  and  liquid  accumulations. 
T;se  may  alone  lead  to  rupture  of  hollow  organs 
oiiibes,  of  the  walls  of  cavities,  or  of  cysts,  by 
c;  ing  extreme  distension,  as  may  be  exemplified 
b She  occasional  rupture  of  the  intestines  from 
o\ -distension,  of  an  emphysematous  luDg,  of  the 
hl  der  from  an  accumulation  of  urine,  of  the 
real  pelvis  in  cases  of  hydronephrosis,  of  a dis- 
tel  ed  gall-bladder,  of  a pleuritic  effusion  through 
(■..diaphragm,  of  a hydatid  or  ovarian  cyst,  or 
otSn  aneurism.  Some  slight  strain  or  injury 
m be  the  immediate  cause  of  the  lesiou  in 
sejral  of  these  conditions.  5.  Pressure. — A 
tu.jur  of  any  kind  may  cause  perforation  of 
va-ms  structures,  as  the  result  of  its  mechanical 
pijiure.  In  the  case  of  an  aneurism  the  pulsa- 
ti<  assists  in  producing  the  lesion.  In  this 
w;  the  most  resisting  tissues  may  be  destroyed, 
ac;  serious  consequences  are  liable  to  ensue. 
6 ■ spontaneous. — In  the  case  of  muscular  tissues 
an  arterial  structures  spontaneous  ruptures  are 
sujosed  to  happen  occasionally,  but  probably 
in  11  such  cases  there  has  been  previous  de- 
gejration,  which  has  been  tho  real  cause  of  the 
rujire. 

iatomical  Characters. — It  must  suffice  to 
nit  ion  here  that  the  morbid  appearances  con- 
siSi  'f  those  presented  by  the  perforation  or  rup- 
tu  itself;  and  of  tho  effects  resulting  therefrom. 
Tt  ;ormer  vary  much  in  extent  and  character  in 


AND  RUPTURES.  1117 

different  cases,  and  no  general  description  can  be 
given  of  them.  As  regards  the  effects  produced, 
there  may  be  none,  but  very  commonly  haemor- 
rhage takes  place;  or  the  contents  of  a hollow 
viscus,  or  of  a fluid  collection,  may  be  found 
poured  out  in  some  abnormal  situation,  and  these 
usually  set  up  inflammation  if  the  patient  live 
long  enough,  the  results  of  which  will  be  evident 
on  'post-mortem  examination.  In  the  case  of  slow 
perforation  of  structures  by  tumours,  various 
effects  may  be  produced,  of  an  irritative  or  de- 
structive character.  Particulars  on  these  points 
are  given  in  other  appropriate  articles.  In  the 
case  of  the  lung,  perforation  is  likely  to  lead  to 
the  escape  of  air  into  the  pleura  or  cellular  tis- 
sue, thus  giving  rise  to  pneumothorax  or  subcu- 
taneous emphysema.  On  the  other  hand,  liquid 
accumulations  may  open  into  the  lung,  and  thus 
be  found  in  the  air-passages,  or  they  may  pro- 
duce more  or  less  serious  effects  upon  the  pul- 
monary tissues. 

Symptoms. — It  is  not  intended  hero  to  describe 
the  symptoms  which  occur  in  connection  with 
traumatic  injuries,  but  merely  to  point  out  those 
likely  to  be  noticed  in  different  cases  which 
come  under  observation  in  medical  practice, 
Under  certain  circumstances  a perforation  or 
rupture  may  take  place  without  any  obvious 
symptoms,  even  when  it  affects  an  important 
structure.  This  may  happen,  for  instance,  even 
when  an  opening  forms  in  a hollow  viscus,  such 
as  the  stomach  or  intestine,  provided  it  has 
become  previously  adherent  to  some  solid  organ, 
or  to  another  part  of  the  bowel,  with  which  it 
then  forms  a communication.  On  the  other  hand, 
very  speedy  or  even  sudden  death  may  ensue,  as 
when  a large  aneurism  or  the  heart  ruptures. 
The  symptoms  to  be  anticipated  are  those  due  to 
the  actual  lesion  itself ; and  those  resulting  from 
the  consequences  mentioned  under  the  anatomical 
characters.  As  regards  the  lesion  itself,  if  it  is 
suddenly  produced,  the  event  is  usually  attended 
with  immediate  marked  symptoms.  Of  these, 
one  of  the  most  common  is  a sudden  pain  at  the 
seat  of  mischief,  often  very  intense,  but  vary- 
ing in  its  characters.  When  a muscle  ruptures, 
a feeling  is  frequently  experienced  as  if  a severe 
blow  had  been  struck,  and  power  is  lost  at  once 
in  the  affected  part.  This  is  well  exemplified  in 
eases  of  rupture  of  the  gastrocnemius,  an  acci- 
dent not  uncommon  at  the  present  day  in  connec- 
tion with  the  game  of  lawn  tennis.  When  a hol- 
low viscus  or  any  fluid  collection  bursts,  or  when 
gas  escapes,  a sensation  as  if  something  were 
being  poured  out  is  often  noticed  by  the  patient. 
At  the  same  time  the  general  system  usually 
suffers  more  or  less  gravely,  as  evidenced  by 
faintness  or  actual  fainting,  or  by  signs  of  shock 
or  collapse,  from  which  the  patient  may  never 
rally,  if  the  structure  involved  is  of  great  im- 
portance in  the  vital  economy,  or  if  continuous 
haemorrhage  should  be  going  on.  The  symptoms 
above  indicated  may  be  repeated  if  the  lesion 
should  extend  after  an  interval.  It  may  be  men- 
tioned that  when  rupture  of  an  abdominal  organ 
takes  place  from  severe  compression  of  the  body, 
there  may  be  no  symptoms  of  the  event  at  the 
outset,  and  only  the  development  of  grave  general 
symptoms  indicates  what  has  happened.  The 
occurrence  of  hemorrhage  into  internal  parts. 


1118  PERFORATIONS  AND  RUPTURES, 
or  the  escape  of  the  contents  of  the  viscera  or 
of  a fluid  accumulation,  may  be  obvious  on  phy- 
sical examination.  Should  the  patient  survive 
in  cases  of  rupture  into  internal  parts,  local  and 
general  symptoms  pointing  to  the  occurrence  of 
inflammation  may  be  expected  to  supervene.  For 
instance,  in  the  ease  of  the  abdomen  there  would 
be  signs  of  peritonitis,  or  of  localised  inflamma- 
tion in  some  part  of  the  cellular  tissue,  probably 
ending  in  suppuration.  In  perforation  of  the 
lung,  symptoms  and  physical  signs  of  pneumo- 
thorax appear,  or  the  presence  of  air  in  the  sub- 
cutaneous cellular  tissue  may  become  evident. 
When  an  opening  is  formed  between  some  col- 
lection of  fluid  and  any  organ  or  passage  which 
communicates  externally,  such  as  the  air-tubes 
or  the  alimentary  canal,  such  fluid  is  likely  to 
be  discharged  in  different  ways,  and  this  may  be 
a favourable  mode  of  termination,  leading  to  a 
cure.  In  the  case  of  slow  perforation  by  a 
tumour,  should  it  take  place  in  an  outward  direc- 
tion, the  lesion  will  probably  become  evident  on 
clinical  examination;  if  internal  structures  be 
affected,  the  process  of  destruction  may  be  ac- 
companied with  continuous  pain,  or  other  symp- 
toms ; and  subsequently  clinical  phenomena  in- 
dicative of  implication  of  various  structures  arise, 
either  suddenly  or  gradually.  For  example,  when 
an  aneurism  or  solid  growth  destroys  any  part  of 
the  spinal  column,  this  is  attended  with  a con- 
tinuous aching  or  grinding  pain ; and  when  the 
canal  is  perforated,  symptoms  arise  indicating 
that  the  spinal  cord  is  involved. 

Diagnosis. — It  is  scarcely  practicable  to  offer 
any  useful  general  remarks  under  this  heading, 
and  it  must  suffice  to  notice  the  following  points. 
The  difficulty  of  diagnosis  varies  much  in  different 
cases,  being  sometimes  very  easy,  in  other  in- 
stances more  or  less  obscure  or  impossible.  The 
practitioner  should  always  be  prepared  for  the 
possibility  of  cases  of  sudden  perforation  or  rup- 
ture of  internal  structures  coming  under  his 
notice,  of  which  he  may  have  known  nothing  pre- 
viously. Under  such  circumstances  a careful 
inquiry  into  the  previous  history  may  reveal 
the  presence  of  symptoms  of  known  conditions, 
which  would  clear  up  any  obscurity;  but,  on 
the  other  hand,  there  may  be  no  such  histor}'. 
There  ought  to  be  no  difficulty,  as  a rule,  if  the 
lesion  occurs  from  some  recognised  cause,  such 
as  certain  kinds  of  injury;  or  if  it  supervene  in 
some  case  under  the  care  of  the  practitioner  for  a 
disease  liable  to  be  attended  with  perforation  or 
rupture  of  some  part,  such  as  typhoid  fever, 
gastric  ulcer,  an  internal  abscess,  or  an  aneurism. 
In  the  case  of  slow  perforation,  it  is  very  important 
to  be  able  to  recognise  the  meaning  of  symptoms 
which  may  arise  from  this  cause. 

Prognosis. — Any  rupture  or  perforation  taking 
place  internally  must  altvays  be  regarded  as  im- 
mediately more  or  less  dangerous  to  life,  and  not 
uncommonly  the  termination  is  necessarily  fatal. 
Much  will  depend  on  the  structure  involved,  the 
extent  of  the  lesion,  and  its  direct  and  remote  con- 
sequences. Caution  must  be  exercised  in  giving  a 
prognosis  in  all  cases,  for  some  patients  recover 
when  such  a result  might  not  bo  anticipated,  and 
especial  care  must  be  taken  in  offering  an  opinion 
if  the  diagnosis  should  not  be  quite  clear.  In 
the  case  of  ruptures  or  perforation  taking  place 


PERICARDIUM,  DISEASES  OF. 
externally,  or  affecting  structures  not  essentia! 
life,  such  as  the  muscles  of  a limb,  the  proemo 
of  each  case  must  be  determined  on  its 
merits. 

T reatment. — In  the  case  of  sudden  internal  pi 
foratioDS  or  ruptures,  the  first  principle  in  tre 
ment  should  be  to  counteract  the  immediate  eftb 
of  the  lesion,  alleviating  pain,  and  rousim;  a 
stimulating  the  patient  by  appropriate  remedi 
Opium  or  morphia  and  alcoholic  stimulants  a> 
of  great  service,  and  they  may  often  be  advyj 
tageously  introduced  into  the  system  by  mea 
of  enemata,  or,  in  the  case  of  morphia,” by  sn 
cutaneous  injection.  Heat  to  the  extremiti 
sinapisms,  and  similar  applications,  are  also  f: 
quently  of  much  value.  The  patient  should 
kept  at  rest,  and  it  may  be  of  essential  impc 
tance  to  endeavour  to  keep  an  organ  which  h 
been  [perforated  in  an  absolute  state  of  rest,  su 
as  the  stomach  or  intestines,  by  withdrawing: 
food,  and  cheeking  peristaltic  movements 
opium  or  other  agents.  The  same  applies 
some  parts  of  the  body,  such  as  a limb,  if 
muscle  or  a vessel  should  be  ruptured,  and  he 
often  the  position  of  the  limb  is  of  much  cons 
quence.  Other  appropriate  measures  will  sngge 
themselves  in  other  instances.  Some  special  inte 
ference  may  be  indicated.  For  instance,  itmigl 
be  clearly  allowable  to  open  the  abdomen 
certain  cases  ; to  strap  or  puncture  the  chest 
relieve  pneumothorax ; or  to  cut  down  and  tie 
ruptured  artery.  Haemorrhage  resulting  from 
lesion  of  this  kind  in  internal  parts,  may  som 
times  be  checked  by  the  constant  application 
ice  externally  over  the  corresponding  part  of  ti 
body.  The  subsequent  treatment  of  cases  ofrn 
ture  or  perforation  must  be  determined  by  t 
effects  which  they  produce,  which  must  be  dea 
with  according  to  their  nature,  each  case  bein 
considered  on  its  own  merits.  The  same  remai 
applies  to  cases  of  gradual  perforation  by  tumon 
and  other  morbid  conditions. 

Frederick  T.  Kobebts. 

PERICAEC  AT,  ABSCESS. — An  abscess 

the  cellular  tissue  around  the  caecum,  if 
Perittpheitis. 

PERICARDIUM,  Diseases  of.  — Stxos 

Fr.  Maladies  dw  Pericarde ; Ger.  Krankhdtm  i 
Herzbcutels. 

The  pericardium  proper  is  a membranous  ha; 
one  part  of  which — the  visceral  layer — close! 
envelopes  the  heart  and  the  roots  of  the  gre; 
vessels  connected  with  it ; while  the  other— tt 
parietal  layer— is  loosely  reflected  round  t!i; 
organ,  and  has  its  external  surface  intimate! 
united  with  a dense  fibrous  sheath  which  pas$< 
upwards,  and  is  gradually  lost  upon  the  extern: 
coats  of  the  vessels,  whilst  it  is  continuous  belol 
with  the  central  aponeurosis  of  the  diaphragu 
A serous  fluid  bedews  the  interior  of  this  sa 
and  facilitates  the  movements  of  the  heart.  : 
that  both  in  structure  and  function  the  pe: 
cardium  may  be  regarded  as  a joint— somewhs 
modified,  no  doubt,  to  suit  its  internal,  positio 
as  well  as  the  nature  of  the  parts  with  whic 
it  is  connected. 

The  morbid  conditions  of  the  pericardium  wi 
be  discussed  in  the  following  order : — 1.  Drop, 
2.  Inflammation  ; 3.  Gas  in  the  Pericardiuu 


PERICARDIUM, 
Malformations ; 5.  New  growths ; and  6.  Peri- 
jrdial  adhesions. 

•We  may  first,  however,  refer  to  a condition  cf 
e pericardium  which  can  hardly  be  described 
: pathological,  consisting  of  slight  opacities, 
lich  are  termed  mil/c-spots.  Tnese  are  fre- 
Jently  observed  upon  the  pericardium  after 
lath,  but  they  give  rise  to  no  clinical  symp- 
1ns,  and  are  merely  to  be  regarded  as  callosities 
ie  to  attrition.  The  most  common  situation 
at  the  base  of  the  right  ventricle  in  front,  but 
!sy  are  also  found  on  the  apex,  and  are  occasion- 
||y  seen  as  white  stripes  upon  the  auricles, 
jd  along  the  course  of  the  coronary  arteries. 
Jch  macule  albide  are  most  common  on  large, 
f-ong,  and  hypertrophied  hearts,  but  they  are 
t altogether  confined  to  these.  When  due  solely 
(attrition,  these  spots  are  formed  by  a mere 
tokening  or  condensation  of  the  normal  tissue  ; 
jt  now  and  then  they  are  fcund  to  consist  of  a 
inlayerof  fibrinous  matter  which  maybe  peeled 
; leaving  the  pericardium  beneath  opaque,  but 
■Serwise  natural.  In  the  latter  case,  of  course, 
»se  spots  cannot  be  regarded  as  simple  callo- 
Jies,  but  as  the  results  of  some  trifling  local 
ri carditis,  running  its  course  without  symptoms 
;d  of  no  clinical  importance,  except  as  afford- 
jr  a probable  explanation  of  those  temporary 
'sic  frictions  which  are  occasionally  to  be  heard 
i those  otherwise  in  apparently  good  health,  as 
l at  least  as  the  heart  is  concerned. 

1.  Pericardium.  Dropsy  of. — Synon.  : Hy- 
- mpericardium  ; IT.  Hydropericarde ; Ger.  Herz - 
'Uelmssersncht. 

During  life  and  in  health  the  serosity  bedew- 
5;  the  internal  surface  of  the  pericardial  sac 
•Ists  in  an  appreciable  quantity,  so  that  an 
dice  or  two  of  fluid  found  in  it  after  death  is 
i,  to  be  regarded  as  anything  abnormal.  When, 
llvever,  the  fluid  present  amounts  to  as  much 
: six  or  seven  ounces,  or  more,  the  condition 
i morbid,  and  is  termed  hydropcricardium,  or 
cpsy  of  the  pericardium.  The  contained  fluid 
ija  yellowish,  greenish,  reddish,  or  reddish- 
Iwn  serosity,  containing  from  one  to  three 
I'  cent,  of  albumen,  and  occasionally  a trifling 
liount  of  fibrinous  matter,  which  coagulates 
t'  simple  exposure  to  the  air — hydrops  lyra- 
mticum  (Virchow,  Gcsammclte  Abhandlungcn, 
1,108).  The  colour  of  the  fluid  is  of  course 
cl  to  the  amount  of  blood-colouring  matter 
ijised  through  it ; and  the  reddish,  or  reddish- 
Iwn  colouration  is  specially  present  when 
f n any  cause,  such  as  the  co-existence  of 
S'rvy,  the  colouring  matter  is  more  readily 
erased  than  usual,  or  in  those  exceptional  cases 
wire  the  walls  of  the  capillaries  are  so  altered 
l nutritive  changes  as  to  rupture, 
all  the  phenomena  present  in  dropsy  of  the 
picardium  are  precisely  similar  to  those  asso- 
ced  with  a similar  amount  of  inflammatory 
e sion,  and  will  be  referred  to  under  that  head, 
hlropericardium  is  a possible  occurrence  in  all 
•Bases,  whenever  there  is,  from  physical  causes, 
a mdency  to  transudation  of  serum  into  the 
c ties  of  the  body.  According  to  the  nature 
oihat  cause  it  may  be  either  an  early  or  a late 
p nomenon,  and  it  frequently  only  attains  any 
e iiderable  proportion  during  the  act  of  dying. 


DISEASES  OF.  1119 

When  dropsy  occurs  from  venous  congestion  due 
to  disease  of  the  heart,  or  to  disease  of  the  lungs, 
such  as  emphysema  or  cirrhosis,  some  degree  of 
hydropericardium  is  not  uncommon  as  an  early 
symptom  ; but  when  the  dropsy  results  from 
hydrsemia  produced  by  chronic  organic  diseases 
of  the  spleen,  liver,  or  kidneys,  or  by  the  ex- 
haustion due  to  cancerous  or  tubercular  diseases, 
the  pericardial  effusion  is  usually  a late  symp- 
tom. 

Treatment. — The  treatment  of  hydroperi- 
cardium resolves  itself  into  the  treatment  of  the 
diseases  upon  which  it  depends;  and  it  is  only 
when  the  fluid  becomes  suddenly  effused,  in  a 
quantity  so  large  as  to  threaten  death  by  sup- 
pression of  the  heart's  action,  that  an  indepen- 
dent treatment  by  paracentesis  may  be  found 
necessary.  Such  sudden  effusion  occasionally, 
but  only  very  rarely,  takes  place  in  the  course 
of  the  acute  albuminuria  following  scarlatina,  or 
even  in  the  more  chronic  albuminuria,  the  result 
of  intratubular  nephritis. 

2.  Pericardium,  Inflammation  of. — Sr- 
non.  : Pericarditis  ; Fr.  Pericardite  ; Ger.  Herz- 
beutelentziindung. 

Acute  inflammation  is  the  most  serious,  if  not 
the  most  frequent,  affection  of  the  pericardium. 

jEtiology. — This  disease,  though  occasionally 
idiopathic,  is  much  more  frequently  secondary 
in  its  character.  So-called  idiopathic  pericar- 
ditis is  usually  associated  with  pleurisy,  fre- 
quently with  bilateral  pleurisy,  and  is  not 
uncommonly  latent  so  far  as  any  direct  symp- 
toms of  pericardial  implication  are  concerned. 
Secondary  pericarditis  may  be.  the  result  of 
wounds  from  without  or  from  within — through 
the  ecsophagus ; of  blowrs  and  contusions  on  the 
praecordial  region  ; of  abscesses  perforating  from 
the  lung,  or  from  the  liver — through  the  dia- 
phragm; of  enteric  fever,  variola,  scarlatina,  and 
pyaemia  in  all  its  forms ; of  the  spreading  by  con- 
tiguity of  the  inflammatory  process  from  neigh- 
bouring organs,  such  as  the  lungs,  pleura,  or 
costal  periosteum.  It  may  accompany  the  local 
development  of  cancer  or  tubercle  ; or  may  be 
due  to  rheumatism,  or  to  one  or  other  of  the 
chronic  forms  of  Bright’s  disease.  By  far  the 
larger  proportion  of  cases  of  pericarditis  occur 
in  connection  with  the  two  last-named  diseases, 
in  about  the  ratio  of  two  of  rheumatic  pericar- 
ditis to  one  of  renal  pericarditis  ; all  other  forms 
lumped  together  forming  an  infinitesimal  and 
incalculable  fraction.  In  rheumatism,  pericar- 
ditis occurs  early ; occasionally  precedes  the 
joint-affection ; and  though  no  period  of  the 
disease  can  be  regarded  as  free  from  the  ten- 
dency to  this  so-called  complication,  just  as  any 
joint  may  be  implicated  at  any  period,  yet  ex- 
perience teaches  us  that  the  heart-joint  is  most 
usually  affected  within  the  first  week  of  the 
rheumatic  onset.  In  renal  disease,  on  the  other 
hand,  it  is  most  usually  a late  phenomenon,  being 
only  too  frequently  the  immediate  precursor  of 
that  fatal  uraemia  which  its  occurrence  serves  to 
precipitate. 

The  pathology,  symptoms,  signs,  and  treat- 
ment of  pericarditis,  however  it  may  arise,  are 
all  very  much  alike,  and  may  be  conveniently 
treated  of  together. 


1120  PERICARDIUM,  DISEASES  OF. 


Anatomical  Characters. — The  morbid  ana- 
tomy of  pericarditis  is  simple  enough.  Very 
early  pericarditis  is  rarely  seen  except  as  asso- 
ciated with  Bright's  disease,  and  then  at  first 
we  have  merely  vascular  injection  with  a few 
shreds  of  lymph  visible  about  the  roots  of  the 
great  vessels.  In  a few  days,  in  those  dry  forms 
of  the  disease  where  but  little  fluid  is  effused, 
the  whole  surface  of  the  heart  may  be  covered 
with  a thin  fibrinous  layer,  which  may,  even  at 
this  early  stage,  have  connected  together  the 
visceral  and  parietal  layers  of  the  pericardium 
somewhat  firmly  (Wilks).  More  usually  there 
is  some  serous  exudation  mingled  with  the 
fibrinous  matter,  which  then  is  found  covering 
the  pericardium  in  a reticular  or  honeycomb 
pattern,  which  Laennec  has  likened  to  the  appear- 
ance presented  on  suddenly  separating  two 
smooth  pieces  of  wood  between  which  a small 
pat  of  butter  has  been  forcibly  compressed. 
The  serous  effusion  not  infrequently  amounts  to 
several  pints ; it  is  always  turbid  from  the  mole- 
cular fibrin  suspended  in  it;  and  is  of  a yellow- 
ish, greenish,  brownish,  or  reddish  colour.  When 
along  with  any  considerable  layer  of  lymph 
upon  the  pericardiac  surfaces,  there  is  much 
fluid  effused,  the  surface  of  the  lymph  is  covered 
with  shaggy  processes  floating  in  the  fluid,  those 
processes  sometimes  presenting  a mammillated 
appearance.  In  a very  short  time  a fine  net- 
work of  capillaries  is  developed  in  the  fibrinous 
exudation;  and  the  rupture  of  these  newly  deve- 
loped capillaries  now  and  then  gives  rise  to  what 
is  termed  ‘ haemorrhagic  pericarditis,’  in  which 
the  fluid,  and  even  the  solid  lymph,  is  deeply 
stained  with  the  blood-colouring  matter.  This 
also  happens  when  pericarditis  is  associated  with 
purpura  or  scurvy;  and  nowand  then, from  simi- 
lar causes,  layers  of  coagulated  blood  are  found 
alternating  with  layers  of  unstained  lymph. 

When  the  disease  does  not  prove  fatal,  the 
exudation  may  be  entirely  re-absorbed,  or  it  may 
become  organised,  or  other  changes  may  occur. 
First  of  all,  the  excess  of  fluid  and  the  molecular 
fibrin  become  absorbed ; then  the  coagulated  fibrin 
may  become  worn  away  by  the  continual  play  of 
the  heart,  and  gradually  entirely  absorbed  : and 
a complete  cure  may  be  thus  effected,  leaving  at 
the  most  only  a slight  thickening  or  opacity  of 
the  pericardium.  But  such  a cure  is  only  possible 
when  the  amount  of  exudation  has  been  incon- 
siderable. More  usually,  connective  tissue  is 
gradually  developed  in  the  fibrinous  layers; 
either  locally,  giving  rise  to  partial  adhesions, 
which  about  the  base  of  the  heart  are  more 
dense,  but  at  the  apex  are  often  drawn  out  to 
fibrous  strings ; or  the  two  layers  of  the  peri- 
cardium may  be  so  closely  united  that  they  can 
only  be  separated  with  considerable  force,  and 
now  and  then,  after  the  lapse  of  some  time,  they 
cannot  be  separated  at  all,  the  cardiac  muscle 
being  torn  in  the  endeavour.  Occasionally  pus, 
or  the  cheesy  or  calcareous  remains  of  such  a 
deposit  is  found,  encysted,  as  it  were,  between 
the  adhering  layers  of  the  pericardium ; and  it 
sometimes  happens  that  this  calcareous  layer 
envelops  the  whole  heart,  which  then  seems  to 
be  converted  into  bone.  Laennec,  Louis,  Allan 
Burns,  and  others  relate  cases  of  this  kind,  and 
the  heart  described  by  Burns  is  still  preserved 


in  the  anatomical  museum  of  the  Eiinbnroi 
University.  In  every  fibrinous  exudation  witliii 
the  pericardium  there  is  at  a particular  stag 
a certain  amount  of  all  those  elements  presea 
which  may  become  pus,  and  these  give  rise  t< 
a milky  opacity  of  the  fluid,  or  if  present  ii 
sufficient  number,  may  metamorphose  the  who! 
exudation  into  pure  pus.  This  may  be  oalj  ; 
transition  stage  ; the  pus-cells  may  break  (Iowa 
a pathological  cream  may  be  formed,  and  thi 
whole  may  be  ultimately  entirely  absorbed 
But  true  purulent  pericarditis,  though  a ran 
occurrence  under  any  circumstances,  is  mos 
frequently  fatal,  and  seems  to  occur  chiefly  iri 
connection  with  serious  general  disease,  or 
accompany  the  rupture  of  local  abscesses' 
pulmonary  or  hepatic,  into  the  pericardium 
What  has  been  termed  an  ‘ ichorous  exudation 
in  the  pericardium,  is  simply  a putrefaction  o, 
that  already  existing,  which  becomes  brownis! 
in  colour  and  stinking.  It  may  arise  iron 
entrance  of  the  air  into  the  pericardium  afte 
paracentesis  conducted  without  antiseptic  pre 
cautions  ; but  it  is  also  believed  that  such  putre- 
faction may  arise  in  patients  greatly  enfeebia 
by  exhausting  diseases,  such  as  cancer,  withoir 
any  entrance  of  air  into  the  pericardium.  An 
exudation  that  has  become  ichorous  may  cor' 
rode  the  pericardium ; is  incapable  of  furthe 
metamorphosis ; and  is  usually  speedily  fatal  by 
the  development  of  pneumo-pericardium.  Se 
Pericardium,  Gas  in. 

Symptoms. — The  symptoms  of  pericarditis  an 
of  comparatively  little  .mportance,  because  the; 
are  frequently  entirely  absent  in  those  so-calle; 
idiopathic  forms  of  the  disease  which  are  pro 
bably  always  fatal,  as  well  as  in  renal  periear 
ditis,  which  is  fatal  in  the  majority  of  cases 
whilst  even  in  rheumatic  pericarditis,  in  which 
the  mortality  is  at  the  most  only  about  16  pe 
cent.,  and  is  nil  according  to  other  author 
(Bamberger,  &c.),  the  symptoms,  though  rarel. 
absent,  are  generally  not  very  well  marked  ol 
distinctive.  As  a rule,  if  pericarditis  be  assoj 
ciated  with  any  other  serious  disease,  such  a| 
pneumonia,  pleurisy,  or  rheumatism,  the  svrop 
toms  are  apt  to  be  swamped  by  those  of  th 
primary  disease.  In  other  instances  the  ad 
vent  of  the  pericarditis  is  indicated  by  a rigor 
a rise  of  temperature,  a feeling  of  anxiety  an; 
oppression  at  the  chest,  and  the  occurrence  o 
increase  of  dyspnoea.  The  decubitus  is  usual!; 
dorsal,  and  syncope  is  liable  to  be  induced  01 
raising  the  patient.  There  is  pain  in  the  car 
diac  region,  with  palpitation  of  the  heart 
The  pulse  is  at  first  full  and  frequent,  alway 
compressible,  frequently  irregular,  usually  <li 
erotic,  and  rapidly  becomes  feeble ; and  ther 
is  a general  exacerbation  of  all  the  symptom 
of  the  already  existing  disease.  Occasional!; 
the  restlessness  and  anxiety  indicative  of  car 
diac  implication  pass  into  delirium,  which  ma 
be  low  and  muttering,  wild  and  maniacal,  oeca 
sionally  accompanied  by  delusions,  and  whic 
may  be  associated  with  tetanic  or  clonic  spasm: 
or  with  convulsions  ending  in  extreme  exhaustior 
or  in  death  by  coma.  The  occurrence  of  deliriur 
in  the  course  of  rheumatic  fever  ought  at  one 
to  direct  attention  to  the  heart;  and  the  sudde 
occurrence  of  spasms  or  coma  in  chronic  rem 


PERICARDIUM, 

[isease,  is  only  too  frequently  found  to  be  asso- 
ciated with  pericarditis  ; both  of  these  pheno- 
aena  being  probably  caused  by  the  saturation 
,f  the  blood  with  the  products  of  retrograde 
letamorphosis,  due  to  the  sudden  development 
f this  inflammation.  It  is  only  in  the  very 
arest  instances  that  we  have  that  extreme 
ppression  of  the  chest,  violent  pain  in  the 
irdiae  region,  hiccough,  fainting,  and  livid 
onntenance,  coupled  with  delirium,  and  ex- 
iremely  rapid  dicrotic  pulse,  which  constitute 
le  classical  portrait  of  pericarditis  ; and  even 
i those  rare  cases  in  which  these  symptoms 
re  observed,  they  are  rather  due  to  the  asso- 
,ation  of  pericarditis  with  an  already  existing 
irious  disease,  than  to  the  pericarditis  itself. 

1 most  cases  physical  examination  gives  us  the 
rst  intimation,  and  in  all  cases  the  only  reli- 
ble  information,  as  to  the  existence  of  pericar- 
tis.  In  all  diseases,  therefore,  in  which  peri- 
rditis  is  a possible  occurrence,  we  must  care- 
lly  examine  the  cardiac  region  from  day  to  day, 
that  we  may  at  once  ascertain  its  occurrence ; 
bile  at  all  times,  the  slightest  pain  in  the  chest, 

■ most  trifling  oppression  of  breathing,  ought  to 
i a sufficient  warrant  for  a most  careful  physical 
lamination  of  the  chest,  because  men  have  been 
lown  to  go  about  their  ordinary  duties — with 
fficulty,  no  doubt — even  while  pericarditis  ex- 
ed. 

Physical  signs. — "Whenever  on  auscultating 
er  the  cardiac  area  we  hear  a friction-sound, 
are  justified  in  assuming  the  probable  exist- 
■pe  of  pericarditis.  And  the  probability  of  this 
cmise  is  increased  just  in  proportion  as  we  can 
ruinate  all  sources  of  fallacy,  and  associate 
iwith  those  symptoms  already  described  as  in- 
oative  of  pericarditis,  and  with  the  other  signs 
psently  to  be  described  as  having  the  same 
.‘nificance.  A friction-sound  due  to  pericar- 
c l roughness  may  be  heard  over  any  or  every 
ft  of  the  cardiac  area,  in  front  or  behind.  Its 
1st  usual  position  is  over  the  base  of  the 
1 rt  in  front,  and  once  heard  in  that  position  no 
shunt  of  subsequent  effusion  suffices  to  efface 
i The  sound  of  such  a friction  appears  super- 
fill,  close  to  the  ear ; it  may  resemble  only  a 
s ht  sound  of  rubbing,  the  crackling  of  paper 
oparchmeut,  or  the  creaking  of  new  leather  ; 
o'jit  times  it  may  simulate  so  closely  the 
b ving  sound  of  a valvular  murmur  as  to  be 
distinguishable  from  such  a murmur  by  tho 
8(,id  alone.  Occasionally  a friction-sound  is 
P'  istently  absent  throughout  the  whole  course 
oi  he  disease,  and  that  even  where  there  is 
abidance"  of  fibrin  effused.  It  is  difficult  to 
ac.unt  for  this.  Some  suppose  it  to  be  due 
toiere  softness  of  the  fibrin ; more  probably 
fsi'.eness  of  the  heart’s  action  has  a good  deal 
toll  with  it,  as  well  as  some  alteration  of  the 
pa: — especially  the  lungs  — overlying  the 
he";,  which  may  render  them  bad  conductors  of 
so:  1. 

iction-fremitus  may  occasionally  be  detected 
by.'ie  hand  placed  over  the  praecordia,  but  this 
is  : always  to  be  felt.  Apart  from  fremitus, 
w>  n the  first  few  days  of  the  onset  of  the 
disve,  we  perceive  by  palpation  an  unusually 
for  ile  and  turbulent  action  of  the  heart,  which 
'»  1 1 occasionally  irregular,  and  is  due  to  in- 

71 


DISEASES  OF.  1121 

flammatory  irritation  of  the  cardiac  muscle.  By- 
and-by,  as  the  inflammation  progresses,  cardiac 
debility  sets  in,  and  the  pulsation  becomes  less 
forcible,  while  in  most  cases  it  is  still  further 
obscured  by  the  occurrence  of  fluid  effusion, 
which  separates  the  apex  from  the  anterior  wall, 
with  which  the  baso  of  the  heart  always  remains 
in  contact.  In  this  way  we  have  produced  that 
phenomenon  which  is  termed  ‘displacement  up- 
wards of  the  apex-beat,’  because  the  more  the 
true  apex  is  pushed  inwards  by  the  effusion, 
the  part  of  the  heart  actually  in  contact  with 
the  chest- wall  approaches  more  closely  the  base 
of  the  ventricles.  Should  the  heart  be  greatly 
hypertrophied,  its  impulse  may  remain  distinct 
throughout  the  whole  course  of  the  disease,  the 
fluid  accumulating  behind  it  and  not  in  front. 

So  long  as  the  serous  accumulation  is  incon- 
siderable, there  is  no  alteration  of  the  percussion- 
sound  ; but  whenever  this  attains  an  abnormal 
amount,  it  is  revealed  by  an  increase  of  the 
cardiac  dulness ; and  in  the  ordinary  dorsal 
decubitus  of  the  patient  this  is  first  observed 
at  the  base,  in  the  line  of  transverse  dulness 
along  the  level  of  the  fourth  rib.  By-and-by, 
however,  the  ordinary  pyramidal  dulness  of  the 
heart,  base  upwards,  becomes  reversed,  and  we 
have  a pyramidal  dulness  with  the  base  below- 
and  the  apex  upwards  ; and  this  apex  may  rise 
as  high  as  the  clavicle,  or  even  above  it.  The 
base,  on  the  other  hand,  may  in  these  cases 
extend  beyond  the  ordinary  position  of  the  apex- 
beat  to  the  left,  especially  if  the  patient  be  made 
to  lie  upon  his  left  side;  but  it  is  mobile, and  on 
turning  the  patient  on  his  right  side  the  dulness 
leaves  the  left  and  passes  towards  the  right. 
Very  groat  emphysema  of  the  lungs  may  obscure 
this  dulness,  but  cannot  altogether  annihilate 
it;  but  of  course  this  method  of  diagnosing  peri- 
cardiac effusion  can  only  be  put  in  force  when 
both  pleurae  are  free  from  fluid.  The  fluid  effu- 
sion, even  when  confined  to  the  pericardium, 
may  amount  to  several  pints,  and  its  pressure 
may  not  only  embarrass  the  heart’s  action,  but 
may  also  so  compress  the  lungs,  particularly  the 
left  one,  as  to  give  rise  to  considerable  dyspnoea; 
and  the  hindrance  thus  presented  to  the  free 
passage  of  the  blood  through  the  lungs  may  give 
rise  to  considerable  systemic  venous  congestion, 
which  is  readily  observed  in  the  turgid  condi- 
tion of  the  jugular  veins. 

As  a rule  inspection  gives  us  little,  if  any, 
information  in  regard  to  the  existence  of  peri- 
carditis. Should  the  quantity  of  fluid  effused  be 
very  considerable,  and  the  chest-walls  flexible, 
some  vaulting  of  the  pericardial  region  may  be 
observed,  due  to  the  effacement  of  the  inter- 
costal spaces,  the  ribs  beiDg  occasionally  also 
more  widely  separated  than  usual,  at  least 
apparently  so  ; and  the  whole  prsecordial  space 
under  these  circumstances  takes  a less  share  than 
ordinary  in  the  respiratory  motions.  Undula- 
tory  movements  due  to  waves  of  fluid,  as  de- 
scribed by  some,  are  never  seen ; such  move- 
ments, if  visible,  depend  upon  the  wobbling  of 
an  enlarged  and  feeble  heart,  and  not  on  any 
fluid  waves. 

Diagnosis. — A friction-sound  has  been  hypo- 
thetically supposed  to  be  occasionally  due  to  mere 
dryness  of  the  pericardiac  membrane.  Possibly 


1122  PERICARDIUM,  DISEASES  OF. 


this  may  be  the  case,  but  it  has  never  been  proved. 
Even  if  it  be  the  case,  then  such  dryness,  asso- 
ciated with  the  symptoms  described,  can  only 
be  an  early  stage  of  inflammation.  Apart  from 
these  it  mayor  may  not  be  an  indication  of  com- 
mencing inflammation,  and  must  be  watched  and 
treated  accordingly.  It  has  also  been  alleged 
that  calcareous  concretions,  and  tubercular  and 
carcinomatous  roughnesses  may  give  rise  to  a 
friction-sound.  Associated  with  the  symptoms 
described,  any  friction-sound,  even  presuming 
such  a possible  origin,  must  be  regarded  as  a 
form  of  pericarditis,  whilst  apart  from  these 
symptoms  it  must  still  be  watched  with  sus- 
picion. The  most  difficult  cases  to  diagnosticate 
are  those  in  which  the  friction-sound  is  due  to 
pleurisy  alone,  and  is  yet  audible  during  cardiac 
action,  when  the  respiration  is  temporarily  sus- 
pended. This  is  a rare  occurrence,  but  it  does 
happen,  and  the  diagnosis  is  almost  impossible. 
The  subsequent  progress  of  the  case  may  show 
that  the  pleura  is  certainly  affected,  but  that  is 
no  proof  that  the  pericardium  is  not  also  impli- 
cated; or  the  pericardium  may  be  assuredly 
diseased,  and  yet  the  friction-sound  may  be 
solely  due  to  pleurisy.  The  general  symptoms 
and  the  condition  of  the  pulse  count  for  some- 
thing, but  the  diagnosis  between  pleurisy  and 
pericarditis  is,  in  such  cases,  manifestly  a difficult 
one,  only  to  be  solved  by  the  further  progress 
of  the  case.  Now  and  then  we  have  a friction 
sound  audible  towards  one  or  other  side — usu- 
ally the  left — of  the  pericardium,  during  suspen- 
sion of  the  respiratory  movements ; the  base  of 
the  heart  being  entirely  free  from  friction,  and 
in  these  circumstances  the  probability  seems 
greatly  in  favour  of  the  strictly  pleural  nature  of 
the  disease.  But  even  in  such  cases  a perfectly 
accurate  diagnosis  is  impossible.  There  is  never 
any  real  difficulty  in  determining  between  a val- 
vular murmur  and  a frictional  pseudo-murmur, 
because  in  the  -case  of  the  latter  the  sound  is 
restricted  to  the  cardiac  area,  and  usually  only 
to  a small  portion  of  that,  and  not  being  propa- 
gated to  any  extent  out  of  its  position  of  maxi- 
mum intensity,  and  then  only  equally  all  round, 
and  not  in  any  of  the  definite  lines  in  which 
valvular  murmurs  are  propagated.  Moreover, 
the  position  of  maximum  intensity  of  a frictional 
pseudo-murmur  never  coincides  with  that  of 
any  valvular  murmur,  except  occasionally  with 
a diastolic  aortic  one ; while,  of  course,  the 
natural  sounds  of  the  heart  are  never  replaced 
by  the  pseudo-murmur,  though  they  may  be 
partially  obscured  by  it,  and  all  the  secondary 
results  of  the  valvular  lesion  simulated  are  en- 
tirely wanting. 

Prognosis. — The  prognosis  in  pericarditis  is 
not  unfavourable ; one  in  six,  or  about  16  per 
eent.,  is  mentioned  by  some  as  the  ordinary 
mortality ; but  according  to  Bamberger,  peri- 
carditis associated  with  rheumatism  or  any  other 
curable  disease  invariably  terminates  favourably, 
though  the  mortality  is  always  large  when  it  is 
associated  with  Bright’s  disease  and  other 
incurablo  affections,  the  fatal  termination  of 
which  is  hastened  by  the  pericardiac  affection. 
Pericarditis,  like  any  other  acute  inflammation 
occurring  in  an  otherwise  healthy  iudividual, 
may  be  expected  to  run  a favourable  course  if 


not  unduly  treated ; and  the  danger  to  life  h 
to  be  calculated  by  the  seriousness  of  the  so 
existing  complications,  and  the  age  and  state  a 
the  vital  powers  of  the  patient.  The  unfavour 
able  phenomena  are,  a large  quantity  of  effusion 
great  dyspnoea,  feeble  heart’s  action,  small  anc 
irregular  pulse,  lividity,  delirium  and  other  ner 
vous  symptoms. 

Tbeatmext. — The  treatment  of  pericarditi' 
must  be  regulated  to  some  extent  by  the  natur 
of  the  disease  with  whieh  it  is  concomitant  I 
it  concur  with  pneumonia  or  pleurisy,  it  un- 
safely enough  he  entrusted  to  the  remedies  eui 
ployed  for  these  diseases ; or  should  it  accom 
pany  rheumatism,  then  we  must  treat  it  as  par 
of  the  rheumatic  affection.  If  we  can  hopefull 
employ  blood-letting  or  mercury  in  the  case  c 
rheumatism,  then  we  may  employ  the  same  rente 
dies  in  pericarditis;  otherwise  there  is  no  reaso 
why  we  should  make  use  of  doubtful  and  dan 
gerous  remedies,  simply  because  the  disease  ha 
attacked  a more  dangerous  part,  hut  rather  th 
reverse.  Those  who  have  shown  the  smalles 
percentages  of  deaths  have  been  the  least  per 
turbative  in  their  treatment,  as  we  might  reason 
ably  expect.  A rheumatic  pericarditis  ought 
therefore,  to  be  treated  simply  as  a rheumati 
affection  ; but  inasmuch  as  pain  implicating  th 
heart  has  a decided  tendency  to  depress  its  ac 
tion,  it  is  of  the  utmost  importance  to  relieve  1 
at  once.  With  this  view  a large,  warm  poultic 
should  be  applied  over  the  heart ; and  morphi 
injected  subcutaneously  at  once,  and  repeate! 
by  the  mouth,  or  subcutaneously,  at  reguh 
intervals,  so  as  to  keep  the  patient  free  fro: 
pain.  Perfect  rest  must  be  enjoined.  Shonl 
there  be  much  dicrotism  of  the  pulse,  or  an 
tendency  of  the  heart  to  fail,  then  digital! 
should  be  administered  at  regular  intervals,  i 
doses  sufficient  to  keep  up  the  cardiac  actioi 
such  as  ten  minims  of  the  tincture  every  for 
hours:  and  with  this  may  be  conjoined  the  u: 
of  chloral  in  five  or  ten-grain  doses,  which  is  n- 
more  useful  as  a sedative  than  as  an  antiphl 
gistic,  and  which  may  very  well  replace  tl 
morphia,  having  the  additional  recommendatiq 
that  it  does  not  interfere  with  the  secretion 
which  demand  attention,  nor  promote  the  swea, 
ing,  so  troublesome  in  rheumatism.  Where 
may  be  considered  advisable  to  give  an  alkal 
such  as  potash  or  ammonia,  with  the  digital: 
it  cannot  be  combined  with  the  chloral,  but  mn 
be  given  separately.  In  recent  times,  saliein  ai 
the  salicylates  have  been  employed  with  succe 
in  the  treatment  of  rheumatism.  They  are  n 
true  specifics  for  this  disease,  but  they  tend 
keep  down  the  fever,  and  apparently  shorten  l 
course.  They  do  not  prevent  the  occurrence 
pericarditis,  but  their  use  is  not  contra-indicat. 
by  its  presence.  Blisters  are  frequentlyrecor 
mended  in  pericarditis,  but  they  may  tend  to  in 
tate  the  patient  and  to  excite  his  heart's  actio 
A few  leeches  often  give  relief  in  suitable  cast 
We  must,  in  fact,  treat  the  pericarditis  as  pa 
of  the  general  rheumatic  attack,  only  requiri 
a little  more  attention  than  usual  in  the  war 
warmth,  and  relieving  pain ; and  all  the  pa 
history  of  this  disease  proves  that  we  shail 
this  way  be  more  likely  to  promote  afavounl 
termination  of  the  disease,  than  by  jeopardisi 


PERICARDIUM,  DISEASES  OF. 
nr  patient  by  dangerous  and  uncertain  medi- 
ations. 

Where  the  amount  of  fluid  effused  is  very 
.reat,  or  -when  the  symptoms  seem  to  point  to 
he  presence  of  pus,  it  may  become  a question 
'hether  paracentesis  should  be  performed  or  not. 
'ho  results  of  this  operation  hitherto  have  not 
een  very  satisfactory,  but  that  is  no  reason 
thy  it  should  not  be  resorted  to  if  it  seem  ne- 
.issary,  especially  as  it  can  now-a-days  be  so 
ksily  done  by  means  of  one  or  other  of  the 
ispirateurs.  The  patient  should  be  placed  in 
ie  recumbent  position,  and  the  needle  entered 
fetween  the  fourth  and  fifth  ribs,  about  half  an 
ch  to  the  left  of  the  sternum,  the  operation 
ing,  of  course,  performed  antiseptically,  and 
e fluid  drawn  off  somewhat  slowly.  For  this 
;ason,  therefore,  we  should  be  careful  in  our 
oice  of  an  aspirateur,  as  one  acting  by  a 
iwerful  vacuum  might  induce  syncope,  by 
ithdrawing  too  rapidly  from  the  heart  a pres- 
re  to  which  it  has  become  accustomed.  A 
iated  heart  has  been  said  to  have  been  punc- 
red,  instead  of  a distended  pericardium,  but  in 
,e  present  day  such  a mistake  is  scarcely  pos- 
jdo,  though,  of  course,  it  must  be  carefully 
arded  against.  It  now  and  then  happens  that 
er  the  acute  symptoms  pass  away,  the  peri- 
■dium  remains  obstinately  distended  with 
id,  and  it  is,  perhaps,  chiefly  in  these  cases  that 
l;racentesis  pericardii  presents  the  most  hope- 
ii  prospects.  See  Paracentesis. 

3.  Pericardium,  Gas  in. — The  putrefaction 
0 an  exudation  causes  the  development  of 
vious  gases  within  the  pericardium,  and  the 
jjduction  of  so-called  pneuino-hydro-pericar- 
I'  m.  This  condition  is  readily  recognised  by 
ti  clear  tympanitic  percussion-note  over  the 
ijally  dull  cardiac  area,  with  a metallic  gurg- 
1 ; accompanying  the  cardiac  movement.  Be- 
tas the  circumstance  already^  mentioned,  pneu- 
r,  hydro-pericardium  may  also  be  caused  by  the 
t rance  into  the  pericardium  of  gases  from  the 
s nach  and  intestines,  or  of  air  from  the  ceso- 
Pjgus  or  lung,  or  ab  extcrno. 

. Pericardium,  Malformations  of. — The 
informations  which  may  be  found  in  connection 
Wi  the  pericardium  are  described  in  the  article 
h rt,  Congenital  Misplacements  of. 

Pericardium,  New  Growths  in.— Both 
ttyrcle  and  cancer  may  become  developed 
irshe  fibrinous  layers  of  a pericarditic  exu- 
d<pn,  usually  secondarily  to  the  occurrence 
ofhese  processes  in  other  organs.  This  is  a 
va  rare  circumstance,  however,  as  is  also  the 
odrrenee  of  tubercular  or  cancerous  nodules  of 
aicondary  character  in  the  substance  or  on 
thlsurfaee  of  the  pericardium  itself,  with  which 
a londary  pericarditis  speedily  becomes  asso- 
A d.  In  either  case,  but  particularly  in  the 
fo|  er,  the  fluid  in  the  pericardium  is  usually 
ot‘  haunorrhagie  character  when  associated 
wi  the  development  of  cancer.  Now  and  then 
tu.  :cular,  and  still  more  frequently  cancerous, 
nt;es  are  formed  in  the  lungs  or  mediastinum, 
an1  pressing  upon  the  pericardium  give  rise  to 
pe  arditis,  which  reveals  itself  mainly  by  the 
*■1  of  efiusion,  and  without  any  direct  symp- 


PERINEPHRITIS.  1123 

toms  of  cardiac  implication.  Such  eases  are  not 
often  recognised  during  life.  The  prognosis  is 
always  fatal;  and  the  treatment  palliative  only. 

6.  Pericardial  Adhesions. — Pathologically 
speaking,  the  most  important  of  all  the  termi- 
nations of  pericarditis  is  adhesion  of  the  two 
layers,  which  in  its  most  exquisite  form  was 
described  by  the  ancients  as  congenital  absence 
of  the  pericardium.  This  is  a state  of  matters 
impossible  to  diagnose,  though  it  may  he  sur- 
mised; and  too  often  it  escapes  even  a sur- 
mise, unless  the  previous  history  of  the  case  be 
well  known.  Very  rarely  there  remains  a per- 
manent depression  over  the  cardiac  area,  the 
result  of  pre-existing  pericarditis  and  subse- 
quent adhesion  of  the  visceral  and  parietal  layers, 
and  also  of  the  superjacent  pleura.  More 
frequently,  but  still  rarely,  this  state  of  matters 
is  revealed  by  a systolic  depression  of  the  parts 
over  the  cardiac  apex.  Even  more  rarely — be- 
cause the  result  of  a more  extensive  inflam- 
mation— we  have  a systolic  depression  over  the 
scrobieulus  cordis,  caused  by  adhesion  of  the 
two  layers  of  the  pericardium  to  each  other, 
and  to  the  pleura  covering  the  diaphragm,  and 
concomitant  adhesion  of  the  diaphragm  to  the 
liver. 

It  can  he  only  rarely  that  extensive  pericar- 
ditis exists  without  a simultaneous  myocarditis, 
and  the  results  of  the  latter  affection  were 
formerly  too  frequently  referred  to  the  peri- 
carditis itself.  An  adherent  pericardium  occur- 
ring iu  early  life  may  hamper  the  future  growth 
of  the  heart,  and  may  thus  produce  one  form  of 
so-called  atrophy  of  the  heart,  with  all  the  con- 
sequent results  of  impaired  nutrition.  But  it  is 
only  when  the  subperieardiac  layer  of  muscular 
fibres  has  been  involved  in  the  inflammation, 
that  we  may  have  atheromatous  or  fibrous 
changes  taking  place ; and,  as  the  result  of 
these,  encasement  of  the  heart  in  a calcareous 
wall ; a local  or,  more  rarely,  a general  thin 
and  fibrous  condition  of  the  cardiac  muscles ; 
and  either  local  or  general  aneurismal  dilatation. 
These  results  are,  however,  rare.  Hypertrophy 
is  not  to  be  regarded  as  the  result  of  pericardial 
adhesion,  hut  of  any  concomitant  lesion  which 
may  be  present,  or  of  some  other  cause : for 
though  pericardial  adhesion  may  co-exist  with 
cardiac  hypertrophy,  it  does  not  give  rise  to  it. 
In  the  larger  proportion  of  cases  simple  pericar- 
dial adhesion  is  to  be  regarded  as  not  produc- 
tive of  any  appreciable  untoward  results. 

G.  W.  Balfour. 

PERIHEPATITIS  (irepl,  around,  and 
riirap,  the  liver)  — Inflammation  of  the  capsule  of 
the  liver.  See  Liver,  Inflammation  of. 

PERINEPHRITIS  (n  ep'i,  around,  and 
yetppbs,  the  kidney). — Stnon.  : Fr.  Perinephritc ; 
Ger.  Perinephritis. 

Definition. — An  acute  or  chronic  disease  of 
the  cellular  tissue  around  the  kidney,  consisting 
of  inflammatory  thickening  of,  and  exudation 
into,  the  tissue,  frequently  followed  by  suppura- 
tion ; characterised  by  fever,  local  pain,  fulness, 
tenderness  on  pressure,  and  in  many  cases  ulti- 
mately by  fluctuation  ; and  resulting  frequently 
in  death,  sometimes  in  spontaneous  recovery. 


1124  PERINEPHRITIS, 


IEtiologY. — Perinephritis  in  most  cases  origi- 
nates from  pyelitis  or  suppurative  nephritis,  by 
perforation  or  by  extension  of  the  inflammatory 
process.  It  is  especially  related  to  pyelitis  from 
urinary  calculus.  It  may  result  from  injuries, 
such  as  blows,  wounds,  or  severe  strains  ; or  from 
extension  of  inflammation  from  neighbouring 
parts,  as  from  the  pelvis,  the  gall-bladder,  or  the 
testicle  and  spermatic  cord.  The  disease  appears 
in  some  cases  to  result  from  exposure  to  cold,  es- 
pecially after  previous  exposure  to  excessive  heat. 
It  arises  also  in  the  course  of,  or  as  a sequel  to 
fevers,  particularly  the  exanthemata.  It  is  most 
common  in  adults,  and  appears  to  affect  equally 
the  two  sexes. 

Anatomical  Characters.— In  the  earlier 
stages  the  cellular  tissue  around  the  kidney  is 
congested ; and  when  exudation  has  supervened 
the  affected  tissue  becomes  solid  and  firm.  Usu- 
ally suppuration  speedily  takes  place  in  the  centre 
of  the  mass,  commencing  either  at  one  or  at 
numerous  points,  and  gradually  extending.  The 
pus  is  sometimes  odourless,  sometimes  fcetid. 
It  is  important  to  remember  that  a faecal  odour 
may  be  present  without  perforation,  from  the 
bowel.  The  perinephritic  abscess  may  become 
so  large  as  to  extend  from  the  level  of  the  liver 
and  spleen  to  the  iliac  fossa,  and  may  project  so 
far  forward  as  to  protrude  the  abdominal  wall. 
The  pus  may  burrow  and  make  its  way  to  the 
surface  at  the  lumbar  region,  in  the  lower  part 
of  the  abdomen,  or  even  in  the  thigh.  More  com- 
monly it  makes  its  wray  into  the  ureter,  or  the 
colon  ; sometimes  into  the  peritoneum.  Occa- 
sionally the  diaphragm  is  perforated,  and  the  pus 
is  discharged  through  the  lung.  Sometimes  rapid 
gangrene  is  induced,  and  sloughy  masses  are 
found,  mingled  with  the  purulent  debris.  Either 
without  going  on  to  suppuration,  or  after  dis- 
charge of  the  pus,  cicatrisation  may  take  place, 
dense  fibrous  tissue  permanently  occupying  the 
place  of  the  structures  which  had  been  involved. 

Symptoms. — The  constitutional  symptoms  in 
perinephritis  are  generally  well-marked.  The 
attack  may  be  ushered  in  by  rigors  recurring  fre- 
quently, sometimes  periodically.  The  temperature 
rises  to  100°  or  even  to  1 05°.  The  pulse  becomes 
rapid,  and  either  bounding  or  feeble.  The  tongue 
is  furred,  there  is  great  thirst,  the  appetite  is  lost, 
and  there  is  a tendency  to  constipation,  due  in 
part  to  the  fever,  in  part  to  the  mechanical  pres- 
sure upon  the  bowel.  The  skin  is  hot  and  dry; 
sometimes  there  are  profuse  sweatings,  particu- 
larly during  the  later  stages  of  the  malady.  The 
local  symptoms  are  pain,  usually  aggravated  by 
movement,  and  markedly  by  pressure ; and  the 
presence  of  a tumour.  The  tumour  rapidly  in- 
creases, and  while  it  is  at  first  hard  throughout, 
it  soon  presents  deep-seated  fluctuation,  which 
becomes  gradually  more  distinct  and  superficial. 
The  skin  in  the  lumbar  region  is  often  cedema- 
tous,  and  is  usually  pale,  excepting  when  perfora- 
tion is  about  to  take  place.  The  position  of  the 
mass  is  important.  It  is  situated  in  the  region 
of  the  kidney,  and  is  inseparable  from  it,  while 
as  a rule  separable  from  the  liver  and  spleen. 
The  urine  may  be  quite  natural,  but  in  many 
cases  it  is  altered,  in  consequence  of  the  presence 
of  pre-existing  pyelitis  or  nephritis ; but  even  in 
cases  which  do  not  originate  in  renal  disease, 


there  is  a tendency  to  diminution  of  the  urini 
at  first,  and  this  is  apt  to  continue  through- 
out, accompanied  by  a dark  colour  of  the  secre- 
tion. 

The  onset  of  perinephritis  is  generally  acute 
but  it  may  be  very  insidious,  especially  whet 
it  follows  pregnancy.  Probably  it  sometime! 
terminates  by  resolution  without  goiDg  on  tc 
suppuration.  When  suppuration  is  once  faith 
established,  it  extends  and  makes  its  way,  eithe": 
to  the  surface  or  into  some  internal  cavity.  Whei 
the  pus  is  making  its  way  outwards,  there  ari 
the  usual  features  of  a burrowing  abscess — th< 
skin  becomes  red  and  prominent,  and  at  last  ai 
opening  is  formed  by  ulceration.  When  the  pit 
makes  its  way  into  the  colon,  a copious  discharg- 
of  pus  by  the  bowel  occurs;  and,  owing  to  thi 
nature  of  the  opening,  faecal  matter  seldom  make 
its  way  into  the  abscess-cavity.  If  bursting  into 
the  ureter  occurs,  discharge  of  pus  from  thi 
bladder  takes  place.  If  into  the  lungs,  a suddei 
discharge  may  take  place  with  coughing,  th 
layers  of  the  diaphragmatic  pleura  having  bee: 
first  agglutinated  together.  With  all  these  mode 
of  termination  there  is,  as  a rule,  fall  of  tempera 
ture,  with  relief  of  the  general  and  local  symp 
toms.  When  the  discharge  takes  place  into  th 
peritoneum,  fatal  peritonitis  is  rapidly  lightu 
up.  When  through  the  diaphragm,  the  tv- 
layers  of  the  pleura  not  being  adherent,  empv 
ema  is  produced,  with  sometimes  gangrene  of  ti- 
lling. In  some  instances  of  perinephritic  absces 
there  is  a fatal  termination  without  perforatiov 
having  occurred,  by  means  of  blood-poisoning 
either  in  the  form  of  pyaemia  with  seconder 
abscesses,  or  of  septicaemia  with  affection  of  th 
spleen  and  other  blood-glands.  In  a few  case 
suppurative  pylephlebitis  has  been  met  with,  at 
companied  by  secondary  abscesses  in  the  liver. 

Diagnosis.— The  concurrence  of  fever  wit 
pain  and  swelling  in  the  region  of  the  kidne) 
is  distinctive  of  perinephritis,  no  other  diseas 
presenting  this  exact  combination.  The  turnon 
is  fluctuating,  and  is  in  the  immediate  neighbom 
hood  cf  the  kidney ; it  is  usually  confined  to  on 
side;  its  mass  may  be  tilted  forward  by  presstu 
on  the  renal  region.  It  must  be  distinguished  froi 
new  formations  of  the  kidney,  spleen,  liver,  q 
mesenteric  glands;  from  hydronephrosis;  ar 
from  extravasation  of  blood  into  the  cellular  ti 
sue,  due  to  rupture  of  an  aneurism.  From  thefir. 
group  it  is  distinguished  by  the  fever,  and  tl 
fluctuation  and  exact  position  of  the  mass ; fro 
hydronephrosis  by  the  fever,  and  the  ckaracte; 
of  the  enlargement ; from  the  aneurismal  extn 
vasation  by  the  comparatively  slow  growth  ■ 
the  tumour,  and  the  absence  of  the  characters  ■ 
aneurism.  In  most  cases  certainty  is  most  readi 
attained  by  means  of  the  aspirator. 

Prognosis. — The  prognosis  is  always  gmv 
and  becomes  increasingly  so  as  the  disease  a- 
vances.  The  duration  is  commonly  short,  tl 
case  terminating  in  from  a fortnight  to  a moat 
sometimes,  however,  a case  lasts  several  month 
A favourable  prognosis  may  be  given  when  pe 
foration  outwards  has  taken  place;  or  when  tl 
abscess  has  burst  internally,  in  such  a directic 
that  the  pus  escapes  freely,  and  there  is  u 
provement  in  the  general  symptoms. 

Treatment. — In  the  earlier  stages  count* 


PERINEPHRITIS. 

.■Station  by  blistering  is  useful.  The  internal 
lc  of  iodide  of  potassium,  and  the  external  appli- 
iion  of  iodine,  may  prevent  suppuration.  Sup- 
rtino-  diet  should  be  given,  but  not  stimulants, 

| less  essentially  necessary. 

When  suppuration  has  taken  place  the  abscess 
fist  be  discharged  by  the  aspirator,  or  by 
fe  incision.  The  latter  is  preferable,  because 
iere  are  often  sloughs  or  masses  of  tissue 
,iich  cannot  be  got  rid  of  by  aspiration.  When 
eration  by  incision  is  resolved  upon,  the  in- 
Sion  should  be  made  in  the  lumbar  region 
rough  the  skin  and  muscular  tissues;  and 
■3  finger  should  be  introduced  into  the  abscess 
. ,-ity,  to  tear  down  any  adhesions  which  may 
.1st.  When  the  pus  has  been  evacuated,  a 
ninage-tube  should  be  introduced,  so  as  to 
lepthe  passage  open,  and  give  free  egress  to 
■3  pus.  The  best  results  are  to  be  expected 
■ien  free  incision  is  adopted,  and  Lister’s  auti- 
stic method  rigorously  employed  during  the 
Oration  and  afterwards.  The  patient’s  strength 
1st  be  maintained  by  nutritious  food,  tonics, 
d stimulants  when  required. 

T.  Geainger  Stewart. 

PERIOD  OP  INCUBATION'. — The  pe- 
: d that  elapses  between  the  entrance  of  an  in- 
i tive  substance  into  the  system,  and  the  first 
ipearance  of  the  symptoms  of  the  disease  which 
■produces.  See  Incubation. 

PERIODICITY  IN  DISEASE.— In  the 
der  physic  the  periodical  phenomena  observed 
many  diseases  exercised  an  important  influ- 
:e  upon  medical  opinion  and  practice.  In  the 

■ ysic  of  the  present  day  these  phenomena,  al- 
iiugh  not  disregarded  by  current  pathology, 

re  scarcely  a place  in  therapeutical  teachings. 

. increased  precision  of  medical  observation, 

■ ile  leading  to  the  removal  of  many  errors  of 
:■  older  writers  on  the  subject,  has  begotten 
ireneral  doubt  as  to  its  value  in  practical 
i dicine,  and  brought  about  a,  perhaps,  too 
discriminate  rejection  of  the  earlier  views  re- 
il'cting  it. 

Two  English  writers,  Thomas  Laycock,  M.D., 
;]  Edward  Smith,  M.D.,  have  in  recent  years 
e-oted  attention  to  the  phenomena  of  perio- 
(jity  in  disease.  Laycock,  from  a general  review 
< the  periodical  phenomena  observed  in  men- 
ijration,  in  utero-gestation  of  the  human  and 
ljite  female,  in  the  development  of  the  ova  of 
ties,  and  in  the  metamorphoses  of  insects,  came 
tllie  conclusion  that  physiological  changes  occur 
i mimals  every  three  and  a half,  seven,  fourteen, 
t'mty-one,  or  twenty-eight  days,  or  at  some  de- 
f!  te  number  of  weeks.  In  other  words,  he  came 
tdie  conclusion  that  there  are  certain  ‘ critical 
ijs’  in  health,  days  in  which  there  are  marked 
cluges  in  the  vital  movements,  whether  that 
c.nge  be  for  the  better  or  the  worse  ; and  that 
t se  days  may  be  stated  generally  as  the  fourth, 
sjmth,  fourteenth,  twentieth  (or  twenty-first), 
t the  twenty-eighth.  Further,  from  a review  of 
t periodical  phenomena  observed  indisease,  par- 
t larly  in  the  groups  of  eruptive,  intermittent, 
a continued  fevers,  and  in  gout,  he  endeavoured 
.'■show  that  the  changes  observed  in  them  fol- 
1 ed  a similar  rule  of  periodicity  to  that  mani- 
t ed  in  health.  He  saw  reason,  moreover, 


PERIODICITY  IN  DISEASE.  1125 
having  regard  to  the  three-and-a-half-day  period 
noticed,  or  seven  half-days,  to  revert  to  the  an- 
cient division  of  the  whole  day  ( vvx^V^pov ) into 
two  parts,  here  following  Graves,  who  had  said: 
‘We  should  not  count  three  days  and  a half,  but 
seven  half-days  ; we  should  not  say  seven  days, 
but  fourteen  half-days.  If  this  method  were 
adopted,  many  of  the  apparently  critical  termi- 
nations in  continued  fevers  would,  I have  no 
doubt,  be  found  strictly  conformable  to  some 
regular  law  of  periodicity.’  Laycock  also  saw 
reason  to  revert  to  the  ancient  doctrine  of  critical 
days  in  fevers,  and  he  thus  elucidates  it : ‘In  the 
essay  on  the  judicatory,  or  critical  days,  found 
among  the  writings  of  Hippocrates,  a critical  day 
is  shown  to  be  that  day  on  which  certain  symp- 
toms will  appear,  enabling  us  to  ascertain — first, 
the  probable  duration  or  termination  of  the  dis- 
ease, and,  secondly,  the  symptoms  likely  to  appeal 
on  certain  future  days.  The  acts  of  mind  which 
deduced  these  inferences  were  termed  judications 
( judicationes — /cpiVets) ; and  the  day  on  which 
those  acts  were  to  be  made  was  termed  judicatory 
((cpiVipos).  So  a day  might  be  judicatory — first, 
of  the  disease,  its  course  and  termination ; se- 
condly, of  the  symptoms  to  happen  on  another 
day.  Thus  jaundice  and  hiccup,  appearing  on 
the  fifth  day  of  fever,  indicated  a fatal  disease  ; 
jaundice,  on  or  after  the  seventh,  indicated  dia- 
phoresis ; on  the  seventh,  ninth,  eleventh,  and 
fourteenth  (if  unaccompanied  by  hardness  in  the 
praecordia),  a favourable  termination.  In  pleu- 
risy, if  the  fever  abates  on  the  seventh  day,  the 
patient  will  recover ; if  it.  do  not,  the  disease  will 
be  prolonged  to  the  fourteenth,  on  which  day  it 
is  sometimes  fatal.  This  is  the  first  and  plainest 
exposition  of  the  doctrine  of  critical  days,  and,  I 
believe,  it  is  correct.’  Laycock  then  proceeds  to 
make  a comparison  of  the  critical  days  of  febrile 
diseases,  and  the  order  of  sequence  observed  by 
intermittents ; and,  further,  to  compare  both 
these  forms  of  fever  with  the  periodicity  observed 
in  the  exanthemata,  and  make  the  facts  bearing 
upon  that  part  of  their  pathology  harmonise  with 
each  other.  ‘ The  critical  days,  according  to  Hip- 
pocrates [doubtless  here  writing,  without  know- 
ing he  did  so,  of  what  we  now  call  continued 
fevers],  are: — 1,  4,  7,  9,  11,  14,  17,  20,  or  21. 
The  paroxysms  of  a tertian  will  take  place  on  the 

1 2 5 7 9 11  13  15  17  19  21  Ttin  T>9 

IP-  2P’  3P*  4V-  5 P-  C P-  7 P*  8 P-#9  P-  10P-  IIP- 

roxysms  of  a quartan  will  take  place  on  the 
T?  |p.  Ip.  3° P.  gV  5%.  V9P.  And  a continued 
fever  existed  with  tertian  or  quartan  exacerba- 
tions, the  more  violent  symptoms  might  be  ex- 
pected to  appear  on  the  days  indicated.  On  com- 
paring the  order  of  days,  discrepancies  between 
the  three  are  sufficiently  obvious  on  a superficial 
consideration,  but  many  of  them  disappear  on 
more  particular  inquiry.  . . . With  regard  to 
the  exanthematous  fevers,  it  will  be  seen  at  once 
that  the  “ critical  days  ” they  exhibit  occur  in 
quartan  order.  . . . Exanthematous  typhus  ex- 
hibits the  tertian  type,  and,  as  might  be  inferred, 
the  critical  days  in  this  fever  are  the  fifth, 
seventh,  ninth,  eleventh,  and  twenty- first.  Scar- 
latina is  sometimes  tertian,  sometimes  quartan.’ 
Since  the  discrimination  of  the  several  varieties 
of  continued  fevers,  and  after  the  date  when 
Laycock  wrote,  medical  observation  lias  not 
tended  generally  to  support  the  doctrine  of 


PERIODICITY  IN  DISEASE. 


1126 

critical  days, as  it  relates  to  this  group  of  febrile 
disorders,  or  to  confirm  the  evidence  upon  which 
that  doctrine  appeared  to  be  founded.  Murchi- 
son’s observations  {Treatise  on  the  Continued 
Fevers  of  Gr eat  Britain,  2nd  edit.  p.  187)  did  not 
support  the  applicability  to  typhus  ; but  in  this 
respect,  as  he  notes,  they  were  not  in  accord 
with  the  observations  of  Gairdner,  Russell,  and 
Traube  of  Berlin.  The  last-named,  indeed,  as 
also  Wunderlich,  revived  the  doctrine.  Relapsing 
fever  may,  perhaps,  be  said  to  illustrate  the 
doctrine,  the  paroxysm  intermitting  on  the 
the  third,  fifth,  or  seventh  day.  According  to 
Murchison  ( Treatise , p.  547)  the  doctrine  fails 
with  respect  to  enteric  fever,  but  he  adds  that  he 
had  ‘ often  noticed  ’ that  the  disease  terminated 
about  the  21st  or  28th  day.  E.  S>egn.m{Medical 
Thermometry,  1876)  reproduces  the  views  of 
Hippocrates  on  critical  days,  and  Wunderlich’s 
seeming  confirmation  of  them  derived  from 
thermometry,  himself  accepting  the  ‘ similitude,’ 
indeed  the  ‘ quasi-identity  of  the  results  ’ ob- 
tained, in  this  regard,  by  the  father  of  Physic  and 
the  modern  professor.  According  to  Wunder- 
lich’s observations  the  majority  of  cases  of  typhoid 
fever  run  a regular  course,  divided  into  periods 
corresponding  in  time  with  the  division  into 
weeks  and  half-weeks.  The  ordinary  course  is 
about  twenty-one  day's,  and  Seguin  describes 
an  ‘ effervescence  of  seven  days,  a fastigium  of 
seven  days,  and  a defervescence  of  seven  days ; ’ 
but  lie  adds,  with  reference  to  the  irregularities 
which  so  often  mark  the  disease,  ‘ simple  as  it 
looks,  how  difficult  it  is  to  make  it  out.’  In 
typhus — simple  uncomplicated  cases — the  ther- 
mometer marks  the  fourth  day  as  the  height,  the 
sixth  to  the  seventh  as  the  turning  point,  and  a 
perturbatio  critica  at  the  end  of  the  second  week. 
‘The  doctrine  of  crises,’  says  Wunderlich,  ‘was 
for  the  ancients  a dogma  ....  for  us  it  must 
become  a law.’  Robert  Lyons  remarks  ( Treatise 
on  Fever,  p.  74,  1861) : ‘ We  are  far  from  deny- 
ing that  at  certain  periods  febrile  disease  pre- 
sents an  unmistakable  tendency  to  terminate  on 
critical  days  ; but  we  think  that  it  is  consistent 
with  observation  to  state  that  a critical  issue  of 

fever is  far  less  common  in  our  day 

than  it  once  was.’  And  this,  indeed,  would  ap- 
pear to  be  a legitimate  conclusion  from  the  ob- 
servations made  in  this  country  bearing  on  the 
subject.  It  would  almost  seem,  in  fact,  on  com- 
paring the  critical  days  set  forth  by  the  older 
writers  with  the  order  of  sequence  followed  by 
the  paroxysms  of  intermittent  fever,  as  if  tho 
indications  of  the  former,  in  the  progress  of  the 
continued  fevers  of  Great  Britain  at  least,  had 
doclined  with  the  diminution  of  sources  of  palu- 
dal malaria. 

Laycock,  as  the  general  result  of  his  investi- 
gation of  the  minor  periods — that  is,  the  daily, 
weekly',  monthly,  and  seasonal  recurrences  of 
vital  movements — as  contra-distinguished  from 
the  major  periods,  that  is  periods  measured  by 
a year,  or  by  a series  of  years,  (which  he  also 
discussed,  but  which  will  be  referred  to  in  this 
article  in  another  connection),  laid  down  the  fol- 
lowing propositions: — (1)  There  is  a general 
law  of  periodicity'  which  regulates  all  the  vital 
movements  of  all  animals.  (2)  The  periods 
within  which  these  movements  take  place  admit 


of  calculations  approximatively  exact.  (3)  'X 
fundamental  unit, — the  unit  upon  which  th 
calculations  should  be  based, — must  for  t 
present  be  considered  as  one  day  of  twelve  hou 

(4)  The  lesser  periods  are  simple  and  compos 
multiples  of  this  unit,  in  a numerical  ratio  3r 
logous  to  that  observed  in  chemical  compound 

(5)  The  fundamental  unit  of  the  greater  perio' 
is  one  week  of  seven  days,  each  day  being  twill 
hours  ; and  simple  and  compound  multiple*, 
this  unit  determine  the  length  of  these  perio 
by  the  same  ratio  as  multiples  of  the  unit 
tw'elve  hours  determine  the  lesser  periods. 

Inquiring  into  the  causes  of  the  periodic 
changes  in  the  vital  movements  of  animals,  La 
cock  saw  reason  to  believe  that  they  were  ! 
part  dependent  upon  cyclical  processes  inhere 
in  the  system  {esoteric),  partly  upon  period, 
agencies  acting  from  without  {exoteric),  or  th  ; 
they  resulted  from  a combination  of  the  tv 
{endexotcric).  Prosecuting  the  inquiry  furtherw:; 
special  reference  to  the  exoteric  agencies,  Ls 
cock  showed  how  closely  the  periodical  chang 
observed  in  vital  movements  were  linked  to  tl 
periodical  phenomena  observed  in  nature  atlarg 
and  this  not  merely  with  reference  to  such  obvioij 
phenomena  as  the  alternation  of  sleeping  an 
waking  in  connection  with  the  diurnal  rotaticj 
of  the  earth,  and  the  succession  of  day  and  nigh! 
but  also  in  respect  to  the  more  recondite  peri*, 
dical  changes  in  the  vital  processes.  He  set  fort1 
data  which  suggested  that  those  changes,  as  we 
as  the  periodical  changes  observed  in  disease,  ha! 
definite  relations  to  the  position  of  the  earth  wit 
reference  to  the  sun,  and  to  the  position  of  tlj 
sun  among  the  spheres ; also  to  the  periodic;' 
fluctuations  occurring  in  atmospherical  temper 
ture,  pressure,  and  magnetism  ; and  ia  the  mas 
netism  of  the  earth,  whether  diurnal,  season;: 
or  secular.  And  of  the  periodicity  observed  i 
pathological  processes,  he  endeavoured  to  shot 
that  (whatever  the  intimate  nature  of  the  path 
logical  process  might  be)  neither  the  beginnin. 
the  continuance,  the  fluctuations,  the  ending,  n 
the  recurrence  could  be  rightly'  understood  apai 
from  its  relations  to  the  phenomena  of  physl 
logical  periodicity  on  the  one  hand,  and  tit 
periodicity  of  physical  phenomena  on  the  otke 
hand.  He  held  that  there  were  not  wanting  it 
dications  in  pathological  phenomena  of  a luna 
period,  and  particularly  of  a lunar  cycle (eighteej 
years,  Howard's  seasonal  cycle) ; the  indication 
of  solar  periods  were  more  obvious : and  it  wa 
to  bo  inferred  that  in  time  we  should  have  ev: 
dence  of  greater  pathological  cycles  correspond 
ing  with  the  greater  astronomical  cycles.  Lay 
cock,  indeed,  saw  clearly  that  so  far  as  exoteri 
agencies  were  active  in  bringing  about  the  peric 
dical  phenomena  observed,  in  physiological  an 
pathological  processes  in  man,  the  changes  of  leas 
period  were  linked  inextricably  to  the  change 
of  greatest  period,  and  that  the  study  of  tb 
greater  periods  must  be  approached,  if  suece; 
were  to  be  hoped  for,  through  the  study  of  tl 
lesser.  I 

Laycock  was  of  opinion  that  as  our  knowleog 
of  the  periodical  phenomena  observed  in  vit; 
changes  becomes  more  exact  and  extensive, 
will  be  possible  to  establish  a science  of  rid 
prolepiics,  having  for  its  object  ‘to  foretell  so c: 


PERIODICITY 

nd  individual  suffering  —in  other  words,  a 
cienee  of  pathological  forecasting. 

Edward  Smith  examined  the  question  of  peri- 
dical  changes  in  living  beings,  in  health  and 
lisease,  from  a stand-point  different  from  that 
taken  by  Laycock.  He  limited  his  observations 
[o  the  human  system,  and  prosecuted  a series  of 
eseacches  on  the  daily,  weekly,  and  seasonal 
hanges  it  underwent,  probably  unique  in  their 
uration  and  extent.  He  adopted  as  criteria  of 
kese  changes  the  rates  of  pulsation  and  inspi- 
ation,  the  quantities  of  carbonic  acid  expired, 
if  air  inspired,  and  of  urea  and  urinary  water 
volved.  The  data  as  to  these  several  changes 
•ere  determined  by  a series  of  observations 
hade  upon  himself  and  others,  some  phthisi- 
a.1,  at  hourly  intervals,  without  intermission, 
liroughout  the  twenty-four  hours,  during  several 
jays  in  succession,  for  the  daily  period,  and  at 
taily  intervals  for  the  longer  periods  of  time, 
ho  fluctuations  observed  in  the  different  pheno- 
tena  of  health,  being  taken  as  indications  of 
hanges  in  the  activity  of  the  vital  processes,  it 
tacame  possible  to  determine  the  progression 
nd  retrogression  of  that  activity  within  the 
|veral  periods  to  which  the  inquiry  was  directed, 
hesc  may  be  briefly  stated  as  follows  : — 

Daily  period  {cycle). — Vital  activity  is  at  the 
West  between  the  hours  of  1 and  3 o’clock  a.m. 
ftcr  3 o'clock  a.m.  the  activity  increases,  at 
irst  slowly,  then  more  quickly,  until  a maximum 
reached  between  the  hours  of  noon  and  2 
m.  A progressive  decline  follows,  rapid  at 
Irst,  slower  as  the  evening  draws  on  and  falls 
to  night,  until  the  minimum  is  reached  be- 
yeen  1 an  1 3 a.m.  The  day,  in  fact,  as  con- 
rns  the  changes  undergone  in  the  human 
i'stemmay  be  divided  into  two  periods,  one  of 
iinimum  change  (approximatively  from  8 p.m.  to 
a.m.) ; and  one  of  maximum  change  (approxi- 
atively  from  8 a.m.  to  8 p.m.)  Within  this 
,ily  cycle,  smaller  cycles  are  observable,  ac- 
rding  to  the  time  and  quality  of  the  meals. 
Weekly  period  {cycle). — A weekly  period  is  not 
own  by  a clear  line  of  progression  of  vital 
ange  throughout  the  week,  but  by  the  indica- 
ms of  a higher  drgree  of  change  which  follow 
Ion  the  first-day  rest  than  are  manifested  at 
fi  close  of  the  sixth  day  of  labour.  The 
idence  of  a seven-days’  period  of  change  in 
3 healthy  system,  on  the  line  of  investigation 
rsued  by  Smith,  and  apart  from  the  social  habit 
periodical  rest,  is  obscure ; but  the  social  habit 
rrobably  the  expression  of  a physiological  want 
tithe  system. 

Seasoned  {annual)  period  {cycle). — A seasonal 
• do  is  very  definitely  marked  by  the  intimate 
'al  changes  observed  in  the  human  system, 
wards  the  close  of  summer  vital  change  has 
:j.ched  its  lowest  point.  With  the  eommenee- 
mt  of  autumn  a progressive  increase  com- 
i nces,  which  continues  through  the  autumn 
al  the  winter,  and  reaches  its  highest  degree  in 
sing.  Towards  the  close  of  spring  vital  change 
1 ins  to  decline  progressively.  This  decline 
Ijceeds  throughout  June  and  July,  at  an  in- 
cising rate  in  the  latter  month,  and  attains  its 
ljest  degree  early  in  September.  The  summer 
tnges  in  the  system  exhibit  the  following 
t mum  and  maximum  conditions  : a minimum 


IN  DISEASE.  1127 

of  carbonic  acid  and  vapour  exhaled,  of  air  in- 
spired, of  the  rate  and  force  of  inspiration,  o? 
alimentation  and  assimilation,  of  animal  heat 
generated,  of  muscular  tone  and  endurance  of 
fatigue,  and,  in  general,  of  resistance  to  adverse 
influence.  A maximum  of  the  rate  of  pulsation, 
of  the  action  of  the  skin,  and  the  elimination  of 
vapour,  of  the  dispersion  of  heat,  of  the  supply 
of  heat  from  without,  and  of  excess  of  heat,  of 
the  elimination  of  urea  and  urinary  water, 
of  the  distribution  of  blood  to  the  surface, 
of  the  imbibition  of  fluids,  of  relaxation  of 
the  tissues,  and  of  poverty  and  carbonisation  of 
blood.  In  the  winter  season  the  above  conditions 
are,  for  the  most  part,  reversed.  The  autumn 
season  is  marked  by  the  conditions  peculiar  to 
the  summer  or  the  winter,  as  the  character  of 
the  season  resembles  the  one  or  the  other ; it  is 
essentially  a period  of  change  from  the  minimum 
to  the  maximum.  The  spring  season  is  character- 
ised in  its  early  and  middle  parts  by  the  highest 
degree  of  efficiency  of  every  function  of  the 
human  system,  but  as  the  season  advances  to  the 
close,  these  conditions  merge  into  those  peculiar 
to  summer. 

The  effect  of  season,  Ed.  Smith  observes,  is 
more  than  the  physical  phenomena  of  tempera- 
ture and  atmospheric  pressure  explain,  and  is  so 
universal  that  even  the  same  amount  of  exertion, 
made  at  two  different  seasons,  produced  different 
degrees  of  effect  upon  the  vital  changes — less 
carbonic  acid  being  evolved  from  it  in  summer 
than  in  winter,  iu  proportion  to  the  relativo 
amounts  when  at  rest  at  these  two  periods. 

The  periodical  changes  here  set  forth  have 
important  bearings  both  upxm  the  liability  to 
and  the  treatment  of  disease.  Smith  endeavoured 
to  formulate  these  bearings  and  thus  to  furnish 
a rational  statement  of  many  facts  which  the  ex- 
perienced practitioner  learns  at  the  bedside,  and 
which  he  applies  empirically. 

Hut  the  interest  of  the  seasonal  period  is 
more  conspicuously  marked  as  it  influences  the 
liability  to  and  recurrence  of  disease  and  parti- 
cular kinds  of  disease.  And  here  it  should  be 
noted  that  Ed.  Smith  discusses  a question  which, 
perhaps,  has  been  too  little  considered,  namely, 
the  viability  of  children  born  in  the  different 
seasons  of  the  year.  This  question  he  believed 
to  have  an  important  bearing  upon  the  great 
loss  of  infant  life  which  occurs  in  the  summer 
season.  Smith  concludes  that  the  viability  of 
those  children  is  greatest  who  are  born  in  the 
winter  and  spring  months. 

The  periodical  fluctuations  observed  in  the 
progress  of  current  diseases  in  the  course  of  the 
'year  appear  to  be  mainly  determined  by  the  in- 
fluence of  seasonal  changes  on  the  individual. 
This  subject  has  recently  been  examined  by 
Alexander  Buchan  and  Arthur  Mitchell,  M.D. 
{Journal  of  the  Scottish  Meteorological  Society , 
Nos.  xliii.-xlvi.),  with  reference  to  the  variations 
of  mortality  in  relation  to  the  weather  for  dif- 
ferent diseases,  at  different  ages,  in  London,  for  a 
period  of  thirty  years.  The  results  obtained  by 
these  gentlemen  are  of  exceptional  value  for  the 
length  of  period  over  which  it  has  been  practi- 
cable to  extend  their  examination — a period  un- 
attainable, for  a like  number  of  diseases  and 
approximate  correctness  of  data,  in  other  mtio- 


1128 


PERIODICITY  IK  DISEASE. 


logical  records.  A series  of  researches  made  by 
Edward  Ballard,  M.D.,  on  the  prevalence  of  cer- 
tain sorts  of  sickness,  in  a particular  district  of 
London,  with  reference  to  meteorological  condi- 
tions, corresponds  closely  with  the  results  shown 
for  the  mortality  in  similar  kinds  of  sickness  by 
Buchan  and  Mitchell,  the  minima  and  maxima 
of  the  sicknesses  necessarily  preceding  by  a 
longer  or  shorter  period  the  minima  and  maxima 
of  the  mortality  arising  from  them.  The  general 
results  obtained  from  the  London  mortality  may 
be  taken  as  representing  the  influence  of  seasonal 
changes  on  disease ; but  the  progress  of  the 
diseases  will  be  found  to  follow  the  progress  of 
the  seasonal  changes,  as  these  may  be  found  to 
differ  in,  and  may  be  modified  by,  different  local- 
ities. The  following  is  a brief  tabular  statement 
of  the  seasonal  mortality  of  the  more  important 
diseases  current,  or  occasionally  present,  in 
London : — 


L 

O 

bij 

t-.’ 

o 

s 

a 

s 

G 

s 

is 

m 

m 

< 

c3 

.d 

%u 

>. 

c 

<L 

a 

is- 

tx 

o 

> 

o 

d 

3 

< 

< 

rjj 

(J 

r"‘ 

Small-pox  .... 

+ 

+ 

4- 

] + 

t 

4- 

- 

- 

= 

- 

- 

_ 

Measles 

+ 

— 

— 

+ 

t 

4- 

— 

— 

— 

4- 

l 

Scarlatina  .... 

+ 

+ 

X 

4- 

4- 

Diphtheria  .... 

+ 

4- 

+ 

4- 

i 

x 

Quinsy  (1G  years) 
Croup 

+ 

+ 

4- 

— 

~~ 

— 

— 

4- 

4- 

t 

+ 

4- 

4- 

4- 

4- 

4- 

Whooping  Cough 

j + 

4- 

4- 

4- 

4- 

— \ 

— 

= 

= | 

= 

— 

4- 

Fevers 

+ 

4- 

4- 

— 

Typhus  . G years) . . 

+ 

+ 

4- 

4- 

— 

— 

+ 

— 

4- 

— 

+ 

Typhoid  (G  years)  . 

+ 

4- 

4- 

H- 

4- 

t 

4- 

Simple  contind.  fever 

+ 

4* 

+ 

4- 

Erysipelas  .... 

+ 

4- 

+ 

t 

X 

Puerperal  fever  . . 

+ 

4- 

4- 

+ 

+ 

+ 

Dysentery  .... 

— 

— 

— 

— 

— 

— 

4- 

4- 

i 

+ 

— 

— 

Diarrhoea  .... 

t 

t 

4- 

— 

— 

— 

Cholera 

+ 

t 

t 

+ 

— 

— 

— 

Rheumatism  . . . 

+ 

4- 

4- 

| + 

+ 

4- 

Privation  .... 

— 

— 

— 

— 

— 

— 

+ 

+ 

4- 

— 

— 

— 

Purpura  and  Scurvy 

— 

— 

4- 

4- 

+ 

4- 

Alcoholism  .... 

— 

— 

— 

— 

4- 

4- 

4- 

4- 

4- 

— 

— 

— 

Thrush 

— 

— 

— 

— 

— 

— 

4- 

4- 

4- 

4- 

— 

— 

Gout 

+ 

4- 

4- 

4- 

4- 

Phthisis 

4 

4- 

4- 

4- 

+ 

4- 

Tabes  Meaenterica  . 

4- 

4- 

4- 

— 

— 

— 

Hydrocephalus  . . 

— 

4- 

4- 

4- 

4- 

4- 

4- 

Heart-disease  . . . 

+ 

4- 

4- 

4- 

— 

— 

— 

— 

— 

— 

4- 

4- 

Laryngitis  .... 

4- 

4- 

t 

4- 

4- 

4- 

Bronchitis  .... 

t 

4- 

4- 

4- 

~ 

— 

— 

= 

— 

| — 

4- 

4- 

Pneumonia  .... 

; + 

4- 

4- 

4- 

— 

— 

— 

= 

— 

— 

4- 

4- 

Asthma 

j + 

4- 

4- 

4- 

4- 

t 

Pleurisy 

4- 

4- 

4- 

4- 

— 

— 

= 

— 

— 

4- 

4- 

Lung-disease  . . . 

! + 

4- 

+ 

4- 

— 

— 

— 

= 

— 

— 

4- 

i 

Enteritis 

' Teething  .... 

! + 

4- 

4- 

4- 

4- 

4- 

4- 

4- 

4- 

Old  age 

1 1 

4- 

4- 

4- 

V Above  the  average.  J Maxima. 

— Below  the  average.  — Minima. 


This  table  indicates  the  seasons  of  prevalence 
of  the  several  maladies  above  and  below  the 
average,  as  shown  by  their  mortality,  also  the 
seasons  of  maximum  and  minimum  prevalence, 
but  it  does  not  exhibit  the  order  of  progression 
and  magnitude  of  movement  of  the  diseases  in 
the  different  seasons.  In  this  place,  however, 
we  are  concerned  solely  with  the  fact  of  periodi- 
cal changes  in  the  prevalence  of  disease  corre- 
sponding with  and,  it  is  inferred,  depending 
upon  the  seasonal  changes.  These  changes,  while 


occurring  more  or  less  in  each  of  the  partienla 
affections,  and  notably  in  certain  groups  of  affec 
tions,  such  as  the  diarrhceal  and  pulmonan 
manifest  widely  varying  relations  between  til 
several  kinds  of  maladies,  except  in  the  group 
referred  to  and  the  different  seasons. 

Periods  of  Seasons  or  of  Years. — Epidemics.- 
A series  of  periodical  phenomena  have  now  t 
be  considered  which  have  been  a source  of  th 
most  eager  speculation  from  the  earliest  times  o 
medicine  to  the  present  day.  So  far  as  mediem 
is  concerned  these  periods  have  been  marked  b 
epidemic  morbid  phenomena — epidemics  in  mar 
epizootics  in  animals,  epiphytics  in  plants.  Th 
recurrence  of  these  phenomena  at  intervals  show 
that  over  and  above  the  periodical  mor’oi' 
changes  which  have  hitherto  been  noted,  an' 
which  are  completed  within  the  day,  the  weel 
or  a series  of  weeks,  and  the  seasons  within 
year,  there  are  periods  of  change  which  requir 
for  their  completion  a series  of  years  of  longer  o 
shorter  duration,  and  which  for  their  elucidatio 
(as  Laycock  showed)  require  to  be  considered  i 
connection  with  the  previously-mentioned  period.1 
These  periodical  morbid  phenomena  are  of  tw 
sorts,  the  one  relating  to  particular  localities 
districts,  or  countries  ( epidemics ) ; the  other  t 
groups  of  several  countries  or  to  the  world  gent 
rally  {pandemics).  There  are,  in  fact,  circuit 
scribed  (local)  and  general  epidemics,  the  sma 
and  the  great  epidemics  of  some  writers;  th 
former,  local  evolutions  of  disease  having  rein 
tion  chiefly  to  the  physical  and  moral  states  c 
communities,  the  latter,  secular  evolutions  (t| 
use  Charles  Anglada’s  phrase  : Maladies  Eteinit 
et  les  Maladies  NouvelUs,  1869),  which  appeart 
have  relation  to,  as  yet,  undetermined  cosmic 
phenomena.  To  these  secular  evolutions  of  di: 
ease  (‘facts  of  cosmo-ehemical  disturbance 
John  Simon)  some  epidemiologists  would  rr 
strict  the  term  epidemic. 

The  law  of  periodicity  of  the  several  disease 
current  in  a country,  and  which  are  apt  to  be 
come  epidemic,  has  not  been  determined.  Eac 
disease  will  need  to  be  considered  apart ; and  i 
those  which  are  communicable  from  the  sick  t 
the  healthy,  the  influence  of  an  aecumulatio 
of  susceptible  persons  in  the  intervals  betwee 
epidemic  prevalence 1 will  have  to  be  distil 

1 The  writer  has  the  following  from  a mathematic, 
friend:— As  a first  case,  let  all  epidemics  be  or  eqm 
intensity ; and  let  there  be  no  condition  operative  i 
determining  an  epidemic  beyond  the  accumulation  < 
susceptible  people. 

Let  p be  the  number  of  susceptible  people  remainm 
in  a population  after  an  epidemic. 

Let  r be  the  annual  excess  of  births  over  deaths  (a 
causes),  with  other  increments  of  susceptible  popi 
lation. 

Let  x he  the  number  of  people  attacked,  or  otherwu 
rendered  insusceptible  during  an  epidemic. 

And  let  n be  the  cycle  of  an  epidemic. 

To  find  n. 

After  an  epidemic,  the  susceptible  = p. 

Next  year  „ „ = p+r. 

„ .»  = p+2r. 

When  epidemic  comes  „ = p+nr. 

After  epidemic  gone  ,,  = p+nr—x 

But  this  = p. 

.■.  nr  = x;  and  n=A. 

r 

On  this  rule,  take  the  case  of  scarlatina  (always  presei 
and  waiting  to  be  epidemic  until  accumulation  of  R 
over  and  above  p has  taken  place,  and  let  us  suppose  oc: 
selves  concerned  with  a community  of  1,000,  of  when 


PERIODICITY 

(ished  from  extraneous  conditions  presumably 
lerative  in  determining  the  periodicity.  Thus, 
j er  the  year  1840,  the  fluctuations  of  small- 
]x  in  the  metropolis  were  obserred  to  have  a 
< se  relationship  with  the  fluctuations  in  quan- 
ty  of  unvaccinated  children  — so  close,  indeed, 
lit  the  periods  of  recurrence  of  epidemic  small- 
]s  could  be  pretty  certainly  forecasted  ; but 
i 1871,  when  one  of  the  periods  of  epidemic 
i rease  arising  from  an  accumulation  of  un- 
ptected  individuals  was  due,  some  other 
determined  condition  concurred  and  gave  to 
tp  epidemic  of  that  and  the  following  year  a 
qiracter  which  had  not  been  observed  in  small- 
jc  since  the  general  introduction  of  vacci- 
r ion.  The  usual  histories  of  epidemics  are 
dost  valueless  for  scientific  purposes  : they  do 
i ; discriminate  those  outbreaks  which  are  essen- 
t ly  of  a local  nature,  and  dependent  chiefly 
uin  the  state  of  a particular  place  and  popula- 
te, from  those  which  are  governed  by  more 
v ely  operative  influences.  In  England  the  data 
a liable  for  such  determination  do  not  exist  for 
n?e  than  forty  years.  Previous  to  the  eom- 
psory  registration  of  deaths,  and  for  a short 
t e afterwards,  the  records  of  the  causes  of 
dth  (which  can  alone  at  present  be  applied  to 
ti  purpose)  were  too  imperfect  to  be  made  use 
Kind  the  popular  accounts  of  the  recurrence 
o maladies  were  untrustworthy.  From  the 
Iitistrar-General's  Reports,  for  the  28  years 
1 .0—77,  it  may  be  inferred  that  small-pox  was 
e)lemic  in  1850-52;  1858;  1863-65;  and  in 
la-72.  Measles  in  1851  ; 1854;  from  1858 
tc 863 ; in  1866  ; 1868  ; and  1874.  Scarlet  Fever 
ip 857— 58  ; 1863-64;  1868-70;  and  in  1874. 
Lhtheria  from  1859  to  1866.  Whooping  Cough 
ir  850 ; 1854-55;  1857-58;  1861-63;  1866- 
and  1872.  ‘Fever,’  from  1851  to  1855;  in 
181-58;  from  1862  to  1866;  and  in  1868. 
Esipelas  from  1850  to  1856  ; 1858-59  ; 1864  ; 
at  1874-75.  Puerperal  Fever  in  1864-65  ; and 
fr  1 1870  to  1876.  Dysentery  from  1850  to  1859. 
ce  in  number  are  insusceptible,  and  another  number 
[p  does  not  at  present  matter  what  number)  are  sus- 
ce  ble then 

let  >-=2  (births -deaths  yearly,  &c.) ; 

1 L let  x=  10  (attacks  in  an  epidemic,  probably  about 
x one  death) ; 

'■  n n = _ = 5 years  as  the  cycle  of  epidemic  recurrence. 

r 

- v,  in  the  same  community,  with  the  same  r,  let  x 
be,  later  than  in  another  otherwise  similar  community 
(M  ‘Vhen  the  epidemic  comes  it  attacks  more  people, 
mr  ig  them  insusceptible) ; the  interval  between  suc- 
cet  , e epidemics  wall  also  be  greater  ; thus  if  x = 20, 
n dp  years,  and  so  on.  On  the  other  hand,  it  r be  larger 
(ei  r through  large  birth-rate  or  other  immigration  of 
sus  itible  persons)  while  x is  constant  : the  interval 
betjcn  successive  epidemics  will  be  less;  thus,  if 
x=  and  r= 3,  n= years,  and  so  on. 

Siagain,  fluctuations  in  the  amount  of  p (from  what- 
cvc  ause arising)  will  make  a difference  in  the  quantity 
P -Jr,  the  number  requisite  for  the  appearance  of  an 
epi  oic ; and  the  interval  between  successive  epidemics 
caxi  altered  in  this  way  as  well  as  by  change  in  n or  r. 

i e now  the  case  of  an  epidemic  influence  needing  to 
he  roduced  from  without,  and  supposing  the  degree  of 
J;s , ensity  not  to  vary ; with  this  alteration  of  hypo- 
tnc,  the  cycle  of  an  epidemic  will  not  be  less  than  the 
nm.  t,  bat  may  be  indefinitely  greater,  owing  to  the 
leqjte  introduction  not  taking  place. 

1,  easy,  in  these  considerations,  to  .find  reasons  for 
iiD  nces  in  epidemic  cycles  among  different  com- 
bm.es,  for  differences  in  the  intensity  of  successive 
epp  uc8,ana  for  apparent  alterations  of  susceptibility 
pn-.'  communities.  And  these  reasons  will  deserve  to 
oe  ( ndered  before  going  in  search  of  other  reasons. 


IN  DISEASE.  3129 

Diarrhoea  m 1852;  1854;  1857;  1859;  1865; 
1868;  and  1870-71;  the  mortality  from  this 
cause  being  moreover  in  excess  throughout  the 
whole  period  1867-74. 

With  regard  to  cholera  and  ‘ fevers  ’ it  must 
here  be  noted  that  Robert  Lawson  bolds,  from 
a widely-extended  range  of  observation,  that 
a series  of  fluctuations  may  be  distinguished 
in  the  prevalence  of  cholera  and  ‘ fevers  ’ fol- 
lowing in  regular  sequence  at  intervals  of  two 
years.  Theso  fluctuations  are  common  to  both 
hemispheres,  and  as  they  appear  to  move  from 
east  to  west,  he  has  designated  them  ‘ pandemic 
waves.’  These  waves  have  a definite  relation, 
ho  believes,  to  the  magnetic  isoclinal  lines,  and 
he  has  laid  down  rules  for  determining  their 
position  at  anytime.  (Trans.  Epidemiological 
Society  of  London,  vol.  iii.  p.  216.) 

The  facts  relating  to  the  secular  evolutions  of 
diseases  are  amongst  the  most  interesting,  if  the 
most  lugubrious,  in  the  history  of  the  human 
race.  Although  their  too-frequent  obscurity  and 
their  extreme  complexity  have  hitherto  inter- 
posed an  insuperable  barrier  to  the  construction 
of  a general  doctrine  regarding  their  occurrence, 
it  is  not  the  less  necessary  that  they  should  re- 
ceive attention.  Here  it  is  possible  only  to  note 
some  of  the  more  salient  indications  of  secular 
periods  of  morbid  evolution.  The  following 
illustrations  (chiefly  according  to  Anglada)  may 
be  mentioned  : — - 

(a)  The  great  pestilence  of  the  5th  century- 
before  Christ,  of  which  the  so-called  ‘ plague  of 
Athens,’  as  described  by  Thucydides,  was  an  in- 
cident. 

(b)  The  pestilences  of  the  2nd  and  3rd  cen- 
turies of  the  Christian  era,  which  are  believed 
to  have  been  of  the  same  nature  as  the  pesti- 
lence of  the  5th  century  n.c.  After  the  3rd  cen- 
tury this  form  of  pestilence  disappeared  from 
history. 

(c)  The  explosion  of  bubonic  (inguinal)  plague 
in  the  6th  century  after  Christ,  when,  for  the  first 
time  in  history,  this  formidable  disease  assumed 
the  epidemic  character  which  it  maintained  to  the 
early  part  of  the  present  century'.  Breaking  out 
in  the  reign  of  Justinian  (a.d.  542),  the  disease 
quickly  occupied  the  whole  of  the  then  known 
earth,  and  began  a tragic  course  which  has  con- 
tinued even  to  our  own  time.  For  twelve  hun- 
dred years  it  had  held  a pre-eminence  among 
pestilential  maladies,  sometimes  more,  some 
times  less  prevalent,  but  at  all  times  deadly. 
In  the  16th  century,  when  quarantine  was  estab 
lished  (see  Quarantine),  69  outbreaks  of  tho 
disease  were  recorded  in  Europe,  of  which  five 
happened  in  England;  in  the  17th  century,  56, 
six  in  England;  in  the  18th  century,  28,  none 
in  England;  and  in  the  first  half  of  the  19th 
century,  15.  In  the  17th  century,  the  area  of 
prevalence  of  the  disease  began  to  decrease.  This 
decrease  went  on  progressively  throughout  the 
18th  and  the  commencement  of  the  19th  centuries, 
the  latest  outbreaks  of  the  malady',  however,  being 
not  less  fatal  than  the  earliest;  and  in  1844  it 
apparently  became  extinct.  But  about  ten  years 
afterwards  the  disease  again  showed  itself  in  tho 
Levant,  and  from  that  time  to  the  present  scat- 
tered circumscribed  outbreaks  have  occurred  id 
Western  Arabia,  (1853,  1874,  and  1879),  North 


i 1 30  PERIODICITY  IN  DISEASE. 

Africa  (1855-59  and  1874),  Mesopotamia  (1867 
and  1873-77),  Persia  (1863,  1870-71,  and  1876- 
77),  and  after  an  absence  of  thirty-six  years  from 
Europe  in  the  province  of  Astrakhan,  Russia 
(1878-79).  Here,  then,  we  appear  to  have  re- 
cords of  one  complete  secular  evolution  of  plague, 
and  to  be  witnessing  the  beginning  of  another. 

The  6th  century  most  probably  also  gave 
birth  to  or  determined  a new  phase  of  activity 
in  small-pox,  measles,  and  even  scarlatina,  as 
great  epidemics. 

( d ) The  gangrenous  pestilence  of  the  middle- 
age  (10th,  11th  and  12th  centuries),  a disease 
long  extinct. 

(c)  The  black-death  of  the  14th  century,  a 
disease  held  by  the  most  competent  writers  to 
differ  essentially  in  nature  from  bubonic  plague, 
and  long  extinct — unless,  indeed,  according  to 
some  writers,  the  Pali  plague  of  India  is  to  be 
regarded  as  the  dregs  of  the  blade-death  of  the 
1 4th  century.  See  Plague. 

(/')  The  sweating  sickness  of  the  15th  and 
16th  centuries,  which,  born  towards  the  close  of 
the  former  century,  after  five  visitations  (1485- 
86,  1507,  1518,  1529,  and  1551)  disappeared, 
about  the  middle  of  the  latter  century. 

Also,  the  great  epidemic  of  syphilis  of  the 
15th  century. 

( g ) The  choleraic  pestilence  of  the  present 
(19th)  century. 

(h)  The  exceptional  development  of  fatal 
diarrhoea,  especially  of  infantile  diarrhoea,  in 
this  century. 

(A  The  occasional  extension  of  the  yellow 
fever  of  the  tropics  into  Europe,  notably  at  the 
beginning  of  the  present  century. 

(j)  The  great  development  of  diphtheria,  a 
disease  that  had  been  well-nigh  forgotten,  within 
the  past  thirty  years. 

(I-)  The  appearance  within  recent  years  of 
cercbro-spinal  fever. 

In  these  phenomena  we  have  evidence  of 
secular  pathological  changes,  to  which  a clue  is 
sought  in  studying  their  relation  with  secular 
meteorological  and  telluric  changes.  In  the  epi- 
demics of  short  recurring  periods— the  lesser 
epidemics,  so  to  speak— it  is  becoming  possible 
to  construct  a theory  of  recurrence,  founded  on 
the  relationship  of  man  to  his  physical  and 
social  surroundings,  and  the  periodical  changes 
which  he  and  they  undergo  in  common  and  in 
subordination  to  the  periodical  changes  observed 
in  Nature  at  large,  and  when  the  disease  is 
communicable  in  relation  to  the  number  of  sus- 
ceptible people  among  a community.  In  the 
epidemics  of  long-recurring  periods — the  greater 
epidemics — the  same  conditions  obtain  ; but  it 
would  appear  as  if  there  were  in  addition  some 
slowly-developed  cumulative  influences  at  work, 
which  manifest  themselves  only  after  long  in- 
tervals of  time.  So  far  as  these  influences  may 
consist  in  meteorological  changes  we  look  princi- 
pally to  India,  where  these  changes  are  more 
uniform  in  their  occurrence,  for  the  earliest  clear 
light  on  the  subj ect.  There,  for  example,  cholera 
is  constantly  present— now  as  a disease  endemic 
to  a particular  region,  now  as  a wide-spread 
epidemic  within  the  limits  of  the  peninsula,  but 
ever  and  anon  breaking  its  bounds  and  spread- 
ing pandemieally  throughout  the  world.  James 


PERIPROCTITIS. 

L.  Bryden,  M.D.,  has  shown  that  the  differ.;] 
developments  of  cholera  within  the  boundaries  i 
India  have  very  definite  relations  to  particnlr 
meteorological  phenomena;  and  it  seems  not  U! 
reasonable  to  suppose  that,  following  the  line , 
research  inaugurated  by  him,  in  progress  of  tin 
it  will  become  possible  to  discriminate  betvee; 
the  meteorological  changes  which  determine  < 
concur  with  epidemic  prevalence  of  the  disea 
within  India,  and  those  which  determine  ( 
concur  with  wider  extensions  of  the  malady- 
such  as  affected  Europe  in  1829-37.  1847-5 
1852-56,  1865-67,  and  1869-73.  Blandford: 
meteorological  researches  promise  much  help  ' 
this  direction,  inasmuch  as  they  are  tending  i 
show  a close  relation  between  the  greater  cvd< 
of  meteorological  change  in  India  and  cycles 
meteorological  change  in  the  sun  s atmospher 
particularly  as  observed  in  the  sun-spot  period1 

It  mightherebe  added  thatthe  late  research 
of  Crudeli  and  Klebs  on  the  development  of  tl 
bacillus  malaria  in.  the  blood  in  intennitte 
fever,  and  the  well-known  observations  on  tl 
appearance  and  disappearance  of  the  spirillum 
relapsing  fever,  seem  to  suggest  a connection h! 
tween  the  periodical  character  of  these  diseas 
and  the  life-cycle  of  these  organisms. 

J.  Nf.ttf.n~  Rtdcliffe. 

PERIOSTEUM,  Diseases  of.  Sec  Box 

Diseases  of. 

PERIPHERAL  (wepl,  around,  and  yep*. 
carry). — Of  or  belonging  to  the  periphery  or  ci 
cumference,  as  opposed  to  the  centre.  Thetei; 
is  now  applied  chiefly  to  morbid  conditions 
nccted  with  nerves  or  their  terminations,  as  dl 
tinguished  from  those  situated  in  the  nerr 
centres,  for  example,  peripheral  paralysis,  pc. 
pheral  pains.  Peripheral  may  also  be  associat 
with  the  vessels,  as  distinguished  from  the  hea 
for  example,  peripheral  resistance  ; and  with  t 
outer  zone  of  the  lobules  of  glandular  organs,  i 
for  instance,  of  the  liver. 

PERIPNEUMONIA  NOTHA  (« 
around,  Trretjpwi',  the  lungs,  and  v6Qos,  false).  - 
obsolete  term,  which  was  formerly  vaguely  a 
plied  to  a variety  of  forms  of  acute  inflame: 
tion  of  the  bronchi  and  lungs. 

PERIPROCTITIS  (wep! , around, and 
T ds,  the  anus). — Definition-. — Inflammation 
the  tissues  surrounding  the  rectum. 

The  lumen  of  the  rectum  is  normally,  exce 

in  the  act  of  defecation,  obliterated  by  the  mucq 

membrane  being  thrown  into  folds  from  eontr 
tion  of  the  muscular  coats  of  the  bowel ; so  th 
a transverse  section  cf  it  in  this  state  would  p 
sent  the  appearance  of  a solid  oval,  with  the  lo 
diameter  transverse.  During  defsecation  the  boy 
is  distended  by  the  passage  of  faeces,  and  m p 

sons  subject  to  constipation  or  flatulence  this  a 

tension  is  often  found  considerably  increased 
accumulations  of  faeces  or  of  flatus.  The  re,  ] 
is,  in  order  to  admit  of  this  mobility,  surronno 
bv  a considerable  quantity  of  loose  cellular! 
sue,  which  below  passes  by  direct  contmuityir 
the  masses  of  adipose  tissue  which  fill  the  is, 

rectal  spaces.  ... 

In  consequence  of  tlie  dependent  position, 
comparatively  great  exposure  to  injury,  uie 


PERIPROCTITIS. 

lularity  and  the  liability  to  congestion  from  the 
unction  of  the  portal  and  systemic  venous  sys- 
sms,  this  cellular  tissue  is  very  liable  to  inflam- 
mation, which  usually  goes  on  to  suppuration. 
Periproctitis  may  be  either  acute  or  chronic. 
Etiology. — Acute  inflammation  around  the 
‘ectum  may  be  of  traumatic  origin.  Unskilful 
atheterisation  in  the  male  subject,  by  -which  the 
oint  of  the  catheter  is  forced  through  the 
rethra  into  the  space  between  the  bladder  and 
>ctum ; penetrating  wounds  of  the  bowel,  caused 
y instruments,  such  as  injection-tubes,  stric- 
ire-dilators,  &c.,  or  by  foreign  bodies  intro- 
duced by  patients  themselves,  or  by  sharp  sub- 
iances.  such  as  fish-bones,  which  have  been 
taidentally  swallowed ; gunshot  wounds  of  the 
art;  penetrating  wounds,  caused  by  falls  on 
jarp  substances ; or  even  contusions,  the  result 
'falls  or  kicks,  may  set  up  such  inflammation.  Or 
maybe  the  result  of  extension  of  inflammation 
|om  surrounding  parts.  Thus  prostatitis,  cys- 
tis,  pericystitis,  ulceration  in  the  membranous 
irtion  of  the  urethra,  sloughing  ulceration  of 
,e  vagina,  and  the  various  kinds  of  ulcers  in  the 
ctum,  may  be  the  exciting  cause.  If  perforating 
cers  be  the  cause,  so  as  to  lead  to  extravasa- 
>n  of  urine  or  faces,  the  inflammatory  process 
very  severe.  In  some  rare  cases  no  exciting 
use  can  be  traced,  and  such  cases  are  known 
■ the  misleading  name  of  ‘ spontaneous  peri- 
octitis.' 

Chronic  periproctitis  always  results  from  the 
tension  of  inflammatory  processes  from  neigh- 
uring  parts.  Disease  of  the  sacrum,  coccyx, 
lower  lumbar  vertebrae,  or  chronic  disease  of 
e pelvic  viscera,  often  leads  to  it.  It  is  charac- 
rised  by  considerable  infiltration  and  thiek- 
•mg  of  the  cellular  tissue,  as  well  as  by  sup- 
ration.  Pyaemia  resulting  from  ligature  of 
imorrhoids  may  be  attended  by  abscesses  in 
is  tissue ; which  also,  though  very  rarely,  have 
en  found  in  pyaemia  from  other  causes. 
Symptoms. — In  acute  cases  the  patient  com- 
fins  of  a feeling  of  weight  in  the  part,  and  of 
,in,  which  is  much  greater  during  defecation, 
the  thickness  of  the  integument  in  this  region, 
d the  fasciee  of  the  part  retard  the  pointing 
wards  the  surface,  extensive  mischief  may 
(st  with  little  external  sign.  Hence  the  im- 
I'tance  iu  all  suspected  cases  of  careful  digital 
(j)loration  of  the  rectum,  by  which  local  ten- 
cness,  increased  temperature,  and  either  hard- 
t s or  fluctuation,  according  to  the  stage  of 
■lamination,  may  bo  detected.  In  chronic 
c es  the  symptoms  are  usually  masked  by  those 
cthe  exciting  cause. 

Treatment. — In  all  cases  accumulation  of 
f es  in  the  rectum  must  be  prevented  by  the 
i of  simple  enemata ; whilst  in  acute  cases 
dly  surgical  interference  is  imperatively  re- 
c red.  In  other  cases,  the  exciting  cause  must 
1 discovered  and  treated  according  to  circum- 
s.ices.  Jeremiah  McCarthy. 

’ERITOHEUM,  Diseases  of. — The  peri- 
t',2um  is  by  far  the  most  extensive  serous 
r ubrane  in  the  body,  while  it  has  numerous 
f s and  attachments,  and  is  in  relation  with 

• iral  organs  and  structures,  so  that  the  con- 

• ^ration  of  its  diseases,  though  similar  in  their 


PERITONEUM,  DISEASES  OF.  1131 
nature,  is  a much  less  simple  matter  than  in  the 
case  of  the  other  membranes  of  this  class.  It 
must  also  be  remembered  that  in  the  female  the 
peritoneal  cavity  is  in  direct  communication  with 
the  uterus,  through  the  Fallopian  tubes.  The 
morbid  conditions  of  the  peritoneum  may  be  dis- 
cussed according  to  the  following  arrangement : — 

1.  Peritoneum,  Acute  Inflammation  of.  - 
Synon.  : Acute  Peritonitis  ; Fr .Peritonite  aigue ; 
Ger.  Acute  Bauch/eilentsundung. 

^Etiology  and  Pathology. — Acute  perito- 
nitis may  arise  under  several  conditions,  which 
can  be  conveniently  included  under  certain  heads. 

a.  Traumatic. — It  was  formerly  believed  that 
any  kind  of  injury  to  the  peritoneum  was  highly 
dangerous,  and  would  lead  almost  inevitably 
to  inflammation.  Not  only,  however,  may  it  be 
punctured  with  an  aspirator  or  trochar  without 
any  harm  resulting,  but  it  may  even  be  freely 
opened  and  manipulated,  under  proper  conditions, 
without  any  injurious  effects,  as  is  constantly 
exemplified  in  the  operation  of  ovariotomy,  and 
in  performing  abdominal  section  for  various  other 
purposes.  At  the  same  time  a very  slight  ope- 
ration affecting  the  peritoneum  may  lead  to 
serious  or  even  fatal  peritonitis,  especially  in 
certain  states  of  the  system,  or  if  septic  mat- 
ters are  introduced  into  its  cavity.  Penetrating 
wounds  of  the  abdomen  are  very  likely  to  be 
followed  by  peritonitis,  but  not  necessarily.  The 
rupture  by  violence  of  an  abdominal  organ  will 
also  lead  to  this  result,  should  the  patient  survive 
long  enough,  from  the  escape  either  of  blood, 
or  of  the  contents  of  a hollow  viscus.  Peri- 
tonitis has  been  attributed  to  a mere  contusion 
over  the  abdomen.  When  it  arises  from  a wound, 
it  is  probably  not  the  simple  injury  to  the  peri- 
toneum that  causes  the  lesion,  but  its  exposure 
to  the  air,  the  introduction  of  septic  matters,  or 
haemorrhage  into  the  peritoneal  sac. 

b.  Perforations  and  Euptures. — In  addition  to 
lesions  due  to  injury,  there  are  several  other 
kinds  of  perforation  and  rupture  which  are  liable 
to  give  rise  to  peritonitis.  These  have  been  dis- 
cussed at  length  in  a special  article  {see  Per- 
forations and  Ruptures),  and  it  will  suffice  to 
mention  here,  that  acute  peritonitis  may  follow 
eitherofthe  followingforms  of  perforation  or  rup- 
ture, if  they  do  not  prove  fatal  too  speedily 
(i.)  of  hollow  viscera,  with  escape  of  their  con- 
tents ; (ii.)  of  solid  organs  which  have  become 
so  softened  as  to  give  way;  (iii.)  of  cystic  or 
other  localised  accumulations  of  fluid ; (iv.)  of 
collections  of  pus  in  connection  with  any  struc- 
ture within  the  abdomen,  even  the  peritoneum 
itself,  or  in  the  abdominal  wall ; (v.)  of  an  aneu- 
rism ; (vi.)  of  a dilated  receptaculum  chyli ; (vii.) 
of  fluid  accumulations  within  the  chest,  which 
have  burst  through  the  diaphragm  into  the  ab- 
domen, such  as  empyema,  pulmonary  abscess,  or 
a hydatid  cyst.  The  peritonitis  depends  mainly 
on  the  materials  which  thus  gain  access  into 
the  peritoneal  sac,  whether  gaseous,  liquid,  or 
solid,  and  which  irritate  it  more  or  less  according 
to  their  nature.  Urine  is  one  of  the  most  viru- 
lent of  such  materials ; and  unhealthy  pus  or 
gangrenous  particles  are  also  highly  injurious. 
The  nature  of  the  irritant  will  also  materially 
influence  the  kind  of  peritonitis  which  is  set  up 


1132 


PERITONEUM,  DISEASES  OR 


c.  Direct  irritation  of  the  peritoneum. — This 
is  a common  source  of  peritonitis,  and  the  irri- 
tation may  be  general , affecting  more  or  less  the 
whole  peritoneum ; or  local.  Thus  it  is  supposed 
that  general  irritation  may  result  from  distension 
of  the  peritoneal  sac  in  cases  of  ascites  ; and 
certainly  from  extensive  morbid  deposits,  such 
as  cancer  or  tubercle.  Local  irritation  may  be 
excited  by  many  different  conditions,  including 
mere  mechanical  pressure  or  friction,  as  from  a 
tumour,  an  enlarged  cancerous  organ,  or  an 
accumulation  in  the  bowels ; as  well  as  localised 
inflammation,  suppuration,  ulceration,  or  gan- 
grene. A very  severe  form  of  peritonitis  is 
liable  to  be  set  up  by  a strangulated  hernia  or 
certain  forms  of  acute  intestinal  obstruction; 
and  this  complication  has  also  to  bo  borne  in 
mind  as  a result  of  mere  local  irritation  in 
typhoid  fever,  and  in  dysentery.  In  some  in- 
stances a minute  and  careful  search  has  to  be 
made  for  the  source  of  irritation  before  it  can 
bo  discovered;  for  instance,  it  may  be  merely  a 
suppurating  absorbent  gland,  deeply  situated. 
Peritonitis  thus  originating  may  be  limited,  or 
may  spread  universally,  this  depending  very 
much  on  the  nature  of  the  irritant.  Extension 
is  due  either  to  the  products  of  inflammation 
passing  along  the  sub-serous  cellular  tissue,  or 
being  conveyed  by  the  absorbent  vessels. 

d.  Extension. — Besides  the  extension  of  peri- 
toneal inflammation  from  a local  irritation,  it 
now  and  then  happens  that  pleurisy  or  peri- 
carditis, especially  if  of  a septic  nature,  spreads 
through  the  diaphragm  to  the  peritoneum,  pro- 
bably by  means  of  the  system  of  lymph-canals 
existing  between  the  serous  membranes  and  the 
diaphragm.  Inflammation  may  also  pass  along 
the  Fallopian  tubes  directly  from  the  uterus 
to  the  peritoneum.  In  this  connection  it  may 
further  be  mentioned  that  infectious  emboli  in 
branches  of  the  abdominal  aorta  have  given  rise 
to  peritonitis ; which  has  also  been  attributed 
to  phlebitis  and  peri-phlebitis,  extending  from 
the  umbilical  and  spermatic  veins. 

e.  Secondary.-—  This  term  refers  to  cases  of 
peritonitis  originating  as  a complication  or  local 
manifestation  of  some  general  condition.  Under 
such  circumstances  the  disease  usually  results 
from  a morbid  or  poisoned  state  of  the  blood — 
especially  when  it  contains  products  of  excessive 
tissue-change  as  in  low  fevers,  abnormal  ma- 
terials, or  infective  agents.  Other  causes  may, 
however,  assist  in  its  development.  The  most  im- 
portant diseases  in  which  secondary  peritonitis  oc- 
curs are  Bright’s  disease ; septicaemia  and  pyaemia, 
to  which  puerperal  peritonitis  probably  belongs ; 
erysipelas,  small-pox,  glanders,  and  other  dis- 
eases of  this  class;  and  perhaps  acute  rheu- 
matism and  gout.  It  has  also  been  said  to  follow 
scurvy’ ; but  in  a large  number  of  cases  of  scurvy, 
which  have  come  under  the  observation  of  the 
writer,  peritonitis  never  occurred. 

f.  Idiopathic. — Occasionally  cases  of  perito- 
nitis occur,  which  cannot  be  referred  to  any  of 
the  recognised  causes.  These  have  been  called 
idiopathic,  and  have  been  attributed  to  exposure 
to  cold,  excessive  eating  or  drinking,  and  va- 
rious other  causes  in  individual  instances.  Many 
authorities,  however,  doubt  their  reality. 

g.  Contagion. — Peritonitis  may  be  originated 


by  contagion,  when  of  the  puerperal  variety, 
and  may  thus  become  epidemic. 

Peritonitis  in  Pemales.  —A  few  special  re- 
marks are  called  for  on  this  point.  Peritonitis 
is  much  more  common  in  females  than  males,  or 
account  of  the  relation  of  the  peritoneum  to  the- 
uterus,  and  the  various  conditions  connected 
with  the  genital  organs  and  functions  which  art 
liable  to  atfect  it.  The  following  are  the  principal 
of  these  conditions  to  which  peritonitis  has  beer 
referred: — (1)  the  uterine  congestion  attending 
menstruation,  aided  by  the  effects  of  cold,  es- 
pecially if  this  should  give  rise  to  inflammation 
of  the  womb;  (2)  the  puerperal  state  and  its! 
accidents,  puerperal  peritonitis  being  a most  im- 
portant form  of  the  disease,  which  is  discussed! 
separately  ; (3)  premature  delivery,  and  es- 
pecially the  use  of  instruments  in  proenrin^ 
abortion  ; (4)  extra-uterine  pregnancy ; (5 
local  diseases,  such  as  inflammation  of  the  sub 
stance  of  the  womb  or  its  lining  membrane,  oi 
in  the  vicinity  of  the  organ ; ovaritis ; uterine 
or  ovarian  tumours;  peri-uterine  haematocele: 
and  inflammation  or  ulceration  of  the  Fallopiar 
tubes  ; (6)  gonorrhoeal  inflammation  spreading 
upwards;  and  (7)  injections  into  the  cavity  oil 
the  uterus. 

Predisposing  Causes. — In  addition  to  sex,  age 
has  to  be  regarded  as  a predisposing  cause  0: 
peritonitis.  It  is  very  rare  in  children,  except 
in  new-born  infants,  in  whom  it  occurs  com- 
paratively frequently,  either  from  inflammation 
or  mortification  of  the  umbilicus,  or  umbilical 
hernia  ; or  as  the  result  of  infection  from  thej 
mother.  The  affection  is  said  to  be  not  uncom- 
mon in  the  foetus,  causing  its  death.  Inehildrer 
peritonitis  is  usually  associated  with  the  acut: 
exanthemata  or  pyiemia,  even  sometimes  follow 
ing  vaccination ; but  it  may  also  be  due  to  tu- 
bercular disease  or  intus-susception,  and  in  very 
rare  instances  has  been  traced  to  an  undescendec 
testis,  or  to  injury  in  administering  an  enema 
Peritonitis  is  predisposed  to  by  previous  at- 
tacks ; and,  it  is  said,  by  accumulation  of  faces 
and  excessive  use  of  strong  purgatives  habitually 
Chronic  renal  disease  may  be  regarded  as  1 
powerful  predisposing,  as  well  as  an  exciting 
cause  of  the  complaint,  a very  slight  irritatioi 
readily  setting  it  up  when  this  affection  is  present 

Anatomical  Characters. — The  pathologies 
changes  in  peritonitis  present  much  variety  undei 
different  circumstances,  as  regards  their  nature 
progress,  and  extent;  and  although  they  re 
semble  in  a general  way  those  observed  in  othe: 
serous  inflammations,  tliev  exhibit  in  most  case: 
distinguishing  peculiarities  of  a striking  kind. 

In  the  early  stage  increased  vaseularisatici 
is  always  noticed,  but  it  may  subside  at  3 late 
period,  or  be  obscured  by  the  inflammatory  pro 
ducts.  There  is  capillary  injection  more  or  les 
diffused,  the  vessels  being  enlarged  and  elongated 
This  is  often  very  marked,  giving  rise. to  intens 
redness,  frequently  not  uniformly  distributed,  bu 
being  especially  observed  where  coils  of  intestm 
touch  each  other,  and  at  the  starting-point  oftk 
inflammation  in  certain  cases.  Small  extravasa 
tions  of  blood  are  not  uncommon,  and  may  b 


numerous. 

The  products  of  the  inflammatory  process  ar 
very  variable,  as  regards  both  their  nature  an 


PERITONEUM, 

aount.  In  certain  cases  they  consist  almost 
tirely  of  a fibrinous  exudation  or  organi sable 
mph,  with  a very  little  serum,  often  more  or 
!is  tiDSed  with  the  colouring  matter  of  the  blood, 
d containing  flakes  of  lymph—  adhesive  peri- 
intis.  The  lymph  is  of  a jellowish-grey  colour, 
d at  first  very  soft  and  easily  separable,  but 
ierwards  it  tends  to  become  firmer  and  more 
jherent.  It  is  deposited  as  a film,  which  be- 
nies  thicker  by  degrees,  and  may  attain  con- 
lerable  thickness.  Usually  the  exudation  forms 
continuous  layer,  though  of  unequal  thickness, 
it  occasionally  it  occurs  in  separate  patches, 
mats  together  loosely,  or  more  or  less  firmly, 
,3  coils  of  intestines  ; and  covers  the  solid  vis- 
la,  where  it  tends  to  attain  a greater  thickness, 
te  subsequent  progress  of  this  form  of  peri- 
hitis  in  cases  of  recovery  is  towards  organisa- 
n of  the  lymph,  and  the  formation  of  thicken- 
■is,  bands  of  adhesion,  and  agglutinations, 
:ich  may  lead  to  grave  consequences. 

In  a small  proportion  of  cases  of  acute  peri- 
• litis  a fluid  effusion  constitutes  the  principal 
irbid  product,  varying  in  quantity,  but  it  may 
come  so  abundant  as  to  distend  the  peri- 
tieum  to  an  extreme  degree.  There  is  a little 
(posit  of  fibrinous  exudation.  The  eflfusion  may 
I mere  serum,  resembling  dropsical  fluid,  and, 
deed,  some  writers  have  regarded  certain  eases 
Mally  looked  upon  as  those  of  ascites,  as  being 
i lly  of  inflammatory  origin  ; while  ascites  may 
site  peritonitis,  and  thus  lead  to  an  admixture 
({inflammatory  effusion.  In  other  cases  the 
f d is  sero-fibrinous,  being  spontaneously  coa- 
t able,  and  greenish-yellow,  or  turbid  or  milky  ; 
vile  flakes  or  larger  fragments  of  lymph  float 
i,  it.  In  this  condition  there  is  often  much 
f'inous  deposit.  If  the  fluid  is  absorbed,  ad- 
bions  will  subsequently  form. 

n the  majority  of  cases  the  products  tend  to 
1 of  a lower  type  than  those  thus  far  described. 
1)  exudation  is  frequently  soft  and  non-organis- 
ae,  or  sometimes  greasy  in  appearance ; not  un- 
cimonly  it  is  greenish-yellow,  and  infiltrated 
Vh  pus-cells.  The  fluid  is  also  sero-purulent 
e'ictually  purulent.  It  may  be  thick,  laudable 
p ; or  more  liquid  and  unhealthy-looking;  or 
d’oloured,  and  more  or  less  offensive  and  foul- 
s' liing  ; or  mixed  with  blood  in  various  propor- 
t|s,  especially  in  scurvy  and  low  fevers.  The 
pj  collects  mainly  in  the  pelvis  as  a rule  ; but 
evictions  of  it  are  also'found  between  the  coils 
oi.ntestine,  and  in  other  parts,  pent  up  by 
b ph  or  adhesions,  which  look  like  abscesses, 
a may  be  of  some  size.  These  collections 
si  etimes  give  way,  and  thus  set  up  secondary 
p tonitis.  In  exceptional  cases  purulent  peri- 
tc  tis  becomes  chronic,  and  accumulations  of 
P burst  externally  or  into  the  intestines.  In 
r.  instances  a gelatinous  or  colloid  material 
cc;  titutes  the  effusion  in  peritonitis. 

rith  regard  to  obvious  changes  presented  by 
tl  peritoneum  and  sub-peritoneal  tissue,  there 
u*;  be  none,  when  the  lymph  is  separated,  the 
p .oneal  surface  being  normal.  In  other  case* 
it  .dull,  lustreless,  swollen,  softened,  and  oedema- 
tc . as  well  as  the  subserous  tissue,  so  that  the 
Be  as  covering  can  be  easily  torn  off  from  the 
01  ns.  Occasionally  the  structures  are  infil- 
trj  '-d  with  actual  pus  ; and  under  certain  cir- 


DISEASES  OF.  1133 

cumstances  localised  gangrene  occurs  at  one  or 
more  spots. 

The  microscopic  changes  and  appearances 
differ  in  the  several  conditions  indicated,  but 
it  must  suffice  to  state  that  they  are  similar 
to  those  observed  in  other  forms  of  serous 
inflammation,  such  as  transudation  from  the 
vessels  ; migration  of  corpuscles  ; separation 
of,  changes  in,  and  proliferation  of  the  endo 
thelial  cells  ; proliferation  of  the  connective- 
tissue  corpuscles  ; and  the  formation  of  vascular 
granulations.  The  proportion  of  cells,  and  their 
vitality,  differ  very  much  in  the  several  kinds  of 
exudation.  The  changes  which  take  place  in 
the  formation  of  adhesions  and  allied  conditions 
are  also  like  those  noticed  in  other  serous  mem- 
branes. See  Serous  Membranes,  Diseases  of. 

In  certain  forms  of  acute  peritonitis  foreign 
materials  of  different  kinds  are  found  in  the  peri- 
toneal sac.  Foetid  gas  may  be  present,  either 
from  decomposition  of  inflammatory  products, 
from  transudation  through  the  intestinal  walls, 
or  from  perforation.  The  last-mentioned  cause 
also  accounts  for  the  presence  of  foreign  bodies, 
the  contents  of  the  stomach  or  intestine,  worms, 
bile,  gall-stones,  urine,  and  other  materials  which 
have  set  up  the  peritonitis. 

The  muscles  of  the  abdominal  wall  are  often 
found  more  or  less  softened,  pale,  and  degene- 
rated in  severe  cases  of  peritonitis.  The  in- 
testines are  almost  always  distended  with  gas, 
in  some  cases  to  an  extreme  degree,  so  that 
they  protrude  when  the  abdomen  is  opened. 
Their  walls  are  infiltrated,  cedematous,  and  soft- 
ened ; and  the  mucous  layer  can  be  readily  sepa- 
rated. The  stomach  is  usually  small  and  more 
or  less  contracted,  being  covered  by  the  intes- 
tines. The  liver  and  spleen  are  often  pale,  or 
discoloured  to  a slight  depth. 

The  morbid  appearances  in  acuto  peritonitis 
may  be  more  or  less  general  or  diffuse,  the 
whole  extent  of  the  membrane,  however,  being 
rarely  involved;  or  local  or  circumscribed,  the 
latter  being  due  to  some  local  irritation,  and 
not  spreading,  either  owing  to  the  nature  of  the 
inflammation,  or  because  it  is  prevented  by  ad- 
hesions. It  may  lead  either  to  a local  forma- 
tion of  lymph,  as  over  the  liver  or  some  other 
organ ; or  to  a circumscribed  collection  of  pus, 
which  becomes  practically  an  abscess,  and  may 
burst  in  various  dii-ections  according  to  its  seat. 
Some  local  varieties  of  peritonitis  have  received 
special  names,  such  as  pelvic,  parietal,  omental, 
hepatic,  nephritic,  and  vesical. 

It  must  be  remarked  that  special  care  is  re- 
quired in  making  a post-mortem  examination  in 
cases  of  acute  peritonitis,  as  in  many  forms  of 
the  disease  the  products  are  extremely  virulent, 
and  cause  dangerous  or  fatal  septicaemia  if  intro- 
duced into  the  system  in  the  smallest  quantity. 
Moreover,  in  some  forms  infection  is  very  liable 
to  be  conveyed  to  other  persons,  and  extreme  pre- 
cautions are  demanded  in  this  matter  in  dealing 
with  women  in  the  puerperal  state. 

Symptoms. — The  fact  must  be  clearly  recog- 
nised at  the  outset  that  the  clinical  history  of 
acute  peritonitis  varies  considerably  in  different 
cases,  according  to  ils  immediate  cause,  the  con- 
dition with  which  it  is  associated,  its  seat  and 
extent,  the  course  which  the  inflammation  takes. 


U34,  PERITONEUM, 

the  products  which  it  originates,  and  other 
circumstances.  So  far  as  the  peritonitis  is 
concerned,  the  phenomena  to  he  anticipated  are 
heal  and  general.  The  local  phenomena  are 
due  to  the  inflammation  itself;  to  its  products ; 
and  to  its  direct  effects  upon  abdominal  organs 
and  structures,  especially  upon  muscular  tissues, 
which  it  first  irritates  and  then  paralyses.  They 
may  be  further  subdivided  into  abdominal  and 
thoracic.  The  general  symptoms  are  either  of  a 
febrile  character ; or  depend  upon  the  absorption 
of  purulent  or  septic  matters  formed  in  the  peri- 
toneum ; or  are  indicative  of  collapse.  It  will  be 
expedient,  in  further  discussing  this  subject,  to 
indicate  first  the  usual  clinical  course  and  phe- 
nomena of  acute  peritonitis ; and  then  tc  point 
out  the  more  important  clinical  varieties  of  the 
disease. 

The  invasion  is  usually  distinct,  being  indi- 
cated by  shivering  or  actual  rigors,  which  may  be 
repeated  several  times.  If  the  peritonitis  is  due 
to  perforation,  however,  the  phenomena  attend- 
ing this  lesion  constitute  the  initial  symptoms, 
but  even  here  rigors  not  uncommonly  occur  sub- 
sequently. The  local  and  general  symptoms 
characteristic  of  peritonitis  speedily  supervene. 

Local  symptoms. — Pain  is  one  of  the  most 
constant  and  striking  symptoms  of  acute  peri- 
tonitis, and  it  comes  on  very  speedily,  or  in  cer- 
tain cases  may  even  precede  rigor.  It  depends 
directly  on  the  inflamed  condition  of  the  perito- 
neum. As  a rule  it  commences  locally,  and 
especially  in  the  lower  part  of  the  abdomen,  but 
it  rapidly  spreads  more  or  less  extensively,  being 
often  felt  over  the  whole  abdomen,  though  not 
uncommonly  more  marked  in  one  or  more  spots, 
such  as  where  the  inflammation  started  from,  and 
also  in  the  umbilical  region.  This  may  depend 
upon  greater  intensity  of  the  inflammation  at 
these  points.  The  pain  is  usually  exceedingly 
severe  and  intense,  and  it  maybe  excruciating  or 
agonising,  as  evidenced  in  the  expression  of  the 
patient’s  face.  In  character  it  is  variously  de- 
scribed as  hot,  burning,  cutting,  boring,  shoot- 
ing, darting,  and  so  on.  Prom  time  to  time 
exacerbations  are  liable  to  occur,  owing  to  spas- 
modic movements  of  the  intestines  disturbing  the 
inflamed  structures.  Any  movement  of  the  body 
increases  the  suffering,  so  that  the  patient  in- 
stinctively keeps  the  trunk  at  rest,  and  assumes 
a characteristic  posture,  so  as  to  relieve  all  ab- 
dominal tension,  namely,  lying  on  the  back,  with 
the  thighs  and  knees  flexed,  and  the  legs  drawn 
well  up.  Moreover,  abdominal  respiration  is 
restrained  or  entirely  checked,  as  the  necessary 
movements  increase  the  pain  ; which  is  also  ag- 
gravated by  any  such  disturbance  as  the  act  of 
coughing,  vomiting,  or  deftecation  causes.  At  the 
same  time  there  is  the  most  exquisite  tenderness, 
so  that  the  patient  dreads  any  objective  exami- 
nation, and  cannot  bear  the  least  touch,  though 
deeper  pressure  is  still  more  unendurable.  In 
some  cases  even  the  weight  of  the  bed-clothes 
cannot  be  tolerated. 

Prominent  symptoms  occur  in  connection  with 
the  alimentary  canal.  The  appetite  is  com- 
pletely lost,  but  there  is  intense  thirst.  The 
tongue  is  furred,  and  often  presents  a peculiar 
appearance,  being  very  small,  red,  and  irritable- 
louki  ng,  and  soon  tending  to  dryness.  The  taste 


DISEASES  OF. 

is  affected,  and  becomes  bitter  or  otherwis- 
disagreeable,  or  even  disgusting.  Nausea  am 
vomiting  are  usually  urgent  symptoms,  and,  a 
a rule,  set  in  very  early.  Vomiting  occurs  whei 
anything  whatever  is  taken,  and  even  spot 
taneously,  while  there  is  a constant  feeling  o 
sickness.  At  first  the  vomited  matters  consis 
of  mucus  and  altered  food ; subsequently  the' 
present  a grass-green  appearance  ; or  under  cer 
tain  circumstances  they  may  become  faeculent 
even  quite  apart  from  intestinal  obstruction 
Gaseous  eructations  are  also  common.  Obsti 
nate  constipation  is  the  rule  in  acute  peritonitis! 
but  exceptionally  diarrhoea  occurs.  At  first  tin 
intestinal  walls  are  more  or  less  spasmodical! 
contracted,  but  they  soon  become  paralysed,  si 
that  they  are  distended  to  a variable  degre 
with  gas,  and  this  frequently  culminates  ii 
extreme  tympanites  or  meteorism.  During  th< 
development  of  this  symptom,  irregular  am 
inefficient  peristaltic  movements  of  the  hove 
often  occur,  or  certain  parts  are  more  distendet 
than  others,  and  these  conditions  may  be  seei 
or  felt,  while  they  give  rise  to  audible  rumblinj 
or  gurling  sounds  or  borborygmi.  The  rapidity 
of  the  distension  of  the  abdomen  will  depenc 
much  upon  the  previous  condition  of  the  abdo-; 
minal  walls,  as  to  whether  they  are  firm  or  las 
and  yielding ; and  upon  the  rapidity  with  which 
their  muscles  become  paralysed. 

The  only  other  notable  local  symptoms  in  the 
abdomen  are  referable  to  the  urinary  organs 
The  urine  not  only  presents  febrile  characters 
but  is  usually  markedly  diminished  in  quantity 
and  may  even  be  suppressed.  What  is  passed  i 
often  hot  and  scalding.  Micturition  may  at  firs 
be  very  frequent,  owing  to  irritation  of  tb 
bladder ; subsequently  retention  is  liable  t( 
occur,  owing  to  paralysis  of  this  organ.  Tb 
urine  is  not  uncommonly  albuminous. 

Jaundice  is  now  and  then  observed  in  cases  o 
acute  peritonitis. 

The  thoracic  symptoms  which  may  resul; 
from  the  local  effects  of  acute  peritonitis  ar< 
hiccough,  which  is  in  many  instances  very  dis 
tressing  ; the  form  of  dyspnoea  in  which  tin 
respirations  are  very  hurried — reaching  40,  -50 
60,  or  more — shallow,  superficial,  and  costal 
sometimes  cough,  although  the  patient  make: 
every  effort  to  suppress  it;  and  cardiac  dis 
turbance,  the  action  of  the  heart  becoming  very 
rapid.  The  disorder  of  the  respiratory  and  cir- 
culating functions  is  partly  due  to  the  genera 
condition,  but  they  are  also  locally  influenced  b} 
the  pain  accompanying  peritonitis;  by  its  direc 
effects  upon  the  diaphragm ; and  by  the  me 
chanical  effects  of  gaseous  or  fluid  accumulation 
upon  the  diaphragm  and  thoracic  contents.  More 
over,  morbid  conditions  within  the  chest  may  b 
associated  with  peritonitis,  such  as  pleurisy 
pneumonia,  or  pericarditis. 

Physical  signs. — The  conditions  resulting frou 
peritonitis  give  rise  to  certain  physical  signs 
which  need  to  be  briefly  indicated.  It  must  b 
remembered  that  in  this  disease  physical  exami 
nation  ought  to  be  practised  most  gently  an< 
cautiously.  The  causes  of  the  abnormal  physica 
signs  are  the  pain  ; the  distension  and  other  dis 
orders  of  the  intestines ; and  the  presence  of  in 
flammatory  products  or  of  other  materials  in  t. 


PERITONEUM.  DISEASES  OE.  1136 


■ritoneal  cavity.  1.  The  abdomen  at  an  early 
■jriod  of  the  case  may  be  slightly  depressed, 
anir  to  tension  of  the  muscles,  but  soon  be- 
cues  more  or  less  enlarged,  and  often  attains  a 
(feat  size,  the  skin  being  stretched,  and  the  lower 
]rt  of  the  chest  also  distended.  Generally 
fe  enlargement  is  quite  symmetrical,  but  no  t al- 
i yg.  A transverse  groove  is  sometimes  visible, 
losing  across  the  epigastrium.  In  very  mus- 
i ar  individuals  the  abdomen  may  be  but  little 
barged  in  peritonitis.  2.  There  is  marked 
Hence  of  diaphragmatic  respiratory  movements, 
ifl  these  movements  as  a whole  are  restricted. 
1e  lower  intercostal  spaces  do  not  fall  in  during 
rpiration.  Very  rarely  a friction-fremitus 
i y be  felt  in  some  part  of  the  abdomen  when  a 
f;l  breath  is  taken.  3.  Intestinal  movements 
s often  seen  or  felt.  4.  Palpation  reveals  that 
4 abdomen  is  smooth  and  regular;  at  first  the 
riscles  are  felt  to  become  as  it  were  instinc- 
tJbly  contracted  when  palpation  is  practised  ; 
s>sequently  the  sensation  is  usually  that  of 
rre  or  less  tympanitic  or  drum-like  tension, 
'lere  are  exceptional  cases  in  which  it  is  that 
t fluid.  5.  Percussion  usually  yields  chiefly 
ffnsre  or  less  tympanitic  sound,  though  not 
nessarily  uniform  in  tone  and  pitch  over  the 
e.ire  abdomen.  The  hepatic  and  splenic  dulness 
a diminished  or  completely  annulled,  even 
t'ugh  there  be  no  gas  in  the  peritoneum  itself, 
/[mall  quantity  of  fluid  cannot  be  detected,  or 
oy  by  careful  examination  in  certain  postures 
(;  Ascites),  and  it  is  usually  hardly  worth 
v ie  in  cases  of  peritonitis  to  disturb  tho  patient 
fij  this  purpose.  Generally  the  dulness  due 
tcfluid  can  be  elicited  in  dependent  parts  of 
tl  abdominal  cavity,  being  as  a rule  distinctly 
ni  able  with  change  of  posture.  It  is  said  that 
titline  of  demarcation  between  the  dulness  and 
tjpanitic  sound  is  found  to  be  zigzag  when 
Cilfully  percussed  out,  owing  to  the  fluid  getting 
imetweon  the  loops  of  intestine.  In  exeep- 
tinl  cases  of  acute  peritonitis  the  dulness  of 
flu  is  the  main  percussion-sound  noticed. 
Futuation  will  be  present  where  there  is 
fhj,  but  it  is  not  a very  reliable  sign  in 
adie  peritonitis.  6.  Auscultation,  as  a rule, 
mely  reveals,  if  anything,  sounds  of  the 
moments  of  flatus  in  the  stomach  and  intes- 
tiij;  or  succussion-sounds,  due  to  the  shaking 
up,of  fluid  and  gas  in  these  organs.  Fric- 
tioisound  is  for  several  reasons  a rare  phe- 
ncjmon,  but  may  occasionally  be  heard  over 
sol  spot  if  the  patient  can  be  made  to  breathe 
sudently  deeply,  mainly  over  a solid  organ, 
an  especially  the  liver.  7.  Examination  of 
th  chest  often  reveals  more  or  less  compression 
of'ie  lower  parts  of  the  lungs  ; and  displace- 
mt,  of  the  heart  upwards  and  towards  the  left. 

\ncral  symptoms.- — Pyrexia  usually  speedily 
set  n in  acute  peritonitis,  but  in  certain  cases 
tin  is  no  rise  of  temperature  throughout. 
IVljs  presenting  considerable  differences,  as  a 
ru!;he  temperature  rises  markedly  at  an  early 
per  l,  and  continues  high  for  a time,  though 
genilly  with  remissions,  having,  however,  no 
regiir  course.  There  are  the  usual  accom- 
paihents  of  fever  ; and  the  urine  is  markedly 
teb'a,  being  concentrated,  high-coloured,  and 
dep  iting  urates  abundantly.  The  pulse  be- 


comes very  frequent,  reaching  120,  140,  or  even 
160 ; it  is  also  small,  sharp,  and  often  peculiarly 
hard,  wiry,  or  thready.  The  increased  rapidity 
of  breathing  is  partly  due  to  pyrexia.  The  pa- 
tient soon  presents  an  aspect  of  serious  constitu- 
tional disturbance ; the  expression  of  the  face  is 
one  of  pain  and  grave  anxiety,  and  the  features 
are  sunken,  pinched,  and  withered.  There  is 
much  debility  or  actual  prostration,  while  at  the 
same  time  the  patient  is  generally  uneasy  and 
restless,  tossing  the  arms  about,  but  keeping  the 
trunk  motionless.  A more  or  less  cyanotic  ap- 
pearance may  be  evident.  There  are  usually  no 
prominent  nervous  symptoms  at  first,  except,  per- 
haps, headache  and  sleeplessness.  The  intellect 
generally  remains  clear  to  the  last,  and  it  oc- 
casionally happens  that  the  supervention  of  peri- 
tonitis rouses  a patient  whose  consciousness  has 
been  previously  more  or  less  blunted.  In  ex- 
ceptional cases  delirium  or  impaired  conscious- 
ness are  early  symptoms.  The  further  progress 
of  the  general  symptoms  will  be  indicated  under 
the  following  heading. 

Course  and  Terminations. — The  large  ma- 
jority of  cases  of  acute  peritonitis  terminate 
fatally,  and  usually  within  a few  days,  the  pro- 
gress being  rapid.  It  is  important  to  notice  that 
the  patient  may  feel  better,  and  that  the  pain 
often  diminishes  or  even  subsides,  sometimes 
suddenly,  while  the  general  condition  is  becoming 
worse  and  worse.  The  tympanites  may  also 
become  less,  or  disappear.  Sometimes  before  the 
close  an  abundance  of  dark,  blood-stained  fluid 
is  discharged  from  the  stomach  and  bowels, 
without  any  effort.  Death  may  occur  while  the 
pyrexia  is  still  high ; but  usually  the  phenomena 
observed  become  those  of  collapse,  combined  with 
signs  of  impaired  respiration  and  stagnant  circu- 
lation. The  patient  is  greatly  prostrated.  The 
countenance  assumes  more  and  more  the  as- 
pect of  collapse,  the  eyeballs  appearing  sunken 
and  surrounded  with  dark  areolae,  the  cheeks 
hollow,  and  the  features  markedly  pinched,  with 
blueness  of  the  lips;  the  expression  is  that 
of  extreme  anxiety.  The  temperature  falls,  and 
often  becomes  sub-normal ; the  extremities  are 
cold ; and  the  skin  is  covered  with  clammy  sweats, 
while  the  prominent  parts  are  peculiarly  cold 
and  blue.  The  pulse  becomes  extremely  rapid ; 
feeble,  sometimes  to  complete  extinction  ; and 
irregular.  The  respirations  are  very  hurried 
and  shallow ; and  the  voice  is  weak  or  lost.  As 
already  stated,  the  mind  generally  remains  clear 
to  the  last ; but  in  some  cases  the  mental  faculties 
are  somewhat  obscured  towards  the  close,  and 
delirium  of  a low  type  occurs ; occasionally  a co- 
matose condition  supervenes.  In  some  instances 
the  symptoms  become  those  of  the  typhoid  state. 

Acute  peritonitis  occasionally  subsides  into  a 
chronic  condition,  in  which  localised  accumula- 
tions of  fluid  remain,  and  the  patient  lingers  on,  the 
temperature  continuing  elevated,  but  presenting 
irregularities.  Different  events  may  then  occur, 
such  as  bursting  of  fluid-collections  in  various 
directions,  the  supervention  of  septicaemia  or 
pyaemia,  or  general  wasting  and  anaemia,  death 
ultimately  taking  place  after  a variable  interval. 

Recovery  ensues  in  a certain  proportion  ol 
cases,  where  the  inflammation  has  not  been  ex- 
tensive, and  where  its  products  are  either  fibri 


-1136 


PERITONEUM,  DISEASES  OF. 


nous  or  sero-fibrinous.  Improvement  is  indicated 
by  a concomitant  diminution  of  the  abdominal 
symptoms ; restoration  of  the  action  of  the  bowels ; 
sometimes  an  increase  in  the  quantity  of  urine; 
a change  in  the  aspect  and  expression  of  the 
patient ; increased  fulness  and  force  of  the  pulse, 
and  diminution  of  its  frequency  ; a gradual  fall  of 
temperature;  restoration  of  sleep;  and  sometimes 
the  occurrence  of  perspiration.  It  is  said  that 
occasionally  a crisis,  with  critical  discharges, 
occurs,  but  this  is  quite  exceptional,  the  decline 
of  temperature  being  usually  by  lysis.  After  ap- 
parent recovery  from  acute  peritonitis  the  effects 
of  adhesions  may  prove  serious. 

Clinical  Varieties. — It  will  only  be  practi- 
cable to  indicate  here  the  most  striking  of  the 
clinical  variations  presented  by  cases  of  acute 
peritonitis.  Two  special  forms  are  described  in 
separate  articles.  See  Puerperal  Diseases;  and 
Pelvic  Peritonitis. 

(a)  Peritonitis  from  Intestinal  Obstruc- 
tion.— Here  the  symptoms  of  the  obstruction  are 
the  most  prominent,  and  the  peritoni  tis  only  modi- 
fies them,  and  helps  to  hasten  the  fatal  issue,  which 
is  mainly  due  to  the  intestinal  condition.  It  is 
in  these  cases  that  the  movements  of  the  bowels 
are  most  evident,  and  the  meteorism  is  extreme. 
The  temperature  may  continue  normal  or  even 
sub-normal  throughout.  The  course  is  usually 
very  rapid. 

( b ) Perforative. — When  general,  this  is  an 
intense  and  very  fatal  form  of  peritonitis,  and 
usually  runs  its  course  very  speedily,  especially 
if  highly  irritating  materials  gain  access  into 
the  peritoneum.  Usually  it  is  distinctly  pre- 
ceded by  the  characteristic  symptoms  of  the 
perforation ; or  some  condition  is  present  in  which 
a perforation  may  be  anticipated.  Therefore, 
if  rigors  occur,  they  follow  a sudden  local  pain, 
which  spreads  rapidly  over  the  abdomen.  The 
local  symptoms  are  extremely  marked,  and  the 
vomiting  is  likely  to  be  most  violent,  except,  it 
is  said,  in  those  cases  where  the  stomach  itself 
is  the  seat  of  a large  perforation.  Moreover, 
there  may  be  signs  of  gas  in  the  peritoneal 
cavity  ( see  Peritoneum,  Gas  in).  The  symp- 
toms of  collapse  are  evident  from  the  first,  and 
quickly  become  aggravated.  The  temperature  is 
often  below  the  normal.  Should  the  perforation 
take  place  into  a limited  portion  of  the  perito- 
neum, the  symptoms  are  correspondingly  limited, 
and  less  severe. 

(c)  Adynamic  or  Typhoid. — Cases  of  peri- 
tonitis maybe  thus  grouped  which  exhibit  a dis- 
position to  the  rapid  development  of  adynamic 
or  typhoid  symptoms.  These  may  depend  upon 
the  condition  with  which  the  peritonitis  is  asso- 
ciated ; or  upon  septicaemia  or  pyaemia,  arising 
from  the  absorption  of  inflammatory  products 
from  the  peritoneum.  In  some  of  these  cases 
the  local  symptoms  are  not  so  evident,  and  may 
be  quite  latent. 

(d)  Latent.— This  term  implies  that  the  cha- 
racteristic symptoms  ofperitonitis  are  either  alto- 
gether absent,  or  so  indefinite  as  to  be  practically 
valueless  for  diagnostic  purposes.  Such  may 
happen  in  cases  belonging  to  the  adynamic  group, 
where  the  patient’s  consciousness  is  so  impaired 
that  he  cannot  feel  pain ; but  even  then  pressure 
over  the  abdomen  may  bring  out  indications  of 


pain,  if  carefully  watched  for.  For  some  latent 
cases  of  acute  peritonitis,  of  which  the  write 
has  seen  a striking  instance,  no  explanation  can 
be  given.  To  this  class  may  also  be  referred 
those  cases  where  it  is  really  difficult  to  draw 
the  line  between  mere  ascites  and  peritonitis 
with  abundant  fluid  effusion. 

(e)  Infantile. — This  has  been  described  as  a 
variety  of  peritonitis.  In  young  infants  pain 
and  tenderness  in  this  disease  are  indicated  by 
the  expression,  and  by  a short  cry  or  whitie 
They  do  not  cry  loudly,  on  account  of  the  pain 
thus  caused.  The  abdomen  is  greatly  distended 
with  flatus.  Vomiting  is  less  common  in  children 
than  in  adults.  Pyrexia  is  usually  considerable 
at  an  early  period ; and  the  pulse  becomes  ex- 
tremely frequent,  even  uncountable.  Occasion- 
ally convulsions  occur.  The  course  is  very  rapid 
in  young  children  as  a rule. 

(f)  Local  or  Circumscribed. — Casesoflocal- 
ised  peritonitis  belong  practically  to  two  groups 
The  first  includes  those  in  which  there  is  a limited 
fibrinous  exudation,  set  up  by  some  local  irrita- 
tion, especially  in  connection  with  some  solid 
organ,  such  as  a cancerous  liver,  or  with  a ru- 
mour. Such  a condition  is  only  indicated  by  s 
correspondingly  localised  pain  and  tenderness 
with  perhaps  friction-fremitus  and  sound,  elicits 
during  the  respiratory  movements.  The  othe; 
local,  as  well  as  the  general  symptoms  of  peri 
tonitis,  are  absent,  and  the  constitution  frequent! 
does  not  appear  to  suffer  in  the  least.  In  th- 
second  group  a limited  effusion  occurs,  whicl 
becomes  purulent ; or  there  may  be  several  suel 
efiusions.  Here  the  symptoms  are  more  severe 
but  the  pain  and  tenderness  are  still  circum 
scribed,  and  in  time  external  objective  sign 
often  appear  in  tlje  corresponding  region  of  th 
abdomen,  such  as  limited  fulness,  a feeling  c 
firmness  followed  by  fluctuation,  redness  of  th 
skin,  and  dulness  on  percussion.  The  mor 
characteristic  local  symptoms  of  acute  peritoniti 
are  either  absent,  or  much  less  prominent  tha 
usual.  The  general  symptoms,  however,  nr 
frequently  very  marked,  but  they  are  merely  c 
a febrile  character,  preceded  in  many  cases  1' 
rigors.  The  subsequent  progress  of  the  symp 
toms  will  depend  upon  the  course  of  event! 
Thus,  general  peritonitis  may  be  set  up;  th 
accumulation  may  burst  externally ; a commun: 
cation  may  be  formed  with  some  internal  hollo 
organ,  especially  the  intestine,  when  gas  finds  it 
way  into  the  space,  giving  rise  to  a limited  tyn 
panitic  sound  on  percussion,  and  the  fluid  is  evf 
cuated  by  the  bowel ; pytemia  may  occur ; or  tit- 
condition  may  become  more  or  less  chronic,  an 
the  fluid  is  ultimately  evacuated  in  some  dire- 
tion  or  other,  or  undergoes  a caseous  change.  < 
is  absorbed,  a cure  resulting,  with  the  formate 
of  thickening  and  adhesions.  Any’  organ  in  tf 
vicinity  of  localised  peritonitis  is  likely  to  1 
disturbed  in  its  functions  ; and  the  accumulate 
of  inflammatory  products  may  physically  inte 
fere  with  neighbouring  structures.  Inflammatic 
of  the  great  omentum  is  attended  with  ve 
marked  superficial  pain  and  tenderness. 

(o')  Complicated. — Clinical  varieties  of  pei 
tonitis  not  uncommonly  result  from  itsassociatl 
conditions.  Thus  it  may  be  modified  by  soi 
disease  to  which  it  is  secondary,  such  as  typho 


PERITONEUM,  DISEASES  OF. 


■ver  or  pyasmia;  or  it  is  accompanied  by  some 
her  affection,  such  as  muco-enteritis,  pleurisy, 

• pericarditis ; or  the  peritonitis  gives  rise  to 
eondary  lesions,  which  modify  the  clinical  his- 
jry  of  particular  cases. 

Diagnosis. — In  well-marked  cases  the  dia- 
osis  of  acute  peritonitis  is  sufficiently  obvious, 
evidenced  by  the  cause  of  the  disease;  its 
ode  of  onset ; the  severity  and  character  of  the 
■,al  symptoms;  the  physical  signs;  the  nature 
jji  gravity  of  the  general  symptoms  ; and  the 
lpid  progress  of  the  case.  More  or  less  diffi- 
aty  may  be  experienced  when  the  peritonitis 
iissociated  with  certain  other  conditions  in  the 
tiomen,  modifying  its  symptoms ; when  it  is  ob- 
t red  by  the  general  stato  of  the  patient;  when 
i symptoms  are  quite  latent ; or  when  the  dis- 
66  is  local.  In  some  instances  it  is  impossible 
caistinguish  between  mere  ascites  and  inflam- 
n:ory  effusion.  It  is  very  important  to  bear  in 
nld  the  conditions  in  which  latent  peritonitis  is 
liile  to  occur.  It  may  happen  that  the  dia- 
g;sis  of  peritonitis  is  clear  enough,  but  that  its 
c:se  cannot  be  discovered,  or  only  after  very 
ti  tough  investigation. 

here  are  certain  affections  which  must  be 
rtembered,  as  being  liable  to  simulate,  and  to 
btnistaken  for,  acute  peritonitis.  1.  The  writer 
hi  seen  cases  of  extreme  tympanites,  accom- 
pffled  with  pain,  in  typhoid  fever,  and  in  low 
fe|le  diseases,  such  as  erysipelas,  very  much 
re/mbling  some  forms  of  peritonitis.  2.  Pain- 
fuconditions  of  the  abdominal  wall  may  prove 
tnblesome,  namely,  muscular  rheumatism, 
lotised  inflammation,  and  cutaneous  hyper- 
asesia.  Here,  however,  although  there  is 
su  rficial  and  usually  diffused  pain,  with  marked 
tewrness,  which  may  be  extreme,  there  are 
no  of  the  grave  abdominal  and  general  symp- 
toi  observed  in  peritonitis,  with  the  peculiar 
pa and  other  characteristic  phenomena.  In 
coi  iction  with  hysteria  i ntense  hyperassthesia  of 
the  bdomen  is  occasionally  met  with,  with  more 
or  ;s  distension,  sickness,  and  constipation,  and 
evqapparently  severe  constitutional  disturbance 
a ubination  of  symptoms  which  may  closely 
sm  ate  peritonitis.  Due  care  should,  however, 
prent  any  mistake  in  diagnosis,  for  the  patient 
is  nerally  obviously  hysterical ; no  cause  of 
per .nitis  can  be  discovered;  the  hypersesthesia 
is  Vy  superficial,  and  pressure  can  be  borne  if 
the'atient’s  attention  is  taken  off;  while  the 
gen  ii  symptoms  are  not  really  those  of  peri- 
ton, s,  and  there  is  little  or  no  pyrexia.  3. 
Pai  d affections  within  the  abdomen  have  to 
be  (jtinguished  from  peritonitis.  These  include 
erat  in  the  stomach ; intestinal  colic  ; the  pas- 
sage hepatic  or  renal  calculi ; painful  affections 
com  ted  with  the  female  generative  organs ; and 
perils  neuralgia  implicating  certain  abdominal 
vise li.  In  many  cases  the  pain  is  accompanied 
with  omi ting,  frequent  pulse,  and  considerable 
genc-jl.  disturbance,  tending  more  or  less  to- 
vrarit  collapse.  The  previous  history  of  the 
case  ;he  mode  of  onset  of  the  symptoms ; as 
well  their  precise  character,  ought  as  a rule  to 
rend  the  diagnosis  at  once  evident.  Moreover, 
the  ijicky  and  neuralgic  pains  are  usually  re- 
lieve by  pressure.  Doubtful  cases  must  he 
watc  1,  when  any  difficulty  will  probably  soon 

72 


1137 

be  cleared  up.  It  must  he  romembered,  how- 
ever, that  some  of  the  conditions  mentioned  may 
set  up  local  inflammation,  and  even  peritonitis, 
and  thus  the  diagnosis  will  be  rendered  more 
obscure.  4.  Certain  objective  morbid  conditions 
within  the  abdomen  must  also  be  alluded  to  in 
relation  to  the  diagnosis  of  peritonitis.  It  may- 
be impossible  to  distinguish  between  this  com- 
plaint and  tho  graver  form  of  enteritis,  espe- 
cially that  resulting  from  intestinal  obstruction, 
but  the  diagnosis  is  not  of  practical  moment,  and 
the  two  diseases  are  usually  combined  sooner  or 
later.  The  positive  diagnosis  of  peritonitis  in 
some  cases  of  perforation  may  also  be  impractic- 
able. In  the  local  forms  of  inflammation  com- 
mencing in  cellular  tissue,  such  as  perinephritis 
and  perityphlitis,  it  cannot  be  certainly  known 
whether  the  peritoneum  is  involved  or  not;  but 
it  may  be  assumed  that  the  neighbouring  por- 
tion of  the  membrane  is  very  soon  implicated, 
and  the  peritonitis  may  become  general.  Pos- 
sibly, circumstances  might  arise  under  which  ac- 
cumulations of  fluid,  such  as  an  ovarian  cyst,  a 
hydatid  cyst,  or  a distended  bladder,  might  simu- 
late peritonitis  with  effusion,  but  there  rarely 
ought,  to  be  any  real  difficulty  in  these  cases. 

; These  conditions,  as  well  as  other  tumours,  may, 
however,  set  up  peritonitis.  5.  It  must  bo  men- 
tioned that  at  first  acute  pleurisy  or  pneumonia 
may  simulate  peritonitis,  the  pain  present  in 
these  diseases  being  referred  to  the  upper  part 
of  the  abdomen,  or  even  to  a more  extensive 
area,  and  being  accompanied  with  tenderness. 
It  may  be  that  in  somo  of  these  cases  the  peri- 
toneum is  locally  inflamed. 

Pbognosis. — Acute  peritonitis  must  alway-s  be 
regarded  as  a serious  disease,  and  in  many  cases 
the  prognosis  is  extremely  grave,  or  even  hope- 
less. Moreover,  its  progress,  when  general,  is 
usually  very  rapid,  so  that  the  patient  may  die 
within  thirty-six  or  forty-eight  hours,  and  gene- 
rally succumbs  within  a week.  Death  may  occur, 
however,  in  three  or  four  weeks,  or  even  at  a 
! later  period.  In  some  of  the  cases  of  very  short 
duration,  death  is  due  rather  to  the  cause  of  the 
peritonitis,  such  as  intestinal  obstruction  or 
perforation,  than  to  the  disease  itself.  The 
indications  giving  hope  of  recovery  have  already 
been  pointed  out,  but  the  practitioner  must  guard 
against  being  misled  into  giving  a hopeful  pro- 
gnosis from  mere  improvement  in  the  subjective 
feelings  of  the  patient,  without  any  correspond- 
ing amelioration  in  the  objective  local  symptoms, 
and  in  the  general  condition.  Even  in  cases  where 
recovery  takes  place,  the  effects  of  adhesions  and 
other  remaining  morbid  conditions  must  be  borne 
in  mind,  as  these  may  subsequently  become 
troublesome  or  even  dangerous. 

The  prognosis  of  acute  peritonitis  will  be  ma- 
terially influenced  by  the  following  considera- 
tions;— 1.  Its  (Etiology. — The  most  grave  forms 
are  those  due  to  perforation ; and  those  of  septic 
origin,  especially  puerperal  peritonitis.  That  as- 
sociated with  Bright’s  disease  and  other  forms  of 
blood-poisoning,  is  also  very  serious.  When  the 
disease  arises  from  direct  injury,  or  from  some 
local  irritation,  the  prognosis  is  much  more  hope- 
ful. 2.  The  patient. — In  young  infants  peritoni- 
tis is  absolutely  fatal,  and  it  is  extremely  grave 
in  children  generally.  A weak  or  low  condition 


1138  PERITONEUM, 

of  the  patient,  from  bad  living,  intemperance, 
previous  illness,  or  other  causes,  renders  the 
prognosis  more  serious.  3.  The  extent , rapidity, 
and  precise  nature  of  the  disease. — Peritonitis 
is  more  serious  in  proportion  to  its  extent,  and 
when  it  is  local  the  result  is  much  more  hopeful, 
especially  if  the  products  of  the  inflammation 
seem  to  be  merely  lymph  or  sero-fibrinous  fluid, 
when  no  particular  danger  need  be  anticipated. 
If  the  course  of  the  disease  is  very  rapid,  the 
prognosis  is  exceedingly  grave,  partly  because 
the  inflammatory  products  are  then  probably  of 
a low  type.  When  peritonitis  shows  any  ten- 
dency to  become  chronic,  there  is  more  hope  ; but 
even  then  a fatal  issue  may  ultimately  occur  from 
various  causes.  4.  The  symptoms. — It  may  be 
stated  generally  that  the  more  severe  the  symp- 
toms of  peritonitis  are  as  a whole,  the  more 
dangerous  is  the  case.  Among  the  chief  indica- 
tions of  special  danger  may  be  mentioned  extreme 
tympanites;  urgent  vomiting;  the  passage  of 
bloody  fluid  from  the  stomach  or  bowels  ; great 
dyspnoea;  incessant  hiccup;  very  high  fever; 
rapid  development  of  signs  of  collapse  ; typhoid 
symptoms,  with  low  nervous  phenomena;  and  an 
extremely  rapid,  feeble,  and  irregular  pulse.  5. 
Complications. — These  may  increase  the  gravity 
of  a case  of  peritonitis,  such  as  pleurisy,  pneu- 
monia, or  pericarditis. 

Theatmext. — It  will  be  evident  that  no  uni- 
form plan  of  treatment  can  be  applicable  to  all 
cases  of  peritonitis,  and  much  judgment  and  con- 
sideration on  the  part  of  the  practitioner  are  often 
needed  in  the  management  of  this  serious  dis- 
ease. There  are,  however,  certain  definite  in- 
dications to  be  recognised,  which  will  now  be 
pointed  out,  as  well  as  the  principal  means  by 
which  they  should  be  carried  out. 

a.  Attention  must,  in  the  first  place,  be  di- 
rected to  the  cause  of  the  peritonitis,  which  in 
obscure  cases  should  be  carefully  sought  for, 
and,  if  possible,  got  rid  of,  or  mitigated.  This 
may  be  illustrated  by  an  accumulation  of  faeces, 
hernia,  and  other  forms  of  intestinal  obstruc- 
tion. In  most  cases,  however,  this  indication 
cannot  be  fulfilled  ; but  even  then  attention  must 
be  directed  to  the  cause. 

h.  The  next  indication  is  to  endeavour  to  com- 
bat the  inflammation  itself,  so  as  to  arrest  or 
subdue  it,  to  influence  its  products,  and  to  obviate 
its  injurious  effects  upon  the  abdominal  organs. 
Rest  for  the  affected  structures  is  most  important, 
so  far  as  it  can  be  obtained.  It  will  rarely  bo 
necessary  to  enjoin  rest  for  the  abdomen  gener- 
ally, and  relaxation  of  its  muscles,  as  the  patient 
will  instinctively  attend  to  this.  It  may  be  de- 
sirable to  raise  the  bed-clothes  from  the  body,  by 
means  of  a cradle  or  other  suitable  apparatus, 
so  as  to  prevent  all  irritation  from  this  source. 
If  not  otherwise  indicated,  it  is  extremely  im- 
portant in  early  cases  of  peritonitis  to  give  as 
little  as  possible  in  the  way  of  food.  Only  frag- 
ments of  ice,  or  small  quantities  of  iced  drinks 
should  be  allowed,  or  iced  milk  or  beef-tea,  if 
they  can  be  retained.  Not  uncommonly  the  stom- 
ach rejects  everything,  and  then  recourse  may  be 
had  to  small  enemata,  and  it  might  be  useful  to 
employ  artificially-digested  aliments  in  this  way, 
according  to  the  plan  of  Dr.  'William  Roberts. 

Abstraction  of  blood,  either  by  venesection  or 


DISEASES  OF. 

by  the  application  of  leeches  to  the  abdomen,  is 
a common  practice  in  acute  peritonitis.  If  this 
measure  is  thought  desirable,  it  is  certainly  pre- 
ferable to  remove  the  blood  locally:  from  ten  to 
thirty  leeches  may  be  applied  in  different  cases, 
but  it  certainly  can  never  serve  any  useful  pur- 
pose to  put  on  a larger  number  than  this,  and 
would  probably  be  followed  bv  untoward  results. 
Removal  of  blood  can  only  be  of  service  in  the 
early  stage  of  the  disease,  and  is  decidedly  in 
jurious  when  the  inflammatory  process  has  pro- 
gressed considerably,  and  especially  if  it  has 
advanced  rapidly.  Moreover,  it  must  not  1* 
practised  in  low  forms  of  peritonitis,  or  if  the 
patient  is  badly  nourished  and  weak  from  any 
cause.  Healthy,  strong,  and  plethoric  subjects 
are  most  likely  to  be  benefited  by  removal  of 
blood.  This  measure  is  also  likely  to  bo  useful 
in  some  forms  of  local  peritonitis. 

The  chief  medicines  which  are  employed  for 
their  immediate  effects  upon  peritonitis  are 
calomel  and  opium,  and  they  are  usually  given 
in  combination,  in  the  form  of  pill,  every  two 
to  four  hours.  The  calomel  is  administered 
until  the  system  is  brought  under  the  influ- 
ence of  mercury ; or,  in  the  case  of  infants, 
this  is  sometimes  effected  by  inunction  with  the 
mercurial  ointment.  In  the  writer’s  opinion, 
mercurialisation  as  a routine  plan  of  treatment 
in  peritonitis  is  to  be  strongly  deprecated,  and 
he  has  never  seen  any  good  result  from  its  em- 
ployment. Opium,  however,  is  a remedy  oi 
extreme  value,  and  is  often  our  sheet-anchor 
Amongst  other  beneficial  effects,  it  acts  upon  the 
stomach  and  bowels,  being  generally  supposet 
to  arrest  peristaltic  action  in  the  latter,  thong) 
some  are  of  opinion  that  it  excites  peristalti 
action,  hut  diminishes  reflex  irritation.  In  what 
ever  way  this  drug  acts,  its  beneficial  effects  upo 
these  organs  are  very  manifest.  Opium  is  usuall 
given  in  the  form  of  pill,  containing  from  gr. 
togr.  ij  of  the  powder,  and  repeated  every  two  t 
four  hours.  It  is  remarkably  tolerated  in  acut 
peritonitis,  unless  there  be  renal  disease,  whe 
it  must  bo  given  very'  cautiously,  nr  not  at  al 
In  children  it  must  also  be  administered  wit, 
due  care.  If  the  stomach  is  extremely irritabl 
tincture  of  opium  may  be  administered  in  tb 
form  of  enema  ; or,  which  is  preferable,  morph 
may  he  substituted,  especially  by  subcutaneoi 
injection  ; and  this  may  be  also  employed  as  a 
adjunct  to  the  internal  exhibition  of  opium, 
the  pain  should  be  very  intense.  Tincture  c 
aconite,  veratrum  viride,  and  digitalis  have  bee 
employed  for  their  effects  on  inflammation  in  tl 
early  stages  of  acute  peritonitis,  but  they  canm 
be  recommended. 

The  question  of  local  applications  to  the  a 
domen,  as  regards  their  immediate  effects  up< 
peritonitis,  is  important,  and  byno  means  decide 
The  common  practice  is  in  favour  of  employn 
hot  applications,  in  the  form  of  light  poultices 
fomentations,  to  which  anodynes  may  be  adde> 
or  turpentine  stupes  or  sinapisms.  The  use 
cold  has,  however,  been  strongly  advocated 
many  authorities  in  the  early  stage  of  peritonit 
and  deserves  a more  extended  and  thorough  tr 
than  it  has  hitherto  received.  It  may  be  c; 
ployed  either  by  means  of  cold  compresses,  £ 
quently  changed;  a bladder  containing  pound 


1139 


PERITONEUM, 

'ice,  not  too  heavy ; or  flannel  dipped  in  iced- 
lvater.  The  effects  claimed  for  this  treatment 
are  that  it  contracts  the  vessels  ; allays  nervous 
irritability,  and  consequently  intestinal  distur- 
bance ; and  alleviates  pain.  The  sensations  of 
, the  patient  must  be  some  guide  as  to  its  con- 
tinuance. At  a later  period  hot  applications  are 
decidedly  to  be  preferred,  as  the  cold  applica- 
tions can  be  of  no  service,  and  -will  probably 
prove  injurious. 

As  certain  cases  advance,  it  may  be  advisable 
to  apply  blisters  to  different  parts  of  the  ab- 
domen, vrith  the  view  of  promoting  the  iibsorp- 
jtion  of  inflammatory  products.  Operative  in- 
terference is  decidedly  indicated  in  some  cases 
hf  considerable  effusion,  the  fluid  being  removed 
by  a trochar.  It  may  also  become  a question 
whether  purulent  collections  should  not  be  let 
nit,  after  acute  symptoms  have  subsided.  Cer- 
ainly  this  measure  is  indicated  if  there  is  any 
oeal  accumulation  of  pus. 

c.  The  general  condition  of  the  patient  in 
■ases  of  acute  peritonitis  always  demands  con- 
rant  attention,  and  in  many  instances  it  is  the 
hief  matter  for  consideration.  Whenever  any 
endency  to  collapse  or  adynamia  sets  in,  alco- 
lolic  stimulants  are  called  for,  in  variable  quan- 
tity according  to  circumstances,  brandy  and 
ihampagne  being  the  most  suitable.  Their  ad- 
ministration must  not  be  left  until  too  late  a 
eriod.  They  are  best  given  at  frequent  inter- 
als  in  small  quantities.  If  stimulants  cannot 
e borne  by  the  stomach,  brandy  should  be  given 
1 enemata.  Liquid  nourishing  food  is  also  often 
quired  in  large  quantities,  and  may  he  admin- 
tered  in  the  same  way.  Quinine  in  full  doses, 
.her,  musk,  camphor,  ammonia,  hark,  and  tur- 
lintine,  are  the  chief  medicines  which  may  be 

lied  for  in  bad  cases,  to  combat  the  general 
mptoms.  Subcutaneous  injection  of  ether  or 
mphor  may  be  of  service  in  extreme  conditions. 

d.  Symptoms  often  call  for  special  treatment 
acute  peritonitis,  although  most  of  them  tend 
be  alleviated  by  the  measures  already  con- 

dered.  It  will  only  he  necessary  to  allude 
ether  to  the  following.  Nausea  and  vomiting 
ly  call  for  small  doses  of  iced  efferveseents, 
th  hydrocyanic  acid  and  morphia ; soda-water 
1 milk ; or  drop-doses  of  creasote.  Constipa- 
n in  many  cases  ought  on  no  account  to  be  dis- 
■bed;  if  any  treatment  is  indicated,  calomel  at 
c,t,  followed  by  enemata,  will  answer  the  purpose. 
,cessive  diarrhoea  in  certain  cases  may  require 
i‘be  checked  by  enemata  containing  laudanum, 
teorism  is  sometimes  relieved  by  calomel ; if 
ry  troublesome,  the  use  of  enemata  containing 
t pentine,  the  passage  of  a long  tube  per  rec- 
0,  or,  in  extreme  cases,  the  puncture  of  the 
o. ended  intestines  in  several  places  with  a fine 
t char,  are  the  measures  indicated.  The  relief 
c -Lis  symptom  is  the  only  direct  way  of  in- 
ducing dyspnoea.  Hiccup  calls  for  narcotics, 
^sr,  the  local  application  of  sinapisms  or  blis- 
t ',  and,  if  dangerous,  inhalation  of  chloroform. 

In  cases  where  recovery  ensues,  much  care 
acquired  during  convalescence,  as  regards  diet 
a general  management ; and  the  absorption  of 
s bid  products  may  be  aided  by  applying  blis- 
-*  or  iodine  to  the  abdomen,  and  by  baths  and 
oi  r measures. 


DISEASES  OF. 

2.  Peritoneum,  Chronic  Inflammation  of. 
Stn'on.  : Chronic  Peritonitis. — This  affection,  like 
the  acute  form,  may  involve  the  peritoneum 
more  or  less  generally ; or  only  over  a localised 
and  limited  area.  The  conditions  included  under 
the  term  are  somewhat  indefinite,  but  not  un- 
commonly they  are  well-marked  pathologically, 
as  well  as  of  considerable  clinical  importance. 

H5tiology  axd  Pathology. — Without  enter- 
ing into  detail*;,  it  must  suffice  to  point  out  the 
circumstances  under  which  chronic  peritonitis 
may  occur: — 1.  There  is  no  doubt  as  to  its  being  a 
sequel  of  one  or  more  attacks  of  acute  peritonitis 
in  some  instances,  either  general  or  local,  but 
especially  the  latter ; and  after  a circumscribed 
acute  peritonitis  the  chronic  affection  may  spread 
more  or  less  generally.  Moreover,  the  conditions 
remaining  after  acute  peritonitis  are  liable  to 
set  up  further  mischief  in  a chronic  manner. 
2.  Chronic  peritonitis  may  become  associated 
with  ascites,  but  more  particularly  when  re- 
peated paracentesis  has  been  performed  for  the 
relief  or  cure  of  this  condition.  3.  Localised 
chronic  peritonitis  is  very  common  as  the  result 
of  continued  irritation,  set  up  by  some  diseased 
organ,  such  as  a cirrhotic  or  cancerous  liver, 
cancer  or  chronic  ulcer  of  the  stomach,  old  her- 
nias, tumours,  and  various  other  obvious  con- 
ditions. There  are,  however,  cases  occasionally 
observed  in  which  the  cause  is  not  so  evident, 
and  these  have  been  referred  to  irritation  by 
accumulations  of  feces,  or  to  repeated  pressure 
or  other  mechanical  causes  acting  from  without. 
4.  Morbid  formations  in  the  peritoneum  itself 
are  very  liable  to  set  up  chronic  inflammation. 
Of  these  the  principal  are  tubercle  and  cancer, 
and  tubercular  and  cancerous  peritonitis  consti- 
tute important  forms  of  this  disease.  5.  In  rare 
instances  a chronic  inflammatory  effusion  col- 
lects in  the  peritoneal  cavity,  without  any  ob- 
vious cause.  This  cannot  he  separated  by  any- 
marked  line  of  demarcation  from  some  latent 
cases  of  acute  effusion.  The  fluid  may  be  actu- 
ally purulent  under  these  circumstances,  hut  is 
generally  serous,  and  cannot  he  distinguished 
from  that  of  mere  ascites.  This  chronic  effusion 
has  been  noticed  during  convalescence  from 
fevers  ; and  has  also  been  attributed  to  cold  and 
wet.  It  may  he  mentioned  here  that  some  cases 
of  chronic  peritonitis  have  also  been  referred  to 
chronic  renal  disease,  and  to  rheumatism. 

.Anatomical  Chauacters. — The  precise  con- 
ditions present  in  an  individual  case  of  chronic 
peritonitis  are  subject  to  great  variety,  as  regards 
their  nature,  extent,  and  site  ; hut  their  general 
characters  can  be  readily  indicated. 

Adhesions  or  thickenings  connected  with  the 
serous  membrane  are  almost  constantly-  present 
in  different  degrees,  and  not  unfrequently  they 
constitute  the  sole  anatomical  evidences  of  chronic 
peritonitis.  They  result  from  the  development 
of  the  inflammatory  products,  and  the  formation 
of  connective  or  fibrous  tissue,  with  new  vessels. 
The  thickening  varies  much  in  degree,  ranging 
from  what  is  scarcely  perceptible,  to  the  produc- 
tion of  a dense  fibrous  mass,  an  inch  or  more  in 
thickness,  as  the  writer  has  seen.  It  may  he  evi- 
dent.in  the  parietal  peritoneum;  around  organs, 
forming  more  or  less  thick  and  firm  capsules  ; 
or  in  the  peritoneal  folds,  especially  the  omentum 


1140  PERITONEUM, 

and  mesentery.  Adhesions  or  agglutinations 
also  form  between  different  parts,  thus  uniting 
organs  to  each  other,  to  the  abdominal  walls, 
or  to  the  mesentery  or  omentum  ; or  sometimes 
matting  the  whole  together  into  an  inseparable 
or  indistinguishable  mass.  They  present  great 
variety,  and  by  the  movements  which  take  place 
within  the  abdomen,  they  may  be  stretched  or 
made  more  loose,  or  even  be  got  rid  of  altogether 
in  some  instances,  when  they  have  formed  after 
an  acute  attack.  On  the  other  hand,  in  many 
cases  the  adhesions  and  thickenings  tend  to  be- 
come gradually  stronger  and  denser,  and  at  the 
same  time  to  undergo  contraction,  so  that  they 
produce  serious  effects. 

In  many  cases  of  chronic  peritonitis  effusion 
of  somekindis  observed.  It  may  be  merely  serous, 
or  containing  fibrinous  flakes,  sero- purulent,  or 
actually  purulent.  Blood  may  also  be  present  in 
it.  Occasionally  this  is  the  prominent  or  only 
anatomical  change  ; and  the  fluid  may  range  in 
quantity  from  a small  to  an  enormous  amount. 
Usually  it  is  associated  with  the  other  condi- 
tions already  described,  so  that  the  fluid  is  not 
free  to  move  about,  and  may  be  actually  circum- 
scribed, or  even  lie  in  the  substance  of  great 
thickenings.  Purulent  accumulations  are  likely 
to  make  their  way  in  various  directions,  either 
outwards  or  into  internal  parts. 

When  chronic  peritonitis  depends  upon  the 
presence  of  tubercle,  cancer,  or  other  morbid 
formations,  these  will  be  evident  on  'post-mortem 
examination.  Moreover,  the  inflammatory  pro- 
ducts may  undergo  degenerative  processes,  and 
hence  caseous  or  cretaceous  particles  or  masses 
be  found.  It  is  highly  probable  that  tubercle 
may  be  formed  secondarily,  as  the  result  of 
infection  from  caseous  or  purulent  collections. 
Pigment  is  also  often  present  in  abundance. 

It  is  important  to  notice  the  obvious  effects 
liable  to  be  produced  upon  the  abdominal  or- 
gans and  other  structures  by  chronic  peritoni- 
tis. They  are  fixed  by  the  adhesions  and  thicken- 
ings, and  may  be  displaced  at  the  same  time. 
Compression  or  constriction  is  often  produced, 
especially  important  in  the  case  of  hollow  viscera, 
as  well  as  distortion,  twisting  or  torsion,  and  in- 
carceration. Some  of  these  effects  may  occur 
acutely  in  connection  with  bands  of  adhesion,  thus 
giving  rise  to  grave  consequences ; and  fixation  of 
the  bowel  may  also  lead  to  intussuception.  The 
omentum  may  be  greatly  distorted,  or  fixed  in 
some  abnormal  situation  ; while  the  mesentery 
has  been  found  extremely  shortened,  so  as  to 
contract  the  small  intestine  to  half  its  length,  its 
serous  covering  and  longitudinal  muscular  layer 
being  shrivelled,  and  its  mucous  lining  thrown 
into  transverse  folds.  The  deeper  tissues  of 
some  of  the  abdominal  viscera  are  likely  to  be 
affected  by  long-continued  chronic  peritonitis; 
and  atrophy  from  compression  may  ensue.  As 
one  good  result  of  this  condition,  mention  must 
be  made  of  the  fact  that  it  is  not  uncommonly  the 
means  of  preventing  or  modifying  the  injurious 
consequences  resulting  from  some  forms  of  per- 
foration of  abdominal  viscera,  by  giving  rise  to 
previous  adhesions  and  thickenings,  and  thus  ob- 
viating the  escape  of  their  contents,  or  limiting 
their  dissemination. 

Symptoms. — The  clinical  history  of  chronic 


DISEASES  OF. 

peritonitis  necessarily  presents  much  diversity. 
The  phenomena  observed  result  from  the  mere 
presence  of  the  inflammatory  products ; the  effects 
produced  upon  the  organs  within  the  abdomen  by 
these  products,  whether  in  the  way  of  mere  func- 
tional disorder,  or  other  more  obvious  derange- 
ments ; the  consequences  of  direct  pressure  upon 
tubes,  vessels,  or  other  structures;  and  the  gene- 
ral or  constitutional  disturbance  often  present. 

According  to  its  mode  of  origin,  chronic  peri- 
tonitis either  remains  after  an  acute  illness,  or 
after  a succession  of  more  or  less  acute  attacks 
or  exacerbations;  or  its  onset  is  gradual  and 
chronic  from  the  first,  and  may  be  very  insidious. 
Of  slight  adhesions  left  after  acute  peritonitis, 
or  originating  from  chronic  causes,  there  are 
often  no  clinical  signs ; or  there  may  be  uneasi- 
ness and  discomfort,  or  even  painful  sensations 
at  times  in  some  part  of  the  abdomen,  especially 
the  iliac  region,  with  a tendency  to  intestinal 
disorder,  in  the  way  of  spasmodic  movements  and 
constipation.  Even  when  there  are  no  symptoms 
whatever,  adhesions  may  at  any  time  cause  serious 
consequences.  In  well-marked  cases  of  ehroni- 
peritonitis  the  symptoms  to  be  expected  are  of 
the  following  nature : — Abnormal  subjective  sen- 
sations are  usually  experienced  in  the  abdomen, 
such  as  tightness,  fulness,  dragging,  or  actual 
pain.  The  pain,  when  present,  is  of  a dull  cha- 
racter, not  severe,  and  liable  to  come  and  go,  or 
to  present  exacerbations  from  time  to  time ; it  is 
often  localised,  and  especially  if  the  peritonitis 
be  circumscribed ; sometimes  there  is  a feeling 
of  local  soreness  or  heat.  The  painful  sensations 
tend  to  be  increased  by  movement,  and  by  shak- 
ing the  body.  They  are  sometimes  aggravated 
by  posture,  in  some  eases  by  bending  forwards 
in  others  by  the  erect  posture  ; and  they  may  be; 
increased  by  going  up  stairs,  especially  if  the  ab- 
domen is  distended.  More  or  less  tenderness  on 
pressure  is  very  common,  even  when  there  is  net 
spontaneous  pain,  but  not  invariable ; it  is  fre- 
quently more  evident  at  certain  spots,  where  it 
may  be  considerable.  Colicky  pains  are  not  un- 
common in  chronic  peritonitis,  and  may  occur 
in  severe  paroxysms,  especially  after  food,  being 
due  to  the  disturbed  action  of  the  bowels,  as- 
sociated with  the  formation  and  movements  oj 
flatus,  which  may  be  abundant,  even  amounting 
to  tympanites.  Appetite  is  often  impaired  or 
variable  ;-  and  dyspeptic  symptoms  are  frequent' 
Constipation  is  the  rule,  and  may  be  very  ob- 
stinate, even  amounting  to  obstruction  under  cer- 
tain conditions.  Sometimes  diarrhoea  is  present 
or  it  may  supervene  at  times,  and  occasionally 
assumes  a dysenteric  character.  This  sympton 
is  very  common  in  tubercular  peritonitis,  in  con 
sequence  of  the  bowel  being  the  seat  of  ulcera 
tion.  In  some  cases  vomiting  occurs  from  tim 
to  time.  When  there  is  considerable  effusion  i: 
the  peritoneum,  the  secretion  of  urine  is  dimm 
ished.  Respiration  may  be  mechanically  inter 
fered  with  from  the  same  cause.  As  the  resul 
of  pressure  by  thickenings  and  other  conditior 
upon  different  structures,  jaundice,  ascites,  oedem 
of  the  legs,  thrombosis,  albuminuria,  or  neuraig 
pains  may  supervene.  When  the  organs  are  a 
matted  together,  their  entire  functions  must  1 
more  or  less  interfered  with. 

General  symptoms  are  usually  present  in  v; 


PERITONEUM, 

ous  degrees  in  eases  of  chronic  peritonitis,  but 
. many  instances  they  depend  mainly  upon  the 
mdition  with  which  this  disease  is  associated, 
;pecially  tuberculosis,  though  they  may  also  be 
•odoced  by  the  peritonitis.  These  symptoms 
'elude  pyrexia,  not  high,  and  having  no  regular 
■urse,  but  presenting  exacerbations,  either  per- 
stent  or  occurring  at  intervals,  and  in  some 
,ses  assuming  a hectic  character;  increased  fre- 
tency  of  the  pulse  ; a sense  of  languor  or  weak- 
,ss ; and  more  or  less  general  wasting  and  anae- 
Ba,  with  dryness  and  harshness  of  the  skin. 

It  must  be  noted  that  in  some  cases  of  chronic 
ritonitis,  even  where  there  is  considerable  ef- 
ision,  the  local  and  general  symptoms  are  very 
ght  and  indefinite,  and  the  patient  only  suffers 
mi  the  discomfort  due  to  the  accumulation  of 
jd.  On  the  other  hand  the  progress  is  not 
commonly  from  bad  to  worse,  ending  in  extreme 
laciation  and  exhaustion,  with  the  formation 
bed-sores ; or  there  may  be  a succession  of 
provements  and  relapses;  while  various  phe- 
mena  result  from  the  opening  of  collections 
pus  in  different  directions.  Thus  death  may 
adually  or  rapidly'  terminate  a case  ; or  pyaemia 
y supervene.  Even  in  bad  cases,  however, 
imperative  recovery  may  ensue,  only  the  effects 
i the  inflammation  remaining,  and  being  more 
i less  troublesome. 

Physical  Signs.  — These  require  separate 
tice,  and  they  may  be  the  only  clinical  indica- 
ms of  chronic  peritonitis.  They  necessarily 
ifer  in  detail  according  to  the  nature  of  the 
normal  physical  conditions  present  in  the  ab- 
onen,  and  they  are  also  liable  to  alter  during  the 
pgress  of  a case  ; but  their  general  characters 
sufficiently  clear.  1.  In  general  chronic  peri- 
t/.itis  enlargement  of  the  abdomen  is  observed, 

: inly  in  proportion  to  the  amount  of  fluid  pre- 
s t ; but  it  depends  partly  on  gas  in  the  intes- 
tes, or  sometimes  on  solid  exudation.  As  a rule 
i s not  very  considerable,  but  the  abdomen  may 
t un  an  enormous  size,  with  stretching  of  the 
e l and  other  accompanying  phenomena.  While 
i.ular  in  shape  on  the  whole,  it  may  present  more 
o ess  want  of  symmetry,  especially  after  a time. 
C the  other  hand,  in  some  cases  the  abdomen 
comes  locally  or  generally  retracted,  and  may 
t,i  exhibit  marked  irregularities.  2.  The  sen- 
s ons  on  palpation  are  very  variable,  but  often 
Ally  characteristic.  It  may  happen  that  thereis 
a iiform  feeling  of  fluid.  More  commonly  the 
S'  ations  are  not  uniform,  but  differ  in  differ- 
e parts  of  the  abdomen,  including  indistinct 
fl  mation  in  localised  areas,  sometimes  very 
li.  ted  and  in  unusual  situations  ; with  firmness 
o:  isistance  around  or  in  other  parts,  ill-defined, 
oijsionally  nodulated ; and  even  distinct  tu- 
u|rs  may  be  felt,  more  or  less  irregular.  These 
itiome  instances  are  due  to  morbid  growths, 
sr.  as  cancer,  but  they  also  originate  in  or- 
g:  sed  inflammatory  products.  Under  certain 
cej  itions  the  abdomen  yields  a peculiar  feeling 
0‘i-ing  movable  as  a whole.  Movements  of  the 
b<  sis  are  sometimes  recognised.  When  there 
11  ocalised  adhesions  between  the  visceral  and 
pcistal  peritoneum,  if  pressure  is  made  at  a 
h1 ) distance  from  the  seat  of  adhesion,  a fold 
tf;  e skin  will  appear  where  this  adhesion  exists. 
Ptibly  general  adhesions  might  be  made  out 


DISEASES  OF.  nil 

by  palpation.  3.  Percussion  occasionally  reveals 
freely  movable  fluid.  Asa  rule,  however,  it  shows 
that  the  fluid  is  not  freely  movable,  or  that  it 
is  actually  loculated  irregularly,  this  condition 
being  associated  with  more  or  less  solid  ma- 
terial. Hence  there  is  extensive  and  diffused 
dulncss,  which  may  be  noticed  mainly  in  front, 
and  not  in  dependent  parts.  Not  uncommonlv 
patches  of  dulness  and  tympanitic  resonance  arc 
found  contiguous  to  each  other,  and  irregularly 
distributed,  unaffected  by  posture.  Over  the 
fluid  fluctuation  ma}r,  perhaps,  be  elicited,  but 
indistinctly ; and  where  there  is  much  solid  the 
sensation  on  percussion  is  that  of  resistance. 
4.  Friction-fremitus  and  -sound  are  sometimes 
present.  5.  Changes  of  posture,  as  a rule,  pro- 
duce comparatively  little  or  no  effect  upon  the 
shape  of  the  abdomen,  the  sensations,  or  the  per- 
cussion-sounds. 

When  chronic  peritonitis  is  localised,  it  may 
be  practicable  to  detect  the  condition  by  palpa- 
tion and  percussion.  Moreover,  when  organs 
become  fixed  by  peritoneal  adhesions,  especially 
if  they  are  diseased  at  the  same  time,  this  state 
of  things  may  often  be  recognised  by  noticing 
that  the  affected  organ  does  not  present  its  normal 
mobility  in  relation  to  manipulation  and  respira- 
tory movements. 

Diagnosis. — In  most  instances  chronic  peri- 
tonitis, if  of  any  extent,  can  be  recognised  with- 
out much  difficulty,  by  attending  to  the  history 
of  the  case,  the  symptoms,  and  the  physical 
signs.  It  may  be  very  difficult,  or  even  impos- 
sible, to  distinguish  positively  between  mere 
ascites  and  chronic  inflammatory  effusion.  All 
the  circumstances  of  the  case  must  be  taken  into 
consideration ; and  in  doubtful  cases  the  re- 
moval of  some  of  the  fluid,  by  means  of  a small 
trochar,  will  aid  the  diagnosis  materially.  It  is 
important  to  determine  the  cause  of  chronic 
peritonitis,  when  present,  and  especially  whether 
it  is  simple  or  tubercular.  Here,  again,  the 
whole  case  must  be  considered,  not  forgetting 
the  age  of  the  patient,  the  family  history,  the 
condition  of  the  main  organs,  and  other  points. 
Tubercular  disease  in  other  parts  may,  however, 
be  accompanied  with  simple  peritonitis.  It  has 
been  said  that  a haemorrhagic  character  of  any 
fluid  removed  is  significant  of  tubercular  peri- 
tonitis, but  this  certainly  cannot  be  relied  upon; 
and  the  same  remark  applies  to  the  occurrence  of 
redness  and  oedema  about  the  umbilicus,  which 
has  been  supposed  to  be  diagnostic  of  the  tuber- 
cular disease. 

It  is  quite  impossible  to  diagnose  with  cer- 
tainty obscure  cases  of  localised  chronic  peri- 
tonitis; and  it  may  become  very  difficult,  even 
in  evident  cases,  to  determine  the  precise  con- 
ditions within  the  abdomen. 

Prognosis. — The  prognosis  of  each  case  of 
chronic  peritonitis  must  be  considered  on  its  own 
merits,  as  regards  the  cause  of  the  disease ; its 
extent  and  products ; the  progress  of  the  morbid 
changes  ; the  effects  produced  on  the  abdominal 
organs  ; and  the  general  symptoms.  Some  cases 
are  of  little  or  no  conseqnence ; others  are  very 
serious;  but  even  in  apparently  serious  cases 
groat  improvement,  or  even  practical  recovery, 
may  take  place.  The  dangers  to  be  feared  from 
the  opening  of  purulent  collections  in  various 


1142 

directions  must  be  borne  in  mind ; and  also  those 
liable  to  arise  from  the  presence  of  bands  of  ad- 
hesion within  the  abdominal  cavity.  Tubercular 
and  carcinomatous  peritonitis  are  necessarily  very 
grave  forms  of  the  disease,  but  the  former  may 
certainly  be  recovered  from. 

Treatment.— With  regard  to  the  local  condi- 
tions in  chronic  peritonitis,  it  is  often  desirable 
to  endeavour  to  promote  the  removal  of  morbid 
products  within  the  abdomen.  For  this  purpose 
it  may  be  important  to  keep  the  patient  entirely 
at  rest  in  bed  fora  time.  The  internal  adminis- 
tration of  iodide  of  potassium  or  syrup  of  iodide 
of  iron  may  be  tried;  and  in  some  instances  diu- 
retics might  be  of  use.  Possibly  the  careful 
employment  of  some  mercurial  preparation  would 
be  serviceable  in  appropriate  cases.  Violent 
purgation  is  to  be  deprecated  ; but  where  there 
is  much  fluid,  advantage  might  be  derived  from 
repeated  diaphoresis,  induced  by  means  of  the 
hot-air,  vapour,  or  Turkish  bath,  or  by  the  use 
of  jaborandi.  Local  measures  are  in  some  in- 
stances of  essential  service,  namely,  counter-irri- 
tation, especially  by  the  application  of  iodine  ; 
friction  with  some  oil  or  ointment ; and  pres- 
sure. The  writer  has  found  pressure  decidedly 
valuable  in  aiding  absorption  in  certain  cases, 
as  well  as  in  giving  support,  the  abdomen  being 
covered  with  cotton-wool,  and  a suitable  band- 
age applied  more  or  less  firmly.  A flannel 
bandage  answers  best.  In  cases  of  large  effu- 
sion, where  absorption  cannot  be  effected,  the 
writer  has  no  hesitation  in  recommending  para- 
centesis, even  repeated  when  required,  having 
seen  signal  benefit  follow  this  treatment.  A 
localised  purulent  accumulation  must  be  treated 
on  general  principles. 

General  treatment  is  often  of  essential  value 
in  cases  of  chronic  peritonitis.  It  is  directed 

the  condition  upon  which  the  disease  depends, 
such  as  tuberculosis,  or  to  its  effects,  but  the 
measures  are  similar  in  the  main,  consisting  of 
good  nutritious  diet,  suitable  sanitary  conditions, 
change  of  air,  and  the  administration  of  cod-liver 
oil,  quinine,  preparations  of  iron,  and  other 
tonics  and  nutrients.  AVine  may  often  be  given 
with  advantage. 

Symptoms  will  probably  need  attention  from 
time  to  time,  such  as  pain,  flatulence,  dyspeptic 
symptoms,  constipation,  diarrhoea,  and  various 
others.  The  organs  generally  must  be  looked 
to,  and  their  functions  promoted.  A free  flow 
of  urine  often  follows  absorption  of  fluid,  or  its 
removal  by  operation. 

There  are  many  cases  of  chronic  peritonitis 
which  need  no  special  treatment,  especially  when 
it  has  merely  caused  local  changes. 

3.  Peritoneum,  Gas  in. — Synon.  : Pneumo- 
peritoneum ; Ty  mpanites  peritonei. 

Gas  may  be  present  in  the  peritoneal  cavity 
from  three  causes,  namely: — 1.  Its  escape  from 
the  alimentary  canal  through  some  abdominal 
communication  ; 2.  Transudation  of  gas  through 
the  intestinal  wall ; 3.  Decomposition  of  mate- 
rials in  the  peritoneal  sac.  The  gas  may  be 
generally  diffused  ; or  limited  by  adhesions.  The 
condition  cannot  bo  said  to  give  rise  to  any  de- 
finite symptoms,  but  it  may  increase  abdominal 
distension  and  discomfort.  When  general  it  might 


DISEASES  OF. 

be  recognised  by  the  following  physical  signs 
1.  There  is  extreme  and  uniform  distension  of  th< 
abdomen,  with  a specially  prominent  epigastriun 
as  the  patient  lies  on  his  back.  Sometime, 
donghy  fluctuation  is  felt  in  the  epigastric  region 
with  a peculiar  pitting  on  pressure.  2.'lh 
percussion-sound  is  markedly  tympanitic  or  evet 
metallic,  full  and  deep  in  tone ; and  this  sound!; 
very  extensive,  completely  annulling  the  anterio 
hepatic  and  splenic  dulness.  3.  Succession  i 
sensations  and  sounds  may  be  produced,  owin: 
to  the  presence  of  gas  and  fluid  in  the  peritonea 
sac.  These  are  more  uniformly  and  extensive! 
diffused  than  when  such  phenomena  arise  fron; 
similar  conditions  in  the  stomach  or  intestines 
The  aortic  sound  may  also  have  a diffused  me; 
tallic  quality  over  the  abdomen.  A local  collet 
tion  of  gas  might  cause  a corresponding  fulnes 
of  the  abdomen,  and  yield  a localised  tympaniti 
or  metallic  percussion-sound,  as  well  as  suceus 
sion  phenomena. 

4.  Peritoneum,  Dropsy  of. — See  Ascitks. 

5.  Peritoneum,  Haemorrhage  into. — Ekol 
may  escape  in  quantity  into  the  peritonet 
cavity  as  the  result  of  injury;  or  from  the  rup 
ture  or  perforation  of  different  structures  withi 
the  abdomen.  An  important  form  of  hsemorrhng! 
is  that  which  results  from  the  rupture  of  a 
aneurism.  More  or  less  blood  may  be  presen 
in  inflammatory  or  dropsical  effusion;  or  itma 
originate  in  the  opening  of  vessels  by  morbi 
growths,  or  the  spontaneous  rupture  of  nej 
vessels.  Haemorrhage  is  not  uncommon  in  cor 
nection  with  tubercle.  It  may  also  occur  fro: 
scurvy  or  purpura. 

Symptoms. — It  might  possibly  happen  th; 
peritoneal  hsmorrhage  could  be  recognised, 
there  were  some  evident  cause  for  this  conditio! 
followed  by  the  physical  signs  of  the  presence' 
blood  in  the  peritoneal  cavity  ; and  general  indi 
cations  of  loss  of  blood.  As.  a rule,  however,  t! 
condition  cannot  he  detected.  The  hamorrhag 
nature  of  an  effusion  can  only  he  recognised  l 
withdrawing  it. 

Treatment. — This  merely  consists  in  the  lot* 
and  general  treatment  for  loss  of  blood,  if  an; 
thing  can  be  done  or  is  required. 

6.  Peritoneum,  Injuries  to.  — The  pel 
toneum  is  liable  to  be  injured  from  without  1 
contusions  and  wounds  of  various  kinds;  at 
from  within  by  perforations  and  ruptures,  t! 
injury  being  aggravated  in  many  cases  of  th 
kind  by  the  introduction  of  matters  into  t: 
peritoneal  cavity,  causing  mechanical  or  chemic 
mischief,  such  as  gases,  food,  faeces,  calculi,  bil 
urine,  pus,  or  worms.  The  mere  injury  to  t. 
serous  membrane  itself  cannot  be  said  to  pi 
duce  any  evident  phenomena,  unless  it  he  exte 
sive ; but  it  leads  usually  to  serious  effeq 
which  have  already  been  considered — name! 
haemorrhage,  which  may  be  on  a large  or  fat 
scale  ; and  acute  inflammation  of  an  aggravat 
type.  Of  course  it  must  be  remembered  th 
along  with  the  injury  to  the  peritoneum,  there 
usually  associated  some  more  or  less  severe  i 
jury  to  an  abdominal  organ  or  other  structw 
and  the  phenomena  resulting  therefrom  will 
present. 


PERITONEUM, 


1143 


PERITONEUM, 
7.  Peritoneum,  Morbid  Formations  and 
New  Growths  in. — These  require  brief  notice, 
ind  may  be  considered  in  the  following  order: — 

P a.  It  is  necessary  to  call  attention  to  the  fact 
.hat  the  sub-peritoneal  tissue,  especially  that  of 
;he  peritoneal  folds,  becomes  in  obeso  persons 
the  seat  of  a large  deposit  of  fat,  an  overgrowth 
of  that  normally  present,  and  this  is  particularly 
noticed  in  the  omentum.  As  a consequence  the 
'unctions  of  the  alimentary  canal  are  unquestion- 
ably liable  to  bo  interfered  with,  and  various 
lyspeptic  symptoms,  flatulence,  and  constipation 
[nay  arise.  Moreover,  this  condition  assists  in 
broducing  enlargement  of  the  abdomen  ; and  in 
uuffling  the  natural  tympanitic  sound.  It  can 
oo  recognised  at  once  by  the  appearance  of  the 
oatient ; but  it  is  important  to  remember  that  it 
may  conceal  some  other  morbid  condition  within 
.he  abdomen.  The  treatment  is  that  for  obesity 
jeuerally  (see.  Obesity).  In  very  exceptional 
instances  distinct  fatty  tumours  have  occurred 
n connection  with  the  peritoneum ; and  these 
nay  become  separated  by  constriction  of  their 
vttachments. 

b.  Tubercle  is  the  most  common  and  important 
lew  growth  in  connection  with  the  peritoneum, 
t occurs  in  three  classes  of  cases,  namely — (1) 
is  a part  of  general  acute  tuberculosis,  the  tu- 
bercle appearing  in  the  peritoneum  as  a diffuse 
[biliary  deposit,  presenting  the  usual  characters ; 
'!)  in  connection  with  tubercular  ulcers  in  the 
ntestines,  localised  granulations  forming  on  the 
||orresponding  surface  of  the  peritoneum  ; (3)  as 
,n  independent  disease,  usually  assuming  a more 
:r  less  chronic  course,  and  accompanied  with 
aflammatory  changes.  This  form  is  usually 
econdary  to,  and  associated  with,  similar  changes 
Jsewhere,  especially  pulmonary  phthisis ; but  it 
B occasionally  primary,  and  may  oxist  for  a time 
r throughout  alone,  as  the  result  of  infection 
tom  caseous  glands,  from  products  remaining 
Jfter  peritonitis,  from  caseous  deposits  in  the 
pididymis,  or  from  othersources,  or  exceptionally 
ithout  any  obvious  cause.  This  diseaso  occurs 
lainly  in  young  persons,  but  is  rare  undor  four 
iars  of  age. 

Anatomical  Chabactebs. — The  morbid  condi- 
ons  found  on  ■post-mortem  examination  in  cases 
[-longing  to  the  third  group,  consist  of  a corn- 
nation  of  disseminated  tubercles  in  different 
pages,  with  signs  of  chronic  peritonitis.  Some- 
jnesthe  tubercle  has  entirely  undergone  caseous 
Ganges.  As  the  result  of  the  peritonitis,  great 
ickeuing  and  extensive  adhesions  are  usually 
esent,  with  much  contraction.  Hence  the  omen- 
imis  often  drawn  up  into  a firm  mass  across  the 
iper  part  of  the  abdomen;  and  the  mesentery  is 
ho  contracted,  drawing  the  intestines  together, 
d distorting  thsm.  More  or  less  etfusion  is 
nost  always  present,  which  generally  contains 
-ered  blood  in  variable  quantity.  Sometimes 
undant  haemorrhage  takes  place  into  the  peri- 
neum. Morbid  changes,  either  of  a tubercular 
iracter,  or  resulting  from  this  disease,  are 
tally  found  in  other  parts  of  the  body. 
[Symptoms. — The  clinical  phenomena  present 
isiderable  variety  in  different  cases,  as  regards 
ir  nature  and  progress.  In  some  instances 
lercular  disease  of  the  peritoneum  begins 
itely,or  in  a succession  of  acute  attacks,  usually 


DISEASES  OF. 
circumscribed,  with  symptoms  like  those  of  peri- 
tonitis, then  subsiding  into  a chronic  condition. 
Ear  more  commonly  the  progress  is  very  chronic 
and  insidious,  or  latent,  ending  in  signs  of  effu- 
sion. In  other  eases  there  are  marked  remis- 
sions of  the  symptoms  during  their  progress,  both 
local  and  general.  The  phenomena  may  be  sum- 
marised as  those  of  the  peritoneal  inflammation  ; 
with  general  symptoms  of  tuberculosis  ; and  often 
signs  of  implication  of  important  organs  in  the 
morbid  condition.  When  the  peritoneal  disease 
is  secondary,  it  can  be  readily  recognised.  The 
course  of  the  diseaso  is  usually  chronic  ; and  as 
a rule  it  terminates  in  death,  but  not  invariably. 

Treatment. — The  treatment  for  tubercula? 
disease  of  the  peritoneum  is  that  of  the  general 
disease ; with  that  suitable  for  chronic  peritonit  is. 

c.  Cancer  is  comparatively  rare  in  the  perito- 
neum. It  is  by  far  most  commonly  secondary, 
originating  from  extension,  or  as  a distinct  se- 
condary formation ; and  especially  following 
malignant  disease  of  the  alimentary  canal,  liver, 
retro-peritoneal  glands,  and  sexual  organs. 
Rarely  this  disease  is  primary,  and  has  then 
been  referred  to  injury  in  some  instances.  It 
occurs  almost  always  after  middle  life,  but  ha« 
been  met  with  in  children. 

Peritoneal  cancer  generally  occurs  in  the 
scirrhous  form,  but  is  occasionally  encephaloid, 
melanotic,  or  colloid,  the  last  being  compara- 
tively frequently  found  in  the  omentum,  and  it 
may  form  an  enormous  growth.  Rarely  the  dis- 
ease assumes  an  acute  character,  the  cancer  being 
in  diffused  nodules.  Usually  chronic,  it  either 
takes  the  form  of  separate  nodular  masses,  which 
may  become  depressed ; or  of  an  infiltration, 
sometimes  of  great  thickness.  Generally  there 
are  associated  signs  of  chronic  peritonitis,  with 
more  or  less  effusion,  which  may  be  haemor- 
rhagic ; extensive  haemorrhages  sometimes  take 
place.  Abdominal  organs  are  often  found  im- 
plicated ; or  the  cancerous  process  may  lead  to 
their  destruction  or  perforation.  In  some  in- 
stances there  is  large  dropsical  effusion  in  the 
peritoneal  cavity. 

Cancer  of  the  peritoneum  may  be  usually  re- 
cognised clinically  when  it  occurs  as  a secondary 
event,  but  oven  then  its  diagnosis  is  not  always 
clear.  As  a primary  disease  it  is  generally 
difficult  to  detect.  The  phenomena  include  the 
physical  signs  of  the  morbid  grow-th,  especially 
as  revealed  by  palpation  and  percussion  ; the 
signs  of  ascites  or  chronic  peritonitis ; disturb- 
ance of  the  abdominal  organs;  the  general 
symptoms  and  cachexia  of  cancer ; and  the  evi- 
dence of  the  existence  of  the  disease  in  other 
parts.  Pain  is  a common  symptom,  and  is  usu- 
ally paroxysmal,  being  due  to  the  cancer  itself, 
as  woll  as  to  other  causes  ; tenderness  is  also 
marked.  The  cancerous  nodules  may  originate 
friction-sound.  The  course  of  the  disease  is 
occasionally  acute,  with  pyrexia ; as  a rule  it  is 
chronic,  with  little  or  no  fever,  or  this  only  occurs 
at  intervals.  Hsemorrhage  may  cause  marked 
anaemia  or  fainting.  The  cancerous  masses  may 
also  originate  pressure-symptoms.  This  disease 
is  necessarily  fatal;  and  treatment  can  only  be 
symptomatic. 

With  regard  to  colloid  of  the  omentum,  it  is 
desirable  to  notice  specially  its  physical  signs 


1144  PERITONEUM,  DLS EASES  OP. 

1.  The  abdomen  may  be  greatly  enlarged,  but  is 
not  uniform  or  quite  symmetrical ; the  umbili- 
cus is  only  stretched,  not  everted.  2.  Palpation 
generally  reveals  firm,  irregular  masses.  If 
present,  fluctuation  is  very  indistinct,  3.  The 
anterior  regions  of  the  abdomen  are  dull  ex- 
tensively. 4.  Usually  a change  of  posture  pro- 
duces little  or  no  effect  upon  the  physical  signs. 
5.  A slimy,  gelatinous  fluid  may  be  removed  by 
the  exploratory  needle  or  aspirator ; and  occa- 
sionally a similar  fluid  is  said  to  be  discharged 
per  rectum,  or  from  the  stomach. 

d.  Among  rare  formations  found  in  the  peri- 
toneum may  be  mentioned  hydatids,  associated 
or  not  with  a similar  disease  in  one  or  more 
organs ; serous,  dermoid,  and  colloid  cysts  ; fibro- 
mata ; myxomata ; and  remains  of  blood-clots. 

8.  Peritoneum,  Malformations  of.  —It 
will  suffice  to  mention  under  this  head  that 
the  folds  of  the  peritoneum,  such  as  the  mesen- 
tery, may  be  abnormal  in  length  or  formation  ; 
that  unusual  bands  or  openings  may  be  present ; 
and  that  prolongations  of  the  peritoneum,  which 
naturally  become  obliterated  or  shut  out  from 
the  general  cavity,  sometimes  do  not  undergo 
these  changes,  as  may  be  illustrated  by  the 
occasional  patency  of  the  process  which  descends 
with  the  testis  into  the  scrotum.  As  the  re- 
sult of  these  abnormalities  displacements  of 
organs  may  occur ; or  their  movements  are 
restricted  or  too  free ; or  constriction  of  the 
intestine  may  take  place.  These  conditions  can 
only  be  recognised  clinically  by  their  effects; 
and  not  uncommonly  they  cannot  be  made  out. 
Treatment  may  sometimes  be  directed  to  their 
cure,  as  is  exemplified  in  the  radical  cure  of  a 
congenital  hernia. 

Frederick  T.  Eobebts. 

PERITYPHLITIS  (wepl,  around,  and 
?u<p\bv,  the  caecum). — Synon.  : Fr.  Perityphlite ; 
Phlegmon  iliaque  ; Ger.  Perityphlitis. 

Definition. — Inflammation  of  the  connective 
tissue  behind  and  around  the  caecum. 

^Etiology. — The  most  frequent  cause  of  this 
not  uncommon  affection  is  an  extension  of  in- 
flammation from  the  caecum  or  the  vermiform 
appendix,  more  especially  if  the  typhlitis 
caused  by  accumulation  of  faeces  or  by  some 
foreign  substance,  such  as  fish-bones  or  cherry- 
stones, has  proceeded  to  ulceration.  The  ana- 
tomical relations  of  the  caecum  in  the  right  iliac 
fossa  are  favourable  to  such  a result. 

Owing  to  the  continuity  of  the  sub-peritoneal 
connective  tissue,  it  is  obvious  that  inflammation 
and  suppuration  in  regions  somewhat  distant 
from  the  iliac  fossa  may  also  extend  into  that 
locality.  Perinephritic  and  psoas  abscesses  may 
therefore  become  causes  of  perityphlitis. 

External  injury,  such  as  blows,  kicks,  or  severe 
compressions,  as  between  the  buffers  of  a train, 
may  induce  inflammation  of  both  bowel  and  sur- 
rounding tissues,  so  that  it  becomes  impossible 
to  say  whether  the  caecum  or  the  connective  tissue 
becomes  first  affected. 

Occasionally  suppuration  in  this  region  may 
result  from  septicaemia ; and  exceptional  cases 
occur  where  no  cause  can  be  assigned  beyond 
cold.  Sec  C-ecusi,  Diseases  of. 

Anatomical  Characters. — Perityphlitis  runs 


PERITYPHLITIS. 

a somewhat  variable  course.  In  one  set  of  (sues 
the  progress  may  be  acute,  marked  by  active 
suppuration,  and  leading  to  the  formation  of  an 
abscess  in  the  iliac  fossa  behind  the  cacnm. 
Such  an  abscess  may  extend  to  a considerable 
distance  in  the  sub-peritoneal  tissue,  upwards 
towards  the  spine,  or  downwards  into  the  pelvis ; 
it  may  op6u  into  the  peritoneal  cavity  or  the 
bowel;  or  point  outwards  in  the  abdominal  wall 
or  downwards  through  the  pelvis.  The  contents 
of  the  abscess  are  usually  extremely  foetid,  and 
a putrid  destruction  of  the  adjacent  tissues, 
especially  the  muscular,  is  frequent.  The  nerve- 
trunks  of  the  lumbar  plexus  escape  this,  but  the 
large  veins — iliac,  ileo-colic,  &c. — are  blocked 
with  coagula. 

More  frequently,  however,  the  disease  is  of  a 
chronic  and  insidious  character,  often  presenting 
obscure  symptoms  preventing  the  real  nature  of 
the  case  from  being  ascertained;  and  it  may 
thus  last  for  many  mouths.  The  inflammatory 
process  leads  then  to  a considerable  thicken- 
ing of  the  connective  tissue,  of  a tough  fibrous 
variety,  rather  than  to  the  formation  of  pus. 
If  the  starting-point  have  been  a perforating 
ulcer  of  the  caecum  or  appendix,  the  bowel 
may  be  found  to  be  firmly  imbedded  in  a 
mass  of  tough  fibrous  tissue,  which  binds  it 
down  closely  to  the  iliac  fossa  and  to  the  abdo- 
minal wall,  penetrating  the  muscular  tissue  and 
extending  even  to  the  bone.  Excavated  in  this 
new-formed  material  are  numerous  irregular 
shaggy  loculi,  communicating  with  one  another, 
and  to  a variable  extent  with  the  gut,  thereby 
allowing  extravasation  of  the  faeces,  though  this 
may  be  to  only  a slight  degree.  Sometimes 
the  intestine  may  be  so  much  involved  and  de- 
stroyed that  its  course  cannot  be  distinctly 
traced,  and  the  path  of  the  bowel-contents  is 
then,  for  a certain  distance,  limited  by  these 
new-formed  irregular  channels.  This  condition 
may  last  for  a long  time,  and  death  may  result 
from  exhaustion  rather  than  from  any  distinct 
lesion,  such  as  peritonitis.  Not  infrequently, 
however,  an  acute  attack  of  suppuration  may 
supervene  in  this  state,  and  give  rise  to  an  ab- 
scess which  may  take  one  of  the  courses  indicated 
above.  Or  when  even  perforation  of  the  bowel 
has  been  thecause,  the  aperture  may  subsequently 
become  closed  up ; and,  as  in  the  cases  where 
the  inflammation  has  started  outside  the  caecum 
the  surrounding  connective  tissue  becomes  much 
thickened  and  indurated,  and,  by’  partly  involv- 
ing the  intestine  in  its  contraction,  produces  ob- 
struction in  the  canal.  The  writer  has  noticed 
a marked  tendency  to  the  deposition  of  pigmeni 
in  the  new-formed  tissue  in  such  cases. 

Symptoms  and  Signs. — These  will  to  a cer 
tain  degree  depend,  especially  at  the  outset 
upon  the  nature  of  the  attack,  and  the  extern 
to  which  the  caecum  is  involved.  If  the  symp 
toms  of  typhlitis  be  much  prolonged,  or  if  in  ad 
dition  to  the  signs  of  that  disease,  an  examinatioi 
should  reveal  the  existence  of  a swelling  deeply 
seated  behind  the  caecum,  then  we  may  suspec 
that  the  inflammation  has  extended  beyond  th( 
gut ; and  the  occurrence  of  rigor  and  a higl 
temperature,  marked  by  a daily  rise  and  fall  " 
two  degrees,  would  go  far  to  make  the  diaguo-a 
certain.  But  such  a deep-seated  swelling  is  no 


PERITYPHLITIS. 


llways  easy  to  make  out,  since  the  distension  of 
the  caecum  and  the  tenderness  render  an  exami- 
nation difficult.  The  recognition  of  the  existence 
of  an  abscess  will  of  course  depend  very  much 
.upon  the  direction  which  it  takes.  In  the  more 
chronic  cases,  and  in  those  which  originate  inde- 
pendently of  typhlitis,  the  symptoms  are  liable  to 
be  obscure  for  a long  time.  Long  before  there  are 
the  physical  signs  of  a tumour  in  the  iliac  fossa, 
md  when  the  occurrence  of  an  injury  may  have 
jeen  forgotten  or  not  thought  of,  the  patient  will 
complain  of  pain  and  numbness  or  anomalous 
;ensations  extending  down  the  right  leg  as  far  as 
he  knee,  with  perhaps  slight  lameness,  and  a 
constant  inclination  to  relieve  the  pressure  of  the 
.bdominal  walls  by  leaning  over  to  the  right  side 
rhen  standing  and  sitting,  or  by  flexing  the  thigh 
■a  the  trunk  when  lying  down.  The  temperature 
s by  no  means  always  elevated,  and  the  bowels 
nay  present  but  very  little  irregularity  in  their 
ction.  Nevertheless,  the  patient  feels  generally 
iling,  in  an  ill-defined  sort  of  way,  and,  with  a 
robably  diminished  appetite,  loses  flesh.  Pain 
|nd  tenderness  on  pressure  may  be  absent  in 
he  iliac  fossa.  As  the  disease  slowly  advances, 
jowever,  and  the  patient  emaciates,  more  defi- 
ite  symptoms  will  present  themselves ; an  in- 
ceasingly  distinct  swelling  is  appreciable,  of  a 
otably  fixed  character,  not  shifting  under  mani- 
ulation,  tender,  and  accompanied  by  an  almost 
instant  pain  extending  down  the  leg,  which  may 
erhaps  be  slightly  cedematous,  from  pressure 
i the  veins.  The  abdomen  is  usually  slightly 
/mpanitic ; and  the  local  swelling  may  increase 
■ the  extent  of  being  visible.  The  bowels  by 
iis  time  are  markedly  irregular.  Sometimes 
.ere  is  diarrhoea,  sometimes  constipation,  or  al- 
rnations  of  these  conditions.  The  impairment 
the  intestinal  peristalsis,  caused  by  the  pres- 
roof  the  inflammatory  new  growth  inconnec- 
m with  the  caecum,  may  by  irritation  produce 
arrhcea,  or  by  obstruction  lead  to  constipation, 
te  stools  are  frequently  pale  and  unformed, 
uniting  is  sometimes  met  with  in  different 
grees  of  severity. 

Associated  with  the  formation  of  abscess,  a 
se  has  been  described  by  Dr.  Quain,  in  which 
sre  existed  a certain  subjective  sensation  of 
’.ell;  a faical  odour,  which  could  not  be  recog- 
ed  by  others,  being  continuously  complained 
by  the  patient,  to  the  extent  of  its  being  al- 
>st  regarded  as  a monomania.  This  smell  gave 
Vi  patient  no  further  annoyance  after  the  abscess 
!I  discharged  and  subsequently  healed. 

Ioukse  and  Terminations.' — 'When  an  ab- 
i ss  has  formed,  the  result  will  much  depend 
i where  it  opens,  and  to  what  extent  it  com- 
vnicates  with  the  caecum.  Rupture  into  the 
] itoneal  cavity  will  almost  surely  be  fatal,  and 
< n those  abscesses  which  burst  on  the  surface 
i!y  lead  to  death,  by  the  exhaustion  caused  by  a 
c onic  cavity  prevented  from  healing  by  its  dis- 
(jrging  faecal  matter.  In  the  most  acute  cases, 
v.Jre  no  perforation  into  the  bowel  has  taken 
pe,  the  resulting  abscess  may  burst  on  thesur- 
fji ; and  the  same  may  be  said  for  many  of  the 
r,  :e  chronic  cases,  when  the  progress  of  the  in- 
1 imation  has  become  arrested  before  it  has  im- 
[■  ated  the  bowel  to  any  great  extent,  and  when 
B'.rtial  absorption  of  the  inflammatory  tissue  has 


11-15 

taken  place.  But  in  other  cases,  and  especially 
where  there  are  burrowing  sinuous  channels  in 
the  iliac  fossa,  with  more  or  less  communication 
with  the  caecum,  recovery  is  of  rare  occurrence, 
and  the  patient  dies  from  exhaustion,  with  per- 
haps-caries  of  the  bone,  a faecal  abscess,  and  a 
chronic  diarrhoea. 

Diagnosis. — The  diagnosis  of  these  cases,  pre- 
vious to  the  recognition  of  a swelling  in  the 
iliac  fossa,  is  only  provisional.  The  history  of 
typhlitis,  with  subsequent  tenderness  and,  per- 
haps, high  temperature,  and  especially  an  ill- 
defined  feeling  of  illness,  the  patient  steadily 
deteriorating  in  health,  should  lead  to  a sus- 
picion of  the  extension  of  the  inflammation  be- 
yond the  caecum.  Should  an  abscess  form  and 
point,  it  will  not  be  difficult  to  recognise,  and 
when  a swelling  is  to  be  felt,  its  nature  will  be 
ascertained  by  attention  to  the  history  of  the 
case,  the  pressure-symptoms  in  the  right  leg, 
and  the  fixity  of  the  tumour.  The  variable  state 
of  the  bowels  renders  them  of  little  account  in 
forming  a diagnosis.  There  is  reason  to  believe 
that  this  malady  is  often  passed  over  unrecog- 
nised, and  is  of  more  frequent  occurrence  than  is 
supposed.  This  is  said  to  be  the  case  in  children, 
in  whom  cases  of  iliac  abscess  around  the  csecum 
are  liable  to  be  mistaken  for  hip-joint  disease, 
though  with  perhaps  scarcely  sufficient  reason. 

Prognosis. — In  the  acute  cases  where  a fecal 
abscess  forms  and  bursts,  a fatal  result,  sooner  or 
later,  is  to  be  feared.  If  rupture  takes  place 
into  the  peritoneal  cavity,  death  will  follow,  and 
even  where  perforation  of  the  abdominal  wall 
occurs,  the  ensuing  exhaustion  is  often  fatal. 
Those  cases  of  abscess  in  which  the  communica- 
tion with  the  bowel  has  not  existed,  or  has  been 
cut  off,  are  the  most  favourable.  Among  the 
chronic  cases  where  the  suppuration  is  but  slight, 
the  prognosis  seems  very  much  to  depend  upon 
tho  extent  to  which  the  intestine  is  implicated ; 
if  this  be  tolerably  free  a favourable  result  may 
be  expected. 

Treatment. — A large  proportion  of  the  cases 
of  perityphlitis  are  amenable  to  treatment. 
Perfect  rest  in  bed  is  of  primary  importance  ; 
and,  since  the  symptoms  are  directly  relieved 
by  the  reclining  position,  the  imprisonment  is 
readily  submitted  to.  Hot  poultices  of  linseed 
meal,  or  fomentations  over  the  ciecum,  and 
changed  as  often  as  necessary,  almost  invariably 
give  marked  relief ; when  an  abscess  is  in  pro- 
cess of  formation,  the  hot  applications  favour  its 
development,  and  so  promote  the  cure,  by  afford- 
ing an  opportunity  for  its  being  opened.  This 
plan,  pursued  for  a week  or  ten  days,  may  be 
sufficient.  In  the  more  chronic  cases  it  may  be 
necessary  to  continue  them  for  a longer  period, 
even  when  the  tension  appears  to  be  lessened,  and 
the  pain  in  the  limb  decreased.  When  the  more 
acute  inflammatory  symptoms  have  subsided, 
counter-irritation,  by  blisters  or  by  a solution  of 
iodine  applied  over  the  affected  part,  tends  to 
promote  absorption,  and  thus  to  remove  thick- 
ened or  condensed  tissues. 

Attention  should  be  especially  directed  to- 
wards maintaining  the  general  health.  The  diet 
should  be  small  in  amount,  frequently  adminis- 
tered, and  of  the  most  nutritive  quality.  Ad- 
vantage is  to  be  derived  from  the  simultaneous 


il  46  PERITYPHLITIS. 

administration  of  the  prepared  digestivo  juices  of 
the  stomach  and  pancreas,  so  that  a minimum 
of  indigestible  food  may  reach  the  lower  bowel. 

Stimulants,  carefully  administered,  are  often 
necessary.  Care  is  required  in  giving  aperients 
when  the  bowels  are  confined.  As  a rule  this 
condition  is  best  relieved  by  enemata  and  gentle 
laxatives,  such  as  confection  of  senna  or  castor 
oil.  Constipation  is  more  favourable  to  the  patient 
than  diarrhoea,  which  is  often  uncontrollable,  or 
obstinately  resists  the  usual  treatment  of  acids 
and  opium,  tannin  and  other  astringents,  whether 
given  by  the  mouth  or  as  enemata.  It  is  much 
easier  to  relieve  the  bowels  than  to  arrest  their 
excessive  action. 

Tonics,  such  as  iron,  ammonia,  and  bark,  are 
of  value,  and  should  be  given  from  the  outset, 
since  the  disease  is  one  that  tends  to  wasting, 
and  it  is  usually  in  a somewhat  enfeebled  con- 
dition that  the  patient  first  presents  himself. 
When  the  acute  phase  has  passed,  change  of  air, 
a sea-voyage,  and  other  aids  to  convalescence 
are  required.  W.  H.  Alt.chist. 

PERI-UTERINE  HEMATOCELE.  See 

Pelvic  PLejiatocele 

PERSONAL  HEALTH.  — Personal  hy- 
giene is  the  science  of  individual  health.  As 
there  are  public  acts  and  laws  which,  observed, 
promoto  the  health  of  communities,  so  there  are 
rules  of  living  and  habits  of  life,  inculcated  by 
competent  observers,  by  attention  to  which  the 
health  of  the  individual  may  be  preserved  or 
increased.  Health  is  a quality  of  body  easily 
comprehensible,  but  difficult  to  define.  It  is 
dealt  out  in  different  measures  at  different 
periods  of  life,  and  is  perhaps  best  described  as 
exemption  from  disease.  It  admits,  however,  of 
being  estimated,  and  we  shall  first  show  how 
this  may  he  done. 

First,  the  form  of  the  individual  must  be  ex- 
amined, to  ascertain  how  far  it  agrees  with  or 
departs  from  certain  mean  standards,  such  as  are 
laid  down  by  anatomists  and  practical  hygienists, 
and  which  give,  in  tables  for  each  age,  what  the 
height,  weight,  girth  of  chest,  and  mobility  of 
thorax  ought  to  be  every  year  of  life.  Thus 
above  the  weight  of  161  lbs.  avoirdupois,  the  cir- 
cumference of  the  chest  ought  to  increase  1 inch 
for  every  10  lbs.  of  additional  weight ; and  for 
every  inch  in  height  over  5 feet  8 inches  the 
mobility  of  the  thorax  ought  to  increase  in  a 
definite  ratio  ( see  Parkes’s  Hygiene , p.  480). 
Then  the  girth-measurement,  taken  round  the 
mamma,  should  be  in  excess  of  that  taken  lower 
down,  at  the  level  of  the  xiphoid  cartilage,  in 
every  man,  although  not  disproportionately  so, 
as  it  is  in  women  who  lace  tightly. 

Secondly,  the  manner  in  which  the  various 
functions  of  the  body  are  performed  must  be 
ascertained.  The  situation  of  the  heart’s  apex- 
beat  is  to  be  determined ; its  impulse  ; its  mode 
of  action  ; the  rhythm  of  its  sounds ; the  way  in 
which  the  circulation  is  being  carried  out ; how 
temperature  is  maintained  .at  the  extremities; 
and  what  individual  capacity  exists  to  resist 
conditions  calculated  to  lower  the  body  tempera- 
ture. The  respiratory,  cerebral,  and  spinal  func- 
tions must  all  be  determined;  the  organs  of 
digestion,  sanguification,  and  excretion,  as  well 


PERSONAL  HEALTH, 
as  their  performances,  will  have  to  be  examined 
in  due  order ; and  the  state  of  general  nutrition 
and  the  condition  of  the  skin  appraised. 

That  state  of  body  which  enables  it  to  per- 
form every  function  which  can  be  reasonably 
required  of  it,  to  accomplish  each  ordinary  task, 
and  be  equal  to  some  exertion  of  brain  and' 
muscle  without  painful  sense  of  fatigue,  is  what 
we  ordinarily  understand  as  healthj  It  would 
be  difficult,  however,  if  not  impossible,  to  lay 
down  the  amount  of  work  or  exertion,  short  o’: 
positive  fatigue,  which  a child,  lad,  woman,  oi 
man  ought  to  be  equal  to  without  preparatior 
or  training  of  any  kind.  Erectness,  firmness 
good  balance  of  body  and  mind,  testify  to  : 
man,  as  they  do  to  a racehorse  or  a gamecock 
An  experienced  eye  recognises  at  a glance  tb 
particular  build  of  man  suitable  to  particula 
taskwork  ; likely  to  excel  in  particular  exercises 
sports,  or  games ; fitted  to  labour  with  his  head 
or  with  his  hands ; to  run,  swim,  or  fight  well' 
There  is,  perhaps,  a little  less  difference  be 
tween  man  and  man  than  between  carthorse 
and  racehorses,  but  it  is  one  of  degree  only 
Fortes  crcantur  fortibus,  and  for  perfect  bod’! 
aptitude  for  any  trade,  profession,  or  particula 
craft,  the  individual  must  be  bom,  bred,  an' 
trained  accordingly.  We  arrive  at  the  folio  win 
signs  or  evidences  of  health  : — 

a.  Good  construction  ; b.  Accommodativenes 
to  change,  individual  adaptability  to  widely  di 
verse  conditions  of  life,  or  of  climate,  withou 
deterioration  of  energy ; c.  Endurance ; d.  Seb 
control — mental,  emotional,  sexual ; and  e.  K( 
sistance  to  morbific  influences. 

Prom  birth  onwards  to  old  age  health  is  nc 
uniform;  it  varies  as  the  body  varies,  accordic 
to  wear  and  tear,  and  treatment — a sufficient! 
obvious  proposition.  At  different  epochs  of  lit 
the  strain,  or  stress,  is  felt  in  different  part 
falls  upon  different  organs,  and  issues  in  pn 
clivity  to  disorder  of  their  several  functions,  (j 
in  wear  or  degeneration  of  the  tissues  of  whic- 
they  are  built."  Our  object  here  is  to  dernoi 
strate  how  individual  health  may  be  secured 
how  disease-tendencies  may  be  avoided  or  dim 
nished;  and  how  a reasonable  measure  of  healt 
may  be  attained  throughout  life,  and  at  evei 
period  of  it.  To  fulfil  this  endeavour  we  divic 
the  life  of  a human  being  into  the  followir 
periods,  and  consider  them  separately  in  relatic 
to  their  special  physiology,  to  morbid  imm 
nencies,  and  to  probable  accidents,  laying  dow 
the  best  rules  of  guidance  in  diet,  clothin 
habits,  exercise  of  body  and  mind ; indicator 
whatever  appears  most  conducive  to  the  heal! 
of  the  individual  at  the  age  mentioned.  It 
of  course  of  first  importance  to  be  born  of 
healthy,  long-lived  stock;  but  for  heredity  ar 
its  effects  the  reader  is  referred  to  the  articj 
Disease,  Causes  of. 

Life  periods. — The  following  are  theperio. 
of  life,  as  they  will  bo  successively  co 
sidered : — 

1 . Intra-uterine  life  and  Gestation. 

2.  Birth.  , 

3.  Infancy,  the  period  between  birth  and  tl 
completion  of  the  first  dentition. 

4.  Childhood,  the  period  boiwocn  2 and 
years. 


PERSONAL  HEALTH. 


5.  Adolescence,  the  period  between  7 and 
14  years. 

6.  Puberty,  the  period  between  Hand  20 
years. 

7.  Adult  age,  the  period  between  20  and 
30  years. 

8.  Maturity,  the  period  between  30  and  45 
years. 

' 9.  Turning-time,  the  period  between  45  and 
30  years. 

10.  Advanced  life,  the  period  between  00 
and  82  years. 

11.  Old  age,  the  period  between  82  and  100 
years. 

1.  The  Intra-uterine  and  Gestation  Period. 
The  health,  habits,  and  conduct  of  the  mother 
during  pregnancy  modify  the  future  individual 
considerably.  Whatever  affects  the  blood  of  the 
nother  affects  that  of  her  fcetus,  and  vice  versa. 
There  are  grounds  for  thinking  that  the  mother 
Dossesses  and  exercises  purifying  and  excretory 
oowers  over  the  blood  of  her  foetus,  appropriating 
ato  her  own  eliminating  organs,  and  in  some 
legree  removing  from  her  offspring,  taints  or 
lisease-germs  derived  from  the  father  of  the 
child,  perhaps  suffering  from  these  herself 
incuriously.  This  surmise  has  been  offered  to 
■xplain  a fact  not  infrequently  observed,  that 
ireviously  healthy  wives,  born  too  of  healthy 
tocks,  married  to  consumptive  husbands,  after 
breeding  one  or  more  children,  tend  to  die 
hemselves  of  a rapid  form  of  phthisis,  al- 
though bearing  children  not  necessarily  con- 
umptive.  On  the  other  hand,  delicate  women 
rho  have  been  impregnated  by  exceptionally 
ound  sires  are  observed  to  improve  in  vigour 
nd  robustness  with  each  succeeding  pregnancy, 
t is  certain  that  smallpox,  scarlatina,  and  measles 
lay  be  conveyed  by  the  mother  to  the  child  in 
tero ; that  typhoid  fever  occurring  to  the  mother 
; usually  fatal  to  her  fcetus ; and  that  the  poison 
f syphilis  derived  from  either  parent  is  ex- 
remely  pernicious  to  the  growth  and  develop- 
lent  of  the  fruit. 

Alcoholic  abuses  committed  by  the  mother 
uring  pregnancy  favour  premature  delivery',  and 
ppear  beyond  this  distinctly  prejudicial  to  the 
ealth  of  the  children  when  these  are  born  alive, 
.16  constitutional  flaw  not  showing  itself  by 
ipparent  malnutrition  so  much  as  by  undue 
Proclivity  in  them  to  manifest  disorders  of  the 
iervous  system — chorea  and  epilepsy  in  child- 
!ood,  hysteria  and  insanity  in  adult  years, 
xperience  shows  the  hygiene  of  this  period  to 
insist  in  temperate  living.  The  pregnant 
oman  should  avoid  excitements  of  all  kinds, 
ike  moderate  exercise,  rise  and  go  to  bed 
irly,  not  alter  her  habits  of  life  abruptly.  In 
he  later  months  she  must  dress  herself  appro- 
riately  to  her  state,  not  so  as  to  interfere  with 
le  emerging  of  the  uterus  from  the  pelvis,  or 
1 as  to  limit  tho  movements  of  the  babe  in 
'era. 

\ 2.  Birth. — Beclard  in  his  work  {Hygiene  de 
Premiere  Enfancc,  Paris,  1852)  pointed  out  a 
ct  of  some  importance  in  the  hygiene  of  birth, 
lien  the  foetus  with  its  membranes  and 
acenta  are  separated  from  the  mother,  and 
dependent  existence  is  commenced,  a good 
ial  of  blood,  properly  the  newborn  child’s,  re- 


1147 

mains  and  is  for  a short  time  after  actual  birth 
lodged  in  the  cord  and  placenta.  If  time 
enough  be  allowed,  and  the  newborn  be  kept 
properly  warm  the  while,  all  this  blood — somo 
two  ounces  or  thereabouts,  and  therefore  no 
unimportant  quantity  when  the  weight  of  the 
child  is  considered — will  find  its  way  into  the 
infant’s  body  ; whereas,  if  the  cord  be  tied  and 
divided  too  quickly,  and  before  tho  umbilical 
vein  becomes  collapsed  and  empties  itself,  the 
child  is  mulcted  of  its  natural  blood-endowment. 
According  to  Pinard’s  observations,  it  is  easy  to 
distinguish  the  babies  who  thus  receive  their 
full  complement  of  blood  at  birth  from  those 
who  do  not.  The  skin  of  the  former  is  rose- 
coloured  and  well  plumped  out,  whereas  the  skin 
of  the  latter  has  an  anaemic  or  icteric  tint,  and 
is  poor ; the  former  infants  grow  and  develop 
more  rapidly,  and  are  altogether  more  vigorous 
than  the  latter.  As  a guide  to  the  accoucheur’s 
practice,  he  inculcates  careful  observation  of  the 
cord  at  birth.  All  pulsation  ceases  in  the  um- 
bilical arteries  directly  the  newborn  breathes 
and  cries  ; but  for  some  while,  different  in  dif- 
ferent cases,  the  umbilical  vein  remains  full ; 
and  the  blood  in  it  continues  liquid  up  to  the 
moment  when  its  last  drop  is  absorbed  into  the 
child's  body.  But  the  cord  must  not  be  liga- 
tured until  the  umbilical  vein  is  flat  and  empty. 
The  accidents  incidental  to  birth  are  multifarious, 
and  belong  to  the  subject  of  parturition.  "We 
may  notice  specially'  asphyxia  from  prolapse  and 
compression  of  the  cord  ; and  prolonged  pressure 
upon  the  infant’s  skull  inducing  epicranial  cephal- 
hematoma, and,  rarely,  apoplexy  and  paralysis. 

If  the  temperature  of  the  external  air  is 
about  60°,  children  may  be  allowed  to  go  out 
when  they  are  eight  or  fifteen  days  old,  after 
cicatrisation  of  the  umbilicus.  Children  born 
in  February  and  September  appear  to  possess 
the  greatest  vitality,  those  born  in  June  the 
smallest.  According  to  statistics  carefully  col- 
lected by  Hr.  E.  Smith  in  his  work  on  Health 
and  Disease,  p.  267,  ‘ the  viability  of  the  infants 
born  in  the  winter  and  spring  months  is  greater 
than  that  of  those  who  come  into  the  world  in 
summer  or  autumn.’ 

No  artificial  purgative  oil,  gruel,  or  sugar- 
water,  should  be  allowed  in  lieu  of  the  mother’s 
first  colostrum  milk. 

3.  Infancy. — The  period  of  infancy  might  be 
subdivided  into  early  and  late ; early  compre- 
hending the  time  from  birth  to  eruption  of  the 
first  teeth ; late,  that  from  the  commencement  to 
the  completion  of  the  first  dentition.  The  lead- 
ing anatomical  feature  of  this  age  is  the  large 
amount  of  blood  relatively  to  the  solids  of  the 
body,  the  laxity  of  all  the  tissues,  the  dispro- 
portionate quantity  of  component  water,  and  the 
large  relative  amount  of  red  blood-corpuscles 
and  of  irou,  which  appears  far  in  excess  of  that 
existing  in  adults.  See  E.  Smith’s  Cycle  of 
Ages,  p.  247. 

The  circumstance  of  chief  physiological  im- 
portance is  that  the  greatest  growth  occurs  in 
the  first  years  of  life.  Quetelet  in  his  essay, 
Sur  V Homme,  shows  that  the  near  average 
weight  of  male  infants  exceeds  that  of  fe- 
males ; boy's  at  birth  weighing  3 kilogrammes 
20  grammes,  and  girls  2 kilogrammes  9 grammes. 


1 143  PERSONAL  HEALTH. 


There  is  no  indicator  so  infallible  as  the 
balance  to  prove  whether  an  infant  is  or  is  not 
being  properly  nourished.  It  appears  that  from 
birth  up  to  the  end  of  the  second  day  all  new- 
borns lose  weight  a little ; they  do  not  increase 
perceptibly  till  after  the  end  of  the  first  week.1 

M.  Odier  states  that  it  is  usual  to  find  an 
infant  increase  30  or  40  grammes  (461  to  606 
grains)  per  diem  during  the  first  five  months  of 
life,  20  grammes  (308  grains)  a day  from  the  fifth 
to  the  eighth  month,  and  10  grammes  (or  155 
grains)  daily  between  the  eighth  and  the  twelfth 
month. 

Dentition  is  the  change  most  characteristic  of 
the  infant’s  growth  and  development. 

In  infantile  life  all  the  vital  functions  go  on 
rapidly.  The  pulse  at  birth  ranges  from  130  to 
140  per  minute ; and  to  the  end  of  the  first  year 
is  from  115  to  120.  The  rate  of  respiration  is 
from  25  to  30.  While  the  circulation  is  rapid, 
the  skin,  from  its  softness  and  vascularity,  dis- 
perses heat  rapidly ; the  cooling  agencies  are  at 
a maximum  ; and  the  heat-maintaining  powers, 
(that  is,  resistance  to  depressing  influences)  are 
at  a minimum.  ‘ The  food  taken  by  infants  is, 
in  proportion  to  the  weight  of  the  body,  from 
three  to  six  times  greater  than  that  taken  by 
adults.’  (Dr.  Smith,  op.  cit.,  p.  247.) 

The  perils  from  without  to  infant  life  are 
mainly  derived  from  cold,  those  from  within 
result  chiefly  from  improper  or  defective  feeding 
and  hyper-nervous  impressionability.  It  is  not 
easy  to  over-feed  young  infants.  If  proper  food, 
that  is,  their  own  mother’s  milk,  be  given  them, 
they  get  rid  of  excess  quickly  enough  by  vomit- 
ing it,  and  the  part  not  appropriated  in  growth 
or  maintenance  is  stored  up  for  future  use  as  fat. 
The  morbid  tendencies  of  this  age  are  towards 
tho  intestinal  and  mucous  tracts.  Catarrhal 
diarrhoea  and  bronchitis,  thrush  and  stomatitis, 
are  epiphenomena  of  all  febriculas  and  states  of 
malnutrition.  Delirium  and  convulsions  attend 
all  general  disorders.  Over-rapid  dentition  is 
associated  often  with  tuberculansation,  retarded 
dentition  with  rickets.  The  more  rapid  the 
eruption  of  the  teeth,  the  greater  the  attendant 
disturbance ; the  more  closely  the  evolution  of 
the  teeth  follows  its  normal  periods  ( see  Teeth- 
ing'), the  less  conscious  are  infant  and  mother 
of  their  appearance.  The  hygienic  rules  for  this 
period  have  reference  principally  to  feeding, 
cleanliness,  clothing,  and  open-air  exercise. 

Diet. — For  diet  the  reader  is  referred  to 
p.  362,  where  the  proper  aliment  for  infants  is 
fully  discussed.  Experience  proves  that  nature 
will  not  be  contradicted — that  no  aliment  is  so 
appropriate  as  the  milk  of  a mother,  or  of  a wet 
nurse  aged  between  twenty-two  and  thirty-five. 
Next  best  to  this  comes  suckling  by  a goat, ; and 
next,  again,  a mixture  of  equal  parts  cow's  and 
ass’s  milk  given  by  a feeding-bottle.  The  suck- 
ling of  her  own  infant  by  the  mother  for  nine 
months  is  good  not  only  for  the  child  but  for  its 
mother.  The  uterus  passes  through  its  retro- 
grade involution  more  properly,  no  periodic  ute- 
rine congestions  delay  it,  and  ovulation  is  de- 
creed. \V  ith  respect  to  the  frequency  of  feeding, 

• The  infant  should  be  weighed  naked  in  a warm  room 
lying  on  a piece  of  flannel  of  ascertained  weight,  in  th( 
Beale  of  a balance  sensitive  to  a drachm. 


and  the  quantity  taken,  tho  reader  may  be  to- 
ferred  to  the  statements  of  Proust.1  During 
the  first  day  of  life,  what  with  scantiness  of  the 
colostrum,  mechanical  obstacles  to  suction,  and, 
the  weakness  of  the  infant’s  efforts,  the  child' 
does  not  extract  more  than  a drachm  each  time 
it  is  placed  to  the  breast.  It  needs  no  more, 
however.  During  the  first  week  of  life  it  should 
be  nursed  ten  times  in  the  twenty-four  hours 
arranging  times  so  that  the  mother  gets  six  hours 
consecutive  rest  at  night.  On  the  second  dav 
each  suckling  should  furnish  about  5 drachms  of 
milk.  On  the  third  day  each  suckling  should 
furnish  about  1 J ounces  of  milk.  On  the  fourth 
day  each  suckling  should  furnish  about  2 ounce; 
of  milk.  During  the  first  month  average-sized 
infants  require  and  obtain  nearly  3 ounces  o: 
breast-milk  at  each  nursing,  and  should  lit 
nursed  nine  times  in  the  twenty-four  hours,  oil 
receive  about  27  ounces  of  milk  a day.  During 
the  second  month  each  suckling  should  furnish 
4|  ounces  of  milk,  and  the  number  of  feeding; 
may  be  reduced  to  seven  per  diem,  which  allow; 
3 It)  ounces  each  twenty-four  hours.  At  three 
months  old  the  infant  sucks  about  5 ounces  at  ? 
meal,  an  equivalent  of  35  ounces  each  twenty- 
four  hours ; and  at  four  months  it  extracts  a; 
much  as  6^  ounces  of  milk  at  each  meal,  which 
may  be  again  curtailed  to  six  each  day,  giving 
37)  ounces  of  aliment.  This  continues  to  ba 
the  quantity  of  milk  and  frequency  of  feeding1 
required  of  a good  nurse  up  to  the  end  of  the 
ninth  month,  but  the  quality  of  the  milk  daring 
this  period  steadily  improves,  becoming  enrichei 
according  as  the  child  sucks  more  vigoronsl}; 
and  at  longer  intervals,  a provision  fraught  with 
mutual  advantage  to  child  and  mother. 

At  the  ninth  month  the  child  may  be  gra 
dually  weaned,  although  the  age  for  weaning 
should  be  governed  by  the  health  of  the  mothei 
or  nurse,  the  forwardness  of  dentition,  and  the 
infant’s  own  craving  for  other  food.  The  lies' 
time  to  seize  for  the  purpose  is  the  interval  o: 
pause  after  the  four  lateral  incisors  are  ent, 
and  before  the  first  molars  appear. 

Dentition,  normal  order  of. — The  two  inferior 
incisors  should  pierce  the  gums  between  the 
fourth  and  seventh  months ; their  eruption  is 
attended  by  a slight  six  days’  disturbance  ot 
health.  Between  the  eighth  and  tenth  months 
the  two  superior  incisors  and  two  superior  latere, 
incisors  appear  within  three  or  four  weeks  c:i 
each  other,  their  eruption  also  being  attendee 
by  slight  fever  and  restlessness.  A pause  non 
ensues  of  from  six  to  twelve  weeks’  duration 
after  which,  and  at  some  period  between  the 
twelfth  and  fifteenth  months,  six  more  teeth 
burst  through  within  a few  weeks.  First,  as  a 
rule,  come  the  two  first  molars  of  the  nppei 
jaw,  then  the  two  lower  lateral  incisors,  anc 
lastly  the  two  lower  first  molars.  Again  c 
pause  follows,  lasting  from  eight  to  twelvt 
weeks ; and  now,  between  the  eighteenth  an. 
twenty-fourth  months,  the  two  lower  canines 
appear,  the  upper  ones  succeeding  them.  I eri 
little  disturbance  marks  their  eruption.  At 
interval  of  six  months  now  intervenes,  and 
between  the  thirtieth  and  thirty-sixth  months 
or  nearly  on  the  completion  of  its  third  year 
* Traiti  d' Uygiine  : Paris,  1S7",  p.  1 15. 


PERSONAL 

ie  child  acquires  its  four  last  or  permanent 
idars,  the  lower  preceding  the  upper,  and  their 
itting  being  attended  often  by  general  disorder, 
roupy  symptoms,  diarrhoea,  and  convulsions. 
Cleanliness  and  Care. — The  infant  requires 
ashing  all  over  from  top  of  head  to  solo  of 
Lt  night  and  morning  every  day,  and  is  best, 
ecause  most  quickly,  immersed  in  a tub  once 
aily.  Infants  who  have  had  convulsions  at  any 
eriod  of  their  lives  are,  as  a rule,  better  washed 
11  over  with  a sponge  in  the  lap  of  their  nurse 
lan  immersed  in  a bath,  as  immersion  is  apt  to 
ighten  them.  The  water  should  be  the  softest 
rocurable.  Rain  water  is  best.  The  tempera- 
ire  of  the  room  during  the  bath  should  be  be- 
veen  65°  and  70°  Fahr. ; that  of  the  bath  itself, 
red  by  the  thermometer,  between  70°  and  90°. 
ixing  the  temperature  of  the  bath  should  not 
e left  to  the  possible  indiscretion  of  a nurse ; 
iany  a woman’s  hand  will  support  water  at  a 
feat  enough  to  parboil  a baby. 

The  nurse  should  be  required  not  to  dawdle 
rer  bath  or  dressing ; the  former  should  occupy 
re  minutes,  the  latter  not  more  than  twenty, 
little  or  no  soap,  or  only  soft  soap,  should  be 
nployed.  The  drying  should  be  accomplished 
iith  soft  dry  cloths,  and  for  baby  powder,  tc 
:event  excoriations,  fuller’s  earth  cannot  be 
upassed.  Eczema  and  intertrigo  are  obviated 
V due  attention  to  the  frequent  change  of 
apers  and  sufficient  cleanliness. 

Clothing. — No  infant  ought  to  be  swathed 
ke  a mummy;  it  requires  keeping  warm,  but 
lould  not  be  overweighted  with  clothes.  Its 
lest  must  be  free  to  expand,  its  limbs  at 
oerty  to  move.  The  more  lightly  its  head  is 
vered,  and  the  more  quickly  all  caps  are  dis- 
eased with,  the  stronger  will  be  its  hair  and 
e less  its  susceptibility  to  catarrh.  Night- 
ps  are  dirt-traps,  and  in  all  classes  alike 
omote  scalp  eruptions  by  provoking  perspira- 
m,  with  which  the  skin  is  softened,  and  by 
lose  decomposition  the  sebaceous  follicles  are 
Rated  and  clogged. 

General  Rules  and  Hygienic  Advice. — Even 
e youngest  infants  require  sunlight  and  open 
Due  discretion  must  be  employed,  how- 
ler, in  sending  them  out.  They  are  better 
tried  in  their  nurse’s  arms,  and  thus  assisted 
maintain  their  own  heat  by  that  derived  from 
jsir  nurse’s  body,  than  placed  in  perambula- 
■s.  So  soon  as  they  can  crawl  they  should  be 
louraged  to  do  so,  either  on  a carpet,  in  a 
tden,  or  on  a dry,  sandy  pathway  protected 
m wind  and  open  to  sunlight.  Cold  and 
' rk  places  are  specially  inimical  to  them;  and 
en  the  weather  is  cold  they  should  be  en- 
< iraged  to  amuse  themselves  on  a blanket  or 
1 1 hearth-rug,  so  as  to  learn  to  stretch  their 
i ibs  and  co-ordinate  all  their  muscular  move- 
nts.  They  learn  first  to  sit  up,  then  to  stand, 
1 ped  by  their  arms,  against  a chair,  next  to 
i nd  without  support,  and  at  some  period 
ween  one  year  and  two  years  of  age  should 
1 able  to  walk  about  by  themselves. 
ileep. — Infants  require  day  as  well  as  night 
f 'P-  Very  young  babies  do  little  elso  but  suck 
‘ ; sleep.  As  they  grow  they  need  and  take  less 
i less  sleep,  and  by  the  time  first  dentition  is 
i implished— three  years  of  age— a child  may 


HEALTH.  ‘ 1149 

usually  dispense  with  day  sleep  altogether,  ex- 
cept a short  hour’s  nap  early  in  the  afternoon 
or  between  eleven  and  twelve.  Sound  sleep  co- 
incides in  the  infant,  as  in  the  adult,  with  short 
sleep  hours,  and  the  strongest  children  require 
least  sleep.  The  infant  should  have  its  own 
cradle,  and  the  child  its  own  cot,  placed  close 
beside  the  bed  with  its  mother  or  nurse.  In 
extra  cold  weather,  hard  frosts,  the  cot  should  be 
artificially  warmed  by  a hot  water-bottle.  The 
sleeping  nursery  ought  not  to  be  kept  warmer 
than  65°,  or  colder  than  50°,  whilst  the  nearer  it 
is  maintained  to  55°  during  the  winter  months, 
and  65°  during  summer,  the  sounder  the  child 
will  sleep.  The  more  freely  the  whole  house  and 
nurseries  are  ventilated,  the  less  prone  the  in- 
fant will  bo  to  all  infantile  disorders. 

4.  Cblldhood. — In  this  period,  between  the 
second  or  third  and  seventh  years  of  life,  the  first 
dentition  is  accomplished,  the  second  uncom- 
menced. The  rate  of  pulse  falls  from  115  to  90 
per  minute,  and  respiration  commensurattly. 
The  excretions  are  all  absolutely  increased.  In 
the  co-ordination  of  muscular  movements  and  in 
mental  operations  great  progress  is  being  made. 
The  cerebro-spinal  structures,  which  nearly 
double  in  volume  between  birth  and  the  second 
year,  continue  to  develop  disproportionately  to 
the  growth  of  the  trunk  and  limbs  between  two 
and  seven.  The  cellular  tissues  are  loose  and 
vascular  still,  and  the  cutaneous  and  mucous 
surfaces  therefore  extra  vulnerable.  A notable 
physiological  feature  of  this  age  is  the  readiness 
to  swell  observable  in  the  lymphatic  glands 
upon  the  slightest  irritation,  and  the  general 
functional  activity  of  all  the  lymphatic  struc- 
tures. It  might  be  distinguished  as  the  life 
period  of  greatest  lymphatic  activity.  From 
these  facts  the  morbid  imminences  may  be  in- 
ferred, namely,  a tendency  to  eczema  and  to 
catarrh  of  mucous  surfaces,  diarrhoea,  laryngeal 
and  bronchial  catarrh,  general  anasarca,  hydro- 
cephalus, susceptibility  to  contagious  impres- 
sions, proclivity  to  tubercular  meningitis,  and 
to  functional  cerebral  disorders  like  delirium 
and  convulsions.  The  incontinence  of  urine,  so 
frequent  in  early  childhood,  may  be  likewise 
referred  to  the  reflex  irritability  of  the  spinal 
centres  characteristic  of  this  age.  According  to 
Lebert  the  cerebellum  attains  its  largest  size, 
relatively  to  the  cerebrum,  between  four  and 
five,  to  which  circumstance  has  been  referred  tho 
occasional  sexual  excitability  and  vicious  prac- 
tices discovered  in  some  children  at  this  early 
age.  However  this  may  be,  the  importance  of 
good  nurses  and  wise  supervision  cannot  be  too 
much  insisted  on,  as  also  the  inculcation  of 
healthy  habits  and  provision  of  proper  amuse- 
ments and  employments. 

Diet. — While  bread,  starch,  and  flesh  foods 
are  taking  the  place  of  cows’  milk  very  greatly, 
they  must  not  be  allowed  to  wholly  supplant  it. 
Eight  ounces  of  bread  may  be  reckoned  about 
equivalent  in  nitrogen  content  to  one  pint  of 
milk,  but  the  former  exceeds  the  latter  in  car- 
bon. The  food  must  be  nutritious  and  abun- 
dant. The  error  committed  is  far  too  often  that 
of  under  than  of  over-feeding.  Young  children 
do  not  require  so  much  variety  in  their  food  us 
adults  do,  but  are  greatly  benefited  by  a change 


PERSONAL  HEALTH. 


1150 

in  their  bread  and  meal  stuffs,  and  a dietary  not 
too  monotonous.  They  do  not  need  meat  more 
than  once  a day,  and  fish  may  bo  substituted  for 
meat,  if  cream  or  butter  sauce  be  provided  with 
it,  once  or  twice  a week.  Milk,  bread,  porridge, 
suet  puddings  and  milky  puddings  should  form 
the  staple  of  their  dietaries ; fresh  vegetables 
well  cooked,  watercress,  cooked  fruit,  and  oranges 
are  most  useful  adjuncts;  while  the  addition 
of  fried  bacon,  clotted  cream,  and  oil,  or  butter, 
when  the  drinking  water  is  hard,  and  the  ten- 
dency of  the  child  is  rather  towards  constipation 
than  otherwise,  is  now  fairly  generally  under- 
stood. It  is  usually  easy  and  always  beneficial 
to  instruct  young  children  to  secure  an  alvine 
evacuation  directly  they  rise  of  a morning  and 
before  their  bath.  Four  meals  a day  are  most 
appropriate — a breakfast  at  eight,  a dinner  at 
twelve,  a tea  at  four,  and  a supper  at  eight. 

Cleanliness. — Washing  all  over  once  a clay, 
and  in  the  morning,  is  as  necessary  as  ever  ; but 
after  first  tubbingin  warm  water  between  98°  and 
100°,  the  child  should  stand  up  and  be  sponged 
all  over  from  a basin  of  cold  water,  and  be 
briskly  dried  with  a largo  towel. 

Sleep. — A child  should  sleep  in  a cot  or  bed 
by  itself,  but  in  the  same  room  with  its  parent 
or  nurse,  since  they  are  apt  to  show  any  dis- 
order by  night  vagaries,  delirious  talking,  rest- 
lessness, or  sleep-walking. 

Between  two  and  five  most  children  are  the 
better  for  twelve  hours  of  sleep  out  of  the 
twenty-four.  At  seven  years  of  age  they  do 
not  require  day  sleep,  but  should  be  in  bed  at 
eight,  and  up  at  six  in  summer  and  between  six 
and  seven  in  winter.  The  best  bed  for  this  age 
is  an  ordinary  iron  bedstead,  with  firm  and 
level  wool  and  hair  mattresses ; not  spring 
beds,  which  do  not  adapt  themselves  so  well  to 
light  bodies,  or  keep  them  uniformly  warm. 
Cotton  sheets,  blankets,  and  counterpane  must 
be  used  according  to  season.  Beyond  saying  that 
the  day  clothing  should  be  warm,  and  merino 
or  wool  put  next  tne  skin,  we  can  add  nothing 
further  about  clothing. 

Exercise.  — Two  things  are  requisite  for 
healthy  growth  and  development  and  a happy 
childhood — a play-room  and  a garden.  Children 
need  a place  like  an  empty  barn,  in  which  they 
can  swing  and  amuse  themselves  in  wet  and 
wintry,  as  well  as  in  hot  sultry  weather,  prac- 
tising those  games  which  are  requisite  alike  for 
the  schooling  of  their  muscles  and  nerves. 

Teaching. — Teaching  such  as  they  need  should 
be  conducted  on  the  Kindergarten  system  ; but 
the  main  rule  for  their  lives  is  open  air  and  ex- 
ercise, the  chief  objects  being  to  harden  their 
skins,  develop  their  muscles,  and  teach  them 
self-control,  love  and  respect  for  those  to  whom 
they  render  implicit,  because  well-nigh  uncon- 
scious, obedience. 

5.  Adolescence. — The  consideration  of  this, 
the  period  of  second  dentition,  between  the  ages 
of  7 and  14,  is  best  prefaced  by  the  order  of 
aruption  of  the  second  teeth. 

About  7 years  the  4 anterior  molars  (perma- 
nent teeth)  are  cut. 

About  8 years  the  4 central  incisors. 

,,  9 „ 4 lateral  incisors. 

„ 1 9 ,.  4 anterior  bicuspids. 


About  11  years  the  4 posterior  bicuspid*. 

„ 12  to  12j  4 canines. 

„ 12^  to  14  4 posterior  molars. 

The  teeth  of  the  lower  jaw  usually  precede 
those  of  the  upper.  Second  dentition  is  accom- 
plished leisurely,  and  accompanied  therefore 
usually  by  no  such  grave  disorders  as  mark  first 
dentition ; but  in  nervous  children  nervous  tricks 
may  manifest  themselves,  as  well  as  marked  lack 
of  emotional  control.  Some  are  hypersensitive, 
others  contradictory  and  difficult;  and  most 
parents  admit  that  between  7 and  8,  if  not  be- 
tween 7 and  14,  they  learn  what  the  charac- 
ters of  their  children  really  are.  Physiologi- 
cally, absorption  of  the  subcutaneous  fat  goes 
on  rapidly,  while  the  muscles  become  more  pro- 
nounced, the  skin  gets  tougher,  its  epidermis 
harder,  and  it  perspires  less  readily.  In  our 
climate  the  morbid  tendencies  of  this  age  are  to 
rheumatism,  chorea,  epilepsy,  the  exanthemata, 
and  typhoid  fever. 

Between  7 and  8 the  appetite  is  apt  to  become 
capricious  ; the  child  physiologically  does  not 
require  60  much  hydrocarbonaceous  food ; and, 
while  growing  fast  and  becoming  leaner,  protests 
against  fat,  often  while  showing  marked  longing 
for  fresh  fruits,  in  which  nature  should  be  in- 
dulged. After  8,  however,  any  marked  defect 
of  appetite  or  loss  of  weight  is  suggestive  of 
undue  cerebral  excitement,  attributable  to  OTer- 
study  or  some  infraction  of  the  laws  of  health. 

Diet. — Three  good  meals  a day  are  sufficient, 
but  four  are  more  advisable.  Constipation  at 
this  age  signifies  usually  irregular  feeding  and: 
overloading  with  pastrycook  supplies,  or  im- 
proper food.  Breakfast  at  eight,  dinner  at  one, 
tea  at.  five,  and  supper  at  eight  appears  the  best 
distribution.  By  supper  is  meant  such  a meal 
as  growing  lads  and  girls  positively  need.  They 
require  either  soup  and  potatoes,  and  bread  and 
butter,  or  some  one  hot  dish  of  meat  or  fish, 
and  the  drink  should  be  either  warm  milk  or 
cocoa  to  about  half-a-pint  of  fluid ; aliment 
enough  is  needed  to  improve  the  circulation  at 
the  extremities  and  obviate  chilblains.  Boys 
and  girls  may  retire  to  bed  within  an  hour  on 
their  supper,  which,  instead  of  making  them 
dream,  will  secure  good  and  refreshing  sleep. 
The  greatest  dangers  at  this  age  arise  certainly 
from  defective  nutrition  and  an  over  sensitive- 
ness of  the  skin.  Neither  wine  nor  beer  is 
necessary,  nor  should  it  be  allowed  without 
medical  authorisation. 

Clothing. — The  objects  of  clothing  are 
warmth,  cleanliness,  and  convenience.  Cotton  or 
silk  shirtings  should  lie  next  the  skin  of  the  chest 
and  trunk.  Merino,  flannel,  or  woollen  materials 
should  protect  the  legs  and  feet ; cloth,  woollen 
jerseys,  furs,  and  skins  are  better  adapted  for  ex- 
ternal coverings.  But  a whole  chapter  could  be 
devoted  to  the  foot  alone,  and  its  clothing  during 
its  growth  and  development.  The  desiderata 
appear  to  be  length  and  breadth  enough,  low 
heels,  impervious  soles,  old  and  flexible  skin; 
for  uppers.  Boots  for  out-door  exercise  are 
advised  for  children,  because  their  ankles  nee* 
support ; shoes  a little  later  on,  because  theyart 
cheaper  and  do  not  repay  re-soling,  and  may  lit 
discarded  at  once  when  worn  out.  The  sam( 
boots  should  not  be  worn  day  after  day.  thci 


PERSONAL  HEALTH. 


squire  time  to  dry  properly  in  damp  weather, 
,nd  the  foot  at  that  age  profits  by  change  of 
pressure.  During  youth  the  adaptation  of  clothes 
|o  special  sports  and  exercises  is  far  from  unim- 
portant to  healrh.  For  violent  muscular  exer- 
ise  flannel  or  merino  next  the  skin,  and  an  easy 
flannel  jacket  or  over-jersey  should  be  worn  ; 
Joth  after  being  used  should  be  hung  up  to  dry 
nd  air  before  being  worn  again.  It  is  well  that 
outh  should  be  reminded  that  rheumatism  is 
irobably  too  often  inflicted  upon  those  who  are 
areless  about  their  dress,  and  negligent  enough 
o wear  the  same  clothes  which  have  been  satu- 
ated  over  and  over  again  with  the  secretions 
rom  the  skin. 

Rest  and  Exercise. — These-  are  requisite  for 
jloth  body  and  mind  at  this  age  ; the  duty  be- 
longs to  parents  and  schoolmasters  to  study  what 
Is  appropriate.  We  annex,  therefore  a table  from 
f’riedlander,  which  shows  how  the  twenty-four 
ours  may  be  wisely  apportioned 


Hours  for 

Age. 

Exercise. 

"Work. 

Leisure. 

Sleep. 

7 

8 

2 

4 

9 or  10 

8 

8 

2 

4 

9 or  1 0 

9 

8 

3 

4 

9 

10 

8 

4 

4 

8 

11 

7 

5 

4 

8 

12 

fi 

6 

4 

8 

13 

5 

7 

4 

8 

14 

5 

8 

4 

7 

15 

4 

9 

4 

7 

6.  Puberty. — The  physiological  feature  of 
his  age  is  the  more  rapid  growth  of  the  whole 
ody,  and  tho  gradual  perfectioning  in  their 
inctions  of  its  several  organs.  The  human 
lant  attains  the  fulness  of  its  organic  life,  and 
le  energies  are  rather  expended  on  corporeal 
irmation  than  on  intellection  (if  we  may  coin 
rch  an  expression).  Growth  in  man,  as  in 
Sants,  proceeds  by  fits  and  starts,  succeeded  by 
piods  of  quiescence  ; seasons  affect  it,  so  do 
applies  of  food  ; boys  do  not  develop  so  rapidly 
autumn  and  winter  as  in  spring  and  summer, 
iris  at  this  age  often  fall  back,  as  it  were,  a 
tie  in  winter,  when  they  are  much  more  con- 
led  indoors,  to  make  a greater  push  forwards 
spring. 

It  is  even  difficult  for  the  digestive  and  assi- 
jilative  powers  to  keep  pace  with  tho  bodily 
quirements,  so  that  the  tendency  is  for  the 
mperature  of  the  body  to  fall  somewhat,  to  be 
maintained  at  the  extremities,  and  for  the 
id  bath  to  be  shunned  for  lack  of  adequate 
action  in  those  who  are  manifestly  growing 
J rapidly. 

The  heart  in  some  is  hardly  equal  to  the  task 
1 ttj  and  when  diseased  we  perceive  both 
pwthand  the  attainment  of  puberty  retarded, 
e lungs,  again,  as  Dr.  E.  Smith  pointed  out 
288,  op.  cit.),  more  often  in  girls  than  in  boys, 
not  expand  in  proportionate  ratio  with  the 
t of  the  body.  The  body  runs  up  tall,  but 
1 thorax  remains  narrow  and  flat,  and  the 
‘ ces  of  the  lungs  approach  too  closely  to  each 
1 er.  The  definition  of  a line — length  without 


115) 

breadth— is  too  closely  imitated.  The  morbid 
imminences  of  this  age  are  few:  disorders  of  the 
nervous  system,  chorea,  and  epilepsy  may  arise  ; 
anaemia  and  rheumatism  are  common  enough. 
Girls  suffer  more  than  boys,  probably  in  conse- 
quence of  insufficient  gymnastic  exercises,  over- 
study in  cramped  postures,  and  from  that  folly 
of  follies,  a forcing-pit  education,  ‘all  articles 
warranted  to  bo  turned  out  highly  finished  by 
eighteen  years.’  It  is  the  age  of  all  others  when 
good  or  bad  habits  of  life  are  formed  ; the  time, 
too,  when  the  seeds  of  disease  are  sown  broad- 
cast, to  spring  up  in  tho  after  age  of  maD-  and 
womanhood. 

Diet. — -Food  should  be  abundant,  varied,  but 
uustimulating.  Three  or  four  moderate  meals 
a day  are  requisite  ; if  at  any  period  of  life  fer- 
mented liquors  are  beneficial,  now  is  that  time. 
Light  bitter  unadulterated  table  beer  or  claret 
and  water  should  be  provided  at  dinner,  but  not 
more  than  half  or  three-quarters  of  a pint  of  it 
allowed.  If  violent  exercise  has  provoked  thirst, 
this  may  be  satisfied  with  plain  water  or  toast- 
and- water  ad  libitum.  Girls  should  take  cocoa- 
nibs  for  breakfast,  with  bread  and  butter,  meat, 
eggs,  bacon,  or  fish,  as  much  as  they  like.  School 
dietaries  err  usually  on  the  side  of  deficiency. 
At  dinner,  as  well  as  substantial  meats,  fruits, 
vegetables,  suet  and  milky  puddings  are  re- 
quired. Tea  should  be  allowed  only  once  in  the 
twenty-four  hours,  at  six  o’clock,  and  a warm 
supper  be  provided  at  nine  o’clock. 

Clothing. — Nothing  need  be  added  to  what 
has  been  already  advised.  Without  entering 
into  minute  particulars,  it  should  be  season- 
able, rather  extra  warm,  and  offer  no  uncomfort- 
able restraints.  AVhen  mothers  complain  of 
their  daughters’  neglected  figures,  the  hygienist 
retorts,  What  gymnastic  exercises  did  you  require 
of  them?  It  is  the  age  for  exercise  of  the  body 
as  wTell  as  of  the  mind  ; boys’  spines  are  straight 
and  girls’  backs  crooked  because  the  former  use 
all  their  muscles  and  the  latter  do  not ; as  the 
body  is  making  its  most  rapid  growth,  so  the 
evil  of  unilateral  use  of  muscles  is  particularly 
baneful.  Sitting  over-long  in  a slouching  atti- 
tude will  tend  to  contract  the  chest,  as  carrying 
too  heavy  weights  over  the  back  will  spoil  the 
normal  spinal  curves  ; so  leaning  too  much  on  one 
side,  standing  too  long  on  one  foot,  even  carrying 
constantly  a pocketful  of  articles  on  one  side  of 
the  dress,  will  suffice  at  this  age  to  induce  spinal 
curvature.  Tho  daily  use  of  the  trapeze,  swing- 

ing, playing  games  like  la  gr&ce,  in  which  both 
arms  are  used,  badminton,  and  lawn-tennis,  in 
which  arms  and  legs  are  employed,  and  every 
muscle  brought  into  due  action,  are  quite  essen- 
tial to  the  proper  development  of  the  thorax  and 
the  muscles  of  the  trunk.  Girls  should  row  and 
run  and  ride  and  swum  and  skate  no  less  than 
lads  do,  in  order  to  become  fit  mothers  for  a 
nation  like  ours. 

The  best  temperature  for  a sitting-room  is 
60°  ; that  for  a sleeping-room  between  50°  and 
55°.  The  hygiene  of  the  bedroom  and  the  bed 
needs  a few  words.  The  temperature  of  the 
room  should  not  rise  above  65°  in  summer,  or 
fall  below  45°  in  winter ; it  must  be  thoroughly 
ventilated  with  a constant  amount  of  fresh  air 
passing  through  it  during  the  day.  The  deside- 


1152 

rata  for  a bed  are  coolness  for  the  spine,  restful- 
ness for  the  trunk  muscles,  and  warmth  without 
too  great  heat  or  too  burdensome  a weight  of  bed- 
clothes : all  objects  are  well  attained  by  a French 
somnier  elastique.  A horse-hair  bolster  is  prefer- 
able to  a pillow,  and  a paper  pillow  to  a feather 
pillow ; a feather  pillow  enwrapping  the  neck 
and  head  heats  the  upper  part  of  the  spinal  cord 
undesirably.  Posture  in  bed  is  not  unimportant. 
The  head  should  be  low,  the  feet  perhaps  a trifle 
raised,  certainly  not  dependent.  ‘ Sleep  not 
on  your  back,  as  a dead  man,’  is  a maxim  attri- 
buted to  Confucius  ; the  opposite  attitude,  on  the 
stomach,  is  restrictive  of  the  intestinal  move- 
ments, and  uncomfortable.  It  is  as  well  to  begin 
the  night  lying  upon  the  right  side  so  long  as 
food  remains  in  the  s-tomach,  and  to  turn  on 
first  waking  upon  the  left  side.  The  best  atti- 
tude is  probably  that  crouched  one  habitually 
selected.  Good  advice  is  to  stretch  yourself 
straight  whenever  you  wake,  in  order  to  render 
the  circulation  of  the  blood  freer.  In  winter 
the  arms  should  lie  under  the  clothes,  in  sum- 
mer above  them. 

The  cold  bath,  or  cold  sponge,  or  shower-bath 
should  be  taken  by  the  robust  every  morning ; 
with  an  occasional  warm  or  tepid  bath  once  a 
week,  for  cleansing  purposes,  throughout  sum- 
mer and  winter.  Whilst  the  young  of  both  sexes 
should  be  encouraged  to  swim,  in  seasonable 
weather,  the  length  of  time  they  stay  in  the 
water  must  be  strictly  limited  according  to  the 
temperature. 

We  abstain  purposely  from  any  discussion  of 
the  hygiene  of  mental  education. 

7.  Adult  Age. — This  is  the  prime  of  life, 
between  20  and  30.  Anatomically,  the  body 
broadens,  the  chest  deepens ; for  feats  of  mus- 
cular prowess — short,  severe  labours— it  is  at  its 
best.  The  intellectual  and  cerebro-spinal  sexual 
energies  are  at  their  maximum.  What  the 
French  call  the  greatest  latitude  of  health, 
that  is,  strength,  exists  at  this  period  ; severe 
strains  are  supported  with  apparent  ease.  In 
male  adults  the  body  gains  weight  by  small 
amounts  for  about  twenty-eight  days,  then  re- 
lapses to  its  normal  average  by  a sudden  crisis, 
attended  by  head-heaviness,  loss  of  appetite, 
and  copious  discharge  of  urine,  or  seminal 
evacuation.  It  is  not  a time  about  which  the 
hygienist  has  much  to  say.  If  the  preceding 
periods  of  life  have  been  wisely  ruled,  the  indi- 
vidual is  at  his  or  her  best.  The  morbid  im- 
minencies  directly  belonging  to  this  age  should 
be  few,  and  certainly  are  usually  due  to  direct 
contravention  of  the  laws  of  health : to  exposure 
to  contagious  influences,  to  irregular  living,  espe- 
cially drinking,  to  excessive  strains  upon  the 
heart  or  its  blood-vessels,  to  pulmonary  inflam- 
mations, to  contravention  of  proper  sexual  rela- 
tions, to  over-emotional  excitement,  or  to  mental 
worry  and  loss  of  sleep. 

The  guiding  rule  for  this  period  is  succinct 
enough  : 1 Sustine  et  abstme' 

Qui  studet  optatam  cursu  contingere  metam 

Multa  tulit  fecit  qite  puer  sudavit  et  alsit, 

Abstinuit  Venera  et  Baccho. 

Hitherto  excess  in  feeding  was  difficult  to  effect, 
quickly  punished,  and  admitted  of  rapid  and 
spontaneous  repair  ; but  now  he  who  would  rise 


HEALTH. 

above  the  ruck  must  rule  with  a tight  reia  all 
his  appetites.  The  penalties  are  not  exacted 
directly  after  the  offence  is  committed;  they  are 
kept  in  store,  but  nature  inflicts  them  with  piti- 
less justice. 

Total  abstinence  from  alcoholic  drinks  may  be 
recommended.  Not  only  does  it  favour  health, 
but  lessens  all  the  temptations  incident  to  these 
important  years,  in  which  a man  carves  out  his 
own  career.  A question  not  infrequently  pro- 
pounded is,  How  shall  I know  when  I have  eaten 
more  than  is  good  for  me  ? If  individuals  are 
dull  or  drowsy  after  a meal  they  have  usually 
eaten  too  much  ; if  they  can  converse,  write,  or 
transact  business  with  ease  after  a meal,  they 
have  fed  temperately. 

Women  may  be  advised  to  marry  not  earlier 
than  21 — between  21  and  28 — when  in  our  eli- 
mate  they  are  best  fitted  to  become  wives  and 
mothers.  Men  had  better  wait  till  between  28 
and  35  to  undertake  the  responsibilities  of  being 
parents.  For  the  generality  of  men  and  women 
we  must  insist  once  more  on  their  not  giving 
up  out-of-door  muscular  exercises.  An  entirely 
sedentary  trade  or  office-life  cannot  be  a healthy 
one  for  either  body  or  mind  ; the  latter  appears 
to  suffer  most  from  it — the  sense  of  morality 
becoming  blunted.  When  the  struggle  for  ex- 
istence is  so  severe  that,  with  early  rising  and  very 
limited  hours  of  sleep,  no  leisure  hour  remains 
for  sports  or  amusement,  the  time  has  arrived 
for  emigration,  war,  enforced  military  service,  or 
revolution. 

Sleep. — Doubtless  different  constitutions  and 
individuals  differently  employed  require  different 
amounts  of  sleep.  While  nothing  dulls  the  in- 
tellect and  weakens  the  recuperative  faculties 
more  than  too  much  sleep,  except  over-feeding 
and  drinking  at  this  age,  so  few  things  are  more 
certain  than  that  a man  may  rise  too  early  for 
making  the  best  use  of  his  twenty-four  houTS. 
He  must  live  in  the  world  and  keep  the  world’s 
pace  still.  John  Wesley’s  advice  in  this  matter 
is  worth  recording.  He  writes  that  any  man  can 
find  out  how  much  sleep  he  really  requires  to 
repair  his  nervous  system  by  rising  half  an  hour 
earlier  every  morning  until  he  finds  that  he  no  j 
longer  lies  awake  at  all  on  going  to  rest  in  bed, 
or  wakes  up  until  it  is  time  for  him  to  get  up. 
Six  to  eight  hours  is  usually  ample  for  healthy 
adults,  with  nine  hours  every  seventh  day.  The i 
mistake  too  often  made  is  that  of  endeavouring 
to  make  up  for  overhard  mental  efforts  by  over 
long  sleep  hours.  Mental  over-fatigue  is  to  be 
repaired  not  by  sleep  but  by  bodily  exercise  in 
tho  open  air.  Exercise  directs  the  blood-flow 
from  the  head  towards  the  muscles,  and  renews 
the  appetite.  As  we  have  pointed  this  out.  as 
the  suitable  age  for  marriage,  we  may  mention 
some  things  which  conduce  not  slightly  to  health- 
ful and  happy  marriages : parity  of  station, 
similarity  of  temper  and  tastes,  and  no  dispro- 
portion either  in  age  or  size. 

8.  Maturity -The  body  has  now  reached  its 

maximum  weight  and  solidarity,  and  the  period 
is  that  of  maximum  endurance.  Men  reach  then 
full  weight  at  40  ; women  later,  sometimes  not 
till  50.  At  this  age  the  soldier  is  fittest  fot 
service,  the  labourer  for  work,  the  artisan  and 
professional  man  for  their  respective  duties 


PERSONAL 


PERSONAL 

Hijih  to  soar  and  deep  to  dive  is  given  to  man 
it  thirty-live.’  The  morbid  tendency  is  towards 
knaemia  and  obesity,  the  former  promoting  the 
atter,  and  both  alike  being  determined  by  a too 
Sedentary  town-life  and  by  daily  occupation  in 
•lose,  ill-ventilated,  and  badly-lighted  chambers. 
Tow  are  perceived  the  first  attacks  of  gout ; 
vhilst  visceral  degenerations  and  atheroma  of 
rteries  may  manifest  themselves — events  all 
f which  may  be  delayed,  if  not  wholly  pre- 
lented,  by  attention  to  the  laws  of  health.  It 
desirable  that  each  individual  should  pay 
eed  to  his  weight  at  this  age,  since  this  indi- 
cates whether  or  no  he  is  living  wisely.  Celsus 
74.  2,  cap.  1)  writes: — ‘Corpus  autem  habilis- 
mum  quadratum  est  nequo  gracile  neque 
besum.  Nam  longa  statura  ut  in  juventa  de- 
ira  est  sic  matura  senectute  confieitur.  Gracile 
)rpus  infirmum,  obesum  hebes  est.’  When, 
jwever,  men  are  engaged  in  trades  or  profes- 
tms  there  is  no  more  difficult  task  than  to 
aintain  their  weight  at  this  age,  the  juste 
k lieu  referred  to  being  a hard  matter  to  secure, 
he  advice  given  by  Celsus  (lib.  1,  cap.  1)  can- 
)t  be  surpassed  in  force  or  brevity:  ‘Sanus 
>mo  qui  et  bene  valet  et  suse  spontis  est  nullis 
■ligare  se  legibus  debet ; hunc  oportet  varium 
■here  vitae  genus,  modo  rnri  esse,  modo  in 
be,  saepiusque  in  agro,  navigare,  venari  quies- 
re  interdum ; siquidem  ignavia  corpus  hebetat 
oorfirmat.’  As  to  diet,  clothing,  and  habits, 

■ need  add  nothing  to  what  has  been  already 
vised  for  a previous  age  ; but  on  exercise  of 
jy  and  mind  there  is  much  to  be  written. 

A.  good  rule  is  laid  down  by  Lynch,  too,  in 
i Guide  to  Health  (p.  290),  that  the  lean 
smld  exercise  ad  ruborem , i.e.  to  glow-point, 
t until  their  bodies  and  spirits  are  heated, 

1 that  will  fatten  them ; and  the  fat  ad  sudo- 
The  more  luxuriously  a man  lives,  the 
ifre  exercise,  and  the  more  active  exercise,  he 
lids.  Want  of  it,  and  the  costive  habit  thus 
S'Orinduced,  may,  as  Kotzobec  observes,  extin- 
£.ih  the  divine  flame  of  genius  and  seriously 
i >air  the  intellectual  powers.  Hypochon- 
ihsis  and  hysteria  are  the  special  punish- 
nits  of  ease  and  affluence  and  indolence.  Ob- 
v isly  a portion  of  each  day  should  be  set  apart 
f exercise.  In  the  households  of  the  wealthy 
a ’mnasium  is  at  least  as  important  as  a bath- 
rln;  and  twenty  minutes  every  morning  before 
bij.kfast  might  well  be  devoted  to  breathing  the 
n:  cles — that  is,  calling  into  play  every  muscle 
ol  le  trunk  and  limbs.  The  chest  should  be  ex- 
P=  led  by  clubs  and  dumb-bells ; swinging  on 
tl  trapeze,  and  hanging  by  the  arms  and  legs, 
in  be  recommended.  Again,  before  forenoon 
or  id-day  meal,  an  hour's  ride  or  walk  must  be 
ob.ined,  and  a third  time  in  the  day  an  hour 
ai  i a half’s  exercise — funcing,  or  walking,  or 
ro  eg — should  be  arranged  before  bed-time,  in 
di  pring  and  summer  seasons.  A great  point 
is : vary  the  exercise  by  every  means  at  hand  ; 
t'lange  the  set  of  muscles  called  chiefly  into 
pkupon  different  days,  as  Celsus  advised;  to 
8"',  ride,  fence,  sail,  row,  shoot,  fish.  Lastly, 
n recommend  only  those  who  are  very  robust 
to  ke  a long  walk  before  breakfast.  Bodily 
ise  should  not  be  undertaken  immediately 
ill  a heavy  meal ; nor  should  those  who  have 
73 


HEALTH.  1153 

sweated  themselves  violently  sit  down  at  once 
to  a full  meal — at  least  an  hour's  rest  should 
intervene. 

Mental  exertion  is  advantageous  to  health; 
even  carried  to  excess,  it  lessens,  rather  than 
increases,  waste  of  tissue.  Over- work  of  a mental 
kind,  with  anxiety,  appears  attended  by  lessened 
appetite,  lessened  nutrition,  and  loss  of  body- 
weight — proof  positive  of  detriment  received. 

9.  The  Turning  Period. — This  period  of 
life,  which  lies  between  45  and  60,  is  also  known 
as  the  grand  climacteric,  or  middle  age.  The  skin 
wrinkles.  Up  to  60  years  of  age  the  skull  may 
continue  to  increase  in  size,  principally  at  its 
anterior  part,  by  enlargement  at  the  frontal 
sinus ; after  60  the  skull-cap  loses  weight,  and 
the  brain  may  waste  but  gets  tougher  and  firmer. 
The  heart  grows  a little  larger,  and  its  walls  are 
thicker.  The  lungs  grow  denser,  a change  com- 
mon to  every  tissue  of  the  body.  The  hair 
grows  gray ; the  features  sharpen  ; the  sight 
alters  ; and  the  hearing  grows  dull.  Pressure 
and  wear  and  tear  begin  to  tell  at  every  part. 
Upon  the  blood-vessels  their  effects  are  more 
marked  in  males  than  females,  because  ordi- 
narily the  former  labour  harder  than  the  latter; 
further,  the  death-rate  of  men  is  greater  than 
that  of  women  at  this  age.  As  the  sexual 
powers  decline,  which  they  do  by  a quick  descent 
between  46  and  63,  the  intellectual  powers  in- 
crease, so  that  mentally  there  is  often  exhibited 
a marked  increase  of  vivacity  and  agreeableness, 
more  noticeable  in  men  than  in  women.  In  the 
latter  the  cessation  of  the  catamenia  is  attended 
usually  by  some  rejuvenescence,  attributable  to 
their  recovering  a little  embonpoint.  It  is  an 
age,  however,  at  which  women  kick  rather,  and 
become  restless  and  uneasy,  the  change  of  life 
being  attended  in  many  by  a renewal  of  their 
juvenile  tempers,  as  between  7 and  14,  and  occa- 
sionally by  a revival  of  their  youthful  ailments 
as  eczema,  skin  eruptions,  and  various  neuroses, 
insomnia,  hysteria,  and  sometimes  epilepsy.  In 
character,  whatever  obstinanev  exists  reaches  its 
climax. 

Morbid  Imminences. — The  inflammatory  dis- 
position is  lessened,  but  there  is  a tendency  to 
venous  plethora  of  the  abdominal  viscera  and 
towards  vicarious  hsemorrhages.  Gout  assails 
its  victims  with  well-characterised  attacks.  New 
growths,  simple  and  malignant,  tend  to  demon- 
strate themselves,  and  rheumatoid  arthritis  to 
appear.  Dr.  "Waterhouse,  in  a letter  to  Sir  T, 
Sinclair,  published  in  his  Cede  of  Health  and 
Longevity  (vol.  i.  p.  33,  Edinburgh,  1807),  no- 
tices the  three  following  periods  as  very  im- 
portant in  every  human  life,  as  sickly  or 
moulting  times.  The  first  he  had  noticed  to 
befall  males  chiefly  at  thirty-six  years  of  age, 
when  the  lean  person  becomes  fatter  and  the 
fat  kine  leaner.  • The  second  sickly  period  hap- 
pens at  some  time  between  forty-three  and  fifty, 
and  lasts  a year,  or  perhaps  two.  During  it  the 
complexion  fades,  the  appetite  fails,  the  tongue 
becomes  furred  at  the  smallest  over-exertion  of 
body  or  mind,  the  muscles  are  flabby,  the  joints 
are  weak,  sleep  is  unrefreshing,  and  the  spirits 
droop.  It  is  no  particular  organ  that  suffers, 
but  a uniform  deterioration  that  is  manifested 
At  this  time  a man  first  experiences  a reluctance 


PERSONAL  HEALTH. 


1154 

io  stoop,  prefers  a carriage  to  riding  on  horse- 
back, and  perceives  each  change  of  the  weather 
affect  him.  This  observation  of  Hr.  Water- 
house  has,  according  to  the  experience  of  many, 
much  justice  in  it;  as  also  that  between  sixty- 
one  and  sixty-cwo  a similar  deterioration  of 
health  takes  place,  hut  with  aggravated  symp- 
toms. 

Hygienic  Rules. — At  the  menopause  women 
should  be  advised  to  abstain,  as  a rule,  from 
alcoholic  drinks,  and  avoid  highly  spiced  and 
seasoned  dishes.  They  may  bo  recommended  to 
take  meat  not  more  than  once  daily,  and  to  live 
chiefly  on  farinaceous  food,  milk,  eggs,  vege- 
tables, and  fresh  fruits.  A tablespoonful  of 
lime-juice  taken  twice  daily  occasionally  for  a 
week  or  ten  days  at  a time  has  a salutary,  depu- 
rating effect  upon  both  stomach  and  kidneys, 
and  clears  the  tongue  when  this  is  foul  in  the 
morning.  Riding  and  walking  exercise  are  highly 
appropriate,  but  very  violent  muscular  efforts 
should  be  avoided.  If  the  individual  be  thin 
and  growing  thinner,  the  clothing  should  be 
extra  warm.  Flannel  abdominal  belts  may  he 
worn  advantageously  in  all  seasons,  but  espe- 
cially in  autumn  and  winter. 

Both  sexes  should  avoid  emotional  excitement 
and  the  stimulation  of  waning  sexual  abilities. 
Prolonged  exposure  to  wet  and  cold  is  sure  to 
be  seriously  resented.  Hot  or  Turkish  baths, 
succeeded  as  they  should  be  by  cold  plunge 
or  douches  to  remove  the  lassitude  otherwise 
provoked,  are  very  beneficial,  and  taken  once  a 
week  may  be  safely  indulged  in  throughout  the 
year.  It  becomes  extra  important  as  the  subcu- 
taneous fat  gets  absorbed,  and  the  skin  wrinkles, 
to  keep  its  pares  clean  and  open  and  capable  of 
perspiring. 

10  and  11.  Advanced  Life,  and  Old  Age. 
The  period  of  advanced  life — sixty  to  eighty- 
two,  and  old  ago,  -from  eighty-two  upwards, 
may  be  advantageously  considered  together. 
When  a man  turns  his  toes  out  much  in  walking 
and  treads  upon  the  whole  base  of  his  foot,  and 
is  always  stopping  to  look  hack,  he  is  already 
old.  The  sagacious  ‘boots’  at  an  inn  can  tell  a 
man’s  age  by  the  state  of  his  shoe-leather. 

‘ Seneetus  ipsa  morbus  insanabilis.'  Some  de- 
generate earlier  than  others,  hut  the  decline  of 
life  is  characterised  in  all  human  kind  alike  by 
an  indurating  condition  of  every  tissue  diametri- 
cally opposed  to  the  cellular  softness  and  laxity 
of  infancy.  The  capillaries  thicken,  the  arteries 
harden,  the  nutritive  metamorphoses  proceed 
more  slowly.  The  muscles  waste ; the  subcu- 
taneous fat  lessens;  the  blood  becomes  poorer 
and  paler.;  the  skin  dry,  sallow,  and  wrinkled; 
further,  it  gets  less  vascular,  and  the  mucous 
surfaces  become  relatively  more  so.  The  teeth 
loosen  and  fall  out ; the  gums  recede  from  them  ; 
and  the  digestive  juices  fail.  The  arteries  be- 
come atheromatous  and  calcareous,  lose  their 
elasticity,  and.  are  liable  to  fibrinous  throm- 
boses, or  to  embolic  pluggings ; and  while  they 
fend  to  block  up  at  one  part,  their  coats  may 
split  and  yield  to  pressure,  bulge  out,  and  form 
aneurisms  or  dilatations  in  other  directions. 
Hence  happen  apoplexies,  brain-softenings,  and 
senile  gangrenes.  The  heart  up  to  an  uncertain 
period  grows  progressively  larger  and  mor«  mus- 


cular, to  meet  the  obstacles  offered  to  the  cir- 
culation ; hut  finally  it,  too,  degenerates,  and  its 
walls  grow  thinner  and  dilate.  The  air-cells  of 
the  lungs  lose  their  elasticity,  and  progressively 
enlarge ; then  merge  into  each  other ; and  become 
emphysematous  at  the  edges  of  the  lobes  where 
least  supported.  Emphysema  implies  degene- 
ration of  capillaries  and  diminution  of  aerating 
surfaces ; and  as  the  pulmonary  area  becomes 
thus  lessened,  the  right  heart  becomes  hypertro- 
phied and  dilated. 

The  dryness  and  lessened  secretion  of  the  skin 
cast  harder  work  upon  the  kidneys  in  eliminating 
water,  and  increase  the  disposition  to  catarrhal 
fluxes  from  the  nasal  passages,  the  bronchi,  and 
the  intestines.  Thus,  while  there  is  a constant 
predisposition  to  skin-irritation  from  its  dry- 
ness, and  to  eczema  from  scratching  and  rubbing 
it,  the  other  morbid  imminencies  towards  bron- 
chial catarrh  and  diarrhoea  very  closely  follow 
the  direction  given  them  by  the  season  of  the 
year  and  greater  or  less  degree  of  external  cold. 
The  bladder  grows  thicker  with  age,  and  its  ca- 
pacity is  less  ; the  prostate  gland  enlarges.  Feu 
persons  after  60  pass  seven  hours  in  bed  without; 
requiring  to  micturate.  Dr.  Rush  regarded  the 
necessity  for  more  frequent  micturition  the  firs: 
symptom  indicative  of  a man's  years  impairing: 
his  bodily  functions.  The  pulse  feels  firmer  ant 
fuller  ; fills  quickly  after  food  is  taken ; but  falls 
in  frequency  and  flags  in  power  in  a marked  de 
gTee  after  fasting.  It  is  a far  less  trastwortin 
indicator  of  the  gravity  of  any  febrile  disorder 
or  of  degrees  of  asthenia,  than  it  was  in  youti 
or  middle  age ; and  it  fails  to  poiut  to  the  prac 
titioner  the  nearness  of  death,  unless  he  hav 
large  experience  of  it. 

There  is  a default  of  reaction  manifest  in  ad 
vanced  life,  so  that  all  acute  disease  is  clinicall 
less  easy  of  recognition,  and  the  beginning  of  tb 
end  is  therefore  apt  to  pass  unobserved.  Th 
thermometer  warns  the  doctor  of  changes  whic 
old  people  do  not  notico  themselves,  but  whic 
it  may  be  of  considerable  importance  to  notice 
A slight  elevation  of  temperature  means  ranch  i 
old  age,  and  should  be  heeded  accordingly.  Tl: 
slightest  change  excites  a young  child  ; nothin 
seems  to  move  the  old  man.  In  extreme  old  at 
life  is  little  more  than  vegetative  existence;  tl 
individual  eats  and  sleeps  and  dreams.  Tl 
sleep  the  aged  get  by  night  does  not  satisl 
them.  Memory  is  one  of  the  first  mental  facu 
ties  to  become  impaired,  but  finally  every  seni 
and  faculty  fail.  Up  to  75  the  strong  of  bo 
sexes  retain  their  digestive  powers,  and  a fa 
amount  of  mental  and  muscular  vigour. 

Hygienic  Rules. — A prime  necessity  for  o 
age  is  warmth ; nothing  kills  the  aged  so  ce 
tainly  as  cold.  It  is  of  first  hygienic  importan 
after  75  that  tho  individual  should  he  lor 
and  cared  for  ; old  people  do  not,  perhaps  cann 
take  care  of  themselves. 

Those  who  live  longest  and  enjoy  the  full' 
measure  of  activity  are  those  who  do  not  on 
tax  their  stomachs  when  their  teeth  begin  to  f 
them,  and  who  adapt  their  aliment  to  their  < 
feebled  powers  of  mastication  by  having  th 
food  properly  cooked  for  them.  Stews,  miuc 
meats  boiled  and  afterwards  baked — cooked,  t> 
is,  twice — are  more  easily  digested  than  itv 


PERSONAL  HEALTH, 
roasts  or  close-fibred  meats.  A moderate  amount 
Df  wine  both  cheers  and  comforts  old  people  ; a 
?[ass  or  two  of  good  Burgundy  or  of  champagne, 
md  an  occasional  glass  of  old  port  wine,  is  most 
•beneficial  to  aged  persons,  and  is  better  for  them 
than  overloading  their  stomachs  with  milk  and 
farinaceous  foods. 

Great  attention  should  be  paid  to  the  func- 
ions  of  the  bowels  and  of  the  skin.  Galen 
jointed  out  that  old  people  should  not  suffer 
heir  bowels  to  remain  costive  beyond  two  days; 
in  the  third  they  should  take  some  gentle  purge, 
mch  as  by  experience  they  have  found  adequate 
o open  their  bodies.  A hot  bath  once  a week, 
md  a hot  foot-bath  every  night,  may  be  advised. 
A short  nap  after  breakfast  and  before  dinner  is 
he  natural  habit  of  the  aged.  Further,  their 
lothing  should  be  extra  warm,  and  their  cham- 
>ers  night  and  day  be  heated.  They  should 
>e  encouraged  to  go  out  in  the  open  air  only  in 
easonable  weather,  and  when  they  are  equal  to 
t should  take  a little  walk  on  a dry  gravel  path 
n some  warm  locality,  sheltered  from  north- 
asterly  winds.  All  change  and  cheerful  society 
ts  good  for  them.  If  their  purses  admit  of  it, 
hey  should  follow  the  swallows  to  warm  winter 
juarters.  If  they  must  winter  in  England,  let 
jiem  shut  themselves  up  throughout  it  in  a well- 
irmed  house. 

Summary. — Ad  vice  for  every  ago  may  be  thus 
iriefly  given  : for  infancy  and  childhood — sus- 
ne ; for  adult  years — sustine  et  abstine  ; for  old 
r 6— sustine  again.  There  is  less  need  now  to 
join  abstine. 

The  hygienist,  however,  seeks  not  to  lengthen 
t the  days  of  age  and  decrepitude;  his  art  is 
•t  to  prolong  life  beyond  its  natural  term, 
oughthis  may  come  subordinately,  but  to  ren- 
r its  period  of  activity  and  utility  longer — ‘ Hie 
‘tor  hoc  opus  cst.’  Some  cynic  observes  that  we 
ve  pointed  out  very  few  habits  as  worth  culti- 
ting,  the  truth  being  we  believe  what  we  have 
dsted  on— that  most  bodily  habits  need  resist- 
;.  Individual  health  is  attained  by  self-denial ; 
oits  imply  self-indulgence. 

Reginald  Southey. 

PERSPIRATION,  Disorders  of. — Synon.  : 
1 Trotdtles  de  la  Sueur ; Ger.  Storungen  des 

l. misses. 

'his  subject  will  be  discussed  in  the  following 
oer: — 1.  Hyperidrosis  ; 2,  Anidrosis  ; 3,  Os- 
njrosis ; 4,  Chromidrosis  ; and  5,  Haematidro- 
si 

• Hyperidrosis. — Definition.  — Excess  of 

P duration. 

‘.Stiology. — The  cause  of  hyperidrosis,  though 
ci  iinly  connected  with  the  vaso-motor  nerves, 
Mill  obscure.  Often  hyperidrosis  seems  to  be 
k x,  and  excited  by  irritation  of  a more  or  less 
(u int  part,  such  as  food  in  the  mouth,  by  which 
d.  nuscles  of  the  blood-vessels  relax,  and  admit 
m ) blood  to  the  sweat-glands ; there  being,  as 
fa.  sis  known,  no  direct  connectionof  the  sweat- 
gl  is  with  the  nerves. 

•ascription.  — Hyperidrosis  may  be  either 
9e  'al  or  local. 

neral  hyperidrosis  occurs  in  acute  rheuma- 

gout,  intermittent  fever,  pyaemia,  phthisis, 
Se  -al  debility,  alcoholism,  and  the  defervescence 


PERSPIRATION,  DISORDERS  OF.  1155 
of  febricula ; in  hot  weather ; in  emotional  ex- 
citement ; or  after  severe  exercise.  It  also  fol- 
lows the  use  of  the  vapour  or  Turkish  bath  ; 
and  is  produced  by  diaphoretics,  such  as  spirit 
of  nitrous  aether,  opium,  antimonials,  and  espe- 
cially jaborandi. 

Paroxysmal  sweating*  of  rapid  onset  lias. been 
seen  in  one  or  two  cases  where  the  patients  still 
had,  or  had  had,  epileptic  fits. 

Partial  hyperidrosis  usually  occurs  on  one 
side  of  the  body,  or  of  the  face  and  head.  Nu- 
merous cases  are  recorded  where  unilateral  facial 
sweating  followed  cerebral  haemorrhage,  and 
accompanied  hemiplegia ; or  occurred  with  sup- 
purative parotitis  and  salivary  fistula  of  the 
same  side.  In  these  the  sweating  occurs  chiefly 
during  mastication,  the  cheek  being  also  red- 
dened. Hyperidrosis  lateralis  sometimes  occurs 
on  the  right  or  left  side  when  the  tongue  is 
touched  with  salt  on  the  corresponding  side. 
Some  cases  of  lateral  hyperidrosis  faciei  occur 
■without  previous  assignable  cause,  and  in  one  the 
affection  was  transmitted  for  three  generations. 
Partial  sweating  may  be  limited  to  the  palms  or 
soles,  and  is  sometimes  hereditary.  Tne  sweat 
is  constant  and  profuse,  and  the  parts  are  red. 
tender,  and  sodden. 

Excessive  sweating  may  cause  sudamina  and 
miliaria,  and  lead  to  an  eczema  of  considerable 
severity. 

Treatment. — In  the  treatment  of  excessive 
sweating  general  tonics,  sulphuric  acid,  quinine, 
iron,  or  strychnia,  may  be  employed.  Flannel 
should  bo  worn,  instead  of  cotton,  on  the  skin, 
and  woollen  socks  instead  of  cotton.  The  skin 
may  be  sponged  with  very  hot  water ; with 
vinegar  and  water  (1  to  3) ; or  with  lotions,  such 
as  one  thus  prepared — Ijb  acidi  sulphurici  di- 
luti  3ij,  aquseOj.;  or  Ijb  acidi  tannici  5j,  spi- 
ritus  vini  rectificati  Jvj.  Powdering  with  talc 
or  violet  powder  will  relieve  temporarily  some 
cases  of  profuse  sweating  in  acute  rheumatism. 
Hyperidrosis  in  phthisis  has  been  temporarily 
benefited  by  zinc,  hyoscyamus,  or  sulphate  of 
atropia  (j0  to  A.  of  a grain  pro  die ) administered 
with  care.  Belladonna  liniment  is  one  of  the 
best  remedies  in  local  hyperidrosis  of  hands  and 
feet. 

2 . Ani  drosis. — Anidrosis,  or  deficiency  of  sweat, 
is  merely  a symptom  in  general  diseases  with  a 
large  flow  of  urine  or  renal  disorder— for  example, 
diabetes  insipidus  and  mellitus,  and  Bright’s 
disease.  It  accompanies  the  earlier  stages  of 
fever;  and  is  a constant  symptom  in  skin  which  is 
the  seat  of  ichthyosis,  psoriasis,  or  prurigo  vera. 
Some  persons  habitually  sweat  little,  especially 
in  winter,  and  the  skin  is  dry  and  rough,  partly 
from  deficient  sebaceous  secretion  (xeroderma)." 

3.  Osmidrosis. — In  some  persons  the  sweat, 
if  retained  on  the  skin,  has  a bad  smell,  especi- 
ally that  secreted  by  the  armpits,  perinaeum, 
genitals,  and  the  feet  and  toes  ; and  to  this  dis- 
order the  name  osmidrosis  is  given.  The  smell 
appears  to  be  due  to  chemical  conversion  of  the 
mixed  secretion  of  the  sweat  and  sebaceous 
glands,  under  the  influence  of  moisture,  and  in 
the  presence  of  macerated  epithelium,  into  the 
higher  fatty  acids  (caproic,  &c.).  Removal  of 
the  accumulated  secretions  by  thorough  washing 
removes  the  smell  for  a time.  The  underclothes 


1156  PERSPIRATION',  DISORDERS  OF. 
also  become  saturated  with  the  sweat,  and  smeE 
badly.  This  affection  is  not  uncommon  in  fe- 
males in  the  armpits,  and  it  may  be  a serious 
affliction  from  the  annoyance  it  causes  to  others. 

Treatment. — This  consists  in  extreme  clean- 
liness, repeated  washing  with  tar-soap,  thorough 
drying,  and  frequent  change  of  linen.  The  parts 
should  be  powdered  with  oxide  of  zinc  and  rice- 
starch  (1  to  4),  and  tincture  of  belladonna  inter- 
nally should  always  be  tried.  Hebra  strongly 
recommends  the  foEowing  ointment  ( Unguentum 
diachyli)  for  foetid  sweating  of  the  feet,  1)1 
Olei  oliv®  optima  Lithargyri,  jiij,  3vj  ; 

Coque ; ft.  unguentum.  The  ointment  to  be 
applied  on  strips  of  linen  every  twelve  hours. 
Thin  and  others  have  had  good  results  from 
disinfecting  the  stocking  soles  with  a saturated 
solution  of  boracic  acid.  Cork  soles  must  be 
worn,  and  disinfected  in  like  manner.  Careful 
inquiry  should  be  made  into  the  state  of  the 
general  health. 

4.  Chromidrosis. — This  condition,  in  which 
there  occurs  a secretion  of  coloured  matter 
(indigo)  by  the  skin,  is  so  rare  as  to  be  of  no 
clinical  importance,  though  of  much  physiologi- 
cal interest. 

5.  Heematidrosis. — This,  the so-caEed  ‘bloody 
sweat,’  is  also  a variety,  if  it  ever  really  occur. 
The  reported  cases  are  probably  due  either  to 
rupture  of  superficial  capillaries  in  the  cutis,  or 
to  a similar  rupture  into  the  duct  of  a sweat- 
gland,  out  of  which  the  blood  finally  escapes. 
The  mechanism  of  this  rupture,  which  seems 
quite  unconnected  with  the  secretion  of  sweat, 
is  very  obscure,  though  the  highest  authorities 
are  sure  that  such  ‘ spontaneous  ’ bleedings  do 
occur.  A number  of  cases  which  have  been 
reported  in  hysterico-neurotic  persons  were  un- 
doubtedly due  to  self-inflicted  punctures. 

Edwaed  J.  Sparks.’ 

PERTUSSIS  {per,  signifying  excess,  and 
tussis,  cough). — A synonym  for  whooping  cough. 
See  Whooping  Cough. 

PESTIS  (Lat.). — A synonym  for  plague.  Sec 
Plaque. 

PETECHIAE  (Ital.  Petecchics,  flea-bites). — 
Synon.  :.Petieul(B  ; Fr.  Petechias ; Ger.  Petechien. 

Description. — Petechi®  are  small  crimson  and 
purple  spots  of  the  skin,  resembling  those  that  re- 
sult from  the  bite  of  a flea.  They  are  circular  in 
figure  ; are  developed  around  the  apertures  of  the 
follicles ; have  an  average  size  of  one  or  two  lines  in 
diameter ; and  are  consequent  on  the  transudation 
of  t he  colouring  matters  of  the  blood,  through  the 
capillary  vessels  of  the  follicles,  into  the  imme- 
diately adjacent  tissues.  They  are  distinguished 
from  spots  resulting  from  simple  hypersmia  by 
pressure  with  the  finger.  Under  pressure  the 
hypermmic  spots  disappear,  but  the  petechi®  re- 
main permanent.  They  are  differentiated  from 
flea-bites  by  the  presence  in  these  of  the  punc- 
ture, which  is  always  perceptible,  and  contrasts 
strongly  with  the  lighter  colour  of  the  rest  of  the 
disk  ; although  it  is  to  be  remembered  that  the 
centre  of  the  petechial  spot  is  always  deepest 
in  colour,  and  becomes  lighter  towards  the  cir- 
cumference. Petechi®  vary  in  tint  of  colour 

1 Revised  by  Dr.  Alfred  Sangstei. 


PH  ANT  Oil  TUMOUR, 
according  to  age  and  the  amount  of  effused  blood 
being  at  first  brightly  crimson,  then  purple,  next 
almost  black,  and  subsequently  fading  away 
through  the  ordinary  colours  of  a bruise.  Hence 
it  is  usual  to  find  them  scattered  over  the  skin 
of  various  shades  of  colour,  ranging  through  all 
the  tints  already  mentioned. 

Petechi®  are  met  with  on  the  mucous  mem- 
branes, as  well  as  on  the  skin,  in  purpura,  scor- 
butus, malignant  fevers,  and  in  several  forms  o! 
congestion  of  the  foEicles  of  the  skin,  associate-1 
with  constitutional  diseases.  Petechia  do  not 
call  for  special  treatment.  See  Purpura 
_ The  term  ‘petechial  is  applied  to  certain  varie- 
ties of  diseases,  such  as  typhus,  when  petechia 
occur  in  their  course,  or  the  eruption  becomes 
hmmorrhagic.  See  Extravasation  ; and  Typhus. 

Erasmus  Wilson. 

PETIT  MAL  (Fr.). — A term  applied  to 
attacks  of  epEepsy  which  are  of  short  duration 
and  slight  intensity.  See  Epilepsy. 

PPAEITERS,  in  Switzerland. — Simple 
thermal  waters.  See  Mineral  Waters. 

PHAGEDAllfA  (<pdyw,  I cat  away). — A 
form  of  ulceration,  which  rapidly  destroys  the 
surrounding  parts.  See  Bubo  ; Gangrene  ; 
Ulcer  ; and  Venereal  Sore. 

PHANTOM  TUMOUR.— Synon.  : Hyste- 
rical  tympanites  ; Spurious  pregnancy. 

Definition. — A peculiar  enlargement  of  the 
abdomen  occurring  in  females  belonging  more  or 
less  distinctly  to  the  hysterical  class.  It  is  sup- 
posed by  the  patient  to  be  a tumour,  or  to  be 
due  to  pregnancy,  though,  in  reality,  it  is  nothing 
of  the  kind,  as  its  name  expresses ; and  it  can 
be  made  at  once  to  disappear  by  placing  her 
•under  the  influence  of  chloroform. 

Description. — The  phantom  tumour  consists 
in  a more  or  less  general  prominence  of  the  ab- 
domen forwards,  varying  in  degree.  The  enlarge- 
ment may  attain  a considerable  size,  hut  is 
always  quite  symmetrical.  The  projection  is 
most  marked  in  the  middle  of  the  abdomen,  and 
usuaEy  a depression  or  constriction  is  observed 
below  the  chest  and  above  the  pubes.  It  is 
rounded,  smooth,  and  quite  regular,  presenting 
a uniform  soft  feeling,  quite  distinct  from  that 
of  gaseous  distension,  fluid  accumulation,  or 
a solid  mass.  The  enlargement  is  peculiarly 
movable,  as  a whole,  from  side  to  side.  There 
is  no  sense  of  true  fluctuation.  Percussion  yields 
a resonant  note,  but  not  usuaEy  excessive,  and 
it  may  be  of  a muffled  character.  On  examina- 
tion per  vaginam  nothing  abnormal  can  be  de- 
tected, such  as  would  be  associated  with  ovarian 
or  uterine  enlargements,  or  with  pregnancy,  i! 
there  should  be  any  doubt  whatever  about  tin 
nature  of  the  supposed  tumour,  it  wiE  be. a 
once  removed  by  placing  the  patient  under  the  in 
fluence  of  chloroform  orother  ansstheEc,  when  i 
immediately  disappears,  the  abdomen  becoming 
quite  flat ; but  it  gradually  returns,  even  befor- 
the  patient  returns  to  consciousness,  on  the  re 
moval  of  the  anmsthetic.  There  is  no  pain  o 
tenderness  in  connection  with  the  enlargement 
nor  are  any  symptoms  due  to  pressure  or  othe 
causes  observed  ; while  the  patient  usually.  pre 
sents  distinct  signs  of  the  hysterical  conditioi 
There  ought,  therefore,  to  be  no  difficulty  in  tli 


PHANTOM  TUMOUK. 

iiagnosis  of  a phantom  tumour.  What  is  the 
•ause  of  (he  enlargement  is  by  no  means  clear, 
Lfc  most  probably  it  is  due  to  a kind  of  para- 
ysisof  the  intestines,  depending  upon  disordered 
nervous  influence. 

Treatment. — In  a patient  having  a phan- 
otn  tumour,  the  general  treatment  for  hysteria 
L that  principally  called  for.  She  should  be 
Constantly  impressed  with  the  fact  that  the  en- 
argementis  not  really  a tumour,  and  is  of  no  con- 
sequence. The  condition  is  by  no  means  easy  to 
:et  rid  of,  but  for  this  object  galvanism  may  be 
.pplied  to  the 'abdomen,  or  in  obstinate  cases, 
he  patient  may  be  put  repeatedly  under  chlo- 
oform.  The  use  of  pressure,  by  means  of  an 
bdominal  bandage  or  elastic  apparatus,  might 
>e  serviceable  in  some  cases.  The  bowels  should 
ie  kept  freely  opened. 

Feed EiucK  T.  Egberts. 

PHABYNX,  Diseases  of. — The  pharynx 
3 often  involved  in  acute  general  diseases  which 
fleet  the  throat,  such  as  scarlatina  and  diph- 
lieria ; or  it  may  be  implicated  along  with  other 
Structures  in  diffused  inflammation  of  the  throat, 
deeration,  gangrene,  or  morbid  growths ; but 
he  diseases  of  practical  importance  connected 
,-ith  the  pharynx  itself  which  need  to  be  discussed 
ere  are  three,  namely,  1.  Acute  inflamma- 
ion  ; 2.  Chronic  inflammation  ; and  3.  Fol- 
icular  inflammation. 

1.  Acute  Inflammation  of  the  Pharynx. — 
ynon.  : Fr.  Pharyngite  aigue ; Ger.  Acute 
'chlundkopfeiitziindung. 

Definition. — An  affection  of  the  pharyngeal 
•ucous  membrane,  characterised  by  a non-exuda- 
ve  catarrhal  inflammation. 

/Etiology. — Some  persons,  though  otherwise 
\bust  enough,  show  a particular  predisposition 
i pharyngeal  catarrh ; and  previous  attacks 
' em  to  increase  the  predisposition.  The  young 
"e,  on  the  whole,  more  liable  to  the  complaint 
an  those  more  advanced  in  nge ; while  all  that 
•ings  the  strength  of  the  individual  below  par, 
Aether  over-work,  exposure,  or  disease,  more 
.rticuiarly  of  a specific  nature,  acts  as  a pre- 
sposing  cause.  Two  of  the  most  common  ex- 
,ing  causes  are  cold  and  damp.  At  other  times 
maytake  origin  in  an  extension  of  the  catarrh 
im  other  organs,  in  a blood-poison,  or  in  a direct 
■itant. 

Symptoms. — Most  frequently,  though  not  uni- 
Irsally,  the  attack  is  ushered  in  by  a certain 
hount  of  fever.  The  patient  experiences  some 
gree  of  chilliness,  if  not  actual  rigor  ; is  rest- 
|»s ; his  temperature  is  exalted  ; the  skin  is  dry ; 
I languor  and  stiffness  of  the  body  are  com- 
tined  of.  This  may  precede  the  pharyngeal 
nptoms  by  some  hours,  but  soon  these  begin 
arrest  attention.  The  patient  discovers  in  his 

■ ■oat  a feeling  of  soreness  or  fulness,  speedily 
ounting  to  pain.  This  is  particularly  noticed 

■ en  an  attempt  is  made  to  swallow.  And  yet 
s very  condition  of  dryness  of  the  throat  pro- 
ves him  to  renew  the  effort  to  swallow,  the 
' pleasantness  of  which  he  manifests  to  the  by- 
1 nders  by  the  wry  faces  thereby  induced.  This 
1 ire  to  swallow  is  greatly  aggravated  if  the 

fla. happens  to  be  involved  in  the  catarrh,  as 
I n its  swollen  condition  it  suggests  the  pre- 


PHABYNX,  DISEASES  OF.  1167 
sence  of  a foreign  body,  which  the  patient  endea- 
vours to  rid  himself  of  by  repeated  swallowing. 
Cough  is  a frequent  accompaniment,  especially  if 
the  inflammation  have  extended  downwards. 

The  inflammation  may  not  extend  into  the 
larynx,  but  more  usually  this  part  is  involved,  and 
then  the  voice  is  altered  in  tone,  becoming  husky 
or  hoarse,  and  it  acquires  the  well-known  ‘nasal 
twang.’  On  inspecting  the  throat,  it  will  be  ob- 
served that  the  mucous  membrane  is  consider- 
ably altered  in  appearance  and  colour,  being 
tumefied  and  redder  than  in  health.  At  first  it 
is  dry,  often  glistening,  and  tense.  But  as  the 
case  progresses  this  condition  is  altered,  a secre- 
tion of  mucus,  more  or  less  abundant  , being  poured 
out,  bathing  the  tonsils  and  posterior  parts  of 
the  pharynx.  This  gives  rise  to  repeated  hawk- 
ing and  attempts  to  expectorate.  Occasionally 
this  catarrhal  inflammation  extends  into  the 
Eustachian  tubes,  exciting  considerable  deafness 
and  pain  in  the  ears.  At  the  same  time  the  oral 
mucous  membrane  is  affected,  as  evidenced  by 
the  usual  symptoms  of  foul  tongue,  had  taste  in 
the  mouth,  accumulation  of  saliva,  and  offensive 
breath.  This  acute  variety,  under  effective  treat- 
ment, usually  subsides  within  a week. 

Treatment. — Dr.  Binger  urges  the  use  of 
tincture  of  aconite,  in  drop  doses  every  quarter 
of  an  hour  for  the  first  two  hours,  and  afterwards 
hourly,  if  the  angina  has  been  seen  at  the  very 
commencement.  He  states  that  the  inflammation 
rarely  fails  to  succumb  to  this  treatment  in 
twenty-four  to  forty-eight  hours.  The  patient 
should  he  confined  to  bed ; a brisk  purgative  ad- 
ministered ; and  bland  nourishment  allowed,  in- 
cluding abundance  of  milk,  ice  ad  libitum,  and 
stimulants  if  called  for.  Warm  fomentations  or 
poultices  may  be  applied  externally,  or  a wet  com- 
press. Steam  may  be  inhaled,  and  a warm  spray, 
medicated  with  morphia,  thrown  into  the  throat 
every  two  hours.  "When  the  swelling  and  redness 
subside,  and  the  parts  no  longer  present  the  dry, 
tense  appearance,  hut  are  covered  with  mucus  or 
pus,  then  is  the  time  to  bring  in  the  astringent 
gargles,  or  to  paint  the  throat  with  glycerine  of 
tannin  or  nitrate  of  silver.  And  now,  also,  tonics 
will  prove  useful. 

2.  Chronic  Inflammation  of  the  Pharynx. 
Synon.  : ‘ Eelaxed  throat.’ — This  is  by  no  means 
an  uncommon  affection,  and  may  exist  without 
having  passed  through  the  acute  form. 

Symptoms. — As  in  the  acute  variety,  so  here 
there  is  the  same  difficulty  in  swallowing, 
amounting  even  to  pain  when  irritating  sub- 
stances are  attempted  to  be  passed  into  the  gul- 
let, but  of  course  in  an  infinitely  less’ degree. 
Persons  suffering  from  this  form  of  sore-throat 
are  specially  liable  to  exacerbations  of  the  ca- 
tarrh, giving  to  the  affection  more  of  a sub- acute 
character,  and  then  their  usual  symptoms  are 
all  aggravated.  The  hawking  and  expectoration, 
which  habitually  go  on,  more  or  less,  during  the 
whole  time  of  t.heir  toilet-making,  is  increased  ; 
and  finding  some  difficulty  in  removing  this 
tough  mucus  from  the  hack  of  the  throat,  this 
hawking  is  continued  till  the  mucous  membrane 
itself  is  strained,  and  some  of  the  ramifying  ves- 
sels give  way,  and  the  patient  is  alarmed  to  see 
blood  mixed  with  the  expectoration.  In  some 
instances,  especially  in  the  case  of  those  who  arc 


PHARYNX,  DISEASES  OF. 


1158 

habitual  topers,  this  hawking  in  the  morning  is 
the  prelude  to  the  morning  vomiting.  The  voice 
is  apt  to  be  husky,  more  particularly  if  the  ca- 
tarrh have  at  all  invaded  the  larynx.  On  inspec- 
tion of  the  throat,  it  will  be  observed  that  the 
mucous  membrane  is  more  or  less  reddened ; it 
presents  a roughened  appearance  ; and  is  some- 
times puffy-looking,  with  numerous  veinlets 
running  across  it,  and  a quantity  of  mucus  ad- 
hering to  the  posterior  part  of  the  throat : this 
last  appearance  is  more  common  in  the  relaxed 
condition  of  the  throat.  This  variety  is  not 
■•.infrequently  found  as  an  accompaniment  of  other 
diseases,  as  of  phthisis,  syphilis,  disorders  of  the 
stomach,  gout,  and  the  effects  of  intemperance. 
The  affection  is  usually  very  obstinate. 

Treatment. — If  the  disorder  be  dependent 
upon  any  other  affection,  then  of  course  the  pri- 
mary disease  must  be  attacked.  But  in  the  case 
of  simple  chronic  pharyngitis  it  will  usually  be 
found  that  the  sufferer  is  considerably  below  par 
in  his  general  health.  This  indication  must  be 
met,  and  the  patient  supplied  with  tonics;  his 
habits  of  life  altered,  his  business  suspended, 
and  much  out-of-door  exercise  enjoined.  Good 
nourishing  diet  should  be  ordered.  Smoking 
must  either  be  entirely  prohibited,  or  if  this  be 
impossible,  it  must  be  much  reduced.  Locally, 
the  affection  is  best  treated  by  sprays  or  swab- 
bing. Gargles  seldom  reach  the  parts  ; but  if 
these  are  to  be  used,  the  best  are  those  of  alum, 
tannin,  chlorate  of  potash,  or  bromide  of  ammo- 
nium. This  latter  is  especially  valuable  in  re- 
laxed throats,  with  elongated  uvula,  and  irritable 
cough.  As  sprays,  many  different  remedies  are 
employed,  the  most  valuable  being  solutions  of 
the  following  in  distilled  water,  in  the  pro- 
portions indicated  to  the  ounce: — Nitrate  of 
silver,  5 to  10  grains  ; tannin,  5 to  15  grains  ; 
alum,  10  to  30  grains;  sulphate  of  zinc,  5 to  10 
grains ; common  salt,  10  to  30  grains ; or  glycerine 
diluted  with  water.  In  swabbing  the  throat, 
glycerine  of  tannin  may  be  used,  Lugol's  solution, 
or  the  simple  tincture  of  iodine.  In  some  eases 
mineral  waters  are  prescribed  with  success. 

3.  Follicular  Inflammation  of  the 
Pharynx.  — Synon.  : Granular  pharyngitis  ; 

1 clergyman’s  sore-throat ; ’ Fr.  Angine  glandu - 
','Mse  ; Ger.  Chronischer  Pharyngitis. 

This  is  another,  by  no  means  rare,  form  of 
chronic  pharyngitis.  On  inspecting  the  throat 
•cf  a sufferer  from  this  affection,  the  posterior 
wall  of  the  pharynx  will  be  seen  to  present  a 
mammi  Hated  appearance.  The  mucous  follicles 
are  much  more  prominent  than  is  usual  in  health, 
and  seem  as  if  distended  with  their  proper  secre- 
tion. The  submucous  tissue,  in  which  they'  are 
imbedded,  is  also  thickened  and  hypertrophied. 
Occasionally  these  tubercles  coalesce,  and  then 
a large  confluent  prominence  is  observed,  stud- 
ding, here  and  there,  the  posterior  wall  of  the 
pharynx.  In  addition  to  the  distension  of  these 
follicles,  in  some  cases  a large  secretion  of  mucus 
is  poured  out,  which,  especially  at  night,  hardens 
and  concretes,  and  presents  a dry,  ugly,  greenish- 
coloured  crust  on  the  back  of  the  pharynx.  At 
ether  times  there  is,  on  the  contrary,  a deficiency 
of  mucus,  and  then  there  is  observed  a dry  var- 
nished-like appearance  on  the  back  of  the  throat. 

Symptoms. — Each  of  these  conditions  gives  rise 


to  a considerable  amount  of  coughing  and  hawk- 
ing ; more  particularly  is  this  the  case  when  the 
adherent  mucus  is  tough,  tenacious,  and  difficult 
of  expectoration.  The  voice  becomes  hoarse  and 
husky,  this  being  very  observable  after  any  con- 
tinuous effort  at  speaking  or  reading.  Swallow- 
ing is  not  attended  with  difficulty  or  pain.  But 
the  presence  of  these  enlarged  follicles  in  the 
throat  suggests  to  the  mind  of  the  patient  the* 
necessity  of  swallowing,  and  consequently  he 
makes  frequent  uncalled-for  attempts  to  swallow 
At  the  same  time  he  perceives  a sensation  o' 
dryness  or  pricking  in  the  thro'at.  Those  wh- 
are  the  subjects  of  this  disorder  will  general!, 
be  found  to  be  over-worked  men — often  clergy 
men ; and  hence  the  erroneous  name  for  the 
affection  of  ‘clergy-man’s  sore-throat  ’—or  thosi 
whose  bodily  and  nervous  energy  have  beer 
in  any  way  reduced.  It  is  a tedious  disorder 
often  lasting  for  years.  There  seems  to  be 
small  disposition  for  the  disease  to  extend  t 
the  larynx  or  lungs ; but  on  examination  M 
means  of  the  rhinoscope,  the  same  enlarged  ap 
pearanee  of  mucous  follicles  may,  in  some  cases 
be  seen  to  extend  to  the  utmost  limits  of  th. 
pharynx,  and  the  mucous  membrane  is  itsel 
tumefied  and  thickened.  If  this  condition  b? 
neglected,  it  may  ultimately  proceed  a stag, 
further,  and  the  character  of  the  secretion  be! 
comes  altered,  presenting  a muco-purulent  ap 
pearanee,  while  the  glands  themselves  becom 
indurated  and,  in  some  cases,  ulcerated.  Oeca 
sionally  it  will  be  found  that  the  mucous  mem 
brane  and  the  follicles  of  the  larynx  take  on  thi 
same  form  of  chronic  inflammation,  specially 
when  the  disorder  is  persistently  ignored  fo 
years.  Arrived  at  this  stage,  the  general  symp 
toms  become  so  aggravated  as  to  forbid  th 
patient,  or  his  friends,  any  longer  to  neglec 
the  disease.  The  hoarseness,  always  presea 
in  a certain  degree  when  speaking  or  siDging 
becomes  constant  and  intensified  ; and  if  th] 
larynx  be  considerably  affected  there  may  b 
complete  aphonia.  And  now  more  decided  pah 
is  complained  of,  and  the  individual  no  longe, 
exhibits  the  same  alacrity  and  interest  in  th 
pursuit  of  his  avocations,  but  becomes  indit 
ferent  to  them,  in  consequence  of  the  increase* 
debility  and  general  languor  which  pervades  hi 
whole  system.  Cough,  however,  is  not  a strik 
ing  symptom ; for  if  tile  disease  do  not  inrad 
the  larynx  to  any-  great  extent  (and  its  tendency 
is  rather  to  progress  upwards  than  downward?' 
then  the  patient  maybe  comparatively freefron 
cough.  The  other  structures  in  the  neighbour 
hood  of  the  pharynx  become  implicated,  whe 
the  disease  assumes  the  ulcerated  form ; and  th 
uvula,  tonsils,  and  soft  palate  become  tnmefieij 
swollen,  elongatod,  and  generally  so  enlarged  a 
greatly  to  interfere  with  the  inspection  of  th 
parts.  The  epiglottis  also  exhibits,  in  sever 
cases,  a tendency  to  become  crooked  and  ul« 
rated.  j 

Treatment. — The  general  rules  already  lai 
down  wi  th  regard  to  the  treatment  of  chronic  ph:; 
ryngitis  apply  equally  in  this  disorder,  only,  per 
haps,  with  greatcrforce.  The  constitutional  treai 
ment  must  be  more  decided.  The  patient  must  1 
absolutely-  forbidden  to  prosecute  his  employmer 
or  profession  any  longer,  if  he  has  any  respect  '< 


PHARYNX,  DISEASES  OF. 
lis  health,  be  he  clergyman,  physician,  barrister, 
linger, photographer,  or  inveterate  smoker,  forthe 
Lbits  and  pursuits  of  these  individuals  are  the 
-ery  provocatives  of  the  disease.  The  constitution 
iiust  be  braced  in  every  possible  way,  by  the 
Ise  of  generous  diet,  tonics,  bathing,  travelling, 
bnd  to  further  the  cure  of  the  affection,  atten- 
ion  must  be  paid  to  the  secretions  generally, 
ihese  being  stimulated  or  altered  by  the  exhibition 
f small  doses  of  blue  pill,  podophyllin,  and 
does.  Iodine  in  some  form  should  be  giveD. 
'lut  the  local  treatment  is  equally,  if  not  more, 
'mportant,  and  to  be  effective  must  be  regularly 
nd  conscientiously  persevered  in  for  months, 
"hero  are  various  methods  of  effecting  this,  as 
inhalations  of  medicated  fluids,  insufflation  of 
arious  powders,  as  alum  or  tannin  ; but  the 
lost  certain  and  efficacious,  because  at  once 
sacking  the  affected  parts,  and  producing  de- 
ided  and  visible  effects,  is  the  direct  application 
f the  selected  remedy  to  the  diseased  parts  by 
[leans  of  a large  camel's-hair  brush.  And  one 
i the  best  of  these  applications  is  a strong 
elution  of  nitrate  of  silver,  varying  in  strength 
•om  twenty  to  eighty  grains  to  the  ounce  of  dis- 
hed water.  If  the  pans  be  much  ulcerated,  a 
ill  stronger  solution  may  be  employed.  Other 
edicaments  which  may  at  a later  stage  be  used 
■e  the  glycerine  of  tannin,  or  a solution  of  tan- 
n in  water  (equal  quantities  of  tannin  and 
ater),  bromide  of  ammonium,  tincture  of  iodine, 

• nitrate  of  uranium.  Of  course  it  must  be 
ft  to  the  discretion  of  the  practitioner  to  decide 
>w  often  he  should  repeat  these  strong  applica- 
nt, as  it  all  depends  upon  the  nature  of  the 
so ; but  as  a general  rule  it  may  be  laid  down 
at  cnce  every  second  day  will  be  quite  suffi- 
pnt  for  the  first  fortnight,  and  after  that  two 
three  times  a week  will  be  often  enough, 
lis  is  to  be  kept  up  till  the  nodulated  appear- 
ce  is  got  rid  of.  As  soothing  applications  the 
ycerine  of  borax  will  be  found  valuable,  or 
yrerine  alone,  or  olive  or  almond  oil.  Gargles 
e useless,  as  they  never  reach  the  affected  parts, 
course  of  mineral  waters  is  sometimes  of  tho 
eatest  value.  Sec  Mineral  Waters. 

Claud  Muirhead. 

PHIMOSIS  (<pi,u6a,  I confine). — Synon.  : 

. and  Ger.  Phimosis. — A morbid  condition  of 

> penis,  in  which  the  glans  cannot  be  suffi- 
ntly  uncovered,  on  account  either  of  congenital 

> allness  of  the  orifice  of  the  prepuce,  or  of 
1 turbance  of  the  natural  relations  between 

i latter  and  the  glans  by  disease.  See  Penis, 

. leases  of. 

?HLEBECTASIA(^>\6i|/,  a vein,  and  e/mzcns, 
i1  ension). — Synon.  : Hypertrophia  vcnarum. 
Definition.  — An  increase  or  spreading  of 
’ ns,  especially  applicable  to  the  minute  ve- 
l es  of  the  cutaneous  or  mucous  surfaces. 
Description. — Phlebeetasia  is  sometimes  con- 
f ital,aswhen  it  gives  rise  to  venous  nsevus  ; and 
either  times  accidental,  proceeding  from  relax- 
f in  of  the  tissues,  or  obstruction  of  the  venous 
i illation.  Phlebeetasia,  from  want  of  tone  of 
f tissues  of  the  skin  and  weak  contractile  energy 
c the  vessels,  is  most  frequently  met  with  on 
t cheeks  and  nose  ; whilst  that  which  results 
I n venous  obstruction  occurs  generally  upon  the 


PHLEGMASIA  ID  GLENS.  1159 

lower  limbs.  On  the  nose  it  is  associated  with 
small  venous  trunks  which  carry,  the  returning 
blood  into  the  deeper  venous  plexuses,  and  are 
very  conspicuous. 

Treatment. — The  treatment  of  phlebeetasia 
consists  in  improving  the  tone  and  vigour  of  the 
skin,  removing  palpable  causes  of  obstruction, 
and  applying  local  astringents.  When  torpid 
action  is  the  chief  cause,  as  happens  in  acci- 
dental phlebeetasia  of  the  face,  daily  friction 
with  sulphur  ointment  is  useful  in  exciting  an 
improved  nutritive  vigour.  Where  large  venules 
are  present,  as  on  the  nose,  they  may  be  oblite- 
rated by  a careful  touch  with  potassa  fusa,  which 
forces  the  blood  to  seek  a deeper  channel.  In 
phlebeetasia  of  a naevous  character  a good  treat- 
ment consists  in  painting  the  surface  night  and 
morning  with  liquor  plumbi.  But  the  capillary 
venous  hypertrophy  of  varicose  or  obstructed 
veins  is  only  to  be  benefited  by  the  removal  cf 
the  cause.  Erasmus  Wilson. 

PHLEBITIS  a vein). — Inflammation 

of  a vein.  See  Phlegmasia  Dolens  ; and  Veins, 
Diseases  of 

PHLEBOLITH  a vein,  and  Af 60s,  a 

stone). — A concretion  formed  in  a vein.  See 
Veins,  Diseases  of. 

PHLEBOTOMY  (<p\etp>  a vein,  and  reyva,  I 
cut). — A synonym  for  venesection.  See  Blood, 
Abstraction  of. 

PHLEGM  (cpAeyw,  I burn;  I distil). — A 
popular  name  for  matter  expectorated.  See  Ex- 

FKCTOKATION. 

PHLEGMASIA  DOLENS  (phlegmasia, 
inflammation  ; and  dolens , painful). — Synon.  : 
Phlegmasia  alba  dolens;  Pop.  White  Leg. ; Fr. 
Phlegmasia  alba  dolens  ; Ger.  Phlegmasia  dolens. 

This  is  a disease  having  very  distinct  charac- 
ters and  easily  identified.  It  has,  therefore,  been 
long  familiarly  known  both  to  the  profession  and 
the  public.  Except  in  lying-in  women,  it  is  un- 
common, few  medical  men  seeing  well-marked  or 
characteristic  cases  of  it  under  any  other  circum- 
stances ; and  it  is  for  the  most  part  ns  a disease 
of  the  puerperal  state  that  it  has  been  the  subject 
of  study  and  investigation. 

FEtiology. — Phlegmasia  dolens  affects  both 
sexes,  and  no  age  is  exempt  from  it.  It  may 
attack  any  part  of  the  body,  but  one  or  other 
of  the  lower  limbs  is  the  ordinary  seat  of 
it.  Occasionally  it  seizes  one  lower  limb  first 
and  then  the  other,  or  the  disease  may  extend 
from  the  one  to  the  other.  The  well-character- 
ised disease,  as  it  affects  lying-in  women,  is  an 
affection  of  the  lower  limbs.  The  left  leg  is  far 
moro  frequently  affected  in  the  puerperal  state 
than  the  right ; and  the  left  leg  is  supposed  to 
be  more  frequently  affected  than  the  other  under 
whatever  circumstances  the  disease  occurs.  In 
lying-in  women  the  comparative  frequency  of 
this  affection,  and  of  several  other  morbid  con- 
ditions on  the  left  side,  is  believed  to  depend  on 
the  circumstance  that  the  parts  on  that  side  of 
the  pelvis  are  more  frequently  subjected  to  pres- 
sure and  bruising  than  the  parts  on  the  other 
side.  This  probably  arises  from  the  compara- 
tive frequency  of  the  right  lateral  obliquity  of 


PHLEGMASIA  DOLENS. 


1160 

the  uterus  throwing  the  direction  of  the  uterine 
power  of  labour  across  the  mesial  line  to  the 
left  side  of  the  pelvis.  The  disease  affects  mul- 
tipart more  than  primiparoe.  It  is  prone  to 
occur  in  successive  confinements. 

From  the  variety  of  circumstances  under  which 
the  disease  may  occur,.-it  will  be  easily  appre- 
hended that  it  may  arise  in  any  period  of  preg- 
nancy or  of  the  puerperal  state,  but  the  time  of 
appearance  of  the  ordinary  disease  in  lying-in 
women  is  the  second  week  after  delivery.  It 
rarely  commences  in  the  first  days ; generally  in 
the  second  or  third  week ; seldom  subsequently, 
in  the  puerperal  state. 

The  special  proneness  of  lying-in  women  to 
this  disease  probably  depends  on  their  liydraemic 
condition. 

Besides  the  puerperal  state,  other  conditions 
render  the  body  liable  to  it.  Among  these  are 
convalescence  from  fever  — especially  typhoid, 
dysentery,  disease  of  the  rectum,  malignant 
disease  of  the  uterus,  interference  with  uterine 
fibroids,  arrestment  of  menses,  and  malignant  and 
tubercular  disease  generally.  The  disease  has 
been  frequently  observed  to  affect  the  leg  of  the 
side  corresponding  with  a previously  commenced 
pleurisy.  Occurring  in  connection  with  any  of 
these  conditions,  the  disease  may  vary  greatly  in 
severity,  from  being  scarcely  recognisable  to  its 
utmost  degree  of  intensity.  But  its  liability  to 
severity  is  not  the  same  in  all  circumstances. 
For  example,  in  connection  with  malignant 
diseases  of  the  womb  it  is  often  very  slight  and 
chronic. 

Anatomical  Characters. — The  'post-mortem 
appearances  referable  to  phlegmasia  dolens  vary, 
especially  in  the  presence  or  absence  of  throm- 
bosis of  the  veins.  Phlebitis,  periphlebitis, 
and  thrombosis  are  generally  found ; but  besides 
these  nothing  special  has  been  made  out.  The 
blood-clots  vary  in  extent,  sometimes  occurring 
as  high  as  the  vena  cava  inferior.  They  vary 
in  appearance,  being  more  or  less  decolourised, 
more  or  less  softened,  or  even  diffluent.  They 
may  be  adherent  to  the  veins,  even  organised,  or 
separable  from  them.  They  may  block  the 
veins,  or  may  allow  passage  of  blood  through 
their  substance.  In  recent  cases  the  clot 
adheres  to  the  internal  coat  of  the  vein,  which 
is  blood-stained.  These  coats  are  thickened 
and  inflamed,  and  the  surrounding  cellular  tissue 
is  also  sometimes  specially  hardened.  In  cases 
complicated  with  pyaemia  there  may  be  found 
suppuration  in  the  clots,  and  other  appearances 
observed  in  that  condition. 

Pathology. — Various  theories,  which  reflect 
the  pathology  of  the  times  at  which  they  ap- 
peared, have  been  held  concerning  the  nature  of 
phlegmasia  dolens.  The  disease  was  ascribed  to 
a metastasis  of  lochia  by  many  pathologists,  and 
by  others  to  a metastasis  of  milk.  These  views 
had  no  basis  of  facts,  or  very  little ; they  rested 
almost  entirely  on  authority,  and  disappeared  as 
pathology  improved.  The  discovery  of  the  lym- 
phatics in  the  last  century  led  to  the  first  attempts 
of  a truly  scientific  kind  to  solve  the  mystery  of 
the  nature  of  this  affection,  the  suggestion  being 
that  it  arose  from  thoir  injury  and  obstructi'Vi. 
Bat  considering  how  imperfect  is  our  acquaint- 
ance even  now  with  the  ongin  and  distribution 


of  these  vessels,  with  the  circulation  through 
them,  and  with  the  effects  of  their  injury  or 
obstruction,  we  must  still  seek  for  information. 
The  next  attempt  to  account  for  this  disease  was 
based  on  the  important  discovery  of  the  throm- 
bosis of  the  veins  of  the  affected  limb.  This  was 
erroneously  assumed  to  be  an  invariable  or  essen- 
tial condition  of  the  disease,  which  was  accord 
ingly  now  regarded  as  phlebitic.  But  the  recur- 
rence of  the  lesions  regarded  as  essential,  the 
phlebitis  and  thrombosis,  without  the  develop- 
ment of  the  characteristic  appearances  of  the 
affected  limb ; and,  on  the  other  hand,  the  occur- 
rence of  the  characteristic  appearances  without 
the  simultaneous  presence  of  the  phlebitis  and 
thrombosis,  demonstrated  the  insufficiency  of  the 
phlebitic  theory.  The  next  theory  to  be  mentioned 
is  a sort  of  retrogression  to  humoral  pathology. 
It  alleged,  but  merely  alleged,  that  a morbid  con- 
dition of  the  blood,  of  undefined  nature,  is,  along 
with  phlebitis  and  thrombosis,  necessary  for  the 
production  of  the  disease.  This  theory  is  nearly 
as  deficient  in  basis  as  the  lochia  or  milk  theory. 
The  confirmatory  experiments  on  the  lower  ani- 
mals, by  injecting  lactic  acid  into  the  circulation,' 
are  in  the  highestdegree  insufficient;  anditleares 
unexplained  important  points,  such  as  the  seat 
of  the  affection.  The  last  theory  to  be  mentioned 
is,  perhaps,  from  its  very  novelty,  likely  to  get 
more  favour  than  it  as  yet  deserves.  It  is  that 
the  disease,  as  it  is  seen  in  lying-in  women,  is 
essentially  a parametritis— that  is,  an  affection 
of  the  cellular  tissue,  commencing,  indeed,  in  the; 
close  neighbourhood  of  the  womb,  but  extending 
to  remote  parts ; and,  it  may  be,  prevailing  in 
them,  while  the  original  inflammatory  affection 
of  the  womb  and  its  immediate  neighbourhood 
has  diminished,  or  even  disappeared.  Parame- 
tric inflammation  extends  in  a similar  manner 
occasionally  as  far  as  the  cellular  tissue  around 
the  kidney.  When  it  extends  to  a limb  it  is 
supposed  to  be  the  eauso  of  phlegmasia  dolens, 
and  to  have  the  phlebitis  and  thrombosis  as  con- 
comitants or  consequences  of  it.  This  theory  is 
to  a certain  extent  an  old  one  in  modern  habili- 
ments. It  is  easily  applied  to  all  forms  of  the 
disease.  The  most  recent  observations  with  a 
view  to  the  elucidation  of  the  pathology  of  this 
disease,  are  concerned  with  the  thrombosis  of 
uterine  sinuses,  which  goes  on  in  the  latter  part 
of  natural  pregnancy,  as  well  as  more  extensively, 
after  delivery. 

The  great  barrier  to  progress  in  our  knowledge 
of  the  nature  of  phlegmasia  dolens  is  the  rarity 
of  necropsie  investigations,  and  the  sometimes 
doubtful  character  of  the  evidence  they  afford. 
Very  few  unexceptionable  post-mortem  investiga- 
tions have  ever  been  made  in  this  disease.  Sueha 
post-mortem  inspection  must  be  made  in  an  early 
stage,  and  in  a patient  dying  accidentally  from 
some  cause  unconnected  with  the  disease  of  the 
limb.  Now,  the  disease  is  not  only  not  fatal  in 
an  early  stage,  but  it  might  be  asserted  that  it  is 
not  fatal  at  all — that  death,  apparently  from  it, 
only  occurs  in  complicated  cases — in  such  as  run 
an  extraordinary  and  rare  course.  In  the  mean- 
time, then,  no  theory  of  the  disease  can  be  re- 
garded as  established,  or  as  having  been  shown 
to  be  sufficient. 

Some  modern  pathologists  believe  that  theN 


PHLEGMASIA  DOLENS.  1161 


.ro  varieties  of  phlegmasia  dolens  dependent  on 
ts  origin  in  disease  of  the  lymphatics,  in  disease 
f the  veins,  or  in  areolar  inflammation.  This 
ubdivision  has  strong  arguments  in  its  sup- 
ort,  but  they  are  far  from  being  conclusive ; 
i.nd  it  cannot  be  used  in  practice,  nor  made 
he  basis  of  any  separate  description  of  tho 
arieties,  which  should  be  held  by  the  advocates 
|t  this  viow  to  be  distinct  diseases.  Whilst  cases 
[f  obstruction  of  the  veins  with  cedema  are  com- 
lon,  cases  of  obstruction  of  the  lymphatics  with 
ifdema  are  probably  rare  ; and  neither  of  these 
bstmctions,  nor  both  of  them,  can  as  yet  be 
lade  to  account  for  all  the  phenomena  of  phleg- 
iasia  dolens.  The  distinctive  characters  claimed 
hr  the  cases  cf  lymphatic  obstruction  are  the 
bsence  of  pain,  absence  of  lividity  or  blueness, 
hd  the  presence  of  hyaline  lines,  indicating  the 
burse  of  distended  superficial  lymphatics.  But 
: requires  only  a very  limited  experience  in  the 
isease  to  be  convinced  of  the  insufficiency  or 
■equent  inapplicability  of  this  distinction  during 
ife. 

Symptoms. — As  a rule  phlegmasia  dolens  is 
receded  by  a slight  access  of  feverish  pheno- 
ena,  seldom  by  a distinct  rigor.  The  pyrexia 
ion  becomes  slight  or  disappears.  It  is  only 
severe  cases,  while  rapidly  progressing  to  a 
imax,  that  the  temperature  of  tho  affected  part 
is  been  observed  to  be  raised. 

Premonitory  symptoms. — Premonitory  symp- 
;ms  are  frequently  absent,  indeed  generally  so  ; 
Sit  there  is  sometimes  an  indefinite  malaise, 
even  feverishness,  for  a day  or  two,  before 
e pain  in  the  limb  is  complained  of.  Another 
emonitory  symptom  is  described,  but  it  also 
certainly  not  always  present — namely,  pain 
d tenderness  in  the  region  of  the  womb,  espe- 
illy  affecting  that  side  of  it  corresponding  to 
e limb  about  to  be  affected. 

Invasion. — The  first  announcement  of  the  dis- 
■se  is  generally  pain  and  tenderness  in  the  groin, 
mg  tlie  course  of  the  femoral  vein,  or  in  the 
m along  the  course  of  the  external  saphena, 
these  situations  the  thrombosed  vein  can  fre- 
' ently  be  felt,  but  not  invariably,  for  sometimes 
) tenderness,  sometimes  the  swelling,  prevents 
being  made  out ; and  sometimes  this  throni- 
ng is  absent,  at  least  in  parts  where  it  can  be 
; ; through  the  skin.  Soon  the  pain  and  tonder- 
: ;s  extend  over  the  whole  affected  parts,  which 
i y be  the  whole  limb,  and  often  a feeling  as  of 
iliing  in  the  bones  is  complained  of.  The  pain 
(sometimes  along  tho  internal  saphena  vein, 
vich  may  be  traced  by  the  finger  till  it  dips 
t oin  the  femoral. 

iimultaneously  with  the  complaint  of  pain,  or 
t hin  a day  or  two  after  it,  swelling  appears, 
inch  gradually  spreads  and  increases  in  hard- 
i|s.  This  swelling  is  not  like  ordinary  oedema- 
t s or  anasarcous  swelling  in  the  sensation  it 
ehmunicates  to  the  hand  of  the  physician,  or  in 
tj  history  of  its  commencement  and  progress, 
b en  it  commences,  and  again  as  it  disappears, 
i nay  be,  comparatively  to  its  perfect  state, 
s , and  it  may  pit  on  pressure ; but  when,  a 
f days  after  its  appearance,  it  is  fully  de- 
q 'ped,  it  is  elastic,  and  nearly  as  hard  as  a solid 
ili'.a-rubber  ball,  and  does  not  pit  on  pressure. 
1 swelling  may  appear  at  once  all  over  the  limb, 


but  frequently  it  commences  above  and  spreads 
downwards.  Sometimes  the  inverse  course  is 
followed.  It  not  rarely  affects  only  the  lower 
parts  of  a limb,  very  rarely  the  upper  parts  only. 
It  does  not  affect  the  lower  more  than  the  upper 
surface  of  the  limb.  It  rounds  off  the  figure  of 
the  limb,  but  does  not  distend  the  skin  or  de- 
stroy the  form  so  entirely  as  a huge  anasarca. 
Occasionally  there  is  an  erythematous  blush  over 
parts  of  the  limb,  but  this  is  not  common,  and  it 
may  be  confined  to  a narrow  surface  along  the 
course  of  a subcutaneous  vein  or  lymphatic. 

In  a characteristic  and  fully  developed  case, 
such  as  is  frequently  observed  in  the  puerperal 
state,  the  limb  presents  a remarkable  appearance. 
The  swelling  affects  the  labium  and  hip  and  the 
whole  limb.  The  form  of  the  limb  is  partly  re- 
tained, but  its  features  are  all  rounded  and  nearly 
lost  in  the  swelling.  Its  colour  is  pale  or  sallow, 
like  that  of  a dead  limb,  and  hence  tho  disease 
is  called  ‘ white  leg.’  But  besides  being  pale,  it 
is  glossy,  as  if  greased  over;  or,  more  clearly, 
its  surface  resembles  that  of  polished  marble, 
and  the  disease  is  sometimes  called  ‘ marble  leg.’ 
In  the  milder  cases  the  swelling  is  less,  is  softer, 
and  may  be  confined  to  a part  of  the  limb. 

The  limb  may  be  kept  in  an  extended  attitude, 
or  it  may  be  slightly' flexed  at  the  joints.  Move- 
ment of  it  causes  much  suffering,  and  the  power 
of  voluntary  motion  is  almost  completely  lost 
while  the  disease  continues. 

After  the  disease  has  lasted  nine  days  or  there- 
abouts, it  generally  makes  no  further  progress, 
but  recedes,  the  pain  and  swelling  diminishing, 
The  rate  of  this  recession  varies  very  much, 
being  probably  more  or  less  directly  in  propor- 
tion to  the  restored  permeability  of  the  vessels. 
In  a favourable  case  several  weeks  may  elapse 
before  the  disease  disappears,  whilst  in  others  the 
cure  may  be  further  or  even  indefinitely  delayed. 

Sequelje,  Complications,  and  Prognosis. — 
The  most  frequent  sequela  of  phlegmasia  dolens 
is  persistent  aching  of  the  limb,  increased  by  cold 
and  damp  weather,  and  by  derangement  of  the 
general  health,  as  well  as  by  exercise.  Another  is 
a tendency  to  cedema  of  the  ankles,  or  a persistent 
cedema  in  that  situation.  Sometimes  the  limb 
remains  deficient  in  muscular  power.  Rarely, 
the  limb  is  not  only  powerless  but  wasted.  And 
in  some  very  uncommon  cases  it  is  the  subject 
of  a great  hypertrophy  of  the  cellular  tissue,  or 
elephantiasis,  simultaneous  with  muscular  wast- 
ing; and  the  elephantiasis  may  be  complicated 
with  more  or  less  extensive  and  intractable 
ulceration.  Such  cases  probably' result  from  per- 
manent destruction  of  large  vascular  passages ; 
and,  falling  into  surgical  hands,  demand  occa- 
sionally treatment  by  amputation. 

The  disease  is  sometimes,  not  frequently, 
complicated  by  other  affections,  or  by  aggra- 
vations of  some  of  its  conditions.  Among  such 
occurrences  are  inflammation  and  suppuration 
of  the  intrinsic  joints  of  the  pelvis,  erysipelas, 
limited  abscesses  (periphlebitis),  diffuse  suppu- 
ration of  cellular  tissue,  gangrene  of  any  part  or 
of  a varying  amount  of  the  entire  lower  portions 
of  the  affected  limb.  These  complications  or 
aggravations  cause  much  danger  to  life,  and  in 
this  respect  their  influence  varies  according  to 
circumstances.  But  there  are  other  complies 


1162  PHLEGMASIA  DOLENS. 

tions  or  aggravations  which  are  more  often  fatal. 
They  may  be  summed  up  in  the  terms  embolism 
and  pyaemia,  and  are  the  consequences  of  detach- 
ment of  a thrombus  in  the  femoral,  or  in  still 
larger  veins,  or  of  a more  slow  breaking  up  of 
blood-clots  into  debris,  more  or  less  puriform, 
which  enters  the  circulatory  current. 

Diagnosis. — The  diagnosis  of  phlegmasia 
dolens  requires  no  discussion.  The  disease  can 
scarcely  be  confounded  with  any  other  if  its 
history  is  taken  into  consideration:  only,  it  is 
necessary  to  remember  that  cedema  with  phlebitis 
or  accompanying  varicose  veins  may  somewhat 
resemble  it. 

Treatment. — The  treatment  of  phlegmasia 
dolens  should  be  both  constitutional  and  local. 
The  former  has  no  special  points,  being  varied 
according  to  the  circumstances  of  the  case,  and 
the  views  of  the  practitioner.  Generally  some 
opiate  is  required  to  procure  sleep,  and  Dover’s 
powder  is  a favourite  form  for  its  administra- 
tion. Local  treatment  is  very  important.  The 
limb  is  to  be  kept  at  rest,  either  in  an  extended 
or  flexed  position,  as  may  prove  most  comfort- 
able. It  should  be  fomented  several  times  daily, 
if  not  constantly.  This  may  be  effected  by  the 
flannel  bandage  wrung  out  of  hot  water,  pre- 
cautions being  taken  for  the  protection  of  the 
patient  and  bed  from  damp.  The  fomentations 
are  sometimes  made  anodyne  by  using  decoctions 
of  poppy-heads  or  otherwise.  Sometimes  infu- 
sion of  chamomile  flowers  is  valued  as  a foment- 
ing medium.  Leechos  are  sometimes  applied 
along  the  course  of  an  inflamed  vein,  but  their 
utility  is,  to  say  the  least,  often  doubtful. 

After  the  acute  stage  of  the  disease  is  past 
the  sequel®  have  to  be  dealt  with.  Of  these 
the  most  frequent  are  aches,  swelling,  cedema, 
and  muscular  weakness;  and  for  these  the  most 
efficient,  but  by  no  means  invariably  successful, 
remedies  are  frictions,  bandaging,  and  faradisa- 
tion. After  all  active  disease  has  disappeared, 
and  after  danger  of  the  moving  of  thrombi  has 
passed,  the  patient  should  diligently  resume  the 
use  of  the  leg.  No  exact  statement  can  be  made 
of  the  time  at  which  the  danger  of  embolism  is 
passed.  It  may  prove  suddenly  fatal  thirty- 
seven  days  after  delivery. 

Persistent  local  hardness  and  tenderness,  pro- 
bably periphlebitic,  may  be  treated  by  gentle 
frictions  with  a mixture  of  mercurial  and  bella- 
donna ointments.  In  using  frictions  of  all  kinds 
the  danger  of  dislodging  a thrombus  is  not  to  be 
overlooked.  J.  Matthews  Duncan. 

PHLEGMATIC  TEMPERAMENT.  See 

Temperament. 

PHLEGMON  (<p\eyfj.aU'u,  I burn — as  a me- 
dical term,  glow,  am  inflamed). — Stnon.  : Pr. 
Phlegmon;  Ger.  Entzundungsgeschwulst. — The 
term  phlegmon  is  almost  disused  now  in  English 
medical  literature.  It  is  still  employed  by  the 
French.  Abernethy  defines  phlegmon  as  the  ‘most 
violent  kind  of  inflammation,’  ‘attended  with 
heat,  redness,  throbbing,  pain,  and  swelling,’  such 
as  ‘generally  takes  place  in  a good  constitution.’ 
Older  writers  describe  it  as  a ‘ tumour  or  apos- 
tume  against  nature,  engendered  of  defluxion  of 
blood,  and  of  colour  red  and  hard.’ 


PHOSPHATIC  CALCULUS. 

Nelaton  describes  simple  or  circumscribe! 
phlegmon  and  diffuse  phlegmon.  He  says 
‘Phlegmon  is  generally  defined  as  inflamma. 
tion  of  the  cellular  tissue ; but  surgeons  ban 
restricted  the  sense  of  the  word,  and  onb 
apply  it  to  inflammation  of  the  free  cellulaV 
tissue,  that  is  to  say,  of  that  which  is  placet 
immediately  beneath  the  integuments  or  whici 
surrounds  the  different  organs.’  The  diffuse 
phlegmon  of  the  French  writers  is  the  phleg 
monous  erysipelas  of  the  English.  See  Eetsi 
felas.  Marcus  Beck. 

PHLEGMONOUS. — A term  applied  t 
extremely  acute  inflammation  of  the  cellnla 
tissue,  spreading  widely,  and  accompanied  b; 
great  exudation,  with  brawny  hardness,  intens 
redness,  heat,  and  pain.  If  unrelieved  by  treat 
ment,  phlegmonous  inflammation  tends  to  termi 
nate  in  gangrene.  See  Erysipelas. 

PHLYCTiBNA  (^Atifeiv,  to  be  hot).— .- 
small  vesicle,  containing  an  aqueous  or  seroc 
fluid,  and  not  exceeding  in  bulk  the  diameter  c 
a pea,  as  in  sudamma,  miliaria,  and  herpes 
The  term  is  sometimes  also  used  in  connex.o 
with  ophthalmia. 

PHLYCTIS  ((fjAilfei v,  to  be  hot). — A vesicl 
or  blister,  averaging  in  size  the  hemisphere  of 
hazel-nut  or  walnut,  and  tilled  with  serous  fluic 
Phlyetis  is  the  Greek  synonym ' of  bulla,  and  1 
applicable  to  the  large  vesicles  or  blisters  c 
pemphigus  or  pompholyx.  See  Pemphigus. 

PHLYZ  ACIUM  (<p\vle iv,  to  be  hot).— A he 
or  inflammatory  pustule.  The  term  phlyzacia  i 
applied  to  acute  pustules  with  an  inflamed  bast 
such  as  those  of  ecthyma  and  smallpox. 

PHOSPHATIC  DIATHESIS  — PHOS 
PHURIA— PHOSPHATIC  CALCULUS. 

1.  Phosphatic  Diathesis. — ..Etiology.  - 
Phosphoric  acid  in  the  urine  is  derived  direct! 
from  the  food,  and  also  from  oxidation  of  tt 
waste  albuminoid  tissues  of  the  body.  The  dail 
excretion  by  the  kidneys  amounts  to  about  5 
grains,  being  greatest  after  the  ingestion  of  foo< 
especially  vegetable  food. 

Characters  and  Composition. — Phosphor 
acid  in  the  urine  is  always  found  combined  wit 
potash,  soda,  lime,  magnesia,  and  ammoui 
These  salts,  variously  associated,  are  held  : 
solution  by  the  acidity  of  healthy  urine,  and  tb 
acidity  is  probably  chiefly  due  to  the  acid  pho. 
phate  of  soda.  Where  this  acidity,  from  at 
cause,  is  greatly  diminished  or  destroyed,  then 
deposit  of  the  phosphates  takes  place;  hut  th 
deposit  by  no  means  shows  that  any  excess 
present.  Careful  quantitative  analysis,  nod' 
strict  precautions  as  to  diet,  can  alone  detect  e: 
cess  or  deficiency ; but,  clinically,  this  is  of  le 
consequence  in  that  no  constant  symptoms  a 
produced  by  excess  or  deficiency,  and  the  re 
importance  to  the  practitioner  lies  in  the  fact 
feebly  acid  or  alkaline  urine  leading  to  their  d 
posit  only.  i 

The  two  most  common  forms  of  phosphat 
sediment  are — (1)  the  triple  phosphate  of  a, 
monia  and  magnesia,  and  (2)  the  amorpho 
phosphate  of  lime. 

(1)  The  triple  phosphate  crystallizes  in  t 


PHOSPHATIC  CALCULUS.  1163 


orm  of  transparent  triangular  prisms  with  be- 
velled ends.  The  deposit  has  a white  appear- 
ance, but  more  frequently  it  shows  as  a slight 
loeculent  cloud  in  the  urine,  resembling  mucus, 
,r  as  an  iridescent  pellicle  on  the  surface.  The 
■rine  is  either  faintly  acid  or  alkaline ; and 
toiling  gives  rise  to  an  opaque  cloud,  which  is 
hntantly  dissolved  by  a drop  of  nitric  acid.  It 
lot  unfrequently  co-exists  with  deposits  of  uric 
ici<5,  urates,  or  oxalate  of  lime ; and  also  in 
enso  urine  with  an  excess  of  urea. 

(2)  Amorphous  'phosphate  of  lime  is  only  found 
,s  a deposit  in  alkaline  urine.  Microscopically  it 
hows  as  pale  granules  or  spheroids,  sometimes 
esembling  the  dumb-bells  of  oxalate  of  lime, 
ometimes  the  pale  urates. 

A third  form  of  phosphatic  deposit,  the  stellar 
hosphate  of  lime,  is  but  rarely  met  with.  It 
■as  first  noticed  by  Dr.  Hassall,  who  considered 
; to  be  a bi phosphate ; it  crystallises  in  minute 
ids,  which  are  gathered  into  sheaf-like  bundles, 
r grouped  in  stars  and  fans.  The  clinical  im- 
ortance  of  this  deposit  is  not  well  understood. 
»r.  W.  Eoberts  has  met  with  it  in  cases  of  dia- 
etes,  phthisis,  and  chronic  rheumatism,  and 
re  writer  has  recently  found  it  in  a diabetic 
atient,  and  also  in  one  convalescing  after  ova- 
otomy. 

Symptoms. — Deposit  of  phosphates  takes  place 
1 many  diseases— diseases  often  of  an  opposite 
naracter,  and  having  no  pathological  resem- 
lance — for  example,  in  acute  cerebritis;  towards 
le  close  of  cases  of  pleurisy,  pneumonia,  and 
hcumatic  fever;  in  certain  periods  of  typhoid 
ver;  and  in  acute  mania.  But  it  may  be  taken 
) proved  that  there  is  no  morbid  condition,  cha- 
ictcrised  by  definite  and  constantly  occurring 
I’mptoms,  and  accompanied  by  the  deposit  of 
jiosphates  in  the  urine,  which  can  be  entitled  to 
e designation  of  a ‘diathesis.’  Prout’s  deserip- 
Sn  of  phosphatic  diathesis  is  merely  that  of 
nmoniacal  urine.  Golding  Bird  associated  the 
(;posit  with  symptoms  of  irritative  dyspepsia, 
•pochondriasis,  and  temporary  exhaustion  of 
e nervous  power;  symptoms  which  are  not 
dike  those  said  to  be  characteristic  of  the 
-called  oxalic  acid  diathesis.  Eemembering, 
iwever,  that  phosphatic  deposit  does  not  neces- 
rily  or  frequently  mean  excess,  but  depends  on 
minished  acidity  or  alkalinity  of  the  urine,  it 
11  be  more  profitable  to  notice  this  latter  eon- 
tion. 

The  urine  becomes  neutral  or  alkaline  from 
;e  presence  of  either  fixed  alkali — potash  and 
da,  or  of  the  volatile  alkali — ammonia.  The 
jntinued  or  frequent  presence  of  alkaline  urine 
)m  fixed  alkali  denotes  grave  disorder,  gene- 
lly  characterised  by  debility,  ansemia,  and 
rvous  dyspepsia ; it  may  and  does  occur  in  the 
iurse  of  many,  even  acute,  diseases  ; it  repre- 
dts  an  altered  condition  of  blood  and  nutrition ; 
j t it  is  not  typical  of  any  one  malady  or  dia- 
jesis,  nor,  so  far  as  analytical  investigations 
ve  yet  gone,  is  there  any  clear  evidence  of 
e truth  of  the  theory,  that  excess  or  deposit  of 
osphates,  and  alkaline  urine,  are  the  result  of 
ireased  cerebral  action  or  of  brain-disease. 
Urine  rendered  alkaline  from  carbonate  of  am- 
nia is  always  accompanied  by  deposit  of  both 
■ms  of  the  phosphates.  The  alkalinity  is  the 


result  of  decomposition  of  the  urea  ; there  is  the 
peculiar  ammoniacal  odour,  reaching  sometimes 
to  intense  putrid  feetor.  This  decomposition  is 
supposed  to  be  due  to  the  presence  of  pus  or 
mucus  acting  as  a ferment ; but  this  will  not 
apply  to  those  cases  in  which  no  pus  or  mucus 
is  present,  and  it  is  probable  that  in  many  in- 
stances the  putrefaction  is  produced  by  germs 
conveyed  into  the  bladder  by  the  catheter.  Am- 
moniacal urine  is  always  indicative  of  lowered 
vitality,  either  from  age  or  spinal  injury  or 
disease  ; it  points  to  no  altered  condition  of 
blood  or  constitution,  but  is  the  result  of  local 
disease.  The  phosphates  which  are  so  freely 
thrown  down  are  the  triple  phosphate  and  the 
amorphous  phosphate  of  lime ; they  are  readily 
deposited  on  any  pre-existing  nucleus,  whether 
it  be  a stone,  a clot  of  blood,  a roughened  ulce- 
rated portion  of  bladder,  or  any  foreign  body; 
but  without  this  pre-existing  nucleus  it  but 
rarely,  if  ever,  happens  that  concretions  form. 

Treatment. — As  there  is  no  real  phosphatic 
diathesis  requiring  special  management,  it  fol- 
lows that  the  treatment  should  consist  in  re- 
moving the  cause  of  the  alkalinity  of  the  urine 
from  fixed  alkali.  The  two  most  common  causes 
are  dyspepsia,  and  nervous  and  general  debility. 
In  those  cases  of  chronic  vomiting  and  irritable 
dyspepsia  in  which  the  urine  loses  and  recovers  its 
acidity  several  times  daily,  no  special  remedies 
addressed  to  the  state  of  the  urine  can  be  of  any 
avail.  The  mineralacids  have  long  been  relied  on 
for  restoring  the  natural  acidity  of  alkaline  urine ; 
it  seems  certain,  however,  that  they  have  no  spe- 
cial or  direct  influence,  but  simply  act  beneficially 
by  their  indirect  tonic  effect  on  the  system. 
Phosphoric  and  benzoic  acids  may  slightly  add 
to  the  acidity  of  the  urine,  and  opium  and  bella- 
donna in  certain  conditions  of  nervous  irritability 
are  known  to  have  the  same  effect ; but  speaking 
generally,  the  mineral,  vegetable,  and  acid  tonics 
are  required  in  almost  all  cases,  and  with  them 
the  usual  adjuncts, namely,  good  air  and  exercise ; 
the  cold  sea -water  bath ; a well-selected  generous 
diet,  largely  composed  of  animal  food;  and  re- 
lief from  anxiety  or  overwork. 

For  alkalinity  and  phosphatic  deposit  depend- 
ing on  volatile  alkali,  it  must  be  remembered 
that  in  this  state  the  urine  is  almost  always 
secreted  acid.  The  local  disease  which  causes  it 
must,  if  possible,  be  remedied — a stone  should 
be  removed ; an  atonic  bladder  emptied  at  stated 
intervals  by  the  catheter,  and  washed  out  with 
disinfectants,  if  necessary ; but  the  vital  strength 
always  needs  to  be  upheld  by  rest,  good  diet,  and 
tonics. 

2.  Phosphatic  Calculus. — Description. — 
Phosphate  of  lime  calculi  are  sometimes  formed 
in  the  kidney,  but  much  more  frequently  phos- 
phatic stones  are  a secondary  deposit  on  some 
pre-existing  nucleus.  They  form  dense  or  porous 
white  layers,  frequently  showing  the  glistening 
crystals  of  the  triple  phosphate  on  the  surface. 
Such  masses  are  soluble  in  acids,  insoluble  in 
alkalis  or  water,  friable,  and  fusible.  They  de- 
velop rapidly,  and  may  reach  an  enormous  size. 

Treatment. — When  of  moderate  dimensions 
phosphatic  calculi  may  be  easily  removed  by 
lithotrity;  but,  as  it  is  often  difficult  to  insure 
the  removal  of  every  minute  particle,  and  as 


1164  PHOSPHORUS,  POISONING  BY. 
they  are  often  accompanied  by  chronic  cystitis 
and  deficient  expelling  power  of  the  bladder,  re- 
currence is  not  infrequent,  and  the  ultimate  re- 
sult unfavourable.  William  Cadge. 

PHOSPHORUS,  Poisoning  by. — Synon.  : 
Fr.  Intoxication  Phosphoree-,  Ger.  Phosphorver- 
giftwng. 

Phosphorus  acts  as  a poison  only  when  in  the 
form  of  yellow,  common,  or  soluble  phosphorus ; 
in  the  allotropic  form  of  red  or  insoluble  phos- 
phorus it  is  inert,  either  as  a therapeutic  or  as  a 
toxic  agent.  Poisoning  by  phosphorus  may  be 
either  acute  or  chronic. 

Acute  poisoning  by  phosphorus  has  recently 
become  not  uncommon  in  this  country.  On  the 
Continent  phosphorus,  in  the  form  of  the  tips 
of  lucifer  matches,  is  frequently  used  for  suicidal 
purposes.  In  England  phosphorus  is  most  com- 
monly taken  in  the  form  of  ‘rat  paste’  or  ‘phos- 
phorus paste,’  a vermin-destroyer  composed  of 
butter  or  other  fats  and  phosphorus,  coloured 
with  Prussian  blue.  Chronic  phosphorus-poison- 
ing from  the  inhalation  of  phosphorus  vapours 
has  long  been  recognised. 

Anatomical  Characters.  — These  are  well- 
marked,  and  consist  of  extreme  fatty  degenera- 
tion of  the  liver,  and  frequently  also  of  the  gastric 
mucous  membrane,  kidneys,  and  cardiac  muscular 
fibre.  The  liver  is  also  greatly  enlarged  and 
white ; and  the  organ  frequently  takes  fire  on 
the  mere  application  of  a spirit-lamp  flame.  On 
microscopical  examination  the  organs  affected 
are  seen  to  be  infiltrated  with  granular  fatty 
matter,  soluble  in  ether;  the  gastric  tubuli  are 
also  filled  with  granular  fat ; and  the  striated 
muscular  fibre  has  more  or  less  completely  lost 
its  normal  appearance,  and  been  converted  into 
a similar  granular  material. 

Symptoms. — 1.  Acute  Phosphorus-Poisoning. — 
On  swallowing  a phosphorus  mixture  a disagree- 
able taste  is  perceived,  which  is  occasionally  fol- 
lowed by  a burning  sensation  in  the  throat,  gul- 
let, and  stomach;  and  speedy  vomiting.  But 
these  signs  of  the  local  action  of  the  poison  may 
be  either  absent,  or  altogether  inconsiderable.  At 
any  rate,  as  a rule,  these  and  the  diarrhoea  and 
colicky  pains  described  by  some  writers,  soon  pass 
off,  leaving  the  patient  apparently  nearly  well ; 
though  a careful  examination  may  reveal  a small, 
feeble  pulse,  and  when  the  patient  is  questioned, 
the  existence  of  obscure  wandering  pains  may  bo 
admitted.  In  the  course  of  a few  days — usually 
two,  three,  four,  or  five — the  patient  becomes 
listless,  dull,  and  slightly  jaundiced.  There  is 
much  headache  and  sleeplessness,  together  with  a 
general  febrile  condition,  gradually  passing  into 
a ‘ typhoid’  state;  increasing  jaundice;  scanty, 
high-coloured,  biliary  urine ; and  a quick  and  very 
feeble  pulse.  Muttering  delirium  supervenes  ; 
there  may  be  violent  vomiting  of  yellow,  biliary 
mucus ; and  the  patient  gradually  sinks,  and  dies 
after  a day  or  two,  or  perhaps  three  or  more,  of 
acute  disease,  and  usually  within  a week  of  the 
administration  of  the  poison.  Death  may  occur, 
however,  at  any  period,  from  one  or  two  to  eight 
or  ten  days,  after  a fatal  dose  of  phophorus, 
which  may,  perhaps,  be  taken  as  half  a grain  for 
an  adult  person. 

Variations  from  the  above  course  of  symp- 


PHOTOPSIA. 

toms  may  be  noted.  In  one  class  of  cases  thi 
symptoms  betoken  a predominance  of  cervou; 
action.  Thus  there  are  cramps  and  pains  if 
the  limbs,  great  prostration  and  faintness,  con 
vulsions,  and,  finally,  coma.  In  another  class,  oc 
casionally  observed,  hsemorrhagic  symptoms  ar 
prominent,  such  as  bloody  vomits  and  haemor 
rhagic  diarrhoea.  As  an  early  symptom  a phos 
phorescent  condition  of  the  vomited  matters,  and 
more  rarely,  of  the  urine,  may  be  noted;  and  i: 
nearly  all  cases  a peculiar  garlicky  odour  oj 
the  breath  is  perceptible.  The  phosphorescent; 
or  luminosity  of  the  rejected  matters  is  of  conrs' 
best  seen  in  the  dark.  If  the  phosphorescen 
condition  of  the  vomit  exist,  this  permits  of  ml 
mistake  in  the  diagnosis ; but  if  this  condition  l 
absent,  the  garlicky  odour  of  the  breath,  and  ai 
enlarged  condition  of  the  liver,  greatly  aid  in  tb 
diagnosis. 

2.  Chronic  Phosphorus -poisoning.  — Chroni 
phosphorus-poisoning  consists  in  poisoning  b- 
phosphorus  vapours.  Workers  in  common  o 
yellow  phosphorus  exhibit  a singular  form  o 
disease,  from  which  workers  in  red  or  amorpheu 
phosphorus  are  exempt.  This  consists  in  cane 
of  the  teeth  and  necrosis  of  the  lower  jaw,  whicl 
appear  to  be  set  up  by  the  direct  access  of  th 
phosphorus  vapours  to  the  part,  since  those  per 
sons  only  are  affected  who  suffer  from  decave; 
teeth. 

Prognosis. — This  is  in  all  cases  very  unfavonr 
able,  and  no  general  rules  can  be  laid  down  re 
specting  it. 

Treatment. — We  know  but  little  respecting 
this.  Good  results  appear  to  be  obtained  fron 
the  administration  of  a magma  of  magnesia,  am 
the  use  of  mucilaginous  drinks.  The  best  results 
however,  have  followed  the  administration  of  oi 
of  turpentine,  which  some  regard  as  a specifi 
antidote  to  phosphorus.  It  may  be  given  i: 
doses  of  10  to  20  minims,  frequently  repeated. 

The  chronic  form  of  the  disease,  which  has  le: 
to  horrible  suffering  and  deformity,  may  be  pre 
vented  by  tho  use  of  red  instead  of  yellow  phos 
phorus  in  the  making  of  matches.  The  use  o 
inhalers,  and  the  impregnation  of  the  atmospher 
with  the  vapour  of  oil  of  turpentine,  are  alsi 
preventive  measures  of  great  service. 

Thomas  Stevenson. 

PHOTOPHOBIA  (<pas,  light,  and  <pi£loi 

fear). — Dread  or  intolerance  of  light;  a symptom 
more  or  less  constant,  of  most  forms  of  inflamma 
tion  of  the  eye.  In  its  most  pronounced  charaen 
it  occurs  in  what  is  called  ‘strumous  ophthal 
mis,’  or  phlyctenular  keratitis.  It  is,  however 
present  in  all  forms  of  inflammation  and  uleeia 
tion  of  the  cornea,  in  iritis  and  cyclitis,  andmor 
rarely  in  choroiditis  and  retinitis.  It  isalsoofte; 
met  with  in  many  diseases  of  the  nervous  system 
in  cerebral  irritation,  meningitis,  eerebritis,  &e 
and  in  many  pyrexial  states.  As  an  ophthalmi 
symptom,  it  may  occur  in  eyes  perfectly  blind 
and  is  probably  due  to  the  irritation  of  the  ciliar 
nerves  by  light.  See  £te  and  its  Appendages 
Diseases  of. 

PHOTOPSIA  (<fws,  light,  and  Sijns,' vision).^ 
The  subjective  sensation  of  flashes  of  light  0 
luminous  spectra,  due  to  an  abnormal  state  c 
some  part  of  tho  special  nervous  apparatus  c 


PHRENIC  NERVI 
(3  visual  sense.  It  is  a modification  of  the 
I'eeial  sensibility,  and,  like  photophobia,  may 
our  in  blind  eyes.  See  Vision,  Disorders  of. 

PHRENIC  NERVE,  Diseases  of. — Sr- 

iN. : Fr.  Maladies  du  Kerf  phrenique ; Ger. 
■ankheitcn  dcs  K erven  phrenicus. — The  prin- 
oal  disorders  affecting  the  phrenic  nerve  are 
•o,  namely,  1.  Paralysis;  and  2.  Spasm. 

1.  Paralysis.; — ^Etiology. — Paralysis  of  the 
■renic  nerve,  that  is,  of  the  diaphragm  which  it 
ipplies,  is  rarely  due  to  disease  of  the  nerve- 
ink.  Its  common  cause  is  disease  at  the  ori- 
ji  of  the  phrenic— the  anterior  grey  matter  of 
•a  spinal  cord  at  the  level  of  the  third  and 
:irth  cervical  nerves.  It  is  commonly  part  of 
late  or  chronic  spinal  myo-atrophy.  Paralysis 
s also  been  observed  by  Duchenne  in  lead 
Isy.  In  a few  cases  the  paralysis  has  been 
:parently  due  to  cold,  supposed  to  have  caused 
: rheumatic  inflammation  of  the  nerve-trunk, 
a few  cases,  also,  the  nerve  has  lost  its  func- 
n in  consequence  of  compression  in  the  neck. 
Anatomical  Characters. — Degeneration  of 
h trunk  of  the  nerve,  wasting  of  tho  nerve- 
ires,  and  increase  of  connective  tissue,  have 
3n  found  in  cases  of  disease  of  the  spinal  cord. 

1 the  anatomical  changes  due  to  other  causes 
idling  is  known. 

Symptoms.— The  evidence  of  paralysis  of  the 
renic  is  inaction  of  the  diaphragm.  When 

0 nerve  is  diseased  there  is  imperfect  action 

1 one  side,  and  this  may  be  conspicuous  or  in- 
stinct. When  both  nerves  are  affected,  as 
'commonly  the  case  in  central  disease,  there  is 
; entire  absence  of  the  normal  protrusion  of  the 
llominal  wall  during  inspiration ; there  may 
fen  be  a recession  of  tho  upper  part  of  the 
illomen,  and  a bulging  during  expiration  in 
t same  situation.  In  ordinary  breathing  the 
i piratory  actions  are  not  quickened  by  para- 
1 is  of  the  diaphragm,  but  if  any  exertions 
: made  the  respirations  become  more  frequent, 
lithe  extraordinary  muscles  of  respiration  are 
t'own  into  action.  All  spasmodic  respiratory 
cions — sneezing,  coughing — are  performed  with 
1)3  energy.  Little  inconvenience  is  experienced 
i ess  bronchitis  comes  on,  and  then  the  les- 
f ed  respiratory  power  may  place  the  patient 
i i condition  of  great  danger. 

Che  phrenic  nerve  is  accessible  to  direct  stimu- 
1 on  in  the  root  of  the  neck,  and  when  it  is 
falysed,  its  irritability  is  usually  lost,  and  the 
c pliragm  can  no  longer  be  made  to  contract. 
1 rare  cases,  however,  the  nerve-trunk  retains 
i irritability. 

'Diagnosis.-— The  diagnosis  of  paralysis  of  the 
ephragm  is  not  always  so  simple  a matter  as 
r;ht  be  supposed.  Its  action  should  be  looked 
f;  not  only  in  deep  breathing,  but  in  ordinary 
fpiration.  Many  persons,  if  told  to  ‘ take  a 
c p breath,’  do  not  put  the  diaphragm  into 
8 on  at  all.  In  forced  breathing  the  chief 
via  action  takes  place  in  the  upper  part  of  the 
c st,  to  which  most  of  the  muscles  of  extra- 
c inary  respiration  are  attached.  It  is  probable 
t t the  centres  for  normal  and  extraordinary 
hithing  are  functionally  not  identical,  and 
t 'j  the  diaphragm  is  chiefly  represented  in  the 
f ner,  so  that  it  does  not  necessarily  act  in 


I,  DISEASES  OF.  1165 

deep  breathing.  There  is  a mechanical  reason 
for  this.  In  the  extreme  action  of  the  inter- 
costal muscles  the  thorax  is  widened  to  such  a 
degree,  that  the  diaphragm  becomes  less  curved 
by  tho  movement  outwards  and  elevation  of 
its  points  of  attachment,  so  that  its  contraction 
does  not  effect  much  additional  enlargement  of 
the  capacity  of  the  thorax.  Hence,  in  many  per- 
sons, without  any  paralysis  of  the  diaphragm,  if 
a deep  inspiration  is  taken,  the  epigastrium  does 
not  advance  ; may  even  recede,  in  consequence 
of  the  movement  of  the  lower  ribs.  This  is  es- 
pecially the  case  in  women,  in  whom  breathing 
is  always  less  diaphragmatic  than  it  is  in  men. 
In  them,  too,  conscious  attention  to  the  act  of 
breathing  is  apt  to  arrest  the  action  of  the  dia- 
phragm. The  tendency  of  voluntary  breathing 
is  to  be  costal  rather  than  diaphragmatic,  no 
doubt  because  the  centre  for  extraordinary 
breathing,  which  is  chiefly  voluntary,  is  brought 
partially  into  action.  In  a woman  under  the 
writer’s  care,  paralysis  of  tho  diaphragm  was 
suspected,  and  during  two  separate  and  prolonged 
examinations  not  the  slightest  action  could  be 
observed.  On  a third  examination,  however, 
more  normal  conditions  were  obtained,  and  the 
action  of  the  diaphragm  was  natural.  This  is 
the  condition  which  has  been  termed  ‘ hysterical 
paralysis  of  the  diaphragm.’ 

It  must  not  be  forgotten  that  immobility  of 
the  diaphragm  may  result  from  other  causes 
than  paralysis  of  the  phrenic  nerve.  In  dia- 
phragmatic pleurisy,  for  instance,  its  movement 
is  lessened  by  a reflex  inhibitory  effect  of  the 
pain.  In  emphysema  of  the  lungs,  in  which  the 
thorax  is  greatly  widened,  the  contraction  of  the 
diaphragm  produces  less  effect-than  in  health. 

On  the  other  hand,  when  the  diaphragm  ia 
really  paralysed,  a doubt  may  arise  as  to  whether 
it  moves  or  not.  This  is  due  to  the  circum- 
stance that  the  movement  of  the  lower  ribs  may 
drag  forward  the  abdominal  parietes  close  to 
them,  and  so  the  protrusion  due  to  descent  of  the 
diaphragm  may  be  simulated.  This  is  especially 
the  case  when  the  abdomen  is  collapsed,  so  that 
when  the  patient  is  recumbent  its  level  is  con- 
siderably below  that  of  the  ensiform  cartilage. 
This  movement  may  be  distinguished  from  that 
due  to  the  descent  of  the  diaphragm  by  a little 
care : the  movement  is  confined  to  the  proximity 
of  the  thorax,  and  there  is  not  the  general  move- 
ment of  the  abdominal  viscera  and  parietes  which 
results  from  the  contraction  of  the  diaphragm. 

Prognosis. — The  prognosis  of  paralysis  of  the 
diaphragm  is  favourable  in  the  rare  instances 
which  are  due  to  exposure  to  cold ; rather  less 
favourable  in  lead-poisoning.  It  is  unfavourable 
when  part  of  progressive  spinal  myo-atrophy. 
When  due  to  acute  spinal  myc-atrophy  (anterior 
cornual  myelitis)  the  prognosis  will  depend  on 
the  indication  afforded  by  other  symptoms  of 
the  position  of  the  chief  disease,  whether  the 
region  from  which  the  phrenic  nerve  arises  is 
gravely  or  slightly  damaged.  When  paralysed 
from  compression  the  prognosis  depends  on  the 
nature  and  origin  of  the  pressure. 

Treatment. — The  treatment  of  the  paralysis, 
which  is  part  of  the  spinal  myo-atrophy,  is  that 
of  the  central  disease.  In  all  cases  causal  in- 
dications must  be  met.  When  due  to  cold,  sina- 


1166  PHRENITIS. 

pisms  should  he  applied  over  that  part  of  the 
phrenic  nerve  which  seems,  from  any  attendant 
pain,  to  he  chiefly  affected.  If  the  nerve  has  not 
lust  its  irritability,  it  may  he  faradised  systema- 
tically. The  points  to  which  the  rheophores 
should  be  applied  are  one  on  the  neck,  just  above 
the  scaleni,  and  one  near  the  diaphragm.  A 
strong  current  has  to  be  used. 

2.  Spasm. — Spasm  of  the  diaphragm  occurs 
chiefly  in  the  form  of  hiccup,  and  as  part  of  the 
respiratory  spasm  in  hydrophobia,  and  does  not 
reed  special  description.  See  Diaphragm,  Dis- 
eases of ; IIicccp;  and  Hydrophobia. 

W.  E.  Gowers. 

PHRENITIS  (<ppyv,  the  mind). — An  obso- 
lete term,  formerly  associated  with  all  forms  of 
acute  inflammation  of  the  brain  or  its  meninges, 
but  especially  the  latter. 

PHTHIRIASIS  {<pOe)p,  a louse). — Svnon.  : 
Pediculosis ; Fr.  Phtkiriase ; Ger.  Ldusesucht. — 
This  disease  of  the  skin  bears  the  same  relation 
to  the  pediculus  that  scabies  does  to  the  aearus 
scabiei. 

Description.  — There  are  three  varieties  of 
phthiriasis,  corresponding  to  the  three  species 
of  pediculi  that  infest  the  human  body.  See 
Pediculus. 

1.  Phthiriasis  capitis.— Phthiriasis  affect- 
ing the  head  is  met  with  chiefly  in  children.  The 
eruption  is  an  artificial  pustular  eczema,  due  to 
the  irritation  of  the  insect,  and  the  scratching  of 
the  sufferer ; in  consequence  of  the  sores  on  the 
scalp,  the  superficial  lymphatic  glands  at  the  back 
of  the  neck  often  become  enlarged. 

2.  Phthiriasis  corporis. — Phthiriasis  of  the 
body  is  confined  to  the  parts  covered  by  the 
clothes,  and  is  most  developed  on  the  back.  It 
is  especially  met  with  in  the  old  and  feeble.  The 
lesions  of  the  skin  consist  of  small  excoriations 
and  scattered  papules,  whose  tops  are  seen  to  be 
torn  and  bleeding  from  the  scratching  of  the  suf- 
ferer. These  bleeding  papules  give  to  the  erup- 
tion its  characteristic  appearance.  In  chronic 
cases  the  general  colour  of  the  skin  is  darkened 
from  an  excessive  deposit  of  pigment. 

3.  Phthiriasis  pubis. — This  variety  of  phthi- 
riasis differs  little  from  that  of  the  body,  except 
that  it  is  limited  to  the  regions  infested  by  the 
crab-louse. 

All  three  varieties  of  the  disease  are  attended 
with  intolerable  itching. 

Treatment. — Phthiriasis  is  easily  cured  by 
means  of  an  ointment  containing  one  part  of  the 
oil  of  delphinium  staphysagria  and  seven  parts 
of  lard.  E.  Liveing. 

PHTHIRIUM  INGUINALE  (<p6elp,  a 
louse).— One  of  the  synonyms  of  the  pediculus 
pubis,  or  crab-louse.  See  Pediculi. 

PHTHISIS  ((pOimp.ou,  I waste). — Synon.  : 
Consumption;  Fr.  Phthisis;  Ger . Schwind-sucht. 

Definition.  — Phthisis,  or  consumption,  is 
the  term  used  to  designate  a disease  charac- 
terised by  progressive  wasting  of  the  body; 
persistent  cough,  with  expectoration  of  opaque 
matter  and  sometimes  of  blood ; loss  of  colour 
and  strength,  shortness  of  breath ; hectic  fever, 
night  sweats,  and  diarrhoea ; these  symptoms 
being  associated  with  certain  well-marked  patho- 


PHIHISIS. 

logical  changes  in  the  lungs,  namely,  the  forma- 
tion of  consolidations  in  a granular  or  diffuse 
form ; which  either  undergo  caseation  and  dis- 
integration, leaving  behind  excavations  in  the 
lung-tissue  ; or,  becoming  indurated  and  shrink- 
ing. cause  contraction  of  the  affected  organ. 

./Etiology. — The  conditions  which  give  ris« 
to  phthisis  are  varied  and  diverse  ; but  by  trac- 
ing out  their  mode  of  action  on  the  individual, 
we  arrive  at  a twofold  arrangement  into  general 
and  local  causes.  In  the  general,  the  constitu- 
tion of  the  individual,  and  the  functions  of  nutri- 
tion and  assimilation,  appear  to  be  first  involved. 
In  the  local,  the  lungs  are  the  primary  seat  of 
disease,  and  changes  in  their  epithelium  and 
parenchyma  lead  to  products  of  a retrograde 
kind,  through  which  the  lymphatic  and  vascular 
systems,  and  the  constitution  generally,  become  in- 
fected. The  general  maybe  called  constitutional, 
and  the  local  inflammatory.  General  causes  are 
those  which  affect  the  whole  system,  such,  for 
example,  as  family  predisposition ; fevers  and  ex- 
anthemata ; syphilis ; insufficient  food ; alcohol ; 
bad  ventilation ; climatic  influences ; dampness 
of  soil ; infection  ; &c.  Amongst  local  causes 
are  to  be  enumerated  inflammatory  affections  of 
the  lungs  and  pleura ; trades  and  occupations 
giving  rise  to  a gritty  atmosphere  ; and  injuries 
to  the  chest.  We  must  bear  in  mind  that  a cause 
may  act  in  two  capacit  ies,  locally  and  generally ; 
for  instance,  scarlatina  may  cause  enlargement 
of  various  lymphatic  glands  throughout  the 
body,  and  render  the  individual  liable  to  the  for- 
mation of  tubercle  generally ; or  scarlatina  may 
leave  behind  it  consolidation  of  portions  of  the 
lungs,  which  may  result  in  caseation,  whence 
may  arise  tubercular  infection  of  the  system. 

The  most  important  causes  of  phthisis  will 
now  be  individually  discussed. 

1.  Pamily  predisposition. — The  influence  of 
heredityas  a cause  of  phthisis  cannot  be  doubted: 
it  has  been  abundantly-proved  by  observation 
and  experiment  on  both  man  and  the  lower 
animals.  The  term  family  predisposition  is 
substituted  for  hereditary  predisposition,  be- 
cause the  latter,  from  its  limitation  to  direct 
descent,  necessitates  the  omission  of  the  evidence 
of  disease  in  collateral  relatives.  The  statistics 
of  the  first  Brompton  Hospital  Report  on  this 
point,  as  compiled  by  Dr.  Quain,  who  contrasted 
them  at  the  same  time  with  the  statistics  of  in- 
sanity, and  those  also  of  Drs.  Cotton  and  Fuller, 
show  that  among  the  lower  classes  hereditary 
predisposition  (that  is,  where  one  or  both  parents 
were  affected)  was  traced  in  2d  per  cent.  The 
writer's  researches  among  1,000  eases  of  the 
upper  classes  show  12  per  cent,  of  direct  here- 
ditary predisposition,  and  48  per  cent,  of  family 
predisposition. 

Family  predisposition  is  more  common  among 
women  than  men,  in  the  proportion  of  57  to  43, 
which  may  be  accounted  for  by  the  more  seden- 
tary and  less  invigorating  life  of  the  former. 
The  transmission  of  phthisis  is  more  common 
through  the  mother  than  through  the  father ; bnt 
where  one  parent  alone  is  affected,  fathers  trans- 
mit more  readily  to  sons,  and  mothers  to  daugh- 
ters than  the  converse.  Dr.  Pollock  lays  stress 
on  the  influence  of  hereditary  predisposition  in 
the  acute  forms  of  phthisis,  and  states  that  on) 


PHTHISIS.  1167 


f 179  cases  only  34  could  positively  declare 
bsence  of  family  taint.  The  principal  effect, 
owever,  of  family  predisposition  is  to  be  seen, 
:.ot  in  any  peculiarity  of  symptoms,  but  by  the 
iifluence  it  exercises  over  the  age  of  attack.  The 
•riter’s  researches  show  clearly  that  this  is  much 
arlier  in  patients  so  predisposed  than  in  others; 
nd  in  females  this  influence  is  greater  than  in 
dales 

2.  Local  infection. — Chronic  inflammatory 
flections  of  organs  and  textures  leading  to  the 
irmation  of  caseous  centres. — Examples  of  this 
.ass  may  be  found  in  cases  of  impetigo  in  children, 
lading  to  enlargement  and  caseation  of  the  cer- 
'ical  glands  ; in  the  so-called  scrofulous  diseases 
f the  joints ; and  in  psoas  and  lumbar  abscess. 

3.  Acute  febrile  diseases.  — Continued 
ivers,  measles,  and  scarlatina  act  partly  by  ex- 
acting the  system,  and  partly  by  bequeathing 
> the  individual  the  legacy  of  caseous  matter 
ther  in  the  lungs  or  glands,  which  prove  the 
■ntres  of  subsequent  tuberculisation. 

4.  Syphilis. — Syphilis,  by  its  debilitating  in- 
uence,  predisposes  to  phthisis ; but  it  also  ap- 
ears  to  act  as  a cause  capable  of  developing  two 
■rms  of  the  disease,  namely  (1)  limited  con- 
ilidation  with  no  great  tendency  to  excavation  ; 
lid  (2)  a form  of  laryngeal  phthisis,  characterised 
|r  ulcers  in  the  larynx  and  in  the  pharynx, 
fficult  to  heal  except  by  specific  treatment, 
jiis  last  has  been  called  syphilitic  disease  of 

e larynx;  but  as  in  the  writer’s  experience 
is  always  associated  with  tubercle  in  the  lungs, 
i thinks  that  the  phthisis  is  caused  by  the 
philis,  and  should  be  classed  accordingly. 

5.  Debilitating  conditions. — Miscarriages, 
.favourable  confinements,  over-lactation,  insuf- 
jent  food,  and  alcoholism  are  recognised  causes ; 
t the  cessation  of  habitual  discharges  is  not 
clearly  admitted.  The  stoppage  of  the  dis- 
urge of  a fistula  in  ano,  and  the  drying  up  of 

old  ulcer,  are  frequently'  followed  by  an  out- 
eak  of  tuberculosis  in  the  lungs. 

C.  Mental  depression. — This  is  often  mixed 
with  other  causes,  hut  occasionally  acts  alone. 
7.  Bad  ventilation. — Dr.  Guy  has  shown 
it  consumption  is  more  rife  among  persons  of 
door  occupations  than  among  those  employed 
' : of  doors ; this  being  true  not  only  of  the 
ljier  classes,  as  printers,  compositors, and  tailors, 
i.  also  of  the  tradesmen  who  live  in  hot  gaslit 
tops,  and  often  sleep  in  miserably  ventilated 
llrooms.  These  are  not  ill- fed,  but  are  never- 
tless  twice  as  liable  to  consumption  as  the 
i|)er  classes.  Hawkers  and  other  outdoor 
tdes,  though  much  exposed  to  catarrh,  are 
flwn  to  be  less  liable  to  consumption  than 
i oor  workers.  Of  nearly  6,000  cases  of  phthisis 
ajaitted  into  the  Brompton  Hospital  during 
t years,  two-thirds  had  indoor  occupations. 
i'  ongst  them  milliners,  sempstresses,  and  tailors 
Ijiish  the  largest  quota,  who  all  live  in  close 
r,ns,  to  which  they  are  almost  entirely  con- 
fid. 

. Climatic  influences.  — A moist  atmo- 
S'ereismore  favourable  to  the  development  of 
c|  sumption  than  a dry  one  ; and,  while  we  recog- 
that  the  combination  of  cold  and  moisture 
i-Ae  of  the  principal  causes  of  the  inflammatory 
h is  of  the  disease  in  Great  Britain,  the  testi- 


mony of  Dr.  Guilbert  indicates  that  a combi- 
nation of  heat  and  moisture,  as  exemplified  in 
the  littoral  of  Peru,  in  the  West  Indies,  &rc., 
produces  an  acute  form  of  consumption,  largely 
prevalent  in  those  districts,  attacking  the  abdo- 
minal organs  in  addition  to  the  lungs. 

9.  Dampness  of  soil.  — The  researches  of 
Dr.  Buchanan  have  demonstrated  that  the  death- 
rates  from  phthisis  in  the  districts  of  Surrey, 
Kent,  and  Sussex,  depend  to  a great  extent  on 
the  geological  formation  of  the  soil ; for  while  in 
the  light  and  sandy  strata,  deaths  from  phthisis 
are  rare,  in  the  heavy  impermeable  ones,  in 
which  clay  predominates,  the  mortality  from 
this  cause  is  high.  The  conclusion  that  wetness 
of  soil  is  a cause  of  phthisis  to  those  living  on 
it,  has  been  confirmed  by  the  Eegistrar-Gcneral 
of  Scotland,  and  by  Dr.  Bowditch  of  the  United 
States ; the  latter  testifying  that  this  law  holds 
good,  not  only  as  regards  villages  and  towns, 
but  eveu  as  regards  individual  houses — the 
houses  on  clay  becoming  the  foci  of  consumption, 
while  others  but  slightly  removed  from  them, 
but  on  a dry  soil,  wholly  escape. 

10.  Inoculation. — From  the  time  of  Laennec 
until  the  present,  experiments  have  been  carried 
on  by  numerous  observers  to  ascertain  whether 
tubercle  is,  or  is  not,  inoculable  ; and  the  results 
of  these  experiments  prove  that  in  guinea-pigs 
and  rabbits  tubercle  can  he  produced  artificially 
by  the  insertion  underneath  the  skin,  not  only  of 
tubercle,  hut  of  various  other  materials,  such 
as  pus,  putrid  muscle,  and  diseased  liver,  taken 
from  non-tubercular  subjects.  There  was  nothing 
specific  in  the  results  of  the  inoculations,  for  the 
materials  most  efficient  in  producing  artificial 
tubercle  were  those  taken  from  low  pneumonia, 
pyaemic  abscess,  &c.  ; while  human  tubercle, 
phthisical  sputa,  foul  pus,  and  putrid  muscle 
were  less  successful,  bio  results  were  obtained 
from  the  material  of  acute  sthenic  pneumonia, 
from  pneumonic  and  bronchitic  sputa,  healthy 
abscess,  diphtheritic  membrane,  syphilis,  typhoid 
intestine,  and  cancer.  It  was  found  by  Dr.  Burdon 
Sanderson  that  tuberculosis  might  he  induced  in 
the  guinea-pig  by  the  insertion  of  a cotton  thread 
under  the  skin,  hut  if  the  seton  was  steeped  in 
carbolic  acid,  no  tubercle  was  produced.  To 
ascertain  the  results  of  mechanical  injury  with- 
out exposure  to  air,  the  scapulae  of  guinea- 
pigs  were  fractured  subcutaneously.  No  tuber- 
culosis resulted.  It  is  evident,  from  these 
experiments,  that  tubercle  is  not  so  potent  for 
infective  purposes  as  many  other  materials,  and 
especially  those  of  a septic  nature,  such  as  pyaemic 
pus  and  putrid  muscle  ; and  this  is  still  further 
borne  out  by  the  seton  experiments,  where  the 
purification  of  the  wound  by  carbolic  acid  appears 
to  have  prevented  the  infective  process,  as  also 
by  the  cases  in  which  the  scapulae  were  fractured. 
These  facts  warrant  the  conclusion  that  tuber- 
culosis is  closely  associated  with  pyaemia,  and 
among  animals  the  difference  between  these  two 
diseases  would  appear  to  be  one  merely  of  de- 
gree ; for  Dr.  Sanderson  found  that  while  the 
injection  of  pus  into  rabbits  produced  death 
from  pyaemic  abscesses  in  forty-eight  hours  in 
some,  in  others  the  slower  results  of  tubercu- 
losis followed.  This  process  generally  consistod 
in  the  development  of  granulations  at  the  seat 


PHTHISIS. 


1163 

of  inoculation,  from  which  tho  neighbouring 
lymphatics  became  infected,  and  this  led  to  a 
dissemination  of  the  products  through  both  the 
lymphatic  and  circulatory  systems. 

Chauveau  found  that  heifers  might  be  infected 
by  mixing  tuberculous  matter  from  their  own 
species  with  their  food.  Bollinger  confirmed 
this  experiment,  but  found  that  carnivora  could 
be  fed  with  impunity  on  fresh  tuberculous  mat- 
ter taken  from  animals  of  the  bovi.ne  species. 

11.  Infection. — The  idea  of  infoetion  being  a 
cause  of  phthisis  still  prevails  in  the  South  of 
Europe,  and  has  lately  been  revived  by  Dr.  Budd 
in  England.  The  evidence  of  the  Brompton  Hos- 
pital negatives  the  idea  of  a contagion  such  as  is 
present  in  small-pox  or  scarlet  fever ; for  it  has 
been  demonstrated  that  the  percentage  of  ac- 
quired phthisis  occurring  among  the  resident  staff 
of  the  institution  is  less  than  that  of  most  general 
hospitals.  An  infective  influence  may  arise  from 
the  expectoration  of  advanced  cases  of  phthisis 
or  of  bronchitis,  whicli  should  bo  counteracted 
by  antiseptics  and  good  ventilation.  That  phthisis 
may  be  communicated  from  husband  to  wife  is 
strongly  maintained  by  Virchow  and  many  Eng- 
lish physicians,  and  Dr.  Hermann  Weber  has 
lately  indicated  by  some  striking  cases  the  danger 
of  pregnancy  to  the  wife  of  a consumptive. 

Cohnheim,  who  appears  to  liavo  confirmed  by 
his  own  experiments  the  doctrine  of  specific  in- 
fection, holds,  in  opposition  to  the  above  views, 
that  the  test  of  tubercle  is  its  inoculability, 
and  prefers  this  to  any  structural  test.  He  con- 
siders that  tubercular  particles  are  conveyed  by 
means  of  organisms  to  the  lungs,  thus  affecting 
the  pleura  and  bronchial  glands,  and  later  the 
larger  bronchi.  The  infection  of  the  intestinal 
canal  arises  from  swallowing  the  sputum. 
Cohnheim  believes  strongly  in  infection  through 
suckling,  and  states  that  he  has  noticed  scrofulous 
inflammation  of  the  mouth  and  pharynx  arise  in 
that  way.  Weigert  maintains  that  meningitis  has 
been  caused  by  infection  through  the  upper  nasal 
passages. 

12.  Local  causes.  — The  local  causes  of 
phthisis  are  those  which  injuriously  affect  the 
bronchi  and  air- passages,  causing  large  epithelial 
proliferation  and  various  inflammatory  lesions, 
followed  by  thickening  and  induration  of  the 
alveolar  walls,  and  in  time  caseation  or  fibrosis. 

Bronchitis , or  bronchial  catarrh,  after  existing 
for  many  years  in  a person,  may  extend  more 
deeply  into  the  alveoli  and  pass  into  a so-called 
catarrhal  pneumonia,  producing  consolidation 
and  eventually  excavation  of  the  lung.  Bron- 
chitis was  the  origin  in  nearly  12  per  cent,  of 
the  writer’s  1 ,000  cases ; and  a very  large  num- 
ber of  the  poorer  classes  trace  their  disease  to 
neglected  catarrh. 

Pneumonia  is  a fruitful  source  of  phthisis, 
though  some  forms  are  more  capable  of  giving 
rise  to  it  than  others.  In  croupous  pneumonia, 
where  the  exudation  is  fibrinous,  and  has  but 
little  epithelium  or  leucocytes  intermingled  with 
it,  absorption  generally  follows,  if  the  patient’s 
constitution  be  in  a fair  state,  and  few  of  these 
cases  go  into  phthisis ; but  where  leucocytes  and. 
epithelial  products  largely  predominate,  absorp- 
tion is  slow,  the  pneumonia  becomes  chronic,  and 
thickening  of  the  alveolar  wall  and  caseation  of 


the  epithelium  take  place,  accompanied  sooner 
or  later  by  the  signs  and  symptoms  of  consump- 
tion. A third  form  of  pneumonia  which  may  ori- 
ginate consumption  is  pleuropneumonia,  or  inter- 
stitial pneumonia,  where  the  inflammation  extends 
to  the  pleura,  and  the  interlobular  connective 
tissue  is  largely  increased.  Many  instances,  too. 
of  phthisis  have  arisen  in  empyema,  through  ab- 
sorption of  the  purulent  fluid,  the  channels  being 
the  elaborate  network  of  lymphatics  which  the 
pulmonary  pleura  has  been  shown  by  Dr.  Klein 
and  others  to  contain. 

13.  Trades  and  occupations  giving  rise  tc 
a dusty  or  gritty  atmosphere. — The  constant 
inhalation  of  particles  of  flint,  iron,  coal,  haru 
clay,  and  even  of  cotton,  flax,  and  straw,  as  is 
the  case  in  certain  trades,  such  as  stonemasons, 
fork-  and  needle-grinders, colliers,  potters, cotton- 
carders,  chaff-cutters,  and  others,  has  beer 
shown  by  Dr.  Greenhow  to  induce  the  disease 
The  various  irritating  particles  have  been  de- 
tected microscopically  and  chemically  in  the} 
lungs,  where  they  appear  to  cause  great  irriti- 
tion,  followed  by  thickening  of  the  bronchi  andi 
subsequent  induration  of  the  lung-tissue,  wiriij 
increase  of  pigment.  Intermingled  in  the  con- 
solidations are  found  grey  and  yellow  tubercle, 
and  also  extensive  cavities,  proving  the  identity 
of  the  disease  with  phthisis. 

14.  Injuries  to  the  lungs. — Injuries  to  the! 
lungsthrough  wounds  are  somewhat  rare  causes oi 
phthisis;  and  their  action  is  chiefly  by  inducing 
the  inflammatory  processes,  chronic  suppuration 
and  abscess,  or  induration  with  shrinking  of  the 
lung-tissue. 

Anatomical  Charactehs.— The  morbid  ana- 
tomy of  phthisis,  acute  and  chronic,  presents 
considerable  difficulties,  partly  from  the  variety 
of  pathological  products,  and  partly  from  the 
complete  disorganisation  of  the  normal  structure 
and  even  of  the  invading  growths.  It  often  hap- 
pens that  several  processes  have  been  going  on  it; 
the  lungs  simultaneously,  each  of  which  brings 
about  the  work  of  destruction  by  a different 
method  and  at  a different  rate,  some  by  obstruc- 
tion through  consolidation,  others  by  caseation 
and  excavation.  On  the  predominance  of  oneoi 
the  other  depends  the  future  of  the  lungs,  for  we 
sometimes  see  one  pathological  element  which 
has  invaded  a large  portion  of  these  organs 
superseded  and  gradually  destroyed  by  another  o; 
more  recent  date,  but  endowed  with  a higher  de- 
gree of  vitality. 

In  advanced  cases  the  lungs  are  for  the  mosf 
part  devoid  of  vesicular  tissue,  and  consolidatec 
by  various  kinds  of  growths  and  exudations 
They  are  also  occupied  by  cavities,  varying  ir 
size  from  a microscopic  point  to  ODe  of  so  large 
a capacity  that  the  lung  is  converted  into  r 
mere  hag  of  thickened  pleura.  The  cavities  art 
of  every  conceivable  form  and  shape,  sometime; 
oval  and  well-defined,  lined  with  a secreting 
membrane,  at  other  times  irregular,  sinuous,  an 
fractuous,  and  presenting  on  section  either  ai 
uneven  surface,  from  which  portions  of  the  wal 
stand  out  like  the  column®  carne®  of  the  heart 
or  a very  rugged  surface,  on  which  ulceratioi 
and  suppuration  appear  to  have  done  thei 
worst ; but,  whatever  be  their  shape  or  thei 
size,  they  indicate  the  destructive  character  o 


PHTHISIS. 


:he  retrograde  processes  by  which  the  disease 
•ailed  pulmonary  consumption  is  characterised. 

The  consolidations  vary,  but  all  partake  more 
,r  less  of  a tubercular  character.  In  some  cases 
{he  lungs  are  disseminated  with  miliary  tuber- 
les  from  apex  to  base,  the  intervening  tissue 
ieing  free  from  excavation,  and  either  engorged 
r consolidated  with  red  hepatization,  or  some- 
imes  apparently  healthy;  in  others  no  trace  of 
piliary  tubercle  can  be  found,  but  the  lungs  are 
ansolidated  throughout  by  caseous  pneumonia, 
ijntaining  cavities  of  various  sizes.  Sometimes 
nere  are  aggregations  of  the  different  forms  of 
lbercles — white,  grey,  and  yellow  in  the  same 
ing— while  the  opposite  lung  may  bo  entirely 
ear ; sometimes  a lung  may  be  shrunk  to  the 
Jze  of  a fist,  its  pleura  thickened,  its  lobules 
ivaded  with  white  fibrous  bands,  its  tissue 
inverted  into  an  iron-grey  structure  by  fibroid 
iowth.  All  these,  and  many  other  diverse  mor- 
|d  appearances,  are  found  in  the  lungs  of  per- 
;ins  dying  of  phthisis,  and  we  must  classify  and 
stinguish  them,  first  describing  their  naked-eye 
ipearances;  secondly,  their  histological  phe- 
)mena;  thirdly,  we  must  consider  the  changes 
hich  take  place  in  other  organs  of  the  body ; 
id  fourthly,  wo  must  indicate  the  pathological 
lation  these  all  bear  to  one  another  and  to  the 
sease  generally. 

The  pri  nci pal  pathological  element  s and  changes 
a; — 1,  grey  and  dark  granulations,  or  miliary 
bercles  ; 2,  white  granulations  ; 3,  yellow 

anulations,  or  yellow  tubercle  ; 4,  caseous 

isses,  or  yellow  infiltration  ; 5,  grey  infiltra- 
' n,  or  catarrhal  pneumonia ; 6,  red  hepatisa- 
|n ; 7,  fibrosis  ; 8,  cretaceous  masses  ; 9,  fibri- 
ns nodules  (blood-residues) ; and  10,  vesicular 
f physema. 

1.  Grey  granulations,  or  miliary  tuber- 
c s. — These  vary  in  size  from  a millet-seed 
( nee  the  name  miliary)  to  a hemp-seed,  scat- 
tad  throughout  the  lung-tissuo.  When  first 
f med  they  are  greyish-white,  more  or  less  trans- 
p ent,  and  will  yield  to  firm  pressure  ; but  after 
a hilethey  either  undergo  caseation,  being  con- 
vied  into  the  yellow  variety,  or  losing  moisture, 
borne  drierand  harder, attaining  the  consistency 
oaartilage.  At  the  same  time  pigment  is  ab- 
smed  by  them ; the  colour  passes  from  a light  to 
a rk grey,  and  to  black;  the  granulations  simul- 
tf : ously  drying  up  and  becoming  obsolescent. 
Tjse  hard  grey  granulations  are  not  uncom- 
mlly  found  after  death  in  old  persons,  and  are 
ai  valence  of  tubercle  having  appeared  at  some 
ptpd  of  their  lives,  and  of  its  having  after- 
w ls  become  obsolescent. 

'ore  commonly  these  grey  granulations  in- 
erse  in  number,  and  form  aggregations  or  clus- 
te  much  resembling  bunches  of  berries,  stand- 
in, ,iut  in  bold  relief  against  the  healthy  or  con- 
ge d lung-tissue  ; their  principal  locality  being 
th  pper  lobes  of  the  lungs,  and  especially  the 
poirior  portions.  In  some  instances  this  ag- 
p . tion  spreads  quickly  and  extensively,  and 
lln  rhole  lungs  become  so  densely  packed  with 
mi  ry  tubercle  that  it  is  difficult  to  find  any 
foi  m of  the  respiratory  surface  free.  This 
r)h  formation  of  tubercle  is  sometimes  suffi- 
tle ; to  cause  death  by  asphyxia,  but  more  com- 
910  ' the  intense  crow'ding  of  the  pathological 

74 


1169 

products  gives  rise  to  their  destruction.  Casea- 
tion commences  in  the  centre  of  the  groups,  und 
cavities  subsequently  form.  The  discrete  form  of 
grey  tubercle  is  generally  found  in  acute  miliary- 
tuberculosis,  and  does  not  vary  much  in  size 
with  the  different  organs  attacked  by  tubercle, 
ns  the  peritoneum,  pleura,  &c.  This  identity  of 
form  suggests  very  forcibly  the  hyperplasia  of 
some  normal  structure  present  in  all  the  several 
organs,  rather  than  an  adventitious  growth. 

2.  White  granulations. — These  formations 
are  more  opaque,  and  softer  than  the  grey',  and 
differ  from  the  latter,  as  we  shall  hereafter  see, 
in  the  arrangement  of  the  histological  elements, 
there  being  more  epithelium  and  less  reticular 
growth  in  them  than  in  the  grey  variety. 

3.  Yellow  granulations. — Yellow  granula- 
tions or  yellow  tubercles  exist  in  greatly  varying 
sizes,  from  a pin’s  head  to  a pea.  They  are 
opaque,  soft,  granular,  amorphous,  easily  sepa- 
rated from  the  adjoining  tissue,  and  sometimes 
surrounded  by  a circle  of  pearly,  transparent 
material.  Dr.  Wilson  Fox  describes  a form  of 
yellow  tubercle  among  children  dying  of  acute 
tuberculosis,  which  is  with  difficulty  separated 
from  the  parenchyma  of  the  lungs ; but  in  adults 
it  is  generally  easily  removed,  the  grey  granula- 
tions with  which  it  is  so  often  associated  remain- 
ing behind. 

Yellow  granulation  is  by  far  the  commonest 
form  of  tubercle,  and  its  frequent  occurrence  in 
phthisis  led  Laennec  not  unnaturally  to  the  con- 
clusion that  it  was  a sui  generis  production,  es- 
sential to  the  disease.  It  seldom  occurs  alone, 
but  is  ordinarily  associated  with  the  grey  and 
white  granulations,  sometimes  forming  with  them 
racemose  groups  in  various  parts  of  the  lung, 
chiefly  in  the  upper  lobes.  At  other  times  it  is 
the  centre  of  an  affected  portion,  groups  of  grey- 
granulations  apparently  radiating  from  it,  thus 
naturally  leading  to  the  supposition  that  a species 
of  local  infection  has  been  set  up  by  the  yellow 
or  caseous  mass.  These  groups,  as  theyinerease, 
exercise  great  pressure  on  the  various  granula- 
tions composing  them  and  on  the  intervening 
lung-tissue,  depriving  them  of  nutrition,  and 
ihus  causing  death  of  the  part  by  caseation.  The 
decayed  portion  is  gradually  removed  either  by 
absorption  by  the  lymphatics,  or  by  expectoration ; 
in  the  latter  case  cavities  result.  Careful  study 
of  one  of  these  tubercular  groups  will  demonstrate 
that  the  yellow  tubercle  is  but  a later  condition 
of  the  grey,  in  which  caseation  has  commenced; 
and  that  the  cavities,  large  or  small,  in  its  neigh- 
bourhood are  the  result  of  the  softening  and  re- 
moval of  the  yellow  tubercle,  and  whatever  lung- 
tissue  happens  to  be  intermingled  with  it. 

4.  Caseous  masses. — Caseous  masses  and 
yellow  infiltration  are  identical  in  constitution 
with  the  yellow  tubercle,  but  differ  in  size  and 
form,  arising  sometimes  from  the  aggregation  of  a 
number  of  yellow  granulations,  but  oftener  from 
the  rapid  caseation  of  inflammatory  exudations  ; 
and  in  this  case  whole  lobes  become  affected 
with  what  is  then  called  yellow  infiltration. 

5.  Grey  infiltration  : catarrhal  pneumo- 
nia.— This  change  is  identical  with  the  ‘gela- 
tinous infiltration’  of  Laennec.  The  pressure 
on  the  walls  of  the  alveoli  caused  by  the  epi- 
thelial aggregations,  as  well  as  the  inflammatory 


PHTHISIS. 


1170 

exudation,  gives  rise  to  obliteration  of  the  vessels 
and  consequent  caseation,  and  in  this  way  large 
tracts  of  grey  pneumonia  are  converted  into 
yellow  masses  and  subsequently  become  exca- 
vations. 

6.  Red  hepatization. — The  result  of  ordinary 
croupous  pneumonia  is  often  found  associated 
with  one  of  tho  above  forms  of  tubercle,  but 
more  commonly  occurring  in  the  lower  lobes, 
than  in  the  upper.  See  Lungs,  Inflammation  of. 

7.  Fibrosis. — Fibrosis  is  largely  present  in 
phthisis,  but  preponderates  in  (1)  cases  originat- 
ing in  pleuro-pneumonia,  pleurisy  or  pneumonia  ; 
and  (2)  in  cases  of  long  duration.  Fibrosis  is  the 
great  element  of  the  contractile  process,  whereby 
the  lungs  are  reduced  considerably  in  size,  cavi- 
ties of  large  capacity  are  cicatrized,  and  caseous 
masses  encapsulated;  and  sometimes  grey  tuber- 
cle is  converted  into  this  tissue. 

A lung  invaded  by  fibrosis  is  reduced  in  size, 
and  presents  on  section  a dense,  tough,  and  very 
hard  structure,  resembling  cartilage  in  its  resist- 
ance to  the  knife.  All  traces  of  the  alveoli  have 
disappeared,  and  nothing  remains  but  a dark 
grey  or  black  fibrous  material,  into  which  run 
long  bands  of  whitish  fibrous  tissue,  harder  than 
the  darker  portions.  The  pleura  is  generally 
thickened,  and  the  septa  apparently  arise  from 
it  and  from  the  connective  tissue  at  the  root  of 
the  lung,  which  is  also  largely  increased.  Fibro- 
sis is  found  in  limited  portions  of  the  lung,  in 
nearly  all  kinds  of  phthisis,  forming  the  scars 
of  contracted  cavities,  or  tendingto  isolate  caseous 
masses  and  tubercular  aggregations.  When  mi- 
liary tubercle  becomes  converted  into  fibroid 
growth,  the  resulting  tissue  is  of  short  duration, 
owing  to  its  deficiency  of  blood  and  lymph- 
vessels  ; caseation  consequently  takes  plaoe  at 
various  points,  and  it  thus  perishes. 

8.  Chalky  masses. — Cretaceous  or  chalky 
material  is  found  in  chronic  cases,  lying  iu  small 
masses  in  various  parts  of  the  lungs,  chiefly  at 
the  apices,  in  the  neighbourhood  of  old  cavities 
or  caseous  tracts,  and  generally  encapsulated  by 
fibroid  tissue. 

9.  Fibrinous  nodules. — These  bodies  have 
been  neticed  by  Dr.  Reginald  Thompson  in  cases 
where  large  haemoptysis  has  occurred.  These 
vary  greatly  in  size,  and  consist  of  inhaled  blood : 
they  -are  situated  at  portions  of  the  lung  where 
inspiratory  action  is  strongest.  When  first  found, 
they  appear  as  white  nodules  with  a zone  of  red 
colouring  matter;  and  even  in  the  old  specimens 
some  traces  of  blood  in  the  form  of  crystals  of  hae- 
matine  are  to  he  found.  Microscopically  they  are 
shown  to  consist  of  fibrin  and  red  corpuscles,  fill- 
ing the  alveoli  and  even  penetrating  the  alveolar 
wall.  The  masses  eventually  either  (1)  separate 
from  the  surrounding  tissue  through  contraction 
of  the  fibrin,  leaving  a capsule  adherent;  or  (2). 
owing  to  admixture  with  bronchial  secretion  or 
some  such  septic  matter,  they  soften  into  a 
mortar-like  material,  and  are  got  rid  of  by  ex- 
pectoration ; or  (3)  if  the  nodule  be  sufficiently 
large,  and  there  he  no  exit  for  its  contents,  the  re- 
sult is  the  formation  in  time  of  a species  of  cavity 
filled  with  glairy  yellow  fluid,  resembling  honey. 

10.  Vesicular  emphysema. — Two  kinds  are 
noted  in  the  lungs  of  phthisical  patients.  Acute 
vesicula  r emphysema  is  found  distributed  through- 


out the  lungs  of  those  dying  of  acute  tuber- 
culosis ; and  chronic  local  emphysema  oecure 
in  connection  with  chronic  tubercular  masses, 
and  specially  in  the  neighbourhood  of  cicatrized 
cavities.  The  vesicles  are  few  in  number,  and 
often  as  large  as  a hazel  nut,  and  are  generallj 
to  be  found  at  the  apex,  or  along  the  anterioi 
border  of  the  lung. 

Microscopical  Characters.  — In  cases  cl 
tuberculosis  and  phthisis,  the  following  histo- 
logical features  (as  classified  by  Dr.  Green)  arc 
present  in  the  lungs.  The  amount  of  important 
to  be  attached  to  each  element  has  not  yet  beer 
determined. 

1.  Exudation. — Exudation  of  fibrin  and  leu 
oocytes  into  the  alveoli,  resembling  that  of  crou 
pous  pneumonia,  the  fibrillation  not  bein'gquit 
so  distinct,  nor  the  coagulum  so  abundant.  L 
a large  number  of  cases  of  phthisis,  the  lung 
consolidation  consists  of  exudatory  product 
mingled  with  epithelial  proliferation  ; and  h 
some  of  the  most  acute  instances,  these  two  pro 
cesses  have  constituted  the  only  lesion. 

2.  Epithelial  accumulations. — An  accumulate 
of  large  epithelial  cells  may  be  found  within  th 
alveoli.  These  are  generally  large,  spheroids 
cells,  about  four  or  fire  times  the  size  of 
leucocyte,  containing  granular  matter,  and 
nucleus  and  nucleolus.  Some  smaller  ones  at 
also  observed,  indistinguishable  from  leucc 
cytes.  Within  the  alveoli  also  are  found  th 
so-called  ‘giant  cells,’  which  are  held  by  Hetic 
to  be  lymphatics  cut  across ; by  Friedlander  t 
be  the  basis  of  tubercle;  by  Klein  and  Gree 
to  be  derived  from  the  alveolar  epithelium,  b| 
fission  or  excessive  development.  These  appec 
at  first  as  spheroidal  masses  of  faintly  granule 
protoplasm,  reaching  jjgth  inch  in  diameter,  wit 
numerous  nuclei — sometimes  as  many  as  thirt; 
and  bright  nucleoli.  After  a while  they  inerea: 
in  size,  and  send  out  branched  processes,  fro 
which  are  developed  other  smaller  protoplasm 
masses,  so  that  a branched  reticulum  is  forme 
round  the  original  giant-cell,  connecting  it  wit 
other  giant-cells.  These  branches  are  often  d 
rectly  continuous  with  the  lymphoid  or  adeno 
network  of  the  alveolar  wall,  to  he  present 
alluded  to,  which  forms  a circle  round  the  giaD 
cell  system.  Giant-cells  are  not  found  in  tl 
earlier  stage  of  tubercle-development,  and  a 
pear  after  some  of  the  products  of  exudatis 
have  been  absorbed.  They  are  devoid  of  at 
vascular  supply,  and  are  consequently  subje 
to  caseation,  having  in  such  cases  previous 
undergone  a peculiar  transformation  into 
fibrillar  material.  Giant-cells  are  regarded 
Green  as  a product  of  low  vitality,  incapable 
forming  organised  tissue;  where  the  protoplas 
grows,  the  nuclei  multiply,  but  the  highs 
manifestation  of  cell-life— division  of  the  cell 
does  not  take  place. 

3.  Interalveolar  growth. — This  is  a thickeni 
of  the  alveolar  wall  by  a small-celled  lymphs 
tissue,  consisting  of  minute  cells  not  larger  th 
a leucocyte,  separated  from  each  other  by  a vs 
delicate  reticulum.  This  growth  appears  to  eo 
mence  in  the  walls  of  the  alveoli  and  termh 
bronchi,  first  in  the  form  of  a few  lvmphc 
cells,  the  network  appearing  later,  and  has  U 
demonstrated  by  Sanderson  to  be  a hyperplasia 


PHTHISIS. 


117) 


the  adenoid  tissue  already  existing  in  the  lungs; 
for  it  must  be  borne  in  mind  that  lymphatics 
and  lymphoid  tissue  are  largely  present  in  these 
organs,  and  that  the  alveolar  wall  is  considered 
ODe  of  the  densest  lymphatic  plexuses  of  the 
whole  body. 

The  small-celled  tissue  spreads  rapidly  through 
the  alveoli,  invading  the  walls  of  the  capillaries, 
the  peribronchial  and  perivascular  sheaths,  di- 
minishing by  pressure  the  calibre  of  the  vessels, 
ind  in  time  obliterating  them,  and  thus  giving 
rise  to  necrobiosis  by  caseation  and  ulceration  of 
he  surrounding  tissues.  The  growth  fills  up 
he  alveoli,  and  thus  infiltrates  whole  tracts  of 
lie  lung,  which  in  time  become  cut  off  from 
joth  air  and  blood  supply.  This  either  degene- 
rates by  caseation,  giving  rise  to  the  formation 
f cavities ; or  the  cells  become  more  spindle- 
'uaped  and  branched ; the  reticulum  more  fibri- 
ated  ; and  then  gradual  fibrosis  of  the  nuclear 
issue  takes  place.  Owing,  however,  to  the  dis- 
ppearance  and  obliteration  of  the  vessels,  this 
ssue  is  not  properly  supplied  with  nourish- 
ient,  and  soon  undergoes  caseation. 

4.  Interlobular  growth. — Increase  in  the  in- 
irlobular  connective  tissue  resembles  the  pro- 
;ss  prevailing  in  the  liver,  kidneys,  and  other 
-gans  during  chronic  disease,  and  is  not  necessa- 
ly  associated  with  consumption.  This  feature  is 
ost  marked  in  cases  of  inflammatory  origin,  or 
■here  the  disease  is  of  very  long  standing ; and  the 
suit  is  best  seen  in  the  large  fibrous  septa  often 
"companying  the  bronchi  and  great  blood-ves- 
1s,  as  is  specially  exemplified  in  fibroid  phthisis, 
ieroscopically  it  is  difficult  to  distinguish  be- 
een  the  interlobular  tissue  and  the  alveolar 
enoid  growth  in  their  early  stages,  both  being 
■hly  cellular ; the  main  differences  being  the 
nation  of  the  former  around  the  lobules, 
I in  the  neighbourhood  of  the  great  air  and 
)od-vessels,  whereas  the  latter  is  found  in  the 
r-eolar  wall  and  smaller  bronchioles.  The 
'.erlobular  tissue  is  not  so  liable  to  retro- 
|.de  changes,  owing  to  the  vascular  supply 
t ng  less  liable  to  obstruction  and  obliteration; 
|i,  again,  the  alveolar  growth  has  a more  deli- 
( e reticulum  of  fibres. 

Changes  in  the  bronchi,  pleuree,  and 
bnehial  glands. — Th ^bronchi  show, in  many 
(lies,  catarrh  of  the  mucous  membrane,  giving 
);!  to  a richly  cellular  secretion,  which  forms 
t;  greater  proportion  of  the  expectoration  of 
ifhisis,  as  tiie  principal  lesion,  and  extending 
) acute  cases  throughout  the  whole  bronchial 
tj; ; but  in  more  chronic  forms  being  limited 
ti  he  bronchi  leading  to  the  affected  lobules.  A 
Bind  and  more  important  change  is  the  infil- 

t.  ion,  noted  by  Kindfleisch,  of  the  sub-epithelial 
claective  tissue  by  large  cells  characteristic 
o crofulous  inflammation,  and  very  difficult  of 
a1  irption.  The  mucous  membrane  appears 
s'jlen  and  opaque ; the  epithelium  may  be 
sll;  and  if  the  sub-epithelial  infiltration  dis- 
itjrate,  small  ulcers  are  formed.  A third 
cl  ige  is  the  infiltration  of  the  peribronchial 
ti  le,  and  the  proliferation  of  lymph-follicles  in 
tl  walls  of  the  smaller  bronchi,  owing  to  trans- 

u. j  ion  of  infective  substances  from  the  bronchi 
ti  ugh  the  lymphatics.  The  bronchi  from  these 
c!  iges  become  reduced  in  calibre,  and  conse- 


quently the  adjoining  ones,  as  noticed  by  Gran- 
cher,  are  often  dilated  through  the  action  of 
increased  air-pressure  on  their  walls. 

In  laryngeal  phthisis  ulceration  is  to  be  found 
in  the  bronchi,  as  in  the  larynx,  the  changes  in 
which  will  be  presently  stated  under  the  head  of 
Laryngeal  phthisis. 

The  pleura  is  often  adherent  over  the  region 
of  tuberculisation,  when  the  formation  has  taken 
place  slowly,  and  is  comparatively  superficial. 
It  is  often  considerably  thickened,  as  in  fibroid 
phthisis,  to  the  extent  of  three  quarters  or  one 
inch  diameter,  the  layers  being  sometimes  sepa- 
rated, as  Dr.  Douglas  Powell  has  shown,  by  a 
gelatinous  material,  consisting  chiefly  of  con- 
nective tissue. 

The  pleura,  peritoneum,  arachnoid,  and  even 
the  pericardium,  may  be  the  seats  of  miliary 
tubercle  in  the  most  acute  form  of  phthisis, 
namely,  miliary  tuberculosis ; but  it  is  generally 
noted  that  the  lungs  are  the  first  organs  at- 
tacked, and  it  is  extremely  rare  for  tubercle  to 
exist  in  any  organ  without  being  also  present  in 
the  lungs. 

The  bronchial,  cervical,  mesenteric,  and  other 
glands  undergo  various  changes.  In  many,  and 
especially  in  advanced  cases,*  the  bronchial 
glands  enlarge  and  become  deeply  pigmented  ; 
in  others  they  seem  to  partake  of  the  changes 
proceeding  in  the  lungs ; they  become  affected 
with  grey  tubercle,  and  caseate,  and  occasionally 
cretify,  the  cretaceous  material  being,  as  a rule, 
in  the  centre  of  the  gland,  though  the  reverse 
is  occasionally  the  case,  and  the  calcareous  mat- 
ter forms  a shell  over  the  whole  gland  (see 
Bronchial  Glands,  Diseases  of).  The  other 
lymphatic  glands,  especially  the  mesenteric,  are 
liable  to  similar  changes. 

Other  organs.— The  stomach  and  intestines 
in  protracted  cases  become  greatly  attenuated,  all 
the  coats  being  thinned  and  wasted,  and  in  many 
cases  are  found  to  have  undergone  lardaceous  de- 
generation, which  is  a common  cause  of  diarrhoea 
in  phthisis.  Where  the  diarrhoea  has  been  very 
persistent,  it  is  common  to  find  extensive  ulce- 
ration of  the  jejunum,  ileum,  csecum,  and  large 
intestine,  extending  even  to  the  sigmoid  flexure 
and  rectum,  the  caecum  being  earliest  attacked, 
and  generally  in  a more  advanced  stage  than  the 
small  intestine.  The  ulcers  vary  much  in  form 
and  extent;  in  some  instances  they  are  circular, 
clearly  cut  depressions ; in  others,  and  this  is 
the  commoner  form,  they  present  large,  raised, 
irregular  edges,  with  faeces  adherent  to  their 
ragged  surfaces,  and  can  be  often  seen  through 
the  attenuated  external  wall  of  the  intestine. 
The  peritoneal  coat,  as  a rule,  is  thickened  in 
their  neighbourhood,  and  thus  perforation  of 
the  intestine  prevented.  The  earlier  stages  of 
this  process  appear  to  be : — miliary  tubercles 
form  in  the  submucous  coat,  not  only  in  the 
solitary  glands  and  Peyer’s  patches,  but  scat- 
tered throughout  the  submucous  layer,  appear- 
ing as  shining  granules  through  the  epithelium  ; 
yellow  points  of  caseation  become  visible  in 
some  parts,  and  small  abscesses  form  in  others, 
the  latter  appearing  to  have  their  seat  in  the 
solitary  and  agminate  glands ; and,  later  on, 
these  discharge,  leaving  ulcers  of  different 
forms.  Ulceration  of  the  large  intestine  pene 


PHTHISIS. 


1 172 

trates  very  deeply,  and  often  resembles  that  of 
old  dysentery.  Perforation  rarely  occurs,  on 
account  of  the  thickening  of  the  peritoneal  coat 
taking  place  outside  the  ulcers,  but  occasionally 
it  does  occur,  causing  fatal  peritonitis. 

The  liver  is  rarely  normal,  but  generally  un- 
dergoes either  fatty  or  lardaceous  degeneration. 
The  spleen  is  softened,  and  very  commonly  larda- 
ceous. The  kidneys  are  not  generally  affected, 
but  where  albuminuria  has  prevailed  towards  the 
close  of  the  disease,  fatty  or  lardaceous  changes 
occur.  The  heart  is  usually  small,  and  the  mus- 
cular tissue  pale,  and  very  often  in  a state  of 
fatty  degeneration  (Quain).  Fatty  growths  may 
be  found  on  the  surface. 

Pathology. — The  nature  of  tubercle  has  long 
been  a subject  of  discussion.  In  the  sixteenth 
century  two  forms  of  tubercle  (scirrhous  and 
caseose)  were  recognised,  showing  that  even  at 
this  period  a distinction  had  been  drawn  be- 
tween grey  and  yellow  tubercle.  Later  on,  the 
similarity  of  the  changes  occurring  in  the  tuber- 
cular masses  to  the  softening  of  scrofulous  glands, 
led  Portal  to  conclude  that  tubercles  were  en- 
gorged lymphatic  glands  situated  at  various 
parts  of  the  lungs,  the  engorgement  terminating 
in  suppuration.  Laennec  applied  the  term  tu- 
bercle to  miliary  and  yellow  granulations,  as 
well  as  to  grey  and  yellow  infiltration,  hut  con- 
sidered that  it  was  a sui  generis  production, 
unconnected  with  inflammation.  Brottssais,  An- 
dra.1,  and  Cruveilhier  assigned  an  inflammatory 
origin  to  tubercle,  the  latter  considering  that 
tubercle  is  the  result  of  chronic  inflammation  of 
the  lymphatics  of  the  lungs.  At  length  Virchow 
restricted  the  term  1 tubercle  ’ to  the  grey  granu- 
lation, which,  according  to  him,  originates  in 
the  connective  tissue,  and  is  of  a cellular  nature. 
Kokitansky,  Dr.  C.  J.  B.  Williams,  and  others 
considered  that  tubercle  is  principally  an  exuda- 
tion from  the  blood-vessels,  the  different  varieties 
depending  on  the  kind  of  exudation,  and  on  the 
part  played  by  the  leucocytes.  Dr.  Williams 
does  not  exclude  the  additional  action  of  the 
local  tissues,  the  connective  tissue,  the  epithe- 
lium, and  the  adenoid  tissue  of  the  lung ; but  he 
assigns  the  principal  part  to  the  exuded  materials 
from  the  blood-vessels,  especially  to  the  leuco- 
cytes, regarding  the  lymphatic  cells  in  the 
small-celled  tissue  ns  identical  with  leucocytes 
in  their  nature  and  action,  and  that  'when  in- 
creased in  their  number  in  denser  masses,  they 
constitute  grey  tubercle.  This  may  pass  into 
the  state  of  yellow  tubercle  by  the  process  of 
caseation,  whicli  consists  of  fatty  degeneration 
and  disintegration  of  these  masses,  entirely  de- 
stroying their  remaining  vitality.  Drs.  Sander- 
son and  Wilson  Fox  have  demonstrated  the  grey 
tubercle  to  consist  of  the  small-celled  adenoid 
tissue  with  such  epithelial  accumulations  as  may 
be  imprisoned  in  the  course  of  its  growth  ; and 
the  latter  holds  that  this  small-celled  tissue  is 
to  be  found  in  all  forms  of  tubercle  and  in  con- 
sumptive infiltrations.  Dr.  T.  H.  Green  main- 
tains the  existence  of  all  four  classes  of  histo- 
logical elements  as  enumerated  above,  in  the 
lesions  of  phthisis,  and  that  the  small-celled 
tissue  is  not  typical  of  phthisis,  as  it  may  ap- 
pear in  chronic  inflammations  of  various  organs, 
as  of  the  kidney  and  liver.  In  some  of  the 


most  rapid  instances  of  acute  phthisis  (not  acute 
tuberculosis)  he  can  detect  nothing  but  the 
products  of  exudation  so  closely  packed  as  to 
cause  their  own  breaking  down.  At  the  same 
time  he  admits  the  large  part  played  by  the 
adenoid  growth  in  grey  granulations.  Charcot, 
after  careful  histological  study,  strongly  advo- 
cates the  unity  of  phthisis,  and  affirms  that  in 
caseous  pneumonia  he  finds,  as  in  grey  granula- 
tion, two  zones — first,  a central  region,  consisting 
of  little  else  than  exudation-products  and  caseous 
debris,  in  which  reagents  can  bring  to  view  fibres 
of  lung-tissue ; and,  secondly,  a peripheral  re- 
gion (‘ zone  embryonnaire’)  made  up  of  adenoid 
growths  and  giant-cells.  He  considers  that  the 
last  two  elements  are  the  basis  of  tubercle,  which 
is  always  a peribronchial  product,  and  that 
caseation  does  not  take  place  without  their  being 
present.  Charcot  points  out  that  croupous  pneu- 
monia occurs  in  tubercular  lungs,  and  clears  up, 
leaving  no  residue  behind  ; and  argues  that  pneu- 
monia alone  cannot  produce  the  caseous  masses. 

Though  great  difference  of  opinion  thus  ap- 
pears to  exist  as  to  the  relative  parts  played  bv 
exudation  and  adenoid  growth  in  the  pathology 
of  phthisis,  it  will  not  be  difficult  to  deduce  some 
general  conclusions  which  may  elucidate  manv 
of  the  difficulties. 

The  part  played  by  inflammation  in  phthisical 
lungs,  in  spite  of  Charcot’s  doctrine,  is  very 
large,  and  we  may  conclude  that  grey  and  yellow 
infiltration  are  varieties  of  the  pneumonic  pro- 
cess, probably  of  a low  type,  with,  as  Dr.  Fox 
remarks,  ‘that  invasion  of  the  alveoli  by  the 
small-celled  tissue  which  leads  to  the  obliteration 
of  the  capillaries  and  slow  necrobiosis  of  tho 
part  involved.’ 

Of  the  inflammatory  products  found  in  phthisis, 
the  fibrinous  or  easily  absorbed  element  is  scarce, 
and  the  corpuscular,  or  cellular,  which  is  not 
easily  absorbed,  is  common  ; and  this  last  ele- 
ment, in  order  to  be  absorbed,  has  generally  to 
pass  through  the  process  of  caseation. 

The  absorption  of  caseous  matter  by  the 
lymphatics  is  attended  by  a considerable  amonit 
of  irritation,  and  thus  we  get  adenoid  hyper- 
plasia or  tuberculosis.  This  may  be  local,  as 
when  we  see  a group  of  miliary  nodules  sur- 
rounding a caseous  centre,  the  rest  of  the  lung 
being  apparently  free  ; or  general,  infecting  the 
lymphatics  of  the  lungs,  and  it  may  be  of  other 
organs,  as  is  seen  in  acute  tuberculosis.  The 
future  of  grey  tubercle  depends  to  a great  extent 
on  its  rate  of  production,  and  its  relation  to 
blood-vessels.  When  not  clustered  closely  to- 
gether, and  when  unaccompanied  by  inflam- 
mation, it  may  gradually  dry  up,  aud  even  ir 
time  be  converted  into  fibrous  tissue;  but  it, 
as  is  usually  the  case,  increaso  of  the  adenoid 
growth  leads  to  obliteration  of  the  capillaries 
we  have  caseation  and  excavation,  with  fresl 
local  infections. 

The  two  principal  factors  in  the  pathology  o 
phthisis  then  are  irritation  and  infection : — 

Irritation. — Under  this  term  may  be  include* 
the  various  inflammatory  processes  and  othe 
local  agents,  which  affect  the  alveolar  wall  is 
proportion  to  the  intensity  of  their  action. 

Infection. — Infection  is  either  local,  throng 
inflammatory  processes,  as  the  result  of  lmtatior 


PHTHISIS. 


>r  from  general  state  of  system,  as  in  eases  from 
family  predisposition,  where  the  lymphatics  are 
oriraarily  affected. 

It,  therefore,  appears  most  probable  thr.t  the 
various  pulmonary  processes — the  exudation  of 
cucocytes,  the  formation  of  giant  cells,  the  ade- 
tboid  hyperplasia,  are  alL  indications  of  some 
General  blood-erasis,  manifesting  itself  chiefly  in 
:he  lungs,  on  account  of  the  large  circulatory 
irea  involved,  but  not  necessarily  confined  to 
heir  limits.  We  may  suppose  that  under  these 
feireumstances  the  blood  has  a tendency  to  form 
md  exude  cells,  which  grow  and  do  not  develop 
,-nto  tissue,  but  die  and  caseate,  and  in  this  state 
irritate  the  lymphatic  system,  and  the  pulmo- 
nary lymphatics  in  particular,  We  must  hear 
n mind  that  the  increase  of  the  adenoid  tissue 
akes  place  after  the  exudation,  the  epithelial 
iiroliferation,  and  formation  of  giant-cells.  What 
he  irritating  quality  of  the  blood  is,  whether 
hemical  or  histological,  and  why  cellular  exu- 
ltations should  be  less  easily  absorbed  than  fibri- 
loue,  are  problems  still  to  be  solved. 

Symptoms. — (a)  First  stage. — The  symptoms 
if  pulmonary  phthisis  in  the  first  stage  may  be 
hus  summarised  : — Cough,  becoming  more  per- 
sistent ; mucous  expectoration  ; loss  of  colour  and 
trength  ; emaciation;  night-sweats ; sometimes 
nss  of  hair ; pulse  somewhat  quickened,  though 
iis  is  not  invariable  ; and  a temperature  rising 
jbove  the  normal  in  the  afternoon,  and  sinking 
elow  it  in  the  morning.  M.  Peter  has  noted  in 
lany  cases  a rise  in  temperature  on  the  affected 
de  during  this  stage ; and  with  regard  to  the 
eneral  temperature  of  the  body,  though  slight 
yrexia  is  often  present,  tubercle-formation  is 
uite  possible  without  any  rise  of  temperature,  or 
iay  even  be  marked  by  a depression,  as  Surgeon- 
lajorAlcock  and  others  have  shown.  Pain  in  the 
pper  parts  of  the  chest  is  occasionally  present ; 
id  the  number  of  respirations  are  generally  in- 
■eased,  though  this  depends  on  the  amount  of 
ilierculisation  proceeding.  Some  hold  that  dys- 
jcea  is  an  early  symptom  and  precedes  all  others, 
itthe  writer  has  found  quite  the  opposite — that 
itients  do  not  notice  their  breath  to  be  short 
itil  their  lungs  are  seriously  involved.  Disturb- 
ce  of  the  digestive  powers,  and  considerable 
stability  of  the  intestinal  mucous  membrane, 
th  a red  streak  on  the  gums,  is  noticeable  in 
me,  though  chiefly  in  the  acute  forms.  The 
fgue  becomes  white,  the  bowels  torpid,  and  the 
ine  scanty.  The  most  constant  of  the  above 
‘mptoms  are  the  persistent  cough,  with  mucous 
pectoration,  and  the  progressive  emaciation  ; 
d in  many  eases  so  obscure  are  the  beginnings 
the  disease,  that  these  are  the  only  symptoms 
icoverable. 

Physical  signs. — The  physical  signs,  after  the 
1st  stage,  depend  to  a great  extent  (1)  on  the 
mber  and  aggregation  of  the  miliary  tubercles ; 

I on  the  amount  of  consolidation  they  give  rise 
> and  (3)  on  the  irritation  which  their  forma- 
n causes  in  the  lung. 

As  a rule  tubercle-formation  commences  at 
I3  apex  of  one  lung,  and  is  detected  by  the 
i mice  of  certain  physical  signs  in  the  supra- 
pular,  supra-clavicular,  or  sub-clavicular  re- 
us, the  signs  extending  downwards  at  a later 
:e.  The  signs  vary  much  in  particular  cases, 


1173 

but  consist  at  the  first  in  an  impairment  of  the 
ordinary  respiratory  murmur  by  a species  of 
crepitation,  differing  from  the  pneumonic  crepi- 
tation chiefly  in  its  more  scattered  character,  in 
its  being  audible  with  both  inspiration  and  ex- 
piration, and  in  its  crumpling  nature.  Many 
authors,  however,  maintain  that  an  earlier  sign 
is  the  ‘ wavy  ’ breathing  (T.  Thompson),  or  ‘ respi- 
ration saccade  ’ of  the  French.  Accompanying 
this  is  increased  vocal  resonance  and  broncho- 
phony, with  more  distinct  conduction  of  the 
cardiac  sounds ; and  percussion  discovers  dul- 
ness  of  varying  shades  in  one  of  the  above- 
mentioned  regions.  When  a certain  definite 
amount  of  consolidation  has  taken  place  some 
impairment  of  the  mobility  of  one  side  of  the 
chest  may  be  noticed:  this  is  to  be  detected 
under  the  clavicle,  where,  if  any  adhesion  of  the 
pleura  exists,  there  may  be  some  flattening. 
Another  significant  sign  is  the  dry  friction- 
sound,  audible  generally  in  the  supra-scapular 
and  scapular  regions,  and  indicating  limited 
pleuritis  from  a nodule  of  tubercle  formed  im- 
mediately below  the  membrane.  The  sub-clavian 
murmur,  much  dwelt  on  by  old  authors,  is  too 
uncertain  to  be  depended  on.  The  dulncss 
usually  appears  first  above  the  scapula,  next  over 
the  sternal  end  of  the  clavicle,  and  gradually 
extends  downwards,  being  limited  generally  for 
a considerable  period  by  the  third  rib. 

A careful  comparison  must  he  made  between 
the  two  sides  of  the  chest,  and  often  between 
different  portions  of  tho  same  side,  as  otherwise 
the  slighter  shades  of  dulness,  and  the  minor  dif- 
ferences in  the  respiration-sounds,  which  charac- 
terise the  presence  of  tubercle  in  the  lung,  will 
escape  notice. 

When  the  crepitation  and  the  wheezing — which 
may  be  considered  as  indicative  of  irritation  in 
the  pulmonary  tissue,  caused  by  tuberculosis — 
have  subsided,  prolonged  expiration,  and  certain 
varieties  of  tubular  sound,  show  condensation  of 
the  lung-tissue  around  the  neighbouring  bronchi; 
and  a certain  amount  of  dulness  is  to  be  de- 
tected. 

(b)  Second  and  Third  stages. — The  symptoms 
which  accompany  the  second  stage,  or  that  of  soft- 
ening  of  tubercular  masses  and  their  subsequent 
excavation,  are  by  no  means  uniform.  Many 
authors  associate  this  stage  with  marked  signs 
of  pyrexia,  with  copious  night-sweats,  and  in- 
crease of  cough  and  emaciation  ; but  this  is  not 
always  tho  case,  for,  according  to  the  writer's 
experience,  the  process  may  go  on  with  even  sub- 
normal temperatures,  and  with  gain  of  weight ; 
but  as  fresh  formation  of  tubercle  often  accom- 
panies the  softening  process,  some  of  the  above 
symptoms,  which  have  been  assigned  to  soften- 
ing, may  be  due  to  the  tuberculisation  and 
pneumonia  accompanying  it.  The  symptoms 
which  should  be  most  depended  upon  for  the  de- 
tection of  softening  are — increase  of  cough,  an  1 
expectoration  of  a yellow  colour,  occasionally 
streaked  with  blood.  If  the  expectoration  be  care- 
fully collected  and  boiled  -with  an  equal  volume 
of  caustie  soda,  of  the  strength  of  20  grains  to 
the  ounce,  and  the  sediment  then  placed  under  a 
moderate  magnifying  power  of  the  microscope, 
delicate  filaments  of  yellow  elastic  tissue,  of 
hook-like  shape,  or  else  exhibiting  the  cha^a© 


PHTHISIS. 


1174 

ters  of  the  alveoli,  may  be  detected.  The  sputum 
chiefly  consists  of  pus,  with  2 to  4 per  cent,  of 
albumen,  and  a large  proportion  of  phosphates. 
Pouehet  found  monads  and  bacteria  ; and  Koch 
has  recently  described  the  peculiar  bacilli,  be- 
lieved by  him  to  constitute  the  virus  of  tubercle. 
Dr.  Ehrlich  has  given  an  elaborate  process  for 
showing  these  bacilli  in  the  sputum.  ( Deut . Med. 
Wochensch.  May  6 ; and  Med.  Times  and  Gosz,, 
May  27,  1882.)  See  Bacilli,  in  Appendix. 

Physical  signs. — The  signs  which  these  changes 
give  rise  to  are  often  obscure.  The  percussion- 
sounds  vary  ; sometimes  there  is  an  increase  of 
dulness,  possibly  due  to  pneumonia  of  adjacent 
lobules  ; at  other  times,  hyper-resonance,  as  if 
air  had  taken  the  place  of  the  expectorated 
masses.  In  all  these  cases  much  depends  upon 
the  situation  of  the  lesion.  The  formation 
of  a cavity  deep  in  the  lung,  and  far  from 
the  chest-walls,  may  take  place  without  being 
detected,  except  by  the  expectoration  ; wdiereas 
the  formation  of  a similar  one  on  the  surface 
gives  rise  to  unequivocal  signs.  Auscultation 
reveals — where  formerly  bronchophony  and  fine 
crepitus  existed — crepitation  of  a very  coarse 
character,  commencing  with  a click  sound,  and 
after  a w’hile  developing  into  a croak.  When 
this  last  note  has  been  reached,  loud  tubular 
sounds  become  audible  on  coughing,  and  we 
soon  get  the  sounds  characteristic  of  a cavity. 
The  great  distinguishing  features  of  these  moist 
sounds  of  softening  are  their  variety,  their  short 
duration,  and  their  concentration  over  one  small 
portion  of  the  lung.  In  phthisis,  crepitation 
much  more  commonly  signifies  tubercle-formation 
or  pneumonia  than  it  does  softening  of  already 
formed  tubercular  masses.  The  formation  of  a 
cavity  is  generally  followed  by  regular  morning 
expectoration,  usually  opaque,  and  nummular 
in  form,  and  in  the  majority  of  cases,  unless 
interfered  with  by  treatment,  by  the  usual  con- 
sumptive train  of  symptoms,  if  these  have  not 
already  appeared.  These  are  — night-sweats, 
slightly  elevated  temperature  at  night,  and  rapid 
loss  of  flesh,  strength,  and  colour.  The  drawn 
look  of  the  face,  the  hectic  spot  on  the  cheek, 
the  pearly  white  colour  of  the  sclerotic,  the  club- 
bing of  the  fingers,  and  other  signs  which  mark 
the  confirmed  consumptive,  generally  belong  to 
this  stage,  and  all  more  or  less  denote  blood- 
infection  from  the  lung-products,  sometimes  even 
simulating  pyaemia. 

The  weakness  of  voice,  so  common  in  chronic 
phthisis,  is  distinct  from  the  total  aphonia  of 
laryngeal  phthisis,  and  has  been  shown  to  be 
due  to  granular  degeneration  of  the  muscles 
of  the  larynx.  Marcet  has  shown  that  in 
phthisis  the  muscles  generally  undergo  degene- 
ration. 

The  history  of  a cavity  follows  one  of  four 
courses.  See  also  Cavity  ; and  Vomica. 

1.  It  may  remain  patent,  secreting  pus,  like  a 
chronic  abscess,  but  not  increasing  in  size. 

2.  It  may  enlarge  by  caseation  and  ulceration 
going  on  in  its  walls,  by  which  process  blood- 
vessels may  become  exposed.  In  this  case  the 
expectoration  becomes  more  nummular  and 
Abundant,  containing  quantities  of  lung-tissue 
and  remains  of  bronchi ; and  excavation  may  in 
time  convert  the  lung  into  a mere  pleural  bag, 


devoid  of  lung-tissue,  with  what  remains  of  the 
bronchi  opening  into  it.  The  physical  signs 
attending  this  increase  in  size  are  amphoric 
breathing,  and  often  hvper-resonance  on  percus- 
sion, or  cracked-pot  sound  ; and  the  voice  and, 
cough  may  be  accompanied  by  metallic  tinkling, 
especially  if  the  communication  with  the  bronchi 
is  narrow. 

3.  It  may  open  into  the  pleura,  and  cause 
pneumothorax  or  pyopneumothorax.  That  this 
does  not  occur  oftener  is  owing  to  the  adhesive 
pleurisy  which  so  often  accompanies  the  early 
consolidations  of  phthisis,  especially  if  the  tu- 
bercle be  superficial.  See  Pleura,  Diseases  of. 

4.  It  may  contract,  and  the  sides  approach- 
ing each  other  form  at  length  a firm,  tough 
cicatrix,  causing  a stretching  of  the  surround- 
ing tissue,  and  often  considerable  displacement 
of  the  neighbouring  organs.  This  is  the  natu- 
ral cure  of  the  third  stage  of  phthisis,  and  is, 
evidenced  in  most  cases  by  a flattening  of  the 
chest-wall,  chiefly  in  the  infra-clavicular  space, 
a disappearance  of  the  cavernous  sounds,  and  a 
substitution  of  deficient  or  harsh  breathing,  and! 
sometimes  of  healthy  sounds  over  the  seat  on 
the  cavity.  Percussion  often  discovers  that  that 
sound  lung  is  drawn  across  the  median  line  to 
the  affected  side  ; and  if  the  cavity  be  in  the  leit 
lung,  the  heart  and  stomach  may  be  displaced, 
upwards,  the  former  organ  being  generally  tilted, 
towards  the  axilla,  the  apex  describing  the  arc 
of  a circle,  of  which  the  centre  is  the  commence- 
ment of  the  aorta.  If  the  cavity  be  in  the' 
right  lung,  we  may  expect  the  liver  to  be  drawn 
up,  and  the  heart  displaced  to  the  right  of  the 
median  lino,  reaching  occasionally  beyond  the 
right  nipple.  Contraction  of  a cavity  always  takes 
place  towards  a fixed  point,  which  is  sometimes 
an  adhesion  of  the  pleura,  but  more  generally 
the  root  of  the  affected  lung ; and  in  this  way 
the  remarkable  vagrancy  of  the  physical  signs 
is  explained  ; for  it  is  not  unusual  to  find  the 
cavernous  sounds  audible  above  the  scapula, 
long  after  they  have  ceased  to  be  heard  in  the 
sub-clavicular  region,  and  again  in  the  inter- 
scapular regions  after  they  have  ceased  to  he: 
audible  in  the  supra-scapular  fossa. 

Of  these  destinies  of  a lung-excavation,  the 
two  first  are  undoubtedly  the  commonest  IV  here 
the  cavity  remains  quiescent,  and  no  fresh 
tubercle-formation  takes  place,  the  patienpmav 
live  on  for  years,  with  only  the  inconvenience 
of  regular  expectoration  and  occasional  dyspnoea, 
and  preserve  the  appearance  of  actual  health. 
Where  a cavity  continues  to  increase  by  further 
ulcerative  processes,  tuberculosis  soon  attacks 
the  opposite  lung ; and  this  organ  passing  rapidly 
from  consolidation  into  excavation,  the  cough 
and  expectoration  increase,  hectic  fever  becomes 
more  frequent,  the  patient  reaches  an  extreme 
state  of  emaciation,  the  adipose  tissue  disappear.- 
from  all  parts  of  the  body,  the  temporal  and 
malar  bones  become  prominent,  the  jaws  art 
sharply  defined,  the  scapulae,  ribs,  and  sacra  al 
stand  out,  as  if,  as  is  really  the  case,  they  were 
only  covered  by  skin,  and  the  patient  becomes 
to  all  appearances  a mere  skeleton.  By  an  all 
wise  arrangement  a kind  of  balance  seems  to  be 
maintained  between  the  diminished  requirement! 
of  the  body  and  the  mass  of  the  blood,  for  this 


itter  is  reduced  in  bulk  in  proportion  to  the 
tssened  respiratory  surface,  and  the  individual 
bus  gradually  dwindles  and. sinks. 

In  the  last  stage  of  phthisis  various  symptoms 
ppear  indicative  of  the  disorganisation  the  blood 
as  undergone,  and  the  manifest  lowering  of  the 
;andard  of  lifo.  Thromboses  may  arise  in  the 
eins  of  the  extremities;  cedema  of  the  ankles 
■nd  feet  ensues  ; bed-sores  form  on  those  parts 
■here  the  pressure  is  greatest,  as,  for  instance, 
n the  hips,  buttocks,  and  sacrum ; and  aphthae 
ppear  on  the  tongue  and  fauces,  and  when 
■amoved  are  succeeded  by  a fresh  crop,  rapidly 
ipreading  round  the  hard  palate,  buccal  surface, 
nd  gums.  Ulceration  of  some  part  of  the 
lucous  membrane  of  the  mouth  and  pharynx  is 
jot  uncommon,  the  part  affected  being  gene- 
ally  the  edge  of  the  tongue,  or  the  buccal  sur- 
ice  in  the  region  of  the  back  molars.  Ulcera- 
on  of  the  soft  palate  rarely  occurs  except  in 
onnection  with  syphilis.  Near  the  end  profuse 
weats  follow  the  swallowing  of  all  fluids.  The 
jreathing  becomes  quicker,  and  expectoration 
lore  and  more  difficult.  Diarrhoea  prevails  at 
Jiis  stage,  and  often  proves  fatal  before  the 
ulmonary  lesions  have  reached  their  furthest 
levelopment. 

Death  may  occur  in  several  ways,  either — 

1)  by  apncea,  from  inability  to  expectorate; 

2)  by  thrombosis  of  the  pulmonary  artery,  in- 
uring lividity  and  dyspnoea ; (3)  by  pneumo- 
iorax;  or,  (4)  by  exhaustion,  the  heart’s  action 
radually  failing,  the  patient  being  utterly  pro- 
rated, either  by  the  wasting  course  of  the 
iisease,  or  by  the  attendant  diarrhoea.  Hsemo- 
tysis  may  cause  death,  either  by  collapse  from 
>ss  of  blood,  or  by  suffocation  through  the  blood 
ipidly  filling  the  air-cells. 

Some  of  the  principal  symptoms  of  phthisis 
jqutre  a fuller  description. 

Temperature,  pulse,  and  respiration. — - 
ho  teuiperature  of  phthisis  is  both  pyrexial 
nd  subnormal,  its  varieties  depending  partly 
a the  amount  of  tuberculisation  and  inflam- 
matory process  going  on.  and  partly  on  the  ex- 
:nt  to  which  the  constitutional  powers  are  de- 
ressed.  The  high  temperatures  are  duo  to  the 
inner,  the  low  ones  to  the  latter  cause.  The 
singe  extends  from  106°  F.  or  107°  F.,  noted  in 
cute  phthisis,  down  to  90-5°  F.,  observed  by  Le- 
Jsrt.  The  writer  has  seen  morning  records  as  low 
ji  91'6°F.  In  many  cases  of  quiescent  phthisis 
i the  first  and  third,  stage,  the  observations  are 
pr  the  greater  part  of  the  day  subnormal,  and 
lly  reach  the  healthy  standard  in  the  after- 
bon.  It  is  even  possible  for  tubercle  to  form, 
id  for  softening  and  excavation  to  take  place, 
ithout  any  rise  of  temperature. 

Where,  however,  tubercle-formation  is  accom- 
mied  by  elevation  of  temperature  it  is  post- 
eridian,  and  by  no  means  continuous  in  cha- 
rter, the  phenomena  being  as  follows : — The 
,se  commences  after  2 p.m.  and  continues  till 
p.m.,  when  the  maximum,  which  may  attain 
•3°  or  104°  F.,  is  reached.  A fall  then  begins, 
d continues  till  4 or  5 a.m.,  when  the  minimum, 
rich  may  be  as  low  as  94°  F.,  but  is  generally 
out  95°  F.  or  96°  F.,  is  attained.  After  this 
gradual  recovery  takes  place,  and  by  10 
11  a.m.  normal  temperatures  are  reached. 


ISIS.  117b 

During  the  process  of  softening  the  post- 
meridian rise  appears  to  he  maintained  later 
in  the  day,  the  maximum  being  reached  at 
10  or  11  p.m.  In  active  cases  in  the  third  stage, 
where  excavation  is  proceeding  or  extending, 
and  where  also  fresh  tuberculosis  may  be  taking 
place,  the  thermic  chart  approaches  more  closely 
to  that  of  suppuration  and  pyaemia,  and  shows 
great  extremes,  the  highest  and  lowest  tempera- 
tures of  phthisis  being  noted  at  this  stage. 
The  rise  commences  soon  after  noon,  and  con- 
tinues till  5 p.m.,  or  even  till  10  p.m.,  when  the 
maximum  of  103°  to  104°  F.  is  reached,  and 
a fall  rapidly  follows,  95°  F.  and  94°  F.  being 
very  commonly  reached  before  6 a.m.  Then  re- 
covery sets  in,  and  normal  records  are  observed 
about  10  a.m.  The  chief  characteristics  of  the 
temperature  in  phthisis  are — (1)  the  post-meri- 
dian form  of  its  pyrexia  ; and  (2)  the  remarkable 
fall  at  night  to  subnormal  figures,  showing  cci- 
lapse  of  the  vital  powers. 

Tho  occurrence  of  liaunoptysis  does  not  gene- 
rally affect  the  temperature,  unless  a large 
amount  of  blood  has  been  inhaled  into  the  air- 
cells.  Under  these  circumstances  catarrhal  pneu- 
monia is  set  up,  and  the  temperature  remains 
elevated  until  its  subsidence  ; or,  if  it  does  not 
subside,  but  gives  rise  to  secondary  tubercle, 
the  chart  will  assume  the  pyrexial  character  of 
acute  tuberculosis.  Night-sweats,  as  a rule, 
lower  the  temperature  for  the  time,  but  they 
are  not  to  bo  regarded  as  a consequence  of  the 
pyrexia,  as  they  are -noted  sometimes  in  nou- 
pyrexial  cases,  but  rather  as  a flux  from  the 
skin,  due  to  loss  of  power  in  its  vaso-motor  sys- 
tem. The  influence  of  diarrhoea  on  the  tempera- 
ture depends  entirely  on  its  form  and  causation. 
Where  it  depends  on  acidity  of  the  prim*  vi* 
and  dyspepsia,  it  exercises  no  influence ; where 
it  arises  from  lardaceous  degeneration  of  the 
intestines,  and  is  accompanied  by  dropsy,  a 
lowering  of  the  standard  may  he  looked  for. 
AVhere,  as  is  generally  the  ease,  it  is  due  to  in- 
testinal ulceration,  a decided  rise  of  temperature 
takes  place,  generally  in  the  evening,  succeeded 
by  equally  well-marked  morning  remissions,  if 
the  ulceration  is  extensive.  Albuminuria,  from 
whatever  cause  arising,  tends,  to  lower  the  tem- 
perature, and  the  more  so  as  the  kidneys  become 
more  deeply  involved,  the  blood  is  more  dis 
organised,  and  dropsy  supervenes. 

The  pulse  varies  greatly,  according  to  the 
form  of  the  disease,  and  tho  amount  of  lung- 
surface  involved.  In  the  greater  number  of  cases 
of  chronic  phthisis  its  character  is  weak,  regu- 
lar, and  little  above  the  normal  standard.  In 
cases  of  acute  disease,  it  has  a frequency  of  100 
to  140,  but  its  rise,  as  a rule,  follows,  sometimes 
after  a long  interval,  that  of  the  temperature. 
Considerable  changes  may  take  place  in  the 
lungs  without  any  rise  of  pulse. 

j Respiration  varies  according  to  the  amount  of 
lung-surface  involved,  being  normal  in  early 
quiescent  stages,  and  rapid  in  cases  of  extensive 
advanced  disease.  Nevertheless  in  acute  phthisis 
and  acute  tuberculosis,  the  respirations  are  gene- 
rally rapid,  even  before  the  lungs  are  largely 
obstructed,  and  in  these  cases  there  is  a definite 
pulse-respiration  ratio.  In  phthisis  generally 
this  cannot  be  said  to  exist  but  the  observation 


PHTHISIS. 


1176 

of  the  number  of  respirations  i3  of  far  more 
importance  than  that  of  the  pulse. 

Diarrhoea. — Diarrhoea  has  a great  influence 
on  the  course  of  the  disease,  and  tends  more  to 
weaken  and  emaciate  the  patient  than  the  harass- 
ing cough,  the  persistent  pyrexia,  or  the  drenching 
night-sweats.  In  the  first  stage  an  opposite 
condition,  namely,  constipation,  prevails,  but  in 
the  third  stage  it  is  tolerably  common  and  very 
obstinate  in  character.  The  diarrhoea  varies  in 
intensity,  according  to  its  cause.  Sometimes  it 
proceeds  from  (1)  acidity  of  the  primae  viae  and 
consequent  indigestion,  and  is  trivial  in  character. 
Sometimes  it  is  due  to  (2)  atony  of  the  intestines, 
and  partakes  of  the  character  of  a flux,  like  night- 
sweats;  (3)  in  other  cases  it  is  due  to  lardaceous 
degeneration  of  the  intestines,  especially  of  the 
small  intestine.  The  diarrhoea  is  not  always 
very  profuse  in  these  last  cases,  but  it  is  very 
persistent,  and  not  uncommonly  accompanied  by 
vomiting  of  a very  obstinate  kind.  Lastly  (I)  it 
may  originate  in  ulceration  of  the  intestines,  as 
has  been  described.  Here  the  diarrhoea  is  very 
persistent,  the  stools  ochrey  and  soft,  and  some- 
times streaked  with  blood;  the  patient  often  com- 
plains of  pain  in  the  abdomen,  referred  to  the  seat 
of  ulceration,  and  experiences  tenderness  on  pres- 
sure. This  is  usually  found  over  the  ileo-caecal 
valve,  but  in  cases  of  extensive  ulceration  the 
writer  has  traced  it  throughout  the  whole  of  the 
ileum,  into  file  colon  (ascending,  transverse,  and 
descending),  and  the  sigmoid  flexure.  Flatus  and 
a tympanitic  condition  of  the  abdomen  is  often 
present  in  extreme  cases,  but  generally  after  in- 
testinal perforation.  The  diarrhoea  prevails  most 
at  night,  but  in  advanced  instances  continues  day 
and  night,  and  exhausts  the  patient  greatly. 

State  of  the  Blood. — The  principal  changes 
in  phthisis  are  a diminution  of  the  red  cor- 
puscles (Malassez),  and  of  the  haemoglobulin 
(Quinquand) ; and  an  increase  in  the  number  of 
leucocytes,  and  in  the  proportion  of  fibrin  and 
phosphate  of  lime.  In  advanced  cases  aggrega- 
tions of  granules,  varying  in  size  from  -^th  to  £ a 
red  corpuscle,  have  been  observed.  The  masses 
are  often  large  enough  in  size  to  occupy  a third 
of  the  field  of  the  microscope  ; and  when  ob- 
served for  one  or  two  hours  at  a temperature  of 
98°  or  100°  F.  these  granules  appear  to  develop 
into  organisms,  and  to  move  about  in  the  blood. 
Their  nature  and  function  are  quite  unknown. 

Varieties. — We  have  hitherto  traced  the  course 
of  a typical  case  of  consumption  in  its  various 
stages,  and  we  must  now  draw  attention  to  the 
different  forms  the  disease  includes,  always  pre- 
mising that  while  they  differ  in  symptoms,  in 
prognosis,  and  iu  duration,  they  cannot  be  erected 
into  distinct  pathological  varieties,  as  they  are 
merely  forms  of  the  same  disease,  and  between 
each  is  to  be  found  every  kind  of  anatomical 
and  clinical  connection. 

The  following  table  gives  the  principal  forms : — 

I.  Acute. — 1.  Acute  tuberculosis.  2.  Scrofu- 
lous pneumonia,  or  acute  phthisis.  3.  Acute 
tuberculo-pneumonic  phthisis. 

II.  Chronic. — 4.  Catarrhal  phthisis.  5.  Fibroid 
phthisis.  6.  Scrofulous  phthisis.  7. Haemorrhagic 
phthisis.  8.  Laryngeal  phthisis.  9.  Chronic 
tubercular  phthisis. 

1.  Acute  Tuberculosis. — This  term  is  re- 


stricted by  the  Germans  to  cases  of  general  tuber- 
culosis where  more  than  one  serous  membrane  is 
affected  with  tubercle,  in  addition  to  the  lung,  but 
it  is  here  used  to  denote  all  acute  pulmonary  cases 
where  miliary  tubercle,  which  has  Dot  begun  to 
easeate,  is  the  principal  lesion.  The  history  is  as 
follows ; a young  person  of  either  sex  is  suddenly 
attacked  with  feverish  symptoms,  pungent  heat 
of  body,  rapid  pulse,  extreme  oppression,  and  over- 
whelming weakness,  dry-coated  tongue,  red  at' 
edges,  soon  becoming  brown  in  the  centre,  6orde« 
on  the  teeth  and  lips,  gastric  disturbance  end 
diarrhoea,  and  occasional  delirium,  the  symptoms 
closely  resembling  those  of  enteric  fever,  foi 
which  the  disease  is  often  at  first  mistaken. 
Cough  and  slight  expectoration  come  on;  fine 
crepitation  and  bronchial  rhonchus  take  the  plaw 
of  the  ordinary  vesicular  sounds ; and  occasionally 
some  dulness  is  detected  over  the  posterior  re- 
gions of  the  chest.  The  patient  wastes  rapidly ; 
the  breathing  becomes  more  and  more  embar- 
rassed ; the  sputum  rusty  ; the  crepitation  mort 
general  and  louder.  Later  on,  the  symptoms  ol 
collapse  appear — the  pulse  becomes  more  rapid 
and  feeble,  the  aspect  ghastly  or  livid,  cold  per- 
spirations appear,  and  death  occurs  within  a feu 
weeks  from  the  date  of  the  first  onset.  Or  the 
symptoms  may  be  more  cerebral  in  character 
denoting  that  the  meninges  are  the  seat  of  miliary, 
tubercle.  The  patient  complains  of  pain  in  the 
head,  vomiting,  and  intolerance  of  light ; begins  tc 
mutter  and  to  give  wrong  answers ; and  then  has 
marked  delirium.  The  aspect  is  heavy  aDd  coni 
fused;  hyperesthesia  of  skin  (Empis)  appears . 
and  double  vision,  though  squinting  is  not  always 
noticeable.  Granulations  can  often  be  detected 
by  the  ophthalmoscope  in  the  fundus  oculi 
Twitchings  of  the  muscles  of  the  extremities  and 
sometimes  of  the  face  occur,  followed  by  convul 
sions,  and  by  paralysis  of  the  sphincters.  Dila- 
tation of  the  pupils  and  other  signs  of  effusion 
supervene,  and  the  patient  dies  comatose.  In 
this  variety,  as  a rule,  the  temperature  remain: 
continuously  high  (between  100°  and  102°  F.1 
but  in  some  instances  under  the  writer's  notice 
it  has  not  risen  above  100°  F.  for  the  last  ten 
days  of  the  patient's  life.  After  death  the  lungs 
are  found  highly  congested  and  pervaded  with 
miliary  tubercle,  soft  in  character,  but  devoid  of 
caseation  ; the  bronchi  full  of  frothy  mucus ; and 
tubercle  may  also  be  found  in  the  peritoneum, 
brain-membranes,  or  pleura,  with  effusion  into 
the  ventricles.  This  form  is  distinguished  from 
capillary  bronchitis  by  the  presence  ot  tever;  from 
enteric  fever  by  the  different  physical  signs; 
from  scrofulous  pneumonia  by  the  great  dyspnea 
and  scanty  expectoration;  and  by  the  head 
symptoms  (when  present)  from  all  the  above. 

Acute  tuberculosis  is  the  most  fatal  form  of 
consumption,  terminating  in  a few  weeks  or  even 
days,  and  is  characterised  by  gastric  distur 
bance,  the  presence  of  family  predisposition 
(Pollock),  and  the  absence  of  haemoptysis. 

2.  Acute  phthisis. — Acute  phthisis  or  scro- 
fulous pneumonia,  is  another  very  acute  variety. 
The  patient,  generally  young,  who  may  have  ha- 
cough  previously,  is  attached  with  sharp  pam 
in  one  side  of  the  chest,  quick  pulse,  high  tem 
perature,  the  skin  being  quite  burning  to  the  ear 
of  the  auseultator,  alternating  with  night  chub 


PHTHISIS.  im 


ad  sweats.  The  general  appearance  betokens 
.neumonia,  but  the  crepitation  commences  at  the 
•pices,  extending  to  the  whole  lungs,  and  is  not 

0 fine  and  even  as  in  pneumonia.  The  cough  in- 
reases  ; the  expectoration  becomes  opaque  and 
urulent,  containing  quantities  of  lung-tissue  ; 
nd  the  temperature  assumes  the  intermittent 

pe.  The  physical  signs  show  at  first  gradual 
nsolidation  of  both  lungs,  but  later  on  declare 
scavation  to  have  taken  place ; and  this  contin- 
es,  the  patient  rapidly  wasting  and  dying  in  a 
w weeks.  Sometimes  the  cavity  opens  into  the 
leura,  which  in  these  cases  is  rarely  adherent, 
hd  death  ensues  by  pneumothorax.  This  form 
not  quite  so  hopeless  as  acute  tuberculosis,  and 
lie  disease  may  stop  short  of  utter  lung-destruc- 
|on,  the  patient  remaining  in  a state  of  crippled 

1 spiration  and  of  health  for  months  and  even 
jars.  The  writer  has  notes  of  one  case  lasting 
iree  and  a half  years  ; another  sixteen  years  and 
jill  living.  After  death  the  lungs  are  found 
'ore  or  less  consolidated,  with  adherent  pleurae, 
|c  indurations  consisting  of  red  hepatisation 
id  caseous  infiltration,  the  latter  largely  pre- 
iminating.  Excavations  abound  in  all  direc- 
ts, and  but  little  or  no  miliary  tubercle  is  pres- 

t.  The  characteristics  of  this  form,  are  (1)  the 
luteness  of  the  disorganising  processes,  exca va- 
in quickly  succeeding  consolidation ; (2)  the 
flammatory  nature  of  the  lesions,  and  the  rarity 
miliary  tubercle  ; (3)  the  occurrence  of  pneu- 
pthorax ; and  (4)  the  freedom  of  other  organs 
im  tuberculosis. 

3.  Acute  tuberculo-pneumonic  phthisis. 

uiis  is  a third  variety,  which  constitutes  a con- 
eting  link  between  the  above  forms,  scrofulous 
eumonia  and  acute  tuberculosis,  as  it  presents 
neofthe  clinical  and  pathological  features  of 
■ ;li,  resembling  the  latter  in  so  far  that  the  tu- 
•culisation  takes  place  rapidly  in  the  lungs, 
d often  involves  other  organs,  as,  for  instance, 
i ; intestines ; and  being  more  akin  to  the  former 
i thc  presence  of  consolidations  of  a pneumonic 
fen,  yet  differing  from  them  both  in  that  the 
lliercle  aggregates,  tends  to  cascate,  and  thus  to 
im  cavities,  through  the  breaking  down  of 
tjiercular  masses,  and  not  of  catarrhal  pneu- 

i nic  products,  this  occurring  while  rapid  tu- 
bculisation  is  taking  place  in  another  part  of 
t lungs. 

. Catarrhal  phthisis. — Catarrhal  phthisis 
sjicwhat  resembles  the  last-named  variety,  and 

I its  origin  in  bronchitis  which  has  gradually 
psed  into  catarrhal  pneumonia.  The  patient 
l'i  been  subject  for  years,  perhaps,  to  attacks  of 
''iter  catarrh,  which  disappear  in  summer ; and 
fuist,  owing  to  a severe  season,  or  from  his  being 

ii  less  favorable  circumstances  than  usual,  his 
cgh  docs  not  cease,  as  formerly,  but  remains 
p sistent,  and  is  accompanied  by  some  purulent 
egetoration,  loss  of  flesh,  and  night-sweats. 

I I bronchial  rales , sonorous  and  liquid,  as  they 
d,  ppear  from  certain  parts  of  the  lung,  become 
n'  e prominent  and  localised  in  others,  espe- 
e y under  the  clavicles,  and  above  and  between 
t!J scapulas.  The  rales  become  coarser,  and  the 
s'  irous  rhonchus  assumes  a croaking  character. 
S:  is  of  consolidation  soon  appear,  but  are  never 
S',  imminent  as  in  other  forms,  owing  to  the 
teporary  emphysema  accompanying  the  bron- 


chitis ; the  dulness  appears  in  patches  over  the 
centres  of  increased  rhonchus  ; the  liquid  rales 
diminish,  owing  to  increasing  obstruction,  and 
give  place  to  a tubular  sound  conveyed  by  the 
extending  consolidation  from  the  larger  bronchi, 
and  heard  best  in  situations  overlying  them,  as 
below  the  clavicle,  and  above  and  within  the  sca- 
pula, in  the  axillary  and  middle  dorsal  regions. 
The  tubular  sound  has  a sharp,  whiffing  charac- 
ter, and  is  often  unaccompanied  by  bronchopho- 
ny, from  the  consolidation  being  insufficient,  and 
the  bronchial  tubes  too  choked  to  produce  it.  If 
the  case  goes  on  unfavourably,  the  expectoration 
becomes  more  abundant,  and  excavation  soon 
takes  place,  with  the  usual  symptoms ; the  pa- 
tient assumes  all  the  appearances  of  advanced 
cavity-phthisis,  and  the  case  from  this  date  can 
hardly  be  distinguished  clinically  from  those  of 
a strictly  tubercular  origin.  After  death  the 
lungs  are  found  to  be  more  or  less  consolidated, 
the  indurations  taking  the  direction  of  certain 
lobules  and  generally  not  affecting  entire  lobes. 
The  indurations  are  of  a grey  or  yellowish  tint, 
with  numerous  yellow  masses  of  caseation  inter- 
vening. Portions  of  the  lung  may  be  found  in 
the  first  stage  of  catarrhal  consolidation,  so  well 
described  by  Dr.  Hamilton,  with  isolated  lobules 
or  groups  of  lobules  of  a leaden  or  purple  colour, 
and  the  adjoining  ones  may  be  emphysematous. 
Wedge-shaped  patches  of  consolidation  can  be 
traced  on  the  pleural  surface,  exuding  on  section 
yellow  catarrhal  fluid  similar  to  that  contained  in 
the  bronchi.  Numerous  excavations  of  irregular 
form  are  seen,  but  in  most  instances  no  trace  of 
tubercle  is  to  be  found,  though  it  is  occasionally 
present.  The  bronchi  are  generally  dilated,  and 
full  of  purulent  matter.  This  form  is  more  com- 
mon among  the  young  than  the  old,  and  arises 
from  wdiooping-cough,  measles,  and  bronchitis, 
the  pathology  being  extension  of  catarrh  from 
the  bronchi  to  the  alveoli,  implication  of  tho 
interstitial  tissue,  large  epithelial  proliferation, 
causing  pressure  and  emptying  of  capillaries, 
degeneration  and  caseation  of  the  alveoli  and 
their  contents,  and  consequent  excavation,  with 
occasionally  lymphatic  infection. 

5.  Fibroid  phthisis. — This  term,  introduced 
by  Dr.  Andrew  Clark,  is  applied  to  cases  of  which 
fibrosis  is  the  principal  feature.  While  this 
process  accompanies  most  instances  of  chronic 
phthisis,  it  specially  characterises  those  in  which 
interstitial  pneumonia  is  present,  and  entirely 
modifies  their  history  and  symptoms.  It  is  gener- 
ally secondary  to  attacks  of  pleurisy  and  pleuro- 
pneumonia, or  to  chronic  pneumonia,  resulting 
from  long-continued  irritation  of  the  lungs, 
through  the  inhalation  of  dust  or  grit,  as  prevails 
among  fork  and  knife  grinders,  colliers,  and 
button-makers.  Taking  the  pleuritic  origin  as 
an  example,  the  following  are  the  symptoms. 

A patient  has  an  attack  of  pleurisy  with  ef- 
fusion, from  which  he  recovers  with  absorption 
of  fluid  ; but  percussion  shows  dulness  over  the 
whole  side  and  somewhat  feeble  respiration.  The 
patient  experiences  dragging  pains  in  the  side ; 
a dry,  hacking  cough,  somewhat  paroxysmal  in 
character,  with  little  expectoration,  continues ; 
and  the  breathing,  always  short,  becomes  still 
more  so  on  exertion.  These  symptoms  increase, 
and  a few  months  later  we  find  marked  imrno- 


PHTHISIS. 


1173 

bility  of  the  affected  side,dulness  throughout,  and 
now  considerable  shrinking  ; the  circumference  of 
this  side,  measuring  one  or  two  inches  less  than 
the  healthy  side.  On  auscultation  we  notice  the 
breathing  to  be  very  deficient  in  some  parts, 
ar.d  in  others  bronchial,  and  sometimes  cavern- 
ous in  character ; but  generally  there  is  every- 
where absence  of  true  vesicular  breathing. 
Careful  percussion  of  the  opposite  side  of  the 
chest  shows  the  line  of  resonance  to  extend 
beyond  the  usual  limit,  passing  to  the  edge  of 
the  sternum,  and  often  an  inch  or  two  further ; 
demonstrating  that  the  contraction  of  the  af- 
fected lung  has  caused  the  healthy  one  to  be 
drawn  across,  in  order  to  fill  up  the  void.  Other 
organs  are  likewise  displaced.  If  the  left  lung 
be  affected,  the  heart  is  tilted,  not  necessarily 
upwards,  as  when  a cavity  is  contracting,  but 
outwards.  The  stomach  rises,  its  note  being 
audible  as  high  as  the  fourth  rib.  The  heart  is 
not  only  displaced,  but  is  uncovered  by  the 
retreating  lung;  and  the  right  auricle  and 
ventricle  are  clearly  distinguished  by  their 
pulsations,  while  the  right  lung  is  drawn  across 
to  the  left  side  to  the  extent  of  one  or  two 
inches.  If  the  right  lung  is  affected,  the  left 
may  be  drawn  over,  and  the  area  of  resonance 
may  extend  as  far  as  the  inner  half  of  the  right 
clavicle,  and  a line  drawn  thence  sloping  to- 
wards the  middle  of  the  sternum.  The  heart 
is  transposed,  and  its  impulse  may  be  traced 
in  the  fourth  interspace  on  the  right  side. 
The  liver  rises  up  to  the  fifth  rib,  and 
shrinking  of  the  chest-walls  takes  place,  as  on 
the  other  side.  The  pulse  may  be  slow ; the 
respiration  often  rapid,  rising  to  50  and  60  per 
minute.  The  temperature  seldom  rises  above 
the  normal,  and  is  sometimes  subnormal.  When 
the  temperature  rises  over  100°  F.  it  signifies 
that  something  beyond  fibrosis  is  going  on.  The 
cough  is  troublesome,  and  often  induces  vomit- 
ing ; and  the  expectoration  becomes  more  and 
more  difficult,  and  in  time,  on  account  of  re- 
tention, foetid.  Meanwhile  the  dyspnoea  in- 
creases, the  other  lung  becoming  involved ; signs 
of  obstructed  circulation  appear ; dropsy  of  the 
extremities  takes  place  and  rapidly  increases ; 
the  urine  becomes  albuminous ; and  the  patient 
dies,  either  of  dyspnoea  or  of  blood-poisoning, 
his  death  contrasting  strongly  with  the  ordi- 
nary termination  of  consumptive  disease.  The 
patient  may,  however,  die  of  apnoea,  without 
albuminuria  or  dropsy.  After  death  we  find 
a lung  contracted  to  the  size  of  a man’s  fist, 
with  enormously  thickened  and  adherent  pleura 
and  widely  dilated  bronchi,  with  interlobular 
septa  much  increased  in  size  and  encroaching  on 
the  lung-structure,  which  seems  to  be  replaced  by 
a fibrous  hard  tissue,  in  parts  mottled  with  grey, 
deeply  pigmented,  and  resembling  cartilage  in 
its  resistance  to  the  knife.  Imbedded  in  this 
structure  are  found  caseous  and  cretaceous 
masses,  or  again,  excavations  of  various  sizes ; 
the  walls  of  these  and  of  the  dilated  bronchi 
being  rigid  and  inelastic,  from  the  presence  of 
the  fibroid  material,  and  thus  affording  some 
explanation  of  the  difficult  expectoration  and 
consequently  troublesome  cough.  Besides  these 
changes,  we  may  find  the  other  lung  the  seat  of 
tuberculosis,  though  this  is  not  constant;  but 


commonly  the  bronchial  glands  are  hardened  and 
deeply  pigmented.  There  is  often  amyloid  disease 
of  the  liver,  spleen,  and  kidneys. 

6.  Scrofulous  phthisis. — This  is  a variety 
where  consumptive  disease  of  the  lung  is  precedec 
by,  or  accompanies,  scrofulous  affectionsof  various 
joints,  caries  of  the  sternum,  ribs,  and  vertebra* 
lumbar  and  psoas  abscesses,  otorrhoea,  fistubi 
in  ano,  or,  as  is  most  common,  enlarged  an 
caseating  glands,  cervical,  bronchial,  axillary 
or  mesenteric.  Kindfleisch  explains  the  non-ai> 
sorption  of  scrofulous  matters  by  the  presence  it 
exudations  of  this  character  of  relatively  larg* 
cells  with  glistening  protoplasm,  and  by  the  fac 
that  the  emigrated  leucocytes,  which  pass  fron 
the  blood-vessels  of  the  inflamed  part  into  tb 
adjoining  structures  or  into  the  lymphatics,  L 
scrofulous  persons  tend  to  grow  larger  on  thei 
way  through  the  connective  tissue,  by  absorptio: 
of  albuminous  substances.  The  large  size  of  th 
cells  has  been  verified  by  Godlee,  Schuppel,  Greet 
and  others.  Cases  of  scrofulous  phthisis  shot 
an  early  infection  of  the  lymphatic  system,  and* 
remarkable  correlation  appears  to  he*  establishe* 
between  the  external  gland  or  discharging  snrfac 
and  the  condition  of  the  lungs.  If  the  gland 
are  suppurating,  or  if  the  fistula  is  open,  or  i 
the  carious  bone  freely  discharges,  the  lung 
disease  will  remain  quiescent,  and  progress  ma 
be  made  towards  arrest ; hut  if,  on  the  othe 
hand,  any  of  the  above  discharges  should  b 
checked  or  cease,  the  lung-disease  passes  int 
fresh  activity,  making  considerable  advanc 
and  extension.  The  temperature-course  in  thes 
cases,  if  active  lung-changes  are  taking  place,  i 
remarkably  fitful,  showing  evening  exacerbation 
of  102°  F.  to  101°  F.  and  morning  depression 
of  96°  F.  to  97°  F. ; and  night-sweats  are  usuall 
very  profuse.  Patients  of  this  type  lose  an 
gain  flesh  with  great  rapidity,  owing  prohahl 
to  the  pyrexia  and  fitfulness  of  the  appetite. 

Scrofulous  phthisis  is  strongly  hereditary : i 
prevails  chiefly  among  children  not  exceedia 
fifteen  years,  as  shown  by  Pollock,  many  c 
these  presenting  the  well-known  strumous  aspec' 
the  clear  complexion,  enlarged  glands,  ckroni 
inflammation  of  the  eyelids,  or  discharging  ear: 
They  are  attacked  early  with  haemoptysis,  accon: 
panied  by  cough  and  wasting.  The  course  of  th 
disease,  probably  on  account  of  the  relief  affords 
by  the  various  discharges,  is  slow,  and  the  patier 
lives  on  for  a considerable  period ; but,  as  migb 
be  expected,  the  development  of  the  individur 
is  slow  and  often  stunted.  Post-mortem  exam 
nation  generally  shows  the  ordinary  destructiv 
lung-changes  of  advanced  tubercular  phthisi 
with  considerable  enlargement  of  the  vanoi 
glands — bronchial,  mesenteric,  cervical,  &c. 

7.  Haemorrhagic  phthisis. — This  name  : 
intended  to  designate,  not  phthisis  arising  froi 
the  results  of  haemoptysis  (phthisis  ab  hemojit 
— Niemeyer),  but  a form  recognised  by  C.  J.  1 
Williams,  Peacock,  Hughes  Bennett,  and  th 
writer,  in  which  large  and  repeated  hmmorrhai 
is  the  principal  feature,  associated  with  a sma 
amount  of  detectable  disease.  It  is  more  con 
mon  among  men  than  women,  in  the  propordo 
of  five  to  one : and  the  period  of  attack  is  lats 
than  in  the  ordinary  forms,  possibly  owing  t 
the  element  o:  heredity  being  generally  abseu 


PHTHISIS. 


10  patient  may  have  had  signs  of  failing  health 
fore  the  haemoptysis,  but  often  he  is  appa- 
,ntly  in  good  health  when  he  is  suddenly 
tacked  with  profuse  haemoptysis,  the  blood 
Ing  florid,  the  haemorrhage  sometimes  lasting 
any  days,  and  always  causing  a reduction  in 
ish  and  strength.  Cough  and  expectoration 
How,  yet  examination  of  the  chest  only  indicates 
ight  signs,  and  sometimes  none  at  all.  When 
■esent  they  are  to  be  found  in  the  supra-  or 
ter-scapular  regions,  or  below  the  clavicle.  Tho 
itient  improves,  and  often  entirely  loses  his 
iugh  before  the  recurrence  of  the  haemorrhage, 
Inch  may  not  take  place,  for  days,  weeks, 
onths,  or  even  years.  If  the  attacks  recur 
j'ten,  the  cough  becomes  persistent;  the  expecto- 
ition,  when  not  sanguinolent,  is  muco-purulent ; 
astingand  night-sweats  appear;  and  the  physi- 
.1  signs  now  show  unmistakable  consolidation, 
hich  goes  on  to  softening  and  excavation.  In 
ost  cases  the  disease  does  not  extend  beyond 
■nsolidation,  and  large  quantities  of  blood  are 
ipectorated  without  fatal  results,  the  patients 
(covering  in  the  intervals,  and  sometimes  living 
a considerable  age.  Peacock  says  that  in 
ost  instances  some  more  or  less  exciting  cause 
to  be  detected,  in  the  form  of  syphilis,  cold, 
'sentery,  bodily  strain,  exertion  of  voice ; but 
e writer  has  often  failed  to  find  one.  The 
ithology  of  this  form  of  phthisis  is  uncertain, 
■cause  few  of  the  patients  die  in  the  early 
age;  but  it  is  probable  that  the  haemorrhage 
j produced  by  tubercular  formations  in  the 
■ighbourhood  of,  and  implicating  the  wails  of, 
me  of  the  larger  vessels  at  the  root  of  the 
ngs.  Though  this  can  be  considered  only  a 
inical  variety  of  pulmonary  phthisis,  the  cases 
e genuine  instances  of  consumption,  as  is  proved 
• the  fact  that,  if  they  live  long  enough,  they 
n the  same  course  of  increasing  consolidation 
d excavation  as  ordinary  phthisis. 

8.  Laryngeal  Phthisis.  See  Larynx,  Dis- 
ses  of. 

9.  Chronic  Tubercular  Phthisis. — This  con- 
tutes  the  ordinary  type  as  sketched  under  the 
ad  of  symptoms.  In  the  autopsies  of  this 
?m  are  to  be  found  all  the  pathological  elements 
phthisis,  namely,  tubercle — miliary,  grey,  and 
lite— caseous  masses, and  infiltration — grey  and 
sarrhal — croupous  pneumonia,  fibroid  tissue, 
d calcareous  deposits, — showing  that  no  abrupt 
thological  line  of  demarcation  can  be  drawn 
(tween  the  different  varieties  of  phthisis,  vvhat- 
|er  clinical  peculiarities  they  may  present ; and 
it  the  appearance  of  miliary  tubercle  is  a 
jitter  of  infection  of  the  lymphatics,  in  which 
ie  plays  an  important  part. 

Diagnosis. — Phthisis  is  distinguished  from 
ler  chest-affections  principally  on  the  evidence 
physical  signs.  The  evidences  of  consolidation 
larate  it  at  once  from  bronchitis ; while  the 
jidency  of  the  signs  to  become  localised  in  the 
, ces  of  the  lungs,  their  special  characters,  and 
{>  combination  of  consumptive  symptoms,  dis- 
' guish  it  generally  from  pneumonia. 

If  the  various  forms  of  phthisis,  the  most  dif- 
) lit  to  diagnose  from  other  diseases  is  acute 
: Hry  tuberculosis,  which  at  its  onset  is  some- 
■jies  mistaken  for  acute  bronchitis,  from  tho 
riles  and  rhonchi  accompanying  the  miliary 


1179 

formation.  It  has  also  been  confounded  with 
enteric  fever,  from  the  high  pyrexia,  the  depres- 
sion of  the  patient,  and  tho  occasional  diarrhoea 
accompanying  it ; but  in  both  cases  the  rapid iy 
advancing  symptoms,  and  the  steadily  progressing 
physical  signs,  such  as  increased  and  scattered 
crepitation,  if  proper  and  frequent  examinations 
be  made,  ought  to  leave  us  iu  no  doubt  as  to  the 
nature  of  the  case. 

The  diagnosis  between  scrofulous  pneumonia 
(acute  phthisis)  and  croupous  pneumonia  is  not 
easy  at  the  ushering  in  of  these  complaints,  the 
physical  signs  not  always  sufficing  for  this  pur- 
pose. In  a short  time,  however,  the  detection  of 
lung-tissue  in  the  sputum,  and  the  rapid  wasting, 
make  matters  quite  certain. 

The  diagnosis  of  chronic  tubercular  phthisis 
from  anaemia  and  chlorosis,  sometimes  confused 
with  it  on  account  of  the  amenorrhoea  often 
common  to  both,  is  made  by  the  physical  signs  ; 
by  the  different  kinds  of  pallor  in  the  two  dis- 
eases ; and  lastly,  in  chlorosis,  by  the  absence 
of  wasting.  The  diagnosis  of  excavation  in 
phthisis  from  bronchiectasis  is  by  no  means 
easy,  as  the  position  of  the  cavernous  sounds  is 
not  always  sufficient  to  determine  the  nature 
of  the  lesion.  Dilated  bronchi  are  found  in 
the  subclavicular  and  interscapular  regions,  and 
where  ulceration  is  proceeding  in  bronchiectasis 
lung-tissue  may  be  detected  in  the  sputum.  The 
convulsive  character  of  the  cough,  and  the  feetid 
expectoration,  abundant,  but  mixed  largely  with 
air,  generally  enable  us  to  decide  in  favour  of 
dilated  bronchi. 

Duration  and  Prognosis. — Early  detection 
of  the  disease,  and  improved  treatment  have 
worked  a great  revolution  in  our  ideas  as  to  the 
duration  of  phthisis. 

The  estimates  of  Laennec,  Louis,  Bayle,  and 
others  assigned  two  years  as  the  mean  duration 
of  life  in  phthisis  generally.  Pollock's  statistics, 
founded  on  between  3,000  and  4,000  hospital 
cases,  give  a considerable  extension  of  this,  in- 
asmuch as  at  the  end  of  two  years  and  a half 
the  majority  were  sufficiently  recovered  to  have 
a fair  expectation  of  life. 

The  statistics  of  C.  J.  B.  AVilliams  and  tho 
writer,  founded  on  1,000  cases  among  the  upper 
classes,  give  an  average  duration  in  198  deaths 
of  7 years  S‘7'2  months  ; and  in  802  living  of  8 
years  2 months.  The  fact  of  these  patieuts 
having  all  been  one  year  and  upwards  under  ob 
serration  necessarily  excludes  some  of  the  acute 
cases ; but  with  this  limitation  these  figures, 
striking  though  they  be,  may  be  taken  as  a cor- 
rect averageforthe  durationof  the  disease  among 
the  upper  classes  under  modern  treatment,  es- 
pecially as  72  percent,  of  the  living  had  recovered 
sufficiently  to  pursue  their  usual  avocations,  and 
many  among  them  had  already  lived  upwards 
of  twenty  years  since  their  first  attack.  The 
duration  of  the  disease  is  found  to  be  considerably' 
influenced  by  age  ; for  it  is  longer  in  proportion 
as  the  age  of  attack  is  later,  this  retarding 
influence  being  more  conspicuous  among  males 
than  females.  Females  are  attacked  earlier,  and 
the  disease  in  them  runs  a shorter  course  by 
nearly  two  years  than  among  males. 

Of  the  varieties  of  phthisis  acute  tuberculosis 
is  the  most  rapid  iu  its  course,  generally  term! 


PHTHISIS. 


1180 

Bating  in  a few  weeks,  or  occasionally  in  a few 
days.  Scrofulous  pneumonia  has  hardly  a less 
rapid  course,  though  it  may  occasionally  be  re- 
tarded, the  disease  becoming  chronic,  and  the 
patient  surviving  for  many  years.  Laryngeal 
phthisis  has  a short  duration,  and  most  un- 
favourable prognosis.  Catarrhal  phthisis  has 
an  average  duration  somewhat  below  the  ave- 
rage of  eight  years  of  ordinary  phthisis.  Fi- 
broid phthisis,  on  the  other  hand,  exceeds  the 
ordinary  duration  by  nearly  two  years.  Htemor- 
rhagic  and  scrofulous  phthisis  are  both  of  long 
duration.  These  calculations  are  based  on  sta- 
tistics of  patients  of  the  upper  classes  treated 
according  to  the  best  medical  and  hygienic  treat- 
ment known  ; but  if  hospital  cases  are  reckoned, 
the  average  of  duration  of  phthisis  generally,  and 
of  its  various  forms,  must  be  held  to  be  much 
lower  than  the  above  estimate. 

The  prognosis  in  phthisis  depends  chiefly  on 
the  extent  to  which  the  system  is  infected,  and 
especially  whether  or  not  other  organs  are  the 
seats  of  tubercle.  Cases  of  acute  tuberculosis 
resemble  closely  those  of  pyaemia  in  their  symp- 
toms and  fatal  course,  and  only  differ  in  the 
nature  of  the  pathological  products.  Similarly 
single-cavity  cases,  where  the  disease  is  strictly 
limited,  bear  a strong  resemblance  to  chronic 
abscesses,  which  go  on  discharging  for  long 
periods,  without  materially  curtailing  the  life  of 
the  patient.  The  future,  therefore,  of  the  patient 
depends  to  a great  extent  on  whether  the  dis- 
ease may  be  considered  local  or  general,  though 
of  course  we  admit  in  both  instances  a consti- 
tutional predisposition,  possibly  of  different 
degrees  of  intensity.  Where  the  infection  is 
rapid  and  complete,  as  in  acute  tuberculosis  and 
most  instances  of  scrofulous  pneumonia,  the  pro- 
gnosis is  most  unfavourable.  Where,  again,  the 
disease  is  limited  to  one  lung,  and  associated 
with  similar  processes  in  the  joints,  as  in  scrofu- 
lous phthisis,  which  act  as  diverticula  to  the 
central  disease,  the  prognosis  becomes  far  more 
hopeful,  and  the  individual  may  last  on  for  many 
years. 

The  prognosis  in  laryngeal  phthisis  is  most 
unfavourable,  on  account  of  these  cases  being 
always  associated  with  extensive  lung-tuber- 
culosis ; while  in  haemorrhagic  phthisis,  where 
the  pulmonary  mischief  is  small  and  limited 
to  the  root  of  the  lungs,  it  is  favourable,  excepting 
of  course  the  accident  of  death  during  an  attack 
of  haemorrhage.  The  most  favourable  prognosis, 
of  phthisis  must  be  retained  for  cases  of  inflam- 
matory origin,  for  here  the  disease  often  remains 
limited  for  considerable  periods  of  time,  and  the 
patient  may  live  on,  almost  unconscious  of  it,  to 
the  natural  term  of  life.  If,  however,  the  fibroid 
element  be  largely  produced,  a new  danger  arises 
from  the  obstruction  to  the  circulation,  caused  by 
the  contraction  of  the  lungs,  dropsy,  dilatation 
of  the  heart,  affection  of  the  kidneys,  and  death. 

The  influence  of  heredity  on  prognosis  lies  in 
its  precipitating  the  onset  of  the  disease,  and  not 
in  its  curtailing  its  duration,  though,  of  course,  an 
individual  attacked  earlier  will  die  at  an  earlier 
age,  the  duration  of  the  disease  being  the  same. 
The  influence  of  stage  must  be  duly  taken  into 
account,  for  statistics  show  a far  more  favour- 
able prospect  for  mere  consolidation  than  when 


a cavity  is  formed,  and  this  is  obv.ous  from  tl 
increase  of  danger  arising  from  two  source 
namely  from  purulent  infection  and  pulmonai 
aneurisms. 

The  grounds  for  an  unfavourable  proouos 
are: — 1,  rapid  extension  of  disease  or  of  luu| 
excavation  ; 2,  persistent  afternoon  pyTexi; 
3,  symptoms  of  great  irritability  of  the  eastr 
intestinal  tract,  red  tongue,  diarrhcea,  twin  ■ 
the  abdomen  ; 4,  great  wasting  with,  or  witi 
out,  pyrexia,  combined  with  a good  appetite : an 
5,  strong  hereditary  predisposition,  showins  i 
6elf  in  several  brothers  and  sisters  being  attache 
at  an  early  age. 

Treatment. — The  treatment  of  phthisis  roa 
be  considered  under  three  heads— 1.  medicimi 
2.  dietetic  and  hygienic  ; and  3.  climatic. 

1.  Medicine. — The  medicinal  treatment  mu: 
be  directed  to  three  objects : firstly,  to  pais 
the  standard  of  nutrition  and  to  counteract  tl 
phthisical  cachexia ; secondly,  to  reduce  and  alia 
the  local  inflammations  and  congestions  whic 
accompany,  and  considerably  complicate,  th 
tubercular  changes ; and  thirdly,  to  relieve  ;h| 
various  urgent  symptoms.  The  first  object  i 
carried  out  by  tonics,  such  as  iron,  quinim 
arsenic,  the  mineral  acids,  and,  above  all,  ccd 
liver  oil,  which  has  been  shown  to  be  the  mo; 
effective  agent  of  all  in  counteracting  phthisicc 
disease.  Some  precautions  are,  however,  nece; 
sary  to  ensure  its  being  tolerated  for  Ion 
periods.  The  pale  oil  should  be  preferred,  an; 
ordered  in  doses  of  from  5j  to  yss  shortly  be1 
fore  or  after  meals.  The  best  vehicles  for  it  ar 
the  vegetable  bitters — such  as  gentian,  calumba 
quassia,  nux  vomica  and  strychnia,  hop,  came 
mile,  and  cascarilla — combined  with  an  acid  o 
alkali,  according  to  the  state  of  thegastricmuccn 
membrane,  and  rendered  more  palatable  by  th: 
addition  of  tincture  or  infusion  of  orange  pcc 
or  syrup  of  ginger.  Various  other  vehicles  ar 
used,  such  as  milk,  salt  and  water,  lemon-juice 
orange  wine,  and  sherry;  while  many  patients 
especially  children,  take  it  best  in  an  emulsion 
composed  of  cod-liver  oil,  a few  drops  of  strop 
liquor  potass*  or  liquor  ammonia,  with  a: 
essential  oil,  like  that  of  cloves  or  cinnamon,  t< 
cover  the  taste.  In  the  great  majority  of  case 
cod-liver  oil  is  well  borne,  if  exhibited  wit 
discretion.  Other  oils  are  of  use,  but  few  equa 
the  cod-liver  oil  in  efficacy,  on  account  of  it 
great  penetrative  power,  and  of  its  forming  wit. 
the  biliary  and  pancreatic  juices  a componn1 
easily  absorbed  by  the  laefeals.  JIalt  extrac 
aud  similar  preparations,  though  of  greatly  m 
ferior  nutritive  power  to  cod-liver  oil,  ofte 
cause  increase  of  weight,  chiefly  by  assisting  th 
patient  to  digest  more  starch.  Of  greatly  m 
ferior  utility  to  the  oil  are  the  preparations  c 
phosphorus  and  sulphur,  such  as  the  hype 
phosphites  of  lime,  soda,  and  iron,  snlphnron 
acid,  and  the  sulphites,  all  of  which  have  a con 
siderable  amount  of  testimony  cited  in  thci 
favour  as  tonics  and  blood-purifiers. 

In  France  the  sulphur  springs  of  EauxBonn,  - 
Cauterets,  Bagneres  de  Luchon,  and  Bagneres  >. 
Bigorre  are  largely  frequented  by  consumptive: 
the  ground  of  this  treatment  being  that  the  ft 
suits  of  Claude  Bernard's  experiments  show  tba 
sulphur  when  absorbed  is  excreted  through  th 


PHTHISIS. 


jpiratory  mucous  membraue.  Peter  considers 
it  any  benefit  that  may  accrue  is  owing  to  the 
iuence  of  sulphurous  acid  on  the  catarrhal 
editions.  The  arsenical  waters  of  La  Bour- 
se and  Koyat  are  strongly  recommended  by 
[.  Noel  Gueneau  de  Mussy. 

We  may  here  consider  the  treatment  of  the 
rexia  of  phthisis.  In  addition  to  rest  in  bed, 
{ti-periodics,  as  quinine  in  large  doses  in  an 
t’ervescing  saline,  salicine  (gr.x),  and  salicylate 
■ soda  (gr.  x to  xx),  may  be  given  every  four 
i. six  hours,  if  the  pyrexia  be  considerable.  If 
p temperature  only  slightly  exceed  100°  F., 
.d  if  it  be  followed  by  much  sweating,  then 
seuic,  in  the  form  of  liquor  arsenicalis  or  liquor 
.jenici  hydrochloricus  (n\ii  to  v),  three  times  a 
, y,  is  indicated.  Where  these  medicines  fail, 
course  may  be  had  to  cold  compresses  over 
je  chest,  to  sponging  with  vinegar  and  water, 
.d  if  the  patient’s  strength  permit,  to  the  ‘ wet 
ck,’  swathing  the  patient  in  wet  sheets;  and 
j the  pyrexia  be  very  persistent  and  tormenting 
the  sufferer,  immersion  in  a bath  of  90°  F., 
vered  gradually  to  GO0  F.,  may  be  tried.  The 
luction  of  temperature  and  consequent  relief 
: great,  but  not  always  permanent  in  character, 
$ pyrexia  in  phthisis  may  be  considered  one 
(its  obstinate  symptoms. 

The  second  object  of  treatment,  the  reduction 
( local  inflammation,  is  best  accomplished  by 
lid  antiphlogistic  means,  such  as  salines,  with 
J without  antimony ; and  counter-irritation  to 
t)  chest-wall  by  blisters,  iodine,  or  vesicating 
liments,  mustard,  or  the  milder  but  still  effec- 
1 .1  application  of  linseed-meal  poultices.  Steady 
mtinuance  with  these  will  often  render  seda- 
tes for  the  cough  unnecessary. 

The  third  object,  namely,  the  palliative  treat- 
i nt,  includes  that  of  the  various  urgent  symp- 
t is. 

The  cough,  when  not  reduced  by  the  counter- 
i tation,  may  be  to  a certain  extent  allayed  by 
combination  of  sedatives,  such  as  opium  and 
i salts,  conium,  henbane,  hydrocyanic  acid, 
iierican  cherry,  with  mild  expectorants,  of 
tick  chloric  ether,  lemon  juice,  and  squills  are 
e.mples.  Where  the  cough  is  frequent  and  the 
e.'ectoration  difficult,  and  there  is  proof  of  ac- 
ts disease,  tubercular  or  pneumonic,  proceeding 
i the  lungs,  an  effervescing  saline,  containing 
cibonate  of  ammonia,  with  small  doses  of  opium 
8 . antimonial  wine,  taken  two  or  three  times  at 
ijht,  will  greatly  relieve  the  symptoms,  the  rule 
i he  treatment  of  consumption  being  to  restrict 
t sedatives,  as  far  as  possible,  to  the  night,  so  as 
t to  interfere  with  the  appetite  and  digestion. 
I s preparations  of  tar,  in  the  form  of  capsule, 
1 , or  solution,  are  useful  in  reducing  profuse 
e ectoration.  The  inhalations  of  iodine,  com- 
pnd  tincture  of  benzoin,  carbolic  acid,  crea- 
so,  larch  and  turpentine,  are  useful  if  expecto- 
r on  is  offensive  or  requires  stimulating  ; or 
a,m,  those  of  chloroform,  conium,  hop,  when 
t1  cough  is  convulsive  and  dry. 

ho  pains  in  the  chest  may  be  alleviated  by 
Fating  with  tincture  of  iodine  or  stimulating 
1 nents,  such  as  turpentine  and  ammonia  ; or 
on  Dr.  Koberts’s  plan,  by  securing  the  ina- 
bility of  the  side  by  strapping. 

: ight-sweats,  when  profuse,  may  be  reduced 


1181 

by  oxide  of  zinc  (gr.  ij  to  iv),  by  gallic  or 
sulphuric  acids,  by  sulphate  of  iron,  byr  arse- 
niate  of  iron  (gr.  £ to  •!■),  but  most  effectually 
of  all  by  tho  preparations  of  belladonna,  in  the 
form  of  the  extract  (gr.  J to  gr.  1),  or  as  solu- 
tion of  sulphate  of  atropia  (iuj  to  ij),  or  used 
hypodermically.  Dover’s  powder  in  10-gr.  doses 
is  useful,  but  Dr.  Murrell  has  lately  strongly  re- 
commended picrotoxine  (gr.jjo,  inform  of  a pill), 
or  muscarine  (ii\v  of  one  per  cent,  solution),  to 
be  taken  at  bed-time,  as  more  effectual. 

Diarrhoea,  where  due  to  bilious  derangement 
and  an  acid  state  of  the  prim®  vise,  is  best 
treated  by  mercurial  purgatives,  combined  with 
carbonate  of  soda  or  lime-water.  Where  it 
partakes  of  the  nature  of  a flux,  accompanied  by 
a pale  tongue  and  great  debility,  it  may  be 
checked  by  astringents,  such  as  hsematoxylon, 
catechu,  krameria,  bael,  and  carbonate  or  citrate 
of  bismuth.  When  ulceration  of  the  intestine 
is  proceeding,  it  is  characterised  by  a red,  irri- 
table tongue,  pain  and  tenderness  of  the  abdo- 
men, and  persistency  of  the  diarrhoea.  Here, 
as  in  other  forms  of  ulceration,  opium  and  its 
salts  answer  best,  and  may  be  given  internally 
with  sulphate  of  copper  (grain  | to  £)  every 
three  or  four  hours.  When  the  stomach  is  too 
irritable  to  tolerate  medicine  by  the  mouth, 
opium  and  morphia  suppositories  are  useful,  but 
still  better  are  opiate  enemata,  which,  acting 
directly  on  the  irritable  ulcers,  check  the  pain 
and  diarrhoea,  and  often  afford  considerable  re- 
lief. In  very  obstinate  cases  tannic  acid  (four 
to  five  grains),  acetate  of  lead  (three  to  four 
grains),  may  be  added  to  the  injection.  The 
opposite  state  of  bowels,  namely,  constipation,  is 
very  common  in  the  early  stages  of  phthisis,  and 
is  best  corrected  by  changes  in  diet,  such  as 
the  use  of  brown  bread  and  oatmeal,  cooked  and 
fresh  fruit,  regular  exercise,  and  if  these  prove 
insufficient,  a mild  aloetic  or  rhubarb  pill,  or 
the  use  of  some  mineral  water,  as  Friedrichshall, 
Pullna,  Carlsbad,  Hunvadi  Janos,  and  others. 

Tho  dyspnoea  of  advanced  cases  generally 
arises  from  difficulty  of  expectoration,  and  the 
greatly  curtailed  respiratory  power,  and  may  be 
relieved  by  spiritus  setheris,  carbonate  of  am- 
monia, and  other  diffusible  stimulants.  The  pain 
arising  from  perforation  in  pneumothorax  is  best 
treated  by  opium,  and  strapping  the  side  to 
limit  tho  movements  of  respiration,  and  if  much 
liquid  effusion  or  accumulation  of  air  takes  place, 
it  is  sometimes  advisable  to  tap  the  chest;  but, 
as  a rule,  the  state  of  the  patient  does  not  allow 
of  very  active  measures. 

Bed-sores  should  be  prevented  by  the  use  of  a 
water-bed,  and  the  skin  of  the  dependent  parts 
can  be  fortified  by  lotions  of  spirit  and  water 
(one  part  in  four).  If  a bed-sore  has  formed,  it 
is  best  to  protect  it  from  friction  by  the  use  of 
circular  air  or  down  cushions,  or  thick  felt- 
plaister,  and  the  raw  surface  can  bo  painted  with 
collodion,  or  be  regularly  dressed. 

2.  Diet. — The  great  object  being  to  introduce 
as  large  a quantity  of  nutritious  food  as  can  be 
digested,  abundance  of  meat,  plainly  cooked, 
with  fresh  vegetables,  and  a fair  amount  of  bread 
and  starchy  food  should  be  given.  Fatty  mate- 
rial, if  it  can  be  digested,  should  be  largely- 
represented  in  the  dietary,  and  many  physicians 


PHTHISIS. 


1182 

advise  large  quantities  of  cream,  butter,  and 
suet ; but,  considering  the  large  amount  of 
fatty  matter  included  in  cod-liver  oil,  which  is 
r.  severe  test  at  first  to  the  digestive  powers, 
it  is  not  advisable  to  increase  the  amount  of 
fat  until  the  oil  is  well  tolerated.  Milk  (1  to 
li  pints  a day),  alone  or  with  lime-water,  is 
a staple  food  for  the  consumptive;  and  when 
cow’s  milk  disagrees,  ass’s  or  goat’s  may  often 
be  substituted  with  advantage.  Koumiss  and 
whey  are  frequently  used  in  (lermany  and  Kus- 
sia,  but  they  have  not  become  popular  in  this 
country.  The  digestive  powers  being,  as  a rule, 
weakened,  much  good  may  be  done  by  the  addi- 
tion of  animal  ferments,  such  as  liquor  pepticus 
and  liquor  pancreaticus  (Benger)  to  the  food, 
which,  becoming  peptonised,  is  much  more  easily 
assimilated  {see  Peptonised  Food).  In  the  early 
stages  stimulants  are  not  largely  required,  as 
they  increase  the  cough  and  lung-irritation  ; but 
when  the  strength  fails,  and  the  powers  of  diges- 
tion are  weak,  they  may  be  given  frequently,  and 
advantageously  combined  with  liquid  nourish- 
ment, such  as  eggs,  soups,  various  meat-essences 
and  panadas,  arrowroot,  and  jelly.  When  wine 
is  required,  in  chronic  cases,  it  will  be  found  that 
claret,  hock,  sauterne,  and  cliablis  tend  to  irri- 
tate the  cough  less  than  the  stronger  vines. 

Hygiene. — The  consumptive  patient  should 
inhabit  a well-ventilated,  well-drained  house, 
built  on  a dry  soil,  sand  or  gravel,  sheltered  from 
cold  winds  and  well  exposed  to  the  south,  not 
hemmed  in  by  trees,  the  most  suitable  for  the 
neighbourhood  of  the  house  being  of  the  coni- 
forae  order.  The  bed-room  should  be  lofty, 
provided  with  a fireplace  for  warmth  and  outlet 
ventilation ; and  unless  the  cubic  space  be  abun- 
dant, inlets  for  the  supply  of  fresh  air,  in  the 
form  of  vertical  tubes,  should  supplement  the 
ordinary  indraught  of  the  door  and  window. 

Clothing  and  Exercise.  — The  underclothing 
should  be  woollen,  either  flannel  or  lambswool, 
or  perhaps  in  summer  merino  may  be  allowed, 
the  object  being  to  secure  a good  non-conductor 
of  changes  of  the  temperature  which  will,  at  tho 
same  time,  absorb  cutaneous  moisture.  The  rest 
of  the  clothes  must  be  adapted  to  the  season,  the 
invalids,  male  or  female,  always  bearing  in  mind 
their  greater  liability  to  catarrh  than  ordinary 
persons,  and  using  wraps  freely,  more  especially 
when  driving. 

Exercise  must  depend  on  the  stage  of  the  dis- 
ease, and  the  strength  of  the  patient.  In  the  first 
stage,  especially  when  the  disease  is  limited  to 
one  lung,  and  no  fever  or  haemorrhage  is  present, 
active  exercise  in  the  form  of  walking  is  ad- 
visable. Under  careful  superintendence  cer- 
tain gymnastic  exercises  may  be  of  benefit, 
which,  by  raising  the  arms,  lift  the  upper  ribs, 
and  increase  the  size  of  the  thoracic  cavity, 
especially  in  the  upper  regions,  and  thus  necessi- 
tate a larger  inspiration  of  air,  and  in  time  this 
leads  to  further  development,  and  even  to  hy- 
pertrophy of  the  healthy  lung.  Emphysema  may 
be  produced  in  the  diseased  lung  by  this  means, 
which  is  useful  in  limiting  any  further  advance 
of  infective  tubercular  disease. 

Hiding  is  excellent  for  a large  number  of 
patients,  being  intermediate  between  the  active 
and  passive  varieties  of  exercise.  Where  tho 


disease  is  more  extensive  and  advanced,  only  tl 
passive  forms  of  driving  and  sailing  are  po 
sible. 

3.  Climate. — The  main  point  to  be  held  in  vie 
is  to  give  the  consumptive  a climate  in  which  i 
can  breathe  freely,  take  abundant  outdoor  exe 
cise,  and  experience  that  amount  of  stimulati: 
influence  which,  while  it  improves  his  appeti 
and  powers  of  digestion,  does  not  irritate  tl 
mucous  membrane  of  the  lungs  or  increase  tl 
cough.  The  selection  is  generally  difficult,  ai 
depends  not  only  on  the  class  of  cases,  but  mu 
be  sometimes  modified  by  individual  peculiarity 
See  Climate,  Treatment  of  Disease  by. 

The  writer’s  statistics,  founded  on  251  consum' 
tives,  who  passed  one  or  more  winters  out . 
England,  assign  the  most  favourable  results 
sea-voyages,  and  the  next  to  Egypt  and  other  dj 
climates.  The  Mediterranean  basin  followsne. 
in  point  of  success;  while  the  moist  tempera 
climates  of  Pau  and  Home  give  far  less  got 
results,  and  Madeira  only  slightly  surpass! 
these.  The  same  statistics  show  the  foreig 
health-stations  to  be  on  the  whole  more  sncces 
ful  in  prolonging  life  than  the  English  one.- 
but  we  must  not  forget  that  the  most  advance 
cases  fall  to  the  lot  of  the  latter,  on  account  of  tl 
difficulty  of  travelling  ; and,  on  the  other  ham 
a great  advantage  enjoyed  by  the  home  statiorl 
is  the  superiority  of  the  food  and  appliances  fc 
invalids,  which  may  in  some  degree  eompensa: 
for  the  smaller  number  of  days  in  which  exercb 
can  be  taken,  and  the  greater  vicissitudes  < 
weather.  Of  the  British  health-resorts  the  drye 
ones,  such  as  Hastings,  Ventnor,  and  Bournt 
mouth,  have  afforded  more  favourable  resultstha 
T orquay  and  Penzance.  It  is  impossible  in  a fe 
sentences  to  lay  down  rules  for  climate-selectio; 
but  a few  general  outlines  may  be  given  of  tl 
suitability  of  different  groups  of  agencies. 

The  British  south-coast  stations  are  benefid 
in  scrofulous  phthisis,  and  in  many  cases  whei 
the  appetite  is  poor,  and  tendency  to  catarrh  nt 
the  prevailing  feature.  In  the  catarrhal  form  c 
phthisis  Madeira,  and  the  West  India  Island, 
especially  the  Blue  Hills  of  Jamaica,  are  ac 
visable;  the  combination  of  warmth  with  salir 
influence,  and  the  absence  of  stimulating  qual 
ties,  seeming  to  answer  best. 

Dry  stimulating  marine  climates,  such  as  th 
Riviera,  Malaga,  and  Algiers,  are  recommends 
in  phthisis  of  inflammatory  origin,  and  in  a. 
cases  where  it  is  desirable  to  combine  stimulatin 
influence  with  a moderate  degree  of  warmth,  an 
decided  dryness  of  atmosphere. 

Where  the  stimulating  influence  is  undesirable 
as  in  patients  of  excitable  temperament,  or  irr: 
table  gastric  mucous  membrane,  the  very  dr 
inland  climates,  like  those  of  Egypt  or  Sout 
Africa,  are  preferred. 

Sea- voyages  to  Australia  and  New  Zealand,  o 
the  shorter  one  to  the  Cape,  are  indicated  i 
cases  of  haemorrhagic  phthisis,  in  cases  of  lim: 
ted  first  or  third  stage,  where  the  patient 
strength  is  unequal  to  much  exercise,  and  wher 
he  or  she  have  suffered  from  close  confinemen 
in  crowded  cities. 

High  altitudes. — The  increasing  mass  of  testi 
mony  in  favour  of  this  form  of  climate-treatmen 
for  consumption,  in  both  Europe  and  America 


PHTHISIS. 

Lugurs  that  in  a few  years  it  will  he  used  more 
largely. 

At  present  the  Andes,  the  Eocky  Mountains, 
ind  the  Alps,  and  even  the  South  African  high- 
lands, are  frequented  by  consumptives ; but  the 
Renditions  of  temperature  and  altitude  manifestly 
vary  greatly ; and  while  the  climates  of  Quito  and 
Santa  Fe  di  Bogota  resemble  in  temperature 
hat  of  Malaga,  the  winter  extremes  of  Davos 
in  the  Alps  are  more  nearly  akin  to  those  of 
panada.  In  all  these  places,  however,  there 
Exists  a distinctly  specific  influence  apart  from 
hat  of  heat  and  moisture,  in  the  form  of  di- 
ninisked  barometric  pressure,  which  is  shown 
to  the  patients  residing  at  high  altitudes.  The 
Shest  becomes  expanded,  and  hypertrophy  of 
She  healthy  lung-tissue  takes  place,  accompanied 
py  vesicular  emphysema  around  the  lesions. 
Patients  in  the  first  or  third  stage  of  phthisis 
Syith  only  limited  lesions,  endowed  with  fair 
nwors  of  circulation  and  able  to  take  exercise, 
.re  the  proper  cases  for  this  form  of  climate, 
nd  in  many  of  such  complete  arrest  of  the  dis- 
ease may  be  confidently  predicted. 

C.  Theodore  Williams. 

PHYSICAL  EXAMINATION-.—1 The  ob- 
ject of  a physical  examination  is  to  ascertain 
[he  precise  seat,  limits,  and  characters  of  those 
evidences  of  disease  which  are  recognisable  by 
lur  senses,  and  which  are  called  physical  signs, 
n making  such  an  examination  we  bring  to  hear 
i’ll  our  senses,  with  whatever  instrumental  aids 
|iiay  he  available  to  detect  the  signs  of  disease. 
!n  the  present  article  a description  will  be  given 
if  the  physical  examination  of — (1)  the  patient 
isnerally ; (2)  the  cerebro-spinal  system  ; (3)  the 
ispiratory  system ; (4)  the  organs  of  circulation  ; 
p)  the  mediastinum ; and  (6)  the  abdomen. 

1.  General  Survey. — Our  attentiou  will  first 
f all  be  naturally  attracted  to  the  physiognomy 
f the  patient,  that  is  to  his  general  appearance 
ad  build.  We  note  his  apparent  height  and 
eight,  and,  if  possible,  correct  our  observation 
y scale  and  measure.  We  observe  the  state 
\f  nutrition,  firmness  or  laxness  of  muscle,  cor- 
ulence,  thinness,  emaciation — atrophy  of  any 
articular  muscle  or  group  of  muscles.  The 
implexion  of  the  patient  is  to  be  remarked, 
hether  clear,  sallow,  dark,  fair,  jaundiced,  or 
gmented ; also  lividity  or  pallor  of  surface  and 
ucous  membranes.  The  apparent  age  as  con- 
asted  with  actual  years  of  the  patient;  elas- 
pity  of  features,  condition  of  hair,  presence  of 
reus,  &c.  The  symmetry  and  play  of  features, 
lie  expression  whether  of  vivacity,  despondency, 
iffering,  anxiety,  paralysis,  or  hysteria.  See 
HYSIOGNOMY. 

Whilst  making  these  preliminary  observations, 
'general  outline  of  the  history  of  the  patient  and 
his  present  illness  will  have  been  elicited. 

The  pulse  should  next  he  noted  (see  Pulse). 
e may,  in  important  cases,  extend  our  in- 
juries or  record  our  observations  by  means  of 
e sphygmograph.  See  Sphygmograph. 

The  respiration  of  the  patient  requires  atten- 
m as  regards  rapidity ; mechanism,  that  is, 
hether  abdominal  or  thoracic  in  normal  pro- 
ntion ; rhythm,  regular  or  irregular,  easy  or 
boured;  and  freedom  or  otherwise  from  pain. 


PHYSICAL  EXAMINATION.  11  S3 

The  action  of  the  nares,  and  any  recession  or 
otherwise  of  soft  parts  during  respiration,  should 
be  especially  observed.  See  Spirometer. 

In  health  and  under  physiological  conditions 
of  age,  exercise,  emotion,  &c.,  there  is  a tolerably 
constant  ratio  between  the  respiration  and  pulse- 
rate,  namely,  one  respiration  to  from  three  to  four 
pulse-beats.  In  disease  this  ratio  is  often  much 
altered.  The  average  respiration-rate  in  a healthy 
adult  is  from  17  to  20  per  minute,  in  the  infant 
about  40  per  minute,  between  one  and  five  years 
about  26  per  minute.  In  old  age  the  prepirations 
are  very  slightly  accelerated:  in  children  they 
arc  quick  and  otten  irregular,  being  momentarily 
suspended  by  anything  that  excites  their  wonder 
or  close  attention. 

The  odour  of  the  hreath  may  attract  attention. 
It  may  under  morbid  conditions  be  fetid,  uri- 
nous, ‘ mercurial,’  alcoholic,  or  gangrenous.  See 
Breatii,  The. 

The  condition  of  the  shin,  whether  dry  or 
hot,  moist  or  sweating,  and  the  presence  or  ab- 
sence of  any  eruption,  scars,  ulcers,  or  pigmen- 
tation, will  be  duly  noted.  The  presence  of 
pyrexia  will  be  exactly  ascertained  by  the  use 
of  the  clinical  thermometer,  an  instrument 
which  ranks  with  the  stethoscope  in  value  ; hut 
the  employment  of  the  thermometer  does  not 
exclude  the  necessity  of  testing  the  condition  of 
the  surface  by  the  hand,  whereby  we  observe  the 
resultant,  so  to  speak,  of  the  bodily  heat,  tem- 
pered it  may  bo  by  evaporation,  or  exaggerated 
by  undue  dryness  in  exposed  parts.  Probably 
the  use  of  the  surface  thermometer,  in  combi- 
nation with  the  ordinary  clinical  instrument, 
would  more  exactly  give  us  this  information, 
upon  which  important  therapeutical  indications 
rest ; but  the  hand  of  the  skilled  observer  fully 
suffices  for  the  purpose.  The  surface  thermo- 
meter is  of  value  in  estimating  localised  eleva- 
tions of  temperature ; for  example,  over  the  site 
of  an  empyema,  in  peritonitis,  and  in  connection 
with  certain  nerve-lesions.  See  Thermometer. 

The  condition  of  the  finger-ends— clubbiug, 
lividity — must  be  observed.  Important  infor- 
mation as  to  previous  acute  illnesses  within  the 
past  six  months  can  be  obtained  by  inspecting 
the  nails,  a transverse  furrow  marking  the 
period  of  defective  or  arrested  nutrition  during 
such  illness. 

The  condition  of  the  teeth  may  indicate  pre- 
vious illness  or  syphilitic  inheritance. 

The  state  of  the  eyes,  and  especially  any  ir- 
regularity of  the  pupils,  requires  attention. 

The  condition  of  the  tongue  and  gums  furnishes 
us  with  valuable  information. 

The  careful  superficial  inspection  of  the  patient 
in  the  manner  above  sketched  w’ill  perhaps  at 
once  lead  to  a more  minute  examination  of  some 
one  organ  or  system  of  organs  as  the  probable 
seat  of  disease ; and  having  thus  far  succeeded 
in  locating  the  disease,  the  other  organs  and 
functions  of  the  body  will  of  course  come  under 
review,  but  the  physician  will  be  more  especially 
inquisitive  with  regard  to  such  organs  or  func- 
tions as  may  he  in  sympathy  with  those  in  which 
disease  has  been  detected. 

It  may  he,  however,  that  on  careful  examination 
we  fail  to  find  any  organic  lesion  to  account  for 
the  symptoms  present,  and  for  signs  of  wasting, 


PHYSICAL  EXAMINATION. 


1184 

pyrexia,  &e.,  which  notify  the  illness  of  the  pa- 
tient. We  may  then — but  not  till  then — refer 
the  case  to  one  of  those  blood-conditions  which 
for  a time  run  their  course  without  manifesting 
any  definite  lesion. 

Again,  it  may  be  that  certain  signs  of  general 
illness,  and  especially  pyrexia  and  wasting,  can- 
not be  accounted  for  sufficiently  by  the  amount 
of  disease  discovered.  Here  we  must  suspect 
that  the  lesion  we  have  ascertained  is  but  an  ex- 
pression of  a more  general  state. 

Having  made  these  remarks — relating  to 
orderly  measures  of  inquiry,  without  a due  re- 
gard to  which  no  physician  or  surgeon,  however 
skilful  in  any  one  department,  can  fail  to  com- 
mit the  errors  of  the  narrowest  specialist — we 
will  proceed  to  consider  the  physical  examination 
of  those  regions  of  the  body,  especially  the  chest 
and  abdomen,  in  which  objective  signs  can  be 
accurately  observed. 

2.  Cerebro-spinal  System,  Physical  Ex- 
amination. of. — The  objective  phenomena  of 
disease  affecting  thenervous  system  are  often  very 
obscure,  and  it  is  the  more  important  that  they 
should  be  sought  for  in  a methodical  manner. 

(a)  The  Head, — The  head  should  be  examined 
ks  to  size,  shape,  condition  of  fontanelles,  the 
presence  of  wounds,  tumours,  or  depressions. 

The  size  of  the  head  varies  greatly  in  different 
people,  without  any  seemingly  corresponding 
variation  in  the  condition  of  the  brain.  It  is 
very  difficult  to  say  whether  enlargement  of 
head  is  due  to  thickening  of  the  skull  or  en- 
largement of  its  contents.  In  rickets  and  in 
hydrocephalus  the  head  is  relatively  large  ; in 
idiocy  relatively  small. 

The  shape  of  the  head  is  of  more  importance 
than  the  size.  We  may  recall  the  long  head, 
with  square,  high  forehead,  of  rickets ; the  broad, 
vaulted  skull,  with  shallow  orbits  and  prominent 
eyes,  of  hydrocephalus. 

The  condition  of  the  anterior  fontanelle  must 
be  carefully  observed  in  all  cases  of  children 
with  cerebral  symptoms— it  should  be  neither 
tense  nor  depressed. 

The  detection  of  local  changes,  such  as  thicken- 
ings, tumours,  scars,  or  depressions  over  the  skull, 
will  throw  much  light  upon  a case  presenting 
cerebral  symptoms. 

(b)  The  Spinal  Column. — -The  spinal  column 
must  be  carefully  examined  for  undue  promi- 
nence or  depression  of  spinous  processes,  or 
other  tumours,  and  for  lateral  or  antero-posterior 
curvature.  Kneading  and  percussion  should  be 
employed  over  each  spinous  process  to  elicit  any 
tenderness.  The  fingers  should  be  passed  firmly 
along  the  spinal  groove  on  either  side  to  ascertain 
if  there  be  any  painful  point,  and  much  care 
must  bo  taken  not  to  confound  such  pain  (com- 
monly neuralgic)  with  true  spinal  tenderness. 
The  application  of  the  hot  sponge,  or  ice-bag, 
successively  to  different  parts  of  the  spine  is  a 
means  of  eliciting  valuable  signs  of  disease. 

In  all  cases  of  suspected  spinal  or  cerebral 
disease  the  superficial  and  deep  reflex  actions 
should  be  tested,  as  affording  important  indi- 
cations respecting  the  integrity  of  successive 
portions  of  the  cord,  and  the  condition  of  the 
parts  above.  See  Spinal  Cord,  Diseases  of. 


By  the  ophthalmoscope  an  example  of  the  cere- 
bral circulation  may  be  observed  in  the  retina, 
and  the  condition  of  vessels  noted.  Certain 
lesions  of  the  optic  disc  correspond  also  with 
deeper  and  more  widespread  nervous  disease  (see 
Ophthalmoscope  in  Medicine).  By  the  use  of 
graduated  compasses  the  sensibility  of  the  peri- 
pheral nerves  may  be  estimated.  Electricity 
enables  us  to  ascertain  the  irritability  of  volun- 
tary muscles;  and  by  the  dynamometer  we  may 
compare  muscular  power  on  the  two  sides,  ike 
Electricity  ; and  Dynamometer. 

Further  details  respecting  the  diseases  of  the 
nervous  system,  and  the  methods  for  their 
diagnosis,  will  be  found  under  appropriate 
headings. 

3.  Respiratory  System,  Physical  Exami. 
nation  of. — The  respiratory  system  includes  the 
respiratory  tract  and  lungs. 

(a)  Larynx. — The  condition  of  the  larynx 
and  trachea  vs  examined  into  by  listening  to  the 
voice,  whether  husky,  altered  in  tone,  or  sup- 
pressed Any  tenderness  or  external  deformity 
is  ascertained  by  careful  palpation. 

By  means  of  the  laryngoscope  the  condition 
of  the  epiglottis,  larynx,  and  trachea  can  be 
thoroughly  explored.  See  Laryngoscope;  and 
Larynx,  Diseases  of. 

(b)  Chest. — In  making  an  examination  of  the 
chest,  the  physician  should  follow  a methodical 
routine  of  inspection,  palpation,  percussion, 
and  auscultation. 

1.  Inspection. — The  general  shape  and  build 
of  the  chest  is  observed  — whether  it  be  the 
broad,  well-formed  chest  of  robust  health;  or  the 
small,  narrow,  long  chest,  with  antero-posterior 
and  lateral  diameters  diminished,  costal  angle 
narrow,  and  ribs  oblique  and  approximated — 
adapted  to  small  lungs.  Or  the  thorax  may  be 
unduly  expanded,  with  wide  intercostal  spaces, 
straightened  ribs,  widened  costal  angle,  and  deep 
antero-posterior  diameter,  to  accommodate  large 
lungs.  Again,  the  thorax  may  be  distorted  by 
various  kinds  of  spinal  curvature,  or  as  the  re- 
sult of  rickets,  or  from  external  pressure,  as  in 
the  depressed  lower  sternum  of  shoemakers  (see 
Deformities  of  the  Chest).  Lastly,  there  may 
be  local  flattenings  or  bulgings. 

The  movements  of  the  chest  are  of  great  impor- 
tance in  diagnosis.  We  estimate  the  freedom  or 
otherwise  with  which  air  enters  the  chest  during 
inspiration  by  the  equable  expansion  of  itsseveral 
parts,  or  by  the  immobility  or  recession  of  any 
portion  the  entry  of  air  into  which  is  retarded  or 
impeded;  and  thiscan  be  accurately  done  bymeans 
of  the  pneumograph.  In  cases  of  general  ob- 
struction to  entry7  of  air,  whether  by  impediment 
at  the  main  air-passage  or  in  itsentire  distribution, 
there  is  universal  recession  of  all  the  soft  parts — 
the  supra-clavicular  region  sinks  downwards,  the 
hypochondria  recede,  and  the  intercostal  spaces 
deepen  during  the  effort  to  expand  the  chest 
against  atmospheric  pressure.  On  the  other  hand, 
when  the  difficulty  of  expansion,  whether  from 
intrinsic  disease  or  obstruction  of  passages,  is  re- 
stricted to  one  side  of  the  chest  or  to  a portion  of 
one  lung,  the  restrained  expansion  during  inspira- 
tion is  limited  to  that  portion.  Thus  from  in- 
spection alone  we  may  often  forma  shrewd  gnosf 


PHYSICAL  EXAMINATION.  HS5 


as  to  the  seat  and  even  the  nature  of  the  disease 
present. 

In  estimating  local  alteration  of  shape  the  eye 
is  perhaps  more  useful  than  any  instrument  of 
measure.  Calipers  of  various  patterns  may  he 
used  for  taking  diameters  in  different  direc- 
tions. Eut  for  recording  differences  of  shape 
on  the  two  sides  the  cyrtometer  is  very  useful. 
This  instrument  was  originally  introduced  by 
M.  TVoillez,  and  consisted  of  two  halves  of 
a jointed  whalebone  measure,  connected  by  a 
hinge,  which  could  be  adapted  accurately  to  the 
shape  of  the  chest,  and  after  removal  the  various 
curves  on  the  two  sides  could  be  traced  on  paper. 
The  cyrtometers  now  most  in  use  are  made  of 
soft  metal,  two  sufficiently  long  pieces  of  which 
are  connected  by  an  indiarubber  joint  or  hinge. 

Double  tape-measures  are  also  used  for  ascer- 
taining the  circumference  on  the  two  sides,  and 
by  their  means  the  relative  expansion  during 
respiration  on  the  two  sides  can  be  compared. 
Various  forms  of  stethometer  have  been  designed 
for  the  same  purpose.  See  Stethometer. 

The  vital  capacity  of  the  lungs  may  be  very 
accurately  estimated  by  means  of  the  spirometer. 
See  Spirometer. 

2.  Palpation. — Palpation  is  employed  in  aid 

of  both  inspection  and  percussion.  # 

a.  During  preliminary  inspection  of  the  chest 
the  position  of  the  heart's  apex-beat  should  be 
invariably,  and  as  a matter  of  habit,  ascertained, 
and  any  deviation  front  its  normal  seat,  namely, 
the  fifth  intercostal  space  one  inch  to  the  sternal 
side  of  the  left  nipple  line,  should  be  noted. 

b.  Any  local  bulging  or  tumour  will  naturally 
bo  manipulated  to  ascertain  its  relation  with 
bone,  or  soft  structure,  whether  it  be  solid  or 
soft,  fluctuating  or  pulsatile. 

c.  In  connection  with  percussion,  the  trained 
observer  will  note  differences  of  resistance,  as 
well  as  of  sound,  over  diseased  areas. 

d.  Increase  or  diminution  of  vocal  vibration 
or  fremitus  will  be  noted  over  any  spot  of  altered 
resonance,  by  applying  the  hand  and  making  the 
patient  utter  some  resonant  words,  such  as 
‘ninety-nine.’ 

Vocal  fremitus  is  increased  by  consolidation 
of  lung;  diminished  by  much  thickening  of  the 
pleura,  by  obstruction  to  the  main  bronchus,  or 
bv air  in  the  pleura;  annulled  by  fluid  in  the 
pleura.  N.B. — In  many  cases  of  fluid  in  the  pleura 
some  vibrations  are  felt,  probably  communicated 
from  above.  The  loudness  or  feebleness  of  the 
. voice  must  of  course  be  taken  into  account  in 
estimating  fremitus,  and  corresponding  parts  on 
the  two  sides  should  always  be  compared. 

Loud,  coarse,  bronchial  rales  may  cause  the 
riiest-walls  perceptibly  to  vibrate,  producing 
rhonchal  fremitus.  Pleuritic  friction  may  like- 
wise be  perceptible  to  the  hand  applied — friction 
fremitus.  In  cases  of  effusion  into  the  pleural 
cavity,  or  in  hydatid  cysts  near  the  surface, 
fluctuation  may  be  elicited  on  palpation. 

3.  Percussion. — Percussion  is  the  method  of 
examination  by  which  we  detect  the  various  de- 
grees of  resonance  of  different  parts  of  the  chest, 
depending  upon  the  relative  amount  of  air  and 
•olid  structure. 

It  is  best  to  use  the  fingers  for  percussing, 
one  finger  of  the  left  hand  being  placed  firmly 


over  the  point  to  be  percussed,  and  struck  with 
one  or  two  of  the  fingers  of  the  right  hand, 
semi-flexed,  so  that  the  tips  of  ths  fingers  fall 
vertically  upon  the  pleximeter  finger.  Percus- 
sion should  be  made  from  the  wrist,  not  from 
the  elbow  ; the  stroke  should,  as  a rule,  be  light, 
and  always  perfectly  even  on  the  two  sides  ; 
sometimes  a heavier  stroke  may  be  needed,  but, 
as  a rule,  far  more  information  is  obtained  from 
light  than  from  heavy  percussion.  In  comparing 
the  percussion  note  over  the  two  sidos  of  the 
chest,  points  exactly  corresponding  must  be 
taken,  and  the  pleximeter  finger  must  be  placed 
in  a corresponding  position  ; for  example,  it 
must  not  he  placed  parallel  with  the  ribs  on 
one  side  and  across  them  on  the  other. 

The  sense  of  touch  is  very  valuable  in  per- 
cussion in  estimating  resistance  of  the  part 
struck.  Dulness,  and  particularly  the  hardness 
and  want  of  resilience  over  thickened  adherent 
pleura,  may  thus  be  readily  felt  by  the  pleximeter 
finger  during  percussion.  This  sense  of  touch 
should  be  carefully  cultivated,  and  its  depriva- 
tion is  a great  disadvantage  in  the  use  of  the 
artificial  pleximeters  and  percussors  first  intro- 
duced by  Piorry,  although  possibly  these  may 
be  useful  for  demonstration  to  a class.  The  ob- 
server should  not  be  content  with  comparing 
corresponding  points  on  the  two  sides  of  the 
chest  front  above  downwards,  but  he  should  in- 
variably trace  any  dulness  or  resonance  from 
either  side  across  the  sternum  to  ascertain  the 
limits  of  resonance  or  dulness  in  this  direction. 
From  neglect  of  this,  important  information  is 
often  missed.  The  height  to  which  the  pulmo- 
nary note  extends  above  the  clavicle  on  the  two 
sides  should  be  compared. 

Regions  of  the  Chest. — For  convenience  in 
describing  the  distribution  of  signs,  both  of  per- 
cussion and  auscultation,  it  is  customary  to  divide 
the  chest  into  regions.  The  names  employed  to 
distinguish  these  regions  sufficiently  define  their 
limits,  namely,  the  supra-clavicular,  clavicular, 
infra-  or  sub-clavicular,  mammary,  infra-mam- 
mary regions  on  each  side  in  front;  the  superior 
and  inferior  axillary  regions ; the  supra-spiuatus, 
infra-spinatus,  interscapular,  and  infra-scapular 
regions  on  each  side  posteriorly. 

(a)  Normat.  Percussion  Signs. — There  is  a 
certain  standard  degree  of  resonance  over  the 
lungs,  only  to  be  duly  estimated  by  experience, 
which  is  known  as  normal  pulmonary  resonance. 
In  certain  regions  of  the  chest  the  pulmonary 
resonance  is  naturally  lessened  or  replaced  by 
dulness.  Pulmonary  resonance  should  commence 
1^  inch  above  the  level  of  the  clavicle.  In  the 
clavicular  and  sub-clavicular  regions,  on  firm 
percussion,  the  note  should  be  even  on  the  two 
sides,  as  low  as  the  third  rib.  Below  this  level 
on  the  right  side,  we  still  obtain  full  resonance 
until  we  arrive  at  the  fourth  space,  where  in  the 
mammary  line  the  note  becomes  slightly  raised 
and  shortened,  becoming  dull  in  the  fifth  space 
and  downwards  to  the  margin  of  the  cartilages. 
On  very  light  percussion  the  pulmonary  re- 
sonance may  be  obtained  half  a space  lower,  and 
at  least  an  inch  to  two  inches’  difference  in  level 
may  be  obtained  between  the  extreme  limits  of 
deep  expiration  and  inspiration.  In  the  lateral 
(axillary)  region  the  limit  of  percussion-resonance 


1186 


PHYSICAL  EXAMINATION. 


reaches  about  an  interspace  lower.  At  the 
sternal  margin  it  is  a little  higher,  from  the 
encroachment  of  the  right  side  of  the  heart  upon 
the  inferior  angle  of  the  lung.  Roughly,  and 
for  clinical  purposes,  a line  drawn  outwards  from 
the  base  of  the  xiphoid  cartilage  may  be  said  to 
define  the  upper  border  of  the  liver-duhiess. 

On  the  left  side,  in  the  line  midway  be- 
tween the  sternum  and  nipple,  we  already,  at 
the  third  cartilage,  obtain  elevation  of  pitch  and 
shortening  of  the  percussion  note;  and  at  the 
fourth  space  dulness.from  the  underlying  heart. 
Between  this  (mid-sterno-nipple)  line  and  the 
sternum,  and  bounded  above  by  the  fourth  carti- 
lage and  below  by  the  level  of  the  apex-beat,  is 
the  normal  area  of  superficial  cardiac  dulness.  In 
the  nipple  line  at  the  corresponding  levels 1 some 
deadening  of  percussion  note  may  be  obtained, 
but  pulmonary  resonance  is  otherwise  clear  to  the 
sixth  rib  ; in  the  lateral  axillary  region  to  the 
seventh.  Below  the  sixth  rib  in  front,  and  the 
seventh  laterally,  stomach  resonance  is  obtained. 

Over  the  sternum , percussion  is  naturally 
somewhat  wooden  and  resisting,  within  degrees 
varying  with  the  condition  of  the  bones.  The 
first  piece  of  the  sternum  is  normally  some- 
what less  resonant  than  the  next  two  pieces,  but 
it  should  be,  on  firm  percussion,  by  no  means 
dull.  Below  the  level  of  the  fourth  cartilages 
the  heart  and  liver  cause  the  note  to  be  dull, 
although  even  hero  a certain  degree  of  reson- 
ance is  in  health  communicated  from  the  adjacent 
right  lung. 

In  the  posterior  regions  of  the  chest  the 
degrees  of  resonance  are  almost  entirely  in  ac- 
cordance with  the  thickness  and  character  of 
superjacent  tissues.  Thus  in  the  scapular  and 
inter-scapular  regions  increased  force  of  percus- 
sion is  necessary  to  elicit  pulmonary  resonance, 
whilst  in  the  lateral  and  infra-scapular  region 
the  percussion  note  is  full  and  low-pitched.  On 
the  right  side  this  resonance  is  replaced  by  dul- 
ness below  the  tenth  rib,  and  deep  percussion 
will  elicit  a certain  impairment  of  resonance  as 
high  as  the  ninth  rib,  in  the  mid-scapular  line. 
On  the  left  side  resonance  should  be  good  to  the 
extreme  base,  except  that  in  the  posterior  axillary 
line  a small  and  restricted  area  of  dulness  may 
be  sometimes  made  out,  corresponding  with  the 
position  of  the  spleen. 

(b)  Mobbid  Percussion  Signs. — Modifications 
in  the  distribution  of  percussion-resonance  over 
the  chest  may  be  produced  either  by  general  or 
by  local  causes. 

General  causes.— Pulmonary  vesicular  emphy- 
sema, by  enlarging  the  lungs  and  extending  their 
boundaries,  causes  encroachment  of  pulmonary 
resonance  over  those  regions — the  prsecordial, 
. right  infra-mammary,  sternal,  and  right  inferior 
basic,  which  are  normally  dull.  In  congenital 
smallness  of  lungs  the  boundaries  of  pulmonary 
resonance  are  somewhat  retracted,  so  that  liver- 
dulness  in  front  and  behind  is  slightly  higher,  and 
heart-dulness  more  extensive. 

Local  causes. — One  class  of  these  are  encroach- 
ments of  other  organs.  Enlargement  of  the  heart 

1 By  employing  the  terms  ‘ lines  ’ and  ‘ levels  ’ to  mean 
the  vertical  lines  and  horizontal  levels,  in  connection 
with  definite  anatomical  points,  e.g.  mid-scapnlar-,  nipple- 
lines, nipple-,  second-,  third  , fourth-,  &c.,  rib  levels,  any 
portion  of  the  chcst-eurface  may  be  accurately  defined. 


will  cause  increased  area  of  praecordial  dulness 
upwards  and  to  the  left,  or  upwards  and  to  the 
right,  according  as  the  left  or  right  side  of  the 
heart  is  most  affected.  Effusion  into  the  peri- 
cardium will  cause  similar  dulness,  extending  up- 
wards towards  the  manubrium  stemi,  and  to  the 
right  beyond  the  sternum.  Aneurismal  tumours 
in  connection  with  the  heart  or  great  vessels, 
give  rise  to  dulness,  chiefly  in  the  neighbour- 
hood of  the  sternum  above  the  fourth  carti- 
lage, or  in  one  or  other  inter-scapular  region. 
Enlargement  of  the  liver  and  spleen  will  cause 
them  to  encroach  upon  the  pulmonary  resonance. 
Effusion  into  the  peritoneum,  if  extensive,  will 
cause  displacement  upwards  of  the  abdominal 
organs  and  diaphragm,  encroaching  upon  the 
lower  area  of  pulmonary  resonance,  and  even 
causing  collapse  of  the  lower  portion  of  the 
lungs,  thus  giving  rise  to  dulness. 

Effusion  of  fluid  into  the  pleura  will  give 
rise  to  absolute  dulness  to  the  level  to  which  the 
effusion  extends  upwards.  The  upper  boundary 
of  this  dulness,  if  the  lungs  be  sound,  varies 
slightly  with  the  position  of  the  patient.  In 
order,  however,  accurately  to  define  the  upper 
margin  of  dulness  from  fluid  effusion  the  lightest 
possible  percussion  must  be  employed.  In  any 
case  of  considerable  effusion  into  the  pleura  the 
dulness  encroaches  upon  the  median  line,  and  to- 
wards the  opposite  side.  See  Pleura,  Diseases  of. 

The  chief  kinds  of  morbid  percussion  signs 
will  now  be  discussed. 

Dulness,  hardness,  flatness. — These  terms  are 
by  no  means  synonymous  with  regard  to  per- 
cussion sounds.  Dulness  varies  infinitely  in 
degree.  Thus  over  a pleuritic  effusion  the  tone- 
lessness  is  absolute : and  to  this  degree  of  com- 
pleteness of  dulness  the  term  flatness  of  percus- 
sion-note is  sometimes  applied.  There  are  but 
a few  other  chest-conditions  in  which  such  abso- 
lute dulness  is  obtained  ; for  example,  extensive 
pericardial  effusions,  hydatid  tumours,  extensive 
malignant  growths  invading  the  lungs  and  in- 
filtrating the  bronchi.  In  inflammatory  conso- 
lidation of  the  lung  there  is  always  a certain 
degree  of  wooden  tone  in  the  percussion  note. 
In  cases  of  scattered  patches,  or  nodules,  of 
consolidation  in  the  lungs,  with  air-containing 
tissue  around,  the  dulness  may  be  only  very 
slight,  amounting  to  a mere  shortening  of  the 
note  with  elevation  of  pitch.  In  estimating  the 
slight  shades  of  dulness  elevation  of  pitch  is  the 
first  point  to  arrest  the  attention.  Hardness  oi 
percussion,  always  more  or  less  appreciable  with 
dulness,  is  associated  especially  with  consolida- 
tions of  lung  overlaid  by  thickened  adherent 
pleura. 

Skodaic  resonance.  - — In  all  eases  of  con- 
siderable effusion  of  fluid  into  the  pleura,  in 
whiclt  the  lung  is  not  completely  collapsed,  a 
peculiar  high-pitched  tympanitic  resonance  is 
found  at  the  sterno-clavicular  region  on  the  same 
side.  This  resonance,  called  Skodaic  resonance, 
is  a very  characteristic  sign,  and  has  been  attri- 
buted to  relaxation  of  luDg  still  in  contact  with 
the  chest-wall.  As  the  effusion  advances  tc 
completely  fill  the  chest,  this  resonance  becomes 
replaced  by  dulness. 

When  effusion  of  fluid  follows  upon  pneumo- 
thorax, the  lung,  unless  held  above  by  stn  nj 


PHYSICAL  EXAMINATION.  118? 


adhesions,  is  already  completely  collapsed  ; and 
above  the  level  of  the  dulness  caused  by  fluid 
there  is  a tympanitic  note,  caused  by  free  air  in 
the  pleura.  In  this  case  the  level  of  the  fluid 
in  the  pleura  shifts  with  every  change  in  the 
position  of  the  patient. 

Whether  the  effusion  be  of  serum,  pus,  or  blood, 
the  percussion  signs  are  the  same. 

Wooden  percussion-note  is  obtained  by  per- 
cussing over  thickened  pleura  with  some  air- 
containing  tissue  beneath.  The  sense  of  re- 
sistance is  marked,  the  pitch  high,  and  the  dura- 
tion of  sound  short.  This  degree  of  dulness, 
with  increased  resistance,  is  commonly  present 
below  the  clavicle  in  cases  of  phthisis,  with 
thickened  pleura,  and  perhaps  small,  empty 
cavities,  bounded  by  hardened  lung-tissue. 

Amphoric  or  tubular  percussion  is  the  sound 
elicited  by  percussing  over  a superficial  empty 
cavity,  connected  by  adhesions  to  the  chest- 
wall.  The  pitch  varies  with  the  size  of  the 
cavity,  but  is  always  somewhat  high.  The 
Eound  can  be  exactly  imitated  by  percussing  the 
cheek  drawn  tensely  over  the  teeth,  with  the 
mouth  slightly  open. 

Cracked  'metal  sound , or  bruit  de  pot  file,  is 
obtained  by  sharp  percussion  over  a cavity  such 
ns  the  above.  Sudden  displacement  of  air  in  the 
cavity  will  cause  the  sound,  which  somewhat 
resembles  that  produced  by  placing  the  two 
aands  hollowed  in  apposition,  and  striking  upon 
\lie  kn.ee.  A little  secretion  in  the  cavity  will  fa- 
cilitate the  production  of  the  sound.  This  sound 
may  often  be  appreciated  by  the  touch  before 
it  can  be  heard.  It  is  of  little  clinical  value. 

Bell-sound  is  elicited  by  combined  percussion 
and  auscultation,  and  when  present  is  charac- 
, teristic  of  pneumothorax.  The  stethoscope  must 
oe  applied  over  the  resonant  part  of  the  chest, 
md  at  another  point  within  the  same  area  a piece 
of  metal,  such  as  a coin,  laid  upon  the  chest, 
must  be  smartly  struck  with  a second  piece  of 
metal.  The  auscultator  hears  a sound  of  a clear 
bell-like  character  within  the  chest,  which  is  of 
.quite  a different  quality  from  that  produced  by 
the  mere  contact  of  metals.  It  is  essential  for  the 
production  of  this  sign  that  the  stethoscope  and 
the  struck  metal  be  both  within  the  area  of'ehest- 
surface  corresponding  with  the  air-containing  sac 
of  the  pleura.  If,  for  instance,  either  be  placed 
over  a point  below  the  level  of  any  fluid  effusion 
present  the  sound  will  be  lost,  to  be  recovered 
.n  altering  the  position  of  the  patient  so  as  to 
displace  the  fluid.  By  means  of  this  sign,  the 
imits  of  a pneumothorax  may  be  accurately 
lefined. 

Hydatid  fremitus  is  a vibratile  sensation, 
(ometimes  to  be  felt  on  smart  percussion  over  an 
lydatid  effusion.  In  cases  of  pyo-pneumothorax 
. similar  sensation  may  sometimes  be  felt,  on 
iercussing  at  the  exact  level  of  the  surface  of 
he  effused  fluid. 

4.  Auscultation. — Auscultation  simply  means 
he  act  of  listening ; but  the  art  of  auscultation 
mplies  a great  deal  more  than  this,  namely,  the 
ppreciation  of  the  healthy  or  morbid  conditions 
'hich  produce  the  sounds  heard  on  applying  the 
it  to  the  chest  or  to  other  parts.  If  the  ear 
f the  observer  be  directly  applied  to  the  chest 
’ part  under  observation,  auscultation  is  said 


to  be  immediate.  If  some  substance  or  instru- 
ment be  used  as  a medium  between  the  ear  and 
the  part  under  observation,  mediate  auscultation 
is  said  to  be  practised.  Such  an  instrument  is 
named  a stethoscope.  See  Stethoscope. 

(а)  Normal  Respiratory  Sounds. — If  the  ste- 
thoscope be  applied  over  the  trachea  of  a healthy 
person,  tubular  blowing,  or  bronchial  respiration, 
is  heard — that  is,  a sound  as  of  air  blown  to  and 
fro  through  a tube,  and  with  moderate  velocity  ; 
the  mechanism  of  the  sound  being  the  entrance 
and  outflow  of  air-currents  through  the  narrowed 
glottic  aperture  of  the  trachea,  producing  sono- 
rous vibrations  within  the  tube  below.  As  the 
stethoscope  is  passed  downwards  to  the  first  piece 
of  the  sternum,  the  same  sound  is  still  heard,  but 
more  distant  and  muffled.  In  the  upper  inter- 
scapular region,  where  the  great  divisions  of 
the  bronchi  arc  comparatively  superficial,  the 
tracheal  sounds  may  still  be  indistinctly  recog- 
nised; but  below  and.  aside  from  these  points 
these  sounds  are  normally  obscured  by  the  vesi- 
cular pulmonary  sounds,  into  the  production  of 
which  they,  however,  necessarily  enter.  • 

The  pulmonary  vesicular  breath-sound  is  pro- 
duced by  the  friction  of  air  entering  the  air-sacs 
from  the  minute  bronchioles,  and  it  is  supple- 
mented by  the  conduction  of  what  remains  of  the 
glottic  breath-sound,  now  infinitely  subdivided. 
During  calm  breathing  the  sound,  accompany- 
ing inspiration  should  be  soft  and  breezy,  giving 
the  idea  of  innumerable  similar  and  associated 
sounds.  In  intensity  the  sound  is  even  from 
commencement  to  near  the  end,  when  it  fades 
without  perceptible  interval  into  the  expiratory 
sound.  The  expiratory  sound  commences  at 
the  moment  inspiration  ceases,  being  continuous 
with  the  inspiratory  sound,  but  it  rapidly  fades 
in  intensity',  ceasing  to  be  audible  after  the  first 
one-fifth  or  one-third  of  the  expiratory  act.  Of 
the  time  occupied  between  the  commencement 
of  one  inspiration  and  that  of  the  next,  the  in- 
spiratory act  occupies  nearly  one-half  (A-ths), 
the  expiratory  act  the  remainder,  with  the  ex- 
ception of  a very  brief  interval  of  pause,  between 
the  end  of  expiration  and  the  commencement  of 
the  next  inspiration.  It  may  here  be  observed 
that  when  the  expiration  is  said  to  be  prolonged, 
it  is  meant  that  the  expiratory  sound  is  audible 
through  a longer  period  of  the  act  than  natural. 

If  the  respiration  be  hurried-  and  forced,  the 
inspiratory  sound  is  coarser  and  louder,  and 
the  expiration  more  audible,  these  sounds  ap- 
proximating to  the  puerile  breathing  which  is 
normal  to  young  children. 

In  health  the  vesicular  breath-sound  should 
be  about  equally  well  heard  over  the  front  and 
back  of  the  chest,  allowance  being  made  for 
additional  thickness  of  covering  over  certain 
regions. 

(б)  Morbid  Respiratory  Sounds. — Puerile, 
compensatory,  or  supplementary  breathing  is 
characterised  by  increased  loudness  of  vesicular 
breath-sound,  with  some  prolongation  of  expi- 
ration. Besides  being  audible  over  the  chest 
generally  in  healthy  young  children,  this  exag- 
gerated breath-sound  may  be  heard  over  certain 
parts  of  the  chest  in  persons  who  have  some 
other  part  disabled  or  diseased.  Thus,  with 
effusion  of  fluid  into  one  pleura,  the  respiraton 


PHYSICAL  EXAMINATION. 


1188 

sounds  over  the  opposite  lung  are  exaggerated 
cr  puerile.  If  one  apex  be  diseased,  the  breath- 
sound  at  the  other  apex  is  exaggerated.  This 
increased  breath-sound  to  make  up  for  deficient 
function  elsewhere  is  called  compensatory  or  sup- 
plementary breathing. 

The  breath-sound  may  be  enfeebled  over  the 
whole  chest,  as  in  cases  of  emphysema  or  thoracic 
muscular  debility.  Localised  enfeeble  ment  of 
breath-sound  may  be  due  to  several  causes— (I) 
local  emphysema ; (2)  adherent  and  thickened 
pleura,  as  after  old  pleurisy  at  the  base ; (3) 
blocking  of  the  alveoli  by  catarrhal  products — 
common  in  commencing  phthisis  at  one  apex; 
(4)  closure  of  bronchial  tubes  by  plugs  of  mucus, 
or  from  spasm.  If  the  rest  of  the  lungs  be  free, 
this  local  enfeeblement  is  made  up  for  by  com- 
pensatory breathing  on  the  opposite  side,  or  in 
other  parts  of  the  same  lung. 

Suppressed  breath-sound  signifies  removal  of 
lung  from  the  surface  by  effusion  of  air  or  of  fluid 
into  the  pleura,  or  occlusion  of  a main  bronchus 
by  compression  or  morbid  growth. 

Wavy  and  jerking  respiration  are  terms  cha- 
racterising a kind  of  respiration,  in  which  the 
inspiration  is  either  partially  or  completely  in- 
terrupted several  times.  The  expiration  is  rarely 
thus  affected.  Waviness  of  respiration  may  be 
due— (1)  to  an  irregular  action  of  the  inspiratory 
muscles,  common  in  nervous  people;  (2)  to  car- 
diac impulse,  in  which  case  these  interruptions 
are  rhythmic  with  the  heart’s  pulsation ; (3) 
unequally  distributed  impairment  of  the  lung- 
elasticity,  for  example  in  early  tubercle-deposits. 
Dr.  Walshe  considers  that  pleuritic  adhesions 
may  have  the  same  effect.  It  will  be  seen  then 
that  waviness  of  breath-sound  is  very  com- 
monly independent  of  any  organic  change,  and 
requires  other  signs  to  render  it  of  any  value  in 
diagnosis.  Jerking  respiration  or  interrupted 
breath-sound  is  more  commonly  due  to  organic 
lesions  of  the  third  kind  mentioned. 

Cogged  breath-sound  is  a somewhat  clumsy 
term  applied  to  a form  of  interrupted  respiration 
in  which  the  interruptions  are  very  even,  three  or 
four  to  each  inspiration.  Much  importance  is 
attached  to  the  sign  by  some  authors.  It  ap- 
pears. to  be  due  to  obstruction  in  the  smallest 
bronchioles,  either  by  dryish  secretion  or  small 
nodules  of  tubercle,  requiring  some  accumula- 
tion of  inspiratory  force  to  overcome  it.  The 
sounds  commonly  give  place  to  a bubbling  rale. 

Harsh  respiration  with  prolongation  of  expi- 
ration implies  a want  of  vesicularity  in  the 
sound.  Whilst  vesicular  breath-sound  has  been 
compared  to  the  sound  produced  by  the  breeze 
passing  through  leaf-laden  trees,  harsh  breath- 
ing, on  the  other  hand,  resembles  a similar 
breeze  traversing  their  naked  branch-tops.  Some 
prolongation  of  the  expiratory  sound  is  insepa- 
rable from  harshness  of  breath-sound.  Harsh- 
ness of  breath-sound  by  no  means  implies  in- 
creased loudness  — rather  the  contrary.  En- 
feebled respiratory  murmur  is  commonly  harsh 
— always  so  when  due  to  alveolar  obstruction. 
The  meaning  of  harshness  of  breath-sound  is 
simply  commencing  consolidation;  it  goes  with 
incipient  dulness,  and  is  one  of  the  earliest  signs 
of  apex-disease  in  consumption.  There  can  be 
little  doubt  that  its  real  mechanism  depends 


upon  the  extinction  of  the  vesicular  part  of  thi 
normal  breath-sound,  and  the  better  conductios 
of  the  glottic  sounds,  which  at  peripheral  parts 
of  the  lung  are  usually  muffled  and  obscured  by 
the  vesicular  sounds.  The  prolongation  of  the 
expiration  is  very  characteristic  of  this  early 
alteration  of  the  respiratory  sounds;  and  it 
may  here  be  observed,  in  passing,  with  regard  tj 
morbid  breath-sounds,  that  the  expiration  is  the 
most  important  part  of  the  respiratory  act  to 
attend  to  in  auscultation. 

Divided  respiration,  usually  described  as  a se- 
parate evidence  of  disease,  is  really  an  inseparable 
factor  of  harshness  of  respiration.  Instead  of 
the  two  component  sounds,  inspiration  and  ex- 
piration, fading  imperceptibly  into  one  another, 
they  are  more  or  less  distinctly  separate,  the 
more  so  as  the  more  typical  bronchial  type  of 
breathing  is  acquired.  Deficiency  of  elasticity 
is  the  cause  to  which  the  division  is  usually 
ascribed  ; it  is,  however,  a significant  feature  of 
glottic  breathing. 

Bronchial  respiration  is  most  typically  heard 
over  simple  lung-consolidation,  as  pneumonia  at 
the  base  orapex.  Skoda  well  describes  the  sound 
as  acoustically  identical  with  that  produced  bv 
placing  the  mouth  in  the  position  to  pronounce 
the  guttural  ch  (as  in  cAoir  or  Christian),  and 
drawing  the  breath  to  and  fro.  The  inspiratory 
and  expiratory  sounds  are  about  equal  in  length, 
nearlyr  identical  in  pitch,  and  distinctly  divided 
from  one  another.  The  sound  varies  in  intensity 
and  definition  from  the  most  intense  tubular 
or  tracheal  breath-sound,  to  the  lower-pitched 
and  more  diffuse  blowing  respiration  {diffused 
bronchial  breathing').  Besides  hepatisation  of 
lung,  this  form  of  respiratory  sound  may  be 
produced  by  other  condensations  of  lung,  for  ex- 
ample, Horn  pressure,  or  by  tumours  extending 
from  the  neighbourhood  of  a large  bronchus  to  the 
surface,  such  as  enlarged  bronchial  glands,  me- 
diastinal growths,  and  aneurismal  tumours.  The 
more  diffused  blowing  sounds  are  due  to  less  com- 
plete consolidation.  Itis  essential  that  the  bronchi 
be  patent,  in  order  that  bronchial  respiration 
maybe  heard;  thus,  in  cases  of  cancerous  growth 
invading  a lung  from  its  root  and  occluding 
the  bronchi,  no  respiration  is  audible.  As  regards 
mechanism,  however,  it  can  scarcely  be  main- 
tained that  the  sound  is  produced  by  the  passage 
to  and  fro  of  the  air  in  the  bronchi  of  the  conso- 
lidated lung ; for  (1)  at  the  period  when  bronchial 
breathing  is  most  distinct,  the  lung  is  immovably 
fixed  by  exudation ; (2)  the  play  of  the  chest-wall 
on  the  affected  side  is  almost  or  quite  restrained: 
(3)  the  air-cells  being  occupied,  there  is  no 
reason  why  air-currents  should  penetrate  the 
bronchi.  Hence  it  would  seem  that  bronchial 
respiration  is  but  the  glottic  breath-sonnd  re- 
verberating through  the  bronchial  tubes,  and 
well  conducted  to  the  surface.  A remarkable 
experiment  of  MM.  Bondet  and  Chauveau 
(Revue  Mensuclle,  1877)  strikingly  confirms  this 
view.  In  a horse  with  hepatisation  of  the  base 
of  one  lung  and  bronchial  breath-sound  over 
the  part  affected,  the  trachea  was  incised  below 
the  glottis,  and  the  wound  held  widely  open' 
the  bronchial  breathing  immediately  disap- 
peared, all  respiratory  sounds  ceasing  over 
this  portion  of  lung,  whilst  elsewhere  the  vest 


PHYSICAL  EXAMINATION. 


tolar  breath-sound  -was  unimpaired.  A musical 
reed  was  now  inserted  into  the  wound,  and 
the  musical  sounds  were  well-conducted  over 
the  consolidation,  but  little  audible  over  the 
healthy  portion  of  lung. 

Cavernous  respiration  is  a breatli-sound  in 
which  the  inspiration  and  expiration  have  both 
a hollow  blowing  quality.  It  is  to  the  expiration 
that  the  hollow  wavering'  quality  characteristic 
of  this  breath-sound  is  especially  attached,  and, 
as  pointed  out  by  Dr.  E.  Thompson,  the  expi- 
ratory sound  is  lower  in  pitch  than  the  inspi- 
ratory. Cavernous  breathing  signifies  pulmonary 
cavity  usually  phthisical,  — (1);  exceeding  in 
size  an  unshelled  walnut;  (2)  either  empty  or 
at  least  partially  so  ; and  (3)  communicating  with 
one  or  more  patent  bronchial  tubes.  Softening 
of  tubercle  or  caseous  pneumonia,  pulmonary 
abscess,  or  bronchial  dilatation  of  sufficient  size, 
are  the  most  common  causes  of  cavity  in  the 
lung.  This  abnormal  sound  is  formed  by — 
(a)  the  passage  to  and  fro  of  air  into  a cavity 
with  the  respiratory  movements;  (b)  the  con- 
duction and  modified  reinforcement  of  the  glot- 
tic respiratory  sound  within  a cavity. 

Amphoric  breath-sound  is  a variety  of  caver- 
nous respiration  having  the  same  characters,  but 
on  an  exaggerated  scale ; that  is,  not  necessarily 
exaggerated  as  regards  loudness,  but  having  all 
the  qualities— blowing  character  and  hollow- 
ness— intensified.  This  sound  is  heard  over  a 
large  superficial  cavity,  either  in  the  lung,  or  in 
the  pleura  freely  communicating  with  the  lung. 
Its  mechanism  is  identical  with  that  of  caver- 
nous respiration,  only  that  the  size  of  the  cavity 
ie  large. 

(c)  Adventitio  ns  Avscui/tatoby  Signs. — A rale 
or  rhonchus  is  a sound  produced  by  impediment 
to  the  entry  or  escape  of  air  within  the  lungs  or 
bronchial  tubes.  The  impediment  may  be  from 
narrowing,  or  secretion  within  the  tubes  ; from 
secretion  within  the  alveoli ; or  from  destructive 
softening  or  oedema  of  the  lung-tissue.  The 
rales  that  may  be  audible  over  the  chest,  are — 
sonorous , sibilant,  crepitant,  sub-crepitant,  mu- 
cous, dry  crackling,  moist  crackling,  and  caver- 
nous. 

Sonorous  and  sibilant  rales  are  noises  of  a 
snoring  or  whistling  kind,  which  are  produced 
in  the  air-passages.  They  are  audible  with  both 
inspiration  and  expiration  (or  with  either),  and 
are  for  the  most  part  transitory  sonnds,  being 
temporarily  or  permanently  removed  by  cough,  or 
in  other  cases  by  the  relief  of  the  spasm  which 
has  occasioned  them.  They  obscure  or  alto- 
gether mask  the  normal  respiratory  sounds.  Any 
narrowing  of  an  air-tube  will  give  rise  to  a 
sonorous  or  sibilant  rale  according  to  the  degree 
of  narrowing  and  the  size  of  the  tube.  Thus, 
if  the  larger  tubes  be  affected,  and  the  narrowing 
not  great,  the  coarser  sound  is  produced.  If, 
on  the  other  hand,  the  finer  tubes  be  partially 
occluded,  or  a larger  tube  be  greatly  narrowed, 
the  finer  sibilus  is  caused.  The  rales  are  audiblo 
throughout  the  territory  of  the  tubes  affected. 
Thus  if  a main  bronchus  be  compressed  or  nar- 
rowed, the  sonorous  rd/e  so  occasioned  will  bo 
heard  throughout  the  lung  on  that  side.  Throat- 
sibilus  in  croup  is  conducted  all  over  the 
chest. 


lias 

The  precise  causes  of  these  rales  are — (1) 
narrowing  of  a bronchus  from  external  pressure 
(uncommon) ; (2)  narrowing  from  local,  cica- 
tricial, thickening  and  contraction  of  the  fibrous 
coat  of  the  tube  (uncommon) ; (3)  mucous  col- 
lections in  the  tubes  giving  rise  to  imperfect  plugs 
which  vibrate,  causing  the  musical  sounds  (very 
common)  ; and  (4)  spasmodic  contraction  of  the 
medium-sized  tubes  (sibilus  in  asthma). 

Dry  rales  signify — (1)  Bronchial  catarrh,  or 
bronchitis,  local  or  general,  as  the  case  may  he, 
affecting  the  larger  and  medium-sized  tubes  ; (2) 
tumours  pressing  upon  the  trachea  or  one  of  the 
main  bronchi ; (3)  numerous  minute  bronchial 
obstructions  occasioned  by  pulmonary  miliary 
tuberculosis ; or  (4)  asthma. 

Stridor  is  a variety  of  sonorous  rhonchus,  due 
most  generally  to  pressure  of  a malignant  or 
aneurismal  tumour  upon  a main  bronchus,  and 
heard  chiefly  over  the  corresponding  side.  It  is 
a coarse,  vibrating  sound,  which,  however,  the 
trained  ear  can  readily  detect  to  he  of  distant 
origin.  Paralysis  of  the  vocal  cords  will,  in 
some  cases,  lead  to  stridor. 

Crepitant  rale,  or  fine,  dry  crepitation,  is  a 
minute  dry  crackling  sound,  in  which  the  crackles 
are  infinitely  small  and  even,  and  occupy  chiefly 
the  latter  part  of  inspiration.  The.  sound  has 
been  compared  to  the  crackling  of  salt  upon  the 
fire,  or  that  produced  by  rubbing  a pinch  of  hair 
between  the  fingers  close  to  the  ear.  Probably  the 
exact  mechanism  of  the  sound  is  the  abrupt  sepa- 
ration of  alveolar  surfaces,  collapsed  by  inflam- 
matory or  other  oedema.  But  there  are  difficulties 
in  the  way  of  any  present  explanation  of  the 
sound.  There  are  at  least  four  conditions  which 
will  give  rise  to  identically  the  same  sound,  as  far 
as  the  ear  can  appreciate  it,  namely  (1)  incipient 
pneumonic  consolidation  (inflamed  cedema  stage) ; 
(2)  ffidema  of  the  lungs  when  not  excessive,  as 
in  certain  stages  of  kidney-disease,  in  obstructive 
heart-disease,  &c. ; (3)  mere  collapse  of  lung 
from  disease,  crepitant  rale  being  often  tem- 
porarily heard  from  this  cause  at  the  extreme 
posterior  bases,  to  disappear  after  a few  deep 
inspirations  ; and  (4)  certain  cases  of  (edema  of 
the  pleura  dependent  upon  old  lung-disease. 
The  fine  crepitation  of  pneumonia  is  peculiar 
only  in  being  associated  with  commencing  tubu- 
lar breath-sound,  the  consolidation  associated 
with  which  gives  an  increased  intensity  and  de- 
finition to  the  crepitant  rale.  When  associated 
with  acute  febrile  symptoms,  fine  crepitation 
indicates  the  congestive  stage  of  acute  pneu- 
monia. If  seated  about  the  base,  the  pneumonia 
is  most  commonly  of  the  typical  croupous  er 
exudative  variety.  If  at  the  apex,  or  in  patches, 
the  disease  may  be  incipient  catarrhal  or  embolic 
(pyaemic)  pneumonia. 

Sub-crepitant  or  muco-crepitant  rale  is  a fine 
bubbling  rale,  of  sharp  definition,  and  well- 
conducted  to  the  ear,  audible  principally  dur- 
ing inspiration,  but  in  less  degree  also  with 
expiration.  This  rale  is  produced  in  the  minute 
bronchioles  and  alveoli,  by  the  penetration  of 
air  through  a thin  liquid.  A certain  amount  of 
lung-condensation  is  necessary  to  give  sharpness 
of  definition  to  the  sound.  Sub-crepitant  rale 
is  most  typically  heard  in  the  resolution  stage 
of  pneumonia.  In  the  second  (secretion)  stage 


PHYSICAL  EXAMINATION. 


1190 

of  broncho-pneumoma  it  is  also  heard.  There 
are  many  rale  sounds  intermediate  between  true 
dry  crepitation  and  the  sub-crepitant  rale,  which 
are  fairly  described  by  the  general  term  crepi- 
tant rede,  fine  or  coarse,  according  to  their  size. 
Many  degrees  of  fineness  or  coarseness  may  be 
distinguished  in  different  parts  of  the  same  lung 
in  some  pneumonic  forms  of  phthisis,  and  it  will 
be  generally  found  in  any  such  cases  that  the 
rales  increase  in  coarseness  as  we  ascend  from 
below  upwards. 

Dry  crackle  is  the  term  used  to  describe  a 
rale  consisting  of  three  or  four  distinct  small 
crackles  heard  during  inspiration.  The  crackles 
are  dry  in  character,  and  sharpl-y  defined.  The 
inspiratory  breath-sound  attending  this  rhon- 
chus  is  usually  feeble  and  harsh,  the  expiration 
harsh  and  prolonged,  but  unattended  with  any 
rale,  unless  it  be  some  sibilus.  Dry  crackling 
most  commonly  signifies  commencing  softening 
of  ‘ tubercular’  deposits,  and  the  sound  may  be 
most  frequently  recognised  in  the  sub-clavicular 
region,  where  this  condition  is  most  often  found 
uncomplicated  by  conditions  depending  upon 
other  stages  of  the  disease. 

Moist  crackle,  or  humid,  clicking  rale,  con- 
sists of  a few  crackles,  heard  during  the  latter 
part  of  inspiration  and  the  commencement  of 
expiration,  sharply  defined,  sometimes  metallic 
in  quality.  The  crackles  vary  in  size  and  in  the 
degree  of  liquidness,  as  must  be  the  case  from 
the  mechanism  by  which  they  are  produced. 
For  this  rale  is  significant  of  liquefaction  of 
tubercular  or  caseous  pneumonic  nodules  in  com- 
munication with  bronchial  tubes ; and  as  such 
adjacent  softenings  coalesce  and  increase  in  size, 
the  crackles  become  larger,  until  they  develop 
into  the  gurgling  or  cavernous  rale.  The  moist, 
crackle  may  be  associated  with  other  rales, 
since  a softening  caseous  nodule  is  often  sur- 
rounded by  congested  pulmonary  tissue  or  pneu- 
monia, giving  rise  to  fine  crepitant  or  sub-crepitant 
sounds.  As  a rule  the  breath-sound  is  more  or 
less  masked  by  the  crackling  rale. 

Cavernous  and  gurgling  rales  are  but  larger  and 
more  liquid  rales,  produced  in  a cavity  or  cavities 
of  moderate  dimensions. 

Metallic  tinkling  rale  requires  for  its  develop- 
ment a large  empty  cavity  in  which  it  may  be 
produced — (1)  by  the  bursting  of  one  or  more 
air-bubbles  through  viscid  contents ; (2)  by 

the  impingement  of  a drop  of  secretion  against 
the  cavern-wall ; or  (3)  by  a bubbling  rale  pro- 
duced in  a bronchus  near  the  cavity,  and  freely 
communicating  with  it.  In  either  case  the  large 
empty  cavity,  necessarily  near  the  surface,  re- 
sonates and  re-echoes  the  sounds,  and  gives  them 
their  peculiar  metallic  quality,  which  has  been 
likened  to  that  produced  by  a pin  dropping  into 
a large  empty  bottle.  Metallic  tinkling  is  by 
no  means  solely  significant  of  pleuritic  cavity, 
as  was  supposed  by  Laennec ; it  may  be  most 
typically  heard  over  a large  dense-walled  empty 
pulmonary  cavern. 

Metallic  echo  is  sometimes  confounded  with 
metallic  tinkle,  with  which  it  is  often  associated, 
and,  indeed,  of  which  it  may  be  said  to  form  a 
part.  It  is  really  not  a rale  at  all,  however,  but 
an  echo  in  a large  cavity,  produced — (1)  by  air- 
vibraninj  caused  by  cough  ; (2)  by  vibrations  on  i 


the  surface  of  fluid  with  a large  air-space  above 
or  (3)  by  vocal  vibrations  reaching  through  the 
cavity  after  true Toice-sound  has  died  away. 

Hippocratic  succussion-soimd  is  the  splaahin" 
sound  heard  in  a pleura  containing  both  air 
and  fluid,  on  shaking  the  patient  somewhat  vigo- 
rously, while  the  ear  is  applied  to  the  chest- 
surface. 

Cough-sounds. — A cavernous  splash  sound  may 
frequently  be  heard  on  listening  over  a cavity, 
and  causing  tho  patient  to  cough,  the  forcibie 
entry  of  air  into  the  cavity  in  itself  largely  con- 
tributing to  the  sound,  and  setting  up  gurgling 
and  splashing  rales  by  the  disturbance  of  con- 
tained fluids. 

Cough-sounds  require  no  explanation,  but  they 
should  be  invariably  tested  in  chest^examination". 
Crepitant  sounds  are  often  developed  after  a 
cough,  which  are  not  to  he  heard  either  on  ordi- 
nary or  deep  inspiration  without  it.  Cavities 
which  are  not  in  free  communication  with  bron- 
chial tubes  may  yield  no  characteristic  breath 
sounds  ; but  the  forcible  propulsion  of  air  into 
them  at  the  moment  of  chest-compression  with 
closed  glottis  elicits  at  once  a characteristic 
localised  snccussion-sound,  attended  with  more 
or  less  coarse  gurgling  rale. 

Voice-sounds. — In  the  ordinary  healthy  spongv 
condition  of  lung,  the  voice-sounds  are  heard 
but  distantly  and  imperfectly,  save  in  certain 
parts  of  the  chest  in  the  neighbourhood  of  the 
trachea  and  its  bifurcation,  that  is,  in  the  upper 
sternal  and  the  upper  interscapular  regions,  where 
the  sounds  are  better  conducted. 

Bronchophony. — At  any  portion  of  the  chest 
where  there  is  consolidation  of  lung,  in  associa- 
tion with  patent  air-tubes,  the  voice-sound  is 
heard  loudly,  as  though  produced  near  or  close, 
under  the  stethoscope.  Although  loudly  heard, 
the  sound  appears  to  pass  away  from  under  tho 
stethoscope.  Any  solid  medium  of  conduction 
between  a large  bronchus  and  the  stethoscope 
will  give  rise  to  bronchophony,  whether  by 
super-position,  or  by  the  portion  of  bronchial 
tree  concerned  being  imbedded  in  solid  lung,  as 
in  lobar  pneumonia,  of  which  the  sound  is  most 
typical.  If,  however,  between  the  conducting 
medium  and  the  larynx  the  bronchial  channel 
he  occluded,  bronchophony  is  no  longer  heard, 
the  voice-sounds  being  enfeebled  or  annulled. 

Pectoriloquy. — If,  on  the  other  hand,  a cavity 
be  present  beneath  the  spot  auscultated,  and  in 
free  communication  with  a bronchus,  the  voice- 
sound  appears  to  be  concentrated  at  the  end  cl 
the  stethoscope,  and  to  pass  through  the  instru- 
ment direct  to  the  ear,  with  exaggerated  and 
even  painful  distinctness.  It  is  rather  the  noisi 
of  the  voice  that  we  hear  in  bronchophony,  but  in 
pectoriloquy  the  sounds  are  most  distinctly  arti- 
culated. This  distinction  is  even  better  appre- 
ciated by  listening  to  a whisper,  which  under 
bronebophouie  conditions  is  merely  a conducted 
hissing  sound,  whilst  in  pectoriloquy  each  syllable 
penetrates  distinctly  to  the  ear.  Pectoriloquy 
may,  however,  he  clearly,  although  not  exactly, 
imitated  by  consolidated  lung  in  the  neighbour- 
hood of  a large  bronchus.  Hence  the  diagnosis 
of  a cavity  near  the  root  of  the  lung  requires 
much  caution. 

JEgophony. — JEgophony  is  a form  of  modified 


PHYSICAL  EXAMINATION. 


bronchophony  in  which  the  voice-sound,  conducted 
through  condensed  lung,  has  further  to  penetrate 
a thin  layer  of  fluid  in  which  the  coarser  vibra- 
tions are  lost,  a certain  quavering  nasal  quality 
being  given  to  the  sound  that  reaches  the  ear.  It 
is  significant  of  effusion  into  the  pleura.  The 
Bound  is  only  to  be  heard  near  the  upper  limits 
of  the  effusion,  where  the  layer  of  fluid  is  thin. 

With  regard  to  the  mechanism  of  these  three 
sounds — bronchophony,  pectoriloquy,  and  aego- 
phony  — there  can  be  no  dispute  about  their 
being  glottic  sounds.  In  bronchophony  they  are 
conducted  through  subdividing  tubes  of  increas- 
ing fineness  enveloped  in  solid  tissue  ; hence  the 
sounds,  although  loudly  heard,  are  not  well- 
defined,  being  largely  converted  into  the  coarser 
vibrations  perceptible  to  palpation  as  fremitus. 
In  pectoriloquy , on  the  other  hand,  the  glottic 
sounds  are  conducted  through  tubes  which,  after 
one  or  two  divisions,  terminate  in  a resonating 
cavity ; hence  the  vocal  vibrations  are  concen- 
trated and  conducted  with  intensity  to  the  ear 
as  through  a speaking-tube.  Finally,  in  agophony 
one  may  suppose  the  bleating  character  of  the 
sound  to  be  due  to  secondary,  and  to  a certain 
extent  disturbing  vibrations  in  the  fluid  medium 
through  which  the  sounds  are  conveyed.  In  sego- 
phony  one  may  commonly  note  a lisp  or  whisper- 
sound  in  addition  to  the  voice-sound,  and  better 
conducted  than  the  voice-sound.  And  it  has 
been  affirmed  by  Bacelli  that  in  cases  of  serous 
effusion  into  the  pleura  the  whisper  is  heard 
well-conducted  with  distinct  articulation — pcc- 
toriloquie aphonique — through  the  thicknessof  the 
fluid,  whereas  in  purulent  effusion  such  whisper 
is  not  conducted.  This  statement  will  be  found 
to  apply,  however,  only  in  certain  cases.  The 
whisper  may  sometimes  be  heard  well-conducted 
through  purulent  fluid. 

The  voice-sounds  are  weakened  or  wholly  ex- 
tinguished by  conditions  which — (a)  shut  off  the 
main  bronchi  from  the  part  auscultated,  as  in 
malignant  growths  invading  the  bronchus  at  the 
root  of  the  lung ; (4)  separate  the  lung-surface 
from  the  thoracic  wall,  as  in  pleuritic  effusions, 
(edematous  thickening  of  pleura,  &e.  (Here, 
however,  we  must  make  exception  in  certain  eases, 
in  which  pectoriloquie  aphonique  is  heard);  (c) 
in  rarefaction  of  the  lung  by  emphysema  the 
voice-sound  is  enfeebled ; and  (cf)inpneumothorax 
it  is  either  much  enfeebled  or  annulled.  In  cases 
of  pneumothorax,  however,  a faint  metallic  echo 
may  often  be  heard  with,  or  rather  after,  the 
voice-sound.  This  echo  has  probably  a precisely 
analogous  mechanism  to  segophony,  save  that 
the  medium  of  secondary  conduction  is  air  in- 
stead of  fluid,  and  hence  the  conduction  is  less 
distinct. 

Autophony. — On  listening  over  a superficial 
cavity  with  condensed  lung-tissue  around,  the 
voice  of  the  auscultator — for  example,  when  re- 
questing the  patient  to  cough  or  to  speak — will 
be  noticed  by  himself  to  he  intensified.  The 
term  autophony  is  applied  to  this  increased  re- 
sonance, which  is  a sign  of  little  clinical  value. 

Pleural  sounds.— The  sounds  originating  in 
diseased  conditions  of  pleura  are  commonly  in- 
cluded under  the  general  term  1 friction  sounds  ’ 
— a term,  however,  very  inadequate  to  describe 
the  varieties. 


1x91 

Th  & pleuritic  nib  or  dry  friction  is  a wavy  or 
uneven  rubbing  sound  heard  close  under  the  ea" 
with  both  inspiration  and  expiration,  but  chiefly 
with  the  former,  unmoved  by  cough,  and  usually 
attended  with  pleuritic  pain.  We  may  often 
fail  to  obtain  this  sound,  through  the  patient 
involuntarily  restraining  the  movement  of  the 
affected  side  on  account  of  the  pain.  A deep  in- 
spiration must,  therefore,  be  always  called  for. 
In  well-marked  cases  the  friction  is  very  loud 
and  leathery,  and  may  be  perceptible  to  the  hand 
applied — -friction  fremitus. 

Pleural  creaking  is  a sound  that  may  he  some- 
times distinguished  over  a portion  of  the  chest, 
when  the  pleurae  are  densely  thickened  and 
adherent. 

Moist  or  spongy  friction  is  most  difficult  to 
distinguish  from  fine  moist  crepitation.  It  is 
heard  almost  entirely  at  the  end  of  deep  inspira- 
tion, and  closely  resembles  the  crepitation  of  a 
moist  sponge.  The  sound  is  due  to  the  pleura 
being  adherent  by  moist,  recent  lymph,  as  in 
the  early  stage  of  adhesive  pleurisy  in  pleuro- 
pneumonia. 

In  cases  of  cedema  of  the  pleura  a fine  crepi- 
tating inspiratory  sound  or  pleural  crepitus  may 
be  heard,  which  it  is  impossible  to  distinguish 
from  a pulmonary  sound.  The  diagnosis  must 
rest  upon  the  very  superficial  character  of  the 
sound,  and  its  being  unchanged  by  cough ; also 
upon  its  being  associated  with  deficient  breath- 
ing without  tubular  quality,  and  with  lessened 
vocal  fremitus.  It  is  an  inspiratory  not  an  ex- 
piratory sound,  being  engendered  by  the  pulling 
out  of  the  spongy  oedema-tissue  during  inspira- 
tion. 

4.  Circulatory  System,  Physical  Exami- 
nation of. — The  condition  of  the  heart  and 
circulation  may  he  investigated  with  great  ex- 
actness, chiefly  by  palpation,  percussion,  and 
auscultation. 

Polsb. — The  p'ulso  gives  ns  very  important 
information  respecting  the  state  of  the  circula- 
tion. Por  a full  description  of  the  pulse  and  its 
different  characters  in  disease,  sec  Pulse  ; and 
Sphygmograph. 

Heart. — (a)  Inspection. — In  health  and 
during  quietude  the  cardiac  impulse  is  barely 
perceptible.  Under  excitement,  however,  throb 
bing  impulse  may  be  noticed  over  the  prsecordia 
and  left  epigastrium.  In  cases  of  great  hyper 
trophy  and  dilatation  of  the  heart,  especially  in 
children,  the  praecordial  region  may  he  obviously 
bulged.  The  impulse  of  the  heart  may  be  ob- 
served to  be  diffused  over  an  increased  area, 
between  the  nipple-line  and  sternum,  in  cases  of 
hypertrophy  and  dilatation.  In  cases  of  dilated 
hypertrophy  of  the  right  ventricle,  or  in  displace- 
ment downwards  of  the  heart  in  emphysema,  the 
impulse  is  very  perceptible  at  the  epigastrium  to 
the  left  of  the  eusiform  cartilage.  A diffused  un- 
dulating impulse  may  he  observed  in  some  cases 
of  pericardial  effusion  and  in  adherent  peri- 
cardium. The  heart  is  often  uncovered,  and  its 
impulse  revealed  on  one  side  or  the  other  by  re- 
traction of  the  lung  in  contractile  or  wasting 
pulmonary  diseases. 

(4)  Palpation. — The  position  of  the  heart’s 
apex  should  first  he  ascertained;  and  the  area. 


1132 


PHYSICAL  EXAMINATION. 


force,  and  rhythm  of  the  cardiac  pulsations,  and 
the  presence  or  absence  of  thrill  or  other  adven- 
titious palpation-signs,  should  next  be  noted. 

Normally  the  heart,  enclosed  in  its  own  peri- 
eardial  sac,  is  situated  in  the  anterior  and  central 
part  of  the  thoracic  cavity,  immediately  above 
the  diaphragm.  Its  position  may  be  roughly 
defined  as  within  the  area  bounded  above  by  a 
line  drawn  across  the  sternum  at  the  level  of 
the  lower  border  of  the  second  cartilages;  on  the 
left  by  a vertical  line  passing  just  within  the  left 
nipple ; and  on  the  right  by  a similar  line  drawn 
at  one-third  of  the  distance  between  the  border 
of  the  sternum  and  the  right  nipple  line.  A 
slanting  line  from  the  base  of  the  ensiform 
cartilage  to  the  upper  border  of  the  sixth  rib  in 
the  left  nipple  line  defines  the  lower  border  of 
the  heart.  Behind  this  area  the  heart  lies  ob- 
liquely, its  base  directed  upwards  to  the  right 
and  backwards,  its  apex  to  the  left  downwards 
and  forwards.  The  organ,  moreover,  is  so  placed 
that  the  right  auricle  and  ventricle  occupy 
nearly  the  whole  anterior  surface ; the  left  auricle 
and  ventricle  the  posterior  and  left  surface. 

The  apex  of  the  heart  in  the  adult  impinges 
in  the  fifth  interspace,  one  inch  within  the  left 
nipple  line.  The  aortic  and  pulmonary  valves 
correspond  with  the  upper  border  of  the  third 
left  cartilage  at  its  junction  with  the  sternum, 
the  aortic  being  on  the  right  of  and  a little  lower 
than  the  pulmonary.  A lino  drawm  from  the 
middle  of  the  third  left  cartilage  as  it  joins  the 
sternum,  to  the  upper  border  of  the  fifth  right 
cartilage  at  the  sternal  margin,  would  correspond 
with  the  mitral  valve  superficially  and  above, 
the  tricuspid  more  deeply  and  below. 

An  altered  position  of  the  apex-beat  may  arise 
from  congenital  displacement  of  the  organ,  for 
example,  from  transposition  of  viscera.  It  may 
arise  from  enlargement  of  the  organ  by  hyper- 
trophy or  dilatation,  affecting  its  right  or  left 
cavities ; or  from  displacement  of  the  organ,  for 
instance,  downwards,  by  emphysema,  aneurism, 
or  tumour;  aside,  by  pleuritic  effusion,  malignant 
disease,  or  contraction  of  lung ; upwards,  by 
abdominal  distension,  disease  in  the  abdomen,  or 
sontraction  of  lung. 

In  continuance  of  palpation,  the  condition  of 
the  arteries  and  veins  at  the  root  of  the  neck 
must  be  observed,  whether  the  arteries  unduly 
pulsate,  or  the  veins  on  one  side  or  both  remain 
full,  or  pulsate. 

(c)  Percussion. — The  praecordial  dulness  may 
be  enlarged  by  retraction  of  the  margin  of  one 
or  both  lungs ; by  effusion  of  fluid  into  the  peri- 
cardium ; or  by  enlargement  of  the  heart  itself, 
either  general  or  restricted  to  one  or  more  of 
its  divisions.  The  cardiac  dulness  may  be 
diminished  or  obscured  by  enlargement  of  the 
lungs  enveloping  it,  or  by  air  effused  into  the 
pericardial  sac. 

(d)  Auscultation. — By  the  simultaneous  con- 
traction of  the  ventricles,  the  closure  of  the 
mitral  and  tricuspid  valves,  and  the  impinge- 
ment of  the  apex  of  the  left  ventricle  against 
the  ribs,  a single  sound  is  produced,  the  first 
sound  of  the  heart.  The  sudden  tense  closure 
of  the  mitral  valve  is  the  principal  cause  of  this 
s <und.  The  first  sound  is  closely  followed  by  the 
seotlid  sound,  which  is  more  tapping  in  quality, 


and  corresponds  with  the  closure  of  the  aortie 
and  pulmonary  valves.  Then  comes  the  diastolic 
pause,  which  may  be  said  to  equal  in  duration 
that  of  the  two  sounds.  The  first  sound  is  most 
loudly  heard  at  the  apex,  the  second  at  the  base 
of  the  heart. 

The  sounds  of  the  heart  are  subject  to  consi- 
derable variations  under  varied  general  condi- 
tions of  health  and  disease. 

(1)  In  general  debility,  anaemia,  and  wasting 
diseases,  the  tendency  is  for  the  first  and  second 
sounds  to  approximate  to  each  other  in  character. 
As  the  ventricular  wall  becomes  atrophic  or  ill- 
nourished  the  first  sound  becomes  more  purely 
valvular,  and  at  the  same  time  more  feeble  and 
tapping,  approaching  thus  in  character  to  the 
second  sound.  Sometimes  in  cases  of  anaemia 
the  first  sound  is  peculiarly  ringing  and  hollow 
in  character. 

(2)  In  chronic  Bright's  disease,  with  thickened 
vessels  and  hypertrophied  ventricles,  the  first 
sound  is  peculiarly  muffled  and  indistinct,  com- 
pared with  the  recognisable  force  of  the  beat. 

(3)  The  rhythm  of  the  heart's  sounds  mav 
be  greatly  changed : — (a)  The  first  or  second,  oi 
both  first  and  second  sounds,  may  be  redupli- 
cated. This  may  occur  as  a temporary  pheno- 
menon in  apparent  health,  but  it  is  more 
commonly  traceable  to  increased  resistance 
either  in  the  pulmonary  or  systemic  circulation. 

(4)  Excessive  rapidity  of  action,  (c)  Irregu- 
larity in  time  and  force  of  beats,  (d)  Inter- 
mittent action.  These  several  phenomena  may 
be.  significant  of  disease  of  the  heart  itself;  or, 
as  is  frequently  the  case,  they  may  be  due  to 
functional  disturbance  through  the  nervous  ap- 
paratus, from  dyspepsia ; or  from  excessive 
smoking,  tea-drinkiug,  or  vencry. 

A murmur  or  bruit  is  an  abnormal  sound, 
invariably  of  a blowing  character,  which  may 
more  or  less  replace  or  obscure  the  normal 
heart’s  sound.  Either  of  the  sounds  of  the  heart 
may  be  replaced  or  attended  by  a murmur; 
and  in  auscultation,  with  regard  to  prognosis, 
it  is  much  more  important  to  note  whether  a 
murmur  wholly  or  only  partially  replaces  the 
normal  sound — that  is,  whether  the  function  of 
the  valve  be  wholly  or  only  partially  disabled — 
than  to  be  guided  by  mere  loudness  of  bruit. 
The  first  sound  at  the  apex  may  be  preceded,  or 
very  rarely,  succeeded  by  a murmur.  For  a de- 
scription of  these  murmurs,  and  of  morbid  peri- 
cardial sounds,  see  Heart,  Valves  of,  Diseases 
of ; Heart,  Functional  Disorders  of ; and  Peei- 
cabdium,  Diseases  of. 

6.  Mediastinum,  Physical  Examination  of. 

Having  examined  the  thorax  with  regard  es- 
pecially to  the  great  organs,  the  lungs  and  heart, 
contained  within  it,  the  mediastinal  region  should 
next  be  explored,  both  anteriorly  and  poste- 
riorly. 

Normal  Signs. — The  anterior  mediastinal  re- 
gion, clinically  speaking,  corresponds  with  those 
portions  of  the  sternum  not  underlaid  by  lung, 
namely,  the  manubrium  and  the  left  half  of  the 
body,  extending  from  the  fourth  cartilage  down- 
wards. 

The  lungs  normally  approximate  beneath  the 
upper  portion  of  the  second  part  of  the  sternum 


PHYSICAL  EXAMINATION. 


from  that  point  to  the  lower  border  of  the  fourth 
tartilages  hiding  the  subjacent  parts.  In  the 
triangular  space  behind  the  upper  sternum,  with 
its  apex  at  the  lower  border  of  the  manubrium 
and  its  base  at  the  episternal  notch,  lie  the 
inferior  extremity  of  the  trachea,  covered  by  the 
left  innominate  vein,  the  summit  of  the  arch 
of  the  aorta,  and  a prolongation  of  the  peri- 
cardial sac,  with  connective  tissue,  and  a few 
small  lymphatic  glands.  The  summit  of  the  arch 
of  the  aorta  corresponds  with  the  level  of  the 
npper  border  of  the  second  rib-cartilage. 

Imperfect  percussion-dulness  and  modified 
bronchial  respiration,  with  weakly  conducted 
heart-sounds,  are  usually  presented  over  this 
region.  On  deeply  depressing  the  finger  behind 
the  sternum  in  the  episternal  notch,  a slight 
pulsation,  communicated  from  the  aorta — which 
vessel,  however,  the  fingers  cannot  reach,  is  felt. 
The  lower  region  of  mediastinal  dulness,  that 
is,  below  the  fourth  cartilage  level,  is  continuous 
on  the  left  of  the  sternum  with  the  heart’s  dul- 
ness, and  indeed,  corresponds  with  the  prsecordial 
region. 

Morbid  Signs. — The  upper  mediastinal  dulness 
may  be  replaced  by  resonance — (1)  from  enlarge- 
ment of  the  lungs  in  emphysema  ; (2)  in  cases 
of  contraction  of  the  upper  part  of  one  lung, 
enlargement  of  the  opposite  lung  wholly  occupy- 
ing the  sternal  region,  and  effacing  the  normal 
mediastinal  dulness.  The  limits  of  normal  me- 
diastinal dulness  may  be  extended,  from  displace- 
ment of  the  anterior  margin  of  the  lungs — (1) 
by  dilatation  or  aneurism  of  the  aorta ; (2)  by 
mediastinal  abscess ; (3)  by  simple  enlargement 
of  the  mediastinal  or  thymus  glands  ; or  (4) 
by  morbid  growth,  cancer,  or  lymphoma.  Eor 
the  diagnosis  between  these  several  conditions 
see  Aorta,  Diseases  of;  and  Mediastinum,  Dis- 
eases of.  It  must  be  borne  in  mind  that  consider- 
ably increased  dulness,  and  even  prominence, 
may  be  due  to  intrinsic  disease  of  the  sternal 
bone,  or  to  thickening  from  periostitis. 

Alterations  in  the  boundaries  of  the  lower 
regicn  of  mediastinal  dulness  are  most  often  due 
to  enlargement  of  the  heart,  or  dilated  pericar- 
dium. Aneurism  of  the  aorta  or  the  heart,  or  a 
growth  extending  forwards,  between  the  heart 
and  the  lung,  from  the  posterior  mediastinum, 
are  the  other  causes  of  increased  inferior  medias- 
tinal dulness. 

Posteriorly  there  is  no  inter-pulmonary  space 
apparent  save  that  occupied  by  the  spinal 
column.  But  in  disease,  and  especially  in  tumour, 
whether  aneurismal  or  of  the  nature  of  morbid 
growth  affecting  the  root  of  the  lungs,  the 
posterior  mediastinal  dulness  involves  the  right 
or  left  interscapular  region,  as  the  case  may  be. 

The  bifurcation  of  the  trachea  corresponds 
with  the  body  of  the  fourth  dorsal  vertebra. 
The  descending  portion  of  the  arch  of  the  aorta 
corresponds  with  the  left  side  of  the  third  dorsal 
vertebra. 

G.  Abdomen,  Physical  Examination  of. — 
The  abdomen  is  that  portion  of  the  body  in- 
cluded between  the  diaphragm  above  and  the 
brim  of  the  true  pelvis  below ; and  is  usually 
divided,  for  convenience  of  clinical  reference, 
into  regions.  Two  horizontal  lines  drawn  at  the 


1193 

level  of  the  ninth  ribs,  and  the  highest  point  of 
the  crest  of  the  ilia  respectively,  and  intersected 
by  vertical  lines  drawn  from  the  eighth  rib  on 
each  side  down  to  the  centre  of  Poupart's  liga- 
ment, divide  the  abdomen  into  nine  regions, 
namely,  epigastric,  umbilical,  and  hypogastric 
in  the  centre ; and  hypochondriac,  lumbar,  and 
iliac  on  each  side,  from  above  downwards. 

( a ) Inspection. — When  examining  a case  of 
abdominal  disease  the  position  naturally  assumed 
by  the  patient  should  be  noticed — whether  it  ho 
indifferent ; or  dorsal  with  the  knees  drawn  up — a 
position  very  characteristic  of  peritonitis  ; or 
lateral,  with  the  thighs  flexed  and  the  body  bent, 
as  in  renal  or  hepatic  colic.  Sometimes  in  cases 
of  colic,  especially  lead-colic,  the  patient  lies  on 
his  belly  with  the  arms  compressing  the  part. 
Frequent  changes  of  posture  are  also  charac- 
teristic of  colic  rather  than  of  peritoneal  in- 
flammation. The  general  size,  shape,  tenseness, 
fluidity,  or  retraction  of  the  abdomen  will  be  next 
observed.  Any  alteration  from  perfect  symmetry 
will  be  noted,  with  the  region  of  any  swelling. 
The  superficial  veins  of  the  abdomen  may  be 
enlarged,  the  internal  mammary  from  above 
meeting  the  superficial  and  deep  epigastrics,  to 
secure  collateral  circulation  between  the  supe- 
rior and  inferior  cavse,  when  either  is  from  any 
cause  compressed  or  occluded. 

(b)  Palpation. — On  placing  the  hand  over  the 
abdomen  for  the  purpose  of  palpation,  the  rigid- 
ity or  otherwise  of  the  muscles,  especially  of 
the  recti,  will  be  noticed  ; and  the  observer  will 
he  careful  to  noto  whether  the  muscle  becomes 
contracted  during  manipulation,  or  was  from  the 
first  unduly  tense.  The  muscles  of  the  abdomi- 
nal walls  are  rigid,  as  a rule,  in  all  inflammatory 
conditions  of  the  peritoneum.  In  local  peritonitis, 
and  over  special  organs  or  tissues  which  are 
painful,  the  muscles  are  also  tense;  thus  it  is  not 
uncommon  to  find  one  rectus  notably  more  rigid 
than  its  fellow. 

In  order  properly  to  examine  the  abdomen  by 
palpation,  it  is  necessary  to  place  the  patient  flat 
on  his  back,  on  a slightly  inclined  plane,  with  a 
round  pillow  placed  under  the  head,  so  as  to  flex 
the  chin  upon  the  sternum.  The  thighs  should 
be  similarly  flexed  upon  the  pelvis  by  means  of 
a second  incline,  on  which  the  legs  should  rest, 
or  by  placing  one  pillow  beneath  the  thighs  and 
two  pillows  beneath  the  legs.  In  this  manner  tho 
muscles  of  the  abdomen  will  be  renderedaslax  ns 
possible.  The  patient  should  further  be  held  in 
conversation,  or  told  to  breathe  deeply  hut  with- 
out effort,  in  order  that  he  may  not  keep  his 
diaphragm  fixed.  It  is  often  a good  plan,  when 
other  efforts  fail  to  prevent  the  patient  from 
keeping  his  diaphragm  fixed,  to  make  him  go  on 
counting  ‘one,’  ‘two,’  ‘three,’  up  to  as  high  a 
number  as  he  can  possibly  reach  without  draw- 
ing breath.  In  this  manner  we  get  the  diaphragm 
thoroughly  relaxed;  and  by  keeping  the  hand  on 
the  abdomen,  deep  palpation  can  be  effected  at 
any  period  of  the  counting  most  suitable  for  the 
purpose.  The  observer  should  be  comfortably 
placed  at  about  the  same  level  as  his  patient. 
The  whole  hand,  previously  warmed,  should  be 
evenly  applied  to  the  surface,  and  the  fingers  then 
depressed  in  different  directions  as  the  hand  is 
smoothly  conveyed  to  different  regions.  If  the 


PHYSICAL  EXAMINATION. 


LI  9-1 

patient  be  poked  about  with  the  ends  of  the 
fingers  by  the  physician  stooping  over  him  he  is 
either  tickled  or  hurt,  his  muscles  contract,  and 
proper  examination  is  impossible. 

It  is  sometimes  useful  to  make  the  patient 
change  his  position  first  to  one  side,  then  to  the 
other.  This  method  is  particularly  to  be  adopted 
in  examining  tumours  which  are  movable,  such 
as  floating  kidneys,  some  uterine  tumours,  and 
aneurismal  sacs.  In  the  case  of  tumours  lying 
over  the  aorta,  it  may  be  impossible,  with- 
out adopting  this  plan,  to  be  sure  whether  the 
pulsation  felt  over  them  is  communicated  or  in- 
trinsic. 

It  is  sometimes  doubtful  whether  a tumour 
is  situated  within  the  rectus  muscle,  or  in  the 
abdomen  beneath  it.  By  keeping  the  hand  over 
the  tumour  and  making  the  patient  raise  himself 
half  to  the  sitting  posture,  so  as  to  cause  the 
recti  to  start  forward  in  contraction,  this  point 
can  be  cleared  up. 

The  temperature  of  the  surface  of  the  abdomen 
to  the  hand  applied,  and  to  the  surface  thermo- 
meter, may  be  distinctly  raised  above  that  of 
the  general  surface  in  peritonitis. 

It  is  often  difficult  to  estimate  the  true  degree 
and  nature  of  pain  in  the  abdomen  caused  by 
pressure.  In  hypersesthesia  of  the  surface  the 
slightest  pressure  causes  suffering ; whilst  deep, 
even  palpation  gives  little  inconvenience.  If  the 
surface  be  pinched  up  the  pain  is  acute.  Pain  in 
the  abdominal  muscles  is  less  acute,  and  is  in- 
tensified by  bringing  these  into  action.  The  pain 
of  peritonitis  is  superficial  in  so  far  as  it  is  com- 
monly associated  with  hypersesthesia  of  surface ; 
but  gentlu,  steady  pressure  is  acutely  painful, 
and  deep  palpation  intolerable.  The  pain  of 
peritonitis  may,  with  the  disease,  be  general  or 
local.  There  is  often  some  difficulty  in  differen- 
tiating the  pain  of  localised  hypersesthesia — 
hysterical  pains  as  they  are  called,  from  those 
of  inflammatory  origin  or  from  tenderness  of 
organs.  By  holding  the  patient  persistently  in 
conversation  respecting  symptoms  associated  al- 
together with  another  part,  as  minute  inquiries 
about  headache,  cough,  &c.,  and  thus  keeping  off 
attention  whilst  the  hand  is  steadily  compress- 
ing the  supposed  painful  parts,  all  doubts  can  be 
removed.  In  neuralgic  and  hysterical  pains 
simulating  peritonitis,  the  tenderness  extends 
beyond  the  confines  of  the  peritoneum. 

Abdominal  organs  may  be  tender  to  palpa- 
tion. 

Fluctuation. — Fluctuation  is  an  important  sign 
of  the  presence  of  fluid  in  the  abdomen,  whether 
the  fluid  be  free  in  the  peritoneum  or  enclosed 
in  a sac.  It  may  be  obtained  by  placing  one 
hand  lightly  on  the  abdomen,  whilst  the  fingers 
of  the  other  hand  smartly  tap  over  another 
part,  when  a fluid  wave  will  be  felt  to  impinge 
against  the  applied  hand.  In  certain  tense 
conditions  of  the  abdomen,  a deceptive  sense 
of  fluctuation  may  be  obtained  from  the  vibra- 
tions of  the  abdominal  walls.  To  prevent  this 
fallacy  the  hand  of  a bystander  should  be  ap- 
plied edgewise  on  the  abdomen,  midway  between 
the  two  hands  of  the  observer,  so  as  to  check 
superficial  vibrations. 

Hydatid  fremitus.— This  is  a kind  of  tense 
fluctuation  appreciable  by  the  pleximeter  finger 


oil  sharp  percussion  over  certain  cysts,  more  par- 
ticularly hydatid  cysts. 

(c)  and  (d)  Percussion  and  Auscultation- 
Percussion  and  auscultation  of  the  abdomen  aro 
adopted  in  accordance  with  the  methods  already 
described.  The  distribution  of  dulness  and  re- 
sonance, varying  or  not  with  the  position  of  the 
patient,  affords  important  evidence  respecting 
fluid  collections,  whether  peritoneal  or  encysted. 
See  Abdomen,  Diseases  of ; and  Ascites. 

By  auscultation  friction-sounds  may  be  heard 
oyer  the  seat  of  peritonitis ; vascular,  aneu- 
rismal, and  placental  bruits ; or  the  sounds  of 
the  foetal  heart  may  be  detected. 

Physical  Examination  of  the  Liyee.— In 
the  right  mammary  line  the  liver  underlies  the 
region  from  the  fifth  rib  to  the  costal  margin ; 
in  the  median  line  from  the  base  of  the  xiphoid 
cartilage  to  an  inch  and  a half  below  that  level 
The  left  extremity  of  the  liver  lies  just  within 
and  behind  the  apex  of  the  heart.  It  may, 
then,  be  roughly  said  that  a horizontal  line 
drawn  from  the  base  of  the  xiphoid  cartilage  to 
the  right  side  of  the  chest  and  to  the  apex  of  the 
heart,  and  a second  line  slanting  from  within 
the  apex-beat  to  the  right  costal  margin  in  the 
nipple  line,  would  mark  the  site  of  the  liver.  It 
has  already  been  observed  how  this  surface  is 
partially  covered  above  by  lung.  In  health  the 
margin  of  the  liver  becomes  lost  to  palpation 
beneath  the  cartilages  in  the  right  nipple  line. 
Its  upper  margin  may  be  defined,  as  already 
shown,  by  deep  percussion,  its  lower  margin  by 
very  light  percussion. 

Displacements. — The  liver  may  be  lowered  in 
position  by  certain  thoracic  conditions,  such  as 
emphysema,  fluid  in  the  pleura  or  pericardium, 
thoracic  tumours,  or  compression  by  tight-lacing. 
When  the  liver  is  thus  lowered,  it  is  some- 
what anteverted  ; and  in  lax  conditions  of  the 
abdomen  its  lower  margin  may  be  covered  by  a 
coil  of  intestines,  thus  requiring  somewhat  deep 
palpation  in  tracing  it. 

The  liver  may  be  raised  by  contractile  tho- 
racic diseases,  especially  c-n  the  right  side,  so 
that  its  margin  recedes  considerably  within  the 
costal  margin.  In  cases  of  doubt  as  to  whether 
extension  of  dulness  upwards  be  liver  or  lung- 
consolidation,  the  observer  must  notice  whether 
the  level  be  shifted  by  respiratory  movements. 
When  the  abdomen  is  distended  from  any  cause, 
the  liver  is  pushed  upwards;  and  in  this  case, 
and  also  in  many  instances  where  the  liver  is 
drawn  upwards,  it  becomes  also  tilted  somewhat 
backwards,  so  that  but  little  more  than  the 
margin  presents  anteriorly.  In  this  condition 
there  may  be  but  little,  if  any,  liver-dulness 
discoverable  anteriorly,  and  it  may  erroneously 
be  concluded  that  the  liver  is  much  diminished 
in  size.  In  these  cases,  however,  the  posterior 
dulness  of  the  liver  is  increased  in  tha  right 
lower  thoracic  region.  In  cases  of  enlargement 
of  the  liver,  therefore,  the  upper  margin  must 
be  accurately  defined,  to  see  if  there  be  exten- 
sion upwards,  and  whether  that  extension  be  even 
or  uneven.  The  lower  margin  must  be  traced 
by  palpation  ; the  mobility  of  the  organ  with 
respiration  estimated;  its  hardness,  soitness, 
sharpness,  evenness,  or  distortion  ascertained ; 
and  whether  it  be  free  or  connected  with  other 


PHYSICAL  EXAMINATION. 


parts — for  example,  the  spleen,  or  an  abdominal 
tumour. 

The  lower  margin  of  the  liver,  when  the  organ 
is  enlarged  or  depressed,  very  frequently  cannot 
he  defined  by  percussion,  being  overlapped  by  in- 
testines. For  instance,  in  eases  of  lax  abdominal 
parietes,  with  moderate  fluid  effusion  in  the  peri- 
toneum, the  intestines  float  up  and  press  between 
the  margin  of  the  liver  and  the  surface.  In  other 
cases  the  front  surface  may  be  unduly  rounded, 
and  the  margin  thus  incurvated  to  a certain  ex- 
tent and  covered  by  intestines.  The  surface  must 
be  felt— whether  smooth,  or  rough,  or  nodulated. 
The  consistence  must  be  estimated  by  palpation 
—whether  hard  or  soft,  or  fluctuating  at  any  part. 

The  gall-bladder  cannot  be  felt  unless  it  be 
distended,  when  it  presents  as  a rounded  tumour 
attached  to  the  margin  of  the  liver  in  the  right 
nipple  line. 

~Phtsical  Examination  of  the  Spleen. — Nor- 
mally, splenic  dulness  may  be  ascertained  on 
light  percussion  in  an  area  on  the  left  side  ex- 
tending from  the  ninth  to  the  eleventh  ribs,  and 
between  the  mid  axillary  and  mid-scapular 
lines.  The  shape  of  the  splenic  dulness  is  oval 
in  the  slant  of  the  ribs. 

In  moderate  enlargement  the  splenic  dulness 
is  increased  in  all  directions ; and  on  placing 
the  hand  deeply  in  the  left  flank,  close  under  the 
ribs,  the  organ  may  be  felt  to  descend  upon  it 
during  inspiration.  As  the  organ  still  enlarges 
it  comes  forwards  aid  downwards,  raising  the 
apex-beat  of  the  heart,  occupying  the  region 
in  front  of  the  scapular  line  and  below  the 
level  of  the  apex-beat,  and  projecting  downwards 
beneath  the  costal  margin  into  the  abdomen.  As 
the  organ  still  further  enlarges,  the  anterior  mar- 
gin curves  forwards,  forming  nearly  a right  angle 
with  the  costal  margin.  It  is  usually  sharply 
defined,  and  may  extend  forwards  to  the  median 
line,  and  downwards  to  the  pelvis.  The  posterior 
margin  of  the  enlarged  spleen  is  also,  in  such 
cases  of  great  enlargement,  to  be  felt  thick  and 
rounded  immediately  in  front  of  the  quadratus 
muscle.  An  enlarged  spleen  extending  into  the 
abdomen  is  superficial  in  its  entire  area ; its 
anterior  and  posterior  borders  are  well-defined ; 
and  it  can  usually  be  moved  between  the  two 
hands  forwards  and  backwards  The  notch  may 
■ be  commonly  felt.  The  surface  may  be  quite 
even  or  nodulated.  Sometimes  on  auscultation  a 
bruit  may  be  audible  over  an  enlarged  spleen. 
Friction-sound  may  also  sometimes  be  heard. 
Certain  alterations  in  the  constitution  of  the 
blood  and  in  the  temperature  of  the  body  are 
intimately  associated  with  diseases  of  the  spleen, 
and  the  examination  of  these  conditions  forms 
an  important  item  in  their  diagnosis. 

Diminution  in  the  size  of  the  spleen  cannot  be 
accurately  estimated,  and  is  of  little  clinical 
moment. 

Physical  Examination  of  thf.  Kidneys. — The 
kidneys,  when  of  normal  dimensions,  cannot,  as 
t a rule,  be  felt,  especially  in  fat  people,  or  when 
the  abdomen  is  enlarged.  They  lie  one  on  either 
side  near  the  spinal  column,  between  the  level 
of  the  spinous  process  of  the  eleventh  dorsal  and 
of  the  second  lumbar  vertebrae,  and  in  the 
mid-line  between  these  spinous  processes  and 
the  outer  margin  of  the  flank.  Imbedded  in  fat, 


1195 

they  rest  on  the  lumbar  muscles.  The  right 
kidney  is  overlain  in  part  by  the  liver,  colon, 
and  intestines ; the  left  by  the  stomach,  colon, 
and  intestines. 

In  order  to  feel  for  the  kidney,  the  patient 
should  he  placed  in  the  position  for  abdominal 
examination.  The  observer,  standing  on  the  side 
opposite  that  of  the  kidney  under  examination, 
then  places  one  hand  along  the  mid-flank  be- 
hind, immediately  below  the  last  rib  ; the  other 
hand  should  rest  upon  the  corresponding  part  of 
the  abdomen  in  front,  firmly  depressing  and  mani- 
ulating  deeply,  so  as  to  bring  the  site  of  the 
idney  between  the  phalangeal  portions  of  the 
two  hands.  At  the  same  time  the  patient  should 
be  made  to  inspire  and  expire  deeply  ; and  it  is 
during  the  stage  of  moderately  deep  expiration 
that  the  organ  will  usually  be  felt. 

Tenderness  of  the  kidney,  if  present,  may  thus 
be  estimated  with  certainty.  Undue  rigidity  of 
the  muscles  on  one  side  may  be  observed. 

If  the  kidney  be  uniformly  enlarged  it  simply 
extends  downwards,  and  comes  more  readily 
under  observation.  In  great  enlargement  of  the 
kidney,  as  in  cancerous  tumour,  or  of  its  pelvis, 
as  in  pyelitis,  the  organ  forms  a tumour  occupying 
the  flank,  and  coming  forwards  from  behind  the 
colon  towards  the  front  of  the  abdomen.  Such  a 
tumour  is  more  or  less  pyramidal  or  rounded  in 
form,  with  a distinct  band  of  resonance  corre- 
sponding with  the  superior  flexure  of  the  colon 
extending  across  it.  The  tumour  may  be  solid  or 
fluctuating,  according  to  its  nature.  Kenal 
tumours  are  most  common  on  the  left  side.  The 
pelvis  of  the  kidifey,  except  when  considerably 
dilated,  does  not  come  under  palpation.  See 
Kidneys,  Diseases  of. 

Movable  kidneys. — The  mobility  of  the  kid- 
neys varies  much,  from  mere  laxness  to  complete 
dislocation.  See  Kidneys,  Diseases  of. 

The  examination  of  the  urine  forms  the  most 
important  part  of  the  physical  diagnosis  of 
kidney-diseases.  See  Ueine,  Morbid  Conditions 
of. 

Physical  Examination  of  the  Pancreas. — 
In  thin  subjects  with  retracted  abdomen,  the 
head  of  the  pancreas  may  he  felt  as  a small, 
somewhat  angular,  tumour  to  the  right  of  the 
median  line,  above  the  level  of  the  umbilicus,  in 
the  region,  in  fact,  of  the  pylorus,  with  thicken- 
ing of  which  it  may  readily  be  confounded. 

Cancerous  enlargement  of  the  pancreas  extends 
forwards,  in  or  near  the  middle  line,  above  the 
umbilicus,  presenting  a tumour  difficult  to  dia- 
gnose. See  Pancreas,  Diseases  of. 

Physical  Examination  of  other  Abdominal 
Viscera. — Diseases  of  the  stomach  and  intestines 
yield  their  proper  signs,  requiring  no  separate  de- 
scription here.  Tumours  of  the  omentum  have  to 
he  distinguished, by  themethod  of  exclusion, from 
affections  of  the  solid  organs  of  the  abdomen. 

The  pelvic  organs — uterus,  and  ovaries,  and 
bladder,  under  certain  conditions  of  enlarge- 
ment— present  themselves  for  diagnosis  as  abdo- 
minal tumours. 

When  distended,  the  bladder  gives  rise  to  a 
pyramidal  area  cf  dulness  extending  in  the  me- 
dian line  from  the  pubes,  broadening  upwards, 
towards  or  even  beyond  the  umbilicus.  The 
tumour  is  firm  but  elastic,  on  palpation  tender, 


1196  PHYSICAL  EXAMINATION, 
and  is  at  once  removed  by  successful  catheteri- 
sation. 

In  pregnancy  at  the  fourth  month  the  uterus 
becomes  perceptible  to  deep  palpation  in  the 
pelvic  basin  in  the  pubic  region.  At  and  be- 
yond the  fifth  month  a tumour  of  growing 
dimensions  extends  from  out  of  the  pelvis  towards 
and  beyond  the  umbilicus.  Dulness  on  percus- 
sion extends  from  the  pubes  over  the  whole 
front  of  the  tumour,  whilst  above  and  in  the 
flanks  a resonant  intestinal  note  is  obtained. 
The  relations  of  dulness  and  resonance  are  not 
appreciably  changed  by  position.  The  tumour 
is  elastic,  and  in  the  advanced  stages  obscurely 
fluctuating.  On  deep  palpation,  an  irregular 
resisting  lobulated  mass  is  to  be  felt,  and  on 
keeping  the  hand  steadily  applied,  undulating 
movements,  or  a distinct  shock  or  jerking  move- 
ment, may  from  tima  to  time  be  felt.  On  ap- 
plying the  stethoscope  with  somewhat  deep 
pressure,  half-way  between  umbilicus  and  pubes 
and  a little  on  one  or  other  side,  the  rapid  beat 
of  the  fcetal  heart  may  be  distinctly  heard,  closely 
resembling  the  tick  of  a watch  under  the  pillow. 
On  bringing  the  stethoscope  nearer  the  inguinal 
region  (usually  on  the  right  side),  the  soft  low- 
pi  tchcd  placental  souffle,  synchronous  with  the 
maternal  pulse,  is  to  be  heard.  Enlargement  of 
the  uterus  from  other  causes,  especially  fibroid 
and  fibro-cystic  growths,  may  lead  to  abdo- 
minal tumours,  which  are  diagnosed  by  com- 
bined vaginal  and  abdominal  examination.  See 
Womb,  Diseases  of. 

Ovarian  tumours  also  present  in  the  abdomen, 
extending  upwards  from  one  or  other  side  of  the 
pelvic  region,  and  with  a disposition  as  they  ex- 
tend to  become  central.  They  are  most  commonly 
cystic,  and — especially  in  the  later  stages — some- 
times present  difficulties  in  diagnosis  from 
pregnancy  or  peritoneal  dropsy.  See  Abdomen, 
Diseases  of;  Abdominal  Aneurism;  Aorta, 
Diseases  of;  Ovaries,  Diseases  of;  and  other 
appropriate  headings. 

E.  Douglas  Powf.ll. 

PHYSIOGNOMY  (<pvms,  nature,  and  yvwgi}, 
judgment). 

Definition.- — Physiognomy  originally  meant 
the  interpretation  of  the  nature  of  an  individual, 
by  the  light  of  the  indications  afforded  by  his 
countenance,  conformation,  and  movements;  but 
the  term  is  frequently  used  for  the  indications 
themselves. 

Physiognomy  in  Diagnosis.  — In  the  early 
ages  of  medical  science  the  doctrine  of  phy- 
siognomy formed  an  important  part  of  all 
systematic  teaching.  In  proportion  as  the 
means  and  practice  of  physical  diagnosis  have 
been  developed,  physiognomy,  being  insusceptible 
of  exact  treatment,  has  fallen  into  the  back- 
ground, and  is  seldom  assigned  a definite  place 
among  methods  of  investigation.  Yet  in  every 
description  of  disease  the  indications  yielded  to 
inspection  have  their  place;  and  practically  it  is 
nc  small  part  of  the  accomplishment  of  a skilful 
physician  to  be  able  to  recognise  readily  in  any 
sick  person  the  outward  signs  which  may  be 
characteristic  of  his  malady. 

The  authors  who  have  treated  systematically 
of  physiognomy  make  it,  in  the  first  place,  sub- 


PHYSIOGNOMY. 

servient  to  the  definition  of  certain  morbid  lem. 
peraments,  to  which  the  name  of  dial  kescs  has  been 
given.  When  in  any  case  the  tendency  belong, 
ing  to  a diathesis  has  gone  on  to  the  production 
of  an  actual  diseased  state,  the  word  cachexia 
has  been  commonly  adopted  to  express  the  ful- 
filment of  the  first  physiognomical  prophecy, 
with  an  extension  of  application  to  diseased 
states  produced  by  accident,  or  without  precedent 
sign  ot  the  existence  of  the  corresponding  dia- 
thesis. Among  modern  English  authors  on 
medicine,  Dr.  Laycock  was  conspicuous  in  allot- 
ting an  important  place  to  the  ‘ physiognomical 
diagnosis  of  morbid  constitutional  states.’ 

Elements  of  Physiognomy. — Besides  such 
larger  groups  of  physiognomical  indications, 
there  are  smaller  groups,  and  even  single  fea- 
tures, which  relate  to  particular  systems  of 
organs,  or  to  individual  parts,  and  which,  in 
proportion  to  their  limitation,  have  mostly  a 
more  precise  meaning.  Before  enumerating  some 
of  these,  it  may  be  of  advantage  to  review  the 
elements  of  physiognomy.  These  are,  in  the 
main,  four  : — 1,  tegumentary — skin,  with  glands 
and  blood-vessels,  mucous  membrane  of  month 
and  throat;  2,  muscular-,  3,  skeletal;  4.  attitudes 
and  movements,  including  those  of  speech. 

The  skin  presents  a large  number  of  points  for 
observation  ; for  example,  its  colour,  as  regards 
pigmentation,  and  as  regards  vascularity;  its 
texture,  as  regards  softness  or  hardness,  smooth 
ness  or  roughnesss,  thickness  or  fineness,  tough- 
ness or  flexibility,  dryness  or  moisture;  the  de- 
velopment and  distribution  of  glands  and  hairs; 
cedema ; tumours,  such  as  warts  ; and  eruptions. 
Besides  these,  in  the  face  lines,  furrows,  and 
ridges  mark  the  excessive  or  defective  action  of 
particular  muscles,  whether  determined  by  habit 
or  disease,  causes  which  also  determine  the  shape 
of  the  orifices  and  skin-prominence  of  the  face. 

As  regards  muscular  variations  there  may  be 
noted  protective  contractions,  to  which  Mr.  Dar- 
win has  drawn  attention  as  part  of  the  basis  of 
the  expression  of  the  emotions,  protective  relaxa- 
tion, reflex  contractions,  spasmodic  contractions, 
and  paralysis.  With  the  conformation  of  the 
bosses,  which  form  the  framework  upon  which  the 
skin  and  muscles  are  moulded,  must  be  associated 
the  teeth,  organs  rich  in  information  touching 
the  health  of  the  mucous  membranes  during 
childhood,  and  of  the  system  at  large  throughout 
life. 

Applications  of  Physiognomy.— Many  of  the 
correlations  between  physiognomy  and  disease 
are  fully  discussed  in  other  parts  of  this  work. 
A few  illustrations  of  the  use  of  the  method  map, 
however,  he  cited  in  this  article. 

The  skin,  alone,  may  yield  indications  sug- 
gestive, pathognomonic,  or  diagnostic,  as  the 
case  may  be.  Of  the  first  kind-  are  the  staining 
of  jaundice,  the  contrasted  tints  of  hectic,  the 
alterations  of  the  hair  in  various  diseases ; of  the 
second  kind  are  the  eruptions  of  exanthematous 
fevers  and  syphilis;  of  the  third  kind  is  the  ob-| 
servation  of  Mr.  Spencer  Wells,  in  dealing  with 
the  diagnosis  of  ovarian  and  uterine  tumours, 
that  ‘there  is  a facial  expression  common  to  I 
women  suffering  from  both  classes  of  disease, 
associated  with  a very  florid  complexion  when 
the  tumour  is  uterine,  whereas  in  the  majority  c. 


PHYSIOGNOMY. 

ovarian  cases  the  complexion  is  pallid.’  In  the 
mucous  membrane  of  the  mouth  the  blue  line  on 
the  <mms  in  chronic  lead-poisoning,  the  spongy 
gums  of  mercurial-poisoning  and  of  scurvy,  and  the 
pigmentation  of  Addison’s  disease  are,  approxi- 
mately, instances  of  the  three  kinds  of  signs. 

In  the  muscles,  independently  of  the  various 
evidences  of  paralysis,  we  may  refer  to  the  ‘risus 
sardonicus  ’ ; to  the  tumid,  expressionless  upper 
lip  of  progressive  muscular  atrophy  (Duchenne) ; 
to  the  fixed  bent  attitude  of  the  head,  and  rigid, 
imperturbed  features  and  unaltered  articulation 
■ of  paralysis  agitans,  as  compared  with  the  shak- 
ing head  and  scanning  articulation  of  dissemi- 
nated sclerosis,  or  the  fatuous  look  which  accom- 
panies the  irregular  movements  of  chorea.  The 
physiognomy  in  plague  is  said  to  be  highly 
characteristic.  See  Plague. 

The  bones  contribute  also  to  our  information. 
They  present  definite  changes  of  form  in  rickets, 
the  projecting  under-jaw  which  in  many  women 
is  associated  with  pelvic  deformity,  the  enlarge- 
ment of  the  cranium  in  hydrocephalus,  and  the 
hour-glass  head  and  altered  teeth  of  inherited 
syphilis. 

As  in  the  diatheses  all  the  four  systems  co- 
i operate  to  form  a characteristic  physiognomy, 
so  in  many  actual  diseases  complex  manifesta- 
tions are  abundantly  presented.  The  changes 
observed  in  the  face  and  neck  in  association  with 
certain  affections  of  the  chest  may  be  selected  as 
illustrating  well  this  kind  of  grouping.  Thus 
in  severe  cases  of  chronic  bronchitis,  with 
emphysema,  the  skin  is  turgid,  blue,  purple,  or 
livid,  the  lower  lip  especially  being  discoloured, 
enlarged,  and  everted;  the  veins,  particularly 
in  the  neck,  are  full  and  prominent ; the  brows 
are  knitted,  the  eyeballs  projected,  the  eyelids 
swollen  and  partly  contracted ; the  lower  jaw,  if 
not  closed,  is  rigidly  set  in  a way  to  give  full 
; effect  to  the  action  of  the  central  muscles  raising 
the  sternum,  which,  with  the  sterno-eleido- 
mastoids,  are  prominent  and  strong;  the  head  is 
bent  forward,  the  shoulders  raised,  the  nostrils 
j expanded  and  thickened.  The  entire  expression 
is  one  of  strain  and  anxiety.  If  there  be,  as  is 
often  the  case,  tricuspid  regurgitation,  the  veins 
of  the  neck  may  be  seen  filled  during  every 
pulsation  of  the  heart. 

In  certain  forms  of  advanced  disease  of  the 
•heart  there  is  the  same  swelling  and  discoloura- 
tion. But  there  is  usually  some  icteric  tinging 
of  the  skin  and  conjunctive,  and  much  weaker 
.signs  of  muscular  strain,  which  in  emphysema 
are  brought  about  by  the  constant  inspiratory 
effort.  The  face  is  generally  calmer  in  ex- 
pression, and  the  head  rather  thrown  back  than 
drawn  forward. 

When  an  aneurism  or  intrathoracic  growth 
presses  on  the  structures  in  the  upper  part  of  the 
chest,  the  face  often  presents  enormous  venous 
turgidity,  and  the  veins  at  the  root  of  the  neck 
ire  often  permanently  distended,  and  unaffected 
oy  the  movements  of  respiration,  sometimes  on  one 
>ide,  sometimes  on  both.  If  there  be  pressure  on 
he  trachea  or  large  bronchi,  or  if  there  be  para- 
ysis  of  therecurrent  laryngeal  nerve,  many  of  the 
nuscular  strains  already  noticed  may  be  present ; 
f there  be  paralysing  pressure  on  the  sympa- 
hetic,  the  pupil  on  the  same  side  will  be  com- 


PHYTOSIS  VERSICOLOK.  1197 

paratively  contracted,  all  the  tissues  on  the  side 
more  swollen,  and  the  secretions  increased.  If 
with  aneurism  there  be  aortic  regurgitation, 
violent  pulsation  of  all  the  arteries  will  usually 
be  noticed,  bringing  into  strong  relief  arteries 
generally  quite  unseen. 

In  these  illustrations  the  appearances  seen  in 
the  head  and  neck  only  are  considered.  If  the 
modification  of  bodily  conformation,  movements, 
and  attitudes  which  go  to  make  up  the  full 
physiognomical  picture  were  also  detailed,  a 
large  addition,  exceeding  the  limits  of  this  ar- 
ticle, would  be  involved.  But  even  so  much  as 
is  here  portrayed  will  serve  to  remind  us  of 
the  large  amount  of  suggestive  information 
which  may  be  gleaned  by  the  observer  before 
proceeding  to  actual  physical  examination  of  the 
patient,  and  may  stand  for  an  example  of  the 
process  which,  under  careful  training  and  prac- 
tice, is  at  last  performed  almost  unconsciously 
by  the  experienced  physician. 

William  M.  Oed. 

X 

PHTSOMETEA  (cpvaa,  air,  and  firirpa, 
the  womb). — A condition  in  which  a collection 
of  gas  or  air  is  formed  in  the  uterus.  See 
Womb,  Diseases  of. 

PHYTOSIS  (<pvrby,  a plant). — A generic 
term  for  plant-formation,  applicable  to  epiphytic, 
phytiform,  or  parasitic  diseases  of  the  skin,  of 
which  there  may  be  enumerated  the  following 
species: — Phytosis  or  tinea  tonsurans ; phytosis 
or  tinea  circinata  ; phytosis  favosa  or  favus ; and 
phytosis  versicolor.  See  Eaves  ; Nosophyta; 
Ringworm  ; and  Tinea. 

PHYTOSIS  VERSICOLOR.— Synox.  : 
Willan,  Pr.,  and  Ger.  Pityriasis  versicolor. 

Depinition. — A disease  of  the  epidermic,  rete 
mucosum,  and  follicular  epithelium,  characterised 
by  the  development  on  the  skin  of  a yellowish- 
brown  discolouration,  sometimes  tawny  and 
sometimes  olive ; consisting  of  small,  irregu- 
larly-shaped patches  and  blotches  of  considerable 
extent,  which  give  to  the  integument  a variegated 
or  mottled  appearance. 

IEtiology. — The  presence  of  phytosis  versi- 
color indicates  defective  nutritive  power  of 
the  skin,  which  is  not  infrequently  associated 
with  general  debility,  and  sometimes  defect 
of  sanguification — with  such  symptoms,  in  fact, 
as  are  present  in  melasma  ; but  these  symp- 
toms are  rarely  very  prominent,  and  the  gene- 
ral inference  may  be  that  the  health  is  un- 
affected. 

Description. — The  most  common  seat  of  phy- 
tosis versicolor  is  the  trunk  of  the  body,  where  it 
assumes  a symmetrical  distribution,  sometimes 
spreading  down  the  flanks  from  the  axillae,  some- 
times occupying  the  middle  line,  and  sometimes 
the  whole  surface  of  the  abdomen,  or  descending 
from  the  groins  upon  the  upper  part  of  the 
thighs,  like  an  apron.  It  is  found  similarly  dis- 
posed on  the  back  of  the  trunk,  or  it  surrounds  the 
neck,  blending  with  a general  swarthiness  of  the 
face ; and  it  is  likewise  met  with  on  the  upper 
arms,  the  flexures  of  the  elbows,  and  those  of 
the  knees. 

When  closely  examined,  it  may  ba  seen  that 


1198  PHl’TOSIS  VERSICOLOR, 
the  discoloured  skin  is  punctated  by  the  aper- 
tures of  the  follicles,  which  are  deeper  tinted 
than  the  rest  of  the  surface,  and  seem  to  perform 
the  office  of  centres,  from  which  the  pigment 
spreads  around,  involving  other  follicles  simi- 
larly affected.  This  inspection  tends  to  satisfy 
us  that  the  follicles  are  the  origin  of  the  morbid 
process  and  discolouration.  Another  observation, 
derived  from  close  inspection,  is  that  the  patches 
are  slightly  elevated,  and  that  they  present  evi- 
dence of  hyperaemia ; and,  further,  we  discover 
that  they  are  very  apt  to  take  on  a ragged  kind  of 
exfoliation,  which  has  gained  for  the  disease  the 
synonym  of  pityriasis. 

Therefore,  the  distinguishing  characters  of  this 
affection  are  its  colour  ; its  patchy  distribution; 
its  exfoliation,  from  the  breaking  up  or  crumbling 
of  the  morbid  epidermis;  and  the  subjective 
symptom  of  itching.  These  characters  present 
considerable  variety.  In  some  instances  the  colour 
of  the  disease  predominates  so  considerably  as  to 
suggest  a pigmentary  affection  simply ; in  others 
the  exfoliation  is  so  remarkable  that  the  term 
pityriasis  would  seem  to  be  fairly  warranted; 
while  in  others,  again,  the  itching  may  he  either 
almost  absent  or  insufferable. 

When  a portion  of  the  exfoliating  epidermis 
is  submitted  to  the  microscope,  it  is  found  to  be 
largely  composed  of  minute  globular  bodies  or 
cells,  which  are  rendered  transparent  by  the  ad- 
dition of  a solution  of  potash.  These  are  pre- 
sumed to  he  a fungous  vegetation,  and  to  the 
individual  globules  the  term  mierosporon  has 
been  applied. 

Phytosis  versicolor  is  a malady  which  is  chiefly 
inconvenient  from  its  appearance,  and  may  exist 
for  years  without  giving  rise  to  any  disagreeable 
symptoms.  Sometimes  there  is  a little  pruritus, 
when  the  patient  becomes  warmed  by  exercise; 
but  occasionally  the  itching  has  been  found  so 
troublesome  aDd  unbearable  as  to  be  a source  of 
considerable  suffering. 

Although,  in  consequence  of  being  considered 
one  of  the  parasitic  diseases,  phytosis  versi- 
color has  been  credited  with  the  reputation  of 
being  contagious,  it  is  very  rarely  met  with  in 
both  husband  and  wife,  how-ever  loDg  it  may 
have  been  present  in  either.  Unlike  tinea,  it  is  a 
disease  of  the  adult ; and  tinea  is  never  attended 
by  pigmentation. 

Sometimes  it  exists  for  years  without  attract- 
ing the  attention  of  the  patient  further  than  the 
inconvenience  of  its  appearance,  and  it  rarely  gets 
well  without  treatment. 

Diagnosis. — The  diseases  with  which  phytosis 
versicolor  is  liable  to  be  confounded  are  the  pig- 
mentary affections,  melasma  and  chloasma,  and 
pityriasis.  The  presence  of  slight  elevation, 
exfoliation,  and  its  flecked  appearance,  as  well 
as  its  symmetrical  distribution,  will  distinguish 
it  from  the  smooth  stains  of  the  former ; and  the 
absence  of  inflammation,  with  exfoliation  rather 
than  desquamation,  from  the  latter. 

Treatment. — In  the  treatment  of  phytosis 
versicolor,  tonic  remedies  and  a tonic  regimen 
are  generally  indicated.  Locally,  it  yields  very 
quickly  to  the  sulphuret  of  potassium  ointment.,  to 
*11  the  mercurial  ointments,  or  to  a lotion  of  per- 
riiloride  of  mercury  ointment  in  almond  emulsion. 
The  use  of  sulphur  soap  is  also  valuable,  and  by 


PIGMENTARY  SKIN-DISEASES, 
keeping  up  a moderate  stimulation  of  the  skin 
it  tends  to  check  the  return  of  the  disease.  Set 
Tinea.  Erasmus  Wilson. 

PI  A MATER,  Diseases  of.  See  Meninges, 

Diseases  of. 

PIARHAEMIA  (7r Tap,  fat,  and  aifia,  blood). 

A morbid  condition  of  the  blood,  in  which  it  con- 
tains free  fat.  See  Blood,  Morbid  Conditions  of. 

PICA  {pica,  a magpie). — A perversion  of 
appetite,  characterised  by  a craving  for  various 
substances  unfitted  for,  or  incapable  of  digestion. 
See  Appetite,  Disorders  of. 

PIGEON-BREAST. — A deformity  of  the 
chest,  in  which  the  ribs  are  flattened  laterally 
and  the  sternum  thrust  forward,  so  that  the 
chest  assumes  somewhat  the  shape  of  the  breast 
of  a pigeon.  See  Deformities  of  Chest. 

PIGMENTARY  SKIN-DISEASES.— 

Synon.  : Chromatopathia ; Chromatopathic  affec- 
tions. 

These  affections  may  be  arranged  under  fonr 
heads,  namely : — 1,  defect;  2,  excess;  and  3,  al- 
teration of  colour : and  4,  artificial  colouring  of 
the  skin. 

1.  Defect  of  Colour. — Defect  of  colour  of 
the  skin  is  due  to  absence  of  pigment ; it  occurs 
both  in  the  rete  mucosum  and  hair,  and  is  either 
general  or  partial.  As  a general  affection  it  is 
known  by  the  name  of  albinism,  the  subject  of 
the  defect  being  called  an  albino.  Considered 
as  a disease  it  is  termed  leucopathia  and  its 
examples  are  aehroma,  leuce,  and  leucasnms. 
See  Albinism. 

2.  Excess  of  Colour. — Excess  of  colour  is 
represented  by  increase  in  quantity  of  the  normal 
pigment  of  the  skin,  giving  rise  to  a series  of 
shades  of  hue,  ranging  from  the  lighter  tints  of 
olive  and  brown  to  the  deepest  tints  of  black ; 
and,  like  the  preceding,  may  be  general  or  par- 
tial. As  a morbid  process  it  is  denominated 
melanopathia,  and  its  examples  chloasma  and 
melasma. 

3.  Alteration  of  Colour.  — Alteration  of 
colour  of  the  skin  is  manifested  by  a variation 
in  hue  of  the  pigmentary  matter,  arising  from  an 
excess  of  one  of  the  primitive  elements  which 
enter  into  the  composition  of  the  normal  brown 
or  black.  Thus  it  may  be  yellow  or  olive,  as  in 
the  two  principal  members  of  this  group,  epheiis 
and  lentigo,  the  general  term  for  the  affection 
being  xanthochroia, ; whilst  the  term  cyanochroia 
has  been  applied  to  a rare  example  of  blue  pig- 
mentation of  the  skin. 

4.  Artificial  Colouring  of  the  Skin. — This 
is  shown  in  the  leaden  or  slate-coloured  hue  re- 
sulting from  a prolonged  use  of  the  salts  of  silver 
as  an  internal  remedy.  The  seat  of  the  disco- 
louration is  the  papillary  layer  of  the  corium, 
and  not  the  reto  mucosum ; and  the  affection 
is  termed  argyria  or  melasma  linctum.  Here 
also  may  be  mentioned  the  yellow  and  green 
pigmentation  of  the  skin  of  jaundice,  and  the 
blue,  green,  and  yellow  stains  of  a bruise;  with 
the  reservation,  that  they  are  temporary,  being 
due  to  bile  or  the  extravasation  of  blood,  whilst 
the  colour  produced  by  the  oxidation  of  silver  in 
the  tissue  of  the  derma  is  permanent 


PIGMENTARY  SKIN-DISEASES. 
IEtiology  and  Pathology.  — Pigmentary  af- 
fections may  be  said  to  be  due  to  derangement  of 
function  of  tlie  integument  consequent  on  dis- 
turbance of  nutrition.  Thus,  in  natives  of  tropi- 
cal countries  a slight  functional  disorder  may 
occasion  arrest  of  pigment-formation  of  varied 
extent,  and  become  the  cause  of  ackroma,  as  we 
see  illustrated  in  the  instance  of  the  pied  negro. 
Similar  effects  may  be  produced  by  hypersemia 
of  the  skin,  as  in  the  case  of  varicose  veins ; and 
again  by  deranged  innervation,  as  in  nervous 
6kock  and  prurigo.  And  to  these  several  causes, 
namely,  deranged  nutrition,  hypersemia,  and 
altered  innervation,  all  the  known  examples  of 
melanopathia  and  leueopathia  may  be  traced.. 

One  of  the  commonest  forms  of  melasma  is  a 
natural  concomitant  of  a delicate  skin — for  in- 
stance, lentigo,  which,  -when  it  appears  on  the 
face,  maybe  attributed  to  the  sun  and  light, but 
occurs  on  the  covered  parts  of  the  body  as  well. 
Ephelis  Solaris  and  ephelis  ignealis  result,  from 
the  action  of  heat ; a pigmentary  stain  not  infre- 
quently follows  the  use  of  a blister ; and  melasma 
is  a common  consequence  of  varicose  veins.  As- 
sociated with  a slight  inflammation  of  the  papil- 
lary layer  of  the  derma  we  have  pityriasis  versi- 
color, and  with  the  more  extensively  deranged 
nutrition  of  the  integument  in  syphilis,  the  form, 
of  melasma  termed  1 copper  colour.’  Morphcea 
and  scleriasis  are  accompanied  with  achroma,  as 
well  as  with  melasma;  and  elephantiasis  in  even 
a greater  degree.  Arsenic,  when  prolonged  in 
its  use  for  a considerable  time,  is  a cause  oi  me- 
Ijlasma;  and  several  chronic  diseases  of  the  skin 
are  succeeded  by  a melasmic  stain. 

Another  series  of  cases  derive  their  origin  by 
reflex  action,  or  directly,  from  the  nervous  sys- 
tem. The  melasma  palpebrarum,  which  in  some 
females  accompanies  every  menstrual  period,  is 
often  exaggerated  in  dysmenorrheea.  In  preg- 
nancy, melasma  of  the  areola  of  the  nipples  is 
a normal  occurrence,  but  there  are  often,  super- 
added  to  this,  chloasma  or  melasma  J'rontis  or 
lj  faciale.  Melasma,  again,  with  achroma,  is  not 
infrequently  associated  with  hysteria,  nervous 
shock,  and  notably  with  Addison’s  disease,  the 
so-called  ‘bronzed  skin  ; ’ and  melasma  is  a con- 
stant attendant  on  prurigo. 

As  an  aberration  of  function  melasma  and 
achroma  indicate  a feebleness  of  skin,  as  well  as 
more  or  less  constitutional  debility ; and,  as  such, 
they  are  occasionally  associated  with  grave  dis- 
order of  the  general  health.  Lentigo,  ephelis, 
and  chloasma  may  be  of  trifling  portent,  but 
miasma  faciale  often  indicates  a wearying  dis- 
turbance of  the  uterine  system ; the  melasma  of 
prurigo  a troublesome  derangement  of  the  peri- 
pheral nervous  system ; the  melasma  and  achro- 
;ma  of  syphilis  and  elephantiasis  a serious  dys- 
crasia;  and  the  melasma  of  Addison’s  disease  a 
dangerous  and  often  fatal  state  of  disease. 

Phognosis. — The  prognosis  of  a return  of  the 
fikin  to  its  normal  state  is  decidedly  unfavour- 
; able,  and  these  discolourations  will  often  endure 
for  a lifetime. 

Treatment.- — As  the  greater  proportion  of 
pigmentary  affections  are  symptomatic  of  con- 
stitutional disorder,  the  latter  will  demand  an 
ippropriate  treatment,  whilst  the  discolouration 
is  dealt  with  by  local  remedies.  Addison’s  dis- 


PIGMENTATION,  MORBID.  1199 
ease,  the  neuroses,  the  dystrophic  affections — 
morphoea  and  scleriasis,  and  the  dyscrasic  affec- 
tions— syphilis  and  elephantiasis,  require  a treat- 
ment suited  to  their  respective  nature.  Partu- 
rition and  cessation  in  the  use  of  arsenic  with- 
draw the  constitutional  cause  of  chloasma  and 
melasma  arsenicale,  and  the  removal  of  local 
irritants,  as  in  ephelis,  tends  to  their  cure.  But 
as  the  local  effect  will  frequently  continue  even 
after  the  constitutional  or  exciting  cause  is  with- 
drawn, we  are  led  to  consider  the  best  form  of 
local  treatment.  Our  most  trustworthy  remedies 
for  the  purpose  of  removing  pigmentary  stains 
are  alkaline  lotions  and  ointments,  headed  by 
soap;  lotions  of  acetic  and  hydrochloric  acid; 
iodine  and  iodide  of  potassium.  A lotion  of  per- 
chloride  of  mercury  in  almond  emulsion  is  com- 
monly resorted  to  for  freckles  and  the  slighter 
forms  of  discolouration.  The  pigment  is 
invited  to  return  in  achromatous  spots  by  the 
stimulation  of  eantharides.  In  every  form  of 
pigmentary  discolouration  stimulation  by  friction 
is  also  serviceable.  Eeasmcs  Wilson. 

PIGMENTATION,  Morbid. — Definition. 
A morbid  process,  consisting  in  the  deposition  of 
colouring  matter  in  situations  where  it  does  not 
normally  occur,  or  in  excess  in  usual  localities. 

Description. — The  abnormal  deposition  of  pig- 
ment may  take  the  form  of  an  uniform  staining 
of  the  tissues,  as  in  icterus  ; or  it  may  occur  in 
patches,  varying  from  mere  specks  up  to  a very 
considerable  size.  The  colouration  may  affect 
the  skin  ( see  Pigmentary  Skin-Diseases),  or  the 
mucous  membrane,  as  in  Addison’s  disease,  where 
patches  of  pigmentation  aro  frequently  seen  on 
the  palate  and  inside  of  the  cheeks  ; or  the  pig- 
ment may  be  deposited  in  granular  masses  in  the 
substance  of  organs,  such  as  the  liver,  brain, 
spleen,  kidneys,  lymphatic  glands,  and  medulla 
of  bones.  New  growths,  both  of  the  epithelial 
and  connective-tissue  type,  may  be  the  seat  of 
extensive  pigmentation,  especially  if  the  tissues 
with  which  they  are  connected  be  normally  the 
repositories  of  colouring  matter  ( see  Melanosis)  ; 
but  the  change  is  by  no  means  limited  to  such 
situations.  Considerable  variety  is  presented  in 
colour.  The  various  shades  of  black  and  brown 
are  usually  attributed  to  the  existence  of  a sub- 
stance called  ‘ melanin,’  though  there  is  reason  to 
believe  that  several  different  pigments  are  in- 
cluded under  this  term.  In  chemical  composition 
melanin  contains  carbon,  oxygen,  hydrogen, 
nitrogen,  and  iron  ; in  this  latter  respect  resem- 
bling hsematin.  ‘ It  is  soluble  in  ether,  alcohol, 
water,  and  acids  ; also  in  boiling  caustic  alkalies, 
thus  distinguishing  it  from  particles  of  carbon ' 
(Gamgee). 

The  bile-pigments  are  obviously  the  cause  of 
icteric  staining.  The  very  exceptional  and 
remarkable  condition  of  eyanoderma  is  attributed 
to  the  presence  of  indigo  ; whilst  the  excessive 
ingestion  of  such  minerals  as  lead  and  silver  is 
liable  to  be  followed  by  a bluish  line  around 
the  gums,  or  a purple  colouration  of  the  skin. 
As  in  the  retina,  choroid,  and  Malpighian  layer 
of  the  skin,  pigment  most  frequently  occurs 
in  epithelial  cells,  though  not  unusually  in  free 
granules  and  flakes. 

Pathology. — Excepting  when  the  colouring 


1200  PIGMENTATION,  MOEBID. 
matters  are  obviously  introduced  from  without, 
tho  morbid,  like  the  normal  pigments,  are  derived 
more  or  less  directly  from  the  heematin  of  the 
blood,  itself  a reddish-brown  substance.  Their 
presence  is  associated  with  two  very  opposite 
conditions  of  nutrition, being  sometimes  an  accom- 
paniment of  tissue-degeneration  and  diminished 
function,  at  other  times  connected  with  extremely 
active  trophic  changes.  It  is  noticeable  that 
the  cklorophyl  of  plants  and  haemoglobin  of 
blood  are  amongst  the  earliest  differentiated 
and  most  widely  distributed  proximate  principles, 
intimately  dependent  upon  which  are  the  respi- 
ratory changes  of  plants  and  animals.  The 
pigmentary  layer  of  the  retina,  the  visual  purple, 
and  the  wide-spread  occurrence  of  pigment  in  the 
nerve-centres,  are  among  the  most  striking  ex- 
amples of  the  connection  of  colouring  matter  with 
normal  functional  changes.  Melanotic  growths, 
which  are  usually  of  remarkable  activity,  the 
temporary  brown  patches  on  the  skin  ( melasma ) 
in  the  neighbourhood  of  painful  spots  in  neu- 
ralgia and  some  uterine  states,  and  the  occa- 
sional sudden  loss  of  colour  in  the  hair  from 
mental  disturbance,  are  illustrations  of  morbid 
nutrition  in  the  same  direction.  In  the  majo- 
rity of  cases  where  pugment  is  met  with,  some 
coincident  blood-change  is  to  be  found.  Thus  in 
the  class  of  malarial  diseases,  masses  of  black 
material  are  formed  in  the  blood  ( melantsmia ), 
from  destruction  of  the  red  corpuscles  during 
the  pyrexial  state,  and  are  liable  to  be  deposited, 
it  is  said,  by  the  white  corpuscles,  in  certain 
organs,  especially  the  spleen.  In  Addison’s  dis- 
ease, purpura,  syphilis,  &c.,  characterised  by 
pigmentation,  the  red  corpuscles  are  obviously 
affected.  The  deposition  of  pigment  appears 
without  doubt  to  be  somehow  under  the  control 
of  the  sympathetic  centres. 

Dr.  Laycock  observes  : — ‘ Fundamentally  the 
entire  series  of  phenomena  in  which  pigmenta- 
tion is  a leading  characteristic,  may  be  regarded 
as  having  reference  to  the  excretion  of  carbon 
after  it  has  served  its  purpose  in  the  economy ; 
and,  pathologically,  the  production  of  pigments 
may  be  taken  as  the  expression  of — (a)  imper- 
fect oxidation  of  carbon,  so  that  it  is  not  elimi- 
nated as  carbonic  or  lactic  acids,  &c. ; (6)  im- 
perfect elimination  of  carbon  proper ; and  (c) 
excessive  production  of  carbon  from  highly  car- 
bonaceous foods.  In  all  these  there  is  a close 
analogy  between  the  carbonaceous  excreta  ag 
morbid  pigmeDts,  and  the  nitrogenous  excreta  as 
morbid  deposits  of  urates,  &e.’  However,  all 
diseases  in  which  the  red  corpuscles  are  altered, 
and  their  oxygen-carrying  power  diminished, 
tend  to  be  associated  with  pigmentation,  from 
imperfect  oxidation  of  the  carbon-waste. 

A spurious  pigmentation  or  blackish  coloura- 
tion by  sulphide  of  iron  is  to  be  met  with  post 
mortem,  or  in  gangrenous  areas,  from  the  union 
of  sulphuretted  hydrogen  with  the  iron  of  the 
blood.  W.  H.  Allchin. 

PILES.— A popular  name  for  haemorrhoids. 
See  Haemorrhoids. 

PIMPLES. — A popular  name  for  papules. 
See  Papula. 

PISA,  in  Central  Italy. — Eather  moist, 
mild,  equable,  calm,  and  relaxing  climate.  Mean 


PITYRIASIS. 

temperature,  winter,  44°  Fahr.  Fast  prevailing 
wind.  See  Climate,  Treatment  of  Disease  by' 

PITTING. — The  formation  of  pits  or  hollow 
cicatrices  in  the  skin,  resulting  from  ulceration, 
as  in  small- pox;  or  from  disorganisation  of  tissue 
and  absorption  of  the  papillary  layer  of  the  skin, 
as  in  syphilis  and  lupus.  Also,  the  depression 
produced  by  pressure  on  an  oedematous  part. 

PITUITOTTS  (ir})TTa>,  I congeal). — A term 
associated  with  phlegm  or  expectoration,  wheD 
this  is  of  the  nature  of  thick  and  adhesive  mucus. 
See  Expectoration. 

PITYRIASIS  (irlrupov,  bran).  — Stnon.  : 
Furfur;  Porrigo ; Fr.  Pityriasis-,  Ger.  Kleien- 
grind. 

Definition. — A branny  exfoliation  of  the  skin ; 
giving  rise  to  scurfiness  or  scaliness  of  the  epi- 
dermis ; and  accompanied  with  heat,  dryness, 
redness,  and  pruritus. 

JEtiologt. — The  cause  of  pityriasis  must  be 
regarded  as  a feeble  state  of  the  skin,  probably 
dependent  on  a low  condition  of  the  general 
system.  In  a symptomatic  form,  however,  it 
may  be  due  to  the  causes  which  control  the 
parent  disease,  as  in  the  case  of  eczema. 

Anatomical  Characters. — Pityriasis  is  a su- 
perficial chronic  inflammation  of  the  skin,  with- 
out exudation  or  swelling,  but  especially  charac- 
terised by  disturbed  nutrition  of  the  epidermis 
and  its  desquamation  in  minute  scales.  Essen- 
tially it  is  a mild  manifestation  of  eczema,  and 
must  bo  regarded  as  one  of  the  forms  of  dry 
eczema. 

Description. — The  most  common  seat  of 
pityriasis  is  the  scalp — for  example,  P.  capitis-, 
and  in  that  situation  it  may  present  several  de 
grees  of  severity,  ranging  between  the  pityriasis 
with  silvery  scales  of  elderly  persons  ( rerasia ). 
or  the  mere  accumulation  of  epidermic  exuria? 
in  children  and  young  persons,  called  ‘dandruff,’ 
and  the  more  extensive  desquamation,  attended 
with  chronic  inflammation,  of  a declining  ec- 
zema or  even  of  psoriasis. 

On  the  sensitive  skin  of  children,  particularly 
those  of  light  complexion,  it  is  apt  to  appear  on 
the  face  in  the  form  of  small,  circular,  reddish 
discs,  coated  over  with  a fine  furfur ; and  occa- 
sionally it  is  met  with  in  patches  on  the  body 
and  limbs,  and  always  maintaining  the  same 
characters,  namely,  heat,  redness,  and  pruritus, 
but  a total  absence  of  serous  exudation. 

The  term  pityriasis,  whilst  strictly  signifying 
an  exfoliation  of  fine  scales  upon  a skin  which  ir 
more  or  less  congested,  yet  falls  short  of  the  acti- 
vity of  eczema,  has  also  been  applied  to  a fur- 
furaceous  state  of  the  skin  accompanying  other 
morbid  affections  of  the  texture ; for  example, 
elephantiasis  Grtz-corum,  and  especially  xero- 
derma in  its  transition  to  ichthyosis.  Another 
form  of  exfoliation  of  the  epidermis  associated 
with  a yellowish  pigmentation  of  the  skin,  re- 
ceived from  Willan  the  name  of  pityriasis  ver- 
sicolor ; but  as  the  pathological  conditions  of  the 
latter  are  totally  different  from  ordinary  pity- 
riasis. and  are  identical  with  the  phytiform  or 
so-called  parasitic  diseases,  this  affection  will  be 
found  treated  of  under  the  head  of  Phttosu 
versicolor. 


PITYRIASIS. 

Diagnosis. — The  description  of  the  physical 
gigns  and  the  pathological  condition  of  this  af- 
fection will  sufficiently  distinguish  it  from  other 
diseases ; although,  as  will  be  perceived,  it  may 
be  an  accidental  accompaniment  of  a variety  of 
cutaneous  affections,  such  as  dry,  chronic  eczema. 
Indeed,  its  idiopathic  form  is  its  rarest  manifes- 
tation. 

Prognosis. — Taken  by  itself,  pityriasis  must 
be  regarded  as  a trivial  affection,  and  one  which 
will  speedily  yield  to  appropriate  treatment. 
Treatment. — Our  efforts  in  this  direction 
' should  be  aimed  at  the  improvement  of  the  nu- 
tritive function  of  the  skin,  aud  the  relief  of  local 
inconvenience  or  suffering.  The  first  indication 
is  to  bo  met  by  general  tonics,  and  by  the  exhi- 
bition of  small  doses  of  some  arsenical  prepara- 
tion; and  the  second  by  the  application  of  the 
red  oxide  of  mercury  ointment  in  a diluted  form 
; (one  part  to  three),  or  the  oxide  of  zinc  ointment. 
The  former  remedy  is  the  more  suitable  for  the 
Bcalp  or  hairy  regions  of  the  body ; and  the  latter 
for  the  unprotected  surface  of  the  face  and 
trunk.  Eeasaics  Wilson. 

PITYRIASIS  VERSICOLOR  (ir  irvpoy, 
bran,  and  versicolor,  of  changing  colour). — A 
synonym  for  phytosis  versicolor.  See  Phytosis 
Versicolor. 

PLACENTA,  Diseases  of. — Synon.  : Fr. 
Maladies  du  Placenta ; Ger.  Kranklieiten  dcs 
Mutterkuchens. — The  frequency  and  importance 
of  placental  disease  is  hardly  yet  sufficiently 
recognised;  and  forty  years  ago,  when  the  late 
Sir  James  Simpson  published  his  memoir  On 
Congestion  and  Inflammation  of  the  Placenta, 
almost  nothing  was  known  on  this  subject. 

The  placenta  being  the  sole  medium  of  vital 
Communication  between  the  foetus  and  mother, 
[any  deviation  from  its  normal  condition,  by 
which  its  development  may  be  arrested,  and  its 
physiological  action  impaired,  must  be  of  serious 
:onsequence. 

The  principal  diseases  to  which  the  placenta 
s subject  are: — 1.  Inflammation;  2.  Conges- 
ion ; 3.  Haemorrhage  ; 4.  Hydatidinous  degenera- 
ion;  5.  Fatty  degeneration;  6.  Atrophy;  7. 
Typertrophy ; 8.  (Edema ; and  9.  Calcareous 
leposits. 

1.  Placenta,  Inflammation  of. — Synon.; 
Tacentitis. — Acute  inflammation  of  the  after- 
irth  is  the  sole  cause  of  those  morbid  adhesions 
.hat  occasion  the  most  serious  dangers  of  parturi- 
ion,  namely,  post-partum  haemorrhage  and  in- 
ersion  of  the  uterus.  Moreover,  it  sometimes 
mses  the  death  of  the  foetus  by  destroying  the 
tructural  integrity  of  the  placenta.  The  dis- 
use is  generally  syphilitic  in  its  origin. 

; Symptoms. — The  symptoms  of  placentitis  are 
) obscure  that  it  is  seldom  detected  until  after 
ie  birth  of  the  child,  when  we  find  the  placenta 
iherent. 

In  many  cases,  however,  this  disease  is  attended 
y constitutional  irritation  or  febrile  disturbance 
) a remittent  character.  A very  usual  symptom 
: placentitis  is  the  return  of  morning  sickness 
■ the  later  months  of  pregnancy,  together  with 
dull  aching  pain,  or  a sensation  of  weight  and 
.lness,  over  the  hypogastric  or  iliac  regions.  The 

*76 


PLACENTA,  DISEASES  OF.  12-H 
placental  souffle  will  also  be  found  intensified  in 
sound,  or  abnormal  in  some  other  respect. 

Treatment. — The  treatment  most  in  use  for 
placentitis  is  a mild  alterative  course  of  mercury 
conjoined  with  tonics,  and  followed  by  iodide  of 
potassium.  Severe  local  pain  may  be  relieved  by 
leeching,  or  by  the  application  of  oleate  of  mer- 
cury with  morphia,  or  by  iodated  liniments. 

2.  Placenta,  Congestion  of.  — This  con- 
dition is  occasionally  met  with  after  a pro- 
tracted labour,  the  placenta  being  then  found 
engorged  with  blood,  hard  and  tumefied,  its 
external  surface  of  a deep  purple  colour,  and 
covered  with  a raised  network  of  tortuous  and 
congested  vessels.  Acute  congestion,  from  the 
sudden  engorgement  of  the  placental  vessels, 
may  also  arise  at  any  period  of  pregnancy,  from 
general  plethora,  or  the  recession  of  some  acute 
inflammatory  disease.  It  may  also  be  occasioned 
bv  the  sudden  check  to  the  placental  circulation 
from  the  death  of  the  embryo. 

The  diagnosis  between  congestion  and  inflam- 
mation of  the  placenta  is  impossible ; and  the 
treatment  is  the  same  in  both  cases. 

3.  Placenta,  Haemorrhage  into. — Acute 
congestion  of  the  placenta  generally  terminates 
by  haemorrhage  into  either  the  deciduous  or 
cellular  (maternal)  portion ; into  the  villous  or 
vascular  (fcetal)  part  of  this  organ ; or  in  some 
cases  into  the  cellular  interspace  between  these, 
thus  constituting  what  Cruveilhier  described  as 
‘apoplexy  of  the  placenta.’  Haemorrhagic  effu- 
sions of  this  kind  are  a frequent  cause  of  mis- 
carriage. 

Occasionally,  especially  amongst  the  ill- 
treated  wives  of  the  labouring  classes,  placental 
hemorrhage  is  the  result  of  external  violence  or 
shock.  The  effusion  then  generally  takes  place 
from  the  central  external  surface  of  the  pla- 
centa, which  is  thus  partially  separated  from  the 
uterus ; but  if  the  effusion  be  limited  to  a few 
ounces,  gestation  may  go  on  undisturbed. 

4.  Placenta,  Hydatidinous  Disease  of. — 
This  consists  in  degeneration  and  abnormal 
development  of  the  placental  villi  of  the  chorion, 
usually  following,  although  occasionally  produc- 
ing, the  death  of  the  foetus.  In  th ^Dublin  Obstet- 
rical Transactions  for  1874-9,  the  writer  has 
related  several  instances  of  this  comparatively 
rare  disease.  In  most  of  these  eases  the  hyda- 
tidiform  mass  was  expelled  from  the  uterus  at 
the  fifth  month.  See  Mole. 

Symptoms. — The  symptoms  of  this  disease  can 
at  first  hardly  be  distinguished  from  those  of 
ordinary  pregnancy.  If,  however,  in  addition  to 
the  signs  that  usually  denote  the  death  of  the 
foetus  in  utero,  the  patient  experiences  occasional 
gushes  of  water,  together  with  slight  haemorrhage 
from  the  uterus,  lasting  for  a short  time,  and 
recurring  at  irregular  intervals,  we  may  suspect 
the  existence  of  hydatidiform  disease  in  the  pla- 
centa of  a blighted  fetus. 

The  expulsion  of  these  growths  from  the  uterus 
is  generally  attended  by  severe  haemorrhage. 

Treatment. — In  the  way  of  treatment, 
nothing  can  be  done  to  arrest  the  progress  of 
the  disease,  although  chlorate  of  potasli  has  been 
suggested  for  thepurpose.  But  an  attempt  should 


1202  PLACENTA,  DISEASES  OF. 
always  be  made  to  prevent  its  recurrence  by  im- 
proving the  general  health  of  the  patient  by 
alteratives  and  ferruginous  tonics,  especially  any 
of  the  milder  saline  chalybeate  waters,  such  as 
Ems,  Kissingen,  or  Schwalbach, 

It  has  been  recommended  that  we  should 
bring  on  the  expulsion  of  hydatidiform  moles  as 
soon  as  they  are  discovered.  This,  however,  is  in- 
advisable. Only  a portion  of  the  placenta  may- 
be affected;  or,  as  the  writer  has  seen,  the  birth 
of  a healthy  living  child  may  be  immediately  fol- 
lowed by  the  hydatidinous  placenta  of  a blighted 
twin  conception.  Hence,  we  should  let  nature 
take  her  course,  for  in  due  time  the  morbid  growth 
will  be  surely  expelled  from  the  uterus,  rather 
Ban  by  unnecessary  interference  run  the  risk  of 
lestroying  a living  foetus. 

5.  Placenta,  Fatty  Degeneration  of. — 
This  is  a common  disease.  The  late  Sir  James 
iimpson,  Virchow,  and  Dr.  Druitt,  as  well  as 
tome  earlier  writers,  have  discussed  the  nature 
jf  the  affection,  on  which  more  light  has  been 
iince  thrown  by  Dr.  Barnes’s  papers  in  the  34th 
and  36th  volumes  of  the  Medico- Ckirurgical 
Transactions , and  by  Dr.  Braxton  Hicks’  re- 
searches in  the  14th  volume  of  the  Obstet- 
rical Transactions.  The  symptoms  and  treatment 
of  this  condition  are  so  obscure,  however,  that  it 
vill  be  unnecessary  to  dwell  on  it  in  the  present 
vork. 

6.  Placenta,  Atrophy  of.— Atrophy  of  the 
placenta  is  an  occasional  cause  of  the  death 
of  the  feetus  between  the  sixth  and  ninth  months 
of  gestation.  The  uterine  placental  villi  in  such 
cases  are  arrested  in  their  development,  under- 
going a retrograde  metamorphosis  into  an  opaque 
molecular  substance,  generally  accompanied  by- 
fatty  deposits  in  the  umbilical  terminal  vessels 
of  the  foetal  portions  of  the  blighted  organ. 

7.  Placenta,  Hypertrophy  of. — This  is  a 
much  more  rare  pathological  condition  than  that 
(ast  mentioned.  We  sometimes,  however,  find 
the  placenta  greatly  enlarged  without  any  other 
apparent  alteration  in  its  structure,  and  in  such 
eases  the  child,  if  alive,  is  usually  diminutive 
and  puny-,  being  stunted  not  only  by  the  blood 
having  been  diverted  from  its  nutrition,  but 
still  more  by  the  compression  of  the  terminal 
umbilical  vessels. 

8.  Placenta,  (Edema  of. — Effusion  of  serum 
is  another  consequence  of  placentitis.  In  the 
few  cases  of  this  kind  that  the  writer  has  seen, 
abortion  occurred,  and  the  placental  villi  w-ere 
enormously  distended  and  bloodless,  being  filled 
with  a serous  fluid.  In  one  instance,  in  addi- 
tion to  the  dropsy  of  the  placenta,  the  umbilical 
cord  was  cedematous  to  an  extraordinary  extent. 

9.  Placenta,  Calcareous  Deposits  in. — Cal- 
careous deposits  are  sometimes  met  with  in  cases 
of  adherent  placenta,  being  usually  situated  in 
the  external  or  uterine  surface,  and  in  the  decidual 
vessels.  In  some  instances,  however,  the  writer 
has  found  these  deposits  scattered  throughout  the 
whole  substance  of  the  afterbirth. 

Thos.  Moke  Madden. 

PLAGUE  (n\-riyv,  plaga.  a stroke). — St- 
non.  : The  Pest;  Inguinal,  Bubonic,  Glandular, 


PLAGUE. 

Oriental,  Indian,  Pali,  and  Levantine  Plague, 
Oriental  Typhus;  Septic  Pestilence;  Pr.  la 
Teste ; Ger.  die  Pest. 

Definition. — A specific  fever,  attended  by 
bubo  of  the  inguinal  or  other  glands,  and  occa- 
sionally by  carbuncles. 

History. — The  term  plague  is  used  by  the 
older  historians  in  two  senses,  (1)  in  a general 
sense,  as  applicable  to  the  prevalence  of  diseases 
accompanied  by  great  mortality,  irrespective  of 
their  nature  ; and  (2)  in  a limited  sense,  as  in- 
dicating the  particular  malady  defined  above. 
The  earliest  notice  of  the  disease  now  designated 
plague  is  found  in  a work  of  Oribasius,  the 
physician  to  the  Emperor  Julian  (a.d.  361— 
363).  He  quotes  from  Eufus  (Alexander)  of 
Ephesus,  a writer  who  lived  in  the  reign  of 
the  Emperor  Trajan  (a.d.  98-117),  a passage 
from  which  it  would  appear  that  plague  had 
been  known  as  an  endemic,  and  occasionally  as 
an  epidemic,  in  Libya  (North  Africa),  Egypt, 
and  Syria,  from  the  end  of  the  third  or  beginning 
of  the  second  century  before  Christ.  The  first 
appearance  of  plague  in  Europe  is  referred  to 
the  6th  century  of  the  Christian  era.  In  the 
reign  of  the  Emperor  Justinian  (a.d.  527-565) 
the  disease  underwent  a development  previously 
unknown.  According  to  contemporary  histo- 
rians, it  broke  out  in  Egypt,  explosively,  and 
presenciy  spread  thence  to  the  neighbouring 
countries  of  Africa  and  Asia;  invaded  and  ex- 
tended over  the  whole  of  Europe ; and  generally 
became  disseminated  throughout  the  then  known 
world,  causing  frightful  mortality  wherever  it 
showed  itself.  From  this  period,  it  is  inferred, 
plague  became  established  in  Europe,  being 
sometimes  more,  sometimes  less  prevalent,  for 
the  1,300  years  following — indeed,  until  the 
ninth  lustrum  of  the  present  century-. 

The  great  pestilence,  most  familiarly  known 
as  the  black-death,  which  swept  over  the 
western  hemisphere  in  the  14th  century,  causing 
an  inconceivable  mortality,  aDd  which  has  been 
designated  black  plague,  although  presenting 
several  of  the  symptoms  of  bubonic  plague, 
is  held  by  some  epidemiologists  to  have  differed 
essentially  from  that  disease.  The  black-death, 
according  to  these  writers,  was  particularly 
characterised  by  a gangrenous  inflammation 
of  the  respiratory  organs,  violent  fixed  pains 
in  the  chest,  vomiting  and  spitting  of  blood, 
and  a horribly-  offensive  and  pestiferous  breath, 
which  could  be  perceived  at  a considerable  dis- 
tance from  the  patient.  Such  symptoms  dis- 
tinguished, these  writers  think,  the  disease  from 
bubonic  plague.  Moreover,  it  is  noted  that  while 
bubonic  plague  had  had  its  apparent  source  in 
Egypt  seven  centuries  before,  black-death,  accor- 
ding to  contemporary  writers,  had  its  origin  in 
Cathay-  (Northern  China),  and  issued  thence  to 
devastate  the  world.  IVriters  who  regard  black- 
death  as  a different  malady-  from  plague,  hold 
that  the  pestilential  manifestation  of  the  disease 
began  and  ended  with  the  dreadful  outbreak  of 
the  14th  century-,  and  that  the  malady  has  long 
been  extinct. 

Other  writers  consider  black-death  to  have 
been  a modification  of  bubonic  plague.  But  if 
this  view  be  accepted,  the  extraordinary  develop- 
ment and  remarkable  modification  which  the  dis 


PLAGUE 


ease  underwent  in  the  14th  century,  stand  quite 
done  in  the  history  of  the  affection,  and  consti- 
:ute  phenomena  which  would  have  to  be  regarded 
is  indicative  of  a secular  evolution  of  morbid 
Langes  ( see  Periodicity  in  Disease).  This  last- 
lamed  view  of  the  relation  between  black-death 
ind  bubonic  plague  is  not  without  a present  in- 
terest. For  Hirsch  and  others  believe  that  the 
Mahamari  of  Northern  India — the  Pali,  or  Ju- 
lian plague,  as  the  disease  is  also  termed — - 
rhich  has  several  times  prevailed  as  a local 
epidemic  since  the  commencement  of  the  present 
entury,  is  a disease  analogous  to  the  black- 
Jeath  of  the  14th  century . Probably  these  wri- 
ers  would  now  include  the  more  recently  known 
Yunnan  plague  in  the  same  category. 

In  the  loth  century  the  countries  in  which 
ilague  was  habitually  present  or  recurred  at 
ntervals, included  Northern  Africa,  Egypt,  West- 
rn  Arabia,  Syria  and  Palestine,  Asia  Minor 
nd  Mesopotamia,  Persia,  probably  India  and 
'kina,  and  Europe  generally.  Throughout  the 
6th  and  17th  centuries  there  are  almost  con- 
nuous  records,  from  year  to  year,  of  the  pre- 
3nce  of  the  disease,  in  greater  or  less  activity, 
•-ithin  this  area  of  prevalence  (Carl  Martin, 
'elermann's  Mittheilungen,  Juli,  1879)-  During 
he  latter  half  of  the  17th  century  a remark- 
ole  lessening  of  the  area  of  prevalence  of 
le  disease  began  to  take  place.  As  regards 
urope,  in  the  course  of  the  twenty  years 
161-1681  plague  disappeared  from  Italy, 
ngland,  Western  Germany,  Switzerland,  the 
etkerlands,  and  Spain.  This  lessening  of  area 
ntinued  throughout  the  18th  century,  the 
imber  of  serious  outbreaks  of  plague  also 
minishing,  two  only  having  occurred  in  that 
ntury,  namely,  (1)  in  1703-13,  (involving 
irkey,  Hungary,  Russia,  Poland,  Austria,  Bo- 
mia,  and  Eastern  Germany),  and  (2)  in  1720- 
• (Provence).  At  the  close  of  the  first  third  of 
e 19th  century,  the  area  of  prevalence  of  the 
sease  had  shrunk  to  the  easternmost  part  of 
3 Turkish  Empire  in  Europe  ; and  in  the  year 
41  plague  ceased  on  the  Continent  altogether. 
While  this  change  had  been  taking  place  in 
irope,  a corresponding  change  had  been  mani- 
ted  in  the  prevalence  of  the  disease  in  its 
•oitats  elsewhere.  Before  its  complete  cessa- 
n in  Europe,  plague  would  appear  to  have 
appeared  fromNorthern  Africa  (except  Egypt), 
m Mesopotamia,  and  from  Persia ; the  exist- 
' '6  of  the  disease  in  Asia  Minor,  Syria,  and 
testine  came  to  an  end  in  1843;  and  in  the 
;.r  1844,  with  the  cessation  of  the  malady  in 
- fpt,  plague  seemed  to  have  become  wholly 
1 inct,  and  Europe  to  have  got  rid  of  a terror 
’ ich  had  harassed  it  for  ages. 

t is  noteworthy  that  during  the  period  of  the 
l.gressive  narrowing  of  the  limits  within  which 
1 gue prevailed,  and  until  its  disappearance,  the 
t :ase  manifested  no  abatement  of  those  charae- 
tj  sties,  as  well  in  respect  to  rapidity  of  course, 
''he  nature  of  the  symptoms,  and  to  its  fatality, 
1 ch  had  made  it  the  dread  of  Europe  and  the 
i ant.  The  outbreak  of  1665  in  London,  which 
P leded  the  disappearance  of  the  disease  from 
1 land,  and  which  is  known  as  The  Great  Plague 
°\  ondon-,  also  the  outbreak  of  1720inMarseilles, 
v :h  preceded  the  disappearance  of  the  disease 


1203 

from  France,  have  become  historical  from  the 
fatality  which  accompanied  them.  Hardly,  if 
at  all,  less  terrible  was  the  outbreak  in  Moscow 
in  1770,  and  the  later  outbreaks  in  Turkey,  in 
Syria,  and  in  Egypt.  Even  at  the  present  day 
the  traveller  in  Persia  and  Kurdistan  comes 
upon  communities  the  growth  of  which  has  been 
arrested,  and  the  ruins  of  villages  which  have  beer, 
depopulated,  by  the  ravages  of  plague  earlier 
in  the  century. 

Notwithstanding  the  disappearance  of  plague 
from  its  last-frequented  haunts,  certain  epide- 
miologists, and  notably  Gavin  Milroy  in  this 
countiy,  having  regard  to  the  long  intervals 
which  had  occasionally  been  observed  between 
recurring  epidemics  of  the  disease,  doubted  its 
cessation.  Their  doubts  were  presently  confirmed 
by  the  re-appearance  of  the  plague  in  the  Levant. 
This  happened  in  1853  (nine  years  after  the 
presumed  cessation  of  the  disease  in  Egypt)  in 
the  Assyr  country,  Western  Arabia,  where  a 
circumscribed  outbreak  occurred.  Other  local 
outbreaks  followed  at  intervals  in  different 
places,  in  the  order  and  countries  here  noted : — 

1853,  the  Assyr  district,  Yemen,  Western 
Arabia ; 1858-59,  province  of  Bengazi,  Regency7 
of  Tripoli,  North  Africa ; 1863,  district  of  Maku. 
Persian  Kurdistan;  1867,  the  marsh  district  on 
the  right  bank  of  the  Euphrates,  south  and  west 
of  Hillah ; 1870-71,  Persian  Kurdistan,  in  the 
district  south-east  of  Lake  Urumiah;  1871-73, 
Yunnan  province,  Western  China;  1873-74, 
the  marsh  district  on  the  left  bank  of  the 
Euphrates,  south  of  Hillah  and  the  position  of 
ancient  Babylon.  This  outbreak  proved  to  be 
the  beginning  of  a manifestation  of  the  dis- 
ease, which  in  the  course  of  the  years  1S74-75, 
1875-76,  and  1876-77,  showed  itself  over  an 
area  extending  from  Bagdad  on  the  north,  to 
Suk-e-Sheyukh  on  the  south,  and  from  the  banks 
of  the  Tigris  and  Shat-el-Hai  on  the  East  to  the 
borders  of  the  Syrian  desert  on  the  west.  Hil- 
lah suffered  from  this  outbreak  in  1 876  (recorded 
death?  1,007),  and  Bagdad,  both  in  1876  (re- 
corded deaths  2,611)  and  1877  (recorded  deaths 
1,672).  The  outbreak  of  1873-74  on  the  Lower 
Euphrates  was  not  the  only  appearance  of  plague 
at  that  period.  Two  other. outbreaks  occurred 
in  1874,  one  in  the  Assyr  district,  Western  Ara- 
bia (the  scene  of  the  outbreak  of  1853),  and 
another  in  the  province  of  Bengazi,  Regency 
of  Tripoli  (the  scene  of  the  outbreak  of  1858-59  ). 
In  1876,  in  addition  to  the  then  prevalence  of 
the  disease  in  the  district  south  of  Bagdad  and 
on  the  Lower  Euphrates,  plague  broke  out  in 
the  Shuster-Dizful  district,  Kkuzistan,  south- 
eastern Persia  ; and  before  the  close  of  the  year 
it  had  shown  itself  also  in  two  villages  of  northern 
Persia,  situated  about  twenty-five  leagues  from 
the  south-eastern  angle  of  the  Caspian  Sea.  The 
same  year  also  there  was  an  outbreak  of  Malta- 
mart,  in  the  mountainous  district  of  Kumaun, 
North-western  India,  which  did  not  terminate 
until  the  following  year.  In  1877  an  outbreak 
occurred  at  Resht,  the  capital  of  the  province  of 
Ghilan,  Persia,  and  in  the  surrounding  district. 
Ghilan  lies  at  the  south-west  angle  of  the  Cas- 
pian Sea.  The  same  year  cases  of  a fatal  bubonic 
febrile  malady7  occurred  in  the  district  of  Baku, 
on  the  Caspian  shore  of  Transcaucasia ; and  aD 


1204  PLAGIjE. 


outbreak  of  a non-fatal  bubonic  affection  took 
place  in  Astrakhan  and  its  vicinage,  since  recog- 
nised as  a form  of  plague.  At  the  beginning  of 
1878  plague  was  reported  in  the  district  of  So- 
uj-Bulak,  Persian  Kurdistan;  and  in  October  the 
disease  broke  out  at  Vetlianka,  a Cossack  settle- 
ment on  the  Lower  Volga,  in  the  province  of 
Astrakhan,  Russia  in  Europe,  and  prevailed  there 
and  in  the  adjacent  districts  on  both  banks  of 
the  river,  until  February,  1879,  with  the  excep- 
tion of  an  isolated  case,  or  more  than  one,  which 
was  observed  in  the  following  month. 

Since  this  outbreak,  when,  after  thirty-seven 
years’  absence,  plague  re-appeared  on  European 
soil,  the  disease  has  shown  itself  again  (Feb- 
ruary-June  1879)  in  the  Assyr  district,  Western 
Arabia,  and  there  have  been  doubtful  rumours 
of  its  presence  in  Persian  Kurdistan. 

^Etiology. — Plague  is  observed  to  bedeveloped 
under  two  principal  sets  of  conditions,  namely,  (a) 
certain  local  states,  physical  or  social,  or  both, 
as  the  case  may  be,  affecting  communities ; and 
(b)  certain  relations  between  persons  sick  of  the 
disease  and  healthy  persons.  To  these  must  be 
added  (e)  particular  seasonal  influences. 

(a)  The  local  condit  ions  which  favour  the  deve- 
lopment of  plague  were  made  the  subject  of  care- 
ful study  by  a commission  of  the  French  Academy 
of  Medicine,  in  1844.  The  report  of  this  com- 
mission, prepared  by  Prus,  sums  up  and  repre- 
sents the  then  existing  knowledge  on  the  subject. 
According  to  the  commission,  plague  was  a pro- 
duct of  Egypt  (where  it  was  held  to  be 
endemic),  Syria,  the  two  Turkeys  (Turkey  in 
Europe  and  Turkey  in  Asia),  and  many  other 
countries  of  Asia,  Africa,  and  Europe;  and  the 
conditions  ‘which  determined  and  favoured’ 
the  development  (birth'  of  the  disease  among 
communities  there,  were  : — dwelling  upon  allu- 
vial and  marshy  soils,  notably  such  as  were 
found  near  the  shores  of  the  Mediterranean,  and 
on  the  banks  of  certain  great  rivers,  the  Nile, 
the  Euphrates,  and  the  Danube  being  specified ; 
a warm  and  humid  atmosphere ; low,  badly 
ventilated  and  crowded  houses ; great  accumula- 
tions of  putrefying  animal  and  vegetable  matters 
in  the  vicinity  of  dwellings;  unwholesome  and 
insufficient  food ; excessive  physical  and  moral 
misery;  and  neglect  of  the  laws  of  health,  as 
well  public  as  private. 

The  recent,  appearances  of  plague  have  served 
to  correct  some,  and  to  confirm  others  of  these 
conclusions  of  the  commission.  Plague  is  no 
longer  endemic  in  Egypt ; but  of  late  years,  as 
already  stated,  it  has  broken  out  in  several 
widely  separated  places  of  Africa  and  Asia. 
In  these  outbreaks  (excluding  from  considera- 
tion for  the  present  the  outbreak  in  Astrakhan 
province),  the  disease  appears  to  have  been  a 
local  product  determined  by  as  yet  entirely 
unknown  conditions.  The  term  1 spontaneous  ’ is 
frequently  applied  to  such  developments  of  dis- 
ease, but  is  best  avoided  as  implying  more  than 
is  warranted  by  our  present  knowledge.  Again, 
the  recent  outbreaks  have  shown  (and  Tholozan 
has  particularly'  dwelt  on  this  subject)  that 
plague  is,  perhaps,  as  much  a disease  of  the 
highlands  as  the  lowlands.  This  is  evidenced 
by  its  persistence,  in  Kumaun,  on  the  Himalayan 
mountains,  and  among  the  mountains  in  Western 


Arabia  and  in  Yunnan.  The  outbreaks  in  Persian 
Kurdistan  in  1870-71,  and  in  the  province  of 
Bengaziin  1873-74,  took  place  on  elevated  table- 
lands. The  outbreaks  also  of  1853  and  1874 
in  Western  Arabia  took  place  among  the  high- 
lands. But,  if  a less  restricted  topography 
must  be  assigned  wherein  plague  may  mamfest 
itself  as  a local  product,  so  to  speak,  the  later 
prevalences  of  the  disease  confirm  folly  the 
conclusions  of  the  Commission  of  1844  regarding 
other  conditions  of  development  which  are  not 
peculiar  to  any  country  or  locality.  The  out- 
break of  1858-59  in  the  province  of  Bengazi 
followed  upon  four  years’  drought  and  failure  of 
crops,  at  a time  when  the  greater  part  of  the 
flocks  and  herds  had  been  destroyed  from  want 
of  food,  and  by  a fatal  epizootic  which  prevailed 
among  them,  plague  breaking  out  when  the 
population  was  suffering  most  from  famine, 
and  when  the  physical  and  social  misery  re- 
sulting from  destitution  was  greatest.  The 
same  was,  in  effect,  the  state  of  things  when 
plague  appeared  in  Maku,  in  Persian  Kurdistan, 
in  1863  ; but  here  it  is  noted  also  that  the  in- 
fected district  was  pervaded  with  the  putrid 
emanations  from  the  unburied  bodies  of  cattle 
which  had  died  from  murrain.  The  outbreak 
of  1867  on  the  Lower  Euphrates  was  confined  to 
marsh-villages  on  the  right  bank  of  the  river : 
and  that  of  1873-74,  in  the  same  district  (the 
beginning  of  the  greater  development  of  1874- 
77),  began  in  marsh-villages  on  the  left  bank  of 
the  river.  The  huts  of  the  particular  class  of 
villages  affected,  writes  W.  H.  Colvill,  ‘ are  on 
ground  which  is  a foot  or  two  lower  than  the 
surface  of  the  water  in  spring ; and  the  ground 
is  so  saturated  with  water,  that  the  refuse  of  the 
village  is  neither  absorbed  nor  can  it  be  eva- 
porated, for  it  acquires  fresh  moisture  from  the 
ground,  and  this  refuse  acquires  the  form  of  a 
bluish-black  oily  fluid  which  surrounds  the  huts 
and  covers  the  paths,  and  stains  the  walls  two 
feet  from  the  ground  ; and,  in  fact,  the  village 
is  in  such  a state  of  filth  that  it  requires  to  be 
seen  to  be  believed.’  The  outbreaks  of  1S67 
and  1873-74  had  been  preceded,  according  to 
Colvill,  by  the  only  two  great  inundations  of  the 
Euphrates  which  had  occurred  since  1831,  theyeai 
of  the  then  latest  outbreak  of  plague  in  Bagdad 
The  outbreak  of  1870-71  among  the  highlands 
of  Persian  Kurdistan,  had  been  preceded  by  a 
fatal  epizootic  among  sheep,  and  ergotism  among 
the  people.  Writing  of  one  of  these  mountain- 
villages — and  the  account  serves  for  all — Castald 
says  : ‘ Whatever  is  most  afflicting  in  poverty 
whatever  is  most  revolting  in  filthiness,  is  aceu 
mulated,  as  if  designedly,  around  these  infectec 
dens,  in  the  interior  of  which  live,  or  rathei 
vegetate,  from  fifty  to  sixty  men,  women,  ant 
children.  The  cultivation  of  some  plots  o 
ground  in  the  neighbourhood  furnishes  thes 
unfortunates  with  insufficient  nourishment 
The  infected  district  escaped  the  famine  wkic. 
at  this  time  prevailed  in  Persia,  but  it  may  be 
question  if  the  inhabitants  escaped  severe  priva 
tion  during  the  winter  in  which  plague  first  ap 
peared.  The  outbreak  of  1874,  in  the  province  f 
Bengazi,  North  Africa,  occurred  among  the  nom; 
die  tribes  occupying  the  Cyrenaic  plateau  at 
time  when  some  of  the  favourite  Arab  campir- 


PLAGUE. 


rrounds  had  been  converted  into  vast  swamps 
iom  heavy  and  protracted  rains,  and  when  the 
,eople  were  reduced  to  the  most  abject  misery  and 
,vere  suffering  from  an  extremity  of  famine,  the 
■esult  of  failure  of  their  crops  for  three  years  in 
accession,  consequent  on  drought.  The  outbreak 
if  1876-77  in  the  mountain-villages  of  Kumaun 
ook  place  among  communities  who  are  described 
is  occupying  houses  in  which  cattle,  grain,  and 
hmilies  are  packed  together  under  conditions  of 
ilth  not  unlike  those  observed  in  the  mountain- 
illages  of  Kurdistan.  Of  the  conditions  under 
vkich  plague  was  observed  in  the  great  towns, 
Is  in  Bagdad  and  in  Resht,  as  also  on  the  Volga, 
hey  were  states  of  filth,  in  and  about  dwellings, 
uch  as  might  be  anticipated  where  no  organised 
Scavenging  had  ever  existed,  and  of  crowded 
md  badly-ventilated  houses.  But  in  Bagdad  and 
he  Mesopotamian  towDS  generally,  the  most 
nfluential  condition  in  promoting  plague  was, 
iccording  to  Colvill  and  Cabiadis,  poverty. 
babiadis,  indeed,  styles  the  disease,  miseries 
inorhus,  thus  reproducing,  in  1878,  a name  by 
;vhich  plague  was  designated  by  some  in  the 
Great  Visitation’  of  London,  1665,  namely,  ‘the 
Poor’s  Plague.’  On  the  other  hand,  the  communi- 
ies  which  suffered  on  the  Volga  were  prosperous 
md  believed  to  have  plenty  (on  somewhat  doubt- 
'ul  evidence,  it  must  be  confessed) ; but  at  the 
ime  of  the  appearance  of  plague  among  them, 
hey  were  living  under  almost  indescribable  con- 
litions  of  filth  accumulated  about  their  houses, 
ind  from  which  the  interiors  were  not  free. 

The  local  conditions  which  have  been  observed 
o be  favourable  to  the  development  of  plague 
;ince  the  reappearance  of  the  disease  in  1853, 
t will  thus  be  seen,  are  similar  to  those  which 
vere  observed  before  its  disappearance  from 
Europe  and  the  Levant  in  1844. 

(5)  That  the  kind  of  relations  maintained  he- 
men  persons  sick  of  plague  and  the  healthy  exer- 
isedan  important  influence  upon  the  propagation 
tf  the  disease,  has  been  made  clearly  manifest  in 
he  recent  outbreaks.  The  more  closely  and  con- 
inuously  the  healthy  were  brought  into  associa- 
ion  with  the  sick,  the  more  certain  were  the  former 
o suffer  from  the  disease.  Thus  persons  living 
a the  same  house  with  the  patient  wrere  pecu- 
liarly liable  to  suffer,  while  those  who  were 
rought  only  occasionally  into  contact  with  him 
■las  the  physician)  were  rarely  affected.  And 
ere,  again,  a difference  was  noted  between  the 
ability  of  the  physicians  and  of  the  surgeons 
nd  their  assistants  to  be  attacked  by  the  disease, 
he  duties  of  the  latter  calling  for  more  frequent 
nd  protracted  visits  to  the  patients  than  the 
uties  of  the  former,  and  they  suffered  to  a greater 
stent.  No  doubt  was  entertained  that  the 
isease  was,  in  ordinary  phrase,  caught  from  the 
ck  by  the  healthy  brought  into  association  with 
lem;  but  there  was  no  certain  evidence  that 
etual  contact  with  the  sick  person  was  neces- 
jirytothe  transmission,  as  the  older  doctrine  of 
pntagion  maintained.  On  the  contrary,  the  evi- 
ence  indicated  that  the  transmission  was  chiefly 
fected  through  the  healthy  breathing  the  same 
tmosphere  as  the  sick,  that  is  to  say,  the  atmo- 
bhere  surrounding  the  sick  person.  There 
ould  appear  to  be,  in  addition,  evidence  of  trans- 
ission  of  the  malady  by  the  agency  of  clothes 


1205 

and  bedding  which  had  been  used  by  the  sick.  The 
newer  information  obtained  on  this  subject  of  the 
transmissibility  of  plague  from  those  sick  of  the 
disease  to  the  healthy,  corresponds  with  the  re- 
sults obtained  on  the  same  subject  by  the  commis- 
sion of  the  French  Academy  in  1844,  and  both  point 
to  a close  analogy  between  the  modes  of  trans- 
mission of  plague  and  of  typhus,  and  between  the 
habits  of  tho  two  infections.  In  plague,  as  in 
typhus,  the  liability  of  the  healthy  to  contract 
the  disease  is  mainly  dependent  on  the  constancy 
and  intimacy  of  communication  with  the  sick. 
In  plague,  as  in  typhus,  the  danger  of  infection 
appears  to  be  principally  proportionate  to  the 
fouling  of  the  atmosphere  surrounding  the  sick 
by  the  effluvium  from  his  body  and  breath  ; and 
in  like  manner  either  infection  would  seem  to 
be  peculiarly  easy  of  destruction  by  free  dilu- 
tion with  air.  Again,  there  seems  to  be  no  trust- 
worthy evidence  to  show  that  the  danger  of  the 
propagation  of  plague  by  fomites  (as  the  older 
writers  have  it),  that  is  to  say,  by  articles  carry- 
ing the  infection  of  the  disease — such  as  cloth- 
ing and  bedding — is  greater  in  plague  than  in 
typhus.  The  condition  for  infection  of  articles 
of  clothing  and  bedding  was  their  very  intimate 
use  by,  or  association  with,  the  sick.  Evidence 
was  entirely  w ’anting  of  articles  other  than  those 
mentioned,  and  under  other  conditions,  being 
capable  of  communicating  the  disease  to  the 
healthy  ; nor  was  there  anything  to  confirm  the 
assumption  that  the  long  array  of  articles  con- 
tained in  quarantine-regulations  regardingplague 
were  capable  of  retaining  and  conveying  the  in- 
fection. 

(c)  Both  tho  sets  of  conditions  here  noted  as 
affecting  the  development  of  plague  appear  to 
be  influenced  by  seasonal  changes.  In  Mesopo- 
tamia the  disease,  during  its  prevalence  there, 
rapidly  declines,  and  becomes  dormant,  with  the 
setting-in  of  the  hot  weather  in  June  (beginning 
to  fall  when  tho  temperature  reaches  86°  F., 
and  ceasing  abruptly  at  113°  F.),  its  activity 
re-awakening  in  winter,  and  gathering  force  with 
the  advancing  spring.  Similar  phenomena 
were  observed  in  Egypt,  whilst  the  disease  pre- 
vailed in  that  country.  In  Constantinople,  on 
the  contrary,  the  disease  was  dormant  during 
the  colder  months  of  the  year,  and  became  active 
during  the  hotter.  The  same  wras  true  of  this 
country  when  the  disease  existed  here,  as  is  par 
ticularly  observed  in  the  season  of  prevalence 
of  the  epidemics  which  have  ravaged  the  metro- 
polis. Here,  as  Wm,  Farr,  Ed.  Smith,  and,  more 
recently,  Buchan  and  Mitchell  have  shown, 
from  the  records  of  mortality,  September  was 
the  month  of  greatest  prevalence,  the  disease 
rising  throughout  July  and  August  and  falling 
throughout  October  and  November.  Further 
north  (in  Moscow,  for  example)  the  disease  has 
prevailed  as  severely  in  the  depth  of  winter 
as  in  the  height  of  summer. 

Incubation. — The  recent  outbreaks  have  not 
furnished  much  additional  information  on  this 
subject,  but,  such  as  it  is,  it  tends  to  confirm 
the  conclusion  of  the  commission  of  the  French 
Academy.  This  was  to  the  effect  that  the  disease 
had  never  shown  itself  among  compromised  per- 
sons after  an  isolation  of  eight  days.  L.  Arnaud 
carefully  studied  the  question  in  the  outbreak  of 


PLAGUE. 


1206 

1874,  in  the  province  of  Bengazi,  and  from  the 
facts  ho  then  collected  concluded  that  the  mean 
time  of  incubation  of  plague  was  five  or  six  days, 
and  that  the  maximum  duration  did  not  exceed 
eight  days.  Hirsch,  from  the  information  he  ob- 
tained at  Vetlianka,  relating  to  the  recent  out- 
break in  the  province  of  Astrakhan,  concluded 
that  the  minimum  period  of  incubation  observed 
there  was  from  two  to  three  days,  the  maximum 
exceeding  eight  days,  and  that  the  average  might 
be  set  down  at  five  days.  He  notes,  however, 
that  very  short  or  very  long  periods  of  in- 
cubation were  seldom  observed. 

Symptoms. — These  are  summarised  here  wholly 
from  the  writings  of  recent  observers : W.  H. 
Colvill  and  Giovanni  Cabiadis  (as  made  known 
by  E.  D.  Dickson)  in  regard  to  plague  in  Meso- 
potamia; Castaldi,  in  regard  to  plague  in 
Mesopotamia,  Persian  Kurdistan,  and  Kesht ; 
L.  Arnaud,  in  regard  to  plague  in  Bengazi  (see 
Blue  Book,  ‘Plague,’  1879);  Doppner  (official 
report);  Hirsch  ( Practitioner , ii.  1879);  and  W. 
H.  Colvill  and  Payne  (official  report),  in  regard 
to  plague  in  the  province  of  Astrakhan.  This 
course  is  taken,  first,  because  the  disease,  as  they 
describe  it,  is  that  which  the  present  generation 
is  called  upon  to  consider ; and,  secondly,  because, 
generally  speaking,  the  symptoms  observed  by 
them  are  similar  to  those  described  by  the 
earlier  writers  on  the  subject. 

Plague  occurred  in  three  forms  in  the  recent 
outbreaks,  namely  (1),  an  abortive  or  larval ; (2), 
a grave  ( plague , as  usually  understood) ; and  ( 3), 
a fulminant  form 

1.  Abortive  (larval)  Plague.— This  form  is 
characterised  by  the  appearance  of  buboes  in 
the  groins,  armpits,  and  neck,  as  a rule  pain- 
less, and  unaccompanied  by  feverishness.  At 
times,  but  rarely,  the  manifestation  of  the  buboes 
is  preceded  and  accompanied  by  a general 
febrile  disturbance  of  the  system,  so  slight  as 
not  to  preclude  the  patient  from  moving  about 
(ambulatory  plague).  At  limes  also,  a bubo  sup- 
purates ; but  more  commonly  these  swellings 
disperse  in  about  fourteen  days.  The  buboes 
are  clearly  distinguishable  from  the  chronic 
glandular  swellings  observed  in  persons  of  a 
scrofulous  tendency,  or  affected  with  any  special 
diathesis.  Cases  of  abortive  plague  were  recorded 
in  the  greater  number  of  the  recent  outbreaks  of 
the  disease  of  which  we  have  detailed  accounts, 
and  were  particularly  observed  preceding  and 
following  the  outbreak  in  Mesopotamia  in 
1873-77,  and  preceding  the  outbreak  in  the 
province  of  Astrakhan  in  1878-79.  It  is  ques- 
tionable whether  this  form  of  the  disease,  un- 
accompanied by  any  marked  febrile  disturbance, 
is  infectious. 

2.  Plague  in  its  usual  form. — The  onset  and 
progress  of  plague  differ  much  in  different  cases, 
and  at  different  periods  of  an  epidemic.  Most 
frequently,  after  a brief  time  of  lassitude,  ach- 
ing in  the  limbs  and  loins  (sometimes  a very 
painful  aching),  and  shiverings,  a febrile  state 
commences;  and  concurrently  with  this,  or 
from  the  second  to  the  fourth  day  of  its 
duration,  buboes  appear  in  the  groins,  the 
armpits,  or  beneath  the  angle  of  - the  jaw. 
The  febrile  state  is  usually  acute,  and  accom- 
panied with  much,  often  severe,  headache,  and 


delirium  or  stupor  ; the  face  being  flushed ; the 
eyes  red  and  turbid ; the  skin  hot ; the  toDgue 
black,  dry  and  fissured,  or  coated  as  with  cotton 
wool,  or  pointed  at  the  tip,  with  red  edges  andl 
thickly  furred  in  the  centre ; the  teeth  and  gums 
covered  with  sordes  ; and  the  thirst  intense.  The 
swelling  of  the  glands  increases,  and  is  ac- ! 
companied  by  much,  sometimes  acute  pain; 
and  if  the  patient  have  lived  on,  suppuration 
may  take  place  about  the  seventh  day,  at' 
which  time,  if  not  earlier,  carbuncles  or  boils 
may  appear.  Of  these  symptoms,  or  groups  of 
symptoms,  it  may  be  noted  more  particularly, 
that  the  disease  is  sometimes  ushered  in  by 
vertigo,  or  convulsive  tremor,  or  a peculiar,  j 
absent,  ‘ lost’  state,  when  the  patient,  if  he  be  ’ 
seized  from  home,  will  be  observed  to  make  his 
way  thither  in  a quasi-automatic  fashion,  with  a 
strange  staggeringgait ; or  else  the  patient,  whilst 
going  about  his  ordinary  avocations,  is  seen  to 
become  distracted,  as  if  impressed  with  some  inde- 
finable fear,  which  prompts  him,  if  away  from  his 
house,  to  rush  wildly  through  the  streets  until  he 
reaches  it,  and  then  throw  himself  on  the  bed  in  a 
state  of  extreme  restlessness ; while,  in  the  gravest 
cases,  the  patient  is  attacked  at  the  same  period 
with  vomiting  of  blood  and  a high  febrile  state. 
Cabiadis  describes  cases  ushered  in  by  a pro- 
longed regular  shake,  which  persists  from  six 
hours  to  three  days,  the  temperature  of  the  body 
remaining  nearly  normal,  and  the  patient  not 
complaining  of  cold.  This  shake  was  invariably 
followed  by  coma,  during  which  the  patient  sank 
rapidly.  The  pulse,  in  the  febrile  state,  runs 
quickly  up  to  100-130  ; and  the  temperature  of 
the  body  to  102-104°,  and  in  the  acutest  cases 
to  107'6°  Fahr.  The  end  of  the  febrile  state 
is  marked  by  a sudden  fall  of  temperature,  the  i 
thermometer  descending  sometimes  as  low  as 
93'2°Fahr.  ; at  the  same  time  a profuse  perspira- 
tion often  occurs.  Heat  in  the  throat  and  in 
the  epigastrium  (inthe  latter,  as  of  burning  char- 
coal there)  was  a not  unfrequent  complaint  of 
the  patients ; and  at  times  a sensation  likened  to 
being  stabbed  by  a knife  in  the  breast  has  oc- 
curred. Nausea  and  vomiting  of  bilious  matters 
were  not  uncommon  (Arnaud) ; and  vomiting  of 
coffee-ground-looking  matter  was  frequent  at  the 
beginning  of  the  outbreak  of  1873-74  on  the 
river  Euphrates.  Constipation  is  the  rule  in 
the  acute  stages  of  the  disease.  It  is  some- 
times followed  by  diarrhoea,  which  has  been 
regarded  as  a favourable  sign.  No  noteworthy 
change  appears  to  have  been  observed  in  the 
urine,  either  as  to  general  appearance  or  quan- 
tity, unless  it  were  mingled  with  blood;  but 
Doppner  describes  its  diminution  and  even  sup- 
pression in  severe  cases  at  Vetlianka.  Humor 
rhages  were  observed  from  the  nose,  the  lungs, 
the  stomach,  the  bowels,  the  vagina,  and  the 
urethra;  and  the  cases  in  which  they  occurred 
all  ended  fatally.  Occasionally  the  respiration  is 
much  hurried,  but  Arnaud  states  that  such  dis-j 
turbances  of  the  respiration  as  he  witnessed  in 
Bengazi  were  of  nervous  origin— a nervous  dys- 
pnoea preceding  death.  The  prostration  is  ex- 
treme in  some  cases,  and  in  a few  instances  m 
which  this  was  observed  consciousness  was  main- 
tained until  just  before  the  patient  expired. 

Of  the  local  signs,  the  appearance  of  the  bufaei 


PLAGUE. 


not  infrequently  precedes  tho  symptoms  of 
general  disturbance.  In  some  cases  they  aro 
first  observed  -within  seven  or  eight  hours  after 
the  febrile  state  has  set  in  ; in  other  and  more 
numerous  cases  they  show  themselves  on  the 
second,  third,  and  fourth  days  of  the  attack,  and 
rarely  on  the  fifth.  When  the  buboes  appear 
first  they  are  sometimes  accidentally  discovered, 
the  patient  having  no  previous  suspicion  that  lie 
is  affected;  but  more  generally  their  appearance 
is  preceded  by  pain  in  the  glandular  organs, 
at  times  sudden  in  accession,  the  patient  exclaim- 
ing he  has  been  stabbed  in  the  groin,  armpit, 
or  elsewhere,  as  the  case  might  be.  The  en- 
larged glands  forming  buboes  are  rarely  nume- 
rous, and  of  a group  only  one  is,  as  a rule, 
conspicuously  enlarged,  sometimes  attaining  a 
size  equal  to  a turkey’s  egg  or  an  orange,  while 
the  others  are  but  little  enlarged.  The  swelling 
at  times  is  very  rapid.  Suppuration  is  not  often 
observed  in  the  fatal  cases,  and  so  it  happened 
that  suppuration  came  to  be  regarded  by  the 
inhabitants  of  the  localities  where  plague  pre- 
vailed as  a favourable  sign ; while  on  the  other 
hand,  ‘flattening’  or  subsidence  of  the  swollen 
glands  in  the  early  days  of  attack  was  held  as 
indicative  of  a fatal  result.  Boils  and.  carbuncles 
occur,  but  not  very  frequently.  Petechia  are 
often  observed,  most  usually  preceding  a fatal 
issue;  at  times  occurring  comparatively  early 
in  the  progress  of  the  disease.  Sometimes  they 
are  distributed  generally  over  the  body,  at 
other  times  they  are  chiefly  localised  in  the 
vicinity  of  the  enlarged  glands.  They  vary 
in  size  from  the  dimensions  of  a grain  of 
millet  to  those  of  a lentil.  They  are  at  times 
so  numerous  that  the  skin  assumes  a livid  hue, 
and  the  corpse  has  a blackened  appearance  after 
death.  This  appearance  is  so  characteristic  of 
the  disease,  says  Cabiadis,  that  the  maladj7  might 
properly  have  been  called,  even  in  this  day, 
black-death. 

The  plague  has  a special  physiognomy,  having 
nothing  in  common  with  either  typhus  or  perni- 
■ cious  fever  in  any  of  its  forms,  or  with  relapsing 
fever.  ‘ The  eyes  are  retracted  within  the  orbits, 
but  not  surrounded  with  the  blue  circle  which 
is  seen  in  cholera ; the  aspect  is  haggard,  but 
without  the  fixity  seen  in  typhous  cases  ; the 
' facial  muscles  are  relaxed  as  other  muscles  of 
' l he  patient,  and  do  not  present  the  wrinkles  and 
contractions  observed  in  a patient  attacked  with 
typhus  or  cerebral  maladies  ; the  countenance  of 
’ the  plague-stricken  expresses  apathy  ’ (Castaldi). 
‘ On  coming  up  to  a patient  suffering  from  an 
attack  of  pernicious  fever,  you  are  struck  with 
tho  gravity  of  lrs  case  and  the  danger  threat- 
. ening  his  life.  The  very  reverse  of  this  meets 
your  eye  when  you  see  for  the  first  time  a case 
of  plague.  Even  the  worst  instances  of  this 
malady  are  apt  to  deceive  an  inexperienced  phy- 
sician, and  make  him  fancy  that  the  case  is 
free  from  danger,  w'hen  in  reality  the  patient  has 
only  a few  hours  to  live.  The  first  instance  of 
plague  seen  by  I)r.  Cabiadis  did  not  seem  to  him 
to  be  one  of  an  alarming  nature.  The  patient 
pooked  stupified,  as  if  intoxicated,  and  did  not 
answer  readily  the  questions  put  to  him.  He 
vomited  blood,  and  had  a small  bubo  in  the  right 
axilla,  but  the  pulse  and  temperature  were 


1207 

normal.  The  patient  died  a few  hours  after  Dr. 
Cabiadis’  visit  ’ (E.  D.  Dickson). 

3.  Fulminant  Plague. — Cases  to  which  this 
term  is  applied  have  been  observed  more  particu- 
larly at  the  commencement  of  plague  epidemics, 
but  also  during  their  course  and  towards  their 
termination.  These  were  cases  which  were 
struck  down  suddenly  with  illness  and  died  in 
a few  hours,  without  any  of  the  characteristic 
indications  of  the  disease — buboes  and  carbuncles, 
for  example— having  shown  themselves.  The 
conclusion  that  they  were  part  of  the  prevailing 
epidemic — the  infection  having  overwhelmed  at 
once,  as  it  were,  the  sufferers — appears  justified 
by  the  prevalence,  at  the  same  time,  of  an  inter- 
mediate class  of  cases,  also  very  quickly  ending 
in  death,  in  which  some  traces  of  glandular  swell- 
ings were  observed,  with  profound  disturbance  of 
the  nervous  centres,  convulsion  or  coma,  and  rapid 
formation  of  vibices  and  purpuric  spots.  The 
cases  of  the  fulminant  class  which  occurred  at 
the  beginning  of  the  outbreak  on  the  Lower 
Euphrates,  1873-71,  were  chiefly  marked  by 
vomiting  of  blood  and  setting  in  of  a high 
febrile  state  concurrently.  The  natives  had  named 
these  cases  ‘ black- vomit’  before  the  actual  nature 
of  the  disease  became  apparent  (Castaldi). 

Mahamari  (Pali  or  Indian  plague) ; Yunnan 
Plague. — The  recent  descriptions  of  these  forms 
of  plague  by  Planck,  Francis,  Eocher,  and  Baber, 
do  not  present  any  such  differences  in  the  cha- 
racter of  the  disease  as  above  described  as  to 
call  for  a separate  aceeunt. 

The  Plague  ok  the  Yoloa,  1878-79. — Only 
one  account  of  this  outbreak  has  come  into  the 
hands  of  tho  writer  from  the  pien  of  an  actual 
observer,  and  it  merits  a separate  notice.  It  is 
contained  in  a report  of  Dr.  Doppner.  principal 
medical  officer  of  the  Cossack  troops  in  the  pro- 
vince of  Astrakhan  at  the  time,  and  is  founded 
on  personal  observation  of  twenty-three  cases 
seen  by  him  when  the  outbreak  was  approaching 
its  greatest  intensity.  His  description  of  the 
symptoms  presents  them  as  forming  two  groups  : 
—1.  Violent  headache  (forehead  and  temples), 
pains  in  the  limbs,  slight  shivering,  followed 
by  high  fever,  pulse  from  100  to  120,  sense  of 
burning  in  the  body  and  eyes,  distension  of 
the  abdomen,  and  enlargement  of  the  liver. 
These  symptoms  lasted  two  or  three  dajrs,  and 
were  in  favourable  cases  followed  by  perspiration 
and  recovery  with  general  debility;  but  in  the 
greater  number,  after  an  interval  of  two  or 
three  days,  the  fever  returned,  accompanied  by 
delirium,  sleeplessness,  restlessness,  a tempera- 
ture of  107’G°Eahr.,  dryness  of  tongue,  fre- 
quent involuntary  dejections,  urine  scanty  and 
reddish.  Death  usually  occurred  in  the  second 
paroxysm  (sometimes,  but  rarely,  after  a third) 
preceded  by  convulsions  and  a general  prostra- 
tion of  the  vital  powers. — 2.  In  other  cases 
the  patient  was  attacked  suddenly  with  palpita- 
tion of  the  heart,  irregularity  of  pulse,  vomiting, 
vertigo,  oppression  of  the  chest,  spitting  of  clear 
blood,  pallor,  an  apathetic  expression,  with  dulled 
eyes  and  dilated  pupils.  The  patient  then 
remained  for  two  or  three  hours  in  a state  oi 
extreme  feebleness,  followed  by  violent  feverish- 
ness and  delirium,  suppression  of  the  urine,  and 
constipation.  Maculae  appeared  upon  the  body ; 


1208 


PLAGUE. 


it  exhaled  a peculiar  odour,  something  like  that 
of  honey  ; and  death  supervened  in  a state  of 
lethargy,  with  complete  prostration  of  the  vital 
powers. 

In  neither  form  of  the  disease,  at  this  stage  of 
the  outbreak,  wero  buboes  a conspicuous  symp- 
tom, and  in  the  latter  form  they  were  rarely 
observed ; but  buboes  (inguinal  and  other)  had 
characterised  a series  of  non-fatal  cases  of 
abortive  plague  which  had  preceded  the  cases 
described,  and  during  the  decline  of  the  out- 
break buboes  were  again  observed.  Death  in  the 
cases  described  occurred  in  from  twelve  hours 
to  three  days.  Decomposition  of  the  body  always 
set  in  rapidly. 

[Dr.  Z.  Petresco,  of  Bucharest,  who,  under  in- 
structions from  the  Roumanian  Government, 
visited  the  seat  of  plague  on  the  Volga,  and 
reached  the  infected  locality  early  in  February 
1879,  received  accounts  of  the  disease  from 
physicians  who  had  witnessed  it  at  Vetlianka 
subsequent  to  the  period  of  time  to  which  Dr. 
Doppner  refers  (November  17  (29)  to  December  4 
(16)1878).  He  states  thatthe  predominant  symp- 
toms were  intenso  headache,  an  acute  febrile 
state  (very  rarely  accompanied  by  delirium), 
and  excessive  prostration  of  vital  force — these 
symptoms  forming  a ‘ triade  semeiotique  patho- 
gnomonique  do  la  peste.’  He  also  states  that, 
at  the  beginning  of  the  outbreak  at  Vetlianka, 
cerebral  and  lymphatico-glandular  disturbances 
were  chiefly  noted,  the  latter  manifested  by  sub- 
maxillary, axillary,  and  inguinal  buboes  ; after- 
wards, at  the  height  of  the  epidemic,  graver 
indications  of  disorder  of  the  nervous  centres 
were  observed,  manifested  especially  by  the 
headache,  vertigo,  feverishness,  and  collapse, 
the  cases  at  times  ending  fatally  in  twelve 
hours  ; lastly,  during  the  decline  of  the  epidemic 
pulmonary  disturbance  predominated  (hemo- 
ptysis with  symptoms  of  catarrhal  pneumonia), 
inducing  the  medical  men  to  diagnose  the  malady 
at  this  time  as  a croupal  pneumonia,  pneumo- 
typhus, or  malignant  typhus. — February  1880.] 

Diagnosis. — ‘ No  other  idiopathic  fever,  at- 
tacking a multitude  of  persons  at  the  same  time, 
is  characterised  by  glandular  swellings,  by  car- 
buncles, and  by  those  severe  manifestations  of 
the  nervous,  sanguineous,  and  biliary  systems 
which  declare  themselves  in  an  attack  of  plague.’ 
— (Cabiadis,  according  to  E.  D.  Dickson.)  As 
regards  perniciousfcver,  with  which  the  disease 
was  confounded  by  some  medical  men  in  Meso- 
potamia, Cabiadis  says  no  intermission  has  ever 
been  observed  in  plague;  no  attack  of  plague 
has  ever  been  cut  short  by  the  administration  of 
sulphate  of  quinine ; and  the  expression  of  coun- 
tenance (see  above),  and  general  aspect  of  a plague 
patient  are  strikinglydifferent  from  those  ofapa- 
tient  affected  with  pernicious  fever.  At  Vetlianka, 
intermissions,  according  to  Doppner,  were  ob- 
served. 

Prognosis. — * Rapid  suppuration  of  the  buboes, 
even  when  accompanied  until  high  fever,  indi- 
cates a favourable  termination ; all  cases  com- 
plicated with  nervous,  haemorrhagic,  or  bilious 
manifestations  end  fatally  ’ (Cabiadis).  Colvill 
is  of  op'nion  that  the  -jecurreDca  of  diarrhoea  in 
the  course  of  plague,  as  seen  in  Mesopotamia, 
was  a favourable  sign. 


Relapses  and  Second  Attacks.  — Arnaui 
notes  both  relapses  and  second  attacks  in  his 
account  of  the  Bengazi  outbreak,  1873-74, 
Age,  Ddeation,  &c. — Cabiadis  and  Colvill 
made  an  analysis  of  numerous  cases  of  plague 
which  came  under  their  observation,  from  which 
the  following  particulars  are  taken  in  illustra- 
tion of  the  foregoing  symptoms,  and  as  elucidating 
other  questions. 

Age. — Dr.  Cabiadis  noted  the  ages  of  1,826 
cases  of  plague  observed  at  Hillah,  in  1876, 
with  the  following  result 


From 

2 months  to  9 years 

. 277 

)» 

10  years  to  19  „ 

. 617 

J* 

20  „ 29  „ 

. 432 

ft 

JO  „ 39  ,,  . 

. 292 

» 

40  „ 49  „ 

. 123 

t J 

60  „ 59  „ 

. 52 

Ji 

60  „ 69  „ 

. 18 

>» 

70  79  „ 

. 11 

>» 

80  „ 89  „ 

old  man  of  113(?)„ 

. 3 

An 

. 1 

Total  .... 
Buboes  and  Carbuncles. 

l,82fi 

Cabiadis 

CoLmi 

1,826  cases 

. 402  cases 

'Buboes-.- 

In  the  Groin  . . . 710  „ 

. 128  „ 

Axilla  . . 466  „ 

. 109  „ 

Neck  ...  98  „ 

= 19  „ 

, 

Crural  region  — „ 

, 

Several  places  122  „ 

. 8 ” 

, 

not  recorded  . — ,, 

. 9 „ 

jy  liUli  ICUJIUCU.  ■ )}  • *7  j 

Carbuncles 36  „ . 9 


Other  manifestations. — Cabiadis.  with  respect 
to  the  1,826  cases  mentioned  above,  gives  the 
following  numerical  statement  of  the  numbers 
in  which  noteworthy  special  symptoms  were  ob- 
served : — 


Dependent  on  the  I 

'Coma  in  . . . 

28 

nervous  centres  1 

Convulsive  shake 

9 

/Petechiae  . . . 

120 

Epistaxis  . . . 

2 

Dependent  on  the 

Haemoptysis  . . 

6 

circulatory  sys-  - 

Haematemesis.  . 

27 

tem. 

Sanguineous  diar- 

rhoea . . . 

14 

-Menorrhagia  . . 

2 

Dependent  on  the 

Bilious  vomiting  . 

32 

assimilative  or- 

Bilious diarrhoea . 

16 

gans. 

Jaundice  . . . 

2 

Duration . — Col  vi  11 

shows  the  duration 

of  531 

fatal  cases  of  plague 

as  follows : — 

Days  after 

Number  of 

attack 

Deaths 

One  day 

. 126 

Two  days  . 

. SO 

Three  „ 

. 105 

Four  „ 

. 76 

Five  „ 

. 60 

Six  „ 

. 26 

Seven  „ 

. 12 

Eight  „ 

. H 

Ten  „ 
Twelve  days 

. 14 

. . . 9 

Sixteen  „ 

. . . 1 

Twenty  „ 

, . r 

PLAGUE. 


Mortality. — The  mortality  appears  to  have 
differed  much  in  different  places  and  at  different 
periods  of  an  epidemic.  Colvill  states,  of  the 
outbreak  of  1874-75  in  Mesopotamia,  that  the 
mortality  in  the  first  half  of  the  epidemic  in 
a village,  was  from  93  to  95  per  cent,  of  those 
attacked,  but  that  during  the  latter  half  of  the 
epidemic  the  greater  number  of  the  attacked  re- 
covered. The  mortality  in  Bagdad  throughout 
the  outbreak  in  1876  was,  he  states,  55'7  per 
cent,  of  the  attacks  (eases  4,585,  deaths  2,556). 
Arnaud  gives  the  mortality  during  the  outbreak 
in  Bengazi,  1874,  at  39  per  cent,  of  the 
attacks  (cases  533,  deaths  208).  According  to 
Cabiadis,  the  mortality  at  Hillah  in  1876  was 
52'6  per  cent,  of  the  attacks  (cases  1,826,  deaths 
961).  Hirsch  estimates  the  mortality  at  Vet- 
lianka,  on  the  Volga  (Astrakhan)  at  82  per 
cent  of  the  attacks  (cases  439,  deaths  358) ; and 
Doppner  states  that  at  one  period  of  the  out- 
break there  was  a mortality  of  100  per  cent,  (in 
other  words  all  who  were  then  attacked  died), 
and  at  another,  and  later  period,  of  43  per 
cent. 

Anatomical  Charactehs. — The  recent  out- 
breaks of  plague  have  added  nothing  to  our 
knowledge  of  the  anatomical  characters  of  the 
disease.  The  outbreaks  occurred  under  circum- 
stances where  anatomical  investigation  was  out 
of  the  question.  The  information  existing  on  this 
subject  was  obtained  almost  solely  at  the  time  of 
the  French  expedition  into  Egypt  at  the  close  of 
the  last  century  and  the  beginning  of  the  pre- 
sent; during  the  outbreaks  of  plague  in  Bes- 
sarabia, 1825,  and  in  Moldavia  and  Wallachia 
(1828-29) ; and  again  in  the  outbreak  of  1834- 
35  in  Egypt.  The  morbid  alterations  noted 
were  ecchymoses  of  the  coverings  of  the  ner- 
vous centres,  of  the  pericardium,  the  omentum, 
and  the  peritoneum ; enlargement  and  softening 
of  the  spleen ; punctated  extravasations  of  blood 
in  the  mucous  membrane  of  the  stomach ; ecchy- 
motie  spots  in  the  mucous  membrane  of  the  in- 
testines;reddish-blackinjection  of  themesenteric 
glands;  extravasation  of  blood — sometimes  con- 
iiderable — into  the  cellular  tissue  about  the  kid- 
neys, the  kidneys  themselves  being  tumefied  and 
presenting  extravasation  of  blood  in  their  tissue 
md  in  their  pelves.  The  most  constant  andcharac- 
eristic  changes  were  observed  in  the  lymphatic 
;lands.  When  buboes  had  been  formed,  the 
lands  presented  manifest  signs  of  inflammatory 
ction  in  various  degrees,  as  also  at  times  the 
urrounding  cellular  tissue,  which  was,  more- 
ver,  frequently  the  seat  of  bloody  extravasa- 
ions.  The  glands  of  the  several  cavities 
’ere  more  or  less  involved  in  or  partook  of 
he  morbid  action  conspicuously  observed  in  the 
uboes ; and  even  where  no  buboes  had  formed, 
idications  of  considerable  changes  were  found 
i the  internal  lymphatic  glands.  In  some 
istances  the  affection  of  the  glands  would 
ppear  to  have  been  general  throughout  the 
ody;  in  others  it  would  be  limited  to  one  or 
lore  of  certain  groups,  in  addition  to  the  more 
iperficial  groups,  as  the  bronchial,  the  medias- 
nal,  the  mesenteric,  the  lumbar,  &c.  The 
lands,  as  a rule,  were  found  more  or  less  en- 
rged, injected,  and  infiltrated  with  sanguineous 
aid. 


1209 

Treatjient. — (a)  Curative. — The  recent  out- 
breaks of  plague  have  thrown  no  positive 
light  upon  its  curative  treatment.  In  Bagdad 
and  Hillah  the  plan  of  treatment  mainly  fol- 
lowed was  the  internal  administration  of  car- 
bolic acid  or  of  quinine,  and  the  use  of  leeches 
and  mercurial  frictions  to  the  buboes  before 
suppuration.  In  some  instances  this  plan 
was  thought  to  have  done  good,  in  others  it 
was  useless,  if  not  detrimental.  In  regard  to 
plague,  as  to  other  grave  general  maladies, 
except  those  arising  from  paludal  poisoning, 
curative  treatment  is  at  present  only  possible 
on  general  principles,  both  as  regards  the  sys- 
temic and  the  local  symptoms.  The  practice 
would  appear  to  be  the  same  in  respect  to  the 
general  symptoms  as  would  guide  the  physician 
in  the  treatment  of  typhus ; in  respect  to  the 
local  symptoms,  such  as  would  apply  to  ordinary 
phlegmon. — (/3)  Hygienic. — In  the  present  state 
of  our  knowledge,  more  importance  is  perhaps 
to  be  attached  to  the  hygienic  treatment  of 
the  disease  than  to  the  curative.  Most  im- 
portant of  all,  perhaps,  is  the  exposure  of  the 
patient  to  abundant,  freely  changing  air;  next 
is  the  use  of  cold  or  tepid  sponging,  as  the 
temperature  of  the  body  and  the  state  of  the 
skin  (as  well  as  the  sensations  of  the  patient,  if 
he  be  sensible)  may  seem  to  call  for;  together 
with  the  large  administration  of  drinks  (acid— 
? mineral,  or  other)  to  combat  the  thirst,  the 
judicious  use  of  liquid  food,  and  especially  of 
stimulants  when  the  dropping  of  the  pulse,  the 
coolness  of  the  skin,  and  the  ataxic  condition 
of  the  patient  call  for  them. 

Prevention. — The  prevention  of  plague  in- 
volves two  sorts  of  considerations,  the  one  re- 
lating to  the  removal  of  the  conditions  which 
favour  the  development  of  the  disease ; the 
other  to  the  limitation  of  the  spread  of  the 
disease,  the  malady  existing,  (a)  The  condi- 
tions favourable  to  the  development  of  plague 
have  been  already  enumerated,  and  include 
all  those  insanitary  states  of  houses,  their  sites 
and  surroundings,  which  form  the  subject  of 
public-health  administration;  also  those  states 
of  poverty  which  have  to  be  dealt  with,  not  only 
as  an  economic  but  as  a public-health  question. 
Of  these  several  conditions,  the  three  which 
■would  seem  most  to  call  for  special  attention  in 
this  country,  in  view  of  impending  plague, 
whether  as  regards  private  individuals  or  as  re- 
gards local  authorities  representing  communities, 
are  over-crowding,  defective  ventilation  of  houses, 
wad.  impoverishment,  (b)  In  respect  to  the  limita- 
tion of  the  disease,  the  malady  being  present, 
the  first  and  most  important  consideration  is 
the  isolation  of  the  patient  under  such  circum- 
stances of  aeration  as  are  stated  above,  as  well 
in  the  interest  of  the  patient  himself  as  of  the 
community ; and  the  disinfection  of  articles  of 
clothing,  or  bedding,  used  by  him,  and  of  the 
room  he  may  have  occupied.  Local  authorities 
have  large  powers  enabling  them  to  provide  be- 
forehand, in  a mode  available  for  the  use  of  the 
whole  community, (Public  Health  Act,  1875,  and 
the  Metropolis  Management  Act,  1858,  together 
with  the  Sanitary  and  Poor  Law  Acts  relating 
to  the  Metropolis),  hospitals  for  the  isolation  of 
cases  of  infectious  diseases,  such  as  plague,  and 


(210  PLAGUE. 


apparatus  and  materials  for  disinfection ; and 
many  authorities  have  already  exercised  these 
powers.  See  Public  Health. 

But  plague  is  the  subject  of  special  measures 
in  this  country,  as  in  every  country  on  the 
Continent  and  Mediterranean  littoral,  to  wit, 
measures  of  quarantine.  Quarantine  aims  at 
preventing  both  the  introduction  of  the  disease 
into  a country,  and  the  spread  of  the  disease, 
if  by  accident  it  should  happen  to  have  been 
introduced,  by  the  isolation  for  a longer  or 
shorter  period,  not  only  of  persons  sick  of  plague, 
but,  in  addition,  of  all  healthy  'persons  who  may 
have  been  exposed,  directly  or  indirectly,  to  the 
infection  of  plague ; also  by  the  isolation  and 
disinfection  of  articles,  described  under  the 
quarantine  law,  as  susceptible  of  conveying 
plague-infection,  coming  from  an  infected  dis- 
trict. Experience  has  shown  that  measures  of 
quarantine  against  infectious  disease  are  futile, 
if  not  impracticable  for  this  country,  from  the 
impossibility  of  closing  all  channels  of  intro- 
duction, in  consequence  of  the  activity  and 
magnitude  of  our  commerce.  But  quarantine 
is  retained  in  regard  to  plague  and  yellow  fever, 
and  has  occasionally  to  be  made  use  of  to  meet 
the  requirements  of  other  nations,  who,  failing 
the  adoption  of  this  system  here,  would  be  likely 
to  impose  disabilities  on  our  shipping  with  refer- 
ence to  the  diseases  named.  Thus  quarantine  was 
revived  in  respect  to  plague,  at  the  time  of  the 
recent  alarm  of  the  disease  on  the  Continent. 
The  doctrine  of  plague  upon  which  the  English 
Quarantine  Act  of  1825  is  based,  as  well  as  the 
laws  of  foreign  countries  relating  to  the  subject, 
is  a traditional  one,  inconsistent  in  many  re- 
spects with  the  later  and  more  accurate  observa- 
tions which  have  been  made  on  the  mode  of 
spread  of  the  disease. 

J.  Netten  Radcliffe. 


JSbb!S}(^  1 strike)-"A  hara_ 

mer-like  instrument  used  in  percussion,  for  strik- 
ing the  surface  of  the  body,  either  directly  or 
indirectly.  See  Physical  Examination. 


PLESSIMETER  \ 
PLEXIMETEE  J 


(irA r\<T<Tw,  I strike,  and 


(ueV pov,  a measure). — A flat  instrument  used  in 
mediate  percussion,  by  being  applied  to  the  sur- 
face of  the  body  to  receive  the  stroke  of  the 
plcssor.  See  Physical  Examination. 


PLETHORA  (TrA-rjew,  I fill).— Fulness  of 
blood.  A condition  in  which  the  vessels  of  the 
body  generally,  or  of  any  part,  are  over-distended 
with  blood.  See  Blood,  Morbid  Conditions  of ; 
and  Circulation,  Disorders  of. 

PLEURA,  Diseases  of. — The  serous  mem- 
brane which  lines  each  cavity  of  the  chest,  and 
is  so  reflected  as  to  cover  the  lung,  is  not  unfre- 
quontly  the  seat  of  disease.  As  in  its  anatomical 
and  physiological  relations,  so  also  in  its  diseases, 
it  presents  analogies  to  the  lining  membrane  of 
a joint.  Its  diseases  may  be  of  external  or  of 
internal  causation.  They  may  be  considered 
under  the  following  headings. 

1.  Pleura,  Injuries  of. — These  may  be  caused 
in  several  ways  : (1)  by  violent  blows  upon  the 


PLEURA,  DISEASES  OF. 
chest,  and  in  this  case  there  is  usually  at  the  same 
time  an  injury  to  the  lung-tissue,  the  effects  of 
which  to  some  extent  overshadow  the  pleural 
lesion  and  its  results  ; (2)  by  direct  wounds  with 
a knife  or  blunter  instrument,  or  a bullet;  and 
(3)  by  fractured  ribs.  In  each  case  inflammation 
of  the  pleura  may  occur.  With  the  surgical 
aspect  of  these  cases  we  here  have  no  concern, 
and  the  pleural  consequences  maybe  sufficiently 
gathered  from  the  following  paragraphs. 

2.  Pleura,  Inflammation  of.  — Synon. 

Pleurisy;  Fr . Pleuresie;  Ger.  Pleuritis. 

Definition. — Pleurisy  is  defined  as  an  inflam- 
mation of  the  pleura,  of  whatever  nature  and 
extent.  Clinically  and  pathologically,  pleurisy 
differs  only  in  its  accidents  from  inflammation 
of  serous  membranes  elsewhere,  and  is  the  most 
common  of  the  serous  inflammations. 

jEtiology. — The  causes  of  pleurisy,  if  local, 
may  be  obvious  enough ; if  general,  not  so 
obvious.  Of  local  causes  the  chief  are  wounds 
or  bruises  of  the  chesGwall ; fracture  of  the  ribs ; 
caries  of  the  spine ; escape  of  irritating  matter 
into  the  pleural  cavity,  whether  from  the  costal 
side,  as  in  periostitis  or  osteitis,  from  the  pul- 
monary side,  as  in  phthisical  excavation,  from 
disease  of  the  bronchial  glands,  or  from  the 
side  of  the  abdomen,  as  in  gallstone,  hydatid, 
subphrenic  abscess  and  the  like.  Foreign 
bodies,  again,  such  as  bones  or  coins  from 
the  oesophagus  or  larynx,  have  been  known 
to  find  their  way  into  the  pleural  cavity,  and  thus 
set  up  mischief.  Acute  pleurisy,  the  result  of 
local  causes,  is  usually  more  or  less  proportioned 
to  these  in  its  severity  and  duration;  pleurisy  of 
general  or  systemic  causation,  on  the  other  hand, 
though  less  regular  in  its  career  than  pneumonia, 
has  yet  a certain  character  of  uniformity.  The 
general  or  systemic  causes  of  this  form  of 
pleurisy  are  very  obscure,  and  none  of  them  are 
accurately  known.  There  are  some  grounds  for 
suspecting  that  a chill  alone  may  be  a cause  of 
acute  pleurisy  ; but  more  probably  we  have  to 
learn  that  chill  must  be  associated  with  other 
factors.  A rheumatic  or  gouty  habit  is  suspected 
to  be  a disposing  condition  by  many,  and  pro- 
bably with  good  reason.  The  depression  of  over- 
work or  harass,  the  debility  of  former  illness 
or  of  convalescence,  and  the  poison  of  malaria 
are  among  the  more  common  disposing  causes. 
Acute  pleurisy  again  often  occurs  as  a part,  or 
as  a complication,  of  other  diseases.  Thus  it  is 
rarely  absent  in  acute  pneumonia ; and  it  occurs, 
as  cardiac  valvulitis  and  pericarditis  occur,  in 
acute  rheumatism,  but  less  frequently.  Acute 
pleurisy  following  scarlatina  is  probably  depen- 
dent upon  a rheumatic  or  nephritic  sequel;  if 
it  arises  otherwise  in  the  malady  the  pleurisy 
is  more  often  of  the  profuser  kind  and  tends 
quickly  to  empyema.  Pleurisy  arises  sometimes 
after  measles,  when  it  is  probably  due  to  pneu- 
monic irritation.  It  is  also  a common  conse- 
quence of  diseases  of  the  kidney,  in  which  mala- 
dies liydrothorax  may  be  simply  dropsical  or  tho 
product  of  pleuritis.  In  septicmmia  and  in  py- 
aemia, again,  a low  pyogenic  pleurisy  often  arises 
as  like  effusions  arise  in  the  joints,  and  may  be 
equally  or  more  latent ; or  it  may  be  caused  by 
the  rupture  of  a pyaemic  abscess  of  the  lung  into 


PLEURA.  DISEASES  OF.  1211 


the  pleural  cavity.1  Acute  pleurisy,  when  ‘idio- 
pathic,’ is  more  often  on  the  left  side  (3  to  2) 
and  is  rarely  bilateral.  When  due  to  more 
specific  causes,  such  as  acute  rheumatism  or  ne- 
phritis, it  is  often  bilateral,  though  rarely  of  equal 
severity  on  the  two  sides.  Acute  pleurisy  is 
common  at  all  ages ; it  is  recorded  often  within 
the  first  six  months  of  life;  in  babies  it  is 
readily  overlooked  unless  there  be  abundant 
effusion,  and  not  rarely  even  then.  In  children 
the  symptoms  are  often  very  latent,  neither 
cough  nor  pain  is  manifest,  and  there  is  little 
displacement  of  viscera  ; yet  it  is  really  more 
common  under  one  year  than  between  the  ages 
of  two  and  five  years.  At  the  age  of  five  it  is 
frequent,  but  it  reaches  its  maximum  frequency 
in  middle  life  (set.  35-45).  The  younger  the  child 
the  more  readily  the  effusion  becomes  purulent, 
and  in  such  cases  the  mischief  often  extends  to 
the  pericardium.  Cases  of  simple  inflammatory 
pleurisy  have  been  recorded  in  persons  beyond 
threescore  years  of  age;  but  in  aged  persons  it  is 
rare,  and  presents  little  reaction  or  pain.  The  male 
sex  is  more  often  affected  than  the  female,  in  the 
ratio  of  about  seven  to  five,  the  difference  being 
probably  due  to  the  class  of  cases  which  owe 
their  origin  to  weather.  It  does  not  appear, 
however,  that  pleurisy  varies  in  prevalence 
with  the  change  of  the  season.  Pleurisy,  under 
one  form  or  other,  is  credited  with  about  2 per 
cent,  of  the  deaths  in  England,  and  with  about 
1 per  cent,  of  the  deaths  of  patients  in  public 
hospitals. 

Anatomical  Chaeactees. — The  morbid  ana- 
tomy of  pleurisies  differs  but  little  from  that  of 
serous  inflammations  elsewhere.  The  costal 
membrane  generally  suffers  the  sooner  and  the 
more  severely.  The  vessels  become  injected  and 
even  yield  in  places,  giving  rise  to  small  irregular 
eccbymoses.  Effusion  of  a sero-fibrinous  and  pro- 
liferative kind  quickly  infiltrates  the  tissue,  and 
the  natural  gloss  of  the  membrane  gives  place  to 
opacity.  The  superficial  epithelium  also  strips 
off  and  papillae  appear,  at  first  isolated,  but  soon 
communicating  together  by  networks  of  vascular 
formation.  At  this  point  all  may  clear  up,  or 
effusion  may  escape  from  the  surface.  In  dry 
pleurisy  the  products  are  chiefly  new-tissue 
elements,  without  much  interstitial  effusion.  In 
activo  cases  the  effusion  is  not  very  volumin- 
ous, but  is  very  rich  in  fibrin;  and  false-mem- 
brane,  often  of  great  thickness,  forms  upon  the 
pleura,  and  sits  tightly.  Some  of  this  loose  or 
adherent  gluey  effusion  degenerates,  and  is  ab- 
sorbed on  resolution  ; some  of  it  organises,  and 
forms  more  permanent  false-membrane  or  bands 
of  connection  and  adhesion.  Into  these  enter 
blood-vessels,  elastic  fibre,  lymph-channels  and 
even  nerves  (Virchow).  Clots  of  fibrin  float  freely 
and  abundantly  in  the  effused  serum,  and  con- 
tain a great  abundance  of  imprisoned  cells.  In 
the  fluid  itself  the  cells  are  fewer,  clear,  granular 
or  multinuclear.  The  more  of  these  cells  the 
greater  the  fear  of  a purulent  transformation. 

1 The  origin  ot  the  pleurisy  which  may  accompany  puer- 
peral aurl  other  diffuse  peritonitis  is  explained  by  Von 
Hecklinghausen’s  demonstration  of  lymph-canals  between 
the  diaphragm  and  the  pleura ; and  its  supervention  in 
cases  of  abscess  of  the  liver  may  receive  a like  explana- 
tion. Reversely  septic  pleurisies  spread  themselves  some- 
limes  from  the  pleural  to  the  peritoneal  cavity. 


There  are  also  found  abundant  free  nuclei  and 
a quantity  of  red  blood-corpuscles,  varying  with 
the  vascularity  of  the  new  growths,  if  the  exu- 
dation be  less  actively  inflammatory  and  more 
serous,  it  is  also  more  abundant,  and  may  amount 
to  100-150  ounces.  It  is  less  disposed  to  form 
firm  membranes  or  adhesions.  This  fluid  is  of  a 
greenish  straw-colour,  like  synovia,  and  is  thin, 
with  flocculent  lymph  in  it.  It  partially  coagu- 
lates when  exposed  to  the  air,  and  is  found  to 
contain  more  degenerated  cell-elements,  tending 
towards  a sero-purulent  character.  In  scurvy, 
tuberculosis,  carcinoma  and  other  cachexias,  and 
even  in  rare  cases  of  simple  pleurisy,  the  effu- 
sions may  be  highly  sanguineous,  and  blood  may 
be  found  alike  in  the  coagula,  in  the  free  and  in 
the  attached  false-membranes. 

When  the  contents  of  the  pleura  are  purulent, 
much  of  the  new  membrane  has  broken  up,  though 
even  here  false  membranes  are  far  from  being 
absent,  and  fibrinous  clots  are  at  times  dis- 
covered. In  cases  of  large  effusion  the  lung  is 
found  compressed,  and  often  bound  down  by  false- 
membranes  extending  from  the  walls  of  the 
cavity.  In  adults  the  lung  is  usually  found  in  the 
vertebra-scapular  space,  being  thrust  upwards, 
inwards,  and  backwards.  It  may  be  compressed 
from  one-quarter  to  one-eighth  of  its  normal 
volume ; is  flattened,  leathery,  bloodless,  and 
airless  ; and  will  sink  in  water.  As  the  pressure 
subsides  the  lung  may,  and  generally  does,  recover 
more  or  less  of  its  former  volume.  It  is  sur- 
prising to  see  how  successfully  re- expansion  may 
take  place  in  spite  of  false-membranes,  bands, 
and  prolonged  compression.  Nevertheless  either 
complete  or  partial  adhesions  or  bands  of  con- 
nective tissue  generally  remain  indefinitely  after 
acute  pleurisy ; and  happily  for  the  most  part 
do  little  harm.  If  the  lung  fail  to  re-expand  to 
any  extent,  its  deficiency  is  made  up  by  the  in- 
ward pressure,  partly  of  neighboxiring  soft  parts, 
and  partly  of  the  chest-wall.  Pleuritic  adhe- 
sions are  very  commonly  found  after  death  from 
other  diseases,  the  origin  of  them  being  un- 
known or  forgotten.  On  the  other  hand,  false 
membranes  and  bands  may  become  the  seat  of 
degenerative  processes;  and  pus,  eretified  pus, 
tubercle  and  the  like  may  be  found  in  them,  with 
or  without  secondary  abscesses  elsewhere.  A 
pleural  cavity  which  has  thus  suffered  is  more 
liable  to  subsequent  inflammations.  The  com- 
pressed lung  in  like  manner  is  liable  to  become 
the  seat  of  degenerative  disease,  and  in  empy- 
ema the  contact  of  pus  promotes  ulcerative  and 
septic  changes  in  the  lung,  as  it  does  likewise  in 
the  vertebrae,  ribs,  and  other  neighbouring  parts. 
In  this  way  the  pus,  finding  for  itself  a passage  in 
the  direction  of  least  resistance,  pierces  through 
lung  or  thorax,  and  establishes  a pulmonary  or 
costal  fistula.  Sometimes  the  pulmonary  fistula 
is  a simple  one,  and  communicates  at  once  by  a 
free  or  a valvular  opening  with  a bronchial  tube, 
or  may  have  so  communicated  by  an  opening 
afterwards  closed  ; at  other  times  the  pus  finds 
a less  direct  route,  and  either  by  a transference 
like  filtration,  or  by  way  of  a number  of  lesser 
ulcerating  channels,  it  reaches  the  more  open 
passages  of  the  lung. 

Subpleural  eechymoses,  though  often  accom 
panying  evidences  of  inflammation,  are  not 


PLEURA,  DISEASES  OF. 


1212 

Always  caused  by  pleurisies.  They  occur  in 
deaths  of  children  after  broncho-pneumonia  and 
diphtheria,  but  there  is  usually  a patch  of  pleu- 
ritic inflammation  upon  and  co-^xtensive  with 
them.  They  are  not  uncommonly  found  in  other 
deaths  also,  bub  are  probably  always  associated 
with  obstruction  to  the  entrance  of  air  intc  the 
Itmg. 

In  all  cases  the  position  of  the  heart  and  other 
viscera  must  be  observed,  and  the  chambers  of 
the  heart,  the  pulmonary  veins,  and  other  vessels 
examined  for  clots.  In  empyema  a careful  ex- 
amination of  the  body  for  secondary  abscesses 
must  be  made,  not  forgetting  the  brain. 

Clinical  Characters  and  Varieties.  — 
Pleurisy  may  be  conveniently  divided  into  kinds, 
according  to  certain  pathological  and  clinical 
differences,  as  follows  : — (a)  Dry  ; (/9)  Acute ; 
(7)  Diaphragmatic  ; (S ) Quiet,  with  large  effusion ; 
(e)  Tubercular-,  (()  Fibroid.  Each  of  these  re- 
quires separate  consideration. 

(a)  Dry  Pleurisy. — This  is  so  called  because 
it  is  attended  with  no  effusion,  or  with  effusion 
so  slight  as  to  escape  notice.  Usually,  if  not 
always,  it  results  in  an  adhesion  of  the  opposite 
surfaces  of  the  membrane.  It  may  not  be 
revealed  by  any  sign  or  symptom  during  life. 
Adhesions,  more  or  less  extensive,  due  to  this 
process,  are  very  often  found  after  death.  Dry 
pleurisy  may  occur  alone,  or  as  a complication  of 
irritative  changes  in  neighbouring  tissues,  as  in 
the  lung  or  chest- wall.  Pain  or  pyrexia,  more  or 
less  fugitive,  may  accompany  dry  pleurisy,  but 
in  many  cases  if  present  they  pass  unnoticed. 
Should  attention  be  drawn  to  the  chest,  friction 
may  generally  be  detected.  An  obscure  pain  in 
the  chest  or  loin,  or  a frequent  teasing  dry  cough, 
may  at  times  be  traced  by  the  close  observer  to 
a patch  of  dry  pleurisy  in  some  part  of  the  chest. 
A friction-sound  due  to  such  a patch  may  be 
transient,  or  may  be  audible  for  many  weeks. 
Recovery  follows  adhesion.  It  is  supposed 
that  some  of  the  pains  in  the  chest  which  ac- 
company phthisis  are  due  to  the  intercurrence 
of  dry  pleurisy;  probably,  however,  they  are 
as  frequently  myalgic  or  neuralgic.  Dry  pleur- 
isy, with  its  resulting  adhesions,  is  rarely  in- 
jurious. Indeed,  it  is  rather  a safeguard  when 
any  destructive  process,  such  as  phthisical 
ulceration,  threatens  to  bore  into  the  pleural 
cavity.  If  it  fail,  and  morbid  matters  escape 
into  the  cavity,  acute  pleurisy  is  the  probable 
consequence.  Dry  pleurisy  often  ends  in  but 
slight,  thickening,  the  two  pleural  surfaces  ad- 
hering without  much  increase  of  substance.  In 
other  eases  the  thickening  may  be  considerable, 
but  this  probably  indicates  some  more  persistent 
irritation,  such  as  we  find,  for  example,  in  those 
dense  coverings  which  often  surround  the  apex 
of  a lung  in  chronic  phthisis.  The  remoter 
consequences  of  dry  pleurisy  are  for  the  most 
part  without  importance.  In  some  instances  it 
may  limit  the  chest-movements,  or,  more  rarely 
still,  may  so  tie  the  parts  as  to  cause  abiding 
pains,  described  as  dragging  or  tightening.  Such 
pains  are  usually  referred  to  the  sub-axillary 
rr  sub-mammary  regions,  and  may  be  really 
annoying.  More  often  they  do  harm  by  minister- 
ing to  needless  fears.  It  is  said  that  in  rare 
cases  hypertrophy  of  the  heart  Las  resulted  from 


the  embarrassment  of  its  action  by  pleural  bands. 
Dr.  Bowditch  tells  the  writer  that  he  has  seen 
this  twice  at  least.  It  is  useless  to  prescribe 
treatment  for  a disease  which  escapes  observation, 
or  is  but  a secondary  event  in  the  course  of 
more  serious  processes.  TVliere  dry  pleurisy  is 
found,  and  is  doing  harm  by  exciting  cough  or 
otherwise,  the  best  practice  is  to  place  several 
light  blisters  in  succession  over  the  affected  nart. 

(0)  Acute  pleurisy. — Acute  pleurisy,  though 
less  serious  than  chronic  dropsical  pleurisy,  isfar 
more  serious  than  dry  pleurisy,  and  generally  ap- 
pears as  an  important  illness.  It  sets  in  with  fever, 
pain,  embarrassment  of  the  breathing  and  cough, 
sometimes  catarrhal,  mostly  reflex.  These  symp- 
toms bear  no  certain  proportion  to  each  other. 
The  fever  has  no  very  characteristic  type,  but  is 
rather  what  is  known  as  a symptomatic  pyrexia. 
Thus  there  is  not  a sharp  rigor  of  onset,  as  in 
pleuro-pneumonia,  but  there  is  often  a succession 
of  chills.  Nor  are  there  any  very  definite  stages 
of  increment  and  acme,  but  rather  a daily  fluc- 
tuation of  remittent,  more  rarely  of  intermittent 
type,  with  evening  rise,  the  elevations  not  often 
reaching  and  rarely  exceeding  40°  C.  (104°  F.) 
At  first  the  arterial  tension  is  high,  the  pulse 
being  small  and  hard  ; after  the  first  onset  the 
tension  falls,  and  the  pulse  becomes  dicrotic. 
As  the  effusion  reaches  its  height  the  fever  in 
acute  pleurisy  gradually  recedes,  unless  the  case 
approaches  to  the  form  5,  when  the  effusion  is 
indeterminate,  and  the  fever  may'  subside,  may 
fluctuate,  or  may  drift  into  hectic  The  pain 
is  often  very  characteristic,  bnt  at  other  times 
is  variable,  and  even  delusive.  Most  commonly 
it  appears  as  a stitch  in  the  side,  about  thcjevel 
of  the  false  ribs,  which  is  intensified  by  inspira- 
tion and  cough.  The  deep  breath  when  partly 
drawn  is  cut  short,  as  if  with  a stab,  while  the 
face  of  the  patient  is  wrung  with  an  expression 
of  sudden  distress.  Such  inspirations  are,  how- 
ever, instinctively  avoided,  and  may  have  to  be 
called  for  by  the  physician,  so  that  the  face  may 
speak  rather  of  apprehended  than  of  actual  suf- 
fering; in  either  case  the  expression  is  a telling 
one  to  the  practised  observer.  The  fixed  als 
nasi,  which  are  dilated  but  do  not  oscillate,  as  in 
some  other  kinds  of  dyspnoea,  the  parted  lips,  the 
bright  eye  of  fresh  fever,  the  cheeks  flushed,  but 
not  congested  as  in  pleuropneumonia,  the  pre- 
occupied and  apprehensive  expression,  the  pos- 
ture semi-erect,  slightly  bent  forward  and  toward 
the  affected  side,  the  shallow  breathing,  the  fixed 
chest,  the  hand  on  the  side,  the  curt  speech,  the 
stifled  cough,  make  up  a clinical  picture  often 
seen,  and  easy  of  recognition.  It  is  a curious 
fact  that  these  symptoms  of  distress  are  gene- 
rally more  marked  in  a robust  patient,  or  one 
previously  healthy,  than  in  the  ailing,  weakly  or 
cachectic.  The  pain,  however,  may  wander  from 
the  lateral  or  ante-lateral  aspect  of  the  lower  ribs, 
and  appear  in  the  hypoehondrium,  or  even  on 
the  opposite  side.  At  other  times  it  may  be- 
come more  diffused,  and  play  upon  the  brachial 
plexus,  darting  from  the  clavicular  and  scapular 
districts  to  the  upper  chest,  shoulder  or  arm. 
This  is,  perhaps,  more  common  in  the  diaphrag- 
matic variety  (7).  In  some  bad  cases,  in  which 
pus  forms  from  the  beginning  or  almost  from 
the  beginning,  the  pain  is  very  distressing  and 


PLEURA.  DISEASES  OF.  1213 


prolonged,  and  the  rigor  very  strong.  What- 
ever be  the  treatment,  we  look  for  some  relief 
of  pain,  cough  and  conscious  dyspncea  on  the 
third  or  fourth  day.1  The  respirations,  how- 
ever, may  still  range  above  the  normal  rate, 
from  the  mechanical  interference  of  increasing 
effusion,  or  of  this  increase  combined  with 
oedema  of  the  open  parts  of  the  embarrassed 
lung,  and  perhaps  of  its  CTerworked  fellow. 
About  the  end  of  the  week,  be  it  more  or  less, 
the  pleurisy  has  run  its  course,  and  the  effusion 
has,  in  favourable  cases,  attained  its  maximum  ; 
the  urinary,  gastric,  and  other  glands  regain 
their  normal  activity ; and  convalescence,  with 
absorption  of  the  exudations,  is  to  be  looked  for. 
Thus  far,  then,  the  disease  is  painful  rather  than 
dangerous,  death  in  the  first  week  of  ordinary 
acute  pleurisy  being  practically  out  of  the  ques- 
tion.2 By  certain  signs  in  the  chest  we  know 
the  height  to  which  the  fluid  has  flowed  in  the 
cavity,  and  we  await  its  ebb.  Usually,  in  a day 
or  two,  some  fall  is  noted,  and  in  favourable 
cases  this  ebb  runs  quickly  at  first,  and  after- 
wards more  slowly  as  the  products  become 
denser.  Some  remnant  is  usually  to  be  de- 
tected after  the  patient  is  about ; and  months,  or 
even  years,  may  elapse  before  the  parts  become 
normally  clear.  Indeed,  the  signs  of  an  old 
pleurisy  may  be  carried  to  the  grave.  Likely 
as  is  this  favourable  result  in  strong  persons, 

. yet  it  is  not  to  be  too  lightly  promised  even  to 
these.  Too  often  when  we  are  awaiting  the 
ebb  we  find  a new  flood,  the  level  of  the  fluid 
rises  into  the  upper  chest,  and  the  patient,  who 
hitherto  has  lain  on  the  sound  side  to  avoid 
pain,  now  turns  on  the  affected  side  to  give  full 
play  to  the  open  lung.  This  flow  may  recur 
with  or  without  renewed  fever,  but  is  generally 
attended  with  a proportionate  increase  of  pulse- 
rate,  and  diminution  of  pulse  in  volume  and 
tension.  Coincident  with  the  diminution  of 
arterial  tension,  which  in  its  turn  is  due  to  the 
pulmonary  obstruction,  is  a diminution  of  the 
urine,  which,  probably,  had  become  more  abun- 
dant as  the  fever  ceased.  That  the  changes, 
both,  of  pulse  and  urine,  depend  upon  the  effu- 
sion, is  shown  by  the  rapid  recovery  of  both 
when  fluid  is  artificially  let  out  from  the  pleura  : 
the  pulse  then  falls  in  rate  and  increases  in  tone 
under  the  finger,  and  the  urine  soon  becomes 
more  abundant.  A little  albumen  is  sometimes 
present  during  the  time  of  pulmonary  obstruc- 
tion. Under  ordinary  circumstances  a renewed 
j flow  of  urine  may  be  indicative  of  pleural  re- 
absorption,  or  the  case  may  pass  on  into  the 
form  7,  or  into  an  empyema.  Neither  event  is 
common,  however,  except  as  a consequence  of 
neglect,  the  symptoms  preceding  these  events 
being  generally  of  a quieter  character.  It  is 
hard  to  tell  when  the  full  chest  contains  serum, 
and  when  pus.  Marked  hectic  may  exist  with 

1 Writers  are  not  yet  agreed  whether  there  be  any  local 
elevation  of  temperature  in  the  affected  side  or  not.  Still 
‘less  can  it  be  said  whether  such  local  temperature  runs 
any  definite  course  of  change. 

1 Malignant  cases  are  related  of  pleurisy,  in  which  the 
temperature  remains  at  40°  or  41°  C.  (104°,  105'4°F.),the 
pulse  reaches  140,  the  tongue  becomes  dry  and  brown 
md  prostration  excessive,  and  the  exudation  runs 
promptly  to  pas.  Such  cases  are  rare,  except  as  complica- 
tions of  septic  and  other  diseases,  and  they  are  almost 
rarely  fatal,  even  after  free  evacuation  of  pus  by  incision. 


serum,  but  if  this  be  associated  with  increased 
temperature  of  the  affected  side,  with  change  of 
countenance,  loss  of  appetite,  wasting  of  flesh, 
failure  of  strength,  thrush,  diarrhoea,  or  with  any 
of  them,  and  the  more  if  there  be  any  inherent 
constitutional  frailty,  ora  septic  element  present, 
we  must  fear  that  the  fluid  is  turning  to  pus. 
In  the  later  weeks  or  months  of  an  acute 
pleurisy  which  has  not  ended  in  resolution, 
death  may  threaten  and  may  not  be  averted. 
In  some  cases,  as  after  scarlatina,  the  effusion 
may  be  purulent  from  the  beginning,  and  a fata] 
result  may  be  feared  even  in  the  earlier  days 
of  the  malady.  Under  ordinary  circumstances, 
however,  in  healthy  persons  who  have  been  care- 
fully treated  from  the  outset,  and  who  have  not 
been  exposed  to  septic  or  malarious  influences, 
we  expect  to  Have  to  deal  with  effusions  mode- 
rate in  quantity  and  stable  in  quality.  The 
effusion  in  such  cases  rarely  remains  at  its 
height  more  than  two  or  three  days ; and  in 
three  weeks  at  farthest  absorption  should  be 
tolerably  complete.  In  other  cases,  fortunately 
rare,  acute  pleurisy,  with  remittent  fever,  con- 
tinues for  many  weeks.  Effusion  in  these  cases 
may  not  be  very  rapid,  but  recurs  gradually 
after  the  removal  of  moderate  quantities  ; or 
it  may  be  so  moderate,  indeed,  as  scarcely  to 
need  removal.  The  signs  are  simply  those  of 
acute  pleurisy,  but  resolution  does  not  take 
place,  or  is  indefinitely  deferred.  Death  may 
result  in  such  cases,  or  the  patient  may  slowly 
recover.  After  death  are  found  evidences  of 
active  simple  inflammation,  partial  or  complete 
obliteration  of  the  lung,  and  sero-fibrinous  exu- 
dation. The  other  side,  and  the  rest  of  the 
body,  may  be  quite  healthy.  The  name  relapsing 
pleurisy  might  be  given  to  these  cases.  When 
inflammation  falls  upon  both  pleurae,  it  generally 
falls  also  upon  the  pericardium,  and  such  cases 
are  terribly  dangerous.  Even  if  moderate  in 
degree  in  each,  yet  taken  together  the  embar- 
rassment of  the  patient  becomes  very  grave,  and 
death  imminently  threatens.  It  is  important  to 
give  relief  by  puncture  as  early  as  possible. 

(7)  Diaphragmatic  pleurisy. — Diaphragmatic 
pleurisy  is  not  essentially  different  from  the 
preceding,  but  the  symptoms  are  peculiar.1  If 
the  inflammation  be,  as  it  may  be,  exclusively 
diaphragmatic,  and  not  costo-pulmonary,  then 
the  ordinary  physical  signs  of  pleurisy  with 
effusion  are  either  absent,  or  so  ill-marked  as 
to  puzzle  the  inexperienced  practitioner.  In 
diaphragmatic  pleurisy  the  patient  is  taken  as 
acutely  as  in  ordinary  pleurisy,  or  the  fever 
may  even  be  higher;  but  his  distress  is  differ- 
ent, greater,  and  more  serious.  The  practitioner 
is  surprised  and  perplexed  to  find  a person,  in 
whom  he  can  discover  no  important  organic  de- 
fect, in  an  agony  almost  mortal.  The  presence 
of  pain  shooting  from  the  lower  ribs  of  one  side 
suggests  pleurisy  ; but  the  ribs  of  both  sides 
play  with  perhaps  more  than  normal  freedom,  and 
no  physical  signs  are  audible,  uuless  it  be  that 
the  practised  ear  may  detect  a want  of  breath- 
murmur  at  the  base  of  one  lung,  and,  after 

1 'Wintrich  is  indisposed  to  admit  that  the  symptoms  cf 
diaphragmatic  pleurisy  are  as  characteristic  as  herein 
described.  Diaphragmatic  pleurisy  may  perhaps  exist 
without  setting  up  such  marked  and  special  symptoms. 


1214  PLEUEA,  DISEASES  OF. 


the  first  day  or  two,  it  maybe,  two  finger-breadths 
of  dulness  there.  Still  no  friction  may  be  heard, 
and  it  seems  impossible  at  first  sight  to  credit 
signs  so  slight  with  clinical  phenomena  so  alarm- 
ing. For  the  patient  is  as  one  having  a clot  in 
the  heart,  or  a sudden  perforation  of  the  pleura, 
so  terrible  and  so  absorbing  is  the  strife  for  in- 
spirations which  never  satisfy,  so  keen  the  dread 
of  any  handling  which  may  interfere  with  the 
one  permanent  need  of  sitting  erect,  and  of  keep- 
ing every  respiratory  muscle  in  full  play.  These 
inspirations  may  range  from  forty  to  fifty  in  the 
minute,  or  may  even  run  with  the  seconds,  ex- 
cept only  when  cut  by  a hiccup  or  a heaving 
of  the  stomach.  To  this  are  added  the  suffering 
of  pain  which  shoots  through  the  waist  to  the 
back,  or  darts  round  the  shoulder-blade  and 
collar  into  the  shoulder,  and  an  impending  sense 
of  dissolution.  The  fever  is  perhaps  not  actually 
higher  than  in  ordinary  acute  pleurisy,  and  the 
normal  character  of  the  heart-sounds  gives  great 
confidence  to  the  physician.  Abdominal  breath- 
ing, however,  rather  than  thoracic  is  instinctively 
lessened,  and  any  pressure  upwards  upon  the 
diaphragm  is  resented.  All  these  things  finally 
lead  to  the  conclusion  that  acute  inflammation 
has  partially  attacked  and  so  far  paralysed  the 
diaphragm,  without  extending  far  upon  t he  pleura 
above ; and  the  diagnosis  is  of  course  the  easier 
if  pleurisy  is  discovered  elsewhere  in  the  chest. 
A patient  thus  attacked  seems  to  be  in  no  little 
danger,  but  recovery  may  be  anticipated.  For- 
tunately the  malady  is  far  less  common  than 
ordinary  pleurisy,  and  indeed  may  be  called  rare. 
As  stated  above,  however,  inflammation  of  the 
diaphragm  may  complicate  ordinary  pleurisy, 
and  introduce  both  the  pains  in  the  brachial 
plexus,  and  the  excessive  and  paroxysmal  dys- 
pucea. 

(5)  Quiet  'pleurisy  with  effusion. — This  form  of 
pleurisy  is  commonly  said  to  be  the  sequel  of 
acute  pleurisy ; but  if  we  except  a few  cases  in 
which  pleurisy,  at  first  sthenic,  afterwards  follows 
the  asthenic  tendencies  of  the  patient,  and  those 
in  which  acute  pleurisy  has  been  treated  with  neg- 
lect, we  shall  find  that  in  the  large  majority  of 
the  remainder  this  form  begins  not  sharply  but 
quietly,  and  indeed  is  often  unnoticed  until  the 
chest  is  laden  with  fluid.  If  the  patient  suffered 
pain  it  was  too  slight  or  too  indefinite  to  en- 
sure attention ; the  low  fever,  unmeasured  by 
the  thermometer,  escaped  observation  ; the  chest, 
slowly  invaded,  accommodated  itself  to  circum- 
stances until  the  fluid  had  nearly  filled  the 
cavity ; and  even  then  the  patient  may  he 
brought  to  the  doctor  only  by  a sense  of  dyspnoea 
on  ascending  bills  or  stairs.  A quick  eye  may 
detect  in  him  an  expansion  of  the  al®  nasi ; or, 
indeed,  may  see  that  the  patient — almost  un- 
known to  himself — is  breathing  at  double,  or 
nearly  double,  the  normal  rate ; or,  again,  a sen- 
sitive patient  and  a vigilant  physician  may  fully 
perceive  the  remittent — almost  intermittent — 
fever,  the  indefinite  pain  and  the  encroaching 
effusion,  and  may  lessen  the  evil  by  timely  inter- 
ference. As  a rule,  where  effusion  is  large  the 
patient  lies  on  the  affected  side,  thereby'  escaping 
the  pressure  of  the  fluid  upon  the  mediastinum, 
and  enabling  the  sound  lung  to  have  free  play. 
This  decubitus  is  not,  however,  invariable,  and 


is  avoided  if  the  affected  side  be  painful.  With 
pyogenic  change  in  the  effusion  the  patient  may 
turn  off  the  affected  side,  as  this  change  some- 
times is  accompanied  by  a renewal  of  tenderness 
to  pressure.  When  the  effusion  has  come  on 
very  gradually,  the  patient  may  be  able  even  to 
lie  on  either  side  indifferently.  In  a few  cases  a 
large  pleural  effusion  may  cause  some  difficulty 
of  swallowing,  but  this  is  rare.  Let  the  reader 
then  remember  that  pleurisy  running  to  large 
serous  effusion  not  only  may  he,  but  generally 
is,  quiet ; and  not  only  may  be,  but  not  uncom- 
monly is  overlooked  until  matters  come  to  an 
extremity.  In  like  manner,  if  the  effusion  he 
purulent  its  accumulation  may  be  equally  rapid 
or  equally  silent;  being  silent  when  it  is  the 
further  change  of  a serous  effusion,  being  silent 
and  rapid  when  it  comes  as  pus  almost,  if 
not  quite,  from  the  outset,  as  in  septic  and 
infectious  diseases,  and  in  children.  If  acute 
pleurisy  drifts  into  chronic  pleurisy,  the  fever, 
which  may  have  vanished  for  a time,  lights 
up  again  fitfully,  and  fresh  brushes  of  inflam- 
mation take  place  in  the  pleura  and  in  the  new 
membranes.  With  this  there  are  also  renewed 
outpourings  of  serum,  and  these  sometimes  in- 
crease so  rapidly  as  to  put  the  patient  in  immi- 
nent danger  of  death  by  syncope.  The  fever  in 
these  stages  is  often  hectic  in  character,  so  that 
the  presence  of  hectic  alone  does  not  prove  the 
effusion  to  be  purulent.  Quiet  dropsical  pleu- 
risy is  very  uncertain  in  duration.  Should  the 
effusion  be  not  excessive,  and  remain  serous, 
months  may  elapse — nay,  even  years — before  it 
is  absorbed ; and  the  absorption  maybe  gradual, 
or  may  be  deferred  for  awhile,  and  then  com- 
pleted more  quickly.  It  is  needless  to  say  that 
even  so  favourable  a result  as  this  cannot  do 
away  with  the  injury  which  the  chest  must  suffer 
from  being  water-logged  for  so  long  a time. 
Very  frequently,  however,  the  effusion  becomes 
sero-purulent  or  purulent : and  if  left  to  itself 
finds  an  exit  gradually  by  many  little  ulce- 
rated spots  through  the  filtering  lung,  and  so 
is  gradually  expectorated ; or  by  an  opening  in- 
to a bronchial  tube,  rushes  with  a sudden  and 
copious  discharge  into  the  mouth.  The  expecto- 
ration in  the  former  case  is  usually  profuse,  in 
offensive,  and  muco-purulent ; in  the  latter,  the 
gush  of  pure  and  often  stinking  pus  is  some- 
times so  great  and  so  sudden  as  to  swamp  the 
lungs  and  threaten  suffocation,  especially  if  it 
occur  during  sleep.  In  either  case  we  have  to 
deal  with  a subsequent  pyopneumothorax,  which, 
if  left  to  itself,  will  probably  end  in  death  by 
slow  hectic  and  marasmus.  The  issue  is  more 
promising  if  the  pus  find  its  way  outward?  be- 
tween the  ribs,  and  this  it  may  do  by  a direct 
opening  or  a sinuous  opening ; or  it  may  gather 
between  the  ribs  and  skin,  forming  there  a large 
superficial  abscess — * empyema-  necessitatis,’  the 
tension  of  which  varies  with  respiration  and 
increases  with  cough,  and  these  of  course  more 
or  less  readily  as  the  communication  is  more 
or  less  direct.  These  changes  in  tension  aid 
in  distinguishing  such  issues  from  the  pleural 
cavity  and  local  abscesses  of  tho  chest-walls. 
In  these  cases,  however-,  the  chest  is  imperfectly 
emptied  ; septic  poisoning  is  but  partially  pre- 
vented ; and  a lingering  illness  is  only  to  be 


PLEUEA,  DISEASES  OF. 


rut  short  Toy  operation.  Again,  the  pus  may 
find  its  way  into  the  opposite  pleura,  thus 
doubling  the  empyema,  and  such  cases  hare 
recovered ; or  into  the  pericardial  or  peritoneal 
cavities,  though  such  terrible  events  are  fortu- 
nately rare;  or  it  may  burrow  between  the  tissues 
and  appear  at  distant  places,  and  thus  may 
mimic  psoas  or  other  sinuous  abscess.  A cure 
of  empyema  by  resorption  is  said  to  be  possible, 
but  the  possibility  must  be  a bare  one. 

In  some  eases  the  fluid  may  rise  in  twenty- 
four  hours  from  the  angle  of  the  scapula  to  the 
' clavicle — an  obliteration  of  breathing  space  far 
more  terrible  in  its  rapidity  than  a more  gradual 
one  to  which  the  system  slowly  adapts  itself. 
This  affection  has  no  definite  course,  for  absorp- 
tion is  difficult,  and  so  far  as  it  occurs  is  too 
often  compensated  by  renewed  febrile  move- 
ments, with  renewed  effusions.  The  lower  cha- 
racter of  the  now-formations,  their  lack  of 
vessels,  and  the  compression  of  those  which  exist, 
hinder  such  absorption  as  may  be  possible  in 
: weakly  persons.  The  fluid  sooner  or  later  becomes 
purulent,  and  makes  for  itself  an  outlet. 

(e)  Tubercular  Pleurisy. — In  considering  the 
relations  of  pleurisy  to  tubercle  we  have  to 
deal  with  four  classes  of  cases: — 1.  Those  in 
which  one  or  more  attacks  of  pleurisy,  not  ap- 
parently itself  tubercular,  have  preceded  phthisis. 

2.  Those  in  which  tubercle  arises  in  the  exuda- 
tions of  a pleurisy  thitherto  simply  inflammator}'. 

3.  Those  in  which  pleurisies  spring  up  here  and 
there  in  the  course  of  pulmonary  phthisis.  4. 
Those  in  which  the  pleurisy  is  tubercular  in  its 
(origin  and  development. 

These  states  will  be  best  considered  reversely, 
[beginning  with  the  last.  True  tubercular  pleurisy 
is  notuncommon,  but,  apart  from  tubercle  in  other 
parts,  rarely  or  never  destroys  life,  and,  being 
i part  of  general  tuberculosis,  is  not  therefore 
found  aloneupon  the  post-mortem  table.  Tubercle, 
however,  sometimes  betrays  its  presence  in  the 
pleura  before  it  manifests  itself  elsewhere,  so  that 
the  occurrence  of  pleurisy  without  definite  cause 
m a delicate  person  should  always  excite  sus- 
picion, and  this  the  more  if  patches  of  inflamma- 
tion spring  up  here  and  there  in  the  membranes  of 
he  two  sides  without  much  resulting  effusion, 
for  the  fluxion  of  tubercles  is  rarely  sufficient 
n degree  or  kind  to  produce  much  effusion. 
!To  great  difficulty  arises  in  deciding  upon  the 
Mature  of  those  intercurrent  pleurisies  which  are 
nmcident  with,  and  so  often  caused  by,  pulmonary 
hthisis  in  the  neighbourhood.  These  very  com- 
monly are  not  tubercular  in  a strict  sense.  More 
ifficulty  will  be  found  in  foreseeing  or  detecting 
he  birth  of  tubercle  in  the  false  membrane  of 
pleurisy  apparently  simple.  Tuberculous 
leurisies  of  this  second  class  are  not  uncommonly 
pet  with  in  practice,  and  followed  to  the  post- 
mortem table.  A pleurisy,  severe  or  not,  but 
pemingly  of  simple  nature,  progresses  towards 
icovery,  and  perhaps,  indeed,  reaches  apparent 
■eovery.  The  temperature,  however,  if  it  has 
i Hen,  fitfully  rises  again  and  the  pulse  quickens, 
■’it  without  much  evidence  of  empyema  or  of 
iy  returning  effusion.  Presently  a patch  of 
eurisy  on  the  other  side,  or  a sign  of  mischief 
the  apex  of  a 1 ung,  betrays  the  character  of 
e relapse.  These  cases  end  as  more  or  less 


1215 

generalised  tuberculosis,  aud  in  the  old  false- 
membranes  are  found  the  caseous  or  softened 
residue  of  the  first  crop.  Most  difficult  of  fore- 
cast are  the  pleurisies  of  the  first  class,  which, 
however  painful  or  profuse,  end  in  recovery 
which  seems  complete.  The  patient,  who  has  re- 
turned to  the  labours  and  delights  of  life,  begins, 
however,  to  be  hectic  and  to  cough  shortly 
and  drily ; signs  of  phthisis  are  detected  in  the 
lung ; and  the  end  comes  in  the  too  familiar  way. 
There  is  little  more  to  be  said  under  this  head, 
but  to  urge  the  physician  to  look  upon  all 
pleurisies  jealously,  and  to  regard  with  positive 
anxiety  all  pleurisies,  however  frank  they  may 
seem,  or  however  happy  in  their  resolution,  which 
arise  in  delicate  subjects,  or  in  the  members  of 
families  tainted  with  consumption. 

(Q  Fibroid  Pleurisy. — Sometimes  as  a pri- 
mary affection,  but  more  often  as  an  ultimate  con- 
sequence of  ordinary  or  of  latent  pleurisy,  the 
membrane  slowly  thickens,  and  allying  itself 
with  a like  irritation  of  the  connective  elements 
of  the  lung,  increases  at  the  expense  of  the 
proper  tissue  of  the  lung,  and  gradually  con- 
tracting after  its  kind,  stifles  and  destroys  a 
great  part  of  that  organ.  Fibroid  pleurisy  gene- 
rally begins  at  the  base  of  the  lung,  and  the  pul- 
monary membrane  may  increase  until  it  forms 
a dense  leathery  covering  of  perhaps  one-third 
of  an  inch  in  thickness.  The  disease  is  very 
chronic,  and  as  the  irritative  overgrowth  of  the 
connective  elements  slowly  advances  into  the 
lung,  and  is  chiefly  important  as  affecting  the 
lung,  little  more  need  be  said  about  it  in  this 
place.  Fortunately  the  affection  is  rare,  and  it 
has  not  therefore  received  the  attention  it  de- 
serves. Commonly  it  ends  in  fibroid  pneumonia. 
Cough  and  dyspncea,  abiding  dulness  on  percus- 
sion, with  lack  of  expansion,  symptoms  of  pul- 
monary irritation  and  bronchiectasis,  all  follow- 
ing a known  attack  of  pleurisy,  should  excite 
suspicion  of  fibroid  hyperplasia.  The  causes  of 
this  abiding  irritation  are  very  obscure;  the  abuse 
of  alcohol  seems  to  be  among  them. 

Pleurisy  may  be  attended  with  other  peculiar 
features  of  not  sufficient  importance  to  justify 
its  division  into  further  varieties.  For  instance, 
it  may  be  attended  with  hccmoi~rhagic  exuda- 
tion— that  is,  with  exudation  mixed  with  more 
or  less  blood.  These  cases,  though  sometimes 
very  acute,  are  usually  chronic ; and  the  haemor- 
rhage depends  on  bleeding  of  the  new  vascular 
tissues,  which  partake  of  some  further  abnormal 
state  of  the  patient,  such  as  scurvy,  carcinoma, 
or  even  phthisis. 

Physical  Signs. — These  are  to  be  detected  by 
the  usual  methods.  Throughout  the  stages  of 
the  disease  inspection  will  tell  us  that  the  move- 
ments of  the  affected  side  are  lessened  either  by 
the  warning  of  pain  indirectly,  or  directly  by 
effusion  which  stops  the  play  of  the  lung.  This 
diminution  of  movement  is  often  to  be  noted 
also  in  the  abdomen  on  the  same  side,  especially 
in  diaphragmatic  pleurisy.  If  the  effusion 
greatly  increase,  the  chest  may  or  may  not  be 
seen  to  bulge  beyond  its  true  lines  ; the  inter- 
costal spaces  are  usually  flattened  up  to  the  level 
of  the  ribs,  and  the  form  of  the  affected  moiety 
of  the  chest  becomes  more  cylindrical,  as  is  best 
shown  by  the  cyrtometer.  The  diaphragm  may  be 


PLEURA,  DISEASES  OF. 


1216 

so  thrust  down  and  forward  as  to  cause  a fulness 
in  the  epigastrium ; in  large  effusions  there  may 
be  bulging  even  of  the  supraclavicular  space ; 
and  the  outline  of  the  affected  side  measured  in 
the  transverse  submammary  line  will  usually 
measure  more  than  on  the  healthy  side.  Half- 
an-inch  is  an  important  difference,  seeing  that 
the  other  and  healthy  side  in  overwork  expands 
in  a young  adult  about  half-an-ineh  or  more  be- 
yond the  normal,  and  falls  again  as  the  com- 
pressed lung  expands  after  paracentesis.  In  re- 
cent effusions  the  skin  is  often  obviously  stretched. 
CEdema  of  the  skin  on  the  affected  side  may  be 
present,  and,  though  not  decisive  of  pus,  is  less 
common  in  serous  effusions.  Though  confined 
to  the  affected  side,  it  sometimes  extends  far 
beyond  the  chest-wall.  The  state  of  the 
veins  of  tho  neck  must  also  be  noted,  and  of 
those  ttpon  the  chest,  as  much  enlargement  of 
these  would  suggest  intrathoracic  tumour  rather 
than  fluid,  as  in  like  manner  would  inequality 
of  the  pupils,  or  other  evidence  of  solid  pressure 
within.  Clubbing  of  the  fingers  may  be  seen 
in  old  cases  of  pleuritic  effusion  not  necessarily 
phthisical.  The  presence  or  absence  of  a 
heart-beat,  and  its  position  if  present,  must  be 
noted.  If  fluid  be  in  the  left  chest  a diffused 
pulsation  in  a tumid  epigastrium  often  replaces 
the  proper  apex-heat,  or  the  heart-beat  may 
be  felt  or  heard  towards  the  right  breast ; if  in 
the  right  chest  this  beat  may  be  detected  towards 
or  upon  the  left  axillary  line.  In  some  cases  of 
limited  but  complete  duiness  in  the  anterior  and 
inferior  region  of  the  left  chest,  it  may  be  difficult 
to  decide  between  fluid  and  pleuro-diaphragmatic 
adhesions.  In  the  latter  case  tapping  might  he 
attended  with  some  risk  of  perforating  the  dia- 
phragm. M.  Jaccoud  says  the  distinction  may 
be  made  in  some  cases  of  adhesion  by  observing 
traction  upon  the  lower  ribs  and  spaces  in  forced 
breathing,  so  that  the  spaces  are  drawn  in  on 
inspiration,  and  the  ribs  drawn  towards  the 
median  line.  But  puncture  in  so  dangerous  a 
situation  could  never  bo  desired.  In  some  rare 
cases  of  empyema  the  whole  of  the  affected 
side  so  pulsates  as  to  simulate  a large  aneurism, 
a phenomenon  which  has  not  yet  received  a 
satisfactory  explanation.  Finally,  in  large  effu- 
sions there  is  often  some  prominence  in  the 
liypoehondrium  of  the  same  side;  the  nipple 
drifts  farther  from  the  sternum,  and  the  shoulder- 
blade  is  thrust  somewhat  out  and  away  from 
the  spine.  All  these  displacements  and  changes 
of  shape  are  of  course  more  readily  brought  about 
in  young  subjects,  and  in  women  more  readily 
than  in  men.  In  children,  also,  we  find  propor- 
tionately less  visceral  displacement.  Thefemale 
diaphragm  is  more  readily  depressed  than  the 
male,  and  the  right  side  of  it  more  readily  than 
the  left.  In  neglected  cases  absorptive  and  atro- 
phic changes  tend  to  bring  about  a retraction  of 
the  affected  side,  the  thoracic  and  intercostal 
muscles  wasting,  and  the  ribs  falling  together, 
with  corresponding  flexure  of  the  spine,  and  great 
elevation  of  the  heart  or  liver.  Such  a deformity 
may,  indeed,  be  permanent  if  the  lung  be  oblite- 
rated ; happily  this  is  not  generally  the  case. 

Valuation  will  help  us  to  find  the  heart’s 
beat ; and  to  ascertain  it  the  liver  or  the  spleen 
be  displaced.  By  the  hand  we  may  sometimes 


detect  the  creaking  of  friction ; and  we  may 
verify  the  imperfect  expansion  of  the  side  or 
abdomen,  the  levelling  of  the  intercostal  spaces 
up  to  the  ribs,  and  possibly  make  out  fluctuation 
in  the  former.  The  most  distinctive  sign  to  the 
hand,  however,  is  the  loss  of  the  vocal  thrill, 
which  is  arrested  by  fluid  effusion.  This  is 
normally  more  distinct  over  the  lower  two-thirds 
of  the  chest.  Here  effusions  usually  first  accu- 
mulate, and  loss  of  this  thrill  is  almost  patho- 
gnomonic of  them;  for  it  occurs  besides  only 
with  those  intrathoracic  growths  which  by  theii 
size  or  position  close  the  bronchial  tubes.  Un- 
fortunately sometimes,  when  most  wanted,  the 
voice  fails  to  awaken  a thrill  in  normal  parts. 
Sometimes  the  limits  of  the  thrill  may  give  a 
gauge  of  the  height  of  the  effusion.  Above  the 
limits  of  the  effusion  the  thrill  is  often  more 
distinct  than  it  is  over  the  corresponding  part 
of  the  sound  lung.  It  must  be  remembered  if 
compressed  lung  lie  between  the  hand  and 
fluid,  that  the  vocal  fremitus  is  none  the  less 
diminished. 

Percussion  of  course  reveals  to  us  a higher 
or  duller  note  over  the  whole  extent  of  the  fluid. 
But  it  cannot  always  tell  us  the  amount  of  fluid 
present,  as  the  level  of  this  depends  on  the  state 
of  the  lung,  and  of  intrathoracic  tension.  More- 
over, during  absorption  duiness  depending  upon 
thick  false-membraues  cannot  be  easily  distin- 
guished from  that  due  to  fluid.  Such  membranes 
may  diminish  vocal  fremitus  also.  IVhen  fluid 
is  present  in  quantity  the  note  struck  is  dull, 
as  if  struck  upon  the  thigh,  and  the  stricken 
finger  receives  a peculiar  sense  of  dead  oppo- 
sition, owing  to  the  loss  of  resilience  or  vibra- 
tion in  the  chest-wall.  Extreme  degrees  of  lung- 
consolidation,  however,  may  rival  fluid  in  these 
particulars.  On  the  other  hand,  in  effusion  the 
level  of  the  duiness  may  vary  with  the  positior 
of  the  patient,  if  its  quantity  be  moderate,  and 
it  be  unconfined  by  adhesions.  Gravitation,  how- 
ever, helps  us  less  in  pleuritic  effusions  than  in 
pleural  and  other  dropsies,  as  in  the  former  case 
the  fluid  is  more  liable  to  be  sacculated,  and 
may  often  be  suspended  by  adhesion  above  the 
base  line  of  the  cavity.  If  the  pleura  seem  full 
of  fluid,  but  the  lung  be  not  much  compressed, 
direct  percussion  by  the  finger-tips  will  give  a 
very  dull  note  and  the  sense  of  resistance,  while 
stronger  mediate  percussion  will  bring  out  a note 
of  somewhat  lower  pitch.  Usually  the  level  of 
the  fluid  is  a little  lower  in  front  than  laterally 
and  behind,  and  the  luDg  if  free  from  much 
adhesion  is  usually  pushed  upwards,  inwards  and 
backwards,  so  that  it  may  be  detected  by  a clearer 
percussion-sound  at  tho  corresponding  side  of 
the  four  or  five  upper  dorsal  vertebrae.  In  acute 
pleurisy  the  fluid  rarely  rises  above  the  third  rib 
in  front,  but  in  quiet  effusive  pleurisy  the  whole 
moiety  of  the  chest  may  become  very  dull  up- 
wards, and  across  to  the  opposite  parasternal  line, 
and  there  may  be  duiness  and  actual  bulging  in 
the  supraclavicular  space.  "When  the  chest  con- 
tains a good  deal  of  fluid,  but  is  not  full,  percus- 
sion over  certain  areas  may  actually  give  a low 
or  tympanitic  percussion-note.  These  tympanitic 
areas  may  be  of  three  kinds — 1,  where  a thin 
layer  of  fluid  lies  over  expanded  lung;  2.  where 
distended  air-cells  compensate  cells  closed  it 


PLEURA, 

Mother  part ; 3,  where,  the  chest  being  full  of 
fluid  and  the  lung  compressed  and  empty,  per- 
cussion in  the  neighbourhood  of  the  trachea  and 
large  bronchi  causes  vibration  therein.  Tym- 
pany when  present  is  nearly  always  immediately 
under  the  clavicle.  If  the  tympany  be  due 
to  the  third  cause,  it  may  have  something  of 
the  cracked-pot  quality.  In  some  cases  the  tym- 
pany is  decreased  on  inspiration  and  increased 
(on  expiration.  The  detection  of  tympany  under 
the  clavicle  may  mislead  the  unwary  into  a belief 
that  the  healthy  side  is  morbidly  dull,  but  on  the 
other  hand  it  is  an  invaluable  help  to  the  phy- 
sician who  takes  it  as  a hint  to  look  for  fluid 
below.  Dulness  due  to  a displaced  liver  may  be 
'distinguished  by  the  removal  of  its  boundaries  on 
inspiration,  and  by  its  anterior  rather  than  pos- 
terior disposition.  In  mere  hydrothorax  the  lung 
generally  floats  more  readil}',  and  the  diaphragm 
and  other  structures  can  usually  be  made  to 
move  in  respiration. 

Auscultation,  before  any  dulness  appears,  usu- 
ally reveals  the  respiration  at  the  part  to  be 
defective  in  quantity,  rhythm,  or  quality ; and 
there  a friction-sound  may  be  audible.  Defec- 
tive inspiration  at  the  outset  is  due  to  arrest  of 
that  act ; afterwards  it  is  due  to  the  false-mem- 
branes  and  effusion  which  hinder  conduction  of 
lound,  compress  the  lung,  and  ultimately  silence 
t.  A friction-sound,  if  ever  generated,  may  be 
'ugitive  and  escape  the  observer,  or  the  embar- 
rassed chest-movements  may  fail  to  give  it  dis- 
inctness.  When  present  it  appears  at  the  out- 
et,  aud  disappears  as  effusion  separates  the  sur- 
aces ; it  may  reappear  as  the  fluid  is  absorbed, 
.’he  friction  of  outset  may  last  but  a few  hours, 
nd,  except  in  dry  pleurisy,  is  rarely  abiding ; 
sturning  friction,  however,  may  continue  for  a 
mger  time,  even  for  weeks.  In  those  cases  in 
■hich  the  surfaces  do  not  separate,  and  friction 
mtinues  for  many  days  without  a break,  we 
ave  to  deal  most  frequently  with  the  drier 
leurisies  of  some  cachexias  or  of  septicaemia, 
iminished  breathing  and  friction,  if  effusion 
,ithers,  are  followed  by  intermediate  pheno- 
ena  due  to  thin  layers  of  fluid.  These  are 
■onchial  breathing,  bronchophony,  and  sego- 
tony.  lEgophony  is  nearly  always  heard  near 
e root  of  the  lung  under  the  scapula  ; it  has 
e character  of  a bleat,  and  when  once  heard 
not  easily  forgotten.  Its  presence  is  patho- 
omonic  of  fluid  ; 1 but  it  is  so  often  absent  that 
is  of  little  practical  value.  As  fluid  increases 
:se  phenomena  give  placo  to  silence,  and  as 
id  gathers  first  at  the  bottom  we  often  find 
once  at  the  base  ; bronchial  resonance  amount - 
,',  it  may  be,  to  pegophony  at  mid-lung  ; and 

■ ectiveor  compensatory  breathing  at  the  apex. 

may  also  meet  with  curious  inverse  changes 
i he  physical  signs,  notwithstanding  an  increase 
( fluid,  if  at  first  this  be  spread  over  a partially 
f anded  lung,  and  afterwards  accumulate  below 

■ s the  lung  floats  upwards,  or  as  intrathoracic 
t'iion  tells  cn  the  other  side.  Thus  dulness 

Several  modifications  of  pectoriloquy  have  been  relied 
o i by  Baeelli  and  other  writers  as  means  of  distin- 
R ring  between  pus  and  serum  in  the  pleura.  Dr. 
n iitch  informs  the  writer  that  the  signs  in  question 
'.  rt  bear  out  the  value  which  has  been  claimed  for 
, ■ > the  phenomena  probably  vary,  not  with  the  den- 
*•  ^ the  effusion,  but  with  states  of  the  lung. 


DISEASES  OF.  1217 

may  actually  recede  with  an  increase  of  fluid, 
and  on  the  other  hand  it  may  rise  upwards  as 
with  a diminution  of  fluid  the  re-inflated  lung 
descends.  For  these  and  other  reasons  it  is  verv 
difficult  to  gauge  the  ebb  of  intrathoracic  effu- 
sions, or  accurately  to  ascertain  their  behaviour 
after  tapping.  In  children,  bronchial  breathing 
and  bronchophony  often  persist  throughout.  Dr. 
Bowditch  says  that  he  has  been  occasionally 
greatly  embarrassed  in  deciding  about  reaccu- 
mulations. ‘ At  times  after  the  effusion  has  been 
withdrawn  the  chest  remains  as  flat  as  ever, 
and  often  it  never  clears  up  in  the  lower  part 
of  the  affected  side  ; but  if  it  remains  in  this 
state  without  producing  untoward  symptoms, 
I have  not  tapped  again,  though  a tentative  as- 
piration could  do  no  harm.’  In  cases  where  the 
lung  is  unbound,  gauging  is  of  course  the  more 
easy.  When  the  chest  is  quite  full  of  fluid  there 
may  be  silence  throughout  to  ear  and  hand ; but 
even  in  such  cases  a faint  or  distant  respiratory 
souffle  is  sometimes  audible  almost  down  to  the 
base.  Moreover,  in  most  cases  breathing  more 
or  less  tubular,  and  some  resonance  on  percussion, 
are  to  be  heard  over  the  root  of  the  lung  in  the 
vertebra-scapular  space.  As  air  re-enters  the 
lung,  respiration  is  at  first  defective,  and  accom- 
panied by  crepitant  rales,  hut  it  improves  gra- 
dually, and  reinforces  itself  as  the  lung  expands 
and  clears.  In  children  silence  on  the  affected 
side  is  less  common,  bronchial  breathing  and 
bronchophony  persisting  in  them  far  more  than 
in  older  persons  ; but  it  is  not  by  any  means 
correct  to  say  that  bronchial  breathing  and 
bronchophony'  always  persist  in  the  pleuritic  effu- 
sions of  children.  Yet  the  pneumonia  of  children 
being  mostly  lobular  the  discovery  in  them 
of  bronchial  breathing  and  bronchophony  is 
highly  suggestive  of  fluid.  In  the  other  lung 
there  is  usually  a slight  general  lowering  of  the 
percussion-note  and  compensatory  breathing ; if 
the  effusion  be  large  enough  to  compress  the  op- 
posite lung,  the  percussion-note  may  he  very 
markedly  lowered.  At  times  morbid  sounds 
may  be  heard,  even  in  the  lung  of  the  affected 
side.  The  gradual  formation  of  a pulmonary 
fistula  may  in  some  cases  be  revealed  some  days 
or  hours  before  evacuation,  by  the  presence  of 
liquid  rales  in  the  upper  third  of  the  affected  side. 

Physical  examination  must  be  applied  r.ot 
only  to  the  investigation  of  the  lung  and  of  the 
contents  of  the  pleura,  but  also  to  determine  the 
position  of  those  neighbouring  parts  which  may 
be  displaced,  such  as  the  liver,  heart,  spleen, 
mediastinum,  and  so  forth. 

Pyopneumothorax. — This  is  a term  applied  to 
that  condition  in  which,  on  perforation  into  some 
open  channel,  air  finds  entrance  into  an  empye- 
matous  cavity.  At  the  same  time  pus  is  eva- 
cuated. The  lung  may  in  a measure  expand,  or 
in  neglected  cases  may  be  irrecoverable ; and  the 
chest-wall  falls  in  more  or  less,  according  to  the 
rigidity  of  the  ribs  in  the  individual.  Dulness 
now  gives  way  to  clearer  and  lower  notes,  ex 
eept  in  such  dependent  parts  as  may  still  be 
occupied  by  effusion,  and  their  pitch  will  varj 
according  to  the  thickness  and  density  of  the 
false  membranes  within,  and  to  the  degree  of 
pulmonary  expansion.  If  the  fistula  be  moderate 
in  size,  little  or  no  blowing  sound  will  bo  heard. 


PLEURA,  DISEASES  OF. 


1218 

but  two  additional  auscultatory  signs  may  be 
obtained,  which  are  alike  in  nature,  but  are  dis- 
tinguishable as  succussion  and  metallic  tinkling. 
See  Pneumothorax. 

Diagnosis. — The  difficulties  of  diagnosis  in 
pleurisy  belong  chiefly  to  the  earliest  and  to  the 
latest  stages  of  the  malady.  In  the  earliest 
stage  the  pleurisy  may  be  latent,  and  so  beyond 
the  possibility  of  diagnosis ; or  a pain  may 
bo  felt,  and  this  pain  may  be  due  to  pleurisy, 
pleurodynia,  or  other  causes.  The  pain  is 
often  referred  to  the  loin  or  abdomen,  thus 
leading  to  suspicion  of  mischief  elsewhere.  In 
the  previous  history  a catching  of  cold,  and  the 
arthritic  diathesis,  would  tell  equally  in  favour 
of  either  view  ; while  prolonged  anaemia  and 
leucorrhoea  would  lead  us  to  think  of  the  latter. 
Unfortunately  a comparison  of  local  tempera- 
ture in  the  two  sides  seems  untrustworthy,  but 
the  presence  of  fever  would  make  us  strongly 
suspicious  of  pleurisy.  It  must  not  be  supposed 
that  diagnosis  in  this  early  stage  is  unimportant. 
Few  errors  are  more  common  than  the  attribution 
of  pleuritic  pains  to  pleurodynia  ; the  pain  dis- 
appears as  an  effusion  slowly  accumulates,  and 
mischief  and  peril,  perhaps  hardly  remediable, 
may  be  the  consequence.  The  careful  observer 
will  listen  anxiously  to  the  chest  day  by  day, 
or  more  than  daily,  until  a friction-sound  be 
audible,  and  this  once  heard  further  mistake 
is  impossible.  Fever  of  course  may  be  present 
with  pleurodynia,  and  an  immediate  diagnosis 
would  then  be  impossible,  unless  something  cha- 
racteristic in  the  stitch  and  start  on  deep  inspi- 
ration betray  the  real  state  of  things  to  the 
practised  observer.  Neuralgic  and  inflammatory 
diseases  of  the  walls  of  the  chest  are  not  likely' 
to  give  rise  to  any  permanent  misunderstanding. 
It  is  said  that  a pericardial  may  be  mistaken  for 
a pleuritic  friction-sound,  but  the  distinction  can 
rarely  be  difficult.  A difficulty  is  more  likely  to 
arise  in  distinguishing  between  a pericardial 
and  a localised  pleuritic  effusion.  Still  this  can 
hardly  be  insuperable.  In  rheumatic  fever  and 
in  some  ocher  diseases  pericardial  may  accom- 
pany or  ensue  upon  pleuritic  effusion,  and  when 
the  latter  is  on  the  left  side,  and  is  abundant, 
the  limit  between  the  two  may  be  beyond  de- 
finition. The  practical  lesson  is  to  remember 
the  likelihood  of  pericardial  effusion,  and  not  to 
overlook  it  if  it  comes. 

In  the  later  stages  of  pleurisy',  when  effusion 
is  abundant,  its  diagnosis  may  be  very  difficult. 
Under  ordinary  circumstances  complete  and  ex- 
tensive dulness  with  loss  of  all  elasticity  in  the 
chest-wall,  of  respiratory  sound,  and  of  vocal 
thrill,  make  diagnosis  easy ; and  if  there  be  re- 
sonance below  the  clavicle,  its  high-pitched  cha- 
racter is  very  characteristic  of  fluid  below.  But 
there  may  be  no  such  resonance,  and  the  voice 
may' fail,  or  fail  to  setup  thoracic  thrill.  More- 
over, vocal  thrill  and  respiratory  murmurs  may- 
vanish  likewise  in  intrathoracic  tumours.  Thus 
the  diagnosis  between  exudations  and  pulmonary 
consolidations  is  sometimes  difficult.  In  acute 
pneumonia  the  course  of  the  fever,  the  expectora- 
tion, and  other  symptoms,  help  us  to  a decision. 
In  pleurisy  with  moderate  effusion,  on  the  other 
hand,  the  limits  of  posterior  dulness  might  be 
changed  by  a few  forcible  inspirations,  such 


changes  being  probably  due  to  a re-expansion  of 
collapsed  lung.  Consolidated  lung  could  not,  of 
course,  be  thus  altered.  In  both  there  may  be 
tubular  characters  of  respiration,  whichare  more 
easily  distinguished  in  print  than  at  times  they 
may  be  in  the  patient.  If  segophonic  we  de- 
cide upon  fluid,  but  if  broncbophonic  we  have 
to  distinguish  as  well  as  we  can  between  the 
‘ sniffling  and  metallic’  bronchophony  (Walshe) 
of  consolidation,  and  the  duller  and  more  dif- 
fused bronchial  sound  of  pleuritic  effusion.  If 
the  dulness  and  breath-sounds  vary  with  the 
position  of  the  patient,  fluid  is  clearly  present. 
Limited  effusions,  such  as  an  encysted  empyema, 
not  large  enough  to  bulge  the  intercostal  spaces, 
to  crush  up  the  lung,  or  to  displace  other  organs, 
are  at  times  quite  indistinguishable  from  a like 
extent  of  chronic  consolidation,  or  of  abscess  in 
the  lower  lobe  of  the  lung;  such  collections, 
though  usually  basic,  are  by  no  means  always 
so,  but,  retained  by  adhesions,  may  occupy  the 
upper  and  anterior  region,  any  part  of  the  middle  1 
region,  or  strips,  or  irregular  districts  in  anv 
direction.  It  may  be  said  in  general  terms  that 
a permanent  very  dull  area  remaining  after  an 
acute  pleurisy  or  pleuropneumonia  most  pro- 
bably corresponds  to  an  encysted  empyema, 
but  not  always.  In  such  cases  fever  may  be 
entirely  absent,  and  the  general  condition  of  the 
patient  may  not  suggest  disease.  Still,  such  n 
collection  of  pus  is  pretty  sure  to  work  mischief 
sooner  or  later — years  later,  it  may  he — but  the 
patient  rarely  escapes  with  impunity  at  last. 
The  difficulties  of  distinguishing  bulky  effusions; 
from  pulmonary  consolidations  are  not  often 
great.  In  the  former  the  intercostal  spaces  may 
be  bulged,  and  the  moiety  of  the  chest  enlarged  ; 
on  the  other  hand  it  but  very  rarely  happens 
that  consolidation  reduces  the  lung  to  silence, 
though  this  may  be  the  case;  in  such  a case  the 
bulk  of  the  half-chest  would  in  all  probability  ba 
lessened,  but  so.  on  the  other  hand,  may  it  be  in 
a chronic  pleurisy'.  The  fact  is,  many  chronic 
cases  can  be  diagnosed  by  the  needle  alone;  and 
it  should  be  noted  that  even  with  the  needle 
more  than  one  puncture  or  two  should  be  made 
before  deciding  against  fluid.  Between  intra 
thoracic  tumours  and  large  pleuritic  effusions? 
difficulty  is  found  only  in  those  cases  in  whicl 
the  tumour  occupies  precisely  the  half  of  tb< 
chest,  but  this  is  not  very  uncommon,  especially 
in  cases  of  aneurism.  It  must  not  be  forgottei 
too  that  fluid  effusion  may  accompany  tumour 
in  which  case  there  maybe  subtympanitic  reson 
ance  under  the  clavicle.  In  favour  of  fluid  alon 
are  the  absence  of  enlarged  veins ; the  equalit 
of  hydrostatic  displacement  of  organs ; the  at 
sence  of  signs  of  localised  pressure,  of  pulse 
retardation,  of  inequality  of  pupils,  and  of  pe 
euliar  sputa.  A curious  pulsation,  of  uncertai 
explanation,  is  sometimes  seen  in  empyema,  an 
must  not  be  mistaken  for  an  aneurismal  throl 
If  fluctuation  be  certainly  felt  in  the  intercosti 
spaces,  tho  disease,  in  part  at  any  rate,  is  a flui 
effusion.  Sometimes  a hepatic,  biliary,  rena 
or  other  subphrenic  abscess,  making  its  wa 
by  a sinus,  occupies  also  some  part  of  tl 
pleural  cavity.  Here  it  may  encyst  itself,  ail 
remain  latent  or  quiescent  for  months  or  year, 
or  it  may  excite  an  effusive  pleurisy  in  tl 


PLEURA,  DISEASES  OF. 


remainder  of  the  cavity,  so  that  two  effusions 
co-exist  in  one  pleura.  Such  collections  may 
of  course  form  pulmonary  fistulae,  and  pus  from 
the  same  central  source  may  in  part  issue  from 
the  urethra  or  rectum,  and  in  part  issue  from 
the  mouth.  Such  cases  are  often  easy  of  dia- 
gnosis ; at  other  times  they  are  more  difficult, 
especially  if  there  be  no  fistula  in  any  direc- 
tion. When  such  pyogenic  cysts  contain  air, 
but  not  by  way  of  the  lung,  it  may  be  sup- 
posed that  they  have  originated  in  some  per- 
forative disease  of  stomach  or  bowel.  It  is  ob- 
vious that  in  these  cases  there  will  be  little 
evidence  of  increased  intra-thoracic  tension. 
Dulness  from  disease  below  the  diaphragm,  but 
encroaching  on  the  thoracic  space,  can  often  be 
displaced  downwards  by  a deep  inspiration.  It 
is  stated  that  in  puncture,  combined  with  the 
ise  of  the  manometer,  when  the  canula  is  in  a 
cavity  beneath  the  diaphragm,  inspiration  is 
ittended  with  an  increase  and  expiration  with 
i decrease  of  pressure,  being  the  reverse  of  that 
vhich  occurs  when  the  canula  lies  in  the  pleura, 
in  peripleuridc  abscess  tension  is  of  course  low 
md  there  is  no  pressure  on  neighbouring  organs  ; 
Dercussion-dulness  is  also  less  profound.  It  is 
’aid  that  pus  from  cellular  abscesses  is  of  higher 
peeific  gravity  (1040)  than  from  large  cavities 
11028-1030). 

: A haemorrhage  into  the  pleura  can  be  dis- 
mguished  from  a serous  or  purulent  effusion, 
nlv  by  a careful  survey  of  all  the  history  and 
ymptoms ; the  direct  physical  signs  helping 
s but  little.  Large  pulmonary  cavities  may 
3 taken  for  encysted  empyema  with  fistulous 
oening  into  a bronchus ; and  here  again,  al- 
lough  a pulmonary  fistula  rarely  gives  rise  to 
ibular  breathing,  unless  the  opening  be  very 
rge,  or  communicate  with  a secondary  cavity, 
;t  diagnosis  by  the  direct  signs  alone  might  be 
lpossible.  The  history  of  the  case,  and  the  state 
' the  other  lung  would  be  important  factors 
decision.  In  another  class  of  cases  the 
stinction  between  chronic  phthisis  and  pleu- 
jsy  may  be  difficult — in  those,  that  is.  in  which 
ere  is  some  old  dulness  and  retraction  of  a 
rt  of  the  side,  with  weak  respiration  and  in- 
finite rdlcs,  and  more  or  less  fever.  The 
sence  of  lung-tissue  in  the  expectoration,  and 
e health  of  the  other  side,  help  to  exclude 
ithisis.  Fibroid  phthisis,  however,  is  not  even 
is  excluded,  and  is  usually  pleuritic  in  origin, 
children  enlargement  of  the  spleen,  with  ex- 
tsion  upwards  and  backwards,  has  not  in- 
quently  simulated  effusion  at  the  base  of  the 
: lung.  Finally,  the  intense  distress  and 
hopnina  of  very  painful  pleurisies — of  dia- 
•agmatic  pleurisy  more  especially — may  simu- 
• 3 cardiac  thrombosis.  The  state  of  the  pulse 
i ne  is  usually  sufficient  to  lessen  the  fears  cf 
1 physician. 

i’Ronxosis. — The  prognosis  of  simple  pleurisy, 

. rt  from  tubercle  or  carcinoma,  is  generally 
l ourable,  unless  the  degree  or  kind  of  effusion 
i the  chest  endanger  life.  If  not  always 
I Durable,  it  is  because  simple  inflammatory 
1 rrisies  seem  sometimes  to  originate  a process 
t chronic  fibrosis,  which  thence  invades  the 
Happily  such  instances  are  rare,  and  in 
61  ndividual  case  the  chance  of  such  an  event 


1219 

: almost  vanishes.  In  ordinary'  inflammatory 
pleurisies,  then,  prognosis  is  quite  favourable; 
in  cases  of  effusion,  where  the  effusion  is  moder- 
ate, it  is  favourable  ; where  the  effusion  is  large, 
it  is  the  less  favourable  the  greater  the  quantity 
and  the  slower  the  absorption.  Signs  of  hyper- 
semia  and  cedema  in  the  working  lung  must  be 
anxiously  watched,  especially  if  an  empty  radial, 
scanty  urine,  and  other  evidences  of  venous 
stasis  be  added.  When  the  chest  is  full,  pro- 
gnosis is  unfavourable  apart  from  operation.  In 
severe  and  acute  cases  the  other  lung  becomes 
cedematous  and  congested,  bloody  and  frothy' 
sputa  may  appear,  carbonic-aeid-poisoning  will 
become  evident  in  the  blue  lips  and  lethargic 
brain,  the  pulse  will  slip  away,  the  heart  fail, 
and  the  extremities  grow  chill ; or,  again,  dislo- 
cation of  the  heart  and  arrest  of  the  pulmonary 
circulation  may  cause  syncope  by'  asystole  or 
thrombosis.  Operation,  however,  raises  the  hope 
of  recovery  greatly — so  much  so  as  to  put  the 
chances  largely  in  favour  of  rapid  recovery  in 
good  subjects.  The  earlier  the  relief,  the  less 
the  probability  of  refilling,  the  less  the  damage 
to  the  lung,  and  the  better  the  hope  of  rapid 
amendment.  In  bad  subjects  prognosis  will  be 
the  less  favourable  the  more  potent  the  adverse 
conditions  ; and  in  pleurisies  secondary  to  other 
diseases  the  prognosis  will  depend  but  partially 
upon  any  one  element  in  the  case.  In  old  people 
operation  is  still  useful,  but  especial  care  must 
be  taken  to  draw  off  the  fluid  very  slowly,  and 
to  watch  the  circulation.  The  conditions  in 
them  unfavourable  to  operation  are  still  more 
unfavourable  to  absorption,  or  to  any'  kind  of 
delay.  In  empyema  the  prognosis  is  grave ; 
unless  operation  be  performed  death  is  very  pro- 
bable, either  by  syncope  before  the  mattei 
escapes,  or  by  exhaustion,  chronic  septicaemia 
or  secondary'  abscesses,  during  a long  period  ot 
incomplete  drainage  of  the  chest.  If  operation 
be  submitted  to,  the  prognosis  is  favourable, 
though  a vast  internal  abscess  with  rigid  walls 
cannot  be  but  a fearful  thing,  and  the  illness  will 
still  be  a long  and  an  anxious  one.  Death  can 
scarcely  be  said  ever  to  be  due  simply  to  the 
operation,  if  carefully  performed  : and  death, 
during  or  directly  following  the  operation,  though 
not  unknown,  is  too  rare  to  be  an  important  fac- 
tor in  our  decisions  or  forecasts.  On  the  whole, 
the  earlier  the  operation  is  performed,  after  it  is 
fairly  indicated,  the  better  the  prognosis.  Among 
the  deferred  dangers  are  amyloid  disease,  a rare 
event,  but  possible  in  cases  of  necrosed  rib  or 
other  bone,  or  of  very  long  and  exhausting  drain ; 
and  phthisis  or  septic  tuberculosis,  happily  made 
also  rare  by  the  density  of  the  false-membranes. 
The  presence  of  albumen  in  the  urine  alone  does 
not  necessarily  preclude  complete  recovery,  nor 
forbid  prompt  operation.  The  beariug  of  age 
and  sex  upon  prognosis  cannot  as  yet  be  decided. 
Experience  indicates  that  it  is  more  hopeful  in 
eases  under  ten  years  of  age  and  above  twenty 
years.  Dr.  Bowditch  says  that  full  pregnancy 
is  no  bar  to  thoracentesis.  The  influence  of  dia- 
thesis on  the  progress  of  local  diseases  must  Le 
estimated  in  all  cases  on  general  principles. 

As  regards  duration,  an  ordinary  case  of  in- 
flammatory  pleurisy  will  last  from  ten  days  to  a 
month,  according  to  the  degree  of  effusion  and 


[220  PLEURA,  DISEASES  OF. 


:he  rate  of  re-absorption.  Chronic  cases  ■with 
large  effusions  may  last  any  length  of  time,  rarely 
Less  than  three  months.  If  tapped  the  fluid  may, 
and  very  often  does  not  return,  or  may  not  re- 
turn after  a second  tapping ; in  such  a case  re- 
covery will  he  prompt.  Empyemas,  opened  under 
the  most  favourable  conditions,  are  often  months 
and  sometimes  years  before  final  closure,  though 
it  seems  that  the  antiseptic  operation  and  dress- 
ings will  much  shorten  the  average  duration.  If 
left  to  itself  an  empyema  usually  opens  through 
the  lung  or  externally.  In  the  latter  case  the  issue 
is  most  commonly  about  the  fifth  interspace  an- 
teriorly. Drainage  is  thus  very  incomplete,  and 
although  some  relief  is  attained,  the  patient 
nevertheless  drags  on  with  a permanent  fistulous 
discharge,  it  may  be  for  years,  but  recovery  with- 
out operation  is  scarcely  to  be  hoped  for. 

Finally,  it  must  not  be  forgotten  that  simple 
pleurisies  may  he  the  forerunners  of  phthisis. 
The  occurrence  or  repetition  of  a pleurisy  in  a 
young  person  of  delicate  habit  or  origin  is  always 
an  alarming  thing,  and  the  more  so  if  not  due 
to  obvious  causes.  The  experienced  physician 
will  call  to  mind  many  cases  in  which  a pleurisy 
to  all  appearance  wholly  recovered  from  at  the 
time,  was  followed  before  many  months  had 
passed  by  definite  signs  of  phthisis.  There  is 
no  evidence  to  show  that  all  such  pleurisies 
are  tubercular  in  nature.  Lastly,  a decided 
attack  of  pleurisy,  occurring  in  the  course  of 
pulmonary  phthisis,  always  means  or  makes 
mischief,  even  if  quickly  got  under. 

Treatment. — 1.  Medicinal. — Dry  pleurisy  re- 
quires little  or  no  treatment.  In  some  cases, 
indeed,  it  may  cause  distress,  as  in  chronic 
phthisis  ; and  if  so,  may  be  relieved  by  spongio- 
piline  and  laudanum,  or  by  any  similar  sooth- 
ing measures.  In  the  cases  in  which  a trouble- 
some cough  is  caused  by  a patch  of  chronic  dry 
pleurisy,  the  cough  and  pleurisy  alike  may  be 
removed  by  the  application  of  blisters.  In  acute 
pleurisy,  however,  much  depends  upon  active 
treatment  at  the  outset;  in  few  maladies  is  early 
attention  better  rewarded,  and  in  few  is  neglect 
more  surely  punished.  Our  great  aim  in  the 
beginning  is  to  diminish  the  pain,  the  inflam- 
mation, the  fever,  and  the  tendency  to  ex- 
cessive exudation.  With  or  without  treatment, 
as  we  have  seen,  the  pain  usually  passes  off  in 
forty-eight  hours,  or  thereabouts ; neverthe- 
less it  is  very  acute  while  it  lasts.  In  sharp 
cases,  occurring  in  healthy  persons,  we  majr 
put  on  six  to  twelve  leeches  according  to  the 
age,  sex,  or  condition  of  the  patient,  and  these 
may  bleed  freely  into  a large  poultice.  This 
measure,  if  adopted  at  the  very  outset,  dimi- 
nishes the  pain,  the  fever,  the  exudation,  and 
the  duration  of  the  case.  When  the  bleeding  has 
ceased  the  chest  should  be  firmly  bandaged,  and 
as  soon  as  the  state  of  the  leech-bites  will  allow 
of  it,  the  affected  side  should  be  firmly  strapped. 
This,  by  giving  rest  to  the  part,  will  favour  re- 
solution and  resorption.  Constant  respiration, 
on  the  other  hand,  favours  effusion,  as  exercise 
favours  it  in  inflammation  of  a joint..  If  called 
to  a case  after  the  first  brunt  is  over — say  after 
a lapse  of  forty  hours — it  is  better  to  omit  the 
leeching,  in  order  that  the  strapping  may  be 
applied  at  once.  It  must  be  carried  out  on  the 


following  plan,  as  laid  down  by  Dr,  Roberts,  of 
University  College  Hospital : — 

Strips  of  a properly-adberent  plaster  spread 
on  some  thick  material,  from  three  to  four  inches 
wide  and  of  sufficient  length,  are  applied  round 
the  affected  side  from  mid-spine  to  mid-sternum, 
or  a little  beyond.  These  are  laid  on  over  a 
variable  extent  of  the  chest,  according  to  the 
requirements  of  the  case,  it  being  sometimes 
necessary  to  include  the  whole  side.  It  is  best 
to  make  the  application  from  below  upwards, 
and  to  fix  the  strips  of  plaster  in  an  oblique 
direction  rather  than  horizontally.  The  patient 
being  directed  to  expire  deeply,  a strip  is  fixed 
at  mid-spine  and  drawn  tightly,  firmly,  and 
evenly  round  the  side  in  the  direction  "of  the 
ribs,  that  is,  a little  obliquely  from  above  down- 
wards and  forwards  ; then  another  strip  is  laid 
on  over  this,  also  extendi  ng  from  mid-spine  to  mid- 
sternum, but  in  the  opposite  direction  to  the  first, 
that  is,  obliquely  upwards  and  forwards  across 
the  course  of  the  ribs ; the  third  should  follow 
the  direction  of  the  first,  overlapping  about  half 
its  width,  the  fourth  that  of  the  second,  and  so 
on  in  alternate  directions,  until  the  entire  side  is 
included  if  required.  Finally,  it  is  often  desirable 
to  apply  over  the  whole  two  or  three  strips  hori- 
zontally, so  as  to  form  a superficial  layer ; and, 
if  necessary,  one  or  two  may  also  be  passed  from 
behind  forwards  over  the  shoulder,  these  being 
kept  down  by  another  strip  fixed  round  the  side 
across  their  ends.  Dr.  Roberts  applies  the 
strapping  in  all  cases  from  the  outset.  The 
writer's  experience  is  in  favour  cf  early  leeching 
in  suitable  cases,  but  it  may  be  possible  to  com- 
bine the  two  remedies.  This  at  the  outset  is 
far  from  easy,  as  a large  poultice  is  almost  an 
essential  part  of  the  leeching.  Some  physicians 
recommend  that  an  attempt  be  made  to  snbdue 
the  local  inflammation  by  the  application  of  ice, 
but  the  results  of  this  method  are  not  satisfac- 
tory. In  addition  to  local  measures,  such  medi- 
cines as  the  following  are  required : — A powder 
consisting  of  Pulveris  ipecacuanhae  compositi 
gr.  v,  and  Pulveris  antimonialis  (James’s)  gr.  iij, 
is  to  be  given  every  six  or  eight  hours,  for  two 
or  three  days.  In  diaphragmatic  and  in  other 
cases,  in  which  pain  is  a marked  feature,  the 
subcutaneous  use  of  morphia  is  also  to  be  re- 
commended, in  doses  of  one-eighth  to  one-fourth 
of  a grain,  or  possibly  more.  The  fever  is 
rarely  severe  or  protracted  enough  to  require 
such  vigorous  antipyretics  as  quinine,  nor  is 
aconite  a very  safe  remedy.  It  is  better  to  give 
in  addition  to  the  powder,  full  doses  of  Liquoi 
ammonise  acetatis  (oij-Siv  for  an  adult)  ever} 
four  hours,  covered  with  a little  milk;  an  alka- 
line effervescent  being  freely  used  also  as  f 
drink.  Thus  vascular  tension  is  lessened,  an: 
activity  of  the  skin  and  kidneys  is  promoted 
In  the  earlier  stages  free  purgation  should  b 
avoided,  but  it  is  well  to  call  gently  upon  th 
alvine  excretion  by  the  use  of  mercurials  an- 
salines. All  solids  must  be  withdrawn  fror 
the  dietary,  and  stimulants,  as  a rule,  forbidder 
The  alkaline  effervescent  or  a cream  of  tartn 
drink,  with  acetate  of  ammonia  mixture,  are  t 
be  continued  after  the  powders  are  withdrawi 
so  as  to  keep  up  free  excretion : for  the  sam 
purpose,  and  also  to  lessen  chest-movement 


PLEURA.  DISEASES  OF.  1221 


the  patient  must  be  kept  closely  to  bed.  For 
some  days  after  the  subsidence  of  the  fever  the 
appetite  for  highly  nitrogenous  diet  must  be 
neld  in  check,  and  it  is  desirable  at  this  stage 
to  lessen  the  amount  of  fluid  in  the  dietary. 
Thus  it  is  to  be  hoped  that,  as  the  patient’s 
general  condition  improves,  the  effusion  in  the 
chest  may  likewise  fall.  If  this  be  not  the 
case  other  remedies  must  be  brought  forward. 
Among  the  chief  of  these  are  blisters,  which,  if 
not  pushed  to  full  vesication,  may  be  repeated  fre- 
quently ; or  the  chest  may  be  kept  continuously 
ruder  the  effects  of  iodine,  though  this  method 
s less  successful  than  the  blisters.  At  the  same 
ime,  or  soon  after,  a pill  may  be  administered 
twice  daily,  containing  a grain  each  of  digitalis 
(fresh  leafj  and  blue  pill.  A grain  of  squill  may 
be  added,  but  squill  has  some  tendency  to  disorder 
the  stomach.  The  use  of  both  blisters  and 
mercury  must,  of  course,  be  avoided  if  the 
kidneys  be  not  sound,  and  mercury  should  be 
avoided  in  any  case  where  a phthisical  tendency 
's  suspected.  Dr.  Bowditch  applies  a solution 
f iodine  (5ss  in  Spiritus  etheris  sulphurici  yj), 
painting  it  on  twice  or  thrice,  or  till  burning  is 
induced,  and  then  reapplies  it  intermittently. 
He  also  administers  iodide  of  potassium  gr.  v, 
thrice  daily  internally,  and  finds  much  help 
from  this  treatment.  In  vigorous  patients  free 
and  repeated  doses  of  some  hydragogue  pur- 
gative-such as  Hunyadi  water— may  be  tried 
before  beginning  the  more  tedious  pills.  Or 
the  ointment  of  oleate  of  mercury  may  be.  rubbed 
freely  into  the  chest,  and  this  may  he  used 
even  in  delicate  persons,  without  fear,  and  in 
those  whose  sensitive  skins  are  intolerant  of 
blisters.  Quinine  may  be  added  to  the  mix- 
lure  containing  iodide  of  potassium,  or  may 
nell  accompany  the  mercurial  course.  But  when 
1 brief  and  gentle  eliminative  course  of  this 
kind  is  ended,  it  is  well  at  once  to  turn  to 
:he  full  tonic  treatment,  with  such  drugs  as 
ron  and  quinine.  Less  active  effusions  in 
lelieate  and  anaemic  subjects  may  need  iron  and 
bitters,  cod-liver  oil,  and  liberal  diet  from  a 
:ery  early  stage,  and  such  cases  are  common. 
It  the  same  time  such  measures  are  not  to  be 
ised  while  the  acuter  stages  are  present — a 
irecaution  too  often  forgotten  ; for  even  in  phthi- 
is  a sharp  intercurrent  pleurisy  must  often  be 
reated  by  salines,  and  perhaps  a leech  or  two 
t first.  These  measures  will  generally  succeed, 
a reducing  not  only  an  acute  effusion  of  moder- 
te  extent,  but  also  many  effusions  of  a more 
bstinate  kind.  If,  however,  the  case  resist 
he  means  prescribed,  the  effusion  will  probably 
icrease,  and  may  need  operative  interference,  as 
1 60  commonly  the  ease  in  latent  pleurisy.  As  a 
eneral  rule,  if  an  effusion  rises  above  the  angle 
f the  scapula,  and  abides  in  this  quantity  or 
tore  for  two  or  three  weeks  in  spite  of  adc- 
uate  treatment,  it  must  be  drawn  off,  whether 
; le  patient  be  embarrassed  by  it  or  not.  In 
ises  where  treatment  by  medicines  has  not  been 
lirly  tried,  where  the  patient  is  in  comparative 
ise,  where  the  effusion  is  not  above  the  spine 
the  scapula  behind  nor  above  the  mamma 
fore,  and  where  the  neighbouring  organs 
re  not  seriously  displaced,  these  operations 
ay  give  place  to  medicine  for  two  or  three 


weeks  longer  if  desired.  The  writer,  however, 
would  advise  the  withdrawal  even  of  a pint  of 
fluid  which  had  lain  in  the  cavity  for  a month, 
as  its  continued  presence,  by  soaking  and  com- 
pressing the  lung,  injures  it,  and  destroys  the 
absorbent  power  of  the  pleura  and  of  its  granu- 
lations. It  is  needless  to  add  that  if  there  be 
effusion  in  both  pleural  cavities,  the  amount  in 
both  must  be  considered  as  one  quantity'.  Be- 
fore resorting  to  operation,  however,  it  is  well  to 
say  that  two  more  methods  remain — the  so- 
called  ‘ thirst  cure,’  which  has  some  good  effect 
in  the  treatment  of  serous  effusion;  and  the 
jaborandi  cure.  The  first  method  consists  in  the 
withdrawal  of  fluid  from  the  diet,  which  should 
be  as  dry  as  possible,  and  consist  of  lean  cold 
meat,  stale  bread  and  the  like.  All  fluids  are 
forbidden,  except  half  a pint  on  the  third  day, 
and  a pint  on  the  seventh  and  eighth  days. 
The  effusion  is  said  under  this  method  to  de- 
crease daily ; the  method,  however,  is  more 
painful  than  tapping,  and  could  not  be  borne  by 
all  patients  without  injury.  The  second  plan 
consists  in  tho  promotion  of  profuse  sweating, 
by  means  of  jaborandi.  Excellent  results  are 
said  to  have  followed  this  method.  The  drug 
is  administered  as  a liquid  extract,  5j  being 
given  every  three  hours.  If  medicinal  and 
dietetic  means  fail  to  remove  a moderate  effu- 
sion, or  if  the  effusion  already  occupy  the  whole 
cr  a great  part  of  the  pleural  cavity,  the  cavity 
must  be  tapped  without  further  delay.  There 
should  be  no  hesitation  in  tapping  instantly  any 
chest  which  is  dull  up  to  the  clavicle,  or  which 
presents  a small  tympanitic  space  under  the 
clavicle.  The  operation  of  removing  fluid  from 
the  chest  by  tapping  (paracentesis  thoracis), 
seems  to  have  been  practised  in  early  times,  but 
has  scarcely  become  familiar  to  us  until  the  last 
quarter  of  a century.  To  Trousseau,  of  Paris, 
and  to  Di\  Bowditch,  of  Boston,  the  profession 
is  chiefly  indebted  for  anything  like  doctrine  in 
this  matter.  Trousseau  was  probably  the  first 
physician  to  recognise  the  means,  and  the  pro- 
priety of  tapping  in  serous  effusions. 

2.  Paracentesis  thoracis. — Taking  the  opera- 
tion as  agreed  upon,  we  will  now  lay  down  the 
precise  method  of  it.  It  may  be  a matter  of  doubt 
whether  the  fluid  contents  of  the  chest  he  serous, 
sero-purulent,  or  purulent.  To  ascertain  this  a 
hypodermic  syringe  may  be  passed  through  the 
wall  of  tho  chest,  and  a sample  of  the  fluid 
drawn  away.  In  this  way  information  is  ob- 
tained as  to  the  nature  of  the  fluid,  and  its 
accessibility.  Should  the  tap  be  dry,  it  can  be 
repeated  elsewhere  more  readily,  and  with  less 
sens9  of  failure,  than  the  greater  operation. 
Tho  precise  place  of  operation  must,  of  course, 
be  chosen  with  great  care  ; but,  happily,  there 
is  plenty  of  margin  for  error.  In  an  encysted 
empyema  with  thickened  walls  four  or  five 
punctures  may  be  needed  before  pus  be  reached. 
If  the  issue  be  purulent  two  openings  will  be 
needed,  when,  after  choosing  the  second  with 
the  greatest  care,  the  first  may  be  closed  ; if  the 
issue  be  serous,  the  complete  emptying  of  the 
cavity  is  not  necessary,  and  not  always  desirable. 
In  cases  of  multilocular  pleuritic  effusion  the 
emptying  of  one  cavity  only  is  of  course  an  in- 
complete measure.  Such  cases  are  unsatisfactory 


PLEURA,  DISEASES  OF. 


1222 

at  best,  and  can  only  be  tested  by  repeated 
puncture. 

If  there  be  no  special  reason  to  the  contrary, 
the  chest  will  be  tapped  on  the  lateral  or  poste- 
rior aspect,  as  there  is  thus  less  danger  of  in- 
terference with  other  organs.  Reasons  to  the 
contrary  may  present  themselves  in  the  case 
of  adhesions  tying  the  lung  to  the  side  or  back 
of  the  cavity,  of  lateral  displacement  of  the 
heart  in  left-side  effusions,  of  deformities  in  the 
individual,  and  so  forth.  The  pointing  of  an 
empyema  forward,  however  well-marked,  is  no  in- 
dication for  an  anterior  opening,  as  this  pointing 
will  recede  when  a posterior  opening  has  been 
made  ; nor  is  the  faintly  audible  sound  of  respi- 
ration over  the  back  of  the  affected  side  a reason 
for  declining  to  operate  posteriorly,  fox-,  such 
faint  sounds  are  often  conveyed  to  the  ear  when 
the  cavity  is  full  of  fluid.  Let  a minute  scrutiny 
then  be  made  of  the  lateral  and  posterior  aspects 
of  the  chest.  Let  any  bulging  of  intercostal 
spaces  be  looked  for,  as  at  such  a spot  false- 
membranes  are  probably  scanty  or  thin,  and 
let  the  ribs  be  minutely  examined,  in  order  to 
ascertain  that  there  is  room  enough  between 
them  for  the  insertion  of  a finger  into  the  cavity, 
if  this  prove  to  be  needful;  or  that,  in  any  case, 
resection  of  a rib  may,  if  possible,  be  avoided. 
The  axillary  line  should  be  chosen  in  all  cases 
in  which  the  effusion  is  believed  to  be  serous.  If 
it  should  appear  that  the  fluid  is  so  limited  or 
encysted  that  it  does  not  gravitate  to  the  bottom 
of  the  cavity,  a tentative  puncture  must  be  made 
at  the  dullest  spot,  regard  being  had  of  course, 
to  file  position  of  neighbouring  organs.  If  there 
lie  no  indication  to  the  eonti'ary,  we  shall  select 
the  fifth  intercostal  space,  a little  in  front  of 
tie  axillax’y  line,  as  oxxr  point  of  entrance,  or  the 
fourth  space  on  the  right  side. 

The  needle  must  now  be  gently  forced 
through  the  skin,  and  then  shot  with  a sharp 
sudden  thrust  through  the  remaining  tissues  into 
the  cavity,  the  operator  being  careful  to  take 
the  mid  space,  and  tlnxs  to  avoid  the  periosteum 
of  either  rib,  and  the  intercostal  artei'y.  If 
the  skin  be  thick  it  is  well  to  incise  it  with  a 
bistoxiry  before  inserting  the  needle.  There  is 
no  objection  to  freezing  the  skin  beforehand,  bxit 
it  is  rarely  desirable.  If  the  fluid  drawn  be  clearly 
serous,  and  the  patient  be  a child,  or,  the  syringe 
capaeioxxs,  it  may  be  well,  if  time  press  not,  to 
wait  a day  or  two  to  see  whether  this  small 
draught  will  set  up  absorption  of  the  rest. 
Many  sucli  cases  are  on  record.  As  a mile,  how- 
ever, it  will  be  needful  to  proceed  to  a further 
evacuation  of  the  cavity.  Eor  this  a special  in- 
strxxment  will  be  needed. 

We  cannot  enter  into  an  account  of  the  many 
instruments  sold  for  paracentesis  thoracis ; 
almost  any  one  of  them  is  satisfactory.  They 
all  consist  in  a fine  trochar  or  perforated  lance- 
headed  needle,  with  an  exhausting  apparatus 
attached  thereto.1  Pumps  of  various  makes 
are  therefore  adapted  to  the  trocliars,  by  which 
the  pressxire  of  the  atmosphere  or  the  choking 

1 The  hollow  needles  sometimes  xised  have  many 
drawbacks.  They  may  prick  the  long  and  cause  cough 
or  even  let  air  into  the  pleural  cavity,  which,  though  not 
septic,  prevents  expansion  o£  the  lung.  This,  though  not 
the  only  one,  is  a sufficient  objection. 


by  clots  may  he  counteracted.  These  pumps 
are  rather  cumbrous,  and  they  are  liable  to  bo 
worked  at  an  excessive  pressure.  The  best 
exhaust  in  ordinary  cases  is  a column  of  the 
fluid  itself,  which  can  be  made  longer  or  shorter, 
as  the  run  of  the  fluid  seems  to  indicate.  This 
column  is  formed  by  attaching  a long,  fine  india- 
rubber  tube,  at  least  four  feet  long,  to  the  collar 
of  the  trochar,  and  its  length  is  varied  by  eleva- 
tion or  subsidence  of  the  basin  of  water  in  which 
its  distal  end  is  placed.  This  tube  has,  of 
course,  the  action  of  a syphon,  and  by  it  alone, 
in  the  vast  majority  of  cases,  we  can  overcome 
the  resistance  of  the  atmosphei’e.  The  diameter 
of  the  tube  should  be  small,  or  the  fine  cannlas 
now  in  use  for  paracentesis  will  not  feed  it; 
moreover,  the  slower  the  issue  of  the  fluid  the 
better.  It  is  well  to  attach  the  tube  to  a short 
branch  of  the  eanula  issuing  at  a small  angle 
from  the  side  of  the  latter,  and  containing  a 
stopcock;  in  such  an  instrument  the  trochar  worts 
like  a piston  in  the  eanula,  and  can  only  be  with- 
drawn to  a point  immediately  beyond  the  opening 
of  the  lateral  channel.  The  advantage  of  this 
arrangement  is  that  on  stoppage  of  the  eanula 
the  troclxar  can  at  once  be  so  pushed  up  as  to 
clear  it.  If  there  be  no  piston-troclxar  the  eanula 
has  to  be  cleared  by  wires— a fidgety  process, 
and  too  often  inefficient.  It  may  be  better  indeed 
under  such  circumstances  to  close  the  wound  and 
reintroduce  it  elsewhere  ; thus  less  pain  and 
annoyance  is  felt  in  tho  end,  and  a better  result 
obtained.  As  inflammatory  serous  effusions  are 
certainly  liable  to  turn  into  pus  if  septic  elements 
be  admitted  to  them  in  the  smallest  quantity, 
the  instruments  used  must  be  scrupulously  dis- 
infected and  air  excluded.  If  the  distal  end  of 
the  delivery  tube  be  placed  in  water,  and  the 
tube  be  emptied  by  running  tho  finger  down  it, 
any  bubbling  will  almost  certainly  point  to 
wound  of  the  lung.  The  cock  should  be  turned 
when  the  patient  is  quiet  and  at  tlxe  beginning 
of  lxis  expiration.  The  fluid  will  run  at  first  in 
a steady  stream,  afterwards  in  gushes  corre- 
sponding to  the  inspirations.  IVhen  the  fluid 
ceases  to  run,  or  coughing  grows  troublesome, 
the  tube  may  be  withdrawn ; for  if  the  fluid  be 
serous  the  presence  of  a remnant,  or  more  than 
a remnant,  of  the  effusion  in  the  cavity  is  of  no 
disadvantage;  if  it  be  seropurulent  the  cavity 
is  certain  to  refill,  and  if  it  be  laudable  pus  it 
will  in  all  probability  refill.  On  the  other  hand.  1 
when  the  lung  expands  imperfectly,  to  exercise 
strong  suction  upon  the  mediastinum  or  on  the 
abnormally  vascular  pleura  is  to  run  the  risk  of 
doing  barm.  The  patient  must  neither  lie  nor  sit 
erect,  but  a semi-reeumbent  position  should  be 
taken,  with  tho  shoxxlders  raised  upon  pillows. 
If  there  be  any  tendency  to  syncope,  an  erect 
position  will  favour  it,  and  a recumbent  position 
is  unfavourable  to  operation  and  to  escape  of 
fluid.  The  patient  must  be  closely  watched,  and 
the  stopcock  turned  on  the  least  sign  of  faint- 
ness, but,  happily,  this  is  rarely  seen.  Cases 
are  reported  in  which  sudden  death  has  occurred 
during  paracentesis,  or  about  the  time  of  it.  but 
cases  of  sudden  death  are  not  uncommon  in  pleu- 
ritic effusion,  whether  punctured  or  not.  Aa 
anaesthetic  is  scarcely  required  for  simple  para- 
centesis. If  the  edge  of  the  eanula  present  nc 


PLEURA,  DISEASES  OF. 


harsh  ridge  upon  the  trochar  the  stab  is  but  little 

painful. 

It  is  -well,  if  there  be  no  indication  to  the 
contrary,  to  inject  one-fifth  of  a grain  of  morphia 
beneath  the  skin  after  the  operation,  to  relieve 
any  irritation  either  by  cough  or  otherwise,  and 
to  secure  subsequent  rest.  The  stopcock  of  the 
instrument  will,  of  course,  be  shut  when  the 
trochar  is  withdrawn,  and  the  puncture  promptly 
closed  on  withdrawal  by  the  finger.  It  is  well 
to  keep  the  finger  in  apposition  for  a few  minutes, 
and  then  to  apply  a simplo  lint-pad  with  short 
strips  of  plaster.  In  favourable  cases  no  second 
tapping  is  needed,  and  the  heart  tends  to  recover 
its  position  on  the  completion  of  the  operation, 
moving  three  inches  perhaps  in  the  course  of  it; 
in  other  cases,  even  of  serous  effusion,  the  seve- 
rity of  the  pleurisy  may  have  so  fettered  the 
lung  that  the  readjustment  of  the  parts  is  much 
more  gradual,  aud  the  space  of  the  effusion  is 
reoceupied  but  slowly  by  the  unfolding  lung  and 
the  yielding  of  the  chest-wall  and  mediastinum. 
In  this  respect  there  is  not  much  difference 
between  serous  and  purulent  formations,  save, 
of  course,  that  neglected  cases  are  more  likely 
to  have  become  purulent.  A rapid  return 
to  the  normal  of  the  physical  signs  is  a very 
good  omen,  and  in  cases  promptly  dealt  with  is 
now  happily  our  common  experience.  In  cases 
which  recover  more  slowly  we  get  less  help  from 
the  physical  signs,  the  conditions  within  the  chest 
being  in  a more  stable  state  of  perversion.  In 
pletiro-pneumonia  the  lung  may  not  he  able  to 
expand  any  more  in  cases  of  paracentesis  for  the 
pleurisy,  so  that  only  some  ten  ounces  or  so  may 
be  obtainable  by  falling  in  of  the  ribs.  In  two 
cases  in  which  the  present  writer  noted  redupli- 
i cation  of  the  second  cardiac  sound  before  tap- 
ping, this  sign  ceased  at  once  on  the  emptying  of 
the  cavity.  It  is  rather  the  rule  than  the  excep- 
tion for  some  dulness  to  remain  below  the  sca- 
pula, and  this  alone  is  no  indication  for  repeating 
the  operation. 

If  there  be  any  subsequent  pain  or  elevation 
of  temperature,  these,  under  ordinary  circum- 
stances, will  prove  to  he  transient.  If  the  rise 
of  temperature  continue  after  the  first  day  or 
two,  the  formation  of  pus  is  to  be  feared.  The 
formation  of  pus,  moreover,  is  net  infrequently 
utended  with  a re-awakening  of  pain.  If  pus 
form,  the  cavity  in  all  likelihood  will  soon  refill, 
md  pus  will  be  detected  on  puncture.  It  is 
desirable,  however,  to  draw  oft'  a considerable 
[uantity  of  a purulent  effusion  by  ordinary  tap- 
ring  before  proceeding  to  any  further  operation, 
jis  in  this  way  any  danger  due  to  the  sudden 
■mptying  of  the  whole  cavity  b.v  the  radical 
■peration  is  avoided.  Soon  after,  or  in  one  or  two 
ays,  according  to  the  state  of  the  patient,  an 
pening  must  he  made  sufficiently  large  to  per- 
j lit  of  the  introduction  of  a sound.  By  means 
f the  sound  the  extent  and  depth  of  the  cavity 
,rill  he  gauged,  and  the  sound  being  directed  to 
ie  lowest  point  iu  the  axillary  or  infra-scapular 
ue  an  opening  must  be  made  upon  it  into  the 
ivity,  through  which  the  latter  will  be  drained 
) the  last  drop.  It  is  impossible  to  take  too 
iuch  pains  to  secure  the  perfect  freedom  of  this 
pening,  or  to  place  it  at  the  lowest  point  in  the 
»vity.  For  this  reason  it  is  desirable  to  give 


1223 

an  anaesthetic,  that  the  operation  may-  be  de 
liberately  performed.  Chloroform  seems  to  put 
less  strain  upon  the  limited  breathing  powers 
than  ether  in  these  cases.  If  the  patient  be  ol 
spare  body,  let  the  opening  be  taken  below  the 
spine  of  the  scapula  ; if  stout  and  muscular,  a 
more  lateral  operation  will  probably  be  pre- 
ferred, though  drainage  is  more  continuous  aud 
thorough  by  a posterior  opening,  and  the  ribs  are 
there  less  liable  to  fall  together.  After  the  pus 
has  run  out,  the  upper  opening  may  be  closed  in 
the  usual  way.  On  no  account  let  a drainage- 
tube  be  run  through  both  openings,  or  it  will 
act  as  a seton. 

It  is  of  the  greatest  possible  importance  that 
all  the  instruments  in  use  be  disinfected,  and  it 
is  desirable,  if  possible,  to  do  the  whole  operation 
and  dressings  by  the  antiseptic  method;  and  this 
is  to  be  followed  up  by  dressing  under  the  spray. 
From  the  time  of  the  operation,  it  has  been 
stated,  the  temperature  will  fall  rapidly  to  the 
Dormal ; if  it  rise  again  during  convalescence 
the  rise  will  be  almost  surely  due  to  occlusion 
of  the  opening.  To  prevent  this  we  insert 
a drainage-tube.  False-membranes  as  thick  as 
wash-leather  may  oppose  themselves  at  first,  aud 
the  tube  therefore,  at  first,  should  be  propor- 
tionately large  ; but  these  soon  break  down  into 
curdy  shreds,  and  the  tube  may  be  reduced  in 
diameter,  and  must  be  gradually  cut  away,  as 
secretion  of  pus  diminishes.  Injections  of  a 
simple  or  antiseptic  character,  into  the  cavity 
of  empyema,  are  in  the  writer’s  opinion  to  be 
avoided.  They  are  rarely  of  use,  they  often 
increase  irritation,  and  are  sometimes  attended 
with  distressing  or  alarming  general  symptoms. 
Tho  great  secret  is  to  secure  free  and  complete 
drainage  ; if  this  be  attained  the  cavity  will 
purify  itself.  This  is  as  true  of  closing  cavities 
as  of  freshly -opened  cavities;  for  to  inject 
sinuses,  in  the  hope  of  procuring  adhesion 
and  closure,  rarely  succeeds  and  often  does 
harm.  In  like  manner  to  probe  the  opening 
of  an  empyema  is  generally  a mistake.  If  the 
opening  discharge  for  a long  period,  it  may  be 
well  once  for  all  to  ascertain  the  length  and 
direction  of  the  sinus,  but  it  is  better  to  enlarge 
the  opening  if  necessary,  or  even  to  make  another, 
than  to  fret  tho  part  by  repeated  explorations. 
Resection  of  a portion  of  a rib  has  been  recom- 
mended by  some  surgeons,  even  as  a part  of  the 
ordinary  operation.  If  a neglected  empyema  have 
shrunk  or  discharged  spontaneously,  or  if,  after 
opening,  the  continuance  of  the  discharge  seem  to 
depend  on  rigidity  of  the  chest-wall  and  arrest 
of  lung,  then  resection  of  a considerable  portion 
of  two  or  three  ribs  may  carefully  be  considered. 
In  this  way  closure  of  the  cavity  may  be  obtained, 
the  spine  and  shoulders  becoming  distorted ; but 
such  cases  will  become  very  rare  as  diagnosis 
and  early  operative  relief  are  more  generally 
understood. 

Id  the  exudations  of  tuberculous  or  carcino- 
matous disease,  operation  is  often  more  than 
justified  by  the  temporary  relief  given  to  the 
sufferer.  If  after  the  removal  of  a collection 
of  pus  and  the  establishment  of  free  drainage  the 
discharge  becomes  more  offensive  and  the  fever 
remains,  the  disease  is  probably  tubercular  ar.d 
the  forecast  of  the  worst. 


PLEURA,  DISEASES  OF. 


122 1 

Sometimes  empyemas  havo  been  treated  by 
repeated  aspirations,  instead  of  by  incision  and 
continuous  drainage.  It  is  hopeless  to  attempt 
the  cure  of  a aero-purulent  discharge  by  this 
method,  but  a collection  of  laudable  pus  once 
removed  by  the  aspirator  has  in  rare  cases  failed 
to  return.  The  chance  of  success  by  this  method 
is  too  slight  to  be  looked  for  with  any  confidence, 
and  the  repetition  of  these  aspirations  does  not 
prevent  the  gradual  condensation  of  the  lung, 
nor  the  formation  of  a pulmonary  fistula.  There 
is  no  difference  in  method  between  the  perfor- 
mances of  these  operations  in  childhood  and  in 
age,  but  in  childhood  recovery  is  generally  more 
rapid  and  sure.  Nor  is  there  any  difference  of 
method  in  operating  upon  a case  in  which  a 
pulmonary  or  other  ill-placed  fistula  has  already 
formed,  nor  is  the  performance  of  the  operation 
much  the  less  urgent  in  such  cases,  even  if  the 
bronchial  opening  be  free  and  not  valvular. 

It  is  desirable  that  after  each  cr  any  removal 
of  fluid  from  the  chest  the  re-expansion  be  as- 
sisted by  respiratory  gymnastics.  The  best 
method  of  obtaining  this  end  is  by  graduated 
exercise ; by  the  inhalation  of  compressed  air 
from  one  of  the  apparatus  constructed  for  this 
purpose  ; or  by  residence  at  high  elevations. 

Means  have  been  proposed  by  which  the  en- 
trance of  air  into  an  empyematous  cavity  under 
drainage  might  he  prevented,  and  the  lung  thus 
helped  to  expand  under  inspiration.  The  per- 
manent need  of  absolute  freedom  in  draining  and 
dressing,  however,  must  discourage  the  use  of 
all  complex  apparatus,  and  if  the  operation  be 
performed  early  and  antiseptically  it  is  marvel- 
lous how  well  the  lung  will  recover  itself. 

3.  Pleura.  Air  in. — Synon.  : Pneumothorax; 
Er.  Pneumothorax ; C-er.  Luf thrust. 

Definition. — Pneumothorax,  as  its  name  im- 
ports, is  the  state  in  which  the  pleural  cavity, 
normally'  vacuous,  or  rather  non-existent  as  a 
space,  contains  air  or  other  gas  without  inter- 
mixture of  liquid.  If  air  or  gas  be  present, 
together  with  pus,  blood,  or  a watery  fluid,  we 
give  to  the  resulting  state  the  compound  names 
Pi/o  pneumothorax,  H&matopneumothorax,  and 
Hi/drapneumothorax  respectively.  The  gaseous 
contents  in  these  eases  may  precede  the  entry  of 
the  fluid  or  succeed  it,  and  in  the  latter  case  it 
may  perhaps  be  developed  as  a product  of  decom- 
position. These  conditions,  though  not  wholly 
unknown  to  the  predecessors  of  Laennec,  never- 
theless were  first  adequately  distinguished  and 
clinically  demonstrated  by  him. 

JEtiologv. — Pneumothorax  is  a commoner 
event  than  would  be  supposed,  were  we  to 
confine  our  attention  to  the  cases  which  have 
received  this  name.  It  is  often  an  incident  in 
the  course  of  other  diseases,  and  of  none  more 
often  than  phthisis.  Pneumothorax  sometimes, 
but  rarely,  appears  as  a primary  event  and  dis- 
appears again  without  further  complication ; 
more  usually  it  occurs  as  one  result  of  wounds 
of  the  chest,  of  purulent  pleuritis,  of  phthisis, 
or  of  some  rarer  disease,  such  as  ulceration  of 
the  oesophagus  or  stomach,  carcinoma  and  the 
like,  which  effects  an  opening  into  the  cavity. 
If  air  be  mechanically  admitted  to  the  cavity, 
lecomposition  of  its  contents  may  add  to  the 
volume  of  that  which  was  admitted.  Even  in 


those  few  cases  in  which  pneumothorax  seems 
‘ idiopathic  ’ — in  which,  that  is,  we  find  pneumo- 
thorax to  be  the  first,  the  sole,  and  the  last 
morbid  state — we  are  almost  bound  to  assume 
that  this  state  is,  in  fact,  secondary,  and  due  to 
some  perforation  the  cause  and  place  of  which 
escape  our  search.  That  such  cases  do  occur  is 
unquestionable;  the  most  frequent  cause  being  a 
strain,  noticed  or  unnoticed  at  the  moment.  Id 
passing  to  the  cases  of  more  obvious  causation, 
those  due  to  wounds  of  the  chest  are  the  first  to 
meet  us,  and  need  not  detain  us.  That  any  wound 
perforating  the  wall  of  the  chest  and  the  pleura 
will  permit  air  to  be  drawn  by  suction  into  the 
pleural  cavity  is  obvious. 

Of  the  same  kind,  but  of  natural  origin,  is 
the  pneumothorax  which  in  empyema  follows 
perforation  of  the  lung  with  ejection  of  the  pus 
upwards,  or  perforation  of  the  chest-wall  by 
natural  ulceration  outwards.  In  these  cases  of 
pyopneumothorax  we  have  to  deal,  of  course, 
with  the  presence  both  of  pus  and  of  air  in  the 
pleura.  Pneumothorax,  though  occurring  but 
in  a minority  even  of  the  ulcerative  cases  of 
phthisis,  yet  is  frequently  met  with  as  a com- 
plication. It  occurs  for  the  most  part  in  the 
later  stages  of  the  disease,  and  often  escapes 
observation  ; less  frequently  it  is  met  with  in 
the  earlier  stages,  and  is  then  betrayed  at  once 
by  its  symptoms.  Its  occurrence  may  be  aided 
or  not  by  such  a strain  as  a fit  of  coughing. 
That  pneumothorax  is  not  a more  uniform  result 
of  ulcerative  processes  in  the  lung  is  due,  of 
course,  to  the  anticipation  of  a breach  of  surface 
by  previous  adhesive  inflammation.  Iu  phthisis, 
happily,  the  perforation  as  a rule  is  minute, 
and.  the  quantity  of  matter  escaping  into  the 
cavity  small — so  small  as  to  he  generally  in- 
adequate to  produce  the  physical  signs  of  fluid 
contents.  In  other  cases  the  escape  is  more 
abundant,  or  a more  abundant  effusion  comes 
from  the  pleura  itself,  as  a consequence  of  the 
resulting  irritation.  We  then  have  to  deal  with 
an  obvious  hydropneumethorax,  or  pyopneumo- 
thorax. The  opening  by  which  air  escapes  into 
the  pleural  cavity  may  be,  and  often  is,  valvular, 
so  that  its  entry  during  inspiration  may  not 
he  balanced  by  its  exit.  In  this  way  air  may 
accumulate  under  pressure.  If,  as  in  empyema, 
the  lung  be  already  collapsed,  this  pressure  is 
the  less  distressing;  if  the  lung  be  wholly 
or  in  part  open,  the  pressure  adds  to  the  de- 
gree of  the  sudden  embarrassment  due  to  rapid 
collapse  of  lung,  and  to  encroachment  upon 
the  surrounding  parts,  including  the  opposite 
lung.  Air  thus  entering  the  pleural  cavity  is 
often  purified  from  septic  elements  by  its  filtra- 
tion through  the  lung,  unless  it  pass  through 
cavities  and  alveoli  already  charged  with  septic 
matters.  In  puncturing  the  chest-wall  with  a 
fine  troehar,  in  cases  of  serous  efiusion,  the  lung 
is  sometimes  wounded,  and  air  escapes  into  the 
pleura.  The  accident  is  an  untoward  one ; but 
the  air  which  thus  escapes  into  the  pleura  is  so 
cleansed  by  its  passage  through  a healthy  lung 
that,  as  a rule,  it  sets  up  no  putrefaction,  SEd 
is  itself  quickly  absorbed.  The  puncture  heals 
too  rapidly  to  permit  of  any  continuous  transpi- 
ration, but  the  quantity  suddenly  admitted  mav 
add  a good  deal  to  the  suffocative  distress  of  the 


PLEURA,  DISEASES  OF. 


patient  A similar  state  of  things  is  not  uncom- 
monly seen  in  the  practice  of  the  surgeon,  when 
an  injury  which  breaks  a rib  also  drives  its 
broken  point  or  points  through  the  costal  and 
pulmonary  pleurae. 

It  is  said  that  in  emphysema  the  bursting  of 
dilated  lobules  may  set  up  pneumothorax,  and 
we  may  wonder  that  this  event  should  be  so 
rare.  Perforation  into  the  pleural  cavity  by 
cancerous  or  other  destructive  changes,  either 
in  the  lung  itself  or  such  neighbouring  organs 
as  the  cesophagus,  the  stomach,  the  bowel  or 
connected  ducts,  is  not  very  rare  in  cases  of 
malignant  disease ; and  the  entry  of  air  and  food 
into  the  pleura  sets  up  suffocative  and  inflam- 
matory symptoms,  which  add  greatly  to  the 
miseries  of  the  last  days  of  life.  There  are,  no 
doubt,  other  ways  of  disease  by  which  air  may 
find  its  way  into  the  pleural  cavity ; but  the 
above  description,  with  little  or  no  essential 
difference,  will  apply  to  all. 

Anatomical  Chabactebs. — Under  this  head 
we  have  little  to  say  in  respect  of  pneumo- 
thorax, and  we  have  not  here  to  deal  with  the 
further  appearances  of  hydrothorax  or  em- 
pyema. A patient  would  rarely  die  of  simple 
pneumothorax ; for  if  death  be  mainly  due  to 
this,  yet  unless  it  occurred  within  the  first  few 
days  it  is  probable  that  some  degree  of  in- 
flammation would  follow  the  disturbance.  In 
the  vast  majority  of  cases,  of  course,  the  pneumo- 
thorax is  secondary  to  some  other  disease,  and 
any  fluid  or  other  products  found  with  tho  air 
in  the  chest  may  be  due — not  to  the  mere  ad- 
mission of  septic  air  into  the  cavity,  but  to  the 
admission  of  decomposing  tissue-elements  into 
it.  As  concerns  the  presence  of  air  alone,  wo 
have  only  to  say  that  in  most  eases — espe- 
cially in  the  eases  in  which  air  has  reached  the 
pleura  by  a valvular  opening — the  affected  side 
of  the  chest  may  be  visibly  distended.  In  such 
a chest  the  pressure  of  the  contained  air  may 
well  have  been  not  passive  only  but  active, 
nnd  on  puncture  the  imprisoned  air  may  escape 
with  a hissing  noise  ; if  the  lung  be  wholly 
retracted,  and  the  air  contained  under  high 
pressure,  the  out-rush  may  be  very  strong — 
strong  enough  to  blow  out  a candle.  This  air 
is  usually  deoxidised,  and  rich  in  carbonic  acid  ; 
if  there  be  decomposing  matters  in  the  cavity,  it 
is  likely  also  to  contain  sulphuretted  hydrogen. 
Neighbouring  parts  will  be  found  more  or  less 
iislocated  directly  as  the  degree  of  compression 
of  the  contained  air,  and  inversely  as  the  amount 
ff  adhesion  limiting  its  extent.  Bilateral  pneu- 
'nothorax  is,  of  course,  incompatible  with  life  ; 
f it  be  found  double  we  may  be  sure  that  one 
fide  of  it  came  on  at  the  moment  of  death. 

Symptoms. — The  symptoms  of  pneumothorax 
ire  of  course  the  more  distinct,  the  less  the  symp- 
toms of  the  primary  malady.  In  those  rare  cases 
n which  pneumothorax  comes  on  apparently  as 
i primary  disease — that  is,  in  which  the  mode 
if  entrance  of  air  into  the  pleural  cavity  is 
dost  obscure — we  find  the  chief  symptoms  to 
ie  dyspnoea  and  a sense  of  faintness,  pain  being 

less  uniform  symptom,  and  present  only  when 
he  entrance  of  air  is  followed  by  irritation  and 
uflammation  from  the  fluid  or  solid  matters  which 
ecompany  the  gaseous.  Aseptic  air  alone  does 


122A 

not  set  up  inflammation,  nor  much  irritation. 
Fever,  in  like  manner,  depends  not  upon  the  en- 
trance of  air,  but  of  the  irritating  matters  accom- 
panying the  air,  and  exciting  inflammation.  It 
may,  like  the  pain,  be  considerable;  it  may  not  be 
present  at  all ; or,  again,  it  may  be  lost  in  the 
fever  of  the  primary’  malady,  or  show  itself  as  a 
slight  exacerbation  of  that  fever.  The  dyspnoea, 
in  part  mechanical,  in  part  probably  reflex,  is 
necessarily  attended  by  increase  of  pulse-rate  ; 
the  two  events  being  but  different  aspects  of  th9 
same  machinery.  The  degree  of  these  accele- 
rations, as  has  been  hinted,  depends  upon  the 
amount  of  previous  accommodation  in  the  chest, 
and  upon  the  amount,  if  any,  of  fluid  and  solid 
concurring  with  the  gaseous  escape.  The  escape 
of  air  with  irritating  matters  suddenly  into  the 
pleural  cavity  of  a person  suffering  but  little 
from  a phthisical  ulceration,  or  of  one  surprised 
by  an  accident  in  the  midst  of  health,  will  cause 
dyspnoea  almost  suffocative  in  degree,  faintness, 
great  acceleration  of  the  pulse,  and  intense  pain. 
If  the  affair  be  more  serious  there  may  also 
be  symptoms  of  collapse,  including  a fall  of 
temperature,  cold  extremities,  ashen  face,  colli- 
quative sweats  and  chill  breath.  On  the  other 
hand,  in  pneumothorax  occurring  towards  the 
end  of  phtliisis,  when  a pulmonary  ulcer  breaks 
into  the  pleura  widely-adherent  about  a lung 
already  half-obliterated,  an  attack  of  chest- 
pain  may  follow  a bad  fit  of  coughing,  and  be 
often  put  down,  like  the  dyspnoea  and  the  pulse- 
rate,  to  the  fatigues  and  distress  of  a restless 
night.  The  patient’s  general  condition  is  not 
very  markedly  altered  in  such  cases,  and  the 
pneumothorax  is  often  overlooked.  Cough  and 
expectoration  of  course  assume  no  proportions 
in  simple  pneumothorax  ; but  if  pneumothorax 
be  established  on  the  bursting  of  an  empyem3 
into  a bronchus,  it  is  obvious  that  cough  and 
expectoration  will  be  the  most  prominent  of  the 
symptoms.  It  is  well  to  remind  the  reader  that 
emphysema  of  the  skin  may  result  from  the  same 
breach  which  causes  the  pneumothorax. 

Th  & physical  signs  are  as  follows ; — The  affected 
side,  in  well-marked  cases,  may  be  enlarged  in 
girth  and  of  a rounder  form.  It  is,  moreover, 
still  in  respiration,  the  half  of  the  chest  being 
fixed  in  the  inspiratory’  position,  or  only  dragged 
a little  by  the  efforts  of  the  accessory  muscles. 
Air,  like  fluid,  may  press  down  the  diaphragm, 
thrust  the  mediastinum  aside,  and  change  the 
place  of  the  heart.  And  even  if  the  admission  of 
air  be  not  through  a valvular  opening,  and  the 
admitted  air  be  passive,  yet.  as  Dr.  Douglas  Powell 
has  shown,  the  elasticity  of  the  opposite  lung 
will  dislocate  the  parts  to  some  extent.  In  other 
cases,  as  in  pyopneumothorax  with  retraction, 
the  affected  side  often  falls  in  so  as  to  be  of  less 
girth  than  the  sound  side.  In  such  a case,  of 
course,  there  is  no  tension  of  the  contained  air. 
Vocal  fremitus  must  be  absent  if  the  lung  be 
wholly  collapsed,  or  far  removed  from  the  wall 
of  the  chest ; if  the  lung  be  adherent  in  part 
to  the  chest-wall,  vocal  fremitus  may  be  pro- 
portionally perceptible,  and  it  may  be  possible 
to  ascertain  by  other  methods  how  far,  if  at  all, 
the  lung  is  adherent.  Decubitus  is  usually  on 
the  affected  side. 

Percussion  gives  us  great  assistance  in  the 


PLEURA,  DISEASES  OF. 


1226 

detection  of  pneumothorax,  the  sound  being 
tympanitic  everywhere  where  lung  is  not,  by  ad- 
hesion or  repression,  kept  in  contact  with  the 
chest-wall,  and  often  extending  beyond  the  nor- 
mal boundaries  of  the  affected  side.  There  is 
something  about  the  loud,  low-pitched  and  exten- 
sive (tympanitic)  vibrations  of  the  stricken  chest 
in  pneumothorax  which  is  very  characteristic. 
On  the  other  hand,  it  is  said  that  if  the  pleura 
be  tightly  distended  by  air  under  high  pressure 
the  percussion  note  may  rise  to  positive  dulness, 
and  the  presence  of  fluid  will  dull  the  percussion 
considerably  or  altogether,  in  districts  which 
will  vary  with  the  quantity  of  fluid  and  the 
position  of  the  patient.  Iu  pyopneumothorax, 
with  a bronchial  fistula,  the  sharp  line  between 
hyper-resonance  and  dulness  may  be  changed 
after  a profuse  expectoration.  By  percussion 
with  palpation  the  dislocation  of  neighbouring 
parts  and  organs  may  be  ascertained.  The  auscul- 
tatory phenomena  of  pneumothorax  are  curious, 
and  were  known  even  to  Hippocrates.  If  we 
confine  ourselves  to  pneumothorax  pure  and 
simple,  auscultation  is  generally  almost  negative ; 
in  rare  cases  we  may  detect  by  a blowing  sound 
the  entrance  and  exit  of  air  by  a free  opening,  but 
in  such  cases  fluid  is  always  present  as  well.  In 
them  there  may  be  faint  amphoric  breathing 
and  a few  resonant  rales , especially  near  the 
shoulder-blade.  The  voice  sounds  in  like  manner; 
and  the  cough  may  be  more  or  less  amphoric. 
Vesicular  breathing  is  never  heard.  In  pneumo- 
thorax, there  is  often  present  the  peculiar  pheno- 
menon called  the  metallic  ring.  After  death  this 
metallic  echo  is  always  to  be  obtained,  but  during 
life  the  increased  tension  of  the  gas  at  the  higher 
temperature  may  prevent  it.  In  addition  to  this 
a very  clear  cracked-pot  sound  may  be  heard  in 
some  cases  of  pyopneumothorax  wdth  a wide 
fistula.  The  metallic  tinkle  of  succussion,  which 
was  known  to  Hippocrates,  consists  in  the 
echo  of  splashing  or  dripping  fluid  in  the  air- 
containing  pleural  cavity ; and  indeed  other 
sounds  generated  inside  the  patient,  such  as  the 
heart-beat,  cough,  &c.,  may  take  this  metallic 
resonance  from  the  chest-cavity, and  may  betray 
pneumothorax  or  illustrate  it.  In  the  same  case, 
at  different  times,  such  sounds  may  be  heard,  or 
may  be  inaudible — changes  which  are,  perhaps, 
due  either  to  mechanical  conditions  dependent, 
upon  adhesions,  the  formation  of  false-mem- 
branes,  the  shape  of  the  cavity,  or  the  tension 
of  the  contained  gases.  See  Physical  Exa- 
mination. 

Diagnosis. — The  diagnosis  of  pneumothorax 
by  the  signs  and  symptoms  above  named  is  not 
difficult,  if  the  occurrence  of  it  be  sudden  and 
the  patient  not  too  ill  to  resent  examination.  If 
the.  presence  of  adhesions  prevent  the  develop- 
ment of  these  symptoms,  the  case  may  be  more 
obscure,  but  by  so  much  the  less  serious.  As,  on 
the  one  hand,  in  an  enormous  moist  cavity  it  is 
conceivable  that  metallic  and  succussion  sounds 
may  bo  heard,  so,  on  the  other  hand,  pyopneumo- 
thorax, restricted  by  adhesions  to  small  dimen- 
sions, might  simulate  a cavity.  Indeed,  diag- 
nosis might  be  impossible  in  such  cases,  but 
speaking  generally,  the  dulness  and  retraction 
of  the  chest-wall  over  a cavity  would  assist  the 
diagnosis.  Distension  of  the  stomach,  wnth  ele- 


vation of  the  diaphragm,  or  diaphragmatic  her- 
nia, could  scarcely  be  mistaken  for  pneumothorax 
by  anyone  who  fairly  took  into  consideration  all 
the  facts  and  history  of  the  case.  As  empy- 
ema, especially  in  children,  is  liable  to  lead  to 
purulent  pericarditis,  so  may  pyopneumothorax 
by  perforative  process  have  pyopneumopericar- 
dium  added  to  it.  Emphysema  of  the  lungs 
gives  rise  to  tympany  sometimes  as  great  as  of 
pneumothorax.  Emphysema,  however,  is  always 
two-sided,  and  rarely  dissociated  from  sibilns 
or  other  sign  of  open  bronchial  tubes.  In  eases 
of  pyo-  or  sero-pneumothorax  there  may  be  great 
difficulty  in  determining  the  quantities  of  fluid 
and  of  gas  respectively  in  the  cavity ; as  much  as 
three  quarts  of  fluid  may  co-exist  with  a great 
deal  of  resonance  above  it.  Tapping  alone  could 
decide  the  matter,  and  in  such  a case  would  pro- 
bably be  indicated. 

Prognosis. — This  obviously  depends  so  largely 
upon  the  causes  and  concomitants  of  the  pneumo- 
thorax, that  any  general  estimate  of  it  is  impos- 
sible. The  tendency  of  air  in  the  pleura  is  to 
absorption.  The  prognosis  of  chest-wounds,  o: 
phthisis,  of  empyema,  contains  differences  too 
wide  for  formulation.  It  is  asserted  that  pneumo- 
thorax, by  the  sudden  oppression  of  the  lung, 
through  the  in-rushing  air,  may  causo  rapid  and 
even  sudden  death. 

Treatment. — The  treatment  of  pneumothorax 
in  like  manner  must  depend  greatly  upon  the 
nature  of  the  primary  malady.  In  pyopneu- 
mothorax from  empyema  operation  is  the  first 
necessity  in  a patient  of  sound  constitution. 
Whether  in  any  given  case  of  phthisis  pyopneu- 
mothorax should  be  dealt  with  by  operation 
may  become  a question — but  a question  usually, 
of  course,  to  be  decided  in  the  negative.  In 
such  cases  opiates  alone  are  our  resource.  Still, 
a case  may  be  imagined  in  which  the  urgency  of 
operation  may  outweigh  its  risks.  In  wounds 
of  the  chest-wall,  or  of  the  pulmonary  pleura, 
the  puncture  rarely  closes  so  soon  as  to  imprison 
the  air  in  a state  of  higher  tension  than  the  at- 
mosphere. Such  a thing  may  occur,  however, 
and  the  displacement  of  organs  and  respiratory 
distress  may  indicate  that  relief  is  urgently 
needed.  If  it  be,  a fine  trochar  may  be  inserted 
into  the  chest,  and  by  means  of  a tube  air  may 
be  permitted  to  escape  through  water  until  equi- 
librium is  re-established.  The  hypodermic  use 
of  morphia  is  as  valuable  in  soothing  the  pain 
and  distress  of  pneumothorax  as  of  like  suffering 
elsewhere.  Walshe  recommends  general  bleed- 
ing, if  admissible,  or  in  any  case  free  dry-cup- 
ping of  the  affected  side.  Among  drugs  he 
chiefly  recommends  musk,  in  five-grain  doses, 
and  very  small  inhalations  of  chloroform. 

4.  Pleura,  Dropsy  of. — Stnon.  : Hydrotho- 
rax ; Fr.  HydrotJwrax ; Gcr.  Bmstwasscrsucht. 

Definition. — As  the  word  implies,  this  is  the 
term  given  to  simple  aqueous  effusions  into  the 
thoracic  cavity. 

Description. — Hydrothorax  is  not  to  be 
classed  with  the  effects  of  inflammation,  but  with 
dropsies  elsewhere,  and  is  the  companion  in  many 
cases  of  ascites  and  anasarca.  In  other  cases  it 
exists  alone,  hot  is  rarely  confined  to  one  side  of 
the  thorax,  and  perhaps  never  exists  as  a sole 
malady.  We  may  say  generally  that  it  is  liable 


PLEURA,  DISEASES  OF. 
to  arise  under  the  following  circumstances : — 
when  the  whole  circulation  is  so  impeded  that 
venous  pressure  is  increased — as,  for  instance,  in 
disease  of  the  mitral  valve  or  its  orifice ; when 
venous  arrest  is  due  to  some  local  causes,  as  for 
instance,  to  the  pressure  of  localised  swellings 
upon  reins,  or  to  venous  thrombosis  ; when  the 
bronchial  glands  are  enlarged  ; when  in  renal 
disease  the  removal  of  water  from  the  sjstem 
is  checked;  or,  finally,  when  the  quality  of  the 
whole  blood  is  so  deteriorated'  by  disease,  or 
the  circulation  is  so  changed  by  cold,  or  other 
such  general  influence,  that  its  serum  tends  to 
exude  passively  from  the  vessels.  In  the  first 
and  third  cases  we  should  expect  to  find  dropsy 
in  both  pleural  cavities,  in  the  second  case  the 
transudation  might  be  limited  to  one  of  them. 
On  the  other  hand  it  is  to  be  remarked  that 
such  transudations  rarely  stand  at  the  same 
height  in  the  two  cavities,  and  indeed  the 
contents  of  one  of  them  is  often  so  small  in 
volume  that  the  hydrothorax  may  seem  to  be 
unilateral.  As  a matter  of  experience  hydro- 
thorax  is  chiefly  seen  in  diseases  of  the  heart 
and  kidneys,  in  scarlet  fever,  in  septic  and  ether 
diseases  of  the  blood,  and  in  the  cancerous  and 
other  cachexias,  whether  there  be  local  disease 
of  the  pleura  or  not. 

Diagnosis.— The  diagnosis  of  hydrothorax  and 
its  measure  are  easy,  except  in  a few  cases  where 
the  effusions  are  restrained  by  adhesions.  The 
luDg  floats  more  readily  than  in  pleuritic  effu- 
sion, and  the  diaphragm  often  retains  its  normal 
relations. 

Treatment. — Hydrothorax  in  the  majority  or 
cases  is  not  formidable  in  itself,  and  (being  not 
uncommonly  an  event  of  the  last  days  of  life)  is 
perhaps  only  noticed  at  the  autopsy.  Diuretics 
and  hydragogue  purgatives  act  more  readily  in 
hydrothorax  than  in  inflammatory  serous  effu- 
'sions.  Still,  if  it  increase  so  far  as  to  harass  the 
breathing  or  to  add  to  the  dangers  of  the  disease, 
'the  fluid  may  be  drawn  away  by  a fine  trochar 
without  any  fear  of  purulent  change.  It  is  well, 
however,  to  prevent  the  entrance  of  air  into  the 
chest,  lest  the  fluid  have  in  any  degree  an  in- 
flammatory nature,  as  it  may  well  have  in 
scarlatina  or  nephritis,  for  instance.  The  opera- 
tion may  be  repeated  a great  number  of  times  if 
re-accumulations  make  it  necessary.  The  fluid, 
if  wholly  non-inflammatory,  will  appear  as  a 
‘.greenish  or  yellowish  transparent  water,  con- 
fining no  clots  nor  coagulating  in  the  vessel ; it 
will  not  contain  corpuscular  elements.  The  pre- 
sence of  a corpuscular  precipitate,  or  any  troub- 
ling of  the  fluid,  will  at  once  suggest  a degree  of 
pleuritis.  In  heart-disease  with  much  venous 
stasis  the  effusion  is  not  rarely  tinged  with 
flood.  If  there  be  coagulation,  however,  the 
ift’usion  is  probably  inflammatory. 

5.  Pleura,  Haemorrhage  into. — Synox.  : 
Hemothorax. — Bloodstained  effusions  may  occur, 
ns  we  have  said,  even  in  simple  pleurisy,  but 
nore  commonly  in  such  conditions  as  scurvy, 
ubercle,  cancers,  and  the  like.  A purely  san- 
guineous effusion  is  generally  the  result  of 
founds  of  the  chest  or  its  viscera  ; but  it  may 
Iso  arise  from  within,  as  from  rupture  of  the 
leart  or  of  an  aneurism,  or  from  a bleeding 
aocer.  The  means  of  examination  or  treat- 


PLEURO-PNEUMONIA.  1227 

ment  of  such  cases,  in  so  far  as  these  are 
possible,  may  be  gathered  from  the  preceding 
sections.  Haemorrhage  into  the  pleura  from  di- 
rect extravasation  may  be  left  awhile,  on  the 
chance  of  reabsorption.  If  this  does  not  seem 
on  the  way,  a tentative  puncture  may  be  made. 
If  the  issue  be  ichorous,  the  patient  will  pro- 
bably become  febrile,  and  the  major  operation 
be  needed  sooner  or  later. 

G.  Pleura,  Morbid  Growths  in.  — The 
pleura  enjoys  no  complete  freedom  from  the  inva- 
sion of  sarcomatous  or  carcinomatous  growths  ; 
but  the  former  class  of  growths  are  very  rare,  ex- 
cept as  intrusions  from  neighbouring  parts.  Can- 
cer is  found  less  rarely.  The  frequency  of  mam- 
mary cancer  and  the  neighbourhood  of  the  pleura 
to  the  breasts  increases  the  danger  of  secondary 
mischief  in  the  former  part.  Pleural  mischief 
is,  indeed,  a common  consequence  of  mammary 
cancer,  and  may  be  the  fatal  conclusion  of  a 
case.  It  occurs  after  or  before  operations  of  ex- 
cision. From  the  cancer  in  the  wall  of  the  chest 
simple  inflammation  often  extends  to  the  pleura, 
and  produces  the  usual  results.  In  other  cases 
the  cancerous  growth  is  itself  propagated  to  the 
costal  pleura,  and  spreads  from  thence.  The 
cancer  is  usually  seen  in  the  form  of  small 
flattened  or  rounded  elevations,  rich  in  blood- 
vessels. If  septic  matters  escape  into  the 
pleural  cavity  its  effusions  may  soon  become 
putrid.  It  is  said  that  a rapid  degeneration  of 
cells,  either  cancerous  or  tubercular,  may  give 
rise  to  a quantity  of  fat-droplets  so  great  that  a 
layer  of  fat  may  be  seen  to  stand  on  the  top  of 
the  serosity  withdrawn  by  tapping.  Blood,  too, 
easily  issues  from  highly  vascular  formations — 
whether  cancerous,  tubercular,  or  simply  inflam- 
matory; and  may  be  seen  in  the  fluids  after 
withdrawal. 

There  is  little  to  be  said  of  the  symptoms  and 
signs  of  such  cases  that  has  not  been  said  already 
under  the  more  general  heads  of  Lungs,  Morbid 
Growths  in  ; Mediastinum,  Diseases  of  ; and 
Pleurisy.  The  diagnosis  of  cancerous  or  other 
such  masses  from  their  own  effusions  or  from 
simple  effusions,  let  it  be  frankly  repeated,  is 
sometimes  impossible  without  the  needle.  The 
prognosis  in  such  cases  will  not  depend  upon  the 
pleuritic  changes  alone  ; and  the  only  remark  to 
be  made  on  their  treatment  is  that  paracentesis, 
in  the  secondary  effusions,  is  not  wholly  to  be 
declined.  Some  such  patients  have  obtained 
from  repeated  puncture  not  only  a prolongation 
of  life,  but  also  great  relief  of  suffering. 

T.  Clifford  Allbctt. 

PLEITBODYNIA  (irAeupa,  the  side,  and 
oSvvtj,  pain).- — Synox.  : Intercostal  myalgia; 

Fr.  Pleurodynia;  Ger.  Seitenschmerz. — A name 
for  muscular  rheumatism  or  cramp  affecting  the 
chest-wall.  See  Cramp  ; and  Rheumatism,  Mus- 
cular. 

PLEUEO-PUEUMOmA.  — This  com- 
pound word  signifies  a combination  of  inflamma- 
tion of  the  pleura  and  of  the  lung  itself.  In  all 
cases  of  acute  pneumonia  there  is  a certain  de- 
gree of  pleurisy  corresponding  to  the  inflamed 
lung;  but  it  is  of  little  or  no  practical  significance, 
there  being  only  some  exudation  on  the  pleural 
surfaces.  Pleuro-pneumonia  implies  that  the 


1228  PLEURO-PNEUMONIA. 
two  morbid  conditions  are  actually  associated  in 
various  degrees,  giving  rise  to  their  respective 
pathological  changes,  and  each  thus  influencing 
the  symptoms  and  physical  signs.  Individual 
eases,  therefore,  present  many  diversities,  in  ac- 
cordance with  the  different  ways  and  degrees  in 
which  the  two  diseases  are  combined.  It  may 
happen  that  they  are  associated  from  the  first; 
or  one  may  supervene  during  the  progress  of  the 
other,  in  this  way  modifying  its  course,  and  not 
uncommonly  rendering  the  diagnosis  more  or  less 
obscure  and  difficult.  It  may  be  affirmed  that 
the  exact  conditions  present  in  the  chest  under 
such  circumstances  can  only  be  positively  deter- 
mined by  adequate  physical  examination ; and  it 
must  be  remembered  that  the  pleuritic  and  pul- 
monary conditions  will  each  tend  to  modify  the 
signs  produced  by  the  other.  No  general  rules 
can  be  laid  down  as  to  prognosis  or  treatment, 
but  every  case  must  be  regarded  on  its  own 
merits,  in  accordance  with  the  principles  laid 
down  in  the  articles  which  treat  of  pneumonia 
arid  pleurisy  respectively.  See  Lungs,  Diseases 
of ; and  Pleura,  Diseases  of. 

Frederick.  T.  Roberts. 

PLEUBOTHOTOK 08  (n\e.vp66ev,  later- 
ally, and  vivos,  tension). — A form  of  tetanic 
spasm,  in  which  the  body  is  bent  towards  one 
side.  See  Tetanus. 

PLICA  POLONICA  (base  Latin).— 
Synon.  : Fir.  la  Plique ; Ger.  lVeickselzopf. — An 
alteration  in  the  direction  of  the  hair,  attended 
with  matting  or  felting,  and  resulting  from 
neglect.  See  Hair,  Diseases  of. 

PLOMBliiEES,  in  Prance. — Simple 

thermal  waters.  See  Mineral.  Waters. 

PNEUMATOCELE  (7rifd,u«i/,  the  lung, 
and  a tumonr).  — Hernia  of  the  lung.  See 

Lungs,  Malpositions  of. 

PNEUMOGASTBIC  NERVE,  Diseases 

of. — Synon.  : Fr.  Maladies  du  Kerf  Pneumogas- 
trique  ; Ger . Krankheitcn  dcs  Vagus. — Of  all  the 
cranial  nerves,  the  pneumogastric  has  the  most 
extensive  distribution,  supplying  the  pharynx, 
larynx,  lungs,  heart,  oesophagus,  and  stomach, 
and  even,  in  part,  the  intestines  and  the  spleen. 
In  some  of  the  so-called  functional  diseases  of  the 
organs  which  it  supplies,  its  action  is  conspicu- 
ously deranged.  The  symptoms  of  its  disease 
are  thus  very  extensive,  and  it  will  be  well  first 
to  describe  them  generally,  and  afterwards  to 
consider  in  detail  those  which  merit  separate 
description. 

Some  of  the  functions  of  the  vagus  depend  upon 
fibres  of  the  spinal  accessory  which  join  it,  but  it 
is  convenient  to  consider  these  in  this  article. 

The  pneumogastric,  it  will  be  remembered, 
arises  from  the  side  of  the  medulla,  between  the 
glosso-pharyngeal  above,  and  the  spinal  acces- 
sory below,  and  to  the  outer  side  of  the  hypo- 
glossal. The  fibres  of  origin  come  from  a tract 
of  grey  matter  which  is  continuous  below  with 
the  nucleus  of  the  spinal  accessory,  and  above  lies, 
in  the  calamus  scriptorius,  between  the  hypo- 
glossal and  internal  auditory  nuclei,  while  to  the 
outer  side  of  the  upper  extremity,  and  more 
deeply  seated,  is  the  nucleus  of  the  glosso-pha- 


PNEUMOGASTRIC  NERVE,  DISEASES  OF, 

ryngeal.  The  trunk  of  the  nerve,  after  receiving 
fibres  from  the  spinal  accessory,  and  giving  off 
some  small  branches  (of  which  the  most  impor- 
tant is  one  to  the  external  ear),  passes  down  the 
neck,  behind,  and  in  the  same  sheath  with,  the 
carotid  artery ; enters  the  thorax  on  the  right 
side,  over  the  subclavian  artery,  and,  on  the  left, 
between  the  subclavian  and  the  carotid ; passes 
through  the  thorax  beside  the  oesophagus;  and 
ends  in  branches  to  the  stomach,  spleen,  and  in- 
testines. The  most  important  branches  are  the 
pharyngeal,  which,  with  the  glosso-pharyngeal, 
forms  the  plexus  of  the  same  name ; the  superior 
laryngeal;  the  recurrent  laryngeal,  which  passes 
back,  the  left  around  the  arch  of  the  aorta,  the 
right  around  the  subclavian  artery ; branches 
to  the  oesophagus ; pulmonary  branches  which, 
by  means  of  the  pulmonary  plexus,  supply  the 
lung ; and  branches  which  form  the  cardiac  plexus 
for  the  heart. 

./Etiology. — The  deep  position  of  the  pnenmo- 
gastric  and  its  branches  preserves  it  from  some 
forms  of  damage,  although  its  extensive  course 
renders  it  liable  to  suffer  from  many  causes.  The 
nucleus  in  the  medulla  may  be  damaged  by  local 
softening,  haemorrhage,  or  slow  degeneration; 
but  in  all  these  cases  other,  adjacent,  nnclei 
suffer  ( see  Labio-glosso-laryngeal  Paralysis). 
The  nerve,  at  its  origin  from  the  medulla,  may 
be  compressed  by  thickening  of  the  meninges, 
growths  from  the  meninges  or  bones,  or  aneur- 
ism of  the  vertebral  artery.  Affections  of  the 
nerve  due  to  syphilis  are  almost  always  the 
result  of  meningeal  disease  in  this  situation. 
Other  adjacent  nerves  commonly  suffer  at  the 
same  time.  The  trunk  of  the  nerve  is  some- 
times, hut  rarely,  implicated  in  punctured  or 
gunshot  wounds  ; incised  and  lacerated  wounds 
damaging  it  are  usually  immediately  fatal  from 
lesion  of  the  large  blood-vessels  to  which  it  is 


contiguous.  In  surgical  operations  the  trunk 
and  branches  of  the  nerve  are  occasionally  in- 
jured. The  trunk  has  been  tied  in  ligature  of 
the  carotid,  and  divided  in  the  removal  of  deep- 
seated  tumours.  In  such  operations  in  the  lower 
part  of  the  neck  it  is  often  also  difficult  to  3void 
injury  to  the  recurrent  laryngeal.  In  excision 
of  an  enlarged  thyroid  both  recurrent  lairngeals 
have  been  repeatedly  excised,  from  the  time  of 
Galen  down  to  the  present.  Sarcomatous  and 
other  tumours,  and  enlarged  glands,  may  com- 
press or  involve  the  nerve  in  almost  any  part  of 
its  course;  and  interference  with  its  function  es- 
pecially occurs  from  such  disease  in  regions  limi- 
ted by  rigid  structures,  as  in  the  upper  part  of  the 
neck,  near  the  skull,  and  in  the  upper  part  of  the 
thorax.  Aneurisms  may  compress  the  nerve  or 
its  branches  ; and  the  recurrent  laryngeals  suffer 
from  this  cause  with  especial  frequency,  because 
they  pass  round  large  blood-vessels.  The  left 
suffers  much  moro  frequently  than  the  right,  be- 
cause the  arch  of  the  aorta  is  more  frequently 
affected  by  aneurism  than  the  subclavian.  Ac 
enlarged  thyroid  may  compress  the  recurrent 
laryngeal  nerves,  and  symptoms  due  to  such  com- 
pression may  vary  with  the  varying  size  of  the 
tumour.  The  nerve  is,  in  rare  cases,  the  seat  of 
neuromata.  Neuritis  of  the  trunk  of  the  nerve, 
due  to  cold,  is  supposed  to  be  an  occasional  cause 
of  symptom*,  but  such  cases  are  extremely  rare. 


PNEUMOGASTRIC  NERVE,  DISEASES  OF. 


Borne  toxic  influences,  and  especially  the  poisons 
of  diphtheria  and  lead,  may  affect  it,  probably  by 
acting  on  its  central  origin. 

Symptoms. — It  must  be  remembered  that  the 
vagus  nerve,  besides  containing  motor  fibres  for 
the  pharynx  and  larynx,  is  the  chief  afferent  nerve 
for  the  respiratory  centre.  It  contains  acceler- 
ating and  inhibitory  fibres  for  this  centre,  but 
the  former  preponderate,  so  that  experimental 
division  of  the  nerve  in  an  animal  renders  the 
respirations  less  frequent,  but  deeper,  while  sti- 
mulation of  the  divided  (central)  end  quickens 
the  respiration,  and  may  even  arrest  it  in  tetanic 
standstill.  The  inhibitory  fibres  are  contained 
chiefly  in  the  superior  laryngeal  nerve,  and  their 
stimulation  arrests  the  respiration  in  muscular 
relaxation.  It  is  the  inhibitory  nerve  of  the 
heart;  slight  stimulation  increasing  the  diastolic 
periods,  and  stronger  stimulation  arresting  the 
action  of  that  organ.  On  division  of  the  nerve 
the  cardiac  contractions  are  accelerated.  It  has 
been  said  to  contain  trophic  fibres  for  the  heart 
and  lungs,  but  this  is  not  certain.  The  pneumo- 
gastric  is  an  afferent  nerve  for  the  vaso-motor 
centre,  the  action  of  which  is  lowered  by  its 
stimulation,  so  that  the  arteries  throughout  the 
body  are  relaxed.  It  is  the  motor  and  sensory 
nerve  for  the  oesophagus  ; the  sensory  nerve  for 
the  stomach  ; and  partly  also  the  motor  nerve 
for  the  stomach  and  intestines. 

Symptoms  due  to  paralysis  of  the  vagus  are 
more  frequently  met  with  than  those  which  result 
from  its  irritation.  Occasionally  both  are  com- 
bined. Laryngeal  spasm  and  vomiting  are  the 
irritative  symptoms  most  commonly  met  with, 
but  occasionally  cardiac  inhibition  occurs.  Czer- 
mak,  for  instance,  was  able  to  arrest  his  heart  for 
a few  beats  at  will,  by  pressing  a small  tumour 
of  the  neck  against  his  pneumogastric.  Concato 
had  a patient  in  whom  a similar  inhibition  could 
be  caused  by  pressure  on  the  right  nerve.  The  in- 
creased frequency  of  pulse  which  corresponds  to 
its  paralysis  has  been  several  times  noted,  and 
has  occasionally  been  associated  with  diminished 
frequency  of  respiration,  although  the  laryngeal 
paralysis,  also  resulting,  has  often  obscured  the 
effect  on  the  respiratory  movements.  Roux  tied 
the  trunk  of  the  vagus  with  the  left  carotid ; in- 
stantly respiration  was  arrested,  but  the  pulse 
was  also  retarded.  The  ligature  was  imme- 
diately relaxed,  but  the  patient  died  in  half  an 
hour.  Robert  also  tied  the  nerve  with  the  caro- 
tid; the  patient,  who  was  conscious,  immediately 
called  out,  ‘ I am  suffocated ! ’ and  his  voice  be- 
came hoarse.  He  recovered,  but  the  hoarseness 
continued  for  six  months.  A good  example  of  in- 
terference with  the  functions  of  the  vagus  has  been 
recorded  by  Guttmann.  A lad,  after  diphtheria, 
presented  paralysis  of  the  palate  and  of  one  ster- 
nomastoid.  His  respiration  quickly  became  re- 
duced to  twelve  per  minute,  and  very  laboured, 
while  his  pulse  rose  to  120,  and  he  died  in  a few 
hours.  In  many  other  cases  a similar  change  in 
the  pulse  and  respiration  has  been  noted,  and 
even  a pulse-ratio  of  160-200.  In  the  face  of 
these  observations,  and  of  experiments  on  animals, 
it  is  not  easy  to  understand  a fact  said  to  have 
been  observed  by  Billroth,  who  excised  half  an 
inch  of  one  pneumogastric,  which  was  implicated 
la  a tumour,  without  any  resulting  symptoms. 


1229 

The  important  central  relations  of  the  vagus 
above  alluded  to  cause  derangement  of  its  func- 
tion to  form  part  of  many  so-called  functional 
disorders  of  the  central  nervous  system.  Its 
nucleus  forms  part  of,  or  is  connected  with,  the 
respiratory  centre,  which  is  conspicuously  dis- 
turbed in  hydrophobia  and  some  other  diseases. 
The  phenomena  of  ‘ Cheyne-Stokes  breathing,’  or 
‘ respiration  of  ascending  and  descending  rhythm,’ 
are  probably  the  result  of  lowered  action  of  the 
respiratory  or  pneumogastric  centre  ( see  Respi- 
ration, Disorders  of).  This  symptom  is  met  with 
in  cerebral  haemorrhage,  uraemia,  meningitis,  and 
in  some  cardiac  diseases.  The  central  connections 
of  the  vagus,  in  the  hemispheres,  extend  to,  or  are 
connected  with,  those  parts  which  are  concerned 
in  emotion,  and  it  is  probably  through  the  agency 
of  this  nerve  that  the  heart’s  action  is  affected 
in  excitement  and  fear.  In  many  epileptic  fits 
the  central  representations  of  the  nerve  are  the 
parts  through  which  the  consciousness  is  first  af- 
fected, and  hence  the  so-called  ‘epigastric  aura.’ 

A similar  disturbance  seems  to  be  the  cause  of 
the  globus  hystericus  and  of  the  laryngeal  spasm, 
which  are  conspicuous  in  some  epileptic  and  hys- 
teroid  seizures.  The  nerve  is  closely  connected 
with  the  centre  or  nerves  for  equilibration,  so  that 
severe  vertigo,  on  whatever  dependent,  is  often 
followed  by  vomiting.  The  pneumogastric  nu- 
cleus is  contiguous  to  the  internal  auditory  nu- 
cleus, and  part  of  the  auditory  nerve,  that  which 
comes  from  the  semicircular  canals  (the  space- 
nerve  of  Cyon)  is  known  to  be  concerned  in  equi- 
libration. In  the  vertigo  which  results  from 
disease  of  this  nerve,  or  of  the  canals  (labyrin- 
thine or  auditory  vertigo)  vomiting  is  very  com- 
mon, and  the  nausea  and  retching  of  sea-sickness 
are  probably  due  to  the  deranged  action  of  the 
semicircular  canals,  in  consequence  of  the  motion 
affecting  the  pneumogastric  centre.  It  is  pos- 
sible that  the  connection  of  the  vagus  with  the 
equilibrial  nerves  is  by  means  of  the  cerebellum, 
diseaso  of  which  so  constantly  causes  vomiting, 
although  this  connection  has  not  yet  been  traced. 
Conversely,  gastric  disturbance  of  the  vagus  is 
often  accompanied  by  vertigo,  especially  when 
combined  with  pre-existent  imperfect  action  of 
the  auditory  nerve. 

1.  Pharyngeal  Branches. — The  branches  of 
the  pneumogastric  which  enter  the  pharyngeal 
plexus  supply  the  constrictors  of  the  pharynx 
and  the  soft  palate.  Some  have  asserted  that 
all  the  pharyngeal  branches  are  derived  from  the 
spinal  accessory;  the  pathological  evidence  that  the 
branches  to  the  soft  palate  are  derived  from  this 
source  is  very  strong,  since  when  one  vocal  cord 
is  paralysed  from  disease  of  the  roots  of  the 
spinal  accessory,  the  levator  palati  on  the  same 
side  is  always  paralysed,  and  very  often  the 
tongue.  See  Palate,  Paralysis  of. 

(1)  Paralysis. — ^Etiology. — The  most  com- 
mon cause  of  paralysis  of  the  pharynx  is  disease 
of  the  origin  of  the  nerve  in  the  medulla ; such 
disease  commonly  also  involves  adjacent  nuclei 
(see  Labio-qlosso-laeyngeal  Paralysis).  Pa- 
ralysis may,  however,  result  from  meningeal 
disease  outside  the  medulla,  from  disease  of  the 
bones  of  the  base  of  the  skull,  but  scarcely  ever 
from  disease  outside  the  skull.  It  occasionally 
forms  part  of  diphtheritic  paralysis. 


1230  PNEU MOG-AST R I C NERVE.  DISEASES  OF. 


Symptoms. — The  chief  symptom  is  difficulty  in 
swallowing.  Food  lodges  in  the  pharynx  about 
the  epiglottis,  and  small  particles  and  liquids  may 
enter  the  larynx.  If  the  paralysis  is  limited  to 
the  superior  constrictor,  liquids  may,  it  is  said, 
be  forced  up  into  the  nose  by  the  contraction  of 
the  middle  constrictor;  but  .'t  is  doubtful  whether 
tins  occurs  unless  the  palate  also  is  paralysed. 
The  affection  of  one  nerve  causes  only  slight 
trouble  in  deglutition,  no  doubt  because  of  the 
circular  arrangement  of  the  muscular  fibres. 

Diagnosis. — The  only  conditions  with  wliicii 
paralysis  of  the  pharynx  can  be  confounded  are 
spasm  and  organic  diseaso.  The  writer  once  saw 
an  elderly  man  with  distinct  pharyngeal  para- 
lysis, who  had  been  sent  to  an  eminent  surgeon 
because  the  difficulty  in  swallowing  was  supposed 
to  indicate  cancer  of  the  throat.  A careful  exa- 
mination is  usually  sufficient  for  the  distinction. 

(2)  Spasm. — Spasm  of  the  pharynx  may  be 
recognised  by  its  paroxysmal  character,  and  is 
almost  always  part  of  ‘functional’  nervous  dis- 
ease. It  forms  part  of  the  spasm  of  hydrophobia ; 
and  occurs  in  hysteria,  and  in  some  other 
allied  states.  Individuals  are  sometimes  met 
with  who  are  unable  to  take  food  except  when 
alone,  so  great  is  the  amount  of  pharyngeal  spasm 
which  the  presence  of  others  induces. 

2.  Laryngeal  Branches.  — It  will  be  re- 
membered that,  of  the  two  laryngeal  nerves,  the 
superior  is  the  sensory  nerve  for  the  larynx,  and 
also  supplies  motor  power  to  the  crico-thyroid 
muscle,  which  is  the  tensor  of  the  cords ; while 
the  recurrent  laryngeal  is  purely  motor,  and  sup- 
plies the  other  muscles.  The  motor  fibres  of  both 
are  derived  from  the  spinal  accessory.  Of  the 
muscles,  the  most  important  in  regard  to  para- 
lysis are  the  chief  abductor,  the  posterior  crieo- 
arytsenoideus  (which  draws  the  postero-external 
angle  of  the  arytenoid  cartilago  backwards,  and 
so  moves  the  processus  vocalis  outwards);  the 
chief  adductor,  the  lateral  crico-arytaenoideus 
(which  draws  the  postero-external  angle  of  the 
arytenoid  cartilage  outwards,  and  thus  the  pro- 
cessus vocalis  inwards);  and  the  arytaenoideus 
(which  approximates  the  two  arytenoid  carti- 
lages). Other  muscles,  acting  at  the  same  time, 
increase  the  power  of  closure. 

(1)  Paralysis. — Only  paralysis  of  the  abduc- 
tors and  adductors  need  be  discussed  in  this 
article.  That  of  the  tensors  and  laxors  of  the 
vocal  cords,  although  very  important  among 
laryngeal  diseases,  is  always  the  result  of  local 
conditions,  not  of  lesions  of  the  pneumogastric 
nerve. 

A2xiotoGY. — Almost  all  diseases  of  the  nerve- 
trunk  affect  the  fibres  to  the  larynx,  the  only 
exception  being  the  diseases  of  the  trunk  below 
the  origin  of  the  recurrent  laryngeal.  Syphilitic 
and  other  intracranial  disease,  injuries,  and 
pressure  by  tumours,  all  have  this  consequence ; 
and  the  motor  paralysis  is,  necessarily,  almost  as 
complete  in  disease  of  the  recurrent  laryngeal  as 
in  that  of  any  part  of  the  trunk  of  the  pneumo- 
gastric. In  diphtheria  the  larynx  is  also  some- 
times paralysed.  Rheumatic  paralysis  is  pro- 
bably always  local.  Diseases  affecting  the  fibres 
of  origin  of  the  spinal  accessory  at  the  medulla, 
or  its  trink  in  the  neck,  or  the  recurrent  nerve, 
usually,  and  diphtheria  occasionally,  cause  para- 


lysis on  one  side  only.  Affections  of  the  nucleus 
of  origin  of  the  nerve  are  usually  bilateral:  and 
the  other  common  cause  of  bilateral  paralysis  is 
the  implication  of  both  reenrrents  in  growths  in 
the  upper  part  of  the  thorax.  Diphtheria  also 
sometimes  causes  paralysis  of  both  nerves. 

Symptoms. — In  complete  unilateral  paralysis 
the  affected  vocal  cord  is  usually  in  half-abduc- 
tion, in  the  position  assumed  after  death.  Al- 
though there  is  loss  of  all  movement,  that  of  ad- 
duction is  the  obtrusive  defect.  In  phonation  the 
unaffected  cord  moves  up  to  or  beyond  the  middle 
line,  while  the  paralysed  cord  remains  motion- 
less; and  the  movements  outwards  in  inspiration 
and  inwards  in  expiration,  are  performed  only 
by  the  healthy  cord.  The  voice,  under  these 
circumstances,  may  be  hoarse,  or  it  may  be  little 
altered,  the  healthy  cord  being  moved  beyond  the 
middle  lme  into  sufficient  proximity  to  the  other 
to  permit  phonation.  Complete  approximation, 
such  as  is  necessary  for  a cough,  is  impossible; 
and  in  the  attempt  to  cough  the  patient  only 
succeeds  in  driving  air  quickly'  through  the  open 
glottis,  and  no  sudden  explosive  cough  is  pos- 
sible. Sometimes,  in  complete  unilateral  para- 
lysis, the  affected  cord  is  not  in  semi-abduction, 
but  is  nearly  up  to  the  middle  line.  It  is  in  the 
position  for  phonation,  and  so  there  is  no  defec- 
tive approximation  in  uttering  vowel-sounds : but 
when  phonation  is  over,  and  especially  during  in- 
spiration, the  healthy  cord  is  abducted,  while  the 
paralysed  cord  remains  motionless.  Thus  the 
loss  of  abduction  is  the  conspicuous  defect.  On 
what  the  difference  in  the  position  of  the  para- 
lysed cord  depends,  whether  it  is  in  abduction  oi 
in  adduction,  is  not  quite  certain.  The  position 
of  adduction  is  seen  especially  in  paralysis  of  the 
recurrent  nerve.  A plausible  explanation,  which 
has  been  suggested  to  the  writer  by  Dr.  Poore,  is 
that  the  position  of  abduction  is  the  early  state, 
and  that  after  a time,  in  some  cases,  the  unopposed 
erico-thy'roid  over-extends  the  cord,  and  so  brings 
it  into  the  middle  line,  just  as  in  other  organs, 
muscles,  the  opponents  of  which  are  paralysed, 
gradually,  by'  their  tonic  shortening,  alter  the 
position  of  parts  to  which  they  are  attached.  In 
paralysis  from  disease  of  the  roots  of  the  spinal 
accessory  at  the  medulla,  the  affected  cord  is  al- 
ways, as  far  as  the  writer  has  seen,  in  a state  of 
partial  abduction,  a fact  which  harmonises  with 
Dr.  Poore’s  explanation,  since,  in  this  case,  the 
crico-thyroid  will  also  be  paralysed.  When  the 
cord  is  in  the  position  of  adduction,  the  voice  is 
high-pitched.  At  rest  there  is  no  dyspncea,  but 
on  exertion  the  unabducted  cord  interferes  with 
the  entrance  of  sufficient  air,  and  respiration  be- 
comes stridulous  and  short ; but  there  is  rarely, 
if  ever,  sufficient  dyspnoea  to  render  tracheotomy 
necessary. 

Bilateral  paralysis  is  much  less  common.  It 
may  be  due  to  central  disease  ; to  diphtheria ; to 
pressure  on  both  recurrent  laryngeal  nerves  from 
tumours  in  the  upper  part  of  the  thorax ; or  to 
the  injury  of  these  nerves  in  the  excision  of  en- 
larged thyroid.  Two  remarkable  cases  have  been 
recorded  (Baumler,  Johnson),  in  which  pressure 
on  one  recurrent  laryngeal  and  vagus  has  caused 
paralysis  of  both  vocal  cords,  in  onecaso  equally, 
in  the  other  less  on  the  side  opposite  to  the  tu- 
mour than  on  the  same  ride.  Dr.  Johnson  snjj 


PNEUMOGASTRIC  NERVE,  DISEASES  OF. 


ge3ts  that  the  mechanism  is  probably  an  inhibi- 
tion of  the  central  nucleus  on  both  sides,  by  the 
pressure  of  the  afferent  fibres  in  the  vagus.  In 
bilateral  paralysis  the  same  difference  in  the 
position  of  the  cords  is  met  -with  as  in  unilateral 
paralysis.  Sometimes  they  are  apart,  in  half- 
abduction, and  sometimes  approximated  in  ad- 
duction. In  each  case  they  are  motionless.  In 
the  first  instance  the  absence  of  the  adduction 
for  phonation  is  more  conspicuous  than  the  want 
of  respiratory  movement,  and  leads  to  the  condi- 
tion being  designated  paralysis  of  the  adductors ; 
in  the  latter  the  absence  of  the  normal  abduction 
on  inspiration  attracts  chief  attention,  and  there 
is  said  to  be  paralysis  of  the  abductors.  It  is  pro- 
bable that  Dr.  Poore’s  explanation  applies  to 
these  cases  also.  The  difference  between  the  two 
in  their  symptoms  is  very  great.  When  the  vocal 
cords  are  in  abduction  phonation  is  almost,  or 
quite,  impossible,  and  there  is  no  closure  of  the 
glottis  in  cough.  There  may  be  no  dyspnoea 
unless  on  very  active  exercise.  When,  however, 
the  cords  are  near  the  middle  line,  the  patient’s 
condition  is  very  different.  He  is  able  to  speak, 
but  only  in  a high,  stridulous  voice.  The  most 
urgent  symptoms  arise  from  the  absence  of  the 
, normal  respiratory  movements.  Instead  of  being 
abducted  in  inspiration,  the  pressure  of  the  air 
brings  the  cords  closer  together,  while  the  cur- 
rent, in  expiration,  separates  them.  This  in- 
: spiratory  approximation  of  the  cords  constitutes 
a source  of  the  gravest  danger.  When  the  pa- 
tient is  at  rest  enough  air  may  enter  to  prevent 
dyspnoea,  but  exertion  brings  on  stridor  and  in- 
; tense  difficulty  of  breathing.  The  least  swelling 
of  the  cords  occludes  the  glottis  entirely.  This 
condition  is  one  of  great  rarity,  and  is  most 
commonly  due  to  central  disease. 

Slight  impairment  of  adduction  of  the  cords  is 
a very  common  and  much  less  grave  affection,  met 
with  in  general  weakness,  hysteria,  and  local  in- 
flammatory diseases.  It  has  been  termed  ‘ phonic 
paralysis,’ because  in  the  slight  effort  of  speaking 
the  cords  are  not  approximated,  while  in  the 
stronger  effort  of  the  cough  they  are  brought  to- 
gether perfectly.  It  does  not  result  from  nerve- 
lesions. 

Ancestliesia  of  the  larynx  may  result  from 
disease  of  the  superior  laryngeal  nerve,  but  is 
extremely  rare  from  this  cause.  Lessened  sensi- 
bility, bilateral,  is  not  uncommon  in  central  dis- 
ease of  the  medulla. 

(2)  Spasm. — The  common  form  of  spasm  of  the 
laryngeal  muscles  is  that  of  the  adductors.  The 
nuscles  which  close  the  glottis  are  far  more 
powerful  than  those  which  open  it,  hence  any  ir- 
‘itation  of  the  nerves — direct,  central,  or  reflex — 
auses  closure.  For  this  closure,  since  it  plays 
■n  important  part  in  many  physiological  pro- 
* esses,  a central  mechanism  is  provided,  which 
3 readily  excited  byT  various  means.  In  cough, 
or  instance,  it  may  be  excited,  not  only  from 
he  special  afferent  nerves  of  the  throat,  larynx, 
nd  hrngs,  but  also  by  those  of  the  stomach,  and 
ven,  it  is  believed,  by  the  branch  of  the  vagus 
’hick  goes  to  the  external  auditory  meatus, 
pasmodic  cough  may  result  from  the  simple  ir- 
tability  of  the  centre,  as  in  hysteria ; and  a pe- 
iliar  barking  cough  is  occasionally  the  result  of 
iisturbat'.on  in  boys.  In  whooping  cough,  again, 


1231 

the  glottis,  after  being  closed,  is  imperfectly  re- 
laxed, so  that  a sound  accompanies  the  next 
inspiration.  Simple  laryngeal  spasm,  without 
implication  of  the  expiratory  muscles  (laryngis- 
mus stridulus),  occurs  in  children,  in  whom,  in 
consequence  of  the  constitutional  condition  known 
as  rickets,  the  central  nervous  system  is  in  a 
state  of  undtie  irritability.  In  this  the  vaso-mo- 
tor  centre  seems  to  participate ; a child,  on  some 
exciting  cause,  as  a start,  a reflex  impression,  or 
on  none,  suddenly  turns  pale,  is  unable  to  get  its 
breath  for  a few  seconds,  and  then,  the  spasm 
relaxing,  air  is  drawn  through  the  slowly  open- 
ing glottis  with  a crowing  noise.  Quite  similar 
attacks  may  occur  in  adults.  It  may  be  accom- 
panied by  distinct  convulsive  action  elsewhere. 
In  the  paroxysms  of  epilepsy  a similar  combi- 
nation is  seen  ; the  epileptic  cry  is  the  result  of 
laryngeal  spasm.  Hydrophobia  also  is  attended 
with  a paroxysmal  closure  of  the  glottis. 

Since  the  closure  of  the  glottis  is  the  physio- 
logical effect  of  irritation  of  the  afferent  laryn- 
geal nerves,  it  is  not  surprising  that  spasm  ac- 
companies a large  number  of  laryngeal  diseases, 
varying  in  its  prominence  according  to  the  irri- 
tative nature  of  the  disease,  and  the  irritability 
of  the  reflex  mechanism  ; and,  since  the  latter  is 
most  intense  in  children,  we  have  in  them  a con- 
dition in  which  the  slightest  local  catarrh  gives 
rise  to  spasm.  The  attacks  tend  to  occur  es- 
pecially at  night,  when  the  reflex  centres,  re- 
leased by  sleep  from  the  control  of  the  higher, 
are  in  their  most  active  state.  Spasm  mayoccur, 
not  merely  from  irritation  of  the  laryngeal  nerve, 
but  from  that  of  the  vagus  below  (or  by  compres- 
sion by  tumour),  the  afferent  nerves  from  the 
lungs  being  sufficient  to  generate  it.  Reflex 
spasm  is  always  bilateral  in  character.  Direct 
spasm  by  irritation  of  the  recurrent  laryngeal 
usually  involves  only  one  vocal  cord ; but  in  a few 
cases  spasm  so  excited  has  been  bilateral.  This 
result  can  only  be  explained  either  by  assuming 
the  irritation  of  some  afferent  fibres,  or  by  as- 
cribing it  to  the  spasm  of  the  arytaenoideus, 
which  is  a bilateral  muscle  (Krishaber). 

A very  rare  condition  of  ‘functional  spasm’ 
has  been  described,  in  which  spasm  is  excited  by 
attempts  to  speak.  It  has  been  thought  to  be 
similar  in  its  nature  to  writer's  cramp. 

3.  Pulmonary  Branches. — The  effect  of  dis- 
turbance of  the  pneumogastric  on  the  respiratory 
movements,  and  the  reflex  effect  of  disturbances 
of  the  afferent  pulmonary  branches,  have  been 
already  described.  The  muscular  fibres  of  the 
bronchi  are  innervated  by  the  nerve,  and  their 
paroxysmal  contraction  in  asthma  is  thought  to 
be  produced  through  its  agency.  It  has  been 
asserted  that  the  plain  muscular  fibres,  said  to 
exist  throughout  the  lung-tissue,  are  supplied 
by  it  (Gcrlach),  and  their  contraction  has  been 
assumed  to  explain  a peculiar  form  of  emphy- 
sema, which  has  been  observed  in  compression 
of  the  pneumogastric  (Tuczek)  ; but,  since  deep 
breathing  of  a costo-superior  type  was  observed, 
it  is  possible  that  the  effect  is  the  result  of  the 
energetic  respiration  from  the  disturbance  of 
the  centre.  The  pneumogastric  is  commonly 
believed  to  contain  vaso-motor  fibres  for  the 
vessels  of  the  lungs,  but  Brown-Sequard  and 
Franck  have  separately  shown  that  these  fibres 


PNEUMOGASTRIC  NEEYE,  DISEASES  OF. 


1232 

are  contained,  not  in  the  vagus,  hut  in  the 
sympathetic.  Vascular  lesions  of  the  lungs 
have,  however,  been  observed  after  section  of  the 
vagus.  Michaelson  noted  rapid  congestion  and 
haemorrhage.  It  is  possible  that  this  may  he  of 
reflex  origin.  The  congestion  noted  after  lesion 
of  the  pons  may  also  be  produced  through  the 
agency  of  the  sympathetic.  In  a case  of  haemor- 
rhage into  the  pons,  fatal  in  two  hours,  the 
writer  found  intense  congestion  with  extravasa- 
tion into  the  left  lung,  and  haemorrhages  in  the 
left  extremity  of  the  stomach. 

After  section  of  the  vagus,  animals  die  from 
chronic  pneumonia,  and  hence  the  vagus  has  been 
supposed  to  be  a trophic  nerve  for  the  lungs. 
But  the  changes  have  been  accounted  for  by  the 
entrance  into  the  bronchi  of  food  from  the 
pharynx,  in  consequence  of  the  obstructive 
paralysis  of  the  oesophagus,  and  the  paralysis  of 
the  larynx  (Traube,  Steiner).  All  admit  that 
this  is  one  cause  of  the  pulmonary  affection,  but 
differ  as  to  its  adequacy  in  all  eases.  The  ques- 
tion is  still  undecided. 

4.  Cardiac  Branches. — The  inhibitory  effect 
of  irritation,  and  acceleration  of  the  heart's  action, 
which  results  from  lessened  action  of  the  vagus, 
have  been  before  alluded  to.  The  increased 
frequency  has  been  several  times  observed  in 
cases  of  local  disease  of  the  vagus  in  the  thorax, 
compression  by  mediastinal  tumours,  &c.  In  a 
case  of  phthisis,  for  instance,  in  which  the  pulse 
was  at  first  occasionally,  and  afterwards  con- 
stantly, frequent  (130-148),  Meixner  found  the 
1 eft  vagus  enclosed  in  a mass  of  enlarged  glands 
in  the  upper  opening  of  the  thorax.  The  vagus 
is  also  the  afferent  nerve  from  the  heart,  and 
although  we  are  normally  unconscious  of  the 
cardiac  action,  some  of  the  disordered  sensations 
of  disease  are  apparently  produced  through  its 
agency.  The  subject  of  angina  pectoris,  and  its 
relation  to  the  vagus,  are  discussed  in  a separate 
article,  but  it  may  be  here  noted  that  in  some 
anginal  attacks  the  heart’s  action  is,  for  a time, 
arrested  or  retarded,  and  that  in  a few  cases 
these  symptoms  have  been  found  associated  with 
organic  disease  of  the  cardiac  plexus.  Thus  in 
a ease  in  which,  during  paroxysms  of  intense 
anginal  anguish,  the  heart’s  action  was  arrested 
for  four  or  six  pulsations,  Heine  found  a tumour 
involving  the  cardiac  plexus.  In  a case  recorded 
by  Blandin,  anginal  attacks  were  associated 
with  a small  tumour  of  the  vagus.  Further, 
there  are  afferent  fibres  from  the  heart  inhibiting 
the  action  of  the  vaso-motor  centre,  and  these 
are  probably  stimulated  in  some  anginal  seizures. 

After  disease  or  injury  of  the  vagus,  the  heart 
has  been  found  in  a state  of  fatty  degeneration, 
and  hence  it  has  been  thought  that  the  vagus 
contains  trophic  fibres  for  the  cardiac  substance. 

5.  Branches  to  the  Alimentary  Canal. — 
The  branches  to  the  oesophagus  are  rarely  diseased 
except  in  cases  of  affection  of  the  nerve-trunk  or 
of  the  centre.  In  very  rare  cases  such  disease 
has  caused  difficulty  in  swallowing,  simulating 
stricture.  Spasm  of  the  oesophagus  is  more 
frequent.  The  vagus  is  the  sensory,  and  in  part 
the  motor  nerve  for  the  stomach.  Its  fibres  are 
very  sensitive  to  any  local  irritation,  and  not 
rarely  the  seat  of  spontaneous  neuralgia.  Hun- 
ger is  generally  believed  to  be  a pneumogastric 


sensation,  and  complete  loss  of  the  sensations  of 
hunger  and  thirst  were  noted  in  a case  of  soften- 
ing of  the  root  of  the  vagus  from  an  aneurism  of 
the  vertebral  artery  (Johnson).  Appetite,  how- 
ever, is  not  always  lost  in  animals  when  the 
pneumogastrics  have  been  divided  (Reid).  In 
some  cases  of  disease  of  the  nerve,  excessive 
appetite  has  been  noted.  This  symptom,  for  it- 
stance,  was  noted  in  one  case,  in  conjunction 
with  dyspnoea,  noisy  breathing,  and  vomiting  of 
unaltered  food : post  'mortem , both  pneumogas- 
trics were  found  atrophied  (Swan).  In  another 
case  of  insatiable  appetite,  small  neuromata 
were  found  on  the  nerve.  It  is  possible  that  the 
polyphagia  may  be  in  part  the  result  of  the 
defective  digestion  of  food. 

The  pneumogastric  is  also  in  part  the  motor 
nerve  of  the  stomach  ; after  its  section  the  con- 
tractions of  the  organ  are  lessened,  although 
not  altogether  arrested.  Vomiting  is  probably 
produced  through  its  agency,  by  varied  reflex 
and  central  irritation.  In  the  latter  case  (as  in 
meningitis)  the  vomiting  is  sometimes  extremely 
rapid.  The  writer  has  known  paroxysmal  vo- 
miting to  result  from  the  intermitting  pressure 
of  a tumour  on  the  vagus ; and  Boinet,  having 
exposed  the  vagus  in  an  operation  in  the  neck, 
noted  that  whenever  he  touched  the  nerve  the 
patient  vomited. 

The  vagus  accelerates  the  contraction  of  the 
intestines,  but  no  intestinal  symptoms  have  been 
noted  from  its  disease. 

General  Diagnosis. — The  chief  symptoms  on 
which  the  diagnosis  of  disease  of  the  vagus,  in 
any  given  case,  would  rest,  are  the  laryngeal 
paralysis ; retarded  respiration ; accelerated  or 
retarded  heart ; and  vomitiDg.  The  diagnosis 
of  the  seat  of  the  disease  rests  upon  the  range 
of  the  symptoms,  and  associated  morbid  pro- 
cesses. Disease  of  the  trunk  of  the  vagus  is 
much  less  common  than  disease  of  its  branches 
or  roots.  Paralysis  of  one  vocal  cord,  for  in- 
stance, is  almost  always  tho  result  of  pressure, 
either  on  the  recurrent  laryngeal,  or  on  the 
roots  of  the  spinal  accessory  at  the  medulla. 
Bilateral  symptoms  are  usually  due  to  central 
disease,  or  else  (if  slight)  are  of  merely  local 
origin.  In  most  cases  of  pressure  on  the  trunk 
and  branches  of  the  vagus  the  cause  of  the 
symptoms  is  distinct,  the  only  exception  being 
deep-seated  tumours  in  the  thorax. 

Pbognosis. — The  prognosis  is  that  of  the  cause 
of  the  disease,  and  is  sufficiently  discussed  in 
other  articles. 

Treatment. — Little  can  be  said  on  the  general 
treatment  of  the  diseases  of  the  pneumogastric, 
since  it  depends  on  the  different  conditions  to 
which  the  symptoms  are  due,  and  which  are  de- 
scribed elsewhere.  Central  disease,  and  causes 
of  pressure  on  the  nerve  are,  as  a rule,  beyond 
the  range  of  treatment.  Whenever  there  is 
reason  to  suspect  pressure  on  the  nerve-roots 
(from  the  combination  of  paralysis  of  the  tongue, 
palate,  and  one'vocal  cord),  iodide  of  potassium 
should  be  given,  since  this  is  more  frequently 
due  to  syphilis  than  to  any  other  cause.  In 
laryngeal  paralysis  the  local  application  of  elec- 
tricity is  sometimes  useful,  but  more  so  in  the 
weakness  which  depends  on  local  causes  than  in 
that  which  is  due  to  nerve-lesioDS.  Injections 


PNEUMOGASTRIC  NERVE. 

of  strychnine  are  also  sometimes  useful,  even,  it 
is  said,  when  its  administration  by  the  mouth  is 
without  effect.  In  central  paralysis  the  treat- 
ment will  depend  on  the  indication  given  by 
the  mode  of  onset  regarding  the  nature  of  the 
lesion,  whether  softening  or  degeneration.  In 
all  spasmodic  affections,  sedative  inhalations, 
especially  chloroform,  are  useful ; and  bromides 
will  lessen  the  irritability  of  the  nerve-centre. 

W.  R.  Gowers. 

PNEUMOGRAPH  (* vetfiuv,  the  lungs,  and 
ypiytii,  I write). — An  instrument  for  recording 
the  movements  of  respiration.  See  Physical 
Examination. 

PNEUMONIA  {■wvevp.tav,  the  lungs). — In- 
flammation of  the  substance  of  the  lungs.  See 
Longs,  Inflammation  of. 

PNEUMO-PERICARDIUM  (ir vevp.a,  air, 
ind  TepucapStov,  the  pericardium). — A collection 
if  gas  in  the  pericardium.  See  Pericardium:, 
Diseases  of. 

PNEUMOTHORAX  (iri/evga,  air,  and 
liipa^,  the  chest). — A collection  of  gas  in  the 
tavity  of  the  pleura.  See  Pleura,  Diseases  of. 

POCK. — A popular  term  for  pustule,  as 
;liough  a pocket  or  pouch  in  the  skin  tilled  with 
ms.  From  the  plural  of  pock  is  derived  pox; 
.ence,  small-pox,  cliicken-pox,  the  great  pox  or 
lenereal  pox,  and  so  forth. 

PODAGRA  (t roDs,  the  foot,  and  &ypa,  a 
Seizure). — A common  synonym  for  gout,  as  it 
jsually  attacks  the  foot.  See  Gout. 

PODALGIA  (ttoOv,  the  foot,  and  uKyos, 
ain). — A name  for  pain  in  the  foot,  due  to  any 
iuse,  such  as  gout,  rheumatism,  &c. 

POINTS  DOULOUREUX  (Fr.)— Tender 
lints  in  connection  with  the  affected  nerves  in 
niralgia.  See  Neuralgia. 

POISONOUS  ANIMALS.  See  Venomous 

NIKALS. 

POISONOUS  FOOD. — Under  certain  con- 
tions,  various  articles  of  diet,  especially  moat, 
gs,  milk,  butter,  cheese,  and  honey,  may  be- 
mc  possessed  of  poisonous  properties,  and 
is  may  arise  from  a variety  of  causeo,  besides 
e introduction  of  known  and  specific  poisons, 
oreover,  certain  kinds  of  animal  food — fish 
iefly — may  be  possessed  of  definite  toxic  pro- 
rties. 

Food  may  be  more  or  less  poisonous — (1)  from 
soundness,  either  from  putridity  or  decomposi- 
n,  and  from  disease  ; (2)  from  the  presence  of 
r asites ; (3)  from  mouldincss,  or  presence  of 
eterious  fungi ; and  (I)  where  the  flesh  is  that 
1 animals  which  have/eiZ  on  noxious  or  poisonous 
, nis ; and  under  this  head  may  also  he  classed 
1 sonous  honey,  which  bees  have  gathered  from 
) sonous  plants.  (5)  It  may  be  of  the  nature  of 
[ sonous  fish,  using  the  term  fish  in  the  popular 
: se.  Parasitic  diseases  might  strictly  be  said 
feome  under  head  (1);  hut  as  they  are  dis- 
used in  separate  articles,  the  preventive  mea- 
ses to  be  adopted  in  the  use  of  food  infested 
'A  parasites  will  alone  he  treated  o'  in  this 
f ;.e.  See  Cysticterci  ; T;enia  ; and  Trichina. 
’oisonous  Vegetables. — Unsound  or  even 

78 


POISONOUS  FOOD.  1233 

rotten  vegetables  and  fruits  may  be  consumed, 
especially  in  hot  summers,  and  become  fertile 
sources  of  varied  forms  of  poisoning.  The  symp- 
toms produced  by  the  ingestion  of  large  quan- 
tities of  unsound  fruit  and  vegetables  are  usually 
of  a diarrhoeal  character,  not  often  of  an  alarm- 
ing  severity,  except  in  the  cases  of  the  young 
and  feeble.  They  may,  however,  sometimes 
attain  a fatal  severity.  The  cause  is  usually 
obvious,  and  the  treatment  is  simple — mild  pur 
gatives,  as  rhubarb  or  castor  oil,  with  or  followed 
by  opiates,  to  remove  peccant  matters  from  the 
intestines  ; and  stimulants,  as  ammonia  or  alco- 
hol, if  there  be  much  collapse. 

Poisonous  Meat. — Tainted  or  putrid  Meat. 
The  obvious  characteristics  of  good,  sound  flesh 
meat  are  that  its  colour  is  red — neither  pale  pink 
nor  deep  purple ; that  it  is  marbled  in  appearance : 
firm  and  elastic  to  the  touch,  scarcely  moistening 
the  fingers  ; having  a slight  and  not  unpleasant 
odour  ; and  that  when  exposed  to  the  air  for  a day 
or  two,  it  should  neither  become  dry  on  the  surface, 
nor  wet  and  sodden.  Sound  meat  is  acid  to  litmus 
paper ; unsound  meat  may  be  neutral  or  alkaline. 
Meat  may  be  tainted  with  physic  administered  to 
the  animal.  It  is  a common  practice  when  a fat 
and  valuable  animal  is  unwell,  to  physic  it,  and  if 
its  recovery  be  not  speedy  to  slaughter  it.  The 
meat  of  such  animals  may  often  be  met  with  in 
our  markets,  and  may  induce  illness  from  the 
physic  with  which  it  is  contaminated.  The  effects 
of  simple  putridity  are  most  varied.  It  is  well 
known  that  some  nations  habitually  eat,  and 
even  prefer,  putrid  in  preference  to  fresh  meat ; 
and  the  development  of  rottenness  in  eggs  for 
the  epicure  is  an  art  in  China.  There  is  no 
doubt  that  habit  has  much  to  do  with  the  toler- 
ance of  putrid  meat — whether  cooked  or  only 
partially  cooked — by  the  stomach.  But  tainted 
game,  and  indeed  all  kinds  of  meat  in  which 
putrefaction  has  commenced,  may,  when  taken, 
indubitably  produce  disease.  This  is  chiefly  of 
a diarrheeal  character,  preceded  by  rigors,  and 
attended  with  collapse,  and  it  may  he  convulsions 
and  other  signs  of  a profound  affection  of  the 
nervous  system. 

The  effects  of  such  tainted  meat  are  slight  as 
compared  with  those  which  are  produced  by  the 
sausage-poisen,  developed  by  a sort  of  modified 
putrefaction  in  certain  German  sausages.  These 
sausages,  when  they  become  musty  and  soft  in 
their  interior,  nauseous  in  odour  and  flavour,  and 
acid  to  test-paper,  acquire  a highly  poisonous 
character,  and  are  frequently  fatal  in  their  effects. 
The  symptoms  produced  by  their  use  are  gastric 
pain,  vomiting,  diarrhoea,  depression,  coldness  of 
the  limbs,  and  weak,  irregular  cardiac  action. 
Fatal  cases  end  in  convulsions  and  oppressed 
respiration,  death  ensuing  from  the  third  to  the 
eighth  day.  The  nature  of  the  sausage-poison, 
which  is  probably  akin  to  that  of  putrid,  and 
indeed  all  non-speeifically  tainted  meats,  has  been 
a matter  of  considerable  controversy.  Some  have 
held  that  the  toxic  action  is  due  to  the  develop- 
ment of  rancid  fatty  acids ; others  believe  that  a 
so-called  catalytic  body  is  produced,  capable  of 
setting  up  by  contact  a similar  catalytic  action. 
Others  have  regarded  the  sausage-poison  as  due 
to  the  formation  of  pyrogenous  acids  during  the 
process  of  drying  or  smoking  the  sausages.  The 


1234  POISONOUS  FOOD, 

recent  discovery  by  Selmi  of  a class  of  poisonous 
alkaloids,  termed  ptomaines,  developed  during 
putrefaction  of  animal  matters,  on  the  one  hand; 
and  the  discovery  by  B.illard  and  Klein,  still  more 
recently,  that  the  fatally  poisonous  properties  of 
ham  prepared  according  to  the  American  method, 
may  be  due  to  the  presence  of  a parasitic  bacil- 
lus, point  to  one  or  other  of  these  two  latter 
causes  as  the  source  of  the  effects  of  sausage- 
poison.  Others  have  referred  the  effects  to  the  pre- 
sence of  a microscopic  fungus  — sarcina  botulina. 

Poisoned  Meat. — The  poisonous  nature  of  the 
flesh  of  animals  which  have  fed  on  certain  plants, 
for  example,  hares  which  have  fed  on  certain 
species  of  rhododendron,  pheasants  on  the  calmia, 
&c.,  has  been  abundantly  demonstrated,  and  need 
only  be  referred  to  here.  The  honey  from  bees 
which  have  garnered  on  poisonous  plants,  as  the 
azalea,  may  likewise  be  deleterious;  and  the  fact 
is  of  classical  interest.  The  milk  even  of  goats 
and  other  mammalia  which  have  browsed  on 
poisonous  herbs  has  also  proved  poisonous. 

Diseased  Meat.— The  poisonous  effects  of  meat 
affected  with  certain  parasites — trichina,  cysti- 
cerci,  trematodes,  &c.,  are  referred  to  in  the  ar- 
ticles bearing  these  names.  Great  quantities  of 
meat  pass  through  our  markets  which  is  undoubt- 
edly the  flesh  of  animals  affected  with  disease — 
foot-and-mouth  disease,  pleuro-pneumonia,  pig 
typhoid,  the  so-called  scarlatina  of  swine,  sheep- 
pox,  &c. ; and  it  is  a quite  undecided  point  as  to 
whether  such  flesh  produces  any  injurious  effects. 
To  stop  the  sale  of  such  meat  would  undoubtedly 
be  to  cut  off  large  sources  of  our  meat  supplies. 
The  evils  attending  the  use  of  such  diseased  meat, 
when  well  cooked,  have  undoubtedly  been  exag- 
gerated ; but,  on  the  other  hand,  there  is  enough 
evidence  to  show  that  the  use  of  certain  kinds  of 
diseased  meat  is  followed  by  serious  results.  Thus 
it  is  generally  admitted  that  the  flesh  of  animals 
which  have  suffered  from  pleuro-pneumonia  and 
murrain,  will  give  rise  to  boils  and  carbuncles. 
Braxy  mutton  may  also  produce  disease  when 
eaten.  Trichina  will  produce  trichinosis ; hy- 
datids the  tape-worm ; &e. 

Poisonous  Fish,  Crustacea,  and  Mol- 
lusks. — Cases  of  poisoning  by  fish,  Crustacea, 
and  the  so-called  shell-fish  of  our  islands  are 
not  unfrequently  met  with.  Generally  it  is  the 
ingestion  of  crabs,  lobsters,  and  mussels  which 
produces  such  results.  These  are  usually  of  a 
distressing,  rather  than  of  a serious  character, 
nettle-rash  beiDg  a common  symptom.  Occa- 
sionally, however,  fatal  results  have  ensued  from 
the  use  of  mussels.  In  tropical  seas  poisonous 
fish  are  more  plentiful — the  golden  sardine,  the 
bladder-fish,  the  grey  snapper,  &c. ; and  these 
being  eaten  by  larger  fish,  as  the  baracosta, 
perch,  globe-fish,  conger-eels,  &c.,  the  latter 
may  become  in  turn  poisonous. 

PREVENTIVE  AND  CURATIVE  MEASURES. Good 

cookery,  that  is,  exposure  to  a sufficiently  high 
temperature  for  a sufficiently  lengthened  time,  is 
undoubtedly  the  best  treatment,  short  of  abso- 
lute destruction,  of  unsound  and  diseased  meat. 
So  long  as  meat  is  high-priced,  and  the  effects  of 
diseased  meat  so  little  understood  and  so  un- 
defined, it  will  be  impossible  to  induce  medical 
officers  of  health  and  sanitary  inspectors  to  seize 
all  the  diseased  and  unsound  meat  which  is  daily 


POISONS. 

offered  for  sale.  Notwithstanding  all  that  ha- 
been  said  to  the  contrary,  experienced  observers 
are  agreed  that  thorough  exposure  of  the  meat 
throughout  to  the  temperature  (140°  Fah.)  at 
which  albumen  is  coagulated,  is  destructive  to 
the  parasites  of  flesh.  Smoking  is  less  effective. 
Salting  is  more  effective  than  smoking  ; but  there 
is  some  evidence  to  show  that  salting  may  merely 
hold  the  life  of  organisms  in  suspense  without 
entirely  destroying  their  vitality’ ; and  thus  in  the 
conversion  of  American  salted  pork  into  American 
hams  in  this  country — a process  of  re-salting  and 
subsequent  drying— the  specific  germ  (a  bacillus) 
has  been  known  to  be  again  rendered  harmful. 
It  is  not  known  whether  efficient  cooking  entirely 
removes  the  deleterious  effects  of  flesh  affected 
with  other  than  parasitic  disease,  as,  for  example, 
pleuro-pneumonia. 

The  curative  measures  for  the  results  of  eating 
poisonous  food  cannot  be  specifically  described. 
They  are  those  which  must  bo  arrived  at  on 
general  principles.  Symptoms  are  to  be  treated, 
and  the  powers  of  the  patient  sustained,  until  the 
deleterious  matter  is  removed  by  excretion,  or 
the  trichina,  e.g.,  has  become  encysted. 

Thomas  Stevenson. 

POISONOUS  GASES.  See  Carbonic 

Acid  ; Carbonic  Oxide  ; Prussic  Acid  ; &c. 

POISONS. — Synon.  : Fr.  Poisons ; Ger.  G-ifte. 

Definition. — There  is  no  legal  definition  of 
the  word  poison,  and  the  definitions  usually  pro- 
posed are  apt  to  include  either  too  much  or  too 
little.  Generally,  a poison  may  be  defined  as  a 
substance  having  an  inherent  deleterious  pro- 
perty, which  renders  it  capable  of  destroying 
life  by  whatever  avenue  it  is  taken  into  the 
system.  Substances  which  act  only  mechani- 
cally, such  as  powdered  glass,  are  not  poisons. 
In  popular  language,  a poison  is  a substance 
capable  of  destroying  life  when  taken  in  smr,.l 
quantities.  A poison,  then,  may  be  defined  as 
any  substance  which  when  introduced  into  the 
system,  or  applied  externally,  injures  health  or 
destroys  life  irrespective  cf  mechanical  means 
or  direct  thermal  changes.  See  Poisonous  Food. 

Action. — PoisoDs  may  exert  a twofold  action. 
Their  action  is  either  local  or  remote,  or  both  i 
local  and  remote.  The  local  action  of  a poison 
is  usually  one  of  corrosion,  inflammation,  or  an 
effect  on  the  nerves  of  sensation  or  of  motion. 
The  remote  actions  of  a poison  are  usually  of  a 
specific  character,  though  some  writers  group 
the  remote  effects  of  poisons  under  two  heads, 
and  speak  of  the  common  and  specific  remote 
effects  of  a poison.  The  local  actions  of  a poison 
of  the  corrosive  class  are  usually  so  well  marked; 
and  so  easily  recognised,  that  the  fact  of  its  ad- 
ministration is  obvious.  Tlie  same  may  he  said, 
in  a lesser  degree,  of  the  irritant  prisons,  espe- 
cially the  mineral  irritants ; but  here  the  symp- 
toms often  so  closely  simulate  those  of  natural 
disease  as  to  render  the  diagnosis  a matter  of 
great  difficulty.  An  accurate  acquaintance  with 
the  remote  specific  effects  of  the  various  common 
poisons  is  indispensable  to  the  medical  practi- 
tioner. The  class  of  poison  which  has  been  ad- 
ministered or  taken  will  thus  be  suggested  tc 
his  mind  by  the  symptoms  observed,  and  not 
| unfrequently  the  specific  poison  will  be  suspected 


POISONS. 


In  this  way  tho  physician  may  often  be  at  once 
able  to  diagnose,  from  the  symptoms  alone, 
ti}e  administration  of  strychnia,  henbane,  or  can- 
tharides.  Great  care  must  be  taken,  however, 
not  to  draw  a rash  conclusion  from  the  one 
symptom  alone  ; as,  for  instance,  from  the  teta- 
nic spasms  which  are  so  marked  a feature  in 
.strychnia-poisoning. 

It  is  generally,  but  not  universally,  held  that 
absorption  is  necessary  in  order  that  a poison 
should  be  able  to  exert  its  specific  effect.  Some, 

; nevertheless,  are  of  opinion  that  a poison  may 
destroy  life  by  an  action  on  the  nervous  system 
before  absorption  has  had  time  to  take  place. 
The  facts  in  support  of  this  view  are,  however, 
few,  and  open  to  doubt. 

Modifying  Circumstances. — The  usual  ac- 
tion of  poisons  may  be  greatly  modified — (1)  by 
the  largeness  of  the  dose,  and  the  state  of 
aggregation,  admixture,  or  chemical  combination 
of  the  poisons  themselves  ; (2),  by  the  part  or 
membrane  to  which  they  are  applied;  and  (3), 
iby  the  condition  of  the  patient.  Thus,  for  ex- 
ample, opium  may  be  a medicament  or  a poison, 
according  to  the  dose  in  which  it  is  given  ; 
and  a dose  of  opium  which  may  be  beneficial  to 
an  adult  in  certain  states  of  the  system  may  be 
fatal  to  a young  child,  or  to  the  adult  when 
suffering,  for  example,  from  Bright's  disease. 
All  barium  salts  are  poisonous,  except  the  sul- 
phate, which  is  one  of  the  most  insoluble  of 
all  mineral  substances.  The  simple  cyanides 
ire  highly  poisonous,  and  the  same  may  be  said 
lof  many  double  cyanides.  But  the  double  cya- 
hde  of  iron  and  potassium  (potassium  ferro- 
•yanide)  is  almost  without  action  on  the  system. 
Che  part  or  tissue  to  which  a poison  is  applied 
must  obviously  greatly  affect  the  activity  of  a 
ooison, owing  to  the  varying  rapidity  with  which 
.bsorption  takes  place  through  the  cutaneous, 
mucous,  serous,  and  other  surfaces  of  the  body, 
hirare  may  be  swallowed  in  a considerable  dose, 
rithout  producing  any  appreciable  effect,  whilst 
small  quantity  of  the  same  substance  intro- 
duced into  a wound  will  speedily  prove  fatal.  It 
as  been  found  that  when  a poison  is  slowly  ab- 
orbed,  so  that  it  can  be  either  disposed  of  in 
he  system  or  again  excreted  more  rapidly  than 
. is  absorbed,  no  poisonous  results  ensue  ; but 
hen  absorption  occurs  so  quickly  that  the 
oison  can  neither  he  excreted  nor  destroyed  in 
le  system  as  rapidly  as  it  is  absorbed,  the 
lecific  effects  of  the  poison  are  developed, 
urare,  for  instance,  is  absorbed  by  the  gastric 
ucous  membrane  more  slowly  than  it  is  ex- 
ited through  the  kidneys.  But  if  the  renal 
■teries  be  ligatured,  the  poison  accumulates  in 
e blood,  and  the  specific  effects  of  the  poison 
e developed,  just  as  when  curare  is  introduced 
to  a wound. 

Idiosyncrasy  has  much  to  do  with  the  poison- 
s or  hurtful  character  of  a substance.  Thus 
rk,  mutton,  certain  kinds  of  fish  (notably  shell- 
h),  and  fungi  (see  Mushrooms,  Poisoning  by), 
ve,  under  certain  circumstances,  and  in  certain 
.•sons,  produced  all  the  symptoms  of  violent 
itant  poisoning ; whilst  others,  who  have 
“taken  of  the  same  food  at  the  same  time, 
re  enjoyed  perfect  immunity.  More  commonly 
who  partake  are  affected,  but  with  varying 


1235 

degrees  of  severity.  Some  persons  are  said, 
on  good  authority,  to  be  capable  of  taking  witli 
impunity  such  violent  poisons  as  corrosive  sub- 
limate or  opium,  in  enormous  doses,  and  this 
independently  of  habit,  which  is  known  to  have 
such  a large  influence  in  modifying  the  effects 
of  some  poisons,  notably  of  the  narcotics.  A 
tolerance  of  poisons  is  sometimes  engendered  by 
disease,  so  that  a poison  may  from  this  cause 
fail  to  produce  its  accustomed  effect.  Thus 
opium  is  largely  tolerated  in  tetanus,  and  in 
mania  from  drink : and  mercurial  compounds 
may  in  severe  febrile  affections  fail  to  produce 
the  usual  constitutional  effects  of  the  metal.  On 
the  other  hand,  kidney-disease,  by  impeding 
elimination,  may  intensify  the  ordinary  effects 
of  a poison,  and  the  like  is  observed  when  opi- 
ates are  given  where  there  is  a tendency  to 
cerebral  congestion. 

Evidence. — In  order  to  raise  a valid  inference 
in  the  mind  of  the  medical  attendant  that  poison 
has  been  administered  to  a patient,  certain  facts 
must  be  brought  under  his  notice ; and  with- 
out the  concurrence  of  at  least  two  or  more  of 
these,  the  actuality  of  poisoning  cannot  be  main- 
tained. The  sources  of  evidence  in  cases  of 
suspected  poisoning  are  the  symptoms,  the  post- 
mortem appearances ; chemical  analysis  of  articles 
of  food  or  drink,  or  of  the  body  and  the  excre- 
tions ; and  experiments  upon  animals.  The  evi- 
dence derived  from  these  sources  being  compared 
with  the  known  properties  and  effects  of  various 
poisons  in  authenticated  cases,  will  enable  the 
physician  to  form  a correct  opinion  as  to  the 
probable  administration  or  not  of  a poison.  The 
poisons  most  commonly  administered  are  opium, 
prussic  acid,  arsenic  in  various  forms,  phospho- 
rus, oil  of  vitriol,  and  oxalic  acid. 

It  is  rarely  that  the  symptoms  exhibited  during 
life  do  not  afford  some  clue  to  the  cause  of  ill- 
ness ; and  most  frequently  the  symptoms  are  all 
that  the  medical  attendant  has  to  guide  him  to 
a diagnosis  of  the  nature  of  the  case,  during  tin- 
lifetime  of  the  patient.  Sometimes,  however, 
persons  are  found  dead  as  the  result  of  poison, 
concerning  the  manner  of  whose  death  nothing 
whatever  can  be  learned  ; a suspicion  of  poison- 
ing arising  from  the  circumstances  under  which 
the  corpse  is  found.  Here  the  aid  of  chemical 
analysis  ought  invariably  to  be  invoked  ; and 
fortunately  in  these  cases  the  delay  involved  in 
making  an  analysis  is  of  comparatively  little 
moment.  The  effects  may  in  the  ease  of  many 
persons  be  either  suddenly  or  slowly  manifested ; 
hence  we  have  acute  and  chronic  poisoning. 
Cases  of  chronic  poisoning  are  usually  the  re- 
sult of  the  repeated  administration  of  small 
doses  of  lead,  copper,  mercury,  phosphorus,  or 
arsenic.  All  of  these  poisons  are  treated  of 
in  separate  articles.  The  general  conditions 
which  should  excite  a suspicion  of  poisoning 
are  the  sudden  onset  of  serious  and  increasingly 
alarming  symptoms,  in  a person  previously  in 
good  health,  especially  if  a prominent  symptom 
be  epigastric  pain;  or  where  there  is  complete 
prostration  of  the  vital  powers,  a cadaverous 
expression  of  the  countenance,  an  abundant  per- 
spiration, and  speedy  death.  In  all  such  cases  the 
aid  of  the  chemist  is  required,  either  to  confirm 
well-founded,  or  to  rebut  ill-founded,  suspicious 


POISONS. 


1236 

Classification. — Various  attempts  have  been 
made  to  classify,  poisons  rationally.  Perhaps 
the  best  classification,  for  the  purposes  of  the 
medical  practitioner,  is  that  which  groups  poi- 
sons according  to  the  more  obvious  symptoms 
which  they  produce.  Our  knowledge  of  the 
more  intimate  action  of  many  poisons  is  still  too 
slight  to  admit  of  any  useful  classification  ac- 
cording to  the  manner  in  which  they  specifically 
affect  the  vital  organs. 

Poisons  may  in  the  maimer  indicated  be  clas- 
sified as:— 1.  Corrosives;  2.  Irritants  ; and 
3.  Neurotics.  It  is  perhaps  at  present  pre- 
mature to  attempt  a systematic  division  of  the 
last  class.  The  class  of  neurotics  embraces 
poisons  so  widely  different  in  their  action  as 
opium  and  strychnine. 

1.  Corrosive  Poisons.  — Enumeration. — 
The  action  of  one  of  the  most  typical  of  these 
poisons,  corrosive  sublimate,  is  fully  considered 
under  a special  head  ( see  Mercury,  Poisoning 
by).  The  most  commonly  administered  corrosives 
are  the  mineral  acids — sulphuric,  nitric,  hydro- 
chloric, and  oxalic  acid ; the  alkalies — potash, 
soda, and  ammonia;  acid,  alkaline,  and  corrosive 
salts — such  as  potassium  bisulphate,  potassium 
carbonate,  zinc,  tin,  and  antimony  chlorides,  and 
silver  nitrate. 

Symptoms. — The  mineral  acids  and  the  alka- 
lies have  scarcely  any  remote  effects  on  the 
system,  their  action  being  almost  purely  local. 
Some  of  the  other  corrosives  enumerated  may 
have,  besides  their  local  effects,  a remote  and 
constitutional  action.  The  symptoms  of  corro- 
sive poisoning  are  marked  and  unmistakable, 
except  when  the  patient  is  an  infant.  Imme- 
diately after  swallowing  the  corrosive  sub- 
stance, there  is  an  acid,  caustic,  or  metallic,  burn- 
ing sensation  felt  in  the  mouth,  fauces,  gullet, 
and  stomach  ; and  this  speedily  extends  over  the 
whole  abdominal  region.  Vomiting  is  speedy, 
or  may,  rarely,  be  altogether  absent.  The  vomited 
matters  consist  at  first  of  the  ordinary  contents 
of  the  stomach,  more  or  less  altered  by  the 
action  of  the  poison.  In  the  case  of  mineral 
acids  they  are  intensely  acid,  and  cause  copious 
effervescence  when  they  fall  upon  limestone  or 
marble.  No  relief  is  afforded  by  the  evacuation 
of  the  stomach ; and  later  the  vomits  may  be 
more  or  less  mingled  with  altered  blood,  which 
may  be  dark,  or  even  black;  shreddy  mucus,  casts 
of  the  gullet  or  stomach  formed  by  the  shedding 
of  the  mucous  membrane,  and  sometimes  even 
the  muscular  wall  of  the  oesophagus,  are  rejected. 
The  abdominal  pain  is  not  relieved,  but  greatly 
aggravated,  by  pressure.  The  whole  abdomen 
becomes  distended,  owing  to  the  gases  evolved 
by  the  action  of  the  poison  ; the  diaphragm  is 
pressed  upon  ; and  intense  dyspnoea  may  result, 
owing  to  pressure  upon  the  thoracic  viscera. 
When  a mineral  acid  has  been  administered, 
there  is  little  or  no  bowel  action,  and  the  urine 
may  be  suppressed;  but  in  poisoning  by  the 
alkalies,  and  by  the  alkaline  carbonates  and  sul- 
phides, there  may  be  purging.  The  mouth, 
tongue,  and  fauces  exhibit  the  local  effects  of 
the  corrosive ; a yellow  coating  in  the  case  of 
nitric  acid;  white  at  first,  and  as  if  covered 
with  white  paint,  from  sulphuric  acid ; and 
whitish  or  brown  and  less  thickly  coated  from  I 


hydrochloric  acid.  Yellow  or  brown  stains  «- 
be  observed  on  the  skin,  extending  downwards 
from  the  angles  of  the  mouth,  and  caused  by  the 
trickling  of  acid  or  other  corrosive  fluid  from 
the  mouth.  Meantime  the  symptoms  develop 
rapidly.  The  pain,  thirst,  dyspnoea,  and  dys- 
phagia increase.  The  patient,  at  first  excited, 
with  rapid,  bounding  pulse,  becomes  bathed 
in  cold  perspiration,  the  countenance  becomes 
pinched,  the  pulse  more  rapid  and  thready. 
Enormous  eructations  of  gas  bake  place,  but 
these  afford  no  relief.  The  patient  may  become 
more  or  less  cyanosed  ; but  this  will  depend 
upon  the  amount  of  dyspncea.  The  intellect  is 
usually  clear  to  the  last.  Signs  of  collapse 
come  on,  and  the  patient  may  sink  within  a 
period  varying  from  six  to  twenty-four  hours. 
If  recovery  does  not  take  place,  death  usually 
supervenes  within  a period  of  twelve  to  twenty- 
four  hours.  Very  frequently,  and  more  espe- 
cially in  poisoning  by  oil  of  vitriol,  the  patient 
survives  the  first  acute  symptoms  only  to  perish  j 
months  after,  should  not  the  aid  of  the  surgeon 
be  invoked  and  gastrotomy  be  performed,  bv 
slow  starvation,  due  to  local  injury  to,  and  sui- 
sequent  stricture  of,  the  oesophagus.  The  use 
of  bougies  in  these  cases,  to  keep  the  gullet 
patent,  seldom  affords  permanent  relief. 

When  nitric  acid,  or  ammonia,  is  the  poison 
taken,  the  vapours  of  the  acid  or  of  the  ammonia 
may  gain  access  to  the  air-passages  and  lungs, 
provoki ng  inflammation,  which  is  commonly  fatal-i 
The  dyspncea  and  chest-symptoms  will  be  greatly 
aggravated  in  these  cases,  and  may  overshadow 
the  more  usual  symptoms  due  to  local  action  on 
the  digestive  canal.  In  poisoning  by  the  camiq 
alkalies  (potash  and  soda  lyes)  diarrhoea,  with 
discharge  of  blood,  is  more  common  than  the 
constipation  observed  in  poisoning  by  the  mineral 
acids.  Entire  suppression  of  urine,  or  anuria,  is 
the  rule  in  poisoning  by  corrosive  sublimate. 

Oxalic  acid  in  concentrated  solution  is  un- 
doubtedly a corrosive  and  irritant  poison.  Very 
commonly,  however,  it  kills  by  its  depressing 
action  upon  the  heart  before  symptoms  of  cor 
rosion  have  become  prominent ; or  the  vomiting 
pain,  and  other  more  immediate  symptoms  o 
corrosive  poison,  are  associated  with  a feebly 
pulse,  clammy  skin,  nervous  symptoms,  aphon;  i 
and  speedy  death,  even  within  ten  minutes  of  thj 
administration  of  the  poison.  To  quote  Chris 
tison’s  language: — ‘If  a person,  immediate!; 
after  swallowing  a solution  of  a crystalline  salt 
which  tasted  purely  and  strongly  acid,  is  at 
tacked  with  burning  in  the  throat,  then  wi: 
burning  in  the  stomach,  vomiting,  particularl 
of  bloody  matter,  imperceptible  pulse,  and  ex 
cessive  languor,  and  dies  in  half  an  hour,  orstil 
more  in  twenty,  fifteen,  or  ten  minutes,  I do  nc 
know  any  fallacy  which  can  interfere  with  th 
conclusion  that  oxalic  acid  was  the  cause  c 
death.  No  parallel  disease  begins  so  abruptl 
and  terminates  so  soon,  and  no  other  crystallic 
poison  has  the  same  effects.’  It  must  be  adde 
that  binoxalate  of  potash,  and  the  soluble  ex; 
lates  generally,  are  as  poisonous  as  the  acid  itsel 
Anatomical  Characters. — The  distinct iq 
between  corrosive  and  irritant  poisons  is  by  r 
means  well-marked ; and  indeed  corrosive  poison 
when  diluted,  act  as  irritants.  Hence  wo  sha 


POISONS. 


describe  the  'post-mortem  appearances  of  corro- 
sive poisoning  under  the  bead  of  irritants. 

Diagnosis. — The  diagnosis  of  corrosive  poi- 
soning rarely  admits  of  difficulty;  and  in  any 
doubtful  case  analysis  will  remove  all  doubt. 

2.  Irritant  Poisons. — Irritant  poisons  are 
of  two  classes — metallic  irritants,  and  vegetable 
Lnd  animal  irritants,  these  latter  being  grouped 
■together.  Perhaps  none  of  them,  however,  act 
ns  pure  irritants  ; and  the  irritant  symptoms 
which  they  produce  are  most  commonly  ac- 
companied by  a well-marked  effect  upon  the 
nervous  system  also.  An  irritant  is  a poison 
[which  causes  inflammation  of  the  parts  to  which 
it  is  applied,  usually  the  alimentary  canal.  By 
Jar  the  most  important  of  the  metallic  irritant 
[poisons  is  arsenic  {see  Arsenic,  Poisoning  by). 
Other  metallic  irritants  are  the  salts  of  anti- 
mony, zinc,  and  other  metals.  Elaterium,  essen- 
tial oils,  and  gamboge  may  he  cited  as  examples 
if  vegetable  irritants ; and  cantharides  of  animal 
irritants.  Irritant  animal  and  vegetable  foods 
are  separately  described.  Sec  Poisonous  Food. 

Symptoms. — Irritants  differ  as  a rule  from 
.porrosive  poisons  in  the  greater  slowness  with 
which  the  symptoms  are  developed.  Usually 
when  an  irritant  is  swallowed,  after  an  interval — 
greater  or  less  according  to  the  specific  character 
of  the  poison— a burning  pain  is  felt,  and  sense 
jif  constriction  of  the  mouth,  throat,  and  gullet, 
:peedily  followed  by  sharp  burning  pain  in  the 
jspigastrium  ; and  this  is  increased  by  pressure — 
l mark  which  serves  to  distinguish  the  attack 
;‘rom  one  of  ordinary  colie.  Nausea,  vomiting, 
ind  great  thirst  ensue ; speedily  followed  by 
lain  and  sense  of  distension  of  the  whole  abdo- 
iuen,  which  is  exceedingly  tender,  and  perhaps 
'isibly  distended.  Most  commonly  the  vomiting 
s followed  by  purging,  tenesmus,  dysenteric 
tools,  and  often  by  dysuria.  Should  the 
loison  not  bo  speedily  removed  from  the  system 
iy  vomiting  and  purging,  these  continue  un- 
elieved,  and  increase  in  severity  ; and  symptoms 
if  inflammatory  fever,  or  it  may  be  of  collapse, 
upervene.  The  pulse  becomes  rapid,  small,  and 
hready  ; the  countenance  is  anxious  ; the  skin 
3 bathed  in  perspiration,  now  warm,  and  again 
old  and  clammy.  The  patient  may  never  rally 
rom  tho  first  shock  to  the  nervous  system ; 
lore  rarely,  having  survived  this,  he  dies  in 
pnvulsions ; or  he  may  perish  of  inanition  after 
tore  protracted  sufferings.  It  must  be  borne  in 
lind  that  those  irritant  poisons — such  as  diluted 
ilphuric  acid — which,  when  taken  in  a more 
incentrated  form,  act  as  corrosives,  may  bring 
jout  starvation,  necessitating  such  operative 
rocedure  as  gastrotomy,  by  the  injury  which 
ley  inflict  upon  the  oesophagus  and  stomach, 
eath  after  the  administration  of  an  irritant 
.lison  may,  it  is  obvious,  occur  at  very  varying 
prods  after  th9  ingestion  of  the  poison. 
Diagnosis. — Irritant  poisoning  may  be  mis- 
ken  for  various  forms  of  natural  disease.  The 
seases  with  which  it  is  most  apt  to  be  con- 
unded  are — gastritis;  gastric  ulcer,  with  or 
ithout  perforation ; peritonitis ; severe  colic  ; 
'Oradic  and  Asiatic  cholera ; and  rupture  of  the 
iraach  or  intestines.  A careful  examination  of 
I e patient,  and  the  history  of  the  case,  will  often 
move  any  doubt  which  may  be  entertained  ; but 


1237 

a microscopic  examination  and  chemical  analysis 
of  the  ejecta  of  the  patient  will  frequently  afford 
the  only  means  of  clearing  up  the  case  during 
life.  Too  frequently  irritant  poison  is  not  sus- 
pected until  a post-mortem  examination  is  made. 
In  every  case  where  a possibility  of  irritant 
poisoning  is  suggested,  the  aid  of  analysis  should 
be  invoked.  For  the  diagnostic  differences — so 
far  as  differences  in  symptoms  are  diagnostic  — 
between  irritant  poisoning  and  the  special  dis- 
eases above  mentioned,  the  reader  is  referred  to 
the  special  articles  in  this  dictionary. 

Anatomical  Characters. — Tho  post-mortem 
appearances  in  irritant  and  corrosive  poisoning 
are  corrosion  of  the  mouth,  fauces,  gullet,  and 
stomach,  the  mucous  membrane  being  shrivelled, 
altered  in  consistence  and  colour,  and  more  or 
less  detached ; irritation  and  inflammation  of  the 
stomach  and  first  portion  of  the  small  intes- 
tines; ulceration;  and  erosion.  In  corrosive 
poisoning  the  stomach  may  be  perforated,  the 
edges  of  the  aperture  being  shreddy;  and  in  the 
case  of  sulphuric  acid  tho  viscera  may  be  black- 
ened (altered  blood)  from  the  action  of  the  acid 
upon  the  blood-pigment.  The  small  intestines 
are  implicated  to  a varying  extent,  or  may  alto- 
gether escape.  The  large  intestine  may  be  at- 
tacked, and  this  is  more  especially  the  case  in 
poisoning  by  mercurial  preparations.  Arsenic 
exerts  a specific  effect  upon  the  gastric  mucous 
membrane.  Remains  of  irritants  may  be  de- 
tected in  the  intestinal  canal,  and  be  recognised 
by  their  physical,  microscopical,  and  chemical 
characters. 

3.  Neurotic  Poisons.  — Enumeration.  • — 
Under  this  head  may  be  ranged  a great  number 
of  poisons,  having  this  in  common,  that  the 
symptoms  produced  by  them  are  more  or  less 
prominently  affections  of  the  nervous  system. 
The  class  embraces  pure  narcotics,  such  as  mor- 
phia ; chloral  hydrate  ; hyoseyamus  ; digitalis  ; 
strychnia  ; prussic  acid  ; nitro-benzol ; phenol 
(carbolic  acid);  alcohol;  aconite;  belladonna, 
and  many  others. 

Symptoms. — These  are  necessarily  of  the  most 
varied  character.  All  that  has  been  said  already 
about  the  onset  of  symptoms,  their  character, 
and  the  circumstances  under  which  they  have 
appeared,  must  bo  borne  in  mind  in  arriving  at  a 
diagnosis. 

Prussic  acid  produces  its  effects  in  the  course 
of  a few  minutes ; or,  it  may  be,  seconds.  The 
course  of  symptoms  is  very  rapid  ; and  death 
may  be  well-nigh  instantaneous.  The  symptoms 
are  convulsions,  great  disturbance  of  respiration, 
with  prolonged  expiration,  dilated  pupils,  and 
cyanosis.  See  Prussic  Acid,  Poisoning  by. 

Morphia  and  opium,  after  a stage  of  excite- 
ment, produce  deep  comatose  sleep,  with  slow 
stertorous  breathing ; contracted  pupils ; and 
clammy,  perspiring  skin ; all  the  other  secretions 
being  more  or  less  suppressed.  See  Opium, 
Poisoning  by. 

Aconite  is  diagnosed  by  the  peculiar  numbness 
and  tingling  of  the  skin  which  it  produces. 

Belladonna,  and  its  alkaloid  atropine,  widely 
dilate  the  pupils,  and  cause  intense  thirst,  with 
mirthful  delirium  and  spectral  illusions. 

Alcohol  in  toxic  doses  produces  profound  in- 
sensibility ; and  there  is,  moreover,  always  mort 


1238  POISONS. 

sr  less  recognisable  by  circumstances  which  will 

be  found  described  under  Alcoholism. 

Nitrobenzol  causes  symptoms  often  undistin- 
guishablo  from  those  of  prussic  acid ; but  in  con- 
sequence of  its  insolubility,  and  the  slowness  with 
which  the  liquid  poison  is  absorbed  by  the  gastro- 
intestinal mucous  membrane,  there  is  often  a pro- 
longed interval  between  the  administration  of  the 
poison  and  the  onset  of  alarming  symptoms. 

Chloral  hydrate  causes  death  after  a stage  of 
unconsciousness ; and  there  is  scarcely  any  diffi- 
culty in  ascertaining  the  nature  of  the  case  by  the 
aid  of  the  surroundings  of  the  patient. 

Carbolic  acid  or  phenol  whitens  and  shrivels 
the  membranes  with  which  it  comes  in  contact, 
and  not  only  acts  as  a corrosive,  but  produces 
speedy  narcosis,  and  greenish  or  black  urine. 
The  peculiar  odour  of  phenol  is  always  percep- 
tible, though  not  infrequently  overlooked. 

Diagnosis. — It  is  impossible  to  enter  fully 
into  the  diagnosis  of  each  individual  neurotic 
poison.  The  most  frequent  and  important  diag- 
noses have  to  be  made  in  supposed  cases  of 
poisoning  by  opium,  alcohol,  and  strychnia  re- 
spectively. 

In  opium-poisoning  the  equally  contracted 
pupils  ; the  possibility  of  rousing  the  patient  by 
means  of  external  stimuli  in  all  except  the  later 
stages — as,  for  instance,  by  flicking  the  feet, 
the  application  of  the  electric  current,  &e. ; and 
the  moist  clammy  skin,  may  serve  to  prevent  the 
case  being  confounded  with  one  of  apoplexy.  In 
alcoholic  coma  there  is  great  danger  of  mis- 
taking the  nature  of  the  case,  in  consequence  of 
the  frequency  with  which  the  alcoholic  odour 
may  be  met  with  in  cases  where  alcohol  has  been 
taken,  either  dietetically  or  medicinally,  in  mode- 
rate or  somewhat  immoderate  doses.  The  very 
careful  use  of  the  stomach-pump  can  do  no  harm, 
and  may  not  only  save  the  patient  if  the  case  be 
one  of  alcoholic  poisoning,  but  also  serve  to  clear 
up  the  diagnosis.  The  tetanic  spasms  of  strychnia 
will  have  to  be  differentiated  from  those  of  true 
(traumatic)  tetanus.  In  this  there  is  not  usually 
any  insuperable  difficulty.  Strychnia  convul- 
sions are  intermittent ; do  not  begin  in  the  lower 
jaw  ; are,  as  a rule,  opisthotonic  in  character ; 
and  do  not  affect  the  same  groups  of  muscles  as 
are  implicated  in  true  tetanus.  See  Opium, 
Poisoning  by  ; and  Stbychnia,  Poisoning  by. 

Treatment.—  Only  the  general  principles  of 
the  treatment  of  poisoning  can  be  indicated  here. 
The  treatment  in  poisoning  by  the  most  impor- 
tant special  poisons  is  described  in  separate 
articles.  The  question  of  the  use  or  non-use  of 
the  stomach-pump  must  be  decided  by  the 
nature  of  the  poison  administered.  Where  one 
of  the  concentrated  mineral  acids,  a caustic 
alkali,  or  other  corrosive  salt,  oxalic  acid  in 
concentrated  solution,  or  carbolic  acid,  has 
been  swallowed,  it  is  generally  held  that  the 
stomach-pump  should  not  be  used,  the  danger 
of  perforation  of  the  gullet  or  stomach  being 
considerable.  In  all  cases  where  a non-corrosive 
poison  has  been  taken,  except  in  the  case_  of 
prussic  acid,  where  the  course  of  the  poisoning 
is  too  rapid  to  permit  of  the  use  of  the  instru- 
ment, the  application  of  the  pump  is  advisable 
and  can  do  no  harm.  In  cases  of  poisoning  by 
opium  and  alcohol,  the  greatest  reliance  must 


POLYPUS. 

be  placed  jn  evacuation  of  the  stomach  by 
aid.  The  corroding  acids  may  be  neutralise 1 
by  the  administration  of  lime-water,  or,  still 
better,  saccharated  lime-water ; highly  diluted 
solutions  of  the  caustic  alkalies ; or,  failing  these, 
the  continuous  use,  in  frequently  repeated  doses, 
of  chalk,  whiting,  or  the  alkaline  carbonates— sc! 
as  to  avoid  dangerous  distension  of  the  abdomen! 
with  carbonic  acid  gas.  On  the  contrary,  the 
caustic  alkalies  may  be  neutralised  by  the  co 
pious  imbibition  of  highly  diluted  acid  liquids. 
Failing  the  use  of  the  stomach-pump,  or  even! 
after  the  use  of  this,  emetics  may  be  administered 
to  relieve  the  stomach  of  irritants.  The  promprl 
administration  of  an  emetic  is  perhaps  never 
inadmissible.  The  effects  of  corrosives  and  irri- 
tants must  afterwards  be  met  by  general  reme- 
dies, such  as  demulcents  and  oil  to  sheathe  the 
mucous  membranes,  opiates  to  relieve  pain,  &cj 
The  effects  of  oxalic  acid  cannot  he  avoided  hy 
the  administration  of  alkalies  and  alkaline  car- 
bonates, for  the  alkaline  oxalates  are  themselves 
highly  poisonous.  Chalk,  whiting,  and  sola!  !ej 
lime-salts  precipitate  oxalic  acid  as  an  iusohi  lei 
calcium  oxalate,  and  form  the  best  remedies) 
No  safe  antidote  is  known  for  carbolic  acid.  Oil 
greatly  allays  the  intolerable  pain  atten  !i::g  the 
local  action  of  this  acid.  In  prussic  acid  poison-, 
ing  artificial  respiration,  persistently  used,  is  our 
sheet-anchor,  and  may  he  supplemented  hy  galva- 
nism, alternate  douches  of  warm  and  cold  water, 
and  other  measures.  After  the  use  of  the  sto-- 
mach-pump  to  remove  unabsorbed  opiates,  sti- 
mulating liquids  containing  tannin,  such  as 
strong  black  coffee,  may  he  given ; the  patient' 
must  be  kept  awake  by  walking  him  about 
flicking  the  feet  with  towels,  the  application  of 
the  Faradic  current,  &c.  Belladonna  in  full 
doses  is  in  some  respects  antagonistic  in  it- 
physiological  action  to  opium.  Conversely  opiates 
are  regarded  as  direct  antidotes  to  belladonna. 
On  the  same  principle  of  counteracting  effects, 
digitalis  and  aconite  are  counter-poisons,  and 
lienee  antidotes  the  one  to  the  other.  The  hap. 
piest  results  have  followed  the  use  of  full  doses 
of  chloral -hydrate  in  strychnia-poisoning;  and 
chloroform  may  be  freely  inhaled  to  allay  the 
tetanic  spasms.  In  alkuloidal  poisoning,  except 
where  a tetanising  poison,  such  as  strychnia  oi 
brucia,  has  been  given,  the  stomach-pump  must 
be  employed ; and  emetics  and  tannin,  in  the 
form  of  tincture  of  galls,  strong  black  coffee,  01 
strong  tea,  should  also  be  given,  with  the  object 
of  precipitating  the  alkaloid  as  an  insoluble  tan- 
nate.  Thomas  Stevenson. 

POLYDIPSIA  (ttoXvs,  much,  and  Siia 
thirst). — A synonym  for  excessive  thirst;  some 
times  used  for  diabetes.  See  Polycbia;  anc 
Thirst. 

POLYPHAGIA  (voAus,  much,  and  1 
eat). — A synonym  for  excessive  hunger.  S< 
Appetite  ; and  Pneumogastric  Nerve,  Disease* 
of. 

POLYPUS  (iroXos.  many,  and  rove,  a foot) 
Synox.  : Ft.  Polype-,  Ger.  Polyp.  . 

Definition. — This  term  is  generally  applies 
to  any  simple  pedunculated  growth,  springing 
from  a mucous  surface ; but  it  is  sometimes  ex- 


POLYPUS. 

tended  so  as  to  include  malignant  pedunculated 
growths  in  similar  situations. 

Varieties. — It  is  clear  that  no  single  de- 
scription will  apply  to  each  member  of  the  class. 
Hence  it  will  be  sufficient  to  enumerate  the 
principal  varieties  of  polypus,  a fuller  account 
of  most  of  which  will  be  found  in  the  article 
Tumours,  and  also  in  connection  with  the  dis- 
eases of  the  several  organs  which  they  affect. 

1.  Polypi  of  the  Nose. — These  are  of  two 
varieties — the  mucous  and  the  fibrous ; both  are 

j classed  among  the  fibromata.  Both  are  covered 
with  ciliated  epithelium ; the  fibrous  variety 
often  involve  the  structures  at  the  back  of  the 
pharynx,  forming  the  so-called  naso-pharyngeal 
\ polypus. 

2.  Polypi  of  the  Ear. — Polypi  of  the  ear 
resemble  those  of  the  nose,  but  present  a variety 
of  structure,  as  some  spring  trom  the  membrana 
tympani,  others  from  the  interior  of  the  tympa- 
num. 

3.  Polypi  of  the  Intestines. — These  polypi 
are  of  much  more  frequent  occurrence  in  the 
rectum  than  in  any  other  portion  of  the  intes- 
tinal tract.  They  are  composed  of  tissue  re- 
sembling that  of  the  mucous  membrane  of  the 
part,  and  are  described  amongst  the  adenomata. 

4.  Polypi  of  the  Uterus. — These  growths 
are  of  three  kinds,  namely: — (a)  Cystic,  which 
arederived  from  the  ovules  of  Naboth  ; (J)  mucous 
or  soft,  resembling  the  polypi  of  the  rectum;  (c) 
hard  or  fibrous,  the  so-called  fibrous  polypus  of 
the  uterus. 

5.  Polypi  in  other  situations. — Less  com- 
mon forms  of  polypi,  consisting  of  some  modifi- 
cation of  the  mucous  membrane  from  which  they 
are  derived,  are  found  in  the  bladder,  the  larynx, 
on  the  gums,  or  sometimes  in  the  sinuses  commu- 
nicating with  the  nose. 

Malignant  polypi  present  no  special  features 
which  would  enable  them  to  be  described  as  a 
class. 

Treatment. — Though  polypi  differ  somewhat 
in  structure,  the  treatment  of  the  simple  varieties 
of  the  class  is  the  same — that  is,  if  removal  be 
considered  advisable.  Either  the  pedicle  may 
be  grasped  and  the  tumour  removed  by  avulsion ; 
or  it  may  be  divided  at  a stroke  by  some  sharp 
instrument,  or  cut  through  slowly  or  rapidly  by 
some  form  of  ecraseur  or  ligature. 

In  removing  a malignant  polypus  a wide 
margin  of  healthy  tissue  must  be  taken  away 
from  around  the  pedicle.  E.  J.  Gom.ee. 

POLYSARCIA  ( rro\\js,  much,  and  crop!, 
3esh).— A term  for  excessive  corpulence  or 
pbesity.  See  Obesity. 

POLYURIA  (irnAvs,  much,  and  obpov,  urine). 
Iynon.  : Diabetes  Insipidus ; Er.  Polyuric ; Diabete 
rnsipide ; Ger.  Zuclcerlosc  Harnruhr. 

Definition. — A malady  or  group  of  maladies, 
■haracterised  by  thirst,  and  a persistently  ex- 
cessive flow  of  watery  urine,  which  has  a low 
pecific  gravity,  and  contains  no  albumin  or 
ugar. 

Attempts  have  been  made  to  subdivide  this 
pmp  into  smaller  sections.  One  such  section  is 
Mydipsia  or  hydruria,  having  the  characters 
boro  specified  as  those  of  polyuria;  another  is 


POLYURIA.  1239 

azoturia,  where  the  solids,  especially  urea,  are 
in  excess  of  the  normal  amount ; and  a third, 
anazoturia,  where  these  are  markedly  deficient. 
The  term  polydipsia,  referring  as  it  does  spe- 
cially to  the  symptom  thirst,  often  used,  puts 
the  cart  before  the  horse.  Hydruria  points  to 
the  dilute  character  of  the  urine  rather  than  to 
its  excessive  quantity.  Azoturia  has  been  made 
to  include  all  cases  where  urea  is  unusually 
abundant,  even  where  the  urine  is  scanty,  as 
in  fevers  ; a condition  totally  averse  from  our 
notions  of  diabetes.  Anazoturia  very  rarely 
occurs ; for,  notwithstanding  the  low  specific 
gravity  of  the  urine  in  polyuria,  owing  to  the 
large  amount  passed,  the  quantity  of  urea  may, 
and  often  does,  exceed  that  excreted  in  health. 
A form  of  polyuria,  often  slightly  marked,  has 
been  described  as  ‘ phosphatic  diabetes,’  on  ac- 
count of  the  excess  of  phosphates  passed.  The 
separation  of  these  cases  into  a distinct  group  is 
hardly  necessary.  Certain  factors  in  the  above 
definition  require  special  attention,  the  better 
to  mark  off  the  malady  so  defined  from  other 
pathological  states.  Thus  the  flow  must  not 
only  be  excessive,  but  persistently  so.  This 
separates  polyuria  from  conditions  where  there 
exists  a merely  temporary  flow  of  an  unusual 
amount. 

JEtiology. — Polyuria  is  limited  neither  by  age 
nor  by  sex.  'It  may  exist  in  the  new-born  infant, 
and  it  may  be  found  in  the  patient  of  seventy,  but 
on  the  whole  it  is  a disease  of  early  rather  than 
advanced  life,  whilst  it  is  about  twice  as  frequent 
in  males  as  in  females.  Nothing  is  more  marked 
in  connection  with  the  causation  of  polyuria  than 
heredity.  Perhaps  the  most  extraordinary  ex- 
ample of  this  is  recorded  by  Dr.  Gee,  where  the 
disease  was  directly  transmitted  through  four 
generations.  Sometimes  one  member  of  the 
family  escaped,  but  the  children  were  sure  to 
be  attacked.  A newly-born  infant,  a member  of 
this  family,  suffered  from  unusual  thirst,  so  much 
so  that  water  had  to  be  given  to  still  it. 

Beyond  inheritance,  nothing  very  definite  can 
be  said  as  to  the  cause  and  origin  of  polyuria. 
It  is  often  connected  with  nervous  affections  or 
nervous  excitement,  and  sometimes  follows  upon 
injuries  to  the  head  or  disease  of  the  brain. 
Drinking  bouts  too  have  been  credited  with  giv- 
ing rise  to  the  disease,  as  have  drinking  cold 
fluids,  and  sudden  exposure  to  cold.  Beyond  these, 
no  cause  of  any  value  can  be  assigned  ; often  in- 
deed the  disease  comes  on  without  even  such 
insufficient  reasons  as  those  given  above,  some  of 
which  have  doubtless  been  assigned  on  the  yiosj 
hoc  principle. 

Symptoms. — Not  much  need  be  said  regarding 
the  clinical  history  of  polyuria.  When  the  result 
of  accident  or  mental  emotion,  its  onset  is  usually 
abrupt,  anditmay  end  in  like  manner;  sometimes 
as  the  result  of  intercurrent  disease  of  a febrile 
kind.  During  its  continuance  thirst  and  watery 
urine  are  the  two  prime  symptoms,  for  there 
may  be  little  wasting,  and  the  general  health  may 
be  good.  Occasionally  there  is  increased  appetite, 
as  in  one  of  Trousseau's  patients,  whom  restaura- 
teurs would  pay  to  stop  away.  In  this  patient, 
too,  there  was  great  toleranco  of  intoxicating 
liquors,  whilst  in  others  the  opposite  condition 
has  been  noted.  Usually  the  bowels  are  con< 


POLYURIA. 


1240 

fined,  and  the  skin  dry,  though  neither  happens 
invariably.  Boils,  to  common  in  diabetes,  are 
rarely  seen;  but  purpuric  spots  sometimes  occur, 
as  does  cedema,  or  that  iaxness  of  subcutaneous 
tissue  which  often  passes  for  oedema,  in  the 
later  stages.  As  long  as  drink  is  supplied  in 
plenty,  the  condition  of  the  patient  is  very  toler- 
able, were  it  not  for  the  broken  sleep  caused 
by  the  incessant  thirst  and  the  desire  to  pass 
water ; but  any  attempt  to  restrict  the  quantity 
of  fluid  gives  rise  to  intense  discomfort,  even 
causing  the  patient  to  drink  his  own  urine. 
Ultimately  this  constant  strain  wears  out  the 
patient,  and  leads  to  death,  if  intercurrent  dis- 
ease do  not  carry  him  off. 

Of  the  phenomena  of  polyuria,  the  urine  alone 
requires  special  notice.  It  is  inordinate  in  its 
quantity,  and  of  a specific  gravity  little  above 
that  of  spring  water.  In  a case  under  the  care 
of  the  writer,  it  remained  persistently  at  1,001 ; 
but  it  may  rise  to  as  much  as  1,008  or  1,010. 
It  is  transparent ; almost  like  water ; of  a faint 
greenish-yellow  tint ; and  with  little  taste,  smell, 
or  acid  reaction.  In  quantity  it  varies  with  the 
amount  of  water  consumed.  If  the  patient  is 
allowed  to  drink  at  will,  the  quantity  passed 
roughly  corresponds  with  that  drunk,  allowance 
being  made  for  the  watery  vapour  passing  away 
by  the  lungs,  and  perhaps  also  by  the  skin.  If 
the  drink  be  restricted,  more  will  be  passed  than 
is  consumed,  by  the  abstraction  of  water  from 
the  body.  On  the  whole  the  quantity  passed 
is  greater  than  in  ordinary  diabetes,  and  may 
sometimes  be  measured  by  the  pailful.  Of  the 
normal  constituents  of  urine,  urea,  though  rela- 
tively deficient  in  any  specimen  examined,  is 
upon  the  whole  in  excess,  sometimes  enormously 
so.  On  the  other  hand,  uric  acid  seems  dimi- 
nished, hut  this  may  depend  on  the  difficulty  of 
estimating  it  in  urine  so  greatly  diluted.  Sul- 
phates and  phosphates,  especially  the  earthy 
salts  of  the  latter,  are  usually  increased,  whilst 
the  only  abnormal  constituent,  if  such  it  can  be 
called,  commonly  found  is  inosite. 

Pathology. — As  in  the  case  of  saccharine 
diabetes,  our  insight  into  the  morbid  processes 
concerned  in  the  production  of  polyuria  has  been 
greatly  aided  by  direct  experiment.  Bernard 
found  that  by  pricking  the  floor  of  the  fourth 
ventricle  above  the  level  of  the  ‘ sugar  puncture  ’ 
he  could  produce  copious  diuresis;  and  in  certain 
animals  injuries  to  the  central  lobe  of  the  cere- 
bellum (the  vermiform  process  of  human  ana- 
tomy) are  followed  by  a like  lesult.  From 
this  part  of  the  nervous  system  the  nervous 
influence  seems  propagated  to  the  kidneys  both 
by  the  splanchnics  and  spinal  cord,  but  the 
exact  course  of  the  fibres  has  not  yet  been 
clearly  demonstrated.  Whether  the  nerves  are 
merely  vaso-motor  fibres,  section  or  paralysis  of 
which  would  produce  turgescence  of  the  vessels 
of  the  kidneys,  or  trophic  fibres,  irritation  of 
which  would  increase  the  activity  of  these  or- 
gans, is  not  yet  determined  ; but  in  all  probabi- 
lity paralysis  of  the  vaso-motor  fibres  is  the 
main  factor  in  the  production  of  hydruria. 

In  the  definition  of  polyuria  given  above  dis- 
ease of  i be  kidneys  was  expressly  excluded  ; and 
after  death,  as  far  as  the  malady  itself  is  con- 
cerned, nothing  is  to  be  found  except  increased 


vascularity.  As  a consequence  of  the  disease, 
however,  persisting  over  many  years,  and  giving 
rise  to  frequent  and  severe  distension  of  the 
bladder,  when  circumstances  may  prevent  its 
being  emptied  with  sufficient  frequency,  thicken- 
ing of  the  walls  of  the  bladder,  dilatation  of  the 
ureters,  and  sacculation  of  the  kidney  have  been 
described ; but  the  accuracy  of  such  observations 
as  the  results  of  simple  polyuria  have  been 
questioned.  Undoubtedly  the  most  important 
lesions  which  hear  on  the  disease  are  those 
which  have  befin  ’found  in  the  brain,  especially 
in  the  neighbourhood  of  the  fourth  ventricle. 
These,  besides  the  injuries  already  alluded  to, 
comprehend  tubercular  and  other  forms  of  in- 
flammation, tumours  of  various  kinds — glioma- 
tous  and  syphilitic,  together  with  other  local 
changes  of  different  kinds. 

Diagnosis. — The  diagnosis  of  polyuria,  accord- 
ing to  the  defini  tion  already  given,  is  easy.  Itrests 
on  these  factors — thirst,  and  persistent  excess 
of  urine,  coupled  with  the  absence  of  sugar  and 
albumin.  It  has  further  to  be  carefully  distin- 
guished from  mere  temporary  excess  of  eatery 
urine.  Such  an  excess  may  occur  where  a .urge 
quantity  of  fluid  of  a diuretic  kind  has  been 
swallowed,  especially  when  there  is  little  or  no 
cutaneous  transpiration.  Again  sudden  flows  of 
urine  may  occur  about  the  period  of  early  conva- 
lescence from  fever,  or  yet  again  when  a hydro- 
nephrosis suddenly  empties  itself.  A 11  these  are 
merely  temporary  and  evanescent  states.  The 
total  absence  of  sugar  distinguishes  polyuria  from 
diabetes,  though  it  is  well  known  that  the  one 
state  may  pass  into  the  other.  In  certain  forms 
of  Bright’s  disease,  especially  those  characterised 
by  contracted  kidney,  the  urine  may  he  excessive 
and  of  low  specific  gravity;  but  in  all  of  these 
albumin  will  be  at  least  now  and  again  found. 
Finally,  polyuria  is  not  to  be  confounded  with 
such  abnormal  discharges  of  urine  as  may  occur 
from  time  to  time  in  what  we  call  hysteria  and 
its  allies.  Hero  the  nervous  symptoms  give  a 
special  feature  to  the  malady  ; nevertheless  poly- 
uria has  strongly  marked  nervous  affinities. 

Prognosis. — This  cannot  be  called  favourable, 
for,  whilst  few  actually  perish  from  the  uncompli 
cated  disease,  still  fewer  are  cured  of  it,  though 
a good  manyT  get  well.  For  some  unaccountable 
reason,  Trousseau  looked  upon  polyuria  as  more 
dangerous  than  diabetes;  hut  ordinary  experience 
cannot  bear  out  this  view.  Probably  its  con- 
nection with  tubercular  disease  in  many  cases 
misled  him.  Under  such  circumstances  the  tu- 
bercular disease  would  run  its  course  just  as 
disease  of  the  nerve-centres  would,  altogether 
independent  of  the  polyuria. 

Treatment. — As  might  he  inferred  from  the 
account  of  the  disease  given  above,  the  treatmeni 
of  polyuria  is  far  from  satisfactory.  If  the  dis- 
ease can  be  assigned  to  any  definite  cause,  we 
must  look  to  that  and  deal  with  it,  rather  than 
with  the  excessive  urination  ; if  not,  it  must  he 
our  endeavour  to  counterbalance  the  draining  of 

the  tissues,  and  the  corresponding  waste,  by  a 

plentiful  supply  of  fluid  and  good  nourishing 
diet.  To  relieve  the  kidneys  from  the  unusual 
stress  thrown  upon  them,  diaphoretics  have  been 
recommended;  at  all  events  great  care  should  he 
taken  of  the  clothing  so  as  to  secure  the  patient 


POLYUKIA. 

from  any  risk  from  cold.  Of  medicinal  remedies, 
that  -which  has  been  most  lauded  is  valerian, 
especially  by  Trousseau,  who  gave  it  in  enormous 
doses.  Probably  it,  like  other  antispasmodic 
remedies,  would  be  found  of  most  service  in 
cases  allied  to  hysteria  or  similar  neuroses.  In 
one  case  under  his  care,  the  writer  tried  the 
whole  range  of  antispasmodic  remedies  without 
effect.  Opium  and  its  alkaloids,  though  so  ser- 
viceable in  diabetes,  are  worse  than  useless  in 
polyuria.  They  diminish  the  thirst  and  the 
urine,  but  they  greatly  increase  the  patient’s  dis- 
comfort. Tonics,  especially  strychnine  and  iron, 
do  good  by  improving  the  general  health.  In 
another  case  under  the  care  of  the  writer,  in  a 
highly  scrofulous  subject,  after  every  medicinal 
remedy  had  been  tried  in  vain,  change  of  air  at 
the  seaside  was  followed  by  almost  complete 
disappearance  of  the  polyuria.  The  importance 
of  attending  to  the  constitutional  state  is  strik- 
ingly indicated  in  this  case.  Finally,  in  the 
hands  of  some  the  constant  electric  current  has 
lone  good,  whilst  it  has  equally  failed  in  the 
ixperience  of  others. 

Alexander  Silver. 

POMPHOLYX(7T0|Uifl>!r,  abulia  or  bladder), 
"his  term  is  applicable  to  the  bullous  affection 
o'  the  skin  more  commonly  denominated  pem- 
pligus,  of  which  it  is,  in  fact,  a synonym.  See 
Pemphigus. 

POUS  VAE.OLII,  Lesions  of. — Synon.  : 

Fr.  Maladies  de  la  Mesocephale;  Ger.  Krankheiten 
der  Brucke. 

Introduction. — The  pons  is  liable  to  a variety 
of  affections,  either  by  morbid  processes  having 
their  primary  seat  here,  or  by  secondary  impli- 
cation from  disease  originating  elsewrhere,  as  by 
tumours  of  the  cerebellum  or  base  of  the  skull, 
or  aneurism  of  the  basilar  artery. 

The  position  of  the  pons,  its  close  relation  to 
the  vital  centres  of  the  medulla  oblongata,  the 
connection  of  the  sensory  and  motor  paths  with 
the  cerebrum  and  spinal  cord  on  the  one  hand, 
and  the  cerebellum  on  the  other,  and  the  transit 
through  it  of  many  of  the  cranial  nerves,  render 
the  symptomatology  of  pontine  affections  highly 
complex  and  diversified. 

Summary  of  Pathological  Conditions.— 
Hcemorrhage  in  the  substance  of  the  pons  is  by 
no  means  uncommon,  and  may  vary  from  a 
minute  focus  up  to  a complete  disorganisation 
and  rupture  into  the  fourth  ventricle.  Embolism 
is  not  common;  but  thrombosis , from  syphilitic  or 
atheromatous  degeneration  of  the  basilar  artery, 
is  frequent,  and  is  the  origin  of  necrotic  softening 
of  an  acute  or  chronic  character. 

Hcemorrhage. — Haemorrhage  into  the  substance 
of  the  pons,  if  of  small  extent,  is  net  necessarily 
fatal ; but  if  it  be  of  large  amount,  death  occurs 
suddenly,  or  within  a very  few  hours.  Sometimes 
.there  is  a sudden  onset  of  coma,  with  complete 
relaxation  of  the  whole  muscular  system.  The 
pupils  are,  as  a rule,  minutely  contracted,  and  the 
1 condition  resembles  profound  narcotic  poisoning. 
The  temperature  may  rise  to  as  much  as  105° 
I'ahr.  or  more.  Deglutition  is  difficult  or  im- 
possible; and  death  ensues  from  cardiac  and 
respiratory  paralysis,  irregularity  in  the  rhythm 


PONS  YAEOLII,  LESIONS  OF.  1241 
preceding  the  fatal  issue.  At  other  times,  and 
of  great  signification  in  a diagnostic  point  of 
view,  muscular  spasms  occur,  either  general  or 
affecting  one  side  more  than  the  other,  with  dis- 
tortion of  the  face,  either  from  paralysis  of  one 
side,  or  this  combined  with  active  spasm  of  the 
other. 

The  occurrence  of  paralysis  of  one  side  of  the 
face  and  of  the  limbs  of  the  other  side,  so-called 
‘alternate’  paralysis,  is  pathognomonic  of  the 
pontine  seat  of  the  lesion. 

Softening. — Acute  embolic  or  thrombotic  soft- 
ening of  the  pons,  with  or  without  loss  of  con- 
sciousness, may  lead  to  death  rapidly,  with  simi- 
lar paralytic  symptoms;  but  days  may  elapse, 
or  even  months,  after  the  first  onset,  with  charac- 
teristic symptoms  indicative  of  the  position  of 
the  lesion,  and  death  ensue  either  from  gradual 
implication  of  the  vital  centres,  or  quite  sud- 
denly. 

Localising  Phenomena. — The  symptoms  most 
characteristic  of  lesions  of  the  pons  are  a com- 
bination of  paralysis  of  certain  cranial  nerves  on 
the  one  side,  and  of  the  limbs  on  the  other.  The 
most  common  combination  is  paralysis  on  one 
side  of  the  face  and  of  the  limbs  on  the  opposite, 
the  face  being  paralysed  on  the  side  of  the 
lesion.  The  facial  paralysis  in  this  case  re- 
sembles peripheral  facial  paralysis,  both  in  the 
implication  of  the  orbicularis  oculi  and  degenera- 
tive changes  in  the  muscles.  The  limbs  may  be 
paralysed  as  to  motion  only,  or  there  may  be  a 
combination  both  of  sensory  and  motor  paralysis. 
Sometimes  the  motor  paralysis  affects  one  limb 
more  than  the  other,  and  there  may  be  a similar 
distribution  of  the  anaesthesia. 

The  alternate  paralysis  of  the  face  on  one  side, 
and  of  the  limbs  on  the  opposite,  occurs  more 
particularly  with  lesions  of  the  pons  situated 
towards  the  pyramids,  at  a point  where  the 
facial  roots  have  not  crossed  over  to  pass  on  to 
the  opposite  hemisphere.  If  the  lesion  be  higher 
up,  near  the  crus  cerebri,  the  face  and  limbs  may 
both  be  paralysed  on  the  side  opposite  the  lesion. 
Amongst  other  varieties  the  face  alone  may  be 
paralysed,  without  affection  of  the  limbs  ; or  one 
side  of  the  face  may  be  paralysed,  and  the  other 
in  a state  of  spasm  ; or  both  sides  of  the  face 
may  be  paralysed  ; or  one  side  of  the  face  may 
be  paralysed,  and  the  limbs  on  both  sides  ; or 
both  sides  of  the  face,  and  the  limbs  on  one 
side.  Spasms  in  the  limbs  paralysed  or  in  the 
others  may  occur  ; and  similar  irritation  of  the 
sensory  strands  may  be  indicated  by  exeentric 
hyperaesthesia  and  paraesthesia. 

Along  with  the  motor  paralysis  of  the  limbs, 
there  is  also  a varying  degree  of  vaso-motor 
paralysis,  and  a difference  in  temperature  of  the 
limbs  of  one  degree  or  more. 

Next  in  frequency  to  affections  of  the  facial 
nerve,  with  or  without  affections  of  the  limbs  of 
the  variable  character  above  mentioned,  comes 
affection  of  the  abducens  or  sixth  cranial  nerve. 
This  gives  rise  to  an  internal  strabismus,  and 
usually  of  the  eye  on  the  same  side  as  the  lesion. 
There  may  be,  therefore,  paralysis  of  the  face 
and  abducens  on  the  side  of  lesion,  and  of  the 
extremities  on  the  opposite  side ; but  cases  have 
been  recorded  of  paralysis  of  the  abducens  on  one 
side,  and  of  the  face  and  limbs  on  the  opposite ; 


1242  PONS  VAROLII,  LESIONS  OF. 
and  also  of  paralysis  of  tlie  face,  abducens  nerve, 
and  limbs  on  the  same  side  as  the  lesion. 

Defects  in  articulation  are  not  unfrequently 
observed,  depending  on  impaired  mobility  of  the 
tongue,  usually  on  the  side  of  the  motor  paralysis 
of  the  limbs,  but  apparently  sometimes  on  the 
other  side.  The  fifth  cranial  nerve  is  also  not 
unfrequently  implicated.  The  sensory  portion 
seems  to  suffer  more  than  the  motor.  But  cases 
have  been  recorded  in  which  the  motor  portion 
of  the  fifth  has  been  specially  affected,  leading 
to  paralysis  and  degeneration  of  the  muscles  of 
mastication. 

The  affection  of  the  sensory  division  shows  itself 
in  more  or  less  marked  anaesthesia  of  the  face,  which 
may  be  general  or  limited  to  the  area  of  distri- 
bution of  some  of  the  branches  only.  The  tongue 
is  not  unfrequently  affected  on  the  same  side, 
and  tactile  and  gustatory  sensibility  impaired  or 
abolished  on  the  anterior  two-thirds.  The  affec- 
tion of  the  fifth  may  occur  on  the  same  side  as 
the  lesion,  with  or  without  affection  of  the  limbs, 
but  it  would  appear  also  that  anaesthesia  of  the 
face  may  occur,  with  implication  of  the  ex- 
tremities on  the  side  opposite  the  lesion. 

There  is  thus  an  extraordinary  complexity 
and  variability  in  the  symptoms  which  may 
bo  met  with  in  connection  with  pontine  lesions. 
Those  which  have  been  mentioned  are  the  most 
common  and  most  significant,  especially  if  they 
occur  in  combination.  Singly  they  have  less 
value,  and  some  of  them,  particularly  defects  in 
articulation,  are  not  specially  characteristic.  But 
a combination  of  paralysis  of  the  limbs  on  one 
side,  either  motor  alone,  or  of  motility  and  sensi- 
bility, and  of  the  face  on  the  other,  is  significant 
of  pontine  lesion.  The  addition  of  paralysis  of 
the  abducens  adds  to  the  certainty. 

Many  other  symptoms  might  be  mentioned 
which  have  been  noted  in  connection  with  lesions 
of  the  pons,  especially  tumours,  which  ought 
perhaps  to  be  ascribed  to  interference  with  the 
functisns  of  neighbouring  structures.  As  in 
other  parts,  however,  tumours  have  been  found 
invading  or  pressing  on  the  pons  without  having 
given  rise  to  any  marked  symptoms  during  life. 
But  at  other  times,  along  with  one  or  more  of 
the  previously  mentioned  symptoms,  impairment 
of  deglutition  has  been  observed,  due  without 
doubt  to  pressure  on  the  medulla  oblongata.  To 
pressure  on  the  medulla  oblongata  should  also  be 
ascribed  the  irregularity  and  ultimate  paralysis 
of  the  cardiac  and  respiratory  movements,  in 
connection  either  with  tumours  or  with  haemor- 
rhagic effusions  into  the  pons  itself. 

When  a tumour  presses  forward  in  the  direc- 
tion of  the  crura  cerebri,  the  third  cranial  nerves 
may  be  implicated.  Ptosis  has  been  observed 
in  such  cases  ; and  external  strabismus,  from 
paralysis  of  the  internal  rectus,  has  also  oc- 
curred, but  comparatively  rarely. 

Vertigo  and  disorders  of  equilibration  have  also 
been  observed,  but  these  may  be  attributed  to  an 
implication  of  the  cerebellum  or  of  its  peduncles. 
Ataxic  symptoms  have,  however,  been  described 
by  Leyden  as  occurring  in  pontine  lesions,  with- 
out affection  either  of  the  cerebellum  or  of  its 
peduncles.  The  writer  has  seen  a case  of  very 
marked  ataxy  associated  with  anaesthesia  of  one 
side  of  the  face,  and  of  the  limbs  and  trunk  on  the 


PORTAL  OBSTRUCTION, 
opposite  side,  due  probably  to  lesion  on  the  right 
side  of  the  pons.  But  the  cases  which  have  been 
recorded  are  not  yet  sufficient  to  establish  any 
very  definite  propositions  in  regard  to  the  exact 
causation  or  special  characteristics  of  the  ataxic 
disorders  in  question.  In  connection  with  tu- 
mours pressing  on  the  pons,  hearing  may  also  be 
impaired  or  abolished  in  one  or  both  ears.  Im- 
pairment of  smell  has  been  observed  on  one  side, 
when  there  has  been  ansesthesia  of  the  face.  This 
is  probably  due  to  the  impairment  of  common 
sensibility  in  the  nostril,  intensified  in  some  cases 
by  the  defective  power  of  sniffing  if  the  facial 
nerve  is  also  paralysed. 

Albuminuria  and  glycosuria  have  occasionally 
been  found  in  connection  with  diseases  of  the 
pons.  It  is  very  doubtful  if  any  causal  relation- 
ship has  been  at  all  satisfactorily  established. 
Very  often  when  albumin  has  been  found,  there 
is  good  reason  to  believe  that  it  has  been  pre- 
existing, for  lesions  of  the  pons  frequently  occur 
in  connection  with  chronic  renal  disease.  Sugar 
has  been  found  sometimes,  and  in  other  cases 
not.  The  same  has  been  found  in  connection 
with  lesions  of  other  nerve-centres.  So  far, 
therefore,  as  facts  go,  the  evidence  in  favour  of 
a direct  relationship  between  pontine  lesions  and 
glycosuria  is  at  present  extremely  slender,  and  in 
need  of  further  investigation. 

Diseases  which  encroach  on  the  intracranial 
space  produce  the  general  symptoms  of  intracra- 
nial tumour,  in  addition  to  the  special  symptoms 
indicative  of  their  invasion  of  the  pons. 

D.  1'f.eeier. 

PORRIGO  LARVALIS  ( [porrigo , scarf, 
and  larva,  a mask). — Porrigo  is  an  old-fashioned 
term,  applied  generally  to  eruptions  on  the  scalp 
and  face,  whether  exudative  or  desquamative; 
larvalis,  masked,  alludes  to  the  covering  of  the 
face  with  an  incrustation  which  conceals  the 
features  like  a mask,  such  as  is  seen  in  a neg- 
lected exudative  eczema  of  the  face,  an  eczema 
pustulosum  or  impetiginodes.  Pathologically, 
porrigo  is  an  eczema.  Sec  Eczema. 

PORTAL  OBSTRUCTION.— This  is  a 

condition  of  not  uncommon  occurrence,  and  calls 
for  brief  general  discussion.  Strictly  speakiDg, 
portal  obstruction  implies  that  there  is  some 
direct  impediment  to  the  flow  of  blood  in  the 
portal  circulation,  either  affecting  the  trunk  of 
the  vein  before  it  enters  the  liver,  or  its  branches 
in  the  substance  of  this  organ.  It  must  be  re- 
membered, however,  that  any  condition  that  in- 
terferes with  the  circulation  beyond  the  portal 
divisions,  whether  in  the  hepatic  vein,  inferior 
vena  cava,  right  side  of  the  heart,  or  lungs,  will 
retard  more  or  less  the  flow  of  blood  through  the 
portal  system ; and  also  that  either  of  the  tribu- 
tary  branches  of  the  portal  vein  may  he  affected 
alone.  The  portal  trunk  may  be  obstructed  by 
direct  pressure  upon  it,  as  by  enlarged  glands,  a 
growth  projecting  from  the  liver,  or  a neighbour- 
ing tumour ; by  changes  in  its  walls,  leading  to 
constriction  or  complete  closure ; or  by  blocking- 
up  of  its  channel,  as  by  a thrombus  ( see  Portal 
Thrombosis!.  Cirrhosis  is  the  most  important 
disease  which  obstructs  the  portal  circulation 
within  the  liver;  but  this  result  may  also  arise 
from  accumulation  of  pigment  and  other  causes. 


PORTAL  OBSTRUCTION. 

Effects. — The  effects  of  portal  obstruction 
will  depend  on  its  seat,  its  degree,  and  the  ra- 
pidity with  which  it  is  set  up.  They  are  merely 
those  which  necessarily  follow  mechanical  venous 
congestion,  namely,  distension  of  the  small  vessels, 
which  may  end  in  changes  in  their  walls  and  vari- 
cosity ; escape  of  serum;  a catarrhal  condition  of 
mucous  surfaces;  haemorrhages;  and,  in  course  of 
time,  permanent  changes  in  organs  and  structures 
which  are  congested.  Their  localisation  in  this 
ease  will  correspond  to  the  structures  from  which 
the  portal  vein  receives  its  tributary  branches. 
Hence  any  of  the  following  conditions  may  re- 
sult in  various  degrees  from  portal  obstruction ; 
— (1)  Congestion  and  catarrh  of  the  mucous 
membrane  lining  the  stomach  and  intestines, 
with  consequent  disorder  of  the  secretions  ; dila- 
tation and  varicosity  of  the  small  vessels  ; or  hae- 
morrhage into  the  alimentary  canal.  (2)  Ascites, 
one  of  the  most  frequent  and  evident  phenomena. 
(3)  Enlargement  of  the  spleen,  either  from  mere 
accumulation  of  blood,  or  in  chronic  cases  w’ith 
permanent  increase  and  alteration  in  the  splenic 
structure.  (4)  Congestion,  followed  by  fibroid 
changes  in  the  pancreas.  (5)  Haemorrhoids,  it  is 
generally  believed.  (6)  After  a while  enlarge- 
ment of  the  superficial  veins  of  the  abdominal 
wall,  owing  to  their  communications  with  the 
portal  vein;  as  well  as  of  the  veins  within  the 
abdomen,  which  are  tributary  to  it. 

Several  of  the  conditions  mentioned  are  ob- 
vious on  clinical  examination  during  life;  others 
are  only  evident  on  ‘post-mortem  examination, 
although  they  assist  in  originating  symptoms, 
especially  in  connection  with  the  alimentary 
canal,  such  as  those  of  dyspepsia,  flatulence,  and 
disordered  bowels.  Haemorrhage  into  the  sto- 
mach or  bowels  is  usually  revealed  by  the  oc- 
currence of  hsematemesis  or  melsena,  but  it  may 
prove  fatal  without  any  discharge  of  blood  ex- 
ternally. It  must  necessarily  happen  that  if  the 
portal  circulation  is  not  properly  carried  on,  the 
functions  of  the  liver  are  proportionately  dis- 
turbed. 

The  signs  of  portal  obstruction  may  set  in  with 
great  acuteness,  or  very  gradually.  Those  indi- 
cative of  acute  obstruction  are  the  rapid  develop- 
ment of  ascites,  returning  speedily  after  para- 
centesis ; enlargement  of  the  spleen ; and  hsmor- 
rhage  into  the  alimentary  canal.  It  must  be 
remarked  that  the  most  striking  phenomena  may 
disappear  in  chronic  cases,  after  a time,  without 
the  removal  of  the  obstruction,  probably  owing 
to  the  development  of  new  channels,  by  which  the 
blood  is  returned  to  the  heart  without  passing 
through  the  liver. 

Diagnosis. — There  ought  to  be  no  difficulty 
in  recognising  the  signs  of  portal  obstruction  in 
marked  cases ; and  it  might  even  be  suspected 
before  these  signs  are  well-developed  under 
certain  conditions.  The  cause  of  the  obstruction 
can  only  be  made  out  by  a consideration  of  each 
case  in  all  its  features. 

Treatment. — Rarely  can  anything  be  done 
directly  to  remove  portal  obstruction.  The  cir- 
culation may  often  be  relieved  to  some  extent  by 
acting  freely  upon  the  bowels,  especially  by  means 
of  saline  and  hydragogue  purgatives.  Treatment 
directed  to  the  effects  of  portal  obstruction  i3 
frequently  highly  efficacious,  and  the  most  im- 


POST-MORTEM  EXAMINATION.  1243 
portant  of  these  may  be  cured  or  relieved,  even 
though  their  cause  remain  unaffected.  The 
special  treatment  of  these  symptoms,  and  also 
of  the  conditions  upon  which  portal  obstruction 
depends,  is  described  in  other  articles. 

Frederick  T.  Roberts. 

POSTAL  THROMBOSIS.— Synon.: Por- 
tal Phlebitis;  Pylephlebitis;  Fr.  Pylephlebite  ; 
Ger.  Pylephlebitis. 

Portal  thrombosis  may  be  divided  into  two 
kinds  : ( A ) the  Adhesive ; and  ( B ) the  Sup- 
purative. 

(A)  Adhesive  Portal  Thrombosis. — Ad- 
hesive portal  thrombosis  is  seen  most  commonly 
in  cirrhosis  of  the  liver,  rarely  as  a cause  of 
the  cirrhosis  itself.  In  the  first  case,  it  arises, 
not  from  an  inflammation  of  the  walls  of  the 
vessel,  but  from  obstruction  to  the  circulation. 
The  thrombus  itself  is  usually  firmly  adherent  to 
the  walls,  tough,  and  of  a red-brown  colour, 
the  vein  being  dilated. 

Symptoms. — The  symptoms  of  portal  throm- 
bosis are  those  of  intense  portal  obstruction. 
There  is  ascites,  rapidly  developing  itself,  and, 
according  to  Frerichs,  returning  rapidly  after 
removal  by  tapping.  The  veins  of  the  walls  of 
the  belly  become  dilated.  There  may  be  hsema- 
temesis  or  a bloody  diarrhoea.  The  spleen  is 
greatly  enlarged.  Jaundice  may  or  may  not  be 
present. 

Diagnosis. — The  diagnosis  of  portal  throm- 
bosis is  a matter  of  great  difficulty,  the  symptoms 
being  very  like  those  of  cirrhosis,  of  which,  in- 
deed, it  is  often  a mere  complication. 

Prognosis  and  Treatment. — The  prognosis 
is  always  bad,  no  instance  of  recovery  being 
known,  and  the  treatment  must  be  the  same  as 
for  cirrhosis. 

(B)  Suppurative  Portal  Thrombosis. — 
Suppurative  portal  thrombosis  is  commonly  met 
with  in  connection  with  some  morbid  process, 
most  often  suppuration,  in  the  parts  from  which 
the  branches  of  the  portal  vein  arise,  as  the  intes- 
tines, of  which  very  often  the  caecum  is  the  seat, 
next  the  stomach,  and  the  spleen.  The  vein  is 
found  greatly  dilated,  and  filled  with  a dirty 
grey  or  reddish  pulp,  which,  under  the  micro- 
scope, shows  small  round  nucleated  cells  like  pus- 
corpuscles.  The  liver  itself  shows,  on  section, 
the  branches  of  the  portal  vein  filled  with  a dif- 
fluent thrombus,  so  that  the  organ  looks  as  if 
pervaded  with  abscesses. 

Symptoms. — The  symptoms  closely  resemble 
those  of  abscess  of  the  liver  or  of  pyaemia.  Traube 
thinks  the  diagnosis  may  be  made  if  the  liver 
and  spleen  be  much  enlarged,  and  if  there  be  re- 
turning attacks  of  rigors  with  raised  tempera- 
ture, while  between  the  attacks  the  temperature 
is  natural  or  only  slightly  raised,  There  must  be 
also  evidence  of  some  suppuration,  which  mav 
involve  the  branches  of  the  portal  vein ; and 
pyaemia  and  endocarditis  must  be  excluded. 
Often,  however,  all  these  signs  fail. 

Prognosis  and  Treatment. — The  prognosis 
is  always  bad ; the  treatment  must  be  the  same 
as  for  abscess  of  the  liver  or  pyaemia. 

J.  Wickham  Lego. 

POST-MORTEM  EXAMINATION. 
Necropsy. 


POST-MORTEM  WOUNDS. 


1244 

POST-MORTEM  WOUNDS. — -Synon.  : 

Dissection-wounds ; Er.  Blessitres  anatomiques ; 
Ger.  Sectionwunden. 

Definition. — A variety  of  poisoned  wounds, 
arising  from  the  inoculation  of  a virus  derived 
from  the  dead  bodies  of  men  or  animals. 

Similar  consequences  may  result  from  the  in- 
oculation of  the  discharges  from  unhealthy  in- 
flammations in  living  bodies,  especially  those 
arising  from  post-mortem  poisoning.  The  condi- 
tions necessary  for  the  production  of  adissection- 
wound  are  the  virus,  a means  of  entrance  of  the 
virus  into  the  system,  and  a condition  of  body 
favourable  to  the  development  of  the  effects  of 
the  virus. 

Patholosy. — The  Virus.  Of  the  exact  nature 
of  the  poison  which  gives  rise  to  post-mortem 
wounds  we  know  but  little.  The  products  of 
ordinary  decomposition  may  cause  local  troubles, 
to  be  mentioned  hereafter,  but  they  never  give 
rise  to  the  graver  forms  of  dissection-wound. 
The  poison  is  present  in  greatest  intensity  in 
fresh  bodies,  and  its  virulence  diminishes  as  de- 
composition advances.  We  have  no  evidence 
that  it  is  the  same  in  all  cases,  and  as  the  effects 
vary  greatly,  we  are  justified  in  assuming  that 
the  poison  also  varies.  The  chief  views  held  as 
to  its  nature  are,  that  it  is  a product  of  a certain 
stage  of  ordinary  decomposition;  that  it  is  the 
product  of  some  special  non-organised  ferment ; 
and  that  it  is  of  the  nature  of  a minute  organ- 
ism, which  has  the  power  of  propagating  itself  in 
the  living  body.  The  first  view  is  probably  un- 
true, as  the  poison  which  gives  rise  to  serious 
dissection-wounds  is  only  found  in  tne  bodies  of 
patients  who  have  died  from  some  unhealthy 
inflammatory  (infective)  process.  It  is  most 
marked  in  cases  of  septic  peritonitis  or  pleurisjr, 
pyaemia,  septicaemia,  puerperal  fever,  diffuse 
cellulitis,  erysipelas,  or  spreading  gangrene. 
Tiie  diminution  of  the  intensity  of  the  poison 
with  decomposition  is  accounted  for  on  thesecond 
theory,  by  supposing  that  the  peculiar  fermeut 
is  destroyed  by  putrefaction  ; and  on  the  third 
theory,  by  the  specific  organism  being  destroyed 
by  the  growth  of  the  ordinary  bacteria  of  decom- 
position, it  being  a well-known  fact  that  when 
two  organisms  are  growing  together  in  the  same 
fluid,  the  stronger  seems  to  overpower  the  weaker, 
to  check  its  growth,  and  finally  to  lead  to  its 
destruction. 

Certain  specific  diseases,  as  glanders  and 
splenic  fever  (malignant  pustule),  may  be  com- 
municated by  inoculation  from  the  dead  body, 
but  these  accidents  are  not  classed  with  ordinary 
dissection-wounds. 

Mode  of  entrance  of  the  poison  into  the  system. 
Whatever  the  virus  may  be,  it  only  acts  by 
direct  inoculation.  This  most  commonly  occurs 
through  an  accidental  wound  or  scratch  during 
the  post-mortem  examination  ; but  a raw  surface 
partly  healed,  or  the  fissures  in  chapped  hands, 
or  the  small  fissures  so  common  at  the  margin 
of  the  nail,  may  equally  serve  as  points  of  inocu- 
lation. In  rare  cases  infection  takes  place 
through  the  unbroken  skin,  the  hair-follicles 
seeming  then  to  serve  as  the  points  of  entrance. 
The  further  progress  of  the  poison  takes  place 
either  by  soaking  amongst  the  lymph-spaces  of 
the  cellular  tissue,  as  shown  by  diffuse  spreading 


cellulitis ; or  by  being  carried  with  the  stream  in 
the  lymphatic  vessels,  as  in  those  cases  in  which 
the  local  affection  is  slight,  and  the  first  trouble 
is  in  the  lymphatic  glands. 

Prevention. — In  order  to  prevent  inoculation 
the  following  points  should  be  attended  to.  Be- 
fore making  a post-mortem  examination  of  a dan- 
gerous case  the  hands  should  be  carefully  looked 
over.  If  any  spot  denuded  of  cuticle  is  found  on 
the  fingers,  an  india-rubber  cot  should  ho  applied, 
its  base  being  bound  round  with  string.  If  the 
whole  hands  are  sore  and  chapped  an  india- 
rubber  glove  may  be  used.  If  no  india-rubber 
cot  for  a finger  is  to  be  found,  an  efficient  water- 
proof covering  may  be  made  at  once  with  gutta- 
percha tissue  and  chloroform.  If  the  hands  are 
sound  they  may  be  well  greased  with  carbolic 
oil  (1  to  10),  but,  as  this  soon  wipes  off,  the  ap- 
plication must  be  repeated  several  times  dur- 
ing the  post-mortem  examination.  Accidental 
wounds  arise  almost  invariably  from  carelessness 
— the  assistant  being  as  often  wounded  as  the 
operator.  There  is  scarcely  any  operation  in  a 
post-mortem  which  requires  two  to  perform  it, 
and  an  assistant  should  therefore  be  dispensed 
with.  The  most  common  acts  of  carelessness  are 
— cutting  towards  instead  of  away  from  the  left 
hand ; and  letting  the  knife  fall  unobserved  into 
one  of  the  cavities,  where  it  is  concealed  by  blood 
or  the  viscera,  and  wounds  the  hands  when  next 
introduced.  Wounds  from  ribs  are  amongst 
the  most  dangerous,  as  they  bleed  but  little.  To 
avoid  these,  when  the  bone-forceps  has  to  be 
used,  in  cases  of  ossification  of  the  cartilages,  the 
ribs  should  he  cut  near  the  nipple  line,  and  the 
skin  folded  over  them  whilst  the  viscera  are 
being  examined.  In  opening  the  hea  1 the  saw 
is  apt  to  slip,  and  to  injure  the  hand  holding  the 
vault.  To  avoid  this,  either  wvap  the  hand  in 
a thick  cloth,  or  hold  the  head  with  the  left  hand 
on  the  face,  where  it  will  be  out  of  danger. 
Punctures  during  the  sewing-up  of  the  body  have 
caused  many  deaths.  These  injuries  are  usually 
due  to  using  too  small  a needle,  which  cannot  be 
kept  properly  under  control.  A common  packing 
needle  sharpened  is  by  far  the  safest  instrument 
that  can  be  used.  In  whatever  way  the  wound 
is  made  the  first  essential  of  treatment  is  to 
make  it  bleed  freely.  If  it  is  on  the  finger  thi? 
may  be  done  by  winding  a piece  of  string  round 
it  from  the  root  to  the  tip : then  wash  it  tho- 
roughly under  a tap  and  suck  it.  Caustics  are 
quite  unnecessary  if  these  directions  are  carried 
out.  After  a.  post-mortem  examination  the  hands 
should  always  be  well  washed  in  some  strong 
antiseptic  solution. 

The  condition  of  body  favourable  to  the  de- 
velopment of  the  effects  of  the  poison. — Nothing  is 
more  common  than  for  two  persons  to  be  wounded 
at  the  same  post-mortem  examination,  and  only 
one  to  suffer  from  it.  Sir  James  Paget  has 
brought  forward  strong  evidence  for  believing 
that  constant  exposure  to  the  poison  gives  a cer- 
tain degree  of  ‘ immunity  from  the  worse  influ- 
ences of  the  virus,’  and  that  one  dissection-wound 
protects  the  sufferer  from  another,  at  least  tor 
some  time.  Anything  which  causes  a depressed 
state  of  health  favours  the  occurrence  of  post- 
mortem  poisoning.  Thus,  we  see  it  in  students 
who  have  been  some  months  resident  in  hospital 


POST-MORTEM  WOUNDS. 


in  nurses  who  are  worn  out  with  attending  a had 
case,  and  in  dissecting  porters  or  others  who  in- 
dulge too  freely  in  alcohol.  Beyond  these  no 
special  predisposing  conditions  are  known.  See 
Predisposition  to  Disease. 

Varieties. — It  will  be  convenient  to  discuss 
the  several  forms  of  post-mortem  wounds  under 
distinct  headings  according  to  the  following  ar- 
rangement : — 

1.  Purely  Local  Affections. 

(a)  Dissecting-porter' s icart,  or  anatomical 
tubercle.— Although  not  exactly  a post-mortem 
wound,  this  affection  must  be  mentioned  here  as 
beincr  one  of  the  effects  of  the  irritation  caused 
by  the  repeated  application  of  putrid  matter  to 
the  skin.  It  is  seen  only  in  those  whose  occu- 
pation brings  them  much  in  contact  with  decom- 
posing animal  matter,  and  is  of  very  rare  occur- 
rence. Its  seat  is  always  at  the  back  of  the  hand 
over  the  knuckles,  or  the  joints  of  the  fingers. 
It  is  characterised  by  a warty  thickening  of  the 
skin,  which  may  in  some  cases  resemble  epithe- 
lioma. In  other  cases  the  thickening  of  the  cu- 
ticle may  give  the  skin  an  ichthyotic  appearance. 
The  enlarged  papillae  are  set  closely  together, 
and  there  is  no  true  ulceration,  but  cracks  and 
fissures  may  exist  in  parts,  from  which  a serous 
discharge  escapes.  The  growth  tends  slowly  to 
spread.  These  warty  growths  are  usually  mul- 
tiple, and  this,  together  with  the  want  of  any 
tendency  to  ulceration,  will  serve  to  distinguish 
them  from  epithelioma. 

Treatment. — In  some  cases  a cure  can  be  ef- 
fected by  the  constant  use  of  wet  dressing  to  soften 
the  epithelium,  combined  with  the  application  of 
a mixture  of  equal  parts  of  glycerine  and  extract 
of  belladonna.  Should  this  fail,  painting  with 
strong  tincture  of  iodine  may  berried,  or,  as  a last 
resource,  the  application  of  some  strong  caustic. 

(b)  The  dissecting-room  pustule. — This  is  al- 
ways the  result  of  the  inoculation  of  some  poi- 
sonous matter  into  a slight  abrasion  or  puncture. 
About  twenty-four  hours  after  inoculation  the 
spot  becomes  red  and  itches.  In  another  twenty- 
four  hours  a small  drop  of  pus  is  seen  raising  the 
cuticle,  and  the  part  is  intensely'  tender.  If  the 
drop  of  pus  be  let  out  the  pain  is  at  once  re- 
lieved. If  no  treatment  be  now  adopted  to  pre- 
vent it,  a small  scab  forms,  under  which  pus  again 
forms,  and  the  redness  and  pain  return  as  before. 
Each  time  that  this  happens  the  sore  increases  in 
size,  till  it  may  reach  about  one-eighth  of  an  inch 
in  diameter,  and  it  then  closely  resembles  in  ap- 
pearance a small  soft  chancre.  Without  treat- 
ment the  condition  may  continue  indefinitely'. 
It  is  very  seldom  accompanied  by  any  constitu- 
tional disturbance.  The  axillary  glands  may  be 
tender,  but  suppuration  is  rare,  except  in  un- 
healthy subjects. 

Treatment. — The  small  pustules  can  usually 
be  cured  simply  by  the  application  of  water- 
dressing, so  as  to  prevent  the  formation  of  a 
scab,  and  the  shutting  in  of  the  pus.  The  treat- 
ment must  be  continued  until  it  is  soundly  healed. 
If  the  smallest  speck  is  unhealed  it  will  relapse 
as  soon  as  the  dressing  is  removed.  If,  in  spite 
of  water-dressing  it  refuses  to  heal,  nitrate  of 
silver  may  be  applied,  or  the  ulcerated  surface 
may  be  covered  with  iodoform. 

(c)  Suppuration  of  the  matrix,  of  the  nail. — 


1245 

This  arises  from  inoculation  through  one  of  those 
small  fissures  at  the  side  of  the  nail  popularly 
known  as  ‘ agnail’  or  1 hangnail.’  The  inflam- 
mation extends  rapidly  to  the  matrix  at  the  root 
of  the  nail.  The  dorsal  aspect  of  the  finger  for 
half-an-inch  below  the  nail  is  swollen,  red,  and 
acutely  tender,  and  oil  pressing  over  this  area  pus 
oozes  out  over  the  nail.  The  inflammation  rarely 
extends  over  the  whole  matrix,  so  that  the  distal 
part  of  the  nail  is  usually  unaffected  and  firmly' 
attached,  while  the  root  is  softened  and  loosened 
by  the  suppuration  beneath  it.  The  discharge 
has  a strong,  offensive  odour  of  decomposition. 
This  condition  is  extremely  chronic,  the  irrita- 
tion being  kept  up  almost  indefinitely  by  the 
putrid  discharge,  which  is  more  or  less  pent  up 
beneath  the  nai.  When  recovery  takes  place 
the  nail  usually  separates. 

Treatment. — The  first  essential  of  treatment 
is,  if  possible,  to  render  the  discharges  aseptic. 
For  this  purpose  the  finger  may  be  soaked  in  a 
concentrated  solution  of  boracic  acid,  and  dressed 
with  boracic  acid  lint ; or  pow'dered  iodoform 
may  be  pushed  with  a piece  of  card  beneath  the 
swollen  skin  over  the  root  of  the  nail.  If  these 
fail  a strong  solution  of  subacetate  of  lead 
(liquoris  plumbi  subacetatis,  1 part,  spiritus 
rectificati  1,  aquae  6)  may  be  tried.  If  all  these 
simpler  means  fail,  the  nail  must  be  removed, 
and  the  raw  surface,  dressed  with  some  mild 
antiseptic  lotion,  will  quickly  heal. 

( d ) Suppuration  of  the  hair-follicles. — This  is 
a somewhat  rare  effect  of  post-mortem  poisoning. 
About  forty-eight  hours  after  exposure  to  infec- 
tion a varying  number  of  small  pustules,  each 
surrounded  by  a red  areola,  form  on  the  hairy 
parts  of  the  hands  and  wrists.  On  careful  exam- 
ination each  pustule  will  be  seen  to  have  a hair 
passing  through  it.  As  a rule  these  pustules 
discharge  and  dry  up  without  causing  further 
trouble,  but  in  some  exceptional  cases  they  may 
be  followed  by  constitutional  symptoms  or 
lymphatic  inflammations. 

Treatment. — All  that  is  necessary  is  to  cover 
the  part  with  cotton-wool,  to  hasten  the  drying 
of  the  pustules. 

(e)  Boils. — Boils,  which  differ  in  no  respect 
from  those  arising  without  known  cause,  may 
form  as  a consequence  of  exposure  to  post-mortem 
poisons.  They  probably  start  from  inflammation 
of  the  hair-follicles. 

Treatment. — This  presents  nothing  special. 

(/  ) Ordinary  Whitlow. — Although  whitlow  is 
common  amongst  nurses  and  others  whose  duties 
oblige  them  to  dress  foul  wounds,  it  is  a very 
rare  consequence  of  post-mortem  wounds.  It 
may',  however,  occasionally*  be  met  with,  and 
then  present  nothing  special.  See  Whitlow. 

2.  Diffuse  Inflammation  of  the  Cellular 
Tissue,  spreading1  from  the  point  of  inoc- 
ulation. 

(a)  Diffuse  Cellulitis. — The  seat  of  inoculation 
becomes  in  from  twelve  to  twenty-four  hours 
more  or  less  red  and  irritable,  and  in  this  state 
it  may  remain  for  another  day,  at  the  end  of 
which  time  a brawny  swelling  of  a dusky  red 
colour  forms  round  it,  and  rapidly  extends  in  all 
directions,  but  chiefly  in  the  line  of  the  lymph- 
stream.  At  the  same  time  there  is  intense 
tension,  burning  pain,  and  severe  constitutional 


POST-MORTEM  WOUNDS. 


1246 

disturbance,  high  temperature,  total  loss  of 
appetite,  and  possibly  delirium.  Red  lines  of 
inflamed  lymphatic  vessels  may  or  may  not  be 
seen  extending  upwards,  but  glandular  abscesses 
are  rare,  as  in  ordinary  cellulitis.  If  unrelieved 
by  treatment,  sloughing  rapidly  follows  the 
brawny  swelling,  first  of  the  subcutaneous  tis- 
sue, and  afterwards  of  the  skin. 

Treatment.— The  only  treatment  in  such  case 
is  free  and  early  incision  into  the  affected  part. 
In  one  case  which  came  under  the  observation  of 
the  writer  the  inoculation  took  place  from  a 
scratch  from  a broken  rib  which  had  penetrated 
a consolidated  lung,  and  caused  the  formation  of 
a foul  abscess.  Swelling  in  the  finger  com- 
menced on  the  second  day,  about  10  p.m.,  and  at 
11  a.m.  on  the  following  morning  it  had  in- 
volved the  whole  finger  and  part  of  the  back  of 
the  hand.  Red  lines  extended  from  it  a little 
way  above  the  wrist.  Two  incisions  were  im- 
mediately made  in  the  palmar  aspect  of  the 
finger,  and  one  on  the  dorsum  of  the  hand,  with 
the  effect  of  at  once  arresting  the  extension  of 
the  process.  In  this  case  the  attack  commenced 
with  slight  nausea,  but  no  chilliness  or  rigor; 
there  was  high  fever  and  delirium  on  the  third 
and  fourth  days.  The  constitutional  treatment 
must  be  the  same  as  in  other  cases  of  diffuse 
cellulitis.  See  Erysipelas. 

(4)  Spreading  Gangrene. — This  is  an  intensi- 
fication of  the  preceding  variety.  A red,  brawny 
swelling  advances  rapidly  up  the  arm,  quickly 
followed  by  gangrene  of  the  subcutaneous  cellu- 
lar tissue  and  skin.  This  condition  is  extremely 
rare  as  a consequence  of  dissection-wounds.  A 
case  occurred  in  1S80,  at  University  College 
Hospital,  under  the  care  of  Mr.  Heath,  in  which 
the  patient’s  life  was  only  saved  by  amputation 
at  the  shoulder-joint..  It  happened  to  a nurse 
from  an  accidental  wound  received  whilst  laying 
out  the  body  of  a patient  who  had  died  of  puer- 
peral fever. 

Treatment.— The  treatment  is  the  same  as 
in  other  cases  of  spreading  gangrene. 

3.  Inflammations  chiefly  affecting  the 
Lymphatics. 

( a ) Inflammation  of  the  Lymphatic  Vessels. — 
This  usually  commences  from  twenty-four  to 
forty-eight  hours  after  inoculation.  The  seat  of 
inoculation  may  show  scarcely  any  signs  of  in- 
flammation, or  it  may  have  developed  into  a 
small  suppurating  sore.  The  invasion  of  the 
lymphatic  inflammation  is  marked  by  elevation 
of  temperature,  chilliness,  or  possibly  a rigor. 
There  is  malaise  and  often  nausea,  with  head- 
ache. Red  lines  are  soon  after  observed  running 
upwards  from  the  seat  of  inoculation  in  the 
course  of  the  lymphatic  vessels.  These  lines  are 
about  one-eighth  to  one-quarter  of  an  inch  in 
width,  and  clearly  defined.  They  are  acutely 
tender.  The  lymphatic  glands  to  which  they  lead 
are  swollen  and  painful.  If  unrelieved  by  treat- 
ment suppuration  frequently  occurs  in  the 
lymphatic  glands,  or  sometimes  in  the  course  of 
the  vessels.  Occasionally  several  lines  may  fuse 
together,  giving  the  appearance  of  a band  of 
cutaneous  erysipelas. 

Treatment. — The  bowels  should  be  well 
opened.  Stimulants  in  moderate  quantities  may 
be  taken,  good  port  wine  being  especially  useful,  I 


with  strong  beef-tea,  milk,  and  eggs.  If  there  is 
much  fever  quinine  may  bo  of  use  in  reducing 
the  temperature.  Locally,  the  whole  course  of 
the  inflamed  vessels  is  to  be  painted  with  a 
mixture  of  glycerine  and  extract  of  belladonna 
in  equal  parts,  and  the  whole  arm  wrapped  in 
hot  fomentations,  which  must  be  frequently  re- 
newed. This  treatment  seldom  fails  to  arrest 
the  progress  of  the  inflammation,  and  ward  off 
suppuration.  If  pus  forms,  either  in  the  course  of 
the  vessels  or  in  the  glands,  it  must  be  let  out  as 
soon  as  it  is  recognised. 

(4)  Abscess  in  the  Lymphatic  Glands. — This 
occurs  either  as  a consequence  of  the  previous 
condition  or  without  any  evident  inflammation  of 
the  lymphatic  vessels.  It  is  frequently  a com- 
plication of  one  of  the  local  forms  first  described. 
The  abscess  forms  either  in  the  gland  at  the  bend 
of  the  elbow  or  in  the  axilla,  and  presents  no 
special  features  requiring  description.  The 
prognosis  is  not  grave. 

Treatment. — The  abscesses  must  be  opened 
as  soon  as  recognised,  and,  if  possible,  treated 
antiseptically. 

(e)  Axillary  Cellulitis This  is  one  of  the 

gravest  effects  of  post-mortem  wound.  It  fre- 
quently occurs  in  cases  in  which  the  local  affec- 
tion at  the  seat  of  inoculation  is  so  slight  as  to 
be  scarcely  recognisable.  From  twenty-four  to 
forty-eight  hours  after  inoculation  the  patient 
is  seized  with  chilliness,  and  frequently  a rigor; 
there  is  great  depression;  with  nausea,  or  even 
vomiting,  and  headache.  The  temperature  ra- 
pidly rises,  reaching  104°  or  105°,  and  there  is 
frequently  delirium.  On  examining  the  axilla 
some  fulness,  with  acute  tenderness,  is  recog- 
nised, and  there  is  pain  in  moving  the  arm.  The 
fulness  soon  extends  to  the  front  of  the  chest,  in 
the  region  of  the  pectoralis  major,  and  the  veins 
of  the  region  may  become  more  clearly  visible 
than  natural.  Later  on  there  may  be  a blush  of 
redness  over  the  pectoral  region,  and  with  this 
there  is  oedema.  If  not  relieved  the  swelling 
and  redness  may  extend  down  the  side  of  the 
chest,  and  show  above  the  clavicle  at  the  root  of 
the  neck.  The  constitutional  condition  assumes 
the  ordinary  characters  of  septictemia.  There  is 
muttering  delirium,  rapidly  failing  pulse,  dry 
tongue,  with  sordes  on  the  lips  and  teeth,  pos- 
sibly diarrhoea,  and  the  patient  sinks  intoa  coma- 
tose condition  and  dies.  Sir  James  Paget,  in 
his  well-known  lecture  on  his  own  case,  explains 
this  condition  by  supposing  that  the  lymphatic 
glands  are  first  swollen,  and  the  flow  of  lymph 
through  them  obstructed,  and  that  the  poison 
then  extends  backwards  in  the  distended  lymph- 
atics till  it  reaches  the  cellular  tissue  in  which 
they  arise,  thus  causing  diffuse  cellulitis,  which, 
if  not  relieved,  or  if  not  speedily  fatal,  may 
extend  to  the  whole  area  which  sends  lymph 
to  the  affected  glands.  If  an  incision  be  made 
early  into  the  affected  cellular  tissue  it  will  be 
found  merely  infiltrated  with  serum : later  on 
the  serum  is  turbid;  still  later  the  whole  areolar 
tissue  would  be  found  in  a sloughy  condition, 
soaked  in  pus. 

Treatment. — The  blood-poisoningaccompany- 
ing  this  condition  is  frequently  fatal  in  spite  of 
any  treatment.  The  only  hope  for  the  patient 
lies  in  early  recognition  of  the  state  of  the  part. 


POST-MORTEM  WOUNDS. 

and  in  making  free  incisions.  These  incisions 
must  thoroughly  open  up  the  axillary  fascia,  and 
if  there  is  any  suspicion  of  extension  beneath 
the  pectoralis  major,  another  incision  must  be 
made  two,  or  even  three,  inches  in  length,  through 
the  muscle.  Thi3  is  best  made  in  the  interval 
between  the  sternal  and  clavicular  portions.  The 
skin  and  fat  only  need  be  divided  with  the  knife, 
the  muscular  fibres  being  separated  with  the 
handle  of  the  scalpel  to  avoid  haemorrhage.  If 
these  incisions  are  made  with  all  antiseptic  pre- 
cautions and  the  antiseptic  dressing  adopted,  the 
patient’s  chance  of  life  is  greatly  increased.  The 
constitutional  treatment  consists  in  free  stimula- 
tion and  abundant  nourishment.  Quinine  may 
possibly  be  useful  in  large  doses. 

4.  Septicaemia. — In  some  cases,  which,  for- 
tunately, are  very  rare,  post-mortem  wounds 
prove  speedily  fatal,  with  the  ordinary  symptoms 
of  acute  septicoemia.  Local  changes  at  the  seat 
of  inoculation  may  be  entirely  wanting. 

5.  Pyaemia. — Pyaemia  may  occur  as  a secon- 
dary complication  of  the  forms  of  post-mortem 
wound  which  are  accompanied  by  suppuration 
and  sloughing;  but  it  presents  nothing  special 
in  such  cases.  See  Pyemia. 

Marcus  Beck. 

PCST-PHARYNGEAL  ABSCESS.  See 

Retro-pharyngeal  Abscess. 

POSTURE. — In  this  article  it  is  intended  to 
point  out  the  main  practical  relations  of  posture 
to  the  aetiology,  diagnosis,  and  treatment  of  va- 
rious diseases.  It  not  uncommonly  happens  that 
a patient  assumes  instinctively  a posture  by 
which  his  condition  may  be  at  once  recognised, 
or  which  gives  indications  of  importance  as  to 
his  management.  In  other  cases  the  practitioner 
makes  systematic  use  of  posture  to  assist  him 
in  his  diagnosis,  or  to  aid  him  in  treatment.  It 
should  he  mentioned  at  the  outset  that  persons 
often  present  peculiarities  with  reference  to  pos- 
ture, which  are  of  no  practical  significance,  and 
are  the  result  either  of  natural  differences  in  in- 
dividuals, or  of  habit.  For  instance,  some  people 
can  only  sleep  with  the  head  raised  very  high,  in 
an  almost  semi-recumbent  position ; others  lie 
with  the  head  very  low7,  even  level  with  or  below 
the  body.  Many  are  unable  to  sleep  on  the  back, 
or  on  one  or  other  side,  and  especially  the  left 
side.  The  subject  will  be  further  discussed  in 
its  relations  to  the  points  mentioned  above. 

1.  etiology  of  Posture. — As  an  immediate 
cause  of  disease,  posture  is  chiefly  important  in 
’ connection  with  occupation.  For  instance,  many 
persons  suffer  from  long-continued  standing ; or, 
on  the  other  hand,  from  sedentary  occupations. 
The  evil  effects  of  the  erect  posture  are  evidenced 
by  the  development  of  varicose  veins  in  the 
; legs,  and  also  by  the  occurrence  of  general  fatigue 
and  debility,  displacement  of  the  uterus,  and 
; other  conditions,  especially  in  young  women  ; 
and  this  subject  has  of  late  received  considera- 
ble attention  in  relation  to  those  employed  in 
drapers’  shops.  Those  callings  which  entail  con- 
stant or  frequent  bending  forward  of  the  body 
[ are  often  very  injurious,  and  this  may  be  aggra- 
vated by  carrying  burdens  on  the  back  and 
shoulders.  Not  uncommonly7  persons  injure  them- 


POSTURE.  1247 

selves  by  habitually  bending  forward  while  sit- 
ting, quite  apart  from  occupation.  Another  il- 
lustration of  the  influence  of  posture  in  causing 
disease  is  where  individuals  have  to  work  in 
constrained  positions,  such  as  colliers  and  mine- 
workers.  The  conditions  thus  induced  are  chiefly 
deformities  of  the  chest,  and  certain  diseases  of 
the  lungs,  heart,  and  vessels.  Posture  is  also  of 
consequence  in  predisposing  to  certain  affections 
under  particular  circumstances,  or  in  modifying 
their  effects.  Thus  the  recumbent  posture  in  low 
febrile  and  other  conditions  aids  in  the  causation 
of  hypostatic  congestion  and  its  consequences ; 
a similar  position  promotes  the  accumulation 
of  morbid  products  in  the  bronchi  in  cases  of 
acute  bronchitis,  which  may  cause  further  mis- 
chief ; and  if  an  attack  of  pleurisy  should  super- 
vene when  a patient  is  obliged  to  lie  on  his  back, 
this  will  materially  modify  the  way  in  which  the 
fluid  accumulates,  for  it  tends  then  to  collect 
posteriorly,  and  may  cover  the  whole  area  of 
the  chest  in  this  aspect,  while  there  is  no  sign 
of  any  fluid  in  front.  Lastly,  a peculiar  posture 
in  performing  certain  acts,  such  as  writing,  may 
have  some  influence  in  originating  affections  of 
the  type  of  writer’s  cramp. 

2.  Posture  in  Diagnosis. — As  examples  of 
postures  spontaneously  adopted  by  patients, 
which  may  give  useful  information  in  diagnosis, 
the  following  are  the  most  striking.  In  many 
cases  the  posture  indicates  great  debility,  help- 
lessness, or  prostration,  and  may  thus  afford  im- 
portant information  as  to  the  general  condition 
of  a patient.  An  inability  to  lie  down  constitutes 
a prominent  feature  in  certain  forms  of  cardiac 
and  pulmonary  disease,  in  consequence  of  inter- 
ference with  the  respiratory  functions,  so  that  the 
patient  is  obliged  to  sit  or  to  be  propped  up  in  bed, 
or  sometimes  even  to  sit  up  in  a chair,  to  assume 
the  erect  posture,  or  to  bend  forward.  Again, 
when  anything  is  pressing  upon  the  main  air- 
tube — such  as  an  aneurism — causing  obstructive 
dyspnosa,  the  patient  may  instinctively  lean  for- 
ward, so  as  to  take  off  the  pressure  as  much  as 
possible.  In  cases  of  unilateral  lung-disease  or 
pleurisy,  the  patient  is  often  unable  to  lie  on  one 
or  other  side,  especially  the  affected  one  ; while 
in  affections  of  the  heart  it  is  frequently  impos- 
sible for  him  to  rest  on  the  left  side.  As  regards 
abdominal  diseases,  acute  peritonitis  is  usually 
characterised  by  a very  striking  posture,  the 
patient  lying  on  liis  back,  with  the  knees  well 
drawn  up  and  bent,  in  order  to  relax  the  abdo- 
minal muscles.  lie  may  also  assume  certain 
positions  in  other  abdominal  affections,  on  ac- 
count of  their  influence  upon  symptoms,  such  as 
pain  or  vomiting.  In  spasmodic  painful  attacks 
connected  with  this  region,  it  is  very  common  to 
see  the  patient  bending  forwards  in  a doubled- 
up  position,  and  pressing  upon  the  abdomen.  In 
nervous  diseases  posture  may  be  of  value  in 
diagnosis.  Thus,  it  may  reveal  paralysis  of  dif- 
ferent parts ; in  cerebral  meningitis  the  patient 
often  lies  in  a curled-up  position,  all  the  limbs 
being  bent  towards  the  body ; in  spinal  meningi- 
tis the  head  may  be  involuntarily  drawn  back- 
wards, in  order  to  try  to  relax  the  muscles  be- 
hind ; in  cataleptic  conditions  any  posture  that 
is  assumed  is  retained  for  a considerable  or  an 
unlimited  time ; while  in  wry-neck  the  head  is 


POSTUBE. 


1248 

turned  to  one  side.  Lastly,  the  position  volun- 
tarily assumed  hy  a limb  may  give  important 
information  as  to  local  diseases  likely  toinfluence 
it  in  this  respect,  such  as  those  of  the  joints. 
The  whole  body  may  be  distorted,  as  well  as  the 
limbs,  in  connection  with  diseases  of  the  articu- 
lations. 

What  has  just  been  stated  will  supply  hints 
as  to  how  the  practitioner  might  avail  himself 
of  alterations  in  posture  in  aiding  him  towards 
a diagnosis  in  certain  cases.  For  instance,  ob- 
serving the  effect  of  such  changes  often  gives 
valuable  information  in  connection  with  pul- 
monary and  cardiac  diseases,  as  evidenced  by 
the  influence  of  the  respective  positions  upon 
breathing,  cough,  the  heart’s  action,  and  other 
symptoms  ; and  the  same  may  be  the  case  in 
some  abdominal  diseases,  as  well  as  in  nervous 
affections  or  in  local  diseases.  Change  of  pos- 
ture is  most  useful,  however,  in  connection  with 
physical  examination,  the  effects  it  produces  upon 
certain  physical  signs  being  noted.  In  this  way 
it  is  of  essential  aid  in  determining  the  presence 
of  fluid  in  cavities,  such  as  the  pleura  or  peri- 
toneum; in  distinguishing  an  internal  aneurism 
from  conditions  simulating  this  lesion  ; in  detect- 
ing certain  solid  formations  in  the  abdominal 
cavity;  and  for  other  purposes.  Details  on  these 
points  are  given  in  other  appropriate  articles. 
It  is  also  of  importance  to  study  the  position 
of  the  patient  in  examining  the  chest ; and  to 
remember  that  posture  may  materially  influence 
physical  signs  connected  with  the  heart. 

3.  Posture  in  Treatment. — Many  of  the  pre- 
ceding remarks  will  afford  suggestions  as  to  the 
value  of  paying  attention  to  posture  as  a thera- 
peutic measure,  and  it  will  at  once  be  evident 
that  if  a wrong  posture  is  the  cause  of  any 
morbid  condition,  the  first  principle  in  treatment 
should  be  to  rectify  it.  Besides,  it  will  not  un- 
commonly be  found,  advantageous  to  watch  pa- 
tients, and  to  allow  them  to  adopt,  or  assist  them 
in  adopting,  such  a position  as  their  own  sensa- 
tions dictate  to  be  the  most  suitable  for  their 
condition.  In  order  to  illustrate  further,  how- 
ever, the  benefits  to  be  derived  from  posture,  it 
may  be  well  to  point  out  some  of  the  diseases  in 
which  its  value  is  most  strikingly  exhibited. 

(a)  Posture  is  of  great  importancewhen  gene- 
ral rest  of  the  body  is  required,  or  when  there  is 
general  exhaustion  or  prostration  of  the  system. 
The  recumbent  posture  is  clearly  indicated  under 
these  circumstances,  for  it  is  the  most  restful 
of  all,  and  involves  little  or  no  expenditure  of 
muscular  force.  Hence  in  acute  febrile  diseases 
of  all  kinds,  one  of  the  first  indications  in  treat- 
ment is  to  keep  the  patient  absolutely  in  bed. 
This  is  also  desirable  where  there  is  excessive 
fatigue  or  prostration  from  any  cause. 

( b ) In  the  management  of  affections  connected 
with  the  respiratory  organs,  attention  to  posture 
is  frequently  of  service.  Here  its  influence  as 
regards  rest  again  comes  in,  for  it  may  be  of 
much  consequence  to  make  as  little  call  as  pos- 
sible upon  the  respiratory  functions.  Moreover, 
symptoms  associated  with  the  breathing  appa- 
ratus are  in  many  cases  strikingly  influenced  by 
posture,  such  as  pain,  dyspnoea,  or  cough ; and  the 
act  of  coughing  may  be  materially  assisted,  and 
made  more  effectual  as  regards  expectoration,  hy 


the  patient  assuming  a sitting  or  erect  position 
The  importance  of  the  prone  posture,  or  of  bend- 
ing forwards,  must  be  remembered  when  there  is 
anything  pressing  on  the  main  air-tube. 

_ (c)  Posture  often  requires  particular  considera- 
tion in  relation  to  disorders  of  the  cardiac  action, 
or  to  actual  disease  of  the  heart.  Thus,  in  the 
syncopal  state  the  patient  should  be  placed  hori- 
zontally, or  even  with  the  head  at  a lower  level 
thin  the  body,  so  that  the  blood  may  more 
readily  reach  the  brain,  and  thus  life  may  be 
sustained.  In  this  state,  or  when  the  heart  is 
acting  with  extreme  feebleness  from  aDy  cause, 
raising  the  patient  into  a sitting  posture  has 
been  known  to  cause  a fatal  result,  and  should 
be  carefully  avoided.  On  the  other  hand,  there 
are  conditions  of  the  heart  in  which  the  patient 
cannot  possibly  lie  down,  and  especially  where 
there  is  much  dilatation ; under  these  circum- 
stances it  may  be  of  the  greatest  service  to  have 
him  constantly  sitting  up  in  a properly-con- 
structed chair,  and  the  beneficial  effects  thus 
produced  are  sometimes  almost  marvellous. 

(d)  In  the  treatment  of  aneurisms,  whether  in- 
ternal or  external,  posture,  is  frequently  made 
use  of  with  advantage.  In  the  cure  of  this  lesion 
in  the  chest  or  abdomen,  rest  is  often  an  impor- 
tant agent,  and  on  this  account  patients  are  kept 
in  the  recumbent  posture  for  weeks  or  months, 
so  as  to  keep  the  heart  as  quiet  as  possible, 
and  also  to  limit  the  demand  of  the  system  for 
food,  which  is  only  given  in  a restricted  quantity. 
Aneurism  in  the  chest  is  one  of  the  causes  which 
may  originate  pressure  on  the  air-tube,  and  on 
this  account  attention  to  posture  may  be  re- 
quired in  connection  with  it.  In  the  case  of 
aneurism  in  the  limbs,  posture  is  sometimes 
made  use  of  to  cure  them,  by  causing  pressure, 
as  flexion  of  the  knee  for  the  cure  of  popliteal 
aneurism. 

(c)  The  influence  of  posture  with  respect  to 
gravitation  may  often  he  recognised  with  advan- 
tage in  the  treatment  of  certain  conditions.  This 
is  well  exemplified  by  its  effects  on  dropsical 
accumulations  in  the  legs  and  scrotum.  Abun- 
dant anasarca  may  frequently  be  got  rid  of  com- 
pletely in  a short  time  by  keeping  the  legs  in  a 
horizontal  position ; and  oedema  of  the  scrotum 
likewise  may  soon  disappear  when  this  part  is 
propped  up.  The  same  principle  is  of  essential 
importance  in  checking  haemorrhage  from  a rup- 
tured varicose  vein  in  the  leg;  and  may  also  be 
made  use  of  in  the  cure  of  varicose  veins.  The 
influence  of  posture  upon  dropsy  may  give  use- 
ful information  as  to  its  cause,  and  as  to  the 
exact  conditions  upon  which  it  depends. 

(f)  As  miscellaneous  illustrations  of  the  em- 
ployment of  posture  in  treatment  may  be  men- 
tioned the  value  of  the  recumbent  position  in 
sea-sickness,  attacks  of  giddiness,  megrim,  and 
neuralgic  affections  about  the  head ; raising  the 
head  in  comatose  conditions  ; the  prone  posture 
in  the  treatment  of  certain  forms  of  spinal  dis- 
ease; prolonged  decumbency  to  restore  a dis- 
placed uterus ; and  various  positions  in  which 
limbs  are  placed  on  account  of  local  diseases,  to 
relieve  pain,  to  prevent  muscular  tension,  t& 
promote  the  escape  of  pus,  or  for  other  pur- 
poses. . . 

(y)  Lastly,  it  must  be  remembered  that  it  is 


POSTURE. 

not  uncommonly  requisite  to  change  the  position 
of  a patient  more  or  less  frequently,  if  he  should 
be  confined  to  his  bed.  For  instance,  it  may 
be  necessary  to  do  this  in  lew  febrile  diseases, 
in  order  to  prevent  the  occurrence  of  hypostasis 
at  the  bases  of  the  lungs,  or  the  formation  of 
bed-sores  on  parrs  subjected  to  pressure.  This 
is  also  necessary  in  many  cases  of  spinal  or 
cerebral  disease,  and  in  very  emaciated  patients 
(see  Ulcer).  Change  of  posture  is  further  use- 
ful in  assisting  the  escape  or  expulsion  of  morbid 
secretions  from  theair-passages  when  they  tend  to 
accumulate  there.  Frederick  T.  Roberts. 

POUGUES,  in  Loire,  Prance. — Alkaline 
chalybeate  waters.  See  Mineral  Waters. 

POULTICE. — Svnon.  : Cataplasm;  Fr. 
Cataplasms ; (ler.  Erciumschlag . — Poultices  are 
soft  moist  applications,  usually  applied  hot,  but 
occasionally  cold  They  may  be  used  merely  as  a 
means  of  applying  heat  and  moisture ; or  may 
contain  some  drug  intended  to  exert  a specific 
effect.  Of  the  innumerable  poultices  formerly 
in  use,  only  six  are  now  officinal. 

Poultices  may  be  arranged  thus  : 1. — The 
simple  poultice,  composed  of  linseed  meal.  The 
practice  of  using  bread  soaked  in  hot  water  as  a 
poultice  has  deservedly  fallen  into  disrepute, 
as  it  soon  becomes  sour  and  offensive.  2.  Dis- 
infecting poultices,  namely,  cataplasma  carbonis, 
and  cataplasma  sodae  chloratae.  3.  Sedative 
poultices,  such  as  cataplasma  fermenti,  and  cata- 
plasma conii.  4.  The  counter-irritant  poultice 
— for  example,  cataplasma  sinapis. 

1.  Simple  Poultice. — The  simple  poultice, 
by  its  heat,  causes  a dilatation  of  the  vessels  of 
the  part  to  which  it  is  applied,  and  thus  hastens 
'.he  progress  of  inflammation,  either  towards  re- 
solution or  suppuration.  It  softens  the  cuticle, 
vnd  relaxes  the  skin  by  its  moisture,  and  thus 
'avours  swelling,  and  lessens  tension  and  pain. 
In  internal  affections,  such  as  bronchitis,  pleurisy, 
or  pericarditis,  large  poultices  are  frequently 
applied  to  the  skin  overthe  inflamed  part.  They 
>enefit  the  patient,  partly  by  their  warmth,  and 
wirtly  by  exerting  an  extremely  mild  counter- 
rritant  effect,  consequent  upon  the  redness  and 
ongestion  of  the  skin  which  they  produce.  They 
re,  however,  somewhat  troublesome  ; they  soon 
ecome  cold  and  hard  ; and  if  the  patient  be  rest- 
>ss  their  weight  causes  them  to  shift,  and  frag- 
ents  break  off  and  drop  into  the  bed,  and  there 
tying  they  cause  considerable  discomfort.  For 
iplieation  to  external  inflammations  a few  folds 
lint,  soaked  in  hot  water  or  any  appropriate 
tion (sedative,  stimulant,  or  antiseptic),  covered 
ith  oil-silk,  and  afterwards  with  a thick  layer 
cotton  wool,  will  be  found  to  answer  every 
irpose  of  a poultice,  and  to  be  much  more 
eanly  and  less  troublesome. 

Linseed-meal  poultices  applied  to  boils  usually 
i use  a fresh  crop  to  spring  up  round  the  ori- 
tal  boil,  from  the  irritation  they  give  rise  to. 
icy  should  consequently  never  be  used,  wet 
racic  lint  being  always  substituted.  In  in- 
■nal  inflammations  a poultice  may  often  be 
vantageously  replaced  by  cotton-wool  only, 
■ered  with  oil-silk  and  secured  by  a bandage, 
any  counter-irritant  action  is  required  a few 

79 


POULTICE.  1249 

drops  of  chloroform  or  turpentine  may  be 
sprinkled  on  the  wool. 

Linseed-meal  poultices  are  best  made  from 
meal  from  which  the  oil  has  been  expressed,  as 
the  pure  meal  becomes  rapidly  rancid.  The 
British  Pharmacopoeia  recommends  the  addition 
of  a little  olive  oil.  The  following  is  a useful 
method  of  making  a linseed-meal  poultice ; — 
Heat  the  basin  in  which  the  poultice  is  to  be 
made  with  boiling  water ; then  empty  it  and  put 
into  it  again  as  much  boiling  water  as  may  be 
necessary  to  make  the  required  poultice  ; sprinkle 
the  meal  into  the  water,  stirring  vigorously,  till 
the  proper  consistence  is  attained ; lastly,  stir  in 
a small  quantity  of  olive  oil.  By  adopting  this 
plan  the  poultice  will  be  free  from  lumps.  The 
poultice  should  then  be  spread  with  a broad 
spatula  on  a piece  of  rag.  It  must  be  of  a uni- 
form thickness,  and  neither  so  thick  as  to  be 
too  heavy,  nor  so  thin  as  to  cool  and  dry  too 
rapidly.  A poultice  should  be  changed  every 
two  or  three  hours  by  day,  and  every  four  at 
night,  if  the  patient  is  sleeping.  In  all  cases 
where  there  is  free  suppuration,  a poultice  is 
the  dirtiest  application  that  can  be  made  to  the 
wound.  TVet.  boraciclint  should  always  be  used 
instead. 

2.  Disinfecting  Poultices.  — Cataplasma 
carbonis  is  a horrible  compound  of  wood-char- 
coal, linseed  meal,  and  bread,  and  was  formerly 
supposed  to  have  some  disinfectant  properties. 
Both  this  and  the  cataplasma  sod<e  chlorates 
have  been  entirely  replaced  by  more  cleanly  or 
efficient  antiseptic  applications.  The  best  of 
these  are  boracic  acid  lint  and  carded  oakum. 
If  carded  oakum  be  used  it  must  be  made  into  a 
soft  and  even  pad,  and  may  be  dipped  in  hot 
water  before  being  applied.  It  is  a most  power- 
ful antiseptic,  and  very  cheap,  but  it  has  the 
disadvantage  of  blackening  the  skin  with  the 
tar  it  contains,  and  sometimes  causes  consider- 
able irritation.  Both  these  inconveniences  may 
be  overcome  to  a certain  extent  by  greasing  the 
skin  with  carbolic  oil  (1  to  10). 

3.  Sedative  Poultices. — Cataplasma  fer- 
menti is  composed  of  beer  yeast,  6;  flour,  14; 
water  (100°  F.),  6.  After  mixing  it  is  to  be 
placed  near  the  fire  till  it  rises.  The  carbonic 
acid  was  credited  with  both  sedative  and  anti- 
septic properties.  It  was  chiefly  used  in  boils, 
but  from  personal  experience  the  writer  can 
state  that  it  has  none  of  the  virtues  attributed 
to  it.  Cataplasma  conii  is  composed  of  hemlock 
leaf,  1 ounce  ; linseed  meal,  3 ounces ; and  boil- 
ing water,  1 0 ounces.  Mix  the  ingredients  and 
add  them  to  the  water  gradually,  constantly 
stirring.  It  has  been  chiefly  used  in  cases  of 
cancer  to  relieve  pain.  Its  dirtiness  and  weight 
are,  however,  strong  objections  to  it. 

4.  Counter-irritant  Poultice. — Cataplas- 
ma sinapis,  the  ordinary  mustard  poultice,  is  an 
invaluable  counter-irritant.  It  is  composed  of 
mustard  in  powder,  2 j ; linseed  meal,  2|q  boil- 
ing water,  10.  The  linseed  meal  is  to  be  mixed 
with  the  water,  and  the  mustard  added,  con- 
stantly stirring.  It  must  be  remembered  that 
mustard  varies  much  in  strength,  and  that  since 
it  has  been  made  the  object  of  the  special  atten- 
tion of  the  authorities  engaged  in  carrying  out 
the  Adulteration  Act,  its  strength  has  consider- 


1250  POULTICE, 

ably  increased.  Its  action  should  extend  only 
to  producing  redness  of  the  skin,  but  if  kept  on 
too  long  it  'will  cause  vesication,  and  has  even 
been  known  to  give  rise  to  sloughing.  The  time 
a mustard  poultice  can  be  kept  cn  varies  from 
ten  minutes  to  half  an  hour  or  more,  according 
to  the  strength  of  the  mustard.  The  guide  most 
usually  relied  upon  is  the  sensations  of  the  pa- 
tient. An  ordinary  patient  is  not  likely  to  keep 
it  on  too  long,  as  the  smarting  soon  becomes 
unbearable.  Patients  who  are  much  in  the  habit 
of  applying  mustard  poultices  to  the  same  part 
— as,  for  instance,  the  front  of  the  chest — acquire 
a singular  power  of  resistance  to  the  irritative 
action  of  the  mustard.  The  mustard  poultice 
is  indicated  whenever  mild  and  rapid  counter- 
irritation is  desired.  It  is  especially  useful  in 
oronchitis,  and  in  muscular  rheumatism,  as  lum- 
bago, or  pleurodynia.  Kigollot’s  mustard-leaves, 
or  tjie  Charts  Sinapis  of  the  Pharmacopoeia,  are 
an  excellent  substitute  for  the  mustard  poultice. 
They  are  cleaner,  more  easily  applied,  and  can 
be  more  accurately  adapted  to  the  spot  required. 
They  should  always  be  used  in  preference  when 
obtainable.  Marcus  Beck. 

PRAECORDIAL  ANXIETY  or  OP- 
PRESSION.— Stnon.  : Fr.  Angoisse  ; Ger. 
Pracor  dial  angst. 

Definition. — A paroxysmal  sensation  of  con- 
striction, attended  with  anxiety,  referred  to  the 
preecordium. 

Description. — Prmcordial  anxiety  is  a dis- 
tressing sensation  in  the  region  of  the  heart, 
characterised  by  an  irregular,  rolling,  tumbling, 
or  falling  motion,  supervening  on  a feeling  of 
constriction.  It  is  accompanied  by  feelings  of 
anxiety ; by  restlessness,  "which  may  pass  into  a 
state  of  extreme  agitation;  by  a sensation  of  ap- 
proaching syncope,  with  fear  of  death  ; and  by 
chilliness  passing  into  a cold  clammy  perspira- 
tion. Though  there  may  be  a soreness  or  dull 
aching,  there  is  neither  pain  nor  palpitation. 
The  urine  is  not  increased,  but  rather  dimin- 
ished. Sleep  is  impossible.  The  attack  often 
comes  on  during  sleep,  and  soon,  perhaps,  the 
restless  anxiety  necessitates  rising  from  the 
couch  and  walking  about;  often  flatulence  op- 
presses, and  gas  is  evolved,  with  relief  to  the 
symptoms.  The  attacks  are  paroxysmal,  of  vary- 
ing duration.  Praecordial  anxiety  appears  to  have 
no  alliance  with  prsecordial  pain  ; it  does  not 
appear  to  be  a simple  neurosis,  but  dependent 
on  some  abnormal  muscular  condition,  whereby 
the  irritability  of  the  heart  is  disturbed,  caused, 
it  may  be,  by  deficient  innervation,  or  by  an 
impure  blood  failing  to  stimulate  it  to  due  ex- 
pansion and  contraction.  The  heart  may  not 
be  altogether  free  from  indications  of  more  than 
functional  disease. 

Treatment. — During  the  paroxysm  relief  is 
generally  obtained  in  locomotion,  and  in  occa- 
sionally administering  small  amounts  of  some 
diffusible  stimulant  or  warm  carminative.  In  the 
intervals  fresh  air,  attention  to  dietetic  rules,  the 
free  evacuation  of  the  bowels  without  purging, 
and  light  nervine  bitters,  will  be  found  useful. 

T.  Shatter. 

PRAECORDIAL  PAIN. — Stnon.:  Heart- 
burn ; Fr.  Cardialgie  ; Ger.  Magcnschmerc. 


PRAiCOKDIAL  PAIN. 

Definition. — By  praecordial  pain  it  is  intended 
in  this  article  to  signify  pain  referred  to  the 
region  of,  but  not  originating  in,  the  heart. 

Description. — Spasmodic,  not  paroxysmal, 
prsecordial  pain  may  vary  from  a slight  uneasi- 
ness to  an  intense  anguish.  It  may  have  differ- 
ent characters;  it  may  he  sharp  and  lancinating, 
dull  and  heavy,  twisting,  or  grinding.  Its  seat 
may  be  defined,  or  it  may  be  diffused  over  a large 
surface.  It  is  met  with  mainly  in  persons  of  a 
nervous  temperament,  in  the  gouty  and  dyspep- 
tic, in  the  course  of  certain  of  the  blood-diseases, 
and  as  an  accompaniment  of  special  female  dis- 
orders. A common  seat  of  this  pain  is  the  left 
fourth  intercostal  space  below,  or,  rather,  outside, 
the  line  of  the  nipples.  The  patient  associates 
it  with  the  heart;  and  yet  describes  it  as  not  so 
deeply  seated,  nor  in  any  respect  influenced  by 
its  action — having  no  rhythmical  exacerbations; 
generally  it  is  confined  to  this  spot,  but  may  be 
diffused  over  the  chest.  A severe  form  of  this 
pain,  though  for  the  most  part  confined  to  the 
region  of  the  heart,  often  extends  from  the  prae- 
cordium  to  the  left  shoulder,  the  neck,  and  the 
stomach ; sometimes,  though  rarely,  to  the  arms. 
These  several  forms  of  pain  have  analogies  with 
each  other,  their  differences  being  mainly  in  seat, 
in  intensity,  and  in  their  complications  with  other 
disorders;  they  are  irregularly  remittent ; they 
do  not  partake  of  the  nature  of  cramp,  or  spas- 
modic constriction  ; and  apparently  they  have 
little  or  no  influence  on  the  heart's  action,  or  on 
that  of  the  respiratory  organs.  For  the  most 
part,  though  their  manifestation  may  be  severe, 
and  therefore  alarming  to  the  patient,  they  do 
not,  simply  and  unassociated,  indicate  the  pre- 
sence of  disease  of  a fatal  tendency.  They  are 
to  be  esteemed  as  capable  of  alleviation,  and 
generally  of  cure.  If  there  be  danger,  it  is 
chiefly  due  to  complications  with  organic  disease 
of  the  heart,  or  other  contiguous  organs;  they 
partake  of  the  nature,  and  obey  the  laws,  indica- 
tions, and  phenomena,  of  ordinary  nerve-pains, 
such  as  tic-douloureux,  or  those  of  sciatica  or 
lumbago ; and  they  have  their  seat  primarily  in 
the  pneumogastrie  or  cardiac  nerves,  and,  secon- 
darily, in  the  nerves  of  the  brachial  plexus,  and 
the  cerebro-spinal  nerves  supplying  the  front  of 
the  thorax. 

Prognosis  and  Treatment. — The  prognosis 
and  the  treatment  of  these  affections  require 
that  their  origin,  seat,  intensity,  persistency,  and 
complications  should  be  well  considered;  each 
being  a measure  of  disorder,  and  a guide  to  the 
means  of  alleviation. 

The  severe  paroxysmal  or  recurrent  pain, 
which  appears  to  have  its  seat  mainly  in  the 
branches  of  the  vagus  nerve,  is  essentially  of 
dyspeptic  origin,  and  requires,  with  well-regu- 
lated diet  and  exercise,  very  careful  medical 
management.  The  indications  for  the  most  part 
are  to  correct  an  acid  or  gouty  diathesis.  Alka- 
lies, and  the  alkaline  mineral  waters,  light  bitter 
infusions,  and  warm  alterative  aperients,  are 
often  most  useful  iu  these  cases.  The  iotereostU' 
pain  is  somewhat  persistent  and  difficult  of  alle- 
viation and  requires,  besides  attention  to  th< 
morbid  states  with  which  it  may  be  associate; 
— the  hysterical  and  dyspeptic,  the  plethoric  arc 
hypochondriacal,  the  emaciation  and  weaknee 


• PRJECORDIAL  PAIN, 
sf  exhausting  diseases,  a strictly  regulated  diet, 
with  exercise  and  residence  in  a pure  air.  The 
pains  originating  in  disordered  conditions  of  tho 
blood  usually  find  relief  in  the  regimen  and 
treatment  laid  down  for  their  alleviation. 

T.  Shaptek. 

PB^ISYSTOLIC. — A term  implying  ante- 
cedence to  the  ventricular  systole,  and  used  in 
eonn exion  with  a cardiac  murmur  or  thrill  oecur- 
mg  during  this  time  of  the  cardiac  revolution. 
/See  Heart,  Valves  of,  Diseases  of ; and  Physi- 
cal Examination. 

PREDISPOSITION  TO  DISEASE.— 

. Definition. — That  state  of  the  body  which 
renders  it  peculiarly  liable  to  be  affected  in- 
juriously by  a morbific  agent ; determining  in 
the  case  of  a ‘ non-specific’  agent  the  particular 
disease  which  it  shall  induce  in  each  of  several 
individuals  similarly  exposed  to  it ; whilst,  in 
. die  case  of  a ‘ specific  ’ agent  or  1 morbid-poison,’ 
it  determines  the  relative  liability  of  several 
individuals  similarly  exposed  to  it,  to  become 
the  subjects  of  the  particular  disease  it  is  capable 
of  originating,  and  also  influences  the  severity  of 
,ts  attack. 

Thus,  of  several  persons  equally  exposed  to 
Bevere  cold,  which,  by  chilling  the  general  sur- 
I face,  produces  contraction  of  the  cutaneous  ca- 
pillaries and  consequent  internal  congestion, 
some  shall  not  suffer  seriously  in  any  way ; but 
i.one  shall  be  attacked  by  bronchitis,  another  by 
■pneumonia,  another  by  apoplexy,  another  by 
castro-mtestinal  disturbance,  another  by  jaun- 
dice, another  by  nephritis,  another  by  gout, 
and  so  on,  according  to  the  part,  of  the  body 
which  the  congestion  most  affects  in  each  in- 
dividual. 

■ Again,  of  several  individuals  equally  exposed 
to  the  poison  of  cholera,  some  shall  escape  alto- 
gether, whilst  others  shall  be  attacked  by  chole- 
■aic  disease : and  of  the  latter,  some  may  suffer 
inly  from  diarrhoea;  in  others  nothing  more  may 
be  induced  than  vomiting,  cramps,  and  rice-water 
■vacuations ; whilst  in  others  the  disease  may 
develop  itself  in  its  full  intensity,  and  rapidly 
■roceed  to  a fatal  termination. 

Predisposition  may  be  either  congenital  or 
cquired ; and  in  the  former  case — unless  in- 
deed by  malformation,  or  by  causes  acting 
trough  the  maternal  system  during  pregnancy, 
is  usually  hereditary. 

Hereditary  predisposition  to  disease  seems  to 
■How  the^  same  modified  laws  of  heredity  as 
le  transmission  of  family  peculiarities.  These 
) not  imply  the  same  duration  or  universality 
the  action  of  the  causes  which  have  evolved 
em  as  do  the  characters  of  species  and  race ; 
d consequently,  whilst  tending  to  perpetuation 
the  parentage  on  both  sides  be  limited  to  such 
participate  in  them,  they  tend  to  die  out  by 
e interbreeding.  Still,  we  often  see  a family 
iture,  or  some  other  physical  or  mental  pecu- 
rity,  ‘ cropping-up  ’ after  a dormancy  of  several 
lerations ; thus  clearly  evidencing  the  trans- 
gsion  of  a potency,  which  manifests  itself 
enever  some  deficient  condition  has  been  sup- 
m.  So  there  are  certain  constitutional  states 
,'imthescs,  which  particular  abnormal  habits  of 


PREDISPOSITION  TO  DISEASE.  1261 
life  tend  to  induce,  when  their  operation  con- 
tinues with  cumulative  force  through  successive 
generations.  These,  when  fully  established,  so 
penetrate  the  entire  organism,  that  perhaps  no 
one  process  goes  on  exactly  as  it  would  in  per- 
fect health.  And,  when  they  have  once  firmly 
rooted  themselves  in  it,  they  tend  to  propagate 
themselves  hereditarily  like  family  characters, 
even  when  the  original  factors  have  ceased  to 
act,  but  still  more  when  they  continue  in  opera- 
tion. Of  this  we  have  a conspicuous  instance  in 
the  hereditary  transmission  of  goitre,  and  its 
gradual  aggravation  into  cretinism,  among  the 
inhabitants  of  those  Alpine  valleys  in  which  a 
close  stagnant  atmosphere,  privation  of  sunlight, 
bad  ventilation  of  dwellings,  filthy  personal 
habits,  and  some  other  local  conditions  not  yet 
understood,  have  concurred,  through  a long  suc- 
cession of  generations,  to  engender  the  constitu- 
tional state  which  expresses  itself  in  these  forms 
of  disease. 

So,  the  fullest  evolution  of  the  gouty,  the 
scrofulous,  or  the  cancerous  diathesis  may  re- 
quire the  continued  action  of  their  factors  for 
several  successive  generations  ; it  may  be  inter- 
fered with  by  the  introduction  of  normal  factors 
by  intermarriage ; and  during  its  progress  the 
manifestation  of  these  diatheses  may  be  so  tri- 
vial as  to  attract  but  little  notice.  But  when 
either  of  them  has  been  fully  established  by  the 
sufficiently  prolonged  action  of  its  causes,  its 
hereditary  transmission,  like  that  of  family  pecu- 
liarities, becomes  the  rule  rather  than  the  ex- 
ception, save  in  so  far  as  it  is  modified  by  inter- 
breeding. And  even  where  it  seems  to  have  died 
out,  never  showing  itself  in  the  spontaneous 
production  of  any  of  its  characteristic  forms  of 
disease,  it  shall  modify  the  course  of  almost  any 
other  malady,  or  complicate  the  results  of  some 
accidental  injury.  Where  both  parents  are  the 
subjects  of  the  same  well-marked  diathesis,  the 
transmission  of  it  to  the  offspring  is  almost  a 
certainty ; and  the  manifestation  of  it  is  likely  to 
be  yet  more  marked,  if  the  parents  inherit  also 
the  same  family  idiosyncrasies.1 

Although  the  predisposition  to  insanity  is 
often  undoubtedly  hereditary,  it  does  not  seem 
to  partake  of  the  constitutional  nature  of  a dia- 
thesis, except  where  it  depends  on  the  existence 
of  one  of  the  definite  forms  of  mal-nutrition 
already  specified.  The  fact  seems  to  be  that 
the  nervous  system  is  so  peculiarly  liable  to  be 
shaped  and  modified  by  the  mode  in  which  it  is 
habitually  called  into  exercise,  that  it  takes-on 
a particular  abnormal  form  of  activity  far  more 
readily  than  any  other  organ  ; and  thus,  when 
a special  form  of  malnutrition  has  once  estab- 
lished itself,  this  may  be  transmitted  to  the  off- 
spring without  the  prolonged  action  of  its  special 
factor  through  many  successive  generations.  We 
see  this  particularly  in  the  effect  of  habitual 
alcoholic  excess,  which  not  only  produces  a 
tendency  to  insanity  in  the  subject  of  it,  but 
also  engenders  in  the  offspring  (especially  when 
both  parents  are  drunkards)  a disordered  state 
of  brain-nutrition,  which  may  express  itself  in 

1 The  worst  case  of  this  kind  that  the  writer  ever  saw 
or  heard  of,  was  where  the  parents  were  first  cousins, 
— children  of  two  brothers  who  were  both  gouty,  and 
who  belonged  to  a family  noted  for  the  strong  personal 
and  mentai  resemblance  of  its  members. 


PREDISPOSITION  TO  DISEASE. 


1252 

idiocy,  epilepsy,  alcoholic  craving,  mental  insta- 
bility, weakness  of  will,  uncontrollable  hysteria 
and  the  like,  as  well  as  in  insanity.  And  the  same 
may  be  said  of  abnormal  moral  habits,  which, 
when  they  have  fixed  themselves  in  the  cerebral 
organism,  tend  to  reproduce  themselves  in  suc- 
ceeding generations ; as  we  see  in  hereditary 
kleptomania. 

But  of  all  these  acquired  forms  of  disordered 
neurosis  it  may  be  said  that,  as  it  is  the  pecu- 
liarity of  the  nervous  system  rapidly  to  grow  to 
the  mode  in  which  it  is  habitually  exercised,  so 
there  is  less  tendency  to  the  hereditary  per- 
petuation of  such  disorder  than  where  it  depends 
upon  an  established  diathesis,  provided  that  the 
right  methods  of  physical  and  moral  invigora- 
tion  are  employed  for  the  restoration  of  the 
brain’s  normal  activity. 

Although  it  can  scarcely  he  doubted  that 
various  other  acquired  predispositions  tend  to 
reproduce  themselves  in  the  offspring,  there  are 
none  which  do  so  with  any  approach  to  the  con- 
stancy and  definiteness  which  are  exhibited  by 
those  which  have  become  ‘ constitutional  ’ ; and 
they  may,  therefore,  be  dismissed  without  special 
notice. 

Among  the  diseases  produced  by  the  action  of 
specific  poisons,  there  are  some  to  which  the 
hereditary  predisposition  must  be  said  to  be 
universal ; the  cases  in  which  these  poisons  are 
imbibed  for  the  first  time  without  producing 
their  characteristic  effects,  being  quite  excep- 
tional. In  this  category  are  to  he  ranked  the  exan- 
themata, and  probably  syphilis.  Dismissing  the 
latter  as  limited  in  its  propagation  by  the  spe 
ciality  of  its  mode  of  transmission,  we  recognise 
the  universality  of  the  predisposition  to  the  for- 
mer in  the  extraordinary  manner  in  which  any 
exanthem  introduced  into  a community,  whose 
isolation  had  prevented  its  invasion  for  a long 
previous  interval,  spreads  through  a whole  popu- 
lation.1 

But  the  original  liability  to  any  of  the  exan- 
themata appears,  as  a rule,  to  be  extinguished 
by  one  attack  of  it ; the  cases  being  exceptional 
in  which  the  poison  develops  itself  a second 
time  in  the  body  of  anyone  who  has  once  fully 
exhibited  its  characteristic  effects.  And  the 
liability  is  greatly  diminished,  and  the  severity 
of  the  second  attack  usually  much  mitigated, 
even  when  the  first  action  has  been  incomplete 
— as  is  often  seen  in  epidemics  of  measles  and 
scarlatina.  This  seems  the  rationale  of  the  ‘pro- 

1  Thus,  in  1846,  the  poison  of  measles  having  been 
conveyed  to  the  Faroe  Islands,  where  it  had  been  un- 

known for  sixty-five  years,  the  disease  rapidly  spread 
among  their  inhabitants,  affecting  old  and  young  alike ; 

more  than  6,000  persons  out  of  a total  of  7,762  were  at- 
tacked by  it  in  the  course  of  six  months ; and  scarcely 
any  escaped,  save  the  few  aged  persons  who  had  been  af- 
fected when  young  in  the  previous  epidemic,  and  the  in- 
habitants of  one  of  the  smaller  islands,  who  kept  up  a 
rigid  quarantine.  The  Icelandic  records  (which  have 
been  well  kept  for  many  centuries)  show  a similar  pre- 
valence of  any  exanthem  that  has  been  introduced  after 
a long  interval.  Thus  in  1707,  out  of  a total  population 
of  about  65,000,  no  fewer  than  16,000  (or  nearly  one- 
fourthl  died  in  an  epidemic  of  small-pox;  so  that  it  can 
scarcely  be  doubted  that,  as  iu  the  previous  case,  almost 
every  individual  exposed  to  the  poison  must  have  been 
attacked  by  the  disease,  unless  he  had  previously  been 
the  subject  of  it.  Thirty-four  years  had  elapsed  since 
the  disease  had  been  last  known  in  the  island ; and  many 
persons  who  had  had  it  before,  took  it  a second  time. 


tection’  afforded  by  vaccination  against  small, 
pox;  there  being  (in  the  writer’s  opinion)  no 
reasonable  doubt  that  the  vaccine  virus  is  nothing 
else  than  small-pox  poison  modified  by  transmis- 
sion through  the  cow,  and  that  the  protective 
influence  of  vaccinia  is  thus  of  the  same  kind  as 
that  exerted  by  a first  attack  of  variola,  though 
perhaps  rather  lower  (unless  re- vaccination  Ins 
been  practised)  in  degree. 

Much  light  has  recently  been  thrown  on  this 
subject  by  parallel  researches  in  epizootic  dis- 
eases ; for  it  has  been  found  that  the  poisons 
of  ‘Splenic  Fever’  and  ‘Fowl-cholera’  can  be 
modified  in  like  manner  by  ‘ cultivation  ’ ; and 
that  the  inoculation  of  these  modified  poisons 
produces  in  the  subjects  of  it  very  mild  forms  of 
those  diseases,  which  serve  as  a protection  against 
their  malignant  attacks.  And  it  may  now  be 
laid  down  with  tolerable  certainty,  (1)  that  the 
blood  of  an  individual  who  has  been  the  subject 
of  any  of  those  specific  diseases  which  usually 
occur  only  once  in  life,  is  so  altered  (whether 
by  addition  or  subtraction),  that  it  is  no  longer 
liable  to  be  acted  on  by  the  same  poison ; and 
(2)  that  this  alteration  may  be  produced,  and 
‘ protection  ’ imparted  to  the  subject  of  it,  by 
even  a greatly  mitigated  form  of  the  disease, 
such  as  may  be  induced  by  the  introduction  of 
an  artificially  modified  poison.  It  may  not, 
Professor  Lister  thinks,  be  too  sanguine  an  anti- 
cipation, that  means  may  ere  long  be  found  fer 
so  tempering  the  poisons  of  measles  and  scarla- 
tina, as  to  make  an  innocuous  ‘vaccination’ 
afford  a similar  protection  against  their  worst 
effects.2 

Acquired  Predisposition. — Any  habitual  in- 
fraction of  the  laws  of  health  will  induce  a 
general  liability  to  disease,  by  producing  a de- 
pressed condition  of  the  vital  activity,  whereby 
the  organism  is  rendered  less  capable  of  resist- 
ing the  influence  of  morbific  agents.  But  this 
infraction  may  be  of  a kind  which  induces  a 
liability  to  some  particular  disease  ; as  when  the 
habit  of  rapidly  eating  a large  meal  tends  to 
injure  the  digestive  power;  or  the  habit  of  living 
in  over-heated  rooms  predisposes  to  bronchial 
and  pulmonary  attacks.3 

It  is,  however,  in  determining  the  invasion 
and  epidemic  spread  of  diseases  that  depend 
upon  the  zymosis  set  up  in  the  blood  by  the 
introduction  of  certain  specific  poisons,  that  the 
effect  of  ‘acquired  predisposition ’ is  most  dis- 
tinctly seen,  and  can  be  most  definitely  expressed. 
During  the  severest  visitation  of  cholera  or  diph- 
theria, for  example,  the  number  attacked  is 
really  small  in  comparison  with  the  entire  popu- 
lation ; and  while,  of  those  who  escape,  the  great 
mass  may  be  assumed  not  to  have  been  ex- 
posed to  the  action  of  the  poison  at  all,  yet  it  is 
unquestionable  that  a large  proportion  of  those 

a See  his  address  ‘ On  the  Delation  of  Micro-organism 
to  Disease,’  in  Quarterly  Journal  of  Mici'oscopic  Science, 
April,  1SS1. 

3 The  writer  was  informed  by  Mr.  Gulliver,  when  sur- 
geon in  the  Life  Guards,  that  the  yoneg  powerful  mer 
of  his  regiment,  mostly  sons  of  Yorkshire  fanners,  suf 
fered  greatly  from  bronchitis  and  pneumonia;  in  corse 
qucnce,  he  believed,  of  their  liability  to  become  chill-.'- 
on  going  oat  into  cold  air,  after  being  shut  np  for  man; 
hours  a day  in  stables  unduly  heated  for  the  purpose  o: 
imparting  sleekness  to  the  coats  of  the  horses ; the  am 
mals  themselves  suffering  in  like  manner. 


PREDISPOSITION  TO  DISEASE. 


who  are  as  fully  exposed  as  those  attacked  by 
the  disease,  do  not  become  the  subjects  of  it.  A 
medical  practitioner,  again,  may  unconsciously 
carry  about  'with  him  a septicsemie  contagium, 
which  is  innocuous,  not  only  to  himself,  but  to 
a large  proportion  of  the  persons  with  whom  he 
comes  into  contact ; and  yet  it  rnay  take  fatal 
effect  upon  certain  individuals,  who,  neverthe- 
less, have  received  no  stronger  a dose  of  the 
poison  than  the  rest.  Further,  it  is  not  unfre- 
quently  seen  that  the  practitioner  or  nurse  who 
long  seems  completely  ‘proof’  against  any  attack 
of  the  epidemic  malady  to  which  he  (or  she)  is 
ministering,  at  last  succumbs  to  it.  It  is  clear, 
in  these  and  similar  cases,  that  there  must  be 
some  ‘predisposing  condition’  not  supplied  by 
the  normal  human  body,  which  determines  the 
zymotic  action  of  the  materics  morbi  in  the  in- 
dividuals who  manifest  its  effects. 

Such  ‘ predispositions  ’ have  been  recognised 
and  specified  by  all  who,  at  various  times,  have 
scientifically  studied  the  aetiology  of  epidemics  ; 
and  it  has  been  universally  noted  that  unwhole- 
some food,  bad  water,  and  foul  air  have  exerted 
a singular  potency  in  favouring  the  action  of 
the  poison  on  individuals  and  communities. 
The  advocates  of  the  ‘ germ-theory  ’ and  of  the 
‘ chemical  theory  ’ of  zymotic  poisons  are  at 
one  in  regard  to  this  fact — that  the  presence  of 
nitrogenous  matter  in  a decomposing  or  readily- 
decomposable  state,  affords  the  best  possible 
■pabulum,  either  for  the  development  of  bacillar 
organisms,  or  for  the  action  of  ferments.  And, 
nuilding  on  this  foundation,  the  writer  long  since 1 
?ame  to  the  conclusion,  that  the  common  con- 
iition  which  all  those  agencies  tend  to  produce, 
which  experience  has  shown  to  be  specially  fa- 
vourable to  the  development  of  zymotic  disease, 
s this:— the  presence,  in  the  blood  of  the  indi- 
•itlual  attacked,  of  an  excess  of  those  decomposing 
effete  matters,  with  which  the  circulating  current 
is  normally  charged  to  a limited  amount,  during 
their  passage  from  the  parts  of  the  body  in  which 
they  are  poured  into  it,  to  the  excretory  organs 
by  which  they  are  eliminated  and  cast  forth. 
If  the  amount  of  these  matters  be  limited  to 
:hat  which  is  being  continually  generated  in  the 
Ordinary  ‘ waste  ’ of  the  body,  and  if  the  great 
'munetories  (the  lungs,  the  liver,  the  intestinal 
::landulas,  the  kidneys,  and  the  skin)  all  do  their 
iroper  work,  the  products  of  that  ‘ waste  ’ are 
Irawn-off  from  the  blood-current  as  fast  as  they 
> re  poured  into  it,  so  that  the  stream  is  kept 
mre.  But  if,  on  the  one  hand,  such  decomposing 
hatters  be  either  abnormally  introduced  from 
■'ithout,  or  be  generated  in  abnormal  amount 
■ ithin  the  body ; or  if,  on  the  other  hand,  the 
ormal  process  of  elimination  be  in  any  way  ob- 
U'ueted  ; or  if,  still  more,  an  abnormal  excess  of 
leone  process  concurs  with  deficient  activity  of 
le  other,  a rapid  accumulation  of  these  matters 
ikes  place  in  the  blood;  and  this,  by  providing 
a s pabulum  requisite  for  the  development  of  the 
,)ison,  supplies  the  very  condition  necessary  for 
s morbific  activity. 

Of  the  effectiveness  of  the  introduction  of 
itrescent  organic  matter,  either  in  food,  water, 

See  his  Paper  on  ‘The  Predisposing  Causes  of  Epi- 
tnics,  in  the  Brit,  and  For . Med.  Chir . Review,  vol.  xi., 

S3,  p.  159. 


1253 

or  air,  the  cholera  epidemic  cf  1848-9  afforded 
instances  so  ‘glaring’  that  they  here  need  only 
to  be  adverted  to. 

Of  the  even  more  marked  potency  of  the  exces- 
sive generation  of  effete  matter  within  the  body,  we 
have  a typical  example  in  the  extraordinary  pro- 
clivity of  the  puerperal  female  to  suffer  from  the 
action  of  any  septic  poison  to  which  she  may  be 
exposed.2  Nothing  can  be  plainer  to  the  physio- 
logist, than  that  the  return  of  the  uterus,  after 
parturition,  to  its  non-pregnant  condition,  in- 
volves a rapid  ‘waste  ’ of  its  muscular  substance, 
the  products  of  which  will  be  poured  into  the 
blood-current  far  more  rapidly  than  they  can  be 
eliminated;  this  state  continuing  until  the  process 
is  completed.  The  like  condition  exists  in  sub- 
jects of  severe  injuries,  and  of  operations ; and  not 
only  do  these  exhibit  a special  proclivity  to  the 
action  of  specific  poisons  like  scarlatina  (the  dis- 
ease only  then  declaring  itself,  although  its  germs 
must  have  been  previously  received  and  lain 
dormant),3  but  they  show  a peculiar  liability 
to  suffer  from  the  ordinary  septic  poisons  which 
have  no  effect  upon  the  healthy  carriers  of  them, 
erysipelas  and  adynamic  ‘ surgical  fever’  being 
thus  communicable.4 

Excessive  exertion,  again,  whether  bodily  or 
mental  (such  excess  being  marked  by  the  feeling 
of  fatigue)  has  always  ranked  among  the  most 
potent  of  predisposing  causes ; and  its  action  is 
clearly  traceable  to  the  same  source,  the  abnor- 
mally rapid  ‘ waste  ’ of  the  tissues,  whereby  the 
blood-current  becomes  unduly  charged  with  the 
products  of  their  disintegration.5 

Ample  evidence  is  afforded  by  army  experi- 
ence, of  the  special  liability  of  soldiers  to  zymotic 
disease,  when  on  long  and  fatiguing  marches ; 
and  this  especially  in  hot  climates,  where,  the 
activity  of  the  respiratory  process  being  reduced 
by  the  high  external  temperature,  the  products 
of  the  ‘ waste  ’ tend  to  accumulate  in  the  blood- 
current. 

Of  the  predisposition  induced  by  the  accumu- 
lation of  effete  matter  consequent  upon  obstructed 
elimination,  none  is  more  marked  than  that  which 
results  from  overcrowding.  The  effect  of  defec- 
tive air-supply  is  not  only  to  reduce  the  quan- 
tity of  carbonic  acid  got  rid  of  by  expiration, 

5 This  proclivity  was  never  more  strikingly  displayed 
than  in  the  former  experience  of  the  Vienna  Lying-in 
Hospital ; where  a comparison  of  the  mortality  in  the  two 
sides  of  the  institution,  one  attended  by  midwives,  and 
the  other  by  medical  students,  showed  that  an  annual 
average  of  from  400  to  500  deaths  out  of  3,000  deliveries  was 
distinctly  traceable  to  the  unclean  habits  of  the  latter, 
who  were  accustomed  to  come  into  the  wards  fresh  from 
the  dead-house.  The  enforcement  of  proper  precautions 
soon  lowered  this  excessive  mortality  to  the  standard  of 
the  other  side. 

a Sir  .Tames  Paget,  in  British  Medical  Journal,  1864,  vol. 
ii.  p.  237. 

* Sir  James  Simpson  in  Edinburgh  Monthly  Journal, 
vols.  xi.  and  xiii. 

5 It  is  within  the  experience  of  everyone,  that  the  sense 
of  fatigue  bears  no  constant  proportion  to  the  amount  of 
exertion  put  forth  ; and  that  whilst,  on  the  one  hand,  anj 
obstruction  to  the  eliminating  processes  (as  by  bad  venti 
lation  of  the  sleeping  apartment)  prevents  its  remova. 
by  rest,  an  unusually  severe  and  prolonged  strain  may 
be  sustained  without  its  induction,  when  the  excretory 
apparatus  is  stimulated  to  increased  activity,  as  in  ‘ train- 
ing.’ And  there  is  strong  reason,  therefore,  for  regard- 
ing this  feeling  as  indicative  of  the  degree  in  which  the 
blood  is  charged  with  the  products  of  nervo-muscular 
‘ waste.’ 


PREDISPOSITION  TO  DISEASE. 


1254 

but  also  (which  is  probably  of  yet  greater  im- 
portance in  relation  to  zymotic  disease)  to  di- 
minish the  normal  oxidation  of  those,  nitrogenous 
effete  matters,  of  which  (when  thus  metamor- 
phosed) it  is  the  special  business  of  the  kidneys 
and  skin  to  get  rid.  The  accumulation  of  these 
within  the  body  speedily  makes  itself  manifest 
in  the  offensiveness  of  the  halitus  of  the  breath 
(the  condensation  of  which  show’s  the  presence 
of  foetid  matter)  and  of  the  cutaneous  transpira- 
tion; and  thus,  although  there  may  be  no  intro- 
duction of  decomposing  matter  into  the  body,  or 
specially  rapid  internal  production  of  it,  the 
blood-current  becomes  as  effectually  charged 
with  the  ‘pabulum  of  the  zymotic  poison  as  if 
this  had  been  injected  into  it.1 

The  strong  predisposition  to  zymotic  dis- 
ease induced  by  intemperance , which  has  been 
no  less  conspicuously  manifested  in  the  ex- 
perience of  our  Indian  army,  seems  clearly 
traceable  to  the  same  source.  For  the  habitual 
presence  of  alcohol  in  the  blood-current  un- 
doubtedly diminishes  the  oxidation  of  the  ‘waste’ 
products,  and  thus  occasions  their  accumulation 
in  the  system ; and  this  at  a greater  rate  in  hot 
climates  than  in  cold,  on  account  of  the  already 
reduced  activity  of  the  respiratory  process  in 
the  former.  Where,  again,  the  rate  of  ‘ waste  ’ 
is  abnormally  increased— as  on  the  march  of 
troops — the  evil  influence  of  alcoholic  liquors  is 
still  more  strongly  manifested ; and  this  will  be 
again  aggravated  by  overcrowding  in  tents  or 
barracks.- 

1 Thus  it  has  come  about,  that,  while  the  average 
mortality  of  European  troops  in  India  under  favourable 
circumstances  does  not  exceed  30  per  1,000,  it  has  been 
raised  at  particular  stations  through  a long  succession  of 
years  — solely  by  overcrowding  in  ill -ventilated  barracks 
— to  75  or  even  100  in  the  1,000  ; whilst  in  certain  Indian 
gaols,  in  which  the  air-space  was  actually  at  one  time  less 
than  100  cubic  feet  per  prisoner,  the  mortality  rose  to  an 
annual  average  of  one  in  four. 

A most  remarkable  instance  of  the  combined  action  of 
’the  two  last-named  ‘predisposing’  causes,  resulting  in  the 
dowWe-charging  of  the  blood  with  the  pabulum  most 
suited  to  the  development  of  zymotic  poison,  was  fur- 
nished by  the  terrible  outbreak  of  cholera,  which  carried 
off  one-eighth  of  the  troops  stationed  at  Kurrachee  in 
1846;  no  fewer  than  464  deaths  having  then  occurred  out 
of  a total  strength  of  3,746.  Some  of  the  troops  (a)  had 
recently  come  off  a long  and  fatiguing  march,  but  were 
well  accommodated  in  airy  barracks  ; and  their  loss  was 
at  the  rate  of  96-6  per  thousand.  In  another  regiment 
(b),  which  had  not  been  on  the  march,  but  was  over- 
crowded in  small  ill-ventilated  tents,  the  rate  was  10S-6 
per  thousand.  And  in  a third  (c),  which  had  made 
the  march  like  a,  and  were  overcrowded  like  b , the  mor- 
tality was  218  per  thousand,  or  at  a rate  actually  exceed- 
ing their  high  rates  added  together. 

3 Of  this,  Dr.  Parkes’s  experience  as  assistant-surgeon 
to  the  84th  Regiment  in  India,  afforded  a striking  illus- 
tration. A large  proportion  of  the  men  of  this  regi- 
ment were  total  abstainers,  and  the  remainder  were 
very  temperate.  Daring  the  year  1846-47,  it  was  quar- 
tered for  eight  months  in  the  healthy  barracks  of  Fort 
St.  George,  Madras  ; it  then  performed  a march  of  be- 
tween 400  and  500  miles  to  Secunderabad,  in  a very  wet 
and  unhealthy  season,  through  a country  infested  with 
fever  and  cholera  ; and  the  remaining  two  months  were 
spent  in  overcrowded  barracks  at  Secunderabad.  Yet 
the  mortality  during  that  year  was  only  13  in  an  average 
strength  of  1,072,  or  at  the  rate  of  12*1  per  1,000.  Con- 
tinuing during  the  next  year  in  the  same  overcrowded 
barracks,  its  loss  was  raised  to  34*9  per  1,000;  but  this 
was  less  than  half  the  average  mortality  of  the  troops 
quartered  in  the  same  barracks  for  fifteen  years  past. 
The  63rd  Regiment,  with  which  they  had  exchanged, 
though  not  specially  noted  for  intemperance,  had  there 
lost  73  men  in  the  first  nine  months  of  the  previous  year, 
or  at  the  annual  rate  of  78  8 per  1,000  : and,  having  then 
inarched  to  Madras  to  take  the  place  of  the  Slth,  had  so 


On  the  connection  between  famine  and  pesti- 
lence, it  is  unnecessary  to  enlarge ; but  it  affords 
the  key-stone  of  our  cumulative  argument.  For 
in  whatever  way  it  is  to  be  accounted  for,  the 
fact  is  certain,  that  a state  of  general  blood-con- 
tamination is  produced  by  the  accumulation  of 
non-eliminated  products  of  ‘ waste.’  In  the  Irish 
famine  of  1847,  the  fcctid  secretions  from  the 
skin,  the  rapid  supervention  of  general  putres- 
cence after  death  and  its  manifestation  even  pre- 
viously, and  the  frequent  termination  of  life  bv 
colliquative  diarrhcea,  all  evidence  the  peculiar 
fitness  of  the  body  so  conditioned  for  the  de- 
velopment of  a zymotic  poison. 

And  thus  wo  seem  furnished  with  a scientific 
rationale  for  all  that  experience  has  taught  as  to 
the  conditions  of  the  spread  of  zymotic  disease ; 
which,  by  giving  greater  definiteness  and  con- 
sistency to  medical  doctrine,  will  afford  a surer 
and  more  positive  basis  for  preventive  hygiene, 
both  public  and  individual. 

But  whilst  it  is  specially  in  establishing  a pre- 
disposition to  zymotic  disease,  and  in  aggravating 
the  severity  of  its  attacks,  that  the  contamination 
of  the  blood-current  by  the  accumulation  of 
‘waste  ’ products  most  strikingly  manifests  itself, 
there  can  he  no  doubt  that  it  lowers  the  healthy 
vigour  of  the  body  generally,  and  thus  renders  it 
more  ready  to  be  affected  by  any  disease  to  which 
it  may  be  constitutionally  liable.  Where  any 
form  of  mal-nutrition  exists — whether  resulting 
from  imperfect  performance  of  the  primary  di- 
gestive processes,  producing  ill-made  blood,  or 
from  imperfect  conversion  of  blood  into  tissne — 
there  must  he  premature  degeneration  and  aug- 
mented ‘waste  ’ ; and  the  rate  of  this  augmenta- 
tion must  tend  to  increase,  if  special  attention  be 
not  given  to  the  eliminating  processes.  Here  are 
have  the  rationale  of  the  fundamental  importance 
of  pure  fresh  air,  as  cool  as  it  can  be  borne,  to 
the  scrofulous  subject ; and  of  the  remarkable 
cures  sometimes  effected  in  patients  in  whose 
lungs  tubercular  deposit  has  already  commenced, 
by  the  hazardous  discipline  of  a hardy  out-door 
life.  When  any  serious  malady  has  occo  cotab 
lished  itself,  the  degeneration  of  tissue,  as  shown 
in  the  rapid  wasting  of  the  body,  takes  place  with 
augmented  rapidity ; and  the  necessity  for  the  re- 
moval of  its  products  is  proportionately  nrgen*, 
And  this  is  not  the  less  important  when  the  pro- 
gress of  the  disease  is  stayed;  for  the  purifica- 
tion of  tho  blood  from  the  contamination  it  has 
received  is  absolutely  essential  to  the  establish- 
ment of  those  recuperative  processes  on  which 
the  final  issue  depends.  Of  the  due  elimination  of 
the  waste-products,  their  oxidation  is  the  first  and 
most  fundamentally- important  act;  and  of  the 
direful  consequences  of  past  ignorance  and  neglect 
of  this  principle — evinced  on  a large  scale  in  the 
overcrowding  and  had  ventilation  of  hospitals, 
poorhouses,  and  gaols — their  records  too  surely 
tell.  Even  now  our  practice  is  far  from  perfect 
in  this  particular ; and  it  ia  -scarcely  going  too 
far  to  affirm  that,  not  only  the  public,  but  the 
medical  profession,  have  still  much  to  learn 
as  to  the  importance  of  an  ample  supply  of  pure 

manysict  wtien  the  twe  reriments  met  cu  the  nail,  'J 
be  forced  to  borrow  tho  S4th’s  dhoolica. 


PREDISPOSITION  TO  DISEASE. 

«ir,  both  for  the  prevention  and  the  cure  of 
disease.1  William  B.  Carpenter. 

PREGNANCY,  Diseases  and  Disorders 

0f# Stn’ON.  : Pr.  Maladies  et  Troubles  de  la 

Orossesse ; Ger.  Krankheiten  und  Stohrungen  dcr 
Schwangerschafts. 

Under  this  heading  are  included  all  those 
complaints  which  arise  from  the  pregnant  state, 
or  which,  occurring  during  gestation,  are  so 
modified,  or  exercise  such  an  influence  over  it, 
as  to  require  special  treatment.  The  subjects  of 
false  pregnancy  and  concealed  pregnancy  will 
also  be  noticed.  The  principal  conditions  which 
demand  consideration  in  this  article  are  there- 
fore the  following  : — 1,  vomiting ; 2,  abortion  ; 3, 
ptyalism ; 4,  retroversion  and  retroflexion  of  the 
uterus ; 5,  anteversion  and  anteflexion ; 6,  em- 
bolism ; 7,  extra-uterine  pregnancy ; 8,  pruritus  of 
the  pudendum  ; 9,  oedema  of  the  labia  and  lower 
extremities ; 10,  oedema  of  the  upper  extremities ; 
11,  haemorrhoids;  12,  dropsy  of  the  amnion; 
13,  cramps  ; 14,  eclampsia;  15,  false,  and  16, 
concealed  pregnancy.  See  Fcetcs,  Diseases  of. 

The  foregoing  list  of  tho  principal  diseases 
. of  pregnancy  might  be  much  extended  if,  follow- 
: ing  the  example  of  eminent  obstetric  authorities, 
we  were  to  include  jaundice,  constipation,  diar- 
rhoea, cardialgia,  headache,  insomnia,  palpita- 
tion and  hypertrophy  of  the,  heart,  rheumatism, 

I inflammation  of  tne  uterus,  &c.  To  these  and 
most  other  diseases  pregnant  women  are  liable  ; 
but  not  being  in  any  way  peculiar  to  pregnancy, 
or  essentially  modified  thereby,  they  require  no 
notice  in  this  place. 

It  would  also  be  beyond  the  scope  cf  this  article 
to  refer  to  all  those  anomalous  sympathetic  dis- 
turbances of  the  nervous  system,  such  as  longings, 
morbid  or  depraved  appetite,  hysterical  irrita- 
bility, nervous  pains,  odontalgia,  &c.,  that  some- 
times attend  gestation,  and  which,  unless  exces- 
sive, may  be  regarded  as  symptoms,  and  not 
included  amongst  the  diseases  of  pregnancy. 

1.  Vomiting. — The  most  common  complaint 
of  pregnancy  is  morning  sickness,  or  nausea  and 
retching,  usually  confined  to  the  forenoon,  and 
continuing  from  the  third  week  after  conception 
until  the  period  of  quickening. 

The  sickness  of  pregnancy  is  generally  attended 
by  no  loss  of  appetite  or  impairment  of  health, 
and  may  thus  be  distinguished  from  vomiting 
caused  by  gastric  or  other  diseases. 

In  some  exceptional  instances,  however,  this 
complaint  assumes  a graver  aspect ; continues 

1 The  peculiar  susceptibility  of  the  nervous  system  of 
children  often  affords  a most  striking  test  of  atmospheric 
.impurity  that  might  otherwise  pass  unheeded.  In  the  last 
century,  trismus  nascentium  (a  disease  now  rarely  seen) 
«as  one  of  the  principal  factors  of  the  very  high  rate  of 
infantile  mortality  which  then  prevailed.  This  disease 
(continued  to  be  very  fatal  in  the  Lying-in  Hospitals  of 
Dublin,  after  it  had  almost  disappeared  from  those  of 
London ; and  it  was  mainly  by  the  attention  to  their 
ventilation  enforced  by  L)r.  Joseph  Clarke,  that  the 
nortality  of  the  infants  born  in  them  was  reduced.  The 
. lisease  has  continued  to  our  own  day,  under  precisely 
amilar  conditions,  in  St.  Hilda,  and  some  parts  of 
Iceland,  n here  two-thirds  of  ull  the  children  born  have 
lied  in  the  first  twelve  days.  Even  in  what  would  be 
iccouuted  the  well-ventilated  dwellings  of  our  own 
( niddle  and  higher  classes,  obstinate  cases  of  spasmodic 
nonp,  recurring  with  the  appearance  of  every  tooth,  are 
requently  seen,  which  immediately  yield  on  the  removal 
4 the  little  patients  to  the  pure  air  of  the  country  or 
he  seaside. 


PREGNANCY.  1255 

throughout  tlie  whole  term  of  gestation ; harasses 
the  patient  by  continual  retching;  and,  as  oc- 
curred in  one  case  which  came  under  the  notice 
of  the  writer,  may  even  cause  death  from  ex- 
haustion. 

^Etiology. — The  aetiology  of  morning  sickness 
is  a subject  on  which  much  ingenuity  has  been 
wasted.  For  many  years  Smellies'  theory  pre- 
vailed. ‘ Perhaps,’  he  says,  ‘ this  complaint  ij 
chiefly  occasioned  by  fulness  of  the  vessels  of  the 
uterus  ....  (this)  being  stretched  by  the 
ovum,  a tension  of  that  part  ensues,  affecting  the 
nerves  of  that  viscus,  especially  those  that  arise 
from  the  sympathetic!  maximi  and  communicate 
with  the  plexus  at  the  mouth  of  the  stomach.' 

Most  of  the  diseases  peculiar  to  women  are 
now  ascribed  by  some  authorities  to  displace- 
ments of  the  uterus,  which  are  regarded  by  Dr. 
Grailey  Hewitt  as  1 the  almost  universal  cause 
of  tho  vomiting  of  pregnancy.’  The  same  writer 
—whose  views,  however,  have  been  controverted 
by  Dr.  McClintock,  Dr.  Tilt,  and  others — insists 
that  ‘it  is  the  compression  undergone  by  the 
uterine  tissues  (markedly  by  the  nervous  fibres 
at  the  seat  of  the  flexion)  which  is  the  cause  of 
the  nausea  and  sickness.’ 

Treatment. — The  treatment  of  this  complaint 
depends  on  the  period  of  pregnancy,  the  severity 
of  the  symptoms,  and  the  constitution  of  the 
patient.  In  ordinary  cases  it  may  be  prevented 
by  the  patient  remaining  in  bed  until  the  usual 
period  for  its  return  has  passed  over.  Her  diet 
should  be  light,  and  she  should  take  as  little 
fluid  as  possible,  especially  avoiding  all  warm 
drinks,  such  as  tea.  The  bowels  should  be  regu- 
lated by  mild  antacid  aperients  or  effervescing 
salines.  At  the  same  time  some  of  the  so-called 
specifics  may  be  ordered,  such  as  oxalate  of 
cerium  in  two-grain  doses,  or  hydrocyanic  acid, 
with  infusion  of  calumba.  It  is  unnecessary  to 
refer  to  all  the,  generally  useless,  remedies 
which  have  been  proposed  for  this  complaint,  in- 
cluding the  dilatation  of  the  cervix  uteri,  first- 
suggested  by  Dubois,  and  more  recently  recom- 
mended by  the  late  Dr.  Copeman,  of  Norwich ; 
the  hypodermic  injection  of  morphia  ; chloral ; 
carbolic  acid;  and  minute  doses  of  ipecacuanha. 

In  some  cases  of  excessive  vomiting  occurring 
in  plethoric  patients,  six  or  eight  ounces  of  blood 
may  be  taken  away  with  advantage.  If,  notwith- 
standing this,  the  sickness  continues,  and  the 
patient  is  in  danger  of  dying  from  exhaustion, 
the  propriety  of  inducing  premature  labour  be- 
comes a grave  question.  In  no  case  should  so 
serious  a measure  be  resorted  to  without  full 
deliberation  and  consultation.  In  all  cases  it 
should  be  deferred  as  long  as  possible,  and  in 
fixing  the  period  for  its  performance  regard 
should  always  he  paid  to  the  possible  viability 
cf  the  feetus. 

2.  Abortion. — The  expulsion  of  the  feetus 
before  the  ordinary  period  of  liability  may  result 
from  diseases  affecting  either  the  mother  or  the 
ovum  Amongst  the  former  are  constitutional 
syphilis,  scrofula,  fevers  (especially  the  exanthe- 
mata), and  general  plethora  ; and,  according  to 
Dr.  R.  Lee,  ‘all  the  chronic  diseases  to  which  the 
uterus  and  its  appendages  are  liable  may  also 
be  considered  causes  of  abortion.’  The  ovuline 
causes  are  cystic  or*other  placental  diseases,  and 


PREGNANCY,  DISEASES  AND  DISORDERS  OF. 


1256 

3yphilis.  It  ,s  unneeessai-y  to  discuss  such  a 
range  of  subjects  here.  See  Miscarriage. 

3.  Ptyalism. — This  is  an  occasional  complaint 
of  early  pregnancy,  butseldom  requires  any  treat- 
ment. In  exceptionally  severe  cases,  salivation 
may  be  controlled  by  the  application  of  tanno- 
glycorine  and  astringent  gargles,  especially  chlo- 
rate of  potash  in  infusion  of  bark;  or,  where 
those  fail,  by  the  application  of  a few  leeches  to 
the  sub-maxillary  glands. 

4.  Retroversion  of  the  Uterus. — This  form 
of  displacement  sometimes  occurs  in  early  preg- 
nancy, from  pressure  of  the  enlarging  womb  on 
the  neck  of  the  bladder,  which,  thus  prevented 
from  completely  emptying  itself,  becomes  so  dis- 
tended that  it  gradually  forces  the  fundus  uteri 
downwards  and  backwards  into  the  hollow  of  the 
eacrum,  whilst  the  cervix  is  tilted  upwards  and 
forwards  against  the  symphysis  pubis.  The  symp- 
toms of  this  occurrence  are  difficulty  in  passing 
water,  or  even  complete  retention  of  urine,  with 
tenesmus  and  powerless  straining  to  empty  the 
bowels.  At  the  same  time  a sense  of  weight,  or 
fulness,  and  bearing-down  pains  in  the  pelvis  aro 
complained  of. 

TiiRAT.MF.NT. — The  treatment  of  retroversion 
during  pregnancy  must  be  prompt,  as,  if  it  be 
complete,  it  not  only  occasions  considerable 
suffering  to  the  patient,  but  also  certainly  ends 
in  the  premature  expulsion  of  the  foetus.  In 
cases  of  slight  retroversion,  the  displacement 
may  be  remedied  by  emptying  the  distended 
bladder  with  the  catheter,  supporting  the  uterus 
with  a Hodges’  pessary,  and  keeping  the  patient 
lying  on  her  face  for  a few  days.  In  complete 
retroversion  this  becomes  a matter  of  consider- 
able difficulty.  The  patient  should  be  placed 
on  her  hands  and  kuees;  the  bladder  emptied; 
and  the  fundus  pushed  up  from  the  rectum  by  a 
couple  of  fingers  of  one  hand,  whilst  with  the 
other  hand  the  cervix  is  pulled  down.  A well- 
bent  pessary  should  be  passed  up  into  the  pos- 
terior cul-de-sac  of  the  vagina,  and  the  recum- 
bent position  rigidly  maintained  for  some  time. 

o.  Anteversion  and  Anteflexion  of  the 
Uterus. — Anteversion  and  anteflexion  of  the 
uterus  are  very  exceptional  complaints  during 
pregnancy.  The  patient  complains  of  bearing- 
down  pelvic  pains,  and  on  examination  the  os 
uteri  will  be  found  in  the  posterior  cul-de-sac  of 
the  vagina,  looking  towards  the  sacrum,  the  fun- 
dus uteri  pressing  on  the  neck  of  the  bladder, 
and  occasioning  at  first  incontinence  of  urine, 
which,  as  the  displacement  increases,  changes  to 
difficulty  in  micturition  or  complete  retention.  In 
anteversion,  abortion  is  said  to  occur  at  an  earlier 
period  than  in  retroversion. 

Treatment. — The  treatment  consists  in  placing 
rhe  patient  on  her  back ; mechanically  reducing 
the  displacement ; and  applying  a cradle  pes- 
sary. 

6.  Embolism. — A\Te  occasional!}',  though,  for- 
tunately, rarely,  meet  with  cases  of  sudden  death 
during  pregnancy  which  cannot  be  accounted  for 
by  any  cardiac  disease,  aneurism,  or  accident. 
In  the  pregnant  state  a strong  predisposition 
to  the  formation  of  a fibrinous  clot  or  thrombus 
exists,  and  this  is  increased  by  any  circumstance 
that  depresses  the  circulation,  such,  for  instance, 
as  the  fainting  that  frequently  attends  quicken- 


ing. The  thrombus  may  be  carried  array  and 
become  impacted  in  the  pulmonary  artery  or 
elsewhere,  at  any  subsequent  period  of  gesta- 
tion, blocking  the  current  of  the  circulation  an! 
causing  sudden  death. 

There  are  no  symptoms  by  which  a thrombus 
can  be  recognised,  until  its  presence  is  discovered 
after  death.  And  the  only  lesson  we  can  learn 
from  the  history  of  such  cases  is  the  necessity  of 
watchfulness  during  gestation,  to  prevent  the 
occurrence  of  any  undue  depression  of  the  circu- 
lation. 

7.  Extra-uterine  Pregnancy. — This  is  a 
rare  condition  of  morbid  gestation,  generally  the 
sequence  of  pelvic  inflammation,  extending  to 
the  Fallopian  tubes,  and  rendering  the  passage 
impervious  to  the  fertilized  ovum.  Hence  mul- 
tiparae  are  most  liable  to  it. 

Four  varieties  of  extra-uterine  pregnancy  are 
described,  namely,  ovarian , interstitial , ventral, 
and  tubal.  The  latter  is  most  common.  The  early 
symptoms  of  ex-foe  tat  ion  cannot  be  distinguished 
from  those  of  natural  pregnancy.  But  as  the 
patient  approaches  the  fourth  month,  she  begins 
to  complain  of  something  unusual  in  her  condi- 
tion ; and,  later  on,  considerable  dull  pain  and 
sense  of  fulness  in  the  pelvis  are  experienced. 
On  examination  the  os  uteri  will  be  found  patu- 
lous, the  cervix  undeveloped,  and  a semi-solid 
tumour  may  be  felt  in  Douglas’s  space  between 
the  vagina  and  rectum.  If,  under  these  circum- 
stances, the  sounds  of  the  foetal  heart  are  heard 
in  an  unusual  situation,  there  can  be  no  doubt 
as  to  the  naturo  of  the  case. 

In  tubal  pregnancy  the  cyst  generally  ruptures 
before  the  third  month,  and  the  patient  dies 
undelivered,  from  shock  and  haemorrhage.  In  ex 
ceptional  cases,  however,  the  misplaced  gestation 
may  go  on  to  the  full  term,  and  the  foetus  having 
then  perished,  after  an  abortive  effort  at  expul- 
sion, it  may  be  retained  for  many  years  without 
material  inconvenience.  Extra-uterine  preg- 
nancy depends  on  causes  entirely  beyond  the 
reach  of  medical  treatment. 

8.  Pruritus  of  the  pudendum. — Pruritus  is 
occasionally  a distressing  result  of  the  general 
hyperaesthesia  and  congestion  of  the  generative 
organs  during  pregnancy,  and  consists  in  intense 
irritation,  extending  over  the  external  orifice  of 
the  vagina,  labia,  and  clitoris.  The  itching  oc- 
curs in  paroxysms  which  are  most  troublesome 
at  night,  and  in  aggravated  cases  wear  out  the 
patient,  mentally  and  physically,  from  the  loss 
of  rest  and  constant  irritation.  In  most  cases 
this  may  be  relieved  by  bromide  of  potassium  in 
large  doses,  and  the  application  of  a strong  solu- 
tion of  borax  or  of  nitrate  of  silver,  or  sedative 
lotions  to  the  affected  parts. 

9.  CEdema  of  the  lower  extremities. — 
(Edema  of  tho  lower  limbs,  from  the  pressure 
of  the  gravid  uterus  on  the  veins,  is  a common 
complaint  in  the  later  months,  and  seldom  re- 
quires any  treatment  beyond  rest  and  aperients. 
Nor  is  the  dropsical  tumefaction  of  the  labia, 
which  occurs  from  the  same  cause,  more  serious. 

10.  (Edema  of  the  face  and  upper  extre- 
mities.— This  is  always  an  alarming  symptom 
during  pregnancy,  foretelling  uraemic  convulsions, 
and,  if  attended”  by  albuminuria,  urgently  de- 
mands active  treatment,  such  as  depletion  by 


PREGNANCY,  DISEASES  AND  DISORDERS  OF.  1257 


(tipping  over  the  loins,  and  strong  saline  purga- 
tives. 

In  all  cases  and  forms  of  dropsy  during  preg- 
nancy, the  urine  should  be  daily  tested  for  albu- 
min; and  if  this  bo  found,  the  case  must  be 
treated  as  one  of  impending  convulsions. 

11.  Haemorrhoids. — At  all  times  women  are 
more  subject  to  this  complaint  than  men,  and 
during  pregnancy,  owing  to  the  pressure  of  the 
gravid  uterus  on  the  hsemorrhoidal  and  internal 
iliac  veins,  comparatively  few  escape  either  in- 
ternal or  external  piles.  As  Smellie  observed. 

‘ the  same  method  of  cure  may  be  administered 
as  that  practised  at  other  times,  though  greater 
caution  must  be  used  in  applying  leeches  to  the 
parts.’ 

12.  Dropsy  of  the  Amnion. — This  condition 
is  met  with  in  some  cases  of  abortion  from  hyda- 
tidinous  or  other  placental  disease.  It  also 
occurs  from  simple  over-secretion  of  the  amniotic 
fluid,  and  is  then  chiefly  of  interest  as  the  cause 
of  a condition  to  which  the  older  writers  at- 
tached great  importance,  namely,  pendulous  belly. 
This  was  regarded  by  Devanter  as  the  ordinary 
source  of  obliquities  of  the  uterus,  and  of  difficult 
labour.  Without  discussing  that,  question,  we 
must  regard  this  condition  as  of  some  impor- 
tance, not  only  from  the  inconvenience  it  occa- 
sions, and  which  can  only  be  palliated  by  an 
abdominal  belt,  but  still  more  from  the  proba- 
bility of  its  leading  to  post-partum  haemorrhage, 
from  inertia  of  the  over-distended  uterus.  Hence 
in  these  cases  it  is  necessary  to  deviate  from  the 
ordinary  rule  of  midwifery  practice,  by  rupturing 
the  membranes,  the  presentation  being  natural, 
as  early  as  possible  during  labour. 

13.  Cramps. — Cramps  in  the  legs,  from  uterine 
pressure  on  the  large  nerve-trunks  at  the  brim 
of  the  pelvis,  are  common  during  the  last  months 
of  pregnancy,  and  generally  come  on  at  night  in 
the  course  of  the  anterior  crural  nerve,  extending 
down  into  the  calves  and  feet.  In  ordinary  cases 
no  treatment  is  required,  unless  friction  over 
the  seat  of  pain,  and  some  aperient,  can  be  so 
called.  Where,  however,  as  sometimes  happens, 
the  cramps  become  unusually  severe  and  fre- 
quent, their  recurrence  may  be  prevented  by  the 
pressure  of  a bandage  or  elastic  stocking. 

14.  Eclampsia. — This  is,  with  one  exception, 
the  most  serious  complication  of  gestation.  The 
true  convulsions  of  pregnancy  are  sui  generis  in 
their  nature,  though  they  are  usually,  but  erro- 
neously. classified  as  hysterical,  epileptic,  or 
apoplectiform  convulsions. 

Hysterical  convulsions,  being  nothing  more 
than  an  attack  of  hysteria,  accidentally  affecting 
a woman  in  the  early  months  of  pregnancy, 
require  no  special  treatment,  nor  any  further 
notice. 

The  so-called  epileptiform  and  apoplectiform 
convulsions  of  pregnancy  are  identical  in  their 
character,  and  are  influenced  in  their  symptoms 
i by  the  constitutional  state  of  the  patient  and  the 
severity  of  the  attack,  rather  than  by  any  essen- 
tial difference  in  the  nature  of  the  disease. 

Symptoms. — The  premonitory  symptoms  of 
convulsions  are  of  considerable  importance,  as 
by  their  timely  recognition,  and  the  adoption  of 
suitable  treatment,  the  approaching  attack  may 
be  often  warded  off.  In  the  majority  of  cases, 


eclampsia  is  preceded  by  oedema  of  the  upper 
extremities,  face,  and  eyelids ; pains  in  the  lum- 
bar region ; albuminuria ; and  headache,  vortigo, 
or  peculiar  irritability  of  temper. 

In  asthenic  eclampsia,  the  clonic  spasms  com- 
mence with  twitching  of  tho  muscles  of  the  eye- 
lids, soon  increasing  in  violence ; extend  to 
every  part  of  the  body ; and  recur  at  irregular 
intervals.  In  anaemic  patients,  throughout  the 
attack,  the  face  may  be  cool  and  pale,  the  eye 
glistening,  and  the  pupil  contracted  ; but,  gene- 
rally, as  the  convulsions  recur  more  frequently, 
the  impeded  respiration  induces  symptoms  of 
venous  congestion : the  faqe  becomes  livid ; the 
breathing  stertorous ; the  pulse  full  and  labour- 
ing ; and  thus  the  disease  passes  from  the  first 
into  the  second  stage,  or  from  the  so-called 
‘epileptiform’  into  the  so-called  ‘apoplectiform’ 
convulsions. 

In  plethoric  women,  however,  the  complaint 
commonly  assumes  the  apoplectic  character  from 
the  first,  setting  in  by  a violent  convulsion,  im- 
mediately after  which  the  patient  falls  into  a 
comatose  state,  the  convulsions  meanwhile  re- 
curring at  frequent  but  irregular  intervals.  After 
some  time,  under  favourable  circumstances,  the 
convulsions  cease,  and  the  patient  slowly  re- 
gains consciousness.  But,  on  the  other  hand, 
the  coma  may  become  more  profound,  the  pulse 
more  labouring,  the  respiration  more  embar- 
rassed, and  the  extremities  colder,  until  at  length 
‘ the  last  sad  scene  of  all  ’ is  closed  by  a violent 
and  final  convulsion. 

These  convulsions  may  occur  at  any  time  of 
pregnancy,  during  labour,  and  within  the  puer- 
peral period. 

Pathology.- — The  cause  of  eclampsia  is  a 
subject  on  which  innumerable  theories  have 
at  different  times  prevailed.  The  older  British 
obstetricians  regarded  congestion  of  the  brain  as 
the  general  cause  of  this  disease,  and  hence  they 
relied  on  blood-letting  for  its  cure.  Next  pre- 
vailed the  opinion,  founded  on  the  views  of  Dr. 
Marshall  Hall  and  Von  der  Kolk,  that  these 
convulsions  are  reflex  actions,  excited  by  uterine 
irritation  acting  upon  the  upper  part  of  the 
spinal  cord  and  medulla  oblongata.  Space  does 
not  allow  of  any  consideration  of  these  or  the 
many  other  more  recent  conjectures  on  the 
causation  of  eclampsia. 

At  the  present  time  this  disease  is  generally 
regarded  as  the  result  of  ursemic  blood-poisoning, 
it  having  been  shown  by  Braunn,  Frerichs,  and 
others,  that  the  convulsions  of  pregnancy  are 
frequently  associated  with  dropsy,  albuminuria, 
diminished  excretion  of  urea  and.  uric  acid,  and 
the  consequent  retention  of  these  compounds  iD 
tho  system. 

That  convulsive  action  may  be  occasioned  by 
ursemic  blood-poisoning  is  well  known  in  other 
diseases  ; and  during  pregnancy  the  same  effect 
may  be  produced  by  the  pressuro  of  the  gravid 
uterus  on  the  renal  emulgent  veins  interfering 
with  the  functions  of  the  kidneys. 

The  influence  of  mental  and  moral  impressions 
in  causing  convulsions  has  been  remarked  by  all 
obstetricians.  The  fact  of  its  being  the  patient’s 
first  pregnancy  has  also  some  influence  ; thus, 
of  eight  cases  that  came  under  the  writer’s  no* 
tice,  five  were  primiparce. 


1258  PREGNANCY,  DISEASES  AND  DISORDERS  OF. 


Teeatment. — Preventive. — In  the  treatment 
of  the  convulsions  of  pregnancy,  whenever  any  of 
the  premonitory  symptoms  already  described, 
and  more  especially  albuminuria,  are  observed, 
we  should  direct  our  efforts  to  the  depuration  of 
the  blood,  by  cupping  over  the  kidneys,  and  the 
administration  of  mild  diuretics,  saline  purga- 
tives, and  diaphoretics.  At  the  same  time  we 
must  endeavour  to  allay  nervous  irritability  by 
sedatives,  of  which  in  these  cases  the  best  is 
bromide  of  potassium. 

Immediate. — During  the  convulsions  precau- 
tions to  prevent  a patient  from  biting  her  tongue, 
or  from  injuring  her  person  in  any  way,  should 
in  the  first  instance  be  taken.  One  of  the  most 
effectual  means  of  shortening  the  paroxysms 
is  cold  affusion  on  the  head  and  face.  In  the 
asthenic  form  of  eclampsia,  however,  this  re- 
medy should  be  used  cautiously.  In  all  cases 
the  bowels  should  be  unloaded  by  calomel  and 
jalap,  or  by  a drop  of  croton  oil,  or  by  the  assa- 
feetida  enema ; the  head  should  be  shaved  and 
blistered,  or  ice  applied,  and  at  the  same  time 
sinapisms  be  put  on  the  legs. 

In  cases  of  sthenic  convulsions  bloodletting 
is — notwithstanding  thedisusage  into  which  this 
has  now  fallen— the  only  remedy  of  undoubted 
efficacy  in  subduing  the  convulsive  action.  If 
the  patient  be  plethoric,  and  her  pupils  be  con- 
tracted, we  may,  as  a rule,  bleed.  If,  on  the 
contrary,  the  pupils  be  dilated,  the  condition 
of  the  brain  may  be  considered  as  ansmic, 
and  bloodletting  would  probably  be  out  of  the 
question. 

The  amount  of  blood  that  may  be  taken  from 
a plethoric  woman  suffering  from  eclampsia 
should  be  measured  by  the  patient’s  condition, 
and  the  effect  produced,  rather  than  by  the 
quantity  abstracted.  In  hysterical  convulsions,  if 
cold  affusion  does  not  suffice,  the  inhalation  of 
chloroform  or  ether  will  generally  cut  short  the 
attack.  But  in  true  puerperal  convulsions,  in 
which  the  writer  has  tried  chloroform  pretty 
extensively,  it  requires  to  be  used  with  great 
caution,  being  contra-indicated  whenever  the 
circulation  is  depressed,  or  where  there  is  any 
tendency  to  apoplectiform  symptoms.  In  suit- 
able cases,  however,  he  has  found  chloroform 
serviceable  in-  subduing  the  convulsions,  and 
prolonging  the  intervals  between  them.  Chloral 
was  suggested  by  the  writer  several  years  ago. 
Opium  was  at  one  time  largely  prescribed  in 
these  cases  ; so  also  was  belladonna,  originally 
introduced  into  practice  by  hi.  Claussier  up- 
wards of  fifty  years  ago,  and  again  recom- 
mended by  recent  writers.  As  a substitute  for 
bloodletting,  the  tincture  of  veratrum  viride  is 
now  employed  by  some  American  obstetricians. 
In  the  actual  treatment  of  convulsions  time  is 
too  important  to  be  wasted  in  experimenting 
with  these  uncertain  drugs  ; though  in  the  pro- 
phylactic treatment  of  convulsions  during  preg- 
nancy and  after  parturition,  the  writer  has  found 
small  doses  of  belladonna  beneficial  in  calming 
the  nervous  susceptibility  so  intimately  con- 
nected with  convulsive  action. 

In  every  case  of  convulsions  towards  the  end 
of  pregnancy,  our  primary  object  should  be  to 
deliver  the  patient  as  speedily  as  is  consistent 
with  her  safety  and  that  of  her  child. 


15.  False  Pregnancy. — Synon.  : Pseudocyc- 
sis. — This  is  a subject  of  considerable  interest 
in  an  obstetric  as  well  as  a medico-legal  aspect. 
Spurious  pregnancy  is  of  more  frequent  occur- 
rence than  is  generally  supposed ; nor  is  it  con- 
fined, as  some  writers  assert,  to  sterile  elderly 
women  of  the  upper  classes,  many  cases  of  the 
kind  having  come  before  the  writer  in  hospital 
and  dispensary  as  well  as  in  private  practice. 

AUtiology. — With  regard  to  the  period  of  life 
at  which  pseudocyesis  is  most  frequent,  authori- 
ties differ.  The  writer  has  known  it  to  occur  in  a 
girl  of  sixteen  years  of  age,  but  the  great  ma- 
jority of  cases  are  met  with  about  the  period  of 
‘ the  turn  of  life,’  or  between  the  ages  of  forty- 
five  and  fifty.  The  causes  of  pseudocyesis,  be- 
sides those  before  roferred  to,  namely  change  of 
life,  dyspepsia,  and  hysteria,  are  very  numerous, 
including  ovarian  disease,  uterine  tumours  and 
physometra,  abdominal  plethora  and  obesity, 
molar  pregnancy,  and  cystic  disease  of  the  ovum. 
Molar  pregnancy  generally'  terminates  between 
the  third  and  fourth  months ; but  if  continued  be- 
yond the  latter  period,  the  absence  of  the  positive 
signs  of  pregnancy  would  show  the  true  nature  of 
the  case. 

Symptoms. — The  symptoms  of  spurious  preg- 
nancy are  occasionally  so  close  an  imitation  of 
those  of  true  gestation  as  to  present  great  diffi- 
culties in  their  diagnosis.  Most  of  the  ordinary 
signs  of  pregnancy  are  simulated  with  extraor- 
dinary exactness  in  many  cases  of  pseudocyesis. 
Thus  we  may  have  amenorrhcea,  followed  by  irri- 
table stomach ; swelling  of  the  mammae ; tur- 
gescence  of  the  nipples ; and  great  and  rapid 
enlargement  of  the  abdomen,  concurring  in  a 
woman  who  wishes  to  become  pregnant.  In  cases 
of  pseudocyesis,  the  last  of  these  symptoms  may 
be  traced  to  an  excessive  deposit  of  fat  in  the 
omentum,  or  to  tumour  ; it  may  be  caused  by 
distension  of  the  large  intestines  by  accumulated 
faeces,  or,  more  commonly,  by  flatus,  constituting 
what  the  poor  in  Ireland  graphically  describe  as 
‘ a windy  dropsy;  ’ or  it  may  bo  due  to  dropsical 
effusion  into  the  peritoneal  cavity. 

If  to  these  symptoms  be  added,  as  is  gener- 
ally the  case,  some  derangement  of  the  patient's 
nervous  system,  we  have  the  superstructure  on 
which  most  cases  of  spurious  pregnancy  are  built. 
As  a rule  those  who  suffer  from  pseudocyesis 
either  fear  or  wish  to  be  pregnant,  and  having  as 
it  were  coached  themselves  up  on  the  subject, 
apply  their  knowledge  to  their  own  fancied 
symptoms  with  such  a morbid  concentration  of 
their  thoughts  on  this  topic,  that  they  become 
monomaniacal  on  it,  and  deceive  themselves  as 
well  as  others. 

Few  cases  are  more  difficult  to  deal  with  in 
practice  than  those  now  under  consideration,  and 
seldom  is  the  obstetric  physician  more  unplea- 
santly' situated  than  when  called  in  consultation 
to  a patient  who,  having  persuaded  herself  and 
those  about  her  that  she  is  pregnant,  has  made 
all  the  usual  preparations  for  the  expected  event, 
and  who,  deceived  by  those  anomalous  periodic 
pains  that  sometimes  occur  in  spurious  ges- 
tation, sends  for  medical  assistance  under  the 
impression  that  she  is  in  labour.  Cases  of  this 
kind  show  the  necessity  for  much  caution  in  pro- 
nouncing any  woman  pregnant.  If  the  physician 


PREGNANCY. 

disregard  the  caution,  and  unfortunately  fall  in 
with  his  patient’s  opinion,  without  sufficient  ex- 
amination in  a case  of  pseudocyesis,  as  soon  as 
the  true  state  of  the  case  becomes  obvious,  he 
will  probably  be  made  the  scapegoat  for  the 
mistake,  and  suffer  all  the  odium  of  which  a 
woman’s  wounded  pride  is  capable. 

Diagnosis. — The  diagnosis  of  spurious  preg- 
nancy is  always  a matter  of  much  difficulty 
during  the  first  months  of  the  disorder.  But, 
however  closely  the  early  symptoms  of  preg- 
nancy may  be  simulated,  the  positive  signs  of 
pregnancy  after  the  fifth  month  cannot  be  coun- 
terfeited. And,  even  from  the  very  first,  in 
spurious  pregnancy,  it  may  generally  he  ascer- 
tained, on  careful  enquiry,  that  there  is  some- 
thing unusual  in  the  symptoms — either  some 
essential  one  is  wanting,  or  else  the  symptoms 
which  belong  to  one  period  of  pregnancy  manifest 
themselves  at  another,  and  commonly  earlier, 
time  than  is  natural. 

The  value  of  auscultation  as  a means  of  dia- 
gnosis in  these  cases  is  doubtful.  Even  in  the 
last  month  of  gestation,  the  fact  of  the  sounds 
of  the  foetal  heart  and  placental  souffle  not  being 
distinguished  on  auscultation,  is  no  proof  that 
the  uterus  may  not  contain  a living  child.  Nor 
is  the  value  of  the  positive  evidence,  derived 
from  tho  sounds  of  the  foetal  heart  and  placental 
souffle,  as  great  as  it  is  sometimes  supposed  to 
he.  An  experienced  auscultator  can  with  cer- 
tainty pronounce  on  the  existence  of  a living 
child  in  vtcro  from  the  auscultatory  signs  pre- 
sent. But  all  medical  practitioners  are  not 
experts  in  this  special  subject;  and  we  have 
seen  sufficient  proof  that,  by  those  who  form  a 
diagnosis,  in  such  cases,  from  the  presence  or 
absence  of  any  one  sign  of  pregnancy,  opinions 
are  sometimes  pronounced  in  haste,  which  have  to 
be  repented  at  leisure. 

A careful  examination  of  the  abdomen  with 
both  hands,  will  enable  us  to  ascertain  if  there 
be  any  uterine  enlargement,  although  not  to 
distinguish  between  the  enlargement  caused  by 
disease,  and  that  occasioned  by  pregnancy.  To 
do  this,  we  must  institute  a vaginal  exploration, 
to  determine  whether  the  conditions  of  the  os 
and  cervix  uteri  be  what  are  usual  at  the  corre- 
sponding period  of  pregnancy. 

In  cases  of  pseudocyesis  where  the  patient, 
being  anxious  to  be  thought  pregnant,  contri- 
butes to  the  deception  by  making  her  abdominal 
muscles  so  tense  and  rigid  that  it  becomes  im- 
possible to  ascertain  the  size  and  position  of  the 
uterus,  we  may  readily  dissipate  the  phantom 
tumour,  and  overcome  the  action  of  the  muscles, 
by  the  use  of  chloroform.  If  the  abdominal  or 
uterine  enlargement  be  occasioned  by  flatus  or 
by  physometra,  percussion  over  the  tumour  will 
afford  an  easy  test. 

Treatment. — It  is  needless  to  add  anything 
about  the  treatment  of  the  cases  we  have  been 
considering.  Pseudocyesis  is  only  an  effect  of 
certain  morbid  conditions,  the  recognition  of 
which  we  have  endeavoured  to  point  out.  The 
treatment  of  these  causes  will  be  found  fully 
described  in  the  articles  on  these  several  sub- 
jects. 

16.  Concealed  Pregnancy. — Concealed  preg- 
nancy is  a subject  so  closely  allied  to  pseudo- 


PRESSURE.  1259 

cyesis,  that  a few  words  on  it  appear  a suitable 
sequence  to  the  foregoing  observations.  Of  late 
years  the  concealment  of  pregnancy  has  become 
more  common  than  was  formerly  the  case.  This 
is  mainly  attributable  to  the  cheap  and  vicious 
literature  which  circulates  so  largely  amongst 
the  generally  badly  reared,  and  oftentimes  sorely 
tempted,  victims  of  seduction  in  our  large  cities, 
w'hose  minds  are  thus  familiarised  with  crimes 
of  foreign  origin,  by  which  too  often  they  seek 
what  they  falsely  think  a safe  mode  of  escaping 
the  penalty  of  their  error.  Hence  it  becomes 
essential  for  every  medical  practitioner  to  be 
prepared  to  meet  cases  of  concealed  pregnancy 
and  attempted  abortion  under  various  disguises, 
and  thus  be  enabled  to  detect  and  frustrate  such 
crimes.  So  often  has  the  writer  detected  preg- 
nancy in  patients  who  applied  for  emmenagogues 
under  the  pretext  of  simple  amenorrhcea,  that 
he  makes  it  a rule — especially  in  hospital  prac- 
tice, where  the  class  of  persons  above  referred 
to  are  more  likely  to  be  met  with — not  to  ad- 
minister any  medicine  of  this  kind  until  he  has 
satisfied  himself  as  to  the  true  state  of  the  case, 
though  this  should  be  done  without  any  expres- 
sion of  a doubt  that  might  be  unfounded. 

Thomas  More  Madden. 

PREMONITORY  (pre,  before;  and  moneo, 
I warn).- — This  word  is  associated  with  symptoms 
which  give  an  indication  or  warning  of  the  advent 
or  onset  of  certain  diseases  or  seizures ; for  in- 
stance, rigors,  during  the  invasion  of  fever,  and 
tho  various  nurse  preceding  an  epileptic  fit. 

PRESBYOPIA  (7r0e<rj3u9,  an  old  man,  and 
2><|/,  the  eye). — Impairment  of  the  power  of  accom- 
modation of  the  eye,  the  result  of  progressive 
senile  changes,  in  consequence  of  which  the 
nearest  point  of  distinct  vision  lies  at  more  than 
nine  inches  from  the  eye.  Distant  vision  may 
be  perfect;  but  the  eye,  unaided  by  an  appropriate 
convex  lens,  cannot  see  clearly  objects  less  than 
nine  or  more  inches  from  the  eye.  See  Vision, 
Disorders  of. 

PRESSURE. — This  is  an  important  subject 
from  several  points  of  view,  but  it  will  only  be 
practicable  in  the  present  article  to  discuss  it 
generally,  without  entering  into  details,  and  to 
offer  suggestions  for  further  consideration. 

1.  .ZEtiology  of  Pressure. — As  one  factor  in 
the  causation  of  various  morbid  conditions,  pres- 
sure is  not  uncommonly  of  much  consequence, 
and  it  may  itself  originate  certain  lesions. 

The  pressure  often  comes  from  without,  of 
which  the  following  illustrations  afford  sufficient 
examples.  General  pressure  upon  the  chest  and 
abdomen  preventing  the  movements  of  breathing, 
may  lead  to  death  from  suffocation,  to  fractured 
ribs,  or  to  other  consequences.  This  sometimes 
happens,  for  instance,  when  a person  is  crushed  in 
a crowff,  or  is  buried  in  a fall  of  earth,  although 
the  head  may  be  free.  Hanging  and  strangu- 
lation are  forms  of  violent  pressure  exercised 
on  the  windpipe  and  vessels  in  the  neck.  The 
pressuro  of  clothing  is  often  very  injurious  in 
connection  with  the  chest,  especially  that  pro- 
duced by  tight  stays.  This  leads  to  contraction 
or  distortion  of  the  chest ; interference  with  thg 
functions  of  the  lungs,  heart,  stomach,  and  other 


PRESSURE. 


1260 

organs ; displacement  of  organs ; or  actual  pul- 
monary disease.  A familiar  illustration  of  the 
effects  of  pressure  is  found  in  the  development  of 
corns  and  deformities  of  the  feet,  from  wearing 
tight  boots;  and  in  the  distortions  of  the  feet 
artificially  produced  in  Chinese  women  by  means 
of  systematic  pressure  applied  in  early  life.  In 
this  connection  may  also  be  mentioned  the  wear- 
ing of  tight  garters,  or  other  forms  of  local  con- 
striction, which  especially  tend  to  interfere  with 
the  passage  of  the  blood  through  the  veins,  and 
to  develop  varicose  veins.  Occupation  may  be 
the  cause  of  pressure  originating  disease.  Thus, 
prolonged  sitting  at  various  occupations  has  been 
supposed  to  set  up  sciatica.  Direct  compression 
upon  any  part  of  the  body,  by  implements  used 
in  certain  callings,  may  originate  morbid  condi- 
tions. For  instance,  pressure  thus  induced  upon 
the  sternum  is  liable  to  cause  deformity  of  the 
chest;  and  when  exercised  upon  the  epigastrium, 
it  has  been  suppose  l to  account  for  the  local 
development  of  cancer  of  the  stomach.  Lastly, 
prolonged  pressure  from  lying  in  one  position 
for  a length  of  time  not  uncommonly  causes 
localised  inflammation,  gangrene,  and  bed-sores, 
in  persons  suffering  from  low  fevers,  paralysis, 
emaciation,  and  other  conditions.  See  Ulcer. 

Pressure  is  often  exerted  by  morbid  conditions 
in  the  body  itself,  affecting  other  structures  in 
the  neighbourhood,  and  thus  inducing  secondarily 
various  symptoms,  pathological  phenomena,  or 
actual  diseases.  It  may  be  more  or  less  diffused, 
as  in  the  case  of  an  effusion  of  fluid  into  a 
serous  cavity  ; or  concentrated  upon  a certain 
limited  region  or  individual  structure,  as  often 
happens  with  aneurisms  and  solid  tumours.  In 
this  way  movements  may  be  interfered  with,  or 
more  obvious  effects  may  be  produced,  namely, 
displacement  of  organs  and  structures ; compres- 
sion of  tubes,  canals,  hollow  organs,  or  vessels, 
which  may  lead  to  their  complete  closure ; irri- 
tation and.  inflammation,  which  may  end  in  sup- 
puration or  gangrene ; or  actual  destruction. 
The  phenomena  induced  will  depend  upon  the 
seat  of  the  cause  of  pressure,  and  the  structure 
which  it  affects. 

2.  Pressure  in  Diagnosis. — Patients  may 
be  couscions  of  a local  subjective  feeling  of 
pressure,  which  in  some  instances  may  be  of  a 
certain  value  in  diagnosis;  but  such  sensations 
must  never  be  regarded  as  reliable.  The  ob- 
jective effects  of  pressure  are,  however,  often 
evident,  and  afford  clinical  signs  of  the  greatest 
diagnostic  value,  as  is  frequently  illustrated  in 
cases  of  diseases  of  the  chest  and  abdomen. 
Moreover,  the  practitioner  can,  by  means  of  pres- 
sure with  the  fingers  or  hand,  himself  determine 
many  points  of  essential  value  in  the  investiga- 
tion of  numerous  cases.  Indeed,  pressure  is  often 
an  important  part  of  palpation  or  manipulation, 
as  employed  in  physical  examination  ( see  Phy- 
sical Examination),  and  is  especially  useful  in 
the  following  particulars: — By  this  means  we  are 
able  to  determine  the  existence  and  degree  of  local 
tenderness  or  hypersesthesia.  Pressure  also  helps 
to  reveal  the  presence  of  air  or  fluid  in  the  sub- 
cutaneous cellular  tissue.  It  is  absolutely  neces- 
sary for  bringing  out  the  feeling  of  fluctuation, 
degree  of  resistance,  tension,  and  other  sensa- 
tions ; while  the  effect  of  pressure  in  modifying 


certain  physical  conditions  may  be  of  great  ser- 
vice in  diagnosis,  as  may  be  exemplified  by  the 
influence  thus  produced  in  many  cases  upon  an 
accumulation  of  faeces  in  the  intestines.  Pres- 
sure upon  arteries  or  veins  is  employed  with 
the  view  of  observing  its  effects  upon  the  local 
circulation,  arteries,  tumours  and  other  morbid 
conditions ; and,  in  the  case  of  the  arteries,  to 
determine  the  compressibility  of  the  pulse. 

3.  Pressure  in  Treatment. — In  this  con- 
nection the  first  point  to  be  noticed  is  the  neces- 
sity of  removing  or  avoiding  any  source  of  exter- 
nal pressure  which  is  causing  mischief ; and  also 
of  getting  rid  of  internal  pressure,  if  this  is 
practicable.  Pressure  may  frequently  be  em- 
ployed with  advantage  as  a therapeutic  agent. 
It  may  be  thus  tised  in  a more  or  less  difftised 
manner ; cr  concentrated  on  a limited  surface. 
It  may  be  practised  by  the  fingers  or  hand;  by 
means  of  plasters,  bandages,  elastic  apparatus, 
and  similar  appliances,  sometimes  of  an  elaborate 
kind ; or  by  special  surgical  apparatus  or  appli- 
ances, such  as  the  tourniquet,  acupressure,  the 
ligature,  the  clamp,  or  trusses  of  different  forms. 
Pressure  also  constitutes  one  element  in  friction 
and  shampooing. 

As  regards  the  objects  for  which  pressure  is  em- 
ployed, in  the  first  place,  it  not  uncommonly  helps 
to  relieve  pain,  which  may  be  illustrated  by  the 
effects  of  manual  pressure  in  subduing  the  pain 
of  intestinal  colic ; the  relief  often  afforded  to 
certain  forms  of  headache  bv  applying  a bandage 
or  handkerchief  tightly  round  the  head  ; and  the 
beneficial  results  following  the  fixing  of  more 
or  less  of  one  side  of  the  chest,  by  means  of 
strapping  or  other  agents,  in  cases  of  pleurisy  or 
pleurodynia.  Local  pressure  may  also  cure  cer- 
tain forms  of  neuralgia.  Agqin,  direct  compres- 
sion is  sometimes  employed  to  check  symptoms 
produced  by  reflex  influence  ; thus  pressure  over 
the  ovary  may  check  vomiting,  spasmodic  or 
convulsive  movements,  and  other  phenomena 
connected  with  hysteria.  Another  use  of  pres- 
sure is  to  arrest  the  process  of  inflammation, 
which  is  exemplified  by  the  practice  of  strap- 
ping the  testicle  in  the  early  stage  of  orchitis. 
In  relation  to  this  point,  a very  important 
object  for  which  it  is  employed  is  to  promote  the 
absorption  of  morbid  accumulations  and  pro- 
ducts of  all  kinds,  whether  originating  from  in- 
flammation or  other  causes.  Thus  it  helps  to 
get  rid  of  air:  of  fluid  effusions,  inflammatory  or 
dropsical ; of  fibrinous  exudations ; and  of  thick- 
enings or  indurations  remaining  after  acute  in- 
flammation, or  resulting  from  chronic  inflamma- 
tory process.  Pressure  is  again  frequently  taken 
advantage  of  for  its  influence  upon  the  blood- 
vessels. Thus  it  checks  different  forms  of  hemor- 
rhage, the  kind  of  compression  required  varying 
with  the  precise  form  of  bleeding.  Elastic  pres- 
sure, according  to  Esmarch’s  method,  has  been 
found  of  great  service  in  preventing  bleeding 
during  operations.  In  connection  with  arteries 
direct  compression  is  also  often  employed  for  the 
cure  of  aneurisms.  As  regards  the  veins,  pres- 
sure is  of  essential  service  in  preventing  the  inju 
rious  consequences  likely  to  result  from  varicose 
dilatation  of  these  vessels,  and  in  giving  them 
support ; while  it  is  also  made  use  of  in  the  cure 
of  this  condition,  especially  in  connection  with 


PRESSURE. 

;ertain  operative  procedures.  In  the  case  of 
the  abdomen,  pressure  is  often  of  much  service 
to  counteract  the  ill-effects  of  relaxed  and 
flabby  walls.  It  may  also  be  used  to  excite 
contraction  in  the  intestines,  bladder,  or  uterus, 
under  certain  circumstances ; and  to  aid  in  the 
removal  of  accumulations  in  the  bowels.  Lastly, 
pressure  is  made  use  of  in  preventing  certain 
forms  of  displacement  of  organs  and  structures ; 
and  in  attempting  to  cure  the  conditions  upon 
which  they  depend,  as  is  exemplified  by  the 
application  of  a truss  in  cases  of  hernia,  and  by 
some  of  the  operations  for  the  radical  cure  of 
this  complaint.  Frederick  T.  Roberts. 

PREVENTION'  OP  DISEASE.  See  Per- 
sonal Health  ; and  Public  Health. 

PRIAPISM. — Synon.  : Fr.  Priapisme ; Ger. 
Priapismus ; li ut hen /cramp f. 

Definition. — A term  generally  understood  to 
signify  unduly  occurring  or  unnaturally  pro- 
longed erection  of  the  penis,  accompanied  or  not, 
as  the  case  may  be,  by  inordinate  sexual  desire. 

It  is  important  to  distinguish  between  mere 
turgescenee  of  the  organ— false  priapism  ; and 
true  priapism,  or  perfect  erection.  The  former 
depends  simply  upon  distension  by  blood,  in- 
duced or  permitted  by  relaxation  of  the  walls  of 
the  blood-vessels  and  blood-spaces  ; it  may  be 
associated  with  comparative  flaccidity,  and,  though 
uncomfortable,  is  rarely  painful.  The  latter 
requires  for  its  production,  not  only  distension 
by  blood,  but  a certain  kind  and  degree  of  ten- 
sion or  contraction  of  the  intrinsic  muscular 
fibres  of  the  trabeculae  and  sheaths ; it  is  cha- 
racterised by  manifest  rigidity,  and  if  long  con- 
tinued— as  it  may  be  for  several  days  or  even 
longer— may  give  rise  to  considerable  suffering. 

Description. — Priapism,  more  or  less  pro- 
nounced, from  time  to  time  occurs  in  connection 
with  various  morbid  affections  of  the  general 
system,  or  of  particular  organs.  Thus  it  usually, 
though  not  invariably,  attends  erotic  mental  de- 
rangement, It  occurs  frequently  in  tetanus  and 
hydrophobia,  and  sometimes,  occasionally  even 
to  a distressing  extent,  during  recovery  from  the 
eruptive  fevers.  It  has  been  noted  in  some  cases 
of  tumour  or  other  disease  of  the  cerebellum  and 
pons  varolii ; and  in  the  earlier  stages,  or  among 
the  first  indications,  of  certain  diseases  of  the 
spinal  cord,  leading  on  to  paraplegia.  An  over- 
loaded condition  of  the  lower  bowel,  especially  in 
conjunction  with  enlarged  and  irritable  prostate, 
inflamed  haemorrhoids,  distension  of  the  bladder, 
stone  in  t.he  bladder,  phimosis,  urethritis,  and 
other  conditions,  may  be  enumerated  as  not  in- 
frequent local  causes  of  troublesome,  though 
transient,  priapism,  acting  either  by  pressure  on 
the  blood-vessels,  or  by  reflex  nervous  influence. 
It  also  occurs  among  the  results  of  injuries  of 
the  central  nervous  system,  as  well  as  of  the 
penis  itself.  Injuries  of  the  spinal  cord,  especially 
in  the  cervical  and  lumbar  regions,  are  liable 
to  be  followed  by  continued  or  recurrent  priap- 
ism, or  by  turgescenee  with  flaccidity.  Sudden 
erection,  with  emission,  not  infrequently  attends 
.injury  of  the  cervical  spine.  Numerous  cases 
are  on  record  in  which,  during  violent  coitus,  or 
otherwise  during  erection,  the  penis  itself  has 
undergone  injury  ; and  some  portions  or  other  of 


PRODROMATA.  1261 

the  sheaths  of  the  corpora  cavernosa,  with  the 
included  blood-vessels,  have  been  ruptured,  or 
some  blood-vessel  has  been  ruptured,  the  sheaths 
remaining  entire.  In  such  cases  extravasation  of 
blood,  followed  by  turgescenee  of  the  corpora 
cavernosa,  occurs  ; and  sooner  or  later  the  most 
persistent,  and  very  often  painful,  priapism 
ensues. 

Treatment. — The  treatment  generally  must 
depend  upon  the  due  recognition  and  treatment 
of  tho  condition  on  which  the  priapism  depends. 
If  of  central  origin,  it  is  to  this  point  that  atten- 
tion must  be  directed.  But  it  not  infrequently 
happens  that  the  local  suffering  is  so  considerable 
as  to  demand  special  measures  for  its  relief.  In 
some  cases  cold  applications,  in  others  warm  or 
hot  fomentations  with  anodynes,  have  proved 
most  efficacious.  Leeching  has  rarely  been  use- 
ful. Bandaging,  masturbation,  and  sexual  con- 
gress have  often  been  tried  ; but  the  result,  as  a 
rule,  has  been  to  increase  rather  than  to  mitigata 
tho  evil.  In  cases  in  which  extravasation  of 
blood  following  injury  is  the  cause,  it  may  be 
necessary  to  make  incisions,  turn  out  any  clots, 
and  arrest  further  haemorrhage  ; but  permanent 
damage  to  the  organ  usually  results,  sometimes 
after  prolonged  suppuration,  and  sometimes  even 
after  risk  to  life. 

Among  the  medicines  that  have  seemed  more 
or  less  useful  in  various  cases  may  be  especially 
mentioned  bromide  of  potassium,  lupuline,  cam- 
phor, hyoscyamus,  and  belladonna.  Free  purga- 
tion is  beneficial  in  some  cases. 

Arthur  E.  Durham. 

PRICKLY  HEAT. — An  eruption  of  minute 
pimples,  which  cover  the  skin  more  or  less  ex- 
tensively, and  are  attended  with  burning  heat, 
and  a most  tormenting  prickly  itching.  The 
affection  occurs  for  the  most  part  in  hot  cli- 
mates, and  attacks  principally  those  who  are 
unaccustomed  to  extreme  heat;  hence  it  is  often 
experienced  by  travellers  in  tropical  regions. 
Pathologically  it  is  a lichen,  attended  with  great 
irritability  of  the  skin,  and  from  its  dependence 
on  heat  of  climate,  has  received  the  designation 
of  lichen  tropicus.  This  disorder  will  be  found 
described  under  the  head  of  Lichen. 

PRIMARY  (primus , the  first). — This  word 
is  either  used  to  imply  that  a disease  originates 
in  an  organ  or  structure  from  a local  cause,  such 
as  primary  pleurisy  or  peritonitis,  or  primary 
attacks ; or  it  is  associated  with  the  first  mani- 
festation of  a disease,  such  as  the  primary  sort 
of  syphilis,  or  primary  cancer.  It  is  also  applied  to 
the  direct  or  immediate  symptoms  of  a disease,  as 
distinguished  from  those  which  may  he  produced 
secondarily  or  remotely. 

PROCIDENTIA  (pro,  downwards,  and  cado, 
I fall). — A falling  down  of  certain  organs  or 
structures  from  their  natural  position,  as  of  the 
uterus,  rectum,  or  iris.  See  Prolapsus. 

PROCTITIS  (irpwKrds,  the  anus). — Inflam- 
mation of  the  anus  or  rectum.  See  Periproc- 
titis ; and  Rectum,  Diseases  of. 

PRODROMATA  (j rph,  before,  and  Spi/ios,  a 
course). — A synonym  for  premonitory  symptoms- 
See  Premonitory. 


1262  PROGNOSIS. 

PROGNOSIS.  See  Disease,  Prognosis  of. 

PROGRESSIVE  MUSCULAR  ATRO- 
PHY.— Synon.  : Paralysis  atrophica-,  Cruveil- 
hier’s  Atrophy ; Wasting  Palsy;  Fr.  Atrophie 
musculaira  ffraisseuse  progressive  (Duehenne) ; 
Ger.  Muskelatrophie ; Muskellahmung. 

Definition. — A chronic  wasting  and  Altera- 
tion in  the  structure  of  the  muscular  tissue, 
which  may  consist  of  (1)  simple  atrophy;  (2) 
atrophy  with  granular  degeneration  ; (3)  atrophy 
with  fatty  degeneration ; and  (4)  atrophy  with 
(the  so-called)  waxy  degeneration. 

-ZEtiology.  — Progressive  muscular  atrophy 
mostly  prevails  among  middle-aged  persons  and 
young  adults,  and  the  male  sex  is  more  liable 
to  suffer  than  the  female — in  the  proportion  of 
about  six  to  one.  Consanguinity,  or  hereditary 
influence,  is  a powerful  predisposing  cause,  and 
in  the  greater  number  of  hereditary  cases  the 
atrophy  becomes  generalised. 

The  principal  exciting  causes  are  excessive 
muscular  exertion ; severe  cold  and  wet — particu- 
larly when  combined ; and  diseases  or  injuries 
of  the  spine.  When  the  disease  follows  cold 
and  wet,  the  atrophy  is  commonly  preceded  or 
accompanied  by  neuralgic  or  supposed  rheumatic 
pains,  either  in  the  muscles  or  in  the  course  of 
their  nerves.  The  disease  is  also  not  uncommonly 
a consequence  of  syphilis.  In  those  cases  that 
seem  to  be  hereditary  there  often  appears  to  be 
no  other  assignable  cause. 

Pathology.  — Progressive  muscular  atrophy 
does  not  originate,  as  was  formerly  believed,  in 
the  muscles  themselves,  but,  as  the  writer  hus 
shown,  from  functional  or  structural  alterations 
in  the  nervous  centres  and  their  nerves.  In 
fatal  cases  these  alterations  are  of  various  kinds. 
They  consist  of  atrophy  of  the  nerve-cells  and 
their  processes  in  the  anterior  cornua  of  the 
opinal  cord,  commencing  in  pigmentary  dege- 
neration, and  ending  frequently  in  their  total 
disappearance.  The  blood-vessels  are  frequently 
dilated,  sometimes  to  an  enormous  degree,  and 
around  them  are  generally  found  areas  of  gra- 
nular or  fluid  disintegration,  of  greater  or  less 
extent,  and  mixed  with  exudations,  or  compound 
granular  corpuscles.  Frequently  there  is  an 
abundance  of  corpora  amylacea.  These  morbid 
changes  occur  in  both  the  grey  and  white  sub- 
stance. Sometimes  one  and  sometimes  both  of 
the  anterior  horns  are  reduced  in  bulk.  The 
anterior  nerve-roots  are  not  unfrequently  wasted 
to  a greater  or  less  extent,  as  Cruveilhier  ori- 
ginally noticed.  In  some  instances  nothing  re- 
mains of  them  but  the  neurilemma;  in  others 
the  fibres  are  in  process  of  partial  disintegration. 

Anatomical  Chaeactees. — The  affected  mus- 
cles suffer  differently  in  their  degrees  of  wasting, 
and  present  a variety  of  aspects.  In  the  same 
muscle,  bundles  in  different  stages  of  atrophy 
may  be  seen  by  the  side  of  others  that  are  un- 
affected. If  the  wasting  be  extreme  in  all  the 
bundles,  a long  muscle  presents  the  appearance 
of  a more  fibrous  cord  or  tendon,  and  a flat 
muscle  may  be  reduced  in  a similar  way  to  a 
kind  of  membrane.  The  atrophy  may  consist 
of  only  simple  wasting,  without  any  granular 
or  fatty  degeneration  ; but  in  the  majority  of 
eases  it  is  accompanied  by  both  these  alterations 


PROGRESSIVE  MUSCULAR  ATROPHY, 
of  structure  to  a greater  or  less  extent,  and  by 
variable  changes  in  colour.  The  muscle  is  paler 
than  natural,  and  sometimes  quite  colourless,  or 
may  have  a faint  yellow  tint.  Its  consistence, 
in  consequence  of  the  increase  of  interfibrillar 
connective  tissue,  is  greater  than  normal.  Under 
the  microscope  the  transverse  and  longitudinal 
strise  are  found  to  have  disappeared  to  a variable 
extent  and  degree,  or  are  even  completely  lost ; 
while  the  sarcous  or  muscular  tissue  is  trans- 
formed into  granules,  which  are  sometimes  so 
fine  that  they  cannot  be  distinguished  as 
separate  particles.  These  granules  are  soluble 
in  acetic  acid. 

Granular  degeneration  or  disintegration  of 
tho  muscular  tissue  may  be  the  only  structural 
alteration,  but  it  is  often  accompanied  or  fol- 
lowed by  fatty  degeneration.  This  latter  change, 
however,  may  make  its  appearance  at  once. 

In  addition  to  this  transformation  of  muscular 
tissue  into  fatty  particles,  fat-cells  in  great 
numbers  are  found  between  the  fibres,  sometimes 
in  groups  and  sometimes  in  linear  succession. 
These  may  increase  in  proportion  as  the  mus- 
cular tissue  is  wasted,  so  that  there  may  be  no 
actual  loss  of  volume  in  the  limb. 

The  waxy  or  vitreous  degeneration  appears  to 
be  confined  to  the  voluntary  muscles,  and  never 
affects  all  the  bundles  of  a muscle.  It  consists 
of  a peculiar  transformation  of  the  tissue  into  a 
colourless,  glistening,  and  homogeneous  sub- 
stance, in  which  the  transverse  and  longitudinal 
stri®  as  well  as  the  nuclei  no  longer  exist. 
Although  this  kind  of  degeneration  is  more 
common  after  acute  diseases,  it  is  not  unfre- 
quently found  in  progressive  muscular  atrophy, 
in  which,  indeed,  all  the  three  kinds  of  altera- 
tion above  mentioned  may  exist,  not  only  in  the 
same  person,  but  in  the  same  muscle. 

Symptoms. — Progressive  muscular  atrophy  dif- 
fers in  many  respects  from  the  simple  atrophy 
which  is  consequent  on  exhausting  diseases  or 
on  paralysis,  is  always  chronic,  bnt  of  variable 
and  uncertain  duration.  It  is  irregular  and 
capricious  iu  its  invasion.  In  most  instances  it 
first  makes  its  appearance  in  the  upper  extremi- 
ties, especially  on  the  right  side.  The  muscles 
of  the  hand  are  generally  those  which  are  first 
attacked — the  thenar  eminence,  then  the  hypo- 
thenar,  and  the  interossei.  When  the  interossei 
are  much  wasted,  the  hand  presents  the  appear- 
ance of  a bird’s  claw,  or  what  Dnchenne  termed 
the  main  en  griffe.  The  atrophy  may  extend  up 
the  limb,  and  then  the  flexors  and  extensors  of 
the  fingers,  and  often  the  muscles  at  the  back  of 
the  forearm,  become  affected.  The  disease  may 
also  involve  the  muscles  of  the  arms  and  trunk 
—the  biceps,  deltoid,  triceps,  pectoral,  latissimi 
dorsi,  rliomboidei,  extensors  and  flexors  of  the 
head,  sacro-lumbales,  the  abdominal  muscles,  and 
the  muscles  of  respiration  and  deglutition.  In 
some  instances  the  atrophy  begins  in  the  muscles 
about  the  thorax,  and  proceeds  to  a considerable 
extent,  while  the  arms  may  escape.  In  other 
instances  it  is  limited  to  the  muscles  of  the  fore- 
arm. Occasionally  it  spreads  to  the  lower  limbs, 
but  seldom  begins  there. 

A variety  of  alterations  in  the  shape  and 
position  of  the  trunk  and  limbs  is  produced  by 
this  irregular  wasting  of  the  muscles,  aid  suei 


PROGRESSIVE  MUSCULAR  ATROPHY. 

alterations  are  characteristic  of  the  disease ; 
for  in  ordinary  atrophy  following  exhausting 
diseases  the  -wasting  of  the  muscles  is  uniform. 

Loss  of  muscular  power  in  the  affected  parts 
is  one  of  the  first  symptoms,  particularly  after 
exertion  or  exposure  to  cold.  The  electric  con- 
tractility of  the  wasted  muscles  is  often  slightly 
diminished.  Still  it  is  of  great  importance  to 
note  that  the  wasted  muscles  respond  to  the 
faradaic  as  well  as  to  the  voltaic  current, 
unless  the  wasting  has  reached  its  final  stage 
when  healthy  muscular  fibres  are  almost  wholly 
absent.  The  patient’s  movements  are  awk- 
ward, and  there  is  a certain  loss  of  muscular 
co-ordination,  in  consequence  cf  the  unequal 
wastin'!  of  the  muscles,  and  the  alteration  in 
their  relative  force  or  antagonism.  At  an  early 
period  the  affected  muscles  are  subject  to 
cramps,  fibrillary  tremors,  and  twitches.  In 
some  cases  there  is  a variable  degree  of  cutaneous 
anaesthesia,  but  usually  the  sensibility  is  unim- 
paired ; while  in  about  half  the  cases  more  or 
less  pain  is  experienced  in  the  atrophied  mus- 
cles, or  before  the  atrophy  commences.  When 
the  muscles  of  the  face  are  affected  its  expres- 
sion is  singularly  altered,  and  the  saliva  dribbles 
from  the  mouth.  The  tongue  is  frequently 
shrunk  and  shrivelled  from  atrophy  of  its  mus- 
cles, and  articulation  is  imperfect ; in  this  case, 
however,  such  signs  and  symptoms  are  usually 
regarded  as  pertaining  to  a distinct  disease  (see 
Labio-Glosso-Laryngeal  Paralysis).  When  the 
apparatus  of  deglutition  is  involved,  cough  is 
excited  on  swallowing  liquids,  which  frequently 
escape  through  the  nose ; when  the  muscles  of 
respiration  are  much  wasted,  there  is  difficulty 
of  breathing,  and  the  patient  commonly  dies 
from  some  bronchial  attack,  in  consequence  of  his 
inability  to  expectorate  the  mucus. 

Diagnosis. — This  is  usually  made  without 
much  difficulty.  The  fact  of  the  slow  progress 
of  the  disease,  with  the  successive  implication 
of  different  muscles  or  groups  of  muscles,  is  very 
characteristic.  It  is  distinguished  from  cases 
of  paralysis  followed  by  muscular  atrophy,  by 
the  fact  that  there  is  no  paralysis  first,  and 
atrophy  after,  as  in  these  cases,  but  rather  a 
weakness  which  increases  pari  passu  with  the 
atrophy.  Then,  again,  in  progressive  muscular 
atrophy  the  muscles  still  respond  to  faradisation, 
whereas  in  post-paralytic  atrophy  this  is  very 
apt  not  to  be  the  case,  and  we  have  instead  to 
do  with  some  form  of  the  ‘reaction  of  degenera- 
tion.’ See  Paralysis. 

Prognosis. — From  what  has  been  already  said 
it  is  evident  that  progressive  muscular  atrophy 
is  a malady  of  the  gravest  nature.  The  only  pro- 
bability of  effecting  a cure,  is  when  the  disease 
, can  be  treated  in  its  earliest  stage,  when  the 
disorder  of  the  nervous  centres  is  merely  func- 
tional, and  before  any  organic  lesions  have  super- 
vened. 

Treatment. — When  the  disease  arises  from  the 
influence  of  damp  and  cold,  or  from  over-exer- 
tion, these  causes  should,  of  course,  be  avoided. 
Warm  clothing  and  warm  baths — particularly 
the  waters  of  Aix-la-Chapelle — are  to  be  recom- 
mended. If  there  be  reason  for  suspecting 
a syphilitic  taint,  iodide  of  potassium,  or  even 
mercury,  if  necessary,  should  be  administered. 


PROSTATE,  DISEASES  OF.  1263 
In  other  cases  cod-liver  oil,  phosphorus,  mineral 
tonics,  and  arsenic  have  been  found  useful.  Rut 
galvanism  in  the  early  stages  of  the  disease  ha* 
proved  tho  most  useful  of  remedies.  The  gal- 
vanic current  should  be  applied  to  the  spinal 
column,  especially  in  the  cervical  region.  When 
we  consider  that  in  the  more  advanced  stages 
of  the  malady  lesions  of  the  spinal  cord  are  in- 
duced, it  is  questionable  whether  the  application 
of  counter-irritants — especially  blisters — to  the 
spine,  has  had  a sufficient  trial. 

J.  Lockhart  Clarke. 

PROLAPSUS  (pro,  forward,  and  labor,  I 
slip). — This  word  signifies  that  an  organ  or 
structure  has  fallen  or  slipped  down,  but  implies 
a greater  degree  of  displacement  than  proci- 
dentia ; so  that  the  organ  or  structure  may  pro- 
trude through  a natural  or  artificial  orifice.  The 
condition  is  of  most  importance  in  connexion 
with  the  rectum  and  the  uterus.  See  Proci- 
dentia; Anus,  Diseases  of ; and  Womb,  Diseases 
of. 

PROPHYLACTIC  f (trpb,  before,  and 

PROPHYLAXIS  (pvAdcrtru >,  I guard). 

These  terms  are  used  in  connexion  with  treat- 
ment, and  indicate  the  means  employed  for  the 
prevention  of  disease.  See  Disease,  Treatment 
of. 

PROSOPALGIA  (irpbo'anruv,  the  face,  and 
&Ay os,  pain). — Prosopalgia  signifies  pain  about 
the  face.  It  may  depend  upon  neuralgia  of  one 
or  more  branches  of  the  fifth  pair  of  nerves  (see 
Tic-Dol’loureux).  Its  paroxysmal  character, 
unilateral  position,  and  anatomical  localisation 
will  indicate  this  form.  Another  form  is  of 
rheumatic  origin.  In  this  the  pain  is  more  or 
less  constant,  diffused  about  the  face  or  forehead, 
and  does  not  follow  the  course  of  a nerve-branch. 
Movements,  and  especially  stooping,  increase  it. 
Occasionally  such  pain  is  of  syphilitic  origin, 
and  is  especially  apt  to  occur  in  connection  with 
the  appearance  of  the  secondary  rash. 

Diagnosis.  — In  rheumatic  prosopalgia  the 
pain  is  diffused  and  increased  by  pressure.  If  it 
depend  on  syphilitic  periostitis  there  will  be  ten- 
derness on  pressure,  and  the  parts  will  be  swollen 
and  less  elastic  than  normal.  There  will  also 
very  likely  be  a certain  amount  of  fever;  and  the 
pain  will  be  increased  at  night. 

Treatment. — Muriate  of  ammonia  in  half- 
drachm doses,  dissolved  in  half  a tumbler  of 
water,  should  be  given  every  four  hours.  If 
there  be  any  evidence  of  syphilitic  infection, 
iodide  of  potassium  should  be  taken,  in  doses  of 
from  ten  to  twenty  grains  every  four  hours. 

For  the  rheumatic  form  of  face-ache  five  grains 
of  iodide  of  potassium,  with  thirty  grains  of  bi- 
carbonate of  potash,  should  be  given  every  four 
or  six  hours,  after  the  administration  of  an 
aperient.  This  may  be  followed  up  by  quinine 
or  iron.  Locally  a mixture  of  equal  parts  of 
camphor,  choral,  and  vaseline  may  be  applied ; 
or  a liniment  containing  chloroform,  belladonna, 
and  opium.  Decayed  teeth  should  be  extracted. 

T.  Buzzard. 

PROSTATE,  Diseases  of. — Synon.  : Ft 
Maladies  de  la  Prostate ; Ger.  KranJckeiten  det 
Prostate. 


1264  PEOSTATE, 

It  is  not  proposed  in  a work  principally  de- 
voted to  medical  subjects  to  deal  at  all  fully 
with  the  affections  of  the  prostate  gland ; the 
present  article  must,  accordingly,  bo  taken  rather 
as  an  index  to  guide  the  practitioner  in  his  dia- 
gnosis, than  as  anything  approaching  a complete 
disquisition  on  their  pathology  or  treatment. 

General  Eelations. — The  points  of  practical 
importance  in  connection  with  the  anatomy  of 
the  prostate  are  as  follows: — In  the  examination 
of  the  rectum  the  healthy  prostate  is  felt  as  a 
firm  substance  in  the  middle  line,  somewhat 
divided  into  two  lateral  lobes.  The  whole  organ 
i3  about  l|Tnch  in  width,  with  its  apex  opposite, 
namely,  in  the  recumbent  posture  below,  the 
apex  of  the  pubic  arch ; that  is,  about  li  inch 
from  the  anus,  in  a moderately  thin  subject,  but 
much  further  in  a very  fat  one.  The  whole 
gland  is  H inch  in  length,  its  posterior  limit 
being  usually  about  three  inches  from  the  anus 
— in  other  words,  about  the  distance  to  which 
the  forefinger  can  reach.  From  this  it  may  be 
deduced  that  the  trigonum  vesica  commences  im- 
mediately behind  it,  and  therefore  that  a fully 
distended  bladder  masks  more  or  less  completely 
the  natural  outline  of  the  gland.  It  may  thus 
also  be  gathered  that  the  vesiculae  seminales  are 
beyond  the  ordinary  reach  of  the  finger,  and 
that  when  these  are  infiltrated  by  disease,  their 
apices,  or  perhaps  only  the  vasa  efferentia,  can 
be  detected.  The  practitioner  should  by  no 
means  neglect  the  digital  examination  of  the 
prostate,  as  it  will  often  yield  information  of  the 
greatest  value.  The  deviations  from  the  normal 
type  he  may  expect  to  meet  with  are — uniform 
or  partial  enlargement  from  simple  hypertrophy, 
orfrom  chronic  or  acute  inflammation,  inthe  latter 
case  possibly  attended  by  a sense  of  fluctuation, 
due  to  abscess ; irregular  hardness,  most  marked 
about  the  vasa  efferentia,  depending  on  a tuber- 
cular deposit ; the  existence  of  small  hard  nodu- 
lar masses,  ■which  are  calculi  in  the  substance  of 
the  gland  ; or  the  irregular  enlargement  caused 
by  a new  growth.  It  must  be  borne  in  mind 
that  tumours  or  abscesses  originating  in  neigh- 
bouring parts  may  surround  the  prostate  and 
completely  mask  its  outline ; thus  the  writer 
has  met  with  a case  of  a large  hydatid  cyst  be- 
tween the  rectum  and  the  bladder  that  rather 
closely  simulated  malignant  disease  of  the  pro- 
state, and  effectually  prevented  its  actual  con- 
dition from  being  determined.  It  will  not  be 
forgotten  that  a certain  degree  of  tenderness  of 
the  prostate  does  not  imply  a deviation  from 
health,  and  that  a more  or  less  considerable 
enlargement  in  old  age  is  so  common  as  to  be 
almost  reckoned  by  some  authors  as  normal. 
The  effect  of  this  enlargement  on  micturition 
will  be  mentioned  further  on.  The  copious 
plexus  of  veins  which  surround  the  prostate 
communicates  fully  with  those  of  the  penis  and 
rectum  ; and  it  is  not  unimportant,  from  a clini- 
cal point  of  view,  to  remember  that  these  are  thus 
connected  not  only  with  the  systemic,  but  with 
the  portal  circulation.  These  veins  may  become 
the  seat  of  phlebitis  and  its  sequelae  from  various 
causes. 

The  principal  diseases  of  the  prostate  maybe 
considered  in  the  following  order  : — 

1.  Prostate,  Hypertrophy  of. — The  re- 


DISEASES  OF. 

suits  of  Sir  Henry  Thompson’s  observation* 
( Clinical  Lectures  on  Diseases  of  the  Urinary 
Organs)  were,  that  one-third  of  all  men  over 
fifty-five  have  some  enlargement  of  the  pro- 
state; but  that  a comparatively  small  numbei 
of  these  suffer  any  inconvenience  from  it;  and 
that  it  usually  begins  between  the  ages  of  fifty, 
seven  and  sixty,  though  it  may  more  rarely  com- 
mence later.  Very  considerable  enlargement  ot 
the  lateral  lobes  may  cause  no  inconvenience ; 
but  if  the  part  which  forms  the  floor  of  the  pro^ 
static  urethra,  the  so-called  middle  lobe,  bo  even 
slightly  enlarged,  difficulty  in  micturition  is  sure 
to  result.  It  is  thus  easy  to  understand  how  a 
simple  hypertrophy  may  reach  enormous  dimen- 
sions without  giving  rise  to  symptoms,  while 
those  which  are  caused  by  the  enlargement  of  a 
prostate,  which  feels  almost  normal  to  the  finger 
introduced  into  the  rectum,  may,  on  the  other 
hand,  be  very  severe  indeed. 

Symptoms. — The  symptoms  are  briefly  these: 
The  stream  of  urine  becomes  dribbling,  and 
there  is  an  obvious  difficulty  in  emptying  the 
bladder ; there  is  frequency  of  micturition,  espe- 
cially at  night  and  in  the  early  morning ; per- 
haps a little  pain  before  the  act,  but  none 
afterwards ; and  no  alteration  in  the  characters 
of  the  urine.  If  unrelieved,  these  early  symp- 
toms are  followed  1 r incontinence,  depending 
upon  over-distension  of  the  bladder ; and,  from 
the  same  cause  not  improbably,  cystitis  and  dila- 
tation of  the  bladder,  dilated  ureters,  and,  per- 
haps, pyelitis  and  chronic  interstitial  nephritis. 
Patients  with  chronic  hypertrophy  of  the  pro 
state  usually  suffer  from  time  to  time  from 
attacks  of  acute  congestion,  such  as  are  de- 
scribed below. 

Anatomical  Characters. — The  structure  of 
a hypertrophied  prostate  is  but  a slight  modi- 
fication of  that  of  the  gland  itself. 

Treatment. — In  regard  to  treatment  cf  hy- 
pertrophy of  the  prostate  it  is  only  necessary 
here  to  give  two  words  of  warning.  First,  that 
most  of  the  evils  resulting  from  this  condition 
depend  upon  the  fact  that  the  bladder  is  never 
emptied ; it  is  essential,  therefore,  that  the 
patient’s  powers  in  this  respect  should  be  ascer- 
tained without  delay  by  catheterisation,  and  if  it 
be  discovered  that  a certain  amount  of  residual 
urine  remains,  he  should  be  taught  to  pass  au 
instrument  himself,  and  directed  to  do  so  at  least 
once  a day.  Secondly^  cystitis  has  often  been 
caused  by  setting  up  putrefaction  of  the  urine 
by  a catheter  not  surgically  clean  ; the  simple 
precaution  of  lubricating  it  with  carbolised  oil 
prevents  with  certainty  this  catastrophe.  The 
reader  must  consult  surgical  works  as  to  the 
difficulties  which  an  enlarged  prostate  offers  to 
the  introduction  of  a catheter,  and  the  manner 
in  which  they  may-  be  overcome. 

2.  Prostate,  Congestion  of — Congestion  is 
a condition  which  follows  on  chronic  hyper- 
trophy, and  is  commonly  known  as  ‘ an  attack 
of  the  prostate.’ 

Symptoms. — An  old  man,  suffering  from  the 
symptoms  above  described,  is  suddenly  seized — 
as  the  result  of  some  indiscretion  in  diet,  an 
exposure  to  cold,  or  some  other  apparently 
trivial  cause — with  complete  retention,  accom- 
panied by  bloody  urine,  possibly  a raised 


PROSTATE,  DISEASES  OF.  1265 


temperature  and  quick  pulse,  and  considerable 
local  uneasiness.  If  the  case  do  not  improve, 
and  especially  if  the  urine  be  allowed  to  putrefy, 
the  tongue  becomes  dry  and  brown,  the  pulse 
more  rapid  and  more  weak,  and  the  patient  passes 
into  a low  typhoid  condition,  which  is  not  un- 
likely to  end  fatally. 

Treatment. — The  treatment  is  in  large  mea- 
sure surgical,  consisting  in  the  proper  passing 
of  catheters;  but  scarcely  less  important  is  the 
careful  regulation  of  the  bowels ; and  the  ad- 
ministration of  a diet  sufficiently  light,  and  yet 
not  too  lowering,  together  with,  in  most  cases,  a 
certain  amount  of  stimulant,  for  it  must  be  re- 
membered that  the  patient  , is  probably  weak, 
and  that  death  from  asthenia  is  much  to  be 
dreaded.  The  writer  would  urgently  insist  on 
the  importance  of  preventing  putrefaction  of  the 
urine,  which  is  the  most  fertile  source  of  death 
in  such  cases;  he  can  affirm  from  experience 
that  this  end  may  be  attained  by  the  thoughtful 
employment  of  antiseptic  treatment,  even  in 
those  cases  in  which  it  becomes  necessary  to 
keep  the  bladder  empty  by  tying  a catheter  into 
the  urethra. 

3,  Prostate,  Chronic  Inflammation  of. — 
Synon.  : Chronic  prostatitis. — This  is  not  an 
uncommon  affection  amongst  young  and  middle- 
iged  men.  depending  most  frequently  on  a pro- 
longed gonorrhoea,  in  which  the  prostatic  part 
rf  the  urethra  has  been  involved. 

Symptoms. — The  symptoms  of  this  disease 
resemble  rather  closely  those  depending  upon 
tone  in  the  bladder,  namely,  frequent  mictu- 
ition,  with  a feeling  of  heat  and  weight  in  the 
lerinaeum,  and  pain  along  the  penis,  extending 
o the  tip ; there  is  also  at  times  a little  blood 
lasaed  at  the  end  of  micturition ; and  all  the 
ymptoms  are  aggravated  by  exercise.  Generally 
here  are  frequent  nocturnal  emissions.  The 
line  is  cloudy,  and  on  standing  yields  a mueo- 
urulent  deposit.  A rectal  examination  shows 
hat  the  prostate  is  enlarged,  sometimes  very 
.lightly,  and  seldom  to  any  great  extent ; it  is 
Iways  tender.  The  diagnosis  can  scarcely  be 
ado  without  passing  the  sound. 

Treatment. — The  treatment  consists  in  rest, 
le  administration  of  laxative  medicines,  and  the 
^plication  of  blisters  or  some  other  form  of 
outer-irritation  to  the  perinaeum;  alcoholic 
imulants  are  to  be  avoided ; and  the  urine 
ould  be  rendered  bland  by  alkalies  and  dibi- 
ts, as  in  cases  of  urethritis. 

4.  Acute  Inflammation  of  the  Prostate. — 
"xon.  ; Acute  prostatitis.—  Acute  prostatitis 
ly  arise  as  the  result  of  a gonorrhoea,  or  cys- 
is;  from  the  irritation  produced  by  calculi 
other  mechanical  cause ; perhaps  sometimes 
opathically,  or  from  exposure  to  cold  or  wet ; 
1 from  undue  sexual  excitement,  or  the  too  free 
i of  alcohol  if  gonorrhoea  be  present.  This 
y occur  in  men  of  any  age,  and  is  accompanied 
symptoms  such  as  those  depending  on  chronic 
animation,  but  much  more  intense ; the  fre- 

1 mey  of  micturition  and  pain  during  tho  act 
i sing  sometimes  almost  unbearable  agony,  and 
I dysuna  amounting  in  some  cases  to  complete 
i mtion,  while  the  tenderness  of  the  gland  is 
| f great,  a condition  which  makes  an  action  of 
' bowels  very  painful.  Such  cases  may  termi- 

80 


nate  by  becoming  chronic;  theyT  may  undergo 
complete  resolution  ; or  suppuration  may  occur ; 
in  any  case  there  will  probably  be  some  elevation 
of  temperature,  and  in  the  event  of  the  forma- 
tion of  abscess  there  may  be  great  and  sudden 
rises  and  falls,  accompanied  by  rigors  and  sweat- 
ings, with  a dry,  brown  tongue,  forcibly  sug- 
gesting pyaemia.  Prostatic  abscess  may  burst 
into  the  rectum,  bladder,  or  perinaeum. 

Treatment.- — The  treatment  of  acute  pros- 
tatitis consists  in  rest,  and  carefully-regulated 
diet ; diluent  and  alkaline  medicines ; purga- 
tives; local  blood-letting  from  the  perinaeum,  by 
leeches  or  otherwise  (some  French  surgeons  have 
recommended  the  application  of  leeches  to  the 
interior  of  the  rectum) ; with  hot  fomentations, 
and  morphia  suppositories.  If  an  abscess  forms 
it  may  be  opened  through  the  rectum,  but  it 
is  better  to  incise  it  through  the  perinaeum,  as 
this  plan  is  most  likely  to  prevent  tho  formation 
of  that  most  troublesome  and  almost  incurable 
condition,  a recto-vesical  fistula. 

Abscesses  sometimes  form  around  the  prostate 
(periprostatic).  They  are  not  so  likely  to  in- 
volve the  danger  of  the  formation  of  a recto- 
vesical fistula  ; and  they  should  be  treated  by 
early  incision. 

b.  Prostate,  Tubercle  of. — This,  though  not 
a common  affection  of  the  prostate,  occurs  per- 
haps more  frequently  than  is  generally  supposed, 
and  is  of  great  interest  to  the  practitioner.  It 
is  usually  a part  only  of  a more  or  less  general 
affection  of  the  genito-urinary  tract.  Thus  in 
cases  where  the  epidydimes  are  hard  and  swollen, 
and  the  cords  knotty  from  tubercular  deposit,  the 
finger  introduced  into  the  rectum  will  probably 
detect  a hard  nodule  in  one  or  both  of  the  vasa 
efferentia.  This,  if  seenyiosf  mortem,  is  found  to 
consist  of  a tubercular  or  cheesy  mass,  and  if  the 
condition  have  advanced  further,  the  prostate 
itself  may  have  become  involved ; there  may  be 
either  separate  ncdules  of  tubercular  deposit  in  a 
more  or  less  advanced  state  of  cheesy  or,  moro 
rarely,  calcareous  degeneration ; or  the  whole  gland 
may  have  become  hollowed  out  into  an  irregular 
cavity,  filled  in  part  with  cheesy  material,  and 
discharging  pus. 

Symptoms. — This  disease  may  begin  in  child- 
hood, or  in  adult  life.  Its  symptoms  are  most 
obscure.  At  first  there  are  probably  none  at 
all,  but  as  the  disease  advances,  there  will  arise 
those  of  tumour  of  the  prostate,  together  with 
those  of  abscess  ; that  is,  there  will  be  occasion- 
ally blood,  and  generally  pus,  in  the  urine; 
frequency  and  pain  in  micturition ; tenderness 
and  swelling  in  the  rectum,  and  so  forth.  Ab- 
scess from  this  cause  has  been  known  to  burst 
into  the  peritoneum. 

Treatment. — The  treatment  can  only  be  pal- 
liative, and  must  be  directed  to  the  relief  of  the 
symptoms  as  they  arise ; but  at  the  best  it  is 
most  unsatisfactory.  Occasionally  it  may  be 
possible  to  open  a tubercular  abscess  through  the 
perinaeum,  but  it  is  open  to  doubt  how  far  such 
a procedure  is  to  the  advantage  of  the  patient. 

6.  Prostatic  Calculi. — These  are  small 
bodies,  generally  multiple,  formed  in  the 
glands  of  the  prostate,  usually  late  in  life,  but 
occasionally  in  comparatively  young  men.  They 
probably  begin  as  a deposit  of  animal  matter. 


1266  PROSTATE,  DISEASES  OF. 

but  later  are  made  up  principally  of  phosphate, 
and  partly  of  carbonate,  of  lime.  They  may  pro- 
duce no  symptoms  at  all,  or  they  may  project 
into  the  urethra,  and  give  rise  to  great  irrita- 
tion at  the  neck  cf  the  bladder,  and  the  symp- 
toms of  vesical  calculus*  such  will  also  be 
present  if,  as  sometimes  happens,  they  convert 
the  whole  gland  into  a single  cavity,  in  which 
the  calculi  lie  side  by  side.  In  this  case  they 
will  be  felt  through  the  rectum,  rubbing  against 
one  another ; and  indeed  prostatic  calculi  are,  as 
a rule,  to  be  felt  in  this  situation. 

Vesical  calculi  of  considerable  size  may  be- 
come encysted  in  the  prostate,  and  on  the  other 
hand  prostatic  calculi  may  find  their  way  into 
the  bladder.  Prostatic  calculi  may  give  rise  to 
abscess. 

If  any  treatment  be  required,  it  is  purely 
surgical,  and  must  consist  in  the  removal  of 
the  stones  by  forceps,  a lithotrite,  or  a perinaeal 
incision. 

7.  Prostate,  Phleboliths  of. — The  patho- 
logist very  often  meets  with  phleboliths  in  the 
veins  surrounding  the  prostate,  the  result  no 
doubt  of  old  phlebitis. 

8.  Prostate,  Tumours  of.- — The  so-called 
fibrous  tumours  of  the  prostate  are  in  all  pro- 
bability simply  local  hypertrophies,  and  are 
composed  principally  of  plain  muscular  tissue. 
Cystic  disease  is  described  as  a pathological  rarity, 
the  gland  being  occupied  by  numerous  cysts, 
containing  serous  or  mucous  fluid.  Melanosis  of 
the  gland  has  also  been  observed.  Cancer  of  the 
prostate  occurs  not  very  unfrequently,  and  is 
usually  soft,  though  it  is  sometimes  hard  enough 
to  be  worthy  of  the  name  of  scirrhus.  The 
writer  would  speak  with  great  caution  of  malig- 
nant tumours  of  the  prostate ; such  as  he  has 
himself  examined  have  been  cancers,  with  a very 
irregular  arrangement  of  both  stroma  and  epi- 
thelial cells. 

Tumours  of  the  prostate  may  be  at  present 
considered  as  beyond  the  reach  of  surgical  in- 
terference, though  suggestions  for  their  removal 
have  been  lately  gravely  made  in  Germany. 

9.  Prostate,  Atrophy  and  Absence  of. — 

Atrophy  of  the  prostate  is  said  to  occur  as  the 
result  of  pressure,  sometimes  from  an  unascer- 
tained cause,  or  from  simple  senile  decay.  Con- 
genital absence  of  the  prostate  has  also  in  rare 
cases  been  observed,  but  is  of  little  clinical 
interest.  R.  J.  Godlee. 

PROSTRATION  (pro,  forward;  and  sterno, 
I stretch). — This  word  signifies  both  the  act  of 
overthrowing,  and  the  condition  of  being  over- 
thrown, overcome,  or  depressed.  In  medical 
science  it  is  generally  employed  in  the  latter 
sense ; and  is  used  to  express  a condition  of 
system  in  which  the  bodily  energies  as  a whole, 
or  the  more  active  of  them,  have  so  completely 
succumbed  to  the  effects  of  injury,  disease,  or 
powerful  emotional  influences,  that  they  cannot 
be  made  to  respond  to  ordinary  stimuli.  When 
prostration  affects  the  whole  system  the  patient 
is  said  to  suffer  from  general  prostration  o f the 
vital  powers.  The  principal  forms  of  prostration 
of  a single  system,  on  the  other  hand,  are — (1) 
muscular  prostration,  in  which  there  is  complete 
exhaustion  of  the  voluntary  muscles  : and  (2)  I 


PRURIGO. 

nervous  prostration , in  which  the  nerve-centres, 
and  especially  those  associated  with  the  mind, 
are  so  completely  overpowered  that  sensation 
and  motion  appear  to  be  in  a measure  temporarily 
suspended. 

The  causes,  symptoms,  and  treatment  of  pros- 
tration in  its  several  forms  are  more  fully  dis- 
cussed in  other  articles.  See  Collapse;  Debi- 
lity ; Exhaustion  ; Shock  ; and  Syncope. 

J.  Mitchell  Bruce. 

PROXIMATE  CAUSES  (proximus,  near- 
est).— A synonym  for  the  immediate  or  exciting 
causes  of  disease.  See  Disease,  Causes  of. 

PRURIGO  (prurire , to  itch). — Synox.  : Fr. 
and  Ger.  Prurigo. 

Description.  —Prurigo  is  the  disease  of  itch- 
ing; but,  as  there  are  various  forms  of  pruritus 
or  itching  of  the  skin,  it  becomes  necessary  to 
determine  what,  besides  itching,  constitutes 
prurigo. 

Pruritus  is  an  excited  state  of  the  nerves  of 
the  skin,  and  as  such,  is  associated  with  various 
forms  of  skin-affection,  for  example,  with  scabies, 
eczema,  and  urticaria ; but  in  these  affections  there 
is  a difference  in  the  cause  of  the  disease.  In 
scabies  and  eczema  the  cause  lies  in  the  tissues 
of  the  skin  ; in  urticaria,  on  the  contrary,  it  is ; 
present  in  the  nerves  themselves.  Hence  urti- 
caria is  denominated  a neurosis,  and  prurigo  is 
also  a neurosis  which  leads  onwards  to  a de- 
fective nutrition  of  the  skin.  What  especially 
characterises  prurigo  is  the  combination  of  pruri- 
tus with  an  altered  state  of  the  skin,  consequent 
on  defective  nutrition;  and,  as  a rule.it  may 
be  said  to  be  restricted  to  the  elderly  period  of 
life,  when  nutritive  power  in  general  is  weakenedj 
or  exhausted. 

The  quality  of  the  itching  in  prurigo  is  not  so 
much  intensity,  for  the  itching  of  chronic  eczema 
and  simple  neurotic  pruritus  from  reflex  causes 
is  often  more  severe.  Its  especial  character  is 
its  pungency,  which  resembles  a burning  and 
gnawing  of  the  flesh  ; and  also  its  mobility,  sug- 
gesting the  idea  of  animals  creeping  and  eating 
their  way  through  the  substance  of  the  skin.  The 
degree  of  severity  of  the  pruritus  has  suggested 
the  names  mitis  and  formicans — idle  terms  which 
ought  to  be  abandoned;  and  as  much  may  be  said 
of  the  epithet  senilis , inasmuch  as  general  pru- 
rigo is  necessarily  a disease  of  an  ill-nourishec 
skin,  and  especially  of  the  kind  of  defective  nu- 
trition which  is  incident  to  old  age. 

If  we  take,  as  factors,  an  ill-nourished  integu- 
ment, in  an  elderly  person ; a dry,  hard  unevei 
skin,  discoloured  from  irregular  pigmentation 
fatless,  and  adhering  loosely  to  the  fascia  be 
neath,  suggesting  the  idea  of  leather  or  parch 
ment ; ar.d  an  irritable  nervous  system,  we  shal 
then  have  a case  deserving  the  name  of  prurige 
Moreover,  to  this  state  of  skin  we  must  ad 
papules  raised  upon  the  surface,  with  heads  tor, 
off  by  scratching,  and  capped  with  small  blac; 
crusts  of  desiccated  blood;  and  abrasions  cause 
by  fierce  and  incessant  scraping  with  the  nail 
All  these  conditions  taken  together  constitu; 
a true  case  of  chronic  prurigo,  a real  pruritj 
senilis. 

A'arieties. — Frurigo  is  a general  affection 


PRURIGO. 


the  skin,  but  it  is  likewise  met  with  occasionally 
is  a local  disease,  in  the  integument  around  the 
anus .prurigo  ani ; and  in  the  folds  of  the  clitoris, 
prurigo  clitoridis.  These  latter  cases  are  always 
accompanied  with  altered  nutrition  of  the  inte- 
gument, more  or  less  condensation  and  hardening 
df  the  tissues,  and  thickening  of  the  epithelium. 
The  symptoms  otherwise  are  the  same  as  those 
of  general  prurigo,  but  are  often  remarkable  for 
their  intense  severity. 

Pathology. —Prurigo  is  essentially  neurotic 
in  its  nature;  a feeble  state  of  nerve-function 
gives  rise  to  the  altered  nutrition  of  the  in- 
tegument, and  irritability  of  nerve-structures  to 
pruritus. 

Prognosis. — The  disease  is  obstinate  and  en- 
during, vexatious  to  the  patient,  and  tending  to 
aggravate  general  irritability,  but  not  hazardous 
:to  life.  Occurring  in  old  age,  with  a tendency  to 
increase,  it  is  apt  to  last  for  years.  Prurigo  cli- 
toridis  is  one  of  the  most  rebellious  of  disorders, 
and  has  a tendency  to  degenerate  into  epithe- 
lioma. 

Treatment. — The  indications  for  treatment 
are  to  tranquillise  the  nervous  system  generally, 
jind  to  improve  the  nutrition  of  the  tissues  of 
he  skin.  For  this  purpose  the  digestive  organs 
should  be  regulated ; a generous  and  nutritive 
diet  enforced ; and  recourse  had  to  nerve-tonics 
:is  well  as  to  general  tonics.  Cod-liver  oil  is 
iften  a useful  remedy,  and  will  be  assisted  by 
minia,  strychnia,  and  phosphorus.  Arsenic  is 
indispensable.  Sedatives  are  frequently  required 
b relieve  pruritus  and  procure  sleep ; and  for 
•his  purpose  the  bromides  and  chloral  hydrate 
ill  do  good  service,  or  in  some  constitutions 
voseyamus  and  morphia.  Violent  exacerba- 
ons  of  pruritus  are  best  controlled  by  single 
rge  doses  of  quinia,  namely,  five  to  ten 
rains. 


Locally,  the  heat  and  shampooing  of  the 
irkish  bath,  frequently  repeated  and  steadily 
usued,  may  bo  regarded  as  curative  in  most 
ises.  This  should  be  succeeded  by  thorough 
'•unction  of  the  skin  with  some  bland  unguent, 
'ch  as  vaseline ; and  a wash-leather  covering 
iould  be  worn  next  the  skin.  Sponging  with 
it  water  or  hot  decoction  of  poppy-heads  will 
ieve  the  pruritus  for  awhile,  and  in  some  in- 
nces  lotions  of  tar,  and  almond  emulsion,  with 
'ax  and  hydrocyanic  acid,  are  very  successful. 

Erasmus  Wilson. 


PRURITUS  (j orurire,  to  itch). — Synon.  : Fr. 
- '.irit;  Ger.  Jueken. 

Definition. — A form  of  perverted  sensation  of 
t skin,  and  most  external  parts  of  the  mucous 
Lnbranes,  characterised  by  itching. 

Etiology. — This  symptom  accompanies  those 
s (-diseases  which  involve  the  uppermost  papil- 
!• ' layers  of  the  cutis,  in  which  lie  the  ends  of 
suory  nerve-filaments.  As  a rule,  it  is  absent  in 
t |:e  which  attack  the  lower  layers,  for  example, 
n t syphilitic  rashes  and  leprosy.  It  may  de- 
p l on  any  of  the  following  causes  : — 

) Local  irritation  from  rough  clothing,  pa- 
R *s  (scabies,  pediculi,  pityriasis  versicolor, 
*1: 1 tonsurans  and  cirdnata),  and  unhealthy  dis- 
d ges  (saccharine  urine,  leucorrhcea).  Perhaps 
“ winter  pruritus  of  Hutchinson  and  Duhring, 


PRURITUS.  126,’ 

which  is  clearly  in  some  way  due  to  the  local 
effects  of  cold,  should  be  placed  here. 

(2)  Inflammations  of  the  skin,  including  all 
forms  of  eczema,  but  especially  the  papular 
(lichen),  psoriasis  in  the  early  stage,  and,  more 
rarely,  pemphigus.  It  exists  to  a slight  degree 
in  roseola;  and  much  irritation  sometimes  fol- 
lows the  pustular  rashes  caused  by  croton  oil 
and  tartar-emetic  ointment.  Mucous  patches 
and  all  forms  of  papular  syphilide,  if  desquamat- 
ing, may  itch. 

(3)  Beflex  irritation  from  distant  organs,  such 
as  the  uterus  and  stomach  in  urticaria,  and  the 
kidneys  in  Bright’s  disease. 

(•1)  The  presence  of  certain  substances  in  the 
blood,  such  as  the  bile-acids  in  jaundice,  and 
copaiba. 

(5)  Undiscovered  causes,  as  in  true  prurigo 
and  the  lichen  urticatus,  or  strophulus,  of  chil- 
dren (see  Lichen  ; Prurigo  ; and  Strophulus). 
Kaposi  admits  a pruritus  cutaneus  universalis  as 
a true  idiopathic  neurosis. 

Symptoms. — Pruritus  may  be  local  or  general, 
slight  or  severe,  continuous  or  intermittent.  It 
is  generally  most  marked  at  night.  It  is  usual 
to  describe  three  special  local  forms. 

(o)  Pruritus  genitalium. — This  form  is  chiefly 
found  in  women  with  uterine  disease,  such  as  a 
granular  condition  of  the  os  uteri,  or  during  preg- 
nancy, or  at  the  change  of  life.  Diabetes  is  a 
frequent  cause,  and  should  always  be  sought  for. 
In  men  P,  scroti  ct  penis  depends  on  eczema  or 
uncleanliness.  Pruritus  on  and  around  the  pubes 
should  always  suggest  the  presence  of  pediculi 
pubis. 

(/3)  Pruritus  ani. — This  is  usually  connected,  in 
adults,  with  piles,  eczema,  or  profuse  sweating  ; 
and  in  children  with  thread-worms. 

(y)  Pruritus  senilis  occurs  in  people  at  or  over 
sixty,  and  most  often  depends  on  the  presence  of 
pedicidi  vestimentorum,  though  in  rare  instances 
it  seems  to  be  a pure  neurosis. 

Diagnosis. — It  is  essential  to  remember  that 
pruritus  is  most  often  a symptom  of  external  ir- 
ritation, and  to  search  for  the  various  causes 
enumerated  above,  especially  animal  parasites. 
The  possible  presence  of  the  latter  should  not  be 
ignored  because  of  the  social  position  of  the  pa- 
tient. 

Treatment. — For  general  pruritus,  if  no  cause 
can  be  found,  the  two  best  remedies  are  tar  and 
sulphur.  Tar  may  be  used  as  a lotion — for  in- 
stance, the  following:  l)b  Liquoris  carbonis  de- 
tergentis  (Wright’s),  ^ss;  glvcerini,  5 j ; aquam 
ad  jx.  Sulphur  maybe  employed  thus,  as  a 
bath : Ijb  Potassii  sulphidi,  5 iv  ; aquae  calidse, 
eong.  xxx.  Flannel  should  be  removed  from  im- 
mediate contact  with  the  skin.  Carbolic  acid 
with  opium  sometimes  gives  relief  in  the  fol- 
lowing form  : II  Tincturas  opii,  3 j ; acidi  car- 
bolici,  5 j ; spiritus  vinirectificati,  5 vj.  Internal 
remedies,  such  as  potassium  bromide,  strychnia, 
conium,  and  morphia,  are  of  very  doubtful  value  ; 
sulphate  of  atropia  in  1 milligramme  doses  has 
proved  effectual  in  a few  cases  of  obstinate  urti- 
caria. In  pruritus  genitalium  extreme  cleanli- 
ness and  a borax  lotion  are  the  best  remedies  : 
1)1  Glyeerini  boracis  5 ij  ; aquam  ad  3 vj  ; ft. 
lotio.  For  pruritus  ani,  a calomel  ointment — 
such  as:  Ijl  Hydrargyri  subchloridi,  3 j ; adipis 


1268  PRURITUS, 

jenzoati,  3 j ; ft.  unguentum— is  to  be  recom- 
mended. See  Eczema;  Phthiriasis;  Scabies;  and 
Urticaria.  Edward  J.  Spares.1 

PRUSSIC  ACID,  Poisoning  by. — Synon.  : 
Fr.  Empoisonnement  par  I'acide  cyanhydrique  ; 
Ger.  Cyanwasserstoffsaurevergiftung. 

Prussic  or  hydrocyanic  acid  is  one  of  the  best 
known  and  most  deadly  of  poisons.  In  the  an- 
hydrous condition  it  is  stated  to  kill  with  almost 
lightning-like  rapidity7.  Prussic  acid  is  met  with 
in  commerce  only  in  a diluted  state.  In  this 
country  two  strengths  of  prussic  acid  are  usual, 
t he  Pharmacopceial  acid,  containing  two  per  cent., 
and  the  so-called  Scheele’s  acid,  containing  about 
five  per  cent.,  respectively,  of  anhydrous  prussic 
acid  in  aqueous  solution.  The  soluble  cyanides, 
more  especially  cyanide  of  potassium,  largely 
used  by  photographers  and  by  electro-platers, 
are  common  articles  of  commerce,  and  produce 
the  same  deadly  results  as  the  acid  itself.  The 
fatal  dose  of  prussic  acid  is  the  equivalent  of 
about  one  grain  of  the  anhydrous  acid. 

Anatomical  Characters. — In  persons  who 
have  died  of  prussic  acid  poisoning  the  eyes 
are  glistening ; the  extremities  are  blue  ; the 
face  is  pale  or  livid ; and  the  lips  are  cyanosed. 
The  blood  throughout  the  body  has  frequently 
the  peculiar  odour  of  the  acid,  and  is  of  a dull 
hue,  with  a peculiar  bluish  cast — a glimmering 
appearance.  The  stomach  is  sometimes  red- 
dened, but  not  more  than  is  common  after  other 
asphyxial  modes  of  death. 

Symptoms. — In  fatal  doses  tho  symptoms  of 
prussic  acid  poisoning  set  in  very  speedily;  and 
in  consequence  of  the  readiness  with  which  this 
poison  is  absorbed  from  the  alimentary  canal, 
and  diffused  throughout  the  circulation,  the  on- 
set of  symptoms  is  reckoned  by  seconds  rather 
than  by  minutes.  Occasionally  the  patient  may7 
be  able  to  walk  into  an  adjoining  room,  to  com- 
pose himself  in  bed,  or  perform  like  actions ; but 
it  is  rarely  that  he  will  have  time  to  dispose  of 
the  cup,  glass,  or  bottle,  in  which  the  poison  was 
contained  before  he  is  taken  seriously  ill.  The 
symptoms  may  be  divided  into  three  stages.  The 
first  stage  is  very  brief,  and  manifests  itself  by 
difficult  respiration,  slow  cardiac  action,  with  a 
tendency  of  the  heart  to  stop  in  diastole,  whilst 
its  beats  are  irregular.  There  is  disturbed  cere- 
bration, and  an  awe-stricken  aspect  of  counte- 
nance. This  preliminary  stage  speedily  ushers  in 
the  second  or  convulsive  stage,  the  onset  of  which 
is  occasionally  signalised  by  a piercing  shriek, 
though  this  is  less  frequently  observed  in  man 
than  in  animals.  With  widely  dilated  pupils, 
the  patient  is  suddenly  thrown  into  violent  clonic 
and  tonic  convulsions.  The  respiration  is  marked 
by  shortness  of  inspiration,  and  prolonged  efforts 
at  expiration.  The  countenance  becomes  cya- 
notic. Vomiting  is  commonly  observed ; and  the 
urine,  faeces,  and  even  semen  in  the  male  are 
spasmodically  evacuated.  The  patient  now  sinks 
down,  probably  in  a state  of  unconsciousness, 
and  with  complete  loss  of  muscular  power.  The 
convulsive  stage  speedily  passes  into  the  third, 
or,  as  it  may  be  termed,  asphyxial  stage,  with 
slow,  gasping,  stertorous  respiration,  extreme  col- 
lapse, lose  of  pulse,  and  more  or  less  complete 
1 Revised  by  Dr.  Alfred  Songster. 


PSEUDO-HYPERTROPHIC  PARALYSIS, 
paralysis  of  motion.  Tho  skin  is  cold,  clammy 
and  cyanosed.  Death  may  be  ushered  in  with 
irregular  spasms.  The  onset  of  symptoms  being 
rarely  delayed  beyond  one  or  two  minutes,  death 
may  occur  within  two  or  three  minutes  more. 
Power  of  volition  is  rarely  continued  in  fatal 
cases  for  more  than  two  minutes  after  taking  the 
poison.  Fifteen  minutes  is  the  longest  interval 
which  has  been  known  to  elapse  between  the 
taking  of  the  poison  and  the  commencement  of 
symptoms;  and  then  the  patient  recovered. 
Should  the  patient  survive  for  thirty  minutes 
good  hopes  may  be  entertained  of  recovery.  The 
longest  period  which  is  known  to  have  elapsed 
between  the  taking  of  the  poison  and  death  was 
one  hour  and  a quarter. 

Diagnosis.  — - This  is  rarely  difficult.  The 
foudroyant  character  of  the  illness,  and  the 
usually  speedy  death  of  the  patient,  coupled  with 
the  peculiar  odour  of  the  acid,  and  the  finding  of 
a cup  or  glass  containing  the  remnants  of  the 
dose,  seldom  leave  any  doubt  as  to  the  nature  of 
the  case.  Nitro-benzol  poisoning  closely  simulates 
prussic  acid  poisoning,  however,  except  that  the 
onset  of  symptoms  is  generally  much  later  in 
nitro-benzol  poisoning  than  when  prussic  acid 
has  been  taken.  Nevertheless,  when  crude  bitter- 
almond  oil,  impure  from  the  presence  of  prus- 
sic acid,  has  been  swallowed,  the  close  similarity 
between  the  odour  of  the  oil  and  that  of  nitro- 
benzol  may  lead  to  error.  Fortunately,  the  same 
treatment  may  be  adopted  in  both  cases. 

Prognosis. — This  in  all  cases  is  very  doubt- 
ful ; and  no  general  rules  can  be  laid  down. 

Treatment. — Prompt  inhalation  of  the  fumes 
of  ammonia  should,  if  possible,  never  be  neglected. 
The  successive  administration  of  a solution  of  the 
mixed  per-  and  proto-salts  of  iron,  followed  by 
an  alkaline  carbonate,  so  as  to  convert  the  acid 
into  an  inert  ferrocyanide,  has  been  recommended 
on  purely  chemical  grounds.  There  is,  however, 
seldom  or  never  time  to  admit  of  this  elaborate 
treatment.  A more  practicable  mode  is  to  treat, 
the  patient  with  alternate  douches  of  warm 
(115°  Fahr.)  and  cold  water,  so  as  to  stimulate 
the  respiratory7  functions;  artificial  respiration 
may  also  be  employed,  together  with  friction  ol 
the  limbs.  An  emetic  should  be  administered 
Faradaic  currents  of  electricity  to  the  cardiac 
region  should  not  be  neglected.  Atropine  if 
not,  as  has  been  asserted,  a true  physiologies 
antidote  to  prussic  acid ; but,  injected  subcu| 
taneously,  it  may  be  of  use  as  a respirator 
stimulant.  Spite  of  all  treatment,  the  patien 
usually  succumbs.  T.  Stevenson. 

PSEUDO-  (fcvS Jjv,  false).— This  is  used  as . 
prefix  to  various  names  of  conditions,  and  signifie 
that  they  simulate  certain  diseases  or  condition 
which  they  really  are  not;  for  example, pseudo 
angina,  pseudo-asthma,  and  pscudo-cytosis. 

PSEUDOCYESIS  (1 pevSfjs,  false,  and  mV' 
pregnancy).  A syuonym  for  spurious  pregnane; 

Sec  Pregnancy,  Diseases  and  Disorders  of. 

PSEUDO-HYPERTROPHIC  MUSCI 
LAR  PARALYSIS.  — Synon.:  Lipomto s 
musculorum,  luxurious-,  Fr.  Paralyste  pseud 
hypertrophique ; Paralysis  myosclerosique ; Ge 
Atrophia  musculorum  lipomatosa. 


PSEUDO-HYPERTROPHIC 

Definition. — This  is  a progressive  muscular 
paralysis,  appearing  mostly  in  boys,  in -which  the 
ultimate  fibres  of  the  affected,  muscles  atrophy, 
j tut  the  muscles  themselves  appear  to  be  hyper- 
.rophied,  in  consequence  of  the  development  of 
uterstitial  fat  and  fibrous  tissue. 

JEtiology.  — Pseudo-hypertrophic  muscular 
paralysis  is  a disease  of  boys,  very  few  cases 
taring  been  observed  in  girls  or  in  adults.  In  a 
large  number  of  cases  it  begins  in  infancy,  the 
.weakness  becoming  manifest  at  the  time  the 
jchild  should  begin  to  walk.  In  some  instances 
it  has  been  found  to  be  hereditary,  several  chil- 
dren in  the  same  family  having  been  affected. 
.Nothing  definite  is  yet  known  as  to  the  direct 
causation  of  the  malady. 

Anatomical  Characters.  — In  the  earlier 
stages  of  the  malady,  the  muscles  chiefly  affected 
are  those  of  the  legs  and  lower  part  of  the 
back,  particularly  the  gastrocnemii,  the  posterior 
muscles  of  the  thigh,  and  the  erectores  spinse. 
These  muscles  are  enlarged,  and  they  are  felt 
to  be  firm  and  hard.  This  is  not,  however,  due  to 
true  hypertrophy,  for  if  a portion  of  the  muscle 
bo  removed  during  life  by  the  emporte-piece , 
an  instrument  constructed  by  Duchenne  for 
this  purpose,  the  muscular  fibres  are  found  to 
;’be  atrophied,  and  much  of  the  apparent  bulk  is 
seen  to  be  due  to  an  interstitial  development  of 
fat  and  fibrous  tissue.  Subsequently,  the  remain- 
ng  muscles  of  the  trunk,  upper  limbs,  am.l 
sometimes  even  of  the  face  become  similarly  af- 
ected,  in  most  cases  these  muscles  merely  wast- 
ng  without  any  apparent  enlargement,  but  in 
ither  cases  the  apparent  hypertrophy  being  pre- 
eut  in  the  upper  as  well  as  the  lower  half  of  the 
iody.  In  the  later  stages  of  the  disease,  the 
vhole  of  the  voluntary  muscles,  including  those 
vhich  at  first  were  enlarged,  become  more  or 
ess  wasted.  The  diseased  muscles  are  found 
fter  death  to  be  composed  in  a great  measure  of 
rdinary  fat-cells.  The  true  muscular  substance 
as  to  a considerable  extent  disappeared,  and  only 
few  ultimate  muscular  fibres  are  seen  running 
t intervals  through  the  fat.  Some  of  these  ulti- 
late  fibres  retain  their  normal  size  and  appear- 
nce ; others  are  much  decreased  in  size,  though 
ill  showing  the  striation;  only  a few  of  the 
frophied  fibres  have  lost  their  striation,  and 
ecome  granular.  The  diseased  muscles  also 
intain  a considerable  quantity  of  fibrous  tissue, 
>me  of  which  is  probably  the  remaining  sheaths 
muscular  fibres  which  have  undergone  com- 
pete atrophy.  There  is  less  fat  and  fibrous  tissue 
tho  wasted  muscles  than  in  those  which  are 
leudo-hypertrophic,  but  the  changes  in  the  initi- 
ate muscular  fibres  are  the  same  in  both. 

Some  doubt  still  exists  as  to  the  pathological 
:atomy  of  the  spinal  cord  in  this  disease.  Seve- 
1 competent  observers,  such  as  Cohnheim  and 
larcot,  have  failed  to  find  any  morbid  changes 
the  nervous  system.  Lockhart  Clarke  and 
pwershave, however,  discovered  important  alter- 
ions  in  the  spinal  cord  in  a case  of  this  disease. 
ie  principal  change  was  extensive  disintegra- 
® of  tIlc  Rrey  matterat  thecentreof  each  lateral 
If  of  the  cord,  and  of  the  anterior  commissure. 
Pathology. — It  has  been  suggested  by  Fried- 
ch  and  others  that  pseudo-hypertrophic  mus- 
ar  paralysis  is  essentially  the  same  disease  as 


MUSCULAR  PARALYSIS.  1269 

progressive  muscular  atrophy,  and  this  view  is 
probably  correct.  The  two  diseases  differ  in  this 
respect,  that  the  former  always  begins  in  the 
lower  limbs,  the  muscles  of  which  are  more  exer- 
cised than  the  arms  in  children.  The  enlarge- 
ment of  the  muscles  might  be  explained  by  sup- 
posing a compensatory  growth  in  the  early  stages 
of  the  malady  in  those  diseased  muscles  which 
have  the  most  important  functions  ; and  the  pos- 
terior muscles  of  the  legs  and  back  have  the 
important  duty  of  keeping  the  body  erect  on  the 
legs.  It  is  a fact  that  the  pseudo-hypertrophied 
muscles  retain  much  greater  power  than  the 
muscles  which  are  merely  atrophied. 

Symptoms. — The  symptoms  of  a well-marked 
case  of  pseudo-hypertrophic  muscular  paralysis 
are  very  striking,  and  cannot  easily  be  over- 
looked or  mistaken.  When  the  child  is  stripped, 
the  muscles  of  the  calves  are  seen  to  be  lar- 
ger and  firmer  than  natural,  and  the  same 
apparent  hi-pertrophy  may  be  present  in  the 
muscles  of  the  thigh,  the  glutei,  the  lumbar 
muscles,  and  others.  Occasionally  the  muscles 
of  the  upper  half  of  the  body  exhibit  a similar 
increase  in  size,  but  much  more  frequently  they 
are  wasted,  so  that  the  emaciation  of  the  upper 
half  of  the  body  contrasts  strongly  with  the  appa- 
rent excess  of  muscular  development  in  thelower 
half.  The  next  most  obvious  symptom  is  pro- 
tuberance of  the  belly.  There  is  no  abdominal 
enlargement,  but  the  an tero -posterior  curvature 
of  the  vertebral  column  in  the  lumbar  region  is 
much  exaggerated,  and  the  shoulders  are  thrown 
back.  This  unnatural  curve  is  not  caused  by 
any  disease  of  the  vertebrae,  for  it  entirely  dis- 
appears when  the  patient  sits  or  lies  down.  When 
the  child  stands,  the  legs  are  held  apart,  and  the 
heels  raised  off  the  ground.  He  walks  almost  on 
tiptoe,  as  in  talipes  equinus,  and  with  a most 
peculiar  gait — a waddle,  as  if  he  needed  to 
balance  the  body  first  on  one  leg  and  then  on  the 
other.  Walking  soon  tires  him.  If  he  attempts 
to  go  fast  he  falls,  and  he  is  very  easily  knocked 
over.  He  can  readily  stoop  so  as  to  touch  the 
floor,  but  generally  has  great  difficulty  in  raising 
himself  to  the  erect  posture,  using  powerful 
muscular  effort,  and  having  to  assist  the  move- 
ment by  means  of  the  hands  placed  on  his  knees. 
When  sitting,  he  can  recover  himself  from  the 
bent  position  with  comparative  ease.  The 
electro-contractility  of  the  muscles  is  unimpaired. 
The  general  health  of  the  patient  is  unaffected 
until  the  later  stages  of  the  disease.  In  many 
cases  of  pseudo-hypertrophic  muscular  paralysis 
there  is  some  deficiency  in  mental  power. 

Duchenne  divides  the  progress  of  pseudo- 
hypertrophic  paralysis  into  three  stages: — In  the 
first  stage,  lasting  several  months  or  even  one 
or  more  years,  there  is  merely  weakness  of  the 
muscles,  causing  the  peculiarities  in  the  attitude, 
and  in  the  mode  of  progression.  Little  or  no 
enlargement  of  the  muscles  has  taken  place. 
During  this  stage  proper  treatment  may  bring 
about  recovery.  In  the  second  stage  the  charac- 
teristic hypertrophy  appears,  and  tho  weakness 
extends  to  the  muscles  of  the  upper  limbs.  This 
stage  may  last  for  years.  In  the  third  stage 
complete  paralysis  of  most  of  the  muscles  of  the 
upper  and  lower  limbs  and  of  the  trunk  super- 
venes. The  patient  lies  helpless,  unable  to  change 


1270  PSEUDO-HYPERTROPHIC  PARALYSIS.  PSOAS  ABSCESS. 


his  position.  All  the  muscles,  even  those  which 
were  formerly  hypertrophied,  pass  into  a state  of 
atrophy.  The  sufferer  may  live  in  this  weak  state 
until  carried  off  by  some  intercurrent  disease. 

Diagnosis.  — Pseudo-hypertrophic  muscular 
paralysis  has  such  peculiar  and  well-marked 
characters  that  it  cannot  easily  be  mistaken.  It 
is  readily  distinguished  from  the  various  forms 
of  spinal  paralysis  by  the  evident  enlargement 
and  unusual  firmness  of  the  paralysed  muscles 
of  the  lower  limbs.  From  spinal  curvature, 
depending  on  disease  of  the  vertebral  column, 
it  differs  in  this  respect,  that  the  curve  of  the 
spine  which  is  present  in  pseudo-hypertrophic 
paralysis  disappears  when  the  patient  sits  or 
lies  down. 

Peognosis. — The  prognosis  is  most  unfavour- 
able. 

Teeatment. — This  is  only  available  in  the 
first  stage,  before  the  hypertrophic  symptoms  are 
marked.  Duchenne  recommends  localised  fara- 
dization and  shampooing,  and  he  records  two 
cases  which  were  cured  by  these  means.  The 
writer  has  seen  one  case  which  had  entered  on 
the  second  stage,  in  which  this  treatment  has 
completely  checked  the  progress  of  the  malady, 
and  even  brought  about  considerable  improve- 
ment in  the  strength  of  the  lower  limbs.  It  is 
probable  that  the  continuous  current  might  prove 
useful.  General  tonic  treatment  is  undoubtedly 
beneficial,  but  no  medicinal  remedies  are  known 
to  have  any  special  control  over  the  disease. 

Alexander  Davidson. 

PSOAS  ABSCESS.— Synon.:  Fr.  Abcesdu 
Psoas ; Ger.  Psoas  abscess. 

Definition. — A variety  of  spinal  abscess, 
formed  by  a collection  of  pus,  confined  by  the 
fascial  sheath  of  the  psoas  magnus  muscle  ; 
conducted  by  it  beneath  Poupart’s  ligament ; 
and  pointing  in  the  thigh,  in  Scarpa’s  space,  ex- 
ternal to  the  femoral  vessels. 

Such  is  the  ordinary  course  taken  by  the  pus 
in  psoas  abscess,  although  it  is  liable  to  a good 
many  modifications.  Thus,  the  matter  may  be 
arrested  just  above  Poupart’s  ligament,  and  the 
abscess  occupy  the  venter  ilii ; it  may  make  its 
way  into  the  inguinal  canal,  and  out  at  the 
external  ring,  and  simulate  a hernia;  or,  again, 
it  may  point  above  Poupart's  ligament,  but  in 
this  instance  the  abdominal  muscles  and  fasciae 
must  have  been  perforated  by  ulceration.  No 
real  difference  exists  between  the  causes  of  lum- 
bar abscess  and  psoas  abscess  ; it  is  rather  a 
question  of  degree,  and  of  the  position  of  the 
ulceration,  and  tho  initial  terms  may  be  re- 
garded as  topographical  only. 

^Etiology. — Psoas  abscess  is  rarely  met  with 
before  puberty,  generally  between  that  period 
and  five-and-thirty  years  of  age  ; and  would 
seem  to  be  more  common  in  males  than  in 
females. 

As  a result  of  spinal  caries  the  abscess  is 
more  liable  to  be  of  the  psoas  form,  if  the  patient, 
during  the  early  stages  of  the  disease,  has  been 
able  to  get  about. 

Anatomical  Chaeactees.  — Psoas  abscess  is 
generally  a result  of  tuberculous  osteitis,  com- 
mencing on  the  anterior  surface,  and  anterior 
portion  of  the  cancellous  tissue,  or  in  the  fibro- 


cartilages,  of  the  lower  dorsal  or  upper  lumbar 
vertebra.*  (see  Spine,  Diseases  of).  It  may  follow 
injury,  however;  and,  moreover,  may  exist  inde- 
pendently of  diseased  bone. 

The  morbid  process  is  one  of  ulceration  and 
of  suppuration.  Tho  tissues  surrounding  the 
affected  parts  become  thickened,  and  confine  the 
pus;  whilst,  from  its  sinking  down,  and  from  the  j 
spreading  of  the  ulceration,  the  abscess  grows 
in  bulk.  More  rarely,  acute  inflammation  may 
occur  in  the  substance  of,  or  immediately  be-  j 
neath,  the  fascia  covering  the  psoas  muscle,  as 
in  psoitis  and  peripsoitis. 

The  pus  of  the  spinal  abscess,  having  gained  I 
the  abdominal  side  of  the  diaphragm,  passes 
into  the  body  of  one  or  other,  or  of  both,  psoas 
muscles ; arrives  at  Poupart’s  ligament ; and  i 
commences  its  downward  course,  this  point  be- 
ing called  the  ‘neck  ’ of  the  abscess.  When  once 
it  has  passed  this  point  it  increases  rapidly  in 
size,  its  appearance  being  preceded  by  a bulging 
in  the  fold  of  the  groin.  Its  subsequent  course 
is  inwards  and  downwards,  following  the  line  of 
the  inner  edge  of  the  sartorius.  It  may,  how- 
ever, lie  over  the  adductors  ; or  may  pass  entire!' 
outwards ; the  direction  straight  downwards  is 
rare.  Cases  have  been  met  with  where  it  his  i 
divided  at  the  groin;  where  the  matter  passed 
the  knee-joint, and  pointedat  thetendoAchillis; 
and  where  it  has  passed  along  the  course  of  the  | 
profunda  femoris  vessels. 

Sometimes  the  abscess  does  not  pass  beneath 
the  crural  arch,  but  by  its  expansion  forms  a well- ; 
defined  globular  tumour  in  the  iliac  fossa.  In  , 
other  cases,  the  pus  may  find  its  way  into  the, 
inguinal  caral ; into  the  intestine ; or,  as  is  the 
case  in  children  frequently,  over  the  crest  of 
the  ilium,  pointing  in  the  buttock. 

Symptoms. — The  earliest  symptoms  preceding 
psoas  abscess  are  generally  not  well-marked. 
There  is  gradual  weakness,  loss  of  flesh,  a pallid, 
complexion,  and  loss  of  appetite.  Later  on  the 
limb  becomes  affected ; limping  occurs  during  or 
after  walking;  and  the  action  of  the  psoas  muscle  I 
becomes  impaired.  Subsequently  a soreness, 
hardly  amounting  to  severe  pain,  is  experienced 
in  the  spine  or  in  front  of  the  thigh,  aggravated 
by  pressure ; or  a swelling  may  appear  in  the 
lumbar  region,  since  this  particular  abscess  is 
merely  a form  of  lumbar.  The  peculiar  symp- 
tom of  psoas  abscess  is  essentially  a fluctuating 
swelling  benoath  and  extending  below  Poupart's 
ligament ; generally  pointing  external  to  the 
great  vessels  ; receiving  an  impulse  on  cough- 
ing; and  disappearing,  or  partially  disappearing, 
on  the  patient's  assuming  the  recumbent  psi- 
tion.  It  must,  however,  be  remembered  that 
the  pus  may  travel  along  other  channels,  or  may 
encroach  upon  other  fascial  sheaths  than  its 
usual  one.  Yet  its  persistence  at  its  ‘neck’  will 
materially  assist  in  its  physical  diagnosis. 

The  contents  of  a psoas  abscess  are  pus  and 
tubercular  matter,  intermixed  with  flakes  o( 
lymph,  and  particles  of  bone  and  fibro  cartilsge. 

Diagnosis. — The  chief  point  of  difficulty  id 
the  diagnosis  of  psoas  abscess  is  that  of  distin- 
guishing it  from  iliac  or  caeeal  abscess.  In  the 
early  stages  it  is  always  associated  with  spma. 
misehief  in  young  subjects.  It  points  below 
Poupart's  ligament ; there  is  an  inclination  n! 


PSOAS  ABSCESS. 

the  trunk  forwards,  and  some  disturbance  of  the 
functions  of  the  psoas ; and  pain  in  walking  is 
complained  of.  Iliac  abscess  arises  in  the  loose 
areolar  tissue  of  the  iliac  fossa,  and  in  some 
cases  may  actually  get  into  the  sheath  of  the 
psoas. 

Sometimes  the  caries  commencing  in  the  lower 
lumbar  vertebra  may  spread  laterally,  and  rise 
above  the  crest  of  the  ilium;  and  the  pus,  being 
discharged  backwards,  may  appear  to  have  com- 
menced with  hip-joint  disease,  as  the  movements 
of  this  joint  are  impaired.  It  is  important  in 
such  cases  to  place  the  patient  under  an  anaesthe- 
tic, and  make  a most  careful  examination. 

Again,  psoas  abscess  usually  makes  its  ap- 
pearance in  the  groin  very  suddenly,  owing  to 
the  giving  way  of  some  confining  tissue. 

Medullary  cancer  may  simulate  psoas  abscess ; 
particularly  if  the  disease  has  invaded  the  spine, 
and  caused  a curvature  of  the  lumbar  vertebra. 
Aneurismal  tumours,  or  blood  which  has  escaped 
by  the  rupture  of  such  tumours,  may  bo  mis- 
taken for  the  disease,  and  particularly  when  such 
extravasation  has  found  its  way  into  the  sheath 
of  the  psoas,  and  is  non-pulsatile. 

Prognosis. — As  a rule  the  prognosis  of  psoas 
abscess  cannot  be  considered  favourable.  It  is 
an  advanced  symptom  of  strumous  dyserasia  ; it 
rarely  gets  well  of  itself;  it  frequently  impairs 
the  functions  of  the  spinal  cord ; and  it  may 
terminate  fatally  by  hectic  or  lesion  of  the  lungs 
or  bowels. 

Treatment. — The  best  method  of  treatment 
of  psoas  abscess  is  that  adopted  by  Lister,  of 
opening  it  by  free  incision  antiseptically ; in- 
serting an  adequate  drainage-tube ; and  dressing 
it  with  scrupulous  care  from  first  to  last  ( sec 
Antiseptic  Treatment).  The  abscess  may, 
however,  open  spontaneously,  and  no  bad  re- 
sults follow ; and,  with  great  care,  and  the  use 
• of  the  prone  couch,  the  patient  may  recover. 

Good  diet,  cod-liver  oil,  iodides,  and  tonics  ap- 
pear to  be  the  most  suitable  internal  remedies. 

Edward  Bellamy. 

PSORIASIS  I rub). — Synon.  : Fr.  and 

Ger.  Psoriasis. — This  word  expresses  the  effort 
to  relieve  itching  ; hence  the  word  psora,  applied 
to  the  disease  eczema  by  the  Greeks,  but  in 
modern  pathology  restricted  to  scabies.  The 
term  has  been  adopted  by  the  French  and  Ger- 
mans as  the  equivalent  of  the  lepra  of  Willan, 
and  is  at  present  generally  used  in  that  sense. 
See  Lepra. 

PSYCHOSIS.  See  Sycosis. 
PSYDRACIUM  (dim.  of  ^uSpaues,  blis- 
ters).—A small  blister,  or  pustule,  without  in- 
flammatory base ; a cold  pustule,  in  contradis- 
tinction to  pblyzacium,  or  hot  pustule. 

PTOMAINES.  See  Appendix. 

PTOSIS  ( irrutris , a fall). — A drooping  or 
falling  of  the  upper  eyelid,  with  inability  to  raise 
it,  due  to  paralysis  of  the  third  cranial  nerve. 
See  Third  Nerve,  Diseases  of. 

PTYALISM  (tttuoAof,  saliva).— A synonym 
for  salivation,  or  excessive  flow  of  saliva.  See 
iiUYARY  Secretion,  Disorders  of. 


PUBERTY,  DISORDERS  OF.  1271 

PUBERTY,  Disorders  of. — Synon.;  Fr. 

Troubles  de  la  Puberte;  Ger.  Storungen  det 
Pubert'dt. 

Of  the  various  periods  into  which  existence 
is  divisible,  certainly  not  tbe  least  important, 
in  its  pathological  aspect,  is  that  intervening 
between  childhood  and  maturity,  when  the  re- 
productive powers  become  developed,  and  which 
is  known  as  Puberty. 

This  epoch  occurs  earlier  in  warm  climates, 
sanguine  temperaments,  and  highly  cultivated 
and  luxurious  states  of  society ; it  is  retarded  by 
the  opposite  conditions ; and  in  these  islands  it 
generally  commences  between  the  ages  of  thirteen 
and  fifteen  in  females,  and  a year  later  in  males. 
Under  the  age  of  fourteen,  a male  is  legally  sup- 
posed incapable  of  committing  a rape;  and  a 
female  under  twelve  is  deemed  incapable  of  con- 
senting to  sexual  intercourse.  By  the  Roman 
law,  the  period  of  the  commencement  of  puberty 
was  identical  with  that  at  which  the  individual 
became  liable  to  military  duty.  Thus  Adrian 
commenced  his  service  at  the  age  of  fifteen. 

Puberty  cannot,  however,  be  estimated  by  age 
alone.  Even  in  this  climate,  the  period  of  the 
commencement  of  puberty  varies  widely ; thus 
the  writer  has  seen  instances  of  menstruation  in 
children  under  ten,  and  has  assisted  at  the  de- 
livery of  a girl  of  fourteen  years  of  age.  More 
frequently,  however,  puberty  is  postponed  beyond 
the  ordinary  period,  which  may  be  also  modified 
by  family  or  hereditary  peculiarities,  and  the 
influence  of  various  diseases. 

In  the  first  stages  of  life,  the  functional  dif- 
ferences between  the  sexes  are  comparatively 
slightly  marked ; but  on  the  approach  of  puberty 
these  suddenly  become  prominent,  and  so  obvious 
does  the  influence  of  the  uterine  system  become, 
that  propter  uterum  est  mulier  is  then  almost 
literally  the  case. 

The  accession  of  puberty  in  the  male  is  at- 
tended by  a characteristic  alteration  of  the  voice, 
from  ‘the  thin  childish  treble’  to  ‘the  deep 
manly  bass,’  owing  to  the  development  of  the 
pomurn  Adami,  and  the  elongation  of  the  thyroid 
cartilage  and  thyro-arytaenoid  muscle.  About 
the  same  time  occurs  the  growth  of  hair  on  the 
skin  on  various  parts  of  the  body.  Before  this 
there  are  observed  the  development  of  the  male 
genital  organs,  the  enlargement  of  the  testes 
and  other  parts  of  the  sexual  apparatus,  the  se- 
cretion of  the  seminal  and  other  accessory  fluids, 
and  the  first  outburst  of  the  sexual  instincts  and 
feelings.  So  slowly  do  the  successive  changes, 
which  mark  the  occurrence  of  puberty  in  the 
male,  proceed,  that  they  are  not  completed  until 
full  age  has  been  passed. 

In  the  female,  on  the  contrary,  when  puberty 
is  reached,  the  individual  passes  at  a bound,  as 
it  were,  from  childhood  to  womanhood,  although 
the  structural  and  functional  changes  involved 
in  the  transition  are  infinitely  more  complex  and 
important  than  is  the  case  in  the  other  sex.  Thus 
the  enlargement  of  the  external  genital  organs 
is  accompanied  with  a still  greater  change  of  the 
internal  organs  of  generation — the  development 
of  the  uterus,  ovaries,  and  mammae,  and  the 
commencement  of  that  periodic  sanguineous 
discharge  per  vaginam,  the  recurrence  of  which 
at  regular  monthly  intervals  marks  the  reriod 


1272  PUBERTY,  DISORDERS  OF. 


within  which  woman  is  capable  of  reproduc- 
tion. 

The  writer  has  found  it  less  easy  to  discover 
the  truedate  of  first  menstruation  than  have  some 
authorities  whose  tables  are  generally  relied 
upon.  In  the  great  majority  of  cases  the  state- 
ments of  those  he  questioned  were  so  indefinite 
as  to  be  practically  valueless,  and  in  only  497 
instances  did  the  writer  get  even  any  approach 
to  accurate  data  on  this  point.  Excluding  all 
cases  of  so-called  infantile  menstruation,  the  re- 
sults of  these  inquiries  may  be  thus  summarised, 
the  mean  age  being  15  : — 


Under  12  . . 

4 menstruated  for  first  time. 

At 

12  . . 

17  „ „ 

»> 

13  . . 

>i  ii  ii  a 

>> 

14  . . 

94  ii  11  fi  ii 

ii 

15  . . 

1^8  „ „ „ „ 

ii 

16  . . 

10^  ii  n a 

ii 

17  - - 

65  ii  ii  ii  11 

ii 

18  . . 

10  ii  ii  ii  ii 

Upwards  of  18 

1^  ii  ii  11  ii 

Generally  speaking,  therefore,  between  the 
ages  of  thirteen  and  fifteen  in  our  climate,  the 
human  female  undergoes  the  change  from  child- 
hood to  puberty ; the  essential  characteristic  of 
this  change  consisting  in  a periodic  sanguineous 
discharge,  per  vaginam,  resulting  from  ovulation. 
The  process  of  menstruation,  from  its  commence- 
ment in  ovarian  congestion,  resulting  in  the  dis- 
charge of  an  ovum,  its  transmission  along  the 
Fallopian  tube,  its  transit  through  the  congested 
uterus,  its  expulsion  thence,  together  with  the 
disintegrated  endo-uterine  mucous  membrane, 
and  the  consequent  haemorrhagic  discharge  from 
the  denuded  uterus,  is  invariably  productive  of 
more  or  less  goneral  constitutional  disturbance 
and  mental  irritation,  so  that  no  woman  can  be 
properly  said  to  enjoy  the  mens  Sana  in  corpore 
sano  whilst  menstruating.  When  this  function 
lias  become  regularly  established,  the  accompany- 
ing constitutional  disturbance  may  be  so  slight 
as  to  bo  practically  unrecognisable.  But  on  the 
first  occurrence  of  ovulation,  few,  if  any,  escape 
somo  sympathetic  constitutional  derangement, 
and  more  especially  some  one  or  other  of  the  pro- 
tean forms  of  hysteria.  Hence,  under  the  guise 
of  nearly  every  disease  that  may  affect  a girl  at 
the  age  of  puberty,  whether  it  be  spinal,  cardiac, 
pulmonary,  or  any  other  disorder,  the  practi- 
tioner must  look  carefully  that  he  has  not  to 
deal  with  some  variety  of  hysteria,  directly 
resulting  from  the  complex  process  by  which 
puberty  is  accompanied. 

Undue  importance  is  attached  to  the  non-ap- 
pearance of  menstruation,  as  the  supposed  cause 
of  all  the  ills  that  female  flesh  is  heir  to.  In 
the  majority  of  cases  of  delayed  menstruation 
the  amenorrhcea  is  the  result  of  constitutional 
disease,  to  the  rational  treatment  of  which,  and 
not  to  any  utero-ovarian  stimulation,  should  the 
efforts  of  the  physician  be  directed.  At  the  same 
time,  the  part  played  by  the  development  of  the 
reproductive  system  in  the  transformation  scene 
from  childhood  to  maturity,  is  unquestionably 
of  the  first  importance.  The  morbid  influence 
of  the  premature  indulgence  of  the  newly- 
awakened  sexual  appetites  at  the  age  of  puberty, 
Mid  tho  many  forms  of  disease  by  which  the  vice 


of  masturbation  is  aveDged  by  outraged  nature, 
are  subjects  the  medical  importance  of  which  it 
would  be  difficult  to  exaggerate,  and  which  it 
would  he  impossible  to  discuss  in  this  article. 

Many  of  the  ailments  common  about  the  period 
of  puberty,  are  but  accompaniments  or  fore- 
runners of  tho  functional  and  organic  changes 
then  commencing.  More  especially  is  this  the 
case  in  the  female  sex.  Hence  the  physician 
must  bear  in  mind  that  the  headaches,  palpita- 
tions, symptoms  of  disordered  nervous  action,  and 
many  of  the  cases  of  haemorrhage  from  various 
organs  which  create  so  much  alarm,  are,  as  Sir 
Henry  Holland  long  since  observed,  but  evidences 
of  ‘new  balances  struck  in  the  allotment  of  the 
blood  to  different  parts ; and  in  the  course  of 
such  changes,  congestions  and  discharges  are 
prone  to  occur,  the  latter  relieving  or  preventing 
tho  former.’  It  is  hardly  necessary  to  point  out 
the  necessity  for  careful  diagnosis  between  symp- 
toms thus  caused,  and  the  evidences  of  actual 
disease  ; for  in  the  former,  the  active  treatment 
required  by  the  latter  would  be  not  only  un- 
necessary, but  positively  injurious,  by  interfering 
with  the  progress  of  those  natural  functional  or 
organic  changes  on  the  establishment  of  which 
these  symptoms  will  cease.  The  circulation  is 
now  vigorous ; not  only  is  the  amount  of  blood 
in  circulation  greater  during  this  period,  but 
also  its  relative  proportions  of  fibrin  and  red 
corpuscles  are  larger,  and  hence  the  roseate 
hues  and  plump  outlines  of  early  youth. 

It  is  sin-prising  how  well  young  persons  at  this 
period  bear  haemorrhagic  discharges,  with  which 
the  experienced  physician  will  he  slow  to  inter- 
fere, lest  by  their  arrest  he  may  bring  on  more 
serious  consequences.  Many  of  those  cases  of 
haemoptysis  which  excite  so  much  alarm,  as  sup- 
posed evidences  of  pulmonary  disease,  and  the 
subsidence  of  which  is  ascribed  to  the  particular 
treatment  adopted,  as  well  r.s  most  cases  of 
haematemesis  occurring  in  girls  about  this  epoch, 
aro  merely  symptomatic  of  the  changes  conse- 
quent on  puberty,  and  require  little  or  nothing 
in  the  way  of  repressive  treatment. 

There  are  few  practical  subjects  more  neglected 
by  physicians  than  the  moral  hygienic  and  phy- 
sical management  of  puberty.  The  effect  of  the 
evolution  of  puberty,  as  the  occasional  exciting 
cause  of  insanity,  has  been  briefly  alluded  to  by 
Dr.  Maudsley  and  some  other  writers  on  mental 
disease.  The  influence  of  over  mental  stimulation 
during  puberty,  as  an  occasion  of  the  increased 
proportion  of  nervous  and  cerebral  disorders,  is 
a subject  of  the  greatest  importance.  At  this 
period  of  life  the  present  cramming  system  of 
education  predisposes  to  insanity,  the  organ  of 
the  mind  being  goaded  into  premature  activity, 
and  overstrained  in  the  effort  to  pass  some  com- 
petitive or  other  examination,  deemed  essential 
to  entrance  on  official,  commercial,  or  profes- 
sional life.  Thus  the  mental  powers  are  worn 
out  and  exhausted  before  they  have  attained 
their  perfection.  In  another  respect  the  modern 
system  is  hurtful  to  the  mind;  for  now-a-days, 
when  education  is  too  often  divested  of  that  moral 
restraint  and  control  formerly  held  to  be  essen- 
tial, ‘it  proves  injurious,’  as  Dr.  Copeland  says. 

- not  only  in  the  way  thus  stated,  but  in  giving 
rise  to  forced,  unnatural,  overreaching  ambitions 


PUBERTY,  DISORDERS  OF. 

and  unprincipled  states  of  society;  and  these 
states,  in  proportion  as  they  are  developed,  are 
the  parents  of  crime,  insanity,  and  suicide.’ 

Thomas  More  Madden. 

PUBLIC  HEALTH.  — In  all  civilised 
tountries  laws  are  made  with  the  intention  of 
removing  conditions  which  injure  the  health  of 
the  people.  In  the  United  Kingdom  these  laws 
are  now  very  numerous,  and  almost  every  year 
new  statutes  regulating  public  healthare  enacted. 
The  general  fault  of  the  laws  in  this  country 
has  been  their  tentative  and  permissive  character; 
powers  are  not  infrequently  given  which  there  is 
no  obligation  to  use,  and  which  are  therefore  not 
used,  and  the  wording  of  the  Acts  has  sometimes 
permitted  evasion. 

It  may  be  believed  that  certain  ambiguities 
of  expression  in  the  Acts  were  avoidable,  but 
that  they  have  arisen  from  the  difficulty  of 
determining  the  proper  limits  of  the  action  of 
the  State,  i.e.  to  what  point  it  is  right  to  inter- 
fere with  private  property,  with  private  enter- 
prise, and  with  individual  responsibilities. 

These  are  difficult  questions,  for  though  it  is 
undoubted  that  the  community,  as  a body,  has  a 
just  power  of  setting  aside  the  rights  of  indi- 
viduals when  necessary  for  the  benefit  of  all  its 
members ; yet  it  is  obvious  that  such  power  must 
be  exercised  with  great  discretion,  lest  the  right 
to  property,  and  the  incentive  to  labour  and  to 
self-improvement,  should  be  endangered.  Still  it 
cannot  be  doubted  that our  sanitary  laws  have  been 
influenced  by  an  unnecessary  timidity,  and  have 
been  too  much  hampered  by  opposing  opinions 
respecting  the  proper  limits  of  these  powers  and 
rights.  There  are  some  writers  who  question 
whether  the  State  has  any  right  to  interfere  with 
individual  action;  but  to  this  it  seems  answer 
enough  to  say  that  a community  is,  after  all, 
nothing  but  a collection  of  individuals,  whose 
united  action  is  merely  the  individual  action 
combined;  that  such  union,  as  represented  by 
the  majority,  is  a necessity  for  the  security  of 
life  and  property,  and  in  those  cases  is  always 
enforced,  and  that  there  can  be  no  reason  why 
this  combined  action  should  not  also  regulate  the 
important  conditions  of  public  health  as  well  as 
ithe  relations  of  property  and  the  conduct  of  indi- 
viduals. Practically,  also,  there  are  conditions 
affecting  the  health  of  its  menibers  with  which 
the  community  at  large  alone  can  deal,  and  with 
which,  therefore,  it  ought  to  deal.  It  can  also  be 
ishown  that  this  common  action  has  already  been 
productive  of  the  greatest  good  in  several  cases, 
and  is  absolutely  necessary  in  order  to  counter- 
act the  ignorance,  carelessness,  selfishness,  and 
avarice  of  men. 

Although  there  are  many  old  statutes,  and  also 
provisions  in  the  common  law  of  England  affeet- 
ng  the  public  health,  the  sanitary  legislation  of 
England  may  be  said  to  date  from  the  passing  of 
the  Public  Health  Act  of  1848  (11  and  12  Viet. 
'.  63).  That  Act  was  followed  between  1855 
ind  1872  by  a variety  of  public  Acts  having 
unitary  objects,  besides  others  of  local  applica- 
ion.  These  public  Acts  have  been  now  consoli- 
dated in  the  great  Act  of  1875  (38  and  39  Viet. 
. 55),  an  Act  for  consolidating  and  amending  the 
Acts  relating  to  public  health  in  England.  This 


PUBLIC  HEALTH.  1273 

Act  is  cited  as  the  Public  Health  Act,  1875.  It 
does  not  apply  to  Scotland  or  Ireland,  which  have 
their  own  Health  Acts,  nor  to  the  Metropolis 
where  former  Kuisance  Removal  and  Sanitary 
Acts  continue  in  force.  This  statute  repeals 
(except  as  regards  the  Metropolis  and  Scotland 
and  Ireland  in  certain  eases)  no  less  than  nine- 
teen Acts,1  and  affects  sixteen  others.  It  has 
not  only  consolidated  but  has  improved  the  law, 
and  in  several  cases  has  given  increased  powers 
to  local  sanitary  authorities. 

In  addition  to  this  Act  two  others  of  impor- 
tance were  passed  in  the  session  of  1875:  the 
Artisans  and  Labourers’ Dwellings  Improvement 
Act,  1875,  which  applies  only  to  the  Metropolis 
and  to  urban  districts  in  England  and  Ireland 
having  a population,  according  to  the  last  census, 
of  25,000  and  upwards.  It  gives  powers  to  clear 
unhealthy  areas,  and  to  superintend  and  regu- 
late the  rebuilding  on  such  areas.  It  is  likely 
to  prove  a very  important  Act,  and  doubtless 
will  in  time  be  followed  by  a statute  dealing  with 
smaller  populations. 

In  the  same  session  an  Act  entitled  ‘ An  Act 
to  repeal  the  Adulteration  of  Food  Acts,  and  to 
make  better  provision  for  the  Sale  of  Food  and 
Drugs  in  a pure  state’  (38  and  39  Viet.  c.  63) — 
short  title,  ‘Sale  of  Food  and  Drugs  Act’ — was 
passed.  It  repeals  entirely  or  partially  four 
Acts,  and  provides  for  the  appointment  of  public 
analysts,  and  for  the  purchase  and  examination 
of  food  and  drugs. 

[More  recent  Acts  are  (a)  The  Rivers  Pollu- 
tion Prevention  Act  of  1876,  to  which  reference 
will  be  made  in  the  course  of  the  present  article  ; 
(5)  The  Contagious  Diseases  (Animals)  Act,  of 
1878,  which  confers  certain  powers  for  the  pro- 
per keeping  of  cows  and  for  the  protection  of  milk 
against  injurious  influences ; and  (c)  the  ‘ Pub- 
lic Health  ("Water)  Act’  of  1878,  enabling  rural 
sanitary  authorities  to  require  the  provision  of 
sufficient  water-supply.  In  intention,  at  least, 
these  Acts  fill  some  serious  gaps  in  the  sanitary 
legislation  of  the  country.] 

In  the  following  article  a general  outline  is 
given  of  the  subject  of  Public  Health.  It  is,  of 
course,  impossible  to  fill  up  the  details,  which 
require  special  works  for  almost  every  heading. 
But  the  outline  will  show  the  points  which  are 
especially  deserving  of  attention,  and  which 
have  to  be  considered  both  in  legislation  and  in 
the  practical  performance  of  the  duties  of  medi- 
cal officers  of  health. 

Condition  of  Open  Lands , Forests,  and  Fivers. 
The  drainage  of  land,  so  as  to  carry  off  water 
readily  and  thus  to  make  both  ground  and  air 
drier,  has  a great  effect  on  public  health.  Ague, 
so  common  formerly  in  England,  has  greatly 
lessened,  and  dysentery,  which  so  often  went 
with  it,  has  almost  disappeared,  in  consequence 
of  drainage. 

The  movements  of  the  ground-water  which, 
by  its  rises  and  falls,  influences  the  moisture 

1 The  only  Sanitary  Acts  of  previous  sessions  remain- 
ing unrepealed  are  the  Bakehouses  Regulations  Act,  the 
Baths  and  Washhouses  Acts,  the  Labouring  Classes 
Lodging  Houses  Acts,  and  the  Artisans’  and  Labourers’ 
Dwellings  Act,  1SG8. 


PUBLIC  HEALTH. 


1274 

and  the  amount  of  air  in  the  soil,  and,  through 
these  conditions,  alters  the  amount  and  rapidity 
of  decomposition  therein,  has  been  supposed  also 
to  influence  health,  and  to  be  especially  con- 
nected "with  the  development  of  typhoid  fever 
and  of  cholera.  A moist  ground  is  also  believed, 
on  tolerably  strong  evidence,  to  be  favourable  to 
the  production  of  destructive  lung-diseases  ; and 
there  is  no  doubt  that  rheumatism  and  catarrhal 
affections  are  more  common  on  damp  soils. 
Although  the  influence  of  the  ground-water  in 
cholera  is  questionable,  and  it  is  not  always  active 
in  the  production  of  typhoid  fever,  it  is  certain 
that  lowering  the  level  of  the  ground-water 
when  it  is  near  the  surface  is  often  followed  by 
the  best  results  on  the  general  health  of  the 
people,  and  in  hot  countries  malarious  diseases 
have  been  greatly  diminished,  even  when  the 
lowering  of  the  ground-water  has  not  exceeded 
a few  inches. 

Land-drainage  operations,  as  they  influence 
public  health,  might  therefore  be  undertaken 
by  the  State,  but,  practically,  they  have  been 
carried  on  in  this  country  by  private  and  local 
enterprise,  aided  of  late  years  by  state  loans  on 
moderate  terms  of  interest  and  repayment.  In 
India  this  question  of  land  drainage  is  of  press- 
ing importance  in  water-logged  and  malarious 
districts,  and  it  is  one  which  in  that  country 
must  eventually  be  met  by  the  State,  though  its 
magnitude  and  cost  will  probably  cause  the 
question  to  be  deferred  as  long  as  possible. 

The  regulation  of  irrigation  operations  also 
may  become  an  important  matter  of  State  con- 
trol if  sewage  irrigation  farms  increase  in  num- 
ber. These  farms  should  not  be  situated  near  to 
houses  (not  within  five  hundred  yards  if  pos- 
sible), and  the  lands  should  be  properly  prepared 
and  drained  so  that  there  is  no  stagnancy  of  the 
water.  If  properly  arranged  it  seems  clear  that 
sewage  irrigation  is  not  hurtful  to  the  public 
health.  Rice-field  irrigation  is  more  difficult  to 
manago,  as  the  water  must  rest  longer  on  the 
ground,  and  underground  drainage  is  less  rapid. 
Rice  fields,  then,  should  be  situated  at  a greater 
distance  from  houses. 

Up  to  the  present  time  no  law  in  England 
deals  with  the  subject  of  land  drainage  in  refer- 
ence especially  to  public  health,  for  the  Land 
Drainage  Act  of  1861  (24  and  25  Viet.  c.  133) 
refers  only  to  agricultural  purposes. 

The  regulation  of  forests  ought  to  be  con- 
sidered a state  matter,  as  the  climate  of  a 
country  and,  therefore,  health  are  greatly  in- 
fluenced by  them.  The  removal  of  forests  pro- 
duces a variety  of  direct  effects.  Greater 
movement  of  air  over  the  earth  is  permitted : 
the  soil  is  rendered  hotter  in  all  temperate  and 
hot  countries,  colder  in  northern  lands  ; the  air 
is  drier  everywhere,  because  the  rainfall  is 
lessened,  the  ground  is  drier,  and  the  evapo- 
ration from  leaves  is  lessened ; the  ground  is 
drier,  because  there  is  not  only  less  rain  but 
freer  evaporation,  and  the  roots  of  the  trees  no 
longer  obstruct  the  movement  of  the  ground- 
water,  which  flows  off  more  rapidly.  These 
direct  effects  have  a varying  sanitary  signi- 
ficance, according  to  circumstances : for  example, 
increased  movement  of  air  may  be  injurious,  if 
malarious  air  be  no  longer  kept  away  from  a 


town,  as  is  supposed  to  be  the  case  with  the 
Roman  Campagna ; again,  in  hilly  countries 
where  the  trees  have  been  too  much  cleared 
off,  there  occurs  aridity  of  soil  as  a rule,  and 
greater  rapidity  in  the  amount  of  water  passing 
into  rivers  during  rains,  and  thus  leading  to 
floods.  In  this  island  the  regulation  of  forests 
is  not  a matter  of  much  national  importance  ; 
it  is  otherwise  in  Germany  and  France,  where 
laws  exist  which  restrain  private  action ; and  in 
Italy,  Greece,  and  Turkey  the  condition  of  the 
forests  requires  grave  consideration  as  a matter 
of  public  health,  as  well  as  of  climate  and  rain- 
fall. In  India  this  is  also  the  case,  and  there 
are  several  important  sanitary  aspects  under 
which  the  operations  of  the  Forest  Department 
need  to  bo  regarded. 

The  regulations  of  rivers,  such  as  the  embank- 
ments, narrowings,  deepenings,  and  removal  of 
obstructions,  have  generally  been  concerned  with 
little  else  than  navigation  or  the  prevention  oi 
accumulations  ; but  they  are  equally  important 
as  they  may  influence  the  outflow  of  the  land- 
water  from  their  drainage  areas,  and  in  that 
way  may  affect  the  dryness  of  the  soil.  In  this 
regard  the  condition  of  all  watercourses  is  a 
matter  of  importance,  and  seems  obviously  a 
case  for  state  control.  It  is  not,  however,  usually 
included  in  the  subjects  of  public  health,  and 
when  any  large  watercourse  is  out  of  order,  and 
inundations  from  the  river  or  from  the  sea  are 
dreaded,  the  Crown  usually  appoints,  on  the 
application  of  the  proprietors  of  the  adjoining 
lands,  a Commission  of  Sewers,  under  the  above 
Land  Drainage  Act,  to  consider  what  should  be 
done. 

In  another  way  the  regulation  of  rivers  is  of 
importance.  They  supply  the  drinking-water  of 
the  community  to  a large  extent,  and  freedom 
from  contamination  is,  therefore,  necessary.  At 
present  this  is  one  of  the  most  difficult  questions 
of  public  health,  and  for  some  years  a Eoyal 
Commission  was  engaged  in  enquiring  into  the 
causes  and  remedies  of  the  pollution  of  rivers. 
The  chief  causes  of  contamination  are  the  dirty 
water  and  sewage  coming  from  towns,  and  the  re- 
fuse of  trade  operations.  The  former  can  he  best 
met  by  irrigation  or  by  filtration  through  land, 
though  the  immense  quantity  of  water  to  be 
purified,  and  the  price  or  position  of  land,  may 
cause  difficulty.  The  admixture  of  trade  refuse 
water  presents,  however,  the  greatest  difficulty; 
to  prohibit  the  flow  into  streams  would  some- 
times be  to  prohibit  the  trade  works.1  At  pre- 
sent there  is  no  settled  standard  of  purity  for 
either  town  or  trifle  water  before  its  discharge 
into  streams,  and  it  is  probable  that  the  standard 
must  vary  with  the  place  and  trade,  and  most 
depend  on  the  composition  of  the  water  as 
originally  supplied,  and  the  relation  between 
its  amount  and  the  body  of  water  into  which  it 
is  discharged.  Under  the  Public  Health  Act  of 
1S75  (clauses  6S  and  69)  a Sanitary  Authority 
can  protect  any  watercourse  within  its  juris- 
diction from  pollution  with  gas  or  with  sewage, 
hut  not  from  pollution  by  trade  refuse.  On  the 
other  hand,  an  Authority  can  be  indicted  by 

1 A Government  Bill  brought  in  in  the  session  of  IS. 5 
had  to  be  withdrawn  in  consequence  of  the  Urge  interest* 
involved  and  in  opposition  to  it. 


PUBLIC  HEALTH. 


landowners  or  others  for  creating  a nuisance 
or  for  inj  uring  the  quality  of  the  -water  by  dis- 
sharging  sewage  into  a stream.  In  certain 
cases,  as  of  the  rivers  Thames  and  Lea,  special 
Acts  restrain  the  pouring  of  sewage  into  them. 

It  may  be  said  on  the  whole  that  legislation 
with  respect  to  pollution  of  rivers  is  at  present 
hesitating,  but  that  its  general  tendency  is 
gradually  to  make  the  rules  for  preserving  the 
purity  of  river  water  more  and  more  stringent. 

[The  Act  of  1876  forbids  putting  into  a 
stream  or  inland  water — (1)  any  solid  refuse  of 
any  manufactory,  or  any  rubbish  or  cinders ; 

(2)  any  sewage,  unless  the  best  practicable 
means  has  been  taken  to  render  it  harmless ; 

(3)  any  polluting  liquid  from  any  factory,  unless 
it  have  been  similarly  made  harmless.  Proceed- 
ings under  this  Act  can  only  be  taken  with  the 
assent  of  the  Local  Government  Board,  who  are 
to  have  regard  to  the  industrial  interests  in- 
volved.] 

Conditions  of  Habitations. — In  the  case  of  a 
town  of  any  size,  the  community  is  represented 
by  the  municipality  or  by  a Board  of  Health  or 
local  Commissioners.  In  the  case  of  country 
parts  and  villages  that  have  no  such  special  body, 
the  Poor  Law  Guardians  are  cle  facto  the  sani- 
tary authority.  In  the  language  of  the  Public 
Health  Acts  of  1872  and  1875,  the  former  are 

I the  Urban,  and  the  latter  the  Kural  Sanitary 
Authorities. 

Of  conditions  operative  upon  the  health  of 
i the  individual  and  of  the  community,  the  one 
that  fulls  most  conspicuously  within  the  pro- 
vince of  these  public  Sanitary  Authorities,  as 
of  the  Legislature  which  created  them,  is  the 
condition  under  which  people  have  their  dwell- 
ing— the  state  and  circumstances  of  their  habi- 
tation, both  in  the  particular  and  in  the  aggre- 
gate. So  true  is  this,  and  so  strongly  is  this 
consideration  felt  in  practice,  that  it  will  be 
convenient  to  arrange  the  various  subject- 
matters  of  the  present  article  with  the  notion 
of  condition  of  habitation  in  the  foreground ; 
and  to  regard  each  subject  as  it  principally  con- 
cerns communities  inhabiting  a larger  or  smaller 
place,  or  as  it  concerns  the  particular  habi- 
tation. Thus  the  general  subject  of  public 
health  will,  with  little  exception,  be  here  dis- 
j cussed  under  the  three  following  divisions  : — • 

I.  Collections  of  houses  forming  cities  and 
towns,  that  is,  populations  over  two  thousand 
porsons! 

II.  Villages,  that  is,  collections  of  houses,  with 
populations  of,  or  under,  two  thousand  persons. 
TH.  Separate  houses. 

I.  Cities  and  Towns. — The  health  of  the  in- 
habitants of  English  towns,  as  judged  of  by  the 
annual  rate  of  mortality,  is  not  so  good  as  that 
of  the  people  of  rural  districts.  The  mean  an- 
nual mortality  differs  in  different  towns  from  20 
or  21  to  35  and  36  per  1,000'of  population,  while 
during  certain  periods  it  may  be  much  more.  In 
rural  districts  the  mortality  is  from  12  to  23  or 
21  per  1,000.  The  causes  of  the  difference  are 

1 There  is  no  official  definition  of  what  constitutes  a 
lovn  or  village,  but  the  above  is  practically  the  best  that 
xui  be  adopted. 


127c 

various  : in  towns  there  is  greater  crowding, 
more  of  complete  destitution,  a higher  degree 
of  impurity  in  the  air  of  the  houses,  a greater 
prevalence  of  infectious  diseases,  and  greater 
exposure  in  unhealthy  trades.  The  urban  in- 
habitants are  also  on  the  whole  more  intem- 
perate, are  less  vigorous  in  frame,  and  have  less 
active  exercise  in  the  open  air  than  the  rural 
population.  In  towns,  however,  it  is  especially 
the  mortality  of  children  under  five  years  old 
which  swells  the  death-rate,  owing  to  the  bad 
food  and  nurture,  and  the  exposure  to  impure  air 
of  the  children  of  the  poor.  In  all  cities  there 
are  districts,  inhabited  by  wealthy  people,  where 
the  mortality  will  bear  comparison  with  healthy 
country  places.  It  ought  to  be  possible,  there- 
fore, to  raise  the  health  of  the  inhabitants 
generally  towards  the  standard  of  these  favoured 
parts  ; and  the  object  of  the  local  government 
should  be,  by  thought  and  contrivance,  to  over- 
come, as  far  as  may  be,  the  difficulties  that 
poverty  puts  in  the  way  of  health. 

Hygienic  Conditions  of  Cities. — These  are  con 
ditions  referable  to  : — - 

1.  The  site  and  soil. 

2.  The  arrangement  and  building  of  houses. 

3.  The  water-supply. 

4.  The  removal  of  refuse  water  and  of  dry 
refuse. 

5.  The  removal  of  excreta. 

6.  The  conservancy  of  the  surface. 

7.  The  supply  of  food,  including  the  regu- 
lation of  slaughterhouses  and  bakehouses. 

8.  The  regulation  of  trades. 

9.  The  arrest  of  infectious  diseases. 

10.  The  disposal  of  the  dead. 

1 1 . The  supervision  of  nuisances. 

(1)  The  Site  and  Soil. — The  sites  of  old  cities 
were  fixed  by  reason  of  war  or  commerce,  or  of 
vicinity  to  water-supply;  when  modern  cities 
arise  it  is  often  in  consequence  of  new  indus- 
tries being  developed,  coal  and  iron,  or  cotton, 
or  woollen  works,  and  the  site  is  determined  by 
convenience  of  trade.  In  England  new  towns 
and  villages  spring  up  without  regulation,  and 
when  they  attain  a certain  size  and  some  sort 
of  municipal  government  is  formed,  it  is  often 
too  late  to  attend  to  arrangement  and  construc- 
tion of  houses  and  to  proper  preparation  of 
the  ground.  It  were  to  be  desired  that  the 
Legislature  should  obtain  for  towns  during  their 
period  of  growth  and  extension,  adequate  atten- 
tion to  such  matters.  In  the  case  of  old  towns 
Local  Improvement  or  Health  Acts  are  often 
obtained,  by  which  the  errors  of  by-gone  times 
are  slowly  and  laboriously  removed. 

In  respect  of  the  site  it  is  necessary  to  dry 
the  ground  if  it  is  at  all  damp,  and  to  keep  it 
from  being  contaminated  by  refuse  and  perme- 
ation of  coal-gas.  It  is  one  of  the  advantages 
of  sewering  towns  that  the  ground  is  thereby 
drained,  and  many  sewers  are  now  laid  so  as  to 
facilitate  the  movement  of  the  ground  water  as 
well  as  to  serve  as  channels  for  house  waters. 
For  this  reason  alone  every  town  ought  to  have 
either  a system  of  sewers  or  deep  drainage  of 
some  kind.  There  should  be  no  cesspits  or 
middens,  or  manure  heaps,  in  uncemented  holes  ; 
every  refuse  of  this  kind  ought  to  be  removed 
and  never  allowed  to  soak  into  the  ground.  The 


PUBLIC  HEALTH. 


1276 

ground  ought  in  fact  to  be  secured  against  every 
source  of  contamination.  Paving  of  all  streets  and 
courts,  so  as  to  prevent  surface  impurities  from 
soaking  in,  and  great  care  in  the  construction  of 
the  public  sewers,  so  that  they  may  allow  of  no 
outflow,  will  keep  the  soil  of  a city  free  from 
those  impurities  which,  under  the  influence  of 
heat,  water,  and  air,  generate  injurious  effluvia 
that  may  be  sucked  into  houses.  It  is  neces- 
sary also  to  have  rules  about  ‘ made  ground.’  In- 
equalities in  the  surface  of  the  ground  are  often 
levelled  by  filling  in  with  refuse  of  all  kinds; 
house  and  chemical  refuse,  and  dredgings  from 
rivers,  with  other  rubbish,  are  sometimes  used. 
Decomposition  goes  on  in  such  soils,  and  even- 
tually, if  not  too  foul,  they  purify  themselves, 
but  for  this  time  is  required.  In  the  ‘ cinder 
refuse  ’ of  Liverpool,  which  is  tolerably  free 
from  impurities,  at  least  three  years  are  re- 
quired for  the  disappearance  of  the  more  easily 
decomposed  animal  and  vegetable  matters.  In 
other  made  soils  it  may  be  longer,  and  when  soil 
is  very  impure,  as  in  the  case  of  old  graveyards, 
it  is  uncertain  how  long  it  is  before  it  would  be 
safe  to  build  upon  it.  Every  made  soil  should 
be  well  drained,  so  that  air  and  water  may 
freely  pass  through  it,  and  the  best  should  have 
been  laid  down  from  two  to  four  years  before 
being  built  upon. 

The  permeation  of  coal-gas  from  pipes  is  a 
point  to  be  guarded  against,  and  the  ease  of 
preventing  this  would  be  much  increased  by  the 
use  of  subways,  the  objections  against  which 
are  more  theoretical  than  practical. 

With  respect  to  the  means  of  covering  the 
sides  of  city  streets  for  foot  passengers  good 
stone  paving  is  essential;  it  not  only  hinders 
the  evolution  of  effluvia  from  the  ground,  but  it 
greatly  increases  the  ease  of  cleaning  the  surface. 
In  many  Acts  full  powers  are  given  for  this 
ptirpose.  (Public  Health  Act  1875,  clauses  149- 
150,  and  42.) 

The  question  of  the  best  kind  of  road  for 
horse  and  carriage  traffic  is  not  quite  so  easily 
settled;  there  are  four  principal  plans;  maca- 
damizing, granite  blocks,  wood,  and  asphalte. 
As  a mere  matter  of  health  the  two  last  are 
preferable;  there  is  less  debris,  greater  ease  of 
cleaning,  and  less  noise.  Both  macadamizing 
and  granite  block  roads  soon  get  worn  into  fine 
mud,  which  is  made  up  of  finely  comminuted 
stone  mixed  with  droppings  from  horses,  and  the 
like.  In  wet  weather  this  is  washed  into  the 
sewers,  which  it  aids  in  obstructing,  and  it  forms 
a useless  part  of  the  sewage.  In  dry  weather 
it  becomes  pulverised  ; floats  in  the  air  and  is 
one  of  the  ingredients  of  city  air,  from  which  it 
is  deposited  as  dust.  Wood  and  asphalte  break 
up  much  more  slowly  and  are  more  easily  cleaned 
both  by  rain  and  by  washing. 

(2)  The  arrangement  and  building  of  houses. 
The  arrangement  of  houses  and  streets  in  towns 
is  influenced  by  many  circumstances.  A good 
return  for  money,  facility  of  locomotion,  and 
beauty  are  the  chief  considerations  in  new  towns. 
In  old  cities  questions  of  defence  and  of  ma- 
terials have  especially  regulated  the  size  and 
direction  of  t heir  streets,  and  the  height  and  com- 
pression of  their  houses.  Many  considerations  will 


always  influence  the  formation  of  streets,  but  a 
free  passage  of  air  to  all  parts  of  a town  is  a 
cardinal  point,  which  should  receive  the  utmost 
attention.  The  more  numerous  and  the  wider 
the  streets  are,  the  less  impeded  will  be  the 
air-flow ; in  no  case  should  a street  be  less  in 
width  than  one  and  a-half  times  the  height  of 
a house.1 

There  should  be  open  spaces  at  the  back  of 
the  houses,  and  all  back-to-back  building  should 
be  illegal.  The  erection  of  narrow  lanes  and 
alleys  should  be  prohibited  in  all  new  towns,  and 
the  back  courts  so  common  in  our  older  towns 
ought  to  be  gradually  removed.  Additional  open 
spaces  should  be  provided  at  intervals ; and 
streets  should  be  so  arranged  as  not  to  form 
stagnant  wells  of  air  between  the  houses.  Wide 
straight  streets  are  useful  for  ventilation,  and 
are  best  for  the  laying  of  pipes  and  tramways. 
Straight  lines  are  by  some  not  considered  beau- 
tiful, but  they  are  certainly  most  convenient. 

In  all  these  points  the  law  gave  some  power 
both  in  the  Public  Health  Act  of  1848  and  in 
some  later  Acts,  which  granted  permissive  powers 
to  sanitary  authorities  to  purchase  dwellings  in 
order  to  improve  streets,  to  set  back  houses  when 
rebuilt,  &c.  These  powers  are  continued  in  the 
Public  Health  Act  of  1875,  clauses  149-160. 
As  regards  existing  towns  power  is  given  to 
urban  authorities  to  make  bye-laws  regulating 
the  width  of  new  streets,  provision  for  sewer- 
age, foundation  of  houses,  spaces  for  air  about 
houses,  the  drainage  of  buildings,  and  other 
points.  So  also  a new  provision  in  this  Act 
orders  that  when  only  the  front  of  a house  in  a 
street  is  taken  down  the  urban  authority  may 
prescribe  the  line  of  the  new  building.  Local 
Improvement  Acts  have  also  been  obtained  by 
some  cities,  giving  larger  powers  of  demolition 
and  reconstruction,  and  the  Artisans'  Dwellings 
Act  of  1875  strengthens  these.  As  much,  however, 
is  left  to  local  authorities  in  these  matters,  there 
will  probably  be  no  uniformity  of  action,  and  it 
seems  important  to  make  very  stringent  general 
rules  on  all  these  points.  Moreover,  as  already 
said,  due  provision  should  be  made  beforehand 
for  the  proper  construction  of  the  many  new 
towns  which  must  needs  spring  up  in  the  course 
of  another  century.  The  case  seems  clear  for 
the  community'  at  large  to  regulate  matters  so 
important  for  the  general  health,  to  a greater 
degree  than  has  been  yet  done  in  any  Act.2 

It  is  not  possible  to  state  with  any  precision 
the  number  of  persons  who  may  be  located  on  an 
acre.  This  will  depend  in  the  main  on  the  con- 
struction of  the  individual  houses  : but  it  may  he 
laid  down  as  a general  rule  that  whatever  be  the 
size  of  the  houses,  the  amount  of  ground  not  occu- 
pied by  them  in  any  given  area  should  be  con- 

1 In  some  local  Acts  the  width  cf  a street  is  fixed  at 
the  height  of  a house,  but  this  is  tco  small. 

5 As  an  instance  of  the  necessity  of  this  state  inter- 
ference, the  case  of  Liverpool  may  be  cited.  More  than  70 
years  ago  the  Corporation  was  warned  by  the  medical 
practitioners  of  Liverpool,  that  the  houses  then  being 
erected,  and  their  arrangement,  must  prove  unhealthy 
dwellings.  No  regard  was  paid  to  this,  and  now  Liver- 
pool will  have  to  undo,  at  enormous  cost,  what  might  at 
the  time  have  been  put  a stop  to  with  ease.  A PaP?2  f/ 
Dr.  Bussell,  of  Glasgow,  in  Public  Health,  March  le  <5, 
exemplifies  the  same  thing  in  a most  striding  manner,  b» 
the  case  of  Glasgow. 


PUBLIC  HEALTH. 


jiderably  in  excess  of  the  amount  actually  taken 
np  by  houses. 

An  important  point  to  determine  is  the  height 
of  the  houses.  In  England  a large  proportion 
of  our  towns  consists  of  low  brick  houses;  if 
these  are  not  too  crowded  they  give  a good  dis- 
tribution of  the  inhabitants  and  oppose  little 
obstacle  to  the  movement  of  air.  When  the 
houses  are  very  lofty  the  air-currents  must  be 
much  more  impeded,  and  therefore  the  streets 
ought  to  be  much  wider,  and  open  spaces  here 
and.  there  more  carefully  provided.  The  con- 
struction of  the  separate  houses  cannot  be 
altogether  a matter  of  municipal  control,  but 
certain  rules  as  to  ground  plan,  foundations,  and 
arrangement  of  closets,  and  the  thickness  of 
party  walls,  are  in  most  towns  enforced  in  respect 
of  new  houses. 

So  in  all  houses,  whether  urban  or  rural,  there 
should  be  means  of  ventilation  for  every  room  ; 
no  inhabited  room  should  have  a borrowed  light, 
but  should  have  a window  opening  directly  on 
the  external  air ; every  window  should  open,  and 
especially  at  the  top ; every  room  should  be 
of  good  height,  not  less  than  nine  feet  in  the 
smallest,  and  ten  and  eleven  feet  in  larger 
rooms  ; the  closets  ought  to  be  arranged  in  such 
a manner  that,  in  addition  to  ventilation  of  the 
closet  itself,  there  should  be  thorough  cross  ven- 
tilation into  the  open  air  between  the  closet  and 
the  rest  of  the  house,  and  this  is  best  accom- 
plished by  having  projecting  portions  of  the 
building  to  contain  the  closets ; every  house 
should  be  properly  provided  with  closets  in  pro- 
portion to  its  population  ; there  should  be  proper 
water-supply,  with  easily  inspected  storage,  if 
house-storage  is  permitted,  and  easy  methods  of 
carrying  off  the  dirty  house-water ; there  should 
be  proper  arrangements  for  the  collection  and 
temporary  storage  of  dry  house  refuse ; and 
house  drains  and  pipes  should  be  constructed 
and  ventilated  on  tho  principles  that  will  pre- 
sently be  set  forth. 

All  these  matters  are  easy  to  regulate  without 
interfering  too  much  with  the  plans  of  the  archi- 
tect, and  have,  in  fact,  been  more  or  less  dealt 
with  in  several  Acts.  In  places  with  urban 
powers,  indeed,  bye-laws  under  the  Public 
Health  Act  can  be  made  to  regulate  the  majo- 
rity of  such  points. 

(3)  The  Water-supply.  In  a town  with  sewers 
and  water-closets  it  is  generally  considered  that 
the  supply  of  water  per  head  daily  should  not 
be  less  than  25  gallons  ; and  if  there  are  trades 
using  large  quantiti  es  of  water,  from  five  to  ten 
gallons  additional  (reckoned  per  head  of  popula- 
tion) are  wanted  for  the  town.  If  there  are  no 
water-closets,  from  14-  to  20  gallons  per  head 
daily  appears  to  be  the  amount  usually  consi- 
dered sufficient  in  large  English  towns. 

Many  Acts,  public  and  local,  regulate  water- 
supply.  The  sanitary  Authorities  of  any  place 
have  had  large  permissive  powers  (under  previous 
Acts,  and  now  under  the  Public  Health  Act  of 
1875,  clauses  51-07)  as  to  constructing,  or  buying 
and  maintaining  waterworks,  and  building  and 
eleansiDg  public  cisterns,  fountains,  &c.,  and 
powers  are  given  also  to  protect  watercourses 
or  watersheds  whence  the  supply  is  derived.  The 


1277 

Public  Health  Act  of  1875  has  also  increased, 
in  some  ways,  the  powers  of  the  local  authority, 
and  in  certain  cases  the  powers  of  the  Public 
Health  (Water)  Act  of  1878  can  be  exercised 
in  towns.  In  local  Acts  powers  are  also  given 
to  ensure  proper  fittings  in  houses,  to  carry  out 
constant  service,  and  other  points  of  the  kind. 

The  following  are  the  matters  of  chief  im- 
portance in  towns  : — (a)  The  supply  should  be 
taken  from  sources  capable  of  affording  a quantity 
adequate  to  the  present  and  proximate  wants  of 
the  town,  with  such  approach  to  constancy  as 
may  be  attainable.  In  quality,1  the  great  points 
are  to  ensure  that  the  water  is  clear  or  is  easily 
and  completely  freed  from  sediment  by  sand- 
filtration,  and  is  well  aerated,  pleasant  to  taste, 
and  without  smell ; that  it  contains  no  inju- 
rious animal  constituents,  and  cannot  become 
contaminated  with  excreta  of  men  or  animals,  or 
with  foul  water  from  houses ; that  it  contains  no 
injurious  amount  of  vegetable  matter  (not  more 
than  2 or  3 grains  per  gallon)  and  that  its  mineral 
constituents  are  of  moderate  amount,  not  exceed- 
ing 60  grains  per  gallon  as  a maximum,  and  con- 
sisting of  such  mineral  matters  as  are  not  likely 
to  be  injurious.  With  respect  to  lime  especially, 
much  discussion  has  taken  place  as  to  whether 
soft  or  hard  water  (from  calcium  carbonate)  is 
best  for  a town  ; the  soft  water  is  preferred  for 
many  trades  and  is  probably  best  for  health, 
though  it  has  been  found  impossible  to  prove 
this  by  statistics ; it  is  certain  that  the  in- 
habitants of  numerous  towns  using  a good 
chalk  water  have  excellent  health,  and  it  would 
seem  in  fact  that  the  question  between  water 
hard  from  calcium  carbonate  and  soft  water  is 
not  an  important  one.  When  water  is  hard  from 
calcium  chloride  and  sulphate  it  seems  more  in- 
jurious to  health.  The  great  point  in  choosing 
water  is,  in  practice,  its  freedom  from  any 
chance  of  contamination  with  excreta,  or  with 
refuse  matter  from  habitations. 

The  sources  of  supply  are  natural  lakes,  arti- 
ficial lakes  and  gathering  grounds,  rivers,  springs, 
and  wells. 

In  towns  of  any  size  superficial  and  shallow 
wells  are  always  suspicious  sources,  as  it  is  im- 
possible to  secure  them  from  foul  overflows  and 
soakages.  Clause  70  of  tho  Public  Health  Act 
1875  gives  power  to  close  wells,  tanks,  cisterns, 
or  pumps  if  the  water  bo  polluted. 

The  duties  of  a medical  officer  of  health  should 
include  the  supervision  of  the  sources  of  supply, 
so  as  to  detect  and  prevent  any  possible  con- 
tamination. 

(5)  The  water  when  supplied,  except  in  the 
case  of  deep  well  waters,  most  commonly  needs 
to  be  stored  and  filtered.  The  reservoirs  of  our 
towns  contain  from  one  to  three  months’ supply,  or 
less  if  the  supply  is  very  constant.  The  reservoirs 
require  to  be  well  placed ; to  be  clear  of  trees, 
and  protected  from  danger  of  anything  being 
thrown  .into  them.  The  filters  are  usually  made 
of  sand  about  3 feet  in  depth,  and  the  water  is 
passed  through  at  the  rate  of  from  ^ to  1 gallon 

1 Section  55  of  the  Public  Health  Act,  1S75,  imposes  on 
the  Local  Sanitary  Authority  the  obligation  of  keeping 
the  supply  of  water  pure  and  wholesome  in  the  case  ot 
waterworks  which  have  been  purchased  or  constructed 
by  them. 


1278  PUBLIC 

to  every  sqaare  inch  of  surface  in  21  hours.  The 
upper  sand  of  the  filters  requires  frequent  clean- 
ing, and  should  be  regularly  inspected.  This 
plan  acts  well,  but  constant  supervision  is  neces- 
sary. 

( c ) After  filtration  the  water  is  distributed  by 
means  of  pipes,  usually  by  iron  pipes,  tarred  or 
concreted  inside,  for  the  larger  conduits,  and  then 
by  lead  pipes,  or  what  is  better,  tinned-lead  pipes 
for  the  smaller.  Both  iron  and  lead,  and  espe- 
cially the  latter,  are  dissolved  by  some  waters, 
and  the  question  whether  lead  is  so  dissolved  has 
often  to  be  answered;  in  examining  into  this 
matter  the  water  should  be  taken  after  it  has 
been  in  contact  with  the  pipes  for  some  hours. 
Carried  down  by  these  pipes  the  water  is  either 
delivered  at  intervals  to  house  cisterns,  or,  what 
is  far  better,  is  supplied  on  the  constant  plan 
without  house-storage.  If  it  be  not  possible 
to  dispense  with  house-cisterns,  they  should  be 
well  made  of  slate  or  concrete,  should  be  able 
to  be  easily  inspected  and  cleaned,  and  their 
overflow  pipes  should  always  end  in  the  open 
air,  never  go  into  any  sewer.  The  greatest 
care  should  be  taken  that  the  cistern  water 
shall  run  no  risk  of  contamination  by  absorp- 
tion of  foul  air  or  by  soakage  into  the  cistern, 
which  should  be  well  covered  to  prevent  dust 
getting  in. 

If  the  constant  system  is  in  force  it  should  be 
truly  constant,  for  if  the  water  is  cut  off  at 
intervals,  and  the  house-pipes  are  then  emptied, 
air  must  be  drawn  into  them  and  this  air  may 
be  foul ; it  has  even  happened  that  dirty  liquids 
have  been  sucked  into  water  pipes,  as  where 
a closet  service-pipe  has  dipped  into  a choked 
closet-pan,  and  in  this  way  excreta  have  not  only 
passed  into  these  house-pipes  but  have  even 
got  into  the  mains.  Under  a constant  system 
and  tmder  an  intermitting  system  alike,  small 
service-cisterns  are  needed  for  water-closets  and 
for  kitchen-boilers,  and  precautions  have  to  be 
taken  with  these  cisterns  equally  with  larger 
storage-cisterns.  In  fact  too  great  care  cannot 
be  taken  in  thoroughly  guarding  water-pipes 
and  cisterns  in  every  way.  The  dangers  con- 
nected both  with  the  intermittent  and  constant 
systems  have  only  been  fully  recognised  during 
the  last  few  years. 

The  sources  of  contamination  of  drinking  water 
are  very  numerous,  and  may  affect  the  water  at 
its  source,  in  its  flow,  in  the  reservoir,  or  during 
distribution.  If  stored  in  houses  it  is  especially 
exposed  to  risk  ; and  this  is  the  grand  argument 
for  constant  service,  that  the  water  may  be  de- 
livered immediately  after  filtration.  The  plan  of 
cistern-storage,  indeed,  lessens  those  risks  that 
are  incidental  to  intermissions ; but  this  plan  de- 
mands that  cisterns  be  properly  made  and  placed, 
and  be  regularly  cleaned.  For  low-rented  houses 
these  conditions  are  very  difficult  of  attainment, 
and  therefore  the  constant  service  is  peculiarly' 
adapted  to  the  houses  of  the  poor.  Siphon- 
filters  of  animal  charcoal  placed  in  cisterns,  filter 
the  water  immediately  before  use,  and  are  much 
to  be  recommended. 

In  all  towns  the  service  should  be  at  high 
pressure,  so  that  water  may  be  carried  to  every 
flror  and  thus  labour  be  spared,  and  the  fresh- 
Qtsn  of  the  water  be  secured.  In  towns  where 


HEALTH. 

the  water  is  not  carried  into  the  houses,  but  is 
fetched  from  ‘hydrants’  or  stand  pipes  in  the 
street,  it  has  to  be  stored  in  the  houses  in  buckets 
and  runs  many  chances  of  impurity. 

A town  requires  water  for  public  purposes, 
such  as  for  public  baths,  washhouses,  flooding 
and  washing  streets,  flushing  sewers,  and  putting 
out  fires.  Statutory  powers  are  given  for  carry- 
ing out  these  objects. 

(4)  The  disposal  of  dirty  house-water  and  dry 
refuse. — After  being  distributed  and  used  in 
houses  or  trades,  the  water  with  the  impurities 
,’t  has  gathered  must  be  carried  out  of  the  town. 
The  inhabitants  should  have  no  difficulty  in 
getting  rid  of  their  dirty  water,  or  the  same 
water  will  come  to  be  used  several  times  for 
cooking  and  for  washing.  Houses  ought  to  have 
convenient  sinks  discharging  by  trapped  pipes 
opening  outside  the  house,  not  into  a drain,  but 
over  a drain-grating.  From  hence  it  must  go 
along  pipes  or  sewers,  and  be  disposed  of  at 
the  outfall  in  some  way.  House-water,  besides 
other  impurities,  invariably  contains  some  por- 
tion of  urine.  It  is  not  fit  to  be  at  once  dis- 
charged into  streams,  but  as  its  fertilising 
powers  are  small  it  is  not  well  adapted  for  irri 
gation  or  precipitation.  The  best  plan  appears 
to  be  to  filter  it  by  intermittent  filtration  on  a 
small  area  of  properly  prepared  and  drained 
ground,  and  then  to  carry  it  into  the  nearest 
stream. 

The  dry  refuse  of  houses  consists  of  cinders 
and  ashes,  remains  of  food, dust  from  sweepings, 
and  various  other  used-up  articles  of  house  life. 
In  some  towns  there  is  little  difficulty  in  disposing 
of  this  refuse.  After  being  carted  away  it  is 
sorted,  and  every  article  finds  a sale.  In  other 
towns,  however,  the  disposal  of  the  house-refuse 
is  a matter  of  difficulty  and  expense.  In  some 
places  the  dry  refuse  is  placed  every'  day  by  the 
inhabitants  in  front  of  the  houses  and  is  removed 
by  scavengers.  In  other  cases  there  is  storage 
of  refuse  on  the  premises  ; if  this  is  done  every 
house  should  have  a properly  prepared  dust- 
bin, well-paved  to  prevent  soakage,  well-covered 
so  as  to  be  kept  dry,  and  so  placed  as  to  be 
convenient  for  the  house  as  well  as  for  the 
town-scavengers.  In  the  building  of  any  house 
the  arrangements  for  the  position  of  the  dusUbin 
are  almost  as  important  as  those  for  the  closets. 
The  removal  ought  to  be  frequent  and  regular, 
but  the  frequency  has  to  be  fixed  by  special 
circumstances. 

(o)  The  removal  of  excreta. — The  excreta  of 
the  skin  and  lungs  are  got  rid  of  by  ventilation 
and  washing,  so  that  this  heading  refers  only  to 
the  solid  and  liquid  excreta.  These  average  re- 
spectively (for  both  sexes  and  all  ages)  about  2) 
ounces  avoirdupois  of  solid  excrement  and  40 
fluid  ounces  of  urine  per  diem. 

The  excreta  ought  not  to  soak  into  the  earth, 
or  to  remain  near  dwellings.  The  common 
privy  and  the  * midden  ’ of  northern  towns  can- 
not be  brought  to  fulfil  these  conditions.  Id 
towns  above  10,000  inhabitants  it  now  seems 
clear  that  there  is  no  possibility  of  using  the 
earth  or  any  deodorising  plan,  on  account  of  the 
expense  of  transport.  Therefore,  for  towns  tw: 


PUBLIC  HEALTH. 


01  perhaps  three  plans  only  remain  : 1.  The  dry 
plan  -with  frequent  removal,  with  perhaps  such 
dcodorisation  as  the  ashes  of  the  house  may  give 
—this  is  the  so-called  ‘ pail  system’  in  some  one 
of  its  forms.  2.  The  water  system,  the  excreta 
leing  carried  off  from  the  house  along  drains 
and  sewers,  by  the  aid  of  water.  3.  The  air  or 
pneumatic  system  of  Captain  Liernur,  in  which 
the  excreta,  unmixed  with  water,  are  sucked 
through  pipes  into  a central  reservoir  by  an  air- 
pump,  worked  by  a steam-engine.  This  plan  of 
removal  is  as  yet  unfamiliar.  It  is  now  being 
fully  tried  on  the  Continent,  and  in  after  years 
there  will  be  reliable  data  as  to  cost  for  original 
plant  and  for  maintenance,  as  to  certainty  and 
efficiency  of  working,  and  as  to  returns  from 
sale,  all  of  which  are  now  matters  of  doubt. 

It  would  not  be  possible  to  discuss  here  the 
relative  value  and  the  technical  details  of  the 
pail  and  the  water  systems.  Both  are  largely  used 
in  England.  The  former  is  used  in  towns  where 
the  barbarous  cesspit  and  midden  plans  are 
abolished,  and  yet  where  proper  sewers  cannot 
be  made,  or  water  is  deficient,  or  land  cannot  be 
obtained  for  irrigation  or  filtration;  it  has  the 
disadvantage  of  keeping  the  excreta  for  some 
days  near  the  house,  and  is  sometimes  attended 
with  nuisances  in  the  working,  but,  on  the 
whole,  it  is  capable  of  keeping  a town  clean 
when  it  is  properly  carried  out,  and  it  is  an 
immense  advance  over  the  old  midden  sj'stem, 
which  retained  the  excreta  for  long  periods  in 
the  very  midst  of  tho  people.  It  is,  however, 
j essential  that  the  removal  of  the  excreta  should 
be  frequent,  that  is,  once  a week  or  so — twice  a 
week  if  practicable.  After  removal  the  excreta 
are  applied  at  once  to  the  land,  or  are  made  into 
poudrette.  In  some  towns  the  house-ashes  are 
thrown  on  a wire  screen,  so  as  to  allow  the 
fine  ash  to  fall  on  the  excreta — this  is  sometimes 
called  the  ‘ash  plan  in  other  cases  deodorants 
are  used.  The  ‘ Goux  system  ’ is  to  place  some 
absorbent  material  round  the  interior  of  the  pail 
to  absorb  the  urine. 

The  water  system  is  more  complicated,  and 
probably  more  expensive,  but  if  properly  carried 
out  is  more  effectual.  If  a town  can  make  good 
sewers,  and  has  water  for  flushing  and  land 
through  which  the  sewer  water  can  be  passed  by 
filtration  or  irrigation  or  both,  the  water  sys- 
tem is  the  best  for  health. 

It  is  essential,  however,  that  sew'ers  should  be 
well  constructed,  and  should  allow  no  deposit, 
and  that  they  should  be  thoroughly  ventilated. 
Deposits  are  prevented  by  having  egg-shaped 
sewers  with  a proper  fall,  easy  means  of  access 
for  inspection  and  cleaning,  and  a regular  flow 
,of  water  with  periodical  flushing.  The  venti- 
lation of  sewers,  which  is  now  enforced  by  law 
[clause  19,  Public  Health  Act,  1875),  is  best  ef- 
fected by  having  numerous  openings — as  many, 
n fact,  as  can  be  made — so  as  to  allow  constant 
ind  free  interchange  between  the  sewer  air 
ind  the  atmosphere.  These  openings  may  be  by 
itreet-gratings  or  by  special  shafts,  according  to 
lireumstances.  Ventilation  through  furnace  chim- 
leys  can  be  sometimes  done,  but  is  of  no  avail 
• or  distant  portions  of  the  sewers.  The  open- 
ngs  may,  at  certain  points  where  the  shafts 
>r  gratings  are  near  he  uses,  have  to  be  guarded 


1279 

by  trays  of  charcoal,  through  which  tho  sewer 
air  passes.  But  in  whatever  way  it  is  done,  the 
rule  must  be  to  have  the  freest  communication 
between  the  sewer  air  and  tho  general  atmo- 
sphere. This  free  ventilation  occasions  no  offence 
if  the  sewers  are  properly  made  and  kept ; while, 
if  the  air  of  sewers  at  the  ventilators  is  found 
offensive,  the  ventilation  will  at  least  have  pro- 
vided against  the  more  dangerous  discharge  of 
the  foul  air  into  houses.  As  a further  provision 
against  possible  reflux  or  suction  of  the  air  of 
the  public  sewers  into  houses  the  following  ar- 
rangement should  be  rendered  imperative  by 
law.  At  some  point  in  the  course  of  every  house- 
drain,  before  it  reaches  the  main  sewer,  there 
should  be  complete  disconnection  by  means  of  (a) 
a ‘ siphon-trap,’  through  which  all  the  liquids  of 
the  house  must  pass,  and  which,  therefore,  must 
always  be  charged  with  water  while  the  house 
is  inhabited  ; and  of  (6)  an  opening  from  the 
house-drain  to  the  outside  air,  made  on  the  house 
side  of  the  siphon- trap,  to  provide  for  the  escape 
of  any  sewer-air  that  may  force  the  trap,  as  well 
as  for  the  ventilation  of  the  house-drain  proper. 
If  this  were  done  the  spreading  of  disease  by 
town  sewers  would  be  impossible,  and  the  greatest 
objection  to  them  would  be  removed.  The  com- 
munity constructs  the  main  sewers,  but  it  would 
seem  just  that  the  owners  of  house  property,  who 
provide  the  house-drains  and  are  obliged  by  law 
to  connect  them  with  the  public  sewer,  should  be 
compelled  to  put  down  one  of  the  open-air  traDS, 
which  renders  reflux  impossible  into  their  houses. 

Sewers  have  been  objected  to  on  account  of 
the  occasional  spread  of  typhoid  fever  and  diar- 
rhceal  affections,  and  perhaps  of  cholera  and 
diphtheria  by  their  agency;  but,  if  properly 
arranged,  and  with  disconnection  between  the 
sewer  and  houses,  there  would  be  no  danger ; and 
it  is  difficult  in  any  case  to  seo  how  sewers  can 
be  displaced  or  be  substituted  by  any  other  plan. 
The  house- water  must  be  carried  off,  and  it  is 
impure  even  if  no  excreta  are  allowed  to  flow 
in.  Even  if  the  pail  or  pneumatic  plan  be 
adopted,  there  must  still  be  town  sewers  for 
dirty  house-water,  and  all  the  precautions  above 
alluded  to  must  be  enforced.  Sewers,  then, 
whether  or  not  they  receive  the  excreta  of  a 
town,  are  a necessity,  and  with  proper  construc- 
tion and  management,  they  certainly  ought  to 
be  solely  beneficial  to  the  public  health.  It  is 
certain  that  when  a town  is  well  sewered  the 
prevalence  of  enteric  fever  is  lessened  even  to 
the  point  of  extinction,  and  diarrhoeal  affections 
have  appeared  to  be  more  uncommon.  Drying 
of  the  soil  by  sewers  also  lessens  phthisis.  It  is 
a question  of  engineering  detail  whether  the 
sewers  carrying  the  house-water  should  also 
carry  off  the  rain  water.  In  some  cases  the 
1 separate  system  ’ (that  is,  having  different  chan- 
nels for  house  and  rain  water)  appears  clearly  the 
best.  The  sewer  water  is  less  in  amount,  more 
regular  in  flow  from  day  to  day,  and  richer  in 
fertilizing  properties. 

With  regard  to  the  disposal  of  the  sewer  water, 
three  plans  can  be  followed  in  the  case  of  towns 
which  cannot  discharge  at  once  into  the  sea  or 
(without  disobeying  the  Bivers  Pollution  Preven- 
tion Act  of  1876)  intoalarge  river : first,  precipi- 
tation at  the  outfall  with  a chemical  agent  such  a! 


1230  PUBLIC 

lime,  aluminous  compounds,  phosphate  of  lime  and 
alumina,  clay,  &e.  A great  number  of  chemical 
agents  hare  been  proposed,  and  several  clarify  the 
water  fairly,  but  none  yield  a deposit  which  pays 
the  expenses  either  as  manure  or  when  burnt 
into  cement.  Precipitation  must,  however,  be 
had  recourse  to  when  land  cannot  be  obtained. 
Second,  irrigation,  one  acre  being  sufficient  for 
the  excreta  of  about  one  hundred  persons.  Third, 
intermittent  filtration,  where  one  acre  is  sufficient 
for  from  2,000  to  3,000  persons;  the  land  re- 
ceives water  six  hours  out  of  the  twenty-four,  and 
is  deeply  drained.  In  neither  extended  irriga- 
tion nor  in  filtration  on  a limited  area  is  there 
any  adequate  profit,  but  still  there  appears  to  be 
some,  and  the  purification  is  more  complete  than 
by  precipitation.  In  some  cases  after  filtration 
the  water  is  passed  over  farm  land,  and  this 
double  purification  appears  to  be  very  satisfac- 
tory. 

It  appears  certain  that  neither  irrigation 
sewage  farms  nor  filter-beds  are  hurtful  to  the 
public  health  when  properly  managed. 

(C)  Tie  conservancy  of  the  surface  area.  — Tho 
cleansing  of  the  surface  area  of  towns  is  secured 
partly  by  powers  originally  given  in  a variety  of 
Sanitary  Acts,  general  and  local,  and  continued 
with  additions  in  the  Public  Health  Act  of 
1875,  clauses  42-50.  These  powers  are  large 
and  on  the  whole  sufficient.  The  sanitary  im- 
portance of  thorough  surface-cleansing  is  ob- 
vious; the  mud  and  dirt  of  towns  and  refuse  of 
all  kinds,  wetted  by  rain  and  exposed  to  heat, 
soon  decompose  and  give  out.  injurious  effluvia, 
especially  in  narrow  courts  and  lanes  where  the 
movement  of  air  is  impeded.  The  excellent 
effect  on  health  of  paving  a town  has  been  often 
observed.  Public  streets  of  all  kinds  can  be 
easily  kept  clean,  but  want  of  paving  and  conse- 
quent foulness  on  private  premises  require  to  be 
Bought  out.  Under  the  above  and  other  clauses 
in  the  Act  the  supervision  of  pigsties  and  stables 
is  carried  out  and,  generally,  conditions  which 
can  give  rise  to  nuisances  injurious  to  health 
can  be  legally  dealt  with. 

(7)  The  Supply  of  Food , including  the  Regula- 
tion of  Slaughter-,  Cow-,  and  Bake-houses. — Avery 
important  duty  of  a municipality  is  to  supervise 
the  food  of  the  people.  While  the  price  and 
quality  must  be  left  to  the  ordinary  operations 
of  commerce,  the  responsibility  of  preventing 
falsifications,  and  of  ensuring  that  the  article 
shall  not  be  injurious  to  health,  must  rest  on 
the  sanitary  authority.  The  regulation  of 
slaughter-houses  and  kn  ackers-yards,  directed 
by  former  Acts,  is  authorised  afresh  by  the  Pub- 
lic Health  Act  of  1875,  clauses  166  to  170. 
Private  slaughtcr-hotises  are  licensed,  and  can  be 
visited  and  subjected  to  bye-laws.  They  are 
often  constructed  out  of  buildings  intended  for 
other  purposes,  are  not  fitted  with  proper  appli- 
ances, and  are  generally  placed  in  the  densest 
part  of  the  town.  The  evils  attending  them  are 
gradually  being  removed  by  the  efection  of  pub- 
lic slaughter-house's,  where  abundant  air,  water, 
good  sewers  and  means  of  cleansing  are  provided. 
The  custom  of  slaughtering  in  the  country  and 
then  sending  the  meat  to  cities  is  increasing,  and 


HEALTH. 

this  again  renders  private  slaughter-houses  lea 
necessary. 

The  transport  of  cattle  and  sheep  to  towns  is  a 
matter  of  very  great  importance  as  respects  both 
the  goodness  of  the  meat  and  the  comfort  of  the 
animals.  It  is  a matter  which  should  be  dealt 
with  in  the  Public  Health  Act,  and  should  be 
under  control  to  a certain  noint.  Space  in  the 
trucks,  supply  of  water  and  food,  length  of  jour- 
neys, and  other  matters,  require  regulation. 

Cowhouses  are  usually  inspected  by  sanitary 
authorities,  in  pursuance  of  the  powers  of  the 
Public  Health  Act,  §§  91-92,  or  of  private  Acts. 
In  the  metropolis  they  have  to  be  licensed  by 
magistrates.  A certain  cubic  space  is  usually 
allowed  to  each  cow  (1,000  cubic  feet  should  be 
the  minimum),  and  cleanliness  is  enforced.  The 
condition  of  small  cowhouses  and  dairies,  and  of 
the  water-supply  and  drains  attached  to  them, 
requires  more  attention  than  it  has  received,  as 
both  enteric  and  scarlet  fever  are  now  known  to 
have  been  spread  by  the  agency  of  milk. 

[To  these  diseases  must  now  be  added  diph- 
theria; and  the  suggestion  that  diseases  of  the 
animals  themselves,  as  well  as  impurities  re- 
ceived from  water  or  air  into  their  milk,  are 
concerned  in  the  production  of  milk-epidemics 
among  human  communities,  will  henceforth  al- 
ways have  to  be  kept  in  view. 

The  foregoing  requirement  has  been  in  a 
measure  fulfilled  by  the  Contagious  Diseases 
(Animals)  Act  of  1878, which  requires  cowhouses 
to  be  licensed,  and  their  sanitary  condition  at- 
tended to ; and  requires  precautions  to  be  taken 
in  dairies  and  milkshops  against  the  contamina- 
tion or  infection  of  milk.  An  Order  of  Council 
has  been  made  respecting  these  various  matters. 
It  is  observable  that  sanitary  authorities  are  not 
charged  with  the  duty  of  inspection  under  this 
Act,  except  in  the  ease  of  corporate  towns  ] 

Bakehouses  are  regulated  under  a special  Act 
(26  and  27  Viet.,  c.  40)  which  was  passed  after 
long  enquiry  into  the  condition  of  the  trado.  By 
this  Act  the  bakehouse  is  ordered  to  be  kept  in 
a cleanly  condition,  to  be  properly  ventilated, 
protected  from  effluvia,  and  not  to  be  used  as  a 
sleeping-place.  The  condition  of  the  bakehouses 
disclosed  by  the  enquiry  referred  to,  was  in  the 
highest  degree  disgraceful  and  repugnant. 

The  inspection  of  the  chief  articles  of  food 
takes  place  under  the  Public  Health  Act  of  1875, 
clauses  116  to  119,  in  respect  of  meat,  game, 
poultry,  fish,  fruit,  vegetables,  corn,  bread,  flour, 
and  milk,  and  under  the  Adulteration  and 
Licensing  Acts  in  respect  to  other  articles  of 
food. 

The  following  are  the  chief  sanitary  points  in 
each  case : — 

1.  Meat. — Much  doubt  exists  as  to  the  extent 
to  which  the  condemnation  of  meat  exposed  to 
sale  should  be  carried.  There  is  no  doubt  that 
meat  sufficiently  decomposed  to  be  discoloured 
and  to  have  a putrid  smell,  and  meat  with  ab- 
scesses and  suppurations,  should  be  condemned, 
but  the  difficulty  arises  with  meat  apparently 
sound  or  not  very  obviously  otherwise,  but  which 
is  derived  from  diseased  animals. 

Though  opinions  differ  on  this  point,  it  _ may 
perhaps  be  said  that  meat  derived  from  animals 
dead  of  inflammatory  diseases  and  of  epidemic 


PUBLIC 

pleuro-pneumonia  may  be  used,  but  that  beef 
from  cattle  dead  of  cattle-plague  and  anthrax 
(malignant  pustule),  mutton  from  sheep  with 
small-pox  and  splenic  apoplexy,  and  pork  from 
pigs  with  earbuncular  diseases,  hog-cholera,  hog- 
typhus,  and  scarlet-fever,  should  not  be  used, 
although  it  is  not  easy  to  give  conclusive  evi- 
dence as  to  bad  effect  in  some  of  these  cases. 
Cattle-plague  meat,  for  example,  has  been  largely 
used  without  injury.  Opinions  are  much  divided 
as  to  whether  the  flesh  of  braxy  sheep,  or  of 
cattle  dead  of  fooLand-mouth  disease,  should  be 
used  or  not,  but  at  present  the  evidence  is  rather 
against  the  view  that  such  flesh  is  injurious. 

In  the  case  of  the  parasitic  diseases  of  animals 
the  question  is  easier.  It  is  of  course  highly 
dangerous  to  use  pork  with  trichina.  [Some 
recent  experiences  are  pointing  to  trichinosis  as  a 
more  common  disease  than  had  been  suspected.] 
Cysticerci  in  pork,  beef,  and  mutton  should  also, 
in  the  writer’s  opinion,  he  a valid  ground  for  not 
permitting  the  sale,  though  this  view  is  not  univer- 
sally or  perhaps  generally  held,  since  as  cysticerci 
are  killed  by  a temperature  of  160°  Fahr.,  it  is 
considered  that  good  cooking  removes  all  danger, 
and  therefore  that  condemning  meat  for  this  cause 
is  an  improper  restriction  on  supply.  On  the 
other  hand,  as  it  is  impossible  to  secure  that  a 
sufficient  temperature  shall  be  applied,  how  can 
. it  be  possible  to  prevent  the  development  of  tape- 
worm if  the  sale  is  permitted  ? The  prohibition 
would  probably  not  long  affect  supply,  as  the 
breeders  and  salesmen  would  take  greater  care 
iu  preserving  the  cattle  from  parasitic  infection  ; 
and  that  this  can  be  done,  by  supplying  pure 
water  and  clean  food,  is  shown  by  the  experience 
of  Upper  India. 

Flukes  in  the  liver  do  not  constitute  a valid 
ground  of  rejection  of  the  meat,  though  the  liver 
ought  not  to  be  eaten. 

Some  very  remarkable  examples  of  an  acute 
pecific  disease  of  peculiar  characters  have  re- 
ently  been  observed  among  consumers  of  meats 
lerived  from  the  pig ; where  the  sole  evidence 
f disease  in  the  meat  has  been  the  presence  of  a 
ultivable  bacillus.  See  Poisonous  Food. 
Sausages  when  musty  and  strong-smelling 
hould  be  rejected,  but,  owing  to  the  spices  used, 
ecomposition  is  not  easily  made  out.  The  pecu- 
ar  ‘sausage-poison’  has  not  been  identified. 

1 Vheat-Flour  and  Bread. — The  chief  points 
ire  to  ascertain  that  there  is  no  ergot,  no  fungi, 
or  acari ; that  alum  has  not  been  used ; and  that 
her  grains  or  mineral  matter  are  not  mixed 
1th  it. 

Under  the  Adulteration  Act  the  following, 
nong  other  articles,  may  have  to  be  examined  : 
rdk,  the  chief  falsifications  in  which  are  ad- 
tion  of  water  or  removal  of  cream.  Falsifica- 
bn  in  other  ways  is  not  common.  It  may  also 
improper  for  use,  owing  to  the  presence  of 
ood,  lacteal  easts,  pus  and  fungi.  Butter',  the 
'sifications  here  are  admixture  with  foreign 
3,  and  excess  of  water  or  of  salt.  Cheese,  which 
ty  he  decomposed,  mouldy,  or  have  copper 
ded  to  preserve  it.  Coffee,  which  may  be 
trid  or  decomposing,  or  mixed  with  chicory, 
isted  corn,  &c.  Tea,  which  may  be  deeom- 
ied,  mixed  with  exhausted  leaves,  or  with  leaves 
, other  than  tea-plants,  or  with  sand,  iron  ore, 

81 


HEALTH.  1281 

colouring  matters  or  facings.  Cocoa,  to  which 
various  starches  may  have  been  added,  or  the 
fat  exhausted.  Oatmeal,  to  which  inferior  barley 
or  wheat-  or  maize-flour  may  have  been  added. 
Maranta  arrowroots,  to  which  potato  starch  or 
inferior  kinds  of  arrowroot  may  have  been  added. 
Spirits,  wine,  and  beer,  in  which  there  may  have 
been  addition  or  subtraction  of  spirit ; improper 
spirits,  as  methyl  or  other  alcohols,  added;  addi 
tion  of  water,  salt,  sulphuric  acid,  ferrous  sul- 
phate, lime-salts,  lead,  eoceulus  indicus,  hot 
spices,  aloes,  quassia,  burnt  sugar,  &o.‘  Vinegar , 
the  chief  falsifications  in  which  are  the  addi- 
tion of  water  and  occasionally  of  sulphuric  acid 
in  excess  of  that  permitted  by  law  part.) 

In  no  case  is  an  examination  of  food  under  the 
Adulteration  or  Licensing  Act  made  to  determine 
the  quality  of  a pure  food ; it  is  directed  simply 
to  detect  the  presence  and  amount  of  foreign- 
substances,  or  of  decomposition  and  putrefaction. 
The  law  permits  mixtures  to  be  sold  in  some 
cases,  if  the  admixture  is  stated  on  a label. 

(8)  The  Begulalion  of  Trades. — Trades  are 
affected  by  the  law  under  two  points  of  view;  1st, 
irrespective  of  the  nature  of  the  trade,  the  place 
where  it  is  carried  on  is  regulated  under  tile 
Mines,  Factories,  and  Workshops’  Acts  ; and  by 
the  Public  Health  Act  of  1875,  urban  authorities 
can  make  byelaws  regulating  offensive  trades, 
such  as  blood  and  bone  boilers,  fellmongers, 
soap,  tallow,  and  tripe  boilers,  &c.  The  object 
of  the  Factories  and  Workshops’  Acts,  among 
other  things  (such  as  restriction  of  labour  at 
certain  ages),  is  to  provide  that  the  common 
conditions  of  health  are  not  violated.  This  is  a 
very  necessary  point,  for  many  workshops  are 
deficient  in  light  and  air,  are  badly  ventilated, 
or  are  rendered  unhealthy  by  gas  burnt  for  light. 
Many  small  workshops  are  owned  by  men  of 
small  capital,  who  often  sacrifice  the  health  of 
workmen  by  compelling  them  to  work  under  very 
unfavourable  conditions.  Happily  the  faults  are 
usually  easily  remedied  by  a little  common  sense 
and  simple  appliances,  and  in  this  respect  the 
Workshops  and  Factories  Acts  have  done  great 
good.  One  special  fault  in  many  workshops  is, 
however,  still  common,  namely,  the  burning  of  gas 
in  large  quantities  in  dark  shops,  without  proper 
means  of  carrying  off  the  products ; the  very 
great  influence  of  this  condition  on  the  lungs 
was  long  ago  pointed  out  by  Dr.  Guy. 

2.  The  other  point  in  the  regulation  of  trades 
is  to  prevent  any  of  the  processes  being  nuisances 
or  injurious  to  the  health,  either  of  the  work- 
people or  the  inhabitants  of  the  surrounding  dis- 
tricts. This  is  an  extremely  wide  subject.  Trades 
may  annoy  and  inconvenience  the  public,  as  by 
offensive  effluvia,  black  smoke,  or  acid  vapour 
which  destroys  vegetation,  yet  may  not  be  dis- 
tinctly injurious  to  health.  On  the  other  hand, 
without  being  notable  nuisances  in  the  above 
sense,  they  may  be  hurtful  to  health,  especially 
those  (and  they  are  very  numerous)  which  give 
rise  to  dust  in  the  air  of  any  kind.  Cotton  and 

1 The  examination  of  adulteration  of  beer  is  now  so 
far  more  difficult  as  the  law  allows  other  bitters  besides 
hops  to  be  used,  and  it  is  understood  there  are  numerous 
cheap  bitters  now  used  in  place  of  hops.  It  is  very  de- 
sirable that  tiie  old  taw  allowing  only  malt  and  hops  t? 
be  used  in  the  making  of  beer  should  be  re-enacted. 


1282  PUBLIC 

woollen  debris,  metallic  vapours,  filings  and 
grindings,  particles  of  size,  clay,  dry  paints,  and 
many  other  substances,  come  under  this  head. 
Much  debate  has  taken  place  as  to  whether  cer- 
tain gases,  such  as  carbonic  acid,  chlorine,  iodine, 
sulphuretted  hydrogen,  sulphurous  acid,  or  the 
foetid  vapours  given  off  from  catgut,  gelatine, 
manuro  and  other  trades,  are  or  are  not  injurious 
to  the  health  of  the  workmen,  or  persons  living 
near  the  factories.  In  many  cases  the  discus- 
sion is  not  closed,  and  fuller  enquiries  are  neces- 
sary ; but  at  present  it  seems  as  if  these  gases 
and  foetid  effluvia,  in  such  proportions  as  they 
are  met  with  about  factories,  are  not  proved  to 
be  unhealthy  (though  their  innocuousness  cannot 
be  asserted),  however  disagreeable  they  may  be  ; 
whereas  there  is  no  doubt  that  the  inhalation  of 
all  solid  particles,  no  matter  whence  derived,  is 
highly  inj urious.  Phosphoretted fumes  escaping 
into  the  air  have  affected  the  jaw-bones  of  per- 
sons exposed  to  them  ; this  happens  now  much 
less  than  formerly. 

The  spread  of  infection  by  trade  operations,  as 
of  anthrax  among  woolsorters,  and  of  smallpox 
among  paper-makers,  has  recently  come  to  de- 
mand recognition. 

There  is  one  article,  the  use  of  which  gives 
rise  directly  and  indirectly  to  a large  amount  of 
sickness,  and  the  trade  in  which  certainly  requires 
regulation,  if  the  public  health  is  to  be  regarded. 
This  is  alcohol  in  its  various  forms.  Owing  to 
peculiar  social  customs,  to  the  insufficient  recog- 
nition of  the  immense  amount  of  harm  produced 
by  excess  of  alcohol,  and  to  a want  of  definition 
of  what  is  excess,  the  laws  of  this  country  have 
not  only  legalized  the  sale  of  a dangerous  article 
of  diet,  but  have  actually  encouraged  the  sale, 
until  an  evil  so  gigantic  has  been  produced  that 
no  one  has  yet  suggested  a reasonable  remedy. 
Yet  the  salo  of  alcohol  is  so  distinctly  a source  of 
disease  and  of  injury  to  the  State,  that  it  must 
be  considered  by  those  who  have  charge  of  the 
Public  Health,  and  in  someway  must  eventually 
be  restri  cted.  One  source  of  the  error  seems  to 
be  that  alcohol  is  regarded  by  the  State,  not  only 
as  a source  of  revenue,  but  as  an  indispensable 
article  of  refreshment.  There  is,  of  course,  no 
question  that  the.  public  must  be  supplied  with 
houses  where  they  cau  obtain  proper  refresh- 
ments, such  as  meat,  bread,  vegetables,  milk, 
coffee,  tea,  or  other  articles  of  the  kind ; and  ‘ pub- 
lic-houses ’ were  intended  to  supply  articles  of 
this  description  ns  well  as  the  alcoholic  liquids 
which  enter  into  the  ordinary  diet  of  most  people. 
Yet,  unfortunately,  a system  has  grown  up  by 
which  our  public-houses  have  become  only  places 
where  alcoholic  liquors  are  sold,  and  this  is 
defended  on  the  ground  that  such  liquids  are  re- 
freshments. The  amount  of  temptation  which 
has  been  put  in  the  way  of  our  working  classes 
by  the  heedless  multiplication  of  these  grog-shops 
during  the  last  forty  years  accounts  for  much 
of  the  drunkenness  which  so  deeply  affects  our 
national  life,  and  injures  the  health  of  the  people. 
A remedy  ought  and  must  be  found  for  this  state 
of  things,  or  else  sanitary  legislation  will  still  pre- 
sent the  absurd  spectacle  of  raising  up  with  one 
hand  what  it  is  smiting  down  with  the  other. 

lit;  1'he  arrest  of  t/ee  Contagious  and  Infections 


HEALTH. 

Diseases. — Small -pox,  scarlet  fever,  measles, 
hooping-cough,  diphtheria,  enteric  fever,  typing 
and  relapsing  fever  have  to  be  dealt  with. 
Among  other  contagious  diseases  also  syphilis 
and  gonorrhoea  must  bo  included. 

Of  late  years,  since  the  recognition  of  the  fact 
that  each  of  these  diseases  must  have  its  own 
special  cause,  the  prevention  of  the  infections 
diseases  has  become  much  easier,  although  tho 
exact  nature  of  the  cause  may  be  unknown.  The 
general  principles  on  which  the  prevention  is 
based  are — 1.  The  recognition  of  the  places  of 
origin  and  conditions  of  formation  of  the  morbid 
agent,  that  is,  whether  it  arises  from  processes 
going  on  in  some  of  the  structures  of  the  human 
body,  or  in  substances  outside  and  independent  of 
the  body,  with  further  question  as  to  the  nature  of 
these  substances,  structures,  or  processes  ; when 
these  points  are  known.it  is  to  be  expected  that 
the  formation  of  the  agent  can  be  prevented  or 
the  agent  can  be  destroyed.  2.  The  recognition 
of  the  means  of  spread  of  the  agent,  after  its 
first  formation,  that  is,  whether  it  spreads  by  the 
help  of  the  air,  or  is  carried  in  drinking  water, 
or  in  food,  or  is  transferred  directly  from  one 
person  to  another;  so  that  when  known  the 
carriage  of  the  agent  may  be  stopped.  3.  The 
early  removal  of  the  person  affected  from  among 
the  community,  so  that  the  risk  of  spreading  in 
any  way  may  be  lessened. 

In  the  case  of  each  of  these  diseases  the  pre- 
ventive measures  are  different,  and  it  is  impos- 
sible here  to  go  into  so  large  a subject  as  the 
prevention  in  each  case.  The  measures  include 
a continual  supervision  over  the  conditions  of 
origin,  introduction,  and  spread  as  far  as  they 
are  known. 

Two  points  must,  however,  he  specially  noted. 
The  isolation  of  persons  ill  with  any  disease 
which  directly  or  indirectly  can  spread  from  one 
person  to  another  is  a necessary  step  in  all  cases. 
In  the  crowded  houses  of  towns  some  diseases 
such  as  typhus,  scarlet  fever,  measles,  relapsing 
fever,  &c.,  spread  with  great  rapidity,  and  the 
only  possible  check  is  to  remove  the  sick  at  the 
earliest  moment  from  the  houses,  and  to  prevent 
persons  ill  with  infectious  diseases  from  expos- 
ing themselves  in  public  places  and  convey- 
ances. 

For  the  first  purpose  sanitary  authorities 
have  powers  (Public  Health  Act  1875,  clauses 
120  to  140)  to  remove  persons  ill  with  infection; 
diseases  to  a proper  hospital  in  special  convey- 
ances; to  prevent  sick  persons  frequentingpublii 
places  or  conveyances  ; to  destroy  bedding  o: 
clothing,  and  to  disinfect  rooms,  houses,  or  cloth 
ing.  Hospitals  for  infectious  diseases  can  als< 
be  built,  and  are  now  being  constructed  in  man; 
towns ; it  is  desirable  to  make  them  simple 
cheap  buildings  of  wood  or  iron,  able  to  bj 
thoroughly  cleaned,  or  after  a tenn  of  years  t 
be  destroyed  and  replaced.  These  hospital 
should  provide  a cubic  space  of  from  1,500 1 
2,000  cubic  feet  with  a floor  space  of  from  12 
to  140  feet;  for  each  patient,  and  efficient  seps 
ration  between  patients  suffering  from  one  an 
another  infectious  disorder.  The  freest  ventilf 
tion,  supply  of  water,  and  means  of  disinfectio 
are  essential.  Under  the  same  Act  a town  is  en 
powered  to  erect  a proper  place  for  disinfeettr 


PUBLIC  HEALTH. 


clothing  and  bedding;  and  disinfecting  chambers 
(heated  by  hot  air,  steam  pipes,  or  gas,  and  in 
which  a heat  of  240°  Fahr.  can  be  reached)  are 
now  provided  in  many  towns  for  the  immediate 
disinfection  by  heat  of  all  soiled  clothes  taken 
from  patients  with  any  of  these  diseases. 

The  disinfection  of  the  excreta  or  of  discharges 
from  the  body,  or  of  tho  air  surrounding  sick 
persons,  is  also  attempted  and  is  evidently  a 
proper  plan  to  follow,  though  the  results  are  at 
present  uncertain.  The  spread  of  scarlet  fever, 
| however,  appears  to  be  arrested  by  rubbing  the 
■ skin  with  carbolized  or  camphorated  oil ; typhoid 
: fever  is  probably  stopped  by  strong  chemicals 
I added  to  the  intestinal  discharge  ; and  the  spread 
[ of  typhus  has  been  also  lessened  and  perhaps 
arrested  by  aerial  purifiers,  especially  nitrous 
5 acid  fumes. 

Small-pox  is  prevented  by  vaccination,  and  for 
j this  there  are  special  Acts  and  a special  organi- 
zation. 

The  prevention  of  syphilis  and  gonorrhoea  by 
periodizal  inspection  of  prostitutes,  and  removal 
of  them  to  lock  hospitals  when  diseased,  is  only 
; carried  out  in  this  country  in  certain  military 
land  naval  stations,  where  the  effect  has  been  to 
lessen  primary  syphilis  by  nearly  one-half,  and 
to  abate  its  virulence.  The  effects  of  the  Conta- 
gious Diseases  Acts  upon  the  women,  in  respect 
not  only  of  curing  them  but  of  influencing  them 
for  good  and  of  reclaiming  them,  has  been  very 
.remarkable.  In  Germany,  Franco,  and  Belgium 
precautions  against  venereal  diseases  have  been 
carried  out  among  the  entire  population  for  many 
years,  with  the  effect  of  greatly  lessening  the 
amount  and  virulence  of  syphilis. 

As  syphilis  has  a most  pernicious  effect  upon 
the  health  of  a very  large  number  of  persons,  it 
■ s most  urgently  to  be  hoped  that  the  Legisla- 
:ure  may  before  long  deal  thoroughly  with  this 
flatter  and  attempt  to  lessen  syphilis,  not 
merely  in  the  army  and  navy,  but  among  the 
lopulatioa  at  large. 

' (10)  The  disposal  of  the  Bead. — Two  points  are 
nvolved  in  the  disposal  of  the  dead  both  in  towns 
nd  villages. 

1 . In  this  country  where  so  many  families  live 
n single  rooms,  and  where  the  custom  of  keeping 
he  dead  five  or  even  six  days  before  burial  is 
jsual,  it  constantly  happens  that  a corpse  is  kept 
or  days  in  the  room  where  all  the  family  life  is 
irried  on.  As  decomposition,  especially  in  some 
iseases,  commences  early,  it  cannot  bo  doubted 
lat  an  unfavourable  effect  on  health  must  be 
ften  produced.  To  avoid  this  detention,  mor- 
lary  chapels  ought  to  be  constructed  in  all 
iwns  and  villages,  and  to  these  all  corpses 
tould  be  removed  from  the  houses  of  the  poor 
ithin  thirty-six  hours  after  death. 

Power  has  long  been  given  (Public  Health 
•ct  of  1848)  to  the  Sanitary  Authority  to  pro- 
‘,de  mortuaries,  and  the  Act  of  1866  gave  power 
remove,  when  necessary,  corpses  from  rooms 
tere  persons  live  and  sleep.  These  powers  are 
ntinued  in  the  Public  Health  Act  of  1 875,  and 
rase  141  also  now  imposes  on  the  local  autho- 
rs the  duty  of  providing  mortuaries,  if  re- 
ared by  the  Local  Government  Board  to  do  so. 
•ry  little  has  as  yet  been  done  in  this  way,  and 


1283 

England  is  in  this  respect  far  behind  some  of 
the  Continental  States. 

2.  The  second  point  is  the  disposal  of  the 
corpse.  The  law  of  England  now  allows  no 
burial-grounds  in  large  cities,  nor  burial  under 
churches,  and  consequently  cemeteries  are  pro 
vided  at  convenient  distances  from  towns.  Theeo 
cemeteries  ought  to  have  a dry  soil,  so  that  tho 
ground  water  shall  never  rise  high  enough  to 
wet  the  corpse  or  to  float  it  up  in  the  vault,  as 
sometimes  happens ; they  should  be  as  far  from 
houses  as  practicable,  and  the  minimum  limit  of 
100  feet  allowed  by  Government  is  much  too 
little ; there  should  be  good  drainage,  and  the 
water  should  not  run  into  any  well  or  water- 
course from  which  drinking-water  is  taken;  the 
site  should  be  well  ventilated  and  well  planted, 
so  that  the  roots  of  plants  may  absorb  the  de- 
composing matters.  The  kind  of  soil  will,  of 
course,  depend  on  the  locality;  in  many  cases 
there  is  no  choice,  but  if  there  be  a choice  a 
marly  soil,  not  too  stiff,  but  allowing  free  per- 
meation by  air  and  free  flow  of  water,  should  be 
chosen;  gravelly  soils  act  pretty  well,  but  are 
said  to  form  a compact  mass  round  the  body, 
which  prevents  access  of  air  and  moisture ; the 
lime  and  chalk  soils  act  better,  and  especially  if 
the  soil  is  alkaline;  very  stiff  clay  preserves 
bodies  longer  than  less  compact  soils. 

Bodies  decay  in  very  various  times,  according 
to  soil,  access  of  air,  amount  of  pressure,  &c. 
In  some  cases  a corpse  may  be  destroyed  in 
three  years ; but  when  ground  has  to  be  used 
over  again,  a period  of  from  five  to  thirty 
years  is  allowed  in  different  countries  before  tho 
second  use.  Bodies  should  be  buried  deeply 
(4  to  6 feet)  in  order  to  lessen  the  chance  of 
contamination  of  the  air,  though  it  is  supposed 
that  when  the  graves  are  shallower,  decomposi- 
tion is  more  rapid ; the  graves  should  not  be 
bricked,  but  the  earth  allowed  to  rest  on  the 
coffin. 

It  has  been  proposed  to  use  not  coffins,  but 
sheets  or  wicker-baskets,  so  as  to  let  the  earth  at 
once  come  in  contact  with  the  body ; and,  in  fact, 
in  many  villages  in  England  it  was  formerly  the 
custom  to  carry  the  corpse  in  a coffin  to  the 
churchyard,  but  then  to  remove  it  from  the 
coffin  and  place  it  in  the  ground  in  a sheet.  If 
the  coffin  is  not  made  too  strongly  it  is  probable 
that  it  does  not  much  delay  decomposition;  so 
that  this  point  does  not  seem  very  material. 

The  decomposition  of  bodies  occurs  by  putre- 
faction, with  rapid  disengagement  of  effluvia ; or 
by  a sort  of  insensible  decomposition,  the  pro- 
ducts being  decomposed  as  rapidly  as  they  are 
formed  by  the  earth.  In  other  instances  the 
decomposition  is  by  saponification.  This  last 
condition  is  said  especially  to  occur  if  the  earth 
is  too  closely  pressed  on  the  body,  and  gets  too 
saturated  with  the  products  of  putrefaction. 

As  in  some  cases  conveniently-situated  and 
proper  land  cannot  be  obtained,  a discussion  has 
lately  arisen  whether  burning,  or,  in  the  case  of 
seaboard  towns,  burying  the  body  in  the  sea, 
might  not  supersede  burial  in  the  ground.  This 
article,  however,  is  not  the  place  to  enter  into 
this  question. 


(11)  The  Supervision  of  Nuisances. — [Nuisances 


1284  PUBLIC 

are  defined  in  the  Public  Health  Act,  § 01,  as 
being — (1)  any  premises,  (2)  any  pool,  ditch, 
gutter,  -watercourse,  privy,  urinal,  cesspool, 
drain  or  ashpit,  (3)  any  animal,  (4)  any  accu- 
mulation or  deposit,  (5)  any  over-crowded  house, 
or  part  of  a house — that  are  ‘ a nuisance  or  in- 
jurious to  health.’  These  words,  as  they  occur 
here,  must  be  read  with  reference  to  the  general 
purposes  of  the  Act,  and  will  therefore  include 
only  things  or  conditions  as  above  that  are  of  a 
nature  to  injure  health  : mere  disagreeableness 
or  annoyance,  though  it  may  be  a ‘nuisance’  at 
common  law,  not  being  enough  to  constitute  a 
nuisance  in  the  above  cases.  Moreover,  (6)  dirty* 
or  unventilated  factories  and  work-places,  or 
any  that  are  unnecessarily  dusty,  and  (7)  manu- 
facturing furnaces  and  the  like  that  do  not  con- 
sume their  own  smoke,  are,  in  this  Act,  included 
with  nuisances  under  certain  limitations. 

It  is  the  duty  of  every  Sanitary  Authority7  to 
cause  inspection  to  be  made  of  their  district  to 
discover  nuisances ; and  a certain  procedure  for 
the  abatement  of  nuisances,  and  for  the  pre- 
vention of  their  recurrence,  is  appointed  by  the 
Public  Health  Act.  For  the  performance  of 
these  functions  the  Authority  is  required  to 
appoint  one  or  more  Inspectors  of  Nuisances,  to 
whose  office  certain  powers  arc  attached.  [The 
work  of  nuisance-inspection,  in  its  every-day  con- 
cern with  conditions  injurious  to  health,  cannot 
be  properly  performed  without  the  constant  and 
intimate  relation  of  the  Medical  Officer  of  Health 
with  the  Inspector;  and  those  districts  are  un- 
questionably best  served  as  to  sanitary  inspection 
where  the  Authority  has  devolved  on  the  Medical 
Officer  the  duty  of  instructing  the  Inspector  and 
of  supervising  his  work.] 

II.  "Villages.— Although  many  of  the  earlier 
sanitary  enactments  had  application  to  villages, 
it  was  not  until  the  passing  of  the  Public  Health 
or  Sanitary  Act  of  1872  (35  and  36  Viet.,  c.  79) 
that  rural  sanitary  authorities  were  constituted. 
These  authorities,  namely,  the  Guardians  of  rural 
Poor  Law  Unions,  can  now  exercise  consider- 
able powers,  and  if  properly  set  in  action  by 
their  medical  health  officers  and  inspectors  of 
nuisances  (whom  the  authorities  are  obliged  to 
appoint),  a great  effect  must  bo  gradually  pro- 
duced upon  the  rural  labouring-class,  whose 
condition  has  up  to  this  time  been  almost  en- 
tirely neglected.  As  the  urban  authority  in 
towns,  so  the  rural  sanitary  authority  in  country 
places  may  provide  water  for  public  use,  may 
make  public  cisterns  or  baths,  mayT  protect  water- 
courses, may  construct  sewers  and  dispose  of 
sewage  matter ; must  take  care  that  no  closet  or 
privy  is  a nuisance;  may  clean  ditches  and  re- 
move refuse,  and  may  make  regulations  as  to 
cellar-habitations  and  common  lodging-houses. 
[Much  increased  power  of  securing  proper  water- 
supply  in  the  particular  house  within  rural  dis- 
tricts has  been  recently  given  by  the  Public 
Health  (Water)  Act  of  1S7S.]  All  powers  pos- 
sessed by  urban  authorities  as  to  trades,  sale 
of  unwholesome  food,  removal  of  nuisances,  pro- 
viding mortuaries  and  hospitals  for  infectious 
diseases,  are  now  also  possessed  by  the  Poor  Law 
Unions  (Public  Health  Act  1875,  clauses  5 and  9). 

At  present,  however,  except  in  those  places 


HEALTH. 

where  several  rural  sanitary  authorities  have 
united  to  appoint  a first-class  sanitary  officer, 
little  has  "been  done  in  English  villages. 

The  problem  is,  in  fact,  by  no  means  an  easv 
one,  but  it  is  being  vigorously  discussed,  and  I 
will  be  no  doubt  eventually  solved  by  the  officers 
of  health  of  large  areas,  many  of  whom  are  men 
of  great  knowledge  and  distinction.  The  diffi- 
culty arises  from  the  houses  in  the  rural  districts 
being,  in  a great  number  of  cases,  old,  dilapi- 1 
dated,  unsuited  for  dwellings,  and  destitute  of 
proper  conveniences.  When  new  houses  are; 
built,  the  sanitary  authority  can  enforce  certain  | 
provisions,  though  it  has  far  less  control  over 
building  operations  than  is  possessed  by  urban 
authorities.  In  the  case  of  houses  already  built, ' 
however,  its  power  is,  from  circumstances,  even' 
more  limited.  There  is  very  little  money  avail-j 
able  for  improvements ; the  poor-rates  are  already 
often  heavy,  and  guardians  hesitate  to  increase' 
them.  The  small  number  of  houses  in  villages! 
also,  in  comparison  with  the  outlay  needful  to 
supply  sewers  and  water,  renders  the  cost  per 
head  relatively  much  greater  than  in  town>. 
Progress,  therefore,  in  rural  districts  must  le 
slow,  but  yet  it  cannot  be  doubted  that  the  pre-| 
sent  condition  will  be  gradually  improved.  In! 
addition  to  bad  construction  and  dampness  ofj 
houses,  the  most  frequent  sanitary  defects  on 
villages  are  as  follows  : — The  water  is  too  often1 
drawn  from  shallow  wells  or  from  small  streams,; 
polluted  by  soaking,  or  from  stagnant  pools  or) 
ditches,  and  its  supply  is  limited.  Often  there 
are  no  means  for  carrying  away  the  dirty  house- 
water,  and  it  is  thrown  on  the  ground  and  soaks 
into  the  soil  close  to  and  under  the  cottage ; the 
excreta  are  generally  thrown  into  an  ashpit  near 
the  house,  or  pass  into  a cesspit  in  the  ground] 
into  which  they7  gradually  soak,  polluting  both 
ground  and  water.  All  sanitary  appliances  are; 
in  fact,  often  wanting.  Attempts  are  now  being 
made  to  purify  and  then  to  guard  the  wells;  td 
collect  rain-water  in  proper  tanks  when  othei 
sources  are  wanting ; or  to  store  the  water  col- 
lected from  the  surface-soil  of  some  area  secun 
from  drainage,  manuring,  or  like  impurities  fa: 
recommended  by  Mr.  Bailey  Denton).  For  the 
disposal  of  the  slop-water,  open  or  partially 
closed  surface  drains  leading  to  ditches,  or  under; 
ground  drains  that  shall  allow  the  water  to  flov 
into  the  soil,  and  other  plans  have  been  proposed 
It  is,  on  any  plan,  important — but  especially  i 
shallow  wells  or  the  surface  soil  are  to  fumis! 
the  drinking  water — to  carry  off  to  a distanco  al 
the  slop)- water  by  drains  of  some  kind.  Forth 
removal  of  excreta  (as  sewers  are  generally  on 
of  the  question)  a pail  system,  with  or  withou 
the  use  of  dried  earth  or  charcoal,  according  t 
circumstances,  has  to  be  used.  If  the  cottage 
have  gardens,  then  tire  simplest  dry-earth  plar 
with  proper  storage  and  the  subsequent  diggin 
into  the  gardens  at  intervals  of  not  more  tha 
three  or  four  weeks,  seems  to  answer  well;  ye 
it  is  very  difficult  to  get  peasants  to  attend  eve 
to  this  simple  matter.  If  the  village  be  a lars 
one,  then  conjoint  action  in  the  procuring,  dry 
ing,  and  distributing  the  earth,  and  in  the  r< 
moval  of  the  mixed  earth  and  excreta,  answer 
well  when  care  is  taken.  In  other  cases  a pa 
system,  with  weekly  or  fortnightly  removal 


PUBLIC 

without  the  use  of  earth  or  other  appliance,  can 
be  employed,  and  may  answer,  as  the  manure 
has  some  value. 

These  seem  at  present  the  directions  in  which 
the  opinions  of  medical  officers  of  health  are 
tending  where  villages  and  labourers’  cottages 
are  concerned,  and  where  larger  works  cannot  be 
undertaken.  The  object,  of  course,  is  to  obtain 
by  simple  means,  and.  at  not  too  burdensome  a 
rate,  the  same  results  which  are  arrived  at  in 
towns  by  more  costly  plans,  namely,  to  ensure 
pure  drinking  water,  and  to  remove  foul  house- 
water  and  excreta;  or,  in  other  words,  to  ensure 
purity  of  the  water,  of  the  air,  and  of  the 
ground. 

III.  Houses. — The  inside  of  a house  is  sup- 
posed to  be  beyond  the  control  of  the  Public 
Health  Authority,  and  is  so  to  a large  extent, 
but  not  altogether.  The  law  takes  cognizance 
of  the  existence  of  nuisance  inside,  as  well  as 
outside,  a house ; and  has  special  provisions  for 
securing  wholesomeness  of  habitation  in  the  fol- 
. owing  cases : — 

1.  Common  lodging-houses  have  been  regu- 
'ated  since  the  great  Public  Health  Act  of  1848, 
.he  authors  of  which  were  evidently  profoundly 
impressed  with  the  great  evils  of  overcrowding. 

1 These  houses  are  registered  and  inspected  ; the 
number  of  lodgers  is  fixed  ; and  ventilation,  and 
l1  cleanliness,  and  water-supply  are  attended  to 
(Public  Health  Act,  1875,  clauses  70-89).  A 
certain  cubic  space  per  head  in  the  sleeping- 
rooms  of  these  houses  is  generally  fixed  by  the 
Authority.  In  the  Metropolis  (where  Acts  of 

11851  and  1853,  administered  by  the  police,  re- 
main in  force)  240  cubic  feet,  in  Dublin  and 
many  other  towns  300  cubic  feet,  are  required 
for  each  adult  inmate. 

2.  Cellar-habitations.  Since  1848  it  has  been 
unlawful  to  use  cellar-habitations,  unless  they 
are  in  accord  with  certain  conditions  of  space, 
height,  window  area,  drainage,  &c.  In  the 
Public  Health  Act  of  1875,  Clause  72  affirms 
these  conditions  afresh,  and  Clause  71  makes  it 
,iunlawful  to  use  any  cellar  as  a dwolling  (that  is, 
.a  place  where  any  person  passes  a night)  which 
has  been  built  or  rebuilt  after  the  passing  of 
|the  Act,  or  which  was  not  lawfully  in  use  when 
|the  Act  was  passed. 

1 With  the  supervision  that  has  been  given  to 
tommon  lodging-houses  during  the  past  thirty 
rears,  they  have  become  much  healthier  and 
noro  decent  habitations.  During  the  same 
period  the  number  of  collar-dwellings  in  our 
owns  has  much  decreased,  and  the  condition  of 
jhoso  still  used  has  notably  improved. 

3.  1 Houses  let  in  lodgings’  or  occupied  by 
Members  of  more  than  one  family.  These  are 
istinguished  from  common  lodging-houses,  where 
ommon  occupation  of  a single  room  by  persons 
f different  families,  or  occupation  for  very  short 
;eriods,  has  been  the  distinction  that  one  and 
nother  authority  have  relied  on  to  establish  their 
1 rmmon  quality.  The  regulation  of  tenemented 
ouses,  as  the  present  class  may  conveniently  be 
>rmed,  dates  from  the  Sanitary  Act  of  1866. 
I ,t  present,  by  Clause  90  of  the  Public  Health 
ict,  1875,  Sanitary  Authorities  have  various 
lportant  powers  conferred  on  them  in  respect 


HEALTH.  1286 

of  that  large  class  of  houses  where  two  or  more 
families  live  in  the  same  house.  But,  for  these 
powers  to  arise,  the  consent  of  the  Local  Govern- 
ment Board  is  required. 

4.  Overcrowding.  The  Nuisances  Removal 
Act  of  1855  (18  and  19  Viet.  c.  121)  empowered 
the  Sanitary  Authority,  on  the  certificate  of  the 
medical  officer  of  health  or  of  two  qualified  medi- 
cal practitioners,  to  take  proceedings  before  a jus- 
tice to  abate  overcrowding  if  the  inhabitants 
consisted  of  more  than  one  family.  In  the  Pub- 
lic Health  Act  of  1875,  clause  91  makes  over- 
crowding, when  dangerous  to  the  health  of  the 
inmates,  whether  of  the  same  family  or  not,  a. 
nuisance  to  be  dealt  with  as  such  under  the 
Act.  Some  towns  have  also  provisions  in  their 
local  Acts,  giving  them  the  same  authority,  and 
in  this  way  the  immense  evil  of  overcrowding  is 
sought  to  be  lessened.  Tho  question  arises 
what  is  overcrowding,  and  usually  the  common 
lodging-house  rules  are  taken,  namely,  an  air- 
space of  300  cubic  feet  per  head.  But  there  is 
no  legal  amount,  except  in  Scotland,  where  the 
General  Improvement  and  Police  Act  of  1862 
enacts  that  children  under  eight  yeai’S  of  age 
shall  have  150  cubic  feet,  and  persons  over  that 
age  300.  Obviously,  the  standard  of  space  per 
person  adopted  as  the  minimum  in  the  bedrooms 
of  common  lodging-houses,  where  the  occupation 
is  by  night  only,  is  too  small  for  those  who  have 
to  occupy  the  same  room  both  by  day  and  night, 
as  is  usually  the  case,  where  the  question  of  over- 
crowding arises  in  the  dwellings  of  the  poor. 
It  would  be  very  desirable  to  raise  the  mini- 
mum (at  all  events  for  persons  over  ten  years) 
to  400  cubic  feet,  and  this  is  really  little  enough. 

The  law,  then,  in  these  several  ways  acts  di- 
rectly upon  houses,  and  if  any  nuisance  is  re- 
ported, or  if  houses  are  found  to  be  dangerous  or 
unfit  for  habitation,  further  powers  come  into 
play. 

Although  public  authority  does  not  extend  to 
all  the  conditions  which  are  next  to  bo  passed 
in  review,  it  will  be  convenient  to  consider  to- 
gether the  various 

CAUSES  OP  UNHEALTHINESS  OF  HOUSES. 

1.  Dampness. — Dampness  arises  from  a damp 
soil,  water  rising  into  walls,  rain  beating  through 
walls  or  coming  from  a leaking  roof,  or  blocked 
water-pipes.  Paving,  concreting,  damp-proof 
courses,  hollow  walls,  &c.,  are  the  remedies. 
Damp  houses  are  unhealthy,  it  would  appear,  by 
reason  of  the  lowering  of  warmth,  giving  rise  to 
catarrhal  and  rheumatic  affections,  and  perhaps 
by  reason  of  increased  decomposition  of  organic 
substances  from  the  constant  excess  of  moisture. 

2.  Excessive  coldness  of  air  from  draughts  or 
from  insufficient  warming. — Although  an  airy 
house  is  the  healthiest,  there  may  be,  not  too 
much,  but  imperfect,  movement  of  air,  so  that 
strong  currents  are  caused  ; or  the  temperature 
may  be  lower  than  is  good  for  health,  even  if  per- 
sons are  well-clothed.  The  draughtiness  is  matter 
of  construction,  and  is  obviated  by  proper  plans 
of  ventilation.  Then,  as  to  warming.  In  towns, 
tho  use  of  hot- water  and  steam  pipes  heated  by  a 
furnace  common  to  several  houses  will,  no  doubt, 
soon  supersede  our  present  inefficient  and  expen- 
sive fireplaces,  and  since  the  supply  of  warmed 


PUBLIC  HEALTH. 


!280 

fresh  air  is  a very  simple  proceeding  when  these 
pipes  are  used,  not  only  will  houses  be  better 
warmed,  but  better  ventilated  and  less  draughty. 

3.  Impurity  of  the  air. — This  arises  from  the 
following  conditions  : — impure  air  drawn  from 
ground  or  basement  into  the  house,  or  passing 
over  impure  earth  or  deposits ; air  in  house 
contaminated  by  effluvia  from  closets  and  pipes ; 
from  combustion ; from  respiration  and  skin- 
transpiration  ; from  uncleanliness  of  persons, 
clothes,  walls,  floors,  and  furniture. 

Each  of  these  conditions  has  to  be  examined 
into  and  rectified  according  to  the  usual  rules 
laid  down  in  works  of  hygiene,  A few  remarks 
may,  however,  be  permitted  on  some  of  the 
headings. 

The  removal  of  respiratory  impurities  can 
only  be  accomplished  by  constantly  removing 
the  air  of  rooms  and  supplying  fresh  air.  This 
is  ventilation,  which  on  account  of  the  very  mo- 
bile character  of  air  and  of  the  ease  with  which 
its  currents  are  reversed,  is  a mechanical  pro- 
blem of  no  little  difficulty.  The  amount  of  air 
required  for  an  adult,  in  order  to  keep  the  air 
free  from  any  odour,  is  3,000  cubic  feet  per  hour ; 
the  carbonic  acid  of  respiration,  which  is  taken 
as  a measure  of  respiratory  impurity,  should  not 
exceed  "2  per  1,000  volumes  of  air.  Practically, 
the  amount  most  persons  get  is  not  more  than 
600  to  1,200  cubic  feet  per  hour,  if  so  much, 
and  the  air  of  their  rooms  smells  fusty  from 
organic  effluvia.  In  cold  times  of  the  year,  the 
entering  air  must  be  warmed,  if  such  great 
changes  are  to  take  place  as  is  implied  in  the 
supply  of  3,000  cubic  feet,  or  in  the  change  of 
air  in  the  air-space  three,  four,  or  even  five 
times  per  hour.  When  warmed  to  nearly  the 
temperature  of  the  surface  of  the  body  (80°  to 
90°  Eahr.)  considerable  movement  of  air  is  borne 
without  difficulty,  but  if  the  temperature  be  much 
lower  a correspondingly  slighter  movement  is 
felt.  Ventilation  in  this  climate  is  therefore  in- 
extricably mixed  up  with  warming,  and  thorough 
ventilation  of  our  rooms  is  impossible  so  long 
as  we  trust  to  radiant  heat  alone  for  warmth. 
The  problem,  therefore,  which  engineers  have  to 
solve  in  warming  and  ventilating  our  rooms,  is 
what  is  the  cheapest  and  most  constant  plan  of 
introducing  warm  air,  of  a temperature  under 
90°  or  95°,  into  our  houses  in  cold  weathor, 
the  conditions  of  the  problem  being  a supply  of 
3,000  cubic  feet  per  head  per  hour,  at  a rate  of 
movement  imperceptible  to  the  feelings  of  the 
persons  in  the  room. 

The  second  point  is  connected  with  the  impu- 
rity of  the  air  from  drains.  The  first  thing  is 
to  be  certain  that  the  air  of  the  house-drain  is 
so  thoroughly  disconnect  ed  from  the  air  of  the 
town  senders  that  no  reflux  from  them  is  possible  ; 
and,  therefore,  that  if  thero  is  any  drain  air 
polluting  the  atmosphere  of  the  house  it  is  not 
the  air  of  the  common  sewer.  That  point  having 
been  settled,  it  will  follow  that  drain-smell  in 
the  house  must  come  either  from  the  ground  or 
from  the  house  pipes  or  closets  themselves.  If 
from  the  ground,  there  is  probably  (if  the  ground 
itself  he  clean,  or  if  the  smell  be  of  new  pro- 
duction) a leaky  pipe  somewhere,  and  the  air 
is  penetrating  through  the  interstices  of  the 
soil  and  is  drawn  into  the  house ; every  house 


should  have  a plan  of  its  drainage,  so  as  to 
facilitate  the  search  for  a broken  pipe.  If  not 
from  the  ground,  the  smell  may  be  from  some 
pipe  in  the  house ; this  arises  from  imperfect 
junction,  especially  when  metal  pipes  are  joined 
on  to  earthenware,  or  from  the  pin-hole  eating- 
away  of  metal  pipes.  Or  a drain-pipe  may  be 
choked  (generally  through  ‘ settling’  at  a joint 
occurring  in  an  ill-laid  and  badly-bedded  pipe), 
and  decomposition  be  going  on  in  its  retained 
contents.  Or  there  may  be  a clogged  or  im- 
perfect trap  with  the  water  either  sucked  out 
of  it  or  becoming  thoroughly  charged  with  fcetid 
effluvia.  In  the  latter  cases,  there  is  a presump- 
tion that  the  ventilation  of  the  house-drain  is 
not  what  it  should  be. 

In  order  to  detect  any  of  these  conditions  it  is 
necessary  that  builders  should  alter  all  their 
plumbing  arrangements ; at  present  they  try  to 
conceal  everything,  so  that,  without  pulling  a 
house  to  pieces,  it  is  impossible  to  examine  if 
pipes  and  traps  are  in  order.  Instead  of  this 
every  pipe  should  be  kept  out  of  walls  andabove 
ground,  and  if  cased  with  wood,  the  case  should 
be  merely  bolted,  and  not  nailed.  If  a pipe 
must  be  carried  underground  it  should  he  laid  in 
a regular  channel  which  can  he  opened ; but,  as 
far  as  possible,  all  pipes  should  be  above  ground 
and  open  to  sight,  and  none  should  run  under 
houses.  The  sewage  and  foul  water  arrange- 
ments of  our  houses  will  never  be  satisfactory 
till  these  matters  are  attended  to,  and  till  the 
examination  of  every  pipe  about  the  house  can 
be  made  without  difficulty,  and  clogging  or  air 
and  water  leakage  detected. 

In  closets  the  chief  points  of  leakage  are  the 
horizontal  pipes  and  the  traps.  In  all  cases  the 
soil  pipe  should  be  ventilated  by  a pipe  carried 
to  the  open  air  at  some  point  away  from  win- 
dows. 

Another  matter  to  be  guarded  against,  whether 
there  be  drain-smell  or  not  about  a house,  is 
the  immediate  opening  of  the  cistern  overflow- 
pipe,  or  of  the  usual  rain-water  pipe,  into  the 
sewer  or  house-drain  ; the  common  practice  is 
to  open  them  into  the  sewer,  perhaps  with  a 
sigmoid  trap,  which,  however,  is  often  dry  at  the 
top  of  them.  Then  sewer  air  passes  up  and 
enters  the  cistern,  or  rooms  which  happen  to  be 
near  the  top  of  the  rain-water  pipe.  .Ill  these 
pipes  should  open  in  free  air  over  a grating,  and 
if  every  householder  would  insist  on  the  builder 
attending  to  these  matters  the  chances  of  in- 
flow of  sewer  air  into  houses  would  be  moch 
lessened. 

Another,  third,  point  of  importance  is  the  way 
in  which  the  products  of  gas-combustion  are 
allowed  to  pass  into  the  air  of  rooms.  Nothing 
can  be  worse  than  the  usual  arrangement ; and, 
as  gas-lights  might  be  made  a valuable  means 
of  ventilation  if  tubes  were  arranged  to  carry 
off  the  burnt  gas,  the  present  plan  of  chandeliers 
is  not  only  hurtful,  but  involves  an  ignorant  waste 
of  useful  force. 

4.  Impurity  of  the  Water. — "Water  delivered 
to  a house  may  become  impure  on  the  premises, 
usually  from  uncleaned  uncovered  cisterns,  ab- 
sorption of  air  from  drains  by  the  surface  of  the 
water,  and  sometimes  by  more  direct  leakage 
from  pipes  into  cisterns.  Lead  may  also  be  taken 


PUBLIC  HEALTH. 


op.  The  remedies  for  these  conditions  are 
obvious. 

5.  Impurities  from  Uncicanliness  of  the  House. 
Walls  and  ceilings  all  absorb  impurities  which 
are  given  out  again  to  the  air,  and  often  become 
highly  impregnated  with  organic  matters.  The 
chinks  of  floors  allow  matters  to  collect  below 
them,  and  then  impure  air  rises  into  the  room. 
Or  furniture . may  harbour  dirt,  and  thus  con- 
tinually contaminate  the  air. 

The  custom  of  re-papering  walls  without  clean- 
ing the  old  paper,  the  decomposition  of  paste 
and  paper  on  damp  walls,  and  the  use  of  arse- 
nical pigments,  may  disengage  impurities.  In 
the  houses  of  the  poor  which  are  not  regularly 
whitewashed,  the  half-crumbling  plaster  is  often 
highly  charged  with  animal  material. 

These  matters  are  to  be  avoided  by  original 
. good  construction  and  by  constant  cleanliness. 
It  is  a great  desideratum  to  make  walls  of  im- 
permeable material,  so  that  they  may  be  washed 
without  difficulty;  but,  at  present,  this  is  an 
expensive  matter. 

If  these  various  points,  which  are  really  ques- 
tions of  purity  of  air  and  water,  and  of  tempe- 
rature and  movement  of  air,  are  properly  dealt 
with,  houses  must  ho  healthy.  These  are  con- 
ditions which  are  not  difficult  to  secure  if  they 
are  clearly  understood  and  if  their  importance 
: is  not  underrated.  The  great  point  is  to  have 
the  house-air  pure,  so  as  in  no  way  to  injure  or 
depress  the  great  function  of  respiration. 

While  we  look  to  the  Municipality  or  Local 
i Sanitary  Authority  to  keep  the  outer  air  pure, 
the  task  of  doing  the  same  for  the  house-air 
must  necessarily  fall  on  the  inhabitants  of  the 
house. 

Vital  Statistics. — The  attention  now  paid  to 
Public  Health  is  in  a large  degree  owing  to  the 
careful  collection  of  the  statistics  of  births  and 
deaths,  and  of  the  causes  of  death,  which  have 
been  tabulated  in  England  for  the  last  thirty-eight 
years.  It  may  truly  be  said,  indeed,  that  not 
only  all  Europe,  but  gradually  the  entire  world, 
'las  been  influenced  by  the  work  of  the  Registrar- 
General  of  England.  "We  are  now  able  to  de- 
ermine  the  limits  of  mortality  and  its  causes 
vith  some  precision,  and  are  being  led  towards 
nterpreting  the  causes  of  too  high  a death-rate. 

The  chief  vital  statistics  bearing  upon  public 
tealth  are  the  determination  of  the  birth-rate; 
f the  general  death-rate  ; of  death-rates  accord- 
ng  to  sex,  age,  and  disease;  and  of  the  health 
f classes  of  the  community,  as  judged  of  by  their 
xpectation  of  life  at  given  ages.  There  are 
rnny  other  problems,  but  these  are  the  most 
nportant.  The  collection  of  statistics  of  sick- 
ess,  apart  from  mortality,  has  not  been  hitherto 
lccessful,  on  account  of  the  difficulty  of  collect- 
'g  the  data  with  sufficient  accuracy.  See  Moe- 
3)  ITT. 

. The  gross  death-rate,  without  distinction  of 
x or  age,  is  that  which  is  commonly  used  to 
press  the  health  of  a town  or  district.  It  is, 
course,  to  be  understood  that  it  is  but  an 
,3mentary  expression  that  should  be  accom- 
nied  by  further  analysis  of  mortality  accord- 
? to  diseases  and  ages,  and  by  consideration  of 
e birth-rate  also,  for  the  deaths  of  newly  horn 


1287 

and  young  children  form  always  a large  item  in 
the  list.  As  far  as  it  goes,  however,  the  general 
death-rate  is  extremely  useful.  It  is  calculated 
on  the  population,  which  in  England  is  ascer- 
tained positively  by  census  every  ten  years,  and 
in  the  intervals  may  be  veryfairly  estimated  from 
a variety  of  data  ascertained  for  the  particular 
place  or  district.  It  was  in  view  of  gross  death- 
rates  in  various  districts  of  England  that  it  waj 
assumed  in  18-18,  when  the  first  Public  Health 
Act  was  passed,  that  in  this  country  the  public 
health  is  nowhere  satisfactory  if  the  death-rate 
of  the  locality  exceed  23  per  1,000  of  popula- 
tion per  annum.  And  under  the  provisions  of 
that  Act  the  General  Board  of  Health  consti- 
tuted by  it  was  empowered  to  send  an  inspector 
to  examine  into  the  hygienic  condition  of  any 
locality,  wherein  the  number  of  deaths  annually 
exceeded  this  iate.  It  would  now  seem  that 
the  number  proper  to  be  regarded  as  constituting 
a standard  for  such  a purpose,  might  reasonably 
be  lowered  from  23  to  22  or  even  21,  but  no 
legal  or  authoritative  statement  has  been  made 
of  late  years.  See  Moutality. 

Further  investigation  of  mortality  statistics 
according  to  age  -and  disease  is,  however,  neces- 
sary to  form  a correct  notion  of  the  sanitary 
state  of  any  district.  Unexpected  results  are 
sometimes  brought  out,  as,  for  example,  that  a 
general  high  death-rate  may  be  owing  entirely  to 
an  extremely  high  infantile  mortality.  The  dis- 
eases which  occasion  the  high  death-rate  will 
then  also  appear,  and  will  indicate  the  directions 
for  remedial  measures.  The  child  death-rate  (that 
is,  the  death-rate  at  ages  below  five  years,  or  even 
for  every  single  year  of  the  five,  calculated  on 
the  population  living  at  the  several  ages;  or  if 
that  be  not  known,  then  on  the  gross  population) 
is  indeed  most  necessary  to  be  known  in  every 
health-enquiry. 

Among  the  poor  population  of  our  large  cities 
the  deaths  of  children  under  five  years  of  age 
may  be  found  to  constitute  half  of  the  total 
deaths  at  all  ages,  and  occasionally  in  some  had 
districts  in  unhealthy  towns  the  deaths  of  chil- 
dren have  reached  60  per  cent,  of  the  total 
deaths,  whereas  in  all  England  the  child  death- 
rate  (under  five  years)  is  but  40  per  cent,  of 
the  total  deaths,  and  in  healthy  districts  and 
good  families  is  below  this,  even  below  30  per 
cent,  of  total  deaths.  In  this  way  of  reckoning, 
however,  the  excessive  mortality  of  infants  is 
obscured  by  an  excessive  mortality  among  older 
people  ; and  a better  measure  is  to  be  found  in 
the  rate  of  annual  mortality  among  100  children 
under  five  years  of  age  living  in  a community. 
Thus  measured,  it  is  found  that  there  may  die 
annually  only  four  among  the  better  classes,  and 
from  ten  up  to  the  immense  mortality  of  twenty- 
six  in  the  worst  parts  of  our  large  towns. 

How  wonderfully  the  child  death-rate  is  in- 
fluenced by  the  high  social  position  of  the 
parents,  which  implies  greater  care  of  the  chil- 
dren, is  strikingly  shown  by  Mr.  Ansell's  very 
useful  tables  of  mortality  among  the  upper 
classes. 

Of  100,000  children  horn  alive  there  are  living 
at  the  end  of  their  fifth  year  in  all  England 
74,000  (in  round  numbers  we  may  say  that  one 
quarter  have  died),  among  the  ‘upper  classes’ 


12S8  PUBLIC  HEALTH. 

(as  defined  by  Mr.  Ansell),  87,000  are  living  at 
the  fifth  year,  while  among  the  peerage  not  less 
than  90,000  are  living.  As  a contrast,  the  writer 
would  refer  to  a street  in  Liverpool,  where  he 
found  the  death-rate  so  high  that  only  10,000 
children  would  be  living  at  the  end  of  five  years 
out  of  100,000  ; or  90  per  cent,  had  died  in  five 
years. 

The  determination  of  the  diseases  producing  a 
given  mortality  is  also  a necessary  part  of  all 
vital  statistics,  regarded  as  expressions  of  the 
public  health. 

Tlio  chief  diseases  causing  mortality7  under  five 
years  of  age  are  diarrhoea  and  convulsions  from 
bad  food ; acute  chest-affections  from  cold  and 
exposure  and  vitiated  air;  and  the  contagious 
infantile  diseases.  The  mortality  from  these 
causes  is  of  course  greater  in  amount  among 
the  children  of  the  poor.  Among  older  people 
phthisis  and  chest-affections,  and  from  time  to 
time  outbreaks  of  infectious  diseases,  hold  the 
first  rank. 

The  degree  of  prevalence  of  the  infectious  or 
so-called  zymotic  diseases  must  be  always  care- 
fully noted,  but  there  are  many  other  preventible 
diseases  quite  as  worthy  of  attention,  and  espe- 
cially the  acute  and  chronic  chest-affections 
which  are  largely  owing  to  removable  unhealthy 
conditions  of  atmosphere  and  mode  of  life. 

The  calculations  necessary  to  bring  out  the  re- 
sult are  of  the  most  simple  kind  if  the  data  are 
known,  namely,  the  number  of  the  population, 
and  of  persons  of  various  sexes  and  ages  ; the 
number  of  deaths,  the  sex  and  age  of  the  persons 
dying,  and  the  diseases  causing  the  mortality. 

' The  national  census  furnishes  some  of  these 
figures,  and  the  medical  profession  contribute  the 
material  for  the  rest.  They  bear,  therefore,  a 
very  great  responsibility  ; for  inaccuracy  of  ro- 
cord  by  them  may  greatly  affect  the  action  of  the 
community7,  taken  on  the  faith  of  the  accuracy  of 
the  statistics. 

Heretofore  statistics  of  mortality  alone  have 
been  available  for  the  purposes  of  the  sanitary 
physician  and  administrator,  and  their  utility 
has  been  unquestionable.  Such  statistics,  how- 
ever, are  necessarily  a very  incomplete  measure 
of  the  influences  affecting  the  public  health. 
When,  in  the  future,  it  shall  have  become  pos- 
sible to  make  proper  record  of  all  sickness, 
whether  fatal  or  not  fatal,  further  progress  in 
the  investigation  of  the  conditions  productive 
of  disease,  and  in  securing  for  the  community 
the  most  healthful  circumstances  of  life,  will 
become  practicable. 

The  third  statistical  point  to  which  reference 
has  been  made  is  the  length  of  life  a person  of  a 
given  age  may  expect  to  live.  This  so-called 
‘ expectation  of  life’  or  ‘mean  after-lifetime’  is 
the  most  exact  test  of  the  general  health  of  a 
people.  It  is  one,  however,  which  can  only  be 
applied  at  long  intervals,  and  by  the  aid  of  very 
accurate  and  numerous  census  and  death  lists. 
It  is  not,  therefore,  applicable  as  a daily  method 
of  determining  the  degree  of  health.  It  appears, 
however,  that,  at  the  present  time,  as  compared 
with  former  periods,  the  expectation  of  life  is 
improving  in  the  chief  European  countries,  and 
the  mean  age  at  death  is  also  greater  than 
formerly. 


PUERPERAL  DISEASES. 

It  is  the  office,  then,  of  the  statistician,  by  his 
study  of  the  distribution  of  disease  and  the 
incidence  of  mortality,  to  guide  towards  an 
appreciation  of  the  causes  thereof,  and  to  a 
better  knowledge  of  the  natural  laws  which 
influence  public  health : and  it  is  the  business 
of  the  sanitary  legislator  and  administrator  to 
give  due  recognition  to  those  natural  laws  in 
their  endeavours  to  maintain  the  health  and  to 
save  the  lives  of  the  people.  The  struggle  with 
disease  and  deatli  is  never-ending,  but  is  not 
indecisive.  It  is  remarkable  how  steadily  public 
health  has  improved  with  each  new  advance  in 
wise  legislation.  In  no  case  has  disappointment 
resulted,  and  in  some  instances  the  good  results 
have  been  really  surprising.  Much  still  remains 
to  be  done,  and  many  sanitary  problems  wait 
for  solution  ; but  the  rapid  progress  of  late 
years  makes  us  confident  that  greater  effects 
still  will  follow  as  the  knowledge  of  the  causes 
of  disease  becomes  more  precise,  and  tho  tech- 
nical means  of  prevention  are  more  efficient!? 
applied.1 

E.  A.  Pabees. 

PUERILE  ( pucr , a boy). — This  word  is  as- 
sociated in  medicine  with  the  respiratory  mur- 
mur when  it  is  exaggerated,  possessing  the  cha- 
racters heard  over  the  lungs  in  a healthy  child. 
See  Physical  Examination. 

PUERPERAL  DISEASES. — The  disease? 

associated  with  parturition,  which  fall  for  con- 
sideration in  the  present  article,  are:— 1.  Puer- 
peral Convulsions ; 2.  Puerperal  Fever ; 3.  Puer- 
peral Peritonitis  ; and  4.  Puerperal  Thrombosis 
and  Embolism.  Certain  other  pathological  con- 
ditions of  equal  importance,  occurring  during 
the  puerperal  state,  are  more  conveniently  dis- 
cussed under  their  several  special  names.  See 
Pelvic  Abscess;  Pelvic  Cellulitis;  Pelvic 
Peritonitis;  and  Phlegmasia  Dolexs.  Puer- 
peral insanity  is  described  in  the  article  In- 
sanity, Varieties  of. 

1.  Puerperal  Convulsions. — Synon.  : Puer- 
peral Eclampsia;  Fr.  Convulsions  des  femmes 
enceintes  et  en  couclie ; Ger.  Eklampsie  in  dtr 
Schwangerschaft  und  irn  Wochenbdt. 

Definition. — A pccular  kind  of  epileptiform 
convulsions,  characterised  by  loss  of  conscious- 
ness and  of  sensibility,  together  with  tonic  and 
clonic  spasms ; occurring  in  the  later  months  of 
pregnancy,  during  labour,  or  after  delivery ; and 
causing  great  danger  to  the  lives  of  both  mother 
and  child. 

./Etiology. — The  frequent  association  of  this 
disorder  with  albuminuria  had  till  lately  given 
rise  to  the  belief  that  it  is  the  result  of  uraemia. 
More  recent  observations,  however,  have  thrown 
a doubt  upon  tips  doctrine.  Many  cases  have 
been  observed  in  which  albumen  was  present  in 
large  quantity  without  convulsions  occurring; 
and  others  in  which  the  eclamptic  attacks  took 
place  without  any  albumen,  or  a mere  trace  only, 
being  present.  ! 

Traube  and  Rosenstein  have  referred  tho 
causation  of  the  convulsions  to  acute  cerebral 

1 This  article,  which  was  written  by  Dr.  Parkes  before 
his  lamented  death,  has  been  revised,  and  a few  pasoakis 
inserted,  marked  [ ],  by  Dr.  George  Buchanan. 


PUERPERAL  DISEASES. 


anaemia,  resulting  from  changes  in  the  blood 
incidental  to  pregnancy,  the  watery  condition  of 
the  blood  being  associated  with  increased  tension 
of  the  arterial  system.  More  recently,  Dr.  Angus 
Macdonald,  of  Edinburgh,  has  pointed  out  that 
he  has  discovered  by  post-mortem  examination, 
extreme  anaemia  of  the  cerebro-spinal  centres, 
with  congestion  of  the  meninges,  without  oedema. 
He  attributes  the  convulsive  attacks  to  irritation 
of  the  vaso-motor  centre  from  an  anaemic  condi- 
tion of  the  blood,  produced  by  the  retention  in  it 
of  excrementitious  matters  which  should  have 
been  eliminated  by  the  kidneys. 

Svmptoms. — Although  frequently  the  convul- 
sions occur  suddenly,  no  previous  indications 
having  been  observed,  still  on  inquiry  it  will 
generally  be  found  that  certain  premonitory 
symptoms  have  been  present.  The  most  promi- 
nent of  these  is  headache,  sometimes  very  in- 
tense, generally  frontal.  Derangement  of  vision 
is  another  grave  indication.  An  important  sign 
when  present  is  oedema,  which  may  attract 
notice  by  puffiness  of  the  face,  especially  of 
the  eyelids,  and  should  immediately  suggest  an 
examination  of  the  feet  and  ankles,  and  of  the 
urine. 

When  the  convulsive  seizure  occurs  it  cannot 
be  mistaken.  The  eyes  first  become  fixed,  and 
rapid  contraction  of  the  muscles  of  the  face 
occurs,  with  rolling  of  the  eyeballs,  the  pupils 
being  lost  under  the  upper  eyelids.  The  face 
becomes  turned  first  towards  one  shoulder,  then 
towards  the  other.  The  convulsions  rapidly  ex- 
tend to  the  other  parts  of  the  body ; after  a short 
period  of  tonic  contraction  violent  clonic  spasms 
occur.  The  face  becomes  livid,  the  tongue  is 
protruded,  and,  if  care  be  not  taken,  it  is  lacerated 
by  the  teeth,  colouring  t he  frothy  saliva  which 
has  been  emitted  at  the  angles  of  the  mouth. 
The  thumbs  become  clenched  in  the  palms,  and 
violent  jerkings  of  the  arms  occur,  whilst  the 
muscles  of  the  face  give  rise  to  a variety  of 
contortions.  Sometimes  involuntary  evacuations 
of  the  bladder  and  rectum  occur  during  the  fit. 
There  is  total  loss  of  consciousness  and  sensation. 
After  a few  minutes  the  symptoms  gradually 
subside ; a longer  interval  occurs  between  the 
clonic  muscular  contractions  ; the  face  loses  its 
lividity ; and  the  breathing  becomes  more  tran- 
quil. After  the  first  fit  has  passed  off  the  patient 
may  recover  her  consciousness  ; but  if  another 
occur  with  rapidity,  and  very  little  time  elapses 
between  the  paroxysms,  death  may  soon  super- 
vene. Where  there  is  a considerable  time  be- 
tween the  attacks,  it  may  be  many  hours  or  days 
before  consciousness  is  restored,  and  recovery 
takes  place.  A remarkable  feature  of  this  dis- 
order is  that  when  the  patient  becomes  sensible, 
and  is  restored  to  health,  she  has  invariably  no 
recollection  of  what  occurred  not  only  during 
her  illness,  but  for  some  time  preceding  the  fits. 
The  writer  has  observed  the  case  of  a woman 
whose  puffy  face  attracted  his  notice  in  the  City 
of  London  Lying-in  Hospital  the  morning  after 
her  labour ; there  was  oedema  of  the  ankles,  and 
the  urine  contained  abundance  of  albumen. 
Having  remarked  that  it  was  a wonder  she  had 
lot  had  convulsions,  he  was  summoned  to  find 
ter  in  this  condition  within  a few  hours.  She 
»-s  comatose  for  three  days,  and  on  subsequent 


1289 

inquiry  she  had  no  recollection  of  being  taken  in 
labour  or  of  being  conveyed  to  the  hospital.  This 
is  by  no  means  an  exceptional  case. 

Prognosis. — This  depends  upon  the  severity 
and  frequency  of  the  paroxysms.  It  is  gener- 
ally considered  that  one  in  every  three  or  four 
cases  proves  fatal.  The  mortality  has  probably 
diminished  of  late  years,  since  indiscriminate 
venesection  has  been  abolished,  and  other  treat- 
ment. adopted. 

Treatment. — The  treatment  of  puerperal  con- 
vulsions depends  greatly  upon  the  period  in  re- 
lation to  labour  at  which  the  eclamptic  attack 
occurs.  Generally  the  paroxysms  in  themselves 
are  sufficient  to  provoke  labour,  and  if  this  pro- 
ceed well,  it  should  be  allowed  to  take  its  own 
course ; officious  manipulation  is  apt  to  increase 
the  severity  of  the  fits.  Under  some  circum- 
stances, however,  the  induction  of  premature 
labour  is  necessary ; or  it  may  be  expedient  to 
deliver  as  soon  as  possible  when  labour  has 
commenced.  Venesection,  which  used  to  be  the 
universal  treatment,  is  now  very  rarely  adopted. 
There  are,  however,  cases  in  which  it  is  un- 
doubtedly called  for ; in  women  of  plethoric 
habit,  with  congested  face,  and  full  pulse,  show- 
ing much  arterial  tension,  it  will  probably  be 
found  of  great  benefit. 

Compression  of  the  earotids,  first  recommended 
by  Trousseau  in  the  convulsions  of  infants,  has 
been  successfully  adopted  by  Dr.  Playfair  in 
puerperal  eclampsia. 

As  soon  as  the  attack  commences  it  is  well  to 
administer  an  aperient,  if  possible. 

The  treatment  which  has  of  late  been  found 
most  serviceable  is  the  administration  of  chloro- 
form, which  not  only  modifies  the  force  of  the 
attacks,  but  appears  in  a marvellous  way  to 
diminish  their  frequency.  It  should  be  freely 
administered  on  the  first  symptoms  of  the  attack, 
and  its  effect  should  be  kept  up  until  the  fit  has 
entirely  subsided. 

Chloral  alone,  or  in  combination  with  bromide 
of  potassium,  may  be  administered  by  the  mouth 
or  rectum,  often  with  great  advantage.  This 
may  obviate  the  necessity  of  a further  continu- 
ance of  the  chloroform  inhalation.  The  hypo- 
dermic injection  of  morphia,  which  lias  been 
condemned  by  some  on  account  of  the  renal 
condition,  has,  nevertheless,  been  frequently 
found  most  efficacious,  notwithstanding  a large 
amount  of  albuminuria  being  present,  and  it  is 
weU  worthy  of  a more  extended  trial  in  pro- 
longed cases. 

2.  Puerperal  Fever.  — Stnon.  : Childbed 
fever;  Puerperal  Septicaemia ; Fr.  Fievre  puer- 
perale-,  Ger.  Puerpcralfieber ; Kindbettficber. 

Definition. — A continued  fever,  occurring 
in  connection  with  child-birth ; often  associated 
with  local  lesions  cf  the  uterus,  vagina,  or  peri- 
neum ; and  caused  by  the  absorption  of  septic 
matter,  not  infrequently  arising  from  the  reten- 
tion of  portions  of  placenta  or  membrane,  or  from 
a putrid  foetus. 

^Etiology. — Puerperal  fever  occurs  not  only 
epidemically  but  endemically,  especially  in  lying- 
in  hospitals ; and  is  communicable  by  contagion. 
Special  sources  from  without  are  cadaveric  matter 
communicated  by  the  hands  of  the  practitioner 
after  making  post-mortem  examinations,  and 


PUERPERAL  DISEASES. 


1290 

septic  matter  conveyed  by  nurses  on  their  hands 
or  on  sponges.  Prolonged  mental  distress,  and 
an  impoverished  state  of  the  blood  from  want 
of  food,  predispose  to  it.  Puerperal  fever  may 
be  produced  by  the  contact  of  other  diseases, 
especially  erysipelas,  whicli  in  some  respects 
bears  a close  analogy  to  it,  a prominent  charac- 
teristic of  both  being  a peculiar  diffuse  inflam- 
mation ; in  one  the  part  affected  being  the  skin 
and  connective  tissue,  in  the  other  the  seat  being 
the  uterus,  uterine  veins,  and  peritoneum. 

Anatomical  Characters. — These  differ  very 
greatly  according  to  the  duration  of  the  fever, 
and  the  parts  of  the  body  affected  by  the  dis- 
ease. In  some  rapidly  fatal  cases  of  a malignant 
type  nothing  has  been  found  but  a peculiar 
alteration  in  the  blood — a great  increase  in  the 
white  corpuscles;  a diminution  in  the  red 
blood-cells  ; an  increase  also  in  the  fibrine  and 
extractive  matters,  lactic  acid  and  fat ; and  fre- 
quently traces  of  bile-pigment. 

Generally,  however,  local  lesions  exist,  and  if 
these  are  seen  after  death,  in  the  shape  of  lacera- 
tions in  the  genital  tract,  they  will  present  an 
unhealthy  appearance,  their  edges  being  swollen 
and  cedematous.  The  uterine  surface  is  generally 
found  intensely  inflamed,  softened,  and  occa- 
sionally in  a state  of  slough.  The  results  of  in- 
flammation may  also  be  found  in  the  veins, 
parenchyma  of  the  uterus,  and  connective  tissue 
around  it ; as  well  as  in  the  lymphatics,  so  large 
and  numerous  at  this  time,  pus  being  frequently 
discovered  in  these  vessels.  The  peritoneum  is 
nearly  always  affected ; it  may  bo  only  congested 
in  patches,  but  is  generally  universally  so  ; the 
intestines  may  all  be  glued  together ; and  the  sac 
may  contain  more  or  less  serum  or  sero-pns,  with 
flaky  lymph.  Inflammatory  swelling,  softening, 
or  abscesses  may  be  found  almost  anywhere,  in 
the  uterine  wall,  ovaries,  kidneys,  spleen,  liver, 
lungs,  muscles,  and  connective  tissue.  Effusion 
into  all  the  serous  cavities  may  arise,  and  pus 
may  be  discovered  around,  or  even  within,  the 
joints.  An  embolus  may  be  found,  a fragment 
of  infected  thrombus  having  escaped. 

Symptoms. — In  no  disease  do  the  symptoms 
vary  more  than  in  this,  depending  upon  the  vio- 
lence of  the  fever,  and  the  localities  attacked  by 
the  poison.  The  fever  generally  originates  within 
three  or  four  days  after  delivery,  though  some- 
times later.  Frequently  there  is,  first  of  all,  great 
depression,  with  headache;  sometimes  the  first 
symptom  is  a rigor.  The  pulse  becomes  rapid 
and  feeble,  130  or  more  per  minute.  The  tem- 
perature rises  to  103°  Eahr.,  or  higher.  The 
skin  is  generally  hot  and  dry.  Vomiting  fre- 
quently occurs  early,  the  ejecta  being  like  coffee- 
grounds,  aud  of  a peculiar  odour.  Diarrhoea  is 
often  very  troublesome,  the  evacuations  being 
horribly  fetid.  The  tongue  soon  becomes  coated 
with  a heavy  fur,  later  on  becoming  dry  and 
raspy ; and  sordes  appear  on  the  lips.  There  is 
often  acute  pain,  with  tenderness  and  swelling, 
of  the  abdomen;  but  peritonitis  with  effusion 
may  occur  without  any  of  these  symptoms.  Some- 
times the  swollen,  tender  uterus  can  bo  felt  in 
the  hypogastrium.  The  lochia  are  generally  sup- 
pressed, and  the  secretion  of  milk  arrested,  though 
sometimes  the  mammie  are  hard  and  painful. 
As  a rule  the  intellect  is  unimpaired,  though  low 


muttering  delirium  frequently  precedes  death. 
The  breathing  is  short  and  hurried.  Pneumonia, 
pleurisy,  or  pericarditis  occasionally  ensue. 
Jaundice  or  albuminuria  may  be  present.  The 
joints  may  swell  and  suppurate;  and  abscesses 
may  form  in  any  part  of  the  body,  sometimes  in 
the  eye. 

Course  and  Terminations.  — The  disease 
generally  runs  a rapid  course,  terminating  fatally 
within  a week.  The  pulse  becomes  more  and 
more  rapid  and  feeble  ; the  breathing  mors 
hurried  and  panting ; tympanites  sets  in  ; a cold 
clammy  sweat  breaks  out ; finally  hiccough,  sub- 
sultus,  and  low  muttering  delirium  come  on,  with 
frequently  incessant  vomiting;  and  the  patient 
sinks  from  exhaustion. 

Treatment.— 1.  Prophylactic. — This  is  of  the 
utmost  importance.  Keeping  in  mind  the  sources 
of  the  disease,  it  behoves  the  practitioner  to 
avoid  every  means  of  communicating  septie 
matter  to  the  patient,  either  personally  or  by 
the  nurse.  If  possible  to  arrange  it,  the  genital 
organs  should  never  be  touched,  for  the  purposes 
of  examination  or  otherwise,  without  the  hands 
having  been  first  thoroughly  rinsed  in  a solution 
of  pure  carbolic  acid  (1  to  20).  All  sponges 
should  be  permanently  kept  in  a similar  solution ; 
and  all  instruments,  such  as  vaginal  syringes  or 
catheters,  be  thoroughly  soaked  in  the  same  be- 
fore use.  Instead  of  cold  cream,  a preparation 
containing  1 drachm  of  absolute  carbolic  acid  to 
2|  oz.  of  benzoated  lard  should  be  employed  for 
lubricating.  The  utmost  care  should  be  observed, 
to  avoid  the  smallest  piece  of  the  placenta  or 
membrane  being  left  within  the  uterus.  Subse- 
quently all  washings  or  svringings  of  the  genitals 
should  be  performed  with  a solution  of  carbolic 
acid  (1  to  40).  The  practitioner  should  order 
all  these  preparations  to  be  in  the  house  previous 
to  the  expected  time  of  delivery. 

2.  General. — The  general  treatment  varies 
with  the  character  of  the  disease.  At  first  ac- 
tive antiphlogistic  remedies  maybe  indicated: 
and  in  some  cases  local  depletion  by  leeches,  in 
others  blisters.  Drugs,  such  as  veratmm  viride 
(much  employed  in  America),  aconite,  digitalis, 
or  salicylic  acid,  may  be  useful  in  lowering  the 
temperature.  The  internal  administration  of 
turpentine  has  been  highly  extolled ; this  drug 
is  often  very  efficacious  when  applied  on  hot 
flannel  to  the  abdomen,  or  used  as  an  enema 
where  there  is  much  tympanites.  Opium,  or 
morphia,  is  invariably  demanded  to  subdue  rest- 
lessness, allay  pain,  and  induce  sleep.  Lauda- 
num, applied  in  poultices  to  the  abdomen,  is 
sometimes  very  grateful  to  the  patient..  When, 
however,  there  is  much  tenderness  and  disten- 
sion, a paste  composed  of  two  parts  of  extract 
of  belladonna  to  one  of  glycerine,  brushed  thickly 
over  the  whole  abdomen,  will  be  preferable. 
Quinine  is  often  of  great  value  in  diminishing  the 
fever ; it  may  be  given  in  doses  of  10  or  15  grains 
night  and  morning.  Warburg's  tincture  may 
answer  still  better.  The  antiseptic  douche  should 
never  be  omitted;  and  a long  vaginal  tube  should 
be  employed,  so  as  to  ensure  the  fluid  passing 
within  the  uterus.  If  used  warm  it  is  often  very 
comforting,  especially  when  the  discharges  are 
fetid.  In  cases  of  a more  chronic  type,  where 
diarrhoea  is  a prominent  symptom,  tincture  of 


PUERPERAL  DISEASES. 

perchloride  of  iron  in  large  doses,  20  to  30 
minims,  is  sometimes  very  serviceable.  One  of 
the  most  important  elements  in  the  treatment  of 
this  exhausting  disease  is  the  frequent  adminis- 
tration of  nutritious  food  and  stimulants — strong 
boef-tea,  milk,  eggs,  champagne,  or  brandy— in 
small  quantities  at  short  intervals.  In  cases  of 
obstinate  vomiting  recourse  must  be  had  to  nu- 
trient eneraata.  The  most  abundant  supply  of 
fresh  air  that  can  be  admitted  with  safety  should 
be  secured. 

It  is  impossible  to  map  out  any  distinct  line 
; of  treatment  for  puerperal  fever.  Each  case 
must  be  combated  according  to  its  individual 
symptoms,  and  demands  constant  attention  ; for, 
though  the  disease  is  fearfully  fatal,  some  of  the 
most  apparently  hopeless  cases  recover. 

3.  Puerperal  Peritonitis. — This,  though  one 
j of  the  most  frequent  complications  of  puerperal 
fever,  sometimes  occurs  independently  of  it, 
other  symptoms  than  those  consequent  upon  the 
local  inflammatory  attack  being  absent. 

Anatomical  Characters. — - The  post-mortem 
appearances,  associated  with  puerperal  perito- 
nitis, differ  only  from  those  described  in  con- 
nection with  puerperal  septicaemia  inasmuch  as 
they  are  confined  to  the  peritoneal  cavity.  There 
wiii  probably  be  found  an  abundance  of  effused 
serum  or  sero-pus,  and  flaky  lymph,  intense  con- 
gestion of  the  peritoneum,  and  the  abdominal 
viscera  will  here  and  there  be  glued  together. 
The  uterus  will  pirobably  be  found  preternatu- 
rally  soft. 

Symptoms. — Generally  within  a week  follow- 
ing delivery  a well-marked  rigor  occurs,  followed 
' by  febrile  disturbance.  The  patient  complains 
of  acute  pain  in  the  lower  part  of  the  abdomen, 

• at  first  in  one  particular  spot,  but  soon  spreading 
over  a larger  area.  The  thighs  become  flexed 
on  the  abdomen  to  relieve  the  tension ; the  belly 
: becomes  much  swollen,  and  excessively  tender  ; 
and  there  are  generally  much  tympanites  and 
obstinate  constipation.  The  pulse  is  very  cha- 
racteristic, being  quick,  wiry,  and  incompressible. 
Vomiting  soon  sets  in.  If  the  disease  do  not 
give  way,  the  abdomen  becomes  more  swollen 
and  tense,  and  no  pressure  upon  it  can  be  borne. 
Everything  that  is  taken  is  vomited ; the  pulse 
becomes  more  rapid  and  feeble  ; the  tongue  is 
dry  and  raspy  ; the  constipation  gives  way  to 
diarrhoea  ; the  skin  becomes  clammy,  and  the 
extremities  cold ; and  the  patient  dies. 

Treatment. — Tho  application  of  leeches  to 
1 the  abdomen,  immediately  the  tenderness  is  com- 
plained of,  may  be  of  much  service  in  subduing 
the  local  inflammation,  and  allaying  pain.  Opium 
is  the  drug  of  all  others  to  be  relied  upon.  Hot 
fomentations  and  counter-irritants,  such  as  tur- 
1 Jentine,  often  give  great  relief.  In  the  first  stage  a 
lopious  enema  of  thin  gruel  with  castor-oil,  to  ob- 
:ain  a free  action  of  the  bowels,  should  be  given. 
vVhere  there  is  much  tympanites,  the  addition  of 
• urpentine  may  be  of  benefit  in  dispelling  the 
latus.  If  vomiting  prevent  nourishment  being 
aken  by  the  mouth,  it  should  be  administered 
>cr  rectum. 

1.  Puerperal  Thrombosis  and  Embolism. 

Definition. — The  occurrence  of  a blood-clot 
u the  right  side  of  the  heart  or  pulmonary  ar- 
eries,  either  formed  in  situ  or  conveyed  there 


PULMONARY  VESSELS.  1291 

from  a distance  by  the  blood-current,  often  giving 
rise  to  sudden  death  after  delivery. 

Anatomical  Characters, — The  condition  of 
the  blood  in  pregnancy  and  the  puerperal  state 
renders  it  liable  to  form  a coagulum,  and  this 
may  occur  in  distant  vessels.  It  is  well  known 
that  in  the  later  months  of  pregnancy  the  amount 
of  fibrin  in  the  blood  is  very  greatly  increased. 
Together  with  this  a diminution  in  the  volume  of 
the  blood  from  uterine  haemorrhage  produces  a 
state  of  exhaustion,  which  causes  a great  pre- 
disposition to  thrombosis.  If,  therefore,  such 
having  occurred  in  distant  vessels,  a portion  of 
coagulum  become  detached,  and  be  carried  away 
till  it  reach  the  pulmonary  arteries,  embolism  is 
tho  result,  and  this  is  one  of  the  great  causes  of 
sudden  death  occurring  after  parturition.  It  has 
been  shown,  however,  that  pulmonary  thrombosis 
may  occur  independently  of  embolism;  large,  firm, 
decolourised  coagula  have  been  found,  on  post- 
mortem examination,  occupying  the  right  side  of 
the  heart  and  the  larger  branches  cf  the  pulmo- 
nary arteries,  which  have  evidently  formed  there, 
all  traces  of  thrombosis  elsewhere  being  absent. 

Symptoms. — These  are  common  both  to  em- 
bolism and  pulmonary  thrombosis.  In  the  great 
majority  of  cases,  the  patient  is  suddenly  seized 
with  severe  dyspnoea ; she  starts  up  and  gasps  for 
breath ; the  face  in  some  cases  has  been  described 
as  pale,  in  others  livid.  She  feels  she  is  dying, 
and  calls  out  for  air  ; the  pulse  becomes  almost 
imperceptible ; and  generally  death  occurs  very 
rapidly.  In  some  cases,  however,  in  which  the 
clot  is  not  sufficiently  large  to  entirely  obstruct 
the  circulation  in  the  lungs,  it  appears  that  ab- 
sorption may  ultimately  take  place  and  recovery 
ensue.  Dr.  Playfair  has  published  some  cases 
which  support  this  theory. 

Treatment. — In  almost  every  case  so  rapidly 
fatal  is  the  seizure  that  there  is  no  time  to  think 
of  treatment.  When,  however,  the  attack  is  not 
so  terribly  rapid  in  its  termination,  every  effort 
must  be  made  to  rally  the  patient,  by  the  admi- 
nistration of  stimulants,  such  as  brandy,  ether, 
or  ammonia,  if  at  hand.  The  most  perfect  rest 
must  be  enjoined,  so  as  to  prevent  the  coagulum 
from  becoming  dislodged,  and  to  promote  its 
absorption.  Dr.  Richardson  has  recommended 
liquor  ammoniae  in  large  doses,  with  a view  of 
dissolving  the  fibrin.  Clement  Godson. 

PUERPERAL  IN  SANITY.  See  In- 
sanity, Varieties  of. 

PULLNA,  in  Austria. — Sulphated  waters. 
See  Mineral  Waters. 

PULMONARY  APOPLEXY— A term 

for  a certain  form  of  haemorrhage  into  the  lungs. 
See  Lungs,  Haemorrhage  into. 

PULMONARY  DISEASES.  See  Lungs, 
Diseases  of. 

PULMONARY  "VESSELS,  Diseases  of. 
The  vessels  of  the  pulmonary  circulation,  more 
especially  the  veins,  enjoy  a considerable  immu- 
nity from  disease.  Primary  affections  of  these 
are  of  most  exceptional  occurrence,  and  the  causes 
leading  to  their  being  secondarily  involved  are 
not  numerous.  It  is  not  easy  to  account  for 
this.  The  pulmonary  arteries  rarely  present  those 


1 292  PULMONARY  VESSELS,  DISEASES  OF. 


iiseased  states  which  are  of  frequent  occurrence 
in  the  arteries  of  the  systemic  circulation,  and 
are  not  even  as  commonly  affected  as  the  sys- 
temic veins,  with  which  they  somewhat  more 
closely  agree  in  point  of  structure,  and  in  the 
kind  of  blood  carried  by  them.  The  portal  vein, 
which  is  comparable  to  the  pulmonary  artery  in 
other  respects  besides  its  plan  of  distribution, 
would  appear  to  be  similarly  free.  For  these 
reasons  affections  of  the  pulmonary  vessels  are 
rather  of  pathological  interest  than  clinical  im- 
portance ; in  the  majority  of  cases  they  are  not 
to  be  recognised  during  life,  or,  if  so,  are  beyond 
the  application  of  any  treatment.  The  trunk  of 
the  artery,  and  especially  the  orifice  in  the  right 
ventricle,  is  singularly  liable  to  present  congenital 
abnormalities,  which  are  treated  of  in  the  article 
IIeaht,  Malformations  of. 

1.  Inflammation.  — JEtiologt.  — Arteritis 
affecting  the  pulmonary  artery,  whether  acute  or 
chronic,  is  of  very  rare  occurrence.  Previous  to 
birth  it  seems  to  be  more  liable  to  exist  than 
subsequently,  and  some  of  the  congenital  defor- 
mities of  the  pulmonary  artery  and  its  ralve  are 
to  be  attributed  to  it.  No  satisfactory  explana- 
tion has  been  offered  of  the  greater  tendency 
of  the  right  heart  and  vessels  to  inflammation 
before  birth,  and  of  the  left  side  and  aorta  sub- 
sequently. After  birth  it  is  almost  invariably 
associated  with  such  acute  blood-diseases  as 
pyaemia,  or  with  those  pyrexial  states  which  are 
apt  to  assume  a septic  character,  as  scarlet  fever. 
Very  rarely  cases  are  met  with  where  no  cause 
can  be  ascertained ; but  it  is  said  that  whilst 
syphilis  favours  arteritis  in  the  aorta,  chronic 
alcoholism  predisposes  to  its  development  in  the 
pulmonary  artery.  Emboli,  especially  if  of  a 
putrid  character,  -which  have  become  lodged  in 
branches  of  the  vessel,  are  very  liable  to  set  up 
inflammation  in  the  contiguous  walls. 

Anatomicau  Characters. — These  correspond 
with  the  usual  characters  of  arteritis.  The  pro- 
cess begins  in  the  sub-epithelial  layer  of  the 
inner  coat,  and  results  in  the  formation  of  a 
variety  of  • connective  tissue,  which  consists  of 
fibres,  fusiform  fibre-cells,  and  homogeneous 
material ; these  constituents  being  developed  in 
varying  proportions,  and  forming  patches  of  grey 
gelatinous  or  semi-cartilaginous  material.  The 
formation  of  pus  and  abscesses  within  the  thick- 
ness of  the  walls,  and  their  subsequent  rupture 
into  tho  lumen  of  the  vessel,  are  practically 
unknown.  The  valves  at  the  commencement  of 
the  vessel  are  the  most  frequent  seat  of  inflam- 
mation, but  it  has  been  seen  in  the  main  trunk 
of  the  vessel.  When  the  vessels  have  become 
much  dilated,  as  from  extreme  mitral  stenosis, 
the  walls  thus  thinned  are  liable  to  undergo 
changes  of  a chronic  inflammatory  character 
(see  Arteries,  Diseases  of).  This  state  is  only 
demonstrable  after  death  ; during  life  it  is  not 
recognised,  except  the  valves  be  affected,  by  any 
known  signs  or  symptoms,  and  a diagnosis  of 
its  existence  has  not  hitherto  been  attempted. 
Under  such  circumstances  no  plan  of  treatment 
can  be  laid  down. 

2.  Degenerations. — (a)  Atheroma. — This,  as 
in  the  systemic  arteries,  occurs  in  two  forms. 
The  one  form  is  a sequence  of  inflammation,  when 
the  patches  of  grey  translucent  material  above- 


mentioned  undergo  fatty  degeneration,  and,  as 
Virchow  pointed  out,  tend  to  ulcerate,  whilst 
similar  patches  in  the  aorta  are  more  liable  to 
calcify.  The  other  form  consists  in  a fatty  dege- 
neration of  the  deeper  layers  of  the  intima  with- 
out any  previous  inflammation,  and  occurring  as 
part  of  a general  atheroma  of  all  the  vessels.  It 
is  in  vessels  whose  structure  has  been  much 
altered  by  distension  that  atheroma  is  most  fre- 
quently seen.  Calcification  of  the  atheromatous 
areas  is  not  unknown.  No  symptoms  are  to 
be  referred  to  this  condition,  though  Dr.  Walshe 
suspects  that  ‘ in  some  instances  it  aids  in  the 
production  of  pulmonary  apoplexy.’ 

(b)  Albuminoid  degeneration. — This  has  been 
recorded  as  having  been  seen  in  the  muscular 
coat  of  branches  of  the  pulmonary  artery. 

3.  Ulceration. — As  already  said,  inflamma- 
tion of  the  vessel-walls  very  rarely  extends  to 
ulceration  of  the  inner  coat,  but  owing  to  the 
extreme  frequency  of  ulcerative  destruction  of 
the  lung-tissue,  the  intra-pulmonary  branches 
of  the  vessels  are  constantly  involved.  Phthisis 
of  whatever  kind,  abscess,  or  gangrene  of  the 
lungs,  will  each  in  their  progress  invade  the 
vessels,  the  walls  of  which,  though  offering  con- 
siderable resistance  to  the  destructive  process, 
sooner  or  later  yield,  and  may  be  the  cause  of  a 
fatal  haemorrhage,  though  very  frequently  a loss 
of  blood  is  prevented  by  blocking  up  of  the 
vessels  with  coagula. 

4.  Dilatation  and  Aneurism, — Axatomical 
Characters. — Varying  changes  of  abnormal  dis- 
tension are  not  unusual,  occurring  in  both  sexes 
and  in  all  ages  beyond  childhood,  and  are  esti- 
mated as  forming  3 per  cent,  of  aneurisms  of 
all  kinds.  The  dilatation  may  affect  the  trunk 
uniformly ; and  an  extreme  case  has  been  re- 
corded where  the  circumference  of  the  vessel  at- 
tained 6 j inches,  the  normal  average  being  taken 
at  3.)  inches.  Or,  limited  in  extent,  the  bulging 
forms  a sacculated,  or,  more  rarely,  a dissecting 
aneurism  of  the  trunk  or  branches,  from  the  size 
of  a walnut  to  a pea,  or  even  smaller,  these  latter 
being  frequently  multiple.  The  conditions  which 
lead  to  these  alterations  in  the  normal  calibre  of 
the  vessel  are  : — (a)  Those  causing  a diminished 
resistance  of  their  coats  to  the  blood-pressure, 
especially  if  this  be  increased,  which  is  often 
the  case,  by  obliteration  of  some  vessels,  and  con- 
sequent rise  in  tension  in  the  remaining  ones, 
or  by  general  obstruction,  such  as  mitral  stenosis 
or  emphysema  would  cause.  (A)  Those  changes 
in  the  lung-structures  which  diminish  the  sup- 
port of  the  vessels,  and  so  allow  of  their  yielding. 
The  results  of  arteritis  and  atheroma  will  furnish 
the  first  condition,  and  ulceration  and  destruction 
of  the  pulmonary  tissue  will  provide  the  latter. 
The  walls  of  true  aneurisms  may  he  thicker  or 
thinner  than  those  of  the  healthy  vessel.and  it  is 
remarkable  that  their  contents  are  never  lami- 
nated coagula,  even  in  the  largest,  but  always 
fresh  clots. 

An  extreme  case  of  distension  of  the  pulmo- 
nary veins  is  recorded  ( Dublin  Journal.  18321, 
especially  the  left,  where  the  vessels  were  di- 
lated to  four  times  their  normal  size,  owing  to 
extensive  obstructions  at  their  openings  into  the 
left  auricle. 

SrMETOiis. — When  the  main  trunk  of  tb? 


PULMONARY  VESSELS,  DISEASES  OF. 


pulmonary  artery  is  the  seat  of  an  aneurismal 
tumour,  there  are  the  usual  signs  of  pulsation 
and  prominence  in  variable  degrees,  most  marked 
to  the  left  of  the  sternum  in  the  second  intercostal 
space ; over  the  same  area  a systolic  bruit  of  a 
superficial  quality  is  to  be  heard,  not  conducted 
above  the  sternum  or  clavicles ; and  a systolic 
thrill  is  to  be  felt.  There  is  also  accentuation  of 
the  second  sound,  with  the  signs  of  hypertrophy 
of  the  right  ventricle.  Should  the  tumour  be  of 
any  considerable  size,  it  will  give  rise  to  those 
conditions  which  commonly  follow  an  obstruction 
to  the  pulmonary  circulation — namely,  lividity, 
dyspnoea,  cough,  and  general  anasarca,  with 
scanty,  high-coloured  urine.  In  an  exceptional 
case  pallor  of  the  face  was  noticed.  Pain  behind 
the  sternum,  and  headache  also  exist.  Since  the 
greater  part  of  the  artery  is  included  within  the 
pericardium,  it  is  into  that  sac  that  rupture  will 
probably  occur. 

The  small  aneurisms  of  the  intra-pulmonic 
branches  give  rise  to  no  known  symptoms  until 
haemoptysis  indicates  their  rupture. 

Diagnosis. — An  aneurism  of  the  trunk  of  the 
pulmonary  artery  may  have  to  be  distinguished 
from  a similar  affection  of  the  aorta,  or  from 
a post-sternal  tumour  to  which  pulsation  has 
been  communicated.  The  tendency  of  pulmonary 
aneurism  to  extend  to  the  left  side,  and  the  non- 
conduction  of  the  bruit  to  the  vessels  at  the  root 
of  the  neck,  with  the  coincident  signs  of  pulmo- 
nary  obstruction,  are  grounds  upon  which  to 
found  a distinction. 

Prognosis. — This  is  of  necessity  grave,  what- 
ever the  size  of  the  lesion,  and  many  eases  of 
fetal  haemoptysis  are  due  to  rupture  of  a small- 
sized sac. 

Treatment. — How  far  such  treatment  as  gal- 
vano-puncture,  the  administration  of  iodide  of 
potassium,  &c.,  as  pursued  in  aneurism  of  the 
systemic  vessels,  is  applicable  to  similar  affec- 
tions of  the  pulmonary  artery,  is  unknown.  For 
the  treatment  of  the  haemorrhage  to  which  their 
rupture  gives  rise,  see  Bjemoptysis. 

5.  Stenosis. — A narrowing  of  the  pulmonary 
artery  may  take  place  at  the  orifice  in  the  conus 
arteriosus,  or  more  rarely  in  the  trunk  or  main 
branches.  In  the  former  situations  it  is  com- 
monly congenital,  the  result  of  endocarditis  or 
myocarditis,  which,  if  developed  within  the  first 
three  months  of  foetal  life,  is  almost  invariably 
accompanied  by  some  compensating  lesion,  such 
as  intraventricular  communication ; whilst  if  the 
affection  of  the  heart  ho  subsequent  to  the  third 
month  of  development,  the  circulation  is  carried 
on  through  a patent  foramen  ovale  and  ductus 
arteriosus  ( see  Heart,  Malformations  of).  It  is 
conceivable  that  stenosis  of  tlio  conus  arteriosus 
may  be  followed  by  secondary  narrowing  and 
closure  of  the  pulmonary  artery,  and  also  that 
defective  development  of  tho  lungs  may  cause 
a narrowed  vessel.  The  condition  is  very  rarely 
due  to  any  acquired  change  in  the  vessel-walls, 
although  a case  is  recorded  of  stenosis  of  the 
artery  from  cartilaginous  thickening  and  calcifi- 
cation of  its  coats.  The  calibre  of  the  tube  may 
be  diminished  by  the  pressure  of  tumours,  such 
as  an  aortic  aneurism  or  adenoid  growths,  or  by 
tiie  shrinking  of  cicatricial  tissue  in  the  adjacent 
lungs. 


1 293 

AVhen  stenosis  is  developed  at  a very  early 
period  of  foetal  life,  the  artery  remains  exceedingly 
narrow  behind  the  obstruction.  AVhen  it  occurs 
late,  the  vessel  may  he  of  normal  capacity,  and 
if  insufficiency  co-exist  with  the  obstruction,  it 
may  even  he  dilated  (Lebert). 

Symptoms. — AVhatever  be  the  cause  of  pulmo- 
nary stenosis,  there  will  be  a deficient  supply  of 
blood  to  tho  lungs,  producing  dyspnoea,  and  the 
obstruction  to  the  circulation  will  give  rise  to  nil 
the  signs  and  symptoms  of  general  venous  conges- 
tion, although  to  a less  degree  than  in  affections 
of  the  tricuspid  orifice.  Hypertrophy  of  the 
right  ventricle,  as  evidenced  by  increased  trans- 
verse measurement  of  the  area  of  cardiac  dul- 
ness ; a basic  thrill ; a systolic  bruit,  of  maximum 
intensity  over  the  heart’s  base,  and  conducted  to 
the  left  of  the  sternum,  but  not  audible  along 
the  course  of  the  aorta  and  great  vessels ; and  a 
marked  accentuation  of  the  second  sound — are  the 
most  important  diagnostic  signs  of  this  condition. 
Cyanosis  is  not  a characteristic,  and  does  not 
occur  unless  there  he  extreme  venous  congestion, 
or  a communication  between  the  two  sides  of  the 
heart.  The  association  of  constriction  of  the 
pulmonary  artery,  both  congenital  and  acquired, 
with  tubercular  phthisis,  has  now  been  too  fre- 
quently observed  for  it  to  be  regarded  as  a co- 
incidence only,  and  their  relation  as  cause  and 
effect  is  generally  admitted. 

Teeatment. — This  affection  is  entirely  beyond 
the  reach  of  remedy. 

6.  Hupture. — Violent  effort  and  great  excite- 
ment have  been  followed  by  rupture  of  the  pul- 
monary artery,  either  of  the  trunk  or  main 
branches ; it  is  said,  even  without  previous  dis- 
ease of  the  vessel  (Chevers,  1816).  But  in  the 
majority  of  recorded  cases  the  coats  were  dege- 
nerated. Death  is  often  instantaneous,  hut  very 
frequently  is  delayed,  even  some  hours.  Aneur- 
isms tend  to  burst  sooner  or  later ; those  of  the 
trunk  usually  opening  into  the  pericardium,  while 
the  intra-pulmonary  dilatations  commonly  rup- 
ture into  cavities  in  the  lung.  Ulceration,  as 
said,  is  of  very  rare  occurrence,  but  a case  is 
recorded  of  its  existence  and  extension  through 
all  the  coats  of  the  vessel,  with  a suddenly  fatal 
termination.  Rupture  of  the  pulmonary  veins 
has  been  recorded. 

7.  Embolism  and  Thrombosis. — The  pulmo- 
nary artery  is  especially  liable  to  become  plugged, 
both  by  substances  lodged  in  it  from  elsewhere,  and 
by  coagula  originating  in  the  vessel  itself.  Its  re- 
lationship to  the  venous  circulation  explains  this. 
Portions  of  broken-down  clots  developed  in  the 
systemic  veins,  from  whatever  cause  ; the  contents 
of  hydatid  and  other  cysts  that  have  burst,  into 
the  venous  current;  fragments  of  cancerous  and 
other  new  growths,  all  of  which  readily  travel 
onwards  towards  the  heart,  pass  into  the  pul- 
monary artery,  in  the  branches  of  which  they 
become  lodged,  according  to  their  size.  Once 
located,  the  plug  will  increase  in  size  by  the  de- 
position on  it  of  successive  layers  of  fibrin, 
sometimes  to  such  au  extent  as  to  obliterate  all 
traces  of  the  original  obstructing  substance.  Oc- 
casionally very  large  thrombi  are  detached  in 
the  systemic  veins,  and  are  arrested  in  the  trunk 
and  main  branches  of  the  pulmonary  artery.  The 
causes  of  thrombosis  of  the  vessel  are  various. 


1294  PULMONARY  VESSELS. 

The  rare  occurrence  of  inflammation  or  degenera- 
tion of  the  artery  renders  obstruction  of  the  vessel 
from  primary  thrombosis  very  uncommon;  but  the 
development  of  clots  iu  the  smaller  branches, 
in  association  with  pneumonia,  phthisis,  gan- 
grene, and  other  destructive  Aing-diseases,  is 
frequent.  In  certain  septic  states,  in  parturient 
women,  and  in  conditions  of  extreme  anaemia,  es- 
pecially with  diminished  heart-power,  when  the 
blood  is  prone  to  clot  in  the  vessels,  the  pulmon- 
ary artery  is  a favourite  locality  for  this  to  occur. 
Thrombi  may  commence  in  the  right  ventricle, 
or,  as  would  appear,  sometimes  on  the  semi- 
lunar valves,  and  extend  into  the  trunk  and,  for 
variable  distances,  into  the  branches  of  the  ves- 
sel. Such  obstructions  are  frequently  developed 
during  the  last  hours  of  life,  when  the  circula- 
tion is  enfeebled  and  slow.  See  Embolism:  ; and 
Heart,  Thrombosis  of. 

Symptoms.— The  symptoms  will,  of  course, 
depend  upon  the  extent  and  completeness  of 
the  obliteration  of  the  pulmonary  circulation.  If 
only  the  smaller  branches  be  occluded,  there  may 
be  no  symptoms  to  be  directly  ascribed  tc  the 
obstruction.  A very  moderate  dyspnma  or  slight 
haemoptysis  would  be  equally  attributable  to  the 
phthisis  or  other  lung-state  which  had  deter- 
mined the  formation  of  the  thrombi. 

In  another  class  of  cases,  when  larger  branches 
are  blocked,  very  marked  dyspnoea  is  developed, 
with  such  symptoms  as  are  conveniently  grouped 
under  the  term  ‘ anginal,’  such  as  pain  in  the 
prseeordia,  a sense  of  great  distress  and  faintness, 
palpitation,  lividity,  and  extreme  pallor,  with 
cold  sweats,  but  no  loss  of  mental  faculties,  and  an 
almost  imperceptible  pulse.  The  onset  of  such  a 
condition  maybe  gradual  or  rapid;  in  the  former 
case  it  depends  on  the  slow  increase  in  size  of  a 
small  thrombus;  in  the  latter,  on  the  sudden 
lodgment  in  some  branch  of  the  artery  of  a solid 
substance  that  has  entered  the  venous  current. 
In  some  cases  these  symptoms  are  present  to 
an  extreme  degree,  and  death  follows  in  a few 
minutes  ; in  fact,  this  lesion  constitutes  one  of 
the  causes  of  sudden  death.  The  appearances 
are  not  those  of  asphyxia,  and  it  is  usual  to 
attribute  the  very  rapidly  fatal  result  to  syn- 
cope or  shock,  as  it  would  seem  to  be  connected 
in  some  way  with  an  arrest  of  the  nerve-govern- 
ance of  the  heart.  In  that  class  of  cases  which 
do  not  terminate  so  quickly,  it  is  usual  to  find 
that  the  symptoms  abate  somewhat,  and  may  be 
followed  at  a variable  interval  of  hours  or  days 
by  a second  or  even  several  attacks,  finally  ending 
fatally.  The  post-mortem  examination  of  such 
cases  shows  a thrombus  of  considerable  extent, 
with  indications  of  its  having  been  formed  at 
different  times. 

Examination  of  the  chest  reveals  no  diagnostic 
signs.  There  is  very  likely  to  be  a basic  systolic 
murmur  conducted  along  the  course  of  the  pul- 
monary artery ; but  this  is  not  constant. 

Diagnosis. — This  is  often  very  uncertain.  The 
conditions  in  which  thrombosis  is  usually  met 
with,  such  as  anaemic  or  parturient  women,  are 
those  in  which  breathlessness,  cardiac  pain,  and 
discomfort,  and  even  a pulmonary  hsemic  bruit, 
are  of  frequent  occurrence.  The  symptoms,  when 
not  of  extreme  rapidity,  are  very  similar  to 
those  caused  by  stenosis  of  the  pulmonary  artery, 


PULSATION. 

which  in  itself  is  difficult  to  diagnose;  and 
lastly,  the  suddenly  fatal  cases  are  almost  iden- 
tical in  their  manifestations  with  rupture  of  the 
heart  or  of  a thoracic  aneurism,  or  even  angina 
pectoris.  The  supervention  of  the  above-detailed 
symptoms  in  a case  of  existing  phlebitis,  in  a 
woman  within  twelve  or  fourteen  days  after  child- 
birth, renders  it  highly  probablethat  they  are  due 
to  a clot  in  the  pulmonary  artery. 

Prognosis. — This  is  to  be  looked  upon  as  of 
the  gravest  character,  if  once  symptoms  arise 
which  indicate  the  existence  of  a clot  in  the  pul- 
monary vessels.  The  smallest  plugs  formed  in 
branches  which  are  being  invaded  by  a progres- 
sive destructive  change  in  the  lungs,  are  pro- 
tective in  character,  and  prevent  or  diminish  an 
haemoptysis  which  erosion  of  the  vessels  might 
produce. 

Treatment. — In  the  most  rapid  cases  death 
takes  place  before  anything  can  be  done;  but  in 
the  less  severe  cases  two  points  have  to  be 
attended  to,  namely,  absolute  rest,  and  free  sti- 
mulation by  brandy,  ether,  and  ammonia,  for  by 
such  means  only  can  any  hope  be  entertained  of 
preventing  an  extension  of  the  clot.  Sinapisms 
over  the  cardiac  region  often  afford  relief. 

W.  H.  Allchin. 

PULMONARY  MURMUR.—  This  word 
may  be  employed  in  two  senses,  namelv  as  sig- 
nifying, first,  the  respiratory  sound  heard  over 
the  lung;  or,  secondly,  a bruit  heard  in  connex- 
ion with  the  pulmonary  artery  and  its  valves. 
See  Heart,  Valves  of,  Diseases  of ; Physical 
Examination;  and  Pulmonary  Vessels,  Dis- 
eases of. 

PULMONARY  VALVES  AND  ORI- 
FICES, Diseases  of.  See  Heart,  Valves  of, 
Diseases  of ; and  Pulmonary  Vessels,  Diseases 
of. 

PULSATION  ( pulso , I beat). — Pulsation 
is  a sensation  of  beating  or  throbbing,  either  ob- 
jectively appreciated  by  inspection  or  palpa- 
tion, or  subjectively  felt.  It  originates  in  the 
presence  of  a pulse  or  rhythmical  rise  and  fall 
of  blood-pressure,  whether  normal  or  abnormal, 
in  connection  with  the  part  where  it  is  situated. 
In  most  instances  this  is  either  the  heart  or  some 
kirge  blood-vessel;  but  in  other  instances  the 
pulsation  has  a different  origin,  especially  when 
the  phenomenon  is  abnormal.  As  instances  of 
normal  pulsation  may  be  mentioned  the  cardiac 
impulse;  the  arterial  pulse  generally;  the  pul- 
sation of  the  umbilical  cord ; and  the  beating 
of  the  fontanelles.  Abnormal  pulsation  may  be 
referable  (1)  to  dilatation  of  a blood-vessel,  as  in 
aneurism  ; (2)  to  vascular  dilatation  and  cardiac 
enlargement,  as  in  aortic  incompetence;  (3)  to 
vascular  dilatation  and  cardiac  excitement,  as  in 
exophthalmic  goitre ; (4)  to  interference  with  the 
passage  of  blood  through  a vein,  or  even  regur- 
gitation into  it,  as  in  the  jugular  pulse  of  tri- 
cuspid disease ; or  (5)  to  the  presence  of  a 
tumour  upon  a large  vessel,  conveying  thenormal 
pulse  unnaturally  to  the  surface  of  the  body,  as 
in  tumour  of  the  pancreas  or  pylorus.  Pulsatiou 
may  also  be  present  (6)  in  any  part  when  it  is 
the  seat  of  inflammation,  the  small  vessels  being 
dilated;  (7)  in  aneurism  by  anastomosis;  and 


PULSATION. 

(3)  in  malignant  disease  of  bone,  which  may 
closely  simulate  aneurism. 

With  respect  to  the  characters  of  this  pheno- 
menon, it  is  of  great  practical  importance  to 
distinguish  true  expansile  or  eccentric  pulsation 
from  pulsation  which  is  communicated  only.  In 
the  former  case  the  seat  of  pulsation  expands 
rhythmically  in  all  directions  ; in  the  latter  case 
it  is  moved  in  one  direction  only,  that  is,  it  rises 
and  falls  under  the  influence  of  tli6  motion  con- 
veyed to  it. 

The  various  pathological  conditions  which 
give  rise  to  pulsation,  and  their  treatment,  are 
fully  discussed  under  appropriate  heads. 

J.  Mitchell  Bruce. 

PULSE,  The. — Synon.  : Fr.  le  Fouls  ; Ger. 
der  Puls. — Each  contraction  of  the  heart, 
by  throwing  the  contents  of  the  left  ventricle 
into  the  aorta,  causes  a sudden  change  in  the  ful- 
ness of  the  systemic  arteries,  which  is  manifested 
by  elongation  and  dilatation  of  these  vessels. 
When  the  finger  is  placed  upon  an  artery,  which 
vans  on  a resisting  plane,  such  as  the  radius 
forms  beneath  the  radial  artery  at  the  wrist, 
slight  compression  by  the  finger  enables  us  to 
detect  an  increased  hardness  in  the  vessel  at 
each  cardiac  contraction.  It  is  this  increase  of 
i hardness,  or  fulness,  or,  in  other  words,  this 
change  in  the  distension  of  the  artery',  which 
constitutes  the  pulse.  In  feeling  the  pulse  the 
finger  slightly  compresses  the  artery,  and  thus 
flattens  it ; the  cylindrical  form  is  restored  by 

I each  pulsation.  The  amount  of  pressure  required 
to  flatten  the  artery  completely,  is  the  rough  and 
ready  way  of  estimating  its  fulness  or  tension, 
and  is  best  performed  by  compressing  the  vessel 
with  the  index  finger,  whilst  the  middle  and  ring 
fingers,  placed  more  distant  from  the  heaTt. 
checkoff  the  pressure  required  to  stop  the  blood- 
flow. 

The  movement  of  the  artery  perceived  by  the 
finger  appears  in  most  cases  to  be  simple,  but 
when  registered  by  the  sphygmograph  it  is  found 
to  be  a compound  of  three  waves,  called  the  sum- 
mit wave,  the  tidal  wave,  and  the  dicrotism.  The 
summit  wave,  which  caps  the  line  of  ascent  of  the 
trace,  is  due  to  the  sudden  vibration  in  the  blood- 
column,  following  immediately  on  the  lifting  of 
the  aortic  valves  by  the  discharge  of  the  contents 
of  the  left  ventricle.  The  tidal  wave,  or  wave 
of  impletion.  or  first  secondary  wave,  as  it  is  also 
called,  is  due  to  the  distension  of  the  arteries, 
following  the  increased  pressure  in  the  aorta  and 
great  vessels,  from  the  reception  of  the  ventri- 
cular contents.  The  dicrotism,  or  great  secondary 
leave,  is  an  oscillation  of  the  blood-column, 
mainly,  if  not  wholly,  produced  by  the  rebound 
of  the  blood  from  the  closed  aortic  valves 
under  the  pressure  of  the  aortic  recoil.  See 
Dicrotism. 

A pulse-trace  (fig.  55)  consists  then  in  a line 
j of  ascent,  a to  b,  which  ends  in  the  summit  wave, 
b,  and  corresponds  to  the  first  part  of  the  ventri- 
cular systole ; from  the  summit  wave  the  tracing 
falls  slightly,  till  it  is  again  raised  by  the  tidal 
wave,  c,  due  to  the  impletion  of  the  vessel.  After 
the  tidal  wave  a more  marked  descent  occurs, 
called  the  aortic  notch,  e,  and  the  line  again  rises, 
into  the  dicrotic  wave,  d.  The  line  of  descent, 


PULSE.  1295 

b to  a1,  is  thus  broken  by  two  waves  and  two 
notches.  The  two  waves  have  already  been  de- 
scribed ; of  the  two  notches  one  precedes  the  tidal 
wave,  and  indicates  a slight  collapse  in  the  arte- 
rial wall  after  the  oscillation  called  the  summit 
wave ; whilst  the  aortic  notch  preceding  the 
dicrotism  marks  the  fall  in  pressure  in  the  arte- 
ries antecedent  to  the  closure  of  the  aortic  valves. 


Fig.  55.  Typical  pnlse-trace.  a to  5,  line  of 
ascent ; b to  a\  line  of  descent ; b,  summit 
wave  ; c,  tidal  wave  ; <?,  dicrotic  wave  or 
dicrotism  ; e,  aortic  notch. 

The  moment  theso  valves  are  closed  the  line  of 
descent  rises  again.  It  is  the  bottom  of  this 
notch,  marking  as  it  docs  the  closure  of  the  aortic 
valves,  which  points  out  the  termination  of  the 
ventricular  systole.  The  remainder  of  the  line 
of  descent  corresponds  with  the  diastole  of  the 
ventricle. 

The  pulse-trace  is  modified  in  its  chief  fea- 
tures by  the  state  of  arterial  fulness  or  tension. 
When  the  tension  is  high  (fig.  56)  the  line  of 
ascent  is  less  lofty ; the  tidal  wave  is  large,  and 


Fig.  56.  Trace  of  pnlse  of  high  tendon, 
often  blended  with  the  summit  wave ; the  aortic 
notch  is  shallow;  the  dicrotism  is  not  much  de- 
veloped ; and  the  line  of  descent  is  gradual. 
When  the  tension  is  low  (fig.  57),  the  line  of  ascent 
is  lofty ; the  summit  wave  distinct ; the  tidal 
wave  small;  the  aortic  notch  deep;  the  dicrotism 


Fig.  57.  Trace  of  pulse  of  low  tension, 
highly  developed ; and  the  line  of  descent  sudden. 
These  modifications  are  interfered  with,  if  the  nor- 
mal elasticity  of  the  arteries  be  lost,  as  in  arterial 
degeneration. 

The  pulse  thus  registered  by  the  sphygmo- 
graph, or  felt  by  the  finger,  is  a movement  of  the 
blood-column,  primarily  caused  by  the  heart,  but 
greatly  modified  by  the  properties  of  the  blood- 
vessels. On  the  heart  depend  the  rate,  the 
rhythm,  and,  to  some  extent,  the  force  of  the 
pulse  ; whilst  on  the  vessels  depend  the  mode  of 
the  blood-flow,  and  the  ease  of  its  passage.  By 
virtue  of  their  elasticity,  the  larger  arteries  con- 


PULSE. 


1296 

vert  the  intermittent,  jerky  impulse  given  to  the 
blood  by  the  heart-beats,  into  an  even  flow  of 
regular  waves  ; and  the  smaller  arteries  regulate, 
by  their  permeability,  the  ease  with  which  the 
blood-stream  flows  onward  to  the  veins,  thus 
governing  to  a great  extent  the  fulness  or  tension 
of  the  arterial  system. 

The  art  of  feeling  the  pulse  consists  in  dis- 
covering, from  the  sensation  imparted  to  the 
finger,  the  condition  of  the  arterial  wall  and  the 
arterial  contents.  When  the  artery  is  felt  to  be 
hard  and  cord-like,  rolling  more  or  less  rigidly 
under  the  finger,  changes  in  the  arterial  coats, 
due  to  degenerative  arteritis  or  senile  change, 
aro  indicated.  The  radial  artery  is  sometimes 
congenitally  anomalous,  and  a high  bifurcation 
of  the  vessel  or  other  peculiarity  may  account 
for  the  absence  or  smallness  of  the  puise  on  one 
or  both  sides.  The  finger,  as  abovo  mentioned, 
also  estimates  the  fulness  of  the  vessel  from  its 
compressibility,  and  hence  learns  how  the  heart 
and  arteries  are  acting.  The  effects  of  their 
action  on  the  form  of  the  pulse-wave  the  sphyg- 
mograph  records.  In  children  the  pulse  may 
often  be  most  accurately  observed  in  the  tem- 
poral artery  during  sleep.  See  Sphvgmogeaph. 

It  will  be  convenient  to  consider  in  succession 
the  frequency,  the  rhythm,  and  the  force  or 
strength  of  the  pulse. 

1.  Frequency. — The  frequency  of  the  pulse 
depends  on  the  rate  of  the  heart's  contractions. 
This  rate  varies  with  age,  position,  sex,  stature, 
and  a number  of  physical  and  psychical  in- 
fluences. In  the  newly-born  infant  the  heart  and 
pulse  beat  some  130  to  140  times  a minute.  The 
rate  gradually  falls,  and  after  the  sixth  year  it  is 
usually  below  100  ; and  a further  decrease  of  30 
beats  a minute  gradually  occurs  before  the  rate 
of  manhood  (70  to  75  a minute)  is  reached.  In 
old  age  the  pulse-rate  often  rises  again  slightly. 

In  the  erect  posture  the  pulse  beats  at  some 
10  a minute  in  the  male,  and  7 in  the  female, 
over  the  sitting  rate,  and  some  5 more  over 
the  rate  of  the  recumbent  position.  The  fe- 
male of  seven  years  has  some  10  pulse-beats  a 
minute  more  than  the  male  of  the  same  age. 
As  regards  stature,  we  may  say  briefly  that  height 
diminishes  the  number  of  beats  slightly,  a man 
of  6 feet  having  a pulse  of  3 or  4 slower  than  a 
man  of  5i  feet. 

Movement  and  exertion  of  all  kinds  quicken 
the  pulse,  and  mental  emotion  or  excitement  in 
neurotic  persons  runs  up  the  rate  very  high.  In 
examining  healthy  people  for  life  assurance,  as 
well  as  when  visiting  patients,  this  must  be  taken 
into  account.  A good  meal  increases  the  fulness 
and  frequency  of  the  pidse,  and  so  does  the  use 
of  stimulants  in  health,  though  in  acute  diseases 
the  reduction  of  the  pulse-rate  is  often  the  test 
of  their  beneficial  action.  The  pulse  is  less  fre- 
quent during  the  night  and  during  sleep  ; it  rises 
in  frequency  during  the  early  hours  of  the  day. 

Increased  frequency. — Such  are  the  conditions 
which  affect  the  pulse-rate  ordinarily  in  healthy 
persons.  In  disease  increased  frequency  is  one 
of  tho  most  common  changes,  as,  for  example, 
the  frequent  pulse  of  all  pyrexial  attacks.  The 
pulse-rate  and  the  pulse-form,  as  recorded  by  the 
sphygmograph,  are  closely  connected  with  the 
temperature-elevation.  The  pyrexial  pulse-trace 


shows  important  modifications  in  the  dicrotic 
wave,  which  becomes  more  and  more  developed 
as  the  pyrexia  increases.  The  aortic  notch  deepens, 
and  when  it  reaches  the  level  of  the  curve-basis 
(tho  line  joining  the  commencement  of  each 
line  of  ascent)  the  pulse  is  called  dicrolous  or 
fully  dicrotnus ; this  form  corresponds  with  a 
pulse-rate  of  over  100  per  minute,  and  a tem- 
perature of  about  103°  Fahr.  When  the  aortic 
notch  sinks  below  the  level  of  the  curve-basis, 
and  the  dicrotic  wave  is  blended  with  the  line  of 
ascent  of  the  next  pulsation,  the  pulse  is  called 
hyper-dicrotous,  and  the  temperature  is  generally 
at  or  over  104°  Fahr.  [see  fig.  62).  The  pulse- 
rate  in  many  febrile  cases  becomes  a prognostic 
sign  of  great  value,  sometimes,  as  in  puerperal 
cases,  being  of  more  value  than  the  temperature. 

Diminished  frequency. — A reduced  pulse-rate 
is  less  commonly  seen.  It  is  met  with  in  certain 
casosof  blood-impurity,  such  as  jaundice,  anaemia, 
and  diabetes  ; in  convalescence  from  pneumonia ; 
in  relapsing  fever  ; in  fatty  degeneration  of  the 
heart ; and  in  some  nervous  affections,  especially 
of  the  medulla.  In  one  of  these  last  cases  the 
writer  has  observed  a pulse  of  24 ; and  a rate  as 
low  as  14  a minute  has  been  recorded. 

2.  Rhythm. — The  rhythm  of  the  pulse  de- 
pends also  on  the  rhythm  of  the  heart ; regular 
heart-action  produces  regularpulse,  and  rice  versa. 
Variations  in  rhythm  are  of  two  kinds,  intermit 
tejice  and  irregularity. 

Intermittence. — Intermittence  means  the  omi? 
sion  of  a beat  from  time  to  time.  This  omission 
may  occur  at  regular  intervals,  for  example,  every 
tenth  or  twentieth  beat ; or  it  may  occur  irregu- 
larly, so  that  every  now  and  then  a beat  is  missed. 
Intermissions  occur  more  rarely  in  the  young 
than  in  the  old,  and  may  be  associated  with  no 
other  evidence  of  disease.  In  some  cases  nervous 
excitement  will  produce  them  ; in  others  they 
depend  on  hypochondriasis,  dyspepsia,  the  exces- 
sive use  of  tobacco,  gout,  over-work,  and  on  fatty 
degeneration  or  some  neurosis  of  the  heart.  Occa- 
sionally an  intermittent  pulse  is  the  first  indi- 
cation of  deep-seated  malignant  disease.  Some 
patients  are  unconscious  of  tho  intermissions, 
while  others  feel  the  heart  stumble  in  its  work, 
as  it  were,  at  each  last  beat.  In  many  persons  in- 
termissions are  habitual,  and  do  not  necessarily 
indicate  disease,  but  they  impair  the  life-value. 
Intermittent  action  is  often  observed  in  old  per- 
sons otherwise  healthy. 

Irregularity. — Irregularity,  the  other  variety 
of  disordered  rhythm,  presents  itself  in  two 
forms,  as  irregularity  in  frequency,  and  irregu- 
larity in  force  or  inequality.  These  two  forms 
are  frequently  associated ; of  a number  of  pul- 
sations no  two  may  seom  equal  in  force,  and  no 
two  may  succeed  each  other  at  equal  intervals  ot 
time.  In  other  cases  a number  of  good,  steady 
beats,  regular  in  frequency  and  equal  in  force, 
may  be  followed  by  a disorderly’  series,  unequal 
and  irregular.  These  abnormalities  are  best 
observed  in  cases  of  mitral  valve  disease  and  in 
dilatation  of  the  heart,  although  the  pulse  may 
be  unequal  and  irregular  in  all  forms  of  heart- 
disease  at  some  period  of  their  evolution.  Mitral 
insufficiency  affords  the  common  examples  of  un- 
equal and  irregular  pulse,  though  in  this  affection 
the  pulse-beats  may  only  be  slightly  unequal 


PULSE. 


In  size  and  form,  but  perfectly  regular  in  the 
periodicity  of  their  occurrence.  In  mitral  stenosis 
irregularity  and  intermissions  are  generally  asso- 
ciated with  inequality.  Some  intermissions  are 
what  are  commonly  called/nte  intermissions,  the 
ventricular  systole  being  too  weak,  or  the  wave 
of  blood  thrown  into  the  aorta  too  scanty,  to  be 
perceived  at  the  wrist.  In  such  cases  the  sphvg- 
mograph  records  the  wave  which  escapes  the  fin- 
ger. In  mitral  cases  irregularity  and  inequality 
are  increased  by  exercise.  See  Sfhygmograph. 

Inequality  in  the  size  of  the  pulsations  often 
depends  on  respiratory  influences.  Deep  inspira- 
tion normally  reduces  arterial  tension,  lessens  the 
size  of  the  pulsations,  and  quickens  the  pulse  ; 
while  expiration  raises  the  tension,  increases  the 
size  of  the  pulsations,  and  slows  the  pulse.  An  ex- 
aggeration of  these  effects  constitutes  the  pul.stts 
paradoxus  or  pulsus  inspirations  inter  mittens.  In 
some  cerebral  cases  the  regular  succession  of 
large  and  small  pulsations  is  observed,  constitu- 
ting the  pulsus  alternans  or  bigeminus. 

In  health  the  pulse  may  sometimes  be  noticed 
to  be  irregular  on  waking;  and  in  convalescence 
from  acute  disease  irregularity  in  force  and  time 
is  not  infrequent. 

The  pulse  may  be  occasionally  suppressed  in 
one  or  all  the  arteries.  When  general,  this  is  due 
to  cardiac  weakness,  and  the  sphygmograph  will 
often  record  a small  gradual  pulse-wave,  which 
escapes  the  finger.  When  partial,  the  suppres- 
sion is  due  to  either  compression,  thrombosis,  or 
aneurism  of  the  main  trunk. 

The  pulse  in  one  radial  occasionally  is  felt  to 
occur  later  than  in  the  other  artery;  this  is  called 
retardation,  and  usually  indicates  aneurism. 

3.  Force. — The  force  of  the  pulse,  which  the 
flngerestimates  by  theamountof  pressure  required 
to  obliterate  it,  and  which  the  sphygmograph 
measures  by  the  weight  or  pressure  required  to 
develop  to  the  full  the  main  features  of  each 
pulsation  in  the  trace,  is  the  product,  in  the  first 
place,  of  the  heart's  vigour.  The  distribution  of 
the  heart's  force,  however,  depends  on  the  state 
of  the  smaller  blood-vessels.  When  these  are 
relaxed  and  open,  a vigorous  heart  has  its  force 
distributed  quickly  over  the  whole  vascular  area 
by  the  rapid  onward  passage  of  the  blood.  When, 
on  the  contrary,  the  arterioles  are  contracted, 
he  heart’s  force  is  retained  in  the  arteries  for  a 
onger  time.  In  the  first  case,  the  pulse  is  soft 
vnd  compressible,  from  the  small  quantity  of 
flood  retained  in  the  artery ; in  the  second  case,  it 
s hard  and  incompressible,  from  the  fulness  of  the 
rtery  with  blood  under  high  pressure.  It  may 
•e  well  to  point  out  here,  that  the  size  of  the 
■ulse  and  the  amplitude  of  the  pulse-trace  are  by 

0 means  fair  indications  of  its  force  or  strength, 
'hese  qualities  depend  on  the  sudden  variations 

1 tension  (fulness  of  blood)  which  the  artery 
ndergoes.  For  instance,  a moderately  strong 
cntricle  will  produce  in  states  of  easy  blood- 
iOw  through  the  capillaries  an  ample  pulse,  but 
Me  easily  compressed  ; whilst  the  same  ventricle, 
•ting  with  even  more  force,  in  conditions  of  les- 
ned  capillary  permeability,  will  produce  a pulse 
nek  less  ample,  but  less  easily  compressed, 
he  simple  experiment  of  feeling,  or  recording 
th  the  sphygmograph,  the  pulse  when  the  capil- 
ries  are  dilated  by  a warm  bath,  and,  again, 

82 


1297 

when  contracted  by  a cold  one,  will  exemplify 
this.  The  permeability  of  the  smaller  vessels 
also  reacts  on  the  heart,  and  influences  both 
the  frequency  and  mode  of  contraction.  When 
the  capillary  circulation  is  easy,  the  heart’s  ac- 
tion is  more  frequent,  and  the  ventricular  con- 
tractions shorter  or  more  sudden  ; when,  on  the 
contrary,  the  circulation  is  obstructed  by  con- 
traction of  the  peripheral  vessels,  the  heart’s 
action  becomes  less  frequent,  and  the  ventricular 
contraction  is  longer  and  less  sudden.  Thus  the 
vascular  tension  may  be  said  to  be  in  inverse 
proportion  to  the  frequency  and  suddenness  of 
the  heart’s  action.  The  force  of  the  pulse,  as  thus 
modified  by  the  state  of  the  peripheral  circula- 
tion, gives  us  some  of  our  most  important  clinical 
information.  Modem  clinical  research  shows  how 
valuable  is  a study  of  this  force  of  the  circulation 
as  manifested  by  the  tension  of  the  arteries.  It 
is  this  quality  of  tension  which  forms  the  best 
basis  for  the  division  of  the  various  pulse-forms 
into  the  two  great  classes  of  hard  and  soft  pulses, 
or  pulses  of  high  and  low  tension.  The  hard  pulse 
requires considerablepressure  to  enable  the  sphyg- 
mograph to  record  its  features  to  the  full ; the 
soft  pulse  yields  the  best  trace  to  slight  pressure. 

Other  Characters. — Thesjjc  of  the  pulse  de- 
pends on  the  development  of  the  line  of  ascent 
and  the  tidal  wave,  which  are  modified  by  the 
volume  of  blood  expelled  by  the  ventricle,  and 
the  state  of  fulness  of  the  arteries.  When  the 
arteries  are  contracted  the  pulse  is  hard  and 
wiry ; when  the  coats  are  relaxed  it  is  large  and 
soft.  The  flickering  pulse  is  indicative  of  feeble 
and  unequal  ventricular  contractions  ; and  the 
undulatory  character  noticed  in  some  weak  pulses 
is  due  to  the  influence  of  the  respiratory  move- 
ments, causing  variations  in  the  tension.  The 
quality  of  suddenness  (quick  ventricular  systole) 
is  betrayed  by  a nearly  vertical  lino  of  ascent ; 
while  the  gradual  pulse  (slow  ventricular  systole) 
has  an  oblique  up-stroke. 

The  following  arrangement  shows  in  a small 
compass  the  principal  varieties  "f  pulse  met  with 
in  practice,  apart  from  the  quality  of  regularity. 

A.  Varieties  of  HardPulse — Pulsus  durua. 


Fig.  58. 


1.  The  hard,  frequent,  sudden,  and  small pulso 
of  peritonitis,  enteritis,  and  pericarditis  : — 

Pulsus  duruset  frequcnsetcelcret  parvus,  fig.  58. 

2.  The  hard,  slow,  gradual,  and  large  pulse  of 
contracted  kidney: — 

Pulsus durus  et  rarus  et  tardus  etmagnus,  fig.  59. 


Fig.  59. 


3.  The  hard,  large,  often  gradual  pulse  of 
cardiac  hypertrophy  and  degeneration  of  blood- 
vessels:— 


.298  PULSE. 


Pulsus  durus  ct  magnus  et  tu.rdu.s- fig.  6U. 


Fig.  60. 


4.  The  hard,  sudden  (Jerky),  large,  and  vi- 
bratory pulse  of  aortic  insufficiency,  with  strong 
ventricle  : — 

Pulsus  durus  ct  cclcr  et  maqnus  et  vibrans — 
fig.  61. 


Fig.  61. 

B.  Varieties  of  Soft  Pulse — Pulsus  mollis. 

1.  The  soft,  frequent  pidse  of  pyrexia:  di- 

srotous  and  hyper-dicrotous  pulses  : — 

Pulsus  mollis  ct  frequens — fig.  62. 


Fig.  62. 


2.  Tlvo  soft,  frequent,  and  large  pulse  of  rlicu- 
maiic  fever  : — 

Pulsus  mollis  et  frequens  et  magnus — fig.  63. 


Fig.  63. 


3.  The  soft,  small,  frequent  and  sudden  pidse 
of  debility: — 

Pulsus  mollis  it  frequens  et  parvus  et  cclcr — 
fig.  64. 


Fig.  64. 


4.  The  soft. frequent,  and  small  {running) pulse 
of  collapse  in  fever  : — 

Pulsus  mollis  ct  frequens  ct  parvus — fig.  65. 


Fig.  65. 

Balthazar  Foster. 


PUPIL,  DISORDERS  OF. 

PUPIL,  Disorders  of.  — Synoh  : Fr. 

Troubles  de  la  Pupille ; Ger.  Storungen  der  Pu- 
pil le. — This  normally-black  aperture  in  the  vari- 
coloured and  more  or  less  pigmented  diaphragm 
called  the  iris,  lies  immediately  in  front  of  the 
lens  of  the  eye.  It  is  circular,  or  nearly  so  ; and 
central,  or  rather  nearer  the  nasal  than  the  tem- 
poral side  of  the  iris.  Through  the  pupil  light 
is  transmitted  to  the  retina,  and,  speaking  gene- 
rally, its  size  is  in  inverse  proportion  both  to  the 
amount  of  light  admitted,  and  to  the  age  of 
the  individual.  The  activity  and  dilatability  of 
the  pupil,  and  the  range  within  which  it  will 
vary  in  size,  are  greatest  in  the  young,  and  least 
in  old  people.  Its  size  varies  very  much  in 
different  persons  exposed  to  the  same  amount 
of  light.  A diameter  of  from  3 to  5 mm.  in 
ordinary  daylight  would  bo  nothing  unusual. 
The  best  method  of  measuring  the  size  of  the 
pupil  is  to  have  a row  of  black  dots,  of  from  1 
to  10  mm.  diameter,  which  may  be  held  up  beside 
it  for  comparison.  The  exercise  of  the  accom- 
modation-power of  the  eye  for  near  objects,  and 
the  act  of  convergence  of  the  axes  of  the  two  eyes 
for  the  same  purpose,  are  accompanied  by  con- 
traction of  the  pupil.  It  is  probably  by  exercis- 
ing these  voluntary  powers  that  some  persons, 
it  is  said,  can  contract  their  pupils  at  will.  Hy- 
permetropes,  who  make  much  use  of  their  ac- 
commodation, have  small,  and,  on  the  contrary, 
myopes  have  large  pupils,  as  a rule.  The  iris  has 
circular  and  radiating  muscular  fibres,  by  which 
the  size  of  the  pupil  is  altered.  The  radiating 
fibres  of  the  dilator  muscle  are  supplied  by  the 
sympathetic  (through  ciliary  nerves  from  the  len- 
ticular ganglion),  and  also,  probably,  by  the  long 
ciliary  nerves  of  the  trifacial;  and  the  sphinctci 
papillae  by  the  third  nerve.  So  that  in  paralysis, 
or  after  section,  of  the  third  nerve,  the  sphincter 
being  inefficient,  the  pupil  is,  in  some  degree  at 
least,  abnormally  dilated,  and  irresponsive  to  light 
(mydriasis) ; and,  on  the  contrary,  contracted 
and  immovable  when  the  eye  is  shaded  (rnyosis), 
if  the  sympathetic  is  defective.  The  pupil  is 
quite  passive,  as  regards  the  light  and  shade,  and 
of  an  uniform  and  medium  size,  if  both  nerves 
are  powerless.  Paralytic  mydriasis,  or  rnyosis,  is 
not  so  much  iu  degree  as  that  produced  by  bella- 
donna (atropin)  and  other  mydriatics,  or  by 
calabar  bean  (eserin)  and  other  myotics,  respec- 
tively. If,  for  instance,  in  a case  of  complete 
third  nerve  paralysis,  the  ordinary  solution  of 
sulphate  of  atropine  is  dropped  into  the  eye 
affected,  the  pupil  becomes  more  widely  dilated, 
and  hence  the  drug  is  supposed  to  paralyse 
the  sphincter  of  the  normal  eye,  and  to  stimulate 
the  dilator  muscle  simultaneously — to  produce, 
iu  fact,  an  artificial  mydriasis,  simulating  at 
ouee  the  paralytic  and  spasmodic  forms  of  the 
disease.  For  mydriasis  from  disease  may  he  a 
result  of  spasmodic  action  of  the  dilator,  or  of 
| defect  in  the  sphincter— of  irritation  of  tho 
; sympathetic,  or  of  paralysis  of  the  third  nerve. 
In  the  latter  ease  only  will  atrepine  produce  a 
greater  dilatation.  The  converse  is  the  truth  as 
to  the  production  of  rnyosis  from  disease,  from 
cerebral  irritation,  or  from  any  disease  paralys- 
ing the  sympathetic.  An  exceedingly  minute 
quantity  of  the  sulphate  of  atropine  locally  ap- 
plied will  produce  mydriasis,  so  that  care  must 


PUPIL,  DISORDEES  OF. 
be  taken  not  too  readily  to  assume  in  any  ease 
that  mydriasis  has  not  been  artificially  produced. 

Mode  of  Examination. — -In  estimating  the 
movements  of  the  pupil  in  an  eye  that  is  not 
blind,  as  the  two  irides  have  a mutual  action, 
the  other  eye  must,  in  the  first  place,  be  alto- 
gether covered  and  excluded;  and  then,  opposite 
a good  light,  the  effects  of  shading  and  exposing 
the  eye  alternately  are  observed.  If  it  ‘ acts  ’ 
doubtfully  (reflex  movement),  the  effect  of  using 
the  accommodation,  assuming  that  the  power  is 
retained,  as  in  reading,  and  then,  with  both 
eyes  open,  of  converging  the  axes,  in  looking  at 
a very  near  object  (voluntary  movement),  is  to  be 
tried.  It  should  be  observed  also  whether  the 
pupil  dilates  normally  when,  in  a moderate  light, 
the  patient  looking  into  the  distance,  the  eye  is 
shaded.  For  want  of  care,  mydriasis  of  one  eye 
has  been  mistaken  for  myosis  of  the  other,  and 
vice  versa.  The  normal  reflex  excitability  of  the 
pupil  is  also  noteworthy.  If  one  of  the  extre- 
mities be  irritated,  if  only  the  palm  of  the  hand 
be  scratched  or  tickled,  the  pupil  will  then  dilate. 
The  changes  in  size  of  the  pupil,  thus  accurately 
tested  in  any  case,  are  a very  uncertain  guide  as 
i to  the  amount  of  vision  in  the  eye  examined.  If 
an  eye  has  no  perception  of  light  (amaurosis)  its 
presence  or  absence  has  no  influence  (though  this 
is  disputed)  on  the  pupil,  which  is  generally  di- 
. lated,  if  the  blindness  is  not  of  spinal  origin,  and 
especially  if  it  is  recent. 

Varieties  and  .Etiology. — There  are  many 
other  well-known  signs  of  paralysis  of  the  third 
nerve  besides  the  dilated  pupil,  and  but  one  of 
the  signs  only  is  very  unlikely  to  appear  in  any 
tuck  case.  The  disease  may,  however,  be  limited 
to  the  lenticular  ganglion.  As  the  cervical 
lympathetic,  which  supplies  the  dilator  pupillae, 
derives  nerve-fibres  from  spinal  nerves,  contrac- 
tion of  the  pupils  is  one  of  the  many  well-known 
signs  of  locomotor  ataxy ; but  it  is  not  always 
present.  It  is  then  of  a paralytic  nature.  The 
pupils  are  uninfluenced  by  light,  but  contract  in 
Accommodating  for  near  objects  (Argyll-Robert- 
'jon).  Myosis  maybe  spasmodic,  as  in  the  case  of 
:iome  watchmakers  and  others.  Unilateral  myosis 
nay  indicate  an  aneurism,  tumour,  or  some 
ither  deep-seated  disease  on  one  side  of  the 
ieck.  The  pupils  are  contracted  when  there  is 
ihotophobia,  and  during  sleep  ; dilated  in  syn- 
ope,  nausea,  stupor,  hydrocephalus,  dyspnoea, 
ften  in  epileptic  fits,  and  by  various  drugs  given 
iternally.  A striking  variability  and  want  of 
ymmetry  as  to  the  size  of  the  pupils  has  been 
bserved  in  the  general  paralysis  of  the  insane. 
"i  mania  the  pupils  are  contracted,  and  in  melan- 
,iolia  dilated.  In  ‘tremulous  iris,’ the  lens  being 
ine  or  removed  backwards  from  contact  with 
te  pupillary  border  of  the  iris,  especially  if  the 
•treous  be  fluid,  it  is  moved  to  and  fro  by  the 
ovements  of  the  eye-ball.  If  the  lens  is  eceen- 
ically  misplaced,  a part  of  the  iris  and  pupil 
;ily  may  be  thus  shaken.  Hippies  (nystagmus 
fecting  the  iris)  is  a very  rare  condition,  in 
hich  the  pupil  is  dilated  and  contracted  spas- 
odically,  without  any  of  the  variations  of  light 
other  causes  by  which  it  is  usually  influenced, 
not  very  uncommon  congenital  defect  of  the 
s is  coloboma — in  which  the  pupil  is  balloon- 
Jped,  the  notch  generally  downwards.  In  foetal 


PURGATIVES.  1299 

life  the  membrana  pupillaris  covers  the  pupil,  and 
some  remains  of  this  may  be  seen,  in  rare  cases, 
in  adult  life,  in  the  form  of  bands  passing  from 
the  front  surface  of  the  iris,  a little  beyond  the 
pupillary  margin,  across  the  pupil,  or  to  the  ante- 
rior lens-capsule.  If  the  pupil,  especially  if  it  be 
somewhat  contracted,  is  inactive,  not  circular,  and 
irregular  in  shape,  this  is  almostalways  the  result 
of  iritis,  probably  of  existing  adhesions  of  the 
pupillary  margin.  The  pupil  also  mechanically, 
in  some  degree  at  least,  may  be  dilated,  inactive, 
and  not  round,  vertically  oval  as  a rule,  in  glau- 
coma — the  lens  being  thrust  forwards  beyond  the 
plane  of  the  iris.  On  the  other  hand,  when  the 
tension  of  the  eyeball  is  diminished,  as  in  para- 
centesis corners , the  pupil  is  at  once  contracted. 
Pupillary  adhesions  ( posterior  synechias ) to  tha 
lens,  as  they  are  at  the  back  of  the  iris,  can  be 
hardly  seen  unless  a drop  of  a mydriatic  solution 
has  been  used.  This,  if  there  are  syneehiaa, 
reveals  them  at  once,  as  the  iris  can  only  dilate 
in  the  intervals  between  them.  But  if  it  have 
not  been  used  before,  during  the  inflammation, 
or  insufficiently,  the  pupil  becomes  very  much 
contracted,  and  may  be  altogether  incapable  of 
dilatation — excluded  (total  posterior  synechia),  or 
occluded,  the  iris  being  adherent  to  a false 
membrane  which  occupies  the  area  of  the  pupil. 
See  Eye.  and  its  Appendages,  Diseases  of ; and 
Third  Nerve,  Diseases  of. 

J.  F.  Stbeatfeild. 

PURGATIVES. — Definition. — Substances 
which  cause  intestinal  evacuations. 

Enumeration.— Purgatives  are  divided  into 
several  classes,  namely,  drastic,  simple,  saline, 
hydragogue,  cholagogue,  and  laxative.  Under  the 
drastic  purgatives  may  be  classed  Colocynth, 
Croton  oil,  Gamboge,  Jalap,  Podophyllin,  Scam- 
mony,  and  Elaterium.  Amongst  the  simple  pur- 
gatives are  Aloes,  Buckthorn  juice,  Castor  oil, 
Rhubarb,  and  Senna.  Under  the  head  saline 
we  have  neutral  salts,  especially  the  Sulphates 
of  Magnesia,  Potash,  and  Soda ; Citrate  and  Tar- 
tarate  of  Potash ; Bitartarate  of  Potash,  Tarta- 
rate  of  Soda,  and  Phosphate  of  Soda.  Hydra- 
gogues  include  Bitartarate  of  Potash,  Elaterium, 
and  Gamboge.  Cholagogues  comprise  Aloes ; Mer- 
curial preparations,  such  as  Calomel,  Blue  pill,* 
and  Grey  powder ; Podophyllin,  Iridin,  Euony- 
min,  and  other  substances  of  the  same  class. 
The  laxatives  are  small  doses  of  simple  purga- 
tives, such  as  Carbonate  of  Magnesia,  Magnesia, 
Olive  oil,  Sulphur,  as  well  as  such  vegetable  sub- 
stances as  contain  salines  and  sugar  in  consider- 
able proportions,  namely,  Cassia,  Figs,  Honey, 
Manna,  Prunes,  Tamarinds, and  Treacle. 

Action. — The  increased  intestinal  evacuation 
produced  by  purgatives  is  partly  due  to  acce- 
leration of  the  peristaltic  movements  of  the  in- 
testine, so  that  the  intestinal  contents  are  hurried 
along  more  quickly,  and  less  time  is  allowed  for 
their  absorption.  Many  authorities,  especially 
in  Germany,  have  held  this  to  be  the  only  way 
in  which  purgatives  act ; but  there  is  no  doubt 
that  many  of  them  also  produce  increased  se- 
cretion from  the  intestinal  glands.  The  dif- 
ferent classes  of  purgatives  affect  the  intestinal 
movements  and  intestinal  secretion  in  different 
degrees.  Laxatives  and  simple  purgatives  act 


1300  PURGATIVES. 

chiefly,  if  not  entirely,  by  increasing  the  peristal- 
tic action.  Some  of  the  drastic  purgatives  act 
in  both  ways;  whilst  the  hydragogue  cathartics, 
as  well  as  the  salines,  especially  increase  the  in- 
testinal secretion.  In  the  case  of  some  of  the 
salines,  as  bitartarate  of  potash,  the  secretion  is 
greatly  increased,  while  the  peristaltic  movement 
is  so  little  affected  that  the  secretion  may  lie  so 
long  in  the  intestine  as  to  be  again  re-absorbed, 
and  the  drug  therefore  fails  to  produce  purga- 
tion at  all.  For  this  reason  it  is  usual  to  com- 
bine such  salines  with  simple  purgatives,  which 
will  accelerate  the  peristalsis. 

Besides  their  direct  action  upon  the  bowels, 
purgatives  exert  an  indirect  effect  upon  the  cir- 
culation, weakening  it,  and  lowering  the  pres- 
sure of  blood  within  the  vessels. 

Cholagogue  purgatives  are  those  which  have  a 
special  power  to  remove  bile  from  the  body. 
They  may  do  this  either  by  stimulating  the 
secretion  of  the  liver,  or  by  quickening  the  ex- 
pulsion of  bilo  from  the  gall-bladder  and  ducts, 
so  that  more  bile  is  poured  into  the  intestine  at 
a time  when  this  is  in  active  movement.  The 
bile  is  therefore  hurried  down  the  intestinal  tube, 
and  reabsorption  is  thus  prevented.  This  ap- 
pears to  be  the  mode  of  action  of  such  purgatives 
as  euonymin  and  iridin.  Such  mercurial  prepa- 
rations as  blue  pill  and  calomel  appear  to  act  in 
a somewhat  different  way.  Experiments,  con- 
trary to  expectation,  have  shown  that  they  do 
not  increase  the  secretion  of  bile,  and  yet  they 
are  amongst  the  most  efficient  cholagogue  pur- 
gatives which  we  possess.  Their  cholagogue 
action  is  probably  due  to  their  exerting  a special 
stimulating  action  upon  the  duodenum,  quicken- 
ing its  peristaltic  movements,  and  thus  hurrying 
down  the  bile,  and  preventing  its  reabsorption. 
Their  beneficial  action  as  cholagogues  is  greatly 
increased  by  the  subsequent  administration  of  a 
saline  purgative,  which  will  tend  to  sweep  the 
bile  out  of  the  lower  part  of  the  small  and  the 
large  intestine,  and  prevent  reabsorption  from 
these. 

Uses. — Purgatives  are  used,  firstly,  to  remove 
faecal  matters  from  the  intestinal  tube.  They 
thus  not  only  prevent  the  accumulation  of  such 
matters,  but  remove  the  irritation  which  their 
presence  produces,  and  which  may  evidence  itself 
in  disturbances  of  other  organs,  for  example, 
headache  and  malaise.  These  disagreeable  symp- 
toms produced  by  constipation  appear  to  be 
partly  due  to  the  irritation  of  the  intestinal 
nerves,  producing  reflex  disturbance  of  the  circu- 
lation ; but  it  is  probable  also  that  they  may  be 
caused  in  part  by  the  toxic  action  of  poisonous 
gases,  liquids,  or  solids  generated  in  the  intestine 
by  imperfect  digestion  or  decomposition  of  the 
food.  For  such  purposes  as  this  we  may  employ, 
• as  we  find  them  necessary,  laxatives  or  simple 
purgatives.  The  second  use  of  purgatives  is  to 
remove  from  the  body  an  excess  of  certain  secre- 
tions such  as  bile,  and  substances  which  may  be 
contained  in  them,  such  as  metallic  or  organic 
poisons  which  are  excreted  in  the  bile  or  intes- 
tinal mucus.  The  third  use  is  to  remove  liquid 
from  the  body  in  cases  of  dropsy,  due  either  to 
cardiac  or  to  renal  disease.  For  such  purposes 
wo  use  hydragogue  cathartics.  The  fourth  use 
is  to  lower  the  temperature  in  fever,  and  for 


PURPURA. 

this  we  chiefly  use  salines.  The  medium  operanii 
here  is  not  yet  well  understood.  The  fifth  use  of 
purgatives  is  to  lower  the  blood-pressure,  and 
thus  to  prevont  the  rupture  of  a blood-vessel,  and 
consequent  apoplexy ; or  to  prevent  further  ex- 
travasation in  a case  where  the  vessel  has  already 
burst,  as  in  haemorrhage  from  the  lungs. 

T.  Laudeb  Bbunton. 

PTJBGIN G. — A popular  synonym  for  diar- 
rhcea ; and  also  applied  to  the  therapeutical 
method  purgation.  See  Diabrhcea;  and  Pcb- 

GATIVES. 

PUBPUKA. — Synon.  Cutaneous  haemor- 

rhages ; Fr.  Purjpura  ; Ger.  Blutfleckenkrankheit. 

Definition. — A diseased  condition  in  which 
circumscribed  effusions  of  blood  take  place  into 
the  upper  layers  of  the  cutis,  and  beneath  the 
epidermis ; occurring  without  or  with  certain  con- 
stitutional symptoms,  or  in  the  course  of  various 
diseases ; and  attended  at  times  by  haemorrhages 
under  and  from  the  mucous  membranes,  as  well 
as  into  the  various  serous  cavities. 

^Etiology. — Cutaneous  haemorrhages  have  been 
seen  as  early  as  the  third  day  after  birth,  and 
indifferently  at  all  other  periods  of  life.  Women 
appear  to  be  more  frequently  attacked  than 
men. 

Cutaneous  haemorrhages,  when  not  due  to  ex- 
ternal injury,  may  occur  in  persons  apparently  in 
the  most  perfect  health,  or  they  may  accompany 
the  most  various  diseases  of  the  general  system. 
They  are  not  infrequent  in  the  course  of  Bright’s 
disease  and  valvular  disease  of  the  heart;  they 
have  been  seen  in  phthisis,  acute  rheumatism, 
cirrhosis  of  the  liver,  leueocythmmia,  intermit- 
tent fever,  and,  in  fact,  in  patients  of  the  most 
different  constitution  and  general  condition,  from 
perfect  health  to  the  most  advanced  cachexia. 
The  exciting  cause  is  usually  quite  obscure,  but 
they  have  been  seen  to  follow  severe  fright,  and 
also  sudden  obstruction  of  the  circulation,  as  in 
severe  coughing  and  epilepsy,  though  this  is 
exceptional.  Purpuric  eruptions  have  followed 
the  use  of  chloral  in  excessive  doses,  and  also  of 
iodide  of  potassium  in  specially  susceptible  in- 
dividuals. 

Anatomical  Characters. — The  rete  mucosum 
and  the  papillary  layer  of  the  cutis  are  the  chief 
seat  of  the  haemorrhage  in  purpura.  Owing  pro- 
bably to  rupture  of  the  capillaries  over  a limited 
area,  the  blood  finds  its  way  into  the  meshes  of 
the  connective  tissue,  and  fills  the  interspaces 
between  the  hair-follicles  and  the  ducts  which 
traverse  these  parts.  Absorption  of  the  serum  is 
soon  followed  by  changes  in  the  haematin  set 
free  from  the  red  corpuscles,  so  that  it  passes 
through  various  tints  of  blue,  green,  and  yellow, 
until  it  is  completely  absorbed.  Very  large  ex- 
travasations may  result  in  long-continued  or  even 
permanent  pigmentation  of  the  part,  owing  to 
the  formation  of  hsematoidin.  Similar  effusions 
to  those  beneath  the  skin  are  found  in  the 
severer  cases  beneath  the  mucous  membranes 
also ; but  in  these  parts  bleeding  from  their 
free  surface  is  not  uncommon,  probably  from 
the  delicacy  and  slight  resistance  of  the  mem- 
brane covering  the  capillaries.  Pcst-mortem  exa- 
mination in  fatal  cases  has  revealed  extensive 


PURPURA. 


extravasation  into  the  pleural,  pericardial,  and 
peritoneal,  and,  very  rarely,  into  the  arachnoid 
cavities.  Extravasation  may  also  occur  into  the 
muscles,  the  periosteum,  and  even  the  hones,  as 
well  as  beneath  the  conjunctiva  and  into  the 
retina.  Cases  complicated  with  other  diseases, 
such  as  phthisis,  or  Bright’s  disease,  will  present 
their  characteristic  lesions. 

Pathology. — Purpura  appears  to  depend  (1) 
on  an  alteration  in  the  nutrition  of  the  coats  of 
the  blood-vessels,  which  makes  them  unequal  to 
the  strain  of  arterial  pressure,  so  that  they  rup- 
ture; or  (2)  on  alterations  in  the  blood  itself 
' excess  of  water,  or  salts,  &e.);  or  (3)  on  both 
causes  combined.  That  weakness  of  the  vessel- 
walls  is  a main  cause,  is  shown  by  the  greater 
frequency  and  extent  of  the  purpuric  eruption 
on  the  feet  and  legs,  and  on  the  most  depen- 
dent parts,  such  as  the  back,  if  the  patient  be 
recumbent,  where  gravity  intensifies  arterial 
pressure.  The  influence  of  the  nervous  system 
may  account  for  some  cases  of  rapid  haemor- 
rhage, for  this  condition  has  been  experimentally 
produced  in  frogs  by  extirpation  of  the  sympa- 
thetic ganglia. 

Embolism  and  thrombosis  have  been  suggested 
as  an  explanation  of  some  cases.  The  relation 
of  the  joint-affections  which  so  often  accompany 
purpura  to  the  latter  is  not  clear,  and  there 
seems  ground  for  believing  that  they  are  not 
always  rheumatic,  but  due  to  haemorrhages  into 
the  synovial  membranes  of  the  joints. 

Symptoms. — Although,  as  has  been  stated 
; above,  cutaneous  haemorrhages  may  occur  under 
6ueh  a variety  of  conditions  that  they  can 
scarcely  be  looked  on  as  characteristic  of  a 
definite  disease,  yet  since  they  not  unfrequently 
appear  in  apparently  healthy  persons,  and  run  a 
definite  course,  it  seems  advisable  to  retain  the 
time-honoured  name  of  purpura  in  these  cases, 
as  well  as  to  include  under  the  generic  name 
two  or  three  minor  species.  It  must,  however, 
be  distinctly  understood  that  there  is  no  abrupt 
line  of  demarcation  between  any  of  the  varieties 
of  purpura,  but  that  the  difference  between  them 
depends  on  the  severity  of  the  accompanying 
symptoms.  The  eruption  has  the  same  general 
characters  in  all  forms  of  purpura.  It  consists 
of  isolated  spots,  whose  colour  varies  from  bright 
red  to  a livid  or  dark  purplish-red.  They  do 
not  disappear  on  pressure.  Their  shape  is  gene- 
rally round  or  irregular,  and  their  edge  is  almost 
always  uneven  and  denticulated.  Their  size 
raries  usually  from  that  of  a pin’s  head  to  that 
i)fa  pea  or  bean,  but  in  some  cases  they  may  be 
■is  much  as  several  inches  in  circumference.  The 
smaller  spots,  not  larger  than  a finger  nail,  are 
'.ermed  ‘ petechi®,’  the  larger  ‘ ecchymoses.’  If 
hey  take  the  form  of  lines  or  broad  stripes  they 
ire  called  ‘vibices.’  The  spots  are  usually  level 
vith  the  skin,  but  they  sometimes  appear  as 
mail  conical  papules  round  the  hair-follicles 
purpura  papulosa,  lichen  lividus — Willan),  or  as 
fheal-like  nodules  (purpura  urticans).  Very 
arely  the  epidermis  is  raised  into  the  form  of 
iullae  containing  serum  and  blood-corpuscles 
purpura  bullosa).  The  duration  of  each  spot 
epends  on  the  amount  of  extravasated  blood 
iving  rise  to  it,  and  on  the  time  necessary  for 
.s  absorption;  but  it  usually  disappears  in  a 


1303 

week  or  ten  days.  The  spots,  once  formed,  do 
not  increase  in  size  except  by  fresh  h®morrhage 
in  their  vicinity.  They  never  end  in  desquama- 
tion, and  only  large  ecchymoses  are  followed  by 
more  than  transient  pigmentation ; but  they  all 
undergo  colour-changes  during  absorption,  by 
which  they  become  brown,  green,  and  yellow, 
while  their  edges  become  more  and  more  inde- 
finite. Their  presence  under  the  skin  is  un- 
attended with  pain  or  any  kind  of  irritation  or 
pruritus,  so  that  the  patient  may  only  discover 
their  existence  accidentally  while  undressing. 

Varieties. — "We  may  now  briefly  consider 
the  varieties  of  purpura : — 

1.  Purpura  Simplex. — In  this  form  the 
eruption  is  either  preceded  for  a few  days  by 
languor  and  loss  of  appetite,  or  else  it  occurs 
without  any  previous  symptom.  The  spots  may 
be  limited  to  the  feet  or  legs,  or  they  may  bo 
scattered  over  the  whole  body,  including,  in 
severe  cases,  the  head  and  face.  They  come  out 
in  crops,  each  of  which  lasts  from  eight  to  ten 
days.  There  may  bo  only  one  or  two  crops,  or 
fresh  ones  may  protract  the  disease  for  several 
weeks  or  months. 

2.  Purpura  Rheumatiea. — Synon.  : Peliosis 
rheumatica.— Rheumatic  purpura  only  differs  from 
the  simple  variety  in  being  attended  with  slight 
fever,  general  stiffness  and  weariness,  and  rheu- 
matic pains  in  the  knees  and  ankles.  The  rheu- 
matic symptoms  vary  much  in  different  cases, 
and  in  some  cases  the  joints  are  not  only  painful 
and  tender,  but  red  and  swollen.  There  may  also 
be  a good  deal  of  gastric  disturbance,  nausea, 
and  bilious  vomiting;  colicky  pains  in  the  belly, 
constipation,  and  diarrhoea  are  not  uncommon. 
Peliosis  rheumatica  is  most  frequent  in  men,  and 
in  healthy  individuals  between  the  ages  of  twenty 
and  thirty  years.  This  form  often  relapses  if  the 
patient  leave  his  bed  too  soon.  Liveing  connects 
P.  rheumatica  with  symmetrical  erythema  (poly- 
morphic erythema)  through  Erythema  nodosum. 
Neither  the  arthritic  symptoms,  with  purpuric 
tendencies,  which  are  common  to  all  these  affec- 
tions, nor  the  character  of  the  eruption  present, 
are  considered  to  be  of  a sufficiently  constant 
and  distinctive  nature  to  separate  one  from  the 
other  by  any  sharp  line  of  demarcation. 

3.  Purpura  Haemorrhagic  a. — This  form  only 
differs  from  purpura  rheumatica  in  tho  greater 
depression  and  constitutional  disturbance  which 
precede  and  accompany  the  outbreak  of  spots  ; 
in  the  greater  extent  of  surface  covered  by  the 
petechi®  ; in  the  larger  size  of  the  ecchymoses  : 
and,  lastly  and  chiefly,  in  the  occurrence  of 
hmmorrliagic  effusions  beneath  the  mucous  mem- 
branes of  the  lips,  cheeks,  gums,  and  palate,  and 
of  more  or  less  copious  free  h»morrhages  from 
the  nose,  mouth,  intestines,  urinary  tract,  and 
more  rarely  from  the  lungs.  The  repetition 
of  these  hsemorrhages  may  rapidly  exhaust  the 
patient’s  strength,  and  cause  death  from  an®mia 
and  collapse,  or  he  may  die  with  so-called 
‘ typhoid  ’ symptoms.  The  h®morrhages  from 
internal  parts  do  not  bear  any  necessary  proDor- 
tion  to  the  skin-eruption,  and  they  may  be  very 
severe  when  the  latter  is  small,  or  vice  versa  ; dot 
need  they  begin  or  end  at  the  same  time  with 
it.  Purpura  h®morrhagica  may,  like  the  other 
varieties,  occur  suddenly,  in  apparently  healthy 


1302  PURPURA. 

persons,  living  under  the  most  favourable  circum- 
stances. 

As  raro  complications  of  these  three  forms  may 
be  mentioned  (a)  true  urticaria,  running  side 
by  side  •with  the  purpuric  eruption ; ( b ) Tenous 
thrombosis;  and  (c)  diarrhoea,  not  of  a bloody 
character. 

4.  Symptomatic  Purpura. — This  titlemight 
be  given  to  a purpuric  eruption  which  sometimes 
occurs  in  the  course  of  cholera,  measles,  scarlet 
fever,  typhus  fever,  and  small-pox,  but-  which 
has  no  special  significance  except  in  the  last- 
named  disease.  There  the  purpuric  spots  come 
out  in  the  first  three  days,  and  so  precede  the 
special  eruption  of  small-pox,  and  patients  at- 
tacked with  it  frequently  die  with  delirium  and 
high  fever. 

Prognosis. — The  prognosis  of  simple  and 
rheumatic  purpura  is  favourable,  as  recovery 
always  occurs.  In  purpura  hsemorrhagica  re- 
covery is  the  rule  in  uncomplicated  cases,  though 
there  are  a few  instances  on  record  which  ended 
fatally  from  the  exhaustion  produced  by  repeated 
haemorrhages,  although  no  cause  could  be  de- 
tected, and  every  known  remedy  was  tried. 
Purpura  accompanying  organic  disease,  such  as 
Bright’s  disease  or  morbus  cordis,  is  unfavour- 
able. The  duration  of  all  the  forms  is  very  un- 
certain, owing  to  their  tendency  to  relapse. 

Diagnosis. — The  fact  that  the  purpuric  spots 
are  unaltered  by  pressure,  and  unattended  with 
itching,  scaliness,  or  tendency  to  discharge,  will 
separate  them  from  almost  every  other  affection 
of  the  skin.  From  scurvy  purpura  is  distin- 
guished by  occurring  in  those  whose  health  has 
not  been  impaired  by  long  privation  from  fresh 
meat  and  vegetables  ; by  the  absence  of  spongy 
gums,  painful  swellings,  and  ulceration  of  the 
skin  ; and  by  its  resistance  to  diet  and  the  use  of 
lime-juice.  Secondary  syphilitic  stains  on  the 
lower  extremities  must  be  distinguished  by 
the  history  and  -by  other  attendant  phenomena. 
Bruises  due  to  injury  are  not  likely  to  lead  to 
error. 

Treatment. — In  the  treatment  of  purpura 
absolute  rest  in  bed  is  necessary,  if  the  erup- 
tion be  general ; elevation  of  the  legs  is  advan- 
tageous if  the  disease  be  confined  to  them.  Any 
derangement  of  internal  organs  mustbe  remedied, 
if  possible.  As  a rule,  tonics,  especially  quinine 
and  iron,  do  most  good  in  purpura  simplex.  Tinc- 
tura  ferri  perchloridi  n\xv-xx,  three  times  a 
day,  is  almost  a specific  in  many  cases  ; and  the 
mineral  acids,  especially  sulphuric  acid,  are  of 
great  value.  The  use  of  purgatives,  as  recom- 
mended by  the  older  writers,  especially  Plumbe, 
has  of  late  fallen  into  disrepute.  In  purpura 
haemorrhagica,  with  copious  bleedings,  ergot  has 
proved  most  effectual.  It  may  be  given  either 
by  the  mouth,  or  else  hypodermically,  as  a solu- 
tion of  ergotin.  Turpentine,  in  ten-minim  doses, 
gallic  acid,  and  other  haemostatics  also  deserve  a 
trial.  Locally,  cold  applications,  or  injections  of 
iced  water,  may  be  resorted  to  in  severe  epistaxis 
or  haemorrhage  from  the  bowel.  Iodide  of  potas- 
sium should  not  be  given  in  purpura,  as  it  ag- 
gravates it  in  some  cases,  and  has  even  given 
ii*e  to  serious  ulceration. 

Edward  I.  Sparks.1 

1 Revised  by  Dr.  Alfred  Songster. 


PUSTULE,  MALIGNANT. 

PURPURIC. — Relating  to  purpura.  See 
Purpura. 

PURRING  TREMOR  or  THRILL.— 

Stnon.:  Fr.  Fremissement  cataire;  Ger.  Schnur- 
rcn. — A physical  sign  felt  by  the  hand  applied 
over  the  heart  or  vessels  in  certain  conditions,  re- 
sembling the  sensation  conveyed  by  the  purring 
of  a cat.  See  Physical  Examination. 

PURTON  (Wiltshire)  Saline  Spa,  contains 
iodine.  See  Mineral  Waters. 

PURULENT  INFECTION.  — Infection 
from  the  absorption  of  pus,  introduced  from  with- 
out, or  formed  within  the  body.  See  Pt.suia, 

PUS. — A product  of  inflammation.  See  In- 
flammation. 

PUSTULE.  — Stnon.:  Fr.  Pustule;  Ger. 
Pustel. — A vesicle  of  the  skin  containing  pus,  as 
in  small-pox  and  ecthyma.  Vesicles  originally 
containing  serum  are  also  apt  to  become  pustules, 
by  a purulent  transformation  of  their  contents. 

PUSTULE,  MALIGNANT.— Stnon.:  Con- 
tagious Carbuncle:  Anthrax;  Fr.  Char  bon  ; Ger. 
Anthrax. — Other  names  are  used  to  designate 
the  more  diffuse  and  general  forms. 

Definition. — A specific  contagious  disease, 
communicated  to  man  from  the  disease  of  homed 
cattle,  horses,  and  sheep,  &c.,  known  as  splenic 
fever,  mal  de  rate , or  MUzbrand,  and  due  to  the 
presence  in  the  system  of  the  bacillus  anthracis 
(Cohn),  or  bacteridium  (Davaine). 

1 . The  local  or  external  form  of  the  affection, 
malignant  pustule  proper,  is  a carbuneular  swell- 
ing having  specific  characters,  attended  with 
more  or  less  intense  surrounding  inflammatory 
oedema,  which  may  exist  alone  (anthrax  cedema, 
oedeme  malin,  anthrax  erysipelas) ; usually  also 
with  lymphangitis.  Constitutional  symptoms 
may  be  slight  or  severe ; and  the  disease  is  often 
fatal. 

2.  General  or  internal  anthrax  is  another  result 
of  the  same  poison,  which  may  exist  independently 
of  any  external  malignant  pustule.  This  form 
has  received  various  names — anthrax  or  charbon 
fever  ( fievre  charbonneuse),  anthraeaemia,  inter- 
nal anthrax,  mycosis  iniestinalis ; and  also  names 
derived  from  its  connection  with  certain  trades 
(woolsorter's  disease),  or  its  occurrence  in  cer- 
tain countries  (Siberian  plague).  This  internal 
form  is  apparently  identical  with  splenic  fever 
of  the  lower  animals  ; its  symptoms  are  usually 
those  of  blood-poisoning,  such  especially  as  pros- 
tration, anxiety,  congestion  of  the  lungs,  and 
rapid  death ; fever  may  he  only  slight.  The 
chief  post-mortem  lesions  are  scattered  haemor- 
rhages in  various  organs;  diffuse  cellular  exu- 
dations; congestion  of  the  lungs;  and  frequently 
a swollen  and  pulpy  condition  of  the  spleen. 

Etiology. — Anthr:ix.  when  occurring  in  man, 
is  invariably  derived  from  cases  of  splenic  fever 
of  the  lower  animals,  either  by  direct  or  indirect 
contagion. 

Splenic  fever  affects  homed  cattle,  sheep,  and 
horses  in  all  parts  of  the  world;  and,  less  fre- 
quently, elephants,  camels,  and  other  herbivora. 
Though  apparently  endemic  in  certain  regions, 
this  is  probably  due  to  the  great  persistence  of 
the  contagion,  and  the  various  wavs  in  which 
it  is  preserved,  owing  to  the  mode  of  disposal  cl 


PUSTULE,  MALIGNANT. 


the  carcases.  The  disea  se  assumes  various  forms, 
nsually  that  of  a general  blood-poisoning,  with- 
out external  swelling;  occasionally  a form  in 
which  there  is  glandular  swelling  and  inflamma- 
tory cedema  (sometimes  bloody)  near  the  seat 
inoculation  (usually  the  mouth  and  pharynx), 
together  with  the  general  blood-poisoning ; and, 
least  frequently,  a form  in  which  there  are  local 
phlegmonous  or  diffused  oedematous  swellings 
affecting  various  parts  of  the  body.  In  the 
common  internal  form  of  splenic  apoplexy  the 
spleen  is  usually  greatly  swollen  and  pulpy ; it 
may  even  rupture,  and  there  may  be  haemor- 
rhages in  the  heart,  lungs,  kidneys,  serous  cavi- 
ties, and  other  parts. 

The  bacillus  anthracis  or  bacteridium  is  a bac- 
terium first  discovered  by  Pollender  in  1819,  the 
name  of  bacteridium,  given  by  Davaine,  being 
;hat  commonly  used  in  France;  that  of  bacillus 
anthracis,  given  by  Cohn,  in  Germany. 

All  parts  of  the  bodies  of  animals  dying 
of  the  disease  are  actively  poisonous,  and  may 
convey  the  disease  by  direct  or  mediate  con- 
tagion. Direct  inoculation  is  rarely,  perhaps 
never,  from  the  living  animal,  usually  from  the 
carcase,  affecting,  therefore,  chiefly  butchers, 
slaughterers,  tanners,  &c.  It  may  also  arise 
from  eating  the  flesh,  though  rarely’,  as  the 
poison  is  destroyed  by  cooking.  Contagion 
may  also  be  conveyed  by  butter  or  milk  (Heu- 
singer).  The  bites  of  flies  may  also  convey  the 
poison. 

Indirect  contagion  occurs  chiefly  in  those  who 
nave  to  deal  with  tho  wool  or  hair  of  animals 
which  have  died  of  the  disease,  espeeialiy  wool- 
packers  and  sorters,  labourers  in  felt  manufac- 
tories, horsehair-cleaners,  furriers,  tanners,  and 
those  engaged  in  like  occupations.  In  these 
cases  the  poison  may  enter  the  system  either  by 
local  inoculation,  or  by  inhalation  of  the  dust 
containing  it.  Lastly,  certain  less  suspected 
modes  of  infection  may  probably  be  occasionally 
active  in  relation  to  man  as  to  animals.  The 
diffusion  of  the  poison  by  water,  and  its  distribu- 
tion by  means  of  wool-waste  and  bone-dust,  used 
as  manure,  especially  deserve  notice,  as  capable 
of  spreading  the  contagion  unsuspected. 

With  regard  to  animals,  the  researches  of 


Fig.  66.  Part  of  the  spleen  of  a guinea-pig  which  died 
of  anthrax,  showing  the  relative  prop,  .rtion  of  bacil- 
lus rods  ar.d  leucocytes.  ( x 100  diam.i  From  a photo- 
micrograph. 

Pasteur  seem  to  show  that  the  bacillus  may  he 
cultivated  in  the  earth  around  buried  carcases, 
carried  to  the  surface  by  earth-worms,  and  so 
distributed  on  vegetation. 

Morphological  Characters  and  Mode  of 
Growth. — As  seen  in  the  blood,  the  bacillus  an- 
thracis consists  of  a motionless,  short,  apparently 
homogeneous  rod  or  filament,  varying  in  length 


130i 

from  10  n (xJqo  inen)  to  20  /j.  (xjso  inch),  and 
in  diameter  averaging  H /j.  inch).  Tlio 

filaments  may  greatly  exceed  this  length,  but  &r« 
rarely  less  than  inch  long. 


Fig.  67.  A part  of  the  same  under  a higher  power 
(x220  dinm)  The  rods  are  made  to  appear  too  thin 
in  the  woodcut.  Fi’om  a photomicrograph. 

These  filaments  are  either  straight,  slightly 
curved,  or  bent  at  an  acute  angle.  The  longer 
of  them  may  be  readily  shown  by  reagents  to  be 
made  up  of  numerous  shorter  segments,  either  en- 
closed in  one  sheath  or  showing  signs  of  division. 

In  some  cases  longer  filaments,  curved  or 
looped,  are  found  in  the  blood  and  in  the  fluid 
of  the  serous  cavities  after  death. 

The  mode  of  their  development  and  multipli- 
cation has  been  studied  artificially.  The  usual 
mode  of  multiplication  in  the  blood  is  by  trans- 


Fig.  68.  Forms  of  bacillus  anthracis.  xfJOO.  a.  Very 
short  rods.  b.  Rods  of  the  usual  length,  c.  Longer 
rods.  d.  Still  longer  rods,  some  bent,  in  course  of  di- 
vision. e.  A filament  from  the  spleen  after  death, 
showing  spore  formation,  and  free  spores.  /.  Rods  in 
which  spores  have  been  formed,  from  the  pericardial 
serum  after  death,  g.  A mass  of  spores,  h.  Jointeu 
rods  found  in  the  spleen  after  death. 

verse  fission.  The  rods  consist  of  a central  proto- 
plasmic core,  surrounded  by  a more  dense 
sheath.  In  ordinary  rapid  fission  the  rod  simplv 
increases  to  nearly  double  its  length ; then  the 
central  protoplasm  splits  in  the  middle,  leaving 
a cLar  space;  finally  the  outer  sheath  becomes 
constricted  and  divides;  and  this  process  is  re- 
peated in  each  segment. 

In  their  growth,  either  under  natural  condi- 
tions or  by  cultivation,  the  filaments,  which  are 
readily  destructible,  may  produce  spores  which 
are  highly  tenacious  of  life. 

Under  cultivation  the  rods  may  elongate  into 
filaments  of  great  length,  forming  loops  or  curves 
or  spirals,  and  become  matted  together  into  b 
felted  mass. 


1304 


PUSTULE,  MALIGNANT. 


The  filaments  may  continue  homogeneous,  and 
show  no  external  signs  of  division,  although  the 
protoplasmic  contents  often  appear  to  be  par- 
tially segmented.  Then,  at  more  or  less  regular 
intervals,  apppar  more  highly  refractile  points, 
around  which  tho  protoplasm  appears  to  coalesce, 


Fio.  69.  From  a cultivation  of  bacillus  antliracis,  after 
forty-eight  hours,  showing  masses  of  filaments,  some 
containing  spores  (which  are  too  closely  massed  to. 
pettier  in  the  woodcut).  From  a photomicrograph  by 
Ur.  Maddox,  x GOO  diameters. 

forming  masses  which  aro  at  first  cylindrical, 
then  oblong,  and  finally  become  long,  ovoid 
bodies,  enclosed  in  the  outer  sheath  (see  figs.  68 
and  69).  These  spores  may  either  escape  laterally 
from  the  filament,  or  the  filament  breaks  up  into 
short  segments,  each  containing  a central  or  a 
terminal  spore  {.tie  fig.  68,./");  or  the  filament 
may  gradually  dissolve,  leaving  a mass  of  spores 
with  some  jelly-like  substance  uniting  them  (see 
fig.  68,  ry). 

However  formed,  the  spore  is  capable  of  being 
preserved,  regenerating  the  bacillus  rod,  and 
reproducing  the  disease. 

Life-history  of  the  anthrax  bacillus. — The 
bacillus  anthracis  requires  for  its  growth  the 
presence  of  a nitrogenised — preferably  albumi- 
nous— pabulum,  and  a supply  of  oxygen.  Its 
vitality  is  destroyed  by  a temperature  of  60°  C., 
and  probably  by  one  even  lower  when  it  is  in 
the  rod  state.  Decomposition  very  rapidly  de- 
troys its  vitality. 

When  dry  the  rods  themselvc-s  can  be  preserved 
a short  time  (only  a few  weeks)  in  an  active  state. 
But  the  life  of  the  spores  is  not  destroyed  by  short 
exposure  to  a temperature  of  nearly  100°  C.  in  a 
moist  state,  and  probably  still  higher  in  a dry 
state.  They  retain  thc-ir  vitality  for  years,  and 
arc  unaffected  by  ordinary  changes  of  climate  or 
temperature.  Prolonged  boiling,  or  exposure  to  a 
pressure  of  eight  atmospheres  of  oxygen,  destroys 
their  vitality. 

Anatomical  Characters. — In  cases  of  malig- 
nant pustule  rigor  mortis  usually  sets  in  early, 
and  passes  off  somewhat  speedily.  The  body  is 
often  cyanosed,  and  there  is  marked  hypostasis. 
The  face  sometimes  appears  swollen ; petechias 
>>n  the  chest  and  abdomen  are  not  uncommon  ; 
decomposition  is  said  usually  to  set  in  early ; 
and  there  may  be  early  post-mortem  emphysema 
of  the  skin  of  the  face  and  neck. 

The  blood  is  generally  dark,  lake,  and  tarry, 
and  sometimes  peiuliarly  viscid,  and  even  in  the 


heart  it  is  often  uncoagulated.  Haemorrhages, 
varying  in  size  from  a pin's-head  ecchymosis  to 
large  extravasations,  are  found  in  various  parts. 
Ecehymoses  beneath  the  peri-  and  endo-cardium, 
and  in  the  cardiac  tissue,  often  occur;  also  in 
the  muscles,  the  connective-tissue  planes,  and 
the  subserous  and  submucous  tissues. 

In  the  lungs  there  are  frequently  haemorrhages , 
and  congestive  oedema,  with  partial  collapse,  is 
common.  The  spleen  is  usually  enlarged,  but 
not  invariably  ; its  tissue  is  dark  and  pulpy,  or 
may  be  completely  diffluent.  The  liver  is  usually 
swollen,  vascular,  and  somewhat  softened,  but 
haemorrhages  are  rare.  The  kidneys  are  often 
hyperaemic,  and  rarely  there  are  extravasations 
in  the  cortex  or  pelvis.  The  stomach  and  intes- 
tines often  present  nothing  abnormal.  In  the 
brain  there  are  frequently  scattered,  punetifonn 
haemorrhages,  and,  rarely,  large  extravasations 
in  the  pia  mater. 

Such  are  the  general  and  constant  conditions 
both  in  tho  external  and  internal  forms.  In  the 
malignant  pustule  itself  the  process  extends 
deeply  into  the  subcutaneous  cellular  tissue; 
the  inner  portion  is  haemorrhagic,  and  may 
he  sloughing  in  the  centre  ; and  haemorrhagic 
patches  radiate  into  the  surrounding  tissue 
(Bollinger),  which  are  extensively  infiltrated 
with  a semi-gelatinous  blood-stained  fluid. 

In  the  pulmonary  form  ecchymosis  and  gela- 
tinous exudation  are  sometimes  found  in  the 
tissue  of  tho  neck,  especially  surrounding  the 
trachea,  in  the  mediastinal  glands,  and  in  the 
lungs  and  pleurae.  Occasionally  the  cervical 
gland  may  be  swollen,  and  infiltrated  with 
blood  ; the  cellular  tissue  surrounding  them  may 
be  cedcmatous,  and  sometimes  contains  large 
haemorrhages.  In  the  mediastinum  is  found  a 
quantity  of  gelatinous  fluid,  sometimes  blood- 
stained or  mingled  with  small  haemorrhages. 
Both  pleural  cavities  usually  contain  serous 
fluid,  often  two  or  three  pints  or  more.  In  the 
pericardium  there  is  a variable  quantity  of  fluid. 
The  bronchial  glands  are  swollen,  sometimes 
greatly  so,  and  may  contain  extravasations  of 
blood  ; and  there  may  be  large  haemorrhages  in 
their  vicinity.  The  mucous  membrane  of  the 
trachea  and  bronchi  may  be  congested,  and  the 
scat  of  small  blood-extravasations;  they  fre- 
quently contain  frothy  blood-stained  mucus. 
From  observations  which  the  writer  has  recently 
made,  there  seems  to  be  no  doubt  that  the 
lesions  frequently  present  in  the  larger  bronchi 
correspond,  both  in  their  anatomical  characters 
and  in  their  relation  to  the  constitutional  in- 
fection, with  the  external  malignant  pustule; 
and  that  the  virus,  having  gained  entrance  by  a 
local  infection  of  the  mucous  membrane,  is  con- 
veyed to  the  bronchial  glands,  and  thence  into 
the  blood.  The  lungs  may  contain  htemorrhagea 
into  their  substance,  either  scattered  lobular 
patches,  or  more  commonly  wedge-shaped  tracts 
at  the  periphery,  and  diffuse  extravasations  in 
the  subpleural  tissue ; hut  in  some  cases  the 
lungs  appear  natural  to  the  naked  eye.  In  this 
form  the  abdominal  viscera  often  appear  per- 
.fectly  healthy. 

In  tho  gastro-intestinal  form  there  is  often 
some  blood-stained  serum  in  the  peritoneal 
cavity.  The  mesentery  and  retro-peritonea1 


PUSTULE,  MALIGNANT. 


connective-tissue  are  infiltrated  -with,  semi-gela- 
tinous  fluid.  The  walls  of  the  stomach,  and  parts 
of  the  intestines,  are  swollen  and  congested.  In 
their  submucous  tissue  there  may  he  gelatinous 
blood-stained  fluid  or  haemorrhages,  which  may 
form  solid  coagula  beneath  the  mucous  mem- 
brane. The  entire  mucous  membrane  is  injected, 
or  merely  stained  with  blood.  The  intestines 
contain  either  blood-stained  mucus  or  watery 
fluid,  more  or  less  mingled  with  blood.  There 
may  also,  though  much  more  rarely,  be  pustular 
and  carbuncular  foci  in  the  intestines,  which 
are  said  to  resemble  the  malignant  pustules  of 
the  skin. 

Microscopic  Anatomy. — The  most  important 
point  in  the  microscopic  anatomy  is  the  pre- 
tence of  the  bacillus  anthracis  in  the  blood  and 
tissues,  either  diffused,  or  forming  masses  in  the 
vessels  and  lymphatics.  It  is  unnecessary  to  de- 
scribe here  other  more  minute  lesions. 


Flo.  70.  Bacilli  from  the  fluid  exuded  from  the  lung  in 
a case  of  internal  anthrax.  X about  700  diam.  n, 
lted  blood-corpuscles,  b and  c,  Large  granular  cor- 
puscles from  the  lung,  d,  Bacilli  of  various  lengths, 
containing  highly  retractile  granules,  or  fully  formed 
spores. 

Symptoms  and  Course. — The  symptoms  of 
malignant  pustnle  vary  greatly  with  the  form  of 
the  disease.  At  least  three  distinct  forms  may 
be  considered. 

1.  Malignant  pustule  or  carbuncle  proper,  the 
form  from  which  the  names  of  charbon  and  an- 
thrax are  derived.  Usually  it  occurs  as  a pri- 
mary lesion  due  to  direct  inoculation ; very  rarely 
secondarily  to  constitutional  infection.  The 
seat  is  usually  either  on  the  face,  neck,  hand,  or 
arm — namely,  those  parts  most  exposed  to  ino- 
culation. 

At  first  a small  red  point  or  pimple  appears 
within  a few  hours,  or  two  or  three  days,  after 
inoculation,  and  may  be  either  painless,  or  at- 
tended by  burning  or  itching.  This  rapidly  ex- 
tends, so  that  in  a few  hours  a large  red  swelling 
may  be  formed.  Sooner  or  later  a small  papule 
appears  at  the  seat  of  inoculation,  and  this  vesi- 
cates at  the  summit ; the  vesicle  bursts  and  dis- 
charges a clear  or  turbid  watery  fluid,  which  is 
often  deeply  blood-stained.  Beneath  this  there  is 
a dark  red.  spot,  which  dries  up,  leaving  a central 
dark  brown  or  black  eschar,  seated  on  an  angry, 
red,  indurated  base.  This  central  eschar  enlarges 
until  it  may  reach  the  size  of  a shilling;  sur- 
rounding it  is  usually  a narrow  ring  of  vesicles, 


1305 

and  beyond  this  a livid  red  area  and  extensive 
brawny  oedema.  When  the  pustule  is  situated 
on  the  face,  the  entire  side  of  the  face,  head,  and 
neck  may  be  involved  in  the  red  cedematous 
swelling.  The  lymphatic  glands  of  the  part  are 
often  greatly  swollen.  The  complete  develop- 
ment of  the  pustule  depends  on  the  length  of 
time  the  patient  survives.  If  recovery  ensue,  the 
central  black  eschar,  on  the  raised,  indurated,  and 
inflamed  base,  may  be  well-marked  at  the  end  of 
ten  days  or  later. 

The  symptoms  vary  much.  Even  where  the 
local  condition  is  severe,  constitutional  symptoms 
may  he  slight  or  wanting  ; or  some  slight  febrile 
symptoms  may  bo  present.  But  where  the  gene- 
ral system  is  involved,  and  the  case  takes  an 
unfavourable  form,  the  symptoms  may  still  pre- 
sent great  variety.  There  may  be  little  fever, 
but  great  mental  depression  and  physical  ex- 
haustion, cold  sweats,  sometimes  diarrhoea,  fol- 
lowed by  delirium  and  coma.  The  mind  maybe 
clear  to  the  last,  only  the  increased  prostration, 
embarrassed  respiration,  and  cyanotic  condition 
foretelling  the  fatal  termination.  In  cases  of 
external  pustule,  fever,  which  may  be  very  high, 
usually  predominates,  and  brain-symptoms  are 
perhaps  the  rule  in  fatal  cases.  Death  may 
occur  in  thirty  or  forty  hours  from  the  first 
appearance  of  the  pustule,  or  be  delayed  till  tho 
fifth  or  sixth  day,  rarely  later.  Healing  of  the 
pustule  may  take  place  by  sloughing,  or  the 
eschar  may  simply  separate  and  the  wound 
granulate.  Multiple  carbuncles  are  said  to  occur 
after  general  infection  from  a malignant  pustule, 
but  they  appear  to  he  usually  merely  ordinary 
furuncles  or  carbuncles.  The  mortality  in  cases 
of  external  malignant  pustule  appears  to  vary  in 
different  outbreaks ; probably  one  in  three  is  a 
safe  estimate. 

Malignant  anthrax  cedema,  without  definite 
pustule,  has  also  been  observed  in  outbreaks 
of  the  disease  ; it  corresponds  in  the  main  with 
malignant  pustule,  and  is  usually  rapidly  fatal. 
The  eyelids  are  the  parts  most  commonly  af- 
fected, hut  it  may  occur  elsewhere. 

2.  Internal  anthrax  differs  greatly  from  ex- 
ternal, and  may  either  be  general,  having  no 
special  lesion  ; or  accompanied  by  local  affections, 
usually  pulmonary,  or  gastro-intestinal. 

The  symptoms  common  to  these  internal 
forms  of  anthrax  vary  much.  The  onset  is 
often  sudden,  but  sometimes  gradual,  preceded 
by  a sense  of  depression  and  exhaustion,  restless- 
ness, loss  of  sleep,  vague  sensations  in  the  limbs, 
and  sometimes  cold  perspirations.  These  symp- 
toms may  last  two  or  three  days  before  more 
definite  symptoms,  but  commonly  only  one  or 
two  days,  or  even  a few  hours.  Whether  after 
premonitory  symptoms,  or  quite  suddenly,  acute 
symptoms  may  set  in.  There  may  be  vomiting, 
shivering — amounting  to  distinct  rigor  or  mere 
sense  of  chilliness — headache,  and  other  symp- 
toms common  to  the  onset  of  many  acute  dis- 
eases. But  what  is  usually  most  noticeable  is 
extreme  physical  prostration,  often  with  great 
mental  depression  and  anxiety,  coldness  of  the 
extremities,  embarrassed  respiration,  and  usu- 
ally speedy  collapse.  The  temperature  is  some- 
times high,  reaching  105°  F.  or  more,  but  mors 
commonly  only  slightly  elevated;  the  rectal 


PUSTULE,  MALIGNANT. 


1306 

temperature  being  100°  to  101°,  whilst  the  axil- 
lary may  be  subnormal.  In  some  cases  delirium 
occurs  early ; in  others  the  mind  is  clear  to  the 
end.  Vomiting  may  recur,  but  is  not  usually 
prominent.  AmoDgst  occasional  symptoms  of 
this  form  are  sensations  of  numbness  or  ting- 
ling in  various  parts,  particularly  of  the  extre- 
mities. Death  usually  occurs  in  forty-eight  to 
sixty  hours  from  the  onset  of  acute  symptoms, 
but  may  be  more  rapid,  or  be  delayed  for  five 
or  six  days.  Owing  to  the  absence  of  definite 
symptoms  this  form,  1 anthraccemia',  has  been 
little  studied.  More  commonly  the  symptoms 
assume  a more  definite  character,  related  either 
to  the  respiratory  or  digestive  system. 

In  the  pulmonary  form  the  symptoms  may 
more  nearly  resemble  those  of  acute  bronchitis 
or  of  pneumonia.  At  the  onset,  there  are  usually 
some  of  the  general  symptoms  just  described. 
Some  bronchitic  sounds  are  heard  over  the  lungs, 
especially  posteriorly,  and  there  may  be  patches 
of  crepitation.  Occasionally  there  is  sore-throat 
and  swelling  of  the  glands  in  the  neck,  but  not 
at  all  constantly.  Cough  may  be  slight  or 
absent,  and  is  rarely  severe.  Put  even  at  this 
stage  there  is  an  amount  of  prostration  and 
embarrassment  of  breathing,  and  tendency  to 
cyanosis,  out  of  proportion  to  the  physical  signs. 
These  rapidly  increase,  the  patient  takes  to  bed, 
there  is  great  prostration,  difficult  and  laborious 
respiration,  cyanosis  and  collapse,  with  or  with- 
out wandering  delirium.  Death  may  occur  in 
twelve  hours,  or  be  delayed  from  two  to  five 
days.  Frequently  there  are  intermissions  or  re- 
missions, followed  by  sudden  relapse. 

In  its  general  features  intestinal  anthrax  is 
somewhat  analogous  to  those  already  described. 
But  early  in  the  case  there  appear  other  symp 
toms — vomiting,  sometimes  dysphagia  slight 
pain,  uneasiness  in  the  abdomen,  colic,  and  diar- 
rhoea. The  diarrhoea  may  bo  from  the  first 
bloody,  and  may  continue  so.  Bleeding  from  the 
mouth  and  pharynx  sometimes  occurs,  and  may 
persist.  Tho  general  symptoms  are  those  of 
extreme  prostration,  cyanosis,  and  collapse,  often 
without  elevation  of  temperature.  Death  may 
occur  in  twenty-four  hours,  or  be  delayed  two  or 
three  days,  rarely  longer.  There  may  be  swell- 
ing of  the  neck,  due  to  glandular  enlargement 
and  infiltration  of  the  cellular  tissue;  and  this 
may  be  a marked  feature  in  the  case. 

It  is  thus  seen  that  in  the  internal  form  of 
anthrax  the  greatest  variety  is  observed. 

Prognosis. — The  prognosis  in  all  these  forms 
is  extremely  unfavourable.  At  the  same  time, 
it  is  stated  that  cases  of  milder  and  less  fatal 
character  sometimes  occur. 

Diagnosis. — 1.  Of  malignant  pustule  proper. 
In  the  earlier  stages  diagnosis  is  very  diffi- 
cult, except  in  persons  who  are  known  to  bo  ex- 
posed to  contagion.  At  a later  stage  tho  charac- 
teristic features  of  the  pustule  above  described 
render  the  recognition  comparatively  easy ; and 
microscopical  examination  of  the  serum  con- 
tained in  the  vesicles  shows  the  presence  of  the 
bacillus.  Moreover,  inoculation  experiments  on 
guinea-pigs  or  mice  will,  if  successful,  usually 
readily  decide  it ; but  no  absolute  conclusion  can 
be  drawn  from  failure. 

2.  Anthrax  eedema  without  pustule  is  ex- 


tremely difficult  to  diagnose,  except  by  a known 
cause  of  contagion,  or  the  presence  of  the  bacillus 
in  the  subcutaneous  exudation. 

3.  Internal  anthrax,  especially  the  pulmonary 
form,  also  presents  very  few  characters  by  which 
it  can  bo  distinguished,  unless  there  is  some 
known  source  of  contagion.  In  the  later  stages, 
if  death  is  delayed  three  or  four  days,  and  acute 
inflammatory  symptoms  set  in,  the  case  is  likely 
to  be  mistaken  for  acute  pneumonia. 

4.  In  intestinal  anthrax  there  is  also  usually 
a known  source  of  possible  contagion,  but  not 
in  all  cases.  When,  however,  the  vomiting  and 
purging  have  set  in,  the  diagnosis  from  eases 
of  irritant  poisoning,  especially  by  antimony  or 
arsenic,  must  be  difficult.  Is  tropical  climates 
the  distinction  from  acute  dysentery  or  from 
yellow  fever  may  be  doubtful. 

Treatment. — In  malignant  pustule,  the  suc- 
cess of  local  treatment  largely  depends  upon  early 
diagnosis.  As  soon  as  any  vesicle  or  pustule, 
likely  to  be  duo  to  this  poison,  is  discovered  in  a 
person  known  to  be  exposed  to  contagion,  active 
local  treatment  should  be  adopted.  Excision 
and  cauterisation  are  the  two  most  effectual 
remedies.  If  there  is  only  a small  pimple,  a free 
crucial  incision,  and  cauterisation  with  pure  car- 
bolic acid,  followed  by  dressing  with  carbolised 
oil  or  carbolic  lint,  is  the  course  to  pursue.  The 
artificial  leech  may  also  be  employed  with  ad- 
vantage- over  the  site  of  the  crucial  incision. 
When  a distinct  carbuncle,  or  rather  eschar,  has 
formed,  free  incision,  followed  by  cauterisation, 
may  be  still  employed  with  advantage.  The 
caustics  most  available  are  carbolie  acid  and 
fuming  nitric  acid.  The  former  is  preferable. 
The  statistics  of  recovery  where  this  trear- 
ment  is  systematically  carried  out  are  highly 
encouraging. 

No  other  than  general  treatment  appears  to 
bo  available  in  the  internal  form.  The  fact  that 
carnivora  suffer  less  readily  than  herbivora  sug- 
gests the  possible  benefit  of  a largely  animal 
diet  in  persons  exposed  to  contagion.  The  in- 
ternal administration  of  quinine  and  of  carbolic 
acid  are  strongly  indicated  in  all  forms ; and  in- 
halation of  air  impregnated  with  carbolic  acid 
might  possibly  be  of  value  in  the  pulmonary 
form.  In  this  form  also,  as  death  appears  often 
to  be  due  to  compression  of  the  lungs  by  pleural 
effusion,  evacuation  of  the  fluid  should  be  tried. 
Stimulants,  especially  ammonia,  ether,  and  alco- 
hol, are  also  indicated. 

Lastly,  and  chiefly,  prophylaxis  is  bv  far  the 
most  important  point.  Stringent  regulations 
with  regard  to  the  destruction  of  the  carcases 
and  hides  of  affected  animals  would  do  more 
to  stamp  out  the  disease  than  any  other  measure. 
But  as  the  disease  is  often  imported  from  distant 
countries,  by  means  of  wool,  hair,  or  hides,  which 
retain  the  contagion  for  long  periods  of  time,  it 
is  only  by  the  thorough  systematic  disinfection  of 
these,  andthe  destruction  ofall  the  material  which 
is  knotvn  to  be  infected,  that  the  disease  can  be 
thoroughly  prevented.  Up  to  the  present  time 
(ISSIj'there  is  no  enactment  in  England,  evei 
in  respect  of  animals  known  to  have  died  of  the 
disease,  which  enables  anyone  to  interfere  with 
such  disposal  of  the  carcase  or  the  oflai  as  tne 
owner  sees  fit.  It  is  greatly  to  be  desired  that 


PUSTULE,  MALIGNANT, 
measures  were  taken  to  place  the  law  in  this 
respect  on  a similar  footing  with  that  in  Ger- 
many and  France.  W.  S.  Greenfield. 

PUTRID  FEVER. — A synonym  for  typhus 
fever.  See  Typhus  Fever. 

PUTRID  SORE-THROAT.—  Sloughing 
ulceration  of  the  throat  from  any  cause,  such  as 
diphtheria,  scarlatina,  or  syphilis.  See  Pharynx, 
Diseases  of;  and  Tonsils,  Diseases  of. 

PYAEMIA  (irvov,  pus,  and  ac/j-a,  blood). — 
Synon.  : Purulent  infection;  Fr.  Pyohemie ; 
Ger.  Pyohdmie;  Pydrnie. 

Definition. — A condition  of  blood-poisoning 
which  gives  rise  to  fever,  accompanied  either  by 
severe  gastro-enteritis  and  visceral  congestions, 
or  by  certain  local  lesions,  which  are  chiefly 
venous  thrombosis,  embolic  abscesses  in  the 
viscera,  acute  suppurations  of  the  serous  mem- 
branes and  joints,  multiple  abscesses  in  the  con- 
nective tissue,  and  eruptions  upon  the  skin.  The 
disease  is  usually,  but  not  always,  sequential  to 
a wound  or  injury. 

./Etiology  and  Pathology. — The  initiatory 
symptoms  and  the  anatomical  characters  of  pyae- 
mia arc  such  as  point  clearly  to  the  introduction 
of  some  morbid  material  into  the  circulation, 
and  not  unnaturally  gave  rise  to  the  idea,  upon 
which  the  name  of  the  disease  was  founded,  that 
this  material  was  pus.  Several  considerations 
formerly  appeared  to  favour  this  belief,  amongst 
which  were  especially  these.  Hunter  believed 
that  the  lining  membrane  of  a vein  secreted  pus. 
Now,  as  cases  of  pyaemia  were  found  to  be  very 
commonly  associated  with  phlebitis,  and  also 
with  what  were  thought  to  be  deposits  of  pus  in 
the  viscera,  a very  simple  explanation  of  the  dis- 
ease seemed  to  be  that  the  inflamed  vein  secreted 
pus,  which  became  mixed  with  the  blood,  and 
was  carried  by  the  circulation  to  some  distant 
organ,  wherein,  being  arrested,  it  formed  the 
focus  of  a suppuration. 

Hunter  observed  that  in  cases  in  which  an 
injury  to  a vein  proved  fatal,  the  coats  of  the 
injured  vein  were  swollen  and  thickened,  and  its 
lining  membrane  was  of  an  unusually  red  colour  ; 
and  he  supposed  that  the  fragments  of  fibrin 
and  the  softening  clots  often  found  in  such  veins 
were  the  products  of  an  inflammation  of  their 
lining  membrane,  which  in  the  one  case  was  of 
an  adhesive,  in  the  other  of  a suppurative  cha- 
racter. He  believed  that  the  coagula  generally 
found  in  inflamed  veins  were  the  means  whereby 
these  inflammatory  products  were  prevented 
from  being  carried  into  the  circulation,  and 
that  if  such  coagula  were  not  formed,  pus  se- 
creted by  the  inflamed  vein  might  be  mixed  with 
the  blood,  and  thus  distributed. 

Hunter,  though  perfectly  familiar  with  the 
secondary  abscesses  of  pyaemia,  does  not  seem 
to  have  connected  them  with  the  introduction 
into  the  blood  of  morbid  material  from  a wound. 
That  these  abscesses  were  the  result  of  an 
entrance  of  pus  into  the  blood,  and  the  arrest 
of  pus-globules  in  the  capillaries  of  the  affected 
organ,  was  maintained  by  others,  who  thus 
looked  upon  the  process  as  a mechanical  trans- 
ference of  pus-cells  from  one  part  of  the  body 
to  another.  These  observers  supposed  that  in 


PYAEMIA.  1307 

healthy  wounds  the  entrance  of  pus  into  the 
veins  was  prevented  by  the  formation  of  a eoa- 
gulum,  but  that  if  this  coagulum  were  not 
formed,  or  became  broken  down,  pus  entered 
the  circulation,  and  gave  rise  to  the  secondary 
abscesses  by  its  arrest  in  distant  organs.  This 
view  was  supposed  to  be  confirmed  by  Cruveil- 
hier’s  experiments,  in  which  he  injected  mer- 
cury into  the  veins,  and  found  that  abscesses 
were  formed  in  the  first  set  of  capillaries  to 
which  these  veins  were  distributed,  and  that 
such  abscesses  were  formed  around  a globule  of 
mercury.  Thus,  if  the  injection  w’ere  made  iDto 
the  systemic  veins,  the  abscesses  were  formed 
in  the  lungs;  if  into  the  portal  veins,  they  were 
formed  in  the  liver. 

But  this  explanation  of  the  phenomena  of 
pyaemia  was  soon  found  to  be  insufficient,  and 
also  to  be  incompatible  with  many  facts  since 
ascertained.  Cases  of  pyaemia  occur  in  which 
there  is  no  primary  suppuration  from  whence 
the  pus  could  be  derived ; there  is  no  evidence 
that  the  lining  membrane  of  a vein  ever  se- 
cretes pus ; the  secondary  abscesses  of  pyaemia 
are  not  deposits  of  pus,  but  true  inflammations, 
and,  if  examined  at  their  commencement,  are 
found  not  to  be  purulent.  Again,  the  first  set 
of  capillaries  occasionally  escape,  and  the  secon- 
dary lesions  occur  in  parts  beyond  them  in  the 
order  of  the  circulation;  and  the  position  of  the 
abscesses  — as,  for  instance,  in  the  lung,  where 
they  chiefly  occupy  the  lower  parts  of  the  organ — 
is  not  explained  by'  the  purely  mechanical  theory. 
Besides  which,  there  are  the  general  symptoms 
of  systemic  poisoning  to  be  accounted  for,  and 
these  are  sometimes  so  severe  as  to  kill  the  pa- 
tient before  any  secondary  lesions  are  developed. 
Experiments  upon  animals  show  that  the  injec- 
tion into  the  veins  of  pus,  or  any  material  con- 
taining solid  particles,  is  usually  followed  by  the 
arrest  of  the  solid  particles  in  the  first  set  of 
capillaries  with  which  they  meet,  and  a conse- 
quent obstruction  of  the  capillary  circulation  ; 
but  the  result  of  this  capillary  obstruction  varies 
according  to  the  nature  of  the  obstructing  sub- 
stance. The  injection  of  septic  liquids  filtered 
from  solid  particles,  causes  fever  and  other  con- 
stitutional symptoms,  varying  according  to  the 
virulence  of  the  poison  contained. 

An  examination  of  the  symptoms  of  pyaemia 
will  show  that  it  consists  of  two  series  of  mor- 
bid processes,  the  first  series  manifesting  the 
general  constitutional  disturbance  due  to  the 
systemic  poisoning,  the  second  having  relation  to 
the  secondary  lesions  thereupon  developed.  Both 
analogy  and  morbid  anatomy  point  to  the  pri- 
mary cause  of  these  being  the  introduction  into 
the  blood  of  an  animal  poison,  which  at  once 
gives  rise  to  the  first  series  or  the  general 
disease  ; and  we  shall  see  that  the  secondary 
lesions  are  to  be  accounted  for,  either  by  a venous 
thrombosis,  leading  to  a capillary  embolism,  or 
by  a stagnation  of  the  diseased  blood  and  the 
changes  which  ensue  thereupon. 

Of  the  exact  nature  of  the  poison  which  gives 
to  the  blood  in  pyoemia  its  infective  character, 
we  are  in  ignorance ; and  it  is  better  to  admit 
this.  Our  powers  of  organic  analysis  are  not 
yet  sufficient  for  the  isolation  of  the  subtle  but 
potent  poisons  upon  which  so  many  of  the  Epe- 


PYJEJHA. 


I *08 

sifle  diseases  depend;  and  -we  do  not  yet  know 
what  it  is  which  gives  to  a pysemic  clot  its  in- 
fective quality.  It  is  certain,  however,  that  the 
poison  may  be  either  generated  within  the  body 
or  introduced  from  without,  and  that  there  are 
predisposing  causes  which  render  a person  pe- 
culiarly prone  to  its  generation  or  reception. 

Of  predisposing  causes,  impure  air,  and  espe- 
cially that  kind  of  impurity  which  results  from  the 
presence  of  decomposing  animal  matter,  is  doubt- 
less the  most  important.  Thus  the  crowding 
together  of  a number  of  persons  with  suppurat- 
ing wounds,  neglect  in  removing  the  discharges 
and  excretions  from  sick  persons,  and  imperfect 
drainage,  are  causes  favouring  the  development 
of  pyaemia.  The  puerperal  condition  is  also 
a powerful  predisposing  cause.  Disease  of  im- 
portant excreting  organs,  whereby  effete  ma- 
terials are  retained  in  the  blood,  also  renders  a 
person  more  liable  to  pyeemia,  as  is  often  ob- 
served in  cases  of  Bright’s  disease ; and  any  great 
nervous  depression  (perhaps  because  of  its  influ- 
ence in  diminishing  excretion)  has  a like  effect. 
Intemperance,  and  acute  fevers,  probably  render 
their  subjects  somewhat  more  prone  to  pyaemia  ; 
but  it  is  a mistake  to  assert  that  chronic  invalids, 
or  persons  in  weak  health,  have  any  special  lia- 
bility to  the  disease.  Children,  though  by  no 
means  exempt  from,  are  somewhat  less  liable  to 
pyaemia  than  adults. 

Pyaemia,  then,  is  caused  by  the  entrance  into  the 
blood  of  an  animal  poison,  which  in  the  majority 
of  instances  originates  in  a wound,  an  injury,  or 
a local  inflammation  ; but  in  some  few  cases  it  has 
been  impossible  to  determine  where  the  disease 
began.  It  is  especially  liable  to  follow  certain  dis- 
eases and  injuries,  and  is  the  gravest  danger  of 
many  operations.  Thus,  it  occurs  very  frequently 
after  compound  fractures,  and  operations  involv- 
ing the  sect  ion  of  a bone ; after  i n juri  es  of  the  bones 
of  the  head,  and  in  connection  with  acute  necro- 
sis of  the  long  bones  from  suppurative  perios- 
titis ; also  after  wounds  or  injuries  of  veins; 
after  parturition  ; in  connection  with  diffuse  cel- 
lular inflammation,  suppuration  of  the  internal 
ear,  and  operations  upon  the  urinary  organs. 
Facial  carbuncle  is  a disease  peculiarly  prone 
„o  lead  to  pyaemia. 

Anatomical  Characters.—' The  morbid  ana- 
tomy of  pyaemia  reveals  two  series  of  changes  — 
the  one  depending  upon  the  primary  infection  of 
the  blood,  the  other  upon  the  secondary  effects 
of  this.  When  the  blood  is  very  profoundly 
infected,  the  results  of  general  blood-poisoning 
are  often  all  that  can  be  found  ; the  patient  dies 
before  the  secondary  affections  can  be  produced. 
When  the  poison  is  smaller  in  quantity,  or  not 
much  in  excess  of  the  eliminative  powers,  the 
secondary  lesions  predominate  ; but  in  most  cases 
changes  of  botli  kinds  are  found. 

The  wound,  or  the  tissues  at  the  site  of  the 
primary  disease  or  injury,  from  whence  the 
poison  has  entered  the  blood,  are  found  in  various 
conditions.  There  is  often,  but  not  always,  sup- 
puration present,  and  the  wound  is  bathed  in 
foul  and  unhealthy  pus  ; or  the  wound  may  be 
dry,  and  discharging  only  a little  thin  ichor;  or 
the  cellular  tissue  may  be  infiltrated  with  sero- 
purulent  fluid.  The  veins  in  the  neighbourhood 
of  the  diseased  tissues  are  often  found  blocked 


with  coagula,  extending  a variable  distance  along 
their  channels,  and  in  different  stages  of  disin- 
tegration. These  clots  may  be  soft  and  dark,  or 
firm  and  adherent  to  the  lining  membrane  of  the 
vein,  and  partially  decolourised  ; or  they  maybe 
broken  down  in  the  centre  to  a reddish-yellow 
pulpy  material,  consisting  of  disintegrated  fibrin. 
Sometimes  the  whole  clot  is  thus  softened,  and 
the  fragments  of  fibrin  have  been  partly  carried 
away  into  the  circulation.  Occasionally,  but 
rarely,  the  clots  contain  real  pua  ; but  the  puri- 
form  material  found  in  the  vessels  is  usually  only 
broken-down  fibrin,  and  the  debris  of  cells. 

An  abscess  may,  however,  open  into  a vein, 
and  thus  pus  may  gain  a direct  entrance  into  its 
channel ; in  such  a case  a coagulum,  consisting 
of  a mixture  of  pus  and  blood,  is  found  in  the 
vessel,  and  we  have  a true  purulent  clot.  Sof- 
tening thrombi  are  found  with  especial  frequency 
in  connection  with  injuries  and  diseases  of  bone, 
as,  for  instance,  in  the  sinuses  of  the  dura 
mater  after  bruising  of  the  cranial  bones,  or  in 
consequence  of  caries  of  the  bones  of  the  ear ; or 
in  the  veins  of  an  unhealthy  stump,  in  which 
there  is  inflammation  or  necrosis  of  the  bone. 

But  it  may  be  certainly  affirmed  that  many 
cases  of  pyaemia  occur  in  which  no  thrombi  are 
found,  and  in  which  the  most  careful  examina- 
tion fails  to  detect  any  morbid  condition  what- 
ever of  the  veins.  It  is  necessary  to  point  this 
out,  because  it  has  been  erroneously  asserted  by 
some  that  phlebitis  is  an  essential  process  in  the 
disease.  It  is  to  be  observed  also  that  the  pre- 
sence of  pus  is  not  a necessary  element  in  the 
causation  of  pyaemia,  as  was  once  supposed; 
well-marked  cases  have  been  seen  in  which  there 
has  been  neither  wound  nor  suppuration  for  its 
origin.  When  a wound  does  exist,  however,  it 
is  usually  found  in  an  unhealthy  condition,  and 
in  this  may  probably  be  found  the  explanation 
of  the  spread  of  pyaemia  by  contagion.  Healthy 
granulations  do  not  allow  the  entrance  of  septic 
matter  into  the  blood ; a wound  may  be  bathed 
with  foetid  fluids  of  a most  poisonous  character, 
and  yet  none  may  be  absorbed,  as  has  been  proved 
experimentally  by  Chauveau;  but  if  the  surface 
of  the  wound  becomes  unhealthy,  the  granula- 
tions no  longer  present  a barrier  to  the  absorp- 
tion of  poisonous  fluids.  This  is  probably  due. 
as  Mr.  Savory  has  suggested,  to  the  dialvsiDg 
property  of  animal  membranes.  If,  then,  the 
secretions  or  exhalations  of  an  unhealthy  wound 
come  in  contact  with  another  secreting  surface, 
an  unhealthy  action  may  thereby  be  set  up  on 
that  surface,  producing  a condition  favourable  to 
the  absorption  of  septic  material.  This  explains 
the  prevalence  of  pysemia  where  a number  of 
persons  with  open  wounds  are  crowded  together. 
A similar  condition  of  wound  may  also  be  in- 
duced by  neglect  of  other  sanitary  precautions, 
especially  by  the  presence  of  decomposing  ani- 
mal matter,  and  the  escape  of  sewer-gas  into  the 
air  surrounding  the  patient. 

In  cases  of  acute  pyiemia  the  morbid  changes 
found  post  mortem  are  chiefly  congestion  and 
softening  of  the  viscera,  local  stagnation  and  ex- 
travasation of  blood,  and  a general  blood-stain- 
ing of  the  tissues — conditions  indicating  profound 
changes  in  the  state  of  the  blood.  In  what  these 
changes  consist  we  are  at  present  ignorant;  but 


PYEMIA. 


osually  the  blood  contains  an  excess  of  leuco- 
cytes, and  its  fibrin  is  diminished  in  quantity 
and  lacks  contractility. 

When  the  disease  is  not  of  this  acutest  form, 
but  is  of  longer  duration,  there  are  developed 
those  secondary  lesions  -which  are  especially 
characteristic  of  pyaemia. 

Most  notable  and  commonest  among  these  are 
the  so-eallod  ‘secondary  deposits’  or  ‘ secondary 
abscesses  ’ of  pyaemia.  These  are  found  most 
frequently  near  the  surface  of  the  viscera,  and 
are  the  result  of  the  obstruction  of  the  terminal 
branches  of  the  vessel  supplying  the  part  with 
blood.  This  obstruction  is  followed  by  engorge- 
ment and  extravasation,  by  inflammation,  and 
by  rapid  necrosis  or  suppuration.  It  is  neces- 
sary more  fully  to  describe  this  process  before 
giving  an  account  of  the  morbid  anatomy  of  in- 
dividual organs  thus  affected.  The  obstruction 
may  be  caused  in  several  ways. 

1.  It  may  be  embolic.  A portion  of  a dis- 
integrating clot  may  be  carried  into  the  circu- 
lation, until  it  meets  with  an  artery  too  small 
to  allow  its  transmission,  or  with  the  first  set 
of  capillaries  in  its  route,  wherein  it  becomes 
arrested.  In  this  way  a portion  of  the  organ 
is  deprived  of  its  arterial  blood-supply,  and 
in  consequence  of  the  absence  of  the  vis-a-tergo 
of  the  heart,  regurgitation  takes  place  from  the 
veins  into  the  capillaries,  and  even  into  the  ter- 
minal arteries,  giving  rise  to  a venous  engorge- 
ment of  the  affected  region.  The  nutrition  of  the 
capillaries  being  interfered  with  by  the  lack  of 
aiterial  blood,  their  walls  become  altered  or  ne- 
crosed, and  extravasation  of  blood  takes  place, 
the  area  of  extravasation  corresponding  with  the 
part  supplied  by  the  obstructed  vessel.  At  the 
same  time  the  vessels  of  the  tissues  immedi- 
ately surrounding  the  obstructed  region  become 
dilated,  and  so  form  a zone  of  intense  hyperaemia. 
So  far,  this  process  is  only  what  occurs  in  any 
case  of  embolism  (as,  for  instance,  when  minute 
fragments  of  fibrin  are  detached  from  an  inflamed 
mitral  valve),  but  the  importance  of  the  process 
in  pyaemia  depends  upon  the  changes  which  sub- 
sequently occur.  Now  the  changes  which  occur 
in  the  tissues  of  a part  the  seat  of  embolism 
depend  upon  the  character  of  the  embolus.  If 
the  embolus  come  from  a part  which  is  gan- 
grenous, gangreue  will  usually  occur  in  the  tissue 
to  which  it  is  carried  ; if  the  embolus  be  puru- 
lent, or  come  from  a suppurating  region,  ‘ then 
the  effect  is  a suppuration  in  the  part  implicated. 
This  suppuration,  however,  is  complicated  with 
the  embolic  passive  hyperaemia  we  have  above 
described,  so  that  the  suppuration  is  incomplete, 
and  consists  rather  in  rapid  breaking-down  of 
the  tissues  than  in  the  formation  of  a large  num- 
ber of  pus-cells,  while  the  characteristic  deep- 
purple  congested  zone  around  the  affected  spot  is 
much  intensified.  Some  describe  this  as  a true 
sphacelus  of  the  affected  part,  but  there  is  no 
necrosis,  and  no  foul  decomposition  of  the  patch 
affected  in  the  suppurative  form  of  embolic  in- 
flammation. Lower  degrees  of  inflammatory 
quality  in  the  embolic  clot  induce  similar  but 
slighter  inflammatory  conditions,  additional  to 
the  states  described  as  due  to  the  mechanical 
obstruction.’  There  are  all  gradations  among 
such  degrees  (Wilks  and  Moxtn). 


1309 

If,  then,  the  embolus  originate  in  a wound 
infected  with  the  pyaemic  poison,  it  sets  up  an 
unhealthy  inflammation  and  rapid  disintegra- 
tion of  the  tissues  wherein  it  is  arrested.  The 
important  difference,  therefore,  between  pyaemic 
and  other  embolism  consists  in  the  fact  that  the 
pyaemic  embolus  is  composed  of  infected  clot. 
Virchow  and  others  have  maintained  that  this 
is  the  sole  mode  of  production  of  the  secondary 
pyaemic  formations.  This  is  incorrect,  for,  al- 
though such  formations  doubtless  often  have 
such  an  origin,  they  may  also  arise  in  a different 
manner.  The  embolic  theory  will  not  account 
for  cases  in  which  the  first  set  of  capillaries  in 
the  order  of  the  circulation  from  the  seat  of 
injury  escape,  and  secondary  deposits  are  found 
in  other  organs  beyond  ; as,  for  instance,  w'here 
they  occur  in  the  liver  after  an  injury  of  the 
head,  and  the  lungs  are  not  affected.  Neither 
does  this  theory  explain  the  cases  in  which  the 
joints  only  are  affected,  as  in  connection  with 
gonorrhoea  or  scarlatina ; nor  are  the  chronic 
cases  in  which  only  superficial  abscesses  occur 
thus  explicable.  It  must  be  remembered,  too, 
that  the  lesions  in  the  lungs  are  found  chiefly 
in  the  inferior  parts  of  the  organ,  which  is  not 
what  would  be  expected  were  their  origin  always 
embolic. 

2.  The  capillary  obstruction  may  be  caused  by 
a local  stagnation  depending  upon  the  poisoned 
state  of  the  blood.  The  infection  of  the  blood 
interferes  with  the  normal  interchange  between 
this  fluid  and  the  tissues,  and  produces  a ten- 
dency to  coagulation  in  the  minuter  vessels.  This 
coagulation  is  especially  prone  to  occur  in  organs 
or  puirts  of  organs  already  congested,  for  where 
the  circulation  is  slow  the  impurity  will  be  the 
greater.  In  this  way  the  greater  frequency  of 
the  secondary  lesions  in  the  lower  than  in  the 
upper  part  of  the  lungs  is  accounted  for.  When 
this  form  of  thrombosis  has  taken  place,  the  part 
so  affected  is  in  a condition  similar  to  that  above 
described  as  due  to  embolism,  and  the  same 
series  of  changes  ensues.  It  must  be  remembered, 
also,  that  the  impurity  of  the  blood  interferes 
with  the  nutrition  of  the  vessels,  which  thus 
easily  allow  of  the  extravasations  that  are  so 
frequently  found,  not  only  in  the  viscera,  but  on 
the  surface  of  the  skin  and  mucous  membranes. 

It  is  more  difficult  to  explain  the  occurrence 
of  the  joint-affections,  and  the  especial  vulnera- 
bility of  certain  organs  to  the  secondary  inflam- 
mations of  pyaemia.  All  that  can  be  said  on  this 
part  of  the  subject  is  that  the  poison  of  pyaemia 
selects  certain  organs  and  tissues  whorein  to  ex- 
pend itself,  just  as  that  of  rheumatism,  syphilis, 
or  typhoid  fever  does. 

The  lungs  are  usually  congested  throughout, 
and  are  very  prone  to  the  secondary  lesions. 
These  are  found  chiefly  near  the  surface  and  in 
the  lower  and  posterior  portions,  and  consist,  in 
the  early  stage  of  the  process,  of  small  extrava- 
sations and  patches  of  congestion ; the  minuter 
branches  of  the  pulmonary  artery  are  herein 
found  plugged  with  coagulum  ; and  haemorrhage, 
or  inflammatory  exudation,  has  taken  place  into 
the  surrounding  tissues.  Thus  we  have  a patch 
of  pulmonary  haemorrhage,  or  of  lobular  pneu- 
monia. Later  on,  the  centre  of  this  area  of  con- 
solidation is  found  in  a state  cf  necrosis,  <uid 


PYJEMIA. 


1310 

its  circumference  surrounded  by  a ring  of  in- 
tense congestion.  The  process  of  disintegration 
occurs  with  great  rapidity,  and  the  central  por- 
tion of  the  nodule  may  be  found  within  forty- 
eight  hours  of  the  first  symptom  of  pulmonary 
mischief,  broken  down  into  a soft  yellow  puri- 
form  material,  or  even  containing  true  pus.  The 
nodules  are  perfectly  circumscribed,  and  average 
in  size  about  that  of  a hazel-nut,  though  they 
may  be  smaller  or  larger.  On  section,  they  are 
seen  to  consist,  in  the  centre,  of  a cavity  filled 
with  pus  or  puriform  debris ; surrounding  this 
is  an  area  of  pneumonic  consolidation,  the  cir- 
cumference of  which  is  formed  by  a narrow  ring 
of  intense  congestion.  The  surrounding  lung  is 
usually  simply  congested,  or  it  may  even  be 
natural  in  appearance.  An  examination  of  the 
early  stages  of  these  changes  shows  the  first 
step  in  the  process  to  be  a blocking  of  the  minute 
branches  of  the  pulmonary  artery;  and  this  may 
occur  either  from  a local  coagulation,  or  by  the 
transference  of  a portion  of  clot  from  some  other 
part,  that  is  to  say,  it  mayr  depend  either  upon 
thrombosis  or  upon  embolism ; but  in  whichever 
manner  it  originates  it  is  followed  by  a rapid  ex- 
udation into,  and  disintegration  of,  the  portion  of 
lung  to  which  the  blocked  vessels  belong.  It  has 
been  pointed  out  that  these  changes  take  place 
chiefly  in  parts  of  the  lung  near  the  surface. 
The  result  of  this  is  that  the  'pleura  becomes 
involved  in  the  inflammation,  and  those  nodules 
which  have  reached  the  surface  of  the  lung  are 
coated  with  a patch  of  lymph,  which  may  subse- 
quently become  part  of  a more  general  pleurisy. 
Or  one  or  more  of  the  abscesses  may  burst  into 
the  pleura,  when  a rapid  effusion  of  sero-purulent 
fluid  takes  place  into  its  cavity. 

Pleurisy  may,  however,  occur  independently 
of  the  lung-disease ; and  in  this  case,  also,  the 
effusion  becomes  rapidly  purulent.  In  the  early 
stage  of  the  disease  numerous  subpleural  ecchy- 
moses  are  frequently  found.  Pleurisy  is  espe- 
cially prone  to  occur  in  those  cases  of  pyaemia 
originating  in  caries  of  the  bones  of  the  ear ; and 
m children  thus  affected  is  often  the  first  symp- 
tom of  the  pyaemic  infection. 

The  heart  is  liable  to  be  affected  by  the  same 
kind  of  embolic  abscesses  as  are  found  in  other 
organs.  They  occur  most  often  in  pyaemia  from 
acute  necrosis,  in  young  persons.  In  the  early 
stage  small  spots  of  congestion,  due  to  the  plug- 
ging of  small  arteries,  are  found  both  on  the  sur- 
face and  in  the  substance  of  the  heart,  and  also 
beneath  the  endocardium.  Later  on,  small 
cavities  containing  pus  or  puriform  fluid,  and 
surrounded  by  a zone  of  congestion,  are  found  in 
the  walls  of  the  organ.  These  abscesses  are  some- 
times very  numerous,  and  may  occur  in  any  part 
of  the  organ  ; they  may  open  on  the  surface  or 
into  the  cavity  of  the  heart ; the  muscular  tissue 
around  them  is  softened  and  broken  down.  The 
pericardium  may  thus  become  inflamed  from  the 
contiguity  of  an  abscess  in  the  wall  of  the  heart ; 
but,  as  with  the  pleura,  pyaemic  pericarditis  may 
occur  independently  of  such  an  origin,  and  in 
either  case  the  effusion  rapidly  becomes  puru- 
lent. The  same  process  may  lead  to  inflammation 
of  the  endocardium. 

The  brain,  although  less  frequently  the  scat 
of  pvsemic  abscess  than  many  of  the  organs,  may 


be  the  sole  organ  affected  by  the  secondary  le- 
sions ; and  it  not  uncommonly  happens  when  this 
is  so,  that  the  general  symptoms  are  unusually 
slight.  Small  extravasations  are  often  found  in 
the  subarachnoid  tissue.  Circumscribed  softening 
ending  in  abscess  is  most  frequent  in  the  white 
matter  of  the  brain.  It  commences  as  a patch 
of  red  softening,  due  to  obstructed  vessels,  which 
subsequently  changes  to  a reddish-yellow  pulp, 
or  to  greenish  pus,  enclosed  by  a more  or  less 
defined  wall.  Such  an  abscess  may  run  a very 
chronic  course,  and  is  then  found  enclosed  in  a 
cyst  of  connective  tissue. 

The  peritoneum,  is  occasionally  found  acutely 
inflamed,  its  surface  vascular  and  coated  with 
lymph  or  pus  ; in  other  cases  the  membrane  is 
spotted  with  numerous  ecchymoses.  Peritonitis 
may  also  be  set  up  by  secondary  abscess  of  the 
liver  making  its  way  to  the  surface,  or  even 
bursting  into  the  abdominal  cavity.  In  some 
cases  of  strangulated  hernia,  death  takes  place 
with  great  rapidity  after  operation,  from  absorp- 
tion of  septic  fluid  which  has  escaped  from  the 
sac  into  the  abdominal  cavity.  In  addition  to 
the  usual  visceral  conditions,  the  peritoneum  is 
then  found  vascular,  and  slightly  coated  with 
commencing  exudation. 

In  acute  cases  of  pyaemia  the  alimentary  canal 
is  often  found  in  a state  of  catarrhal  inflamma- 
tion, or  of  intense  congestion,  accompanied  by 
small  spots  of  haemorrhage.  The  intestinal  flux 
is  probably  eliminative,  for  in  animals  which  re- 
cover after  the  injection  of  septic  matter  into  the 
blood,  diarrhoea  is  usually  a prominent  symptom. 

The  liver  is,  next  to  the  lungs,  the  organ  in 
which  secondary  deposits  are  most  frequently 
found  in  pyaemia.  In  acute  cases  the  organ  is 
found  congested,  softened,  and  swollen : it.  has 
lost  elasticity ; and  its  texture  on  section  is 
confused  and  clouded.  Secondary  abscess  is,  of 
course,  especially’  prone  to  occur  in  connection 
with  dysenteric  and  other  lesions  of  the  bowel, hut 
is  also  found  in  cases  of  general  pyaemia,  origi- 
nating in  any  part  of  the  body.  It  commences 
by  plugging  of  the  portal  capillaries,  leading,  as 
has  been  explained  with  regard  to  the  lung,  to 
congestion  and  stagnation  of  blood  in  the  affected 
portion  ; tho  nutrition  of  this  portion  being  thus 
interfered  with,  necrotic  changes  soon  com- 
mence. and  the  infective  character  of  the  clot 
gives  the  start  to  destructive  inflammation.  The 
capillaries  surrounding  the  diseased  area  dilate, 
and  inflammatory  exudation  occurs  into  its  cir- 
cumference ; at  the  same  time  central  disintegra- 
tion is  rapidly  going  on  ; and  in  a short  time  we 
find  a purulent  collection,  surrounded  by  a zone 
of  exudation  and  congestion.  Occasionally  these 
abscesses  run  a more  chronic  course,  and  become 
encysted  : and  it  seems  probable  that  the  tropical 
hepatic  abscesses,  which  often  attain  a large 
size,  have  an  embolic  origin,  connected  with  the 
ulceration  of  dysentery’,  and  may  thus  be  classed 
with  pyaemic  suppurations.  It  must  be  remem- 
bered that  pyaemic  abscess  in  other  parts  is  not 
always  acute.  Sometimes,  but  more  rarely,  he- 
patic abscess  originates  in  embolism  of  the  he- 
patic artery,  in  which  case  the  suppurations  are 
usually  smaller  and  more  scattered. 

The  spleen  may  be  simply  swollen  and  soft,  or 
may  contain  abscesses  precisely  resembling  those 


PYACMIA. 


described  in  the  liver ; the  same  may  be  said  of 
the  kidneys. 

Inflammation  of  the  bones  and  joints  may  be 
either  the  cause  or  the  effect  of  pyaemia.  The 
frequency  with  which  pymmia  originates  in 
diffuse  periostitis  and  osteo-myelitis  is  well 
Known.  In  such  cases  the  heart  and  kidneys 
are  especially  liable  to  be  the  seat  of  secondary 
deposits,  and  the  disease  is  generally  of  a severe 
form.  The  bone  is  found  stripped  of  its  investing 
periosteum,  and  separated  from  it  by  a quantity 
of  pus.  The  surface  of  the  bone  is  bare,  aDd  of 
a yellowish-white  colour  ; the  medulla  is  usually 
also  inflamed,  and  is  tumid  and  vascular,  or  it 
may  be  infiltrated  to  a varying  extent  with 
purulent  fluid.  Sometimes,  as  after  amputation, 
die  medulla  is  the  part  chiefly  affected,  and  the 
inflammation  extends  to  a greater  distance  along 
the  interior  than  the  exterior  of  the  bone.  These 
changes  may  also  be  secondary  effects  of  pyremic 
infection  from  disease  of  other  parts.  The  dis- 
ease is  usually  arrested  at  the  epiphyses,  but 
it  may  spread  to  the  adjacent  joints.  The 
joint-affection  most  commonly  found  in  py- 
aemia is  an  extremely  rapid  suppuration.  In  no 
other  kind  of  joint-inflammation  does  the  de- 
struction of  the  tissues  involved  so  quickly  take 
place.  The  cartilages  may  be  found  extensively 
ulcerated,  and  the  joint  filled  with  purulent  fluid, 
within  forty-eight  hours  of  the  first  symptom 
of  inflammation.  At  first  the  synovial  membrane 
is  swollen  and  vascular,  and  the  joint  distended 
with  a slightly  turbid  fluid.  This  fluid  usually 
quickly  becomes  purulent,  and  superficial  ero- 
sions and  softening  of  the  cartilages  occur,  soon 
leading  to  extensive  ulceration  and  irreparable 
destruction  of  the  joint. 

Iu  ‘gonorrhoeal  rheumatism,’  which  some  con- 
sider a mild  form  of  pyaemia,  the  effusion  is 
not  generally  purulent,  and  the  same  maybe  said 
of  the  joint-swellings  occurring  in  women  with 
other  purulent  discharges.  So  again,  scarla- 
tinal pyaemia  (in  which  the  infection  takes  place 
from  the  ulcers  in  the  throat),  though  often  of  a 
severe  kind,  is  not  infrequently  attended  with 
merely  serous  effusions  into  the  joints,  from 
which  complete  recovery  takes  place. 

The  muscles  and  cellular  tissue  are  often  in- 
vaded by  pytemic  abscesses,  and  by  inflammatory 
exudations  and  extravasations  of  blood.  In  the 
muscles  the  process  commences  in  the  cellular 
tissue  between  the  fibres.  Abscess  in  the  inter- 
muscular septa  and  the  subcutaneous  cellular 
tissue  is  often  the  result  of  the  more  chronic 
forms  of  pyaemia. 

The  skin  in  many  eases  of  pyaemia  is  found 
more  or  less  jaundiced ; petechiae  and  sudamina 
are  not  uncommon  ; and  sometimes  a pustular 
eruption  is  seen.  Patches  of  livid  congestion  also 
occur,  some  of  which  may  have  passed  into  gan- 
grene in  the  centre  or  where  subjected  to  pres- 
sure. 

The  morbid  anatomy  of  other  organs  shows 
that  secondary  abscesses  may  occur  in  almost 
tiny  situation;  among  the  less  rare  may  be  men- 
tioned the  eye,  the  prostate  gland,  and  the  tes- 
ticle. 

Before  leaving  the  consideration  of  the  patho- 
logy of  pyaemia,  it  is  necessary  to  allude  to  the 
connection  which  is  supposed  by  some  to  exist 


1311 

between  bacteria  and  this  disease.  It  is  said  by 
Dr.  Sanderson  that  great  numbers  of  microzymes 
are  found  in  the  blood  and  inflammatory  exuda- 
tions of  animals  suffering  from  acute  infective 
fever,  produced  by  inoculation  of  septic  matter. 
Olliers  (Wilks,  Moxon,  Goodhart)  have  failed 
to  find  bacteria  in  the  blood  of  living  cases  of 
pytemia,  though  they  may  be  found  in  great  num- 
bers after  death.  The  committee  appointed  by 
the  Pathological  Society  ‘ to  investigate  the 
nature  and  causes  of  those  infective  diseases 
known  as  pyaemia,  septicaemia,  and  purulent 
infection,’  state  that,  ‘although  bacteria  of 
various  forms  were  found  in  the  blood  in  a 
number  of  cases,  they  could  not  be  found  in  all 
the  cases,  nor  were  they  discovered  constantly 
in  those  cases  where  at  one  or  other  time  they 
were  present’  {Trans,  of  Path.  Soc.,  vol.  xxx. 
pi.  44).  Our  knowledge  of  these  organisms  is  at 
present  insufficient  to  enable  us  to  speak  certainly 
of  the  part  which  they  play  in  connection  with 
this  disease,  but  the  investigation  is  one  of  great 
interest  and  importance.  See  Bacteria;  and 
Micrococcus. 

Symptoms. — A patient  who  has  become  the 
subject  of  pyaemia,  often  appears  to  be  progress- 
ing quite  favourably  up  to  the  moment  when  the 
disease  attacks  him  ; in  other  cases  there  may 
have  been  loss  of  appetite,  depression,  or  rest- 
lessness, for  a day  or  two,  with  perhaps  some 
little  elevation  of  temperature.  The  wound, 
if  there  he  one,  has  probably  assumed  an  un- 
healthy appearance  : its  surface  may  be  dry,  or 
the  discharge  may  be  thin  and  offensive,  the 
healing  process  is  arrested,  and  recent  adhe- 
sions may  give  way.  The  attack,  however, 
is  usually  sudden,  and  is  almost  invariably 
ushered  in  by  a severe  rigor,  followed  by  sweat- 
ing. The  rigors  are  of  variable  duration  and 
frequency,  but  are  usually  severe  while  they 
last ; occasionally  they  recur  with  such  regula- 
rity as  to  simulate  ague.  The  patient  at  first 
may  not  feel  particularly  ill.  but  he  rapidly  be- 
comes so.  Pains  in  the  limbs  and  general  un- 
easiness occur ; the  pulse  becomes  weak  and 
rapid ; fever,  of  an  intermittent  type,  commences, 
with  its  usual  accompaniments  of  loss  of  appe- 
tite, restlessness,  and  thirst.  The  tongue  be- 
comes dry  and  brown ; diarrhoea  frequently 
occurs ; and  the  skin  and  conjunctiva  may  become 
jaundiced.  If  the  infection  be  profound,  the 
prostration  is  extreme  ; there  is  usually  cough 
and  diarrhoea ; muttering  delirium  sets  in  early, 
and  soon  leads  to  unconsciousness  and  death.  Id 
such  cases  the  blood-poisoning  kills  before  there 
is  time  for  the  development  of  any  secondary 
lesions. 

In  less  acute  cases  local  symptoms  soon  be- 
gin to  appear.  A day  or  two  after  the  initial 
rigor  pain  and  swelling  of  one  or  more  joints 
occurs,  or  a subcutaneous  abscess  forms,  or  dis- 
colourations  or  pustules  are  seen  on  the  skin. 
Cough,  attended  with  rusty  expectoration,  is 
common  ; the  respirations  are  rapid  and  shallow  ; 
there  is  pain  in  the  chest ; and  perhaps  dyspnoea 
or  orthopncea  from  pleuritic  effusion.  Mean- 
while the  depression  increases ; jaundice  fre- 
quently comes  on;  and  the  face  assumes  a 
pinched  and  anxious  expression.  There  is,  more- 
over, often  a peculiar  sweet  smell  about  the 


PYAEMIA. 


1312 

patient,  somewhat  resembling  that  of  diabetic 
urine.  The  rigors  mostly  cease  after  the  first 
few  days,  but  the  temperature  usually  maintains 
a remittent  character.  The  skin  shows  a ten- 
dency to  slough  on  very  slight  pressure,  so  that 
troublesome  bed-sores  easily  form ; and  patches 
of  superficial  gangrene  sometimes  occur  without 
any  such  provocation.  Vomiting  is  not  a symp- 
tom of  frequent  occurrence  ; and  though  there  is 
usually  no  appetite,  yet  nourishment  is  often 
freely  taken  and  digested.  The  cerebral  symp- 
toms are  not  usually  severe,  unless  there  be 
secondary  lesions  in  the  brain ; but  there  is 
often  a low  form  of  delirium ; and  towards  the 
end  the  patient  usually  becomes  unconscious, 
and  passes  the  evacuations  unknowingly.  Death 
may  occur  from  general  exhaustion ; or  from 
the  severity  of  some  local  lesion,  as,  for  example, 
from  pericarditis,  pleurisy,  or  cerebral  abscess. 

The  duration  of  the  disease  is,  in  the  majority 
of  cases,  from  a week  to  ten  days.  It  may,  how- 
ever, prove  fatal  in  forty-eight  hours  ; or,  on  the 
other  hand,  it  may  be  prolonged  for  weeks  or 
even  years. 

Pyaemia  may  commence  at  any  stage  of  disease 
or  injnry ; the  most  common  period  of  invasion 
is  during  the  second  week. 

Certain  peculiarities  must  be  noted  concern- 
ing some  forms  of  pyaemia,  for  which  no  satis- 
factory explanation  can  he  given.  For  instance, 
in  acute  necrosis  pyasmic  symptoms  are  fre- 
quently seen  almost  from  the  commencement  of 
the  disease,  and  yet  these  cases  of  pyaemia  are 
sometimes  of  very  long  duration.  Such  cases, 
though  severe,  are  among  the  least  fatal ; and 
when  death  does  take  place,  abscesses  are  usu- 
ally found  in  the  heart  and  kidneys.  The  pyaemia 
arising  from  disease  of  the  internal  ear  is  espe- 
cially prone  to  lead  to  pleurisy,  which  is  often 
the  prominent  condition  throughout.  That  va- 
riety of  pyaemia  associated  with  gonorrhoea  and 
with  scarlatina  tends  especially  to  affect  the 
joints,  and  these  are  often  the  only  parts  in- 
vaded; hut  this  joint-inflammation  is  very  dif- 
ferent from  that  which  occurs  in  the  course  of 
other  cases  of  pyaemia,  for  the  effusion  is  gene- 
rally slight,  and  does  not  become  purulent.  Such 
joint-affections  are  not  uncommon  after  partu- 
rition. There  is,  moreover,  a chronic  form  of 
pyaemia  which  is  not  very  rare,  and  whiclt  re- 
sembles the  acute  and  typical  form  ‘in  the  for- 
mation of  widely-dispersed,  shapeless  collections 
of  pus  or  allied  inflammatory  matter ; in  the  pro- 
bability that  these  formations  are  dne  to  some 
infection  of  the  blood  by  the  entrance  of  diseased 
inflammatory  products ; and  often  in  the  occur- 
rence of  rigors  and  profuse  sweatings,  of  phle- 
bitis, and  inflammations  of  joints.  But  they  differ 
from  the  acute  type  in  that  their  course  extends, 
continuously  or  with  relapses,  over  many  weeks 
or  months,  and  is  often  free,  at  least  in  its  later 
6tages,from  all  severe  general  disturbance  of  the 
health,  and  from  nearly  all  risk  of  life’  (Paget). 

‘ The  election  of  a single  tissue,  and  the  observ- 
ance of  an  uniform  method  of  disease,  in  the  second- 
ary affections,  are  characteristic  of  chronic  rather 
than  of  acute  pyaemia.  They  are  very  marked 
in  some  of  the  cases  that  follow  parturition,  in 
which  women  suffer  for  many  weeks  with  a suc- 
■>ession  of  abscesses  in  the  subcutaneous  connec-  I 


tive  tissue  of  the  limbs,  and  usually  (after  long 
suffering)  recover  completely.  Such  cases  are 
.also  sometimes  seen  in  men’  (Paget). 

Occasionally,  also,  cases  are  seen  of  unusual 
duration,  in  which  there  are  severe  constitu- 
tional symptoms  throughout.  For  the  particu- 
lars of  the  following  remarkable  case  of  pyaemia 
after  parturition,  in  which  severe  symptoms  ex- 
tended over  a period  of  five  months,  the  writer 
is  indebted  to  Mr.  Pollock,  who  attended  the 
patient  with  Sir  Thomas  Watson,  Dr.  Babington, 
and  Mr.  Headland: — 

Lady  P.  was  confined  on  July  9,  1849.  A few 
days  after  confinement  there  was  slight  phleg- 
masia dolens  of  one  leg,  which  passed  off  in  a 
fortnight.  On  August  8,  she  was  attacked  with 
violent  rigors,  fever,  and  sweating,  with  rapid 
pulse  and  great  anxiety  of  countenance ; in  fact, 
with  well-marked  symptoms  of  severe  pvaemic 
fever.  The  rigors  and  sweatings  continued  with 
great  severity  for  fifteen  days,  when  she  became 
slightly  better,  and  was  removed  into  the  country. 
Early  in  September  there  was  a recurrence  of 
the  symptoms,  and  these  continued  with  varying 
severity  till  October  29,  when  she  was  attacked 
with  acute  pleuro-pneumonia.  This  subsided, 
but  the  rigors  continued,  and,  in  the  latter  part 
of  November,  Dr.  AVatson  diagnosed  consolida- 
tion and  secondary  abscess  of  the  lung.  A few 
days  afterwards  a quantity  of  pus  was  expec- 
torated, and  this  was  followed  by  rapid  im- 
provement, and  eventually  by  complete  recovery, 
the  patient  being  quite  well  when  the  present 
article  was  written. 

Diagnosis. — The  chief  difficulties  in  the  diag- 
nosis of  pyaemia  arise  from  the  occasional  pro- 
minence of  some  local  symptom,  which  masks  the 
general  disease.  Probably  the  most  common 
mistake  is  to  regard  a case  of  acute  necrosis,  with 
early  joint-symptoms  and  rigors,  as  one  of  rheu- 
matism. Herein,  however,  there  is  an  absence 
of  the  acid  perspirations  and  the  coated  tongue 
of  rheumatism ; the  rigors  are  more  frequently 
repeated ; and  a careful  examination  will  reveal 
mischief  about  the  shaft  of  the  bone  as  well  as  in 
the  joint.  When  the  chest-affection  is  severe,  as 
in  the  pleurisy  of  children  with  disease  of  the  in- 
ternal ear,  it  may  be  looked  upon  as  the  primary 
disease ; but  a sudden  attack  of  pleurisy  occur- 
ring in  anyone  withotorrhoea,  should  at  once  give 
rise  to  a suspicion  of  pyaemia.  The  Liter  stages 
of  the  disease  may  present  some  resemblance  to 
typhus  or  enteric  fever,  but  the  history  would 
give  marked  distinctions  ; and  in  the  majority  of 
cases  the  diagnosis  is  sufficiently  easy  at  any 
period  of  the  disease. 

Prognosis. — The  prognosis  in  all  acute  cases 
of  pyaemia  is  very  unfavourable.  The  great 
majority  die,  sooner  or  later  ; either  early  in  the 
disease,  from  the  general  blood-poisoning,  or 
subsequently,  from  the  gravity  or  exhausting 
character  of  the  secondary  lesions.  Yet  some 
few  do  undoubtedly  recover,  and  these  are  they 
in  whom  the  viscera  escape,  and  the  disease  ex- 
pends itself  upon  the  surface  of  the  body,  or  runs 
a chronic  course  without  involving  vital  organs. 
Puerperal  pyaemia  is  less  fatal  than  surgical. 

Treatment. — The  unsatisfactory  results  of 
the  treatment,  and  the  great  mortality  of  pyaemia, 
are  the  strongest  reasons  for  taking  every  pos- 


PYiEMIA. 

Bible  precaution  for  its  prevention.  A considera- 
tion of  the  causes  •which  predispose  to,  aud  fa- 
vour the  development  of,  the  disease,  will  suggest 
certain  prophylactic  measures.  Of  these  none 
are  more  important  than  to  surround  a patient 
who  is  suffering  from  an  injury  or  operation, 
with  an  abundance  of  fresh  air,  and  to  carefully 
guard  him  from  the  exhalations  of  decaying  or- 
ganic matter.  Overcrowding,  and  especially  tho 
accumulation  of  cases  in  which  suppuration  is 
going  on,  should  be  avoided.  The  careful  drain- 
age of  wounds  is  of  the  greatest  importance  ; for 
whether  germs  be  admitted  or  not,  one  obvious 
way  of  preventing  decomposition  in  a wound  is 
to  take  care  that  nothing  is  left  therein  to  decom- 
pose. The  wound  should  be  kept  scrupulously 
clean,  and  the  dressings  changed  sufficiently  often 
to  prevent  the  discharge  becoming  foul.  Anti- 
septic dressings  are  very  useful  in  this  respect, 
and,  whatever  other  advantages  they  may  or 
may  not  possess,  it  is  certainly  desirable  to 
apply  to  a wound  a dressing  which  prevents 
the  decomposition  of  the  discharge,  and  the 
contamination  of  the  surrounding  atmosphere 
(see  Antiseptic  Treatment).  The  integrity  and 
functional  activity  of  the  chief  excreting  organs 
should  be  inquired  into  in  all  cases  of  operation 
or  injury,  so  that  the  accumulation  of  effete 
material  in  the  blood  may  be  guarded  against ; 
and  it  should  be  remembered  that  the  sudden 
change  of  condition  that  an  operation  or  acci- 
dent frequently  involves,  may  in  itself  seriously 
interfere  with  the  action  of  the  bowels  and 
kidneys. 

When,  however,  pyaemia  is  developed,  it  must 
! lie  admitted  that  treatment  has  over  it  but 
i little  control.  The  chief  indication  is  to  combat 
, the  extreme  depression  which  is  always  present, 
and  to  endeavour  so  to  support  the  patient  that 
he  may  be  able,  if  vital  organs  escape,  to  pass 
Iliroughthe  series  of  severe  local  affections  that 
[may  be  anticipated.  The  satisfactory  results 
obtained  by  Professor  Polli,  of  Milan,  from  the 
indministration  of  sulphurous  acid  to  animals 
into  whom  putrid  injections  had  been  made,  have 
lot  followed  the  use  of  this  remedy  in  the  human 
mbject ; yet  there  is  reason  to  think  it  has  some- 
imes  done  good,  and  to  encourage  us  to  give  the 
mlphites  in,  at  least,  some  of  the  more  chronic 
ases.  Probably,  however,  the  most  useful  me- 
dicine is  quinine,  which  sometimes  produces 
larked  benefit;  it  should  be  given  in  full  and 
requently-repeated  doses. 

The  local  affections  must  be  treated  on  general 
rmciplcs.  The  secondary  abscesses  should  be 
pened  early  ; and  this  is  especially  important 
'ith  regard  to  the  joints,  from  whence  the  pus 
pould  be  evacuated  directly  we  are  sure  of  its 
sistence.  When  the  infection  appears  to  ori- 
mate  in  the  inflammation  of  an  accessible  vein, 
te  vessel  should  be  divided  between  the  heart 
id  the  inflamed  part,  in  the  manner  recom- 
ended  by  Mr.  Henry  Lee.  If  symptoms  of 
'aemia  occur  in  connection  with  inflammation 
a long  bone,  the  question  of  amputation  must 
considered  ; and  there  are  strong  reasons  for 
! lie-ring  that  by  this  measure  the  disease  may 
tnetimes  be  arrested.  During  the  progress  of 
1 3 disease  bed-sores  must  be  carefully  guarded 
linst,  and  the  diet  studiously  adjusted  to  the  | 

83 


PYLORUS,  DISEASES  OF.  1313 
daily  needs ; in  fact,  much  will  depend  in  this, 
as  in  the  majority  of  serious  disorders,  upon 
careful  nursing,  judicious  feeding,  and  the  ob- 
servance of  every  hygienic  precaution. 

J.  Warrington  Ha-ward. 

PYELITIS  (irveXos,  a vessel). — Synon.  : Fr. 
Pyelite  ; Ger.  NierenbccJcenentziindung . — Inflam- 
mation of  the  pelvis  of  the  kidney.  See  Kid- 
neys, Diseases  of. 

PYLEPHLEBITIS. — Inflammation  of  the 
branches  of  the  portal  vein,  often  associated  with 
thrombosis.  See  Portax  Thrombosis. 

PYLORUS,  Diseases  of. — The  muscular 
fibres  of  the  stomach  are  disposed  in  three  layers. 
Immediately  belowthe peritoneum theyare  placed 
in  a longitudinal  direction;  these  are  continuous 
with  those  of  the  oesophagus,  and  pass  downwards 
over  the  organ,  being  continued  to  the  duodenum  ; 
they  are  collected  into  bands  of  considerable- 
thickness  along  the  curvatures,  especially  the 
upper,  and  become  stronger  as  they  approach  the 
pylorus.  The  middle  layer  surrounds  the  whole  of 
the  stomach,  but  to  the  left  of  the  cardiac  orifice 
the  fibres  are  thin,  and  are  replaced  by  those 
that  are  oblique.  At  the  pylorus  they  form  a 
thick  band  or  ring,  acting  as  a sphincter  to  the 
opening  into  the  duodenum.  The  oblique  fibres 
are  continuous  with  the  deep  layer  of  the  mus- 
cular coat  of  tho  oesophagus.  They  arch  over 
the  fundus,  but  are  quite  lost  towards  the  oppo- 
site end  of  the  organ.  The  muscular  coats  of 
the  stomach  are  formed  of  involuntary  or  un- 
striped fibres,  being  composed  of  elongated  fibre- 
cells,  which  are  united  together  by  a sparing 
amount  of  connective  tissue.  The  connective 
tissue  is  much  thicker  and  stronger  at  the 
pylorus  than  at  other  parts  of  the  organ,  giving 
a great  amount  of  firmness  and  strength  to  that 
region.  The  mucous  membrane  is  also  thicker, 
and  the  gastric  tubes  are  wider  than  elsewhere. 
Most  of  these  contain  gastric  cells,  but  are  lined 
with  conical  epithelium  to  a greater  depth  than 
in  the  more  actively  secreting  regions.  Some 
anatomists  have  stated  that  in  the  human 
stomach,  as  in  many  of  the  lower  animals,  there 
are  no  pepsin-forming  cells  in  this  part;  but  in 
numerous  cases  the  writer  has  been  able  to  obtain 
an  active  artificial  gastric  juice  from  the  mucou3 
membrane  covering  it. 

The  pylorus  participates  in  the  diseases  of  the 
stomach,  which  are  fully  described  under  that 
heading  (see  Stomach,  Diseases  of).  As  the 
outlet  of  that  organ,  however,  the  patency  of  the 
pylorus  is  of  so  great  importance  that  its  ob 
struction  will  be  specially  considered  here. 

Pylorus,  Obstruction  of. — An  obstruction 
to  the  passage  of  the  contents  of  the  stomach 
into  the  duodenum  is  not  unfrequent,  and  may 
arise  from  very  different  pathological  conditions. 
1.  The  most  common  of  these  is  the  presence  of 
a cancerous  tumour  at  the  pyloric  end  of  the 
stomach.  It  usually  surrounds  the  opening, 
and  rarely  spreads  to  the  intestines.  On  micro- 
scopical examination  the  muscular  fibres  in  tho 
vicinity  of  such  tumours  are  sometimes  found  to 
he  hypertrophied,  the  contractile  fibres  being  en- 
larged and  increased  in  number.  More  generally 


(314  PYLORUS,  DISEASES  OF. 

■'lie  cells  are  atrophied,  although  to  the  naked  eye 
the  muscular  bundles  may  seem  to  be  enlarged  : 
6omet‘imes  the  contractile  cells  are  faint  and 
small,  in  other  cases  they  arc  reduced  to  fibrous 
tissue,  and  no  trace  of  the  original  structure  can 
be  discovered.  This  condition  of  the  muscular 
tissue  furnishes  us  with  an  explanation  of  the 
fact,  that  there  is  often  great  obstruction  to  the 
passage  of  the  gastric  contents  into  the  duo- 
denum, where  the  pyloric  opening  seems  only 
partially  constricted,  anditis  to  this  loss  of  mus- 
cular contractility,  and  not  to  the  mere  narrow- 
ing of  the  opening,  that  vre  must  lookin  order  to 
understand  how  in  many  cases  the  stomach  be- 
comes dilated  from  its  incapacity  to  discharge- 
its  contents.  2.  The  pylorus  is  sometimes  nar- 
rowed by  fibroid  thickening  of  the  submucous 
tissue.  This  morbid  change  may  be  confined  to 
the  opening  only,  or  it  may  extend  some  dis- 
tance from  the  part  chiefly  affected,  producing  a 
hard,  leathery  condition  of  the  coats.  Tho  same 
effect,  although  to  a less  degree,  is  produced  by 
an  obstruction  of  this  kind  as  by  cancer.  The 
muscular  bundles  become  hypertrophied,  their 
contraction  being  embarrassed  by  the  tough, 
fibrous  tissue  that  surrounds  and  separates  them. 
3.  The  pyloric  opening  may  be  obstructed  by  an 
ulcer.  This  may  arise  either  by  its  cicatrix  pro- 
ducing a contraction,  which  leaves  only  a small 
opening  through  which  the  food  has  to  find  its 
way  ; or,  on  the  other  hand,  the  muscular  coat 
may  have  been  destroyed  by  the  ulceration,  and 
the  stomach  may,  in  this  way,  be  unable  to  force 
onwards  its  contents.  4.  The  pylorus  or  the 
duodenum  may  be  constricted  by  the  pressure  of 
a tumour.  Cases  have  occurred  where  a can- 
cerous gall-bladder  has  compressed  these  parts, 
but  more  generally  the  pressure  is  caused  by 
glands  enlarged  by  malignant  disease.  In  a case 
which  came  under  the  notice  of  the  writer,  the 
opening  was  constricted  by  enlarged  scrofulous 
glands  occurring  in  a man  affected  with  phthisis. 
5.  Adhesions  may  form  between  the  duodenum  or 
pylorus  and  the  neighbouring  parts,  and  in  this 
way  they  may  produce  a difficulty  in  the  pas- 
sage of  the  food  from  the  stomach.  A curious 
case  fell  under  the  writer's  notice  in  which  a 
man  received  a severe  blow  on  the  abdomen, 
which  was  followed  by  symptoms  of  obstructed 
pylorus.  On  post-mertem  examination  a portion 
of  the  upper  part  of  the  small  intestine  was 
found  to  be  bent  upon  itself  by  the  exudation  of 
lymph  into  the  mesentery  close  to  its  edge. 

Effects. — The  effect  of  any  considerable  ob- 
struction at  the  pyloric  opening  is  to  produce  a 
greater  or  less  degree  of  dilatation  of  the  stomach. 
The  most  prominent  symptom  is  vomiting,  occur- 
ring at  irregtdar  intervals,  and  usually  several 
hours  after  taking  food.  Along  with  this  we  find 
heartburn,  and  other  signs  of  indigestion;  and 
a gradual  loss  of  flesh  and  strength.  The  treat- 
ment must  be  directed  to  these  effects  and  symp- 
toms. See  Stomach,  Diseases  of — Dilatation. 

Samufx  Fenwick. 

PYONEPHRITIS  — Inflammation  of  the 
kidney,  leading  to  the  formation  of  abscess.  See 
Kidney,  Diseases  of. 

PYOPNEUMOTHORAX— A morbid  con- 


PYROSIS. 

dition  of  the  pleural  cavity,  in  which  it  contain* 
both  pus  and  gas.  See  Pleura,  Diseases  of. 

PYRENEES.  Ste  Bagnebes-de-Bigorre  ; 
Eaux  Bonnes:  Eacx  Chaudes  ; and  Pah;  and 
Climate,  Treatment  of  Disease  by. 

PYREXLA  (vCp,  fire,  and  I have). — 
This  word  is  commonly  employed  as  a synonym 
for  fever;  but  it  is  applied  by  some  pathologists 
to  elevation  of  the  body-heat  from  any  cause. 
See  Fever  ; and  Temperature. 

PYRMONT,  in  Germany. — Don  waters  and 
salt  waters.  See  Mineral  Abaters. 

PYROMANIA. — A name  which  has  been 
given  to  insanity  when  the  patient  manifests  a 
propensity  to  incendiarism.  Its  claim  to  be  re- 
garded as  a special  form  of  insanity  has  not  been 
established.  See  Insanity,  Varieties  of. 

PYROSIS  ( nvpSu , I burn.) — Synon.  : Water- 
brash  ; Fr.  Pyrosis  ; Ger.  Sodbrennen. 

Description. — Patients  affected  with  water- 
brash  experience  a severe  spasmodic  pain  at  the 
epigastrium,  which  is  often  attended  with  a feel- 
ing of  constriction,  and  after  the  lapse  of  a few 
minutes  relief  is  afforded  by  the  rejection  of  a 
quantity  of  watery  fluid.  The  fluid  is  usually 
tasteless,  without  any  smell,  and  seldom  amounts 
to  more  than  two  or  three  ounces.  Micro- 
scopically, it  presents  numerous  epithelial  scales 
from  the  mouth,  and  the  writer  has  also 
found  in  it  some  gastric  cells.  It  is  neutral  to 
test-paper,  is  not  albuminous,  and  in  one  case 
in  which  he  carefully  examined  it,  it  gave  a 
dense  precipitate  with  baryta,  and  a bulky  pre- 
cipitate with  nitrate  of  silver,  soluble  in  nitric 
acid.  Frerichs  remarked  that  the  fluid  contains 
sulphocyanuret  of  potassium,  and  therefore  be- 
lieved it  was  only  saliva.  But  it  is  evident  that 
it  can  scarcely  be  possible  to  obtain  it  entirely 
free  from  the  salivary  secretion,  and  therefore 
no  great  weight  can  be  allowed  to  the  observa- 
tion. Waterbrash  is  not  necessarily  connected 
with  structural  disease  of  the  stomach,  for  the 
majority  of  those  who  suffer  from  it  recover  per- 
fectly. Again,  in  some  cases  the  fluid  rejected 
is  evidently  only  saliva.  In  some  persons  affected 
with  disease  of  the  pylorus,  the  rejection  of  a 
tasteless  fluid  takes  place,  but  this  is  neither 
accompanied  nor  preceded  by  pain. 

Pathology  and  .'Etiology.  — Much  differ- 
ence of  opinion  has  been  expressed  as  to  the 
source  of  the  fluid  which  constitutes  water- 
brash.  It  has  been  referred  to  the  oesopha- 
gus, stomach,  duodenum,  and  pancreas.  The 
pancreas  seems  unlikely'  to  be  the  organ  from 
which  it  comes,  for  the  fluid  is  unmixed  with 
bile,  and  we  should  imagine  a more  violent  effort 
would  be  required  to  reject  it  from  a part  so 
distant  from  the  mouth.  Again,  the  cesophagus 
is  very  intolerant  to  any  collection  of  liquid  in 
it,  and  it  would  only  be  by  a spasmodic  closure 
of  the  cardiac  orifice  that  such  an  accumulation 
could  occur  in  this  tube.  As  regards  the  stomach, 
it  seems  improbable  that  the  larger  and  more 
active  end  of  this  organ  should  be  the  source 
of  the  liquid,  for  any  irritation  should  produce 
an  acid,  not  a tasteless,  fluid.  At  the  pyloric 
end,  however,  there  is  a mass  of  tubes,  lined 


PYROSIS. 

ehiefly  with  conical  epithelium,  whose  office  it 
is  to  secrete  mucus,  and  as  the  only  organic 
change  that  has  been  found  along  with  water- 
brash  is  thickening  at  the  pylorus,  we  may  reason- 
ably conclude  that  this  is  the  part  whence  the 
fluid  is  ordinarily  derived. 

Waterbrash  seldom  occurs  before  puberty  ; it 
affects  females  more  than  males ; and  chiefly 
presents  itself  in  persons  of  middle  age.  It 
is  more  prevalent  in  some  countries  than  in 
others ; and  is  most  general  amongst  those  who 
subsist  on  food  of  a coarse  and  indigestible 
kind. 

Treatment.— All  sources  of  gastric  irritation 
should  fee  removed,  such  as  every  form  of  insol- 
uble or  irritating  food.  Astringents,  with  or  with- 
out opium,  are  the  most  efficacious  remedies.  They 
should  be  given  in  the  intervals  between  diges- 
ion,  so  that  they  may  act  directly  on  the  mucous 


QUARANTINE.  1315 

membrane.  Lime-water,  bismuth,  zinc,  or  other 
mineral  astringents,  or  vegetable  astringents, 
such  as  kino,  krameria,  logwood,  or  tannin,  may 
be  preferred  ; but,  on  the  whole,  the  writer  has 
found  the  oxide  and  nitrate  of  silver  the  most 
efficacious.  Unless  there  be  some  objection  to 
it,  opium  may  be  combined  with  the  astringents, 
as  it  both  lessens  the  pain  and  seems  to  re- 
strain undue  secretion  ; or  mercurial  alteratives 
may  be  given,  as  their  use  is  often  attended  with 
the  best  results.  Samuel  Fenwick. 

UYTHOGENIC  PEVEB  (7 rvdco,  I rot,  and 
yevviu,  I beget). — A synonym  for  typhoid  fever. 
See  Typhoid  Fevee. 

PYURIA  (tvvov,  pus,  and  oupov,  the  urine). — 
A name  for  a condition  of  the  urine  in  which  it 
contains  pus.  See  Urine,  Morbid  Conditions  of. 


Q 


QUARANTINE  (quaranta,  Italian,  forty), 
irsox. : Fr.  Quarantainc ; Ger.  Quarantane. 

Definition. — The  enforced  isolation  of  indi- 
viduals and  certain  objects  coming,  whether  by 
sea  or  by  land,  from  a place  where  dangerous 
communicable  disease  is  presumably  or  actually 
present,  with  a view  of  limiting  the  spread  of 
the  malady.  The  objects  liable  to  quarantine 
include — on  the  assumption  of  their  being  apt  to 
carry  the  contagion  or  infection  of  the  disease  — 
the  luggage  and  personal  effects  of  the  indi- 
viduals isolated,  certain  articles  of  merchandise, 
and  ships  ; and,  in  land  quarantine,  carriages  and 
other  vehicles.  Sometimes  entire  communities 
and  districts  are  subjected  to  quarantine. 

History. — - According  to  systematic  writers, 
quarantine  had  its  origin  in  the  fourteenth  cen- 
tury, when  the  principle  of  isolation,  applied 
■ from  a much  earlier  period  to  leprosy  {mal  de 
1 SI.  Lazare),  began  to  be  extended  to  pestilential 
diseases;  and  leper  hospitals  {lazarets),  then 
•falling  into  disuse  from  the  decline  of  the  dis- 
ease, were  converted  to  (as  we  should  now  say) 
juarantine  uses.  To  this  day  quarantine  estab- 
■ishments  retain  the  name  significant  of  their 
original  purpose — namely,  lazarets.  Fodere  sug- 
;ests  that  the  period  of  forty  days  during  which 
!t  was  customary  formerly  to  enforce  isolation, 
nd  from  which  the  designation  quarantine  is 
1 erived,  had  its  source  in  the  teaching  of  Hippo- 
■ rates,  who,  according  to  Pythagoras,  attributed 
| special  virtue  for  the  completion  of  many  things 
1 > that  period  of  time.  The  methodical  establish- 
ient  of  quarantine  dates  from  the  sixteenth  cen- 
iry,  when  the  earliest  doctrines  of  contagion,  in 
ie  original  acceptation  cf  the  term,  were  also 
rmulated.  These  doctrines,  fantastic  though, 
many  respects,  they  now  appear,  still  largely 
ihere  to  the  practice  of  quarantine.  Plague, 
we  low  understand  the  word  {see  Plague), 


was  the  disease  against  which  quarantine  was 
chiefly,  indeed  almost  wholly  levelled,  until  the 
beginning  of  the  present  century  ; and  the  system 
is  so  imbued  with  the  notions  formerly  held  as  to 
this  malady,  that  it  has  -been  found  impossible 
to  disembarrass  it  from  them,  in  endeavouring  to 
apply  quarantine  to  other  forms  of  disease.  It  is 
noteworthy  that,  as  plague  declined  in  Western 
Europe,  and  the  area  of  its  prevalence  in  the 
Levant  became  more  and  more  restricted,  the 
system  of  quarantine  appears  to  have  become 
more  elaborate.  Speculative  notions,  uncon- 
trolled by  experience,  and  applied  to  the  system, 
caused  it  to  be  overlaid  with  grotesque  and 
puerile  details.  Notwithstanding,  however,  these 
drawbacks,  the  arbitrariness  of  the  system,  and 
the  losses  it  inflicted  upon  commerce,  without 
obvious  proportionate  gains,  the  advantages 
offered  by  quarantine  in  the  protection  of  a 
country  from  pestilential  disease  appeared  theo- 
retically to  be  so  great,  that  neither  administra- 
tive follies,  nor  the  lessons  as  to  its  fallacies  de- 
rived from  experience,  nor  its  general  futilities, 
availed  to  bring  about,  the  substitution  of  a more 
rational  system  of  protection. 

Quarantine  remained  substantially  unmodified 
from  the  termination  of  the  last  century  to  the 
fifth  decade  of  the  present,  since  which  time  it 
has  undergone  great  changes,  with  a view  of 
rendering  the  practice  more  consistent  with  ex- 
isting knowledge  of  the  diseases  to  which  it  is 
applied,  and  of  freeing  it  from  the  more  prepos- 
terous detentions  and  practices  which  had  be- 
come attached  to  it. 

Quarantine  Acts. — In  the  present  article  we 
shall  deal  only  with  quarantine  as  it  exists  in 
this  country.  In  Great  Britain  and  Ireland 
quarantine,  wdiieh  is  carried  out  under  an  Act 
of  Parliament  passed  in  the  reign  of  George  IV. 
(6  Geo.  IV.,  cap.  78),  has  no  longer  a medical 


1316  QUARANTINE. 


signification.  It  is  practised,  and  that  only  to 
a limited  extent,  solely  with  a view  of  relieving 
our  maritime  commerce  from  disabilities  which 
would  else  be  imposed  upon  it  by  other  coun- 
tries, ra  which  quarantine  is  regarded  as  an 
essential  part  of  the  public  health  administra- 
tion. The  regulation  of  quarantine  is  not  a func- 
tion of  t he  department  of  the  Government  which 
is  concerned  with  the  sanitary  administration  of 
the  kingdom  (the  Local  Government  Board),  but 
of  the  Privy  Council,  aided  by  the  Board  of 
Trade,  the  subject  being  dealt  with  as  an  inter- 
national commercial  question.  In  what  follows 
an  authoritative  official  memorandum  of  the  late 
medical  officer  of  the  Local  Government  Board 
(Dr.  E.  C.  Seaton)  on  the  subject  is  closely 
adhered  to. 

The  Quarantine  Act  provides  for  land  quaran- 
tine and  the  quarantine  of  inland  waters,  as  well 
as  for  maritime  quarantine — internal  and  external 
quarantine,  so  to  speak.  It  does  not  appear  that 
internal  quarantine  has  ever  been  enforced  in 
this  country  since  the  Act  was  passed.  Mari- 
time quarantine  alone  has  been  practised,  and 
this  has  been  applied  to  three  diseases  only,  all  of 
them  infectious  diseases  offoreign  origin,  namely, 
plaguo,  cholera,  and  yellow  fever.  Of  plague  there 
has  been  no  question  in  English  ports  for  the  last 
thirty  years  or  thereabouts,  except  a slight 
alarm  in  1879,  consequent  upon  an  outbreak 
in  south-eastern  Russia,  province  of  Astrakhan. 
Against  cholera  quarantine  has  not  been  enforced 
since  1858,  its  futility  as  a precautionary  mea- 
sure in  this  country  having  then  been  abundantly 
manifested,  yellow  fever  is  the  sole  disease  at 
present  subjected  to  it  in  our  ports,  and  this,  as 
already  stated,  not  from  the  medical  necessity, 
but  from  the  commercial  exigency  of  the  case.  The 
only  quarantine  establishment  now  remaining 
in  England — that  at  the  Motherbank — is  main- 
tained in  respect  of  this  disease.  Infectious  dis- 
eases habitually  current  in  this  country,  such  as 
small-pox,  scarlet  fever,  &c.,  notwithstanding 
that  the  phraseology  of  the  Quarantine  Act  covers 
any  ‘ infectious  disease  or  distemper,’  have  al- 
ways been  in  practice  exempt  from  quarantine, 
and  dealt  with  under  the  general  sanitary  law  of 
the  kingdom.  It  appears  to  have  been  recog- 
nised that  measures,  primarily  designed  to  pre- 
vent the  introduction  into  the  country  of  dis- 
eases only  coming  to  us  from  abroad,  and  which 
involved  international  considerations,  would  be 
misapplied  if  used  for  the  purpose  of  preventing 
the  importation  of  diseases  ordinarily  existing 
here,  the  limitation  of  which,  and  not  the  ex- 
clusion, could  alone  be  in  question. 

The  measures  which  have  been  substituted  for 
quarantine  against  cholera — the  only  foreign  epi- 
demic which  at  present  much  concerns  the  health 
of  this  country — consist  in  a ‘ system  of  medical 
inspection,’  the  details  of  which  are  set  forth  in 
an  Order  of  the  Local  Government  Board,  dated 
the  17th  July,  1873.  This  plan  differs  from 
‘ quarantine  ’ in  the  following  essential  re- 
spects 

(a)  It  affects  only  such  ships  as  have  been 
ascertained  to  be,  or  as  there  is  reasonable 
ground  to  suspect  of  being,  infected  with  cholera 
or  choleraic  diarrhoea  ; no  vessel  being  deemed 
infected  unless  there  has  been  actual  occurrence 


of  cholera  or  of  choleraic  diarrhoea  on  board 
in  the  course  of  the  voyage. 

(6)  It  provides  for  the  detention  of  the  vessel 
only  so  long  as  is  necessary  for  the  require- 
ments of  a medical  inspection  ; for  dealing  with 
the  sick  (if  any)  in  the  manner  it  prescribes ; and 
for  carrying  out  the  processes  of  disinfection. 

(c)  It  subjects  the  healthy  on  board  to  deten- 
tion only  for  such  length  of  time  as  admits  of 
their  state  of  health  being  determined  by  medical 
examination. 

The  measures  for  dealing  with  the  sick  under 
this  Order  are  but  an  adaptation  to  a particular 
exigency  of  the  principles  of  sanitary  adminis- 
tration with  regard  to  infectious  diseases,  which 
are  in  force  under  the  general  sanitary  law  of  the 
kingdom. 

But  though  quarantine  has  no  present  practical 
existence  in  this  country,  except  as  regards  vel- 
low  fever,  and  all  other  infectious  diseases  are 
dealt  with  either  under  the  general  sanitary  law 
of  the  country,  or  such  modification  of  it  as 
has  been  just  described  with  regard  to  cholera, 
the  machinery  which  is  maintained  under  the 
Quarantine  Acts,  for  obtaining  information  as 
to  the  existence  of  infectious  diseases  on  board 
foreign-coming  ships,  is  made  available  for  deal- 
ing with  all  diseases  of  that  kind,  whether  they 
are  quarantinable  or  not.  The  quarantine  ques- 
tions, as  they  are  termed,  which  it  is  the  duty 
of  the  Customs  to  put  to  the  masters  of  all  such 
vessels,  embrace  all  infectious  diseases;  and,  ia 
the  event  of  any  such  disease  not  of  a quarantin- 
able kind  being  found  to  exist  on  board,  or  to 
to  have  existed  in  the  course  of  the  voyage,  the 
quarantine  officer  is  required  to  detain  the  ves- 
sel and  to  forward  the  information  with  the  least 
practicable  delay  to  the  sanitary  authority  of  the 
port.  In  regard  to  cholera,  moreover,  both  the 
customs  and  the  sanitary  authority  have  certain 
powers  of  detaining  the  vessel  specified  in  the 
order  of  the  Local  Government  Board  above 
referred  to. 

The  provisions  under  Articles  12.  13,  and  11 
of  the  Order  of  the  Local  Government  Board,  as 
to  the  mode  of  dealing  with  persons  who  may 
arrive  from  abroad  infected  with  cholera,  will  be 
better  understood  if  a succinct  statement  be 
made  of  the  ordinary  provisions  of  the  law  with 
regard  to  infectious  diseases  in  England.  The 
authorities  which  have  to  administer  that  law, 
as  now  existing  under  the  Public  Health  Act. 
1875,  are  the  urban,  rural,  and  port  sanitary 
authorities  of  the  districts  into  which  the  whole 
kingdom  is  divided,  and  these  authorities  are 
empowered  ; — 

(a)  To  pirovide  hospitals  or  temporary  places 
for  the  reception  of  the  sick  (section  131); 

(5)  Where  a hospital  or  place  for  such  pur- 
pose is  provided,  to  remove  thither  by  order  of 
any  justice,  on  a certificate  signed  by  a legally 
qualified  medical  practitioner,  any  person  who 
is  suffering  from  any  dangerous  infectious  dis- 
order, and  is  without  proper  lodging  or  aecom 
modation,  or  lodged  in  a room  occupied  by  more 
than  one  family,  or  on  board  any  sitp  or  vessel 
(section  124) ; 

(c)  To  make  regulations  (to  be  approved  by 
the  Local  Government  Board)  for  removing  to 
any  hospital,  to  which  the  local  authority  is  an- 


QUARANTINE. 

tilled  to  remove  patients,  and  for  keeping  in  suck 
tospital,  so  long  as  may  be  necessary,  any  persons 
brought  within  their  district  by  any  ship  or  boat, 
who  are  infected  with  a dangerous  infectious  dis- 
order (section  125); 

(d)  To  provide  and  maintain  a carriage  or 
carriages,  suitable  for  the  conveyance  of  persons 
suffering  under  any  infectious  disorder  (section 

123); 

(c)  To  cleanse  and  disinfect  infected  premises, 
and  articles  therein ; to  destroy  any  bedding, 
clothing,  or  other  articles  which  have  been  ex- 
posed to  infection  from  dangerous  infectious  dis- 
order, giving  compensation  for  the  same  ; and 
to  provide  all  necessary  means  for  the  disinfec- 
tion of  infected  things  (sections  120,  121,  122)  ; 

(/)  To  take  proceedings  against  (1)  any  per- 
son who,  while  suffering  from  any  dangerous 
infectious  disorder,  wilfully  exposes  himself  with- 
out proper  precautions  against  spreading  the 
said  disorder,  in  any  street,  public  place,  shop, 
.nn,  or  public  conveyance,  or  enters  into  any 
public  conveyance  without  previously  notify- 
ug  to  the  owner,  conductor,  or  driver  thereof 
that  he  is  so  suffering ; or  (2)  any  person  who, 
being  in  charge  of  any  person  so  suffering,  so 
exposes  such  sufferer ; or  (3)  any  person  who 
gives,  lends,  sells,  transmits,  or  exposes  without 
previous  disinfection,  any  bedding,  clothing, 
•ags,  or  other  things  which  have  been  exposed 
.o  infection  from  any  such  disorder ; or  (4)  any 
owner  or  driver  of  a public  conveyance,  who 
Bhall  not  have  immediately  provided  for  the  dis- 
infection of  such  conveyance,  after  it  has  to  his 
knowledge  conveyed  any  person  suffering  from  a 
dangerous  infectious  disorder ; or  (5)  the  owner 
of  any  house  in  which  any  person  has  been  suf- 
fering from  any  dangerous  infectious  disorder, 
who  shall  knowingly  let  it  or  part  of  it  for  hire, 
without  having  previously  disinfected  it,  and  all 
articles  therein  liable  to  retain  infection,  to  the 
satisfaction  of  a legally-qualified  medical  man  ; 
or  (6)  any  person  who,  showing  for  the  purpose 
of  letting  for  hire  any  house  or  part  of  a house, 
shall  make  false  statements  as  to  the  existence 
of  infectious  disease  therein,  or  within  six  weeks 
previously  (the  several  acts  here  enumerated 
constituting  offences  liable  to  penalty  under  the 
Public  Health  Act,  secs.  126,  128,  129); 

(y)  To  provide  mortuaries,  and  to  obtain  the 
removal  thither,  by  order  of  a justice,  of  the 
body  of  one  who  has  died  of  any  infectious  dis- 
ease, which  is  retained  in  a room  where  persons 
live  or  sleep,  or  of  any  dead  body  in  such  a state 
as  to  endanger  the  health  of  the  inmates  of  the 
house  or  room  in  which  it  is  retained  (secs.  141, 
142); 

(A)  To  make  inspection  of  their  district,  with 
a view  to  ascertain  what  nuisances  exist  calling 
lor  abatement  under  the  powers  of  the  Act,  and 
to  enforce  the  provisions  of  this  Act  in  order  to 
abate  the  same  (sec.  92)  ; a provision  which  ex- 
tends to  shipping — any  ship  or  vessel  lying  in  any 
river,  harbour,  or  other  water,  within  the  dis- 
trict of  a sanitary  authority,  being  subject  to  the 
jurisdiction  of  that  authority,  in  the  same  manner 
as  if  it  were  a house  within  such  district ; 

(»)  Finally,  to  appoint  a medical  officer  of 
health,  inspector  of  nuisances,  or  several  of 
those  officers,  according  to  the  needs  of  the  dis- 


QUINISM.  1317 

trict,  and  other  requisite  officers,  to  aid  them 
in  the  proper  and  efficient  execution  of  tho  Act 
(secs.  189,  190).  The  duties  of  the  medical 
officer  of  health  and  of  the  inspector  of  nuisances, 
when  (as  is  the  case  in  the  greater  number  of 
instances)  the  assent  of  the  Local  Government 
Board  has  to  be  given  to  their  appointment,  are 
set  forth  in  Orders  of  the  Board  dated  March 
1880. 

The  general  powers  above  enumerated,  if  exer- 
cised duly  and  with  reasonable  diligence,  aro 
held  sufficient  to  provide  for  the  exigencies  which 
may  arise  in  our  ports  from  the  introduction  of 
infectious  diseases  by  ships,  whether  the  disease 
he  current  in  this  country  or  be  of  foreign  origin 
not  naturalised  here  ; hut  iu  the  case  of  a non- 
naturalised  disease,  such  as  cholera,  certain  addi- 
tional securities  are  taken  by  the  Order  of  the 
Local  Government  Board,  17th  July,  1873,  pre- 
viously referred  to.  The  general  powers,  more- 
over, which  are  available  against  the  importation 
of  infections  diseases  by  shipping,  ar&  available 
also,  and  have  on  occasions  been  used,  against 
their  exportation  in  like  way  to  other  places. 

The  relative  advantages  of  the  system  of  medi- 
cal inspection  and  of  quarantine  as  against  cholera 
in  the  ports  of  Europe,  underwent  thorough  dis- 
cussion at  the  International  Sanitary  Conference 
which  was  held  in  Vienna  in  1871.  A large 
majority  of  the  delegates,  including  those  from 
every  State  of  the  first  rank  except  Erance,  de- 
clared in  favour  of  the  former  system.  The 
minority,  while  adhering  to  quarantine,  agreed 
to  a system  which  would  considerably  diminish 
its  stringency  as  heretofore  practised. 

Haeby  Leach. 

QUAKT.AN  ( qvartus , the  fourth). — A form 
of  ague,  in  which  the  paroxysm  returns  after  an 
intermission  cf  two  days.  See  Intermittent 
Fevee. 

QUEENSTOWN,  in  South  of  Ireland. — 

Mild,  not  relaxing,  winter  climate.  Southern  ex- 
posure, with  shelter.  Mean  winter  temperature 
44T°  Eahr.  See  Climate,  Treatment  of  Disease 
by. 

QUINISM.- — Syxox.  : Cinchonism  ; Er.  Qui- 
nisme ; Ger.  Cinchonism  us. 

Definition. — A group  of  symptoms,  chiefly 
connected  with  the  nervous  system,  produced  by 
the  presence  of  quinine  in  the  system. 

Axatohical  Characters. — In  the  rare  cases 
in  man  in  which  death  has  been  due  to  quinism, 
post-mortem  examination  has  revealed  only  con- 
gestion of  the  brain,  liver,  and  lungs.  In  addi- 
tion to  these,  congestion  of  the  spinal  cord,  kid- 
neys, stomach,  and  intestines  has  been  found  in 
experiments  on  animals. 

Symptoms. — Large  doses  of  quinine,  or  smaller 
doses  long  continued,  may  produce  two  separate 
sets  of  symptoms,  each  independent  of  the 
other,  according  as  they  act  locally  on  the  intes- 
tinal canal,  or  upon  the  nervous  system  after 
absorption.  It  is  to  the  nervous  symptoms  that 
the  term  cinchonism  is  usually  restricted. 

Before  considering  these  symptoms  in  detail, 
however,  it  may  he  advisable  to  mention  the 
local  effects  of  quinine  upon  the  intestinal  c-anal. 
These  are,  irritation,  either  of  the  stomach  ol 


1318  QUINISM, 

intestines,  ■which  manifests  itself  sometimes  in 
vomiting,  and  sometimes  in  purging.  Not  un- 
frequently,  also,  small  doses  of  quinine  -will 
cause  headache,  independently  of  either  vomit- 
ing, purging,  or  the  nervous  symptoms  which 
are  peculiar  to  cinchonism.  This  headache  is 
probably  caused  reflexly  by  the  irritant  action 
of  the  quinine  on  the  stomach  or  intestines,  and 
may  not  depend  on  any  special  action  that  it 
exerts  upon  the  nervous  system  after  its  absorp- 
tion. 

The  nervous  symptoms  to  which  the  term 
cinchonism  is  applied  consist  of  affections  of  the 
hearing  and  sight,  cephalalgia,  and  sometimes 
giddiness.  Delirium,  convulsions,  and  collapse 
are  said  to  occur  after  very  large  doses. 

Noises  are  heard  in  the  ears,  the  sounds  being 
of  a humming  character,  or  resembling  a distant 
waterfall,  the  ringing  of  bells,  or  the  striking  of 
a clock.  These  noises  are  accompanied  by  more 
or  less  deafness,  voices  being  heard  as  if  the 
speakers  were  at  a distance.  Sometimes  the 
deafness  becomes  complete.  It  is  usually  tem- 
porary, but  frequently  lasts  for  several  days  after 
the  quinine  has  been  stopped,  and  has  occasion- 
ally proved  permanent.  Affections  of  the  sight 
are  less  common.  They  consist  of  occasional 
optical  illusions,  intolerance  of  light,  amblyopia, 
mydriasis,  and  even  blindness  after  large  doses. 
Headache  may  sometimes  be  produced  by  small 
doses  of  quinine,  without  any  affection  of  the 
sight  or  hearing ; and,  on  the  other  hand,  the 
hearing  may  be  very  considerably  affected  with- 
out any  headache  occurring,  although  this  is 
frequently  present.  The  pain  chiefly  affects  the 
top  of  the  head  and  the  temples.  Occasionally  a 
curious  sensation  is  observed,  as  if  the  top  of 
the  head  were  coming  off.  This  sensation  is  not 
accompanied  by  pain.  Giddiness  also  comes  on, 
so  that  the  patient  may  have  difficulty  in  stand- 
ing or  walking,  either  after  a single  large  dose, 
or  after  repeated  or  continued  moderate  doses. 
This  is  preceded  by  an  affection  of  hearing,  sight 
remaining  unaffeetod.  The  giddiness  is  probably 


RABIES. 

partly  due  to  weakness  of  the  circulation,  ia 
part  to  the  action  of  quinine  on  the  nerves  and 
nervous  centres.  Experiments  on  animals  have 
shown  that  quinine  diminishes  greatly  the  reflex 
function  of  the  spinal  cord,  diminishes  also  sen- 
sibility, and,  finally,  paralyses  the  extremities. 
In  some  persons  large  doses  of  quinine  cause  a 
febrile  condition  unaccompanied  by  cephalalgia, 
but  preceded  by  humming  in  the  ears,  disturb- 
ance of  the  mental  faculties,  and  a slight  rigor. 
In  others,  the  cerebral  symptoms  have  been  so 
marked  as  almost  to  amount  to  a temporary 
mania. 

.The  circulation  is  weakened  by  large  doses  of 
quinine,  the  heart  becoming  feebler,  and  the 
arterial  tension  diminishing.  Not  unfrequently 
fainting  has  been  observed ; and  therefore  per- 
sons fully  under  the  influence  of  quinine  should 
be  careful  not  to  rise  up  suddenly.  In  some 
casse  collapse  and  coma  occur,  occasionally  ac- 
companied by  convulsions. 

Treatment. — As  a chemical  antidote  in  cases 
of  quinine  poisoning,  tannin  or  substances  con- 
taining it  should  be  given ; and  to  combat  tho 
symptoms  produced  by  quinine,  already  described, 
ammonia  should  he  administered,  and  counter- 
irritation should  be  applied  to  the  skin.  Cold 
compresses  to  the  head,  leeches  behind  the  ears, 
and  purgatives  may  be  employed  when  there  is 
excitement  or  delirium.  Alcohol  and  diffusible 
stimulants  may  he  given  if  there  is  a tendency 
to  collapse.  T.  Lauder  Brcnton. 

QUINSY  ( cynanche , sore-throat). — A popu 
lar  synonym  for  acute  inflammation  of  the  tonsils. 
See  Tonsils,  Diseases  of. 

QUINTAN  ( quinius , the  fifth).— A form  of 
ague,  in  which  the  paroxysm  returns  after  &n 
intermission  of  ninety-six  hours.  See  Intebjut- 
tent  Fever. 

QUOTIDIAN  ( quotidie , daily). — A form  of 
I ague,  in  which  the  paroxysm  occurs  at  the  same 
i hour  every  day.  See  Intermittent  Fever 


B 


RABIES  (rabies,  rage  or  madness). — Synon.  : 
Fr.  la  Rage ; Ger.  Hundsvmth. 

Definition. — A non-febrile  disease,  due  to  a 
specific  poison;  and  most  frequently  met  with 
in  the  canine,  feline,  vulpine,  lupine,  and  other 
species  of  carnivora;  but  communicable  by  ino- 
culation to  all  warm-blooded  animals.  It  is 
accompanied  by  an  inclination  to  attack  other 
animals  ; and  is  characterised  by  nervous  dis- 
turbances, together  with  listlessness,  uneasiness, 
wildness,  cramps,  paralysis,  rapid  emaciation, 
altered  voice,  quick  course,  and  fatal  termina- 
tion. 

-Etiology. — Various  antecedent  phenomena 
are  supposed  to  be  either  the  actual  or  predis- 


posing causes  of  rabies  ; but  we  may  say  that 
neither  climate,  season,  food,  water,  sex,  genital 
excitement,  pain,  anger,  age,  nor  breed,  as  far  as 
we  are  able  to  judge,  has  the  slightest  effect 
in  producing  the  disease. 

Many  persons  still  adhere  to  the  belief  that 
rabies  arises  spontaneously  in  the  canine,  anc 
probably  also  in  the  feline,  lupine,  and  vulpine 
species  of  carnivora ; although  most,  if  not  all, 
admit  such  cases  to  be  extremely  rare  (Boer- 
haave,  Hamilton,  Gilman,  Coleman,  Renault, 
Haubner,  Williams,  Hill,  &c.).  Qthers  (Maynell, 
Blaine,  Youatt,  Virchow,  Gerlaeh,  Roll,  Bollin- 
ger, the  writer  and  many  more)  believe  that  it 
never  arises  spontaneously,  but  that  it  is  always 


RABIES. 


the  result  of  tho  introduction  of  the  specific  ani- 
mal poison  into  the  system,  either  by  a bite  from 
* rabid  animal,  or  by  the  absorption  of  the  virus 
through  the  medium  of  an  abraded  surface.  To 
prove  beyond  doubt,  in  any  given  case,  that  af- 
fected animals  had  never  been  bitten,  nor  placed 
in  contact  -with  those  already  diseased,  is  ex- 
tremely difficult. 

Contagium. — The  nature,  composition,  and 
the  circumstances  necessary  for  the  production 
of  this,  as  ■well  as  of  most  other  animal  poisons, 
is  still  a mystery.  All  -we  know  is,  that  it  is  a 
fixed  virus,  and  therefore,  can  only  be  introduced 
into  the  system  by  inoculation.  It  seems  to  be 
more  concentrated  and  abundant  in  the  saliva 
than  in  any  other  part  of  the  body;  but  we  have 
reason  to  believe,  it  is  present  in  the  secretions 
and  excretions  (Roll,  Hering),  in  the  blood,  and 
consequently  in  all  organs  and  parts  of  the  still 
warm  body  (Haubner,  Eckel,  Lafosse,  Roll, 
Fleming,  and  others) ; although  others  (Breschet, 
Majendie,  Dupuytren),  from  some  cause  or  other 
failed  to  transmit  the  disease  by  inoculating  with 
the  blood  of  rabid  animals.  Whether  tho  poison 
is  present  in  the  saliva,  blood,  and  other  parts 
during  the  incubative  stage  is  unknown.  There 
is  no  evidence  to  show  that  dried  virus  is  viru- 
lent ; and  the  contagium  is  found  to  be  destroyed 
by  ordinary  influences,  such  as  heat,  calcium 
chloride,  caustic  alkalies,  and  concentrated 
acids.  It  is  a disputed  point  whether  the  meat 
and  milk  of  rabid  animals  are  fit  for  animal 
food ; but  few  doubt  the  innocuousness  of  butter 
and  cheese  made  from  such  milk.  M.  Galtier 
has  recently  (1881)  found  that  the  saliva  of  a 
rabid  dog  which  has  succumbed  to  the  disease, 
or  has  been  killed,  does  not  lose  its  virulent  pro- 
perties through  mere  cooling  of  the  body.  It  is 
important,  therefore,  in  examining  the  cavities 
of  the  throat  and  mouth  after  death,  to  guard 
against  inoculation.  The  same  observer  has  also 
found  that  the  saliva  of  a rabid  dog,  obtained 
from  the  living  animal  and  kept  in  water,  con- 
tinues virulent  for  five,  fourteen,  or  even  twenty- 
four  hours  in  the  case  of  the  rabbit.  Water  from 
which  a mad  dog  may  have  drunk  must,  therefore, 
be  considered  dangerous  for  at  least  twenty-four 
hours.  Although  previous  observations  and  ex- 
periments seem  to  prove  that  tho  virus  loses  its 
potency  as  soon  as  the  body  is  cold,  or  rigor 
'mortis  has  set  in,  and  it  has  therefore  been  as- 
sumed, a fortiori,  that  the  flesh  of  rabid  animals 
might  be  eaten  cooked  (Dr.  Lecamus)  or  un- 
cooked (Decroix,  Bourrel,  &c.)  with  impunity, 
even  if  the  mucous  surfaces  were  injured,  these 
statements  must  now  be  received  with  great  re- 
serve. 

Animals  that  are  inoculated  with  fresh  (warm) 
saliva,  blood,  &c.  do  not  in  all  eases  contract  the 
disease.  Renault  inoculated  ninety-nine  animals 
(horses,  dogs,  and  sheep),  and  only  sixty-seven 
became  affected.  Roll  says  that  successful 
inoculations  vary  from  21  to  70  per  cent.,  whilst 
from  the  bites  of  rabid  dogs  the  proportion  varies 
between  20  and  70  per  cent.,  showing  that  the 
disease  is  comparatively  less  likely  to  follow 
from  the  natural  (bite)  than  from  the  artificial 
(injection,  &e.)  introduction  of  the  virus.  This 
is  probably  due  to  the  bleeding  produced  by  the 
bite  washing  the  poison  out  again,  or  to  the  bit  - 


1319 

ten  subject,  the  clothes,  hair,  &c.  wiping  the 
teeth  before  they  pierce  the  skin.  The  recent 
researches  of  MM.  Rasteur  and  Galtier  seem  tc 
show  that  the  diluted  poison  of  hydrophobia, 
injected  into  the  blood  of  animals,  acts  as  a pre- 
ventive of  the  development  of  the  disease.  It 
must  also  be  remembered  that  the  percentage  — 
however  the  poison  is  introduced — is  larger  in 
carnivorous  than  in  herbivorous  animals  or  man, 
Fleming  tabulates  them  thus  : — ‘ Dogs  and  cats 
hold  the  first  place  in  the  scale  of  susceptibility ; 
then  man  and  the  pig;  next  ruminants,  the  sheep 
and  goat  being  more  susceptible  than  the  ox  ; 
and  lastly  the  horse.’ 

It  has  been  denied  by  some  authorities  (Betti, 
Girard,  Vakl,  Huzard,  Dupuy,  Lafosse,  &c.),  that 
the  virus  of  other  than  canine  and  feline  animals, 
or  those  which  use  their  teeth  as  natural  weapons 
of  defence,  is  capable  of  transmitting  the  disease 
to  others.  But  of  late  years,  this  has  been 
proved  by  many(Bourrell,  Eckel,  Berndt,  Youatt, 
Breschet,  Majendie,  Earle,  and  others)  to  be  in- 
correct. 

Incubation. — The  period  of  incubation  in 
rabies  ranges  between  extremely  wide  limits  ; 
but  the  average  period  in  any  animal  maybe  said 
to  be  from  three  to  six  weeks.  It  is  compara- 
tively shorter  in  young  than  in  old  animals. 
Spinola  said  that  gestation  prolongs  it,  and 
according  to  Fleming  it  appears  sometimes  to  be 
hastened  by  excitement,  anger,  sexual  irritability, 
terror,  injury  to  the  cicatrix,  sudden  changes  of 
temperature,  and  other  causes. 

Anatomical  Characters.  — The  anatomical 
changes  in  rabies  are  by  no  means  constant,  nor 
do  they  at  all  equal  what  one  would  expect  to 
find,  judging  from  the  symptoms  presented 
during  life.  The  following  are  the  principal 
lesions  found. 

The  skin  may  be  covered  with  mud,  and 
wounded,  especially  about  the  lips.  The  visible 
mucous  membranes  maybe  injected;  the  teeth 
fractured ; the  tongue  swollen,  dark  red,  and 
wounded.  The  mucous  membrane  of  the  fauces, 
larynx,  trachea,  pharynx,  oesophagus,  stomach, 
and  intestines  may  be  swollen,  congested,  hyper- 
aemie,  or  may  present  haemorrhagic  erosions, 
and  signs  of  catarrh.  The  tonsils  and  salivary 
glands  may  be  enlarged  and  vascular.  The 
stomach  usually  contains  some  indigestible  and 
foreign  substances,  such  as  pieces  of  wood,  lea- 
ther, straw,  hay,  or  iron.  These,  however,  are 
rarely  found  in  herbivorous  animals.  The  small 
intestines  are  usually  empty,  or  only  contain  r, 
mixture  of  bile  and  mucus.  The  solitary,  agmi- 
nate, and  mesenteric  glands  may  be  found  en- 
larged. The  spleen  is  frequently  enlarged  and 
congested,  hence  the  disease  has  often  been  mis- 
taken for  anthrax.  The  blood  is  dark-coloured, 
and  coagulates  with  a soft  loose  clot.  The  kid- 
neys and  bladder  may  be  hypersemic,  and  the  lat- 
ter is  usually  emptied  and  contracted.  The  lungs 
are  generally  gorged  with  blood.  The  vessels  of 
the  cerebro-spinal  coverings  may  be  congested, 
and  serous  effiisions  in  the  cavities  will  be  some- 
times observed.  Williams  says  : ‘ On  the  lower 
surface  of  the  medulla  oblongata,  at  the  origin 
of  the  seventh,  eighth,  and  ninth  pairs  of  nerves, 
the  membranes  are  generally  highly  congested, 
thickened,  softened,  and  matted  together.’  The 


ltABIES. 


1320 

brain-substance  may  be  soft  and  friable  ; there 
is  rarely  congestion  ; and,  as  a rule,  the  brain  is 
pale  and  bloodless  (Fleming! 

The  microscopical  changes  have  not  at  pre- 
sent been  thoroughly  worked  out.  Benedikt  con- 
cludes, from  examinations  of  numerous  sections 
taken  from  various  parts  of  the  nervous  centres, 
that  the  pathological  process  in  this  disease 
consists  in  acute  exudative  inflammation  with 
hyaloid  degeneration,  which  doubtless  arises 
from  the  exudative  infiltration  of  the  connective 
tissue  (Fleming).  See  Hydrophobia. 

Sysiptojis. — In  the  lower  animals,  the  trains 
of  symptoms  are  so  marked,  that  they  have 
given  rise  to  the  distinction  of  two  different 
forms  of  the  disease : one  in  which  the  nervous 
system  is  excited,  hence  the  terms  furious,  wild, 
or  ‘excited’  rabies;  the  other,  where  it  seems 
to  be  depressed,  and  to  which  the  names  of 
‘dumb  tranquil,’  ‘torpid,’  or  ‘ paralytic’  rabies 
have  been  given.  Although  this  distinction  is 
convenient  for  description,  it  must  not  be  for- 
gotten that  paralysis,  in  some  form  or  other, 
usually  sets  in,  sooner  or  later,  in  the  excited 
form ; whereas  in  the  latter  it  is  rarely,  and  then 
only  for  a short  time,  preceded  by  any  signs  of 
excitement  or  inclination  for  mischief.  In  other 
words,  the  symptoms  of  rabies  may  be  divided 
into  three  stages,  namely,  the  premonitory,  irri- 
tative, and  paralytic.  In  the  ‘furious  ’ form,  all 
three  stages  are  well-marked;  but  in  the  ‘dumb’ 
form,  only  the  first  and  last.  The  transition 
from  one  stage  to  the  other  is  gradual  and  im- 
perceptible. 

The  premonitory  stage  is  characterised  by  an 
alteration  in  the  manner  and  habits  of  the 
animal.  Dogs,  for  instance,  that  are  naturally 
friendly  and  docile,  suddenly  turn  surly  and 
bad-tempered,  and  as  quickly  return  again  to 
their  former  docile  manner,  showing  more  affec- 
tion than  usual.  Nearly  all  animals  are  rest- 
less, and  frequently  change  their  posture  and 
position.  Most  are  dull,  lazy,  languid,  and  seek 
seclusion  from  society  by  hiding  themselves  in 
dark  and  quiet  places.  Irritation  at  the  seat  of 
inoculation,  demonstrated  by  rubbing,  nibbling, 
or  scratching  the  cicatrix,  is  frequently  an  early 
symptom.  The  appetite  is  lost,  and  in  rumin- 
ants rumination  is  suspended.  Sometimes  a 
depraved  appetite  is  present,  evidenced  in  dogs 
and  pigs  by  their  eating  all  sorts  of  strange 
things,  such  as  wood,  iron,  &c. ; and  these,  as 
well  as  sheep,  often  swallow  their  own  faeces  and 
urine  ; whilst  the  latter  have  been  seen  to  lick 
blood  and  even  eat  their  wool.  Carnivorous  ani- 
mals and  pigs  frequently  ‘gulp,’  as  if  trying  to 
swallow  something,  or  retch,  as  though  to  free 
their  throat  from  some  foreign  body  ; and  vomit- 
ing sometimes  occurs.  The  visible  mucous 
membranes  are  red,  and  saliva  almost  always 
(except  in  horses)  drivels  from  the  mouth,  due  in 
all  probability  to  dysphagia.  The  sexual  organs 
of  all  species,  except  the  pig  (Haubner),  are 
frequently  excited  in  the  early  stage  of  this 
disease,  and  ungovernable  salacity  is  present. 
The  bowels  are  constipated ; the  urine  sup- 
pressed. 

These  symptoms  may  hist  from  twelve  to 
forty-eight  hours,  and  then  gradually  pass  either 
into  the  irritative,  marking  the  ‘ maniacal  ’ form, 


or  into  the  paralytic  stage,  characteristic  of  tb 
‘ melancholic  ’ form. 

The  irritative  stage  is  distinguished  by  a pro- 
pensity to  injure  other  animals  ; by  great  uneasi- 
ness ; and  by  paroxysms  of  fury  and  excitement, 
with  intervals  of  quietude  and  exhaustion. 

The  increased  restlessness,  which  marks  the 
commencement  of  this  stage,  is  manifested  dif- 
ferently by  various  animals.  They  are  con- 
stantly changing  their  position  and  posture. 
Dogs  lie  down  in  one  place  and  quickly  shift  to 
another  ; horses  move  their  ears  backwards  and 
forwards,  as  though  they  were  listening  to  some 
distant,  sound. 

During  the  paroxysms  dogs  become  excited; 
disturb  their  beds  ; tear  carpets,  mats,  or  what- 
ever comes  in  their  way;  and  bite  their  kennels, 
chains,  other  animals,  and  even  their  own 
bodies.  They  may  lie  quietly  for  a time,  and 
then  suddenly  jump  up  with  a peculiar  howl; 
remain  in  the  same  posture  for  a time ; look 
vacantly'  around  them  ; then  suddenly  walk  for- 
ward as  though  following  something ; and  all  at 
once  snap  at  some  imaginary  object.  The  dog 
may  obey  its  master’s  call,  although  reluctantly, 
and  look  up  pitifully',  as  though  it  did  not  wish 
to  be  disturbed.  The  tongue  is  swollen,  and 
frequently  dipped  into  water  to  cool  it,  although 
the  poor  creature  cannot  swallow  any,  and 
saliva  hangs  in  strings  from  the  angles  of  its 
mouth.  The  countenance  is  anxious  and  hag- 
gard. If  the  animal  should  succeed  in  escaping 
from  its  kennel  at  the  early  part  of  this  stage, 
lie  wanders  forth  ‘ on  the  march,’  apparently  not 
knowing  or  caring  where  he  goes.  If  any- 
thing comes  in  his  way  he  immediately  attacks 
it,  and  then  resumes  his  journey'.  The  gait  and 
carriage  of  the  dog  are  at  first  natural,  but  as 
the  nervous  energy  fails,  he  becomes  unsteady 
and  tottering  ; the  tail  drops  between  his  legs; 
his  head  is  carried  near  the  ground  ; the  abdo- 
men is  ‘ tucked  up  ; ’ and  the  poor  beast,  which 
a few  days  previously  was  plump  an  1 fresh-look- 
ing, is  now  comparatively  a skeleton.  Dogs 
generally  endeavour  to  retrace  their  way  back 
to  their  homes  to  die.  Cats  are  very  savage, 
arch  their  backs,  lash  their  tails,  and  freely  use 
their  teeth  and  claws.  Horses  become  very 
violent,  frequently  neigh,  bite  the  bars  and 
mangers,  kick,  paw,  and  endeavour  to  get  loose. 
Cattle  rarely,  if  ever,  use  their  teeth,  but  bellow, 
paw  the  ground,  butt  and  toss,  frequently  break- 
ing their  horns.  Sheep  seldom,  but  goats  often, 
use  their  teeth.  Their  natural  timidity  is  re- 
placed by  a pugnacious  disposition,  and  they 
will  even  attack  dogs.  Pigs  slaver  at  the  month, 
bite  their  fellows  and  other  animals,  and  become 
very  wild.  Poultry  make  stupid  high  jumps  and 
other  frenzied  movements,  peek  one  another, 
and  chuckle  frequently.  The  voice  of  all  animals 
affected  with  rabies  is  altered  in  character,  and 
is  continually  being  exercised.  In  dogs,  the  cha- 
racter of  the  voice  is  one  of  the  best  diagnostic 
signs  of  the  disease.  It  has  a peculiar  high-toned, 
croupy.  ringing  sound,  as  if  the  bark  and  howl 
were  blended  together.  In  the  early  part  of  this 
stage  of  the  malady,  the  eyes  are  bright  and 
glaring— especially  in  cats  ; but  as  the  disease 
advances,  the  bulbus  oculi  retracts  in  its  ortit, 
and  the  membrana  nietitaus  is  forced  half  ov«i 


RABIES. 


the  cornea,  giving  the  animal  a horrible  and  for- 
'orn  appearance. 

At  first  the  paroxysms  are  strong  and  pro- 
longed, but  as  the  disease  progresses  they 
become  -weak  and  short,  and  the  periods  of 
depression  which  intervene  between  the  pa- 
roxysms are  lengthened,  until  finally  the  animal 
has  not  power  or  strength  to  move  his  limbs, 
when  th q paralytic  stage  may  be  said  to  have 
commenced.  We  now  notice  continual  twitching 
aud  convulsions  of  the  muscles — even  tetanus; 
and  death  soon  takes  place. 

The  'paralytic  stage  of  the  ‘ dumb  ’ or  ‘ torpid  ’ 
form  of  the  disease  is  marked  by  ‘dropping’  or 
paralysis  of  the  inferior  maxilla,  rendering  the 
animal  unable  to  bite  or  bark.  Although  at  the 
commencement  of  this  stage  there  may  be  an 
inclination  in  the  dog  to  leave  its  abode  and 
‘march;’  still  it  is  less  so  than  in  furious 
rabies,  and  if  he  do  go,  the  creature  either 
quickly  returns  again,  or  seeks  some  secluded 
spot  in  which  to  die.  The  animal  endeavours  to 
remain  quietly  in  a dark  place,  and  takes  little 
notice  of  what  is  going  on  around  him.  The 
tongue  is  swollen,  livid,  and  hangs  out  of  the 
mouth  ; the  saliva  is  tenacious  and  abundant. 
Paralysis  of  the  posterior  extremities  soon  sets 
in,  and  death  quickly  follows.  When  the  tranquil 
form  of  rabies  attacks  other  animals  than  dogs, 
it  usually  paralyses  the  posterior  extremities. 

Duration  and  Termination. — Rabies  gener- 
ally takes  a rapid  course,  sometimes  killing 
within  forty-eight  hours,  aud  rarely  lasting  more 
than  ten  days,  although  cases  of  canine  madness 
have  been  reported  to  have  lasted  from  fifteen 
to  twenty  days.  The  duration  depends  to  a cer- 
tain extent  upon  the  constitutional  vigour  of  the 
animal.  The  termination  is  fatal  in  all  animals. 

Diagnosis. — Marochetti  and  others  have  as- 
serted that  rabies  can  be  diagnosed  a few  days 
after  inoculation,  by  the  presence  of  a sub- 
lingual vesicular  eruption,  but  there  is  no  evi- 
dence to  warrant  us  in  believing  this  statement ; 
and  Sir.  Fleming  remarks,  ‘that  it  is  much  to  be 
regretted  that  those  who  have  seen  these  lyssi 
did  not  resort  to  inoculation  with  the  contents 
of  the  vesicles  to  prove  whether  they  really 
contained  the  morbific  elements  or  not.’ 

The  most  characteristic  symptom  of  the 
‘ furious  ’ form  is  undoubtedly  the  peculiar 
voice ; and  of  the  ‘ dumb  ’ form  the  dropping  of 
the  inferior  maxilla.  But  since  these  symptoms 
only  appear  when  the  disease  is  comparatively 
advanced,  we  must  take  other  symptoms  into  con- 
sideration, such  as  the  behaviour  of  the  animal, 
its  physiognomy,  inclination  to  bite,  and  to  eat 
strange  and  indigestible  substances.  An  ac- 
quaintance with  the  history  of  the  case  is  neces- 
sary if  we  would  avoid  confounding  it  with  other 
diseases. 

Epilepsy  is  distinguished  from  rabies  by  the 
sudden  and  complete  loss  of  sense,  champing  of 
the  jaws,  foaming  at  the  mouth,  convulsions, 
cries,  and  rapid  recovery. 

Distemper  has  sometimes  been  mistaken  for 
rabies,  from  the  fact  that  catarrh  of  the  eyes  and 
nose,  giddiness,  weakness,  and  emaciation  are 
sometimes  present  in  both  diseases;  and  it  is 
just  this,  with  the  fact  that  epilepsy  is  some- 
times a sequela  to  distemper,  that  undoubtedly 


1321 

led  the  late  Mr.  Grantley  Berkeley,  a professed 
authority  on  rabies,  to  state,  ‘that  dogs  become 
utterly  insane  from  distemper,  and  that  if  this 
disease  be  prevented  by  vaccination,  hydro- 
phobia (rabies)  will  be  decreased.’  It  is  scarcely 
necessary  to  say  that  such  assertions  are  liable 
to  cause  great  mistakes. 

Foreign  substances  in  the  fauces  or  pharynx, 
especially  in  the  dog,  may  be  distinguished  from 
rabies  by  the  history  of  the  case,  and  by  careful 
examination. 

Inflammation  of  the  throat  only  presents  one 
symptom  of  rabies,  namely,  inability  to  swallow. 

Gastritis  and  enteritis  may  be  distinguished 
by  the  absence  of  the  nervous  symptoms,  and 
by  the  pain  produced  on  pressing  the  abdomen. 

Phrcnitis , especially  in  horses,  may  be  con- 
founded with  rabies  ; but  although  the  animals 
may  be  delirious,  there  is  no  inclination  to  do 
mischief,  nor  are  they  irritated  by  the  presence 
of  a dog  or  a person,  and  the  course  of  the  disease 
will  soon  decide  the  question. 

Tetanus  in  the  dog  has  been  confounded  with 
Eibies,  but  this  is  such  a rare  disease  in  dogs, 
cats,  cattle,  sheep,  goats,  and  pigs,  as  to  call  for 
no  special  mention.  In  horses  such  a mistake 
could  scarcely  happen. 

Anthrax.  The  pathological  changes  of  rabies 
and  anthrax,  says  Mr.  Fleming,  have  at  times 
lent  some  support  to  the  idea  that  they  were 
identical,  or  at  least  resembled  each  other.  Al- 
though vertigo,  and  a disposition  to  fury,  do  in 
some  cases  accompany  anthrax  in  the  lower  ani- 
mals (especially  in  the  horse),  the  other  symp- 
toms of  anthrax,  the  rapidity  with  which  it  runs 
its  course,  and  the  pathological  anatomy  of  the 
several  diseases,  will  serve  to  distinguish  one 
from  the  other.  The  presence  of  the  bacillus 
anthracis  in  the  blood  is  absolutely  character- 
istic. 

Cattle-plague.  The  fits  of  delirium  that  now 
and  again  appear  in  this  disease,  as  well  as  the 
great  depression,  apathy,  and  the  unsteady  gait, 
have  a resemblance  to  those  present  in  a certain 
stage  of  rabies.  But  this  resemblance  is  very 
superficial.  The  existence  of  the  plague  in  the 
district,  and  the  appearance  of  the  visible  mu- 
cous membranes,  and  the  other  symptoms  during 
life,  as  well  as  the  pathological  alterations  after 
death,  are  sufficient  to  establish  a distinction 
(Fleming). 

A ferocious  dog  has  frequently  been  mistaken 
for  a rabid  one. 

There  are  no  post-mortem  signs  sufficiently 
trustworthy  or  characteristic  to  enable  us  to 
form  a correct  diagnosis  of  rabies.  The  history 
of  the  case,  however,  together  with  the  fact  that 
foreign  bodies  are  present  in  the  stomach,  and 
the  mucous  membrane  of  the  fauces,  larynx,  and 
stomach  congested,  will  materially  assist  us  in 
forming  a correct  opinion. 

TREATMENT.-The  curative  treatment  of  rabies, 
so  far  as  our  experience  at  present  goes,  has  yet 
to  be  discovered;  and  since  the  malady  is” so 
dangerous  to  other  animals  and  man,  we  think 
its  cure  ought  not  to  be  undertaken,  except  by 
experienced  persons  and  under  adequate  restric- 
tions. 

The  prophylactic  treatment,  however,  de- 
serves our  best  consideration.  If  an  animal  has 


1822  RABIES. 

been  inoculated  by  a bite  from  a rabid  animal  or 
otherwise,  the  circulation  in  the  part  should  be 
immediately  stopped  by  a compress  above  it ; the 
wound  thoroughly  washed,  sucked,  or  cupped  ; 
and  all  parts  that  are  supposed  to  have  been  in 
contact  with  the  virus  excised,  and  either  the 
actual  or  potential  cautery  freely  applied.  In  the 
lower  animals,  some  of  the  wounds  may  escape 
our  notice  on  account  of  the  hair,  and  therefore 
even  after  the  above  precautions  are  taken,  the 
subject  must  be  treated  as  suspicious.  Cows, 
sheep,  and  pigs,  if  the  wounds  have  been  promptly 
cauterised,  may  be  used  for  food,  provided  they 
have  been  killed  within  twenty-four  hours  of  the 
inoculation.  If  an  animal  is  suspected  of  being 
inoculated  from,  or  has  been  in  company  with, 
one  affected  with  rabies,  it  should  be  kept  in  a 
secure  place,  and  watched  for  at  least  four 
months,  and  then  only  allowed  to  go  out  muzzled, 
but  it  is  preferable  to  destroy  it.  If  such  an 
animal  has  bitten  any  person,  it  should  not  be 
destroyed  until  it  has  been  positively  ascertained 
whether  it  is  rabid  or  not.  All  affected  animals 
should  be  killed  at  once  and  burned,  or  buried 
deep  with  quick-lime.  The  researches  of  AIM. 
Pasteur  and  Galtier  suggest  the  advantage  that 
may  result  from  the  intravenous  injection  of  the 
diluted  poison,  for  the  purpose  not  only  of  pre- 
venting the  disease,  but,  even  after  an  animal 
has  been  bitten,  of  mitigating  the  severity  of  the 
symptoms. 

When  a case  of  rabies  has  occurred,  notice 
ought  to  be  given  at  once  to  the  local  authori- 
ties, to  prepare  them  for  making  and  enforcing 
stringent  measures  to  prevent  its  spread.  No 
dogs  ought  to  be  allowed  to  enter  public  build- 
ings or  conveyances,  or  to  frequent  the  public 
streets  or  highways,  without  a muzzle,  under  the 
penalty  of  being  seized  by  the  police. 

If  a rabid  animal  is  at  large,  notice  should 
be  given  of  the  fact  to  the  neighbourhood  as  soon 
as  possible.  All  kennels,  chains,  collars,  and 
places  with  which  a rabid  animal  has  been  in 
contact  should  be  scalded  and  disinfected. 

George  A.  Banham. 

RACHITIS  (^dx,s-  the  spine). — A synonym 
for  rickets.  See  Rickets. 

RAGATZ,  in  Switzerland. — Simple  ther- 
nnd  waters.  See  Mineral  Waters. 

RAILWAY  ACCIDENTS.  Results  of.— 

The  results  of  railway  accidents  are,  first,  imme- 
diate, such  as  those  which  follow  directly  and 
continuously  on  the  occurrence  of  the  accident; 
and,  secondly,  indirect  or  remote,  which  follow  at 
a later  period,  after  an  interval  of  apparent  im- 
munity. The  points  of  difference  between  rail- 
way injuries  and  those  sustained  in  other  ways, 
such,  for  instance,  as  by  a fall  from  a horse  or 
a carriage,  are  virtually  those  of  degree.  This 
effect  is  referable,  firstly,  to  the  great  weight 
and  impulse  of  the  train,  crushing  perhaps  com- 
pletely some  portion  of  the  body;  secondly,  in 
the  caso  of  collision,  to  the  sudden  arrest  of 
momentum  of  such  ponderous  bodies  in  more  or 
less  rapid  motion,  causing  thereby  violent  vibra- 
tory shocks  to  the  travellers.  Thirdly,  the 
occurrence  being  sudden  and  unexpected,  the 
muscles  are,  as  it  were,  taken  by  surprise,  and 


RAILWAY  ACCIDENTS, 
before  contraction  takes  place,  the  ligament*  at 
the  spine  are  frequently  strained  or  even  torn. 
There  is  no  time  for  preparation ; the  whole  is 
the  work  of  an  instant.  Fourthly,  in  cases  of 
injury  to  those  who  jump  or  fall  from  a train  in 
motion,  the  gravity  of  the  resulting  injury  de- 
pends on  the  rate  of  speed  of  the  train  at  the 
moment ; on  the  part  of  the  body  which  first 
strikes  the  ground,  and  the  angle  at  which  it  is 
struck  ; on  the  weight  o'f  the  person  ; and  also 
on  the  nature  of  the  ground. 

Accidents  which  happen  to  persons  either  get- 
ting into  or  out  of  trains  not  in  motion,  possess 
no  special  characters.  It  should,  however,  fcs 
mentioned  that  serious  spinal  injuries  have  oc- 
curred to  persons  sitting  in  a train  not  in  motion, 
when,  by  a sudden  unexpected  jerk,  a violent 
shock  is  sustained. 

It  is,  therefore,  this  violent  and  sudden  cor,- 
motion  of  the  system  which  constitutes  the  main 
feature  in  this  class  of  injuries,  a condition  which 
does  not  obtain  in  cases  where  there  is  less  sud- 
den violence. 

Most  of  the  direct  results  of  railway  accidents 
are  so  obvious  as  not  to  need  description  here. 
They  consist  of  various  kinds  of  fractures,  con- 
tusions, and  lacerations,  caused  either  by  the 
force  of  the  collision,  or  by  crushing  and  grind- 
ing under  the  wheels  of  the  carriages  when  the 
individual  has  been  run  over,  or  by  fragments  of 
splintered  wood,  iron,  and  glass,  or  by  burns  or 
scalds.  These  injuries  either  cause  immediate 
death  ; or  the  patient  may  ultimately  succumb,  or 
he  may  he  permanently  injured,  or  recover.  Oc- 
casionally death  results  simply  from  fright ; the 
influence  of  intense  fear  on  the  minds,  especially 
of  persons  suffering  from,  heart-disease,  aneu- 
rism, and  the  like,  being  sufficient  toeause  death. 
The  primary  depression  produced  on  the  nervous 
and  circulatory  system  continues  and  deepens; 
there  is  no  power  to  rally;  and  a fatal  result 
from  syncope  ensues. 

Direct  results  on  the  cerebro-spinal  sys- 
tem.— The  injuries  following  directly  upon  a 
railway  accident  are  of  considerable  interest, 
both  on  account  of  the  difficulty  of  arriving  at  a 
definite  diagnosis,  and  because  of  the  important 
issues  dependent  on  the  prognosis.  They  com- 
prise conditions  of  general  shock  and  concussion, 
where  the  symptoms  presented  are  principally 
subjective;  and  of  local  injury,  such  as  fracture 
of  the  skull  or  of  the  spine,  implicating  the 
brain,  the  spinal  cord,  or  their  membranes, 
stretching  or  rupture  of  spinal  ligaments,  to  a 
greater  or  lesser  extent,  injury  to  the  pelvis, 
and  other  lesions. 

For  a description  of  concussion  of  the  core, 
and  the  localisation  of  lesions  of  the  spinal  cord. 
sec  SrixAL  Coed,  Diseases  of. 

Indirect  results. — In  this  class  of  cases  the 
extent  of  the  injury  is  not  evident  at  the  time 
of  the  accident ; for  instance,  a person  in  a col- 
lision receives  a shock  of  apparently  a temporary 
character;  recovers  himself  sufficiently  to  be 
able  to  assist  his  fellow-sufferers ; returns  home; 
and  resumes  his  usual  avocations.  After  an 
interval  of  days,  symptoms  of  spinal  trouble 
show  themselves  ; the  person  experiences  pain 
in  this  region,  tenderness  on  pressure  or  on  the 
application  of  a hot  sponge,  and  inability  tc 


RAILWAY  ACCIDENTS,  RESULTS  OF.  ].?•> 


sleep  or  to  attend  to  business ; he  hears  noises 
in  the  ears ; and  he  feels  a general  exaltation  of 
the  sentient  faculties.  Cases  such  as  these  are 
frequently  the  subject  of  litigation  as  regards 
claims  for  damages  against  railway  companies. 

Medico-legal  questions  in  connexion  with 
railway  accidents.— In  cases  of  claim  for  com- 
pensation for  these  injuries,  it  is  of  the  highest 
importance  that  the  medical  men  engaged  should 
make  themselves  thoroughly  acquainted  with  all 
the  circumstances  connected  with  the  accident 
and  its  results.  This  applies  to  the  medical 
attendant  of  the  injured  person,  as  well  as  to 
the  medical  officer  examining  on  behalf  of  the 
company. 

It  will,  therefore,  be  well  to  refer  to  the 
general  character  of  some  of  the  fraudulent 
claims  made  upon  railway  companies. 

Fraudulent  claims. — -There  are  three  prin- 
cipal kinds  of  fraud  practised,  and  sometimes 
with  success,  namely,  first,  by  persons  who,  as 
may  be  subsequently  proved,  were  not  even  pre- 
sent at  the  time  of  the  accident ; secondly,  by 
those  who,  though  present  and  unhurt,  yet  simu- 
late symptoms  of  injury;  and,  thirdly,  by  those 
who,  having  sustained  some  trifling  injury,  wil- 
fully and  intentionally  exaggerate  their  symp- 
toms, in  order  to  obtain  an  unfair  amount  of  com- 
pensation. There  are,  therefore,  certain  points 
to  which  the  medical  man  should  attend,  lest  he 
should  be  led  away  by  a well-planned  history, 
and  thus  unwittingly  be  made  a party  to  such 
transactions. 

Duties  of  the  medical  attendant. — 1.  It  is 
desirable  to  obtain  in  writing  the  patient's  state- 
ment as  regards  the  accident ; if  possible  ascer- 
taining, approximately,  the  rate  of  speed  of  the 
I rain  when  the  accident  occurred,  the  position  of 
the  person  in  the  carriage,  and  whether  other 
persons  were  present  or  not. 

2.  Note  bruises  or  any  sign  of  local  injury  on 
any  part  of  the  body. 

•3.  Where  injury  to  the  spine  is  alleged,  the 
investigation  should  be  conducted  as  far  as  pos- 
sible according  to  the  following  systematic 
plan : — 

(1)  Examine  the  spine  by  percussion,  and  by 
the  application  of  a hot  sponge. 

(2)  Seek  for  any  paralytic  phenomena  by — - 

(a)  Measurement  of  limbs. 

( b ) Comparative  degree  of  surface  sensibility. 

(c)  Comparative  amount  of  electrical  irrita- 
bility of  muscles. 

(d)  The  existence  of  spasm  or  tremor  of  the 
muscles  of  the  spine  and  limbs. 

(3)  Ophthalmoscopic  examination  must  be 
made,  in  order  to  determine  the  existence  or 
non-existence  of  local  lesion,  confirmatory  or 
otherwise,  of  cerebral  or  spinal  symptoms. 

This  done,  it  becomes  the  duty  of  the  medical 
attendant  to  form  an  opinion  after  satisfying 
himself  on  the  following  points : — 

a.  Has  the  patient  really  been  injured? 

0.  What  is  the  nature  of  the  injury  ? 

y.  Is  the  injury  a possible  result  of  the  acci- 
dent as  described? 

S.  Is  the  train  of  symptoms  consistent  with 
the  appearance  of  injury. 

He  should  also  remember  that  the  simulation 
of  symptoms,  such  as  spinal  tenderness  or  mus- 


cular tremor,  can  frequently  be  detected  by  dis- 
tracting the  attention,  when  pressure  on  the  part 
previously  complained  of  may  be  exercised  with 
impunity,  and  the  muscular  tremors  will  cease. 
This,  however,  is  not  conclusive  of  imposture, 
for  in  hysteria,  when  the  attention  is  diverted, 
the  same  occurs.  Again,  the  existence  of  organic 
disease  previous  to  the  accident  should  be  looked 
for,  as  it  has  happened  that  symptoms  referable 
to  disease — locomotor  ataxy,  for  example — have 
been  erroneously  ascribed  to  injury.  The  urine 
should  be  examined  in  every  case. 

As  an  instance  where  the  truth  of  a patient's 
statements  may  be  tested  by  the  astuteness  of 
the  medical  man,  a case  may  be  mentioned  where 
the  plaintiff,  who  had  travelled  up  some  fifty 
miles  to  London  to  be  examined,  stated  among 
other  symptoms  that  his  urine  continually  drib- 
bled from  him.  The  surgeon  immediately  asked 
to  see  his  shirt,  which  had  been  worn  at  least 
six  hours,  when  it  was  found  perfectly  dry  and 
devoid  of  any  stain  of  urine  .'  In  another  ease  a 
man  presented  extreme  spinal  tenderness,  even 
to  the  extent  of  complaining  of  pain  when  the 
part  was  blown  upon  with  the  breath.  A sheet 
of  paper  being  interposed,  without  the  patient's 
knowledge,  the  effect  was  the  same. 

Duties  of  the  medical  officer  examining 
on  behalf  of  the  railway  company. — The 
medical  officer  of  the  company  should  not  con- 
stitute himself  the  agent  of  the  company  for 
settling  the  terms  of  compensation.  The  exa- 
mination should  be  made,  if  possible,  in  the 
presence  of  the  patient’s  medical  attendant,  anil 
should  be  conducted  thoroughly,  with  tact,  and 
without  inflicting  any  unnecessary  mental  or 
bodily  pain. 

A report  of  the  case  should  be  drawn  up  at  the 
time,  giving: — - 

1.  The  patient’s  account  of  the  accident,  and 
of  his  subsequent  and  present  symptoms. 

2.  The  present  condition  of  the  patient,  noting 
particularly  any  objective  signs  of  injury. 

3.  An  opinion  as  to  whether  the  symptoms 
complained  of  are  likely  to  be  the  result  of  the 
accident,  as  to  the  probability  of  recovery,  and 
at  what  period. 

As  the  plaintiff  in  an  action  has  a right  to  a 
copy  of  this  report,  it  should,  of  course,  be  worded 
with  extreme  care. 

The  actual  question  of  pecuniary  compensa- 
tion does  not  concern  either  the  medical  atten- 
dant of  the  patient  or  the  medical  adviser  of  the 
company.  They  merely  have  respectively  to  bring 
forward  facts  in  support  of  their  opinions  as  to 
the  value  of  symptoms,  and  how  far  they  are 
dependent  upon  the  injury. 

By  an  early  investigation  in  such  a manner 
as  indicated,  the  practice  of  fraud  would  be  ren- 
dered impossible,  and  by  an  accurate  knowledge 
and  statement  of  facts  much  conflict  of  medical 
opinion  might  be  avoided. 

Unintentional  exaggeration  of  symptoms. 
There  are  certain  persons  who,  undoubtedly 
injured,  without  having  any  fraudulent  de- 
sign, may  yet  unintentionally  exaggerate  their 
symptoms  in  consequence  of  the  continual  direc- 
tion of  their  minds  to  their  sufferings,  whilst  an 
action  for  damages  is  pending.  The  suspense  and 
anxiety,  the  examinations  by  the  medical  man, 


1324  RAILWAY  ACCIDENTS, 
and  the  repeated  interviews  with  their  solicitors, 
keep  them  in  a constant  state  of  nervous  excite- 
ment. When,  therefore,  their  claims  are  settled, 
it  is  natural  that  the  relief  they  experience 
should  frequently  be  attended  by  beneficial  re- 
sults, or  even  complete  recovery.  See  Feigned 
Diseases. 

Treatment.— The  chief  injuries  received  at 
the  time  of  a railway  accident  being  surgical, 
the  treatment  adapted  for  each  particular  case 
will  be  found  in  surgical  works.  Nevertheless 
there  are  some  general  points  in  the  immediate 
treatment,  to  which  any  medical  man  present  on 
such  occasions  would  do  well  to  attend. 

1.  Hcemorrhagc. — Death  from  haemorrhage 
should  be  prevented  by  promptly  adopting  pres- 
sure of  some  kind.  If  no  tourniquet  be  at  hand, 
or  india-rubber  band,  a handkerchief  tied  round 
the  limb  and  twisted  tight  with  a piece  of  stick, 
will  suffice  for  the  time,  or  direct  pressure  by 
the  finger. 

2.  Fractures. — Temporary  splints  may  be  im- 
provised out  of  cushions,  newspapers,  straps,  and 
broken  pieces  of  wood,  &c.,  so  that  the  injured 
may  be  removed  witli  as  little  pain  as  possible, 
and  simple  fractures  may  be  prevented  becoming 
compound.  Simple  dislocations  should  be  reduced 
at  once  if  possible. 

3.  Shock,  collapse , and  fright. — In  the  treat- 
ment of  these  conditions  great  caution  is  required 
to  maintain  the  vital  power  until  reaction  sets 
in.  The  temperaturo  of  the  body,  the  strength 
and  rate  of  the  heart’s  action,  together  with  the 
respiration,  should  be  kept  up  by  stimulants  and 
warmth.  Mr.  Savory,  in  his  article  on  Shock  in 
Holmes’s  System  of  Surgery,  is  careful  to  point 
. ut,  however,  the  dangers  of  over-stimulation, 
whereby  the  flickering  powers  may  be  extin- 
guished altogether. 

J.  Exposure  to  wet  mid  cold. — Every  endea- 
vour should  of  course  be  made  to  prevent  pro- 
longed exposure,  by  sheltering  the  injured  as 
much  as  possible,  and  securing  their  early  remo- 
val to  any  neighbouring  houses. 

W.  Rose. 

RALES  (Fr.,  Rattles). — Certain  adventitious 
sounds  heard  on  auscultation,  in  connection  with 
the  respiratory  organs,  during  the  act  of  breath- 
ing, in  various  morbid  conditions.  See  Physical 
Examination  ; and  Rhonchcs. 

RAMOLLISSEMENT  (Fr.,  Softening).— 
This  word  is  associated  with  all  forms  of  soften- 
ing of  t issues  and  organs  ; but  by  English  patho- 
logists it  is  generally  used  to  denote  softening 
of  the  central  nervous  system.  Sec  Softening. 

EANULA  (ranula,  dim.  of  rana,  a frog). — 
A cystic  growth  in  connection  ■with  the  mouth, 
and  having  several  modes  of  origin.  See  Mouth, 
Diseases  of. 

RAPE. — Synon.  : Fr.  Viol ; Gcr.  Eothzucht. 

Definition. — By  the  English  law  rape  is  de- 
fined as  ‘the  carnal  knowledge  of  a woman  for- 
cibly and  against  her  will.’ 

General  Remarks. — The  crime  of  rape  is 
punishable  by  penal  servitude  for  life.  The 
carnal  knowledge  of  any  girl  under  ten  years  of 
age  is  punishable  in  the  same  way ; and  the 
carnal  knowledge  of  any  girl  between  ten  and 


RAPE. 


twelve,  under  any  circumstances,  is  punishable 
by  three  years’  penal  servitude,  since  the  law 
rightly  considers  that  children  under  twelve  can 
have  no  power  to  consent  to  sexual  intercourse. 

Of  cases  of  rape  recorded  by  Casper,  73  per 
cent,  were  upon  the  persons  of  little  children 
under  twelve.  Of  136  cases  put  upon  record  by 
this  author,  the  ages  were  as  follows  : — 


From 
„ 12 
„ 15 

19 


to  12  years  of  age,  99  cases. 
„ 1^  ..  ,,  20  „ 

18  ..  „ 8 „ 

„ 25  „ „ 7 „ 

47  „ „ 1 , 


For  proof  of  the  crime  of  rape  it  is  not  neces- 
sary that  the  force  employed  should  have  been 
of  a violent  physical  kind.  A mere  threat  of 
violence,  or  even  of  moral  injury,  is  ‘force’  in 
the  eyes  of  the  law.  The  surreptitious  adminis- 
tration of  chloroform,  ora  narcotic,  for  the  pur- 
pose of  having  intercourse  with  a woman  against 
her  will,  is  also  force  in  the  eyes  of  the  law. 

The  moral  character  of  the  woman  is  theo- 
retically, but  seldom  practically,  beside  the  ques- 
tion ; and,  provided  force  be  used  and  the  woman's 
consent  be  wanting,  sexual  intercourse  even  with 
a prostitute  is  legally  ‘ rape.’ 

The  punishment  of  the  crime  of  rape  was  pro- 
vided for  in  the  criminal  code  of  Moses,  who 
ordained  that  the  ravisher  of  a betrothed  dam- 
sel should  die. 

The  Roman  law  punished  the  crime  with  death 
and  confiscation  of  goods,  but  provided  the  fol 
lowing  saving  clause  : — 

Bapta  raptoris,  aut  mortem.,  ant  indotatas  nup 
tias  optet. 

Upou  this,  says  Percival,  there  arose  what 
was  thought  a doubtful  case  : ‘ Una  node  qui- 
dam  duas  rapuit ; altera  mortem  qptar,  altera 
nuptias.' 

Many  accusations  of  rape  are  false  and  trumped 
up,  and  are  only  brought  by  the  woman  when  she 
finds  that  some  sexual  indiscretion  is  likely  to 
bring  her  into  trouble,  or  cannot  be  concealed  by 
reason  of  her  pregnancy. 

This  being  the  case,  stale  accusations  should  be 
received  with  very  great  caution.  Ths  laws  of 
Henry  III.  provided  that  the  accusation  should 
be  made  immediately,  ‘ dim  rcccns  fucrit  malefi - 
cium.’  By  the  old  Scotch  law  no  delay  was 
allowed  in  bringing  the  accusation  ultra  unam 
noctem,  and  by  the  modern  Scotch  law  a delay 
of  three  days  is  alone  permitted.  By  the  law  of 
England  no  limit  is  placed  on  the  time  at  which 
an  accusation  of  rape  may  be  made.  An  English 
jury  is,  however,  naturally  chary  of  giving  cre- 
dence to  a stale  charge  of  rape.  Some  few  years 
back  a charge  of  rape  was  brought  against  a 
gentleman  of  position  in  one  of  the  home  coun- 
ties, by  a girl  with  whom  he  had  had  connection 
some  five  months  previously.  There  was  no  evi 
denee  that  the  girl  had  offered  any  resistance, 
and  as  the  accusation  was  brought  only  after 
pregnancy  had  become  evident,  and  after  ineffec- 
tual attempts  had  been  made  to  extort  money 
from  the  defendant’s  relatives,  and  as  the  charge 
was  evidently  made  at  the  instigation  of  an 
uncle  who  was  a superintendent  of  police,  and  a 
cousin  who  was  a lawyer,  the  case  was  dismissed. 


EAPE. 


It  shows,  we  think,  an  imperfection  in  the  Eng- 
lish law  that  it  should  be  possible,  under  such 
circumstances,  to  prefer  a charge  of  so  serious  a 
crime. 

The  law  for  the  substsnt.alion  of  a charge 
of  rape  i3  satisfied  with  proof  of  a minimum 
amount  of  ‘ carnal  knowledge.’  The  mere  touch- 
ing of  the  vulva  by  the  penis  is  carual  know- 
ledge in  the  eyes  of  the  law.  The  complete 
introduction  of  the  penis  into  the  vagina  need 
not  be  proved,  and  still  more  is  proof  of  emis- 
sion unnecessary. 

The  Sion's  of  Eape. — From  what  has  gone 
before,  it  is  evident  that  there  need  be  no  signs 
whatever.  If  a girl  be  overawed  by  a threat  and 
her  vulva  be  touched  by  the  penis,  that  is  rape  ; 
and,  if  proved,  is  punishable  as  such. 

On  the  other  hand,  the  signs  of  rape  may  be 
very  obvious,  for  example  : — 

(n)  The  woman  may  have  been  heard  to  cry 
for  help. 

(h)  There  may  bo  the  signs  of  a struggle  at 
the  spot  where  the  rape  was  alleged  to  have 
occurred. 

(c)  There  may  be  damage  to  the  woman’s 
clothing,  and  bruises  of  various  parts  of  her 
body — signs  that  she  has  been  subjected  to 
physical  force. 

(d)  The  genital  organs  may  be  found  injured  ; 
the  vulva  bruised  and  perhaps  bleeding ; the  hy- 
men recently  ruptured;  and,  in  cases  where  the 
disparity  in  size  between  the  man  and  woman 
is  very  great,  rupture  of  the  perinseum  and  mortal 
injuries  to  the  vagina. 

(«)  Seminal  spots  may  be  found  upon  the 
woman’s  clothing,  which  is  a certain  proof  of  a 
previous  ‘intimate  relation  ’ with  a male.  Blood- 
spots  also  afford  valuable  evidence,  but  neces- 
sarily not  so  conclusive.  Care  must  be  taken 
not  to  confound  menstrual  fluid  with  blood. 

The  concurrence  of  all  these  signs  would 
amount  to  certain  evidence  of  forcible  connec- 
tion. It  must  be  borne  in  mind,  however,  that 
violence  may  be  done  to  the  female  organs  in 
ether  ways  than  by  forcible  connection,  and  the 
medical  examiner  should  be  upon  his  guard 
against  inferring  too  much  from  the  evidence 
afforded.  He  also  should  be  on  the  look-out  for 
facts  which  may  rebut  assertions  made  by  the 
woman.  Thus,  signs  of  a previous  pregnancy  or 
the  evidence  of  previous  venereal  disease  (scars 
in  the  groin,  sores  upon  the  pudenda,  or  symp- 
toms of  constitutional  syphilis)  may  serve  to 
disprove  any  assertions  which  might  be  made 
as  to  the  woman’s  virginity  or  previous  chastity. 
To  prove  whether  or  no  a woman  be  ‘ virgo 
Intacta  ’ is  next  to  impossible,  and  we  can  only 
state  the  probabilities  for  and  against.  Such  a 
question,  however,  is  quite  beside  the  mark  in 
many  cases  of  rape  ; but  the  presence  of  an 
unruptured  hymen  is  an  unlikely  occurrence 
after  forcible  connection.  An  examination  of 
the  person  of  the  supposed  ravisher  may  afford 
Borne  corroborative  evidence.  Blood  or  recent 
seminal  spots  upon  the  linen  or  clothing,  and 
injury  to  the  person  or  clothing,  all  afford  their 
quota  of  evidence  of  a sexual  act  combined  with 
violence. 

It  is  a matter  of  doubt  whether  the  rape  of  a 
woman  of  fair  size  and  strength  be  possible  by 


1325 

an  unaided  man.  If  a woman  be  in  the  enjoy 
ment  of  her  faculties  she  is  capable  of  offering 
an  amount  of  resistance  which  would  be  well- 
nigh  insuperable ; and  if  she  have  offered  a decent 
resistance,  the  person  of  the  ravisher  should  bear 
evidence  of  it. 

Bape,  as  we  have  seen,  is  most  often  com- 
mitted on  children  of  tender  years.  It  is  well  to 
he  on  one’s  guard  against  error  with  regard  t'l 
the  rape  of  little  children.  It  must  have  corns 
within  the  experience  of  most  members  of  the 
profession,  and  especially  of  those  engaged  in 
hospital  practice,  to  have  brought  to  them  chil- 
dren suffering  from  a purulent  discharge  from 
the  vagina,  the  mother  at  the  same  time  alleg- 
ing that  someone  must  have  violated  the  child. 
It  must  be  borne  in  mind  that  purulent  dis- 
charges from  the  vagina  are  not  uncommon  in 
ill-fed,  dirty,  scrofulous  children ; and  that  after 
some  of  the  infantile  acute  specifics,  sloughing 
of  the  pudenda  is  a rare,  though  recognised, 
occurrence.  The  case  of  Jane  Hampson,  set.  4, 
who  died  of  sloughing  of  the  genitals  at  Man- 
chester in  1791,  should  stand  as  an  incentive  to 
caution  in  these  matters.  The  signs  were  con- 
sidered as  those  of  defloration,  and  the  coroner’s 
jury  returned  a verdict  of  murder  against  the 
boy  who  slept  with  her,  but  luckily  for  the  mal9 
child  there  occurred  many  other  cases  of  slough- 
ing of  the  pudenda  in  Manchester  before  he  was 
brought  to  trial,  and  as  the  doctor  who  was 
called  to  Hampson  recognised  and  acknowledged 
his  error,  the  boy  was  discharged.  It  was  at 
one  time  a popular  belief  that  connection  with 
a virgin  was  a sure  cure  for  venereal  disease, 
and  this  has  led,  no  doubt,  to  many  eases  of 
rape  on  young  children.  The  presence  of  vene- 
real disease  in  one  or  both  of  the  parties  may 
be  of  value  as  evidence.  Its  presence  in  the 
woman  and  not  in  the  man  affords  a strong  pre- 
sumption against  rape. 

The  finding  of  spermatozoa  within  the  vagina 
is  proof  positive  of  connection.  But  here,  again, 
care  must  be  taken  not  to  mistake  for  sperma- 
tozoa the  trichomonas  vaginalis — a microscopic 
organism,  not  unlike  a tadpole  in  shape,  which 
has  been  described  by  M.  Donne,  as  occasionally 
found  in  vaginal  mucus.  It  must  be  remem- 
bered, also,  that  seminal  fluid  may  eontaki  no 
spermatozoa.  Eape  is  occasionally  effected  with 
so  much  violence  that  death  results.  Ogston 
records  the  case  of  one  Margaret  Paterson,  who 
was  raped  between  Edinburgh  and  Dalkeith  by 
two  carters,  who  took  her  into  their  cart  on  the 
pretence  of  helping  her  on  her  journey.  They 
forcibly  held  her  down  and  repeatedly  violated 
her  person,  and  afterwards  took  stones  from  the 
road,  coals,  straw',  prickly  plants,  &c.,  and  forced 
them  into  the  vagina.  They  then  left  her  in  a 
ditch,  and  she  died  in  three  days  of  her  injuries. 
Post  mortem  the  vagina  and  rectum  were  found 
lacerated  and  broken  dowm  into  one  passage,  and 
the  abdominal  viscera  in  a high  state  of  inflam- 
mation. The  two  carters  were  convicted  and 
executed. 

It  has  been  doubted  whether  pregnancy  can 
follow  rape,  but  there  seem  to  be  no  sufficient 
grounds  for  this  doubt. 

'When  called  to  a case  of  supposed  rape  the 
medical  examiner  must  remember  to  take  note 


1326  RAPE, 

if  every  circumstance — the  time  that  has  elapsed 
since  the  alleged  outrage,  the  mental  state  of  the 
woman,  her  size  and  physical  power  as  compared 
with  that  of  the  man,  evidences  of  a struggle 
m the  surroundings  of  the  woman,  or  on  her 
clothing  and  person.  He  should  keep  his  mind 
open  to  receive  any  facts  which  may  throw  light 
on  the  moral  character  of  the  woman.  He  should 
accurately  take  note  of  the  exact  condition  of  the 
genital  organs  and  linen  ; should  take  possession 
of  all  stained  linen  for  the  purpose  of  chemical 
and  microscopic  examination ; and  should  re- 
move a portion  of  any  discharge  which  may  he 
found  in  the  vagina  for  the  same  purpose.  In 
drawing  up  a report,  he  should  describe,  as  accu- 
rately and  drily  as  possible,  all  facts  which  he 
may  notice ; and  should  be  carefully  upon  his 
guard  against  drawing  any  undue  conclusions 
from  those  facts.  G.  V.  Poore. 

BASH. — An  outbreak  of  redness  of  the  skin, 
or  efflorescence  ; called  by  the  Greeks  an  exan- 
thema, or  blossoming  out.  The  word  rash,  or  as 
it  were  ‘ rush,’  conveys  the  idea  of  suddenness, 
whilst  in  reference  to  development  it  is  generally 
extensive.  The  best  illustrations  of  the  rashes 
and  of  the  meaning  of  the  term  are  erythema, 
the  red  rash ; roseola,  the  rose-rash ; rubeola, 
the  crimson  rash,  generally  known  as  measles ; 
scarlatina,  the  scarlet  rash;  purpura,  the  purple 
rash;  and  urticaria,  the  nettle  rash. 

RATIONAL  (ratio,  reason).  In  conformity 
to  reason. — A term  applied  to  the  mental  state  ; 
also  to  treatment  when  founded  on  scientific  prin- 
ciples, in  contradistinction  to  empirical  treatment, 
founded  solely  on  experience.  See  Conscious- 
ness, Disorders  of;  and  Disease,  Treatment  of. 

REACTION. — "When  any  substance  or  in- 
fluence affects  the  organism  sufficiently  to  cause 
appreciable  physiological  disturbance  within  it, 
it  is  said  to  have  a. physiological  action  upon  the 
body ; or,  more  briefly,  to  act  or  to  have  an  action 
upon  it.  If  the  effect  of  such  an  influence  have 
been  well-marked,  the  organism  does  not  simply 
return  to  the  original  or  ordinary  condition,  or 
to  what  is  called  the  ‘physiological  balance,’ 
with  the  cessation  of  the  influence;  hut  passes 
beyond  it  into  a state  characterised  by  pheno- 
mena?, which  are,  speaking  broadly,  the  opposite 
of  the  former.  The  condition  which  is  thus  the 
effect  or  outcome  of  the  action  is  called  the  re- 
action ; and  the  same  name  is  also  given  to  the 
process  by  which  the  primary  effect  passes  into 
the  secondary.  The  cold  hath  furnishes  a fami- 
liar illustration  of  physiological  action  and  reac- 
tion. The  contraction  of  the  superficial  vessels, 
the  pallor,  the  sensation  of  intense  cold,  and 
the  fall  of  temperature,  which  are  the  immediate 
effects  of  the  cold  bath,  are  speedily  replaced  by 
such  exactly  opposite  phenomena  as  dilatation 
of  the  cutaneous  vessels,  flushing  of  the  skin,  a 
warm  glow,  and  a rise  of  temperature ; and  in  the 
same  way  the  primary  nervous  stimulation  gives 
way  to  a feeling  of  general  calmness  and  com- 
fort. It  is  generally  found  that  the  phenomena 
cf  action  and  reaction  are  in  direct  proportion  to 
each  other,  unless  the  action  be  excessive,  in  which 
case  reaction  may  not  set  in.  In  other  instances 
the  irritability  or  excitability  of  the  organism, 


RECTUM,  DISEASES  OF. 
whether  as  a whole  or  in  part,  may  be  either 
unnaturally  increased  or  unnaturally  diminished, 
and  the  reaction  he  excessive  or  imperfect  accord- 
ingly. 

Excessive  emotional  excitement,  whether  plea- 
surable or  painful  in  nature,  such  as  joy  or  fear, 
may  similarly  be  followed  by  corresponding  de- 
pression, by  prostration,  or  even  by  death.  In 
the  reaction  which  follows  severe  injuries,  espe- 
cially when  they  are  met  with  under  circum- 
stances of  intense  fear — for  example,  in  railway 
accidents,  both  the  bodily  and  the  mental  func- 
tions, so  called,  are  simultaneously  involved. 

The  effects  of  reaction  are  also  illustrated 
locally  in  the  condition  of  wounds.  Local  re- 
action takes  the  form  chiefly  of  inflammation, 
and  is  carefully  studied  by  the  surgeon,  who  finds 
in  it  a ready  means  of  estimating  the  severity  of 
an  injury;  the  vigour  of  the  system  generally, 
and  of  the  affected  part ; or,  it  may  be,  the  value 
of  some  particular  kind  of  treatment. 

Reaction  may  itself  call  for  treatment  when 
it  is  either  imperfect  or  excessive.  Stimulation 
is  demanded  in  the  former  case,  for  instance,  by 
warmth,  alcohol,  or  ammonia.  When  reaction 
is  excessive,  nervous  and  circulatory  sedatives 
are  equally  indicated. 

J.  Mitchell  Brcce. 

EECEPTACUIUM  CHYLI.  Diseases  of. 

The  receptaeulum  chyli  is  the  dilated  portion 
forming  the  commencement  of  the  thoracic  duct, 
which  receives  the  contents  of  the  lacteal  vessels 
and  of  the  lymphatics  of  the  lower  limbs  and 
abdomen.  It  lies  deep  in  the  abdominal  cavity, 
about  the  level  of  the  first  lumbar  vertebra.  The 
only  morbid  conditions  which  need  he  specially 
noticed  in  connection  with  it  are  dilatation  and 
rupture.  The  receptaeulum  has  been  found  iu 
rare  instances  enormously  dilated,  and  its  walls 
thickened.  It  has  also  been  known  to  burst  as 
a result  of  this  dilatation,  with  the  escape  of  its 
contents  into  the  peritoneal  cavity,  fatal  perito- 
nitis being  thus  set  up.  It  would  bo  quite  im- 
possible to  diagnose  these  conditions  during  life, 
and  they  have  only  been  discovered  on  post- 
mortem examination. 

Frederick  T.  Roberts. 

RECRUDESCENCE  (re-,  again,  and  cru- 
desco,  I become  fresh). — The  increase  or  exacer- 
bation of  a disease  or  morbid  process,  after  a 
temporary  diminution ; for  example,  of  fever  o* 
inflammation. 

RECTUM,  Diseases  of. — Srxox. : Fr.  Ma- 
ladies da  Rectum  ; Ger.  Krankheiien  des  Afasi- 
darms. 

The  diseases  of  the  rectum  may  be  con- 
veniently discussed  in  the  following  order: — 1. 
Congenital  imperfections  ; 2.  Fistula  in  Ano ; 3. 
Malignant  Disease ; 4.  Polypus  ; 5.  Prolapsus ; 
6.  Stricture ; 7.  Villous  Tumour ; and  8.  Ulcera- 
tion. Other  diseases  connected  with  the  rectum 
will  be  found  discussed  under  special  headings. 
See  Ants,  Diseases  of  ; Defecation,  Disorders 
of ; Hemorrhoids  ; and  Stools,  Characters  of. 

1.  Congenital  Imperfections. — Malforma- 
tions of  the  rectum  may  be  classed  as  follows 
1.  Imperforate  anus,  without  deficiency  of  the 
rectum.  2.  Imperforate  anus,  the  rectum  bema 


RECTUM,  DISEASES  OF.  1327 


partially  or  wholly  deficient.  3.  Anus  opening 
into  a cul-de-sac,  the  rectum  being  partially  or 
•wholly  deficient.  4.  Imperforate  anus  in  the 
male, "the  rectum  being  partially  or  -wholly  de- 
ficient, the  bo-wel  communicating  with  the  urethra 
or  neck  of  the  bladder.  5.  Imperforate  anus  in 
the  female,  the  rectum  being  partially  deficient 
and  communicating  with  the  vagina.  6.  Imper- 
forate anus,  the  rectum  being  partially  deficient, 
and  opening  externally  in  an  abnormal  situation 
i>y  a narrow  outlet.  7.  Narrowing  of  the  anus. 
These  imperfections  can  be  remedied  only  par- 
tially or  completely  by  surgical  operations. 

2.  Fistula  in  Ano. — Description.  — The 
loose  areolar  tissue  around  the  lower  part  of  the 
rectum  is  occasionally  the  seat  of  abscess,  which 
bursts  externally  near  the  anus  ( see  Peri- 
proctitis). But  instead  of  the  part  healing 
afterwards,  like  abscesses  in  other  situations,  the 
walls  contract  and  become  fistulous,  and  the 
patient  is  annoyed  by  a discharge  from  the  open- 
ing. On  introducing  a probe  it  may  pass  through 
a small  opening  in  the  coats  of  the  rectum  into 
the  bowel.  The  case  is  then  called  a complete 
fistula.  When  there  is  no  external  opening,  the 
complaint  is  named  blind  internal  fistula.  The 
external  orifice  is  usually  near  the  anus,  being 
indicated  by  a button-like  growth  with  a central 
opening.  The  abscess  before  bursting  may  have 
burrowed  to  some  distance,  and  the  external 
orifice  may  be  situated  in  the  direction  of  the 
buttock  or  perineum.  Fistula  in  ano  arises  also 
in  other  ways.  It  commonly  originates  in  a 
phlegmonous  abscess,  the  action  of  the  sphincter 
muscle  and  the  disturbance  of  defecation  prevent- 
ing the  closure  of  the  sac.  An  ulcer  just  within 
tho  external  sphincter  sometimes  perforates  the 
bowel,  allowing  the  escape  of  feculent  matter 
into  the  areolar  tissue,  and.  thus  leads  to  abscess. 
Ulceration  induced  by  a pointed  foreign  body, 
as  a fish-bone,  may  also  induce  a rectal  abscess. 
In  all  these  eases  the  inner  orifice  of  the  fistula 
is  just  within  the  external  sphincter.  Fistula 
occurs  also  in  phthisical  subjects,  owing  to  tuber- 
cular ulceration  of  the  mucous  membrane  of  the 
rectum.  The  inner  opening  is  sometimes  found 
higher  up  the  bowel,  and  there  may  be  more 
than  one,  the  sinuses  being  complicated.  An  anal 
fistula  is  an  annoying  complaint.  The  patient  is 
troubled  with  a discharge  which  stains  the  linen, 
and  with  the  escape  of  flatus.  Fistula  is  a dis- 
ease of  middle  life,  more  common  in  meu  than 
in  women. 

Treatment. — The  cure  is  by  a surgical  opera- 
tion. 

3.  Malignant  Disease. — The  coats  of  the 
rectum  are  subject  to  carcinomatous  and  sarco- 
matous disease.  These  growths  invade  the  bowel 
to  a greater  or  less  extent,  contracting  the  pas- 
sage irregularly,  and  sometimes  almost  closing  it. 
Fungoid  growths  also  spring  from  the  coats  and 
project  into  the  bowel,  blocking  the  passage.  The 
degeneration  and  invasion  of  tissues  mayreachthe 
vagina  in  the  female,  or  the  urethra  and  bladder 
in  the  male,  and  may  even  penetrate  the  perito- 
neum. Malignant  disease  may  attack  any  part 
of  the  bowel,  but  generally  appears  in  the  lower 
part,  within  three  inches  of  the  anus.  It  is  liable 
also  to  affect,  though  less  frequently,  the  point 
where  the  sigmoid  flexure  terminates. 


Description. — The  disease  generally  com- 
mences insidiously.  Its  early  symptoms  are 
often  similar  to  those  of  simple  stricture,  and 
the  real  disease  is  not  detected  until  a con- 
siderable change  has  taken  place  in  the  con- 
dition of  the  bowel.  The  patient  is  troubled 
with  flatulency;  has  difficulty  in  passing  his 
motions;  and  as  the  disease  progresses,  ex- 
periences pains  about  the  sacrum,  which  gradu- 
ally increase  in  severity,  and  dart  down  the  limbs. 
The  stools  become  relaxed  and  frequent;  contain 
blood;  and  in  passing  cause  a scalding  pain. 
Often  also  there  is  a thin  offensive  serous  dis- 
charge. Loss  of  retentive  power  may  ensue, 
from  destruction  of  the  sphincter,  or  of  the  nerve 
supplying  the  muscle.  As  the  disease  advances 
the  patient  loses  flesh,  and  exhibits  the  blanched, 
sallow  look,  anxious  countenance,  and  emaciated 
appearance  commonly  observed  in  persons  suffer- 
ing from  malignant  disease.  In  consequence  of 
communications  established  with  the  neighbour- 
ing passages,  liquid  feces  escape  from  the  urethra 
in  the  male  and  vagina  in  the  female ; and  at 
length  the  patient  becomes  hectic  and  exhausted, 
worn  out  by  this  painful  and  distressing  malady. 
Complete  obstruction  may  occur,  and  accelerate 
the  fatal  termination.  There  is  great  variety 
in  the  degree  of  suffering,  and  of  constitutional 
derangement.  The  sufferings  are  in  some  in- 
stances excruciating,  in  others  very  slight.  Ma- 
lignant disease  usually  occurs  in  middle  life,  but 
occasionally  in  the  aged.  It  is  more  common  in 
men  than  in  women. 

Treatment. — Little  can  be  effected  by  reme- 
dies in  this  terrible  disease,  beyond  palliation 
of  the  symptoms,  and  ease  from  pain.  The  gene- 
ral health  may  be  supported  by  tonics.  The 
motions  must  be  kept  soft  by  medicines  or  by 
injections,  and  pain  must  be  alleviated  by  chloral 
or  morphia  in  suppositories  or  subcutaneous  in- 
jections. In  cases  of  obstruction,  as  well  as  in 
cases  of  severe  suffering,  life  may  be  prolonged 
by  colotomy.  Excision  of  the  diseased  bowel 
has  also  been  resorted  to,  but  not  with  much 
success. 

4.  Polypus. — Polypus  of  the  rectum  occurs 
in  two  forms,  the  soft  or  follicular,  and  the  hard 
or  fibrous. 

Description.- — The  soft  polypus  consists  of  an 
agglomeration  of  elongated  follicles,  covered  with 
a distinct  cylindrical  epithelium,  with  a network 
of  small  vessels  ramifying  in  it,  and  a peduncle 
which  varies  in  length.  The  polypus  is  usually 
single,  but  several  may  exist.  In  children  the 
polypus  usually  makes  its  appearance  at  the 
anus  after  a stool,  resembling  a small  strawberry, 
being  soft  in  texture,  granular  on  the  surface, 
and  of  a red  colour.  It  has  a narrow  pedicle 
about  the  size  of  a crowquill,  two  or  three  inches 
in  length,  attached  to  the  wall  of  the  rectum.  It 
produces  no  suffering,  but  causes  a slight  bloody 
discharge.  The  hard  or  fibrous  polypus  occurs 
in  adults,  is  of  a pear-shape,  and  has  a peduncle 
more  or  less  long  and  thick.  It  seldom  bleeds, 
but  occasions  a slight  mucous  discharge ; and 
when  the  peduncle  is  long,  the  growth  pro- 
trudes at  the  anus  after  stool. 

Treatment. — The  treatment  is  very  simple. 
For  the  soft  polypus  a ligature  should  be  tied 
round  the  pedicle.  This  gives  no  pain,  and  the 


RECTUM,  DISEASES  OF. 


1328 

polypus  comes  away  in  two  or  three  days.  It 
Bhould  not  bo  excised  without  the  previous  appli- 
cation of  a ligature,  as  dangerous  bleeding  is 
liable  to  follow.  The  hard  polypus  may  be  re- 
moved by  ligature  or  the  ecraseur. 

5.  Prolapsus.  — In  relaxed  states  of  the 
sphincter  muscle  and  coats  of  the  bowel,  loose 
folds  of  mucous  membrane  are  liable  to  protrude 
and  require  replacement.  This  protrusion  and 
exposure  of  thickened  mucous  membrane,  with 
or  without  internal  haemorrhoids,  has  been  erro- 
neously described  by  writers  as  prolapsus  of  the 
rectum.  In  the  true  prolapsus,  there  is  much 
more  than  an  eversion  of  the  lining  mombrane 
of  the  bowel.  The  gut  is  inverted ; there  is  a 
‘falling-down’  and  protrusion  of  the  whole  of 
the  coats — a change  analogous  to  intussuscep- 
tion, but  differing  from  it  in  the  circumstance 
that  the  involved  intestine,  instead  of  being 
sheathed  or  invaginated,  is  uncovered  and  pro- 
jects externally. 

.^Etiology. — Prolapsus  is  observed  generally 
between  the  ages  of  two  and  four,  but  may  occur 
later  in  life.  In  infancy  it  is  produced  by  pro- 
tracted diarrhoea.  The  straining  efforts  to  pass 
water  in  stone  in  the  bladder  also  give  rise  to 
this  affection  in  young  subjects.  In  adults  the 
descent  results  chiefly  from  a weakened  condition 
of  the  sphincter  and  levator  ani  muscles.  It  is 
more  common  in  women  than  in  men,  arising  in 
the  former  from  the  parts  being  weakened  in 
child-bearing.  Young  subjects  generally  outgrow 
this  complaint  by  the  period  of  puberty ; and 
common  as  is  prolapsus  in  early  life,  it  is  rather 
rare  in  young  grown-up  subjects. 

Description. — The  length  of  bowel  protruded 
varies  from  an  inch  to  six  inches  or  even  more. 
When  not  of  any  great  length,  the  protrusion 
forms  a rounded  swelling  which  overlaps  the 
anus,  at  which  part  it  is  contracted  into  a nock. 
In  its  centre  there  is  a circular  opening  commu- 
nicating with  the  intestinal  canal.  An  inversion 
of  greater  length  forms  an  elongated  pyriform 
tumour,  the  free  extremity  of  which  is  tilted 
forwards  or  to  one  side.  The  protrusion  may 
present  the  usual  florid  appearance  of  the  mucous 
membrane ; or  a violet,  livid  colour  from  conges- 
tion, consequent  upon  contraction  of  the  sphincter. 
The  mucous  surface  is  often  thickened  and  glan- 
dular, and  sometimes  ulcerated  from  friction 
against  the  thighs  and  clothes.  Thickening  of 
the  coats  of  the  bowel  accounts  for  the  difficulty 
in  reducing  the  parts,  and  keeping  them  reduced 
afterwards,  so  often  experienced  in  the  treat- 
ment of  these  cases  in  children,  the  bowel  being 
too  large  to  be  conveniently  lodged  in  its  natural 
position,  and  like  a foreign  body  exciting  the 
action  of  expulsion.  An  atonic  or  relaxed  state 
of  the  sphincter  muscle  is  shown  by  the  facility 
with  which  one  or  two  fingers  can  bo  passed 
through  the  anus  even  in  young  children. 

Treatment. — In  children  irritability  of  the 
bowels  and  diarrhoea  must  be  checked,  and  dis- 
ordered secretions  corrected,  by  suitable  reme- 
dies. In  slight  cases  it  will  be  sufficient  to 
direct  the  nurse  by  steady  compression  to  push 
the  protrusion  back  into  the  pelvis.  The  relaxed 
state  of  the  membrane  may  be  treated  with 
astringent  injections  of  alum,  or  muriated  tinc- 
ture of  iron,  used  cold.  If  the  bowel  slips  down 


when  the  child  moves  about,  a rectal  supporter 
may  be  worn.  When  the  exposed  surface  is 
ulcerated,  it  may  be  painted  with  a solution  of 
nitrate  of  silver,  20  grains  to  the  ounce.  The 
patient  should  bo  made  to  relieve  the  bowels  in 
the  recumbent  posture.  In  adults  the  anal 
aperture  may  be  contracted,  and  the  fall  of  the 
rectum  prevented,  by  the  application  of  the 
mineral  acids  or  of  potassa  fusa  to  the  mucous 
membrane  near  its  junction  with  the  skin.  In 
more  severe  cases  the  complaint  may  be  remedied 
by  operation. 

6.  Stricture.— Stricture  may  be  very  limited 
in  extent,  and  is  then  termed  annular-,  or  the 
contraction  may  include  a portion,  more  or  less 
considerable,  of  the  coats  of  the  bowel.  Above 
the  stricture  the  rectum  is  commonly  dilated  and 
thickened,  owing  to  a general  hypertrophy  of  the 
bowel,  particularly  of  the  muscular  coat.  The 
mucous  coat  at  this  part  is  usually  red  from 
capillary  injection,  and  ulcerated,  and  supplies 
an  abundant  purulent  discharge.  Often  ulcerated 
apertures  lead  to  fistulous  passages,  extending 
some  distance,  and  opening  externally  near  the 
anus  or  in  the  buttock,  and  in  women  in  the 
vagina.  The  stricture  is  usually  at  the  lower 
part  of  the  bowel,  from  an  inch  and  a half  to 
two  inches  from  the  anus.  It  also  occurs  at  the 
point  where  the  sigmoid  flexure  terminates  in 
the  rectum.  The  disease  originates  in  chronic 
inflammation  of  the  mucous  and  submucous  areo- 
lar tissue  of  the  rectum.  Women,  in  whom  the 
disease  is  much  more  common  than  in  men,  have 
ascribed  its  origin  to  a difficult  labour,  during 
which  the  bowel  was  injured.  Strictures  of  the 
rectum  often  also  originate  in  the  contraction 
consequent  upon  the  healing  of  ulcers  or  wounds 
in  the  bowel,  especially  syphilitic.  It  is  a dis- 
ease of  middle  life. 

Description. — The  earliest  symptom  is  habi- 
tual constipation,  with  difficult  defecation  when 
the  motions  are  solid.  As  the  contraction  in- 
creases, the  constipation  becomes  more  obsti- 
nate, and  the  stools  are  diminished  in  calibre, 
and  are  often  voided  in  lumps.  A brown  slimy 
fluid  escapes  with  the  motions,  and  there  is  a 
burning  sensation  after  stool,  and  flatulent  dis- 
tension of  the  colon.  As  the  disease  makes  pro- 
gress and  ulceration  ensues,  the  discharges  be- 
come purulent  and  bloody,  and  the  sufferings  are 
much  increased.  There  is  sometimes  so  copious 
a discharge  as  to  mislead  the  practitioner,  the 
stricture  being  overlooked,  and  the  case  treated 
as  one  of  protracted  diarrheea.  The  appetite  may 
remain  good,  and  the  general  health  may  be  but 
little  impaired  but  in  the  course  of  time  the  de- 
rangement of  the  digestive  functions,  the  irrita- 
tion kept  up  by  the  disease,  and  the  exhausting 
discharges  firing  on  hectic  symptoms.  The 
appetite  fails,  the  body  emaciates,  night-sweats 
become  profuse,  and  the  stricture  directly  or 
indirectly  becomes  the  cause  of  death.  This  is 
sometimes  hastened  by  a lodgment  of  hardened 
feces  or  some  foreign  body  just-  above  the  stric 
t-ure,  so  as  to  block  up  the  passage,  and  occasion 
all  the  symptoms  of  internal  obstruction.  In 
patients  with  stricture  small  flattened  excres- 
cences are  usually  observed  at  the  margin  of  the 
anus.  These  cutaneous  growths  resemble  ad- 
lapsed  external  piles,  except  that  they  are  redder 


RECTUM,  DISEASES  OF. 
in  colour,  and  are  kept  moist  by  the  escape  of  an 
irritating  discharge  from  the  bowel.  In  many 
eases  the  interior  of  the  rectum  is  abundantly 
studded  with  small  excrescences  or  irregular 
growths  of  the  surface,  and  folds  of  the  mucous 
membrane,  the  result  of  chronic  inflammation. 

Diagnosis. — A stricture  in  the  lower  part  of 
the  rectum  can  be  easily  detected  by  tactile 
examination.  It  must  be  borne  in  mind  that 
the  bowel  is  liable  to  be  obstructed  by  disease 
of  the  neighbouring  viscera,  an  enlarged  or  dis- 
placed uterus,  fibrous  tumours  of  this  organ,  an 
ovarian  growth,  pelvic  hsematocele,  excessively 
hypertrophied  prostate,  or  hydatid  tumour  be- 
tween the  bladder  and  rectum. 

Treatment. — The  main  object  in  treatment  is 
to  dilate  the  contracted  parts  sufficiently  for  the 
free  passage  of  the  motions,  and  this  is  to  be 
effected  by  mechanical  means — by  the  passage 
of  bougies.  Means  must  also  be  adopted  to 
relieve  the  irritability  of  the  part,  and  to  ensure 
the  regular  passage  of  soft  evacuations.  Opiate 
suppositories  at  bed-time,  castor  oil,  cod-liver 
oil,  aperient  waters,  and  local  applications  of 
solution  of  nitrate  of  silver,  are  the  remedies 
required.  In  old  inveterate  strictures,  wearing 
out  the  patient’s  strength,  the  writer  has  recom- 
mended colotomy. 

".  Villous  Tumour. — Villous  tumour,  a 
growth  similar  to  that  which  occurs  in  the 
bladder,  springs  from  the  mucous  membrane  of 
the  rectum,  generally  by  a broad  base  ; is  soft  in 
structure  ; and  is  composed  of  a number  of  pro- 
jecting papillae  or  villi.  It  is  innocent  in  charac- 
ter, and  is  not  apt  to  return  after  removal.  Its 
chief  peculiarity  is  a remarkable  disposition  to 
bleed.  The  villous  tumour  occurs  only  in  adults, 
and  is  a rare  disease.  It  should  be  removed  by 
ligature  if  possible,  or  by  the  clamp-forceps. 

8.  Ulceration.  — Description.  — Chronic  ul- 
! ceration  may  arise  from  dysentery,  tubercular 
disease,  or  syphilis.  Dysenteric  ulcers  are  exten- 
sive, and  occur  to  persons  who  have  been  in 
| tropical  climates,  or  exposed  to  hardships,  and 
deprived  of  proper  nutriment.  The  tubercular 
. ulcer  is  usually  small  in  size,  but  indisposed  to 
. heal.  Syphilitic  ulcers  are  large,  deep,  and  ir- 
regular, and  occur  generally  in  women.  It  is  a 
. question  whether  they  are  due  to  direct  conta- 
gion, the  mucous  membrane  of  the  bowel  be- 
coming inoculated  with  matter  from  sores  on  the 
vulva,  or  in  a more  direct  way,  or  whether  the 
ulceration  is  the  result  of  constitutional  disease, 
fhe  chief  symptoms  are  a purulent  discharge 
Tom  the  anus ; motions  loose  and  mixed,  or 
.'oated  with  a slimy  fluid  and  streaked  with 
blood ; soreness  in  defecation  ; and  occasionally 
tenesmus.  The  characters,  position,  and  extent 
»f  ulceration  can  be  ascertained  by  examination 
vith  the  finger  and  with  the  speculum. 
Treatment. — The  treatment  depends  on  the 
ature  and  extent  of  the  disease,  and  upon  the 
onstitutional  condition  of  the  patient.  In  severe 
ises  the  patient  should  be  kept  in  the  recum- 
ent  position.  In  extensive  destruction  of  the 
aicous  surface,  with  free  discharges,  especially 
hen  originating  in  dysentery,  vegetable  astrin- 
mts,  such  as  simaruba  and  krameria,  combined 
ith  mineral  acids  and  opiates,  are  of  great  scr- 
ee in  restraining  the  tenesmus  and  irritating  | 

84 


REFLEX  DISORDERS.  132S 
discharges.  The  nitrate  of  bismuth,  with  mag- 
nesia and  anodynes,  also  affords  great  relief,  and 
the  sulphate  of  copper  with  opium  may  often 
be  given  with  advantage.  When  the  ulceration 
is  consequent  on  constitutional  syphilis  or 
scrofula,  the  remedies  appropriate  to  these  dis- 
eases are  required.  The  local  treatment  consists 
in  the  application  of  weak  solutions  of  nitrate  ot 
silver  or  sulphate  of  copper,  and  anodyne  injec- 
tions with  mucilage,  or  anodyne  suppositories. 

T.  B.  Curling. 

RECURRENT  DISEASES.  — Disease- 
which  have  a tendency  to  return  after  theii 
actual  or  apparent  cure  or  removal,  either  with 
out  any  obvious  cause,  such  as  cancer  or  ague 
or  from  some  very  slight  cause,  such  as  gout  o.' 
rheumatism. 

EECU3EEUT  INSANITY.  See  In 

sanity,  Varieties  of. 

RECURRENT  LAEYN GEAL  NERVE 
Diseases  of. — See  Pneumogasthic  Nerve.  Dis 
eases  of. 

RED  GUM.— An  eruption  of  scattered  red 
pimples  on  the  skin  of  infants  ; more  scientifi- 
cally described  as  lichen  urticatus.  In  infants 
the  eruption  has  obtained  the  name  of  strophu- 
lus, from  its  presumed  association  with  a dis 
ordered  state  of  the  bowels,  accompanied  with 
colic.  The  term  ‘ gum  ’ alludes  to  a resemblance 
between  a pimple  on  the  skin  and  the  exudation 
of  gum  from  a tree  in  the  form  of  a drop,  and  is 
an  illustration  of  the  frequent  reference  to  the 
vegetable  kingdom  in  the  nomenclature  of  skin- 
diseases.  See  Lichen;  and  Strophulus. 

Erasmus  Wilson. 

REDUPLICATION. — -A  doubling;  a term 
generally  used  in  reference  to  the  sounds  of  the 
heart.  See  Physical  Examination. 

REDUX  (Lat.,  returned). — A term  signifying 
the  return  of  certain  physical  signs,  after  their 
temporary  disappearance  in  the  course  of  a dis- 
ease ; usually  associated  with  crepitation  in  pneu- 
monia, and  with  friction  in  pleurisy  and  pericar- 
ditis. Redux  signs  are  usually  significant  of  a 
favourable  tendency  in  a disease.  See  Physicai 
Examination. 

REFLEX  DISORDERS.  — These  consti- 
tute a very  varied  group  of  affections,  most  of 
which  are  individually  considered  elsewhere,  in 
separate  articles.  But  it  will  be  useful  here  to 
say  a few  words  concerning  them  as  a group,  in 
order  that  the  mutual  relations  of  many  appa- 
rently discordant  conditions  may  thus  be  set 
forth,  from  the  point  of  view  of  their  origin  or 
pathogenesis. 

Pathology. — The  factors  concerned  in  the 
production  of  a reflex  disorder  are  in  kind  those 
which  are  needful  for  the  production  of  a ‘ reflex 
action’ — though  in  the  former  case  such  causes 
act  for  an  inordinately  long  time,  or  else  with  an 
intensity  which  is  altogether  unusual.  In  each 
case  we  must  have  (a)  afferent  impressions  re- 
sulting from  the  influence  of  a foreign  body  or 
a pathological  state  (such  as  inflammation  or 
ulceration),  acting  as  an  irritant  upon  afferent 


EEFLEX  DISORDERS. 


1330 

nerves,  either  in  some  part  of  their  course,  or  in 
their  peripheric  sites  of  distribution — whether 
such  sites  be  situated  upon  the  external  surface 
of  the  body,  or  upon  some  part  of  one  or  other  of 
the  mucous  surfaces  within  the  body.  Thus  it 
happens  that  the  determining  cause  may  in  some 
cases  be  associated  with  painful  impressions, 
though  in  many  other  instances  such  impressions 
may  be  more  or  less  completely  absent.  Occa- 
sionally mental  emotions  may  take  the  place  of 
peripheric  impressions,  as  inciters  of  abnormal 
reflex  phenomena. 

The  next  essential  factor  ( b ) is  that  the  af- 
ferent impressions  (painful  or  non-painful)  pro- 
duced by  the  irritant  or  pathological  state,  should 
pass  from  the  nerves,  conveying  them  through  a 
related  nerve-centre,  which,  from  one  or  other 
cause,  chances  to  be  in  a state  of  exalted  acti- 
vity; and  thence  ( c ) be  reflected  along  one  or 
other  set  of  efferent  nerves,  so  as  to  produce 
effects  of  this  or  that  order. 

Yaiiieties.— As  efferent  nervesare  distributed 
to  glands,  and  to  muscles  (both  involuntary  and 
voluntary),  reflex  phenomena  may  show  them- 
selves in  one  or  other  of  two  principal  directions 
— that  is,  (1)  by  the  modification  of  the  quan- 
tity Or  quality  of  some  secretion,  or  (2)  by  the 
production  of  spasmodic  contractions  in  certain 
muscles,  either  of  the  involuntary  or  of  the 
voluntary  type.  In  these  ways,  multitudinous 
and  varied  effects  are  apt  to  be  produced  on  dif- 
ferent occasions,  as  may  be  gathered  from  the 
following  brief  illustrations. 

1.  Modified  secretions. — The  morbid  effects 
belonging  to  this  class  of  reflex  disorders  show 
themselves,  for  the  most  part,  by  a diminution 
rather  than  by  an  increase  in  the  amount  of 
the  secretion  of  the  gland  whose  functions  are 
affected,  as  when  irritation  of  some  of  the  abdo- 
minal nerves  leads  to  a suppression  of  the  renal 
secretion,  by  setting  up  some  form  or  mode  of 
inhibitory  influence.  The  action  of  cold  upon 
the  external  surface  of  the  body  in  producing  an 
increased  secretion  of  urine,  is  probably  brought 
aoout  by  an  augmented  determination  of  blood 
to  the  kidneys,  and  not  as  a simple  result  of 
reflex  action.  The  mental  conditions  of  anxiety, 
fear,  or  terror  do,  however,  often  lead  to  an 
increased  secretion  of  urine;  and  the  increased 
secretion  in  these  cases  may  be  brought-  about 
by  simpler  and  more  purely  reflex  influences. 
Again,  precisely  the  same  mental  states  may 
lead  to  an  arrest  of  the  salivary  secretion,  as 
well  as  to  such  an  increase  of  the  intestinal  se- 
cretions as  to  produce  loose  evacuations  or  actual 
diarrhoea.  Other  instances  might  be  included 
under  this  head,  but  they  are  all  of  them  phe- 
nomena whoso  precise  mechanism  is  compara- 
tively obscure.  Still  in  each  case  the  mode  of 
production  of  the  phenomena  would  seem  to 
conform  to  the  type  indicated. 

2.  Muscular  spasms. — The  morbid  effects  be- 
longing to  this  second  class  of  reflex  disorders 
are  also  variable  in  their  occurrence,  and  more 
or  less  uncertain  as  regards  their  precise  me- 
chanism. Still,  reflex  spasms,  set  up  by  some 
contiguous  source  of  irritation,  are  met  -with  not 
unfreqwently  in  the  urethra  and  neck  of  the 
bladder,  in  the  sphincter  of  the  vagina,  or  at  the 
commencement  of  the  oesophagus.  They  may 


also  occur  in  the  bronchi,  or  in  portions  of  the 
intestinal  canal;  likewise  in  the  ureters  or  in 
the  gall-ducts,  during  tho  passage  of  calculi 
along  either  of  them. 

As  an  instance  of  a spasm  engendered  in  in- 
voluntary muscular  fibres,  under  the  influence  of 
a mental  emotion  or  state,  rather  than  a peri- 
pheric irritation,  one  may  cite  the  sudden  con- 
traction of  the  uterus  in  certain  cases  of  abortion 
induced  by  fright,  auger,  or  other  powerful 
mental  emotion.  Again,  acts  of  vomiting  are  pro- 
duced occasionally  by  certain  sights  or  odours. 

In  the  voluntary  muscles  tonic  spasms  of  a 
reflex  character  occur,  especially  in  children  or 
in  females  of  a nervous  temperament,  in  the 
form  of  contractions  of  some  of  the  muscles  of 
the  extremities  more  especially,  though  at  ether 
times  the  muscles  of  the  jaw  or  some  of  the  mus- 
cles of  the  neck  may  be  the  parts  involved.  See 
Spasm. 

Of  infinitely  more  importance,  however,  are 
the  multitudinous  cases  in  which  some  sources  of 
irritation,  either  within  or  on  the  surface  of  the 
body,  occasion,  in  various  more  or  less  obscure 
ways,  through  the  intervention  of  the  great  en- 
cephalic centres,  convulsions  or  fits  of  one  or 
other  variety  ( see  Convulsions  ; and  Epilepsy). 
Here  we  have,  as  a result  of  the  peripheric  irri- 
tation, a whole  series  of  spasms,  partly  tonic  and 
partly  clonic  in  character.  It  is  worthy  of  note, 
too,  that  an  irritant  at  the  surface  of  the  brain, 
in  certain  regions,  is  just  as  potential  as  an  irri- 
tant acting  upon  the  mucous  membrane  of  the 
intestine. 

But  another  class  of  reflex  muscular  spasms 
still  remains,  to  which  an  immense  amount  of 
importance  is  attached  by  some  pathologists, 
namely,  those  which  are  brought  about  through 
the  agency  of  vaso-motor  nerves  acting  upon  the 
contractile  walls  of  1 flood-vessels.  It  is  well 
known  that  under  tho  influence  of  direct  irri 
tation,  vaso-motor  nerves  may  cause  small  ar- 
teries and  arterioles  to  contract  to  an  extreme 
degree,  and  that  this  condition  is  apt  to  be  fol- 
lowed by  one  of  extreme  dilatation  of  these  same 
vessels.  It  is  known  also  that  under  the  in- 
fluence of  emotions  the  calibre  of  the  vessels  in 
certain  parts  of  the  body  is  apt  to  vary  greatly. 
Of  this  we  have  examples  in  the  temporary  pal- 
lor of  the  countenance  produced  by  fright,  and 
in  the  suffusion  of  the  face  and  neck,  from  un- 
natural fulness  of  vessels  of  these  parts,  in  the 
act  of  blushing.  On  the  other  hand  it  is  assumed 
that,  as  a result  of  some  abiding  irritation  in  the 
intestine,  in  the  bladder,  or  in  other  parts,  reflex 
contractions  of  the  arterioles  in  certain  regions 
of  the  spinal  cord  (also  of  an  abiding  character)  ; 
may  be  brought  about,  so  as  more  or  less  com- 
pletely to  annul  the  functions  of  this  particular 
portion  of  the  cord,  and  thereby  ro  lead  to  para- 
lysis of  the  lower  extremities — that  is,  to  para- 
lysis of  the  limbs  chiefly'  in  relation  with  tho 
region  of  the  cord  affected.  This  is  the  generally 
assumed  mode  of  production  of  a so-called  ‘ re- 
flex paralysis.’  Others,  however,  imagine  that,  in 
certain  cases  at  least,  such  a paralysis  may  be 
brought  about  differently — not  by  the  reflex  ac- 
tion producing  a spasm  of  vessels  in  a part  ol 
the  spinal  cord,  but-  by  a spasm  of  die  vessel* 
supplying  the  great  nerves  and  muscles  of  the 


REFLEX  DISORDERS. 

limbs  affected.  The  anaemia,  thus  supposed  to 
be  induced  in  either  case,  is  regarded  as  the 
cause  of  an  ensuing  paralytic  condition.  But  the 
question  as  to  the  probability  of  the  existence 
of  ‘ reflex  paralysis  ’ need  not  be  here  discussed, 
since  the  arguments  for  or  against  the  existence 
of  such  a paralysis  which  are  applicable  to  one 
form  of  it  are  applicable  also  to  another,  and 
these  are  set  forth  in  the  article  Spinal  Coed, 
Special  Affections  of — Reflex  Paraplegia. 

It  is  right  here,  however,  to  add  that  the  late 
Dr.  Meryon  put  forth  an  entirely  different  account 
of  the  origin  of  ‘ reflex  paralysis.’  He  assumed 
that  the  irritating  body  or  process  (that  is, 
an  influence  slight  in  degree,  but  long-continued) 
gave  rise  to  a determination  of  blood  in  related 
portions  of  the  spinal  cord ; that  the  continuance 
of  this  condition  led  to  an  overgrowth  of  con- 
nective tissue ; that  this  overgrowth  caused 
pressure  upon  the  imbedded  nerve-fibres;  and 
i hus  induced  paralysis  in  related  portions  of  the 
body.  This  view  is  throughout  based  upon  po- 
sitions of  which  no  proof  exists  ; and  if  such  a 
mode  of  production  of  paralysis,  in  response  to 
local  irritation,  did  really  obtain,  it  would,  by 
hypothesis,  be  by  the  establishment  of  a per- 
manent lesion,  as  a result  of  which  we  certainly 
should  have  no  right  to  expect  a fluctuation  in 
the  degree  of  the  paralysis,  in  accordance  with 
fluctuations  in  the  amount  or  intensity  of  the 
local  irritation,  or  a comparatively  sudden  ces- 
sation of  the  paralysis  so  occasioned,  sequential 
to  a cessation  of  the  local  irritation.  Yet  these 
are  the  assumed  differential  characteristics  of  a 
paralysis  of  reflex  origin. 

It  does  not  seem  to  be  imagined  by  anyone 
that  a local  irritation  is  capable  of  engendering 
a condition  of  paralysis  by  any  direct  inhibitory 
process.  The  intervention  of  altered  conditions 
of  vaso-motor  nerves  and  of  altered  states  of 
vessels  seems  to  be  postulated  by  all.  Yet  some 
such  direct  influence  may,  perhaps,  be  more  pos- 
sible in  those  related  cases  in  which  the  starting- 
point  or  primary  cause  of  paralysis  is  a mental 
state  rather  than  a peripheric  irritation — that  is, 
in  the  aetiologically  obscure  cases  described  by 
Reynolds  as  paralysis  dependent  upon  idea.  See 
Spinal  Coed,  Special  Affections  of,  No.  9. 

It  is  right  here,  also,  to  mention  a class  of 
phenomena  which  have  some  analogies  to  reflex 
disorders,  that  is,  the  numerous  cases  in  which, 
as  a consequence  of  irritation  in  one  or  other 
region,  pain  is  felt  in  some  more  or  less  distant 
part  of  the  body,  as  when  a stone  pressing  upon 
the  neck  of  the  bladder  causes  severe  pain  at  the 
meatus  urinarius,  or  when  disease  of  the  stomach 
or  of  the  liver  causes  a pain  which  is  felt  in  the 
scapular  region.  H.  Charlton  Bastian. 

REFLEXES,  Spinal. — See  Spinal  Coed, 
Diseases  of;  p.  1458. 

REFRACTION,  Disorders  of.  See  Vision, 
Disorders  of. 

REFRIGERANTS  ( refrigero , I cool). — De- 
finition.— Remedial  agents  which  lower  the 
body-heat,  either  in  health  or  in  disease ; or  which 
»ilay  thirst,  and  impart  a feeling  of  coolness. 

Enumeration. — The  chief  refrigerants  are  : — 


RELAPSING  FEVER.  13S1 
the  whole  class  of  Febrifuges  ; Water ; Ice  ; 
Effervescing  drinks  ; Acids ; and  the  juices  or 
Fruits. 

Action. — As  the  name  implies,  anything  may 
be  ranked  as  a refrigerant  which  lowers  the  body 
temperature,  and  we  may  here  consider  in  how  far 
the  drugs  described  under  Febkifuges  have  the 
property  of  cooling  down  the  healthy  organism. 
Quinine  and  alcohol  have  but  a slight  and  tran- 
sient lowering  effect,  and  salicylic  acid  has  none 
at  all;  and  this  is  readily  explained,  if  we  believe 
that  their  antipyretic  properties  in  fever  de- 
pend on  their  destructive  influence  over  the  pro- 
toplasm of  septic  ferments. 

Refrigerants,  however,  are  popularly  held  to 
be  those  drugs  which  relieve  the  thirst  of  the 
fever-stricken  patient,  by  moistening  his  dry  lips 
and  cooling  his  parched  tongue.  Ice  or  iced 
drinks  manifestly  fulfil  these  indications;  aud 
acids,  which  are  often  the  most  grateful  of  all, 
act  very  efficiently  by  directly  stimulating  the 
salivary  secretion.  R.  Farquharson. 

REGIMEN  (rego,  I govern). — This  word  is 
not  uncommonly  used  as  synonymous  with  hy- 
gienic management.  In  a more  restricted  sense 
it  is  applied  to  the  regulation  of  diet,  both  in 
health  and  disease.  See  Diet  ; and  Personal 
Health. 

REGURGITATION  [re-,  again,  and  g2irgiio, 

I swallow). — This  word  is  technically  applied  to 
the  reversal  of  the  natural  direction  in  which  the 
current  or  contents  flowthrough  a tube  or  cavity 
of  the  body.  Thus  the  food  may  regurgitate 
from  the  stomach  into  the  cesophagus  and 
mouth  ; the  bile  from  the  duodenum  into  the 
stomach;  and  blood  from  the  aorta  or  pulmo- 
nary artery  into  the  ventricles,  from  the  ven- 
tricles into  the  auricles,  or  from  the  heart  into 
the  veins,  when  the  respective  valves  are  incom- 
petent. See  Heart,  Valves  of,  Diseases  of ; and 
Rumination. 

REHME  (Oeynhausen),  in  Germany. — 

Gaseous  thermal  salt  waters.  See  Mineral 
Waters. 

REICHENHALL,  in  the  Bavarian  Alps. 

Common  salt  waters.  See  Mineral  Waters. 

REINERZ,  in  German  Silesia. — Iron 
waters.  See  Mineral  Waters. 

RELAPSE  (re-,  back,  and  labor,  I slip). — 
The  return  of  a disease,  which  has  apparently 
ceased,  during  or  immediately  after  convales- 
cence; or  of  a particular  symptom  in  the  course 
of  a disease.  Relapses  are  well  exemplified  in 
typhoid  fever  and  acute  rheumatism. 

RELAPSING  FEVER.— Synon.  : Famine 
Fever  (Irish  writers);  Fr.  Fievre  a rechute-,  Ger. 
Hungerpcst.  Also  many  other  names,  according 
to  the  localities  where  it  has  prevailed  as  au 
epidemic. 

Definition. — A continued  contagious  fever  ; 
characterised  by  absence  of  eruption,  and  a 
tendency  to  relapse  at  intervals  of  from  five  to 
seven  days,  and  for  an  indefinite  number  of 
times  ; and  generally  occurring  as  an  epidemic. 

All  medical  writers,  from  the  earliest  times 


1332  RELAPSING  FEVER. 


recognise  the  existence  of  a relapsing  form  of 
continued  fever ; hut  this  disease  had  until  recent 
years  been  included  under  the  general  term  ‘ Con- 
tinued fever.’  Even  in  the  great  Irish  famine 
fever  of  1847,  many  of  the  Dublin  physicians  did 
not  sufficiently  distinguish  between  typhus  and 
relapsing  fever ; and  we  find  a statement  often 
made  that  the  fever  relapsed  into  typhus,  or  that 
typhus  relapsed  into  a form  without  spots. 
There  is  no  doubt  that  typhus  and  relapsing 
fever  co-existed  at  the  time  of  the  Irish  famine, 
as  they  have  invariably  done  at  all  times  and 
places  in  seasons  of  great  scarcity. 

Geographical  Distribution-. — Northern  Eu- 
rope seems  to  be  the  favourite  habitat  of  re- 
lapsing fever.  It  has  been  met  with  in  America, 
but  not  as  an  epidemic,  having  been  imported 
from  Europe,  and  not  showing  a tendency  to 
spread.  An  epidemic  outbreak  occurred  at  Pe- 
shawur  in  the  Punjab,  and  also  in  Egypt.  Epi- 
demics have  been  more  common  in  the  British 
Isles  than  elsewhere.  The  most  extensive  epi- 
demics have  arisen  in  Ireland  in  times  of  famine, 
and  extended  thence  to  England  and  Scotland. 
An  epidemic  was  confined  to  Scotland  in  1843, 
and  another  to  London  in  1868. 

JEtiology.  — Predisposing  causes.  — - Males 
suffer  more  from  relapsing  fever  than  females,  in 
the  proportion  of  about  1'5  to  1.  The  disease  is 
most  common  between  the  ages  of  fifteen  and 
twenty-five.  Season  seems  to  have  little  effect, 
hilt  it  appears  to  be  more  prevalent  in  winter  than 
at  other  seasons,  because  the  other  predisposing 
causes  are  more  intense  at  that  time  of  the  year. 
All  the  causes  which  predispose  to  contagious 
zymotics  favour  more  or  less  the  prevalence  of 
relapsing  fever.  The  most  powerful,  however, 
are  scarcity  of  food,  overcrowding,  and  want  of 
cleanliness. 

Exciting  causes. — Relapsing  fever  is  contagious, 
and  has  always  been  found,  to  spread  in  proportion 
to  the  facilities  for  communication.  It  has  been 
transported  from  long  distances  by  affected 
persons ; attacks  attendants  on  the  sick,  and 
persons  not  predisposed  when  they  are  exposed 
to  its  contagion ; and  may  be  communicated  by 
fomites.  It  seems  to  act  through  but  a short 
distance.  The  period  of  incubation  is  uncertain, 
sometimes  being  apparently  almost  absent,  at 
other  times  stated  to  extend  to  fourteen  or  twenty- 
one  days. 

Famine  and  its  consequences,  or  famine  alone, 
is  a cause  for  the  origin  of  relapsing  fever  dc 
novo.  Some  doubt  the  truth  of  this  statement, 
but  it  is  usually  received  by  writers  upon  the 
disease.  The  evidence  in  favour  of  famine  as  a 
cause  rests  upon  the  1 fact  that  after  it  has  been 
absent  for  many  years,  it  breaks  out  on  each 
occasion  under  precisely  similar  circumstances  ’ 
(Murchison).  The  circumstances  preceding  an 
outbreak  are  invariably  failure  of  crops,  and 
consequent  famine.  Relapsing  fever,  although 
usually  prevailing  among  overcrowded  persons 
in  large  towns,  must  not  he  considered  to  depend 
upon  this  condition,  except  so  far  as  overcrowd- 
ing favours  the  spread  of  contagion.  The  over- 
crowding in  towns  during  an  epidemic  results 
from  the  same  cause  as  that  producing  the  fever ; 
namely,  the  scarcity  of  food  in  the  country,  which 
drives  people  into  the  towns. 


Anatomical  Characters.—  These  are  no! 
marked,  except  where  complications  have  caused 
death.  The  liver  and  spleen  are  both  found  en- 
larged in  all  cases,  especially  the  latter  organ. 
The  digestive  organs  exhibit  nothing  particular, 
except  in  those  cases  where  there  has  been  leng 
deprivation  of  food,  or  where  dysentery  cr 
diarrhoea  has  accompanied  or  preceded  the  dis- 
ease. Certain  small  bodies  termed  spirilla  have 
been  found  in  the  blood  of  patients  suffering 
from  relapsing  fever;  these  bodies  decrease  as 
the  paroxysms  subside,  and  are  absent  during  the 
intermissions.  Spirilla  were  discovered  by  Ober- 
meier,  of  Berlin,  in  1872,  and  the  discovery  was 
further  confirmed  by  Engel  in  1 873.  Spirilla  vary 
considerably  in  number  in  different  cases  and  at 
different  times.  They  are  constant  in  size,  and 
form  spiral  fibrils,  of  which  the  convolutions  are 
extremely  small ; the  spiral  form  remains  after 
all  motion  has  ceased.  Their  movements  are  of 
three  kinds — undulations  passing  along  the  whole 
fibril,  flexions  occurring  at  various  points,  and 
locomotive  movements.  These  variations  some- 
times give  the  bodies  a circular  appearance,  a 
figure-of-8  shape,  or  an  arrangement  in  long 
chains.  Large  colourless  transparent  cells,  ir, 
some  cases  from  two  to  four  times  the  size  ,.f 
colourless  blood-corpuscles,  are  also  found  in  the 
blood  in  relapsing  fever.  See  Spirillum. 

Symptoms. — The  invasion  of  the  disease  is 
usually,  marked  by  rigors,  frequently  of  a trivial 
character,  amounting  only  to  slight  chilliness. 
This  is  followed  by  debility  and  giddiness;  ex- 
treme weakness  is  not  so  marked  as  in  the  eariv 
stages  of  other  forms  of  continued  fever.  There 
is  headache,  followed  after  a few  hours  by  hot 
skin ; the  temperature  rises  to  about  105°  F.,  or 
sometimes,  it  is  stated,  as  high  as  108°;  the  pulse 
rises  to  from  110  to  130,  occasionally  countirg 
140  at  an  early  stage  of  the  disease.  The  tongue 
is  covered  with  a moist  creamy  fur,  which  iu 
severe  cases  becomes  brown  and  dry7  in  the  centre, 
and  in  the  worst  forms  becomes  black  all  over. 
There  is  great  thirst,  as  in  all  febrile  diseases ; 
loss  of  appeti  te ; some  abdomi  nal  tende  rness,  espe- 
cially in  the  epigastric  region ; occasionally  nausea, 
and  more  rarely  vomiting ; the  bowels  are  usually 
confined,  but  in  some  cases  diarrhoea  prevails. 
In  such  cases  the  diarrhoea  is  of  a dysenteric 
character,  and  is  probably  due  to  the  dysen- 
teric tendency  which  usually  prevails  in  time  of 
famine,  when  relapsing  fever  is  prevalent.  The 
skin  generally  presents  a jaundiced  hue;  and 
careful  examination  will  detect  more  or  less  en- 
largement of  the  liver  and  spleen.  There  is  great 
muscular  and  articular  pain.  The  pain  in  the 
back  is  frequently  of  the  most  intense  character. 
Headache  is  more  complained  of  than  in  the 
other  forms  of  fever.  There  is  sometimes,  but 
not  as  a rule,  delirium  towards  the  end  of  the 
first  week.  In  from  five  to  seven  days  from  the 
invasion  of  the  disease,  the  symptoms  suddenly 
subside,  and  the  patient  quickly  becomes  con 
valescent,  being  for  the  time  apparently  well. 
This  convalescence  is  frequently  accompanied  or 
preceded  by  a critical  evacuation  from  the  bowels, 
kidneys,  or  uterus,  or  by  profuse  diaphoresis. 
It  may  be  permanent,  but  more  commonly  the 
patient  remains  well  for  a few  days  or  a week, 
and  then  suddenly  relapses,  and  passes  through  ah 


RELAPSING  FEVEE. 


REMITTENT  FEVEE.  1333 


ihe  symptoms  previously  detailed.  There  may  be 
ji  second  or  a third  relapse,  and  even  a fourth  has 
been  recorded.  At  no  time  during  the  progress 
of  the  disease  is  any  specific  eruption  developed, 
although  on  the  second  or  third  day  a reddish 
mottled  rash  has  been  met  with,  which,  however, 
is  irregular  in  its  appearance,  development,  and 
duration,  and  usually  terminates  in  desquamation. 
Purpuric  spots  have  been  sometimes,  and  suda- 
rnina  very  frequently  met  with. 

Complications. — Pulmonary  complications  are 
not  so  common  in  relapsing  fever  as  in  typhus 
or  enteric  fever.  Bronchitis,  pneumonia,  and 
laryngitis  may  occur,  especially  bronchitis,  but 
these  complications  are  not  severe.  Cardiac, 
arterial,  or  venous  affections  are  rare,  with  the 
exception  of  haemorrhages,  which  must  be  con- 
sidered as  being  connected  with  the  purpuric  ten- 
dency which  usually  prevails  in  times  of  scarcity. 
Nervous  complications  are  more  rare  than  in  any 
other  form  of  adynamic  fever.  Dysentery  and 
diarrhoea  in  somo  epidemics  have  proved  to  be 
most  serious  complications,  and  are  of  frequent 
.eeurrence  whenever  relapsing  fever  prevails. 
Abscess  and  other  suppurative  forms  of  inflam- 
mation are  nor.  common.  In  pregnant  females 
attacked  by  this  fever  abortion  usually  occurs  at 
in  early  stage ; and  premature  labour,  with  death 
of  the  foetus,  and  considerable  danger  to  the 
mother,  in  the  later  stages  of  pregnancy.  Death 
of  the  mother  has  sometimes  happened  from 
post-partum  limmorrhage. 

Diagnosis. — Eelapsing  fever  is  most  likely  to 
be  mistaken  for  other  forms  of  continued  fever, 
and  may  be  confounded  with  the  eruptive  fevers 
in  their  earlier  stages,  especially  small-pox.  It 
differs  from  typhus  in  having  a higher  tempera- 
ture and  quicker  pulse  at  the  outset;  in  the 
absence  of  the  specific  eruption,  of  the  extremely 
heavy  aspect  of  the  patient,  and  of  the  delirium 
jf  typhus  ; in  the  presence  of  extreme  pains  in 
.he  back,  vomiting,  and  jaundiced  tinge  of  the 
?km  ; and  finally  in  the  sudden  cessation  of 
symptoms,  and  the  tendency  to  relapse. 

It  differs  from  enteric  fever  in  the  suddenness 
of  its  onset,  enteric  fever  having  a slow  inva- 
sion ; the  want  of  the  marked  and  extensive 
daily  variations  in  temperature ; the  absence  of 
the  characteristic  abdominal  symptoms  and 
eruption  ; and  the  absence  of  the  localised  iliac 
tenderness  and  the  peculiar  diarrhoea  of  enteric 
fever.  The  tongue  also  serves  to  distinguish  re- 
lapsing from  enteric  fever  ; in  the  latter  having 
a well-marked  red  tip  and  edges,  in  the  former  a 
light  covering  fur.  Eelapsing  fever  at  its  com- 
mencement has  been  confounded  with  small-pox, 
on  account  of  the  extreme  pain  in  the  back  and 
marked  vomiting  which  accompany  both  these 
diseases,  but  the  appearance  of  the  specific  erup- 
tion will  soon  decide  the  question. 

Pbognosis,  Duration,  Terminations,  and 
Mortality. — The  prognosis  of  relapsing  fever  is 
usually  favourable,  tile  mortality  being  low,  from 
1'2  to  2 per  cent,  in  London,  up  to  4 and  4o  per 
cent.,  in  other  places ; the  average  rate  being 
about  4 per  cent.  The  chief  causes  influencing 
the  rate  of  mortality  seem  to  be  the  prior  state 
of  the  patient,  and  the  duration  of  the  disease 
before  medical  relief  is  applied  for.  Purpuric 
symptoms,  severe  dysentery  or  diarrhoea,  serious 


haemorrhages,  or  extensive  chest-complications 
always  indicate  a grave  prognosis. 

Treatment. — The  treatment  of  the  disease 
mnst  be  preventive  and  curative.  The  chief 
promoting  causes  of  the  disease  being  famine 
and  contagion,  the  means  for  prophylaxis  art- 
obvious.  The  active  treatment  must  chiefly  be 
directed  towards  the  relief  of  symptoms,  and 
sustaining  the  strength  of  the  patient.  The  use  ot 
quinine  and  mineral  acids  in  the  earlier  stages, 
and  a plentiful  supply  of  light  and  nourishing 
food  in  the  later,  will  be  found  sufficient.  A 
considerable  amount  of  the  success  of  treatment 
must  depend  upon  the  dieting  of  the  patient.  It 
must  he  kept  in  mind  that  most  of  these  patients 
have  been  in  a state  of  starvation.  It  will  he 
necessary,  therefore,  to  carefully  and  gradually 
increase  the  supply  of  food.  The  food  at  first 
must  he  of  a most  digestible  and  fluid  kind, 
which  may  gradually  he  altered  to  a diet  of  a 
more  solid  and  general  character.  Dysentery  has 
not  infrequently  been  caused  by  the  sudden  feed- 
ing of  patients  suffering  from  relapsing  fever  in 
its  early  stages.  Milk,  light  starchy  puddings 
made  with  milk,  thin  custards,  and  finally  chicken, 
chops,  and  general  diet  will  be  found  the  best 
course  in  this  disease.  Stimulants  may  be  occa- 
sionally requisite,  but  are  seldom  necessary  in 
any  quantity,  or  for  a length  of  time. 

T.  W.  Gremshaw. 


RELAXATION 

RELAXED 


}< 


re-,  again,  and  laxo,  I 


loose). — -These  words  signify  a condition  of 
looseness,  and  are  used  somewhat  vaguely'  in  a 
variety  of  associations.  Thus  we  speak  of  gene- 
ral relaxation,  to  express  a want  of  muscular 
tone  or  vigor.  Local  relaxation  refers  to  a con- 
dition of  abnormal  looseness  of  a part,  as  of  the 
joints,  muscles,  the  uvula,  or  the  throat,  which  are 
then  said  to  be  relaxed.  Another  signification  of 
the  term  relaxation  is  that  of  looseness  of  the 
bowels,  as  in  diarrhoea. 


REMEDY  ( remedium , a cure). — A remedy 
properly  signifies  a therapeutic  agent  which  pos- 
sesses a recognised  influence  in  preventing,  re- 
lieving, or  removing  a particular  morbid  condi- 
tion. Thus  vaccination  is  a remedy  for  small-pox  ; 
quinine  for  ague  ; mercury  and  iodide  of  potas- 
sium for  syphilis ; and  opium  for  pain.  See 
Disease,  Treatment  of. 


REMISSION" 

REMITTENT 


y re-,  again,  and  mitto,  I 


send). — A disease  is  said  to  he  remittent  when  it 
is  characterised  by  periodical  difninutions  of 
symptoms,  followed  by  exacerbations,  as  in  re- 
mittent fever  and  neuralgia.  The  period  during 
which  the  symptoms  are  in  abeyance  is  called  a 
remission.  See  Remittent  Eever. 


REMITTENT  EEVER. — Synon.  ; Bilious 
Remittent ; Fr.  Fievre  remittente ; Ger.  B'osar- 
tiges  Endemisekes  Either. 

Definition. — A paroxysmal  fever  of  malarial 
origin,  in  which  the  paroxysms  do  not  intermit, 
hut  only,  as  the  name  implies,  remit. 

General  Observations. — Remittent  fever  is 
the  most  severe  of  the  class  to  which  it  be- 
longs ; it  is  a more  acute  affection  than  inter- 


REMITTENT  FEVER. 


1334: 

mittent  fever,  more  severe  in  its  symptoms, 
more  rapid  in  its  course,  and  the  direct  mor- 
tality is  ten  times  greater  than  in  any  other 
form  of  malarial  fever.  It  is  commonly  known 
in  India  as  jungle  fever,  because  it  is  in  jungles 
there  at  certain  • seasons  of  the  year  that  it  is 
most  frequently  contracted.  It  often  obtains 
local  names  derived  from  places  notorious  for 
producing  it,  a practice  productive  only  of  con- 
fusion and  misapprehension.  It  is  sometimes 
said  to  hold  a middle  place  between  intermittent 
and  continued  fever;  the  more  nearly  it  resembles 
the  latter,  the  more  dangerous  it  is.  In  other 
words,  the  less  distinct  the  periods  of  remission, 
and  the  longer  the  stage  of  exacerbation,  with 
its  high  temperature,  and  other  disturbances  of 
the  system  which  characterise  that  stage,  the 
greater  is  the  risk  of  such  blood-  and  organic 
changes  as  are  incompatible  with  life. 

Remittent  fever  is  usually  seen  in  its  gravest 
forms  in  hot  climates,  but  has  often  been  very  fatal 
in  malarial  regions  in  temperate  climates,  as  in 
Walcheren.  This,  in  unhealthy  countries,  is  often 
the  first  form  of  fever  that  attacks  new-comers, 
but  such  are  seldom  exposed  to  second  attacks  ; 
in  other  words,  there  is  in  this  type  less  ten- 
dency to  a recurrence  of  the  disease  than  in  the 
intermitting  form.  It  may  be  that  the  extremely 
energetic  character  of  the  symptoms  in  the  remit- 
tent type  is  more  effectual  in  destroying,  alter- 
ing, or  ‘ eliminating  ’ the  poison,  than  the  milder 
intermittent  attack.  In  1865,  out  of  3,199  cases 
of  remittent  fever  admitted  into  the  military 
hospitals  of  Algeria,  only  359  had  second  attacks; 
while  out  of  15,080  cases  of  intermittent  fevers, 
4,295  were  re-admitted  with  the  same  type  of 
fever  ( Statistique  Mcdicale  de  VArmee , 1865). 
The  medical  officers  of  our  army  in  Spain  ob- 
served that  their  men,  on  entering  a malarial 
locality,  generally  suffered  severely  from  the  re- 
mittent form,  while  the  inhabitants  of  the  coun- 
try were  only  affected  by  the  intermittent  type. 
Survivors,  however,  who  remain  in  the  locality, 
become,  like  the  inhabitants,  only  liable  to  the 
milder  type  of  the  disease. 

Aetiology. — Remittent  fever  is  found  when- 
ever its  specific  cause  is  generated  in  sufficient 
concentration  to  cause  it.  This  will  probably 
be  found  to  correspond  with  the  germ  origin  of 
intermittent  fever  (see  Intermittent  Fever; 
and  Malaria).  It  prevails  in  the  malarial  parts 
of  the  Old  and  New  World.  Our  armies  have 
suffered  from  it  both  in  temperate  and  hot  cli- 
mates ; in  the  East  and  West  Indies,  and,  with 
extreme  malignity,  on  the  West  Coast  of  Africa. 
It  is  a common  disease  in  the  malarious  parts  of 
Italy;  and  the  French  army  lias  suffered  much 
from  it  in  Algeria.  It  is  seen  in  the  deltas  of 
great  rivers,  in  the  terrain  of  India,  in  jungles, 
and  in  other  districts  iu  the  same  country  long 
left  uncultivated. 

Anatomical  Characters. — The  morbid  ana- 
tomy of  remittent  fever  is  the  same  as  in  inter- 
mittent fever;  the. difference  is  only  in  degree. 
Congestion  of  the  mucous  coat  of  the  stomach 
and  duodenum,  with  softening,  is  more  marked 
than  in  other  types  of  malarial  fever,  as  -well 
ns  enlargement  of  Brunner  s glands.  The  pig- 
mentary degeneration  of  the  spleen  and  liver  is 
more  intense,  often  extending  also  to  the  brain 


and  spinal  cord,  giving  them  a bronzed  appear- 
ance. 

Symptoms.— Premonitory. — These  are  much 
the  same  as  in  a severe  intermittent. 

Cold  Stage. — The  term  is  hardly  applicable  in 
this  fever ; the  patient  is  sensible  only  of  a slight 
sensation  of  chilliness,  which  very  rarely  passes 
into  rigors.  Nevertheless,  the  thermometer  indi- 
cates a temperature  above  the  normal,  and  in  the 
hot  stage  this  quickly  rises  to  106°,  107°,  and 
sometimes  to  110°  F. 

Hot  Stage. — As  this  develops,  the  whole  sys- 
tem is  profoundly  disturbed.  There  is  the  high 
temperature  already  indicated,  which,  when  fully 
developed  in  the  worst  cases,  approaches  within 
three  degrees  of  that  in  which  the  albuminoid 
constituents  of  the  muscular  tissue  begin  to  co- 
agulate. This  grave  symptom  is  seen  in  its  ut- 
most intensity  in  those  who  have  exposed  them- 
selves, perhaps  after  indulging  in  alcoholic  liquor, 
to  a powerful  sun,  without  reasonable  precau- 
tions. With  this  there  is  necessarily  pungent 
heat  of  skin ; an  intensely  flushed  face ; severe 
headache ; pain  in  the  back  and  limbs  ; quick 
respiration;  a pulse  of  120  or  more;  a foul,  dry, 
and  bile-tinted  tongue ; a sense  of  oppression  at 
the  epigastrium,  with  fulness  and  tension  in  that 
region  ; and  violent  vomiting,  which  brings  do 
relief  to  the  gastric  oppression. 

This  vomiting  is  one  of  the  most  distressing 
symptoms ; the  quantity  of  fluid  vomited  far  ex- 
ceeds what  has  been  taken  by  the  patient : at 
first  it  is  colourless,  then  bilious,  aDd  sometimes 
bloody.  In  pernicious  cases  it  closely  resembles 
the  ‘ black  vomit’  of  specific  yellow  fever.  With 
the  above  symptoms  there  is  an  anxious  counte- 
nance, and  much  restlessness.  In  this  condition 
the  patient  remains  from  six  to  twelve  hours. 
Then  the  more  urgent  symptoms  abate ; the 
temperature  falls  two,  three,  or  more  degrees  ; 
the  skin  becomes  slightly  moist,  far  short  of 
the  profuse  sweating  in  an  intermittent  fever; 
headache  sensibly  diminishes ; and  the  nausea, 
vomiting,  and  epigastric  tension  either  cease  or 
sensibly  abate.  This  is  the  remission,  always 
anxiously  looked  for,  not  only  as  a relief  to  the 
patient,  but  as  a precious  time  for  treatment.  In 
bad  cases,  when  the  other  symptoms  remit  so 
little  as  to  escape  the  notice  of  all  but  an  expe- 
rienced observer,  the  thermometer  wiil  indicate 
at  least  an  attempt  at  a remission.  This  lasts 
from  two  to  twelve  hours ; the  longer  it  is,  the 
more  favourable  is  the  prognosis.  A feeliDg  of 
chilliness  then  returns,  quickly  followed  by  the 
hot  stage,  with  all  its  distressing  symptoms. 
This  is  the  exacerbation  of  systematic  authors, 
which  in  its  turn  gives  way  to  the  remission. 

A morning  remission  in  this  fever  is  so  in- 
variable as  to  be  a point  of  diagnostic  value, 
and  it  is  an  old  rule  in  military  practice  so  to 
time  the  morning  visit  as  to  insure  seeing  the 
patient  while  it  lasts.  The  exacerbation  usuallv 
returns  about  noon,  and  in  severe  cases  lasts  till 
midnight.  Sometimes  two  exacerbations  occur, 
one  at  noon,  the  other  at  midnight,  with  a slight 
evening,  and  more  distinct  morning,  remission. 

The  skin  sometimes  assumes  a yellow  ant, 
and  if  there  be  with  this  anything  resembling 
black  vomit,  a false  diagnosis  of  yellow  fever 
may  be  made.  The  term  ‘ yellow  remittent-  if 


.REMITTENT  FEVER. 


eorrectly  enough  applied  to  such  cases,  but  the 
resemblance  between  these  and  cases  of  specific 
yellow  fever  is  only  superficial. 

Hiccough  is  a troublesome  symptom,  and  if  it 
appears  late  in  the  disease,  and  continues  during 
the  remission,  is  not  a favourable  one. 

The  bowels  are  usually  constipated,  but  in 
pernicious  cases  the  motions  sometimes  become 
very  loose,  bloody  and  offensive,  a condition  of 
evil  omen. 

Jaundice  is  rare,  although,  as  already  said, 
the  skin  has  often  a yellowish  tinge,  more  de- 
pendent on  blood-changes  than  from  an  icteric 
cause. 

Hepatitis. — The  only  cases  of  suppurative  in- 
flammation of  the  liver,  occurring  in  the  course 
of  remittent  fever,  that  have  come  under  the 
writer's  observation,  were  brought  to  Netley 
from  the  Gold  Coast,  where  this  serious  compli- 
cation appears  common. 

Delirium. — Except  in  men  who  have  lived 
imprudently,  and,  in  addition  to  the  poison  of 
malaria,  have  indulged  freely  in  alcohol,  active 
delirium  is  rare.  Like  in  all  malarial  fevers,  the 
symptoms  and  lesions  in  remittents  point  more 
to  implication  of  the  abdominal  organs  than  of 
the  nerve-centres. 

The  urine  is  acid,  scanty  and  high-coloured, 
rarely  albuminous — so  rarely,  that  its  absence 
is  a point  of  diagnosis  between  malarial  remit- 
tent and  specific  yellow  fever.  During  the  hot 
stage  the  secretion  of  urea  is  greatly  increased, 
but  lessened  when  convalescence  sets  in.  In  two 
very  severe  cases  treated  by  the  writer  in  Liclia, 
there  was  profuse  secretion  of  bloody  urine 
throughout,  which  lasted  until  convalescence 
set  in. 

The  adynamic  form  of  remittent  fever  is  one 
of  great  gravity.  It  is  becoming  every  day  more 
apparent  that  in  bygone  years — and  perhaps 
even  now  in  India — cases  of  enteric  fever  have 
been,  and  are,  mistaken  for  malarial  remittent. 
The  diagnosis  is  not  so  easy  as  it  may  appear 
to  those  who  are  familiar  with  enteric  fever  pure 
and  simple,  as  seen  intemperate  climates.  There 
are  cases  of  a mixed  nature,  in  which  a thread 
of  malaria,  so  to  speak,  runs  through  the  symp- 
toms and  obscures  them.  The  term  ‘ typho- 
malarial  ’ has  come  into  use  in  India  to  distin- 
guish this  class  of  cases,  which  are  as  difficult 
to  treat  successfully  as  to  diagnose  clearly. 
French  and  Italian  writers  would  apply  their 
favourite  term  ‘ pernicious  ’ to  such  cases,  which 
are  characterised  from  an  early  stage  by  great 
prostration ; brief  and  uncertain  remissions  ; a 
quick  and  compressible  pulse ; a black  and  dry 
tongue,  the  teeth  being  covered  with  sordes ; 
rapid  respiration  ; epigastric  tension  and  oppres- 
sion ; the  bowels  being  loose,  and  the  motions 
bloody,  with  a disposition  to  haemorrhage  from 
the  mucous  surfaces  generally.  Such  cases  are 
often  fatal,  and  post-mortem  examination,  in 
addition  to  the  common  lesions  of  malarial 
fever,  reveals  ulceration  of  Peyer’s  patches. 

Duration. — The  duration  of  a remittent  fever 
is  from  five  to  fourteen  days  ; but,  as  in  all  mias- 
matic fevers,  it  is  much  affected  by  the  action 
et  remedies.  In  the  worst  forms  death  is  rare 
before  the  eighth  day. 

Diagnosis. — 1.  From  specific  yellow  fever. — 


1335 

Remittent  is  paroxysmal ; yellow  fever  is  con- 
tinued. Remittent  has  a morning  remission ; 
yellow  fever  has  not.  Haemorrhage  from  any 
source  is  exceptional  in  remittent ; in  yellow  fever 
it  proceeds  from  mouth,  nose,  eyes,  ears,  bowels, 
and  even  the  urinary  passages.  Even  in  the 
worst  remittents  albuminous  urine  is  rare  ; it 
is  the  rule  in  yellow  fever.  Over  remittent 
fever  the  power  of  quinine  is  beyond  question  ; 
the  drug  is  powerless  in  yellow  fever.  Death  in 
the  worst  remittents  is  never  seen  before  the 
eighth  dajr;  in  specific  yellow  fever  it  is  common 
on  the  third  day.  The  mortality  rate  in  yellow- 
fever  is  often  forty  per  cent,  of  those  affected., 
that  of  remittent  does  not  in  ordinary  circum- 
stances exceed  four  or  five  per  cent.,  and  is  often 
less.  Yellow  fever  is  portable  and  contagious  ; 
remittent  is  neither.  Yellow  fever  has  a special 
habitat  of  its  own,  and  can  only  exist  as  an 
endemic  disease  in  countries  where  the  mean 
temperature  does  not  fall  below  7-°  F.  Lastly, 
specific  yellow  fever  has  never  established  a 
footing  on  the  shores  of  India,  where  malarial 
remittent  is  an  endemic  disease. 

2.  Enteric  fever,  puro  and  simple,  ought  not  to 
be  easily  confounded  with  remittent  It  is  marked 
off  by  the  difference  in  the  thermometric  curve  : 
in  enteric  fever,  the  rise  of  temperature  is  slow; 
in  remittents  it  attains  its  maximum  in  a few 
hours.  There  is  also  the  characteristic  eruption, 
the  iliac  gurgling,  and  the  peculiar  stools  of 
typhoid,  all  absent  in  remittent.  As  mentioned 
above,  the  diagnosis  is  not  so  easy  when  the  pe- 
culiar symptoms  of  malarial  mask  or  obscure 
those  of  enteric  fever.  Still,  due  observation  of 
the  peculiar  combination  of  symptoms  will  en- 
able careful  practitioners  to  make  a good  prac- 
tical diagnosis,  and  to  regulate  their  treatment 
accordingly.  It  may  seem  unscientific  to  speak  of 
two  specific  diseases  existing  together,  and  as  it 
were  struggling  for  the  mastery  in  the  system. 
The  writer’s  belief  is,  that  in  the  doubtful  cases 
the  real  disease  is  enteric  fever,  the  symptoms 
being  merely  modified  by  malaria,  in  the  same 
way  as  they  are  in  many  other  diseases. 

Prognosis. — This  is  favourable  when  the  re- 
missions are  distinct;  when  each  succeeding  ex- 
acerbation diminishes  in  force ; when  the  skin 
acts  freely;  and  when  the  urine  deposits  the  sedi- 
ment described  as  critical  in  intermittent  fever 
as  the  attacks  pass  off. 

Faint  and  uncertain  remissions ; a tendency 
to  collapse  at  the  close  of  an  exacerbation ; the 
sudden  setting  in  of  dangerous  complications ; 
the  predominance  of  typhoid  symptoms ; sup- 
pression of  urine ; and  a general  disposition  to 
htemorrhage  from  the  mucous  surfaces,  are  all 
signs  of  evil  omen. 

Treatment. — After  a large  experience  in  the 
treatment  of  malarial  fevers  in  some  of  the  most 
unhealthy  regions  in  the  East,  the  writer  desires 
to  place  on  record  the  fact  that  he  has  never 
seen  any  but  disastrous  results  from  treatment 
based  on  the  belief  that  remittent  fever  is  an  in- 
flammatory disease.  The  practitioner  who  keeps 
this  in  view,  and  acts  on  the  principle  of  saving 
power  as  much  as  possible,  will  save  more  lives 
than  the  man  who,  alarmed  by  the  violent  dis- 
turbance of  the  system,  attempts  to  calm  it  by 
lowering  treatment  • or  the  other,  who,  halting 


REMITTENT  FEVER. 


1336 

between  two  opinions,  seeks  to  cure  his  patients 
by  an  incompatible  mixture  of  depressing  and 
conservative  remedies.  With  the  reservations 
already  given  when  treating  of  intermittent 
fever,  no  better  combination  of  a purgative  with 
quinine  can  be  given,  to  begin  the  treatment, 
than  Livingstone’s,  described  in  the  article  on 
that  disease  ; but  whatever  be  the  purgative  se- 
lected, it  should  be  suited  to  bring  away  copious 
bilious  discharges,  which  will  greatly  mitigate 
the  vomiting,  and  it  should  be  combined  with 
quinine.  A good  formula  is  from  3 to  5 grains 
of  calomel,  compound  extract  of  colocynth,  and 
powder  of  scammony,  with  a drop  or  two  of  any 
aromatic  oil ; this  acts  effectually  on  the  whole 
tract  of  the  intestine,  usually  without  nausea  or 
griping,  and  a like  quantity  of  quinine  may  be 
added. 

Two  courses  are  now  open  to  the  practitioner. 
One  is  to  postpone  the  further  administration 
of  quinine  until  the  first  remission.  In  the 
other  the  exacerbation  is  disregarded,  and  qui- 
nine is  given  in  full  and  effective  doses  at  once. 
If  the  first  plan  be  decided  on,  much  may  be  done 
to  promote  the  comfort  of  the  patient,  to  lower 
the  temperature,  and  thus  to  hasten  the  period 
of  remission.  In  strong  men,  when  the  tempera- 
ture is  high,  exceeding  105°  Fahr.,  with  head- 
ache, violent  action  of  the  heart,  rapid  respira- 
tion, oppression  and  restlessness,  drop  doses  of 
the  tincture  of  aconite  every  quarter  of  an  hour 
until  ten  or  twelve  doses  have  been  taken, 
calm  the  patient,  reduce  the  force  of  the  heart’s 
action,  assuage  the  headache,  and  sometimes  in  a 
marked  manner  relievo  urgent  and  distressing 
symptoms.  Used  in  this  way,  and  its  effects 
watched,  aconite  is  a valuable  and  safe  remedy, 
and,  acting  in  the  same  way,  it  is  as  useful  in 
specific  yellow  fever.  It  has  also  this  great  re- 
commendation, if  cautiously  used,  that  it  leaves 
uo  sting  behind. 

When  the  temperature  rises,  as  it  often  does, 
to  105-6°  or  110°,  more  energetic  means  are 
callod  for.  The  patient  should  be  placed  in  a 
batli  at  90°  Fahr.,  which  should  be  cooled  down 
until  the  thermometer  indicates  a temperature 
1-5°  below  the  normal  temperature  of  his  body. 
T ho  effect  of  this  in  calming  the  patient,  reliev- 
ing the  oppression,  and  checking  vomiting,  is 
often  very  striking.  When  removed  from  the 
bath  the  patient  should  be  wrapped  in  a blanket. 
In  adynamic  cases,  where  the  use  of  the  bath  is 
not  deemed  prudent,  the  same  good  effects  may 
be  brought  about  by  spoDging  the  surface  with 
water,  the  temperature  of  which  is  gradually  re- 
duced as  directed  above. 

On  the  first  appearance  of  the  remission  qui- 
nine must  be  given  by  the  mouth,  bowel,  or  skin. 
If  there  is  no  vomiting,  by  the  mouth;  if  the 
remedy  will  not  remain  on  the  stomach,  then  it 
must  be  given  by  bowel  or  skin.  Of  the  incon- 
veniences and  occasional  danger  of  the  latter 
method,  the  writer  has  spoken  in  the  article 
Intermittent  Fever,  to  which  the  reader  is  re- 
ferred. If  the  hypodermic  method  is  ever  justi- 
fiable, in  the  face  of  thedanger  of  inducing  tetanus 
in  the  manner  described,  it  is  in  the  grave  and 
pernicious  forms  of  this  disease,  when  life  is 
threatened,  and  time  presses.  If  the  remedy  is 
given  by  mouth  or  rectum,  at  least  half  a drachm 


should  be  introduced  into  the  system  during  the 
remission.  It  is  in  remittent  fever  of  the  urgent 
kind  under  notice  that  the  Tinctura  WaTburgi 
already  mentioned  (see  Intermittent  Fever)  is 
most  useful.  As  is  now  well  known,  the  active 
ingredient  in  this  remedy  is  quinine;  and,  if 
used  as  directed  in  the  article  referred  to,  it  is 
as  safe  as  it  is  effective.  American  physicians 
appear,  in  treating  this  disease,  to  follow  chiefly 
the  second  plan  mentioned,  and  trusting  to  the 
known  property  of  quinine  to  diminish  and  not 
to  increase  temperature,  they  give  it  during  the 
hot  stage.  The  great  difficulty  here  is  the 
vomiting;  during  the  exacerbation  it  is  almost 
impossible  to  get  anything  to  remain  on  the 
stomach.  It  must  then  be  administered  by 
enema  to  the  extent  of  half  a drachm,  half  the 
quantity  being  given  in  the  same  way  three 
hours  before  the  return  of  the  exacerbations. 
Full  doses  of  from  15  to  20  grains  of  the 
bromide  of  potassium  at  bedtime  tend  to  calm 
restlessness  and  promote  sleep.  The  above 
treatment  must  be  persistently  followed  day  by 
day  until  the  fever  is  overcome. 

It  will  be  seen  from  the  above  remarks  that  ob- 
stinate vomiting  is  not  only  a source  of  extreme 
and  exhausting  distress  to  the  patient,  but  also  one 
of  the  chief  embarrassments  of  the  practitioner. 
The  means  advised  above  are  often  effectual  in 
checking  it,  and  they  may  be  supplemented  by 
the  use  of  ice  when  available,  by  external  stimu- 
lants over  the  stomach,  or  by  the  application  of 
cloths  sprinkled  with  chloroform  over  the  same 
region.  Drop  doses  of  Fowler's  solution  of  ar- 
senic have  been  found  by  Bellot  the  younger 
effective  in  checking  this  distressing  symptom 
in  yellow  fever,  and  the  same  remedy  may  pos- 
sibly be  of  use  in  cases  resisting  other  means. 
But  in  the  writer’s  experience  vomiting,  as  a 
rule,  subsides  with  the  other  symptoms,  when 
the  exacerbations  are  controlled  by  quinine. 
AVhat  was  said,  under  the  head  of  intermittent 
fever,  of  the  daDger  of  pausing  in  the  use  of 
quinine,  to  treat  this  or  thatcomplication.is  most 
emphatically  repeated  here. 

On  the  first  sign  of  collapse  in  any  stage,  re- 
course must  be  had  to  stimulants;  white  wine 
whey  is  an  exeollont  vehicle  for  the  administra- 
tion of  alcohol,  if  that  be  called  for;  good  cham- 
pagne, if  available,  or  the  best  Rhenish  wine 
within  reach,  often  answer  admirably,  and  are 
keenly  relished.  Livingstone's  party  used  bitter 
ale,  and  speak  in  praise  of  it  as  a stimulant 
grateful  to  the  patient.,  ‘ frequently  remaining  on 
the  stomach  when  all  others  are  rejected.’  The 
large  experience  of  such  intelligent  observers  on 
such  a subject  is  worthy  of  respect.  It  is  hardly 
necessary  to  dwell  on  the  necessity  of  sustain- 
ing the  patient  during  the  remission  by  a diet 
adapted  to  the  irritable  condition  of  the  stomach. 
With  one  remark — one  pregnant  remark  by  the 
Rev.  Horace  Waller,  the  fellow-traveller,  friend, 
and  biographer  of  the  illustrious  Livingstone — 
we  shall  close  this  article;  ‘One  thing,  however, 
must  be  strongly  urged : it  is  that  all  notions 
about  not  being  able  to  “ stand  quinine,”  that  it 
“flies  to  the  head,”  and  so  forth,  must  be 
banished  as  utter  nonsense.  In  Africa  everyone 
can  stand  quinine ; there  is  scarcely  a disorder 
there  in  which  it  is  not  positively  required.’  Th* 


REMITTENT  FEVER. 


RENAL  CALCULUS.  1337 


writer  adds  from  his  experience  that  this  is  as 
true  of  malarial  regions  in  other  parts  of  the 
world  as  it  is  of  Africa.  W.  C.  Maclean. 

REMOTE  CAUSES. — This  expression  is 
used  as  a synonym  for  predisposing  causes.  See 
Disease,  Causes  of ; and  Predisposition  to 
Disease. 

RENAL  CALCULUS.— Stnon.:  Nephro- 
lithiasis ; Fr.  Calcul  renal ; Ger.  A 'icrenstein. 

Definition. — A concretion  formed  by  the  de- 
posit of  one  or  more  of  the  solid  constituents 
of  the  urine.  It  differs  only  in  size  from  the 
gritty  particles  called  ‘gravel’ ; it  may  be  single, 
or  there  may  be  many  ; it  may  be  present  in  one 
or  both  kidneys  at  the  same  time  ; and  it  occurs 
at  all  periods  of  life,  from  the  foetus  in  utcro  up 
to  the  extremest  age. 

jEtioloqt. — The  majority  of  urinary  calculi 
are  primarily  formed  in  the  infundibula  or  urini- 
ferous  tubes  of  the  kidney ; and  are  caused  by 
precipitation,  in  the  nascent  state,  of  uric  acid  or 
oxalate  of  lime.  This  precipitation  may  be  due 
to  a real  excess  of  the  insoluble  uric  acid,  or  to 
deficiency  of  the  water  of  the  urine  ; but  the  pre- 
cise form  and  proximate  cause  of  the  deposit  are 
determined  by  the  presence  of  a colloid  matrix, 
composed  of  mucus  or  blood-globules,  or  other 
animal  basis  ( sea  Calculus).  Increase  by  gra- 
dual accretion  goes  slowly  on  until  blockage  of 
the  duct  occurs ; the  calculus  is  then  either 
floated  by  the  urinary  stream  into  the  pelvis  of 
the  kidney  and  onwards  through  the  ureter,  or  it 
becomes  impacted  in  some  part  of  its  transit  and 
develops  into  a full-formed  renal  stone,  which, 
minute  at  first,  may  grow  to  enormous  propor- 
tions. 

Varieties. — By  far  the  most  frequent  variety 
cf  renal  calculus  in  this  country  is  that  composed 
of  uric  acid ; in  the  eastern  counties,  where  stone 
is  most  common,  it  is  very  rare  indeed  to  find  in 
the  adult  any  other  primary  form.  Even  in  chil- 
dren, in  whom  oxalate  of  lime  is  not  uncommon, 
uric  acid  is  the  most  prevalent.  It  is  thought 
by  some  pathologists  that  oxalate  of  lime  forms 
the  first  starting-point  even  of  uric  acid  stones, 
but  this  statement  lacks  proof.  The  sparing 
solubility  of  uric  acid  and  oxalate  of  lime  is  pro- 
bably the  cause  of  their  greater  frequency  in 
calculi ; but  other  agents  may  occasionally  be 
found  to  constitute  the  primary  nucleus  of  renal 
stone,  such  as  cystine,  carbonate  of  lime,  phos- 
phate of  lime,  either  by  itself  or  in  combination 
with  the  ammonio-magnesian  phosphate,  form- 
ing what  is  designated  the  fusible  calculus,  and 
urate  of  ammonia  or  the  mixed  urates.  The 
phosphates  and  urates,  however,  are  more  likely 
to  occur  as  secondary  than  as  primary  deposits. 
Mixed  or  alternating  calculi  are  frequently  met 
with,  in  which  are  seen  alternate  strata  or  layers 
of  uric  acid,  oxalate  of  lime,  and  phosphates,  the 
latter  generally  constituting  the  external  part. 

Pathological  Effects. — The  action  of  a cal- 
culus on  the  structure  and  condition  of  the  kidney 
depends  much  on  its  size.  At  first  it  may  pro- 
duce irritation  and  local  congestion,  possibly 
leading  to  actual  inflammation,  and  even  abscess 
within  or  external  to  the  capsule.  This  may 
Happen  when  the  stone  develops  in  the  tubular 
or  secreting  structure  ; but  when  it  remains  and 


enlarges  in  the  pelvis  of  the  kidney,  chronic  pye- 
litis  is  more  likely  to  ensue,  with  changes  of  an 
atrophic  character.  The  pelvis  dilates;  pressure 
comes  to  be  slowly  exerted  on  the  renal  struc- 
ture, causing  wasting,  until  but  little  secreting 
tissue  is  left ; and  a large  stone  remains,  occupy- 
ing the  pelvis  and  branching  into  the  calyces,  in 
shape  resembling  a cauliflower,  and  with  little 
covering  beyond  the  capsule  of  the  kidney. 

Symptoms. — The  genesis  of  renal  concretions 
is  always  unrevealed  by  symptoms  ; their  reten- 
tion and  development  up  to  a considerable  size 
or  in  great  numbers  may  be  unsuspected  and  un- 
noticed ; and  even  their  transit  and  escape  through 
the  urinary  passages  may  be  painless.  Usually, 
however,  there  is  some  degree  of  lumbar  pain, 
generally  restricted  to  the  side  affected,  spread- 
ing more  or  less  to  the  front  of  the  body,  and  down 
towards  the  groin  and  bladder.  The  pain  is  apt 
to  be  aggravated  by  exercise — especially  by  car- 
riage exercise,  and  it  is  liable  on  such  occasions 
to  become  very  severe ; so  also  w'hen,  from  any 
cause,  it  is  disturbed  in  its  bed,  or  makes  a fruit- 
less attempt  to  enter  the  ureter  (renal  colic). 

"When  a stone  of  some  magnitude  is  passing 
down  the  ureter,  symptoms  of  a very  acute  cha- 
racter usually  ensue.  The  pain  rises  to  intense 
agony  in  the  loin,  and  along  the  course  of  the 
ureter  down  to  the  bladder  and  testicle ; fre- 
quently there  is  sickness  or  vomiting  ; the  patient 
is  bathed  in  warm  perspiration  ; and  he  some- 
times passes  into  a state  of  fainting  and  collapse. 
The  bladder  is  frequently  irritable  ; the  urine 
is  smoky  from  the  presence  of  blood,  or  of 
elongated  clots ; or  almost  pure  blood  escapes. 
These  symptoms  may  come  on  suddenly;  may 
last  a few  hours  or  a few  days ; and  may 
end  as  suddenly  when  the  calculus  reaches  the 
bladder. 

The  changes  produced  in  the  urine  by  renal 
calculus  may  be  very  slight.  Haemorrhage  is 
the  most  common  and  most  characteristic ; some- 
times it  is  in  quantity  enough  to  render  the  urine 
smoky  or  like  porter  ; at  other  times  it  can  only 
be  detected  by  the  microscope.  When  it  exists 
in  any  palpable  amount,  albumen  will,  of  course, 
be  present  too.  Pus,  mucus,  and  epithelium 
corpuscles  will  show  themselves  when  the  cal- 
culus has  produced  some  degree  of  pyelitis.  In 
long-standing  cases  a tumour  may  be  felt  in  the 
situation  of  the  kidney.  The  patient  resting  on 
his  back,  and  the  knees  being  drawn  up,  the 
surgeon  with  one  hand  behind  presses  the  kidney 
forwards,  and  with  the  other  in  front  presses 
it  backwards  below  the  margin  of  the  ribs.  He 
may  thus,  in  young  and  thin  persons — aided,  per- 
haps, by  the  administration  of  ether — differen- 
tiate a renal  stone  from  any  of  the  usual  kinds 
of  renal  tumours. 

Diagnosis. — Renal  calculus  may  bo  mistaken 
for  various  diseases : — 1.  Bilious  attacks,  intes- 
tinal colic,  or  perityphlitis.  The  sickness  and 
pain  in  the  flank  are  present  in  all,  but  in  ne- 
phritic colic  the  pain  is  apt  to  be  more  located 
in  the  loin,  although  this  is  by  no  means  always 
so.  The  presence  of  haematuria  will  be  conclu- 
sive. In  typhlitis  and  perityphlitis  there  will  be 
fever  and  local  tenderness.  2.  Obscure  pain 
in  the  back,  due  to  chronic  lumbago  or  neuralgia. 
In  these  conditions  the  pain  is  generally  across 


i 33S  RENAL  CALCULUS. 

the  back,  and  not  unilateral ; it  is  aggravated  by- 
movements  of  the  affected  muscles ; and  there  is 
no  lisematuria  or  other  urinary  complication.  3. 
Cancer  or  other  renal  tumour.  Pain  and  hsema- 
turia  are  characteristic  of  both  stone  and  cancer, 
but  in  calculus  the  health  is  generally  good, 
while  in  cancer  it  is  always  deteriorated.  In 
stone  there  is  seldom  any  tumour,  and  when  it 
does  exist  it  must  be  of  limited  size  and  hard, 
whereas  in  cancer  it  is  diffused  and  may  be  soft. 

Prognosis.  — The  frequent  formation  and 
escape  of  renal  stones  may  continue  for  a great 
many  years  without  any  material  injury  to  the 
general  health.  Even  when  blockage  of  the 
ureter  takes  place,  leading  to  hydronephrosis  and 
atrophy  of  the  organ,  or  to  nephritis  or  peri- 
nephritis with  abscess,  a fair  measure  of  health 
may  be  preserved,  provided  the  other  kidney  is 
in  a healthy  condition.  When  both  organs  are 
affected,  or  when  complications  arise,  such  as 
amyloid  or  tubercular  disease,  or  chronic  pye- 
litis, then  the  health  steadily  deteriorates,  ema- 
ciation proceeds,  with  hectic  and  fatal  exhaus- 
tion. 

Treatment. — -Bearing  in  mind  that  the  large 
majority  of  renal  stones  are  composed  of  uric 
acid,  and  that  it  is  not  difficult  to  form  a correct 
diagnosis  on  this  point,  itwill  be  necessary  chiefly 
to  consider  the  treatment  of  this  form  of  concre- 
tion. Preventive  treatment  consists  in  a rigid 
limitation  as  to  the  quantity  of  food  taken.  It  is 
customary  to  condemn  a free  use  of  animal  food 
and  highly-seasoned  dishes  ; but  it  should  be 
borne  in  mind  that  stone  prevails  largely  amongst 
the  poor,  who  seldom  can  indulge  in  animal  food 
to  excess,  and  it  is  not  unfrequent  in  countries 
where  no  animal  food  is  taken.  Par  more  impor- 
tant is  it,  both  as  to  food  and  drink,  to  observe  a 
strict  moderation  as  to  the  amount  taken.  In 
this  way  digestion  and  assimilation  will  be  easy 
and  perfect ; crude  matters  will  not  find  their 
way  into  the  bicod;  the  chemical  conversion 
of  uric  acid  will  be  complete  ; and  precipita- 
tion in  the  uriniferous  tubes  will  be  obviated. 
When  the  proclivity  to  uric  acid  calculi  is  de- 
cided, or  when  a small  stone  is  known  to  exist, 
the  free  use  of  diluents  and  alkaline  remedies 
is  undoubtedly  of  importance.  The  waters  of 
Vichy,  Ems,  and  Neuenahr,  taken  freely  at  the 
springs,  with  or  without  baths,  but  with  the 
great  aid  of  change  of  air  and  mode  of  life, 
constitute  the  most  efficient  plan  of  treatment; 
but  it  must  be  admitted  that  in  the  majority  of 
cases  this  good  effect  is  only  transient.  Some 
high  authorities  recommend,  in  preference  to 
the  simple  alkaline  treatment,  the  use  of  those 
saline  aperient  waters  whose  chief  ingredient  is 
sulphate  of  soda,  such  as  Carlsbad  and  Fried- 
richshall;  and  undoubtedly  they  have  a most 
beneficial  action,  by  promoting  digestion  and 
assimilation.  But  as  with  the  alkaline  remedies, 
whether  natural  waters  or  drugs,  so  with  the 
salines,  their  action  is  evanescent.  Leave  them 
off  and  let  the  patient  return,  perhaps  to  a place 
whore  calculus  is  frequent,,  or  to  habits  of  care- 
less living,  or  to  over- work,  and  the  morbid  ten- 
dency will  almost  certainly  recur.  If  there  are 
clear  indications  of  the  actual  presence  of  a renal  I 
stone,  composed  of  uric  acid,  of  moderate  size  and 
recent  date,  the  solvent  treatment,  as  described  | 


RESISTANCE. 

by  Dr.  Wm.  Roberts,  should  be  fully  carried  oat. 
It  depends  for  its  success  on  the  known  solubility 
of  uric  acid  and  its  salts  in  alkaline  solutions  of 
definite  strength,  the  most  efficient  being  about 
60  grains  to  the  pint;  above  and  below  this 
strength  the  solvent  power  diminishes.  The 
patient,  if  an  adult,  should  take  40  to  50  grains 
of  the  acetate  or  citrate  of  potash  in  3 or  4 ozs. 
of  water  every  three  hours  during  the  dav,  and 
once  at  least  in  the  r'ght;  this  plan  should  be 
continued  for  twc  three  months.  During  the 
treatment  the  urine  should  be  frequently  exa- 
mined, and  if  any  approach  to  an  ammoniaea! 
state  should  appear,  the  treatment  must  he  sus- 
pended for  a time.  The  effect  of  the  treatment 
must  be  estimated  by  the  diminution  of  lumbar 
pain,  and  by  the  escape  of  small  calculi;  no  ill- 
effects  are  caused;  seldom  any  indigestion;  and 
no  impairment  of  general  health.  Other  drugs 
have  been  employed  for  the  solution  of  uric  acid, 
such  as  carbonate  of  lithia,  phosphate  of  soda, 
tartrates  and  carbonate  of  potash  and  soda,  and 
carbonate  of  limo.  Some  years  ago  the  writer 
conducted  some  experiments  with  prepared  chalk, 
and  found  that,  when  given  to  the  extent  of  20  to 
30  grains  in  mucilage  and  mint  water,  three  or 
four  times  a day,  it  had  a most  marked  effect  in 
quickly  removing  uric  acid  deposits,  and  it  will 
have  this  effect  even  in  the  febrile  state.  It  did 
not,  in  the  quantities  given,  produce  alkalinity  of 
the  urine,  hut  it  acted  distinctly  as  a diuretic. 

In  the  crisis  of  nephritic  colic,  narcotics  are 
called  for,  in  doses  large  enough  and  frequent 
enough  to  control  the  pain.  If  sickness  is  trouble- 
some, morphia  may  be  administered  subcutane- 
ously, and  if  there  be  vesical  irritation,  by  sup- 
pository. If  the  agony  he  extreme  and  in  pa- 
roxysms, chloroform  may  he  inhaled  occasion- 
ally; while  the  hot  bath,  anodyne  fomentations, 
and  stupes  are  useful  aids  to  relieve  and  soothe. 

Surgical  treatment  of  renal  stone  is  coming 
prominently  into  notice  at  the  present  time. 
Incision  in  the  lumbar  region  and  removal  of 
stone  from  the  kidney  is  as  old  as  Hippocrates; 
and  when  abscess  and  sinus  exist,  leading  to  a 
stone  impacted  in  the  kidney,  or  when  a lumbar 
swelling  is  present  which  is  obviously  caused 
by  a renal  stone,  an  exploratory  incision  for  its 
removal  is  clearly  warranted,  and  has  been  suc- 
cessful in  several  instances.  So,  too,  lies  the  en- 
tire extirpation  of  a kidney  containing  calculi,  as 
well  as  for  other  diseases  of  the  organ.  For  th» 
conditions  which  justify  and  call  for  these  opera- 
tions, and  for  the  steps  to  be  taken  in  their  exe- 
cution, the  records  of  surgery  must  be  consulted. 

Wm.  Cadge. 

RENAL  COLIC.  — Srxox.  : Xcphralgia 

calculo-sa  ; Fr.  Colique  niphretique-,  Ger.  Xieren- 
schmcrzcn. — The  name  commonly  applied  to  the 
symptoms  which  arise  when  a renal  calculus 
either  passes,  or  attempts  to  pass,  down  the 
ureter.  Sec  Renal  Calculus. 

RENAL  DISEASES. — See  Kidneys,  Dis- 
eases of. 

RESISTANCE. — The  sensation  recognised 
by  the  fingers,  of  the  degree  to  which  a part 
yields  or  resists  when  palpation  or  percussion  i» 
being  performed.  Sec  Physical  Examination. 


RESOLUTION. 

RESOLUTION  ( resolvo , I loose). — The  re- 
turn of  a diseased  part  to  its  natural  condition ; 
ehiefly  applied  to  the  process  of  inflammation 
when  it  subsides  gradually,  and  without  the 
occurrence  of  suppuration  or  other  unfavourable 
termination.  See  Inflammation. 

RESOLVENTS  (resolvo,  I loose). — Any- 
thing which. aids  the  absorption  of  effused  pro- 
ducts may  be  included  in  this  class  of  remedies ; 
the  most  efficient  being,  externally,  counter-irri- 
tation and  poultices ; and  internally,  mercury 
and  iodide  of  potassium.  Our  knowledge  of  the 
precise  mode  of  their  action  is  still  very  vague. 
The  subject  of  blisters  and  the  like  is  considered 
under  Counter-irritation.'  It  is  generally  held 
that  mercury  renders  fibrin  less  cohesive ; and 
that  iodide  of  potassium — in  virtue,  probably,  of 
the  free  iodine  which  is  separated  within  the 
blood — has  a special  affinity  for  albuminous 
bodies,  and  for  that  form  of  lowly  organised 
fibrin  which  is  so  commonly  deposited  in  the 
tissues  during  the  more  advanced  stages  of  con- 
stitutional syphilis.  It  is  difficult,  however,  to 
discuss  this  therapeutical  heading  from  a strictly 
scientific  standpoint,  deriving  its  origin  as  it  does 
from  a past  epoch,  when  pathological  science  was 
still  in  its  infancy,  and  when  very  active  modes 
of  treatment  were  held  to  possess  virtues  which 
further  experience  has  not  confirmed.  Free  bleed- 
ing and  blistering,  combined  with  copious  saliva- 
tion, were  held  in  these  days  to  have  a most 
powerful  influence  in  checking  inflammation  and 
removing  its  sequel® ; and  we  are  only  now  learn- 
ing to  assign  to  unaided  nature  the  due  share 
which  she  takes  in  effecting  what  we  are  accus- 
tomed to  call  the  ‘cure’  of  disease. 

R.  Farquharson. 

RESONANCE  ( resono , I sound  again,  echo). 
Resonance  signifies  the  character  of  the  sound 
yielded  on  percussion  over  the  greater  part  of 
the  chest,  and,  within  wide  limits,  of  the  abdo- 
men also.  The  degree  of  resonance  depends  prin- 
cipally upon  the  proportion  of  air  contained  in 
the  underlying  cavities  or  organs.  Vocal  reso- 
nance is  the  voice-sound  transmitted  through  the 
chest  to  the  ear  of  the  auscultator.  It  is  increased 
or  diminished  in  accordance  with  the  physical 
conditions  present  in  the  chest-cavity. 

Hyper-resonance  is  a term  used  to  signify  un- 
due resonance  over  a given  part. 

Deficient  resonance  is  commonly  called  dulness. 
It  is  often  used  with  the  same  comparative  or 
localapplication  as  hyper-resonance.  Sec  Physical 
Examination.  R.  Douglas  Powell. 

RESPIRATION,  Disorders  of. — A due 
performance  of  the  function  of  respiration  is  es- 
sential to  the  well-being  of  the  economy,  and  any 
derangement  of  this  function  is  likely  to  be  fol- 
lowed by  more  or  less  disturbance  of  the  system, 
varying  in  degree  and  gravity,  but  often  of  a 
serious  character.  Moreover,  the  phenomena  re- 
sulting from  such  a derangement  are  commonly 
of  much  significance  with  reference  to  diagnosis, 
prognosis,  and  treatment.  Therefore,  disorders 
affecting  breathing  demand  attentive  and  care- 
ful observation  and  consideration  in  every  case  ; 
while  their  general  study  by  no  means  receives 
the  thought  and  attention  which  its  importance 


RESPIRATION,  DISORDERS  OF.  1533 

emphatically  requires.  In  a short  article  it  will 
be  impossible  to  do  more  than  give  a very 
condensed  summary  of  the  subject,  and  to  sug- 
gest points  for  the  further  consideration  of  those 
who  are  interested  in  it.  The  several  forms  of 
disordered  breathing  associated  with  particular 
diseases  are  indicated  in  their  appropriate  ar- 
ticles. 

Before  considering  the  disorders  of  respiration, 
it  will  be  well  to  call  to  mind  the  following 
points  relating  to  the  performance  of  the  act  in 
health.  The  average  frequency  of  breathing  is  from 
sixteen  to  twenty  per  minute  in  adults,  although 
this  rate  is  easily  disturbed  temporarily  by  va- 
rious physiological  conditions.  The  function  is 
powerfully  under  the  influence  of  the  nervous 
system,  and  it  is  ordinarily  carried  on  either  by 
centric  or  reflex  stimulation,  without  any  con- 
sciousness of  the  act  on  the  part  of  the  indi- 
vidual, and  independent  of  any  voluntary  effort. 
In  ordinary  respiration  scarcely  any  movement 
or  other  sign  of  the  act  is  observable  to  an  on- 
looker, and  the  actual  quantity  of  air  changed 
with  each  breath  is  very  small,  amounting  only 
to  from  16  to  2.)  cubic  inches  ; but  in  this  respect 
also  the  act  is  very  liable  to  be  disturbed,  while 
a person  is  able  voluntarily,  without  any  diffi- 
culty, to  breathe  more  or  less  deeply,  performing 
‘ extraordinary  respiration,’  and  he  may  thus 
change  large  quantities  of  air,  and  call  into  play 
every  part  of  his  lungs.  Remembering  what 
respiration  is  intended  for,  the  conditions  required, 
for  its  proper  performance  in  connection  with  the 
breathing-apparatus  are,  that  there  should  be  a 
sufficient  supply  of  air  suitable  for  the  purpose, 
and  an  adequate  passage  for  its  entrance  and 
exit;  that  there  should  be  enough  healthy  lung- 
tissue;  that  the  blood  should  pass  freely  through 
the  lungs,  and  be  within  certain  limits  of  a 
proper  quality;  that  there  should  be  no  me- 
chanical impediment  to  the  free  working  of  the 
lungs,  especially  if  suddenly  called  upon  to  do 
extra  work ; and  that  the  forces  by  which  the 
respiratory  movements  are  carried  on,  namely, 
the  muscles,  including  the  diaphragm,  and  the 
elasticity  of  the  lungs  and  chest-walls,  are 
equal  to  their  work.  If  the  act  of  breathing 
is  watched  and  investigated,  it  will  be  found  that 
normally  expiration  is  rather  longer  than  in- 
spiration ; but  there  is  no  striking  difference  be- 
tween the  two  divisions,  the  ratio  being  as  twelve 
to  ten  in  males,  fourteen  to  ten  in  females.  More- 
over, the  movements  are  both  thoracic  and  ab- 
dominal, the  former  being  distinctly  made  up  of 
expansion  and  elevation  during  inspiration,  of 
retraction  and  depression  during  expiration,  es- 
pecially when  a full  breath  is  taken.  The  inter- 
costal spaces  in  most  parts,  as  well  as  the 
supra-elavicular  fossae,  seem  to  sink  in  during 
inspiration,  so  as  to  become  more  evident,  this 
being  more  marked  in  proportion  to  the  depth  of 
the  inspiration.  It  will  further  be  noticed  that 
the  precise  movements  differ  in  different  per- 
sons, and  according  to  the  extent  of  respiration. 
The  lower  ribs  and  diaphragm  act  principally  in 
males  and  children  during  ordinary  breathing ; 
in  adult  females  the  respiration  is  upper  costal. 
In  extraordinary  breathing  the  movements  are 
chiefly  upper  thoracic  in  all  persons. 

Respiration  is  markedly  influenced  by  physio- 


1340  RESPIRATION, 

logical  conditions,  such  as  exercise,  diet,  sleep, 
and  various  ethers  ; these  must  he  remembered 
in  considering  its  derangements. 

With  these  introductory  remarks,  the  disorders 
of  respiration  may  now  be  more  conveniently 
studied. 

Aetiology  and  Pathology.— The  numerous 
causes  and  conditions  which  lead  to  disturbances 
of  respiration  can  be  brought  within  well-defined 
groups,  and  it  is  desirable  in  the  first  instance  to 
study  them  from  such  a general  point  of  view. 
This,  however,  only  gives  a superficial  insight 
into  the  subject,  and  does  not  indicate  the  kind  of 
disorder  that  is  produced  by  each  cause,  or  how 
it  acts,  while  many  conditions  act  in  more  ways 
than  one;  and  still  further,  in  any  individual  case 
there  may  bo  more  than  one,  perhaps  several 
causes  at  work,  all  of  which  ought  to  be  recog- 
nised. These  causes  and  conditions  may  be 
summarised  in  the  following  manner,  and  it  will 
be  seen  that  several  of  them  act  indirectly  on  the 
respiratory  process : — 

1.  Conditions  acting  directly  through  the  ner- 
vous system. — These  include: — (a)  Centric  lesions 
in  connection  with  the  brain,  involving  the  re- 
spiratory centre,  either  directly  or  indirectly,  such 
as  injury,  haemorrhage,  or  a tumour.  ( A ) Disease 
or  injury  of  the  upper  part  of  the  spinal  cord, 
paralysing  the  nerves  supplying  the  respiratory 
muscles,  (e)  Functional  nervous  disturbance, 
as  from  mere  nervousness,  emotion,  hysteria, 
tiance,  or  chorea.  ( d ) Conditions  affecting  im- 
mediately the  nerves  concerned  in  respiration, 
either  irritating  or  paralysing  them,  especially 
the  pneumogastric,  recurrent  laryngeal,  or  phrenic 
nerves.  These  nerves  may  be  themselves  dis 
eased,  or  affected  by  a neighbouring  condition, 
such  as  a tumour,  (e)  Reflex  causes,  transmitted 
from  the  skin,  as  when  cold  water  is  dashed 
upon  it;  or  from  organs,  as  the  stomach,  intes- 
tines, or  ovaries.  It  is  important  to  remember 
that  causes  connected  with  the  nervous  system 
frequently  aggravate  disorders  of  breathing  other- 
wise occasioned. 

2.  Abnormal  conditions  of  the  blood. — In  this 
group  are  merely  included  conditions  of  the  blood 
us  a whole,  and  not  any  local  derangement  af- 
fecting the  pulmonary  circulation.  They  are  : — - 
(a)  Deficient  quantity  of  blood,  especially  from  a 
sudden  or  rapid  loss,  (A)  Anaemia  or  hydrsemia. 
(c)  Deficient  aeration.  ( d ) A poisoned,  impure 
state  of  the  blood  in  connection  with  narcotism, 
the  anaesthetic  state,  pyrexia,  the  typhoid  con- 
dition. uraemia,  pyaemia  or  septicaemia,  diabetes, 
and  other  diseases. 

3.  Functional  disorders,  or  organic  diseases, 
connected  with  the  heart. — These  are  common 
sources  of  disturbance  of  breathing  of  various 
kinds,  depending  upon  the  intimate  relation  of 
the  nerves  and  nerve-centres  governing  the  heart 
and  respiratory  organs;  upon  the  effects  they 
produce  as  regards  the  pulmonary  circulation; 
or  sometimes  upon  their  direct  interference  with 
the  movements  of  breathing,  by  exerting  pressure 
upon  the  lungs,  especially  the  left,  upon  the 
left  bronchus,  or  upon  the  chest-walls,  particu- 
larly the  diaphragm.  This  last  cause  is  only 
noticed  in  cases  of  great  enlargement  of  the  heart, 
orof  considerable  pericardial  effusion.  The  breath- 
ing, however,  is  frequently  disturbed  in  connection 


DISORDERS  OF. 

with  disorders  of  cardiac  action ; diseases  of  valves 
and  orifices,  especially  the  mitral  and  tricuspid: 
enlargements  of  the  heart,  particularly  dilata- 
tion ; degenerations  ; congenital  malformations ; 
and  clotting  of  blood  in  the  cavities  of  the 
heart. 

4.  Abnormal  conditions  of  the  air  inhaled.— 
The  physiological  effects  produced  upon  the  re- 
spiratory act  by  various  states  of  the  air  in- 
spired are  well  known.  These  especially  depeid 
upon  its  composition  ; its  temperature  ; and  its 
condensation  or  degree  of  pressure.  From  a 
clinical  point  of  view  these  deviations  have  to 
1c  borne  in  mind,  as  they  are  more  liable  to  be 
induced  in  certain  diseases,  and  may  also  be 
made  available  for  therapeutic  purposes. 

5.  Conditions  affecting  the  apparatus  concerned 
in  the  respiratory  movements. — These  refer  to  the 
chest-walls  and  the  diaphragm,  and  they  in- 
clude : — ( a ) Certain  painful  affections,  causing 
th9  patient  to  limit  or  modify  the  movements, 
such  as  the  early  stage  of  pleurisy,  pleurodynia, 
or  peritonitis.  (A)  Spasm  or  paralysis  of  the 
muscles,  from  any  cause,  (c)  Organic  changes,  as 
undue  softness  or  rigidity  of  the  thoracic  walls, 
cancerous  infiltration,  muscular  atrophy  or  fatty 
degeneration,  acute  or  chronic  inflammation  of 
the  diaphragm. 

6.  Obstruction  involving  the  main  air-passages. 
This  may  be  situated  in  the  mouth,  throat, 
larynx,  trachea,  or  primary  bronchial  divisions, 
and  is  due  to  a variety  of  causes,  which  cannot 
he  discussed  here  further  than  to  state  tint  the 
obstruction  may  depend  upon  pressure  from 
without;  spasm  or  paralysis  of  the  muscles  of 
the  larynx;  some  internal  obstruction,  whether 
from  deposits,  secretion,  foreign  bodies,  or  new 
growths  ; or  organic  changes  in  the  walls  of  the 
tubes,  leading  to  their  constriction. 

7.  Physical  conditions  independent  of  the  respi- 
ratory apparatus,  but  interfering  with  it  in  various 
ways. — These  may  lie  within  the  chest,  as  in  the 
case  of  thoracic  aneurism,  or  a mediastinal  solid 
tumour  or  abscess.  They  act  by  compressing 
the  lungs  or  heart,  obstructing  tubes,  affecting 
nerves,  or  interfering  with  the  moving  apparatus. 
Or  the  cause  of  the  disorder  may  lie  in  the  ab- 
domen,  such  as  excessive  flatulence  or  tympa- 
nites, abundant  fluid  in  the  peritoneum,  enlarged 
organs,  ovarian  tumours,  or  a pregnant  uterus. 
They  act  mainly  mechanically,  by  impairing  the 
movements  of  the  diaphragm.  Breathing  often 
becomes  worse  after  food,  in  consequence  of  dys- 
pepsia leading  to  flatulent  distension. 

8.  Conditions  affecting  the  pleura. — Any  ac- 
cumulation of  air  or  fluid  in  one  or  both  pleural 
sacs  will  necessarily  tend  to  disturb  respiration, 
as  in  pneumothorax,  pleurisy,  hydrothorax,  or 
hsemothorax.  It  acts  mechanically,  and  the  de- 
gree of  disorder  will  depend  on  the  amount  of  the 
collection,  the  rapidity  with  which  it  takes  place, 
the  previous  condition  of  the  lungs,  and  other 
circumstances.  Pleuritic  adhesic  ns  and  agglu- 
tinations also  tend  to  embarrass  respiration  more 
or  less  seriously. 

9.  Morbid  conditions  of  the  lungs. — These  have 
been  left  to  the  last,  and  it  will  be  readily 
understood  that  all  diseases  of  the  lungs  tend 
more  or  less  to  produce  disorders  of  breath- 
ing. At  the  same  time  it  must  not  be  forgotten 


1341 


RESPIRATION, 

that  these  organs  may  be  affected,  even  some- 
what extensively,  under  certain  conditions,  with- 
out any  obvious  respiratory  disturbance.  Pul- 
monary diseases  act  in  various  ways,  of  which  the 
most  important  are  by  affecting  the  pulmonary 
circulation  and  the  amount  of  blood  in  the  lungs  ; 
by  interfering  with  the  entrance  or  exit  of  air 
through  the  bronchial  tubes  ; by  temporarily  dis- 
abling or  permanently  destroying  more  or  less  of 
the  pulmonary  textures;  or  by  influencing  the 
respiratory  act  through  its  forces,  and  especially 
through  the  impairment  or  loss  of  the  elastic 
force  of  the  lungs  required  for  expiration. 

Classification. — The  arrangement  of  the  nu- 
merous forms  of  disordered  respiration  is  by  no 
means  an  easy  matter,  and  may  be  founded  on 
different  plans.  Before  giving  that  which  seems 
to  the  writer  to  be  a practical  arrangement,  he 
would  urge  the  great  importance  of  endeavouring 
to  recognise  in  every  case,  by  due  investigation, 
what  is  the  real  nature  of  the  deviation  from 
normal  breathing,  and  not  merely  to  call  it 
i‘ dyspnoea,’  or  'difficulty  of  breathing.’  More- 
over, it  must  be  remembered  that  there  may  be 
more  than  one  form  of  disordered  respiration  in 
the  same  case. 

The  disturbance  of  breathing  may  be  sudden, 
acute,  or  chronic ; and  its  several  forms  may  be 
included  under  three  main  divisions,  namely  ; — 
1.  Deficient  Respiration.  2.  Dyspnoea  or 
Difficulty  of  Breathing.  3.  Peculiar  Dis- 
orders. 

1.  Deficient  Respiration. — This  compre- 
hends the  following: — 

(a)  Slow  breathing.—  The  frequency  of  the 
respirations  may  be  notably  reduced,  without 
any  other  obvious  disorder.  Or  this  may  be 
associated  with  marked  shallowness  of  the 
movements,  so  that  in  extreme  cases  breathing 
seems  to  have  almost  or  entirely  ceased,  and  can 
scarcely  be  recognised  even  by  the  most  delicate 
tests.  These  deviations  are  observed  in  various 
conditions  or  diseases  affecting  the  nervous  sys- 
tem, such  as  hysteria,  trance,  shock  or  collapse, 
narcotic  poisoning,  and  some  cases  of  cerebral 
disease.  They  are  accompanied  by  impairment 
or  loss  of  consciousness,  real  or  assumed,  and  with 
other  varying  symptoms.  Sometimes  the  breath- 
ing is  slow  but  deep,  and  may  then  be  sighing, 
stertorous,  or  attended  with  flapping  of  the  cheeks 
in  expiration ; this  is  noticed  in  apoplectic  con- 
ditions. These  disorders  of  breathing  do  not 
: obviously  disturb  the  patient. 

( b ) Restrained  breathing. — By  this  is  meant 
that  the  patient  makes  a voluntary  and  conscious 
effort  to  restrain  or  modify  the  act,  because  it 
produces  or  increases  some  painful  or  other  mor- 
|bid  sensation.  It  may  he  obvious  at  once  to 
the  observer,  or  may  only  be  revealed  when  the 
patient  is  made  to  take  a deep  inspiration.  The 
respirations  are  often  increased  in  frequency,  but 
.may  be  below  the  normal.  The  entire  move- 
'ments  may  be  affected,  or  only  those  of  either  the 
, chest  or  the  abdomen,  or  even  only  of  one  side 
if  the  chest.  The  early  stage  of  pleurisy,  peri- 
tonitis, and  angina  pectoris  afford  examples  of 
liseases  causing  this  disorder  of  breathing. 

(c)  Shallow  and  feeble  breathing. — The  most 
striking  feature  in  some  conditions  is  the  ex- 
feme  feebleness  and  limitation  of  the  act  of  re- 


DISORDERS  OF. 
spiration.  This  has  already  been  alluded  to, 
as  noticed  in  some  eases  of  slow  breathing,  but 
the  frequency  is  often  much  above  the  normal, 
and  the  class  of  cases  now  under  considera- 
tion differ  essentially  from  those  previously  men- 
tioned. The  disorder  indicates  gradual  cessation 
of  the  respiratory  functions  and  pulmonary  action, 
becoming  more  and  more  obvious,  and  gradually 
terminating  in  death.  Little  or  no  air  is  changed, 
and  at  last  the  breathing  becomes  a mere  in- 
effectual gasp.  This  form  of  disturbance  is  ob- 
served in  persons  slowly  dying  from  various 
causes;  in  gradual  filling  of  the  air-tubes  in 
fatal  cases  of  bronchitis  ; and  in  cases  of  apoplexy 
or  narcotism.  It  is  often  accompanied  by  rat- 
tling or  gurgling  rales,  due  to  the  presence  of 
fluid  in  the  air-passages,  which  become  by  de- 
grees filled  up.  It  may  follow  certain  forms  of 
dyspnoea. 

( d )  Ineffectual  breathing.— The  derangement 
thus  named  can  only  be  recognised  by  making  the 
patient  attempt  to  draw  a full  breath.  He  may 
then  have  the  sensation  of  an  inability  to  do  this, 
or  to  expand  the  chest  properly.  What  is  more 
important,  however,  is  that  this  impairment  of 
the  respiratory  act  is  often  evident  on  objective 
examination,  when  it  is  seen  that  in  certain 
conditions  the  most  powerful  efforts  to  breathe 
produce  little  or  no  result,  and  the  movements 
are  obviously  more  or  less  ineffectual,  either  as  a 
whole,  unilaterally,  or  locally.  This  may  arise 
from  various  causes,  such  as  paralysis  or  spasm 
of  the  muscles,  rigidity  of  the  chest-walls,  dis- 
tension of  the  lungs  in  emphysema,  pleuritic  and 
other  conditions  interfering  with  their  expansion, 
and  certain  morbid  changes  in  these  organs. 
Ineffectual  breathing  is  frequently  associated 
with  some  form  of  dyspnoea. 

2.  Dyspncea  or  Difficulty  of  Rreathing. — 
WTthout  making  too  marked  a distinction  be- 
tween them,  and  remembering  that  they  may  be 
combined,  there  are  certain  forms  of  disordered 
breathing,  usually  characterised  as  dyspncea, 
which  deserve  separate  recognition. 

(a)  Obstructive  dyspnoea. — This  signifies  that 
there  is  some  obvious  impediment  or  difficulty 
presented  to  the  transmission  of  air  through 
some  part  of  the  air-passages  in  respiration.  The 
nature  and  severity  of  the  disorder  vary  with 
the  seat,  cause,  and  degree  of  obstruction.  Thus 
it  may  he  that  a swollen  tongue,  or  enlarged 
tonsils  or  other  throat-conditions,  block  up  the 
passage  more  or  less  completely,  and  the  patient 
breathes  through  the  nose,  often  with  obvious 
difficulty ; or  if  some  air  passes  by  the  throat,  it 
does  so  with  much  noise,  especially  when  the 
patient  is  asleep. 

The  most  important  form  of  obstructive  dys- 
pncea, however,  is  that  which  is  connected  with 
the  main  air-tube,  and  it  usually  attracts  im- 
mediate attention.  It  may  be  associated  either 
with  the  larynx  or  the  trachea,  and  in  the  for- 
mer case  is  liable  to  exacerbations.  The  gravity 
of  the  phenomena  vary  with  the  degree  of  ob- 
struction, but  they  are  more  or  less  of  the  fol- 
lowing kind.  The  patient  is  usually  conscious 
of  a difficulty  in  the  passage  of  the  air  during 
respiration,  referred  to  some  spot,  which  may 
become  very  distressing ; the  act  of  breathing 
is  usually  more  or  less  laboured,  and  this  may 


1342  RESPIRATION,  DISORDERS  OF. 


culminate  in  a violent  effort  or  struggle  to  breathe. 
The  frequency  of  respiration  is  often  below  the 
normal,  or  at  any  rate  it  is  but  little  increased, 
while  the  relative  length  of  inspiration  and  ex- 
piration is  disturbed.  The  difficulty  may  be 
experienced  only  during  inspiration,  or  during 
both  divisions  of  the  act  of  breathing,  but  is 
usually  most  marked  in  inspiration,  though  occa- 
sionally during  expiration.  Various  noises  are 
produced  by  the  passage  of  the  air  through  the 
narrowed  part,  and  with  experience  these  become 
of  great  importance  as  indicating  the  existence 
and  seat  of  obstruction.  Signs  of  deficient 
aeration  of  the  blood  are  liable  to  accompany 
this  form  of  dyspnoea;  and  in  acute  cr  sudden 
cases,  or  if  the  obstruction  is  very  marked,  there 
is  danger  of  actual  suffocation  or  apncea,  which 
may  occur  rapidly  or  even  suddenly.  Physical 
examination  will  indicate  that  air  does  not  enter 
properly  into  the  lungs,  as  evidenced  especially 
by  recession  of  the  lower  part  of  the  chest,  par- 
ticularly marked  in  children,  in  whom  this  form 
of  dyspnoea  is  likely  to  lead  to  most  serious 
consequences. 

The  obstruction  may  be  situated  lower  down 
in  the  respiratory  tract,  either  in  one  of  the 
main  bronchial  divisions,  or  in  the  tubes  distri- 
buted through  the  lungs,  and  then  the  character 
of  the  disorder  merges  in  that  of  ordinary  dys- 
pnoea, except  that  it  is  likely  to  be  attended 
with  various  noises,  and  that  the  physical  signs 
of  deficient  entrance  of  air  into  one  or  both  lungs 
are  evident.  When  there  are  objective  signs 
of  deficient  entrance  of  air  into  the  lungs,  the 
condition  is  termed  inspiratory  dyspnoea.  This, 
however,  may  also  depend  upon  weakness  of  the 
chest-walls,  and  of  the  inspiratory  muscles,  as  in 
rickets. 

(b)  Excessive  breathing — Ordinary  dyspnoea. — 
Tins  is  the  disorder  usually  met  with  in  various 
degrees,  and  it  implies  that  respiration  is 
carried  on  in  excess.  The  act  may  be  too  fre- 
quent, or  too  powerful,  or  both,  so  that  more 
than  the  ordinary  amount  of  air  is  changed  in  a 
given  time.  The  movements  of  the  chest  are 
more  or  less  free  under  different  circumstances. 
In  severe  cases  the  patient  is  obviously  distressed, 
and  the  act  of  breathing  is  laboured,  and  may  be 
noisy.  Then  the  aloe  nasi  are  seen  to  work ; the 
patient  cannot  speak  except  in  broken  sentences, 
owing  to  want  of  breath ; and  there  may  be  signs 
of  apncea.  This  form  of  dyspnoea  is  familiarly 
illustrated  by  the  effects  of  undue  exercise,  such 
as  running.  Clinically  it  is  associated  in  dif- 
ferent degrees  with  numerous  conditions,  such 
as  nervous  disorders ; fevers  and  other  blood- 
diseases  ; many  cardiac  affections ; conditions 
intei’fering  with  the  action  of  the  lungs;  and 
various  diseases  of  these  organs,  interfering  with 
their  functions,  especially  if  acute. 

(c)  Shortness  of  breath. — While  associated  with 
other  forms  of  dyspnoea,  this  disorder  frequently 
exists  alone  in  various  degrees,  and  it  may  be 
of  much  consequence  in  drawing  attention  to 
disease  of  a serious  character.  Shortness  of 
breath  signifies  that  the  breathing  becomes  more 
or  less  hurried,  and  the  individual  becomes  con- 
scious of  dyspnoea,  after  making  some  effort, 
which  ordinarily  does  not  cause  any  such  effects, 
such  as  walking  ralher  quickly  or  upstairs,  sing- 


ing, coughing,  or  even  taking  a few  deep  breaths 
in  physical  examination  of  the  chest.  When  at 
rest  he  may  feel  perfectly  comfortable,  and  breath- 
ing is  quite  natural,  but  it  is  easily  disturbed  in 
the  manner  above  indicated.  This  disorder  is 
observed  in  general  debility ; very  markedly  in 
anaemia ; in  many  cardiac  conditions,  especially 
degeneration ; in  pleurisy  frequently,  and  in 
many  cases  of  chronic  lung-disease,  such  as 
phthisis  or  emphysema. 

(i d ) Expiratory  dyspnoea. — In  the  form  thus 
designated  the  difficulty  is  experienced  in  expi- 
ration, which  becomes  prolonged  and  laboured, 
in  some  cases  extremely  so,  the  extraordinary 
muscles  of  expiration  being  called  fully  into  play. 
The  relative  lengths  of  inspiration,  expiration, 
and  the  pauses  are  thus  deranged,  and  inspira- 
tion may  become  very  short,  even  a mere  gasp, 
There  is  often  a sense  of  discomfort  or  even 
distress,  and  this  is  liable  in  certain  conditions 
to  be  increased  by  exertion,  or  after  taking  food, 
or  in  certain  postures.  Expiratory  dyspnoea  may 
be  a prominent  feature  in  some  cases  of  obstruc- 
tion of  the  air-tubes ; but  is  essentially  connected 
with  impairment  of  tho  expiratory  elastic  force 
of  the  lungs  in  cases  of  emphysema,  and  of  the 
chest-walls  when  they  are  rigid,  these  two  con- 
ditions often  going  together.  These  conditions 
are  frequently  aided  materially  by  blocking-up 
of  the  bronchi,  as  the  result  of  bronchitis ; or  by 
spasmodic  contraction  of  these  tubes,  in  connec- 
tion with  asthma. 

(c)  Orthopnoea. — This  is  almost  always  com- 
bined with  one  or  more  of  the  other  forms  of 
dyspnoea,  and  the  term  indicates  that  the  patient 
can  only  breathe  at  all,  or  at  any  rate  comfort- 
ably, when  the  body  is  in  a more  or  less  upright 
posture.  In  some  cases  it  is  sufficient  if  he  is 
propped  up  ; in  others  he  has  to  sit  bolt  upright 
in  bed,  or  to  bend  forward ; in  others  still  he 
.is  obliged  to  sit  up  altogether  in  some  kind  cf 
chair,  or  even  to  stand,  this  being  the  only  pos- 
ture in  which  breathing  can  be  carried  on. 
Cases  of  cardiac  disease,  of  acute  pericardial  and 
pleuritic  effusion,  of  acute  pneumonia,  of  asthma, 
and  of  aneurismal  or  other  thoracic  tumours, 
afford  illustrations  of  the  causes  of  this  disorder. 

(f)  Paroxysmal  dyspnoea. — This  may  be  of 
various  kinds,  but  as  its  designation  implies,  it 
signifies  that  the  dyspnoea  comes  on  mainly  or 
entirely  in  fits  or  paroxysms.  It  is  chiefly  ex- 
emplified by  paroxysms  of  laryngeal  dyspncea ; 
by  some  eases  of  cardiac  dyspnoea ; and,  above 
all,  by  fits  of  bronchial  asthma.  See  Asthma. 

3.  Peculiar  Disorders. — It  is  scarcely  prac- 
ticable to  bring  these  under  any  definite  sub- 
divisions, and  it  will  suffice  to  notice  the  very 
curious  and  often  indescribable  disorders  of 
breathing  observed  in  certain  nervous  eases;  the 
interrupted,  jerky,  sighing,  or  yawning  respira- 
tion which  may  be  present  in  various  conditions ; 
and  the  peculiar  disturbance  which  has  been 
named  Cheyne- Stokes  respiration.  This  is  rare, 
but  may  occur  in  connection  with  certain  car- 
diac diseases,  especially  fatty  degeneration;  in- 
jury to  the  brain ; and  cerebral  haemorrhage.  It 
is  characterised  by  the  breathing  at  intervals 
becoming  by  degrees  more  and  more  rapid  and 
deep  up  to  a certain  point ; and  then  subsiding 
in  the  same  gradual  manner,  until  finally  there  is 


RESPIRATION,  DISORDERS  OF. 
a complete  cessation  of  respiration,  -with  a dead 
silence,  the  pause  lasting  a variable  time,  and 
then  the  same  series  of  phenomena  being  re- 
peated. 

Effects. — Many  of  the  disorders  of  breathing 
■which  have  now  been  considered  are  not  attended 
with  any  obvious  effects,  and  are  practically  of 
little  or  no  consequence.  Moreover,  it  must  be 
noted  that  patients  may  become  so  accustomed 
even  to  marked  derangements  of  the  function  of 
respiration,  that  they  are  not  conscious  of  any 
injurious  results  therefrom.  Most  individuals 
under  such  circumstances,  however,  are  conscious 
of  more  or  less  discomfort  or  other  sensations, 
referable  to  some  part  of  the  respiratory  appa- 
ratus. These  are  very  unreliable  and  vague  in 
their  meaning;  but  there  are  effects  which  give 
important  information  in  many  cases,  and  which 
depend  either  upon  the  want  of  due  aeration  of 
the  blood,  or  upon  the  interference  with  the 
general  venous  circulation  which  disorders  of 
breathing  so  frequently  induce.  These  will  vary, 
not  only  with  the  nature  of  the  disorder,  but 
also  with  its  degree,  and  the  rapidity  with  which 
it  is  set  up.  Thus  there  may  bo  actual  suffoca- 
tion, sudden  or  rapid,  or  a condition  approaching 
more  or  less  that  of  asphyxia  or  apnoea  (see 
Asphyxia).  Or  a chronic  state  of  venous  con- 
gestion and  venosity  of  the  blood  may  be  set  up, 
indicated  by  a tendency  to  cyanosis,  with  en- 
largement of  the  superficial  capillaries  ; general 
chilliness  and  coldness  of  the  extremities  ; men- 
tal apathy  or  dulness,  with  headache  and  other 
signs  of  morbid  blood-supply  to  the  brain ; 
general  languor,  laziness,  and  muscular  weak- 
ness ; dyspeptic  disorders;  changes  in  the  urine; 
and  other  phenomena.  In  cases  where  the  respi- 
ratory functions  are  chronically  affected  in  chil- 
dren and  young  persons,  in  such  a way  that  the 
blood  is  never  properly  aerated,  growth  and 
development  are  markedly  impeded.  Patients 
suffering  thus  may  present  a peculiarly  stunted 
appearance.  The  features  tend  to  become  per- 
manently thick  and  coarse ; and  the  ends  of  the 
fingers  and  toes  may  become  clubbed.  In  certain 
forms  of  dyspnoea  the  fat  of  the  body  tends  to 
disappear  ; while  the  muscles  of  respiration  may 
become  hypertrophied  from  excessive  use. 

Treatment. — The  indications  to  be  fulfilled 
in  treating  disorders  of  respiration,  and  the 
measures  by  which  these  are  to  be  carried  out, 
must  obviously  present  considerable  variety  in 
different  cases,  and  it  will  only  be  practicable 
here  to  offer  a few  general  hints  on  the  subject. 
In  the  first  place  no  treatment  whatever  may  be 
called  for  in  some  instances ; while  in  other  cases 
nothing  can  be  of  any  service.  The  primary  in- 
dication should  always  be  to  attend  to  the  cause 
of  the  disorder,  and  by  curing,  removing,  or  alle- 
viating this,  the  disturbance  may  often  be  got  rid 
of  or  materially  diminished.  This  may  be  illus- 
trated by  treatment  directed  to  laryngeal  ob- 
struction, ansemia,  pleuritic  pain  or  effusion, 
bronchitis,  or  cardiac  derangement.  By  improv- 
ing the  condition  of  the  blood  when  ansemia  is 
present,  breathing  is  frequently  much  improved, 
even  when  there  is  some  actual  disease  to  dis- 
turb it,  such  as  phthisis  or  cardiac  disease. 
Attention  to  the  condition  of  the  air  inhaled  is 
m some  cases  of  much  importance,  as  regards  its 


RESPIRATORY  ORGANS.  1343 
purity,  temperature,  degree  of  moisture,  pressure, 
and  other  points.  It  must  be  remembered  that 
some  forms  of  dyspncea  actuallyrequire  an  atmo- 
sphere which  contains  an  excess  of  carbonic  acid. 
Great  advantage  frequently  arises  from  giving 
proper  instructions  to  patients  as  regards  posture, 
avoidance  of  exertion,  diet,  the  act  of  coughing, 
or  even  the  act  of  breathing  itself.  This  is  espe- 
cially important  in  certain  forms  of  paroxysmal 
dyspnoea  ; and  any  cause  which  is  known  to  pro- 
duce any  such  attack  should  be  carefully  avoided. 
Moreover,  the  patient  may  sometimes  be  mate- 
rially assisted  in  the  act  of  breathing  by  mecha- 
nical means.  Not  uncommonly  active  measures 
are  called  for,  for  the  purpose  of  relieving  some 
more  or  less  urgent  form  of  dyspnoea.  For  this 
purpose  various  means  are  indicated  in  different 
cases,  such  as  venesection,  or  local  removal  of 
blood  from  the  chest ; dry-cupping  over  the  chest ; 
the  internal  administration  of  antispasmodios, 
stimulants,  pulmonary  sedatives,  or  other  ap- 
propriate agents ; inhalations  of  different  kinds, 
in  the  form  of  gas,  vapour,  or  smoke;  subcuta- 
neous injections  of  morphia  or  other  active 
drugs;  or  the  application  to  the  chest  of  sina- 
pisms, hot  poultices,  fomentations,  or  turpen- 
tine stupes.  Treatment  may  be  urgently  de- 
manded, directed  to  the  asphyxial  condition 
(see  Asphyxia)  ; and  operative  procedures,  such 
as  laryngotomv  or  tracheotomy,  may  be  called 
for.  in  chronic  cases,  where  the  respiratory 
functions  are  imperfectly  carried  on,  the  condi- 
tions resulting  therefrom  must  he  remembered, 
and  as  far  as  possible  obviated.  Warm  clothing 
is  essential  under  such  circumstances  ; and,  if 
practicable,  a residence  in  a genial  and  warm 
climate  is  often  of  the  greatest  consequence. 

Frederick;  T.  Roberts. 

RESPIRATORY  MURMUR.— The  sound 
heard  on  auscultation  over  the  lungs  in  respira- 
tion. See  Physical  Examination. 

RESPIRATORY  ORGANS,  Diseases  of. 
The  diseases  which  must  be  referred  to  in  this 
article  are  those  involving  the  special  organs 
by  which  the  function  of  respiration  is  per- 
formed. These  organs  comprise,  first,  the  lungs, 
in  which  the  process  of  respiration  takes  place  ; 
secondly,  those  organs  through  which  the  air  is 
brought  into  contact  with  the  blood,  that  is,  the 
air-passages,  and  the  agencies  by  which  the 
movement  of  the  ait  is  effected  ; and  thirdly, 
indirectly,  those  organs  by  which  the  blood  is 
brought  into  contact  with  the  air,  that  is,  the 
heart  and  blood-vessels. 

Frequency  and  Fatality. — General  Etio- 
logy.— Before  enumerating  the  several  morbid 
conditions  of  the  respiratory  organs,  it  will  be 
well  to  indicate  the  importance  of  this  class  of 
diseases— an  importance  which  is  due  partly  to 
the  remarkable  frequency  with  which  they  occur, 
and  partly  to  the  great  fatality  by  which  they 
are  attended. 

On  reference  to  the  returns  of  the  Registrar- 
General  (Annual  Report  for  1880),  we  find  his 
calculations  showing  that  whilst  during  25  years 
(1850-74)  50387  per  million  of  persons  living 
died  of  zymotic  diseases,  no  fewer  than  5840 
died  of  diseases  of  the  respiratory  organs  (in- 


RESPIRATORY  ORGANS,  DISEASES  OF. 


1344 

eluding  phthisis,  and  excluding  the  organs  of  cir- 
culation). This  report  further  shows  that  the 
two  great  classes  of  diseases,  the  zymotic  and 
respiratory,  together  accounted  for  almost  one- 
half  of  all  the  deaths  from  every  cause,  includ- 
ing accidents.  It  must  be  remembered,  further, 
that  these  figures  represent  only  the  number  of 
deaths  from  respiratory  diseases,  and  give  but  a 
rough  indication  of  the  number  of  instances  of 
illness  more  or  less  grave  from  the  same  causes. 

When  we  come  to  investigate  more  closely  the 
nature  of  these  diseases,  it  is  not  difficult  to 
account  for  the  frequency  of  their  occurrence. 
Complicated,  delicate,  and  sensitive  as  the  respi- 
ratory organs  are  in  structure  and  function,  in- 
cluding the  pulmonary  circulation,  and  the  very 
important  changes  in  the  blood  which  occur  in 
the  capillaries  of  the  lungs ; controlled  by  the 
nervous  system,  itself  subject  to  a great  variety 
of  influences  of  a morbific  character;  dependent 
for  the  performance  of  the  healthy  act  of  respi- 
ration upon  the  continual  movement  of  the  me- 
chanism which  admits  air  to  the  lungs,  namely, 
the  chest-walls  and  the  respiratory  passages ; 
affected  also  by  the  temperature  of  the  air, 
subject  ns  it  is  to  great  variety,  by  its  purity, 
liable  as  this  is  to  be  contaminated  by  noxious 
gases  and  impure  particles,  as  well  as  to  be 
damaged  in  its  quality  by  alterations  as  regards 
dryness  and  moisture — it  is  easy  to  understand 
how  the  respiratory  organs  should  become  so  fre- 
quently the  seat  of  disease.  Besides  the  more 
important  influences  to  which  we  have  referred, 
it  will  suffice  to  mention  the  effect  that  is  exerted 
by  such  factors  as  occupation,  age,  sex,  and  cli- 
mate. These  several  aetiological  points  will  be 
found  fully  discussed  in  the  articles  Climate  ; 
and  Disease,  Causes  of.  The  influences  of  inhe- 
ritance and  diathesis  also  contribute  powerfully 
to  the  causation  of  disease  of  the  respiratory 
organs,  more  especially  as  predisposing  elements 
in  the  production  of  phthisis,  although  the  in- 
fluence of  both  can  be  traced  in  certain  other 
morbid  states,  such  as  bronchitis,  asthma,  &c. 

General  Pathology. — The  respiratory  organs 
are  liable  to  the  several  forms  of  injury  and  of 
disease  which  affect  the  other  organs  and  tissues 
of  the  body.  The  injuries,  including  wounds  and 
the  presence  of  foreign  bodies,  are  chiefly  of 
surgical  interest.  The  chief  diseases  are: — 1, 
disturbances  of  circulation,  including  inflamma- 
tion and  its  effects ; 2,  degenerations ; 3,  new 
growths  ; 4,  malformations  and  malpositions  ; o, 
deformities ; and  6,  nervo-muscular  disorders. 

1.  Disturbances  of  the  circulation  are  found 
more  especially  in  the  mucous  membrane  of  the 
air-passages,  in  the  substance  of  the  lungs,  and 
in  the  serous  coverings  of  these  organs.  Thus  we 
have — as  instances  of  inflammation,  specific  or 
otherwise — laryngitis  and  tracheitis  (including 
croup  and  diphtheria);  bronchitis,  in  its  several 
and  varied  forms  ; pneumonia,  and  pleurisy ; 
ulceration,  which  may  occur  in  any  part  of 
the  tract ; and  gangrene,  especially  of  the  lungs. 
Congestion  more  generally  affects  the  lung-sub- 
stance, but  it  is  also  to  be  met  with  in  the 
mucous  membranes  of  the  passages.  Haemor- 
rhage may  occur  from  any  portion  of  the  air- 
passages,  or  from  the  substance  of  the  lung  itself, 
as  the  result  of  congestion,  of  tubercular  disease 


and  its  effects,  of  disease  of  the  heart  and  blood- 
vessels, and  other  causes.  Examples  of  throm- 
bosis and  embolism  may  be  found  in  the  pulmo- 
nary artery  and  veins. 

2.  Examples  of  degenerative  disease  are  pre- 
sented by  the  indurations  which  the  cartilaginous 
tissues  of  the  larynx,  trachea,  and  chest-walls 
undergo ; in  the  degeneration  which  is  traceable 
in  the  air-cells  in  connection  with  emphysema; 
the  pigmentary  and  calcareous  changes  found  in 
the  bronchial  glands  and  lung-tissue ; and  the 
caseous  degeneration  of  inflammatory  and  new 
growths,  such  as  tubercle. 

3.  The  most  important  of  the  new  growths  are 
tubercle;  malignant  disease  in  its  several  forms, 
whether  primary  or  secondary,  extending  from 
surrounding  parts  ; syphilis  in  its  various  stages, 
more  especially  affecting  the  larynx;  and  hyda- 
tids. 

4.  Malformations  and  malpositions  of  the 
lungs  and  air-passages  are  of  rare  occurrence, 
and  are  of  most  importance  when  portions  of  the 
lungs  are  undeveloped,  as  in  atelectasis. 

5.  Deformities  implicate  most  frequently  the 
walls  of  the  chest. 

6.  Lastly,  there  are  the  various  nervo-mus- 
cular affections  comprehended  under  the  names 
of  whooping  cough,  nervous  aphonia,  spasmodic 
cough,  laryngismus  stridulus,  hiccup,  spasmodic 
dyspnoea  including  asthma,  paralysis  of  the  laryn- 
geal muscles,  of  the  walls  of  the  chest,  or  of 
the  diaphragm ; also  pleurodynia  and  intercostal 
neuralgia. 

Although  we  have  thus  spoken  of  the  several 
portions  of  the  respiratory  organs,  and  the  dis- 
eases which  affect  them,  as  having,  so  to  say, 
separate  relations,  we  find  no  such  isolation 
existing  in  the  natural  history  of  their  diseases. 
Thus,  for  example,  we  seldom  find  inflammation 
of  the  lung  in  the  absence  of  an  affection  of  the 
pleura ; whilst  when  the  like  process  affects  the 
air-passages,  it  is  rarely  limited  to  one  part,  such 
as  the  larynx,  trachea,  or  bronchi,  without  in- 
volving others,  and  it  frequently  passes  on  into 
the  substance  of  the  lung  itself.  Again  one 
morbid  process  may  be,  and  is  very  frequently, 
associated  with  others;  thus  inflammation  may 
lead  to  degeneration  of  tissue,  or  vice  versa ; new 
growths  may  give  rise  to  obstruction  of  breath- 
ing, to  inflammation,  and  frequently  to  hemor- 
rhage ; and  nervo-muscular  affections  may  he 
either  the  cause  or  the  effect  of  similar  disorder 
or  disease.  Here,  too,  we  have  to  observe  the 
relation  between  heart-disease  and  disease  of 
the  lungs ; likewise  between  morbid  states  of 
these  organs  and  diseases  of  the  abdominal 
organs. 

General  Symptomatology. — The  special 
symptoms  of  disease  of  the  respiratory  organs 
are  founded  essentially  on  disturbances  which 
prominently  affect  their  functions.  Thus  wo 
have; — 1.  disorders  of  the  respiration,  as  fully 
discussed  in  the  preceding  article.  2.  There  are 
also  obstructions  and  consequent  disturbances  of 
the  circulation,  which  cause  (a)  congestion  of  the 
superficial  or  deep-seated  organs,  including  the 
heart  itself,  the  cavities  of  which  may  become 
dilated  ; and  (6)  haemorrhages,  especially  haemo- 
ptysis. 3.  There  occur  disorders  of  secretions 
and  morbid  products,  giving  rise  to  varieties 


KESPIK  AT  OH  Y OBGANS,  DISEASES  OE. 


of  expectoration  of  more  or  less  importance,  as 
symptomatic  of  different  forms  of  disease  ( see 
If  xpecto ration).  4.  Cough  is  a symptom  sel- 
dom absent,  presenting  many  varieties.  It  is 
sometimes  entirely  referable  to  nervous  disturb- 
ance, and  of  a reflex  character ; whilst  at  other 
times  it  is  the  means  by  which  secretions  are 
expelled,  which  might  otherwise  accumulate,  and 
lead  to  further  embarrassment  and  distress  (see 
Cough).  The  diseases  of  the  respiratory  organs 
are  often  attended  by  local  and  constitutional 
disturbance,  as  are  diseases  of  other  organs, 
such  as  pain,  fever,  wasting,  and  general  debility, 
which  will  vary  according  to  the  nature  of  the 
morbid  process  and  the  part  involved,  as  will  be 
found  fully  described  under  special  headings. 

Physical  Signs. — The  function  of  respiration 
is  so  intimately  associated  with  physical  condi- 
tions and  mechanical  actions,  that  the  respiratory 
organs  afford  special  materials  for  the  applica- 
tion of  the  principles  of  physical  diagnosis.  The 
movements  of  air  and  the  resonance  of  the  voice 
i lirough  the  several  classes  of  air-passages,  and 
into  the  minute  textures  of  the  lungs,  cause 
characteristic  sounds  which  are  readily  recognis- 
able by  the  ear.  These  sounds  become  modified 
by  the  presence  of  disease,  and  afford  charac- 
teristic evidence,  by  which  its  existence  and  na- 
ture may  be  determined.  The  size,  the  shape, 
and  the  movements  of  the  chest-walls  afford  also 
available  evidence  in  physical  diagnosis.  Valu- 
able information  is  afforded  by  a part  that  is  re- 
sonant becoming  dull,  or  by  a part  which  should 
lie  dull  becoming  resonant.  For  further  informa- 
tion ou  these  points  see  Physical  Examination. 

Treatment. — The  diseases  of  the  respiratory 
organs  must  be  treated,  whether  for  prevention 
or  for  cure,  on  those  general  principles  which 
are  applicable  to  the  treatment  of  the  diseases  of 
other  viscera;  with  such  modifications  as  may 
lie  called  for  by  the  special  structure  and  func- 
tion of  the  organs  themselves,  and  by  any  spe- 
cial features  which  disease  affecting  them  may 
present.  These  general  principles,  and  their 
particular  applications,  are  so  fully  set  forth  in 
the  articles  which  treat  of  the  several  diseases 
of  the  different  parts  of  the  respiratory  system, 
that  it  is  not  necessary  to  discuss  them  again  here. 

But  seeing  the  extremo  frequency  with  which 
disease  of  these  organs  occurs,  and  its  grave  re- 
sults, affecting  alike  the  young  and  the  aged,  those 
who  labour  and  those  wiio  pursue  only  pleasure, 
those  who  live  in  cabins  and  those  w7ho  live  in 
castles — for  tequo  pulsat  pede  pauperum  tabernas 
regnmque  turns — we  may  enter  a little  more 
fully  on  the  subject  of  their  prevention. 

Preventive  Treatment. — The  principles  which 
must  guide  us  in  this  direction,  independently 
of  those  which  fall  under  the  head  of  general 
hygiene,  fully  treated  of  in  other  articles,  are : — 

1.  That  a supply  of  uncontaminatcd  air  is 
essential  for  the  prevention  of  lung-disease. 

. Impure  air  is  found  in  the  homes  of  the  poor, 
and  in  their  close  and  crowded  workshops  ; hut 
it  also  abounds  in  the  assembly  room,  the  ban- 
queting hall,  and  such-like  places.  The  remedy 
for  this  evil  will  be  found,  when  people  are 
made  to  feel  that  pure  air  is  as  essential  to 
health  and  life  as  is  unadulterated  food ; and 
when  those  who  construct  houses  are  convinced 

85 


1345 

that  they  have  no  more  essential  duty  to  per- 
form than  that  of  devising  means  ft>r  the  re- 
moval of  impurities,  and  for  the  supply  of  wire 
air  and  pure  water. 

2.  Pure  air,  however,  can  only  be  utilized  by 
freedom  of  the  respiratory  movements.  Many 
employments  and  trades  involve  constrained 
positions,  which,  no  doubt,  are  often  unavoidable ; 
but  even  in  such  cases  a knowledge  of  the  fact 
that  such  positions  are  hurtful,  with  a desire  to 
remedy  the  evil,  will  frequently  suggest  means 
for  its  mitigation.  Like  results  follow  a very 
different  source  of  restriction  on  the  movements 
of  the  chest,  namely,  the  use  of  stays  and  other 
articles  of  dress,  which  not  only  compress  the 
chest- walls  and  prevent  their  free  movements,  bur 
even  displace  the  contained  organs.  Much  harm 
may  also  result  from  a practice  which  is  called 
‘ setting  up’  or  drill  in  the  army.  The  recruit  is 
required  to  ‘throw  back  the  shoulders,’  an  act  by 
which  the  pectoral  muscles  are  made  to  act  as 
constricting  bands.  The  drill  sergeant  aims  at 
expanding  and  throwing  forward  the  chest-wall, 
which  he  does  not  effect  by  merely  throwing 
back  the  shoulders.  This  object  can  only  be 
accomplished  by  teaching  the  person  drilled  to 
take  a deep  inspiration,  and  to  carry  the  chest- 
walls  forward.  The  frequency  with  which  dis- 
eases of  the  lungs,  and  of  the  organs  of  circula- 
tion within  the  chest,  occur  in  the  army  is  a 
recognised  fact,  which  may  in  some  degree  be 
explained  by  this  objectionable  system  of  drill. 

3.  In  the  prevention  of  chest-disease  it  is 
necessary  to  guard  against  vicissitudes  of  atmo- 
sphere and  temperature.  This  fact  is  more  readily 
admitted  than  its  teachings  are  adopted.  Most 
persons  cannot  entirely  avoid  exposure  to  these 
vicissitudes,  but  even  in  such  cases  counteracting 
influences  are  often  practicable,  and  should  al- 
ways be  employed.  Again,  there  are  those  who, 
not  always  from  necessity,  having  respired  heated 
air,  perhaps  for  hours,  suddenly  expose  the  deli- 
cate respiratory  mucous  membrane  to  cold  air. 
or  the  heated  surface  of  the  body  to  a chilling 
draught.  Disease  thus  originated  is  within  the 
knowledge  of  all  of  us,  and  all  know  that  such 
results  might  have  been  obviated  by  forethought. 
Lastly,  there  is  the  necessity  for  protecting  the 
organs  within  the  chest  by  suitable  covering. 
Suitable,  for  example,  as  is  the  dress  worn  by 
ladies  during  the  day,  the  dress  or  rather  the 
undress  of  many  in  the  evening,  would  seem 
almost  designed  to  leave  uncovered  and  unpro- 
tected, both  front  and  back,  as  much  as  possible 
of  tho  space  which  contains  the  lungs.  Many 
instances  of  grave  disease  havo  thus  originated. 
The  remedy  is  not  far  to  seek,  in  resisting  the 
objectionable  rules  of  fashion. 

If  more  attention  were  given  to  obtain  pure 
air  for  respiration,  and  to  secure  freer  action  of 
the  respiratory  organs,  and  if  more  precautions 
were  practised  in  guarding  against  the  effects  of 
atmospheric  changes,  it  is  but  a truism — which 
will  not  lose  in  force  by  being  repeated  here — to 
say  that  diseases  of  the  respiratory  organs  would 
be  infinitely  less  frequent  in  their  occurrence 
than  they  are,  and  less  serious  in  their  results. 

Finally,  if  these  remarks  apply,  as  they  do,  to 
the  strong  and  healthy,  it  is  unnecessary  to  urge 
the  absolute  necessity  of  insisting  upon  theprac- 


1343  RESPIRATORY  ORGANS, 
deal  suggestions  which  they  convey  in  the  case 
of  persons  whose  respiratory  organs  are  either 
constitutionally  delicate  by  inheritance,  or  have 
been  previously  weakened  by  disease.  Such  are 
the  chief  victims  of  chronic  lung-disease  ; and  in 
no  class  of  disease  is  prevention  so  absolutely 
essential.  R.  Quain,  M.D. 

REST.  Therapeutics  of. — In  considering 
rest  as  a therapeutic  agent  it  is  requisite  to  under- 
stand its  nature,  the  indications  for  its  use,  its 
varieties,  and  the  ways  of  employing  it.  There 
are  three  ehief  varieties  : — 1 , Rest  of  the  whole 
body  by  sleep  ; 2,  rest  of  the  mind ; and  3,  local 
rest  of  a diseased  organ  or  inflamed  part.  Of 
any  of  these,  but  of  the  third  in  particular, 
the  practitioner  may  direetly  avail  himself  in 
the  treatment  of  disease.  The  modus  operandi 
of  these  varieties  of  rest  consists  in  allowing  the 
impaired,  perverted,  or  lost  functions  of  a part, 
or  of  the  whole  of  the  human  frame,  to  be  rein- 
stated by  maintaining  the  equilibrium  of  demand 
and  supply.  Hence  it  is  only  by  availing  oneself 
of  the  physiological  properties  of  the  component 
parts  of  the  body,  that  rest  becomes  a thera- 
peutic agent;  and  it  must  be  borne  in  mind  that 
physiological  rest  does  not  mean  another  variety, 
but  rather  that  it  regulates  the  employment  of 
one  or  more  of  these  varieties ; and  that  whether 
applied  to  the  whole  frame,  to  the  mind,  or  to 
a localised  part,  it  is  the  agent,  in  the  guiding 
hands  of  the  practitioner,  which  cures. 

1.  Best  of  the  whole  body  and  mind:  repose 
in  sleep. — This  form  of  rest,  which  is  so  neces- 
sary to  the  well-being  and  the  due  perform- 
ance of  the  several  functions  of  the  human 
body,  accomplishes  two  ends : — First,  the  arrest 
of  further  waste  of  nerve-force  and  tissue- 
metamorphosis — a checking  or  ‘diminution  of 
chemical  action’  (B.  Jones);  and,  secondly,  the 
repair  of  the  used-up  materials.  Rest  of  sleep, 
in  a healthy  man,  does  not  of  itself  restore 
energy  to  the  weary  limbs,  or  vigour  to  the 
exhausted  frame — it  does  but  place  the  patient 
in  the  best  possible  condition  for  nature’s  recu- 
perative powers  to  exercise  their  sway  without 
detraction  or  interruption.  Sleep  maybe  looked 
upon  as  both  a preventive  of  disease,  and  a curative 
means.  The  want  of  sleep  and  its  attendant 
physiological  processes  of  repair  to  the  growing 
tissues  of  an  infant — arising  from  whatever  cause 
it  may,  such  as  teething,  vesical  calculus,  flatu- 
lence, or  worms — becomes  of  itself  adirect cause 
of  arrest  of  development  and  of  wasting  diseases, 
a-nd  lays  the  seeds  of  future  misery  and  early 
death.  A healthy  adult  can  for  a time,  with  im- 
punity, do  without  much  sleep ; but  let  it  never 
be  forgotten  not  only  that  the  want  of  it  acts  as 
a great  predisponent  to  the  infection  of  fever  and 
all  contagious  diseases,  and,  in  fever,  to  diseases 
of  the  brain ; but  also  that  in  any  disease,  if 
carried  too  far,  it  becomes  a cause  of  death. 

2.  Best  of  the  mind:  relaxation. — The  light 
story, Ahe  strains  of  music,  the  change  of  scene 
and  society,  are  familiar  to  all  as  among  the 
many  ways  by  which  rest  is  given  to  the  over- 
worked brain  and  careworn  mind. 

The  waste  of  nerve-force  attendant  on  long  and 
deep  thought,  and  the  many  strains  put  upon  the 
brain  in  these  days  of  emulation  and  hurry,  must 


REST,  THERAPEUTICS  OF. 
be  repaired,  in  like  manner  a3  muscular  waste, 
by  sleep  and  cessation  from  all  mental  work  for 
a time.  In  too  many  cases  has  it  happened  that 
insomnia,  the  first  indication  of  the  disturbance 
of  that  equilibrium  of  the  mental  state  compre- 
hended in  the  term  ‘ 6anity,’  has  ended,  before 
long,  within  the  portals  of  an  asylum,  in  epi- 
lepsy, insanity,  or  idiocy. 

Hence,  ‘in  all  diseases,’  writes  Hilton,  ‘of  no 
matter  what  nature,  of  the  cerebro-spinal  system, 
when  the  evidence  of  disease  is  in  deranged 
function,  it  becomes  our  duty  to  look  upon  and 
treat  the  altered  nerve-substance  as  we  do  con- 
tusion and  laceration  of  soft  parts  and  congestion 
of  organs,  and  to  give  the  brain  absolute  rest,  to 
rely  on  nature’s  power  to  repair  the  injury  or 
disturbance,  and  to  avoid  stimulants  which  excite 
rapid  circulation,  as  much  as  possible.  The  brain 
disturbed  in  its  vital  endowment  becomes  un- 
equal to  even  its  ordinary  duties.  It  recovers 
itself  slowly ; it  then  soon  becomes  fatigued  from 
use  ; and  if  claims  are  made  upon  it  too  soon  after 
injury — that  is,  before  structural  and  physiolo- 
gical integrity  is  re-acquired— the  patient  is  very 
likely  to  suffer  from  serious  disease  of  the  brain. 
The  brain  requires  absence  from  occupation,  or 
rest,  for  its  complete  recovery’,  and  this  should  he 
in  proportion  to  the  severity’  and  duration  of  the 
symptoms  it  presents  ; in  fact,  the  length  of  time 
which  has  been  required  by  nature  for  the  repair 
of  the  injury  must  be  in  proportion  to  the  severity 
of  the  local  injury;  and  the  more  severe  the  in- 
jury the  longer  the  time  required  for  perfect  re- 
covery of  the  functions  of  the  brain.  If  this  prin- 
ciple were  only  adopted  generally  and  the  plan  car- 
ried out,  we  should  not  witness  so  many  chronic 
diseases  of  the  brain.’  See  Personal  Health. 

3.  Local  rest. — This,  which  may  be  called  me- 
chanical rest,  is  well  known  to  every  surgeon  to 
be  an  agent  of  supreme  value  in  the  treatment 
of  wounds,  fractures,  displacements  or  inflamma- 
tion of  joints : as  it  is  obvious  that  every  move- 
ment to  which  a wounded  or  inflamed  part  is 
subjected  must  act  on  the  one  h3nd  like  the  repe- 
tition of  the  original  injury,  and  upon  the  other 
like  a continuance  of  the  irritating  cause.  Tims 
rest  is  not  only  a negative  advantage,  as  saving 
the  patient  from  renewed  injury  or  irritation, 
but  a positive  remedy,  as  it  diminishes  the  heat 
of  the  body,  reduces  the  pulse,  and  alleviates 
pain.  Rest  is  of  so  much  value  in  the  treatment 
of  inflammation,  that  in  some  instances  no  means 
will  advance  the  cure  without  it,  and  numerous  in- 
juries of  the  body’,  externally  or  internally’,  would 
do  well  with  perfect  local  rest  and  nothing  else. 

It  was  on  this  principle  that  Pott  treated  all 
fractures  of  the  extremities,  by  relaxing  the 
muscles  which  had  been  thrown  into  spasm  by 
the  fracture;  and  it  is  this  principle  that  nature 
would  teach,  when  we  see,  in  hip-joint  disease, 
immobility  of  the  inflamed  parts  maintained  by 
the  vital  anchylosis  of  the  capsular  muscles; 
when  we  notico  the  recti  abdominis  become 
hard  and  rigid  in  hepatic  abscess  or  peritonitis; 
and  when  we  find  the  fractured  ends  of  a rib 
held  together  in  a cylinder  of  ensheathing  callus. 

To  a physician  mechanical  rest  is  an  invaluablo 
agent,  and  yet  its  benefits  are  not  recognised  in 
a practical  way  at  all  as  frequently  or  as  fully  m 
they  should  be. 


BEST.  THERAPEUTICS  OF.  1347 


Api- ligation. — The  application  of  rest  in  dis- 
eased conditions  of  the  different  parts  of  the  body 
is  so  varied,  and  the  cases  in  which  it  should  be 
employed  are  so  numerous,  that  it  would  be  im- 
possible to  enumerate  them  all.  In  surgical  prac- 
tice rest  is  constantly  used  in  the  treatment  of 
injuries  and  diseases.  Here  we  shall  only  deal 
with  its  employment  in  medical  practice,  and 
shall  select  a few  examples,  to  illustrate  its 
benefit  in  different  regions  of  the  body. 

A.  Diseases  of  the  respiratory  organs. 
The  obj  ects  of  the  treatment  by  rest  may  be  stated 
to  be  (Roberts) : — 1.  To  maintain  structures, 
which  are  actually  diseased,  orin  danger  of  becom- 
ing so,  in  as  quiescent  a state  as  possible  ; in  short 
to  try  to  produce  mechanical  rest,  as  is  ordinarily 
done  in  the  case  of  a diseased  joint.  2.  To  check 
or  limit  the  entrance  of  irritating  gases— be  they 
noxious,  or  simply  of  a different  degree  of  tem- 
perature or  humidity  from  that  of  the  internal 
part  with  which  the  air  comes  in  contact.  3.  To 
quiet  the  circulation  through  theorgans,  which  are 
being  placed  in  a condition  suitable  for  repair. 

1.  Acute  inflammation  of  the  larynx  and  bron- 
chi— The  patient  is  to  bo  placed  m an  equable 
and  moderately  high  temperature,  and  the  atmo- 
sphere impregnated  with  moisture;  all  speaking 
or  using  the  voice  must  be  forbidden,  while  the 
patient's  wants  may  be  made  known  by  means 
of  a slate  and  pencil  (Hilton).  Thus,  not  only 
is  the  breathing  quieter  and  less  frequent,  but 
all  irritation  of  cold  and  of  di’y  air  prevented. 

! 2.  Acute  capillary  bronchitis.-—  In  this  disease, 

while  general  rest  is  to  be  maintained,  the  indi- 
cations to  relieve  the  congested  right  heart,  and 
to  remove  the  mucus  which  is  causing  the  symp- 
toms of  asphyxia,  predominate;  and  physiolo- 
; gical  rest  cannot  in  this  instance  be  obtained  by 
mechanical  rest.  Here  relief  is  attainable  by 
restraining  with  the  one  hand  the  outpouring  of 
mucus  into  the  small  tubes  of  the  lung,  and 
getting  rid  of  that  which  is  already  poured  out, 
by  means  of  alkalies  and  stimulating  expec- 
torants ; and  by  maintaining,  with  the  other  hand, 
the  forces  of  the  circulation,  and  relieving  the 
overloaded  right  heart,  by  liydragogue  cathar- 
tics, diuretics,  and  diaphoretics. 

3.  Pleurisy. — In  addition  to  keeping  the  pa- 
tient quiet,  restraining  breathing,  and  forbidding 
conversation,  the  most  effectual  way  of  employ- 
ing rest  to  the  inflamed  surfaces  of  the  serous 
membrane,  is  by  mechanically  fixing  the  side 
with  adhesive  plaster,  as  we  would  do  for  an 
inflamed  joint.  The  forms  of  pleuritis  to  which 
this  is  most  applicable  are : — Acute  general 
pleurisy,  seen  early;  dry  pleuris}7  of  a small 
area;  that  accompanying  pneumonia,  the  result 
t of  a fractured  rib ; and  in  the  advanced  stages  of 
phthisis  pulmonalis,  where  fits  of  coughing  and 
pain  are  produced  by  stretching  of  those  bands 
of  organised  lymph  which  bind  the  costal  and 
visceral  layers  together.  It  is  also  applicable  in 
[external  fistula,  and  in  pleurodynia.  The  plan 
proposed  by  Ur.  Roberts,  and  which  has  answered 
remarkably  well  in  the  hands  of  the  writer,  is  as 
follows ; — Apply  two  or  three  layers  of  plaster, 
cut  in  strips  of  about  four  inches,  thus : the  first 
strip  is  laid  on  obliquely  in  the  direction  of  the 
ribs,  the  second  across  the  course  of  the  ribs,  the 
dlird  in  the  direction  of  the  first,  the  fourth  as  the 


second,  and  so  on  until  the  entire  side  is  covered, 
A strip  is  also  passed  over  the  shoulder,  which 
is  kept  down  by  another  fixed  round  the  side 
across  its  ends.  Each  strip  should  be  long 
enough  to  extend  from  the  spine  to  the  sternum. 

4.  Phthisis  pulmonalis. — The  stage  at  which 
mechanical  rest  becomes  a decided  therapeutic  is 
that  of  breaking-down  of  the  lung-tissue,  and  the 
formation  of  large  cavities.  Its  application  at 
an  earlier  stage  is  also  useful  in  relieving  the 
distress  of  breathing;  but  it  seems  most  suit- 
able as  a means  of  checking  the  short  hacking 
cough,  and  the  stitch-like  pains,  produced  by 
stretching  of  those  parts  of  the  lungs  which 
have  been  united  by  adhesive  inflammation  to 
the  costal  layers  of  the  pleura.  By  means  of 
strapping  the  upper  part  of  the  chest,  corre- 
sponding to  the  disease,  with  diachylon  spread 
on  leather,  and  filling  all  the  hollows  previously 
with  cotton-wool,  so  as  to  prevent  all  motion  on 
inspiration  or  expiration,  rest  and  quiet  is  ob- 
tained, and  not  only  is  cicatrisation  encouraged, 
should  such  have  commenced,  but  the  risk  of 
either  haemorrhage  by  rupturo  of  an  artery,  or 
the  laceration  of  the  pleura  pulmonalis  and  con 
sequent  pneumothorax,  is  averted. 

B.  Diseases  of  the  heart  and  blood- 
vessels.— 1.  Pericarditis.  The  mode  of  apply- 
ing rest  in  this  disease  must  necessarily  be 
different  from  that  which  obtains  in  pleurisy,  as 
actual  arrest  or  even  limitation,  to  any  degree, 
of  the  heart’s  action — which  theoretically  and  by 
analogy  might  be  expected  to  be  followed  by 
the  best  results — would  of  course  be  out  of  the 
question.  Rest  must  therefore  be  diffei’entlv 
attained,  by  general  rest  and  quiet,  and  by  phy- 
siological medication.  The  advantages  of  perfect 
rest  in  the  horizontal  position,  are  evident,  as 
by  it  the  attrition  of  the  inflamed  surfaces 
against  oach  other  is  lessened  by  some  17,280 
beats  in  the  twenty-four  hours,  and  thereby  the 
tendency  to  effusion  diminished,  and  resolution 
encouraged.  The  medicine  above  all  others  to 
produce  physiological  quiet  is  opium.  When 
not  otherwise  contra-indicated,  and  when  care- 
fully watched,  it  is  to  be  used  freely,  in  grain 
doses  every  second  or  third  hour,  as  it  is  remark- 
ably little  liable  to  produce  narcotism. 

2.  Internal  aneurism. — For  a long  time,  until 
recent  years,  this  disease  was  looked  upon  as 
beyond  the  reach  of  medicines  or  cure.  Valsalva 
saw  the  clue  to  treatment,  and  attempted  to  in- 
duce rest,  and  such  a state  of  the  general  circula- 
tion that  the  aneurismal  sac  might  be  filled  by  the 
fibrin  of  the  blood ; but  the  means  he  adopted  wero 
not  physiologically  correct  , and  to  Mr.  Tufnell,  of 
Dublin,  is  due  the  credit  of  having  so  modified 
the  treatment  as  to  obtain  that  rest  which  alone 
can  cure  the  aneurism.  Mr.  Tufnell’s  method 
may  shortly  be  stated  to  be  as  follows: — The 
patient  is  to  be  placed  in  a bright  airy  room  on 
a prepared  bed  or  couch,  on  which  he  must  be 
contented  to  remain  for  eight  or  ten  weeks.  He 
must  thus  lie  in  the  horizontal  position,  and  not 
even  for  a moment  assume  the  erect  posture. 
Accordingly  the  bed  must  be  so  constructed 
that  the  requirements  of  nature  can  be  attended 
to  without  alteration  of  position.  The  diet  is 
to  be  restricted  to  a minimum  of  solids  and 
fluids.  The  patient’s  mind  is  to  be  freed  from 


1348  EEST,  THERAPEUTICS  OF. 
all  anxiety,  and  pain  and  sleeplessness  relieved 
by  opium.  The  object  of  these  means  is  to 
give  rest  to  the  aneurism  (1)  by  reducing  the 
absolute  quantity  of  blood  circulating,  without 
taking  any  of  its  ingredients  from  it  by  bleeding; 
(2)  by  rendering  the  blood  hyperinotic;  (3)  by. 
diminishing  the  rate  and  force  of  the  current 
through  the  sac.  The  horizontal  position  in  a 
healthy  individual  makes  a difference  of  at  least 
twelve  cardiac  beats  a minute  less  than  in  the  erect 
position,  and  in  disease  this  difference  amounts 
to  twenty  or  even  forty  beats.  Taking  it  at  the 
lowest  rate  of  difference  it  is  evident  that  in  the 
horizontal  position  the  blood  circulates  17,280 
times  less  through  the  body  in  the  twenty  four 
hours.  The  aneurismal  sac  is  proportionately 
less  often  distended,  and  the  threatened  breach 
in  the  wall  of  the  artery  is  averted  by  layers  of 
fibrin  deposited  by  the  more  slowly  moving  and 
concentrated  stream. 

C.  Diseases  of  the  abdominal  viscera. — 

In  the  therapeutic  consideration  of  disease  of 
these  organs  the  principle  of  rest  is  not  less 
plainly  indicated  than  in  the  other  parts  of  the 
body  we  have  discussed ; and  by  neglect  of  so 
simple  and  yet  so  potent  an  agent  all  other  treat- 
ment may  signally  fail  to  relieve  or  to  cure. 

1.  Diseases  of  the  stomach  and  intestines. — 
The  whole  basis  of  treatment  often  depends  upon 
strict  diet,  and  in  some  cases  temporary  total  de- 
privation of  food,  enemata  supplying  the  requisite 
nourishment.  Local  rest  can  best  be  obtained 
by  the  physiological  action  of  opium  upon  the 
vermicular  movements  of  the  intestines,  and  by 
avoiding  all  irritants  or  purgatives.  Opium  may 
be  required  in  full  doses,  so  as  to  arrest  all  peri- 
stalsis ; and  thus  an  inflamed  or  ulcerated  sur- 
face is  placed  at  rest,  and  nature  is  enabled  to 
prevent  perforation,  and  cure  the  disease.  It 
cannot  be  too  strongly  stated  that  the  injudicious 
employment  of  purgatives  in  threatened  perfora- 
tion is  not  only  unscientific,  but  the  worst  pos- 
sible practice,  as  it  is  almost  sure  to  result  in  the 
death  of  the  patient.  This  line  of  treatment  by 
rest  holds  good  in  simple  or  cancerous  gastric 
ulcer,  Curling’s  ulcer,  typhoid  ulceratioD,  and  that 
due  to  foreign  bodies  in  the  appendix  vermiformis. 
The  practitioner  will  find  it  also  his  best  guide 
and  indispensable  aid  to  cure  in  perityphlitis, 
hepatic  abscess,  ileus,  after  operations  for  hernia, 
and  in  various  other  conditions. 

2.  Inflammation  of  the  kidneys. — As  the  skin 
and  bowels  may  vicariously  perform  many  of  the 
excretory  functions  of  the  kidney,  the  first  indi- 
cation in  acute  nephritis  is  to  relieve  and  rest 
that  organ,  by  general  rest,  local  depletion,  and  by 
calling  vigorously  upon  the  skin  and  intestines. 
In  some  cases  where  the  equilibrium  of  secretion 
and  excretion  is  thrown  much  out  of  balance, 
and  where  convulsions  and  dropsy  point  to  an 
hydrsemic  and  toxsemic  state,  we  should  use  vene- 
section as  the  readiest  and  most  efficient  means 
of  attaining  our  object,  of  curing  by  rest. 

Conclusion. — The  foregoing  illustrations  show 
the  benefit  of  rest  in  its  varied  aspects,  not  as 
a remedy  to  the  exclusion  of  others,  but  as  a 
therapeutic  agent  by  which  nature  is  reinstated 
on  the  throne,  so  that  she  may  again  exercise 
her  vital  powers  to  restore  order,  give  health,  and 
maintain  life,  J.  Mager  Finnt. 


RESUSCITATION. 

RESTLESSNESS. — This  signifies  a con- 
dition of  constant  movement ; the  movements 
being  random  and  non-purposive,  or  only  semi- 
purposive  and  fitful  in  character.  The  condition 
itself  may  be  due  to  the  most  various  causes. 
Thus  it  may  be  met  with  in  children  who  are  tho 
subjects  of  connate  mental  defects,  and  who  ary 
scarcely  over  at  rest  during  their  waking  hours ; 
or  it  may  be  seen  for  a time,  and  especially  in 
‘nervous’  people  under  conditions  of  extreme 
mental  excitement.  In  various  forms  of  delirium, 
or  of  mania,  either  subacute  or  acute,  restless- 
ness also  exists  to  a well-marked  degree.  Where 
it  occurs  in  fevers  to  a notable  extent  it  usually 
co-exists  with  delirium.  Restlessness  is  likewise 
a prominent  feature  in  patients  who  are  suffer- 
ing from  severe  and  abiding  pain  in  almost  any 
part  of  the  body;  or  in  those  who  have  suddenly- 
lost  large  quantities  of  blood,  either  from  the 
uterus  or  elsewhere.  See  Jactitation. 

Treatment.— -This  being  a mere  symptom, 
dependent  upon  very  many  totally  different  un- 
derlying conditions,  its  treatment  in  each  parti- 
cular case  resolves  itself  into  the  treatment  of 
the  general  condition  upon  which  tho  symptom 
is  dependent. 

H.  Charlton  Bastian. 

RESUSCITATION  {re-,  again,  and  suscito, 
I stir  up). — Definition'.— The  recovery  from  sus- 
pended animation  or  apparent  death.  In  these 
conditions,  of  course  all  signs  of  circulation  and 
respiration  have  disappeared,  but  usually  the 
failure  of  one  function  has  preceded  the  other. 
For  the  purposes  of  treatment  we  may  regard  as 
(A.)  syncope  those  eases  where  the  lips  and  mu- 
cous membrane  are  found  pale  and  exsanguine ; 
and  as  (B.)  asphyxia  those  where  they  are  dark- 
coloured. 

A.  Syncope. — Syncope  may  arise  (1)  from  men- 
tal emotion,  sudden  pain,  or  shock;  (2)  from 
drugs  and  poisons,  including  anaesthetics,  espe- 
cially chloroform ; (3)  from  haemorrhage,  or  any 
thing  which  reduces  the  due  supply  of  blood  to  the 
heart;  and  (4)  from  fatty  degeneration  or  dila- 
tation of  that  organ. 

T reatment.  — Place  the  patient  horizontally  on 
his  left  side,  with  the  pelvis  and  feet  raised,  Nria- 
ton  has  urged  complete  inversion  of  the  body,  but 
by  its  interference  with  the  free  action  of  the 
diaphragm  this  method  may  be  injurious.  The 
windows  of  the  room  should  be  opened ; the  face 
fanned ; and  a little  cold  water  may  be  sprinkled 
on  the  forehead.  Smelling  salts  being  held  to 
the  nostrils,  if  natural  breathing  has  not  re- 
turned, begin  Howard’s  method  of  artificial  re- 
spiration : — Position  of  patient.  Face  upwards; 
a hard  roll  of  clothing  beneath  thorax,  with 
shoulders  slightly  declining  over  it.  Head  and 
nock  bent  back  to  the  utmost.  Hands  on  top  of 
head.  Strip  clothing  from  waist  and  neck.  Posi- 
tion of  operator. — Kneel  astride  patient's  hips : 
place  your  hands  upon  his  chest,  so  that  the  hall 
of  each  thumb  and  little  finger  rest  upon  tho 
inner  margin  of  the  free  border  of  the  costal 
cartilages,  the  tip  of  each  thumb  near  or  upon 
the  xiphoid  cartilage,  the  fingers  dipping  into  the 
corresponding  intercostal  spaces.  Fix  your  elbows 
firmly,  making  them  one  with  your  hips.  Action 
of  operator. — Pressing  upwards  and  inwards  to- 


RESUSCITATION. 


wards  the  diaphragm,  use  your  knees  as  a pivot, 
and  throw  your  weight  slowly  forwards  two  or 
three  seconds,  until  your  face  almost  touches  that 
of  your  patient,  ending  with  a sharp  push  which 
helps  to  jerk  you  back  to  your  erect  kneeling 
position.  Rest  three  seconds  ; then  repeat  this 
movement  as  before,  continuing  it  at  the  rate  of 
seven  to  ten  times  a minute ; taking  the  utmost 
care,  on  the  occurrence  of  a natural  gasp,  gently 
to  aid  and  deepen  it  into  a longer  breath,  until 
respiration  becomes  natural. 

This  method  is  said  to  keep  the  passage 
through  the  larynx  free  without  the  aid  of  an 
assistant  or  any  contrivance  for  the  purpose,  and 
is  recommended  for  that  reason.  Artificial  re- 
spiration must  precede  the  use  of  the  stomach- 
pump,  aud  be  continued  until  either  the  pulse 
or  natural  respiration  returns.  Keep  up  the 
temperature  of  the  body  by  hot  blankets  or  hot 
bottles.  Stimulating  the  heart  by  galvanism  has 
been  recommended,  but  it  is  a doubtful  remedy. 
It  is  not  easy  to  make  it  produce  general  and 
effective  contraction,  such  as  would  cause  the 
ilood  to  move  forward,  and,  failing  to  do  this, 
it  probably  does  harm  by  exhausting  the  irrita- 
bility of  those  parts  which  it  does  excite.  Ether, 
or  nitrite  of  amyl,  may  be  held  to  the  nostrils. 
A little  brandy  and  hot  water,  eau  de  cologne 
and  water,  wine,  or  other  stimulant,  as  sulphuric 
ether  or  sal  volatile,  is  now  to  be  given,  with 
care  that  none  of  it  enters  the  trachea.  If  swal- 
lowing is  impracticable,  inject  warm  fluids  into 
'.lie  rectum.  In  cases  of  syncope  from  loss  of 
blood  transfusion  may  be  required.  See  Trans- 
fusion. 

B.  Asphyxia,  (a)  Asphyxia  Neonatorum. — The 
mouth  and  nostrils  of  the  infant  should  be  wiped 
dry ; and  the  body  freely  exposed,  whilst  the 
head  is  allowed  to  fall  back  over  the  hand  which 
supports  the  nape.  A few  drops  of  cold  water 
may  be  sprinkled  upon  the  chest,  and  the  face 
should  be  fanned  or  blown  upon  for  one  minute 
only.  Next  inflate  the  lungs  by  blowing  into  the 
nose  and  mouth ; and  then  squeeze  the  trunk. 
The  body  should  now  be  immersed  in  water  at 
100°,  from  which  the  chest  should  be  raised 
every  half-minute  and  sprinkled  with  cold  water. 
Sylvester’s  method  of  artificial  respiration  is  the 
best.  Marshall  Hall’s  and  Howard's  methods  may 
be  used  after  the  first  inspiration  has  occurred, 
or  together  with  mouth-to-mouth  insufflation 
( see  Artificial  Respiration).  Experiments 
made  by  Dr.  Champneys  show  that  Hall  and 
Howard’s  methods  of  artificial  respiration  are 
absolutely  useless  as  a means  of  directly  inflat- 
ingthe  lungs  of  still-born  children;  and  also  that 
Sylvesters  method,  and  its  modification  by  Bain 
and  Pacini,  introduce  more  air  than  any  other 
method. 

(b)  Asphyxia  from.  breathing  noxious  gases. 
The  body  should  bo  brought  into  fresh  air  ; arti- 
ficial  respiration  be  at  once  commenced  ; whilst 
an  assistant  should  blow  into  the  nostrils  three 
or  four  times ; and  hot  blankets  and  hot  water 
bottles  be  applied. 

(c)  Asphyxia  from  mechanical  obstruction  of 
the  air-passages. — The  cause  of  obstruction  must 
be  removed,  if  possible,  by  adopting  the  inverted 
position  of  Howard’s  method.  Coins  or  plum- 
stones  may  thus  dislodge  themselves.  In  the 


1349 

absence  of  forceps,  a button-hook  or  the  handle 
of  a tablespoon  may  be  useful,  especially  in  the 
removal  of  a lump  of  hard  food.  Laryngotomy 
or  tracheotomy  must  be  performed  the  instant 
the  pulse  becomes  imperceptible  at  the  wrist. 

(d)  Asphyxia  from  poisons  or  anesthetics. — In 
the  asphyxia  of  advancing  coma  from  narcotics 
and  anaesthetics,  the  breathing  may  stop  from 
failure  of  the  medulla  and  respiratory  tract.  In 
this  case  artificial  respiration,  by  simply  com- 
pressing the  chest  at  intervals  of  five  seconds, 
may  suffice,  but  very  often  there  is  the  mecha- 
nical obstruction  in  the  larynx  to  be  considered. 
If  raising  the  chin  and  throwing  the  head  back 
do  not  effect  a free  passage  of  air,  Howard’s  or 
some  other  method  of  artificial  respiration  should 
bo  commenced  (see  Artificial  Respiration). 
ft  is  well  to  understand  that  when  the  muscles 
of  the  larynx  are  paralysed,  the  glottis  becomes 
valvular  in  action  or  partially  so — that  is  to  say, 
it  permits  air  to  pass  outward  freely,  but  only 
a weak  current  of  air  to  pass  inward.  A strong 
current  brings  the  sides  together  and  gives  riso 
to  complete  obstruction.  This  is  chiefly  caused 
by  the  drawing  together  of  the  relaxed  arytaeno- 
epiglottidean  folds  of  mucous  membrane ; and  in 
order  to  obviate  this  kind  of  obstruction,  the 
folds  should  be  tightened,  by  throwing  back  the 
head  and  raising  the  chin  as  far  as  possible 
away  from  the  sternum.  This  will  render  it 
unnecessary  to  catch  hold  of  the  tongue  with 
artery  forceps,  the  treatment  usually  recom- 
mended. 

(e)  Asphyxia  from  drowning. — In  asphyxia 
from  immersion  in  water  there  are  two  serious 
complications,  namely,  first,  the  presence  of  water 
and  mud  in  the  air-passages,  and,  secondly,  the 
depressing  effect  of  cold.  With  the  view  of  more 
effectually  removing  the  water  from  the  air-tubes 
Howard  gives  the  following  rules  : — Position  of 
patient.  Face  downwards.  A hard  roll  of  cloth- 
ing beneath  the  epigastrium,  making  that  the 
highest  point,  the  mouth  the  lowest.  Forehead 
resting  on  forearm  or  wrist,  keeping  mouth  from 
ground.  Position  and  action  of  operator.  Place 
left  hand,  well-spread,  upon  thebaseof  the  thorax 
to  the  left  of  the  spine  ; the  right  hand  upon  the 
spine,  a little  below  the  left  and  over  the  lower 
part  of  the  stomach.  Throw  upon  them,  with  a 
forward  motion,  all  the  weight  and  force  the  age 
and  sex  of  the  patient  will  justify,  ending  this 
pressure  of  two  or  three  seconds  by  a sharp 
push,  which  helps  you  back  again  into  the  up- 
right position.  Repeat  this  two  or  three  times, 
according  to  the  duration  of  the  emersion,  and 
then  resort  to  the  method  described  in  the  treat- 
ment of  syncope. 

The  following  rules  have  been  published  by 
the  Royal  Humane  Society.  They  recommend 
the  Sylvester  method,  but  probably  this  and  the 
modification  by  Bain,  in  which  the  anterior  fold 
of  the  axilla  on  both  sides  is  grasped  with  the 
clavicle  and  pulled  upwards,  are  less  useful  than 
the  Howard  plan,  which  favours  the  patency  of 
the  air-passages. 

Directions  for  Restoring  the  Apparently 
Dead. 

I. — If  from  Drowning  or  other  Suffoca- 
tion, or  Narcotic  Poisoning. — Send  immedi- 
ately for  medical  assistance,  blankets,  and  dry 


1350  RESUSCITATION. 

clothing,  hut  proceed  to  treat  the  patient  in- 
stantly, securing  as  much  fresh  air  as  pos- 
sible. 

The  points  to  be  aimed  at  are— first,  and  im- 
mediately, the  RESTORATION  OF  BREATHING  ; and, 
secondly,  after  breathing  is  restored,  the  pro- 
motion OF  WARMTH  AND  CIRCULATION. 

The  efforts  to  restore  life  must  be  persevered 
in  until  the  arrival  of  medical  assistance,  or  until 
the  pulse  and  breathing  hare  ceased  for  at  least 
an  hour. 

Treatment  to  Restore  Natural  Breathing. 

Rule  1. — To  maintain  a free  entrance  of  air 
into  the  windpipe, — Cleanse  the  mouth  and  nos- 
trils ; open  the  mouth  ; draw  forward  the  patient’s 
tongue,  and  keep  it  forward:  an  elastic  band  over 
the  tongue  and  under  the  chin  will  answer  this 
purpose.  Remove  all  tight  clothing  from  about 
the  neck  and  chest. 

Rule  2.  — To  adjust  the  patient's  position. — 
Place  the  patient  on  his  back  on  a flat  surface, 
inclined  a little  from  the  feet  upwards;  raise  and 
support  the  head  and  shoulders  on  a small  firm 
cushion  or  folded  article  of  dress  placed  under 
the  shoulder-blades. 

Rule  3. — To  imitate  the  movements  of  breath- 
ing. — Grasp  the  patient’s  arms  just  above  the 
elbows,  and  draw  the  arms  gently  and  steadily 
upwards,  until  they  meet  above  the  head  (this  is 
for  the  purpose  of  drawing  air  into  the  lungs)  ; 
and  keep  the  arms  in  that  position  for  two 
seconds.  Then  turn  down  the  patient’s  arms, 
and  press  them  gently  and  firmly  for  two  seconds 
against  the  sides  of  the  chest  (this  is  with  the 
object  of  pressing  air  out  of  the  lungs.  Pressure 
on  the  breast-bone  will  aid  this). 

Repeat  these  measures  alternately,  deliber- 
ately, and  perseveringly,  fifteen  times  in  a minute, 
until  a spontaneous  effort  to  respire  is  perceived, 
immediately  upon  which  cease  to  imitate  tho 
movements  of  breathing,  and  proceed  to  induce 
CIRCULATION  AND  WARMTH. 

Should  a warm  bath  be  procurable,  the  body 
may  bo  placed  in  it  up  to  the  neck,  continuing 
to  imitate  the  movements  of  breathing.  Raise 
the  body  in  twenty  seconds  in  a sitting  position, 
and  dash  cold  water  against  the  chest  and  face, 
and  pass  ammonia  under  tho  nose.  The  patient 
should  not  be  kept  in  the  warm  bath  longer  than 
five  or  six  minutes. 

Rule  4. — To  excite  inspiration. — During  the 
employment  of  the  above  method  excite  the  nos- 
trils with  snuff  or  smelling-salts,  or  tickle  the 
throat  with  a feather.  Rub  the  chest  and  face 
briskly,  and  dash  cold  and  hot  water  alternately 
on  them. 

Treatment  after  Natural  Breathing  has 
been  Restored. 

Rule  5. — To  induce  circulation  and  warmth. 
Wrap  the  patient  in  dry  blankets,  and  com- 
mence rubbing  tho  limbs  upwards  firmly  and 
energetically.  Promote  the  warmth  of  the  body 
by  the  application  of  hot  flannels,  bottles,  or 
bladders  of  hot  water,  hot  bricks,  &c.,  to  the  pit 
of  the  stomach,  armpits,  between  the  thighs,  and 
at  the  soles  of  the  feet.  Warm  clothing  may 
generally  be  had  from  the  bystanders.  When 
swallowing  has  returned,  a teaspoonful  of  warm 
water,  small  quantities  of  wine,  warm  brandy 
and  water,  or  coffee  should  be  given.  Sleep 


RETRACTED  ABDOMEN. 

should  be  encouraged.  During  reaction  large 
mustard  poultices  to  the  chest  will  relieve  the 
distressed  breathing. 

II.  — If  from  Intense  Cold. — Rub  the  body 
with  snow,  ice,  or  cold  water.  Restore  warmth 
by  slow  degrees.  It  is  dangerous  to  apply  heal 
too  early. 

III.  — If  from  Intoxication. — Lay  tho  indi- 
vidual on  his  side  on  a bed  with  his  head  raised. 
The  patient  should  be  induced  to  vomit. 

IV.  — If  from  Apoplexy  or  Sunstroke.— Cold 
should  be  applied  to  the  head,  which  should  be 
kept  raised.  Tight  clothing  should  be  removed, 
and  stimulants  cautiously  used. 

How  soon  should  alcoholic  stimulants  be 
given?  Certainly  not  until  natural  respiration 
has  been  induced,  and  in  cases  of  narcotic  poison- 
ing, not  until  consciousness  has  been  restored. 
If,  on  the  return  of  consciousness,  the  patient  is 
in  pain  or  faint,  the  inhalation  of  a few  drops  of 
ether  or  smelling  ammonia  is  indicated.  In  their 
absence  a few  teaspoonfuls  of  brandy  may  be 
given.  Hot  tea  and  coffee  should  be  the  first 
refreshment  swallowed,  and  in  general  it  should 
not  be  pressed  upon  the  patient,  as  vomiting  is 
more  exhausting  than  waiting  a few  hours  for 
food.  J.  T.  Clover. 

RETCHING-  (A.-Saxon,  hracan). — An  in 
effectual  effort  at  vomiting,  sometimes  accom- 
panied by  the  expulsion  of  gas  from  the  stomach. 
Sec  Vomiting. 

RETENTION  ( re-,  back,  and  teneo,  I hold). 
This  word  is  employed  in  medical  science  to 
imply  that  some  material,  whether  solid  or  liquid, 
which  ought  to  be  discharged,  is  retained  or 
kept  back  in  a cavity  or  canal,  either  natural  or 
artificial.  Thus  we  speak  of  retention  of  urine, 
faces,  menses,  and  bile ; and  also  of  pus  under 
certain  circumstances. 

RETENTION  OP  URINE. — See  Mictu- 
rition, Disorders  of. 

RETINITIS. — Inflammation  of  the  retina. 
See  Eye  and  its  Appendages,  Diseases  of. 

RETRACTED  ABDOMEN.— The  abdo- 
men as  a whole  presents  under  certain  circum- 
stances more  or  less  depression  of  its  anterior 
wall,  when  it  is  said  to  be  retracted,  and  this  mar 
reach  such  a degree  that  the  abdomen  becomes 
boat-shaped,  and  its  anterior  boundaiy  some- 
times seems  almost  to  come  into  contact  with  the 
spinal  column  behind.  The  bony  prominences 
of  the  crest  and  anterior  angles  of  the  ilium,  the 
pubes,  Poupart’s  ligament,  and  the  lower  margin 
of  the  chest  often  stand  out  prominently.  In 
some  instances  the  retraction  is  partial,  involving 
the  lower  part  of  the  abdomen,  while  the  upper 
part  is  enlarged. 

A retracted  abdomen  frequently  renders  itmoro 
easy  to  investigate  by  physical  examination 
the  contents  of  this  cavity ; and  it  must  be  re- 
membered that  the  condition  may  be  associated 
with  diseases  of  abdominal  organs  which  can 
thus  be  readily  detected,  or  with  abdominal  tu- 
mours. It  may,  however,  also  itself  give  infor- 
mation of  importance  in  diagnosis.  The  chief 
conditions  under  which  a retracted  abdomen  may 
be  met  with,  so  as  to  be  of  clinical  importance,  an 


RETRACTED  ABDOMEN. 

*s  follows: — 1.  In  certain  cases  of  disease  of  the 
brain  or  its  membranes,  and  especially  acute 
meningitis.  2.  In  some  forms  of  intestinal  colic, 
particularly  that  form  associated  with  lead-poison- 
ing— the  so-called  painter's  colic.  3.  As  a part 
of  marked  general  emaciation  from  any  cause, 
bnt  especially  that  due  to  starvation,  or  to  chronic 
diarrhcea  from  intestinal  ulceration  and  other 
conditions.  4.  In  connection  with  chronic  dis- 
eases of  the  oesophagus,  stomach,  intestine,  or 
pancreas,  causing  obstruction  in  some  part  of  the 
alimentary  canal,  so  that  food  cannot  be  taken 
in,  or  is  prevented  from  passing  along.  Here 
the  retraction  is  also  partly  due  to  the  general 
emaciation.  5.  As  one  of  the  consequences  of 
chronic  peritonitis.  It  will  be  seen,  from  a 
consideration  of  the  causes  just  mentioned,  that 
retraction  of  the  abdomen  immediately  results 
either  from  a spasmodic  contraction  of  the  intes- 
tines and  abdominal  muscles ; general  wasting  ; 
absence  of  food  from,  and  contraction  of  tho 
alimentary  canal;  or  peritoneal  adhesions.  It 
may  be  mentioned  that  marked  temporary  re- 
traction of  the  abdomen  is  sometimes  noticed  in 
connection  with  the  act  of  breathing,  in  conse- 
quence of  disordered  action  of  the  diaphragm. 

Frederick  T.  Roberts. 

RETRACTED  CHEST.  See  Deformities 
of  the  Chest. 

RETROCEDENT  [retro,  back,  and  cedo,  I 
depart). — A term  employed  in  connection  with 
certain  acute  diseases,  when  their  prominent  ex- 
ternal manifestations  disappear  or,  as  it  were, 
go  back.  Retrocession  is  often  associated  with 
the  simultaneous  occurrence  of  internal  disturb- 
ance. The  phenomenon  is  observed  in  gout, 
rheumatism,  certain  skin-disoases,  and  the  erup- 
tive fevers. 

RETROFLEXION  (retro,  back,  and  jlccto,  I 
bend). — A form  of  displacement  in  which  an 
organ  is  bent  backwards  upon  itself.  See  Womb, 
Diseases  of. 

RETRO-PHARYNGEAL  ABSCESS.— 
Synon.  : Post-pharyngeal  abscess  ; Fr.  Ahces 
retro-pkaryngien ; Ger.  Retropharyngeal  Ahsccss. 

Definition. — A collection  of  pus  in  the  loose 
areolar  tissue  which  connects  the  pharynx  with 
the  muscles  lying  upon  the  vertebral  column, 
namely,  the  longus  colli  and  the  rectus  anticus 
major. 

-Etiology. — This  is  a somewhat  rare  affection, 
and  is  more  commonly' met  with  in  children  than 
in  adults, more  particularly  in  those  of  astrumous 
diathesis.  Idiopathic  inflammation  of  this  tissue, 
though  usually  assigned  as  one  of  the  causes  of 
the  affection,  is  not  often  seen.  More  frequently 
tho  inflammation,  and  resulting  abscess,  is  a 
secondary  disorder,  dependent  upon  an  inflamed 
condition  and  suppuration  of  a post-pharyngeal 
gland,  or  caries  of  some  of  the  cervical  vertebrae, 
or  their  cartilages.  Amongst  other  causes,  pyaemia 
has  been  noted  ; and  it  has  also  been  observed 
as  a sequela  to  some  of  the  acute  fevers. 

Symptoms. — As  in  all  disorders  where  inflam- 
mation plays  a part,  so  here  the  onset  of  the 
disease  is  marked  by  increase  of  temperature  and 
pulse,  nausea,  general  restlessness  and  malaise, 


REVULSENTS.  1355 

and  already  some  amount  of  soreness  of  throat 
is  complained  of.  The  degree  of  pyrexia  and 
constitutional  disturbance  will  vary  with  the 
condition  and  constitution  of  the  sufferer.  Soon 
this  soreness  of  throat  develops  into  the  true 
characteristic  pain  on  making  the  attempt  tc 
swallow,  a symptom  which  is  never  wanting, 
and  which  goes  on  gradually,  though  slowly,  aug- 
menting, till  almost  complete  dysphagia  is  es 
tablished.  Accompanying  this,  or  at  least  soon 
after,  is  observed  a peculiar  stiffness  of  the  neck, 
which,  coincidently  with  the  difficulty  of  swallow- 
ing, becomes  more  apparent  with  the  progress  oi 
the  disease.  A certain  amount  of  swelling  of  the 
neck  may  also  be  observed,  specially  towards  the 
angles  of  the  lower  jaw.  Difficulty  in  breathing 
is  another  prominent  symptom  of  the  disorder, 
which,  more  particularly  if  the  abscess  be  large, 
becomes  greatly  aggravated  when  the  patient  as- 
sumes the  horizontal  posture.  On  first  looking  at 
such  a child  with  its  embarrassed  respiration,  its 
anxious  expression,  its  cyanotic  lips  and  cheeks, 
one  might  well  be  excused  for  momentarily  dia- 
gnosing the  case  as  one  of  croup,  were  it  not 
that,  loud  and  hurried  as  are  the  respirations, 
they  are  not  of  a whistling  character.  Here  also 
the  voice  is  altered ; at  first  hoarse  and  indis- 
tinct, it  assumes  what  is  described  as  a snuffling 
tone,  or  a toneless  voice.  On  inspecting  the 
throat,  a round  swelling  is  observed  in  the  pos- 
terior wall  of  the  pharynx,  occupying  the  centre 
of  the  pharyngeal  space,  or  more  to  one  side, 
whereby  the  cavity  is  greatly  diminished  in  size. 
The  mucous  membrane  presents  a livid  colour. 
On  passing  the  finger  over  the  root  of  the  tongue 
and  beyond  the  soft  palate,  this  tumour  will  be 
felt  to  be  either  hard  and  tense,  or  soft  and 
somewhat  indistinctly  fluctuating,  according  to 
the  stage  of  the  disease.  When  tho  tumour 
attains  an  extraordinary  size  it  has  been  seen  to 
project  in  front  of- the  soft  palate.  A quantity 
of  mucus  usually  fills  the  mouth.  All  attempts 
at  swallowing  are  fruitless. 

Prognosis.— The  prognosis  is  always  doubt- 
ful. Most  usually  well-pronounced  cases  termi- 
nate fatally — invariably  so  if  the  disease  depends 
upon  caries  of  the  vertebrse. 

Treatment. — Little  can  be  expected  in  the 
way  of  arresting  the  disease.  Usually  it  is 
well-pronounced  before  the  physician  is  called 
to  see  the  child,  or  it  is  some  time  before  he 
can  be  quite  sure  of  his  diagnosis.  Ice  may 
be  freely  administered,  and  is  most  grateful  to 
the  patient.  So  soon  as  the  presence  of  an 
abscess  is  distinctly  established,  surgical  inter- 
ference must  at  once  be  had  recourse  to,  and  the 
abscess  laid  open  by  a well-guarded  bistoury. 
Sustaining  treatment  is  urgently  demanded. 

Claud  Muirhead. 

RETRO  VERSION  (retro,  back,  and  verto, 
I turn).- — A form  of  displacement  in  which  an 
organ  is  turned  back.  See  Womb,  Diseases  of. 

RE-VACCINATION.— The  operation  of 
repeated  vaccination.  See  Vaccination. 

REVULSENTS  ( revello , I draw  away). — 
This  term  dates  from  the  time  of  the  humoral 
pathology,  and  signifies  therapeutical  measures 
which  draw  the  humours  from  the  part  affected, 


1352  REVULSENTs. 

\ny  detailed  consideration  cf  such  supposed 
effects  could  only  be  interesting  from  an  his- 
torical point  of  view.  R.  Fahquharson. 

RHEUMATIC  ARTHRITIS.  — Synon.  : 
Rheumatic  Gout;  Rheumatoid  Arthritis;  Fr. 
Rhumatisme  noueux;  Usuredes  Cartilages ; Ger. 
Arthritis  Deformans. 

Definition. — A disease  of  the  joints,  the 
essential  nature  of  which  is  still  unknown  ; cha- 
racterised by  chronic  inflammatory  and  degene- 
rative changes,  involving  the  various  articular 
structures  ; and  leading  to  deformity. 

^Etiology. — In  a considerable  proportion  of 
cases,  rheumatic  arthritis  follows  ordinary  acute 
rheumatism  immediately,  or  it  appears  after  an 
interval  of  several  years,  during  which  time 
;hronic  rheumatism  of  a milder  degree  may  have 
b6en  complained  of.  Persons  of  all  ages  may  thus 
juffer,  but  the  disease  generally  begins  between 
•wenty  and  forty.  It  is  commonly  believed  to 
ia  more  frequent  in  women,  but  this  is  doubtful. 
Depressing  influences  of  all  kinds,  including  acute 
liseases,  frequent  pregnancy,  super-lactation, 
prolonged  physical  exertion,  and  mental  distress, 
■ire  unquestionably  predisposing  factors.  The 
iiseaso  is  hereditary. 

Tiie  exciting  cause  is  generally  chill;  but  in 
many  instances  injury  of  a joint  is  the  starting 
point  of  the  morbid  process. 

Anatomical  Characters. — Two  well-marked 
forms  of  this  disease  are  met  with,  according  as 
a single  joint  only,  or  several — perhaps  all — of 
the  joints  are  affected.  In  every  respect  the 
anatomical  characters  are  identical  in  the  two 
forms. 

Examined  at  an  early  stage  of  the  morbid  pro- 
cess, an  affected  joint  is  found  to  be  enlarged; 
the  synovial  membrane,  capsule,  and  ligaments 
being  distended  and  stretched  by  a considerable 
amount  of  effusion.  The  synovial  membrane  is 
hyperoemic,  swollen,  and  thickened;  its  fimbriae 
are  enlarged  and  vascular  ; intra-articular  fibro- 
cartilages,  ligaments,  and  tendons  are  vascular 
and  softened;  and  the  articular  cartilages  are 
partially  removed,  leaving  a roughened,  vascular, 
porous-like  surface  behind. 

In  the  more  advanced  stage  of  the  process  the 
effusion  is  considerably  less,  or  may  be  completely 
re-absorbed ; and  the  capsule  and  ligaments  are 
much  thickened,  or  even  partially  calcified.  The 
intra-articular  structures,  including  fibro-carti- 
lages,  ligaments,  tendons,  and  articular  cartilages, 
have  disappeared  in  a great  measure,  leaving 
little  or  no  trace  behind.  Peculiar  pendulous 
bodies,  consisting  of  masses  of  fibro-cartilage, 
are  attached  to  the  interior  of  the  synovial  mem- 
brane ; more  rarely  they  are  free.  The  articular 
cartilages,  where  their  opposed  surfaces  are  in 
mutual  contact,  are  replaced  by  an  ivory-like 
layer  of  bone  ; whilst  at  other  parts  the  surfaces 
present  a pink  colouration,  with  small  spots  of 
more  intense  hypersemia.  The  articular  surfaces 
are  variously  altered  in  shape  and  size.  Thus 
articular  cavities  are  widened,  and  occasionally 
deepened,  by  enlargement  of  the  circumference,  in 
the  form  of  ‘lips,’  or  by  the  production  of  separate 
bony  masses  in  the  same  situation ; whilst  the 
heads  of  bones  are  enlarged ; present  similar  ‘ lips’ 
or  sharp  edges  at  their  widened  margins ; become 


RHEUMATIC  ARTHRITIS, 
flattened  at  right  angles  to  the  axis  of  pressure; 
and  thus  preserve  their  relations  with  the  cor- 
responding cavities.  The  shafts  of  the  hones 
may  be  considerably  altered  in  shape,  increased 
in  size,  and  altered  in  density.  The  associated 
tendons  are  frequently  dislocated  from  their 
course  beside  the  articulations,  and  atrophied  or 
actually  absorbed;  and  the  corresponding  muscles 
are  similarly  atrophied.  Burs®  in  the  neigh- 
bourhood of  joints  may  he  distended  with  fluid, 
and  contain  fibro-cartilaginous  bodies.  The  ana- 
tomical changes  in  this  disease  frequently  pre- 
sent a remarkably  symmetrical  distribution. 

Pathology. — A diversity  of  opinion  still  pre- 
vails upon  the  essential  nature  of  rheumatic 
arthritis.  The  view  most  generally  held  at  the 
present  time  appears  to  be,  that  it  is  a disease 
distinct  from  rheumatism  and  gout,  with  which 
it  was  confounded  until  the  time  of  Ilaygarth 
(1805).  Quite  recently  Mr.  Hutchinson  has  shown 
that,  in  a certain  number  of  instances,  there  is  an 
element  of  gout  in  the  disease,  as  evidenced  by  the 
family  and  personal  history  of  the  patient,  and 
by  the  occasional  presence  of  urates  in  the  arti- 
cular structures  post  mortem.  The  writer’s  ex- 
perience is  almost  entirely  in  favour  of  the  strictly 
rheumatic  nature  of  the  disease,  as  was  main- 
tained by  Todd.  In  a large  proportion  of  cases 
he  has  found  that  the  morbid  process  started  in 
an  attack  of  ordinary  acute  rheumatism ; an 
observation  which  is  entirely  in  accord  with  the 
account  of  the  origin  of  rheumatic  arthritis  given 
by  Dr.  Adams,  of  Dublin,  in  his  classical  work 
on  this  subject.  In  numerous  instances  the 
family  history  is  distinctly  rheumatic.  The 
writer  has  also  found  the  heart  diseased  in  a 
much  larger  proportion  of  cases  than  is  usually 
stated  in  accounts  of  the  disease.  Finally,  he 
has  found  that  no  lino  can  be  drawn  between 
acute  and  sub-acute  cases  of  rheumatism;  be- 
tween sub-acute  and  chronic  cases  of  rheumatism; 
or  between  chronic  rheumatism  and  so-called 
‘ rheumatic  arthritis,’  the  latter  being  only  a moro 
severe  development  of  the  former.  Whatever, 
therefore,  the  essential  nature  of  rheumatism 
may  be,  the  writer  holds  that  all  the  conditions 
named  are  expressions  of  one  morbid  process, 
which  differ  from  each  other  chiefly  in  intensity 
and  the  manner  of  their  evolution. 

Symptoms.— The  symptoms  of  rheumatic  ar- 
thritis iD  its  condition  of  full  development  arc 
exceedingly  characteristic.  The  patient  com- 
plains of  pain  and  stiffness  in  connection  with 
one  or  more  joints ; and  on  examination  these 
are  found  to  bo  swollen,  more  or  less  dis- 
torted, and  tender.  The  history  of  these  changes 
in  the  joints  proves  to  be  that,  either  in  con- 
sequence of  an  attack  of  acute  rheumatism, 
or  not,  first  one  and  then  others  of  the  arti- 
culations became  painful,  tender,  hyperaemic 
and  swollen;  that  the  resulting  enlargement 
had  not  completely  disappeared  before  the  acute 
symptoms  recurred ; and  that,  by  a repetition  of 
similar  acute  or  subacute  attacks,  tho  joints 
have  reached  their  present  condition.  Thus 
the  disease,  whilst  chronic  in  its  course,  consists 
essentially  at  first  of  recurrent  acute,  or  sub- 
acute, attacks,  which  increase  in  frequency  whilst 
their  effects  persist,  and  so  finally  become  fusee 
as  it  were  into  a continuous  whole. 


RHEUMATIC  ARTHRITIS. 


The  lucal  symptoms  and  signs  vary  -with  the 
particular  joint  affected ; but  in  every  instance 
they  are  chiefly  these — pain,  tenderness,  creak- 
ing on  movement,  impairment  of  mobility,  en- 
largement, and  deformity.  The  pain  is  generally 
distressing,  and,  by  its  continuousness  and 
severity,  may  render  the  patient’s  life  miserable, 
especially  as  it  increases  at  night  and  prevents 
sleep.  It  is  aggravated  by  movement,  and 
there  is  tenderness  on  forcible  disturbance  of 
!hs  articular  surfaces.  Creaking  or  crepitation, 
audible  and  palpable,  is  a highly  characteristic 
feature,  which  can  be  elicited  and  appreciated 
either  by  the  patient  or  by  the  practitioner,  and 
in  the  case  of  large  joints  may  be  so  loud  as  to 
be  audible  at  a distance. 

The  mobility  of  the  affected  joints  becomes 
more  and  more  impaired  as  the  disease  progresses 
— at  first  on  account  of  pain,  afterwards  in  con- 
sequence of  anatomical  changes.  Thus  the  vari- 
ous joints  may  become  fixed  by  a ‘false’  (very 
rarely  a ‘ true  ’ ) anchylosis,  so  that  the  hands 
cannot  be  closed ; the  wrists  are  immovable  ; the 
arms  can  hardly  be  removed  from  the  side;  the 
jaws  are  fixed ; the  head  cannot  be  rotated  : the 
patient  may  be  unable  to  sit;  and  the  knees, 
ankles,  and  toes  may  be  similarly  impaired  in 
function. 

The  variety  of  deformity  is  almost  endless ; 
and  the  particular  character  it  assumes  depends 
as  much  on  the  joint  involved,  as  on  the  nature  of 
the  process  itself.  Thus  the  knee,  elbow,  wrist, 
and  knuckles  may  present  considerable  iutra- 
articular  effusion,  especially  in  the  earlier  stages; 
whilst  the  shoulder,  hip,  and  intra-phalangeal 
joints  exhibit  more  limited  swelling  and  ‘drier’ 
signs.  The  terminal  digital  joints  become  cubi- 
cal or  ‘ nodous  ’ ; the  middle  digital  joints  become 
spheroidal  in  outline,  or  are  partially  dislocated 
backwards  or  forwards ; and  the  knuckles  are 
the  seat  of  a peculiar,  oblique  dislocation  of  the 
fingers  towards  the  ulnar  side.  The  lower  ends 
of  the  radius  and  ulna  project  backwards,  and 
give  a full  appearance  to  the  dorsum  of  the 
wrist,  which  may  be  further  increased  by  carpal 
and  bursal  enlargements.  The  elbow-joint  is 
swollen;  and  bursal  collections — fluid  and  solid 
— develop  over  the  olecranon.  The  shoulder 
presents  signs  of  wasting,  rather  than  of  enlarge- 
ment, due  to  atrophy  of  the  deltoid  and  other 
muscles ; the  head  of  the  humerus  at  the  same 
time  lies  unnaturally' forwards  and  upwards;  and 
a corresponding  depression  is  apparent  behind. 
At  the  hip-joint  the  disease  gives  rise  to  flatten- 
ing of  the  buttock,  shortening  of  the  limb,  and 
eversion  of  the  foot ; enlargement  can  sometimes 
be  felt  in  connection  with  the  head  of  the  bone  and 
acetabulum  ; occasionally  the  patient  maybe  not 
only  lame  but  unable  to  sit,  and  must  accordingly 
either  stand  or  lie  constantly.  The  knee  is  en- 
larged by  the  presence  of  considerable  effusion 
in  the  earlier  stage  ; and  when  this  afterwards 
becomes  absorbed,  local  bony  growths  are  easily 
felt,  giving  increased  breadth  to  the  patella,  and 
forming  sharp  crests  at  the  lateral  margins  of 
the  articular  surface  of  the  condyles.  The  disease, 
as  it  affects  the  ankle  and  foot,  does  not  require 
Jpecial  description.  At  the  temporo-maxillary 
urticulation  rheumatic  arthritis  gives  rise  to 
obvious  enlargement  in  front  of  the  ears,  and 


1353 

possibly  to  distortion  or  asymmetry  of  the  chin. 
Prominent  nodular  swelling  is  the  principal  sign 
of  the  disease  at  the  sterno-clavicular  artieula 
tion.  In  the  spine  it  produces  rigidity  chiefly,  as 
well  as  pain  locally  and  down  the  arms,  and  leads 
to  stooping  in  various  attitudes. 

The  general  condition  of  the  subject  of  rheu- 
matic arthritis,  when  it  is  advanced,  is  one  of 
debility  and  ansemia.  The  face  is  pale  and  ex- 
pressive of  suffering;  the  complexion  is  muddy. 
The  skin  is  peculiarly  inactive,  and  rarely  per- 
spires ; the  patient  looks  pinched,  and  complains 
of  a feeling  of  cold ; the  extremities  are  often 
miserably  cold  and  livid ; and  the  palms  of  the 
hands  are  damp  or  even  soppy.  Bodily  activity 
is  greatly  impaired,  by  interference  with  the 
movements  of  the  limbs ; in  many  instances  the 
patient  is  completely  crippled  and  bed-ridden. 
Even  the  voice  and  the  hearing  may  be  impaired, 
from  involvement  of  the  laryngeal  and  auditory 
articulations.  The  various  bodily  functions  are 
feeble,  and  frequently  deranged ; and  although 
the  mind  may  be  active,  the  condition  is  rendered 
wretched  in  the  worst  cases  by  pain  and  helpless- 
ness. 

CoonsE  and  Terminations. — Unless  the  dis- 
ease be  treated  early,  the  course  is  essentially 
progressive  towards  deformity.  Death  from 
rheumatic  arthritis  is  rare ; its  other  distressing 
effects  have  been -sufficiently  indicated. 

Diagnosis. — The  diagnosis  of  rheumatic  ar- 
thritis necessarily  depends  upon  the  view  enter- 
tained of  its  pathology.  If  considered  a distinct 
disease,  it  is,  as  a rule,  easily  separated  from  gout 
by  the  entire  absence  of  tophi  in  the  joints  and 
ears ; by  the  history  of  the  disease  ; and  in  doubt- 
ful cases  by  the  absence  of  uric  acid  in  the  blond. 
Erom  chronic  rheumatism,  as  ordinarily  defined, 
it  is  diagnosed  by  the  amount  of  deformity  pre- 
sent; but  the  writer  holds  that  the  two  con- 
ditions are  identical.  Chronic  synovitis  of  trau- 
matic or  constitutional  origin  maybe  occasionally 
mistaken  for  rheumaticartfiritis,  but  the  presence 
of  the  latter  disease  in  several  joints,  probably 
symmetrically,  should  remove  all  doubt.  Rheu- 
matic arthritis  of  the  hip  and  shoulder  has  pro- 
bably been  frequently  described  as  ‘dislocation’ 
and  ‘ intracapsular  fracture.’ 

Phogxosis.— The  prognosis  of  this  disease  is 
favourable  as  regards  life ; but  unfavourable  as 
regards  cure,  comfort,  or  ability  to  follow  active 
bodily  employment.  The  prognosis  is  much 
better  in  the  rich,  who  can  seek  relief  by  change 
of  climate  in  the  earlier  stages,  than  it  is  amongst 
the  poor,  in  whom  the  disease  must  in  a measure 
be  allowed  to  pursue  its  progressive  course. 

Treatment. — The  treatment  of  rheumatic  ar- 
thritis must  be  applied  in  two  directions;  first, 
to  arrest,  if  possible,  the  morbid  process,  and, 
secondly,  to  relieve  the  distressing  symptoms.  In 
a large  number  of  cases  the  second  indication 
only  can  be  fulfilled,  for  the  disease  is  frequentlv 
too  advanced,  or  the  circumstances  of  the  patient 
are  too  poor,  to  afford  a prospect  of  cure. 

In  the  early  stages  of  the  disease  much  can 
be  done  by  energetic  treatment,  which  must  be 
partly  constitutional  and  partly  local.  If  circum- 
stances permit,  the  patient  should  be  advised  to 
visit,  according  to  the  season  of  the  year,  either 
the  baths  of  this  country,  of  Germany,  or  of  France 


1354  RHEUMATIC  ARTHRITIS, 
in  summer ; or  the  Algerian  springs,  the  French 
Riviera,  or  Italy  in  winter.  Buxton,  Bath,  and 
Strathpeffer  are  the  best  home  baths.  Aix-les- 
Bains,  Aix-la-Chapelle,  Baden-Baden,  and  Wies- 
baden may  be  recommended  from  May  till  Sep- 
tember. The  other  places  named,  especially 
Hammam  R’lrha  in  Algiers,  are  winter  resorts. 
A voyage  to  the  tropics  or  subtropics  will  suit 
other  cases.  The  climate  of  Egypt  proves  bene- 
ficial in  some  instances ; and  advantage  may  be 
taken  there  of  the  Eastern  method  of  treating 
rheumatic  affections  by  means  of  baths  and  rub- 
bing, which  are  undoubtedly'  successful  in  some 
cases.  See  Mineral  Waters. 

The  most  valuable  internal  remedies  for  rheu- 
matic arthritis  aro  cod-liver  oil,  iron,  and  arsenic. 
Cod-liver  oil  should  be  taken  regularly  if  the 
digestion  permit.  Either  iron  or  arsenic,  or  the 
two  combined,  should  bo  taken  in  full  doses  for 
periods  of  weeks  or  months,  and  their  effect  care- 
fully noted.  Dr.  Garrod  especially  recommends 
the  syrup  of  the  iodide  of  iron. 

The  diet  should  be  carefully  ordered.  Whilst 
all  excess  is  avoided,  as  well  as  indulgence  in 
malt  liquors,  wines,  and  rich  indigestible  dishes, 
a generous  supply  of  mixed  animal  and  vege- 
table food  will  be  found  to  be  most  suitable.  The 
clothing  must  bo  warm,  flannel  or  other  woollen 
material  being  worn  both  summer  and  winter. 
The  greatest  possible  care  must  be  exercised  to 
avoid  cold  and  damp,  in  the  choice  of  a residence 
and  in  the  routine  of  daily  life. 

The  local  treatment  is  to  be  considered  of 
hardly  less  importance  than  the  constitutional. 
On  the  first  appearance  of  the  disease,  counter- 
irritation should  be  freely  applied  to  the  joints. 
The  most  convenient  form  is  iodine  paint,  which 
should  be  used  so  freely  that  the  skin  becomes 
of  a mahogany  colour,  and  desquamation  follows 
in  a few  days.  The  joints  should  be  carefully 
protected  by  cotton-wool  or  flannel.  Between 
the  subacute  attacks  of  the  disease,  efforts  should 
bo  made  to  restore  the  healthy  nutrition  of  the 
affected  joints.  Whilst  the  internal  treatment 
already  indicated  is  persevered  with,  ora  trial  is 
given  to  guaiacum  or  iodide  of  potassium  in  ob- 
stinate cases,  counter-irritation  should  be  replaced 
by  a method  of  less  severe  but  systematic  stimu- 
lation. The  joints  that  can  be  easily  reached 
should  be  thoroughly  fomented  night  and  morn- 
ing, by  wrapping  a piece  of  cambric  or  flannel 
around  them,  and  sponging  water  over  this,  as 
hot  as  can  be  borne.  After  several  minutes  of 
such  treatment  the  joint  should  be  thoroughly 
rubbed,  either  with  a stimulating  liniment,  such 
as  the  turpentine  or  acetic,  turpentine  liniment, 
with  a mild  mercurial  ointment,  or  with  some 
bland  oil,  such  as  cod-liver  oil  or  goose-grease. 
The  effect  of  such  local  treatment,  if  pursued 
steadily,  is  in  the  experience  of  the  writer  often 
remarkable,  mobility  being  restored  in  cases 
where  the  joints  have  been  useless  for 
months. 

In  very  advanced  cases,  especially  in  old  sub- 
jects, it  is  manifestly  impossible  to  expect  much 
improvement.  Anodyne  treatment  is  then  chiefly 
called  for,  and  a good  deal  can  be  done  in  this 
direction  by  well-chosen  local  applications,  the 
preparations  of  opium  being  of  course  the  most 
successful.  The  general  health  will  demand  sup- 


RHEUMATISM,  ACUTE. 

port  by  a well-regulated  diet,  and  the  interna* 
treatment  suggested  above. 

J.  Mitchell  Bruce. 

RHEUMATIC  FEVER. — A popular  syno- 
nym for  acute  rheumatism.  See  EHECitATisir, 
Acute. 

RHEUMATIC  GOUT. — A popular  name 
for  several  kinds  of  chronic  joint-disease,  espe- 
cially rheumatic  arthritis  and  chronic  rheuma- 
tism. 

RHEUMATISM,  Acute  (|5e0/ia,  a fluxion). — 
Synon.  : Rheumatic  Fever ; Fr.  Rhumalisme  ar- 
ticulaire  aigu;  Ger.  Hitziger  Gelenkrheumatismw. 

Definition. — An  acute  febrile  disease  ; caused 
by  certain  obscure  climatic  and  diathetic  in- 
fluences ; and  characterised  by  pyrexia,  sweats, 
and  acute  shifting  inflammation  of  the  joints  and 
other  structures. 

./Etiology. — Predisposing  causes. — Of  the 
predisposing  causes  of  acute  rheumatism,  the 
most  important  is  inheritance,  which  can  be 
traced  in  27  per  cent,  of  all  cases.  Previous  at- 
tacks increase  the  liability  to  a return  of  the 
disease ; but  there  is  a limit  to  predisposition 
from  this  cause  after  several  attacks.  The  great 
majority  of  first  attacks  occur  in  persons  under 
the  age  of  thirty  ; and  the  larger  proportion  of 
these  between  the  ages  of  sixteen  and  twenty-five. 
At  the  same  time,  rheumatism  is  by  no  means 
uncommon  either  in  children  or  in  persons  past 
middle  life.  Rather  more  males  than  females 
suffer;  but,  apart  from  other  circumstances,  the 
influence  of  sex  is  inconsiderable.  Occupation 
and  social  position  are  important  as  predisposing 
causes;  laborious  outdoor  occupations,  in  which 
persons  are  exposed  to  chills,  poverty,  and  the 
many  evils  associated  with  these,  contributing 
to  furnish  the  largest  percentage  of  cases.  Cer- 
tain regions  or  districts,  or  even  parts  of  dis- 
tricts, appear  to  deserve  the  name  of  ‘rheu- 
matic,’ from  the  number  of  residents  who  suffer 
from  the  disease,  and  from  the  probability  that 
a person,  otherwise  predisposed  to  rheumatism, 
will  be  more  likely  to  be  attacked  if  he  enter  such 
an  area. 

Determining  causes. — The  most  common  ex- 
citing cause  of  acute  rheumatism  is  exposure  tc 
cold  and  wet ; or,  to  express  the  same  fact  in 
other  words,  the  disease  has  an  intimate  atiolo- 
gical  relation  to  weather,  season,  and  climate. 
Some  apparent  exceptions  to  this  statement  really 
accord  with  it;  thus  acute  rheumatism  is  not 
uncommon  in  warm  weather,  on  account  of  the 
frequency  of  chills  from  over-heating.  Rheuma- 
tism may  suddenly  make  its  appearance  after  a 
sprain  or  other  injury  to  a joint,  which  may  also 
determine  the  distribution  of  the  disease  in  the 
articulations.  Similarly,  the  order  of  invasion 
of  the  several  joints  is  due  in  some  instances  to 
the  amount  cf  exercise  to  which  they  have  been 
respectively  subjected.  Anattackof  acuterheu- 
matism  is  occasionally  referred  to  derangement 
of  digestion,  and  of  the  functions  of  the  liver, 
especially  in  subjects  who  have  previously  su;- 
fered.  Indulgence  in  abundant  rich  or  indi- 
gestible food  will  certainly  determine  a relapse 
in  persons  convalescing  from  the  disease,  and 
may  possibly  induce  an  attack  in  the  predisposed 


RHEUMATISM,  ACUTE. 


Depressing  bodily  or  mental  influences  may  ex- 
eite  rheumatism  under  similar  circumstances. 
Exhaustion  by  lactation,  or  by  chronic  uterine 
diseases,  tedious  convalescence,  the  puerperal 
state,  and  possibly  simple  despondency,  may  act 
in  this  way  in  different  instances. 

Anatomical  Chakactjsp.s. — The  ■post-mortem 
appearances  in  acute  rheumatism  are,  on  the 
whole,  remarkably  negative,  not  so  much  on 
account  of  the  absence  of  morbid  changes  in  the 
affected  parts,  as  from  the  slight  degree  to  which 
these  changes  have  advanced.  On  opening  an 
affected  joint,  we  find  moderate  hypersemia,  with 
occasional  ecchymosis,  of  the  synovial  membrane 
and  fibrous  tissues  connected  with  the  articula- 
tion ; a somewhat  opaque,  granular,  swollen 
appearance  of  the  synovial  surfaces  ; and  a con- 
siderable amount  of  inflammatory  effusion.  This 
effusion  is  generally  a thin,  clear,  alkaline,  albu- 
minous fluid ; occasionally  turbid,  with  flakes  of 
fibrin  and  cell-products  ; rarely  purulent.  The 
cartilages  connected  with  the  joint  probably 
share  in  the  inflammatory  changes,  especially  if 
the  process  be  severe  ; and  the  associated  soft 
parts,  including  the  tendons  and  their  sheaths, 
are  very  frequently  hyperaemic,  and  the  seat  of 
effusion. 

A fatal  termination  in  acute  rheumatism  is 
always  the  result  of  somo  complication,  inter- 
current disease,  or  injury;  and  in  such  cases  the 
non-arthritic  lesions  are  necessarily  the  most 
important.  Of  these  the  most  frequent  are 
congestion  or  inflammation  of  the  lungs,  and 
inflammation  of  the  heart  and  pericardium.  In- 
flammation of  the  pleura  is  much  less  commonly 
found;  and  in  rarer  instances  inflammation  of 
the  peritoneum,  larynx,  testes,  and  renal  tubules. 
When  pyrexia  has  been  great  the  solid  viscera 
present  granular  degeneration,  and  are  prone  to 
rapid  decomposition ; and  in  cases  of  hyperpy- 
rexia the  blood  is  fluid.  The  blood  has  frequently 
been  subjected  to  chemical  analysis,  but  without 
any  positive  result  of  a pathological  kind.  The 
reaction  of  the  liquor  sanguinis  is  alkaline,  as 
in  health.  The  fibrin  has  been  said  to  increase 
in  amount  to  1 per  cent,  instead  of  ’2  per  cent. 
The  amount  of  urea  is  not  above  the  normal. 
Neither  uric  acid,  lactic  acid,  nor  any  other  ab- 
normal principle  has  been  found  in  the  blood 
during  an  attack  of  acute  rheumatism. 

Patholoot. — The  pathology  of  acute  rheuma- 
tism is  still  obscure,  and  in  the  present  article 
it  will  be  sufficient  to  enumerate  the  principal 
theories  upon  the  subject. 

1.  Lactic  acid  theory. — Lactic  acid  accumu- 
lates in  the  body,  and  the  symptoms  are  directly 
referable  to  the  action  of  this  poison  upon  the 
system  (Prout,  Todd,  Richardson). 

.2.  Xcrvons  theory.  — Chill  of  the  peripheral 
parts  of  the  body,  especially  of  the  skin  and 
joints,  causes  disturbance  of  corresponding  parts 
of  the  central  nervous  system ; and  this  gives 
rise  to  pain  and  vaso-motor  (?)  or  trophic  changes 
of  the  same  peripheral  parts,  and  to  fever  (Can- 
statt;  Seitz). 

3.  Combination  of  1 and  2. — Chill  causes  ac- 
cumulation or  retention  of  lactic  acid;  this  acts 
on  the  central  nervous  system  ; and  the  dis- 
ordered nervous  centres  react  upon  the  joints, 
&c.  as  in  2 (Senator). 


135  6 

4.  Combination  of  2 and  1 . — Chill  disturbs  the 
nervous  system ; this  disturbs  nutrition  gene- 
rally; lactic  or  some  other  acid  is  retained,  and 
acts  as  a poison,  as  in  1 (Fuller). 

5.  Infective  theory. — Chills  are  attended  with 
the  entrance  of  micrococci  into  the  system,  and 
endocarditis  is  the  result.  The  joint-symptoms 
are  secondary  and  embolic,  as  in  pyaemic  arthritis 
(Hueter). 

6.  Germ  theory. — The  disease  is  due  to  the 
presence  in  the  blood  of  a vegetable  organism 
of  definite  characters — Zymotosis  translucens 
(Salisbury). 

7.  Malarial  theory. — Rheumatism  is  duo  to 
the  presence  in  the  system  of  a poison,  which  is 
of  the  nature  of  a miasm,  entering  from  with- 
out. This  miasm  is  generically  allied  to,  but, 
specifically  distinct  from,  the  miasm  of  malarial 
fever  (Maclagan). 

Without  attempting  to  criticise  these  theories 
we  may  conclude  that,  whilst  the  true  pathology 
of  acute  rheumatism  cannot  possibly  be  settled 
until  the  essential  nature  of  fever  is  thoroughly 
understood,  the  most  promising  directions  from 
which  we  may  expect  light  to  be  thrown  upon  it 
are,  first,  the  effect  on  the  system  of  organic 
poisons,  whether  introduced  from  without,  or 
produced  within  it  as  the  intermediate  products 
of  nutrition  ; and,  secondly,  the  intimate  relation 
of  the  nervous  system  to  the  body-heat,  to  the 
skin,  and  to  nutrition. 

Under  these  circumstances  it  is  impossible  at 
present  to  estimate  the  respective  significance 
and  relative  importance  of  the  phenomena  con- 
stituting the  ‘ disease  ’ rheumatism.  But  for  the 
purpose  of  intelligible  description,  it  is  neces- 
sary that  such  of  the  phenomena  as  are  only  oc- 
casional in  their  appearance  should  bo  separated 
from  such  as  are  constant ; and  that  the  latter 
should  be  treated  as  the  essential  symptoms 
of  the  disease,  whilst  the  former  are  regarded 
as  complications.  The  constant  phenomena  of 
acute  rheumatism,  thus  considered,  are  probably 
but  three,  namely,  fever,  sweats,  and  arthritis  ; 
whilst  inflammation  of  the  cardiac  structures, 
lungs,  and  serous  membranes  would  be  included 
under  the  head  of  the  occasional  phenomena  or 
complications.  This  plan  of  description  of  acute 
rheumatism  will  be  adopted  in  the  present  ar- 
ticle, for  convenience’  sake  only,  and  will  imply  no 
actual  criticism  of  the  theories  of  the  pathology 
of  the  disease  just  enumerated;  athough  with 
several  of  them  it  necessarily  cannot  agree. 

Symptoms.  — General  description.—  After 
suffering  for  a time  from  aching  pains  in  the 
limbs  and  trunk,  flying  pains  and  stiffness  in  the 
joints,  malaiso,  chilliness,  and  sore-throat,  the 
subject  of  an  attack  of  acute  rheumatism  is  seized 
with  severe  pain  in  one  or  more  of  his  joints, 
experiences  a chill  or  slight  rigor,  and  is  found 
to  have  several  degrees  of  fever.  The  local  and 
general  symptoms  quickly  develop ; and  a striking 
picture  is  presented  by  tho  patient.  He  lies  mo- 
tionless in  bed,  flat  on  his  back,  with  every  joint 
at  rest  and  carefully  guarded.  The  neck,  back, 
and  legs  are  straight;  the  arms  folded  across 
tho  body,  or  extended  along  either  side  ; the 
eyes  alone  are  moved,  and  follow  the  practitioner 
as  he  approaches  the  bedside.  The  face  is  found 
bedewed  with  perspiration ; and  the  rest  cf  the 


RHEUMATISM,  ACUTE. 


1356 

body  is  profusely  covered  with  sweat,  which  gives 
off  a sour,  acrid  odour.  The  countenance  is  full, 
heavy,  and  expressive  of  a subdued  feeliDg  of 
pain  and  dread  of  movement;  the  complexion  may 
le  of  a dirty,  sallow  colour,  or  even  slightly  jaun- 
diced ; and  the  cheeks  are  probably  flushed.  The 
affected  joints  prove  to  be  swollen  and  red;  hot 
to  the  touch ; remarkably  tender  ; and  the  seat 
of  pain,  which  varies  much  in  character  and 
intensity.  One  joint,  or  several,  or  nearly 
every  joint  in  the  body,  may  be  found  in  the 
condition  just  described.  The  patient  complains 
of  a feeling  of  illness,  thirst,  and  anorexia; 
the  tongue  is  foul  and  creamy ; the  throat  is 
somewhat  sore ; and  the  bowels  are  irregular. 
The  pulse  is  frequent,  weak  even  to  dierotism, 
and  rather  full.  Respiration  is  somewhat  ac- 
celerated ; and  there  may  be  slight  cough.  The 
urine  is  scanty,  high-coloured,  very  acid,  and 
loaded  with  lithates.  The  skin  is  covered  with 
perspiration,  congested,  and  warm  ; and  probably 
presents  sudamina  or  miliaria  in  places.  The 
patient’s  mind  is  perfectly  clear,  and  his  atten- 
tion appears  to  be  chiefly  directed  to  the  main- 
tenance of  the  affected  joints  in  the  most  easy 
position  possible.  Until  successful  in  this  en- 
deavour he  is  restless  and  miserable ; and  even 
if  he  have  obtained  temporary  relief  and  have 
gone  to  sleep,  he  is  liable  to  be  suddenly  aroused 
by  involuntary  spasm  of  the  muscles  connected 
with  the  affected  joints.  The  pain  is  so  severe 
when  the  disease  is  at  its  height,  that  sleep  can- 
not be  obtained. 

Such  is  the  condition  of  a patient  suffering 
from  a fully-developed  attack  of  uncomplicated 
rheumatism.  For  a period,  which  would  appear 
to  be  perfectly  indefinite,  these  symptoms  con- 
tinue, varying  considerably  in  intensity  from  day 
to  day.  Rut  whilst  the  condition  thus  persists, 
the  remarkable  and  characteristic  fact  is  con- 
stantly observed  in  this  disease,  that  the  arthritic 
phenomena  are  at  once  transient  and  erratic,  that 
is,  that  the  rheumatism  passes  rapidly  from  joint 
to  joint,  the  joints  which  were  affected  the  one  day 
being  nearly  well  the  next,  and  a fresh  series 
swollen  and  painful.  In  this  manner  most  of  the 
joints  of  the  limbs  may  have  been  affected  in  the 
course  of  a week,  and  the  number  of  joints  si- 
multaneously affected  is  very  variable.  There- 
after the  disease  may  make  a further  invasion  of 
joints  previously  involved,  and  that  repeatedly. 

At  last,  the  rheumatism  appears  to  have  ex- 
hausted itself ; no  fresh  joint  is  attacked ; and  the 
parts  last  affected  lose  more  or  less  completely 
the  final  traces,  both  objective  and  subjective,  of 
the  severe  process  which  they  have  undergone, 
being  for  some  time,  however,  stiff,  feeble,  and 
painful  on  movement.  The  patient  now  assumes 
a less  constrained  posture  ; the  other  symptoms 
decline;  the  perspirations  disappear;  the  counte- 
nance becomes  more  bright ; spirits  and  strength 
return ; tho  tongue  cleans,  and  the  appetite  is 
rapidly  restored;  the  pulse  falls  in  frequency; 
urine  is  passed  in  greater  quantity,  is  less  acid, 
aud  no  longer  deposits  urates ; and  the  tempera- 
ture falls  to  the  normal. 

The  patient  being  convalescent,  a relapse  of 
the  disease  by  no  means  uncommonly  occurs, 
after  a few  days  or  w'eeks ; and  that  in  any  de- 
gree, from  a slight  swelling,  redness,  and  pain  of 


a single  joint,  to  a combination  of  the  various 
symptoms,  as  severe  as  the  first,  or  possibly 
more  so. 

Analysis  of  symptoms. — Invasion. — In  the 
great  majority  of  cases  the  patient  gradually 
‘ sickens  for’  acute  rheumatism  for  several  days 
before  the  symptoms  are  fully  declared.  He  feels 
ill  and  out  of  sorts,  chilly,  indisposed  to  eat  or 
work;  sleeps  badly;  complains  of  slight  sore- 
throat,  aching  pains  in  the  limbs,  and  shooting 
shifting  pains  in  the  joints;  and  presents  a sal- 
low, patchy  complexion,  and  a dull,  heavy  yel- 
lowish appearance  of  the  eyes.  Altogether,  the 
condition  of  the  patient  is  very  much  that  of  the 
subject  of  a severe  catarrh;  the  tongue,  diges- 
tion, bowels,  urine,  and  pulse  presenting  the  or- 
dinary characters  of  moderate  fever.  On  careful 
examination  it  is  found  that  the  pains  are  of  two 
kinds.  The  first  kind  are  by  far  the  more  severe, 
and  consist  of  severe  muscular  aching  in  various 
parts  of  the  limbs  and  trunk;  whilst  the  second 
kind  are  of  the  nature  of  flyingpains  in  the  joints 
or  associated  parts.  The  muscular  aching  ap- 
pears to  be  similar  to,  or  even  identical  with  the 
‘break-bone’  pains  which  are  familiar  in  common 
catarrh,  and  in  the  invasion  stage  of  some  erup- 
tive fevers.  They  are,  therefore,  not  character- 
istic. The  flying  pains,  which  are,  however,  not 
always  present — especially  in  first  attacks,  are 
actually  situated  in  the  articulations,  forinstance 
the  ankles,  knees,  or  wrists,  and  are  of  the  nature 
of  sharp  twinges,  suddenly  leaving  one  joint  to 
return  as  quickly  in  another.  Towards  the  end 
of  the  stage  of  invasion,  these  pains  become  less 
‘shifting;’  and  when,  as  the  patient  will  say, they 
have  ‘settled’  in  one  or  more  joints,  the  rheu- 
matism has  passed  into  the  second  stage,  that  of 
the  declared  disease.  Stiffness  of  the  joints  may 
also  be  present,  especially  in  recurrent  attacks. 

In  the  invasion  period  the  skin  does  not  yet 
present  the  perspiratory  activity  which  is  sc 
characteristic  a symptom  of  acute  rheumatism ; 
but  rather  a moistness,  gre:isiness,  or  oiliness, 
with  heat  and  some  congestion.  The  tempera- 
ture is  raised  one  degree  or  more.  The  sore- 
throat,  which  consists  in  pharyngeal  catarrh, 
follicular  tonsillitis,  or  even  actual  acute  suppu- 
rative inflammation,  is  remarkably  characteristic. 
The  milder  forms  are  soon  lost  in  the  more  urgent 
symptoms. 

The  duration  of  the  stage  of  invasion  of  acute 
rheumatism  varies  greatly,  the  flying  pains  in 
the  joints  ‘ settling’  much  more  quickly  in  some 
cases  than  in  others.  In  a small  proportion  oi 
cases  the  disease  is  so  rapidly  developed  that  the 
stage  of  invasion  is  wanting.  The  patient  on 
waking  in  the  morning  finds  one  or  more  joints 
affected ; or  he  appears  to  be  struck  down  during 
the  day  without  the  slightest  warning;  and  in- 
stances are  not  uncommon  in  which  persons,  thus 
suddenly  seized  with  acute  rheumatism,  have 
been  removed  to  hospital,  for  supposed  sprain  or 
fracture  of  the  limbs.  In  rarer  instances  the 
feverish  symptoms  of  the  invasion  stage  may  be 
well-marked  without  any  pains  whatever. 

Declared  disease. — 1.  Phenomena  eonneeted 
with  the  joints. — The  physical  signs  presented  t y 
a joint  affected  with  acute  rheumatism  naturally 
vary  much.  The  swelling  is  usually  considerable, 
and  is  chiefly  referable  to  effusion  into  the  cavity 


RHEUMATISM,  ACUTE. 


of  the  articulation,  fluctuation  being  frequently 
discoverable.  It  is  rare  for  the  peri-articular 
effusion  to  be  so  abundant  as  to  yield  pitting  on 
pressure.  The  amount  of  intra-articular  effusion 
(as  well  as  the  pain)  greatly  influences  the  po- 
sition of  the  joint,  but  most  joints  are  main- 
tained in  a position  a few  degrees  removed  from 
extension.  Careful  examination  will  determine 
the  increase  and  the  disappearance  of  the  swell- 
ing, as  the  joints  are  attacked  and  recover 
respectively. 

Pain  is  the  most  distressing  of  all  the  eymp- 
toms  in  uncomplicated  rheumatism.  It  is  always 
severe,  and  sometimes  almost  unbearable ; but 
it  varies  with  the  different  joints,  and  with 
the  degree  and  duration  of  their  involvement, 
In  degree  it  may  be  said  to  increase  steadily 
for  several  hours ; it  remains  excessive  for  a 
time;  and  it  then  slowly  and  steadily  declines. 
Its  character  is  very  differently  described  by 
different  sufferers.  When  a joint  is  attacked  by 
rheumatism,  the  first  sensation  felt  by  the  patient 
is  one  of  soreness  on  movement.  As  the  condition 
develops,  the  soreness  increases  to  an  ache  of  a 
subdued,  throbbing  character.  In  the  course  of 
a few  hours  the  ache  ‘ works  up’  into  an  intense 
pain,  apparently  associated  with  a feeling  of  cramp, 
the  slightest  movement  of  the  articulation  being 
almost  unbearable.  The  severe  pain  now  gra- 
dually declines — in  some  instances  from  the  time 
the  swelling  reaches  its  height.  After  several 
hours  the  onty  pain  that  remains  is  a distressing 
sensation  as  if  the  parts  had  been  severely 
bruised ; and  the  effusion  which  accompanied  the 
excessive  pain  having  declined  along  with  it, 
rest  of  the  joint  again  becomes  all-important, 
the  very  slightest  movement  being  sufficient  to 
restore  the  wearying  ache.  Finally,  the  pain 
completely  disappears,  and  nothing  remains  be- 
yond. a feeling  of  stiffness  and  helplessness  when 
the  joint  is  moved. 

Whilst  the  course  of  the  pain  of  an  acute 
rheumatic  attack  is  usually  such  as  has  been 
described,  it  is  greatly  modified  by  a variety  of 
circumstances,  such  as  the  particular  joint  af- 
fected, the  age  and  sex  of  the  patient,  the  condi- 
tion of  the  nervous  system,  and  the  presence  of 
certain  temperaments.  In  some  instances  the 
pairs  are  increased  at  night. 

Tenderness  is  a constant  and  well-marked 
symptom  of  acute  rheumatism.  Reference  has 
already  been  made  to  the  effect  of  movement  on 
the  pain  in  its  different  stages,  especially  towards 
the  end ; and  to  the  characteristic  posture  and 
anxious  expression  of  the  patient,  who  suffers 
intensely  from  the  slightest  shake  of  the  bed,  or 
even  a footfall  on  the  lloor.  Tenderness  finally 
declines  into  the  feeling  of  stiffness. 

The  redness  of  a rheumatic  joint  is  a simple 
pink  blush  of  erythema,  very  rarely  purpuric. 
Its  intensity  varies  much  with  the  deep  or  super- 
ficial situation  of  the  articulation,  and  it  is 
therefore  most  marked  in  connection  with  the 
joints  of  the  hands  and  feet,  the  knees,  and  the 
ankles. 

Heat  of  the  affected  joint  is  a well-marked 
objective  sign  of  acute  rheumatism.  The  articu- 
lation feels  decidedly  warmer  to  the  hand  than 
the  surrounding  parts ; and  this  observation  is 
eonfirmed  by  the  thermometer. 


1357 

The  electrical  sensibility  of  the  skin  connected 
with  an  acutely  rheumatic  joint  has  been 
described  by  Drosdoff  as  being  remarkably 
diminished,  the  area  of  nervous  alteration  cor- 
responding exactly  with  the  area  of  redness,  and 
its  duration  with  the  duration  of  the  other  local 
signs  and  symptoms. 

The  favourite  joints  involved  in  acute  rheuma 
trlsm  are  the  larger  articulations,  especially  the 
knees,  ankles,  wrists,  shoulders,  and  elbows ; the 
hip  joint  less  frequently  than  the  others.  The 
fingers  come  next  in  order  of  frequency ; then  the 
toes  ; whilst  the  remaining  articulations  are  more 
rarely  affected. 

Corresponding  rather  closely  with  the  frequency 
of  attack  is  the  favourite  order  of  invasion  ; the 
ankles  being  more  frequently  the  first  to  be  in- 
volved, then  the  knees,  and  so  on.  In  other 
instances  it  is  observed  that  the  disease  passes 
along  the  joints  of  the  lower  limbs,  including  the 
hips,  to  those  of  the  upper  limbs  ; frequently  its 
distribution  is  symmetrical  bilaterally ; whilst  in 
some  cases  it  is  unilateral,  the  homologous  joints 
of  the  upper  and  lower  limb  being  simultaneously 
invaded.  The  smaller  joints  suffer,  as  a rule, 
towards  the  termination  of  the  attack. 

2.  Disorders  of  neiylibouring  muscles. — The 
muscular  pains  of  the  stage  of  invasion  of  acute 
rheumatism  disappear  in  the  declared  disease, 
or  are  lost  in  the  presence  of  more  severe  symp- 
toms. They  are  replaced,  however,  by  pains  in 
the  soft  parts  of  the  limbs  related  to  the  affected 
joints,  especially  the  muscular  insertions  and 
fasciae  ; and  even  the  whole  limb  may  ache,  with 
much  stiffness  and  a feeling  of  utter  powerless- 
ness. Painful  twitchings  are  also  common,  espe- 
cially during  sleep;  and  when  the  acute  pain 
has  passed  off,  marked  muscular  debility  remains 
behind. 

8.  Temperature.  — Acute  rheumatism  is  at- 
tended by  well-marked  pyrexia,  but  this,  like  the 
disease  as  a whole,  is  variable  in  degree,  course, 
and  duration.  The  sudden  invasion  of  the  seve- 
ral joints,  their  speedy  relief,  the  alternation  of 
extreme  bodily  distress  with  comparative  com- 
fort, and  especially  the  variety  of  pyrexic  dis- 
eases with  which  the  rheumatism  may  he  com- 
plicated, would  hardly  lead  us  to  expect  a typical 
temperature  curve.  In  uncomplicated  cases, 
however,  the  fever  follows  a tolerably  definite 
course.  Pyrexia  makes  its  appearance  at  inva- 
sion ; it  continues  as  long  as  the  local  symptoms 
preserve  an  acute  or  subacute  character ; and 
with  them  it  declines  and  disappears.  The  de- 
gree of  the  pyrexia,  in  the  great  majority  of  cases, 
is  in  direct  proportion  to  the  severity  of  the 
joint-disease.  Mild  local  symptoms — that  is, 
moderate  pain,  short  duration  of  symptoms  in 
any  given  joint,  and  a small  number  of  joints 
affected,  are  accompanied  by  moderate  fever, 
ranging  from  99°  to  102°  Fahr.  On  the  other 
hand,  severe  local  symptoms — that  is,  severe 
pain,  the  full  development  of  the  several  signs 
in  the  affected  parts,  and  the  simultaneous  in- 
volvement of  several  joints,  are  attended  by  a 
temperature  of  101°  to  10-1°  Fahr.  In  another, 
but  very  small  class  of  cases,  the  temperature, 
whatever  it  may  previously  have  been,  rises 
rapidly  to  an  alarming  height,  so  as  to  be  en- 
tirely out  of  proportion  to  the  joint-symptoms, 


RHEUMATISM,  ACUTE. 


i358 

which  either  continue  as  before,  or  even  dis- 
appear. This  condition  of  hyperpyrexia  is  re- 
garded in  the  light  of  a complication,  and  as 
Bueh  'will  be  presently  described. 

The  type  of  the  fever  in  uncomplicated  cases 
is  remittent,  the  thermometer  rising  -25°,  '50°,  or 
D0°Fh.  in  the  evening.  The  primary  elevation 
of  temperature  at  the  commencement  of  the  dis- 
easo  is  somewhat  rapid;  the  decline  or  defer- 
vescence is  decidedly  more  gradual,  although  it 
is  generally  irregular,  being  almost  invariably 
broken  by  temporary  rises,  or  interrupted  by  the 
supervention  of  some  pyrexic  complication.  The 
occurrence  of  a relapse  is  marked  by  a return  of 
pyrexia,  which  probably  presents  the  same  gene- 
ral characters  as  before. 

4.  Skin. — Profuse  acid  sweats  constitute  one 
of  the  characteristic  phenomena  of  acute  rheu- 
matism. The  brow  is  covered  with  drops  which 
trickle  down  the  face;  and  the  whole  body 
perspires  profusely,  and  is  bathed  in  an  atmo- 
sphere of  wet  steam.  Although  usually  uni- 
versal, the  sweats  may  sometimes  be  unequally 
distributed.  It  is  doubtful  whether  any  relation 
can  be  traced  between  the  amount  of  perspiration 
and  the  hour  of  the  day  or  night,  the  tempera- 
ture, or  the  pulse  ; but  it  perhaps  varies  directly 
with  the  severity  of  the  pain.  The  sweats  con- 
tinue throughout  the  whole  attack,  making  their 
appearance  at  an  early  date  and  disappearing 
gradually  with  the  subsidence  of  the  other  symp- 
toms. They  do  not  intermit  in  the  striking  way 
of  the  sweats  of  the  hectic  or  septic  states,  un- 
less towards  the  end  of  a severe  protracted  at- 
tack, when  the  patient  is  greatly  debilitated ; but 
at  certain  parts  of  the  day  the  skin  may  be  found 
to  be  perspiring  less  freely,  or  even  to  be  per- 
fectly dry.  The  sweat  of  acute  rheumatism  pos- 
sesses a peculiar  sour,  acrid  smell;  and  this  is  so 
powerful,  and  pervades  so  thoroughly  the  neigh- 
bourhood of  the  patient  when  the  blankets  are 
disturbed,  that  the  diagnosis  of  the  disease  can 
frequently  he  made  from  it  alone.  Like  the  sweat 
in  health,  it  is  acid  in  reaction,  rarely  alkaline 
from  decomposition.  No  other  test  can  be  readily 
applied  to  it  clinically.  The  rheumatic  patient 
may  complain  of  the  unpleasant,  but  never  of  the 
‘ weakening  ’ effect  of  the  perspirations  which  is 
observed  in  hectic  fever;  on  the  contrary,  he 
may  describe  them  as  bringing  great  relief  to 
the  bodily  condition.  In  Rss  acute  cases  the 
skin  may  present  a shiny  or  greasy  appearance, 
rather  than  actual  perspiration.  When  the 
sweats  are  severe,  sudamina  make  their  appear- 
ance, especially  about  the  trunk;  and  in  some 
cases  the  skin  is  covered  with  a profuse  eruption 
of  miliaria. 

5.  Digestive  system. — The  tongue  is  covered 
with  a thick,  white,  moist  fur,  which  varies 
closely  with  the  rheumatic  condition,  and  serves 
as  a ready  indication  of  the  same.  The  thickness 
of  the  coating  is  sometimes  very  great.  Occa- 
sionally the  tongue  is  dry ; very  rarely  brown, 
baked-looking,  or  cracked.  The  sense  of  taste 
is,  in  a greatmeasure,lost ; the  mouth  is  parched; 
thirst  is  urgent  and  difficult  to  satisfy  ; and  the 
reaction  of  the  saliva,  or,  more  correctly,  of  the 
fluids  of  the  mouth,  is  said  to  become  acid.  Ap- 
petite is  lost,  until  the  disease  begins  to  decline, 
when  hunger  returns  very  early  and  urgently. 


Sore-throat  occurs  in  some  cases  during  the  de 
dared  disease,  but  is  much  less  common  than  in 
the  stage  of  invasion.  Sickness  is  rarely  present. 
Dyspepsia,  attended  with  flatulence,  is  common, 
unless  the  most  digestible  food  only  be  given. 
Irregularity  of  the  bowels  i3  characteristic  of 
acute  rheumatism,  either  constipation  or  diar- 
rhma  being  almost  constantly  present;  and  the 
two  conditions  frequently  alternate.  Diarrhoea 
is  perhaps  more  common  in  first  than  in  subse- 
quent attacks.  The  motions  are  dark  and  foul. 
Pains  in  the  belly  are  by  no  means  rare,  and  are 
frequently  connected  with  diarrhoea,  but  they 
occur  also  in  constipation ; and  at  times  they  are 
accompanied  by  attacks  of  distressing  flatulence. 

6.  Circulation.  — The  circulatory  symptoms 
proper  to  acute  rheumatism  are  modified  by 
complications  affecting  the  heart  in  a very  large 
proportion  of  cases.  When  no  special  circulatory 
complication  exists,  the  pulse  is  regular,  80  to 
120,  full,  sometimes  hard,  sometimes  soft,  or  even 
dicrotic ; but  it  naturally  varies  much  with  the 
severity  and  stage  of  the  disease.  The  effect  of 
the  various  complications  on  the  pulse  will  he 
presently  described. 

7.  Respiratory  system.  — The  frequency  of 
the  respirations  in  uncomplicated  rheumatism  is 
somewhat  increased;  slight  cough  is  occasion- 
ally present;  and  under  these  circumstances  a 
few  dry  rhonchi  may  be  heard  over  the  chest.  On 
the  other  hand  respiratory  complications  may  be 
of  a serious  and  even  fatal  character,  and  will 
demand  consideration  in  their  proper  place. 

8.  Urine. — Throughout  an  attack  of  acute 
rheumatism  the  urine  is  scanty,  high-coloured, 
and  strongly  acid  ; and  it  deposits  a quantity  of 
urates.  Albuminuria  is  rare.  Quantitatively 
examined,  the  urine  is  found  to  contain  an  actual 
excess  of  urea,  and  a considerable  (but  probably 
only  a relative)  excess  of  uric  acid,  colouring 
matter,  and  sulphates ; the  water  is  below  the 
normal  amount ; and  the  chlorides  are  diminished, 
although  less  so  than  in  pneumonia.  Lactic  acid 
has  never  been  found  in  excess.  Any  marked  de- 
parture from  these  characters  of  the  urine,  espe- 
cially in  the  appearance  of  more  than  a passing 
trace  of  albumin,  is  to  be  considered  as  a com- 
plication of  the  rheumatism. 

9.  Nervous  system.— As  a rule,  consciousness  and 
clearness  of  intellect  are  preserved  throughout. 
Delirium  is  very  uncommon ; and  when  either 
delirium  or  stupor  supervenes,  it  will  generally 
be  found  that,  in  otherwise  uncomplicated  cases, 
the  temperature  has  risen  to  an  excessive  degree. 
Very  rarely  the  pyrexia  remains  moderate  in 
these  circumstances,  and  such  cases  have  been 
described  by  the  name  of  ‘ cerebral  rheumatism.’ 
There  is  generally  great  distress  of  mind  in  acute 
rheumatism ; and  in  other  than  first  attacks, 
the  previous  experience  of  its  protracted  course 
and  dangers,  and  the  recollection  of  the  pains  and 
other  sources  of  bodily  discomfort  greatly  affect 
the  patient,  and  produce  an  amount  of  anxiety 
which  is  almost  characteristic  of  the  disease. 
Sleep  is  either  impossible,  or  at  best  is  constantly 
broken  and  unrefreshing,  when  the  pain  is  severe. 

10.  Expresssion. — The  debility  or  prostration, 
which  forms  an  important  element  of  fever  from 
whatever  cause,  is  present  in  acute  rheumatism, 
but  it  is  in  a great  measure  obscured  by  the  ex- 


RHEUMATISM,  ACUTE. 


pression  referable  to  pain,  and  to  the  effort  to 
preserve  an  easy  position.  Towards  the  end  of 
an  attack,  when  pain  is  subsiding  and  movement 
is  comparatively  easy,  the  patient  and  the  prac- 
titioner begin  to  appreciate  the  degree  to  which 
the  bodily  strength  has  been  reduced.  This  loss 
is  always  great,  and  is  sometimes  extreme,  vary- 
ing, of  course,  with  the  severity  and  duration  of 
the  disease. 

Varieties. — The  description  just  given  ap- 
plies to  a fully-developed  attack  of  acute  rheu- 
matism, without  complication,  of  indefinite  but 
not  protracted  course,  and  of  favourable  termi- 
nation. It  is  only  a minority  of  cases,  however, 
that  are  of  this  nature.  Occasionally  the  symp- 
toms are  very  mild  or  the  attack  very  short,  in 
which  event  the  rheumatism  is  said  to  be  sub- 
acute. Again,  as  nearly  as  possible  every  second 
case  proves  to  be  complicated  with  some  affection 
of  the  viscera,  especially  the  organs  of  circula- 
tion and  respiration.  These  departures  from  the 
‘typical’  course  of  acute  rheumatism,  as  it  is 
called  for  the  sake  of  description,  will  next  be 
considered. 

Subacute  rheumatism. — Under  this  name 
are  comprised  a variety  of  cases  of  the  disease, 
which,  whilst  of  comparatively  little  severity, 
exhibit  the  greatest  possible  differences  in  their 
other  clinical  characters.  Several  well-marked 
groups  of  these  may  bo  distinguished,  and  de- 
mand separate  consideration. 

(a)  Th e first  group  of  subacute  cases  is  one  in 
which  the  duration  of  the  disease  is  unusually 
short — probably  from  ono  to  three  days.  The 
number  of  joints  affected  is  very  small ; and  the 
general  symptoms  appear  to  bo  arrested  before 
attaining  any  considerable  severity. 

(b)  In  a second  group  of  subacute  cases,  after 
exceedingly  mild  invasion-symptoms,  a single 
joint  only  is  attacked,  with  little  pyrexia,  whilst 
the  skin  presents  a shiny  or  oily  dampness  rather 
than  true  perspiration.  The  rheumatism  disap- 
pears in  a few  days  ; or  it  shortly  relapses  in  the 
same  or  in  some  other  joint.  Thisformof  subacute 
rheumatism  maybe  difficult  to  diagnosefrom  gout. 

( c ) Widely  different  from  the  foregoing  is  an- 
other and  the  most  common  variety  of  subacute 
rheumatism.  Such  are  many  of  the  recurrent  cases 
of  the  disease,  and  of  the  instances  of  first  attacks 
in  old  subjects.  It  may  be  stated  broadly  that 
the  first  attack,  or  first  and  second  attacks,  of 
rheumatism  are  more  severe  than  subsequent 
ones ; that  the  severity  diminishes  with  each  re- 
currence of  the  disease;  and  that  persons  attacked 
for  the  first  time  after  middle  life,  suffer  less  than 
younger  subjects.  In  all  these  cases,  the  pheno- 
mena connected  with  the  joints,  and  the  general 
symptoms,  including  the  pyrexia  and  the  sweats, 
are  mild  in  degree,  although  by  no  means  of  short 
duration.  In  recurrent  cases  the  patients  are 
frequently  the  subjects  of  chronic  heart-disease, 
in  whom  exposure  to  some  of  the  determining 
causes  of  rheumatism  has  lighted  up  fresh  endo- 
and  peri-carditis,  and  therewith  moderate  fever 
and  subacute  rheumatism  of  the  joints.  The 
anxiety  of  the  practitioner  will  be  confined  to  the 
condition  of  the  heart;  but  during  the  progress 
of  the  complaint,  joint  after  joint  may  become 
painful,  tender,  slightly  swollen,  and  red. 

( d ) Lastly,  there  is  a large  and  well-marked 


1359 

group  of  subacute  cases  of  rheumatism  in  which 
the  disease  runs  what  may  be  called  a latent 
course,  and  which  occur  especially  in  children. 
The  joints  are  so  slightly  affected  that  the  cha- 
racteristic signs  and  symptoms  of  rheumatism 
may  bo  entirely  overlooked.  Children  frequently 
pass  through  an  attack  of  acute  rheumatism, 
without  the  true  nature  of  the  complaint  being 
suspected  by  their  medical  attendant ; and  in 
other  instances  the  diagnosis  is  first  made  on  the 
discovery  of  one  or  other  of  its  familiar  com- 
plications, notably  heart-disease.  The  child  is 
feverish,  and  complains  of  pain  and  tenderness 
in  the  limbs.  Moderate  swelling  and  redness  of 
the  affected  joints  pass  unheeded  in  the  full  and 
high-coloured  body  of  the  patient ; and  pain  and 
tenderness  in  these  subjects  are  either  entirely 
disregarded,  or  referred  to  ‘growing,’  or  to  ‘a 
cold.’  Lastly,  the  sweats  are  much  less  profuse,  or 
entirely  wanting,  the  skin  being  hot  with  several 
degrees  of  fever.  Whilst  the  disease  in  children 
runs  this  exceedingly  mild  course,  and  one  which 
seldom  exceeds  a week  in  length,  it  is  accom- 
panied, in  a comparatively  large  proportion  of 
cases,  by  acute  cardiac  disease — a fact  which 
greatly  increases  the  necessity  for  its  early  dia- 
gnosis. A more  completely  latent  form  of  acute 
rheumatism  has  been  described  by  Graves,  in 
which  articular  symptoms  are  entirely  wanting, 
whilst  the  other  symptoms  may  be  of  the  usual 
character  and  follow  the  usual  course. 

When  these  four  prominent  groups  of  sub- 
acute rheumatism  have  been  described,  there  still 
remain  a large  number  of  mild  cases,  which 
are  too  indefinite  to  be  treated  of  in  a general 
article.  All  possible  varieties  of  the  disease  will 
be  encountered  in  practice,  according  as,  on  the 
one  hand,  the  ‘typical’  course  is  pursued,  or,  on 
the  other  hand,  the  disease  assumes  a subacute 
character. 

Course,  Duration,  and  Terminations. — The 
course  of  acute  rheumatism  is  extremely  indefi- 
nite. The  average  duration  of  acute  symptoms 
under  expectant  treatment  has  been  estimated  at 
nine  days  ; it  is  probably  rather  less  under  cer- 
tain other  methods  of  treatment;  audit  is  much 
prolonged  by  neglect.  The  entire  duration  oj 
an  attack  is  much  greater  than  this,  and  neces- 
sarily less  definite,  namely,  two  to  six  or  even 
ten  weeks  ; and,  speaking  broadly,  it  increases 
with  the  age  of  the  patient,  up  to  middle  age. 
Convalescence  is  generally  protracted  (before 
the  health  is  perfectly  restored) ; and  it  is  very 
common  to  hear  persons  who  have  suffered  from 
acute  rheumatism  state  three  or  four  months  as 
the  time  they  were  ‘ ill.’  Convalescence  is  ac- 
companied by  desquamation  of  the  hands  and 
feet,  and  perhaps  of  the  body  generally ; and  may 
be  marked  by  obstinate  anaemia.  In  many  cases 
stiffness,  pain,  and  weakness  remain  in  the  joints 
and  neighbouring  muscles. 

The  great  majority  of  cases  of  acute  rheuma- 
tism ultimately  end  in  recovery,  the  proportion 
of  deaths  as  the  immediate  result  of  an  attack 
being  only  about  four  per  cent.  On  the  other 
hand,  a large  number  of  persons  suffer  from 
remote  effects  of  the  disease,  many  of  which  are 
not  only  distressing,  but  likely  to  lead  to  death. 
Of  the  immediately  fatal  cases,  the  larger  pro- 
portion are  associated  with,  if  not  actually  du« 


RHEUMATISM,  ACUTE. 


1360 

to,  acute  disease  of  the  respiratory  organs.  The 
fatal  eases  which  present  cardiac  disease,  espe- 
cially acute  pericarditis,  are  scarcely  less  nume- 
rous. Altogether  it  may  be  said  that  from  a 
half  to  three-fourths  of  all  cases  of  death  during 
acute  rheumatism  are  referable  to  acute  cardiac 
and  pulmonary  disease,  either  separately  or  com- 
bined. It  is  doubtful  whether  acute  rheumatism 
per  se  ever  proves  fatal — that  is,  whether  any 
patient  dies  from  excessive  pain,  sweating,  and 
consequent  exhaustion.  Hyperpyrexia  is  the 
most  common  cause  of  death  next  to  pulmonary 
and  cardiac  complications.  In  a small  number 
of  cases,  meningitis,  acute  alcoholism,  and  other 
complications,  to  be  mentioned  presently,  lead 
to  a fatal  termination. 

The  remote  consequences  of  acute  rheumatism 
are,  on  the  whole,  more  serious  than  the  imme- 
diate effects.  In  a few  instances  the  disease 
leaves  behind  it  a condition  of  joints  which  passes 
into  ‘ chronic  rheumatism’  or  ‘rheumatic  arthri- 
tis.’ A more  common  effect  is  valvular  disease 
of  the  heart,  which,  in  the  majority  of  cases,  is 
referable  to  acute  endocarditis  occurring  as  a 
complication  of  rheumatism.  It  is  impossible  to 
estimate  the  number  of  cases  of  disease  of  the 
lungs,  vessels,  brain,  kidneys,  and  other  organs, 
which,  in  their  turn,  are  caused  by  such  heart- 
disease.  It  is  also  probable  that  the  vessels 
suffer  directly  from  the  effects  of  rheumatism. 
When,  in  addition  to  these  effects,  we  consider 
the  remote  effects  of  pneumonia  and  pleurisy, 
and  of  the  other  less  common  complications  of 
rheumatism,  as  well  as  the  liability  to  a return 
of  the  disease  and  its  complications  which  seems 
to  be  engendered  by  a first  attack,  it  is  difficult 
to  exaggerate  the  extent  and  seriousness  of  the 
ultimate  results  of  this  disease. 

Complications. — Acute  rheumatism  is  fre- 
quently accompanied  by  certain  other  affections, 
which  modify  its  course  and  greatly  increase  its 
gravity.  The  appearance  of  these  complications 
is  in  every  case  anxiously  apprehended  ; and  the 
prevention  of  the  most  serious  of  them  is  re- 
garded as  the  chief  indication  in  the  treatment  of 
the  disease.  The  principal  are — inflammation 
of  the  heart  and  pericardium  ; hypersemia  and 
inflammation  of  the  lungs,  bronchi,  and  larynx; 
inflammation  of  the  various  serous  membranes  ; 
various  nervous  affections,  such  as  chorea,  me- 
ningitis, and  mental  derangement;  erythema 
nodosum,  and  scarlatina ; albuminuria ; hy- 
perpyrexia; haemorrhages;  and,  lastly,  various 
concomitant  or  intercurrent  conditions. 

The  relations  of  these  complications  to  acute 
rheumatism  are  very  various.  The  largest  and 
by  far  the  most  important  group,  comprising 
cardiac  inflammations,  pneumonia,  pleurisy,  peri- 
tonitis, erythema  nodosum,  chorea,  and  menin- 
gitis, can  only  be  described  as  having  an  intimate 
but  obscure  genetic  relation  to  rheumatism.  This 
relation  is  indicated  in  many  ways,  such  as  the 
frequency  of  their  occurrence  during  an  attack 
of  acute  rheumatism ; the  comparative  infre- 
quency of  certain  of  them  in  any  other  connec- 
tion ; the  manifest  analogy  that  exists  between 
the  parts  affected  in  some  of  them  and  the  joints ; 
the  direct  increase  of  their  frequency  with  the 
intensity  of  the  general  rheumatic  symptoms, 
that  is,  of  the  cause  of  the  disease ; the  transient 


and  migratory  character  which  they  may  present, 
alternating  as  they  sometimes  do  with  each  other 
and  with  the  arthritis  ; their  occasional  occur- 
rence before  the  joint-symptoms,  or  even  with- 
out them,  or  in  the  person  of  a blood-relation  of 
a rheumatic  subject ; their  amenability  to  anti- 
rheumatictreatment ; and,  lastly,  their  occurrence 
in  the  course  of  acute  rheumatism  as  a part  only 
of  a manifestly  general  disease. 

Other  complications  appear  to  be  effects  of 
rheumatism,  such  as  albuminuria  and  mental 
disorder  : and  chorea  is  believed  by  some  autho- 
rities to  belong  to  this  category  rather  than  to 
the  former.  Scarlatina,  dysentery,  and  profuse 
haemorrhages  are  perhaps  related  to  it  celiologi- 
cally.  Lastly,  such  conditions  as  bronchitis, 
hyperpyrexia,  and  delirium  tremens  are  to  be 
considered  as  merely  concomitant  or  intercurrent 
diseases. 

The  chief  of  these  complications  must  now  be 
considered  in  detail,  in  the  order  of  their  rela- 
tive importance. 

1.  Cardiac  complications. — These  are  by 
far  the  most  frequent  complications  of  rheuma- 
tism, being  present  in  no  fewer  than  fifty  per 
cent,  of  all  cases.  The  percentage  of  acute  cardiac 
disease  is,  however,  less  than  this — almost  cer- 
tainly aljout  one-third,  the  remaining  cases  being 
chronic,  or  chronic  and  acute  cardiac  disease  com- 
bined. These  numbers  refer  only  to  organic  dis- 
ease of  the  heart,  namely,  endocarditis,  pericar- 
ditis, myocarditis,  and  the  effects  of  these,  singly 
or  in  combination.  But,  besides  inflammatory 
affections,  there  may  occur  functional  disorders 
of  the  heart,  characterised  chiefly  by  palpitation, 
cardiac  distress,  and  the  presence  of  various  ab- 
normal physical  signs ; and,  according  to  some 
observers,  the  latter  class  are  of  as  frequent  oc- 
currence as  the  former. 

The  circumstances  under  which  cardiac  inflam- 
mation most  frequently  makes  its  appearance  in 
acute  rheumatism  are — first,  and  specially,  early 
age,  rheumatic  children  rarely  escaping  disease 
of  the  heart,  youths  seldom,  and  the  liability 
rapidly  diminishing  after  the  thirtieth  year; 
secondly,  severity  of  the  rheumatic  attack — with 
which  the  liability  to  cardiac  complication  in- 
creases in  direct  proportion  ; thirdly,  the  female 
sex — women  being  more  subject  to  rheumatic 
disease  of  the  heart  than  men ; and,  fourthly, 
neglect  of  proper  treatment  during  and  after  the 
attack. 

The  time  of  appearance  of  cardiac  symptoms 
has  been  variously  stated  by  different  observers. 
As  a matter  of  fact,  they  are  generally  discovered 
when  the  patient  comes  under  observation ; they 
certainly  begin  most  frequently  in  the  first  week 
of  illness ; but  they  by  no  means  uncommonly 
make  their  appearance  in  the  second  week,  aud 
may  occur  at  any  period. 

Inflammation  of  the  heart  and  pericardium  are 
fully  described  under  their  appropriate  headings 
(see  Heart,  Inflammation  of ; and  Pericardioi. 
Diseases  of).  The  influence  of  the  presence  of 
cardiac  complications  on  the  course  and  pro- 
gnosis of  an  attack  of  acute  rheumatism,  is  so  im- 
portant as  to  alter  the  whole  aspect  of  the  case, 
and  to  prove  the  chief  cause  of  anxiety.  Affec- 
tions of  the  heart  are  by  far  the  most  common 
cause  of  death  from  rheumatism,  immediate  and 


RHEUMATISM,  ACUTE. 


remote ; and  even  when  they  do  not  prove  fatal, 
they  constitute  the  most  distressing  of  the  remote 
affects  of  the  disease. 

2.  Respiratory  complications. — Diseases  of 
the  respiratory  organs  have  been  variously  stated 
to  occur  in  from  one  in  every  six  to  one  in  every 
sixteen  cases  of  acute  rheumatism  ; and  in  the 
larger  proportion  of  immediately  fatal  cases  they 
are  the  direct  cause  of  death.  The  most  common 
is  pleuro-pneumonia  ; pleurisy  alone  the  next ; 
then  pneumonia ; and  severe  bronchitis,  pul- 
monary congestion,  and  laryngitis  are  more  rare. 
They  may  probably  occur  at  any  period  of  the 
rheumatic  attack;  but  the  most  serious  forms 
will  necessarily  appear  towards  the  termination, 
for  the  obvious  reason  that  they  so  frequently 
prove  fatal.  The  supervention  of  acute  respira- 
tory diseases  is,  as  a rule,  easily  recognised  by  the 
appearance  of  their  several  symptoms  and  signs. 

3.  Hyperpyrexia. — This  is  one  of  the  most 
alarming  complications  of  acute  rheumatism,  but 
happily  one  of  the  most  rare.  The  condition  is 
fully  described  in  another  article  (see  Tem- 
perature). ^qoerpyrexia  may  occur  at  any 
period  of  the  disease ; generally  when  the  symp- 
toms are  fully  developed  ; but  even  during  con- 
valescence. The  principal  indications  of  the 
approach  of  hyperpyrexia,  which  it  is  of  the  last 
importance  to  recognise,  are  flushing  of  the  face  ; 
brightness  and  restlessness  of  the  eyes ; an 
eager,  excited  expression  and  behaviour ; disap- 
pearance of  pain  and  swelling  from  the  joints, 
and  arrest  of  the  perspirations ; delirium  ; and 
increase  of  the  general  symptoms  of  fever.  On 
the  occurrence  of  any  of  these  symptoms  in  an 
otherwise  uncomplicated  case  of  acute  rheuma- 
tism, the  temperature  should  at  once  be  taken, 
and  the  observation  repeated  every  half-hour. 
If  the  body-heat,  prove  to  be  over  103°,  and  to 
be  still  rising,  measures  must  be  immediately 
adopted  to  prevent  the  hyperpyrexia,  which  is 
certainly  threatening. 

4.  Nervous  complications. — The  reputed 
frequency  of  these  complications  has  been  greatly 
reduced  since  the  discovery  that  the  majority 
of  the  cases  of  so-called  ‘ cerebral  rheumatism  ’ 
and ‘rheumatic  meningitis’  aro  really  instances 
of  hyperpyrexia.  These  cases  being  excluded, 
the  frequency  of  cerebral  disturbance,  in  uncom- 
plicated rheumatism,  is  not  greater  than  in  other 
pyrexial  diseases.  Cerebral  embolism  may  occur 
from  endocarditis  ; meningitis  is  very  rarely  ob- 
served ; and  a peculiar  form  of  insanity  has  been 
described  by  German  authors  in  connection  with 
acute  rheumatism.  Delirium  tremens  occasion- 
ally supervenes  when  there  is  a history  of  alco- 
holism. Chorea  bears  a remarkable  relation  to 
acute  rheumatism  (see  Chorea).  Occasionally  it 
appears  during  an  attack;  and  choreic  twit.ch- 
ings  may  thus  be  the  prominent  symptoms  dur- 
ing the  first  days  of  the  illness,  especially  in 
children. 

5.  Cutaneous  complications.  — In  a small 
proportion  of  instances,  acute  rheumatism,  or  a 
condition  which  practically  cannot  be  distin- 
guished from  it,  is  associated  with  erythema 
nodosum ; sometimes  the  arthritic  symptoms 
and  sometimes  the  skin-affection  being  the  first 
to  appear,  and  the  two  conditions  being  further 
associated  with  some  of  the  complications  already 

86 


1361 

mentioned.  Urticaria  is  less  frequently  seen  in 
the  same  connections.  A remarkable  condition, 
in  which  arthritic  symptoms  are  associated 
with  purpura,  haemorrhages,  vascular  thromboses, 
and  possibly  ulcerative  endocarditis,  is  known  as 
peliosis  rheumatica,  or  purpura  rheumatica.  See 
-Erythema  ; Purpura  ; and  Urticaria. 

6.  Renal  complications. — Albuminuria  does 
not  occur  in  more  than  ^ or  1 per  cent,  of  all 
cases  of  acute  rheumatism;  and  the  so-called 
‘rheumatic  nephritis,’  has  probably  no  real  ex- 
istence. The  frequency  of  albuminuria  is  not 
greater  than  can  be  accounted  for  by  renal  em- 
bolism, the  probable  existence  of  chronic  cardiac 
and  renal  disease,  the  possible  association  oi 
scarlatina,  and  the  presence  of  pyrexia. 

7.  Serous  inflammations. — Peritonitis  is  a 
very  rare  complication,  described  chiefly  bv 
French  writers.  Rheumatic  ‘orchitis,’  or  in- 
flammation of  the  tunica  vaginalis,  is  occasionally 
met  with.  Rheumatic  pleurisy  and  meningitis 
have  been  already  referred  to. 

8.  Gout. — When  acute  rheumatism  attacks 
a subject  of  the  gouty  diathesis,  its  symptoms 
may  bo  considerably  modified.  The  pain,  swell- 
ing, and  selection  of  particular  joints  have  all  a 
gouty  character  more  or  less  ; and  whilst  the 
disease  is  more  amenable  to  treatment  directed 
against  the  gout,  it  has  possibly  a greater  ten- 
dency to  lapse  into  a chronic  affection  of  the 
smaller  joints. 

9.  Scarlatina. — Scarlatina  may  make  its  ap- 
pearance at  any  period  during  the  course  of  acute 
rheumatism.  The  concurrence  of  the  two  dis- 
eases may  occasionally  be  accidental ; possibly 
they  mutually  predispose  to  each  other,  by 
lowering  the  general  health  and  increasing  the 
liability  to  chill ; whilst  some  authorities  hold 
that  many  of  the  ordinary  complications  of  scar- 
latina, as  well  as  the  arthritis,  are  essentially  rheu- 
matic, such  as  serous  inflammations  and  nephri- 
tis. The  occurrence  of  rheumatism  as  a com- 
plication of  scarlatina  is  discussed  elsewhere. 
See  Scarlet  Fever. 

Diagnosis.— Although  acute  rheumatism  can 
generally  be  easily  recognised,  its  diagnosis  is 
sometimes  a matter  of  the  greatest  difficulty. 

In  the  stage  of  invasion , it  is  most  readily  con- 
founded with  the  acute  specific  fevers,  including 
influenza,  and  with  catarrh,  in  which  pyrexia  and 
aching  of  the  limbs  are  prominent  symptoms. 
If  sore-throat  be  comparatively  well-marked, 
and  the  development  of  the  joint-affection  slow, 
the  practitioner  may  be  led  to  diagnose  simple 
catarrh  instead  of  rheumatism,  and  to  make  light 
of  a complaint  which  is  about  to  develop  into  a 
serious  disease.  In  every  doubtful  case  a cer- 
tain number  of  facts  should  be  kept  clearly  in 
view,  namely,  the  history  of  the  attack;  the  pos- 
sible occurrence  of  previous  attacks  of  rheuma- 
tism; the  family  history  ; the  absence  of  symp- 
toms characteristic  of  other  diseases,  such  as 
eruptions  or  coryza ; the  development  of  pain  or 
tenderness  in  a definite  joint,  and  acid  sweats; 
and  most  important  of  all,  the  discovery  of  the 
signs  of  inflammation  of  the  heart. 

In  the  second  or  declared  stage,  when  one  or 
more  joints  are  involved,  an  entirely  different 
group  of  diseases  have  to  be  diagnosed  from 
rheumatism,  namely,  gout,  ‘ rheumatic  arthritis,' 


RHEUMATISM,  ACUTE. 


1362 

gonorrhoeal  rheumatism,  pyaemia,  glanders,  and 
acute  synovitis  or  arthritis  of  traumatic  or  dia- 
thetic origin.  In  doubtful  cases  the  characteristic 
phenomena  of  rheumatism  must  be  kept  clearly 
in  mind,  especially  the  transient  and  erratic 
course  of  the  arthritic  symptoms,  and  the  pro- 
bable presence  of  cardiac  complications. 

Acute  c/out  may  generally  be  diagnosed  by  the 
suddon  invasion  at  night  of  a single  joint  — 
probably  the  great  toe,  in  a man  of  middle  or 
advanced  age;  by  the  severity  of  the  pain,  "which 
is  relieved  by  the  occurrence  of  a characteristic 
swelling  of  the  part ; by  the  history  of  previous 
attacks  of  the  same  description ; and  by  the 
insignificant  amount  of  constitutional  disturbance 
attending  the  arthritis.  The  discovery  of  uric 
acid  in  the  blood  "will  definitely  settle  the  diag- 
nosis of  gout. 

Pyemia  is  usually  associated  with  an  injury 
or  pre-existing  surgical  disease ; and  the  fever  has 
a markedly  remittent  character.  Rigors  are  the 
rule,  whilst  they  are  the  exception  in  rheuma- 
tism; the  sweats  are  distinctly  intermittent ; the 
arthritis  is  neither  transient  nor  migratory,  but 
may  advance  to  suppuration  of  the  joints  ; and 
the  symptoms  of  blood-poisoning  and  extensive 
ani  multiple  visceral  disease  shortly  supervene. 
Still  it  is  a fact,  which  cannot  be  insisted  upon 
too  strongly,  that  cases  of  pysemia  are  frequently 
mistaken  at  first  for  acute  rheumatism. 

Gonorrhoeal  rheumatism  may  be  recognised  by 
being  persistent,  whether  one  or  more  joints  be 
involved;  by  the  typo  and  degree  of  the  py- 
rexia ; by  the  absence  of  cardiac  complications, 
as  a rule;  by  the  presence  of  conjunctivitis;  and, 
most  certainly  of  all,  by  the  existence  of  a ure- 
thral discharge. 

Bheumatic  arthritis  may  be  distinguished  by 
the  characteristic  deformity  of  the  joints. 

For  the  diagnosis  of  glanders  see  Glanders. 

Ordinary  synovitis  is  rarely  multiple ; is  per- 
sistent and  not  migratory;  and  has  an  appre- 
ciable cause,  whether  traumatic  or  diathetic.  See 
Joints,  Diseases  of. 

The  numerous  difficulties  which  beset  the 
diagnosis  of  sub-acute  rheumatism,  in  children 
especially,  have  already  been  sufficiently  dwelt 
upon. 

Prognosis. — In  a disease  which  runs  so  un- 
certain a course,  and  which  may  bo  complicated 
by  such  a variety  of  dangers,  the  prognosis  is 
necessarily  most  uncertain.  The  proportion  of 
fatal  cases,  and  of  cardiac  complications,  and 
the  average  duration  of  an  attack,  can  easily  be 
stated ; but  in  a given  case  there  is  at  first  no 
positive  means  of  foretelling  wdiat  course  the 
disease  will  run  in  any  one  of  these  respects. 
The  prognosis  must  be  specially  guarded  in  per- 
sons worn  out  by  mental  or  physical  overwork 
or  anxiety  ; in  young  women  of  full  flabby  habit, 
with  tendency  to  anaemia  and  disturbance  of  the 
uterus,  stomach,  and  circulation ; and  in  women 
after  delivery — all  subjects  in  whom  cardiac  in- 
flammation and  failure,  and  pulmonary  complica- 
tions are  to  be  apprehended.  Ill-declared,  ‘ weak’ 
symptoms,  connected  with  the  joints,  indicating 
that  the  bodily  strength  and  power  of  resistance 
are  low,  are  less  favourable  than  well-pronounced 
‘ honest’  pains  and  a warm  sweating  skin,  which 
generally  point  to  a favourable  termination  as 


regards  life.  It  must,  however,  be  observed 
that  the  risk  of  complications  in  some  degree 
increases  with  the  severity  of  the  local  symptoms. 
The  probability  of  cardiac  complications  de- 
cidedly declines  after  the  first  week,  but  the  pos- 
sibility continues  as  long  as  fresh  joints  are  being 
invaded.  Rheumatism  may  be  expected  to  run 
an  exceedingly  mild  course  in  children,  but  the 
danger  of  cardiac  complications  is  very  great. 
In  old  subjects  it  may  be  safely  assumed  that 
the  disease  will  end  favourably.  The  superven- 
tion of  pulmonary  complications,  especially  in 
association  with  cardiac  disease,  or  of  hyper- 
pyrexia, should  cause  anxiety,  as  immediately 
threatening  life.  Remote  danger  from  acute 
rheumatism  is  chiefly  to  be  estimated  by  the 
occurrence  of  heart-disease,  and  by  the  nature  of 
the  same. 

Treatment. — The  difficulties  which  beset  an 
attempt  to  estimate  the  relative  and  absolute 
value  of  the  different  measures  that  have  been 
proposed  for  the  treatment  of  acute  rheumatism, 
may  be  said  to  be  at  present  insurmountable. 
Under  the  most  favourable  circumstances  the 
number  of  carefully  observed  cases  of  any  dis- 
ease, subjected  to  a particular  treatment,  must 
be  very  large,  before  a safe  conclusion  can  be 
drawn  respecting  the  result.  The  most  favour- 
able circumstance  for  therapeutical  observa- 
tions is  manifestly  uniformity  of  the  course  of 
the  morbid  process.  This  condition  is  as  much 
as  possible  wanting  in  the  problem  before  us. 
Rheumatism  is  a disease  of  indefinite  duration, 
of  infinite  degree  of  severity,  and  beset  with  a 
number  of  complications.  It  is  not  always  pos- 
sible to  estimate  the  duration  of  the  attack 
when  the  case  first  comes  under  observation. 
Lastly,  many  of  the  recorded  cases  have  been 
treated  by  such  complicated  methods,  that  it  is 
frequently  quite  impossible  to  eliminate  the  re- 
spective effects  of  the  various  drugs  administered. 
In  approaching  the  question  of  the  therapeutics  of 
acute  rheumatism  at  the  present  time,  these  facte 
cannot  be  kept  too  clearly  in  view,  for  perhaps 
no  disease  has  been  alleged  to  have  been  success- 
fully treated  by  so  many  different  remedies. 

1.  General  treatment — When  called  upon 
to  treat  a case  of  acute  rheumatism,  the  prac 
titioner  must,  in  the  first  place,  make  certain 
special  arrangements  for  the  nursing  of  the 
patient.  In  addition  to  the  ordinary  measures 
proper  in  every  case  of  an  acute  febrile  disease 
which  will  probably  prove  of  some  duration,  he 
must  especially  secure  for  the  rheumatic  patient 
perfect  quiet,  extreme  gentleness  of  every  ne- 
cessary movement,  and  the  prevention  or  relief 
of  the  discomfort  attendant  on  constant  and 
profuse  perspirations.  Next  to  a good  strong 
nurse,  and  perfect  hygienic  arrangements  of  the 
sick-room,  a proper  bed  is  of  the  utmost  impor- 
tance in  the  general  management  of  the  case. 
The  bed  must  be  firm ; standing  on  a firm 
floor;  sufficiently  narrow;  and  placed  in  such  a 
position  as  to  be  readily  accessible  from  either 
side,  and  allow  the  attendants  to  reach  any  part 
of  the  limbs  or  trunk  of  the  patient,  without 
interfering  with  the  position  and  comfort  of  the 
other  parts.  Further,  the  bed  must  be  ‘made 
as  a ‘ rheumatic  bed  ; ’ that  is,  a pair  of  blanket* 
must  be  placed  between  the  sheets — the  one 


RHEUMATISM,  ACUTE. 


ever,  the  other  under  the  patient,  so  as  to 
absorb  the  profuse  sweat,  and  diminish  the  risk 
of  chill  from  dampness  of  the  linen.  The 
patient  should  be  furnished  with  a long  flannel 
bed-gown,  made  to  fasten  with  tapes  down  the 
front  and  along  the  arms,  so  that  the  chest  or 
any  joint  may  be  reached  with  the  least  possible 
disturbance.  Arrangements  must  be  made  for 
collecting  the  urine  and  stools  in  bed ; and  the 
use  of  a urinal  and  a bed-pan,  or  a properly 
arranged  towel  for  these  purposes,  is  impera- 
tive. 

These  nursing  arrangements  being  completed, 
the  physician  may  turn  his  attention  to  the 
consideration  of  the  therapeutics  proper  of  the 
case.  Two  indications  have  to  be  fulfilled,  namely, 
first,  the  relief  of  local  symptoms  which  may 
be  urgent;  and,  secondly,  the  reduction  of  the 
fever  and  the  removal  of  the  general  distress. 
An  effort  must  be  made  to  secure  these  ends  by 
separate  measures,  or  by  following  some  system 
that  will  effect  both.  The  various  measures  at 
our  disposal  will  now  be  considered,  beginning 
with  those  which  are  at  once  the  most  simple, 
and  the  most  urgently  required. 

2.  Local  palliative  treatment. — Best. — The 
most  ready  and  satisfactory  measure  of  a local 
kindfor  the  relief  of  symptoms  is  the  application 
of  cotton-wool  to  the  rheumatic  joints.  Cotton- 
wool is  to  be  wrapped  in  some  quantity  around 
the  parts,  and  secured  by  a moderately  firm 
roller,  or  by  a piece  of  warm  flannel  with  the 
ends  stitched  together.  The  affected  articulation 
is  thus  at  once  kept  at  rest  and  protected  from 
cold  and  pressure  ; whilst  uniform  support  is 
obtained.  The  relief  obtained  by  this  simple 
arrangement  is  often  remarkable.  The  joints 
should  be  carefully  sponged  with  warm  water 
and  soap,  or  warm  water  slightly  alkalinized 
by  carbonate  of  soda,  before  this  or  any  other 
application  ; and  the  cotton-wool  must  be  oc- 
casionally changed,  especially  if  the  perspira- 
tions be  profuse.  The  principle  of  support 
and  prevention  of  movement  is  more  thoroughly 
carried  out  in  a method  of  treatment  which  has 
found  more  favour  with  Continental  than  with 
English  practitioners.  This  method  consists  in 
placing  the  joints  in  splints,  as  they  become 
affected ; in  bandaging  them  firmly ; or  in  encas- 
ing them  in  plaster  of  Paris.  The  results  are  said 
to  be  very  satisfactory ; the  pain  being  reduced 
to  a minimum,  the  fever  falling,  and  the  course 
of  the  disease  essentially  shortened. 

Anodynes. — When  the  pain  is  severe,  and  relief 
is  not  to  be  obtained  by  simple  rest  and  protec- 
tion, anodynes  may  be  applied  to  the  rheumatic 
joints.  Opium  in  any  of  its  ordinary  forms,  bella- 
donna and  its  allies,  and  other  familiar  anodynes, 
may  severally  answer  best  in  particular  instances. 
These  substances  may  be  applied  on  the  surface 
of  lint,  secured  and  supported  by  a bandage; 
or  the  affected  part  may  be  lightly  rubbed  or 
smeared  with  the  anodyne  preparation  in  the 
form  of  liniment,  and  then  wrapped  in  cotton- 
wool or  flannel,  as  already  described.  Heat  is 
generally  grateful  to  acute  rheumatic  joints,  but 
in  many  cases  it  is  felt  to  be  useless  in  the  acute 
stage  unless  it  be  quite  extreme.  Thus  simple 
warm  fomentations  may  give  relief ; but  the 
patient  may  urgently  demand  their  constant 


1863 

renewal,  so  that  they  may  be  almost  scalding. 
There  are  obvious  objections  to  such  a plan  of 
treatment.  Extreme  cold  has  been  recommended 
by  some  authorities,  notably  Professors  Esmarch 
and  Hueter,  in  the  form  of  ice.  It  is  seldom 
used  in  this  country. 

Blisters.— A favourite  method  of  treatment 
with  some  physicians  consists  in  the  application 
of  blisters  to  the  rheumatic  joints.  The  blisters, 
usually  of  cantharides,  are  intended  to  act  less  as 
counter-irritants  than  as  ‘derivatives’  or  ‘ eva- 
cuants.’  Dr.  Herbert  Davies,  who  introduced  the 
blister-treatment  in  this  country,  contends  that 
the  rheumatic  poison  is  especially  abundant  in 
the  neighbourhood  of  the  joints,  and  is  actually 
separated  with  the  blister-serum,  and  so  re- 
moved from  the  body.  In  its  original  and  com- 
plete form,  the  blister-treatment  consists  in 
applying  a strip  of  cantharides  plaster  near 
every  affected  joint  at  the  height  of  the  inflam- 
matory stage.  In  some  cases  the  amount  of 
blistered  surface  may  thus  be  enormous.  The 
serum  is  encouraged  to  drain  away,  and  the 
surface  heals  in  due.  course.  It  has  been  claimed 
for  the  blister-treatment  that  it  relieves  the  pain, 
shortens  the  course  of  the  disease,  and  lessens 
the  tendency  to  cardiac  complications.  Of  the 
first  effect,  there  is  probably  little  doubt;  the 
other  effects  are  questionable ; and  statistics 
show  that  other  methods  of  treatment  are  more 
efficacious  in  these  respects.  On  the  other 
hand,  the  danger  of  strangury,  sloughing,  and 
even  pyaemia,  and  the  substitution  of  another 
form  of  severe  pain  for  that  dispelled,  must  be 
mentioned  as  objections  to  its  employment.  Fcr 
these  and  other  reasons,  a modification  of  the 
blister-treatment  has  been  proposed,  probably 
at  the  sacrifice  of  the  principle,  namely,  local 
blistering  when  a stimulant  is  demanded,  in  cases 
attended  with  much  depression ; when  the  joint- 
symptoms  are  unusually  severe ; when  other 
less  severe  means  have  failed ; and  when  the 
condition  threatens  to  become  chronic. 

Leeches. — The  local  abstraction  of  blood  by 
means  of  leeches,  whilst  it  relieves  pain,  is  very 
rarely  called  for,  unless  the  arthritis  be  so  severe 
and  persistent  as  to  threaten  to  lead  to  suppur- 
ation. 

Electricity. — It  is  said  that,  in  some  cases, 
marked  relief  follows  galvanization  of  the  rheu- 
matic joints. 

Indirect  anodynes. — Certain  lotions,  of  other 
than  direct  anodyne  properties,  have  been  re- 
commended as  local  applications,  to  produce 
a specific  effect  upon  the  rheumatic  joints,  and 
thus  indirectly  afford  relief.  The  chief  of  these 
are  alkaline  solutions,  especially  solutions  of 
the  carbonates  of  potash  and  soda,  sopped  into 
flannel  wrapped  around  the  joints.  They  may 
be  combined  with  preparations  of  opium.  Their 
value  is  somewhat  doubtful. 

3.  Medicinal  treatment. — (a)  Alkalies.— 
Before  the  introduction  of  salicylic  acid  the 
alkalies  were  in  general  use  in  the  treatment  of 
acute  rheumatism.  The  alkaline  method  consists 
in  the  internal  administration  of  sufficiently 
large  doses  of  certain  alkaline  salts,  such  as  the 
carbonates,  citrates,  tartrates,  and  acetates,  to 
render  the  urine  quickly  alkaline ; m maintaining 
this  reaction  as  long  as  the  rheumatic  symptoms 


RHEUMATISM,  ACUTE. 


1364 

continue  ; and  in  gradually  allowing  a neutral  or 
an  acid  reaction  to  return  by  diminishing  the  dose 
as  the  disease  declines.  It  is  claimed  for  this 
method  that  as  the  alkalies  begin  to  exhibit  their 
action  on  the  system,  the  whole  aspect  of  the 
case  becomes  more  favourable,  the  general  dis- 
tress being  alleviated,  the  temperature  falling, 
and  the  local  symptoms  relieved ; that  these 
favourable  effects  continue  to  become  more  and 
-nore  marked,  until  the  rheumatic  condition  has 
disappeared  ; that  the  average  duration  of  the 
attack  is  greatly  shortened,  not  exceeding  6' 75 
days  in  the  acute  stage,  and  13'5  days  before 
the  disappearance  of  pain  ; and  that  the  propor- 
tion of  complications  is  reduced  as  low  as  2 per 
cent.  only.  In  other  words,  it  is  asserted  that  in 
alkalies  a direct  antidote  exists  to  the  morbid 
influence  (whatever  that  may  be)  which  is  the 
essence  of  rheumatism. 

The  plan  of  administering  alkalies  varies  con- 
siderably. Some  practitioners  give  largo  and 
frequently  repeated  doses,  in  order  to  obtain  the 
speediest  possible  effect  upon  the  system  ; whilst 
others  give  a moderate  amount,  or  otherwise 
modify  the  exhibition  of  the  salts.  Of  the  two 
plans  the  first  is  unhesitatingly  to  be  preferred. 
To  obtain  the  full  effect  of  potash  upon  the 
system,  not  less  than  half  a drachm  of  the  bicar- 
bonate in  an  ounce  of  water  should  be  prescribed 
at  once,  either  alone  or  with  citric  acid  in  the 
effervescing  form  ; and  the  dose  is  to  be  repeated 
every  four  hours.  An  equal  amount  of  the  ace- 
tate of  potash  may  be  added  to  each  dose,  if  a 
still  more  rapid  and  powerful  action  of  the  alka- 
lies be  desired.  The  urine  will  probably  become 
alkaline  within  twenty-four  hours,  and  when 
once  this  effect  has  been  obtained,  it  may  very 
easily  be  kept  up,  by  continuing  the  alkalies  at 
longer  intervals,  which  may  be  further  increased 
as  the  symptoms  decline.  The  effect  of  the  drugs 
upon  the  patient  must  be  carefully  watched,  and 
the  amount  and  frequency  of  the  dose  varied 
accordingly,  or  its  administration,  if  necessary, 
stopped.  Finally,  when  the  rheumatism  is  re- 
lieved, quinine  may  be  added  to  the  alkaline 
mixture ; and  as  convalescence  advances,  the 
potash  may  be  entirely  withdrawn.  Constipa- 
tion occurring  in  the  course  of  treatment  may  be 
relieved  by  combining  the  tartrate  of  potash  and 
soda  -with  the  bicarbonate  instead  of  the  acetate, 
tartaric  acid  being  used  to  cause  effervescence  ; 
or  if  more  obstinate,  by  a calomel  and  coloeynth 
pill. 

The  alkaline  influence  upon  the  system  maybe 
further  increased,  in  a very  agreeable  way,  by 
supplying  the  ordinary  effervescing  potash  or 
soda-water  as  a drink,  either  alone,  or  combined 
with  milk,  or  with  fresh  lemon-juice.  The  pa- 
tient may  be  encouraged  to  drink  this  in  quan- 
tity, unless  there  be  special  indications  to  the 
contrary,  such  as  cardiac  distress.  Should  there 
be  diarrhoea,  lime-water  may  be  substituted  for 
the  potash  or  soda-water.  Should  alkalies  per- 
sistently cause  purgation,  their  administration 
must  be  discontinued. 

The  objections  that  have  been  raised  to  the 
alkaline  treatment  are  chiefly  two:  first,  that  it 
is  useless — an  objection  which  is  not  supported 
by  statistics ; and,  secondly,  that  it  is  dangerous, 
an  objection  which  only  bears  testimony  to  the 


power  of  the  means  employed,  and  suggests  that 
the  greatest  care  must  be  taken  lest  the  exhibi- 
tion of  alkalies  should  be  overdone. 

( b ) Modified  alkaline  treatment. — A modifica- 
tion of  the  preceding  plan  has  been  highly  re- 
commended by  Dr.  Garrod,  and  consists  in  the 
administration  of  quinine  from  the  very  first, 
in  combination  with  large  doses  of  alkalies ; as 
much  as  five  grains  of  the  alkaloid  (thus  in  the 
form  of  a carbonate)  being  given  every  four  hours. 

(c)  Symptomatic  remedies.— The  most  obvious 
general  remedies  for  the  relief  of  symptoms  are 
anodynes  and  apyretics.  So  much  benefit  follows 
the  use  of  opium  in  some  cases,  by  relieving  pain 
and  diminishing  nervous  irritability,  that  it  has 
acquired  a reputation  even  as  a specific.  Although 
formerly  given  in  large  and  frequent  doses,  such 
as  a grain  every  three  or  eight  hours,  either  alone 
or  combined  with  mercury,  opium  is  now  seldom 
employed  in  acuto  rheumatism,  except  in  the 
form  of  a moderate  dose  of  Dover’s  powder,  or  of 
a morphia  draught  at  night,  to  relieve  pain  and 
induce  sleep.  For  these  purposes  it  is  employed 
by  most  practitioners,  including  those  who  adopt 
what  they  call  the  purely  expectant  method  of 
treatment.  The  effect  of  the  opium  must  be  care- 
fully watched,  in  the  presence  of  the  many  com- 
plications which  may  possibly  arise  and  contra- 
indicate its  use. 

Apyretics. — The  vigorous  employment  of  apy- 
retie  measures  is  unquestionably  the  method  of 
treatment  of  acute  rheumatism  in  greatest  repute 
at  present.  It  has  been  found  that  when  the 
temperature  is  reduced  by  these  means,  the  whole 
condition  of  the  patient  improves;  the  joint- 
symptoms  decline;  and  the  morbid  process  being 
apparently  interrupted,  the  risk  of  cardiac  com- 
plications is  removed,  at  least  for  a time.  Many 
apyretic  remedies  have  been  recommended,  such 
as  quinine,  tartar  emetic,  veratrum  viride,  digi- 
talis, aconite,  mercury,  and  various  diaphoretics. 
The  use  of  quinine  has  been  already  referred  to. 
At  the  present  time  reliance  is  chiefly  placed  upon 
two  powerful  remedies  of  this  class,  namely,  the 
cold  bath  or  the  wet  pack,  and  salicylic  acid. 

The  cold  bath  is  the  most  powerful  and  speedy 
method  of  reducing  the  temperature  in  acute 
rheumatism,  but  is  seldom  resorted  to  except 
in  cases  of  hyperpyrexia.  When  this  condition 
threatens,  the  cold  bath  or  the  wet  pack  is  to  be 
unhesitatingly  employed,  in  the  manner  described 
elsewhere  (see  Temperature).  If  the  symptoms 
be  less  urgent,  cold  sponging  of  the  trunk  may 
be  sufficient  to  reduce  the  temperature. 

The  use  of  salicylic  acid,  the  salicylates,  and 
salicin,  introduced  by  Dr.  Maclagan,  constitutes 
the  present  routine  treatment  of  acute  rheuma- 
tism ; and  the  results  obtained  from  it  are  cer- 
tainly more  favourable  than  from  any  other 
method.  Fifteen  to  25  grains  of  salicvlate  of 
soda,  20  grains  of  salicylic  acid,  or  15  grains 
of  salicin,  are  given  everyone,  two,  three,  or  four 
hours,  until  the  temperature  falls  to  the  normal, 
after  which  the  dose  of  the  drug  is  reduced,  so  as 
to  be  simply  sufficient  to  maintain  the  apyrexia 
for  several  days.  The  salicylates  are  best  given 
in  watery  solution,  variously  flavoured;  salicylic 
acid  in  milk,  or  combined  with  liquor  ammonise 
acetatis;  and  salicin  in  wafers,  or  in  solution. 
Different  practitioners  prefer  the  different  form; 


RHEUMATISM,  ACUTE. 


*f  the  active  substance ; the  salicylate  of  soda  is 
probably  most  extensively  used,  being  readily 
dissolved,  whilst  salicin  is  less  liable  to  excite 
unpleasant  symptoms.  These  are  deafness  and 
noises  in  the  ears,  delirium,  cardiac  depression, 
sickness,  and  collapse.  Short  of  these  effects, 
the  salicylates  reduce  the  temperature  to  the 
normal  in  the  course  of  twenty-four  to  forty-eight 
hours,  relieve  the  pain  and  other  arthritic  symp- 
toms, and  markedly  improve  the  condition  of  the 
patient  generally ; the  duration  of  the  disease,  and 
perhaps  the  risk  of  cardiac  complications  being 
thereby  diminished.  The  average  duration  of 
acute  symptoms  under  the  salicylates  is  about 
three  or  four  days. 

The  principal  drawback  to  the  use  of  the  sali- 
cylates is  the  fact  that,  whilst  they  cannot  be 
continued  for  any  length  of  time  in  sufficient 
loses  to  maintain  apyrexia,  without  the  risk  of 
producing  toxic  symptoms,  the  rheumatism  fre- 
quently returns  as  soon  as  their  exhibition  is 
stopped.  Thus  on  the  second  or  third  day  after 
the  disease  has  been  checked,  the  symptoms  are 
jgain  as  severe  as  at  first,  and  the  risk  of  car- 
diac complications  is  again  present.  Whilst  this 
objection  is  undoubtedly  valid,  it  is  still  time 
that  in  a considerable  proportion  of  eases  no  such 
relapse  occurs,  and  that  the  patients  are  there- 
fore virtually  relieved  orcuredwithinforty-eight 
to  sixty  hours.  If  the  salicylates  fail  or  dis- 
agree, recourse  must  be  had  to  alkaline  treat- 
ment or  to  some  other  method.  Certain  practi- 
tioners combine  the  full  alkaline  method  with 
the  salicylates  from  the  first;  others  prescribe 
the  alkalies  in  diminished  doses.  Unfortunately 
Hntemia  appears  to  be  more  marked,  and  con- 
valescence more  slow,  after  treatment  with  sali- 
cylates. 

Hcrmatinic  remedies  may  be  considered  to  be 
xdicated  by  the  great  antenna  which  accompanies, 
Rnd  yet  more  markedly  follows,  an  attack  of 
acute  rheumatism.  Dr.  Russell  Reynolds  has 
recommended  perchloride  of  iron  in  large  doses ; 
end  very  favourable  results  have  attended  its 
administration,  forty-three  per  cent,  of  all  cases 
being  convalescent  in  the  first  week. 

Alcoholic  stimulants,  in  moderate  doses,  are 
indicated  in  a large  proportion  of  cases  of  acute 
rheumatism,  when  the  symptoms  are  severe  and 
protracted.  Resides  this  routine  use  of  alcohol, 
a special  virtue  is  claimed  for  its  free  adminis- 
tration, as  in  other  fevers,  by  the  school  of  Todd 
and  his  disciples,  in  preserving  the  strength  and 
relieving  the  pain.  Brandy  may  certainly  he  freely 
administered  with  advantage  in  eases  attended 
with  extreme  depression,  even  to  the  amount  of 
24  ozs.  per  diem,  especially  in  the  event  of  car- 
diac failure. 

Tonics  are  indicated  during  convalescence;  for 
example,  quinine  and  iron,  separately  or  com- 
bined either  with  alkalies  or  acids,  and  strych- 
nia. Tonics  should  not  be  commenced  too  early. 

( d ) Empirical  remedies. — Lemon-juice  appears 
to  havo  proved  successful  in  some  eases,  in 
doses  of  eight  ounces  or  less  in  twenty-four  hours. 
Since  the  course  of  acute  rheumatism  is  now 
known  to  be  indefinite,  the  number  of  carefully 
recorded  cases  treated  by  lemon-juice  is  insuffi- 
cient to  permit  a trustworthy  inference  to  be 
drawn  respecting  its  value.  Similar  doubts  may 


1366 

be  cast  upon  the  alleged  value  of  many  other 
so-called  remedies  for  the  disease,  such  as  pro- 
pylamine and  trimethylamine , in  4-  to  8-minim 
doses  every  two  hours ; nitrate  of  potash  to  the 
amount  of  an  ounce  in  the  twenty-four  hours; 
cynara  or  artichoke  ; and  the  cyanides  of  potas- 
sium and  zinc.  Colchicum  was  formerly  given 
extensively  in  acute  rheumatism,  but  has  fallen 
into  disrepute  since  this  disease  has  been  sepa- 
rated from  gout.  It  may,  however,  bo  given 
with  advantage  for  rheumatism  in  a gouty 
subject,  to  relieve  pain.  Guaiacum  is  useful  in 
sub-acute  lingering  cases.  Bromide  of  potassium 
has  been  found  very  useful  in  American  practice, 
probably  by  relieving  pain  and  restlessness. 
Calomel,  in  doses  of  5 to  10  or  even  20  grains, 
repeated  for  several  nights,  followed  by  saline 
purgatives  in  the  morning,  was  highly  recom- 
mended in  some  cases  by  the  last  generation  of 
medical  authorities,  but  cannot  be  said  to  be 
employed  at  the  present  day.  The  same  remark 
applies  to  venesection. 

4.  Expectant  treatment.- — Reference  must 
here  be  made  to  the  observations  of  Sir  Wil- 
liam Gull  and  Dr.  Sutton  upon  the  course  of 
acute  rheumatism  when  treated  by  simple  rest, 
and  the  exhibition  of  a placebo.  The  comfort  of 
the  patient  is  secured  by  ordinary  means;  and 
small  doses  of  opium  are  given  to  complete  this 
effect  when  indicated.  The  results  have  been 
remarkably  favourable,  but  less  so  than  those  of 
several  other  methods  of  treatment,  nine  days 
being  the  average  duration  of  acute  symptoms, 
and  the  number  of  cardiac  complications  being 
very  small. 

5.  Treatment  of  complications. — For  an 
account  of  the  treatment  of  the  complications  of 
acute  rheumatism,  the  reader  is  referred  to  the 
respective  articles  on  each  of  these  in  other  parts 
of  this  work  {sec  Heart,  Inflammation  of;  Lungs, 
Inflammation  of;  Pericardium,  Diseases  of;  &c.) 
The  plan  of  treatment  which  is  being  pursued 
for  the  rheumatism  may  have  to  bo  temporarily 
suspended,  or  possibly  completely  changed,  on 
the  appearance  of  any  of  these  complications. 
The  treatment  of  hyperpyrexia  is  described  in 
the  article  Hydrotherapeutics. 

The  state  of  the  bowels  requires  the  most 
careful  retention.  Constipation  must  be  relieved 
by  any  of  the  ordinary  means  ; and  a purgative 
sometimes  gives  remarkable  relief.  Diarrhoea 
may  be  checked  by  lime-water  or  bismuth,  or 
by  a judicious  dose  of  castor  oil,  according  to  its 
cause.  The  surface  of  the  body  must  be  regu- 
larly sponged  with  a very  weak  tepid  solution  of 
an  alkaline  carbonate. 

6.  Diet. — The  proper  diet  in  acute  rheuma- 
tism is  the  same  as  that  in  most  other  kinds  of 
fever.  The  patient  must  be  fed  at  short  and 
regular  intervals,  night  and  day,  with  the  most 
digestible  forms  of  nutritious  food ; and  may  be 
encouraged  to  drink  milk,  or  milk  and  soda- 
water  occasionally.  It,  must  not  be  forgotten, 
however,  that  in  all  probability  the  system  is 
already  overloaded  with  the  products  of  imper- 
fect assimilation  and  transformation;  that  the 
digestive  system  is  weak  and  irritable;  and  that 
the  heart  may  be  seriously  affected  by  the  ad- 
dition of  much  fluid  or  solid  material  to  the 
blood.  As  the  acute  symptoms  decline  and  appe- 


1366  RHEUMATISM,  ACUTE, 
tite  returns,  fish,  milk-puddings,  and  shortly 
afterwards  chicken,  sweetbread,  and  other ‘light’ 
articles  of  diet  may  be  allowed,  and  will  be 
greatly  relished.  Meat  must  be  strictly  for- 
bidden until  every  rheumatic  symptom  has  dis- 
appeared. Thirst  is  best  relieved  in  the  acute 
stage,  as  already  stated,  by  aerated  alkaline 
waters,  either  alone  orin  combination  with  lemon- 
juice  or  milk,  the  quantity  given  being  regulated 
by  the  practitioner,  and  accurately  recorded. 

7.  General  after-treatment. — The  general 
management  of  a case  of  rheumatism  after  the 
decline  of  the  acute  symptoms  is  scarcely  less 
important  than  at  the  commencement  of  the  at- 
tack. The  patient  should  be  encouraged  to  keep 
his  bed  for  several  days  after  the  disappearance 
of  the  joint-symptoms  ; and  this  advice  becomes 
imperative  when  cardiac  complications  exist. 
Rest  and  comfort  of  body  and  mind  must  be  se- 
cured at  this  period,  for  the  purpose  of  quieting 
the  action  of  the  heart,  and  allowing  the  endo- 
carditic  process  which  affects  the  valves,  and 
which  probably  outlasts  the  articular  process, 
quietly  to  subside.  All  attempts  must  therefore 
be  avoided  at  completing  the  cure  of  acute  rheu- 
matism within  a certain  small  number  of  days. 
Even  with  these  precautions  the  first  day  of  sit- 
ting up  generally  proves  an  anxious  time  to  the 
practitioner  in  cardiac  cases.  Locomotion  must 
be  forbidden  for  several  days,  and  very  gradu- 
ally permitted.  When  the  patient  is  able  to 
move  about  and  go  into  the  open  air,  the  danger 
of  a relapse  during  the  first  weeks  must  be  care- 
fully kept  in  mind.  Sudden  and  extreme  changes 
of  temperature  are  especially  to  be  avoided  ; and 
for  this  purpose  the  patient  must  be  warmly 
clad,  and  studiously  avoid  draughts  and  expo- 
sure to  cold  in  other  forms. 

J.  Mitchelu  Bruce. 

RHEUMATISM,  Chronic.— Synon.  : Fr. 
Rhumatisme  articulaire  chronique ; Ger.  Chron- 
ischer  Rheumatismus. 

Definition. — A disease  of  the  joints,  of  chronic 
course;  referable  to  certain  obscure  influences  ofa 
diathetic  and  climatic  nature  ; and  characterised 
by  various  degrees  of  inflammatory  and  degener- 
ative changes  in  the  articular  structures. 

FEtiology. — The  causes  of  chronic  rheuma- 
tism, as  far  as  they  are  known,  are  the  same  as 
those  of  the  acute  disease.  The  most  powerful 
predisposing  causes  are  inheritance,  previous  at- 
tacks of  acute  rheumatism,  poverty,  physical  and 
mental  depression,  and  laborious  occupations  en- 
tailing exposure  to  chills.  For  the  last  reason 
men  are  more  liable  to  the  disease  than  women. 
Chronic  rheumatism  is  most  common  in  middle 
life  or  advanced  age,  although  by  no  means  rare 
in  young  adults.  Exacerbations  of  the  symptoms 
are  usually  referable  to  exposure,  and  are  accord- 
ingly most  frequent  or  protracted  in  cold  wet 
weather. 

Anatomical  Characters  and  Pathology. — A 
variety  of  anatomical  changes  may  be  met  with 
in  chronic  rheumatism,  whilst  iu  the  least  severe 
form  of  the  disease  no  definite  changes  in  the 
articular  structures  can  be  discovered.  In  one 
Tarioty  recurrent  liyperaemia  and  effusion  are 
found  in  connection  with  the  synovial  structures, 
and  witli  the  articular  and  periarticular  tissues 


RHEUMATISM,  CHRONIC, 
generally.  In  the  most  severe  cases  the  joiuta 
are  enlarged  and  deformed,  in  consequence  of 
anatomical  changes  which  appear  to  bo  identical 
with  those  of  rheumatic  arthritis.  See  Rheu- 
matic Arthritis. 

This  disease  is  truly  rheumatic  in  its  nature, 
being  intimately  associated  with  acute  rheuma- 
tism. In  many  of  the  best  marked  cases  tha 
patient  has  previously  suffered  from  the  acuta 
disease,  either  immediately  before  or  more  re- 
motely; whilst  in  other  instances  one  or  more 
acute  attacks  occur  in  the  course  of  the  chronic 
disease.  In  yet  another  group  of  eases,  a single 
member  of  a family  will  suffer  from  chronic 
rheumatism,  ending  in  deformity,  whilst  his 
brothers  and  sisters  arc,  without  exception,  at- 
tacked with  the  acute  disease.  The  predisposing 
and  exciting  causes  are  also  identical  in  acute 
and  chronic  rheumatism.  Indeed,  in  every  par 
ticular  the  two  forms  of  affection  run  into  each 
other,  and  are  inseparably  associated. 

Symptoms. — The  clinical  characters  of  chronic 
rheumatism  vary  extremely  in  different  instances. 
The  leading  symptoms  of  the  disease  are  chiefly 
two,  namely,  pain  and  stiffness  in  connection 
with  the  joints  and  associated  structures,  recur- 
ring indefinitely  for  any  length  of  time,  aggra- 
vated by  cold  wet  weather,  and  decidedly  in- 
creased at  night.  More  carefully  investigated, 
the  pains  are  found  to  have  their  seat  in  the 
joints,  in  the  tissues  of  the  limbs  between  the 
joints,  or  in  both.  Any  or  all  of  the  articula- 
tions may  be  affected,  but  the  site  differs  consi- 
derably’ in  the  different  classes  of  the  disease  tc 
be  presently  described.  The  pain  is  of  a severe, 
aching,  wearying  character,  attended  with  a 
sense  of  heaviness  and  uselessness  of  the  limb; 
it  is  relieved  by  rubbing,  and  by  exposure  to  a 
cold  atmosphere ; and  is  increased  by  slight 
warmth.  Free  use  of  the  joint,  although  at  first 
attended  by  much  pain,  often  affords  relief; 
whilst,  on  the  other  hand,  severe  exercise  of  the 
limbs  during  the  day  is  liable  to  be  followed  by 
severe  aching  in  the  night.  The  affected  joints 
also  feel  markedly  dry  and  stiff,  and  creak  on 
movement ; but  exercise  or  rubbing  may  also 
remove  these  sensations. 

These  symptoms  may  last  indefinitely  for 
years,  either  recurring  at  intervals,  especially  in 
the  winter  and  spring  seasons,  or  being  persis- 
tent almost  day  aud  night  without  intermission. 

Such  are  the  essential  characters  of  chrocicrheu- 
matism.  Its  other  features  are  so  variable  as  to 
permit  of  the  formation  of  several  well-defined 
classes  or  degrees  of  the  disease,  as  follows : — 

1 . First  degree. — In  this  class  of  chronic  rheu- 
matic cases  the  pain  and  stiffness  just  described 
are  the  only  articular  symptoms  present  Fo 
apparent  anatomical  change  is  produced,  either 
iu  the  joints  or  in  the  associated  parts.  The 
subjects  of  this  form  of  the  disease  may  be  other- 
wise well,  vigorous,  and  long-lived,  in  spite  of 
the  severe  pains  byr  which  their  rest  is  broken 
in  cold  wet  weather.  They  may  or  may  not  bave, 
or  have  had,  acute  rheumatism. 

2.  Second  degree. — In  a more  severe  form  ef 
chronic  rheumatism,  the  pain  is  associated  with 
obvious  anatomical  changes;  and  tho  disease 
assumes  the  character  of  a recurrent  subacute 
rheumatism,  making  its  appearance  at  intervals 


RHEUMATISM,  CHRONIC, 
for  years.  The  articular  phenomena  consist  of 
redness,  tenderness,  and  swelling,  the  hands  be- 
ing the  favourite  seat  of  the  affection.  These 
subacute  attacks  last  for  days ; and  leave  behind 
them  a distinct  amount  of  swelling,  which  may 
not  have  completely  disappeared  before  the  next 
invasion.  The  process  may  thus,  in  course  of 
time,  lead  to  considerable  enlargement,  or  even 
deformity  of  the  joints. 

3.  Third  degree. — Chronic  rheumatism  of  the 
most  marked  degree  generally  occurs  in  persons 
who  either  have  had , or  may  afterwards  h ave,  acute 
rheumatism ; and  is  characterised  by  recurrent 
attacks  of  severe  pain,  tenderness,  swelling,  and 
hypersemia  of  one  or  more  joints,  which  lead  to 
marked  enlargement  and  deformity.  A single 
joint  may  be  affected  at  first : but  the  disease 
gradually  invades  the  others,  both  large  and 
small,  until  the  whole  articular  system  is  in- 
volved. After  some  years  the  subacute  attacks 
follow  so  closely  upon  each  other,  and  their  local 
effects  are  so  marked,  that  the  patient  is  never 
free  from  distressing  pain ; and  the  joints  become 
anchylosed,  dislocated,  and  otherwise  disorgan- 
ised. At  the  same  time  the  general  nutrition  is 
gradually  impaired  ; and  the  sufferer  is  anaemic, 
wasted,  and  debilitated.  Chronic  rheumatism 
of  the  most  severe  degree  thus  merges  into,  if  it 
be  not  actually  identical  with,  the  class  of  disease 
known  as  ‘rheumatoid’  or  ‘rheumatic’  arthritis. 
See  Rheumatic  Arthritis. 

It  is  necessary  to  understand  that  the  division 
just  made  of  the  leading  varieties  of  chronic 
rheumatism  into  three  groups,  according  to  its 
degree,  has  been  employed  for  the  sake  of  de- 
scription only.  In  a large  number  of  instances 
the  disease  possesses  certain  characters  both  of 
the  first  and  second  degrees;  whilst  it  is  evident 
that  cases  belonging  to  the  second  degree  may 
very  readily  advance  into  the  third. 

Course  and  Terminations. — The  disease,  as 
its  name  implies,  is  essentially  chronic,  generally 
lasting  throughout  the  life  of  the  individual 
whom  it  attacks,  and  leading  to  various  condi- 
tions of  debility  and  deformity,  according  to  the 
degree  of  its  intensity.  In  many  instances  the 
patient  is  rendered  unfit  for  work ; and  such  cases 
form  a considerable  proportion  of  the  inmates  of 
union  infirmaries  and  other  charitable  institu- 
tions. Death  as  a direct  result  of  the  disease  is 
rare. 

Complications. — Cardiac  disease  is  met  with 
in  a considerable  number  of  cases  belonging  to 
the  third  or  most  severe  degree  of  chronic  rheu- 
matism, being  referable  to  endocarditis,  which 
complicated  the  original  acute  attack.  Dyspep- 
sia and  calculous  disorders  are  not  unfrequently 
seen  in  the  subjects  of  the  less  severe  forms. 

Diagnosis. — If  chronic  rheumatism  be  re- 
garded as  a distinct  disease  from  ‘ chronic  rheu- 
matic arthritis,’  it  is  only  in  its  most  severe 
form  that  it  can  be  confounded  with  the  lat- 
ter. A definite  history  of  acute  rheumatism  ; 
the  presence  of  cardiac  disease  ; and  the  non- 
involvement of  such  articulations  as  the  jaw,  the 
stemo-clavicular  joint,  and  the  spine,  are  consi- 
dered to  be  features  which  render  probable  the 
diagnosis  of  true  chronic  rheumatism  from  rheu- 
matic arthritis.  But  in  the  opinion  of  the  writer, 
the  two  diseases  are  identical. 


RHEUMATISM,  GONORRnCEAL.  1367 

The  pain,  swelling,  heaviness,  weariness,  and 
weakness  associated  with  varix  of  the  lower  ex- 
tremities, sometimes  resemble  closely  the  symp- 
toms of  the  milder  forms  of  chronic  rheumatism. 
Physical  examination  at  once  removes  all  doubt. 

Prognosis.— The  prognosis  of  chronic  rheu- 
matism is  favourable  as  regards  life,  but  very 
unfavourable  as  regards  cure ; patients  rarely 
losingtlie  tendency  to  recurrenceof  pain  through- 
out the  whole  of  their  life.  Within  a short  time 
of  the  commencement  of  the  disease  it  will  be 
easy  to  discover  which  of  the  principal  forms  it 
is  likely  to  assume ; and  the  prognosis  may  be 
made  accordingly. 

Treatment.— The  treatment  of  chronic  rheu- 
matism consists  in  (1)  the  relief  of  pain  ; and 
(2)  the  arrest  of  the  rheumatic  tendency,  or  the 
treatment  of  the  disease  proper. 

1.  Palliative  treatment. — This  chiefly  consists 
in  counter-irritation  by  iodine  or  cantharides ; 
the  application  of  anodynes,  such  as  preparations 
of  opium,  belladonna,  and  chloroform;  or  friction 
with  various  stimulating  liniments,  containing 
camphor,  soap,  turpentine,  or  acetic  acid.  Regu- 
lar warm  fomentations  night  and  morning,  with 
very  warm  or  even  hot  water,  followed  by  rub- 
bing and  the  application  of  a stimulating  lini- 
meut  under  warm  rollers,  is  one  of  the  most 
efficacious  methods  of  local  treatment,  the  pains 
being  prevented  or  relieved,  and  the  stiffness  re- 
moved often  to  a remarkable  degree.  Altogether, 
whatever  view  may  be  taken  of  the  pathology  of 
the  disease,  thorough  local  treatment  of  the  joints 
and  limbs  will  generally  be  attended  with  decided 
relief. 

2.  General  treatment. — The  most  successful 
treatment  of  the  condition  of  system  with  which 
chronic  rheumatism  is  associated,  is  removal  of 
the  patient  from  the  variable  weather  of  England, 
to  the  warm  and  settled  climate  of  sub-tropical 
or  tropical  countries.  In  the  case  of  the  poor 
this  is,  of  course,  impossible  ; and  in  them  we 
have  recourse  to  warmth  of  clothing  and  housing, 
as  far  as  they  can  be  secured,  relief  from  mus- 
cular exertion,  and  the  most  nutritious  and  heat- 
producing  diet  that  can  be  supplied,  especially 
oils.  To  secure  these  necessary  comforts,  the 
chronic  rheumatic  poor  have  frequently  to  be 
admitted  permanently  into  charitable  institu- 
tions. Iron  and  cod-liver  oil  are  the  drugs  best 
suited  to  support  the  general  health.  Courses  of 
the  mineral  waters  of  Bath,  Buxton,  and  Strath- 
peffer,  in  this  country ; and  of  many  foreign  baths, 
such  as  Aix-les-Bains,  Aix-la-Chapelle,  Wies- 
baden, Baden-Baden,  and  Hamman  R’lrha,  prove 
invaluable  in  many  cases  to  those  who  can  afford 
to  try  them.  The  ordinary  Turkish  bath  may 
also  afford  temporary  relief,  if  properly  employed. 
See  Rheumatic  Arthritis. 

J.  Mitchell  Bruce. 

KHEUMATISM,  Gonorrhoeal. — Synon.  : 

Fr.  Arthrite  blennorrhagique ; Ger.  Tripperrheu 
matismus. 

Definition. — A form  of  inflammation  of  the 
joints  and  associated  structures,  the  essential 
nature  of  which  is  unknown,  occurring  in  the 
subjects  of  inflammatory  discharge  from  the 
genito-urinary  mucous  membranes. 

.Etiology. — This  disease,  as  its  name  implies 


J 368  RHEUMATISM, 

s generally  referable  to  the  presence  of  gonor- 
rhoea. It  may  originate,  however,  in  any  kind 
of  inflammatory  discharge  connected  with  the 
urethra,  such  as  gouty  or  traumatic  urethritis  or 
gleet.  It  is  much  more  common  in  men  than  in 
women,  apparently  on  account  of  the  comparative 
immunity  from  gonorrhoea  of  the  female  urethra; 
but,  on  the  other  hand,  an  affection  of  the  joints 
which  strongly  resembles  it,  is  found  in  connec- 
tion with  chronic  uterine  disease,  or  in  the  puer- 
peral state.  Either  a rheumatic  or  a gouty  his- 
tory is  frequently  to  be  traced  in  the  patient. 
Previous  attacks  powerfully  predispose  to  the 
return  of  the  disease  on  the  recurrence  of  ure- 
thritis, even  in  a mild  form. 

Amongst  exciting  causes  the  most  important 
appear  to  be  injury  of  a joint,  such  as  sprain; 
and  chill  during  the  course  of  gonorrhoea. 

Persons  who  have  suffered  from  the  disease 
are  frequently  found  to  be,  and  to  have  been, 
peculiarly  susceptible  of  urethral  inflammation  ; 
excessive  sexual  intercourse  being  regularly  fol- 
lowed by  discharge  in  such  individuals. 

Anatomical  Characters. — In  recent  cases  of 
this  disease  the  structures  connected  with  one  or 
more  of  the  articulations  are  acutely  inflamed. 
The  cavity  contains  a variable  amount  of  serous 
effusion,  according  to  its  form  and  size;  the  knee, 
for  example,  being  considerably  distended,  whilst 
the  digital  joints  are  more  moderately  enlarged. 
The  various  component  parts  are  hyperaemie  and 
swollen  ; and  the  peri-articular  structures  full  or 
even  cedematous.  In  more  advanced  cases  the 
joints  are  found  to  contain  either  sero-purulent 
or  purulent  materials ; the  cartilages  may  be 
eroded ; and  finally  the  articulations  may  become 
completely  disorganised  or  anchylosed.  The 
cardiac  structures  are  not  affected.  The  eye  may 
present  the  ordinary  appearances  of  catarrhal 
conjunctivitis. 

Symptoms. — The  disease,  as  ordinarily  ob- 
served, commences  at  any  period  in  the  course 
of  gonorrhoea — very  frequently  within  a week  of 
its  appearance,  but  possibly  not  until  it  has  de- 
generated into  a slight  gleet,  or  apparently  dis- 
appeared. The  patient  is  probably  first  aware 
of  pain  in  the  loins,  or  of  swelling  and  pain  in 
the  soles  of  the  feet,  and  very  shortly  these  symp- 
toms involve  the  ankles.  In  other  instances  the 
knees  or  wrist-joints  suddenly  become  painful, 
tender,  and  swollen — possibly  after  strain  or 
exertion.  At  the  same  time  the  patient  is  fever- 
ish, suffering  from  malaise  and  anorexia;  the 
tongue  becomes  foul;  and  the  pain,  helplessness, 
gonorrhoea,  and  general  illness  give  rise  to  rest- 
lessness and  depression.  Along  with,  perhaps  even 
before,  the  articular  symptoms,  conjunctivitis 
sets  in,  affecting  one  or  both  eyes,  and  although 
of  a well-marked  catarrhal  kind,  usually  passes 
off  in  a few  days  with  little  or  no  treatment. 

The  physical  signs  connected  with  the  joints 
are  generally  well-marked,  the  parts  being  hy- 
peraemie and  much  swollen,  both  from  intra- 
artuular  effusion  and  from  exudation  around. 
The  amount  of  oedema  of  the  dorsum  of  the  hand 
or  foot  when  the  neighbouring  joints  are  iu- 
rolved  by  gonorrhoeal  rheumatism,  and  of  the 
sopor  part  of  the  subcutaneous  surface  of  the 
tibia  when  tho  knee-joint  is  affected,  is  often  re- 
markable. The  severity  of  the  pain  varies  much. 


GONORRHOEAL. 

At  times  it  is  great,  preventing  sleep,  especially 
as  it  is  usually  aggravated  at  night;  in  other 
instances  it  is  extremely  slight,  and  the  con- 
dition is  then  more  chronic  in  character.  The 
pain  is  ‘gnawiDg’  or  ‘aching;’  according  to 
some  patients,  it  is  more  severe  before  the  swell- 
ing appears,  according  to  others  it  is  aggravated 
by  the  swelling.  An  important  feature  of  the 
pains  in  gonorrhoeal  rheumatism  is  that  in  some 
cases  they  are  not  limited  to  the  joints,  but 
involve  the  fibrous  structures,  especially  ‘he 
loins,  the  plantar  and  palmar  fasciae,  the  tendo 
Achillis,  and  the  sheaths  of  nerves,  such  as  the 
great  sciatic.  The  muscles,  or  their  aponeuroses, 
also  appear  to  suffer;  the  fleshy  parts  of  the  arm, 
forearm,  and  thigh  being  occasionally  complained 
of.  Frequently  indeed  the  patient  declares  that 
the  pains  are  universal.  Stiffness  is  also  felt, 
particularly  w£en  a joint  or  limb  lias  been  kept 
long  in  one  position.  Tenderness  varies  much, 
like  the  other  phenomena,  being  exquisite  in 
some  instances,  and  entirely  absent  in  others. 
Portions  of  the  tendon-sheaths  may  be  found 
swollen  and  tender. 

The  heart  and  pericardium  are  very  rarely,  if 
ever,  involved. 

Such  is  the  usual  appearance  presented  by  a 
case  of  gonorrhoeal  rheumatism  within  the  first 
week  of  its  appearance.  Under  favourable  cir- 
cumstances the  symptoms  may  decline;  but  in 
the  majority  of  instances  one  joint  after  another 
is  invaded  by  the  morbid  process,  whilst  those 
already  attacked  either  slowly  recover  or  con- 
tinue affected,  the  disease  being  thus  protracted 
for  several  weeks  or  even  months.  Cases  are 
met  with  in  which  all  the  joints  of  one  or  more 
limbs  are  simultaneously  affected  with  gonor- 
rhoeal rheumatism,  and  have  been  so  affected  for 
ten  or  sixteen  weeks  ; certain  of  the  articulations 
being  but  recently  invaded,  whilst  others  are 
slowh’  recovering  from  the  attack  with  which  the 
disease  commenced.  In  this  manner  every  joint 
in  the  body  may  be  invaded,  including  the  jaw, 
the  sterno-elavicular  articulations,  and  the  spinal 
column. 

The  class  of  case  just  described  constitutes 
the  most  severe  form  of  gonorrhoeal  rheumatism. 
Happily,  in  most  instances  the  disease  is  much 
milder,  only  one  or  two  joints  being  affected, 
and  the  process  either  ending  with  a sharp  pain- 
ful hurst  of  acute  synovitis,  or,  on  the  contrary, 
lapsing  into  a state  of  chronic  intra-articular 
effusion,  with  neither  tenderness  nor  pain. 

When  the  disease  is  protracted,  either  in  one  or 
in  many  joints,  the  constitutional  symptoms  lose 
their  acute  character.  There  is  little  or  no  py- 
rexia; the  appetite  is  fair;  and  the  patient  may 
even  go  about  his  work.  But  the  health  is  gra- 
dually impaired,  the  patient  being  debilitated 
and  depressed  ; in  the  most  severe  cases  he  may 
be  completely  crippled,  and  reduced  to  a condition 
of  great  helplessness  and  wretchedness. 

Pathology. — Opinion  is  greatly  divided  upon 
the  essential  nature  of  gonorrhoeal  rheumatism 
Three  leading  views  may  be  mentioned.  It  is 
believed  by  some  pathologists  that  ‘ gonorrhoeal 
rheumatism’  is  nothing  more  than  acute  or  sub- 
acute rheumatism,  associated  with  gonorrhoea 
or  other  similar  discharge.  Other  authorities 
recognise  in  the  disease  a mild  form  of  pyaemia, 


RHEUMATISM,  GON ORRHCEAL. 

the  source  of  infection  being  usually  the  urethra. 
The  third  view  is  perhaps  not  inconsistent  with 
either  of  the  other  two.  It  represents  gonorrhceal 
rheumatism  as  a trophic  or  nutritive  disorder, 
due  to  reflex  disturbance ; the  urethral  inflam- 
mation affecting  primarily  certain  centres  in 
the  spinal  cord  and  brain,  and  the  altered  con- 
dition of  these  giving  rise  to  the  articular 
changes. 

According  to  both  the  pyaemic  and  the  trophic 
or  reflex  theory  of  gonorrhceal  rheumatism,  the 
joint-affection  may  originate  in  a purulent  dis- 
charge from  any  mucous  surface,  the  urethra  in- 
cluded. Thus  j oint-disease  has  occasionally  been 
observed  in  association  with  chronic  uterine  dis- 
charges, dysentery,  and  chronic  bronchitis.  It  is 
beside  the  purpose  of  the  present  article  to  enter 
iuto  a discussion  of  these  theories. 

Cocese,  Duration,  and  Tekhinations. — 
The  variable  course  of  gonorrhceal  rheumatism 
has  been  already  sufficiently  indicated.  The 
duration  of  the  disease  is  quite  indefinite,  vary- 
ing from  a few  days  to  many  months.  The  most 
unfavourable  termination  of  the  disease  is  anchy- 
losis of  the  joints,  with  hopeless  crippling ; but 
this  is  rare.  It  never  proves  fatal  directly. 

Diagnosis. — The  diagnosis  of  this  disease 
turns  upon  the  existence  of  an  urethral  discharge, 
in  association  with  articular  inflammation.  The 
occurrence  of  the  latter  in  young  male  subjects 
should  always  rouse  the  suspicions  of  the  prac- 
titioner as  to  the  presence  of  gonorrhoea ; and  he 
ought  at  once  to  ascertain,  by  careful  inspection, 
the  state  of  the  urethra,  never  accepting,  the 
patient’s  statement  on  the  subject.  In  some 
instances  the  history  of  a recent  gonorrhcea  may 
alone  remain.  The  previous  occurrence  of  one  or 
more  similar  attacks  in  connection  with  gonor- 
rhcea will  confirm  the  diagnosis.  Ophthalmia  in 
association  with  subacute  articular  symptoms 
ought  immediately  to  suggest  the  presence  of 
gonorrhceal  rheumatism. 

Pbognosis. — The  prognosis  is  generally  fa- 
vourable. In  young,  healthy  subjects,  under  care- 
ful treatment,  the  disease  will  probably  shortly 
subside ; whilst  it  will  prove  protracted  and  ob- 
stinate under  the  opposite  circumstances.  Gonor- 
rhceal rheumatism  increases  in  severity,  and  the 
prognosis  is  correspondingly  more  unfavourable, 
in  subsequent  attacks.  Another  point  which 
should  be  seriously  impressed  upon  the  patient, 
by  way  of  tvarning,  is  that  the  risk  of  the  recur- 
rence of  arthritis  also  increases  with  each  expo- 
sure to  gonorrhceal  infection. 

Treatment.  — The  treatment  of  gonorrhceal 
rheumatism  is  still  unsatisfactory.  Whilst  some 
practitioners  endeavour  to  check  the  urethral  in- 
flammation as  speedily  as  possible,  others  strive 
to  encourage  the  discharge.  The  former  plan 
appears  to  be  the  more  rational  and  the  more 
successful ; and  the  treatment  of  the  gonorrhoea 
should  therefore  be  persevered  with.  The  atten- 
tion of  the  practitioner  will,  however,  be  directed 
chiefly  to  the  joints.  If  the  local  symptoms  be 
severe,  absolute  rest  is  necessary,  the  patient 
being  confined  to  bed,  and  the  affected  limb  pro- 
tected by  a splint  in  such  a way  that  applications 
tan  be  made  to  the  joints.  Anodynes  may  be 
called  for  at  first,  such  as  poultices,  fomentations 
— simple  or  opiated  or  a liniment,  composed  of 


RHEUMATISM,  MUSCULAR.  1369 
equal  parts  of  extract  of  belladonna  and  glycerine. 
In  other  instances  leeches  may  be  tried;  and 
blistering  in  others,  where  there  is  either  great 
pain,  unrelieved  by  anodynes,  or  persistent  effu- 
sion. In  subacute  cases  with  little  pain  or  gene- 
ral disturbance,  strapping  may  be  sufficient;  and 
in  a more  chronic  form  of  the  disease  friction  of 
the  joint  and  moderate  exercise  may  effect  a cure, 
for  example,  of  the  knee  by  walking. 

Internal  treatment  must  be  pursued  simul- 
taneously. In  acute  cases  free  purgation  should 
be  obtained  at  first,  and  this  should  be  followed 
by  a course  of  alkaline  salines,  either  alone  or  in 
combination  with  quinine.  If  the  disease  per- 
sist, iodide  of  potassium  should  be  given,  com- 
bined with  alkalies  or  with  iron,  according  to 
circumstances.  In  other  cases  mercurials  effect 
a cure,  especially  if  there  be  a syphilitic  taint, 
which  is  not  uncommonly  the  case.  The  diet 
must  be  carefully  regulated  in  the  different 
stages.  In  very  chronic  cases  of  gonorrhceal 
rheumatism,  with  threatening  anchylosis,  the 
patient  should  be  sent  if  possible,  to  a warm 
watering-place,  and  be  subjected  to  a thorough 
course  of  treatment  both  externally  and  inter- 
nally See  Rheumatic  Arthritis. 

J.  Mm  hell  Bruce. 

RHEUMATISM,  Muscular. — 3ynon.  : Fr. 
Bhumatisme  musculaire ; Ger.  Muskelrheuma- 
tismus. 

Definition. — A disorder  connected  with  fibro- 
museular  structures;  generally  associated  with 
the  rheumatic  diathesis  ; and  characterised  by 
local  pain  and  spasm,  and  a certain  degree  of 
fever. 

^Etiology. — Muscular  rheumatism  is  most 
frequently  observed  in  the  subjects  of  the  rheu- 
matic diathesis.  It  occurs  in  both  sexes,  and 
at  all  ages ; children  and  adults  being  specially 
liable  to  rheumatic  torticollis,  and  older  subjects 
to  lumbago  and  chronic  muscular  rheumatism  of 
the  limbs.  The  exciting  causes  are  chiefly  two ; 
first,  exposuro  to  cold — above  all,  exposure  of  a 
muscular  part  to  a ‘draught’  after  exertion; 
and  secondly,  sprain  or  strain  of  the  fibro- 
muscular  structures.  Muscular  pain,  tenderness, 
and  spasms  are  also  common  in  the  invasion  of 
acute  rheumatism,  and  in  gonorrhceal  and  chronic 
articular  rheumatism. 

Anatomical  Characters. — Mothing  is  known 
respecting  the  anatomical  characters  of  muscular 
rheumatism,  if,  indeed,  there  be  any  discoverable 
change  in  the  muscular  or  fibrous  structures. 

Symptoms. — The  disorder  usually  commences 
with  slight  febrile  disturbance,  possibly  accom- 
panied by  sore-throat.  Either  simultaneously, 
or  in  children  after  one  or  two  days,  pain  is 
experienced  in  the  region  of  some  definite  muscle 
or  muscular  mass,  such  as  the  sterno-inastoid  or 
the  muscles  of  the  loins;  and  this  speedily  be- 
comes so  severe  as  to  constitute  the  leading 
symptom  of  the  attack.  The  pain  is  present 
only  when  the  affected  muscle  is  thrown  into 
action,  so  that  it  may  be  perfectly  relieved  by 
relaxation  or  rest  of  the  parts  involved.  The 
slightest  movement,  however,  from  the  position 
of  relief  is  instantly  attended  with  excruciating 
pain,  of  a peculiar  spasmodic  character,  which 
persists  until  relaxation  is  again  secured.  Th« 


1370  RHEUMATISM, 

constant  effort  to  avoid  pain  gives  rise  to  a 
feeling  and  appearance  of  stiffness,  causing  the 
patient  to  assume  characteristic  attitudes  of  the 
head,  trunk,  or  limbs.  Tenderness  on  grasping 
the  muscle  is  occasionally  well-marked.  In  some 
cases  several  of  the  joints  may  be  affected  with 
pain  and  stiffness. 

The  constitutional  symptoms  of  muscular 
rheumatism  are  generally  those  of  mild  pyrexia. 
The  tongue  is  furred  ; the  appetite  is  impaired ; 
the  bowels  are  confined;  the  pulse  is  somewhat 
frequent,  full,  and  soft;  and  there  is  a feeling 
of  malaise.  In  other  instances  these  symptoms 
are  extremely  slight  or  altogether  wanting,  the 
patient  suffering  from  nothing  more  than  local 
pain.  Occasionally  there  is  catarrhal  ophthal- 
mia. 

Muscular  rheumatism  usually  persists  for 
several  days,  and  gradually  declines,  but  in  the 
milder  cases  it  may  last  for  weeks.  One  form 
of  the  disorder  is  essentially  chronic,  the  patient 
suffering  for  years  from  pain  in  various  fibro- 
muscular  structures,  especially  those  of  the 
shoulder,  arm,  thigh,  and  leg,  during  cold,  wet 
weather. 

Varieties. — The  following  local  varieties  of 
muscular  rheumatism  are  recognised  by  special 
names : — 

1.  Muscular  torticollis.— Synon.  : Acute 
Wry-neck;  ‘Stiff-neck’;  Caput  obstipum.— Here 
the  sterno-mastoid  muscle  is  chiefly  involved,  but 
any  or  all  of  the  cervical  muscles  may  be  pain- 
ful. This  form  is  most  frequently  observed  in 
young  subjects,  and  is  often  markedly  recurrent. 
It  is  easily  recognised  by  the  fixed  position  of 
the  head  ; and  has  to  be  diagnosed  from  spas- 
modic torticollis,  sterno-mastoid  tumour,  sprain, 
and  spinal  disease. 

2.  Pleurodynia. — The  ftbro-muscular  struc- 
tures of  the  chest- wall  are  the  seat  of  rheuma- 
tism in  this  variety.  Cough  is  a common  excit- 
ing cause  of  the  complaint,  which  is  seen  chiefly 
in  adults.  Pain  is  complained  of  in  the  chest- 
wall,  usually  on  one  side ; and  in  some  instances 
it  may  be  excruciating,  and  of  a distressing  spas- 
modic character.  On  examination  it  is  found 
that  a particular  intercostal  space,  or  the  origin 
of  the  pectoral  or  serratus  muscles,  is  the  seat 
of  localised  tenderness  ; and  that  every  respira- 
tory act  causes  lancinating  pain  in  the  same 
situation.  The  respiratory  movements  of  the 
affected  side  are  restrained;  but  the  ordinary 
physical  signs  of  pleural,  pulmonary,  and  cardiac 
disease  are  absent,  as  are  also  the  points  dou- 
loureux, which  characterise  intercostal  neuralgia. 
If  the  movements  of  the  corresponding  ribs  be 
restrained  by  plaster  or  bandage,  the  pain  is 
effectually  controlled.  The  direct  constitutional 
disturbance  is  generally  not  great,  unless  sleep 
be  prevented  by  pain. 

3.  Lumbago.  — The  muscular  and  fibrous 
structures  of  the  loins  aro  here  the  seat  of  pain, 
most  commonly  the  erector  spinse,  less  commonly 
the  latissimus  dorsi,  or  other  smaller  muscles  in 
the  same  situation,  on  one  or  both  sides.  As  the 
muscles  of  the  back  support  the  body  in  the  erect 
position,  and  participate  in  the  various  move- 
ments of  bending  the  trunk  in  all  directions,  the 
patient  may  be  compelled  to  remain  at  absolute 
rest  in  bed.  More  frequently  he  is  able  to  go 


MUSCULAR. 

about,  although  with  pain,  or  in  a stooping  atti- 
tude. The  amount  of  febrile  disturbance  is  gene- 
rally moderate. 

Lumbago  is  easily  recognised  by  the  character- 
istic muscular  pain  referred  to  the  loins,  greatly 
increased  by  bending,  straightening  the  back,  or 
by  turning  in  bed;  and  by  tenderness  of  the 
muscles  on  pinching,  without  acute  defined  ten- 
derness on  pressure,  as  in  abscess  or  neuralgia. 
At  the  same  time  it  cannot  be  insisted  upon  too 
strongly,  that  careful  examination  of  the  back, 
of  the  abdomen  generally',  and  of  the  urine,  will 
alone  prevent  the  practitioner  from  falling  into 
the  not  uncommon  error  of  treating  cases  of 
serious  disease  for  simple  lumbago.  Renal  cal- 
culus, lumbar  abscess  connected  with  spinal 
caries,  perinephritis,  perityphlitis,  abdominal 
aneurism,  disease  of  the  rectum,  uterus,  or  blad- 
der, and  spinal  meningitis,  are  the  principal 
morbid  conditions  which  must  be  borne  in  mind 
and  excluded  in  every  instance,  before  the  dia- 
gnosis is  settled.  Pain  in  the  loins  is  also  a very 
common  accompaniment  of  affections  of  the  but- 
tock and  lower  limbs,  such  as  sciatica,  rheumatic 
affections  of  the  hip-joint,  and  perhaps  lameness 
from  any  cause.  It  is  also  very'  frequently  met 
with  in  gonorrhoeal  rheumatism. 

4.  Cephalodynia. — Muscular  rheumatism 
may  affect  the  scalp,  giving  rise  to  a dull,  aching 
kind  of  headache,  on  the  brow  or  occiput,  aggra- 
vated by  movement,  and  occasionally  compli- 
cated with  tenderness  of  the  eyeballs  and  oph- 
thalmia. 

5.  Dorsodynia. — Synon. : Omodynia;  Scapu- 
lodynia. — These  names  are  given  to  rheumatism 
involving  the  structures  of  the  upper  part  of  the 
back  and  shoulders.  It  occurs  chiefly  in  persons 
much  exposed  to  the  weather ; and  has  to  be  diag- 
nosed chiefly  from  rheumatism  of  the  shoulder- 
joint,  and  certain  less  common  forms  of  neuralgia 
connected  with  the  upper  dorsal  nerves  and 
arms. 

6.  Abdominal  rheumatism.— Muscular  rheu- 
matism of  the  abdominal  walls  is  occasionally 
observed,  either  alone  or  in  association  with 
lumbago. 

Diagnosis. — Speaking  generally,  muscular 
rheumatism  has  chiefly'  to  be  diagnosed  from  neu- 
ralgia, and,  as  a rule,  this  can  easily  be  done  by 
the  paroxysmal  character  of  the  latter,  the  tetio- 
logical  relations,  and  especially  the  physical  signs. 
The  practical  diagnosis  of  the  chief  local  varieties 
has  already  been  sufficiently  indicated. 

Prognosis. — The  prognosis  of  muscular  rheu- 
matism is  highly  favourable.  Under  careful 
treatment  recovery  may  be  anticipated  in  a few 
days  or  weeks.  But  the  disorder  is  one  which 
is  peculiarly  liable  to  recur  on  exposure  to  its 
exciting  causes. 

Treatment. — The  treatment  of  muscular  rheu- 
matism consists  in  remedying  the  constitutional 
condition  ; and  in  relieving  the  local  pain.  _ At 
the  very  commencement  of  the  illness,  a hot  air  or 
Turkish  bath  may  answer  both  these  indications, 
and  give  immediate  relief.  The  first  indication 
will,  however,  be  generally  best  fulfilled  by  free 
purgation,  followed  by  alkaline  salines,  such  as 
the  bicarbonate,  citrate,  or  acetate  of  potash,  and 
acetate  of  ammonia.  Iu  more  feeble  subject! 
quinine  may  be  given  in  combination  with  alka- 


RHEUMATISM,  MUSCULAR. 

lies ; and  iodide  of  potassium  in  protracted 
cases.  The  diet  should  be  of  the  simplest 
tharacter. 

The  best  local  treatment  consists  of  absolute 
rest  of  the  affected  parts,  which  may  be  va- 
riously secured  in  different  instances  by  confine- 
ment to  bed,  by  strapping,  or  by  plasters. 
Counter-irritants  or  anodynes,  applied  locally, 
give  great  relief,  and  for  this  purpose  either  a 
hypodermic  injection  of  morphia,  mustard  poul- 
tices, cupping,  warm  opiate  fomentations,  or 
various  liniments  composed  of  extract  of  bella- 
donna and  glycerine,  opium,  aconite,  or  chloroform 
and  camphor,  or  of  various  combinations  of  these, 
may  be  ordered.  Belladonna  plaster  gives  at 
once  relief  and  support  in  mild  cases.  The  con- 
tinuous galvanic  current  occasionally  dispels 
the  pain  and  stiffness  almost  immediately.  The 
affected  muscles  must  be  kept  warm  and  care- 
fully protected  from  cold,  especially  in  torti- 
collis. When  rheumatism  involves  the  muscles 
of  the  limbs,  warm  anodyne  liniments  are  the 
best  local  application. 

Great  care  should  be  exercised  to  prevent  the 
recurrence  of  muscular  rheumatism,  by  wearing 
warm  woollen  clothing ; by  avoiding  exposure  to 
damp  and  draughts;  by  attending  to  the  diges- 
tion and  the  bowels;  and  by  abstaining  from 
severe,  sudden,  and  awkward  muscular  efforts. 
In  chronic  or  recurrent  cases  of  the  disorder,  the 
patient  should,  if  possible,  visit  some  cf  the 
English  or  foreign  baths  indicated  in  the  article 
on  Rheumatic  Arthritis. 

J.  Mitchell  Beuce. 

RHINOSCOPY  (^lv,  the  nose,  and  <Ticoirco>, 
I examine). — Synon.  : Er.  and  Ger.  Bhinoscopie. 
The  practitioner  is  often  called  upon  to  explore 
the  nasal  cavities,  either  with  the  fingers  or 
with  instruments.  In  proceeding  to  seo  the 
interior  of  the  fossae,  it  must  be  borne  in  mind 
that  the  apertures  of  the  nostrils  descend  lower 
than  their  bony  floor ; therefore,  after  having 
thrown  back  the  patient’s  head,  the  nose  should 
be  elevated,  and  the  nostrils  dilated  by  means  of 
dressing  forceps.  Owing  to  the  narrowness  of 
the  fossae  digital  examination  is  difficult,  but  a 
knowledge  of  their  anatomy  will  facilitate  the 
introduction  of  instruments;  and  the  finger  can 
be  passed  through  the  mouth  and  behind  the 
velum  pendulum  palati,  to  explore  the  margins 
of  the  posterior  nares,  and  the  naso-pharyngeal 
cavity. 

Rhinoscopy,  or  the  optical  examination  of  the 
cnoanie,  may  be  either  anterior  or  posterior.  An- 
terior rhinoscopy  is  simply  and  easily  conducted  by 
means  of  a speculum,  either  in  the  form  of  a small 
aural  speculum;  or,  better  still,  by  Thudichum  s 
nasal  dilator ; and  it  will  be  found  that  reflected 
light,  in  most  instances,  answers  better  than 
direct  sunlight.  Posterior  rhinoscopy  must  be 
employed  to  obtain  a view  of  the  deeper  portions 
of  the  structures,  and  of  the  posterior  aspect  of 
the  nares. 

Instruments  and  Method. — The  instruments 
used,  and  the  method  of  examination,  are  the  same 
as  that  in  laryngoscopy  (see  Laryngoscope,  The), 
excepting  that  the  mouth-mirror  is  directed  for- 
wards and  upwards,  and  placed  beneath  or  be- 
hind the  velum  pendulum  palati.  By  this  means, 


EIBS,  DISEASES  OF.  1371 
not  only  the  nasal  passages  are  brought  under 
observation,  but  the  structures  in  immediate  re- 
lation with  them. 

On  proceeding  to  make  a rhinoscopic  examina- 
tion, the  patient  should  be  directed  to  breathe 
through  the  nostrils  while  the  mouth  is  open,  so 
that  the  velum  may  be  flaccid,  and  the  introduc- 
tion of  the  mirror  facilitated.  Some  patients  are 
unable  to  sustain  this  means  of  respiration,  and 
in  such  cases,  by  causing  the  emission  of  nasal 
sounds,  such  as  the  French  en,  the  velum  is 
forced  forwards  and  the  palate  drops.  The  velum 
may  be  pulled  forward  by  means  of  forceps,  but 
this  operation  is  liable  to  cause  spasmodic  action 
of  the  palatal  muscles,  and  it  may  take  a long  time 
before  the  parts  become  accustomed  to  the  pro- 
ceeding. It  is  almost  always  necessary  to  use  a 
tongue  depressor,  as  more  room  is  obtained, both 
for  observation  and  manipulation.  The  best  form 
of  hand  mirror  is  the  ordinary  larvngoseopic  one, 
with  the  glass  set  at  an  oblique,  and  not  a right 
angle  to  the  handle ; and  in  using  it,  and  looking 
at  the  reflection  of  the  various  structures  at  the 
back  of  the  nares  or  vault  of  the  pharynx,  it  must 
be  remembered  that  only  a perspective  view  can 
bo  obtained,  owing  to  the  position  of  the  parts. 
The  structures  which  come  under  observation 
by  the  use  of  the  rhinoscopic  mirror  are — the 
posterior  surface  of  the  soft  palate  and  uvula, 
the  posterior  and  part  of  the  lateral  portions  of 
the  septum  of  the  nose,  the  turbinated  bones, 
the  nasal  meatuses,  the  pharyngeal  walls  of  the 
Eustachian  tube  and  its  orifice,  the  vault  or  roof 
of  the  pharynx,  the  lateral  walls  of  the  pharynx, 
and  the  upper  portion  of  the  posterior  wall  of 
the  pharynx. 

The  morbid  conditions,  for  the  inspection  and 
treatment  of  which  it  may  be  requisite  to  uso 
the  rhinoscope,  are  described  in  the  articles 
Nose,  Diseases  of;  and  Phaeynx,  Diseases  of. 

Edward  Bellamy. 

RHONCHAL  FREMITUS. — A physical 
sign,  appreciated  by  palpation  of  the  chest, 
elicited  by  the  act  of  breathing  when  certain 
secretions  or  other  materials  are  present  in  the 
larger  air-tubes  or  in  a cavity.  See  Physical 
Examination. 

RHONCHUS  (pe'yx“,  I snore). — Ehonchi 
are  sounds  heard  on  auscultation  when  the  air- 
channels  are  partially  obstructed.  The  term  is 
restricted  by  some  authors  to  the  so-called  dry 
and  more  or  less  musical  sounds  produced  in 
the  bronchial  tubes,  for  instance,  sonorous  and 
sibilant  rhonehus ; the  bubbling  and  crepitating 
sounds  in  chest-disease  being  spoken  of  as  rales. 
By  other  authorities,  again,  all  such  sounds, 
whether  sibilant  or  crackling,  are  described 
either  as  rhonchi  or  as  rales , the  terms  being 
interchangeable.  See  Physical  Examination. 

E.  Douglas  Powell. 

RHYTHM  d>v8/j.bs,  a measured  movement). 
Tho  relative  proportion  between  the  several  parts 
of  certain  actions.  In  medical  science  it  is 
generally  applied  to  the  movements  of  respira- 
tion, and  to  the  action  of  the  heart.  See  Physical 
Examination. 

RIBS,  Diseases  of. — See  Chest-walls,  ilis> 

eases  of. 


RICKETS. 


1372 

RICKETS  (A.-Saxon,  ricg,  the  back).  — 
Synon.  : Rachitis;  Er.  Rkachitismc ; Ger . Eha- 
ckitis ; Englische  Krankheit. 

Definition. — A general  disease  affecting  the 
nutrition  of  the  whole  body  ; arresting  natural 
growth  and  development;  perverting  and  delay- 
ing ossification ; retarding  dentition ; causing  the 
bones  to  become  soft,  and  to  yield  to  pressure, 
and  the  muscles  and  ligaments  to  waste  ; and  in 
many  cases  producing  alteration  of  the  brain, 
liver,  spleen,  and  lymphatic  glands. 

JEtioeogy. — Rickets  is  the  consequence  of  slow 
impairment  of  nutrition,  and  the  causes  which 
produce  it  are  principally : — bad  feeding,  foul 
air,  damp  cold  rooms,  want  of  sunlight,  want  of 
exerciso,  and  want  of  cleanliness.  Of  these,  per- 
haps the  first  two  have  the  greatest  influence  in 
causing  the  disease;  for  if  the  quantity  of  nu- 
tritive material  introduced  into  the  system  be 
restricted  by  an  improper  selection  of  food,  and 
if  the  oxidation  of  waste  matters  be  hindered 
by  an  insufficient  supply  of  fresh  air,  interference 
with  nutrition  is  necessarily  carried  to  a high 
degree.  A pure  bracing  air  will  by  itself  do 
much  in  counteracting  the  effects  of  an  improper 
dietary,  for  it  has  been  noticed  that  injudicious 
feeding  is  less  hurtful  in  country  places  where 
the  air  is  dry  than  in  large  towns.  This,  how- 
ever, may  be  partly  explained  by  the  greater 
vigour  of  the  digestive  organs  in  the  former 
case,  enabling  the  child  to  derive  nourishment 
from  food  which,  under  other  conditions,  would 
be  innutritious.  Some  children  are  affected 
more  readily  and  more  severely  by  these  causes 
than  are  others,  for  the  more  the  strength  of  the 
child  is  reduced  before  the  actual  exciting  causes 
of  the  disease  come  into  play,  the  more  quickly 
does  the  patient  fall  a victim  to  their  effects. 
Therefore,  all  influences  which  impair  the  general 
strength,  such  as  weakness  in  the  parents,  or,  in 
the  case  of  the  child  himself,  an  attack  of  acute 
disease,  or  even  unusually  troublesome  dentition, 
must  be  looked  upon  as  predisposing  causes  of  the 
disorder.  There  is  no  proof  that  rickets  is  here- 
ditary. A tubercular  family  predisposition  ren- 
ders the  occurrence  of  rickets  unlikely.  Recently 
a distinguished  foreign  physician  has  attempted, 
by  arguments  drawn  chiefly  from  morbid  ana- 
tomy, to  prove  rickets  to  be  invariably  a conse- 
quence of  inherited  syphilis.  But  the  reasons  for 
rejecting  this  hypothesis  are  overwhelming. 

Anatomicai,  Characters. — • The  bones  are 
affected  in  three  ways : — growth  is  retarded ; the 
spread  of  ossification  into  parts  still  cartilaginous 
is  interfered  with ; and  bone  already  ossified  is 
softened.  The  growth  of  bone  is  not  sompletely 
arrested ; it  rather  becomes  irregular.  There  is 
considerable  development  of  the  cartilaginous 
epiphyses,  and  also  of  the  fibrous  periosteum ; 
but  these  parts  ossify  incompletely  and  slowly ; 
and  as  the  normal  increase  in  size  of  the  medullary 
cavity  continues  in  the  usual  way,  the  bone  comes 
gradually'  to  consist  less  and  less  of  osseous  sub- 
stance, and  more  and  more  of,  as  yet,  unossified 
matter  proliferated  at  the  circumference.  It  is 
in  this  way  that  the  bones  become  soft,  and  not 
from  any  abnormal  absorption  of  earthy'  salts 
from  bone  already  ossified.  The  process  of  cal- 
cification itself,  besides  being  retarded,  is  ab- 
normal ; it  has  indeed  been  described  as  rather  a 


process  of  petrifaction  than  of  true  ossification, 
On  account  of  the  softness  of  the  long  bones,' 
serious  deformities  ensue,  as  will  be  afterwards 
described.  The  flat  bones  become  greatly  thick- 
ened from  proliferation  of  the  periosteum.  This 
is  especially  noticeable  at  the  edges  of  the  cranial 
bones ; and  when  ossification  is  completed,  the 
sutures  of  the  skull  can  be  felt  to  be  prominent 
In  parts,  however,  and  especially  in  the  occipital 
bone,  the  osseous  substance  becomes  thinned  in 
places  from  absorption  under  the  pressure  of  the 
growing  brain.  This  condition,  which  is  called 
‘ craniotabes,’  can  be  detected  by  palpation.  Cal- 
cification is  very  slow  in  the  cranial  bones,  and 
the  fontanelle  often  remains  open  long  after  the 
end  of  the  second  year. 

_ The  liver,  spleen,  lymphatic  glands,  and 
kidneys  are  sometimes  enlarged.  The  increase 
i n size  is  due,  not  to  the  presence  of  any  foreign 
growth  or  deposit  in  these  organs,  but  to  irregular 
hypertrophy  of  their  fibroid  and  epithelial  ele- 
ments, conjoined  with  a deficiency  in  earthy  salts 
- — an  alteration  analogous  to  the  changes  in  the 
bones.  The  brain  is  enlarged  from  an  increase  of 
the  neuroglia,  not  of  the  nerve-elements.  The 
voluntary  muscles  are  small,  pale,  flabby,  and 
soft.  Under  the  microscope  their  stria;  are  seen 
to  be  indistinct.  The  urine  contains  less  urea 
and  uric  acid  than  natural,  but  more  phosphates, 
especially  phosphate  of  lime. 

Symptoms. — In  most  cases  the  symptoms  proper 
to  rickets  are  preceded  by  others  which  indicate 
a certain  amount  of  interference  with  the  diges- 
tive functions.  There  is  occasional  vomiting; 
the  bowels  are  often  relaxed  ; and  the  motions 
are  habitually  loose,  pasty-looking,  and  offen- 
sive. 

The  beginning  of  the  disease  is  marked  by 
profuse  sweating  of  the  head,  face,  and  neck; 
this  is  especially  seen  if  the  child  fall  asleep 
either  at  night  or  in  the  day.  Almost  at  the 
same  time  he  begins  to  throw  off  the  bed-clothes 
at  night.  He  will  do  this  even  in  winter,  and 
may  be  seen  lying  almost  naked  in  the  coldest 
weather.  Later  on,  it  is  noticed  that  the  child 
dislikes  to  be  touched,  and  cries  when  danced 
about.  He  seems  to  be  generally  tender,  and 
to  dread  movement  of  any  kind.  The  occurrence 
of  tenderness  marks  the  commencement  of  the 
characteristic  changes  in  the  bones.  The  ends 
of  the  long  bones  enlarge  ; the  flat  bones  become 
thickened  ; and  all  the  bones  lose  their  firmness 
and  grow  softer.  These  changes  affect  the  osseous 
system  as  a whole,  and  lead  to  serious  deformi- 
ties. If  the  child  had  been  able  to  walk,  he 
becomes  unsteady  on  his  legs,  or  even  loses  the 
power  of  walking  altogether.  He  sits  or  lies 
about ; is  drowsy  in  the  daytime ; and  at  night 
moves  his  head  restlessly  from  side  to  side,  so 
as  in  many  cases  to  wear  the  hair  off  the  occiput. 
The  flesh  is  soft  and  flabby ; the  motions  remain 
loose  and  offensive;  and  the  child  appears  to  be 
occasionally  troubled  with  abdominal  discomfort, 
for  he  may  be  found  asleep  in  his  cot.  resting 
upon  his  hands  and  knees  with  his  head  buried 
in  the  pillow. 

The  softness  of  the  bones  causes  them  to  yield 
readily  to  pressure,  and  it  is  to  this  cause,  and 
not  to  the  force  of  muscular  action,  as  was  at 
one  time  supposed,  that  the  deformities 


BICKETS. 


chiefly  due.  The  long  hones  become  bent  and 
twisted.  The  direction  of  the  bending  depends 
upon  the  direction  in  -which  the  force  of  pressure 
is  applied,  and  in  the  lower  limbs  will  therefore 
vary  according  as  to  whether  the  child  can  ir 
cannot  walk.  Sometimes,  however,  if  the  disease 
begins  before  the  child  is  able  to  support  himself 
upon  his  feet,  the  lower  limbs  may  escape  de- 
formity altogether.  They  are  usually  in  such 
cases  particularly  small  and  thin,  with  weak, 
flabby  muscles,  but  the  bones  themselves  are 
straight.  Force  of  gravity  is  another  cause  of 
deformity  of  bone.  Thus,  in  the  humerus  there 
is  often  a curve  where  the  deltoid  is  inserted: 
this  is  produced  in  great  measure  by  the  weight 
of  the  hand  and  forearm  when  the  limb  is  raised 
by  the  deltoid  muscle. 

.The  skull  is  elongated  from  before  backwards  ; 
the  fontanelle  is  wide  ; the  sutures  are  thickened  ; 
the  forehead  is  high,  square,  and  sometimes 
prominent ; and  the  head  generally  looks  large. 
The  face,  on  the  contrary,  appears  small  out  of 
proportion  to  the  head,  for  the  growth  of  the 
facial  bones  is  arrested.  By  palpation  of  tho 
occiput  the  condition  named  ‘ craniotabes  ’ can 
sometimes  be  detected.  It  is  an  early  symptom. 
Dentition  is  much  delayed,  and  the  teeth  when 
cut  are  deficient  in  dental  enamel,  so  that  they 
decay  rapidly. 

The  spine  is  curved  on  account  of  muscular 
and  ligamentous  weakness  ; and  if  this  weakness 
he  great,  the  natural  posterior  curve  of  the  spine 
is  so  much  exaggerated  as  almost  to  simulate 
angular  curvature.  It  disappears,  however,  at 
once  when  the  child  is  lifted  up  by  the  shoulders. 
Sometimes  the  spine  is  curved  laterally. 

The  deformity  of  the  chest  has  the  following 
characters : — The  softened  ribs  sink  in  so  as 
to  present  a groove  passing  downwards  and  out- 
wards on  each  side  of  the  sternum.  The  bottom 
of  the  groove  is  formed  more  by  the  ribs  than 
the  cartilages,  so  that  the  enlarged  ends  of  the 
ribs,  looking  like  a row  of  beads  under  the  skin, 
can  be  seen  lying  along  the  outer  side  of  the 
groove.  The  sternum  is  forced  forwards  by  this 
bending  of  the  ribs,  and  the  antero-posterior 
diameter  of  the  chest  is  increased.  The  defor- 
mity is  due  to  the  pressure  of  the  external  air. 
In  healthy  breathing  this  pressure  is  overcome 
by  the  resistance  of  the  thoracic  walls,  aided  by 
the  force  of  the  inspired  air.  In  the  rickety 
child  the  resistance  offered  by  the  softened  ribs 
is  greatly  reduced,  and  they  therefore  sink  in  at 
the  parts  where  they  are  least  supported.  On  ac- 
, count  of  the  softened  state  of  his  ribs,  the  breath- 
ing of  a rickety  child  is  quick  and  laborious. 

The  pelvis  is  pressed  upon  from  above  by  the 
spine  and  the  abdominal  contents,  from  below 
by  the  heads  of  the  thigh-bones  ; and  the  direc- 
tion of  these  forces  varies  according  to  the  posi- 
tion of  the  child.  The  general  shape  thus  pro- 
duced Is  triangular,  and  the  pelvic  cavity  is  often 
greatly  narrowed. 

A rickety  child  is  short  for  his  age  ; for  his 
limbs,  besides  being  bent,  are  stunted,  growth  in 
them  being  more  or  less  arrested.  His  joints  are 
largo,  and  loose  from  relaxation  of  the  liga- 
ments. If  the  disease  be  severe,  the  child  gets 
anaemic  and  wastes,  and  tho  muscles  become 
very  flabby  and  small.  His  belly  is  big,  even 


13?  3 

when  there  is  no  splenic  enlargement,  from 
shallowness  of  pelvis  and  flatulent  accumulation. 
Such  children  give  little  trouble.  They  are 
quiet,  and  seldom  cry  if  left  alone.  They  are 
late  in  walking,  late  in  talking,  cut  their  teeth 
late,  and  in  nursery  phraseology  are  ‘back- 
ward children.’ 

Complications. — One  of  the  chief  characteris- 
tics of  rickets  is  the  intense  sensitiveness  to  cold 
with  which  it  is  always  accompanied;  and  it  is  to 
chills  in  different  forms  that  a large  proportion 
of  deaths  occurring  in  this  disease  must  be  attri- 
buted. A catarrh  may  affect  the  chest  or  the 
belly,  and  in  either  case  the  complication  is  a 
very  dangerous  one. 

A pulmonary  catarrh  in  a young  child  should 
never  be  made  light  of,  on  account  of  its  tendency 
to  cause  collapse  of  the  lung ; and  if  the  child  be 
the  subject  of  rickets,  the  danger  is  really  Immi- 
nent on  account  of  the  softness  of  the  ribs. 

If  the  chill  affect  the  abdomen,  as  it  is  very 
apt  to  do,  an  intestinal  catarrh  is  set  up,  and 
unless  the  diarrhoea  be  quickly  arrested,  the 
strength  of  the  child  becomes  seriously  reduced. 

Besides  its  influence  in  increasing  the  suscep- 
tibility of  the  body  to  cold,  rickets  also  heightens 
the  nervous  impressibility  of  the  child.  This 
effect  is  not  a common  result  of  mere  weakness, 
for  in  an  ordinary  case  of  malnutrition  with 
wasting,  the  natural  sensitiveness  of  the  nervous 
system  to  external  impressions  is  impaired.  It 
must  be  therefore  looked  upon  as  a peculiarity 
of  tho  rickety  state.  Its  effects  are  seen  in  the 
attacks  of  laryngismus  stridulus  and  convulsions 
to  which  these  children  are  so  liable.  Few  cases 
of  laryngismus  occur  in  children  who  are  not  the 
subjects  of  rickets.  Such  patients  usually  have 
carpo-pedal  contractions,  and  are  liable  to  be  con- 
vulsed upon  the  very  slightest  provocation.  On 
account  of  the  backwardness  of  the  teeth  in  this 
disease,  all  nervous  derangements  are  commonly 
attributed  to  dentition  ; but  in  rickets  dentition, 
although  delayed,  is  not  necessarily  troublesome ; 
in  fact  the  teeth,  when  they  appear,  are  usually 
cut  with  singular  ease. 

Another  complication  often  met  with  in  rickets 
is  chronic  hydrocephalus:  the  excess  of  fluid  is 
however  small.  This  complication  is  often  sus- 
pected where  it  does  not  really  exist. 

Diagnosis. — When  the  symptoms  of  rickets 
are  well  marked,  the  bony  distortions  themselves 
are  sufficiently  characteristic  to  make  the  nature 
of  the  disease  unmistakeable.  It  is,  however,  of 
great  importance  to  recognise  the  early  symptoms 
of  the  disorder,  so  that  by  prompt  treatment  we 
may  prevent  the  osseous  and  other  changes  taking 
place.  It  must  be  remembered  that  loss  of 
flesh  is  a late  symptom,  and  that  a rickety  child 
is  not  necessarily  a thin  one.  If  an  infant  pass 
the  ninth  month  without  any  appearance  of  a 
tooth ; if  his  wrists  enlarge  ; and  if  on  inquiry  we 
find  that  he  is  subject  to  head-sweats  at  night, 
and  likes  to  lie  naked  in  his  cot,  the  diagnosis  of 
rickets  may  be  made  without  hesitation.  Weak- 
ness of  the  legs  in  a young  child  is  often  a source 
of  anxiety  to  parents,  and  a medical  practitioner 
is  consulted  because  the  child  is  twelve  months  old 
and  cannot  stand.  In  these  cases  the  early  signs 
of  rickets  will  almost  certainly  be  discovered 
Looseness  in  the  joints  is  common  in  cases  of 


RICKETS. 


!374 

rickets,  ■where  the  symptoms  of  the  disease  mani- 
fest themselves  at  the  end  of  the  second  year. 
The  relaxation  of  the  ligaments  is  not  as  a rule 
combined  with  much  hone  deformity,  although  it 
may  be  so.  AVeakness  of  the  legs  from  rickets 
is  distinguished  from  essential  paralysis  by  the 
fact  that,  aLthough  there  may  be  no  power  of 
standing,  the  child  is  yet  able  to  move  his 
limbs ; and  that  the  muscles,  although  weak,  are 
uot  powerless. 

Prognosis. — The  duration  of  rickets  is  depen- 
dent upon  the  duration  of  the  causes  which 
produce  it.  So  long  as  the  baneful  influences 
under  which  the  disease  originated  are  in  opera- 
tion, the  morbid  processes  continue  ; but  when  a 
better  hygiene  is  adopted,  and  failing  nutrition 
is  restored,  recovery  begins. 

AVhen  recovery  takes  place,  the  symptoms  gra- 
dually become  less  intense  and  finally  disappear. 
The  enlargement  of  the  joints  greatly  diminishes, 
and  even  the  bony  distortions  become  notably 
reduced,  while  the  bones  themselves  become 
thick  and  strong.  Growth,  however,  is  not  rapid, 
and  if  the  disease  have  been  severe,  the  child  sel- 
dom readies  the  average  height. 

AVhen  the  disease  terminates  fatally,  it  is 
usually  through  one  of  the  complications  which 
have  been  mentioned.  Sometimes  the  child  sinks 
and  dies,  apparently  worn  out  by  the  intensity' 
of  the  general  disease ; but  even  in  these  cases 
the  immediate  cause  of  death  is  usually  as- 
phyxia, through  the  softened  state  of  the  ribs. 
One  cause  of  the  great  mortality  from  bron- 
chitis in  children  is  the  frequency  with  which 
that  complaint  attacks  rickety  subjects,  even  a 
mild  catarrh  being  seriously  dangerous  when  the 
ribs  are  much  softened. 

In  estimating  the  prospects  of  recovery  in  any 
particular  case,  we  must  pay  attention  to  the 
amount  of  chest-distortion  ; and  to  the  presence 
or  absonce  of  disease  of  the  glandular  system. 
If  the  ribs  he  much  softened,  there  is  always 
cause  for  anxiety ; and  if  in  a case  of  pulmonary 
catarrh  there  he  great  recession  of  the  lower  ribs 
in  inspiration,  the  condition  is  a serious  one. 
The  presence  of  any  complication,  except  per- 
haps chronic  hydrocephalus,  necessarily  increases 
the  gravity  of  the  case. 

Treatment. — As  rickets  is  the  direct  result  of 
mal-nutrition  produced  by  the  anti-hygienic  con- 
ditions in  which  the  child  has  been  living,  our 
first  care  must  he  tc  alter  these  conditions.  AATe 
must  see  that  the  living  rooms  are  thoroughly 
ventilated;  that  the  child  is  taken  out  regularly 
into  the  open  air ; that  he  is  warmly  dressed ; and 
that  his  skin  is  kept  perfectly  clean  by  the 
abundant  use  of  soap  and  water.  AVe  must  next 
select  a diet  for  the  patient  which  is  at  once 
sufficiently  digestible  and  nutritious.  The  term 
‘digestible’  as  applied  to  diet  is  a relative  term. 
Food  digestible  to  one  infant  is  indigestible 
to  another,  and  food  readily  digested  by  a 
child  in  his  natural  state  of  health  becomes  in- 
digestible to  him  when  his  stomach  is  temporarily 
weakened  by  teething  or  any  febrile  attack.  It 
is  not,  however,  sufficient  that  the  diet  should  he 
digestible ; it  must  also  be  nutritious.  Children 
kept  too  long  at  the  breast  frequently  become 
rickety  even  although  fed  at  the  same  time  upon 
other  and  suitable  food  ; for  the  watery  breast- 


milk,  which  forms  the  principal  part  of  their 
diet,  is  sufficient  by  its  bulk  to  satisfy  their  desire 
for  food,  without  supplying  the  required  nourish- 
ment to  the  tissues.  Rickety  children  at  the 
breast  should  at  once  be  weaned,  and  if  under 
twelve  months  old,  should  be  fed  principally 
upon  milk  guarded  with  liquor  ealcis  saceharatus, 
in  the  proportion  of  fifteen  drops  to  the  bottle- 
ful. They  may  take  besides,  broths,  bread 
and  butter,  and  occasionally  the  yolk  of  an  egg 
lightly  boiled  or  beaten  up  with  milk.  Instead 
of  bread  and  butter,  the  milk  may  be  thickened 
for  some  mea.s  with  Chapman’s  wheat  flour 
baked  in  an  oven  ; hut  farinaceous  food  should  be 
given  with  very  great  caution  to  these  children, 
on  account  of  their  tendency  to  acid  indigestion, 
which  renders  a starchy  diet  particularly  likely 
to  disagree.  Under  twelve  months  of  age  the 
child  can  seldom  hear  more  than  one  teaspoonful 
of  a farinaceous  powder  twice  in  the  day.  After 
the  first  year,  strong  beef-gravy,  and  flower  of 
broccoli  stewed,  may  be  added  to  the  diet.  At 
sixteen  or  eighteen  months  old,  a little  mutton 
may  be  given,  carefully  pounded  in  a warm 
mortar.  A mealy  potato  well  boiled  and 
mashed  may  be  allowed,  hut  the  effect  of  all 
farinaceous  food  is  to  bo  carefully  watched.  The 
presence  of  flatulent  pains  is  a sure  sign  that  the 
proper  quantity  has  been  exceeded. 

The  diet  and  general  hygienic  arrangements 
having  been  regulated,  the  secondary  question  of 
drug-giving  has  to  be  considered.  Before  adopt- 
ing tonic  treatment,  it  is  important  to  improve  the 
condition  of  the  bowels.  A dose  of  castor  oil  or  of 
rhubarb  aud  soda  should  be  given  to  clear  away 
undigested  food,  and  afterwards  a few  grains  cf 
bicarbonate  of  soda  witha  drop  of  tincture  of  opium 
in  a little  aromatic  water  will  soon  remove  the 
offensiveuess  of  the  motions.  Citrate  of  iron  may 
then  he  added  to  the  mixture,  and  the  child  should 
begin  at  once  to  take  cod-liver  oil.  The  dose  of 
the  oil  should  he  small  at  first  (m.  xv— xx),  and 
while  it  is  being  taken,  the  motions  should  be 
watched  for  any  appearance  of  oil  in  the  stools; 
if  this  occur,  the  dose  is  too  large  and  must  be 
diminished.  As  convalescence  advances  other 
medicines  may  he  given ; and  iron  wine,  quinine, 
decoction  of  oak  hark,  reduced  iron,  and  Parrish's 
food  are  all  useful.  So  long  as  the  previous 
directions  have  been  attended  to,  the  exact  tonic 
used  is  of  comparatively  little  moment : but  cod- 
liver  oil  should  never  be  omitted  from  the  treat- 
ment. Lime  has  been  strongly  recommended  by 
some  authors,  hut  according  to  the  writer’s  expe- 
rience is  of  little  value  unless  combined  with 
iron  as  in  Parrish's  food,  in  which  ease  it  is  pro- 
bably not  to  the  lime  that  the  benefit  is  to  be 
attributed.  It  may  onee  more  be  repeated  that 
in  rickets  the  success  of  treatment  is  in  direct 
proportion  to  the  conscientiousness  with  which 
the  rules  relative  to  diet  and  general  manage- 
ment have  been  carried  out ; and  the  mother 
should  he  made  to  understand  that  the  chi  Ids 
recovery  depends  upon  her  own  watchfulness  and 
care. 

The  bone  deformities  can  bo  prevented  to  a 
certain  extent,  by  hindering  the  child  from  walk- 
ing while  the  hones  are  still  soft  The  bowing 
of  the  legs  is  often  owing  to  the  child's  getting 
upon  his  feet  before  the  hones  have  become 


RICKETS. 

sufficiently  consolidated  to  bear  the  weight  of 
the  body.  In  these  cases  light  well-padded 
splints  which  project  below  the  feet  will  be  the 
best  safeguard.  When  the  ligaments  of  the  joints 
are  loose  and  weak,  the  joints  may  be  much 
strengthened  by  a well-fitting  silk  elastic  sup- 
port. 

After  the  tenderness  of  the  body  has  subsided, 
the  child  should  be  well  shampooed,  especially 
along  the  spine,  both  morning  and  evening. 

With  regard  to  the  complications : — diarrhoea 
and  pulmonary  catarrh  must  be  treated  upon 
ordinary  principles.  A good  flannel  bandage 
very  much  diminishes  the  tendency  to  relaxation 
of  the  bowels,  and  is  of  further  value  in  retarding 
the  too  rapid  descent  of  the  diaphragm,  and  so 
in  diminishing  to  a certain  extent  the  recession 
of  the  chest-walls  during  inspiration.  The 
uervous  complications  are  best  treated  with 
bromide  of  ammonium  or  of  potassium.  Laryngis- 
mus stridulus  is  often  cured  at  once  by  bathing 
the  whole  body  three  times  a day  with  water  of 
the  temperature  of  60°  Fh. 

Eustace  Smith. 

RIGIDITY  ( rigidus , cold,  frozen,  stiff). — - 
Stnon.  : Fr.  Bigidite;  Ger.  Starrlicit. — This  term 
implies  the  existence  of  a more  or  less  fixed  con- 
dition in  parts  that  ought  to  be  freely  movable. 
It  is  a state  met  with  principally  in  the  limbs, 
where  it  is  dependent  upon  certain  unnatural 
conditions  of  the  joints  or  of  the  muscles,  either 
separately  or  in  combination.  It  may,  however, 
occur  iD  the  trunk  as  a whole,  or  in  the  neck, 
owing  to  the  existence  of  tetanic  or  tonic  spasms 
in  muscles,  due  to  one  or  other  of  various  causes. 
The  valves  of  the  heart,  and  the  arteries,  when 
stiffened  by  fibrosis,  are  said  to  be  rigid.  Again 
it  is  a term  commonly  applied  to  a condition  of  the 
1 os  uteri  ’ during  parturition,  in  certain  women, 
in  whom  the  orifice  of  the  womb  does  not  dilate 
co-ordinately  with  the  increase  in  force  of  the 
uterine  contractions.  The  term  is  also  sometimes 
used  in  connection  with  the  features.  Marked 
ligidity  of  a limb  at  this  or  that  joint  often 
results  from  joint-disease.  Perhaps  more  fre- 
quently, however,  rigidity  in  a limb  is  primarily 
dependent  upon  altered  functional  or  nutritive 
conditions  of  its  muscles,  which  may  or  may  not 
be  associated  with  actual  paralysis  implicating 
the  same  parts. 

Numerous  cases  exist  in  which,  without  the 
existence  of  paralysis,  or  with  a comparatively 
small  amount  of  it,  tonic  .spasms  occur  in  the 
muscles  of  a limb,  so  as  to  entail  rigidity  (see 
Spasm).  This  may  be  met  with,  for  instance,  in 
hysteria,  and  in  the  early  stages  of  some  spinal 
diseases,  more  especially  in  primary  lateral 
sclerosis. 

More  frequently  still,  however,  rigidity  is 
found  in  association  with  distinct  paralysis.  For 
many  years  a distinction  has  been  made  between 
two  kinds  of  rigidity  associated  with  paralysis  ; 
the  one  of  which,  known  as  ‘ early  rigidity,’  is 
apt  to  supervene  soon  after  the  onset  of  a cere- 
bral or  spinal  paralytic  affection ; whilst  the 
other,  known  as  ‘ late  rigidity,’  comes  on  rather 
:u  old  cases  in  which  mere  paralysis  with  flac- 
cidity  of  muscles  may  have  been  previously  pre- 
sent, The  former  is  now  believed  in  many  cases 


RIGOR.  1875 

to  have  a tendency  to  pass  into  the  latter  form  ; 
and  where  this  latter  becomes  well-developed,  it 
is  commonly  associated  with  a secondary  or  with 
a primary  sclerosis  of  the  corresponding  lateral 
column  of  the  spinal  cord,  even  though  the  initial 
paralysing  lesion  may  he  in  some  portion  of  the 
motor  tract  of  the  opposite  cerebral  hemisphere 
(see  Spinal  Coed,  Introduction  to  Diseases  of). 
In  early  rigidity  we  have  to  do  with  mere  func- 
tional changes  in  the  muscles,  and  the  condition 
itself  of  rigidity  is  not  constant;  it  intermits 
from  time  to  time  during  the  day,  and  commonly 
disappears  during  sleep.  But  in  late  rigidity, 
associated  with  extensive  secondary  degenera- 
tions in  the  spinal  cord,  the  nutrition  of  the 
nerves,  as  well  as  of  the  muscles  and  their  ten- 
dons, appears  to  suffer,  and  that,  for  the  most 
part,  in  an  irretrievable  manner.  This  more 
severe  condition  of  rigidity  is  associated  with 
actual  shortening  of  muscles  or  tendons,  and  in 
this  stage  but  little,  if  any,  difference  exists 
between  the  degree  of  rigidity  of  the  limbs  by 
night  and  by  day.  See  Motility,  Disorders  of. 

H.  Charlton  Bastian. 

RIGOR. — Stnon.  : Shivering-fit ; Fr. Frisson ; 
Ger.  Frostanfall. 

Symptoms. — This  state  is  characterised  by  the 
following  phenomena  — There  is  general  shiver- 
ing, the  tremulous  movements  not  infrequently 
being  so  great  as  to  cause  chattering  of  the 
teeth.  The  face  wears  an  expression  of  great 
discomfort,  or  even  of  distress.  The  complexion, 
especially  on  the  lips  and  beneath  the  nails,  is 
blue  and  livid.  The  tongue  is  moist,  although 
thirst  is  felt.  The  fingers  are  shrivelled  and 
‘dead;’  the  skin  dry  and  corrugated  (cutis 
anserina) ; and  the  cutaneous  sensibility  dimi- 
nished. The  respiration  is  quickened  and  shal- 
low. The  pulse  is  frequent,  small,  and  firm.  The 
temperature  of  the  general  surface  is  raised, 
although  a sensation  of  cold — sometimes  of 
severe  cold— often  referred  to  the  back  or  the 
abdomen,  is  present.  The  extremities,  however, 
as  the  fingers,  ears,  and  nose,  may  be  colder  than 
natural.  With  these  maybe  combined  other  symp- 
toms, such  as  headache,  nausea,  vomiting,  and 
the  special  pains  in  the  back  or  the  limbs,  which 
are  proper  to  the  different  species  of  fever ; hut 
delirium  is  rarely  present. 

Pathology  and  .Etiology. — Rigors  are  the 
result  of  the  disturbance  of  some,  as  yet  undeter- 
mined, nervous  tract,  which,  however,  is  clearly 
connected  with,  if  not  indeed  the  same  as,  the 
great  co-ordinating  centre  in  the  medulla  for  the 
respiratory,  cardiac,  and  vascular  movements, 
and  which  must,  further,  be  in  intimate  relation 
with  the  thermotaxic  centre,  if  such  exist.  One 
of  the  exciting  causes  of  this  disturbance  may 
be  the  existence  of  some  abnormal  differences 
between  the  temperature  of  the  surface  and  that 
of  the  interior  of  the  body.  This  suggestion  of 
Liebermeister,  at  any  rate,  supplies  an  answer 
to  one  or  two  perplexing  questions.  It  enables 
us  to  understand  how  it  is  that  a man  already  in 
the  grasp  of  a serious  disorder,  the  temperature 
of  whose  body  is  raised,  and  is  rapidly  rising, 
has  yet  the  same  sensation  of  cold  as  a healthy 
man  whose  external  temperature  is  below  the 
normal,  and  whose  nervous  and  vascular  system* 


1376  EIGOE. 

are  merely  reacting  in  a perfectly  natural  man- 
ner under  one  of  the  commonest  conditions  of 
animal  life,  for  in  each  case  the  surface  is  colder 
than  the  deeper  parts,  and  thus  gives  rise  to  a 
sensation  of  cold.  It  gives  a “plausible  solution 
of  the  paradox  that  the  greater  the  absolute 
heat  of  the  body  as  a whole,  the  more  acute  is 
the  sensation  of  cold ; and  it  establishes  on  a 
scientific  basis  the  empirical  belief  in  the  value 
of  rigors  as  marking  the  access  of  disease,  when 
it  is  seen  that  their  presence  is  a proof  that 
increased  tissue-change,  as  shown  by  the  in- 
creased production  of  heat— the  very  essence  of 
fever — has  already  begin. 

The  early  diagnosis  of  fevers,  whether  idio- 
pathic or  symptomatic,  is  often  greatly  facili- 
tated by  the  careful  study  of  the  phenomena  of 
the  initial  rigors.  Putting  on  one  side  the  cases 
in  which  a local  cause  may  be  found  to  exist, 
very  violent  rigors  occur  chiefly  in  connection 
with  the  following  diseases Malarial  fevers, 
relapsing  fever,  variola,  scarlatina,  erysipelas, 
pyaemia,  and  croupous  pneumonia.  They  are 
less  marked  in  typhus  and  enteric  fever,  pleu- 
risy, catarrhal  pneumonia,  and  bronchitis.  It 
must,  however,  be  remembered  that,  in  apprais- 
ing the  value  of  any  nervous  symptom,  such 
as  rigors,  the  personal  factor  is  of  extreme 
importance,  and  that  general  rules  derived  from 
averages  are  here  more  than  ever  misleading,  if 
applied  indiscriminately  to  individuals. 

An  additional  argumentfor  their  central  origin 
is  found  in  the  well-known  fact,  that  in  children 
and  in  persons  of  unstable  nervous  equilibrium 
— for  example,  epileptics — convulsions  are  a fre- 
quent result  of  the  same  causes  which  produce 
rigors  in  other  cases. 

Eigors  occur  under  the  following  conditions : — 
1.  In  health,  when  a more  or  less  extensive  part 
of  the  surface  of  the  body  is  chilled  by  external 
cold.  Indeed  the  chilling  of  even  a very  small 
extent  of  skin  is  sufficient  to  produce  them.  2. 
From  irritation  of  a sensory  nerve,  and  espe- 
cially in  connection  with  some  mucous  surface. 
Thus  rigors  are  an  everyday  result  of  the  pre- 
sence of  irritating  matters  in  the  stomach  or 
bowels,  of  catheterism.  and  of  the  passage  of 
biliary  or  renal  calculi.  3.  With  the  access  or 
the  exacerbation  of  some  local  disease,  espe- 
cially if  it  be  one  which  is  to  end  in  the  forma- 
tion of  pus.  Eigors  occur,  not  only  at  the  be- 
ginning, but  also  during  the  progress,  and  with 
great  violence  just  before  the  bursting  of  an 
abscess.  Thrombosis  in  veins  is  also  attended 
by  rigors.  The  writer  himself  once  experienced 
very  violent  rigors  in  connection  with  extensive 
thrombosis  of  the  veins  of  the  left  arm,  due  to 
a prick  received  at  a ■post-mortem,  examination, 
although  no  suppuration  whatever  took  place 
during  the  whole  course  of  his  illness.  4.  At 
the  beginning  of  idiopathic  and  symptomatic 
fevers,  that  is,  when  the  fever  has  already 
begun,  and  the  increased  heat-production  in  the 
viscera  has  destroyed  the  natural  balance  be- 
tween the  temperature  of  the  interior  and  of  the 
surface  of  the  body. 

Although  for  practical  purposes  it  is  conve- 
nient to  distinguish  these  different  modes  of 
origin  of  rigors,  they  are  essentially  identical ; 
that  is,  in  each  we  have  the  effect  of  irritation 


RINGWORM. 

of  a,  certain  kind  conveyed  by  afferent  nerve*  to 
some  central  tract  or  organ. 

Treatment.  — Warm,  mildly  stimulating 
drinks  and  external  warmth  are  always  grateful 
to  the  patient,  and  perhaps  shorten  the  duration 
of  the  attack.  Tincture  of  aconite,  in  5-minim 
doses,  has  the  reputation  of  preventing  the  occur- 
rence of  rigors  from  local  sources  of  irritation, 
and  may  perhaps  be  useful  when  they  arise  from 
more  general  or  from  constitutional  causes. 
Nitrite  of  amyl  also  has  been  employed,  appa- 
rently with  some  measure  of  success.  But  the 
only  effectual  treatment  is  that  of  the  diseased 
condition  with  which  they  are  associated,  and 
this  can  rarely  be  begun  with  advantage 
before  the  termination  of  the  rigors  or  ‘cold 
stago.’  Until  that  period  has  arrived  it  is  at 
best  useless  to  attempt  any  internal  medication; 
even  quinine  is  of  little  or  no  avail  in  this  stage 
of  malarial  fever,  and  often  seems  merely  to  ag- 
gravate the  sickness,  headache,  and  general  dis- 
comfort, which  are  the  usual  concomitants  of 
rigors.  J.  Andrew. 

RIGOR  MORTIS  (Lat.  The  stiffness  of 
death). — Synon.  : Fr.  Bigidite  eadaverique ; Ger. 
Todtenstarre.—  The  stiffening  of  the  muscles 
after  death,  due  to  coagulation  of  their  plasma. 
See  Death,  Signs  of. 

RINGWORM.— Stnon.  : Tinea ; Fr.  Teigne- 
Ger.  Bingunirm. 

Definition. — A disease  of  the  hair-follicles 
and  hair,  of  a circular  figure,  and  spreading  in 
the  form  of  a ring. 

Etiology. — Eingworm  is  essentially  a dis- 
ease of  the  nutritive  period  of  life  ; it  is  con- 
tagious, and  sometimes  communicated  to  the 
adult,  particularly  to  women  : in  the  latter  case 
appearing  on  the  unhairy  parts  of  the  body,  such 
as  the  neck,  the  shoulders,  the  chest,  and  the 
arms.  It  is  very  generally  taught  and  believed 
that  the  cause  of  tinea  is  the  growth  and  de- 
velopment of  a fungus-plant;  that  the  disease 
is  propagated  by  means  of  sporules,  which  are 
accidentally  conveyed  from  one  person  to  an- 
other; and  that  the  subsequent  folliculitis  and 
other  pathological  processes  result  from  the 
irritation  caused  by  the  parasitic  fungus.  That 
the  disease  does  not  become  universal,  instead  of 
being  sporadic,  is  explained  by  the  admission  that 
the  spores  require  a favourable,  that  is.  a morbid 
soil  for  their  evolution  and  growth.  The  writer 
of  this  article  entertains,  however,  a different 
opinion,  and  believes  that  the  folliculitis  is  con- 
sequent on  a depressed  state  of  health  of  the  in- 
dividual ; that  the  follicular  epithelium  is,  there- 
fore, imperfectly  developed  : and  that  the  phyti- 
form  growth'  is  a proliferation  of  the  granular 
elements  of  the  immature  epithelial  cells  and  of 
the  hair-cells — a degeneration,  in  fact,  of  their 
component  elements. 

Description. — Eingworm  of  the  scalpis  recog- 
nised by  loss  of  hair  in  one  or  numerous  patches 
of  a circular  or  oval  figure,  and  of  an  average 
diameter  of  half  an  inch  or  an  inch.  The  base 
of  the  patch  is  somewhat  elevated ; more  or  less 
papulated,  from  prominence  of  unhealthy  fol- 
licles; coated  with  a furfuraceous  desquama- 
tion ; roughened  by  the  stumps  of  hair  broken  a: 


RINGWORM. 


different  lengths ; and  sometimes  covered  with  a 
matted  stratum  of  withered  and  discoloured  hair. 
There  is  rarely  any  redness  or  inflammation  of 
the  patches,  their  prominence  being  due  to  dis- 
tension of  the  follicles  with  dry  epithelial  exuviae, 
and  accumulation  of  furfuraeeous  desquamation. 
Occasional^,  however,  the  patch  is  bordered  by 
an  inflammatory  ring,  and  the  latter  is  some- 
times surmounted  with  minute  pustules.  On  the 
scalp  it  destroys  the  hair,  which  loses  colour  and 
texture,  appears  like  tow,  and  breaks  off  close  to 
the  follicle.  In  chronic  cases  a peculiar  scurfi- 
ness — ‘ diffuse  ringworm  ’ — is  the  result.  On  the 
body  it  forms  red,  slightly  raised  rings,  which 
may  present  a concentric  arrangement. 

Anatomical  Characters. — A microscopic  ex- 
amination of  the  epithelium  of  the  follicles  and 
of  the  hair,  detects  in  the  substance  of  both 
a phytiform  structure,  which  is  identical  in  ap- 
pearance with  that  of  mucedinous  fungi,  consist- 
ing of  mycelium  andsporules,  and  growing  and 
proliferating  like  a vegetable  fungus  {sec  Epi- 
phyta)  ; and  this  parasitic  fungus  has  received 
the  name  of  trichophyton.  Hence,  ringworm  is 
regarded  as  a parasitic  disease,  and  its  contagion 
is  supposed  to  reside  in  the  sporules  of  the  epi- 
phyte, which,  it  is  presumed,  are  communicated 
from  one  child  to  another  by  the  agency  of 
combs,  brushes  and  the  atmosphere  itself. 

The  permeation  of  the  shaft  of  the  hairs  by 
the  trichophyton  renders  them  brittle ; they 
break  off  close  to  the  aperture  of  the  follicle ; 
and  when  this  occurs  over  the  whole  surface  of 
the  patch,  the  ragged  stumps  suggest  the  idea 
of  having  been  eaten  off  by  the  grub  of  a tinea 
or  moth.  Hence  the  terms  tinea  and  ringworm 
applied  to  the  disease  ; the  grub  being  presumed 
to  devour  the  hairs  from  the  centre  towards  the 
circumference,  and  so  to  give  rise  to  the  ring  or 
circular  figure  of  the  patch.  Looking  to  the 
scurfiness  of  the  patches,  Willan  adopted  the 
term  porrigo  for  its  designation  ; for  example, 
porrigo  tonsurans  and  porrigo  scutulata ; the 
latter  from  the  shield-like  figure  of  the  patches. 
Its  growth  by  the  circumference,  creeping  as  it 
were  into  the  surrounding  skin,  suggested  the 
term  herpes  tonsurans ; and  the  discovery  by 
Gruby  of  a fungus-structure  commends  the  term 
phy/osis  as  a generic  title.  A variety  of  ringworm 
is  known  as  lcerion.  See  Kekion. 

Pathologically,  tinea  is  a chronic  folliculitis 
with  some  degree  of  infiltration  of  the  skin  ; it 
• is  propagated  from  a centre  to  neighbouring  fol- 
licles, and  constitutes  a thickened  disk  with 
thickened  margin.  On  the  scalp,  where  the  fol- 
licles are  large,  the  former  prevails  and  the  dis- 
ease becomes  chronic ; whereas  on  the  non-hairy 
skin,  where  the  follicles  are  small,  the  inflamma- 
tion subsides  within  the  area,  and  travels  on- 
wards by  the  circumference.  The  folliculitis  of 
ringworm  rarely  exceeds  in  pathological  manifes- 
tation the  production  of  a papule  with  congested 
and  infiltrated  base ; but  in  certain  constitutions 
it  may  give  rise  to  a vesicle,  and  even  to  a pustule ; 
the  latter  more  particularly  where  the  strumous 
diathesis  prevails.  The  more  pathognomonic 
characters  of  tinea  are  evinced  by  an  excessive 
accumulation  of  laminse  of  epithelium  within  the 
follicles,  and  by  a disorganised  condition  of  the 
hair ; the  epithelium  as  well  as  the  hair  being 

87 


1377 

penetrated  and  filled  with  the  mycelium  and 
sporules  of  the  trichophyte.  In  the  shaft  of  the 
hair  the  trichophyte  is  seen  in  the  form  of  stems 
branching  from  point  to  point,  or  rows  of  glo- 
bular sporules ; whilst  the  envelope  of  the  hair 
is  oftentimes  composed  exclusively  of  sporules. 

Diagnosis. — The  diagnosis  of  ringworm  in  its 
fully  developed  state  is  by  no  means  difficult. 
The  circular  and  oval  disks,  and  stumps  of  broken 
hair,  are  pathognomonic  of  tinea  of  the  scalp  ; 
whilst  the  circular,  red,  and  elevated  rings  of 
tinea  annulata  on  the  non-hairy  skin  are  equally 
so.  Only  two  affections  approach  it  in  appear- 
ance, namely,  dry  eczema  and  area;  but  in 
eczema  capitis,  which  is  often  furfuraeeous,  there 
are  no  stumps  of  broken  hairs,  the  hairs  being 
unaffected,  and  the  disease  is  more  chronic,  or 
there  may  be  a previous  history  of  eczema,  or 
evidence  of  its  presence  on  other  regions  of  the 
body.  Alopecia  areata  or  porrigo  decalvans  ex- 
hibits a total  loss  of  hair  on  a smooth  spot,  with 
no  other  morbid  affection  of  the  skin  than  simple 
atrophy.  See  also  Kehion. 

Prognosis. — The  prognosis  of  ringworm  is 
twofold: — Is  it  contagious  ? Will  it  last  long? 
To  which  wo  must  answer  that  it  is  contagious 
wherever  that  state  of  health  exists  which  is 
favourable  to  its  development;  and,  secondly, 
that  its  duration  will  be  governed  by  the  age,  as 
well  as  by  the  powers  of  constitution  of  the 
patient.  It  is  very  rarely  met  with  in  infancy 
and  never  in  the  adult;  and, left  to  itself,  it  has 
a natural  tendency  towards  cure.  Nevertheless, 
it  is  sometimes  prolonged  for  several  years,  and 
may  interfere  very  seriously  with  the  education 
of  children  afflicted  with  it ; while,  in  general, 
it  is  kept  up  by  defective  hygienic  conditions  and 
unsuitable  diet. 

Treatment. — The  t reatment  of  ringworm  must 
be  constitutional  as  well  as  local : constitutional 
to  improve  assimilation  and  nutrition ; and  local 
to  stimulate  a feeble  tissue  to  a more  vigorous 
and  healthy  function.  The  constitutional  reme- 
dies must  consist  of  generous  diet,  fresh  air, 
and  exercise;  ordinary  tonics,  and  especially 
arsenic  in  nutritive  doses — for  example,  two  or 
three,  minims  of  liquor  axsenicalis,  or  their  equi- 
valent of  other  arsenical  preparations,  with  the 
meals,  three  times  a day.  The  best  local  treat- 
ment is  moderate  friction  with  the  iodide  of  sul- 
phur ointment,  diluted  with  two-thirds  of  ben- 
zoated  lard,  night  and  morning ; daily  brushing 
with  the  hair-brush ; and  no  washing.  Where 
the  iodide  of  sulphur  ointment  proves  irritating, 
the  nitric  oxide  of  mercury  ointment,  diluted  in 
similar  proportion,  may  be  substituted.  Tinea 
annulata  of  the  body  should  be  pencilled  with 
the  liniment  of  iodine  daily,  until  the  rings  are 
arrested;  and  the  same  liniment  may  be  applied 
to  suspicious  spots  cn  the  scalp,  or  as  an  addi- 
tional stimulus  to  the  scuta  themselves. 

The  parasitic  theory  of  the  disease  has  led  to 
the  use  of  sulphurous  acid  and  perchloride  of 
mercury  under  the  name  of  ‘ parasiticides  ’ ; but 
these  remedies  have  no  special  advantage  over 
those  already  named;  and  the  corrosive  sub- 
limate is  dangerous  unless  employed  with  great 
care. 

In  the  French  school,  avulsion  of  the  hairs, 
called  ‘ epilation,’  is  the  practice  commonly 


1378  RINGWORM. 

adopted  * the  process  of  tearing  out  the  hair 
boing  followed  by  the  use  of  a weak  solution  of 
corrosive  mblimate.  This  practice  brings  to 
mind  that  terrible  French  remedy  the  pitch-cap, 
and  is  utterly  unnecessary  for  cure.  See  Epi- 
phytic Skin-Diseases;  and  Tinea. 

Erasmus  Wilson. 

RIPPOLDSAU,  in  the  Black  Forest, 
Germany. — Mixed  iron  waters.  See  Mineeal 
Waters. 

RISUS  SARDONICUS  or  SARDONIUS 

( risus , a laugh  ; and  sardonius,  connected  with, 
or  caused  by,  the  herb  sardonia  or  sardoa,  that  is, 
belonging  to  Sardinia). — A peculiar  expression 
of  the  face,  in  which  the  features  are  distorted 
by  spasm  of  the  muscles,  so  as  to  present  the 
appearance  of  a painful  grin  or  laugh.  It  is 
usually  observed  in  tetanus.  See  Tetands. 

RODENT  ULCER. — Synov.:  Fr.  Cancroide , 
Ger.  Epithelialkrebs.—  Rodent  ulcer  must  be  re- 
cognised as  a kind  of  tumour ; but  its  exact  posi- 
tion amongst  other  forms  of  new  growth  is  still 
not  definitely  decided.  Hence,  in  this  work  a 
special  article  is  devoted  to  its  consideration. 
Most  authors  agree  in  classing  it  amongst  the 
epitheliomas. 

Clinical  Characters. — Naked-eye  appearances. 
A distinguishing  feature  of  most  rodent  ulcers 
Is  the  fact  that  ulceration  follows  pare  passu  with 
.lew  growth,  the  result  being  that,  as  in  the  case 
of  lupus,  instead  of  the  formation  of  a swelling 
or  tumour,  an  actual  diminution  of  the  size  of  tho 
part  occurs.  Another  characteristic  of  the  dis- 
ease is,  that  whilo  it  often  makes  its  appearance 
at  a period  of  life  which  might  be  considered 
early  for  an  epithelioma,  it  runs  a course  of  ex- 
treme chronicity,  and  rarely,  if  ever,  affects  the 
lymphatic  glands.  Many  eases  last  for  twenty 
or  thirty  years,  interfering  but  little  with  the 
general  health,  and  at  times  in  part  undergoing 
a process  of  feeble  cicatrization.  Rodent  ulcer 
begins  as  a pimple,  usually  on  some  part  of  the 
face,  and  most  frequently  on  the  side  of  the  nose 
or  about  the  eye.  After  remaining  quiescent  for 
a long  time,  perhaps  years,  ulceration  occurs,  and 
continues  to  spread  with  great  slowness,  involv- 
ing in  its  course  every  structure  that  it  meets. 
Thus  in  time  huge  caverns  are  excavated  in  the 
face ; the  eyeball  may  be  destroyed ; the  nose  and 
upper  jaw  may  disappear;  and,  not  unfrequeutly, 
if  the  disease  reach  the  forehead,  the  dura  mater 
is  exposed,  and  the  brain  is  seen  pulsating  at  the 
bottom  of  the  cavity.  The  appearance  of  the 
ulcer  is  characteristic:  the  surface  is  glistening, 
and  is  covered  with  very  imperfect  granulations ; 
it  has  an  uneven  level,  and  is  mottled  with  yel- 
low and  red ; the  margin  is  very  slightly  raised, 
and  somewhat  indurated,  has  a purplish  pink 
colour,  and  is  often  considerably  undermined. 
The  discharge  is  thin  and  purulent.  Capillary 
haemorrhage  not  unfrequently  occurs,  but  more 
severe  bleeding  is  rare.  A section  through  the 
edge  shows  the  narrow  margin  of  new  growth,  in 
which  alone  the  characteristic  structure  is  to  be 
made  out.  Death  may  occur  from  old  age  or  other 
causes  independent  of  the  disease  ; from  an  at- 
tack of  erysipelas  or  meningitis,  or  from  maras- 


ROSEOLA. 

mus  induced  by  the  constant  worry  and  dis- 
charge. 

Microscopical  Appearances. — Many  tumoure 
which  approach  somewhat  nearly  the  condition 
above  described  will  be  found  on  examination  to 
exhibit  the  structure  of  a lobular  epithelioma 
( see  Cancer)  ; but  the  most  typical  ones  will 
usually  exhibit  something  like  the  appearance 
represented  in  fig.  119,  facing  p.  204.  Beneath 
the  epidermis,  and  imbedded  in  a varying 
amount  of  stroma,  consisting  of  more  or  less 
well-developed  fibrous  tissue,  are  large,  roundish, 
and  irregular  masses  of  densely-packed  epi- 
thelial cells  of  small  size,  the  circumferential 
ones  taking  an  oval  shape,  while  the  deeper  ones 
are  circular.  There  is,  as  a rule,  no  tendency  to 
the  formation  of  globes ; but,  in  some  cases  which 
have  run  a typical  course,  imperfect  nests  have 
been  found  ; the  so-called  prickle-cells  are.  as 
far  as  the  writer  has  observed,  never  seen.  The 
cells  are  smaller  than  those  usually  seen  in  an 
epithelioma,  and  suggest  the  origin  of  the  growth 
from  the  sweat-glands,  a view  which  is  favoured 
by  the  fact  that  the  epithelial  masses  occasion- 
ally assume  a more  or  less  distinctly  tubular 
arrangement.  Strenuous  advocates  are  found  in 
support  of,  and  in  opposition  to  this  theory  of  the 
primary  source  of  rodent  nicer,  and  the  same 
may  be  said  of  other  hypotheses,  such  as  that  it 
starts  from  the  hair-follicles  or  the  sebaceous 
glands ; but,  in  default  of  stronger  evidence  than 
is  at  present  forthcoming,  it  would  he  unwise  to 
dogmatise  upon  the  question.  The  reader  will  find 
some  of  the  literature  of  the  subject  in  the  late 
Mr.  Charles  H.  Moore's  book  on  rodent  cancer,  in 
Dr.  J.  Collins  Warren’s  monograph  on  rodent 
ulcer,  and  in  the  various  communications  to  the 
Pathological  Transactions ; but  in  German  writ- 
ings he  must  search  under  the  head  of  Epithelial 
Cancer,  to  which  class  rodent  ulcer  has  always 
been  consigned. 

Prognosis. — The  prognosis  in  a ease  of  rodent 
ulcer  may  he  implied  from  what  has  been  said 
of  its  clinical  features. 

Treatment. — The  obvious  treatment  is  free 
removal  by  the  knife  in  the  early  stages.  Mr. 
Moore  was  a strong  supporter  of  the  plan  of 
removing  even  very  large  ulcers;  he  was  in  the 
habit  of  proceeding  with  the  knife  as  far  as  pru- 
dence would  allow,  and  applying  chloride  of  zinc 
paste  to  any  parts  it  was  considered  unsafe  to  re- 
move. This  treatment  in  his  hands  and  in  that 
of  others  has  been  followed  by  very  marked 
success.  R.  J.  Godlee. 

ROISDORF.  in  Germany. — Mixed  alkaline 
table  waters.  See  Mineral  Waters. 

ROME,  Central  Italy. — Moderately  warm, 
moist,  fairly  calm,  sedative  winter  climate. 
Mean  temperature,  winter,  46  75°  Fahr.  Prevail 
ing  winds,  tS.E.  and  N.  Sec  Climate,  Treatment 
of  Disease  by. 

ROSALIA  ( rosa , a rose). — A rose-coloured 
rash ; a term  formerly  applied  to  scarlatina  and 
rubeola,  before  these  rashes  were  clearly  differ 
entiated. 

ROSEOLA  (rosa,  a rose). — Syxon.  : Fr. 
Roseole,  Ger.  Roseola. — This  affection,  the  name 


ROSEOLA. 

of  which  is  derived  from  its  crimson  tint  of 
colour,  is  one  of  the  exanthemata  or  rashes 
of  the  skin,  and  in  common  parlance  is  called 
‘ rose-rash.’  In  general  characters  it  resembles 
a mild  form  of  measles,  and  has  consequently 
received  the  name  of  ‘ false  measles.’ 

.IEtiology. — The  cause  of  this  exanthem  is 
feverish  excitement,  resulting  from  heat  and 
exhaustion ; hence  it  is  frequently  epidemic  in 
hot  weather.  Although  allied  in  appearance  with 
measles,  it  cannot  be  regarded  as  contagious. 
Frequently  it  is  symptomatic. 

Description. — Eoseola  ordinarily  assumes  the 
form  of  a punctated  rash,  more  or  less  suffused, 
but  it  sometimes  occurs  in  small  erythematous 
blotches,  which  spread  by  the  circumference 
and  form,  rings.  In  the  latter  cases  it  is  only 
distinguishable  from  erythema  by  its  roseate 
colour. 

The  exanthem  forms  part  of  a slight  febrile 
attack,  attended  with  weariness,  lassitude,  nau- 
sea, and  prostration  ; and  is  accompanied  with 
more  or  less  redness  of  thefauces.  and  sometimes 

[with  swelling  and  tenderness  of  the  submaxillary 
glands  and  occasionally  of  the  neighbouring 
lymphatic  glands.  The  exanthem  has  a course  of 
tour  or  five  days  or  a week,  and  then  disappears, 
leaving  the  patient  convalescent;  and,  like  its 
congeners  the  exanthemata,  it  begins  with  the 
head,  then  travels  downwards  to  the  trunk  of 
the  body,  and  is  last  perceivable  on  the  arms 
and  legs.  It  is  rarely  of  sufficient  force  to  he 
followed  by  exfoliation  of  the  epidermis. 
Varieties.  — Besides  those  objective  terms 
i which  liken  roseola  to  measles,  it  has  likewise 
been  called  after  tho  seasons  when  it  commonly 
occurs,  R.  cestiva  and  R.  autwmnalis.  Other 
terms,  such  as  R.  'punctata,  corymbosa,  maculosa, 
orbicularis,  annulata,  and  papulata  relate  to 
varieties  of  its  pathological  characters.  An 
exanthem,  identical  in  appearanco  with  idio- 
pathic roseola,  is  met  with  in  secondary  syphilis; 
the  punctated  rash  which  is  associated  with  con- 
tinued fever  is  likewise  a roseola  ; whilst  other 
forms,  which  have  been  observed  associated  with 
variola,  vaccinia,  gout,  rheumatism,  and  cholera, 

I may  he  regarded  as  erythemata  resulting  from 
venous  hyperEemia, 

Diagnosis. — The  diagnosis  of  roseola  has  been 
sufficiently  illustrated  by  the  above  description 
—a  punctated  rash,  corymboid  like  measles,  but 
sometimes  orbicular  or  annulate  like  erythema  ; 
its  special  pathognomonic  characteristic  being  its 
crimson  or  rose  colour. 

Prognosis. — The  prognosis  of  roseola  is  fa- 
vourable ; the  feverish  disturbance  subsides  in  a 
few  days  or  a week.  Tho  prognosis  of  symptomatic 
cases  necessarily  varies. 

Treatment. — Rest  and  repose  together  form 
nn  important  element  in  the  treatment  of  roseola. 
A mild  purge  may  be  necessary  to  regulate  the 
digestive  organs,  and  may  be  accompanied  with 
effervescent  salines.  Locally,  the  skin  should 
he  anointed  with  some  soothing  and  un-irritat- 

img  oily  substance,  such  as  vaseline,  olive  oil,  or 
benzoated  lard.  Erasmus  Wilson. 

ROSE-RASH. — A popular  name  for  roseola. 
See  Roseola. 

ROTHELN. — The  German  synonym  for  ru- 


ROUND-WORMS.  1370 

bella  ; frequently  employed  by  English  practi  - 
tioners.  Sec  Rubella. 


r1 


ROUND-WORMS.  — In  respect  of  their 
form  the  various  species  of  nematoid  entozca 
more  or  less  resemble  earth- 
worms, and,  consequently,  are 
collectively  called  round-worms ; 
but  the  term  is  by  many  persons 
restricted  to  the  large  lumbricoid 
parasites  which  infest  man  and 
several  of  the  lower  animals. 

Description. — The  human 
round- worm  (Ascaris  lumbricoidcs ) 
varies  much  in  size,  the  males 
measuring  from  four  to  seven 
inches  in  length,  and  the  females 
usually  from  nine  to  fourteen 
inches,  though  an  instance  has 
been  recorded  from  America  where 
a female  measured  seventeen 
inches.  The  general  structure  of 
the  worm  was  long  ago  investi- 
gated by  Cloquet,  Owen,  Dujar- 
din,  Busk,  and  others;  but  the 
most  modern  and  important  addi- 
tions to  our  knowledge  of  its 
anatomy  are  due  to  the  writings 
of  Eberth,  Bastian,  Schneider,  and 
Leuckart.  In  the  matter  of  deve- 
lopment, the  writings  and  labours 
of  Nelson,  Thomson,  Kolliker, 
Meissner,  Richter,  Davaine,  and 
Heller  are  particularly  noteworthy. 
The  precise  manner  in  which  the 
essential  act  of  fertilisation  is  ac- 
complished in  nematoids  carries 
with  it  no  practical  issue,  but  ex- 
periments with  the  mature  ov-a 
have  an  important  bearing  on 
questions  of  sanitation  and  infec- 
tion. Verloren,  Vix,  and  others 
have  reared  intra-chorional  em- 
bryos of  various  nematode  species 
in  water;  and  the  writer  himself 
has  watched  the  development  of 
the  eggs  of  Ascaris  lumbricoidcs , 
in  fresh  water,  through  all  the 
stages  of  yelk-segmontation  up  to 
the  stage  of  an  imperfectly  organ- 
ised, coiled  embryo,  subsequently 
keeping  the  ova  alive  in  this  con- 
dition for  a period  of  three  months. 
Dr.  Davaine  pushed  the  facts  of 
development  much  further.  He 
kept  the  ova  alive  for  upwards  of 
five  years.  He  administered  some 
of  these  five-year-old  embryos  to 
I rats,  and  had  the  satisfaction  of 
finding  a few  of  the  eggs  in  the 
rodents’  faeces,  with  their  con 
F' % lumbricoi-  tai?e.d  embryos  still  alive,  but 
des ; male, with  striving  to  escape  the  shells.  As 
exserted  spi-  a general  result  it  may  be  said 
(origiSl) " S1ZS  ^at  t'10  embryos  escaped  their 
shells ; but  only  in  the  case  of 


early  embryonal  stage  of  growth,  did  the  gastric 
juice  of  the  experimental  animals  act  upon  the 
shells,  and  thus  liberate  the  contents  of  the  ovx 


1380  ROUND- 

Tf  yet  more  practical  importance  are  the  obser- 
vations of  Holler,  respecting  a •post-mortem  ‘find’ 
made  in  May,  1872.  In  the  small  intestines  of  a 
lunatic  he  discovered  eighteen  specimens  of  very 
young  round-worms ; all  of  them  being  referable 
to  the  species  in  question  (A.  lumbricoides).  They 
severally  measured  from  i to  i an  inch  in  length. 
Now,  as  Heller  himself  has  pointed  out,  between 
the  embryos  as  they  appear  at  the  time  of  their 
expulsion  from  the  egg  and  the  smallest  round- 
worms  hitherto  seen  in  the  human  subject,  we 
have,  as  regards  size,  an  immense  gap  to  bridge 
over.  This  1 find  ’ of  Heller’s,  therefore,  tends  to 
make  it  appear  almost  certain  that  the  common 
round-worm  completes  its  life-cycle  without  the 
necessity  of  having  to  pass  through  the  body  of 
any  intermediary  animal  bearer.  The  truth  of 
this  conclusion,  moreover,  is  borne  out  by  nu- 
merous facts,  which  have  come  to  the  knowledge 
of  the  writer.  In  one  instance  brought  under 
his  notice,  a local  endemic  of  roundworm-hel- 
minthiasis was  clearly  traceable  to  drinking 
water  from  a filthy  stream,  into  which  sewage- 
deposits  flowed.  The  further  treatment  of  this 
subject,  in  reference  to  public  health,  will  be 
found  more  fully  discussed  in  the  writer's  second 
memoir  ‘ On  the  Dispersion  and  Vitality  of  the 
Germs  of  Entozoa,’  read  before  the  Association 
of  Medical  Officers  of  Health  ( Medical  Times  and 
Gazette , 1871,  p.  215). 

The  Ascaris  mystax  is  described  in  the  article 
Ascakjdes. 

Symptoms. — The  symptoms  superinduced  by 
round-worms,  and  the  practical  management  of 
cases,  more  immediately  concern  the  physician 
and  practitioner;  but  in  England,  the  disorder 
is,  speaking  relatively,  not  very  prevalent.  In 
some  countries  round-worms  in  the  human  sub- 
ject are  extremely  frequent,  this  being  especially 
the  case  in  tropical  regions,  as  in  India,  in 
China,  in  Central  America,  and,  according  to  Dr. 
Dyce,  still  more  notably  in  the  Mauritius  ( Medi- 
cal Gazette,  1834).  Whilst,  in  British  practice, 
we  seldom  encounter 
more  than  one,  or,  it 
may  be,  several  spe- 
cimens in  each  patient, 
it  is  no  uncommon  ex- 
perience abroad  to  en- 
counter several  scores 
in  a single  bearer. 
Now  and  then  from 
one  to  several  hun- 
dred specimens  have 
FlO.  72.  Ascaris  mystax  ; male  fieen  removed  from  a 

£.aAteS^rtKatUral  ***•  but  such 

instances  are  compa- 
ratively rare  in  England.  Marshy  and  low-lying 
grounds,  in  the  neighbourhood  of  dwellings,  are 
eminently  productive  of  round-worms,  hence 
their  comparative  abundance  in  some  parts  of 
Holland,  and  in  the  lake-districts  of  Sweden. 
Dr.  Brandt,  of  Oporto,  informs  the  writer  that 
lumbricoids  are  very  common  in  Portugal,  affect- 
ing something  like  75  per  cent,  of  the  children, 
who  frequently  pass  large  numbers  by  the 
mouth  as  well  as  by  the  anus. 

Many  remarkable  phenomena  result  from  the 
presence  of  these  large  worms  in  the  human  sub- 
ject. Ordinarily,  the  symptoms  bear  a close 


•WORMS. 

resemblance  to  those  arising  from  thread-worms, 
but  the  results  are  commonly  of  a graver  charac- 
ter. As  stated  in  the  writer’s  published  lectures 
(Worms,  p.  113),  they  give  rise  to  colicky  and 
shooting  pains  about  the  abdomen,  followed 
generally  by  more  or  less  dyspepsia,  and  ac- 
companied with  nasal  itching,  nausea,  vomiting, 
and  even  diarrhoea.  Sometimes,  also,  there  is 
cerebral  disturbance,  attended  with  general  rest- 
lessness and  convulsive  twitchings  during  sleep. 
In  severe  cases,  amaurosis,  catalepsy,  convulsions, 
erotomania,  and  death  by  enteritis  or  by  per- 
foration of  the  intestine,  have  been  known  to 
occur.  These  worms  have  a remarkable  ten- 
dency to  grope  about  the  intestinal  canal,  as  if 
seeking  a new  abode,  and  thus  it  is  that  they 
not  unfrequently  make  their  way  into  various 
and,  so  to  speak,  unsuitable  parts  of  the  body, 
where  they  cannot  thrive.  Amongst  other  strange 
situations,  they  have  not  unfrequently  been 
found  in  the  gall-duct,  in  the  cavity  of  the 
thorax,  and  especially  in  the  parietes  of  the 
abdomen.  This  habit  of  wandering  often  proves 
fatal  to  them.  Any  foreign  solid  body  in  the 
intestine,  with  a suitable  hole  in  it,  is  sure  to 
attract  their  attention,  and  to  form  a sort  of 
worm-trap.  Thus  these  parasites  have  been 
strangled  by  metallic  buttons,  by  ‘ hooks  and 
eyes,’  by  an  open-topped  thimble,  and  by 
other  miscellaneous  foreign  bodies  accidentally 
or  purposely  swallowed  by  their  human 
bearers. 

Numerous  cases,  many  of  them  fatal,  have 
appeared  in  journals  during  the  last  half-century. 
The  writer’s  treatises  on  Entozoa  (1864)  and 
Parasites  (1879),  as  well  as  Davaine's  Trade 
(1877),  abound  with  references  of  this  kind,  and 
since  these  books  were  published  other  notable 
cases  have  been  placed  on  record.  Amongst  fatal 
instances  occurring  in  this  country,  the  cases  by 
Blair  (Edinburgh  Medical  Journal,  1861)  and 
Rogers  (Lancet,  1848)  deserve  mention.  An 
interesting  example  of  perforation  and  conse- 
quent abdominal  abscess,  followed  by  successful 
treatment,  was  also  recorded  by  Sheppard  (Bri- 
tish Medical  Journal,  1861).  A case  very  similar 
to  this  has  been  orally  communicated  to  the 
writer  by  Dr.  Reginald  Pierson,  of  Leipzig,  the 
patient,  a soldier,  having  come  under  his  care 
during  the  Franco-German  war. 

Children  appear  to  be  more  liable  to  harbour 
large  numbers  of  these  worms  than  grown  per- 
sons. Kiichenmeister  refers  to  a case  where  a 
child  passed  103  worms,  and  to  a second  in- 
stance where  another  child  was  infested  by  up- 
wards of  300  ; whilst,  in  Gilli's  yet  more  strik- 
ing case  the  child  voided  no  less  than  510  worms 
(Giorn.  d.  Sci.  Med.  di  Torino,  1S43).  In  a case 
communicated  to  the  writer  by  Dr.  Mackeith, 
of  Sandhurst,  Kent,  the  patient,  a child  of  only 
five  years,  passed  upwards  of  300  worms,  most 
of  them  having  been  expelled  in  consequence 
of  appropriate  treatment  with  santonine  and 
aloetic  mixtures.  One  of  the  specimens  mea- 
sured 15  inches  in  length.  The  sympathetic 
nervous  symptoms  are  often  most  serious.  Hy- 
steria, catalepsy,  chorea,  epileptiform  seizures, 
paralysis,  loss  of  sight,  deafness,  mental  de- 
fects, eclamptic  fits,  convulsions,  maniacal  ex- 
citement, and  other  obscurer  phenomena,  have 


ROUND-WORMS. 


been  recorded  as  due  to  the  presence  of  these 
worms.  That  these  affections  have  in  most  in- 
stances been  exclusively  duo  to  the  presence 
of  the  parasites,  is  proved  by  the  fact  of  the 
frequent  and  immediate  disappearance  of  the 
symptoms  following  the  expulsion  of  the  worms. 
The  writer  is  indebted  to  Dr.  H.  Cooper  Rose 
for  particulars  of  a case,  in  which  a child  only 
fifteen  months  old  suffered  from  severe  convul- 
sions, the  symptoms  entirely  disappearing  after 
the  expulsion  of  upwards  of  a score  of  these 
lumbricoids.  Cases  of  the  most  violent  delirium, 
and  even  of  complete  idiocy,  have  entirely  re- 
covered upon  the  employment  of  suitable  vermi- 
fuges ; whilst  in  instances  whero  the  presence 
of  the  worms  has  either  been  overlooked  or 
disregarded,  a fatal  result  has  ensued.  In  the 
standard  work  by  Davaine,  numerous  instruc- 
tive references,  with  particulars  of  the  cases,  are 
fully  recorded ; whilst  the  writer’s  introductory 
work  supplies  many  others.  In  this  connection, 
also,  an  interesting  and  instructive  paper  by 
Assist.-Suxg.  G.  D.  D.  Goopta  appeared  in  the 
Indian  Medical  Gazette,  and  London  Medical 
Becord,  1871-  From  observations  made  at  the 
dispensary  at  Tangail,  he  concludes  that  lum- 
jricoid  worms  may  be  an  exciting  cause  of 
suicide.  Such  deaths  are  more  common  among 
the  Mussulmans  than  the  Hindoos.  Round- 
worms  were  found  by  Goopta  in  twelve  out  of 
eighteen  bodies  of  suicidal  hanging,  that  is, 
in  about  67  per  cent.  The  greater  number  of 
those  who  committed  suicide  were  of  the  age 
it  which  the  worm  is  frequent.  When,  by  reflex 
action,  the  worms  bring  on  irritation,  the  suf- 
ferers turn  peevish  and  low-spirited,  and  can 
scarcely  withstand  any  trifling  reprimand  or  cor- 
rection. To  them  these  insignificant  causes  be- 
come so  painful,  that  they  immediately  resolve 
to  relieve  themselves  by  suicide,  the  hanging- 
method  being  generally  adopted. 

Diagnosis. — The  diagnosis  of  round-worm  is 
usually  a very  simple  matter,  because  the  patient 
is  sure  sooner  or  later  to  pass  one  or  more  para- 
sites, even  though  he  or  she  may  not  have  taken 
medicine.  In  cases  where  only  one  worm  exists 
its  presence  is  rarely  suspected,  and  in  those 
instances  where  the  existence  of  these  worms  is 
overlooked,  although  many  happen  to  be  present, 
it  often  turns  out  that  they  are  lodged  in  the  sto- 
mach instead  of  occupying  their  more  usual  seat, 
namely,  the  small  intestines.  In  all  obscure  cases 
of  dyspepsia  and  the  like,  especially  if  there  be 
colic,  it  is  well  for  the  practitioner  to  make  a 
microscopic  examination  of  the  faeces.  In  cases 
of  chronic  vomiting,  especially  if  there  be  hse- 
matemesis,  the  contents  of  the  stomach  should 
be  carefully  scrutinised,  for  in  this  way,  as  the 
writer  himself  has  found,  the  ova  of  the  lumbri- 
coids may  be  detected,  and  the  true  nature  of  the 
case  will  at  once  become  apparent.  On  the  other 
hand,  the  practitioner  should  exercise  the  greatest 
caution  lest  he  give  encouragement  to  the  notion 
of  parasitism  (so  often  erroneously  entertained 
by  hypochondriacal  subjects),  without  fully  going 
into  the  history  and  other  particulars  of  any 
given  case. 

Treatment. — When  once  we  are  satisfied  as  to 
Lhc  presence  of  round -worms,  their  expulsionis  ne- 
cessary, and,  fortunately,  not  very  difficult  of  exe- 


1331 

cution.  Of  the  many  vermifuges  recommended, 
none  are  equal  to  santonine,  which  in  the  case  of 
children  may  be  administered  in  the  form  of 
powder,  in  doses  of  two  to  four  grains,  mixed 
with  sugar  and  sprinkled  on  bread  and  butter, 
and  followed  by  a saline  cathartic,  or  a large 
spoonful  of  castor-oil.  Many  prefer  to  mix  the 
crystalline  powder  with  the  oil  itself,  or  to  com- 
bine it  with  two  or  three  grains  of  the  resin 
of  scammony.  The  plan  of  giving  the  drug  over 
night,  followed  by  a morning  cathartic,  is  objec- 
tionable to  some  extent,  since  it  leaves  abundance 
of  time  for  the  santonine  to  exert  its  physio- 
logical action,  which  is  not  the  purpose  in- 
tended. For  adults  from  five  to  ten  or  even 
fifteen  grains  are  often  employed  on  the  Conti- 
nent ; but  the  writer  has  seen  evil  effects  from 
the  larger  doses,  and  considers  it  imprudent  to 
administer  more  than  five  grains  once  a day 
for  three  days  in  succession,  combined  with 
castor-oil.  If  larger  doses  are  given  the  effects 
should  be  carefully  watched,  as  this  drug  has 
been  known  to  produce  tenesmus,  spasms,  and 
even  haemorrhage.  The  writer  has  several  times 
noticed  giddiness,  with  more  or  less  mental  con- 
fusion, as  the  result  of  moderate  dosing  with 
santonine.  In  all  cases  it  is  as  well  to  tell  the 
patient  that  vision  is  apt  to  become  tempo- 
rarily impaired;  and  that  the  daylight,  as  well 
as  all  objects  looked  at,  may  appear  yellow,  or, 
in  rarer  cases,  blue  or  green.  The  urine  almost 
alway  s acquires  a deep  yellow  or  red  tinge,  which 
is  alone  sufficient  to  alarm  some  patients.  For- 
tunately these  physiological  phenomena  quickly 
disappear.  Perhaps,  as  regards  the  employment 
of  santonine,  it  is  as  well,  in  the  case  of  young 
persons,  to  follow  the  advice  of  Kjichenmeister, 
who  remarked  that  we  ‘ should  never  administer 
more  than  eight  grains  in  two  days,  divided  into 
closes  of  two  grains  each  twice  a day.’ 

Amongst  the  various  other  remedies  employed, 
aloes,  scammony,  jalap,  calomel,  sulphur,  and 
turpentine  hold  a prominent  place ; but  their 
utility  as  vermifuges  is  for  the  most  part  due 
rather  to  their  drastic  properties  than  to  any 
specific  action  on  the  worms  themselves.  As  a 
lumbricifuge,  no  remedy  is  equal  to  santonine, 
which,  however,  may  be  combined  with,  or  fol- 
lowed by,  any  one  of  the  above-mentioned  drugs 
with  advantage.  If  santonine  and  turpentine  be 
employed,  they  should  be  combined  with  castor- 
oil.  Dr.  Pockles,  of  Holzminden,  recommends  the 
powdered  root  of  male  fern  in  conjunction  with 
ordinary  purgatives ; whilst  kamala  and  kousso 
are  spoken  of  favourably  by  others.  In  doses  of 
from  one  to  two  drachms,  the  kamala  powder 
has  proved  effectual  in  the  hands  of  Drs.  Mac- 
kinnon,Ramskill,andLeared.  The  South  .African 
fern-powder,  or  ‘payna,’  so  much  employed  by 
the  Kaffirs  for  tape- worm,  has  also  been  recom- 
mended ; but  its  lumbricifuge  virtues  are  probably 
inferior  to  those  of  kousso  and  male  fern,  which 
latter  drugs  ought,  in  the  writer’s  opinion,  to  be 
employed  only  in  cases  of  taenia.  According  to 
Davaine,  the  so-called  ‘varec,’  or  Corsican  moss, 
which  is  procured  from  various  species  cf  sea- 
weed, is  much  employed  in  France,  but  the  re- 
sults obtained  are  variable,  probably  owing  to 
adulteration.  Dr.  E.  J.  "Waring  speaks  favour- 
ably of  several  Indian  remedies.  Thus  the  zet-ei 


1382  ROUND-WORMS, 

or  theet-tsce,  the  black  varnish  of  the  Burmese, 
is  said  to  be  a most  efficacious  lumbricifuge,  and 
the  Burmese  also  employ  a fungus,  or  worm- 
mushroom,  called  thanmo , which,  according  to 
Dr.  Packman,  has  considerable  anthelmintic 
power.  The  inhabitants  of  Java,  and  the  Chinese 
living  at  Macao,  employ  a worm-fruit  termed 
ciy-tlum,  obtained  from  the  plant  quisgualis 
indica.  There  is  also  a small  annual,  vernonia 
anthelmintica , extensively  distributed  throughout 
Hindostan,  the  seeds  of  which,  according  to 
Waring,  are  held  in  the  highest  repute  amongst 
the  people  of  Southern  India.  Many  other  drugs 
having  drastic  and  anthelmintic  properties  are 
employed  in  Eastern  countries  ; but  of  all  the 
various  remedies  none  is  so  satisfactory  as  san- 
tonine,  combined  with  or  followed  by  purgatives, 
and  continued  for  several  days  in  succession.  See 
Ascarides  ; and  Lumbricus. 

T.  S.  CoBBOLD. 

ROYAT,  in  France.  — Muriated  alkaline 
waters.  See  Mineral  Waters. 

SUBBING  SOUND. — A synonym  for  fric- 
tion-sound. See  Physical  Examination. 

RUBEFACIENTS  {ruber,  red,  and  facio,  I 
make). — A class  of  counter-irritants  which  pro- 
duce simple  redness  of  the  skin.  See  Counter- 
irritants. 

RUBELLA  (dim.  of  Btibeola). — Synon.  : 
Rubeola  sine  catarrho  ; Raise  Measles  ; German 
Measles  ; Epidemic  Roseola;  Er.  Eougeole ; Ger. 
Rbtheln. 

Definition. — A specific  eruptive  fever,  the 
rash  appearing  during  the  first  day  of  the  illness, 
beginning  on  the  face  in  rose-red  spots,  extend- 
ing next  day  to  the  body  and  limbs,  subsiding 
with  the  fever  on  the  third  day,  and  not  preceded 
by  catarrh  or  followed  by  desquamation. 

.ZEtiology. — Propagated  by  contagion,  rubella 
occurs  in  epidemics,  often  of  limited  extent,  but 
with  sporadic  offshoots.  It  has  a long  period  of 
incubation,  mostly  a fortnight,  the  extremes  being 
from  six  to  twenty-one  days.  Hence  a difficulty 
in  tracing  the  source  of  personal  infection;  this 
is  increased  by  the  slight  and  transient  nature  of 
the  illness  allowing  patients  to  mix  freely  with 
others.  One  attack  is  preventive  of  a recurrence, 
but  is  not  protective  against  either  measles  or 
scarlet-fever,  nor  do  attacks  of  either  of  these 
diseases  in  any  way  modify  the  liability  to  this 
one  ; it  is  as  distinct  from  them  as  is  chicken- 
pox  from  small-pox.  During  epidemics  of  measles 
or  of  scarlet-fever  mild  and  irregular  cases  of 
botli  are  not  unfrequontly  mistaken  for  this  ex- 
anthem  ; well-marked  outbreaks  of  it  are  often 
attributed  to  measles,  while  slight  attacks  of 
scarlet-fever  are  miscalled  rotheln,  and  a hybrid 
disease  imagined  which  bas  no  existence.  Very 
young  infants  seem  less  suscept  ible  than  older 
children  ; a child  at  the  breast  has  been  known  to 
escape  when  the  mother  and  other  children  in 
the  family  have  been  attacked.  Adults  not  un- 
frequently  suffer,  as  many  persons  escape  attacks 
in  childhood;  sex  makes  no  difference.  The 
disease  is  contagious,  even  before  the  rash  is 
thrown  out,  and  it  continues  to  be  so  for  some 


RUBELLA. 

days,  or  it  may  be  weeks  afterwards.  Second 
attacks  are  rarer  than  in  scarlet-fever,  but  the 
rule  against  them  may  be  less  absolute  than  for 
measles.  Rbtheln  is  seldom  fatal ; when  a mor- 
tality is  reported  as  high  as  3 per  cent,  of  the 
attacks,  measles  is  present. 

Symptoms. — Slight  fulness  of  head,  heaviness, 
pain,  or  giddiness  is  felt,  with  aching  of  the  tack 
or  limbs,  and  a little  tenderness  of  the  throat,  for 
twelve  hours  or  a day  before  the  rash  appears. 
Very  often  the  rash  is  first  seen  with  surprise,  as 
the  feeling  of  illness  has  passed  or  may  have  es- 
caped notice.  Some  enlargement  of  the  lymphatic 
glands  in  the  neck  is  an  early  sign,  most  marked 
in  children.  There  is  redness  of  the  fauces  and 
uvula,  less  mottled  than  in  measles,  not  so  in- 
tense as  in  scarlet  fever;  the  tonsils  are  full 
and  smooth;  there  is  no  ulceration.  Sometimes 
an  odour,  as  in  measles,  attends  the  rash.  The 
eyes  are  suffused,  but  there  is  little  or  no  coryza; 
the  lids  are  somewhat  swollen  and  irritable ; the 
face  is  flushed,  and  the  cheeks  are  red  or  full  be- 
fore the  appearance  of  the  spots.  These  are  bright 
red,  raised,  rounded,  with  clear  skin  between  them, 
but  they  soon  coalesce ; not  grouped  as  in  measles, 
the  spots  are  more  prominent  than  in  scarlet- 
fever,  and  there  is  not  the  finely-diffused  redness 
of  the  neck  and  chest  observed  in  that  disease. 
Moreover,  the  rash  is  already  fading  from  the  face 
and  upper  part  of  the  body  while  extending  to 
the  limbs,  so  that  it  is  less  intense  on  the  third 
day.  It  leaves  some  itching,  or  a very  fleeting 
yellowish  tinge,  but  no  discoloured  mottling  of 
the  skin,  and  no  desquamation.  However  little 
illness  is  felt  at  the  beginning,  a continuous  rise 
of  temperature  commences  with,  or  just  before 
the  rash;  it  may  reach  102°-3°,  or  be  only  2° 
Fahr.  above  the  normal;  with  rest  in  bed  this 
may  fall  one  degree  by  the  end  of  the  second  day, 
but  is  evenly  maintained  as  the  eruption  pro- 
ceeds, and  subsides  with  it  on  the  third  day. 
During  the  following  week  it  is  readily  disturbed, 
either  raised  by  exertion  or  depressed  by  fatigue 
or  chill.  At  this  time  recrudescence  of  the  rash 
has  been  observed. 

Slight  catarrhal  signs  not  unfrequently  come 
on  after  the  rash  has  faded,  the  eyelids  are 
sticky,  the  nostrils  stuffed,  the  throat  sore,  or 
some  cough  begins.  Exposure,  or  want  of  care 
at  this  time  may  determine  serious  disturbance  of 
health,  generally  with  pulmonary  complication. 

The  urine  is  often  high-coloured  in  the  early 
part  of  the  illness,  the  chlorides  are  increased 
but  there  is  no  albuminuria,  nor  has  this  ever 
been  known  to  follow.  In  some  few  cases  tran- 
sient complaint  of  the  throat  or  of  fatigue  has 
been  made  a week  before  the  rash,  or  epistaxis 
has  occurred  ; fulness  of  the  small  cervical  glands 
is  often  felt,  but  no  constant  intermediate  symp- 
toms are  found,  and  any  feeling  of  sickness  is 
without  fever. 

Diagnosis.— The  sudden  onset  of  this  form  of 
rubeola  without  previous  sneezing  or  cough  dis- 
tinguishes it  from  measles,  to  which  it  is  much 
more  nearly  allied,  as  well  by  general  characters 
as  by  the  kind  of  rash,  than  to  scarlet-fever;  but 
the  spots  are  more  evenly  distributed  at  wider 
intervals,  each  with  an  areola  of  its  own  before 
coalescence,  and  not  in  groups  with  a common 
areola  ; there  is  no  gradual  rise  of  temperaturs 


.RUBELLA. 

before  the  rash,  nor  the  sudden  fall  afterwards, 
both  characteristic  of  measles.  The  small  lym- 
phatic glands  in  this  ailment  are  palpably  en- 
larged down  the  sides  of  the  neck,  and  perhaps 
behind  the  ears,  but  not  specially  at  the  angle 
of  the  jaw,  as  in  scarlet-ferer.  The  rash  on  the 
second  day  may  look  like  that  of  scarlet-fever, 
or  the  red  flush  of  scarlet-fever  at  first  sparsely 
distributed,  or  with  prominent  red  papillae,  may 
lead  to  mistake ; but  the  sudden  onset  is  much 
more  marked  in  scarlet-fever  when,  should  the 
rash  appear  as  early,  yet  it  is  more  intense  on 
the  third  day,  especially  on  the  neck  and  chest ; 
moreover,  the  fever  persists  till  the  fifth  day, 
even  when  not  greatly  elevated;  there  is  also 
the  state  of  the  pulse  and  tongue,  and  the  pro- 
minence of  throat-symptoms.  Sometimes  it  is 
not  till  the  second  or  third  week  that  the  kind 
of  desquamation,  and  possibly  signs  of  renal 
irritation,  or  the  occurrence  of  other  cases, 
complete  the  diagnosis.  The  length  of  interval 
between  successive  cases  is  also  a distinction. 
Roseola  is  not  contagious ; it  occurs  in  red  points 
or  spots,  not  raised  above  the  healthy  skin  be- 
tween ; there  are  no  throat-symptoms,  no  en- 
larged lymphatic  glands,  or  fever.  Erythema 
affects  parts  of  the  skin  only  : attention  restricted 
to  the  character  of  the  eruption  often  leads  to 
error. 

Pathology. — As  in  most  infectious  diseases, 
particles  given  off  from  the  sick,  chiefly  by  the 
breath,  attach  themselves  to  the  mucous  surface 
of  the  throat  or  air-passages,  and  either  multiply 
themselves,  or  produce  a morbid  change  in  tho 
material  around  them ; this  morbid  matter  enter- 
ing the  lymphatics  is  at  first  arrested  in  their 
glands,  and  thence  enters  the  blood.  Fora  time 
some  of  this  may  be  deposited  again  at  the  point 
from  which  it  started,  or  the  amount  be  too 
small  to  produce  that  arrest  of  nerve-tone  which 
permits  the  dilated  vessels  and  increased  com- 
bustion of  general  fever.  A special  effect  on  the 
vaso-motor  nerves  of  the  skin  is  necessary  to 
produce  the  turgidity  of  the  rash,  and  this  not 
of  the  momentary  character  of  a passing  irrita- 
tion. Local  irritation  of  the  sympathetic  in  the 
neck,  starting  from  the  mucous  membrane,  may 
determine  the  early  appearance  of  the  rash  on 
tho  face.  The  skin  generally  has  not  the  intense 
vascular  injection,  with  the  exudation  that  results 
in  detached  epidermis,  as  seen  in  scarlet-fever, 
nor  do  the  congested  vessels  of  the  papillae  leave 
such  dilated  meshes  as  after  measles.  Whether 
any  special  microzyme  is  associated  with  rubella 
there  is  no  histological  research  to  show. 

Prognosis. — Recovery  is  so  much  the  rule, 
that  were  it  not  for  the  mischief  any  febrile  dis- 
turbance may  exeito  in  weakly  children,  and  the 
risk  of  pulmonary  disease  from  premature  ex- 
posure, all  cases  of  rubella  might  be  expected  to 
do  well,  In  severe  eases  the  throat  must  be 
looked  to,  and  in  all  cases  the  chest  examined. 
We  must  bear  in  mind  that  infection  persists  for  a 
month,  and  that  two  months  may  elapse  before 
health  is  quite  restored. 

Treatment. — Rest  in  bed  for  three  days,  and 
confinement  to  the  house  for  a week,  is  almost  all 
that  is  required ; the  fever  demands  no  secretion 
to  be  increased  for  its  mitigation,  nor  any  special 
means  for  its  control.  Dilute  acids  may  be  given 


RUPTURES.  1383 

for  relaxed  throat ; and  tonics,  such  as  bark  oi 
iron,  during  convalescence. 

William  Squire. 

BFBEOLA. — A synonym  for  measles.  See 
Measles. 

BUMINATION  ( ruminn , I chew  again.) — 
Synon.  : Fr.  Rumination  ; Ger.  Wicderkaucn. — 
Rumination,  which  is  the  normal  method  of 
digestion  in  a large  class  of  animals,  occurt 
occasionally  in  the  human  subject.  In  the 
cases  recorded  the  return  of  the  food  usually 
took  place  about  a quarter  of  an  hour  after  the 
meal  had  been  finished.  The  regurgitation  seems 
to  have  been  produced  by  the  contractions  of 
the  muscular  coat  of  the  stomach,  assisted 
by  those  of  the  diaphragm  and  abdominal 
muscles.  The  food  is  usually  stated  to  have  had 
no  acid  taste,  and  therefore  could  not  have  un- 
dergone any  digestion.  Dr.  Copland  recommends 
that  the  meals  should  be  deliberately  and  care- 
fully masticated.  As  to  medicinal  treatment,  he 
had  found  benefit  from  ipecacuanha  and  aloes 
twice  a day,  and  a tonic  draught  one  hour  before 
dinner.  Samuel  Fenwick. 

RUPIA.  (pi-nos,  dirt  or  filth). — Synon.  : Fr. 
and  Ger.  Rupia. — A term  applied  to  the  crusts 
formed  by  the  desiccation  of  purulent  and  ichor- 
ous discharge,  over  the  foul  sores  or  ulcers  of 
syphilis  and  lupus. 

Description.— The  crusts  of  syphilitic  rupia 
vary  in  thickness  and  extent.  Sometimes  they 
are  flat  and  rugged,  and  sometimes  prominent ; 
and  they  are  generally  marked  on  the  surface 
by  concentric  lines,  which  indicate  the  peripheral 
growth  of  the  ulcers  which  they  conceal.  Their 
colour  is  grey,  sometimes  brown,  and  more  or 
less  mottled  with  black,  from  admixture  of  blood 
with  the  purulent  secretion.  When  of  large  size 
and  flat  they  suggest  the  idea  of  an  oyster-shell 
imbedded  in  the  skin ; at  other  times  they  aro 
conical  in  shape,  like  the  shell  of  the  limpet. 
This  latter  variety  results  from  the  desiccation 
of  the  discharges  poured  out  by  a pustule  in 
course  of  centrifugal  growth,  and  the  consequent 
superaddition  of  fresh  layers  to  the  under  sur- 
face of  the  original  crust. 

Rupial  crusts  found  in  lupms  are  harder,  and 
never  so  large  as  those  of  syphilis.  They  differ 
also  in  pathological  structure,  being  concretions 
of  epidermal  substance,  instead  of  mere  desic- 
cated masses  of  morbid  secretions. 

Treatment. — The  treatment  of  these  two 
forms  of  affection  is  that  of  the  diseases  which 
they  separately  represent,  namely,  syphilis  and 
struma.  Syphilitic  rupia  is  chronic  syphilis  in  a 
state  of  ulceration,  and  calls  for  the  treatment 
applicable  to  that  disease.  Iodide  of  potassium 
will  heal  the  ulcerations,  and  then  the  crusts  of 
rupia  will  fall  off  of  themselves.  It  is  better  to 
avoid  removing  them  artificially,  as  they  consti- 
tute a natural  covering  to  the  ulcers  whilst  the 
latter  remain  in  existence. 

Erasmus  Wilson. 

RUPTURES  ( rumpo , I break). — Synon.  ■ 
Fr.  Ruptures;  Ger.  Risse. — The  subject  of  rup 
ture  of  organs  generally  has  been  thoroughly  dis- 
cussed in  the  article  Perforations  ant>  Ruptures 


1384  RUPTURES. 

io  which  ihe  render  is  referred ; and  the  considera- 
tion of  this  lesion  in  connection  with  particular 
organs  is  fully  entered  upon  where  this  is  re- 
quired, as  in  the  case  of  the  heart,  stomach,  and 
other  important  viscera.  The  general  meaning 


SALIVARY  GLANDS. 

of  the  word  is  so  evident  that  it  needs  no  defi- 
nition. In  addition  to  its  obvious  meaning,  the 
word  is  used  in  a popular  sense  as  a synonym 
for  hernia,  which  is  spoken  of  as  a rupture.  See 
Hernia.  Frederick.  T.  Robert*. 


s 


SACCHORRHCEA  (<ra.Kxapov,  sugar,  and 
fiew,  I flow). — A term  applied  to  the  escape  of 
sugar  from  the  body  in  any  of  the  excretions  or 
in  discharges,  such  as  the  urine,  sweat,  or  expec- 
toration. See  Diabetes  Mellitus. 

ST.  ANTHONY’S  FIRE.  — A popular 
synonym  for  erysipelas.  See  Erysipelas. 

ST.  GALMIER,  in  Loire,  France. — A 
simple  acidulated  table-water.  See  Mineral 
Waters. 

ST.  MORITZ,  in  Upper  Engadine,  Swit- 
zerland.— A cool,  bracing,  mountain  climate. 
Mixed  chalybeate  springs.  Altitude,  6,000  feet. 
See  Climate,  Treatment  of  Disease  by ; and 
Mineral  Waters. 

ST.  SAUVEUR.  in  the  French  Pyrenees. 
Sulphur  Waters.  See  Mineral  AVaters. 

ST.  VITUS'S  DANCE -A  popular  synonym 
for  chorea.  See  Chorea. 

SALIVARY  GLANDS,  Diseases  of. — 

Synon.:  Fr.  Maladies  des  glandes  salivan-es ; Ger. 
Krankhciten  der  Speichcldrusen. 

Summary. — These  glands,  as  well  as  their 
ducts,  are  liable  to  be  attacked  by  inflammation  ; 
the  latter  may  also  become  mechanically  oc- 
cluded. The  parotid  gland  is  the  seat  of  the 
disorder  known  by  the  name  of  Cynanche  paro- 
tidea,  or  Mumps  (see  Mumps).  Salivary  calculus 
and  salivary  Jistula,  as  well  as  ranula,  are  de- 
scribed in  the  article  Mouth,  Diseases  of.  Oc- 
casionally the  parotid  is  sympathetically  invaded 
by  inflammation  during  the  height  of,  or  at  the 
termination  of,  other  acute  diseases,  and  this 
affection  requires  special  consideration  here. 

Metastatic  or  symptomatic  Parotitis. — 
This  affection  is  met  with  during  the  course 
of,  or  convalescence  from,  several  of  the  acute 
eruptive  fevers,  such  as  typhus,  enteric  fever, 
scarlatina,  small-pox,  or  measles.  It  commences, 
according  to  the  researches  of  ATrchow,  with 
congestion  of  the  gland,  followed  by  the  usual 
result.  Soon  thereafter  the  duct  becomes  af- 
fected ; and  there  is  found  in  it  a tough,  filamen- 
tous, whitish  substance,  which  speedily  is  trans- 
formed into  pus.  This  invades  the  lobules  of  the 
gland  ; these  then  soften  and  break  down,  until 
the  whole  of  the  gland-tissue  is  more  or  less 
destroyed,  as  well  as  the  interstitial  tissue,  by 
phlegmonous  inflammation.  Sometimes,  however, 
Duly  the  gland-tissue  proper  is  destroyed,  and 


the  gland,  when  examined  post  mortem,  ap- 
pears as  if  studded  with  numerous  suppurat- 
ing islands.  This  phlegmonous  inflammation 
spreads  from  its  seat  of  origin  in  various  direc- 
tions. most  frequently  to  the  neighbouring  con- 
nective tissue  enveloping  the  muscles  found  in 
this  situation,  descending  even  to  the  clavicle, 
not  even  sparing  the  periosteum  and  bones;  and 
it  has  even  been  known  to  pass  to  the  brain  and 
its  coverings. 

Symptoms. — If  this  affection  develop  itself 
during  the  height  of  an  acute  disease,  then,  by 
reason  of  the  stupifying  effect  of  the  primary 
disease,  the  more  manifest  subjective  symptoms 
are  wanting,  and  the  complaint  is  consequently 
said,  somewhat  improperly,  to  come  on  insi- 
diously. Bat  careful  observation  will  reveal,  by 
the  unusual  rise  in  temperature,  th;  increased 
restlessness,  and  the  somewhat  distressed  look  of 
the  patient,  that  some  new  complication  is  about 
to  discover  itself,  and  will  warn  the  intelligent 
practitioner  to  make  a close  physical  examination 
of  the  various  organs.  Probably  the  first  indi- 
cation of  this  metastatic  parotitis  will  be  a little 
swelling  about  the  lobe  of  the  ear,  and  closer 
investigation  will  show  loss  of  the  usual  depres- 
sion between  the  lower  jaw  and  the  mastoid  pro- 
cess, and  in  its  place  a more  or  less  hard  tumour. 
Pressure  will  usually  elicit  an  expression  of 
pain  from  the  apathetic  patient.  The  inflamma- 
tion may  end  either  in  resolution  or  in  suppura- 
tion. The  former  termination  may  be  looked  for 
if  the  enlargement  have  formed  slowly,  and  dur- 
ing the  convalescence  of  the  individual  from  the 
original  disease.  Suppuration  is,  in  all  cases,  to 
be  dreaded;  and  this  is  indicated  by  the  irregu- 
larly reddened  appearance  of  the  swelling,  and 
ultimately  the  sense  of  fluctuation.  Occasionally 
the  pus  finds  its  way  outwards,  or  discharges 
through  the  external  auditory  meatus,  this  latter 
being  by  no  means  an  uncommon  method  of  exit; 
or  the  pus  burrows  about  in  the  cellular  tissue 
investing  the  various  muscles  in  this  region. 

Prognosis. — This  depends  greatly  on  the  se- 
verity of,  and  the  stage  of,  the  primary  disease 
during  which  this  complication  declares  itself. 
If  it  make  its  appearance  at  the  height  of  the 
fever,  and  particularly  if  that  be  a grave  form  of 
fever,  then  the  prognosis  must  be  very  guarded. 
Trousseau  remarks  that  it  is  an  affection  from 
which  he  has  almost  never  seen  enteric  or  other 
fever  patients  recover.  This  is  certainly  not  in 
accord  with  the  experience  of  this  country.  If  tt 


SALIVAEY  GLANDS,  DISEASES  OP. 
occur  during  convalescence  from  a fever  or  other 
disease,  the  prognosis  is  then  much  more  favour- 
able. 

Treatment. — WaTm  poultices  must  be  ap- 
plied from  the  first ; supporting  measures  used  ; 
and  the  patient’s  powers  sustained  by  plentiful 
nourishment,  and  the  exhibition  of  stimulants 
and  tonics.  If  there  be  any  tendency  to  suppu- 
ration, the  poulticing  must  be  diligently  main- 
tained, and  an  opening  made  into  the  abscess 
the  moment  that  fluctuation  is  sensibly  made  out. 
Caution  must  be  exercised  in  this  case,  for  if  no 
pus  be  evacuated,  the  incision  not  only  is  useless, 
but  rather  increases  the  cedema  of  the  tissues, 
besides  putting  the  already  weakened  patient  to 
unnecessary  pain. 

Enlargement  of  the  Parotid  Gland. — This 
may  be  either  benign  or  malignant.  In  the 
former  case  it  is  usually  the  result  of  a previous 
parotitis,  or  it  may  be  due  to  the  development  of 
some  tumour  in  the  body  of  the  gland.  Such  cases 
are  distinguished  from  the  malignant  variety  by 
the  skin  always  remaining  freely  movable  over  the 
tumour,  and  over  the  lower  jaw ; while  in  the  ma- 
lignant affection  the  lower  jaw  is  with  difficulty 
defined,  and  is  not  readily  moved.  The  tumour 
is  always  limited  to  one  side ; and  the  malignant 
growth  never  has  its  starting  point  in  this 
gland,  similar  disease  being  found  in  other  or- 
gans. The  simple  tumour  may  be  modified,  if 
not  altogether  removed,  by  the  external  and  in- 
ternal use  of  iodine  long  continued  ; failing  this, 
surgical  operation  is  called  for.  The  malignant 
variety  is  incurable.  Claud  Mulrhead. 

SALIVATION-.—  Stnon.  : Ptyalism  ; Er. 
Salivation  ; Ger.  Speicheljluss.— Increased  flow 
of  saliva  can  only  be  styled  a disease  when  the 
amount  secreted  exceeds  that  which  in  health 
passes  into  the  stomach.  Strictly  speaking, 
ptyalism  is  not  a distinct  disease,  any  more 
than  dropsy  can  be  so  accounted,  but  it  obtains 
a position  as  an  independent  disorder  in  the 
nomenclature  of  diseases,  and  must  therefore  be 
shortly  noticed. 

jEtiologv. — The  causes  which  give  rise  to 
salivation  are  numerous,  as  are  also  the  diseases 
of  which  it  is  a symptom.  Thus  any  irritation 
of  the  mucous  membrane  of  the  mouth  and 
fauces  at  once  induces  an  increased  flow  of 
saliva.  Hence  this  is  one  of  the  leading  symp- 
toms of  aphthse,  thrush,  cancrum  oris,  ulcers, 
and  excoriations  of  the  mouth  and  tongue,  scor- 
butic and  syphilitic  affections  of  the  mouth, 
glossitis,  mumps,  and  various  affections  of  the 
fauces  and  pharynx.  This  salivation  may  also 
be  a reflex  effect,  as  when  it  occurs  in  cases  ot 
tic,  facial  neuralgia,  pregnancy,  or  gastric  affec- 
tions. Ptyalism  is  also  the  result  of  the  inges- 
tion of  certain  drugs,  mineral  and  vegetable,  as 
in  the  case  of  the  prolonged  use  of  mercury  and 
iodine.  These  seem  to  produce  an  alteration 
in  the  character  of  the  saliva,  as  well  as  in  the 
quantity.  An  increased  or  diminished  flow  of 
saliva  is  also  induced  by  direct  nervous  agency, 
as  when  mental  emotions,  such  as  fear,  suddenly 
render  the  mouth  parched  and  dry ; and  the 
opposite  effect  is  induced  by  the  thought  of  pala- 
table articles  of  food,  and  then  the  mouth  is 
said  t«  ‘water.’  In  various  conditions  the  saliva 


SARCINA.  1385 

dribbles  away,  as  in  the  insane,  in  paralytic 
persons,  in  those  stupified  by  disease,  such  as 
typhus,  and  in  teething  children. 

Symptoms. — The  symptoms  of  salivation  are 
evident  enough.  The  individual  complains  of  no 
pain,  but  of  the  exceeding  discomfort  in  the  con- 
stant spitting  and  gathering  of  saliva  in  the 
mouth,  which  interrupts  speech,  deglutition,  and 
sleep.  If  it  continue  unchecked  for  some  time  tba 
patient  emaciates.  When  the  affection  is  due  tc 
mercury,  the  first  evidence  of  the  constitutional 
action  of  the  drug,  which  precedes  the  salivation, 
is  a peculiar  taste  in  the  mouth,  of  a ‘coppery’ 
nature,  with  tenderness  of  the  gums  of  the  upper 
jaw,  and  fcetid  odour  of  the  breath  ; then  there 
are  observed  salivation,  large  flabby  tongue,  and 
if  it  goes  still  farther,  ulceration  of  the  gums 
and  mouth. 

Treatment. — When  salivation  is  due  to  some 
nervous  cause,  or  if  the  cause  be  not  very  appa- 
rent, ten-drop  doses  of  tincture  of  belladonna 
thrice  daily  are  often  sufficient  to  put  an  end  to 
it  in  one  or  two  days.  If  it  be  induced  by 
mercury  or  other  drug,  the  use  of  this  must 
bo  entirely  suspended.  Mild  astringent  mouth- 
washes should  be  ordered,  such  as  chlorate  of 
potash,  alum,  or  acetate  of  lead  in  solution,  to  be 
used  frequently.  Clatjd  Muibhead. 

SALZBRUNN,in  German  Silesia. — Alka- 
line waters.  See  Mineral  Waters. 

SALZKAMMEBGUT,  in  Austria. — An 
inland  bracing  summer  climate.  See  Climate, 
Treatment  of  Disease  by ; and  Ischl. 

SAND-WORM.  — A term  sometimes  em- 
ployed to  designate  the  sand-flea  or  jigger.  See 
Chigoe. 

SANGUINE  TEMPERAMENT.  See 
Temperament. 

SANGUINEOUS  ( sanguis , blood). — This 
word  is  used  in  relation  to  the  presence  of  blood 
in  discharges,  effusions,  or  extravasations,  when 
they  consist  more  or  less  of  this  fluid,  as  in 
haemoptysis,  haemorrhagic  pleurisy,  and  cerebral 
haemorrhage. 

SANITARY"  ( sanitas , health). — Relating  to 
health ; a term  generally  used  in  connection 
with  laws,  measures,  &c.,  bearing  on  health.  See 
Personal  Health  ; and  Public  Health. 

SAN  REMO,  Western  Italian  Riviera. 
A mild,  sheltered,  equable,  moderately  dry,  and 
calm  winter  climate.  Mean  temp,  winter,  48-5°. 
Exposed  to  E.  winds.  Soil,  clay.  See  Climate, 
Treatment  of  Disease  by. 

SARATOGA,  in  NewYork,  United  States. 
Alkaline  chalybeate  waters,  containing  traces  of 
iodine  and  bromine.  The  springs  of  Ballston, 
a few  miles  from  Saratoga,  are  of  a like  character. 
See  Mineral  Waters. 

SARCINA  ( sarcina , a pack  or  bundle). — 
A genus  of  microscopic  fungi,  belonging  to  the 
order  Saccharomycetes  of  the  lowest  division  of 
the  vegetable  kingdom,  Vrotophyta , and  of  occa- 
sional occurrence  in  the  human  body,  where  they 
were  first  discovered  by  Goodsir  in  1842  (see 
Parasites,  Vegetable).  This  organism  presents 
under  the  microscope  a characteristic  appearance, 
best  to  be  compared  to  a corded  wool-pack,  hence 


138G  SARCINA. 

the  name.  The  constituent  cells,  of  a diameter  of 
about  jgi^th  of  an  inch,  are  arranged  in  square 
groups  of  four,  sixteen,  or  thirty-two.  Eor  an 
illustration  see  Microscope  in  Medicine,  fig.  38. 

Three  species  of  sarcina  are  of  interest  in 
human  pathology,  namely — 1.  Sarcina  ventriculi 
2.  Sarcina  urines ; and  3,  Sarcina  botulina. 

1.  Sarcina  ventriculi. — This  species  of  sar- 
cina is  of  frequent  occurrence  in  the  stomach, 
and  in  the  vomit  of  gastric  dilatation  from  pylo- 
ric obstruction;  in  some  cases  of  gastric  ulcer  and 
carcinoma  without  dilatation  ; and  in  rare  cases 
of  gastric  catarrh.  Sarcin®  are  not  sufficiently 
constant  to  be  of  much  diagnostic  value,  and  are 
certainly  not  pathognomonic  of  a dilated  stomach, 
as  has  been  supposed.  Their  appearance  is  usu- 
ally associated  with  a state  of  fermentation  of 
the  gastric  contents,  which  appear  like  yeast.,  and 
are  of  an  acid  reaction  and  smell ; but  it  would 
seem  that  the  organism  is  developed  in  the  pro- 
gress of  the  fermentation,  and  is  not  the  actual 
cause  of  the  condition,  for  when  placed  in  suit- 
able surroundings,  living  sarcin®  have  not  been 
observed  to  set  up  fermentative  changes,  and 
cases  are  recorded  by  Beale  and  others  of  their 
occurrence  in  vomit  that  showed  no  signs  of  fer- 
mentation. 

Sarcinse  are  easily  detected  under  the  micro- 
scope. A drop  of  liquor  potass®  added  to  a 
fragment  of  vomit  on  the  glass  slide,  and  covered 
with  thin  glass,  is  sufficient  to  display  their  cha- 
racteristic appearances. 

2.  Sarcina  urinae. — This  species  of  sarcina 
is  of  much  rarer  occurrence ; and  it  is  very 
doubtful  whether  it  is  not  always  developed  after 
the  urine  has  been  voided.  It  is  somewhat 
smaller  than  the  gastric  variety,  but  otherwise 
closely  resembles  it. 

3.  Sarcina  botulina. — The  ‘sausage  poison  ’ 
has  been  attributed  by  M.  Van  den  Corput  to  the 
presence  of  a species  of  sarcina,  to  which  this 
name  has  been  given.  See  Poisonous  Food. 

Sarcin®  have  also  beon  stated  to  have  been 
found  in  the  f®ees,  in  a case  of  abscess  of  the 
lung,  in  the  ventricles  of  tha  brain,  in  hydrocele 
fluid,  in  gangrenous  intestines,  and  in  cholera 
stools.  W.  H.  Allchin. 

SARCOCELE  (<rap|,  flesh,  and  K7)\i j,  a 
tumour). — A name  for  any  solid  enlargement  of 
the  testes.  See  Testes,  Diseases  of. 

SARCOMA  (aapt,  flesh). — A tumour  com- 
posed of  some  modification  of  embryonic  connec- 
tive tissue.  See  Tumours. 

SAROOPTES  SCABIEI. — A synonym 
for  acarus  scabiei.  See  Acarus. 

SATURNISM  ( saturnus , lead), — A synonym 
for  lead-poisoning.  See  Lead,  Poisoning  by. 

SATYRIASIS  (irarvpos,  a satyr). — A mor- 
bid desire  for,  and  indulgence  in,  sexual  inter- 
course in  the  male. 

SCAB. — A rough  incrustation  formed  by  the 
drying-up  of  the  discharge  from  a woirad  or  an 
ulcer,  or  of  the  contents  of  a pustule.  The  word 
is  also  vulgarly  used  as  a synonym  for  scabies. 

SCABIES  (scabies,  scab,  mange). — Stnox.  : 
Itch;  Fr.  Gale ; Ger.  Krdtzc. 

Definition. — A simple  inflammation  of  the 


SCABIES. 

skin,  produced  by  the  irritation  of  the  acarus 
scabiei  and  the  scratching  of  the  sufferer. 

-Etiology. — Tae  cause  of  scabies  is  the  pre- 
sence of  the  acarus  scabiei.  Scabies  is  conta- 
gious, inasmuch  as  the  parasite  is  easily  trans- 
ferred from  one  person  to  another.  See  Acarus. 

Description. — The  parts  of  the  body  most 
likely  to  be  attacked  are  the  soft  skin  between 
the  fingers,  and  on  the  flexor  side  of  the  wrists 
and  elbows ; the  lower  part  of  the  abdomen,  but- 
tocks, and  penis;  and  in  children  the  feet  and 
legs.  The  acarus  generally  attacks  both  sides 
of  the  body  symmetrically,  and  in  adults  is  never 
met  with  in  the  skin  of  the  face  or  scalp ; but 
any  other  part  of  the  body  may  be  affected. 

The  eruption  produced  by  the  acari  and  by 
scratching  is  a scattered  artificial  eczema  ; and 
the  extent  and  severity  of  the  disease  will  depend 
chiefly  on  its  duration.  The  most  characteristic 
feature  for  the  purposes  of  diagnosis  is  the 
scabies’  burrow,  which  resembles  roughly  an  old 
pin-scratch.  Examined  closely,  it  has  a dotted 
and  beaded  appearance  with  ragged  dirty  edges 
at  its  entrance,  where  the  roof  of  the  cunicnlus 
has  been  worn  away  by  rubbing.  At  the  distant 
end  of  the  burrow  may  be  sometimes  seen  the 
parent  acarus,  which  is  easily  extracted  by  insert- 
ing the  point  of  a pin  along  the  burrow  and 
touching  the  animal,  which  immediately  adheres 
to  the  pin,  and  may  thus  be  removed  for  the 
purposo  of  examination. 

Diagnosis. — The  following  points  serve  to 
distinguish  scabies: — (1)  the  particular  parts 
attacked  ; (2)  the  eruption,  which  consists  of  scat- 
tered and  isolated  papules,  vesicles,  and  pustules, 
with  their  tops  more  or  less  torn  by  scratching; 
(3)  the  history  of  the  case,  and  especially  of 
contagion  ; (4)  the  presence  of  the  scabies'  bur- 
row ; and  (5)  the  demonstration  of  the  acarus  by 
means  of  the  microscope. 

Treatment. — The  usual  plan  of  treating 
scabies  is  by  the  use  of  either  (1)  sulphur  oint- 
ment; or  (2)  sulphur  baths  or  lotions.  The  for- 
mer is  the  more  effectual  method,  although  the 
latter  may  bo  occasionally  preferred.  In  order 
to  cure  an  ordinary  case  of  scabies,  it  is  simply 
necessary  that  the  patient,  before  going  to  bed, 
should  thoroughly  apply  and  gently  rub  in  the 
sulphur  ointment  to  every  part  of  the  body, 
excepting  the  skin  of  the  face  and  scalp:  and  in 
order  to  keep  the  ointment  in  contact  with  the 
skin,  he  should  sleep  in  his  under  clothes,  such 
as  drawers,  jersey,  socks,  and  gloves,  and  in  the 
morning  take  a warm  bath  and  put  on  clean 
clothes.  The  process  should  be  repeated  the  next 
night ; after  which  the  ointment  should  be  used, 
every  night  for  a week  or  ten  days,  to  those  parts 
of  the  body  only  which  are  especially  attacked 
by  the  disease. 

The  ointment  should  contain  a drachm  of  sul- 
phur to  an  ounce  of  benzoated  lard,  but  for 
young  children  an  ointmeDt  of  about  half  this 
strength  is  most  suitable.  A common  mistake 
is  to  conti  eue  the  use  of  the  strong  sulphur 
ointment  of  the  Pharmacopoeia  for  several  weeks, 
thus  producing  an  irritable  state  of  skin, 
which  is  mistaken  for  a continuation  of  the 
scabies. 

If  a sulphur  bath  be  preferred,  it  may  be 
made  by  dissolving  half  a pound  of  sulphurated 


SCABIES. 

potash  in  thirty  gallons  of  water.  It  is  neces-  j 
eary  to  repeat  the  bath  several  times  at  intervals 
of  a few  days. 

If  it  be  desired  to  treat  scabies  by  a lotion, 
Vlemingkx’s  solution  may  be  used.  It  is  made 
by  boiling  five  gallons  of  water  with  a quarter  of 
a pound  of  quick  lime  and  half  a pound  of  sul- 
phur until  three  gallons  are  left.  This  lotion  is 
effective,  but  it  is  apt  to  irritate  tlio  skin,  and 
is  not  so  generally  useful  as  the  sulphur  oint- 
ment. E-  Li  VEING. 

SCALD. — An  injury  to  any  part  of  the  body, 
caused  by  the  action  of  moist  heat,  either  in  the 
form  of  steam  or  of  a hot  fluid.  See  Heat, 
Effects  of  Severe  or  Extreme. 

SCALD-HEAD  (Saxon  scall,  a separation 
or  discontinuity  of  surface).— A popular  term, 
commonly  used  as  the  negation  of  ring-worm  ; 
all  diseases  of  the  scalp,  in  the  belief  of  the 
people,  being  either  ringworm  or  scald-head. 
The  term  finds  a more  suitable  application  to 
that  form  of  folliculitis  of  the  scalp  which  is 
denominated  kerion.  Kerion  begins  with  circum- 
scribed tumefaction  of  the  scalp  and  profuse 
exudation  from  the  hair-follicles,  and  terminates 
by  elimination  of  the  hair  and  baldness ; the 
latter  being  generally  temporary  but  sometimes 
permanent.  Erasmus  Wilson. 

SCALY  ERUPTION. — The  pathology  of 
a scaly  eruption  is  an  excessive  formation  of  un- 
healthy epidermis,  which,  instead  of  presenting 
the  normal  characters  of  that  structure,  is  lami- 
nated and  brittle,  and  falls  off  in  tke  shape  of 
scales.  The  scales  offer  various  degrees  of  size 
and  cohesion,  some  being  minute,  silvery,  and 
micaceous,  and  others  large  and  tough.  Three 
scaly  eruptions  have  been  described  by  derma- 
tological authors  ; the  lepra  vulgaris  of  Willan, 
now  called  psoriasis;  the  psoriasis  of  Willan, 
which  is  a chronic  eczema  ; and  pityriasis.  But 
besides  these,  inflammation  of  the  skin  of  what- 
ever denomination,  is  attended  with  desquama- 
tion of  the  epidermis,  of  which  the  most  striking 
example  is  dermatitis  exfoliativa  or  pityriasis 
rubra.  Erasmus  Wilson. 

SCARIFICATION  ( scarifico , I make  an 
incision). — This  is  an  operation  in  which  small 
superficial  incisions  are  made,  either  through  the 
skin  or  mucous  membrane,  to  allow  the  escape 
of  blood,  as  in  wet-cupping ; of  serous  fluid,  in 
relieving  dropsical  effusions ; or  to  liberate  .the 
teeth,  as  in  difficult  dentition. 

SCARLATINA. — A synonym  for  scarlet 
fever.  See  Scablet  Fever. 

SCARLET  FEVER.— Synon.  ; Scarlatina; 
Febris  Scarlatina ; Fr.  Scarlatine;  Ger.  Scharlach 
fieber. 

Definition. — An  infectious  specific  fever, 
characterised  by  deep  redness  of  the  throat ; a 
finely  diffused  scarlet  rash,  most  intense  on  the 
third  day,  beginning  to  fade  on  the  fifth  or  sixth 
with  some  subsidence  of  fever,  and  followed  by 
desquamation  of  the  cuticle,  in  both  small  and 
large  flakes  ; and  afterwards  possibly  by  rheu- 
matic or  renal  symptoms,  with  a tendency  to 
Berous  effusions. 

./Etiology. — Some  product  of  the  sick,  how- 
ever conveyed  to  those  hitherto  unaffected, 


SCABLET  FEVER.  1387 

especially  the  young,  always  reproduces  this 
disease,  which  again  gives  off  infecting  material 
with  identical  properties.  No  other  origin  for 
scarlet  fever  car.  now  be  admitted ; its  extension 
to  any  new  locality  is  traceable  to  an  imported 
infection.  The  periodical  recurrence  of  epi- 
demics in  large  communities  is  mainly  attribut- 
able to  an  increase  in  the  number  of  the  suscep- 
tible. Wherever  scarlatina  spreads,  children  are 
the  chief  victims.  Even  among  people  not  pro- 
tected by  a previous  attack,  a le;s  liability  is 
noticed  with  advancing  years. 

In  adults,  unless  specially  predisposed,  the 
attack  is  less  severe  than  during  adolescence  aud 
childhood ; young  infants  often  escape  or  have  the 
disease  in  a mitigated  form.  In  England,  where 
scarlet  fever  prevails  more  than  in  any  other 
country,  except  perhaps  the  United  States,  and 
causes  the  highest  mortality  of  any  epidemie 
disease,  two-thirds  of  all  the  deaths  from  it  occur 
in  the  first  five  years  of  childhood.  Five  per  cent, 
of  the  whole  mortality  falls  in  the  first  year, 
fifteen  in  the  second,  twenty  per  cent,  in  each  of 
the  two  next  years,  thence  progressively  decreas- 
ing, that  for  all  ages  over  fifteen  being  less  than 
five  per  cent.,  and  more  than  half  of  those 
deaths  being  in  the  next  decade.  The  following 
decade  shows  a slightly  increased  incidence  on 
women,  partly  because  they  are  more  with  the 
sick,  and  partly  from  a greater  susceptibility 
after  childbirth.  Sex  has  no  directly  predis- 
posing influence.  The  proportional  mortality 
from  this  cause  is  about  eight  to  ten  thousand 
of  population  in  England  aud  Wales,  the  range 
being  from  O'o  to  1'5  per  1,000;  in  Liverpool 
this  has  reached  to  3'7,  and  in  London  to  two 
per  thousand.  From  two  to  five  per  cent,  of  all 
the  yearly  deaths  are  from  this  disease;  in 
London  this  proportion  varied  from  eight  per 
cent,  in  1S70,  to  one  per  cent,  two  years  after- 
wards. Epidemics  of  scarlet  fever  are  not  evenly 
distributed — they  subside  in  one  place,  while 
they  extend  in  another;  in  epidemic  years  (as  1S63 
and  1870)  the  increase  becomes  very  general. 

The  fatality  of  3,984  cases  treated  in  special 
hospitals  in  London  in  three  years,  1S77  to  1879, 
was  449.  The  death-rate  ranges  from  6 to  1 6 pei 
cent.  Taken  generally,  the.  proportion  of  deaths 
to  attacks  must  be  near  ten  per  cent. ; nor  is 
this  rate  of  fatality  less  in  non-epidemic  years, 
or  in  seasons  when  the  disease  is  less  prevalent 
It  varies  greatly  in  different  epidemics,  and  in 
different  communities,  only  in  limited  puerperal 
epidemics  ever  reaching  the  high  proportion 
measles  sometimes  does.  Sometimes  it  passes 
as  lightly  as  measles  often  does,  but  it  is  very 
often  much  higher.  Consequently,  since  many 
more  children  have  measles  and  fewer  die,  while 
many  families  escape  scarlet  fever  altogether 
and  the  deaths  from  it  are  double  those  from 
measles,  the  proportional  fatality  of  scarlet  fever 
is  much  greater  than  in  measles.  In  both  dis- 
eases many  of  the  milder  cases  escape  notice, 
and  so  the  rate  given  may  be  too  high. 

The  influence  of  season  on  scarlet  fever  is 
marked  with  us  by  an  autumnal  increase  of  the 
disease  ; the  number  of  deaths  from  it  in  London 
is  always  at  its  highest  at  the  end  of  October. 
Cold  has  very  little  effect  on  the  intensity  of  the 
disease ; in  many  indirect  ways  it  may  check  its 


SCAELET  I EVER. 


1388 

Bpre.id.  Heat  favours  its  diffusion,  but  les- 
sens the  severity  of  the  attack  or  of  its  after- 
consequences. Epidemics  tend  to  recur  every 
five  or  six  years,  as  a fresh  series  of  the  suscep- 
tible arises.  They  often  extend  with  us  in  dry 
seasons,  and  subside  after  wet  ones.  In  oppo- 
sition to  some  views  of  the  relation  of  moist  air 
and  subsoil  water  to  infection,  we  see  rain 
wash  the  air  of  floating  particles,  and  carry  off 
others  by  the  sewers. 

A defective  hygiene  from  imperfectly  drained 
dwellings  greatly  increases  the  dangers  of  this 
disease.  Defective  ventilation  will  aggravate  the 
type,  or  intensify  the  infection  which  a free 
ventilation  would  dissipate.  The  best  conditions 
of  personal  hygiene  are  often  powerless  in  modi- 
fying  the  dangers  of  individual  liability;  the 
healthy  and  well-to-do  enjoy  no  exemption;  no 
mildness  of  type  in  the  infecting  source  is  any 
safeguard  against  the  dangers  to  follow,  even  to 
members  of  the  same  family.  Individual  sus- 
ceptibility is  most  variable  ; sometimes  persons  in 
not  very  good  health  escape  while  with  the  sick, 
but  on  returning  in  improved  health  to  them  as 
convalescents,  or  to  the  house  they  have  left, 
are  at  once  seized.  After  surgical  operations  the 
predisposition  to  recei  ve  infection  is  increased ; 
any  shock  or  injury  may  determine  a seizure 
alter  an  exposure  otherwise  harmless.  How 
long  after  quitting  an  infected  place  such  injury 
may  excite  disease  is  uncertain.  An  idiosyncrasy 
to  suffer  seriously  from  this  kind  of  disease 
marks  even  the  robust  in  certain  families ; in 
others  there  is  a liability  to  more  than  one  at- 
tack. The  rule  against  a recurrence  prevails  so 
largely  as  to  be  the  great  element  of  personal 
safety  to  anyone  again  exposed  to  infection. 
Any  person,  however  safe,  may  be  the  carrier  of 
infection  ; not  only  the  hands  that  have  touched 
the  sick  and  things  in  actual  contact  with  them, 
bat  clothes  or  even  papers  that  have  been  in  the 
sick-room  may  convey  it. 

Infection  attaches  to  the  whole  period  of  ill- 
ness. Greatest  at  the  height  of  the  disease,  it  is 
given  off  for  six  weeks,  it  may  be  for  nine  and 
ten  weeks  after.  A recrudescence  or  relapse  is 
possible  as  late  as  the  fourth  week ; this,  if  not 
a re-infection,  prolongs  the  duration  of  the  infec- 
tious period  ; so  also  may  any  serious  complica- 
tion delaying  convalescence.  During  all  this  time 
infection  may  be  received  by  clothes  or  near  sur- 
faces, and  retained  by  them  for  months,  unless 
driven  off  by  cleansing  and  disinfectants.  A dry 
heat  of  212°  will  disinfect  woollen  clothing;  a 
curtain  from  the  bed  of  a child  only  sickening  for 
scarlet  fever,  folded  and  put  away  without  such 
care,  has  set  up  the  disease  after  a long  interval. 
Clothes  removed  to  a distance  and  unpacked 
months  afterwards  will  give  off  infection.  Per- 
sons protected  by  a previous  attack  from  again 
undergoing  scarlet  fever,  when  much  exposed  to 
it  may  have  sore-throat  or  other  signs  of  partial 
sickening,  sufficient  to  start  the  disease  else- 
where. Every  case  of  sore-throat  occurring  in 
an  infected  house  is  capable  of  conveying  scarlet 
fever,  whether  the  subject  of  it  be  protected  or 
not.  Sore-throat  in  children  is  always  a sufficient 
reason  for  keeping  them  at  home.  It  is  the  slight 
cases  of  infectious  sore-throat,  not  bad  enough  to 
prevent  children  from  going  out  of  doors,  or  even 


to  schools  and  parties,  that  elude  our  efforts  to 
arrest  epidemics  of  this  kind  in  their  usual  course. 
Infection  begins  at  the  very  commencement  of 
sickening,  but  at  that  time  is  more  readily  con- 
trolled. Scarlet  fever  having  gained  entrance  into 
a healthy  house  need  not  spread;  timely  isola- 
tion of  the  first  case,  or  separation  of  the  suscep- 
tible, is  mostly  successful,  for  the  rash  is  an  early 
symptom  at  once  attracting  attention.  If  others 
have  received  infection  the  sickness  will  appear 
in  less  than  a week,  when  a second  separation  is 
sure  to  be  effective.  Till  the  week  is  over  those 
who  may  have  escaped  are  not  to  be  sent  among 
other  families. 

The  period  of  incubation  is  a short  one:  not 
more  than  from  three  to  five  days,  it  may  bo  as 
short  as  three  hours ; it  may  possibly  extend  to 
seven  days.  The  longest  clear  interval  from  a 
single  definite  exposure  to  sickening  has  been 
four  and  a half  days.  In  most  of  the  instances 
where  four  to  five  days  have  intervened,  two  or 
three  of  these  days  have  not  been  without  sore- 
throat  or  other  signs  of  invasion.  It  is  such  cases 
that  are  infectious  before  the  seizure  is  definite. 
In  separating  children  from  an  infected  house 
anyone  who  has  received  infection  is  sure  to 
show  evidence  of  it  before  the  week  end.  The  only 
exceptions  to  this  rule  are,  where  some  com- 
munication has  been  kept  up  with  the  infected 
house,  where  clothes  have  retained  infection,  or 
some  source  of  it  has  existed  in  the  second 
house.  All  accurate  investigation  of  the  cause 
of  infection  in  scarlet  fever  tends  to  reduce  the 
estimate  of  the  average  incubation-period  to  less 
than  three  days.  In  the  longer  periods  adduced 
it  is  probable  that  infection  attaches  to  something 
without,  instead  of  immediately  acting  on  or 
within  the  sufferer.  A week  or  more  may  inter 
vene  between  successive  cases  in  any  familv, 
when  precautions  sufficient  only  to  delay  the 
spread  of  infection  have  been  maintained. 

Inoculation  will  reproduce  scarlatina,  all  the 
symptoms  appearing  with  the  usual  rapidity  and 
not  less  than  the  usual  severity.  Some  modifica- 
tion has  resulted  from  inoculating  a serous  exuda 
tion  from  the  skin  during  eruption ; redness  began 
at  the  point  of  insertion  in  thirty  hours,  this  ex- 
tended during  three  days,  faded  after  five  days, 
and  proved  protective.  Attempts  at  implanting 
the  disease  by  desquamated  epidermic  scales  have 
mostly  failed ; as  with  diphtheritic  exfoliations, 
the  active  contagion  is  not  long  or  intimately 
associated  with  dead  material.  The  particulate 
contagion,  carried  in  the  blood,  can  permeate 
everywhere,  for  mothers  ill  from  it  have  given 
birth  to  infants  affected  with  angina;  yet  the 
mother  may  suffer,  and  the  child  escape.  Animals 
are  inoculable  with  the  blood  of  persons  with 
scarlet  fever.  A dog  has  contracted  fever  and 
bad  throat  from  being  in  bed  with  a scarlet  fever 
patient ; such  illness  is  not  necessarily  identical 
with  that  originating  it,  nor  need  it  be  directly 
transmissible  as  a specific  disease  either  to  dogs 
or  men,  but  here  is  a way  in  which  animals  may 
carry  infection  from  one  person  to  another. 

Infection  has  many  times  been  traced  to  milk. 
The  facility  with  which  this  fluid  will  absorb  aDd 
convey  infection  is  very  remarkable ; for  it  tc 
stand  in  the  room  with  sick  people  is  enough  to 
cause  it  to  be  tainted ; the  cream  is  specially 


SCARLET 

prono  to  impregnation.  In  some  cases  conva- 
lescents from  scarlet  fever,  in  others  healthy 
persons  coming  from  an  infected  house,  have 
milked  the  cows,  and  handled  or  distributed  the 
milk.  In  no  case  has  any  diseased  state  of  the 
cows  been  discovered  to  exist. 

Pathology  and  Anatomical  Characters. — 
Scarlet  fever  results  from  the  entrance  of  an 
infecting  particle  into  the  blood;  how  minute 
or  of  what  nature  is  uncertain.  Micrococci 
are  found  in  the  blood  during  this  fever,  even 
within  the  globules  ; and  in  the  serum  rapidly 
oscillating  bodies  appear  as  dark  specks  among 
the  globules  ( x 500)  ; also  rod-like  bodies  made 
up  of  three  or  four  of  the  more  minute  ones. 
Such  serum  injected  under  the  skin  caused  sud- 
den fever  in  the  rabbit,  with  similar  bodies  in 
the  blood,  again  inoculable.  Not  only  the  blood 
and  serum  of  the  subject  of  scarlet  fever,  but 
most  secretions  of  the  body  carry  infection. 
Minute  spores,  similar  to  those  in  the  blood, 
traverse  membranous  septa,  and  have  been  found 
in  the  renal  epithelium.  Most  abundant  in  the 
breath,  infection  attaches  also  to  the  nasal  or 
pharyngeal  secretion.  The  first  serous  exudation 
from  the  skin  has  been  used  for  inoculation;  des- 
quamated cuticle  is  less  effective.  Infection  is 
generally  received  by  the  throat  and  lungs,  seldom 
by  a wound  or  abrasion  of  the  skin,  and  never  by 
the  unabraded  skin  ; at  first  it  multiplies  at  the 
point  of  reception,  hence  probably  the  day  or 
two  of  sore-throat ; and  is  delayed  but  little  in 
the  lymphatics  before  entering  the  blood.  In- 
fection is  most  rapid  when  carried  direct  to  the 
lungs,  as  when  inhaled  through  a tracheotomy 
tube,  no  particles  being  detained  on  the  pharynx. 
Many  of  the  first  effects  of  the  disease,  such 
as  the  quick  pulse  and  nerve-disturbance,  are 
directly  attributable  to  the  high  temperature. 
The  state  of  the  skin  adds  to  the  fever ; secretion 
is  checked ; there  is  a general  hyperaemia,  not 
specially  of  the  papillae  as  in  measles,  with 
serous  exudation  in  its  upper  layers.  A bad 
throat  gives  rise  to  irritating  and  injurious  se- 
cretions, keeps  up  the  fever,  and  interferes  with 
the  supply  of  necessary  diluents.  The  products 
of  increased  tissue-change  are  imperfectly  elimi- 
nated by  the  kidneys.  Further  stress  on  the 
kidneys  is  caused,  partly  by  the  high  fever,  and 
partly  by  a special  irritant  in  the  blood  acting 
upon  its  vascular  and  secreting  structures.  The 
vascular  changes  occur  early,  chiefly  in  the  cor- 
tical part;  the  glomeruli  are  obstructed  ; there 
is  a proliferation  of  epithelial  nuclei  in  the  Mal- 
pighian corpuscles,  distending  them  to  twice 
their  size,  and  so  compressing  the  vascular  tuft ; 
there  is  hyaline  degeneration  of  their  capil- 
laries, and  in  the  elastic  intima  of  the  afferent 
vessels,  which  has  been  found  after  two  days’ 
illness  (Klein);  also  thickening  of  the  small 
arteries  in  other  parts,  with  germinating  nuclei 
in  the  muscular  coat.  The  brunt  of  the  dis- 
ease falls  first  on  the  glomeruli ; thence  arise 
stasis  and  hypersemia  of  intertubular  capillaries ; 
then  signs  of  parenchymatous  nephritis,  with 
cloudy  swelling  of  epithelium-cells,  inAease  of 
their  nuclei,  and  granular  change  in  some  of 
the  convoluted  tubes  may  be  found.  Sometimes 
there  is  granular  matter  or  blood  in  them,  and  in 
the  cavity  of  Bcwman’s  capsule.  Epithelium  in 


FEVER.  1389 

some  cases  begins  to  be  detached  from  the  largei 
ducts  of  the  pyramids.  After  the  first  week 
changes  due  to  interstitial  as  well  as  to  paren- 
chymatous nephritis  commence ; the  connective 
tissue  round  the  larger  vessels  is  infiltrated  with 
lymphoid  cells,  thence  spreading  to  the  base  oi 
the  pyramids  and  to  the  cortex,  some  parts  oi 
which  become  pale  and  firm,  and  the  tubules 
obliterated.  After  this  process  has  reached  a 
certain  degree  the  evidence  of  parenchymatous 
change  increases — crowding  of  the  urinary  tubes 
with  lymphoid  cells,  granular  and  fatty  de- 
generation of  epithelium,  with  casts  or  cylinders 
of  various  kinds  in  the  tubes,  and  abundant 
products  of  inflammation.  These  changes  may 
commence  round  an  artery  plugged  with  fibrin  ; 
they  lead  to  enlargement  of  the  kidney,  with 
obliteration  of  tubules  and  Malpighian  corpus- 
cles, the  latter  undergoing  fibrous  degeneration. 
Klein  also  describes  early  interstitial  hepatitis. 
He  found  the  same  hyaline  degeneration  and 
thickening  of  arteries  in  the  spleen  and  intes- 
tines as  in  enteric  fever,  but  most  marked  in  the 
spleen,  with  degeneration  of  surrounding  adenoid 
tissue.  Veins  obstructed  with  fibrin  were  found 
in  the  cervical  glands,  with  degenerative  changes; 
in  the  centre  of  the  lymphatic  follicles  here,  and 
in  the  pharynx  and  tonsils,  the  lymph-cells  were 
replaced  by  large  granular  cells. 

Thickening  of  the  walls  of  the  smaller  arteries, 
and  some  change  in  the  capillaries  of  the  pia 
mater,  have  been  noticed  in  this  as  in  other  acute 
fevers,  otherwise  the  early  cerebral  symptoms  are 
not  marked  by  anatomical  change.  In  uraemia 
leucocytes  are  found  in  the  perivascular  spaces  of 
the  brain  and  cord.  Later  cerebral  mischief,  ex- 
cept from  caries  of  the  temporal  bone,  is  more  raM 
than  after  measles.  Hemiplegia  from  embolinm 
has  occurred  in  the  second  week  of  scarlet  fever. 
Besides  the  results  of  endo-  and  peri-carditis, 
blood-clots  and  fibrinous  coagula  are  found  in 
the  heart.  The  blood  in  scarlet  fever  has  been 
said  to  be  deficient  in  fibrin ; it  is  less  readily 
formed  in  this,  as  in  other  specific  fevers,  until 
some  secondary  inflammation  arises ; in  the  after 
dyscrasia  it  more  readily  separates.  Tubercular 
peritonitis  has  followed. 

Ulcerative  endocarditis,  or  suppurative  sy- 
novitis, almost  as  certainly  fatal,  may  occur. 
Among  the  secondary  lesions  of  scarlet  fever  aro 
the  ulceration  and  suppuration  of  inflamed  glands, 
with  sloughing  of  the  cellular  tissue  around 
them  or  in  other  parts.  Fatal  haemorrhage  has 
resulted  from  an  injured  artery.  Good  recovery 
has  been  made  after  sloughing  in  the  neck  has 
extended  to  the  sheath  of  the  carotid,  exposing 
all  the  deep  muscles,  and  leaving  the  salivary 
glands  bare  but  uninjured. 

Symptoms.— The  invasion  of  scarlet  fever  is 
abrupt.  The  ingress  of  fever  is  seldom  marked 
by  rigors,  not  always  by  chilliness ; slight 
pallor,  languor,  vertigo,  drowsiness  by  day,  rest- 
lessness, starting,  or  delirium  at  night,  aching 
of  the  limbs  and  forehead,  sore-throat,  and 
vomiting,  are  constant;  in  children  convulsions 
or  coma  may  occur.  Sudden  illness  comes  on 
within  an  hour  of  apparent  health,  or  after  a 
day  or  two's  warning  sensations  in  the  throat. 
The  temperature  begins  to  rise  at  once,  the 
pulse  becomes  very  rapid,  and  this  at  fir*t  is 


SCARLET  FEVER. 


1 390 

perhaps  more  marked  than  the  rise  in  tempera- 
ture ; but  soon  suffusion  of  the  eyes,  flushing  of 
the  face,  and  great  heat  succeed,  with  thirst  and 
pain  in  deglutition,  or  some  stiffness  of  neck.  The 
lymphatic  glands  at  the  angles  of  the  jaw  can 
be  felt  enlarged  and  tender ; already  the  arch  of 
the  palate  and  both  tonsils  are  red  ; the  redness 
extends  a little  on  to  the  palate  ; the  tongue  is 
furred,  not  red,  except  at  the  edges  and  tip. 
Very  often  a fine  flush  of  redness  suffuses  the 
neck  and  chest  soon  after  the  sore-throat  is 
complained  of,  perhaps  within  a few  hours  of 
the  first  suspicion  of  illness.  The  eruption  may 
thus  be  among  the  earliest  obvious  signs  of  the 
disease  ; it  generally  appears  by  the  second  day, 
and  is  well  established  on  the  third,  or  it  may 
be  delayed,  suppressed,  or  recede,  when  the 
severity  of  the  prodromata  serve  as  a guide. 
Coma,  convulsions,  or  vomiting  may  persist,  with 
considerable  depression,  and  yet  the  tempera- 
ture be  near  105° ; it  may  even  reach  106°  i'ahr. 
at  this  time.  More  frequently  the  greatest  dis- 
turbance of  pulse  and  temperature  is  from  the 
the  third  to  the  fifth  day. 

The  rash  begins  in  fine  red  points,  closely 
spread  over  a large  surface  ; the  specks,  brightest 
in  the  centre,  fade  into  each  other  so  as  to  leave 
no  clear  skin  between ; not  raised  above  the 
widely  diffused  flush,  they  disappear  under  the 
pressure  of  the  finger,  and  return  directly  it  is 
removed.  These  bright  dots  may  be  closely 
set,  forming  red  patches  in  some  places,  or  be 
more  scattered  in  others,  and  these  may  seem  to 
be  slightly  raised  before  the  skin  is  turgid. 
The  red  patches  are  well  seen  in  the  flexures 
of  the  joints;  the  finger-nail  drawn  firmly  across 
this  redness  on  the  abdomen  or  thigh  leaves 
a white  streak  where  the  vessels  contract  for 
a time ; after  steady  pressure  the  skin  is  of 
a yellowish  tint ; or  petechia  may  be  seen. 
The  sides  of  the  neck,  the  face,  and  the  chest 
first  show  the  rash,  which  soon  spreads  to  the 
trunk  and  limbs  ; or  it  may  come  out  on  them  at 
once.  The  skin  is  of  a burning  heat,  not  always 
dry,  sometimes  with  free  perspiration ; miliaria 
often  appear  where  the  rash  is  most  intense ; 
these  minute  exudations  are  not  the  result  of 
perspiration,  though  sudamina  may  occur.  The 
eruption  reaches  its  fullest  extension  and  in- 
tensity by  the  fourth  day,  fading  on  the  fifth  and 
sixth.  The  heat  and  swelling  then  subside,  and 
the  skin  feels  dry  and  inelastic,  or  a partial  sub- 
cutaneous cedema  of  the  eyelids,  feet,  or  hands  is 
noticeable;  in  other  parts  the  cuticle  is  easily 
thrown  into  fine  wrinkles,  and  is  ready  to  des- 
quamate ; this  begins  from  the  sixth  to  the  ninth 
day,  when  the  specific  morbid  process  is  sub- 
siding. 

Sore-throat  is  always  present ; during  the  day 
or  two  before  the  seizure,  and  almost  from  the 
time  of  receiving  the  infection,  some  traces  of 
this  are  observable.  During  the  attack  the  red- 
ness spreads  from  the  tonsils  to  the  palate,  uvula, 
pharynx,  and  epiglottis ; it  becomes  more  intense; 
and  there  is  swelling  with  some  oedema.  The 
mucous  membrane  is  either  dry  and  shining,  or 
coated  with  thick  mucus  clogging  the  fauces ; the 
tonsils  project  and  are  smeared  with  sticky  secre- 
tion, while  sometimes  there  is  abrasion  of  their 
surface  or  sl'glit  ulceration, rarely  abscess.  These 


conditions  and  the  symptoms  they  produce  are 
worst  during  the  first  three  days  of  the  illness, 
and  subside  as  the  rash  is  thrown  out.  After  the 
first  week,  in  severe  cases,  ulceration,  not  confined 
to  the  tonsils,  may  occur ; the  connective  tissue 
around  the  lymphatic  glands  in  the  neckbecomes 
brawny  and  may  slough,  or  that  under  the  lower 
lid  suppurate ; persistent  coryza  stuffs  the  nos- 
trils with  acrid  discharge,  or,  extending  along 
the  Eustachian  tube,  fills  the  middle  ear  with  pus, 
bursting  the  tympanum,  deafness  not  being  the 
only  or  worst  result.  Otorrhoea  from  the  meatus 
is  less  serious  ; this  is  not  at  first  purulent.  The 
tongue  is  red  and  bare  after  the  eruption,  the 
white  fur  clearing  from  before  backwards ; the 
mucous  surfaces  are  left  tender,  and  care  as  to 
ingesta  is  required ; there  may  be  also  much  and 
serious  trouble  with  deglutition ; vomiting,  the 
most  constant  of  the  ingressional  nervous  signs, 
rarely  persists  as  a gastric  symptom ; sometimes 
there  is  a tendency  to  diarrhoea,  but  consti- 
pation is  rare,  except  as  an  after-consequence. 

The  pyrexia  of  scarlet  fever  is  characteristic; 
high  at  the  first,  it  keeps  high,  or  rises  higher 
for  three  or  four  days  ; there  is  then  a marked, 
though  incomplete  subsidence  after  the  rash  is 
thrown  out,  mostly  on  the  fifth  or  sixth  days, 
sometimes  earlier;  but  the  temperature  rarely 
becomes  normal  till  the  second  week,  some  fever 
lingering  after  the  eruption  is  over.  When  the 
greatest,  tension  of  skin  is  passed,  the  surface 
temperature  has  been  found  on  the  fifth  and 
sixth  days  at  97°,  with  101°  in  axilla  and  105° 
in  recto;  the  latter  keeping  at  103°  for  two  or 
three  days  longer.  A crisis  is  to  be  looked  for  on 
the  fourth  or  fifth  day  ; defervescence  not  till  the 
eighth  or  ninth ; and  this  is  often  further  delayed 
by  complications  or  relapse.  There  are  no  other 
constant  remissions  during  the  febrile  period,  hut 
some  nocturnal  exacerbations  occur  during  the 
first  part  of  it,  often  associated  with  harmless 
delirium.  The  persistence  of  more  serious  de- 
lirium then  and  later  in  persons  of  all  ages  points 
to  meningeal  irritation  ; coma  in  children  may 
depend,  not  only  on  the  high  temperature,  but  on 
the  state  of  the  arachnoid  cavities ; even  hemi- 
plegic signs  have  occurred  independently  of  the 
embolism  so  often  consequent  on  endocarditis; 
uraemic  coma  is  rare ; intra-cranial  inflammation 
and  abscess  not  unfrequently  result  from  caries 
of  the  temporal  bone  after  otitis. 

The  chief  respiratory  disturbances  are,  at  first 
irritative  cough,  and  symptoms  resulting  from 
oedema  of  the  glottis;  the  breathing  is  always 
quickened  when  the  pulse  is  rapid  and  the  fever 
high.  Pleurisy  with  effusion  has  occurred  at 
all  periods  of  scarlatina,  more  frequently  in  the 
later  stages,  with  a limited  pneumonia,  pulmo- 
nary congestion,  or  br  oncho-pneumonia. 

On  the  side  cf  the  circulation,  besides  the 
quick  pulse,  there  is  the  liability  to  endocarditis 
during  the  eruptive  period  or  later,  and  to  peri- 
carditis ; these  complications  often  prolong  the 
duration  of  the  fever,  and  give  rise  to  special 
symptoms  and  dangers. 

The  urine  is  altered  as  in  other  fevers : tho 
increase  of  nitrogenous  waste,  in  proportion  to 
the  degree  of  fever,  is  eliminated  most  largely  at 
the  crisis.  At  first  the  quantity  of  urine  is  less; 
the  chlorides,  much  diminished,  reappear  as  the 


SCARLET 

fever  declines  ; the  urea,  relatively  increased,  is 
less  absolutely  so  than  it  is  afterwards  with  a 
freer  excretion  ; urate  of  soda  is  deposited ; uric 
acid,  diminished  on  the  second  and  third  days, 
increases  at  the  febrile  crisis,  often  appearing  in 
abundance  on  the  fifth  and  sixth  days,  then  again 
normal,  but  increasing  after  rheumatism  or  other 
febrile  disturbance ; phosphoric  acid,  normal  du- 
ring the  first  four  days,  is  much  diminished  on 
the  fifth,  then  remains  below  the  standard  till  the 
eighth  or  ninth  day,  when  there  is  often  a deposit 
of  earthy  phosphates,  with  a pale,  barely  acid 
urine.  Oxaluria  may  follow. 

The  kidneys,  almost  as  constantly  as  the  throat 
and  skin,  are  the  seat  of.  important  changes,  to 
which  the  state  of  the  urine  is  a trustworthy 
guide;  this  consequently  must  be  the  subject  of 
repeated  examination.  At  first  there  may  be 
suppression  of  urine  for  more  than  one  day ; 
this  yielding,  tube-casts,  blood,  and  albumin  are 
found,  clearing  off  as  the  secretion  becomes 
freer.  Such  transient  albuminuria  may  occur  in 
other  fevers,  but  here  the  first  congestion  of  the 
glomeruli  increases— it  may  be  while  the  skin- 
affection  is  at  its  height,  more  frequently  in  its 
decline — and  a distinctive  form  of  nephritis  is  set 
up, generally  about  the  ninth  and  tenth  day,  when 
the  skin  is  desquamating.  This  has  a marked 
febrile  disturbance  of  its  own,  often  leads  to 
chronic  kidney-disease,  and  is  attended  through- 
out with  albuminuria.  Later  in  the  disease 
albuminuria  and  hsematuria  set  in  without  rise 
of  temperature.  Both  these  conditions  are  often 
followed  by  dropsy.  Albuminuria  commonly 
begins  during  the  desquamation-period  in  the 
second  week ; possibly  as  early  as  the  fourth 
day ; rarely  for  the  first  time,  with  fever  or 
signs  of  kidney-irritation,  after  the  twenty-first, 
but  even  as  late  as  the  thirty-first  day.  Three 
stages  of  this  condition  are  noticed.  The  quan- 
tity of  urine  in  the  first  stage  is  much  dimi- 
nished, the  urea  even  more  in  proportion  than 
the  water ; the  specific  gravity  is  increased ; the 
turbidity  from  urates  deposited  is  cleared  by 
heat  or  the  addition  of  hot  water,  showing  no 
smoky  tint  from  blood ; if  this  stage  be  pro- 
longed, albumin  is  found,  with  finely  granular 
or  clear  casts,  seldom  with  blood-discs  or  renal 
epithelium ; but  they,  together  with  epithelial 
tube-casts,  are  freely  washed  out  as  this  stage 
is  passing  away.  The  second  stage  is  marked  by 
diuresis ; the  pale  urine  of  low  specific  gravity 
acquires  a smoky  tint  from  blood-discolouration  ; 
this  may  deepen  to  brown  or  give  a brighter 
red  deposit ; albumin  to  a large  amount  may 
pass,  with  pale  urine,  when  there  is  but  little 
blood ; the  whole  quantity  of  albumin  may  be 
greater,  though  proportionally  less  than  in  the 
earlier  stage  ; it  diminishes  towards  the  close  of 
this  period,  as  the  urine  gradually  clears  ; some 
blood-corpuscles,  renal  epithelium,  and  tube-casts 
| are  found  in  the  deposit.  Clear  urine  still  in 
■ excess  and  slightly  flocculent,  marks  the  third 
stage,  in  which  the  albumin  gradually,  but  not 
always  entirely,  disappears. 

The  urine  may  not  be  much  lessened,  at  first, 
in  mild  cases,  and  yet  afterwards  become  al- 
buminous ; or  a well-marked  first  stage  in  a 
severe  case  is  not  always  followed  by  albumin- 
uria. This  is  often  a specific  effect  of  the  disease, 


FEVER.  1391 

and  independent  of  chill.  There  may  be  hsema- 
globinuria  in  the  later  stages,  with' deep  bloody 
colour,  and  no  great  increase  of  albumen. 

Haematuria,  if  partly  dependent  on  a blood- 
state,  is  one  of  the  more  obvious  indications 
of  kidney-mischief.  Another  is  afforded  by  the 
occurrence  of  scarlatinal  dropsy.  Allowing  for 
an  error  from  mere  surface-cedema  being  mis- 
taken for  it  in  the  first  week,  and  later  for  the 
effects  of  anaemia,  anasarca  is  fairly  indicative  of 
albuminuria  past  or  present. 

Albuminuria  may  he  absent,  or  only  have 
existed  for  a day  or  two  before  the  anasarca  or 
ascites  began.  Anaemia  is  a very  marked  late 
feature  of  the  disease,  so  that  pallor  and  chronic 
dropsical  cachexia  often  go  together.  Apart  from 
renal  dropsy,  there  is  a form  of  scarlatinal 
dropsy  which  occurs  suddenly  in  the  second  or 
third  week,  as  the  result  of  a special  inflamma- 
tion of  serous  membranes,  often  associated  with 
rheumatism,  or  with  some  degree  of  albumi- 
nuria. Serous  effusions  into  the  pericardium  or 
pleurae,  indicated  by  dyspnoea,  are  ascertained 
by  their  distinctive  physical  signs.  They  are 
part  of  a general  tendency  to  inflammation  of 
the  serous  membranes.  Pleurisy  is  more  com- 
monly associated  with  albuminuria  ; it  may  tend 
either  to  hydrothorax  or  to  empyema.  Pericar- 
ditis is  more  commonly  associated  with  rheuma- 
tism. 

Eheumatism  is  frequently  induced  by  scarlet- 
fever;  before  the  end  of  the  first  week,  just  after 
the  rash  is  fullest,  pains  begin  in  several  joints — 
wrists,  ankles,  or  knees ; the  fever,  instead  of  sub- 
siding, rises;  and  the  pulse  again  becomes  quick, 
full,  and  hard.  At  this  time  pericardial  friction 
is  to  be  looked  for,  or  an  endocardial  murmur 
may  he  heard  either  at  base  or  apex;  an  apex 
murmur  is  sometimes  heard  when  there  is 
neither  rheumatism  nor  albuminuria,  and  may 
not  necessarily  mean  endocarditis.  Pains  in  the 
limbs,  or  arthritic  symptoms,  may  come  on  as 
late  as  the  third  week,  with  renewed  fever  of  the 
rheumatic  type,  sometimes  with  profuse  perspi- 
rations ; the  articular  swellings  mostly  subside, 
but  there  is  also,  unlike  what  is  seen  in  rheuma- 
tism, the  possibility  of  suppuration. 

Sloughing  of  the  cellular  tissue  around  in- 
flamed glands,  or  of  the  skin  over  them,  is  a 
more  frequent  and  less  fatal  evidence  of  the  same 
tendency.  Sometimes  diphtheritic  necrosis  oi 
mucous  membrane,  or  of  blistered  and  ulcerated 
surfaces,  after  scarlet  fever,  evinces  a specific 
dyscrasia. 

Desquamation  begins  earliest  where  the  rash 
has  been  most  intense ; it  may  he  seen  as  early 
as  the  fourth  day,  more  frequently  on  the  sixth 
and  seventh ; rarely  it  is  delayed  beyond  the  tenth 
day;  it  may  be  to  three  weeks;  and  it  is  seldom 
completely  over  in  less  than  six  weeks.  The 
desquamation-period,  really  the  whole  time  of 
cure,  is  also  spoken  of  as  occupying  the  second 
week,  and  as  marked  by  a subsidence  of  fever 
even  to  below  the  normal.  There  is  generally  a 
remission  of  fever  at  this  time,  but  without  any 
great  depression  of  temperature  ; the  pulse  also 
is  weak,  and  may  he  irregular;  considerable  de- 
pression and  a sense  of  debility  about  the  tenth 
day  are  frequently  to  be  noticed.  All  this,  if 
coincident,  can  hardly  he  consequent  upon  do 


1392  SCAULET 

squamation.  As  soon  as  the  vessels  of  the  skin 
are  less  tense,  the  wrinkled  epidermis  becomes 
scurfy  and  separates.  This  is  first  seen  on 
the  chin  and  sides  of  the  neck,  the  less  deli- 
cate cuticle  being  raised  and  removed  on  small 
patches,  which  increase  as  the  edges  are  detached, 
leaving  a large  new  surface  of  skin ; the  thick 
epidermis  of  fingers  and  feet  peels  off  in  larger 
flakes,  or  in  casts.  A shreddy  look  of  hands  or 
toes  may  betray  a mild  attack  of  scarlet  fever, 
overlooked  from  three  to  six  or  eight  weeks 
before. 

New  cuticle  is  rapidly  formed  during  conva- 
lescence, and  is  more  than  once  cast  off  and 
renewed.  Sometimes  there  is  a pause  in  this 
process,  and  desquamation  is  thought  to  be  over, 
when,  with  change  of  air  or  improved  nutrition, 
a further  peeling  of  what  seems  healthy  cuticle 
occurs,  not  without  risk  of  a further  dissemina- 
tion of  infection,  up  to  the  ninth  week  of  con- 
valescence. Any  form  of  desquamation  begin- 
ning later  than  this  can  seldom  or  never  be  the 
bearer  of  infecting  particles  ; even  the  flakes  of 
a second  desquamation  carry  infection  so  loosely 
as  to  be  readily  deprived  of  it  by  the  ordinary 
means  of  washing  and  exposure.  In  fact,  des- 
quamation, though  a very  good  sign  that  infec- 
tion still  attaches  to  its  subject,  because  recovery 
is  barely  complete,  is  not  the  only,  nor  even  the 
chief,  means  of  its  diffusion.  It  is  only  the  fine 
dust  first  rising  from  the  surface,  just  after  the 
rash  is  at  its  height,  and  especially  when  at- 
tended with  miliary  exudation,  that  is  charged 
with  the  intensest  essence  of  infection. 

But  infection  is  given  off  before  this  is  formed, 
as  well  as  after  it  is  cast  off.  The  secondary  le- 
sions of  the  throat,  nose,  and  lips  are  infectious ; 
abscesses,  formed  more  than  three  weeks  after  the 
disease  began,  yield  an  infecting  pus  contami- 
nating specifically  the  lancet  used  for  their  eva- 
cuation ; nor  can  any  definite  time  less  than  six 
weeks  be  fixed  when  the  specific  morbid  process 
may  be  supposed  to  have  ceased.  A kind  of  re- 
crudescence, but  without  the  reappearance  of  the 
rash,  would  seem  possible  up  to  the  eighth  week ; 
and,  as  in  menstruation,  the  casting  off  in  the 
tenth  week  of  d&bris  of  tissue  formed  perhaps  a 
fortnight  before,  may  not  be  without  the  ele- 
ments of  infection.  Children  are  very  liable  to 
weak  throat  or  a return  of  coryza  for  some 
months  after  convalescence  from  scarlet  fever ; 
also  to  ecthyma,  eczema,  or  psoriasis  long  after 
all  possibility  of  infection  has  ceased. 

Varieties. — 1.  Scarlatina  mitior,  called  also 
Scarlatina  simplex  or  benigna.  Tho  rash  appears 
only  on  parts  of  the  skin,  and  soon  fades ; the 
throat,  hardly  sore,  is  of  a pinky  red,  with  tonsils 
just  rounded,  the  back  of  the  pharynx,  perhaps, 
streaked  with  mucus  from  the  small  glands ; the 
fever  is  so  slight  that  it  is  said  to  be  absent ; the 
early  fine  desquamation  escapes  notice;  and  it 
may  be  three,  four,  or  five  weeks  before  peeling  on 
the”  hands  and  feet  proves  the  true  nature  of  the 
illness.  In  some  mild  cases  the  rash  is  well- 
marked,  but  there  is  no  high  fever ; the  tempera- 
ture, not  exceeding  102°,  falls  on  the  third  or 
fourth  day.  In  neither  of  these  cases  is  apyrexia 
complete  till  the  third  week  ; but  there  is  no  great 
illness,  the  rash  is  forgotten,  and  precautions  are 
relaxed  till  some  anasarca  is  noticed,  or  others 


FEVER. 

are  ill  with  more  marked  symptoms.  Desqua- 
mation is  not  later  after  a mild  attack,  nor  more 
prolonged  than  after  a severe  one,  but  it  may  be 
the  only  distinctive  sign  left  of  a marked  impair- 
ment of  health  and  of  its  cause. 

2.  Scarlatina  gravior. — This  includes  all  the 
more  serious  cases,  some  called  Scarlatina  angi- 
nosa,  when  endangered  by  the  severity  of  the 
throat-symptoms ; others  Scarlatina  maligna, 
when  marked  from  the  first  by  high  fever  or  its 
consequences.  This  latter  form  is  known  also  as 
the  adynamic  when  exhaustion  or  collapse  rapidly 
ensues,  in  some  cases  even  before  the  rash  has  had 
time  to  appear.  There  are  all  grades  of  severity 
between  these  and  the  slighter  forms  of  the  dis- 
ease. We  sometimes  see  themildestkindof  attack 
in  one  child  set  up  the  worst  form  in  another ; or 
the  disease  may  begin  moderately,  and  bad  symp- 
toms appear  on  tho  third  or  fifth  day,  such  as  rest- 
lessness, depression,  weak  and  rapid  pulse,  dusky 
rash,  lividity  or  pallor,  dysphagia,  sore  mouth, 
dry  tongue,  tympanites,  and  cold  perspirations. 
Again,  these  signs  of  exhaustion  may  follow  upon 
some  complication  in  the  second  week,  while  the 
temperature  is  still  high ; or  appear  as  late  as 
the  fourth  or  fifth,  after  great  emaciation,  when 
the  fever  is  over.  Diphtheria,  either  of  mucous 
surfaces  or  of  the  skin,  appears  in  some  of  these 
cases,  not  as  a new  infection,  but  as  one  result 
of  the  disease.  So  among  several  children  with 
scarlet  fever,  one  may  have  only  a faint  rash, 
slow  to  appear,  soon  fading,  or  perhaps  again 
returning,  called  Scarlatina  anginosa  maligna ; 
but  the  appearances  in  the  throat  and  other 
signs  are  those  of  diphtheria;  or  one  child 
with  such  a throat  and  no  noticeable  rash  has 
started  scarlatina  among  others.  Some  malig- 
nant cases,  mostly  fatal,  show  extreme  pros- 
tration from  the  first,  with  rapid  pulse  and 
grave  nervous  disturbance;  the  temperature  is 
always  high — 105°  or  more,  even  when  the  skin 
feels  cool.  Several  of  these  fatal  cases  follow 
one  another  in  a household,  either  from  a de- 
veloped intensity  in  the  infection,  from  a family 
predisposition  to  suffer  from  it,  or  from  some  such 
tendency  to  excessive  temperature-disturbance. 

The  infection  of  scarlet  fever  is  readily  re- 
ceived, by  those  who  have  not  previously  suffered 
fromit,intheeourseof  most  diseases;  andinmany 
of  them  it  proves  a serious  complication.  Surgical 
scarlet  fever  differs  in  no  respect  from  ordinary 
scarlet  fever ; it  will  spread  to  the  susceptible 
who  have  no  wound  or  open  sore,  not  to  those 
who  are  protected  by  a previous  attack,  though 
in  the  same  ward  and  recently  operated  on.  One 
attack  of  scarlet  fever  is  so  generally  protective 
against  a recurrence  that  the  not  infrequent  in- 
stances of  exceptions  to  this  rule  in  no  way  in- 
validate the  more  important  practical  deductions 
from  it ; those  who  have  already  had  it  may  at- 
tend on  the  sick  or  mix  with  convalescents.  Some 
persons  have  two  or  three  attacks,  or  are  liable 
to  sore-throat  whenever  they  come  in  contact 
with  it  ; still  the  rule  is  constant  enough  to  he 
depended  on  for  purposes  of  diagnosis. 

Diagnosis. — The  sudden  illness,  with  high 
temperature,  quick  pulse,  and  severe  nervous 
symptoms,  without  previous  cough  or  sneezing, 
but  with  sore-throat  and  tender  swelling  of  the 
glands  at  tho  angle  of  the  jaw,  at  once  point  to 


SCARLET  FEVER. 


scarlet  fever  in  a child  who  has  not  had  it ; this 
is  made  certain  by  the  early  rash. 

Diphtheria  may  come  on  in  the  same  way,  with 
slight  suffusion  of  face,  or  more  insidiously,  but 
the  throat-signs  are  distinctive.  Herpetic  sore- 
throat  has  a shorter  febrile  stage,  and  no  rash. 
The  rash  of  rubeola  is  in  spots,  and  leas  diffused 
at  first;  in  doubtful  cases,  perhaps  called  feb- 
rile rosoola,  albumin  is  to  be  looked  for  in  the 
first  fortnight,  and  desquamation  afterwards,  be- 
fore an  absolute  diagnosis  from  rubeola  is  formed. 
Erythema  may  result  from  septicaemia,  and 
from  mercury,  arsenic,  sulphur,  iodine,  bromides, 
chloral,  salicine,  quinine,  copaiba,  ipecacuanha, 
bolladonna,  opium,  and  oil  of  turpentine — the 
two  last  only  of  these  followed  by  desquamation. 

Prognosis. — Caution  is  needed  in  the  prognosis 
of  the  mildest  cases  of  scarlet  fever,  as  these  are 
not  exempt  from  all  the  complications  of  the  ill- 
ness, or  the  accidents  of  convalescence. 

High  initial  fever,  severe  angina,  fever  rising 
on  the  fifth  day  or  persisting  beyond  the  tenth, 
and  great  depression,  all  betoken  danger.  There  is 
danger  from  sloughs  and  secondary  suppuration  ; 
from  cardiac  inflammation  and  its  consequences; 
and  from  kidney-disease,  either  at  first,  or  from 
albuminuria  slowly  increasing  for  two  or  three 
months ; the  earlier  effects  of  renal  dropsy  are 
of  more  hopeful  prognosis.  Family  predisposition 
is  to  be  considered,  as  well  as  the  age  of  the 
patient;  individual  susceptibility  more  than  the 
character  of  the  prevailing  epidemic.  The  tem- 
perature has  reached  111°  Fahr.  with  recovery, 
and  115°  in  a fatal  case. 

Treatment. — This  must  have  regard  to  the 
care  of  the  patient,  and  the  safety  of  others.  All 
cases  must  be  treated  in  bed  for  two  or  three 
weeks;  a hair  mattress,  not  too  thick,  is  better 
than  a feather  bed,  and  no  extra  covering  is  re- 
quired. Carpets  and  woollen  curtains  should 
be  removed  from  the  room;  this  must  be  kept 
cool  and  well -ventilated  by  a partly-open  window 
and  an  open  fire,  but  without  draughts  that 
come  directly  on  to  the  patient.  A linen  screen 
suspended  before  the  door  is  useful ; a basin  of 
water  made  pink  w'ith  permanganate  of  potash 
should  stand  ready,  in  which  to  dip  the  Angers, 
or  anything  used  by  the  patient;  a stronger 
solution  is  required  for  the  immersion  of  body 
linen  when  removed,  or  for  the  excretions.  Ko 
medicines  will  cut  short  scarlet  fever;  simple 
salines,  as  acetate  of  ammonia  or  chlorate  of 
potash,  which  act  slightly  on  the  skin  and  kid- 
neys, tend  to  its  mitigation  if  plenty  of  liquid 
be  given.  The  best  relief  is  obtained  from 
tepid  sponging  over  the  whole  body,  part  at  a 
time,  twice  in  the  twenty-four  hours,  or  a tepid 
bath,  and  oil  or  cold-cream  used  to  the  skin 
afterwards.  Where  the  fever  is  not  very  high 
nor  the  rash  intense,  a warm  bath  is  comfortable. 
The  hot  pack  is  injurious,  most  so  when  the  rash 
is  imporfect  and  the  nervous  disturbance  indi- 
cates excessive  body-heat.  In  such  cases  cold 
affusion  or  the  cautious  use  of  the  wet  pack  would 
moderate  fever  ; but  these  means  must  be  so  used 
as  to  soothe  and  not  to  tire  the  patient.  Frequent 
enemata  of  cold  water  supply  fluid  to  the  body 
and  reduce  temperature.  It  is  not  until  after  the 
fever  is  over  that  scrubbing  with  carbolic  soap, 
and  detergent  baths,  with  carbolic  inunctions, 

88 


1893 

should  bo  practised.  During  the  fever  a little 
Condy’s  fluid,  or  aromatic  vinegar,  added  to  the 
water  for  sponging  the  bcdy,  or  the  solution  ot 
peroxideof  hydrogen, is agreeableand  refreshing, 
neutralising  some  of  the  morbid  exhalations,  ii 
not  quite  disinfecting  them.  For  this  latter  pur- 
pose strong  acetic  acid  (1  to  5),  or  carbolic  acid 
(1  to  20  of  oil),  w-ould  be  required.  Carbolated 
oil  (1  to  40)  can  bo  used  with  advantage  from 
the  first,  so  that  the  earliest  skin-dust  may  be 
intercepted.  Condy's  fluid  sprayed  into  the 
room  at  times  sweetens  the  air,  or  chlorinated 
soda  may  be  sprinkled  about  the  room. 

The  throat-symptoms  often  claim  early  atten- 
tion. Swallowing  soon  becomes  easier  and  the 
external  swelling  less  after  small  lumps  of  ice 
have  been  repeatedly  held  to  melt  at  the  back  of 
the  mouth;  young  children  can  have  a teaspoon- 
ful of  iced-water  with  a morsel  of  ice  in  it  given 
frequently;  older  persons  find  relief  from  inhal- 
ing steam.  A warm  compress  with  cotton-wool 
over  it  should  be  applied  round  the  neck.  Puffy 
swelling  over  the  glands  is  often  removed  by 
fomentation,  or  by  warm  linseed  poultices  con- 
stantly renewed.  A warm  poultice  held  close  up 
to  the  ear  relieves  pain  from  the  tonsil.  Mischief 
within  the  throat  is  lessened  by  taking  chlorate 
of  potash  into  the  mouth,  or  by  the  solution  of  it 
in  spray-;  a sloughy  throat  requires  chlorinated 
soda  solution,  one  part  to  ten  of  water.  Here  also 
the  acid  chlorine  mixture  is  useful ; it  is  made  by 
dropping  strong  hydrochloric  acid  on  to  chlorate 
of  potash  in  a bottle  (m3  of  the  acid  and  gr.  j 
of  the  salt  to  each  ounce  of  capacity),  and  then 
adding  vrater  to  dissolve  the  liberated  chlorine. 
Large  doses  of  chlorate  of  potash  are  objection- 
able, as  tending  to  renal  irritation.  For  the 
control  of  fever  eliminants  and  depressants  are 
to  be  avoided  ; aconite  is  not  needed  in  the  mild 
cases  of  fever  and  sore-throat  ; it  is  prejudicial 
in  the  more  severe  forms.  The  mineral  acids 
moderately  control  heat-production,  and  may  be 
given  diluted  from  the  first.  A tendency  on  the 
fifth  day  to  increase  of  an  already  high  tem- 
perature has  been  checked  by  the  substitution  of 
acids  for  salines.  In  all  cases  with  high  tempera- 
ture stronger  remedies  of  this  class  are  required. 
Of  these,  the  two  most  effective  and  most  suitable 
in  scarlet  fever  are  quinine  and  digitalis.  Of 
the  former,  two  or  three  doses,  on  the  third  or 
fifth  day,  at  the  rate  of  one  grain  for  every  two 
years  of  age,  reduces  fever,  and  so  prevents  the 
worse  forms  of  throat  and  kidney  mischief.  If 
the  urine  be  scanty,  or  already  contain  albumin, 
digitalis  is  to  be  preferred';  it  is  of  marked  bene- 
fit where  the  pulse  has  been  much  accelerated  in 
the  early  stages;  and  it  is  specially-  suited  to  com- 
bine with  iron  in  the  later  stages  of  the  disease, 
or  with  iron  and  a saline  when-diuretics  are  re- 
quired. The  combination  of  digitalis  and  quinine 
in  all  the  graver  forms  of  scarlet  fever  seems  to 
be  specially  indicated.  The  sulpho-carbolate 
of  soda  has  been  used  with  more  advantage  than 
the  newer  derivative  of  carbolic  acid,  the  sali- 
cylic. Salicylate  of  soda  is  not  well  suited  for 
administration  in  scarlet  fever,  as  the  acid  is 
secreted  by  the  kidneys  and  may  irritate  them  ; 
when  given  it  has  caused  perspiration  and  reduced 
the  pulse  and  temperature,  but  the  worst  symp- 
toms of  bad  cases  were  not  lessened  by  it,  while 


1394  SCARLET  FEVER, 

the  tendency  to  rheumatism  and  to  albuminuria 
were  increased.  It  is  effective  against  the  rheu- 
matism that  follows  scarlet-fever  when  there  is  no 
kidney-lesion.  In  most  of  these  cases  pcrchloride 
of  iron  in  full  doses  is  the  best  remedy.  Acute 
leidney -congestion  should  he  treated  by  dry-cup- 
ping to  the  loins,  hot  epithems  round  the  body,  or 
a warmly-packed  poultice  across  the  back ; a brisk 
aperient  is  often  most  useful  at  the  beginning  of 
this  as  of  other  secondary  complications.  Here 
free  secretion  from  the  bowels  is  to  be  favoured 
by  salines,  and  their  diuretic  action  should  be 
aided  by  plenty  of  liquid.  Free  action  of  the 
skin  can  be  obtained  by  the  hot-air  bath,  or  by  the 
hypodermic  injection  of  pilocarpin.  Two  drops  of 
a 5 per  cent,  solution  of  the  muriate  answers  well ; 
the  sixth  of  a grain  will  produce  perspiration  i n 
an  adult;  or  one-twentieth  of  a grain  may  be 
given  every  hour  till  perspiration  ensues.  Chil- 
dren require  full  doses  of  pilocarpin,  up  to  one- 
tenth  of  a grain  twice  a day  in  azoturia.  More 
urea  and  less  water  has  resulted  after  some 
days’  use  of  it  Diarrhoea  at  the  febrile  crisis 
seldom  need  be  checked;  care  as  to  ingesta, 
and  warm  applications  or  poultices,  perhaps  with 
a little  opium  externally,  suffice  for  its  relief. 
G-reat  caution  is  required  at  all  times  in  the  use 
of  any  opiates  ; there  are  many  soothing  means 
which  promote  sleep  without  resorting  to  direct 
sedatives.  Chloral  is  not  very  suitable. 

The  diet,  at  first  limited  to  milk  and  liquids, 
may  consist  also  of  eggs  and  beef-tea  as  soon  as 
more  food  can  be  taken,  with  fish  or  fowl,  and 
soup  with  vegetables.  Lemon-juice,  oranges,  or 
grapes  may  supplement  the  vegetable-supply  in 
rheumatic  or  renal  complications.  Caution  is 
required  as  to  meat,  and  even  the  supply  of  beef- 
tea  should  be  limited,  while  milk  can  be  given 
ad  libitum,  and  eggs  may  be  largely  depended  on. 
Alcoholic  stimulants  are  only  to  be  used  with 
great  caution ; they  are  apt  to  excite  a return  of 
fever  if  given  early,  and  may  embarrass  the  re- 
storation of  the  kidney-function  ; still  there  are 
many  bad  cases  where  a little  brandy  has  to  be 
added  to  the  egg  and  milk,  or  where  wine  must 
be  allowed.  Moreover,  after  high  fever  a con- 
dition like  that  of  heat-exhaustion  comes  on, 
with  shallow  breathing,  weak,  slow,  or  irregular 
pulse,  cool  surface,  restlessness  and  threatened 
collapse,  where  brandy,  ammonia,  bark,  and  even 
opium  may  be  needed.  During  convalescence  chill 
and  fatigue  must  be  guarded  against.  Careful 
diet  is  required,  and  some  preparation  of  iron  with 
meals,  or  bitters  and  bark  as  tonics.  We  must  not 
advise  change  of  air  too  soon ; three  weeks  indoors 
for  the  disease  to  cease,  and  three  weeks  at  home 
ifter  that,  for  restoration  of  health,  is  the  safest 
rule  for  all.  Warm  baths  on  three  or  four  suc- 
cessive days,  with  plenty  of  soap  to  remove  all 
roughness  of  skin,  and  fresh  woollen  clothing, 
are  required  before  leaving  the  sick-room.  The 
hair  should  be  dressed  with  carbolic  oil  after 
washing,  or  with  a mixture  of  acetic  acid,  gly- 
cerine, and  spirit.  Infection  can  be  removed 
from  clothes  and  bedding  by  storing  all  that 
does  not  undergo  a heat  of  212°  in  washing. 
The  best  means  of  disinfecting  the  room,  and  what 
is  not  easy  to  remove  from  it,  is  by  burning 
-sulphur  or  bisulphide  tff  'vrbon  in  it.  An  ounce 
vsnd  a half  of  sulphur  should  be  burnt  for  every 


SCIATICA. 

100  cubic  feet  of  clear  space.  See  Disinfec- 
tion. 

No  convalescent  should  mix  with  susceptible 
children  until  six  weeks  from  the  seizure,  how- 
ever sbght  the  attack;  if  convalescence  have 
been  interrupted,  or  some  after-effects  of  the 
disease  remain,  this  interval  has  to  be  two  or 
three  weeks  longer.  Those  much  with  the  sick 
should  wash  their  hands  after  assisting  the 
patient,  and  change  their  outer  dress  on  leaving 
the  room.  A solution  of  salicylic  acid  in  gly- 
cerine promises  to  be  of  some  use  in  clearing 
infectious  particles  from  the  throat,  and  so  may 
act  as  a preventive  against  one  mode  of  infec- 
tion. No  true  prophylactic  i3  known. 

William  Sqcukk. 

SCHISTZNACH,  in  Switzerland. — Sul- 
phur waters.  See  Mineral  Waters. 

SOSLAN GEUB AD,  in  Germany. — Sim- 
ple thermal  waters.  See  Mineral  Waters. 

SCIATICA. — Synon.  ; Fr.  AY vralgie  scia- 
tique  ; Ger.  Hiiftweh. 

Definition. — Neuralgia  in  the  district  of  the 
sciatic  nerve. 

Sciatica  is  signalised  by  paroxysmal  pain  in 
any  or  all  of  the  following  localities:  the  but- 
tock ; the  back  of  the  thigh  ; the  knee;  the  front, 
back,  and  outside  of  the  leg  ; and  the  whole  foot 
except  its  inner  border.  The  condition  is  fre- 
quently ofperipheral  origin, and  is  thendependent 
on  inflammation  of  the  sheath  and  surroundings 
of  the  nerve-trunk.  Or  it  may  arise  independently, 
to  all  appearance,  of  any  local  canse  in  the  nerve 
itself,  and  is  then  probably  caused  by  some 
impairment  of  nutrition  of  a nerve-centre.  As 
the  diagnosis  of  peri-neuritis  from  neuralgia  is 
as  yet  not  certainly  differentiated,  the  two  con- 
ditions will  be  considered  together. 

YEtiot.ogt. — Predisposing  causes.  — The  pre- 
disposing causes  of  sciatica  are  arterial  degene- 
ration ; anaemia ; the  rheumatic  and  gouty  dia- 
theses ; the  toxic  influence  of  malaria,  chronic 
alcoholism,  syphilis,  and  lead ; inherited  neu- 
rotic disposition  ; fatigue  ; and  a damp  and  cold 
climate. 

Exciting  causes. — These  include  exposure  of 
the  limb  to  a draught  of  cold  air  for  some 
long  time,  which  is  a common  source  of  the 
affection  ; sitting  on  a cold  or  damp  seat;  over- 
walking;  strains;  concussion  of  the  spine;  the 
encroachment  of  morbid  growths;  blows  upon 
or  wounds  of  the  nerve-trunk;  malignant  and 
other  tumours  of  the  pelvis;  disease  of  the  ver- 
tebra or  pelvic  bones  ; the  pressure  of  the  gravid 
uterus  ; rheumatic  or  gouty  inflammation  of  the 
sheath  of  the  sciatic  nerve,  or  of  one  or  other 
of  its  branches  ; syphilitic  periostitis,  causing  a 
swelling  which  presses  upon  the  trunk  or  some 
branch  of  the  sciatic  nerve;  and  a gumma  in  the 
slieatli  of  the  nerve. 

In  chronic  rheumatic  arthritis  of  the  hip-joint 
the  sciatic  nerve  may  sometimes  be  felt  to  have 
hard,  knotty  swellings  upon  it,  apparently  aris- 
ing from  a chronic  peri-neuritis.  This  is  asso- 
ciated with  very  obstinate  sciatica. 

Sciatica  affects  especially  the  middle  ago  of 
life — from  forty  to  fifty  years,  is  rare  in  youth, 
and  but  seldom  commences  in  elderly  persons 


SCIATICA.  1395 


Venereal  excesses  have  a closer  connection  with 
iciatica  than  with  any  other  form  of  neuralgia. 

The  violent  manipulation  of  a professional 
rubber,  employed  to  treat  a dull  aching  in  the 
sciatic  region,  may  bring  about  acute  sciatica. 

Anatomical  Characters. — Nothing  certain 
is  as  yet  known  of  the  seat  of  the  lesion  in  cases 
of  neuralgia  proper  manifested  in  the  district  of 
the  sciatic  nerves. 

The  few  changes  which  nave  been  observed 
post  mortem  in  eases  of  sciatica  have  been  in 
the  direction  of  thickening  of  the  sheath  of  the 
nerve,  the  result  of  inflammation.  It  has  often 
happened,  however,  that  in  cases  which  during 
life  have  been  supposed  to  be  examples  of  neu- 
ritis, no  trace  of  the  inflammatory  process  has 
been  found  in  the  nerve  or  its  covering. 

Symptoms. — After  more  or  less  of  vague  dis- 
comfort in  the  affected  limb,  deadness,  tingling, 
stiffness,  or  some  such  abnormal  sensation,  pain 
occurs  in  some  part  of  the  district  already  in- 
dicated. This  is  variously  spoken  of  as  shooting, 
darting,  screwing,  tingling,  or  burning;  and  the 
sufferer  will  often  map  out  with  precision  the 
course  of  various  branches  of  the  nerve  as  the 
seat  of  his  distress.  Sometimes  the  leg  is  de- 
scribed as  being  numbed,  and  as  if  it  were  going 
to  burst.  Occasionally  the  feeling  resembles  a 
very  faint  shock  of  a battery.  As  is  charac- 
teristic of  neuralgia  generally,  the  pain  may 
be  apparently  spontaneous  in  origin,  whilst  in 
certain  cases  it  is  also  liable  to  be  aggravated 
by  movement,  but  in  no  case  is  it  only  excited 
when  muscular  contraction  takes  place.  It  may 
either  occur  in  paroxysms,  with  intervals  of 
complete  immunity  varying  from  minutes  to 
hours;  or  there  may  be  more  or  less  continuous 
suffering,  with  frequent  and  violent  exacerba- 
tions. Throbbings  or  pulsations  of  the  pain  are 
often  described.  It  is  not,  as  a rule,  accom- 
panied by  pyrexia.  When  the  pain  is  at  its 
height,  a powerlessness  of  the  muscles  of  the 
limbs  isapt  to  be  experienced,  and  this  not  simply 
on  account  of  the  distress  of  moving,  but  from 
an  actual  paresis,  dependent  doubtless  upon  a 
depressing  influence  communicated  to  the  motor 
centres,  from  a like  cause  affecting  the  vaso- 
motor centres  the  limb  will  feel  cold,  not  only 
subjectively,  but  to  the  touch  of  another. 

Tender  points  may  be  met  with  in  all,  but  more 
often  in  some  few  only,  of  the  following  situa- 
tions:— the  posterior  inferior  spine  of  the  ilium; 
about  midway  between  the  tuber  ischii  ami  tro- 
chanter major  ; the  fold  of  the  buttock;  head  of 
the  fibula;  behind  each  malleolus;  in  the  popliteal 
space.  There  is  commonly  some  cutaneous  ames- 
thesia  in  some  part  of  the  limb,  and  sometimes 
replacing  this  there  will  be  found  patches  of 
skin  which  are  hyperalgesic.  The  tactile  sense 
proper  is  lowered  at  these  points,  whilst  the 
sense  of  temperature,  especially  for  heat,  is  often 
heightened.  At  the  same  place  a weak  voltaic 
current  is  felt  as  extremely  and  quite  abnor- 
mally painful.  Cramp  of  the  calf  muscles  is 
common.  It  is  often  impossible  for  the  patient 
to  sit,  owing  to  the  tenderness  of  the  nerve-trunk 
near  the  tuber  ischii.  The  act  of  putting  on  a stock- 
ing, stooping,  or  sneezing  gives  rise  to  great  pain, 
j There  are  great  differences  in  the  course  and 
character  of  the  affection.  In  some  persons  the 


disease  from  the  first  presents  the  characters  of  a 
chronic  affection.  There  is  never  pain  sufficient, 
for  example,  to  prevent  sleep,  and  it  may  not  ar- 
rive at  a degree  of  severity  to  interfere  much  with 
locomotion.  But  the  patient  is  worn  by  a more  cr 
less  constant  aching  in  the  district  of  the  sciatic 
nerve,  which  becomes  especially  marked  after 
long  sitting,  as  on  a railway  journey,  and  most 
of  all  if  the  seat  is  somewhat  hard.  Fatigue  of 
body  and  mental  worry  have  great  effect,  in  such 
cases,  in  intensifying  the  symptoms,  which,  on 
the  other  hand,  may  almost  entirely  disappear 
in  circumstances  favourable  to  health  and  men- 
tal exhilaration.  Sciatica  of  this  type  is  prone 
to  attack  the  middle-aged,  to  be  permanent, 
and  to  acquire  additional  intensity  with  advanc- 
ing years.  In  contrast  with  such  cases  are 
those  which  from  the  first  exhibit  the  charac- 
teristics of  an  acute  affection.  The  pain  is  so 
agonizing  that  no  posture  affords  relief,  sleep  is 
impossible,  the  general  health  suffers,  and  the 
patient  is  placed  completely  hors  de  combat. 
The  disease  may  last  for  weeks  or  months  with- 
out material  intermission,  the  patient  being 
confined  helplessly  to  his  bed.  Or  after  some 
weeks  of  acute  suffering,  improvement  may  take 
place,  to  be  followed  only  by  a relapse,  which  is 
even  more  violent  than  the  original  attack. 

Although  the  recumbent  position  is  always 
that  which  is  most  grateful  to  the  patient,  yet 
it  will  happen  that  after  a night  passed  in  sleep 
attempts  to  move  the  affected  limb  cause  it  to  be 
more  painful  than  after  walking,  and  there  is  a 
distressing  stiffness  about  it. 

In  some  persons  the  disease  attacks  once,  in  a 
very  severe  form,  it  may  be  at  a comparatively 
early  period  of  life,  and  never  recurs.  More 
often  it  tends  to  recurrence,  and  with  such  per- 
sistence that  the  patient  will  speak  of  ‘ his 
sciatica  ’ as  a companion  which  is  always  present, 
though  occasionally  for  a term  out  of  sight.  Or 
it  may  alternate  with  attacks  of  typical  neu- 
ralgia in  other  parts  of  the  body;  or  be  replaced 
by  various  functional  disorders  of  the  nervous 
system,  accompanying  an  excess  of  uric  acid  in 
the  urine. 

The  disease  may  be  accompanied  by  consider- 
able muscular  atrophy  of  the  limb,  and  a quasi- 
paralytic condition,  which,  though  capable  of 
improvement,  may  leave  the  patient  more  or 
less  lame  for  the  rest  of  his  life.  Or  the  wasting 
which  has  accompanied  the  acute  symptoms  of 
the  disease  may  gradually  cease  as  these  subside, 
and  during  the  somewhat  prolonged  convales- 
cence the  limb  may  be  restored  to  its  original 
size,  and  the  lameness  be  no  longer  observed. 
Sciatica  often  follows  lumbago.  In  some  cases 
years  may  elapse  between  the  attacks,  but  much 
more  frequently  it  is  a question  of  a few  days  or 
weeks. 

Diagnosis. — There  are  three  conditions  of  the 
muscular  system  which  are  apt  to  be  confounded 
with  sciatica: — 1.  Myalgia  from  over-exertion  of 
the  flexor  muscles  at  the  back  of  the  thigh.  Here 
the  pain  will  be  found  at  the  points  of  insertion 
of  the  muscles,  and  is  only  felt  during  their 
action.  2.  Bheumatism  in  the  muscles  from 
exposure  to  cold.  Here  again,  the  pain  is  not 
spontaneous,  as  in  sciatic  neuralgia,  but  is 
always  dependent  on  muscular  action.  3.  A low 


*396  SCIATICA, 

inflammation  of  the  loose  bursal  tissue  which 
separates  the  large  muscles  of  the  thigh,  brought 
about  by  the  presence  of  some  morbid  material 
conveyed  by  the  lymphatic  vessels  with  which 
the  spaces  are  in  direct  communication.  Uric 
acid  and  pus  are  especially  liable  to  cause  this 
affection.  Sacro-iliac  disease  may  be  distin- 
guished by  its  always  occurring  in  youth;  by  the 
pain  being  confined  to  the  sacral  neighbourhood ; 
and  by  the  limb  being  lengthened  at  an  early 
period.  From  hip-joint  disease,  especially  in  the 
slow  insidious  form  which  it  sometimes  takes, 
sciatica  is  not  always  distinguished  with  facility. 
The  paroxysmal  character  of  the  pain,  presence 
of  tender  points,  absence  of  result  from  forcible 
movement  of  the  joint,  and  absence  of  charac- 
teristic position  or  shortening  of  the  limb,  will 
best  serve  for  diagnosis.  The  lameness  in  scia- 
tica may  lead  to  the  idea  of  paraplegia,  from 
which  the  disease  may  be  distinguished  by  the 
perfect  integrity  of  the  other  limb,  as  well  as  by 
the  paroxysmal  pains,  tender  points,  and  the  his- 
tory showing  that  the  poworlessness  was  second- 
ary to  the  pain.  From  the  darting  pains  in  the 
thigh  consequent  on  renal  calculus,  sciatica  may 
be  easily  distinguished  by  careful  examination. 

The  affection  maybe  limited  to  a single  branch, 
and  when  this  is  the  terminal  portion  of  the 
anterior  tibial  nerve  supplying  the  big  toe,  there 
is  a 'prima  facie  resemblance  to  gout.  It  may  be 
distinguished  from  this,  however,  by  noting  the 
absence  of  heat,  swelling,  redness,  or  pain  on 
moving  the  joint ; and  the  presence  of  a small  spot, 
at  which  alone  pressure  is  extremely  painful. 

Syphilitic  periostitis,  with  inflammation  of  the 
sheath  of  the  sciatic,  may  be  distinguished  from 
malignant  disease  by  the  effect  of  large  doses  of 
iodide  of  potassium.  Sciatica  may  be  distin- 
guished from  the  lightning-like  pains  of  locomo- 
tor ataxy  by  the  presence  of  the  patellar  tendon- 
reflex.  See  also  Lecture  by  Mr.  Hutchinson, 
Medical  Times  and  Gazette , Vol.  I.  1882. 

Treatment. — This  should  be  constitutional, 
as  well  as  local.  Gout,  rheumatism,  syphilis, 
malaria,  if  inquiry  show  that  either  of  these 
conditions  lies  at  the  base  of  the  disease,  will 
need  the  treatment  appropriate  to  each.  Against 
a gouty  or  rheumatic  basis  the  diet  should  be 
spare,  and  mainly  of  a vegetable  character,  with 
milk- — all  stimulants  being  avoided.  Bicarbon- 
ate of  potash  in  effervescence,  citrate  of  lithia, 
iodide  of  potassium,  and  colchieum  will  be  the 
drugs  most  likely  to  afford  relief.  If  the  rheu- 
matic character  be  very  pronounced,  it  will  be 
well  to  give  salicylate  of  soda  in  twenty-  or 
thirty-grain  doses,  dissolved  in  half  a tumbler 
of  water,  every  three  or  four  hours.  If  syphilis 
be  suspected,  iodide  of  potassium  or  of  sodium 
should  be  given,  in  doses  of  from  ten  to  thirty 
grains  throe  times  a day  or  oftener. 

Quinine,  in  doses  of  five  grains,  may  be  em- 
ployed if  there  be  reason  to  believe  that  there  is 
a malarious  taint. 

The  recumbent  position  is  very  necessary  in 
all  cases  of  any  severity ; and,  should  the  distress 
be  very  great,  it  is  a good  plan  to  put  the  patient 
on  a water  mattress.  Warmth  is  also  neces- 
sary. Sometimes  the  rapidly-repeated  applica- 
tion of  hot  linseed  poultices  will  give  much 
relief.  Occasionally,  if  the  pain  and  tenderness 


SCLEREMA  KEONATOEUM. 
be  very  exquisite,  and  the  patient’s  age  and  con- 
dition do  not  counter-indicate  it,  the  application 
of  a few  leeches  to  the  upper  and  back  part  of 
the  thigh  is  useful.  The  hypodermic  injection 
of  morphia  gives,  of  all  remedies,  the  most 
speedy  relief.  It  is  best  to  employ  a solution 
of  one  grain  in  thirty  minims,  and  to  inject  at 
first  three  minims  twice  in  the  twenty-four  hours, 
if  necessary.  The  dosr  may  be  increased  by  one 
minim  at  a time  if  it  be  found  desirable;  but 
it  is  rarely  necessary,  except  in  cases  of  malig- 
nant disease,  to  exceed  eight  minims  of  such  a 
solution.  The  dose  and  frequency  should  be 
diminished  as  relief  is  obtained.  The  bowels 
should  be  kept  thoroughly  relieved.  Flying 
blisters,  not  larger  than  a five-shilling  piece, 
one  following  another  as  it  heals,  not  on  the 
same  but  on  a closely  adjoining  part  of  the  skin, 
may  usually  be  applied  with  much  advantage. 
Even  in  cases  dependent  upon  malignant  disease 
they  will  often  give  relief  for  a time.  Spongio- 
piline  WTung  out  of  boiling  water,  and  sprinkled 
with  the  liniment-um  sinapis  compositum,  makes 
a good  counter-irritant,  and  will  sometimes  take 
the  place  of  blistering. 

The  continuous  voltaic  current  is  often  pallia- 
tive, and  sometimes  perhaps  curative.  From  20 
to  40  cells  may  be  employed,  and  whilst  one  rheo- 
phore  is  applied  to  the  sacro-iliac  synchondrosis, 
the  other  is  put  into  a tub  of  saltwater,  in  which 
the  patient  places  his  foot.  The  strength  should 
be  arrived  at  gradually,  and  the  application  con- 
tinued for  ten  minutes  at  a time.  Then,  without 
removing  the  rheophores,  the  strength  of  the  cur- 
rent must  be  gradually  reduced  to  zero.  With- 
out this  precaution  a shock  will  be  given,  which 
is  very  undesirable.  The  electrical  application 
should  not  be  employed  during  the  very  acute 
stage,  but  rather  in  cases  of  moderate  severity, 
or  where  the  most  formidable  suffering  has  sub- 
sided. The  current  may  be  conveyed  into  a bath 
if  preferred.  One  rheophore  is  allowed  to  fall 
into  the  bath,  the  other  is  held  by  the  patient 
above  the  level  of  the  water,  which  should  be  of 
a temperature  of  95°  Fahrenheit,  and  should 
contain  some  salt.  In  some  cases,  after  acute 
symptoms  have  subsided,  good  has  appeared  to 
be  done  by  enveloping  the  limb  in  a flannel 
bandage,  over  the  folds  of  which  sulphur  is 
sprinkled.  In  other  cases  it  is  said  that  the 
spirit  of  turpentine  taken  internally  has  cured 
where  other  remedies  have  failed.  In  obstinate 
cases  the  sheath  of  the  nerve  may  be  punctured 
in  a few  places  with  a sharp  needle.  See  Acu- 
puncture. 

The  baths  of  Buxton,  Wiesbaden,  Wildbad, 
Eoyat,  and  Gastein  have  been  found  useful  in 
treating  sciatica;  and  artificial  hotair  or  vapour 
baths  may  be  beneficial  in  some  instances. 

The  sciatic  nerve  has  been  cut  down  upon  and 
stretched  with  advantage  in  several  cases  of  con- 
firmed sciatica.  See  Nerves,  Diseases  of  (3). 

T.  Buzzard. 

SCIIl RHUS  (a-icippos,  a hard  tumour). — A 
hard,  glandular,  cancerous  tumour.  See  Tv 
HOURS. 

SCLEREMA  NEONATORUM  (<rjr Angis, 

hard;  and  neonatorum,  of  the  newly-born).  - 
Synon.  : Skin-bound  disease. 


SCLEREMA  NEONATORUM. 

Definition-. — A congenital  affection,  or  one 
ippearing  in  early  infancy,  characterised  by  a 
stretched  and  tense  condition  of  the  skin. 

Description. — The  disease  usually  commences 
on  the  lower  extremities,  and  gradually  involves 
the  entire  surface.  The  skin  becomes  glossy- 
looking  and  of  a yellowish  or  reddish  colour,  but 
it  may  be  mottled.  To  the  touch  it  is  firm  and 
rigid,  like  bacon-rind,  and  cannot  be  pinched  up 
between  the  fingers.  The  surface  is  cold,  feel- 
ing like  that  of  a half-frozen  corpse.  The  infant 
is,  in  fact,  skin-hound  ; all  movement  becomes 
impossible  ; and  the  features  remain  fixed  and 
staring.  Death  within  a limited  period  is  the 
ordinary  termination,  recovery  rarely  occurring 
spontaneously. 

The  disease  is  usually  associated  with  affec- 
tions of  the  respiratory  and  circulatory  systems, 
and  has  been  observed  in  connection  apparently 
with  congenital  syphilis. 

Microscopic  observation  has  thrown  hut  little 
light  on  the  nature  of  sclerema  neonatorum. 
Ihe  subcutaneous  tissue  has  been  found  to  con- 
tain a stiff,  stearine-like  deposit;  but  the  disease 
teems  to  differ  from  the  scleroderma  of  adults 
in  the  absence  of  increased  fibrous  tissue,  which 
is  peculiar  to  the  latter  affection. 

Treatment. — No  treatment  appears  to  avail 
in  this  disease,  but  that  for  syphilitic  taint  has 
been  suggested.  Alfred  Sangstee. 

SCLERODERMA  (rncAypbs,  hard,  and  Slppa, 
the  skin). — Definition. — A disease  characterised 
by  hardness  of  the  skin. 

./Etiology. — The  cause  cf  this  singular  com- 
plaint must  be  regarded  as  an  error  of  nutrition, 
or  rather  a perversion  of  nutrition.  A tissue  of 
low  organisation,  white  fibrous  tissue,  grows  in 
excess  and  without  restraint ; strangles  and  de- 
stroys the  more  highly  organised  structures — 
vessels,  nerves,  and  muscles;  and  takes  the  place 
of  the  vanished  structures,  thereby  converting  a 
part  enjoying  active  life  into  an  inert,  almost 
bloodless  and  nerveless  cicatricial  mass. 

Anatomical  Characters.— Scleroderma  con- 
sists in  the  development  and  proliferation  of  white 
fibrous  tissue,  and  the  atrophy,  to  a greater  or  less 
extent,  of  the  more  highly  organised  tissues  which 
enter  into  the  composition  of  the  part.  This 
morbid  change  is  most  energetic  wherever  the 
white  fibrous  tissue  is  most  abundant;  hence  its 
occupation  of  the  integument  and  the  ligamentous 
structures  of  the  fingers  and  joints.  And  for  a 
similar  reason  it  is  apt  to  follow  the  sheaths  of 
muscles,  and  produce  consolidation  of  an  entire 
limb.  The  newly-formed  fibrous  tissue  is  iden- 
tical with  cicatricial  tissue,  and,  like  the  latter, 
manifests  a disposition  to  contract,  which,  in 
fact,  is  one  of  the  main  features  of  the  disease. 

Description. — The  integument  in  this  disease 
is  hard,  rigid,  white,  and  contracted.  On  the 
face  the  features  are  distorted  by  the  contraction 
of  the  skin ; the  eyelids  are  drawn  apart ; the 
mouth  is  pinched  in  size,  or  forced  open ; the 
neck  and  limbs  are  clasped  by  the  morbid  skin  ; 
the  fingers  and  toes  are  bent  and  deformed;  and 
even  the  hones  are  forced  through  ulcerated 
openings,  produced  by  the  pressure  of  the  skin 
against  the  ends  of  the  last  phalanges  or  the 
prominences  of  the  joints. 


SCLEROSIS.  1397 

This  is  an  extremepieture  of  generalised  sclero- 
derma. More  frequently-  the  disease  is  partial, 
and  is  limited  to  certain  regions  of  the  body; 
and  most  commonly  it  is  met  with  in  the  clavi- 
cular regions  of  the  trunk.  Here  it  msy  appear 
as  white  blotches,  irregular,  smooth  and  shining, 
dense,  and  suggesting  the  appearance  of  ivory  or 
marble;  but  at  first  they  may  he  hypersemic. 
Occasionally  minute  glittering  spots  may  be  seen 
dispersed  around,  and  among  these  larger  blotches. 
Similar  blotches  may  be  found  on  the  trunk  and 
limbs, rarely  numerous,  and  occasionally  solitary; 
the  latter  are  known  as  morpkaa.  As  these 
blotches  sometimes  occur  in  the  course  of  nerves, 
scleroderma  is  believed  by  some  to  he  of  neurotic 
origin. 

Diagnosis. — The  diagnosis  of  scleroderma  is 
embodied  in  the  preceding  description ; the 
parts  affected  are  hard,  rigid,  white,  smooth  or 
wrinkled,  and  distorted  or  deformed. 

Prognosis. — The  prognosis  of  sclercderma  is 
highly  unsatisfactory.  Parts  of  small  extent  have 
been  known  to  recover  their  healthy  texture  and 
function  ; even  when  extensive,  the  disease  has 
been  known  to  improve  ; but,  in  general,  it  must 
be  regarded  as  incurable. 

Treatment. — In  the  treatment  of  scleroder- 
ma, the  whole  of  our  tonic  measures,  both  in 
diet  and  drugs,  must  be  brought  into  use — 
quinine,  iron,  phosphorus,  strychnia,  arsenic,  cod- 
liver  oil,  and  so  forth.  As  a local  stimulant, 
electricity  has  been  employed,  apparently  with 
some  beneficial  result.  But  as  yet  the  treat- 
ment of  scleroderma  is  as  essentially  unsatis- 
factory as  its  cause  is  difficult  to  determine. 

Erasmus  Wilson. 

SCLEROMA  (aK\Tiphs,  hard). — A term  sig- 
nifying a hardening  of  the  softer  tissues  of 
the  body  under  the  influence  of  disease.  See 
Sclerema  Neonatorum;  Scleroderma;  and 
Sclerosis. 

SCLEROSIS  ((TK\vpbs,  hard).— Synon. : Fr. 
Sclerose ; Ger.  Sclerosis. 

Definition. — A state  of  induration,  hardness, 
or  toughness.  The  term  is  also  applied  to  the 
process  by  which  such  a state  is  brought  about 
in  organs  and  tissues. 

Induration  of  organs  has  long  been  recognised, 
and  before  the  microscope  came  into  ordinary  use, 
this  term,  as  well  as  its  correlative,  ‘softening,’ 
was  very  commonly  employed  by  pathologists 
in  their  descriptions  of  certain  morbid  conditions 
found  in  different  organs  of  the  body. 

Since  Laennec,  under  the  influence  of  a mi staken 
impression,  first  gave  the  name  ‘ cirrhosis  of  the 
liver’  to  one  of  the  common  diseases  of  that 
organ,  it  has  gradually  become  more  and  more 
common  to  apply  this  name,  cirrhosis,  to  analo- 
gous conditions  of  induration  in  other  organs ; 
hence  the  word  ‘ cirrhosis,’  and  the  phrase 
‘ cirrhotic  process,’  have  come  to  be  used  as  the 
equivalents  of  ‘ induration,’  and  ‘ process  of  in- 
duration,’ although  the  Greek  word  from  which 
cirrhosis  is  derived  ( Kippbs , yellow,  or  tawny), 
has  a totally  different  signification.  See  Cir- 
rhosis. 

In  recent  times  a limitation  in  the  use  of  this 
phrase  has  sprung  up.  The  real  nature  of  iudu- 
rations  of  orgms  cf  the  central  nervous  system 


1398  SCLEROSIS. 


SCLEROSTOMA. 


as  well  as  the  frequency  of  such  processes,  were 
recognised  much  later  than  the  period  above 
referred  to.  Yet  if  ve  make  allowance  for  the 
peculiarities  in  the  texture  of  the  brain  and 
spinal  cord',  and  remember  that  even  its  connective 
tissue  (neuroglia)  has  a modified  constitution  as 
compared  with  that  of  other  organs,  it  is  evident 
that  these  indurations  of  brain  and  spinal  cord 
are  due  to  so-called  * cirrhotic  processes.’  Such 
processes,  in  fact,  occur  in  them  with  great  fre- 
quency, and  constitute  the  anatomical  basis  of 
several  distinct  diseases.  Only  it  so  happens 
that  the  old  and  etymologically  unsuitable  name 
has  never  been  applied  to  them.  It  has  always 
been  common  to  speak  of  such  an  indurating 
process,  as  it  occurs  in  the  brain  or  in  the  spinal 
cord,  by  a word  of  similar  import  derived  from 
the  Greek  language — that  is,  as  a ‘sclerosing 
process,’  and  ot'  the  pathological  state  itself  as 
one  of  ‘sclerosis.’  The  subject  will  be  found 
fully  treated  of  in  other  parts  of  this  work.  See 
Insanity,  Morbid  Histology  of;  anl  Spinal 
Cord,  Special  Diseases  of. 

H.  Charlton  Bastian. 

SCLEROSIS,  Cerebro-Spinal  \ „ oTVT>T 

SCLEROSIS.  Spinal  | Spinal 

Cord,  Special  Diseases  of.  Disseminated  or  Multi- 
locular  Sclerosis. 


SCLEROSTOMA  (<r/c\i)pl>s,  hard, and  ariyea, 
a mouth). — A genus  of  strongyloid  parasites  in 
which  may  be  placed  the  species  of  human  ne- 
matode sometimes  called  strongylus  quadriden- 
tatus  after  Siebold,  dochmius  duodenalis  after 
Leuckart,  or,  more  commonly,  anchylostomum 
duodenale  after  Dubini,  Dies- 
ing, and  other  helmintholo- 
gists. This  helminth  gives 
rise  to  a special  form  of  tro- 
pical anaemia  which  is  notun- 
common  in  Brazil,  where  it 
is  designated  oppilagao,  or 
cangago.  As  in  Europe  the 
parasite  is  most  frequently 
called  the  Anchylostomum,  so 
also  the  disease  occasioned 
by  its  presence  is  often  called 
Anchylostomosis.  Without 
doubt  C.  von  Siebold's  nomen- 
clature is  the  best,  zoologi- 
cally speaking ; but  it  has 
been  found  more  convenient 
to  treat  of  the  parasite  and  its 
disease  in  this  place. 

Description. — The  male 
parasite  measures  about  one- 
third  of  an  inch  in  length, 
*'VofaaSU the  female  being  very  nearly 
(A),  and  female  (b)  half  an  inch.  The  Hunterian 
x 5 diameters.  Museum  contains  specimens 
of  this  entozoon  contributed  by  Dr.  J.  E.  da 
Silva  Lima,  of  Bahia. 

Symptoms  and  Diagnosis. — In  persons  affected 
with  this  disease,  according  to  the  late  Dr.  Wueli- 
erer,  there  is  extreme  pallor  of  the  visible  mucous 
membranes,  with  excessive  weakness,  dyspnoea, 
palpitation,  and  a tendency  to  syncope.  Drop- 
sical effusions  supervene,  and  death  sometimes 
follows  from  dysentery  and  diarrhoea ; but  the 


loss  of  blood  consequent  upon  the  suction-wounds 
of  the  selerostomes  is  the  real  cause  of  the 
malady,  whether  the  attacks  prove  fatal  or  not. 
When  the  symptoms  just  mentioned  occur  many 
person  resident  in  a warm  country,  the  presence 
of  these  parasites  will  naturally  be  suspected.  In 
such  cases  anthelmintics  should  be  administered, 
followed  by  a careful  inspection  of  the  faeces,  in 
which  the  worms  or  their  ova  may  be  found. 

Histoby. — The  worm  was  first  discovered  by 
Dubini  at  Milan,  and  seems  to  be  tolerably  commcn 
throughout  Northern  Italy ; but,  according  to  Pru- 
ner,  Bilharz,  and  Griesinger,  it  is  still  more  abun- 
dant in  Egypt.  The  ‘ Egyptian  chlorosis,’  as  the 
disorder  is  also  sometimes  termed,  has  been  de- 
scribed in  the  standard  works  of  Kiichenmeister 
and  Davaine,  and  also,  with  great  care,  by  Leuc- 
kart (Die  Mensch.  Par.,  s.  455  et  seq.),  who  closely 
follows  Griesinger  (Archivf. physiol.  Heillc.,  1854). 
The  writer  has  carefully  gone  over  the  late  Dr. 
Wucherer’s  admirable  memoir  on  this  subject, 
and  only  refrains  from  quoting  his  statements  at 
greater  length  from  want  of  space  (‘Ueber  die 
Anchylostomumkrankheit,  tropische  Chlorose, 
oder  tropische  Hypoiimie,’  Deutsches  Archie  fur 
Klin.  Med.,  1872,  ss.  379-400).  The  estimable 
author  not  only  supplied  the  writer  with  abundant 
materials  for  confirming  what  others  had  already 
made  out  respecting  the  structure  of  this  worm 
(Entozoa,  p.  361);  but  he  supplied  the  specimens 
which  formed  the  subject  of  the  excellent  illus- 
trations given  by  Dr.  Weber  in  the  Path.  Soc. 
Trans,  for  1S67  (vol.  xviii.,  p.  274).  Numerous 
prior  observations  made  by  Wucherer  in  the 
Gazcta  -IT  d tea  da  Dahia  are  included  in  the 
memoir  above  quoted,  and  they  have  been  re- 
ferred to  in  the  writer’s  recent  work  ( Parasites , 
1879,  p.  2\Zet  scq.).  When  Wucherer  announced, 
through  Dr.  Jobini  at  the  Rio  Academy,  his  dis- 
covery of  the  Egyptian  chlorosis  in  Brazil,  his 
views  as  to  the  true  cause  of  the  disorder  met 
with  opposition.  The  general  opinion  was  that 
the  Anchylostomata  were  not  the  primary  and 
necessary  cause  of  this  tropical  ansemia,  but 
rather  a co-operating  agent  in  its  production. 
Against  this  view  Dr.  Wucherer  afterwards  very 
properly  protested  (Gazcta,  January  15,  1868). 
In  the  meantime,  says  Wucherer,  ‘ Dr.  Le  Roy 
de  Mericourt,  prompted  by  my  first  communi- 
cation, had  invited  the  physicians  of  the  French 
colonies  to  seek  for  anchylostomes.  Drs.  Mo- 
nester and  Grenet,  at  Mayotta  (which  lies  about 
12°  S.  lat.  to  the  north-east  of  Madagascar), 
ascertained  the  presence  of  entozoa  in  hy po- 
lemics. Dr.  Grenet  sent  the  duodenum  and  a 
portion  of  the  jejunum  of  an  hypoaemic  corpse 
to  Le  Roy  de  Mericourt,  who  compared  tho 
anchylostomes  with  Davaine's  description,  and 
recognised  them  as  examples  of  A.  duodenale.  In 
the  year  1868  Dr.  Rion  Keraugel  found  anchy- 
lostomes  in  the  bodies  of  hyposemies  in  Cayenne. 
Thus  (adds  Wucherer)  the  occurrence  of  anchy- 
lostomes in  hyposemies  has  been  authenticated 
by  Pruner,  Bilharz,  and  Griesinger,  in  Egypt ; 
by  myself,  Dr.  Moura,  Dr.  Turinho,  and  other 
physicians,  in  Brazil ; by  Monesiier  and  Grenet, 
in  Comorens  ; and  by  Rion  Kerangel  in  Cayenne. 
It  thus  also  appears,  from  the  wide  separation 
of  these  several  localities,  that  the  anchylc- 
stomrs,  it  duly  sought  for,  will  be  found  in  manT 


SCLEKOSTOMA. 

ether  countries.’  Dr.  Wucherer  was  correct ; 
end  what  has  since  been  unwisely  called  Tunnel 
Trichinosis  is  merely  another  name  for  the 
same  disease,  which  recently  caused  so  much 
havoc  among  the  workmen  in  the  St.  Gothard 
tunnel.  This  outbreak  was  specially  investigated 
by  Professor  Perroncito,  of  Turin,  and  by  Dr. 
Bugnion  of  Geneva.  The  memoir  by  Perroncito 
(Osserv.  El-mint,  relative  alia  Malattia  sviluppa- 
tusi  en demica  — R.  Accad.  dei  Lir.cei,  1S79-8U),  is 
idustrated  with  figures  of  the  larval  anchylo- 
stomes.  Figures  of  the  adult  worm  are  given  by 
Bugnion  in  his  memoir,  with  a valuable  biblio- 
graphy ( Revue  de  la  Suisse  Romande,  May 

and  June  1881).  More  recently  Dr.  Perroncito 
lias  communicated  to  the  Academie  des  Sciences 
h s observations  on  a like  outbreak  amongst  the 
miners  of  St.  Etienne. 

Treatment. — Perroncito  gives  the  following 
t xceben : advice  as  to  treatment : — ‘The  strength 
should  bj  sustained  with  food  easy  of  digestion, 
very  nourishing,  aided  by  the  best  tonics  and  re- 
cmstitu-nts,  whilst  we  proceed  at  the  same  time 
ti  destroy  the  worms  which  constitute  the  funda- 
mental cause  of  the  oligaemia.  None  of  the  pa- 
tients subjected  to  treatment  with  the  best  anthel- 
mintics, with  a good  meat  diet  and  rich  wine, 
need  succumb,  unless  the  anpemia  has  arrived  at 
that  extreme  degree  in  which  the  organic  powers 
cease  to  regenerate  the  blood ; and  still  less,  if 
at  the  same  time  they  take  preparations  of  iron 
and  bitters.’  He  adds : ‘ The  ethereal  extract 
of  male  fern  appears  to  me  most  adapted  to  kill 
the  different  species  of  parasites ; only  it  must 
not  be  supposed  that  one  or  two  doses  will  be 
sufficient  to  liberate  the  intestines  from  thou- 
sands and  perhaps  millions  of  helminths  that 
live  on  chyle  and  blood.’  Prof.  Perroncito  men- 
tions the  case  of  a young  St.  Gothard  patient, 
with  large  quantities  of  anchylostomes,  combined 
with  not  a few  anguillulse  and  some  ascarides, 
who  was  treated  with  male  fern  so  successfully 
that  even  the  ‘ first  draught  ’ occasioned  great 
relief.  This  was  followed  by  santonine  and  the 
nourishing  diet  above  recommended.  The  pa- 
tient’s strength  rapidly  increased,  and  he  was 
afterwards  perfectly  restored  to  health.  In 
many  other  cases  under  Perroncito’s  care  the 
same  excellent  results  followed.  This  success 
has  been  acknowledged  by  Dr.  Bugnion  in  his 
admirable  paper  published  in  the  Brit.  Med. 
Jour,  for  March  12,  1881.  Like  Wucherer,  Dr. 
Perroncito  had  to  encounter  much  opposition. 
The  tunnel  disease  was  referred  by  his  oppo- 
nents to  any  cause  rather  than  the  true  one. 
At  length,  says  Dr.  Bugnion,  the  parasitic 
character  of  the  malady  was  irresistibly  recog- 
nised when  ‘Dr.  Sonderegger  had  treated  a young 
engineer  of  the  works.  The  patient  showed  all 
the  symptoms  of  Egyptian  chlorosis ; and  after 
having  taken  santonine  with  calomel,  evacuated 
the  anchylostomes  in  large  numbers.’  The 
writer  has  encountered  similar  opposition  in  re- 
spect of  certain  destructive  animal  epidemics, 
which  he  has  found  to  be  caused  by  strongyloid 
and  other  parasites.  Further  confirmation  of 
the  truth  of  Perroncito's  determinations  was 
afforded  by  cases  under  the  care  of  Professor 
Biiumler,  Dr.  Schonboehler,  and  Dr.  Damur 
respectively.  Particulars  of  these  cases  are 


SCROFULA.  1399 

given  by  Dr.  Bugnion,  who  also  concludes  hia 
interesting  paper  by  the  surprising  statement 
that  ‘in  the  report  published  in  June  1880 
by  Dr.  Sonderegger,  who  was  retained  by  the 
Federal  Government,  of  the  bodies  in  117  cases 
of  death  only  a single  examination  was  made.’ 
The  conduct  of  the  authorities  of  Airolo  in  re- 
fusing the  necessary  post-mortem  inspections  was 
certainly  most  reprehensible. 

T.  S.  CoBBOLD. 

SCLEROTIC,  Diseases  of.  See  Eye  and 
its  Appendages,  Diseases  of. 

SCORBUTUS. — A synonym  for  scurvy.  iS*« 
Scurvy. 

SCRIVENER'S  PALSY. — A synonym  for 
writer’s  cramp.  See  ’Writer’s  Cramp. 

SCROFULA  (scrofa,  a sow). — Syn'on.  : Fr. 
Scrofule ; Ger.  Scrofeln. — If  we  would  raise  the 
true  doctrine  of  scrofula  we  must  build  upon  the 
foundations  of  the  ancients.  The  Hippocratic 
choirades  (xoipdSes),  struma  vera,  or  glandular 
scrofula,  should  ever  be  the  criterion  or  note  of 
what  is  scrofulous.  Guided  by  this  principle,  we 
may  extend  the  use  of  the  word  scrofula  far  beyond 
its  ancient  limits,  without  any  fear  lest  the  mean- 
ing of  the  term  should  become  proportionally 
vague  and  indefinite.  In  the  first  place,  struma 
vera  will  be  to  us  the  sign  of  a present  and  an- 
tecedent strumous  diathesis,  or  special  disposition 
to  this  form  of  disease.  In  the  next  place,  upon 
the  strumous  diathesis,  thus  signified,  will  be 
found  to  depend  many  forms  of  disease  other 
than  glandular.  And  for  this  very  reason,  because 
the  meaning  of  the  word  scrofula  can  be  thus 
widened,  it  becomes  highly  important  that  the 
criterion,  note,  or  principle  itself  should  be  well 
defined  and  understood. 

I.  Struma  Vera:  Scrofulous  Lymphatio 
Glands. 

Anatomical  Characters. — Matthew  Bailiie 
writes  thus  : ‘ The  most  common  morbid  affec- 
tion of  the  absorbent  glands  is  scrofula.  In  this 
case  the  glands  are  frequently  a good  deal  en- 
larged, and  sometimes  feel  a little  softer  to  the 
touch  than  in  a healthy  state.  When  cut  into, 
they  sometimes  exhibit  very  much  the  natural 
appearance ; but  it  is  more  common  to  find  that 
some  of  them  contain  a white,  soft,  cheesy  matter, 
mixed  with  a thick  pus : this  is  the  most  decided 
mark  of  a scrofulous  affection.’ 

But  this  cheesy  change  is  a late  stage  of  the 
strumous  affection.  Scrofulous  glands,  which 
are  only  potentially,  but  not  actually,  cheesy, 
present  to  the  naked  eye  very  much  the  natural 
appearance,  as  Bailiie  says.  If  we  take  a chain 
of  lymphatic  glands,  all  somewhat  enlarged,  but 
only  some  of  them  cheesy,  we  should  expect  to 
find  the  earlier  stage  of  the  strumous  lesion  in 
the  glands  which  look  most  natural.  These  ap- 
parently natural  lymphatic  glands,  therefore,  are 
those  which  we  choose  for  examination  first  of 
all. 

Virchow  taught  that  the  primitive  strumous 
lesion  consisted  in  a simple  hyperplasia  of  tha 
gland-tissue.  But  to  Schiippel  (1871)  belongs 
the  merit  of  having  proved  that  a scrofulous 
gland  is  indeed  a tuberculous  gland.  In  the 
earlier  stage  of  the  lesion,  the  gland  is  studded 


SCROFULA. 


1400 

n-ith  microscopic  tubercles,  possessing  characters 
described  in  the  article  on  tubercle.  And  the  sub- 
sequentchanges,  cheesy  and  other,  which  thegland 
undergoes,  are  due  to  changes  in  the  tubercles. 
[See  Scrofula  by  Mr.  Treves,  Lond.  1882.) 

Symptoms. — In  the  living  person  strumous 
lymphadenitis  may  be  distinguished  from  what 
we  may  call  genuine  lymphadenitis.  The  first 
character  of  the  scrofulous  disease  consists 
in  an  excessive  irritability  or  inflammability  of 
the  glands,  constituting  what  Thomas  White 
long  ago  called  an  ‘ inflammable  diathesis.’ 
Vulnerability  is  a word  employed  by  Virchow 
to  signify  the  same  peculiarity,  which  may  as- 
sume two  forms : namely  (i.)  that  the  inflam- 
mation is  much  greater  in  a scrofulous  per- 
son than  in  a healthy  person,  under  the  same 
conditions;  and  (ii.)  that  glands,  wdiich  in  a 
person  not  scrofulous,  would  not  inflame  at  all 
under  the  circumstances,  in  a strumous  person 
do  inflame.  Another  character  of  the  scrofulous 
disease  consists  in  its  obstinacy,  intractability, 
pertinacity.  Once  enlarged,  ihe  strumous  gland 
remains  enlarged  for  a long  time.  The  reason  of 
this  lies  in  the  nature  of  the  scrofulous  inflamma- 
tion and  its  products.  A genuine  lymphadenitis, 
in  a healthy  person,  will  resolve,  suppurate,  or 
organise  in  a short  time.  In  struma  vera,  reso- 
lution, suppuration,  and  organisation  take  place 
very  slowly,  even  when  they  take  place  at  all. 
Commonly  the  inflammatory  products  remain, 
where  they  were  produced,  inert  and  passive,  and 
sooner  or  later  undergo  the  cheesy  change.  Hence 
the  intractability  of  strumous  lymphadenitis. 

II.  Antecedent  Scrofulous  Lesions. — 
Lymphatic  glands  do  not  enlarge  spontaneously. 
There  is  always  some  antecedent  lesion  which 
sets  up  a change,  similar  to  itself,  in  the  asso- 
ciated glands.  Of  all  tissues  of  the  body,  the 
lymphatic  is  the  most  embryonic,  the  least  dif- 
ferentiated or  organised.  For  this  reason  it  is 
also  the  most  plastic  of  all  tissues,  and  endowed 
with  most  potentiality.  A venereal  sore  causes 
a venereal  bubo,  cancer  causes  cancer,  and  so 
forth.  Let  ns  inquire  into  the  characters  of  the 
lesions  which  precede  and  cause  the  strumous  or 
tuberculous  lymphadenitis. 

In  general,  these  primitive  lesions  are  also 
inflammatory.  And  inflammations  being  com- 
monly the  result  of  injury,  we  might  expect 
these  primitive  inflammations  to  be  usually 
seated  in  those  parts  of  the  body  which  are  most 
directly  subject  to  injury.  Such  is  the  ease.  The 
skin,  the  mucous  membranes,  the  subcutaneous 
connective  tissue,  the  bones,  and-  the  joints  are 
the  most  frequent  seats  of  the  original  scrofulous 
disease.  Occasionally  the  primitive  lesion  affects 
the  solid  secreting  glands,  especially  the  kidneys 
and  the  testicles. 

The  distinguishing  characters  of  these  primi- 
tive lesions  are  those  common  to  all  strumous 
inflammations,  and  those  peculiar  to  the  special 
inflammation.  1.  The  common  characters  of 
scrofulous  inflammation  have  already  been  partly 
enumerated  with  respect  to  the  lymphatic  glands. 
Functionally,  vulnerability  and  obstinacy  mark 
the  primary  as  well  as  the  secondary  lesions. 
Structurally,  the  chief  peculiarities  are  found  in 
the  inflammatory  product.  This,  when  fresh,  is 
rich  in  cells,  which  are  much  larger  than  the 


corpuscles  of  a genuine  exudation,  and  which 
consist  of  a dim  glistening  protoplasma,  and  a 
large  nucleus,  either  single  or  double  ; in  short, 
epithelioid  cells.  Scrofulous  exudation  is  either 
infiltrated,  diffused,  and  assuming  no  particular 
shape ; or  it  is  tubercular.  And  lastly,  it  is  re- 
bellious, and  resolves,  suppurates,  or  organises 
slowly  and  imperfectly.  The  defective  vascu- 
larity of  strumous  products  will  account  in  part 
for  thpse  peculiarities.  2.  The  special  charac- 
ters of  scrofulous  inflammations  can  only  briefly 
be  alluded  to.  In  the  skin,  the  most  character- 
istic lesions  are  those  which  the  French  school 
have  called  scrofulides.  The  common  dermatitis, 
or  eczema,  is  modified  when  it  occurs  in  a scro- 
fulous person : eczema  impetiginodes,  in  parti- 
cular, often  shows  the  characters  of  vulnerability, 
obstinacy,  and  recidivity,  and  of  an  exudation 
rich  in  cells.  Impetigo  of  the  eyelashes  (tinea 
tarsi),  and  otitis  externa  are  common  strumous 
diseases.  In  the  mucous  membranes  scrofulous 
inflammations  possess  similar  characters.  The 
secretion  is  sticky,  rich  in  cells,  and  tending  to 
form  scabs.  The  mucosa,  according  to  Rind- 
fleisch,  is  infiltrated  with  an  exudation,  some- 
times so  copious  that  the  corpuscles  form  a com- 
plete layer  beneath  the  epithelium,  and  reach 
deeply-  into  the  submucosa.  Actual  tubercles 
may  form,  and  intractable  ulceration  may  follow 
upon  the  exudation,  whether  diffused  or  tuber- 
cular. Ophthalmia,  coryza,  ozsena,  angina 
faucium,  otitis  interna,  laryngitis,  bronchitis, 
enteritis,  pyelitis,  cystitis,  vaginal  and  vulvar 
catarrh,  are  common  forms  of  strumous  inflam- 
mation of  mucous  membranes.  In  the  connective 
tissue  scrofulous  disease  possesses  the  same  cha- 
racters, which  need  not  be  narrated  again  ; slow 
cold  abscesses,  which  will  neither  discharge  nor 
disperse.  Besides  abscesses,  local  exudations, 
which  are  equally  obstinate,  but  which  go  no 
further  than  a chronic  oedema  or  induration,  are 
often  present  in  the  subcutaneous  tissue  of  scro- 
fulous persons ; the  lips  and  eyelids  are  affected 
thus  with  especial  frequency.  Scrofulous  arthri- 
tis, osteitis,  and  periostitis  are  described  under 
their  appropriate  articles.  Lastly,  the  lungs, 
kidneys,  and  testicles  may  be  the  seat  of  primi- 
tive strumous  disease. 

III.  Tertiary  Scrofula.— We  have  traced 
struma  backwards  from  the  secondary  lympha- 
denitis to  the  primary  lesion.  We  must  now 
assert  that  scrofulous  disease  may  be  dissemi- 
nated over  the  whole  body,  in  a manner  precisely 
similar  to  the  dissemination  of  cancer  in  its  last 
stage.  This  disseminated  or  tertiary  scrofula  is 
nothing  else  than  general  tuberculosis.  The 
tubercular  dyscrasia,  approached  from  our  pre- 
sent point  of  view,  is  tertiary  scrofula.  See 
Tubercle. 

IV.  The  Scrofulous  Diathesis. — Strumous 
lesions  imply  the  existence  of  a strumous  dia- 
thesis, or  special  disposition  to  strumous  disease. 
Upon  this  topic  we  will  ask  three  questions: 
How  may  the  strumous  diathesis  be  recognised? 
What  is  the  strumous  diathesis  in  itself?  and 
What  are  its  causes  ? 

1.  The  strumous  diathesis  may  be  detected  in 
two  ways — directly  or  indirectly ; it  may  be  mani- 
fested by  the  patient  himself  or  by  his  kindred. 
The  latter  or  indirect  means  of  discovering 


SCROFULA. 

icrofula  depends  upon  a fact  in  aetiology,  to 
wit,  the  strongly  hereditary  nature  of  this  dia- 
thesis. 

1.  Struma  manifests  itself  in  the  patient  him- 
self, in  the  first  place,  by  means  of  the  charac- 
teristic lesions  which  have  been  already  enume- 
rated; and  secondly,  by  means  of  the  phlegmatic 
temperament.  Now  the  doctrine  of  tempera- 
ments, however  true  we  may  feel  it  to  be,  seems 
to  lie  beyond  the  power  of  exact  definition. 
With  regard  to  the  phlegmatic  or  lymphatic 
temperament  more  particularly,  we  may  say  that 
its  chief  characters  seem  to  consist,  structurally, 
in  a defect  of  blood,  and  an  excess  of  serum, 
lvmph,  or  phlegm ; and  functionally,  in  languor. 
But  although  scrofula  is  especially  common  in 
the  phlegmatic  temperament,  the  phlegmatic  tem- 
perament does  not  necessarily  imply  scrofula; 
and, moreover,  scrofula  maybe  met  with  in  san- 
guineous and  melancholic  temperaments.  So 
that,  as  was  afore  said,  it  is  not  possible  to  lay 
down  any  definite  rule  upon  this  topic. 

ii.  Struma,  manifesting  itself  in  the  kindred 
of  a person,  may  be  deemed  a proof  that  the 
person  akin  possesses  the  same  diathesis.  In 
the  first  place,  his  kindred  may  be  known  to 
have  suffered  from  strumous  diseases.  In  the 
next  place,  a great  mortality  in  the  family  would 
probably  be  due  to  the  strumous  diathesis,  since 
no  other  diathesis  can  compare  with  it  in  highly 
hereditary  character,  and  in  the  large  number  of 
dependent  fatal  lesions,  occurring  at  all  ages. 

2.  Of  the  intimate  nature  of  scrofula  we  know 
very  little.  When  we  ask  what  that  property  is 
which  serves  as  bond  of  union  between  the  dia- 
thesis and  its  manifestations,  and  between  those 
manifestations  among  themselves,  we  cannot  say 
more  than  that  scrofula  is  a special  form  of 
constitutional  weakness,  debility,  or  degeneracy 
of  mankind.  We  do  not  know  what  determines 
the  special  form,  nor  what  are  the  relations 
between  struma  and  other  degenerate  habits, 
such  as  bronchocele,  leprosy,  cancer.  The  scrofu- 
lous debility  or  defective  vitality  manifests  itself 
chiefly  in  two  ways.  First,  in  a defective  power 
of  resistance  to  external  influences ; hence  the 
vulnerability  of  strumous  persons.  Next,  in  a 
defective  power  of  growth  and  development ; a 
defect  which  shows  itself  not  only  in  the  inflam- 
matory process  (constituting  obstinacy,  intrac- 
tability), but  also  in  the  delayed  or  defective 
growth  of  some  or  all  parts  of  the  body.  This 
opens  up  the  whole  topic  of  malformations,  con- 
genital idiocy,  delayed  developments ; but  at  pre- 
sent experience  hardly  carries  us  any  further. 

3.  ./Etiology  is  another  weak  part  of  the  doc- 
trine of  scrofula.  In  this  place  it  is  not  possible, 
and  under  any  circumstances  it  would  hardly 
be  profitable,  to  do  more  than  set  down  a few 
general  propositions.  Whatever  lessens  health 
and  strength  tends  to  beget  scrofula  ; and  tends 
to  beget  it,  not  so  much  in  the  enfeebled  person 
himself,  as  in  his  offspring.  Once  produced, 
struma  is  highly  hereditary.  The  latter  two 
propositions,  taken  together,  express  the  fact 
that  the  scrofulous  diathesis  is  commonly  con- 
genital. Among  the  anti-hygienic  conditions 
in  the  parent,  which  tend  to  manifest  themselves 
as  scrofula  in  the  child,  must  be  mentioned  con- 
stitutional syphilis,  and  the  age  of  the  parents 


SCURVY.  1401 

at  the  time  of  conception,  either  too  advanced  or 
too  youthful.  Congenital  scrofula  does  not  often 
show  itself  during  the  first  year  of  life.  From 
the  second  year  onwards,  during  the  whole  period 
of  growth  and  development,  strumous  diseases  are 
very  common.  After  middle  life  they  become 
less  common  ; yet  a strumous  person  may  mani- 
fest his  diathesis  even  in  extreme  old  age. 

Treatment. — The  treatment  of  scrofula  is 
preventive  and  curative  ; and  relates,  moreover, 
to  the  strumous  disposition  and  the  dependent 
structural  lesions.  The  prevention  of  the  dis- 
position clearly  consists  in  avoiding  the  predis- 
posing and  exciting  causes  thereof.  Its  cure  is 
to  be  sought  in  carrying  out  the  rules  of  health: 
fresh  air  and  sunlight  are  especially  needful  (see 
Personal  Health).  Iodine,  once  thought  to  be 
a specific,  has  much  sunk  in  repute;  cod-liver  oil 
ought  perhaps  to  be  reckoned  foocl  rather  than 
a drug.  The  cure  of  the  local  lesions  does  not  only 
relate  to  the  sundry  lesions  themselves,  but  is 
also  a means  of  preventing  further  development 
of  the  disease.  Cure  and  prevention  thus  go 
hand  in  hand.  The  treatment  of  the  primary 
local  inflammations  will  be  found  in  the  appro- 
priate articles.  With  regard  to  the  glandular 
abscesses  and  phlegmonous  scrofulides — the  chief 
sources  of  general  tubercular  infection — it  would 
seem  to  be  more  reasonable  to  favour  an  out- 
ward discharge  of  the  matter,  than  to  strive  to 
promote  its  absorption.  Scrofulous  bones  have 
been  removed  with  the  same  intention. 

S.  J.  Gee. 

SCURF. — A popular  name  for  the  furfur  or 
bran-like  exfoliation  which  forms  at  the  roots  of 
the  hair.  It  is  also  called  dandruff.  It  is  com- 
posed of  the  normal  desquamation  of  the  epi- 
dermis of  the  scalp,  with  the  addition  of  the 
epithelial  exuviae  thrown  off  by  the  hair- follicles. 
See  Pityriasis, 

SCURVY. — Synox.  : Scorbutus ; Fr.  Scorbut ; 
Ger.  Scharbock. 

Definition. — Scurvy  is  characterised  clini- 
cally by  intense  general  debility;  sponginess 
and  swelling  of  the  gums  ; ecchymoses,  closely 
resembling  bruises,  about  the  thighs  and  legs  ; 
a brawny  hardness  about,  and  sometimes  a con- 
traction of,  the  muscles  of  the  calf;  pearly  con- 
junctivae ; and  a sallow  aspect  somewhat  akin  to 
mild  jaundice. 

From  a pathological  point  of  view  the  disease 
is  characterised  by  effusion  of  a semi-organisable 
fibrinous  material  in  the  tissues  of  the  gums, 
between  the  strise  of  the  muscles  of  the  thighs, 
legs,  and  sometimes  (but  comparatively  seldom) 
of  the  arms,  and  also  between  the  periosteum 
and  the  bones  of  the  extremities,  and  occasion- 
ally of  the  ribs;  ecchymoses  sometimes  found 
about  the  thoracic  and  abdominal  aortie  and  the 
alimentary  canal ; and  a generally  blanched  con- 
dition of  all  the  tissues. 

./Etiology. — Scurvy  is,  in  an  eminent  degree, 
cosmopolitan.  It  may  prevail  in  a mild  or  severe, 
an  intermittent  or  endemic  form,  in  any  lati- 
tude, in  any  country,  or  among  any  variety  of 
the  human  race,  inasmuch  as  the  predisposing 
and  exciting  causes  may  exist  anywhere  under 
certain  circumstances.  War,  famine,  shipwreck, 
or  any  other  accident  or  exigency  that  deprives 


SCUKVT. 


1402 

human  beings  for  a length,  of  time  of  fresh  vege- 
table food,  is  sufficient  to  introduce  scurvy  into  a 
community.  Although  very  vaguely  described  by 
Hippocrates  and  other  early  writers,  there  is  no 
doubt  that  in  semi-civilised  and  savage  countries 
scurvy  was  endemic.  Most  military  historians, 
who  have  chronicled  the  sanitary  circumstances 
of  armies  from  the  thirteenth  century  to  the 
date  of  the  last  American  war,  speak  of  its 
ravages,  and  in  the  early  months  of  the  Crimean 
War  the  French  lost  more  men  by  scurvy  than 
by  the  guns  of  the  enemy.  It  has  also  from  the 
earliest  times  been  a chief  foe  to  sailors,  and 
until  the  beginning  of  the  seventeenth  century, 
it  constituted  a formidable  item  in  the  mortality 
list  of  the  navy,  in  this  as  in  other  countries. 
In  the  spring  of  1810,  an  outbreak  of  the  dis- 
ease occurred  among  the  prisoners  at  the  Mill- 
bank  Penitentiary,  and  was  confine!  exclu- 
sively to  the  military  sections  of  the  inmates, 
whose  diet  differed  in  one  important  respect 
from  that  of  the  other  convicts.  The  last  ex- 
tensive outbreak  on  land,  other  than  those  that 
have  arisen  in  consequence  of  war,  occurred  in 
Ireland  during  the  potato  famine  in  1847,  when 
th«  inhabitants  suffered  severely.  Since,  how- 
ever, the  prophylactic  properties  of  a vegetable 
diet  have  been  understood,  scurvy,  except  in 
times  of  war,  has — unless  under  very  exceptional 
and  always  preventable  conditions — ceased  to 
assume  formidable  proportions  either  ashore 
or  afloat.  It  is  indeed  in  civilised  communities 
very  rarely  found  on  land.  It  is  almost  extinct 
in  the  Eoyal  Navy,  owing  to  the  introduction  of 
lime-  and  lemon -juice,  and  also  to  the  greater 
variety  in  the  scales  of  diet ; and  during  tire  last 
eight  years  it  has  diminished  in  the  .British  Mer- 
cantile Marine,  by  from  seventy  to  eighty  per 
cent.,  in  consequence  of  legislative  enactments 
that  secure  a proper  quantity  and  quality  of 
antiscorbutics  to  the  crews  of  all  long-voyage 
ships.  Cases  of  the  disease  are  still  seen 
occasionally  at  the  Seamen’s  Hospital  at  Green- 
wich, usually  associated  with  some  other 
disease,  as  dysentery,  ague,  etc. ; hut  in  some 
instances  clearly  caused  by  carelessness,  either 
on  the  part  of  the  captain  in  serving,  or  on  the 
part  of  the  crew  in  not  taking,  the  lime-juice 
provided. 

Pathology  and  Anatomical  Characters. — 
Although  the  aetiology  of  scurvy  is  so  well  under- 
stood, yet  we  are  still  in  ignorance  of  the  pre- 
cise nature  of  the  alterations  of  the  blood  and 
tissues  which  precede  aud  accompany  the  deve- 
lopment of  the  disease.  The  most  important 
contributions  hitherto  made  to  our  knowledge 
of  the  pathology  of  scurvy  are  those  of  Mr. 
George  Busk  and  Dr.  Garrod.  The  former,  in  a 
series  of  analyses  made  of  the  blood  drawn  from 
scorbutic  patients,  showed  that  there  was  a con- 
siderable diminution  of  the  red  blood-corpuscles, 
an  increase  in  the  amount  of  fibrin  and  albumen, 
and  no  deci'easo  in  the  amount  of  potash  salts. 
Dr.  Garrod  observed  that  in  scorbutic  diets 
potash  existed  in  smaller  quantities  than  in  anti- 
scorbutic ones,  and  was  led  to  determine  the 
amount  of  that  substance  in  the  blood  and  urine 
of  a patient  suffering  from  scurvy,  and  he  found 
it  considerably  diminished.  From  this  observa- 
tion, he  brought  forward  the  theory  that  scurvy 


depended  upon  a deficiency  of  potaRh  in  the 
system.  The  fact  that  potash  is  diminished  in  the 
urine  of  patients  suffering  from  scurvy,  has  been 
confirmed  by  Ralfe  and  others.  But  it  is  doubt- 
ful whether  the  disease  is  produced  by  a de- 
ficiency of  that  base  in  the  system,  since  the 
administration  of  large  quantities  of  beef-tea, 
containing  more  potash  than  in  the  ordinary 
anti-scorbutic  dietary  of  the  Seamen’s  Hospital, 
fails  to  exercise  a curative  effect,  and  it  is  not 
till  the  patient  obtains  lime-juice  or  potato  that 
he  recovers.  Dr.  Buzzard  considers  that,  although 
the  organic  acids  and  potash  separately  do  net 
represent  the  requisite  material,  it  is  to  be 
found  in  the  chemical  combination  of  the  acid 
and  the  base.  Dr.  Balfe,  from  observations 
founded  on  the  effect  which  the  withdrawal,  for  a 
considerable  period,  of  all  fresh  succulent  vege- 
tables and  fruits  has  on  the  urine  of  healthy 
persons,  and  from  the  analyses  of  urines  from 
patients  suffering  from  the  (disease,  states  that 
the  ‘ primary  alterations  in  scurvy  seem  to 
depend  on  a general  alteration  between  the 
various  acids,  inorganic  as  well  as  organic,  and 
the  bases  found  in  the  blood,  by  which  (a)  the 
neutral  salts,  such  as  the  chlorides,  are  either 
increased  relatively  at  the  expense  of  the  alka- 
line salts;  or,  (6)  that  these  alkaline  salts  are 
absolutely  decreased.  This  condition  produces 
diminution  of  the  normal  alkalinity  of  the 
blood,  and  he  suggests  that  this  diminution 
produces  the  same  results  in  scurvy  patients  as 
happens  in  animals  when  attempts  are  made  to 
reduce  the  alkalinity  of  the  body  (either  by  in- 
jecting acids  into  the  blood  or  feeding  with 
acid  salts),  namely,  dissolution  of  the  blood- 
corpuscles,  ecchymoses  and  blood-stains  on 
mucous  surfaces,  and  fatty  degeneratiou  of  the 
muscles  of  the  heart,  the  muscles  generally,  and 
the  secreting  cells  of  the  liver  aDd  kidney.’ 

The  most  marked  morbid  changes  of  scurvy 
are  the  cedematous,  spongy,  and  occasionally 
ulcerated  gums ; the  bruised-like  condition  ol 
the  legs ; and  the  brawny  hardness,  confined 
usually  to  the  gastrocnemius  and  hamstring 
muscles.  On  cutting  these  across,  tough  fibrinous 
effusions  are  found  packed  between  the  muscular 
strise,  giving  the  cut  surface  a streaky  appear- 
ance. If  tbe  anterior  surface  of  the  tibia  be 
examined,  the  same  kind  of  effusion  will  be 
often  found  between  the  periosteum  and  the  bone. 
It  would  appear  that  the  effusion  is  due,  not  to 
the  degenerated  condition  of  the  vessels,  but  to 
a chemical  alteration  of  the  blood. 

In  severe  cases  the  ribs  will  sometimes  be 
found  detached  from  the  cartilages,  and  old  frac- 
tures occasionally  become  disunited.  Beyond  a 
general  anaemic  condition,  and  occasional  eeehy- 
motic  spots  about  the  pleura  and  pericardium,  the 
contents  of  the  thorax  present  no  special  appear- 
ances. In  examining  the  abdominal  viscera,  at- 
tention should  be  directed  to  the  spleen,  which 
is  usually  friable,  and  often  rotten  and  pulpy ; 
to  the  external  coats  of  the  intestines,  in  which 
patches  of  effusion  will  frequently  be  found;  and 
to  tbe  mucous  coat  of  the  large  intestine,  which 
if,  as  is  frequently  the  case,  the  disease  be  com- 
plicated with  dysentery,  will  be  studded  with 
ulcers  of  varying  depth,  which  have,  however,  en- 
tirely lost  their  dysenteric  character,  and  becomi 


SCURVY. 


ragged  along  the  edges,  ill-defined,  but  not,  as  a 
rule,  very  much  excavated.  The  body  is  not 
always  badly  nourished,  and  the  cheeks  are 
usually  puffy  on  account  of  the  swollen  gums, 
hut  local  or  general  dropsy  is  seldom  present. 

Symptoms. — -The  most  striking  features  of 
scurvy  are  a complexion  of  sallow,  dull,  leaden 
nue,  analogous  only  to  that  of  a patient  who  has 
been  for  a long  time  subject  to  attacks  of  some 
form  of  remittent  or  intermittent  fever,  or  to 
that  of  a person  recovering  from  jaundice;  pearly- 
white  conjunctive  ; puffy  and  sometimes  bloated 
cheeks;  gums  spongy,  bluish-red  in  colour,  swol- 
len sometimes  to  such  an  extent  as  to  hide  the 
teeth  both  in  front  and  behind,  and  tending  to 
bleed;  teeth  more  or  less  loose,  some  already 
lost ; tongue  clean  and  pale ; no  special  charac- 
teristic about  trunk  and  upper  limbs  (though  the 
latter  are  now  and  then  slightly  ecchymosed) ; 
shortness  of  breath,  but  no  other  chest-complica- 
tion ; no  abdominal  tenderness  or  anything  ab- 
normal as  to  the  functions  of  the  abdominal  or- 
gans ; thighs  and  legs  usually  presenting  a more 
or  less  bruised  appearance,  particularly  justabove 
and  below  the  knee;  brawny  indurations  of  the 
hams  and  calves  of  the  legs,  often  painful  and 
tender ; and  the  effusions  above  described  may 
be  so  dense  and  abundant  as  to  fix  the  legs  in 
a semi-flexed  position.  Node-like  swellings  are 
also  often  observed  over  the  tibia,  owing  to  effu- 
sions between  the  periosteum  and  the  bone. 
There  are  also  usually  a large  number  of  spots 
and  patches,  very  much  like  those  of  purpura, 
scattered  indifferently  about  the  lower  limbs. 
There  is  sometimes  considerable  oedema  about 
the  ankles;  but  in  uncomplicated  scurvy,  pitting 
on  pressure  anywhere  is  the  exception  rather 
than  the  rule.  The  bowels  are  more  or  less  con- 
stipated, appetite  is  good,  and  there  is  no  thirst. 
The  breath  has  a peculiar  offensive  odour,  and 
this  may  be  aggravated  by  ulceration  or  slough- 
ing of  the  gums,  or  necrosis  of  the  jaw.  General 
debility  varies  in  degree,  but  may  be  excessive, 
with  weak  voice,  and  some  tendency  to  fainting, 
if  the  patient  is  put  or  kept  in  a sitting  position. 
Ho  feels  more  or  less  general  aching,  and  a sen- 
sation of  contusion  in  the  legs.  The  skin  is  dry 
and  harsh,  and  desquamates  over  the  legs.  Heart 
and  lung  sounds  are  normal.  The  urine  is  free 
from  albumin,  of  normal  specific  gravity,  with 
abundant  chlorides  ; urea,  phosphates,  and  po- 
tash are  said  to  be  deficient. 

Complications  and  Sequeue. — Simple  scurvy 
is  now  rarely  seen  inland  (except  in  times  of  war 
or  famine),  and  not  very  often  afloat.  It  still, 
however,  complicates  diseases  or  accidents  that 
occur  at  sea  to  a considerable  extent,  and  so  pro- 
longs convalescence  almost  indefinitely.  A sailor, 
for  example,  goes  out  from  England  to  Calcutta, 
and  shortly  after  arrival  in  the  latter  port  is 
attacked  with  dysentery  or  intermittent  fever, 
fractures  a limb,  or  becomes  syphilitic.  He  re- 
mains in  India  a very  short  time,  ships  in  a 
convalescent  and  enfeebled  condition,  lies  up 
before  the  ship  has  been  at  sea  many  days,  and 
probably  does  little  or  no  work  during  the  entire 
passage.  The  berth  that  he  occupies  constantly 
(and  with  very  little  change  of  clothing)  is  pro- 
bably wet,  his  food  scanty  and  unvaried,  and  his 
lime-juice  or  other  antiscorbutics  (as  he  cannot 


1403 

go  to  fetch  them)  served  out  irregularly,  or  per- 
haps refused  when  given.  Under  such  circum- 
stances, scurvy  soon  begins  to  ‘ colour’  the  ori- 
ginal disease.  The  intestinal  canal  in  cases  of 
dysentery,  the  spleen  in  cases  of  ague,  buboes 
and  chancres  in  syphilis,  are  all  attacked,  so  to 
speak,  scorbutically.  Wounds,  scratches,  ulcers, 
or  any  other  breaches  of  surface  will  not  heal, 
and  fractures  sometimes  become  disunited;  so 
that,  as  a consequence,  the  recovery  of  the 
patient  after  his  arrival  is  deferred  (solely 
on  account  of  the  existence  of  this  scorbutic 
condition)  for  several  weeks  or  months.  In  fact, 
all  processes  of  repair,  internally  and  externally, 
appear  to  be  arrested,  and  no  advance  is  made 
until  the  scorbutic  symptoms  have  entirely  dis- 
appeared. Hemeralopia  is  sometimes  associated 
with  scurvy,  and  it  may  be  considered  that  night- 
blindness  is  induced  by  scorbutic  conditions,  in- 
asmuch as  this  affection  has  decreased  pari  passu 
as  scurvy  has  diminished  in  the  British  Mercan- 
tile Marine,  and  is  now  seldom  complained  of 
by  sailors.  In  bad  cases  haemorrhage  may  take 
place  from  mucous  surfaces.  Nausea  and  vomit- 
ing may  also  occur. 

The  sequelae  of  uncomplicated  scurvy  are, 
practically  speaking,  nil,  for  the  patient,  when 
properly  treated,  makes  a rapid  and  complete 
recovery,  leaving  no  trace  of  the  disease  behind. 
There  appears,  however,  to  be  little  doubt  that 
one  illness  renders  the  patient  less  able  to  resist 
successfully  future  attacks  of  the  disease,  if  placed 
under  the  same  predisposing  conditions.  Several 
instances  are  recorded  of  old  sailors,  who  have 
been  the  subjects  of  two  or  three  attacks;  but 
these  have  been  generally  complicated  with  some 
other  disorder,  delirium  tremens  being  occa- 
sionally superadded. 

Diagnosis. — The  diagnosis  of  scurvy  cannot 
be  difficult  if  the  symptoms  described  above  exist, 
and  a dietetic  history  is  carefully  made  out.  As 
Parker  records,  in  a very  valuable  paper  published 
on  that  subject  in  the  second  volume  of  the  Bri- 
tish and  Foreign  Medico-  Chirurgical  Review,  ‘ it 
may  be  confidently  asserted  that  an  invariable 
antecedent  of  every  case  of  scurvy  is  a deficiency 
or  absolute  want  of  fresh  vegetable  food.’  This 
important  item  of  information  being  established, 
the  spongy  gums,  and  the  bruised-like  condition 
of  the  lower  limbs  (this  latter  condition  not  being 
connected  with  any  history  of  accident  or  injury), 
with  great  general  debility,  should  be  sufficient 
to  determine  the  nature  of  the  disease.  For  even 
in  mild  cases  the  condition  of  the  gums  is  quite 
unlike  that  produced  by  mercury.  Moreover,  the 
mercurial  feetor  is  absent,  but  a foetid,  earthy 
odour  exists.  Nor  has  the  dull  blue  margin 
seen  in  the  gums  in  cases  of  lead-poisoning  any 
resemblance  to  the  scorbutic  condition.  Scurvy 
might  be  occasionally  confounded  with  purpura, 
as  in  some  cases  haemorrhagic  spots  only  exist 
about  the  legs,  with  no  ecchymoses  or  hardness 
round  the  calf  and  hamstring  muscles.  But  the 
condition  of  the  mouth,  the  absence  of  severe 
cachexia,  and,  as  Niemeyer  remarks,  the  compa- 
rative absence  of  epistaxis,  hsematemesis,  hsema- 
toma,  and  bloody  evacuations  from  the  bowels  in 
scurvy,  will  aid  at  once  to  settle  the  diagnosis. 
The  disease  is  now,  under  ordinary  circum- 
stances, rare  among  women  and  children.  The 


SCURVY. 


1401 

possibility  of  its  existence  should  not,  however, 
be  overlooked.  Ur.  H.  G.  Sutton  read  at  the 
Clinical  Societ}7,  in  1871,  notes  of  two  cases  of 
acute  scurvy  in  women,  but  no  particulars  as  to 
dietetics  are  given.  Dr.  Dickinson  had  under  his 
care  at  the  Children’s  Hospital,  Great  Ormond 
Street,  a girl,  ten  years  of  ago,  who  was  the  sub- 
ject of  genuine  uncomplicated  scurvy,  whose  diet 
had  for  some  months  consisted  chiefly  of  bread 
and  butter,  with  no  meat,  and  little  or  no  milk. 
Single  cases  are  also  occasionally  noted  by  phy- 
sicians, caused  for  the  most  part  by  pursuing 
strictly  a scorbutic  regimen,  for  the  purpose  ol' 
combating  some  other  obstinate  disorder. 

Prognosis. — Scurvy  existing  apart  from  other 
maladies  is  not  a fatal  disease.  The  patient 
may  be  seen  in  a state  of  excessive  prostration, 
with  feeble  pulse,  whispering  voice,  and  a ten- 
dency to  syncope,  unless  the  recumbent  position 
be  rigorously  maintained  ; but  a few  days’  rest, 
under  favourable  conditions,  and  proper  treat- 
ment, produce  a marvellous  change,  which  re- 
sults in  a steady  and  very  satisfactory  convales- 
cence. But  before  this  prognosis  is  given,  care 
should  be  taken  to  ascertain  that  the  scurvy 
does  not  cover  any  other  chronic  or  organic  dis- 
ease. Dysentery,  syphilis,  and  the  various  forms 
of  intermittent  fever,  are  undoubtedly  its  worst 
complications,  and  either  of  these  maladies  will, 
even  under  favourable  circumstances,  prolong 
convalescence  considerably.  The  duration  of 
the  disease  is  limited  only  by  the  vitality  of  the 
causes  that  produce  it,  for  as  long  as  the  scor- 
butic diet  and  other  predisposing  conditions 
exist,  so  long  will  the  disease  maintain  the 
mastery,  and  progressively  increase  in  severity. 
M.  Villemin,  writing  on  the  causes  and  nature 
of  scurvy,  in  the  Gazette  dcs  Hopitaux , 1874, 
says,  as  the  result  of  experiences  gleaned  during 
the  siege  of  Paris,  that  scurvy  is  a contagious 
disease,  and  should  ba  classed  with  typhus.  It 
is  impossible,  in  face  of  facts  recorded  both  as  to 
sea  and  land  scurvy7,  to  subscribe  to  this  opinion, 
and  it  is  difficult  to  understand  on  what  grounds 
such  a dictum  can  be  based. 

Treatment. — If  the  patient,  w'hen  firstbrought 
under  notice,  be  so  ill  as  to  be  unable  to  walk 
or  stand,  great  care  should  be  taken  that  the 
recumbent  position  is  adopted  and  maintained. 
Many  severe  cases  of  scurvy  have  been  lost  by 
the  neglect  of  this  apparently  simple  precaution. 
The  patient,  in  the  absence  of  the  nurse,  sits  up 
in  bed,  and  has  a sudden  attack  of  syncope,  from 
which  he  never  recovers.  Having  regard  to  this, 
let  the  patient  be  undressed  carefully,  and 
washed  (without  a bath),  any  wounds  or  abra- 
sions being  covered  with  simple  water-dressing. 
The  direct  treatment  of  the  disease  is  almost 
purely  dietetic,  starting  upon  the  principle  that 
want  of  fresh  vegetable  diet  has  been  the  ex- 
citing cause  of  the  illness.  So  the  diet  should 
consist  of  mashed  potatoes ; any  variety  of  green 
meat  (the  Cruciferce  being  perhaps  the  best) ; 
oranges, pears,  apples;  and,  as  a convenient  anti- 
scorbutic, lime-  or  lemon-juice  at  the  rate  of  from 
three  to  four  ounces  daily7,  mixed  with  about 
eight  times  its  bulk  of  water,  sweetened  to  taste, 
and  used  as  a drink.  Solid  animal  food  should 
be  given  at  least  orce  a day,  and  in  liberal  quan- 
tity. as  soon  as  it  can  be  properly  masticated. 


Begin  in  bad  cases  with  beef  tea,  mutton  broth, 
milk,  eggs,  fish  and  minced  meat,  in  fact,  any  and 
all  varieties  of  nutritious  animal  food,  in  con- 
junction with  the  vegetable  diet ; for  the  appetite 
is  usually  good,  and  the  digestive  powers  almost 
unimpaired.  If  great  prostration  exist,  brandy, 
in  small  and  frequent  doses,  must  of  course  be 
given ; but  as  a general  rule,  very  little  is  re- 
quired. Malt  liquors  are  undoubtedly  antiscor- 
butic, and  it  is  well  to  give  a pint  of  ale  or 
porter  daily  if  no  dysenteric  complication  exist. 
Milk  is  also  to  a certain  extent  antiscorbutic, 
and  should  be  given  freely7.  Sir  James  Paget  re- 
lates of  a surgeon  that  he  lived  for  nineteen  years, 
engaged  in  active  practice,  on  milk  and  bread- 
stuffs  exclusively,  and  at  the  end  of  that  time 
only  was  attacked  with  scurvy.  As  regards 
therapeutics,  little  or  nothing  net!  be  done. 
All  active  treatment,  general  and  local,  is  em- 
phatically wrong.  The  administration  of  mer- 
cury7 to  scorbutic  patients  (through  errors  of 
diagnosis)  did,  in  former  years,  an  enormous 
amount  of  mischief,  and,  even  in  the  presence 
of  chest-complications,  all  counter-irritants  to 
the  skin  must  be  avoided.  Chlorate  of  potash, 
in  the  form  of  a mouth-wash,  or  given  inter- 
nally, probably7  assists  to  cleanse  and  purify 
the  gums  and  mouth ; and  if  old  ulcers  or 
open  sores  exist  upon  any  part  of  the  body,  lint, 
wetted  with  weak  lime-juice,  is  said  to  promote  a 
healthy  surface.  But  whether  any  complication 
be  internal  or  external,  no  processes  of  elimina- 
tion or  repair  will  advance  satisfactorily  until 
the  scorbutic  symptoms  disappear.  If  no  grave 
disorder  beyond  the  scurvy  exist,  recoveiy  is 
very  rapid,  and  few  diseases  are  so  eminently 
satisfactory  to  treat.  The  gum-swellings  recede, 
and  the  ecchymoses  on  the  legs  begin  to  disap- 
pear after  two  or  three  days  of  treatment ; and 
the  brawny  tenderness  of  the  muscles  of  the 
lower  limbs  diminishes  daily,  the  fibrinous  effu- 
sions causing  it  being  steadily  and  quickly  ab- 
sorbed. Dysentery  is  the  most  common  compli- 
cation of  scurvy,  and  is  usually  tedious7  and 
troublesome.  A fair  trial  should  be  given  to  the 
treatment  above  recommended,  excluding  malt 
liquors,  and  substituting  a small  allowance  of 
brandy,  and  as  a rule  the  dysentery  and  scurvy 
will  disappear  together. 

The  antiscorbutic  treatment  proper  to  combat 
the  advent  of  this  disease  is  sufficiently  indi 
eated  in  the( above  remarks,  for  it  will  be  plainlj 
seen  that  scurvy  is  due  to  the  absence  of  certain 
necessary  ingredients  in  diet.  "When  these  in- 
gredients cannot  be  given  in  the  usual  form,  the 
mostconvenient  substitutes  are  lime-juice,  lemon- 
juice,  and  in  a minor  degree  citric  acid.  Garrod 
recommends  salts  of  potash,  and  John  Morgan, 
of  Dublin,  thinks  that  phosphorus  is  deficient 
where  scurvy  exists.  But  the  great  mass  of  evi- 
dence, collected  during  the  last  fifty  years,  goes 
to  prove  that  lime-  and  lemon-juice  contain,  in 
natural  combination,  the  best  and  most  conve- 
nient prophylactic  elements  against  scurvy.  Its 
use  in  the  Royal  Navy  has,  since  the  close  of 
the  last  century,  been  chiefly  instrumental  in 
driving  the  disease  out  of  the  service;  and  legis- 
lative enactments  passed  in  1867,  whereby  a 
proper  and  genuine  supply  of  juice  was  secured 
to  all  British  sailors,  have  resulted  in  the  deereaw 


SCURVY. 

M scurvy  in  our  own  Mercantile  Marine  by  from 
70  to  80  per  cent.  Single  cases  are,  of  course, 
occasionally  met  with  afloat,  for  the  disease,  al- 
though almost  entirely  preventive,  will  never 
be  practically  exteinnnated  from  the  merchant 
navy  until  legislators,  snip-owners,  and  ship- 
masters are  convinced  that  it  is  commercial 
economy  to  send  to  sea  only  healthy  men. 
Scurvy  will,  of  course,  always  be  liable  to  occur 
in  times  ot'  war  and  famine ; and  among  any  class 
of  the  population  the  possibility  of  its  existence 
in  single  cases,  in  consequence  of  dietetic  de- 
ficiencies, should  never  be  overlooked. 

Hakey  Leach. 

SCYBALA  (oKv&a\ov,  dung). — Faeces  in  the 
form  of  hard  rounded  lumps,  whether  discharged 
or  retained  in  the  intestine.  See  F;ecf.s,  Examina- 
tion of. 

SEA-AIR;  SEA-BATHS;  S E A- 
V'OYAGES. — The  physiological  and  therapeu- 
tical effects  of  sea-bathing  cannot  be  separated 
from  those  of  sea-air;  for  it  is  impossible  to 
take  sea-batlis  without  being  under  the  influence 
of  sea-air;  and  the  stay  at  the  seaside  alone, 
without  sea-bathing,  produces  on  many  consti- 
tutions all  the  effects  which  are  usually  ascribed 
to  sea-bathing.  Residence  at  the  seaside,  that 

is,  the  influence  of  sea-air,  is  to  be  regarded  as  a 
special  kind  of  climatic  treatment,  while  the 
action  of  the  sea-bath  is  analogous  to  the  stimu- 
lating forms  of  the  cold-water  treatment. 

As  the  sea-air  and  the  s%a-bath  owe  part  of 
their  properties  to  the  constitution  of  sea-water, 
it  will  be  well  to  begin  with  the  latter,  then 
consider  the  characters  and  influences  of  the 
sea-air  and  the  sea-bath,  and  add  some  notes  on 
seaside  watering-places,  and  on  sea-voyages. 

Sea-water. — Temperature. — The  sea-water  is 
of  more  equable  temperature  than  the  surrounding 
air.  It  is,  as  a rule,  warmer  than  the  atmosphere 
in  winter,  and  cooler  in  summer ; although  on 
chilly  days  in  summer,  especially  after  a series  of 
hot  ones,  the  temperature  of  the  sea-water  is  often 
higher  than  that  of  the  air.  Th6  variations  of 
the  temperature  of  sea-water  from  night  to  day, 
and  from  one  day  to  another,  are  much  less  than 
those  of  the  air.  It  would,  however,  be  erroneous 
to  assume,  as  is  sometimes  done,  that  the  tem- 
perature of  the  sea-water  near  the  shore  is  the 
same  at  different  times  of  the  day.  The  writer 
has  often  measured  it  at  the  Riviera,  and  the 
south  coast  of  England,  and  has  repeatedly  found 

it,  at  one  f.m.  and  two  f.m.,  from  5°  to  7°  Fahr. 
higher  than  on  the  corresponding  mornings  at 
seven  or  eight  a.m.  As  to  the  different  seasons, 
the  sea-water  reaches  its  highest  temperature  in 
summer  much  later  than  the  air  ; and  as  it  loses 
its  heat  less  rapidly  than  the  latter,  it  is  mostly 
warmer  in  autumn  and  winter  than  the  sur- 
rounding air,  and  gives  off  warmth  to  the  latter. 
During  the  sea-bathing  season,  namely,  from  the 
end  of  May  to  the  beginning  of  October,  the  tem- 
perature of  the  sea-water  at  the  coasts  of  Eng- 
land, the  north  of  France,  Belgium,  Holland, 
and  Germany,  varies  in  general  from  about  56° 
to  72°  Fahr.,  while  in  the  Bay  of  Biscay  and  in 
the  Mediterranean  it  is  considerably  higher. 

Constituents.— Sea-water  holds  in  solution  a 


SEA-AIR,  SEA-BATHS,  &c.  1405 

large  amount  of  salts,  varying  somewhat  in 
different  localities,  and  slightly  even  in  the  same 
place  at  different  times.  The  Mediterranean  is 
richest,  with  about  2|  to  3§  percent. ; whilst  the 
water  at  the  coasts  of  the  British  Channel  and 
German  Ocean  varies  from  2£  to  3£  per  cent. 
The  water  of  the  Baltic,  owing  to  the  large 
number  of  streams  which  enter  it,  is  much  less 
salt,  containing  only  about  £ per  cent.  Five- 
sixths  of  all  the  salts  are  chlorides  of  sodium 
and  magnesium,  whilst  the  remainder  consist  of 
the  sulphates  and  carbonates  of  lime,  magnesia, 
and  potash. 

Sea-air. — The  sea-air,  and  the  air  at  the  sea- 
shore, are  considerably  influenced  by  the  con- 
stant evaporation  taking  place  from  the  sea,  and 
also  by  the  temperature  of  the  sea.  Owing  to 
these  circumstances,  the  sea-air  contains  in 
general  more  moisture,  relative  as  well  as  ab- 
solute ; and  is  more  equable  in  temperature,  the 
summer  being  less  hot,  and  the  winter  less  cold 
at  the  seaside  than  at  inland  places  in  the  same 
latitude  ; the  day  also  may  be  regarded  as  less 
warm  in  summer,  the  night  as  less  cool  in  winter. 
A very  important  fact  is  the  comparative  purity  of 
the  sea-air  from  organic  admixture  and  inorganic 
dust,  while  the  occasional  presence  of  a greater 
or  smaller  amount  of  saline  particles  cannot  be 
regarded  as  a disadvantage.  The  amount  of  ozone 
is  greater  ; that  of  carbonic  acid  smaller.  The 
variations  of  the  barometer  are  greater,  but  more 
regular  in  their  occurrence,  and  this  possibly 
exercises  a.beneficial  influence  on  the  functions 
of  life.  The  greater  density  of  the  atmosphere, 
which  means  a comparatively  large  amount  of 
oxygen  in  a given  volume  of  air,  is  often  con- 
sidered as  one  of  the  principal  causes  of  the  stimu- 
lating effect  of  sea-air;  but  Frankland’s  and 
Tyndall’s  experiments  on  combustion  render  the 
usual  reasoning  on  this  point,  with  regard  to 
combustion  and  tissue-change,  rather  doubtful. 
Nor  is  the  fact  to  be  overlooked  that  the  air  at 
the  sea-shore  is  mostly  in  greater  agitation  than 
the  inland  air ; and  by  this  circumstance  is 
probably  to  be  explained  the  experience  of 
Benecke  (‘  Sea-air  and  Mountain-air,’  Deutsch. 
Arch./.  Klin.  Med.,  vol.  xiii.  p.  80,  1874),  that 
the  same  body  of  hot  water  loses  its  heat  more 
rapidly  at  the  sea-shore  than  at  various  eleva- 
tions in  Switzerland,  varying  from  3,000  to 
6.000  feet  above  sea-level— an  experience  from 
which  we  may  infer  that  living  bodies  likewise 
give  off  more  heat  at  the  sea-shore  than  in 
elevated  inland  regions.  The  physiological 
effects  of  sea-air  may  be  designated,  with 
Braun  ( Curative  Effects  of  Baths  and  Waters, 
English  edition,  187-5,  p.  253),  as  ‘powerful 
stimulation  of  the  change  of  substance,  both 
retrogressive  and  formative,  expressed  in  a 
striking  increase  of  urea,  and  decrease  of  uric 
acid  and  phosphoric  acid  in  the  urine,  in  the 
greatly  increased  requirements  of  food,  and  in 
the  rapid  and  considerable  increase  of  the 
weight  of  the  body.’  A certain  power  of  re- 
sponding to  the  increased  stimulus  of  the  sea- 
air  is,  however,  required  of  the  constitution  ; 
for  the  increased  tissue-change  necessitates  an 
increase  in  the  ingestion  of  food,  and  in  the 
processes  of  excretion  of  the  products  of  retro- 
gressive tissue-change.  If  the  digestive  and 


i40G  SEA-AIE.  SEA-BATHS.  SEA-VOYAGES. 


Assimilative  organs  be  unablo  to  satisfy  the 
former  demand,  various  digestive  disturbances 
arise,  the  appetite  fails,  and  emaciation  is  often 
the  consequence.  In  many  of  these  conditions 
greater  benefit  is  derived  from  mountain  health- 
resorts,  where  the  demands  made  on  the  constitu- 
tion are  less  great,  and  where  less  food  is  required. 
If  the  excretory  functions  be  imperfect,  as  is 
the  case  in  so-called  ‘bilious’  individuals,  and 
in  some  undefined  gouty  tendencies,  headaches, 
giddiness,  constipation,  or  other  symptoms  usu- 
ally called  ‘ biliousness,’  make  their  appearance, 
and  sometimes  render  the  removal  from  the 
sea-shore  necessary,  though  the  use  of  aperient 
remedies,  reduction  in  the  amount  of  food,  and 
especially  of  stimulants,  and  active  exercise  at 
some  distance  from  the  sea,  often  suffice  to 
correct  this  defective  elimination  and  its  con- 
sequences. In  many  cases  of  this  kind,  however, 
courses  of  mineral  waters,  especially  the  alka- 
line, saline,  or  common  salt  springs,  ought  to 
precede  the  stay  at  the  seaside.  See  Mineral 
Waters. 

Sea-batlis. — The  sea-bath  may  be  regarded 
as  a powerfully  stimulating  cold-water  bath, 
modified  in  its  action  by  the  saline  ingredients  ; 
by  the  admixture  of  mechanical  particles,  or- 
ganic as  well  as  inorganic;  by  the  varying 
degree  of  motion  through  the  waves  ; and  by  the 
alternation  in  the  exposure  of  a part  of  the 
body  to  the  waves  and  to  the  air.  We  have 
already  discussed  the  temperature  of  the  sea- 
water, and  the  saline  ingredients;  but  the 
temperature  of  the  surrounding  air,  and  the 
degree  of  motion  in  the  air,  also  exercise  a 
modifying  influence  on  the  effects  of  the  sea- 
bath.  The  motion  of  the  water  varies  con- 
stantly, according  to  the  size  and  force  of  the 
waves,  and  the  effect  of  the  bath  to  a great 
degree  depends  on  this  point.  When  the  waves 
are  in  any  degree  powerful,  the  upper  part  of 
the  body  is  exposed  to  the  coming,  the  lower  to 
the  receding  wave,  and  the  cutaneous  nerves  are 
not  only  influenced  by  the  cold,  but  also  by  the 
force  of  the  water,  and  by  the  sand  and  other 
substances  mixed  with  it.  In  a quiet  sea 
these  influences  are  considerably  lessened.  The 
alternation  of  exposure  to  the  water  and  the 
air,  likewise  occasioned  by  the  waves,  is  peculiar 
to  the  sea-bath,  and  is  another  source  of  con- 
stantly changing  impressions  on  the  cutaneous 
nerves. 

Bathing-season,  and  Rules  for  tjsing  it. — 
The  season  for  sea-bathing  varies  according  to  the 
climate  of  the  locality.  Thus  it  extends  on  the 
Mediterranean  shores  from  May  to  October  and 
even  November ; on  the  shores  of  the  English 
Channel  and  German  Ocean  from  J une  to  Sep- 
tember and  the  beginning  of  October.  The  time 
of  the  day  for  sea-bathing  must  depend  on  the 
individual,  on  the  weather,  and  on  the  tide. 
Delicate  persons  ought  not  to  bathe  with  a 
perfectly  empty  stomach ; but  also  never  after  a 
full  meal.  The  duration  of  each  bath  is  to  be 
regulated  according  to  the  constitution  of  the 
batter,  the  force  of  the  waves,  and  the  tem- 
perature of  the  water.  Weakly  persons  ought 
not  to  remain  in  the  water  over  half  a minute 
to  five  minutes,  but  immersion  for  one  and  two 
minutes  is  in  many  such  cases  all  that  is  useful 


and  permissible,  while  stronger  individuals  may 
remain  from  five  to  ten  minutes.  The  bather, 
we  may  say  in  general  terms,  ought  to  leave  the 
water  as  soon  as  the  reaction  manifests  itself. 

In  many  cases,  the  warm  sea-water  bath  may 
be  recommended  with  advantage,  when  the  cold 
sea-bath  is  forbidden.  Indeed,  courses  of  bath- 
ing in  warm  sea-water  are  not  sufficiently  used 
in  a systematic  way,  though  the  medical  prac- 
titioner possesses  in  them  a gentle,  manageable, 
and  efficacious  means  of  treatment  daring  winter 
as  well  as  during  summer.  They  are  in  their 
action  analogous  to  warm  common  salt-baths  ( see 
Baths  ; and  Mineral  Waters).  Unfortunately 
the  arrangements  are  still  very  defective  at  many 
localities.  Some  physicians  at  seaside  places 
are  beginning  to  make  more  extensive  use  of 
them,  and  with  excellent  results.  The  tepid 
swimming-bath  of  sea-water  we  may  regard  as 
intermediate  between  the  warm-bath  and  the 
bath  in  the  open  sea,  and  likewise  as  very  useful 
in  appropriate  cases.  With  due  care  it'  can  be 
employed  also  in  winter.  It  offers  the  advantage 
of  the  combination  of  one  of  the  most  perfect 
modes  of  muscular  exercise,  with  exposure  of  the 
skin  to  the  influences  of  the  sea -water  bath. 

The  physiological  effects  of  the  sea-baths  are 
similar  to  those  of  the  sea-air.  Abstraction  of 
heat  and  stimulation  of  the  cutaneous  nerves 
lead  to  increased  tissue-change,  retrogressive  as 
well  as  productive.  Increased  appetite  and  in- 
creased weight  of  body  are  usually  observed 
in  those  who  are  benefited  by  sea-baths;  while 
loss  of  appetite,  headache,  digestive  disturb- 
ances, and  loss  of  weight  are  often  observed  in 
those  who  are  unable  to  bear  the  shock,  or  the 
increased  demand  on  the  body,  or  who  remain 
too  long  in  the  bath,  or  take  it  too  frequently. 

Cases  not  suited  for  Sea-bathing.— Persons 
affected  with  diseases  of  the  heart,  or  of  the  blood- 
vessels and  lungs,  with  organic  diseases  of  the 
nervous  system,  with  enlargement  of  the  liver, 
or  with  other  organic  diseases  of  the  abdominal 
viscera,  ought  to  avoid  bathing  in  the  open  sea, 
which  may  produce  most  injurious  effects,  such  as 
violent  palpitation  and  dyspnoea  extending  over 
many  months,  sleeplessness,  total  loss  of  appe- 
tite, and  great  emaciation.  Old  persons,  and 
persons  with  feeble  circulation,  whether  from 
age  or  otherwise,  ought  to  avoid  bathing  in  the 
open  sea.  excepting  on  warm  days,  and  with  a 
very  quiet  sea. 

Cases  to  be  benefited  bt  Sea-bathing.— 
Sea-bathing  is  useful  in  many  conditions  con- 
nected with  weakness  or  atony  of  the  skin,  such 
as  tendency  to  profuse  perspiration,  or  to  taking 
cold  at  every  change  of  temperature,  or  exposure 
to  wind  or  draught. 

In  scrofulous  complaints,  long-continued  re- 
sidence at  the  seaside  promises  more  than 
other  climatic  agents ; but,  as  we  have  to  deal 
with  constitutional  defects,  and  as  our  aim  must 
be  to  alter  the  constitution,  two.  three,  or  even 
more  years  are  often  required.  In  many  cases, 
judicious  courses  of  sea-bathing,  the  use  of 
warm  sea-water  baths,  and  sponging  with  sea- 
water, assist  the  climatic  element  of  seaside 
residence.  Education  at  schools  situated  at  the 
seaside  offers,  in  scrofulous  children,  the  greatest 
advantages. 


SEA-AIR,  SEA-BATHS,  SEA-VOYAGES.  1407 


Id  muscular  rheumatism,  the  moderate  use  of 
the  sea-bath  combined  with  sea-air  is  useful. 
In  more  recent  rheumatic  joint-affections  the 
sea-bath  is  mostly  injurious,  whilst  the  more 
gentle  action  of  the  sea-air,  combined  with  the 
use  of  warm  sea-water  in  local  and  general 
baths,  is  frequently  beneficial.  Persons  affected 
with  so-called  nervous  rheumatism — a term 
which  is  applied  sometimes  to  hysterical  cases, 
sometimes  to  spinal  irritation,  and  also  to 
rheumatism  combined  with  nervous  weakness  — 
often  derive  benefit  from  the  gentle  use  of  the 
sea-bath,  and  still  more  from  the  sea-air. 

In  some  functional  diseases  of  the  nervous 
system,  the  sea-bath  forms  an  excellent  remedy, 
if  it  be  adapted  to  the  individual  case;  for  in- 
stance, in  hysterical  paralysis  and  other  forms 
of  hysteria,  in  the  milder  forms  of  diphtheritic 
paralysis,  and  in  nervous  dyspepsia.  It  must, 
however,  be  borne  in  mind  that  many  persons, 
with  a tendency  to  neuralgia,  nervous  asthma, 
hysterical  convulsions,  and  other  forms  of  hys- 
teria, are  unable  to  stand  prolonged  residence  at 
the  sea,  especially  at  the  Riviera.  In  such  cases, 
mountain  climates  are  generally  more  advantage- 
ous, during  summer  and  autumn.  In  many  forms 
of  anaemia,  when  it  does  not  depend  on  organic 
disease  of  the  heart  and  blood-vessels  or  other 
viscera,  but  on  direct  loss  of  blood  or  its  con- 
stituents, on  confinement,  grief,  and  imperfect 
food,  on  slow  and  imperfect  development,  sea- 
air  exercises  a good  effect.  Hence  the  benefit 
obtained  in  many  cases  of  amenorrhcea,  chlorosis, 
and  allied  complaints.  Often,  however,  the 
demauds  made  by  the  sea-air  on  the  constitution 
are  too  great,  and  the  invalids  lose  weight; 
whereas  they  gain  on  mountains  of  moderate 
elevation. 

In  chronic  pneumonia,  in  the  remains  of 
pleuritic  effusion,  and  in  phthisis,  the  sea-air,  by 
its  purity  and  its  more  equable  temperature,  is 
useful ; but  as  wind  is  in  most  cases  to  be  avoided, 
sheltered  localities  are  essential.  Sea-bathing  is 
in  this  class  of  cases  hazardous.  The  beneficial 
effects  in  whooping-cough,  when  the  first  stage 
is  over,  are  well  known.  Regarding  asthma, 
nothing  can  be  said  with  certainty ; some  cases 
of  nervous  asthma  are  benefited  at  the  seaside, 
while  others  are  aggravated ; on  the  whole  the 
writer’s  experience  is  more  in  favour  of  elevated 
regions  than  of  the  seaside.  Whenever  the 
effect  is  not  yet  known,  the  recommendation  of 
seaside  residence  or  mounta  m-air  must  be  re- 
garded as  a trial ; only  in  complications  with 
heart-disease,  the  injurious  effect  may  be  re- 
garded as  certain.  The  advantage  to  be  obtained 
in  tendency  to  catarrh  we  have  already  men- 
tioned. 

In  addition  to  the  conditions  named,  there  are 
many  which  cannot  be  designated  by  the  name 
of  any  disease ; but  which  are  only  states  of 
weakness,  manifesting  themselves  in  various 
ways,  as  inability  to  sustain  mental  or  bodily 
efforts,  tendency  to  abortions,  to  leucorrhcea 
without  any  disease,  &c.  In  such  states  of 
weakness  the  stimulating  effect  of  the  sea-air, 
combined  with  the  grand  aspect  of  the  sea,  are 
found  eminently  useful. 

Seaside  Watering-places. — England  is  re- 
markably well  provided  with  seaside  places,  and 


the  different  localities  offer  considerable  variety 
with  regard  to  climate.  The  east  coast,  which 
may  he  designated  as  drier  and  more  bracing, 
is  especially  to  be  recommended  from  the  middle 
of  June  to  the  middle  of  October.  The  principal 
places  on  the  east  coast  are,  beginning  with  the 
north,  Tynemouth,  Redcar,  Saltburn-by-the-Sea, 
Whitby,  Scarborough,  Eiley,  Bridlington,  Cro- 
mer, Yarmouth,  Lowestoft,  Aldborough,  Dover- 
court,  Walton-on-the-Naze,  Southend,  Margate, 
Broadstairs,  Ramsgate,  Heal,  and  Dover.  On 
the  south-eastern  and  southern  coast,  which 
may  be  regarded  as  intermediate  between  the 
eastern  and  the  south-western  coast,  we  have 
Folkestone,  Sandgate,  Hastingswdth  St.  Leonards- 
on-Sea,  Eastbourne,  Seaford,  Brighton,  Wor- 
thing, Littlehampton,  Bognor,  the  Isle  of  Wight, 
Bournemouth,  and  the  Channel  Islands.  These 
places  differ  considerably  with  respect  to  the 
soil  on  which  they  lie ; the  position — close  to 
the  sea  or  on  a cliff;  the  aspect;  and  the  con- 
figuration of  the  locality  itself  and  the  surround- 
ing country.  Even  different  parts  of  the  same 
place  offer  different  advantages.  Thus  the  lower 
part  of  Folkestone,  near  the  lower  Sandgate 
road,  is  sheltered  from  the  north,  by  the  cliff, 
while  the  houses  on  the  cliff  itself  are  more 
or  less  freely  exposed  to  the  winds  from  all 
quarters,  and  therefore  preferable  during  the 
summer  months.  Hastings  with  St.  Leonards  is 
remarkably  sheltered  from  the  north,  north-west, 
and  to  some  degree  from  the  north-east  winds, 
and  is  through  this,  and  through  the  influence 
of  the  sea,  some  degrees  warmer  during  the  late 
autumn  and  the  early  winter  months — we  may 
say  till  February — than  closely  adjacent  but  less 
sheltered  places.  In  the  Isle  of  Wight,  the 
Undereliff,  with  Ventnor  and  Bonchurch,  is  shel- 
tered by  the  hills  from  north  and  north-east 
winds,  like  Hastings,  and  more  so ; and  has 
during  winter  a more  equable  and  a higher  tem- 
perature than  other  parts  of  the  island.  The 
Undercliff  is  therefore  more  adapted  for  climatic 
treatment  during  the  colder  part  of  the  year ; 
whileSandown,  Shanklin,  Cowes,  Ryde,  Alum  Bay, 
and  Freshwater  are  more  suited  for  sea-bathing 
and  climatic  purposes  during  the  warmer  months. 
Bournemouth  is  sheltered  as  well  by  the  configu- 
ration of  the  hills  as  by  the  pine-woods,  which 
serve  as  a protection  from  violent  winds.  On 
the  south-western  coast,  which  may  be  regarded 
as  somewhat  moister  and  more  sedative,  Swan- 
age,  Weymouth,  Sidmouth,  Budleigh  Salterton, 
Dawlish,  Torquay,  Teignmouth,  and  Penzance 
are  the  principal  sea-bathing  places,  amongst 
which  Torquay  may  he  regarded  as  the  most 
important  winter  health-resort.  On  the  North 
Devon  coast  we  may  name  Lynmouth,  Hffa- 
combe,  and  Minehead  ; on  the  Bristol  Channel, 
Weston-super-Mare,  Portishead,  and  Clevedon  ; 
on  the  Welsh  coast,  Tenby,  Aberystwith,  Pen- 
maenmawr,  Llandudno,  Rhyl ; and  in  Lancashire, 
Westmoreland,  and  Cumberland,  Grange,  shel- 
tered by  configuration,  Southport  and  Blackpool. 
Fleetwood,  St.  Bees,  and  Silloth. 

Scotland  likewise  offers  abundant  localities 
for  sea-bathing,  the  most  frequented  of  which 
are  Nairn  on  the  east  coast,  Rothsay  in  Bute, 
Ardrossan  near  the  firth  of  Clyde,  and  the  Isle 
'.f  Arran  on  the  west. 


1408  SEA-AIR,  SEA-BATHS.  SEA-VOYAGES. 


Ireland  is  even  richer,  ^vith  Bray  and  Kings- 
town, near  Dublin  ; Duneannon  and  Tramore  on 
the  south  coast;  Rostrevor  and  Fortrush  further 
north;  Bundoran  in  the  north-west ; Kilkee  in 
the  south-west;  and  Queenstown,  a sheltered 
and  warm,  but  moist,  climatic  health-resort  in 
the  south,  where  are  also  Youghal  and  Bally- 
cotton. 

On  the  north  coast  of  France,  Calais,  Boulogne, 
St.  Valery,  Treport,  Dieppe,  Etretat,  Fecamp, 
Havre,  Trouville,  Deauville,  Villers-sur-Mer,  and 
Dinard,  are  the  most  favourite  resorts;  on  the 
south-west,  Arcachon  and  Biarritz  ; and  on  the 
south,  Marseilles,  Cannes,  and  Nice. 

The  west  and  south-west  coasts  of  Italy  possess 
many  good  localities  for  sea-bathing  for  those 
requiring,  or  at  all  events  bearing  heat,  such  as 
Bordighera,  Alassio,  San  Remo,  Castellamare, 
Sorrento,  and  the  islands  of  Capri  and  Ischia. 

On  the  coast  of  Belgium,  Holland,  and  Ger- 
many the  most  important  localities  are  Blanken- 
berghe,  Ostend,  Scheveningen,  Borkum,  Norder- 
ney,  Baltrum,Langeroog,  Spikeroog,  Wangeroog, 
DaDgast,  Cuxhaven,  Wyk,  and  Westerland. 

The  coasts  of  Norway,  Sweden,  and  Denmark 
offer  likewise  good  opportunities  for  sea-bathing, 
combined  with  bracing  soa-air,  from  July  to 
September. 

Sea-voyages. — Sea- voyages  have  from  remote 
antiquity  formed  a mode  of  treatment  in  chronic 
diseases,  especially  of  the  respiratory  organs,  and 
have  more  lately  been  much  recommended  in  the 
treatment  of  consumption  and  scrofulous  affec- 
tions ; but  the  different  influences  to  which  the 
invalid  is  exposed  on  long  sea-voyages  are  but 
little  appreciated  in  their  details  by  the  majority 
of  the  public,  or  by  medical  men. 

The  essential  advantages  which  are  generally 
ascribed  to  sea-voyages  are  the  enjoyment  of 
perfectly  pure  sea-air,  abundance  of  light,  and 
free  exposure  to  the  sea-breezes ; absence,  or  at 
all  events  great  limitation,  of  bodily  exertion  ; 
and  the  probability  of  psychical  repose.  The  un- 
initiated frequently  regard  these  advantages  as 
more  or  less  fixed  and,  so  to  say,  measurable 
qualities,  and  speak  of  sea-voyages  in  the  same 
way  as  of  sea-bathing,  cold-water  treatment, 
mineral-water  cures,  or  mountain  climates.  The 
advantages  of  sea-voyages  are,  however,  by  no 
means  fixedqualities,  and  they  are  often  mixed  up 
with  unfavourable  influences,  such  as  bad  weather, 
sea-sickness,  improper  food,  &e.  In  every-day 
life  it  is  an  acknowledged  fact,  and  not  less  so  in 
all  climatic  cures,  that  the  house  in  which  the 
invalid  lives  exercises  a most  powerful  influence 
on  his  chance  of  regaining  and  maintaining  his 
health ; and  that  the  house  alone  often  mars  the 
effect  of  the  best  adapted  climatic  change.  In 
the  same  way  the  floating  house,  the  ship,  with 
its  arrangements,  forms  one  of  the  most  impor- 
tant elements  in  the  compound  agent  ‘ sea-voyage.’ 
The  arrangements  of  ships,  however,  are  no- 
toriously often  very  imperfect,  and  the  narrow 
cabin  never  stands  comparison  with  a good  bed- 
room, the  only  counterbalance  to  this  drawback 
often  being  that  the  invalid  is  forced  to  be  the 
whole  day  long  on  deck,  that  is,  in  the  open  air, 
in  order  to  escape  from  the  confined  state  of  the 
cabin.  By  this  circumstance  alone,  however,  the 
majority  of  the  more  serious  cases  ought  to  be 


excluded  from  sea-voyages  in  ordinary  shipg,  as 
they  cannot  be  easily  moved  from  the  cabins  to 
the  deck,  and  vice  versa.  The  hygienic  conditions 
of  the  ship,  the  space  allotted  to  each  passenger, 
the  ventilation  of  the  rooms,  the  arrangement  of 
the  decks,  must  in  every  case  be  a matter  of  care- 
ful enquiry  ; but  it  would  require  too  much  space 
to  enter  into  the  details  in  this  place.  There  are 
iron  and  wooden  ships,  steamers  and  sailing 
vessels.  The  iron  ships  have  the  advantage  of 
being  easily  kept  clean  and  free  from  smells, 
but  they  are  apt  to  become  very  hot  under  the 
influence  of  the  tropical  sun.  The  sailing  vessels 
can  be  kept  more  free  from  smoke  and  dust ; but 
they  are  dependent  on  wind,  and  if  they  meet  in 
the  tropics  with  perfect  calms  (doldrums),  the  pas- 
sengers may  have  to  endure  intolerable  heat  for 
several  days  and  possibly  weeks.  The  combina- 
tion, therefore,  of  sailing  power  for  ordinary  con- 
ditions, with  steam  to  be  used  only  incase  of  need, 
would  appear  to  possess  the  preference  for  ships 
to  be  used  for  therapeutic  purposes  (invalid  ships). 

A second  point  of  paramount  importance  for 
every  delicate  person  is  the  food,  and.  in  this  re- 
spect again  the  ship-life  on  long  voyages  is  less 
advantageous  than  the  life  in  well-supplied  health- 
resorts  or  at  home.  Although  the  food  on  first- 
rate  ships  is  now  much  improved,  compared  with 
former  times,  yet  it  is  impossible  to  offer  the 
same  variety,  or  the  same  delicate  cooking,  as  in 
first-class  hotels  or  private  establishments.  A 
certain  amount  of  monotony  in  food  is  scarcely 
to  be  avoided,  and  invalids  with  a delicate  appe- 
tite ought  therefore  not  to  attempt  long  sea- 
voyages,  excepting  under  very  favourable  cir- 
cumstances, as,  for  instance,  on  large  privato 
yachts  provided  with  good  cooks. 

Sea-sickncss,  or  rather  the  degree  of  liability 
to  sea-sickness,  depends  on  peculiarities  of  con- 
stitution, which  are  only  to  be  recognised  by  ex- 
posure to  the  influences  of  the  open  sea  in  differ- 
ent states  of  agitation.  Sec  Sea-sickxbss. 

We  have  given,  under  the  head  of  sea-air,  the 
prominent  qualities  of  sea-climates  ; but  the  most 
cursory  consideration  of  the  climatic  conditions 
to  be  encountered  in  a long  sea-voyage,  shows 
that  there  must  be  great  differences  between  the 
physiological  and  therapeutical  influences  of  sea- 
climates  in  latitude  50°  and  in  latitudes  15°  and  5°. 
The  air  in  the  tropical  regions  has  a much  higher 
temperature  and  a larger  amount  of  absolute 
moisture ; the  atmospheric  movement  is,  as  a rule, 
though  by  no  means  always,  slighter ; the  baro- 
metric pressure  is  somewhat  less  in  the  tropics 
than  in  the  temperate  zones ; and  the  daily  and 
annual  variations  of  atmospheric  pressure  are 
greater  in  the  former  than  in  the  latter.  There 
is  also  a difference  between  the  same  degrees  ot 
latitude  on  the  north  and  south  of  the  equator, 
the  temperature  in  the  southern  hemisphere,  for 
instance,  being  somewhat  lower  than  in  the 
northern,  but  these  differences  are  comparatively 
small.  The  effects  of  the  climatic  conditions  of 
sea-life  in  different  latitudes  on  the  constitution 
are  very  complicated.  "We  will  here  only  point  tr. 
a few  facts,  namely,  that  in  some  delicate  consti- 
tutions the  functions  of  life  are  performed  more 
easily  under  the  influence  of  greater  heat;  that 
many  delicate  persons  can  eat  and  digest  better, 
are  able  to  take  more  exercise,  sleep  better,  and 


SEA-AIR,  SEA-BATHS.  SEA-VOYAGES.  1409 


their  mental  functions  are  more  active  under 
the  same  circumstances ; but  that  in  the  majority 
of  average  persons  continued  great  heat  produces 
lassitude,  a tendency  to  diarrhoea  and  other  diges- 
tive derangements,  and  imperfect  sleep.  Further, 
that  in  most  individuals  the  bodily  temperature 
rises  above  the  natural  heat  (in  general  about 
Fahr.,  and  in  some  persons  as  much  as  2°  and  3° 
Fahr.) ; and  that  pulmonary  haemorrhage  occurs 
more  frequently  under  high  than  under  ordinary 
degrees  of  heat.  Morbid  states  accompanied 
with  pyrexia  and  with  a tendency  to  pulmonary 
haemorrhage  ought  therefore  not  to ‘be  exposed 
to  tropical  heat. 

The  climatic  conditions-  to  be  met  with  in 
different  voyages  through  the  same  regions  vary 
at  different  seasons,  but  they  vary  still  more  in 
voyages  through  different  seas,  especially  ac- 
cording to  the  longitude  and  latitude.  Our 
knowledge  of  different  sea-climates,  that  is,  of  the 
different  climatic  conditions  in  different  parts  of 
the  ocean,  is  as  yet  not  perfect.  Hr.  Faber,  in  a 
communication  ‘ On  the  Influence  of  Sea-voyages 
on  the  Human  Body,’  Practitioner,  March  1876), 
shows  that  the  equability  of  sea-climates  is  by 
no  means  so  complete  as  is  generally  assumed  ; 
and  that  great  changes  in  temperature  and  atmo- 
spheric movements  occur  not  rarely  on  successive 
days,  and  even  on  the  same  day. 

Therapeutical  Uses. — The  opinions  of  differ- 
ent writers  on  the  therapeutic  value  of  sea- 
voyages  in  the  treatment  of  disease  vary  con- 
siderably. In  the  last  century  Gilchrist  revived 
the  practice  of  sea-voyages,  and  strongly  recom- 
mended them  in  cases  of  phthisis.  In  more 
recent  times  Jules  Rochard,  the  well-known 
French  climatologist,  has  collected  a large  body 
of  evidence  from  the  French  Navy  to  dispel  the 
faith  in  sea-voyages ; but  we  must  bear  in  mind 
that  the  hygienic  condition  in  which  the  sailors 
used  to  live  were  not  perfect,  and  are  no  doubt 
inferior  to  those  of  well-arranged  private  ships 
of  the  present  day.  Dr.  Walshe,  on  the  other 
hand,  is  in  favour  of  well-planned  voyages.  The 
majority  of  physicians  entirely,  or  almost  entirely, 
confine  themselves  to  diseases  of  the  respiratory 
organs  in  recommending  sea-voyages  ; but  their 
therapeutic  field  is  no  doubt  much  larger,  and 
the  result  is  probably  more  generally  favour- 
able in  some  other  complaints. 

1.  Phthisis. — The  writer  has  had  the  oppor- 
, tunity  of  witnessing  the  effects  of  sea-voyages 
of  two  to  seven  months’  duration,  in  twenty-one 
cases  of  phthisis  in  the  first  or  the  beginning  of 
the  second  stage.  Of  these  twenty-one  cases  ten 
benefited  considerably,  six  remained  stationary, 
five  became  worse.  The  voyages  were  all  either 
to  the  Cape  of  Good  Hope  and.  back,  or  to  Aus- 
tralia and  New  Zealand  and  back,  between  the 
months  of  September  and  May.  Of  the  five  bad 
results  three  occurred  in  patients  who  went  to 
Australia  and  India  and  back,  with  scarcely 
any  rest  on  land  ; they  seemed  to  have  gained 
in  the  first  part  of  the  journey,  but  more  than 
lost  the  gain  in  the  latter  part,  apparently  from 
dislike  of  food,  from  the  monotony  of  the  life,  and 
from  exhaustion.  In  seven  cases  of  phthisis  in 
the  second  stage  the  result  of  sea-voyages  was 
favourable  only  in  2,  indifferent  in  2,  bad  in  3 
tascs.  In  4 cases  in  the  third  stage  the  result 

89 


was  bad  in  2,  indifferent  in  the  two  others, 
which  latter  were  stationary  or  ‘ quiescent’  cases. 
The  writer  has  also  notes  of  4 cases  of  phthisis 
in  the  first  and  the  beginning  of  the  second 
stage,  where  long  summer  voyages  (namely, 
from  three  to  five  months)  with  whalers  to  the 
northern  seas,  wero  tried,  the  result  being  favour- 
able in  3 cases,  unfavourable  in  1,  apparently 
through  inability  to  bear  the  want  of  variety  in 
food. 

2.  Laryngeal  and  bronchial  catarrh  and  asthmst^ 
In  simple  chronic  catarrh  of  the  larynx  sea- 
voyages,  or  cruising  in  yachts  from  this  country 
to  the  Mediterranean,  to  the  Azores  and  Ma- 
deira, had  very  good  results  in  8 cases  out 
of  9.  Satisfactory  was  also  the  effect  of  a 
similar  plan  in  7 cases  of  chronic  bronchial  ca- 
tarrh. In  a tendency  to  bronchitis  from  pulmo- 
nary emphysema  the  benefit  was  likewise  evident 
in  7 cases  out  of  8,  but  here  the  effect  was,  from 
the  nature  of  the  circumstances,  less  permanent,. 
Of  6 cases  of  asthma,  2 cases  of  a bronchitic 
kind  were  benefited;  2 of  a nervous  character 
aggravated  ; and  2 were  neither  better  nor  worse. 
Eight  cases  of  hay-asthma  were,  while  on  the 
high  seas,  quite  free,  but  those  who  returned 
while  the  complaint  was  still  in  season,  were 
immediately  attacked. 

3.  Scrofula. — In  9 cases  of  scrofulous  affections 
(caries  of  bones,  affections  of  joints,  glandular 
swellings  and  ulcerations)  one  or  several  long 
sea-voyages  were  tried  ; in  6 of  them  the  effect 
was  quite  satisfactory,  in  3 less  decided. 

4.  Vesical  disease. — In  3 cases  of  irritable 
bladder  sea-voyages  on  yachts  in  warm  climates 
have  likewise  proved  useful. 

!>.  Cardiac  disease. — Decidedly  injurious  was 
the  effect  of  sea-voyages  in  5 cases  of  dilatation 
of  the  heart,  combined  with  chronic  bronchitis. 
In  2 cases  of  enlargement  of  the  liver,  connected 
with  weakness  of  the  heart,  the  result  was  like- 
wise unsatisfactory. 

6.  Shin-disease. — Chronic  eczema  was,  in  d 
cases  out  of  6,  aggravated  by  sea-voyages. 

7.  L’eri'ous  disorders. — In  4 out  of  6 cases  ol 
mental  irritability,  long  sea-voyages,  especially 
in  yachts,  had  favourable  results ; in  the  oth  the 
mental  condition  was  aggravated  ; in  the  6th  great 
improvement  of  the  mental  state  was  obtained, 
but  this  was  accompanied  by  considerable  exhaus- 
tion, from  inability  to  take  a sufficient  amount 
of  food.  Of  3 cases  of  melancholia  2 were  ap- 
parently cured,  the  third  remained  uninfluenced. 
In  4 cases  of  locomotor  ataxy,  in  the  earlier 
stage,  cruising  in  comfortable  yachts  in  the 
Mediterranean,  with  occasional  landing,  during 
the  autumn,  winter,  and  spring  months,  has  been 
very’  beneficial ; in  two  of  these  the  disease  has 
apparently  been  arrested,  by  persevering  with 
this  course  during  five  and  six  years. 

8.  Dipsomania. — Finally,  the  writer  has  tried 
long  sea-voyages  in  yachts  in  five  cases  of  dipso- 
mania, stimulants  having  been  entirely  excluded 
from  the  dietary.  In  one  of  these  cases  the  re- 
sult appears  to  be  permanently  good  ; in  the 
four  others  it  was  good  for  the  time  with  regard 
to  the  state  of  the  body’  as  well  as  of  the  mind, 
but  there  were  relapses,  which  in  two  of  the  cases 
have  led  to  several  repetitions  of  the  trial,  each 
time  apparently  with  more  lasting,  but  as  yet 


1410  SEA-AIK,  SEA-BATHS,  &c. 
aot  permanent,  result.  Well-arranged  sea-voyages 
deserve  therefore,  at  all  events,  a place  in  the 
management  of  this  most  terrible  affection. 

Conclusions. — From  a comparison  of  these  ex- 
periences with  those  of  other  observers,  the  writer 
is  inclined  to  infer  that,  under  favourable  cir- 
cumstances, sea-voyages  of  not  too  long  duration 
may  be  rendered  beneficial  in  the  early  stages 
of  phthisis.  The  voyage  to  Australia  and  New 
Zealand  and  back,  after  a stay  of  a few  months  in 
these  climates — Hobart’s  Town,  in  Tasmania,  for 
instance — specially  recommends  itself.  The  in- 
valids referred  to  left  in  the  second  half  of  Sep- 
tember, or  in  October  or  November,  and' returned 
in  May  or  June.  In  this  way  the  more  unfavour- 
able seasons  of  England  are  avoided,  and  instead 
of  the  short  and  sunless  days,  long  and  bright 
ones  are  obtained.  To  go  to  Australia  and  to 
return  immediately  has  proved  exhausting  in 
several  instances.  Another  good  plan  is  to  go 
to  the  Cape  of  Good  Hope,  and  ascend  in  easy 
stages,  by  diligence  and  bullock-carts,  to  the 
higher  regions  (Bloemfontain,  for  instance),  and 
to  return  after  a stay  of  three  or  four  months 
or  more.  This  plan,  however,  is  rather  expen- 
sive ; and  it  requires  a considerable  amount  of 
bodily  strength,  and  the  inclination  to  stand  a 
certain  amount  of  roughing  with  regard  to 
accommodation  and  food. 

The  voyage  to  the  northern  seas  requires  a 
peculiar  mental  disposition,  and  would,  under  the 
present  conditions,  be  resorted  to  only  under  ex- 
ceptional circumstances  ; but  it  has  been  very 
beneficial  in  the  three  cases  of  early  phthisis 
mentioned— all  of  them  possessing  a satisfactory 
fund  of  strength,  combined  with  love  of  sea-life 
and  a good  digestion. 

The  combination  of  yachting  in  the  Mediter- 
ranean, and  residence  at  one  or  several  of  the 
health-resorts  of  those  regions,  or  with  a visit  to 
Upper  Egypt,  has  repeatedly  proved  successful 
in  cases  under  the  observation  of  the  writer,  not 
only  in  pulmonary  invalids,  but  also  in  cases 
of  mental  irritability,  exhaustion,  chronic  rheu- 
matism, and  gout.  This  plan,  however,  is  some- 
what expensive. 

In  hay-asthma  sea-voyages  during  the  season 
of  the  aomplaint  are  to  be  recommended;  but  in 
other  forms  of  asthma  the  result  is  uncertain, 
and  the  advice  should  not  be  given  without  con- 
sideration of  all  the  circumstances. 

In  some  forms  of  mental  irritability,  and  in 
the  earlier  stages  of  locomotor  ataxy,  sea- 
voyages,  and  especially  yachting,  in  the  subtropi- 
cal regions,  offer  many  advantages,  particularly 
during  the  colder  and  damper  seasons  of  our 
climate,  as  it  allows  of  the  combination  of  the 
enjoyment  of  sun,  light,  and  pure  air,  with  rest 
of  body  and  mental  repose.  In  slighter  forms  of 
.mental  irritability  or  overwork  shorter  voyages 
,are  often  sufficient,  and  even  preferable  ; and 
the  voyages  to  Madeira,  to  the  West  Indies, 
or  to  Brazil  and  the  Biver  Plate,  may  thus  be 
recommended  during  the  colder  season. 

Dipsomania  and  other  morbid  passions  may 
!be  treated  with  great,  advantage  by  sea-voyages 
sand  yachting,  provided  that  stimulants  and  the 
other  injurious  influences  which  the  weak  per- 
■son  is  unable  to  resist,  can  thus  be  entirely  re- 
moved. 


SEA-SICKNESS. 

The  time  may  come  when  we  shall  have  Mero- 
peut  icsh  ips,  speci  ally  arranged  for  different  classes 
of  invalids.  If  would,  for  instance,  not  be  wise 
to  mix  those  suffering  from  dipsomania  with  sick 
persons  to  whom  a moderate  amount  of  stimu- 
lants is  useful. 

CIRCUMSTANCES  COUNTER-INDICATING  SeA-VOY- 
ages.  The  circumstances  which  render  it  neces- 
sary to  avoid  sea-voyages  are: — 

1.  Unconquerable  sea-sickness. 

2.  Great  temporary  or  permanent  weakness 
and  exhaustion. 

3.  Permafient  delicacy  of  appetite,  with  ina- 
bility to  become  accustomed  to  a certain  mono- 
tony of  food,  or  to  a certain  coarseness  in  the 
preparation  of  food. 

4.  Inability  to  bear  the  glare  of  the  sea,  as  it 
occurs  in  tendency  to  glaucoma. 

5.  Persistent  sleeplessness  while  at  sea. 

6.  Dilatation  and  weakness  of  the  fibres  of  the 
heart,  with  or  without  valvular  disease. 

7.  Enlargement  of  the  liver,  especially  when 
caused  by  dilatation  of  the  right  ventricle. 

8.  Advanced  stages  of  consumption,  unless 
the  affection  be  quite  stationary. 

9.  Morbid  conditions  -with  a tendency  to 
pyrexia. 

10.  A tendency  to  haemorrhage. 

It  is  the  influence  of  great  heat  that  ought  to 
be  avoided  by  the  two  classes  of  cases  last  men- 
tioned. A voyage  through  tropical  seas,  espe- 
cially in  sailing  ships,  might  prove  dangerous 
in  such  subjects,  from  the  possibility  of  being 
becalmed. 

11.  A tendency  to  epilepsy  or  maniacal  fits. 
This  ought  specially  to  contraindicate  sea-voyages 
to  tropical  climates. 

For  further  information  regarding  sea-voy- 
aces,  reference  may  be  made  to  The  Ocean  as  a 
Health-resort , 1 S80,  by  Mr.  William  S.  Wilson ; 
and  further  to  a treatise  on  sea-voyages,  by  Dr. 
Faber  of  Stuttgart,  which  is  issued  as  a part 
of  Von  Ziemssen’s  Handbueh  dcr  AUaemcinen 
Thera  pic.  Hermann  Weber. 

SEA-SICKNESS.  — Synon.:  Fr.  Mai  it 

mrr ; Ger.  Scckrankhcit. 

Definition. — A peculiar  functional  disturb- 
ance of  the  nervous  system,  produced  by  shock, 
resulting  from  the  motion  of  a ship.  The  most 
prominent  symptoms  are  a state  of  general  de- 
pression, giddiness,  vomiting,  and  derangement 
of  the  bowels  and  of  the  urinary  secretion. 

Pathology. — The  immediate,  cause  of  sea-sick- 
ness is  referable  to  the  shock,  or  series  of  shocks, 
to  the  nervous  system,  produced  by  the  motion  of 
a ship.  A precisely  similar  condition  may  fre- 
quently be  induced  by  any  forcible  motion  for 
which  the  individual  is  unprepared,  or  to  which 
he  is  unaccustomed,  as  the  motion  of  a swing. 
The  nervous  system  is  taken  unawares,  and  is 
unable  to  adapt  the  emissions  of  nerve-force  to 
the  unexpected  demands  made  on  it.  The  mo- 
mentary displacement  of  the  viscera,  especially 
the  stomach,  the  unusual  impression  on  the 
vision,  and  the  feeling  of  insecurity,  further  con- 
tribute to  die  general  shock. 

The  action  of  the  heart  and  of  the  arteries  is 
deranged  through  reflex  influence,  causing  giddi- 
ness from  anaemia  of  the  brain,  and  diminished 


SEA-SICKNESS. 


teripheral  circulation.  The  stomach  is  also  af- 
fected through  reflex  action,  rendering  it  intole- 
rant of  the  presence  of  any  substance,  and  caus- 
ing the  gastric  juice  to  be  actively  secreted. 
The  acid  secretion  acts  as  a direct  irritant  to 
the  stomach,  and  prolongsthe  sickness.  At  length 
habit  enables  the  nervous  system  to  adapt  itself 
to  the  new  condition  of  motion,  and  to  overcome 
the  disturbing  influence ; shock  consequently 
ceases  to  be  produced ; the  reflex  derangements 
of  the  circulation  and  viscera,  giddiness,  nausea, 
and  other  disorders,  are  no  longer  called  forth  ; 
and  convalescence  ensues.  It  is  not  within  the 
scope  of  this  article  to  notice  the  many  theories 
which  have  been  adduced  to  account  for  sea- 
sickness, but  most  late  writers  attribute  it  to 
reflex  nervous  disturbance.  Dr.  Chapman's  theory 
is,  that  there  is  an  undue  amount  of  blood  in  the 
nervous  centres  along  the  back,  producing  an 
abnormally  large  number  of  exciting  impulses, 
which  cause  a copious  secretion  of  mucus  in  the 
stomach  and  bowels,  vomiting,  and  coldness  of 
the  extremities  from  contraction  of  the  minute 
arteries.  Some  persons  are  totally  insusceptible 
to  the  shock  producing  sea-sickness. 

Constipation  is  probably  the  result  of  the  want 
of  the  gastro-biliary  juices  and  mucus  in  the 
bowels, these  being  vomited;  and  the  diminution 
of  urine  may  be  accounted  for, in  part  at  least, by 
the  increased  secretion  of  mucus  and  saliva. 

Anatomical  Characters. — The  writer  has 
only  had  the  opportunity  of  taking  notes  of  one 
autopsy  in  a case  of  ordinary  sea-sickness,  in 
which  the  patient  died  suddenly.  The  appear- 
ances were  those  of  death  by  simple  syncope, 
there  being  no  organic  disease  present.  The 
brain,  however,  was  not  examined. 

Symptoms. — Sea-sickness  may  be  divided  into 
the  stages  of  (1)  Depression,  (2)  Exhaustion, 
(3)  Reaction,  and  (4)  Convalescence. 

The  early  symptoms  are  sudden  giddiness, 
slight  at  first,  but  increasing  with  the  motion 
of  the  vessel ; and  a sense  of  weight  and  un- 
easiness at  the  epigastrium,  speedily  followed 
by  nausea  and  vomiting.  At  first  any  food 
that  may  have  been  in  the  stomach  is  rejected; 
and  afterwards  acid,  greenish-yellow,  gastro- 
biliary  secretions,  often  in  large  quantity,  with 
mucus.  Diarrhoea  is  sometimes  present,  but 
constipation  is  more  usually  the  rule  throughout. 
Tho  flow  of  saliva  is  increased,  while  the  urinary 
secretion  is  lessened.  Appetite  is  lost,  even 
the  sight  or  smell  of  food  being  loathsome.  The 
secretion  of  milk  is  frequently  arrested  in  nursing 
women ; in  others  the  menstrual  flow  is  aug- 
mented. Sea-sick  patients  are  always  worse  in 
the  morning.  Women  suffer  more  severely  than 
men  as  a rule,  while  old  people  and  young  chil- 
dren are  but  slightly  affected,  or  escape  alto- 
gether. In  the  majority  of  cases  a favourable 
reaction  takes  place  without  further  symptoms, 
the  vomiting  and  nausea  cease  spontaneously,  a 
ravenous  appetite  succeeds,  and  the  patient  feels 
well.  In  other  instances  great  exhaustion  super- 
venes rapidly  or  gradually  The  patient  feels 
miserably  helpless.  He  suffers  from  coldness  of 
the  extremities,  thirst,  headache,  and  spasmodic 
pain  in  the  stomach,  and  complains  of  numbness 
of  the  surface  of  the  body.  There  is  frequently 
4 great  tendency  to  heavy  sleepiness ; and  vomit- 


1411 

ing  of  gastro-biliary  fluids,  sometimes  mixed  with 
striae  of  blood,  takes  place  whenever  they  collect 
in  the  stomach.  A semi-comatose  condition,  from 
which  the  patient  is  with  some  difficulty  roused, 
is  sometimes  met  with  in  very  severe  cases,  and 
requires  assiduous  treatment. 

In  these  prolonged  cases  reaction  may  assume 
a febrile  character,  with  a rapid  pulse,  flushed 
face,  hot  skin,  and  urine  containing  lithates ; and 
convalescence  is  slow. 

An  occasional  but  rare  form  of  sea-sickness  is 
swooning,  but  without  vomiting  or  any  other 
symptom.  The  patient  lies  motionless  and  almost 
deathlike  for  a variable  period.  This  state  is  not 
without  danger.  Another  form  is  frontal  head- 
ache, neuralgic  or  anaemic. 

Complications  and  Sequels.— Fainting  and 
hysterical  attacks  are  the  most  common  compli- 
cations of  sea-sickness  in  women.  Pregnant 
women  occasionally  abort.  A weak  and  irritable 
condition  of  the  stomach,  resembling  subacute 
gastritis,  or  a state  of  general  debility,  may 
remain  for  a long  time. 

Duration-. — The  ordinary  duration  of  sea- 
sickness in  long  voyages  is  from  three  to  five 
days,  but  it  may  last  for  weeks. 

Prognosis. — This  is  almost  invariably  favour- 
able, yet  death,  although  extremely  rare,  may 
occur  from  syncope  or  from  exhaustion. 

Treatment. — It  may  be  premised  that  there 
is  no  known  means  of  preventing  sea-sick- 
ness in  those  susceptible  of  it.  The  majority  of 
cases  get  well  spontaneously,  but  there  are  many 
which  will  require  systematic  treatment,  espe- 
cially in  long  voyages.  Measures  should  be 
taken  to  counteract  the  nervous  shock,  and  to 
sustain  the  system  during  its  continuance. 

_ Diet  before  embarking  should  be  light.  Fresh 
air  is  a powerful  element  in  the  treatment,  to 
obtain  which  the  voyager  should  remain  on  deck 
whenever  the  weather  permits,  or  in  a deck-room. 
The  temperature  of  the  body  should  be  main- 
tained by  wrapping  up  in  shawls,  and  hot  bottles 
applied  to  the  feet  if  necessary.  The  faco  may 
be  bathed  occasionally  with  eau  de  Cologne,  and 
the  vapour  of  ammonia  inhaled  through  the  nose. 
In  the  early  stages  alkalies  are  indicated,  to 
counteract  the  irritant  effects  of  the  acid  gastro- 
biliary  secretions,  together  with  diflusibfe  stimu- 
lants frequently  administered.  A draught  may 
be  given,  consisting  of  bicarbonate  of  soda,  grains 
10-20,  ammoniated  tincture  of  valerian,  rn.xv, 
chloroform,  niiii-v,  dissolved  in  half  a drachm  of 
rectified  spirit, _mueilage  of  acacia, 3jss,  and  cam- 
phor water  to  jj.  Such  a draught  may  be  given 
every  two  hours,  or,  omitting  the  mucilage,  it  may 
begiven  in  effervescence  with  citric  acid.  Chloro- 
form is  valuable  as  a sedative  to  the  stomach, 
as  well  as  being  a general  stimulant.  Other  use- 
ful drugs  are  Hoffman’s  anodyne,  hydrocyanic 
acid,  and,  in  prolonged  cases,  bismuth.  Iced 
champagne  is  often  valuable.  Ice  sucked  slowly 
allays  thirst,  and  relieves  vomiting.  A full  dose 
of  opium  sometimes  acts  like  a charm,  through 
the  rest  which  it  procures,  or  morphia  may  be 
injected  subcutaneously.  Hydrate  of  chloral  is 
also  a valuable  narcotic.  More  recently  nitrite 
of  amyl  and  nitro-glycerine  have  been  success- 
fully employed  in  some  instances. 

External  sedative  applications  over  the  stomach 


1412  SEA-SICKNESS. 

do  good,  such  as  a liniment  composed  of  equal 

fiarts  of  belladonna,  chloroform,  and  camphor 
iniments;  and  a binder  rolled  firmly  round  the 
body  is  useful.  When  the  patient  is  in  his  berth 
he  should  lie  on  his  back,  -with  his  head  low, 
as  immovable  as  possible.  Notwithstanding  the 
vomiting,  food  should  be  pressed  on  the  patient; 
and,  lest  exhaustion  occur,  light  semi-fluid  food 
is  the  best,  such  as  arrowroot,  given  frequently 
in  small  quantities.  Afterwards  toasted  bread, 
with  beef-tea  or  chicken  broth,  and  when  these 
are  borne,  boiled  fowl,  pickled  meats,  or  corned 
meat  with  pickles,  may  be  tried.  Acids  at  this 
stage  aid  digestion,  which  has  become  weakened 
through  the  vomiting  of  so  much  gastric  juice 
and  bile.  Beer  ancl  alcoholic  drinks  should  be 
avoided  in  the  earlier  stages  ; but  at  a later 
period,  claret,  champagne,  or  brandy,  or  stout, 
may  be  allowed  with  benefit.  Diarrhoea  and 
other  symptoms  should  be  treated  on  general 
principles.  For  short  voyages  the  best  that  can 
be  done  is  to  remain  on  deck  when  possible, 
avoid  alcoholic  drinks,  and  follow  the  general 
directions  above  given.  Dr.  Chapman  recom- 
mends the  application  of  ice  along  the  spine,  in 
order  to  lessen  the  nervous  currents  by  its  seda- 
tive influence;  and  this  treatment  is  occasionally 
successful  in  arresting  the  vomiting. 

J.  DE  ZoUCHE. 

SEAT- WORM. — A synonym  of  the  small 
thread-worm,  or  oxyuris  vcrmicularis.  By  prac- 
titioners the  small  and  troublesome  entozoa  here 
referred  to  are  more  frequently  spoken  of  as 
ascaridcs,  thotigh,  as  explained  elsewhere,  the 
expression  is  not  correct.  The  term  seat-worm 
is  suggestive,  inasmuch  as  the  presence  of  these 
parasites  is  apt  to  give  rise  to  irritation  in  the 
neighbourhood  of  the  anus ; hut  it  is  somewhat 
objectionable  and  misleading,  since  it  tends  to 
favour  the  view  still  very  commonly  entertained 
and  taught  by  medical  men,  that  the  rectum  and 
sigmoid  flexure  of  the  colon  constitute  the  true 
habitat  of  this  entozoon.  The  ctecum  forms  the 
‘head-quarters’  of  the  seat-worm,  and  the  know- 
ledge of  this  fact  has  an  important  hearing 
upon  the  method  of  treatment  to  be  pursued.  Sec 
Ascakides  ; Oxyuris  ; and  Thread-worm. 

T.  S.  COBBOLD. 

SEBACEOUS  FOLLICLES,  Diseases 

of. — Synon.  : Fr.  Maladies  des Follicules  sebaces; 
Ger.  Krankheiten  der  Talgdrusen. 

The  sebaceous  follicles  of  the  skin  are  sub- 
ject to  disease  depending  both  upon  internal 
and  external  causes.  Those  follicles  which  are 
attached  to  hairs,  and  those  which  are  isolated, 
show  little  difference  in  this  respect. 

Enlargement  or  hypertrophy  of  the  follicles 
is  often  seen,  and  appears  to  arise  chiefly  from 
internal  causes,  occurring  either  at  a particular 
stage  of  development,  or  from  some  general 
alteration  of  nutrition,  such  as  follows  a parti- 
cular diet  or  excess  of  particular  kinds  of  food. 
This  form  constitutes  acne  punctata,  an  affection 
in  which  the  affected  portion  of  skin  appears 
covered  with  black  spots;  these  being  the  open- 
ings of  the  enlarged  sebaceous  follicles,  choked 
with  plugs  of  sebaceous  matter,  the  outer  ends 
of  which  become  blackened.  The  plugs  or  co- 


SECRETIONS  AND  EXCRETIONS. 

medones,  when  examined,  are  found  to  consist  of 
solid  fatty  matter  (sebaceous  secretion),  closely 
packed  epithelial  scales,  and  minute  rudiments 
of  hairs.  The  parasite  Demodcx  folliculorum  is 
often  present,  but  does  not  appear  to  exercise 
any  influence  on  the  disease.  Not  unfrequently 
an  imperfectly  formed  hair  occupies  the  centre  of 
the  mass.  Acne  punctata  occurs  in  those  parts 
of  the  body  where  there  are  numerous  rudiments 
of  hairs,  and  where  hairs  grow  commonly,  though 
not  uniformly,  in  the  male  sex.  Hence  it  is  con- 
fined to  the  face,  neck,  and  upper  part  of  the  back 
and  chest. 

When  inflammation  is  set  up  in  hypertrophied 
follicles  suppuration  follows,  and  we  hare  acne 
suppurativa. 

The  condition  called  lichen  pilaris  is  sub- 
stantially the  same  as  hypertrophic  acne,  being 
produced  by  over-growth  of  cells  in  the  sheath 
of  the  hair  and  the  sebaceous  follicle.  See  Acne. 

J.  F.  Payne. 

SEBORRHCEA  {sebum,  fat,  and  £e'w,  I flow ). 
An  ungrammatical  synonym  for  stearrhcsa.  See 
Stearbhoea. 

SECONDARY  ( secundus , the  second). — In 
contra-distinction  toprimary,  the  word  secondary 
is  used  with  the  following  significations.  .Ftio- 
logically  it  implies  that  a disease  is  not  local  in 
its  causation  and  origin,  but  is  manifested  as  a 
secondary  lesion — either  as  the  result  of  some 
general  or  constitutional  condition,  or  of  an 
affection  which  has  previously  involved  some 
other  structure  or  organ,  it  may  be  in  a remote 
part  of  the  body.  It  also  signifies  the  later 
manifestations  of  a disease,  as  distinguished 
from  those  which  occur  at  an  early  period,  as  in 
the  case  of  secondary  syphilis  or  secondary  cancer. 
The  term  is,  moreover,  applied  to  symptoms, 
when  they  are  more  or  less  remote  from  the 
seat  of  mischief,  or  are  only  indirectly  set  up  by 
the  disease  with  which  they  are  associated. 

Frederick  T.  Roberts. 

SECRETIONS  AND  EXCRETIONS, 
Disorders  of.  — Although  the  derangements 
affecting  the  chief  secretions  and  excretions  of 
the  human  body  are  considered  in  detail  in  other 
parts  of  this  work,  it  may  serve  a useful  purpose 
to  deal  with  them  from  a general  standpoint,  as 
there  are  several  facts  which  apply  to  them  col- 
lectively. Those  that  have  principally  to  be 
borne  in  mind  are  the  secretions  poured  into 
the  alimentary  canal — namely,  the  saliva,  gastric 
juice,  bile,  pancreatic  juice,  and  intestinal  secre- 
tions ; the  milk ; the  urine ; and  the  sweat.  Of 
secondary  importance,  from  a clinical  point  of 
view,  are  the  various  mucous  secretions,  the 
tears,  and  the  semen  ; the  serous  secretions  have 
also  to  be  remembered.  It  is  assumed  that  the 
physiological  distinction  between  a secretion  and 
an  excretion  is  understood. 

Varieties  of  Disorder. — 1.  Secretions  and 
excretions  are  very  liable  to  chaity  s m quan- 
tity. A definite  amount  of  each  of  these  should 
be  formed  during  the  twenty-four  hours,  vary- 
ing within  recognised  limits,  and  influenced  by 
certain  physiological  conditions.  The  quantity 
produced,  however,  often  deviates  from  the 
healthy  standard,  in  the  direction  either  of  .a1 


SECRETIONS  AND  EXCRETIONS,  DISORDERS  OF. 


txfliss,  or  (b)  deficiency.  In  the  former  case  the 
amount  of  the  secretion  formed  is  often  far 
above  the  normal,  or  what  is  needful  for  its  pur- 
pose ; in  the  latter  case  various  degrees  of  defi- 
ciency occur,  culminating  in  an  absolute  sup- 
pression of  a particular  secretion  or  excretion. 

2.  Changes  in  quality  are  also  frequently  no- 
ticed, and  these  may  be  associated  with  changes 
in  quantity,  or  they  may  exist  alone.  The  quali- 
tative changes  include  the  absence  or  deficiency 
of  one  or  more  of  the  normal  chemical  ingre- 
dionts  of  the  fluid  ; excess  of  either  of  these 
ingredients  ; absence,  deficiency,  or  imperfection 
of  formed  organic  elements,  as  in  the  case  of  the 
semen  ; or  the  presence  of  adventitious  and  ab- 
normal ingredients.  It  may  also  be  mentioned 
here  that  the  quality  of  secretions  is  often  modi- 
fied by  admixture  with  excess  of  mucus  or  with 
morbid  products. 

3.  Another  disorder  affecting  certain  secre- 
tions and  excretions  is  interference  with  their 
escape  by  the  normal  channels,  so  that  they  are 
retained.  This  applies  particularly  to  those 
which  have  one  or  more  special  ducts  for  their 
exit,  liable  to  be  obstructed  in  various  ways.  The 
escape  of  the  bile,  pancreatic  juice,  urine,  paro- 
tid secretion,  milk,  and  other  fluids  may  be  thus 
prevented. 

4.  Allied  to  the  deviation  just  noticed  is  that 
in  which  a secretion  flows  in  some  abnormal 
direction.  As  illustrations  may  be  mentioned 
salivary  fistula,  in  which  the  parotid  secretion 
escapes  through  an  opening  on  the  outside  of 
the  cheek ; external  biliary  fistula,  or  the  open- 
ing of  the  gall-bladder  in  various  other  direc- 
tions ; vesico-vaginal  or  vesico-reetal  fistula, 
where  the  urine  passes  from  the  bladder  into  the 
vagina  and  rectum  respectively ; and  closure  of 
the  lachrymal  duct,  so  that  the  tears  flow  over 
the  cheeks.  In  this  connection  allusion  must  also 
be  made  to  those  cases  in  which  a reservoir  of 
some  secretion  ruptures,  and  thus  its  contents 
escape.  For  instance,  the  gall-bladder  may  give 
way,  or  the  urinary  bladder,  the  bile  or  urine 
consequently  escaping  into  the  peritoneum. 

JEtiology. — The  causes  which  produce  one  or 
other  of  the  disorders  of  secretion  just  indicated 
are  as  follows : — 1.  Alterations  in  quantity  and 
quality  are  often  immediately  induced  by  ner- 
vous disturbance.  The  influence  of  the  nervous 
system  upon  the  act  of  secretion  is  well  known, 
and  it  may  be  centric  in  origin,  as  in  the  case  of 
strong  emotion ; direct,  when  the  nerve  influenc- 
ing a particular  secretion  is  irritated,  compressed, 
or  otherwise  disturbed ; or  reflex,  due  to  some 
remote  irritation  affecting  such  a nerve.  The 
effect  of  neuralgia  upon  the  secretion  of  the 
tears,  saliva,  and  perspiration,  is  often  very 
striking.  2.  Similar  disorders  frequently  depend 
upon  derangements  affecting  the  local  circulation 
in  the  secreting  gland.  This  is  well  exemplified 
in  the  case  of  the  urine,  which  is  abundant  and 
watery  as  the  result  of  active  congestion  of  the 
kidney;  deficient,  concentrated,  and  otherwise 
abnormal  when  these  organs  are.  the  seat  of 
venous  congestion.  The  bile  is  also  considerably 
modified  in  quantity  and  quality  by  portal  con- 
gestion. 3.  General  conditions  of  the  system 
materially  affect  secretions,  from  various  causes, 
Weh  as  pyrexia,  plethora  or  anaemia,  shock  or 


1413 

collapse,  and  the  typhoid  condition.  Moreover, 
they  may  be  disordered  in  connection  with  dis- 
eases which  produce  marked  effects  upon  the 
general  system,  such  as  phthisis.  4.  Functional 
derangements  of  the  glandular  structures  which 
form  different  secretions  are  very  common,  and 
may  be  due  to  many  causes.  Amongst  others 
may  be  mentioned  a want  of  due  and  proper 
stimulation;  excessive  or  too  frequent  stimula- 
tion ; injurious  habits  which  affect  certain  secre- 
tions ; and  want  of  tone  or  imperfect  nutrition 
of  secreting  tissues.  Such  causes  frequently 
operate  injuriously  in  relation  to  the  secre- 
tions poured  into  the  alimentary  canal.  The 
sweat  is  affected  by  neglecting  cleanliness  of 
the  skin.  5.  Organic  diseases  of  the  glandular 
structures  necessarily  modify  secretions  more  or 
less,  either  temporarily  from  acute  disease,  or 
permanently  from  some  chronic  mischief,  which 
may  ultimately  entirely  check  a secretion.  These 
diseases  are  of  different  kinds,  and  cannot  be 
specially  indicated  here,  but  they  all  tend  to 
alter  or  destroy  the  secreting  structures.  C. 
The  secretions  generally  may  be  affected  by  cer- 
tain abnormal  elements  which  accumulate  in 
the  blood.  Under  such  circumstances,  however, 
some  excretions  become  the  special  channels  for 
the  elimination  of  these  elements,  and  thus  are 
liable  to  be  seriously  deranged.  Thus  in  diabetes, 
whatever  its  pathology  may  be,  the  accumulation 
of  sugar  in  the  system  leads  to  the  characteristic 
changes  in  the  urine  observed  in  this  disease, 
while  at  the  same  time  the  cutaneous  excretion 
is  diminished.  It  may  further  be  remarked  here 
that  if  the  elements  which  ought  to  be  removed 
by  a certain  excretion  are  not  thus  eliminated, 
they  may  find  their  way  by  other  channels,  and 
thus  modify  the  quality  of  other  fluids.  This  is 
exemplified  by  the  elimination  of  urea  in  other 
directions  when  it  is  not  excreted  by  the  kidneys. 
7.  A secretion  may  be  properly  formed,  but  it  is 
in  manycases  subsequentlymodified  by  admixture 
with  morbid  products  derived  from  surfaces  with 
which  it  has  to  come  in  contact,  such  as  excess 
of  or  unhealthy  mucus,  or  pus.  Also,  in  the 
case  of  the  stomach,  the  habit  of  taking  large 
quantities  of  water  or  other  fluids  may  so  dilute 
the  digestive  secretions,  as  to  make  them  unfit 
to  perform  their  functions  properly.  8.  With 
regard  to  the  causes  which  impede  the  escape  of 
secretions,  these  are  either  of  a mechanical 
nature,  the  duct  being  obstructed  by  something 
lodging  in  it,  such  as  a calculus  or  plug  of 
mucus,  or  being  pressed  upon  from  the  outside ; 
or  due  to  organic  disease,  narrowing  or  closing 
the  channel  or  its  orifice ; or  possibly  occasion- 
ally to  muscular  spasm  or  to  paralysis  of  the 
duct.  Such  conditions  may  be  temporary  or  per- 
manent. The  discharge  of  secretions  in  abnormal 
directions  is  the  result  of  organic  lesions,  either 
congenital  or  acquired,  by  which  the  unusual 
channels  and  communications  are  formed. 

Effects  and  Symptoms. — Disorders  affecting 
secretions  and  excretions  are  often  directly  ac- 
countable for  a variety  of  sj-mptoms,  as  well  as 
for  certain  definite  morbid  conditions,  and  these 
effects  are  usually  readily  explained.  1.  With 
reference  to  their  quantity,  secretions  and  ex- 
cretions must  be  regarded  as  mere  liquids  of  a 
particular  kind,  and  symptoms  may  therefore 


1414  SECRETIONS  AND  EXCRETIONS,  DISORDERS  OE. 


simply  depend  upon  their  amount.  Eor  instance, 
deficiency  or  excess  of  saliva  and  buccal  mucus 
will  cause  respectively  dryness  of  the  mouth,  or 
a mere  or  less  profuse  flow  of  saliva;  an  abun- 
dance of  gastric  juice  may  account  for  acidity  and 
acid  eructations ; the  quantity  of  the  secretions 
in  the  alimentary  canal  often  aids  in  the  causa- 
tion of  diarrhoea  or  constipation;  and  variations 
in  the  amount  of  the  cutaneous  excretion  give 
rise  either  to  undue  sweating,  or  to  dryness  of 
the  shin.  2.  Certain  actions  are  frequently  influ- 
enced by  disorders  of  secretion.  Mere  alterations 
in  quantity  may  affect  t.haee  actions.  Thus,  pro- 
fuse salivation  causes  frequent  spitting  or  swal- 
lowing ; abundant  secretion  in  the  air-passages  ex- 
cites coughing  and  expectoration;  excess  of  fluids 
in  the  stomach  or  intestine  may  cause  vomiting 
or  purging  respectively  ; a free  secretion  of  urine 
renders  micturition  more  frequent.  But,  apart 
from  the  quantity,  the  quality  of  a secretion  may 
further  influence  these  actions.  Of  this  we  have 
a striking  illustration  in  diabetic  urine,  which 
is  in  itself  irritating,  and  excites  the  bladder  to 
empty  itself.  The  bile  is  another  example,  for 
undoubtedly  this  fluid  has  an  irritating  effect 
upon  the  intestine,  and  may  also  increase  the 
secretions  of  this  canal,  so  that  in  these  ways 
excess  of  bile  may  be  a cause  of  diarrhoea,  while 
its  deficiency  is  an  important  element  in  many 
cases  of  constipation,  owing  to  the  want  of  its 
stimulating  action  upon  the  intestinal  wall.  3. 
Each  secretion,  as  distinguished  from  an  excre- 
tion, has  certain  definite  functions  to  fulfil,  and 
a number  of  symptoms  may  be  due  to  the  fact 
that  a particular  secretion  fails  to  perform  its 
functions.  This  may  arise  from  the  fact  that  it 
is  suppressed  or  deficient  in  quantity  ; abnormal 
in  quality,  and  therefore  inadequate  for  its  work; 
or  for  some  reason  or  other  does  not  reach  the 
place  in  which  this  work  is  carried  on,  as  when  a 
duct  is  obstructed,  or  a fistula  allows  the  escape 
of  a secretion,  so  that  it  is  lost.  Symptoms 
arising  from  this  cause  are  mainly  observed  in 
connection  with  the  alimentary  canal,  and  they 
are  of  extremely  common  occurrence,  as  well  as 
of  varied  character.  Many  of  the  symptoms  in 
dyspeptic  cases  are  to  be  thus  explained,  and  a 
knowledge  of  the  physiological  uses  of  the  dif- 
ferent digestive  secretions  will  indicate  the  de- 
rangements to  be  anticipated  when  one  or  other 
of  them  is  unequal  to  its  work.  It  must  be 
remembered  not  only  that  these  secretions  are 
concerned  directly  in  digesting  the  food,  but  that 
some  of  them  also  prevent  fermentation  and 
decomposition,  and  their  imperfect  action  in 
these  respects  may  originate  important  symp- 
toms. Under  this  heading  the  lacteal  secretion 
may  be  alluded  to.  Deficiency  in  its  quantity,  or 
imperfection  in  its  quality,  often  renders  it  unfit 
to  fulfil  its  function,  that  is,  the  proper  nourish- 
ment of  the  infant  who  is  supposed  to  live  upon 
the  maternal  milk.  4.  If  certain  secretions  or 
excretions  are  seriously  cheeked  or  altogether 
suppressed,  or  if  they  are  retained  in  any  part, 
so  that  they  become  subsequently  absorbed,  ob- 
vious effects  on  the  entire  system  are  produced, 
which  may  be  of  a very  serious  character.  Thus, 
in  tho  case  of  the  bile,  jaundice  and  its  accom- 
panying phenomena  are  evident;  in  connection 
with  tho  uriDe  we  may  have  dropsy  or  uraemic 


symptoms.  Impaired  cutaneous  excretion  also 
produces  effects  upon  the  system,  although  these 
are  not  so  marked.  5.  What  may  be  regarded  as 
the  secondary  effects  of  disorders  connected  with 
secretions  must  also  not  be  forgotten.  If  their 
escape  be  prevented,  they  are  liable  mechanically 
to  produce  important  lesions.  Thus  they  often 
lead  to  distension  of  hollow  organs,  such  as  the 
bladder  or  gall-bladder.  Moreover,  they  may  at 
the  same  time  excite  irritation  and  inflammation, 
especially  if,  as  in  the  case  of  the  urine,  decom- 
position take  place,  with  the  formation  of  irri- 
tating products.  By  these  combined  effects, 
important  organs  may  ultimately  be  completely 
disorganised,  such  as  the  kidney  or  liver.  Re- 
tention of  milk  in  the  mammary  glands  is  one 
important  cause  of  inflammation  and  abscess  in 
these  organs.  When  certain  secretions  or  ex- 
cretions find  their  way  into  abnormal  situations 
they  may  also  originate  more  or  less  serious  con- 
ditions. Thus  if  urine  or  bile  escape  into  the 
peritoneum,  acute  peritonitis  will  be  set  up. 

Teeatment. — Without  entering  into  any  de- 
tails, it  will  suffice  to  indicate  in  this  article  the 
principles  upon  which  disorders  of  the  secretions 
and  excretions  are  to  be  treated.  1.  Any  obvious 
cause  of  such  disorders  must  be  rectified  or  got 
rid  of  at  the  outset,  if  practicable,  as,  for  in- 
stance, injurious  habits,  neuralgia,  and  many 
other  causes.  2.  When  secretions  are  abnormal 
in  their  formation,  either  as  regards  quantity  or 
quality,  means  are  often  within  reach  for  cor- 
recting these  errors.  This  may  not  uncommonly 
be  effected  by  acting  upon  the  general  system, 
by  means  of  tonics  or  other  suitable  agents,  and 
thus  indirectly  influencing  sceretion  ; but  there 
are  also  special  therapeutic  agents  employed  for 
their  immediate  offects  upon  particular  secre- 
tions or  excretions,  such  as  the  gastric  juice,  the 
bile,  the  urine,  and  the  sweat.  With  regard  to 
quantity,  remedies  are  used  to  diminish  this 
when  excessive,  as  well  as  to  increase  it  when 
deficient.  It  may  be  mentioned  here  that  mea- 
sures for  augmenting  certain  secretions,  and  es- 
pecially excretions,  are  often  resorted  to  for  other 
therapeutic  purposes,  when  they  are  not  in  any 
way  abnormal.  Care  must  be  taken  not  to  carry 
measures  for  promoting  the  formation  of  secre- 
tions too  far,  otherwise  in  the  long  run  they  axe 
liable,  by  over-stimulation  and  in  other  ways,  to 
do  far  more  harm  than  good.  This  applies  parti- 
cularly to  those  cases  where  there  is  organic 
mischief  affecting  the  glandular  structures,  and 
interfering  with  their  formation.  Secretions  and 
excretions  are  often  materially  influenced  in 
quantity  and  quality  by  acting  upon  the  circula- 
tion in  the  organs  which  form  them,  either  di- 
rectly or  indirectly.  3.  It  may  be  practicable  to 
treat  some  disease  which  originates  a disordered 
secretion,  and  thus  to  influence  it.  This  may  be 
illustrated  by  diabetes,  and  by  diseases  of  parti- 
cular organs,  the  secretions  of  which  are  affected. 
In  this  way  marked  effects  are  sometimes  pro- 
duced. 4.  When  certain  secretions  are  wanting 
or  very  deficient,  especially  the  gastric  ittice  and 
bile,  their  place  may  be  supplied  by  administer- 
ing the  important  elements  of  these  secretions, 
or  by  making  them  artificially.  The  elements  of 
the  pancreatic  juice  are  also  now  frequently 
given  in  different  forms.  Thus  the  want  or  de- 


SECRETIONS  AND  EXCRETIONS, 
fluency  of  these  fluids  in  the  digestive  process 
may  often  be  entirely  made  up  for.  An  impor- 
tant use  of  some  of  these  substitutes,  at  present 
much  in  vogue,  is  that  introduced  by  Dr.  Wil- 
liam Roberts,  by  -which  the  food  is  artificially 
digested  in  different  degrees  before  it  is  taken 
fcv  the  patient.  5.  The  symptoms  which  disor- 
ders of  secretions  give  rise  to  often  need  special 
treatment,  -whether  they  be  of  a local  or  general 
character — for  instance,  c-oustipation,  diarrhoea, 
flatulence,  jaundice,  ursemia,  and  oiher  pheno- 
mena. G.  In  many  cases  attention  has  to  be 
directed  to  the  prevention  of  an  accumulation  of 
a secretion  or  excretion,  or  to  its  removal  if  it 
have  accumulated.  This,  may  be  illustrated  by 
retention  of  the  milk  in  the  mammary  gland ; 
and  of  the  urine  in  the  bladder.  The  effects  of 
any  such  accumulation  also  need  to  be  recognised 
in  treatment,  such  as  dilatation  of  an  organ, 
inflammation,  or  rupture.  7.  Operative  proce- 
dures may  be  required  in  some  cases,  either  to 
remove  an  accumulation  which  cannot  otherwise 
be  got  rid  of ; or  to  cause  a secretion  to  pass  in 
its  proper  direction,  in  those  cases  where  there  Is 
an  abnormal  communication  or  fistula,  or  a closed 
passage,  such  as  an  obstructed  lachrymal  duct. 

It  must  be  remembered  that  there  are  many 
disorders  of  secretions  and  excretions  which  are 
merely  temporary,  and  which  need  no  treatment 
whatever.  Frederick  T.  Roberts. 

SEDATIVES  ( sedo , I ease  or  assuage). — 
Synost.  : Fr.  Sedatifs;  Ger.  Bcruhigcnde  Mittcl. 

Definition. — Therapeutic  measures  which 
exert  a soothing  action  upon  the  system,  by 
diminishing  pain,  lessening  functional  activity, 
or  tranquillising  disordered  muscular  movement. 

Sedatives  may  be  divided  into  the  following 
groups : — 

1.  General  Sedatives.— -Constitutional  seda- 
tives, like  stimulants,  widely  overlap  other  thera- 
peutic divisions.  The  type  of  all  soothing  action 
assuredly  must  be  a full  narcotic,  an  anaesthetic 
vapour,  or  a subcutaneous  injection  of  morphia, 
either  of  which  renders  the  sufferer  temporarily 
oblivious  to  any  excruciating  agony,  such  as  that 
of  biliary  or  renal  colic.  In  fact,  general  seda- 
tives must  be  looked  for  exclusively  in  the  nar- 
cotic and  anaesthetic  class  ; and  if  the  constant 
consumption  of  vital  energy  by  disease  be  not  com- 
pensated by  sleep,  we  prescribe  opium,  chloral, 
or  hyoscyamus. 

2.  Local  Sedatives. — Under  this  heading  we 
must  place  extreme  cold,  which,  applied  either 
in  the  form  of  ice,  or  more  effectually  by  the 
ether  spray,  deadens  the  sensibility  of  the  skin, 
and  prevents  the  prick  or  cut  of  a slight  opera- 
tion from  being  felt.  Next  come  aconite,  opium, 
belladonna,  veratria,  and  blisters,  which  soothe 
by  a direct  action  on  the  sensory  nerves,  or  by 
influencing  the  circulation  of  the  parts  around. 
These  are  useful  in  neuralgic  or  rheumatic  pain, 
or  in  the  acute  suffering  of  superficial  inflamma- 
tory conditions.  Again  some  substances  may  be 
regarded  as  sedatives,  in  virtue  of  their  power  in 
allaying  the  excessive  itching  of  prurigo  and 
other  chronic  skin-affections.  Hydrocyanic  acid, 
eirbolic  acid,  chloroform,  borax,  and  chloral  are 
tmong  the  best  remedies  for  this  purpose. 

3 Pulmonary  Sedatives. — Pulmonary  seda- 


SELTERS.  1415 

tives  are  also  deserving  of  mention,  and,  passing 
by  emetics  and  nauseants,  which  undoubtedly 
depress  the  breathing  power,  we  find  that  vera- 
tria, Calabar  bean,  prussic  acid,  and  several  other 
drugs  directly  tend  to  paralyse  the  respiratory 
centre,  on  which  action  the  greater  part  of  their 
poisonous  influence  seems  to  depend. 

4.  Spinal  Sedatives. — Spinal  sedatives  have 
precisely  an  opposite  effect  to  spinal  stimulants, 
and  it  has  been  amply  proved  that  Calabar 
bean,  gelsemiuum,  bromide  of  potassium,  and 
methylconia  powerfully  lower  reflex  excitability 
through  the  cord  and  the  great  ganglia  of  the 
brain. 

5.  Stomachic  Sedatives. — Irritable  condi- 
tions of  the  mucous  membrane  of  the  stomach, 
giving  rise  to  pain,  vomiting,  pyrosis,  and  other 
symptoms,  are  commonly  met  with,  and  require  a 
considerable  variety  of  treatment.  If  gastrodynia 
fails  to  yield  to  bismuth,  soda,  or  hydrocyanic 
acid,  recourse  may  be  had  to  small  doseS  of  nitrate 
of  silver  or  of  arsenic;  or  blistering  over  the  epi- 
gastrium may  produce  the  desired  effect.  If  vomit- 
ing be  the  prevailing  symptom,  hydrocyanic  acid 
again  proves  useful,  carbonic  acid  in  the  form 
of  effervescing  draughts,  or  minute  and  oft- 
repeated  doses  of  nux  vomica  or  ipecacuanha. 
Combined  with  this,  we  must  take  especial  care 
to  enjoin  a mild  and  unstimulating  dietary,  of 
which  milk  and  lime-water  should  form  the  prin- 
cipal ingredients. 

6.  Vascular  Sedatives.— Vascular  sedatives 

have  the  power  of  lowering  the  heart's  action  ; 
and  emetics  and  tobacco  do  this  by  the  general 
depression  following  nausea  and  the  act  of  vomit- 
ing. Other  drugs,  however,  act  directly  on  the 
heart  itself,  either  by  paralysing  the  muscular 
tissue  of  which  its  walls  are  composed,  or  by  a 
more  special  influence  over  its  nerve-supply. 
Slowing  of  its  action  may  be  effected  either  by 
stimulation  of  the  inhibitory  branches  of  the 
vagus,  or  by  interference  with  the  sympathetic 
ganglia  which  work  in  the  opposite  direction ; and 
experiment  has  not  in  all  cases  made  it  quite 
clear  what  is  the  true  explanation.  But  what- 
ever the  exact  physiological  explanation  may 
be,  we  have  some  practical  rules  for  our  guid- 
ance in  the  use  of  these  remedies,  and  more  es- 
pecially of  digitalis,  which,  cardiac  tonic  though 
it  be,  is  also  a true  sedative  to  that  organ. 
Vlien  the  heart-muscle  is  weak  and  languid,  it3 
contractions  are  necessarily  less  efficient  than  in 
health;  and  in  order  to  perform  its  allotted 
amount  of  routine  work  in  propelling  the  blood, 
its  cavities  must  fill  and  empty  more  rapidly 
than  usual.  The  result  of  this  is  seen  in  the 
hurried,  feeble,  and  often  irregular  pulsations  of 
the  organ  ; and  digitalis,  by  bracing  up  the  mus- 
cular fibres,  and  giving  increased  tone,  renders 
its  action  more  efficient,  and  enables  it  to  take 
more  prolonged  periods  of  repose.  Other  cardiac 
sedatives  are  aconite,  veratrum  viride,  colchi- 
cum,  and  hydrocyanic  acid,  but  they’  are  seldom 
used  for  this  purpose,  although  aconite,  whether 
through  its  action  on  the  heart,  or  on  the  small 
vessels,  is  very  effective  in  early  inflammatory 
conditions.  R.  Farquharson. 

SELTERS,  in  Germany. — Muriated  alka- 
line table-water.  See  Mineral  "Waters. 


141 C SEMEIOLOGY. 

SEMEIOLOGY  (<rqp.tiov,  a symptom  ; and 
\d-yos,  a discourse).— A synonym  for  symptoma- 
tology, or  the  doctrine  of  the  signs  and  symp- 
toms of  disease.  See  Disease,  Symptoms  and 

Signs  of. 

SEMILUNAR  VALVES,  Diseases  of. 
SeeHEAitT,  Valves  of,  Diseases  of. 

SENILE  INSANITY.  See  Dementia. 

SENILITY  ( senex , an  old  man). — Syncs’.  : 
Senile  marasmus ; Fr.  Vieillesse ; Ger.  Greiseiv- 
liter. 

Definition. — That  condition  of  body  which 
usually  supervenes  naturally  after  the  seventieth 
year,  but  sometimes  occurs  prematurely. 

Senility  is  separated  from  the  previous  period 
of  maturity  by  the  climacteric  stage,  which  in  men 
occurs  between  the  ages  of  fifty  and  sixty,  and 
in  women  about  ten  years  earlier.  When  of 
premature  occurrence  this  state  is  commonly 
secondary  to  some  exhausting  illness,  where 
failure  of  the  trophic  influence  of  the  nervous 
system  has  been  marked.  All  the  signs  and 
symptoms  of  senility  have  been  seen  in  indi- 
viduals under  twenty  years  old. 

We  do  not  know  why  the  body,  after  it  has 
reached  a state  of  maturity  and  vigour,  should 
gradually  decline ; why,  when  once  an  even 
balance  between  tissue-waste  and  restitution  is 
established,  it  is  not  maintained  indefinitely. 
How  far  the  failure  is  due  to  some  inherent 
tendency,  and  how  far  to  external  influences,  is 
wholly  conjectural.  The  term  ‘involution’  has 
been  suggested  to  express  the  progressive  senile 
changes  in  the  tissues  and  organs. 

Anatomical  Chauacters. — The  mostuniversal 
structural  characteristic  of  old  age  is  a progres- 
sive atrophy  of  almost  all  the  tissues  and  organs. 
The  degree  of  wasting  varies,  but  there  is  a 
general  diminution  in  body-weight  and  height, 
except  in  persons  whose  climacteric  has  been 
marked  by  an  increase  of  the  adipose  tissue, 
when  the  total  loss  of  weight  may  be  inconsider- 
able. Among  the  organs  which  exhibit  simple 
atrophy  in  the  highest  degree,  are  the  brain  and 
spinal  cord  ; the  generative  organs,  especially 
the  ovaries,  and  to  a less  extent  the  testes,  the 
uterus,  and  the  mammary  glands  ; the  mucous 
membrane  and  glands  of  the  digestive  tract;  the 
bronchial  and  vesical  mucous  membranes;  the 
spleen  and  lymphatic  glands,  the  latter  even  to 
complete  disappearance  ; and  the  kidneys.  The 
teeth  fall  out;  the  muscles  waste;  and  the  bones 
become  thin  and  deficientin  animal  matter,  some, 
as  the  lower  jaw,  being  much  altered  in  shape. 
A most  important  change,  and  one  that  exerts  a 
very  direct  influence  on  tissue-nutrition,  is  an 
extensive  shrinking  and  even  obliteration  of  the 
capillaries  in  almost  all  the  textures.  The  skin 
becomes  much  diminished  in  thickness,  especially 
in  the  papillary  layer,  the  constituent  papillae 
being  very  indistinct ; and  loss  of  hair  and  change 
of  colour  are  well-known  features. 

An  exception  to  the  almost  universal  atrophy 
occurs  in  the  prostate,  the  fibro-muscular  struc- 
tures of  which  undergo  considerable  hypertrophy 
in  most  old  men.  The  entire  organ  may  be  so 
affected,  or  only  one  lobe  ; and  the  weight  has 
been  recorded  as  attaining,  in  an  extreme  case, 


SENILITY. 

to  20  ounces.  Very  rarely  the  viscus  wastes 
with  age. 

Associated  with  this  atrophy  it  is  usual  to 
find  degenerations — fatty,  calcareous,  or  pigmen- 
tary— all  of  which  are  to  be  regarded  as  evi- 
dences of  deficient  nutrition,  comparable  to  the 
differentiation  and  growth  which  characterise 
the  commencement  of  life.  The  arcus  senilis 
the  atheroma  and  calcareous  degeneration  of  the 
vessels,  the  calcification  of  cartilages,  the  fatty  de- 
generation of  muscular  and  glandular  epithelial 
tissue,  the  deposition  of  pigment  in  some  spots, 
and  the  deficiency  of  the  same  in  the  hair  and 
skin  of  the  coloured  races,  are  illustrations  of 
true  degenerative  changes. 

The  products  of  degeneration  may  accumulate 
in  the  textures,  and  cause  them  to  be  thicker 
than  they  are  in  health,  as  is  seen  in  the  vessels, 
the  walls  of  which  are  often  much  thickened, 
and  the  meninges  of  the  brain,  which  are  opaque 
and  toughened.  The  pericardium  and  endocar- 
dium, and  the  capsule  of  the  liver  and  spleen,  are 
similarly  altered. 

The  blood  contains  fewer  corpuscles  and  less 
solid  constituents,  is  more  watery,  and  coagulates 
more  readily.  The  total  quantity  is  less. 

The  semen  is  very  frequently  wanting  in  sper- 
matozoa, and  contains  in  their  place  granular 
fatty  cells,  like  colostrum  corpuscles,  with  a few 
red  blood-corpuscles;  but  this  is  not  invariably 
the  case,  for  perfect  spermatozoa  are  occasionally 
met  with  at  an  advanced  age. 

Physiological  Characters. — The  results  of 
such  structural  imperfections  appear  in  deterior- 
ation of  the  purely  physical,  as  well  as  of  the 
specially  vital,  properties  of  the  tissues.  There 
is  an  increased  rigidity  in  some  parts,  as  the 
tendons  and  blood-vessols ; and  a diminished  co- 
hesion in  others,  as  the  nails  and  bones,  which 
are  brittle  and  easily  broken.  Perhaps  the  most 
prominent  and  distinguishing  mark  of  old  age  is 
a loss  of  elasticity ; the  skin,  cartilages,  blood- 
vessels, and  lungs  show  this  to  a very  marked 
extent,  in  the  wrinkled  integuments,  dilated 
vessels,  and  distended  air-cells.  It  has  been 
noticed  that  this  dilatation  particularly  affects 
the  thin-walled  veins,  and  more  especially  those 
which  do  not  run  with  arteries,  are  more  super- 
ficial in  position,  and  are  concerned  less  with 
nutrition  than  with  the  proper  return  of  blood 
—the  ‘derivative  circulation’  of  Sucquet.  The 
advantage  of  this  is  apparent,  for  such  an  ar- 
rangement must  be  a safety-valve  in  the  case 
of  the  brain,  to  which  organ  there  is  a liability 
to  determination  of  blood,  and  where  the  vessels 
are  apt  to  rupture ; hence  the  frequent  turges- 
cence  of  the  nose  and  ears,  and  development  of  the 
veins  of  tbe  diploe,  in  the  aged.  The  muscular 
contractility  and  nervous  irritability  are  dimin- 
ished ; and  degeneration  of  the  cells  of  glands 
leads  to  failure  in  their  powers  of  secretion. 

The  heart's  beat  is  weak,  and  frequently  in- 
termittent, from  defect  in  rhythmical  nervous 
stimulation  ; the  sounds  are  feeble  and  often  al- 
tered ; and  there  is  a general  tendency  to  venous 
congestion.  The  mean  rate  of  pulse  after  the 
age  of  sixty-five  years  is  75,  gradually  diminish- 
ing to  70. 

The  tissues,  which  differ  in  chemical  compo- 
sition from  those  of  mature  life,  must  in  their 


SENILITY.  1417 


metabolism  form  different  products  of  waste  ; 
whilst  the  altered  blood,  circulating  in  a restricted 
area  with  diminished  force,  must  offer  to  the  or- 
gans a different  pabulum  from  that  which  they 
hare  hitherto  received,  supplied  as  it  is  by  im- 
paired digestive  organs.  The  enfeebled  respiration 
prevents  complete  oxidation ; and  the  excretory 
organs,  being  degenerated,  withdraw  from  the 
body  less  perfectly  the  results  of  metamorphosis. 
The  quantity  of  urine  is  often  diminished  to  15 
or  20  ounces  per  diem,  in  old  men  enjoying  good 
health.  It  contains  a total  amount  of  solids 
less  than  the  normal  standard,  but  the  urine 
itself  may  be  relatively  of  higher  specific  gra- 
vity, and  deeper  colour,  from  its  diminished 
quantity. 

As  the  nutritive  functions  fail,  so  do  those  of 
the  neuro-muscular  system.  The  sense-organs 
imperfectly  receive  impressions,  which  are  but 
dimly  communicated  to  the  sensorium,  whence 
feebly  emanate  the  impulses  needful  to  deter- 
mine movements  in  muscles  whose  protoplasmic 
contractility  is  gradually  diminishing.  Mean- 
while the  higher  mental  qualities,  such  as  me- 
mory, judgment,  and  reason,  dependent  as  they 
are  upon  the  most  perfect  nutrition,  gradually 
fail.  The  opposite  conditions  of  wakefulness 
and  drowsiness  are  frequently  met  with,  and 
seem  to  be  due  to  brain-wasting,  as  well  as  to 
some  change  in  the  cerebral  circulation. 

Notwithstanding  the  lowered  vitality,  the  ave- 
rage body-temperature  is  slightly  higher  than  it 
is  in  adult  life,  but  the  power  of  resisting  cold  is 
diminished. 

The  power  of  reproduction,  lost  by  women  at 
the  climacteric,  jefore  the  stage  of  senility  sets 
in,  is  occasionally  preserved  by  men  to  an  ad- 
vanced age. 

Thus  the  old  man  presents  a strong  contrast 
in  his  vitality  to  that  of  the  child,  for  whilst  the 
life  of  the  latter  is  so  largely  dependent  upon, 
and  so  readily  responsive  to,  external  or  peri- 
pheral impressions,  the  former  lives  more  and 
more  within  himself;  the  distinctive  animal 
functions  gradually  failing,  as  his  existence  be- 
comes restricted  to  the  performance  of  those  of 
self-nutrition.  The  progressive  impermeability 
of  the  capillaries,  and  the  lessened  vitality  of  the 
skin,  alike  tend  to  withdraw  from  the  surface 
towards  the  central  organs  the  manifestations 
of  life. 

Diseases  of  Old  Age. — In  a certain  number 
of  cases,  the  progressive  deterioration  in  struc- 
ture and  failure  in  functional  capacity  mutually 
adapt  themselves,  and  produce  an  old  age  which 
may  be  as  healthy  as  the  maturity  or  childhood 
may  have  been.  But  in  the  course  of  the  changes 
which  mark  this  period,  the  body  is  liable  to 
certain  influences,  both  intrinsic  and  extrinsic, 
which  lead  to  diseases  characteristic  of  this  stage 
of  life,  as  there  are  those  of  infancy  and  puberty. 
Death  from  old  age,  when  the  organs  have  gra- 
dually and  uniformly  failed,  is  not  unknown,  but 
the  fatal  end  is  more,  commonly  due  to  some  dis- 
ease. which  has  cither  lasted  from  an  earlier 
period,  or  is  especially  the  acquirement  of  this 
stage. 

The  maladies  particularly  characteristic  of 
oil  age  are  marked  by  certain  general  features, 
which  they  owe  to  that  condition  of  nutrition  in 


which  the  tissues  are  at  this  period.  Thus,  as  a 
rule,  they  present  but  little  activity  in  their  pro- 
gress, or  but  slight  severity  in  symptoms,  though 
they  are  none  the  less  likely  to  bring  about  a fatal 
result,  from  the  ill-resisting  power  of  the  whole 
system.  Diseases  of  an  acute  character  are  rare 
at  this  time;  and  such  as  do  occur  assume  an 
adynamic  form  and  are  very  liable  to  run  a most 
insidious  and  even  latent  course.  When  once 
established,  an  illness  tends  more  perhaps  to- 
wards maintaining  an  isolated  attitude,  with- 
out those  sympathetic  disturbances  of  many 
other  organs  so  pre-eminently  the  case  in  chil- 
dren. The  power  of  reaction  possessed  by  the 
aged  is  but  very  slight ; owing  to  this,  diseases 
readily  lapse  into  a chronic  state,  or  even  pre- 
sent a chronic  character  from  the  outset,  whilst 
comparatively  trifling  causes  may  lead  to  serious 
results. 

There  is  probably  no  single  disease  which  is 
met  with  in  advanced  age  only;  rather  is  it  the 
ease  that  many  diseases  which  prevail  at  certain 
periods  of  life  are  wanting  in  old  age.  The 
degeneration  of  every  tissue  and  organ  entails 
a failure  in  function;  and  should  this  failure 
predominate  in  any  one  system,  we  have  some 
exception  to  what  may  be  taken  as  the  normal 
standard  of  the  senile  state,  and  therefore  a 
disease  of  it.  The  same  difficulties  surround 
the  question  why  one  set  of  organs  should  be 
affected  rather  than  another,  as  at  other  ages ; 
but  there  nevertheless  does  exist  a preference 
towards  affections  of  the  brain,  heart,  and  lungs. 

Diseases  of  the  brain. — The  cerebral  Issions 
may  be  a general  senile  wasting  and  softening, 
with  complete  enfeeblementof  nerve-function;  or 
of  a more  localised  character  from  rupture  or 
occlusion  of  some  vessel.  The  liability  to  vencus 
engorgement  is  very  prone  to  manifest  itself  in  the 
brain,  and  cerebral  congestion  of  varying  extent 
is  frequent.  The  cerebral  vessels  are  especially 
prone  to  atheromatous  changes,  and  hence  the 
great  frequency  of  apoplexy  in  old  age.  The 
meninges  are  free  from  morbid  change  beyond 
thickenings,  and  offer  none  of  the  inflammatory 
conditions  so  common  in  early  life. 

Diseases  of  the  heart. — The  degeneration  of 
the  cardiac  substance  may  lead  to  a state  of 
asthenia,  gradually  becoming  fatal ; dilatation  of 
the  orifices  may  be  the  more  prominent  lesion, 
with  all  the  consequent  symptoms  of  obstructed 
circulation ; or  they  may  be  constricted,  from 
atheroma  or  thickening  of  the  cusps  or  rings. 
All  degrees  of  cardiac  dyspnoea  are  met  with ; 
and  every  form  of  irregularity  in  cardiac  rhythm. 

Diseases  of  the  lungs. — Pulmonary  diseases  are 
important,  since  they  are  commonly  the  imme- 
diate causes  of  death  in  the  aged.  A bronchial 
catarrh,  or  at  least  a considerable  increase  in 
the  bronchial  secretion,  is  a normal  state  in  the 
very  old;  and  this  has  been  regarded  as  a com- 
pensation for  the  arrested  skin-action.  The  tran- 
sition from  this  to  severe  bronchitis  is  both  easy 
and  frequent,  and  is  favoured  by  the  liability  to 
lung-congestion,  and  the  enfeebled  heart-power. 
Even  more  serious  is  a senile  form  of  lobular 
pneumonia,  which  seems  to  be  set  up  in  the  con- 
gested and  cedematous  areas,  possibly  as  a further 
stage  of  the  bronchitis.  Such  pneumonia  is  of 
very  frequent  occurrence,  and  often  requires  care- 


1418  SENILITY, 

fully  looking  for,  since  direct  symptoms  are  want- 
ing. When  a generally  ill-defined  illness  is  pre- 
sent in  an  old  person,  this  condition  should  be 
suspected. 

diseases  of  the  digestive  organs. — The  digestive 
organs,  supposing  they  have  escaped  the  dangers 
of  earlier  periods,  are  not  often  the  seat  of  disease 
at  this  time  of  life.  The  perversions  of  function 
they  present,  such  as  constipation  and  flatulence, 
may  be  conveniently  comprised  under  the  term 
atonic  dyspepsia,  and  are  mainly  to  be  attributed 
to  deficient  muscular  power  in  the  alimentary 
canal,  and  to  a deficiency  in  the  digestive  fluids. 
Nevertheless,  a good  appetite  and  very  fair  di- 
gestion are  far  from  beiug  the  exception  in  old 
people.  An  acute  form  of  diarrhoea  of  a dys- 
enteric character  has  been  described  as  occur- 
ring at  this  period. 

Diseases  of  the  skin. — The  skin,  which  suffers 
so  much  diminution  in  nutrition  and  thickness, 
often  exhibits  as  a result  marked  changes  in 
sensibility,  even  to  the  existence  of  an  intoler- 
able pruritus,  no  cause  for  which  is  visible.  The 
scratching  which  is  resorted  to  for  relief  sets 
up  a prurigo  which  intensifies  the  discomfort. 
The  unhealthy  integument  offers  a very  favour- 
able nidus  for  pediculi,  and  phthiriasis  is  accord- 
ingly a common  senile  affection. 

Diseases  of  the  urinary  organs. — Recent  ob- 
servations go  to  show  that  the  senile  kidney  is  in 
a condition  of  diffuse  interstitial  nephritis,  with 
progressive  atrophy  of  the  tubes,  similar  in  many 
respects  to  the  1 gouty  kidney,’  but  not,  like  it, 
associated  with  cardiac  hypertrophy.  The  urine 
is  in  such  cases  albuminous,  but  the  general 
symptoms  of  Bright’s  disease  met  with  in  middle 
life  are  usually  wanting.  Glycosuria,  often  in- 
termittent, is  of  very  frequent  occurrence  in  old 
people ; but  is  rarely  attended  by  the  constitu- 
tional disturbance  of  diabetes.  Notwithstanding 
the  very  imperfect  action  of  the  skin  and  kidneys 
as  excretory  organs,  diseases  directly  attributable 
to  non-elimination  of  waste-products  are  not 
characteristic  of  old  age,  except,  of  course,  so  far 
as  helping  in  the  general  degeneration. 

Irritability  of  the  bladder,  or  even  vesical 
catarrh,  is  very  common  in  old  men,  being  largely 
determined  by  the  prostatic  enlargement ; and 
both  retention  and  incontinence  of  urine  follow, 
from  the  diminished  toue  of  the  viseus. 

Vascular  disease. — The  tendency  of  the  blood 
to  coagulate,  added  to  the  opportunities  it  has 
for  stagnating  in  the  dilated  channels  and  cavi- 
ties of  a weak  heart,  makes  thrombosis  and 
embolism  characteristic  lesions  of  the  senile 
state.  The  result  of  the  obstruction  is  gangrene 
{gangrana  senilis),  which  is  readily  established 
in  tissues  the  capillaries  of  which  have  wasted 
or  are  obliterated,  with  corresponding  deficiency 
of  nutrition. 

Arthritic  lesions. — Very  few  old  people  escape 
chronic  rheumatism  in  one  or  other  of  its  many 
forms.  The  fibrous  tissues  of  the  joints,  fasciae, 
and  tendons  are  thickened,  with  the  result  of 
producing  that  stiffness  of  the  limbs  so  charac- 
teristic of  the  aged.  The  pain  is  rarely  acute, 
but  it  is  lasting,  and  aids  in  bringing  about 
the  general  deficiency  of  motor  power.  Renal 
disease  is  to  be  found  in  a large  proportion  of 
these  cases.  True  gout  is  scarcely  a disease  of 


SENSATION,  DISORDERS  OE. 

old  age,  though  often  continued  on  from  an  early 
period  of  life. 

Scrofula,  Cancer,  and  Syphilis. — Sir  James 
Paget  refers  to  a senile  form  of  scrofula  occurring 
in  people  over  sixty  years  of  age,  in  whom  the 
constitutional  signs  have  appeared  in  early  life, 
with  almost  complete  freedom  during  maturity. 
He  describes  the  general  'features  of  this  con- 
dition as  being  similar  to  those  in  childhood,  but 
slower  in  their  course,  and  more  complete  in 
the  degeneration  produced.  The  cancerous  and 
syphilitic  cachexiee  very  rarely  manifest  them- 
selves for  the  first  time  in  old  age. 

Treatment. — Old  age  itself,  as  a period  of  life, 
is  clearly  no  more  to  be  treated  as  such  than  life 
at  any  other  stage.  But  regarded  as  a marasmus 
or  cachexia,  it  has  been  sought  to  avert  it  as 
long  as  possible,  or  mitigate  its  effects;  and  for 
the  attainment  of  longevity  many  means  have 
been  proposed,  though  as  yet  without  any  reliable 
result,  the  most  diverse  plans  having  been  equally 
successful  or  futile.  See  Personal  Health. 

It  is  unnecessary  in  the  present  article  to  ex- 
plain the  treatment  of  the  diseases  of  old  age,  as 
appropriate  remedies  are  set  forth  under  the 
special  headings.  It  is  sufficient  here  to  indicate 
that,  whatever  may  be  the  malady,  and  whatever 
be  the  treatment  pursued,  it  must  not  be  forgotten 
that  we  are  dealing  with  organs  in  which  the 
structure  is  deteriorating  and  whose  vitality  is 
failing,  and  that  all  measures  of  a depleting  or 
depressing  character  must  be  avoided.  The  pa- 
tient must  be  nourished  in  every  way  by  food, 
stimulants,  tonics,  and  such  remedies;  and  this 
rule  must  not  be  departed  from  on  any  account. 
The  power  of  secretion  being  so  diminished,  the 
efficacy  of  drugs  is  often  lessened,  and  theirgood 
effects  but  imperfectly  manifested.  Among  the 
most  important  hygienic  indications  is  the  main- 
tenance of  warmth.  A fall  in  temperature  both 
lowers  the  genoral  vitality,  and  establishes  a local 
disease,  and  its  effects  are  more  easily  prevented, 
than  cured  when  once  established. 

W.  H.  Allchin. 

SENSATION,  Disorders  of. — The  sensory 
apparatus — consisting  of,  lsr,  a peripheral  end- 
organ  for  receiving  impressions  ; 2nd,  an  afferent 
nerve  which  conducts  thpm  ; and,  3rd,  a ganglionic 
nerve-centre  which  undergoes  a change,  perceived 
by  the  consciousness  as  a feeliDg — may  be  dis- 
ordered in  various  degrees.  The  lesion  occasion- 
ing the  disorder  may  exist  at  any  point  of  the 
apparatus.  As  regards  (a)  the  nerves  of  spaial 
sensibility — the  olfactory,  optic,  auditory,  and 
gustatory,  the  terms  hyperesthesia  or  excess  of 
feeling,  and  anesthesia  or  want  of  feeling,  are 
applied  respectively  to  conditions  of  exaggerated 
or  defective  sensibility.  In  reference  to  (n)  the 
remaining  sensory  nerves,  the  perceptions  pro- 
duced by  which  are  known  as  common  sensations, 
the  same  terms  are  used,  as  well  as  certain  others 
indicating  perversions  of  sensibility,  which  can 
scarcely  be  included  in  this  simple  classification. 
There  is  a good  deal  of  confusion  existing  in  iho 
employment  of  these  terms,  and  their  use  can 
only  be  defended  cn  account  of  their  possessing 
a certain  amount  of  convenience  for  purposes  of 
distinction.  Pain  is  separately  described.  Set 
Pain. 


SENSATION,  DISORDERS  OF.  1419 


A.  Special  sensibility. 

1.  Olfactory  hyperesthesia.  This  is  probably 
always  of  central  origin.  It  is  shown  by  sub- 
jective sensations  of  strong,  usually  disagreeable, 
odours ; and  occurs  occasionally  in  the  insane 
and  epileptic,  as  well  as  in  hysteria. 

2.  Olfactory  anesthesia.  Synon.  : Anosmia. — 
This  is  occasionally  congenital,  but  otherwise  rare, 
and  (unless  where  the  mucous  membrane  of  the 
nares  has  been  destroyed  by  ulceration)  is  usually 
dependent  on  disease  of  the  brain,  or  growths 
upon  the  olfactory  lobes.  It  may  also  arise  from 
laceration  of  the  olfactory  filaments,  as  a result 
of  contre-coup  in  blows  upon  the  occiput.  There 
may  be  complete  anosmia,  whilst  the  common 
sensibility  of  the  nares  is  retained.  On  the 
other  hand,  in  peripheral  lesion  of  the  fifth  nerve 
there  may  be  partial  loss  of  smell,  owing  doubt- 
less to  impaired  nutrition  of  the  nasal  mucous 
membrane.  Integrity  of  the  mucous  membrane 
is  apparently  necessary  (probably  for  mechanical 
reasons)  to  the  perfect  functioning  of  this  special 
sense.  It  sometimes  happens  that  there  are 
subjective  sensations  of  bad  odours,  wdiere  the 
power  of  perceiving  objective  odours  is  absent. 
Anosmia  may  occasionally  result  from  a long- 
continued  nasal  catarrh,  and  is  then  probably 
connected  with  some  modification  of  the  mucous 
membrane  which  receives  olfactory  impressions. 

3 .Optic  hyperesthesia. — This  disorder  is  marked 
by  the  production  of  luminous  and  chromatic 
sensations,  independent  of  external  influences. 
The  disordered  function  may  be  caused  by,  or 
associated  with,  coarse  disease  of  the  brain,  over- 
stimulation  of  the  optic  nerve  by  light,  insanity, 
dolirium  tremens,  epilepsy,  or  hypochondriasis. 
Spectra  of  luminous  angularities,  resembling  the 
lines  of  fortifications,  showers  of  sparks,  or  bright 
colours  occur  sometimes  in  the  course  of  migraine. 
A subjective  sensation  of  colours  (most  often  red) 
occurs  occasionally  as  the  aura  of  an  epileptic  fit. 

4.  Optic  anesthesia. — This  may  depend  upon 
changes  in  the  retina,  in  the  trunk  of  the  optic 
nerve  or  tract,  or  in  the  nervous  ganglia  which 
form  its  central  termination.  The  terms  am- 
blyopia and  amaurosis  are  usually  employed  to 
designate  different  degrees  of  imperfect  vision, 
the  latter  the  most  advanced.  Amblyopia  is  often 
met  with  in  the  disused  eye  in  cases  of  strabis- 
mus, without  any  structural  change  being  neces- 
sarily capable  of  detection  by  the  ophthalmo- 
scope, such  as  would  explain  the  loss  of  nervous 
sensibility.  In  some  instances,  however,  of  this 
kind,  the  optic  disc  has  a shrivelled,  ill-nourished 
look;  it  is  dull;  and  the  retinal  vessels  are 
small.  Amblyopia  may  consist  in  a general 
obscurity  of  vision,  a deficiency  in  the  power  of 
definition,  a contraction  of  the  field  of  vision,  or 
anomalies  of  colour-vision.  It  occurs  occasion- 
ally in  hysterical  hemiansesthesia,  and  is  then 
limited  to  one  eye,  on  the  same  side  as  the  other 
defects  of  sensation  ; it  is  frequently  the  prelude 
of  an  epileptic  fit. 

Ophthalmoscopical  examination  of  the  eye, 
together  with  the  patient's  general  condition, 
will  usually  reveal  the  cause  with  facility.  Am- 
blyopia may  be  a symptom  of  optic  neuritis.  The 
optic  neuritis  will  probably  be  dependent  upon 
tumour,  abscess,  aneurism,  or  some  coarse  change 
within  the  cranium,  such  as  meningitis.  Or 


there  may  be  neuro-retinitis , in  which  the  retina 
still  more  largely  participates  in  theinflammatory 
changes,  a condition  liable  to  be  induced,  amongst 
other  causes,  by  syphilis,  diphtheria,  or  over- 
lactation. But  the  symptom  is  frequently  absent 
in  both  conditions  up  to  a certain  point,  the 
patient  being  able  to  read  small  print  even  when 
the  pat  hological  changes  are  strongly  pronounced. 
Sometimes  amaurosis  also  occurs  in  diabetes, 
from  retinal  changes.  In  hemeralopia  there  is 
retinal  torpor,  which  is  sometimes  not  accom- 
panied by  any  manifest  structural  change.  The 
disorder  is  connected  with  anaemia,  impaired 
nutrition,  and  various  causes  of  exhaustion,  and 
is  especially  common  in  scurvy.  It  may  occur 
in  Bright’s  Disease,  but  is  here  found  associated 
with  haemorrhages  and  other  changes  character- 
istic of  albuminuric  retinitis. 

5.  Hemiopia. — This  is  a condition  in  which  a 
half  of  the  field  of  vision — usually  a lateral  half 
— is  cut  off.  It  may  depend  upon  coarse  dis- 
ease, such  as  a tumour  or  clot,  pressing  upon 
an  optic  tract.  It  occurs  sometimes  in  hemi- 
plegia, complicated  with  paralysis  of  the  third 
nerve  opposite  to  the  side  on  which  the  limbs 
are  paralysed,  and  depends  then  upon  lesion  of 
the  corresponding  crus  cerebri.  It  is  frequently 
seen  in  a hemiplegia  which  is  attended  with 
strongly  marked  and  persistent  anaesthesia  of 
the  affected  limbs,  and  dependent  upon  coarse 
disease  in  the  neighbourhood  of  the  optic  thala- 
mus. It  is  not  rarely  met  with  also,  but  only  as  a 
transient  symptom,  in  migraine.  It  is  occasion- 
ally, but  only  seldom,  met  with  in  hysteria. 

6.  Auditory  hyperesthesia.— In  certain  states 
of  nervous  exhaustion  in  fever,  and  sometimes  in 
hysteria  and  hypochondriasis,  sound-producing 
vibrations  painfully  affect  the  auditory  nerve.  It 
is  doubtful  w-hether  the  proper  function  of  the 
nerve  is  ever  really  much  intensified.  Pain, 
rather  than  an  increased  power  of  hearing,  is  the 
result  of  hyperaesthesia  of  the  auditory  nerve. 

7.  Tinnitus  aurium. — This  is  almost  always 
subjective,  although  it  must  be  borne  in  mind  that 
an  aneurism  in  the  neighbourhood  of  the  temporal 
bone  may  occasion  this  condition,  and  this  may 
possibly  give  evidence  of  its  presence  on  auscul- 
tating the  skull.  The  sounds  may  be  of  various 
kinds — rumbling,  musical,  roaring,  hammering — 
and  may  depend  either  upon  some  irritation  of 
the  auditory  nerve  itself,  or  upon  affection  of 
some  other  part  of  the  organ  of  hearing.  It 
seems  probable  that  affection  of  any  portion, 
from  the  external  auditory  meatus  to  the  Eus- 
tachian tube,  may  give  rise  to  the  condition.  The 
difficulty  of  diagnosing  the  seat  of  the  affection 
is  very  great. 

Tinnitus  aurium  may  also  be  dependent  upon 
some  altered  condition  of  the  walls  of  blood- 
vessels, in  connection  with  anaemia  or  cerebral 
congestion.  It  is  often  produced  bv  large  doses 
of  quinine.  In  certain  cases  it  is  of  central 
origin.  The  sensation  of  a loud  noise  occasionally 
marks  the  commencement  of  an  epileptic  seizure 
or  of  a syncopal  attack.  Deranged  digestion  may 
produce  it.  There  may  be  subjective  sensations 
of  sound  in  an  ear  w'hich  is  quite  deaf  to  exter- 
nal impressions. 

Careful  examination  of  such  parts  of  the  audi- 
tory apparatus  as  can  be  reached  should  be  made, 


1420  SENSATION,  DISOKDERS  OF. 

ere  a conclusion  is  come  to  respecting  the  origin 
cf  tinnitus  aurium  in  a particular  ease.  It  is 
not  uncommonly  found  to  be  dependent  simply 
upon  an  accumulation  of  wax  in  the  external 
uuditory  meatus.  Tinnitus  aurium  is  very  often 
associated  with  vertigo.  Not  uncommonly 
occurring  in  persons  of  gouty  habit,  it  is  possibly 
caused,  in  such  cases,  by  some  deposit  in  a joint  of 
the  ossicles,  causing  inflammation  and  stiffness. 

Tinnitu  aurium  is  always  a distressing,  and 
often  an  intractable,  affection.  "Where  it  de 
pends  upon  some  anaemic  condition,  it  is  most 
likely  to  be  cured  by  remedies  appropriate  to 
this  state.  Of  course,  if  caused  by  accumulation 
of  wax,  the  removal  of  this  is  a simple  remedy. 
Subjective  sensations  of  sounds,  especially  of 
voices  of  men  or  animals,  occur  frequently  in 
various  forms  of  insanity,  in  which  case  they  are 
spoken  of  as  hallucinations. 

8.  Auditory  anesthesia. — This  may  be  due  to 
disease  or  suspended  functional  activity  of  the 
auditory  nerve ; and  probably,  in  some  cases,  to 
lesion  of  the  superior  temporo-sphenoidal  con- 
volution of  the  brain — Perrier’s  centre  for  hear- 
ing. Hardness  of  hearing  and  deafness  are  the 
forms  taken  by  varying  degrees  of  acoustic  anaes- 
thesia. The  cause  may  be  disease  in  the  osseous 
labyrinth  of  the  bone  itself  or  its  lining  mem- 
brane, or  tumours  which  cause  compression  aud 
atrophy  of  the  nerve,  basilar  meningitis,  extra- 
vasations, or  new  formations.  Syphilis  may  bring 
about  acoustic  anaesthesia  by  causing  periostitis 
and  consequent  pressure  upon  the  auditory 
nerve.  A most  fruitful  source  of  deafness  is 
disease  of  the  temporal  bone  from  scarlatina.  In 
some  instances  the  auditory  nerve  is  atrophied, 
as  part  of  that  generalised  disorder  of  the  sensory 
nervous  system  which  is  called  locomotor  ataxy. 
In  cases  of  so-called  nervous  deafness  enquiry 
should  be  made  as  to  the  occurrence  of  ‘light- 
ning pains,’  and  the  state  of  the  patellar  tendon 
reflex  should  be  investigated. 

Disease  of  the  pons  Varolii  or  medulla  ob- 
longata may  occasion  deafness,  through  lesions 
affecting  the  nucleus  of  the  auditory  nerve  or 
the  commencement  of  its  trunk.  It  is  more  likely 
than  not  that  in  these  circumstances  the  auditory 
nucleus  would  not  suffer  alone,  but  that  there 
would  be  evidence  of  other  cranial  nerves  being 
involved,  which  would  aid  the  diagnosis. 

9.  Gustatory  hyperesthesia.  — This  disorder 
occurs  probably  only  in  the  course  of  mental  and 
epileptic  disorders,  where  the  subjective  sensa- 
tion of  a taste  (most  often  perhaps  of  an  offen- 
sive character)  is  sometimes  complained  of.  Such 
a condition  is  of  central  origin. 

10.  Gustatory  anesthesia. — This  is  of  frequent 
occurrence.  There  may  be  a total  inability  to 
appreciate  the  taste  of  substances  applied  to  the 
tongue,  or  more  or  less  delay  in  their  recognition. 
It  is  sometimes  observed  in  cases  of  peripheral 
paralysis  of  the  facial  muscles,  and  then  depends 
upon  the  lesion  of  the  portio  dura  involving  the 
chorda  tympani.  It  is  the  anterior  portion  of 
the  tongue  which,  in  such  circumstances,  exhibits 
the  loss  of  function.  So  also  in  disease  of  the 
trigeminus  in  the  floor  of  the  skull,  there  is  fre- 
quently gustatory  anaesthesia  in  the  anterior  por- 
tion of  the  tongue.  The  glosso-pharyngeal  nerve 
by  its  terminal  branches  presides  over  the  sense 


SEPTICEMIA. 

of  tiste  in  the  posterior  third  of  the  dorsal 
aspect  of  the  tongue.  Disease  or  lesion  of  the 
trunk  of  this  nerve  destroys  the  sense  of  taste  in 
this  region.  See  Taste,  Disorders  of. 

The  disorders  of  special  sensation  which  we 
have  described  are  so  bound  up  with  lesions  cf 
the  various  nerves  subserving  the  functions,  or 
of  the  nervous  centres,  that  they  can  only  be 
considered  from  an  aetiological  and  therapeutical 
point  of  new  in  connection  with  these.  PLefer- 
ence  must,  therefore,  be  made  to  the  sections 
devoted  to  such  lesions. 

B.  Common  Sensibility. — Disorders  of  those 
centripetal  nerves,  the  perceptions  produced  by 
which  are  known  as  * common  sensations,’  are 
considered  under  the  head  of  Touch,  Disorders 
of.  T.  Buzzard. 

SEPTIC  ( o"hira> , I make  rotten  or  putrid;  I 
make  fester  or  mortify.) — This  word  is  nsed 
with  some  vagueness.  It  has  been  employed 
in  both  the  senses  indicated  by  the  derivation, 
that  is,  either  as  merely  synonymous  with 
putrid,  or  as  signifying  some  special  or  even 
specific  virulence  in  decomposing  matter.  The 
confusion  will  be  better  understood  by  referring 
to  the  definition  of  Septicemia.  There  is  no 
doubt  the  word  had  better  he  abandoned,  and 
putrid  used  in  its  6tead  ; or  else  that  it  be 
clearly  understood  to  have  no  meaning  beyond 
putrid.  Marcus  Beck. 

SEPTICEMIA  ( oTiiTTiKbs , putrid,  and  alua, 
blood). — Synox.  : Pr.  Septicemie ; Ger.  Septir 
cdrnie. — This  term  properly  means  the  condition 
produced  by  the  entrance  of  septic  matter  into 
the  blood.  Great  confusion  has,  however,  been 
caused  by  using  it  to  signify  two  entirely 
distinct  conditions.  The  first  of  these  cannot 
be  better  defined  than  in  the  words  of  Dr. 
Burdon  Sanderson,  in  his  Lectures  on  the ‘In- 
fective Processes  of  Disease  ’ {Brit.  Med.  Joum., 
Dec.  29,  1877).  He  says:  ‘What  I mean  by 
septicemia  is  a constitutional  disorder  of  limited 
duration,  produced  by  the  entrance  into  the 
blood-stream  of  a certain  quantity  of  septic 
material.  It  must,  therefore,  be  regarded,  not 
so  much  as  a disease  as  a complication,  differing 
from  pyaemia,  not  only  in  the  fact  that  it  has 
no  necessary  connection  with  any  local  process, 
either  primary  or  secondary,  but  also  in  the 
important  particular  that  it  has  no  develop- 
ment. Pyaemia  is  a malignant  process  which 
goes  on  and  on  to  its  fatal  end  : but  in  the  case 
of  septicaemia,  inasmuch  as  the  poison  which 
produces  it  has  no  tendency  to  multiply  in  the 
organism,  there  is  no  reason  why  the  morbid 
process  should  not  come  to  an  end  of  itself,  un- 
less either  the  original  dose  is  fatal,  or  3 second 
infection  takes  place  from  the  same  or  another 
source.’  The  process  here  described  is  merely 
poisoning  by  the  absorption  of  the  chemical 
products  of  putrefaction.  It  is  no  mere  an  in- 
fective process  than  the  poisoning  that  would 
result  from  the  application  of  arsenic,  mercury, 
or  any  other  inorganic  substance  to  a raw  surface. 

On  the  other  hand,  Koch  of  Berlin,  Davaine, 
and  many  others  include  under  the  term  septi- 
caemia all  those  cases  of  general  infection  from 
a wound  in  which  no  metastatic  inflammations 
are  present.  Koch  especially  describes  as  septi- 


SEPTICAEMIA. 

eaernia  in  mice  a disease  in  which,  as  the  result 
of  the  inoculation  of  an  infinitesimal  dose,  the 
animal  dies  within  a certain  period,  without  the 
formation  of  any  secondary  local  centres  of  in- 
flammation. The  blood,  however,  is  so  com- 
pletely impregnated  with  the  poison  that  merely 
scratching  the  ear  of  another  mouse  with  a 
needle  dipped  in  the  opened  heart  of  the  first, 
is  sufficient  to  start  a similar  process  in  that 
animal,  and  so  on  indefinitely.  In  this  case  the 
process  is  truly  infective,  and  the  poison  multi- 
plies in  the  body  of  the  animal.  The  poison 
lias  been  shown  by  Koch  to  consist  of  a distinct 
form  of  microscopic  organism. 

These  two  conditions  must  be  kept  distinct  if 
we  are  to  avoid  confusion.  In  both  forms  the 
development  of  the  poison  is  associated  with 
putrefaction,  in  the  first  necessarily,  in  the  second 
accidentally.  The  former  is  an  inevitable  con- 
sequence of  the  entrance  of  the  products  of 
putrefaction  into  the  circulation  ; the  latter  can 
only  occur  if  the  specific  organism,  which  is  the 
cause  of  it,  should  happen  to  find  a place  amongst 
those  which  are  necessarily  associated  with  all 
putrefactive  changes.  The  latter  also,  although 
usually  originating  in  conjunction  with  what  we 
ordinarily  speak  of  as  putrefaction,  can  be  trans- 
ferred from  animal  to  animal  by  inoculation, 
without  the  intervention  of  any  putrefactive  pro- 
f cess  whatever. 

If,  therefore,  we  use  the  word  septic  as  mean- 
ing no  more  than  putrid,  the  two  conditions 
indicated  above,  at  present  often  indiscriminately 
spoken  of  as  septicaemia,  may  be  defined  as  fol- 
lows : — 

Septic  poisoning. — The  effects  produced  by  the 
absorption  of  a poisonous  dose  of  the  chemical 
products  of  putrefaction. 

Septic  infection. — An  infective  disease  caused 
by  the  entrance  into  the  blood,  and  by  the  mul- 
tiplication therein,  of  a specific  organism  most 
commonly  developing  in  wounds  or  cavities,  the 
fluids  of  which  are  at  the  same  time  in  a state 
of  putrefaction. 

It  must  be  understood  that  this  article  is 
merely  intended  to  indicate  the  meanings  of  the 
word  septicamia.  The  fuller  discussion  of  the 
subject  comes  under  Pyaemia.  See  Pyemia. 

Marcus  Buck. 

SEPTUM  COBDIS,  Deficiency  of.  See 
Heart,  Malformations  of. 

SEQUELAE  ( sequor , I follow).— Conse- 
quences or  sequels.  This  word  is  applied  to 
symptoms  or  morbid  conditions  which  either 
remain  or  supervene  after  various  diseases  have 
run  their  course;  such  as  renal  disease  after 
scarlatina,  paralysis  after  diphtheria,  or  cardiac 
disease  after  acute  rheumatism. 

SEBOUS  CYST. — A cyst  containing  serous 
fluid.  See  Cysts. 

SEBUM  / In  physiology  the  ls<lmd 

portion  of  the  blood,  which  separates  after  coagu- 
lation, is  named  the  serum , and  this  is  taken 
as  a type  of  fluids  of  more  or  less  similar 
composition,  consisting  of  a watery  solution  of 
albumin  with  certain  salts.  In  pathology  ws 
have  to  deal  with  serum  outside  the  blood-vessels, 
either  as  a mere  dropsical  accumulation,  cr  as  a 


SEBOUS  MEMBRANES.  1421 
consequence  of  inflammation.  It  may  be  thug 
met  with  in  the  cellular  tissue  under  the  skin 
or  a mucous  membrane,  and  in  other  parts;  in 
serous  cavities  ; in  certain  organs,  as  the  lungs 
and  the  ventricles  of  the  brain;  or  as  a discharge 
from  the  surface  of  the  skin,  as  in  cases  of  eczema. 
Its  precise  composition  varies  considerably  under 
different  circumstances.  Clinically  serous  fluid 
is,  as  a rule,  of  most  importance  on  account  of 
its  mechanical  effects,  when  it  accumulates  in 
quantity  in  various  parts,  and  these  effects  may 
be  most  serious.  Its  presence  can  usually  be 
detected  by  objective  or  physical  examination. 
The  treatment  required  will  be  either  that  for 
dropsy  or  inflammation,  modified  by  local  consi- 
derations, according  to  the  principles  laid  down 
in  other  special  articles. 

FREDERICK  T.  BoBERTS. 

SEBOUS  MEMBRANES,  Diseases  of. 

Synon.:  Maladies  du  systemc  sereux ; Ger.  Krank- 
heiten  der  Serbscnhaute.— These  constitute  an 
important  class  of  diseases,  and  although  they 
are  discussed  under  /he  headings  of  the  several 
serous  membranes,  it  will  be  advantageous  to 
consider  them  generally,  according  to  the  plan 
followed  in  the  case  of  the  mucous  membranes. 
These  membranes  line  closed  cavities,  except  the 
peritoneum  in  the  female,  which  communicates 
with  the  uterus  through  t.heFallopian  tubes,  and 
thus  with  the  exterior  of  the  body.  They  consist 
of  a basement-membrane,  covered  with  epithe- 
lium, usually  of  the  scaly  variety,  and  a sub- 
serous  cellular  tissue  underneath.  In  addition 
to  their  more  obvious  function,  of  allowing  free 
movement  for  organs,  they  are  intimately  con- 
nected with  the  absorbent  system,  the  vessels  of 
which  freely  open  on  their  surfaces.  Fibro-serous 
membranes  constitute  a variety  in  which  there 
is  an  outer  fibrous  covering,  lined  by  a serous 
layer,  of  which  the  pericardium  is  an  example. 
These  introductory  remarks  will  clear  the  way 
for  the  consideration  of  the  nature  and  causes  of 
the  diseases  of  serous  membranes,  which  will 
now  be  pointed  out. 

1.  Injury. — The  serous  membranes  are  liable 
to  be  injured  from  without,  chiefly  as  the  result 
of  wounds  pienetrating  the  cavities  which  they 
line,  hut  also  by  fractured  bones,  especially  in 
the  case  of  the  ribs  and  skull.  It  is  believed 
that  a severe  external  contusion  may  affect  an 
underlying  serous  membrane.  Another  impor- 
tant cause  of  injury  to  these  structures  is  some 
perforation  or  rupture  taking  place  within  the 
body  (see  Perforations  and  Ruptures).  They 
are  frequently  more  or  less  injured  in  various 
operations.  Any  kind  of  injury  to  this  class  of 
membranes  was  formerly  regarded  with  great 
dread,  and  operations  in  which  they  were  in 
any  way  interfered  with  were  considered  highly 
dangerous ; more  recent  experience  has,  however, 
shown  that  mere  damage  to  a serous  membrane 
is  not  serious  in  itself.  More  or  less  grave  con- 
sequences are  liable  to  follow,  from  haemorrhage ; 
from  the  admission  of  air,  especially  if  it  con- 
tains septic  matters;  or  from  the  escape  of  solid 
or  liquid  materials  into  a serous  cavity.  In  ad- 
dition to  their  direct  effects,  these  often  set  up 
inflammation,  which  may  prove  fatal. 

2.  Inflammation. — Serous  inflammations  are 


1422  SEROUS  MEMBRANES,  DISEASES  OF. 


of  common  occurrence,  and  without  entering  into 
details,  their  causes  may  he  thus  summarised: 
(a)  Some  injury  from,  without  including  that  set 
up  by  fractured  bones,  (h)  Perforations  and 
ruptures  within  the  body,  the  inflammation  be- 
ing then  mainly  due  to  the  materials  which  gain 
access  into  the  serous  cavity,  (e)  Mechanical  or 
chemical  irritation  of  any  kind.  Many  cases  be- 
longing to  the  former  groups  would  come  under 
this  one;  as  well  as  those  in  which  inflammation 
is  set  up  by  necrosed  bone,  diseased  organs,  and 
tumours,  or  as  the  result  cf  over-distension  of  a 
serous  membrane.  This  class  would  also  include 
those  cases  in  which  a serous  inflammation  is 
purposely  excited  by  the  injection  of  certain 
chemical" irritants.  The  occurrence  of  peritonitis 
from  the  entrance  into  the  peritoneum  of  mate- 
rials from  the  uterus  may  also  be  mentioned  here. 
(d)  Morbid  growths  in  connection  with  a serous 
membrane.  These  deserve  separate  mention, 
though  they  likewise  act  by  causing  local  irrita- 
tion. ( e ) Extension  of  inflammation  from  other 
structures.  In  this  way  the  morbid  process 
may  pass  from  one  serous  membrane  to  another. 
Serious  forms  of  inflammation  may  probably  ex- 
tend to  the  serous  membranes  by  means  of  the 
lymphatics.  (/)  Certain  general  states  of  the 
system,  in  connection  with  low  fevers,  Bright's 
disease,  and  other  affections,  (q)  Causes  acting 
upon  the  general  system  from  without,  such  as 
cold,  when  the  inflammation  is  said  to  be  idio- 
pathic. Different  serous  membranes  present  dif- 
ferent degrees  of  liability  to  be  affected  by  one 
or  other  of  the  causes  mentioned;  and  these  pro- 
duce different  effects,  according  to  their  nature. 

Cases  of  serous  inflammations  present  much 
diversity  as  regards  their  severity  and  rate  of 
progress,  and  the  morbid  changes  are  thus  mate- 
rially influenced  in  their  character,  as  well  as 
by  the  cause  of  the  inflammation,  the  particular 
membrane  affected,  and  other  circumstances.  In 
general  terms  they  may  be  grouped  as  acute, 
subacute,  and  chronic  in  their  origin  and  course; 
but  those  which  are  more  or  less  acute  at  first 
often  leave  behind  permanent  morbid  conditions. 
Taking  an  ordinary  case  of  an  acute  serous  in- 
flammation, running  a regular  course,  it  presents 
the  following  more  or  less  obvious  stages  in  its 
anatomical  characters : — (u)  Increased  vascula- 
rization, consequent  redness  of  the  membrane, 
and  sometimes  small  haemorrhages,  accompanied 
with  dryness,  loss  of  polish,  opacity,  and  swell- 
ing. ( b ) Deposit  of  organisable  lymph  or  fibri- 
nous exudation  upon  the  surface,  containing  a 
variable  number  of  cells,  (c)  Effusion  of  fluid 
into  the  serous  cavity,  more  or  less  of  the  nature 
of  serum,  but  also  containing  a variable  propor- 
tion of  fibrin  and  cells.  (<f)  Absorption  of  the 
fluid,  (e)  The  formation  of  fibrous  thickenings, 
or  of  adhesions,  bands,  or  agglutinations  between 
the  opposing  surfaces  of  the  serous  membrane. 

Such  being  the  usual  course  of  events  in  a 
typical  case  of  serous  inflammation,  it  must  suf- 
fice to  point  out,  without  entering  into  any  de- 
tails, some  of  the  more  common  variations.  There 
may  be  little  or  no  fluid,  the  exudation  being 
the  prominent  morbid  product.  This  exudation 
varies  much  in  its  quality,  and  may  be  of  a very 
low,  unorganisable  type,  resembling  in  some  in- 
stances thick  pus.  Again,  the  effusior  is,  under 


cerfaincircumstances,  liable  to  become  sero-puru- 
lent  or  actually  purulent,  or  it  may  be  so  from 
the  first.  In  other  conditions  it  is  htemorrhagic. 
Its  quantity  is  very  variable.  There  is  a class  of 
cases  in  which  the  prominent  morbid  change  is 
the  accumulation  of  a serous  effusion,  not  un- 
commonly in  large  amount,  and  it  may  take  place 
very  gradually  and  insidiously.  The  slow  and 
chronic  formation  of  localised  adhesions  is  very 
common  in  connection  with  serous  membranes, 
without  any  clinical  indications  of  their  develop- 
ment. Gas  may  be  present  in  serous  cavities  in 
cases  of  inflammation,  and  then  results  second- 
arily from  decomposition  of  the  effusion.  In 
rare  instances  pus  collects  in  the  subserous  tissue; 
or  actual  destruction  or  gangrene  may  occur. 

With  regard  to  the  extent  of  the  disease,  cases 
of  serous  inflammation  are  usually  divided  into 
general  or  diffuse,  and  local  or  circumscribed, 
though  the  former  terms  do  not  necessarily  im- 
ply that  the  whole  of  a serous  membrane  is 
implicated.  As  a rule  the  effusion  is  freely 
movable  in  the  cavity,  but  it  maybe  more  or  less 
limited  by  former  adhesions,  or  even  completely 
loeulated  and  encysted.  Serous  inflammations 
are  often  accompanied  with  changes  in  the  organs 
and  structures  which  they  cover,  these  being  either 
the  cause  or  effect  of  such  inflammatory  changes. 
Moreover,  an  effusion,  especially  if  purulent,  may 
open  in  various  directions,  and  thus  originate 
secondary  consequences  more  or  less  serious. 
Not  uncommonly  it  has  to  be  removed  by  opera- 
tion. 

Pathologists  are  not  quite  agreed  as  to  the 
microscopic  changes  which  take  place  in  inflam- 
mation of  serous  membranes,  but  the  following 
are  the  chief  points  to  be  noticed.  The  epithe- 
lium undergoes  marked  changes,  its  cells  usually 
becoming  enlarged  and  swollen,  granular,  and 
cloudy,  whilst  its  nuclei  divide  and  multiply, 
and  active  proliferation  goes  on.  In  low  forms 
they  merely  undergo  fatty  degeneration  and  de- 
struction, and  are  shed  abundantly.  The  fibrin 
escapes  from  the  blood-vessels,  and  migration  of 
corpuscles  also  takes  place.  The  cells  in  the  sub- 
stance of  the  serous  membrane,  and  the  connec- 
tive-tissue corpuscles  proliferate  more  or  less. 
Vascular  granulations  often  form  on  the  surface, 
which  are  believed  to  be  of  much  service  in 
absorbing  the  effusion,  as  well  as  in  forming 
adhesions.  Pus-cells  are  derived  from  the  epithe- 
lium, and  from  migration.  Adhesions  ordinarily 
result  from  the  development  of  the  cellular  ele- 
ments in  the  exudation,  the  fibrin  undergoing 
fatty  degeneration  ; after  pus  is  formed  they  ori- 
ginate by  granulation.  In  these  adhesions  blood- 
vessels, elastic  fibres,  lymph-chambers,  and  even 
nerves  may  ultimately  be  developed. 

3.  Dropsical  Effusion. — The  serous  cavities 
are  often  the  seat  of  a mere  dropsical  accumula- 
tion, owing  to  the  escape  of  fluid  of  a mere  or 
less  serous  character  from  the  vessels.  It  may 
be  in  very  large  quantity,  and  collect  either 
rapidly  or  gradually.  Sometimes  it  is  not  easy 
to  draw  the  line  between  an  inflammatory  and  a 
dropsical  effusion;  and  it  is  probable  that  the 
latter,  by  distending  a serous  membrane,  may 
really  set  up  a secondary  inflammatory  condition. 
The  fluid  is  occasionally  blood-stained.  The  con- 
dition may  be  entirely  local,  or  a part  of  a more 


SEROUS  MEMBRANES,  DISEASES  OF. 


or  less  general  dropsy.  It  may  arise  from  : — (a) 
Local  obstruction  to  the  venous  circulation,  which 
is  best  exemplified  by  ascites  associated  with 
portal  obstruction.  (6)  General  obstruction  to 
the  circulation,  in  certain  cases  of  cardiac  and 
pulmonary  disease,  (c)  Bright's  Disease.  ( d ) 
Chronic  adhesions  and  thickenings  originating 
in  past  inflammation  ; and  morbid  growths,  such 
as  tubercle  or  cancer.  These  probably  act  by 
pressing  upon  the  small  vessels,  (e)  Exposure  to 
cold,  sudden  suppression  of  chronic  skin-diseases, 
and  other  causes  which  are  supposed  to  originate 
active  internal  congestion. 

4.  Haemorrhage. — As  has  been  already  stated, 
more  or  less  blood  may  be  present  in  inflamma- 
tory or  dropsical  effusions  in  serous  cavities.  As 
a distinct  morbid  condition,  haemorrhage  into 
these  spaces  may  be  due  to  : — (a)  External  in- 
jury. ( b ) Rupture  of  an  organ,  whether  healthy 
or  diseased,  (c)  I he  bursting  of  an  aneurism, 
(d)  The  rupture  of  vessels  in  connection  with 
some  morbid  growth,  especially  cancer,  (e)  Pur- 
pura and  scurvy  in  exceptional  cases. 

5.  Accumulation  of  Gas. — This  condition, 
in  connection  with  serous  cavities,  may  result 
from: — ( a ) Decomposition  of  inflammatory  pro- 
ducts, or  of  gangrenous  materials,  (4)  Perfo- 
ration or  rupture  of  a hollow  organ  contain- 
ing air  or  gas,  whether  due  to  external  injury, 
or  originating  from  within.  This  accounts  for 
most  cases  of  escape  of  air  into  the  pleura 
from  the  lung,  and  of  gas  from  the  intes- 
tine into  the  peritoneum,  (c)  Transmission  of 
gas  through  the  walls  of  a hollow  viscus  into  a 
serous  cavity,  which  sometimes  happens  in  tho 
case  of  the  intestine.  The  gas  varies  much  in  its 
composition,  according  to  the  cause  of  its  pre- 
sence, and  its  seat.  In  pneumothorax  it  is  usually 
modified  air;  in  pneumoperitoneum  it  is  offen- 
sive and  foetid.  Not  unusually  the  gas  is  asso- 
ciated with  inflammatory  effusion  or  other  mate- 
rials; or  it  may  set  up  inflammation,  and  cause 
effusion. 

6.  Foreign  Materials.— Various  objects  may 
be  found  in  serous  cavities,  either  introduced 
from  without,  as  the  result  of  injuries;  or  having 
entered  from  internal  organs,  especially  in  the 
case  of  the  abdomen.  Amongst  others  may  be 
mentioned  dirt,  bullets  or  shots,  food,  faeces, 
urine,  worms,  and  calculi.  These  are  very  liable 
to  set  up  inflammation,  often  of  a very  severe  and 
dangerous  character. 

7.  Morbid  Growths. — Tubercle  and  cancer 
are  the  two  important  growths  which  may  be 
found  associated  with  serous  membranes.  In 
the  folds  of  the  peritoneum  accumulation  of  fat 
often  occurs.  Amongst  rare  morbid  formations 
may  be  mentioned  hydatids ; cysts  of  different 
kinds ; fibromata  ; myxomata  ; and  remnants  of 
blood-clots.  They  may  produce  inflammation  or 
mere  sorous  effusion. 

8.  Malformations. — The  serous  membranes 
sometimes  present  unusual  arrangements,  espe- 
cially the  peritoneum,  and  these  may  become  of 
clinical  importance. 

SvMrroJis. — The  clinical  phenomena  which 
are  associated  with  diseases  of  serous  membranes 
come  within  very  defined  limits,  and  can  be 
roodily  understood,  as  the  following  outline  will 
chow. 


1423 

1.  Morbid  sensations.-  Pain  is  usually  a pro- 
minent symptom  in  acute  serous  inflammations. 
It  is  not  uncommonly  very  severe  ; variable  in  its 
character,  but  often  sharp  and  darting  ; subject 
to  exacerbations ; and  increased  by  any  move- 
ment or  action  which  disturbs  tho  inflamed  mem- 
brane. Where  tbe  membrane  can  be  affected  by 
pressure,  as  in  the  case,  of  the  peritoneum,  marked 
tenderness  is  observed,  and  it  may  become  ex- 
treme. It  must  be  remembered,  however,  that 
pain  is  not  a necessary  accompaniment  of  acute 
serous  inflammation.  In  connection  with  adhe- 
sions and  thickenings,  painful  sensations  may 
he  experienced,  owing  to  the  implication  of 
branches  of  nerves  ; and  also  in  other  conditions 
associated  with  chronic  inflammation.  Another 
kind  of  morbid  sensation,  often  felt  in  diseases  of 
serous  membranes,  is  that  of  distension  or  fulness, 
due  to  various  accumulations  in  their  cavities. 

2.  Effects  on  neighbouring  structures. — These 
account  for  most  of  tbe  prominent  symptoms 
associated  with  diseases  of  serous  membranes. 
(a)  Acute  inflammation  will  at  first  cause  irri- 
tation of  certain  muscular  organs,  such  as  the 
intestines,  bladder,  or  heart,  and  thus  excite  or 
disturb  their  actions.  A similar  effect  is  liable 
to  be  produced  on  tho  brain  and  spinal  cord. 
Subsequently  these  organs  tend  to  become 
weakened,  or  even  paralysed,  owing  to  their  tis- 
sues being  involved  in  the  inflammatory  process  ; 
and  thus  striking,  or  even  dangerous,  symptoms 
may  arise.  ( b ) The  various  accumulations  in 
serous  cavities  produce  more  or  less  mechanical 
effects,  often  of  great  importance,  especially  if 
the  accumulation  take  place  rapidly.  The  most 
evident  are  distension  of  the  walls  of  cavities 
lined  by  serous  membranes;  compression  of 
organs  and  tubes,  as  of  the  lungs ; displacement 
of  various  structures ; and  embarrassment  of  the 
action  of  organs,  such  as  the  heart  and  lungs. 
In  these  several  ways  not  only  may  subjective 
sensations  be  produced,  but  different  objective 
phenomena,  which  may  prove  very  serious,  or 
even  fatal.  In  the  case  of  the  arachnoid,  lymph 
may  affect  important  nerves,  by  enclosing  and 
compressing  them.  ( c ) Another  important  class 
of  symptoms  are  those  due  to  the  effects  of 
adhesions,  agglutinations,  thickenings,  or  morbid 
growths.  Thus  organs  may  be  fixed  in  abnormal 
positions,  their  actions  interfered  with,  different 
structures  directly  pressed  upon,  or  hollow 
organs  strangulated  and  obstructed.  See  Ad- 
hesions. 

3.  Ruptures  and  discharges. — Accumulations 
in  serous  cavities  may  rupture  in  various  direc- 
tions, and  in  this  way  originate  symptoms.  If 
they  burst  internally,  they  will  also  probably  set 
up  secondary  lesions,  with  their  corresponding 
phenomena.  When  liquid  accumulations  open 
into  organs  which  have  an  external  communica- 
tion, such  as  the  lungs  or  intestines,  they  are 
discharged.  They  may  also  burst  externally, 
either  directly,  or  after  having  first  made  their 
way  into  the  subcutaneous  tissue. 

4.  Physical  signs. — These  are  of  great  impor- 
tance as  clinical  indications  of  morbid  conditions 
of  most  of  the  serous  membranes,  of  which  they 
may  be  the  only  evidence.  They  are  described 
in  other  appropriate  articles,  and  it  must  suffice 
to  state  here  that  they  reveal  one  or  other  of  the 


1424  SEROUS  MEMBRANES, 
following  conditions: — ( a ) Some  deposit  upon, 
or  roughness  of,  the  surfaces  of  the  membrane, 
associated  ■with  inflammation  or  morbid  growths. 
( b ) Accumulation  of  a fluid,  of  whatever  kind, 
and  whether  freely  movable  in  the  cavity  or 
localised,  (c)  A collection  of  gas,  or  of  gas  and 
fluid  together.  ( d ) Adhesions  or  agglutinations. 
( e ) The  presence  of  solid  masses,  due  to  inflam- 
matory thickening,  or  to  morbid  formations, 
especially  cancer.  (/)  Physical  effects  produced 
on  organs  by  the  abnormal  state  of  the  serous 
cavities. 

5.  General  symptoms. — The  system  is  liable 
to  suffer  in  different  ways  in  cases  of  disease 
of  serous  membranes.  Thus  syncope,  shock,  or 
collapse  may  occur  in  connection  with  injuries 
and  haemorrhages.  Inflammation  causes  pyrexia, 
usually  varying  much  in  degree,  but  in  some 
instances  very  high.  Septictemia  may  arise  from 
the  absorption  of  inflammatory  products  of  low 
type  ; and.  collapse  occurs  in  many  cases  of  peri- 
tonitis. Signs  of  the  general  cachexia  may  be 
present  in  cases  of  cancer  or  tuberculosis. 

Treatment. — It  is  scarcely  practicable  to  give 
any  serviceable  general  outline  of  treatment 
directed  to  diseases  of  serous  membranes,  this 
being  so  much  influenced  by  a variety  of  circum- 
stances. In  the  large  majority  of  cases  the  mea- 
sures adopted  have  some  relation  to  acute  inflam- 
mation, being  intended  either  to  prevent,  limit,  or 
subdue  this  process ; to  get  rid  of  its  products, 
either  by  absorption  or  in  other  ways;  to  obviate 
or  relieve  its  effects  upon  organs  and  other  struc- 
tures ; to  alleviate  symptoms ; and  to  affect  the 
general  condition.  Attention  may  also  have  to 
bo  directed  to  the  after-effects  of  inflammation, 
in  the  way  of  adhesions,  or  to  similar  conditions 
arising  from  chronic  inflammation.  In  a con- 
siderable group  of  cases  the  object  of  treatment  is 
to  endeavour  to  remove  accumulations,  especially 
of  fluid,  from  serous  cavities,  whether  of  inflam- 
matory or  other  origin.  Eor  this  purpose  it  is 
not  uncommon  at  the  present  day  to  resort  to 
operative  interference,  by  means  of  aspiration, 
tapping  with  the  trochar  and  cannula,  and  other 
methods.  General  and  local  rest  are  often  of 
much  service  in  the  treatment  of  morbid  condi- 
tions connected  with  serous  membranes;  and 
local  applications  are  also  frequently  useful  for 
various  purposes.  Bleeding,  either  general  or 
local,  has  been  extensively  practised,  and  is  still, 
in  the  treatment  of  serous  inflammations,  and 
also  the  exhibition  of  calomel  and  opium ; but, 
in  the  writer's  opinion,  the  routine  adoption  of 
this  line  of  practice  cannot  be  too  strongly  de- 
precated. Medicines  and  local  measures  which 
tend  to  promote  absorption  are  often  of  decided 
value,  especially  in  the  case  of  inflammatory  or 
dropsical  effusions. 

Frederick  T.  Robekts. 

SERPIGIN OUS  ( serpo , I creep). — This  term 
is  used  in  connection  with  certain  morbid  con- 
ditions, such  as  ulcers  or  eruptions,  -when  they 
spread  in  a creeping  manner. 

SETON,  Use  of. — A method  of  counter- 
irritation,  which  consists  in  the  insertion  of  a 
tape  or  cord  beneath  the  skin.  See  Counter- 
Irritants. 


SEXUAL  FUNCTIONS  IN  THE  FEMALE. 

SEVENTH  NERVE,  Diseases  of.  See 
Facial  Paralysis;  Facial  Spasm;  Hearing, 
Disorders  of ; Salivation  ; and  Taste,  Disorders 
of. 

SEVILLE,  in  Spain. — A variable,  rather 
bracing,  inland  winter  climate.  See  Climate, 
Treatment  of  Disease  by. 

SEXUAL  E UNCTIONS  IN  THE 
FEMALE,  Disorders  of. — Introduction. — 
The  influence  of  the  sexual  functions  on  the  gene- 
ral health  is  alluded  to  in  the  article  Puberty, 
Disorders  of.  But,  as  the  setiological  importance 
of  the  reproductive  system  is  by  no  means  limited 
to  that  period,  we  may  here  briefly  consider  the 
effect  of  sexual  disorders  generally  on  the  bodily 
health. 

The  connection  between  female  sexual  dis- 
orders and  some  of  the  derangements  of  the 
general  health  hardly  admits  of  any  satisfactoiy 
explanation  beyond  their  dependence  on  reflex 
action  originating  in  utero-ovarian  irritation. 
Long,  however,  before  this  doctrine  was  applied 
to  these  complaints,  their  existence  in  connection 
with  uterine  and  ovarian  disorders  was  well- 
recognised,  and  was  ascribed  by  old  writers  to 
what  they  termed  the  consensus  nervorum,  or 
sympathy,  by  which,  as  Prochaska  says,  ‘the 
operation  of  a stimulus  is  not  limited  to  the 
nerves  immediately  irritated,  but  is  extended  to 
distant  parts  in  known  or  unknown  connexion 
with  the  irritated  nerves.’ 

The  remarkable  difference  in  the  constitu- 
tional sympathies  with  sexual  disorders  in  the 
opposite  sexes,  is  accounted  for  by  the  compara- 
tively subordinate  character  of  the  male  reproduc- 
tive organs.  In  the  female,  on  the  contrary,  the 
utero-ovarian  functions  are  connected  with  every 
vital  action,  from  the  evolution  of  puberty  until 
the  climacteric  period,  which  terminates  her  dis- 
tinctive sexual  or  reproductive  life,  is  passed. 
Woman  is  therefore  always  liable,  as  Dr.  Storer 
observes,  ‘to  a host  of  diseases  peculiar  to  her 
sex,  to  which  we  find  neither  homologue  nor 
analogue  in  man.’ 

TEtiology. — First,  with  respect  to  the  effect  of 
the  general  health  in  the  causation  of  sexual  dis- 
orders in  women,  there  can  be  no  doubt  that  these 
are  in  many  cases  the  result  of  some  constitutional 
diathesis.  Of  the  large  number  of  patients  suffer- 
ing from  chronic  uterine  disorders,  such  as  endo- 
metritis, cervicitis,  ulceration  and  areolar  hyper- 
plasia of  the  cervix,  ovaritis,  pelvic  or  ovarian 
abscesses,  sterility,  repeated  miscarriages,  and 
all  the  derangements  of  menstruation  that  have 
come  under  the  writer's  care,  the  majority  were 
of  well-marked  strumous  diathesis,  or  suffered 
from  scrofulous  disease  of  other  parts.  The  most 
common  of  uterine  diseases  is  cervicitis,  and  in  it 
the  scrofulous  form  of  inflammation  is  generally 
evident.  The  inflammatory  action  in  these 
cases  is  attended  by  a characteristic  tendency 
to  produce  #excoriations  of  the  cervical  mucous 
membrane,  resulting  in  typical  strumons  ulcers, 
which  are  tedious  beyond  patience  in  their  cure 
by  the  local  applications  generally  relied  on, 
but  yield  readily  when  these  are  conjoined  with 
appropriate  constitutional  treatment. 

Gout  and  rheumatism,  neuralgia,  and  second- 
ary syphilis,  should  also  be  recognised  as  amongst 


SEXUAL  FUNCTIONS  IN  THE  FEMALE.  1428 


the  occasional  constitutional  causes  of  chronic 
Vitcrine  or  peri-uterine  disease.  In  all  such  cases 
the  functions  of  the  affected  organs  are  deranged 
to  a greater  or  less  extent. 

Results. — We  turn  next  to  consider  the  con- 
verse question — the  effect  of  sexual  disorders  on 
the  bodily  health.  In  many  instances  the  local 
symptoms  of  uterine  and  ovarian  complaints 
attract  so  much  attention,  that  the  practitioner 
may  neglect  the  constitutional  conditions  with 
which  sexual  disorders  are  connected.  Thus 
derangements  of  tho  catamenial  function  are 
generally  associated  with  the  nervous  complaints 
of  women.  Many  forms  of  hysteria,  and  the 
morbid  excitability  and  perversion  of  the  natural 
feminine  instincts,  without  any  tangible  delu- 
sion or  perceptible  affection  of  tho  intellectual 
powers,  which  are  so  frequently  met  with, 
are  thus  conjoined  with  amenorrhcea  or  dysme- 
norrhosa.  The  connexion  between  hysteria  and 
uterine  or  ovarian  disorders  is  too  obvious  to 
call  for  any  notice  here  (see  Hysteria  ; and  In- 
sanity, Varieties  of).  In  the  present  article  we 
shall  briefly  notice  a few  of  the  principal  dis- 
orders which  may  thus  originate  in  sexual  dis- 
turbances. 

Epilepsy. — Epilepsy  in  women  is  very  often 
symptomatic  of  uterine  or  ovarian  disorder,  and 
is  curable  by  the  restoration  of  the  suppressed 
functional  discharge,  or  tho  allayment  of  the 
existing  local  irritation. 

Perversions  of  tastes  and  temper. — Tho  influ- 
ence of  the  sexual  system  in  the  causation  of 
nervous  disorders  is  well  illustrated  by  those 
strange  alterations  in  tastes  and  dispositions, 
that  irritable  condition  of  mind,  those  unreason- 
able likings  or  aversions,  irresistible  longings 
and  foolish  fancies  which,  even  in  women  na- 
turally strong  and  well-minded,  commonly  ac- 
company and  are  produced  by  pregnancy.  Of 
a similar  nature  are  the  nervous  excitability, 
waywardness  of  temper,  physical  and  mental 
lassitude,  and  depression  of  spirits  which  have 
been  generally  noticed  as  constant  attendants  on 
the  menstrual  periods  in  many  women.  These 
are  also  of  interest  as  demonstrating,  despite  any 
exceptional  cases  to  the  contrary7,  the  futility 
of  that  hopeless  contest  with  Nature’s  laws,  in 
which  those  are  now  engaged  who  would  have 
woman  abandon  her  own  high  sphere,  to  become 
in  every  profession  and  in  every  avocation  the 
rival,  instead  of  the  helpmate,  of  man. 

Erotomania  and  Nymphomania.— In.  connec- 
tion  with  this  subject  erotomania  and  nympho- 
mania must  be  referred  to.  The  former  is  but 
an  undue  exaltation  of  that  sentimentality  which 
to  some  extent  is  a natural  characteristic  of 
female  youth,  and  which  is  fostered  into  morbid 
development  by  ill-directed  education,  and  the 
prevailing  sensuous  tone  of  much  of  our  popular 
literature.  Highly-coloured  amatory  word-pic- 
tures fill  the  minds  of  the  young,  unfit  them 
for  the  duties  of  life,  and  give  rise  to  those 
predominant  illusions  which  morbidly  occupy 
the  thoughts  of  the  erotomaniac,  and  may 
ultimately  pass  into  the  grosser  pruriency  of 
lymphomania.  Whether  originating  in  this  way 
>r  not,  nyunphomania,  when  developed,  is  an 
intirely  distinct  disorder  from  the  last-named 
mnplaint,  and  is  generally  connected  with 

90 


physical  irritation  or  disease  of  -sbme  part  of 
the  sexual  organs.  Frequently  it  is  associated 
with  subacute  endometritis  or  ovaritis,  resulting 
in  irritation  and  congestion  of  the  erectile  struc- 
ture of  the  internal,  as  well  as  of  the  external, 
generative  organs.  In  these  cases  pruritus  of 
the  vulva  generally  exists ; and  the  local  hyperms- 
thetic  condition  is  followed  by  structural  disease 
in  the  affected  parts,  hypertrophy  of  the  nymph* 
and  clitoris,  vaginismus,  and  chronic  follicular 
vulvitis. 

The  moral,  hygienic,  and  medical  treatment  of 
these  conditions  is  discussed  in  other  articles 
in  this  work.  Here  it  is  only  necessary  to  add. 
that  in  the  treatment  of  no  forms  of  disease  is  the 
exercise  of  the  highest  qualities  of  the  physi- 
cian more  required  than  in  the  management  of 
erotomania  and  nymphomania.  In  these  case? 
he  must  act  on  the  religious  and  moral  as  well 
as  on  the  physical  constitution  of  his  patients 
he  must  seek  to  turn  tho  perverted  current  o' 
thought  into  better  channels  ; insist  on  healthy 
occupation  of  mind  and  body;  and  clearly  poin'. 
out  the  physical  ill-health  and  mental  debase- 
ment which  surely  await  on  sexual  abuses.  At 
the  same  time  the  judicious  practitioner  will 
endeavour  to  strengthen  the  physical  powers  by 
tonics  ; to  diminish  general  plethora  hy  saline 
purgatives,  to  remove  local  congestions  by  appro- 
priate treatment;  and  to  lessen  nervous  irrita- 
bility by  the  bromides  and  other  nerve-sedatives. 
Generally  such  patients  are  idle  and  over-fed,  and 
require  work  and  abstinence,  and  in  addressing 
these  persons  their  medical  attendant  may  well 
re-echo  the  advice  given  to  Falstaff  by  his  quon- 
dam friend  Prince  Hal,  and  desire  them  to 
‘ Purge,  foreswear  sack,  and  live  cleanly.’ 

With  regard  to  local  treatment  in  cases  of 
nymphomania,  all  that  need  be  said  is  that, 
vaginal  examinations,  being  likely  to  increase 
the  irritability  of  the  hypersesthetic  parts,  should, 
as  a general  rule,  be  altogether  avoided  ; or,  at 
least,  should  be  resorted  to  only  in  exceptional 
instances,  and  when  absolutely  indispensable. 
At  the  same  time,  however,  it  is  obvious  that 
where  nymphomania  is  the  result  of  local  disease, 
neither  moral  nor  general  medical  treatment  can 
be  of  use  until  the  topical  exciting  cause  is  re- 
moved. It  may  be  admitted  that,  in  certain 
exceptional  cases  and  with  suitable  restrictions 
clitorideetomy  is  a useful  procedure. 

Insanity.—' The  effect  of  sexual  disorders  on 
the  mental  functions  can  be  only  very  briefly 
alluded  to.  The  fact  is  certain  that  insanity  in 
women  is  frequently  connected  with  functional 
derangement  or  organic  disease  of  some  portion 
of  the  utero-genital  organs.  Indeed  in  both  sexes, 
although  less  obviously  in  men,  reflex  irritation 
from  the  soxual  system  has,  probably,  much  to 
do  with  the  causation  of  insanity.  In  the  insane 
there  is  usually  a peculiar  insensibility  to  the 
ordinary  symptoms  of  disease,  resulting  from 
the  impaired  nutrition  and  lowered  vitality  of 
the  nervous  centres  and  nerves  of  sensation. 
Therefore,  in  such  cases,  in  the  absence  of  the 
usual  evidences  of  sexual  disorders,  the  existence 
of  these  diseases  is  very  likely  to  be  overlooked. 
During  the  last  few  years  several  instances 
of  mental  derangement,  of  hysteria  approxi- 
mating to  insanity,  and  of  other  forms  of 


1426  SEXUAL  FUNCTIONS  (FEMALE), 
aervous  disturbance  arising  from  ovarian  causes, 
have  come  within  the  writer's  observation.  In 
some  of  these  cases  the  nervous  disorder  had 
existed  for  a considerable  time  before  its  local 
exciting  cause  was  suspected.  And,  more  than 
once,  the  writer  has  seen  this  ultimate  recogni- 
tion and  treatment,  of  obscure  uterine  or  ova- 
rian disease  in  a woman,  who  had  been  for 
years  in  a lunatic  asylum,  followed  by  the  resto- 
ration of  mental  as  well  as  physical  health. 

The  ordinary  occurrence  of  menstrual  irregu- 
larities, and  especially  of  amenorrbcea,  in  the 
early  periods  of  insanity,  is  recognised  by  nearly 
all  writers  on  this  subject;  and  there  seems  a 
general  concurrence  of  opinion  as  to  the  direct 
connection  between  suppression  of  the  menses 
and  mental  derangement  in  many  instances.  One 
of  the  most  remarkable  cases  of  this  kind  is  that 
of  a girl,  mentioned  by  Pinel,  who  ‘ from  the  age 
of  ten  years  was  in  a state  of  incoherence  from 
suppression  of  the  catamenia.  One  day  on  ris- 
ing from  bed  she  ran  and  embraced  her  mother, 
exclaiming,  “Mamma! Iam  well.”  Theeatamenia 
had  just  flowed  spontaneously,  and  her  reason 
was  immediately  restored.’ 

Puerperal  mania, — Puerperal  mania  is  another 
instance  of  the  influence  of  uterine  or  peri-uterine 
causes  in  disturbing  the  nervous  system.  The 
setiology  of  this  disease  is  very  complicated,  and 
it  must  be  ascribed  to  the  combined  operation  of 
several  distinct  factors.  Foremost  amongst  these 
is  the  local  condition  of  the  denuded  uterus  dur- 
ing involution  ; and  the  shock  and  exhaustion 
consequent  on  parturition  under  conditions  of 
mental  depression,  as  shewn  by  the  fact  that 
twelve  out  of  twenty  cases  that  came  under  the 
writer’s  notice  occurred  amongst  unmarried  pa- 
tients in  the  Lying-in  Hospital.  Any  circum- 
stances that  occasion- suppression  of  the  lochia  or 
of  the  mammary  secretion  at  this  time,  when  the 
nervous  system  is  in  a state  of  peculiar  tension, 
and  the  physical  powers  lowered,  act  directly  as 
exciting  causes  of  puerperal  mania. 

Alcoholism. — Uterine  and  ovarian  disorders 
must  also  be  reckoned  amongst  the  predisposing 
causes  of  intemperance.  The  craving  for  alcohol 
in  women  of  all  classes,  may  frequently  be 
dated  from  the  first  painful  menstrual  period, 
when  stimulants  are  often  forced  by  foolish 
mothers  into  reluctant  lips.  The  pain  of  dysme- 
norrhoea  being  thus  relieved,  at  the  next  epoch 
the  girl  naturally,  and  no  longer  unwillingly, 
seeks  similar  solace,  until,  finally,  the  victim  of 
dysmenorrhoeal  alcoholism  becomes  a habitual, 
and  perhaps  an  incurable,  drunkard. 

Cardiac  disorder. — Of  the  cases  of  supposed 
heart-disease  in  nervous  women,  which  daily 
come  before  those  connected  with  any  large 
hospital,  in  the  greater  number  of  instances  the 
cardiac  complaints  are  the  result  of  hysteria, 
originating  from  chronic  uterine  or  ovarian 
disorder,  on  the  cure  of  which  all  the  cardiac 
symptoms  will  subside.  It  is  needless  to  dwell 
further  here  on  the  functional  irregularities — 
palpitation,  dyspnoea,  and  other  symptoms  of  the 
same  kind — which  are  thus  connected  -with  over- 
stimulation  and  irritation,  or  disease,  of  the 
female  sexual  system. 

General  health.— The  consequences  of  pre- 
mature or  excessive  indulgence  and  abuse  of 


SHAMPOOING. 

the  sexual  appetites  on  the  general  healtn. 
claim  merely  a passing  notice  in  this  article. 
At  no  former  time  was  it  so  necessary  as  at 
present  for  medical  practitioners  to  recognise 
the  evidences  of  these  abuses  and  excesses ; to 
which  are  due  a large  and  increasing  proportion 
of  the  disorders,  mental  and  physical,  by  which 
human  life  is  embittered  or  its  duration  shor 
tened.  The  pathological  results  of  these  abuses, 
acting  through  and  upon  the  nervous  system, 
and  the  long  train  of  maladies  thus  occasioned, 
must  be  familiar  to  every  experienced  physician 
who  encounters  in  his  practice  the  cachectic 
and  debilitated  victims  of  the  excesses  referred 
to.  To  these  causes  must  be  mainly  ascribed 
the  failure  of  physical  stamina,  the  liyperaes- 
thetic  nervous  condition,  and  the  want  of  mental 
power  and  determination,  noticeable  amongst 
too  many  of  the  youth  of  the  present  day.  Thus 
the  evils  resulting  from  this  wide-spread  sen- 
suality, the  effects  of  which  are  now  seen  in  our 
hospitals  and  lunatic  asylums,  have  attained 
such  proportions  as  to  be  a subject  of  national 
as  well  as  medical  importance. 

With  respect  to  the  constitutional  relations  of 
chronic  disorders  of  the  female  sexual  organs.  Dr. 
Harnes  very  truly  observes  ‘ that  disorder  of  the 
sexual  organs  cannot  long  continue  without  entail- 
ing constitutional  disorder,  or  injuriously  affect- 
ing the  condition  of  other  organs.’  The  most  com- 
mon of  the  chronic  complaints  peculiar  to  women 
are  subacute  endometritis  and  cervicitis.  Next 
in  frequency  are  the  functional  disorders  occa- 
sioned by  ovarian  congestion  and  irritation.  And, 
thirdly,  in  this  connection  are  the  various  dis- 
placements and  flexions  of  the  uterus.  The  two 
first  of  these  in  all  cases  react  on  the  general 
health.  And  even  in  the  third,  where  local 
symptoms  and  local  treatment  obviously  claim 
most  consideration,  the  secondary  consequences 
of  the  uterine  dislocation  often  require  attention, 
after  the  displacement  or  flexion  has  been  me- 
chanically remedied. 

Thomas  Moef.  Madden. 

SEXUAL  FUNCTION’S  IN  THE 
MALE,  Disorders  of. — Disturbances  of  the 
most  important  sexual  functions  in  the  male 
are  described  under  the  following  headings,  to 
which  the  reader  is  referred: — Impotence; 
Masturbation  ; Spermatorrhoea  ; Sterility  in 
the  Male  ; and  Testes,  Diseases  of. 

SEXUAL  ORGANS,  Diseases  of.— The 

diseases  of  the  several  sexual  organs  in  the 
male  and  female  will  be  found  described  under 
their  special  headings.  See  Penis,  Diseases  of ; 
Testes,  Diseases  of;  Ovaries,  Diseases  of; 
Vagina,  Diseases  of;  Womb,  Diseases  of;  Ac. 

SHAKING  PALSY. — A synonym  for 
paralysis  agitans.  See  Paralysis  Agitans. 

SH AMPO  OIN G.-Syxox.:  Massage ; Knead- 
ing ; Medical  rubbing ; Fr.  Massage;  Ger.  Mas- 
siren. 

Definition'. — A process  of  treatment  by  rub 
bing,  which  consists  in  deep  manipulation. 

Applications. — The  shampooer  grasps  the 
part,  and  by  squeezing  it  laterally  in  the  palms 
of  his  hands  in  a peculiar  manner,  in  which  the 
muscles  of  the  thumb  are  brought  into  vigorous 


SHAMPOOING. 

ase,  exerts  a compressing  force  upon  the  deep 
muscular  structures  by  a kind  of  kneading  pro- 
cess. Muscular  contractility  is  thus  stimulated, 
and  the  circulation  increased,  so  as  to  produce  a 
corresponding  increase  of  temperature. 

By  frequently  repeating  this  process,  the  nutri- 
tion of  the  limbs  operated  upon  is  increased, 
and  the  flesh  becomes  much  firmer,  with  a corre- 
sponding increase  in  muscular  power.  In  India, 
where  shampooing  appears  to  have  been  an 
ancient  practice,  it  is  employed  to  restore  en- 
feebled and  debilitated  muscles,  exhausted  by 
the  heat  of  the  climate.  In  England  shampooing 
has  of  late  years  been  much  more  generally  used, 
and  since  the  introduction  of  the  Turkish  baths, 
where  trained  shampooers  are  always  in  attend- 
ance, it  can  be  more  readily  obtained. 

Uses. — In  infantile  paralysis,  if  the  limbs  af- 
fected are  shampooed  for  half-an-hour  twice  a 
day  by  a competent  nurse,  in  addition  to  the  use 
of  galvanism  and  of  warm  clothing,  the  process 
of  recovery — to  which  there  is  always  a natural 
tendency — will  be  materially  facilitated.  In  the 
more  severe  forms  of  paralysis,  iu  the  adult,  less 
benefit  can  be  expected  from  shampooing,  though 
the  warmth  and  circulation  in  paralysed  limbs 
are  improved  by  its  use.  In  limbs  weakened  by 
the  long-continued  use  of  mechanical  supports 
for  any  surgical  purpose,  shampooing  is  found  to 
be  of  great  service  in  improving  the  muscular 
strength,  and  restoring  a healthy  and  vigorous 
circulation. 

As  employed  by  Dr.  Weir  Mitchell,  and  de- 
cribed  by  Dr.  Playfair  ( Lancet , 1881,  I.  p.  857. 
and  II.  p.  991),  shampooing  appears  to  be  of 
great  value  also  in  the  systematic  treatment  of 
nervous  prostration  and  hysteria. 

William  Adams. 

SHINGLES  ( cingulum , a girdle). — A popu- 
lar name  for  herpes  zoster.  See  Hekfes  ; and 
Zoster. 

SHIVERING.  See  Rigor. 

SHOCK. — Synon.  : Fr.  Choc  ; Ger.  Skoh  ; 
Wimdstupor ; WwidschrecJc. 

Definition. — A condition  of  sudden  depression 
of  the  whole  of  the  functions  of  the  body,  due  to 
powerfulimpressions  upon  the  system  by  physical 
injury  or  mental  emotion.  Its  more  obvious 
manifestations  are  signs  of  lowered  activity  of 
the  cardiac,  respiratory,  and  sensorial  functions; 
and  reduction  of  the  surface  temperature. 

General  Description. — If  a person  be  unex- 
pectedly subjected  to  the  influence  of  extreme 
terror,  if  a large  bone  or  joint  be  shattered,  or  an 
important  viscus  injured,  the  entire  system  re- 
ceives a profound  impression,  and  its  functional 
activity  is  more  or  less  stunned.  The  whole 
body  appears  to  sympathise  with  the  injury  in- 
flicted on  one  of  its  parts ; thepatient  is  prostrated 
by  an  indescribable  sense  of  bodily  anguish  and 
oppression ; he  feels  sick  and  faint ; is  seized  with 
tremor ; totters  or  falls ; the  surface  becomes  pale, 
cold,  and  covered  with  sweat ; the  expression  of 
countenance  is  vacant,  yet  anxious ; and  the 
respiration  and  circulation  are  weak  and  ir- 
regular. 

Shock  varies  in  degree,  from  the  most  trifling 
amount,  which  rapidly  disappears,  to  that  pro- 


SHOCR  1427 

dueing  instantaneous  death.,  as  in  the  case  of 
lightning  stroke,  or  of  a severe  blow  on  the  epi- 
gastrium. 

The  intensity  of  shock  depends  on  the  nature 
and  extent  of  the  injury  producing  it:  on  the  co- 
existence of  internal  or  external  haemorrhage  ; 
and  also  upon  the  age,  habits,  temperament,  and 
idiosyncrasy  of  the  individual,  and  his  mental 
condition  at  the  time  of  the  injury.  Direct 
violence  applied  to  the  brain  or  spinal  cord  pro- 
duces shock  in  the  most  intense  form,  but  in  such 
cases,  which  are  beyond  the  scope  of  this  article, 
the  symptoms  due  to  the  local  lesion  predominate, 
and  are  of  course  the  more  important. 

Shock  is  usually  immediate  in  its  effects,  but 
sometimes  these  may  be  for  a time  deferred  by 
intense  mental  preoccupation  or  excitement. 

; Nature,’  as  Hunter  said,  ‘ does  not  feel  the  in- 
jury.’ The  soldier  during  the  excitement  of 
battle  may  be  unconscious  for  a time  of  the 
severity  of  his  wound,  but  presently  he  is  re- 
called to  a sense  of  danger,  and  the  depression 
which  ensues  will  be  increased  in  proportion  to 
the  previous  excitement. 

./Etiology. — Intense  mental  impressions,  such 
as  extreme  terror,  or  apprehension  of  death  or 
mutilation,  are  capable  of  producing  shock  in 
persons  of  excitable  nervous  temperament.  Some 
individuals  are  so  readily  affected,  that  a certain 
degree  of  shock  may-  be  induced  by  the  most 
trifling  lesion,  or  even  by  the  sight  of  an  injury 
inflicted  upon  another. 

It  may  be  stated  generally,  however,  that 
whatever  is  calculated  to  produce  psychical  de- 
pression, will  aggravate  the  shock  induced  by 
other  causes.  Wounds,  for  instance,  inflicted  on 
the  soldiers  of  a beaten  army,  or  on  those  in  a 
closely  besieged  town,  are  often  followed  by 
greater  shock  than  are  wounds  of  a similar 
severity  occurring  under  different  circumstances. 

Injury  is  the  chief  cause  of  shock.  As  a rule 
the  more  extensive  the  injury,  the  nearer  it  is 
to  the  centre,  and  the  more  it  assumes  a crushing 
character,  the  greater  will  prove  the  amount  of 
shock.  The  crushing  of  a fiDger  or  bruising  of  a 
testicle  often  occasions  severe  shock ; so  also  do 
extensive  burns  and  scalds.  Intense  pain,  without 
serious  organic  lesion,  is  capable  of  producing 
shock,  as  may  be  witnessed  during  the  passage  of 
a gall-stone  through  the  duct,  or  of  a calculus 
through  the  ureter. 

Loss  of  blood  associated  with  the  injury 
greatly  augments  the  degree  of  shock ; and  it  may 
be  impossible  to  separate  the  symptoms  due  to 
the  more  direct  physical  impression  from  those 
caused  by  the  haemorrhage.  Shock  is,  however, 
independent  of  the  presence  both  of  pain  and  of 
haemorrhage.  During  the  operation  of  castration 
a patient,  while  under  the  influence  of  chloroform, 
and  in  the  absence  of  haemorrhage,  may  present 
all  the  symptoms  of  profound  shoek,  the  moment 
the  cord  is  divided.  After  disarticulation  at  the 
hip  or  shoulder  joints,  and  in  other  great  opera- 
tions, the  patient  may  present  features  of  shoek, 
altogether  independently  of  either  pain  or  loss 
of  blood.  Ovariotomy,  especially  the  opening  of 
the  abdomen,  is  said  to  be  occasionally  attended 
by  shock ; but  it  does  not  occur  after  ovariotomy, 
except  when  the  operation  is  severe  and  pro 
tracted,  or  associated  with  haemorrhage. 


SHOCK. 


1428 

The  frequency  of  shock  after  operation  has 
diminished  since  the  introduction  of  anaesthetics, 
but  chloroform  itself  may  occasion  some  of  its 
symptoms;  and  it  is  by  no  means  unlikely  that 
fatal  accidents  during  chloroform-administra- 
tion may  be  due  to  the  combined  depressing 
influences  of  the  shock  and  the  anaesthetic. 

Injuries  extensively  involving  the  bones  and 
joints  are  prone  to  induce  shock.  The  tempera- 
ture has  been  observed  in  some  instances  to  fall 
during  the  sawing  of  the  bone  in  amputation. 

Kailway  accidents,  happening  as  they  do  very 
suddenly,  and  occasioning  great  alarm;  acute 
peritonitis  caused  by  the  escape  of  irritating  sub- 
stances into  the  abdominal  cavity,  as  in  perfora- 
tion in  typhoid  fever;  the  strangulation  of  a 
hernia ; or  a sudden  and  severe  intussusception, 
may  each  and  all  bo  attended  by  symptoms  of 
shock  in  a more  or  less  intense  degree. 

H athoxog y. — It  is  still  difficult  to  explain  the 
modus  operands  by  which  any  kind  of  physical 
injury,  of  sufficient  severity,  implicating  any  por- 
tion of  the  body,  may  produce  the  set  of  pheno- 
mena known  as  shock.  The  story  told  by  the 
symptoms  is  one  of  depression  of  the  whole  vital 
functions,  associated  with  all  the  evidences  of  a 
diminished  circulation  of  blood  in  those  portions 
of  the  periphery  which  we  can  examine  during 
life.  The  integument  is  blanc-hed  and  shrunken ; 
the  pulse  is  thready  or  imperceptible ; the  veins 
are  collapsed ; and  open  wounds,  unless  involv- 
ing large  arterial  trunks,  bleed  slightly  or  cease 
to  bleed;  while  the  lowered  temperature,  as 
registered  in  the  axilla  and  mouth,  marks  a co- 
incident diminution  of  tissue-metamorphosis. 
That  the  brain  suffers  from  a similar  privation 
of  blood  is  indicated  by  the  enfeebled  pulsation 
of  the  carotid  arteries ; by  the  anaemic  condition 
of  the  retinal  vessels,  as  shown  by  the  ophthal- 
moscope ; and  by  the  mental  torpor  and  feeble 
irritability,  conjoined  or  separate,  which  consti- 
tute invariable  features  of  the  condition.  IIow 
far  the  chaDge  is  shared  by  other  organs  it  is  at 
present  impossible  to  say,  but,  awaiting  further 
investigations,  the  facts  already  known  are  suf- 
ficiently definite  and  constant  to  guide  us  in  the 
direction  of  a rational  pathology. 

The  manifestations  of  inadequate  blood-supply 
to  the  tissues  in  general  are  almost  identical 
with  those  of  haemorrhagic  asthenia ; but  no 
heemorrhage  has  taken  place,  and  tve  must  seek 
the  blood  which  has  left  the  anaemic  parts  in 
some  other  vascular  territories. 

If  we  make  a post-moricm  examination  in  a 
case  where  death  has  forestalled  nature’s  effort 
at  reaction,  one  striking  phenomenon  is  revealed, 
namely,  an  enormous  distension  of  the  abdominal 
vessels  governed  by  the  splanchnics.  Into  this 
capacious  set  of  vessels  has  been  diverted  a great 
mass  of  the  blood  destined  for  other  regions; 
and  being  thus  practically  withdrawn  from  the 
general  circulation,  it  has  produced  a useless 
congestion  of  the  abdominal  viscera,  at  the  ex- 
pense of  the  nutrition  of  the  rest  of  the  system, 
while  the  weakened  heart  contracts  feebly  but 
hastily  upon  the  scanty  supply  which  now  passes 
through  its  cavities. 

Physiologists  have  taught  us  the  probable 
cause  of  this.  Long  since  it  was  demonstrated 
that  stimulation  of  the  central  end  of  the  divided 


depressor  branch  of  the  vagus,  in  the  rabbit, 
produces  an  immediate  lowering  of  the  blood- 
pressure  in  the  arteries  of  the  head,  neck,  and 
extremities;  this  effect  coinciding  with,  and  de- 
pending upon,  a dilatation  of  the  abdominal 
arteries,  and  a consequent  derivation  of  the  blood- 
flow  in  the  direction  of  least  resistance,  or  to- 
wards the  abdominal  viscera.  If,  however,  the 
splanchnic  nerves  be  cut,  the  reflex  circuit  is 
broken,  and  the  balance  of  the  circulation  becomes 
restored,  or  nearly  so,  although  the  irritation  of 
the  depressor  nerve  be  continued.  The  experiment 
of  Goltz,  of  directly  paralysing  the  splanchnic  of 
a frog  by  sharply  striking  the  abdomen,  was  fol- 
lowed by  the  same  result  as  is  the  reflex  paralysis 
of  the  same  branches  through  the  depressor 
nerve ; and  it  is  likely  that  the  severe  shock 
caused  in  man  by  a severe  blow  on  the  epigastrium, 
owes  its  origin  to  a similarly  induced  paralytic 
dilatation  of  the  visceral  arteries.  Lor  the  pre- 
sent we  may  thus  accept,  as  the  most  plausible 
interpretation  of  the  symptoms  of  shock,  a sudden 
dilatation  of  the  abdominal  vessels,  attributable 
to  an  inhibitory  influence  exerted  upon  the 
splanchnics,  through  the  medium  of  a special  re- 
flex centre,  which  is  in  more  or  less  direct  com- 
munication with  the  sensorium,  and  with  all 
parts  of  the  body.  Much,  however,  remains  to  be 
done.  It  has  been  shown  that  when  a rabbit  is 
narcotized  by  chloral,  stimulation  of  the  central 
end  of  the  divided  sciatic  nerve  will  induce  a 
lowering  of  arterial  pressure,  corresponding 
closely  to  that  initiated  by  stimulation  of  the  de- 
pressor branch ; and  in  all  probability  a similar 
experiment  upon  any  nerve  containing  afferent 
fibres  would  be  followed  by  the  same  result  But 
if,  on  the  other  hand,  the  same  stimulation  be 
performed  while  the  animal  is  paralysed  by 
curare,  it  is  remarkable  that  the  effect  is  reversed, 
the  vessels  controlled  by  the  splanchnics  contract- 
ing, and  the  general  arterial  tension  being  con- 
sequent^’ increased.  These  observations  are  in 
the  highest  degree  suggestive,  and  may  hereafter 
form  the  basis  for  a plan  of  treatment  of  shock, 
that  will  be  a landmark  in  surgical  therapeutics. 

Symptoms. — The  symptoms  of  shock  are  of 
two  kinds— namely,  first,  those  due  to  a stun- 
ning or  blunting  of  the  vital  powers,  aptly 
styfed  Wundstupor  by  the  Germans ; and 
secondly,  those  attributable  to  mental  terror, 
anxiety,  and  agitation  — Wundschrcck.  These 

may  exist  together,  or  separately,  or  one  may 
pass  into  the  other. 

1 .Pure  or  torpid  shock,  as  distinguished  from  the 
latter  form,  which  may  be  termed  ‘ erethitic  shock,’ 
is  manifested,  if  only  slight  in  degree,  by  transient 
symptoms.  The  patient  becomes  pale  and  faint ; 
complains  of  nausea;  trembles;  and  experiences 
a sense  of  oppression,  confusion,  and  anxiety: 
the  surface  becomes  cold  and  moist ; beads  of 
sweat  form  on  the  brow ; and  the  limbs  may  be 
unable  to  support  the  weight  of  the  body.  The 
duration  depends  much  on  constitutional  pecu- 
liarity ; the  symptoms  either  passing  off  in  a few 
minutes,  or  lasting  for  an  hour  or  two.  If  the 
shock  be  severe,  the  patient  immediately  after 
the  receipt  of  the  injury  is  stunned ; liis  senses 
and  consciousness  are  benumbed ; the  counte- 
nance and  the  surface  generally  become  deadly 
pale,  and  are  bathed  with  sweat;  the  a ni  manor 


14  US) 


SHOCK. 


jf  the  face  is  replaced  by  a mingled  expression 
of  torpor  and  anxiety ; from  time  to  time  mus- 
lular  contractions  and  uneasy  movements  of  the 
oody  may  occur,  but  usually  there  is  an  absence 
of  voluntary  effort ; the  eyes  are  dull,  vacant, 
and  motionless,  and  the  pupils  are  usually  di- 
lated ; the  temperature — an  important  index  to 
the  severity  of  the  shock — ranges  from  one  to 
ttvo  degrees  or  more  below  the  normal,  and  is 
much  lower  when  there  has  been  severe  .loss  of 
blood  ; the  respiration  is  remarkably  slow  and 
irregular — faint, scarcely  perceptible,  inspirations 
alternating  with  deep  sighs  ; and  the  pulse  may 
be  almost  or  quite  imperceptible  at  the  wrist, 
very  weak,  insufficient,  and  very  rapid.  The 
patient  is  conscious,  but  he  sees  and  acts  as 
through  a mist,  and  cannot  realise  his  position  ; 
urgently  questioned,  he  replies  slowly  and  with 
evident  effort ; his  voice  is  weak  and  hoarse ; he 
may  complain  of  coldness  and  numbness  of  his 
limbs,  but  appears  scarcely  sensible  of  pain. 
There  may  be  nausea,  and  even  vomiting  ; and 
relaxation  of  the  sphincters,  with  involuntary  dis- 
charge of  faeces,  is  occasionally  observed. 

The  fall  of  temperature  in  shock,  excluding 
cases  of  injury  to  the  brain  and  spinal  cord — 
where  it  is  greatest  of  all — is  proportionately 
greater,  other  things  being  alike,  in  injuries 
extensively  involving  bones  and  joints,  in  burns 
and  scalds,  and  in  the  cases  where  there  has 
been  considerable  loss  of  blood.  It  is  greater  in 
amount  in  men  of  forty  than  in  those  of  twenty. 
During  the  War  ot  the  Commune  a number  of  ob- 
servations were  taken,  and  the  average  tempera- 
ture varied  from  96'5  to  97'5°,  the  lowest  tem- 
perature observed  being  93'5°.  The  fall  was 
greater  after  shell-  than  bullet-wounds ; and 
amongst  the  insurgents  than  in  the  regular 
troops. 

2.  In  the  shock  with  excitement — restless  or  ere- 
ihitic  shock — symptoms  of  anxiety  and  restless- 
ness predominate.  This  form  is  often  witnessed 
in  association  with  previous  haemorrhage,  or 
when  there  is  great  pain,  as  in  crushing  injuries 
of  important  parts,  and  in  burns  or  scalds.  In- 
dividual idiosyncrasy,  however,  has  an  important 
influence  upon  the  condition.  The  ordinary 
symptoms  of  shock,  such  as  pallor,  cold  surface, 
frequent  pulse,  and  feeble  respiration  are  present. 
The  patient  in  addition  betrays  a marked  and 
unceasing  restlessness,  tossing  about  in  bed.  and 
throwing  his  arms  and  head  from  side  to  side  ; 
his  consciousness  is  but  little  impaired,  yet  he 
pays  no  heed  to  questions  ; nothing  seems  to  com- 
fort or  quiet  him  ; he  appears  as  if  overwhelmed 
by  some  indescribable  anxiety  and  oppression,  of 
which  he  vainly  struggles  to  rid  himself.  Vomit- 
ing and  painful  eructations  are  usually  present 
in  such  cases.  There  is  often  considerable  tremor, 
and  sometimes  the  case  will  pass  into  well- 
marked  delirium  tremens.  The  torpid  may  pass 
into  the  erethitic  form  of  shock  ; or  shock  with 
excitement  may  lapse  into  a torpid  condition, 
which  is  always  a change  cf  bad  omen. 

Duration.— Shock,  unless  it  be  the  result  of 
serious  or  fatal  injury,  is  generally  recovered 
from  speedily  and  completely.  It  may  be  quite 
gone  in  fifteen  minutes  or  half  an  hour;  or  it 
may  continue  five  or  six  hours,  or  longer,  and 
then  pass  awaj’.  The  erethitic  or  restless  form 


of  shock  does  not  continue  so  long  as  the  torpid. 
The  less  important  the  vital  lesion ; the  less  it 
has  been  complicated  with  loss  of  blood ; th6 
greater  the  power  of  the  individual;  the  less 
his  nervous  susceptibility  ; and,  finally,  the  more 
efficient  the  treatment,  the  shorter  will  prove  the 
duration  of  the  shock. 

Terminations. — Recovery  or  reaction  takes 
place  readily  from  the  milder  forms  of  shock, 
especially  when  aided  by  suitable  treatment. 
Prom  the  more  severe,  it  is  more  difficult  and 
protracted ; or  the  case  may  end  more  or  less 
rapidly  in  fatal  collapse.  When  the  reaction 
proceeds  favourably,  the  pulse  becomes  stronger 
and  fuller,  the  respiration  deeper,  and  the  bodily 
warmth  returns.  The  mind  appears  to  awaken 
to  the  exercise  of  its  faculties,  to  shake  off  its 
oppression,  and  to  appreciate  the  nature  of  the 
previous  injury,  and  of  the  existing  circum- 
stances ; and  both  the  mental  and  physical  equi- 
librium are  by  degrees  restored.  Vomiting  is 
often  an  early  symptom  of  recovery. 

The  reaction  is  not  always  steady.  Fluctu- 
ations may  occur ; and  relapses  after  an  im- 
provement often  occur  once  or  twice,  each  time, 
however,  with  diminished  severity. 

When  the  torpid  form  of  shock  passes  into 
the  erethitic,  the  condition  becomes  one  termed 
‘ prostration  with  excitement’ ; the  respiration  is 
hurried,  the  skin  hot,  and  the  face  flushed.  There 
are  great  thirst,  headache,  and  scanty  urine,  with 
restlessness,  tremor,  incoherence  or  delirium,  and 
sleeplessness ; and  death  from  exhaustion  fre- 
quently follows,  preceded  by  a haggard,  "wild 
expression  of  face,  a pulse  that  cannot  be  counted, 
subsultus,  and  hiccough. 

After  severe  shock  symptoms  of  excessive  re- 
action are  not  uncommon  ; and  their  gravity  will 
vary  with  the  intensity  of  the  previous  shock. 

Complications  and  Sequel.®. — The  compli- 
cations which  may  arise  are  those  due  chiefly  to 
loss  of  blood,  or  peculiar  to  the  form  of  injury 
received.  From  ordinary  uncomplicated  shock 
recovery  is  usually  perfect,  but  occasionally,  es- 
pecially after  railway  shock,  permanent  deterior- 
ation of  health  follows,  or  some  impairment  of  a 
special  sense  ; or  the  mental  vigour  or  temper  of 
the  individual  may  be  changed  for  the  worse. 
In  these  cases  organic  changes  in  the  nerve- 
centres  have  probably  supervened.  In  drunkards 
the  shock  of  injury  very  often  terminates  in  or- 
dinary delirium  tremens. 

Pre-existing  organic  disease,  especially  of  the 
heart  or  kidneys,  renders  persons  more  suscep- 
tible of  the  effects  of  shock,  and  shock  more 
dangerous  and  severe. 

Diagnosis. — The  phenomena  of  shock  bear 
some  resemblance  to  those  of  concussion  and  of 
syncope.  Concussion  is  usually  distinguished 
from  shock  by  the  predominance  of  intellectual 
disturbance  over  the  circulatory  symptoms ; and 
syncope  is  in  most  cases  marked  by  its  more 
transitory  duration,  and  by  its  origin  in  loss  of 
blood,  or  in  other  of  the  well-known  causes  of  the 
condition.  Shock,  however,  may  co-exist  with 
either  concussion  or  syncope. 

Prognosis. — This  mainly  depends  on  the  na- 
ture of  the  injury,  and  the  physical  and  mental 
power  of  the  individual,  Otherwise,  the  longer 
the  shock  endures,  the  feebler  the  manifestations 


1430  SHOCK. 

of  life,  and  more  especially  the  lower  the  tem- 
perature falls,  the  more  unfavourable  becomes 
the  prognosis.  A fall  of  temperature  below  96° 
nearly  always  presages  a fatal  issue.  It  is  a 
very  unfavourable  sign  when  no  rise  of  tempera- 
ture takes  place  in  four  or  eight  hours  after  the 
receipt  of  injury.  Extreme  feebleness  of  pulse 
and  respiration,  marked  tremor,  profuse  cold 
sweat,  singultus,  a feeling  of  impending  dissolu- 
tion, and  involuntary  evacuations,  all  indicate 
gravity  of  the  case. 

Tbeatment.  — The  objects  of  treatment  in 
shock  are  to  sustain  the  lessened  vitality,  but 
not  to  over-stimulate  it ; and  to  moderate  subse- 
quent reaction  when  it  is  excessive. 

To  apply  external  warmth  is  the  first  and 
plainest  indication,  as  it  is  one  of  the  best  ap- 
peals to  the  misdirected  circulation.  Hot  water 
bottles  and  hot  blankets  may  be  applied  to  the 
extremities  ; hot  turpentine  epithems  and  sina- 
pisms to  the  precordia  ; and  turpentine  may  be 
rubbed  along  the  spine  with  advantage.  If  the 
patient  cannot  swallow,  an  alcoholic  stimulant 
may  be  injected  into  the  rectum;  and  ammonia 
may  be  inhaled,  or  subcutaneously  injected.  Slap- 
ping the  hands  and  feet  promotes  recovery  in 
some  cases,  but  this  measure  is  inefficacious  in 
cases  of  severe  injury,  or  those  accompanied  by 
great  loss  of  blood. 

In  profound  shock,  unaccompanied  by  loss  of 
blood,  the  breathing  must  be  carefully  watched, 
and  failure  guarded  against  by  artificial  respira- 
tion. The  phrenic  nerve  may  be  usefully  stimu- 
lated by  electrodes  placed  along  its  course  in  the 
neck,  and  in  the  epigastrium.  If  the  external 
jugular  vein  be  gorged  with  blood,  it  may  prove 
advantageous  to  open  it,  and  thus  relieve  the 
stagnation  of  the  venous  circulation.  Where 
shock  lias  been  accompanied  by  severe  haemor- 
rhage, transfusion  in  extreme  cases  should  be  re- 
sorted to.  As  soon  as  practicable,  nourishment 
must  be  administered,  as  well  as  stimulants. 
Tincture  of  belladonna  has  been  given  in  half- 
drachm doses  every  hour  in  some  cases,  with 
the  view  of  stimulating  the  cardiac  action,  and 
helping  to  contract  the  paralysed  arterioles. 
The  use  of  calabar  bean  lias  been  recommended, 
on  account  of  its  power  to  diminish  the  venous 
accumulation  in  the  abdomen,  by  causing  con- 
traction of  the  veins. 

If  shock  be  associated  with  excitement,  which 
should  be  regarded  as  a sign  of  want  of  power, 
the  patient  always  requires  support;  and  opium, 
or,  when  this  drug  is  not  desirable,  henbane  or 
chloral,  may  often  be  given  with  advantage. 
Au  ice-coil  to  the  head  allays  excitement  and 
promotes  sleep.  In  the  torpid  form  of  shock 
narcotics  are  inadmissible.  Should  inflammatory 
reaction  take  place,  a regulated-  diet,  rest  to 
mind  and  body,  a gentle  mercurial  purge,  when 
the  secretions  are  deranged,  and  in  young  ple- 
thoric subjects  the  cautious  administration  of 
antimony,  or  a local  blood-letting,  are  the  chief 
means  to  be  adopted.  Throughout  the  treat- 
ment caution  should  always  be  exercised  not  to 
strain  the  action  of  remedies  too  far. 

The  question  of  operation  in  shock  may  oc- 
casionally be  difficult  to  solve.  As  a rule  a pa- 
tient suffering  from  severe  shock  should  never 
be  operated  upon ; unless,  indeed,  bleeding  be  I 


SIALAGOGUES. 

going  on,  or  the  arteries  and  nerves  are  much 
exposed  and  lacerated  from  the  violence  of  the 
injury.  When  an  operation  appears  to  be  com- 
pulsory no  anaesthetic  is  required.  It  is  better, 
however,  to  await  partial  reaction  whenever  it  is 
possible  to  do  so. 

William  Mac  Coemac. 

SHORTNESS  OP  BREATH.  See  Rg- 

spibation,  Disorders  of. 

SHORT-SIGHTEDNESS.  See  MAopia  ; 

and  Vision,  Disorders  of. 

SIALAGOGUES  ( <r'ia\oi >,  saliva,  and  S.ya, 
I move). — Synon:  Fr .Sialagogues-,  Ger .Speichel- 
treibende  Mitteln.  ' 

Definition. — Remedies  which  increase  the  se- 
cretion of  saliva. 

Enumebation. — The  principal  sialagogues  are 
Dilute  Acids,  Ether,  Ginger,  Rhubarb,  Horse- 
radish, Iodide  of  Potassium  and  other  iodides, 
Jaborandi,  Mezereon,  Mercury  and  its  salts. 
Mustard,  Tobacco,  Physostigma,  Pyrethrum,  and 
Pebbles. 

Action. — There  are  two  essential  factors  in 
the  secretion  of  saliva ; the  first  is  the  activity 
of  the  secreting  cells  in  the  gland,  the  second  is 
a sufficient  supply  of  nutritive  material  to  them, 
from  which  they  may  form  a secretion.  This 
nutritive  material,  though  it  may  be  derived  di- 
rectly from  the  lymph-spaces  around  the  cells, 
must  be  ultimately  supplied  by  the  blood  circu- 
lating through  the  glands.  Usually,  therefore, 
when  the  gland  is  in  action,  the  supply  of  blood 
is  greatly  increased,  the  arteries  dilating,  and 
the  blood  flowing  rapidly  through  them.  Some 
drugs,  such  as  physostigma,  will  stimulate  the 
secreting  cells,  while  they  contract  the  blood- 
vessels; and  under  these  circumstances,  although 
the  secretion  may  begin  actively,  it  soon  comes 
to  a standstill  from  want  of  material.  The  se- 
creting cells  may  be  excited  to  activity,  by  sub- 
stances which  stimulate  the  nervous  structures 
within  the  gland  itself,  as,  for  example,  calabai 
bean  (physostigma)  ; by  stimuli  proceeding  di- 
rectly from  the  encephalon,  as  seen  in  salivation 
occurring  from  the  mere  idea  of  savoury  food; 
and  by  stimuli  applied  to  the  mouth  and  exciting 
the  gland  reflexly.  Nausea  is  almost  always 
accompanied  by  salivation,  and  substances  which 
cause  nausea  almost  invariably  cause  salivation, 
the  irritation  of  the  stomach  causing  reflex  sali- 
vary secretion.  The  stimulus  here  passes  up 
the  afferent  nerves  to  the  medulla,  and  travels 
down  the  efferent  nerve  to  the  gland. 

Sialagogues  are  divided,  according  to  their 
mode  of  action,  into  two  classes  ( 1 ) topical  or 
direct ; and  (2)  specific,  remote,  or  indirect  siala 
gogues.  The  names  direct  and  indirect  are  com- 
plete misnomers,  just  as  they  are  in  the  case  ol 
emetics,  and  they  ought  to  be  discarded,  inas- 
much as  the  so-called  ‘direct’  sialagogues  are 
those  which  do  not  act  directly  on  the  gland, 
but  on  the  mouth ; and  the  ‘ indirect  ’ are  those 
which  do  act  upon  the  gland,  affecting  either 
the  nervous  structure  contained  within  it,  or  the 
nerve-centres  directly  connected  with  it. 

The  topical  sialagogues  are  dilute  acids,  ether, 
ginger,  rhubarb,  horseradish,  mezereon,  mustard, 
pebbles,  pyrethrum,  and  tobacco.  The  rcmcit 


SIALAGOGUES. 

eiaiagogues  are  iodide  of  potassium  and  other 
iodides,  jaborandi,  mercury  and  its  salts,  physo- 
stigma,  and  tobacco. 

Topical  sialagogues  excite  secretion  of  salira 
reflexly,  the  afferent  nerves  being  the  lingual 
and  buccal  branches  of  the  fifth,  and  the  glosso- 
pharyngeal nerves.  The  afferent  nerves,  through 
which  nauseants  probably  excite  the  salivary 
secretion,  are  the  vagi. 

Of  remote  sialagogues,  iodide  of  potassium 
probably  acts  upon  the  gland-structures,  but 
upon  which  part  has  not  yet  been  determined. 
It  may,  however,  also  act  reflexly,  by  stimu- 
lating the  sensory  nerves  of  the  mouth,  as  it 
is  excreted  in  the  saliva,  and  the  taste  of  it  is 
often  persistent.  Mercury  probably  acts  partly 
by  affecting  the  gland-structures,  and  partly  by 
affecting  the  mouth.  Jaborandi,  physostigma,  and 
tobacco  appear  to  affect  the  terminal  branches 
of  the  secretory  nerves  in  the  glands. 

Uses. — Saliva  is  useful  in  keeping  the  mouth 
moist,  and  thus  facilitating  mastication,  deglu- 
tition, and  the  movements  of  the  tongue  in 
speaking.  By  moistening  the  fauces  it  also  pre- 
vents or  lessens  thirst.  A pebble  placed  under 
the  tongue,  or  masticated,  will  keep  up  a slight 
flow  of  saliva,  aDd  may  be  useful  for  these  pur- 
poses. Where  this  is  insufficient,  dilute  acids 
are  employed  (see  Acids).  As  the  flow  of  blood 
to  the  glands  is  greatly  increased  through  secre- 
tion, sialagogues  have  been  used  as  derivatives, 
to  lessen  inflammation,  congestion,  and  pain  in 
other  parts  of  the  head,  as  in  tooth-ache,  ear- 
ache, and  inflammation  of  the  ear,  nose,  or  scalp. 
Saliva  has  also,  however,  a digestive  power 
upon  starch,  and  increase  of  the  flow  may  be 
advantageous  in  imperfect  digestion  of  this  sub- 
stance. When  swallowed,  the  saliva  stimu- 
lates the  secretion  of  gastric  juice,  and  increased 
salivary  secretion  therefore  tends  to  aid  gastric 
digestion.  To  attain  this  object  it  is  best  to 
chew  a piece  of  ginger  or  of  rhubarb. 

T.  Lauder  Brunton. 

8IBBENS.  - — This  term,  derived  from  a 
Scotch  word,  signifying  ‘ kindred,’  is  suggestive 
of  a disease  prevalent  in  families,  and  presumed 
to  be  a form  of  chronic  syphilis. 

SIBILANT  BALE,  or  RHONCHUS  : 
SIBILUS  ( sibilus , whistling). — A variety  of 
dry  rale  or  rhonchus,  of  a whistling  or  high- 
pitched  musical  character,  usually  produced  in 
the  smaller  divisions  of  the  bronchi.  See  Physi- 
cal Examination ; and  Rhonchus. 

SICILY. — A warm,  moist,  winter  climate. 
Climate  of  base  of  .(Etna  more  variable  than  N. 
coast.  See  Climate,  Treatment  of  Disease  by  ; 
and  Paleemo. 

SICK  HEADACHE. — A popular  synonym 
for  megrim.  See  Megrim. 

SICKNESS. — A common  name  for  vomit- 
ing. See  Vomiting. 

SIGHT,  Disorders  of.  See  Vision,  Dis- 
orders of. 

SIGNS  OF  DISEASE.  See  Disease, 
Symptoms  and  Signs  of ; and  Physical  Exami- 

BATION. 


SIXTH  NERVE,  DISEASES  OF.  1431 

SINGULTUS  (Lat.  sobbing,  hiccup). — n 
synonym  for  hiccup.  See  Hiccup. 

SINUS  (Lat.). — Pathologically,  sinus  means 
a narrow  track  of  variable  length,  leading  from 
a chronic  abscess  to  a free  surface.  See  Abscess. 

SINUSES  CEREBRAL,  Diseases  of, 

See  Meninges,  Diseases  of. 

SINUSES,  NASAL,  Diseases  of.  Si* 

Nose,  Diseases  of. 

SIXTH  NERVE,  Diseases  of. — The  sixth 
nerve,  or  abducens  oculi,  confers  motor  power 
on  the  external  rectus  muscle  of  the  eyeball, 
and  its  morbid  states  of  excessive  or  defective 
function  are  indicated  by  corresponding  spasm  or 
paralysis  of  that  muscle. 

1.  Spasm  of  the  external  rectus.— This 
condition  is  very  rare,  except  as  a consequence 
of  some  change  in  the  visual  functions  of  the  eye. 
The  external  rectus  may  then  habitually  overact, 
causing  divergent  strabismus.  Permanent  con- 
traction occurs  when  there  is  complete  paralysis 
of  its  antagonist,  the  internal  rectus.  Spasm 
may  occur  from  irritation  of  the  nucleus  or 
fibres  of  the  sixth  nerve,  as  in  meningitis  of 
the  base.  The  symptoms  are  inclination  out- 
ward of  the  affected  eye,  and  consequent  diver- 
gent strabismus.  The  treatment  is  that  of  the 
cause  on  which  it  depends.  Sec  Strabismus. 

2.  Paralysis  of  the  external  rectus. — 
JEtiology. — The  common  causes  of  this  condition 
are  cold,  acting  possibly  on  the  nerve-fibres 
within  the  muscle,  but  more  probably  by  giving 
rise  to  inflammation  around  the  trunk  of  the 
nerve  ; syphilis,  by  causing  growth  on,  or  exuda- 
tion round,  the  nerve,  or  meningeal  thickening  ; 
meningitis;  pressure  on  the  nerve  by  aneurism 
or  tumour ; and  organic  diseases  of  the  pons. 
Transient  or  permanent  paralysis  sometimes 
accompanies  sclerosis  of  the  posterior  columns 
of  the  spinal  cord  (locomotor  ataxy) ; its  cause  is 
obscure. 

Symptoms.— Paralysis  of  the  external  rectus 
causes  inability  to  move  the  affected  eye  out- 
wards, and  hence  convergent  strabismus,  and 
homonymous  diplopia  when  looking  at  an  object 
on  the  affected  (say  left)  side  of  the  middle 
line,  the  images  becoming  more  distant  as  the 
object  is  moved  to  the  left,  but  parallel,  and  on 
the  same  level,  so  long  as  it  is  on  the  level  of 
the  eye.  When  looking  up  or  down  as  well  as 
out,  the  second  image  slants,  the  two  being 
nearer  together  at  the  lower  end,  and  the  second 
image  the  lower  of  the  two  when  looking  up 
and  out.  On  looking  down  and  out,  the  two 
images  are  nearer  together  at  the  top  than 
at  the  bottom,  and  the  second  image  is  on  a 
higher  level  than  the  other.  There  is  erroneous 
projection  of  the  field  of  vision. 

Diagnosis. — Paralysis  of  the  sixth  nerve  ia 
easily  recognised,  except  when  slight  in  degree. 
In  the  latter  case  it  may  often  be  detected  by 
a careful  search  for  the  diplopia,  or  by  the 
secondary  deviation  of  the  sound  eye  in  the 
same  direction  when  that  eye  is  covered  and  an 
object  fixed  by  means  of  the  weak  muscle.  See 
Strabismus. 

Prognosis. — The  prognosis  is  most  favourable 
when  the  paralysis  is  due  to  cold  or  svuhilis  : least 


.432  SIXTH  NERVE,  DISEASES  OF. 
favourable  when  due  to  meningitis  or  tumour. 
When  associated  with  ataxy,  it  is  usually  re- 
covered from,  but  a return  is  common. 

Treatment.— When  the  complaint  is  of  rheu- 
matic origin,  the  treatment  should  consist  of  hot 
fomentations  to  the  temple ; counter-irritation 
by  blisters  ; and  iodide  of  potassium  and  tonics 
internally.  If  of  syphilitic  origin  iodide  of 
mercury  or  of  potassium  should  of  course  be 
given. 

In  spinal  mischief,  strychnia  and  arsenic  are 
useful.  In  obstinate  cases,  faradization,  or  the 
interrupted  battery  current,  may  be  applied  to 
the  muscle  through  the  eyelid,  or  to  the  temple 
to  produce  a reflex  effect.  The  direct  applica- 
tion to  the  muscle  through  the  conjunctiva  is 
too  painful.  W.  R.  G-owees. 

SKIN,  Diseases  of. — Synox. : Fr.  Maladies 
de  la  Peau  ; Ger.  Hautkrankheiten. 

Definition. — Cutaneous  diseases  may  be  de- 
fined as  an  aberration  of  the  skin  from  the 
standard  of  health,  evidenced  by  an  alteration  in 
its  appearance,  qualities,  sensibility,  functions, 
and  relations  to  the  rest  of  the  organism. 

Classification. — The  ancients  classed  diseases 
of  the  skin  according  to  colour,  roughness  or 
smoothness,  and  bulk.  At  the  present  time  we 
shall  find  no  better  classification  for  all  practical 
purposes  than  — (1)  diseases  of  the  circulation-, 
(2)  of  nutrition  ; and  (3)  of  sensibility.  This  ap- 
plies to  the  skin  in  general;  but  the  compound 
nature  of  the  skin — consisting  as  it  does  of  a 
pigment-organ,  the  rete  mueosum  ; a homy 
covering,  the  epidermis ; an  apparatus  of  sebi- 
parous  and  sudoriparous  glands;  and  a special 
outgrowth  of  the  derma,  the  hair — requires  an 
expansion  of  this  classification,  so  as  to  include 
specially  the  diseases  of  these  separate  parts. 
Hence  a very  simple  subdivision  of  diseases 
of  the  skin,  founded  on*the  anatomical  struc- 
ture of  the  organ,  would  be,  besides  diseases  of 
the  skin  in  general — (4)  diseases  of  the  retc 
mueosum ; (5)  diseases  of  the  epidermis;  (G) 
diseases  of  the  glandular  apparatus;  and  (7) 
diseases  of  the  liair- follicles  and  hair. 

1.  Disease,  of  the  Circulation. — Diseases  of 
the  cutaneous  circulation  are  manifested  by 
hypersemia,  and  principally  by  inflammation; 
and  inflammation,  according  to  its  origin  from 
ordinary  constitutional  causes  or  from  blood- 
poison,  admits  of  a division  into  common  inflam- 
mation and  specific  inflammation.  Common  in- 
flammation is  represented  by  eczema,  erythema, 
pemphigus  and  anthrax ; and  specific  inflamma- 
tion by  the  exanthemata,  syphilis,  and  elephan- 
tiasis. The  four  examples  of  diseases  of  common 
inflammation  above  mentioned  may  be  taken  as 
types  of  so  many  groups  of  cutaneous  disease, 
for  example,  eczematous,  erythematous,  phlyc- 
tenous,  and  anthracoid.  The  eczematous  group 
comprises  eczema,  scabies, lichen,  and  impetigo; 
the  erythematous  group,  erythema  and  ery- 
sipelas ; the  phlyctenoid  group,  miliaria,  pem- 
phigus, and  herpes;  and  the  anthracoid  group, 
ecthyma,  hordeolum,  furunculus,  and  anthrax. 
In  like  manner,  treating  specific  inflammation 
according  to  the  same  method,  we  have  an  ex- 
anthematous group,  composed  of  rubeola,  scar- 
latina, and  variola ; a syphilous  group  presenting 


SKIN,  DISEASES  OF. 
itself  in  the  forms  of  erythema,  papule,  tubercle, 
ulcer,  and  gummated  tumour ; and  an  elephantous 
group,  which  includes  the  macular,  tubercular, 
anaesthetic,  and  mutilating  forms  of  elephan- 
tiasis. 

2.  Diseases  of  Nutrition. — Diseases  of  nutri- 
tion are  consequent  on  aberration  of  nutritive 
function,  sometimes  in  the  form  of  dystrophy  or 
altered  nutrition,  sometimes  as  atrophy  or  ab- 
sence of  nutrition,  and  sometimes  as  hypertrophy 
or  excessive  growth.  Under  the  head  of  dys- 
trophic affections  are  to  be  included — lepra  or 
psoriasis,  struma  or  scrofula,  lupus,  lymphoma, 
xanthoma,  and  epithelioma ; under  that  of  atro- 
phic affections — dc-rmatoxerasia,  ichthyosis,  sau- 
riosis, striae  atrophicae,  morphcea,  and  scleriasis  ; 
and  under  the  head  of  hypertrophic  affections — 
spilus,  verruca,  cornu,  clavus,  angeioma,  fibroma 
general  and  partial,  and  mycosis ; general  fibroma 
including  spargosis  or  elephantiasis  Arabum;  and 
partial  fibroma,  molluscum,  and  cheloma. 

3.  Diseases  of  Sensibility. — Diseases  of  in- 
nervation comprehend  pruritus,  prurigo,  derma- 
talgia,  neuroma,  which  are  examples  of  dys- 
aesthesia ; with  hyperssthesia  and  anaesthesia. 

4.  Diseases  of  Pigmentation . — Disease  of  the 
rete  mueosum,  the  seat  of  the  colour  of  the 
skin,  constituting  ehromatopathia  and  a group  of 
chromatopathic  affections,  has  its  principal  seat 
in  the  rete  mueosum,  and  is  manifested  by  excess 
of  pigment,  termed  melasma  or  melanopathia ; 
deficiency  of  pigment,  termed  achroma  or  leuco- 
pathia;  and  aberrations  from  the  normal  standard 
of  colour,  as  in  xanthochroia  or  excess  of  yellow, 
and  cyanopathia,  or  the  presence  of  blue  pigment 
in  the  skin.  To  this  group  must  also  be  added 
the  leaden  or  slate-coloured  hue  of  the  integument, 
produced  by  the  chemical  operation  of  nitrate  of 
silver  on  the  superficial  portion  of  the  corium, 
named  melasma  tinctum  and  argyria. 

5.  Diseases  of  the  Epidermis  and  Nails. — 
Diseases  of  the  epidermis  and  nails  constitute  an 
epidermic  and  onychopathic  group  of  affections 
of  the  skin,  the  former  of  these  being  remarkable 
for  the  presence  of  a phytiform  growth  within 
its  structure,  as  in  tinea  or  ringworm,  and  lavas — 
the  so-called  nosophyta ; and  the  latter  embrac- 
ing all  the  varieties  of  disease  of  form,  texture, 
colour,  and  bulk  of  the  nails. 

6.  Diseases  of  the  Cutaneous  Glands. — Diseases 
of  the  glands  of  the  skin  and  their  functions 
constitute  a group  of  steatopathic  affections, 
and  another  of  idrotopathic  affections.  Of  these, 
the  former  includes  steatorrhrea  or  excessive 
secretion,  comedones  or  impacted  secretion,  mol- 
luscum contagiosum  scu  adenosnm  or  hyper- 
trophy of  the  sebiparous  glands,  encysted  tu- 
mours resulting  from  dilatation  of  the  follicles 
with  sebaceous  secretion,  and  sebaceous  horns 
consequent  on  the  desiccation  of  inspissated 
sebaceous  matter,  exuded  through  an  aperture 
of  the  cyst.  The  idrotopathic  affections  compre- 
hend excess,  deficiency,  and  alteration  of  cuta- 
neous perspiration,  represented  by  the  terms 
liyperidrosis,  anidrosis,  osmidrosis  or  feetid  per- 
spiration, chromidrosis  or  coloured  perspiration, 
haemidrosis  or  sanguineous  sweat,  and  inflamma- 
tion of  the  sweat-glands. 

7.  Diseases  of  the  Hairs  and  Hair-folliclcs  — 
Diseases  of  the  hair-follicles  and  hair  are  rs- 


SKIN,  DISEASES  OF. 


presented  by  affections  of  the  hair-follicles 
proper,  for  example,  folliculitis,  acne,  gutta 
rosacea,  sycosis,  and  favus  ; and  by  special  affec- 
tions of  the  hair,  comprehending  alteration  of 
quantity,  colour,  and  structure. 

iETiOLOsr. — The  aetiology  of  cutaneous  diseases 
embraces  most  of  the  causes  ■which  give  rise  to 
disease  of  other  organs  *of  the  body ; the  only 
special  characteristic  of  the  skin  being  its  peri- 
pheral distribution,  and  its  consequent  exposure 
to  friction  and  to  the  action  of  the  atmosphere. 
Like  other  organs  it  is  dependent  for  its  health 
upon  healthy  nutrition  and  innervation.  When 
nutrition  is  defective  in  infancy  and  youth,  the 
skin  loses  its  powers  of  resistance  ; it  becomes 
abnormally  sensitive  to  the  action  of  irritants 
from  within  and  from  without;  and  it  is  conse- 
quently prone  to  eczema,  lichen,  struma,  and  acne. 
Hence  derangements  of  digestion  and  cutting  of 
teeth  are  common  causes  of  eczema  in  infants; 
struma  is  often  developed  for  the  first  time  with 
the  appearance  of  the  permanent  teeth ; and  acne 
accompanies  the  active  development  of  the  hair 
at  and  after  puberty.  Thus,  in  considering  the 
aetiology  of  diseases  of  the  skin,  we  may  take 
as  a starting-point  a weak  organ,  whatever  the 
causes  of  that  weakness  of  organ  may  havo  been, 
and  then  endeavour  to  discover  the  agency  of 
the  exciting  cause.  A weakly  parent  may  become 
the  mother  of  an  ill-nourished  infant,  or  may  be 
unable  to  supply  it  with  congenial  food ; a weak 
and  sensitive  skin  follows;  and  then  a variety  of 
excitants,  operating  on  a skin  so  predisposed,  may 
give  rise  to  an  eczema.  Or,  if  in  place  of  a weakly 
parent  we  assume  a faulty  digestive  apparatus, 
the  skin  may  equally  bo  the  sufferer,  and  then 
an  accidental  malassimilation  will  become  an 
exciting  cause  of  eczema,  erythema,  or  urticaria. 
In  like  manner  an  external  irritant,  such  as 
friction,  may  promote  the  development  of  an 
eczema.  The  cause  may,  however,  be  in  itself  so 
potent  as  to  develop  an  exanthem  in  an  other- 
wise healthy  skin,  as  in  the  exanthematous 
fevers. 

Disturbances  of  innervation  may  be  associated 
with  discolouration  of  the  skin,  as  in  Addison's 
disease  ; or  with  eruptions,  such  as  herpes. 

Next  to  malassimilation  and  specific  poisons  as 
causes  of  cutaneous  disease,  defective  nutrition 
is  evinced  in  ichthyosis,  achroma,  alopecia,  and 
lupus  erythematosus;  and  aberration  of  nutrition 
in  struma,  lupus,  lepra  vulgaris,  and  in  the  various 
forms  of  hypertrophy,  general  and  partial. 

Poisonous  articles  of  food  may  produce  skin- 
eruptions.  Thus  urticaria  follows  the  use  of  cer- 
tain kinds  of  fish,  more  especially  mussels,  or 
of  other  indigestible  substances.  Certain  drugs, 
too,  have  a specific  action  on  the  skin,  giving 
rise  to  various  forms  of  rash  ; for  example,  the 
salts  of  iodine  and  bromine,  cubebs,  copaiba,  and 
quinine.  Borax  has  recently  been  said  by  Dr. 
Gowers  to  produce  psoriasis  ( Lancet , 1881,  vol. 
ii.). 

As  a summary  of  the  aetiology  of  cutaneous 
diseases,  they  may  be  said  to  be  the  product  of 
a feeble  organ,  induced  by  debility  or  derange- 
ment of  constitution  ; and  the  therapeutical 
corollary  will  follow — restore  power  to  the  con- 
stitution, the  organ  will  recover,  and  the  disease 
trill  cease. 


1433 

Symptoms. — The  semeiology  or  symptomato- 
logy of  cutaneous  diseases  is  principally  mani- 
fested by  alteration  of  the  colour,  texture,  and 
sensibility  of  the  skin.  Change  of  colour  may 
proceed  from  abnormal  circulation,  giving  rise  to 
various  tints  of  red, ranging  from  scarlet  to  livid; 
or  from  aberrations  of  pigment.  Change  of  tex- 
ture is  evinced  by  abnormal  hardness  or  softness, 
thickness  or  thinness,  roughness  or  smoothness, 
swelling  or  prominence,  or  solution  of  continuity 
in  the  form  of  cracks  or  ulcers. 

Colour. — (a)  The  brighter  tints  of  redness  pro- 
ceed from  active  hyperamia , while  the  duller,  the 
purple,  and  the  livid  are  the  consequence  of  pas- 
sive hyperemia.  The  brightest  of  the  hues  of  red- 
ness are  met  with  in  erythema,  urticaria,  eczema, 
and  scarlatina;  the  tint  of  roseola,  rubeola,  and 
the  syphilodermata  trenches  on  the  purple ; while 
the  lrypersemia  resulting  from  venous  congestion 
is  livid  and  almost  black,  as  we  see  evinced  in 
morbus  ccerulms,  in  chilblain,  and  in  anthrax. 
Angeieetasia  and  ntevi  are  scarlet, crimson,  purple 
or  livid,  in  correspondence  with  the  activity  of 
circulation  through  their  blood-vessels  ; and 
effusions  of  blood  into  the  cutaneous  tissues,  as  in 
purpura  and  ecchymosis,  range  between  crimson 
and  black.  It  is  essential  to  distinguish  between 
a redness  which  is  transient  and  one  which  is 
permanent;  between  that  which  maybe  regarded 
as  a pathological  blush,  such  as  erythema  and 
urticaria,  that  which  indicates  a superficial  in- 
flammation, as  in  the  case  of  eczema  and  ervsipe- 
las,  or  a deeper  inflammation,  as  in  the  instance 
of  furunculus  and  anthrax ; and  in  the  case  of 
permanent  redness,  a state  of  angeieetasia  or  a 
vascular  nsevus. 

(b)  Changes  of  colour  from  aberration  of  pig- 
mentation are  commonly  restricted  to  the  rete 
mucosum,  and  range  in  hue  from  the  whiteness 
of  achroma,  through  the  yellow  and  brown  stains 
of  lentigo  and  chloasma,  to  the  deepest  black  of 
melasma.  Altered  pigmentation  is  also  met  with 
in  the  tissue  of  the  corium  ; as  in  the  yellow 
tints  of  xanthoma,  the  black  deposits  of  melasma, 
the  chemical  stain  of  oxide  of  silver,  and  the 
mechanical  colouration  of  tattoo. 

Texture. — Alterations  of  texture  of  the  skin 
are  discoverable  by  the  touch  as  well  as  by  the 
eye.  Infiltration  of  the  cutaneous  tissues  commu- 
nicates to  the  hand  a feeling  of  density  and 
thickness;  this  may  always  be  observed  in  eczema, 
where  it  gives  rise  to  slight  swelling,  but  is  most 
conspicuous  in  erysipelas,  and  in  the  tumescent 
forms  of  erythema.  Similar  infiltration,  together 
with  hyperemia  and  hypertrophy,  produces  the 
various  forms  of  pimples,  tubercles,  and  tumours 
of  the  substance  of  the  skin.  IVe  must,  however, 
except  from  this  cause  the  tubercles  of  urticaria, 
which  are  consequent  on  muscular  contractility; 
and  those  of  chronic  syphilis,  elephantiasis,  lupus, 
lymphadenoma,  and  epithelioma,  which  are  due 
to  the  formation  of  a new  tissue.  In  chronic 
eczema,  in  the  lepra  of  the  Greeks,  and  in  dif- 
fused lichen  planus,  the  skin  is  sometimes  found 
as  hard  and  dense  as  leather,  from  infiltration ; 
and  in  this  state  it  not  infrequently  cracks  and 
breaks,  so  as  to  produce  chaps  or  rhagades.  The 
skin  is  apt  to  be  roughened  in  chronic  eczema 
by  hypertrophy  and  exfoliation  of  the  epidermis, 
and  most  conspicuously  so  in  lepra  vulgaris; 


1434  SKIN,  DISEASES  OF. 

while  a state  of  congenital  roughness  of  the  skin 
is  pathognomonic  of  xeroderma  and  ichthyosis. 
In  alopecia  universalis  the  skin  is  morbidly  soft 
and  smooth  ; and  it  is  likewise  smooth  and  thin, 
from  defect  of  nutrition,  in  alopecia  areata.  The 
texture  of  the  skin  is  also  rendered  abnormal  by 
the  prominence  of  the  follicles  of  the  skin  in  the 
form  of  papulae,  as  in  a cutis  anserina  resulting 
from  vascular  congestion  and  infiltration  instead 
of  from  muscular  spasm;  by  the  production  of 
vesicles  and  sero-pustules,  the  consequence  of 
exudation  ; by  surface  exudation  giving  rise  to 
crusts  of  various  thickness — all  of  these  states 
being  common  to  eczema ; by  the  hypertrophic 
laminse  of  epidermis  generated  by  the  congested 
blotches  of  lepra  vulgaris  ; and  by  the  ulcers  of 
lupus,  syphilis,  and  elephantiasis.  It  is  impor- 
tant, therefore,  to  discriminate  between  variation 
of  texture  due  to  alteration  of  the  skin  in  its 
whole  or  in  its  parts.  Thickness  and  condensa- 
tion may  proceed  from  infiltration  solely,  from 
infiltration  with  active  hypertemia,  from  infiltra- 
tion with  hypertrophy,  or  from  the  development 
of  a new  and  abnormal  tissue  : it  may  be  re- 
stricted to  the  derma  proper,  or  it  may  spread  to 
1 he  subcutaneous  tissues ; or  the  alteration  may 
bo  one  involving  separately  the  papillse,  the 
glands,  or  the  fibrous  or  other  tissues  of  the 
corium. 

Sensibility. — Altered  sensibility  may  present 
itself  as  an  excess  or  defect  of  sensibility,  itching, 
tingling,  pricking,  heat,  chill,  or  actual  pain. 

Diagnosis. — The  diagnosis  of  cutaneous  dis- 
eases is  governed  primarily  by  the  physiognomy 
of  the  affection,  aided  by  corroborative  evidence 
supplied  by  the  history,  constitution,  age,  dura- 
tion, cause,  regional  distribution,  symptoms,  &c. ; 
in  a word,  by  all  the  information  which  patho- 
logy and  experience  have  brought  to  bear  on  the 
subject. 

Prognosis. — The  prognosis  of  cutaneous  dis- 
eases is  in  general  favourable.  They  are  vexatious 
to  the  patient,  sometimes  on  account  of  their  ugli- 
ness, at  other  times  from  the  teasing  itching,  or 
even  pain,  by  which  they  are  accompanied;  but 
they  are  rarely  fatal.  Indeed  their  gravity  is 
regulated  by  their  cause,  and  by  the  constitution 
of  the  patient,  rather  than  by  their  own  intrinsic 
qualities.  The  most  universal  of  cutaneous  dis- 
eases, eczema,  originates  in  malassimilation  ; and 
its  cure  or  persistency  will  depend  on  our  po-wers 
of  restoring  assimilation  to  a healthy  standard, 
and  this  again  will  be  governed  by  the  circum- 
stances and  position  in  life  of  the  patient.  Ery- 
thema, and  especially  urticaria,  are  due  to  a state 
of  constitution,  and  in  themselves  are  simply  a 
symptom  of  constitutional  disorder.  Sufferers 
from  pemphigus  sometimes  die,  because  pem- 
phigus is  often  a symptom  of  asthenia  and  ca- 
chexia ; and  anthrax,  which  occasionally  kills  by' 
pain  alone,  is,  in  general,  only  fatal  from  con- 
stitutional complication.  In  specific  inflamma- 
tion of  the  skin  the  prognosis  turns  upon  the 
curability  of  the  major  disorder — of  the  rubeola, 
the  scarlatina,  the  variola,  the  syphilis,  or  the 
elephantiasis  ; and  these  are  all  curable,  saving 
accidental  complications,  except  elephantiasis, 
which  must  be  regarded  as  an  incurable  disease. 
In  the  dystrophic  affections  — the  Greek  lepra, 
struma,  and  epithelioma,  medicine  is  placed  at  , 


SKIN,  BRONZED. 

the  mercy  of  a feeble  constitution ; and  although 
we  may  do  much  to  improve,  we  cannot  profess 
to  cure.  The  same  may  be  said  for  the  rest  of 
the  nutritive  affections  ; we  can  cure  some,  such 
as  ichthyosis,  hut  we  must  fail  signally  in  our 
attempts  to  cure  others,  because  we  possess  no 
direct  means  of  renovating  a faulty  constitution, 
or  of  giving  strength  -and  energy  to  a feeble 
organ,  and  thus  restoring  its  normal  function. 
The  neuropathic  affections,  again,  present  to  us 
the  problem  of  cure  of  a disordered  nervous 
system;  if  that  disorder  be  simply  functional  or 
due  to  derangement  of  general  health,  we  shall 
probably  succeed ; if  the  alteration  in  the  nerve- 
tissue  be  organic,  we  must  necessarily  fail. 

Treatment. — The  treatment  of  cutaneous 
diseases  divides  itself  naturally  into  constitu- 
tional and  local.  Sometimes  the  constitutional 
treatment  is  alone  essential,  as  in  non-nlcerative 
syphilis;  at  other  times  local  treatment  only  is 
required,  as  in  the  chronic  forms  of  eczema, 
termed  psoriasis  by  Willan  and  Bateman ; but 
in  general  a judicious  combination  of  the  two  is 
necessary.  The  aim  of  therapeutical  treatment 
should  be  to  restoi^  healthy  function  and  normal 
vital  power ; and  the  recovery  of  these  will  fre- 
quently prove  sufficient  to  accomplish  the  cure  of 
the  local  affection,  if  the  latter  have  been  shielded 
in  the  meantime  by  soothing  applications.  Mild 
tonic  aperients,  succeeded  by  tonics,  especially 
by  quinine,  iron,  and  arsenic,  constitute  the  spe- 
cial treatment  of  the  whole  family  of  inflamma- 
tory affections  of  the  skin.  Where  the  restora- 
tion of  the  nutritive  power  of  the  skin  is  a 
primary  indication,  as  in  non-inflammatory  lepra 
vulgaris,  and  ia  every  instance  in  which  the 
nutrition  of  the  skin  is  to  be  amended,  arsenic 
may  be  regarded  as  a specific  remedy. 

The  local  remedies  for  cutaneous  diseases  are 
alleviative,  stimulant,  and  caustic.  Alleviative 
remedies,  such  as  the  oxide  of  zinc  ointment,  are 
especially  adapted  to  the  inflammatory  affections, 
headed  by  eczema  ; chronic  eczema  and  lepra 
vulgaris  or  psoriasis  require  the  stimulating 
help  of  the  mercurial  ointments  and  tar;  while 
lupus  and  epithelioma  necessitate  the  employment 
of  caustics,  such  as  nitrate  of  silver  and  potassa 
fusa.  Besides  these,  which  are  the  essential  re- 
medies, there  are  others  adapted  for  special  pur- 
poses, which  are  mentioned  in  connection  with 
the  different  diseases  to  which  they  are  appli- 
cable. They  consist  principally  of  absorbent 
powders  and  lotions ; lotions  to  relieve  pruritus ; 
and  sulphur  applications  for  scabies. 

The  several  diseases  of  the  skin  are  fully  dis 
cussed  under  their  respective  headings. 

Erasmus  Wilson. 

SKIN,  BRONZED. — A form  of  pigmentary 
discolouration  of  the  skin,  embodying  a reddish 
tint,  in  lieu  of  the  yellow  and  green  hues  which 
are  met  with  in  lentigo  and  chloasma,  and  the 
absolute  black  of  melasma.  When  the  com- 
plexion is  darkened  by  the  action  of  the  atmo- 
sphere and  of  the  sun.  it  is  said  to  be  bronzed ; 
and  the  term  ‘bronzed  skin’  has  become  familiar 
also  in  consequence  of  its  application  to  the 
melasma  of  the  skin  in  Addison's  disease.  Bronzed 
skin,  again,  calls  to  mind  the  copper  colour  of 
chronic  syphiloderma,  in  which  the  melasma  is 


SKIN,  BRONZED. 

modified  by  red  and  yellow.  In  alliance  with 
Addison's  disease,  melasma  mnst  not  be  regarded 
as  specific,  but  simply  as  the  ordinary  melasmic 
change  of  colour  of  the  disordered  skin,  of  which 
the  ‘ bronze  ’ tint  is  an  accidental  modification. 
See  Addison’s  Disease  ; and  Pigmentary  Skin- 
diseases.  Erasmus  Wilson. 

SKIN,  DISCOLOURED.  See  Pigmentary 
Skin-Diseases. 

SKIN-BOUND  DISEASE.— A popular 
bynonym  for  Sclerema  neonatorum.  See  Sclerema 
Neonatorum. 

SKODAIC  RESONANCE. — A peculiar 
high-pitched  resonance,  found  chiefly  at  the  ster- 
Rc-clavicular  region  of  the  chest,  in  some  cases 
of  pleural  effusion.  See  Physical  Examination. 

SKOLIOSIS(cnco\il>s,crooked). — A synonym 
for  curvature  of  the  spine.  See  Spine,  Diseases 
and  Curvatures  of. 

SKULL,  Diseases  and  Deformities  of. — 

Synin.  : Fr.  Maladies  da  Crane-,  Ger.  Krank- 
des  Schddcls. — The  principal  diseases  and 
deformities  of  the  skull  will  be  discussed  in  the 
lo. lowing  order  : — 1.  Changes  of  shape  ; 2.  Vari- 
ations in  size  ; 3.  Meningocele  and  Hernia  Cere- 
1 r;  . 4.  Cephalhoematoma  ; 5.  Inflammation  ; 6. 
Pickets;  7.  Craniotabes ; 8.  Syphilis;  and  9. 
Tumours. 

i . Changes  of  shape.-The  shape  of  the  skull 
not  only  varies  much  amongst  the  different  races 
of  mankind,  but  in  each  race  variations  are  to 
be  found,  sometimes  depending  upon,  sometimes 
independent  of,  disease  in  the  individual.  A 
glance  at  any  extensive  collection  of  crania  is 
sufficient  to  indicate  how  much  larger  some 
skulls  are  than  others,  in  proportion  to  their 
width  ; how  in  some  the  vertical  diameter  is  pro- 
portionally great,  in  others  small ; how  some  hare 
wide  cheekbones,  some  depressed  noses,  and  others 
projecting  jaws.  The  old  classification  of  Blu- 
menbach  has  now  been  superseded  by  the  nume- 
rous and  minute  observations  of  recent  investi- 
gators. Eor  a short  account  of  the  methods  of 
craniometry  now  in  use,  and  of  the  present  tran- 
sitional state  of  the  science,  the  reader  is  referred 
to  the  ninth  edition  of  Dr.  Jones  Quain’s  Anatomy, 
vol.  i.  p.  80,  where  he  will  also  find  references  to 
most  of  the  important  works  upon  the  subject. 

The  skull  is  seldom  perfectly  symmetrical ; 
the  asymmetry  beiDg  usually  more  marked 
behind  than  in  front.  This  is  shown  not  only 
by  a coarse  examination  of  the  exterior,  but  by 
referring  to  the  differences  between  the  sulci 
and  foramina  on  the  two  sides,  which  are  so 
commonly  met  with.  A familiar  illustration  is 
afforded  by  the  fact  that  the  nose  is  rarely  if 
ever  exactly  in  the  mid  line  of  the  body  ; but 
much  more  striking  deviations  from  perfect 
symmetry  may  occur,  as,  for  instance,  in  a 
case  recently  reported  by  Mr.  Pearce  Gould  to 
the  Pathological  Society,  in  which  one  half  of 
the  cerebellum  was  absent,  and  there  was  a cor- 
responding deficiency  of  the  cerebellar  fossa  on 
the  occipital  bone.  Many  savage  races  pro- 
duce abnormalities  of  the  shape  of  the  skull, 
by  the  application  of  external  pressure  during 


SKULL,  DISEASES  OF.  1435 

early  infancy ; and  a similar  result  has  been 
supposed  to  be  consequent  on  the  method  of 
wrapping  up  the  heads  of  children  that  is  adopted 
in  some  parts  of  France.  A marked  asymme- 
try of  the  skull  accompanies  that  rare  disease, 
‘hemiatrophy  of  the  face,’  supposed  by  Mr.  Hut- 
chinson to  be  related  in  some  way  to  morphoea, 
There  are  also  recorded  cases  of  hypertrophy 
of  the  tones  of  the  face  and  skull.  A re- 
markable instance  of  this  disease,  or  rather  o( 
the  development  of  enormous  hyperostoses,  was 
shown  by  Mr.  Hutchinson,  in  His  recent  lectures 
on  Surgical  Affections  of  the  Nervous  System, 
at  the  Royal  College  of  Surgeons.  Here  the 
hyperostoses  appeared  closely  confined  to  parts 
which  were  supplied  by  branches  of  the  fifth 
nerve.  Some  of  these  hypertrophic  cases  are,  no 
doubt,  examples  of  exostosis,  others  of  inflamma 
tory  enlargement.  An  uniformly  thickened  skull, 
depending  presumably,  though  not  certainly,  on 
the  latter  cause,  may  be  either  porous  like  can- 
cellous bone,  or  dense  and  heavy  like  ivory.  There 
is  in  the  museum  of  the  College  of  Surgeons  an 
example  of  both  varieties,  each  of  which  measures 
in  many  parts  no  less  than  ^ in.  in  thickness ; in 
the  porous  variety  the  sutures  are  usually  more 
or  less  completely  ossified.  The  writer  has  seen 
a case  in  which,  without  apparent  cause,  the 
growth  of  one  half  of  the  lower  jaw  appeared  to 
be  arrested  about  the  age  of  puberty,  which  gave 
a peculiar  inequality  to  the  face.  Remarkable 
deformity  of  the  skull  may  result  from  the  con- 
strained position  in  which  the  head  is  held  by 
patients  suffering  from  torticollis. 

2.  Variations  in  size.-The  size  of  the  skull  is 
also  subject  to  considerable  variations  in  different 
races.  It  is  somewhat  larger,  on  the  average,  in 
men  than  in  women.  Amongst  individuals  also 
there  are  very  great  differences.  Great  intellects 
have  sometimes  been  associated  with  large  crania, 
but  oftener  there  has  been  no  such  relationship, 
and  not  unfrequently  the  opposite  has  been  tho 
case.  Far  greater,  however,  are  the  modifications 
of  size,  which  depend  upon  pathological  condi- 
tions and  defects  of  development.  Some  of  these 
are  briefly  as  follows  : — 

a.  Microcephalic  idiots. — Amongst  this  class  of 
idiots,  which  must  be  made  to  include  the  cretins, 
the  skull  is  remarkably  deficient  in  size.  Micro- 
cephalic  skulls  may  be  caused  by  a too  early 
union  of  the  sutures,  in  which  case  the  want  of 
development  of  the  brain  may  be  looked  upon 
as  a result  of  this  synostosis ; or  there  may  be 
a normal  condition  of  the  sutures  as  regards 
union,  but  both  the  brain  and  the  skull  remain 
undeveloped.  The  low  forehead  and  animal  face 
which  are  characteristic  of  this  condition,  give  a 
remarkably  unpleasing  appearance  to  the  child. 
The  amount  of  idiocy  depends  upon  the  size  and 
structure  of  the  brain,  and  the  development  of 
the  convolutions.  See  Cretinism. 

b.  Ancncephalic  monsters. — This  class  exhibits 
a more  or  less  complete  deficiency  in  the  develop- 
ment of  the  cranial  bones,  as  well  as  of  the  brain. 
The  great  variety  of  abnormalities  which  may  be 
met  with  will  be  found  described  in  the  article 
Brain,  Malformations  of. 

c.  Hydrocephalic  infants. — These  infants  have 
skulls  of  a size  proportionate  to  the  amount  of 
fluid  which  is  present,  and  they  may  thus  some- 


SKULL,  DISEASES  AND  DEFORMITIES  OF. 


1436 

times  reach  enormous  dimensions.  See  Hydro- 
cephalus, Chronic. 

In  this  connection  must  be  mentioned  that 
extremely  rare  disease  in  children— hypertrophy 
and.  sclerosis  of  the  brain,  which  involves  a cor- 
responding increase  in  the  size  of  the  skull.  See 
Brain,  Hypertrophy  of. 

3.  Meningocele  and  Encephalocele. — 
Closely  related  also  to  hydrocephalus  are  the 
cases  of  meningocele  and  encephalocele.  It  may 
briefly  be  stated  here  that  they  involve  the  exis- 
tence of  a deficiency  at  some  point  of  the  skull, 
through  which  the  membranes  of  the  brain,  con- 
taining cerebro-spinal  fluid,  or  indeed  some  part 
of  the  brain  itself,  may  protrude.  The  most 
frequent  seat  of  this  disease  is  the  occipital  bone, 
and  the  next  in  frequency  the  nasal  part  of  the 
frontal  bone,  but  tumours  of  this  nature  have 
been  met  with  in  other  situations.  It  is  of  the 
highest  importance  to  diagnose  these  two  kinds  of 
tumour  from  those  developed  in  the  bones  of  the 
skull  or  outside  them;  mistakes  in  diagnosis  have 
not  unfrequently  led  to  most  disastrous  results, 
as,  for  example,  when  a meningocele  has  simu- 
lated a polypus  of  the  nose,  and  its  removal  has 
been  undertaken.  If  patients  who  have  suffered 
from  meningocele  or  encephalocele  recover — a 
most  rare  occurrence — a small  hole  may  remain 
in  the  bone  which  presented  the  deficiency,  or 
Tie  opening  may  be  completely  obliterated. 

4.  Cephalheematoma. — True  cephalhaema- 
toma  is  a collection  of  blood  between  the  perios- 
teum and  the  skull.  It  occurs  congenitally, 
usually  on  the  right  parietal  bone,  but  often  on 
the  left,  and  as  a rule  varies  in  size  from  an  inch 
to  two  inches  in  diameter ; and  it  is  surrounded 
by  a hard,  well-defined  margin,  which  ultimately 
is  composed  of  bone.  It  is  probably  in  most 
eases,  if  notin  all,  the  result  of  mechanical  violence 
during  delivery.  An  exactly  similar  condition 
is  often  seen  as  the  result  of  a contusion  in 
later  life.  If  left  alone  a cephalhaematoma 
generally  disappears.  If  suppuration  have  taken 
place  incision  becomes  necessary.  See  Cephal- 
hematoma. 

The  term  cephalhaematoma  might  equally  well 
be  applied  to  collections  of  blood  between  the 
dura  mater  and  the  skull.  Such  effusions  are 
probably  always  traumatic,  and  result  from  the 
rupture  of  a meningeal  artery  or  vein.  If  serious 
results  do  not  immediately  follow  from  pressure 
on  the  brain,  considerable  thickening  of  the  dura 
mater  may  be  set  up,  accompanied  by  the  symp- 
toms known  as  those  of  pachymeningitis.  See 
Meninges,  Cerebral,  Inflammation  of,  Simple 
Traumatic. 

5.  Inflammatory  Diseases. 

a.  Inflammation  of  the  diploe  and  its  veins. — 

In  cases  of  injury  to  the  skull,  whether  of  the 
nature  of  fracture  or  of  simple  exposure  in  a 
scalp-wound,  inflammation  of  the  diploic  veins 
is  not  uncommon,  if  the  wound  be  allowed  to 
putrefy.  Under  such  circumstances  if  the  outer 
table  be  removed,  the  whole  diploe  and  its  veins 
are  found  to  be  filled' with  pus,  or  on  applying 
a trephine  to  a bone  thus  affected,  the  pus  may 
be  seen  to  exude  from  the  divided  veins.  The 
dura  mater,  under  such  circumstances,  may  be 
affected,  or  pus  may  collect  between  it  and  the 
bone.  Pysemia,  with  its  characteristic  concomi- 


tant symptoms,  is  tho  frequent,  if  not  the  invari- 
able, result.  It  is  not  assumed  that  in  this  affec- 
tion the  outer  and  inner  tables  of  the  skull  escape, 
but  it  is  only  in  the  diploe  that  the  pathological 
process  is  obvious  to  the  naked  eye. 

The  only  treatment  that  has  been  suggested — 
trephining — does  not  offer  any  hope  of  alleviating 
the  symptoms. 

b.  Chronic  osteitis. — This  may  affect  the  bones 
of  the  skull  without  apparent  cause,  but  in  the 
majority  of  cases  depends  upon  the  syphilitic 
taint.  Sometimes  all  the  bones  of  the  skull 
become  thickened  and  enormously  massive,  the 
surface  being  much  roughened  and  often  worm- 
eaten.  At  other  times  irregular  hyperostosis 
may  be  the  result.  Considerable  thickenings  of 
some  of  tho  cranial  bones,  the  result  of  an  im- 
perfect vascular  osseous  deposit,  are  found  in 
some  infants  affected  with  congenital  syphilis. 
These  are  mostly  met  with  about  the  fonta- 
nelles,  especially  on  the  frontal  and  parietal,  and 
sometimes  the  temporal  bones.  The  irregular 
hyperostoses  are  mostly  the  result  of  local  peri- 
ostitis; in  fact,  they  are  ossified  nodes.  Chronic 
osteitis  is  the  cause  of  the  falling-in  of  the  bridge 
of  the  nose  or  the  massive  condition  of  the  same 
part,  which  gives  such  a characteristic  appear- 
ance to  a child  suffering  from  congenital  syphilis. 

The  treatment  must  be  directed  against  the 
constitutional  taint,  if  any  is  to  be  discovered. 

c.  Caries. — Chronic  osteitis  can  hardly  be  con- 
sidered apart  from  caries,  which,  again,  in  the 
majority  of  cases,  depends  upon  syphilis,  though 
more  rarely  on  the  strumous  diathesis.  It  is 
usually  caused  by  the  penetration  of  a superficial 
ulcer  into  the  deeper  structures,  or  by  the  sepa- 
ration of  the  periosteum,  resulting  from  perios- 
titis. It  is  frequently  associated  with  more  or  less 
chronic  osteitis  and  necrosis.  One  of  the  most 
frequent  seats  of  caries  of  the  skull  is  the  fore- 
head, as  a sequence  of  tertiary  syphilitic  ulcera- 
tion ( corona  Veneris).  Another  common  seat  is 
the  hard  palate,  which  is  often  perforated  as 
the  disease  advances.  Caries  may  occur  in  the 
occipito-atlantal  articulation  (Pott's  disease), 
followed  by  a train  of  symptoms  which  will  be 
found  discussed  in  other  parts  of  this  work. 
Caries  of  the  temporal  bone,  either  of  the  petrous 
or  mastoid  portions,  frequently  follows  otitis 
media,  and  is  not  uncommonly  the  intermediate 
stage  between  this  disease  and  meningitis  or 
cerebral  abscess. 

Beyond  precautions  for  maintaining  cleanli- 
ness, little  or  nothing  can  be'done  to  relieve  this 
condition  by  the  surgeon  ; and  with  regard  to 
other  cases  of  caries  of  the  skull,  whether  con- 
sidered pathologically  or  clinically,  nothing  can 
be  added  which  does  not  apply  to  the  same 
disease  in  other  parts  of  the  body.  Caries  of 
the  occipito-atlantal  articulation  is  well  treated 
in  the  early  stages  by  the  actual  cautery. 

d.  Necrosis. — Necrosis  of  the  skull  not  unfre- 
quently depends  upon  a traumatic  cause,  such  as 
scalp-wounds  or  burns;  but  here  again  the  syphi- 
litic form  is  exceedingly  common.  It  may  also  de- 
pend upon  disease  cf  the  middle  ear.  Simple  trau- 
matic necrosis  leads  to  the  separation  of  a seques- 
trum in  the  usual  way.  Syphilitic  necrosis  often 
depends  upon  some  form  of  ulceration,  or  upon 
periostitis,  and  maybe  accompanied  by  extensive 


SKULL,  DISEASES  ANTD  DEFORMITIES  OF. 


caries  and  chronic  osteitis.  The  separation  of 
syphilitic  sequestra  is  generally  a remarkably 
tedious  process ; and  they  are,  moreover,  often 
surrounded  by  little  or  no  reparatory  callus,  so 
that  after  their  removal  it  is  no  rare  occurrence 
to  find  the  dura  mater  pulsating  over  a large 
area  at  the  bottom  of  the  -wound.  At  the  same 
time  this  rule  is  not  invariable  ; it  is  common  to 
find  great  thickening  if  necrosis  of  the  bones  of 
the  orbit  occur,  which  may  cause  permanent  dis- 
placement of  the  eyeball.  The  writer  has  seen 
a large  piece  of  the  body  of  the  sphenoid  sepa- 
rated as  a sequestrum,  including  the  sella  tur- 
cica, and  removed  through  the  nose  without  the 
slightest  evil  result  to  the  patient. 

Necrosis  is  not  unfrequently  met  with  affect- 
ing the  bones  of  the  face.  Thus  a part  or  the 
whole  of  the  upper  or  the  lower  jaw  may  die, 
and  be  separated  as  a sequestrum.  Necrosis  of 
the  jaws  often  depends  on  inflammation  set  up 
by  carious  teeth.  Another  cause,  happilynotnow 
frequently  met  with,  is  the  poisonous  effect  of 
the  fumes  of  phosphorus  in  persons  employed  in 
the  manufacture  of  this  substance,  and  in  that 
of  lucifer  matches  (see  Phosphorus,  Poisoning 
by).  The  same  remarks  apply  to  the  abuse  of 
mercury.  But  besides  these  more  special  causes, 
necrosis  of  the  bones  of  the  face  may  depend 
upon  those  more  general  states  which  are  sup- 
posed to  stand  to  necrosis  of  other  bones  in  the 
relation  of  cause  and  effect ; such  as  fevers  and 
the  like.  The  amount  of  thickening  round  a 
necrosed  upper  jaw  has  not  unfrequently  led  to 
its  removal  in  mistake  for  a tumour ; it  is,  there- 
fore, of  the  highest  importance  to  examine  all 
swellings  in  this  region  with  great  care. 

Treatment. — If  the  membranes  be  left  ex- 
posed, some  protection  must  be  provided  for  the 
cranial  contents  ; otherwise  the  treatment  of  ne- 
crosis of  the  skull  must  be  conducted  on  general 
principles.  Sequestra  in  the  mastoid  process  or 
around  the  tympanum  should  be  carefully  dealt 
with,  on  account  of  the  danger  of  setting  up 
meningitis,  which  any  surgical  interference  in- 
volves. In  dealing  with  necrosis  of  one  half  of 
the  lower  jaw  it  must  be  remembered  that,  un- 
less sufficient  callus  have  been  thrown  out  before 
the  removal  of  the  sequestrum,  the  other  half 
will  lose  its  support  and  assume  an  altogether 
unnatural  and  almost  useless  position,  leaving 
the  patient  in  a condition  in  which  he  can  hope 
for  but  little  relief  from  surgery. 

e.  Periostitis. — Periostitis  of  the  skull  has  been 
already  referred  to.  It  may  depend  upon  syphilis 
or  struma — most,  commonly  the  former,  and  gives 
rise  to  what  are  known  as  nodes.  The  inflam- 
matory subperiosteal  effusion  may  be  fluid  or 
solid  (soft  and  hard  nodes) ; and  it  may  undergo 
true  or  spurious  suppuration  or  ossification,  or 
may  be  completely  absorbed.  The  most  common 
position  for  cranial  nodes  is  the  frontal  bone.  As 
in  the  case  of  periostitis  elsewhere,  nodes  are  the 
seat  of  characteristic  nocturnal  pain,  which  is  ex- 
tremely distressing  and  exhausting  to  the  patient. 

Treatment.— The  treatment  in  any  case  is 
by  the  administration  of  iodide  of  potassium ; 
the  effect  of  which  is  most  marked,  however,  in 
syphilitic  cases,  the  pain  being  usually  removed 
in  two  or  three  days.  If  suppuration  occur,  in- 
sision  is  required. 


1437 

6.  Rickets. — In  a rickety  infant  the  skull 
looks  large;  though  it  maybe  questioned  whether 
this  does  not  depend  on  a deficient  development 
of  the  bones  of  the  face.  The  frontal  and  parietal 
eminences  appear  too  prominent ; the  fontanelle.s 
remain  patent  much  longer  than  in  a healthy 
infant ; and  in  some  cases  the  anterior  fontaneila 
may  be  unclosed  as  late  as  the  fourth  or  sixth 
year.  The  skulls  of  rickety  children  have  a 
peculiarly  massive  feel ; they  are  sometimes  long 
in  proportion  to  their  width,  conforming  to  the 
shape  known  as  dolieoceplialic.  For  a more 
detailed  account  of  this  and  other  conditions 
see  a paper  by  S.  J.  Gee,  M.D.,  in  vol.  vii.  of 
the  St.  Bartholomew’s  Hospital  Reports , on'The 
shape  of  the  head  looked  at  from  a medical  point 
of  view.’  The  head  of  an  adult  who  has  been 
the  subject  of  rickets  in  his  childhood,  has  often 
a very  characteristic  appearance ; an  apparently 
large  square  skull,  with  a prominent  forehead 
towering  above  a diminutive  and  pinched-up 
face,  giving  to  the  individual  a decidedly  intel- 
lectual aspect. 

Craniotabes  occurs  occasionally  in  rickety 
skulls,  but,  as  will  be  afterwards  shown,  we  do 
not  yet  know  how  far,  if  at  all,  it  depends  upon 
the  constitutional  condition. 

7.  Craniotabes. — By  this  term  is  meant  the 
occurrence  of  spots  of  remarkable  thinness  in  the 
skull,  such  that  an  indentation  may  be  produced 
by  the  pressure  of  the  finger.  True  craniotabes, 
as  opposed  to  the  gelatiniform  degeneration  of 
the  outer  table  (Parrot),  attacks  the  inner  aspect 
of  the  skull.  For  its  production  an  undue  soft- 
ness of  the  bone  appears  to  be  necessary,  to- 
gether with  the  occurrence  of  pressure,  either 
from  within  or  from  without.  It  is  rarely  found 
congonitally,  and  then  affects  the  anterior  part 
of  the  skull.  It  is  common  in  syphilitic  infants 
under  one  year  of  age,  and  then  affects  usually 
the  posterior  parts  of  the  parietal  bones.  These 
positions,  it  will  be  noticed,  are  those  most  sub- 
jected to  pressure  under  the  two  conditions 
mentioned.  Craniotabes  has  been,  by  some  ob- 
servers, associated  with  rickets,  but  the  relation 
of  the  one  to  the  other  is  at  present  doubtful. 
It  disappears  as  age  advances,  and  requires  no 
special  treatment.  See  M.  Parrot,  Revue  Men- 
suclle,  1879,  p.  769  ; and  Dr.  Barlow  and  Dr. 
Lees,  Pathological  Transactions,  1880,  p.  236, 
and  1881,  p.  323. 

8.  Syphilitic  affections.— From  the  fore- 
going observations  it  will  be  seen  that  syphilis, 
congenital  or  acquired,  has  much  to  account 
for  amongst  diseases  of  the  skull.  It  may  cause 
periostitis,  with  consequent  nodes ; chronic 
osteitis,  with  consequent  hypertrophy,  local  or 
general;  caries  ; necrosis ; and  craniotabes.  As 
a general  rule,  it  may  be  stated  that  syphilitic 
affections  of  bone  are  amongst  the  later  manifes- 
tations of  this  disease.  The  inflammatory  forms 
are  usually  accompanied  by  severe  nocturnal 
pains,  and  they  may  be  expected  in  most  cases 
to  yield  to  the  administration  of  iodide  of 
potassium. 

9.  Tumours. — It  is  necessary  to  refer  in  the 
briefest  possible  way  to  the  tumours  of  the  skull. 
Primary  growths  may  spring  from  the  diploe,  or 
from  the  inner  and  outer  tables  of  the  cranial 
bones.  Perhaps  the  most  common  are  exostoses, 


1438  SKULL,  DISEASES  OF. 
and  some  of  the  various  kinds  of  sarcoma,  either 
of  which  may  reach  an  enormous  size.  The  former 
may  assume  various  characters.  A remarkable 
instance  of  one  presenting  the  appearance  of  a 
horn  will  be  found  described  in  the  Path.  Trans. 
vol.  iii.  p.  149.  These  alone,  and  then  only  in  cer- 
tain cases,  admit  of  removal  by  the  surgeon.  In 
connection  with  the  bones  of  the  face,  tumours  of 
the  antrum  or  of  the  upper  jaw,  of  various  kinds, 
and  tumours  of  the  lower  jaw,  are  not  uncommon. 
In  the  latter  position  the  various  forms  of  epulis — 
myeloid,  fibrous  or  malignant,  and  cystic  tumours 
are  frequently  met  with.  Exostoses  often  grow 
from  the  jaws  and  the  orbit,  and  in  connection 
with  the  latter  the  different  kinds  of  odontoma 
must  be  mentioned.  Secondary  tumours  of  all 
kinds  may  affect  the  skull ; thus  more  than  one  in- 
stance is  on  record  of  a pulsating  growth,  occur- 
ring secondarily  to  a similar  growth  in  the  thy- 
roid gland.  Of  these  secondary  affections  the 
commonest  are  those  which  affect  the  skull  by 
the  direct  extension  of  tumours  from  within  or 
without ; for  example,  the  epitheliomata  of  the 
scalp  or  mouth,  or  rodent  ulcer  of  the  face. 

E,  J.  Godlee. 

SLEEP,  Disorders  of. — Synox.  : Fr. 

Troubles  du  Sommeil ; Ger.  Stbhmngen  dcs 
Schlafes. — A proper  amount  and  kind  of  sleep 
is  needful  in  order  that  the  body  may  be  main- 
tained in  a state  of  health.  But  the  actual 
amount  of  sleep  taken  and  necessary  for  persons 
in  health  varies,  within  wide  limits,  according  to 
age,  the  soundness  of  the  sleep  itself,  and  indi- 
vidual idiosyncrasy. 

Age  is  a very  important  modifying  factor. 
Thus  an  infant  may  sleep  for  twenty  hours  out 
of  the  twenty-four,  and  young  children  up  to  the 
age  of  ten  commonly  sleep  for  fourteen  or  at  least 
twelve  hours.  In  children  from  ten  to  fifteen  years 
old,  the  duration  of  sleep  usually  varies  between 
twelve  and  ten  hours.  In  persons  from  fifteen 
to  twenty-five  the  period  should  not  sink  below 
eight  hours  ; from  the  latter  age  on  to  fifty  it 
may  fall  to  seven  hours ; and  after  thisage  about 
the  same  amount  of  sleep  is  required  by  the 
majority  of  persons,  though  some  find  six  hours 
sufficient,  and  a few  can  (without  apparent  in- 
jury) take  habitually  even  as  little  as  five  hours’ 
sleep.  The  instances  in  which  a duration  of  sleep 
habitually  less  than  this  is  needed,  are  altogether 
rare  and  exceptional. 

Soundness  of  sleep,  too,  is  subject  to  much  in- 
dividual variation.  In  childhood  and  in  early 
life,  sleep  is  commonly  mere  profound  than  it  is 
in  adults,  and  much  sounder  than  in  old  age. 
But  over  and  above  these  variations  incident  to 
age,  there  are  individual  differences.  Some  persons 
are  naturally  ‘ light  ’ and  others 1 heavy  ’ sleepers. 
As  a rule,  those  who  can  do  with  a small  amount 
of  sleep  belong  to  the  latter  category.  And 
similarly  in  regard  to  amount  there  are  indivi- 
dual differences ; some  persons  are  able  to  do 
with  a comparatively  small  amount,  while  others 
seem  to  require  to  sleep  decidedly  beyond  the 
average  periods  above  stated. 

The  disorders  of  sleep, — that  is,  the  variations 
outside  the  above  limits— belong  td  three  prin- 
cipal categories,  in  the  first  of  which  may  be 
ranged  all  those  cases  where  sleep  is  excessive  in 


SLEEP,  DISOEDEES  OF. 
amount;  in  the  second  those  in  which  it  is  defec- 
tive in  soundness  or  in  amount;  and  in  the  third 
those  in  which  it  is  unnatural  in  character. 

I.  Amount  of  sleep  excessive. — This  oc- 
curs commonly  in  more  or  less  demented  persons 
or  in  idiots,  whose  brain-activity  i3  below  the 
usual  level.  Such  persons,  when  their  natural 
wants  are  satisfied,  are  apt,  like  the  lower  ani- 
mals, to  sleep  away  a large  portion  of  their  time. 

But  some  individuals  of  notable  intellectual 
power  may  occasionally,  even  in  a state  of 
health,  though  after  greatly  prolonged  labours 
with  previous  deprivation  of  rest,  continue  to 
sleep  soundly  for  twenty-four  or  even  thirty-six 
hours. 

In  many  brain-affections,  and  in  some  cases 
of  blood-poisoning,  a condition  of  unnatural 
sleep  bordering  upon  stupor  may  be  present  for 
many  days.  Obscure  cases  in  which  sleep  is 
prolonged  for  weeks,  or  even  months,  are  occa- 
sionally met  with  in  this  country.  This  rare 
condition  only  supervenes  in  persons  of  an 
obviously  ‘ nervous  ’ temperament,  and  the  state 
itself  seems  generally  to  be  a kind  of  trance 
allied  to  catalepsy. 

On  the  West  Coast  jf  Africa  a curious  endemic 
disease  occurs  known  as  the  ‘sleeping  sickness’ 
(see  Gore,  Brit.  Med.  Journal , Jan.  2,  1875),  the 
aetiology  and  pathology  of  which  is  altogether 
obscure.  It  begins  with  a swelling  of  the  cer- 
vical glands,  together  with  an  increasing  ten- 
dency to  sleep.  The  somnolence  becomes  more 
and  more  constant,  until  at  last  the  patient  can- 
not even  be  aroused  to  take  nourishment.  The 
disease  lasts  from  six  to  twelve  months,  and  is 
generally  fatal.  See  Teaxce. 

II.  Amount  of  sleep  defective. — Under 
this  head  we  have  to  do  with  two  kinds  of  failure 
— a defect  of  quality  ( disturbed  or  restless  sleep); 
and  a defect  in  quantity  ( [wakefulness , insomnia, 
pervigilium).  These  two  defects  often  co-exist, 
though  in  many  cases  we  may  have  the  former 
condition  existing  alone. 

(a)  Disturbed  or  restless  sleep. — This  is  a most 
common  complaint,  apt  to  occur  in  persons  of  all 
ages,  and  under  the  influence  of  many  different 
causes,  some  of  the  most  frequent  of  which  are 
these ; — indigestible  food,  or  food  of  excessive  or 
unaccustomed  quantity,  taken  not  long  before 
going  to  bed;  painful  conditions  of  any  kind; 
discomfort  induced  by  undue  cold  or  excessive 
heat;  mental  excitement  or  worry;  prolonged 
overwork  (mental) ; over-fatigue  (bodily) ; fe- 
brile conditions  ; inflammations ; gouty  states  of 
the  system ; imperfect  action  of  the  liver : exces- 
sive haemorrhages ; acute  and  chronic  illnesses 
of  various  kinds ; the  state  of  convalescence 
from  many  acute  diseases.  Lastly,  sleeping  in  a 
novel  or  uneasy  condition,  or  in  the  midst  of 
unaccustomed  noises,  may  also  he  mentioned  as 
a not  unfrequent  cause.  Under  any  of  these 
various  conditions  sleep  may  be  fitful  and  dis- 
turbed, the  persons  often  starting  or  turning 
about  uneasily,  dreaming  much,  and  from  time 
to  time  waking  under  the  influence  of  dreams 
of  a distressing  or  oppressive  character.  In  one 
of  the  most  extreme  of  the  latter  conditions, 
especially  when  it  has  been  evoked  by  indiges- 
tible food,  the  state  known  as  nightmare  is  in- 
duced. See  Nightmare. 


SLEEP.  DISORDERS  OF.  1439 


Treatment. — The  treatment  of  disturbed  sleep 
must  of  course  vary  widely  according  to  the 
nature  of  the  influences  under  which  it  has  arisen. 
These  may  at  times  be  easily  corrected,  but  in 
other  cases  where  the  disturbed  rest  is  depend- 
ent upon  pain  difficult  to  annul,  or  upon  some 
acute  or  chronic  disease,  it  may  be  impossible  or 
extremely  difficult  to  ensure  sound  sleep,  not- 
withstanding the  best  directed  efforts  to  correct 
or  neutralize  the  disturbing  causes  in  operation. 
It  may  then  be  necessary  to  hare  recourse  to  the 
measures  recommended  under  the  next  heading. 

(h)  Insomnia  or  wakefulness. — Under  this  head 
we  ma}T  have  either  complete  or  partial  insomnia. 
The  condition  is  complete  when  the  person  gets 
no  sleep  at  all  for  night  after  night,  as  in  acute 
mania,  delirium  tremens,  in  those  suffering  from 
some  very  severe  pain,  or  in  persons  under  the 
influence  of  profound  grief  or  mental  anxiety.  On 
the  other  hand  we  may  have  partial  insomnia  of 
different  kinds.  In  the  one  set  of  cases  the  per- 
sons who  suffer  from  it  may  lie  awake  for  long 
periods  (one  to  several  hours)  before  being  able 
to  get  to  sleep  at  all,  and  then  sleep  may  be 
more  or  less  sound  and  continuous  till  morning. 
In  other  cases  patients  do  not  experience  so 
much  difficulty  in  getting  to  sleep,  though  after 
they  have  slept  for  one,  two,  or  more  hours  they 
awake  and  cannot  again  fall  asleep ; they  lie 
awake  often  in  a state  of  mental  depression,  or 
even  actually  tortured  by  gloomy  or  horrible 
forebodings. 

Various  cases  are  on  record  in  which  absolute 
insomnia  has  lasted  not  only  for  days  but  even 
for  weeks,  interrupted  only  by  mere  snatches  of 
6leep  during  brief  intervals. 

In  this  whole  class  of  cases,  however,  the  suf- 
ferers themselves  are  apt  to  form  exaggerated 
estimates  of  the  amount  of  their  wakefulness, 
and  to  become  more  or  less  hypochondriacal 
upon  the  subject. 

Treatment. — In  many  of  these  cases  the  art 
of  the  physician  is  very  severely  taxed.  When- 
ever it  is  possible,  insomnia  should  be  corrected 
by  a studious  attention  to  the  general  health 
and  habits  of  the  patient,  and  by  endeavouring 
to  ensure  the  presence,  as  far  as  possible,  of 
the  physiological  conditions  which  favour  sleep. 
Mental  repose,  bodily  comfort,  a sufficient  degreo 
of  warmth,  a certain  amount  of  fatigue,  com- 
bined with  perfect  quietude,  are  essentials.  To 
ensure  the  first  of  these  conditions  it  may  be 
needful  to  prohibit  all  study  for  some  hours 
before  retiring  to  rest.  An  evening  walk,  so  as 
to  induce  a certain  amount  of  bodily  fatigue,  is 
often  beneficial  where  it  can  be  had  recourse  to. 
A cup  of  warm  beef-tea,,  gruel,  or  some  weak 
stimulant,  just  before  going  to  bed  may  also  have 
a salutary  influence,  and  the  former  may  be 
repeated,  or  taken  preferentially,  during  the 
night.  Monotonous  sensorial  impressions  (sounds 
or  gentle  frictions) ; or  a monotonous  dwelling 
of  the  mind  upon  certain  uninteresting  imagi- 
nary sights  or  verbal  repetitions  are,  again,  not 
unfrequently  found  to  act  as  provocatives  of 
sleep. 

Where  such  measures  are  unavailing,  recourse 
must  be  had  to  hypnotics  and  sedatives,  such  as 
bromide  of  potassium,  chloral,  opium  in  one  or 
other  of  its  forms,  morphia  by  mouth  or  sub- 


cutaneously, hy«.scyamine,  Indian  hemp,  &e.,  in 
doses  appropriate  to  the  age  and  condition  of  the 
patient.  In  the  more  urgent  cases  the  doses  of 
such  hypnotics  may  have  to  be  repeated  till 
sleep  is  procured ; but  in  many  of  these  urgent 
conditions  the  sedative  influence  of  packing  in 
the  wet  sheet  must  not  be  forgotten.  Where 
hypnotics  are  had  recourse  to,  it  is  of  great  im- 
portance to  see  that  their  use  is  not  continued 
after  the  need  for  them  has  passed.  Abrupt  dis- 
continuance is  often  most  inadvisable,  but  rather 
a gradual  diminution  of  the  dose,  with  or  without 
the  knowledge  of  the  patient. 

III.  Sleep  unnatural  in  character.  — 
Under  this  head  we  have  to  do  with  various  un- 
natural conditions,  in  which  the  abeyance  of  func- 
tion characterising  sleep  is  more  partial  than  that 
which  normally  exists.  In  disturbed  sleep  the 
physiological  condition  pertaining  to  sleep  is 
generally  less  profound  than  it  should  be,  just  as 
in  other  cases  of  unusually  deep  sleep  (akin  to 
stupor)  such  a condition  is  generally  more  pro- 
found than  natural.  In  the  cases  to  which  we 
now  refer,  however,  sleep  is  partial  in  its  area ; 
portions  of  the  brain  that  are  usually  involved 
in  the  physiological  condition  peculiar  to  sleep 
remain  exempt,  so  that  the  sleeper  exhibits 
powers  which  sleep  usually  annuls.  Hence  we 
may  have  somniloqiiy  or  sleep-lalking  ; and  som- 
nambulism or  sleep-walking.  In  those  who 
exhibit  the  former  phenomena,  dream-thoughts 
are  capable  of  evoking  correlative  acts  of  speech, 
and  such  persons  will  sometimes  allow  a listener 
to  hold  a sort  of  conversation  with  them,  of 
which  in  the  waking  state  they  recollect  nothing. 
This  dream-conversation  may  be  more  or  less 
coherent.  Dreams  themselves,  too,  vary  much 
in  their  coherency  in  different  individuals.  In 
some  persons  whose  sleep  is  to  that  exten' 
unnatural,  powers  are  displayed  which  even  sun 
pass  those  of  the  waking  state.  Mathematical 
problems  have  been  solved  during  such  sleep ; 
poems  and  music  have  been  composed  and 
written  out,  which  have  altogether  surprised  the 
same  person  when  awake.  The  writer  has  re- 
cently seen  a young  lady  liable  to  what  may  be 
termed  1 singing  fits,’  in  which  she  would  lie  for 
hours  incapable  of  being  aroused  by  ordinary 
means,  singing  without  intermission  songs,  hymn3, 
and  portions  of  operas  in  promiscuous  succes- 
sion, but  in  a manner  very  decidedly  excelling 
that  of  which  she  was  capable  wThen  awake.  In 
all  these  states  we  have  to  do  with  a morbid 
condition  of  sleep,  partial  in  its  area,  and  in 
which  there  is  the  farther  peculiarity  that  certain 
faculties  are  in  a condition  of  exalted  activity. 
The  alliances  here  are  intimate  with  the  condi- 
tions that  have  of  late  been  studied  under  the 
name  of  ‘ hypnotism,’  but  which  were  formerly 
included  under  the  term  animal  magnetism  (see 
Magnetism,  Animal).  The  same  remark  applies 
to  somnambulism  also.  Here  the  morbid  sleeper 
possesses  an  unwonted  power  of  calling  his 
muscles  generally  into  activity  in  response  to  his 
dream-thoughts.  Sight  in  relation  to  the  dream 
may  be  good,  though  unrelated  visual  impressions 
are  not  taken  cognizance  of.  Muscular  sense- 
impressions  also  are  freely  acted  upon,  but  the 
sleep-walker  may  be  quite  deaf  to  all  ordinary 
auditory  impressions. 


1440  SLEEP,  DISORDERS  OF. 

Treatment. — These  are  to  he  regarded  as  dis- 
tinctly morbid  conditions,  and  the  persons  mani- 
festing them  may  often  be  cured  by  attention  to 
the  general  health,  and  the  use  of  remedies  cal- 
culated to  give  tone  to,  and  allay  the  irritability 
of  the  nervous  system.  A line  of  treatment,  in 
fact,  not  very  dissimilar  from  that  to  which  one 
would  have  resort  in  convulsions  or  epilepsy,  will 
often  suffice  to  cure  these  minor  manifestations 
of  nervous  disorder. 

Finally  sleep  may  be  disturbed  by  certain 
phenomena  occurring  to  the  person  in  this  con- 
dition, which,  though  scarcely  to  be  spoken  of  as 
disorders  of  sleep,  ought  at  least  to  be  mentioned 
under  this  head.  One  of  minor  significance  is 
snoring,  which  at  times  may  be  so  loud  as  to 
awaken  the  sleeper ; but  another  of  far  greater 
significance  is  the  tendency  to  the  occurrence  of 
convulsive  or  epileptic  attacks,  which  in  some 
patients  occur  only  during  sleep. 

II.  Charlton  Bastian. 

SLOUGH  (Sax.  Slog,  afoul  hole  or  hollow). — 
The  dead  material  resulting  from  gangrene, 
ulceration,  or  low  forms  of  inflammation  of  soft 
tissues.  A slough  may  be  in  the  form  of  a mass, 
as  in  gangrene;  or  in  shreds,  as  in  ulcers  and 
unhealthy  wounds,  which  are  then  said  to  be 
sloughing.  See  Gangrene  ; and  Ulceration. 

SMALL-POX.— Synon.  : Variola ; Fr.  la 
pelite  Verole  ; Gcr.  Blattern. 

Definition. — An  acute  specific,  infectious  dis- 
ease, characterised  by  sudden  and  severe  fever, 
which  after  forty-eight  hours  is  followed  by 
an  eruption  of  pimples  on  the  forehead,  face, 
and  wrists,  gradually  passing  over  the  body. 
Thi3  eruption  is  followed  by  a fall  of  tempera- 
ture, and  in  from  ten  to  fourteen  days  it  passes 
through  the  stages  of  vesicle,  pustule,  and  crust; 
it  also  appears  on  certain  mucous  membranes, 
and  is  sometimes  complicated  with  haemorrhage 
into  the  skin,  and  from  the  mucous  surfaces. 

^Etiology. — When,  where,  or  how  small-pox 
arose  is  not  known  It  certainly  appeared  in 
Europe  in  the  sixth  century.  It  arises  now  from 
contagionand  frominoculation.  It  affects  all  races 
of  men,  every  age,  and  both  sexes.  No  climate 
is  free  from  its  ravages.  It  rages  with  special 
virulence  where  it  appears  for  the  first  time,  and 
in  such  cases  may  carry  off  whole  tribes.  It  is 
exceptionally  severe  among  negroes  and  the  in- 
habitants of  warm  climates  generally.  Its  sub- 
jects are  unvaccinated  or  badly  vaccinated  per- 
sons, extensive  observation  having  shown  that  in 
proportion  to  the  efficiency  of  vaccination  is  the 
rarity  and  mildness  of  small-pox.  As  a rule  it 
attacks  the  same  person  once  only,  but  there  are 
exceptions  to  this  rule.  Some  few — of  whom 
Morgagni,  Boerhaave,  and  Diemerbroek  are  said 
to  have  been  examples — are  insusceptible  of 
small-pox. 

Anatomical  Characters. — Small-pox  is  the 
result  of  a specific  morbid  poison,  which,  after  a 
period  of  incubation  of  about  thirteen  days,  pos- 
sibly sometimes  less,  manifests  itself  by  high 
fever  and  an  eruption  on  tho  skin.  The  erup- 
tion is  sometimes  preceded  by  rashes  of  an  ery- 
sipelatous, scarlet,  or  measly  character,  chiefly 


SMALL-POX. 

seen  on  the  lower  abdomen,  the  groins,  and 
the  upper  and  inner  part  of  the  thighs,  along 
the  sides  of  the  chest  and  about  the  axillae. 
Sometimes  they  are  seen  upon  the  face  and 
neck,  and  occasionally  they  cover  the  body.  They 
are  distinguished  from  the  haemorrhagic  rashes 
by  the  absence  of  blue-black  spots,  and  are 
usually  associated  with  the  milder  cases.  ‘As 
regards  the  skin-eruption,  the  papules  are  due, 
in  the  first  instance,  partly  to  punctiform  hy- 
peraemia  of  the  cutis,  over  which  the  epider- 
mic cells,  andmore  especially  those  of  the  super- 
ficial portion  of  the  rete  mucosum,  become 
swollen.  By  degrees,  serous  fluid  is  poured  out 
into  the  substance  of  the  affected  epidermis, 
raising  the  homy  layer  from  the  swollen  group 
of  cells  below,  but  detaching  it  imperfectly,  so 
that  a number  of  small  irregular  intercommuni- 
cating serous  cavities  are  produced.  But  soon 
suppuration  occurs  in  tho  subjacent  rete  mu- 
cosum, and  the  pus-corpuscles  then  rapidly  diffuse 
themselves,  and  the  pock  is  converted  into  a 
pustule.  The  umbilicated  character  which  is  so 
common  is  due  to  the  presence  either  of  a hair  or 
of  a sudoriparous  gland,  the  connection  of  which 
with  the  subjacent  true  skin  has  not  yet  been 
destroyed.  The  suppurative  process  need  not 
implicate  the  true  skin  below ; but  not  unfre- 
quently  it  involves  and  destroys  it  to  a greater 
or  less  depth,  and  is  prolonged  inwards  along 
the  hairs  or  glands.  Under  the  former  circum- 
stances the  pustule  leaves  no  permanent  trace ; 
under  the  latter  a depressed  cicatrix  results, 
presenting  numerous  pits  upon  its  surface.’ 
(Bristowe,  Theory  and  Practice  of  Medicine.') 

Post-mortem  examination  shows  nothing  be- 
yond external  appearances,  special  to  small- 
pox, except  a trace  of  eruption  on  the  larynx  and 
vocal  cords.  The  blood  is  in  most  cases  imper- 
fectly coagulated,  and  in  black  cases  not  at  all. 
In  the  latter  ecchymoses  of  the  mucous  and 
serous  membranes  will  be  found.  Pleuritic 
effusions  and  pneumonic  consolidations  are  some- 
times found,  but  the  most  common  lung-compli- 
cation is  broncho-pneumonia.  In  variola  hsemor- 
rhagica  pustulosa  haemorrhage  is  generally  found 
in  the  substance  of  the  lungs,  heart,  kidneys, 
and  liver. 

Symptoms. — Small-pox  may  be  described  under 
six  forms:— (1)  discrete;  (2)  confluent;  (3) 
haemorrhagic  pustular;  (4)  malignant ; (5)  in- 
oculated ; (6)  small-pox  after  vaccination  and  re- 
vaccination (modified). 

(1)  Discrete. — In  the  discrete  form  the  disease 
begins  with  rigor,  fever,  lumbar  pain,  headache, 
and  sickness,  with  copious  perspirations;  fol- 
lowed by  an  eruption  on  the  forehead,  face,  and 
wrists.  This  is  usually  most  abundant  on  these 
parts,  next  most  abundant  on  the  hands  and 
feet,  and  least  so  on  the  limbs  and  trunk.  The 
eruption  is  followed  by  a remission  of  the 
general  symptoms,  and  a fall  of  temperature, 
which  continues  until  about  the  eighth  day,  which, 
in  this  article,  is  always  the  day  of  disease.  Be- 
tween the  third  and  the  eighth  days  the  pimples 
appear  on  the  extremities  and  the  trunk,  and 
change  into  greyish-white  vesicles,  circular,  flat- 
tened, depressed  in  the  centre,  and  surrounded 
by  a red  ring.  During  this  time  also  vesicle* 
may  be  seen  in  the  mouth  and  the  upper  part  of 


1441 


SMALL-POX. 


the  pharynx  and  larynx,  and  there  will  he  some 
soreness  in  these  parts.  On  the  eighth  day  some 
of  the  vesicles  become  pustular,  lose  their  central 
depression,  and  become  globular,  whilst  the  red- 
ness which  surrounds  them  becomes  more  marked. 
With  this  change  the  temperature  rises,  and  the 
general  symptoms  return  ; but  these  are  of  short 
duration,  for  the  pustules  either  dry  up  rapidly 
and  form  scales,  or  burst  and  form  scabs ; the 
temperature  falls  by  about  the  tenth  day ; and 
the  patient  is  then  convalescent,  fatal  results 
being  extremely  rare,  except  in  unvaccinated 
children  under  one  year.  When  the  crusts  have 
fallen,  and  the  desquamation  which  follows  them 
is  complete,  there  will  often  be  pitting. 

(2)  Confluent. — -In  this  form  the  initial  symp- 
toms are  essentially  the  same  as  the  former,  but 
more  severe.  The  eruption  appears  about  the 
same  time,  and  in  the  milder  varieties  is  dis- 
crete until  the  disease  has  reached  the  vesicular 
or  the  pustular  stage  ; but  in  the  more  severe 
forms  it  is  confluent  from  the  first,  and  instead 
of  showing  distinct  closely  packed  papules,  the 
whole  face  is  swollen,  presenting  the  appearance 
of  a tense  elastic  mass.  When  the  eruption  is 
well  out  the  temperature  falls,  and  the  general 
symptoms  remit,  but  to  a less  extent  than  in 
the  discrete  variety,  and  this  remission  continues 
until  about  the  eighth  day.  Up  to  this  time 
more  or  less  delirium  is  present  in  many  cases, 
and  it  is  sometimes  maniacal  and  suicidal  in  cha- 
racter: drowsiness  and  stupor  sometimes  bike 
its  place,  and  occasionally  alternate  with  it.  On 
this  day,  the  eighth,  the  vesicles  begin  to  be- 
come pustular,  the  areola  to  deepen,  the  tem- 
perature to  rise,  and  the  general  symptoms  to 
return.  At  the  same  time  the  face  becomes 
extremely  swollen;  the  eyelids  close  from  cede- 
matous  swelling  ; saliva  flows  copiously  from  the 
mouth ; the  glands,  and  the  subcutaneous  tissue 
of  the  neck  and  lower  jaw  enlarge;  and  the 
early  delirium  usually  disappears.  One  of  three 
things  may  now  take  place: — (1)  the  disease 
may  go  on  regularly  to  the  eleventh  day;  (2)  the 
development  of  the  pustules  may  cease,  the  face 
remaining  flat,  of  an  opaque  white  colour ; or 

(3)  haemorrhage  may  take  place  into  the  skin 
beneath  the  vesicles,  and  from  the  mucous  mem- 
branes, that  is,  may  become  haemorrhagic  pustular. 
In  either  of  the  last  two  events  death  is  almost  in- 
variable, and  often  rapid.  Inthe  first  the  swelling 
of  the  face  increases  for  the  next  three  clays,  during 
which  time  the  vesicles  become  pustular,  and  the 
hands  and  feet  swell.  There  will  be  increased 
sore-throat,  increased  salivation,  great  thirst, 
sleeplessness,  delirium,  rising  temperature,  and 
occasionally  laryngitis.  On  or  about  the  eleventh 
day  the  temperature  and  the  general  symptoms 
will  have  reached  their  height,  the  pustules  will 
discharge  their  contents,  and  crusts  will  form. 
After  this,  in  favourable  cases  the  temperature 
will  begin  to  fall,  and  the  symptoms  of  the  so- 
called  ‘ secondary  fever  ’ to  decline.  By  the  four- 
teenth day  crustation  will  be  complete  on  the  face, 
where  it  is  most  commonly  found,  the  general 
symptoms  will  have  disappeared,  the  temperature 
will  have  become  normal,  and  convalescence  es- 
tablished. In  unfavourable  cases  it  is  about  this 
time,  the  eleventh  day,  that  death  usually  occurs. 
It  is  preceded  by  low  delirium,  variable  tempera- 

91 


ture,  subsultus,  involuntary  motions,  and  occa- 
sionally haemorrhage  into  the  skin  and  the  pus- 
tules. When  the  crusts,  which  in  this  form  are 
often  retained  many  weeks,  fall  off,  and  when  the 
desquamation  is  complete,  there  is  pitting,  which, 
at  first  of  a reddish-brown  colour,  in  process  ot 
time  becomes  white. 

(3)  Haemorrhagic,  pustular,  or  vesicular. — 
This  form  of  small-pox  constitutes  the  connect- 
ing link  between  the  confluent  and  the  malignant. 
With  the  latter  it  is  often  confounded,  and 
hence  true  malignant  has  sometimes  been  said  to 
end  in  recovery.  It  is  characterised  by  haemor- 
rhage into  the  skin  beneath  the  vesicles  or  the 
pustules.  There  are  generally  petechise,  some- 
times ink-spots,  and  often  subcutaneous  haemor- 
rhage. Recovery  is  very  rare.  Death  may  take 
place  in  the  vesicular  or  the  pustular  stage. 

(4)  Malignant. — Svxon. : Variolanigra ; Va- 

riola hcBmorrhagica ; Black  Small-pox ; Purpura 
variolosa.— This  form  is  invariably  fatal.  Its 
distinguishing  features  are  haemorrhage  into  the 
skin,  and  irregularity  in  the  form  of  the  erup- 
tion. The  illness  commences  with  the  ordinary 
symptoms,  but  accompanied  by  marked  lumbar 
pain,  prsecordial  anxiety,  and  coldness  of  the 
extremities.  This  is  followed,  about  the  third  or 
fourth  day,  by  ecchymosis  into  the  conjunctive, 
and  a purpuric  or  scarlatiniform  rash,  sometimes 
covering  the  whole  body,  but  most  marked  over 
the  lower  abdominal  region,  and  the  upper  and 
inner  part  of  the  thighs,  in  which  rash  large  and 
small  dark  blue,  deep  violet,  or  black  spots  are 
seen.  The  ordinary  eruption  is  sometimes  entirely 
absent,  or  when  present  is  very  meagre  and  much 
modified.  In  the  majority  of  cases  it  is  limited 
to  a few  scattered  vesicles,  more  often  found  on 
the  fingers  and  toes  than  elsewhere.  With  these 
appearances  there  will  often  be  found  on  the  skin 
hard  tumours,  of  variable  size,  of  the  same  colour 
as  the  spots ; and  from  one  or  more  of  the  mucous 
surfaces  there  will  be  bleeding.  Death  some- 
times takes  place  as  early  as  the  third  day, 
most  commonly  on  the  fifth,  rarely  later  than 
the  seventh.  The  temperature  usually  fluctuates 
about  102°(Fahr.),  sometimes  reaches  104°,  and 
is  sometimes  nearly  normal  during  the  whole 
course  of  the  disease.  The  mind  is  almost  always 
clear  throughout.  This  form  of  small-pox  has 
received  so  little  mention  of  late  years,  although 
it  is  well  described  by  Sydenham,  that  the 
writer  thinks  notes  of  a few  cases  will  be  use- 
ful set.  24,  unvaccinated.  Condition  on 

fourth  day : — Very  restless,  pulseless ; losing 
blood  from  vagina ; repeated  vomiting ; some 
papular  eruption  with  ink-black  spots  ; bruise 
about  the  size  of  a shilling  over  the  insertion  of 
the  right  deltoid.  Mind  clear.  Fifth  day : — 
Patient  called  the  nurse,  who  had  just  left  the 
bedside,  on  immediately  returning  to  which  she 
found  the  patient  dead.  J.  W.,  set.  28.  One 
fair  vaccination-mark  and  one  bad.  Illness  com- 
menced with  lumbar  pain  and  vomiting.  On  the 
fourth  day : — Face  red  and  swollen  ; papular 
eruption  on  hands,  and  general  erythematous 
rash,  with  spots  like  leech-bites ; haemoptysis  ; 
temperature  100-4°.  Mind  clear.  Sixth  day: — 
Left  eye  black  ; blue  spots  on  face;  hsematuria; 
haemoptysis;  feeble  pulse;  temperature  99°; 
death.  J.L.,  set.  23,  three  good  vaccination-marks. 


1442 


SMALL-POX. 


On  fourth  day : — Anxious  and  restless,  with 
general  scarlatinous  rash,  most  marked  over  the 
groins  and  lower  abdomen,  of  a brick-red  colour, 
with  many  lead-coloured  spots;  face  natural, 
except  for  conjunctival  ecchymosis  and  bruised 
eyelids  ; lead-coloured  spots  on  the  sides  of  the 
trunk  and  borders  of  the  axilla;  petechiae  on 
legs  ; a few  vesicles  between  the  shoulders ; mind 
clear;  temperature  101°;  continued  much  the 
same  until  the  morning  of  the  seventh  day,  when 
haemoptysis  occurred,  and  the  patient  died ; tem- 
perature 98‘0°.  This  form  of  small-pox  occurs 
at  all  ages,  and  in  both  sexes.  It  is  never  found 
in  well-vaccinated  subjects  under  fifteen,  nor  in 
those  who  have  been  efficiently  revaccinated 
about  that  age. 

(5)  Inoculated. — On  the  second  day  of  in- 
oculation a pimple  rises,  which  by  the  fourth  has 
developed  into  a vesicle,  and  by  the  seventh  or 
eighth  into  a pustule,  when  the  patient  has  rigors, 
swelling  and  pain  in  the  axillary  glands,  and 
more  or  less  fever,  followed  on  the  eleventh  day 
by  the  ordinary  small-pox  eruption  (Bristowe), 
which  passes  through  the  usual  stages.  The  in- 
oculated pustule  attains  full  development  on  or 
about  the  eleventh  daj',  and  by  the  fourteenth 
there  will  be  a crust.  The  characteristic  of  the 
disease  thus  induced  is  its  mildness.  It  pro- 
tects from  small-pox  in  the  same  degree  as  first 
attacks  of  that  disease  protect  from  second 
attacks.  The  objections  to  it  are  (1)  that  small- 
pox so  induced  is  infectious;  and  (2)  that  it  is 
sometimes  fatal. 

(6)  Small-pox  after  Vaccination  and  He- 
vaccination.  (a)  After  vaccination. — Speaking 
generally  it  may  be  said  that  good  vaccination 
protects  from  small-pox,  and  that  when  it  does 
not  protect  absolutely'  it  renders  the  disease 
milder,  the  disfigurement  less  marked,  and  re- 
duces the  mortality  directly  as  the  efficiency  of 
the  vaccination  and  revaccination.  Persons  under 
fifteen  years  of  age  with  two  good  cicatrices  are 
very  rarely  the  subjects  of  severe  small-pox,  and 
if  they  contract  it,  death  is  almost,  if  not  quite 
unknown.  After  this  age,  however,  certain,  chiefly' 
inefficiently  vaccinated,  persons  become  again 
susceptible,  and  the  disease  in  some  of  these 
is  occasionally  severe.  Post-vaccinal  small-pox 
may  be  described  under  the  following  three 
forms : — (1)  In  one  class  of  cases  there  is  more 
or  less  feeling  of  illness,  headache,  slight  fever, 
possibly  some  lumbar  pain,  followed  on  the  third 
day  by  a sparse  eruption  of  papules,  which  abort 
and  soon  disappear.  (2)  In  another  class  there 
are  severo  initial  symptoms,  followed  on  the  third 
day  by  an  eruption  of  papules,  and  a remission 
of  the  fever.  On  the  fifth  day  the  papules  will 
have  become  vesicles,  which  in  a day'  or  two  dry 
up  without  any  recurrence  of  fever,  leaving  the 
patient  convalescent  at  the  end  of  a week.  (3) 
In  a third  class  the  initial  symptoms  are  very 
severe,  sometimes  indistinguishable  from  those 
of  confluent  small-pox,  and  they  last  forty-eight 
hours,  after  which  an  abundant  eruption  comes 
out,  the  whole  face  swelling  as  in  severe  con- 
fluent. The  temperature  now  falls,  and  the  dis- 
ease in  some  cases  will  abort  at  this  stage ; in 
others  it  will  go  on  to  the  vesicular  stage  and 
then  abort,  the  patient  becoming  convalescent 
about  the  end  of  a week,  without  any  recurrence 


of  fever.  In  the  case  of  adults  who  have  beea 
vaccinated  only  in  infancy,  and  in  children  who 
have  been  badly  vaccinated,  the  disease  may  run 
an  unmodified  course  and  end  fatally. 

(b)  After  revaccination  (successful).  Small- 
pox, after  this,  is  practically  unknown.  Daring 
the  epidemic  of  1871,  110  persons  were  engaged 
in  the  Homerton  Fever  Hospital  in  attendance 
upon  the  small-pox  sick ; all  these,  with  two  ex- 
ceptions, were  revaccinated,  and  all  but  these 
exceptions  escaped  small-pox.  The  experience 
of  the  epidemic  of  1876-77  was  of  the  same 
kind,  all  revaccinated  attendants  having  escaped, 
whilst  the  only  one  who  had  not  been  vaccinated 
took  the  disease  and  died  of  it.  So,  in  the  epi- 
demic of  1881,  of  SO  nurses  and  other  attendants 
of  the  Atlas  Hospital  Ship  (small-pox)  the  only 
person  who  contracted  small-pox  was  a house- 
maid who  had  not  been  revaccinated.  At  the 
same  time  a single  efficient  revaccination  about 
puberty  is  not,  in  the  writer’s  opinion,  an  effec- 
tual protection,  even  against  death,  for  all  time. 

Coursk,  Termination,  Complications,  and 
Sequel®. — In  the  discrete  form  of  small-pox  the 
great  majority  of  cases  recover;  half  of  the 
confluent  cases  die  about  the  eleventh  day,  and 
the  malignant  cases  invariably  die.  In  small-pox 
modified  by  vaccination  the  course  of  the  disease 
will  depend  upon  the  quantity  and  quality  of 
this,  as  shown  by  the  marks.  If  these  be  of  the 
best  kind,  three  or  four  in  number,  and  in  a pa- 
tient under  fifteen,  the  disease  is  invariably  mild. 
In  some,  however,  who  have  passed  puberty,  the 
best  primary  vaccination  loses  in  power;  but 
nevertheless,  it  almost  invariably  modifies  the 
disease,  and  when  death  occurs  it  is  usually  due 
to  some  accidental  complication.  Of  complications, 
laryngitis,  bronchitis,  pneumonia,  and  in  particu- 
lar broncho-pneumonia,  are  the  most  common. 
Glossitis  occurs  occasionally.  On  two  occasions 
the  writer  has  met  with  cerebral  symptoms, 
which  were  shown  after  death  to  depend  upon 
cerebral  haemorrhage.  Aphasia  with  right  hemi- 
plegia he  has  seen  twice;  and  once  a condition 
like  dementia,  shown  after  death  to  depend  upon 
thrombosis  of  the  basilar  artery.  In  the  cases 
of  cerebral  haemorrhage  the  eruption  was  not 
fully  developed,  hut  at  the  time  of  death  they 
did  not  seem  likely  to  become  cases  of  extreme 
confluence.  One  was  in  a girl  twenty-one  years 
of  age,  with  two  good  vaccination-marks  ; and 
the  other  in  a boy  of  eight  with  four  fair  marks. 
In  both  cases  the  event  occurred  in  patients 
who  suddenly  became  dangerously  ill,  and  the 
seriousness  of  whose  illness  could  not  be  as- 
cribed to  a small-pox  which  was  by  itself  mild. 
It  may  be  that  this  would  he  found  to  be  the 
immediate  cause  of  death  in  other  cases,  if 
post-mortem  examination  were  more  frequent 
and  complete.  It  has  been  said  that  small-pox 
is  occasionally  complicated  with  scarlatina  or 
measles ; and  Dr.  Murchison,  Professor  Monti 
of  Vienna,  Dr.  Theodore  Simon  of  Hamburg, 
Mr.  Marson.  late  of  the  London  Small-pox  Hos- 
pital, and  others  have  published  cases  in  support 
of  this.  There  is  no  doubt  that  eruptions  in- 
distinguishable from  those  of  scarlatina  and 
measles,  appear  in  many  cases  of  variola ; but 
whether  the  presence  of  such  eruptions,  which 
are  hut  one  symptom,  constitute  evidence  uper 


SMALL-POX. 


ivhich  to  maintain  the  co-existence  of  two  speci- 
fically distinct  diseases — an  opinion  which  has 
the  support  of  Trousseau  ( Clinique  Medicate, 
vol.  i.  'p.  32,  edition  1868) — may  be  doubted. 
Pregnancy  has  been  said  to  be  a grave  com- 
plication of  small-pox.  It  is  certain,  however, 
that  many  pregnant  women  recover  without  in- 
jury ; lut  abortion  in  confluent  cases  is  often 
fatal,  on  account  of  the  attendant  bleeding.  Of 
sequelae  the  most  common  is  pitting.  Mania  and 
dementia  are  occasionally  seen.  Erysipelas,  ab- 
scesses, gangrene  of  the  extremities,  particularly 
the  tips  of  the  hands  and  feet,  enlargement  of  the 
glands  of  the  neck,  conjunctivitis,  iritis,  perfor- 
ating ulcer  of  the  cornea,  are  not  uncommon,  and 
then  occasionally  one  or  both  eyes  may  be  de- 
stroyed. The  specific  small-pox  eruption,  however, 
never  appears  on  the  corneal  conjunctiva.  The 
changes  which  take  place  in  the  eye  are  late  in 
■.he  disease,  and  in  all  probability  due  to  defective 
nutrition.  Otitis,  parotitis,  orchitis,  and  ovaritis 
occur  sometimes  ; and  pyaemia  occasionally. 

Diagnosis. — This  cannot  be  made  with  cer- 
tainty until  the  eruptiou  appears.  Fever,  head- 
ache, lumbar  pain,  and  vomiting  during  the  time 
of  an  epidemic  of  smdl-pox,  should  arouse  sus- 
picion ; and  should  these  be  followed  after 
forty-eight  hours  by  an  eruption  of  papules  on 
the  forehead,  face,  and  wrists,  the  diagnosis  may 
beconsidered  certain.  The  difficulty  of  exact  diag- 
nosis depends  on  the  fact  that  in  many  cases  all 
the  main  features  are  not  present  together,  and 
that  one  begins  to  trust  to  the  existence  of  some 
one  prominent  symptom.  Fever  with  headache, 
oackache,  and  vomiting  may  occur  in  continued 
fevers ; but  the  later  appearance  of  the  eruption, 
and  the  fact  that  it  is  not  found  in  the  situations 
in  which  that  of  small-pox  occurs,  ought  to  nega- 
tive the  idea  of  small-pox.  Small-pox  is  occasion- 
ally preceded  by  eruptions  which  simulate  those 
of  measles,  scarlatina,  or  erysipelas,  and  these 
eruptions  are  associated  with  fever  and  other 
symptoms  of  constitutional  disturbance.  If  the 
disease  be  small-pox,  the  eruption  will  change 
within  twenty-four  or  thirty-six  hours,  or  will 
show  signs  of  malignancy.  Pyaemia,  glanders,  and 
acute  rheumatism  with  a pustular  eruption,  may 
also  be  mistaken  for  small-pox,  but  attention  to 
the  history  of  the  case  will  be  enough  to  enable 
one  to  form  a correct  opinion.  So  far  as  erup- 
tion alone  may  lead  to  error,  the  point  for  diag- 
nosis turns  on  the  query,  Could  the  eruption 
have  reached,  or  would  it  not  have  gone  beyond 
its  existing  stage,  if  the  disease  on  which  it 
depended  were  small-pox  ? Of  eruptions  unat- 
tended by  general  symptoms,  syphilides,  acne, 
eczema,  erythema,  and  urticaria  are  most  fre- 
quently mistaken  for  small-pox  ; but  mistakes  of 
this  kind  may  in  most  cases  be  avoided  by  a 
careful  consideration  of  the  history.  Lumbar 
pain  is  found  with  fever  in  pneumonia,  but  phy- 
sical examination  of  the  chest  ought  to  settle  the 
question;  moreover,  there  is  no- eruptiou  beyond 
occasional  herpes.  In  lumbago  there  is  no  fever. 
Labour-pains  are  unattended  by  fever ; more- 
over, they  usually  come  on  gradually  and  in  the 
belly  first,  and  are  not  constant.  It  must  be 
borne  in  mind,  however,  that  pregnant  women, 
when  suffering  from  small-pox,  may  have  labour- 
pains  and  the  initial  symptoms  of  small-pox  con- 


1443 

currently.  Cases  of  black  or  malignant  small- 
pox will  present  little  difficulty ; but  if  scarla- 
tina, measles,  and  typhus  prevail  at  the  same 
time,  there  will  be  gieat  difficulty  in  arriving  at 
an  exact  diagnosis  as  to  which  form  of  malig- 
nant fever  exists  in  the  case  under  observation. 
The  diagnosis  from  chicken-pox  has  been  treated 
of  in  that  article.  See  Chicken-pox. 

Phognosis. — This  will  have  been  gathered 
from  what  has  preceded.  Small-pox  is  most 
fatal  in  unvaccinated  children  under  five,  and  in 
adults  over  thirty.  At  these  periods  of  life  half 
or  more  may  die.  The  lowest  mortality  in  the 
unvaccinated  occurs  from  ten  to  fifteen.  The 
discrece  form  is  rarely  fatal  in  adults,  but  it  is 
so  occasionally  when  it  occurs  in  unvaccinated 
children.  Half  of  the  confluent  cases  will  die. 
and  of  the  malignant  all,  and  nearly  all  children 
under  one  year,  whatever  form  the  disease  may 
assume.  As  regards  vaccination  in  prognosis,  it 
may  be  stated  generall}’  that  the  unvaccinated 
will  die  at  the  rate  of  about  50  per  cent.,  the 
badly  vaccinated  at  the  rate  of  about  26  per  cent., 
and  the  well  vaccinated  at  the  rate  of  about  2’3 
per  cent.  See  Vaccination. 

Treatment. — There  is  no  specific  for  small- 
pox, its  complications  or  sequela;,  and  the  treat- 
ment is  therefore  to  be  conducted  on  general 
principles.  The  following  are  points  of  im- 
portance : — (1)  The  patient  should  be  placed  in 
a large,  well-ventilated  room.  He  should  be 
fed  at  intervals  on  easily  digestible  food,  such  as 
milk,  beef-tea,  chicken  broth,  and  eggs  beaten 
up  ; and  occasionally,  according  to  habit,  a little 
wine  or  spirit  may  be  given.  He  should  be  per- 
mitted to  drink  iced  water  or  iced  lemonade  as 
he  pleases.  He  should  have  a feather-bed,  the 
sheets  ought  to  be  of  the  softest  material,  and 
the  coverings  light ; and  there  should  be  two 
beds  in  the  room,  in  order  that  the  patient  may 
be  changed  daily.  (2)  Two  competent  nurses 
should  be  obtained,  one  to  attend  the  patient  by 
day,  the  other  by  night,  and  these  should  never 
for  a moment  lose  sight  of  him.  (3)  The  hair 
should  be  cut  short.  (4)  Heat  of  skin  should  be 
relieved  by  cold-water  sponging,  and  the  swell- 
ing of  the  eyelids  and  other  painful  parts  by  the 
constant  application  of  cold  compresses.  (5)  To 
relieve  itching  olive  oil  may  be  used,  or,  what  is 
better,  vaseline,  which  applied  as  a dressing  to 
the  face  will  facilitate  the  removal  of  scabs  : 
and  to  destroy  the  disagreeable  odour,  some  kind 
of  deodorant,  such  as  sanitas  powder,  should 
be  sprinkled  about  and  over  the  patient’s  face 
and  bed.  (6)  To  procure  sleep,  opium  ; or  some 
form  of  alcohol,  diluted  with  warm  water,  mav 
be  given.  (7)  Salivation  should  not  be  inter- 
fered with,  but  the  mouth  should  be  kept  clean, 
and  sedatives  avoided  during  its  continuance. 
(8)  When  delirium  is  marked,  in  addition  to  the 
nurse  there  should  be  an  attendant,  one  accus- 
tomed to  deal  with  lunatics,  and  of  some  bearing 
if  possible.  Mechanical  restraint  should  be 
avoided,  and  the  ‘strait  jacket’  and  ‘tying 
down’  strictly  forbidden.  The  patient  ought 
not  to  be  left  for  one  moment  alone,  otherwise 
he  may  have  to  be  looked  for  wandering  along 
some  street,  or  drowned  in  the  nearest  water- 
course. He  should  never  be  argued  with,  and 
never  flatly  contradicted.  If  he  should  imagine 


1U4  SMALL-POX. 

tiis  attendants  are  bent  upon  injuring  or  killing 
him,  they  should  be  changed.  If  he  be  excited  by 
the  mere  presence  of  others,  as  may  happen  in 
hospital  wards,  he  should  be  treated  by  himself 
in  a dark  room.  Should  he  persist  in  getting 
out  of  bed  and  putting  on  his  clothes,  in  walk- 
ing about  his  room,  or  in  sitting  over  the  fire, 
he  should  be  permitted  to  do  so,  for  to  the 
fretted  and  fevered  patient  moving  about  is  a 
relief.  In  maniacal  delirium  chloroform  may  be 
administered.  (9)  The  eyes  should  be  carefully 
watched,  and  in  severe  cases  an  ophthalmic 
surgeon  should  be  consulted.  (10)  About  the 
eleventh  day  laryngitis  often  supervenes,  and 
for  this  tracheotomy  should  be  performed  when 
there  arises  distinct  difficulty  of  breathing. 
Although  in  the  majority  of  such  cases  the 
patient  dies,  the  relief  from  suffering  is  so  great 
that  the  operation  should  be  performed.  (11) 
When  crusts  begin  to  form  about  the  nostrils 
they  should  be  removed,  and  generally  the  pa- 
tient should  bo  kept  in  bed  until  suppuration 
under  the  crusts  has  ceased  and  the  skin  is 
healed.  (12)  Abscesses  should  be  opened  when 
they  appear,  and  a water-bed  should  be  ordered 
at  the  same  time.  (13)  The  patient  may  be  dis- 
charged safely  when  the  crusts  and  scales  have 
disappeared,  and  not  less  than  six  baths  have 
been  given,  at  intervals  of  two  days.  Such  is 
the  general  treatment  of  confluent  small-pox  ; in 
the  discrete  kind  little  is  needed ; in  the  malig- 
nant none  is  of  any  avail. 

The  prophylaxis  of  small-pox  is  discussed 
under  Vaccination.  Alex.  Collie. 

SMELL,  Disorders  of.  See  Nose,  Diseases 
of;  and  Olfactory  Nerve,  Morbid  Conditions 
of. 

SNAKE-POISONS.  See  Venomous  Ani- 
mals. 

SNEEZING,  Excessive.  — Syxon.  ; Fr. 
Coryza  spasmodiquc ; Ger.,  Nieselcrampf. 

Definition. — An  affection  characterised  by 
frequent  and  uncontrollable  attacks  of  sneezing, 
out  of  all  proportion  to  the  nasal  secretion. 

^Etiology. — The  causes  of  excessive  sneezing 
may  be  broadly  classified  as  extrinsic  and  in- 
trinsic. Extrinsic  causes  include  especially  va- 
rious vegetable  substances  in  the  form  of  pow- 
der, of  which  tobacco-snuff  is  the  type,  and  the 
pollen  of  certain  plants  ( see  Hay  Fever).  The 
intrinsic  conditions  in  connexion  with  which 
the  affection  occurs  vary  considerably.  In  some 
cases  it  is  associated  with  whooping-cough  and 
asthma,  and  it  is  not  uncommon  in  gouty  persons. 
It  is  sometimes  a symptom  of  the  hysterical  con- 
dition, and  not  unfrequently  associated  with  dis- 
ordered menstruation,  or  some  other  derange- 
ment of  the  sexual  functions.  It  has  been  met 
with  in  pregnancy,  and  even  during  more  than 
one  pregnancy  in  the  same  person,  ceasing  in  the 
intervals,  and  has  been  supposed  to  replace 
morniDg-sickness  (Barnes).  In  some  persons  a 
bright  light  or  intense  colour  is  sufficient  to 
determine  an  attack  of  sneezing. 

Symptoms. — The  morbid  sneezing  has  no  special 
.characters.  It  is  distinctly  a reflex  act,  being 
excited  usually  by  some  slight  impression  on  the 
•fifth  nerve.  A slight  catarrhal  condition  of  the 


SOFTENING. 

nasal  mucous  membrane  is  common.  The  secre- 
tion has  been  thought  to  be,  in  some  cases,  of  a 
specific  character,  analogous  to  that  of  hay  fever. 

Treatment. — The  attack  itself  maybe  usually 
cut  short  by  a strong  impression  on  some  branch 
of  the  fifth  nerre;  when  this  fails,  a mustard 
poultice  to  the  back  of  the  neck,  or  an  emetic, 
may  be  employed.  Atomised  astringent  nasal 
inhalations,  or  the  vapours  of  creasote  or  iodine 
are  useful.  The  immersion  of  the  head  in  cold 
water  has  been  recommended.  Any  irregularity 
in  the  functions  of  the  genital  or  other  organ’s 
must  be  attended  to ; and  iron,  quinine,  and 
arsenic,  if  not  otherwise  objectionable,  are  useful 
in  removing  the  liability  to  the  complaint.  See 
Catarrh  ; and  Hay  Fever.  W.  E.  Gowers. 

SNUFFLES. — A popular  term  for  the 
condition  in  which  a nasal  discharge  exists  in- 
children  suffering  from  congenital  syphilis.  See 
Syphilis. 

SODEN,  in  Taunus,  Germany.  — Common 
salt  waters.  See  Mineral  Waters. 

SOFTENING. — Syxon.  : Fr.  EamoUisse- 
ment ; Ger.  Erwcichung. — A term  of  pathological 
significance,  implying  that  an  organ  ortissuehas 
a degree  of  consistence  less  than  that  which  is 
natural  to  it.  This  is  a condition  which  occurs 
in  various  organs  or  parts  (1)  as  a result  of 
pathological  changes  during  life ; and  (2)  as  a 
consequence  of  different  post-mortem  influences. 

(1)  Intra-vitam  softening. — With  regard 
to  the  first  order  of  changes,  the  brain  and  the 
spinal  cord  are  the  organs  in  which  these  condi- 
tions are  most  common,  and  in  which  it  is  apt  to 
assume  its  most  typical  characters  ( see  Brain, 
Softening  of ; and  Spinal  Cord,  Softening  of). 
It  occurs  also  in  the  osseous  system  (see  Boxes, 
Diseases  of).  The  liver  and  spleen  may  like- 
wise be  softer  than  natural,  and  so  may  the 
mucous  membrane  of  the  stomach  or  intestines, 
or  the  tissue  of  the  heart.  In  nearly  all  such 
cases  the  principal  cause  of  this  diminished  con- 
sistence is  a fatty  degeneration  or  infiltration, 
associated  with  more  or  less  of  serous  infiltration 
(see  Fatty  Degeneration,  and  the  diseases  of 
the  several  organs  mentioned).  This  pathological 
condition  is  the  reverse  of  those  conditions  of 
induration  known  by  the  name  of  sclerosis  in 
some  organs,  and  cirrhosis  in  others.  Sec  Scle- 
rosis. 

(2)  Post-mortem  softening. — The  softening 
due  to  the  definite  pathological  processes  just 
referred  to  as  occurring  during  life,  has  to  be 
clearly  discriminated  from  certain  softenings 
which  may  supervene  after  death  as  a result  of 
traumatisms  or  mere  post-mortem  changes.  Thus 
the  tissue  of  the  brain  or  of  the  spinal  cord,  in 
some  parts,  may  be  diminished  in  consistence, 
and  rendered  more  or  less  pulpy,  owing  to  its 
Laving  been  bruised  during  the  operations  neces- 
sary for  exposing  these  organs  to  view.  The 
same  organs  likewise  diminish  in  consistence  by 
mere  lapse  of  time  after  death,  and  the  more 
quickly  in  proportion  to  the  heat  of  the  weather. 
In  the  stomach  also  post-mortem  softenings  are 
most  prone  to  show  themselves,  should  the  oKnn 
contain  gastric  juice  at  the  time  of  death.  Here 
we  get  softening  first,  and  afterwards  solution  of 


SOFTENING. 

the  mucous  membrane  and  other  tissues  of  the 
organ.  See  Stomach,  Softening  of. 

H.  Charlton  Bastian. 

SOLIS  ICTUS  (Latin).— A synonym  for 
sunstroke.  See  Sunstroke. 

SOMNAMBULISM. — Sleep-walking.  See 
Sleep,  Disorders  of. 

SOMNILOfiUT.  — Sleep-talking.  See 
Sleep,  Disorders  of. 

SOMN  OLEN CE.  — An  unnatural  drowsiness 
or  disposition  to  sleep.  See  Sleep,  Disorders  of. 

SONOROUS  BALE.  — A variety  of  dry 
rale  or  rhonehus,  of  a low-pitched  character, 
resembling  snoring  and  similar  sounds,  and  pro- 
duced in  the  larger  air-tubes.  See  Physical 
Examination  ; and  Rhonchus. 

SOPOR  (Lat.).— An  unnatural  deep  sleep, 
from  which  the  patient  can  only  be  roused  with 
difficulty.  See  Consciousness,  Disorders  of. 

SOPORIFICS  (sopor,  heavy  sleep).-SYNON. : 
Fr.  Soporifiques ; Soporativcs  ; Ger.  Einschla- 
fernde  Mittel. — A synonym  for  hypnotic  agents. 
See  Narcotics. 

SORDES  (Lat.,  filth).— Definition.— Crusts 
which  form  upon  the  lips  and  teeth  of  persons 
suffering  from  extreme  exhaustion. 

Description.— Sordes  occur  commonly  in  what 
is  called  the  typhoid  state,  whether  this  be 
due  to  typhoid  or  puerperal  fever,  pneumo- 
nia, or  any  like  disease.  They  appear  first  as 
.bin,  light-yellowish  crusts  upon  the  prolabia, 
generally  in  close  proximity  to  the  teeth;  gradu- 
ally increase  in  thickness  and  in  area ; and, 
changing  their  colour  to  brown,  or  even  black, 
at  length  extend  to  the  adjacent  surfaces  of  the 
teeth.  They  seldom  or  never  cover  those  por- 
tions of  the  teeth  which  are  hidden  by  the  lips, 
but  spread  over  their  exposed  surfaces  ; so  that, 
as  the  patient  lies  with  slightly  parted  lips,  they 
bridge  over  the  interval  in  the  form  of  a narrow 
band  upon  the  middle  of  the  incisors  of  the 
upper  jaw.  When  the  lips  are  more  widely 
separated,  the  sordes  do  not  extend,  unless  in 
conditions  of  extreme  exhaustion,  over  the  whole 
of  the  exposed  surfaces  of  the  teeth,  but  form 
two  ridges,  corresponding  with  the  margins  of 
the  upper  and  lower  lips. 

Sordes  are  composed  of  various  schistomycetes, 
mingled  with  debris  of  food  and  epithelium. 
Micrococcus  occurs  almost  constantly  ; bacillus 
subtilis  frequently ; and  the  writer  has  found, 
each  in  a single  instance,  sarcina  ventrieuli  and 
spirochseta  plicatilis. 

Pathology  and  TEEATMENT.-These  organisms, 
which  are  of  constant  occurrence  on  the  papil- 
lary surface  of  the  healthy  tongue,  are  easily 
dislodged  from  the  smooth  lips  and  teeth.  Eut 
in  conditions  of  great  prostration,  especially  when 
the  prostration  is  associated  with  delirium,  the 
slight  frictions  necessary  for  their  removal  are 
not  made,  and  they  obtain  so  firm  a hold  that 
they  can  only  be  removed  by  careful  and  re- 
peated cleansing.  Such  cleansing  may  with  ad- 
vantage be  performed  with  a piece  of  soft  rag,  or 
ft  brush  dipped  in  a weak  solution  of  Condy’s 
fluid.  II  EKE Y T.  Butlin. 


SPASM.  1445 

SORE-THROAT.  — A popular  name  for 
various  affections  of  the  pharynx,  larynx,  and 
tonsils.  See  Larynx,  Diseases  of;  Pharynx, 
Diseases  of ; Throat,  Diseases  of ; and  Tonsils, 
Diseases  of. 

SOUFFLE  (Fr.). — A soft,  blowing  sound. 
The  term  is  applied  either  to  the  respiratory 
murmur  heard  over  the  lungs;  or  to  certain 
murmurs  heard  in  connection  with  the  heart  or 
blood-vessels.  See  Physical  Examination. 

SOULZMATT,  in  France. — Alkaline  table- 
water.  See  Mineral  W aters. 

SFA,  in  Belgium. — Iron  waters.  See  Mine- 
ral Waters. 

SPAIN,  Southern.  See  Malaga  ; and 
Climate,  Treatment  of  Disease  by. 

SPANB3MIA  (avavbs,  rare,  and  ai/ia, 
blood). — A condition  of  blood,  in  which  the 
amount  of  its  solid  constituents  is  below  the 
normal,  the  blood  then  appearing  thin.  See 
An/Emia  ; and  Blood,  Morbid  Conditions  of. 

SPAS.  See  Mineral  Waters. 

SPASM. — Synon.  : Fr.  Spasme;  Ger.  Krampf. 
Definition. — A name  given  to  abnormal  con- 
traction, occurring  either  in  muscular  organs,  in 
single  muscles,  or  in  groups  of  muscles. 

1.  Spasm  of  muscular  organs. — Concerning 
spasms  of  organs  not  much  requires  to  be  said 
here.  We  may  cite  as  instances  those  spasms 
which  occur  in  the  pharynx  in  hydrophobia  ; the 
contractions  of  the  oesophagus  in  cesophagismus 
and  in  some  cases  of  hysteria ; the  painful  con- 
tractions of  the  intestine  which  are  presumed 
to  occur  in  certain  cases  of  colic ; of  the  lower 
end  of  the  rectum  in  tenesmus ; of  the  bladder 
or  of  the  urethra  in  certain  cases  of  inflamma- 
tion with  irritability ; of  the  vagina  in  vaginis- 
mus; of  the  uterus  in  rare  cases  of  sudden  abor- 
tion resulting  from  shock  ; possibly  of  the  heart 
in  certain  diseases  of  that  organ;  of  the  vessels 
in  various  regions  of  the  body,  and  on  various 
occasions,  from  over-action  of  vaso-motor  nerves  ; 
of  the  bronchial  tubes  in  certain  cases  of  asthma 
and  hay-fever ; of  the  glottis  in  laryngismus 
stridulus,  and  in  pertussis  ; as  well  as  of  the  gall- 
ducts  or  ureters  under  conditions  of  irritation, 
either  direct  or  reflex.  In  reference  to  many  of 
these  conditions  the  reader  may  refer  to  special 
articles  in  which  they  are  considered.  All  are 
due  to  excessive  nervous  stimuli,  maintaining 
conditions  of  muscular  contraction,  which  are 
unusual  both  in  degree  and  in  duration.  These 
spasms  are,  therefore,  tonic  in  type,  and  in 
almost  all  the  cases  cited  it  is  involuntary  mus- 
cular fibres  that  are  involved. 

2.  Spasm  of  single  muscles  or  of  groups  of 
muscles. — The  next  class  of  spasm  is  that  which 
affects  the  striped  or  voluntary  muscles.  They 
are  divisible  into  two  main  categories,  that  is, 
into  tonic  spasms,  in  which  the  contractions  are 
uninterrupted,  and  clonic  spasms,  in  which  con- 
tractions and  relaxations  occur  in  quick  succes- 
sion ; the  former  being  typified  by  cramps,  and 
the  latter  by  convulsions. 

Under  tonic  spasms,  we  may  have  cramps  of 
brief  duration,  affecting  a single  muscle,  such  as 


1446  SPASM, 

the  diaphragm  in  hiccup  ; or  of  prolonged  dura- 
tion, as  in  tho  sterno-mastoid  in  certain  cases 
of  wry-neck.  The  tonic  contraction  may  affect 
several  muscles  at  the  same  time,  as  in  lock-jaw, 
or  the  painful  cramps  which  occasionally  occur 
in  the  calves  of  the  legs,  or  in  other  parts  of  the 
body.  Such  local  spasms  occur  also  in  the  con- 
ditions known  as  tetany,  in  conjugated  deviation 
of  the  eyes,  and  in  writer's  cramp  ; likewise  in 
spasmodic  spinal  paralysis,  in  hysterical  para- 
lysis, and  under  various  conditions  of  irritative 
organic  disease  implicating  motor  nerves,  or 
motor  centres  or  tracts,  either  in  the  spinal  cord 
or  in  the  brain.  More  general  tonic  spasms 
occur  in  catalepsy,  in  tetanus,  and  in  strychnia- 
poisoning. 

This  whole  class  of  tonic  spasms  is  supposed 
to  be  due  to  irritation,  mechanical  or  chemical 
(nutritive),  operating  directly , either  upon  motor 
centres  or  upon  the  fibres  conveying  motor  inci- 
tations in  some  part  of  their  course  between  the 
brain  and  the  muscles.  In  other  cases,  however, 
tonic  spasms  are  of  reflex  origin,  and  the  cause 
of  irritation  operates  in  or  upon  sensory  sur- 
faces, nerves,  or  centres. 

Clonic  spasms  are  also  of  various  kinds.  They 
may  be  limited  to  single  muscles,  such  as  the  orbi- 
cularis palpebrarum ; or  they  may  aflfectparticular 
groups  of  muscles,  such  as  those  of  one  side  of 
the  face,  or  the  muscles  of  the  lower  jaw  on  both 
sides,  or  certain  of  the  abdominal  muscles,  or 
some  of  the  foot  muscles,  as  in  ankle-clonus.  In 
other  cases  elouie  spasms  may  be  more  general, 
taking  the  form  of  unilateral  or  of  bilateral  con- 
vulsions. The  latter  also  may  be  irregular  or  of 
co-ordinated  type.  See  Convulsions. 

Where  clonic  spasms  are  much  slighter  in 
degree  and  in  range,  affecting  some  muscular 
fibres  and  that  to  a small  extent,  rather  than 
entire  muscles  in  a more  marked  manner,  we  have 
the  production  of  tremors,  which  may  be  either 
fine  or  coarse,  local  or  general. 

Transition  conditions  exist,  connecting  all 
these  various  manifestations  more  or  less  closely 
with  one  another.  They  constitute,  indeed,  one 
great  assemblage  of  related  though  apparently 
heterogeneous  phenomena,  which  have  mostly 
received  separate  consideration  under  their  re- 
spective names.  Though  it  is  desirable  that  their 
fundamental  relationship  should  have  been  thus 
briefly  pointed  out,  no  practical  end  would  be 
achieved  by  dwelling  further  upon  the  group 
as  a group,  upon  the  physiological  meaning  or 
origin  of  the  several  forms  of  spasm,  or  on  their 
therapeutic  treatment,  which  will  be  found  de- 
scribed under  separate  articles.  Sec  also  Moti- 
lity, Disorders  of. 

H.  Charlton  Bastian. 

SPASMODIC.  — Synon.  : Fr.  Spasmodique  ; 
Ger.  Krampfhaft. — A descriptive  epithet  applied 
or  applicable  to  conditions  or  diseases  in  which 
spasms,  and  mostly  those  of  the  tonic  class,  are 
met  with  as  prominent  or  essential  constituents  ; 
for  example,  spasmodic  croup,  spasmodic  asthma, 
spasmodic  stricture.  See  Spasm. 

SPECIFIC. — When  applied  to  a disease,  the 
word  specific  signifies  that  such  disease  is  pro- 
duced by  a Special  cause,  and  has  special  charac- 


SPECTROSCOPE  IN  MEDICINE, 
ters,  for  example, syphilis  and  the  eruptive  fevers. 
When  applied  to  a remedy,  it  implies  that  the 
substance  has  a distinct  and  definite  effect  in 
the  cure  of  a certain  disease,  such  as  mercury  in 
syphilis,  or  quinine  in  ague ; or  that  it  acts  upon 
a particular  organ,  as  ergot  upon  the  uterus. 

SPECTACLES,  ITses  of.  See  Vision,  Dis- 
orders of ; and  Strabismus. 

SPECTROSCOPE  IN  MEDICINE.— 

As  one  of  the  instruments  of  research  in  prac- 
tical medicine  the  spectroscope  is  of  quite  recent 
introduction  ; and,  as  yet,  it  can  hardly  be  said 
to  have  taken  a place  amongst  those  of  general 
application.  It  has  been  of  service  to  the  phy- 
siological chemist,  in  the  analysis  of  the  tissues 
of  the  body;  and  for  the  detection  of  blood- 
stains, and  perhaps  of  poisons,  it  promises  to  be 
of  value  to  the  practising  physician.  It  is 
towards  a more  complete  knowledge  of  the  na- 
ture of  animal  and  vegetable  pigments  that  it 
would  seem  to  be  of  most  use. 

Description. — The  application  of  the  instru- 
ment depends  on  the  principle  that  all  matter, 
in  whatever  condition — solid,  liquid,  or  gaseous 
— possesses  the  property  of  absorbing  certain  of 
the  rays  of  light  by  which  it  may  be  illuminated, 
and  reflecting  others.  This  being  granted,  if  the 
spectrum  be  taken,  that  is,  the  series  of  compo- 
nent colours  into  which  a light— whether  sun, 
gas,  paraffin,  or  electric— may  be  split  up  in  its 
passage  through  a prism  ; and  if  there  be  intro- 
duced between  the  source  of  light  and  the  prism 
the  material  to  be  investigated,  there  will  be  pro- 
duced certain  definite  and  characteristic  modi- 
fications of  the  spectrum,  in  the  form  of  dark 
bands  of  various  intensity  and  position.  Such 
are  called  absorption-spectra,  and  are  those  re- 
ferred to  here. 

The  mechanical  arrangement  required  to  at- 
tain this  object  consists  of  (n)  a glass  prism,  so 
placed  as  to  give  a minimum  deviation  of  the 
refracted  rays ; between  which  and  the  observer 
is  (b)  a small  telescope  through  which  the  re- 
fracted rays  pass  to  the  eye ; and  on  the  distal 
side  of  the  prism,  between  it  and  the  source  of 
light,  is  (c)  a tube,  carrying  next  to  the  prism  a 
double-convex  lens,  and  at  the  other  extremity 
(rf)  a slit,  the  margins  of  which  are  constricted 
by  accurately  and  movably  adjusted  knife- 
edges.  Tho  length  of  this  tube,  called  the  colli- 
mator, is  equal  to  the  focal  length  of  the  convex 
lens.  The  whole  apparatus  may  be  carried  on  a 
stand,  so  arranged  that  the  telescope  may  move 
round  the  prism  as  a centre,  and  the  angle  it 
makes  with  the  collimator  recorded  on  a scale. 
A simpler  instrument  has  been  constructed  by 
Browning,  which  can  be  carried  in  the  pocket. 

By  an  ingenious  arrangement  the  instrument 
has  been  adapted  to  the  microscope,  forming  the 
microspectroscope , and  is  then  applicable  to  the 
examination  of  very  minute  quantities.  But  in 
this  case  there  is  no  telescope,  the  spectrum 
formed  by  the  prism  being  viewed  directly. 

Applications. — In  the  greater  number  of  cases 
where  the  spectroscope  is  applicable  to  medicine, 
it  is  for  the  examination  of  fluids,  although  6olida 
and  morbid  gases  have  also  been  investigated. 
For  fluids  it  is  sufficient  to  arrange  the  instrument 


SPECTROSCOPE  IN  MEDICINE, 
to  that  the  spectrum  of  a gas  or  paraffin  flame 
is  obtained,  and  then  to  place  a test-tube  (a  flat 
one  is  best)  between  the  slit  and  the  light.  Some 
practice  is  required  in  adjusting  the  instrument, 
regulating  the  size  of  the  slit,  excluding  extrane- 
ous light,  and  obtaining  the  most  suitable  degree 
of  dilution  and  thickness  of  stratum  of  the  fluid 
to  be  examined.  The  positions  of  the  absorption- 
bands  are  most  conveniently  recorded  by  refer- 
ring them  to  the  standard  Frauenhofer  lines  of 
the  solar  spectrum. 

Certain  precautions  require  to  be  borne  in 
mind  in  regard  to  the  absorption-spectra.  Thus 
it  appears  that  every  substance  has  not  its  own 
spectrum,  entirely  distinct  from  that  of  any 
other,  but  that  many  bodies,  very  different  in 
nature,  possess  the  same  spectrum,  as  carmine 
and  oxyhemoglobin ; it  is  by  the  behaviour  of 
the  spectra,  under  the  treatment  of  the  fluids 
with  reagents,  that  the  spectroscopic  results 
come  to  be  of  definite  value,  Again,  the  same 
substance  may  give  different  spectra  according 
as  it  is  in  a solid,  fluid,  or  gaseous  state;  or  so- 
lutions of  the  samo  body  in  different  media  may 
give  different  absorption-bands. 

1.  Blood. — Haemoglobin,  both  in  the  oxidised 
and  reduced  condition,  is  easily  recognised  by  its 
spectrum.  The  former  shows  the  dark  lines  in 
the  yellow  and  green  regions  of  the  spectrum, 
the  one  next  D being  darker  and  more  strongly 
marked  than  the  other,  which  is  near  to  b. 
Reduced  haemoglobin,  on  the  other  hand,  gives 
but  one  dark  band,  in  a position  between  the 
two  of  oxyhsemoglobin.  The  spectrum  of  blood 
is  identical  with  that  of  haemoglobin,  of  which 
of  a grain  may  be  detected  by  the  spectro- 
scope ; but  ‘ there  does  not  appear  to  be  any 
probability  of  our  being  able  to  decide  by  this 
means  whether  the  blood  is  or  is  not  human  ’ 
(Sorbv). 

Carbonic  acid  and  many  other  gases,  such  as 
carbonic  oxide,  or  coal-gas  which  contains  seven 
per  cent,  of  CO,  nitrous  oxide  (NO),  and  sul- 
phuretted hydrogen  (SH2),  and  the  cyanides 
of  hydrogen,  potassium,  &c.,  nitrite  of  amyl, 
iodine,  &e.,  all  possessing  an  affinity  for  hsemo- 
globin,  show  characteristic  absorption-spectra ; 
and  investigation  by  the  spectroscope  of  blood 
treated  with  these  reagents,  helps  to  explain  the 
poisonous  characters  that  most  of  these  bodies 
possess,  and  show  it  to  be  chiefly  due  to  their 
combining  so  closely  with  the  haemoglobin  that 
the  latter  ceases  to  be  an  oxygen-carrier ; whilst 
CO2  is  very  loosely  combined,  and  is  easily  sepa- 
rated by  mere  exposure  of  the  reduced  haemo- 
globin to  the  air. 

The  various  derivatives  of  haemoglobin,  such 
as  haematin,  both  acid  and  alkaline,  haematoidin, 
and  haemin,  all  give  characteristic  spectra,  by 
which  they  may  be  recognised. 

It  is  necessary  to  be  acquainted  with  the 
spectra  of  these  bodies,  as  well  as  of  oxy-  and  re- 
duced haemoglobin,  since  in  many  of  the  situa- 
tions in  which  blood  is  sought  for — as  in  urine, 
vomit,  fluid  of  cysts,  and  stains  on  clothes — it 
has  undergone  changes  into  one  or  other  of 
these  derivatives.  Ammonium  sulphide  is  the 
most  convenient  agent  for  reducing  haemoglobin  ; 
and  in  examining  any  fluid  for  this  body,  it 
should  always  be  employed,  since  it  is  by  the 


SPECULUM.  144? 

behaviour  of  haemoglobin  under  its  influence  that 
it  may  be  identified  and  distinguished  from 
carmine. 

In  the  investigation  of  blood-stains,  their  age, 
as  well  as  the  character  of  the  material  in  which 
they  are  found,  must  be  considered.  Distilled 
water,  glycerine,  or  dilute  solution  of  ammonia 
or  nitric  acid  may  be  used  to  dissolve  out  the 
stain,  with  the  result  of  giving  a solution  of 
haemoglobin  or  haematin,  which  may  be  enclosed 
in  an  ordinary  microscopic  cell  and  examined 
with  the  microspectroscope. 

2.  Bile. — It  is  said  that  fresh  human  bile 
yields  no  spectrum,  but  that  when  diluted,  or  if 
hydrochloric  or  nitric  acid  be  added,  an  ab- 
sorption-band appears  at  F,  which  is  due  to  j. 
pigment  known  as  urobilin.  This  spectrum  may 
be  regarded  as  a test  for  bile. 

3.  Urine. — Healthy  urine  gives  a spectrum 
with  an  absorption-band  at  F,  identical  with 
that  of  urobilin,  which  behaves  on  treatment  with 
reagents  in  the  same  manner  as  the  spectrum  of 
that  pigment,  and  hence  it  may  be  regarded  as 
a normal  colouring  matter  of  the  urine,  and  ab- 
sent in  some  diseases.  Other  pigments  appear, 
from  the  spectra  given,  to  be  present  in  certain 
diseased  states  and  in  pregnancy.  Sugar  and 
albumen  are  not  to  be  detected  in  the  urine  by 
the  spectroscope. 

4.  Faeces. — On  spectroscopic  examination  the 
band  of  urobilin  is  presented. 

See  The  Spectroscope  in  Medicine,  by  Dr. 
MacMunn,  and  Dr.  Thudichum's  researches  in 
the  Reports  of  the  Medical  Officer  of  the  Privy 
Council.  W.  H.  Allchin. 

SPECULUM  (Lat.)  — Synon  : Fr.  Speculum  ; 
Miroir  ; Ger:  Speculum  ; Spiegel. 

Definition.— An  instrument  adapted  for  ex- 
ploring the  several  channels  and  deeper-seated 
parts  of  the  human  body.  The  chief  of  these  are 
the  ear,  the  eye,  the  nose,  the  mouth,  the  throat, 
the  rectum,  and  the  vagina.  For  each  of  these 
there  are  specially  adapted  instruments. 

Description. — Specula  are  made  of  various 
materials,  and  in  a variety  of  shapes.  The  spe- 
culum is  intended  not  only  to  permit  and  facili- 
tate inspection,  but  also  to  dilate  the  canals  and 
to  expose  parts,  in  order  that  they  may  be  treated 
surgically,  or  have  medicaments  applied  to  them. 
For  this  reason  a cylindrical  speculum  will  not 
always  answer  the  purpose  ; we  have,  therefore, 
bivalve  and  trivalve  specula,  and  many  other 
forms.  On  account  of  the  friability  of  glass, 
other  material  has  not  infrequently  to  be  used, 
such  as  white  polished  metal  or  wood  ; the  latter 
is  objectionable,  as  it  has  no  reflecting  power  ; 
but  when  it  becomes  necessary  to  apply  the 
actual  cautery  through  a speculum,  a substance 
must  be  employed  that  is  a non-conductor  of 
heat  and  non-friable,  such  as  wood. 

Vahieties. — Aural  specula. — Of  these  there 
are  several  forms,  and  some  are  known  under 
the  name  of  ‘ auriscopes.’  Some  have  a trum- 
pet-shaped opening,  which  facilitates  the  in- 
troduction of  light,  and  greatly  increases  the 
illuminating  and  reflecting  power.  There  are 
also  bivalve  aural  specula  with  a screw  lever, 
and  others  with  handles  attached  so  as  to  sepa- 
rate the  blades. 


1448  SPECULUM. 

Eye  specula. — These  are  known  by  the  name 
rf  eyelid  retractors  and  ophthalmoscopes,  both  of 
which  are  really  specula  for  examining  the  eye, 
though  not  generally  classified  as  such.  See 
Ophthalmoscope. 

Nasal  specula. — There  are  several  of  these, 
the  great  purpose  they  have  to  serve  being  that 
of  dilating.  One,  known  as  Elsberg’s,  is  three- 
bladed. 

Throat  specula. — Specula  for  examination  of 
the  throat  are  generally  called  laryngoscopes. 
See  Laryngoscope. 

Bectal  specula. — These  are  cylindrical,  bi- 
valve, or  trivalve.  The  cylindrical  are  made  on 
the  principle  of  Pergusson’s  vaginal  speculum, 
but  with  an  opening  so  as  to  expose  the  wall 
of  the  rectum  at  whatever  part  it  be  adapted 
to.  The  valvular  forms  are  made  of  white 
metal. 

Vaginal  specula. — Of  these  there  are  many. 
Perhaps  the  most  useful  is  that  known  as  Fer- 
gusson’s,  which  is  cylindrical  and  made  of  glass, 
with  a coating  of  mercury  behind  it,  so  as  to 
give  it  reflecting  power,  and  backed  by  vul- 
canized india-rubber.  An  improved  variety  of 
this  is  of  a tapering  form,  so  as  to  admit  more 
light.  See  Womb,  Diseases  of. 

Sims’  duck-bill  speculum  is  of  great  use  in 
retracting  the  peringeum  and  dilating  the  vagina, 
when  space  is  required  for  operation,  as  in  vesico- 
vaginal fistula.  Then  there  are  bivalve  and  tri- 
valve metallic  specula.  Wooden  cylindrical  spe- 
cula are  always  used  when  the  actual  cautery  is 
applied,  for  reasons  already  mentioned.  For  the 
ordinary  purposes  glass  is  the  preferable  mate- 
rial, as  it  is  unaffected  by  caustics. 

The  uses  of  specula  will  be  found  described  in 
connexion  with  the  diseases  of  the  several  organs 
to  which  they  have  reference. 

Clement  Godson. 

SPEECH,  Disorders  of. — Synon.  : Troubles 
du  Langage;  Ger.  Siohrungen  der  Sprache. — De- 
fects of  speech  are  very  various  in  their  nature, 
degree,  and  mode  of  causation.  They  are  capable 
of  being  classified  from  several  different  points 
of  view.  We  shall  not  attempt  to  do  more  in  the 
present  article  than  point  out  the  nature  and 
relations  of  the  several  kinds  of  defects,  which 
will,  in  almost  all  cases,  be  found  to  have  re- 
ceived consideration  under  their  own  proper 
headings. 

-ZEtiology  and  Pathology.  — Disorders  of 
speech  may  depend  upon  (1)  congenital,  or  (2) 
acquired  defects  of  the  brain,  or  of  certain  of  its 
nerves  and  sense-organs. 

1.  Congenital  defects. — The  most  frequent  and 
important  of  these  defects  is  deafness,  which 
entails  mutism,  so  that  the  individuals  thus 
afflicted  are  known  as  ‘ deaf-mutes.’  It  must, 
however,  be  borne  in  mind  that  this  condition 
of  mutism  or  dumbness  may  also  be  brought 
about  by  absolute  deafness  occurring  from  any 
cause  after  birth,  but  before  the  child  begins 
to  talk  ; or  even  after  it  has  learned  to  talk, 
up  to  the  fifth  or  seventh  year.  In  cases  of 
the  latter  type,  the  child  soon,  when  without 
the  accustomed  guidance  derived  through  the 
sense  of  hearing,  forgets  how  to  speak  and 
becomes  dumb.  In  addition  to  this  class  of 


SPEECH,  DISORDERS  OF. 
cases,  there  are  those  of  congenital  idiocy  with- 
out deafness,  but  in  which  the  child  never  learns 
to  talk  or  articulate  in  the  proper  sense  of 
the  term  {see  Idiocy).  There  are  also  other 
cases  allied  to  the  last,  in  which,  owing  to 
some  intra-cranial  lesion  occurring  either  before, 
during,  or  soon  afterbirth,  the  child’s  subsequent 
mental  condition  is  greatly  impaired,  as  well 
as  its  motor  power.  In  these  most  deplorable 
cases  the  child  may  never  be  able  to  speak 
in  any  distinct  or  articulate  fashion,  it  may  not 
be  able  to  walk  or  even  stand,  or  it  may  only  be 
able  to  accomplish  these  latter  acts  imperfectly. 
In  some  of  these  children  there  is  evidence  of 
the  existence  of  a hemiplegic  condition,  with 
arrest  of  growth  of  the  paralysed  limbs.  Such 
patients  are  also  frequently  subject  to  one-sided 
fits ; but  it  is  not  certain  whether  in  these  cases 
the  inability  to  speak  is  especially  prone  to  occur 
in  those  who  are  congenitally  paralysed  on  the 
right  side.  In  some  of  the  less  severe  examples 
of  this  latter  type  which  have  come  under  the 
writer's  observation,  speech  has  been  merely 
deferred — the  child  has  not  commenced  to 
speak  till  the  fourth,  fifth,  or  even  the  sixth 
year.  See  Dumbness. 

2.  Acquired  defects. — Among  acquired  defects 
of  speech  we  have  troubles  of  various  degrees  and 
kinds,  which  may  come  on  at  any  period  between 
infancy  and  old  age,  and  which,  as  regards  dura- 
tion, may  be  temporary  or  permanent.  The  great 
variations  in  the  extent  and  nature  of  these 
defects  is  due  to  the  fact  that  the  impeding  con- 
dition or  lesion  may  act  (1)  upon  parts  of  the 
brain  concerned  with  the  genesis  of  thought,  and 
of  the  will  to  speak,  (2)  upon  some  part  of  the 
nervous  channels  or  centres  concerned  with  the 
actuation  of  speech,  or  (3)  upon  the  peripheral 
nerves  and  organs  concerned  with  articulation 
and  vocalisation.  Thus  it  happens  that  acquired 
defects  of  speech  may,  in  one  set  of  cases,  be 
associated  with  the  most  marked  alterations  in 
the  intelligence  or  previous  mental  condition  of 
the  patient,  whilst  in  others  they  may  be  repre- 
sented by  mere  defective  articulation  or  vocalisa- 
tion. In  briefly  referring  to  the  principal  varie- 
ties, we  will  pass  from  the  simple  to  the  more 
complex  types. 

Proper  vocalisation  is  essential  for  the  pro- 
duction of  normal  speech  ; where  it  alone  is  de- 
fective we  have  to  do  with  various  kinds  of  apho- 
nia, which  may  be  due  to  very  different  causes 
{see  Voice,  Disorders  of).  Again,  articulation  as 
a mere  motor  act  may  be  interfered  wi(h  or  per- 
verted in  diverse  modes.  "Where  speech-move- 
ments are  incoordinate,  we  have  such  common 
defects  as  stuttering  or  stammering  {see  Stam- 
mering) ; or  else  those  less  marked  perversions 
of  speech- movements  which  are  met  with  in  some 
cases  of  chorea.  Again,  where  the  movements 
concerned  in  speech  are  more  simply  defective, 
we  have  that  indistinctness  of  articulation  and 
blurred  utterance  which,  in  various  degrees,  is 
so  commonly  associated  with  different  forms  of 
paralysis  due  to  cerebral  disease.  To  this  kind 
of  defect  the  name  ‘ Aphemia  ’ is  now  commonly 
applied.  It  presents  itself  under  many  various 
conditions,  and  with  different  degreos  of  com- 
pleteness. It  may  show  itself  in  its  most  ex- 
treme form  in  ‘ labio-glosso-laryngeal  paralysis, 


SPEECH,  DISORDERS  OF. 
or  in  ether  forms  of  bulbar  disease.  This  blurred 
or  difficult  articulation  is  also  one  of  the  signs 
met  with  in  general  paralysis  of  ttie  insane  and 
in  disseminated  cerebro-spinal  sclerosis.  Again, 
it  occurs  in  association  with  hemiplegia  caused 
by  different  lesions  in  various  parts  of  the  brain, 
between  the  medulla  below  and  the  cerebral 
cortex  above.  As  a rule  it  is  most  marked  and 
most  persistent  in  hemiplegia  due  to  disease  of 
the  pons  Varolii,  while  in  lesions  higher  up  it  is 
apt  to  be  slight  and  more  transitory,  especially 
where  such  lesions  exist  on  the  right  side  of  the 
brain.  It  is  evident,  indeed,  that  this  kind  of 
defect  is  specially  prone  to  occur  where  there  is 
damage  to  the  first  parts  of  the  outgoing  tract 
leading  from  the  left  cortical  auditory  word- 
centre,  or  to  any  lower  parts  of  the  same  tract, 
or  when  there  is  damage  to  the  actual  motor 
centres  for  articulation  situated  in  the  medulla 
oblongata  (see  Brain  as  an  Organ  of  Mind, 
1880,  p.  618).  Damage  to  the.  upper  part  of 
these  tracts,  however,  so  long  as  it  is  situated 
above  the  level  of  the  left  corpus  striatum,  gives 
rise  to  a form  of  this  aphemic  defect  which  is 
commonly  known  as  aphasia  (see  Aphasia).  The 
writer’s  most  recent  investigations  have  led  him 
to  the  conclusion  that  this  condition  may,  in 
reality,  and  in  full  accordance  with  modern  doc- 
trines as  to  the  strict  localisation  of  cerebral  func- 
tions, be  induced  by  damage  in  parts  of  the  cor- 
tex comparatively  remote  from  the  ‘third  frontal 
convolution  ’ (op.  cit.  p.  680).  Such  forms  of 
speech-defect  may  exist  without  obvious  mental 
impairment,  and  it  is  worthy  of  note  that  they 
may  sometimes  be  induced  without  coincident 
hemiplegia,  by  over-work,  either  literary  or 
clerical,  or  under  the  influence  of  great  excitement. 
Related  to  speech-disorders  of  this  type  are  the 
other  more  complex  and  extremely  varied  defects 
of  speech  classed  under  the  head  of  amnesia. 
These  are  often  associated  with  grave  meDtal 
and  volitional  defects.  The  writer  has  recently 
come  to  the  conclusion  that  they  are  especially 
apt  to  occur  in  association  with  lesions  involving 
tho  supra-marginal  lobule,  the  angular  gyrus, 
and  the  posterior  part  of  the  upper  temporal  con- 
volution, that  is  to  say,  the  convolutions  which 
bound  the  upper  end  of  the  4 Sylvian  fissure  ’ 
(op.  cit.  p.  683).  These  are  parts  of  the  cortex 
which,  according  toFerrier,  have  much  to  do  with 
visual  and  auditory  impressions.  They  would 
accordingly  be  concerned  with  the  appreciation, 
on  the  one  hand,  of  printed  and  written  charac- 
ters, and,  on  the  other,  of  spoken  words  ; and 
seeing  that  such  parts  of  the  cortex  must  also 
afford  the  starting-points  for  volitional  incitations 
to  acts  of  writing,  reading,  and  speaking,  it  can 
easily  be  understood  how  much  damage  to  the 
brain  in  these  regions  may  interfere  with  intel- 
lectual ‘ appreciation,’  as  well  as  with  intellec- 
tual ‘ expression.’ 

Finally,  in  this  relation,  reference  should  be 
made  to  certain  forms  of  speechlessness  occa- 
sionally met  with  in  hysterical  females,  or  in  the 
insane  of  both  sexes,  in  which  there  may  be  a 
deficiency  of  will  to  speak,  dependent  upon  per- 
verted cerebral  action,  either  without  or  with 
a discoverable  basis  of  actual  morbid  changes. 
In  such  cases,  also,  there  may  be  no  apparent 
motive ; or  the  speechless  condition  may,  in  the 


SPERMATORRHCEA.  1449 

insane,  stand  in  direct  or  indirect  relation  to 
certain  delusions. 

Teeatment.— The  treatment  of  these  various 
defects  of  speech  will,  of  course,  depend  upon 
their  causes  and  associated  conditions.  Reference 
must,  therefore,  be  made  to  the  several  special 
articles  in  which  the  different  forms  of  such 
defects  are  considered. 

H.  Chablton  Bastlan. 

SPERMATORRHCEA  (<nrepg.a,  seed,  and 
pe «,  I flow). — Svnon.  : Fr.  Spermatorrhee ; Ger. 
Samenfluss. 

Definition. — A real  or  apparent  discharge  of 
seminal  fluid,  occurring  without  voluntary  sexual 
excitement. 

Two  varieties  may  be  recognised.  (1)  True 
spermatorrhoea  is  the  discharge  of  spermatozoa 
from  the  urethra,  or  in  the  urine,  at  periods 
other  than  during  sexual  excitement.  (2)  False 
spermatorrhoea,  or  prostatorrkcea,  is  the  discharge 
of  a seminal-like  fluid,  destitute  of  spermatozoa. 

^Etiology. — Local  irritation,  whether  from 
masturbation  pr  from  some  diseased  or  disor- 
dered condition  of  the  genital  organs,  is  the 
cause  of  spermatorrhoea  in  the  first  instance. 
Such  morbid  conditions  are  balanitis,  phymosis, 
a long  prepuce,  urethral  catarrh,  irritability  of 
the  prostate,  a tender  spot  in  the  urethra, 
spasmodic  contraction  of  the  levator  ani,  varico- 
cele, rectal  irritation,  worms  in  the  intestinal 
canal,  constipation,  and  changes  in  the  nerves  or 
nerve-centres  supplying  the  genito-urinary  tract, 
inducing  either  hyperaesthesia  or  anaesthesia. 
Any  of  these  states  may  give  rise  to  masturba- 
tion, or  masturbation  may  in  turn  cause  most  of 
them.  Should  the  conditions  that  determine  the 
irritation  persist,  the  very  smallest  mental  or 
local  stimulus  is  sufficient  to  continue  the  dis- 
ease indefinitely. 

Symptoms. — The  first  symptom  that  alarms 
tho  subject  of  spermatorrhoea  is  the  occurrence 
of  frequent  nocturnal  emissions,  at  first  with, 
and  afterwards  without,  erotic  sensation.  These 
reduce  his  strength,  render  him  weak  and  irri- 
table, and  gradually  prey  upon  his  mind;  and 
if,  as  frequently  happens,  masturbation  be  prac- 
tised, they  induce  a condition  of  extreme  mental 
depression.  When  the  patient  reaches  this  state, 
the  mere  reference  to  sexual  matters,  the  sight 
of  anything  lewd,  the  act  of  defecation,  or  a 
chance  irritation  of  the  penis  during  walking, 
riding,  or  driving,  is  often  sufficient  to  cause  au 
abortive  or,  it  may  be,  a complete  emission.  The 
discharge  may,  in  advanced  cases,  find  its  way 
into  the  bladder  and  be  passed  with  the  urine  ; 
a condition  which  is  regarded  by  the  patient  as 
the  most  serious  of  all.  The  discharge  may  be 
the  ordinary  seminal  fluid ; or  it  may  be  less  in 
quantity,  clearer,  tenacious,  more  like  the  syno- 
vial fluid  in  appearance  and  consistence.  In  the 
latter  case  it  seldom  contains  spermatozoa,  and 
it  is  usually  only  the  forerunner  of  the  other 
more  serious  state,  or  it  may  intermit  with  it. 
These  conditions  combine  to  render  the  patient 
for  the  time  being  physically  and  mentally  a 
wreck,  sleepless,  listless,  nervous,  anaemic,  and 
with  an  old  and  insipidly  anxious  look  upon  his 
muddy  or  pimpled  face.  Connection  becomes 
well-nigh  impracticable,  the  discharge  of  semen 


1450  SPERMATORRHOEA. 

occurring  before  the  introduction  of  the  orga  n ; or 
erection  may  be  impossible  or  imperfect. 

Diagnosis.  — In  the  diagnosis  of  the  cause  of 
spermatorrhoea,  the  condition  of  the  external 
genitals  must  first  be  determined.  The  presence 
of  a tender  spot  in  the  urethra,  or  the  existence 
of  hyperaesthesia  or  anaesthesia  or-  stricture,  can 
be  made  out  by  passing  a catheter.  The  acorn - 
pointed  boogie  is  the  best  for  diagnosing  the 
exact  seat  of  such  troubles.  The  discharge  itself 
must  be  found  and  examined  microscopically,  the 
presence  of  spermatozoa  establishing  true  sper- 
matorrhoea. Glairy  fluids,  like  that  of  prostator- 
rhoea,  occur  in  the  urethra  during  the  last  stages 
of  a gleet,  or  in  straining  at  stool,  and  also  in 
stricture.  The  history  of  the  ease,  and  catheter- 
ism,  readily  clear  up  the  cause  of  the  discharge. 

Prognosis. — In  the  generality  of  instances  the 
patient  gets  quite  well,  either  by  ordinary  care 
on  his  own  part,  or  by  medical  treatment.  In 
other  cases,  however,  the  development  of  some 
inherited  disease  manifests  itself  simply  from 
the  weak  condition  to  which  the  patient  is  re- 
duced. In  some  instances  dementia  or  melan- 
cholia is  induced,  and  the  patient  continues  his 
impure  habits  even  whilst  under  watch  and  ward 
in  a lunatic  asylum. 

Tbeatment. — Should  any  local  irritation  ap- 
pear sufficient  to  cause  spermatorrhoea,  it  ought 
to  be  treated  and  removed,  if  possible.  A long 
prepuce  should  be  cut  off,  balanitis  cured,  a vari- 
cocele relieved,  or  rectal  irritation  removed.  To 
prevent  masturbation  many  plans  have  been 
tried,  such  as  the  application  of  iodine  to  the 
penis,  or  touching  the  parts  with  caustics,  which, 
by  the  pain  they  cause,  prevent  the  patient  med- 
dling with  the  organ.  These  measures,  or  such  as 
these,  combined  with  encouragement  from  the 
medical  attendant,  and  resolution  on  the  part 
of  the  patient,  will  help  towards  a cure.  The 
situation  of  a tender  spot  in  the  urethra  can  be 
made  out,  either  by  a bougie — the  acorn-pointed 
bougie,  as  above  mentioned,  being  the  best  for 
such  a purpose — or  by  pressure  on  the  perineum. 
AVhen  discovered,  the  tenderness  may  be  relieved 
by  blisters  on  the  perineum,  or  by  applying 
caustics  directly  to  the  tender  surface,  either  in 
substance  or  in  solution.  The  solution  chiefly 
used  is  one  of  nitrate  of  silver,  varying  in  strength 
from  ten  to  sixty  grains  to  the  ounce,  and  it  is 
best  applied  by  the  silver  syringe-catheter.  The 
patient’s  digestion,  and  impaired  physical  and 
mental  condition  must  be  looked  after.  Sto- 
machic and  nervine  tonics,  such  as  gentian, 
strychnia,  phosphates,  and  iron,  are  the  most 
useful,  and  must  be  given  for  some  time.  To 
allay  irritability  of  the  genital  organs,  the  bro- 
mides and  belladonna  may  be  given  separately 
or  in  combination.  For  hyperaesthesia  the  extract 
of  belladonna,  in  half-grain  doses  morning  and 
evening,  is  especially  useful ; it  may  be  given 
with  the  tonics  recommended  above.  Should 
anaesthesia  of  the  urethra  and  genitals  exist, 
galvanism  has  been  tried  and  proved  successful. 
The  patient  should  sleep  on  a hard  bed,  and  get 
up  the  moment  he  wakes.  Cold  hip-baths  morn- 
ing and  eveniug,  walking  exercise,  and  mixing 
in  company  as  much  as  possible,  are  useful  ad- 
juvants to  treatment.  See  Masturbation. 

James  Cantlie. 


SPHINCTERS,  DISORDERS  OF. 

SPEZIA,  Bay  of,  in  Central  Italy. — A 

calm,  moist,  moderately  warm,  equable,  winter 
climate.  Prevailing  winds,  S.  and  E.  See  Cli- 
mate, Treatment  of  Disease  by. 

SPHACELUS  (crtpal 'w,  I destroy). — The  pro- 
cess of  mortification,  or  the  dead  mass  resulting 
from  this  process.  See  Gangrene. 

SPHINCTERS,  Disorders  of. — Stnon.  : 

Fr.  Troubles  dcs  Sphincters ; Ger.  Stohrungen 
der  Schlicssmuskeln. 

From  a practical  point  of  view,  it  is  here 
only  needful  to  refer  to  disordered  actions  cf 
the  sphincters  of  the  bladder  and  of  the  rectum. 
The  disorders  themselves  are  in  each  case  of 
two  kinds.  We  may  have  to  do  with  spasm 
of  the  sphincter  vesicae  or  of  the  sphincter  ani, 
leading  to  or,  at  least,  aiding  in  bringing  about, 
retention  of  urine  and  retention  of  faeces  re- 
spectively; or,  on  the  other  hand,  there  may  be 
paralysis  of  these  sphincters,  leading  to  incon- 
tinence of  urine,  and  favouring  incontinence  of 
faeces. 

.ZEtiology  and  Pathology. — These  opposite 
modes  of  disordered  function  of  the  sphincters 
of  the  bladder  and  the  rectum  may  be  variously 
induced ; but  the  causes  may  be  ranged  in  three 
principal  categories,  according  as  they  are — 
(1)  of  peripheral  or  reflex,  (2)  of  spinal,  or  (3) 
of  cerebral  origin. 

(1)  Ecflex  causes. — These  are  not  always  dis- 
tinct from  those  of  the  next  category,  and  they 
more  frequently  reveal  themselves  as  spasms 
than  as  paralyses.  Retention  of  urine  due  to 
reflex  spasm  of  the  sphincter  of  the  bladder  is 
frequent  enough,  especially  in  stricture  of  the 
urethra  or  stone  in  the  bladder.  On  the  other 
hand,  a weak  action  of  the  sphincter,  with  undue 
irritability  of  the  bladder,  may  lead  to  nocturnal 
incontinence  of  urine  in  children.  Temporaiy 
paralysis  of  both  sphincters  may  occasionally  he 
induced  by  a kind  of  cerebral  reflex,  under  the 
influence  of  fright.  Spasmodic  conditions  of  the 
sphincter  ani  may  be  induced  by  the  irritation 
of  fissures  or  small  ulcers  just  within  the  anus, 
and  may  tend  greatly  to  increase  the  suffering 
of  the  patient  during  or  after  defecation. 

(2)  Spinal  causes. — The  majority  of  the  cases 
of  disordered  action  of  the  sphincters  will  be  due 
to  this  class  of  causes.  They  are  incidents  of 
functional  or  of  structural  diseases  of  the  spinal 
cord,  or  of  the  nerves  by  which  such  sphincters 
are  supplied.  Here,  too,  we  may  have  irritation 
of  the  spinal  centres  or  of  their  nerves,  causing 
spasms  and  corresponding  retention  of  urine  or 
of  feces  ; or  we  may  have  pressure  upon  or  de- 
structive lesions  of  the  same  parts,  in  and  issuing 
from  the  lower  lumbar  region  of  the  cord,  leading 
to  paralysis  of  the  sphincters,  and  a corresponding 
incontinence  of  urine  or  of  feces.  Irritation  or 
destruction  of  the  channels  in  the  cord,  by  which 
voluntary  incitations  are  conducted  to  these 
sacral  centres,  may  also  lead  to  spasm  or  para- 
lysis of  either  of  the  sphincters  ( see  Spinal 
Cord,  Diseases  of,  § 9,  7,  S).  In  many  struc- 
tural diseases  of  the  cord  entailing  paraplegia, 
paralysis  of  the  sphincters  (owing  to  its  dif- 
ferent sequel*)  becomes  an  important  condition, 
which  notably  influences  the  gravity  of  the  die- 


SPHINCTERS,  DISORDERS  OF. 
ease,  and  demands  the  exercise  of  great  care  in 
counteracting  its  effects,  as  far  as  this  may  be 
possible.  See  Spinal  Coed,  Softening  of. 

(3)  Cerebral  causes. — In  cerebral  disease, 
where  the  mind  or  consciousness  is  profoundly 
Affected,  there  may  be  incontinence  of  faeces  or 
of  urino.  Yet  such  events  can  scarcely  be 
said  to  be  due  to  a disordered  action  of  the 
sphincters.  If  no  restraining  or  inhibitive  power 
be  exercised  by  the  cerebral  hemispheres,  then 
the  spinal  reflex  mechanisms  regulating  the 
action  of  the  detrusor  muscles  and  of  their  related 
sphincters  are  called  into  play  from  time  to  time. 
The  latter  become  relaxed  coincidently  with  the 
contraction  of  the  expulsor  muscles  of  the  bladder 
or  rectum,  when,  from  either  viscus,  a sufficiently 
powerful  set  of  afferent  impressions  passes  to 
the  related  spinal  centre.  So  that  in  hemi- 
plegia with  mental  impairment,  in  dementia,  or 
in  stupor  or  coma,  we  commonly  meet  with  in- 
continence of  urine  and  of  faeces.  Over-action 
or  epasm  of  these  sphincter  muscles  may  also 
occur  under  various  perverted  cerebral  condi- 
tions, especially  in  hysteria;  thus  occasioning  an 
undue  retention  of  the  contents  of  the  bladder  or 
of  the  rectum,  as  the-  case  may  be. 

The  sphincter  of  the  vagina  is  also  liable  to 
be  affected  by  spasm,  but  this  subject  is  consi- 
dered in  another  part  of  this  work.  See  Vagina, 
Diseases  of. 

Treatment. — The  treatment  of  disorders  of 
the  sphincters  must  of  course  depend  upon  the 
nature  of  the  cause,  and  upon  the  nature  of  the 
particular  defect  existing  in  each  individual  case. 
When  the  exciting  cause  is  local,  it  must  be 
remedied  if  possible.  Where  due  to  structural 
disease  in  the  spinal  cord  or  in  the  brain,  the 
above  disorders  present  themselves  among  many 
other  morbid  signs  and  symptoms,  and  in  these 
cases  we  must  always  strive  to  correct,  as  far  as 
it  may  be  possible,  the  original  and  common 
eause  of  the  morbid  symptoms  in  question. 

H.  Charlton  Bastian. 

SPHTGMOGRAPH,  The  ( atpuy/ibs , the 
pulse,  and  yp£<pa),  I write). 

Definition. — The  pulse- writer;  an  instru- 
ment devised  to  record  the  form  of  the  move- 
ments of  the  arterial  pulse. 

History. — The  idea  of  this  instrument  is  as 
old  as  Galileo,  but  it  is  only  in  recent  years  that 
it  has  assumed  a practical  form.  The  first  regis- 
tering instrument,  for  recording  the  movements 
of  an  artery,  was  used  by  Ludwig  in  1847,  ten 
years  after  Herisson  had  devised  his  sphygmo- 
meter, by  which  he  showed  in  a column  of  fluid  the 
movements  of  the  pulse.  It  was  with  this  in- 
strument that  Chelius  demonstrated  the  second 
wave,  or  dicrotism  of  the  normal  pulse. 

Vierordt  was  the  first  to  construct  a sphyg- 
mograph  which  could  be  applied  on  man,  utilis- 
ing an  idea  of  King’s,  who  had  previously 
demonstrated  the  pulsation  of  the  veins  in  the 
neck  by  attaching  to  them  a delicate  lever.  The 
instrument  of  Vierordt,  however,  did  not  record 
the  form  of  the  pulse-movements  accurately,  and 
for  the  most  part  registered  only  a series  of  uni- 
form curves.  This  physiologist  remarked  that 
the  problem  was  to  place  on  the  pulse  a very 
delicate  elastic  spring,  and  by  means  of  it  to 


SPHYGMOGRAPH.  1453 

transmit  the  movements  of  the  pulse  to  the  writ- 
ing lever.  Marey  succeeded  in  doing  this  by  the 
invention  of  his  sphygmograph,  which  became, 
after  the  publication  of  his  work  in  1863,  forth- 
with applicable  for  clinical,  as  well  as  physiolo- 
gical, research.  Its  introduction  gave  the  study 
of  the  pulse  a scientific  basis,  by  causing  the 
arteries  to  write  their  autographs,  and  thereby 
restored  to  its  first  importance  the  neglected  art 
of  reading  the  pulse. 

DESCRiprioN.-Although  there  are  now  several 
sphygmographs  at  work  in  the  field  of  clinical 
inquiry,  it  will  be  necessary  to  describe  only  that 
of  Marey,  which  is  most  commonly  in  use. 

The  essential  part  of  the  instrument  is  a deli- 
cate spring,  armed  at  its  free  end  with  an  ivory 
pad  which  rests  upon  the  artery.  The  spring 
is  fixed  by  its  other  extremity  to  the  frame- 
work, and  receives  the  pulse-movements,  which 
are  transmitted,  amplified,  and  recorded  by  an 
arrangement  of  two  levers.  The  lower  lever  is 
hinged  to  the  steel  spring,  so  that  it  can  move 
up  and  down  at  its  free  end,  which  terminates 
in  a vertical  knife-edge  considerably  above  the 
ivory  pad,  which  rests  on  the  artery.  This  knife- 
edge  can  be  raised  or  lowered  by  means  of  a 
screw,  and  so  adjusted  and  maintained  in  con- 
tact with  the  upper  lever,  near  its  centre  of 
motion.  This  second  or  upper  lever,  which 
points  in  the  opposite  direction  to  the  lower  one, 
is  very  light,  and  carries  at  its  free  end  a pen, 
which  records,  on  a plate  moved  by  clockwork, 
the  vertical  movements  transmitted  to  it  through 
the  first  lever,  from  the  spring  resting  on  the 
artery.  By  this  arrangement  of  levers  the  move- 
ments originally  received  by  the  spring  from  the 
artery  are  amplified  some  fifty  times  in  the 
record. 

The  tracing  is  called  a pulse-trace,  and  con- 
sists of  a series  of  pulsations,  varying  in  num- 
ber and  form  according  to  the  frequency  and  the 
characters  of  the  pulse.  See  Pulse. 

The  frame  of  the  instrument,  to  which  the 
spring  is  fixed,  holds  the  clockwork  by  means  of 
which  the  recording  plate  is  made  to  travel. 

The  framework  is  also  made  so  as  to  fit  easily 
on  the  arm,  and  is  retained  in  position  by  straps, 
the  arm  resting  on  a suitable  pad  or  cushion. 

The  regulation  of  the  pressure  of  the  spring 
on  the  artery  is  one  of  the  most  important  points 
in  the  application  of  the  instrument.  It  requires 
to  be  accurately  regulated  and  measured,  in  order 
to  estimate  the  character  of  the  pulse,  and  render 
a comparison  of  traces  trustworthy,  as  was  first 
pointed  out  by  the  writer.  This  is  effected  by  a 
regulator  screw  connected  with  the  steel  spring, 
and  furnished  with  a registering  dial,  which 
records  the  pressure  at  which  the  maximum 
rendering  of  the  pulse  is  obtained.  By  this  ar- 
rangement the  tension  of  the  pulse  can  be  fairly 
estimated  by  the  sphygmograph. 

Application. — In  the  application  of  the  in- 
strument, the  first  important  point  to  observe 
is  accuracy  of  adjustment  of  the  ivery  pad  of 
the  spring  over  the  radial  artery.  Thir  can  be 
best  done  by  marking  the  position  of  the  artery 
with  ink,  and  then  carefully  adjusting  the 
spring.  Secondly,  the  pressure  on  the  artery 
must  be  regulated  by  means  of  the  pressure 
screw,  so  as  to  obtain  the  greatest  amplitude 


1452 


SPHYGMOGRAPH. 


of  movement  by  the  lever,  and  the  record  of  all 
the  waves  of  the  pulse.  Thirdly,  the  friction 
between  the  recording  pen  and  the  receiving 
plate,  on  which  the  trace  is  recorded,  must  be 
reduced  to  a minimum.  Smoked  glass  and  paper 
are  the  best  receivers ; pens  that  write  with  ink 
are  apt  to  blur  the  finer  features  of  the  trace. 
The  tracings  on  smoked  glass  or  paper  are  fixed 
and  rendered  permanent  by  varnish ; the  tracing 
papers,  which  should  be  well  enamelled,  may  be 
smoked  by  being  held  over  burning  paraffin  or 
camphor,  or  even  over  an  ordinary  vesta  match. 
When  the  traces  are  recorded,  they  may  be  fixed 
by  varnish  made  of  gum  benzoin,  or  Burgundy 
pitch  in  methylated  spirit  (1  in  8),  or  ordinary 
tincture  of  'tolu. 

Uses. — The  applications  of  the  sphygmograph 
to  clinical  inquiry  are  numerous  and  impor- 
tant. Precision  is  given  to  the  study  of  the  pulse, 
and  by  the  aid  of  a graphic  representation  of  its 
form  the  finger  is  taught  what  to  feel.  A pulse- 
trace  {see  Pulse)  shows  at  a glance  the  rate, 
regularity,  and  equality  of  the  heart-beats.  Ir- 
regularities, and  especially  inequalities,  that 
escape  the  finger,  are  registered ; and  indications 
as  to  pulse-tension  and  heart-strength,  most  im- 
portant for  prognosis  and  treatment,  are  ob- 
tained. In  acute  visceral  inflammations,  for 
instance,  slight  inequalities  in  the  pulsations 
otherwise  unrecognisable  may  be  recorded,  and 
the  first  signs  of  heart-failure,  and  the  necessity 
for  stimulants  thus  suggested.  Again,  the  un- 
dulatory  pulse  of  a ventricle,  too  weak  to  resist 
respiratory  influences,  is  disclosed  in  the  tracing; 
and  prognosis  and  treatment  may  be  correspond- 
ingly modified. 

Indications.  — The  evidence  yielded  by  the 
Sphygmograph  mainly  concerns  : — 1 . the  modo  of 
the  heart’s  contraction  ; 2.  the  condition  of  the 
peripheral  circulation ; 3.  the  state  of  the  arteries 
and  their  coats ; and  4.  valvular  diseases  of  the 
heart. 

1.  The  mode  of  the  heart’s  contraction. — 
The  sphygmographic  tracing  shows  this  by  the  line 
of  ascent.  When  the  heart-muscle  acts  suddenly 
and  vigorously,  the  line  is  vertical  and  lofty,  and 
terminates  in  a pointed  summit-wave.  Unless  the 
vessels  are  over-full  of  blood,  there  follow  well- 
marked  tidal  and  dicrotic  waves.  On  the  other 
hand,  when  the  heart's  contraction  is  feeble,  the 
line  of  ascent  is  less  vertical  and  lofty ; the 
summit  wave  is  less  distinct ; and  the  tidal  and 
dicrotic  waves  are  less,  or  the  former  is  blended 
with  the  summit  wave.  The  pulse,  moreover, 
unlike  the  pulse  of  a vigorous  ventricle,  is  easily' 
obliterated  by  pressure.  A note  of  the  pressure 
at  which  the  most  perfect  trace  is  collected 
should  always  be  made,  as  it  enables  the  observer 
to  compare  results  at  different  times. 

2.  The  condition  of  the  peripheral  circula- 
tion.— The  easy  or  difficult  passage  of  the  blood 
through  the  arterioles  and  capillaries,  causing 
low  or  high  pulse  tension,  is  estimated  by  the 
pressure  required  to  develop  or  to  obliterate  the 
three  waves,  but  more  especially  the  tidal  and 
dicrotic  waves.  Obstructed  peripheral  circula- 
tion is  manifested  by  increase  of  the  tidal  wave, 
diminution  of  dicrotism,  and  lessened  height  of 
line  of  ascent  and  summit  wave  (fig.  74).  The 
heart,  apart  from  febrile  or  nervous  excitement, 


contracts  less  suddenly  under  these  conditions. 
On  the  other  hand,  in  easy  and  quick  capillary 
circulation,  such  as  occurs  in  fevers,  the  sudden 
heart-contraction  increases  the  height  of  the  line 


Fio.  74. 

of  ascent,  exaggerates  the  summit  wave,  lessens 
the  tidal  wave,  and  fully  develops  the  dicrotic 
wave  (fig.  75).  In  such  conditions  the  fully 


Fig.  75. 


Fig.  76. 


dierotous  and  hyperdicrotous  traces  are  recorded 
(fig.  76).  The  rapid  onflow  of  blood  is,  moreover, 
shown  by  the  more  sudden  fall  of  the  line  of  de- 
scent. It  is  by  the  comparative  study  of  the 
three  waves,  and  the  pressure  required  to  record 
them  fully’,  that  we  obtain  valuable  indications 
as  to  heart-strength  and  pulse-tension  in  acute 
diseases,  and  in  the  earliest  stages  of  some  chronic 
affections. 

3.  The  state  of  the  arteries. — There  are 
three  chief  conditions  of  the  arteries  that  modify 
the  pulse: — (a)  the  state  of  the  muscular  coat; 
(5)  degenerative  conditions  of  the  arterial  walls  ; 
and  (c)  the  presence  of  aneurism. 

{a)  When  the  muscular  coat  is  contracted,  the 
artery  imparts  to  the  finger  a hard,  wiry  sensa- 
tion, which  shows  in  the  tra^e  by  a short  line  of 
ascent,  and  the  blending  of  the  summit  and  tidal 
waves  in  an  oblique  line  of  descent,  scarcely 
broken  by  dicrotism  (fig.  77).  In  the  oppositecon- 
dition  of  relaxed 
arterial  coats,  the 
dicrotic  and  sum- 
mit waves  are  en- 
larged, and  the 
tidal  waves  less- 
F10-77-  ened.  These 

changes  can  be  experimentally  illustrated  by  the 
application  of  cold  and  heat  to  the  surface  of  the 
body.  The  cold  and  hot  stages  of  ague  also  show 
the  two  states. 

(4)  Infiatninatory  and  degenerative  processes 


Fla.  78. 


lead  to  rigidity  of  the  arteries,  whereby  the  msdi- 


SPHYGMOGRAPH. 


1453 


lying  influence  of  their  elasticity  on  the  blood- 
movement  is  lost.  The  blood- wave  in  the  radial 
artery  consequently  approaches  more  to  that  im- 
parted by  the  heart’s  systole.  In  these  condi- 
tions the  pulse  often  beats  visibly,  sc  that  we  are 
prepared  for  the  amplitude  of  the  trace.  The 
tidal  wave  is  large,  nearer  to,  and  often  blended 
with  the  summit  wave,  while  the  dicrotism  which 
occurs  early  inthelineof  descent  is  badlymarked. 
The  presence  of  these  peculiarities  often  leads  to 
the  early  diagnosis  of  unsuspected  atheroma  of 
the  great  vessels  (fig.  78). 

( c ) When  the  sac  of  an  aneurism  is  seated  on 
amain  trunk  after  its  origin  from  the  aorta,  it 
acts  as  an  elastic  bag,  and  so  modifies  the  pulse- 
form  by  rendering  the  line  of  ascent  oblique, 
diminishing  or  abolishing  the  summit  wave, 
modifying  the  dicrotism,  and  more  or  less  con- 
necting the  three  waves  into  a simple  curve. 
To  the  finger  these  changes  mean  retardation 
(oblique  line  of  ascent),  and  diminution  of  force 
(loss  of  summit  wave).  Such  peculiarities  in 
the  left  radial  artery  are  produced  by  an  an- 
eurism of  the  left  subclavian,  or  in  the  right 
radial  by  innominate  aneurism.  When  the 
aneurism  is  connected  with  the  thoracic  aorta  in 
its  ascending  portion,  there  is  frequently  a dis- 
similarity between  the  two  radial  pulse-traces, 
which  is  persistent,  one  being  smaller  than  the 
other,  more  vibratory,  or  more  easily  obliterated 
by  increased  pressure.  The  pulse  usually  more 
affected  is  the  right,  as  the  aneurism  tends  to 
implicate  the  innominate  artery.  In  aneurism 
of  the  transverse  portion  of  the  arch,  the  left 
pulse  is  more  commonly  diminished  in  force 
and  amplitude  (figs.  79  and  80).  In  aneurisms 


Fig.  79.  Eight  Radial  Tracing. 


Fig.  80.  Reft  Radial  Tracing, 
of  the  descending  thoracic  and  abdominal  aorta, 
the  dicrotic  wave  is  often  much  increased  in  both 
pulses,  while  the  right  radial  yields  usually  the 
more  normally  developed  trace. 

These  signs  may  be  more  or  less  simulated  by 
pressure  of  tumours  on  the  arterial  trunks,  or  by 
their  partial  obstruction  by  clots.  The  sphygmo- 
graphic  signs  of  aneurism,  therefore,  require  to 
bo  confirmed  by  the  use  of  the  ordinary  means 
of  diagnosis.  In  some  cases,  however,  the  pulse- 
traces  alone  suffice  to  indicate  the  lesion  and  its 
seat. 

4.  Valvular  diseases  of  the  heart. — Val- 
vular diseases  of  the  heart  generally  influence 
the  pulse-trace.  In  aortic  regurgitation  this  is 
Btrikingly  seen  (fig.  81).  The  strong,  dilated 
ventricle  contracts  suddenly  on  a large  charge  of 
blood,  and  consequently  there  is  a lofty  line  of 
&ecent,  ending  in  a pointed  summit-wave.  The 


tidal  wave  is  small  in  proportion  to  the  trace  ; 
and  the  dicrotism, which  occurs  later  than  normal 
in  the  line  of  descent,  is  generally7  much  dimi- 
nished, on  account  of  the  leakage  into  the  ven- 
tricle interfering  with  the  rebound  of  the  blood- 
column  from  the 
closed  valves.  The 
dicrotic  wave,  thus 
starved,  is  followed 
by  a rapid  fall  in 
the  tracing,  showing 
the  quick  emptying 
of  the  artery.  It 
G‘  81,  is  this  contrast  be- 

tween the  height  of  the  summit  wave  and  the 
rapid  fall  of  the  trace,  unbroken  by  any  sus- 
taining wave,  that  gives  the  pulse  its  splash- 
ing and  collapsing  character.  These  features, 
the  small  dicrotism  and  the  rapid  fall,  indicate 
the  amount  of  regurgitation.  In  some  cases 
of  this  valve-lesion  the  tracing  shows  a well- 
marked  tidal,  and  a fairly-developed  dicrotic 
wave;  and  increased  pressure  by  the  spring  of 
the  sphygmograph,  instead  of  obliterating  the 
trace  as  usual,  shows  that  there  is  a fair  amount 
of  tension.  Such  features  commonly  occur  in 
older  persons,  in  whom  the  valve-defect  is  due 
to  atheroma, and  not  to  rheumatism,  and  the  pulse- 
form  is  modified  by  the  addition  of  the  characters 
of  the  pulse  of  degenerated  arteries.  When  such 
features  are  observed  in  rheumatic  cases,  they 
point  to  perfect  compensation  and  small  valver 
defect. 

In  aortic  stenosis  the  trace  testifies  to  the 
amount  of  the  lesion.  When  the  narrowing  is 
extreme  the  summit  wave  is  lost,  the  line  of 
ascent^  becomes  oblique  and  gradual,  and  the 
pulse  is  felt  to  be  retarded.  More  commonly  a 
break  in  the  line  of  ascent  marks  the  position  of 
tho  summit  wave,  while  above  it  rises  the  large 
tidal  wave,  due  to  the  strong  sy7stole  (fig.  82).  In 
cases  in  which  the  ob- 
struction is  less  in  degree, 
the  summit  of  the  tracing 
may  be  forked  by  a sharp 
division  between  the  sum- 
mit and  tidal  waves.  The 
dicrotic  wave  is  lessened. 

Fig.  82.  The  ]oss  or  c]lec]<ed  de- 

velopment  of  the  summit  wave,  followed  by  an 
exaggerated  tidal  wave,  arising  from  a strong 
and  often  dilated  ventricle,  pushing  a large 
blood-wave  gradually  into  the  arteries  through 
the  narrowed  aortic  orifice,  are  the  character- 
istics of  this  lesion  when  pure.  When  it  is 
associated  with  aortic  regurgitation,  the  large 
tidal  wave  is  still  pronounced. 

Mitral  valve  lesions,  which  are  less  immediately 
connected  with  the  arterial  blood-movement, 
present  less  decided  characteristics. 


In  mitral  regurgitation  the  tracing  is  often  of 
the  normal  outline,  and  in  such  cases  the  com- 
pensation is  fairly  perfect.  In  some  cases,  in  ad- 
dition to  great  rapidity,  the  pulse  is  small  and 
shabby,  in  striking  contrast  to  the  vigour  of  the 
impulse  (fig.  83).  The  line  of  ascent  is  sloping,  and 
the  tidal  and  dicrotic  waves  poorly  defined.  In 
other  cases,  great  irregularity  is  the  chief  feature 
of  the  trace,  a series  of  small,  ill-developed  pulse- 
waves  being  succeeded  by  large  and  well-formed 


1454  SPHYGMOGKAPH. 


SPINA  BIFIDA. 


pulsations.  On  analysis,  the  senes  of  small,  in- 
effectual heart-contractions  correspond  to  inspi- 
ration, and  the  fuller  and  more  vigorous  ones  to 

the  respiratory 
pause.  In  other 
conditions 
similar  irregu- 
larities are 
caused  by  the 
same  influences. 

Fig.  83.  Burdon  Sander- 

son, who  first  referred  these  irregularities  to 
their  cause,  says : ‘ The  mechanical  effect  of  in- 
spiration is  to  augment  the  quantity  .of  blood 
contained  in  the  pulmonary  circulation,  and 
hence  to  increase  the  frequency  of  the  con- 
tractions of  the  heart.  This  increased  frequency 
depends  on  the  distended  state  of  the  auri- 
cles, in  consequence  of  which  the  ventricles  fill 
more  rapidly  during  their  period  of  relaxa- 
tion. In  this  way  the  length  of  the  diastolic 
pause  is  diminished,  and  the  hurried  action  of  the 
heart  satisfactorily  accounted  for ; but  the  ques- 
tion still  arises,  Why  are  the  rapid  beats  which 
occur  in  inspiration  also  ineffectual  ? V ery  pro- 
bably because  the  mitral  valve  does  not  close  ; 
the  heart  being  distended  with  blood,  its  walls 
are  kept  apart  to  such  an  extent  that  the  cur- 
tains do  not  meet.  The  ventricle  contracts, 
but  much  of  its  blood  is  discharged  into  the 
auricle,  to  be  returned  to  the  ventricle  as  soon  as 
its  contraction  is  over.  It  is  not  until  the  effect 
of  inspiration  in  keeping  the  auricles  full  ceases, 
that  the  curtains  get  near  enough  to  allow  the 
heart  to  make  an  effort  sufficiently  effectual  to 
send  a full  tide  of  blood  into  the  aorta,  and  thus 
relieve  the  distended  pulmonary  circulation.’ 
Similar  peculiarities  are  occasioned  by  the 
same  mechanism  in  tricuspid  regurgitation  and 


dilated  heart. 

In  mitral  stenosis  the  sphygmographic  evidence 
is  very  important.  The  pulse-tracing  shows  irre- 
gularity in  the  line  of  descent,  which  often  is 
greatly  prolonged  through  a missed  pulsation — a 
true  intermission  in  the  beat,  and  sometimes 
broken  by  the  interpolation  of  a small,  abortive 
pulsation  (fig.  84).  These  abortive  pulsations 


Fig.  84. 


are  due  to  over-distension  of  the  auricle,  causing 
premature  auricular  contractions,  which  propa- 
gate themselves  to  the  ventricle,  and  so  produce 
a ventricular  contraction  on  a small  charge  of 
blood.  They  mostly  occur  during  inspiration, 
from  the  causes  above  described.  The  rhyth- 
mical relations  between  the  contractions  of  the 
auricle  and  the  ventricle  are  thus  disturbed,  and 
hence  the  features  above  described. 

These  are  the  special  characters  of  the  pulse 
of  mitral  stenosis.  In  some  cases  where  the  ste- 
nosis is  not  great  and  the  compensation  perfect, 
the  pulse  is  regular  in  time  and  form,  or  nearly 


so;  but  in  these  cases  characteristic  irregularities 
can  often  be  produced  by  vigorous  exertion. 

Finally,  in  therapeutical  investigations  the 
sphygmograph  is  indispensable  as  a means  of 
discovering  the  influence  exerted  by  a drug  on 
the  state  of  the  vessels,  on  the  condition  of  the 
peripheral  circulation,  and  on  the  vigour  of  the 
heart.  The  modifications  in  the  form  of  the 
pulse-trace  above  described  enable  the  investi- 
gator to  estimate  these  effects. 

Balthazar  Foster. 

SPINA  BIFIDA  {spina,  the  spine,  and 
bifida,  cleft). — Synon.  : Fr.  Hydrorhcichis  conge - 
nilale ; Ger.  Riickenspalte. 

Definition. — A congenital  malformation,  with 
arrest  of  development,  of  some  portion  of  the 
spinal  column. 

Generally  there  is  a deficiency  of  two  or  three 
spinous  processes  and  the  laminae ; the  rudi- 
mentary portions  of  the  arches  of  the  vertebrae 
being  spread  out  and  irregularly  expanded.  The 
spinal  cord  being  thus  left  unprotected,  its  mem- 
branes protrude  through  the  aperture  poste- 
riorly, forming  a kind  of  hernial  tumour. 

Anatomical  and  Clinical  Characters. — At 
birth  the  tumour  in  spina  bifida  is  generally 
about  as  large  as  a walnut,  and  either  spherical 
or  oval  in  form.  It  may  be  met  with  in  any 
part  of  the  spinal  column,  but  with  rare  excep- 
tions it  occurs  in  the  lumbar  or  lumbo-saeral 
region.  The  tumour  is  filled  with  eerebro-spinal 
fluid,  and  is  therefore  always  tense,  with  distinct 
fluctuation  ; its  tension  increases  when  the  child 
cries,  and  may  be  diminished  by  pressure.  The 
cutaneous  covering  of  the  tumour  is  generally 
very  thin  and  attenuated,  sometimes  having 
the  appearance  of  a transparent  membrane,  of  a 
bluish  or  congested  colour.  In  other  cases  the 
skin  is  of  its  normal  thickness  and  colour.  The 
nerve-trunks,  formingthecauda  equina,  frequently 
traverse  the  interior  of  the  sac  in  the  median 
line,  and  after  being  reflected  from  the  posterior 
wall  of  the  sac,  recross  its  cavity  towards  their 
normal  distribution.  The  tumour  is  nearly  al- 
ways solitary,  but  cases  in  which  a second  tu- 
mour existed  have  been  recorded. 

Diagnosis. — Difficulty  in  the  diagnosis  of  spina 
bifida  can  hardly  ever  occur,  and  the  characters 
above  described  will  readily  distinguish  it  from 
congenital  tumours  of  a fatty,  fibrous,  or  cystic 
character  occasionally  met  with. 

Coaiplications.  — Spina  bifida  is  sometimes 
associated  with  hydrocephalus,  with  club-foot, 
or,  it  is  said,  with  some  paralytic  symptoms ; 
the  latter  complication  probably  occurring  only 
in  those  cases  in  which  the  nerves  of  the  cauda 
equina  traverse  the  sac  of  the  tumour. 

Course  and  Terminations. — The  majority  of 
cases  of  spina  bifida  terminate  fatally,  often 
within  a few  days  or  weeks  of  birth ; the 
children  dying  from  convulsions,  frequently  pre- 
ceded by  rupture  of  the  sac,  and  the  escape  of 
its  contents.  When  the  fluid  only  oozes  gradu- 
ally, relief  follows  ; and  sometimes  spontaneous 
and  complete  cure  thus  occurs,  the  tumour  con- 
tracting to  a small  nodule,  and  the  aperture  in 
the  canal  closing  more  or  less  completely.  In 
some  cases,  when  the  cutaneous  covering  is  thick 
and  normal,  the  tumour  may  gradually  .ncreass 


SPINA  BIFIDA. 

it  size  without  material  inconvenience,  up  to 
the  adult  period  of  life,  attaining  the  size  of  a 
child’s  head,  or  even  larger  dimensions. 

PiiOGNOsis. — This  must  generally  be  unfavour- 
able, especially  when  the  tumour  is  of  large 
size  at  birth,  and  its  covering  only  thin,  mem- 
branous, and  vascular,  with  a broad  base.  When 
the  base  of  the  tumour  is  narrow,  and  its 
cutaneous  covering  thick  and  normal,  the  prog- 
nosis may  be  more  favourable,  especially  if  the 
malformation  be  situated  on  the  sacrum. 

Treatment. — The  result  of  any  treatment  of 
spina  bifida  must  be  extremely  doubtful,  but  in 
many  cases  the  process  of  spontaneous  cure  has 
been  successfully  imitated  by  small  tappings  fre- 
quently repeated,  and  followed  by  light  compres- 
sion, covering  the  tumour  with  cotton  wool  or 
lint,  and  strips  of  plaster.  Only  a portion  of  the 
fluid  should  be  allowed  to  escape  at  the  time  of 
operation  ; and  the  puncture  should  always  be 
made  at  the  side  of  the  tumour,  so  as  to  avoid  any 
possible  injury  to  the  nerve-trunks  which  may 
traverse  the  sac.  Cases  have  been  successfully 
treated  by  the  injection  of  small  quantities  of 
iodine.  Dr.  J.  Morton,  of  Glasgow,  has  used  a 
solution  made  by  dissolving  10  grains  of  iodine 
and  30  grains  of  iodide  of  potassium  in  an  ounce 
of  glycerine — half  a drachm  of  which  solution 
may  be  injected,  without  allowing  the  fluid  con- 
tents of  the  tumour  to  escape,  at  intervals  of  a 
week  or  ten  days.  The  writer  has  seen  a case 
successfully  treated  in  this  way  by  Dr.  Murray 
at  the  Great  Northern  Hospital.  Other  opera- 
tive measures,  such  as  compression  of  the  neck 
of  the  tumour  by  means  of  a clamp  or  ligature, 
and  also  excision,  have  been  employed,  occasion- 
ally with  success;  but  no  such  attempt  should 
be  made  except  under  the  most  favourable  cir- 
cumstances, w'hen  the  tumour  has  a very  nar- 
row base — more  or  less  pedunculated,  and  is 
situated  over  the  sacrum ; otherwise  death  from 
convulsions  or  meningitis  would  probably  fol- 
low any  such  attempts. 

W.  Adams. 

SPINAL  ACCESSORY  NERVE, 
Diseases  of. — The  upper  fibres  of  the  spinal 
accessory  nerve  emerge  from  the  surface  of  the 
medulla  oblongata,  below  the  pneumogastric. 
They  arise  from  a column  of  nerve-cells  adjacent 
to  the  nucleus  of  the  hypoglossal,  and  continuous 
with  the  nucleus  of  the  pneumogastric.  The 
fibres  join  the  latter  nerve  and  innervate  the 
movements  of  the  larynx.  Their  share  in  the 
nerve-supply  to  the  pharynx  is  unsettled,  but  it 
is  probable  that  the  levator  palati  is  supplied 
by  these  fibres,  since  paralysis  of  the  vocal  cord, 
tongue,  and  palate  is  occasionally  due  to  disease 
at  the  surface  of  the  medulla  in  this  region 
(Hughlings  Jackson).  The  lower,  spinal,  fibres 
of  the  nerve  emerge  from  the  side  of  the  cord 
as  low  as  the  sixth  or  seventh  cervical  nervos, 
and  pass  through  the  substance  of  the  lateral 
columns,  arising  from  the  anterior  cornua,  in 
common  with  the  motor  fibres  of  the  upper 
cervical  nerves.  This  spinal  part  of  the  nerve 
ascends  through  the  foramen  magnum,  and  is 
connected  with  the  bulbar  portion  for  a short 
distance  ; the  two  parts  then  separate,  the  latter 
joining  the  pneumogastric,  the  former  passing  to 


SPINAL  ACCESSORY  NERVE.  1456 
the  neck,  and  supplying  the  sternomastoid  and 
the  upper  part  of  the  trapezius. 

1.  Paralysis. — JEtiology. — The  nucleus  of 
origin  of  the  nerve  may  be  diseased  by  slow 
degeneration  of  the  motor  cells,  as  in  progressive 
muscular  atrophy  and  chronic  bulbar  paralysis. 
In  the  former  the  upper  part-  of  the  trapezius, 
supplied  by  this  nerve,  is  usually  affected  later 
than  any  other  muscle ; it  is  the  ultimum  mo- 
riens,  as  Duehenne  called  it.  The  nucleus  of 
origin,  especially  the  bulbar  portion,  may  ba 
damaged  by  acute  processes,  softening  or  hae- 
morrhage (acute  bulbar  paralysis).  The  fibres  of 
origin  are  sometimes  damaged  by  injuries,  such 
as  fracture  or  dislocation  of  the  upper  cervical 
vertebra  ; by  narrowing  of  the  foramen  magnum ; 
by  tumours  external  to  the  cord ; and  especially 
by  meningitis,  syphilitic  or  simple,  in  this  region. 
The  spinal  part  of  the  nerve,  from  its  long 
course,  is  especially  liable  to  suffer.  The  nerve 
is  rarely  injured  in  fractures  of  the  skull.  The 
causes  of  paralysis  of  the  vagal  portion,  after  its 
junction  with  the  pneumogastric,  have  been  con- 
sidered in  the  article  on  diseases  of  that  nerve. 
The  spinal  part,  in  its  course  to  the  muscles, 
may  suffer  in  rare  cases  from  rheumatic  inflam- 
mation, or  from  injury ; may  be  compressed  by 
enlarged  glands ; or  implicated  in  abscesses  in 
its  neighbourhood. 

Symptoms. — Paralysis  of  the  spinal  accessory 
may  be  total,  when  the  disease  involves  the 
nerve  where  both  parts  are  united,  but  is  much 
more  commonly  partial,  on  account  of  the  exten- 
sive origin  of  the  spinal  portion,  and  the  early 
separation  of  the  two  divisions.  The  symptoms 
indicating  disease  of  the  accessory  part  of  the 
nerve,  as  loss  of  movement  of  the  vocal  cords, 
are  described  in  the  article  on  the  pneumogastric 
nerve.  The  paralysis  of  the  palate,  which  is  so 
often  associated,  is  best  recognised  by  the  de- 
fective movement  in  phonation. 

The  loss  of  function  of  the  spinal  portion  of 
the  nerve  is  shown  by  paralysis  of  the  muscles 
which  it  supplies — the  sternomastoid  and  trape- 
zius. Unilateral  paralysis  of  these  muscles  does 
not  affect  the  posture  of  the  head,  but  the  head, 
when  behind  the  vertical  position,  cannot  be  ro- 
tated to  the  opposite  side.  Paralysis  of  the 
trapezius,  which  may  occur  alone  if  the  disease 
of  the  nerve  is  behind  the  sternomastoid,  is  con- 
fined to  the  upper  part  of  the  muscle,  that  pro- 
ceeding from  the  occipital  bone  to  the  clavicle. 
The  middle  part  of  the  muscle  receives  a suffi- 
cient nerve-supply  from  the  cervical  nerves  to 
prevent  conspicuous  paralysis  or  wasting.  The 
loss  of  the  upper  part  alters  the  contour  of  the 
neck,  and  the  shoulder  is  not  raised  in  deep  in- 
spiration. The  shoulder  can,  however,  still  be 
elevated  voluntarily,  this  movement  being  effected 
by  the  middle  part  of  the  muscle.  Abduction  of 
the  arm  by  the  deltoid  is  interfered  with,  on 
account  of  the  loss  of  the  support  afforded  by 
the  upper  part  of  the  trapezius,  and  the  supple- 
mental action  of  other  muscles  causes  a slight 
rotation  of  the  scapula.  The  paralysed  muscles 
undergo  wasting,  which  is  usually  rapid,  and  is 
accompanied  by  the  reactions  which  characterise 
nerve-degeneration. 

Prognosis  and  Treatment. — The  prognosis 
and  treatment  of  paralysis  of  the  spinal  accessory 


] 456  SPINAL  ACCESSORY  NERVE, 
nerve  are  those  of  the  morbid  process  causing 
tho  paralysis.  In  all  cases,  if  the  muscles  waste 
and  present  loss  of  irritability,  electricity  should 
be  applied,  the  voltaic  current  being  in  most 
cases  required. 

2.  Spasm. — The  muscles  supplied  by  the 
spinal  accessory  nerve  are  frequently  the  seat  of 
spasm,  causing  ‘ torticollis,’  or  ‘ wry-neck.’  The 
spasm  is  due  to  an  affection  of  the  centres,  pro- 
bably above  the  nucleus  of  the  nerve,  and  is 
described  in  a special  article.  See  Wry-Neck. 

W.  R.  Gowers. 

SPINAL  CORD,  Diseases  of.— Though 
the  spinal  cord  is  commonly  regarded  as  a single 
organ,  it  is  one  which  is  very  composite  in  struc- 
ture, and  still  more  so  in  function.  It  is  in  part 
(1)  a mere  aggregate  of  connecting  fibres  between 
the  body  generally  and  the  brain— that  is,  an  ac- 
cumulation of  channels  of  conduction  for  sensory 
impressions  of  all  kinds,  both  superficial  and 
deep,  on  their  way  to  the  brain ; and  also  for 
outgoing  motor  incitations  from  the  brain  to  all 
voluntary  muscles  of  the  body,  as  well  as  to 
those  pertaining  to  the  viscera  and  their  ducts, 
and  to  blood-vessels.  In  part,  however,  the 
cord  also  consists  (2)  of  a serial  aggregation 
of  more  or  less  fused  ganglia  having  to  do  with 
the  execution  of  voluntary  and  all  sorts  of  reflex 
actions  ; with  the  functional  activity  of  organs  ; 
and  with  the  nutrition  of  tissues. 

The  structural  bases  for  these  two  principal 
sets  of  functions  are  most  intimately  knit  toge- 
ther; those  of  the  second  set  are  not  wholly  dis- 
tinct from  those  of  the  first — to  a considerable 
extent  they  are  the  same  elements,  capable  of 
being  called  into  play  voluntarily,  as  well  as  in 
a reflex  manner. 

In  order  to  facilitate  references  in  the  special 
articles  on  diseases  of  tho  spinal  cord  to  the 
details  set  forth  in  this  Introduction , it  will  be 
divided  into  a series  of  numbered  sections. 

§ 1.  General  relations  of  the  spinal 
cord. — Continuous  with  the  medulla  oblongata 
above,  the  spinal  cord  begins  at  the  level  of  the 
upper  border  of  the  body  of  the  first  cervical  ver- 
tebra, whilst  it  ends  in  a narrow-pointed  extremity 
opposite  the  upper  part  of  the  body  of  the  second 
lumbar  vertebra,  or  perhaps  a trifle  higher. 
Throughout  the  whole  of  this  extent  it  is  en- 
closed within  the  narrow  spinal  canal,  and  is 
invested  by  two  membranes,  the  pia  mater  and 
the  arachnoid.  Beneath  the  latter  and  in  the 
meshes  of  the  looser  pia  mater  there  is  situated 
(as  over  the  cerebrum)  a certain  amount  of 
cerebro-spinal  or  subarachnoid  fluid.  Envelop- 
ing the  cord  much  more  loosely,  outside  the 
arachnoid,  is  the  firm  spinal  dura  mater. 

§ 2.  Anatomical  Data  concerning  the  Struc- 
ture of  the  Spinal  Cord. 

The  arrangement  of  the  several  anatomical 
components  of  the  spinal  cord  is  essentially 
similar  throughout  its  extent..  Its  two  halves 
are  marked  off  from  one  another  in  front  by 
the  deep  ‘anterior  longitudinal  fissure’  (fig. 
85  a),  and  posteriorly  by  a median  septum  of  con- 
nective tissue  rather  than  by  an  actual  fissure. 
Each  half  contains  a central  mass  or  core  of 

frey  matter,  shaped  something  like  a comma, 
'he  grey  masses  in  the  two  halves  of  the  cord 


SPINAL  CORD,  DISEASES  OF. 

are  turned  back  to  back,  and  are  connected  with 
one  another  by  means  of  an  intervening  bridge 
of  matter,  answering  to  the  ‘grey  commissure.’ 
In  front  of  this  bridge  of  grey  matter  lie  some 
white  fibres,  which  constitute  the  ‘white  com- 
missure.’ Through  the  centre  of  the  grey  commis- 
sure there  runs  a fine  central  canal — the  canal 
of  the  cord — which  is  lined  with  a layer  of  epi- 
thelium-like cells. 

The  thick  anterior  extremity  of  the  grey 
matter  in  each  half  of  the  cord  is  known  as  the 
anterior  cornu , and  the  much  thinner  posterior 
extremity  as  the  posterior  cornu.  This  latter 
approaches  near  to  the  surface  of  the  cord  in  its 
postero-lateral  region,  and  is  here  joined  by  the 
posterior  roots  of  the  spinal  nerves.  Their  point 
of  entry  on  each  side  divides  the  white  substance 
of  the  corresponding  half  of  the  cord  into  pos- 
terior and  antero-lateral  columns.  The  portions 
of  the  white  substance  of  the  cord  lying  behind 
and  between  the  posterior  roots,  constitute  the 
two  posterior  columns , each  of  which  is  again 
subdivided  by  a slight  superficial  fissure  into 
an  external  tract  or  root-cone,  and  an  internal 


Fig.  85.— Transverse  sections  o£  Spinal  Cord,  11  natural 
size.  A.  Through  middle  of  cervical  swelling ; 
a.  col.,  anterior  column  : l.  col.,  lateral  column ; rl. 
tone,  root  zone  ; col.  of  G.,  column  of  Goll ; a.  r.,  ante- 
rior roots  ; p.  r.,  posterior  roots ; a.  corn.,  anterior 
cornu  ; p.  corn.,  posterior  cornu.  B.  Section  through 
mid-dorsal  region.  C.  Section  through  middle  of  lum- 
bar region. 

(These  figures  show,  accurately,  the  relative  propor- 
tions of  the  different  component  parts  of  the  cord  in  the 
three  situations  named.) 

wedge-shaped  portion,  or  ‘ column  of  Goll.'  The 
portions  of  the  white  substance  which  on  each 
side  lie  in  front  of  the  posterior  roots  constitute 
the  antero-lateral  columns.  The  inner  portions 
of  the  anterior  columns  border  upon  the  anterior 
fissure,  hut  there  is  no  real  line  of  demarcation 
to  define  the  bounds  of  the  anterior  and  of  the 
lateral  columns  respectively,  because  the  anterior 
roots  are  connected  with  the  anterior  cornua  in  a 
difluse  or  scattered  manner,  and  not  in  a compact 
bundle  like  that  formed  by  the  fibres  of  each 
posterior  root. 

Eor  some  particulars  concerning  the  blood- 
vessels of  the  spinal  cord,  see  § 6,  (S)  and  (9). 

§ 3.  Physiological  Data  concerning  thi 
Spinal  Cord. 


SPINAL  COED,  DISEASES  OF. 


In-going  cnannel8  of  conduction  to  the 

brain. — The  paths  for  these  impressions  soon 
after  their  entry  into  the  spinal  cord  by  the 
posterior  roots  cross  to  the  opposite  half  of  the 
cord,  decussating  -with  their  fellows  of  the  other 

side. 

Impressions  of  touch,  pressure,  temperature, 
and  tickling  travel  in  the  main  by  the  posterior 
columns — though  probably  some  of  them  ascend 
in  portions  of  the  lateral  columns. 

Impressions  producing  pain,  after  passing  with 
the  nerve-roots  through  portions  of  the  posterior 
columns,  principally  traverse  the  grey  matter  of 
the  cord.  Disease  or. damage  of  tlieso  posterior 
columns,  as  well  as  of  the  grey  matter,  often 
causes  a more  or  less  marked  retardation  in  the 
transmission  of  such  impressions. 

The  path  traversed  by  impressions  from 
muscles  to  the  encephalon  (so  important  for  the 
regulation  of  movements)  is  not  distinctly  known 
— but  it  is  to  be  found  possibly  in  the  posterior 
columns.  These  channels  are  said  by  Brown- 
SSquard  to  decussate  in  the  pons  Varolii,  rather 
than  soon  after  their  entry  into  the  spinal 
cord. 

The  path  for  the  transmission  of  impressions 
from  the  ‘ genital  centres  ’ in  the  lumbar  region 
of  the  cord  to  the  brain,  is  also  probably  situated 
in  the  posterior  columns. 

The  physiological  anatomy  of  the  cord  in  the 
lumbar  rogion  seems  to  be  slightly  different  from 
what  it  is  higher  up  in  the  dorsal  and  cervical 
regions,  since  in  the  former  situation»ordinary 
sensory  impressions  from  the  lower  extremities 
are  said  to  pass  through  the  lateral,  rather  than 
through  the  posterior  columns.  Those  from  the 
pelvic  region,  the  sexual  organs,  the  perinaeum 
and  anal  regions,  however,  are  supposed  to  pass 
upwards  through  the  posterior  columns. 

§ 4.  Outgoing  channels  of  conduction 
from  the  brain. — All  that  is  certainly  known 
concerning  the  paths  for  voluntary  motor  inci- 
tations is  that,  below  the  decussation  of  the 
pyramids,  they  are  to  be  found  mainly  in  the 
posterior  part  of  the  lateral  column  (‘crossed 
pyramidal  tract’).  The  fibres  descend  through 
these  columns  to  different  levels,  according  as 
their  stimuli  are  destined  to  evoke  the  activity 
of  different  nerves  and  muscles;  thus,  if  a move- 
ment of  the  arms  is  to  be  excited,  they  go  only 
as  low  as  to  some  part  of  the  cervical  enlarge- 
ment; but  if  the  movement  is  of  the  legs,  as 


1457 

far  as  to  the  lumbar  swelling.  In  each  case 
such  motor  fibres  then  penetrate  the  grey  matter 
(anterior  horns),  and  come  into  relation  with  some 
of  the  great  nerve-cells  contained  therein,  whence 
outgoing  fibres  arise,  which  cluster  together 
outside  the  cord  and  constitute  the  fibres  of  the 
anterior  roots.  The  motor  paths  for  the  foot 
and  leg,  in  the  lumbar  lateral  column,  are  said 
to  lie  more  towards  the  circumference  of  the  cord 
than  those  for  the  thigh-muscles. 

On  the  other  hand,  some  (see  p.  1460)  of  the 
pyramidal  fibres  of  the  medulla  pass  into  and 
through  the  spinal  cord  on  the  same  side,  that 
is  without  decussating,  and  constitute  the  inner 
part  of  the  anterior  columns  (‘direct  pyramidal 
tract’).  Some  of  its  fibres  are  thought  to  cross 
into  the  anterior  horn  of  the  opposite  side,  by 
means  of  the  anterior  or  white  commissure. 
Whence  these  fibres  come,  and  what  is  their 
precise  function  iu  relation  to  those  of  the 
‘ crossed  pyramidal  tract,’  no  one  as  yet  seems  to 
know.  These  are  questions  still  unsolved  ; the 
only  common  point  of  agreement  is,  that  these 
fibres  of  the  ‘direct  pyramidal  tract’  are  in 
some  way  concerned  with  movement  rather  than 
with  sensation. 

It  is  probably  an  error  to  suppose  that  there 
are  any  special  routes  for  the  conduction  of 
reflex  motor  impulses  from  the  brain,  apart  from 
those  concerned  with  the  excitation  of  voluntary 
movements. 

Again,  it  is  not  known  that  any  separato 
motor  fibres  are  prolonged  into  the  spinal  cord 
from  the  cerebellum.  But  it  seems  highly 
probable  that  certain  of  the  ingoing  channels  of 
conduction  pass  from  the  cord  to  the  cerebellum, 
as  well  as  to  the  cerebrum.  Some  of  these  may 
be  situated  in  the  posterior  median  columns,  and 
some  in  the  outer  part  of  the  lateral  columns 
(‘  direct  cerebellar  tract  ’ of  Flcchsig). 

§ 5.  Spinal  reflexes.— The  reflexes  of  purely 
spinal  mechanism  which  are  of  importance  (by 
their  presence,  absence,  or  variation)  as  indica- 
tions of  disease  of  the  spinal  cord  in  different 
longitudinal  regions  have  been  divided  into  (a) 
the  superficial  or  skin  reflexes,  and  (h)  the  deep 
or  so-called  ‘ tendon  reflexes.’ 

(a)  Skin  reflexes.  The  most  important  of  these 
are  tabulated  below.  The  designation  of  the 
parts  of  the  cord  upon  which  they  severally  de- 
pend is  based  upon  a very  useful  table  published 
hy  Dr.  Gowers. 


Name  of 
Reflex 

Mode  of  Excitation. 

Nature  of  Result 

' 

Level  of  Cord  upon 
which  Reflex  depends 

Plantar  reflex 

Tickling  sole  of  foot 

Movements  of  toes;  of  these 

1st,  2nd,  and  third  sacra 

Gluteal  reflex 

Irritation  of  skin  of  buttock  . 

and  foot ; or  of  these  and  leg. 
Contraction  of  glutsei 

nerves  (lower  part  of 
lumbar  enlargement) 

4th  and  5th  lumbar  nerves 

Cremasteric 

Irritation  of  skin  of  upper  and 

Drawing  up  of  testicle 

1st  and  2nd  lumbar  nerves 

reflex 

Abdominal 

inner  part  of  thigh 
Irritation  of  skin  of  abdomen 

Contraction  of  upper  or  of  lower 

8th  to  12th  dorsal  nerves 

reflex 

Epigastric 

along  edge  of  ribs,  and  above 
Poupart's  ligament 
Stroking  side  of  cbest  over  Gth 

part  of  abdominal  muscles 
A dimpling  of  corresponding 

4th  to  6th  or  7th  dorsal 

reflex 

and  5ch  intercostal  spaces 

side  of  epigastric  region  (con- 

nerves 

j Scapular  reflex 

Irritation  of  skin  in  interscapu- 

traction  of  highest  fibres  of 
rectus  abdominis 
Contraction  of  posterior  axillary 

6th  or  7th  cervical  to  2nd 

lar  region 

fold  (teres),  or  of  several  of 
scapular  muscles 

or  3rd  dorsal  nervea 

92 


1458 


SPINAL  COED,  DISEASES  OF. 


These  skin-reflexes  vary  much  in  different 
individuals,  as  regards  the  facility  with  which 
they  may  be  obtained.  They  are  often  more 
marked  in  children  and  in  women  than  in  men; 
though  when  the  latter  are  of  an  irritable  or 
nervous  temperament,  some  or  all  of  the  skin- 
reflexes  may  in  them  be  well-marked  even  in 
conditions  of  health. 

In  cases  where  extensive  transverse  lesions 
exist,  situated  higher  up  in  the  cord  than  the 
nerves  upon  which  any  of  these  reflexes  depend, 
such  reflexes  are  commonly  supposed  to  be  ex- 
aggerated in  intensity.  This,  however,  is  not 
always  the  case.  Tho  fact  that  this  or  that  reflex 
exists,  shows  not  only  that  the  afferent  and  effe- 
rent nerves,  but  that  the  track  through  the 
spinal  cord  at  the  corresponding  level,  is  practi- 
cally undamaged.  It  is  not,  however,  necessarily 
true  that  absence  of  either  of  the  reflexes  is  an 
indication  of  disease  at  the  corresponding  level 
in  the  spinal  cord.  It  may  be  so  ; but  it  may 
also  be  that  the  disappearance  of  the  reflex  is 
dependent  upon  disease  in  some  part  of  the 
afferent  or  of  the  efferent  nerves,  leaving  the 
cord  itself  intact.  Or  it  may  also  happen  that 
the  particular  reflex  is  simply  not  to  be  obtained 
in  the  individual  under  examination.  Or,  again, 
with  a complete  transverse  lesion  in  the  lower 
cervical  region,  under  certain  conditions,  all  re- 
flexes dependent  upon  lower  portions  of  the  cord 
may  (though  contrary  to  usual  beliefs)  be  abo- 
lished. See  Spinal  Cord,  Softening  of. 

Further,  it  must  be  borne  in  mind  that  in  cer- 
tain cases  of  hemiplegia  (even  where  hemianaes- 
thesia  does  not  co-exist)  these  skin-reflexes  are 
often  notably  diminished  or  even  abolished  on 
the  paralysed  side  of  the  body ; though  the  re- 


verse condition  of  things  will  probably  obtain 
in  regard  to  the  deep  or  ‘ tendon  reflexes  ’ next 
, to  be  considered.  It  will  probably  be  found, 
hereafter,  that  this  repressing  effect  upon  the 
; skin-reflexes  is  associated  with  the  existence 
of  lesions  in  special  parts  of  the  brain,  atd  not. 
with  lesions  in  other  localities,  though  such 
several  sites  are  at  present  very  imperfectly 
known. 

(5)  ‘ Tendon  reflexes.’  Much  discussion  has 
taken  place  as  to  whether  these  are  ‘ reflexes  ’ at 
all,  in  the  proper  sense  of  the  term.  Into  this 
question  we  do  not  propose  to  enter.  The  phe- 
nomena themselves,  to  which  alone  reference 
will  bo  made,  are  chiefly  two  in  number,  namely, 
ankle  clonus ; and  that  variously  known  as  the 
knee  phenomenon , patellar  tendon  reflex , knee  re- 
flex, or  knee  jerk. 

There  is  a distinct  difference  in  regard  to  these 
j two  phenomena.  The  ‘ knee  j erk  ’ occurs  in  health, 
so  that  it  is  its  absence  which  is  of  principal 
significance  in  certain  diseases.  ‘Ankle  clonus,’ 
on  the  contrary,  is  a phenomenon  not  to  be 
obtained  in  a state  of  health,  so  that  its  pres- 
ence is  thought  by  some  to  be  a positive  sign  of 
disease  of  the  spinal  cord.  This  is  a view  which 
requires  limitations— and  limitations  of  such  a 
kind  as  to  deprive  the  manifestation  of  ankle- 
clonus  of  much  of  its  diagnostic  significance. 
It  may  exist,  for  instance,  after  one-sided  fits 
dependent  upon  disease  of  the  cerebral  cortex; 
and,  again,  it  may  exist  to  a well-marked  ex- 
tent where  the  antero-lateral  columns  of  the 
cord  are  pressed  upon  at  a certain  level,  even 
though  (as  in  the  condition  above  referred  to) 
no  lateral  sclerosis  of  the  cord  has  been  de- 
veloped. 


Name  of 
Reflex 

Mode  of  Excitation 

Nature  of  Result 

Level  of  Cord  upon 
which  Reflex  depends 

Knee  jerk 

By  striking  patellar  tendon 
with  edge  o£  hand  or  with 
percussion  hammer,  whilst 
leg  hangs  loosely  over  fellow, 
or  over  forearm  of  operator. 
Also  by  striking  quadriceps 
tendon,  above  patella 

A single  upward  jerk  of  tho 
leg  and  foot,  slight  or  distinct 

2nd  and  3rd  la  in  bar  nerves 

Antle  clonus  . 

With  knee  extended  or  very 
slightly  flexed,  b}r  pressing 
quickly  and  firmly  against 
anterior  part  of  sole  of  foot 
(so  as  to  stretch  calf-muscles) 
and  then  keeping  up  the  pres- 
sure 

A series  of  clonic  contractions 
at  the  ankle-joint,  continuing 
as  long  as  the  pressure  is 
maintained,  and  instantly 
ceasing  -when  it  is  relaxed. 

If  the  condition  is  very 
highly  marked,  it  may  spread 
to  the  whole  limb,  or  even  to 
that  of  the  opposite  side. 

1st  to  3rd  sacral  nerves 
(lower  part  of  lumbar 
enlargement) 

Both  these  physical  signs  have  lately  attracted 
much  attention.  /Inkle  clonus  was  originally 
described  by  Brown-Sequard  in  1858;  it  was 
more  particularly  defined  in  the  human  subject 
by  MM.  Charcot  and  Vulpian  in  1866;  audits 
diagnostic  importance  has  since  been  repeatedly 
enforced  by  these  observers.  In  1874  the  me- 
chanism of  the  knee-jerk,  and  the  fact  of  its 
absence  in  certain  spinal  diseases,  especially 
locomotor  ataxy,  began  almost  simultaneously 
to  engage  the  independent  attention  of  Erb  and 
of  Westphal,  and  subsequently  of  many  other 
observers. 

For  a brief  reference  to  tho  functional  acti- 


j vity  of  the  vaso-motor  centres,  and  of  their  nerves 
j emanatingfromthespinal  cord, see  § 9,  (4)and(5). 

§ 6.  Pathological  Data  concerning  the 
Spinal  Cokd.  (General  -Etiology  and  Pa- 
thology.) The  spinal  cord  itself  may  be  da- 
maged by  disease  invading  it  from  without — that 
is,  taking  origin  either  in  the  bony  canal  or  in  the 
enveloping  membranes;  or  it  may  be  the  seat  of 
intrinsic  pathological  changes.  As  the  former 
conditions  may  and  do  constantly  produce  func- 
tional derangements  or  actual  structural  changes 
of  a secondary  order  in  the  cord  itself,  we  must 
take  cognisance  of  them  here,  so  that  the  various 


SPINAL  COED, 

peculiarities  as  to  their  occurrence  may  be  made 
known  and  considered  side  by  side  with  those 
pertaining  to  the  different  causes  of  disease  of 
intrinsic  origin,  from  which  they  have  to  be  dis- 
tinguished at  the  bedside. 

(a)  Extrinsic  causes. 

(1)  Stabs  or  bullet-wounds  may  involve  limited 
regions  and  parts  of  the  spinal  cord. 

(2)  Fracture  with  dislocation  of  some  of  the 
vertebra  (as  results  of  severe  falls  or  other  me- 
chanical violence)  exists  as  an  occasional  cause  of 
an  associated  paraplegia,  produced  by  the  crush- 
ing of,  or  pressure  upon,  the  spinal  cord.  This 
;S  most  apt  to  occur  in  the  cervical  region, 
though  the  dorsal  and  lumbar  regions  are,  to  a 
less  extent,  liable  to  similar  accidents. 

(3)  Scrofulous  caries  of  the  vertebra  may  exist 
in  either  region,  and  may  or  may  not  be  asso- 
ciated with  angular  curvature  in  a corresponding 
portion  of  the  spine.  The  paraplegia  or  other 
result  of  interference  with  the  functions  of  the 
cord  in  the  majority  of  cases  of  this  disease,  is 
not  duo  so  much  to  its  compression  by  diseased 
bone,  as  to  the  irritation  and  subsequent  com- 
pression of  the  cord  by  inflammatory  products. 

(4)  Cancer  of  the  vertebra  occurs  either  as 
a primary  or  as  a secondary  affection.  Such  a 
new  growth  may  involve  the  dura  mater  or  not, 
and  as  it  grows  it  may  at  first  irritate  and  sub- 
sequently compress  the  spinal  cord  itself. 

Other  diseases  of  the  spine  are  rare  as  causes 
of  disease  of  the  spinal  cord.  Still  aneurysmal 
erosion  of  vertebrae  with  subsequent  pressure 
upon  the  cord  must  not  be  forgotten,  and  rarely 
an  aneurism  bursts  into  the  spinal  canal.  Ex- 
ostoses and  enchondromatous  growths  from  the 
bones  may  also  quite  rarely  compress  the  cord. 

(a)  Cancer  of  the  spinal  meninges,  or  new 
growths  of  other  kinds  ( see  Meninges,  Spinal, 
Diseases  of),  may  also  involve  irritation,  and 
subsequently  compression,  of  the  anterior  or  pos- 
cerior  nerve-roots  or  of  the  spinal  cord  itself  in 
one  or  other  region.  Hydatids,  again,  should  be 
remembered  as  possible  causes  of  spinal  disease, 
especially  where  their  existence  has  already  been 
detected  in  the  body  in  other  situations. 

(6)  Hemorrhage  into  or  upon  the  Meninges. 
See  Meninges,  Spinal,  Diseases  of. 

The  foregoing  groups  of  causes  of  disease 
of  the  spinal  cord,  give  rise  to  sets  of  symptoms 
having  a generic  resemblance,  because  in  each 
case  compression  acts  upon  the  cord,  or  upon  the 
spinal  roots  and  cord,  from  without,  in  one  or 
other  direction. 

(b)  Intrinsic  causes. 

(7)  Hemorrhage  occurs  with  extreme  rarity 
in  the  spinal  cord.  This  is  due,  in  the  main, 
to  the  firmer  texture  of  the  cord,  and  to  the 
greater  abundance  of  supporting  connective  tis- 
sue around  its  blood-vessels,  as  compared  with 
those  of  the  brain.  When  haemorrhage,  cf  idio- 
pathic origin,  does  take  place  into  the  spinal 
cord,  it  almost  invariably  occurs  in  the  softest 
portion  of  the  organ,  namely,  its  central  core  of 
grey  matter — and  in  this  region  it  may  extend 
for  some  distance  upwards  and  downwards.  As 
a result  of  falls  or  blows,  also,  haemorrhage  into 
the  substance  of  the  cord  is  a lure  event ; still, 
under  these  conditions,  it  occurs  occasionally — 
mostly  in  association  with  laceration  of  the  sub-  ( 


DISEASES  OF.  1459 

stance  of  the  cord.  Of  this  latter  kind  of  lesion, 
resulting  from  a fall  from  a height  of  about  -25 
feet,  the  writer  has  recorded  a remarkable  in- 
stance ( Med- Chirurg.  Trans.  voL  L,  1867),  in 
which,  although  the  cord  was  lacerated,  there 
was  no  external  wound  and  no  fracture  or  dis- 
location of  vertebrae. 

(8)  Embolism,  occurs  -with  great  rarity  in  the 
spinal  cord,  and  is  still  more  seldom  recognised 
when  it  does  occur.  This  is  due  to  the  fact  of 
the  small  size  of  the  arteries  of  the  cord — the 
absence  amoDg  them  of  any  large  trunk,  like  the 
middle  cerebral,  coming  off  more  or  less  directly 
from  one  of  the  great  vessels  arising  from  the 
arch  of  the  aorta.  Emboli  reach  the  brain  much 
more  rarely  by  way  of  the  vertebrals  than  by 
way  of  the  carotids-;  and  the  principal  arteries  of 
the  spinal  cord  are  either  direct  offsets  from  the 
vertebral  (anterior  spinal),  or  indirect  brandies 
from  the  same  (posterior  spinal) — the  latter  aris- 
ing from  the  inferior  cerebellar,  which  are  twigs 
from  the  termination  of  the  basilar  artery.  Apart 
from  these  vessels,  the  blood-supply  of  the  cord 
comes  from  still  smaller  twigs,  derived  from  the 
intercostal  and  lumbar  arteries,  which  anasto- 
mose with  and  reinforce  the  anterior  and  pos- 
terior vessels,  at  intervals,  along  the  whole  length 
of  the  cord.  All  the  principal  vessels,  small 
though  they  are,  seem  to  anastomose  freely  with 
one  another.  Thus,  even  if  embolism  of  spinal 
arteries  should  occur  at  times,  as  it  probably 
does,  its  effects  would  be  diminished  in  impor- 
tance and  obscured  clinically  as  well  as  post 
mortem,  by  reason  of  these  vessels  not  being 
* end  ’ arteries. 

(9)  Thrombosis  would,  however,  be  capable 
of  occurring  in  diseased  spinal  arteries,  as  well 
as  in  those  of  other  parts  of  the  body.  Sub- 
sequent observations  may  perhaps  show  that 
degenerative  changes  or  endarteritis  are  particu- 
larly common  in  the  spinal  arteries,  so  that  the 
occurrence  of  thrombosis  in  them  would  thereby 
be  rendered  all  the  more  easy  and  likely  to  occur. 
A similar  process  may  also  take  place  in  the 
peculiarly  tortuous  network  of  veins  which 
surrounds  the  spinal  cord  on  all  sides — perhaps 
even  with  more  facility  than  in  the  veins  of 
other  parts — when  general  and  other  local  con- 
ditions favour  its  occurrence.  Ollivier  calls  at 
tention  to  the  probably  natural  slowness  of  the 
blood-current  through  the  spinal  veins,  and  to 
the  multiplicity  of  causes  which,  owing  to  their 
influence  upon  respiration  and  cardiac  action, 
tend  still  further  to  retard  it — such  as  violent 
emotions  or  efforts,  and  those  diseases  which 
greatly  interfere  with  respiration,  or  with  the 
force  and  regularity  of  the  heart’s  action.  He 
adds  that  he  has  often  seen  in  elderly  persons 
fibrinous  clots  filling  the  veins  of  the  cord,  as 
well  as  those  which  accompany  its  nerve-roots. 

Thus  one  of  the  common  causes  of  ordinary 
degenerative  softening  as  it  occurs  in  the  ence- 
phalon, would  also  he  operative  in  the  cord. 

(10)  White  softening  of  the  spinal  cord  is  very 
common  ; often  implicating  its  whole  transverse 
area  for  a variable  extent.  It  differs  in  no 
respect  in  its  naked-eye  or  microscopical  appear- 
ances from  the  process  as  it  is  met  with  in  the 
encephalon.  It  is  altogether  unreasonable  to 
assume,  in  accordance  with  current  nomencla- 


(460  SPINAL  CORD, 

ture,  that  this  condition  is  mostly  a result  of 
inflammation  and  therefore  to  he  spoken  of  as  a 
myelitis , when  the  pathologists  of  our  time  have 
declared  that  the  similar  process  in  the  cerebrum 
and  cerebellum  is  mostly  of  degenerative  origin. 

(11)  Myelitis.— The  writer  is  far  from  deny- 
ing that  primary  inflammation  may  involve  areas 
of  the  cord,  and  entail  ‘softening’  of  its  sub- 
stance. He  believes,  however,  that  ‘ acute  mye- 
litis’ is  far  more  likely  to  occur  as  a secondary 
process,  in  connection  with  pressure  upon  and 
consequent  irritation  of  some  part  of  the  cord, 
encroached  upon  by  fractures  or  dislocations  of 
the  vertebrae,  or  otherwise  wounded ; also  as  an 
occasional  sequela  of  scrofulous  vertebral  caries, 
of  the  direct  pressure  made  upon  the  cord  by 
some  meningeal  tumour,  or  of  haemorrhage  into 
its  substance.  Yet  he  is  far  from  believing  that 
all  the  secondary  softenings  met  with  in  the 
spinal  cord  are  necessarily  of  inflammatory 
origin.  Many  of  these  also  are  due  to  degenera- 
tive rather  than  to  inflammatory  causes. 

Processes  of  degenerative  ‘ softening’  are 
mostly  brought  about  quickly,  and  they  would, 
in  the  main,  correspond  with  what  is  commonly 
spoken  of  as  1 acute  myelitis.’  As  for  ‘ chronic 
myelitis  ’ (in  the  commonly  understood  sense  of 
chronic  softening)  the  writer  believes  that  no 
such  disease  should  be  any  longer  described. 
Many  ‘softenings’  are  in  a certain  sense  chronic, 
as,  though  they  may  be  more  or  less  abrupt  in  their 
onset,  they  tend  to  last  long  rather  than  to  kill 
quickly.  Again,  other  maladies  which  the  older 
physicians  would  have  ascribed  to  ‘chronic  mye- 
litis’ or  ‘chronic  softening,’  are  now  known  to 
partake  more  of  the  nature  of  chronic  indurations, 
and  to  have  as  their  bases  processes  of  sclerosis. 

(12)  Processes  of  sclerosis  are  extremely  com- 
mon in  the  spinal  cord.  In  nature  they  are 
over-growths  of  the  connective  tissue  of  this 
organ  altogether  similar  to  those  occurring  in 
other  organs  and  tissues,  under  the  name  of 
‘fibroid  substitutions’  or  ‘ non-inflammatory 
hyperplasias  of  connective  tissue.’  Yet  here, 
again,  certain  pathologists  would  have  us  see  re- 
sults of  inflammation,  and  they  accordingly  speak 
of  such  changes  as  examples  of  ‘ chronic  mye- 
litis.’ Sclerosis  occurs  under  various  forms,  and 
constitutes  the  basis  of  several  distinct  diseases, 
which  are  in  all  cases  gradual  and  more  or  less 
slow  in  their  onset,  as  well  as  in  their  progress. 
It  may  occur  (a)  as  a diffuse  general  overgrowth 
(after  the  manner  of  a cirrhosis  in  other  organs) ; 
(b)  in  the  form  of  bands  limited  to  particular 
columns  of  the  cord  (especially  the  posterior  and 
the  lateral) ; or  (c)  in  an  insular  manner,  so  as 
to  form  islets  of  sclerosis,  scattered  altogether 
irregularly  through  the  cord  at  different  levels, 
as  in  ‘disseminated  sclerosis.’ 

(13)  Tissue-changes  allied  to  these  in  theirre- 
sults  or  later  stages,  though  they  have  a peculiar 
history  and  course  of  their  own  at  the  com- 
mencement, are  tho  so-called  ‘secondary  de- 
generations' which  occur  in  certain  regions  of 
the  cord  as  a result  either  of  some  previous 
damage  or  injury  to  this  organ  itself,  or  as  a 
sequence  of  brain-disease. 

These  ‘ secondary  degenerations  ’ illustrate  facts 
originally  made  known  by  Waller,  but  which  were 
confirmed  and  extended  by  Phillipeaux  and  Yul- 


DISEASES  OF. 

pian,  to  the  effect  that  when  nerve-fibres  are 
severed  from  their  connections  with  ganglion- 
cells  situated  at  one  or  other  extremity,  the 
white  substance  of  Schwann  gradually  breaks  up 
in  the  course  of  seven  to  fourteen  days,  and  un- 
dergoes a process  of  fatty  degeneration,  by  which 
it  is  ultimately  resolved  into  a multitude  of 
mere  molecules  and  fat-particles.  The  white 
columns  of  the  cord  are  composed  of  great  aggre- 
gations of  nerve-fibres  running  parallel  with  ont 
another,  so  that  when  one  of  these  columns  is  cut 
across,  or  when  the  continuity  of  its  fibres  is 
interrupted  by  some  severe  lesion  occurring  in 
their  midst,  a process  of  ‘secondary  degenera- 
tion ’ manifests  itself  simultaneously  in  all  the 
fibres  thus  damaged ; and  the  united  result  ap- 
pears as  a band-like  tract  of  degeneration,  run- 
ning upwards  or  downwards  in  the  particular 
column  of  the  cord  affected. 

In  order  to  deal  as  briefly  with  this  subject 
as  possible,  it  may  be  said  that  experience  has 
hitherto  shown  that  such  band-like  tracts  of 
‘ secondary  degeneration  ’ occur  especially  in  each 
lateral  half  of  the  cord,  in  three  situations, 
namely,  (1)  in  the  lateral  columns;  (2)  in  the 
inner  portions  of  the  anterior  columns ; and  (3) 
in  the  posterior  columns.  The  degenerations  in 
the  lateral  and  anterior  columns  take  place  in 
each  in  a direction  downwards  from  the  site  of 
section  or  lesion  of  the  fibres,  at  whatever  level 
the  damage  may  chance  to  exist ; whilst  those  in 
the  posterior  columns  take  place  in  an  upward 
direction,  starting  from  the  section  or  seat  of 
destructive  lesion  by  which  these  columns  may 
be  invaded. 

The  fibres  that  undergo  the  descending  de- 
generation in  the  lateral  columns  are  generally 
believed  to  be  those  which  transmit  volitional 
stimuli  to  the  various  voluntary  muscles  of  the 
body,  and  which  have  been  previously  alluded  tc 
as  coming  into  relation  with  motor  cells  in  the 
anterior  cornua  at  different  levels.  These  different 
fibres  are  supposed  to  enter  the  lateral  columns  at 
the  commencement  of  the  spinal  cord,  passing  into 
them,  in  fact,  as  a result  of  the  ‘decussation  of 
the  pyramids.’  Thus,  the  motor  tract  continued 
downwards  from  one  corpus  striatum,  let  us  say 
the  left,  continues  along  the  crus  and  through 
the  pons  on  the  same  side ; thence  passing  into 
the  medulla  a considerable  proportion  of  its  fibres 
decussate  with  their  fellows  and  thereby  reach  the 
right  lateral  column,  down  which  they  proceed  as 
a compact  group  in  the  manner  indicated.  The 
remainder  of  the  fibres  of  the  left  motor  tract 
(those  which  do  not  decussate)  pass  down  also 
in  a compact  body  and  occupy  most  of  the  inner 
half  of  the  right  anterior  column.1  Thus,  if 
the  whole  of  tho  left  motor  tract  be  seriously 
damaged  or  cut  across  in  the  corpus  striatum  or 
at  any  point  above  the  ‘ decussation  of  the  pyra- 
mids ’ we  should  have  a small  band  of  degenera- 
tion in  the  anterior  column  on  the  same  side, 
and  also  a larger  band  of  degeneration  in  the  op- 
posite (or  right) lateral  column  (fig.  86,  H) — that 
is,  we  should  have  the  form  of  secondary  degene- 
ration associated  with  many  cases  of  hemiplegia. 

■ Tnough  this  is  the  rule,  yet  it  would  appear  from 
the  observations  of  Flechsig  that  developmental  anomalies 
are  apt  to  occur,  so  that  the  relative  proportion  between 
the  decussating  and  the  non-decussating  fibres  is  subject 
to  much  variation  in  different  individuals 


SPIN  AX  COED,  DISEASES  OF. 


H61 


But  if  there  be  complete  section  of  or  destructive 
disease  involving  the  antero-lateral  columns  of 
one  side  of  the  cord  itself,  then  we  should  have 
a band  of  degeneration  in  the  anterior,  as  well 
as  in  the  lateral,  column  of  the  same  half  of  the 
cord.  Or  if  either  column  be  cut  or  damaged 
singly,  then  in  such  column  a band  of  degenera- 
tion would  be  found  extending  downwards  from 


are  represented  in  fig.  87>  Px,  in  the  upper  cervical 
region  and  in  the  medulla.  He  then,  as  he 
has  since,  found  ascending  areas  of  degeneration 
occupying  the  superficial  portion  of  the  lateral 
columns,  which  were  traced  upwards  into  the 
restiform  bodies.  It  would  seem  possible  that 
the  fibres  which  undergo  degeneration  in  this 
latter  case  correspond  with  those  of  the  direct 


Pig.  86.— P.  Showing  descending  areas  of  degeneration  : 
a.  in  inner  part  of  anterior  columns ; l.  in  lateral 
columns  (mid-dorsal  region).  Case  of  paraplegia,  from 
oomplete  transverse  softening  in  upper  dorsal  region. 

U.  Showing  descending  degenerations  in  case  of  right 
hemiplegia , from  extensive  softening  of  left  corpus 
striatum.  (Twice  natural  size.) 


the  seat  of  lesion.  Or  if,  as  so  frequently  hap- 
pens, we  have  to  do  with  a total  transverse  lesion, 
represented  for  instance  by  a focus  of  softening 
extending  through  the  whole  thickness  of  the 
cord  in  the  upper  dorsal  or  in  some  other  region 
(so  that  the  patient  suffers  from  complete  para- 
plegia), we  should  then  find  large  areas  of  secon- 
dary degeneration  in  each  lateral  column  below, 
as  well  as  smaller  areas  in  the  inner  part  of  each 
anterior  column  (fig.  86,  P).  The  areas  in  both 
situations  become  less  extensive  as  they  descend, 
and  gradually  wear  themselves  out  in  the  lower 
part  of  the  lumbar  swelling  (see  Med.-Chir. 
Trans,  vol.  1.,  pi.  x.).  It  was  stated  by  Bouchard, 
and  has  been  commonly  repeated  by  succeeding 
writers,  that  the  areas  in  the  anterior  columns 
do  not  appear  beyond  the  mid-dorsal  region,  but 
this,  as  the  writer  pointed  out  in  1867,  is  cer- 
tainly not  the  rule. 

In  such  a case  as  that  last  cited,  namely,  one  of 
paraplegia  due  to  a total  transverse  lesion  in  the 
upper  dorsal  region,  there  would  he  found  above 
the  seat  of  lesion  certain  ascending  degenerations 
— the  principal  of  which  would  be  situated  in 
the  posterior  columns,  though  others  smaller  and 
less  commonly  known  are  to  be  met  with  in  the 
outer  part  of  the  lateral  columns  (fig.  87,  P).  The 
ascending  degenerations  in  the  posterior  columns 
are  often  strictly  limited  to  the  so-called  ‘ columns 
of  Goll.’  Situated  on  each  side  of  the  posterior 
median  fissure,  they  together  constitute  a median 
wedge-shaped  patch,  whose  apex  extends  for- 
wardstothe  commissure,  and  whose  base  is  at  the 
posterior  surface  of  the  cord.  This  band  of  dege- 
neration reaches  upwards  to  the  medulla,  though 
the  exact  course  of  its  fibres  through  this  region 
is  uncertain.  Nothing  definite,  indeed,  is  known 
as  to  the  functions  subserved  by  the  fibres  com- 
posing the  ‘ columns  of  Goll.’  It  seems  clear,  how- 
ever, that,  under  certain  conditions,  the  areas  of 
ascending  degeneration  in  the  posterior  columns 
may  be  differently  arranged,  and  not  completely 
limited  to  the  ‘ columns  of  Goll,’  since  in  a case 
with  a lesion  of  some  kind  in  the  mid-cervical 
region  (whose  nature  is  not  known  because,  un- 
fortunately, this  part  of  the  cord  was  not  pre- 
served) the  writer  long  ago  found  such  areas  as 


Px 


P 


Fig. 87. — P.  Showing  ascending  areas  of  degeneration: 
p,  in  columns  of  Goll ; and  l,  along  outer  border  of 
lateral  columns,  in  middle  of  cervical  swelling.  Case  of 
paraplegia,  from  complete  transverse  softening  in 
upper  dorsal  region. 

Px.  Different  arrangement  of  ascending  areas  in  poste- 
rior columns  in  upper  cervical  region.  (See  Trans  oj 
Med.-Chir.  Soc.,  vol.  1.,  18G7,  pi.  ix.)  (Twice  natural 
size.) 

1 cerebellar  band,’  located  by  Flechsig  in  this 
situation.  Such  fibres  would  be  afferent  in  func- 
tion, but  would  probably  only  constitute  a small 
part  of  the  afferent  fibres  going  to  the  cere- 
bellum. (Nothing  is  known  at  present  as  to  any 
band  of  efferent  or  motor  fibres  entering  the  cord 
from  the  cerebellum,  and  none  such  may  exist. 
The  cerebellar  influence  upon  the  motor  tract 
— of  whatever  nature — may  be  expended  upon 
certain  centres  situated  in  the  pons  varolii,  or 
even  in  the  corpora  striata.) 

In  these  areas  of  degeneration,  in  addition  to 
the  changes  already  mentioned  as  occurring  in 
the  nerves  themselves,  other  processes  take  place. 
There  is,  for  instance,  a very  distinct  but  secon- 
dary overgrowth  of  the  connective  tissue  through- 
out the  diseased  area,  as  well  as  an  abundant 
development  of  large  granulation-corpuscles,  pre- 
cisely similar  to  those  met  with  in  ordinary  foci 
of  softened  nerve-tissue.  The  granulation-cor- 
puscles are  closely  packed  amongst  the  meshes 
of  the  connective-tissue  overgrowth  and  the 
atrophied  nerve-fibres  (see  Med.-Chir.  Trans., 
vol.  1.  pi.  xi.  figs.  19,  20).  In  preparations  which 
have  been  immersed  in  bichromates  or  in  chromic 
acid,  these  corpuscles  do  not  become  stained  to 
anything  like  the  same  extent  as  the  healthy 
nerve-tissues  ; hence  the  areas  containing  them 
remain  pale,  and  are  consequently  to  be  traced 
with  the  greatest  ease  in  spinal  cords  which  have 
been  immersed  for  a week  or  two  in  these  fluids, 


1462  SPINAL  COED, 

though  when  they  were  in  the  fresh  state  no 
such  areas  may  have  been  detectable,  even  on 
the  most  careful  examination,  by  the  naked  eye. 

(14)  New  growths  in  the  substance  of  the  spinal 
cord  itself  are  not  very  common,  nor,  on.account 
of  the  limitations  of  space  within  the  spinal 
canal,  do  they  ever  attain  a very  large  size.  For 
this  situation  a growth  equalling  a hazel-nut  in 
bulk  would  he  esteemed  large.  In  regard  to  the 
nature  of  the  growth,  this  is,  of  course,  a matter 
of  purely  pathological  interest,  since  the  clinical 
signs  and  symptoms  which  a growth  in  the  spinal 
cord  is  capable  of  causing  would  not  vary  with 
its  nature,  but  would  be  wholly  dependent  upon 
its  situation  and  its  rate  and  manner  of  increase. 
Cancer  occurs  within  the  spinal  cord  almost  solely 
as  a secondary  extension  from  a similar  growth 
pre-existing  in  the  dura  mater  or  in  the  vertebrae, 
or  possibly  in  more  distant  parts.  In  altogether 
exceptional  cases  it  may  occur  primarily  in  the 
spinal  cord.  Gliomata,  sarcomata,  and  myxo- 
matam  ay  also  occasionally  be  met  with,  either  in 
pure  or  in  blended  types.  Tubercular  or  scrofu- 
lous nodules  are  also  apt  to  occur,  either  alone 
or  in  combination  with  a tubercular  meningitis. 
Syphilitic gummata  may  likewise  be  found  in  the 
substance  of  the  cord,  though  their  presence  in 
this  situation  is  not  so  frequent  as  it  is  in  asso- 
ciation with  the  spinal  meninges. 

(15)  Atrophy  with  degeneration  of  ganglion-cells 

is  apt  to  occur  as  a secondary  process  with  ex- 
treme frequency  in  portions  of  the  grey  matter 
of  the  cord  which  happen  to  be  more  or  less  im- 
plicated by  other  contiguous  pathological  changes. 
But  in  two  or  three  distinct  diseases  the  ganglion 
cells  of  the  anterior  cornua,  in  different  parts  of 
the  cord,  are  prone  to  be  suddenly  overtaken  by  an 
stiologically  obscure  and  altogether  inexplicable 
failure  of  nutrition,  which  speedily  reveals  itself 
by  entailing  an  atrophy  of  the  particular  cells 
affected.  This,  for  instance,  occurs  as  the  ana- 
tomical basis  of  ‘ infantile  paralysis,’  and  of  the 
similar  form  of  paralysis  now  known  to  occur 
(though  more  rarely)  in  adults.  In  these  diseases 
whole  groups  of  contiguous  and  functionally-re- 
lated cells  are  affected  simultaneously,  and  as  the 
atrophy  progresses,  there  is  generally  evidence 
of  a secondary  overgrowth  of  the  neuroglia  sur- 
rounding such  nerve-cells,  in  the  anterior  cornua. 
To  assume  that  this  process  is  inflammatory  in 
type,  as  the  terms  ‘cornual  myelitis’  or  ‘acute 
anterior  polio-myelitis’ imply,  seems  to  the  writer 
altogetherunwarrantable.  Inflammation  does  not 
limit  itself  to  individual  tissue-elements,  and  the 
slight  overgrowth  of  the  contiguous  neuroglia 
may  well  be  a secondary  process  of  simple  hyper- 
plasia. This  latter  process  is  indeed  less  evident 
where,  as  in  ‘ progressive  muscular  atrophy,’  the 
initial  and  mysterious  atrophy  of  individual  gan- 
glion-cells occurs  more  slowly  and  more  sparsely. 
Cells,  here  and  there  in  particular  groups,  -undergo 
in  this  affection  the  atrophic  process,  leaving 
others  around  them  for  a time  as  healthy  as 
ever.  Yet,  as  the  disease  progresses,  the  ranks 
of  the  healthy  cells  become  gradually  thinned  in 
an  altogether  irregular  manner ; and  this  atrophy 
of  nerve-cells,  as  it  occurs,  speedily  entails,  for 
reasons  to  be  set  forth  in  the  next  section,  a 
corresponding  atrophy  of  functionally  related 
muscular  fibres.  , 


DISEASES  OF. 

§ 7.  Trophic  Relations  between  different 
Tissues  and  different  parts  of  the  Spinal 
Cord. — Irritation  of  the  posterior  cornua,  or  of 
the  posterior  roots  of  the  spinal  nerves,  may  give 
rise  to  various  pustular  or  vesicular  eruptions 
in  related  portions  of  the  skin,  often  associated 
with  neuralgic  pains  in  these  same  regions.  In 
other  cases,  with  lesions  in  some  parts  of  the 
grey  matter,  ulceration  or  actual  sloughing  of 
certain  related  tracts  of  skin  are  easily  deter- 
mined— especially  under  the  combined  influence 
of  continued  external  pressure  and  frequent  irri- 
tation from  urine  or  faeces,  as  in  some  cases  of 
paraplegia. 

Degeneration  or  destruction  in  any  way  of  the 
great  ganglion-cells  of  the  anterior  cornua,  or 
of  the  anterior  roots  of  the  spinal  nerves  (either 
within  or  outside  the  cord),  gives  rise,  in  the 
course  of  two  or  three  weeks,  to  atrophy  of  the 
muscle-fibres  with  which  such  cells  or  nerve- 
roots  are  in  relation.  Wo  thus  get  an  atrophic 
paralysis,  associated  with  the  electrical  ‘reaction 
of  degeneration.’ 

Certain  diseases  affecting  the  grey  matter  of 
the  cord  (in  ways  and  sites  which  cannot  be  pre- 
cisely defined)  are  also  apt  to  be  associated  with 
chronic  diseases  of  the  joints.  Sometimes  com- 
paratively unimportant,  they  lead  in  other  in- 
stances to  great  atrophy  of  the  articular  ends  of 
the  bones,  and  possibly  to  dislocation  with  utter 
destruction  of  the  joint,  as  in  some  cases  of  loco- 
motor ataxy.  Atrophy,  with  brittleness  of  bones, 
may  also  be  metwith  in  the  same  orin  allied  cases. 

The  fact  of  the  existence  of  these  trophic 
troubles  in  association  with  such  lesions,  may  be 
admitted  wholly  irrespective  of  the  explanation 
of  their  pathogenesis.  Whether  they  are  due  to 
altered  states  or  influences  transmitted  by  or- 
dinary motor  and  sensory  nerves  in  relation  with 
such  tissues,  or  to  altered  influences  through  cer- 
tain purely  hypothetical  ‘trophic  nerves, Ties  alto- 
gether outside  the  fact  of  the  mere  co-existence 
of  the  several  trophic  troubles  with  the  several 
lesions — which  is  the  point  of  more  immediate 
interest  for  the  practitioner  of  medicine. 

§ 8.  General  Symptomatology,  and  General 
and  Regional  Diagnosis. — Taking  them  in  con- 
junction with  some  of  the  simpler  principles  of 
nerve-physiology,  the  practitioner  has  to  make 
use  of  the  various  kinds  of  data  above  enume- 
rated in  the  investigation  of  the  precise  nature 
of  every  case  of  disease  of  the  spinal  cord  which 
comes  before  him.  Under  the  word  ‘ nature’  we 
include,  of  course,  both  sides  of  the  diaguosis 
that  has  to  be  made,  namely,  the  regional  and 
the  pathological. 

The  practitioner  is  compelled  to  interpret  the 
patient’s  symptoms,  and  the  various  signs  he  is 
able  to  recognise  for  himself,  by  the  aid  of  such 
data  when  he  attempts,  for  instance,  to  ascertain 
what  parts  of  the  cord  are  damaged,  and  in  what 
order  they  have  been  implicated.  He  may  wish 
to  know  whether  the  posterior  or  the  lateral 
columns  are  specially  involved ; whether  the  grey 
matter  is  much  damaged;  and,  if  60,  whether 
the  damage  more  particularly  affects  the  anterior 
cornua  or  other  parts.  Again,  he  may  wish  to 
know  whether  the  anterior  or  the  posterior  spi- 
nal nerve-roots  are  specially  involved;  and,  if  sa 


SPINAL  COED, 
whether  they  are  merely  irritated  or  more  severely 
damaged,  and  -whether  they  have  been  simul- 
taneously or  successively  affected.  For  the  pre- 
sent we  shall  concern  ourselves  with  this  aspect 
of  the  problem  only,  though  it  will  subsequently 
be  shown  in  our  account  of  the  several  diseases 
of  the  spinal  cord  what  light  the  coexistence  of 
certain  groups  of  these  facts  throws  upon  the 
other  aspect  of  the  problem,  namely,  upon  the 
question  of  the  pathological  nature  of  the  lesion. 

Some  of  the  facts  already  cited  have,  however, 
to  be  translated  into  their  clinical  equivalents, 
and  to  be  supplemented  by  others  derived  more 
exclusively  from  the  clinico-pathological  study 
of  spinal  diseases,  in  order  to  form  a series  of 
data  more  immediately  useful  in  the  interpreta- 
tion of  the  phenomena  of  diseases  of  the  spinal 
cord  in  their  regional  relations. 

Regional  Diagnosis. — We  already  possess  a 
number  of  valuable  clinical  data  available  for 
throwing  light  upon  the  regional  side  of  the 
problem  of  diagnosis.  It  must  be  borne  in  mind, 
however,  that  the  regional  diagnosis  of  diseases 
of  tho  spinal  cord  is  itself  a twofold  problem.  It 
involves  a consideration  : (a)  of  the  transverse 
area  involved  ; and  ( b ) of  the  longitudinal  situa- 
tion and  extent  of  the  disease  in  such  areas. 

(a)  Diagnosis  of  the  transverse  area  in- 
volved.— The  facts  to  be  tabulated  under  this 
head  may  be  set  down  in  the  order  of  their  rela- 
tion to  different  component  parts  or  regions  of 
the  spinal  cord. 

(1)  Anterior  roots  of  spinal  nerves. — Irritation 
of  these  may  give  rise  to  various  forms  of  twitch- 
ing or  to  tonic  spasms  in  related  muscles.  Great 
pressure  upon  or  destruction  of  the  anterior  roots 
will  give  rise  to  local  paralysis  in  the  related 
muscles,  followed  in  the  course  of  a week  or  two 
by  marked  atrophy,  and  the  establishment  of 
the  electrical  ‘reaction  of  degeneration’  (see  Pa- 
iulysis,  Motor).  There  will  also  be  an  abolition 
of  reflex  excitability  of  these  muscles  in  response 
to  skin-irritation,  or  from  blows  upon  or  stretch- 
ings of  their  tendons. 

(2)  Antero-latcral  columns. — Increasing  pres- 
sure upon  or  disease  of  these  columns  gives  rise 
to  paresis,  gradually  deepening  into  motor  para- 
lysis of  parts  deriving  their  nerve-supply  at  or 
below  the  seat  of  lesion. 

When  the  disease  occurs  in  the  lateral  column 
more  especially,  there  may  be  twitcliings  or 
Btartings  in  the  muscles  below,  or  well-marked 
spasms,  and  possibly  painful  cramps.  There  may 
also  be  great  exaltation  of  the  superficial  and 
deep  reflexes,  if  the  manifestation  of  the  latter 
is  not  hindered  by  pre-existing  spasms.  Motor 
paralysis  exists  to  some  extent,  but  without  any 
appreciable  impairment  of  sensibility.  No  marked 
wasting  of  muscles,  or  diminution  in  electrical 
reactions,  usually  occurs. 

(3)  Grey  matter. — (a)  Of  anterior  cornua. — 
Disease  of  these  parts  causes  motor  paralysis, 
with  atrophy,  loss  of  faradic  excitability  and 
of  reflex  excitability  in  related  muscles — as  in 
cases  of  disease  of  the  anterior  roots  of  spinal 
nerves. 

(b)  Of  posterior  cornua  and  central  parts. — 
Damage  of  these  regions  of  grey  matter  will,  ac- 
cording to  its  completeness  in  transverse  extent, 
cause  more  or  less  delay  or  defect  in  the  trans- 


DISEASES  OF  it 63 

mission  of  painful  impressions,  and  perhaps  in- 
terfere also  with  other  modes  of  sensibility. 

Some  trophic  lesions  in  skin  and  joints  may 
also  be  met  with  (see'§  7). 

At  different  levels  in  the  cord  special 
centres  (represented  in  both  anterior  and  pos- 
terior regions  of  grey  matter)  in  connection  wit b 
definite  functions,  may  be  interfered  with  tv 
morbid  conditions  implicating  the  grey  matter 
(see  below  § 9 [1-10]). 

(4)  Posterior  columns. — The  results  of  disease 
confined  to  this  situation  (more  especially  to  the 
‘ root-zones  ’)  will  be — ataxy  or  signs  of  inco- 
ordination of  movements  ; interference  with  im- 
pressions of  touch,  pressure,  temperature,  and  of 
‘ muscular  sense  ’ ; abolition  of  knee-reflex  ; and 
diminution  or  loss  of  sexual  desire. 

(5)  Posterior  roots  of  spinal  nerves. — From  ir- 
ritating lesions  there  will  arise  lancinating  or 
other  pains  in  the  skin  and  deeper  textures  of 
related  portions  of  the  limbs,  and  possibly  trophic 
skin-lesions.  Pressure  or  destructive  lesions  will 
give  rise  to  loss,  in  various  degrees,  of  different 
modes  of  sensibility,  superficial  and  deep  ; and 
diminution  or  abolition  of  the  superficial  and 
deep  reflexes  in  related  regions  of  the  body. 

§ 9.  (b)  Diagnosis  of  the  longitudinal  si- 
tuation and  extent  of  the  lesion. — This  is  a 
consideration  distinctly  secondary  to  the  other, 
since  at  whatever  longitudinal  level  the  disease 
may  be  situated,  its  clinical  characters  will  al- 
ways be  qualified  by  the  part  or  parts  of  the 
transverse  extent  of  the  cord  that  may  bo  in- 
volved. Here  we  have  to  depend  in  the  main 
upon  the  signs  indicative  of  the  implication  of 
particular  sensory  and  motor  nerves,  whose  exact 
relations  with  different  portions  of  the  spinal 
cord  are,  of  course,  known.  Such  signs  may  con- 
sist of  some  excess  or  defect  of  sensibility,  of 
motilit}’,  or  of  reflex  action. 

We  are  accustomed  also  to  obtain  informa- 
tion of  a more  general  kind  from  the  fact  that 
special  centres  in  connection  with  different  viscera, 
and  functions  situated  at  different  longitudinal 
levels  in  the  cord  may  be  more  or  less  deranged. 
To  this  portion  of  the  subject  it  will,  indeed,  be 
found  most  convenient  to  give  attention  in  the 
first  place. 

Evidence  from  perverted  activity  of  spinal 
centres. 

(1)  The  lateral  columns  in  the  upper  cervical 
region  contain  the  motor  paths  for  the  muscles 
of  respiration,  so  that  section  or  disease  of  them 
at  a lower  level  interferes  with  the  movements  of 
respiration  on  the  same  side  of  the  chest  (tho- 
racic muscles)  ; whilst,  if  the  lesion  reaches  as 
high  as  the  fourth  and  third  cervical  nerves 
(the  origin  of  the  phrenic)  the  diaphragm  itself 
also  becomes  paralysed,  and  the  movements  of 
respiration  must  therefore  almost  cease. 

(2)  Again,  the  upper  cervical  region  of  the 
cord,  if  it  does  not  contain  actual  centres  con- 
nected with  the  excitation  of  the  heart’s  action, 
is  at  all  events  traversed  by  certain  channels 
for  the  transmission  of  cardiac  stimuli  (whose 
point  of  exit  from  the  cord  is,  with  sympathetic 
fibres,  lower  down). 

Thus  different  lesions  in  this  upper  cervical 
region  of  the  cord  may,  according  to  their  nature 


1464  SPINAL  CORD.  DISEASES  OF. 


and  extent,  greatly  interfere  with  the  heart’s 
action,  as  well  as  with  the  respiratory  movements. 
The  frequency  of  the  pulse  may  be  either  notably 
accelerated  or  retarded;  whilst  the  respiratory 
movements  may  be  slower  or  much  quicker  than 
natural,  and  also  extremely  irregular  and  per- 
verted in  rhythm. 

(3)  The  lower  cervical  and  upper  dorsal  re- 
gions of  the  cord  also  contain  the  so-called  ‘ cilio- 
spinal  centre,’  or  the  fibres  emanating  from  it. 
These  pass  outwards  with  the  fibres  of  the  an- 
terior roots  in  the  above-named  regions,  and 
thence  into  the  cervical  sympathetic.  Irritation 
of  them  causes  dilatation  of  the  pupil  on  the 
same  side,  whilst  section  or  other  destructive 
lesion  causes  contraction  of  the  pupil. 

(4)  The  vaso-motor  nerves  for  the  side  of  the 
head  and  neck  arise  in  similar  regions  of  the 
cord,  and  leave  it  in  the  same  manner.  Irrita- 
tion of  them  produces  contraction  of  the  blood- 
vessels ; section,  severo  compression,  or  destruc- 
tion causes  dilatation  of  the  blood-vessels  of  these 
regions.  See  Sympathetic  System,  Disorders  of. 

(5)  Generally  it  may  be  said  that  section  of 
one  half  of  the  cord  or  destruction  of  it  for  any 
extent  longitudinally,  causes  at  first  paralysis  of 
blood-vessels  in  the  lower  parts  of  the  body  on 
the  same  side— this  vaso-motor  paralysis  carry- 
ing with  it  in  the  same  parts  an  increase  of 
temperature  and  an  exaltation  of  sensibility.  In 
a short  time,  however,  the  vaso-motor  paralysis 
(and  with  it  the  increase  of  heat  and  sensibility) 
passes  away,  owing  to  the  vaso-motor  centres  in 
parts  of  the  spinal  cord  below,  and  to  the  peri- 
pheral vaso-motor  centres,  adapting  themselves  to 
act  independently  of  those  in  higher  parts  of  the 
cord  and  of  the  supreme  regulating  centre  in  the 
medulla  oblongata.  (As  a rule  the  higher  vaso- 
motor centres  control  those  lower  down,  but 
after  temporary  paralysis  even  the  peripheral 
vaso-motor  centres  seem  to  resume  control  over 
related  blood-vessels.) 

(6)  Tho  movements  of  the  stomach  and  intes- 
tines. generally  are  certainly  influenced  by  the 
cord  in  different  regions,  so  that  in  various  cases, 
under  perversions  of  this  normal  spinal  influence, 
we  may  get  vomiting,  diarrhoea,  or  obstinate  con- 
stipation— as  direct  results,  that  is,  of  morbid 


changes  in  certain  parts  of  tho  cord  in  which 
intestinal  sympathetic  fibres  have  their  roots. 
The  exact  situations  of  these  centres  and  paths  of 
stimulation  are,  however,  only  vaguely  known. 

In  the  grey  matter  of  the  lumbar  swelling 
of  the  cord  there  are  aggregated  a number  of 
centres  having  to  do  with  important  functions, 
which  may  be  variously  interfered  with  by  dis- 
ease. These  centres  are  those  which  regulate— 

(7)  the  evacuation  of  the  rectum  ; (8)  the  evacu- 
ation of  the  bladder ; (9)  erection  and  ejaculatio 
seminis ; and  (10)  the  contractions  of  the  uterus. 

In  each  case  the  spinal  centre  constitutes  an 
independent  reflex  centre,  provided  with  its  af- 
ferent and  efFerent  nerves,  but  in  each  case  also 
there  is  more  or  less  of  connection  between  the 
spinal  centre  and  others  in  the  cerebral  hemi- 
spheres. There  must  therefore  be  double  sets  of 
internuncial  fibres  for  each  centro  traversing  the 
whole  length  of  the  spinal  cord  and  medulla; 
partly  for  the  transference  of  afferent  impressions 
from  each  centre  to  the  brain,  and  partly  for  the 
conduction  of  efFerent  impressions  in  the  reverse 
direction.  In  the  case  of  the  uterine  centre  these 
cerebral  connections  are  of  comparatively  slight 
importance  ; since,  with  a complete  transverse 
lesion  in  the  cervical  or  even  in  the  upper  dorsal 
region,  the  process  of  parturition  may  still  be 
successfully  accomplished.  So  long  as  the  spinal 
mechanism  is  complete  and  perfect,  parturition 
may  take  place  without  the  need  of  cerebral  co- 
operation. Our  subsequent  remarks  will,  there!'  re, 
refer  principally  to  the  other  three  lumbar  centres. 

Complete  transverse  lesions  occurring  in  any 
part  of  the  dorsal  or  cervical  regions  will,  of 
course,  entirely  cut  off  all  the  above-mentioned 
lumbar  spinal  centres  from  connection  with,  and 
therefore  from  any  voluntary  control  by,  the 
cerebral  hemispheres.  But  various  limited  local 
lesions  in  particular  transverse  areas  of  the  cord 
(though  such  areas  cannot  at  present  be  definitely 
specified)  may  produce  similar  results,  so  far  as  the 
cerebral  control  of  any  one  or  two  of  the  lumbar 
centres  is  concerned.  According  as  the  sever- 
ance of  these  lumbar  spinal  centres  from  cerebral 
correlation  and  control  is  complete  or  partial, 
one  or  other  of  the  following  results  would  be 
produced : — 


Name  of 

Complete  Severance 
from  Cerebrum 

Incomplete  Severance  from  Cerebrum 

Centre 

Afferent  and  Efferent 
Internuncial  Fibres 

Afferent  Internuncial 
Fibres  Only 

Efferent  Internuncial 
Fibres  Only 

Rectal  centre 

Unconsciousness  of  need,  and  in- 
ability to  prevent  evacuation 
Result. — Constipation,  ■with  in- 
continence of  faces  after  an 
aperient 

Unconsciousness  of  need  and 
therefore  no  attempt  to  re- 
strain evacuation 

Consciousness  of  need  to 
evacuate,  with  no  ability 
to  restrain  the  act 

Vesical  centre  . 

Unconsciousness  of  need,  and  in- 
ability to  prevent  micturition 
Result. — Reflex  evacuation  in 
gushes  at  intervals 

Unconsciousness  of  need  and 
therefore  no  attempt  to  re- 
strain micturition 

Consciousness  of  need,  but 
inability  to  restrain  mic- 
turition 

Sexual  centre  . 

— 

Diminution  or  absence  of  sexual 
desire.  Erections  and  emis- 
sions, if  they  occur,  wholly 
dependent  upon  the  spinal 
reflex  mechanism 

With  simple  destruction  of 
fibres,  nearly  same  results  as 
*et  down  in  previous  column  ; 
but  with  irritation  of  afferent 
fibres  there  might  be  great  in- 
crease of  desire  (satyriasis  or 
nymphomania) 

Feelings  of  desire,  but  no 
erection  in  response. 

Erection  and  emissions, 
if  present,  purely  through 
spinal  reflex. 

But  with  irritation  of 
efferent  fibres  there  may 
be  persistent  erections, 
mostly  without  desire 

SPINAL  COED,  DISEASES  OF. 


The  rectal  and  the  vesical  spinal  centres  are 
each  composed  of  two  parts  with  their  separate 
afferent  and  efferent  nerves — one  in  relation  with 
a sphincter  muscle,  and  the  other  in  relation 
with  detrusor  or  expulsive  muscles  in  functional 
opposition  with  the  former.  These  several  nerve- 
fibres,  both  afferent  and  efferent,  are  probably 
all  contained  in  the  sacral  nerve-trunks — that 
is,  they  both  reach  and  leave  the  lumbar  swell- 
ing as  constituents  of  these  nerve-trunks.  De- 
struction or  irritation  of  either  of  these  sets  of 
fibres,  or  of  one  of  the  centres,  will  necessarily 
interfere  to  some  extent  with  the  working  of  this 
particular  centre,  so  that  its  functions  may 
be  interfered  with  in  several  different  ways. 
There  may  be  various  degrees  of  irritability  of 
the  bladder  or  rectum,  or  various  degrees  of 
paralysis  of  these  organs. 

In  cases  of  paralysis  of  the  bladder,  especially 
when  owing  to  lesions  implicating  its  spinal 
centre,  the  urine  soon  becomes  foetid  and  alka- 
line, and  inflammation  (alone  or  with  ulceration) 
is  most  apt  to  be  set  up  in  its  mucous  mem- 
brane. 

The  details  as  to  the  modes  of  disturbance  of 
:he  genital  function,  where  disease  implicates  its 
lumbar  centre  or  the  afferent  and  efferent  nerves 
in  connection  therewith,  are  both  less  known 
ind  of  less  clinical  importance  than  where  it  in- 
volves the  internuncial  fibres  between  this  centre 
•md  the  cerebrum.  Again,  should  the  lumbar 
portion  of  the  cord  beeomo  affected  in  a preg- 
nant woman  so  as  to  involve  the  uterine  centre , 
unless  the  contents  of  the  womb  were  thrown 
off  during  some  initial  period  of  irritation,  this 
organ  would  be  quite  incapable  of  expelling  the 
foetus  and  its  accessories. 

Evidence  from  implication  of  particular  sen- 
sory or  motor  nerves. 

1 10.  The  more  precise  indications  concerning 
the  longitudinal  implication  of  the  spinal  cord 
are,  as  already  stated,  derivable  from  the  level 
at  which  alterations  in  sensibility  or  in  motility 
(either  voluntary  or  reflex)  are  to  be  detected. 
The  more  closely  the  lesion  approaches  to  what 
is  called  a ‘total  transverse  lesion,’  the  more 
distinctly  will  signs  of  this  order  reveal  them- 
selves. It  is  important,  too,  to  recollect  that 
the  fibres  of  different  sensory  roots  are  to  some 
extent  dispersed  through  cutaneous  surfaces  over- 
lying  the  muscles  supplied  by  the  corresponding 
motor  roots. 

In  regard  to  sensibility,  the  upper  limit  at 
which  the  trunk  is  affected  is  often  sharply  de- 
fined by  the  presence  of  a feeling  of  constriction, 
of  pain,  or  of  numbness  (‘girdle  sensation’)  en- 
circling the  body.  This  sensation  is  generally 
supposed  to  be  due  to  irritation  of  the  roots  of  the 
nerves  as  they  traverse  the  posterior  columns 
(or  perhaps  outside  them)  at  the  upper  level  of 
the  lesion.  This  symptom  may  of  course  be 
absent,  but  in  many  cases  of  paraplegia  it  is 
well-marked. 

Then  again  the  muscles  which  are  paratysed 
can  generally  be  pretty  well  defined,  so  that  a re- 
ference to  the  nerves  by  which  they  are  inner- 
vated will  also  enable  us  to  fix  upon  the  region 
of  the  cord  from  which  they  proceed.  Thus  we 
obtain  indications  as  to  the  upper  level  of  disease 
in  the  motor  tracts. 


1465 

These  latter  indications  are,  however,  by  no 
means  so  distinct  as  many  might  suppose,  because 
the  majority  of  limb  and  trunk  muscles  receive 
fibres  from  more  than  one  motor  root,  as  Preyer 
and  Krause  showed  long  ago.  And  the  view 
subsequently  indicated  by  E.  Eemak  that  func- 
tionally related  or  synergic  muscles  are  repre- 
sented 'together  in  the  anterior  horns  of  the 
spinal  cord  has  been  confirmed  and  extended  by 
Ferrier  and  Yeo  {Proceed,  of  Royal  Soc.,  March 
24,  1881,  p.  12),  by  their  experiments  on  the 
functional  relations  of  the  motor  roots.  They 
find  that  stimulation  of  individual  roots  of  the 
brachial  and  crural  plexuses  result,  not  in  mere 
unrelated  contractions  of  various  muscles,  but 
in  highly  co-ordinated  synergic  contractions,  lead- 
ing to  definite  movements.  But  as  the  1 muscles 
thrown  into  action  by  each  root  are  innervated 
inmost  cases  by  several  nerve-trunks,’  the  result 
‘of  section  of  each  motor  root  would  therefore 
be  paralysis  of  the  corresponding  combination, 
not  necessarily,  however,  of  the  individual  mus- 
cles involved  ....  whilst  weakened,  they  might 
yet  act  in  other  combinations  in  so  far  as  they 
were  supplied  by  other  roots.’  Different  com- 
bined movements  which  have  been  found  to  be 
dependent  upon  particular  motor  roots  are  citel 
by  the  authors  in  this  valuable  paper. 

The  integrity  of  those  reflex  actions  which  can 
be  elicited  either  in  health  or  in  disease,  depends, 
of  course,  upon  the  integrity  of  the  entire  nervous 
arcs  concerned  (that  is,  upon  integrity  of  in-going 
fibres,  centres,  and  out-goingfibres).  Thus  though 
the  impairment  of  a reflex  may  not  necessarily  be 
due  to  central  causes,  its  presence,  on  the  other 
hand,  clearly  shows  that  the  grey  matter  and 
other  regions  of  the  cord  which  must  be  traversed 
by  its  stimuli  are  not  impassable ; whilst  its 
exaltation  will  indicate  the  probable  existence  of 
some  central  change,  by  which  the  grey  matter 
in  question  is  rendered  more  excitable,  or  else 
by  which  it  is  cut  off  from  cerebral  inhibitory 
influences. 

§ 11.  For  practical  purposes  it  will  be  well 
here  to  group  together  the  various  indications 
as  to  longitudinal  localisation  to  which  we  have 
referred — classifying  them  as  they  are  related  to 
one  or  other  of  four  imaginary  segments  of  the 
spinal  cord. 

(a)  Cervical  region  of  the  cord. — This 
corresponds  externally  to  the  space  between  the 
occiput  and  the  upper  border  of  the  1th  cervical 
spine  (8 th  cervical  nerve). 

The  1st,  2nd,  and  3rd  cervical  spinous  pro- 
cesses are  respectively  opposite  the  origins  oi 
the  3rd,  4th,  and  5th  cervical  nerves.  The 
phrenic  nerve  (motor  nerve  of  the  diaphragm) 
arises  from  the  4th,  or  from  the  3rd  and  the  4th 
oervical  nerves.  Opposite  the  3rd  cervical  spine 
(level  of  5th  cervical  nerve)  the  cervical  swell- 
ing of  the  cord  begins  ; whilst  it  ends  opposite 
the  7th  cervical  spine  (level  of  1st  dorsal  nerve). 

Disease  of  ‘his  region  may  involve  interference 
with  respiration,  and  possibly  weakness  of  voice; 
interference  with  the  heart’s  action — pulse  very 
frequent,  or  the  reverse  ; flushing  or  pallor  of 
the  head  and  neck  ; continued  priapism  (with 
crushing  lesions) ; augmentation  of  temperature 
in  the  body  generally  (hyperpyrexia) ; and  marked 
contraction  or  dilatation  of  the  pupil. 


I4G6  SPINAL  COED, 

The  innervation  of  the  shoulder,  arm,  and  hand 
muscles  is  derived  from  spinal  nerves  between 
the  6th  cervical  and  1 st  dorsal  inclusive  ; those 
supplying  the  ulnar  side  of  the  hand  and  fore- 
arm arising  from  the  lower  level,  that  is,  from 
the  upper  part  of  the  next  region. 

(6)  Upper  half  of  the  dorsal  region  of  the 
cord.  — This  corresponds  externally  to  the  space 
between  the  1th  cervical  spine  (ls<  dorsal  nerve ) 
and  the  ith  dorsal  spine  ( 6th  dorsal  nerve). 

The  results  of  disease  here  are  apt  to  be 
these : — The  ‘ scapular  reflex  ’ may  be  abolished, 
calling  into  activity  as  it  does  the  last  two  or  three 
cervical  and  the  first  two  or  three  dorsal  nerves ; 
the  intercostal  muscles  are  paralysed  at  different 
levels;  a ‘girdle  sensation’  is  felt  at  different 
levels  ; there  may  be  prominence  of  certain  verte- 
bral spines,  and  possibly  tenderness  on  pressure 
or  on  tapping  over  them ; the  ‘ epigastric  reflex  ’ 
may  be  abolished,  depending  as  it  does  upon 
the  spinal  cord  at  the  level  of  the  4th  to  the  6th 
or  7th  pairs  of  dorsal  nerves;  and  priapism 
(with  crushing  lesions)  may  occasionally  be  met 
with. 

(c)  Lower  half  of  the  dorsal  region  of  the 
cord. — This  corresponds  externally  to  the  space 
between  the  upper  border  of  the  5th  dorsal  spine 
(' Ithdorsal  nerve)  and  the  lower  border  of  the  10 th 
dorsal  spine  ( space  below  12th  dorsal  nerve). 

Disease  here  may  give  rise  to  the  following 
symptoms  : — The  ‘ abdominal  reflex’  maybe  abo- 
lished, depending  as  it  does  upon  the  integrity 
of  the  cord  between  the  levels  of  the  8th  dorsal 
and  the  1st  lumbar  nerves.  Paralysis  of  lower 
intercostal  muscles  or  of  abdominal  muscles  may 
possibly  occur,  in  addition  to  paralysis  of  the 
lower  extremities.  ‘ Girdle  sensation  ’ may  be 
felt  at  different  levels  (the  umbilicus  correspond- 
ing with  the  10th  dorsal  nerve,  and  the  ‘ ensi- 
form  area’  with  the  6th  and  7th  dorsal  nerves). 
There  may  be  prominence  of  certain  of  the  lower 
dorsal  spines,  with  possible  tenderness. 

Id)  Lumbar  region  of  the  cord. — This  cor- 
responds externally  to  the  space  between  the  lower 
border  of  the  10th  dorsal  spine  ( just  below  12 th 
dorsal  nerve),  and  the  upper  border  of  the  2nd 
lumbar  vertebra. 

Here  the  symptoms  are  Paralysis,  not  im- 
plicating the  abdominal  muscles,  hut  limited  to 
more  or  less  of  those  of  the  lower  extremities.' 
No  ‘ girdle  sensations’  around  the  trunk.  Three 
superficial  reflexes  may  he  abolished,  namely, 
the  ‘ cremasteric,’  which  depends  upon  the  integ- 
rity of  the  cord  in  the  upper  lumbar  region ; 
and  the  ‘ gluteal  ’ and  the  ‘ plantar,’  both  of 
which  seem  to  he  dependent  upon  the  integrity 
of  the  lower  part  of  the  lumbar  region  of  the 
cord.  A deep  reflex  may  also  be  abolished, 
namely,  the  so-called  ‘ knee-jerk,’  which  is  de- 
pendent upon  the  upper  lumbar  region  of  the 
cord.  ‘ Anklo-clonus  ’ may  he  met  with  when 
diseaso  affects  the  upper  or  mid-lumbar  regions 
of  the  cord,  but  not  where  the  lower  lumbar 
region  is  implicated.  Loss  of  sensibility  about 
the  perineum  and  anus  (if  not  due  to  disease  of 
nerve-trunks),  is  indicative  of  disease  of  the  pos- 
terior columns  in  the  lower  lumbar  region.  Ab- 
solute paralysis  of  the  bladder  and  rectum  may 
be  present,  with  tendency  to  inflammation  and 
ulceration  of  the  former  organ. 


DISEASES  OF. 

In  the  clinical  data  above  given  are  included 
the  majority  of  the  facts  upon  which  the  reyiona 
diagnosis  of  diseases  of  the  spinal  cord  most  in 
all  cases  he  based.  In  them  also  will  be  found 
the  explanations,  so  far  as  they  can  be  given  in 
moderate  compass,  of  the  sy7nptoms  met  with  in 
different  diseases  of  the  spinal  cord.  An  obvious 
advantage  will  be  found  to  have  resulted  from 
this  somewhat  lengthy  preliminary  discussion, 
if,  as  it  ought  to  do,  it  tends  to  give  the  prac- 
titioner a more  thorough  insight  into  the  nature 
and  relations  of  the  several  diseases  of  the 
spinal  cord,  at  the  same  time  that  it  aids  him  in 
their  diagnosis. 

Although  it  is  true  that  the  groups  of  symptoms 
presented  in  different  diseases  of  the  spinal  cord, 
considered  individually  and  collectively,  afford 
the  materials  upon  which  a regional  diagnosis 
must  ho  founded,  it  is  no  less  true  that  a part 
of  the  symptomatology  (namely,  that  comprised 
in  the  mode  of  origin  and  the  mode  of  establish- 
ment of  the  disease,  together  with  what  may  be 
gathered  from  the  patient’s  state  general^-,  from 
his  family  history  and  from  his  personal  history) 
constitutes  the  basis  upon  which  a pathological 
diagnosis  has  to  be  arrived  at.  Again,  although 
the  arrival  at  a regional  diagnosis  is  often  spoken 
of,  and  may  seem  to  he  a process  altogether 
distinct  from  that  involved  in  the  arrival  at  a 
pathological  diagnosis,  yet,  as  a matter  of  fact, 
in  the  investigation  of  many  individual  cases 
of  spinal  disease,  it  will  he  found  that  the  one 
problem  is  not  settled  first,  and  the  other  after- 
wards, but  that  both  are  tentatively  considered 
more  or  less  simultaneously.  Thus,  certain  em- 
pirically known  pathological  conditions  may 
afford  at  once  a ready  explanation  of  a given 
group  or  sequence  of  symptoms,  as  in  ‘infantile 
paralysis,’  in  ‘ locomotor  ataxy,’  or,  in  a more 
general  sense,  in  angular  curvature  of  the  spine. 
Here,  therefore,  the  pathological  diagnosis  goes 
hand  in  hand  with  the  regional  diagnosis,  and 
in  working  them  out  each  gathers  additional 
confirmation  from  the  establishment  of  the  other. 
Sometimes,  however,  as  in  the  case  of  traumatic 
injuries  (including  stabs,  and  fractures  with  dis- 
locations of  vertebrae),  the  pathological  diagnosis 
is  at  once  obvious,  and  the  regional  diagnosis 
alone  requires  to  he  settled  in  detail. 

For  the  above  reasons  it  has  been  necessary  to 
tabulate  in  this  article  certain  ‘ Pathological 
data  concerning  the  Spinal  Cord’  (§  6), 
though  it  would  not  be  found  specially  advan- 
tageous were  we  to  follow  out  this  part  of  the 
subject  further,  and  attempt  here  to  set  down 
the  more  general  clinical  data  and  dcduciic-ns 
of  pathological  import,  necessary  to  be  borne  in 
mind  for  the  arrival  at  a pathological  diagnosis, 
in  order  to  form  a series  of  facts  and  deductions 
comparable  with  those  already  given  in  elucida- 
tion of  the  problems  of  regional  diagnosis  (§§ 
8-11).  These  other  problems  will  be  dealt  with, 
as  far  as  possible,  in  the  descriptions  of  the 
several  diseases  of  the  spinal  cord. 

H.  Cha.ri.ton  Dastixv 

SPINAL  CORD,  Special  Diseases  of. — 
In  order  that  the  mutual  relations  of  the  dif- 
ferent diseases  of  the  spinal  cord  may  he  the 
more  readily  appreciated,  their  names  are  her* 


SPINAL  COED,  SPECIAL  DISEASES  OF. 


let  down  in  groups,  and  they  will  be  severally 
considered  in  the  same  order,  which  is  one  based 
upon  their  causes  and  nature,  rather  than  upon 
alphabetical  considerations.  This  list  will,  there- 
fore, in  addition  serve  as  an  index  to  tho  pre- 
sent article  The  names  of  the  different  diseases 
now  to  be  described  are  printed  in  block  type  ; 
while  the  names  of  those  diseases  which  are  dis- 
cussed separately  in  different  parts  of  the  work 
(to  which  the  reader  is  referred),  are  printed  in 
small  capital  letters. 

I.  Diseases  of  the  Spinal  Cord  dependent 
upon  known  organic  changes  : — 

I.  Concussion  of  the  Spinal  Cord  ; 2.  Punc- 
tured or  Gun-shot  "Wounds  of  the  Spinal  Cord ; 

3.  Sudden  Crushing  Lesions  of  the  Spinal  Cord ; 

4.  Slow  Compression  of  the  Spinal  Cord  ; 5.  Au- 
remia  of  the  Spinal  Cord ; 6.  Hypersemia  of 
the  Spinal  Cord  ; 7.  Inflammation  of  the  Spinal 
Cord;  8.  Heemorrhage  into  the  Spinal  Cord; 
9.  Softening  of  the  Spinal  Cord. 

10.  Infantile  Paralysis;  11.  Acute  Spinal 
Paralysis  of  Adults;  12.  Acute  Ascending  Para- 
lysis; 13.  Chronic  Spinal  Paralysis;  14.  PitO- 
oefssive  Muscular  Atrophy;  15.  Pseudo- 
hypertrophic  Paralysis. 

16.  Locomotor  Ataxy  ; 17.  Spasmodic  Spinal 
Paralysis;  18.  Amyotrophic  Lateral  Sclerosis; 
19.  Multiple  or  Disseminated  Sclerosis. 

20.  Tumours  and  New  Formations  of  the 
Spinal  Cord;  and  21.  Malformations  of  the 
Spinal  Cord. 

II.  Diseases  dependent  upon  unknown 
or  imperfectly  known  organic  changes:  — 

22.  Tetanus;  23.  Tetany;  24.  Torticollis; 

26.  Writer’s  Cramp  ; 26.  Spinal  Irritation  ; 

27.  Eefiex  Paraplegia ; 28.  Intermittent  Para- 
plegia ; 29.  Hysterical  Paraplegia ; 30.  Para- 
plegia dependent  on  Idea;  31.  Neurasthenia 
Spinalis  ; and  32.  Toxic  Spmal  Paralysis. 

In  addition  to  these  diseases,  dependent  upon 
changes  limited  to  the  spinal  cord,  other  affec- 
tions should  here  be  mentioned,  in  which  the 
spinal  cord  is  implicated  (in  modes  more  or  less 
known)  together  with  the  cerebrum  in  one  or 
other  of  its  regions.  These  ccrcbro-spinal  affec- 
tions are  as  follows: — 1.  General  Paralysis 
of  the  Insane  ; 2.  Cerebro-Spinal  Sclerosis  ; 
3.  Paralysis  Agitans  ; 4.  Hydrophobia  ; and 

5.  Chorea. 

For  an  account  of  the  diseases  dependent 
upon  morbid  changes  in  the  membranes  of  the 
spinal  cord,  see  Meninges,  Spinal,  Diseases  of. 

1.  Spinal  Cord,  Concussion  of. — Synon.  : 
Commotio  Medulla  Spinalis ; Fr.  Commotion  de 
la  Moelle  Epiniere ; Ger.  Erschutterung  des  Eiick- 
enmarks. 

.Etiology. — This  condition  is  met  with  prin- 
cipally in  persons  who  have  fallen  from  a height, 
or  in  those  who  have  been  present  in  a railway 
collision.  In  these  cases  the  brain  is  apt  to 
suffer  as  well  as  the  spinal  cord,  and  it  is  not 
always  easy  to  unravel  the  respective  symptoms 
due  to  shock  of  this  or  that  great  segment  of  the 
cerebro-spinal  system. 

Anatomical  Characters, — In  many  of  these 
cases  there  are,  in  all  probability,  no  morbid 
thanges  that  would  be  discoverable.  In  others, 


1467 

however,  minute  extravasations  of  blood,  or 
actual  ruptures  of  the  nerve-tissue,  may  occur — 
and  this  sometimes  even  to  a marked  extent, 
as  in  a case  seen  by  the  writer.  An  example  of 
slighter  lesions  is  recorded  by  Sir  Wm.  Gull,  in 
which  small  extravasations  of  blood  were  found 
in  the  anterior  and  posterior  cornua  as  well  as 
in  the  posterior  columns  of  the  cord.  In  neither 
of  these  cases  was  there  any  external  or  visible 
injury ; but  in  each  paraplegia  was  produced 
immediately  after  the  fall  that  determined  the 
lesions  in  the  cord.  In  addition  to  haemorrhages 
into  the  substance  of  the  spinal  cord  itself,  there 
is  in  these  cases  tho  possibility  of  the  occurrence 
of  meningeal  haemorrhages,  pressing  upon  the 
cord  or  its  nerve-roots;  and  within  a day  or 
two  after  the  occurrence  of  the  concussion  itself, 
there  is  the  possibility  of  some  local  and  sub- 
acute inflammation  being  set  up  in  the  mem- 
branes of  the  cord. 

Symptoms. — In  the  great  majority  of  these 
cases  no  complete  paralysis  is  induced,  even  at 
first.  There  may  at  most  he  paresis  of  one  or 
more  limbs,  general  prostration,  nausea  with 
occasional  vomiting,  a rapid  and  possibly  ir- 
regular or  intermittent  pulse  (especially  after 
the  least  exertion),  with  occasional  startings 
and  twitchings  of  the  limbs,  whose  sensibility 
may  be  diminished,  exalted,  or  unaffected.  The 
temperature  will  probably  be  at  first  depressed, 
as  a result  of  shock,  though  subsequently  a 
febrile  elevation  may  continue  for  somo  days. 
The  tongue  may  be  furred,  the  appetite  bad,  the 
bowels  constipated ; whilst  in  regard  to  micturi- 
tion there  may  he  either  some  delay  and  difficulty, 
or,  on  the  contrary,  an  irritability  of  the  bladder, 
with  difficulty  in  retaining  its  contents  after  the 
desire  to  micturate  is  once  felt.  With  this  thero 
is  often  general  restlessness,  nervousness,  and 
insomnia. 

In  more  severe  cases  of  concussion,  even  where 
there  is  no  complication  resulting  from  appre- 
ciable lesions,  the  shock  to  the  system  {see 
Shock)  may  be  more  profound,  and  there  may 
he  paralysis  of  limbs,  lasting  perhaps  for  some 
days,  and  then  rather  suddenly  disappearing. 

Diagnosis. — The  questions  to  be  determined 
are,  whether,  looking  to  the  symptoms  presented 
by  the  patient,  there  is  likely  to  be  any  organic 
lesion  or  change  in  the  spinal  cord  or  its  mem- 
branes ; or  whether  we  have  to  do  with  mere 
functional  perturbations  induced  by  the  shock  or 
blow  to  which  the  patient  has  been  subjected. 
In  the  absence  of  definite  paralysis,  or  even  with 
its  presence  for  the  first  few  days,  the  answer  to 
this  preliminary  question  will  often  be  shrouded 
in  doubt.  To  come  to  a definite  opinion  as  to 
the  precise  nature  of  the  change  which  a spinal 
cord,  deemed  to  be  damaged  in  some  way  after 
a concussion,  has  undergone,  lapse  of  time  and 
several  examinations  of  the  patient  are  often 
required. 

In  many  cases  in  which  compensation  for  an 
injury  is  claimed  a further  complication  appears. 
Here  it  is  that  the  difficulty  arises  as  to  how 
much  the  symptoms  experienced,  or  said  to  be 
experienced,  may  be  due  to  an  excited  imagina- 
tion, and  how  much  to  causes  independent  of 
the  imagination,  whether  voluntarily  or  involun- 
tarily aroused.  It  must  be  conceded  that  symp* 


SPINAL  CORD,  SPECIAL  DISEASES  OF. 


toms  of  injury  are  undoubtedly  feigned  by  un- 
scrupulous persons;  and  it  seems  also  equally 
clear  that,  even  unknowingly  to  the  patient,  the 
excitement  consequent  upon  the  accident,  the 
details  heard  concerning  the  injuries  of  others, 
combined  with  the  inquiries  of  doctors  and  cf 
sympathising  friends,  tend  to  keep  up  and  to 
exaggerate  symptoms  in  many  nervous  patients, 
over  and  above  those  which  may  have  resulted 
from  the  shock.  Such  patients  also  may  make  a 
more  speedy  recovery  subsequent  to  trial  snd 
compensation,  than  they  had  been  making  before 
the  trial,  and  yet  they  may  not  have  been  in  any 
sense  impostors.  It  is  true  that  such  persons, 
however,  do  not  recover  quite  so  quickly  as 
those  others  who  for  their  own  unscrupulous 
ends  have  been  previously  exciting  their  imagina- 
tions in  a voluntary  manner. 

Prognosis. — In  only  the  severest  cases  of 
concussion  or  shock  is  there  actual  danger  to 
life  ( see  Shock).  Where,  however,  great  pros- 
tration is  induced,  and  especially  in  those  who 
may  previously  have  been  suffering  from  heart- 
affections,  or  from  a very  excitable  nervous 
system,  life  may  be  speedily  brought  to  a close  ; 
or  at  most  such  patients  may  not  survive  a 
severe  concussion  more  than  a day  or  two. 

Severe  concussions  of  the  cord  may  also  form 
the  starting-points  of  many  and  varied  deviations 
from  health,  which  may  not  begin  to  show  them- 
selves for  weeks,  or  perhaps  even  months,  after 
the  initial  shock.  Among  such  sequels,  which 
have  come  under  the  writer’s  notice,  may  be 
mentioned  the  following; — Loss  of  flesh  with 
general  failure  of  nutrition,  epileptiform  fits, 
progressive  muscular  atrophy,  lateral  sclerosis 
of  the  spinal  cord,  a slowly  increasing  paraplegia 
(of  uncertain  pathological  basis),  and  caries  of 
rertebrs  followed  by  angular  curvature  and 
paraplegia. 

In  other  and  slighter  cases,  time  and  rest, 
with  suitable  medical  treatment,  may  be  ex- 
pected to  lead  to  perfect  recovery,  sometimes 
speedily,  but  sometimes  only  after  protracted 
periods  of  impaired  health. 

Treatment. — In  the  first  instance,  symptoms 
of  shock  have  to  be  combated  by  the  employment 
of  warmth  and  stimulants.  In  subsequent  stages, 
rost  in  the  recumbent  position  must  be  enjoined 
for  a time.  It  is  of  the  first  importance  to  make 
sure  that  the  patient  does  take  complete  rest, 
and  is  kept  free  from  excitement  during  the  first 
few  days  after  any  concussion  accident,  and  that 
he  gets  sound  sleep  at  night,  under  the  influence 
of  bromide  of  potassium,  or  of  this  together  with 
chloral.  If  the  condition  of  restlessness,  with 
disturbed  sleep,  can  be  checked,  then  a mitiga- 
tion of  other  symptoms  may  be  expected  to  fol- 
low. The  application  of  ice  to  the  spinal  column 
may  at  times  be  desirable ; or  pain . must  be  re- 
lieved by  the  subcutaneous  injection  of  small 
doses  of  morphia.  Later  on  tonics,  with  a simple 
nutritious  diet  and  plenty  of  fresh  air,  together 
with  rest,  will  be  needed  for  the  complete  resto- 
ration of  the  patient. 

2.  Spinal  Cord,  Punctured  or  Gun-shot 
Wounds  of. — Synon.  ; Acute  Traumatic  Lesions 
of  the  Spinal  Cord ; Fr.  Plaies  ct  contusions  de  la 
Moellc  Epiniere ; Ger.  RiicJcenmdrhszerreissungen. 


^Etiology  and  Anatomical  Characters. — 
Punctured  or  gun-shot  wounds  of  the  spinal  cord 
are  commonly  made  with  knife,  dagger,  sword,  or 
bullet. 

In  each  set  of  cases,  the  wound  in  the  spinal 
cord  will  be  associated  with  perforation  or 
rupture  of  some  of  the  membranes,  and  also 
with  haemorrhage,  either  between  them  or  into 
the  substance  of  the  cord.  The  arches  of  the 
vertebrae  or  their  articular  processes  and  some 
of  the  ligaments  connecting  them  may  be  more 
or  less  damaged,  and  a wound  commonly  exists 
through  the  contiguous  skin  and  muscles.  In  the 
cord  itself,  there  may  be  either  a clean-cut  wound 
through  certain  of  its  columns  and  parts,  or  a 
broader  crushing  lesion.  In  each  case  more  or 
less  blood  may  be  effused  upon  and  below  the  cut 
surfaces  of  the  cord.  At  later  stages,  there  may 
be  signs  of  inflammation  of  the  membranes,  as 
well  as  cf  local  inflammatory  softening  of  the 
substance  of  the  cord. 

Symptoms. — The  signs  and  symptoms  con- 
sequent upon  wounds  of  this  kind  are  subject  to 
endless  variations,  in  accordance  with  the  dif- 
ferent regions  of  the  cord  involved,  the  actual 
extent  of  the  wound  in  its  substance,  and  the 
possible  presence  of  varying  amounts  of  effused 
blood.  These  wounds  often  involve  only  a por- 
tion of  the  transverse  area  of  the  cord.  It 
is  indeed  in  this  class  of  cases  more  especially 
that  hemiplegia  spinalis  and  hemiparaplegia  are 
met  with.  Thus  where  a unilateral  lesion  exists 
in  the  mid  or  upper  cervical  region,  both  arm 
and  leg  are  paralysed,  so  that  the  state  known 
as  hemiplegia  spinalis  is  produced  ; but  where  it 
occurs  in  the  dorsal  region,  the  one  leg  only  is 
paralysed,  and  we  have  what  is  known  as  hemi- 
paraplegia. 

The  essential  peculiarity  in  the  latter  eases 
is  that  on  the  side  of  lesion  there  is  complete 
motor  paralysis  in  the  limbs  or  limb  below; 
whilst  on  the  opposite  side,  the  limbs  or  limb, 
and  the  trunk  up  to  the  middle  line,  are  more  or 
less  completely  anaesthetic — sensitiveness  to  im- 
pressions of  touch,  pain,  temperature,  and  tick- 
ling being  alike  abolished. 

Other  minor  peculiarities  are  these : — On  the 
side  of  motor  paralysis , there  is  also  vaso-motor 
paralysis,  which  carries  with  it,  as  consequences, 
(a)  an  elevation  ot  temperature  (from  lj°  to  2° 
Fahr.),  and  ( h ) a hyperssthesia  for  all  modes  of 
sensibility  (owing  in  part  to  hyperemia  in  the 
limb  and  cord).  Surrounding  the  body,  at  the 
level  of  the  upper  margin  of  antesthesia  on  the 
side  of  sensory  defect,  there  is  usually  a narrow 
girdle  of  hyperesthesia ; whilst  below  this  level, 
on  the  side  of  the  lesion,  there  is  a half  band  of 
hemiannesthesia — whose  depth  varies  with  the 
longitudinal  extent  of  the  lesion.  (The  complete 
zone  of  hyperesthesia  is  probably  due  to  hy- 
peremia of  nerve-roots,  and  of  the  grey  matter 
of  the  cord  immediately  above  the  lesion ; wh;le 
the  half-zone  of  antesthesia  is  dependent  upon 
destruction  of  the  nerve-roots,  and  of  the  spinal 
cord  for  a certain  extent.) 

If  bed-sores  occur,  they  are  met  with  on  tho 
side  of  sensory  paralysis ; whilst  in  one  or  two 
cases  signs  of  a joint-affection  (in  the  knee  prin- 
cipally) have  occurred  on  the  side  of  motor 
paralysis.  There  seems  no  reason  for  expecting 


SPINAL  COKD.  SPECIAL  DISEASES  OF.  1469 


any  special  muscular  atrophy  or  diminution  of 
fnradaic  irritability  on  the  side  of  motor  para- 
lysis, except  in  those  muscles  whose  nerve- 
eupply  comos  from  the  portion  of  the  anterior 
iornua  actually  destroyed  by  the  lesion.  In 
many  cases,  especially  at  first,  there  is  paralysis 
of  the  bladder  and  of  the  rectum,  or  there  may 
be  incontinence  of  urine.  Later  on  these  troubles 
tend  to  diminish.  Nothing  definite  is  known 
in  regard  to  the  condition  of  the  skin-refiexes  and 
tendon-reflexes  in  these  states. 

Where  anomalies  exist  in  regard  to  the  extent 
of  decussation  of  the  pyramids  (Flechsig),  the 
above-described  effects  of  unilateral  lesions  of 
the  cord  would  also  undergo  corresponding 
variations. 

In  gun-shot  wounds,  whether  occasioned  by 
pistol  or  rifle,  splinters  of  bone  may  be  de- 
pressed at  times,  so  as  to  compress  and  irritate 
the  cord,  and  thus  the  symptoms  may  be  made 
to  approximate  more  closely  to  wounds  of  the 
next  category. 

After  a few  days  the  symptoms  may  be  com- 
plicated by  those  of  spinal  meningitis,  or  ex- 
tended by  the  spread  of  an  inflammatory  soften- 
ing of  the  cord  above  and  below  the  seat  of 
lesion. 

Diagnosis. — The  primary  cause  of  the  patient’s 
condition  is  generally  only  too  obvious.  It  may 
be  clear  that  we  have  to  do  either  with  a 
punctured  or  with  a gun-shot  wound  in  some 
region  of  the  spine  ; but  subsequently  many,  and 
often  very  difficult,  questions  require  to  be 
solved.  It  is  of  first  importance  to  learn 
whether  the  cord  itself  is  really  damaged,  or 
whether  the  symptoms  are  in  the  main  caused 
by  epi-dural  or  sub-arachnoid  haemorrhages  (see 
Meninges,  Spinal,  Haemorrhage  into).  In  the 
former  case  there  will  be  evidence  of  complete 
or  partial  interruption  of  conduction  in  the 
cord,  to  or  from  all  parts  below  the  seat  of 
lesion,  and  not  of  a mere  local  implication  of 
nerve-roots.  If  it  seem  probable  that  the  cord 
itself  is  damaged,  we  have  to  determine  whether 
it  is  completely  cut  across,  or  only  partially 
damaged — and  if  the  latter  to  what  extent. 
These  questions  must  be  decided  in  the  main  by 
reference  to  the  signs  given  in  Introduction, 
§8. 

Should  the  case  be  seen  for  the  first  time 
several  days  after  the  injury,  an  exact  diagnosis 
as  to  the  amount  of  damage  to  the  cord  itself 
is  often  greatly  obscured  by  the  existence  then 
of  certain  secondary  pathological  conditions — 
more  especially  localised  inflammation  of  the 
meninges,  or  secondary  inflammatory  softening, 
extending  perhaps  above  or  below,  or  in  both 
directions,  from  the  original  wound.  A process 
of  softening  may  also  extend  transversely  through 
the  whole  substance  of  the  cord,  even  where  only 
a unilateral  lesion  had  previously  existed. 

Prognosis. — This,  as  a rule,  is  bad  in  all 
cases  of  traumatic  injury  of  the  spinal  cord;  and 
the  gravity  of  the  case  is  usually  the  greater  the 
higher  the  wound  happens  to  be  situated  in  the 
cervical  region.  Wounds  of  the  dorsal  or  lumbar 
region  of  the  cord  are  rather  less  serious,  so  far 
as  life  is  concerned. 

The  degree  of  recovery  from  paralysis  of  limbs 
will  greatly  depend  upon  the  nature  and  extent 


of  the  wound.  A clean-cut  wound  may  bo  filled 
up  by  the  growth  of  a kind  of  cicatricial  tissue  ; 
but  it  has  not  yet  been  accurately  determined 
whether  the  nerve-substance  of  the  cord  can  be 
reproduced  in  man.  There  seems,  however,  reason 
for  supposing  that  some  amount  of  reparation 
of  nerve-tissue  may  take  place  in  the  cut  spinal 
cord  even  of  man — especially  in  early  life. 

Treatment. — Absolute  rest,  with  cold  appli- 
cations, and  possibly  local  blood-letting,  will  be 
needed  in  the  first  instance. 

Subsequently,  when  immediate  danger  from 
shock  and  from  tho  spreading  of  local  inflam- 
mation has  passed  away,  the  patient  must  be 
treated  upon  the  general  principles  applicable 
to  all  cases  of  paraplegia — which  principles 
will  be  found  set  forth  in  (9)  Spinal  Cord, 
Softening  of. 

3.  Spinal  Cord,  Sudden  Crushing  Le- 
sions of;  Fr.  Compressions  brusques  de  laMoeUe 
Epiniere;  Ger.  Riickenmarksquchchunpen. 

.Etiology  and  Anatomical  Characters. — 
The  above  form  a class  of  wounds  sufficiently 
distinct  to  need  separate  treatment.  This  kind 
of  damage  to  the  cord  may  be  produced  by  the 
sudden  giving-way  of  a carious  vertebra  in  any 
part  of  the  spinal  column  ; more  rarely  from  a 
heavy  blow  on  the  back,  which  does  not  fracture 
the  spine;  or,  in  a modified  form,  from  the  burst- 
ing into  the  spinal  canal  of  an  aortic  aneurism, 
after  its  erosion  through  the  vertebrae.  But  in 
the  majority  of  cases  such  wounds  of  the  spinal 
cord  are  the  results  of  forms  of  external  violence 
which  cause  fracture  and  dislocation  of  vertebrae, 
in  some  portion  of  the  spinal  column  between 
the  upper  cervical  and  the  upper  lumbar  region. 
When  this  occurs  displacement  of  vertebrae,  even 
to  a slight  extent,  especially  in  the  dorsal  re- 
gion, in  which  the  spinal  canal  is  narrowest,  is 
sufficient  to  produce  severe  pressure  upon,  or 
crushing  of,  the  spinal  cord.  The  membranes 
may  not  be  torn  across,  but  the  substance  of  the 
cord  itself  may  be  greatly  compressed  or  reduced 
to  a blood-stained  semi-fluid  mass  of  pulp.  Afte » 
some  hours  there  are  obvious  signs  of  a com 
mencing  inflammatory  reaction  in  the  membranes  ; 
and  above  and  below  the  seat  of  lesion  similar 
changes  are  apt  to  be  set  up  in  the  spinal  cord 
itself,  which  may  go  on  to  tho  production  of  a 
variable  amount  of  inflammatory  softening.  The 
patient  may  die,  however,  before  any  of  these 
latter  changes  have  been  established. 

Symptoms. — These  vary  much,  according  to 
the  region  of  the  cord  involved.  Still,  in  spite 
of  differences  thus  dependent  upon  the  seat  of 
injury,  there  is  a certain  general  similarity  in 
the  symptoms  produced  by  all  crushing  lesions 
of  the  spinal  cord.  They  are  usually  of  this 
nature : — Complete  paralysis,  both  motor  and 
sensory,  of  parts  below  the  seat  of  lesion ; in 
addition  to  severe  pains  in  the  back,  girdle 
pains  surrounding  the  body  at  the  upper  limit  of 
sensory  and  motor  paralysis  ; increased  heat  or 
possibly  undue  coldness  of  the  body  through- 
out the  paralysed  parts ; complete  paralysis  of 
bladder  with  retention  of  urine,  gradually  giving 
place  to  incontinence ; paralysis  of  intestine, 
extremely  obstinate  at  first,  but  subsequently 
complicated  with  involuntary  evacuations  after 


1470  SPINAL  CORD,  SPECIAL  DISEASES  OF. 


the  administration  of  purgatives ; extinction  of 
all  reflex  actions  at  first. 

In  the  course  of  two  or  three  days,  if  the 
patient  should  survive,  other  general  symp- 
toms become  well-marked,  owing  to  the  es- 
tablishment of  a local  meningitis,  together  with 
some  amount  of  traumatic  myelitis.  Amongst 
vnese  we  have  general  fever,  with  an  increase  of 
the  ‘girdle  sensation,’  and  of  pains  in  the  limbs; 
twitehings  in  the  limbs  or  in  particular  muscles ; 
and  also  a general  increase  m reflex  actions  for 
a time. 

The  above-mentioned  complicating  patholo- 
gical processes  may  gradually  subside,  but  there 
will  still  be  danger  to  life  from  the  supervention 
of  severe  cystitis  or  of  extensive  bed-sores,  to- 
gether w'ith  one  or  other  of  the  various  sequelae 
to  which  such  conditions  are  apt  to  give  rise. 

The  additional  symptoms  and  variations  met 
with,  according  as  the  crushing  lesion  occur.?  in 
different  regions  of  the  cord,  are  as  follows.  (They 
increase  in  number  the  higher  the  lesion  occurs 
in  the  spinal  cord.  See  Introduction,  § 11.) 

When  it  is  situated  in  the  lumbar  swelling  we 
have,  in  addition  to  the  limitation  of  the  para- 
lysis to  the  lower  extremities,  and  a more  or 
less  complete  extinction  of  related  reflex  actions, 
the  appearance  of  rapid  atrophy  in  the  paralysed 
muscles,  together  with  the  manifestation  of  the 
electrical  ‘reaction  of  degeneration.’  The  blad- 
der and  rectum  are  apt  to  be  completely  para- 
lysed. 

AVith  the  lesion  in  some  part  of  the  dorsal 
region  we  have  sensory  and  motor  paralysis  of 
the  trunk  up  to  a certain  level,  with  an  absence 
of  the  rapid  atrophy  and  before-mentioned  elec- 
trical reaction  in  the  muscles  of  the  lower  extre- 
mities, though  some  atrophy  and  the  presence  of 
this  reaction  may  occur  in  one  or  more  of  the 
trunk  muscles.  In  addition  (and  notably  with 
the  lesion  in  higher  parts  of  the  dorsal  region) 
there  may  he  some  weakness  of  voice,  some 
interference  with  the  movements  of  respiration 
(especially  with  those  of  expiration),  as  well  as 
marked  and  continuous  priapism.  The  super- 
ficial and  deep  reflexes  may  he  depressed  or 
exalted,  according  to  the  condition  of  the  grey 
matter  below  the  seat  of  lesion. 

AVith  the  lesion  in  the  lower  cervical  region 
the  upper  extremities  are  partly  paralysed,  both 
as  regards  sensation  and  motion  ; the  movements 
of  respiration  are  much  more  gravely  interfered 
with  (expiration  especially),  whilst  inspiration 
is  of  a purely  abdominal  type ; the  voice  is  not- 
ably weak  and  feeble.  Continued  erection  of 
the  penis  is  more  frequently  met  with;  and  in 
some  cases  a remarkable  hyperpyrexia  super- 
venes, in  which  the  temperature  before  death 
may  rise  to  108°-112°  Fahr.  Should  death  not 
occur  in  this  way,  it  is  very  apt  to  supervene 
in  the  course  of  a few  days,  by  gradual  failure  of 
respiration,  which  grows  worse  than  it  was  in 
the  early  days  of  the  affection,  owing  to  the  se- 
condary myelitis  which  becomes  established,  im- 
plicating the  cord  and  nerve-roots  at  a level 
higher  than  the  original  wound.  The  pulse  is 
often  much  interfered  with,  but  variously ; it 
may  be  slower  or  much  more  frequent  than  na- 
tural; it  may  be  small,  irregular,  and  frequent; 
or  full,  regular,  and  infrequent  in  its  beats. 


There  may  also  he  signs  of  paralysis  cf  the  sym- 
pathetic vaso-motor  nerves  supplying  the  neck 
and  head,  perhaps  to  a more  marked  extent  on 
one  side  than  on  the  other. 

AVhere  the  lesion  occurs  in  the  upper  cervical 
region  of  the  cord  complete  paralysis  of  the 
trunk  and  of  all  four  extremities  may  be  recog- 
nised, if  death  does  not  occur  too  suddenly  to 
allow  even  this  to  be  observed.  The  sudden 
death,  so  apt  to  occur  in  these  cases,  is  due  to 
the  fact  that  in  them  the  diaphragm  is  paralysed, 
as  well  as  the  other  respiratory  muscles.  AVhere 
the  lesion  does  not  involve  the  whole  of  the  roots 
of  the  phrenic  nerve,  and  where  the  shock  has 
not  been  too  abrupt  and  violent,  life  (with  ex- 
tremely difficult  respiration  and  almost  complete 
loss  of  voice)  may  be  prolonged  for  a few  hours. 

An  admirable  series  of  cases  illustrating  these 
crushing  injuries  to  the  spinal  cord  is  to  be 
found  in  Ollivier’s  work  (3me  ed.,  t.  i.,  p.  253  et 
scq.). 

Diagnosis. — If  the  existence  of  fracture  and 
dislocation  of  vertebrae  can  be  substantiated,  the 
probabilities  are  always  in  favour  of  the  pre- 
sence of  a crushing  lesion  in  the  spinal  cord. 
Otherwise  after  a very  severe  fall  or  blow  upon 
the  hack,  doubts  may  be  at  first  entertained  as 
to  whether  we  have  to  do  with  the  effects  of 
concussion  alone,  or  with  this  plus  some  amount 
of  crushing  of  the  cord  or  of  haemorrhage  upon  or 
beneath  its  membranes.  The  subsequent  course 
of  the  symptoms  may,  however,  in  a day  or  two, 
enable  us  to  resolve  these  doubts. 

Prognosis.—' Tho  prognosis  in  lesions  of  this 
kind,  as  already  indicated,  is  much  graver  than 
in  the  case  of  mere  punctured  wounds  of  the 
cord — these  being  oftener  slight  and  partial  in 
their  transverse  extent.  Death  may  occur  im- 
mediately ; or  at  any  time  during  the  first  week ; 
in  the  main  from  failure  of  respiration  and  of 
the  heart’s  action.  It  is  only  in  exceptional 
cases,  and  where  the  lesion  is  in  the  dorsal  or 
lumbar  region,  that  life  is  prolonged  for  several 
weeks  or  months.  Such  lesions  are  probably 
too  severe  to  admit  of  anything  like  thorough 
repair  with  proper  nerve-tissue.  Paralysis, 
therefore,  of  a more  or  less  complete  kind,  is 
lasting.  But  even  where  life  is  prolonged  for  a 
few  months,  it  is  ultimately  lost,  owing  to  the 
establishment  of  sloughing  bed-sores  and  ulcera- 
tive cystitis,  followed  perhaps  by  blood-poison- 
ing, extensive  meningitis,  or  other  complications. 

Treatment. — In  many  of  these  cases  treat- 
ment is  useless  and  death  inevitable.  In  those 
which  are  of  a less  urgent  nature,  the  possibility 
(faint  though  it  may  be)  of  bringing  about  some 
slight  relief  by  trepauning,  with  the  view  of  ele- 
vating any  depressed  fragments  of  the  vertebral 
arches,  should  not  be  lost  sight  of.  Except,  in- 
deed, for  tho  fact  that  parts  surrounding  the 
cord  are  damaged,  so  that  rest  in  one  position  is 
often  indicated,  the  treatment  of  these  cases  after 
the  first  urgent  symptoms  have  abated  does  not 
differ  from  that  which  is  appropriate  in  other 
well-marked  cases  of  paraplegia,  where  there  is 
a tendency  to  the  formation  of  sloughing  bed- 
sores, and  to  the  establishment  of  cystitis.  See 
(9)  Spinal  Cord,  Softening  of. 

4.  Spinal  Cord,  Slow  Compression  of. 


SPINAL  COED,  SPECIAL  DISEASES  05. 


Synon.  : Chronic  Traumatic  Lesion  of  the  Spinal 
Cord ; Fr.  Compression  lente  de  la  Moelle  Epi- 
nierc  ; (in  part)  Paraplegie  douloureuse  des  ean- 
cereux ; Ger.  Lang  same  Compression  des  RiicJccn- 
rnarks. 

JEtiology  and  Anatomical  Characters. — 
The  most  frequent  causes  of  the  set  of  symptoms 
grouped  under  this  head  are  to  he  found  in  dis- 
sases  of  the  vertebrae,  and  especially  simple  in- 
flammatory cr  scrofulous  caries  of  the  bodies  of 
the  Tertebrae  (leading  to  angular  curvature , or 
‘ Pott’s  Disease ’).  Still,  ether  kinds  of  disease 
of  the  vertebra  may  also  be  productive  of  slow 
compression  of  the  spinal  cord,  and  of  that  form 
of  localised  softening  of  the  organ  -which  is  so 
commonly  met  with  in  this  class  of  cases  (the 
so-called  ‘compression  myelitis’).  Among  these 
may  be  mentioned  cancer  of  the  vertebrae,  either 
primary  or  secondary ; also  exostoses  projecting 
into  the  spinal  canal,  or  more  irregular  thicken- 
ing of  the  bones  in  this  situation.  In  cases  of 
vertebral  caries,  a tough,  yellow,  scrofulous 
growtli  often  infiltrates  the  posterior  vertebral 
ligament,  and  thence  spreads  to  the  dura  mater, 
here  producing  thickening  and  irregular  fungosi- 
ties  which  may  press  injuriously  upon  the  spinal 
cord — more  especially  upon  its  antero-lateral 
columns.  In  these  cases  the  organ  may  be  dis- 
tinctly softened  opposite,  and  perhaps  for  a very 
short  distance  above  and  below,  the  site  of  com- 
pression. At  first  such  softening  is  principally 
apparent  in  the  columns  above  mentioned;  but 
in  cases  of  longer  duration  it  may  involve  the 
whole  thickness  of  the  cord,  and  be  followed  by 
the  usual  ascending  and  descending  ‘ secondary 
degenerations  (§  6,  [13]).’  The  softened  matter 
itself  is  an  almost  bloodless  fluid  or  semi-fluid 
pulp,  either  of  a whitish  or  dull  yellowish-white 
colour,  and  there  is  generally  no  undue  vascula- 
rity of  the  immediately  adjacent  portions  of  the 
cord. 

In  certain  crises  of  slow  compression  no  such 
softening  of  tho  cord  is  produced ; there  is  rather 
a slow  atrophy  or  disappearance  of  the  nerve- 
substance  as  the  pressure  increases,  together 
with  a sclerosis  of  what  remains.  This  may 
occur,  for  instance,  where  the  cord  is  pressed 
upon  by  some  exostosis,  or  by  irregular  growth 
and  thickening  of  the  inner  surface  of  the  spinal 
canal,  such  as  occurs  occasionally  in  one  or  other 
of  the  cervical  vertebrae. 

It  has  long  been  known  that  no  constant  rela- 
tion exists  between  the  amount  of  angular  cur- 
vature and  of  paralysis  in  different  cases  of  ver- 
tebral caries.  Paralysis  may  be  absent  where 
curvature  is  most  marked.  On  the  other  hand, 
with  no  curvature  and  with  only  a slightly 
marked  projection  of  one  or  two  vertebral  spines, 
paralysis  may  yet  exist  to  a well-marked  degree. 
This  is  due  to  the  fact,  that  in  such  cases  the 
cord  is  only  very  rarely  compressed  by  the 
bones,  whilst  it  is  frequently  more  or  less 
pressed  upon  by  the  yellowish  growths  which 
protrude  from  the  inflamed  or  carious  vertebrae, 
or  which  produce  thickening  and  infiltration  of 
the  dura  mater  at  the  seat  of  disease,  and  changes 
of  this  sort  may  be  well-marked  even  where 
no  angular  curvature  is  appreciable. 

Again,  where  angular  curvature  is  present,  the 
posterior  surface  of  the  bodies  of  the  vertebrae, 


1471 

corresponding  with  the  angle,  is  often  bent, 
rough,  and  eroded,  and  the  cord  over  it  is  apt 
to  become  softened,  though  there  may  be  no 
compressing  growths  or  thickenings  of  the  mem- 
branes. 

Thus  it  happens  that  the  paralysis  in  these 
cases  may  be  variously  produced.  And  seeing 
that  it  is  often  due  to  pressure  by  inflammatory- 
products  rather  than  to  pressure  or  irritation 
from  the  diseased  bones  themselves,  we  may  the 
better  understand  the  fact  that  occasionally  a 
great  improvement  may  set  in  and  become  esta- 
blished in  regard  to  the  paralysis,  although  the 
angular  curvature  of  the  spine,  and  therefore  the 
distortion  of  the  spinal  canal,  remains  as  obvious 
as  it  ever  has  been. 

In  addition  to  slow  compression  of  the  cord 
resulting  from  diseases  of  the  bones  of  the  spine, 
a somewhat  similar  condition  may  be  induced  by 
the  various  kinds  of  tumours  of  the  meninges,  or 
by  hydatid  growths  implicating  these  parts  (see 
Meninges,  Spinal,  Diseases  of ; Tumours).  Con- 
fined within  the  narrow  limits  of  the  spinal 
canal,  such  tumours,  even  though  of  smaE  size, 
may  soon  come  to  exercise  a very  injurious 
amount  of  pressure  upon  the  spinal  cord. 

Symptoms,  Course,  and  Terminations. — We 
shall  point  out  some  of  the  distinguishing  cha- 
racteristics of  the  paralysis  which  is  often  asso- 
ciated with  vertebral  caries,  and  afterwards  refer 
to  the  peculiarities  met  with  where  meningeal 
tumours  exist. 

In  vertebral  caries  with  commencing  pressure 
upon  the  spinal  cord,  the  symptoms  will  be 
different,  according  to  the  part  of  the  column 
implicated.  The  affection  is  frequently  ushered 
in  by  an  abiding  pain  in  the  spine  and  parts 
adjacent,  often  supposed  to  be  ‘rheumatic’  in 
nature.  Such  pains  commonly  disappear  when  tho 
patient  is  in  the  recumbent  position,  except  dur- 
ing the  acts  of  sneezing  or  coughing.  They  are 
commonly  induced  by  particular  kinds  of  move- 
ments, which  are  more  or  less  difficult  on  this 
account.  There  is  also  some  weakness  in  the  lower 
part  of  the  body  and  in  the  lower  extremities. 
The  mere  ‘ weakness’  may  continue  for  weeks  or 
even  months  before  there  is  anything  like  actual 
paralysis ; though  at  last  this  may  show  itself 
somewhat  abruptly.  The  patient  now  becomes 
unable  to  stand,  though  lie  can  still  move  his 
legs  slightly  whilst  lying  in  bed.  At  this  stage 
sensation  is  little,  if  at  all,  interfered  with;  but 
there  may  already  be  some  increase  in  the  readi- 
ness with  which  the  knee-reflex  manifests  itself, 
and  ankle-clonus  may  also  be  easily  attainable. 
Next  there  may  be  startings  of  the  limbs,  and 
commencing  rigidity  of  the  muscles  when  pas- 
sive movements  are  attempted;  followed  after 
a time  by  a more  marked  rigidity  (which,  when 
present  in  the  calf  muscles,  will  prevent  tho 
manifestation  of  ankle-clonus  and  of  the  knee- 
reflex).  Later,  if  pressure  increases,  and  espe- 
cially where  a complete  transverse  softening 
becomes  established,  sensibility  in  its  various 
modes  becomes  implicated.  At  this  period  the 
exaltation  of  the  reflexes  often  diminishes.  For 
a time  the  degree  of  impairment  of  sensibility 
and  the  freedom  with  which  knee-reflex  and 
ankle-clonus  may  be  obtained  fluctuates.  Mean- 
while, painful  spasmodic  contractions  of  the  legs 


1472  SPINAL  CORD.  SPECIAL  DISEASES  OF. 


(with  flexion  of  hip  and  knee  joints)  become 
habitual,  persisting  through  day  and  night  with 
only  rare  intermissions. 

Although  there  is  some  general  wasting  of  the 
muscles,  together  with  a flabby  condition  when 
they  are  relaxed,  they  still  react  almost  normally 
to  the  faradic  current.  The  skin  is  often  dry  and 
scurfy.  The  temperature  of  the  limbs  is  gene- 
rally slightly  lower  than  normal. 

At  the  first  onset  there  may  bo  for  a few  days 
a difficulty  in  voiding  the  urine,  but  this  power 
soon  returns  and  often  continues  long  after  the 
limbs  have  become  powerless.  The  bowels  are 
perhaps  somewhat  constipated,  but  there  is  no 
incontinence  of  faeces,  unless  diarrhcea  super- 
venes from  any  cause,  or  except  when  the  reflex 
activity  of  the  bowel  is  greatly  exalted  under 
the  influence  of  aperient  medicines. 

The  above  condition  of  things  may  last  long 
without  much  variation.  But  after  a time  there 
will  be  a gradual  mitigation  of  the  symptoms,  or 
the  reverse.  In  the  latter  case  loss  of  voluntary 
control  over  the  bladder  and  rectum  appears ; 
and  (especially  when  sensibility  of  the  body  and 
limbs  becomes  impaired)  the  tendency  to  the 
formation  of  sloughs  and  gangrenous  bed-sores 
becomes  increased.  With  these  conditions  other 
complications,  such  as  cystitis,  blood-poisoning, 
(See.,  may  appear  and  greatly  aggravate  the  con- 
dition of  the  patient,  helping  to  bring  about  a 
more  speedy  termination. 

In  the  case  of  tumours  arising  from  the 
meninges,  the  onset  of  the  affection  may  also  be 
very  gradual  at  first,  though,  perhaps,  rather 
suddenly  intensified  at  last.  Here,  however, 
the  pressure  very  often  comes  upon  the  cord 
from  behind,  or  it  may  at  the  same  time  impli- 
cate one  or  both  lateral  regions  of  the  cord.  At 
first,  therefore,  we  commonly  get  variously-im- 
paired sensibility  and  neuralgic  pains,  or  pains 
mixed  with  startings  and  cramp-like  contrac- 
tions in  certain  muscles,  occurring  in  those  par- 
ticular regions  of  the  body  or  limbs  which  are 
in  relation  with  the  nerve-roots  slightly  pressed 
upon  and  irritated  by  the  new  growth.  Great 
differences  exist  in  different  cases  in  regard  to 
the  degree  and  persistence  of  the  initial  pains. 
Subsequently  these  same  nerves  and  the  cord 
itself  may  become  more  severely  pressed  upon, 
and  then  loss  of  sensibility  over  the  field  of 
distribution  of  the  nerve-roots  is  met  with,  to- 
gether with  loss  or  impairment  of  sensibility  in 
all  or  some  parts  of  the  body  whose  nerve-supply 
is  from  the  cord  below  the  compressed  region. 
With  this  a minor  amount  of  motor  paralysis 
also  occurs,  which,  however,  subsequently  be- 
comes more  marked,  and  ultimately  complete. 
When  this  takes  place  we  have  all  the  signs  and 
symptoms  met  with  in  a case  of  total  transverse 
softening  of  the  spinal  cord  at  the  level  impli- 
cated (see  Spinal  Cord,  Softening  of).  This 
change  is,  in  fact,  commonly  established  by  the 
persistence  and  increase  of  pressure  due  to  the 
new  growth. 

These  are  the  broad  outlines  of  the  symptoms 
met  with  in  such  cases,  which,  of  course,  are 
subject  to  innumerable  variations  in  individual 
cases,  in  accordance  with  differences  in  the  region 
of  the  cord  affected,  together  with  the  rate  of 
growth,  mode  of  incidence,  and  size  of  the  tumour. 


In  cancer  of  the  vertebrae,  also,  we  have  much 
the  same  grouping  of  symptoms;  the  prelimi- 
nary pains  being  here  especially  severe  (see 
Charcot’s  Lemons,  t.  H.,  ed.  3,  p.  86). 

Diagnosis. — In  the  paralysis  associated  with 
vertebral  caries  the  diagnosis  depends  upon  the 
recognition  of  this  causal  condition,  which,  in 
the  early  stages,  is  often  a matter  of  some  diffi- 
culty. Much  will  depend  upon  the  existence  of 
pain  in  particular  regions  of  the  spine,  or  radiat- 
ing therefrom ; of  pain  which  is  relieved  by  the 
recumbent  position,  and  greatly  aggravated  by 
coughing,  sneezing,  or  stooping  movements  of 
different  kinds  (see  H.  Marsh  in  Brit.  Med. 
Journ.,  voL.  i.  1881,  p.  913).  And  yet  in  the 
absence  of  signs  of  caries,  or  of  a scrofulous 
habit  of  body  or  history,  or  of  an  exciting  cause 
for  caries,  in  cases  where  there  may  be  little  or 
no  prominence  of  vertebral  spines,  and  even  no 
pain  from  firm  pressure  or  the  application  of  a 
hot  sponge,  we  may  be  helped  in  our  diagnosis 
of  the  existence  of  caries  by  the  distinctive  cha- 
racters of  the  paralysis  itself,  namely,  its  impli- 
cation of  motility  principally,  the  exaggeration 
of  the  tendon-reflexes,  the  more  or  less  marked 
rigidity  of  the  legs,  and  the  continuance  of  con- 
trol over  the  bladder  and  rectum. 

In  cases  of  the  latter  type,  or  where  there  is 
only  a slight  prominence  of  two  to  four  vertebral 
spines,  it  may  be  difficult,  however,  to  establish 
a diagnosis  between  caries  and  cancer  of  the 
bodies  of  the  vertebr®.  It  is  true  that  a rounded 
prominence  of  several  vertebral  spines  is  met 
with  in  cancer  more  frequently  than  the  angular 
projection  commonly  associated  with  caries;  yet 
this  single  character  will  not  always  aid  us ; we 
must  look  also  to  the  presence  or  absence  of 
severe  pains,  to  the  clinical  grouping  of  symp- 
toms generally,  and  to  the  history  of  the  patbnt. 

The  diagnosis  of  the  other  causes  of  slow  com- 
pression of  the  cord  to  which  reference  has  been 
made  (exostoses  or  meningeal  tumours),  is  usu- 
ally a matter  of  extreme  difficulty.  We  must  be 
guided  by  probabilities  based  upon  other  asso- 
ciated states  or  conditions  that  may  be  recogni- 
sable in  our  patient,  and  also  by  the  mode  of 
onset  of  the  affection. 

Prognosis. — Wo  can  only  speak  in  general 
terms  concerning  the  prognosis  of  the  rather 
miscellaneous  conditions  which  form  the  subject 
of  this  article.  Cancer  of  the  vertebrae  or  of  the 
dura  mater,  compressing  the  cord,  is  the  most 
serious  of  them  all.  The  progress  of  such  cases 
is  usually  both  rapid  and  extremely  painful,  so 
that  the  end  comes  inevitably  before  many 
months  have  expired. 

In  vertebral  caries  associated  with  compres- 
sion of  the  cord,  the  prognosis  is  extremely  un- 
certain. Under  suitable  treatment  many  of 
these  cases  practically  recover  more  or  less  fully. 
The  process  of  caries  is  arrested,  the  spoiled 
vertebrae  are  strengthened  and  bridged  over  by 
growth  of  new  bony  tissue  (though,  of  course, 
the  angular  curvature  of  the  spine  remains), 
whilst  recovery  from  the  paralysis  may  be  more 
or  less  complete.  This  latter  kind  of  recovery 
takes  place  occasionally  even  after  paralysis,  with 
almost  persistent  contractions  of  the  lower  ex- 
tremities, has  existed  for  from  twelve  to  eighteen 
months  or  even  longer. 


SPINAL  (JOKD.  SPECIAL  DISEASES  OE.  147fl 


In  other  cases,  of  exostosis,  hydatids,  or  men- 
ingeal tumours,  compressing  the  spinal  cord,  the 
prognosis  will  depend  upon  the  part  of  the  cord 
involved,  upon  the  rate  of  increase  of  the  symp- 
toms of  compression,  and  upon  the  extent  to 
which  a secondary  myelitis  or  softening  is  es- 
tablished. The  disease  in  these  cases,  in  spite 
of  stationary  periods,  or  even  those  of  slight  im- 
provement, is  more  or  less  continuously  progres- 
sive, though  it  may  last  for  many  months,  or, 
occasionally,  even  for  a year  or  two.  Some  of  the 
complications  or  accidents  incident  to  the  para- 
plegic condition  ultimately  bring  the  patient’s 
life  to  a close. 

Treatment. — Rest  in  the  recumbent  or  in  the 
prone  position  is,  of  course,  absolutely  essential 
in  cases  of  vertebral  caries  or  of  cancer  of  the 
vertebrae.  In  addition  to  this  in  many  cases  of 
vertebral  caries,  some  form  of  Sayre's  jacket  may 
be  needed,  in  order  more  effectually  to  secure 
absolute  immobility  of  the  affected  portion  of 
the  spinal  column.  This,  however,  would  have  to 
be  reserved  for  the  more  chronic  cases  or  stages 
■ — for  those  in  which  local  treatment  was  no  longer 
considered  to  be  necessary  or  desirable. 

In  cases  of  paraplegia  associated  with  verte- 
bral caries,  the  patient’s  general  health  requires 
the  utmost  attention  during  the  period  in  which 
we  are  endeavouring  to  check  the  disease  by 
the  influence  of  rest.  Good  nutritious  food  and 
cod-liver  oil  will  be  required,  combined  with 
steel  wine  or  the  syrupus  ferri  phosphatis.  In 
some  eases  iodide  of  potassium  (together  with 
iodide  of  iron  or  small  doses  of  bichloride  of 
mercury)  seems  to  do  good. 

In  regard  to  local  measures,  counter-irritation 
of  some  kind  is  generally  had  recourse  to,  either 
in  the  form  of  flying  blisters  near  to  and  on  each 
side  of  the  portion  of  the  spinal  column  which 
is  affected,  or  else  by  the  renewed  application  of 
moxas  or  the  actual  cautery  to  these  regions. 
The  latter  more  severe  measures  are  still  re- 
commended by  some  authorities,  though  the 
experience  of  others,  amongst  whom  was  the  late 
Sir  Benjamin  Brodie,  is  against  their  employment, 
as  being  of  little  or  no  use,  and  therefore  adding 
needlessly  to  the  sufferings  of  the  patient.  The 
writer  is  strongly  inclined  to  think  that  all  the 
good  which  moxas  or  the  actual  cautery  are  in- 
tended to  bring  about,  may  be  as  effectually 
achieved  by  the  aid  of  flying  blisters  applied  to 
the  spine  from  time  to  time. 

In  the  case  of  an  hydatid  tumour  pressing  upon 
the  spinal  cord,  and  also  situated  in  part  out- 
side the  vertebral  spines,  tapping  might  bring 
much  relief.  In  the  majority  of  the  other  con- 
ditions comprised  within  the  limits  of  this  article, 
little  can  be  done  to  cure  the  condition  which  is 
the  cause  of  the  spinal  disease,  so  that  it  would 
only  remain  for  us  to  treat  the  paraplegia  and  its 
attendant  conditions  upon  the  general  principles 
applicable  to  them,  which  are  fully  considered 
under  (9)  Spinal  Cord,  Softening  of. 

5.  Spinal  Cord,  Anaemia  of. — Anaemia  is 

not  to  be  considered  as  the  basis  of  any  ordinary 
or  common  disease  of  the  cord ; or,  in  other 
words,  there  is  no  definite  group  of  symptoms 
the  existence  of  which  is  likely  to  be  recognised 

more  than  once  in  a lifetime  in  any  actual  pre- 

93 


sent  patient,  which  would  justify  the  diagnosis 
‘anaemia  of  the  cord.’ 

First,  the  writer  would  repudiate  the  notion 
that  antsmia  or  chlorosis,  as  a mere  blood-disease, 
is  capable  of  producing,  on  the  side  of  the  spinal 
cord,  any  set  of  symptoms  which  can  be  marked 
off  from  those  characterising  the  condition  as  a 
whole.  In  these  diseases  the  functions  of  all  the 
organs  are  impaired  by  reason  of  the  impoverish- 
ment of  the  blood.  The  brain  and  spinal  cord, 
on  account  of  the  delicacy  of  their  functions,  will, 
of  course,  suffer  to  a notable  degree  ; and  when 
general  debility  is  extreme,  a paresis  of  the  lower 
extremities  may  be  notable  beyond  that  of  other 
parts  of  the  body',  because  tile  legs  in  stand- 
ing or  in  walking  have  to  support  so  great  a 
weight.  Where  anything  more  than  such  pa- 
resis exists  —that  is,  where  there  is  actual  para- 
plegia, such  symptoms  are  not  to  be  explu.nd' 
by  a mere  anaemia  of  the  cord.  Other  causes 
are  to  be  looked  for.  Jaccoud’s  whole  group  of 
paraplegics  dyscrasiques  will  probably  disappear 
before  a more  thorough  knowledge  of  the  actual 
mode  of  causation  of  these  and  many  other 
obscure  forms  of  paraplegia. 

Secondly,  embolism  and  thrombosis  of  spinal 
arteries  will  produce  temporarily5 * 7,  and  in  quite- 
limited  regions  of  the  cord,  a condition  of 
anaemia.  Such  local  anaemia  would  probably  soon 
be  rectified  by  the  establishment  of  a collateral 
circulation;  and  in  the  event  of  this  not  taking 
place,  local  ‘softening’  of  the  organ  would  en- 
sue. A paralysis  owning  such  an  origin  would 
not,  therefore,  be  spoken  of  as  resulting  from 
‘ anaemia  of  the  cord.’ 

Thirdly7,  pressure  upon  parts  of  the  cord  will 
occasion  anaemia  and  ultimately  softening,  but 
the  symptoms  in  a case  of  this  sort  will  depend 
mainly  upon  the  pressure  itself  interfering  with, 
the  functions  of  the  nerve-tissue  thus  affected. 

Beyond  the  conditions  above  referred  to,  there 
is  the  possibility  that  definite  groups  of  para- 
lytic symptoms  may  be  occasioned  by  anaemia 
induced  by  mere  functional  spasm  of  the  arteries 
iD  certain  regions  of  the  cord — spasm,  that  is, 
which  persists  day  after  day.  This  is  supposed 
by  Brown-Sequard  to  be  the  condition  existing 
in  the  cases  of  so-called  1 reflex  paralysis  ’ ( see 
27,  Keflex  Paraplegia).  If  such  a condition 
of  persisting  arterial  spasm  be  possible,  and  an 
actual  cause  of  paralytic  symptoms,  we  may 
well  ask  whether  it  too  ought  not  after  a time 
to  lead  to  actual  softening  of  the  cord. 

There  will  still  remain  a very  few7  exceptional 
cases,  in  which  a condition  of  real  anaemia  of  the 
spinal  cord  is  brought  about  in  man,  just  as  it 
has  been  brought  about  in  some  of  the  lower 
animals  whose  abdominal  aorta  has  been  tied 
or  compressed.  When  the  blood-supply  is  thns 
suddenly  cut  off  from  the  lumbar  region  of  the 
cord  in  animals,  their  hinder  limbs  become  para- 
lysed almost  immediately,  and  continue  paralysed 
as  long  as  the  blood-supply  of  the  cord  happens  to 
be  arrested.  But  if,  after  a mere  brief  interval,  the 
blood  is  again  allowed  to  take  its  natural  course, 
the  temporary  paralysis  disappears  completely  in 
a very  short  time.  A condition  of  this  kind  seems 
to  have  occurred  in  a patient,  formerly  under  the 
care,  of  Sir  W.  Gull,  who  suddenly  became  para- 
plegic, app  irently  owiDg  to  an  abrupt  arrest  of 


SPINAL  COED,  SPECIAL  DISEASES  OF. 


:474 

file  blood-current  through  the  abdominal  aorta, 
is  was  indicated  by  the  cessation  of  the  femoral 
and  other  pulses  in  the  lower  extremities  (see 
Guy's  Hospital  Reports,  1857,  p.  311).  The 
man  continued  paraplegic  for  months,  and  only 
recovered  when  the  collateral  circulation  became, 
after  a time,  pretty  fully  established.  In  a very 
few  other  cases  referred  to  by  Erb,  in  which 
paraplegic  symptoms  were  associated  with  an 
obstruction  of  some  kind  in  the  abdominal  aorta 
he  thinks  that  these  symptoms,  supervening  as 
they  did  rather  less  suddenly,  may  have  been  in 
great  part  due  to  the  deficient  blood-supply  to 
the  muscles  and  nerves  of  the  lower  extremities, 
rather  than  to  ansemia  of  the  cord — to  a peri- 
pheral, that  is,  rather  than  to  a centric  anaemia. 

6.  Spinal  Cord  and  its  Membranes,  Hy- 
pereemia  of. — -This  condition  again  is  more  fre- 
quently talked  of  than  it  deserves,  looking  to  the 
small  amount  of  positive  knowledge  we  possess 
upon  the  subject. 

Hypersemia  of  the  cord  must  be  either  passive 
or  active,  that  is,  it  must  be  a result  of  me- 
chanical congestion  or  of  arterial  determination. 

Mechanical  Congestion. — In  obstructive  heart- 
disease  extreme  congestion  of  the  spinal  cord 
may  exist  for  months  without  producing  any 
distinct  symptoms  of  disease  of  the  spinal  cord. 
A constantly  congested  spinal  cord  would  doubt- 
less perform  its  functions  in  a less  vigorous  man- 
ner than  natural,  but  such  effects  would  be  slowly 
evolved  and  comparatively  obscure.  After  a long 
time  the  effects  might  become  more  marked, 
owing  to  the  overgrowth  of  connective  tissue 
within  the  organ.  We  may  indeed  have  the 
starting-point  of  a general  sclerosis  of  the  spinal 
cord  under  such  conditions ; but  this  secondary 
change,  when  only  slightly  marked,  may,  even  in 
the  spinal  cord,  produce  no  definite  symptoms. 

General  mechanical  congestion  of  the  cord  is 
probably  more  frequent  and  more  easily  brought 
about  than  a congestion  involving  parts  of  the 
organ.  From  various  causes  there  may  be  undue 
pressure  upon  certain  veins,  which  directly  or 
indirectly  convey  blood  away  from  special  re- 
gions of  the  cord  and  its  membranes.  Such  an 
event  cannot,  however,  be  regarded  as  a likely 
cause  of  a congestion  productive  of  morbid  spi- 
nal symptoms,  if  we  consider  the  absence  of  dis- 
tinct symptoms  resulting  from  extreme  general 
congestion  of  the  cord ; and  also  the  fact  of  the 
very  free  anastomosis  of  all  the  spinal  veins. 

Active  hypercemia  may  in  its  origin  be  of  two 
kinds — ‘reflex’  or  ‘inflammatory.’ 

‘Keflex’  hypersemia  of  the  cord  and  its  mem- 
branes is  possibly  a phenomenon  of  great  fre- 
quency, manifesting  itself  locally  in  certain  regions 
— the  seat  of  the  process  varying  according  to 
the  conditions  under  which  it  arises.  It  might 
be  immediately  caused  by  vaso-motor  paralysis, 
implicating  certain  vessels  of  the  cord  and  their 
branches ; and  would  thus  involve  an  increased 
afflux  of  blood  to  the  tissues  contained  in  the 
corresponding  vascular  t erritories.  We  know  that 
such  an  increased  afflux  of  blood  may  exist  in 
other  tissues  for  some  time  without  inducing 
tissue-changes  of  an  appreciable  kind  (Brown- 
Sequard).  It  is  fair  to  suppose,  moreover,  that 
any  symptoms  induced  by  such  increased  afflux 


of  blood  to  certain  regions  of  the  cord  would  be 
indicative  of  exalted  rather  than  of  depressed 
function  (for  example,  hypermsthesia,  actual  pains 
and  spasms,  or  increased  reflex  excitability,  rather 
than  their  opposites). 

In  weak  and  irritable  states  of  the  nervous 
system  it  is  quite  possible  that  such  vaso-motor 
paralysis,  and  also  vaso-motor  spasms  inducing 
localised  anaemias,  may  manifest  themselves  in 
spinal  vessels,  as  they  do  in  cutaneous  vessels 
by  familiar  flushes  or  pallors.  If  occurring  in 
the  skin,  however,  these  would  be  temporary 
phenomena,  and  not  capable  of  producing  the 
symptoms  of  an  abiding  disease.  How  frequent 
such  reflex  local  hyperaemias  (whether  brief  or 
prolonged)  may  be  in  the  spinal  cord,  and  in 
what  precise  manner  they  are  excited,  we  do  not 
know.  Suppression  of  the  menses  or  of  htemor- 
rhoidal  fluxes,  the  prosence  of  worms  in  the 
intestine,  the  prolonged  incidence  of  cold  and 
wet,  or  severe  concussions  of  the  spine,  any  or 
all  may  operate  in  this  particular  manner — but 
for  proof  that  they  do,  as  matter  of  fact,  we  may 
look  for  evidence  in  vain. 

The  subject  of  ‘ inflammatory  hypersemia’  will 
bo  briefly  considered  under  the  next  heading.  In 
this  case,  in  addition  to  changes  in  the  vascular 
system,  the  effects  of  the  inflammatory  process 
as  a whole  have  to  be  taken  into  account.  Even 
in  the  first  stage  of  inflammation  something 
prior  to  and  beyond  the  mere  ‘ active  ’ conges- 
tion has  to  be  thought  of. 

From  what  is  said  above,  it  may  be  seen  how 
shadowy  is  our  present  knowledge  concerning 
the  existence  of  any  definite  sets  of  symptoms 
which  can  be  ascribed  to  non-inflammatory 
hypersemia  of  the  cord  and  its  membranes,  either 
general  or  local.1 

7.  Spinal  Cord,  Inflammation  of. — Sykox.- 

Myelitis;  Myelitis  Acuta;  Softening  of  the 
Spinal  Cord  (in  part);  Fr.  My  elite;  Myilitt 
aigue ; Inflammation  cle  la  Moelle  Epinierc ; Ramo- 
lissemcnt  de  la  Moelle  Epinierc  (in  part) ; Ger. 
Myelitis;  Rucke n ma risen tzundung ; Erweichung 
dcs  Riickenmarks  (in  part). 

Nature,  /Etiology,  and  Pathology. — To 
speak  definitely  on  this  subject,  in  the  present 
state  of  knowledge,  is  extremely  difficult.  This 
is  due  to  several  causes.  In  the  first  place,  it  is 
owing  to  the  fact  that  so  much  uncertainty 
exists  in  the  m;uds  of  many  eminent  patholo- 
gists and  physicians  as  to  what  ought  rightfully 
to  be  included  under  this  term  ; and,  secondly, 
because  by  a very  large  number  of  writers  the 
term  is  understood  and  used  in  the  vaguest 

‘ The  view  in  regard  to  congestion  as  a cause  of 
definite  morbid  symptoms  on  the  side  of  the  brain  and 
of  the  spiral  cord  has  been  entertained  for  the  last  six- 
teen years  at  least  by  the  present  writer,  and  the  above 
article  (6)  has  been  in  manuscript  for  nearly  three  years. 
It  seems  necessary  for  him  to  make  this  statement  to  pre- 
vent further  misunderstanding  arising  from  the  fact  that 
his  name  appears  ns  one  of  the  authors  of  a paper  on 
‘Congestion  of  the  Brain,’  in  Dr.  Reynolds's  System  of 
Medicine,  in  which  a much  more  important  r6le  is  at- 
tached to  Congestion  as  a producer  of  definite  morbid 
symptoms.  The  present  writer  was.  however,  only  the 
author  of  the  sections  on  * Pathology ' and  ‘ Morbid  Ana 
tomy  ’ in  the  above-mentioned,  article,  and  was  not,  pre- 
vious to  its  publication,  aware  of  the  views  entertained 
by  the  accomplished  editor  of  the  work  in  question  in 
regard  to  the  supposed  great  clinical  significance  o( 
Congestion  when  it  exists  in  the  hrain. 


SPINAL  COKD.  SPECIAL  DISEASES  OF.  1470 


manner,  but  'with,  a manifest  tendency  to  com- 
prise under  it  the  largest  possible  number  of 
affections  of  the  spinal  cord.  Critical  dis- 
crimination seems  to  have  been,  and  still  to  be, 
in  abeyance  -with  many  who  describe  or  report 
cases  of  disease  of  the  spinal  cord.  They  set 
down  as  instances  of  ‘ myelitis  ’ not  only  all 
cases  in  which  the  substance  of  the  spinal  cord  is 
softened,  but  still  more  all  those  in  which  it 
is  indurated — and,  no  less  impartially,  those  in 
which  it  is  merely  degenerated. 

(1)  The  notion  that  common  ‘softenings’  of 
the  spinal  cord  are  of  inflammatory  origin  has 
persisted  with  little  alteration,  although  for 
nearly  twenty  years  pathologists  have  been  inter- 
preting altogether  differently  the  mode  of  pro- 
duction of  apparently  similar  1 softenings  ’ of  the 
cerebrum  and  cerebellum.  Can  it  be  that  ‘ soft- 
ening’as  it  occurs  in  the  majority  of  cases  in 
these  latter  organs  is  of  non-inflammatory  origin; 
while  in  the  majority  of  apparently  similar 
cases  occurring  in  the  spinal  cord,  the  process  is 
really  inflammatory  in  its  nature  ? 

(2)  Then,  again,  without  adequate  cause,  the 
very  localised  changes  occurring  in  and  around 
the  great  ganglion-cells  of  the  anterior  cornua,  in 
‘acute’  and  ‘chronic  spinal  paralysis,’  and  in 
‘ progressive  muscular  atrophy,’  have  been  set 
down  as  inflammatory  in  their  nature,  and  new 
names  have  been  given  to  these  affections,  tend- 
ing to  ratify  this  view  as  to  their  origin.  Thus 
they  are  spoken  of  by  some  as  cases  of  anterior 
rpolio-myelith,  or  more  briefly,  and,  so  far,  better, 
as  cases  of  cornual  myelitis.  But  localisation  of 
an  inflammatory  process  to  great  ganglion-cells 
and  their  immediate  surroundings,  at  present  con- 
stitutes a rather  unintelligible  process  to  many 
pathologists.  And  mysterious  as  these  par- 
ticular changes  are,  from  the  point  of  view  of 
their  aetiology,  on  any  hypothesis  that  has  yet 
been  started,  it  is  at  least  simpler,  and  more 
harmonious  with  the  nature  of  the  observed 
conditions  themselves,  to  regard  them  as  of  a 
degenerative  type.  If  the  slower  and  more 
isolated  changes  characteristic  of  ‘ progressive 
muscular  atrophy,’  are  to  be  placed  in  this 
category  (and  in  regard  to  them  there  is  abso- 
lutely no  evidence  either  clinical  or  pathological 
that  can  be  adduced  in  favour  of  an  inflammatory 
origin),  then  also  it  becomes  easy  to  believe  that 
under  some  at  present  imperfectly  defined  con- 
ditions, a change  of  the  same  kind  may  set  in 
more  rapidly  in  these  the  most  specialised  of  all 
the  anatomical  elements  met  with  in  the  spinal 
cord,  so  as  to  produce  the  more  acute  affections 
above  referred  to.  The  slight  secondary  over- 
growth of  neuroglia  often  occurring  around  the 
degenerated  ganglion-cells,  does  not  in  the  least 
militate  against  this  view  as  to  tho  pathology  of 
the  process  ; a similar  secondary  change  occurs 
also  in  the  process  next  to  be  referred  to,  and 
will  be  found  to  be  easily  explicable  without  the 
necessity  of  having  recourse  to  the  ever-ready 
and  fashionable  hypothesis  of  inflammation. 

(3)  ‘Secondary  degenerations’ of  the  spinal  cord 
have  indeed,  in  spite  of  their  name,  and  of  what 
is  known  as  to  their  origin,  been  erroneously 
regarded  of  late  by  some  writers  as  inflamma- 
tory changes  (Ziemssen's  Cyclopadia,  vol.  xiii. 
p.  769).  When  nerve-fibres  are  cut  across,  those 


portions  which  are  severed  from  their  connection 
with  certain  ganglion-cells  are  no  longer  able 
to  preserve  their  nutritive  integrity.  Simulta- 
neously throughout  their  whole  length  fatty 
degeneration  affects  their  white  substance.  Myo- 
line  breaks  up,  and  becomes  disintegrated  as  it 
does  in  non-inflammatory  softenings  in  the  brain; 
and  very  speedily  granulation-corpuscles  begin 
to  form  abundantly  throughout  the  changing  area. 
But  though  fatty  degeneration  thus  occurs  simul- 
taneously in  all  the  cut  fibres  of  the  band,  the 
vascular  supply  of  this  tract  of  tissue  has  not 
been  altered.  Since  the  blood  in  the  diseased 
area  is  not  utilised  by  the  nerve-tissues  proper, 
except  to  a very  small  extent,  a large  excess  of 
nutriment  is  placed  at  the  disposal  of  the  neu- 
roglia, and  this  undergoes  a well-marked  hyper- 
plasia. Thus  a band  of  tissue-change  is  pro- 
duced in  which  some  of  tho  characteristics  of 
softening  are  blended  with  those  pertaining  to 
a patch  of  sclerosis.  In  brief,  we  have  effects 
resulting  from  a primary  fatty  degeneration  of 
the  nerve-fibres,  and  a secondary  hyperplasia  of 
the  neuroglia  ; and  from  first  to  last  there  is  not 
the  least  reason  for  believing  in  the  existence  of 
an  inflammatory  process. 

(4)  If  we  turn  now  to  ‘ sclerosis  ’ of  the  cord 
of  primary  origin,  we  again  meet  with  processes 
which  are  commonly  regarded  and  described  as 
forms  of  ‘ chronic  myelitis'  This  nomenclature 
is  objectionable  as  applied  to  the  processes  in 
the  spinal  cord,  just  as  it  is  in  its  application  to 
like  processes  occurring  in  other  organs,  as  the 
liver,  the  lungs,  or  the  kidneys.  Fibroid  over- 
growth, which  forms  the  basis  of  so  many  ex- 
amples of  ‘cirrhosis  ’or  ‘sclerosis’  in  different 
organs  and  tissues  of  the  body,  is  a process  pa- 
thologically intermediate  between  inflammation, 
on  the  one  hand,  and  degeneration  on  the  other. 
Thus,  what  were  formerly  named  ‘interstitial 
inflammations,’  are  now  the  ‘non-inflammatory 
hyperplasias’  of  some  pathologists,  and  tho 
‘ fibroid  degenerations  ’ of  others.  It  would 
seem  that  the  view  as  to  the  inflammatory  nature 
of  such  processes  is  erroneous,  if  we  look  either 
to  what  is  known  concerning  their  modes  of  ini- 
tiation, or  to  the  actual  nature  of  the  changes 
themselves  (which  agree  in  every  particular  with 
those  of  infiltrating  new  growths) ; it  would 
seem,  moreover,  not  less  erroneous  if  we  look  to 
the  clinical  history  of  the  affections  themselvc-3 
in  which  these  scleroses  occur.  It  conveys, 
therefore,  an  altogether  erroneous  implication  to 
speak  of  such  mere  fibroid  overgrowths  as  so 
many  instances  of  ‘ chronic  myelitis.’ 

Thus,  it  will  be  seen  that  the  writer  attri- 
butes to  inflammation  a far  more  restricted  role. 
in  the  production  of  morbid  conditions  of  the 
spinal  cord  than  is  customary.  The  various 
forms  of  so-called  ‘chronic  myelitis’  he  would 
exclude  from  that  category.  lie  would  do  the 
same  for  the  set  of  changes  known  as  ‘ secondary- 
degenerations ’;  and  also  for  those  which  ar  e 
characterised  by  more  or  less  acute  atrophic 
processes  implicating  the  great  ganglion-cells  of 
tho  anterior  cornua. 

Of  the  processes  above  referred  to  in  order, 
there  remains,  therefore,  only  the  class  of  ‘ soft- 
enings ’ of  the  spinal  cord.  That  many  of  theae 


1473  SPIRAL  CDltD,  SPECIAL  DISEASES  OF. 


are  of  a simply  degenerative  type  (due  to  dis- 
turbances of  blood-supply),  and  that,  in  the 
great  majority  of  cases,  these  are  the  instances 
iu  which  ‘ softening’  appears  to  occur  as  a pri- 
mary process,  the  writer  feels  assured.  On  the 
other  hand,  it  seems  clear  that  in  many  cases 
changes,  truly  inflammatory  in  their  origin  and 
progress,  may  terminate  in  the  production  of 
states  of  ‘ softening’  of  the  cord,  which  are  indis- 
tinguishable by  naked  eye  from  the  softenings 
of  degenerative  type,  and  which  can  as  yet  also 
be  very  imperfectly  discriminated  by  the  micro- 
scope. 

These  latter  inflammatory  softenings  very 
rarely  occur  as  primary  pathological  states ; they 
are  met  with  rather  as  secondary  changes. 

Thus  we  may  get  inflammatory  softenings 
spreading  (a)  around  and  from  wounds  or  other 
traumatic  lesions  of  the  spinal  cord;  or  (6) 
starting  from  some  blood-clot  or  tumour  situated 
in  or  pressing  upon  the  substance  of  the  cord. 
It  is  not  by  any  means  clear,  however,  that  all 
the  forms  of  softening  which  arise  in  the  latter 
manner  should  be  regarded  as  of  an  inflamma- 
tory nature ; and  much  room  for  doubt  also  exists 
as  to  the  real  pathogenesis  of  many  cases  of  so- 
called  ‘ compression  myelitis  ’ (p.  1471). 

Another  cause  of  true  inflammatory  changes 
in  the  spinal  cord  ( myelitis  peripherica)  is  to  be 
found  (c)  in  spinal  leptomeningitis  ( see  Me- 
ninges, Spinau,  Diseases  of ; Leptomeningitis). 

Suppuration  is  clearly  a process  of  inflam- 
matory origin,  and  might  therefore  be  expected 
to  occur  occasionally  in  the  midst  of  ‘ soften- 
ings ’ which  result  from  inflammation.  In  the 
light  of  what  has  been  said  above,  the  follow- 
ing statement  by  Erb  is  of  considerable  in- 
terest. * Actual  suppuration  occurs  very  rarely,’ 
he  says,  ‘ in  acute  myelitis.  When  abscess  of  the 
cord  does  form,  it  is  generally  secondary  to  a 
severe  traumatic  lesion  or  to  suppurative  menin- 
gitis. In  spontaneous  myelitis,  on  the  other 
hand,  suppuration  is  exceedingly  rare,  and  has 
only  been  observed  in  a very  few  cases.’  Thus 
suppuration  is  met  with  just  in  those  forms  of 
softening  (‘myelitis’)  which  are  undoubtedly  of 
inflammatory  origin  ; and,  on  the  other  hand,  it 
is  not  met  with  in  the  ordinary  cases  of  primary 
or  spontaneous  softening,  here  assumed  to  be  of 
non-inflammatory  nature. 

In  instances  other  than  those  above  men- 
tioned, suppuration  rarely  occurs  in  the  spinal 
cord.  Small  disseminated  abscesses  may,  how- 
ever, be  found  in  pyeemic  cases,  as  they  are  in 
the  brain  and  in  other  organs. 

One  other  condition  requires  to  be  referred 
to  here,  and  that  is  the  so-called  acute  central 
Tiiyelitis,  described  originally  by  Albers,  and  after- 
wards studied  by  Hayem  (see  Archives  de  Physio- 
logic, 1874,  p.  603).  These  are  cases  in  which 
apparently  spontaneous  ‘ softening ’is  met  with, 
implicating  in  the  main  the  central  grey  matter, 
and  that  often  through  a considerable  extent  of 
the  cord.  At  times,  however,  the  softening  ex- 
tends beyond  the  grey  matter,  so  as  to  involve 
more  or  less  of  the  surrounding  white  substance, 
when  it  has  been  termed  myelitis  diffusa.  Con- 
siderable obscurity  still  prevails  in  regard  to  the 
setiology  of  these  affections.  In  some  cases,  such 
a change  has  been  met  with  as  part  of  an  infective 


process,  in  which  minute  vessels  in  the  grei 
matter  of  the  cord  have  been  found  obstructed 
with  micrococci.  Occasionally,  moreover,  in 
certain  at  present  imperfectly  known  condi- 
tions, minute  thromboses  may,  as  Dr.  J.  Hamil- 
ton has  shown,  occur  throughout  the  spinal 
cord,  and  more  especially  in  its  grey  matter,  and 
thus  lead  on  in  the  main  to  the  production  of 
a central  softening  (see  British  and  Foreign 
Review,  April  1876,  p.  447).  In  this  latter 
case,  the  patient  was  suffering  from  pyelitis, 
and  it  is  supposed  that  there  may  have  been  some 
blood-poisoning.  Still  it  was  not  ascertained  that 
the  multitudes  of  minute  thrombi  were  either 
associated  with  or  caused  by  micrococci  in  the 
vessels.  It  appears  probable,  however,  that  if 
from  any  cause  minute  widespread  obstructions 
of  small  vessels  occur  in  the  spinal  cord,  soft- 
ening would  take  place  principally  in  the  grey 
matter,  owing  to  its  greater  vascularity.  IV  e 
should  thus  get  that  particular  distribution  of 
this  change  which  is  met  with  principally  in  cases 
of  so-called  ‘ acute  central  ’ or  ‘ diffuse  myelitis.’ 

A careful  study  of  the  two  cases  of  this 
disease  recorded  by  Hayem  has  by  no  means 
sufficed  to  convince  the  writer  that  they  ought 
to  be  regarded  as  having  had  an  inflammatory 
origin.  Neither  the  symptoms  nor  the  mode  of 
onset  of  the  disease  lend  any  distinct  support  to 
this  view;  nor  do  the  results  of  the  elaborate 
examination,  to  which  the  spinal  cords  were 
submitted  by  this  accomplished  observer,  at  all 
satisfy  the  writer  that  the  pathological  condi- 
tions mot  with  were  inflammatory  either  at  their 
commencement  or  in  their  subsequent  progress. 
See  Spinal  Cord,  Softening  of. 

Symptoms,  Course,  and  Terminations.— 
From  what  has  been  said  it  will  be  seen  that  true 
inflammatory  conditions  of  the  cord  are  only  with 
extreme  rarity  of  primary  origin,  and  that  they 
occur,  for  the  most  part,  as  secondary  complica- 
tions in  association  (a)  with  wounds  or  injuries 
of  the  cord  ; ( b ) with  foreign  bodies  in  its  sub- 
stance ; or  (c)  with  spinal  leptomeningitis,  either 
simple  or  tubercular. 

The  supervention  of  a real  myelitis  in  the  course 
of  either  of  these  diseases  of  the  spinal  cord 
would  perhaps  be  associated  with  an  exaggera- 
tion of  the  already  existing  febrile  condition; 
with  an  increase  in  the  amount  of  paralysis,  and 
in  the  degree  of  interference  with  sensibility: 
possibly  also  with  more  pain,  restlessness,  and 
spasms. 

Myelitis  may  become  associated  with  more  or 
less  of  distinct  suppuration,  and  almost  certainly 
goes  on  to  the  formation  of  well-marked  foci 
of  softening.  These  may  remain  limited  in  site, 
but  occasionally  they  have  a distinct  tendency 
to  spread  above  and  below  the  original  seat  of 
injury  or  disease.  Such  depots  would  probably 
undergo  subsequent  changes,  very  similar  in  kind 
to  those  prone  to  occur  in  foci  of  non-inflamma- 
tory softening. 

Diagnosis. — All  that  can  be  said  under  this 
head  has  been  referred  to  above  in  connection 
with  the  symptoms  characterising  the  superven- 
tion of  myelitis. 

Prognosis. — The  gravity  of  any  wound  or  lesion 
of  the  spinal  cord,  or  attaching  to  the  presence 
in  it  of  blood-clot  or  tumour,  is,  of  course,  greatly 


SPINAL  COED,  SPECIAL  DISEASES  OF.  1477 


Increased  by  the  supervention  of  inflammatory 
changes  about  their  immediate  confines.  Again.; 
the  fact  that  an  inflammation  of  the  spinal  me- 
ninges is  complicated  with  similar  changes  in 
the  substance  of  the  spinal  cord  itself,  cannot  fail 
greatly  to  aggravate  a case  of  simple  spinal  lep- 
tomeningitis. For,  even  should  recovery  from  the 
acute  affection  take  place,  the  actual  degree  of 
abiding  paralysis,  ataxy,  or  impairment  of  sen- 
sibility would  much  depend  upon  the  degree  in 
which  the  substance  of  the  spinal  cord  had  been 
itself  implicated. 

Treatment. — The  amount  of  power  that  we 
possess  in  controlling  an  inflammatory  condition 
of  the  spinal  cord  is  probably  not  great.  Little 
'.{  anything  is  at  present  to  be  done  with  mere 
drugs.  The  patient  should,  if  possible,  lie  in 
-he  prone  position,  or,  failing  this,  on  his  side, 
with  absolute  rest.  The  advisability  of  abstract- 
ing blood  locally  by  cupping  or  leeches  should 
be  entertained,  and  must  depend  much  upon  the 
amount  of  local  pain  or  tenderness.  In  some  cases 
it  seems  to  be  of  service.  Or  we  may  trust  rather 
to  the  application  of  cold  externally,  in  the  form 
of  ice-bags,  along  the  spine.  At  the  same  time 
the  patient  should  be  kept  upon  spoon  diet,  with 
a sparing  amount  of  stimulants ; and  the  bowels 
should  be  relieved  by  the  aid  of  copious  warm 
enemata,  which  may  also  act  usefully  as  de- 
rivatives. The  limitations  circumscribing  our 
efforts  at  direct  therapeutics  must  be  compen- 
sated as  far  as  possible  by  attention  to  the  state 
of  the  general  health,  and  by  the  most  careful  and 
assiduous  nursing,  in  the  hope  that  the  morbid 
process  may  after  a time  abate,  and  that,  in  the 
absence  of  collateral  complications,  the  patient 
may  make  a more  or  less  complete  recovery’. 

8.  Spinal  Cord,  Heemorrliage  into. — Sy- 
non.  : Hamatomydia  ; Hcematorrhagia  Medulla 
spinalis;  Spinal  Apoplexy ; Fr . Hematomyelie; 
Apoplexie  de  la  Mcelle  Epiniere ; Bes  hemorrka- 
gics  intrarachid iennes ; Ger.  Riickenmarksapo- 
plcxie;  Spinalapnplexie. 

.ZEtiology  and  Anatomical  Characters. — 
Haemorrhage  into  this  organ  is  a comparatively 
rare  event.  It  occurs  under  three  different  con- 
ditions, namely — (1)  as  a result  of  concussion  or 
violence;  (2)  as  a secondary  event,  consequent 
upon  a definite  pre-existing  morbid  condition  ; 
and  (3)  as  a primary  event,  or  local  pathological 
accident. 

We  are  here  specially  concerned  with  haemor- 
rhages into  the  spinal  cord  belonging  to  the  third 
of  these  categories,  and  may  in  a few  words  dis- 
miss the  other  two. 

(1)  Traumatic  haemorrhages,  small  in  extent, 
may,  as  already  stated,  occur  in  almost  any 
region  or  part  of  the  cord  as  a result  of  some 
severe  concussion  (see  Spinal  Cord,  Concussion 
of).  Again  it  may  occur  in  the  grey  matter,  and 
even  in  the  white  substance  to  a smaller  extent, 
close  to  and  as  an  appanage  of  wounds  of  the 
cord.  In  each  of  these  cases  symptoms  due  to 
the  hsemorrliage  itself  would  probably  bo  ob- 
scured by  the  general  set  of  symptoms  resulting 
from  the  concussion  or  injury’. 

(2)  Secondary  haemorrhages  are,  however,  more 
closely  connected,  from  the  point  of  view  of 
symptomatology,  with  those  forming  the  special 


subject  of  this  article.  During  the  growth  of  cer- 
tain soft  tumours  in  the  cord,  a rupture  of  some 
of  their  vessels  may  take  place,  so  as  to  cause 
haemorrhage  either  into  the  growth  itself,  or  else 
into  contiguous  regions  of  the  cord.  Such  an 
event  would  be  signalised  clinically  by  the  sud- 
den exacerbation  of  the  symptoms  previously 
existing.  But  a combination  of  greater  import- 
ance, though  one  of  considerable  obscurity,  con- 
sists in  the  co-existence  of  a ‘ central  my’elitis  ’ of 
the  grey  matter  of  the  cord  through  more  or  less 
of  its  extent,  together  with  a central  haemorrhage 
of  nearly  similar  extent.  The  existence  of  any 
such  ‘central  myelitis’  as  an  independent  dis- 
ease of  the  cord  seems  to  the  writer  very  doubt- 
ful. It  is  at  least  equally  probable  that  the 
haemorrhage  has  been  primary,  and  that  the 
‘myelitis’  or  softening  is  of  secondary  origin 
around  the  blood-clot.  It  need  not  be  denied, 
of  course,  that  in  other  cases  haemorrhage  does 
occur  occasionally  into  the  midst  of  a focus  of 
softened  tissue  in  the  spinal  cord,  just  as  it 
occurs  occasionally  under  similar  conditions  in 
the  midst  of  softened  brain-tissue. 

(3)  Primary  haemorrhages  differ  as  regards 
the  amount,  the  site,  and  the  distribution  of  the 
blood  effused,  in  different  cases.  In  connection 
with  scorbutic  states,  and  also  independently  of 
these,  small  haemorrhages  may  occasionally  occur 
into  the  substance  of  the  cord,  without  pro- 
ducing any  distinct  symptoms.  But,  at  other 
times,  a comparatively  large  quantity  of  blood 
may  be  effused  into  the  cord,  and  then  it  occurs 
almost  invariably  into  the  central  regions  of  the 
grey  matter,  through  which  it  may  extend  for  a 
variable  distance.  When  the  quantity  is  smaller, 
the  blood  may  be  effused  into  the  grey  matter  of 
one  side  only. 

Though  this  kind  of  haemorrhage  is,  in  con- 
tradistinction to  the  others,  spoken  of  as  primary, 
yet  it  is  almost  invariably  preceded  by  some 
pathological  changes  in  the  vessels  of  the  cord. 
These  constitute  the  predisposing  conditions,  and 
the  actual  rupture  takes  place,  rarely,  when  the 
person  is  at  rest,  or,  more  frequently,  under  the 
influence  of  some  distinct  exciting  cause — such 
as  muscular  exertion  of  one  kind  or  another. 

Primary  haemorrhage,  though  rare,  is  most 
prone  to  occur  in  persons  between  the  ages  of 
twenty  and  forty,  and  not  with  increasing  fre- 
quency as  age  advances.  This  constitutes  a 
further  notable  difference  between  haemorrhages 
into  the  brain  and  those  of  the  spinal  cord. 

Symptoms. — These  are  necessarily  subject  to 
great  variations,  according  as  the  haemorrhage 
takes  place  into  the  cervical,  the  dorsal,  or  the 
lumbar  region.  The  kind  of  variation  thus  in- 
duced may  be  gathered  by  reference  to  the  Intro- 
duction, § 11. 

Here  it  is  of  importance  to  set  forth  the  pe- 
culiarities (both  as  regards  mode  of  onset,  and 
nature  of  the  symptoms)  which  belong  to  haemor- 
rhage as  compared  with  other  pathological  con- 
ditions of  the  cord.  First,  its  tendency  is  to  take 
place  suddenly  and  without  warning;  and,  se- 
condly, for  the  blood  to  be  effused  into  the  grey 
matter  for  some  distance,  thus  giving  rise  to  a 
characteristic  grouping  of  symptoms.  There  may, 
therefore,  be  a sudden  onset  of  pain  in  the  back 
(possibly  severe);  followed  almost  immediately 


SPINAL  CORD,  SPECIAL  DISEASES  OF. 


1478 

by  complete  motor  and  sensory  paralysis  of  the 
legs  and  trunk  up  to  a certain  level,  together 
with  complete  paralysis  of  the  bladder  and  rec- 
tum. At  first  there  may  be  an  abolition  of  all 
reflexes,  and  possibly  a lowering  of  temperature 
in  the  legs;  though  after  a day  or  two — should 
the  injury  be  in  the  dorsal  or  lower  cervical 
region  of  the  cord — there  may  be  increased  heat 
of  legs,  owing  to  vaso-motor  paralysis,  and  a 
return  with  some  exaggeration  of  various  re- 
flexes. Rapid  atrophy,  with  the  appearance  of 
the  electrical  ‘reaction  of  degeneration,’  occurs 
in  all  muscles  that  are  in  immediate  functional 
relations  with  the  portions  of  the  cord  damaged. 
Cystitis,  together  with  sloughing  bed-sores  and  all 
their  consequences,  tend  to  occur  early,  and  that 
often  in  spite  of  all  precautions  that  may  be  taken. 

Where  the  haemorrhage  invades  pretty  fully, 
but  is  limited  to,  the  grey  matter  of  one  half  of 
the  cord,  we  may  have  groups  of  symptoms  that 
take  the  form  of  hemiplegia  spinalis  or  hemi- 
paraplegia.  See  (2)  Spinal  Cord,  Punctured 
or  Gun-shot  Wounds  of. 

Diagnosis. — -The  absolutely  sudden  onset  of 
the  paralysis,  which  may  be  complete  in  the 
lower  extremities  in  tho  course  of  a fewminutes  ; 
(especially  when  associated  with  a sudden  pain- 
ful sensation  in  the  back,  or  one  which  radiates 
into  the  limbs);  as  well  as  the  almost  complete 
and  sudden  loss  of  sensibility  in  the  paralysed 
parts,  form  a group  of  symptoms  which  are 
typically  distinctive  of  hsemorrhage  into  the  grey 
matter  of  the  cord. 

The  condition  most  likely  to  be  confounded 
with  it  is  a large  hemorrhage  outside  the  dura 
mater,  causing  compression  of  the  cord.  Here 
tho  onset  would  also  be  sudden,  but  almost  in- 
variably associated  with  some  mechanical  injury 
or  shock.  The  paralysis  of  motion  too  would  gene- 
rally be  much  more  marked  than  the  interference 
with  sensibility.  The  subsequent  progress  of 
such  a case  would  further  tend  to  separate 
it  from  a case  of  intra-medullary  haemorrhage, 
since  (even  with  a severe  meningeal  haemorrhage 
in  the  cervical  region)  if  the  patient  should  sur- 
vive the  first  effects  of  the  lesion,  the  symptoms 
might  be  expected  soon  to  grow  less  aud  less 
urgent,  and  recovery  may  be  more  or  less  com- 
plete. No  such  amelioration  is,  however,  to  be 
expected  in  the  case  of  a well-marked  haemor- 
rhage into  the  grey  matter  of  the  cord,  in  the 
cervical  region  or  elsewhere. 

On  the  side  of  the  brain  embolism  is  capable 
of  initiating  paralytic  symptoms  with  as  much 
suddenness  as  a haemorrhage,  but  in  the  spinal 
cord,  for  reasons  previously  stated,  this  does  not 
occur  (see  Introduction,  § 6 (8)). 

It  does,  however,  happen  occasionally  that  a 
process  of  softening— probably  caused  by  throm- 
bosis— has  its  occasioning  conditions  initiated 
suddenly.  When  this  occurs  paraplegia  sets  in 
almost  as  abruptly  as  if  it  were  occasioned  by 
haemorrhage ; but  then  it  is  usually  an  incom- 
plete paraplegia,  and,  for  a time  at  least,  unac- 
companied by  loss  of  sensibility.  In  the  course 
of  a few  days,  in  such  a case,  sensory  paralysis 
may  supervene,  and  the  motor  paralysis  may 
become  more  complete.  In  the  exceptional  cases 
of  paraplegia  of  sudden  onset  due  to  this  cause, 
there  is  generally  no  initial  pain  in  the  back, 


though  there  may  be  pains  and  burning  sensa- 
tions in  the  limbs. 

Phognosis. — Where  the  haemorrhage  is  at  all 
large,  so  as  to  extend  through  the  grey  matter 
for  the  distance  of  an  inch  or  more,  the  prognosis 
is  always  grave.  Very  few  of  such  cases  recover. 
They  are,  in  fact,  liable  to  be  aggravated  by  the 
establishment  of  a secondary  process  of  softening 
in  the  grey  matter,  which  may  slowly  extend 
both  above  and  below  the  blood-clot  as  well  as 
around  it.  Should  this  softening  reach  far  into 
the  cervical  region,  or  should  the  haemorrhage 
itself  implicate  this  part  of  the  cord,  the  patient 
may  not  survive  more  than  a few  days.  But  if 
the  primary  and  secondary  pathological  changes 
are  limited  to  the  lumbar  or  to  the  dorsal  region 
of  the  spinal  cord,  the  fatal  event  is  usually 
brought  about  more  slowly,  after  an  interval  of 
weeks  or  perhaps  even  of  months — and  then 
commonly  from  the  occurrence  of  sloughing 
bed-sores,  together  with  cystitis  and  other 
accompaniments  of  a severe  paraplegia. 

In  the  case  of  small  haemorrhages  limited  to 
some  fractional  part  of  the  transverse  area  of 
the  cord,  and  of  slight  longitudinal  extent,  the 
prognosis  is  of  course  much  more  favourable, 
and  there  is  no  reason  why  partial  recovery,  at 
least,  may  not  occur. 

Treatment. — In  the  treatment  of  a case  of 
spinal  hsemorrhage,  should  the  patient  be  seen 
immediately  after  its  occurrence,  absolute  quie- 
tude, with  rest  in  the  recumbent  or  prone  pos- 
ture, should  be  ensured. 

Bleeding,  either  local  or  general,  is  useless. 
Purgatives  also  are  contra-indicated. 

Should  the  pulse  be  full,  and  the  heart’s  action 
excited,  decided  benefit  may  be  derived  from 
ten-minim  doses  of  tincture  of  digitalis,  in  com- 
bination with  15  or  20  grains  of  bromide  of  potas- 
sium, given  for  the  first  three  doses  at  intervals 
of  three  or  four  hours,  and  subsequently  every 
six  or  eight  hours  for  two  or  three  days.  These 
drugs  will  also  favour  sleep,  and  exercise  a gene- 
ral calmative  influence. 

Position  and  rest  are  perhaps  the  means  to  be 
principally  relied  upon  to  prevent  a recurrence 
or  continuance  of  the  haemorrhage;  such  mea- 
sures may  be  supplemented  by  warm  applica- 
tions to  the  feet  and  calves  of  the  legs;  though 
the  patient  should  in  other  respects  be  kept 
perfectly  cool.  Ice  to  the  spine  may  be  applied, 
but  is  of  doubtful  utility.  Spoon  diet  should  be 
strictly  enjoined  for  a few  days  at  least. 

The  patient's  urine  will  require  to  be  drawn  off 
by  catheter,  and  extra  precautions  ought  to  bo 
taken  to  ensure  its  antiseptic  cleanliness.  After 
a day  or  two,  if  the  bowels  have  not  been  moved, 
a laxative  should  be  administered,  since,  as  in 
many  other  forms  of  paraplegia,  there  may,  at 
first,  be  obstinate  constipation  rather  than  incon- 
tinence of  faeces. 

Subsequently,  the  case  requires  to  be  treated 
in  all  respects  like  any  other  very  bad  case  of 
paraplegia — extra  precautions  being  observed 
throughout,  in  order,  as  far  as  possible,  to  guard 
against  the  onset  of  bed-sores  and  cystitis.  Fuller 
details  concerning  such  treatment  will  be  found 
under  the  next  article,  Spinal  Cord,  Softening 
of,  since  this  is  by  far  the  most  common  cause  of 
paraplegia. 


tiFlNAL.  UOKD.  SPECIAL.  DISEASES  OF. 


9.  Spinal  Cord,  Softening  of.  — Synon.  : 
Non-inflammatory,  white,  or  simple  softening; 
Myelomalacia-,  Mollitics  Medulla  spinalis;  Acute 
Myelitis  (in  part);  Compression  Myelitis  (in 
part) ; Fr.  Ramollissement  de  la  Moclle  Epmiere ; 
Uer.  Erweichung  des  Riickemnarks. 

Nature  of  Change. — The  writer  has  already 
intimated  ( see  Myelitis)  his  opinion  that  far  too 
large  a share  is  assigned  to  inflammation  in  the 
pathogenesis  of  diseases  of  the  spinal  cord.  This 
mistake  is  particularly  obvious  in  regard  to  acute 
inflammations.  It  has  long  been  the  fashion  to 
speak  of  almost  every  focus  of  ‘softening’  that 
occurs  in  the  spinal  cord  as  being  the  result  of 
an  ‘ acute  myelitis  ’ ; and  we  find  even  Erb  (in 
Z-iemssen's  Cyclopedia,  vol.  xiii.)  putting  for- 
ward, as  characteristics  of  an  inflammatory  soft- 
ening, peculiarities  which  certainly  ought  not  to 
be  regarded  in  such  a light — and  this  although 
he  seems  otherwise  strongly  inclined  to  hold  a 
similar  opinion  to  that  above  expressed.  Whilst 
admitting  that  a true  myelitis  is  not  distinguish- 
able macroscopieally,  in  the  great  majority  of 
cases,  from  a simple  or  non-inflammatory  soften- 
ing, Erb  adds  a statement  to  the  effect  that  the 
1 microscopical  examination  can  alone  furnish  con- 
clusive evidence.’  Jn  the  opinion  of  the  writer, 
however,  such  evidence  as  that  which  is  cited 
by  Erb  (foe.  cit.  p.  470)  is  quite  inconclusive. 

It  is  evident,  indeed,  that  we  are  still  almost 
as  destitute  of  microscopical  as  we  are  of  macro- 
scopical  characters,  of  a trustworthy  description, 
for  enabling  us  to  decide  whether  any  given 
focus  of  softening  has  been  of  inflammatory  or 
of  simple  Don-inflammatory  origin.  Such  re- 
searches as  those  of  Hamilton  {Quart.  Joarn.  of 
Micros.  Science,  Oct.  1375)  and  others  must  be 
prosecuted  further  and  multiplied  before  any 
certain  means  of  deciding  such  a question  will 
exist. 

In  the  present  state  of  knowledge,  therefore, 
it  would  appear  that  the  ‘ non-inflammatory 
softenings  ’ of  the  cord  are  represented  by  the 
primary  and  apparently  idiopathic  ‘softenings’ 
which  frequently  occur  in  this  organ. 

^Etiology  and  .Pathogenesis. — Concerning 
the  setiology  of  non-inflammatory  softening  of 
the  spinal  cord,  it  is  impossible  to  speak  posi- 
tively. The  disease  presents  itself  as  a spon- 
taneous or  idiopathic  affection,  sometimes  with- 
out apparent  cause  or  definite  antecedent  condi- 
tions of  any  kind,  but  at  others  as  a sequence  of 
one  or  other  of  various  known  and  common  ante- 
cedent conditions. 

Thus  in  certain  cases  the  symptoms  set  in 
more  or  less  suddenly  after  some  great  bodily 
fatigue;  in  others  after  extreme  sexual  ex- 
cesses ; or  they  may  occur  during  the  period  of 
convalescence  from  certain  acute  fevers,  such  as 
variola,  typhus,  and  other  exanthemata,  or  after 
rheumatic  fever.  During  the  first  week  or  two 
after  childbirth  there  is  likewise  a liability  to 
such  symptoms  ; and  also  in  the  later  stages  of 
syphilis.  These  different  conditions  may  act  very 
variously  in  contributing  to  bring  about  a focus 
of  softening  in  the  spinal  cord,  and  nothing  more 
than  conjectures  can  be  advanced  in  regard  to  its 
pathogenesis  in  the  several  cases. 

Again,  the  symptoms  indicative  of  a primary 
softening  of  the  cord  may  set  in  after  the  action 


1479 

of  other  conditions,  regarded  by  some  as  excit- 
ing rather  than  as  predisposing  causes.  Of  these 
the  following  may  be  enumerated; — Prolonged 
exposure  to  cold  and  wet ; sudden  suppression  ol 
the  menses  or  of  other  accustomed  fluxes ; vio- 
lent emotional  disturbances;  or  the  existence  ot 
some  inflammation  in  one  or  other  of  the  pelvic 
organs,  such  as  the  uterus  or  the  bladder  and 
urethra  (instances  of  the  latter  class  being  some 
of  the  cases  formerly  supposed  to  be  of  ‘ reflex  ' 
origin).  In  regard  to  these  ‘ exciting  causes,’  all 
that  is  certainly  known  is,  that  softening  of  the 
cord  seems  to  set  in  not  unfrequently  in  persons 
who  have  been  subjected  to  one  or  other  of  them ; 
but  in  what  precise  mode  either  of  them  is 
related  to  the  subsequent  softening,  nothing  very 
definite  can  be  said.  Something,  nevertheless, 
may  be  advanced  by  way  of  suggestion — with 
the  view  more  especially  of  giving  some  direc- 
tion to  the  investigations  needful  for  clearing  up 
this  subject. 

Spinal  and  cerebral  softenings  probably  own 
a similar  mode  of  origin.  Of  the  obstructions 
of  vessels  which  so  largely  determine  cerebral 
non-inflammatory  softenings,  it  is  those  due  to 
thrombosis  rather  than  to  embolism  which  inter- 
vene in  the  main  for  the  production  of  corre- 
sponding conditions  in  the  spinal  cord  {see  In- 
troduction, § 6,  (8)  and  (9)). 

It  is  well  known  that  the  causes  of  thrombosis 
are  principally  three,  and  that  in  different  cases, 
now  one  now  another  of  them  may  be  most  in- 
fluential ; whilst  in  other  instances  two  or  more 
of  these  causes  may  co-operate.  These  three 
causes  are  (a)  thickenings,  irregularities,  or  de- 
generations of  the  inner  coats  of  the  vessels  ; (5) 
slowness  of  blood-current ; (c)  peculiarities  in 
the  chemical  composition  of  the  blood,  rendering 
it  more  than  usually  prone  to  coagulate. 

The  thrombosis  may  take  place  in  the  arteries 
or  in  the  veins,  and  the  plexiform  arrangement  of 
the  spinal  vessels  which  oxists,  together  with  the 
slowness  of  their  blood-current,  may  favour  the 
occurrence,  as  well  as  the  spread  of  the  process 
when  it  has  once  been  initiated.  Thus  a process 
of  coagulation,  beginning,  perhaps,  in  some  very 
small  vessel,  may  gradually  extend  so  as  to 
involve  larger  and  larger  branches,  and  thereby 
increase  the  area  of  the  cord  which  is  deprived 
of  its  proper  blood-supply.  And  it  is  especially 
worthy  of  note,  in  this  connection,  that  the 
blood-supply  of  the  lower  end  of  the  cord  (where 
primary  softenings  are  most  common)  is  peculiar 
and  easily  interfered  with.  To  this  important 
point  Dr.  Moxon  has  recently  called  attention 
{Brit.  Med.  Jour.  vol.  i.,  1881).  In  short,  the  ana- 
tomical conditions  existing  in  the  cord,  both  on 
the  arterial  and  on  the  venous  side  of  its  circula- 
tion, are  probably  of  a kind  distinctly  to  favour 
the  occurrence  of  thrombosis  ; and,  if  there  were 
space  for  it,  we  might  attempt  to  show  some- 
thing as  to  the  respective  modes  of  action  of  the 
very  different  exciting  and  predisposing  causes 
which  have  been  previously  enumerated,  as  seem- 
ing to  be  in  relation  with  primary  softening  of 
this  part  of  the  nervous  system. 

Anatomical  Characters.- — In  regard  to  their 
distribution  or  extent  in  the  cord  many  varieties 
of  softening  exist.  These  have  beon  commonly 
recognised,  though  they  have  been  mostly  de 


SPINAL  COED,  SPECIAL  DISEASES  OF. 


1480 

scribed  under  corresponding  designations  as  so 
many  varieties  of  ‘ myelitis.’  Thus,  we  may 
have  a ‘ complete  transverse  softening,’  involving 
the  entire  thickness  of  the  cord  for  a variable 
longitudinal  extent,  either  in  the  lumbar,  the 
dorsal,  or  in  the  cervical  region.  Or  the  softening 
may  be  more  limited  to  certain  subdivisions  of 
the  cord  in  one  or  other  of  these  regions — and 
then  constitute  an  ‘ incomplete  transverse  soften- 
ing.’ Thus  it  may,  in  one  set  of  cases,  princi- 
pally affect  the  anterior  columns  and  grey  mat- 
ter ; in  another  set  the  posterior  columns  and 
more  or  less  of  the  grey  matter.  Or  the  soften- 
ing may  be  central,  and  almost  confined  to  the 
grey  matter  through  a considerable  extent  of 
the  cord,  as  in  ‘diffuse  central  softening;’  when 
this  change  involves  the  white  columns  as  well 
as  the  grey  matter  for  a considerable  extent,  we 
have  what,  is  called  ‘diffuse  softening’  of  the 
cord.  When  a small  focus  of  softening  exists 
which  only  involves  part  of  the  transverse  area 
of  the  cord,  and  that  for  a very  limited  extent, 
we  have  a ‘ circumscribed  softening’  of  the  cord ; 
and  where  many  of  these  small  foci  are  scattered 
through  different  parts  and  regions  of  the  organ, 
wo  havo  what  is  known  as  ‘ disseminated  soften- 
ing.’ 

An  accidental  damage  during  the  opening  of 
the  spinal  canal  must  not  be  confounded  with 
the  results  of  pathological  change.  In  a spinal 
cord  bruised  in  the  manner  indicated  the  nerve- 
substance  may  be  softened  and  diffluent,  and 
somewhat  rescmblo  a patch  of  real  pathologi- 
cal softening.  Examination  with  the  microscope, 
however,  would  show,  amongst  the  fragments 
of  myeline  from  the  broken  nerve-tubules  in 
the  former  case,  an  entire  absence  of  the  large 
granulation-corpuscles,  which  are,  on  the  con- 
trary, invariably  present  in  a patch  of  real 
pathological  softening.  If  there  were,  after  such 
an  examination,  still  room  for  doubt,  this  might 
be  resolved  by  the  fact  that  the  softened  nerve- 
matter  in  a patch  of  real  softening  of  the  cord, 
has  its  specific  gravity  lower  by  3-5  degrees 
than  that  of  other  healthy  portions  of  the  organ, 
whilst  iu  the  patch  of  merely  bruised  nerve- 
substance  it  would  not  be  appreciably  lower 
than  normal.  The  normal  specific  gravity  of 
the  spinal  cord  varies  commonly  from  1033— 
1041  in  different  individuals — the  higher  figures 
being  most  frequently  met  with  in  elderly  per- 
sons. The  modes  of  estimating  the  specific 
gravity  have  been  discussed  by  the  writer  in 
Journ.of  Ment.  Science,  vol.  xi.  1866. 

Where  the  process  of  softening  has  gone  on  to 
its  final  stages — in  a case, for  instance,  of  ‘com- 
plete transverse  softening’ — the  whole  substance 
of  the  cord  in  the  affected  site  is  reduced  to  a 
rather  dirty-looking  milky  fluid,  which,  when 
the  membranes  are  cut  across,  flows  out  so  as  to 
leave  a complete  gap  in  the  cord-substance  for 
an  extent,  it  may  be,  of  one  to  three  inches. 

Symptoms,  Course,  and  Terminations. — The 
symptomatology  of  this  disease  presents  an  ex- 
tremely wide  range,  i n accordance  with  the  vary- 
inff  extent  and  sites  of  the  softening  in  the  cord, 
as  existing  in  different  patients. 

In  ‘circumscribed’ and  ‘ disseminated  soften- 
ing,’ for  instance,  the  symptomatology  would  be 
excessively  variable  in  different  patients,  and, 


especially  in  the  latter  class  of  eases,  it  might 
be  extremely  difficult  to  arrive  at  a diagnosis. 
The  symptoms  could,  in  fact,  only  be  interpreted 
by  the  light  of  the  general  principles  applicable 
to  the  regional  and  pathological  diagnosis. 

Again,  incases  of  ‘diffuse  central  softening’ 
the  symptoms — except  for  the  fact  that  they  set 
in  gradually  rather  than  abruptly — would  bear  a 
close  resemblance  to  those  of  haemorrhage  into 
the  spinal  cord,  where  the  blood  is  effused  into 
the  central  grey  matter  for  a certain  extent  (see 
No.  8,  Spinal  Cord,  Haemorrhage  into). 
There  is  some  doubt,  indeed,  whether  these  latter 
cases  may  not  occur  principally  as  epipheno- 
mena  sequential  to  a primary  central  softening. 

The  symptomatology  of  ‘ incomplete  transverse 
softenings’  of  the  cord,  is  for  the  most  part  ex- 
emplified by  the  second  stages  of  various  forms 
of  so-called  ‘ compression  myelitis  ’ — cases,  that 
is,  in  which  the  anterior  regions  of  the  cord  more 
especially  are,  in  one  set  of  cases,  principally 
pressed  upon  either  by  tumour,  or  by  the  inflam- 
matory products  associated  with  vertebral  caries 
(‘  Pott's  Disease  ’) ; whilst  in  another  set  the  pos- 
terior columns  and  posterior  grey  matter  may 
undergo  a similar  softening,  under  the  influence 
of  the  pressure  of  a new  growth  impinging  upon 
the  cord  from  behind.  Cases  of  this  type,  how- 
ever, may  easily  and  do  often  merge  into  ‘ com- 
plete transverse  softening  ’ (commonly  known  as 
‘complete  transverse  myelitis  ’).  Both  complete 
and  incomplete  forms  also  often  occur  in  the 
cord,  quite  independently  of  pressure. 

Of  these  states  it  'will  be  well,  for  the  sake  of 
brevity,  to  confine  our  attention  principally  to 
‘complete  transverse  softening.' 

In  a case  of  complete  transverse  softening  in- 
volving the  mid-dorsal  region,  the  temperature 
in  the  axilla  usually  varies  between  98°  and 
100°F.,  though  with  an  extension  of  the  pathologi- 
cal process,  or  towards  the  close  of  the  disease,  it 
may  rise  to  101°,  102°,  or  even  higher.  Mean- 
while the  lower  extremities  themselves  are  often 
distinctly  cold  to  the  hand — the  temperature 
being  in  some  cases  more  or  less  subnormal.  It 
is  important  to  note  this,  because  it  might  have 
been  supposed  that  hyperaemia  and  a slightly 
elevated  temperature  would  exist,  owing  to  the 
vaso-motor  nerves  of  the  limbs  being  paralysed. 

The  motor  paralysis  of  the  lower  extremities 
is  absolute,  and  the  abdominal  muscles  are  also 
powerless.  The  feet,  as  the  patient  lies  in  bed, 
are  extended  and  often  inverted,  so  that  the  great 
toes  cross  one  another.  The  skin  after  a time 
tends  t.o  become  dry  and  scurfy.  The  muscles 
feel  flabby  to  the  hand,  but  they  waste  only  to  a 
slight  extent,  and  continue  week  after  week  to 
show  only  a small  amount,  if  any,  of  diminution 
in  the  degree  of  their  irritability  to  faradaic  and 
to  galvanic  currents. 

The  sensibility  of  the  limbs  is  completely  abo- 
lished both  for  tactile  and  painful  impressions,  as 
urell  as  for  differences  of  temperature  and  tick- 
ling. A like  abolition  of  sensibility  exists  over 
the  trunk  up  to  the  level  of  the  ‘ ensiform  area  ’ 
whilst  above  this  level  the  sensibility  becomes 
quite  natural.  Though  the  upper  limit  of  anaes- 
thesia may  be  quite  sharply  defined,  yet  in  these 
cases  of  complete  transverse  softening  there  if 
often  no  distinct  ‘ girdle-sensation.’ 


SPINAL  COED,  SPECIAL  DISEASES  OF. 


The  muscles  of  the  lower  extremities  may 
show  some  slight  irritability  when  they  are  for- 
cibly tapped,  and  when  the  soles  of  the  feet  are 
strongly  tickled  there  may  he  very  slight  move- 
ments of  the  toes  ; but  beyond  this  there  is  often 
an  entire  absence  of  all  reflex  movements — there 
is  no  ankle-clonus,  no  knee-reflex,  and  a similar 
absence  of  the  cremasteric  and  abdominal  re- 
flexes.1 In  the  initial  stages  of  the  affection, 
however,  and  especially  when  the  softening  is 
not  completely  transverse,  all  these  reflexes  may 
be  extremely  well-marked  fora  time,  though  they 
tend  gradually  to  diminish. 

For  the  first  ten  days  or  a fortnight  there  is 
often  complete  retention  of  urine,  but  after  this 
time,  when  the  lumbar  region  of  the  cord  again 
becomes  capable  of  manifesting  to  some  extent 
its  centric  functions,  the  initial  retention  gives 
place  to  incontinence  of  urine.  This  fluid  may  be 
discharged  at  intervals  of  two  to  three  hours  in 
small  quantities,  owing  to  the  occurrence  of  reflex 
contractions  of  the  bladder  whenever  it  attains 
a certain  degree  of  fulness.  The  passage  of  a 
catheter,  however,  in  these  cases  will  often  show 
that  the  bladder  is  never  completely  emptied — 
two  to  four  ounces  remaining  after  the  reflex 
contractions.  Unless  special  precautions  are  taken, 
the  urine,  in  such  patients,  speedily  becomes  am- 
moniacal,  and  more  or  less  loaded  with  mucus. 

The  bowels  are  usually  constipated,  and  re- 
lieved only  after  the  administration  of  aperients 
or  enemata.  At  these  times  there  is  generally 
incontinence  of  faeces — the  patient  having  no 
power  of  controlling  the  reflex  actions  concerned 
in  defecation  when  they  have  once  been  strongly 
excited.  The  actual  passage  of  the  motion  is 
moreover  often  unfelt. 

Under  the  irritative  influences  emanating  from 
the  seat  of  softening  during  the  period  of  its 
establishment,  a small  bed-sore  may  begin  to 
form,  often  amenable  to  treatment.  Later  on, 
sloughs  are  apt  to  form  upon  the  heels,  over  the 
malleoli,  and  in  other  situations  habitually  ex- 
posed to  continuous  pressure.  But  the  most  fre- 
quent site  for  intractable  sloughing  bed-sores  is 
over  the  sacrum.  Inflammation  of  the  mucous 
membrane  of  the  bladder  is  at  last  set  up  ; and 
the  inflammation  may  extend  up  one  or  both 
ureters,  so  as  to  implicate  the  pelvis  of  the  kid- 
ney, when  minute  abscesses  may  also  form  in 
the  kidney  itself. 

Under  the  influence  of  these  various  conditions 
the  patient’s  appetite  and  strength  gradually  fail ; 
emaciation  proceeds ; and  death  after  a time  may 
come  from  sheer  exhaustion,  aided,  perhaps,  by 
some  intercurrent  inflammatory  affection  of  the 
lungs.  Other  modes  of  death  are  pointed  out  in 
the  section  on  Prognosis. 

Diagnosis. — The  recognition  of  this  disease  at 
the  bedside  often  presents  considerable  difficul- 

1 In  one  recent  case  in  which  paraplegia  had  existed  for 
over  three  months,  in  consequence  of  a complete  trans- 
verse softening  in  the  upper  dorsal  region  (with  the 
above-mentioned  clinical  signs),  the  writer  was  much 
struck  with  the  extremely  pallid  appearance  of  the  grey 
matter  through  the  whole  length  of  the  cord  below  the 
seat  of  softening.  The  absence  of  the  reflexes  maybe  in 
part  due  to  such  condition  of  the  grey  matter,  and  this 
itse'f  may  be  caused  by  a spasm  of  its  vessels  in  some 
u ay  induced  by  the  lesion  above.  Some  amount  of  spasm 
may  also  exist  in  the  vessels  of  the  limbs,  whose  tempera- 
lure  Is  often  rather  sub-normal. 


1481 

ties.  We  must  be  guided  partly  (a)  by  the 
patient's  history  and  state  ; partly  ( b ) by  the 
mode  of  onset  of  the  disease  ; and  partly  (c)  by 
the  symptoms  of  the  fully  established  affection. 

(a)  The  points  in  regard  to  previous  history 
which  are  of  principal  significance  are  referred 
to  under  the  head  of  lEtiology.  In  regard  to  (i) 
mode  of  onset,  this  is  usually  not  abrupt  and 
sudden  ; there  is  rather  a slow  increase  of  para- 
lysis during  a week,  ten  days,  or  a fortnight. 
Still,  it  is  a fact  that  softening  of  the  cord  (ap- 
parently due  to  thrombosis)  does  occasionally 
cause  a sudden  incomplete  paralysis,  though  such 
paralysis  increases  subsequently  in  the  manner 
above  stated.  Such  a case  must  not  therefore 
be  confounded  with  haemorrhage  into  the  cord, 
merely  by  reason  of  its  absolutely  abrupt  onset. 

The  extent  to  which  the  diagnosis  turns  upon 
( c ) the  nature  of  the  symptoms  of  the  fully-estab- 
lished affection,  cannot  be  very  definitely  defined 
except  in  some  cases.  When  the  softening  is 
slight  and  partial,  it  gives  rise  to  no  distinctive 
symptoms;  hut  where  there  are  clinical  signs  cf 
the  existence  of  a complete  transverse  lesion,  the 
chances  are  that  the  lesion  itself  is,  if  not  a pri- 
mary, at  all  events  a secondary  softening. 

In  regard  to  the  regional  diagnosis  of  soften- 
ing of  the  spinal  cord,  the  following  points 
require  to  he  borne  in  mind  : — 

The  indications  as  to  the  transverse  area  in- 
volved, and  as  to  the  upper  limits  of  the  change 
in  the  spinal  cord,  are  wholly  derivable  from  the 
presence  or  absence  of  the  various  signs  and 
symptoms  which  have  been  set  forth  in  the 
Introduction,  § 8,  (a),  and  § 11. 

The  attempt  to  ascertain  the  lower  level  of  the 
lesion,  and  consequently  its  longitudinal  extent 
in  the  cord,  is  always  difficult,  and  often  cannot 
he  achieved  with  any  success.  The  indications 
are  all  obscure,  uncertain,  and  apt  to  fail.  This 
is  especially  the  case  if  we  attempt  to  base  an 
opinion  on  the  fact  of  the  existence  or  absence  of 
superficial  reflexes  (see  § 5,  (ft) ).  Thus, complete 
transverse  softening  may  exist  in  the  upper  dor- 
sal region,  and  extensive  secondary  degenera- 
tions may  have  been  produced,  yet  for  week  after 
week  there  may  he  a complete  absence  of  all 
the  reflexes  (superficial  and  deep)  dependent 
upon  the  cord  below  the  upper  dorsal  region. 
This  the  writer  has  lately  ascertained  by  re- 
peated clinical  examinations  of  cases  whose  na- 
ture has  been  subsequently  verified  post  mortem. 

Pbognosis.— The  prognosis  in  a case  of  para- 
plegia must  always  involve  a twofold  problem: 
— (1)  as  to  the  duration  of  paralysis,  or  the  pro- 
bability of  recovery  ; (2)  as  to  the  danger  to  life. 

(1)  The  chance  of  ultimate  recovery  from  para- 
lysis would  vary  inversely  with  the  size  or 
extent  of  the  lesion  existing  after  the  first  ten 
days  or  a fortnight — that  is,  by  the  time  soften- 
ing has  been  unmistakably  established,  and  when 
the  chance  of  such  an  event  being  warded  off  by 
the  establishment  of  a collateral  circulation  no 
longer  exists.  But  where  a reinstatement  cf 
blood-supply  does  take  place,  all  symptoms  of 
paralysis  may  gradually  disappear  in  the  course 
of  some  weeks,  or,  it  may  he,  months. 

(2)  Danger  to  life  is  brought  about  in  many 
ways,  and  a fatal  result  may  be  entailed  (a)  by 
a gradual  extension  upwards  of  Ihe  process  of 


1482  SPINAL  COItD.  SPECIAL  DISEASES  OF. 


Boftening  (especially  where  it  exists  in  the  lower 
cervical  or  upper  dorsal  region)  so  as  to  involve 
paralysis  of  the  diaphragm,  or  an  extreme  inter- 
ference with  the  heart’s  action.  ( b ) Inflamma- 
tion of  the  bladder,  followed  by  implication  of 
other  portions  of  the  urinary  tract,  may  lead  on 
to  death  after  the  paralysis  has  lasted  for  some 
months,  (c)  About  the  same  period  extensive 
bed-sores  may  form,  and  the  patient  may,  after 
a time,  die  exhausted,  or  from  blood-poisoning, 
(i d ) The  supervention  of  an  intercurrent  pneu- 
monia may  lead  on  to  a fatal  result ; or  (e)  the 
end  may  come  from  the  extension  inwards  of  the 
process  of  sloughing,  so  as  to  lead  to  the  esta- 
blishment of  a rapidly  fatal  spinal  meningitis. 
Still,  in  some  cases  the  patient  may  remain 
paralysed  for  a very  long  time  before  a fatal  ter- 
mination is  brought  about. 

Treatment. — Our  power  to  deal  with  the  soft- 
ened condition  itself  of  the  spinal  cord  is  ex- 
tremely small,  whether  it  may  have  been  caused 
by  thrombosis  or  by  compression.  Luring  the 
early  stages  probably  the  less  that  is  done  in  the 
way  of  active  interference  the  better.  The  prin- 
cipal indications  are  that  the  patient  should  have 
absolute  rest  in  bed,  and  for  the  first  few  days  at 
least  a rather  sparing  diet ; spoon  diet  being  de- 
sirable where  distinct  elevation  of  temperature 
exists.  The  secretions  should  be  regulated,  and 
the  urine,  if  necessary,  drawn  off  by  a thoroughly 
clean  catheter  smeared  with  carbolised  oil.  Seda- 
tives, such  as  bromide  of  potassium,  either  alone 
or  in  combination  with  chloral,  may  be  needed  at 
night,  for  a time,  so  as  to  ensure  sound  and  re- 
freshing sleep. 

Should  the  patient’s  general  health  be  weak  or 
deranged,  as  is  so  often  the  case,  every  effort 
must  be  made  to  improve  it  by  means  of  an  easily 
assimilated  but  generous  diet,  gradually  increased, 
and  by  the  exhibition  of  suitable  tonics,  with  or 
without  small  doses  of  cod-liver  oil.  It  is  far 
better  to  trust  to  such  general  means  than  to  the 
supposed  influence  of  phosphorus,  or  any  other 
drug.  To  expect  any  of  them  to  have  a direct 
influence  in  restoring  softened  nerve-tissue  is 
vain;  and  any  good  that  may  be  achieved  by 
drugs  alone  is  probably  brought  about  either  by 
their  power  of  regulating  some  of  the  principal 
functions  of  the  body,  or  by  improving  its  nutri- 
tive processes  generally. 

Still  scarcely  any  morbid  condition  exists  in 
which  more  constant  care  and  vigilance  are  needed 
than  in  the  paraplegic  stale,  in  order  to  correct 
or  ward  off  its  numerous  incidental  troubles  or 
complications. 

One  of  the  first  points  claiming  attention  in 
the  early  stages  of  a case  of  paraplegia  is  to  take 
such  measures  as  will  stave  off  the  occurrence  of 
bed-sores  as  long  as  possible.  These  precautions 
are  especially  needful  where  the  paraplegia  is 
complete,  and.  where  loss  of  sensibility  exists. 
The  patient  should  at  an  early  stage  of  the  dis- 
ease be  placed  upon  a water-bed ; and  those 
forms  are  most  suitable  in  which  there  is  a 
canal  through  the  centre  for  the  passage  down- 
wards of  the  evacuations.  The  patient  must  be 
kept  scrupulously  clean  and  dry ; and  no  folds 
of  the  bed-clothes  must  be  permited  to  piress 
against  the  skin.  If  possible,  the  patient  should 
aot  l>e  allowed  to  lie  habitually  upon  his  back, 


but  occasionally  in  a prone  or  lateral  po: it  mu 
The  skin  over  the  sacrum  especially  must  be 
carefully  watched,  and  on  the  least  sign  of  a 
patch  of  undue  redness  there,  it  should  be  rubbed 
once  or  twice  a day  with  a mixture  of  equal 
parts  of  olive-oil  and  spirits'  of  wine.  If  it 
becomes  actually  abraded  it  should  be  dress  ed 
with  zinc  ointment,  smeared  over  a piece  of  soft 
lint. 

For  the  first  fortnight  or  more  there  may  be 
complete  retention  of  urine,  which  then  requires 
to  be  drawn  off  night  and  morning  by  catheter. 
Luring  this  period  great  care  should  be  taken  in 
regard  to  the  cleanliness  of  the  catheter  em- 
ployed, and  only  instruments  which  have  been 
smeared  with  carbolised  oil  should  be  used.  Care- 
lessness in  this  respect  will  tend  to  bring  on  cys- 
titis at  an  early  date,  with  alkalinity  of  urine, 
and  may  thus  quite  prematurely  aggravate  the 
bladder-troubles.  As  soon  as  the  bladder  begins 
to  empty  itself  again,  in  a reflex  manner,  at 
intervals  throughout  the  day,  the  use  of  the 
catheter  may  be  discontinued,  as  long  as  the 
water  which  comes  away  continues  to  be  clear 
and  acid.  During  this  period  of  incontinence  it 
will  be  necessary  to  draw  off  the  urine  from 
time  to  time  for  the  purposes  of  examination. 
As  before  stated,  the  bladder  never  completely 
empties  itself.  After  this  state  of  things  has 
continued  for  some  weeks,  the  urine  at  last  gene- 
rally becomes  alkaline,  ammoniacal,  and  more  or 
less  mixed  with  mucus.  At  this  stage  the  blad- 
der should  again  be  emptied  once  or  twice  daily, 
and  washed  out  each  time  with  6 to  8 oz.  of 
quinine  solution  (2  grains  to  the  ounce,  with 
enough  of  dilute  sulphuric  acid  to  dissolve  it); 
or  with  a 1-2  per  cent,  solution  of  the  new  drug, 
‘ resorcin.’  This  will  prove  the  best  means  of 
warding  off  or  of  mitigating  inflammation  of 
the  bladder ; and  thus  perhaps  of  preventing  its 
extension  to  the  ureters  and  kidneys. 

In  regard  to  the  bowels,  purgatives  will  pro- 
bably be  required  from  the  first,  as  without 
their  use  there  will  be  no  evacuation.  Some- 
times a simple  enema  will  suffice.  Scybals  tend 
to  accumulate  in  the  large  intestine,  unless  its 
contractility  can  be  aroused  occasionally  by  a 
large  injection,  consisting  of  three  pints  of  warm 
thin  gruel,  together  with  half  an  ounce  of  spirits 
of  turpentine  and  an  ounce  of  castor  oil. 

Where  the  disease  has  reached  the  chronic 
stage,  and  when  death  is  not  inevitable,  the  mus- 
cles should  be  faradised  or  galvanised  three 
times  a week,  with  a view  to  maintaining  their 
nutrition,  and  in  old  and  extreme  cases  of  this 
sort,  good  results  seem  occasionally  to  have  been 
obtained  by  passing  fine  needles  through  the 
skin  into  the  muscles,  and  then  connecting  these 
needles,  one  after  another,  with  the  negative 
pole  of  a voltaic  battery  of  suitable  strength, 
the  positive  pole  being  applied  at  the  same  time 
to  the  back,  or  to  the  limb  above  the  transfixed 
muscle,  by  means  of  a damp  sponge,  in  the  usual 
way.  This  method,  recommended  especially  by 
Dr.  J.  E.  Morgan,  is  only  suitable  where  there  is 
also  loss  of  sensibility. 

When  in  the  final  stages  of  paraplegia  large 
and  sloughing  bed-sores  have  formed,  they  will 
require  the  most  constant  care  and  attention. 
Poultices  may’  be  at  first  needed  till  the  sloughs 


1483 


SPINAL  COED,  SPECIAL  DISEASES  OF. 


nave  separated,  and  afterwards  the  wounds  must 
be  variously  dressed  according  to  their  condition. 
An  ointment  composed  of  ten  grains  of  carbolic 
acid  to  one  ounce  of  vaseline  may  be  employed  ; 
or  more  stimulating  applications  may  be  needed. 
Sometimes  the  iodide  of  starch  paste  forms  a 
suitable  dressing. 

10.  Infantile  Paralysis.  See  Infantile  Pa- 
ralysis. 

11.  Acute  Spinal  Paralysis  of  Adults. — 
Synon.  : Poliomyelitis  Anterior  Acuta ; Acute 
Inflammation  of  the  Grey  Anterior  Horns ; Acute 
Atrophic  Spinal  Paralysis  ; Fr.  Paralysie  spinale 
atrophique  aigiie\  Ger.  Poliomyelitis  Anterior 
Acuta  ; Acute  Spinallahmung  bci  ilrwachscnen. 

This  is  essentially  the  same  disease  as  that 
known  as  infantile  paralysis  (see  Infantile 
Paralysis),  though  presenting  certain  differences 
from  the  fact  of  its  occurring  in  adults.  Its 
existence,  however,  was  not  distinctly  recognised 
till  about  the  year  1865,  when  illustrative  cases 
were  published  almost  simultaneously  by  Du- 
chenne  and  Morritz  Meyer.  Now  that  observers 
have  been  on  the  look-out  for  it,  it  has  proved 
to  be  one  which  is  by  no  means  uncommon, 
although  it  is  very  much  rarer  than  the  similar 
affection  in  infancy  or  early  childhood.  The 
disease  is  more  difficult  to  recognise  in  adults, 
because  in  them  other  affections  occur  with  which 
it  is  quite  possible  that  it  may  be  confounded. 

aEtiology. — The  aetiology  of  this  affection  in 
adults  is  just  as  obscure  as  it  is  in  children. 
Sometimes  it  manifests  itself  without  any  assign- 
able cause ; whilst  at  other  times  there  is  the 
possibility  that  exposure  to  wet  and  cold,  some 
shock  or  blow,  or  some  antecedent  acute  febrile 
illness  may  have  had  to  do  with  its  origin. 

Symptoms. — It  will  principally  be  necessary 
in  this  place  to  point  out  the  manner  in  which 
the  group  of  signs  and  symptoms  characteristic 
of  the  disease  in  infancy  becomes  modified  when 
it  occurs  in  the  adult. 

The  first  set  of  differences  is  due  to  the  minor 
irritability  of  the  nervous  system  in  the  adult.,  as 
compared  with  that  of  the  young  child.  The 
initial  febrile  symptoms  may  be  so  slight  as  to 
escape  notice ; convulsions  have  never  been  met 
with;  and  preliminary  head-symptoms  are  gener- 
ally very  slight.  Some  headache,  or  mental 
dulness,  may  be  present ; and  vomiting  occurs 
not  unfrequently. 

Paralysis  then  sets  in  speedily— it  may  bo 
within  a few  hours — and  is  more  or  less  wide- 
spread. The  muscles  are  flaccid ; reflex  actions 
are  abolished  or  greatly  diminished.  In  the 
course  of  a few  days,  generally,  improvement  as 
regards  motor  power  sets  in,  and  very  slowly  pro- 
gresses. It  may  go  on  continuously  to  complete 
recovery  in  the  course  of  a few  months;  or,  as 
often  happens,  such  recovery  is  only  partial. 
In  the  latter  case  certain  muscles  or  groups  of 
muscles  remain  paralysed,  and  in  them  a rapid 
atrophy  occurs.  When  tested  electrically,  these 
muscles  exhibit  the  ‘ reaction  of  degeneration.’ 
The  affected  parts  are  cold,  and  sometimes  more 
or  less  cyanotic.  There  is  no  impairment  of 
sensibility ; and  no  interference  with  the  func- 
tions of  the  bladder  or  rectum. 

All  the  characters  mentioned  in  the  last  para- 


graph accord  with  those  which  present  them- 
selves in  infantile  paralysis,  but  later  on  differ- 
ences again  show  themselves.  One  of  the  cha- 
racteristic features  in  the  child  is  arrest  of  growth 
in  the  parts  affected,  so  that  the  limbs  or  parts 
of  limbs  paralysed  remain  more  or  less  abortive. 
This,  of  course,  cannot  occur  in  the  adult ; and 
also  owing  to  the  fact  that  the  joints  are  stronger, 
the  secondary  deformities  (often  so  serious  in 
the  child)  are  not  met  with  to  the  same  extent  in 
adults. 

Prognosis.— This  is  not  a disease  dangerous 
to  life.  Complete  recovery  not  unfrequently 
takes  place,  and  that  too,  as  tho  writer  has  re- 
cently seen,  where  the  paralysis  may  have  been 
widespread,  affecting  all  the  limbs  for  a time, 
and  leading  to  marked  atrophy  in  the  muscles  of 
the  lower  extremities.  In  other  cases,  there  is 
left  in  particular  parts  a chronic  remainder  of 
paralysis  with  atrophy,  just  as  we  find  to  be  the 
case  in  children. 

Diagnosis. — The  mode  of  origination  of  the 
disease;  the  fact  that  the  paralysis  is  purely 
motor,  and  accompanied  by  no  interference  with 
sensibility ; the  fact  that  after  the  first  few  days 
at  least  the  functions  of  the  bladder  and  rectum 
are  not  interfered  with ; and  also  that  in  later 
stages  there  is  atrophy  of  muscles,  and  tho  exist- 
ence of  the  electrical  ‘reaction  of  degeneration’ 
— these  constitute  a group  of  conditions  which, 
taken  as  a whole,  is  thoroughly  distinctive. 

The  disease  with  which  it  is  most  liable  to  be 
confounded  is  that  about  to  be  described,  namely, 
(13)  Chronic  Atrophic  Spinal  Paralysis. 
The  points  of  distinction  will,  therefore,  be 
given  under  it.  ‘ Progressive  muscular  atrophy,’ 
if  we  bear  in  mind  its  very  chronic  onset,  is  much 
less  liable  to  be  confounded  with  the  present 
disease,  as  also  if  we  recollect  that  in  it  atrophy 
makes  its  appearance  before  paralysis  rather  than 
after,  and  that  the  electrical  reactions  are  notably 
different. 

The  fact  of  the  absence  of  spasms,  the  diminu- 
tion of  reflexes,  the  non-interference  with  sensi- 
bility and  with  the  sphincters,  together  with  the 
abrupt  origin  of  the  disease,  suffice  to  separate 
the  acute  spinal  paralysis  of  adults  from  all  other 
affections  of  the  spinal  cord. 

Treatment. — This  disease  must  be  dealt  with 
on  precisely  the  same  principles  as  those  which 
are  applicable  to  the  corresponding  affection  in 
young  children.  Kepetition  is,  therefore,  here 
unnecessary.  See  Infantile  Paralysis. 

12.  Acute  Ascending  Paralysis. — Synon.: 

Paralysis  Ascendens  Acuta ; Landry's  Paralysis ; 
Fr.  Paralysie  ascendante  aigue ; Ger.  Paralysis 
ascendens  acuta. 

Definition. — A mysterious  affection  of  the 
spinal  cord,  first  definitely  described  by  Landry 
in  1859  ; characterised  on  its  clinical  side  by  the 
existence  of  a progressive  paraly’sis,  advancing 
rapidly  from  below  upwards,  so  as  finally  to 
implicate  parts  dependent  for  their  innervation 
upon  the  medulla  oblongata  ; characterised  also 
on  its  anatomical  side  by  the  most  puzzling 
absence  of  any  appreciable  pathological  change. 

On  account  of  the  latter  peculiarity,  the  dis- 
ease ought  not  tobedescribed  in  the  presentplace, 
but  rather  to  constitute  the  first  of  Class  II. 


1484  SPINAL  COED,  SPECIAL  DISEASES  OF. 


But  this  disease,  together  ■with  ‘ acute  spinal 
paralysis’  and  ‘chronic  spinal  paralysis,’  have 
such  an  amount  of  similarity  from  a clinical 
point  of  view,  that  it  seems  very  desirable  for 
their  descriptions  to  follow  one  another,  so  that 
mutual  alliances  as  well  as  differences  may  be 
the  more  distinctly  appreciated. 

-Etiology  and  Patholoqt. — The  causes  and 
pathogenesis  of  this  affection  are  just  as  ob- 
scure as  those  of  the  disease  last  referred  tc. 
Exposure  to  cold,  and  emotional  disturbances 
(with  or  without  suppression  of  menstruation  in 
the  female)  have  been  observed  occasionally  as 
precursors.  Occasionally,  too,  this  disease  has 
supervened  during  convalescence  from  some  pre- 
vious acute  febrile  malady.  Syphilis  is  thought 
by  a few  (but  on  no  sufficient  evidence)  to  have 
something  to  do  with  the  pathogenesis  of  this 
affection.  Westphal,  again,  is  inclined  to  believe 
in  the  possibility  of  some  toxic  influence — though 
this  also  is  little  more  than  a mere  supposition. 
The  disease  seems  principally  to  occur  in  persons 
between  the  ages  of  twenty  and  forty,  and  to  be 
decidedly  more  frequent  in  males  than  in  females. 
Although  the  brain  and  spinal  cord  of  those 
who  have  died  from  this  affection  have  now  been 
frequently  examined  by  skilled  observers,  the 
results  have  hitherto  been  entirely  negative,  so 
far  as  morbid  anatomy  is  concerned. 

Symptoms,  Course,  and  Terminations.  — 
About  the  prodromata  there  is  nothing  distinc- 
tive— they  may  be  absent.  When  present  there 
may,  for  a few  days,  or  even  for  a few  weeks,  be 
a slight  febrile  condition  from  time  to  time,  with 
a sense  of  weariness,  and  more  or  less  numbness 
in  the  limbs,  especially  in  the  tips  of  the  fingers 
and  in  the  feet. 

The  disease  then  more  definitely  declares  itself 
by  a marked  weakness  of  the  lower  extremities ; 
soon  to  be  followed  by  actual  paralysis,  which, 
as  in  the  ‘subacute  and  chronic  spinal  paralysis,’ 
shows  itself  first  in  the  distal  portions  of  the 
limbs,  and  gradually  approaches  the  trunk,  so 
that  in  the  course  of  two  or  three  days  the  para- 
lysis of  the  lower  extremities  becomes  complete. 

The  trunk  muscles  are  next  and  soon  impli- 
cated in  a similar  manner.  The  patient  can  no 
longer  sit  up  or  turn  in  bed.  Eespiration  be- 
comes more  and  more  affected,  and  defsecation  is 
interfered  with,  through  weakening  of  the  abdo- 
minal muscles. 

Next,  though  sometimes  after  a distinct  inter- 
val, the  upper  extremities  become  implicated ; 
though  here  again  the  paralysis  first  involves 
the  distal  portions  of  the  extremities,  and  thence 
gradually  spreads  (after  a period  in  which  mere 
paresis  exists),  till  the  whole  limbs  become  com- 
pletely powerless. 

The  paralysed  limbs,  both  upper  and  lower, 
are  lax,  and  show  no  trace  of  contraction.  Though 
the  muscles  are  flaccid,  they  do  not  undergo  a 
marked  amount  of  atrophy,  as  is  the  case  in 
‘ s*mte  spinal  paralysis.’ 

In  accordance  with  this  latter  peculiarity,  there 
is  the  further  striking  characteristic  that  the 
electrical  reactions  of  nerves  and  muscles  continue 
perfectly  normal.  This  seems  now  to  be  a well- 
attested  fact,  and  it  has  been  verified  by  good 
observers  even  after  complete  paralysis  (without 
atrophy)  has  existed  for  several  weeks. 


Sensibility  is  scarcely,  if  at  all  affected;  nor.  as 
a rule,  are  pains  complained  of  in  the  paralyse! 
parts. 

The  nutrition  of  the  skin  is  not  impaired,  60 
that  there  is  no  tendency  to  the  formation  of  bed- 
sores. Coldness  and  cyanosis  do  not  seem  to  bo 
characteristics  of  this  affection. 

The  sphincters  are  usually  not  at  all  affected. 
Constipation  is  often  marked,  anddefaecationmay 
be  rendered  difficult  owing  to  paralysis  of  the 
abdominal  muscles. 

In  regard  to  reflex  actions,  these — especially 
the  skin-reflexes — may  not  be  much  affected  at 
first,  but  may  be  abolished  later  on.  Existing 
information  is  defective  concerning  ‘ tendon-re- 
flexes ’ in  this  affection,  and  the  writer  has  made 
no  observations  on  the  point  himself. 

As  a rule  there  is  no  febrile  elevation  of  tem- 
perature. 

At  the  stage  above  indicated,  in  nearly  one- 
third  of  the  recorded  cases,  or  it  may  be  even 
before  the  arms  have  become  much  implicated, 
the  disease  becomes  arrested,  and  after  a brief 
interval  recovery  of  power  begins  to  manifest 
itself — usually  in  a reverse  order,  so  that  power 
is  regained  first  over  the  arms,  then  over  the 
trunk,  and  subsequently  (in  the  course  of  several 
weeks)  over  the  lower  extremities. 

But  in  the  remaining  two-thirds  of  the  cases, 
after  the  arms  have  become  paralysed,  the  dis- 
ease still  progresses  so  as  to  affect  the  cervical 
muscles,  the  diaphragm,  and  finally  the  muscles 
innervated  by  the  motor  nerves  of  the  medulla. 
Thus,  in  its  later  phases  the  disease  is  charac- 
terised by  a greatly  increasing  difficulty  in  re- 
spiration; great  weakness  invoice;  extreme  ra- 
pidity of  pulse;  and  possibly  by  inequality  of 
the  pupils.  Finally,  increasing  paralysis  of  the 
muscles  concerned  with  articulation  and  degluti- 
tion sets  in  ; and,  owing  to  the  augmenting  dif- 
ficulties of  respiration,  death  may  arrive  at  any 
moment  by  asphyxia.  This  climax  of  the  disease 
may  be  reached  in  the  course  even  of  three 
or  four  days ; on  the  other  hand,  it  may  not  be 
reached  until  as  many  weeks  have  elapsed. 
Whenever  the  disease  has  advanced  so  far  as 
seriously  to  implicate  the  medulla,  recoveries  are 
comparatively  rare. 

In  quite  exceptional  cases  the  disease  may  pur- 
sue a reverse  order  throughout;  implicating  the 
nerves  of  the  medulla  first,  then  those  of  the 
cervical  region  of  the  cord,  and  so  on.  The  cele- 
brated Cuvier  is  said  to  have  died  from  the  dis- 
ease, progressing  in  this  very  unusual  manner. 

Prognosis. — Nothing  can  be  added  concern- 
ing prognosis  beyond  what  has  been  above  indi- 
cated in  speaking  of  the  course  and  terminations 
of  the  disease.  It  seems  the  rule  that,  the  more 
rapid  the  progress  of  the  disease,  and  the  earlier 
the  medulla  is  affected,  the  more  is  a fatal  ter- 
mination to  be  feared.  Still,  even  in  the  most 
acute  cases,  improvement  may  take  place. 

Diagnosis. — So  far  as  the  established  disease 
is  concerned,  we  have  in  this  affection,  in 
‘ acute  spinal  paralysis  of  adults.’  and  in  sub- 
acute forms  of  ‘ chronic  spinal  paralysis  ’ mala- 
dies that  present  certain  well-marked  points  of 
similarity.  In  each  we  have  to  do  with  simple 
motor  paralysis,  with  no  fever,  no  tenderness  or 
pains  in  the  spine,  no  pains  in  the  limbs  or  con- 


SPINAL  COKD.  SPECIAL  DISEASES  OE.  1485 


tractions,  and  with  no  incontinence  of  urine  or 
faeces,  or  tendency  to  the  occurrence  of  bed-sores. 

‘ Acute  ascending  paralysis’  differs  from,  both 
these  affections,  however,  in  the  important  fact 
that  rapid  atrophy  does  not  set  in  in  the  paralysed 
muscles,  and  that  the  electricial  reactions  in  no 
way  differ  from  those  met  with  in  healthy  nerves 
and  muscles.  In  the  very  acute  cases,  of  a few 
days’  duration  only,  these  distinctions  would  be 
worthless,  as  sufficient  time  would  not  have 
elapsed  to  make  it  possible  for  either  of  them 
to  occur.  In  such  rapid  cases,  therefore,  the 
distinctly  progressive  character  ot  the  disease  is 
that  which  will  serve  to  distinguish  it  from  the 
more  severe  cases  of  ‘acute  spinal  paralysis,’ 
in  which  the  paralysis  sets  in  simultaneously 
throughout  the  whole  of  the  parts  affected,  and 
often  with  a pretty  distinct  initial  febrile  dis- 
turbance. Then,  again,  there  is  the  fact  that 
this  latter  disease  has  no  tendency  to  involve  the 
medulla,  and  is  only  very  rarely  fatal. 

It  is  in  the  diagnosis  of  the  more  slowly  evolved 
forms  of  ‘ acute  ascending  paralysis,’  from  the 
similarly  progressive  eases  of  ‘chronic  spinal 
paralysis,’  that  the  development  of  rapid  atrophy 
of  the  muscles,  together  with  the  ‘ reaction  of 
degeneration  ’ comes  to  be  distinctive  of  the 
latter  affection.  Then,  again,  in  ‘acute  ascend- 
ing paralysis,’  there  is  a longer  persistence  of 
reflex  actions,  and  a far  greater  tendency  to  the 
manifestation  of  symptoms  showing  that  the 
medulla  oblongata  is  involved. 

Treatment. — -The  absence  of  any  known 
pathological  substratum  for  this  disease  makes 
it  extremely  difficult  to  lay  down  any  directions 
for  treatment.  It  would  appear  that  we  have 
to  do  with  a simple  alteration  of  the  molecular 
condition  of  the  spinal  motor  nerve-centres,  un- 
accompanied by  any  known  inflammation  or  irre- 
gularity of  vascular  supply. 

Under  these  circumstances,  the  patient  should 
be  put  upon  a nutritious  but  easily  assimilable 
diet,  with  a fair  amount  of  stimulants  ; and, 
further,  we  may  endeavour  to  induce  a change  in 
the  nutritive  and  functional  activity  of  the  spinal 
cord,  by  having  recourse  to  frictions  of  the  skin 
or  gentle  shampooing  of  the  limbs,  together  with 
brief  daily  applications  of  weak  faradic  currents 
to  many  of  the  affected  muscles. 

From  drugs,  perhaps  the  best  chance  of  bene- 
ficial results  may  be  looked  for  from  combina- 
tions of  iron  and  arsenic,  or  from  the  cautious 
use  of  small  doses  of  strychnia.  Iodide  of  potas- 
sium would  probably  be  useless.  Sulphur  baths 
should  be  had  recourse  to  in  the  more  chronic 
cases. 

13.  Chronic  Atrophic  Spinal  Paralysis. 
■Synon. : Subacute  and  Chronic  Inflammation  of 
the  Grey  Anterior  Horns ; Poliomyelitis  Anterior 
Subacuta  et  Chronica-,  Fr.  Paralysis  generals 
spinale  anterieure  subaigue  ; Ger.  Subacute  Spi- 
nallahmung  Erwachsener ; Subacute  Spinalpara - 
lysie. 

Nature,  .^Etiology,  and  Pathology. — This 
disease  was  described  by  Duchenne  in  1853,  and 
then  again  more  completely  in  1872,  as  a more 
or  less  rapidly  advancing  motor  paralysis,  as- 
sociated with  atrophy  of  the  muscles  affected, 
»nd  loss  of  their  faradic  excitability. 


He  believed  the  disease  to  be  dependent  upon 
a chronic  degeneration  occurring  in  the  grey 
anterior  horns,  and  this  view  is  supported  by  the 
few  examinations  as  yet  made  of  persons  who 
have  been  the  subjects  of  this  affection.  The 
pathological  changes  in  the  anterior  horns  have 
been  associated  with  atrophy  of  the  anterior 
nerve-roots. 

The  c-auses  of  the  malady  are  at  present 
almost  wholly  unknown  ; but  it  occurs  princi- 
pally in  individuals  between  the  ages  of  thirty 
and  fifty  years.  As  with  other  chronic  spinal 
affections,  so  here,  there  has  often  been  one  or 
other  of  the  following  events  occurring  some 
little  time  before  the  onset  of  the  disease : — 
Exposure  to  cold  and  damp,  some  shock  or  con- 
cussion, venereal  excesses,  or  great  fatigue  in- 
duced by  other  causes.  But  what  share  the 
pre-existence  of  one  or  other  of  these  conditions 
may  have  had  in  initiating  the  disease  cannot  at 
present  be  defined. 

Symptoms. — In  the  subacute  cases,  paralysis 
may  become  developed  (usually  in  the  lower 
extremities  first)  in  the  course  of  a few  days  or 
weeks  ; at  the  same  time  there  may  be  some 
very  slight  initial  febrile  disturbance,  and  pos- 
sibly some  shooting  pains  in  the  back  and  limbs. 

In  the  more  chronic  cases,  the  latter  symptoms 
may  be  absent,  and  the  onset  of  paralysis  is 
very  much  slower.  There  may  be  at  first  mere 
paresis,  felt  most  in  the  ankles  and  knees ; 
but  gradually  (often  after  many  months)  this 
deepens  into  distinct  paralysis  of  certain  groups 
of  muscles,  or  of  the  entire  limbs.  The  muscles 
are  flabby  and  progressively  waste  ; at  the  same 
time  they  cease  to  respond  well  or  even  at  all  to 
the  faradic  current,  and  become  more  sensitive  to 
the  voltaic.  There  may  also  be  notable  fibrillar 
twitchings  in  the  muscles  undergoing  this 
atrophic  process. 

Sensibility  is  unaffected.  Skin  and  tendon 
reflexes  are  abolished.  The  temperature  of  the 
affected  limbs  is  lowered ; and  the  feet  especially 
are  apt  to  be  cold  and  cyanotic. 

Soon  the  arms  become  affected  in  a similar 
manner,  and  here  the  paralysis  may  first  affect 
either  the  extensors  or  the  flexors.  It  may 
remain  more  or  less  limited  to  certain  groups 
of  muscles,  or  may  gradually  extend  so  as  to 
implicate  the  whole  limb.  The  distal  parts  are 
usually,  however,  more  completely  involved  than 
the  proximal.  In  the  arms  the  same  kind  oi 
phenomena  occur  as  in  the  lower  extremities, 
and  there  is  a similar  absence  of  rigidities  or 
contractures. 

There  is  no  tendency  to  the  formation  of  bed- 
sores, and  the  nutrition  of  the  skin  seems  to  be 
unimpaired. 

The  rectum,  the  bladder,  and  the  sexual 
organs  are  usually  quite  unaffected. 

After  a time,  the  excessive  reaction  of  the 
wasted  muscles  to  the  galvanic  current  decidedly 
diminishes ; though  in  the  earlier  stages  of  this 
affection  the  electrical  ‘reaction  of  degenera- 
tion ’ exists  with  all  its  characteristic  details. 

Prognosis,  Course,  and  Terminations. — In 
the  subacute  cases,  after  a month  or  two, 
improvement  may  gradually  begin  to  manifest 
itself;  and  in  exceptional  instances  this  may  go 
on  slowly,  but  steadily,  to  complete  recovery.  In 


1486  SPINAL  CORD,  SPECIAL  DISEASES  OF. 


other  of  these  cases,  however,  certain  muscles 
or  groups  of  muscles  do  not  undergo  the  same 
improvement  as  the  others  ; they  may  continue 
paralysed,  and  become  more  and  more  atrophied. 

In  the  more  chronic  cases,  recovery  is  scarcely 
to  be  looked  for ; though  after  the  symptoms 
have  developed  to  a certain  extent,  it  occasion- 
ally happens  that  no  further  advance  is  made. 
Such  patients  may  remain  in  much  the  same 
condition  for  years. 

In  another  class  of  cases  the  malady  proves 
more  continuously  progressive,  so  that  after 
implicating  the  upper  and  lower  extremities 
severely,  the  morbid  process  may  extend  to  the 
tipper  cervical  region  of  the  cord,  so  as  greatly 
to  interfere  with  respiration ; or  it  may  even 
extend  to  the  medulla,  so  as  to  involve  the 
tongue  and  pharyngeal  muscles,  and  more  or 
less  interfere  with  the  functions  of  articulation 
and  deglutition.  In  such  cases  death  is  liable 
to  occur  through  asphyxia  or  slowly  progressing 
exhaustion. 

In  the  majority  of  cases  of  this  disease, 
more  or  less  complete  recovery  cccurs,  though 
it  may  be  only  after  two  to  four  years. 

Diagnosis. — This  malady  bears  a closer  resem- 
blance to  the  1 acute  spinal  paralysis  ’ of  adults 
than  to  any  other  affection.  The  two  diseases 
are  naturally  distinct  in  their  modes  of  initiation, 
but  as  established  diseases  (that  is,  in  their  later 
phases)  they  would  be  very  difficult  to  discrimi- 
nate from  one  another  in  the  absence  of  definite 
information  as  to  modes  of  onset— and  such  in- 
formation is  often  not  to  be  obtained.  It  is  the 
abrupt  commencement  of  the  paralysis  over  a 
wide  area  of  the  body  that  is  met  with  in,  and 
which  is  so  distinctive  of,  ‘ acute  spinal  para- 
lysis’; whilst  in  the  subacute  forms,  and  more 
especially  in  ‘.chronic  atrophic  spinal  paralysis,’ 
we  have  to  do  with  a distinctly  progressive 
spread  of  the  disease  from  part  to  part. 

In  regard  to  the  discrimination  of  these  sub- 
acute and  chronic  forms  of  spinal  paralysis  from 
some  other  varieties  of  spinal  cord  disease,  the 
reader  may  refer  to  what  has  been  said  concern- 
ing the  grounds  on  which  the  diagnosis  of  ‘ acute 
spinal  paralysis  ’ is  to  be  made  ( see  (11),  Acute 
Spinal  Paralysis  of  Adults). 

In  ‘ amyotrophic  lateral  sclerosis  ’ the  upper 
extremities  may  be  paralysed,  wasted,  and  flaccid 
as  they  are  in  ‘ chronic  spinal  paralysis  ’ ; but 
then  in  the  former  disease  there  would  be  the 
characteristically  different  combination  of  para- 
lysis without  wasting,  but  with  more  or  less 
rigidity  in  the  lower  extremities. 

For  the  distinguishing  characters  of  ‘acute 
ascending  paralysis’  see  the  account  of  that 
affection,  in  the  preceding  article. 

Treatment.  — Possibly  counter-irritation  to 
the  spine  in  the  early  stages  may  do  good,  and 
should  certainly  be  tried.  Local  bleeding  would 
probably  be  useless.  A nutritious  and  easily 
digestible  diet,  tonics,  and  rest  are  essential  in 
the  early  stages,  together  with  a thorough  super- 
vision of  the  general  health.  Later  on,  electrical 
treatment  by  the  voltaic  current  must  be  had 
recourse  to,  and  must  be  perseveringly  continued 
for  long  periods,  until  the  muscles  again  begin  to 
respond  to  the  faradic  current.  The  electrical 
treatment  is  what  is  principally  to  be  relied  upon, 


and  except  in  the  subacute  cases  it  may  be  com- 
menced almost  from  the  first,  should  the  patient 
happen  to  come  under  observation  during  the 
early  stage  of  the  malady.  Sulphur  or  brine- 
baths  seem  at  times  to  do  much  good. 

14.  Progressive  Muscular  Atrophy.  See 
Progressive  Muscular  Atrophy. 

15.  Pseudo-hypertrophic  Paralysis.  See 
Pseodo-hypertrophic  Muscular  Paralysis. 

16.  Locomotor  Ataxy.  See  Locomotor 
Ataxy. 

17.  Spasmodic  Spinal  Paralysis.— Synox.: 

Paralysis  spinalis  spastica ; Primary  Sclerosis  of 
the  Lateral  Columns ; Idiopathic  or  Primary 
Lateral  Sclerosis ; Pr.  Tabes  dorsal  spasmodique 
(Charcot);  Ger.  Spastische  Spinalparalysie ; Pri- 
m'dre  Skleroseder  Scitenst range des Ruckcnmarks; 
Primare  Lateralsklerose  des  Ruckcnmarks. 

This  is  one  of  the  most  recently-recognised  of 
the  diseases  of  the  spinal  cord.  It  was  described 
first  by  Erb  in  1875,  and  within  a few  months 
of  the  same  time  in  a thorough  and  indepen- 
dent manner  by  Charcot.  Although  these  ob- 
servers indicated  with  precision  the  probable 
pathology  of  the  disease,  they  were  not  able  to 
verify  their  anticipations  by  the  examination  of 
any  patient  who  had  died  from  (or  whilst  sutfer- 
ing  from)  this  complaint.  This  last  step  has 
been  recently  accomplished  in  this  country  by 
Dr.  Dresehfeld. 

But  even  before  the  disease  was  distinctly  de- 
scribed, its  probable  existence  and  principal  fea- 
tures wore  in  part  anticipated  by  Tiirek  and  by 
Charcot — both  of  them  being  guided  more  espe- 
daily  by  the  clinieal  effects  produced  by  ‘ secon- 
dary degenerations  ’ in  the  lateral  columns,  as 
occurring  in  association  with  hemiplegia. 

zEtiology  and  Pathology. — The  disease  is 
distinctly  more  common  in  males  than  in  females : 
it  occurs  in  the  majority  of  cases  in  adults  from 
twenty  to  fifty  years  of  age.  Erb  and  others 
have  also  described  spasmodic  forms  of  paralysis 
occurring  in  children,  which  may  possibly  be 
instances  of  this  disease.  The  writer  has' met 
with  it  once  in  a child  of  about  ten  years  of  age, 
but  then  the  lateral  sclerosis  seemed  onlv  to 
form  a prominent  part  of  what  was  really  a 
‘ multiple  sclerosis  ’ of  cerebro-spinal  type. 

In  some  cases  the  disease  appears  indepen- 
dently of  any  appreciable  predisposing  or  excit- 
ing causes ; but,  in  other  instances,  falls  or 
other  traumatic  influences  seem  to  be  distinctly 
connected  with  its  origin.  On  rare  occasions 
exposure  to  wet  and  cold  has  seemed  to  have 
had  some  influence  over  the.  genesis  of  this,  as 
well  as  over  so  many  other  forms  of  spinal  dis- 
ease. 

Anatomical  Characters. — In  the  only  un- 
doubted case  which  has  yet  been  investigated  poll 
mortem,  namely,  in  that  of  Dr.  Morgan,  where 
the  spinal  cord  was  examined  by  Dr.  Dresehfeld 
( British  Medical  Journal,  January  29,  1S81, 
p.  152),  the  following  pathological  conditions 
were  observed  : — ‘ The  cord,  when  examined  in 
the  fresh  state,  showed  to  the  naked  eye  no 
abnormality,  except  softening  in  the  lowest  dor- 
sal region.  After  hardening  in  bichromate  of 


SPINAL  CORD,  SPECIAL  DISEASES  OF.  1487 


Rmmonia.  sections  of  the  cord  showed  already  to 
the  naked  eye  one  light-coloured  patch  in  each 
lateral  column  ’ — and  this  throughout  the  cervi- 
cal, the  dorsal,  and  the  lumbar  regions  of  the 
cord.  This  hand  of  morbid  tissue,  presenting  all 
the  typical  characters  of  a sclerosis,  occupied 
the  greater  portion  of  the  lateral  columns,  hut 
without  implicating  the  grey  matter  or  extend- 
ing quite  to  the  surface  of  the  cord.  The  anterior 
and  the  posterior  columns  were  perfectly  healthy. 
The  microscopical  characters  of  primary  sclerosis 
in  the  spinal  cord  are  briefly  described  in  the 
article  on  ‘multiple  sclerosis.’  See  (19)  Mul- 
tiple Sclerosis  of  the  Spinal  Cord. 

The  occurrence  of  the  slight  softening  in  this 
case  was  an  accidental  complication,  otherwise 
the  lesions  actually  found  agreed  very  perfectly 
with  Charcot’s  scientific  predictions  as  to  the 
probable  pathological  changes  peculiar  to  this 
affection  of  the  spinal  cord. 

Symptoms. — This  disease  often  sets  in  almost 
imperceptibly,  and  the  symptoms  continue  to 
develop  themselves  in  a very  slow  and  gradual 
manner. 

Patients  begin  to  complain  first  of  mere  weak- 
ness of  the  lower  extremities,  and  this  continues 
to  increase  till  a well-marked  condition  of  paresis 
exists.  There  is  great  difficulty  in  getting  up- 
stairs, and  the  feet  begin  to  drag  even  when  the 
patient  walks  on  level  ground.  This  paresis  may 
soon  be  associated  with  more  or  less  of  muscular 
twitchings,  often  more  marked  in  the  morning, 
but  sometimes  more  especially  at  night,  and  of  a 
painful  character.  Soon  an  actual  stiffness  of 
the  muscles  of  the  legs  begins  to  manifest  itself, 
which  becomes  apparent  principally  when  pas- 
sive movements  are  attempted,  or  even  when 
the  patient  seeks  himself  to  move  the  limbs.  At 
last  some  amount  of  rigidity  of  muscles  may  be 
more  or  less  continuously  present,  so  as  greatly 
to  interfere  with  locomotion,  or  in  some  cases 
even  to  prevent  it  altogether. 

In  the  early  stages  of  the  disease,  ankle-clonus 
can  be  elicited  with  the  greatest  ease,  and  the 
knee-jerk  is  found  to  be  distinctly  exaggerated 
on  both  sides.  When  one  of  these  patients  is  in 
the  sitting  posture,  commencing  pressure  on  the 
toes  of  one  foot,  as  in  the  act  of  rising,  will  at 
once  initiate  the  characteristic  tremors  of  ankle- 
clonus.  All  such  signs,  however,  will  probably 
diminish  as  the  rigidity  becomes  more  marked. 

Whilst  the  patient  is  able  to  walk  he  often 
exhibits  a typical  ‘ spastic  gait.’  The  legs  are 
generally  kept  close  together,  owing  to  a spas- 
modic contraction  of  the  adductors  of  the  thighs; 
the  toes  trail  or  are  dragged  along  the  ground ; 
and  then , when  the  heel  is  beginning  to  be  brought 
down,  a spasmodic  contraction  of  the  calf  muscles 
may  take  place,  tending  to  raise  the  patient  upon 
his  toes  and  almost  throw  him  forward.  In  this 
way  a mixed  and  very  irregular  kind  of  walking 
is  necessitated,  partly  to  be  accounted  for  by 
mere  powerlessness,  and  partly  by  the  occurrence 
of  strong  muscular  spasms.  In  some  instances, 
either  owing  to  variations  in  the  amount  of  the 
spasms,  or  it  may  be  to  the  great  weight  of  the 
patient,  this  spastic  walk  is  not  well-marked.  In 
all  cases,  however,  it  is  quite  different  from  the 
ataxic  gait ; and  when  standing  with  feet  close 
together,  no  increase  of  unsteadiness  or  feeling 


of  vertigo  is  occasioned  when  the  patient  closes 
his  eves. 

Sensibility  is  little,  if  at  all,  affected  ; still,  in 
some  instances  it  is  apt  to  be  slightly  impaired. 
In  one  case,  at  present  under  the  writer’s  care, 
ability  to  recognise  differences  of  temperature 
was  for  a time  greatly  lessened  ; and  although 
tactile  sensibility  is  scarcely  at  all  interfered 
with,  the  patient  has  frequently  complained  cf  a 
diminished  power  in  appreciating  the  exact  posi- 
tions of  his  legs.  Skin-reflexes  are  often  nor- 
mal, but  occasionally  they  may  be  slightly  in- 
creased. 

The  muscles  do  not  atrophy,  and  their  elec- 
trical reactions  continue  to  be  almost  normal  ; 
whilst,  according  to  Erb,  that  of  the  nerves  is 
slightly  but  distinctly  lowered  to  both  currents. 
Sexual  desires  are  not  affected,  but  sexual  dis- 
ability may  be  occasioned  to  a variable  extent — 
partly  owing  to  weakness  or  actual  paralysis, 
and  partly  to  mere  spasms  of  muscles.  Micturi- 
tion is  often  scarcely  at  all  interfered  with ; there 
is  nothing  like  incontinence  of  urine  or  of  faeces, 
though  there  may  be  an  obstinate  amount  of 
constipation. 

No  vaso-motor  or  trophic  disturbances  in  the 
limbs  are  usually  present. 

As  the  disease  progresses  (it  may  be  very 
slowly,  and  in  the  course  of  years)  the  muscles 
of  the  trunk  become  affected,  so  that  weakness 
and  spasms  (often  of  a very  painful  character) 
occur  in  the  abdominal  and  back  muscles.  After 
a time  the  arms  also  may  become  implicated,  and 
in  the  same  fashion  as  the  legs,  excepting  that 
when  permanent  contractions  of  the  muscles  come 
on,  they  mostly  fix  the  arm  to  the  side,  whilst 
the  forearm  is  pronated  and  half-flexed,  and  the 
fingers  and  wrist  are  strongly  flexed. 

In  rare  cases  the  disease  is  limited  to  one  side 
of  the  body,  beginning,  for  instance,  first  in  one 
leg,  and  then  extending  to  the  arm  on  the  same 
side,  so  as  to  present  a kind  of  hemiplegic  dis- 
tribution. Just  as  rarely,  too,  the  disease  may 
first  affect  the  two  upper  extremities,  and  then 
extend  down  the  trunk,  so  as  ultimately  to  in- 
volve the  lower  extremities. 

During  the  development  of  the  disease  shiver- 
ing fits,  affecting  the  muscles  of  the  jaws  as  well 
as  almost  all  the  muscles  of  the  body,  may  occur 
from  time  to  time,  lasting  for  half  an  hour  or 
more,  and  though  quite  unaccompanied  by  any 
changes  of  temperature,  they  may,  nevertheless, 
be  provoked  by  cold.  Sometimes,  however,  such 
attacks  occur  spontaneously;  or  they  may  spread 
from  some  accidentally  initiated  ankle-clonus,  or 
other  well-marked  spasm. 

Persons  suffering  from  this  disease  often  re- 
main in  an  almost  stationary  condition  for  a 
series  of  years,  at  any  particular  stage  of  the 
disease  that  may  happen  to  have  been  attained. 
Ultimately,  however,  there  is  a tendency  to  com- 
plete paralysis  of  the  parts  affected,  with  perma- 
nent contractures — the  legs  at  this  stage  being 
often  immovably  fixed  in  a condition  of  rigid 
extension.  As  a rule,  pains  are  not  complained 
of  at  any  stage  of  the  disease,  though  some 
patients  suffer  much  from  painful  eramplike  con- 
tractions, occurring  either  in  tbe  lower  extremi 
ties,  or  else  in  some  of  the  abdominal  muscles. 

Complications. — So  long  as  the  morbid  procesi 


1488  SPINAL  CORD.  SPECIAL  DISEASES  OF. 


remains  limited  to  the  lateral  columns,  no  other 
symptoms  present  themselves.  Should  it,  how- 
ever, invade  the  grey  matter  in  particular  regions 
of  the  cord,  then  characteristic  complications  are 
apt  to  arise,  and  it  may  also  be  said  that  the 
gravity  of  the  disease  becomes  very  distinctly 
increased.  The  way  for  a fatal  termination  may 
then  be  paved  through  the  gradual  increase,  for 
instance,  of  bladder-troubles;  or  through  the  oc- 
currence of  severe  bed-sores,  and  collateral  events 
to  which  they  may  give  rise. 

Another  possible  extension  of  the  sclerosis  is 
to  the  posterior  columns,  so  that  we  may  get  a 
variable  mixture  of  the  symptoms  pertaining  to 
‘ spasmodic  spinal  paralysis,’  and  to  ‘ locomotor 
ataxy.’  It  should  be  borne  in  mind,  however, 
that  such  a complicated  clinical  grouping  some- 
times develops  in  the  reverse  order. 

Usually  in  patients  suffering  from  this  disease, 
there  is  no  association  with  cerebral  symptoms, 
nor  is  there  any  tendency  to  the  springing  up  of 
cerebral  complications.  Still,  in  one  case  under 
the  writer’s  care  a subacute  maniacal  condition 
became  developed ; whilst  in  another  case  dia- 
betes to  a slight  but  tractable  extent  has  mani- 
fested itself.  In  both  instances,  however,  there 
happens  to  have  been  a marked  hereditary  pre- 
disposition to  the  occurrence  of  insanity  and  of 
diabetes  respectively. 

Prognosis. — As  hinted  above  under  the  head 
of  complications,  so  long  as  the  disease-process 
remains  limited  to  the  lateral  columns,  as  it 
does  in  the  great  majority  of  eases,  ‘ spasmodic 
spinal  paralysis  ’ carries  with  it  no  danger  to 
life.  Such  patients  may  survive  for  an  indefinite 
time,  even  though  for  years  after  permanent 
contractures  have  become  established  they  may 
have  been  absolutely  confined  to  bed.  Still  Erb 
speaks  of  two  cures,  and  of  decided  improvement 
in  some  other  cases,  and  is  inclined  to  think  that 
this  affection  may  prove  a little  more  amenable 
to  treatment  than  some  of  its  congeners. 

Diagnosis. — The  grouping  of  symptoms  met 
with  in  this  disease  is  so  characteristic,  that 
there  ought  to  be  no  difficulty  in  recognising  it. 
In  no  other  affection  of  the  spinal  cord  have 
we  the  combination  of  a gradually  progressive 
paralysis  beginning  in  the  lower  extremities, 
associated  with  muscular  twitchings  and  rigid- 
ities; greatly  exalted  tendon-reflexes;  no  im- 
pairment of  sensibility  and  no  pains ; no  wasting 
of  muscles  or  other  trophic  changes ; and  no 
interference  with  the  functions  of  the  bladder 
and  rectum. 

The  real  difficulty  arises  in  the  recognition  of 
the  complex  forms  of  the  disease,  or  of  com- 
binations of  this 'disease  with  others,  then  coming 
under  observation  for  the  first  time.  This,  for 
instance,  is  the  case  where  we  have  to  do  with 
a combination  of  posterior  and  lateral  sclerosis, 
in  which,  in  order  to  arrive  at  a diagnosis  of  the 
existing  condition,  the  observer  must  be  able  to 
recognise  the  respective  effects  or  modifications 
that  may  result  from  the  combination  of  the 
t.wo  diseases.  Another  difficulty  of  the  same 
kind  arises  when  the  symptoms  of  the  disease 
are  complicated  by  extension  of  the  sclerosis 
to  the  grey  anterior  horns,  the  characters  of 
which  will  be  next  described  under  the  head  of 
Amyotrophic  lateral  sclerosis. 


Again,  when  ‘multiple  sclerosis’  affects  iu 
the  main  the  lateral  columns,  the  real  diagnosis 
can  only  be  arrived  at  by  the  recognition  of 
symptoms  which  could  not  be  produced  by  a 
mere  affection  of  the  lateral  columns.  Thus  the 
writer  has  at  present  under  his  care  a little  girl, 
ten  years  of  age,  first  brought  to  him  on  account 
of  head-symptoms,  which  suggested  the  possibi- 
lity of  intracranial  tumour,  but  in  whom,  after  a 
few  months,  sisrns  of  lateral  sclerosis  have  be- 
come developed  in  a very  typical  manner.  She 
now  presents  the  most  characteristic  spastic  gait, 
being  frequently  raised  quite  upon  the  points 
of  her  toes  as  she  walks.  There  is  also  great 
exaggeration  of  th6  tendon-reflexes,  and  no  im- 
pairment of  sensibility.  The  case  seems  clearly 
one  of  ‘ multiple  ’ or  ‘ cerebro-spmal  sclerosis.’ 

Treatment. — In  the  treatment  of  ‘ spasmodic 
spinal  paralysis,’  as  in  that  of  locomotor  ataxy, 
we  must  use  such  means  as  are  most  likely  to  be 
of  avail  in  checking  the  causal  process  of 
sclerosis  in  the  columns  of  the  cord.  The 
general  health  of  the  patient,  and  the  regula- 
tion of  his  mode  of  life,  must  receive  our  most 
careful  attention.  Sound  sleep  must  also  be 
ensured,  as  far  as  possible. 

Nitrate  of  silver  has  been  praised  by  some; 
but  the  writer  believes  that,  on  the  whole,  more 
good  is  to  he  obtained  from  iodide  of  potassium 
in  eight-  or  ten-grain  doses,  either  with  or  with- 
out liquor  arsenicalis.  Small  doses  of  cod-liver 
oil  also  seem  to  do  good.  There  is  no  particular 
indication  for  electrical  treatment  in  this  disease: 
but  stimulation  of  the  skin  and  subjacent  parts, 
by  frequent  frictions  and  shampooings,  may  be 
of  service,  and  so  also  may  sulphur  baths. 
There  are  mostly  no  pains  to  be  allayed;  but 
occasionally  painful  cramp-like  contractions  of 
the  muscles  cause  much  distress  to  patients 
suffering  from  this  disease.  These  pains  are 
difficult  to  relieve,  though  good  may  be  done, 
in  some  cases,  by  the  extract  of  calabar  bean  in 
increasing  doses.  For  the  rest,  any  accidental 
accompaniments  of  the  malady  must  be  treated 
upon  the  general  principles  applicable  to  the 
management  of  other  spinal  affections.  ‘ Nerve- 
stretching ’ might  be  beneficial,  as  in  certain 
cases  of  locomotor  ataxy,  though  there  is  room 
for  doubt  on  this  point. 

18.  Amyotrophic  Lateral  Sclerosis. — Sv- 
non.  : Fr.  Sclerose  laterals  amyotrophique. 

This  is  an  extremely  interesting  and  rare 
affection,  which  might  perhaps  be  regarded  as  a 
mere  variety  of  the  ordinary  lateral  sclerosis; 
still  it  is  a variety  which  pursues  a very  distinc- 
tive course,  and  constitutes  a disease  much  more 
formidable  than  its  prototype,  since  it  seems 
almost  invariably  to  lead  to  a fatal  termination 
in  two  or  three  years. 

Pathoi.ogy,  and  Anatomical  Charactees. — 
The  peculiarity  of  this  form  of  lateral  sclerosis 
lies  principally  in  the  fact  that  it  commences  in 
the  cervical  region,  and  soon  spreads  to  the 
contiguous  anterior  horns  of  grey  matter ; 
thence,  after  more  or  less  of  an  interval,  it 
extends  in  two  directions  : — (a)  downwards,  so 
as  to  involve  the  dorsal  and  lumbar  lateral  co- 
lumns, and  also  the  contiguous  anterior  cornua 
of  grey  matter ; and  (b)  upwards,  so  as  to  im- 


SPIN  All  CORD,  SPECIAL  DISEASES  OF.  1489 


plicate  the  upper  cervical  region  of  the  cord  and 
the  medulla  oblongata  in  a similar  fashion. 

Thus  it  will  be  seen  that  there  are  three 
peculiarities  about  this  form  of  lateral  scle- 
rosis; ('l)that  it  begins  in  the  cervical  region  of 
the  cord,  and  subsequently  affects  the  lumbar 
portion ; (2)  that  it  does  not  remain  limited 
to  the  lateral  columns,  but  soon  spreads  to  the 
contiguous  anterior  cornua,  where  it  leads  to 
destruction  of  the  great  motor  ganglion-cells ; 
and  (3)  that  it  almost  invariably  extends  up- 
wards also,  so  as  to  involve  the  medulla  ob- 
longata, and  thus  to  gradually  bring  about  the 
death  of  the  patient. 

Symptoms,  Course,  and  Terminations. — Being 
marked  by  the  anatomical  characters  above  de- 
scribed, it  will  be  easily  understood  that  patients 
suffering  from  this  disease  present  an  admixture 
of  such  signs  and  symptoms  as  may  be  met  with 
separately  in  ‘lateral  sclerosis,’  in ‘progressive 
muscular  atrophy,’  and  in  ‘ bulbar  paralysis.’ 
We  have,  in  fact,  the  following  typical  grouping 
and  sequence  of  symptoms  : — 

1.  Paresis,  gradually  increasing  to  actual  pa- 
ralysis of  the  upper  extremities,  and  soon  asso- 
ciated with  distinct  muscular  atrophy,  fibrillar 
twitekings,  &c.  Any  movements  that  can  be 
executed  are  weak,  and  associated  with  tremors. 
More  or  less  marked  rigidity  of  muscles,  and 
finally  actual  contractures  occur,  in  which  the 
arms  are  fixed  close  to  the  sides  of  the  body  ; the 
forearms  are  semi-flexed  and  pronat.ed,  whilst 
the  hands  and  fingers  are  strongly  flexed. 

2.  After  an  interval  of  some  months,  a similar 
group  of  symptoms  becomes  developed  in  the 
lower  extremities.  Again,  we  have  paresis 
gradually  increasing,  with  muscular  tensions, 
exaggerated  tendon-reflexes,  and  an  increasing 
amount  of  rigidity  of  the  lower  limbs,  wrhich 
are  usually  fixed  in  the  extended  position.  At 
a later  period  in  the  lower  extremities,  as  com- 
pared with  the  arms,  a process  of  muscular 
atrophy  sets  in,  with  development  of  the  ‘reac- 
tion of  degeneration,’  and  fibrillar  twitekings  in 
the  affected  muscles. 

During  the  whole  of  this  time,  there  is  little 
or  no  interference  with  sensibility.  There  is 
usually  no  implication  of  the  sphincters,  and  no 
tendency  to  the  formation  of  bed-sores. 

3.  In  the  last  stage  of  the  disease,  there  is 
evidence  of  extension  of  the  morbid  process 
upwards  to  the  upper  cervical  region  and  the 
medulla.  Signs  of  bulbar  paralysis  present 
themselves  in  the  usual  way,  by  paralysis  with 
atrophy  of  the  tongue  and  lips,  and  by  progressive 
weakening  of  the  muscles  of  the  palate,  pharynx, 
and  larjmx.  The  phrenic  nerve  has  also  gene- 
rally become  involved,  and  when  weakness  of  the 
diaphragm  is  added  to  weakness  or  actual  para- 
lysis of  the  other  muscles  of  respiration,  this  all- 
important  function  becomes  more  and  more  im- 
paired, and  thus  a fatal  termination  may  at  any 
time  be  easily  brought  about.  Increasing  dif- 
culty  of  articulation  and  deglutition  may  have 
existed  for  some  months  before  death. 

Prognosis. — As  already  indicated,  the  prog- 
nosis is  bad  ; the  disease  usually  advances  to  a 
fatal  termination  in  from  one  to  three  years. 

Diagnosis. — In  the  early  stages,  when  amyo- 
trophic latenl  sclerosis  affects  the  arms  only,  it 

94 


is  characterised  by  its  gradual,  painless  onset4 
the  absence  of  impairment  of  sensibility,  tha 
fact  that  weakness  sets  in  first,  and  that  twitch- 
ings  and  tensions  of  muscles  soon  declare  them- 
selves, either  before  or  after  themuscular  atrophy 
becomes  very  obvious.  This  combination  is 
already  sufficiently  distinctive,  in  the  absence  of 
pain  iu  the  back,  tenderness  over  the  spine,  oi 
any  other  evidence  of  vertebral  disease. 

When  the  disease  advances  to  its  second  and 
third  stages,  the  picture  becomes  gradually  more 
and  more  distinctive,  and  easily'  to  be  separated 
from  all  other  affections  of  the  spinal  cord  ; 
especially  if  we  are  duly  impressed  by  the  nega- 
tive symptoms,  namely,  the  absence  of  sensory 
impairment,  of  bladder-troubles,  and  of  bed- 
sores. 

Treatment. — Little  success  has  hitherto  at 
tended  the  treatment  of  this  disease.  The  indi- 
cations are  to  endeavour  to  arrest  the  process  of 
sclerosis,  partly  by  the  most  assiduous  attention 
to  the  general  health,  and  partly  by  the  adminis- 
tration of  iodide  of  potassium,  either  alone  or  in 
combination  with  arsenic  or  small  doses  of  bi- 
chloride of  mercury.  In  the  early  stages  fara- 
disation should  be  had  recourse  to  • sulphur  or 
mineral  baths  may  be  tried  ; and,  if  possible, 
residence  in  some  high  and  bracing  health-re- 
sort, or  at  all  events  in  a climate  where  much 
time  may  be  spent  in  the  open  air.  In  later 
stages  little  can  be  done,  except  by  general 
treatment. 

19.  Multiple  Sclerosis  of  the  Spinal  Cord. 
Synon.  : Disseminated  Sclerosis;  Insular  Scle- 
rosis; Multilocular  Sclerosis;  Fr.  Sclerose  en 
plaques  disseminees ; Ger.  Multiple  Sklerose  des 
Ruclcenmarks. 

Nature  and  AEtiologt. — Nothing  approach- 
ing to  an  adequate  recognition  of  the  characters 
and  importance  of  this  disease  was  made  anterior 
to  the  year  1866.  Then,  and  in  the  two  or  three 
subsequent  years,  the  malady  may  be  said  to  have 
been  identified  and  characterised  by  Vulpian  and 
Charcot,  but  more  especially  by  the  latter  and 
his  pupils. 

It  is  a disease  produced  by  the  development  of 
patches  of  scleros:s  (overgrowths  of  neuroglia') 
of  varying  size  and  shape,  throughout  the  spinal 
cord,  and  also  in  different  parts  of  the  brain. 
Clinically  the  disease  is  met  with  under  the 
most  diverse  forms,  according  to  the  different 
sites  and  sizes  of  the  patches  of  sclerosis  occur- 
ring in  different  cases.  These  different  forms  of 
the  disease  are  divisible  into  three  partially  dis- 
tinct types,  according  as  the  morbid  changes 
and  symptoms  occur  in  and  are  referable  (1)  to 
the  spinal  cord  alone  ( spinal  type);  (2)  to  tho 
cerebrum  alone  ( cerebral  type);  or  (3)  to  the 
brain  and  spinal  cord  ( cerebro-spinal  type).  As 
the  dominant  symptoms  of  the  disease  are  often 
those  of  the  spinal  type,  even  where  there  is  also 
an  extension  of  the  morbid  process  to  the  cere- 
brum, it  will  be  most  convenient  to  speak  here 
in  the  main  of  the  ‘ cerebro-spinal  ’ type.  It  is, 
moreover,  both  more  frequent  and  a more  cha- 
racteristic malady  than  either  of  the  simpler 
forms. 

In  regard  to  the  aetiology  of  the  disease,  little 
can  be  said.  It  may  occur  with  or  without  the 


SPINAL  CORD,  SPECIAL  DISEASES  OP. 


1490 

predisposing  influence  of  a neurotic  tendency.  It 
■a  at  least  as  common  in  females  as  it  is  in 
males ; and  though  rarely  occurring  in  children 
under  ten  years  of  age,  it  is  perhaps  most  com- 
mon between  the  ages  of  ten  and  thirty  years. 
Beyond  the  age  of  forty  it  again  becomes  exces- 
sively rare. 

Amongst  the  exciting  causes,  exposure  to  wet 
and  cold  would  seem  to  t ike  the  first  rank. 
After  this  come  traumatic  influences  of  various 
kinds,  mental  shocks  or  troubles,  great  fatigues 
from  mental  or  bodily  labour,  and  finally  the 
state  of  convalescence  from  several  acute  dis- 
eases, such  as  typhus,  cholera,  variola,  or  other 
specific  fevers.  It  has,  indeed,  been  said  to  occur 
sometimes  as  a sequence  to  severe  and  long- 
continued  hysteria;  but  in  some  of  such  cases 
at  least  it  would  seem  to  be  far  more  probable 
that  the  early  and  obscure  symptoms  connected 
with  this  affection  were  those  which  were  re- 
garded as  hysterical.  ‘Hysteria’ may  be  produced 
or  simulated  in  many  ways,  but  as  itself  a pro- 
ducer of  organic  changes  its  rule  is  assuredly 
open  to  grave  doubts. 

Anatomical  Characters. — The  patches  of 
sclerosis  which  constitute  the  anatomical  basis 
of  this  disease,  do  not  differ  in  their  essential 
nature  or  in  their  appearance  (macroscopic  or 
microscopic)  from  the  similar  overgrowths  of  the 
neuroglia  that  occur  in  locomotor  ataxy  and  in 
primary  lateral  sclerosis. 

On  the  cut  surface  of  the  spinal  cord,  medulla, 
or  other  portion  of  brain,  the  foci  of  sclerosis 
mostly  reveal  themselves  as  greyish,  greyish- 
red,  or  semi-gelatinous  yellowish  patches,  differ- 
ing principally  by  reason  of  slight  contrasts  in 
colour,  from  the  dead  white  of  the  more  healthy 
columns  of  the  cord,  and  from  the  natural  ap- 
pearance of  the  grey  matter.  The  tissue  of  the 
patches  may  either  be  level  with,  project  slightly 
above,  or  sink  slightly  beneath,  the  general  cut 
surface  of  the  cord.  The  same  differences  also 
exist  in  regard  to  those  patches  which  involve 
the  external  surface  of  the  cord — they  may  at 
times,  when  the  new  growth  is  excessive,  rise 
slightly  above  the  surface ; whilst  later  on,  when 
shrinking  has  occurred  in  the  cirrhotic  patch, 
some  amount  of  superficial  depression  may  be 
met  with. 

The  patches  vary  much  in  size;  in  the  spinal 
cord  they  range  from  a mere  pin’s  head  to  that 
of  a large  pea,  or  of  a bean  ; whilst  in  the  cere- 
brum or  in  the  cerebellum  they  may  attain  still 
larger  dimensions.  In  the  spinal  cord  the  patches 
occur  in  all  parts  of  its  longitudinal  extent,  and 
they  may  occupy  very  variable  portions  of  the 
transverse  area  of  the  cord.  Some  involve 
principally  the  lateral,  others  the  anterior  or 
the  posterior  columns  of  the  cord  ; or  portions 
of  the  grey  matter,  either  alone  or  in  conjunc- 
tion with  one  or  more  of  these  columns,  may  be 
implicated  for  a variable  extent,  transversely 
and  longitudinally.  Patches  of  different  sizes, 
and  varying  in  their  transverse  extent,  occupy 
different  levels  of  the  cord,  and  may  thus  occur 
in  an  irregular  series  throughout  the  organ. 

These  spinal  foci  of  sclerosis,  again,  may  be 
associated  with  patches  of  the  same  kind  dis- 
tribute! through  the  medulla,  pons,  and  cerebral 
peduncles,  in  part  superficially  and  in  part 


within  their  substance.  Similar  patches  may  he 
found  in  variable  number,  and  quite  irregularly 
distributed,  through  other  parts  of  the  cere- 
brum, as  well  as  through  the  cerebellum. 

In  regard  to  the  microscopical  characters  ot 
these  foci  of  sclerosis,  certain  differences  are 
met  with  in  different  cases,  principally  depen- 
dent upon  the  age,  or  stage  of  formation,  of  the 
patches.  Without  going  into  minute  details,  it 
may  be  said  that  there  is  in  all  cases  a hyper- 
plasic  overgrowth  of  the  neuroglia  which  natu- 
rally exi-ts  around  and  between  the  nerve-ele- 
ments. The  nature  of  this  change  becomes  quite 
distinct  when  properly  prepared  sections  of  the 
cor!  have  been  tinted.  The  new  tissue  takes 
the  staining  fluid  freely,  and  when  the  circum- 
ference of  a patch  (especially  some  small  onei 
is  examined,  it  becomes  obvious  that  numerous 
thickened  processes  of  neuroglia  connect  it  with 
the  healthy  tissue  around.  It  is  by  the  hypei- 
trophy  and  gradual  fusion  of  these  circumfer- 
ential prolongations  that  the  morbid  growth  pro- 
gressively encroaches  upon  the  previously  healthy 
portions  of  the  cord.  As  this  mere  interme- 
diate tissue  grows,  it  presses  upon  and  con- 
stricts the  nerve-fibres  and  nerve-cells,  so  as 
to  cause  atrophy  of  the  latter  and  a partial 
atrophy  of  the  former.  For  there  is  reason  to 
believe  that  the  nerve-fibres  do  not  wholly  dis- 
appear ; in  these  patches  of  primary  sclerosis  (as 
in  the  case  of  ‘secondary  degenerations’)  it  is 
the  white  substance  of  Schwann  which  disappears, 
whilst  the  axis-cylinders,  or  a considerable  num 
ber  of  them,  persist.  In  the  new  tissue  itself  we 
find  the  usual  granular  or  very  finely  fibrillar 
matrix,  containing  minute  spherical  or  ovoidal 
plastides,  also  branched  cells,  and  occasionally  a 
few  granulation-corpuscles.  The  latter  are  met 
witli  especially  during  the  earlier  stages  of  a 
patch  of  sclerosis  ; just  as  corpora  amylacen  or 
colloid  bodies  may  be  found  in  older  patches. 
The  walls  of  the  capillaries  as  well  as  of  arteries 
and  veins  are  generally  greatly  thickened,  and 
the  vessels  in  a patch  of  this  kind  may  be  both 
numerous  and  large;  in  other  cases,  however, 
the  number  of  vessels  existing  in  the  patch 
is  by  no  means  so  conspicuous.  It  is  well 
known  that  the  adventitia  or  outer  coat  of  the 
vessels  in  these  patches  is  specially  apt  to  become 
thickened,  and  that  this  sort  of  over-growth 
may  extend  inwards,  so  as  to  cause  fibroid  dege- 
neration of  the  middle  coat  and  even  of  the 
intima.  It  is  probable  that  proliferation  also 
takes  place  from  the  inner  surface  of  the  intima 
(an  endarteritis),  and  that  occasionally,  owing  to 
this  cause,  a thrombosis  may  be  brought  about. 
Certain  it  is  that  the  writer  has  on  several 
occasions  found  the  larger  vessels  of  a patch 
of  spinal  sclerosis  blocked  by  an  old  and  firm 
thrombus. 

Pathogenesis. — With  reference  to  the  starting 
point  of  a patch  of  sclerosis  something  may  be 
attributable  to  general  causes  or  tendencies,  such 
as  exist  in  scrofulosis,  in  syphilis,  or  in  other 
cachectic  states  of  the  system.  Still,  a general 
tendency  of  this  kind  to  hyperplasia  can  only  be 
adduced  as  a very  partial  explanation,  since  not 
unfrequently  disseminated  sclerosis  maybe  met 
with  in  the  absence  of  any  cachexia ; and.  more- 
ov;r  patches  of  sclerosis  may  occur  in  the  nervous 


SPINAL  COED,  SPECIAL  DISEASES  OF.  1491 


system  only,  or  to  no  notable  extent  in  other 
organs  of  the  body.  This,  therefore,  would  indi- 
cate the  existence  of  something,  or  of  some  pro- 
cess, of  an  abnormal  kind  taking  place  in  the 
spinal  cord  and  brain,  and  again  not  uniformly 
through  them,  but  in  foci  situated  here  and  there. 
It  is  no  explanation,  as  some  seem  content  to  sup- 
pose, merely  to  say  that  the  abnormal  processes 
are  ‘ chronic  inflammations  ’ ; since  whether  it  is 
or  is  not  advisable  to  speak  of  the  changes  by 
this  name,  we  should  still  have  to  ask  what  is  the 
cause  of  such  local  departures  from  healthy  nu- 
trition. Doesthe  process  begin  in  the  connective- 
tissue  elements  themselves?  or  is  there  some 
primary  change  in  the  small  vessels  (possibly  of 
the  nature  of  endarteritis)  leading  to  obstructions 
and  a sequential  overgrowth  of  the  neuroglia? 
It  would  seem  pretty  certain,  at  all  events,  that 
the  change  in  the  nerve-elements  proper  follows 
the  overgrowth  of  the  neuroglia — as  certain,  in- 
deed, as  that  throughout  a band  of  ‘ secondary 
degeneration’ the  order  of  these  changes  is  exactly 
reversed.  There  fatty  degeneration  and  atrophy 
of  the  nerve-fibres  are  the  first  evonts,  and  these 
are  followed  by  hyperplasia  of  the  neuroglia.  See 
Introduction,  § 6,  (13). 

One  of  the  most  interesting  facts,  in  connec- 
tion with  these  patches  of  primary  sclerosis,  is 
to  bo  found  in  the  circumstance  that  they  them- 
selves rarely  lead  to  bands  of  descending  ‘secon- 
dary degeneration’  in  the  anterior  or  lateral 
columns,  or  of  ascending  degeneration  in  the 
nosterior  columns.  The  fact  itself  has  been  long 
observed,  and  always  regarded  as  rather  surpris- 
ing. The  writer  believes  it  to  be  explicable 
by  the  fact  previously  mentioned,  that  the  bulk 
of  the  axis-fibres  remain,  so  that  the  nerve-fibres 
below  the  seat  of  lesion  (or  above  in  the  ease  of 
the  posterior  columns)  are  not  absolutely  cut  off 
from  the  nerve-cells  which  exercise  a ‘ trophic  ’ 
influence  over  them.  Some  nerve-tremors  may 
still  pass  along  the  damaged  fibres  in  the  sclero- 
tic patch,1  and  thus  the  nerves  in  the  parts  be- 
yond do  not  degenerate  as  they  would  do  if  the 
fibres  had  been  absolutely  cut  across.  Some 
fibres  may  be  completely  strangled  and  then  ab- 
sorbed, and  in  such  a case  the  continuations  of 
these  nerve-fibres  would  degenerate.  In  the  final 
stages  of  a sclerotic  patch  this  kind  of  sequence 
is  apt  to  occur ; so  that  towards  the  end  there 
may  be  the  tendency  to  the  occurrence  of  some 
amount  of  secondary  degeneration,  even  though 
the  degenerated  fibres  may  not  constitute  a very 
compact  band. 

Symptoms. — It  can  easily  be  understood,  from 
what  has  already  been  said,  how  much  the  symp- 
tomatology of  this  disease  is  liable  to  vary  in 
different  cases,  according  to  the  varying  situation, 
extent,  and  order  of  evolution  of  the  morbid 
patches.  That  it  is  possible  to  assign  anything 
like  a definite  symptomatology  for  this  affection, 
is  due  to  the  fact  that  there  are  certain  seats  of 
election  in  which  the  patches  of  sclerosis  are 
specially  apt  to  occur.  The  sites  affected  with 
special  frequency  are  the  lateral  columns  of  the 
cord,  the  medulla,  and  the  pons ; and  it  is  with 

1 In  support  of  this,  there  is  the  fact  mentioned  by 
Charcot,  that  an  optic  nerve  which  was  affected  through 
lt3  whole  thickness  by  sclerosis  was  yet  capable  of  per- 
forming its  functions. 


the  occurrence  of  patches  of  sclerosis  in  these 
situations  that  we  have  the  following  set  of 
correlated  symptoms  pertaining  to  the  ‘ cerebro- 
spinal’ type  of  the  disease. 

A slowly  ensuing  paresis  of  the  lower  extremi 
ties  begins,  first  in  one  limb  and  then  after  a 
time  it  involves  the  other.  During  this  time  the 
paresis  develops  into  a more  and  more  marked 
paralysis,  though  the  sensibility  of  the  limbs  re- 
mains almost  completely  unaffected  — nothing 
more  than  a temporary  numbness  being  com- 
plained of  in  the  majority  of  cases,  whilst  light- 
ning-like pains  and  girdle-sensations  are  alto- 
gether absent.  After  an  interval,  first  one  and 
then  another  upper  extremity  may  become  weak 
and  subsequently  more  or  less  paralysed.  During 
theso  early  stages  of  the  disease  more  or  less 
distinct  remissions  of  symptoms  may  occur  from 
time  to  time. 

Meanwhile  a most  typical  sign  soon  shows 
itself  in  the  paretic  or  semi-paralysed  limbs, 
in  the  form  of  a marked  trembling  or  shaking 
of  those  muscles  or  parts  of  a limb  which  are 
called  into  voluntary  action  with  any  intensity, 
although  these  phenomena  immediately  subside 
when  the  voluntary  exertion  ceases.  The  invo- 
luntary movements  consist  either  of  extremely 
well-marked  tremors,  like  those  met  with  in 
some  cases  of  paralysis  agitans,  or  else  of  move- 
ments of  greater  range,  more  resembling  those 
of  chorea. 

Later  some  paresis  of  the  trunk-muscles  may 
gccut,  as  well  as  of  those  of  the  neck ; and  this  mav 
be  followed  by  a similar  affection  of  the  tongue, 
lips,  and  facial  muscles — possibly,  also,  of  those 
of  the  palate,  pharynx,  and  larynx.  When  a 
patient  affected  in  this  manner,  who  has  been  pre- 
viously lying  perfectly  still  inbed,  is  told  to  endeav- 
our to  situp,  shakings  and  tremors  begin  in  almost 
all  parts  of  the  body,  and  the  scene  is  strangely 
changed  until  all  voluntary  efforts  cease  and  the 
recumbent  position  is  again  assumed.  The  same 
kind  of  thing  is  seen  when  movements  of  par- 
ticular parts  of  the  body  are  attempted : thus 
when,  in  the  sitting  posture,  the  patient  attempts 
to  hold  up  one  leg,  tremors  of  it  immediately 
begin;  ask  him  to  take  hold  of  something  or  to 
squeeze  a dynamometer,  and  the  upper  extremity 
called  into  action  at  once  begins  to  shake;  request 
him  to  put  out  his  tongue,  and  immediately  irre- 
gular protrusions  of  the  organ  occur,  associated 
with  twitchings  about  the  angles  of  the  mouth 
and  even  in  other  parts  of  the  body.  The  act  of 
walking  may  cause,  in  more  or  less  advanced 
cases,  tremors  of  the  legs,  arms,  trunk,  head, 
and  neck — all  at  the  same  time. 

Movements  of  slight  intensity  occasion  either 
no  shakings  or  merely  tremors  of  a very  fine  kind. 
The  latter  are  seen  in  the  early  stages  of  the 
disease,  when  writing  is  attempted.  Almost  each 
letter  registers  a number  of  fine  tremors,  mixed 
here  and  there  with  greater  irregularities.  In 
more  advanced  cases,  however,  the  movements 
are  so  disorderly  that  writing  becomes  either 
impossible  or  wholly  illegible. 

Just  as  there  is  no  loss  of  ordinary  sensibility, 
so  we  find  that  patients  remain  fully  conscious 
as  to  the  positions  and  movements  of  their 
limbs,  and  that  closure  of  the  eyes  occasions  no 
increased  uncertainty  of  their  movements ; nor, 


1492  SPINAL  CORD.  SPECIAL  DISEASES  OF. 


when  in  the  standing  position,  are  they  rendered 
more  giddy  or  more  unsteady  by  such  a pro- 
ceeding. 

Up  to  this  stage  there  may  be  no  distinct  in- 
terference with  the  functions  of  the  bladder  or 
the  rectum.  The  tendon-reflexes  are,  however, 
generally  distinctly  exaggerated ; ankle-clonus 
may  be  obtained  with  readiness,  and  the  knee- 
jerk  is  often  more  pronounced  than  usual.  There 
is  no  tendency  to  the  formation  of  bed-sores ; no 
wasting  of  muscles ; nor  is  any  alteration  in  their 
electrical  excitability  met  with. 

After  variable  and  often  long  periods,  the 
affected  lower  extremities,  which  have  become 
more  and  more  paralysed,  may  in  some  cases 
show  signs  of  commencing  bar-like  rigidity.  The 
limbs,  as  the  patient  lies  in  bed,  are  closely  drawn 
together,  and  in  a condition  of  rigid  extension, 
which  is  generally  increased  when  any  attempts 
to  move  them  are  made.  At  first  this  condition 
of  the  limbs  ensues  from  time  to  time,  in  the  form 
of  paroxysms  lasting  for  an  hour  or  two.  But, 
after  a time,  the  attacks  are  both  more  frequent 
and  longer,  so  that  ultimately  the  condition  of 
rigidity  becomes  permanent.  Contractions  of 
the  arms  are  less  common,  and  when  they  occur 
they  become  fixed  at  times  in  a different  position 
from  that  met  with  in  simple  lateral  sclerosis 
(see  Spasmodic  Spinal  Paralysis) ; that  is, 
like  the  lower  extremities,  in  a condition  of 
extension,  and  closely  drawn  to  the  sides  of 
the  body.  At  this  period  ankle-clonus  can  often 
be  elicited  with  the  greatest  ease,  and  the 
movements  of  the  one  leg  may  extend  to  the 
opposite  lower  extremity,  and  may  indeed  set  up 
more  or  less  of  general  tremor  throughout  the 
body.  Exposure  to  cold,  or  irritation  of  the 
skin  m various  ways,  will  also  often  suffice  to  set 
up  this  general  tremor,  which,  as  Brown-S6quard 
showed,  may  commonly  be  caused  to  cease  in- 
stantly by  a forcible  flexion  of  one  of  the  great 
toes.  With  the  cessation  of  the  tremors  conse- 
quent upon  this  manoeuvre,  the  limbs  may  also  be 
left  for  a time  in  a supple  and  flaccid  condition. 

The  manifestation  of  tremors  of  the  tongue, 
lips,  and  face  is  of  course  a sign  that  the  medulla 
oblongata  is  affected;  and  when  this  occurs, 
simultaneously,  or  very  soon  after,  other  evi- 
dences of  the  implication  of  the  medulla  and 
of  contiguous  portions  of  the  cerebrum  may  be 
met  with.  Articulation  may  become  more  or  less 
affected,  the  speech  being  rendered  slow,  hesi- 
tating, and  measured,  syllable  by  syllable ; or 
it  may  be  jerky  in  character — becoming  especi- 
ally thick  and  blurred  in  the  later  stages  of  the 
disease.  The  power  of  swallowing  is  less  fre- 
quently impaired,  but  in  advanced  stages  it  is 
apt  to  be  affected. 

Nystagmus  is  very  frequently  met  with.  Dip- 
lopia, or  actual  paralysis  of  the  ocular  muscles,  is 
rare.  Amblyopia  not  unfrequently  exists ; perhaps, 
in  one  eye  only.  Actual  blindness  is  very  rare. 

Vertigo,  sometimes  to  a marked  extent,  is  no 
uncommon  symptom ; and  as  the  cerebrum  be- 
comes more  and  more  affected,  a condition  of 
well-marked  hebetude,  or  actual  dementia,  gradu- 
ally becomes  pronounced.  This  betrays  itself 
externally  by  a blank,  expressionless  aspect  of 
the  face ; the  patient  becomes  childish  in  manner, 
hia  memory  fails,  he  takes  interest  only  in  trifles, 


laughs  constantly  also  at  the  merest  trifles,  or,  on 
the  other  hand,  is  very  easily  moved  to  tears. 

During  this  condition  of  things  a subacute 
maniacal  condition  may  supervene ; or  the  patient 
may  develop  ‘delusions  of  grandeur’  precisely 
similar  to  those  met  with  in  1 general  paralysis  of 
the  insane’ — examples  of  which  the  writer  has 
recently  seen  in  two  of  his  own  patients.  In  other 
cases  persons  suffering  from  this  disease  mav 
lapse  into  a profoundly  melancholic  condition. 

At  this  stage,  too,  apoplectiform  or  epileptic 
form  attacks  are  particularly  apt  to  occur  from 
time  to  time.  After  such  attacks,  of  whichever 
kind,  the  limbs  on  one  side  of  the  body  and  the 
face  are  left  more  or  less  paralysed ; and  where 
the  attack  has  been  epileptiform  in  character, 
the  convulsive  twitchings  are  often  limited  to 
this  one  side  of  the  body.  As  Charcothas pointed 
out,  these  attacks  are  precisely  similar  to  those 
which  occur  in  general  paralytics,  or  in  cases  of 
old  hemiplegia  with  descending  sclerosis.  They 
answer  to  the  so-called  ‘ congestive  attacks,’  but, 
as  Charcot  contends,  they  do  not  seem  to  he 
associated  with  any  new  appreciable  lesions  of  a 
‘ gross  ’ order.  Such  epileptiform  attacks  may 
be  brief,  or  they  may  last  for  hours ; or,  off  and 
on,  even  for  days.  In  all  of  them  the  tem- 
perature begins  to  rise  almost  at  once — without 
any  initial  period  of  depression — and  may  even 
reach  104°  in  a few  hours,  or  in  a day  or  two. 
The  temperature  then  begins  to  fall  again ; or 
should  it  continue  to  rise  to  a still  higher  point, 
the  attack  is  very  apt  to  terminate  fatally. 

Every  attack  of  this  kind  leaves  the  patient  in 
a manifestly  worse  condition,  both  bodily  and 
mentally ; and  perhaps  in  one  of  them  at  last 
death  may  occur. 

Varieties. — The  symptomatology  of  this  dis- 
ease is  likely  to  be  considerably  modified  in  differ- 
ent cases,  but  principally  in  two  directions,  pro- 
ductive of  complications  of  the  same  kind  as 
those  which  are  also  apt  to  occur  in  ‘ spasmodic 
spinal  paralysis.’  In  each  disease  there  may  in 
some  cases  be  a special  affection  of  the  posterior 
columns,  in  one  or  other  region  of  the  cord,  bring- 
ing with  it  more  interference  with  sensibility, 
and  an  admixture  of  other  symptoms  pertaining 
to  locomotor  ataxy.  It  is,  perhaps,  principally 
in  these  cases  that  the  ‘crises  gastriques' t pains, 
vomiting,  and  occasionally  diarrhoea)  are  also 
met  with.  In  other  instances  there  may  bean  ex- 
tension of  the  sclerosis  to  the  grey  matter  of  the 
anterior  cornua  in  one  or  other  region  (as  well  as 
to  other  parts  of  the  grey  matter),  leading, 
amongst  other  phenomena,  to  muscular  atrophy 
in  related  regions  of  the  body.  In  either  of 
these  ways  the  symptoms  of  the  original  diseaso 
may  be  complicated,  and,  to  a certain  extent, 
obscured. 

Many  other  differences  also  present  themselves 
in  special  cases,  owing  to  the  varying  situations 
in  which  the  morbid  patches  make  their  first  ap- 
pearance. In  a fair  proportion  of  the  cases  the 
disease  seems  to  reveal  itself  first  in  the  brain 
rather  than  in  the  spinal  cord. 

Terminations. — After  pursuing  a very  slow 
course  for  years  (often  five  to  ten),  the  miserable 
sufferers  from  this  disease  may  at  last  be  carried 
off'  in  various  ways.  Death  may  take  place  it 
one  of  the  apoplectiform  or  epileptiform  attacks 


SPINAL  CORD,  SPECIAL  DISEASES  OF. 


occurring  either  in  patients  who  are  merely 
slightly  demented,  or  in  those  who  are  otherwise 
actually  insane;  or,  at  last,  in  cases  in  which 
there  is  great  interference  not  only  with  articu- 
lation hut  also  with  deglutition,  the  functions 
of  the  heart  or  of  respiration  may  also  become 
affected,  and  may  thus  lead  on  to  a fatal 
termination. 

In  other  cases,  after  the  disease  has  lasted  for 
years,  and  when  the  grey  matter  of  the  cord  has 
become  seriously  involved,  accidents  may  super- 
vene similar  to  those  which  occur  in  the  final 
stages  of  many  cases  of  paraplegia.  The  bladder 
.nay  become  paralysed,  and  after  a time  inflam- 
mation and  ulceration  may  be  set  up,  followed 
by  secondary  inflammation  of  the  ureters  or 
kidneys.  Or  bed-sores  may  form,  sloughing 
may  go  on  extensively,  and  the  patient  may  at 
last  die  exhausted,  or  from  the  supervention  of 
blood-poisoning  or  some  acute  inflammatory 
disease. 

Diagnosis. — In  its  early  stages  the  diagnosis 
of  this  disease  may  present  very  considerable 
difficulties.  This  is  especially  the  case  when  the 
morbid  process  begins  in  the  cerebrum.  Here  for 
a time  there  may  be  nothing  distinctive,  and  we 
have  to  wait  for  the  further  development  of  the 
disease  before  anything  like  a positive  diagnosis 
is  possible.  Similarly,  where  the  disease  begins 
only  with  spinal  symptoms,  it  is  often  extremely 
difficult  to  diagnose  it  with  certainty  in  its  very 
early  stages.  The  important  characters  in  the 
more  typical  forms  of  the  disease  are  the  youth 
of  the  patient,  the  paresis  gradually  increasing, 
first  in  one  and  then  in  the  other  lower  extremity, 
with  no  alteration  in  sensibility  or  in  the  elec- 
trical irritability  of  the  nerves  or  muscles. 
When  ankle-clonus  becomes  easily  obtainable, 
and  when,  moreover,  the  peculiar  tremors  and 
disordered  movements  on  voluntary  excitation 
of  the  muscles  are  met  with,  together  with  the 
absence  of  any  such  tremors  in  the  condition 
of  rest,  and  some  amount  of  paresis  or  of  similar 
symptoms  in  one  or  both  upper  extremities,  the 
diagnosis  of  the  ‘ spinal  ’ type  of  this  disease  can 
be  no  longer  difficult  or  doubtful. 

By  far  the  most  typical  cases,  however,  are 
those  of  the  ‘ cerebro-spinal  ’ type,  in  which,  with 
such  symptoms  as  are  above  indicated,  there  are 
also  some  others  due  to  disease  of  the  medulla 
or  pons — such  as  have  been  indicated  in  speaking 
of  the  symptomatology  of  the  disease.  In  these 
cases  the  disease  is  really  quite  distinctive;  so 
that  even  when  the  patient  is  seen  at  this  stage 
for  the  first  time,  the  malady  ought  to  be  easily 
recognised.  Chorea  is  the  affection  with  which  it 
is  most  apt  to  be  confounded ; but  the  absolute 
cessation  of  all  tremors  anddisorderedmovements 
in  multiple  sclerosis  when  the  patient  is  at  rest, 
and  their  immediate  re-initiation  (mainly  in  the 
parts  moved,  but  also  often  to  some  extent  in 
others)  on  the  occurrence  of  voluntary  efforts, 
is  a thoroughly  distinctive  characteristic. 

Paralysis  agitans  ought  to  be  distinguished 
from  disseminated  sclerosis  with  even  more  ease. 
It  is  scarcely  ever  met  with  in  persons  under  the 
age  of  thirty-five,  just  as  multiple  sclerosis  is 
only  rarely  met  with  in  persons  beyond  such 
an  age.  The  movements  of  paralysis  agitans 
•re  only  to  a slight  extent  exaggerated  by  volun- 


1493 

tary  exertion  of  the  parts  ; and  such  movements, 
in  the  form  of  fine  tremors,  do  not  cease  to  any- 
thing like-  the  same  extent  under  conditions  of 
rest.  There  is  generally  no  shaking  of  the  head 
and  neck  in  paralysis  agitans. 

Mercurial  poisoning  with  tremors  can  be  easily 
distinguished,  on  inquiry  into  the  history  of  th« 
patient,  and  the  mode  of  onset  of  the  disease. 

In  those  more  irregular  cases  of  multiple 
sclerosis,  in  which  there  is  either  an  implication 
of  the  posterior  columns  of  the  cord,  or  of  the 
grey  matter  in  some  region  or  regions,  the  dia- 
gnosis of  the  complex  nature  of  the  affection  must 
bo  based  upon  the  general  principles  applicable 
to  the  regional  diagnosis  of  spinal  cord  dis- 
ease. 

Phoonosis. — Absolute  cure  of  this  disease  is 
scarcely  to  be  hoped  for.  The  most  that  lias 
been  done,  hitherto,  as  a result  of  treatment,  has 
been  to  bring  about  more  or  less  distinct  re 
missions,  and  also  to  delay  the  progress  of  the 
disease.  Death  usually  occurs  in  from  five  to 
ten  years,  in  one  or  other  of  the  modes  already 
indicated. 

Treatment. — Many  drugs  have  been  tried, 
but  hitherto  with  little  or  no  positive  result,  in 
the  treatment  of  this  affection.  Nitrate  of 
silver  has  seemed  to  do  good  in  some  cases, 
especially  in  the  early  stages.  But  the  writer  is 
much  more  disposed  to  trust  to  iodide  of  potas- 
sium in  eight-  or  ten-grain  doses  three  times  a 
day,  with  or  without  moderate  doses  of  perchlo- 
ride  of-mercury  or  of  liquor  arsenicalis  ; com- 
bining the  use  of  those  drugs  with  cod-liver  oil 
and  a good  nourishing  diet.  From  time  to  time, 
however,  the  above  medicines  should  be  omitted, 
and  simple  tonics  taken  in  their  place.  In  the 
early  stages  of  the  disease,  sulphur  baths  and 
shampooing  of  the  limbs  may  be  of  service ; and 
in  all  cases  it  is  of  great  importance  to  see  that 
the  patient  obtains  sound  sleep,  since  in  this,  as 
in  all  other  chronic  spinal  diseases,  the  patient’s 
downward  course  is  sure  to  be  greatly  hastened 
where  refreshing  sleep  is  not  obtained. 

No  distinct  indications  exist  for  the  treatment 
of  this  affection  by  electricity,  and  no  advantages 
have  as  yet  been  recorded  from  its  use.  The 
complications  of  the  disease,  which  may  occur 
in  its  later  phrases,  must  be  treated  in  accord- 
ance with  the  general  principles  applicable  for 
this  as  for  other  spinal  affections.  Every  effort 
must  be  made  to  preserve  the  general  health  of 
the  patient,  as  this  will  probably  be  found  to  be 
the  surest  means  of  arresting  or  holding  in 
check  the  progress  of  the  disease. 

20.  Spinal  Cord,  Tumours  of. — Svnon.: 
Intra-medullary  Tumours;  Fr.  Tuncurs  de  la 
Moellc ; Tumeurs  rachidiennes ; Ger.  Krank- 
haften  Gesckwillste  des  Ruckenmarks. 

^Etiology  and  Anatomical  Characters. — 
Tumours  originating  in  the  substance  of  the 
spinal  cord  may  be  regarded  as  belonging  to  two 
classes,  according  as  they  represent  (a)  mere 
local  accidents  in  the  form  of  perverted  tissue- 
changes  ; or  ( b ) such  local  accidents  developing 
under  the  influence  of  a distinct  general  state, 
such  as  syphilis  or  scrofulosis. 

(a)  Of  the  purely  local  overgrowths,  the 
most  typical,  and  perhaps  also  the  most  fre< 


14S4  SPINAL  COED.  SPECIAL  DISEASES  OF. 


quently  occurring  fire  gliomata.  The  considera- 
tion of  these  growths  comes  in  natural  sequence 
to  that  of  sclerosis  affecting  different  regions 
of  the  cord.  In  such  a tumour  we  have  an  exu- 
berant overgrowth,  as  Virchow  and  most  other 
pathologists  suppose,  starting  from  the  neuroglia 
of  a certain  portion  of  the  cord.  At  first  the 
growth  infiltrates  and  substitutes  itself  in  the 
place  of  a certain  amount  of  nerve-tissue;  but 
it  soon  grows  excessive  in  quantity  (spreading 
in  area  perhaps  at  the  same  time),  and  thus 
comes  to  exercise  a more  and  more  marked  com- 
pression upon  the  remaining  tracts  of  nerve- 
tissue  composing  the  cord  at  the  same  level, 
within  the  narrow  and  unyielding  boundaries 
of  the  spinal  canal.  These  gliomata  are  often- 
times extremely  vascular.  They  are  liable  to 
undergo  a certain  amount  of  central  softening  ; 
and  into  their  substance,  especially  in  the  soft- 
ened feci,  haemorrhages  are  very  apt  to  occur. 
Softening  of  nerve-tissue  may  also,  at  a certain 
stage,  take  place  around  the  growth,  and  thence 
may  extend  for  a variable  distance  above  and 
below. 

Other  tumours  of  an  allied  nature,  such  as 
sarcomata  and  myxomata , also  at  times  develop, 
either  in  their  pure  types  or  with  blended 
characters,  within  the  spinal  cord.  They  pre- 
sent few  intrinsic  peculiarities  in  their  manner 
of  affecting  the  cord.  They  rarely  attain  any 
large  size  ; indeed  the  limitations  of  the  spinal 
canal  only  permit  of  much  increase  in  one  direc- 
tion. And  elongated  growths  are  occasionally 
met  with.  To  a considerable  extent,  such  tu- 
mours have  an  infiltrating  mode  of  growth, 
though  their  boundaries  are  apt  to  be  rather 
more  defined  than  are  those  of  gliomata. 

In  regard  to  the  causes  of  these  tumours, 
almost  nothing  more  definite  can  be  said  than 
that  they  seem,  at  times,  to  find  occasion  and 
conditions  suitable  for  their  initiation  after  some 
blow  upon  the  spine  or  concussion  of  the  spinal 
cord. 

(6)  Of  the  growths  which  tend  to  occur  in 
the  spinal  cord  (as  occasionally  in  other  parts  of 
the  body)  under  the  influence  of  some  general 
disease  or  diathetic  condition,  two  are  especi- 
ally to  be  named.  These  are  scrofulous  growths 
(‘tubercular’),  and  syphilitic  gummata.  The 
former  are  generally  small,  varying  in  size  from 
a mustard  seed  to  a pea,  and  only  very  rarely 
attaining  the  dimensions  of  a hazel-nut.  Next  to 
gliomata  they  are  the  new  growths  most  fre- 
quently met  with  in  the  substance  of  the  spiual 
cord.  When  small,  they  may  occur  in  associa- 
tion with  a cerebro-spinal  tubercular  meningitis ; 
but  at  other  times  they  are  found,  and  especi- 
ally the  larger  growths,  existing  independently 
of  any  acute  inflammation  of  the  meninges.  In 
this  latter  case,  the  tumours  may  be  combined 
with  a certain  amount  of  adjacent  and  secondary 
softening  of  the  substance  of  the  cord. 

Syphilitic  gummata,  originating  in  the  cord 
itself,  occur  only  with  the  greatest  rarity.  They 
are  more  frequently  found  starting  from  the 
meninges,  and  then  they  may  press  upon  or 
actually  grow  into  the  nerve-substance. 

Cancer  is  believed  not  to  occur  primarily  in 
the  substance  of  the  spinal  cord,  though  it  may 
grow  into  its  substance,  or  seriously  press  upon 


it,  when  originating  either  in  the  meninges  or  it 
the  vertebra. 

Symptoms,  Course,  and  Terminations — The 
difficulties  of  diagnosis  are  almost  always  very 
great  in  the  case  of  tumours  of  the  spinal  cord, 
because  in  their  early  stages,  and  occasionally 
for  prolonged  periods,  they  aro  associated  with 
slight  and  somewhat  vague  symptoms. 

Independently  of  the  variations  in  different 
cases,  consequent  upon  the  longitudinal  situation 
or  level  of  the  tumour  in  the  spinal  cord,  the 
symptoms  to  which  they  give  rise  in  various 
parts  of  the  body  may  be  more  or  less  vague 
anomalies  of  sensibility  in  different  regions, 
associated  with  a certain  amount  of  weakness, 
often  not  amounting  to  actual  paralysis. 

Growths  from  the  meninges,  or  from  the 
vertebra,  pressing  upon  the  spiual  cord,  are  not 
quite  so  apt  to  run  a latent  course  for  any 
length  of  time,  since  they  are  rather  more  prone 
to  involve  the  anterior  or  the  posterior  roots  on 
one  or  on  both  sides— at  first  irritating  them, 
and  subsequently  causing  paralysis  from  pres- 
sure. Thus  localised  numbness,  pains,  or  anaes- 
thesia, either  alone  or  associated  with  twitch!  ngs, 
cramps,  or  paralysis,  confined  to  certain  parts 
of  the  body,  are  rather  more  common  incidents 
during  the  growth  of  extra-  than  of  intra-me- 
dullary  tumours.  Still  the  diagnosis  between 
these  two  classes  of  tumours  may  be  impossible. 

Sclerosis,  in  its  ‘insular’  form,  especially  when 
the  patches  are  few  or  close  together,  may  also 
present  symptoms  almost  inseparable  from  the 
first  stage  of  some  intra-medullary  tumour. 
The  important  fact  is,  however,  that  sclerosis 
in  the  cord  tends  to  become  more  and  more 
generalised,  and  thus  gives  rise  to  a propor- 
tionately widening  range  of  symptoms ; or  else 
it  limits  itself  to  special  columns,  and  thus 
becomes  associated  with  more  special  sets  of 
symptoms. 

With  any  of  these  tumours  of  the  spinal 
cord,  the  symptoms  are,  after  a time,  liable  to 
undergo  a sudden  and  grave  increase,  owing  to 
the  occurrence  of  a haemorrhage  into  its  sub- 
stance and  perhaps  into  adjacent  regions  of  the 
spinal  cord,  or  else  owing  to  the  commencement 
of  a process  of  secondary  transverse  softening. 
Beyond  these  possibilities  of  sudden  grave  aug- 
mentation of  symptoms,  the  course  of  intra- 
medullary tumours  is  also  apt  to  be  marked  by 
peculiar  exacerbations  and  remissions  from  time 
to  time,  in  association  with  periods  of  altered 
growth  or  vascularity  of  the  tumour  itself. 

Diagnosis. — The  very  gradual  onset  of  the 
symptoms  in  cases  of  tumour  of  the  spinal  cord, 
is  a point  of  great  importance  in  the  diagnosis 
of  these  conditions.  Thus,  for  instance,  we 
eliminate  arachnoid  or  intra-medullary  haemor- 
rhages, and  also  the  numerous  class  of  cases 
of  softening  of  the  spinal  cord,  with  other  affec- 
tions having  a more  or  less  abrupt  origin.  The 
diagnosis  of  tumour  of  the  cord  as  distinct  from 
its  compression  by  disease  of  vertebra  (where 
there  is  also  generally  a slow  evolution  of 
paralytic  symptoms),  must  be  based  in  part 
upon  the  absence  of  any  evidence  of  vertebral 
disease.  The  diagnosis  from  meningeal  tumours 
has  already  been  referred  to  under  the  head  cf 
symptoms  ; and  so  also  has  the  diagnosis  from 


SPINAL  CUED.  SPECIAL  DISEASES  OF.  1193 


mere  Bclerosis  of  the  spinal  cord,  in  which  the 
connective-tissue  overgrowth  is  not  sufficiently 
bulky  to  amount  to  an  actual  tumour. 

If  the  arrival  at  a diagnosis  as  to  the  existence 
of  a tumour  of  the  spinal  cord  is  a process 
beset  with  difficulties,  these  by  do  means  cease 
when,  passing  from  the  primary,  we  have  to 
approach  the  secondary  question  as  to  the  nature 
of  the  growth  presumed  to  exist.  Put  little  is 
possible  in  this  direction.  It  is  true  that,  with 
a history  of  pre-existing  syphilis,  even  without 
the  evidence  of  other  simultaneous  manifesta- 
tions, we  should  be  warranted  in  assuming  it 
to  be  even  more  than  possible  that  an  existing 
growth  was  syphilitic  in  nature,  and  in  treating 
the  patient  accordingly ; and  that  all  the  more 
because  this  is  about  the  only  kind  of  new-growth 
as  to  which  we  have  distinct  evidence  of  its 
amenability  to  the  influence  of  remedies.  The 
presumptions  in  favour  of  the  tubercular  or 
scrofulous  nature  of  a supposed  new-growth  in 
the  spinal  cord,  would  rarely  carry  with  them 
more  than  a moderate  amount  of  cogency.  Still, 
occasionally  the  general  habit  of  the  patient, 
together  with  the  fact  of  the  existence  of  scro- 
fulous enlargement  of  glands,  or  of  some  forms 
of  phthisis,  might  give  more  or  less  probability 
to  such  a conclusion.  Beyond  this  not  much  can 
be  done  in  the  way  of  diagnosing  special  kinds  of 
tumours.  We  might  be  guided  in  our  opinion 
as  to  the  possible  existence  of  a sarcoma  by  the 
presence  of  one  or  more  of  such  growths  in 
other  parts  of  the  body ; or  failing  this,  we  may 
recollect  that  primary  cancer  affecting  the  spinal 
cord  is  almost  unknown,  and  that  gliomat.ous 
tumours  are,  next  to  the  tubercular  or  scrofu- 
lous, those  which  are  most  frequently  met  with 
in  the  cord  itself. 

Prognosis. — The  prognosis  in  all  these  cases 
is  bad.  Life,  it  is  true,  may  last  for  months  or 
even  years,  but  the  tendency  is  for  the  primary 
affection  to  set  up  other  secondary  accidents,  in 
the  form  either  of  haemorrhage  or  of  softening. 
Thus,  paralysis  is  rendered  more  complete,  and 
the  way  is  paved  for  an  ultimate  fatal  termi- 
nation, through  the  intervention  of  cystitis  and 
renal  mischief;  by  way  of  bed-sores  with  ex- 
haustion and  blood-poisoning  ; or  by  extension  of 
softening  upwards  to  the  cervical  region  and  the 
supervention  of  respiratory  paralysis. 

Treatment. — In  the  case  of  the  existence  of 
a syphilitic  tumour  in  the  spinal  cord,  we  may 
attempt  (and  with  some  expectation  of  success) 
to  treat  the  causal  morbid  condition  with  large 
doses  of  iodide  of  potassium,  either  alone  or  in 
combination  with  bichloride  of  mercury.  But  in 
almost  all  other  cases  little  can  be  done  in  this 
direction,  and  we  are  reduced  to  the  necessity  of 
dealing  with  the  paraplegic  state,  and  its  atten- 
dant conditions,  as  best  we  can,  and  also  of  at- 
tending to  the  general  health,  with  the  view  of 
arresting  the  progress  of  the  disease,  and  keep- 
ing its  possible  complications  in  check.  See 
section  on  Treatment,  in  Spinal  Cord,  Soften- 
ing of. 

21.  Spinal  Cord,  Malformations  of. — Va- 
rious conditions  are  comprised  under  this  head 
which  are  of  little  or  no  interest  to  the  practi- 
tioner. Tho  spinal  cord  may  be  absent,  imper- 


fectly developed,  or  double.  Again,  cases  occur  in 
which  the  spinal  cord  is  either  unduly  long  or 
unduly  short,  or  in  which  it  may  present  some 
trifling  lack  of  symmetry.  One  of  the  most  in- 
teresting of  these  latter  conditions  is  due  to  the 
fact  recently  discovered  by  Flechsig  of  the  pos- 
sible non-uniform  distribution  of  the  pyramidal 
tracts  upon  the  two  sides  of  the  cord,  so  that 
the  amount  of  decussation  of  the  motor  fibres, 
not  only  in  different  individuals  but  also  in  the 
two  halves  of  the  same  cord,  may  be  quite  un- 
equal. In  the  latter  case  an  asymmetrical  de- 
velopment of  the  antero-latoral  columns  on  ths 
two  sides  would  be  met  with. 

Congenital  dilatation  of  the  central  canal  oj 
the  Spinal  Cord  ( Hydrcrrachis  interna , or  Hydro* 
myelus),  though  an  interesting  pathological  con- 
dition, does  not  reveal  itself  by  any  distinct 
symptoms  during  life. 

Confusion  is,  however,  apt  to  arise  between 
this  mere  unimportant  congenital  anomaly,  and 
the  existence  of  cavities  in  various  parts  of  the 
grey  matter  of  the  cord,  more  or  less  centrally 
situated,  which  are  to  be  regarded  as  remainders 
or  products  of  some  pre-existing  pathological 
changes.  These  latter  conditions  have  received 
much  attention,  and  the  various  forms  have  been 
described  under  the  name,  originally  given  by 
Ollivier,  of  1 Syringomyelia.’  Here,  again,  we 
have  to  do  with  matters  of  exclusively  patholo- 
gical interest. 

Congenital  dilatation  of  the  central  canal  in 
its  most  developed  form  is  apt  to  be  connected 
with  spina  bifida.  See  Spina  Bifida. 

II.  Diseases  of  the  Spinal  Cord  depen- 
dent upon  Unknown,  or  very  imperfectly* 
known,  Organic  Changes. 

22.  Tetanus.  See  Tetanus. 

23'.  Tetany.  See  Tetanv. 

24.  Torticollis.  See  Wry-Neck. 

25.  Writer’s  Cramp,  &c.  See  “Writer’s 
Cramp. 

26.  Spinal  Irritation.  See  Spinal  Irrita- 
tion. 

27.  Keflex  Paraplegia.  Synon.  : Urinary 
Paraplegia  (in  part);  Fr  .Paroplegie  reflexe ; 
Paraplegie  fonctionnelle ; Ger.  Reflex  Paralysis 
spinalis. 

General  Eemarks. — Some  practitioners  be- 
lieve that  paralyses  of  various  kinds  are  brought 
about  purely  by  reflex  influences.  They  would 
include  under  this  category  some  of  the  cases  of 
paralysis  of  separate  muscles,  such  as  the  ocular ; 
some  cases  of  paralysis  of  one  or  both  arms  ; or 
some  of  the  cases  of  paralysis  of  one  or  both 
lower  extremities.  It  is  the  latter  class  of  cases 
with  which  we  are  now  specially  concerned, 
though  much  of  what  is  to  be  said  in  the 
present  article  may,  mutatis  mutandis , be  consi- 
dered applicable  to  the  whole  class  of  so  called 
‘ reflex  paralyses.’ 

Those  who  believe  in  the  frequent  existence 
of  this  form  of  paralysis  are  considerably  less 
numerous  than  they  were  twenty  years  ago, 
when  the  notion  of  its  frequency  and  importance 
was  warmly  espoused  by  Brown-Sequard  ( Lccts , 
on  Paral.  of  Lower  Extremities,  1861),  and  when 


1496  SPINAL  COED,  SPECIAL  DISEASES  OF. 


the  morbid  anatomy  of  the  spinal  cord  was  still 
very  imperfectly  known.  The  number  of  com- 
petent observers  was  smaller,  whilst  the  difficulty 
in  detecting  morbid  changes  in  this  organ  was 
much  greater  then  than  it  is  now  that  we  are 
accustomed  to  employ  more  elaborate  methods 
for  its  preservation  and  for  its  examination.  Yet 
one  of  the  strongest  of  the  arguments  brought 
forward  in  favour  of  the  existence  of  ‘ reflex  para- 
plegia ’ was  the  absence  of  discovered  lesions  in 
the  spinal  cord  in  a class  of  cases  reported  upon 
by  Stanley  in  1833  (Med.-Ckir.  Trans.,  vol.  xviii. 
p.  260)  in  which  paraplegia  was  associated  with 
various  morbid  conditions  of  the  urinary  organs — 
cases,  in  fact,'  of  the  so-called  ‘ urinary  para- 
plegia.’ And  the  main  support  for  the  opinions 
of  those  who  still  believe  in  the  existence  of  a 
class  of  reflex  paraplegias,  now  also  lies  in  the 
absence, in  certain  cases  of  paraplegia  terminating 
fatally,  of  any  actually-discovered  lesion. 

.Etiology  and  Pathogenesis.  — The  inter- 
pretation of  the  paralyses  of  this  class  put  for- 
ward by  Brown-Sequai'd  is  as  follows  : — That  an 
irritation,  operating  upon  certain  sensory  nerves, 
produces  impressions  which,  after  impinging 
upon  the  properly  related  grey  matter  in  the 
spinal  cord,  are  thence  in  part  reflected  aloDg 
vuso-motor  nerves  regulating  the  calibre  of  cer- 
tain blood-vessels  which  supply  either  (a)  the 
portion  of  the  spinal  cord  in  relation  with 
the  paralysed  parts,  or  else  ( b ) the  great  nerves 
or  the  muscles  themselves  of  the  paralysed 
parts.  In  either  case  this  reflection  of  impres- 
sions resulting  from  irritation  of  sensory  nerves, 
upon  such  special  groups  of  vaso-motor  nerves, 
is  supposed  to  lead  to  a persistent  spasm  of  the 
vessels  which  they  innervate,  so  as  to  cause  a 
continuous  anaemic  condition,  either  of  certain 
vascular  territories  in  the  spinal  cord  itself,  or 
else  of  the  related  nerve-trunks  and  muscles.  In 
either  case,  too,  the  nutrition  of  the  parts  involved 
in  this  anaemia  is  supposed  to  suffer — so  that  their 
functions  can  no  longer  be  carried  on  or  only  in 
a very  imperfect  manner — and  thus  a more  or 
less  complete  paralysis  results,  which  is  capable, 
however,  of  being  mitigated  from  time  to  time, 
ot  actually  intermitting,  or  indeed  of  being  ab- 
ruptly cured,  according  as  temporary  diminutions 
or  a complete  disappearance  of  the  original  ex- 
citing cause  may  lead  to  a diminution  or  to  an 
actual  cessation  of  the  supposed  profound  anaemia 
produced  by  the  supposed  spasms  of  vessels. 
These  are  the  theories  upon  which  the  doctrines 
of  ‘ reflex  paraplegia  ’ are  based. 

Among  the  sources  from  which  the  initial  irri- 
tation is  supposed  to  proceed,  almost  all  parts 
of  the  body,  internal  as  well  as  external,  are 
included.  Thus  irritative  impressions,  it  is 
thought,  may  emanate  from  almost  any  part 
of  the  urinary  tract— from  the  urethra  to  the 
kidney  ; in  other  cases  similar  impressions  may 
emanate  from  some  portion  of  the  female  genital 
organs;  in  others  from  the  intestinal  canal, 
owing  to  the  presence  of  worms  or  some  such 
persistent  causes  of  irritation;  in  others  from 
some  portion  of  the  thoraoic  organs ; or,  as  it 
seems  to  be  held,  from  irritated  sensitive  nerves 
in  almost  any  part  of  the  body,  whether  situated 
near  the  surface  or  deep  amongst  the  tissues. 

The  assemblage  of  symptoms  supposed  to  cha- 


racterise these  forms  of  reflex  paralysis  presents 
nothing  like  a distinctive  mode  of  grouping.  And 
of  the  several  components  of  the  group  put  for- 
ward by  Brown-Sequard  in  1861  ( loc . cit.,  p.  33), 
as  pertaining  to  one  of  the  most  typical  varieties, 
viz.,  ‘ urinary  paraplegia,’  none  can  now  have  any 
pretensions  to  be  regarded  as  distinctive,  except- 
ing the  alleged  tendency  of  the  paralysis  to  vary 
in  degree  with  variations  in  the  malady  on  which 
it  is  supposed  to  depend,  together  with  its  ten- 
dency to  spontaneous  or  easy  cure  coincidentally 
with  or  soon  after  the  cessation  of  the  urinary 
troubles,  whatever  they  may  have  1 een.  In 
harmony  with  this  latter  character  also  are  the 
alleged  facts  that  speedy  cures  have  been  brought 
about  of  eases  of  paraplegia,  especially  in  chil- 
dren, after  the  expulsion  from  the  alimentary 
canal  of  tape- worms  or  round-worms ; or,  of 
cures  of  the  same  disease  in  adult  females  after 
the  cessation  of  some  uterine  inflammation;  or 
of  cures  of  a paralysis  of  ocular  muscles  after 
the  removal  of  some  carious  tooth  which  had 
previously  been  exercising  an  irritative  influence 
upon  branches  of  the  dental  nerve. 

It  would  be  improper  and  useless  to  deny  the 
existence  of  such  eases  ; they  are  theoretically 
possible.  On  the  other  hand,  the  writer  is  com- 
pelled to  believe,  after  a very  extensive  expe- 
rience, that,  if  they  exist,  they  can  only  occur  as 
extremely  rare  events. 

Although  it  is  theoretically  possible  that  an 
irritation  of  a sensory  nerve  may  be  reflected  on 
vaso-motor  nerves,  so  as  to  lead  to  arterial  spasms 
in  certain  territories  of  the  spinal  cord  or  in  cer- 
tain groups  of  muscles,  neither  proof  nor  even 
analogy  exists  in  favour  of  the  view  that  such  a 
condition  of  spasm  could  be  maintained  for  days 
or  even  weeks.  Nor,  if  it  could  occur  for  these 
prolonged  periods,  and  to  such  an  extent  as  to 
annul  some  of  the  most  important  functions  of  the 
spinal  cord  during  this  time,  is  it  at  all  clear  that 
the  nutrition  of  the  cord  in  the  affected  regions 
would  not  he  seriously  interfered  with  by  such 
prolonged  anremia  ; and  if  so  the  assumed  speedy 
resumption  of  healthy  functions  after  the  disap- 
pearance of  the  vascular  spasms  would  constitute 
another  difficulty,  since  such  speedy  recovery 
would  be  incompatible  with  the  theory  upon 
which  the  explanation  of  the  disease  is  based. 

Again,  it  is  almost  certain  that  many  of  the 
eases  formerly  supposed  to  belong  to  this  cate- 
gory of  ‘ reflex  paralysis  ’ had  no  right  to  figure 
therein.  Cases  of  diphtheritic  paralysis  have 
been  proved  to  belong  to  a different  category; 
and  there  is  good  reason  to  believe  that  in  other 
instances  the.  morbid  conditions  really  existing 
as  causes  of  the  paralysis  have  simply  been  over- 
looked, either  because  the  appreciable  changes 
wore  only  slightly  advanced  at  the  time  of  the 
patient's  death,  owing  to  the  brief  duration  of 
the  illness,  or  because  of  the  want  of  a thorough 
examination  of  the  cord,  conducted  with  all  need- 
ful aids,  care,  and  expenditure  of  time. 

It  seems  clear,  therefore,  that  the  opinions  of 
those  who  believe  in  the  existence  of  ‘ reflex  para- 
lysis,’ and  of  ‘reflex  paraplegia’  in  particular, 
stand  much  in  need  of  farther  support.  Well- 
observed  and  well-recorded  instances  of  the 
disease  are  urgently  wanted,  if  reflex  paraplegia 
is  to  retain  its  elaim  to  a place  in  our  nosology. 


SPINAL  COED.  SPECIAL  DISEASES  OF.  1497 


28.  Intermittent  Paraplegia. — Synon.  : In- 
termittent Spinal  Paralysis-,  Fr.  Paralysie  Spinal 
Intermittente ; Ger.  Intermittizender  Paralysis 
Spinalis. — Very  few  cases  of  paraplegia  of  this 
type  have  been  recorded,  and  it  must  also  be  a 
condition  of  extreme  rarity. 

The  earliest  recorded  example  was  made 
known  by  Eomberg,  and  as  this,  both  in  its 
nature  and  its  course,  seems  to  have  been  a 
typical  instance,  it  may  be  cited  here.  ‘ A 
woman,  sixty-four  years  of  age,  after  being  quite 
well  the  day  before,  was  suddenly  attacked  with 
paralysis  of  the  lower  extremities  and  of  the 
sphincters.  Sensibility  was  unchanged,  conscious- 
ness clear,  the  temperature  cool,  pulse  80,  small 
and  empty,  no  pain  in  the  spinal  cord.  The 
next  day  there  was  an  astonishing  change  in  the 
condition.  The  patient  could  walk  again  and 
void  urine  voluntarily,  and  only  complained  of 
weakness  in  the  legs.  The  following  morning 
there  was  paraplegia  again,  which  had  set  in 
at  the  same  hour  as  it  had  done  two  days  before. 
A third  paroxysm  was  awaited,  which  also  set 
in  at  the  appointed  time,  although  without  para- 
lysis of  the  sphincters.  Quinine  effected  a rapid 
cure.’ 

Two  other  cases  are  cited  by  Erb.  In  one  of 
them  there  were  also  three  attacks  before  cure 
took  place  under  the  influence  of  quinine ; but  in 
the  other,  observed  by  Hartwig,  attacks  of  in- 
termittent paralysis  seem  to  have  gone  on  for 
many  months.  It  is  worthy  of  note  that  in  the 
two  former  cases  there  is  no  statement  that  the 
patient  had  previously  suffered  from  ague ; whilst 
in  that  of  Hartwig,  although  the  man  had  been 
afflicted  with  tertian  intermittent  fever  five  years 
previously, for  a few  weeks,  there  is  no  mention 
made  of  the  recurrence  of  any  other  symptoms  of 
this  type,  even  during  the  period  that  the  patient 
continued  subject  to  the  attacks  of  intermittent 
paraplegia. 

We  know  absolutely  nothing  as  to  the  real 
cause  or  intimate  pathology  of  such  attacks. 
Any  future  cases,  therefore,  deserve  to  be  ob- 
served and  recorded  with  the  greatest  care. 
Meanwhile  it  should  bo  remembered  that  the 
cases  already  observed  seem  to  have  proved  ex- 
tremely amenable  to  the  influence  of  quinine 
and  of  arsenic. 

29.  Hysterical  Paraplegia.  See  Hysteria. 

30.  Paraplegia  dependent  on  Idea. — Na- 
ture and  .ZEtiology. — This  is  a form  of  para- 
lysis, of  purely  ‘ functional  ’ type,  ccasionally 
occurring  in  neurotic  impressionable  persons, 
and  yet  not  dependent  upon  any  ordinary  hys- 
terical condition.  Attention  was  first  called  to 
such  cases  by  Dr.  Eussell  Eeynolds,  who  cited, 
amongst  others,  a typical  instance  in  which  a 
young  lady,  whilst  attending  to  a paraplegic 
father,  amidst  the  additional  anxieties  consequent 
upon  straitened  circumstances  and  the  fatigues 
incident  to  teaching  in  order  to  obtain  the  bare 
necessaries  of  life,  became  at  last,  under  the 
influence  of  long-continued  strain,  together  with 
an  abidi ng  fear  (inspired  by  actual  physical  weak- 
ness) that  she  herself  was  becoming  paralysed, 
reduced  de  facto  to  this  condition,  as  the  final 
outcome  of  a slowly-increasing  weakness  (see 
British  Medical  Journal,  November  6,  1869). 


Pathology. — Such  a condition  n.ay  occur  quite 
independently  of  hysteria,  and  be  just  as  free 
from  anything  like  conscious  simulation  or  de- 
sire to  exaggerate.  We  cannot  say  positively 
that  the  state  is  induced  by  what  is  called  ‘inhibi- 
tion,’ or  by  definite  vascular  spasms  such  as  are 
supposed  to  form  one  of  the  pathological  bases  of 
the  class  of  so-called  ‘ reflex  ’ paralyses,  and  yet 
both  these  modifying  influences  over  the  func- 
tional activity  of  the  spinal  cord  may  be  in  part 
operative  when  imagination,  continuously  excited 
in  some  one  direction,  has  a tendency  to  pervert 
the  functional  activity  of  this  portion  of  the 
nervous  system. 

The  same  conditions  that  exist  as  more  lasting 
states  in  these  cases,  probably  exist  temporarily, 
under  the  influence  of  suggestion,  in  hypnotised 
persons.  See  Magnetism,  Animal. 

Symptoms. — There  is  a paralysis  of  motion 
in  the  lower  extremities,  more  or  less  complete, 
often  partial,  and  generally  without  implication 
of  sensibility.  There  is  unabated  control  over 
the  bladder  and  rectum. 

Dr.  Eeynolds  points  out  that,  while  such 
patients  may  be  wholly  incapable  of  lifting  a 
foot  from  the  bed,  they  often  find  themselves 
able  to  turn  or  sit  up  without  any  assistance. 
And  in  slighter  cases,  though  they  may  be  un- 
able to  stand  for  a moment,  such  patients  may 
yet  be  able  to  move  the  legs  in  any  direction 
while  in  the  recumbent  position. 

Diagnosis. — The  character  of  the  paralysis, 
and  its  limitation  in  range,  is  thought  to  be  of 
importance.  But  still  more  important  is  the  esta- 
blishment of  the  fact  of  the  pre-exislence  of  long- 
continued  fears  or  fancies  (in  a person  of  deli- 
cate or  neurotic  temperament),  of  such  a nature 
as  to  be  in  accordance  with  the  patient’s  now- 
present  condition,  combined  with  the  absence 
of  all  signs  positively  indicative  of  any  struc- 
tural defect  in  the  spinal  cord. 

Where  such  a condition  exists  (as  it  may) 
as  a mere  complication  of  an  actually  existing 
structural  disease,  the  diagnosis  becomes  either 
impossible  or  extremely  difficult.  It  is,  iu  fact, 
only  possible  after  prolonged  observation  and 
experience  as  to  the  course  of  the  symptoms. 

Prognosis. — The  prognosis  is  extremely  good 
if  the  nature  of  the  malady  be  divined,  and  a 
right  course  of  treatment  adopted.  Under  such 
circumstances,  an  almost  complete  cure  may 
easily  be  brought  about  in  a week  or  ten  days  ; 
but,  failing  this  recognition,  the  morbid  condi- 
tion, may,  it  is  said,  under  ordinary  treatment, 
persist  for  an  almost  unlimited  period. 

Treatment. — The  practitioner  must  inspire 
the  patient  with  confidence  that  the  malady  is 
curable,  and  surround  her  (or  him)  with  cheer- 
ful, hope-inspiring  attendants  and  influences.  At 
the  same  time,  with  the  view  of  supporting  her 
confidence  (if  for  no  other  reason),  he  should 
faradise  the  muscles  of  the  apparently  paralysed 
limbs  daily,  or  have  recourse  to  frictions  or 
shampooings  combined  with  passive  movements. 
He  must  make  the  patient  attempt  to  stand  or 
walk,  with  the  necessary  support ; administer 
opiates,  or  bromide  of  potassium  with  chloral,  to 
procure  sleep,  if  necessary ; and  carefully  seek  to 
restore  the  patient’s  general  health  and  nutri- 
tion. In  this  class  of  cases  especially,  it  would 


1498  SPINAL  COED,  SPECIAL  DISEASES  OF. 


seem  probable  that  the  influence  of  ‘suggestion,’ 
if  hypnotism  could  be  induced  according  to 
Braid’s  method,  might  be  capable  of  producing 
an  almost  immediate  cure.  See  Beaidism. 

31.  neurasthenia  Spinalis. — Synon.  : Func- 
tional Nervous  Weakness  of  the  Spinal  Cord. 

Nature  and  FEtiology. — Under  this  name, 
descriptions  have  been  given  of  a combination 
of  symptoms  not  unfrequently  met  with  in 
males  as  well  as  females,  but  more  especially  in 
the  former.  They  are  supposed  to  represent  a 
condition  of  extreme  nervous  debility,  coming 
on  obscurely,  or  at  all  events  not  as  a sequence 
of  some  previous  severe  illness  or  shock.  Still 
the  symptoms  met  with  often  approximate 
closely  to  those  pertaining  to  a state  of  con- 
valescence from  some  serious  febrile  illness ; and 
are  not  at  all  unlike  some  of  those  which  may 
follow  concussion  of  the  spinal  cord. 

Such  symptoms  when  occurring  independently 
are  most  prone  to  show  themselves  in  those  who 
are  naturally  of  a neurotic  temperament.  They 
may  be  excited  by  over-fatigue  of  various  kinds, 
especially  when  this  has  been  coupled  with  dis- 
turbed sleep  for  some  time.  Prolonged  exercise 
cr  over  mental  work  may  have  been  the  particular 
exciting  causes  of  fatigue;  though  perhaps  much 
more  frequently  this  is  to  be  found  in  sexual 
excesses  (of  a natural  or  unnatural  order),  either 
extending  in  the  form  of  habitual  indulgence 
over  a considerable  period,  or  as  more  isolated 
but  marked  excesses.  At  other  times,  symptoms 
of  neurasthenia  spinalis  set  in  without  obvious 
provocatives  of  either  type. 

Pathology. — Concerning  the  actual  cause  of 
spinal  neurasthenia  little  or  nothing  can  be  said. 
Sometimes  there  may  be  the  co-existence  of  dis- 
tinct cerebral  symptoms  of  an  analogous  type ; 
though  on  other  occasions  the  symptoms  are 
more  purely  spinal.  This  malady  is  perhaps 
capable  of  being  induced  by  mere  altered  mole- 
cular states  and  actions  of  the  tissue-elements 
of  the  spinal  cord.  A kind  of  persistent  ‘fatigue 
condition  ’ exists,  so  that  their  nutrition  cannot 
bo  properly  maintained.  Although  some  may 
imagine  the  existence  of  some  more  than  usually' 
antemic  condition  of  the  spinal  cord,  of  this,  as  a 
fact,  there  is  no  evidence.  To  speculate  upon 
other  modes  in  which  such  a set  of  symptoms 
might  be  brought  about,  would  in  the  present 
state  of  our  knowledge  be  of  little  service.  There 
is,  however,  the  possibility- that  this  morbid  con- 
dition may  be  due  in  the  main  to  a functional 
disease  of  the  cerebellum— especially  if  the  views 
of  Eolando,  Luvs,  and  others,  as  to  the  functions 
of  this  great  organ,  should  prove  correct  even  in 
part. 

Symptoms. — A feeling  of  utter  weakness  and 
prostration  induced  by  even  the  smallest  amount 
of  muscular  exertion,  is  the  central  symptom, 
though  this  is  usually  associated  with  coldness, 
and  more  or  less  numbness  of  the  extremities. 
Pains,  too,  may  be  felt  in  the  muscles  of  the 
limbs  and  in  some  parts  of  the  back,  though 
there  is  commonly  no  tenderness  over  any  part 
of  the  spine.  These  symptoms  may  be  unusu- 
ally distinct  after  any  activity  of  the  genital 
function,  and  they  may  then  be  associated  with 
extreme  wakefulness,  or  sometimes  with  pro- 


tracted inability  to  sleep.  Occasionally,  and 
especially  when  this  latter  symptom  is  not 
present,  the  patients  may  present  a florid  and 
fairly  healthy  appearance,  strangely  at  variance 
with  the  extreme  debility  complained  of. 

Diagnosis. — The  points  of  greatest  impor- 
tance are  the  existence  of  extreme  weakness, 
with  no  evidence  of  anything  like  actual  para- 
lysis, or  indeed  of  any  symptoms  which  would 
indicate  an  actual  structural  disease  of  the  spinal 
cord.  This  being  so,  and  diabetes  being  also 
eliminated,  we  may  oftentimes  (and  especially 
where  the  existence  of  one  or  other  of  the  above- 
mentioned  exciting  causes  has  been  established) 
pretty  confidently  conclude  that  we  have  to  deal 
with  what  is  here  named  ‘neurasthenia  spinalis.’ 

Prognosis. — A relief  of  this  condition  is  ulti- 
mately to  be  looked  for  under  the  influence  of 
rest  aDd  suitable  treatment ; but  in  regard  to  the 
rapidity  with  which  any  such  amelioration  of 
the  patient’s  symptoms  is  to  be  brought  about, 
great  differences  exist  in  different  cases.  Weeks, 
months,  or  even  years  may  be  required  before 
a natural  amount  of  vigour  is  restored. 

Treatment. — Eest,  especially  in  the  direction 
of  previous  excesses,  is  the  first  and  indispen- 
sable requisite.  Every  effort  should  be  used  to 
obtain  regular  and  sound  sleep.  The  action  of 
these  potent  restoratives  should  he  supplemented 
by  a generous  and  easily  assimilable  diet,  to- 
gether with  a moderate  amount  of  stimulants. 
Ilypophosphites  of  the  alkalies  with  iron  and 
small  doses  of  strychnia  (which  may  be  con- 
veniently given  in  the  form  of  a syrup)  often 
prove  decidedly  beneficial.  An  abundance  of 
fresh  air  is  desirable,  and  especially  that  of  ele- 
vated and  bracing  mountain  situations.  Daily- 
frictions  and  shampooing,  aided  by  stimulating 
saline  baths,  may  also  prove  to  be  of  much 
use. 

32.  Toxic  Spinal  Paralysis. — Under  this 
name  it  will  be  right  to  refer  to  a class  of  cases 
of  paraplegia  produced  by  poisons  of  various 
kinds.  It  constitutes  a somewhat  heterogeneous 
group,  concerning  which  our  knowledge  is  still 
very  defective — in  the  main,  because  such  cases 
are  happily  of  rare  occurrence. 

Of  the  toxic  agents  taken  into  the  body,  and 
capable  of  entailing  a paraplegia,  some  are 
minerals,  such  as  arsenic  and  lead ; others  are 
of  vegetable  origin,  such  as  aconitia,  conia, 
veratria,  prussic  acid,  ergot,  and  alcohol ; whilst 
others  again  are  of  animal  origin.  In  the 
majority  of  cases,  their  action  as  ‘causes’  is  not 
sufficiently  potent  to  lead  to  paralysis  as  any- 
thing like  an  invariable  effect.  They  need  the 
concurrence  of  other  favouring  circumstances, 
probably  in  the  main  intrinsic  ; but  under  the 
combination  of  conditions  thus  resulting,  a para- 
plegia may  be  induced — in  actual  modes,  how- 
ever, that  may  differ  considerably7  among  them- 
selves. It  is  only  in  this  attenuated  sense  that 
the  above-mentioned  poisons  are  to  be  regarded 
as  ‘causes’  of  paraplegia.  They  ought  perhaps, 
from  this  point  of  view,  to  he  considered  as  pre- 
disposing rather  than  as  exciting,  and  in  no  case 
as  proximate,  causes  of  paraplegia. 

This  holds  good,  for  all  that  we  know,  con- 
cerning the  fitful  and  irregular  manner  in  which 


SPINAL  COED,  DISEASES  OF. 
arsenic,  lead,  or  alcohol  (and  probably  to  a simi- 
lar extent  other  toxic  substances)  give  rise  to 
paraplegic  symptoms  in  those  who  have  taken 
them  to  excess.  Thus,  according  to  Tanquerel 
des  Planches,  out  of  200  cases  of  lead-poisoning, 
ia  only  fifteen  did  the  paralysis  implicate  the 
lower  extremities  ; and  in  only  one  of  these  did 
it  occur  as  a distinct  paraplegia.  This  case 
might,  therefore,  have  been  due  to  a fortuitous 
combination  of  conditions — in  short,  it  might 
have  been  a coincidence  rather  than  a definite 
result  of  the  taking  of  lead.  Again,  in  regard 
to  arsenic,  it  is  true  that  in  certain  cases  Orfila 
observed  paraplegic  conditions  in  dogs  which 
had  taken  large  quantities  of  this  drug  ; but 
such  symptoms  would  seem  to  be  met  with 
only  occasionally  as  a result  of  acute  arsenical 
poisoning  in  man,  and  perhaps  with  equal 
rarity  in  those  who  habitually  consume  large 
quantities  of  this  substance. 

Probably  the  mode  of  action  of  alcohol  as  a 
cause  of  paraplegia  is  very  nearly  as  general 
and  ill-defined,  yet  Dr.  Wilks  goes  so  far  as  to 
speak  of  an  ‘alcoholic  paraplegia,’  resulting  from 
excesses  in  spirit-drinking.  Alcohol,  like  many 
poisons,  when  taken  in  undue  quantity,  may 
deteriorate  the  nutrition  of  the  body  generally; 
it  may  spoil  the  integrity  of  its  more  delicate 
tissues,  and  thus  interfere  with  the  discharge  of 
some  of  its  finer  functions.  In  this  way,  through 
general  spoiling  and  degeneration,  the  way  may 
be  led  on  to  the  development  of  special  changes 
favouring  paralysis,  now  in  this  and  now  in 
that  part  of  the  nervous  system.  If  either  one 
of  a group  of  possible  morbid  changes,  induced 
upon  such  a basis,  chances  to  affect  principally 
the  lower  part  of  the  spinal  cord,  a paraplegia 
may  be  induced.  The  principal  justification, 
however,  for  speaking  of  such  a state  as  an 
‘alcoholic  paraplegia,’ probably  lies  in  the  fact 
that  here  (as  indeed  in  all  cases  of  toxic  para- 
lysis) the  first  therapeutic  indication  is  to  be 
found  in  the  renunciation  of  the  harmful  agent. 

The  notion  has  recently  been  advanced  by 
Moxon,  that  a certain  class  of  poisons,  which 
own  the  common  property  of  being  ‘ depres- 
sants of  the  circulation,’  have  a tendency  to 
paralyse  the  hind  legs  rather  than  the  fore  legs 
of  animals.  In  this  group  are  included  aconitia, 
conia,  and — doubtfully — veratria,  chloral,  and 
prussic  acid.  He  is  of  opinion  that  these  drugs 
act  by  causing  further  impediments  ‘ to  the  ex- 
ceedingly and  peculiarly  difficult  blood-supply  of 
the  caudal  end  of  the  spinal  cord’  ( British  Medi- 
cal Journal , April  2,'  1SS1,  p.  498).  It  should  be 
borne  in  mind  that  extreme  feebleness  of  blood- 
current  is  of  itself  a common  cause  predisposing 
to  the  occurrence  of  thrombosis  both  in  arteries 
and  in  veins,  and  that  such  a condition  may 
intervene  in  some  of  these  cases  of  poisoning, 
and  lead  to  the  development  of  paraplegia.  This 
would  enable  us  to  account  for  the  otherwise 
inexplicable  fact  of  the  maintenance  of  the  para- 
lysis long  after  other  effects  of  the  poison  have 
passed  away.  H.  Charlton  Bastian, 

SPINAL  IRRITATION".  — Syxon.  ; Ra- 
thialgia  ; Fr.  Rackialgie  ; Ger.  R'uckgratschnicrz . 

Definition. — Notwithstanding  the  doubts  that 
have  been  entertained  by  many  authorities,  both 


SPINAL  IRRITATION.  1499 

British  and  foreign,  spinal  irritation  is  an  affec- 
tion which  has  a real  existence  and  deserves  a 
special  name.  Although  spinal  irritation  maybe, 
like  other  affections,  allied  with,  or  caused  by, 
various  organic  or  functional  nervous  diseases, 
the  name  ought  to  be  kept  for  a special  spinal 
complaint,  chiefly  characterised  by  a morbid 
excitability  of  the  sensitive  nerves  of  the  spine, 
manifesting  itself  by  spontaneous  pains,  and  by 
tenderness  under  pressure,  or  when  the  affected 
parts  are  moved. 

AEtiology. — Rachialgia  is  more  common  in 
certain  countries  than  in  others— more  so,  par- 
ticularly, in  Great  Britain,  Ireland,  and  the 
United  States  than  in  Continental  Europe.  This 
probably  accounts  for  the  fact  that  this  affection 
was  first  studied  and  described  by  a number  of 
Irish  and  American  writers.  Sex  is  an  impor- 
tant setiological  element : out  of  304  cases  col- 
lected by  the  two  Griffins  and  by  Hammond, 
there  were  only  forty-two  men.  The  writer  has 
seen  it  in  three  men  only  out  of  more  than  fifty 
cases.  It  occurs  chiefly  in  girls  between  fifteen 
and  twenty-five.  As  regards  other  causes  the 
most  important  are: — excessive  walking  or  driv- 
ing; violent  movements  of  the  spine,  or  a blow 
upon  it;  abuse  of  sexual  intercourse  ; masturba- 
tion ; and  severe  diseases,  such  as  typhoid  fever, 
scarlatina,  fever  and  ague,  dysentery,  and  diph- 
theria. 

Anatomical  Characters  and  Pathology. — 
In  simple  rachialgia  there  is  no  organic  altera- 
tion that  the  naked  eye  can  see,  or  the  microscope 
can  show.  At  most  a congestion  is  sometimes 
found.  Still  organic  affections  of  the  spine  and 
its  fibrous  tissues  may  give  rise  to  the  functional 
affection  we  are  now  studying,  so  that  a necropsy 
may  show  pathological  alterations  of  various 
kinds  in  the  fibrous  and  bony  tissues  of  the 
spine.  As  regards  the  physiological  pathology 
of  spinal  irritation,  the  symptoms  belong  to  two 
distinct  groups,  one  composed  of  local  morbid 
manifestations,  and  the  other  of  those  which  are 
distant.  As  regards  the  first  of  these  groups,  it  in- 
cludes.tenderness  and  the  various  kinds  of  pain  ; 
there  is,  in  a measure,  similitude  between  the 
symptoms  and  those  of  neuralgia.  The  tender- 
ness especially  is  often  similar  to  that  which  is 
detected  in  some  points  of  a nerve  attacked  with 
neuralgia.  Still  there  are  differences  (especially 
as  regards  the  kinds  of  pain)  which  prevent  a 
complete  assimilation  of  rachialgia  with  a com- 
mon neuralgia.  The  group  of  symptoms  appear- 
ing at  a distance  from  the  spine,  is  composed  of 
reflex  or  direct  effects  of  irritation  of  the  spinal 
nerves.  Among  these  symptoms  we  find  referred 
sensations,  muscular  spasms,  increased  tonicity, 
contraction  of  blood-vessels,  trembling,  altera- 
tions of  secretion  and  nutrition,  inhibition  of  the 
heart,  &c. 

Dr.  Quain  communicates  to  the  writer  his  con- 
viction that  spina]  pain  and  tenderness  exist  more 
often  as  transmitted  or  referred  phenomena  con- 
nected with  morbid  states  of  the  mucous  mem- 
brane than  is  generally  recognised.  Thus  he  finds 
pain  present  over  the  posterior  cervical  region 
in  cases  of  congestion  or  follicular  disease  of  the 
mucous  membrane  of  the  pharynx  and  adjacent 
parts.  In  the  dorsal  region  the  like  pains  and 
tenderness  are  constantly  found  in  cases  of  gas- 


SPINAL  IRRITATION. 


1500 

trodynia,  associated,  it  may  be,  with  morbid 
states  of  the  mucous  membrane  of  the  stomach. 
In  the  lumbar  and  sacral  regions  similar  condi- 
tions are  traceable  in  connexion  with  disordered 
states  of  the  mucous  membrane  of  the  intestines, 
or  of  the  urinary  and  genital  organs.  As  we  find 
extreme  sensitiveness  of  the  retina  in  cases  of 
disease  of  the  conjunctiva — or  as  we  find  pain 
at  the  end  of  the  penis  in  cases  of  stone  in  the 
bladder — so  may  we  have  many  of  these  other 
reflex  or  referred  troubles  in  connection  with 
distant  disorders. 

Symptoms. — Spinal  tendcmesi. — This  is  the 
essential  and  only  constant  feature  of  rachialgia. 
Its  existence,  however,  might  not  he  found  out 
if  questions  were  merely  asked,  or  a cursory 
examination  were  made,  as  the  symptom  may 
be  slight  and  localised  in  one  vertebra,  and  the 
patient  may  not  he  aware  of  its  presence.  It 
may  be  found  in  any  part  of  the  spine,  and  cor- 
respond to  only  one,  to  many,  or  even  to  all  of 
the  vertehrse.  "When  very  limited,  tenderness 
exists  more  frequently  at  the  lower  part  of  either 
the  dorsal  or  the  cervical  regions,  less  often  in 
the  latter.  The  symptom  is  elicited  in  two  ways 
— by  pressure  or  movement.  "When  the  ten- 
derness is  slight,  pressure  will  succeed  in  show- 
ing its  existence,  while  a movement  might  prove 
ineffectual.  It  is  essential  to  he  extremely  cau- 
tious in  making  pressure,  as  not  only  a consider- 
able and  lasting  pain  may  result  from  sudden 
and  great  pressure,  hut  very  serious  convulsive 
paralytic  or  psychic  manifestations  may  be  pro- 
duced. The  writer  has  seen  cases  in  which 
attacks  of  catalepsy,  of  tonic,  clonic,  or  choreic 
movements,  of  temporary  (and  in  one  case  of 
prolonged)  paralysis  of  the  lower  or  upper  limbs, 
of  exophthalmos  with  mental  disorder,  &c.,  had 
been  caused  by  heavy  pressure  on  the  cervical  or 
dorsal  vertebrae.  Usually  the  place  where  pres- 
sure gives  rise  to  the  greatest  pain  is  the  spi- 
nous process.  Sometimes,  however,  the  disorder 
is  unilateral,  and  then  the  seat  of  greatest  tender- 
ness is  the  transverse  process.  Very  frequently 
myalgia  co-exists  with  rachialgia,  and  then  the 
muscular  masses  so  attacked,  on  one  or  on  the 
two  sides  of  the  spine,  are  very  tender  under 
pressure.  There  is  often  hyperaesthesia  of  the 
6kin  itself,  and  the  writer  found  this  so  great  in 
one  case  that  any  unexpected  touch,  or  even 
a gentle  breath  of  air  on  the  skin,  made  the 
patient  (a  strong  and  courageous  man)  scream 
out.  The  tactile  hyperaesthesia  in  that  case  was 
so  great  that  the  two  points  of  the  aesthesiometer, 
which  on  the  spine  are  felt  by  a healthy  person 
only  when  distant  one  from  the  other  at  least  an 
inch  and  a half,  were  distinctly  recognised  when 
distant  less  than  a line,  that  is,  when  almost 
touching  each  other.  In  a number  of  cases  sensi- 
bility is  morbidly  increased  in  every  nerve-fibre 
of  all  the  tissues  of  one  or  more  vertebrae  and 
of  the  neighbouring  parts.  There  is  no  absolute 
relation  between  the  pain  caused  by  pressure 
and  the  constant  spontaneous  pain  existing  in 
many  cases,  as  there  may  he  considerable  ten- 
derness without  any,  or  with  very  little,  spon- 
taneous pain,  and  there  may  he  only  moderate 
tenderness  although  a constant  or  almost  con- 
stant severe  pain  is  complained  of. 

Tenderness  is  often  discovered  by  movement 


of  the  spine  performed  voluntarily  or  involun- 
tarily by  the  patient,  or  produced,  for  diagnosis’ 
sake,  by  the  physician.  Generally,  however,  the 
pain  thus  generated  is  somewhat  different  from 
that  due  to  pressure  on  the  spiuous  processes,  and 
is  chiefly,  if  not  only,  sn  increase  of  the  constant 
spontaneous  pain. 

Pains  referred  to  the  periphery  of  the  body, 
or  to  internal  otgans.  are  often  associated  with 
local  tenderness  developed  by  pressure.  These 
transmitted  pains,  as  well  as  the  local  pains 
caused  by  pressure,  may  last  for  hours — nay,  for 
days,  showing  how  carefully  the  examination  for 
tenderness  should  be  made.  It  is  well,  when  we 
have  to  deal  with  hysterical  or  timid  patients,  to 
judge  of  the  degree  of  tenderness  more  from  the 
sudden  and  involuntary  movement  of  the  spine, 
when  we  press  upon  it,  than  from  the  patient’s 
statements  as  regards  the  degree  of  local  or 
referred  pains  felt.  The  amount  of  blushing  of 
the  face  when  a tender  spine  is  pressed  upon,  is 
also  a means  of  appreciating  the  degree  of  ten- 
derness, especially  when  the  affected  part  is  in 
the  lower  third  of  the  cervical  region,  or  the 
upper  third  of  the  dorsal  region. 

Spontaneous  spinal  pain. — This  symptom  is 
less  important  than  tenderness,  because  it  is  not 
constant,  and  also  because  it  often  exists  in 
organic  spinal  complaints.  It  is  increased  in 
most  eases  by  pressure  on,  or  by  movement  of, 
the  spine.  According  to  Dr.  Hammond’s  obser- 
vation it  is  found  in  about  one  case  out  of  three 
of  spinal  irritation.  The  writer  believes  that 
its  frequency  is  much  greater.  It  is  quite  vari- 
able in  its  character  and  degree.  It  may  con- 
sist only  or  chiefly  in  a feeling  of  heaviness,  of 
coldness,  of  heat,  of  pricking,  or  of  itching.  In 
many  cases  it  increases,  and  in  some  it  de- 
creases, when  the  sitting  or  standing  posturo 
is  assumed.  Lying  flat  on  the  back  usually 
diminishes,  but  sometimes  increases  it.  Its  seat 
is  generally  at  the  point  where  the  spinal  nerves 
emerge  from  the  spine,  resembling  in  this  re- 
spect a neuralgic  pain. 

Visceral  functional  disturbances. — Rachialgia 
is  often  followed  or  accompanied  by  various  func- 
tional disorders,  more  or  less  directly  caused  by 
it.  The  stomach  and  the  heart  are  the  parts 
chiefly  affected ; but  other  viscera  (the  liver,  the 
kidneys,  or  the  bowels)  are  also  sometimes  af- 
fected. 

Vaso-mofor  disturbances. — These  may  appear 
anywhere,  but  the  face  exhibits  them  more  often 
and  more  intensely  than  other  parts.  They  con- 
sist chiefly  in  alternations  of  great  paleness  and 
flushing. 

'Motor  disturbances. — A fixed  contraction  of 
some  muscles,  especially  in  the  fore-arm,  has  beeu 
pointed  out  by  Mr.  Teals.  Dr.  C.  B.  Radcliffe 
says  that  this  contraction  does  not  disappear 
during  sleep.  This  slight  rigidity  increases 
when  an  effort  is  made  to  loosen  it,  A great 
variety  of  other  motor  disturbances  may  ap- 
pear in  this  affection,  as  will  be  mentioned  here- 
after. 

The  symptoms  of  rachialgia  necessarily  vary 
with  the  different  regions  of  the  spine. 

1.  Cervical  Region. — Spinal  irritation  in 
very  frequent  in  this  region,  although  less  so  than 
in  the  dorsal.  Of  301  cases  collected  by  the  two 


SPINAL  IRRITATION. 


Griffins,  and  by  Dr.  Hammond,  the  affection  was 
confined  to  the  cervical  region  71  times,  and  it 
occupied  parts  or  all  of  the  cervical  and  dorsal 
regions  in  82  cases.  More  than  elsewhere,  pres- 
sure on  the  spine,  when  the  disorder  is  in  the 
neck,  will  produce  referred  sensations.  For  in- 
stance, pressure  on  the  two  upper  vertebrae  may 
cause  pain  in  the  forehead;  pressure  on  the  third 
and  fourth  vertebra  a pain  in  the  pharynx ; and 
on  the  last  cervical  a pain  behind  the  sternum. 
According  to  the  best  observers,  especially  Still- 
ing and  the  two  Griffins,  the  following  symp- 
toms have  been  noticed  in  eases  of  cervical 
spinal  irritation:  vertigo,  headache,  psychical 
disturbances,  insomnia,  nightmare,  neuralgic 
pains  in  the  head,  face,  neck,  shoulders,  chest, 
and  upper  limbs,  contraction  of  flexor  muscles 
in  the  fore-arms,  clonic  spasms,  fibrillary  move- 
ments in  the  shoulders  and  arms,  disturbances 
in  phonation  and  deglutition,  dyspnoea,  spas- 
modic cough,  fainting,  and  palpitation  of  the 
heart. 

2.  Dorsal  Region. — This  is  the  region  most 
frequently  attacked,  although  the  united  statis- 
tics of  the  brothers  Griffin  and  Dr.  Hammond  do 
not  clearly  establish  this  point.  The  stomach  is 
the  principal  seat  of  disturbance  in  dorsal  rach- 
ialgia.  It  shows  its  irritation  by  pain,  pyrosis, 
eructations,  nausea,  and  vomiting.  Palpitation 
of  the  heart  is  not  rare  ; but  dyspnoea  and  cough 
are  less  frequent  than  in  cervical  rachialgia.  So 
are  neuralgic  pains,  involuntary  movements,  and 
tonic  spasms. 

3.  Lumbar  Region. — Rachialgia  is  rarely 
localised  in  the  lumbar  region.  Dr.  Hammond 
has  seen  it  fifteen  times,  and  the  two  Griffins 
thirteen  times.  The  writer  has  only  seen  it  four 
times  out  of  more  than  fifty  cases.  It  manifests 
itself  or  is  accompanied  by  the  following  symp- 
toms : neuralgia  in  the  lower  limbs,  myalgia  in 
the  lumbar  and  abdominal  regions,  painful  spasms 
of  the  vesical  or  anal  sphincters,  uterine  and 
ovarian  pains,  with  or  without  menstrual  dis- 
turbances, disorders  of  motility,  such  as  tonic  or 
choreic  movements  in  the  lower  limbs,  pseudo- 
paraplegia, &e. 

4.  General  Rachialgia. — It  is  assuredlyquite 
rare  to  find  every  vertebra  tender.  The  writer 
has  seen  it  but  twice.  But  it  is  not  so  rare 
to  find  cases  in  which  almost  every  part  of  the 
spine  is  affected.  The  two  Griffins  have  seen 
it  in  fifteen  cases  out  of  a hundred  and  forty- 
eight.  Hyperasthesia  is  then  usually  greater 
than  in  localised  rachialgia.  The  pains  produced 
even  by  the  gentlest  pressure  on  one  spinous 
process  usually  extend  to  the  whole  vertebral 
column.  The  various  symptoms  pointed  out  as 
due  to  localised  spinal  irritation  are  present  liere 
together,  and  show  themselves  in  the  four  limbs, 
the  head,  the  neck,  the  trunk,  and  the  internal 
organs— especially,  however,  in  the  heart  and 
the  stomach. 

Diagnosis. — The  symptoms  of  spinal  irrita- 
tion are  so  characteristic  that  it  is  only  in  cases 
of  complication  of  this  affection  with  another 
that  doubts  might  arise.  A sprain  of  the  spine, 
intense  congestion  of  the  cellular  tissue  and  of 
the  muscles,  and  inflammation  of  the  parts  close 
to  the  spine,  involving  the  fibrous  tissue  binding 
together  the  vertebra,  and  due  to  some  trau- 


1501 

matie  cause,  will  certainly  give  origin  to  the  local 
and  sympathetic  symptoms  of  spinal  irritation, 
together  with  those  due  to  inflammation  or  con- 
siderable congestion.  There  cannot  be  a mistake. 
Two  distinct  morbid  states,  then,  follow  a blow 
or  some  other  traumatic  agency  on  the  spine.  In 
the  same  way  we  find  hysteria  co-existing  with 
spinal  irritation.  Indeed,  it  is  extremely  rare  to 
find  that  hysteria,  beginning  by  any  symptom, 
will  not  soon  be  accompanied  by  some  degree  of 
spinal  irritation;  and,  on  the  other  hand,  in 
almost  all  cases  of  genuine  spinal  irritation, 
more  or  less  marked  hysterical  symptoms  will 
appear,  so  that  these  two  affections  almost,  always 
are,  at  least  partly,  blended  together.  The  sin- 
gular and  rare  affection  described  by  Trousseau 
under  the  name  of  tetany , can  hardly  be  mis 
taken  for  rachialgia,  not  only  because  the  most 
important  symptoms  of  spinal  irritation  are  ab- 
sent or  very  slight  in  tetany,  but  also  because 
in  this  last  aftection  the  muscular  contraction 
is  generally  accompanied  by  trembling,  anaes- 
thesia, and  a feeling  of  great  fatigue.  Tetanus, 
and  the  organic  affections  of  the  spinal  cord  and 
its  meninges  may  be  put  aside,  as  although  there 
may  be 'spinal  tenderness  in  some  of  those  affec- 
tions, especially  in  meningitis,  the  other  symp- 
toms clearly  establish  their  existence,  and  not 
that  of  mere  rachialgia.  The  same  may  be 
said  of  Pott's  disease,  or  other  morbid  structural 
alterations  of  the  vertebra. 

Prognosis. — It  is  impossible  to  agree  with 
those  physicians  who  take  a light  view  of  spinal 
irritation.  If  an  American  practitioner  has,  as 
he  states,  cured  133  patients  out  of  156,  he 
has  been  exceptionally  fortunate.  Although  a 
cure  can  often  be  obtained,  and  sometimes  very 
quickly,  this  affection,  when  at  all  powerful,  will 
frequently  resist  treatment,  or  reappear  after  a 
temporary  cure.  The  writer  would  say,  he,  rever, 
that  many  patients  refuse  to  submit  to  the  most 
energetic  means  of  treatment,  and  that,  there- 
fore, we  cannot  know  what  would  have  been 
their  fate  under  better  means  than  those  used. 
Still,  death  is  never  caused  in  a direct  way  by 
this  affection.  Its  worst  feature  is  that  it  ren- 
ders the  patient  most  miserable  from  pains,  weak- 
ness, and  the  various  functional  disorders  it  pro- 
duces. 

Treatment. — In  this  affection,  as  well  as  in  all 
functional  disorders,  anaemia  exists  so  frequently, 
and  participates  so  certainly  in  the  production,  or 
at  least  in  the  persistence,  of  the  symptoms,  that 
the  writer  can  easily  accept  the  statement  of 
some  physicians,  that  certain  remedies,  such  as 
iron,  quinine,  the  mineral  acids,  alcoholic  stimu- 
lants, cod-liver  oil,  arsenic,  andnux  vomica,  have 
been  used  successfully  against  rachialgia.  Indeed, 
some  of  these  means — one  or  another,  according 
to  special  circumstances — ought  almost  always 
to  be  used.  The  writer’s  own  experience  does 
not  confirm  that  of  Dr.  Hammond  as  regards  the 
beneficial  effects  he  attributes  to  zinc.  Internal 
remedies  taken  by  the  mouth  are  certainly  less 
important  than  external  ones,  or  medicines  used 
by  subcutaneous  injection.  As  regards  this 
last  means  there  is  no  doubt  that  injections  of 
morphia  or  atropia  under  the  skin,  especially 
when  made  near  the  focus  of  pain  or  tenderness, 
are  of  great  service,  not  only  for  a time  against 


1602 


SPINAL  IRRITATION. 

these  symptoms,  but  also  frequently  against  the 
affection  itself.  The  writer  employs  with  more 
benefit  the  following  substances  together  than 
one  of  them  alone  in  such  cases,  as  well  as  in 
cases  of  neuralgia : sulphate  of  morphia,  from  § 
to  | a grain,  sulphate  of  strychnia,  from  jb  to  L- 
of  a grain,  and  sulphate  of  atropia  from  ^ to  ^ 
of  a grain,  beginning  with  the  minimum  dose, 
and  reaching  quickly  the  maximum  one,  if  the 
increase  can  be  borne.  When  the  pain  or  tender- 
ness is  localised  in  a small  part  of  the  spine,  the 
writer  has  obtained  great  relief  from  the  use  of 
an  ointment  of  aconitia,  two  grains ; veratria, 
four  grains;  and  lard,  two  drachms.  Every 
counter-irritant,  including  galvanism  (if  we  can 
look  upon  it  in  such  a way),  has  been  used  with 
benefit  in  some  eases.  Applications  of  ice  and  of 
the  actual  cautery  will  be  found  to  be  the  best. 
Ice  may  be  employed,  finely  pounded,  as  a kind 
of  poultice,  applied  on  a large  surface  and  cn  the 
bare  skin,  or  in  frictions  on  the  two  sides  of  the 
spine,  and  by  either  process  only  for  three  to  six 
minutes,  twice  a day.  If  there  be  no  success  by 
these  means,  the  application  of  a very  hot  piece 
of  flannel  on  the  principal  seat  of  pain  is  advis- 
able, followed  after  five  minutes  by  the  applica- 
tion of  ice  according  to  one  or  other  of  the 
two  above  methods.  When  the  whole  spine  is 
tender  or  painful,  each  of  its  three  regions  should 
be  treated,  one  after  the  other.  Next,  if  not 
first  in  importance,  is  the  use  of  the  actual 
cautery,  after  the  following  rules : — First,  the 
instrument  must  be  at  white  heat ; secondly,  it 
must  have  a very  small  surface;  thirdly  it  must 
be  applied  quickly  although  firmly ; fourthly,  it 
must  make,  on  each  day  of  application,  three  or 
four  cauterisations  on  each  sideof  the  spine,  and 
these  irritations  must  extend  over  two  or  three 
inches  in  length ; fifthly,  the  operation  is  to  be  re- 
peated every  day  for  eight  or  ten  days,  care  being 
taken  that  the  instrument  be  passed  each  time 
on  unaltered  skin.  The  writer  uses  a Paquelin 
cautery,  with  which  there  is,  on  account  of  the 
above  rules,  neither  great  pain  nor  a sore  pro- 
duced. The  outer  layer  of  the  skin  dries  up  and 
becomes  brown,  but  there  is  no  blister  or  ulcer 
or  purulent  discharge.  This  is  a most  valuable 
means  ef  treatment,  especially  when  the  pain  and 
tenderness  of  the  spine  are  intense.  If  all  the 
means  already  mentioned  have  failed,  or  even 
when  they  have  not  been  tried,  and  when  the 
patient  is  attacked  in  a great  extent  of  the 
spine,  and  is  quite  submissive  and  willing  to  do 
as  she  is  told,  absolute  rest  of  the  tender  and 
painful  parts  is  to  be  employed.  In  Hilton’s 
valuable  work  on  Rest  and  Pain , the  rules  are 
given  which  must  be  followed  in  such  cases. 
The  words  absolute  rest  express  exactly  what  is 
needed.  It  would  be  worse  than  useless  to  make 
a patient  with  spinal  irritation  lie  down,  and 
stay  in  bed  for  two,  three,  or  four  weeks,  if  he 
or  she  were  allowed  to  turn  in  bed,  or  to  move 
the  spine  at  all  at  the  affected  part.  If  the  rest 
of  the  part  is  really  absolute  and  constant,  a 
cure  is  almost  always  obtained  after  a few  weeks. 
So  long  as  the  difficult  treatment  lasts,  every 
attention  must  be  paid  to  the  nourishment,  to 
the  state  of  the  bowels,  and  to  the  occupation  of 
the  mind  of  the  patient.  It  need  not  be  said  that 
Other  means  of  treatment  (especially  subeuta- 


SPINE,  DISEASES  OP. 
neous  injections  against  pain),  are  to  be  used 
during  the  period  of  rest.  Fresh  air  must  be 
admitted  to  the  room  as  far  as  the  season  allows. 
The  muscles  of  the  limbs  (which  are  to  be  left 
without  voluntary  movement)  are  to  be  gently 
galvanised  several  times  a day.  so  as  not  only  to 
improve  their  nutrition,  but  to  act  also  on  the 
general  circulation  of  the  blood.  On  getting  out 
of  bed,  when  it  is  ascertained  that  both  pain  and 
tenderness  have  disappeared  from  the  spine,  the 
patient  must  for  a time  (a  week  or  more)  be 
most  careful  to  avoid  moving  the  parts  much 
which  have  been  affected.  The  writer  cannot  con- 
clude this  article  without  referring  the  reader  to 
a lecture  of  one  of  the  ablest  physicians  of  oor 
time,  Dr.  S.  Weir  Mitchell,  of  Philadelphia,  in 
which  rules  not  essentially  different  from  the 
above  are  given.  See  ‘Rest  in  the  Treatment  of 
Nervous  Disease,’  in  A Series  of  American  Clini- 
cal Lectures,  vol.  i.  No.  4,  New  York,  1875. 

C.  E.  BrOWN-SeQU  A RD. 

SPINE,  Diseases  and  Curvatures  of. — 

Synon.  : Fr.  Maladies  et  Courburcs  du  Rhachis ; 
Ger.  Krankheiten  and  Kriimmungcn  des  Riick- 
grates. 

General  Remarks. — Tho  vertebral  column  isa 
complex  anatomical  structure,  consisting  of  large 
masses  of  bone,  chiefly  cancellous,  forming  the 
bodies  of  the  vertebrae ; large  flat  discs  of  fibro- 
cartilage  placed  between  the  bodies  of  the  ver- 
tebra; ; and  connecting  ligamentous  structures. 
On  either  sideof,  and  behind  the  vertebral  canal, 
in  which  the  spinal  cord  is  placed,  are  the  ob- 
lique articulating,  and  the  spinous  processes, 
with  which  are  connected  the  large  group  of 
muscles,  whereby  the  various  movements  of  the 
spinal  column  are  regulated,  and  the  erect  posi- 
tion of  the  body  maintained. 

All  these  structures  are  liable  to  special  forms 
of  disease,  such  as  are  met  with  in  other  parts  of 
the  body  where  similar  structures  exist.  Hence 
a certain  analogy  may  be  traced  between  the 
most  ordinary  forms  of  disease  which  c.oa  ir  in  the 
spinal  column,  and  the  joint-diseases  of  the  ex- 
tremities ; but  the  absence  of  articular  cartilage 
and  synovial  membrane  between  the  bodies  of 
the  vertebra,  destroys  much  of  the  analogy 
Nevertheless,  in  the  ordinary  form  of  disease  ot 
the  spinal  column,  or  ‘ Pott’s  disease,’  we  havo 
as  its  chief  characteristics,  caries  and  necrosis  of 
bone,  with  ulceration  of  the  intervertebral  car- 
tilage, accompanied  by  suppuration.  The  liga- 
ments are,  as  in  other  parts  of  the  body,  especially 
liable  to  the  rheumatic  form  of  inflammation. 
The  muscles  are  especially  liable  to  paralytic 
and  spasmodic  affections,  such  as  occur  in  the 
muscles  of  the  extremities,  and  other  parts  of 
the  body.  The  spine  is  also  very  liable  to 
various  forms  of  curvature.  Other  forms  of 
disease,  such  as  tubercular  deposits,  cystic  and 
malignant  growths,  are  occasionally  met  with, 
but  do  not  require  special  description  in  con- 
nection with  the  spinal  column.  The  diseases  of 
the  spinal  cord  and  its  membranes  are  described 
in  other  articles.  The  only  affections,  therefore, 
which  demand  special  consideration  in  this 
place  are  (1)  Potth  Disease  ; and  (2)  Lateral 
• Curvature. 

1.  Pott's  Disease  of  the  Spine. — Synon.: 


SPINE,  DISEASES  AND  CURVATURES  OP.  15t3 


Spinal  caries  ; Fr.  Mai  vertebral  de  Pott ; Ger. 
Pott’sche  Krankkeit. 

Definition. — A destructive  disease  of  the 
6pinal  column,  depending  upon  ulceration  of  the 
intervertebral  cartilages ; generally  associated 
with  caries  and  necrosis  of  the  bodies  of  the  ver- 
tebra; and  named  after  the  distinguished  sur- 
geon Percival  Pott,  who  first  described  its  pa- 
thological characters. 

Anatomical  Characters. — The  disease  may 
commence  either  in  the  intervertebral  cartilages, 
or  in  the  bodies  of  the  vertebrae.  In  the  majority 
of  cases  ulceration  of  one  or  more  interver- 
tebral cartilages  occurs,  as  the  result  of  subacute 
inflammation  ; and  the  adjacent  surfaces  of  the 
bodies  of  the  vertebra  become  destroyed  by 
caries  and  necrosis.  When  the  disease  com- 
mences in  the  bones,  primary  necrosis  occurs 
in  one  or  more  of  the  bodies  of  the  vertebrae, 
as  it  is  observed  to  do  in  other  situations  where 
cancellous  bone  exists  in  large  masses.  In  a 
later  stage,  the  osseous  and  cartilaginous  struc- 
tures are  all  involved  in  the  destructive  pro- 
cess, and  a chasm  is  formed  in  the  anterior  part 
of  the  spinal  column,  which  subsequently  be- 
comes bent  upon  itself,  the  spinous  processes 
projecting  posteriorly  so  as  to  produce  the  dis- 
tortion described  as  angular  curvature  of  the 
spine.  The  angular  form  of  tbo  projection  is 
most  marked  in  the  dorsal  region,  in  consequence 
of  the  natural  curve  of  the  spinal  column  in  a 
posterior  direction,  and  also  from  the  length  of 
ihe  spinous  processes.  In  the  cervical  and  lum- 
bar regions  an  opposite  condition  obtains,  and 
an  obtuse  posterior,  rather  than  angular,  projec- 
tion occurs  ; and  this  may  be  absent,  even  in 
cases  ot'  extensive  disease. 

If  the  case  proceed  favourably  towards  a 
curative  termination,  the  destructive  processes 
become  arrested,  and  a healthy  reparative  pro- 
cess is  established,  terminating  in  bony  anchy- 
losis between  the  bodies  of  the  vertebra,  which 
have  become  approximated  after  the  loss  of 
structure.  Ossification  also  proceeds  along  some 
of  the  ligamentous  structures  passing  between 
the  laminie,  as  well  as  between  the  spinous  pro- 
cesses. Thus  the  resulting  angular,  or  posterior, 
projection  becomes  a persistent  deformity — a 
deformity  essential  to  the  cure  of  the  case. 

IEtiology. — Pott's  disease  of  the  spine  may 
be  either  of  local  or  of  constitutional  origin. 
When  local,  it  results  from  injury,  and  the  vio- 
lence may  be  either  direct  or  indirect. 

Cases  traceable  to  direct  violence  are  of  more 
frequent  occurrence  in  adult  life,  for  instance, 
the  fall  of  earth  from  the  roof  of  a tunnel 
upon  the  back  of  a man, in  the  stooping  position ; 
the  fall  of  a sack  of  wheat  upon  the  back  of  a 
person  passing  under  it ; or  a fall  from  a ladder. 
The  evidence  .of  direct  injury  is  not  so  easily 
obtained  when  the  disease  occurs  in  childhood, 
but  occasionally  we  see  spinal  curvature  deve- 
loped in  robust  and  healthy  children,  who  have 
never  had  any  previous  illness,  and  whose  family 
history  is  unexceptionally  good.  In  such  eases 
we  can  hardly  doubt  that  some  slight  accident, 
met  with  in  boisterous  play,  must  have  been  the 
immediate  cause  of  the  disease ; and,  in  some  in- 
stances the  writer  has  obtained  undoubted  evi- 
dence to  this  effect.  The  immediate  symptoms 


are  slight  and  transient,  but  in  the  course  of  a 
few  months  conclusive  evidence  of  the  existence 
of  disease  is  developed. 

Indirect  violence  frequently  gives  rise  to  Pott’s 
disease  of  the  spine,  and  in  all  probability  lays 
tbe  foundation  of  the  mischief  in  the  greatest 
number  of  cases,  although  the  accident,  as  a pro- 
ducing cause,  cannot  be  traced  in  every  instance, 
especially  when  the  disease  occurs  in  childhood, 
as  it  most  frequently  does.  The  kind  of  acci- 
dent alluded  to  is  a rick  or  twist  of  the  spine, 
as,  for  example,  when  a child  imitating  the 
clown  in  a pantomime,  turns  head  over  heels,  or 
when  a boy  is  taken  up  by  the  arms,  and  swung 
round  by  a man  on  to  his  back  in  play.  The 
latter  occurred  to  a boy  who  was  for  several 
years  under  the  writer’s  care;  the  immediate 
symptoms  were  not  severe,  and  passed  off  in  a 
short  time,  but  disease  of  the  spine  was  gra- 
dually developed,  with  external  abscess,  through 
which  portions  of  necrosed  bone  came  away;  the 
boy  ultimately  recovered.  A fall  out  of  bed  has 
frequently  been  known  to  lay  the  foundation  of 
spinal  disease,  and  in  many  of  these  accidents 
there  is  no  evidence  of  direct  injury  to  the  spine. 
In  young  adults,  a rick  or  twist  of  the  spine 
received  in  wrestling,  and  in  the  rough  game  of 
foot-ball,  or  by  a fall  from  a horse,  has  been  known 
to  precede  the  development  of  disease  without 
any  direct  blow  upon  the  spine.  In  all  these 
cases,  the  injury  done  to  the  articulation  is  in 
all  probability  hy  laceration  of  the  ligaments, 
just  as  in  severe  sprains  at  the  knee  and  ankle- 
joint;  and  when  such  an  injury  occurs  in  a person 
of  marked  strumous  constitution,  the  destructive 
inflammatory  processes  of  ulceration  and  caries 
usually  follow,  as  they  do  at  other  articulations, 
when  both  local  and  constitutional  causes  are 
combined. 

When  of  constitutional  origin,  disease  of  the 
spine  is  generally  developed  in  children  in  whom 
we  have  sufficient  evidence  of  a strumous  consti- 
tutional condition,  frequently  associated  with  a 
consumptive  family  history;  still  cases  are  often 
met  with  where  we  have  no  such  indications,  but 
in  which  the  disease  has  been  developed  during 
a condition  of  induced  constitutional  debility, 
that  is,  after  an  attack  of  scarlet  fever,  measles, 
or  whooping-cough.  In  this  class  of  cases  we 
have  the  absence  of  any  history  of  a local  in- 
jury, either  direct  or  indirect,  and  the  disease 
appears  to  depend  essentially  upon  the  constitu- 
tional condition  of  the  patient. 

Symptoms  and  Diagnosis. — 1.  Early  stage. 
During  the  early  stage  of  Pott’s  disease  of  the 
spine,  that  is,  before  the  production  of  angular 
curvature — a stage  which  usually  occupies  a 
period  of  from  six  to  nine  months — the  symp- 
toms are  often  so  ill-defined,  that  an  accurate 
diagnosis  cannot  be  formed.  Turn  symptoms, 
namely,  pain  on  motion,  and  pain  on  percussion 
over  the  spinous  processes,  have  been  too  gene- 
rally relied  upon  as  indicating  the  existence  of 
disease  ; but  both  these  symptoms  are  frequently 
absent  when  disease  exists,  and  are  also  pre- 
sent in  an  exaggerated  form  when  there  is  no 
disease,  so  that  their  diagnostic  importance  is 
uncertain.  Still,  when  present  in  conjunction 
with  other  symptoms,  they  are  often  of  mate- 
rial diagnostic  Talue.  A certain  amount  of  fixity 


SPINE,  DISEASES  AND  CUEVATUBE3  OF. 


1504 

in  a portion  of  the  spinal  column,  that  is,  a 
want  of  flexibility  in  the  stooping  position,  is  of 
importance  as  showing  a condition  of  reflex  mus- 
cular contraction,  similar  to  that  which  exists  at 
tho  hip-  and  knee-joints,  in  the  early  stage  of 
disease. 

There  are  some  regional  peculiarities  of  impor- 
tance in  reference  to  diagnostic  symptoms ; and 
the  special  symptoms  present,  with  more  or  less 
distinctness  in  different  regions,  may  be  grouped 
in  two  classes,  namely— 

(а)  Pain  occasioned  by  certain  movements,  in 
which  particular  muscles  attached  to  the  ver- 
tebrae which  are  the  seat  of  disease,  are  called 
into  play  ; and  pain  occasioned  by  percussion 
over  one  or  more  spinous  processes. 

(б)  Attitudes  assumed  by  the  patient  to  avoid 
piain  on  motion. 

In  the  upper  cervical  region,  a constrained  and 
fixed  position  of  the  head,  to  avoid  pain  on  motion, 
always  exists  in  the  early  stage  of  spinal  disease; 
and  the  child  finding  a difficulty  in  keeping  the 
head  in  the  erect  position,  acquires  the  habit  of 
supporting  the  chin  by  the  hands,  the  elbows 
frequently  resting  on  a table  or  chair.  This 
attitude  is  of  great  diagnostic  value.  Occa- 
sionally in  this  region  the  disease  is  ushered  in 
by  obscure  cerebral  symptoms,  resembling  those 
of  subacute  meningitis. 

In  the  lower  cervical  and  upper  dorsal  regions 
there  are  no  very  distinctive  symptoms,  but  in 
children  there  is  not  unfrequently  a troublesome 
cough,  sometimes  supposed  to  be  a mild  form  of 
whooping-cough,  probably  depending  upon  irri- 
tation of  the  recurrent  laryngeal  nerve. 

In  the  middle  dorsal  region  the  absence  of 
symptoms  in  the  early  stages  of  Pott’s  disease  is 
most  marked,  probably  from  the  comparative 
immobility  of  this  portion  of  the  spinal  column, 
motion  in  any  direction  being  very  limited;  and 
probably  also  from  the  absence  of  any  muscular 
attachments  to  the  bodies  of  the  vertebrae.  Local 
piain,  and  pain  on  percussion,  are  sometimes 
present.  The  patient  moves  about  slowly  and 
cautiously,  and  sometimes  sits  with  the  arms 
extended,  the  hands  resting  on  a chair,  to  re- 
lieve the  spine  of  the  superincumbent  weight 
and  the  effect  of  pressure  at  the  seat  of  disease, 
as  well  as  to  assist  in  breathing. 

In  the  lower  dorsal  and  upper  lumbar  regions , 
the  early  stage  of  disease  is  characterised  by 
pain  experienced  in  the  various  movements  in 
which  the  psoas  muscles  are  brought  into  play, 
such  as  the  stooping  position,  putting  on  stock- 
ings, lacing  boots,  or  lifting  even  a light  weight 
from  the  ground ; the  act  of  going  up  and  down 
stairs;  any  attempt  to  rise  suddenly  from  the 
horizontal  to  the  sitting  or  standing  position, 
especially  in  the  morning  after  a night's  rest ; any 
attempt  to  twist  the  body  round  suddenly  when 
lying  down,  as  in  the  act  of  turning  suddenly 
from  the  back  to  the  stomach.  In  this  region 
also  may  be  mentioned  as  a diagnostic  symptom 
the  attitude  assumed  by  the  patient  in  the  sit- 
ting position,  as  described  in  the  cervical  and 
upper  dorsal  region. 

2.  Advanced  stage. — In  the  second  stage  of 
Pott’s  disease,  that  is  when  angular  curvature 
is  developed,  any  previous  difficulties  of  dia- 
gnosis which  may  have  existed  are  cleared  away, 


and  we  know  the  disease  has  existed  probably 
from  six  to  nine  months,  and  that  a loss  of 
substance  in  the  intervertebral  cartilage  and 
bone  has  occurred.  But  exceptional  cases,  ip 
which  diagnosis  may  be  doubtful,  occasionally 
occur  in  two  situations,  namely,  when  a posterior 
projection  of  the  spinous  processes  takes  place, 
either  of  the  seventh  cervical  and  first  dorsal 
vertebrae,  or  of  the  eighth  or  ninth  dorsal  ver- 
tebrae— situations  iu  which  it  may  be  said  that-a 
spurious  form  of  angular  curvature  may  exist, 
as  an  exaggerated  condition  of  the  naturally 
prominent  spinous  processes  existing  in  these 
situations.  The  projection  of  the  spinous  pro- 
cesses may  he  accompanied  with  such  symptoms 
as  local  pain  on  pressure  or  percussion,  pain  ex- 
tending along  the  shoulders  and  down  the  arms, 
leading  to  the  suspicion  of  the  existence  of  dis- 
ease. When  occurring  in  girls,  the  symptoms  in 
these  cases  are  generally  due  to  hysteria ; but  as 
in  some  cases  disease  is  subsequently  developed, 
the  diagnosis  should  he.  cautiously  given,  and 
any  treatment  based  upon  it  cautiously  fol- 
lowed out.  The  projection  of  the  spinou6  pro- 
cesses of  the  seventh  cervical  and  first  dorsal 
vertebrae  may  often  be  traced  to  a natural  con- 
formation and  family  peculiarity,  as  we  see  in 
some  short-necked  and  round-shouldered  girls. 
This  condition  often  occurs,  in  a more  marked 
degree,  in  adults,  and  is  increased  by  a thicken- 
ing and  hypertrophied  condition  of  the  cellular 
tissue,  possibly  also  by  fluid  in  a bursa ; in  such 
cases  the  neuralgic  pains  which  accompany  it  are 
due  to  a gouty  or  rheumatic-gouty  tendency. 

Course,  Duration,  and  Terminations. — The 
progress  of  Pott’s  disease  of  the  spine  is  extremely 
variable,  hut  as  a general  rule,  within  a period 
of  from  six  to  nine  months  from  the  commence- 
ment, angular  curvature  is  produced.  If  the 
case  proceed  favourably,  without  external  abscess 
or  paralysis,  the  disease  becomes  arrested,  and 
bony  anchylosis  takes  place  in  about  three 
years.  When  abscess  and  paralysis  occur,  the 
period  of  recovery  is  frequently  prolonged  to 
five  or  seven  years.  The  subject  of  psoas  and 
lumbar  abscess  will  be  found  treated  of  elsewhere. 
See  Lumbar  Abscess  ; and  Psoas  Abscess. 

Becovery  from  the  incomplete  form  of  pa- 
ralysis which  occurs  in  these  cases,  usually  takes 
place  in  about  two  years.  When  the  disease 
does  not  terminate  favourably  in  bony  anchy 
losis,  death  occurs ; usually  preceded  by  abscess, 
paralysis  with  meningitis,  and  inflammatory 
softening  of  the  cord.  In  children  the  mortality 
is  probably  about  one  in  twenty,  and  in  adults 
about  one  in  five  cases. 

Prognosis. — The  prognosis  in  Pott's  disease 
of  the  spine  will  be  much  more  favourable  in 
children  than  in  adults,  but  in  both  it  will  be 
unfavourable  in  proportion  to  the  rapidity  with 
which  the  disease  pursues  its  course,  and  also 
in  proportion  to  the  evidence  of  a strumous  or 
tubercular  diathesis;  a large  proportion  of  cases 
occurring  in  children  and  young  adults  having  a 
phthisical  family  history. 

Treatment. — The  treatment  of  this  disease 
must  be  both  constitutional  and  local.  The  con- 
stitutional treatment  is  of  importance,  because 
in  a large  number  of  cases  in  which  this  disease 
occurs,  there  is  evidence  of  a strumous  or  tuber 


SPINE,  DISEASES  AND  CUKVATUKES  OF.  130fi 


*nlar  diathesis,  indicating  the  exhibition  of  cod- 
j'ver  oil  'with  hypophosphite  of  lime,  iron,  and 
other  drugs  of  the  same  class. 

The  local  treatment,  especially,  varies  very 
much  according  to  the  age  of  the  patient  and  the 
region  in  which  the  disease  is  seated,  the  prin- 
ciples being  essentially  recumbency,  counter-irri- 
tation, and  mechanical  support.  With  regard  to 
the  local  treatment  in  the  first  stage,  that  is,  pre- 
vious to  the  production  of  angular  curvature,  a 
stage  which  usually  lasts  from  six  months  to  a 
year,  if  the  disease  can  be  diagnosed,  absolute 
recumbency  should  be  insisted  upon  ; and  coun- 
ter-irritation in  some  form  or  other,  such  as  by 
blisters,  the  actual  cautery,  issues,  or  moxas,  is 
also  generally  useful.  Mechanical  support  to 
the  spine  in  any  form  is  not  indicated  in  this 
stage. 

In  the  second  stage  of  the  disease,  that  is,  when 
angular  curvature  has  taken  place,  absolute  re- 
cumbency should  still  be  insisted  upon  for  a pe- 
riod of  from  one  to  two  years  from  the  probable 
date  of  the  commencement  of  the  disease.  This  is 
more  especially  necessary  when  disease  occurs  in 
the  cervical  or  upper  dorsal  regions,  as  there  is 
not  only  a greater  tendency  to  paralysis,  and 
danger  to  life  in  this  situation,  but  when  dis- 
ease takes  place  in  the  upper  dorsal  region,  and 
recumbency  is  not  carried  out,  the  ultimate  de- 
formity is  always  much  greater  than  it  need  be. 
Absolute  recumbency  contributes  not  only  to  the 
arrest  of  disease,  but  to  a diminution  of  the 
ultimate  deformity. 

When  this  disease  occurs  in  infancy,  or  in 
young  children,  in  any  region,  absolute  recum- 
bency must  be  insisted  upon,  the  child  living 
and  being  carried  about  in  a spinal  tray  made  of 
basket-work  with  a mattress  inside.  When  dis- 
ease occurs  in  the  cervical  or  upper  dorsal  re- 
gion, extension  by  the  head  may  be  combined 
with  absolute  recumbency,  and  this  was  first 
introduced  by  Mr.  Fisher,  who  used  a rack-and- 
pinion  extension  movement.  The  writer  has 
adopted  this  principle  with  great  advantage  in  a 
case  of  cervical  caries,  with  partial  paralysis,  but 
he  employed  the  weight  and  pulley  attached  to 
the  upper  extremity  of  the  plane  on  which  the 
patient  was  kept  day  and  night. 

As  the  case  improves,  in  the  course  of  one  or 
two  years,  partial  recumbency  with  mechanical 
support,  that  is,  recumbency  for  about  half  the 
day,  may  be  substituted  for  absolute  recumbency, 
and  this  is  especially  applicable  to  cases  of  disease 
occurring  in  the  middle  and  lower  dorsal  regions, 
when  the  disease  is  not  extensive,  and  appears 
to  be  running  a slow  or  chronic  and  favourable 
course.  As  to  the  kind  of  support,  a piece  of 
thick  gutta-percha  applied  and  moulded  to  the 
back,  whilst  the  child  is  lying  on  its  stomach, 
and  retained  by  a bandage  passed  round  the 
body,  answers  very  well  for  hospital  practice. 
A better  kind  of  support  is  made  of  thick  leather, 
blocked  on  a plaster  of  Paris  cast  of  the  back, 
with  elastic  in  front.  The  plaster  of  Paris 
jacket  applied  during  suspension,  introduced 
into  this  country  by  Professor  Lewis  Sayre 
of  New  York  in  1877,  is  very  useful,  espe- 
cially in  hospital  practice,  where  any  rules 
laid  down  are  certain  to  be  disregarded.  The 
principle  of  applying  a form  of  support  to  the 

95 


spine  during  the  progress  of  disease,  whilst  the 
patient  is  suspended  by  the  head,  is  novel,  and 
has  been  very  useful,  but  must  be  employed 
with  caution.  It  secures  immobility,  relieves  un- 
due pressure,  and  diminishes  the  consecutive  or 
compensating  curves,  in  many  cases  to  a greater 
extent  than  can  be  accomplished  by  horizontal 
extension  ; and  plaster  of  Paris  is  a very  useful 
material  for  the  purpose,  easily  obtained,  and 
can  bo  applied  by  any  surgeon.  The  disadvan- 
tage, however,  of  not  being  able  to  remove  it  foi 
washing  purposes  is  very  great,  and  the  liability 
to  the  production  of  sores  from  pressure  and 
friction,  is  also  an  objection  to  its  use.  The 
material  which  has  now  to  a great  extent  su- 
perseded the  plaster  of  Paris  is  the  poroplastic 
felt,  which  is  applied,  when  softened  by  steam, 
whilst  the  patient  is  suspended,  and  being  buckled 
on  in  front,  can  be  removed  as  often  as  required. 

Partial  recumbency  with  mechanical  support, 
in  some  modified  form,  must  be  continued  in  all 
cases  occurring  in  childhood,  long  after  disease 
has  ceased;  and  in  some  cases,  in  which  the  re- 
sulting deformity  threatens  to  be  considerable, 
even  until  the  completion  of  growth. 

2.  Lateral  Curvature  of  the  Spine. — Defi- 
nition'.— A deformity  or  contortion  of  the  spine, 
in  which  the  bodies  of  the  vertebra  deviate 
laterally  in  a horizontal  direction,  with  or  with- 
out a corresponding  deviation  of  the  apices  of 
the  spinous  processes. 

TEtiology. — The  causes  of  lateral  curvature 
are  both  local  and  constitutional,  and  as  one 
or  other  of  these  causes  may  predominate,  so  the 
cases  admit  of  being  arranged  in  three  classes. 

Class  1.— Cases  in  which  the  constitutional 
largely  predominate  over  the  local  causes. 

Class  2. — Case3  depending  upon  constitu- 
tional and  local  causes  in  about  equal  degrees. 

Class  3. — Cases  essentially  depending  upon 
local  causes  acting  mechanically,  so  as  to  disturb 
the  equilibrium  of  the  spinal  column. 

In  cases  belonging  to  the  first  class  the  spinal 
curvature  generally  occurs  under  twelve  years  of 
age.  Occasionally  it  is  met  with  as  a congenital 
affection.  Many  cases  occur  in  infancy  or  early 
childhood,  that  is,  under  three  or  four  years  of 
age;  but  the  majority  between  seven  and  ten 
years  of  age.  "When  congenital,  spinal  curvature 
is  sometimes  associated  with  osseous  malforma- 
tion, but  it  also  occurs  without  any  such  compli- 
cation. The  cases  included  in  the  first  class  can 
frequently  be  traced  to  an  hereditary  predisposi- 
tion, lateral  curvature  occurring  in  two  or  three 
generations,  and  several  members  of  the  same 
family  are  frequently  affected.  The  children 
usually  exhibit  signs  of  constitutional  debility, 
and  the  local  causes  of  curvature  cannot  be 
traced,  except  in  infancy,  when  the  children  are 
nursed  always  on  one  arm. 

In  the  second  class  the  spinal  curvature  gene- 
rally occurs  between  the  ages  of  twelve  and  six- 
teen. Hereditary  tendency  is  not  usually  trace- 
able. These  cases  may  be  arranged  in  two  sub- 
divisions, (a)  cases  defending  upon  induced  con- 
stitutional or  general  debility , combined  with  local 
causes  acting  mechanically ; and  (b),  those  clearly 
of  a ricketty  character. 

(a)  The  local  causes  are  the  long  continuance 
of  certain  bad  positions,  such  as  standing  or 


SPINE,  DISEASES  AND  CURVATURES  OF. 


1506 

one  leg;  the  long  continuance  cf  the  sitting  and 
stooping  position  ; sitting  cross-legged  ; occupa- 
tions which  render  the  long  continuance  of  some 
particular  position  necessary,  such  as  needle- 
work, book-folding,  ironing,  nursing  children, 
and  carrying  heavy  weights. 

( h ) The  second  series  includes  cases  of  lateral 
curvature  of  a rachitic  character,  associated  with 
the  general  rachitic  conformation  of  the  skeleton. 

In  the  third  class  spinal  curvature  generally 
occurs  previous  to  the  completion  of  growth. 
These  cases  are  essentially  unconnected  with  any 
constitutional  affection  or  hereditary  predisposi- 
tion, and  frequently  co-exist  with  the  natural 
amount  of  muscular  strength.  As  local  causes, 
in  addition  to  habits  and  occupations  above  re- 
ferred to,  may  be  mentioned  the  effects  of  a 
wooden  leg,  and  inequality  in  the  length  of  the 
legs  from  any  cause,  such  as  would  disturb  the 
equilibrium  of  the  spinal  column. 

Anatomical  Characters.  — In  the  so-called 
lateral  curvature  of  the  spine,  the  spinal  column 
does  not  yield  in  a purely  lateral  direction, 
as  a flexible  column  would  bend,  but  presents 
the  appearance  of  a spiral  twist,  owing  to  the 
bodies  of  the  vertebrae  turning  round  in  a di- 
rection of  horizontal  rotation,  so  that  their  an- 
terior surfaces  are  directed  laterally  along  the 
convexity  of  the  curvature.  In  a severe  case 
this  rotation  commonly  extends  to  a quarter  of 
a circle  in  the  centre  of  the  curve,  and  diminishes 
from  this  point  to  the  two  extremities,  so  that 
the  vertebrse,  unequally  turned  upon  themselves, 
cease  to  correspond  in  their  natural  relations  to 
each  other.  This  deviation  of  the  bodies  of  the 
vertebras  does  not  necessarily  correspond  to,  nor 
is  it  always  indicated  by,  any  lateral  deviation  of 
the  apices  of  the  spinous  processes,  although 
such  deviation  generally  exists  to  some  extent. 
In  all  cases,  however,  the  internal  deviation  of 
the  bodies  of  the  vertebrae  is  much  greater  than 
the  deviation  externally  of  the  apices  of  the 
spinous  processes. 

In  all  cases  of  confirmed  lateral  curvature, 
whether  slight  or  severe,  structural  changes 
exist,  varying  in  degree  according  to  the  severity 
and  duration  of  the  curvature.  The  structures 
affected  aro  the  intervertebral  fibro-eartilages, 
the  bodies  of  the  vertebrae,  and  the  oblique  arti- 
culating processes.  All  these  suffer  simply  from 
mechanical  pressure,  arising  from  the  unequal 
distribution  of  the  weight  of  the  body.  The 
fibro-cartilages  and  the  bodies  of  the  vertebrae 
suffer  from  unequal  compression  in  the  concavity 
of  the  curve,  and  become  more  or  less  wedge- 
shaped.  The  articular  facets  on  the  oblique  ar- 
ticulating processes,  which  form  the  only  direct 
articular  connections  between  the  separate  bones 
of  the  vertebral  column,  undergo  important  struc- 
tural changes  at  an  early  period  of  the  formation 
of  lateral  curvature,  that  is,  as  soon  as  it  becomes 
confirmed.  These  articular  facets  become  altered 
in  their  direction  and  aspects,  according  to  the 
' extent  of  the  lateral  deviation,  or  rotation,  of  the 
bodies  of  the  vertebrse.  In  the  lumbar  region, 
where  the  articular  facets  are  naturally  nearly 
vortical  in  direction,  looking  inwards  and  out- 
wards respectively,  they  gradually  assume,  in  a 
severe  case  of  lateral  curvature,  an  oblique  di- 
rection, looking  obliquely  upwards  and  down- 


wards. Mr.  Alexander  Shaw  first  directed  at- 
tention to  these  changes  in  the  oblique  articulat- 
ing processes  which,  as  he  observes,  receive  the 
weight  of  the  body  in  the  act  of  leaning  to  one 
side,  and  are  the  only  bony  structures  which 
check  the  lateral  movements  of  the  trunk ; and 
when  any  such  position  is  long  persisted  in,  the 
articulating  processes,  which  are  soft  and  imper- 
fectly formed  at  the  age  of  puberty,  become 
wasted  by  absorption,  as  the  result  of  unequal 
pressure.  The  joints  of  the  articulating  pro- 
cesses being  situated  posteriorly  as  well  as  late- 
rally, the  spinal  column  cannot  yield  in  their 
direction,  without  wheeling  partially  round. 
Hence  the  rotation  of  the  bodies  of  the  vertebrae 
becomes  confirmed,  together  with  the  other 
structural  deviations  described. 

The  ligamentous  structures,  including  chiefly 
the  short  ligamentous  bands  passing  between 
and  connecting  the  bodies  of  the  vertebras  and 
the  intervertebral  cartilages,  and  also  the  short 
articular  ligaments  connected  with  the  oblique 
articulating  processes,  become  adapted  to  the 
alterations  in  the  bones,  and  in  the  articulating 
surfaces.  It  is  an  error  to  assume  that  in  con- 
firmed curvature  the  ligaments  are  relaxed,  and 
elongated  on  one  side,  and  contracted  on  the 
other,  as  generally  described  ■ although  in  the 
physiological  condition  described  as  ‘ weak  spine,' 
with  an  inclination  to  lateral  curvature,  a con- 
dition of  muscular  debility  and  general  liga 
mentous  relaxation  undoubtedly  exists. 

The  muscles  have  not  been  shown  to  exhibit 
any  structural  changes  in  the  early  stage  of 
lateral  curvature  of  the  spine,  except  in  those 
rare  instances  in  which  the  curvature  depends 
upon  partial  paralysis.  In  the  late  stages,  or  in 
adult  cases  of  long  standing,  the  spinal  muscles 
havo  been  found  much  wasted,  pale  in  colour,  and 
in  more  or  less  advanced  stages  of  fatty  degene- 
ration. In  the  early  stages  of  curvature  an 
increased  prominence  of  the  spinal  muscles  is 
observed  on  the  convexity  of  the  curve,  whether 
in  the  dorsal  or  the  lumbar  region ; but  this  does 
not  depend  upon  any  spasmodic  or  active  muscu- 
lar contraction.  The  muscles  are  simply  dis- 
placed, or  pushed  outwards,  by  the  angles  of  the 
ribs  in  the  dorsal  region,  and  the  transverse 
processes  of  the  vertehrte  in  the  lumbar  region, 
which  are  thus  displaced  as  a part  of  the  rotation 
movement  described. 

Other  structural  changes  exist  in  the  ribs, 
which  become  distorted  and  altered  in  shape,  so 
as  to  lead  to  deformity  of  the  chest,  characterised 
by  a prominence  and  flattening  of  the  ribs,  which 
become  bent  at  their  angles  on  the  side  of  the 
convexity — usually  on  the  right  side,  and  a de- 
pression of  the  ribs  on  the  side  of  the  concavity. 

Anteriorly,  the  symmetrical  form  of  the  chest 
is  completely'  destroyed ; the  sternum  becomes 
very  oblique,  its  lower  extremity  projecting ; and 
the  cartilages  of  the  ribs  corresponding  to  the 
side  of  the  concavity  of  the  curve — usually  the  left 
— are  prominent,  and  bent  upon  themselves.  The 
oblique  diameter  of  the  chest,  therefore,  is  in- 
creased, but  its  capacity  is  altogether  diminished, 
causing  considerable  disturbance  in  the  relative 
position  of  the  heart  and  lungs,  and  giving  rise 
to  functional  derangement  of  these  organs. 

The  pelvis  also  becomes  distorted  in  lateral 


SPINE,  DISEASES  AND  CURVATURES  OF. 


curvature,  but  only  in  one  class  of  cases,  namely, 
those  of  rachitic  origin,  in  which  the  evidence 
of  general  rickets  is  unmistakably  present.  In 
all  other  cases  of  lateral  curvature  of  the  spine, 
the  pelvis  is  of  its  full  natural  size,  and  well- 
formed. 

Symptoms  and  Diagnosis. — Lateral  curvature 
of  the  spine  is  generally  supposed  to  be  indicated 
by  a lateral  deviation  of  the  apices  of  the  spinous 
processes,  but  such  deviation  may  exist  either  as 
a functional  or  as  a structural  condition.  It  may 
be  seen  in  a case  of  weak  spine  with  muscular 
debility  and  ligamentous  relaxation,  such  as  is 
frequently  met  with  in  quickly  growing  girls  ; or 
it  may  co-exist  with' rotation  of  the  bodies  of  the 
vertebras  in  confirmed  lateral  curvature.  The 
evidence  of  rotation  of  the  bodies  of  the  vertebrae 
precedes  the  lateral  deviation  of  the  apices  of  the 
spinous  processes  in  many  cases,  whilst  in  others 
the  two  conditions  co-cxist,  and  appear  to  take 
place  simultaneously  ; but  rotation  of  the  bodies 
of  the  vertebra  may  proceed  to  a considerable 
extent,  the  bodies  moving  horizontally  through 
a quarter  of  a circle,  with  only  very  slight  devia- 
tion laterally  of  the  apices  of  the  spinous  pro- 
cesses. It  is  therefore  the  evidence  of  rotation  we 
must  look  for  in  cases  of  commencing  structural 
curvature,  and  not  the  lateral  deviation  of  the 
apices  of  the  spinous  processes.  Rotation  of  the 
bodies  of  the  vertebrae  is  always  evidenced  by  a 
posterior  projection  of  the  angles  of  the  ribs  on 
one  side,  and  depression  on  the  other,  in  the 
dorsal  region ; and  a corresponding  posterior 
projection  of  the  transverse  processes  of  the 
vertebra  on  one  side,  and  depression  of  the 
other  in  the  lumbar  region.  Upon  these  condi- 
tions alone  can  the  existence  of  rotation  of  the 
bodies  of  the  vertebra  be  determined. 

Course,  Duration,  and  Terminations. — The 
progress  of  lateral  curvature  is  extremely  vari- 
able, tending  naturally  towards  a process  of 
spontaneous  arrest  in  some  cases,  and  in  others 
to  a progressive  increase,  with  proportionate  de- 
formity. The  course  depends  very  much  upon 
the  form  and  situation  of  the  curvature,  especially 
whether  it  assumes  the  character  of  the  so-called 
‘ single  ’ or  ‘ double  ’ curve  ; descriptive  terms 
which,  though  not  anatomically  accurate,  are  suffi- 
ciently so  for  practical  purposes.  The  cases  which 
naturally  lead  to  spontaneous  arrest  are  those  in 
which  a double  curvature  exists,  one  in  the  dor- 
sal, and  the  other  in  the  dorso-lumbar  region,  the 
two  curves  being  about  equal  in  length ; whilst 
the  cases  in  which  a progressive  increase  of  cur- 
vature and  deformity  is  certain  to  occur,  are 
examples  of  the  so-called  long  single  curve, 
frequently  involving  the  whole  of  the  dorsal, 
together  with  a portion  of  the  lumbar  region, 
or  the  whole  of  the  lumbar  and  a considerable 
portion  of  the  dorsal  region.  In  cases  of  double 
curvature  with  a marked  irregularity  in  the  length 
of  the  curves,  increase  will  also  certainly  occur, 
but  to  a less  extent  than  in  the  long  single  curves. 
With  regard  to  the  duration  and  terminations 
of  lateral  curvature,  these  have  already  been 
described  in  the  observations  made  in  reference 
to  the  course. 

Prognosis. — The  prognosis  will  be  unfavour- 
able in  proportion  to  the  early  age  at  which  the 
spinal  curvature  commences,  and  the  evidence  of 


1507 

I constitutional  causes  with  hereditary  tendency ; 
and  also  in  proportion  to  the  inequality  in  the 
length  of  the  curves,  when  double,  or  in  cases  of 
so-called  long  single  curves.  The  prognosis  will 
be  favourable  in  proportion  to  the  absence  of 
these  conditions. 

Treatment. — -For  practical  purposes  all  cases 
of  lateral  curvature  of  the  spine  may  be  arranged 
in  three  classes: — 1.  physiological  curves ; 2. 
commencing  structural  curves ; and  3.  confirmed, 
structural  curves. 

1.  With  regard  to  the  treatment  of  cases  in 
the  first  class,  'physiological  curves , no  mechanical 
treatment  by  any  form  of  spinal  support  should 
be  given,  but  reliance  placed  entirely  upon 
physiological  means,  such  as  gymnastic  exer- 
cises, partial  recumbency,  and  attention  to  the 
general  health.  In  some  cases  an  elastic  brace 
attached  to  stays  may  be  of  use. 

2.  In  the  second  class,  commencing  structural 
curves , these  form  the  only  curable  cases  of  late- 
ral curvature,  and  in  their  treatment  the  writer 
recommends  a combination  of  mechanical  sup- 
port, gymnastic  exercises,  and  partial  recum- 
bency. By  this  combination  of  physiological  and 
mechanical  means,  the  further  progress  of  curva- 
ture will  be  arrested,  and  the  best  opportunity 
afforded  for  recovery  from  such  slight  structural 
damage  as  may  have  already  occurred. 

3.  In  the  third  class,  confirmed  structural 
curves , mechanical  support  of  some  kind  must  be 
resorted  to,  and  continued  during  the  period  of 
growth,  with  the  hope  of  preventing  increase,  and 
obtaining  some  improvement  in  the  curvature ; 
but  confirmed  lateral  curvature,  whether  slight 
or  severe,  with  its  adapted  series  of  structural 
changes,  is  essentially  an  incurable  affection. 
The  most  efficient  retentive  spinal  support  is 
that  form  of  instrument  made  with  a pelvic 
belt,  and  spring  plates  attached  to  vertical  bars 
at  the  back,  without  any  mechanism  requiring 
alteration  by  the  surgeon.  In  some  favourable 
cases,  the  stronger  spinal  instrument-,  with  steel 
plates  attached  to  levers,  and  adjusted  by  racli- 
and-pinion  movements,  may  be  used  with  ad- 
vantage. Sayre’s  plaster-of-Paris  jacket  has 
been  largely  employed  in  these  cases ; but,  from 
what  the  writer  has  observed  in  the  practice  of 
others,  he  disapproves  of  its  application,  on  the 
following  grounds : that  it  fails  as  a curative 
agent,  the  gain  in  height  by  extension  being 
quickly  lost ; that  it  weakens  the  spinal  muscles 
by  its  constant  use,  and  hinders  gymnastic  exer- 
cises ; that  it  restrains  respiratory  movements, 
and  prevents  active  exercise ; that  it  is  an  unne- 
cessary restraint  at  night ; and  that  it  interferes 
with  bathing  and  cleanliness.  Another  form  of 
support  has  been  recently  introduced — the  poro- 
plastic  jacket,  which  when  softened  by  steam  is 
applied  in  the  same  way  as  the  plaster-of-Paris 
jacket  during  suspension,  and  is  free  from  the 
disadvantages  of  the  latter,  as  it  can  be  removed 
at  night,  or  at  any  time,  for  the  purpose  of  gym- 
nastic exercises.  It  acts  as  an  efficient  and  light 
retentive  support  in  many  cases  of  incurable 
curvature.  In  this  class  of  cases  mechanical 
support,  in  whatever  form  it  may  be  employed, 
must  be  combined  with  partial  recumbency'  and 
gymnastic  exercises  during  the  period  of  growth ; 
but  after  this  period  little  good  will  be  derived, 


1508  SPINE,  DISEASES  OF. 
except  from  mechanical  support,  when  a disposi- 
tion to  increase  of  curvature  exists.  When  there 
appears  to  be  no  disposition  to  increase  of  cur- 
vature, all  mechanical  support  should  he  discon- 
tinued, attention  being  paid  only  to  the  general 
health.  Wm.  Adams. 

SPIRILLUM  (dim.  of  spira,  a twist,  a curl). 
This  is  the  name  given  to  the  most  important  of 
the  genera  belonging  to  the  tribe  of  Spiral  Bac- 
teria ( Spirobacteria , Cohn).  The  three  genera  of 
this  tribe  are  closely  related  to  one  another,  as 
may  be  gathered  from  the  citation  of  the  charac- 
ters by  which,  according  to  Cohn,  they  are  to  be 
severally  distinguished.  He  describes  them  as 
follows : — Vibrio,  ‘ filaments  short,  light,  sinuous  ’ ; 
Spirillum,  ‘filaments  short,  spiral, rigid’;  Spiro- 
chete, ‘filaments  long,  spiral,  flexible.’  The  alli- 
ances between  the  two  latter  genera  especially 
are  found  to  be  so  strong  that  many  naturalists 
sink  the  latter  generic  name,  and  include  all  such 
species  under  the  one  genus  Spirillum. 

The  interest  attaching  to  these  organisms,  from 
a medical  point  of  view,  is  due  to  the  fact  that 
one  of  them,  as  originally  discovered  by  Ober- 
meier,  is  very  frequently  found  in  the  blood  of 
relapsing  fever  patients,  during  the  first  pa- 
roxysms of  the  disease  (see  Relapsing  Fever). 
This  organism  is  generally  known  as  Spirillum 
Obermcieri,  though  some  speak  of  it  by  the  name 
of  Spirochete  Obermcieri.  In  length  it  equals 
the  breadth  of  2-5  red  blood-corpuscles  (see 
Fig.  88).  It  is  quite  indistinguishable  in  size, 


Flo.  S8.  Spirillum  Obermeieri,  amongst  red  blood-cor- 
puscles. (After  Koch.)  x 700. 

in  general  conformation,  and  in  the  character 
of  its  movements,  from  another  form  originally 
described  by  Ehrenberg  as  Spirochete  plicatilis, 
which  is  to  be  found  in  some  infusions,  in  stag- 
nant fresh  or  salt  water,  and  (as  Cohn  has  dis- 
covered) in  the  mucus  about  the  teeth  of  some 
persons  wholly  free  from  fever  of  any  kind 
(see  Sobdes).  Some  regard  the  presence  of 
Spirillum  Obermcieri  in  the  blood  as  clear  evi- 
dence that  it  is  the  cause  of  relapsing  fever; 
others  look  upon  its  existence  there  as  a mere 
epiphenomenon— believing,  as  the  writer  is  in- 
clined to  do,  that  it  appears  as  a consequence 
rather  than  as  a cause  of  the  morbid  processes 
constituting  the  fever.1 

H.  Charlton  Bastlan. 

1 Dr.  Vandyke  Carter  of  Bombay  has  of  late  succeeded 
In  reproducing  the  disease  by  inoculation,  incertainsmall 
monkeys.  But,  for  suck  a method,  there  was  a large 
proportion  ot  failures,  viz.  six,  in  twenty-one  trials.  Dr. 


SPLEEN,  DISEASES  OF. 

SPIRO  PITTITE.  See  Spirillum. 

SPIB  OMETER  (spiro,  I breathe,  and  pirpor, 
a measure).— Synon.  : Fr.  Spirometre ; Ger.  Spi- 
rometer. 

Definition. — An  instrument  for  measuring  the 
vital  capacity  of  the  chest. 

Description. — The  object  of  the  several  in- 
struments that  have  been  designed  for  this 
purpose,  is  to  measure  the  total  amount  of  air 
expelled  from  the  chest  by  the  deepest  expiration 
following  upon  the  deepest  inspiration. 

All  our  knowledge  of  spirometry  is  derived 
from  Dr.  Hutchinson's  exhaustive  paper  in  the 
Medico-  Chirv.rgical  Transactions  of  1846.  The 
instrument  designed  by  Hutchinson  consisted  ol 
a mouthpiece  and  tube  communicating  with  a 
gasometer  of  registered  and  graduated  capacity, 
into  which  the  patient  breathed. 

A very  convenient  and  accurate  spirometer 
has  within  the  last  few  years  been  introduced  by 
Mr.  Lowne,  which  works  on  the  principle  of  the 
anemometer.  The  advantage  of  this  instrument 
is  its  portability. 

Dr.  Waldenburg  describes  and  figures,  at  page 
202  of  his  work  Die  Pneumatische  Behandlung, 
4'c.,  a spirometer  identical  in  principle  with 
Hutchinson’s,  but  more  elaborate,  and  capable  of 
being  employed  for  the  purpose  of  inhalation  of 
compressed  or  rarefied  air. 

Results. — The  chief  results  of  Dr.  Hutchin- 
son’s labours  may  he  thus  summarised.  The  vital 
capacity  varies  according  to  height,  weight,  age, 
and  disease. 

(1)  Height.  There  is  an  increase  of  8 cub.  in. 
in  vital  capacity  for  every  inch  in  height  between 
5 ft.  and  6 ft.  Thus  the  vital  capacity  of  a healthy 
person  at  5 ft.  to  5 ft.  1 in.  being  174  cub.  in.,  at 
5 ft.  4 in.  it  would  he  174+ 32  = 206  cub.  in. ; at 
5 ft  8 in.  238;  &c. 

(2)  Weight.  Excess  in  body-weight  is  asso- 
ciated with  diminished  capacity  in  the  proportion 
of  about  1 cub.  in.  per  lb.  excess. 

(3)  Age.  From  thirty  to  sixty  years  the  vital 
capacity  decreases  nearly  li  cub.  in.  per  year. 

(4)  Disease.  The  spirometer  furnishes  a very 

accurate  standard  of  health  or  of  the  extent  of 
disease,  as  regards  the  chest,  the  vital  capacity 
in  lung-disease  diminishing  from  10  to  70  per 
cent.  R.  Douglas  Powell. 

SPITTING  OP  BLOOD.— A popular  sy- 
nonym for  haemoptysis.  Sec  Hjemopttsis. 

SPLEEN,  Diseases  of. — Stnon.  : Fr.  Mala- 
dies de  la  Rate ; Ger.  Krankheiten  der  Mila. — In 
the  Nomenclature  of  Diseases  published  by  the 
Royal  College  of  Physicians  of  London,  in  1869, 
the  diseases  of  the  spleen  are  classified  under 

Carter,  in  reference  to  this.  Eays  (Medico-Ctiirvrg.  Trans., 
1S80,  p.  125) : — ‘ The  discrepancies  indeed,  in  my  experi- 
ments are  marked  enough  to  render  it  doubtful  if  the 
spirillum  itself  does  represent  the  contagion  proper,  at.  1 
not  rather  some  other  agency  which  at  certain  periods  is 
associated  with  it.’  A similar  doubt  was  expressed  by 
Dr.  Murchison,  who,  when  referring  to  the  disappearance 
of  the  organisms  from  the  blood  before  the  crisis  of  the 
fever,  their  absence  during  the  intermission,  and  their  re- 
appearance with  the  relapse.of  fever,  said  (Patti.  Trans. 
1875,  p.  317) : ‘ It  seems  difficult  to  account  for  their 
appearance  and  annihilation  twice  over,  except  on  the 
supposition  that  the  soil  was  suitable  for  their  develop- 
ment during  the  febrile  process  and  unsuitable  whan  the 
febrile  process  was  complete.’ 


SPLEEN,  DISEASES  OF. 


diseases  of  the  digestive  system.  Hut  the  spleen, 
which  is  the  largest  of  the  structures  known  as 
• ductless  glands,’  is  not  immediately  concerned 
with  the  processes  of  digestion,  and  its  develop- 
mental origin  shows  it  to  be  unconnected  with 
the  digestive  organs,  although  it  lies  in  the 
abdomen.  Its  diseases  ought  rather  to  be 
classified  with  those  cf  the  other  ‘ductless 
glands,’  namely,  the  thyroid,  the  thymus,  and 
the  supra-renal  capsules.  It  is  now  generally 
admitted  that  the  fimctions  of  the  spleen  are 
intimately  connected  with  the  work  of  sangui- 
fication, through  certain  special  chemical  pro- 
cesses (metabolic)  giving  rise  to  an  assemblage 
of  transformations  of  proteids,  associated  in 
some  way,  still  unknown,  with  the  metamor- 
phoses of  the  blood-corpuscles.  The  spleen  is 
most  probably  one  of  the  seats  of  formation  of 
the  white  blood-corpuscles,  and  of  destruction  of 
.he  red.  It  is  in  fact  a blood-lymph-gland  ; and 
the  most  important  indications  of  splenic  disease 
ire  derived  from  the  constitutional  state  due  to 
extreme  anaemia.  This  anaemia  is  characterised 
by  the  mucous  membranes  appearing  pale  and 
bloodless,  the  complexion  and  general  surface 
waxy,  earthy-like,  or  sallow ; there  is  great 
debility  and  gradual  wasting,  characteristic  dys- 
pnoea, a tendency  to  haemorrhages,  general  ana- 
sarca and  dropsy, — phenomena  which  are  due 
to  tho  poverty  of  the  blood,  justly  referable  to 
some  morbid  condition  of  the  spleen,  and  now 
generally  recognised  by  the  name  of  splenic 
cachexia.  Another  important  function  of  the 
spleen,  in  connection  with  the  other  ductless 
glands,  ought  not  to  be  lost  sight  of  in  the  study 
it'  its  diseases,  namely,  that  it  acts  as  a diver- 
ticulum for  tho  accommodation  of  a relatively 
large  quantity  of  the  blood,  upon  which  those 
active  metabolic  processes  take  place  which  con- 
stitute a special  function  of  the  spleen.  Its 
anatomical  structure  eminently  fits  it  for  this. 
After  every  meal  it  is  in  a' state  of  more  or  less 
congestion  or  hypereemia,  which  reaches  its 
maximum  about  five  hours  after  the  taking  of 
,ood,  and  it  then  returns  to  its  normal  bulk.  Its 
yielding  capsule  and  its  veins,  remarkable  for 
their  large  calibre  and  great  distensibilitv,  even 
when  the  distending  force  is  small,  sufficiently 
explain  the  rapid  physiological  and  morbid 
congestions  with  which  the  organ  is  affected, 
as  well  as  the  rapid  subsidence  of  splenic  en- 
largements. The  ductless  glands,  and  especially 
the  spleen,  vary  so  much  in  magnitude  within 
healthy  limits,  that  it  is  difficult  to  state  their 
usual  weight  and  dimensions.  The  spleen  may, 
however,  be  stated  to  range  in  weight  in  the 
adult  from  four  to  ten  ounces  avoirdupois  ; but 
in  eases  of  enlargement  weights  as  high  as 
18  lbs.,  20  lbs.,  and  even  40  lbs.  are  on  record. 
In  atrophic  states  the  writer  has  weighed  it  as 
low  as  half  gn  ounce.  In  relation  to  the  body 
its  normal  weight  is  about  1 to  350  or  400  up  to 
the  age  of  forty ; and  as  age  advances,  the  rela- 
tion becomes  as  1 to  about  700.  It  usually 
measures  about  5 inches  in  length  ; 3t)  inches 
from  the  front  to  the  posterior  edge;  and  1^- 
inches  in  thickness.  Its  bulk  averages  from  9 J- 
to  15  cubic  inches ; and  its  specific  weight  is 
about  1 0G0. 

In  the  following  paragraphs  the  diseases  of  the 


1609 

spleen  will  be  shortly  noticed  mainly  in  the  order 
in  which  they  have  been  named  in  the  nomen- 
clature of  the  College. 

1.  Acute  Inflammation. — Svxorr. : Splenitis. 
As  a primary  affection  acute  inflammation  of  the 
spleen  is  of  rare  occurrence  in  this  country.  It 
has  been  known,  however,  to  result  from  blows, 
or  other  kinds  of  accidental  violence;  but  such 
injuries  are  more  apt  to  cause  rupture  of  the 
organ.  It  is  mainly  to  the  occurrence  of  haemor- 
rhagic infarctions  that  splenitis  is  due,  with 
more  or  less  consecutive  suppuration.  These 
infarctions  occur  during  the  course  of  contagious 
fevers ; in  blood-poisoning,  such  as  pyaemia ; 
and  in  valvular  diseases  of  the  heart,  where 
vegetations  of  fibrin  form  on  the  valves,  leading 
to  embolism.  Such  infarctions  are  generally 
well-defined  accumulations  of  fibrin  in  more  or 
less  rounded  masses  when  limited  and  in  the  sub- 
stance of  the  organ,  but  generally  wedge-shaped 
when  involving  larger  portions.  The  base  of  the 
wedge  is  towards  the  periphery,  where  it  may 
cause  an  elevation  of  the  capsule,  the  apex  being 
directed  towards  the  hilus  of  the  spleen.  The 
infarctions  vary  in  size  from  a pea  to  a hen’s  egg ; 
and  are  at  first  of  a dark  brown  or  brownish- 
red  colour,  and  quite  hard.  Colour,  however,  is 
soon  lost,  and  they  become  yellowish-white.  A 
margin  of  acute  inflammatory  reaction  is  often 
well-marked  round  their  boundaries.  Under 
such  circumstances  the  spleen  is  enlarged,  and  of 
a deep  purple  colour ; its  tissue  so  soft  as  to  be 
easily  broken  down — about  the  consistence  of 
coagulated  blood.  Pus  may  form,  generally  in 
one  or  more  abscesses  containing  each  a variable 
quantity ; or  the  whole  spleen  may  be  converted 
into  a bag  of  pus.  Splenic  abscesses  have  been 
known  to  open  externally,  into  the  left  thoracic 
cavity,  the  stomach,  the  transverse  colon,  and  tho 
cavity  of  the  peritoneum,  where  circumscribed 
peritonitis  generally  forms  a limiting  sac  for  tho 
pus.  Splenitis  may  also  terminate  by  the  infarc 
tion  caseating,  or  becoming  a mass  of  fibro- 
cellular  substance,  which,  gradually  shrinking 
up,  leaves  a cicatrix-like  contraction  on  the 
capsular  surface,  in  which  calcification  may  oc- 
cur. These  fibrinous  infarctions  in  the  spleen  cor- 
respond to  the  areas  which  mark  the  terminal 
divisions  of  the  branches  of  the  splenic  arteries, 
commencing  to  deposit  beyond  where  they  break 
up  into  the  hair-pencil-like  small  twigs  known 
as  penicilli.  Secondary  splenitis  is  generally  the 
result  of  pyaemia  or  blood-poisoning,  ending  in 
abscess.  Such  pymmic  blocks  or  infarcts  resemble 
the  simply  fibrinous  infarcts  in  shape,  but  they 
are  more  irregular,  because  the  process  tends  to 
extend  beyond  the  limits  of  the  area  of  the 
terminal  twigs  of  the  blood-vessels;  and  they 
rapidly  proceed  to  suppuration,  with  inflammation 
of  the  capsule  of  the  spleen  which  covers  the 
base  of  the  infarct,  and  probably  due  to  its  very 
septic  properties.  In  such  eases  there  seems  to 
be  some  spontaneous  local  coagulation  of  the 
blood  in  the  splenic  vessels — the  blood  itself 
being  morbid,  as  in  contagious  fevers  such  as 
typhus — without  any  evidence  of  embolism. 

Symptoms  axb  Physic  at.  Signs. — The  symp- 
toms and  physical  signs  of  splenitis  are  mainly 
due  to  the  presence  of,  and  changes  associated 
with,  infarcts.  The  hyperaemia  and  inflammation 


SPLEEN,  DISEASES  OF. 


*510 

cause  tlie  whole  gland  to  swell.  In  cardiac 
diseases,  with  embola  from  valvular  vegetations, 
these  infarcts  are  generally  numerous,  and  the 
swelling  is  therefore  proportionally  great,  with 
tumefaction  and  some  pain  in  the  left  side  : and 
probably  there  is  ascites  and  dropsy.  Such 
splenitis  may  go  on  even  to  suppuration,  without 
marked  local  symptoms.  The  enlargement  of  the 
spleen — sometimes  called  ‘splenic tumour’ — can 
generally  be  recognised  by  palpation,  aided  by 
percussion.  Its  form  is  that  of  the  spleen  ex- 
aggerated ; and  the  lobulation  or  notching  of  its 
swollen  anterior  edge  can  sometimes  be  felt 
through  the  wall  of  the  abdomen,  if  the  patient 
he  thin.  The  enlarged  gland,  growing,  as  it  were, 
out  from  beneath  the  ribs  on  the  left  side,  can 
sometimesbetraeed  extending lowdown,  asfaras, 
and  even  into,  the  pelvic  region,  well  over  beyond 
the  right  side  of  the  lima  alba,  and  backwards 
towards  the  spine,  where  its  margin  can  be 
separated  from  the  mass  of  dorsal  muscles.  Its 
lower  end  can  also  generally  be  felt  as  a rounded 
edge.  The  tumour  is  movable  in  all  directions  by 
manipulation,  change  of  posture,  and  by  the  act  of 
respiration,  when  adhesions  do  not  fix  it.  Weight 
and  uneasiness,  rather  than  local  soreness,  are 
present.  The  splenic  cachexia  exists  ; and  there 
may  occur  hsemorrhages  from  the  stomach  and 
bowels  towards  the  fatal  end  of  such  cases,  often 
so  profuse  as  rapidly  to  hasten  dissolution. 

Diagnosis. — The  diagnosis  of  enlarged  spleen, 
resulting  from  splenitis  due  to  one  or  other  of 
the  causes  referred  to,  requires  the  exclusion  of 
lardaceous  disease ; malignant  or  other  tumours 
about  the  cardiac  end  of  the  stomach  or  tail  of 
the  pancreas ; such  swollen  conditions  of  the 
spleen  as  exist  in  Hodgkin’s  disease ; an  enlarged 
left  lobe  of  the  liver ; and  renal,  omental,  or 
supra-renal  growths. 

2.  Hypertrophy. — Simple  enlargement  of  the 
spleen  occurs  under  a great  variety  of  circum- 
stances ; but  true  hypertrophy,  uncomplicated, 
and  in  its  simplest  form,  is  a rare  occurrence, 
in  which  nothing  abnormal  is  to  be  seen  in  the 
spleen  or  in  the  blood.  Enlargement  with  hy- 
peroemia  (congestion  of  the  spleen)  occurs  as  a 
result  or  concomitant  of  pyrexia  in  many  specific 
fevers — notably  in  enteric  and  malarious  fevers, 
erysipelas  and  puerperal  fever,  pyeemia,  and  acute 
tuberculosis.  The  capsule  of  a spleen  so  enlarged 
appears  very  tense.  The  gland  feels  plump  and 
elastic ; but  on  section  its  substance  is  generally 
soft,  pulpy,  almost  liquid,  very  full  of  blood,  and 
of  a dark  colour.  Sometimes,  however,  it  is  so 
firm  that  a more  or  less  smooth  or  coarsely  gran- 
ular surface  is  shown  on  section,  with  an  abun- 
dant new  formation  of  small  lymph-cells  and 
nuclei,  many  of  them  contained  in  large  mother 
cells  (compound  splenic  corpuscles),  and  seen 
especially  in  the  splenic  pulp  and  vein.  This 
condition  constitutes  the  nearest  approach  to  true 
hypertrophy,  iu  which,  with  an  increase  in  the 
quantity  of  diffuse  granular  matter,  the  enlarge- 
ment is'  due  less  to  hyperemia  simply  than  to 
increase  of  normal  structural  constituents.  Thus 
the  organ  may  attain  two  or  three  times  its 
natural  size  ; but  the  enlargement  is  only  tem- 
porary, and  subsides  as  the  pyrexia  subsides. 
Such  simple  hypertrophy  sometimes  results  from 
long-continued  or  mechanical  hypersemia,  follow- 


ing any  obstruction  to  the  portal  circulation,  or 
obstructive  valvular  disease  of  the  heart. 

The  hypertrophy  consequent  on  malaria  being 
fully  described  in  another  article  (see  Malahia), 
there  only  remain  to  he  noticed  two  special 
forms  of  splenic  hypertrophy,  one  named  by  the 
College  of  Physicians  as  a subvariety — namely 
(a)  leucocyth&mia  or  leuktemia ; and  the  other  (b) 
a peculiar  enlargement  originally  described  by 
Dr.  Hodgkin,  hut  which  has  not  been  named 
by  the  College  as  a substantive  disease.  It  is, 
however,  an  affection  which  presents  such  very 
striking  peculiarities,  that  it  requires  a distinct 
appellation  and  description. 

a.  LeucocythtBmici. — Leucocythsemia  is  fully 
described  under  its  own  heading;  but  a brief 
account  may  be  given  of  the  disease  in  the  pre- 
sent article.  It  has  a much  more  extended 
pathology  than  is  implied  by  a mere  hyper- 
trophy of  the  spleen,  although  the  enlargement 
of  the  spleen  is  almost  constant.  The  disease 
is  one  sui  generis,  in  which  the  number  of  the 
white  corpuscles  of  the  blood  is  greatly  increased, 
with  a simultaneous  diminution  of  the  red.  It  is 
generally  brought  about  by  chronic  exhausting 
diseases,  exposure  to  cold  and  wet,  or  such 
serious  acute  diseases  as  typhus  fever,  pneu- 
monia, puerperal  fever,  or  affections  of  the  lym- 
phatic glands  ; and  it  is  almost  always  attended 
by  enlargement  of  the  spleen.  The  condition 
is  generally  associated  with  cough,  diarrhoea, 
epistaxis,  haemorrhagic  effusions,  and  furuncu- 
lous or  pustular  eruptions.  The  increase  of  the 
colourless  corpuscles  of  the  blood,  which  with 
the  enlargement  of  the  spleen  are  the  prominent 
characteristics  of  this  disease,  does  not  seem  in 
any  case  to  have  occurred  alone.  Other  and 
variable  morbid  states  are  always  associated ; or 
some  change-producing  event  in  the  constitution, 
such  as  happens  during  the  period  of  gestation 
and  the  process  of  parturition,  precedes  or  co- 
exists with  the  augmentation  of  the  colourless 
blood- cells.  The  largest  spleens  are  found  ia 
connection  with  this  disease.  There  is  a true 
hypertrophy  of  the  organ  in  all  its  parts,  so  that 
its  substance  on  section  appears  to  be  quito 
natural,  although  sometimes  paler  than  usual 
(as  all  the  organs  are),  and  sometimes  having  a 
peculiar  smooth  lustrous  appearance.  Lymphatic 
structures  also  are  to  be  sometimes  seen  in  sepa- 
rate or  conglomerate  masses  in  its  substance. 
These  are  composed  mainly  of  adenoid  tissue, 
like  a congeries  of  splenic  corpuscles  or  Halpig- 
liian  bodies.  The  liver  is  frequently'  enlarged 
and  pale.  Affections  of  the  lymphatic  glands 
sometimes  also  predominate ; especially  in  such 
cases  as  Virchow  has  described,  where  a lym- 
phatic diathesis  prevails,  and  there  is  a progres- 
sive inclination  of  the  lymphatic  system  to  the 
formation  of  lymphatic  elements,  while  lym- 
phatic gland-tissue  tends  to  grow  beyond  itspre- 
existing  boundaries.  The  liver,  in  such  cases,  as 
well  as  the  spleen,  contains  numerous  accumula- 
tions in  whitish  granules,  or  some  kind  of  lymph 
tissue.  This  constitutes  lymphamia,  or  the  lym- 
phatic form  of  leueocythasmia ; the  other  being 
the  splenic.  It  may  also  be  associated  with  an 
increase  in  the  medulla  of  the  bones.  The  causes 
which  bring  about  this  form  of  hypertrophy  of 
the  spleen,  with  its  attendant  changes  in  thf 


SPLEK.Y,  DISEASES  OF. 


blood,  are  yet  obscure;  still  there  is  sufficient 
evidence  to  show  that  some  acute  inflammatory 
processes  may  lay  the  foundations  of  tho  morbid 
state.  Tho  writer  has  seen  the  lymphatic  form 
of  the  disease  follow  so  conspicuously  after  expo- 
sure to  cold  and  wet,  as  to  leave  no  doubt  of  the 
relation  of  the  diseaso  to  the  exposure  in  the 
connection  of  effect  and  cause,  the  inflammatory 
swellings  of  the  lymphatic  glands  commencing 
immediately  after  the  exposure.  There  is  also 
evidence  to  show  that  the  disease  may  exist  in  a 
latent,  masked,  or  subacute  form  for  an  un- 
known period,  till  the  occurrence  of  some  more 
acute  disease,  or  change-producing  period  like 
child-birth,  unmasks  the  constitutional  state, 
after  which  the  disease  rapidly  proceeds  to  a 
fatal  issue.  In  females  four  cases  out  of  teu 
have  had  their  first  beginnings  rendered  obvious 
after  pregnancy. 

Symptoms. — In  the  majority  of  cases  intense 
‘splenic  cachexia’  prevails,  with  tho  usual 
physical  signs  of  splenic  tumour.  Weight  and 
fulness  of  the  abdomen  are  the  chief  subjective 
local  sensations;  but  transitory  pains  are  fre- 
quently experienced  there.  Ascites  and  anasarca 
are  usually  also  present.  The  surface  of  the 
body  is  pale  ; vomiting,  diarrhrea,  or  constipation 
may  prevail  by  turns ; and  jaundice  is  not  infre- 
quent ; but  diarrhoea  to  a considerable  amount 
is  by  far  the  most  frequent  and  dangerous  com- 
plication, and  the  most  difficult  to  arrest  or  con- 
trol. Haemorrhage  occurs  generally  as  epistaxis, 
or  from  the  gums.  The  course  of  leueocythae- 
mia  is  usually  chrome,  and  an  extreme  degree  of 
emaciation  is  the  result ; but  it  is  uot  till  towards 
the  fatal  issue  that  febrile  phenomena  set  in,  the 
type  of  which  is  usually  hectic.  In  the  diagnosis 
of  this  disease  it  is  necessary  to  examine  the 
blood  microscopically,  in  order  to  demonstrate 
the  varied  increase  of  the  colourless  blood-cor- 
puscles and  diminution  of  the  red.  A single 
drop  of  blood  is  sufficient  for  this  purpose,  most 
conveniently  obtained  by  a needle  puncture  of 
the  patient's  finger,  the  resulting  drop  of  blood 
being  examined  under  a magnifying  combination 
of  at  least  250  diameters.  The  colourless  cor- 
puscles will  then  bo  seen  to  form  at  least  a 
sixth,  a fourth,  or  nearly  a half  of  the  whole 
number  of  corpuscles.  A proportion  of  one 
white  to  ten  red,  or  even  as  many  as  one  to 
three,  is  not  uncommon — an  increase  which 
gives  to  the  blood  a paler  and  more  opaqiie 
appearance  than  is  natural.  In  splenic  leuksemia 
the  white  corpuscles  are  larger  and  more  granu- 
lar than  normal.  The  red  corpuscles  may  be 
reduced  to  one  half,  or  one  quarter,  of  the  nor- 
mal amount.  As  leukssmic  blood  decomposes, 
Charcot  discovered  that  it  contained  microscopic, 
colourless,  elongated,  octohedral  or  spindle- 
shaped  crystals,  insoluble  in  water,  but  soluble 
in  acids  and  alkalies,  which  he  and  \ ulpian 
regarded  as  proteid  bodies. 

Prognosis. — Hitherto  no  instance  of  cure  is 
known.  All  the  cases  have  progressed  to  a fatal 
termination  in  about  fourteen  months — the  mini- 
mum duration  being  about  three  months,  and  the 
maximum  about  four  j'ears.  Death  takes  place 
gradually  by  asthenia  and  exhaustion  ; or  rapidly 
from  htemorrhage  or  diarrhoea. 

b.  Hodgkin's  disease. — Tho  other  form  of 


1511 

splenic  hypertrophy  is  that  which  has  been  de- 
scribed by  the  name  of  ‘ Hodgkin's  disease.’  It 
is  also  known  as  lymphadenoma.  It  is  charac- 
terised by  a peculiar  white  deposit  or  growth  in 
the  spleen,  in  addition  to  mere  hypertrophy  ; 
which  is  sometimes  also  seen  in  the  liver,  kid- 
neys, and  lungs.  An  enormous  enlargement 
of  the  lymphatic  glands  throughout  the  body, 
accompanied  during  life  by  a remarkable  anaemia 
and  disposition  to  subcutaneous  oedema,  arc 
usually  the  earliest  phenomena.  The  groups  of 
glands  in  the  order  of  their  most  frequent  in  - 
volvement  are  the  cervical,  axillary,  inguinal, 
retro-peritoneal,  bronchial,  mediastinal,  and  me- 
senteric. The  new  growth  is  at  first  limited 
to  the  glands,  blit  eventually  advances  beyond 
their  capsules,  so  that  the  enlarged  giants  be- 
come confluent  in  lobulated  masses,  which  may 
invade  and  infiltrate  adjacent  tissues.  The  dis- 
ease differs  from  leucocythsemia  in  this  respect, 
that  there  is  no  marked  increase  in  the  white 
corpuscles  of  the  blood;  nor  has  it  anything  to 
do  with  lardaceous  disease.  The  enlargement-  of 
tbe  lymphatic  glands  appears  as  the  primary 
affection,  and  consists  in  a general  hypertrophy 
of  every  part-  of  the  glands  ; but  the  exact  nature 
of  the  defined  white  bodies  which  pervade  the 
spleen  is  not  clearly  made  out.  Their  growth 
commences  in  the  Malpighian  bodies.  They  arc 
similar  to  what  are  found  in  the  liver,  lungs, 
and  kidneys  ; and  are  composed  mostly  of  lym- 
phoid or  adenoid  cells  imbedded  in  the  stroma, 
similar  to  the  structure  of  a lymphatic  gland. 
See  Lymphadenoma. 

Symptoms. — These  are  indicative  of  general 
ill-health — paleness  and  sallowness  of  complexion 
preceding  all  other  signs.  Weakness  gradually 
increases,  the  patient  begins  to  totter  on  his 
legs,  and  at  last  is  unable  to  walk.  Sexual  appe- 
tite is  lost ; and  emaciation  progresses,  with 
marked  antemia,  a pale  sclerotic,  and  a feeble 
pulse.  The  legs  finally  become  osdematous. 

Prognosis. — The  disease  is  eminently  malig- 
nant, death  usually  taking  place  through  derange- 
ment of  tire  functions  of  the  lymphatic  system. 

3.  Lardaceous  Disease. — Albuminoid  dis- 
ease is  rarely  limited  to  the  spleen,  but  usually 
also  affects  the  liver,  kidneys,  and  sometimes  the 
intestinal  villi  in  the  same  patient.  The  trabe- 
cular interspaces,  but  more  commonly  the  ]Mal- 
pighian  sacculi,  are  filled  with  the  new  material, 
so  that  each  corpuscle  looks  like  a sago-grain. 
The  spleen  sg  affected  is  usually  enlarged,  and 
is  specifically  as  well  as  absolutely  heavier  than 
in  health.  Sec  Albuminoid  Disease. 

A lardaceous  spleen  implies  a long-standing 
cachexia,  and  in  its  most  intense  form  is  seen 
after  protracted  caries  and  necrosis  of  bone,  es- 
pecially when  associated  with  scrofula  or  syphilis ; 
or  even  after  external  injury  which  leads  to 
protracted  bone-disease.  Hence  the  question  is 
still  undecided  whether  lardaceous  disease  arises 
from  such  local  sources,  or  is  a constitutional  or 
general  diseaso. 

4.  Cancer. — Cancer  of  the  spleen  is  extremely 
rare  as  a primary  lesion.  It  chiefly  occurs  as  an 
infective  process,  following  generally  cancer  of 
the  stomach  or  other  viscus  ; or  as  generally  dis- 
seminated encephaloid  growths. 

5.  Hare  Diseases. — Here  it  is  only  necessary 


i 51 2 SPLEEN,  DISEASES  OE. 
io  mention  hydatid  disease,  tubercle,  and  the 
3plenic  enlargement  occasionally  occurring  in 
congenital  syphilis. 

Treatment. — Treatment  of  these  diseases  of 
the  spleen  by  medicinal  remedies  is  extremely 
uncertain,  as  can  readily  be  understood  from 
what  is  known  of  their  pathology.  All  sources 
of  mechanical  congestion  must  if  possible  be 
removed  or  relieved.  Saline  purgation  may  be 
useful  for  this  purpose  ; also  compound  jalap 
powder,  with  rhubarb,  and  sulphate  of  iron  may  be 
taken  in  such  quantities  as  will  produce  three  or 
four  stools  in  the  twenty-four  hours.  The  iodides 
and  bromides  of  potassium  have  also  been  recom- 
mended. The  biniodide  of  mercury,  in  the  form 
of  an  ointment,  rubbed  into  the  skin,  has  also 
had  a beneficial  effect  in  reducing  simple  splenic 
enlargement  when  not  otherwise  complicated. 
In  the  chronic  hypertrophies,  such  as  leucocythce- 
mia  and  Hodgkin’s  disease,  improvement  of  the 
general  health  is  all  that  can  be  arrived  at,  by  the 
employment  of  tonics,  change  of  air,  and  atten- 
tion to  the  hygiene  of  the  patient.  Sec  Leuco- 
cyth/Emia  ; and  Lymph  adenoma. 

William  Aitken. 

SPLENIC  FEVER.  Sec  Pustule,  Malig- 
nant. 

SPLENIZATION. — A morbid  state  of  the 
lung,  in  which  it  somewhat  resembles  the  spleen 
in  colour  and  consistence.  Sec  Lungs,  Compres- 
sion of. 

SPORADIC  ( (r7r64w,  I scatter). — This  term 
is  used  in  connection  with  the  occurrence  of 
diseases  occasionally,  and  in  an  isolated  manner, 
amongst  individuals;  as  distinguished  from  those 
diseases  which  appear  endemically  or  epidemi- 
cally. See  Disease,  Classification  of. 

SPORADIC  CHOLERA.  Sec  Choleraic 
Diarrhoea. 

SPOTS. — A popular  name  for  eruptions  on 
the  skin.  See  Eruption  ; and  Macuue. 

SPOTTED  FEVER. — A popular  name  for 
typhus  fever.  See  Typhus  Fever. 

SPRAT'S,  Therapeutical  Uses  of.  Sec 
Inhalations. 

SPUTUM  ( spuo , I spit.)  See  Expectoration. 

SQ.UAMJE  {squama,  a scale). — Scales.  A 
synonym  for  scaly  diseases  of  the  skin.  See 
Scaly  Eruption. 

SQUINTING.  A popular  name  for  stra- 
bismus. See  Strabismus. 

STADIUM  (Latin,  a stage). — A period  or 
stage  in  a disease,  as  in  fever ; for  example, 
stadium  increment i,  stadium  convalescents. 

STAGNATION  OF  BLOOD.— Local  ar- 
rest of  the  circulation.  See  Circulation,  Dis- 
orders of ; and  Inflammation. 

STAINS. — This  word,  as  applied  to  the  skin, 
is  synonymous  with  ‘ maculae.’  See  Macula. 

STAMMERING.— Synon.  : Fr.  Begaic- 

ment;  Ger.  Stottern. 

Definition. — Under  the  head  of  stammering, 
in  its  broadest  sense,  are  included  many  different 


STAMMERING. 

forms  of  defective  articulation,  such  as  the  in- 
ability, congenital  or  acquired,  to  pronounce  cer- 
tain letters  or  certain  combinations  of  letters,  the 
tendency  to  hesitate  or  stumble  in  utterance  or 
to  transpose  letters  or  syllables,  and  the  habit 
of  interjecting  meaningless  sounds  or  words  into 
the  pauses  which  occur  in  the  course  of  continu- 
ous speech.  But  the  term  is  generally  used,  at 
any  rate  in  English,  as  synonymous  with  stultcr- 
ing,  to  imply  a spasmodic  affection  of  the  organa 
concerned  in  speech,  in  virtue  of  which  the  enun- 
ciation of  words  becomes  suddenly  checked,  and 
a painful  pause  ensues,  not  infrequently  marked 
by  a prolongation,  or  a repetition  in  rapid  se- 
quence, of  the  particular  literal  sound  at  which 
the  check  arises. 

^Etiology. — Stammering  is  to  some  extent 
hereditary,  although  a large  number  of  stam- 
merers are  certainly  free  from  hereditary  taint. 
It  is  sometimes  imitative.  The  defect  rarely,  if 
ever,  shows  itself  before  the  age  of  four  or  "five 
years.  Usually  it  comes  on  from  this  time  up  to 
the  period  of  puberty.  But  it  may  originate  at 
any  age  ; sometimes  after  febrile  disorders  ; some- 
times in  connection  with  nervous  affections,  such 
as  epilepsy,  hysteria,  and  tabes  dorsalis ; some- 
times it  attends  mere  temporary  failure  of  health ; 
sometimes  it  appears  in  connection  with  soreness 
or  irritation  of  the  mouth ; sometimes  it  is  induced 
by  simple  nervousness  or  excitement.  In  many 
of  these  cases  the  stammering  is  temporary  only, 
and  disappears  with  its  cause.  And  as  a general 
rule  confirmed  stammerers  have  their  infirmity 
aggravated  under  similar  circumstances.  Occa- 
sionally, on  the  other  hand,  stammering  ceases 
during  the  presence  of  illness.  It  is  a curious 
fact  that  men  stammer  in  much  larger  proportion 
than  women.  Cases  of  persistent  stammering, 
arising  in  childhood,  sometimes  recover  in  the 
course  of  time  ; and,  as  a general  rule,  some  im- 
provement takes  place  after  the  attainment  of 
maturity,  and  especially  as  age  advances. 

Description. — It  has  often  been  maintained 
that  stammering  occurs  only  in  connection  with 
the  enunciation  of  the  explosive  consonants, 
that  it  never  attends  the  utterance  of  the  vowels, 
and  that  it  never  manifests  itself  during  the 
acts  of  whispering  and  of  singing.  All  these 
statements,  however,  though  founded  on  fact, 
axe  more  or  less  inaccurate.  For  though  it  is  at 
the  explosive  consonants  b,  p,  d,  t,  hard  g and  k, 
that  stammerers  for  the  most  part  come  to  grief, 
stammering  is  by  no  means  uncommon  during 
the  articulation  of  the  continuous  consonants, such 
as  v.f  th , s,  sh,  y,  w,  in,  n,  and  even  occurs  when 
vowel-sounds  are  being  produced;  and  though  it 
is  certainly  rare  for  patients  to  stammer  when 
whispering  or  singing,  there  are  exceptions  to 
this  rule. 

When  stammering  takes  place  in  connection 
with  the  explosive  consonants,  the  barriers  by 
whose  sudden  opening  after  complete  closure  the 
several  consonantal  sounds  are  produced,  instead 
of  separating,  as  they  should  do,  remain  spas- 
modically closed;  and  the  patient  struggling  to 
overcome  the  spasm,  either  remains,  foravariable 
but  short  time,  absolutely  voiceless,  or  overcoming 
the  resistance  fitfully,  utters  the  consonantal 
sound  in  a series  of  two  or  more  successive  puffs. 
In  the  utterance  of  b and p it  is  the  lips  which 


STAMMERING.  1513 


remain  closed ; in  the  utterance  of  d and  t it  is 
the  barrier  formed  by  the  tongue,  whose  tip  is 
pressed  against  the  superior  incisors  or  anterior 
part  of  the  palate  ; in  the  production  of  hard  g 
and  k it  is  the  barrier  formed  by  the  pressure  of 
the  dorsum  or  root  of  the  tongue  against  the 
posterior  part  of  the  palate. 

In  pronouncing  the  continuous  consonants,  the 
barriers  at  which  the  distinctive  sounds  are  pro- 
duced are  not  in  absolute  or  uniform  contact; 
and  the  consonantal  sounds  are  continued  during 
the  passage  of  air  through  the  constricted  oral 
channel  or  through  the  nose.  When,  therefore, 
stammering  attends  their  pronunciation,  it  is  not 
due  to  any  spasmodic  closure  of  the  parts  engaged, 
but  rather  to  their  fixation  in  the  natural  position 
they  have  assumed,  and  to  the  frequent  association 
therewith  of  more  or  less  rhythmical  attempts 
to  close  them  or  to  separate  them  more  widely 
from  one  another.  The  resulting  sounds  therefore 
either  come  to  a full  stop,  or  are  simply  prolonged 
or  drawled,  or  are  repeated. 

In  the  utterance  of  the  vowels  the  mouth  and 
its  appendages  play  only  a subordinate  part,  and 
a free  passage  is  maintained  for  the  passage  of 
air  through  the  mouth.  It  is  at  the  rima  glot- 
tidis  that  the  fundamental  sound  is  produced, 
and  it  is  mainly  to  spasm  of  this  part  that  vowel- 
stammering is  due. 

JBut  the  hitch  in  utterance  may  also  originate 
in  the  respiratory  apparatus,  and  not  infrequently 
stammering  depends  on  a sudden  inspiration  or 
expiration,  or  on  an  arrest  of  the  respiratory 
movements. 

It  will  thus  be  seen  that  stammering  may  be 
caused  by  spasm  of  either  of  the  three  mecha- 
nisms concerned  in  the  mechanical  production  of 
speech  ; namely,  the  mouth,  wherein  words  are 
articulated ; the  larynx,  where  phonation  is 
effected ; and  the  respiratory  apparatus,  which 
regulates  the  supply  of  air  to  the  organs  of  speech 
and  of  music.  At  the  same  time  there  is  no 
doubt  that  stammering  is  far  more  frequently 
connected  with  spasm  of  the  muscles  of  articu- 
lation than  with  spasm  of  the  larynx  or  of  the 
respiratory  muscles,  and  that,  of  the  three,  respi- 
ratory spasm  is  the  least  common.  Not  infre- 
quently, however,  the  different  varieties  of  spasm 
are  associated  in  s greater  or  less  degree. 

The  degree  and  character  of  stammering  differ 
largely  in  different  cases.  Sometimes  it  is  no- 
thing more  than  a scarcely  perceptible  hitch  in 
the  enunciation  of  a particular  letter;  sometimes 
it  is  so  severe  and  continuous  that  the  patient 
becomes  almost  unintelligible.  The  most  dis- 
tressing cases  are  those  in  which  the  spasm  ex- 
tends to  parts  unconnected  with  speech,  it  may 
be  to  nearly  the  whole  muscular  organism.  In 
such  a case  the  spasm  commences,  let  us  assume, 
at  the  base  of  the  tongue ; the  mouth  opens  widely, 
and  remains  in  that  position;  the  muscles  of  ex- 
pression work  convulsively  ; the  glottis  contracts; 
respiration  becomes  arrested;  the  face  becomes 
congested  and  the  veins  dilated  ; violent  spas- 
modic movements  involve  the  trunk  and  limbs; 
and  only  after  some  time,  either  when  the  pa- 
tient becomes  exhausted  or  he  resolutely-  restrains 
his  attempts  to  articulate,  does  his  paroxysm  come 
to  an  end.  A stammerer  of  this  kind  is  a truly 
pitiable  object.  Fortunately  for  him,  however, 


these  severe  paroxysms  are  not  always  present ; 
they  increase  in  number  and  intensity  under 
excitement  or  nervousness;  and,  on  the  other- 
hand,  may  be  replaced  to  a large  extent  in  ordi- 
nary quiet  conversation  by  merely  slight  hitches 
or  drawls  or  reduplications  of  letters.  A condition 
allied  to  stammering,  to  which  the  name  Aph- 
thongia  has  been  given  by  Fleury,  has  been  occa- 
sionally observed.  It  seems  to  be  tire  product  of  in- 
tense excitement,  and  of  temporary  duration  only  ; 
and  to  be  characterised  by  powerful  spasm  of  the 
muscles  supplied  by  the  hypoglossal  nerves,  inclu- 
ding the  sterno-hyoid,  sterno-thyroid,  and  thyro- 
hyoid muscles,  which  comes  on  whenever  an 
attempt  to  speak  is  made,  and  totally  prevents 
speech. 

Pathology. — The  pathological  explanation  of 
stammering  is  obscure.  There  is  no  reason  to 
believe  that  it  depends  on  any  discoverable  ma- 
terial lesion,  either  of  the  organs  concerned  in 
speech,  or  of  the  nervous  mechanism  which  con- 
trols them.  It  appears  to  be  allied  to  a series  of 
spasmodic  affections,  which  have  been  especially 
studied  by  Duchenne,  in  which  complex  co-ordi- 
nated movements  (facility  in  the  execution  of 
which  is  only  attained  by  long  practice)  are  con- 
cerned; such,  for  example,  as  scrivener's  palsy, 
and  the  recurrent  spasms  which  occasionally 
compel  the  skilful  pianist  or  violinist,  and  the 
practised  swordsmau,  to  give  up  their  pastime  or 
avocation.  Speech  is  pre-eminently'  an  act  of  this 
kind.  It  is  slowly  and  laboriously  learnt  in 
early  childhood ; and  ease  and  accuracy  of  arti- 
culation are  the  result  only  of  long  and  con- 
tinuous practice.  We  are  born  with  tho  capa- 
city for  speech,  but  articulate  speech  itself  is 
the  outcome  of  careful  education.  For  its  suc- 
cessful performance  it  is  necessary  that  three 
distinct  and  complex  mechanisms — the  respira- 
tory, the  phonetic,  aud  the  articulatory — shall 
act  with  precision  and  in  exact  concordance;  that 
the  lungs  shall  be  expanded  at  suitable  inter- 
vals, and  to  a suitable  degree,  and  that  the  force 
of  expiration  shall  be  regulated  with  nicety; 
that  the  rima  glottidis  shall  be  opened  or  closed 
according  as  surd  or  sonant  letters  are  to  be 
produced,  and  that  the  tension  of  the  cords  shall 
be  accurately  adjusted  to  the  pitch  of  the  musical 
tones  required  to  be  produced;  and  that  the 
movements  of  the  lips,  jaws,  tongue,  and  soft 
palate  shall  be  accurately  adjustable  for  each 
literal  sound,  and  capable  of  passing  from  one 
set  of  adjustments  to  another  with  rapidity  and 
smoothness.  Of  all  these  co-ordinated  move- 
ments, those  connected  with  articulation  are  the 
most  various  in  their  grouping,  the  most  rapid 
in  their  changes,  and  the  latest  learnt.  It  is 
natural,  therefore,  that  the  hitch  or  spasm  inter- 
rupting speech  should  occur  mainly  in  connec- 
tion with  these,  andmainly,  if  not  exclusively,  at 
the  instant  of  passing  from  one  literal  sound  to  an- 
other; that  is  to  say,  at  the  moment  of  transition 
from  one  set  of  muscular  combinations  to  an- 
other set.  It  is  natural  too  that  the  laryngeal 
or  the  thoracic  spasm  should  occur  rather  in 
association  with  articulation  than  at  other  times; 
inasmuch  as  the  movements  are  more  various 
and  intricate  during  articulation  than  they  are 
during  ordinary  respiration,  or  even  than  they 
are  in  the  production  of  musical  notes,  as  in 


<514  STAMMERING. 

singing.  In  the  last  case  the  laryngeal  changes, 
though  extremely  delicate  and  exact,  are  mainly 
of  one  kind  only,  dependent,  namely,  on  varia- 
tions of  tension  in  the  vocal  cords. 

Treatment. — In  dealing  with  cases  of  stam- 
mering it  is  necessary  in  the  first  place  to  coun- 
teract, or  cure,  if  possible,  any  affection  of  the 
mouth  or  throat,  or  any  general  disorder  that 
may  be  present,  -which  are  frequent  causes  of 
temporary  stammering,  or  of  aggravation  of 
habitual  stammering.  Assuming,  however,  that 
the  patient  is  in  other  respects  in  absolutely 
good  health,  -what  can  be  done  ? Many  kinds  of 
medical  treatment  have  been  practised,  and  even 
operative  measures  ; but,  as  far  as  the  writer 
knows,  without  beneficial  result.  The  only 
methods,  indeed,  of  any  real  efficacy,  are  edu- 
cational methods.  Tho  patient  should  he  taught 
to  practise  slow  and  deliberate  utterance,  and 
whenever  the  tendency  to  stammering  occurs 
in  connection  with  any  letter,  to  check  himself 
momentarily  by  voluntary  effort,  and  then  to  try 
again,  rather  than  to  struggle  against  his  defect. 
Ho  should,  moreover,  be  taught  to  accustom 
himsolf  so  to  regulate  the  admission  of  air  into 
his  chest  during  speech,  that  his  utterance  may 
never  fail  for  want  of  breath.  Further,  con- 
sidering that  excitement  and  nervousness  always 
aggravate  stammering,  he  should  learn,  as  far 
as  possible,  either  to  avoid  speaking  under 
theso  conditions,  or  to  restrain  excitement  and 
nervousness,  or  so  to  control  himself  as  to  speak 
with  special  care  and  deliberation  when  he  is 
thus  affected.  These  measures  should  not  only 
be  observed  in  ordinary  conversation,  hut  be 
habitually  and  systematically  practised  in  read- 
ing aloud  ; and  especially  those  sounds,  or  those 
combinations  of  sounds,  or  those  transitions  from 
one  sound  to  another,  which  are  most  difficult 
for  him,  should  he  made  file  subject  of  care- 
ful and  constant  study.  By  suc-h  means  habitual 
stammering  is  occasionally  cured,  or  if  not  cured, 
so  far  kept  in  abeyance  that  an  occasional  momen 
tary  pause  in  speech  is  the  only  surviving  indi- 
cation of  it  that  the  practised  ear  can  detect. 
More  frequently,  however,  the  stammerer  re- 
mains a stammerer,  either  because  he  has 
nover  had  the  patience  and  determination 
which,  are  necessary  to  carry  out  the  line  of 
treatment  above  indicated,  or  because  his  infir- 
mity is  one  for  which  treatment  is  unavailing. 
By  taking  advantage  of  the  well-known  fact  that 
stammering  almost  always  disappears  during 
singing,  many  stammerers  have  been  able  to 
counteract  their  defect  by  intoning.  This  method 
has  proved  of  special  efficacy  in  the  cases  of 
clergymen  and  other  public  speakers. 

J.  S.  Bristows. 

STAPHYLOMA  (aratpvJeii,  a bunch  of 
grapes). — Synon.  : Fr.  Slaphylome ; Ger . Sta- 
phyloin. — This  word  was  applied  by  old  writers, 
in  the  jargon  which  was  once  supposed  to  he 
scientific,  to  any  limited  protrusion  of  the  tunics 
of  the  eyeball.  It  was  first  used  to  denote  the 
protrusion  which  occurs  in  the  circum-corneal 
sclerotic  zone,  as  a consequence  of  localised  in- 
flammation of  this  region.  The  tissue  affected 
by  the  inflammation  in  such  a case  becomes 
softened,  yields  to  the  intra-ocular  tension,  and 


SSaTIoTIGS,  medical. 

projects ; but  being  restrained  by  bands  of 
lymph,  or  by  thicker  portions  of  its  own  struc- 
ture, from  projecting  uniformly,  the  prominence 
becomes  more  or  less  sacculated ; and  the  most 
prominent  portions,  being  thinner  than  the  rest, 
and  permitting  the  dark  pigment  of  the  interior 
of  the  eye  to  show  through,  present  an  appear- 
ance which  may  be  compared  to  that  of  a minia- 
ture bunch  of  purple  grapes — a real  or  fancied 
resemblance  from  which  the  term  ‘staphyloma’ 
was  derived.  This  form  has  more  recently  been 
termed  ‘ staphyloma  of  the  sclerotic,’  to  distin- 
guish it  from  ‘ staphyloma  of  the  cornea,’  which 
is  the  protrusion  left  when  the  corneal  tissue 
has  been  destroyed  by  ulceration,  either  wholly 
or  in  part,  and  the  resulting  cicatrix,  formed  of 
iris-tissue  coated  over  by  lymph,  yields  to  the 
pressure  of  the  fluids  within  the  eye  and  be- 
comes prominent.  Corneal  staphyloma  is  de- 
scribed either  as  partial  or  complete,  according 
to  the  amount  of  cornea  which  is  replaced  by 
cicatrix. 

Staphyloma  posticum  is  a phrase,  applied  to 
that  protrusion  of  a circumscribes  portion  of 
the  sclerotic,  in  the  immediate  vicinity  of  the 
optic  nerve,  which  occurs  in  some  cases  of  my- 
opia ; and  which,  by  increasing  the  elongation 
of  the  eyeball,  increases  also  the  degree  of  the 
short  sight.  It  would  he  highly  desirable  ti 
abandon  the  term  ‘staphyloma’  in  favour  or 
‘ protrusion,’  with  sncli  appended  words  as  might 
serve  to  indicate  the  place  and  nature  of  the 
change.  Sic  Eye  and  its  Appendages,  Diseases 
of.  II.  Brudenell  Carter. 

ST  Aft  V ATI  OY  (Sax.  Stearfian,  to  perish). 
This  term  is  generally  applied  either  to  depri- 
vation of  food,  or  to  the  series  of  phenomena  to 
which  such  want  gives  rise.  The  word  is  often 
used  synonymously  with  fasting,  which,  how- 
ever, may  be  more  accurately  applied  to  volun- 
tary starvation.  Sec  Fastinci. 

STASIS  (erraa,  I stop). — Local  arrest  of  the 
circulation.  See  Inflammation. 

STATISTICS,  Medical. — This  term  signi- 
fies the  collection  of  numbers  respecting  healthy 
and  morbid  processes,  and  respecting  disease 
and  death ; the  application  of  arithmetical  and 
algebraical  operations  to  such  numbers  ; and  the 
deduction  of  conclusions  therefrom. 

But  little  use  of  statistical  methods  was  made 
in  medicine  before  the  present  century ; and 
much  of  the  progress  that  science  has  recently 
made  is  largely  to  be  ascribed  to  the  direct  use 
of  such  methods  in  pathology,  aetiology,  and 
therapeutics,  and  to  the  indirect  influence  they 
have  had  in  promoting  accuracy  of  thought. 

The  value  of  statistics  depends  upon  the  eom- 
pleto  uniformity  of  the  facts  observed,  and  upon 
the  accuracy  with  which  the  observations  are 
made.  It  may  be  well  here  to  remember  the 
words  of  Rousseau,  quoted  by  M.  Louis : ‘ Je 
sais  que  la  verite  est  dans  les  choses  et  non  dans 
mon  esprit  qui  les  juge,  ct  que  mains  queje  mets 
du  mien  dans  les  jugements  que  fen  portc , plus  )c 
suis  sur  d'approchcr  de  la  verite.’ 

In  England  much  use  of  statistics  has  recently 
been  made  in  tho  investigation  of  the  causes  of 
disease  among  communities.  See  Morbid  nr; 


STATISTICS,  MEDICAL. 
Mortality;  Periodicity  in  Disease  ; and  Public 
Health.  G.  B. 

STEARRHCEA  (trre'ap,  fat,  and  pia,  I 
flow). — Synon.  : Steatorrhoea. 

Definition. — A flux  of  the  fatty  secretion  of 
the  skin.  By  an  ungrammatical  combination  of 
the  Latin  sebum  with  the  Greek  verb,  it  is  some- 
times written  seborrheea. 

IEtiology. — An  ill-nourished  or  debilitated 
condition  of  the  skin  must  be  regarded  as  the 
cause  of  this  affection ; the  debility  being  some- 
times temporary,  as  in  young  persons,  and 
sometimes  permanent,  as  in  the  elderly. 

Description. — Like  other  secretions,  that  of 
the  sebum  of  the  sebaceous  glands  and  follicles 
is  liable  to  excess.  It  is  sometimes  diffused  over 
the  surface,  forming  a greasy  stratum,  and  some- 
times accreted  in  laminae  of  various  extent. 
This  is  the  stearrheea  simplex,  an  affection  most 
commonly  met  with  on  the  face. 

The  excessive  secretion  in  its  normal  state  is 
colourless,  but  occasionally  it  is  stained  with 
melanie  or  biliary  pigment ; lienee  the  terms 
stearrheea  nigricans  and  stearrheea  favescens. 
Sometimes,  as  in  elderly  persons,  the  epithelial 
element  of  the  secretion  prevails  over  the  fatty 
element,  and  in  that  case  it  is  apt  to  adhere 
closely  to  the  epidermis.  In  the  latter  case  the 
concretion  may  be  accompanied  by  excoriation, 
and  sometimes  by  asthenic  ulceration,  of  the 
skin. 

Diagnosis. — Stearrhoea  is  so  obvious  in  its 
nature  as  to  be  unlikely  to  be  confounded  with 
other  affections  of  the  skin.  It  is  sometimes 
associated  with  acne ; and,  in  certain  cases  of 
excessive  accumulation,  has  been  denominated 
‘ ichthyosis.’ 

Prognosis. — Stearrheea  is  an  affection  which 
admits  of  immediate  relief,  and  is  generally  cur- 
able. In  elderly  persons,  however,  it  is  some- 
times the  precursor  of  epithelioma  of  the  skin, 
or  of  rodent  ulcer. 

Treatment. — The  abundant  use  of  soap  as  a 
detergent,  followed  by  the  application  of  a lotion 
of  lime-water  with  oxide  of  zinc  and  calamine, 
very  speedily  exerts  a favourable  influence 
on  the  skin.  Concretions  may  be  softened 
previously  to  removal,  by  pencilling  with  olive 
oil,  or  by  inunctions  with  vaseline.  And  where 
the  encrusting  laminm  are  incorporated  with 
the  epidermis,  a cold  starch-poultice,  made  as 
starch  is  ordinarily  prepared,  may  advantage- 
ously precede  other  curative  operations. 

In  both  young  and  elderly  persons  it  will  be 
necessary  to  improve  the  general  health,  which 
is  usually  defective.  And  it  may  be  found 
desirable  to  conclude  the  treatment  by  the  ad- 
ministration of  three  minims  of  liquor  arsenicalis 
three  times  a day,  as  a neuro-  and  nutritive 
tonic.  Erasmus  Wilson. 

STEATOMA  ( ariap , fat,  and  6gbs,  like). — - 
Synon.  : Er.  Steatome ; Ger.  Steatom. — An  athero- 
matous cyst.  Sec  Cysts. 

STEATOZOON  (oreap,  fat  or  sebum,  and 
(aov,  an  animal).—  Theterms  Steatozoon  and  En- 
tozomi  folliculorum  were  given  by  Sir  Erasmus 
Wilson  to  the  microscopic  animalcule  called  by 


STERILITY  IN  THE  FEMALE.  Idl5 
Gustav  Simon  Acarus  folliculorum,  and  by  Owen 
Demodex  folliculorum.  See  Acabus. 

STENOSIS  ( nrevia , I constrict).— A con- 
striction, narrowing,  or  stricture  of  an  opening 
or  a tube ; for  instance,  mitral  or  aortic  stenosis, 
in  the  heart ; and  stenosis  of  the  oesophagus. 

STEECOEACEOU3  ( stercus , dung).  — 
Fmcal;  a term  generally  applied  to  vomited 
matter,  when  it  presents  the  characters  of  feces 
See  Vomit. 

STERILITY  IN  THE  FEMALE. — 

Synon. : Barrenness;  Fr.  Sterilite , Ger.  Un- 
fruchtbarkeit. 

Definition. — Want  cf  the  power  of  reproduc- 
tion in  the  female. 

Frequency. — In  the  general  community  the 
proportion  of  childless  marriages  seems  to  be 
about  1 in  8,  or  8o;  among  members  of  the 
peerage  1 in  6T1.  Whether  Kehrer  be  correct  in 
estimating  that  the  husband  is  in  fault  in  at  least 
oue-fourth  of  the  cases  of  sterilitas  matrimonii 
remains  to  be  proved.  Doubtless  he  is  nearer 
the  truth  than  those  who  attribute  the  sterility 
in  nine  cases  out  of  ten  to  some  fault  in 
the  wife,  because  whilst  the  comparatively  rare 
cases  of  male  impotence  are  readily  enough 
recognised,  and  also  the  rarer  cases  of  asperma- 
tism,  the  cases  of  azoospermatism , where  an 
azoic  semen  is  ejaculated,  are  for  the  most  pare 
altogether  overlooked.  The  possibility  that  the 
cause  of  the  childlessness  may  be  found  in  the 
male  must,  therefore,  always  be  borne  in  mind. 
But  we  confine  ourselves  here  to  the  considera- 
tion of  sterility  iu  the  female.  See  Ihpotency  , 
and  Sterility  in  the  Male. 

./Etiology. — For  generation  the  essential  pro- 
duct in  the  female  is  the  ovum;  and  in  her 
reproductive  apparatus  we  find  (i.)  oviparous 
organs  for  its  production;  (ii.)  oviducts  for  its 
transmission ; (iii.)  an  ovigerent  organ  or  nest 
in  which  the  ovum  is  hatched;  and  (iv.)  copula- 
tive organs  for  the  reception  of  the  semen,  the 
spermatozoa  of  which  constitute  the  essential  con- 
tribution of  the  male.  In  a married  woman  in 
whom  the  generative  function  is  iu  abeyance,  the 
sterility  may  be  primitive  or  acquired.  In  the 
former  case  we  have  to  do  with  a female  who  has 
never  borne  a child;  in  the  latter  the  woman 
may  have  borne  one  or  more  children,  but  has  for 
some  years  ceased  to  conceive.  Iu  either  case 
we  search  for  the  fault  in  one  or  more  of  these 
four  planes  of  her  sexual  apparatus. 

I.  Faults  in  the  ovaries. — The  ova  are 
developed  iu  the  ovaries,  and  the  conditions 
which  interfere  with  ovulation — that  is,  the  regu- 
lar ripening  of  an  ovisac,  and  the  discharge  of  an 
ovum — diminish  or  destroy  the  possibility  of  con- 
ception. Such  conditions  are  found  in ; — 

1 . Absence  or  imperfect  development. — Cases  of 
absence  or  defective  development  of  the  ovaries 
are  rarely  met  with,  except  in  women  in  whom 
the  rest  of  the  sexual  apparatus  is  also  anoma- 
lous. 

2.  Displacements. — One  or  both  ovaries  may 
be  found  displaced.  Instead  of  lying  at  the  level 
of  the  pelvic  brim,  they  have  fallen  into  the 
pouch  of  Douglas.  In  this  position,  though  the 
ripening  and  dehiscence  of  the  ovisacs  may  le 


1518  STERILITY  IN 

duly  taking  place,  the  discharged  ova  are  not 
received  into  the  free  extremity  of  the  Fallopian 
tube.  The  displaced  ovary,  moreover,  is  ex- 
tremely likely  to  be  the  seat  of  some  degree  of 
inflammation. 

3.  Inflammation. — Oophoritis, acute orckronic, 
lessens  the  conception-power  in  various  ways. 
It  may  lead,  1st,  to  destruction  of  the  follicles,  so 
that  no  ova  are  produced ; 2ndly,  to  condensation 
of  the  stroma,  so  that  the  regular  ripening  of  the 
ovisacs  is  impeded ; 3rdly,  to  deposits  on  the  sur- 
face, which  prevent  the  dehiscence  of  the  ovisacs ; 
or,  4thly,  to  adhesions  of  the  ovary,  in  situations 
which  hinder  the  entrance  of  the  discharged  ova 
into  the  oviducts. 

4.  Degenerations. — The  neoplastic  degenera- 
tions to  which  the  ovaries  are  most  liable  are  the 
cystic;  and  all  the  varieties  of  eystomata,  as  well 
as  the  fibromata,  the  sarcomata,  and  the  carcino- 
mata, are  commonly  attended  with  sterility. 
Where  both  ovaries  are  affected  the  sterility  is 
absolute,  from  the  complete  loss  of  function  in 
the  organs  ; and  even  where  only  one  is  affected, 
tho  disturbance  in  the  relations  of  the  pelvic 
organs,  caused  by  the  growing  mass,  is  likely  to 
prevent  impregnation.  See  Ovaries,  Diseases  of. 

II.  Faults  in  the  oviducts. — The  Fallopian 
tubes  or  oviducts  serve  not  only  for  the  recep- 
tion of  the  discharged  ova,  and  their  transmission 
downwards  to  the  uterus ; they  serve  also  for 
the  upward  transit  of  the  spermatozoa.  In  most 
cases  it  is  probably  somewhere  in  their  canal, 
perhaps  towards  the  free  extremity,  that  the  male 
and  female  elements  come  into  union. 

1 . Absence.  — Defective  development  of  the 
Fallopian  tubes  is  usually  associated  with  other 
abnormalities  of  the  sexual  apparatus,  especially 
with  rudimentary  conditions  of  the  uterus. 

2.  Inflammation. — Inflammatory  changes  may 
be  found  affecting  either  the  external  serous 
covering,  or  the  internal  mucous  lining.  In  the 
former  case  sterility  results  from  adhesions,  which 
lead  to  displacements  of  the  free  extremities,  so 
that  they  are  not  in  a position  to  receive  the  ova 
discharged  on  the  bursting  of  an  ovisac ; or  from 
bands  which  constrict  the  tubes,  and  so  occlude 
their  canal.  In  the  latter,  changes  in  the  se- 
cretion may  prejudice  the  vitality  of  the  sperma- 
tozoa or  ova  ; or  the  thickenings,  polypoidal  cr 
other,  may  obstruct  the  canal;  or  complete  atresia 
may  be  produced,  and  their  permeability  be  thus 
entirely  lost.  See  Faixopian  Tubes,  Diseases  of. 

3.  Degenerations.— The  tubes  are  rarely  enough 
the  seat  of  neoplasms;  but  when  such  do  develop 
in  their  walls,  occlusion  of  their  canal  and  con- 
sequent loss  of  function  may  ensue. 

ill.  Faults  of  the  uterus. — In  the  process  of 
reproduction,  the  uterus  serves  as  the  receptacle 
or  nest,  in  which  the  fertilised  ovum  is  carried 
during  the  period  of  incubation.  In  its  prolife- 
rating mucous  membrane  tho  chorionic  villi  take 
root;  through  its  expanded  blood-vessels  the  foetal 
blood  is  brought  into  relation  with  the  maternal ; 
its  walls  grow  in  correspondence  with  the  increase 
in  size  of  the  ovum ; and  its  largely  developed 
muscular  fibres  are  the  main  agents  in  the  ex- 
pulsion of  the  ovum  when  it  is  finally  hatched. 
It  plays  such  an  important  part  in  the  female 
economy  that  the  name  of  it  is  often  used  as  sy- 
nonymous with  tho  sexual  apparatus ; and  some 


THE  FEMALE. 

of  its  morbid  conditions  are  among  the  com- 
monest causes  of  sterility. 

1.  Defective  development. — First,  it  may  be  an- 
sent  al  together,  or  represented  merely  by  a fibrous 
nodule.  Secondly,  it  may  be  small,  having  under- 
gone arrest  at  some  stage  of  its  growth,  and  re- 
maining infantile, juvenile,  oradolescent.  Thirdly, 
it  may  be  bieornuous — retaining  the  trace  of  its 
original  duplicity  by  the  presence  of  a septum 
running  through  the  body  alone,  or  running 
through  both  body  and  cervix,  perhaps  through 
the  vaginal  canal  as  well.  Fourthly,  it  may  be 
unicornuous — only  one  of  the  halves  of  the  organ 
having  been  developed,  while  the  other  tube  may 
be  obliterated,  or  attached  as  a rudimentary  by- 
horn to  the  better  developed  tube.  Fifthly,  a more 
frequent  malformation  is  found  in  a conical  form 
of  the  cervix,  which  is  not  infrequently  compli- 
cated with,  sixthly,  narrowness  of  the  os.  This 
last  condition  may  exist  by  itself,  forming  a well- 
recognised  cause  of  sterility,  and  furnishing  some 
of  the  cases  in  which  a most  satisfactory  cure 
can  be  accomplished. 

2.  Displacements. — First,  descent  of  the  uterus 
is  found  as  the  predominant  morbid  condition  in 
some  cases  of  sterility,  but  this  is  more  frequently 
associated  with  the  deviations  auteriorly  or  pos- 
teriorly. Of  these,  secondly,  the  antrotersions, 
flexion  and  version,  are  very  frequent  among 
women  who  have  never  conceived  at  all ; thirdly, 
the  retroversions,  flexion  and  version,  are  more 
common  in  women  who  have  given  birth  to  one 
or  more  children,  and  have  subsequently  re- 
mained sterile.  The  flexions,  in  particular,  form 
a very  clearly  recognisable  and  often  remediable 
cause  of  sterility. 

3.  Changes  in  size. — The  retrogressive  changes 
which  occur  in  the  uterus  after  labour  sometimes 
go  on  morbidly,  and  in  one  group  of  cases  leave 
the  organ  in  a condition  of,  first,  super-involution. 
The  uterus  may  be  reduced  to  a little  tube  which 
only  admits  the  sound  for  half  an  inch.  Even 
when  the  degree  of  super-involution  is  less,  and  it 
still  measures  two  and  a quarter  inches  in  length, 
it  is  apt  to  cause  amenorrheea  and  sterility.  In 
another  group  of  cases  the  uterus  remains  hyper- 
trophied in  a condition  of,  secondly,  sub-involu- 
tion, which  is  inimical  to  conception  ; and  when 
conception  does  take  place  in  such  a uterus, 
abortion  is  liable  to  occur. 

4.  Inflammation.  — Among  the  commonest 
causes  of  sterility  must  be  ranked  the  inflamma- 
tory changes  to  which  the  uterus  is  so  liable, 
whether  the  process  have  affected  mainly  the  ex- 
ternal, middle,  or  internal  coat ; and  in  many  of 
the  cases  where  some  other  condition  tending  to 
sterility  is  present,  inflammatory  changes  come 
in  to  increase  the  difficulty,  and  to  cloud  the 
prospects  of  recovery.  First,  perimetriiis  is  usually 
only  an  element  of  a more  general  pelvic  peri- 
tonitis, which  often  leaves  behind  it  fixations  and 
displacements  of  the  uterus,  preventing  conception 
or  promoting  early  abortion.  Secondly,  mcsomc- 
tritis,  leading  to  thickening  of  the  walls  of  the 
organ,  produces  an  expansion  of  its  cavity  and 
disturbance  of  its  function.  It  is  rarely  possible 
to  dissociate  it  from,  thirdly,  endometritis,  which 
is  attended  also  with  dilatation  of  the  cavity,  but 
which  is  further  mischievous  from  the  deleterious 
influence  of  its  abnormal  secretions  on  the  life 


STERILITY  IX  THE  FEMALE, 
ind  progress  of  the  spermatozoa,  and  from  the 
difficulty  with  which  a fertilized  ovum  gets 
healthily  engrafted  on  its  surface.  Moreover,  in 
certain  cases  of  long  standing,  some  of  the  uterine 
entices  may  become  more  or  less  occluded,  a re- 
sult which  is  more  especially  apt  to  ensue  in  the 
external  orifice  when  caustics  have  been  applied 
to  the  cervical  canal. 

5.  Degenerations. — First,  'myomata.,  or  fibroid 
tumours,  are  found  in  a considerable  proportion 
of  barren  women.  Whether  sub-peritoneal,  in- 
tra-mural, or  sub-mucous,  they  interfere  in  many 
ways  with  conception,  and  give  a proclivity  to 
miscarriages  or  dangerous,  labours  when  concep- 
tion has  occurred.  Secondly,  sarcomata  have 
usually  their  seat  in  the  uterine  cavity,  and  seem 
to  be  an  absolute  bar  to  impregnation.  Thirdly, 
carcinomata  have  been  sometimes  met  with  in 
tho  pregnant  uterus ; but  these  are  commonly 
seated  in  the  cervix,  and  it  is  usually  only  in  an 
early  stage  of  the  mischief  that  conception  can 
occur.  See  Womb,  Diseases  of. 

IV.  Faults  in  the  external  organs. — In 
various  ways  the  organs  which  serve  for  the  recep- 
tion of  the  spermatic  fluid  may  be  so  affected 
that  their  copulative  function  is  disturbed  or  de- 
stroyed, and  the  patient  remains  sterile. 

1.  Malformations. — Occlusions  of  the  labia  are 
rare  ; but  the  vaginal  canal  may  be  impervious, 
firstly,  from  abnormal  conditions  of  the  hymen ; 
secondly,  from  atresia  in  some  part  of  its  course  ; 
or,  thirdiy,  from  complete  absence.  Even  it  will  be 
found  that  in  certain  cases  where  tho  rest  of  the 
generative  apparatus  seems  to  be  well-developed, 
a preternatural  shortness  of  the  canal  is  found  in 
some  sterile  women,  from  whom  the  semen  es- 
capes immediately  after  it  is  thrown  into  the 
cavity. 

2.  Injuries. — The  injurious  influences  of  a bad 
labour  on  the  reproductive  power  of  a woman 
may  be  found,  first,  in  an  undue  •patency  of  the 
canal,  usually  from  extensive  rupture  of  the 
perinseum ; secondly,  more  frequently  from  at- 
resia, partial  or  complete  ; or,  thirdly,  from  fistu- 
lous formations,  leading  to  communication  with 
the  neighbouring  cavities. 

3.  Infiammation. — In  its  acute  stages,  inflam- 
mation of  the  pudenda  and  vagina  produces,  first, 
dyspareuma ; in  its  more  chronic  forms  it  may 
be  productive  of,  secondly,  unhealthy  discharges, 
which  endanger  the  vitality  of  the  spermatozoa  ; 
or  it  may  lead,  thirdly,  to  occlusions  of  the  labia, 
or  of  the  vaginal  orifice  or  canal.  Partly  of 
inflammatory  origin  is  the  condition,  fourthly, 
of  vaginismus,  which  is  not  an  uncommon  cause 
of  impossible  connection. 

1.  Degenerations. — The  various  neoplasms  oc- 
cur with  rarity  in  the  vaginal  canal ; but  in  the 
pudenda — sometimes  from  their  bulk,  sometimes 
from  their  sensitiveness — they  interfere  with  con- 
nection, as  in  cases  of  elephantiasis  labiorum  or 
of  urethral  caruncle. 

Diagnosis  and  Prognosis. — Investigation  into 
a case  of  sterility  may  require  that  we  satisfy  our- 
selves as  to  the  fertilizing  powers  of  the  male, 
and  the  due  fulfilment  of  the  marital  function. 
Occasionally  some  concurrent  disturbance  in  the 
functions  of  tho  sexual  apparatus  of  the  female, 
or  of  the  neighbouring  organs,  may  enable  us  to 
make  a close  guess  at  the  cause  of  her  barren- 


STEKIL1TY  IN  THE  MALE.  151? 
ness  ; but  we  can  only  arrive  at  a true  conclusion 
by  a careful  physical  examination,  having  in 
view  such  a vidimus  of  causes  as  we  have  given. 
Some  of  the  conditions,  such  as  the  more  pro- 
nounced malformations,  or  imperfect  develop- 
ment, make  us  regard  her  as  hopelessly  sterile  : 
others,  such  as  uterine  flexions  and  stenosis,  and 
some  vaginal  occlusions  and  injuries  and  tender, 
ness,  wo  may  undertake  to  treat  with  good  hops 
of  fruitful  result.  See  Vagina,  Diseases  of. 

Treatment. — In  commencing  tho  treatment 
of  any  case  we  must  bear  in  mind  that  moibid 
conditions  may  be  present  in  more  than  one  of 
the  planes  of  the  sexual  system,  and  that  we 
must  begin  with  the  removal  of  tho  obstacle 
that  lies  nearest  the  surface.  Urethral  caruncles 
and  other  sensitive  structures  in  tho  vulva  must 
be  cut  off  or  cauterised.  Contractions  of  the 
vaginal  orifice  or  canal  must  bo  stretched  ; and 
where  there  is  complete  atresia  an  aperture  must 
be  formed  and  kept  patulous.  Stenosis  of  the 
uterine  orifices  may  be  overcome  by  temporary 
dilatation  with  a tangle-tent,  which  the  writer  has 
more  than  once  seen  followed  by  impregnation. 
Where  such  dilatation  fails,  the  os  may  be  di- 
lated more  permanently,  by  tearing  it  with  an 
instrument  like  a pair  of  long  dressing-forceps, 
the  blades  of  which  are  forced  apart  after  it  has 
been  passed  into  the  cervix  ; or  by  dividing  the 
cervix  at  both  sides,  or  in  one  or  other  lip,  with 
a liysterotome.  The  deviations  of  the  uterus 
must  be  rectified  ; versions,  after  replacement, 
being  usually  retained  by  some  modification  of 
Hodge's  pessary;  flexions  demanding  in  addi- 
tion the  use  of  an  intra-uterine  stem.  The  stem- 
pessary  of  zinc  and  copper  introduced  into  tbe 
interior,  is  tho  best  means  of  stimulating  to  its 
full  function  the  imperfectly  developed  uterus, 
and  the  uterus  which  has  withered  from  super- 
involution.  Morbid  conditions  in  the  interior  of 
the  uterus  require  direct  applications  to  its 
cavity.  And,  as  in  a large  proportion  of  the 
cases,  some  inflammatory  mischief  complicates 
the  other  morbid  condition,  it  is  often  helpful  to 
the  cure  to  make  the  patient  use  hot  douches 
and  baths,  and  the  internal  remedies  which 
tend  to  remove  the  effects  of  inflammatory  action. 
It  is  to  the  beneficial  influence  which  the  waters 
of  Ems,  Aix,  Kissingen,  and  other  spas  exert  on 
chronic  metritis,  that  their  reputation  for  curing 
sterility  is  mainly  due.  In  cases  where  the 
natural  method  of  getting  spermatozoa  brought, 
into  relation  with  the  ova  has  failed,  success  is 
said  to  have  followed  the  introduction  of  seminal 
fluid  by  means  of  a fine  syringe  and  tube  into 
the  cavity  of  the  uterus— a line  of  treatment 
legitimate,  it  may  be,  but  only  to  be  followed  in 
quite  exceptional  circumstances. 

Alexander  Russell  Simpson. 

STERILITY  IW  THE  MALE. — Synon.  : 
Fr.  Sterilite  ckez  I’homme  ; Ger.  Unjruchtbarfceit 
dcs  Manncs. — Sterility  in  the  male  has  been  con- 
founded with  impotence,  no  distinction  having 
been  drawn  between  inability  to  procreate  and 
incapacity  for  sexual  intercourse.  A man  may, 
however,  be  subject  to  sterility,  independently  of 
impotence.  See  Impotence. 

Description. — Sterility  may  arise  from  the  fol- 
lowing causes  : — 1.  malposition  of  the  testicles 


1518  STERILITY  IN  THE  MALE. 

2.  obstruction  in  the  excretory  ducts  of  the  tes- 
ticle; 3.  impediments  to  the  ejaculation  of  the 
seminal  fluid;  or  4.  aspermatismus  or  non-ejacu- 
lation. 

1.  Malposition  of  the  testicles. — -A  testicle 
which  does  not  pass  into  the  scrotum  is  nearly 
always  small  in  size,  and  often  undeveloped,  not 
having  undergone  the  enlargement  and  change 
in  structure  'which  takes  place  at  puberty.  A 
testicle  thus  detained  fails  in  some  animals,  us 
well  as  in  man,  to  secrete  a fertilising  fluid  ; and 
a male  with  this  defect  on  both  sides,  though, 
often  potent  and  efficient  for  sexual  intercourse, 
is  incapable  of  impregnating  the  female.  Many 
striking  cases  illustrating  this  point  have  come 
under  the  notice  of  the  writer,  cases  of  persons 
with  retained  testes,  who  have  married  without 
their  wives  becoming  pregnant,  and  in  whom  the 
fluid  emitted  in  coition  has  been  destitute  of 
spermatozoa — azoospermatism i.1  The  facts  which 
have  been  adduced  as  opposed  to  the  conclusion 
that  cryptorchies  are  sterile,  are  chiefly  instances 
in  which  they  are  reputed  to  have  procreated 
children ; but  it  is  remarkable  that  as  yet  no 
case  has  been  found  in  which  a retained  testicle 
has  been  fully  proved  to  be  capable  of  secreting 
a fertilising  fluid.  Spermatozoa  have  been  found 
absent  in  every  case  of  retained  testicle,  without 
exception,  in  which  search  has  been  made  for 
them. 

2.  Obstruction. — The  lymph  exuded  in  the 
cavity  and  walls  of  the  excretory  duct  of  the 
testicle  in  epididymitis,  is  liable  to  produce  ob- 
struction of  the  canal.  This  may  be  only  tem- 
porary, the  lymph  becoming  absorbed  under 
treatment.  Where  the  obstruction  is  complete 
and  permanent,  an  induration  is  left  in  the  tail 
of  the  epididymis;  and  when  this  exists  on 
both  sides,  sterility  is  the  result.  Many  curious 
cases  of  sterility  from  this  cause  have  fallen 
under  the  writer’s  observation.2  They  show  the 
great  importance  of  steadily  prolonging  the  treat- 
ment of  epididymitis,  until  the  enlargement  and 
induration  of  the  part  have  disappeared.  The 
excretory  duct  of  the  testicle  is  liable  also  to  be 
interrupted  by  tubercular  deposits  in  the  epi- 
didymis. Sterility  from  this  cause  in  persons 
with  double  tubercular  disease  of  the  epididymis 
is  not  uncommon. 

3.  Urethral  impediments. — A close  stricture 
in  the  urethra  so  completely  interrupts  the  pas- 
sage of  the  seminal  fluid,  that  in  ejaculation 
it  regurgitates  into  the  bladder,  where  it  mixes 
with  the  urine.  This  is  a condition  which  is 
remediable  by  the  cure  of  the  stricture. 

4.  Aspermatismus. — Sterility  sometimes  arises 
from  a cause  which  has  been  expressed  by  the 
term  aspermatismus.  Thus,  it  is  essential  to  the 
complete  performance  of  the  sexual  act,  that  the 
local  excitement  should  culminate  in  the  reflex 
action  of  expelling  the  collected  semen.  Unless 
this  takes  place  coition  is  unsatisfactory  and 
fruitless.  There  are  cases  of  men  who  never 
experience  ejaculation,  even  after  prolonged  coi- 
tus, though  they  are  subject  to  nocturnal  emis- 
sions. This  appears  to  arise  in  some  instances 
from  defective  sensibility  in  the  glana  penis, 

1 For  detailed  e viilence  on  this  subject,  see  Treatise  on  j 
Diseases  of  the  Testis , by  the  writer. 

■ Vide  lib.  cit.  i 


STERTOR. 

which  the  writer  has  endeavoured  to  correct  by 
the  application  of  the  acetum  cantliaridis  to  the 
glans,  and  by  electro-magnetism.  In  one  case 
of  non-ejaculation,  the  nerves  proceeding  to  the 
glans  appear  to  have  been  destroyed  by  a syphi- 
litic ulcer  on  the  dorsum  penis,  or  to  have  been 
compressed  in  its  cicatrisation. 

Conclusion'. — The  question  may  ariso  whether 
a man  who  has  the  inclination  and  power  tc 
copulate,  but  who  is  nevertheless  sterile,  is  justi- 
fied in  contracting  marriage.  That  a man  who 
is  unable  to  fulfil  the  command,  ‘ to  be  fruitful 
and  multiply,’  is  right  in  disappointing  the 
hopes  and  perilling  the  happiness  of  a woman 
cannot,  in  the  writer's  opinion,  bo  maintained ; 
and  he  has  felt  it  his  duty  to  give  advice  in 
accordance  with  this  opinion. 

T.  CuKLING. 

STERNUTATORIES  ( sternuo , I sneeze). 

Synon.  : Errhines  ; Fr.  Sternutatoires ; Ger.  Lies- 
mittel. 

Definition. — Remedies  which  cause  sneezing 
and  produce  an  increased  secretion  from  the 
mucous  membrano  of  the  nose. 

Enumeration. — The  principal  sternutatories 
are  Tobacco  Snuff,  Veratrum  album,  Euphor- 
bium,  and  Ipecacuanha. 

Actions  and  Uses. — The  action  of  these  drugs 
is  simply  one  of  stimulation  and  irritation  of 
the  part  to  which  they  are  applied;  and  the 
slight  amount  of  gentle  excitement  furnished  by 
snuff  has  ensured  a very  wide  popularity  for  this 
preparation  of  tobacco. 

White  hellebore  causes  almost  uncontrollable 
sneezing  when  incautiously  inhaled,  and  powdered 
ipecacuanha-root  is  well  known  to  cause  exces- 
sive irritation  in  exceptional  cases.  No  use  is 
now  made  of  these  therapeutical  actions,  and  it 
seems  hardly  necessary  to  retain  the  term  ster- 
nutatories any  longer  in  our  nomenclature. 

R.  Faequharson. 

STERTOR  (sterto,  I snore). — Stnon.  : Fr. 
Sterteur;  Bonflement;  Ger.  Schnarc/ien;  Bocheln. 

Definition. — A term  commonly  applied  to 
sounds  in  the  throat  resembling  snoring,  which 
occur  in  the  apoplectic  and  like  conditions.  In 
this  article  the  writer  would  extend  the  name 
to  other  sounds  formed  in  any  part  of  the  respi- 
ratory passages  or  mouth  by  the  movements  of 
the  air,  under  the  like  circumstances. 

Varieties. — Several  varieties  of  stertor  may 
he  recognised,  as  follows : — 

1.  Nasa l.  — X asal  stertor  arises  from  approxi- 
mation of  the  ate  nasi  towards  the  septum  by 
the  ingoing  air,  as  in  the  act  of  sniffing. 

2.  Buccal. — This  form  of  stertor  is  due  to 
vibrations  of  the  lips,  and  puffings  and  flappings 
of  the  cheeks  during  inspiration  or  expiration. 

3.  Palatine. — Arises  from  vibrations  of  the 
soft  palate,  whether  the  breath  passes  through 
the  mouth  or  the  nose. 

4.  Pharyngeal. — Pharyngeal  stertor  is  caused 
by  the  lolling  back  of  the  base  of  the  tongue 
iuto  near  contact  with  the  posterior  wall  of  the 
pharynx. 

5.  Laryngeal. — This  variety  is  referable  to 
vibrations  of  the  chordae  vocales. 

6.  Mucous. — Mucous  stertor  is  a term  which 


STEKTOK. 


uuiy  be  g'.veu  to  the  bubbling  of  air  through 
mucus  in  the  trachea  or  larger  air-tubes. 

/Etiology. — One  or  more  of  the  varieties  of 
stertor,  in  varying  degrees  of  intensity',  may  oc- 
cur in  any  of  the  following  morbid  conditions, 
namely  Suffocation  ; epilepsy  ; convulsions  in 
children ; the  death-agony ; fractures  of  the 
skull,  and  concussion  of  the  brain  ; bronchitis — - 
particularly  that  of  the  old,  sudden  oedema  of 
the  lungs,  and  large  haemorrhages  from  the  lungs; 
great  exhaustion ; chloroform-poisoning,  drunken- 
ness, and  opium-poisoning ; drowning,  and  all 
conditions  in  which  mucus  or  fluid  exists  in  the 
lungs ; and  all  forms  of  sopor,  whether  natural 
or  the  result  of  accident  or  disease. 

Description. — The  general  phenomena  of 
stertor  are  those  of  suffocation. 

A patient  may  be  found  lying  in  a state  of 
complete  unconsciousness,  with  a congested,  tur- 
gid, and  expressionless  face  ; usually  dilated  and 
fixed  pupils  ; insensitive  conjunctives ; a hot  and 
perspiring  skin;  throbbing  arteries;  a full  and 
bounding  pulse  ; and,  lastly7,  noisy  breathing,  the 
direct  result  of  mechanical  interference  with  the 
passage  of  air  into  or  out  of  the  lungs,  whether 
arising  from  contractions  of  theorifices,  and  vibra- 
tions of  the  soft  parts  of  the  nose,  lips,  cheeks, 
palate,  pharynx,  and  larynx, or  from  mucus  in  the 
trachea  and  bronchial  tubes.  When  the  obstruc- 
tion to  the  breathing  is  only  slight,  but  long- 
continued,  the  face  may  be  of  a dusky  pallor,  and 
there  is  an  entire  absence  of  turgidity  and  con- 
gestion. 

Pathology. — All  the  varieties  of  stertor, 
whether  manifested  singly  or  in  combination, 
have  been  usually  regarded,  especially  in  the 
cass  of  apoplexy,  as  symptoms  essentially  and 
mysteriously  connected  with  the  primary7  disease. 
This  is  not  the  true  account  of  them.  Whatever 
may  be  the  original  cause,  these  symptoms  only 
indicate  a varying  amount  of  obstruction  to  re- 
spiration, sometimes  so  great  as  to  be  fatal  in 
itself,  but  only  as  a secondary  and,  so  to  speak, 
accidental  consequence  of  the  primary  disorder. 
Stertor  is,  in  fact,  ‘suffocation.’  In  its  effects 
it  may  be  compared  with  croup,  and  being  equally 
dangerous  it  may  equally  require  relief.  But 
even  buccal  stertor,  which  many  authors  have 
looked  upon  as  of  so  grave  importance,  may  not 
(infrequently  be  observed  in  ordinary  sleep ; and 
the  writer  has  seen  recoveries  from  apoplexy,  in 
which  at  different  times  all  the  forms  of  stertor 
have  been  present.  Stertor  in  apoplexy  being, 
then,  apoplexy  plus  suffocation,  the  whole  subject, 
as  regards  diagnosis,  prognosis,  and  morbid  ana- 
tomy, must  be  approached  from  a new  point  of 
view.  The  congested  and  turgid  face,  the  noisy 
breathing,  the  rales  in  the  chest,  the  throbbing 
arteries,  and  the  full  and  bounding  pulse,  which 
are  the  generally  received  symptoms  of  sthenic 
apoplexy,  and  which  have  been  regarded  as  in- 
dicating the  adoption  of  venesection  and  active 
remedies,  are  neither  more  nor  less  than  signs  of 
suffocation.  Immediately  upon  the  removal  of 
obstructions  to  the  breathing,  all  these  symptoms 
disappear,  and  with  them  the  necessity  for  active 
treatment.  Long  ago  Heberden  and  Eothergill 
questioned  the  propriety  of  bleeding  in  such  cases, 
and  the  latter  thought  that  these  violent  symp- 
toms arose  from  an  exertion  of  the  vires  vites 


1519 

to  restore  health  ; whereas  they  really  indicate 
a struggle  to  overcome  an  impediment  to  respi- 
ration and  circulation.  Directly  this  impediment 
is  removed,  all  is  quiet  in  apoplexy,  and  the  prae 
titioner  is  enabled  to  judge  of  the  real  state  of  the 
case — which  side  is  paralysed,  whether  the  nerves 
are  losing  or  recovering  their  power,  and  what 
evidences  exist  as  to  greater  or  less  interference 
with  the  functions  of  organic  life. 

Treatment. — In  stertor,  as  in  strangulation, 
we  must  proceed  at  once  to  remove  the  impedi- 
ment to  free  respiration. 

Nasal  stertor. — This  maybe  relieved  by  press- 
ing upwards  the  tip  of  the  nose,  or  by  keeping  the 
nares  open  by  the  handle  of  a common  salt-spoon. 

Laryngeal  stertor. — This  never  appears  dan- 
gerous enough  to  warrant  tracheotomy,  which 
alone  would  remove  it. 

Buccal,  pharyngeal,  palatine,  and  niveous 
stertor. — These  varieties  of  stertor  arc  readily 
treated  by  placing  the  piatient  comfortably  on 
one  side,  and.  affording  support  by  well-arranged 
pillows.  In  this  position  the  buccal  and  palatine 
stertor,  if  any  remain,  will  be  too  feeble  an 
impediment  to  require  further  attention.  The 
tongue  drops  to  the  side  of  the  pharynx,  and 
leaves  plenty  of  room  for  the  ingoing  air.  The 
mucus  or  fluid,  too,  whether  resulting  from  these 
or  other  forms  of  stertor,  drains  away  into  the 
lowermost  lung,  thus  preventing  the  formation 
of  large  foam-vesicles  in  the  trachea  (the  ‘ death- 
rattles  ’),  which  are  always  dangerous  respiratory 
impediments.  Care  should  be  taken  to  keep  the 
neck  rather  straight,  as,  if  the  chin  be  brought 
too  near  the  sternum,  the  thyroid  cartilage 
presses  upwards  and  backwards,  and  piushes  the 
base  of  the  toBgue  towards  the  back  of  the 
pharynx.  In  the  management  of  mucous  stertor 
it  must  be  observed  that,  after  a time,  varying 
from  one  day  to  three  or  four,  the  lower  lung 
becomes  filled  with  mucus,  though  the  patienx 
is  still  breathing  quite  placidly.  If  at  this  stage 
the  patient  he  turned  over  on  the  other  side,  the 
mucus  begins  travelling  across  the  trachea  into 
the  opposite  lung;  is  caught  on  its  passage  by 
the  ingoing  air  ; and  is  whipped  into  foam,  which 
at  once  blocks  up  the  larger  air-tubes  of  the  only 
lung  that  can  work,  and  so  instant  distress  and 
danger  result.  If  the  life  of  the  patient  be  not 
at  once  destroyed,  still  the  additional  shock  re- 
duces very  much  the  chances  of  ultimate  reco- 
very. Under  these  circumstances  change  of  posi- 
tion should  always  be  tentative,  and  time  for 
some  return  of  nerve-vigour  should  be  allowed 
before  it  is  attempted.  This  warning  applies 
with  equal  force  to  all  cases  where  mucus  or 
fluid  obstructs  the  air-passages,  as  in  drowning 
and  bronchitis.  In  drowning,  it  may  he  re- 
marked that  the  water,  on  entering  the  lungs, 
becomes  quickly  inspissated  with  mucus,  forming 
a milky  foam,  which  can  only  be  slowly  eva- 
cuated by  the  application  of  Dr.  Marshall  Hall’s 
or  other  process  of  artificial  respiration.  See 
Artificial  Besfiration  ; and  Besuscitaticn. 

Hubert  L.  Bowles. 

STETEOGEAPH  {arrfios,  the  chest,  and 
ypaepw,  I write). 

Definition7. — An  instrument  for  recording  thf 
movements  of  the  chest. 


1520  STETHOGRAPH. 

The  indices  in  stethometers  are  adapted  to 
record  maximum  expansion  at  anyone  point.  Dr. 
Sanderson’s  ‘ recording  stethometer,’  described 
and  figured  in  the  Handbook  to  the  Physiological 
Laboratory , consists  essentially  of  a tympanum, 
on  one  side  of  which  a knob  is  fixed,  for  appli- 
cation to  the  chest-surface.  This  tympanum  is 
in  communication  with  a second  tympanum  by 
means  of  an  air-tube,  and  the  fluctuations  of  the 
second  tympanum  are  recorded  by  a writer  upon 
a revolving  surface  of  paper.  By  means  of  this 
instrument,  prcperly  adjusted,  the  respiratory 
movements  of  the  chest  at  any  point  can  be  re- 
corded, as  regards  both  depth  and  rhythm. 

R.  Douglas  Powell. 

STETHOMETER  (itt~)6os,  the  chest,  and 
(Uerpor,  a measure). — Synon.  : Pr.  Stethometre  ; 
Ger.  Stethometer. 

Definition. — An  isntrument  for  measuring 
the  mobility  of  the  chest,  and  of  its  several  parts, 
during  respiration. 

Description. — Various  forms  of  stethometer 
have  been  designed.  Dr.  Sibson's  ‘ chest-measurer  ’ 
consisted  of  a simple  arrangement  by  which  a 
rod,  attached  by  a movable  rack  to  an  index, 
might  bo  applied  vertically  in  succession  to  dif- 
ferent parts  of  the  chest  (see  Sibson's  Collected 
Works , vol.  ii.)  Dr.  Qnain’s  stethometer  con- 
sists of  a cord  attached  to  an  index  working  on 
a graduated  dial  (London  Journal  of  Medicine, 
Oct.  1850).  Expansion  on  the  two  sides  may  be 
measured  and  compared  by  means  of  the  double 
tapes,  or  the  soft  metal  cyrtometers,  held  so  that 
the  ends  overlap  in  the  median  line.  A more 
elaborate  instrument  is  that  of  Dr.  Ransome, 
who  has  with  it  made  valuable  observations  on 
the  respiratory  movements  ( Med.-Chir . Trans- 
actions, vol.  lxiv.  p.  185). 

R.  Douglas  Powell. 

STETHOSCOPE  (<tti}9os,  the  chest,  and 

0- Koirioi,  I examine). — Synon.  : Fr.  Stethoscope  ; 
Ger.  Stetlioscop. 

Definition. — An  instrument  employed  as  a 
medium  for  the  conduction  of  sound,  between 
the  ear  and  the  chest  or  other  parts,  in  auscul- 
tation. 

Description. — Stethoscopes  are  of  various 
patterns.  They  are  commonly  made  of  a thin, 
cylindrical  piece  of  wood,  perforated  through  its 
length,  which  is  of  about  6 in.  to  8 in. ; expanded 
at  one  end  to  a somewhat  trumpet-like  extre- 
mity, for  convenient  application  to  the  chest; 
and  at  the  other  end  provided  with  a flat,  broad 
surface,  to  which  the  ear  can  be  comfortably  ap- 
plied. Some  practitioners  prefer  a solid  stetho- 
scope— that  is,  one  in  which  there  is  no  central 
canal.  Others  prefer  the  stethoscope  to  he  made 
of  metal;  others,  again,  of  vulcanite.  An  instru- 
ment made  of  cedar  wood,  with  a perforation  of 
about  Ath  in.  in  diameter,  a ehestpiece  about 

1- ?-  in.  in  diameter,  and  a slightly  concave  ear- 
piece 2)  in.  to  2|in.  in  diameter,  is  perhaps  the 
best  adapted  for  auscultation. 

Some  auscultators  at  the  present  day  use  the 
binaural  stethoscope,  which  consists  of  a short 
hollow  ehestpiece,  of  an  elongated  conical  shape, 
from  which  two  flexible  tubes,  formed  of  wire 
noils  covered  with  felt,  extend,  terminating  in  j 


STIMULANTS. 

metal  tubes  tipped  with  ivory,  to  fill  the  meatus 
of  the  ear  on  each  side.  This  instrument  has 
some  advantages.  It  can  he  more  readily  applied 
to  different  parts  of  the  chest  without  the  ob- 
server being  obliged  to  adopt  constrained  pos- 
tures ; and  by  occupying  both  ears  whilst  the 
ehestpiece  is  applied,  it  excludes  extraneous 
sounds,  and  considerably  intensifies  the  chest 
sounds.  The  disadvantages  are,  that  sounds  pro- 
duced in  the  mouth  and  throat  of  the  patient, 
which  would  he  recognised  by  the  disengaged 
ear  of  an  observer  using  the  ordinary  stethoscope, 
are  apt  to  be  mistaken  for  modified  pulmonary 
sounds.  Again,  with  the  aid  of  the  ordinary 
stethoscope  impulses  of  various  kinds,  cardiac  or 
aneuri3mal,  not  recognisable  on  ordinary  pal- 
patioD,  are  very  appreciable  by  the  ear,  which 
might  escape  attention  with  the  binaural  instru- 
ment. Intensification  of  auscultatory  signs,  also, 
whilst  perhaps  an  advantage  in  the  common  run 
of  practice,  is  not  so  to  persons  learning  auscul- 
tation, and  whose  hearing  is  not  defective. 

The  differential  stethoscope,  which  is  a binaural 
stethoscope  having  the  tube  connected  with  each 
ear  attached  to  a separate  ehestpiece,  is  useful 
in  some  cases  of  heart-disease,  and  for  simulta- 
neously comparing  the  two  sides  of  the  chest — 
provided  the  two  ears  of  the  observer  are  of 
equal  auscultatory  power.  Finally,  some  prac- 
titioners prefer  a single  flexible  tube,  with  an 
earpiece  fitting  into  tho  meatus,  and  a chest- 
piece.  It  has  been  attempted  to  apply  the  tele- 
phone, and  even  the  microphone,  to  stethoscopy, 
but  as  yet  without  success. 

R.  Douglas  Powell. 

STHENIC  (cOtvos.  strength). — This  term  is 
applied,  first,  to  individuals  when  they  are  vigo- 
rous and  strong  ; and,  secondly,  to  inflammatory 
diseases,  when  they  assume  an  active  character, 
such  as  sthenic  pneumonia,  as  distinguished  from 
asthenic.  Sec  Disease,  Classification  of. 

STIFF-NECK. — A popular  name  for  mus- 
cular torticollis.  See  Rheumatism,  Muscular. 

STILLICIDIUM  (si ilia,  a drop,  and  cado.  I 
fall). — The  falling  of  a fluid  drop  by  drop.  The 
term  is  used  to  express  the  flowing  of  the  tears 
over  the  lower  eyelid  in  obstructions  of  the  la- 
chrymal passages ; also  the  dropping  of  the  urine 
in  strangury  (see  Eye  and  its  Appendages, 
Diseases  of ; and  Strangury).  As  a thera- 
peutic method  of  application,  stillicidium  signi- 
fies the  dropping  of  a fluid  upon  a part.  See 
Cold,  Therapeutics  of. 

STIMULANTS  ( stimido , I stir  up).— De- 
finition.— A stimulant  is  anything  which  in- 
creases the  natural  function  of  a part,  or  which 
causes  a slight  degree  of  superficial  irritation. 

Enumeration. — Stimulants  may  be  divided 
into  general,  cardiac,  vascular,  and  cerebral,  as 
Alcohol,  Ether,  Opium,  and  Ammonia;  spinal, 
including  Nux  vomica,  Strychnia,  Phosphorus, 
Morphia,  Ergot,  and  Belladonna;  an&stomachic, 
as  Ginger,  Capsicum,  Mustard,  and  other  so- 
called  carminative  substances. 

Actions. — Taking  the  term  stimulant  in  its 


STIMULANTS. 

widest  sense,  we  are  bound  to  admit  that  it  has 
very  close  ties  of  relationship  with  almost  every 
other  therapeutical  group.  Thus  a drastic  pur- 
gative is  a stimulant  to  the  intestinal  mucous 
membrane ; and  cholagogues  promote  the  se- 
cretion of  the  liver.  So  we  have  stimulating 
diuretics,  diaphoretics,  and  emetics,  and  drugs 
which  directly  stimulate  certain  organs  or  glands, 
as  when  ergot  evacuates  the  contents  of  the 
womb,  or  jaborandi  causes  a copious  salivary 
flow.  It  is  quite  sufficient  for  our  present  pur- 
pose, however,  merely  to  direct  attention  to 
these  bearings  of  the  subject,  which  will  receive 
fuller  notice  in  other  articles,  and  the  enume- 
ration already  given  shows  within  what  limits 
we  must  proceed. 

General  Stimulants.— The  agents  which 
are  sometimes  called  ‘general  stimulants’  act, 
in  the  first  instance,  on  the  nervous  structures 
of  the  heart,  improving  the  tone  and  vigour 
of  the  circulation;  and,  as  a result  of  the  in- 
creased quantity  of  blood  sent  to  the  brain,  the 
intellectual  functions  seem  to  be  temporarily 
augmented.  Alcohol  in  small  quantity  un- 
doubtedly makes  the  pulse  fuller  and  firmer ; 
gives  rise  to  a pleasant  glow  and  sensation  of 
general  warmth  ; and  appears  to  lend  rapidity 
and  freedom  to  the  cerebral  operations.  Opium, 
in  small  doses,  has  much  the  same  effect.  But 
pushed  beyond  this  point,  or  given  in  larger 
quantity,  both  these  drugs  enter  upon  their 
sedative  and  narcotic  phase ; dulness  succeeds 
the  briskness  of  excited  function  ; and  a semi- 
paralysed  condition  of  nervous  energy  ensues, 
ending  in  sleep.  Diffusible  stimulants,  as  they 
are  called,  such  as  ether,  and  ammonia,  stimulate 
perhaps  less  actively  in  the  first  instance ; but 
their  effects  pass  more  speedily  away,  and  are 
not  succeeded  by  any  prolonged  or  well-marked 
period  of  subsequent  depression. 

Vascular  Stimulants. — Cardiac  and  cerebral 
stimulants  are  included  in  what  has  just  been 
said,  but  a special  division  of  vascular  stimu- 
lants is  supplied  by  those  drugs  which  seem  to 
brace  up  and  give  tone  to  weakened  vessels.  It 
is  thus,  no  doubt,  that  we  may  explain  the  in- 
fluence of  opium  in  lending  a healthier  action  to 
indolent  or  spreading  ulcerations ; or  to  the 
faculty  which  quinine  seems  to  possess  in  some 
degree  of  arresting  localised  suppuration. 

Spinal  Stimulants. — The  best  type  of  spinal 
stimulant  is  strychnia,  which  powerfully  excites 
the  reflex  functions  of  the  cord,  and  whose 
tetanising  action  is  somewhat  imitated,  in  the 
lower  animals  at  least,  by  morphia  and  thebaia. 
Under  this  heading  we  may  also  include  bella- 
donna and  carbonate  of  ammonia,  which  have  a 
well-marked  stimulating  influence  over  the  re- 
spiratory centre,  situated  in  the  medulla  oblon- 
gata. 

Stomachic  Stimulants.— Stomachic  stimu- 
lants run  closely  on  a parallel  with  tonics,  and 
probably  act  by  gently  irritating  the  mucous 
membrane,  and  supplying  a sensation  strongly 
resembling  the  natural  physiological  craving  or 
desire  for  food,  which  constitutes  hunger. 

Uses. — Whatever  views  we  may  hold  regard- 
ing the  propriety  of  recommending  stimulants  to 
persons  in  full  health,  the  urgent  necessity  for 
their  administration  in  certain  diseased  condi- 


STING.  1521 

tions  is  one  of  the  fundamental  principles  of 
medicine.  True  although  it  be  that  we  may 
often  treat  acute  illness  very  successfully  with- 
out alcohol,  it  is  no  less  an  acknowledged  fact 
that,  under  well-recognised  conditions,  wo  are 
bound  to  give  it  to  our  patients  with  no  sparing 
hand.  When  the  tongue  is  becoming  dry  and 
brown;  when  the  pulse  is  weak,  soft,  rapid,  and 
irregular  ; when  the  first  sound  of  the  heart  is 
low  and  muffled  ; and  when  muttering  delirium  i» 
settingin — then  we  know  that  the  time  for  wine 
or  spirit  has  arrived,  and  that  under  its  judicious 
use  the  tongue  will  moisten,  the  pulse  become 
slower  and  firmer,  and  the  sufferer  may  sink 
into  a refreshing  sleep.  Good  whisky  or  brandy, 
or  the  effervescing  wines,  are  best  suited  for 
these  emergencies,  and  must  be  given  at  regu- 
lar intervals  and  in  carefully-measured  doses, 
according  as  the  progress  of  the  disease  and 
the  condition  of  the  patient  seem  to  render  their 
administration  necessary.  In  convalescence  also 
a little  stimulant  will  promote  the  appetite  and 
increase  the  general  tone ; and  good  port,  Bur- 
gundy, or  Madeira,  or  some  of  the  lighter  beers, 
will  act  well,  in  virtue  of  their  tonic  properties. 

Although  it  seems  to  he  now  generally  acknow- 
ledged that  stimulants  are  not  required  by  the 
strong  and  robust,  many  dwellers  in  large  towns, 
frequently  pursuing  unhealthy  occupations,  sub- 
ject to  much  mental  strain  and  worry,  and  suffer- 
ing perhaps  from  depression  and  want  of  appetite, 
derive  great  benefit  from  a little  sound  wine  or 
beer.  Under  the  influence  of  the  stimulant,  the 
secretion  of  gastric  juice  is  augmented,  and  more 
food  can  be  taken  and  digested,  the  only  caution 
being  that  the  dose  shall  be  strictly  moderate  in 
quantity,  and  invariably  taken  with  the  meals. 
See  Alcohol. 

The  diffusible  stimulants  also  have  their  place 
in  tlie  treatment  of  disease,  when  we  wish  to 
produce  a slighter  and  more  transient  effect ; and 
carbonate  of  ammonia  is  of  especial  service  in 
the  advanced  stages  of  bronchitis,  from  its  stimu- 
lating influence  on  the  respiratory  centre. 

Nux  vomica  and  strychnia  are  occasionally 
used  with  benefit  in  spinal  disorders  when  the 
more  acute  symptoms  have  passed  away,  and 
when  loss  of  function  from  sheer  debility  seems 
to  be  the  principal  obstacle  to  the  recovery  of 
the  patient. 

The  stomachic  stimulants  find  their  applica- 
tion in  cases  where  the  appetite  flags,  and  when 
the  desire  for  food  requires  to  be  promoted  by 
artificial  means.  Dwellers  in  tropical  climates 
make  greater  use  than  ourselves  of  cayenne  and 
other  fiery  additions  to  the  dietary  ; and  it  seems 
probable  that  by  thus  attracting  an  increased 
flow  of  blood  to  the  stomach,  more  gastric  juice 
may  be  secreted,  and  the  individual  be  justified 
in  consuming  the  greater  quantity  of  food  which 
the  increased  development  of  appetite  seems  t" 
render  necessary.  B.  Barquhaiison. 

STINT G : STINGING  PLANTS  AND 
ANIMALS.  — Synon.  : Tr.  Aiguillon-,  Ger. 
Stcichil. 

Definition. — A sting  is  an  abnormal  sensa- 
tion, partly  painful,  and  partly  itching  in  cha- 
racter, usually  caused  by  the  introduction  be- 
neath the  skin  of  some  poison  of  an  animal  or 


96 


1522  STING. 

vegetable  origin.  Either  increment  of  the  sen- 
sation may  predominate,  and  the  stung  surface 
may  be  simply  painful  and  tender,  or  the  itching 
may  be  intense,  and  lead  to  considerable  scratch- 
ing for  its  relief. 

In  the  ■widest  acceptation  of  the  word,  the 
effect  produced  by  the  application  to  the  skin  of 
such  substances  as  mustard,  cantharides,  strong 
carbolic  acid,  and  the  like,  may  be  denominated 
as  stinging ; but  here  it  is  proposed  to  consider 
only  the  wounds  inflicted  by  stinging  plants  and 
animals.  The  subject  of  venomous  animals  is 
separately  discussed.  See  Venomous  Animals. 

2Etiology. — The  severity  of  the  sensation  and 
of  the  local  constitutional  effects  of  stinging, 
depends,  not  only  on  the  quality  and  quantity 
of  the  irritant,  but  also  on  individual  suscep- 
tibility; in  some  persons  the  effect  may  be 
extremely  mild  and  transient,  in  others  severe 
symptoms  may  ensue. 

In  respect  to  the  peculiar  susceptibility  of 
the  person  attacked,  the  greatest  difference  is 
observable  amongst  individuals,  and  even  in  the 
same  person  at  different  times.  In  many  of  the 
recorded  fatal  cases,  the  victim  had  been  pre- 
viously stung  and  had  suffered  severely.  There 
seems,  however,  reason  to  believe  that  the  system 
becomes  more  resistant  to  the  effects  after  re- 
peated stingings,  as  is  seen  to  be  the  case  among 
bee-keepers,  and  those  continually  exposed  to 
mosquitoes.  Some  variations  in  the  violence  of 
the  poison,  whether  of  animal  or  plant,  occurs 
with  the  season  of  the  year. 

Stinging  Plants. — These  are  almost  entirely 
limited  to  the  order  Urticacea,  of  which  the  fol- 
lowing species  are  the  most  important:  V.  zirens, 
U.  dioica  (British),  U.  crenulata,  U.  stimulans 
(Indian),  U.ferox  (New  Zealand),  U.  giffas  (New 
South  Wales),  (which  forms  lofty  trees),  and  U. 
urentissima  (Java).  A few  species  of  the  order 
Malpighiacias  also  possess  stinging  properties. 

In  the  nettles  the  urticating  organs  consist  of 
unicellular  hairs  tapering  towards  the  free  end, 
which  terminates  in  a bent  knob,  and  swelling 
out  at  the  attached  extremity,  where  it  is  received 
into  a cup-shaped  depression  of  a cellular  pedicel. 
The  acrid  fluid,  the  nature  of  which  has  not  been 
determined,  but  is  supposed  to  be  an  acid  similar 
to  malic  or  acetic  acid,  is  regarded  as  being 
secreted  by  the  pedicel  and  stored  in  the  sting- 
ing hair,  from  which  it  escapes  into  the  integu- 
ment when  the  brittle  knobbed  tip  is  broken  off 
by  contact.  The  hairs  in  the  Malpighiads  are 
peltate  and  not  tapering. 

Stinging  Animals.  — Urticating  organs, 
known  as  trichocysts,  cnidce,  or  thread-cells , simi- 
lar in  function  only  to  the  stinging  cells  of 
nettles,  are  found  in  many  animals,  such  as  the 
Infusoria,  some  Annelida,  and  several  Nudibran- 
chiate  mollusca.  They  are,  however,  best  de- 
veloped and  most  characteristic  in  the  Coelente- 
rata,  of  which  the  jelly-fishes  or  sea-nettles  are 
the  best  known.  These  organs  consist  of  cells, 
containing  an  acrid  fluid,  and  prolonged  into  a 
long  filament  which  presents  numerous  modifi- 
cations of  barbs  and  serrations.  The  filament  is 
usually  spirally  coiled  within  the  cell,  from  which 
it  is  everted  on  contact,  convey .ng  the  fluid  into 
the  surface  that  it  penetrates.  Great  variety  exists 
In  the  form,  size,  and  disposition  of  these  organs; 


STITCH. 

in  many  of  the  Actinozoa  or  sea-anemones  they 
are  arranged  in  rope-like  clusters,  enclosed  in 
fine  tubes,  within  the  body-cavity. 

The  power  of  stinging  is  possessed  very  gene- 
rally by  members  of  the  articulate  sub-kingdom, 
such  as  spiders  and  scorpions  among  the  Arach- 
nida ; bees,  wasps,  mosquitoes,  and  ants  among 
the  Insecta.  The  bite  of  the  flea  or  hug  produces 
itching  rather  than  a sting.  In  all  cases  of  true 
stinging  an  irritant  fluid,  thought  to  be  of  the 
nature  of  formic  acid,  is  introduced  beneath  the 
skin  by  some  penetrating  organ,  which  may  Le 
connected  with  the  trunk  or  with  the  terminal 
segment  of  the  abdomen. 

Effects. — Tbe  introduction  of  the  poison  of 
a stinging  vegetable  or  animal  is  followed,  either 
immediately  or  within  a very  short  lime,  by 
erythema  of  the  affected  part,  the  surface  being 
red  and  swollen.  If  a mucous  membrane,  as 
of  the  mouth,  have  been  the  seat  of  the  wound, 
the  swelling  is  intense,  the  tongue  cannot  be  pro- 
truded, and  swallowing  becomes  difficult  or  even 
impossible.  Nor  are  the  results  limited  to  the 
locality  of  the  sting,  the  erythema  often  spread- 
ing to  a considerable  extent,  from  the  hands  ot 
face,  which  are  obviously  the  most  frequent  start- 
ing-point, to  the  arms,  neck,  and  trunk.  Asso- 
ciated with  the  local  manifestations,  general 
symptoms,  often  of  a most  severe  and  even  fatal 
character,  have  been  known  to  occur.  Well- 
authenticated  cases  of  death  from  the  stings  of 
bees,  wasps,  scorpions,  and  even  some  species  of 
tropical  nettles,  have  been  placed  on  record. 

In  the  majority  of  such  cases  the  poison  has 
brought  on  a state  of  syncope ; severe  prostra- 
tion, pallor,  and  pulselessness  being  the  most 
general  symptoms  ; and  death  has  been  known  to 
occur  within  a quarter  of  an  hour,  or  from  that 
to  a few  hours.  When  the  case  does  not  prove 
fatal,  recovery  is  generally  rapid  and  the  patient 
is  quite  well  in  a day  or  two;  but  this  is  n a 
always  so,  and  tho  effects  of  some  nettles  (ior 
example,  Urtica  urentissima,  the  Devil's  leaf  of 
Java)  are  said  to  last  for  years. 

Treatment. — (a)  Local. — Innumerable  appli- 
cations have  been  suggested  as  specifics  in  cases 
of  stinging.  Among  those  most  generally  re- 
sorted to  are  alkalies,  6uch  as  liquor  ammonia?, 
or  a solution  of  bicarbonate  of  soda  or  of  potash. 
If  applied  to  the  stung  surface  directly  they  are 
undoubtedly  efficacious.  Carbolised  oil  (1  in  20) 
has  been  successfully  employed  for  the  stings  of 
bees  and  wasps.  Lint  soaked  in  chloroform,  and 
laid  over  the  scat  of  the  bite,  is  recommended; 
and  ipecacuanha  applied  externally  is  said  to  be 
most  beneficial.  The  writer  has  found  nothing  so 
successful  for  the  relief  of  mosquito-bites  as  the 
oil  of  pennyroyal,  which  has  the  further  effect  of 
most  completely*  keeping  away  these  insects. 

(L)  General. — When  constitutional  symptoms 
are  produced,  stimulation  with  brandy,  ammonia, 
and  ether  is  an  absolute  necessity,  and  one  or 
other  of  these  should  be  administered  without 
stint,  as  life  undoubtedly  depends  on  counteract- 
ing the  cardiac  depression. 

W.  H.  Allchi  s. 

STITCH. — A sharp  catching  pain  in  the  sid^ 
generally  associated  with  pleurisy,  pleurodynia, 
or  intercostal  neuralgia.  See  Pleura,  Diseases  of. 


STOMACH, 

STOMA.CH.  Diseases  of.  — Synon.  : Fr. 
Maladies  de  VEstomac ; Ger.  Krankheiten  des 
Magens. — The  stomach  is  a widely  expanded 
gland,  exceeding  in  activity  cf  function  any 
other  secreting  structure  in  the  body.  When 
its  surface  is  examined  ■with  a microscope  of 
low  power,  it  presents,  in  every  part,  small 
superficial  pits  or  depressions,  which  are  sur- 
rounded by  slightly  elevated  ridges.  Into  these 
pits  open  a number  of  the  tubes  which  form 
tho  secreting  structure  of  the  organ.  The  whole 
of  the  surface  of  the  mucous  membrane,  as  well 
as  the  depressions  just  mentioned,  is  covered 
by  a layer  of  conical  epithelium,  whose  office 
it  is  to  secrete  mucus,  as  well  as  to  shield 
the  sensitive  textures  beneath  it.  When  a ver- 
tical section  of  the  walls  of  the  stomach 
is  made,  the  whole  of  the  glandular  portion 
is  seen  to  be  composed  of  tubes,  placed  per- 
pendicularly to  the  surface.  In  the  infant  the 
tubes  are  arranged  in  groups,  which  are  sepa- 
rated from  those  near  them  by  a sparing  amount 
of  fibrous  tissue,  along  with  blood-vessels  and 
nerves  ; but  in  the  adult  this  method  of  arrange- 
ment is  much  less  clearly  seen.  The  tubes  vary 
in  form  in  different  parts.  As  a rule  they  are 
single,  and  placed  side  by  side ; but  in  the 
pyloric  region  they  are  wider,  and  occasionally 
give  off  caecal  prolongations  towards  their  lower 
ends.  The  writer  has  sometimes  suspected  that 
these  apparent  projections  from  the  tubes  were 
the  result  of  the  sections  not  being  carried  quite 
perpendicularly  through  the  membrane.  Each 
tube  is,  on  the  average,  about  of  an  inch  in 
length,  by  to  555  of  an  inch  in  breadth ; but 
there  is  considerable  variety  in  this  respect  in 
the  different  parts  of  the  stomach.  In  the  car- 
diac portion  they  are  generally  shorter,  and  in 
the  pyloric  wider,  than  in  the  middle  region. 
Each  tube  is  formed  externally  of  a transparent, 
structureless  membrane,  named  the  basement 
membrane.  The  upper  portion  of  its  length  is 
lined  for  a variable  distance  from  the  pit  into 
which  it  opens  by  conical  epithelium,  whilst  the 
remaining  part  is  filled  with  the  true  gastric 
colls.  The  gastric  cells  are  round  or  oval  in 
shape,  and  about  Y2S0  Part  °f  an  inch  in  diameter. 
They  present  a prominent  central  nucleus,  along 
with  fatty  and  albuminous  granules.  These 
cells  appear  to  secrete  and  contain  the  pepsin, 
on  which  the  digestive  power  of  the  gastric 
secretion  depends.  In  the  pyloric  region  we 
meet  with  numerous  tubes  which  are  entirely 
filled  with  conical  epithelium,  and  others  in 
which  only  their  lower  ends  present  true  gas- 
tric cells.  Some  authors  have  asserted  that 
the  tubes  in  the  pyloric  region  are  entirely 
devoid  of  cells  containing  pepsin.  Although 
such  appears  to  be  the  case  in  some  of  the 
lower  animals,  it  is  not  true  as  regards  the 
human  subject.  The  tubes  are  retained  in  their 
position  by  fine  fibres,  that  pass  up  between 
them  from  the  sub-mucous  tissue  to  the  surface. 
The  arteries  perforate  the  muscular  structure, 
and  send  up  branches  between  the  tubes.  In 
this  position  they  give  off  fine  branches,  which 
communicate  freely  with  the  neighbouring  ves- 
sels. Arrived  at  the  surface  they  again  increase 
in  size,  and  form  a dense  network  of  capillaries 
which  occupies  the  ridges  of  the  pits  into  which 


DISEASES  OF.  1523 

the  tubes  open.  From  this  network  the  veins 
pass  downwards  between  the  tubes,  and  even- 
tually pour  their  contents  into  the  larger  venous 
trunks  situated  in  the  submucous  tissue.  The 
lymphatics  are  arranged  in  two  sets:  one  situated 
immediately  beneath  the  peritoneum ; and  the 
other  between  the  mucous  and  muscular  layers. 
They  communicate  with  glands  chiefly  situated 
near  the  lesser  curvature.  The  nerves  are  de- 
rived from  the  sympathetic  and  pneumogastric 
nerves.  In  the  submucous  tissue  their  branches 
form  a plexus,  and  are  connected  with  numerous 
ganglia. 

Such  being  an  outline  of  the  structure  of  the 
stomach,  its  diseases  will  now  bo  considered,  and 
in  alphabetical  order.  Several  important  sub- 
jects, intimately  associated  with  disorder  or 
disease  of  the  stomach,  are  discussed  separately 
under  their  own  headings.  See  Digestion,  Dis- 
orders of ; Digestive  Organs,  Diseases  of ; 
Eructation  ; Flatulence  ; Pylorus,  Diseases 
of ; and  Pyrosis. 

1.  Stomach,  Abscess  in  the  "Walls  of. — 
This  is  a rare  disease,  and  appears  to  occur 
under  two  distinct  forms.  In  one  the  walls  of 
the  stomach  are  the  seat  of  cancer  or  of  fibroid 
thickening.  In  cancer  inflammation  occasionally 
takes  place  in  the  newly-formed  structure,  and 
the  pus  resulting  from  it  bursts  through  a 
number  of  openings  in  the  mucous  membrane. 
A similar  condition  occasionally  occurs  in  fib- 
roid thickening.  Some  have  supposed  that  the 
thickening  in  such  cases  is  the  result  of 
the  inflammation  that  produced  the  pus  ; but 
more  probably  the  suppuration  is  an  acute 
change  supervening  on  a chronic  morbid  con- 
dition. 

Still  more  rarely,  general  suppuration  occurs 
in  the  submucous  tissue  of  the  stomach.  In  most 
of  the  cases  of  the  kind  which  have  been  re- 
corded the  patients  have  died  of  pyaemia,  and  in 
all  probability  the  suppuration  is  secondary.  In 
the  cases  of  localised  suppuration  that  have  come 
under  the  notice  of  the  writer  there  were  no  dis- 
tinctive signs  likely  to  attract  the  attention  of 
the  practitioner.  Dr.  Brinton  describes  the  symp- 
toms of  this  form  of  gastritis  as  ‘ violent  pain, 
and  tenderness  in  the  region  of  the  stomach, 
attended  by  severe  and  frequent  vomiting,  and 
by  high  febrile  reaction.  The  pain  and  vomiting 
increase  in  severity,  and  the  tenderness  becomes 
so  excessive  as  to  suggest  peritonitis,  the  more 
so  that  it  is  often  accompanied  by  some  tym- 
panites, which  however,  like  itself,  sometimes 
differs  from  that  of  general  peritonitis  in  being 
limited  to  the  epigastrium.  By-and-by  jaundice 
may  come  on.  In  any  case  the  febrile  excite- 
ment rapidly  merges  into  prostration,  which  is 
associated  with  delirium,  and  ends  in  death  in 
from  forty-eight  hours  to  a few  days  from  the 
commencement  of  the  attack.’ 

Treatment. — The  treatment  of  such  cases, 
where  they  can  be  recognised  during  life,  must 
be  the  same  as  that  required  for  the  general 
affection  of  which  they  form  a part. 

2.  Stomach.,  Albuminoid  Disease  of. — - 
Albuminoid,  waxy,  or  lardaceous  disease  not  un- 
frequently  affects  the  mucous  membrane  of  the 


STOMACH,  DISEASES  OF. 


1524 

stomach  and  bowels.  It  is  always  associated 
with  a similar  condition  of  the  liver,  spleen,  or 
kidneys,  the  writer  not  having  met  with  any  case 
where  the  digestive  tract  was  alone  the  seat  of 
this  morbid  change.  The  mucons  membrane  pre- 
sents a pale  and  bloodless  appearance,  and  affords, 
with  iodine,  the  well-known  brownish-red  reac- 
tion. In  some  cases  the  surface  of  the  stomach 
is  much  congested,  tough,  and  thickened  from  the 
co-esistence  of  chronic  catarrhal  gastritis.  Dr. 
Wilson  Fox  states  that  ‘in  some  instances  all 
traces  of  the  epithelial  cells  are  destroyed,  and 
the  contents  of  the  tubes  are  converted  into  the 
refracting,  homogeneous,  irregular  masses,  into 
which  the  histological  elements  of  the  tissues  are 
always  changed  in  cases  of  this  disease.’  From 
its  constant  association  with  a similar  condition 
of  important  organs,  it  is  difficult  to  assign 
to  this  affection  of  the  mucous  membrane  any 
characteristic  symptoms.  In  all  probability,  the 
diarrhoea  that  accompanies  lardaceous  disease 
originates  from  a similar  affection  of  the  intes- 
tinal tract ; and  the  vomiting  that  more  rarely 
presents  itself  may  be  a consequence  of  a morbid 
condition  of  the  stomach. 

3.  Stomach,  Atony  of. — There  are  numer- 
ous cases  of  indigestion  in  which  the  most  careful 
inquiry  fails  to  ascertain  any  structural  change 
in  the  stomach.  These  are  usually  classed  under 
the  head  of  ‘ atonic  dyspepsia,’  and  the  symp- 
toms seem  to  arise  either  from  an  imperfect 
secretion  of  gastric  juice,  or  from  the  muscular 
movements  of  the  organ  being  so  enfeebled 
that  the  food  is  allowed  to  remain  an  undue 
length  of  time  in  the  first  part  of  the  digestive 
canal. 

^Etiology. — A feeble  state  of  the  digestion 
may  occur  at  all  ages,  but  more  especially  in  the 
decline  of  life.  The  stomach,  like  all  other  glands, 
lose3  its  power  of  secretion  as  age  advances,  and, 
consequently,  we  find  dyspepsia  a common  com- 
plaint amongst  the  old.  Females  are  more  liable 
to  it  than  males,  who  are  more  apt  to  suffer  from 
inflammatory  changes  in  the  gastric  mucous  mem- 
brane. It  cannot  be  too  much  impressed  upon 
the  mind  of  the  practitioner,  that  an  enfeebled 
condition  of  the  stomach  is  a constant  result  of 
gastritis,  and,  in  like  manner,  a diminution  in  the 
power  of  the  digestion  predisposes  to  attacks  of 
inflammation.  Atonic  dyspepsia  may  be  an  here- 
ditary disease,  and  when  this  is  the  case  the 
symptoms  usually  manifest  themselves  at  an 
early  period  of  life.  So  long  as  the  growth  of  the 
body  continues,  little  trouble  is  experienced  in 
such  cases  ; but  from  twenty  to  thirty,  when  the 
necessity  for  great  activity  of  the  nutritive 
powers  censes,  the  patient  feels  himself  inca- 
pable of  digesting  his  food  as  easily  as  before. 
It  is  not,  however,  necessary  that  the  child 
should  experience  the  same  form  of  gastric  dis- 
order as  his  parent,  for  one  may  suffer  from 
mere  feebleness  of  digestion,  whilst  the  other 
may  have  been  Liable  to  the  inflammatory  form 
of  dyspepsia.  It  is,  perhaps,  scarcely  neces- 
sary to  observe  that  there  is  no  complaint  so 
liable  to  be  excited  by  errors  in  diet.  A sto- 
mach, which,  although  it  performs  its  functions 
feebly,  may  be  able  to  digest  as  much  food  as  is 
requisite  for  the  maintenance  of  health,  may  be 


incapable  of  disposing  of  enough  to  satisfy  th>) 
desires  of  a person  who  seeks  his  pleasure  in  the 
gratification  of  his  palate.  Consequently,  one 
of  the  most  common  causes  of  atonic  dyspepsia, 
more  especially  amongst  the  richer  classes  of 
society,  is  to  be  found  in  the  undue  frequency  of 
meals.  Every  practitioner  is  consulted  by  per- 
sons complaining  of  dyspepsia  produced  by  food, 
in  some  shape  or  another,  being  taken  every  two 
or  three  hours,  under  the  supposition  that  they 
are  suffering  from  debility.  In  reality,  the  feel- 
ing of  exhaustion  from  which  they  suffer  arises 
from  the  stomach  never  being  allowed  a sufficient 
period  of  repose.  It  is  called  into  renewed  ac- 
tivity by  the  introduction  of  fresh  food  before 
the  last  meal  has  been  passed  into  the  duodenum. 
Imperfect  digestion  is  the  necessary  consequence, 
and  only  a small  portion  of  what  is  eaten  is  dis- 
solved and  reaches  the  blood.  On  the  other 
hand,  atonic  dyspepsia  constantly  arises  amongst 
the  poor  from  an  imperfect  supply  of  food,  or 
from  the  food  not  being  of  a nutritious  nature. 
The  out-patient  rooms  of  our  public  institutions 
are  daily  frequented  by  females  who  are  existing 
on  tea  and  a scanty  supply  of  bread,  and  who 
could  be  readily  cured  by  a more  generous  diet.  An 
immoderate  use  of  alcoholic  liquors  seems  chiefly 
to  favour  the  production  of  inflammatory  gastritis ; 
but  the  writer  has  constantly  seen  those  who  had 
habituated  themselves  to  such  indulgence  become 
the  victims  of  feeble  digestion  as  soon  as  they 
have  abandoned  the  use  of  stimulants.  It  is, 
however,  much  better  that  persons  who  are 
unable  to  take  stimulants  in  moderation  should 
suffer  from  dyspepsia  than  subject  themselves 
to  the  innumerable  other  evils  arising  from 
drunkenness.  Imperfect  mastication  is  a com- 
mon cause  of  this  complaint.  The  writer  has 
found  that  only  19  per  cent,  of  those  who  were 
not  dyspeptics  confessed  to  the  habit  of  eat- 
ing very  quickly,  whilst  amongst  the  sufferers 
from  gastric  disorders  '51  per  cent,  were  in  the 
habit  of  imperfectly  masticating  their  food. 
Persons  who  live  chiefly  on  liquids,  such  as  tea 
and  soup,  are  more  liable  than  others  to  feeble 
digestion.  In  all  probability  the  mucous  mem- 
brane becomes  relaxed,  and  the  gastric  juice  is 
too  much  diluted  to  dissolve  the  food  with  the 
requisite  rapidity.  Insufficient  exercise  is  an- 
other very  common  cause  of  the  complaint,  and 
those  wrho  lead  indolent  and  luxurious  lives  pay 
the  penalty  in  the  shape  of  dyspepsia.  Consti- 
pation is  another  common  cause  of  this  form  of 
indigestion,  and  it  is  partly  by  producing  this 
symptom  that  sedentary  occupations  exercise 
such  a prejudicial  influence.  As  the  gastric  fluid 
is  secreted  from  the  blood,  it  is  evident  that  a 
normal  amount  and  quality  of  the  latter  must  be 
necessary  for  the  perfect  performance  of  the 
digestive  process.  Consequently,  we  find  that 
the  digestion  becomes  feeble  in  all  cases  of 
ansemia,  however  this  condition  may  have  been 
produced.  Numbers  of  cases  are  constantly  pre- 
senting themselves  in  the  out-patient  depart- 
ment of  every  hospital  in  which  the  symptoms 
of  atonic  dyspepsia  are  maintained  by  long- 
standing leucorrhoea  or  other  discharges.  The 
nervous  system  controls,  not  only  the  secretion 
of  the  gastric  fluid,  but  also  the  muscular  action 
of  the  organ.  Any  deviation,  therefore,  from  its 


STOMACH.  DISEASES  OF.  1525 


normal  state  is  apt  to  be  attended  with  an  alte- 
ration in  the  secretion  and  motions  of  the  sto- 
mach. In  the  more  acute  disorders  of  the  brain 
we  often  have  an  excess  of  acid  secreted ; but 
whenever  the  nervous  system  is  enfeebled,  the 
functions  of  the  digestive  canal  are  weakened  in 
a corresponding  degree. 

Symptoms. — The  invasion  of  atonic  dyspepsia 
is  always  gradual,  and  in  a large  proportion  of 
the  eases  the  symptoms  replace  those  of  acute 
or  chronic  gastritis.  There  is  seldom  any  severe 
pain,  but  the  patient  often  complains  of  a feeling 
of  fulness  and  distension  after  meals,  which 
begins  shortly  after  eating,  and  lasts  for  an 
hour  or  two.  In  other  instances  there  is  a sen- 
sation of  constriction,  produced  by  flatulence, 
which  affects  the  lower  part  of  the  chest,  and  is 
relieved  by  eructation.  Occasionally,  the  pain 
radiates  to  the  shoulders,  or  passes  down  the  left 
arm  and  hand,  so  severely  as  to  simulate  angina 
pectoris.  It  is  distinguished  from  that  complaint 
by  its  coming  on  shortly  after  food,  and  not  after 
exertion.  In  other  cases  the  constriction  is  ac- 
companied by  dyspnma,  arising,  no  doubt,  from 
the  movements  of  the  diaphragm  being  impeded 
through  its  being  pushed  upwards  by  the  dis- 
tended stomach.  In  men  of  advanced  age  who 
are  inclined  to  obesity  there  may  be  considerable 
embarrassment  of  the  pulmonary  and  cardiac 
functions  from  this  cause,  especially  where  any 
unusual  exertion  is  undertaken  after  a meal.  It 
is,  perhaps,  unnecessary  to  say  that  in  hysterical 
persons,  and  in  those  whose  nervous  systems  have 
been  unduly  excited  by  alcohol,  there  is  often  a 
shrinking  from  the  slightest  touch  upon  the 
skin.  In  these  conditions  the  tenderness  is  gene- 
ral ; it  is  not  increased  by  deep  pressure,  and  is 
often  most  loudly  complained  of  w'hen  the  hand 
is  applied  to  a part  distant  from  the  stomach. 
Vomiting  rarely  presents  itself,  excepting  as  the 
result  of  some  t emporary  error  in  diet,  or  as  an 
accompaniment  of  hysteria  or  phthisis.  Eructa- 
tions are  generally  complained  of  ; but,  instead 
of  the  acidity  that  accompanies  catarrhal  in- 
flammation of  the  stomach,  only  gas  or  small 
portions  of  undigested  food  are  returned.  The 
appetite  is  generally  deficient;  in  some  cases 
there  is  a craving  for  various  indigestible  sub- 
stances, but  this  is  not  so  common  as  in  the 
inflammatory  affections  of  the  stomach.  Some- 
times there  is  an  aversion  to  all  food.  The 
tongue  is  usually  broad,  flabby,  indented  by  the 
teeth,  but  not  red,  pointed,  or  injected,  as  in 
gastritis.  Thirst  as  a rule  is  absent.  The  large 
intestine  corresponds  in  the  feebleness  of  its 
functional  power.  The  bowels  are  consequently 
constipated,  the  stools  disordered,  and,  in  many 
cases,  they  contain  largo  portions  of  undigested 
food.  The  most  common  appearance  is  of  pieces 
of  fibre-like  tissue  that  have  escaped  the  action  of 
the  stomach,  often  mistaken  by  patients  for  worms. 
The  urine  is  usually  pale  and  of  low  specific  gra- 
vity. If  it  deposits  lithates,  the  sediment  is  pale 
in  colour  ; more  generally  oxalates  or  phosphates 
make  their  appearance.  A long  continuance  of 
imperfect  digestion  produces  loss  of  flesh  and 
strength,  but  this  is  never  to  the  extent  that  oc- 
curs in  the  organic  affections  of  the  stomach.  The 
pulse  is  slow  and  feeble.  The  heart  is  especially 
apt  to  be  affected  with  palpitation.  Often  the 


patient  complains  of  a sudden  tumbling  sensa- 
tion, as  though  the  heart  had  turned  over;  at 
other  times  the  palpitation  comes  on  after  exer- 
tion, and  relief  is  obtained  by  stooping,  or  some 
other  change  of  posture.  Some  are  chiefly  tor- 
mented at  nights.  They  are  awakened  at  two 
or  three  o’clock  in  the  morning  with  violent  and 
irregular  palpitation.  Such  cases  occur  most 
frequently  in  the  old,  and  often  indicate  a fatty 
condition  of  the  organ.  The  skin  is  cold  and 
clammy ; and  irregularities  in  the  circulation, 
producing  coldness  of  the  hands  or  feet,  are  con- 
stant sources  of  complaint. 

The  nervous  symptoms  constitute  the  most 
distressing  manifestations  of  the  disease,  more 
especially  when  the  affection  itself  arises  from 
an  exhausted  condition  of  the  nervous  system. 
The  patient  awakes  at  two  or  three  in  the  morn- 
ing, and  is  unable  to  sleep  for  many  hours, 
when  perhaps  he  falls  into  a troubled  and  unre- 
freshing slumber.  There  is  often  great  irrita- 
bility of  temper,  gloom  obscures  the  mind,  or 
the  patient  is  incapable  of  concentrating  his 
mental  powers,  or  he  becomes  feeble  and  irre- 
solute in  character. 

Diagnosis. — Atonic  dyspepsia  is  not  likely  to 
be  confounded  with  the  painful  affections  of  the 
stomach — namely,  ulcer  and  cancer.  It  is,  how- 
ever, a point  of  great  practical  importance  to 
distinguish  it  from  an  inflammatory  affection  of 
the  mucous  membrane.  This  is  the  more  difficult 
because  these  conditions  so  often  replace  each 
other  in  the  progress  of  a case  of  chronic  dys- 
pepsia. The  chief  differences  are  as  follows.  In 
atonic  dyspepsia  there  is  no  epigastric  tenderness, 
which  is  usually  present  in  gastritis.  There  is 
no  pain  excepting  what  may  easily  be  referred  to 
flatulent  distension ; and  acidity  and  heartburn 
are  much  more  rare  in  the  former.  Vomiting, 
again,  is  unusual  in  atonic  dyspepsia;  common 
in  gastritis.  The  tongue  is  broad,  flabby,  .and 
tolerably  clean,  and  forms  a striking  contrast  to 
its  injected  tip  and  edges,  and  thick  coating  in 
the  latter  affection.  The  urine  is  pale,  depositing 
oxalates  or  phosphates,  in  a feeble  state  of  the 
stomach ; high-coloured,  and  loaded  with  lithates. 
when  the  organ  is  inflamed. 

Treatment. — The  first  and  most  important 
point  is  to  remove,  as  far  as  possible,  all  the 
causes  of  the  disease.  It  is  evident  if  a patient 
is  eating  too  frequently,  or  masticates  his  food 
imperfectly,  or  leads  an  indolent  and  luxurious 
life,  all  drugs  must  be  unavailing  to  remove  his 
disease,  so  long  as  he  maintains  it  by  an  erro- 
neous system  of  living.  Again,  the  food  should 
be  of  such  a nature  as  will  require  the  least  pos- 
sible exertion  on  the  part  of  the  stomach.  Thus, 
lightly-cooked  mutton,  chicken,  or  game  is  more 
easily  digested  than  beef,  pork,  or  lamb.  Eoast 
meat  is  more  digestible  than  boiled.  Soups  and 
broths  should  be  avoided,  as  well  as  any  large 
quantity  of  hot  tea  or  coffee.  In  bad  cases 
vegetables  had  better  be  omitted  from  the  die- 
tary for  a time  ; but  as  soon  as  the  patient  im- 
proves they  should  be  again  employed.  Great 
mischief  is  often  done  by  forbidding  fora  length 
of  time  all  vegetable  food  ; for,  although  the  fla- 
tulence and  other  symptoms  may  be  thereby  re- 
lieved, the  general  health  soon  suffers.  In  many 
cases  it  will  be  found  useful,  where  we  are  forced 


1526  STOMACH,  DISEASES  OF. 


to  forbid  vegetables,  to  order  one  or  two  table- 
spoonfuls  of  lemon  juice  daily.  This  may  be 
either  tal^en  diluted  with  water,  or  squeezed 
from  the  lemon  over  the  meat.  When  there  is 
much  tendency  to  acidity,  light  puddings  and 
farinaceous  food  must  be  sparingly  used,  but 
otherwise  they  generally  agree  well.  Pastry 
and  new-baked  bread  should  be  avoided  in  all 
cases. 

When  a person  of  middle  age  and  inclined  to 
obesity  is  troubled  with  feeble  digestion  it  is 
better  that  he  should  avoid  potatoes,  spirituous 
liquors,  sweets  and  fatty  substances ; and  that 
ho  should  use  dry  toast  instead  of  bread,  and 
a simple  but  varied,  diet.  A dinner-pill  of  rhu- 
barb, ipecacuanha,  and  ginger  may  be  given  to 
aid  digestion,  accompanied  by  a nervine  tonic, 
such  as  strychnia  or  tincture  of  nux  vomica, 
combined  with  nitro-hydrochloric  acid. 

Innumerable  remedies  are  recommended  for 
this  form  of  indigestion,  but  in  order  that  they 
should  be  usefully  employed,  it  is  necessary  to 
ascertain  the  cause  from  which  the  imperfect 
secretion  of  gastric  juice  has  arisen.  In  a large 
proportion  of  the  cases  the  feeble  condition  of 
the  mucous  membrane  has  resulted  from  previous 
inflammation.  There  is  a second  class  where, 
although  the  gland-structure  is  normal,  the 
blood  is  deficient  in  quantity,  or  is  abnormal  in 
quality.  In  a third  the  defect  originates  with 
an  exhausted  condition  of  the  nervous  centres. 
Each  of  these  states  requires  a separate  medici- 
nal treatment,  and,  although  one  often  merges 
into,  or  is  associated  with,  another  condition,  yet 
the  features  of  one  or  other  appear  more  pro- 
minently in  each  case  that  comes  under  our 
notice. 

Where  the  feeble  digestion  has  arisen  from  a 
relaxed  state  of  the  mucous  membrane  produced 
by  previous  inflammation,  the  tonic  should  be  of 
an  astringent  character.  It  is  in  such  cases 
that  the  nitric,  nitrohvdrochloric,  or  phosphoric 
acid,  either  alone  or  in  combination  with  bitter 
infusion,  is  required.  Acids  are  best  given  when 
the  stomach  is  empty,  so  that  they  may  directly 
affect  the  vascular  system  of  the  organ.  If  me- 
tallic preparations  are  preferred,  the  perchloride 
of  iron  may  be  used.  Notwithstanding  the  ad- 
verse opinions  of  many  authors,  the  writer  has 
often  found  pepsin  very  valuable  in  these  cases. 
The  pepsina  porci  is  the  best  preparation,  and 
it  may  be  given  along  with  capsicum  or  ipecacu- 
anha before,  not  after,  meals.  One  reason  why 
pepsin  so  often  proves  inefficacious  is  that  it  is 
not  administered  in  sufficient  doses.  In  cases  of 
feeble  digestion  in  young  children  or  aged  per- 
sons, much  benefit  will  sometimes  result  from 
the  addition  of  pepsin,  in  larger  quantities  than 
usually  prescribed,  to  milk,  warmed  and  left  to 
stand  a short  time  before  being  taken  ; or  pep- 
tonised  food  may  be  ordered  in  seme  cases.  See 
Peptonised  Food. 

AVhere  the  dyspepsia  arises  from  anaemia,  re- 
course must  be  had  to  iron.  If  it  is  con- 
nected with  excessive  menstrual  discharge  or 
leucorrhcea,  the  writer  has  often  found  the  phos- 
phate of  iron  and  manganese  a useful  prepara- 
tion. In  other  cases  it  may  be  combined  with 
quinine.  The  saccharo-carbonate  and  the  am- 
monio-eitrate  are  very  valuable  and  unirritating 


salts.  It  is  a good  plan  in  these  cases  ta 
alternate  the  steel  with  other  tonics,  and  as 
liberal  a diet  should  be  given  as  can  be  easily 
digested. 

Where  the  nervous  system  is  chiefly  in  fault, 
preparations  of  nux  vomica  and  phosphorus, 
or  those  of  zinc  and  arsenic,  are  chiefly  of  use. 
Zinc  may  be  given  as  a valerianate  along  with 
quinine,  or  as  a superphosphate  in  combina- 
tion with  iron.  It  is  in  this  class  of  cases  that 
preparations  of  silver,  such  as  the  nitrate  and 
oxide,  are  chiefly  valuable. 

The  colon  is  usually  as  atonic  as  the  stomach, 
and  therefore  the  bowels  require  attention  in 
almost  every  case  that  comes  beneath  our  notice. 
All  severe  purgatives  should  be  avoided;  for 
nothing  so  increases  the  feebleness  of  the  diges- 
tion as  the  indiscriminate  employment  of  this 
class  of  drugs.  Salines,  such  as  the  sulphate 
of  magnesia  and  the  various  mineral  waters, 
must  be  especially  prohibited.  The  most  useful 
aperients  are  rhubarb  pill,  combined  with  nux 
vom:ca  or  belladonna.  When  there  is  no  affection 
of  the  rectum,  the  extract  of  aloes  answers  well ; 
or  if  this  part  is  irritable  some  mild  aperient, 
such  as  senna  electuary,  may  be  employed. 
AVhero  a slight  amount  of  acidity  is  present  the 
compound  rhubarb  powder  of  the  pharmacopoeia, 
or  an  occasional  dose  of  soda  and  rhubarb,  is 
most  suitable. 

4.  Stomach,  Atrophy  of. — Analogy  would 
lead  us  to  expect  that  the  structure  of  the  sto- 
mach would  be  liable  to  atrophy,  since  this  change 
is  so  often  met  within  the  kidney,  liver,  and  other 
glandular  organs  ; and  this  expectation  would 
be  strengthened  if  we  considered  the  great  func- 
tional activity  of  the  gastric  mucous  membrane, 
and  its  especial  liability  to  inflammatory  changes. 
We  find  that  atrophy  of  portions  of  the  gland- 
structure  of  the  stomach  is  exceedingly  common, 
although  sufficient  usually  remains  intact  to  en- 
able the  organ  to  perform  its  functions.  From 
his  own  investigations  the  writer  is  led  to  be- 
lieve that  a certain  amount  of  anatomical  change 
occurs  in  every  person  after  he  has  reached  the 
middle  period  of  life,  when  the  necessity  for  a 
superabundant  supply  of  nutriment  has  ceased. 
It  takes  place  first  in  the  pyloric  region,  and 
tends  gradually  to  extend  as  age  advances. 
Caution  is  required  in  the  investigation  of  such 
changes  in  the  case  of  the  stomach,  lest  the 
effects  of  post-mortem  digestion  should  be  mis- 
taken for  those  of  disease.  In  both  the  mucous 
membrane  is  attenuated,  and  the  structure  de- 
stroyed; but  in  the  former  it  is  soft,  and  can 
he  readily  detached  by  the  slightest  pressure  of 
the  finger;  in  the  latter  it  is  firm,  adherent, 
and  usually  pale  and  anaemic.  Microscopically,  in 
post-mortem  solution,  the  surface  is  uneven ; in 
atrophy  it  is  smooth,  and  the  openings  of  the 
tubes  are  sharp,  defined,  and  often  enlarged.  On 
a section  being  made,  in  the  former  the  tissue  is 
seen  to  be  reduced  to  a mere  mass  of  cells  and 
fat ; in  the  latter  the  lower  ends  of  the  tubes 
are  often  enlarged  and  loaded  with  cells. 

Anatomical  Characters. — In  atrophy  of  the 
stomach  the  mucous  membrane  usually  escapes 
post-mortem  digestion;  it  is  thin,  smooth,  and 
firmly  adherent  to  the  subjacent  coats.  Micro- 


STOMACH,  DISEASES  OF. 


scopically,  in  the  earlier  stage  of  the  disease 
the  solitary  glands  are  enlarged,  and  filled  -with 
cells  and  nuclei.  The  gastric  tubes,  and  some- 
times the  subjacent  muscular  fibres,  are  dis- 
placed by  theso  bodies,  -which  are  scattered  every- 
where through  the  membrane.  The  tubes  adhere 
firmly  to  each  other,  hut  they  still  contain 
normal  cells.  Later  in  the  disease  the  solitary 
glands  appear  empty  in  their  centres,  but  sur- 
rounded by  thick  layers  of  nuclei ; the  tubes  can 
no  longer  be  traced  throughout  their  whole 
extent,  but  can  only  be  recognised  as  bulbs  filled 
with  fatty  cells,  or  as  lines  of  cells,  whilst  the 
whole  tissue  is  obscured  by  fatty  and  granular 
matters.  In  the  last  stage  the  solitary  glands 
have  disappeared,  and  the  tubes  are  replaced  by 
fibres.  In  some  cases  observed  by  the  writer, 
although  the  mucous  membrane  was  very  thin, 
it  was  so  fatty  that  33  per  cent,  was  removed 
when  digested  in  ether.  These  anatomical  changes 
seem  to  produce  a concomitant  decrease  in  func- 
tional power,  Tost-mnrtem,  digestion  seldom  oc- 
curs, even  in  the  summer,  and  in  one  case  in 
which  the  writer  performed  artificial  digestion 
with  the  whole  mucous  membrane,  only  six- 
tenths  of  a grain  of  albumen  was  dissolved,  and 
in  two  others  the  albumen  was  only  softened. 
When  a similar  experiment  was  performed  with 
the  stomachs  of  persons  who  had  died  of  other 
diseases,  four  grains  of  albumen  was  the  average 
amount  dissolved,  the  remainder  being  softened 
and  translucent. 

Symptoms  and  Causes. — Atrophy  of  the  sto- 
mach presents  itself  clinically  in  three  different 
forms  : — 

1.  We  find  it  combined  with  inflammation  of 
some  of  the  other  coats  of  the  organ,  and  proving 
fatal  by  the  exhaustion  of  the  patient.  A man, 
thirty-nine  years  of  age,  was  admitted  into  the 
London  Hospital,  under  the  care  of  the  writer, 
in  1873.  Some  enlarged  lymphatic  glands  of  the 
axilla  had  existed  for  twelve  months,  and  for  six 
months  he  had  suffered  pain  immediately  after 
eating,  attended  by  vomiting  shortly  after  meals. 
AVhen  admitted,  the  vomiting  occurred  daily, 
and  he  brought  up  an  intensely  acid  fluid.  This 
gradually  subsided,  but  he  lost  flesh  and  strength, 
and  died  from  exhaustion.  On  post-mortem  exa- 
mination, all  the  organs  proved  to  be  healthy, 
excepting  the  stomach,  the  coats  of  which  for 
some  distance  from  the  pylorus  were  greatly  thick- 
ened, whilst  the  mucous  membrane  was  exten- 
sively atrophied  throughout  the  whole  organ. 
Cases  like  this  are  mentioned  by  most  authors 
on  diseases  of  the  stomach,  and  are  usually 
quoted  to  show  how  slight  may  be  the  anato- 
mical changes  sufficient  to  produce  death.  But 
when  the  microscope  is  brought  to  hear  upon 
the  point,  the  atrophy  of  the  glandular  structure 
is  found  to  be  very  extensive,  so  much  so  that 
if  an  equal  amount  of  morbid  change  were  to 
present  itself  in  a closely-packed  glandular 
organ,  as,  for  example,  in  the  kidn-ey  or  liver,  it 
would  he  at  once  recognised  and  its  importance 
acknowledged. 

2.  The  second  class  includes  a large  number 
( f the  casps  known  as  1 idiopathic  anrnmia,’  and, 
in  all  probability,  the  morbid  alterations  re- 
eult,  not  from  inflammation,  but  from  degene- 
ration. The  writer  has  met  with  some  marked 


1527 

cases  corroborating  this  statement.  Dr.  Hand- 
field  Jones  quotes  a case  of  ‘ extreme  anaemia,’ 
in  a man  aged  sixty-two,  in  which  there  was 
general  atrophy  of  the  stomach  {Morbid  Con- 
ditions of  the  Stomach,  p.  108).  Sappey  men- 
tions the  case  of  a young  man,  aged  thirty- 
two,  who  had  died  in  a state  of  marasmus, 
in  whom  almost  all  the  pepsiniferous  glands 
had  been  destroyed,  excepting  those  in  the  py- 
loric region.  It  is  evident  from  these  cases  that 
a considerable  proportion  of  those  suffering  from 
idiopathic  ansemia  are  really  the  subjects  of 
atrophy  of  the  stomach.  There  is  not  much 
emaciation,  for  the  pancreas,  liver,  and  absorb- 
ing apparatus  of  the  intestines  are  capable  of 
digesting  and  taking  up  the  fat.  But  the  heart, 
like  the  other  tissues,  becomes  loaded  with 
fatty  matter ; and  it  has  therefore  often  hap- 
pened that  the  general  feebleness  and  evident 
want  of  blood  have  been  attributed  to  this 
state  of  the  centre  of  the  circulation,  and  the 
patient  has  been  said  to  have  died  of  ‘ fatty 
heart.’ 

3.  There  is  a third  class  of  cases  in  which 
atrophy  of  the  stomach  occurs,  without  any  very 
especial  symptoms  during  life  pointing  to  the 
organ  thus  seriously  diseased.  The  writer  care- 
fully examined  the  structure  in  fifty-seven  per- 
sons who  had  died  of  cancer  affecting  various 
organs  of  the  body.  Fifteen  of  these  were  fe- 
males, who  suffered  from  cancer  of  the  breast, 
and  of  these  75  per  cent,  presented  well-marked 
atrophy  of  the  glandular  structure  of  the  sto- 
mach. In  twenty-four  there  was  disease  of  the 
uterus,  and  gastric  atrophy  was  present  only  in 
three  of  these;  whilst  no  case  occurred  amongst 
persons  affected  with  malignant  disease  of  the 
glands,  bones,  or  skin.  It  is  evident,  therefore, 
that  the  atrophy  of  the  stomach  only  accom- 
panies certain  forms  of  cancer.  In  those  cases  of 
cancer  of  the  breast  where  the  microscope  dis- 
closed atrophy,  the  mucous  membrane  was  much 
attenuated  and  its  weight  diminished ; in  one 
case  it  only  weighed  360  grains,  the  average 
weight  in  females  dying  from  other  diseases 
being  720  grains.  The  amount  of  pepsin  con- 
tained in  the  gland-structure  was,  in  every  ease 
in  which  it  was  tested,  remarkably  deficient. 
The  diminution  in  the  weight  of  the  mucous 
membrane  in  these  cases  was  not  thp  result  of  a 
general  wasting  of  the  body,  for  in  cancer  of  the 
uterus  the  average  weight  was  660  grains.  The 
co-existence  of  this  serious  disease  of  the  stomach 
with  cancer  of  the  breast,  supplies  us  with  an 
explanation  of  the  fact,  that  many  cases  die  some 
time  after  an  operation  has  been  performed,  in 
whom  there  has  been  but  a trifling  reappearance 
of  the  malignant  growth,  and  no  great  amount 
of  discharge  or  of  bleeding,  to  account  for  the 
gradual  loss  of  flesh  and  strength.  The  writer 
has  seen  different  cases  of  this  kind,  and  has 
remarked  that  the  cancerous  tumour  is  usually 
slow  in  its  growth,  liable  to  contract,  and  that 
eventually  nodules  form  in  different  parts  of 
the  skin.  The  dyspeptic  symptoms  are  limited 
to  failure  in  appetite,  ofteu  a disgust  for  animal 
food,  and  flatulence,  accompanied  by  a gradual 
loss  of  flesh,  strength,  and  colour. 

Diagnosis. — Atrophy  of  the  stomach  can  only 
be  diagnosed  by  the  exclusion  of  all  other  dis- 


STOMACH,  DISEASES  OF. 


1528 

eases  that  tend  to  produce  anaemia.  Hemorrhage 
and  other  discharges  must,  of  course,  be  strictly 
inquired  for,  and  it  must  not  be  forgotten  that 
bleedings  may  be  going  on  in  the  digestive  canal 
without  havdng  attracted  the  observation  of  the 
patient.  It  must  be  also  remembered  that  anae- 
mia very  often  occurs  from  merely  temporary 
failure  of  the  digestive  powers,  at  the  com- 
mencement and  termination  of  the  catamenia. 
When  we  meet  with  a case  of  progressive  anae- 
mia in  a person  of  middle  life,  we  should  also 
examine  the  blood  in  order  to  exclude  leukaemia. 
In  this  disease,  as  is  well  known,  the  white 
blood-cells  are  greatly  increased  in  number, 
whilst  the  writer  has  found  in  atrophy  of  the 
stomach  a diminution  in  both  kinds  of  cells. 
Where  we  find  the  above  diseases  absent,  no  dis- 
colouration of  the  skin,  and  no  signs  of  malig- 
nant disease,  we  may  fairly  suspeet  the  presence 
of  gastric  atrophy.  This  suspicion  would  be 
strengthened  if  the  patient  were  affected  with 
cancer  of  the  breast,  or  a hard  malignant  tu- 
mour of  any  other  organ. 

Treatment. — The  most  important  point  in 
treatment  is  the  regulation  of  the  diet.  As 
there  is  usually  a great  distaste  for  animal  food, 
the  ingenuity  of  the  practitioner  is  often  severely 
taxed  to  discover  some  form  of  food  likely  to 
furnish  albumen  to  the  system  which  the  patient 
can  be  prevailed  upon  to  take.  The  articles 
of  diet  that  usually  agree  best  are  mutton,  fowls, 
game,  soles,  whiting,  haddock,  and  oysters.  It 
is  often  necessary  to  order  that  the  meat  should 
be  beaten  up,  or  minced,  so  that  it  may  be 
swallowed  quickly.  Milk  and  eggs,  where  they 
agree,  are  invaluable,  and  in  the  later  stages 
soups  and  animal  broths  may  be  substituted 
for  solid  food.  The  writer  has  often  recom- 
mended specially  prepared  beef-tea,  which  may 
be  composed  of  extract  of  beef  that  has  been 
digested  by  means  of  pepsin.  Some  patients 
object  greatly  to  the  taste  of  it,  and  it  is  a 
useful  plan  to  give  it  mixed  with  ordinary  beef- 
tea  or  chicken-broth,  or  with  a proportion  of 
invalid  turtle-soup.  In  some  cases  gluten  bread 
and  gluten  chocolate  answer  well.  Other  ar- 
ticles^ diet,  composed  of  starch  and  sugar,  are 
usually  more  readily  taken,  and  more  easily 
digested. 

As  regards  medicines,  steel  in  all  shapes  is 
beneficial.  It  may  be  combined  with  strychnia, 
quinine,  or  other  bittors,  according  to  the  cir- 
cumstances of  the  case.  Arsenic  may  be  used 
with  advantage,  but  it  will  be  found  a good  plan 
to  alternate  it  with  other  tonics.  Pepsin  is  often 
prescribed,  but  it  does  not  produce  much  benefit. 
Acids  are  often  valuable,  the  most  useful  being 
the  hydrochloric  and  phosphoric.  They  are  best 
given,  it  is  said,  shortly  after  a meal. 

Change  of  air,  travelling,  and  freedom  from 
the  cares  of  business,  are  generally  of  more  use 
in  retarding  the  progress  of  the  disease  than 
any  drugs  we  can  prescribe. 

5.  Stomach,  Cancer  of. — Malignant  disease 
of  this  organ  is  much  less  common  than  simple 
ulceration,  but  nevertheless  the  stomach  is  more 
frequently  the  seat  of  cancer  than  any  other 
organ  in  the  body,  with  the  exception  of  the 
uterus.  It  is  almost  always  primary,  unless  it 


arise  from  an  extension  of  disease  from  seme 
neighbouring  organ.  Secondary  malignant  affec- 
tions of  the  stomach  are  exceedingly  rare. 

AStioeogy. — The  tendency  to  gastric  tancer 
increases  with  the  age  of  the  individual.  Dr. 
Brinton  collected  605  cases,  and  found  the 
average  age  at  death  to  be  fifty ; the  greatest 
liability  being  between  sixty  and  seventy.  It  is 
very  rare  below  thirty,  and  up  to  forty  tho 
liability  is  scarcely  equal  to  one-fifth  of  the 
whole.  Males  seem  to  be  twice  as  liable  to 
gastric  cancer  as  females,  and  although  the 
accuracy  of  this  statement  has  been  called  in 
question,  the  writer’s  own  experience  tends  to 
confirm  it.  In  a large  number  of  cases  there  is 
a history  of  hereditary  transmission,  and  so  com- 
pletely is  this  established,  that  the  mere  fact  of 
more  than  one  member  of  a family  having  suf- 
fered from  cancer,  would  lead  us  to  diagnose  its 
presence  in  a doubtful  case.  Neither  anxiety, 
poverty,  nor  intemperance  seems  to  influence  the 
development  of  the  disease. 

Anatomical  Characters. — All  the  varieties  of 
cancer  of  the  stomach  are  here  met  with,  but  scir- 
rhus  is  by  far  thre  most  common.  According  to 
the  researches  of  Dr.  Brinton,  it  constitutes  72 
per  cent,  of  all  the  cases.  N ext  in  order  of  fre- 
quency he  places  the  medullary  form,  which 
amounts  to  18  per  cent.  Colloid  cancer  is  much 
more  infrequent,  excepting  when  in  combination 
with  seirrhus.  These  different  forms  are,  how- 
ever, very  often  combined  with  each  other.  Thus 
we  meet  with  seirrhus  combined  with  medul- 
lary or  colloid  cancer.  Microscopically  the  new 
growths  present  the  ordinary  appearances  cha- 
racteristic of  the  forms  of  the  disease  to  which 
they  belong.  Cancer  seems  generally  to  begin  in 
the  submucous  tissue,  and  spreads  from  thenco 
to  the  other  coats.  The  muscular  structures 
vary  in  appearance  in  different  cases.  In  some 
tho  normal  tissue  has  been  completely  destroyed, 
and  what  appears  to  the  naked  eye  as  muscle 
proves  to  be,  under  the  microscope,  a mass  of 
cancer  cells  and  fibres.  In  other  cases  we  find, 
even  at  some  distance  from  the  disease,  the 
muscular  bundles  much  increased  in  thickness, 
and  the  contractile  fibre-cells  greatly  enlarged, 
with  very  prominent  nuclei.  Again,  the  pressure 
of  the  new  growth  puts  a stop  to  nutrition,  so 
that  the  muscular  bundles  seem  to  be  reduced  to 
a mere  mass  of  fibrous  threads.  Of  equal  in- 
terest are  the  changes  produced  in  the  mucous 
membrane.  Over  the  tumour  the  glandular 
tissue  is  generally  destroyed,  and  nothing  but 
cells  and  fibres  represent  the  original  texture. 
But  in  every  case  examined  by  the  writer  exten- 
sive disorganisation  of  the  glandular  structures 
has  been  found  at  a distance  from  the  original 
disease.  This  is  most  marked  in  seirrhus,  where 
we  meet  with  the  intertubular  spaces  filled  with 
fibres,  the  tubes  being  atrophied,  and  often  re- 
duced to  mere  bulbs  filled  with  fatty  cells. 
AVhere  the  softer  varieties  of  cancer  form  the 
main  portion  of  the  disease,  the  tubes  are  every- 
where apparent,  but  are  unusually  loaded  with 
cells,  whilst  between  and  below  them  nucleated 
cells  are  everywhere  profusely  scattered.  This 
destruction  of  the  glaudular  structure  in  can- 
cer of  the  stomach  is  in  marked  contrast  to 
what  we  find  in  cases  of  simple  ulcer,  fer  in 


STOMACH,  DISEASES  OF. 


this  the  normal  condition  of  the  tubes  can  be 
readily  seen  at  a very  short  distance  from  the 
edge  of  the  sore.  Cancer  tends  in  the  majority 
of  cases  to  attack  the  orifices  of  the  stomach, 
and  here  again  is  another  point  of  difference 
between  it  and  simple  ulcer.  Its  most  frequent 
seat  is  at  the  pylorus ; according  to  Dr.  Brin- 
ton  60  per  cent,  of  all  the  cases  being  located  in 
this  region.  In  13  per  cent,  it  affected  the  car- 
diac orifice,  the  fundus  being  scarcely  ever  pri- 
marily attacked.  It  always  has  a tendency 
to  spread  in  a transverse  direction,  so  that 
an  annular  stricture  is  a common  result.  When 
it  affects  the  pylorus,  it  scarcely  ever  impli- 
cates the  duodenum;  and,  on  the  other  hand, 
it  seldom  appears  at  the  cardiac  orifice  with- 
out spreading  to  the  lower  end  of  the  oeso- 
phagus. 

Symptoms. — The  symptoms  of  gastric  cancer 
usually  show  themselves  very  insidiously.  The 
patient  complains  of  slight  disturbance  of  diges- 
tion, acidity,  flatulence,  or  want  of  appetite.  It 
has  been  stated  that  in  the  majority  of  cases 
there  has  been  no  previous  liability  to  dyspepsia. 
No  certain  rule  can  be  laid  down  respecting  this 
point.  In  many  of  the  cases  observed  by  the 
writer,  dyspepsia  has  been  present  for  years, 
whilst  in  others  there  have  been  no  symptoms 
of  gastric  derangement,  and  the  first  signs  of  the 
cancer  have  occurred  whilst  the  patient  seemed 
in  perfect  health.  In  some  the  fatal  illness  has 
been  ushered  in  by  hsematemesis  ; but  this  is 
uncommon.  Pain  is  one  of  the  most  prominent 
symptoms.  At  first  it  is  only  slight,  and  is 
often  described  as  a dull,  gnawing  sensation, 
but,  as  the  complaint  progresses,  it  assumes 
a more  neuralgic  character.  Generally,  it  is 
referred  to  the  epigastrium ; in  other  instances 
to  the  back,  or  to  the  hypochondrium.  It  is  or- 
dinarily increased  during  digestion,  but,  unlike 
the  pain  of  ulcer,  it  is  often  equally  severe 
when  the  stomach  is  free  from  food.  The  pain 
of  cancer  lias  been  said  by  some  authors  to 
be  occasionally  of  a colicky  character.  This, 
probably,  arises  from  a co-existing  atony  of 
the  colon,  for  the  writer  has  seen  cases  where 
this  kind  of  pain  was  quite  relieved  when  pro- 
per attention  was  directed  to  the  large  intes- 
tine. There  is  generally  tenderness  on  pres- 
sure over  the  seat  of  the  cancer,  but  it  is  not 
so  localised,  nor  so  severe,  as  in  simple  ulcer. 
Unless  the  pylorus  is  obstructed,  there  is  rarely 
much  complaint  of  acidity  or  flatulence.  This 
arises  from  the  fact  that  the  absence  of  ap- 
petite prevents  the  patient  from  indulging  in 
any  large  amount  of  food.  Wrhen  the  growth 
affects  the  pylorus,  the  same  symptoms  are  pro- 
duced as  in  obstruction  of  this  opening  from 
any  other  cause  (see  Pylorus,  Diseases  of). 
A’omiting  is  a very  general  symptom,  having 
occurred,  according  to  Dr.  Brinton,  in  87  per 
cent,  of  his  cases.  It  varies  greatly,  according 
to  the  part  of  the  organ  affected.  In  disease  of 
the  cardiac  orifice  it  is  almost  always  present,  and 
arises  partly  from  the  co-existing  affection  of  the 
(esophagus.  When  the  body  of  the  organ  is  alone 
implicated,  it  may  be  entirely  absent,  but  in 
pyloric  contraction  it  usually  takes  place  at  a 
lengthened  interval  after  food.  Loss  of  appetite 
is  almost  always  present,  and  it  shows  itself,  not 


1529 

only  in  the  later  stages,  but  at  a comparatively 
early  period  in  the  disease.  The  loss  of  appetite 
is  most  marked  in  scirrhus,  and  it  often  forms  a 
useful  diagnostic  sign,  for  in  simple  ulcer  the 
appetite  is  generally  unaffected.  The  tongue  is 
usually  dry,  but  thirst  is  seldom  much  com- 
plained of.  The  bowels  are  often  confined  in 
the  earlier  stages,  from  the  imperfect  muscular 
action  of  the  upper  part  of  the  canal,  but  as  the 
disease  progresses  diarrhoea  frequently  occurs, 
and  tends  to  enfeeble  the  patient.  The  most  strik- 
ing feature  of  the  disease  is  the  steady  and  often 
rapid  loss  of  flesh  and  strength  that  accom- 
pany it.  We  meet  in  the  post-mortem  room  with 
no  other  examples  of  such  extreme  emaciation 
as  are  encountered  in  bodies  after  death  from 
this  disease.  No  case  ever  runs  its  whole  course 
without  this  symptom  manifesting  itself.  The 
lips  become  pale,  and  the  skin  often  of  a greenish, 
or  slightly  jaundiced  hue.  How  are  we  to  explain 
this  cachexia,  which  seems  always  to  occur  in 
gastric  cancer,  although  it  is  often  not  even 
marked  in  the  malignant  affections  of  other 
organs  ? No  doubt,  where  there  is  a rapidly 
growing  tumour,  the  wasting  of  the  blood  and 
the  co-existing  dischage  from  the  seat  of  the 
disease,  are  sufficient  to  account  for  it.  Where, 
as  in  scirrhus,  these  conditions  are  often  absent, 
the  chief  cause  of  the  loss  of  appetite,  the 
failure  in  strength,  and  the  change  'n  colour,  is 
the  atrophy  of  the  glandular  structure  of  the 
stomach,  which,  as  already  pointed  out,  usually 
accompanies  the  disease.  The  pulse  is  ordinarily 
soft  and  feeble,  for  in  this,  as  in  other  forms 
of  cancer,  an  enfeebled  condition  of  the  heart, 
arising  from  a softened,  fatty  state  of  its  muscu- 
lar tissue,  is  commonly  present.  If  fever  is  ex- 
cited by  the  occurrence  of  any  losal  inflammation, 
the  pulse  is,  for  a time,  increased  in  force  and 
frequency'.  Although  the  above  are  usually  th9 
symptoms  of  gastric  cancer,  the  practitioner  must 
not  expect  them  to  be  always  present.  He  may 
be  called  to  a middle-aged  or  elderly  man,  in 
whom  a rapid  loss  of  flesh,  strength,  colour,  and 
appetite  are  the  only  indicati  ons  of  the  fatal  disease 
under  which  he  labours.  The  patient  may  assert 
that  he  has  neither  pain,  nausea,  flatulence,  nor, 
in  fact,  any  symptom  pointing  to  a derangement 
of  his  gastric  functions.  The  mere  loss  of  ap- 
petite and  strength  in  an  elderly  person  should 
be  sufficient  to  awaken  suspicion,  and  demand 
a most  careful  exploration  of  all  the  abdominal 
organs. 

Couese  and  Dubation. — Cancer  of  the  sto- 
mach destroys  life  more  rapidly  than  a similar 
affection  of  almost  any  other  organ  in  the  body, 
and  it  has  been  calculated  that  the  average 
duration  of  the  disease  is  about  one  year, 
the  maximum  being  thirty-six  months,  whilst 
the  shortest  period  in  which  life  is  destroyed 
from  the  first  symptoms  being  noticed  is  only 
one  month.  The  encephaloid  form  is  most  rapid 
in  its  course,  because  its  growth  is  quicker,  and 
the  neighbouring  organs,  such  as  the  liver  and 
lymphatic  glands,  are  more  often  implicated. 
Colloid  cancer  is  the  slowest  in  producing  death, 
and  most  of  the  more  chronic  cases  have  con- 
sisted of  this  form  of  malignant  tumour  Severe 
haemorrhage  is  more  rare  than  iu  simple  ulcer, 
but  there  is  a greater  tendency  to  a constant 


STOMACH,  DISEASES  OF. 


1530 

Dozing  of  blood  from  the  ulcerated  surface.  The 
blood,  thus  slowly  effused,  is  acted  upon  by  the 
gastric  juice,  and  when  vomiting  occurs,  it  is 
rejected  like  ‘ coffee  grounds.’  This  appearance 
of  the  vomited  matter  used  to  be  considered  as 
pathognomonic  of  cancer,  but  it  is  now  known 
that  it  only  arises  from  the  blood  being  slowly 
effused,  and  may,  therefore,  present  itself  in 
other  forms  of  gastric  disorder.  Peritoneal  per- 
foration is  more  rare  than  in  simple  ulcer  ; but 
we  more  frequently  meet  with  communication 
between  the  stomach  and  other  organs,  such  as 
the  colon.  In  such  a case  there  may  be  sterco- 
raceous  vomiting,  or  diarrhoea  maybe  excited  by 
the  gastric  contents  finding  their  way  into  the 
large  intestine.  Marked  relief  of  the  symptoms 
of  cancer  may  be  temporarily  afforded  by  such  a 
perforation,  although  this  is  not  common.  In 
still  more  rare  cases  adhesions  occur  between 
the  stomach  and  the  parietes  of  the  abdomen, 
and  an  external  opening  is  produced.  As  the 
disease  progresses,  other  symptoms  are  generally 
observed.  In  some  cases  ascites  occurs;  in  others 
cederna  of  the  legs;  in  others  jaundice  is  pro- 
duced by  the  pressure  of  the  enlarged  glands  on 
tho  gall-ducts,  or  by  the  implication  of  the  liver 
itself. 

Physical  Signs. — Tho  chief  and  most  impor- 
tant physical  sign  presented  by  gastric  can- 
cer, is  the  presence  of  a tumour.  Dr.  Brin- 
ton  calculated  that  it  is  present  in  80  per  cent, 
of  all  the  cases,  and  probably  this  estimate  is 
not  far  from  the  truth.  It  is  usually  well-de- 
fined, hard,  and  nodular;  and  not  unfrequently 
isolated  nodules  can  be  felt  in  its  neighbourhood. 
The  sound  on  percussion  is  generally  more  or 
less  tympanitic.  The  tumour  is  usually  found 
iu  the  epigastrium,  or  in  the  right  hypochondriac 
region,  more  rarely  near  the  umbilicus.  As  a 
rule,  it  is  fixed,  and  does  not  move  downwards 
with  the  respiration ; but  in  some  instances, 
where  adhesions  had  not  formed,  it  has  been 
dragged  downwards  by  the  weight  of  the  stomach, 
and  has  presented  itself  as  low  as  the  liypogas- 
trium.  It  is  most  readily  discovered  when  the 
pylorus,  or  the  smaller  curvature,  is  the  part 
affected.  Where  the  cardiac  orifice  is  the  seat  of 
the  mischief,  the  growth  may  be  so  deeply  situ- 
ated that,  unless  it  is  of  large  size,  it  may 
elude  discovery.  There  are  certain  chances 
of  error  as  regards  a tumour  caused  by  gas- 
tric cancer,  against  which  we  should  be  on  our 
guard.  Thus  the  swelling  may  arise  from  a 
feculent  collection  in,  or  from  disease  of,  the 
colon.  Again,  cases  are  given  where  the  stomach 
was  found  filled  with  string,  hair,  or  cocoa-nut 
shavings,  and  in  each  case  a tumour  existed 
during  life.  The  rectus  muscle,  when  in  a state 
of  tension,  may  give  rise  to  the  sensation  of  a 
tumour,  and  it  is  only  by  altering  the  position  of 
the  patient  that  the  mistake  can  be  obviated. 

The  size  of  the  stomach  in  gastric  cancer 
varies  according  to  the  orifice  affected,  and  in 
this  way  may  prove  a useful  aid  in  diagnosis. 
When  the  pylorus  is  obstructed,  the  organ  is 
Bsuallv  enlarged;  when  the  cardiac  orifice  is 
narrowed,  the  organ  becomes  decreased  in  size, 
and  we  derive  less  assistance  from  tho  examina- 
tion of  the  vomited  matters  than  might  be 
expected.  In  dilated  stomach  they  are  in  a 


state  of  fermentation,  and  contain  sarcin®  and 
torulae.  Occasionally  there  are  portions  nf 
cancerous  masses,  but,  as  a general  rule,  these 
are  too  much  decomposed  to  afford  satisfactory 
evidence.  In  one  case  observed  by  tho  writer,  a 
number  of  particles  of  the  intestine,  with  the 
villi  attached,  were  discovered  by  the  microscope 
in  the  rejected  fluids,  showing  that  the  can- 
cerous mass  had  invaded  the  duodenum.  In  some 
instances  of  doubtful  cancer,  the  fluids  vomited 
become  quite  solid  when  boiled  with  liquor  po- 
tass® ; and  this  may  prove  a useful  indication  iu 
certain  cases. 

Diagnosis. — In  the  earlier  stages,  and  before 
the  existence  of  ulceration,  gastric  cancer  may  be 
readily  overlooked.  We  are  apt  to  consider  a 
person  who  complains  of  pain  at  the  epigastrium, 
flatulence,  and  other  symptoms  of  indigestion,  as 
merely  suffering  from  dyspepsia.  The  loss  of 
appetite  is,  however,  generally  a more  promi- 
nent symptom  in  the  early  stages  of  cancer  than 
in  dyspepsia,  and  if  the  patient  be  a person  of 
middle  age,  and  is  rapidly  losing  flesh,  the  pro- 
gress of  the  case  should  be  most  narrowlv 
watched,  and  the  abdomen  frequently  explored 
for  any  appearance  of  tumour.  The  chief  diffi- 
culty in  diagnosis  is  to  distinguish  cancer  from 
simple  ulcer;  and  it  is  often  requisite  to  watch 
the  case  for  some  time  before  a decided  opinion 
can  be  formed.  As  a general  rule,  the  pain  is 
more  severe,  more  increased  by  food,  and  more 
relieved  by  vomiting,  in  cases  of  ulcer  than 
of  cancer.  On  the  other  hand,  it  is  less  fixed 
to  one  spot,  and  is  more  neuralgic  in  cancer. 
The  vomiting  is  more  immediate  after  food, 
when  the  cardiac  orifice,  and  is  longer  delayed, 
when  the  pylorus  is  affected  by  cancer  than  in 
cases  of  simple  ulcer.  The  fluids  rejected  in 
chronic  ulcer  contain  no  fragments  of  mucous 
membrane,  although  these  may  be  present  in 
acute  cases,  and  the  rejected  matters  do  not 
solidify  when  boiled  with  liquor  potass®,  as  they 
sometimes  do  in  cancer.  In  one  doubtful  case 
the  writer  ventured  on  the  diagnosis  of  a simple 
ulcer,  from  finding  in  the  fluids  vomited  a short 
time  after  eating  a large  amount  of  peptones. 
The  patient,  against  all  expectation,  perfectly 
recovered.  Severe  h®matemesis  should  lead  us 
to  suspect  ulcer,  frequent  ‘coffee-ground’  vomit 
incline  us  to  the  diagnosis  of  cancer.  Loss  of 
flesh  and  strength,  although  present  in  both  cases, 
is  much  more  rapid  and  decided  in  cases  of 
cancer  ; and,  in  like  manner,  where  we  can  find 
no  evidence  of  hamorrhage  from  any  organ, 
great  pallor  of  the  lips  and  throat  should  lead  us 
to  suspect  it.  Again,  as  cancer  seldom  appears 
in  those  below  thirty-five  years  of  age,  and 
quickly  destroys  life,  we  should  decide  in  favour 
of  simple  ulcer  if  the  symptoms  occurred  in  a 
young  person,  and  had  lasted  for  many  years. 
The  presence  of  a tumour,  in  case  proper  pre- 
cautions have  been  used  to  prevent  mistakes  on 
this  point,  will  settle  the  question  in  favour  of 
cancer. 

In  doubtful  cases,  the  distinction  between  a 
tumour  of  the  stomach  and  colon  may  be  some- 
times assisted  by  the  plan  adopted  in  the  fol- 
lowing case.  A pitient  was  admitted  into  the 
London  Hospital  with  a hard  tumour  below  the 
left  hypockondrium.  As  his  symptoms  did  no! 


STOMACH,  DISEASES  OF.  1531 


definitively  point  to  gastric  cancer,  there  was 
much  difference  of  opinion  as  to  the  nature  of 
the  disease.  The  lowest  edge  of  the  tumour 
was  first  marked  out  with  ink  on  the  skin,  when 
a considerable  quantity  of  soap  and  water,  well 
frothed,  was  injected  by  the  rectum.  The  edge 
of  the  tumour  was  raised  two  or  three  inches, 
but  its  note  on  percussion  was  not  clearer  than 
before.  As  soon  as  the  bowels  had  acted  freely, 
the  patient  was  requested  to  drink  a pint  of 
effervescing  liquid,  and  now  the  edge  of  the 
tumour  descended  considerably,  and  the  note  on 
percussion  became  more  tympanitic.  From  the 
injection  into  the  colon  raising  the  tumour,  it 
was  plainly  not  connected  with  the  intestine, 
whilst  from  the  percussion  note  becoming  clearer 
after  the  drinking  of  the  soda  water,  it  was 
evident  that  it  overlay,  or  was  in  some  way 
connected  with,  the  stomach.  In  all  doubtful 
cases  the  stomach-pump  should  be  used. 

Prognosis. — The  prognosis  of  any  case  of  gas- 
tric cancer  is  always  unfavourable.  It  is  bad  in 
proportion  to  the  rapidity  of  the  progress  of  the 
case ; the  early  occurrence  of  the  vomiting  ; the 
frequency  of  haemorrhage  ; and  the  evidence  that 
other  organs,  such  as  the  liver,  are  also  impli- 
cated. 

Treatment. — There  is  not  much  to  be  ex- 
pected in  the  treatment  of  this  disease.  Inas- 
much as  we  are  unable  to  check  the  progress 
of  the  malady,  all  our  efforts  must  be  directed 
to  the  relief  of  symptoms,  and  to  support,  as 
well  as  we  can,  the  strength  of  the  patient.  Good 
and  well-selected  food,  rest,  and  a fair  supply 
of  stimulants,  often,  for  a time,  appear  to  afford 
new  strength  to  those  overpowered  by  the  dis- 
ease. If  the  body  of  the  stomach  be  the  part 
affected,  the  indications  for  treatment  are  the 
same  as  in  simple  ulcer.  "When  the  pylorus  is 
narrowed,  the  same  plan  must  be  pursued  as 
when  stricture- of  that  opening  has  occurred  from 
any  other  cause.  Cardiac  obstruction  often  brings 
with  it  the  greatest  misery  to  the  patient.  He  is 
tormented  with  hunger  which  he  is  unable  to 
appease,  and  death  gradually  approaches  by 
starvation.  In  such  cases  the  writer  has  in  vain 
tried  the  application  of  ice-bags,  belladonna  ex- 
ternally and  internally,  and  the  hypodermic  in- 
jection of  morphia.  So  long  as  nutritive  ene- 
mata  can  be  borne  they  should  be  given,  and  if 
diarrhoea  is  produced  by  them  small  doses  of 
laudanum  may  be  mixed  with  them.  In  a case 
of  this  kind  in  the  London  Hospital,  great  relief 
was  afforded  by  the  passing  of  a narrow  gum 
clastic  tube  into  the  stomach,  and  pouriDg 
through  it  liquid  food.  After  the  tube  had  been 
used  for  a little  time  the  patient  was  able  to  take 
liquids,  and  gained  considerably  in  weight ; but 
eventually  the  opening  became  so  constricted 
that  the  tube  could  not  be  made  to  enter  the 
stomach. 

6.  Stomach,  Concretions  in. — Concretions 
in  the  stomach  are  composed  of  various  indigest- 
ible substances  that  have  been  swallowed,  such 
as  hair,  paper,  cotton,  cocoa-nut  fibre,  &c.  They 
chiefly  occur  in  idiots  and  lunatics.  In  some  of 
the  cases  recorded  a tumour  has  been  observed 
during  the  life  of  the  patient.  Concretions  of 
this  kind  may  give  rise  to  perforation,  but  more 


generally  they  set  up  inflammation  of  the  mucous 
membrane,  followed  by  peritonitis. 

7.  Stomach,  Contraction  of. — Contraction 
of  the  stomach  may  be  general,  or  confined  to  one 
part.  When  general,  the  stomach  is  uniformly 
reduced  in  size.  This  condit;on  is  the  result  of 
long-continued  abstinence  from  food.  Thus,  in 
disease  of  the  oesophagus  or  of  the  cardiac  orifice 
of  the  stomach  we  meet  with  it,  and  sometimes 
to  such  an  extent  that  the  organ  is  contracted  to 
the  size  of  the  intestine.  Again,  when  vomiting 
has  been  excessive  and  long-continued,  as  in 
acute  gastritis,  a diminution  in  capacity  is  ob- 
served. In  all  these  cases,  although  the  organ 
appears  to  be  so  much  reduced  in  size,  it  readily 
assumes  its  normal  dimensions  when  artificially 
distended.  The  stomach  may  be  generally  les- 
sened by  the  contraction  of  a cancer  or  ulcera- 
tion situated  in  the  smaller  curvature.  The 
lessened  capacity  may  be  partly  due  to  the  small 
amount  of  food  that  could  be  retained  on  ac- 
count of  the  constant  vomiting,  but  it  is  chiefly 
owing  to  the  drawing  together  of  the  orifices, 
which  in  extreme  cases  may  be  separated  from 
each  other  by  a very  small  space.  Partial  con- 
traction of  the  stomach  may  result  from  the 
puckering  up  of  the  coats  of  the  organ  by  the 
cicatrisation  of  an  ulcer.  Cases  are  recorded  in 
which  the  stomach  was  divided,  by  the  contrac- 
tion of  a cicatrix,  into  two  distinct  pouches,  com- 
municating with  each  other  by  a very  narrow 
canal.  Where  the  contraction  occurs  in  the 
pyloric  region,  the  contents  of  the  stomach  can- 
not be  forwarded  iffto  the  duodenum,  and  hyper- 
trophy of  the  muscular  structure,  together  with 
dilatation  of  the  fundus  of  the  stomach,  is 
generally  the  consequence.  See  Pylorus,  Dis- 
eases of. 

8.  Stomach,  Dilatation  of. — This  may  occur 
either  in  an  acute  or  chronic  form. 

(1)  Acute  dilatation. — This  form  is  exceed- 
ingly rare,  and  has  attracted  but  little  atten- 
tion until  of  late  years.  The  earliest  case  on 
record  is  that  of  a lady  mentioned  in  the  fourth 
volume  of  the  Pathological  Transactions , by 
Dr.  Miller  and  Dr.  Humby.  She  had  been 
under  treatment  for  piles  shortly  before  her  ill- 
ness, and  the  abdomen  had  been  observed  to 
have  increased  in  size.  She  was  attacked  with 
vomiting  of  immense  quantities  of  fluid.  The 
vomiting  ceased  four  days  afterwards,  and  the 
abdomen  was  found  to  be  greatly  enlarged.  After 
death  the  cause  of  the  abdominal  distension 
proved  to  be  the  stomach,  which  was  so  much 
dilated  that  it  was  capable  of  holding.  10  pints 
of  liquid.  Dr.  H.  Bennett,  of  Edinburgh,  relates 
a similar  case,  and  attributes  the  dilatation  to  a 
large  quantity  of  effervescing  liquid  the  patient 
had  swallowed  to  allay  his  thirst.  Dr.  Hilton 
Fagge,  in  the  Guy's  Hospital  Reports  (vol.  xviii. 
Third  Series),  describes  two  cases  that  had  fallen 
under  his  notice,  and  also  mentions  that  two 
similar  cases  had  been  observed  at  Guy’s  Hos 
pital  during  fourteen  years. 

Diagnosis. — The  signs  of  the  dilatation,  ac 
cording  to  Dr.  Fagge,  are : — ‘ 1 . A rapidly  in  ■ 
creasing  distension  of  the  abdomen,  which  is 
unsymmetrieal,  the  left  hypoehondrium  being 


STOMACH,  DISEASES  OF. 


1532 

full,  while  the  right  hypochondrium  is  compara- 
tively flattened.  2.  The  existence  of  a surface- 
marking descending  obliquely  towards  the 
umbilicus  from  the  left  hypochondrium,  and 
corresponding  with  the  dragged-down  lesser 
curvature  of  the  stomach,  this  line  appearing  to 
descend  with  each  inspiration.  3.  The  presence 
of  fluctuation  in  the  lower  part  of  the  abdomen. 

4.  The  occurrence  of  splashing  when  the  dis- 
tended part  of  the  abdomen  is  manipulated. 

5.  The  presence  of  a uniformly  tympanitic  note 
over  a large  part  of  the  distended  region,  when 
the  patient  lies  flat  on  his  back.  Above  the 
pubes,  on  the  other  hand,  there  may  be  dulness 
on  percussion,  simulating  that  of  a distended 
bladder.’ 

Treatment. — -There  is  no  doubt  that  the  treat- 
ment recommended,  and  in  one  case  employed, 
by  Dr.  Fagge  is  the  proper  one,  namely,  to 
empty  the  distended  stomach  as  quickly  as  pos- 
sible with  the  stomach-pump  ; and  to  maintain 
life  by  nutrient  and  stimulating  enemata. 

(2)  Chronic  dilatation. — .Etiology, — The 
most  common  causes  of  dilated  stomach  are  con- 
ditions that  prevent  the  egress  of  the  digested 
food  into  the  duodenum.  1.  Cancer  affecting  the 
pylorus  is  the  most  usual  cause.  It  may  pro- 
duce obstruction  at  the  duodenal  opening,  either 
by  the  formation  of  a hard  scirrhous  ring,  or  by 
the  projection  inwards  of  fungoid  growths.  2. 
The  narrowing  of  the  pylorus  arises  in  some 
cases,  not  from  malignant  disease,  but  from 
fibroid  thickening  taking  place  below  the  mu- 
cous membrane ; or  more  rarely  thickening  of 
the  mucous  membrane  alone  suffices  to  narrow 
the  opening  into  the  duodenum.  3.  A simple 
ulcer  near  the  pylorus,  or  the  cicatrix  of  a 
healed  ulcer,  may  cause  the  obstruction.  4.  The 
pressure  of  tumours  upon  the  pylorus  or  duo- 
denum externally  may  prevent  the  due  evacua- 
tion of  the  contents  of  the  stomach.  The  tu- 
mours are  usually  of  a malignant  nature,  but, 
more  rarely,  the  same  effect  may  arise  from 
enlarged  scrofulous  glands.  5.  The  stomach  may 
be  displaced  by  adhesions,  or  the  pylorus  so 
dragged  downwards  that  dilatation  results.  6. 
The  stomach  may  become  dilated  from  paralysis 
of  its  muscular  coat,  produced,  as  in  a case 
given  by  Dr.  Wilks,  by  injury  to  the  splanchnic 
nerves ; or,  as  in  an  instance  which  occurred  to 
the  writer,  from  a fibroid  change  in  the  muscular 
coat.  A certain  amount  of  dilatation  is  by  no 
means  uncommon  as  a result  of  chronic  catarrhal 
gastritis. 

Anatomical  Characters  and  Pathology. — 
When  we  lay  open  the  abdomen,  the  stomach  is 
found  to  be  greatly  increased  in  size,  often  so 
much  so  that  it  appears  to  fill  the  whole  cavity. 
The  greater  curvature  lies  below  the  umbilicus, 
in  extreme  cases  even  as  low  as  the  pubes. 
The  position  of  the  pylorus  varies  according  to 
the  nature  of  the  co-existing  disease.  Sometimes 
it  is  tied  down  by  adhesions  to  its  original  site; 
at  others  it  has  been  dragged  downwards  by 
the  weight  of  the  enlarged  organ,  and  is  situated 
at  a much  lower  level.  When  the  stomach  is 
laid  open,  it  is  found  partially  or  wholly  filled 
with  a dark-coloured  frothy  fluid,  the  amount  of 
its  contents  being  often  enormous.  The  rug* 
are  effaced  by  the  constant  stretching,  and  the 


mucous  membrane  presents  a level  surface,  which 
is  generally  more  or  less  softened  by  the  action 
of  the  acid  contents  upon  it  after  death. 
Microscopically,  the  glandular  structure  is  found 
to  have  suffered  from  the  long-continued  stretch- 
ing. In  one  case  the  writer  found  the  tubes 
visible,  but  widely  separated  from  each  other, 
the  gastric  cells  being  large  and  fatty.  In 
another  case  the  destruction  had  proceeded  still 
further ; a large  proportion  of  the  tubes  had 
been  destroyed,  and  were  replaced  by  fibrous 
tissue,  the  muscular  tissue  being  also  thin  and 
fibrous.  In  other  cases  the  muscular  structure 
proves  to  be  in  a state  of  hypertrophy,  this  con- 
dition being  usually  most  distinct  in  the  pyloric 
region. 

Symptoms. — As,  with  the  rare  exceptions  be- 
fore noticed,  where  the  dilatation  occurs  sud- 
denly, the  stomach  only  slowly  enlarges,  the 
symptoms  manifest  themselves  very  gradually. 
They  are  preceded  by  those  of  the  malady  which 
gave  rise  to  the  dilatation.  Thus,  the  patient 
may  for  many  years  have  suffered  from  the 
severe  pain  after  food  and  vomiting  indicative 
of  ulceration  ; or  frequent  attacks  of  waterbrash, 
or  flatulence  and  acidity,  may  have  led  to 
the  suspicion  of  fibroid  degeneration  of  the 
pylorus.  Unless  cancer  should  co-exist,  there  is 
seldom  much  complaint  of  pain,  but  a sensation 
of  weight  and  fulness  is  usually  experienced. 
More  generally,  attacks  of  heartburn  present 
themselves,  and  a scalded  feeling  of  the  stomach 
and  oesophagus  annoys  the  patient.  In  some, 
there  is  a constant  sense  of  craving  referred  to 
the  epigastrium.  Vomiting  is  almost  always 
present,  although  it  may  be  absent  for  consider- 
able intervals.  It  does  not  occur,  as  in  gastric 
ulcer,  shortly  after  food,  nor  is  there  usually 
any  complaint  of  nausea.  The  patient  feels  full 
and  uncomfortable,  often  has  a sensation  as  if 
fermentation  were  going  on  in  the  abdomen  for 
two  or  three  days,  until  he  gets  relief  by  the 
evacuation  from  the  stomach  of  an  enormous 
quantity  of  liquid.  In  other  cases,  the  vomiting 
occurs  more  frequently,  most  generally  at  night, 
or  towards  the  morning.  He  experiences  great 
relief  for  a few  hours  or  days,  as  the  case  maybe, 
until  the  fluid  again  collects  in  sufficient  quantity 
to  produce  discomfort.  There  is  no  great  amount 
of  straining  during  the  attacks  of  vomiting,  and 
if  the  abdomen  be  examined  as  soon  as  the  act 
is  terminated,  the  stomach  is  still  found  to  be 
full.  It  seems,  indeed,  as  if  the  contents  were 
only  partially  pumped  off  by  the  action  of 
the  diaphragm  and  the  abdominal  muscles,  the 
stomach  itself  being  quite  passive.  In  some 
casos  hsmatemesis  occurs,  but  this  is  rare, 
unless  cancer  be  also  present.  The  characters 
of  the  vomited  matter  are  peculiar ; usually 
they  are  of  a more  or  less  dark  brown  colour, 
very  sour,  edging  the  teeth  and  scalding  the 
throat  of  the  patient.  When  the  liquid  is 
allowed  to  stand,  it  soon  becomes  covered  with  a 
thick  scum,  and  deposits  a thick  brown  sedi- 
ment. Chemically,  it  is  found  to  contain  various 
acids  produced  by  the  decomposition  of  the 
food.  Microscopically,  we  meet  with  sarcinse 
and  torul*  in  great  abundance,  intermixed  with 
particles  of  partially  digested  food,  and  with 
mucus.  In  a few  cases,  bile  is  evacuated,  but 


STOMACH,  DISEASES  OF. 


this  is  an  uncommon  circumstance,  and  espe- 
cially where  there  is  a narrow  stricture  at  the 
pylorus.  Acid  eructations  are  very  common,  and 
often  more  distressing  to  the  patient  than  any 
other  symptom.  Thirst  is  usually  complained  of, 
and  an  excessive  secretion  of  saliva  is  frequently 
remarked.  The  tongue  has  nothing  characteris- 
tic. The  appetite  is  bad  where  cancer  co-exists, 
but  in  other  cases  it  is  good,  often  voracious. 
The  bowels  are  almost  always  constipated,  and 
the  stools  hard  and  knotty.  The  urine  is  usually 
acid,  and  often  deposits  an  abundant  sediment 
of  lithates.  The  nutrition  of  the  patient  soon 
suffers,  and  loss  of  flesh  and  strength  always 
accompanies  the  disease.-  Death  eventually  takes 
place  by  exhaustion,  being  not  unfrequently  pre- 
ceded by  swelling  of  the  feet  and  legs. 

Physical  Signs. — The  abdomen  is  perhaps  dis- 
tended, and  covered  with  enlarged  and  tortuous 
veins.  The  shape  is  characteristic,  the  upper 
curvature  of  the  stomach  being  visible  as  it 
stretches  across  between  the  false  ribs,  the  epi- 
gastrium being  hollow  instead  of  prominent,  and 
the  abdomen  much  fuller  on  the  left  than  on  the 
right  side.  "When,  as  is  so  often  the  case,  the  mus- 
cular coat  is  in  a state  of  hypertrophy,  the  ver- 
micular movements  may  be  seen  through  the 
stretched  and  attenuated  integuments.  The 
movements  are  slow  and  gradual,  proceeding 
usually  towards  the  right  side  of  the  body.  They 
are  almost  constant,  but  can  be  quickened  by 
the  application  of  cold  or  by  galvanism.  Too 
great  stress  must  not  be  laid  upon  this  symptom. 
Vermicular  movements  are  visible  in  the  parts 
above  the  stricture,  whenever  any  portion  of 
the  gastro-intestinal  tube  is  contracted.  The 
sounds  on  percussion  vary  as  the  dilated  sto- 
mach is  full  of  air  or  of  fluid.  The  tympanitic 
sound  is  best  heard  when  it  is  only  partially 
full.  By  changing  the  position  of  the  patient, 
we  are  enabled  to  show  that  the  fluid  gravitates 
in  the  enormously  dilated  organ.  By  lowering 
the  head  and  raising  the  hips  and  legs,  we 
may  generally  define  the  lower  boundary  of  the 
stomach,  by  the  clear  sound  which  is  thus 
exchanged  for  a dull  one  on  percussion.  Bam- 
berger asserts  that,  by  placing  the  stethoscope 
over  the  stomach  whilst  the  patient  is  drinking, 
we  can  hear  the  fluid  fall  into  the  distended 
cavity.  This,  in  the  writer’s  opinion,  is  of  little 
value,  for  he  has  distinctly  heard  the  passage  of 
food  through  a stricture  of  the  cardiac  opening, 
where  the  stomach  was  smaller  than  normal. 

Diagnosis. — With  ordinary  care,  a dilated 
stomach  is  not  likely  to  be  confounded  with  any 
other  abdominal  disease.  The  chief  points  to 
bear  in  mind  are — the  large  extent  over  which 
there  is  a tympanitic  sound;  the  irregular  dis- 
tension of  the  abdomen  ; the  hollowness  of  the 
epigastric  region;  the  fulness  of  the  left  side 
of  the  abdomen;  the  vermicular  motion  apparent 
over  the  dilated  organ  ; the  peculiarity  of  the 
vomiting;  and  the  large  amount  of  fluid  thus 
evacuated  of  an  acid  character,  presenting  under 
the  microscope  torulae  and  sarcinse.  The  dia- 
gnosis of  the  cause  of  the  dilatation  must  be 
determined  by  the  history  of  each  case. 

Treatment. — The  indications  for  treatment 
are  sufficiently  evident,  but  unfortunately  they 
are  most  difficult  to  meet. 


1 333 

a.  It  is  evident  that  it  is  a matter  of  th*  first 
importance  to  keep  the  stomach  as  empty  as 
possible,  so  as  to  allow  of  its  contraction.  This 
can  only  be  effected  by  giving  small  quantities 
of  liquid  food  at  a time,  and  frequently.  But  it 
must  not  be  forgotten  that  if  the  patient  fails 
to  fill  the  long-distended  organ,  a sensation  of 
faintness  and  craving  will  be  induced  that  will 
tempt  him  to  set  at  defiance  all  our  directions 
Consequently,  we  may  be  often  obliged  tc 
give  way  to  his  solicitations,  and  allow  food  of 
a solid  character.  The  main  point,  however,  is, 
as  much  as  possible,  to  restrict  the  supply  of 
food.  In  bad  cases  the  writer  finds  it  a good 
plan  to  order  nutrient  enemata,  as  well  as  small 
quantities  of  food  by  the  mouth.  See  Enema. 
The  plan  of  washing  out  the  stomach,  by  means 
of  a stomach-pump,  with  Vichy  water  or  a strong 
alkaline  solution,  has  not  been  so  successful  i.i 
th6  bands  of  tho  writer  as  he  expected.  In  one 
case  it  had  no  appreciable  effect  in  giving  relief; 
and  in  another  the  patient  complained  so  much 
of  it  that  he  was  forced  to  abandon  its  use. 

b.  The  muscular  action  of  the  stomach  must 
be  as  much  as  possible  facilitated.  The  writer 
has  used  galvanism,  but  with  no  ultimate  benefit. 
Elastic  abdominal  belts  may  afford  support  to 
the  overloaded  organ.  What,  however,  is  always 
more  or  less  beneficial  is  to  keep  up  a free  action 
on  the  large  intestine  by  enemata.  Injections  of 
gruel  and  barley  water,  mixed  with  castor  oil  and 
turpentine,  answer  the  purpose  best. 

c.  Symptoms  must  be  relieved  as  they  arise. 
The  subcutaneous  injections  of  morphia  are  in- 
valuable for  the  relief  of  pain.  In  some  cases 
chloral  answers  better,  but,  on  the  whole,  it  is 
inferior  to  preparations  of  opium.  One  of  the 
most  distressing  symptoms  is  acidity.  This  is 
best  relieved  by  a combination  of  bismuth  with 
magnesia  or  soda,  or  by  lime-water  given  fre- 
quently. Sir  William  Jenner  recommends  the 
hyposulphite  of  soda  to  relieve  the  acidity.  Others 
have  recommended  carbolic  acid  and  creasote. 
The  plan  the  writer  has  often  adopted  with  suc- 
cess is,  to  restrict  the  patient  to  a diet  from 
which  all  starch  and  sugar  are  carefully  excluded. 
Thus,  at  breakfast  we  may  give  weak  coffee, 
dandelion  coffee  without  sugar  or  milk,  and 
lime-water,  always  with  gluten  bread.  Th6 
other  meals,  which  should  be  frequent  and  very 
sparing,  may  consist  of  soup  or  animal  broths, 
or — if  it  be  thought  advisable  to  allow  solids — of 
mutton,  game,  chicken,  or  fish.  No  vegetables 
should  be  permitted,  and  the  patient  should 
be  restricted  to  gluten  bread  or  almond  cake 
instead  of  wheaten  bread.  With  such  a diet, 
assisted  by  cod-liver  oil,  patients  for  a time 
may  improve  greatly,  and  gain  both  flesh  and 
strength.  In  persons  affected  with  dilated  sto- 
machs from  atrophy  of  the  muscular  coat,  lasting 
benefit  may  be  obtained ; especially  if  the  com- 
plaint be  recognised,  and  treated  in  a decided 
way. 

0.  Stomach,  Fibroid  Thickening  cf. — 
This  condition  has  received  various  names,  such 
as  ‘ cirrhosis  of  the  stomach,’  ‘sclerosis,’  ‘plastic 
linitis,’  &c.  Allusion  has  been  made  in  another 
article  to  thickening  of  the  coats  of  the  stomach 
I of  a similar  nature  to  that  affecting  the  pylorus, 


STOMACH,  DISEASES  OF. 


1534 

and  usually  producing  hypertrophy  of  the  mus- 
cular layer,  narrowing  of  the  opening  into  the 
duodenum,  and  eventually  dilatation  of  the  organ 
( see  Pylorus,  Diseases  of).  Such  cases,  although 
not  common,  are  every  now  and  then  met  with, 
and  in  many  instances  the  thickening  of  the 
6ubmucous  tissue  extends  for  some  distance  from 
the  pylorus,  producing  a tough,  leathery  condi- 
tion of  the  coats.  More  rarely  the  thickening 
occurs  in  other  parts  than  at  the  pyloric  end. 
Thus,  in  one  case  of  caries  of  the  spine,  the 
stomach  was  attached  to  the  spinal  column  by 
a dense  layer  of  connective  tissue,  which  slso 
involved  the  coats  of  the  organ.  Over  the  mass 
was  a large  ulceration  with  thickened  base  and 
edges.  But  apart  from  these  local  thickenings, 
we  occasionally  meet  with  a form  of  the  disease, 
in  which  the  coats  of  the  whole  organ  are  im- 
mensely hypertrophied. 

^Etiology. — Males  seem  to  he  more  liable  to 
this  complaint  than  females,  and  it  occurs  at  an 
earlier  period  of  life  than  cancer.  Dr.  Brinton 
states  that,  whilst  the  average  age  of  cancer  is 
fifty,  that  of  fibroid  thickening  is  only  thirty- 
four.  Mechanical  injury  seems  in  some  instances 
to  have  produced  this  disease. 

Anatomical  Characters. — On  opening  the 
abdomen,  there  are  almost  always  found  signs  of 
general  peritonitis,  either  acute  or  chronic.  In 
some  cases  a thick  layer  of  lymph  overlies  and 
unites  the  various  organs  ; in  others  only  fluid, 
mixed  with  flakes  of  lymph,  is  discovered.  The 
stomach  is  round  or  oval  in  shape,  smooth 
on  the  surface,  firm  to  the  touch,  and  forming 
a tumour  in  the  epigastric  or  hypochrondriac 
region.  When  cut  into,  its  walls  do  not  collapse  ; 
and  its  cavity  is  often  so  much  reduced  in  size 
as  to  be  capable  of  containing  only  a few 
ounces  of  fluid.  The  thickness  of  the  walls 
varies  greatly,  but  in  some  instances  they  have 
been  described  as  upwards  of  an  inch.  As  a 
general  rule,  they  are  thicker  at  the  pylorus  than 
elsewhere,  but  the  opening  into  the  duodenum 
is  not  necessarily'  constricted,  although  such  is 
not . infrequently  the  case.  The  coats  are  of  a 
dirty  grey  colour,  but  the  distinction  between 
them  can  be  readily  made  out.  The  chief  seat 
of  the  thickening  seems  to  be  in  the  submucous 
tissue;  but  the  muscular  layers,  as  well  as  the 
connective  tissue  between  the  muscular  bundles 
and  the  subserous  structure,  are  allmuch  increased 
in  thickness  and  density.  The  mucous  mem- 
brane is  thrown  into  folds  or  elevations,  or  stud- 
ded over  by  small  projections,  most  of  these 
appearances  being  probably  the  result  of  the 
diminished  capacity  of  the  organ.  Microscopic- 
ally, the  mucous  membrane  is  usually  found 
healthy.  All  those  who  have  examined  such 
cases  have  come  to  the  same  conclusion,  namely, 
that  the  connective  tissue  alone  is  universally 
increased  in  thickness,  and  that  there  is  an 
absence  of  any  indication  of  cancer. 

Symptoms. — In  a case  observed  by  the  writer 
the  symptoms  followed  immediately  after  the 
receipt  of  an  injury  to  the  epigastrium;  but 
usually  they  have  come  on  insidiously.  There  is 
generally  pain  in  the  epigastrium,  increased  by 
fcod,  in  some  instances  shooting  into  the  back  and 
shoulders.  The  tumour  formed  by  the  thickened 
stomach  is  almost  always  tender  on  pressure,  but 


not  remarkably  so,  unless  peritonitis  is  present. 
Vomiting  is  a general  symptom ; in  some  it 
occurs  directly  after  food,  in  others  the  fluid  re- 
jected is  thin,  like  saliva.  Towards  the  close  of 
the  disease  vomiting  of  blood  is  not  unfrequent, 
but,  unless  ulceration  occur,  there  is  an  absence 
of  the  coffee-ground  fluid  so  constantly  marked 
in  cancer.  The  appetite  is  always  bad,  and 
decreases  as  the  disease  advances;  the  bowels 
are  usually  confined.  There  is  loss  of  flesh  and 
strength  ; the  pulse  is  feeble  towards  the  end 
cf  the  case ; dropsy,  both  of  the  peritoneum 
and  lower  extremities,  generally  shows  itself ; 
and  the  patient  dies  from  exhaustion,  or  is 
cut  off  by  the  occurrence  of  peritonitis.  The 
duration  of  the  malady  varies  greatly.  In  some 
cases  it  has  been  known  to  last  for  many  j-ears, 
whilst  in  others  tho  patient  has  died  in  a few 
months. 

Physical  Signs. — In  almost  every  instance  a 
tumour  has  been  observed  during  life.  It  is 
generally  situated  in  the  epigastrium,  but  may 
present  itself  in  either  hypochondrium.  In  one 
patient  it  was  supposed,  from  its  situation,  to  he 
a cancer  of  the  spleen.  It  is  smooth  upon  the 
surface,  more  or  less  tender  to  the  touch,  and 
usually  movable  from  side  to  side.  On  per- 
cussion, the  sound  is  not  perfectly  dull,  as  in 
the  case  of  a solid  tumour. 

Diagnosis.  — This  complaint  may  be  con- 
founded with  cancer,  or  with  foreign  bodies  in 
the  stomach.  It  must  be  most  difficult,  if  not 
impossible,  to  diagnose  the  more  acute  cases 
from  cancer.  The  smoother  surface  of  the 
tumour,  and  the  non-affection  of  the  liver  or 
other  organs,  are  the  most  likely  points  ou 
which  stress  may  he  laid,  to  distinguish  between 
the  two  diseases.  In  the  chronic  cases  of  fibroid 
thickening,  the  long  duration  of  the  illness,  the 
less  constant  pain,  the  vomiting  directly  after 
food,  the  loss  frequent  occurrence  of  coffee- 
ground  vomiting,  and  the  absence  of  the  history 
of  a family  predisposition  to  cancer,  may  afford 
some  grounds  for  a diagnosis.  To  distinguish 
these  cases  from  foreign  bodies  in  the  stomach, 
we  must  remember  that  the  latter  are  found 
chiefly  in  idiots  and  in  the  insane,  or  in  hysteri- 
cal females.  The  writer  has  long  been  in  the 
habit  of  distending  the  stomach  in  all  doubtful 
cases,  by  making  the  patient  drink  freely  of  soda 
water;  and  in  one  instance  where  thecoatsof  the 
stomach  were  much  thickened,  he  succeeded  bv 
so  doing  in  proving  the  case  to  be  one  of  fibroid 
disease.  The  note  on  percussion  became  more 
tympanitic,  and  the  lump  descended,  hut  in  the 
case  of  a foreign  body  in  the  stomach  no  change 
would  be  effected  by  such  a manoeuvre. 

Thickening  of  the  walls  of  the  stomach  may, 
as  just  said,  closely  simulate  cancer.  It  is  neces- 
sary therefore  that  we  should  he  on  our  guard 
against  such  a mistake.  Although  fibroid  thick 
ening  of  the  stomach  is  ver}'  rare,  yet  we  should 
not  be  too  hasty  in  giving  a settled  opinion  until 
the  presence  of  a tumour,  attended  by  other 
general  and  physical  signs,  leaves  little  doubt  as 
to  the  correctness  of  the  diagnosis. 

Treatment. — Careful  attention  to  diet  is  the 
most  essential  point  in  the  treatment  of  this 
disease.  The  diminution  in  the  size  of  the 
stomach  is  sufficient  to  show  that  only  small 


STOMACH.  DISEASES  OF.  1535 


quantities  of  food  can  be  retained,  and  the  im- 
paired condition  of  the  motor  apparatus  indi- 
cates the  necessity  that  the  nourishment  should 
consist  only  of  liquids.  Milk  and  animal  soups 
seem  best  fitted  for  such  cases.  Opium  is  almost 
th9  only  medicine  likely  to  be  of  value ; but 
occasional  leeches,  and  small  blisters,  frequently 
repeated,  to  the  epigastrium,  tend  to  relieve  the 
sufferings  of  the  patient. 

.0.  Stomach,  Gangrene  of. — It  is  supposed 
by  many  modern  authors  that  ulcerations  of  the 
stomach  are  produced  by  the  solution,  by  means 
of  the  gastric  j uice,  of  small  patches  of  the  mucous 
membrane  that  have  been  deprived  of  their  vita- 
lity, and  become  gangrenous.  Such  may  no  doubt 
be  the  case,  when  the  m'orbid  condition  is  con- 
fined to  merely  isolated  patches  of  the  stomach ; 
but  where  acute  gastritis  coexists,  there  is  a com- 
plete suspension  of  the  secretion  of  gastric  juice, 
and  the  writer  has  in  such  cases  seen  the  edges 
of  the  slouuhing  tissue  still  remaining  attached 
to  the  neighbouring  healthy  structures.  Where 
there  has  been  great  depression  of  strength  we 
occasionally  meet  with  sloughing,  to  a consider- 
able extent,  of  the  mucous  membrane  of  the 
stomach,  both  in  the  inferior  animals  and  in  man. 
Cases  of  sloughing  of  the  stomach  occurring  in 
the  human  subject  have  been  recorded  by  various 
authors.  Dr.  Habershon  mentions  one  in  which, 
along  with  diseased  kidneys  and  pneumonia,  there 
were  several  sloughs  at  the  lesser  curvature  of 
thestomach,  ‘ the  longest  two  inches  in  length  and 
about  one  in  breadth,  black  and  slightly  raised ; 
a section  showed  that  the  slough  was  situated  in 
a sort  of  cup  of  slightly  thickened  tissue.  Two 
smaller  sloughs  were  situated  near  to  it.’  The 
most  ordinary  form  of  gangrene  of  the  stomach  is 
where  it  occurs  in  cancer  of  the  organ.  A large 
mass  of  sloughing  tissue  is  found  connected  with 
a malignant  ulceration,  often  of  large  size,  and 
generally  situated  towards  the  pyloric  end  of  the 
organ. 

Treat:, ient. — Gangrene  of  the  stomach  is  be- 
yond treatment. 

11.  Stomach,  Hernia  of.  See  Stomach,  Mal- 
positions of. 

12.  Stomach,  Hypersemia  of. — The  mucous 
membrane  of  the  stomach  is  frequently  found  to 
be  congested  after  death,  where  there  has  been 
but  little  evidence  of  disease  during  life. 

^Etiology  and  Anatomical  Characters.— 
Gastric  hypersemia  may  arise  from  different 
causes.  If  an  animal  be  killed  when  fhsting, 
the  lining  membrane  of  the  stomach  is  found 
to  be  pale  and  anaemic ; but  if  death  should 
occur  whilst  digestion  is  going  on,  the  ves- 
sels are  seen  to  be  filled  with  blood.  The  same 
thing  is  observed  in  the  human  subject,  and 
serves  to  explain  the  frequent  occurrence  of  a 
congested  state  of  this  organ  after  death.  In 
other  instances  the  increased  vascularity  is  the 
result  of  a lavish  employment  of  alcoholic  stimu- 
lants during  the  later  hours  of  life.  The  most 
extreme  degrees  of  hypersemia  of  the  stomach 
are  met  with  in  cases  of  diseased  heart,  more 
especially  when  the  mitral  valve  has  been  con- 
stricted. When  we  open  the  stomach  we  are  at 
once  struck  with,  the  dark,  purple  condition  of 


its  lining  membrane,  the  appearance  of  conges- 
tion being  most  evident  iD  the  pyloric  region 
and  terminating  abruptly  at  the  end  of  the  •oeso- 
phagus. The  rugse  seem  thick  and  prominent, 
and  the  whole  surface  is  covered  with  a layer 
of  tenacious  mucus.  Spots  of  extravasated 
blood  present  themselves,  some  being  softened  on 
their  surface,  as  though  they  had  been  acted 
upon  by  the  gastric  juice.  There  is,  however, 
seldom  any  of  the  general  softening  character- 
istic of  the  action  of  the  gastric  juice  after  death, 
and  the  surface  looks  raw  and  uneven  after  the 
removal  of  the  adherent  mucus.  The  whole 
stomach  has  a thickened,  fleshy  feeling,  and  is, 
in  reality,  considerably  increased  in  bulk.  In 
three  males  who  died  of  heart-disease  the  average 
weightof  thegastric  mucous  membrane  was  found 
to  be  1,026  grs.,  and  in  three  females  it  amounted 
to  800  grains.  As  the  average  weight  in  fifteen 
males,  who  had  died  of  other  diseases,  was  864 
grains,  and  in  thirteen  females  530  grains,  it  is 
evident  that  the  bulk  is  greatly  increased  in 
hypersemia.  Microscopically,  sections  of  the 
stomach  have  an  opaque  appearance,  from  the 
quantity  of  blood  and  serum  they  contain,  but, 
after  being  for  some  time  macerated,  they  are 
more  transparent.  In  some  cases  the  tubes  can  be 
readily  separated  from  each  other,  and  are  normal ; 
but  in  others  they  are  of  unusually  large  size, 
and  distended  with  cells  and  granular  matter. 
The  blood-vessels  are  always  enlarged,  and  in 
long-standing  cases  the  coats  of  the  veins  are 
thickened.  The  capillaries  surrounding  the  ori- 
fices of  the  tubes,  where  the  backward  pressure 
of  the  blood  must  be  chiefly  felt,  on  account  of 
their  want  of  support,  are  especially  dilated  and 
engorged  with  blood.  Long-continued  congestion 
produces  the  same  effect  in  reducing  the  secre- 
tion of  the  stomach,  as  it  does  on  that  of  the 
kidneys  and  other  glandular  organs.  The  secre- 
tion of  acid  is  evidently  lessened,  for  in  some 
instances  phosphates  have  been  found  in  the  con- 
tents of  the  stomach,  and,  as  a general  rule,  the 
mucous  membrane  does  not  present  the  appear- 
ance of  post-mortem  solution.  But  the  formation 
of  pepsin  is  also  impaired.  The  writer  made  an 
artificial  gastric  juice  from  the  mucous  membrane 
of  three  males  dying  of  heart-disease,  and  found 
only  2'9  grains  of  albumen  were,  on  the  average, 
dissolved,  whilst  the  average  amount  digested  by 
the  mucous  membrane  of  persons  who  had  died  of 
other  maladies  was  4 grains.  In  the  case  of  three 
females  a still  smaller  amount  of  solvent  power 
was  displayed.  In  one  only  2 grains  were  di- 
gested, and  in  the  other  two  scarcely  any  effect 
was  produced  upon  the  albumen.  There  can  be, 
therefore,  no  doubt  that  long-continued  conges- 
tion of  the  gastric  mucous  membrane  not  only 
produces  anatomical  changes,  but  also  diminishes 
the  characteristic  secretion  of  the  organ.  The 
question  may  be  asked  why  hypersemia  is  more 
intense  in  the  pyloric  than  in  the  more  actively 
secreting  portions  of  the  organ?  In  all  proba- 
bility it  arises  from  the  fact  that  the  vessels  of 
the  stomach  perforate  the  muscular  coat  ob- 
liquely, before  they  pass  upwards  between  the 
tubes  to  the  surface.  The  circular  fibres  must 
compress  these  vessels  during  their  contraction; 
and  the  veins,  from  the  greater  tenuity  of  their 
coats,  and  from  their  not  being  protected  by 


STOMACH,  DISEASES  OK 


1536 

surrounding  fibrous  tissue,  must  feel  the  effects 
of  the  compression  more  than  the  arteries.  But 
the  transverse  muscular  fibres  are  comparatively 
thin  and  weak  in  the  larger  portion  of  the 
stomach,  and  become  firmer  and  stronger  as  we 
approach  the  pylorus.  Consequently,  the  veins 
are  moro  liable  to  compression  during  the  more 
energetic  motions  of  this  region,  and  the  effects 
of  the  congestion  are  here  more  appreciable. 

13.  Stomach,  Hypertrophy  of  the  Walls 

of.  See  Stomach,  Eibroid  Thickening  of. 

11.  Stomach,  Inflammation  of.— Stnon.  : 
Gastritis;  Fr.  Gastrite ; Ger.  Gastritis. 

All  the  coats  of  the  stomach  may  he  simul- 
taneously inflamed,  but  this  is  rarely  met  with, 
and  the  cases  in  which  it  occurs  are  referred 
to  under  other  headings  {see  Stomach,  Fibroid 
Thickening  of).  Usually  the  mucous  mem- 
brane is  alone  the  seat  of  the  disease,  and  it  has 
of  late  years  been  the  custom  to  describe  this  as 
‘gastric  catarrh.’  This  term  is  objectionable,  as 
catarrh  is  so  generally  applied  to  the  inflamma- 
tion of  mucous  membranes  of  a much  more  simple 
anatomical  structure.  It,  should  be  borne  in 
mind  that  the  mucous  membrane  of  the  stomach 
is  in  reality  an  expanded  gland,  the  elements  of 
which  have  a greater  functional  activity  than 
those  of  any  other  secreting  structure  in  the 
human  body.  The  injuries  inflicted  upon  it  by 
disease  are  therefore  in  no  way  analogous  to 
those  suffered  by  an  ordinary  lining  membrane, 
but  tend  to  lessen  or  altogether  destroy  the 
function  of  an  organ  of  primary  importance  to 
the  well-being  of  the  individual.  In  addition 
to  this,  the  anatomical  changes  are  not  always 
of  the  same  character,  but  seem  to  the  writer  in 
certain  cases  quite  distinct  from  those  ordinarily 
produced  by  catarrh.  Inflammation  of  the  mu- 
cous membrane  of  the  stomach  will  therefore  be 
described  under  two  forms,  namely,  (1)  Catar- 
rhal ; and  (2)  Erythematous  gastritis.  It  will  he 
also  necessary  to  consider  the  disease  according 
as  it  occurs  in  an  acute  or  chronic  form. 

(1)  Acute  Inflammation — Acute  Gastritis. 
./Etiology.— Acute  catarrhal  gastritis  is  most 
common  in  persons  of  middle  and  advanced  age, 
aud  it  more  frequently  affects  females  than  males. 
Sometimes  it  occurs  in  gouty  and  rheumatic 
subjects,  and  is  relieved  when  the  disease  ap- 
pears in  the  joints.  Again,  it  presents  itself 
in  those  who  suffer  from  disease  of  the  heart, 
emphysema  of  the  lungs,  cirrhosis  of  the  liver, 
aud  other  disorders  that  have  a tendency  to 
keep  up  a congested  condition  of  the  digestive 
tract.  Under  these  circumstances  it  often  proves 
very  dangerous,  and  snaps  the  feeble  thread  by 
which  the  patient  clings  to  life.  The  most  com- 
mon causes  are,  however,  errors  in  diet;  various 
indigestible  substances,  such  as  cheese  or  shell- 
fish, being  especially  liable  to  produce  it.  Above 
all,  an  immoderate  indulgence  in  spirituous  liquors 
is  apt  to  set  up  this  form  of  inflammation,  not 
infrequently  laying  thereby  the  foundation  for 
other  and  more  serious  morbid  changes. 

Acute  erythematous  gastritis  is  more  generally 
met  with  in  children  and  in  j'oung  persons,  and 
constitutes  a considei'able  number  of  the  so- 
called  ‘ gastric  ’ and  1 remittent  ’ fevers,  so  com- 


mon at  this  period  of  life.  It  also  presents  itself 
in  scarlet  fever  and  other  eruptive  disorders,  and 
although  it  usually  passes  off  without  provoking 
any  local  symptoms  during  the  fever,  it  never- 
theless constantly  leaves  a liability  to  a frequent 
recurrence  of  the  disorder.  Considering  how 
often  the  recurrence  takes  place,  it  is  strange 
that  so  little  attention  has  been  attached  to  the 
circumstance.  A similar  morbid  condition  of  the 
stomach  often  makes  its  appearance  in  the  last 
stage  of  phthisis  and  other  exhausting  disorders, 
and  adds  greatly  to  the  danger  and  sufferings  of 
the  patient. 

Anatomical  Charactebs. — In  catarrhal  gas- 
tritis the  stomach  is  usually  contracted  and 
empty.  The  lining  membrane  is  covered  with 
a tenacious  or  thready  mucus,  beneath  which  it 
appears  irregularly  congested.  It  is  softer  than 
usual;  and  often  presents  numerous  small  hae- 
morrhages. These  are  most  commonly  met  with 
in  the  pyloric  region,  are  round  or  oval  in  shape, 
and  frequently  superficially  ulcerated.  Micro- 
scopically, the  pits  on  the  surface  of  the  mem- 
brane are  found  to  be  swollen,  prominent,  and 
their  vessels  are  much  congested.  On  section, 
the  gastric  tubes  are  seen  to  be  greatly  dis- 
tended with  large  granular  cells,  which,  by  their 
increased  size  and  number,  bulge  outward  the 
basement-membrane,  so  as  to  produce  an  irre- 
gular outline.  The  solitary  glands  are  greatly 
enlarged. 

We  meet  with  the  most  perfect  examples  of 
acute  erythematous  gastritis  in  scarlatina.  In  the 
earlier  stages  there  is  no  increased  secretion  of 
mucus,  and  often  but  slight  injection  of  the  sur- 
face, whilst  at  a later  period  the  mucous  mem- 
brane may  be  even  paler  than  usual.  Microsco- 
pically, the  gastric  tubes  are  much  distended  by 
granular  and  fatty  matters,  so  that  the  cells  are 
quite  obscured,  and  in  many  cases  these  seem  to 
be  reduced  greatly  in  number.  Casts  of  the  tubes 
are  in  some  instances  met  with  in  the  contents 
of  the  stomach.  It  will  be  observed  that  the 
morbid  appearances,  which  are  strictly  analogous 
to  those  of  the  skin  in  scarlatina,  differ  from 
those  produced  by  catarrh,  in  the  amount  of 
mucus  not  being  increased,  and  in  the  tubes 
being  distended  by  an  albuminous  fluid,  instead 
of  by  an  increased  growth  of  the  cells  them- 
selves. It  is  therefore  analogous  to  an  erythe- 
matous affection  of  the  skin,  with  which,  indeed, 
it  is  associated  in  scarlatina  ; whilst  the  catarrhal 
form  is  analogous  to  the  eczematous  and  other 
inflammations  of  the  cutis,  which  are  charac- 
terised by  a more  abundant  formation  of  the  cel- 
lular elements. 

Symptoms. — The  catarrhal  form  of  gastritis  is 
sometimes  preceded  for  a few  days  or  hours  by  a 
feeding  of  general  weakness ; in  other  cases  the 
attack  comes  on  without  warning.  There  is  sel- 
dom any  complaint  of  pain  in  the  region  of  the 
stomach,  although  a sense  of  fulness  and  uneasi- 
ness is  not  uncommon.  Vomiting  is  always  pre- 
sent, and  constitutes  one  of  the  most  charac- 
teristic signs  of  the  disease.  At  first  any  re- 
mains of  the  previous  meal  are  rejected,  but 
afterwards  a thick,  glairy  mucus  is  expelled, 
attended  with  violent  retching.  The  tongue  is 
foul,  and  the  breath  often  offensive,  from  the  co- 
existence of  oral  catarrh.  There  is  an  absence  of 


STOMACH,  DISEASES  OF. 


appetite,  or  a positive  aversion  to  all  food.  The 
bowels  are  confined  ; the  urine,  which  is  often 
pale  and  copious  before  the  attack,  becomes 
scanty  and  high-coloured  during  its  continuance. 
The  pulse  is  rarely  quickened,  and  the  tempera- 
ture of  the  skin  unaltered.  There  is  almost 
always  headache,  the  pain  chiefly  affecting  the 
forehead  and  eyes,  and  being  accompanied  by 
intolerance  of  light  and  sound. 

In  erythematous  gastritis,  on  the  contrary, 
pain  at  the  epigastrium  is  a prominent  symptom, 
excepting  when  the  disease  accompanies  eruptive 
fevers.  It  usually  comes  on  directly  after  food, 
sometimes  shooting  into  the  shoulders,  or  down 
the  left  arm.  In  phthisical  cases  a feeling  of 
rawness  in  the  oesophagus  and  stomach  is  more 
generally  complained  of.  The  pain  is  associated 
with  tenderness  on  pressure  over  the  pit  of  the 
stomach.  In  children  there  is  usually  an  ab- 
sence of  pain,  but  the  tenderness  is  well-marked. 
Vomiting  is  as  general  as  in  the  catarrhal  form, 
but  the  matters  rejected  seldom  contain  much 
mucus.  Nausea  is  present  where  vomiting  is 
absent,  and  in  the  slighter  cases  forms  the  chief 
ground  of  complaint.  Thirst  is  almost  always 
troublesome ; the  tongue  is  at  first  red  and  in- 
jected, but  in  a day  or  two  is  apt  to  become  dry 
and  glazed.  Diarrhoea  generally  accompanies  the 
disease,  the  stools  being  foetid  and  unhealthy.  The 
pulse  is  quick,  often  out  of  all  proportion  to  the 
severity  of  the  other  symptoms.  The  tempera- 
ture of  the  skin  is  increased,  especially  in  children. 

Both  these  forms  of  gastritis  generally  sub- 
side, but  in  other  cases  the  disease  shows  a 
tendency  to  become  chronic.  In  both  there  is  a 
diminution,  or  entire  cessation,  of  the  secretion 
of  the  stomach.  This  does  not  arise  from  any 
deficiency  in  the  amount  of  pepsin  in  the  tubes, 
for  the  writer  has  found  the  mucous  membrane 
after  death  capable  of  forming  an  active  artificial 
gastric  juice.  In  all  probability,  the  secretion 
of  acid  is  arrested,  or  its  flow  into  the  stomach 
prevented,  by  the  swelling  of  the  orifices  of  the 
tubes  or  of  the  pits  into  which  they  open.  The 
result,  however,  is  that  fermentation  occurs  in 
any  food  that  may  be  placed  in  the  organ ; the 
inflammation  is  thereby  kept  up ; and  largo 
quantities  of  torulae,  mixed  with  food  or  mucus, 
are  rejected  by  vomiting. 

Diagnosis. — The  vomiting  of  aeute  catarrhal 
gastritis,  attended,  as  it  so  frequently  is,  by 
headache,  is  apt  to  be  confounded  with  the  gas- 
tric irritability  of  brain-disease.  In  affections 
of  the  brain  the  vomiting  occurs  more  directly 
after  food,  and  is  often  unattended  by  nausea. 
The  tongue  may  be  clean,  whilst  the  pulse  is 
quick,  the  skin  hot,  the  bowels  obstinately  con- 
fined, and  other  symptoms  are  present  pointing 
to  some  brain-lesion.  In  gastritis  the  nausea  is 
more  complained  of : the  tongue  is  foul ; the  pulse, 
in  the  catarrhal  form,  but  little  quickened  ; the 
skin  comparatively  cool ; the  bowels  often  re- 
laxed ; and  there  is  a history  of  previous  at- 
tacks, or  of  some  dietetic  error  or  co-existing 
visceral  disorder.  Acute  erythematous  gastritis 
may  at  first  closely  simulate  typhoid  fever,  espe- 
cially in  children.  It  is,  however,  distinguished 
from  it  by  the  gastric  symptoms  being  promi- 
nent from  the  onset ; by  their  sudden  occur- 
rence ; by  the  rapid,  not  gradual,  rise  of  the 

97 


1537 

temperature  ; by  the  red,  injected  tongue ; and 
by  the  spleen  not  being  enlarged.  The  fall  in 
the  temperature,  and  the  absence  of  eruption 
and  of  diarrhoea,  serve  to  prevent  mistakes  after 
the  first  week  of  the  illness. 

Prognosis. — When  gastritis  is  uncomplicated, 
the  prognosis  is  favourable,  but  it  is  otherwise  if 
it  take  place  in  the  course  of  some  serious  chronic 
disorder. 

Treatment. — The  general  principle  to  be  kept 
in  view  is  to  afford  the  stomach  as  perfect  phy- 
siological rest  as  possible.  In  severe  cases, 
therefore,  it  is  best  to  let  the  patient  abstain 
entirely  from  all  food  for  twenty-four  or  forty- 
eight  hours,  allowing  him  to  suck  only  a little 
ice,  in  order  to  allay  thirst.  If  there  be  much 
exhaustion,  or  if  the  attack  be  a protracted  one, 
the  strength  may  be  supported  by  nutrient 
enemata.  Sometimes  the  subcutaneous  injection 
of  morphia  assists  in  giving  rest  to  the  inflamed 
organ.  In  acute  catarrhal  gastritis,  especially 
when  it  is  attended  with  portal  congestion,  or 
has  arisen  from  excessive  indulgence  in  spiri- 
tuous liquors,  we  can  often  put  a stop  to  the 
attack  by  calomel.  Five  grains  may  be  placed 
on  the  tongue,  and  be  followed  by  a saline 
aperient,  or  a second  dose  may  be  administered 
the  following  day.  When  there  is  diarrhoea  or 
much  exhaustion,  it  is  a good  plan  to  give  a 
grain  every  few  hours.  In  the  slighter  attacks 
effervescing  liquids  often  give  great  relief  to  the 
patient.  In  the  earlier  stage  of  erythematous 
gastritis,  nitrate  of  potash  or  muriate  of  am- 
monia, along  with  hydrocyanic  acid,  is  generally 
of  benefit ; the  bowels  being  at  the  same  time  re- 
lieved by  some  mild  aperient,  or  by  an  enema. 

In  both  forms  the  practitioner  should  be  on 
the  watch,  lest  the  symptoms  should  be  kept  up 
by  fermentation.  This  is  readily  determined 
by  placing  a drop  of  the  vomited  matters,  mixed 
with  a weak  solution  of  iodine,  under  the  micro- 
scope. Torulie,  if  present,  will  bo  detected  by 
their  brown  colour,  round  or  oval  shape,  and 
their  tendency  to  the  formation  of  chains  of 
cells.  In  case  of  fermentation,  carbolic  acid, 
creasote,  or  sulphurous  acid  may  be  prescribed. 
The  glycerine  of  carbolic  acid,  in  doses  of  ten  or 
twelve  drops,  is  to  be  preferred,  combined  with 
tincture  of  belladonna  or  solution  of  morphia.  In 
other  cases  the  sulphurous  acid  seems  to  answer 
better. 

Occasionally  the  vomiting  appears  to  persist 
from  exhaustion.  When  this  is  suspected  to  be 
the  case,  stimulants  must  bo  had  recourse  to, 
and  the  writer  has  seen  champagne  stop  sickness 
at  once,  when  all  other  remedies  had  been  fruit- 
lessly tried.  It  is  in  such  circumstances  that  the 
hypodermic  use  of  morphia  is  so  valuable  ; a 
single  dose  often  giving  sleep,  and  allowing  the 
stomach  sufficient  repose  to  recover  its  normal 
tone. 

When  there  is  much  epigastric  tenderness, 
the  application  of  a few  leeches  is  often  of  great 
value.  This  is  chiefly  the  case  where  the  attack 
has  occurred  as  a complication  of  some  other 
gastric  disorder,  such  as  ulcer.  In  obstinate 
cases  of  catarrhal  gastritis,  dry-cupping  may  be 
used  with  benefit.  In  the  erythematous  form 
we  always  find  warm  external  applications  use- 
ful, such  as  poultices  of  linseed  meal,  with  or 


STOMACH,  DISEASES  OF. 


1538 

without  mustard,  hot  fomentations,  and  in  some 
eases  stimulant  or  opiate  liniments. 

When  it  is  considered  advisable  to  allow  food, 
it  should  he  in  the  form  of  liquid.  It  should 
be  given  in  small  quantities  at  a time,  and  he 
often  repeated.  In  catarrhal  gastritis  all  sac- 
charine and  starchy  fluids  should  he  avoided, 
on  account  of  their  tendency  to  ferment.  It  is 
hest  to  restrict  the  patient  to  chicken-broth,  or 
mutton  or  beef-tea,  or  milk  mixed  with  soda, 
Vichy,  or  Seltzer  water.  In  the  erythematous 
form,  where  there  is  less  tendency  to  fermenta- 
tion, barley-water,  arrowroot,  or  other  farina- 
ceous food  mixed  with  milk,  may  be  used.  It 
often  happens  that  condensed  milk  is  tolerated 
where  cow’s  milk  is  rejected. 

(2)  Chronic  Inflammation  ; Chronic  Gas- 
tritis. 

This  is,  perhaps,  the  most  common  disease  met 
with  in  practice,  and  comprises  all  the  forms  of 
chronic  gastric  derangement  usually  described 
under  the  head  of  ‘ inflammatory  dyspepsia.’  It 
is  almost  always  of  a catarrhal  nature,  for  when 
signs  of  erythematous  gastritis  present  them- 
selves, it  will  generally  he  found  that  the  latter 
affection  is  an  acute  attack  supervening  on 
chronic  changes  of  a catarrhal  nature. 

^Etiology. — Men  are  more  subject  to  chronic 
gastritis  than  females;  and  amongst  the  working 
classes,  the  writer  found  it  was  most  frequent  in 
men  between  forty  and  fifty,  and  in  women 
between  fifty  and  sixty.  In  a large  proportion 
of  the  cases  that  occur  in  early  life  it  is  an  here- 
ditary disease,  and  the  mother  is  much  more  apt 
to  transmit  it  than  the  father.  It  often  results 
from  attacks  of  acute  inflammation.  Persons  of 
a full  habit  of  body  are  more  especially  liable  to 
chronic  gastritis,  and  it  is  in  such  that  the  com- 
plaint usually  proves  especially  rebellious  to 
t.roatment.  Of  alL  causes,  errors  in  diet  are  most 
apt  both  to  induce  it,  and  to  maintain  it  when 
once  it  lias  been  lighted  up.  Thus,  a too  free 
supply  of  animal  food  is  one  of  the  most  potent 
causes,  and  equally  so  is  the  habit  of  too  fre- 
quent repetition  of  meals,  without  allowing  a 
sufficient  interval  between  them.  This  habit  of 
eating  too  frequently  is  greatly  kept  up  by  the 
craving  which  is  so  common  a symptom  of  the 
disease.  Imperfect  mastication  is  another  com- 
mon cause:  hut,  above  all,  the  immoderate  use 
of  alcohol  occupies  a prominent  place.  It  is 
strange  how  frequently  we  discover  signs  of 
chronic  gastritis  after  death,  where  no  particular 
complaint  has  been  made  of  any  derangement  of 
the  digestive  organs.  This  is  more  especially  the 
case  where  cirrhosis,  chronic  congestion  of  the 
liver,  diseased  heart,  and  other  disorders  tending 
to  obstruct  the  portal  circulation,  are  present.  In 
like  manner,  it  is  apt  to  occur  whenever  any  ex- 
cretory organ  is  performing  its  office  imperfectly, 
as  in  chronic  diseases  of  the  kidney,  or  when 
constipation,  or  inactivity  of  the  skin  exists.  It 
is  very  common  in  gouty  subjects,  and  in  fe- 
males who  suffer  from  catamenial  derangements. 
It  is  often  met  with  in  persons  who  have  died  of 
phthisis  and  other  wasting  disorders. 

Anatomical  Ciiakacters.—  The  mucous  mem- 
brane of  the  stomach  is  covered  with  a layer  of 
.greyish -white,  tough,  transparent  mucus,  which 
ibrmly  adheres  to  the  surface.  On  its  removal 


an  abnormal  amount  of  vascularity  becomes 
apparent,  the  veins  being  large  and  prominent. 
The  surface  is  often  of  a grey  or  slate  colour, 
and  not  unfrequently  numerous  hiemorrhagic  ero- 
sions present  themselves.  This  is  more  espe- 
cially the  case  where  long-continued  congestion 
has  been  kept  up  by  cardiac  or  hepatic  disease. 
In  other  cases  the  surface  is  strikingly  uneven, 
being  studded  over  with  numerous  little  pro- 
minences, separated  from  each  other  by  shallow 
furrows.  This  condition  is  named  ‘mammilla- 
tion.’  More  rarely,  small  polypoid  formations 
project  from  the  membrane.  The  whole  mem- 
brane is  firm  and  tough,  and  can  be  stripped 
away  from  the  subjacent  structures  in  flakes  of 
considerable  size.  These  anatomical  changes  are 
more  common  in  the  pyloric  region  than  in  the 
more  actively  secreting  portions  of  the  orgaL. 

Microscopically,  in  the  slighter  cases  the  ana- 
tomical changes  may  be  limited  to  enlargement 
and  thickening  of  the  small  pits  on  the  surface, 
together  with  dilatation  and  congestion  of  the 
blood-vessels.  Hut  when  the  disease  has  been 
of  long  standing,  a section  shows  the  glandular 
structure  itself  to  have  participated.  The  secret- 
ing tubes  are  closely  united  together,  and  to  the 
subjacent  coats ; their  basement-membrane  is 
greatly  thickened ; and  they  are  distended  with 
cells  and  granular  matters,  which  often  project 
like  little  lumps  from  their  orifices.  At  a later 
stage  the  tubes  become  atrophied,  and  onlyafew 
fatty  cells  remain  to  point  out  their  former  site  : 
or  their  free  ends  are  obstructed,  whilst  their 
lower  ends  are  dilated  into  a flask-like  form.  The 
grey  pigment  may  be  deposited  either  between 
the  tubes  or  in  the  cells  themselves.  The  soli- 
tary glands  are  generally  enlarged,  and  tend  to 
atrophy  the  tubes  by  their  pressure.  Patches  of 
thickened  layers  of  epithelium  may  remain  at- 
tached to  the  surface,  showing  that  a condition 
may  exist  in  the  stomach  analogous  to  squamous 
diseases  of  the  skin. 

Symptoms. — There  is  a great  difference 
amongst  authors  as  to  the  symptoms  produced 
by  chronic  catarrhal  gastritis.  This,  no  doubt, 
in  part,  arises  from  the  fact  that  simple  and 
uncomplicated  cases  are  so  rarely  fatal,  and 
that  we  have,  therefore,  hut  few  opportunities  of 
verifying  the  diagnosis  by  'post-mortem  examina- 
tion. But  it  also  depends  on  the  symptoms  of 
other  co-existing  affections  being  so  often  de- 
scribed along  with  those  arising  from  the  de- 
ranged stomach.  There  is  seldom  much  com- 
plaint of  pain,  excepting  it  be  a sense  of  fulness 
and  oppression  at  the  epigastric  region  after 
food.  When  there  is  acidity,  the  patient  ofteu 
experiences  a severe  burning  from  the  stomach 
to  the  throat.  In  such  cases  temporary  relief 
may  he  afforded  by  food  or  stimulants,  on  ac- 
count of  the  introduction  of  fresh  aliment  ex- 
citing the  stomach  to  increased  action,  so  that 
the  decomposing  remains  of  the  previous  meal 
are  either  neutralised  or  hurried  through  the 
pylorus.  There  is  generally  a certain  amount 
of  tenderness  at  the  pit  of  the  stomach,  which  is 
most  evident  in  the  cases  in  which  congestion  of 
the  liver  is  also  present  The  appetite  is  variable, 
being  usually  lessened,  but  in  other  cases  a crav- 
ing for  food  is  experienced.  Nausea  is  a common 
symptom,  but  vomiting,  in  the  ordinary  run  of 


STOMACH,  I 

Cdsos,  is  not  so  frequent  as  might  be  expected. 
When  the  affixstica  Das  been  induced  by  drunken- 
ness, a rojoction  ci  mucus  in  the  early  morning 
lakes  place,  aud  iu  gouty  subjects  this  forms  a 
most  distressing  symptom.  Acid  eructations,  and 
a sour  taste  in  the  mouth,  are  commonly  com- 
plained of.  These  probably  arise  from  particles 
of  undigested  food  remaining  entangled  in  the 
mucus,  setting  up  acetous  fermentation  in  the 
saccharine  and  starchy  articles  of  diet.  The 
writer  prevailed  upon  a number  of  patients  who 
were  suffeiing  from  this  symptom  to  excite  vomit- 
ing in  the  early  morning  by  drinking  warm  water, 
fn  every  case  a quantity  of  thick,  ropy  mucus 
was  rejected,  and  intermixed  with  it  were  por- 
tions of  partially  digested  food.  In  some  the 
r.mount  of  fluid  rejected  was  so  large  that  the 
conclusion  could  not  be  resisted  that  the  muscular 
coat  had  been  enfeebled  by  the  inflammation, 
and  had  been  thus  unable  to  completely  expel 
its  contents.  Thirst  is  often  present,  and,  as  a 
general  rule,  is  most  complained  of  towards  even- 
ing. The  bowels  are  usually  confined,  but  where 
the  catarrhal  condition  has  extended  to  the  in- 
testines, frequent  attacks  of  diarrhoea  take  place. 
The  urine  is  high-coloured,  depositing  lithates  ; 
but  as  the  inflammatory  condition  subsides,  it 
may  become  of  low  specific  gravity,  alkaline 
or  slightly  acid,  and  may  deposit  pale-colourcd 
lithates  or  phosphates.  Where  the  oral  cavity 
is,  as  is  usually  the  case,  also  inflamed,  the  throat 
presents  a red,  congested  appearance.  The  tongue 
is  large,  indented  with  the  teeth,  and  if  the  liver 
is  simultaneously  congested,  is  coated  with  a 
thickened  epithelium  of  a brown  or  yellow  hue. 
If  the  catarrh  have  extended  to  the  salivary 
- glands,  the  surface  of  the  tongue  becomes  dry,  or 
is  covered  with  a white,  creamy  mucus.  If  the 
duodenum  be  affected,  the  patient  is  liable  to 
jaundice  from  obstruction  of  the  biliary  passages ; 
more  generally  the  results  of  imperfect  lacteal 
absorption  are  shown  in  the  loss  of  flesh,  dry- 
ness and  harshness  of  the  skin,  and  imperfect 
nutrition  of  the  hair  and  nails.  The  pulse  is 
ordinarily  slow,  full,  and  regular.  A short 
cough  is  often  complained  of,  from  coexisting 
laryngeal  irritation.  The  temperature  is  seldom 
increased,  excepting  towards  evening,  and  the 
patient  often  complains  of  coldness  in  the  ex- 
tremities. The  nervous  system  almost  always 
suffers.  There  is  great  watchfulness,  or  the 
patient  wakes  after  a few  hours  of  broken  and 
disturbed  slumber.  Attacks  of  headache  are 
frequent,  the  pain  affecting  chiefly  the  forehead 
and  eyeballs. 

It  is  necessary  to  notice  two  important  varie- 
ties of  the  complaint,  both  on  account  of  their 
practical  importance,  and  also  from  the  little  at- 
tention they  have  received  from  authors.  In  one 
class  of  cases  the  prominent  symptom  consists 
in  the  rejection  of  an  enormous  quantity  of  mucus. 
This  may  occur  almost  constantly,  vast  amounts 
of  glairy  or  of  blood-stained  mucus  being  re- 
jected. In  other  instances  the  vomiting  occurs 
only  every  few  days,  mostly  after  breakfast ; 
and,  from  the  quantity  expelled,  it  would  almost 
appear  as  if  a gradual  accumulation  took  place 
between  each  attack,  until  the  stomach  was 
excited  to  get  rid  of  it.  There  is  often  no  nausea 
preceding  the  vomiting,  and  but  few  gastric 


1SEASES  OF.  1530 

symptoms  between  the  attacks.  This  form  of 
gastric  catarrh  is  most  apt  to  occur  in  females, 
but  it  may  also  affect  the  other  sex.  The 
second  variety  appears  to  be  an  eczema  of  the 
stomach ; at  any  rate,  the  catarrh  of  the  mucous 
membrane  replaces  a similar  catarrhal  condition 
of  the  skin,  and  is  often  relieved  as  soon  as  the 
latter  reappears.  In  many  cases  the  condition 
may  he  attributable  to  a gouty  diathesis,  of 
which  both  the  skin-affection  and  that  of  the 
stomach  are  but  the  expressions.  Still,  this  alter- 
nation between  the  disorder  of  the  skin  and  ato- 
mach  is  not  infrequently  witnessed  in  practice. 

Diagnosis. — The  only  disease  likely  to  lead  to 
mistakes  in  diagnosis  is  atonic  dyspepsia  ; but 
we  may  meet  with  very  rare  cases  of  chronic 
catarrhal  gastritis  that  are  difficult  to  distin- 
guish from  ulceration  and  cancer  of  the  sto- 
mach. Where,  as  occasionally  happens,  a cer- 
tain amount  of  haematemesis  presents  itself,  the 
diagnosis  between  this  disease  and  ulceration 
requires  care.  But  in  catarrh,  there  is  usually 
some  co-existing  disease  of  the  heart  or  liver, 
or  some  disorder  of  menstruation  ; there  is  an 
absence  of  pain,  or,  if  pain  be  present,  it  is 
relieved,  not  increased,  by  food,  as  in  the  case  of 
ulcer.  Again,  the  vomiting  is  less  excited  by 
food;  the  epigastric  tenderness  is  slight  and 
diffused,  not  confined  to  one  particular  spot,  as 
in  ulcer.  Cases  are  sometimes  mistaken  for 
cancer.  The  pain,  however,  in  gastric  catarrh  is 
slighter;  the  tenderness  comparatively  trifling; 
and  the  hsematemesis  never  excessive  or  long- 
continued,  as  in  cancer.  On  the  other  hand,  in 
the  latter  disorder  there  is  a more  rapid  loss  ot 
flesh  and  strength,  and  more  pallor  of  the  lips 
and  complexion.  The  discovery  of  a tumour  iu 
the  epigastric  region,  or  in  some  other  organ, 
would  remove  all  doubts  as  to  the  real  naturo 
of  the  malady. 

Treatment. — The  first  point  in  treatment  is 
to  discover,  if  possible,  the  cause  of  the  dis- 
ease. It  is  useless  to  attempt  to  relieve  an 
inflammation  of  the  stomach,  so  long  as  the 
veins  of  the  organ  remain  in  a state  of  con- 
gestion produced  by  a disease  of  the  heart  or 
lungs.  Cases  that  had  been  ineffectually  treated 
for  months  with  purgatives  and  tonics,  yield  at 
once  to  rest  and  digitalis,  prescribed  on  account 
of  the  discovery  of  a dilated  heart.  In  other 
instances,  chronic  Bright’s  disease,  by  preventing 
the  due  elimination  of  the  effete  matters,  gives 
rise  to  the  gastritis  ; and,  under  such  circum- 
stances, treatment  directed  to  the  relief  of  the 
original  affection  yields  more  satisfactory  results 
than  that  which  would  be  ordinarily  prescribed 
for  inflammatory  dyspepsia.  Constipation  will 
be  often  found  to  have  preceded  the  gastric 
symptoms,  which  have  been  produced  by  the 
food  being  too  long  retained  in  the  stomach, 
from  the  diminished  muscular  activity  of  the 
whole  canal.  Here  a regular  action  of  the 
bowels  is  the  main  indication  for  the  relief 
of  the  gastric  catarrh.  There  is  often,  as  before 
mentioned,  a craving  for  food  every  two  or  three 
hours,  set  up  by  the  presence  of  mucus  in  the 
stomach.  Numbers  of  cases  prove  rebellions 
to  treatment,  because  the  patient  persists  in 
seeking  temporary  relief  by  frequently  cramming 
the  stomach  with  food,  or  because  he  keepc  the 


154C  STOMACH,  DISEASES  OF. 


mucous  membrane  in  a state  of  excitement  by 
stimulants,  taken  under  the  idea  that  debility 
is  the  cause  of  his  sufferings.  In  the  majority 
of  very  obstinate  cases,  ono  or  other  of  these 
habits  requires  to  be  overcome,  before  other 
treatment  can  be  made  available.  The  mere 
removal  of  the  cause  producing  the  disease  is 
often  sufficient  to  ensure  its  cure,  but  in  other 
instances  we  are  forced  to  employ  other  means. 
The  chief  indication  in  the  ordinary  run  of  cases 
is  to  take  off  any  increased  pressure  upon  the 
venous  circulation.  In  any  glandular  structure 
we  can  only  effect  this  object  by  lessening  the 
amount  of  blood  flowing  to  it,  or  by  increasing 
She  rapidity  of  the  circulation  through  the  organ 
by  stimulating  its  secretion.  The  first  of  these 
objects  in  the  case  of  the  gastro-intestinal  tract 
is  accomplished  by  purgatives,  which  drain  away 
a large  quantity  of  the  liquid  portions  of  the 
blood  which  has  to  pass  through  the  vena  portae. 
In  young  and  vigorous  subjects,  therefore,  sa- 
lines, such  as  the  sulphate  of  magnesia,  the  tar- 
trate of  soda,  or  the  mineral  waters  of  Pullna  or 
Friedrichshall,  may  be  employed.  These  may  be 
assisted  by  small  doses  of  mercurials,  given  every 
second  or  third  night.  The  salines  should  not 
be  too  long  continued  alone,  as  they  are  apt  to 
enfeeble  the  muscular  powers  of  the  canal.  After 
a short  period,  it  is  necessary  to  combine  them 
with  a tonic,  such  as  quinine  or  calumba,  or  with 
sulphate  or  phosphate  of  iron.  In  moro  feeble 
subjects,  or  in  those  who  have  previously  suffered 
from  atonic  dyspepsia,  it  is  better  to  relieve  the 
congestion  by  stimulating  the  biliary  secretion. 
For  this  purpose,  taraxacum  or  chamomile  may 
be  employed,  assisted  by  a pill  each  night,  con- 
taining podophyllin  or  blue-pill.  In  another 
set  of  cases,  where  the  patient  is  not  robust, 
both  objects  may  be  attempted  at  once — by  the 
administration  of  soda  and  rhubarb. in  the  day, 
assisted  by  an  occasional  dose  of  blue  pill  at 
night,  or  by  a course  of  the  Carlsbad  water 
every  morning. 

It  has  been  before  remarked  how  readily  fer- 
mentation is  set  up,  whenever  the  secretion  of 
the  gastric  juice  is  lessened  or  arrested.  This 
circumstance  must  he  borne  in  mind  in  the  treat- 
ment of  this  as  well  as  of  other  gastric  disorders. 
As  soon  as  the  more  urgent  symptoms  of  chronic 
gastritis  are  subdued  in  any  case,  tonics,  such  as 
iron,  calumba,  or  quinine,  along  with  acids,  may 
be  nsed  to  obviate  the  enfeebled  state  of  diges- 
tion that  always  results  from  the  long  continu- 
ance of  the  inflammation. 

The  treatment  of  cases  where  immense  quan- 
tities of  mucus  are  vomited  must  be  conducted 
on  a different  principle.  Here  the  venous  sys- 
tem is  iu  a state  of  passive  congestion,  and  no 
active  inflammation  of  the  mucous  membrane  is 
in  progress.  We  must  use  astringents,  the  best 
of  which  are  bismuth,  nitrate  or  oxide  of  silver, 
oxalate  of  cerium,  kino,  tannin,  and  opium.  Purg- 
ing makes  the  patient  worse.  In  order  to  ob- 
viate the  ill-effects  of  the  astringents  it  is  neces- 
sary to  give  each  night  a pill  of  podophyllin  and 
creasote,  or  of  nux  vomica  and  aloes,  or  some 
other  similar  preparation.  The  disease  has  been 
relieved  by  placing  around  the  abdomen  a fold 
of  flannel  dipped  in  dilute  nitro-hydrochlorie 
acid,  and  covered  with  india-rubber  cloth. 


Eczema  of  the  stomach  is  most  difficult  to 
treat  satisfactorily,  probably  because  it  depends 
on  the  general  state  of  health.  It  is  best  re- 
lieved by  moderate  doses  of  solution  of  potash, 
taken  a little  before  the  time  when  the  scalding 
pain  is  expected,  assisted  by  a pill,  every  night, 
of  podophyllin  and  creasote.  As  soon  as  the 
urgent  symptoms  have  been  overcome,  benefit 
may  be  expected,  either  from  the  compound 
iron  mixture,  or  from  quinine  combined  with 
ammonia.  Flannels  dipped  in  a solution  of 
common  washing  soda,  and  covered  with  india- 
rubber,  may  he  applied  over  the  epigastrium 
with  benefit;  or  a liniment  of  croton  oil  may  be 
employed.  The  latter  must  he  used  with  great 
caution,  as,  from  the  unusual  irritability  of  the 
skin,  the  eruption  is  apt  to  be  very  severe. 

Theoretically,  it  might  be  expected  that  a fari- 
naceous diet  would  not  be  suitable  in  these  cases ; 
inasmuch  as  it  is  apt  to  set  up  fermentation.  It  is 
better  to  confine  the  patient  to  sparing  meals  of 
mutton,  chicken,  game,  or  fish  along  with  bread. 
Vegetables  and  fruit  should  be  at  first  avoided, 
but  may  be  freely  used  as  soon  as  the  more 
urgent  symptoms  have  subsided.  The  breakfast 
is  the  most  difficult  meal  to  manage,  for  tea  and 
coffee  are  apt  to  disagree  and  increase  the  mis- 
chief. Dandelion  coffee  is  often  very  useful  in 
such  cases.  It  is  made  by  boiling  the  roasted 
and  dried  root  of  the  taraxacum  with  a quarter 
of  its  weight  of  the  best  coffee.  Where  this 
cannot  he  readily  obtained,  the  succus  taraxaci 
of  the  Pharmacopoeia  may  be  taken,  along  with 
weak  coffee.  If  milk  does  not  disagree,  it  may 
he  nsed,  mixed  either  with  lime-water.  Seltzer,  or 
Vichy  water.  Alcohol  should  be  avoided,  hut  if 
from  long  habit  or  other  circumstances  its  use 
is  necessary,  a small  quantity  of  weak  spirit  and 
water  should  be  substituted  for  wines. 

1 5.  Stomach,  Malposition  of. — The  stomach 
may  he  displaced  congenitally  ; or  as  a resuit  of 
accident  or  disease. 

In  congenital  displacement  the  stomach  may 
he  situated  on  the  right  side  of  the  body,  the 
fundus  pointing  to  the  right  hypochondrium, 
the  pylorus  to  the  left.  But,  as  in  such  cases 
it  will  he  also  found  that  there  is  a similar  mal- 
position of  the  heart,  liver,  and  spleen,  no  mistake 
in  diagnosis  is  likely  to  occur.  As  a congeni- 
tal condition,  the  stomach  may  occupy  the  left 
pleura,  through  a partial  arrest  of  development 
of  the  diaphragm.  It  may  be  also  situated  in  the 
left  pleura,  owing  to  a rupture  of  the  diaphragm. 
It  is  said  that  such  a state  has  given  rise  to  a 
mistake  in  diagnosis  between  it  and  pneumo- 
thorax of  the  left  side.  In  both  there  is  a clear 
sound  on  percussion,  and  a gurgling  produced  by 
motion  of  the  body.  Besides  this,  the  pressure  of 
the  distended  stomach  has  been  seen  to  displace 
the  heart,  and  produce  dyspnoea.  Bamberger 
has  pointed  out  that  in  protrusion  of  the  sto- 
mach into  the  left  pleura  the  respiratory  sounds 
can  be  heard  in  the  upper  part  of  the  left  lung; 
the  clear  note  on  percussion  becomes  duller  after 
food  ; and  any  metallic  sounds  that  may  present 
themselves  are  unconnected  with  the  breathing 
of  the  patient.  The  dyspnoea  of  congenital  dis- 
placement is  only  occasional,  not  persistent,  and 
it  will  be  found  to  have  existed  for  years,  id 


STOMACH,  DISEASES  OF. 


stead  of  occurring  suddenly,  as  in  pneumothorax. 
When  the  hernia  has  resulted  from  an  accident, 
it  is  usually  accompanied  by  vomiting  of  fluid 
containing  sarcinse,  and  by  other  signs  indicating 
that  the  stomach  does  not  get  freely  emptied  of 
its  contents.  The  organ  may  be  displaced  down- 
wards by  the  weight  of  a tumour  situated  in  its 
coats.  This  is  more  especially  the  case  with  the 
pylorus,  which  is  generally  the  seat  of  such  a 
morbid  change.  Under  these  circumstances,  the 
pylorus  maybe  so  depressed  as  to  occupy  the  right 
iliac  region,  or  it  may  have  fallen  still  lower, 
snd  be  united  by  adhesions  to  some  of  the  pelvic 
viscera.  In  some  cases  the  stomach  is  found  in 
the  contents  of  large  umbilical  and  scrotal  herniae. 
An  interesting  case  of  this  nature  is  recorded  by 
the  late  Mr.  Moore  ( Transactions  of  the  Medico- 
Chirurgical  Society,  vol.  xlvi.),  where  a stomach, 
so  enlarged  as  to  be  capable  of  containing  a gallon 
and  a half,  was  situated  in  the  sac  of  an  umbili- 
cal hernia.  There  were  several  sloughs  on  its 
inner  membrane,  and  in  one  spot  a perforation 
had  taken  place,  the  size  of  a sixpence.  When  a 
stomach  is  much  dilated,  in  case  no  adhesions 
have  been  formed  between  it  and  some  of  the 
neighbouring  organs,  it  is  displaced  downwards 
by  the  weight  of  its  contents.  As  a result  of 
this,  the  umbilical  region  is  much  distended, 
whilst  the  epigastrium  is  hollow  and  sunk  in'* 
wards,  so  that  a distinct  prominence  can  be  often 
discovered,  stretching  between  the  lower  part  of 
the  left  hypochondriac  region  and  the  other 
side. 

16.  Stomach,  Morbid  Growths  in. — The 
stomach  is  liable  to  all  the  forms  of  morbid 
growth  that  are  met  with  in  the  other  structures 
of  the  body.  Excepting  the  breast  and  uterus,  no 
part  is  so  frequently  the  seat  of  malignant  disease. 
All  the  varieties  of  cancer  attack  this  organ,  and 
not  unfrequently  they  are  combined.  Thus  we 
meet  with  scirrhus  and  encephaloid,  or  scirrhus 
and  colloid,  in  the  same  tumour. 

Scirrhus  is  by  far  the  most  common,  constitut- 
ing, according  to  the  researches  of  Dr.  Brinton, 
three-fourths  of  the  whole  number.  Its  most  usual 
seat  is  the  pylorus  or  the  lesser  curvature,  and 
here  it  forms  a tumour  that  rarely  invades  the 
duodenum,  but  tends  to  surround  the  organ.  When 
a section  is  made  at  an  early  period  of  the  dis- 
ease, the  distinction  between  the  different  coats 
is  readily  seen.  The  peritoneum  and  the  tissue 
directly  beneath  it  are  thickened,  the  muscular 
structure  is  of  a grey  colour,  and  much  increased 
in  bulk,  the  bundles  of  fibres  being  divided  from 
each  other  by  firm  septa  of  connective  tissue. 
The  mucous  membrane  covering  the  tumour  may 
appear  to  the  naked  eye  to  be  healthy.  Sooner 
or  later  ulceration  takes  place,  and  a deep  exca- 
vation results,  with  thickened  elevated  edges, 
and  with  a base  not  unfrequently  covered  with 
fungoid  projections.  Microscopically  the  tumour 
presents  the  ordinary  appearances  of  scirrhus. 
The  muscular  structure  is  usually  in  a state  of 
degeneration  near  the  cancerous  structure,  even 
when  it  has  not  been  invaded  by  the  disease.  The 
mucous  membrane  has  been  more  or  less  dis- 
eased in  all  the  cases  the  writer  has  examined, 
even  at  a distanco  from  the  tumour.  The  tubes 
were  generally  united  to  each  other,  and  were, 


1541 

in  many  places,  in  a state  of  atrophy  or  of  fatty 
degeneration. 

Encephaloid  cancer  has  affected  the  stomach 
in  about  one-tenth  of  the  cases  recorded,  accord- 
ing to  the  inquiries  of  Dr.  Brinton.  It  forms  soft, 
quickly-growing  nodules,  which  project  below  the 
peritoneum,  or  elevate  the  mucous  membrane. 
It  seems  generally  to  commence,  as  scirrhus  does, 
in  the  submucous  tissue.  When  ulceration  occurs, 
numerous  fungoid  masses,  which  are  often  very 
vascular,  project  upwards.  The  muscular  coat 
is  more  completely  destroyed  in  the  neighbour- 
hood of  the  tumour  than  in  scirrhus,  and  the 
mucous  membrane  is  generally  diseased  in  all 
parts  of  the  organ.  The  tubes  are  not,  however, 
so  much  atrophied  as  in  the  harder  form  of 
cancer,  but  are  usually  distended  with  cells,  and 
the  subtubular  and  intertubular  spaces  are  occu- 
pied by  cells  of  various  sizes. 

Colfoid  cancer  is  generally  associated  with 
scirrhus.  The  structure  feels  softer  than  when- 
scirrhus  is  present  alone,  and  consists  in  part  of 
a gelatinous  material  contained  in  round  or  oval 
spaces  bounded  by  connective  tissue.  Dr.  Brin- 
ton calculates  that  only  9 per  cent,  of  all  the 
cases  of  cancer  of  the  stomach  are  composed  of 
colloid  uncombined  with  scirrhus. 

Villous  cancer  presents  a mass  of  elongated 
processes,  which,  under  the  microscope,  seem  to 
be  composed  of  fibrous  tissue  loaded  with  cancer- 
cells,  each  usually  possessing  a loop  of  blood- 
vessels. All  the  villous  projections  that  are 
found  on  the  mucous  membrane  of  the  stomach, 
are  not,  however,  necessarily  malignant,  some 
being  of  the  nature  of  fibrous  papilloma.  See 
Stomach,  Cancer  of. 

Lipoma,  sarcoma,  and  adenoma  are  also  occa- 
sionally met  with  in  the  stomach. 

Tubercle  is  very  rare,  and  only  found  where 
there  has  been  general  tuberculosis. 

17.  Stomach,  Neuroses  of. — The  subject  of 
gastric  neuralgia  has  been  already  partially  dis- 
cussed (see  Gastraxgia),  and  it  has  been  pointed 
out  that  it  rarely  occurs  independently  of  symp- 
toms indicating  some  disorder  of  the  digestion. 
The  writer  has,  however,  met  with  it  as  a perio- 
dical affection  unattended  by  any  gastric  disease. 
These  cases  occur  chiefly  in  females  of  a nervous 
temperament,  are  worse  at  the  catamenial  pe- 
riods, and  yield  to  treatment  of  a tonic  character. 

Hyperesthesia  of  the  stomach  is  a very  common 
accompaniment  of  various  gastric  disorders.  Its 
presence  in  a measure  accounts  for  the  very  great 
degree  of  suffering  experienced  in  many  cases  of 
ulceration,  and  it  often  confers  upon  a ease  of 
atonic  dyspepsia  an  amount  of  pain  that  leads 
the  practitioner  to  suspect  his  patient  is  affected 
with  some  grave  organic  disease  of  the  organ. 
This  increased  sensibility  of  the  stomach  often 
leads  to  mistakes  in  the  treatment  of  gastric  ulcer, 
by  inducing  us  to  persevere  with  liquid  diet  and 
opium  long  after  the  sore  has  completely  healed. 
In  hyperesthesia  of  the  stomach  iron  occupies 
the  most  important  place  as  a remedial  agent, 
and  may  be  combined  with  quinine,  strychnine, 
or  other  bitters.  Arsenic,  in  doses  of  three  or 
four  minims  of  Fowler’s  solution,  gradually  in- 
creased and  given  directly  after  food,  is  often 
exceedingly  useful.  The  nitrate  and  oxide  of 


1542  STOMACH.  DISEASES  OF. 


silver  are  favourite  remedies  with  many  prac- 
titioners, but  the  writer  has  found  them  less 
useful  than  the  tonics  before  mentioned.  As  soon 
as  it  can  be  borne,  porter  or  bitter  ale  will  be 
found  beneficial.  In  the  majorit.yof  eases  change 
of  air  and  a carefully  regulated  diet  are  more 
efficacious  than  drugs. 

Spasm. — Spasm  of  the  stomach  is  a frequent 
complaint,  and  chiefly  occurs  in  females  who 
are  subjects  of  atonic  dyspepsia.  The  attacks 
mostly  occur  after  a meal  of  an  indigestible 
character ; but  in  other  instances  a single  mouth- 
ful of  food,  taken  after  a long  fast,  may  pro- 
duce it.  In  the  former  case  the  painful  spasm 
probably  arises  from  the  stomach  becoming  over- 
distended with  flatus,  which  it  has  been  unable 
to  expel,  on  account  of  a spasmodic  contraction 
of  the  cardiac  orifice.  In  the  latter  the  organ 
is  most  likely  distended  by  flatus,  and  the  en- 
trance of  food  excites  a contraction  which  the 
exhausted  muscle  is  unable  fully  to  execute. 
During  the  attack  relief  may  be  obtained  either 
by  a subcutaneous  injection  of  morphia,  or  by  a 
draught  containing  opium  combined  with  chloro- 
form or  other,  or  with  some  essential  oil,  such 
as  mint  or  cinnamon.  The  treatment  between 
the  attacks  must  be  conducted  on  the  principle 
laid  down  for  atonic  dyspepsia.  See  Stomach, 
Atony  of. 

Paralysis  of  secretion.— It  now  and  then  oc- 
curs that  the  power  of  the  stomach  to  secrete 
appears  to  become  paralysed,  just  as  we  occa- 
sionally find  to  be  the  case  with  the  kidney,  and 
probably  with  other  organs  of  the  body. 

Vomiting. — One  of  the  most  important  of  the 
neurotic  affections  of  the  stomach  is  where  vomit- 
ing is  habitually  present,  without  any  other 
signs  leading  us  to  suspect  disease  of  the  sto- 
mach itself.  Deference  is  not  made  here  to  the 
cases  where  the  vomiting  accompanies  preg- 
nancy, or  uterine  or  brain  disease,  but  where  it 
occurs  without  any  nausea.  It  chiefly  presents 
itself  in  hysteria  and  phthisis,  and  in  the  latter 
disorder  is,  according  to  the  writer's  observation, 
most  frequently  met  with  where  the  apex  of 
the  right  lung  is  chiefly  affected.  Hysterical 
vomiting  comes  on  whilst  the  patient  is  eating, 
or  almost  immediately  after  the  meal  is  fin- 
ished. A person  will  leave  the  table  suddenly, 
reject  what  has  been  taken,  and  often  complain 
again  of  hunger.  What  is  vomited  is  not  sour, 
and  seems  to  consist  only  of  food  in  the  state  it 
had  been  in  just  before  being  swallowed.  There 
is  no  pain,  and  although  the  flesh  and  strength  are 
reduced,  it  is  not  to  the  extent  that  might  have 
been  expected.  In  all  probability,  therefore,  only 
a part  of  what  is  taken  is  returned,  for  in  severe 
cases  the  symptom  is  present  whenever  an  at- 
tempt is  made  to  take  food.  Various  methods 
of  treatment  have  been  putin  force,  and  in  many 
cases  without  any  success.  Electricity  has  been 
strongly  recommended,  whilst  morphia,  hydro- 
cyanic acid,  aconite,  bismuth,  oxalate  of  cerium, 
nitrate  of  silver,  and  innumerable  other  remedies 
have  been  employed.  According  to  the  writer's 
experience  the  most  useful  plan  is  to  adminis- 
ter a dose  of  morphia  and  solution  of  potash 
a few  minutes  before  food.  In  other  case<=,  he  has 
tried  ice  for  the  same  purpose.  The  food  should  be 
of  a digesti  b'e  nature,  but  sol  ds  agree  better  than 


liquids,  although  nstances  are  given  where  the 
irritability  of  the  stomach  has  been  overcome 
by  small  quantities  of  liquid  food  given  every 
half-hour.  In  very  obstinate  cases  all  food  must 
be  abstained  from,  and  life  supported  for  a few 
days  by  nutritive  enemata. 

Cases  occasionally  present  themselves  in  which 
symptoms  of  disease  of  the  spinal  cord  follow 
affections  of  the  stomach.  In  such  cases  vomit- 
ing has  been  excessive  and  frequently  recur- 
ring; pains,  evidently  of  a neuralgic  character, 
have  first  attacked  the  feet  and  extended  up- 
wards; and  as  the  pains  have  subsided,  para- 
lysis has  gradually  crept  on.  The  treatment 
found  most  successful  has  been  the  employment 
of  sedatives  so  long  as  the  pain  continued  severe, 
followod  by  the  use  of  electricity  and  mineral 
tonics  when  the  paralysis  alone  remained.  The 
valerianate  of  zinc  combined  with  quinine  is 
often  very  efficacious  in  restoring  the  patient  to 
health.  In  other  cases  strychnia,  quinine,  and 
iron  have  been  employed,  either  alone  or  in  com- 
bination. 

18.  Stomach,  Perforation  cf. — With  the 
exception  of  a few  rare  cases  where  the  coats 
of  the  stomach  have  been  penetrated  by  me- 
chanical injuries,  or  by  the  extension  of  disease 
from  some  of  the  neighbouring  organs,  per- 
foration is  the  result  of  simple  or  cancerous 
ulceration.  In  the  majority  of  the  cases  of  ulcer- 
ation, the  peritoneal  covering  of  the  stomach 
inflames  as  the  disease  approaches  it,  and  the 
organ  becomes  attached  to  some  of  the  adjoin- 
ing parts.  In  this  way  a barrier  is  formed 
against  an  opening  being  made  into  the  peri- 
toneal cavity ; and,  as  the  ulceration  deepens, 
its  base  is  formed  of  the  structures  to  which 
the  coats  of  the  stomach  adhere.  It  has  been 
calculated  by  Dr.  Drinton  that  70  per  cent,  of 
the  simple  ulcers  situated  at  the  posterior  sur- 
face, are  closed  in  by  union  with  the  pancreas  or 
liver.  But  when  this  safeguard  does  not  exist, 
the  extension  of  the  ulceration  outwards  finally 
reaches  the  peritoneum,  this  thin  membrane 
sloughs,  and  a portion  of  the  contents  of  the 
stomach  escapes  into  the  peritoneal  cavity.  Sud- 
den and  violent  peritonitis  is  immediately  set 
up,  which  is  almost  always  followed  by  fatal 
consequences.  In  some  cases,  instead  of  the 
contents  escaping  from  the  stomach,  a mere 
leakage  occurs  through  the  peritoneum,  which 
is  sufficient  to  produce  inflammation  of  the 
serous  membrane.  Hence  it  may  happen  that, 
instead  of  general  peritonitis,  circumscribed 
inflammation  is  set  up  by  the  perforation,  and 
an  abscess  follows,  bounded  by  the  neighbouring 
organs,  which  have  become  closely  united  to 
each  other  and  to  the  stomach.  Some  cases  are 
recorded,  where  an  abscess  thus  formed  was 
evacuated  through  the  lungs  by  perforation  of 
the  diaphragm,  the  pus  exciting  in  its  passage 
gangrenous  pneumonia  or  pneumothorax.  The 
writer  has  known  the  gush  of  pus  from  the 
abscess  produce  sudden  death  by  suffocation  ; 
and  in  a few  cases  placed  on  record  an  external 
opening  has  taken  place,  and  a gastric  fistula 
has  been  established.  Occasionally,  the  stomach 
adheres  to  the  colon,  or  even  to  a coil  of  the 
small  intestine,  and  an  extension  of  the  ulcer 


STOMACH,  D 

brings  about  a communication  between  these 
organs.  Ulcerations  situated  in  the  anterior 
surface  of  the  stomach  are  most  apt  to  per- 
forate the  peritoneum,  as  the  greater  mobility 
of  this  region  lessens  the  chance  of  adhesions 
taking  place.  Simple  ulcerations  are  more  apt 
to  penetrate  the  serous  sac  than  those  of  a can- 
cerous nature,  as  adhesions  are  much  more  apt 
to  occur  in  the  case  of  the  latter.  Perforation 
again  takes  place  more  readily  in  the  3Toung 
than  in  those  of  more  mature  age,  and  it  is 
especially  liable  to  affect  females.  More  than 
half  the  cases  amongst  females  occur  between 
the  ages  of  fourteen  and  thirty,  but  in  the  other 
sex  the  effects  of  age  are  not  so  strongly  marked. 

Symptoms. — In  cases  of  chronic  ulcer,  the 
symptoms  produced  by  the  perforation  are  pre- 
ceded, for  a more  or  less  lengthened  period,  by 
pain,  vomiting,  or  hsematemesis.  But  in  young 
persons  the  occurrence  of  perforation  often  takes 
place  with  startling  suddenness,  and  the  pain 
comes  on  when  the  patient  believes  herself  to  be 
in  perfect  health.  In  most  cases  careful  inquiry 
shows  that  there  has  been  previously  slight 
uneasiness  after  food,  flatulence,  or  other  signs 
of  disordered  digestion.  It  is,  however,  impor- 
tant to  recognise  the  fact,  that  this  terrible 
accident  occasionally  occurs  where  there  has  been 
no  previous  complaint  of  ill-health,  and  that  aoy 
sudden  and  severe  pain  in  the  abdomen  in  a 
young  person  should  never  be  treated  lightly. 
In  a large  proportion  of  the  cases  admitted  into 
a hospital,  purgatives  or  stimulants  have  been 
previously  given,  and  it  has  occasionally  hap- 
pened that  castor  oil,  or  some  other  medicine, 
has  been  detected  in  the  peritoneal  cavity  on 
examination  after  death.  The  first  symptom 
of  peritoneal  perforation  is  a sudden  aDcl  severe 
pain  in  the  abdomen,  and  this  is  not  necessarily 
referred  to  the  region  of  the  stomach.  It  is 
quickly  followed  by  retching  or  vomiting;  and 
when  the  patient  is  seen  by  the  practitioner, 
the  symptoms  of  general  peritonitis  are  present 
in  a marked  degree.  The  patient  lies  upon  his 
back,  with  his  knees  raised,  dreading  to  make 
the  slightest  motion,  speaking  only  in  a slow 
and  guarded  manner,  and  breathing  quickly  and 
carefully,  lest  the  action  of  the  diaphragm  and 
abdominal  muscles  should  increase  his  suffering. 
The  face  is  pale,  and  expressive  of  pain  and 
anxiety;  the  whole  abdomen  tense,  and  so  ex- 
cessively tender  that  the  slightest  pressure  is 
dreaded;  the  pulse  is  quick,  small, and  com- 
pressible; the  extremities  are  cold;  and  the 
bowels  obstinately  confined.  The  patient  may 
either  sink  in  the  stage  of  collapse,  or  the  pulse 
may  recover  its  strength,  the  extremities  regain 
their  warmth,  and  death  may  occur  from  peri- 
tonitis some  days  later.  One  well-authenticated 
case  has  been  recorded  where  recovery  took  place ; 
and,  on  the  patient  subsequently  dying  from  a 
fresh  perforation,  the  results  of  the  former  pene- 
tration of  the  abdominal  cavity  were  observed. 
Several  cases  which  are  related  as  recoveries 
from  perforation,  have  been  recorded  of  late 
years  in  the  public  journals  ; but  the  evidence 
that  they  really  were  so  seems  to  be  insufficient. 
When  perforation  of  the  colon  takes  place,  the 
pain  is  often  very  severe,  from  tire  co-existence 
of  peritonitis  ; and  the  sudden  appearance  of 


1SEASES  OE.  1543 

faeces,  or  of  foetid  gas  in  the  vomited  matters, 
indicates  the  presence  of  an  opening  into  the 
large  intestine.  In  other  cases,  the  communica- 
tion between  the  organs  appears  to  be  of  a val- 
vular kind,  so  that  severe  diarrhoea  may  occur 
from  the  entrance  of  the  gastric  contents  into 
the  gut,  without  any  appearance  of  faeculent 
matters  in  the  fluid  rejected  from  the  stomach. 
Where  perforation  of  the  diaphragm  has  oc- 
curred, there  has  usually  been  severe  febrile 
action,  with  great  pain  in  the  side  or  epigastrium, 
followed,  after  an  interval  of  some  time,  by  the 
symptoms  and  physical  signs  of  pneumothorax  or 
gangrenous  pneumonia. 

Diagnosis. — Peritoneal  perforation  is  most  apt 
to  be  confounded  with  colic,  or  the  passage  of  a 
biliary  or  renal  calculus.  In  all  these  cases  there 
is  the  occurrence  of  sudden  and  severe  excru- 
ciating pain  of  the  abdomen,  often  attended 
by  vomiting,  and  all  may  be  accompanied  with 
great  depression.  In  perforation,  however,  the 
patient  lies  in  the  recumbent  position,  with  the 
legs  drawn  up ; whilst  in  the  passage  of  calculi 
or  colic  he  is  restless  and  tosses  about.  In  the 
former,  the  pulse  is  rapid,  and  there  is  intense 
abdominal  tenderness  ; in  the  latter  the  patient 
often  seeks,  by  pressure  over  the  seat  of  the 
pain,  to  relieve  his  suffering,  and  the  pulse  is 
but  little  quickened.  In  perforation,  there  is 
often  a history  of  symptoms  indicating  gastric 
ulcer ; in  colic,  not  infrequently,  an  account  of 
previous  attacks  of  a similar  description. 

Treatment. — The  only  chance  the  patient  has 
of  escape  from  death  is  in  the  most  perfect 
rest,  both  of  the  whole  body  and  of  the  diges- 
tive canal.  Food  and  drink  of  every  kind  must 
be  forbidden,  and  even  enemata  should  be  avoided. 
A full  dose  of  opium  must  be  administered,  as 
much  as  2 grains,  and  a smaller  quantity  re- 
peated every  three  or  four  hours  subsequently. 
Cold  applications  externally  have  beeD  recom- 
mended, but  it  will  be  generally  found  that 
warm  fomentations  give  more  relief  If  im- 
provement take  place,  it  will  be  better  to 
support  the  strength  of  the  patiert  for  some 
time  by  nutrient  enemata,  than  by  tood  given 
by  the  mouth. 

19.  Stomach,  Softening  off  —There  are  few 
stomachs  examined  after  death,  more  especially 
during  the  warmer  months  of  the  year,  that  do 
not  show  some  signs  of  softening.  When  this 
change  is  only  slight,  the  surfaces  of  the  rugse 
alone  seem  softened,  and  have  a semitransparent 
appearance.  When  it  is  more  extensive,  the 
whole  of  the  liningmembrane  covering  the  fundus 
has  a smooth,  thin,  translucent  appearance,  and 
is  either  readily  detached  by  the  finger,  or  forms 
a slimy  mucus  overlying  the  subjacent  coats. 
Where  the  process  has  proceeded  still  farther, 
the  muscular  and  peritoneal  layers  are  soft  and 
pulpy ; and  occasionally  the  organ  is  perforated, 
and  the  contents  are  found  in  the  cavity  of  the 
peritoneum.  More  rarely  still,  the  softening 
affects  the  neighbouring  organs,  the  oesophagus 
or  diaphragm  being  perforated ; and  the  gastric 
contents  may  be  found  in  the  left  pleura.  The 
nature  of  this  process  has  given  rise  to  no  small 
discussion.  John  Hunter,  who  first  remarked 
its  occurrence  in  healthy  persons  who  had  beer 


1544  STOMACH.  DISEASES  OF. 


killed  by  accidents,  attributed  it  to  the  action  of 
the  gastric  fluid  upon  the  stomach  after  death. 
Some  pathologists  of  eminence,  -whilst  admitting 
that  softening  may  result  from  post-mortem  solu- 
tion, contend  that  certain  forms  of  this  condition 
occur  during  life,  and  differ  in  their  character 
from  cadaveric  changes.  Rokitanski  distinguishes 
two  primary  forms  of  softening : one  a disease  of 
infant  life,  called  gelatinous  softening,  in  which 
the  whole  fundus  is  converted  into  a greyish, 
transparent  jelly,  and  which  is  usually  an  accom- 
paniment of  brain-affections.  The  other,  in  which 
the  parietes  of  the  stomach  are  converted  into  a 
dark-brown  pulp,  occurs  either  in  brain-diseases, 
or  as  a sequela  of  typhus,  pyaemia,  acute  tubercu- 
losis, acute  cancer,  and  other  diseases.  One  chief 
cause  of  difference  in  the  appearances  of  these 
forms  is  the  state  of  the  blood-vessels.  In  the  first 
the  pallor  arises  from  the  anaemic  condition  of  the 
lining  membrane  ; whilst  in  the  latter  the  dark- 
brown  colour  is  probably  dependent  on  the  action 
of  the  acid  upon  the  blood  contained  in  the  dis- 
tended veins  and  capillaries.  Notwithstanding 
theauthority  of  the  distinguished  pathologist  just 
named,  it  is  generally  believed  at  the  present  day 
that  all  the  various  forms  of  softening  are  merely 
the  result  of  post-mortem  digestion,  and  that  the 
differences  in  appearance  between  them  are  but 
the  effects  of  the  varying  amount  of  acid  that 
may  exist  in  the  stomach  at  the  time  of  death. 

Certain  circumstances  have  been  found  to 
favour  the  occurrence  of  post-mortem  softening 
of  the  stomach  : — 1.  The  condition  of  the  atmo- 
sphere at  the  time  of  death  is  one  element.  It 
was  in  summer  that  the  cases  occurred  that  first 
attracted  the  attention  of  Hunter,  and  it  is  found 
that  the  extent  of  softening  which  occurs  in  cold 
weather  is  comparatively  trifling  to  what  is  ob- 
served in  the  warmer  months  of  the  year.  This 
is  what  might  have  been  anticipated,  for  we 
know  that  heat  is  requisite  in  order  that  arti- 
ficial digestion  should  proceed  quickly.  2.  The 
amount  of  the  contents  of  the  stomach  exercises 
a considerable  influence.  When  death  has  oc- 
curred whilst  the  stomach  is  empty,  little  or  no 
softening  occurs,  but  if  it  contain  food  the  mu- 
cous membrane  is  sure  to  present  some  indica- 
tions of  change.  3.  The  nature  of  the  contents 
of  the  stomach  is  still  more  important  in  de- 
termining the  amount  of  softening.  It  is  well 
known  that  the  presence  of  an  acid  in  the  gastric 
juice  is  requisite  for  the  performance  of  diges- 
tion, and  we  consequently  find  that  there  is  the 
greatest  extent  of  change  where  there  is  a large 
amount  of  acid  in  the  contents  of  the  stomach  at 
the  time  of  death.  This  fact  has  been  inge- 
niously used  to  explain  why  the  post-mortem 
changes  are  so  extensive,  as  remarked  by  Roki- 
tanski, in  brain-disease  and  in  the  case  of  chil- 
dren. It  is  believed  that  an  unusual  amount  of 
acid  is  secreted  in  cerebral  affections,  as  we 
know  is  the  case  in  certain  irritations  of  the 
liver  and  kidney;  and  as  the  food  of  children 
is  mostly  composed  of  milk,  it  is  assumed  that 
the  lactic  acid  resulting  from  its  decomposition, 
united  with  the  pepsin  contained  in  the  stomach, 
forms  a digestive  fluid  possessing  great  activity. 
4.  The  condition  of  the  stomach  as  regards  the 
amount  of  pepsin  stored  up  in  it  exercises  a 
considerable  influence  upon  the  chance  of  its  soft- 


ening. It  has  been  elsewhere  shown  that  in 
typhoid  fever,  chronic  atrophy,  and  chronic  liy- 
peraemia,  the  amount  of  pepsin  stored  up  in  the 
gastric  mucous  membrane  is  very  small,  and  it 
is  in  these  disorders  that  we  meet  with  very 
little  alteration  in  the  organ  after  death.  5.  An- 
other point,  which  has  not  attracted  sufficient 
notice,  is  that  the  texture  of  the  organ  varies  in 
different  cases,  and  that  some  more  readily  yield 
to  the  solvent  action  of  the  gastric  juice  than 
others.  To  prove  this  the  writer  placed  in  an 
artificial  digestive  fluid  equal  portions  of  three 
human  stomaclis.  The  first  was  normal ; the 
second  in  a state  of  fatty  degeneration ; whilst, 
in  the  third,  the  tubes  were  replaced  by  fibrous 
tiss  i,e,  and  the  blood- vessels  were  much  congested. 
After  a few  hours’  digestion  the  first  piece  was 
found  reduced  to  a pulp;  the  second  was  gelatinous, 
and  of  a yellow  colour  ; the  third  formed  a black, 
opaque  mass,  quite  unlike  the  others.  Here,  it 
will  be  observed,  the  colour  and  appearance  of  the 
different  specimens  varied;  and  in  many  cases, 
as  for  example  in  children,  the  softness  of  their 
healthy  mucous  membrane  greatly  determines 
the  rapidity  and  completeness  with  which  the 
gastric  fluid  acts  upon  it.  To  ascertain  if  this 
was  correct  the  writer  placed  in  some  artificial 
gastric  fluid  four  pieces  of  stomach.  The  first 
was  taken  from  a healthy  dog  and  was  soft ; the 
second  from  a healthy  human  subject ; the  third 
and  fourth  from  females  who  had  died  from 
cancer  of  the  breast,  and  the  mucous  membranes 
of  whose  stomachs  were  extensively  atrophied. 
After  three  hours’  digestion  at  100°,  the  first 
broke  up  into  fragments ; the  second  was  reduced 
to  a pulp ; whilst  the  third  and  fourth  showed 
only  a little  softening  on  their  surfaces,  hut  were 
in  other  respects  unaltered.  The  completeness 
with  which  the  first  two  were  dissolved  was  found, 
from  other  experiments,  to  have  partly  arisen 
from  the  acid  being  imbibed  by  the  tissue,  and 
coming  into  contact  with  the  pepsin  stored  up  in 
the  gastric  cells,  which  were  absent  in  the  dis- 
eased structures  of  the  third  and  fourth  speci- 
mens. But  the  question  arises,  whether  soften- 
ing of  the  mucous  membrane  of  the  stomach  ever 
occurs  without  post-mortem  solution  ? This  must 
be  answered  in  the  affirmative.  During  the  con- 
tinuance of  the  cattle-plague  the  animals  affected 
were  killed,  and  in  some  cases  the  stomachs  were 
immediately  removed  and  brought  to  the  writer. 
In  each  case  the  mucous  membrane  was  very  soft, 
and  presented,  under  the  microscope,  the  usual 
appearances  of  gastritis.  Again,  in  certain  dis- 
orders— as,  for  example,  in  cancer  of  the  uterus 
— the  writer  has  always  found  the gastric  mucous 
membrane  very  soft,  where  there  was  no  appear- 
ance of  cadaveric  change.  This  softness  probably 
arises  from  imperfect  nutrition,  and  is  analogous 
to  the  fatty  heart  so  commonly  met  with  in  such 
cases.  Fatty  degenerations  of  the  stomach  are 
by  no  means  uncommon — for  instance,  the  whole 
membrane  has  been  found  in  this  state  in  a case 
of  gastric  ulcer  ; and  we  can  scarcely  suppose 
that  an  organ  in  such  a condition  can  have  the 
same  firmness  as  when  the  glandular  texture  is 
in  a perfectly  healthy  state. 

20.  Stomach,  Ulcer  of. — .Etiolost. — The 
age  of  the  individual  is  allowed  by  all  observers 


STOMACH.  DISEASES  OF.  1545 


to  be  one  of  the  chief  predisposing  causes  of 
gastric  ulcer.  Where  the  functions  of  the  sto- 
mach are  most  actively  performed,  as  in  child- 
hood, it  is  scarcely  ever  met  with,  Dr.  Brin- 
ton  having  been  only  able  to  find  two  cases 
out  of  226  in  children  below  ten  years  of  age. 
It  becomes  gradually  more  frequent  as  age  ad- 
vances. Females  are  more  liable  to  the  dis- 
ease than  males,  in  the  proportion  of  three  to 
one.  The  chief  preponderance  of  liability  amongst 
females  occurs  at  the  commencement  and  the 
cessation  of  the  catamenia.  In  both  sexes,  want 
of  food,  mental  anxiety,  and  other  depressing 
conditions,  have  been  referred  to  as  tending  to 
produce  the  disease  in  question.  Many  authors 
regard  intemperance  as  one  of  the  most  potent 
causes.  Although  the  writer  has  certainly  seen 
the  symptoms  of  gastric  ulcer  follow  a too  free 
use  of  alcohol,  yet  he  has  been  greatly  surprised 
to  find  how  rarely  the  stomach  has  presented 
any  signs  of  disease,  beyond  those  of  catarrhal 
gastritis,  in  a considerable  number  of  persons 
who  had  died  of  delirium  tremens.  Some  have 
affirmed  Riat  tuberculosis  is  a common  predis- 
posing cause,  whilst  Dr.  Brinton  has  remarked 
that  persons  affected  with  phthisis  are  not  more 
liable  to  gastric  ulcer  than  other  persons.  The 
writer  has  found  the  ordinary  ulcer  rare  in  such 
cases,  but  superficial  ulcers  near  the  pylorus  are 
by  no  means  infrequent,  and  are  probably  the 
result  of  the  acute  erythematous  gastritis,  to 
which  attention  lias  been  directed,  as  tending  to 
complicate  the  later  stages  of  pulmonary  disease 
(•wee  Stomach,  Inflammation  of).  If  we  sum  up 
tho  chief  causes,  we  find  the  conclusions  con- 
firmed to  which  morbid  anatomy  directs  us.  Ad- 
vanced age,  which  gives  rise  to  fatty  and  fibroid 
degenerations,  both  of  the  tissues  and  the  blood- 
vessels, is  the  chief  predisposing  influence  of 
gastric  ulcer.  In  like  manner,  syphilis  and  tu- 
bercular affections,  which  lead  to  ulcerations  of 
the  skin,  by  diminishing  the  reparative  powers 
of  the  system,  seem  also  to  induce  gastric  ulcer- 
ation. In  addition  to  these  all  conditions  that 
lead  to  chronic  catarrhal  gastritis,  suctqas  uterine 
affections,  and  diseases  of  the  heart  and  liver, 
have  also  a decided  tendency  to  set  up  the  dis- 
ease. 

Anatomical  Characteks  and  Pathologv. — 
Ulcerations  in  this  organ  are  of  frequent  occur- 
rence, being  present,  according  to  the  researches 
of  Dr.  Brinton,  in  about  5 per  cent,  of  the 
deaths  arising  from  all  causes.  The  ulcers  are 
usually  round  or  oval,  varying  in  size,  as  a gene- 
ral rule,  from  the  diameter  of  a fourpenny-piece 
to  that  of  a half-crown.  They  have  been  found 
to  destroy  life  when  so  small  that  the  most  care- 
ful search  was  necessary  to  ascertain  their  exist- 
ence, and,  on  the  other  hand,  they  may  be  met 
with  many  inches  in  diameter.  When  of  recent 
formation,  the  edges  are  sharp,  and  the  sore 
looks  as  if  a portion  of  the  mucous  membrane  had 
been  punched  out ; but  when  it  has  lasted  for 
some  time,  the  edges  are  hard,  callous,  and  ad- 
here to  the  subjacent  tissue.  The  diameter  of  the 
ulcer  usually  lessens  from  above  downwards ; so 
that  in  case  the  peritoneum  has  given  way,  the 
perforation  may  be  a mere  chink.  The  base  of 
the  ulcer  may  be  formed  either  of  the  muscular 
coat  or  peritoneum,  or  of  some  of  the  neighbour- 


ing organs — such  as  the  pancreas,  liver,  or 
spleen— which  have  become  attached  to  the 
stomach  by  adhesions.  Microscopically,  in  recent 
cases  the  writer  has  generally  found  the  tubes 
around  the  ulcer  healthy,  with  the  exception  that 
a few  blood-globules  are  extravasated  amongst 
them.  In  older  cases,  the  surrounding  tissues 
are  matted  together,  and  the  tubes  are  com- 
pressed and  atrophied,  whilst  the  newly-formod 
fibrous  tissue  closely  unites  the  edges  of  the 
lesion  to  the  parts  below  and  around  them.  But 
the  mischief  is  always  confined  to  the  neigh- 
bourhood of  the  ulcer,  and  we  never  discover  a 
general  atrophy  of  the  secreting  structures  of 
the  stomach,  as  in  malignant  disease.  At  the 
most,  the  mucous  membrane  presents  the  signs  of 
fatty  degeneration,  or  the  usual  appearances  of 
acute  or  chronic  catarrhal  gastritis.  Where  the 
ulceration  is  spreading,  the  tubes  immediately 
around  it  may  be  seen  to  be  more  or  less 
emptied  of  their  secreting  cells,  whilst  their 
basement  membranes  have  fallen  together.  Still 
further  off  may  be  remarked  tubes  only  partially 
filled  with  cells,  and  the  mucous  membrane  is 
consequently  thin  and  soft. 

Gastric  ulcers  are  most  common  in  the 
pyloric  region,  being  chiefly  situated  on  the 
posterior  surface,  and  near  the  smaller  curva- 
ture. When  two  are  present,  it  is  not  unusual 
to  find  them  opposed  to  each  other,  as  though 
they  had  been  both  produced  by  the  same  irrita- 
tion. When  an  ulcer  exists  in  the  duodenum, 
it  is  very  common  to  find  one  also  in  the  stomach. 

There  has  been  much  difference  of  opinion  as 
to  the  method  by  which  gastric  ulcers  are  pro- 
duced. Some  authors  are  fond  of  pointing  out 
that  sores  of  this  character  are  confined  to  the 
stomach  and  duodenum,  where  an  acid  secretion 
comes  in  contact  with  the  tissues  ; whilst  in  the 
remaining  parts  of  the  small  intestine  they  are 
rarely  discovered.  Hence  it  has  been  assumed 
that  they  are  dependent,  in  some  way  or  another, 
upon  the  solvent  action  of  the  gastric  juice. 
But  it  should  be  remembered  that  the  ulcera- 
tions are  very  rare  where  the  power  of  secretion 
is  most  active,  and  where  it  remains  longest  in 
contact  with  the  mucous  membrane — namely, 
at  the  fundus ; and  also,  that  they  are  extremely 
uncommon  in  childhood,  when  the  gastric  func- 
tions are  most  energetically  performed.  Instead, 
therefore,  of  the  presence  of  the  gastric  juice 
being  the  cause  of  the  stomach  being  so  espe- 
cially liable  to  ulceration,  may  not  the  rarity  of 
ulcerations  in  the  small  intestines  be  rather  due 
to  the  greater  development  of  the  lymphatic 
system  in  them,  which  obviates  the  ill-effects  of 
any  temporary  congestion,  and  to  the  fluid  na- 
ture of  the  contents  of  this  portion  of  the  canal  ? 
We  have  not  here  space  to  discuss  the  various 
hypotheses  that  have  been  invented  to  account 
for  the  production  of  gastric  ulcers ; but  we 
may  fairly  allow  that,  like  ulcerations  on  the 
exterior  of  the  body,  they  must  originate  from 
very  different  causes. 

1.  They  may  be  produced  by  the  sloughing  of 
portions  of  the  mucous  membrane  arising,  from 
general  debility.  Such  cases  have  been  dis- 
covered in  persons  broken  down  by  syphilitic 
disease,  kidney-affections,  and  other  exhausting 
maladies.  We  see  analogous  cases  of  sloughing 


STOMACH,  DISEASES  OP. 


1546 

of  the  mucous  membrane  of  the  oral  cavity  in 
a similar  state  of  health. 

2.  The  death  of  small  portions  of  the  mucous 
membrane  has  been  attributed  to  embolism  of 
the  arteries  of  the  stomach.  Against  this,  as  a 
common  cause,  is  the  fact  that  the  gastric  ulcer 
is  generally  single,  and  that  we  constantly  fail 
to  discover  ulcerations  where  numerous  emboli 
can  be  proved  in  the  vessels  of  the  other  prin- 
cipal organs  of  the  body.  It  is  probable,  how- 
ever, that  some  rare  cases  are  to  be  attributed 
to  this  cause. 

3.  The  perforating  ulcers  so  commonly  met 
with  in  young  persons  were  attributed  by  Koki- 
tanski  to  haemorrhagic  erosions  of  the  mucous 
membrane,  produced  by  catarrh.  His  opinion 
seems  to  be  supported  by  the  fact,  that  these 
ulcers  are  most  frequently  present  where  catarrh 
is  most  common,  namely  at  the  pyloric  region  ; 
and  also  that  their  occurrence  is  usually  pre- 
ceded only  by  symptoms  indicating  a slight  at- 
tack of  catarrhal  gastritis. 

4.  Dr.  Copland  pointed  out  how  often  the 
arteries  of  the  stomach  were  diseased,  where  an 
ulcer  was  present,  especially  in  old  people.  The 
truth  of  this  remark  the  writer  can  confirm,  from 
the  microscopic  examination  of  a number  of  spe- 
cimens ; and  to  this  circumstance  we  must  also 
attribute  much  of  the  difficulty  experienced  in  the 
cicatrization  of  gastric  ulcers.  Where  the  arte- 
ries are  healthy,  it  will  be  often  found  that  the 
veins  are  thickened  and  tortuous,  and  it  need  not 
be  pointed  out  that  the  effect  of  a similar  condi- 
tion is  daily  seen  in  the  production  of  ulcera- 
tions of  the  lower  extremities. 

5.  Probably  not  less  powerful  in  setting  up 
these  ulcers  in  the  aged  are  the  fatty  and  fibroid 
degenerations  of  the  mucous  membrane,  so  often 
discovered  on  microscopical  examination.  It 
seems  reasonable  to  suppose  that  in  tissues  thus 
altered,  a slight  irritation  would  be  sufficient  to 
set  up  an  ulcerative  process. 

When  a small  and  superficial  ulcer  of  the 
stomach  heals,  only  a slight  scar  is  left ; but 
where  it  has  been  of  large  size,  and  has  pene- 
trated more  deeply,  the  organ  may  be  puckered 
up  by  the  cicatrix,  and  considerable  change  of 
shape  may  be  produced.  The  ulceration  may, 
on  the  other  hand,  produce  death  by  laying 
open  a blood-vessel ; by  perforating  the  perito- 
neum or  some  of  the  neighbouring  organs;  or,  in 
more  rare  cases,  by  giving  rise  to  abscess  of  the 
liver. 

Symptoms. — Pain  is  by  far  the  most  constant 
and  prominent  symptom  of  ulcer  of  the  stomach. 
At  first,  it  is  only  a feeling  of  uneasiness  after 
food,  but  as  time  goes  on  it  increases  in  con- 
stancy and  severity.  It  commences  shortly  after 
food,  and  persists"  during  the  whole  period  of 
digestion,  or  until  the  contents  of  the  stomach 
are  rejected  by  vomiting.  In  some  cases  it 
begins  as  soon  as  food  has  been  taken,  but  more 
generally  an  interval  of  fifteen  or  twenty 
minutes  elapses  before  it  is  complained  of.  The 
pain  is  usually  relieved  by  the  recumbent  posi- 
tion, but  in  some  the  patient  finds  relief  by 
bending  the  body  over  a chair  or  by  lying  on 
one  side.  The  writer  has  seen  eases  of  large 
aleers,  in  which  there  was  little  or  no  pain,  the 
sore  being  apparently  insensible  to  irritation,  as 


is  sometimes  seen  to  be  the  case  in  old  ulcers 
of  the  legs.  The  pain  is  referred  to  one  spot, 
which  is  usually  situated  in  the  epigastrium, 
but  more  rarely  it  affects  the  left  hypochon- 
drium  or  the  umbilical  region.  In  a consider- 
able number  pain  is  experienced  in  the  back, 
usually  at  a place  between  the  last  dorsal  and  the 
first  lumbar  vertebrae,  or  rather  a little  to  the 
left  side  of  this  region.  It  is  not  uncommon  for 
the  pain  to  increase  for  a few  days,  and  then 
gradually  to  subside.  These  exacerbations  the 
writer  has  chiefly  observed  in  very  chronic  cases. 
They  probably  point  to  an  extension  of  the  ulcer- 
ation, for  they  not  infrequently  precede  haemor- 
rhage and  perforation.  In  almost  every  case  we 
meet  with  tenderness  on  pressure  over  the  seat  of 
the  sore.  This  may  be  so  great  that  the  patient 
is  unable  to  wear  his  clothes  moderately  tight;  in 
others  it  requires  a careful  search  to  discover  the 
sore  spot.  The  tender  part  is,  as  a rule,  opposite 
the  place  to  which  the  pain  is  referred,  and  can 
often  be  covered  by  the  finger-end.  General 
tenderness  is  no  test  of  an  nicer,  as  it  is  often 
present  in  congested  liver,  gastric  catarrh,  and 
other  complaints  of  the  epigastric  region.  It  is 
necessary  to  be  careful  in  testing  for  the  exist- 
ence of  a gastric  ulcer  by  the  finger,  for  a very 
slight  pressure  often  suffices  to  bring  on  a par- 
oxysm of  pain,  even  when  the  stomach  is  empty 
of  food.  The  tender  spot  may  be  situated  in  the 
epigastrium,  in  the  hypochondrium,  or  near  the 
umbilicus,  but  it  is  most  generally  in  the  first- 
mentioned  locality. 

Vomiting,  although  often  present,  is  a much 
more  variable  symptom.  It  seldom  occurs  directly 
after  food,  as  is  often  the  case  in  cancer,  because 
the  cardiac  orifice  is  rarely  the  scat  of  simple 
ulcer.  It  is  preceded  by  nausea,  not  infrequently 
by  a copious  flow  of  saliva,  and  it  relieves  the 
pain  by  freeing  the  stomach  of  its  acrid  contents. 
The  tongue  may  be  perfectly  clean,  or  may  be 
thickly  coated.  As  the  abnormal  appearances  of 
the  tongue  in  dyspepsia  arise  from  an  extension 
of  gastric  catarrh  to  the  mucous  membrane  of 
the  mouth,  a perfectly  clean  tongue  is  present,  if 
tho  ulcer  is  unattended  by  gastritis.  Flatulence 
is  not  a common  symptom,  inasmuch  as  the 
amount  of  food  taken  is  limited,  on  account  of 
the  pain  produced  by  it.  Extreme  acidity  occa- 
sionally presents  itself,  but  it  is  not  so  common 
as  the  statements  of  some  authors  would  lead  us 
to  imagine.  The  appetite  is  seldom  much  affected, 
especially  in  the  young.  Patients  often  remark 
that  they  could  and  would  eat  freely,  were  it 
not  for  the  dread  of  the  pain.  The  bowels  are 
generally  confined.  The  stools  are  knotty,  and 
in  many  cases  contain  mucus.  There  is  nothing 
characteristic  about  the  urine.  It  is  usually 
clear,  and  is  passed  frequently,  and  in  unusually 
large  quantities.  Whenever  the  disease  has  lasted 
for  some  time  there  is  a loss  of  strength  and 
energy,  arisingfrom  imperfect  nutrition,  from  the 
frequent  attacks  of  pain,  and  from  the  vomiting. 
The  duration  of  gastric  ulcer  varies  greatly.  In 
some  eases  the  sore  seems  to  heal  rapidly ; whilst 
in  others  the  symptoms  often  subside  and  re- 
appear, so  that  the  patient  remains  an  invalid 
for  years.  Chronic  cases  in  old  people  are  often 
very  difficult  to  cure,  and  great  patience  and  per- 
severance are  required  in  order  to  obtain  ever 


STOMACH,  DISEASES  OF. 


»n  alleviation  of  the  symptoms.  The  symptoms 
produced,  by  haemorrhage  and  perforation  are 
elsewhere  described.  See  Hj;jiatemesis  ; and 
Stomach,  Perforation  of. 

Physical  Signs. — In  a recent  case  of  gastric 
ulcer  we  can  expect  no  assistance  from  physical 
signs,  but  where  the  disease  has  lasted  for  some 
time  evidence  of  adhesions  may  be  detected.  Ad- 
hesions may  be  suspected,  when  it  is  found,  by 
auscultation  and  auscultatory  percussion,  that 
only  a small  portion  of  the  stomach  is  in  ap- 
position with  the  abdominal  walls,  and  more 
especially  if  this  part  is  the  tender  spot,  and 
does  not  vary  its  position  with  different  states  of 
distension  of  the  organ.  Again,  if  the  stomach 
is  found  to  be  of  considerable  size  when  empty, 
and  its  extent  not  increased  by  food,  we  may 
suspect  that  its  motions  are  trammeled  by  adhe- 
sions. The  microscope  affords  but  little  assist- 
ance in  the  detection  of  gastric  ulcer,  because  the 
extension  of  this  disease  is  usually  very  slow, 
and  we  therefore  have  little  chance  of  discover- 
ing portions  of  the  mucous  membrane  in  the 
vomited  matters. 

Treatment. — The  main  indication,  where  the 
symptoms  of  ulcer  of  the  stomach  are  urgent, 
is  to  give  to  the  affected  organ  as  perfect  a 
state  of  rest  as  is  possible.  The  patient  must 
be  placed  in  the  recumbent  position,  unless 
it  produce  pain,  and  must  retain  it  strictly. 
In  the  more  chronic  cases,  or  when  the  more 
severe  symptoms  have  subsided,  a limited  amount 
of  exercise  may  be  permitted,  lest  the  gene- 
ral health  become  deteriorated  by  confinement. 
In  urgent  cases  mere  position  is  not  enough, 
and  physiological  rest  must  be  insured.  It  is, 
therefore,  often  necessary  to  interdict  the  use 
of  all  food,  and  to  keep  up  the  nutrition  of 
the  body  by  nutritive  enemata.  In  less  severe 
cases  it  is  only  necessary  to  confine  the  patient 
to  liquid  food,  taken  in  small  quantities  and  fre- 
quently. Milk  must  form  the  basis  of  diet, 
and  it  can  be  either  taken  alone,  or,  if  there  be 
much  acidity,  mixed  with  lime-water  or  with 
Seltzer  or  Vichy  water.  In  some  cases  butter- 
milk agrees,  where  sweet  milk  produces  vomit- 
ing. In  others  the  concentrated  Swiss  milk  is 
more  readily  digested.  But  sometimes  milk 
in  all  forms  disagrees,  unless  it  be  mixed  with 
some  farinaceous  material,  such  as  arrowroot, 
sago,  tapioca,  or  corn-flour.  As  the  patient  im- 
proves a more  nutritious  diet  may  be  prescribed, 
such  as  beef  tea,  mutton  broth,  chicken  broth, 
eggs,  maccaroni,  or  light  puddings.  Vfhere  the 
patient  is  young  and  otherwise  healthy,  leeches 
are  often  of  great  service.  Some  practitioners 
have  objected  to  their  use,  but  the  writer  has  often 
seen  them  of  signal  benefit.  It  is  seldom  neces- 
sary to  apply  more  than  six  at  a time,  and  they 
may  be  repeated  from  time  to  time,  as  the  case 
requires.  In  others  dry-cupping  answers  a good 
purpose.  "Where  there  is  reason  to  object  to  the 
effects  of  the  leeches,  a bladder  filled  with  ice  and 
applied  to  the  part  often  affords  relief ; but,  in 
general,  hot  poultices  and  fomentations  are  more 
useful.  In  long-standing  cases  great  benefit  is 
often  derived  from  repeated  small  blisters,  or 
from  the  application  to  the  epigastrium  of  tartar- 
emetic  ointment  or  croton  oil.  The  most  valuable 
remedy  in  all  cases  is  opium.  It  relieves  pain, 


1547 

I controls  the  action  of  the  muscular  coat,  and  re- 
| strains  the  secretion  of  the  stomach.  It  is  best 
given  in  doses  of  one  or  two  grains,  once  or  twice 
a day,  shortly  before  food.  It  is  a common  prac- 
tice to  apply  morphia  hypodermically,  but  tnis  in 
some  cases  produces  vomiting,  and  must,  there- 
fore, be  used  cautiously.  Besides  this,  it  must 
be  remembered  that  the  sedative,  when  taken  by 
the  mouth,  is  more  directly  applied  to  the  ulcer- 
ated and  tender  surface.  The  vomiting  is  a most 
distressing  symptom,  and  tends  to  prevent  the 
healing  of  the  sore.  The  fluids  rejected  should 
be  often  examined  by  the  microscope.  If  torulae 
or  sarcinae  are  present,  recourse  must  be  had  to 
carbolic  acid,  creasote,  or  sulphurous  acid;  at 
the  same  time  a small  blister  should  be  applied 
to  the  epigastrium.  "When  a large  quantity  of 
mucus  is  discharged,  the  case  is  best  treated  with 
full  doses  of  bismuth,  magnesia,  and  morphia, 
or  with  oxalate  of  cerium.  As  soon  as  the  more 
active  symptoms  subside,  it  is  necessary  to  ad- 
minister tonics.  Some  preparation  of  iron  may 
be  selected  ; the  saccharo-carbonate  or  citrate 
answers  the  purpose  best. 

When  the  case  is  still  more  chronic,  prepara- 
tions of  silver,  copper,  and  zinc  have  been  recom- 
meuded.  The  nitrate  of  silver  is,  in  the  opinion 
of  most  authors,  to  be  preferred,  whilst  others 
have  looked  upon  it  as  inert  in  the  doses  usually 
given.  The  writer  has  certainly  seen  great  benefit 
from  both  it  and  the  sulphate  of  copper ; but,  on 
the  other  hand,  he  has  seen  mischief  result  from 
the  administration  of  these  salts  at  too  early  a 
period.  As  the  bowels  are  almost  always  con- 
fined in  gastric  ulcer,  it  is  necessary  to  promote 
their  action  by  castor  oil,  small  doses  of  aloes, 
or  enemata.  In  the  more  acute  stage  of  the  dis- 
ease all  irritating  aperients  must  be,  of  course, 
carefully  avoided,  and  the  bowels  should  be  re- 
lieved only  by  injections. 

21.  Stomach,  Vessels  of,  Diseases  of. — 
The  blood-vessels  of  the  stomach  are  frequently 
diseased,  and  their  morbid  conditions  no  doubt 
play  an  important  part  in  the  production  of  ana- 
tomical changes  in  the  other  structures  of  the 
organ.  Dr.  Copland,  many  years  ago,  drew 
attention  to  an  atheromatous  state  of  the  ar- 
teries as  frequently  present  along  with  gastric 
ulcer,  and  the  same  remark  has  since  been  made 
by  Virchow.  From  repeated  examinations  of 
cases  of  chronic  gastric  ulcer  with  the  micro- 
scope, the  writer  can  confirm  the  truth  of  these 
statements.  He  has  constantly  found  the  ar- 
teries thickened  and  enlarged  in  the  neighbour- 
hood of  the  ulcer.  Not  unfrequently  the  vessels, 
as  well  as  the  other  textures  of  the  organ,  are 
in  a state  of  fatty  degeneration,  the  condition 
being  in  some  degree  analogous  to  what  is  ob- 
served in  fatty  degeneration  of  the  heart,  in 
connexion  with  obstruction  of  the  coronary  ar- 
teries. Where  the  arteries  are  healthy  in  gas- 
tric ulcer,  the  veins  of  the  mucous  membrane 
are  generally  thickened  and  dilated,  display- 
ing a state  like  that  so  constantly  remarked 
in  the  veins  of  the  lower  extremities  where 
ulcers  have  been  long  existing.  In  cancer  of 
the  stomach  the  smaller  arteries  in  the  neigh- 
bourhood of  the  malignant  growth  have  been 
often  found  greatly  thickened.  This  condition 


1548  STOMACH,  DISEASES  OF. 

5eems  to  bp.  an  important  one  in  determining 
■•he  future  progress  of  the  malignant  growth,  as 
leading  to  its  being  imperfectly  supplied  with 
blood,  and.  its  consequent  sloughing.  But  an 
abnormal  state  of  the  smaller  arteries  of  the 
stomach  is  also  met  with  where  there  is  no  other 
disease.  There  has  been  much  dispute  whether  a 
similarly  thickened  condition  of  the  arteries  in 
contracted  kidney  is  a result,  or  merely  a co- 
existing state,  of  other  morbid  changes.  The 
occurrence  of  thickened  arteries  in  the  stcmach 
without,  as  well  as  with,  other  structural  altera- 
tions, seems  to  show  the  opinion  of  those  to  be 
correct  who  hold  that  the  arterial  changes  in 
atrophy  of  the  kidney  are  not  necessarily  the 
result  of  the  other  abnormal  states.  Affections 
of  the  veins  of  the  mucous  membrane  of  the 
stomach  are  constantly  present  in  heart-disease, 
and  in  cirrhosis  of  the  liver.  In  such  complaints 
we  usually  find  the  vessels  much  dilated  and  the 
coats  thickened.  Samuel  Fenwick. 

STOMACHICS  ( a-ri/xaxos , the  stomach). 
Synon.  : Fr.  Stomachiqiics ; G-er.  Magenmittel. 

Definition. — Substances  which  increase  the 
functional  activity  of  the  stomach. 

Enumeration. — The  most  important  stomach- 
ics are  Alcohol,  Acids,  Alkalies,  Aromatics,  Bit- 
ters, Arsenic,  Pepsin,  and  Strychnia  or  Nux 
Vomica. 

Action. — In  the  act  of  digestion  the  stomach 
has  the  threefold  function  of  secretion,  move- 
ment, and  absorption.  By  an  abundant  secretion 
of  gastric  juice  some  of  the  albuminous  consti- 
tuents of  the  food  are  quickly  digested ; and 
this  digestion  is  aided  by  the  movements  of  the 
stomach,  which  mingle  the  gastric  juice  with 
the  food,  and  aid  solution  by  breaking  up  the 
particles.  From  the  stomach,  also,  absorption  of 
some  of  the  products  of  digestion  goes  on.  Some 
stomachics,  such  as  alcohol  and  dilute  alkalies, 
increase  the  secretion  of  gastric  juice ; pos- 
sibly also  bitters,  and  small  doses  of  arsenic. 
Dilute  acids,  given  after  meals,  and  pepsin  supply 
the  essentials  of  gastric  juice  when  secretion  is 
leficient.  It  is  not  improbable  that  the  peri- 
staltic movements  of  the  stomach  are  increased 
uy  strychnia  and  nux  vomica.  We  want  ex- 
periments on  the  action  of  drugs  which  increase 
absorption.  It  is  also  probable  that  some  of 
the  good  results  of  bitters  are  due  to  their  pre- 
venting abnormal  processes  of  fermentation  in 
the  stomach.  T.  Laudeb  Bbunton. 

STOMATITIS  (iTrifia,  the  mouth). — 
Synon.  : Fr.  Stomatite ; Ger.  Mundschlcimhaut- 
cntzundung. 

Definition. — Inflammation  of  the  mouth. 

"Varieties. — Stomatitis  is  chiefly  met  with  in 
infants  and  young  children.  It  presents  itself 
under  three  varieties  : — 1.  Follicular;  2.  Ulcer- 
ative; and  3.  Gangrenous. 

1.  Follicular  Stomatitis. — This  form  of  in- 
flammation of  the  mouth  is  very  apt  to  arise 
when  children  are  recovering  from  the  eruptive 
fevers.  But  it  may  also  be  met  with  in  com- 
paratively strong  children,  both  in  connection 
with  severe  dental  irritation,  and  also  originat- 
ing in  a true  herpes  of  the  mouth,  analogous  to, 
and  sometimes  associated  with,  herpes  labialis. 


STOMATITIS. 

Follicular  stomatitis  has  its  origin  in  the 
follicles  of  the  mucous  membrane,  which  become 
inflamed,  and  exhibit  spots  of  white  exudation. 
There  is,  however,  no  breach  of  surface.  The 
name  of  aphtha  is  often,  though  incorrectly,  given 
to  simple,  or  follicular,  stomatitis  ; and  the  term 
thrush  is  popularly  applied  to  both  complaints 
{see  Aphth.e  ; and  Thrush.)  Follicular  stoma- 
titis is  not  a serious  complaint,  though  it  in- 
dicates a weak  state  of  health  and  a faulty 
nutrition.  The  little  patient  swallows  with  dif- 
ficulty. There  is  an  increased  flow  of  saliva; 
the  mouth  is  hot  and  tender  ; the  sub-maxillary 
glands  are  swollen ; and  the  bowels  are  dis- 
ordered. 

2.  Ulcerative  Stomatitis. — This  is  merely 
an  advanced  form  of  the  preceding  variety.  The 
inflamed  follicles  break  and  form  small  ulcers, 
covered  with  a greyish  or  yellowish  slough. 
These  ulcers  may  remain  separate  and  distinct, 
or  several  may  coalesce  to  form  one  larger  ulcer. 
Sometimes  the  ulcerative  process  spreads  rapidly. 
This  is  especially  apt  to  be  the  case  when  the 
disease  is  situated  on  the  gums.  In  a severe 
case  the  bases  of  the  teeth  and  the  alveoli  may 
be  exposed. 

Treatment. — The  treatment  of  these  two 
varieties  of  stomatitis  must  be  conducted  on  the 
same  principles,  and  may,  therefore,  be  given  under 
the  same  head.  It  is  necessary  to  put  the  child 
in  a favourable  hygienic  condition,  and  to  regu- 
late its  diet.  If  it  be  at  the  breast,  inquiry 
should  be  made  as  to  whether  it  is  fed  regu- 
larly, and  only  at  proper  intervals.  This  should 
be  insisted  upon.  If  the  milk  evidently  disagree, 
the  infant  must  be  weaned.  In  some  cases, 
however,  it  may  be  enough  to  supplement  the 
mother’s  milk  with  some  suitablefood.  'With  older 
children  attention  must  be  directed  to  the  nutri- 
tious quality  of  their  food,  and  to  the  regularity 
of  their  meals.  If  it  be  possible  for  the  child  to 
have  a change  of  air,  this  alone  will  often  have 
a most  beneficial  effect.  Small  doses  of  grey 
powder,  or  of  rhubarb  and  magnesia,  should  be 
given  to  regulate  the  bowels  ; while  at  the  same 
time  chlorate  of  potash  and  bark  should  be  pre- 
scribed. Subsequently  a course  of  cod-liver  oil. 
or  of  the  syrup  of  the  iodide  of  iron,  or  of 
Parrish’s  chemical  food,  will  be  useful. 

Locally,  the  mouth  should  be  washed  with  some 
simple  detergent.  Borax  is  the  most  valuable; 
but  when,  as  not  unfrequently  happens,  there  is 
some  feetor  of  the  breath,  a little  tincture  of 
myrrh,  or  Condy’s  fluid,  may  be  used  with 
advantage. 

3.  Gangrenous  Stomatitis. — Synon.  : Cart- 
er um  oris;  Noma. — Occasionally,  but  very  rarely, 
we  meet  with  a much  more  formidable  variety  of 
stomatitis,  arising  out  of  the  ulcerative  form,  and 
supervening  upon  measles,  or  some  other  debili- 
tating blood-disease.  In  ennerum  oris  one  cheek, 
generally  near  the  angle  of  the  mouth,  becomes 
swollen,  red,  brawny,  and  shining.  The  whole 
thickness  of  the  cheek  is  affected  by  an  acute 
inflammation,  which  runs  on  rapidly  to  gangrene. 
The  internal  surface  is  the  seat  of  a deep  foul 
ulcer,  and  the  little  patient  can  hardly  open  his 
mouth.  Gradually  the  redness  passes  into  livid- 
ity;  and  a black  point  appears,  which  is  soon  the 
centre  of  a large  slough  When  this  separates. 


STOMATITIS. 

the  teeth  and  the  interior  of  the  mouth  are  ex- 
posed to  view. 

Treatment. — Everything  must  be  done  to 
support  the  patient’s  strength  by  milk,  beef-tea, 
wine,  and  stimulant  medicines.  The  mouth 
should  be  syringed  frequently  with  warm  water, 
or  with  a disinfectant  mouth-wash.  The  cheek 
must  be  covered  with  a poultice  or  a fomentation 
until  the  slough  separates,  and  then  the  raw  sur- 
faces must  be  dressed  with  a stimulating  lotion 
— for  example,  of  carbolic  or  nitric  acid,  or  of 
sulphate  of  zinc.  If  the  gangrenous  inflammation 
threaten  to  spread,  the  edges  must  be  thoroughly 
touched  with  strong  nitric  acid.  Indeed  some 
consider  it  well  to  treat  the  ulcer  inside  the 
cheek  in  this  manner  from  the  commencement. 
In  order  to  do  this  effectually  it  will  be  neces- 
sary to  administer  an  anaesthetic.  But,  in  spite 
of  all  that  can  be  done,  gangrenous  stomatitis  is 
a very  fatal  disease. 

W.  Faielie  Clauke. 

STONE. — A popular  name  for  calculus.  Sec 
Calculus. 

STOOLS,  Characters  of.  — The  physical, 
chemical,  and  microscopical  examination  of  eva- 
cuations from  the  bowels,  or  ‘ stools,’  have  been 
fully  considered  in  the  articlo  Faeces.  There 
remain  to  be  described  here  certain  characters 
which  the  stools  possess  in  special  diseases. 
Owing  to  the  extreme  variety  in  appearance, 
quantity,  consistency,  colour,  and  composition 
which  healthy  motions  present,  their  charac- 
teristics in  disease  are  of  doubtful  significance, 
and  it  is  but  rarely  that  a diagnosis  depends 
on  their  investigation,  unless  it  be  for  the  dis- 
covery of  such  bodies  as  entozoa,  gall-stones, 
pius,  or  other  objects  accidentally  swallowed, 
and  occasionally  pus  or  blood. 

In  a few  diseases  only  do  the  evacuations  pre- 
sent features  of  sufficient  constancy  to  be  in  any 
way  distinctive,  and  even  then  it  is  rather  as  an 
element  in  the  diagnosis,  than  as  being  actually 
pathognomonic,  that  they  are  to  be  considered. 
As  might  be  expected,  these  maladies  are  amongst 
those  in  which  there  exists  some  serious  lesion 
of  the  gastro-intestinal  tract,  or  of  its  tributary 
glands.  The  following  may  be  referred  to  in 
this  category : — ■ 

Cholera. — During  the  stages  of  the  onset, 
crisis,  and  reaction  of  Asiatic  cholera,  the  stools 
present  a successive  series  of  changes  in  colour, 
consistency,  and  composition.  During  the  pre- 
liminary diarrhoea  the  contents  of  the  bowel  are 
voided  in  a semi-formed,  pappy,  and  increasingly 
fluid  condition,  with  a progressive  alteration  in 
colour  from  the  normal  tint  to  almost  colourless- 
ness. During  the  algid  stage  about  50  to  100 
ounces  are  discharged,  in  10  to  20  portions,  of 
a rice-water  or  whey-like  appearance,  inodorous, 
and  wholly  wanting  in  bile-pigment.  The  ex- 
creta on  standing  deposit  whitish  floeculi,  con- 
sisting of  epithelium,  fungi,  granular  debris,  and 
crystals  of  salts,  chiefly  phosphates ; occasionally 
a few  blood-corpuscles  are  seen.  The  supernatant 
fluid  is  alkaline  ; and  it  contains  a large  propor- 
tion of  chloride  of  sodium,  and  a little  albumen. 
When  the  stage  of  reaction  sets  in,  the  stools 
become  coloured,  at  first  greenish,  and  they  then 


STOOLS.  1549 

generally  assume  the  normal  colour  and  consis- 
tency as  the  diarrhma  becomes  less  profuse.  In 
this  stage  they  are  sometimes  very  fetid. 

Dysentery. — In  this  disease,  more  than  in  any 
other,  are  the  stools  diagnostic,  especially  if  with 
their  appearance  their  odour  be  taken  into  ac- 
count, as  they  are  peculiarly  fetid,  or  even  gangre- 
nous. The  frequency  of  the  stools  is  very  great, 
amounting  sometimes  to  hundreds  in  the  day, 
but  a few  drachms  being  voided  on  each  occasion. 
Considerable  variation  is  met  with,  dependent  on 
the  severity,  type,  or  stage  of  the  case ; but  the 
first  discharges,  and  perhaps  the  only  ones  in 
mild  cases,  consist  of  pale  yellow  masses  of  glairy 
mucus,  often  specked  with  blood,  ar.d  with  or 
without  a small  quantity  of  pale,  feculent  matter. 
The  microscope  reveals  a few  leucocytes  and  free 
nuclei,  with  blood-corpuscles,  enclosed  within  the 
structureless  mucus.  In  later  stages,  when  there 
is  suppuration  of  the  mucous  membrane,  small 
red  lumps,  of  an  appearance  like  raw  washed 
meat,  are  seen  in  yellowish  or  reddish  albumi- 
nous fluid.  These  masses  consist  of  red  blood- 
corpuscles,  imbedded  in  a stroma  of  viscid 
mucus,  with  pus  and  epithelial  cells  and  granu- 
lar debris.  Sometimes  the  stools  consist  chiefly 
of  blood;  at  other  times  pus  predominates;  and 
when  the  disease  is  of  a very  malignant  cha- 
racter, large  gangrenous  portions  of  the  bowel 
are  voided  with  a brownish  serous  fluid.  The 
mucus  is  sometimes  expelled  in  a form  resem- 
bling masses  of  boiled  sago.  It  is  said  that  a 
partial  diagnosis  of  the  extent  of  the  disease 
may  be  made  by  a study  of  the  characters  of 
the  stools. 

Enteric  fever. — Previous  to  the  establishment 
of  the  intestinal  ulceration  in  typhoid  fever,  the 
stools  consist  of  brownish  masses,  more  or  less 
formed ; but  subsequently  what  is  often  re- 
garded as  a characteristic  appearance  is  pre- 
sented, namely,  pale  yellow  semi-fluid  pea-soupy 
evacuations,  of  an  alkaline  reaction,  and  offen- 
sive odour.  On  standing,  the  motions  deposit  a 
yellow  flocculent  sediment  of  particles  of  food, 
granular  debris,  fungi,  epithelial  cells,  and 
crystals  of  triple  phosphates.  The  fluid  has  a 
sp.  gr.  of  1015  ; and  contains  4 per  cent,  solids, 
chiefly  albumen  and  chloride  of  sodium.  Not 
infrequently  blood  is  found,  and  sometimes  por- 
tions of  Peyer's  patches  that  have  sloughed  off. 
The  diagnosis  between  typhoid  and  tubercular 
ulceration  of  the  bowels  is  not  to  be  made  with 
any  certainty  from  the  appearance  of  the  stools. 
For  although  the  above  description  applies  to 
the  evacuations  in  many  cases  of  enteric  fever, 
in  others  they  are  much  more  consistent,  and 
even  clayey.  Identical  discharges  are  met  with 
in  tubercular  disease  of  the  intestines. 

Pancreatic  disease. — In  those  morbid  condi- 
tions where  the  pancreatic  juice  is  not  secreted, 
from  destruction  of  the  gland,  as  in  cancer, 
or  when  the  secretion  is  prevented  gaining  en- 
trance into  the  bowel  from  occlusion  of  the  duct, 
it  has  long  been  known  that  the  stools  are  liable 
to  contain  fat  in  variable  quantity,  occurring  in 
the  form  of  loose  drops,  or  lumps,  or  smeared  over 
the  fseces,  or  discharged  free  from  feculent  mat- 
ter, constituting  a stearrheea.  This  condition  is 
much  more  likely  to  be  met  with  when  the  bile 
Is  prevented  from  flowing  into  the  duodenum, 


1550  STOOLS, 

although  the  existence  of  such  obstruction  is  not 
a necessity.  And  further,  it  must  be  admitted 
that  fat  has  been  found-wanting  in  the  stools  when 
there  has  been  marked  pancreatic  disease.  It 
must  not  be  forgotten  that  healthy  evacuations 
contain  a small  quantity  of  fat,  which  may  be 
considerably  increased  if  the  amount  ingested  be 
excessive.  Hence  fat  in  the  stools  cannot  be  re- 
garded as  absolutely  indicative  of  disease  of  the 
pancreas,  though  very  often  associated  with  it. 
Owing  to  the  frequent  association  of  diabetes 
with  disease  of  the  pancreas,  such  as  cancer  or 
atrophy,  fatty  stools  are  often  met  with  in  that 
disease. 

Hepatic  disease.-It  is  only  in  affections  of  the 
liver  in  which  there  exists  some  interference  with 
the  flow  of  bile  into  the  intestine,  that  the  stools 
present  a characteristic  appearance,  namely,  a 
want  of  colour,  varying  from  a pale  yellow  to 
a whitish- clay  tint,  in  proportion  to  the  degree 
of  exclusion  of  the  bile.  Such  evacuations  are 
almost  always  unformed  and  of  ‘porridge-like’ 
consistency ; rarely  in  the  form  of  pale  scybala. 
From  want  of  bile  their  odour  is  invariably 
offensive ; and  they  may  be  even  putrid  in 
cancer  of  the  liver.  Since  haemorrhage  from  the 
mucous  surface  frequently  complicates  icterus, 
the  faeces  are  sometimes  blackened  from  blood. 
In  a few  recorded  cases  of  hepatic  disease,  where 
the  pancreas  has  been  unaffected,  fat  has  been 
found  in  the  stools,  sometimes  in  largo  quan- 
tities. 

Fever.-In  the  general  febrile  state,  when  there 
is  no  primary  affection  of  the  digestive  organs, 
the  motions  are  diminished  in  quantity,  and  as  a 
rule  drier,  though  very  frequently  unformed. 
The  colour  is  generally  darker,  due  probably  to 
the  increased  destruction  of  blood-corpuscles, 
and  increased  elimination  of  bile-pigment;  and 
the  odour  is  more  offensive  than  in  health. 

Other  diseases. — In  other  affections  of  the 
chylopoietic  viscera  the  characters  of  the  alvine 
discharges  are  so  variable  in  quantity,  colour, 
consistency,  odour,  and  composition,  that  no 
general  remarks  can  be  made  and  no  diagnostic 
indications  recorded.  Sometimes  in  grave  dis- 
eases the  motions  are  not  to  he  distinguished 
from  those  in  health,  whilst  a trifling  change  in 
diet  or  habitation,  or  a slight  catarrh,  may  be 
accompanied  by  the  discharge  of  faeces  differ- 
ing in  many  respects  from  the  normal.  The  fact 
is  that  no  standard  can  be  taken,  so  numerous 
and  frequent  are  the  disturbing  causes. 

Severe  constitutional  diseases  of  a chronic 
character,  as  rickets  and  scrofula,  where  the 
general  nutrition  is  seriously  affected,  and  the 
blood  much  alteredin  quality,  are  very  frequently 
characterised  by  stools  which  are  pale  in  colour 
and  fetid  in  odour.  The  deteriorated  quality  of 
the  intestinal  secretions,  and  consequent  imper- 
fect digestion  of  the  contents  of  the  bowel,  will 
account  for  this. 

The  significance  of  blood  in  the  motions  has 
been  explained  in  the  article  Helena. 

Pus  in  any  considerable  quantity,  and  espe- 
cially if  free  from  admixture  with  faeces,  may  be 
taken  to  indicate  the  rupture  into  the  bowel  of 
an  abscess,  since  the  inflammatory  conditions  of 
the  canal,  such  as  enteritis  and  dysentery,  are 
cot  accompanied  with  very  extensive  pus-pro- 


STKABISMUS. 

duction.  The  contents  of  pericacal  or  perirectal 
abscesses  are  usually  extremely  ill-smelling. 
See  also  Kothnagel,  Zeits.  f.  Klin.  Med.,  iii., 
P-  241.  TV.  H.  Allchin. 

STRABISMUS. — Stxon.  : Squint;  Fr. 
Strdbisme ; Ger.  Strabismus;  Schielen. 

Definition. — A condition  in  which  the  two 
eyes  are  not  directed  to  the  same  point  in  space. 

Description. — Squint  is  commonly  either  (1) 
convergent,  or  (2)  divergent ; but  (3)  there  may 
be  a deviation  either  upwards  or  downwards. 
When  one  eye  appears  to  be  normally  directed, 
and  the  other  to  deviate,  it  is  convenient  to  dis- 
tinguish the  former  as  the  working,  and  the 
latter  as  the  squinting  eye. 

The  extent  or  degree  of  strabismus,  or,  as  it 
is  more  usually  called,  the  magnitude  of  a squint, 
is  expressed  in  terms  of  millimetres.  In  con- 
vergent or  divergent  squint  it  is  customary  to 
measure  the  distance  between  an  imaginary  ver- 
tical line  bisecting  the  palpebral  fissure,  and 
another  imaginary  vertical  line  bisecting  the 
pupil  of  the  deviating  eye.  In  an  upward  or 
downward  squint,  the  distance  between  the  hori- 
zontal diameter  of  the  pupil,  and  an  imaginary 
horizontal  line  bisecting  the  palpebral  fissure, 
would  give  the  measurement  required. 

1.  Convergent  strabismus. — This  is  seen 
under  two  principal  forms ; (a)  that  which  de- 
pends upon  paralysis  or  paresis  of  one  of  the 
external  recti  muscles,  permitting  the  antagonist 
internal  rectus  to  exert  a preponderating  influ- 
ence upon  the  position  of  the  eye;  and  that 
which  depends  upon  excessive  development  of  both 
interni,  in  consequence  of  an  error  of  refraction, 
whether  (5)  hypermetropia,  or  (c)  myopia. 

(a)  Paralytic  convergent  strabismus. — Thisform 
of  strabismus  is  met  with  in  all  degrees,  from 
the  slightest  weakening  of  the  affected  external 
rectus  to  complete  paralysis. 

IEtiology. — Paralytic  convergent  strabismus 
is  primarily  a nerve-affection,  in  which,  how- 
ever, the  muscle  concerned  will  after  a time  he 
liable  to  undergo  degenerative  changes.  The 
strabismus  usually  commences  somewhat  sud- 
denly, in  persons  of  adult  age.  and  often  rapidly 
increases  in  degree ; the  paralysis,  which  at  first 
was  only  partial,  becoming  complete.  In  the 
great  majority  of  cases  it  is  associated  with 
syphilis  ; but  it  is  also  met  with  as  a result  of 
impaired  nutrition  or  degenerative  change  in  the 
nervous  centres,  consequent  upon  anxiety  or  over- 
work. In  some  of  the  syphilitic  cases,  it  appears 
to  he  due  to  central  mischief,  such  as  gumma  or 
arterial  occlusion;  in  others  to  pressure  upon 
the  trunk  of  the  sixth  nerve  by  periosteal  thick- 
ening or  other  morbid  growth. 

Diagnosis. — In  pronounced  eases,  the  diagnosis 
is  easy;  and  depends  upon  the  fact  that,  even 
when  the  working  eye  is  closed  or  covered,  the 
squinting  eye  cannot  he  directed  outwards  by 
voluntary  effort.  If  the  paralysis,  although  con- 
siderable in  degree,  is  not  complete,  the  eye 
cannot  he  directed  outwards  as  far  as  usual ; if 
the  paralysis  is  complete,  the  pupil  cannot  be 
carried  external  to  the  middle  line  of  the  palpe- 
bral fissure.  “When  the  affected  muscle  is  only 
slightly  weakened,  the  nature  of  the  condition 
may  not  he  at  once  apparent  from  the  limitation 
of  movement ; and  the  degree  of  deviation  mat 


STRABISMUS. 


be  so  slight  that  it  is  not  easy  immediately  to  i 
pronounce  ■which  eye  is  affected.  This  doubt 
may  be  removed,  and  the  existence  of  paresis 
made  manifest,  by  the  following  tests.  The 
surgeon  should  stand  in  front  of  the  seated 
patient,  and  should  hold  up  before  him,  in  the 
middle  line,  and  at  a convenient  reading  dis- 
tance, some  small  object,  telling  him  to  look  at 
it  steadily.  By  his  own  hand,  or  by  a piece  of 
ground  glass,  the  surgeon  then  cuts  off'  the  view 
of  the  object  first  from  one  of  the  patient's 
eyes  and  then  from  tie  other,  watching  their 
movements  as  he  does  so.  When  the  object  is 
concealed  from  the  squinting  eye,  the  other  one, 
seing  already  rightly  directed,  will  remain  sta- 
tionary to  continue  the  act  of  seeing,  and  the 
squinting  eye  will  also  remain  stationary;  but, 
when  the  object  is  concealed  from  the  working 
eye,  the  other,  or  squinting  eye,  being  wrongly 
directed,  and  not  receiving  th6  image  of  the 
object  upon  its  yellow  spot,  will  make  a slight 
outward  movement  in  order  to  take  up  correct 
fixation.  At  the  same  moment,  the  working 
eye,  behind  the  obstruction,  will  execute  an 
inward  movement  of  somewhat  greater  ampli- 
tude than  the  outward  movement  of  its  fellow. 
Let  it  be  supposed  that  there  is  slight  weaken- 
ing of  the  right  externus,  producing  slight  in- 
version of  the  right  eye.  When  the  object  is 
screened  from  the  right  eye,  the  left  still  sees  it 
clearly  and  sharply,  and  both  eyes  remain  at  rest. 
When  the  object  is  screened  from  the  left  eye, 
the  right  receives  the  image  upon  a point  of 
its  retina  internal  to  its  yellow  spot,  and  sees  it 
only  indistinctly.  The  right  eye,  therefore,  makes 
an  excursion  outwards,  sufficient  in  amount  to  bring 
the  image  of  the  object  upon  its  yellow  spot,  and 
to  enable  it  to  see  better ; but  the  motor  impulse 
by  which  the  necessary  movement,  of  the  ex- 
ternal rectus  is  called  forth,  is  conveyed  at  the 
same  time  to  the  internal  rectus  of  the  left  eye, 
as  a result  of  the  habitual  association  of  the  two 
eyes  and  of  their  muscles  in  the  act  of  looking 
towards  the  right ; and  the  sound  muscle,  under 
a given  motor  impulse,  contracts  more  vigorously 
than  the  weakened  one.  The  result  is  that  the 
excursion  inwards  of  the  working  eye  is  larger 
than  the  excursion  outwards  of  the  squinting 
cne  ; and  in  this  way  the  fact  of  paresis  of  the 
right  externus  is  rendered  manifest. 

This  form  of  strabismus  is  at  first  attended  by 
distressing  double  vision,  which  often  produces 
giddiness,  but  which  diminishes  in  time,  as  the 
patient  learns  to  neglect  or  mentally  to  suppress 
the  image  of  the  squinting  eye.  The  smaller 
the  deviation,  the  more  distressing  will  be  the 
double  vision  ; because,  the  nearer  to  the  yellow 
spot  is  the  image  of  the  squinting  eye,  the  more 
definite  will  it  be,  and  the  less  readily  will  it  be 
distinguished  from  that-  of  the  other.  In  cases 
of  very  slight  deviation,  the  equality  of  the 
double  images  renders  it  difficult  to  tell  the  true 
from  the  false,  and  leads  the  patient  into  fre- 
uuent  error  with  regard  to  the  position  of  the 
object  looked  at. 

TnEATitEirr. — The  treatment  of  paralytic  stra- 
oismus  is  primarily  that  of  the  syphilis  or  of 
the  nerve-exhaustion  upon  which  the  paralysis 
depends  ; but  it  is  also  necessary  to  endeavour 
to  minimise  the  inconveniences  of  the  double 


1551 

vision  while  it  continues,  and  to  provide  against 
permanent  degeneration  of  the  paralysed  muscle 
from  disuse.  The  former  indication  may  be  ful- 
filled by  covering  the  squinting  eye  with  a patch, 
or  with  an  opaque  glass  in  a spectacle  frame ; 
and,  as  the  double  vision  is  only  troublesome 
when  the  eyes  are  directed  to  the  side  of  the 
affected  muscle,  it  is  often  sufficient  to  render 
opaque,  by  grinding  or  otherwise,  the  outer  half 
of  the  glass  which  covers  the  affected  eye.  The 
nutrition  of  the  muscle  may  be  preserved,  when 
the  paralysis  is  incomplete,  by  systematic  volun- 
tary endeavours  to  call  it  into  action;  these 
endeavours  being  made  three  or  four  times  a 
day  for  a few  minutes  at  a time.  For  this  pur- 
pose, the  working  eye  should  be  closed  or  covered, 
and  the  squinting  eye  should  be  directed  as 
much  as  possible  towards  the  outer  side.  When 
the  paralysis  is  complete,  so  that  the  eye  cannot 
be  carried  beyond  the  middle  line  of  its  eyelid- 
opening, it  is  necessary  to  exercise  the  affected 
muscle  by  localised  electric  currents,  after  the 
manner  of  Duchenne.  In  cases  where  there  is 
no  response  to  induced  currents,  those  of  a cell 
battery  will  sometimes  be  found  effectual.  Ths 
exercise  by  electricity  should  he  repeated  at 
short  intervals,  such  as  every  two  or  three  days, 
until  the  nerve-function  is  beginning  to  be  re- 
stored, so  that  the  muscle  can  again  be  exercised 
by  the  wilL 

In  cases  of  paralytic  strabismus  of  old  stand- 
ing, it  is  sometimes  necessary  to  have  recourse 
to  tenotomy  of  the  contracted  intemus,  before 
the  eye  can  be  restored  to  its  correct  position. 
It  may  be  laid  down  as  a general  principle  that 
every  case  can  be  cured,  by  combined  tenotomy 
and  volitional  or  electrical  exercises,  as  long  as 
the  paralysed  muscle  will  respond,  in  however 
small  a degree,  either  to  the  will  or  to  one  form 
or  other  of  electric  current ; but  that,  where  the 
eye  does  not  move  outwards  in  obedience  to  the 
will,  and  where  neither  induced  nor  battery  cur- 
rents produce  contraction  of  the  paralysed  muscle, 
no  good  is  to  be  expected  from  either  operative 
or  medicinal  treatment. 

(5)  Convergent  strabismus  due  to  excessive  de- 
velopment of  both  interni. — .-Etiology. — As  a re- 
sult of  errors  of  refraction,  about  90  per  cent,  of 
this  class  of  cases  are  due  to  flat-eye  or  hgger- 
metropia.  The  flat  formation  of  the  eye  requires, 
for  acute  vision  of  near  objects,  a strenuous  ac- 
commodation-effort ; and  this,  by  the  intimate  as- 
sociation which  exists  between  the  nerve-centres 
governing  the  accommodation  muscles,  and  those 
governing  the  interni,  produces  a corresponding 
effort  of  convergence.  As  soon  as  a child  who  is 
born  with  flat  eyes  begins  to  take  careful  notice  of 
near  things,  his  accommodation  muscles  and  his 
internal  recti  are  both  called  into  frequent  and 
energetic  exercise  ; and  the  consequence  is  that 
the  interni  become  excessively  developed  in  re- 
lation to  their  antagonists,  the  externi,  so  that 
the  normal,  or  resting  position  of  the  eyes,  in- 
stead of  being  one  of  parallelism,  becomes  one 
of  convergence.  The  result  of  this  is  that  the 
child  would  receive  double  images,  of  equal 
intensity,  of  all  objects  situated  either  nearer  to 
him,  or  farther  from  him,  than  the  point  at  which 
the  convergent  optic  axes  would  meet  if  pro- 
longed. Let  us  suppose  that  this  point  is  one  foot 


STRABISMUS. 


1552 

distant  from  the  eyes  ; and  that  the  child  wishes 
to  look  at  an  object  which  is  eighteen  inches  dis- 
tant. He  cannot  do  this  with  both  eyes,  because 
the  externi  are  unable  to  overcome  their  more 
powerful  antagonists.  If,  however,  he  combines 
the  right  externus  with  the  left  internus,  as  in 
the  act  of  looking  to  the  right  with  both  eyes,  he 
becomes  able  to  fix  the  object  correctly  with  his 
right  eye  ; and  if  ha  combines  the  left  externus 
with  the  right  internus,  as  in  the  action  of  look- 
i ng  to  the  left  with  both  eyes,  he  becomes  able  to 
fix  the  object  correctly  with  his  left  eye.  But 
as,  in  either  case,  both  eyes  start  from  a position 
not  of  parallelism  but  of  convergence,  the  effort 
which  carries  the  right  eye  from  its  convergent 
state  to  the  middle  of  its  palpebral  fissure  will 
carry  the  left  from  its  convergent  state  to  one  of 
much  greater  convergence,  and  vice  versd  with 
the  left  eye  ; so  that,  while  one'  eye  is  directed 
to  the  object  of  vision,  the  other  is  rolled  far 
inwards.  In  this  way,  the  image  is  received 
upon  the  yellow  spot  of  the  working  eye,  and 
upon  so  peripheral  a portion  of  the  retina  of  the 
squinting  eye  that  it  is  easily  neglected  by  the 
consciousness,  and  ceases  to  be  a source  of  con- 
fusion or  embarrassment. 

Diagnosis. — The  state  of  things  in  ,an  ordi- 
nary case  of  squint  beginning  in  childhood  is 
the  following.  In  a state  of  rest,  as  when  the 
attention  is  not  directed  to  any  object,  or  during 
sleep,  or  under  an  anaesthetic,  the  eyes  are 
equally  convergent ; but  as  soon  as  any  object  is 
looked  at,  one  eye  fixes  this  object  and  the  other 
rolls  inwards.  If  the  degree  of  flatness  is  alike 
in  both  eyes,  and  if  the  muscles  in  both  are  of 
equal  power,  sometimes  one  will  be  the  squinting 
eye  and  sometimes  the  other  ; and  in  most  cases 
this  condition  obtains  for  a time.  The  squint  is 
then  said  to  be  ‘ alternating.’  Generally  speak- 
ing, however,  it  is  for  some  reason  easier  to  work 
with  one  eye  than  with  the  other;  either  because 
it  is  flat  in  a less  degree,  or  because  its  accommo- 
dation muscle  or  its  external  rectus  is  stronger 
than  the  corresponding  muscle  of  its  fellow  ; 
and  then  this  eye  is  used  in  preference  to,  and 
gradually  supersedes,  its  fellow;  becoming 
always  the  working,  while  that  is  always  the 
squinting  eye.  The  squint  is  then  said  to  bo 
‘ permanent.’ 

Treatment. — It  would  appear  at  first  sight, 
from  the  rationale  of  the  affection,  that  the 
squint  which  depends  upon  flat- eye  could  always 
be  prevented,  or  even  cured,  by  the  habitual  use 
of  convex  spectacles ; but,  as  a matter  of  fact, 
the  balance  of  power  between  the  externi  and 
the  interni  becomes  deranged  at  so  early  a period 
of  life,  that  spectacles  could  not  be  applied  until 
too  late.  In  every  pronounced  case  of  stra- 
bismus, it  is  necessary  to  perform  tenotomy  of 
the  interni,  sometimes  only  of  one  but  far  more 
frequently  of  both ; and  the  only  question  to  be 
considered  is  that  of  the  time  most  favourable 
for  the  operation. 

In  determining  this  question,  the  points  chiefly 
to  be  taken  into  account  are  the  state  of  vision, 
and  the  age  of  the  patient.  When  a squint  be- 
comes permanent,  the  vision  of  the  habitually 
squinting  eye  frequently  becomes  impaired,  appa- 
rently as  a result  of  the  continued  mental  sup- 
pression of  the  image  which  it  receives ; and  in  a 


person  who  is  suffered  to  grow  up  to  adult  age 
squinting,  this  impairment  of  vision  often  falis 
little  short  of  blindness,  and  admits  of  no  remedy. 
No  change  is  discoverable,  generally  speaking, 
by  the  ophthalmoscope ; but  the  power  of  re- 
sponding to  impressions  upon  the  retina  seems 
to  be  lost.  On  the  other  hand,  as  long  as  the 
squint  is  alternating,  and  each  eye  is  used  by 
turns,  the  sight  does  not  usually  suffer. 

The  immediate  effectof  tenotomy  of  one  or  both 
interni  is  to  release  the  eyes  from  their  position 
of  enforced  convergence,  and  to  diminish  the 
power  of  the  interni  to  rotate  them  inwards. 
The  divided  muscles  soon  acquire  new  attach- 
ments farther  back  upon  the  eyeball  than  their 
former  ones,  so  that  their  power  is  permanently 
diminished,  and  this  diminution  may  even  be  in 
excess,  so  as  to  leave  an  undesirable  preponder- 
ance of  the  externi,  and  a corresponding  tendency 
to  eversion.  The  surgeon,  even  by  the  best  planned 
operation,  cannot  absolutely  determine  the  future 
position  of  the  eyes.  That  determination  has  to 
be  effected  by  the  muscles  themselves  under  the 
guidance  of  vision  ; and  a perfect  result  after  a 
squint  operation,  by  which  is  meant  the  restora- 
tion of  parallelism  when  at  rest,  without  im- 
pairment of  the  power  of  volitional  convergence, 
can  only  be  obtained  by  an  instinctive  re-arrange- 
ment of  the  muscular  forces  concerned,  a re- 
arrangement mainly  brought  about  by  efforts  to 
avoid  double  vision,  which  is  often  the  immediate 
result  of  an  operation.  While,  therefore,  it  is 
always  possible  to  remove  by  tenotomy  a coarse 
and  manifest  malposition,  it  is  only  possible  to 
obtain  a perfect  result  when  the  recti  muscles 
are  well-developed,  when  the  acuteness  of  vision 
is  equal  or  nearly  so  in  the  two  eyes,  and  when 
the  power  of  attention  to  visual  impressions  is 
sufficiently  active  to  render  double  images  dis- 
tressing. The  muscular  development  and  the 
power  of  attention  are  both  deficient  in  early 
childhood ; and  hence,  so  long  as  vision  does  not 
suffer,  it  is  better  to  defer  operating  for  squint 
until  about  eight  years  of  age.  As  long  as  the 
squint  is  alternating,  there  is  no  fear  that  the 
vision  will  suffer,  and  it  is  then  safe  and  desir- 
able to  wait ; but,  as  soon  as  the  squint  becomes 
permanent,  it  is  necessary  to  test  the  vision  of  the 
squinting  eye  from  time  to  time,  and  to  provide 
for  this  eye  being  exercised  every  day,  by  keeping 
the  other  closed  or  covered  for  short  periods.  If, 
in  spite  of  such  exercise,  the  vision  of  the  squint- 
ing eye  is  found  to  be  undergoing  progressive 
deterioration,  the  operation  should  be  performed 
without  delay,  at  however  early  an  age ; and  the 
parents  should  be  warned  that  it  may  perhaps 
be  necessary,  for  the  attainment  of  perfect  har- 
mony of  movement  between  the  two  eyes,  to 
operate  again  at  some  future  time. 

It  will  sometimes  happen  that  a child  is  first 
brought  for  advice  at  an  earlier  age  than  eight, 
in  whom  the  squint  has  already  become  per- 
manent in  one  eye,  and  in  whom  the  vision  of 
that  eye  has  already  begun  to  suffer.  In  such 
cases,  it  is  best  to  devote  a few  weeks  to  endea- 
vours to  improve  the  vision  of  the  squinting  eye 
by  compulsory  exercise ; and  if  these  endeavours 
should  be  in  any  degree  successful,  to  continue 
them  as  long  as  improvement  under  their  em- 
ployment is  perceptible.  If  no  improvement 


STRABISMUS. 

ihould  be  produced,  the  operation  should  be  per- 
formed -without  further  loss  of  time. 

(c)  The  convergent  squint  of  short-sighted 
people. — This  is  not  a very  common  affection,  and 
depends  upon  the  fact  that,  spectacles  to  afford 
distant  vision  not  having  been  worn,  the  ex- 
tend, which  produce  the  approximate  parellelism 
of  the  optic  axes  required  for  distant  vision, 
have  not  been  exercised  ; while  the  intend  have 
been  constantly  exercised  in  producing  conver- 
gence for  the  vision  of  near  objects.  The  former 
muscles,  therefore,  have  been  suffered  to  fall  into 
a condition  of  feebleness  from  disuse,  while  the 
latter  have  undergone  abnormal  development. 
In  such  cases  the  eyes  are  usually  equally  con- 
vergent, such  a position  giving  single  vision  of 
near  objects;  while  double  vision  of  distant  ones 
is  not  irksome,  on  account  of  the  indistinctness 
with  which  they  are  seen. 

Treatment. — When  the  convergent  squint  of 
of  a short-sighted  person  is  of  small  magnitude, 
it  may  sometimes  be  cured  by  wearing  glasses 
which  correct  the  short-sight  for  distance,  and 
call  upon  the  external  recti  to  take  up  their 
proper  function.  More  frequently,  however, 
they  fail  to  respond  ; double  vision  is  produced ; 
and  tenotomy,  followed  by  the  use  of  the  spec- 
tacles, is  required.  Such  cases  usually  turn  out 
perfectly  well. 

2.  Divergent  squint. — This  is  nearly  always 
a consequence  of  defective  vision  of  the  squinting 
eye,  which  wanders  outwards  for  want  of  guid- 
ance from  visual  impressions.  It  may  also  follow 
from  unskilfully  performed  or  excessive  opera- 
tions for  the  core  of  convergent  squint. 

Treatment. — The  operation  for  divergent 
squint  is  not  a mere  tenotomy,  but  requires  the 
shortening  of  the  internal  rectus  of  the  squinting 
eye,  or  its  advancement  to  a point  of  attachment 
nearer  to  the  corneal  margin;  and  the  results  of 
such  an  operation  are  less  under  command  than 
those  of  tenotomy.  The  muscle  may  not  attach 
itself  firmly  in  the  new  position,  or  the  connect- 
ing medium  may  stretch  after  a short  time. 
The  operation  may  be  undertaken  more  hope- 
fully, the  better  the  vision  of  the  divergent  eye; 
and  it  is  often  very  successful.  It  is  neverthe- 
less most  prudent,  in  every  instance,  to  prepare 
the  patient  for  the  possibility  of  failure,  or  of 
only  partial  success.  It  is  in  no  case  likely  that 
the  defect  will  be  increased  by  failure  of  the 
operation  ; and,  as  the  chief  motive  for  its  per- 
formance is  usually  the  improvement  of  appear- 
ance, it  may  be  uhdertaken  with  propriety  in 
almost  every  case. 

3.  Complex  squint. — The  forms  of  strabis- 
mus in  which  the  deviation  is  either  upwards  or 
downwards  are  not  sufficiently  numerous  to  be 
brought  under  any  general  rule.  They  depend 
either  upon  spasm  of  the  muscle  producing  the 
deviation,  or  upon  paralysis  or  paresis  of  its  an- 
tagonist ; and  every  case  must  be  investigated 
and  treated  upon  its  merits,  by  tenotomy  or  elec- 
trisation, or  both  combined,  according  to  the  par- 
ticular circumstances.  Various  irregular  forms 
of  strabismus  are  also  seen,  in  the  course  of 
certain  acute  and  chronic  diseases  of  the  nervous 
system,  which  entail  loss  or  impairment  of  mus- 
cular co-ordination,  such  as  meningitis  and  loco- 
motor ataxy;  but  such  forms  are  usually  easily 

98 


STRANGULATION.  1553 

to  be  distinguished  as  symptoms  of  the  general 
disorder,  requiring  no  treatment  or  considera- 
tion apart  from  it.  In  chronic  diseases,  such  as 
locomotor  ataxy,  it  may  be  conducive  to  comfort 
to  exclude  the  squinting  eye  from  vision,  for  the 
purpose  of  obviating  the  inconveniences  inci- 
dental to  double  images. 

R.  Brudenell  Carter. 

STRANGULATION  ( strangulo , I choke). 
In  pathology  this  term  is  employed  to  express 
either  the  process  or  the  condition  of  constriction 
of  a tube,  when  it  is  so  complete  that  the  passage 
of  the  contents  is  prevented.  See  Hernia  ; and 
Intestinal  Obstruction. 

STRANGULATION  as  a Mode  of  Death 

( 'strangulo , I choke).— Synon.  : I’r.  Strangula- 
tion; Ger.  Erwiirgung. 

Definition. — The  act  and  effect  of  constric- 
tion of  the  neck  and  air-passages  by  means  of  a 
ligature  or  manual  pressure  (throttling).  Death 
results  essentially  from  asphyxia. 

IEtiology. — Strangulation  is  chiefly  homi- 
cidal, but  it  may  be  suicidal  or  accidental.  Ac- 
cidental strangulation  may  occur  in  a variety  of 
ways,  as  in  the  case  of  a child  from  tightening 
of  a cravat  round  the  neck,  from  the  end  catch- 
ing in  the  wheel  of  a perambulator;  in  the  case 
of  a drunken  woman  by  fixation  and  tightening 
of  her  bonnet-strings ; and  in  the  case  of  a 
cripple  by  a rope  attached  to  a weight  accident- 
ally becoming  tightened  in  front  of  the  neck. 

it  was  at  one  time  doubted  whether  suicide 
could  be  effected  by  strangulation,  owing  to  the 
fact  that  the  hands  relax  when  insensibility 
comes  on,  rendering  it  impossible  to  keep  up 
sufficient  tension  on  the  ends  of  the  ligature. 
But  when  the  ligature  is  wound  more  than  once 
round  the  neck,  or  some  method  is  adopted  by 
which  the  ligature  can  be  tightened  like  a tour- 
niquet, as  by  the  insertion  of  a piece  of  stick 
which  catches  behind  the  ear  or  elsewhere,  it  is 
quite  possible ; and  numerous  instances  are  on 
record  of  suicide  so  effected.  In  most  cases, 
however,  the  presumption  is  in  favour  of  homi- 
cide, and  in  all  cases  of  strangulation  by  manual 
pressure  this  may  be  looked  upon  as  certain. 

Signs. — In  addition  to  the  general  indications 
of  asphyxia  ( see  Asphyxia),  there  are  special 
signs  of  strangulation  which  vary  with  the  de- 
gree of  force  employed,  and  the  amount  of  resist- 
ance offered  by  the  victim. 

To  strangle  an  individual  of  normal  strength, 
and  in  full  possession  of  all  his  faculties,  is  barely 
possible,  without  causing  evident  signs  of  violence 
on  various  parts  of  the  body.  The  existence  of 
injuries  of  this  kind  is  valuable  evidence  of  the 
mode  of  death.  Very  often  cranial  injuries  are 
found,  from  the  individual  having  been  first 
knocked  down  by  a blow  on  the  head.  Ecchv- 
moses,  abrasions,  and  other  signs  of  mechanical 
violence  are  generally  to  be  found  in  various 
parts  of  the  body.  If  the  strangulation  has  been 
effected  by  manual  pressure,  the  front  or  sides 
of  the  neck  exhibit  bruised  marks,  corresponding 
to  the  thumb  and  fingers,  with,  perhaps,  curved 
excoriations  corresponding  to  the  nails.  The  re- 
lative size  of  the  marks  produced  by  the  thumb 
and  fingers,  and  the  direction  of  the  nail-marks, 


1504  STRANGULATION. 

indicate  the  way  in  -which  the  pressure  has 
been  exerted,  and  whether  with  the  right  or  left 
hand. 

When  a ligature  has  been  empleyed,  a mark 
is  left  on  the  neck,  which  varies  with  the  nature 
of  the  ligature,  and  the  way  it  has  been  disposed. 
Usually  it  is  a transverse,  shallow  furrow;  single, 
double,  or  multiple,  according  to  the  number  of 
folds ; and  continuous,  or  interrupted  in  places. 
The  bottom  of  the  groove  is  generally  pale,  and 
not  parchmented  as  in  hanging,  owing  to  the 
pressure  not  being  kept  up  so  long  as  to  lead  to 
dessication.  Eechymoses  in  the  course  of  the 
groove  are  met  with  more  frequently  than  in 
hanging,  owing  to  the  great  violence  frequently 
exerted. 

Very  commonly  punctated  eechymoses  are 
visible  on  the  conjunctivas,  face,  neck,  and  chest. 
They  are  considered  by  Tardieu  to  be  more  fre- 
quent in  strangulation  than  in  asphyxia  from 
other  causes,  or  from  overstraining,  which  like- 
wise may  lead  to  them.  In  the  subcutaneous 
cellular  tissue,  and  in  the  fasciae  of  the  muscles 
above  and  below  the  hyoid,  extravasations  are 
frequently  found,  as  well  as  on  the  external  sur- 
face of  the  thyroid  cartilage  and  trachea.  The 
lungs  vary  as  regards  their  vascularity,  but  on  the 
surface  it  is  common  to  find  pseudo-membranous 
patches,  which  are  due  to  the  rupture  of  some  of 
the  superficial  air-cellsand  collection  of  air-bubbles 
under  the  pleura.  In  the  substance  of  the  lungs 
congested  patches,  or  apoplectic  extravasations, 
are  often  found,  varying  in  size,  according  to 
Tardieu’s  description,  from  half  a franc  up  to  a 
five-franc  piece — extravasations,  therefore,  much 
larger  than  those  usually  found  in  suffocation. 

Treatment. — The  treatment  of  asphyxia  from 
strangulation  is  that  of  asphyxia  in  general.  See 
Artificial  Respiration  ; Asphyxia  ; and  Re- 
suscitation. D.  Terrier. 

STRANGURY  (arpay a drop,  and  oipoy, 
urine). — Synon.  : Stillicidium  urines ; Fr.  Stran- 
gurie ; Ger.  Harnstrenge. 

Definition.— A condition  characterised  by  a 
frequent  and  urgent  desire  to  pass  the  urine, 
which  is  voided  in  drops  or  in  very  small  quan- 
tities, with  a sense  of  painful  spasm  in  the  peri- 
neum, and  often  with  no  feeling  of  relief. 

iETiOLOGY.—  Strangury  occurs  under  such  a 
great  variety  of  circumstances  that  it  can  be 
regarded  only  in  the  light  of  a symptom.  It  is 
found  in  nephritis  or  intense  congestion  of  the 
kidney,  however  induced  ; and  thus  becomes  a 
symptom  after  the  administration  of  large  doses 
of  turpentine,  or  the  use  of  cautharides,  either 
internally  or  in  the  form  of  a blister.  It  like- 
wise occurs  in  acute  or  chronic  inflammation  of 
the  bladder,  prostate,  and  urethra;  in  hyper- 
trophy of  the  prostate ; in  cancer  and  other 
tumours,  and  in  stone  of  the  bladder;  and  in 
advanced  stricture  of  the  urethra. 

Treatment.  1.  Preventive  treatment . — Stran- 
gury may  be  prevented  from  following  the  appli- 
cation of  a blister  to  the  surface  of  the  body,  by 
allowing  it  to  remain  on  but  for  a short  time, 
following  it  by  a poultice,  or  by  sprinkling  the 
skin  of  the  part  with  powdered  camphor. 

2.  Curative  treatment. — Regarding  strangury 
-as  but  a symptom  of  some  other  morbid  condi- 


STROPHULUS. 

tion,  wo  must  consider  it  as  we  should  cough, 
headache,  or  dropsy,  and  treat  it  with  a view 
to  removing  the  condition  on  which  it  depends. 
With  regard  to  relieving  the  more  urgent  local 
symptoms,  warm  hip-baths  and  fomentations, 
hypodermic  injections  of  morphia,  and  supposi- 
tories of  morphia  or  of  belladonna,  may  be  used 
with  advantage. 

STRATHPEFFER,  in  Ross-sRire. — Sul- 
phur waters.  See  Mineral  Waters. 

STRICTURE  ( stringo , I bind). — A contrac- 
tion of  a tube,  duct,  or  orifice  ; for  instance,  of 
any  part  of  tlio  alimentary  canal  or  of  the  uri- 
nary passages.  See  Urethra,  Diseases  of. 

STRIDOR:  STRIDULOUS  ( strideo , I 

creak). — Stridor  is  the  name  given  to  a peculiar 
noisy  form  of  breathing,  produced  in  the  larynx ; 
varying  greatly  in  its  character — being  either 
harsh,  musical,  or  crowing  ; and  due  to  various 
forms  of  obstruction.  Ttie  term  stridulous  is 
applicable  to  the  respiration,  the  cough,  or 
the  voice,  when  they  possess  the  characters  of 
stridor.  See  Larynx,  Diseases  of;  Pneumo- 
gastric  Nerve,  Diseases  of;  and  Voice,  Dis- 
orders of. 

STROKE. — A popular  synonym  for  an  at- 
tack of  apoplexy  or  sudden  paralysis ; but  also 
used  in  the  compound  words,  sun-stroke,  heat- 
stroke, and  wind-stroke,  to  indicate  the  effects  of 
these  agents. 

STRONGYLU3  ( OTpoyyvKos , cylindrical). 
Synon.  : Fr.  Stronglc ; Ger.  Pallisadenwurm. — 
A genus  comprising  many  species  of  nematoid 
worms.  The  large  kidney-worm,  sometimes 
called  Eustrongylus  gigas,  has  only  once  been 
found  in  the  human  body.  The  case  was  un- 
doubtedly genuine,  and  the  specimen  is  still 
preserved  in  the  museum  of  the  Royal  College 
of  Surgeons.  See  Sclerostoma. 

STRONGYLUS  DUODENALTS.  See 

Sclerostoma. 

STROPHULUS  ( errpiipos , a twisting  of  the 
bowels,  or  colic). — Synon.  : Pr.  Strophulus : Ger. 
Schalknotchen. 

Definition. — A papular  eruption  of  the  skin 
in  infants ; referable,  as  the  derivation  of  the 
word  implies,  to  derangement  of  the  bowels. 

Description. — The  eruption  is  a lichen,  a form 
of  folliculitis,  rarely  extensive,  and  unassociated 
with  constitutional  symptoms.  Its  principal  seat 
is  the  face,  but  it  may  also  be  dispersed  over  the 
trunk  of  the  body  and  limbs.  Its  duration  will 
ho  influenced  by  the  nature  of  its  cause. 

Some  variety  in  colour,  duration,  and  cause 
has  given  rise  to  several  names  applied  to  the 
eruption.  It  is  sometimes  ephemeral,  and  has 
been  termed  S.  eolations  ; sometimes  the  pimples 
are  pale  or  shining,  hence  5.  albidus  and  S.  Can- 
didas. More  frequently  they  are  red  and  in- 
flammatory, and  either  dispersed  or  aggregated, 
S.  confertus ; and  occasionally  an  interpapular 
hypertemia  or  inflammation  gives  rise  to  the 
variety  known  as  S.intertinetus.  When  associated 
with  dentition  this  trivial  rash  is  termed  ‘ red 
gum  ’ and  ‘ white  gum  ’ ; whilst  under  conditions 
of  aggravation  it  is  prone  to  run  into  eczema. 


STROPHULUS. 

Treatment. — The  treatment  of  strophulus  is 
one  of  attention  to  the  general  health  and  con- 
dition of  the  infant.  A few  doses  of  magnesia 
and  rhubarb,  and  even  a grain  of  calomel,  may 
sometimes  be  found  useful,  but  in  general  a dis- 
creet attention  to  the  food,  with  rest  and  warmth, 
will  be  all  that  is  necessary.  Locally,  the  rash 
should  be  dusted  oyer  with  fuller’s-earth  powder, 
or  sponged  with  a lotion  of  lime-water  and  oxide 
of  zinc,  with  or  without  calamine. 

Erasmus  Wilson. 

STEUCTUEAL  DISEASES. — Diseases 
attended  by  recognisable  anatomical  changes, 
as  distinguished  from  functional  diseases.  See 
Disease,  Classification  of. 

STRUMA  1 , . . , ,, 

STRUMOUS  / ( struma>  a scrofulous  swell- 
ing.)— Synonyms  for  scrofula  and  scrofulous.  See 
Scrofula. 

STRYCHNIA,  Poisoning  by. — Synox.  : 
Fr.  Empoisonnement  par  la  Strychnine ; Ger. 
Strychninvergiftung. — The  seeds  of  Strycknos 
nux  vomica,  commonly  known  as  nux  vomica,  as 
well  as  several  other  plants,  owe  their  powerful 
toxic  (excito-motor)  properties  to  an  alkaloid, 
strychnia ; and  in  a minor  degree  to  another 
alkaloid,  brucia,  which  is  said  to  produce  the  same 
physiological  effects  as  strychnine.  Strychnia 
is  a white  crystalline  substance,  very  sparingly 
soluble  in  aqueous  liquids,  to  which,  however,  it 
communicates  an  intolerably  bitter  taste.  It  is 
more  freely  soluble  in  acid  and  alcoholic  liquids. 
When  mixed  with  flour  and  sugar,  and  coloured 
by  admixture  with  either  soot  or  Prussian  blue, 
strychnia  forms  the  basis  of  several  well-known 
forms  of  ‘ vermin-killer.’  Spite  of  its  repulsively 
bitter  taste,  strychnia  has  been  administered  with 
homicidal  intent  in  such  liquids  as  infusions  of 
tea  and  cocoa,  and  in  other  media. 

Anatomical  Characters. — The  anatomical 
characters  after  death  by  strychnia-poisoning  are 
very  ill-marked,  and  at  most  consist  of  some 
congestion  of  the  vessels  of  the  spinal  cord;  and 
even  this  may  be  wanting. 

Symptoms. — Except  when  taken  in  the  form  of 
pill,  strychnia  and  all  substances  containing  it 
produce  an  immediate  and  intensely  bitter  taste, 
which  is  also  at  the  same  time  of  a quasi-metallic 
character,  and  is  very  persistent.  Since  the 
fatal  dose — half  a grain  of  the  alkaloid — is  small, 
and  the  poison  is  readily  soluble  in  the  acid  gas- 
tric fluid,  its  physiological  effects  are,  as  a rule, 
not  long  delayed.  They  may  be  unmistakable 
after  the  lapse  of  two  minutes ; but  commonly 
they  are  not  well-marked  till  five,  ten,  or  even 
twenty  minutes  after  administration.  They 
begin  with  a stage  of  restlessness,  excitement, 
and  a vague  sense  of  impending  peril.  The  special 
senses,  too,  are  often  preternaturally  sharpened. 
A feeling  of  chokiDg  or  impending  suffocation  en- 
sues ; then  there  is  a trembling  of  the  whole  body ; 
jerkings  of  the  head;  and  often,  in  a moment, 
the  whole  body  becomes  stiff  and  rigid,  assuming 
a bow-like  form,  (opisthotonos),  i.e.,  arched  for- 
wards and  resting  perhaps  on  the  head  and  heels 
only.  The  muscles  even  of  the  chest  and  abdo- 
men are  tense  and  fixed,  so  thatrespiration  is  im- 
peded, giving  rise  to  more  or  less  cyanosis.  The 


STRYCHNIA,  POISONING  BY.  1555 
feet  are  either  ineurvated  or  excurvated.  The 
angles  of  the  mouth  are  drawn  down,  so  as  to 
give  rise  to  the  well-known  risus  sarclonicus  of 
tetanus.  Attempts  to  administer  medicine  by 
either  cup  or  spoon  have  been  known  to  result 
in  the  patient’s  biting  the  cup  or  spoon  in  two, 
in  consequence  of  a violent  spasmodic  closing  of 
the  jaws.  During  the  paroxysm,  and  indeed 
throughout  the  intoxication,  the  cerebral  faculties 
are  unimpaired,  and  the  convulsions  are  purely 
of  spinal  origin.  The  pupils  are  dilated.  In  a 
few  minutes,  and  often  in  half  a minute,  the 
muscular  tension  relaxes,  and  there  is  a complete 
remission  of  the  spasms.  The  patient  lies  ex- 
hausted, and  bathed  in  perspiration ; the  rapid 
pulse  of  excitement  falls  in  frequency ; respira- 
tion becomes  more  normal ; and  the  dusky  lividity 
of  the  countenance  passes  off.  This  remission 
is,  however,  of  no  long  duration.  A gentle  touch, 
a footstep,  even  a breath  of  air  impinging  on  the 
patient,  results  in  a new  crisis;  and  often  with  a 
wild,  despairing  cry,  a renewed  convulsion,  simi- 
lar to  but  more  intense  than  the  preceding 
one,  is  ushered  in.  The  patient  rarely  dies 
during  the  first  or  second  paroxysm,  but  the 
alternation  of  convulsions  and  quiet  is  repeated 
again  and  again  till  death  ensues,  usually  in 
half  an  hour  or  an  hour;  or  in  non-fatal  cases 
the  fits  become  less  and  less  frequent,  less  in- 
tense, and  eventually  cease.  Death  takes  place 
commonly  during  a paroxysm,  from  asphyxia  ; 
but  it  may  also  occur  in  the  intervals  between 
the  paroxysms,  from  exhaustion. 

Diagnosis. — The  characteristics  of  strychnia- 
coDvulsions  are  so  well-marked,  as  already  de- 
scribed, that  there  is  little  likelihood  of  the 
nature  of  the  case  being  overlooked;  and  the 
only  disease  with  which  strychnia-poisoning 
can  readily  be  confounded  is  tetanus — traumatic, 
idiopathic,  or  hysterical.  In  the  hysterical  form 
of  the  disease,  as  described  by  some  writers, 
the  well-marked  hysterical  symptoms,  the  closed 
or  half-closed  eyes,  the  desire  to  be  fanned,  and 
the  incomplete  remissions  of  spasm,  servo  for 
diagnosis.  Except  in  the  history  there  is  nothing 
to  distinguish  between  the  traumatic  and  idio- 
pathic forms  of  the  disease,  so  that  what  is  here 
stated  with  regard  to  the  diagnosis  between 
strychnia-tetanus  and  traumatic  tetanus,  ap- 
plies also  to  the  idiopathic  form.  In  traumatic 
tetanus  the  muscular  symptoms  begin  with  pain 
and  stiffness  of  the  neck  and  jaws,  gradually 
passing  into  spasms ; and  the  jaw  is  one  of  the 
earliest  parts  affected.  The  strychnia-symptoms, 
on  the  other  hand,  develop  rapidly,  and  begin 
in  the  extremities,  or  a general  convulsion  at 
once  seizes  the  whole  body.  Moreover,  the  jaw 
is  usually  last  affected,  and  its  muscles  relax 
first.  The  strychnia-relaxation  is  complete,  or 
rarely  almost  complete ; whilst  in  traumatic 
tetanus  there  is  permanent  muscular  rigidity, 
and  no  complete  remission  of  spasm.  Strychnia- 
tetanus  is  an  affair  of  minutes,  or  at  most  of 
half  a dozen  hours  ; whilst  traumatic  tetanus 
never  kills  within  twelve  hours,  and  generally  ex- 
tends ovfer  a few  days.  In  strj-chnia-poisoning  the 
most  trivial  movement  or  touch  will  set  up  a 
convulsion  ; whilst  during  the  spasms  firm  grasp- 
ing of  the  hands,  and  hard  rubbing  of  the  rigid 
muscles,  will  often  afford  grateful  relief.  This 


1556  STRYCHNIA,  POISONING  BY. 
distinction  is  not  marked  in  traumatic  tetanus. 
An  analysis  of  the  urine  by  Stass’s  method,  which 
often  affords  certain  indications  of  strychnia, 
and  may  be  made  in  a few  minutes,  will,  in 
doubtful  cases,  at  once  remove  all  uncertainty  as 
to  the  nature  of  the  disease. 

Prognosis. — The  prognosis  is  at  all  times 
doubtful.  The  patient’s  life  cannot  be  considered 
safe  till  the  convulsions  clearly  exhibit  marked 
decrease,  both  infrequency  and  intensity. 

Treatment.— Should  the  convulsions  have 
already  set  in,  the  use  of  the  stomach-pump  is  out 
of  the  question.  An  emetic  of  warm  water  with 
mustard,  or  carbonate  of  ammonia,  should  be 
given  without  a moment’s  delay.  The  patient 
should  be  touched  as  little  as  possible,  and 
absolute  quiet  observed  in  the  sick-room.  Ex- 
cellent results  have  ensued  from  the  administra- 
tion of  large  doses  of  bromide  of  potassium ; even 
half  an  ounce  in  one  dose  has  been  given.  The 
salt  serves  the  double  function  of  rendering  the 
poison  insoluble,  and  counteracting  its  physio- 
logical effects.  The  gastric  irritation  produced 
by  such  large  doses  of  the  bromide  as  are  neces- 
sary militates  against  its  use.  Chloral  in  full 
doses,  and  the  anaesthetic  administration  of 
chloroform  vapour,  are  the  best  remedies.  The 
free  use  of  chloroform  not  only  alleviates  the 
pain  and  allays  the  spasms,  but  allows  time  for 
the  elimination  of  the  poison  from  the  system. 
Nitrite  of  amyl  has  been  recommended  by  Dr. 
Barnes.  Strychnia-poisoning  more  often  ends 
fatally  either  from  the  lateness  with  which  re- 
medies are  applied,  or  their  non-application, 
than  from  their  inefficient  character. 

Thomas  Stevenson. 

STUPE  (stupa,  tow.)  — A synonym  for  a 
fomentation.  See  Fomentation. 

STUPOR  (Lat.). — Stnon  : Pr.  Stupeur ; Ger. 
Stupor ; Stumpfsinn. — A partial  loss  of  con- 
sciousness. See  Consciousness,  Disorders  of. 

STUTTERING.  See  Stammering. 

STYPTICS  (<tt iipoi,  I constringe). — Defini- 
tion.— In  former  years  this  term  was  held  to 
include  internal  astringents,  like  the  famous 
Huspini’s  styptic,  of  which  gallic  acid  was  the 
principal  ingredient,  but  wTe  now  limit  its  use  to 
substances  locally  used  to  arrest  haemorrhage. 

Enumeration. — The  chief  styptics  are  Cold, 
the  Actual  Cautery,  Perchloride  of  Iron,  Tan- 
nin, Matico,  strong  Acids,  Alum,  Acetate  of 
Lead,  and  Collodion. 

Actions  and  Uses. — One  class  of  styptics 
encourages  the  coagulation  of  the  blood,  by  sup- 
plying a rough  material  around  which  fibrin 
may  be  deposited,  in  obedience  to  a well-known 
physiological  law ; the  principal  of  these  being 
matico,  tannin,  and  the  old-fashioned  cobweb. 
Others,  in  addition  to  their  primary  action  in 
favouring  the  formation  of  a clot,  coagulate  the 
albumen  of  the  tissues,  or,  like  acetate  of  lead, 
cause  the  bleeding  mouths  of  the  smaller  vessels 
to  contract.  The  use  of  styptics  is  usually 
limited  to  the  general  oozing  which  is  observed 
occasionally  to  follow  the  application  of  leeches, 
or  the  infliction  of  small  wounds  by  accident  or 
for  surgical  purposes,  and  may  render  essential 
service  under  a great  variety  of  circumstances. 


SUDAMINA. 

If  ice,  pressure,  or  posture  fail  to  check  bleed- 
ing, we  may  have  recourse  to  some  of  the  mort 
potent  applications.  R.  Fauquuakson. 

STY  (Sax.  steigon,  to  rise  up). — Stnon.:  Hor- 
deolum- Fr.  Comperc-Loriot-,  Orgelet ; Ger.  Ger- 
stenkorn. 

Definition. — A boil  on  the  margin  of  the 
eyelid. 

Description. — A sty  does  not  differ  in  any 
essential  respect  from  a boil  in  any  other  situa- 
tion, but  it  is  usually  of  small  size,  and  com- 
mences in  the  follicle  of  an  eyelash.  Sties  are 
most  common  in  young  people,  especially  in 
anaemic  girls,  and  are  often  very  troublesome  by 
frequent  recurrence,  in  which  case  they  may 
create  a certain  amount  of  permanent  disfigure- 
ment by  destroying  hair-bulbs,  and  producing 
bald  gaps  in  the  eyelid  margins.  They  are 
mostly  associated  with  some  obvious  derange- 
ment of  the  general  health,  which  should  be 
made  the  subject  of  treatment. 

Treatment. — An  individual  sty,  if  seen  suffi- 
ciently early,  when  it  is  as  yet  only  a small 
pimple,  may  often  be  rendered'  abortive  by  pull- 
ing out  the  eyelash  which  passes  through  it,  and 
touching  the  spot  with  a fine  point  of  nitrate  of 
silver ; but,  when  the  time  for  this  method  has 
passed  away,  there  is  nothing  to  he  done  locally 
beyond  the  application  of  a fomentation  or  poul- 
tice, and  a touch  with  a sharp  lancet  as  soon  as 
pus  can  be  seen.  Pain  is  at  once  relieved  by  the 
incision,  and  the  swelling  speedily  subsides. 

R.  Brudeneix  Carter. 

SUBACUTE. — A term  applied  to  a disease 
when  it  has  characters  intermediate  betweeu 
acute  and  chronic,  whether  in  course  or  in  inten- 
sity. See  Acute  ; Chronic  ; and  Disease,  Dura- 
tion of. 

SUBCUTANEOUS  INJECTION.  See 
Hypodermic  Injection. 

SUBSTITUTION.— This  word  is  used  in 
pathology  in  connection  with  degeneration,  when 
a newly-formed  tissue,  inferior  to  the  original  in 
organisation  orfunctional  activity,  takes  the  place 
of  the  normal  structure.  See  Degeneration. 

SUBSULTUS  TENDINUM  (Lat.).- A 
twitching  movement  of  the  tendons,  caused  by 
sudden  momentary  contractions  of  the  muscles 
to  which  they  belong.  This  is  especially  apt  to 
show  itself  in  the  tendons  about  the  wrist  in  the 
later  stages  of  many  low  fevers.  It  manifests 
itself  principally  in  states  of  great  prostration, 
and  is  often  associated  with  delirium  or  other 
signs  of  cerebral  irritation.  See  Typhus  Fever. 

SUCCUSSION  (succussio,  a shaking). — A 
method  of  physical  examination,  which  consists 
in  suddenly  shaking  the  trunk  of  the  patient,  so 
that  certain  sensations  or  sounds  may  be  pro- 
duced, which  are  indicative  of  the  presence  of 
gns  and  fluid  in  a hollow  space,  such  as  the 
pleural  cavity.  See  Physical  Examination. 

SUDAMINA  (sudor,  sweat). — Stnon.  : Fr. 
Sudamina  ; Ger.  Schm-issbldschcn. — This  term  it 
applied  to  minute  vesicles  of  the  cuticle,  asso- 
ciated with  a relaxed  and  perspiring  state  of 
the  skin.  In  size  they  have  been  compared  to 
a millet-seed,  milium  ; and  when  they  occur  hi 


SUDAMINA. 

considerable  numbers  they  constitute  the  erup- 
tion known  as  miliaria  {see  Miliaria).  In  some 
instances  they  would  seem  to  be  produced  by 
rupture  of  the  sudoriparous  ducts,  and  escape 
of  the  sweat  into  the  rete  mucosum  of  the  skin. 
See  SGdoeipabous  Glands,  Diseases  of. 

Erasmus  "Wilson. 

SUDORIFIC 3 {sudor,  sweat,  and  facio,  I 
make). — A synonym  for  diaphoretics.  See  Dia- 
phoretics. 

SUDORIPAROUS  GLANDS,  Diseases 

of. — Synon.  : Fr.  Maladies  des glandcssudoripares ; 
Ger.  Krankheiten  der  Schweissdriiscn. — The  per- 
spiratory, sudoriparous,  or  sweat  glands  are  sub- 
ject to  varieties  of  development  and  growth;  and 
likewise  to  changes  resulting  from  a low  degree 
of  inflammation,  or  of  congestion,  of  their  capil- 
lary blood-vessels. 

1.  Atrophy  and  Hypertrophy. — "We  may 
recognise  both  atrophy  and  hypertrophy  of  the 
sudoriparous  glands,  but  they  are  very  rare 
affections. 

2.  Subacute  Inflammation. — Synon.:  Hy- 
droadenitis. 

This  disease  of  the  sweat-glands  originates 
with  hyperaemia,  which  renders  the  glands  visible 
through  the  cuticle,  and  in  rare  instances  passes 
into  the  formation  of  a minute  quantity  of  pus, 
and  pustulation.  Another  affection  of  the  per- 
spiratory glands,  beginning  with  congestion  and 
disintegration  of  the  epithelium  of  the  excretory 
duct,  and  resulting  in  the  formation  of  minute 
globules  of  transparent  fluid,  which  either  re- 
main in  the  deep  stratum  of  the  epidermis,  or 
are  developed  into  isolated  single  or  multilocular 
vesicles,  followed  by  exfoliation,  is  limited  to  the 
fingers  and  hands,  particularly  their  palmar  sur- 
face. This  affection  has  received  the  names  of 
(1)  dysidrosis  (Tilbury  Fox),  from  the  presence  of 
a mechanical  impediment  to  the  escape  of  the 
sweat ; and  (2)  cheiropompholyx  (Hutchinson), 
from  the  association  of  clusters  of  vesicles,  which 
occasionally  form  a multilocular  bleb  of  moderate 
elevation,  and  of  about  half  an  inch  in  breadth. 
Occasionally  the  bleb  may  become  in  appear- 
ance a real  pompholyx,  and  cover  the  whole 
of  the  palm  of  the  hand,  in  which  case  the  fluid 
which  it  contains  is  remarkable  for  its  putrid 
odour. 

Diagnosis. — Dysidrosis  is  distinguished  from 
eczema  by  the  absence  of  superficial  inflam- 
mation and  exudation ; by  the  apparent  depth 
within  the  epidermis  of  the  sero-globules ; by 
their  tendency  to  resorption  ; by  their  limitation 
to  the  hands  and  occasionally  the  feet ; and  by 
the  absence  of  eczema  on  other  parts  of  the 
body.  From  a certain  resemblance,  the  sero- 
globules  of  dysidrosis  have  been  compared  to 
sago-grains.  It  is  not  a grave  affection,  but  is 
undoubtedly  troublesome,  and  is  usually  met 
with  in  persons  of  delicate  health,  especially 
females,  and  during  or  after  a hot  season. 

Treatment.— In  disorders  of  the  sudoriparous 
glands  the  general  health  predisposing  to  such 
affections  is  chiefly  to  be  considered.  This  is 
especially  the  case  in  dysidrosis,  which  calls  for 
the  use  of  tonic  remedies,  and  a generous  diet. 
Locally,  the  best  remedies,  in  all  stages  of  the 
complaint,  are  lotions  of  oxide  of  zinc  or  prepared 


SUFFOCATION.  1557 

chalk  with  lime-water.  In  other  cases  painting 
with  liquor  plumbi  has  proved  very  successful. 

Erasmus  Wilson. 

SUFFOCATION  (suffoeo, I stifle). — Synon.: 
Fr.  Suffocation ; Ger.  Erstickung. 

Definition. — The  term  suffocation  is  some- 
times employed  synonymously  with  asphyxia.  In 
the  strict  medico-legal  sense  it  signifies  asphyxia 
induced  by  obstruction  of  the  respiration  other- 
wise than  by  direct  pressure  on  the  neck  (hang- 
ing, strangulation),  or  submersion  (drowning). 

Etiology. — Death  by  suffocation  is  usually 
the  result  either  of  accident  or  of  homicide, 
rarely  of  suicide. 

Suicide  by  suffocation  is  not,  however,  un- 
known. Cases  of  suicide  by  immurement  in  a 
box  or  trunk,  or  by  thrusting  a pad  or  other  ob- 
struction down  the  throat,  have  been  reported; 
and  it  has  been  averred  that  slaves,  both  in 
ancient  and  modern  times,  have  committed  sui- 
cide by  rolling  the  tongue  back  into  the  pharynx. 

Accidental  suffocation  is  very  common  by  dis- 
eases causing  occlusion  of  the  air-passages ; by 
the  impaction  of  pieces  of  food  or  other  obstacles 
in  the  pharynx ; by  the  entry  of  foreign  bodies 
into  the  larynx,  as  a seed,  coin,  or  food  in  cases 
of  bulbar  or  general  paralysis,  or  matters  vomited 
in  a state  of  insensibility ; by  mechanical  pres- 
sure on  the  chest  and  abdomen,  as  in  crowds,  or 
in  falls  of  earth  or  heavy  bodies  ; by  various  dis- 
eases preventing  the  expansion  of  the  lungs ; by 
diseases  of  the  lungs  themselves ; or  by  obstruc- 
tion of  the  pulmonary  circulation.  Suffocation 
of  new-born  children  by  smothering  under  bed- 
clothes, non-removal  of  maternal  envelopes,  or 
overlying,  may  happen  from  carelessness  as  well 
as  from  intent.  See  Overlying. 

Homicidal  suffocation  is  resorted  to  chiefly  in 
infants,  or  in  the  case  of  persons  feeble  and 
infirm,  or  rendered  powerless  or  insensible  by 
intoxication  or  narcotics.  Closure  of  the  mouth 
and  nostrils  by  the  hands,  or  obstruction  of  the 
mouth  and  nostrils. by  a pillow,  mattress,  or  the 
like,  perhaps  combined  with  pressure  on  the 
chest,  is  the  method  usually  adopted.  Formerly 
suffocation  by  mechanical  pressure  on  the  chest 
was  a judicial  punishment — the  peine  forte  et 
dure. 

Symptoms  and  Signs. — The  mode  of  death, 
and  the  general  post-mortem  indications  are  those 
of  asphyxia  {see  Asphyxia).  The  special  indi- 
cations of  suffocation,  and  the  way  in  which  it 
has  been  brought  about,  may  be  evident  from  the 
place  where  the  body  is  found,  and  its  surround- 
ings ; or  foreign  bodies,  or  disease  obstructing 
the  air-passages  or  respiratory  mechanism,  may 
be  clearly  evident  on  post-mortem  dissection ; 
or  there  may  be  marks  of  violence  and  indica- 
tions of  pressure  on  the  chest,  flattening  of  the 
nose,  &c.,  pointing  to  homicidal  violence.  The 
absence  of  marks  of  constriction  of  the  neck 
excludes  strangulation  and  hanging. 

But  in  the  absence  of  all  such  indications  as 
have  been  enumerated  above — and  they  may  all 
be  absent,  especially  in  cases  of  infanticide— the 
question  is  whether  any  trustworthy  conclusion 
can  be  formed  as  to  asphyxia  by  suffocation. 

The  condition  of  the  lungs  is  of  especial  im- 
portance in  this  relation.  The  lungs  may  1? 


155S  SUFFOCATION, 

congested,  or  pale,  or  congested  only  posteriorly; 
but  the  surface  is  often  uneven,  owing  to  an  em- 
physematous condition  of  some  of  tie  superficial 
air-cells;  and  in  particular  the  lung  looks  as  if  it 
had  been  sprinkled  with  minute  drops  of  a dark 
purple  fluid.  These  spots,  not  much  larger  than 
a pin’s  head,  are  known  as  ‘ Tardieu’s  spots,’ 
and  are  due  to  minute  capillary  extravasations 
under  the  pleura.  They  are  not,  however,  con- 
fined to  the  surface  of  the  lungs,  but  are  found 
also  in  considerable  numbers  on  the  thymus 
gland,  the  base  of  the  great  vessels,  under  the 
parietal  pleura,  and  also  under  the  pericranium. 
Tardieu,  who  first  called  special  attention  to 
these  spots,  considered  them  absolutely  diagnostic 
of  death  by  suffocation,  as  distinguished  from 
other  modes  of  asphyxia.  But  numerous  other 
observations  have  shown  that  this  cannot  be 
accepted  as  correct,  inasmuch  as  similar  ex- 
travasations have  been  found  in  cases  of  hanging, 
strangulation,  drowning,  and  deaths  from  cere- 
bral injuries.  It  seems,  however,  fairly  well  es- 
tablished that  they  occur  most  frequently,  and 
in  largest  number,  in  suffocation,  especially  in 
infants.  Their  formation  depends  on  excessive 
vascular  tension  during  the  asphyxiating  process. 
Similar  spots  have  been  found  in  the  lungs  of 
still-born  foetuses,  conditioned  by  obstruction  of 
the  placental  circulation ; and  in  the  lungs  of  new- 
born children  perishing  from  other  causes,  extra- 
vasations of  a like  nature  have  been  observed. 
It  would,  therefore,  be  unsafe  to  rely  abso- 
lutely on  Tardieu’s  spots  as  indications  of  suffo- 
cation, though,  in  the  absence  of  other  causes 
of  death,  and  in  presence  of  these  spots  in  large 
uumbers  and  in  clusters,  the  opinion  of  death 
by  suffocation  would  be  fairly  justified. 

Treatment. — The  treatment  of  impending 
suffocation  is  that  of  asphyxia.  Sec  Artificial 
Respiration  ; Asphyxia  ; and  Resuscitation. 

D.  Ferrier. 

SUFFOCATIVE  BREAST-PANG.— A 

synonym  for  angina  pectoris.  See  Angina  Pec- 
toris. 

SUFFOCATIVE  CATARRH.— A sy- 
nonym for  asthma.  See  Asthma. 

SUFFUSION  (suffimdo,  I pour  down). — The 
process  or  the  result  of  the  unnatural  pouring 
out  of  a fluid  into  the  tissues  ; closely  analogous  to 
effusion  and  extravasation.  See  Extravasation. 

SUGGILLATION  (suggilo,  I make  black 
by  beating). — The  appearance  produced  by  ex- 
travasation or  ecchymosis  of  blood.  The  term 
is  limited  by  some  authorities  to  the  appearance 
of  livid  spots  on  the  body  after  death. 

SUICIDAL  INSANITY.  Sec  Insanity, 

Varieties  of — Impulsive  insanity,  and  Melan- 
cholia. 

SULPHUR  WATERS.  See  Mineral 
Waters. 

SUNSTROKE. — Synon. : Insolation;  Heat- 
Btroke ; Fr.  Coup  de  Soleil ; Ger.  Scnnenstich. 

Definition. — Certain  pathological  conditions 
resulting  from  exposure  to  solar  or  artificial 
heat. 

Thr^e  well-marked  varieties  of  sunstroke  are 
recognised,  namely  : — 1.  Exhaustion  and  failure 


SUNSTROKE. 

of  the  heart’s  action  in  syncope  ; 2.  A condition 
like  shock,  in  which  the  nerve-centres,  and  espe- 
cially the  respiratory , are  affected,  causing  rapid 
failure  of  the  respiration  and  circulation  ; and  3. 
Intense  pyrexia,  due  to  vaso-motor  paralysis,  and 
to  the  nerve-centres  being  over-stimulated  and 
then  exhausted  by  the  action  of  heat  on  the  body 
generally. 

./Etiology  and  Pathology. — These  morbid 
conditions,  being  due  to  heat  alone,  are  not  pe- 
culiar to  any  country  or  climate,  and  are  liable 
to  occur  wherever  persons  are  exposed  under 
any  circumstances  to  great  heat,  whether  solar 
or  artificial.  Soldiers  marching  or  fighting, 
when  oppressed  by  weight  of  clothing  and  ac- 
coutrements, are  apt-to  suffer  either  from  simple 
heat-exhaustion,  or  that  form  of  insolation  which 
results  from  direct  action  of  the  sun  oil  the 
head  and  neck.  This  is  common  enough  in 
India  during  the  hot  season,  in  other  tropical 
countries,  and  in  America;  and  is  not  unknown 
in  Europe  or  even  in  England,  during  the  heat 
of  summer.  AVorkmen,  artificers,  and  stokers, 
and  other  persons  in  heated  rooms,  hospitals, 
barracks,  tents,  and  even  ships,  especially  in 
hot  climates,  are  liable  to  suffer  from  heat-ex- 
haustion, which  may  pass  into  the  dangerous 
condition  of  fever  or  insolatio. 

But  the  most  frequent  cases  are  those  which 
come  on  in  houses,  barracks,  tents,  ships,  by 
night  or  in  the  day,  away  from  the  direct  solar 
rays.  A form  of  disease  sometimes  described 
as  ‘ ardent  fever  ’ in  India,  is  this  condition 
supervening  on  the  ordinary  phenomena  of  ephe- 
meral fever.  It  seems  pretty  well  understood 
that  heat  alone  is  the  effective  cause  of  the 
so-called  sunstroke.  Malarial  and  certain  hy- 
grometric  or  barometric  states  of  the  atmosphere 
have  no  special  influence,  beyond  that  which 
they  may  exert  on  the  general  vigour  of  the  con- 
stitution, or  in  rendering  a person  more  or  less 
susceptible  to  heat,  and  so  far  predisposing  him 
to  suffer  from  it. 

A dry  air,  such  as  that  of  North  India,  with 
hot  winds,  is  much  better  tolerated  at  a high 
temperature,  than  the  damp  atmosphere  of  Bengal 
at  a much  lower  one ; for  the  dry  hot  air  favours 
evaporation,  and  thus  keeps  the  body  cool, 
whilst  in  the  damp,  heavy  atmosphere  the 
natural  cooling  function  is  almost  in  abeyance. 
Vigorous,  healthy  persons  of  moderately  spare 
frame,  possessing  sound  viscera,  and  leading 
temperate  and  regular  lives,  can  tolerate  a great 
amount  of  heat,  in  an  otherwise  pure  atmo- 
sphere, and  are  much  less  liable  to  suffer  from  it 
than  those  in  whom  these  conditions  do  not 
exist.  Acclimatisation  has  also  considerable 
influence  in  conferring  toleration.  New  arrivals 
are  more  prone  to  suffer  than  those  who  have 
become  accustomed  to  the  climate.  It  is  well 
known  that  the  native  can  bear  an  amount  of 
sun  on  his  shorn  head,  neck,  and  half-naked  body 
with  indifference  if  not  pleasure,  that  would  very 
soon  prostrate  a European.  But  to  a tempe- 
rature of  the  air  rising  above  a certain  standard, 
all  succumb  : and  the  natives  of  India  suffer  like 
others,  and  die  in  numbers  every  year  from  loo- 
mama  or  ‘ hot  wind  stroke.’ 

The  exact  amount  and  duration  of  tolera- 
tion of  a high  temperature  depend  to  a great 


SUNSTROKE. 


extent,  therefore,  on  the  vigour  of  constitution 
and  the  present  state  of  health.  The  natural 
refrigerating  powers  of  the  body,  when  in  health, 
are  such  as  to  enable  men  to  support  very  high 
temperatures,  much  above  that  of  the  normal 
state  of  the  body.  Thus  in  the  hot  dry  winds 
no  inconvenience  beyond  discomfort  is  felt,  so 
long  as  transpiration  and  perspiration  are  free, 
which  cool  down  the  body,  enabling  it  to  resist 
the  great  heat.  It  is  obvious  that  in  this  there 
is  a great  expenditure  of  force,  and  when  it 
fails  suffering  soon  ensues.  Disordered  health, 
dissipation,  over-fatigue,  anything  in  fact  that 
depresses  nerve-power,  reduces  the  normal 
physiological  capacity,  and  consequently  renders 
a man  more  liable  to  succumb. 

Anatomical  Charactebs. — In  cases  where 
death  has  taken  plate  suddenly,  as  from  shock , 
there  is  no  very  remarkable  appearance.  The 
heart  may  be  found  firmly  contracted,  but  not 
always  so — it  may  be  flaccid.  The  lungs  and  the 
brain  and  its  membranes  may  be  found  some- 
what congested,  but  not  invariably.  As  in  cases 
of  shock,  the  venous  trunks — specially  those  of 
the  abdomen  and  the  right  side  of  the  heart,  may 
be  found  too  full  of  blood,  and  the  pulmonary 
vessels  may  be  over-loaded  with  blood.  The 
blood  itself  is  dark  and  grumous,  and  is  found 
effused  in  patches  of  ecchymoses,  and  indeed 
rendering  the  body  more  or  less  livid ; the  coagu- 
lability of  the  blood  is  also  impared  and  it  is 
wanting  in  oxygen. 

In  death  from  ordinary  cases  of  thermic  fever  the 
lungs  and  pulmonary  system  are  often  deeply  con- 
gested; the  heart  is  firmly  contracted,  from  coagu- 
lation of  myosin;  the  whole  venous  system  is  en- 
gorged; and  the  body  even  before  death  is  marked 
by  petechial  patches,  or  extensive  ecchymoses  of 
a livid  appearance.  The  blood  is  generally  more 
fluid  and  grumous  than  natural  ; its  coagula- 
bility is  impaired ; and  it  is  acid  in  reaction.  The 
globules,  though  generally  presenting  no  abnor- 
mal change,  are  somewhat  crenated,  and  have 
less  tendency  to  form  rouleaux  than  natural;  and 
the  quantity  of  oxygen  is  much  diminished.  The 
body  for  some  time  after  death  retains  a high 
temperature  ; when  first  opened  the  viscera  feel 
pungently  hot,  and  the  incisions  drip  dark  blood. 
Rigor  mortis  comes  on  very  rapidly,  from  early 
coagulation  of  myosin. 

The  brain  and  membranes  may  be  found  con- 
gested, and  in  some  cases  there  may  be  evidence 
of  meningitis.  Serous  effusions  into  the  ven- 
tricles, cr  haemorrhage  into  the  brain-substance, 
may  have  occurred,  and  are  not  improbable  in 
the  congested  condition  sometimes  existing  in 
the  head;  but  the  cause  of  death  is  asphyxia,  not 
apoplexy,  and  the  most  important  changes  are 
found  in  connection  with  the  thoracic  viscera. 

Symptoms — (1)  Syncopal  form. — Synox.  : 
Heat-exhaustion. — Simple  exhaustion  and  syn- 
cope may  occur  under  great  fatigue  or  over- 
exertion, or  depression  from  any  cause,  during 
exposure  to  a high  temperature.  There  is  de- 
pression of  nerve-force,  and  prostration  of  mus- 
cular power ; the  skin  is  pale,  cold,  and  moist ; 
and  the  pulse  is  quick  and  feeble.  Death  may 
occur  rapidly  in  the  state  of  collapsefrom  failure 
of  the  heart.  Complete  recovery  is  frequent. 

(2)  Asphyxial  form. — Synox.  : Sunstroke 


1559 

proper. — Asphyxia  and  apncea  may  come  on 
very  rapidly,  after  certain  premonitory  symptoms 
of  depression  and  weakness,  though  occasionally 
without  prodromata,  during  exposure,  especially 
of  the  head  and  spine,  to  the  direct  rays  of 
a powerful  sun,  when  the  atmosphere  is  much 
heated,  and  the  nervous  energy  has  been  de- 
pressed by  over-fatigue,  dissipation,  or  ill- 
ness. The  brain  and  nerve-centres,  especially 
the  respiratory,  are  overwhelmed  by  the  sudden 
elevation  of  temperature ; and  respiration  and 
circulation  fail,  the  failure  of  the  latter  being 
probably  due  to  the  inhibitory  influence  of 
the  vagus.  When  death  takes  place,  as  it  does 
sometimes,  very  suddenly,  during  great  excite- 
ment or  exertion,  it  has  been  attributed  to  rapid 
ante-mortem,  coagulation  of  the  cardiac  myosin. 
This,  however,  though  it  may  occur  occasionally, 
is  generally  a post-mortem  change,  the  heart's 
action  being  brought  to  a close  by  the  heat ; in 
the  same  manner  as  it  has  been  shown  by 
Claude  Bernard  and  Lauder  Brunton  that  the 
effect  of  high  temperature  on  animals  is  first  to 
accelerate  and  finally  to  stop  the  heart,  and  espe- 
cially the  ventricles,  in  a state  of  contraction. 
Recovery  is  frequently  complete,  but  sometimes 
tedious,  and  in  many  cases  imperfect,  ending  in 
serious  impairment  of  health  or  intellect,  indica- 
tive of  structural  changes  caused  in  the  nerve- 
centres.  The  symptoms  of  this  form  of  insolation, 
the  real  coup  de  soleil,  are  those  of  sudden  and 
violent  injury  to  the  nerve-centres — unconscious- 
ness and  cold  skin,  feeble  pulse,  all  the  symp- 
toms of  depression  ; death  resulting  from  rapid 
failure  of  the  respiration  and  circulation.  If 
not  fatal,  reaction  may  result  in  a variety  of 
conditions  indicative  of  the  injury  done  to  the 
cerebro-spinal  system. 

(3)  Hyperpyrexial  form. — Synox.  ; Heat- 
fever. — An  intense  state  of  fever,  the  result  of  the 
i nfluence  of  heat  on  the  nerve-centres,  and  through 
them  on  the  vaso-motor  nerves,  and  of  the  heat- 
ing of  the  body  generally,  by  the  direct  action 
of  either  artificial  or  solar  heat,  may  occur,  quite 
independently  of  the  immediate  operation  of  the 
sun's  rays.  It  comes  on  as  frequently  at  night, 
or  in  the  shade,  as  in  the  day  or  in  the  sun- 
shine, especially  in  persons  who  are  exhausted 
by  fatigue,  overcrowding,  depression  from  any 
cause,  such  as  dissipation,  want  of  rest,  present 
or  recent  illness,  and  notably  when  the  atmo- 
sphere is  impure  from  overcrowding  or  want  of 
cubic  space. 

The  temperature  of  the  body  rises  to  108’, 
110°  Fahr.,  or  higher.  The  brain,  medulla,  and 
cord,  the  nerve-centres  generally,  and  especially 
the  respiratory,  suffer  from  over-stimulation,  fol- 
lowed by  exhaustion.  Respiration  and  circula- 
tion fail ; there  is  dyspnoea,  with  hurried,  gasping 
breathing ; great  restlessness  ; thirst ; fever ; fre- 
quent micturition;  and  a pungent  burning  heat 
of  skin,  which  is  sometimes  dry,  sometimes 
moist.  The  pulse  varies  ; in  some  it  is  full  and 
laboured,  in  others  quick  and  jerking.  The  face, 
head,  and  neck  are  congested  to  lividity,  and 
the  carotid  pulsations  are  visible.  The  pupils, 
contracted  at  first,  may  dilate  widely  before 
death.  Delirious  convulsions,  frequently  epi- 
leptiform in  character,  coma,  relaxation  of  the 
sphincters,  and  suppression  of  urine  come  on. 


SUNSTROKE. 


1560 

and  are  frequently  the  precursors  of  death,  which 
is  due  to  asphyxia.  Recovery  not  unfrequently 
partially  occurs,  to  be  followed  by  relapse  and 
death ; or  secondary  consequences,  the  result  of 
over  - heating,  end  in  meningitis  or  cerebral 
changes,  which  may  destroy  life  or  intellect  at 
a later  period,  or  permanently  compromise  the 
whole  health  or  that  of  some  important  function. 

The  premonitory  symptoms  of  this  form  of 
insolation  often  manifest  themselves  for  some 
hours,  and  it  may  be  days,  before  they  culmi- 
nate in  the  dangerous  condition  just  described. 
These  premonitory  symptoms  are  general  ma- 
laise ; disordered  alvine  or  other  secretions ; 
profuse  and  frequent  micturition ; restlessness  ; 
sleeplessness,  and  apprehension  of  impending 
evil ; hurried  and  shallow  breathing ; prmcordial 
anxiety ; giddiness  and  headache  ; occasionally 
nausea  or  vomiting ; thirst  and  anorexia  ; and 
feverishness,  which  soon  amounts  to  a pungent 
heat  of  skin  with  high  temperature.  These  symp- 
toms vary  considerably,  but  they  point  to  a pro- 
foundly disturbed  state  of  the  cerebro-spinal 
nerve-centres,  and  to  pathological  changes  in  the 
organs  or  structures  whose  functions  have  been 
so  gravely  disturbed.  Death  results  from  as- 
phyxia and  apneea.  Recovery  is  often  incom- 
plete ; or  is  followed  by  permanent  impairment 
of  health,  and  generally  by  intolerance  of  heat 
and  exposure  to  the  sun. 

Terminations. — The  mortality  from  sunstroke 
is  about  45  to  50  per  cent. ; but  of  those  who 
recover  many  are  permanently  injured,  and  re- 
main invalids  for  the  remainder  of  life,  which  is 
often  shortened  by  the  changes  induced.  There 
may  be  some  weakness,  due  to  obscure  structural 
change  in  the  cerebrum,  or  to  a chronic  form  of 
meningitis  which  affects  the  sufferer  in  various 
degrees  of  intensity ; or  epilepsy,  impairment  of 
memory,  great  nervous  irritability,  headache, 
insanity,  partial  paraplegia,  partial  or  complete 
blindness,  and  extreme  intolerance  of  heat — es- 
pecially of  the  sun’s  heat,  rendering  the  person 
utterly  incapable  of  serving  or  living  in  a hot 
climate,  or  of  enduring  exposure  to  the  sun.  Or 
it  may  gradually  end  in  complete  fatuity,  insan- 
ity, or  meningitis — which  accounts  for  the  in- 
tense cephalic  pain ; or,  in  a lesser  degree,  in 
disordered  innervation  and  derangement  of  the 
functions  generally,  thus  seriously  compromising 
the  general  health. 

Treatment. — (1)  In  cases  of  simple  exhaustion 
simple  treatment  is  all  that  is  needed.  Re- 
moval to  a cooler  locality,  the  cold  douche  (but 
not  too  much  prolonged),  or  the  administration 
of  stimulants  may  be  beneficial.  Tight  or  op- 
pressive clothing  should  be  removed,  and  the 
patient  treated  as  in  syncope  from  other  causes. 
See  Resuscitation. 

Rest  and  freedom  from  exposure  to  over-exer- 
tion, fatigue,  or  great  heat  should  afterwards  be 
enjoined. 

(2)  In  that  form  of  sunstroke  where  the  person 
is  struck  doion  suddenly  by  a hot  sun,  the  patient 
should  be  removed  into  the  shade.  Here  a 
douche  of  cold  water  must  be  allowed  to  fall  in 
a stream  on  the  head  and  body,  from  a pump  (or 
as  in  India  from  the  mussuek,  or  other  simi- 
lar contrivance),  the  object  being  twofold — to  re- 
duce the  temperature  of  the  over-heated  centres, 


and  to  rouse  them  into  action.  During  the  as- 
sault on  the  White  House  picquct  in  the  last 
Burmese  war,  numbers  of  men  were  struck  down 
by  the  direct  action  of  the  sun  during  the  month 
of  April.  They  were  laid  out  perfectly  uncon- 
scious, in  their  red  coats  and  stocks  (worn  in 
1852),  but  were  recovered  by  the  cold  douche 
freely  applied  by  the  mussuek  over  the  head  and 
body.  In  some  cases  flagellation  with  a broom 
was  added ; and  all  recovered  with  the  exception 
of  two  cases,  both  of  which  had  been  bled  on  the 
spot  where  they  fell.  Mustard  plasters  and 
purgative  cnemata  may  also  be  useful. 

If  recovery  be  imperfect,  and  followed  by  any 
indication  of  injury  to  the  nerve-centres,  or  by 
the  supervention  of  meningitis,  other  treatment 
may  be  necessary,  according  to  the  indications. 
Much  exposure  to  the  sun  should  be  carefully 
guarded  against ; and  unless  recovery  be  com- 
plete and  rapid,  the  sufferer  should  be  removed 
to  a cooler  climate,  the  most  perfect  rest  and 
tranquillity  of  mind  and  body  enjoined,  and  the 
greatest  care  observed  with  regard  to  extreme 
moderation  in  the  use  of  stimulants. 

(3)  In  the  cases  of  thermic  fever,  heat  being 
the  essential  cause  of  the  disease,  the  object  is  to 
reduce  the  temperature  of  the  body  as  quickly  as 
possible,  and  before  tissue-changes  have  resulted. 
As  the  hyperpyrexia  is  due  not  only  to  the  direct 
operation  of  heat,  but  to  fever  set  up,  remedies 
such  as  may  influence  this  disturbed  condition 
have  been  suggested.  The  results  have  appeared 
in  some  cases  to  justify  the  theory,  and  the  hypo- 
dermic injection  of  morphia  or  quinine  has  been 
considered  to  produce  good  results,  by  its  influ- 
ence on  the  vaso-motor  nerves,  and  its  power  in 
retarding  tissue-change. 

Bleeding  has  now  happily  been  almost  aban- 
doned. The  congested  livid  surface,  coma,  and 
stertor,  which  formerly  suggested  it,  are  not  now 
so  treated.  There  are  cases  in  which  it  may  still 
be  practised  with  advantage ; but  they  are  the 
exception  and  not  the  rule.  In  cases  where 
venesection  has  appeared  first  to  give  relief  and 
mitigate  the  symptoms,  the  improvement  has 
been  often  transient,  and  been  followed  by  re- 
lapse into  a more  dangerous  condition,  which 
has  terminated  fatally.  At  the  same  time  no 
absolute  rule  can  be  laid  down  in  this  disease 
with  reference  to  the  abstraction  of  blood ; and 
it  is  quite  possible  that  greater  immediate  dan- 
ger to  life  may  exist  in  an  over-distended  right 
heart  than  in  the  loss  of  an  amount  of  blood 
which  might  have  tided  the  patient  over  that 
state  of  peril.  Each  ease  must  in  this  respect  be 
treated  on  its  merits.  The  treatment  generally 
consists  in  the  judicious  use  of  cold,  either  by 
affusion  or  by  the  application  of  ice  to  the  sur- 
face ; the  reduction  of  temperature  being  watched 
with  a thermometer  in  the  axilla,  mouth,  or 
rectum. 

Care  should  be  taken  not  to  continue  the  cold 
application  too  long,  as  danger  arises  from  de- 
pressing the  temperature  below  the  normal 
standard.  The  bowels  should  be  relieved ; and 
blisters  may  be  applied  to  the  calvaria  and  neck. 

In  the  epileptiform  convulsions  that  occur  so 
frequently,  the  inhalation  of  chloroform  or  of 
ether  may  be  of  benefit,  but  their  administration 
must  be  carefully  watched.  The  earliest  aud 


SUNSTROKE. 

most  severe  symptoms  having  subsided,  the 
febrile  condition  that  follows  is  treated  on  ordi- 
nary principles — salines  and  aperients  being 
given,  but  not  to  the  extent  of  depressing  the 
patient.  The  diet  must  be  carefully  regulated, 
and  be  of  the  blandest  and  most  nourishing 
nature. 

As  improvement  progresses,  other  symptoms 
may  supervene,  indicative  of  intra-cranial  mis- 
chief. Where  they  are  indicative  of  menin- 
gitis, iodide  of  potassium  and  counter-irritants 
may  be  used  with  advantage.  Removal  to  a 
cooler  climate  is  essential.  As  a general  rule,  it 
is  desirable  that  the  sufferer  should  not,  for 
a long  period  at  least,  return  to  a hot  or  tropical 
climate;  and  he  should  be  guarded  against  all 
undue  exposure  to  heat,  work,  or  mental  anxiety 
of  any  kind. 

The  sequels  of  sunstroke  are  frequently  from 
such  causes  most  distressing,  rendering  the  pa- 
tient a source  of  suffering  to  himself  and  of 
anxiety  to  his  friends. 

The  less  severe  symptoms — those,  probably, 
indicative  of  the  slighter  forms  of  meningitis,  or 
of  abnormal  change  of  the  brain  or  nervous 
system — occasionally  pass  away  after  protracted 
residence  in  a cool  climate  ; but  they  not  unfre- 
quently  also  cause  much  suffering,  and  shorten 
life.  As  they  point  to  permanently  disturbed,  if 
not  structurally  injured,  cerebro-spinal  centres, 
the  treatment  required  is  as  varied  as  the  symp- 
toms presented.  Joseph  Faybeb. 

SUPPOSITORY  ( suppono , I place  below). 
Synon.  : Fr.  Suppositoire;  Ger.  Stuhleapfchen. — 
A suppository  is  a solid  mass,  which  is  intro- 
duced through  the  anus  into  the  rectum  for 
certain  therapeutic  purposes.  The  material  of 
which  it  is  made  should  be  capable  either  of 
being  dissolved,  or  of  melting  at  the  tempera- 
ture to  which  it  is  exposed  in  the  rectum.  Sup- 
positories are  simple  or  medicated.  The  former 
may  be  exemplified  by  pieces  of  soap  or  tallow- 
candle,  which  are  popularly  used  as  supposi- 
tories. The  British  Pharmacopoeia  recognises 
seven  medicated  suppositories ; and  they  are  cast 
into  moulds  of  a conical  or  pastille  shape,  so  as 
to  facilitate  their  introduction  into  the  bowel. 
It  may  be  well  to  give  a list  of  these  officinal  pre- 
parations, according  to  the  following  plan,  with 
the  proportions  of  their  active  ingredients : — 

1.  Suppositories  made  with  white  wax,  oil  of 
theobroma,  and  benzoated  lard,  each  weighing 
15  grains: — (1)  S.  Acidi  Tannici,  3 grains  ; (2)  S. 
flydrargvri,  5 grains  of  mercurial  ointment; 
f3)  S.  Morphiae,  jr  grain  of  hydrochlorate  of 
morphia ; (4)  S.  Plumbi,  3 grains  of  acetate  of 
lead  and  1 grain  of  opium. 

2.  Suppositories  made  with  glycerine  of  starch, 
curd  soap,  and  starch: — (1)  S.  Acidi  Carbolici 
cum  Sapone,  1 grain  of  carbolic  acid ; (2)  S. 
Acidi  Tannici  cum  Sapone,  3 grains  of  tannic 
acid;  (3)  S.  Morphiae  cum  Sapone,  1 grain  of 
hydrochlorate  of  morphia. 

Besides  these  officinal  suppositories,  others  are 
often  prepared  and  used,  containing  belladonna 
and  other  agents  ; and  the  practitioner  may  em- 
ploy many  drugs  in  this  way  with  advantage, 
according  to  his  own  judgment. 

Application. — A suppository  must  be  intro- 


SUPRA-RENAL  CAPSULES.  1561 

duced  well  into  the  rectum,  beyond  the  sphincter 
ani.  At  first  this  should  be  done  by  the  prac- 
titioner, or  by  a competent  nurse ; but  subse- 
quently many  patients  learn  to  use  suppositories 
themselves  without  any  difficulty.  The  supposi- 
tory should  be  oiled  and  passed  in  gradually 
and  gently,  without  any  undue  force.  It  may  be 
necessary  to  keep  the  finger  applied  for  a mo- 
ment, until  the  tendency  to  expulsive  action  on 
the  part  of  the  rectum  has  subsided. 

Uses. — A suppository  may  be  used  for  the 
following  purposes  : — (1)  As  a mere  aperient,  by 
exciting  the  expulsive  action  of  the  bowel  through 
local  irritation,  which  also  has  a reflex  effect 
upon  the  intestine  above.  (2)  On  the  other  hand, 
to  subdue  excessive  action  of  the  bowel,  and 
thus  check  diarrhoea.  (3)  To  bring  medicinal 
agents  in  contact  with  the  rectum  in  a suitable 
form,  in  order  to  affect  some  local  disease.  As- 
tringents may  be  thus  used.  (4)  To  influence 
adjacent  organs,  the  active  ingredients  of  the 
suppository  being  absorbed.  For  instance,  a 
morphia  suppository  will  often  produce  a marked 
effect  upon  the  bladder  and  generative  organs. 
(5)  To  produce  the  general  effects  of  a drug  upon 
the  system.  This  of  course  occurs  only  after 
absorption,  and  may  be  exemplified  by  the  effects 
of  morphia  or  mercury. 

Fbedeeick  T.  Robebts. 

SUPPRESSION. — The  complete  stoppage 
of  a natural  secretion  or  excretion,  such  as  the 
urine  ; or  of  a normal  discharge,  as  of  the  menses. 
The  word  is  used  in  contradistinction  to  reten- 
tion, which  signifies  that  these  fluids  merely  re- 
main in  the  body  unexpelled. 

SUPPURATION. — The  formation  of  pus. 
See  Abscess  ; and  Inflammation. 

SUPRA-RENAi  CAPSULES,  Diseases 

of. — Synon.  : Fr.  Maladies  des  Capsules  sur- 
renales  ; Ger.  Krankheiten  der  Nebennieren. 

Of  the  morbid  conditions  of  the  supra-renal 
bodies  by  far  the  most  important  is  that  con- 
nected with  Addison’s  disease,  which  is  described 
separately.  See  Addison’s  Disease. 

Other  morbid  changes  producing  neither  pig- 
mentation nor  asthenia,  belong  to  two  categories, 
namely  (1)  those  beginning  within ; and  (2)  those 
originating  without  the  supra-renal  bodies.  Some 
of  the  latter  may,  however,  give  rise  to  the  symp- 
toms of  true  Addison's  disease,  as  when  the  mis- 
chief seems  to  begin  in  caries  of  the  spine,  and 
ends  in  the  characteristic  form  of  supra-renal 
changes  commonly  associated  with  that  malady. 
The  bodies  may  be  otherwise  extensively  dis- 
eased, and  yet  no  special  pigmentation  and  no 
special  asthenia  make  their  appearance.  Thus 
there  may  be  the  usual  anomalies  of  develop- 
ment, amounting  even  to  what  has  been  called 
total  absence,  but  this  probably  depended  on 
defective  examination.  Certainly  the  bodies  may 
be  hypertrophied.  Both  the  organs  themselves 
and  their  coverings  are  liable  to  inflammation, 
especially  if  the  structures  connected  with  the 
kidney  be  likewise  attacked,  and  the  process 
spread  from  them.  They  may  also  be  the  seat 
of  various  forms  of  degeneration  , but  here  again 
we  are  on  doubtful  ground,  for  the  earliest  change 
in  the  bodies  in  Addison’s  disease  is  what  w ns 


1562  SUPRA-RENAL  CAPSULES, 
invariably  called  by  the  older  pathologists  lar- 
daceous,  whilst  the  secondary  chaDge  is  a form 
of  fatty  degeneration.  With  regard  to  tubercle , 
some  authorities  would  have  the  anatomical 
change  in  Addison’s  disease  to  be  of  this  nature. 
Cysts  sometimes  occur,  but  the  exact  mode  of 
their  origin  is  not  quite  clear.  They  may  be 
compensatory,  like  one  variety  of  emphysema, 
or  they  may  be  destructive. 

We  are  on  surer  ground  when  we  speak  of 
luemorrhage  and  malignant  disease.  One  case  of 
what  may  fairly  be  described  as  thrombosis  is 
reported  by  Klebs  from  Lucke’s  clinique.  There 
can  be  no  doubt  about  the  not  unfrequent  occur- 
rence of  haemorrhage,  however  arising.  Neither  is 
there  any  question  as  to  the  existence  of  malig- 
nant disease  in  certain  cases,  sarcoma  being  more 
common  than  carcinoma;  but  in  most  cases  these 
do  not  originate  within,  but  without,  the  supra- 
renal bodies.  Asa  rule,  all  these  changes  give 
rise  to  no  characteristic  symptoms  during  life  ; 
and  are  eitheraccidentally  discovered  after  death, 
or  by  careful  clinical  search.  The  important 
point  to  bear  in  mind  is  that  not  one  of  them 
gives  rise  to  the  symptoms  of  Addison's  disease. 

Alexander  Silver. 

SURGICAL,  KIDNEY.  —Definition.  — 
This  term,  although  open  to  many  objections, 
may  be  conveniently  employed  to  group  together 
the  various  morbid  conditions  which  arise  in 
the  kidney  as  the  result  of  diseases  of  the  lower 
urinary  tract. 

Pathology. — Diseases  of  the  lower  urinary 
tract  react  on  the  kidney  in  three  ways : — (a)  by 
obstructing  the  passage  of  urine,  and  so  causing 
abnormal  tension  throughout  the  whole  urinary 
tract  above  the  obstruction  ; (5)  by  causing  re- 
peated disturbances  of  the  circulation  in  the 
kidney,  through  the  medium  of  the  nervous 
system ; ( c ) by  decomposition  of  the  secretions 
spreading  from  without  to  the  bladder,  and 
extending  to  the  pelvis  and  even  into  the  tubules 
of  the  kidney. 

(a)  Obstruction  to  the  free  passage  of  urine 
may  occur  in  the  ureters  from  congenital  mal- 
formation ; from  impaction  of  a calculus ; or  from 
pressure  of  a tumour  growing  in  the  neighbour- 
hood. It  may  occur  at  the  vesical  orifice  of  the 
ureter,  from  the  thickening  of  the  wall  of  the 
bladder  in  hypertrophy ; from  the  thickoning  and 
induration  of  the  submucous  tissue,  and  the 
swelling  of  the  mucous  membrane  in  chronic 
cystitis ; or  from  the  growth  of  villous  or  can- 
cerous tumours  round  the  orifice.  Obstruction 
of  such  a nature  as  to  cause  secondary  renal 
affection  also  occurs  in  any  disease  in  which  the 
bladder  is  unable  to  empty  itself,  and  is  conse- 
quently in  a permanent  state  of  greater  or  less 
distension,  as  in  hypertrophy  of  the  prostate  or 
atony  of  the  bladder.  Stricture  of  the  urethra 
and  stone  in  the  bladder  cause  obstruction  at 
the  vesical  orifices  of  the  ureters,  by  the  chronic 
cystitis  to  which  they  give  rise.  There  is  no 
reason  to  believe  that  the  valvular  orifices  of 
the  ureters  ever  become  incompetent,  so  as  to 
allow  of  regurgitation  from  the  bladder  to  the 
pelvis  of  the  kidney.  The  only  force  concerned 
in  producing  the  remarkable  degree  of  dilatation 
so  often  met  with  in  the  ureter  and  pelvis  of  the 


SURGICAL  KIDNEY. 

kidney  is  the  force  of  secretion.  The  abnormal 
tension  thus  produced  extends,  therefore,  equally 
from  the  point  of  obstruction  to  the  closed  ex- 
tremities of  the  urinary  tubules. 

( b ) Diseases  or  injuries  causing  irritation  of 
the  lower  urinary  tract,  especially  of  the  trigone 
of  the  bladder  and  the  prostatic,  membranous, 
and  bulbous  portions  of  the  urethra,  react  on 
the  kidney  in  a reflex  manner,  through  the 
medium  of  the  nervous  system.  The  effect  pro- 
duced is  a disturbance  of  the  renal  circulation, 
probably  a temporary  arterial  contraction  with 
anaemia,  followed  by  dilatation  with  hyperaemia. 
Such  disturbances  tend  to  aggravate  any  inflam- 
matory process  which  may  be  going  on  in  the 
kidney  as  the  result  of  other  sources  of  irrita- 
tion. If  the  kidney  be  already  much  diseased, 
the  circulation  may  become  completely  arrested 
by  choking  of  the  vessels  during  the  stage  of 
hyperaemia,  and  total  suppression  of  urine  may 
result,  terminating  in  some  cases  fatally.  The 
evidence  of  this  reflex  disturbance  of  the  renal 
circulation  is  derived  from  the  following  facts. 
1.  Many  cases  have  been  recorded  of  death  from 
total  suppression  of  urine  occurring  as  a conse- 
quence of  operations  involving  some  mechanical 
irritation  of  the  parts  above  mentioned.  In  such 
cases  the  kidney  has  always  been  found  in  tensely 
congested.  2.  It  is  a matter  of  common  surgical 
experience  that  operations  on  the  urinary  organs 
frequently  prove  fatal  by  inducing  acute  inflam- 
mation of  the  kidneys.  This  is  (as  will  be  pre- 
sently shown)  often  tho  result  of  the  introduction 
of  the  causes  of  decomposition  into  the  bladder, 
followed  by  extension  of  decomposition  to  the 
kidney.  But  cases  frequently  occur  in  which  tho 
patient  before  the  operation  was  suffering  from 
cystitis,  with  putrid  urine,  and  had  been  so  suf- 
fering for  some  time,  and  in  these  it  is  evident 
that  the  final  acute  attack  is  the  direct  result  of 
the  irritation  of  the  operative  procedure.  3.  By 
direct  observation  of  the  urine  passed  after  such 
an  operation  as  forcible  dilatation  of  a stricture, 
evidence  of  a disturbance  of  the  renal  circulation 
may  be  obtained.  In  tho  most  typical  cases  there 
is  temporary  suppression  of  urine,  probably  cor- 
responding to  a period  of  anaemia  of  the  kid- 
ney, with  contracted  vessels.  This  may  last  from 
one  to  three  hours.  It  is  followed  by  a gradual 
increase  in  the  quantity  of  urine,  which  now  fre- 
quently becomes  uniformly  tinged  with  blood, 
the  amount  of  blood  often  increasing  for  some 
hours,  and  then  slowly  diminishing.  This  blood 
cannot  be  supposed  to  flow  at  so  late  a period 
from  a lacerated  wound,  such  as  is  produced  by 
forcible  dilatation  ; it  is  uniformly  mixed  with 
the  urine,  and  free  from  clots.  The  presumption 
is,  therefore,  that  it  comes  from  the  kidney.  In 
most  cases  the  period  of  suppression  is  too  short 
to  be  noted,  and  in  others  an  immediate  increase 
in  the  flow  of  urine  has  been  observed.  The 
rigor  which  frequently  occurs  within  a few  hours 
of  an  operation  on  the  lower  urinary  tract  is,  in 
many  cases,  doubtless  due  to  this  disturbance  of 
the  renal  circulation. 

(c)  Tho  final  fatal  inflammation  of  the  kidney 
is,  in  most  cases,  due  to  extension  of  decomposi- 
tion of  the  urine  from  the  bladder  to  the  pelvis 
and  kidneys.  The  balance  of  evidence  is  now  so 
greatly  in  favour  of  the  view  that  decomposition 


SURGICAL  KIDNEY. 


»f  urine  is  due  in  all  eases  to  the  introduction  of 
microscopic  organisms  from  ■without,  that  it  may 
be  almost  looked  upon  as  definitely  proved.  These 
organisms  may  find  their  way  into  the  bladder, 
either  by  being  carried  thither  by  instruments 
introduced  by  the  surgeon,  or  by  spreading  in- 
wards by  multiplication  in  the  layer  of  ropy 
mucus  or  other  discharge  which  adheres  to  the 
walls  of  the  urethra  in  acute  inflammation  of 
the  bladder,  in  chronic  cystitis  accompanying 
stricture  or  stone,  in  gonorrhoea,  or  injury.  As 
no  regurgitation  takes  place  in  any  case  from  the 
bladder  to  the  ureters,  the  decomposition  may 
remain  long  limited  to  the  bladder,  but  when, 
from  the  other  sources  of  irritation,  a catarrhal 
condition  of  the  pelvis  of  the  kidney  is  induced, 
ropy  threads  of  mucus  come  to  lie  with  one  end 
in  the  ureter  and  the  other  in  the  foul  bladder, 
and  by  means  of  these  the  organisms  find  their 
way  into  the  ureter,  and  there  multiplying  may 
extend  far  into  the  kidney-substance.  In  such 
cases  the  microscope  frequently  shows  the  tubules 
of  the  pyramids  completely  plugged  with  micro- 
cocci. The  effeets  produced  by  the  extension  of 
putrefaction  to  the  kidney  will  be  described  with 
the  form  of  kidney  it  gives  rise  to. 

Anatomical  Chaeacters.  — There  are  four 
forms  of  renal  affection  which  may  result  from 
the  foregoing  sources  of  irritation. 

I.  Chronic  interstitial  infamination,  followed 
by  absorption  of  the  medullary  portion,  and  later 
on  by  stretching  and  thinning  of  the  cortex,  with- 
out pyelitis. — This  condition  is  the  uncomplicated 
effect  of  obstruction  to  the  free  flow  of  urine  and 
of  the  consequent  increased  urinary  pressure.  It 
is  most  frequently  met  with  in  cases  of  pressure 
on  the  ureter  from  without.  In  diseases  of  the 
bladder  and  urethra  it  is  almost  always  compli- 
cated by  an  acute  attack  of  interstitial  inflam- 
mation, which  is  the  immediate  cause  of  death, 
and  which  more  or  less  conceals  the  appear- 
ances about  to  be  described.  In  the  early  stage 
there  is  slight  dilatation  of  the  ureter  and 
pelvis  of  the  kidney.  The  kidney  itself  is  in- 
creased in  size ; the  capsule  separates  without 
difficulty,  but  may  leave  the  surface  somewhat 
wanting  in  its  natural  smoothness.  The  venous 
stars  on  the  surface  are  often  clearly  marked,  the 
cortical  substance  being  of  a pale  pinkish  white 
or  sometimes  yellowish  colour.  On  section  the 
cortex  is  found  to  be  wider  than  natural;  some- 
times considerably  so.  The  medullary  portion 
is  usually  pale,  like  the  cortex,  but  the  large 
veins  at  the  cortico-medullary  junction  are  often 
distended  with  blood.  The  kidney-substance  is 
tougher  than  natural.  The  Malpighian  bodies 
can  usually  be  clearly  seen,  sometimes  as  red 
dots.  Microscopic  examination  shows  an  over- 
growth of  the  interstitial  connective  tissue.  Be- 
tween the  tubules,  and  especially  around  the 
Malpighian  bodies,  are  crowds  of  small  round 
cells.  In  consequence  of  this  new  growth,  the 
kidney  is  somewhat  squeezed  within  its  capsule, 
and  as  soon  as  the  heart's  action  ceases  the 
smaller  vessels  empty  themselves.  Hence  the 
distended  condition  of  the  veins,  and  the  anaemic 
appearance  of  the  cortex.  The  epithelium  shows 
no  change.  The  next  stage  observed  is  com- 
mencing absorption  of  the  medullary  portion ; 
the  ureter,  pelvis,  and  calices  become  still  more 


1563 

distended;  the  papillae  aro  first  flattened,  and 
then  the  pyramids  become  hollowed  out.  This  is 
a process  of  pure  absorption,  there  being  no  ulcer- 
ation. The  cavity  formed  by  the  dilated  calyx, 
and  the  hollow  left  by  the  disappearance  of  the 
pyramid,  are  lined  by  a continuous  smooth  layer 
of  opaque  white  mucous  membrane.  In  the  final 
stages  the  cortex  in  its  turn  becomes  thinned  and 
stretched,  until  at  last  the  whole  kidney  may  be 
dilated  into  a large  sac,  one  side  of  which  is 
smooth,  being  formed  by  the  thickened  walls  of 
the  dilated  pelvis,  and  the  other  is  deeply  sac- 
culated, each  saeculus  corresponding  to  a lobe  of 
the  kidney.  On  this  side  the  wall  is  formed  of 
the  thinned  and  stretched  cortex,  sometimes  no 
thicker  than  a shilling,  to  which  the  capsule, 
now  thickened  and  opaque,  is  firmly  adherent. 
In  the  later  stages  the  microscope  shows  the 
same  abundant  small-cell  infiltration,  with  the 
development  of  a greater  or  less  amount  of 
fibroid  tissue.  The  Malpighian  bodies  show 
marked  changes.  The  capsules,  instead  of  being 
delicate  and  membranous  in  structure,  become 
greatly  thickened,  apparently  by  dense  fibroid 
tissue  formed  round  them  in  concentric  layers. 
As  this  change  progresses  the  vessels  may  be- 
come strangulated  and  finally  obliterated,  and 
the  corpuscle  then  shrivels,  and  comes  to  be 
represented  by  a circular  body  almost  homo- 
geneous in  the  centre,  but  marked  by  a few 
curved  lines  indicating  the  situation  of  the  ob- 
literated vascular  tufts.  Bound  this  centre  is 
a concentrically  laminated  layer,  formed  by  the 
thickened  capsule.  Even  in  the  most  advanced 
stages  the  epithelium  of  the  convoluted  tubules 
shows  remarkably  little  change  beyond  beirg 
somewhat  flattened. 

If  at  any  stage  obstruction  to  the  free  flow 
of  the  urine  be  removed  the  process  ceases.  The 
new  tissue  between  the  tubules  undergoes  de- 
velopment into  dense  fibroid  tissue,  the  process 
being  accompanied  by  great  contraction.  The 
kidney,  from  being  increased  in  size,  may  thus 
become  much  smaller  than  natural,  excessively 
tough  and  puckered,  and  irregular  in  form.  If 
the  distension  have  reached  the  most  extreme 
stage  before  the  primary  disease  is  relieved,  the 
kidney  may  come  to  be  represented  merely  by  a 
small  nodule  of  dense  fibroid  tissue. 

II.  Acute  diffuse  interstitial  nephritis  without 
suppuration. — In  this  variety  both  kidneys  are 
usually  affected.  The  kidney  is  increased  in 
size,  and  the  surrounding  fat  is  sometimes  cede- 
matous  and  adherent  to  the  capsule.  When  re- 
moved the  capsule  separates  without  difficulty, 
butoften  leaves  the  surface  coarse;  it  is  somewhat 
opaque,  and  often  marked  with  ramifying  vessels. 
The  surface  is  usually  of  a pale,  yellowish-white 
colour,  often  mottled  with  dark  red,  or  in  some 
cases  the  red  may  greatly  predominate.  The 
mottling  often  corresponds  to  the  bases  of  the 
lobules  of  the  gland,  some  of  which  are  paler 
than  others,  inconsequence  of  the  more  advanced 
condition  of  the  interstitial  inflammation.  On 
section  the  cortex  presents  the  same  colour  and 
mottled  appearance  as  the  surface,  and  is  evi- 
dently' swollen.  The  pyramids  may  be  pale,  but 
are  often  dark  red,  contrasting  strongly  with  the 
paler  cortex.  The  Malpighian  bodies  are  usually 
clearly  visible,  and  may  show  on  the  cut  surface 


SURGICAL  KIDNEY. 


1564 

as  red  dots.  The  consistence  cf  the  kidney- 
substance  is  unnaturally  soft,  unless  previous  to 
the  acute  attack  it  has  been  indurated  by  the 
chronic  process  first  described.  The  pelvis  may  be 
merely  dilated,  its  mucous  membrane  opaque, 
and  its  contents  free  from  decomposition,  but 
more  commonly  it  is  marked  by  ramifying  ves- 
sels, and  presents  evidence  of  chronic  congestion, 
in  pigmentation  and  thickening  with  induration. 
In  other  cases  it  is  intensely  injected,  and  some- 
times covered  with  a membranous  exudation 
mixed  with  phosphatic  deposit.  In  these  cases 
the  urine  and  mucus  it  contains  are  in  a state 
of  decomposition.  In  consequence  of  the  pallor 
of  the  kidney  sometimes  met  with  as  a result  of 
the  emptying  of  the  vessels  after  death,  this 
form  of  kidney  may,  without  the  microscope, 
be  confounded  with  the  large  white  or  the  fatty 
kidney. 

On  microscopic  examination  the  following 
conditions  are  found.  Between  the  tubules  is  a 
very  abundant  accumulation  of  small  round 
cells.  These  are  especially  abundant  round  the 
Malpighian  corpuscles.  So  far  it  is  merely  an 
intensification  of  the  condition  described  as  re- 
sulting from  increased  urinary  pressure.  The 
change  is  not  uniform;  every  field  of  the  micro- 
scope varies.  In  one  part  the  renal  structure 
may  appear  almost  normal,  and  close  by  the  new 
cells  may  be  heaped  up  to  such  an  extent  as 
nearly  to  conceal  the  tubules.  In  the  pyramidal 
portion  a similar  condition  is  met  with.  The  renal 
epithelium  throughout  is  slightly  more  cloudy 
than  natural,  and  somewhat  swollen,  but  the 
nuclei  of  the  cells  are  readily  to  be  seen  in  sec- 
tions prepared  in  the  ordinary  way.  The  adhe- 
sion of  the  epithelium  to  the  membrana  propria 
is  somewhat  lessened,  so  that  unless  consider- 
able care  be  taken  it  will  wash  out  in  preparing 
the  specimen.  Fibrinous  casts  may  be  seen  here 
and  there  in  the  tubules,  and  occasionally  small 
round  cells  resembling  those  outside  the  tubule 
may  be  seen  within  it.  Signs  of  previous  chronic 
change  are  often  met  with,  such  as  dilatation  of 
some  of  the  straight  tubules,  and  obliteration  of 
some  of  the  Malpighian  corpuscles. 

III.  Acute  interstitial  nephritis  with  scattered 
points  of  suppuration. — Suppuration  of  the  kidney, 
Suppurative  nephritis,  or,  when  accompanied 
hy  pyelitis,  Pyelo-nephritis  {Bayer);  TJroseptic 
kidney  {Dickinson) ; Parasitic  kidney  {Klebs). — 
This  form  of  surgical  kidney  is  by  far  the  most 
common.  It  is  the  usual  cause  of  death  in  fatal 
cases  of  disease  of  the  bladder  or  urethra,  in 
which  putrefaction  of  the  contents  of  the  blad- 
der has  occurred.  It  thus  comes  to  be  one  of 
the  most  common  fatal  complications  in  cases  of 
injury  or  disease  of  the  spinal  cord,  with  para- 
lysis of  the  bladder.  It  has  been  frequently  stated 
that  it  is  invariably  associated  with  putrid  urine 
in  the  pelvis  of  the  kidney  and  septic  pyelitis ; 
but  cases  are  undoubtedly7  occasionally  met  with 
in  which  the  condition  is  well-marked,  and  yet  the 
pelvis  is  free  from  inflammation,  and  its  contents 
are  healthy.  The  naked-eye  appearances  of 
acute  suppurative  nephritis  are  the  following. 
The  surrounding  fat  may  be  cedematous  and  un- 
naturally adherent  to  the  capsule.  The  whole 
kidney  is  considerably  swollen,  and  its  substance 
soft.  The  capsule  ia  opaque  and  thickened,  and 


marked  by  fine  ramiform  injection.  It  separatee 
easily,  but  tears  the  kidney-substance  in  so  doing. 
As  it  peels  off,  yellowish-white  spots,  surrounded 
by  a red  zone,  come  into  view.  Some  of  these 
are  minute  drops  of  pus  escaping  from  the  small 
abscesses  as  the  capsule  is  stripped  off,  others 
are  on  the  point  of  breaking  down  into  pus,  but 
are  still  solid.  Those  abscesses  are  grouped  to- 
gether in  areas  corresponding  to  the  bases  of  the 
Jobes  of  the  kidney.  If  the  veins  can  be  recog- 
nised, the  abscesses  will  often  be  seen  to  corre- 
spond to  the  points  at  which  the  interfascicular 
veins  appear  ou  the  surface.  On  section  the 
cortex  is  seen  to  present  much  the  same  appear- 
ance as  in  tho  last  form  of  kidney,  but  in  addi- 
tion yellowish  streaks  are  seen  passing  from  the 
points  of  suppuration  deeply  into  the  cortex,  and 
often  into  the  medullary  portion.  These  streaks 
correspond  to  the  course  of  the  interfascicular 
vessels.  They  differ  from  embolic  infarcts  in  their 
great  length  compared  to  their  breadth.  The 
pelvis  is  usually  in  a condition  of  most  intense 
inflammation,  and  the  mucous  membrane  is  often 
covered  with  a layer  of  exudation  mixed  with 
phosphates.  Its  contents,  composed  of  urine, 
blood,  and  mucus  in  a state  of  decomposition,  are 
excessively  foul.  Cases,  however,  do  occur  in 
which  a similar  condition  of  suppuration  in  the 
kidney  is  met  with  without  pyelitis. 

Occasionally  the  kidney  is  found  to  be  sur- 
rounded by  a large  abscess,  arising  from  a per- 
foration of  the  pelvis.  More  frequently  one  of 
the  superficial  abscesses  in  the  cortex  bursts 
beneath  the  capsule,  and  gives  rise  to  a large 
collection  of  pus  separating  the  capsule  from  the 
kidney. 

The  microscope  shows  tho  small-celled  in- 
filtration between  the  tubules  in  a still  more 
intense  form  than  in  the  varieties  before  de- 
scribed. In  the  areas  of  suppuration  the  kidney- 
substance  has  entirely  disappeared,  and  its  place 
is  occupied  by  leucocytes  packed  closely  to- 
gether. In  the  central  parts  of  these  accumula- 
tions of  small  round  cells  the  intercellular  sub- 
stance has  softened,  and  the  formation  of  pus  has 
taken  place.  The  amount  of  general  interstitial 
change  varies  considerably;  sometimes  between 
the  areas  of  suppuration  the  kidney-substance 
is  almost  healthy,  in  other  cases  there  is  a very 
marked  general  interstitial  inflammation.  The 
epithelium  appears  to  take  no  part  in  the  forma- 
tion of  the  new  cells.  It  is  cloudy  and  swollen, 
but  undergoes  no  proliferation.  In  the  straight 
tubules  it  is  often  found  to  have  been  thrown  off. 
Many  of  the  tubules,  even  in  the  convoluted 
part,  are  found  choked  with  micrococci.  Klebs 
describes  these  as  entering  into  the  epithelium, 
and  subsequently  finding  their  way  into  the  in- 
tertubular lymph-spaces,  where  he  believes  they 
cause  the  interstitial  inflammation  and  suppu- 
ration. This  has  not  been  confirmed  by  other 
observers,  but  it  seems  highly  probable  that  the 
micrococci  do  play  an  important  part  in  causing 
the  inflammation.  Possibly  the  exact  part  they 
take  may  be  more  clearly  demonstrated  by  the 
improved  methods  of  observation  lately  intro- 
duced. It  may  safely  be  affirmed  that  wherever 
they  are  to  be  seen  immediately  after  death,  septic 
processes  were  taking  place  during  life,  and  it  is 
highly  probable  that  even  if  they  do  not  them- 


SURGICAL 

selves  pass  out  of  the  tubules,  the  septic  products 
they  give  rise  to  soak  out  into  the  lymph-spaces, 
and  thus  cause  a diffuse  inflammation  of  the 
intertubular  tissue.  The  lines  of  inflammation, 
as  before  stated,  follow  the  course  of  the  inter- 
fascicular veins,  and  the  lymphatics  also  follow 
the  same  direction.  In  the  pyramidal  portion 
thrombosis  of  the  small  veins  is  occasionally  met 
with,  but  this  is  probably  merely  secondary. 

If  such  an  acute  condition  as  is  above  de- 
scribed be  set  up  in  a kidney  already  altered  in 
form  by  dilatation  from  increased  urinary  pres- 
sure, the  appearances  will,  of  course,  correspond- 
ingly differ. 

IV.  The  cicatricial  kidney. — This  is  the  re- 
sult of  recovery  from  one  of  the  preceding  condi- 
tions, probably  only  from  one  or  both  of  the  first 
two,  as,  if  the  disease  reach  the  stage  of  sup- 
puration, the  patient  is  hardly  likely  to  survive. 
The  kidney  is  shrunken,  irregular  in  form,  and 
marked  by  deep  cicatrices.  The  substance  is  ex- 
cessively tough,  and  the  capsule  firmly  adherent. 
Small  cysts  may  be  scattered  through  its  sub- 
stance, which  are  supposed  to  result  from  stran- 
gulation of  the  tubules.  The  microscope  shows 
a great  excess  of  dense  fibroid  intertubular  sub- 
stance, and  numerous  obliterated  glomeruli  are 
met  with. 

The  varieties  of  kidney  here  described  may 
be  combined  in  various  ways.  Thus  a di- 
lated kidney  may  suffer  from  acute  diffuse  inter- 
stitial inflammation,  with  or  without  suppura- 
tion ; or  a cicatricial  kidney  may,  from  a return  of 
the  primary  disease,  again  suffer  from  an  acute 
attack.  It  seems  probable  that  increased  urinary 
pressure,  combined  with  considerable  reflex  irri- 
tation, is  quite  sufficient  to  give  rise  to  a degree 
of  interstitial  nephritis  which  is  incompatible 
with  life,  and  may  possibly  even  culminate  in 
suppuration.  The  extension  of  decomposition  of 
urine  from  the  bladder  to  the  pelvis  of  the  kidney 
is  alone  a sufficient  cause  for  disseminated  sup- 
puration of  the  kidney;  but  both  the  extension 
of  decomposition  and  its  more  serious  conse- 
quences are  greatly  predisposed  to  by  the  effect 
produced  on  the  kidney  by  the  two  first  causes 
of  irritation;  in  fact,  it  is  comparatively  rare  to 
meet  with  cases  in  which  septic  suppuration 
occurs  in  a kidney  previously  perfectly  healthy. 

Symptoms. — Simple  chronic  insterstitial  in- 
flammation, with  dilatation  of  the  kidney  from 
increased  urinary  pressure,  gives  rise  to  but  few 
symptoms,  and  is  very  difficult  to  recognise.  The 
most  important  signs  are,  that  the  quantity  of 
urine  secreted  is  increased,  and  its  specific  gra- 
vity lowered.  To  avoid  error,  the  whole  urine 
passed  in  twenty-four  hours  should  be  collected, 
and  the  specific  gravity  taken.  Single  observa- 
tions are  open  to  numerous  fallacies.  There  may 
be  a trace  of  albumin,  or  it  may  be  entirely  ab- 
sent. In  one  very  marked  case  discovered  after 
death  at  University  College  Hospital,  the  urine 
had  a specific  gravity  of  1 009,  and  was  free  from 
albumin.  A few  hyaline  casts  may  be  present, 
but  they  are  by  no  means  constant.  The  exact 
state  of  the  urine  is  often  concealed  by  the 
mucus,  blood,  and  pus  from  the  lower  urinary 
tract.  It  is  surprising  how  much  urine  is  se- 
creted by  a kidney  which  is  reduced  to  a mere 
sac,  with  no  pyramids  and  a cortex  no  thicker 


KIDNEY.  1565 

than  a shilling.  In  a case  that  came  under  the 
observation  of  the  writer,  there  had  been  no 
diminution  in  the  secretion,  and  the  specific  gra- 
vity was  1‘008.  In  some  cases  the  distended 
kidney  may  be  recognised  by  palpation,  but  this 
is  not  common.  There  are,  in  fact,  no  definite 
symptoms,  either  subjective  or  objective,  accom- 
panying this  form  of  renal  disease.  It  is  not 
accompanied  by  hypertrophy  of  the  heart,  nor 
by  marked  increase  of  the  arterial  tension. 

Subacute  interstitial  nephritis  gives  rise  to 
more  marked  symptoms.  It  runs  an  irregular 
course,  often  lasting  for  weeks  or  even  months, 
and  terminating  either  in  recovery  or  in  a final 
acute  attack  with  suppuration.  If  the  disease 
arise  as  the  direct  result  of  some  operation  on 
the  lower  urinary  tract,  its  commencement  is 
usually  marked  by  a rigor;  in  other  cases  it 
comes  on  more  gradually,  with  frequent  chills 
but  no  actual  rigor.  The  temperature  is  high  at 
night,  reaching  101°  to  102°  Fahr.,but  it  falls  to- 
wards morning,  so  that  if  it  be  only  taken  at  that 
time,  the  elevation  may  be  completely  overlooked. 
The  patient  becomes  weak  and  languid,  and  ema- 
ciates rapidly.  He  loses  appetite,  and  there  may 
be  nausea  or  occasional  vomiting.  There  may 
be  diarrhoea,  but  this  is  by  no  means  constant. 
The  mouth  becomes  datum}',  and  the  tongue  foul, 
with  a tendency  to  dryness.  In  severe  cases  the 
tongue  becomes  dry  and  brown,  and  sordes  form 
on  the  teeth  and  lips.  The  skin  is  usually  moist 
and  clammy,  and  there  is  not  the  dryness  so 
frequently  met  with  in  other  forms  of  renal 
disease.  There  is  no  oedema.  In  some  cases 
the  swollen  kidney  may  be  felt  by  palpation  in 
the  loin,  and  tenderness  may  be  elicited  on  deep 
pressure,  but  this  is  by  no  means  constant.  The 
patient  may  complain  of  pain  in  the  lumbar- 
region,  but  this  symptom  is  of  little  value,  as  it 
is  often  absent,  and  may  arise  from  many  other 
causes  than  renal  disease.  The  pulse  presents 
nothing  characteristic.  The  patient  frequently 
sinks  into  a drowsy  state,  somewhat  resembling 
the  effect  of  an  overdose  of  opium,  but  true  coma 
is  rarely,  if  ever,  present,  and  convulsions  never 
occur.  The  urine  is  passed  in  fair  quantity, 
often  in  excess  of  the  normal  amount.  The  amount 
of  albumin  is  never  very  great,  but  it  is  usually 
difficult  to  estimate  accurately  how  much  is 
renal,  and  how  much  is  derived  from  blood  or 
pus  from  the  lower  urinary  tract.  Microscopic  ex- 
amination may  show  hyaline  casts,  or  occasionally 
pus-casts  ; renal  epithelium  is  also  frequently 
met  with  ; but  all  microscopic  examination  is 
rendered  difficult  by  the  presence  of  mucus  and 
pus  from  the  lower  urinary  tract.  If  the  primary 
disease  either  be  removed  or  relieved  by  treat- 
ment, the  symptoms  gradually  subside  ; if  not, 
they  remain  without  much  change  till  the  pa- 
tient gradually  dies  exhausted,  or  an  acute  attack 
rapidly  leading  to  suppuration  of  the  kidney 
puts  an  end  to  the  case. 

Acute  interstitial  nephritis  with  suppuration 
most  frequently  forms  the  fatal  termination  of 
the  variety  of  disease  just  described,  but  it  may 
occur  without  any  previous  symptoms.  The 
invasion  is  marked  by  a severe  rigor,  often  occur- 
ring within  a few  hours  of  some  operation  on  the 
lower  urinary  tract.  The  rigor  is  accompanied 
by  great  elevation  of  temperature,  and  followed 


SURGICAL  KIDNEY. 


1566 

by  profuse  perspiration,  during  which  the  tem- 
perature falls,  perhaps  below  normal,  but  it  soon 
rises  again,  and  remains  slightly  raised,  with 
evening  exacerbations.  The  rigor  may  be  re- 
peated during  the  progress  of  the  case  at  irre- 
gular intervals.  The  general  symptoms  resemble 
in  every  respect  those  just  described  as  indica- 
tive of  subacute  interstitial  nephritis,  but  they 
are  increased  in  intensity.  The  strength  rapidly 
fails,  there  is  great  emaciation,  the  pulse  be- 
comes feeble,  and  the  tongue  ‘ like  a piece  of 
broiled  ham.’  There  may  be  occasional  vomiting 
and  diarrhoea.  As  the  fatal  termination  ap- 
proaches, the  temperature  falls  often  consider- 
ably below  normal,  the  skin  becomes  cold  and 
clammy,  and  the  patient  sinks  into  a drowsy 
condition,  seldom  deepening  into  actual  coma. 
Although  the  patient  is  often  said  to  be  dying  of 
‘ uraemia,’  there  are  none  of  the  uraemic  symp- 
toms observed  in  acute  Bright’s  disease.  There 
are  no  convulsions  or  actual  coma,  and  no 
cedema.  The  urine  is  usually  so  foul  as  to  defy 
accurate  examination,  either  chemically  or  by 
the  microscope.  It  is  secreted  in  fair  quantity 
to  the  end  of  the  case.  Pus  and  blood  are  al- 
ways found  in  it,  but  it  is  impossible  to  say 
whether  they  come  from  the  kidney  or  from  the 
lower  urinary  tract.  Renal  epithelium  and  pus- 
casts  are  occasionally  met  with. 

It  will  be  seen  from  the  above  description  that 
the  symptoms  closely  resemble  those  of  septic- 
aemia, and  it  is  very  probable  that  blood-poison- 
ing, from  absorption  of  the  putrid  matter  in  the 
pelvis  of  the  kidney  and  lower  urinary  tract,  is, 
in  fact,  an  important  factor  in  the  disease. 

Suppression  of  urine  following  operations  on 
the  lower  urinary  tract  is  a well-recognised,  but 
fortunately  rare,  cause  of  death.  In  such  cases 
the  kidney  is  always  found  to  be  intensely  gorged 
with  blood,  and  the  microscope  reveals  the  signs 
of  previous  chronic  interstitial  inflammation. 

Urethral  fever  is  a name  given  to  the  febrile 
disturbance,  accompanied  by  a rigor,  which  so 
often  follows  operations  on  the  lower  urinary 
tract.  It  is  impossible  to  discuss  here  the  in- 
numerable theories  which  have  been  put  for- 
ward from  time  to  time  to  explain  its  origin  and 
nature.  It  is  most  probable  that  it  is  due  to  a 
passing  congestion  of  the  kidney  arising  as  a 
reflex  phenomenon,  as  described  in  the  earlier 
part  of  this  article. 

Diagnosis. — As  before  stated,  the  diagnosis 
of  the  more  chronic  secondary  renal  conditions  is 
frequently  impossible.  A careful  observation  of 
the  case  for  a few  days  will  usually  suffice  to  de- 
termine the  presence  of  subacute  consecutive 
renal  inflammation.  The  acute  form  with  sup- 
puration may  resemble  pyaemia.  From  this  it 
may  be  distinguished  by  the  absence  of  secondary 
inflammations  in  the  joints,  subcutaneous  tissue, 
and  lungs  ; by  the  lower  temperature,  falling 
towards  death ; and  by  the  early  and  excessive 
dryness  of  the  tongue.  Pains  ‘all  over  the 
body  ’ are  often  complained  of  in  pysemia,  while 
in  suppurative  nephritis  the  patient  is  usually 
free  from  pain,  except  such  as  may  arise  from 
the  local  disease.  With  the  greatest  care  in 
observation,  however,  the  diagnosis  may  remain 
doubtful  till  death.  From  septicaemia  it  often 
cannot  be  distinguished,  for  doubtless  blood- 


poisoning from  absorption  of  the  putrid  matter 
in  the  kidney  is  an  important  element  of  the 
disease  in  many  cases. 

Prognosis. — This  depends,  in  the  chronic  cf 
subacute  form,  entirely  upon  the  possibility  of 
removing  or  relieving  the  primary  disease.  After 
suppuration  has  commenced  in  the  kidney,  it 
is  very  doubtful  if  recovery  ever  takes  place. 
If  decomposition  has  extended  from  the  bladder 
to  the  pelvis  of  the  kidney,  the  patient’s  chance 
of  recovery  is  much  reduced.  It  is  sometimes 
possible  to  ascertain  this  in  the  following  way. 
Wash  out  the  bladder  carefully  with  diluted 
Condy’s  fluid  until  the  solution  as  it  comes  out 
of  the  bladder  retains  its  purple  colour.  Then 
leave  the  catheter  in  for  a few  minutes,  and 
examine  the  first  drops  that  flow  from  it.  If 
these  are  clear  and  acid,  it  is  evident  that  the 
decomposition  is  still  limited  to  the  bladder. 

Treatment. — The  most  essential  element  of 
the  treatment  is  to  remove  the  cause  if  possible, 
but  the  act  of  doing  so  is  seldom  unaccompanied 
by  the  danger  of  increasing  the  disease,  involving, 
as  it  often  does,  severe  operationsupon  the  urinary 
organs,  as  lithotomy,  lithotrity,  internal  or  ex- 
ternal urethrotomy,  &c.  These  operations  would 
of  course,  if  possible,  be  avoided  if  the  renal 
symptoms  were  at  all  marked.  The  fatal  termi- 
nation being  in  almost  all  cases  associated  with 
putrefaction  of  the  urine  in  the  bladder,  and  ex- 
tension of  the  putrefactive  process  to  the  pelvis 
of  the  kidney,  it  is  needless  to  point  out  that  our 
best  hope  of  preventing  consecutive  renal  in- 
flammation lies  in  the  prevention  of  decompo- 
sition in  the  bladder,  by  scrupulous  attention  to 
cleanliness  in  the  instruments  used.  This  can- 
not be  too  much  insisted  upon  in  the  manage- 
ment of  cases  of  paralysis  of  the  bladder  from 
injury  or  disease  of  the  spinal  cord.  Actual 
cleanliness  can  only  be  obtained  by  the  use  of 
antiseptics.  For  this  purpose  all  catheters 
should  be  washed  in  some  powerful  antiseptic 
lotion,  and  when  used  should  be  greased  with 
carbolic  oil  (1  to  10)  or  some  other  antiseptic 
preparation.  Perhaps  the  best  preparation  is 
that  recommended  by  Mr.  Lund,  composed  of 
carbolic  acid,  1 part,  castor  oil,  4 parts,  olive  oil. 
12  parts.  If  decomposition  should  occur  in  the 
bladder,  antiseptic  lotions  must  be  injected,  in 
order,  if  possible,  to  restore  the  healthy  condi- 
tion before  extension  has  taken  place  to  the 
kidneys.  The  best  solutions  for  this  purpose 
are  quinine,  gr.  iij ; dilute  sulphuric  acid,  miij, 
water  ad  tj  ; Condy's  fluid,  5j  ad  jx  ; and  thy- 
mol solution  (saturated).  Carbolic  acid  is  rather 
too  irritating,  as  also  is  chloride  of  zinc. 

If  the  symptoms  of  subacute  interstitial  ne- 
phritis are  present,  the  patient  will  frequently 
derive  much  benefit  from  a pure  milk  diet.  At 
the  same  time  small  doses  of  opium  seem  to 
promote  the  action  of  the  skin,  and  so  to  relievo 
the  kidney  without  producing  the  dangerous 
effects  so  much  to  be  feared  in  Bright’s  disease. 
The  action  of  the  skin  may  at  the  same  time 
be  still  further  promoted  by  vapour  baths.  The 
bowels  should  be  kept  freely  open.  Counter- 
irritation, either  by  dry-cupping  or  mustard 
poultices  over  the  loins,  followed  by  hot  fomen- 
tations, is  frequently  of  use.  If  the  urine  is  foul, 
it  may  be  greatly  improved  by  the  adminis 


SURGICAL  KIDNEY, 
tration  of  benzoate  of  ammonia  or  benzoic  acid 
in  ten-grain  doses  every  six  hours.  When  the 
symptoms  of  the  acute  form  are  well-marked, 
operations  to  relieve  the  cause  only  hasten  the 
fatal  event.  By  careful  nursing,  and  the  treat- 
ment above  described,  the  symptoms  may  be  so 
far  reduced  in  intensity  as  to  render  an  opera- 
tion for  the  removal  of  the  cause  justifiable. 

Marcus  Beck. 

SWEAT  GLANDS,  Diseases  of. — See 
Sudoriparous  Glands,  Diseases  of. 

SWEATING,  Disorders  of.  See  Perspi- 
ration, Disorders  of. 

SWELLING. — Synon.  : Er.  Gonjlement ; 
Tumefaction ; Ger .Schviellung . — This  term,  when 
employed  in  medicine,  is  applied  both  to  the  pro- 
cess and  to  the  condition  of  increase  in  volume 
of  any  part  of  the  body.  In  a small  number  of 
instances  swelling  is  a normal  process,  and  may 
be  periodical ; for  example,  the  swelling  of  the 
mammae  at  puberty,  during  menstruation,  and  in 
pregnancy;  of  the  uterus  during  gestation  ; and 
of  the  penis  during  erection.  As  a rule,  however, 
swelling  is  a morbid  process  or  condition,  and 
many  examples  of  it  are  afforded  by  disease. 
These  may  be  broadly  classified  as — (A)  Local  or 
circumscribed ; and  (B)  General  or  diffused  swel- 
ling. 

(A)  Circumscribed. — The  most  important  va- 
rieties of  this  kind  of  swelling  are  : — 1.  Simple 
hypertrophy,  as  of  the  thyroid  gland  in  some 
forms  of  goitre ; 2.  Swelling  due  to  disorders  of 
the  circulation  or  inflammation,  as  in  congestion 
of  mucous  membranes,  and  in  ordinary  abscess  ; 
3.  GEdema,  and  certain  other  rarer  exudations 
into  the  connective  tissues  ; 4.  Extravasations 
of  blood,  urine,  gas,  and  other  products ; 5. 
Dilatation  or  distension  of  natural  cavities  or 
vessels,  as  of  the  serous  sacs  and  joints  by  effu- 
sions of  any  kind,  of  the  stomach  and  bowels  by 
gas,  of  an  artery  in  aneurism,  and  of  the  jugular 
veins  in  tricuspid  disease ; 6.  Disturbed  relations 
cf  parts,  as  in  dislocation  of  the  joints,  and  in 
hernia ; 7.  Retention  and  accumulation  of  na- 
tural secretions  and  excretions,  as  of  urine  in  the 
bladder,  and  feces  in  the  bowels;  and  8.  New 
growths  or  tumours  proper,  including  cysts  and 
parasites.  Inflammatory  enlargements  and  new 
growths  constitute  by  far  the  most  common  causes 
of  local  swelling. 

(B)  Diffused. — Infiltrations  of  the  subcuta- 
neous connective  tissue  constitute  the  principal 
varieties  of  swelling  that  fall  under  this  head. 
Such  are  anasarca,  myxoedema,  general  emphy- 
sema, and  the  much  more  uncommon  cases  of 
general  swelling  of  the  body  which  result  from 
the  stings  of  certain  plants  and  animals,  and  the 
use  of  poisonous  food. 

‘ Cloudy  swelling  ’ is  a term  applied  in  morbid 
histology  to  a condition  of  the  cell  in  which  it 
appears  at  once  enlarged  and  finely-granular,  as 
in  parenchymatous  degeneration  or  inflammation 
(see  Degeneration).  ‘ White  swelling’  (tumor 
albus ) is  a popular  synonym  for  scrofulous  dis- 
ease of  a joint,  usually  of  the  kneo. 

The  treatment  of  swelling  depends  entirely 
upon  its  causo.  J.  Mitchell  Bruce. 


SYCOSIS.  1567 

SWINE-POX. — A form,  possibly,  of  modi- 
fied small-pox,  in  which  the  pock  completes  its 
development  imperfectly.  It  forms  a pustule, 
but  the  pustule  neither  umbilicates  nor  matu- 
rates. Willan  termed  this  kind  of  pock  varicella 
globularis ; whilst  popularly  it  has  also  been 
called  ‘ hives.’  See  Chicken-pox. 

SYCOSIS  (cvkov,  a fig). — Synon.  : Menta- 
gra  ; Fr.  Sycose  ; Ger.  Feigwarzenftechte. 

Definition. — A folliculitis  affecting  the  hair- 
follicles  of  the  face,  and  particularly  those  of  the 
chin  and  whiskers. 

PEtiology  and  Pathology. — The  most  fre- 
quent cause  of  sycosis  vulgaris  is  a cold  temper- 
ature ; we  meet  with  it  usually  after  the  patient 
has  been  exposed  to  inclement  weather.  But 
any  other  cause,  whether  local  or  constitutional, 
capable  of  setting  up  inflammation  in  those  very 
importantcutaneous  structures,  the  follicles,  and 
especially  the  follicles  of  the  larger  hairs,  may 
be  an  excitant  of  the  disease.  It  has  been  as- 
sumed that  the  hairs  may  have  some  share  in 
keeping  up  the  disease  ; but  we  must  recollect 
that  the  seat  of  the  pus-formation  is  the  sub- 
epithelial  surface  of  the  true  skin,  and  consequently 
that  the  hair  is  not  bathed  in  the  pus,  but  is 
separated  from  it  by  the  epithelium.  The 
microscope  has  shown  that  those  phytiform  cell- 
structures  which  are  to  be  met  with  wherever 
epithelium  is  in  a state  of  softening  and  decay, 
and  which  have  been  spoken  of  as  parasitic 
fungi,  are  present  in  the  softened  epithelium  of 
the  follicles  in  this  disease ; and  the  opinion 
has  been  ventured  that  the  disease  may  be  of 
a parasitic  character,  and  therefore  contagious. 
And  just  as  the  disease  is  supposed  to  originate 
sometimes  in  the  use  of  a bad  razor,  so  also  it 
has  been  assumed  that  the  disease  may  be  pro- 
pagated by  shaving.  Indeed  the  term  sycosis 
contagiosa  has  been  applied  to  it  under  this  sus- 
picion. See  Tinea. 

Description. — Sycosis  is  known  by  the  pre- 
sence of  a crop  of  pustules,  each  perforated  by 
a hair,  and  more  or  less  acuminated,  developed 
on  a ground  which  is  red  and  inflamed,  and  more 
or  less  swollen  and  infiltrated.  The  pustules 
break  and  form  prominent  crusts  ; and  a succes- 
sive crop  of  pustules  makes  its  appearance 
every  day,  thus  prolonging  the  disease  for  weeks, 
months,  and  even  years.  Essentially  the  disease 
is  an  inflammation  of  a chronic  and  aggravated 
character;  and  is  attended  with  burning  heat, 
stiffness,  and  considerable  pain  and  suffering. 

Varieties  and  Complications. — Sycosis  may 
be  simple — sycosis  vulgaris — and  vary  only  in 
degree;  or  it  maybe  complicated  with  lupus  ery- 
thematosus. The  former  will  present  a variety 
of  appearances  referable  to  the  constitution  of 
the  patient,  or  to  the  care  or  neglect  of  the  dis- 
ease. "When  neglected,  the  crusts  will  accumulate 
amongst  the  hairs,  and  increase  the  local  irrita- 
tion ; so  that  the  integument  may  be  projected 
in  the  form  of  hard  tubercular  masses,  by  the 
Latins  called  fici,  and  by  the  Greeks  crviea  ; and 
a veritable  sycosis  may  be  the  consequence.  In 
this  way  a mild  form  of  the  disease  would  be  a 
mentagra,  and  a severe  form  a sycosis. 

The  lupoid  form  of  the  disease  is  accompanied 
I by  atrophy  of  the  papillary  layer  of  the  skin  - 


1568  SYCOSIS, 

the  elimination  and  destruction  of  the  hairs, 
and  the  production  of  cicatricial  tissue,  which 
converts  the  diseased  part  into  a huge  scar, 
either  perfectly  smooth,  or  roughened  by  an  inter- 
lacement of  bands  of  white  fibrous  tissue. 

Diagnosis. — The  diagnosis  of  sycosis  is  self- 
evident  ; no  other  affection  of  the  skin  answers  to 
the  definition  of  a pustular  inflammation  of  the 
hair-follicles,  limited  to  the  hairy  regions  of  the 
face. 

Pbognosis. — Sycosis  is  obstinate  and  trouble- 
some, even  in  its  mildest  forms;  whilst  its  more 
severe  or  more  chronic  forms  are  apt  to  last  for 
months,  or  even  years.  The  lupoid  variety  has 
all  the  tediousness  of  lupus  erythematosus  super- 
added  to  the  follicular  disease. 

Treatment. — Whenever  any  derangement  of 
general  health  can  be  detected,  this  must  receive 
our  considerate  attention ; but  very  constantly 
the  disease  is  unaccompanied  by  symptoms  of 
disorder  of  constitutional  function,  and  we  are 
constrained  to  rely  chiefly  on  local  treatment. 
In  the  earlier  stages  or  more  acute  forms  of  the 
affection  the  local  treatment  should  be  palliative  ; 
and  in  a chronic  stage  stimulant  in  various  de- 
grees. Fomentations  with  decoction  of  poppy- 
heads,  water-dressings,  and  especially  cold  starch 
poultices,  relieve  the  heat  and  local  suffering, 
and  are  extremely  benelicial.  In  less  severe 
cases  the  cold  starch  poultice,  which  consists  of 
starch  (without  blue)  made  in  the  usual  way 
and  allowed  to  cool,  may  be  applied  at  night, 
and  the  oxide  of  zinc  ointment  or  calamine  oint- 
ment during  the  day.  The  acetate  of  lead  oint- 
ment is  likewise  very  useful  in  some  cases. 
Considerable  benefit  is  also  obtained  by  epilation 
of  such  of  the  hairs  as  are  loosened  by  the  sup- 
puration of  the  follicles. 

In  chronic  forms  of  the  disease  the  iodide  of 
sulphur  ointment,  diluted  with  two-thirds  of  ben- 
zoated  lard  or  vaseline,  is  an  excellent  remedy  ; 
so  likewise  are  ointments  of  the  yellow  and  red 
oxides  of  mercury  ; while  in  the  lupoid  forms  of 
the  affection,  pencilling  the  congested  portions  of 
the  skin  with  the  liquor  plumbi  is  to  be  preferred. 

Erasmus  Wilson. 

SYMMETRY,  in  Relation  to  Disease.— 
Certain  diseases  and  degenerations  manifest 
themselves  in  changes  of  structure  which  are 
arranged  symmetrically  in  correspondence  with 
the  symmetrical  construction  of  the  body.  They 
appear  most  frequently  in  bilateral  symmetry 
in  corresponding  parts  of  the  right  and  left 
sides.  More  rarely,  they  appear,  not  only  in 
this  bilateral  symmetry,  but  in  an  arrangement 
accordant  with  the  homologies  of  parts  in  their 
relations  to  the  longitudinal  vertebral  axis  of  the 
body,  as  the  soles  and  palms,  the  knees  and 
elbows. 

The  most  marked  symmetry  is  found  in  the 
group  of  senile  degenerations  ; as  in  thinning  of 
the  hair  and  baldness,  in  wasting  and  wrinkling, 
and  the  arcus  senilis.  It  is  scarcely  less  com- 
plete in  the  less  simply  degenerative  changes  of 
atheromatous  arteries,  and  the  wasting  and  in- 
creasing fattiness  of  senile  bones.  In  athero- 
matous arteries  also,  the  homologous  symmetry, 
as  well  as  the  bilateral,  is  often  seen ; the 
changes  in  the  radial  corresponding  with  those 


SYMMETRY  IN  DISEASE. 

in  the  peroneal,  and  those  in  the  ulnar  with  those 
in  the  anterior  tibial. 

Among  symmetrical  diseases  the  best  ex- 
amples are  seen  in  chronic  rheumatic  arthritis 
or  osteo-arthritis,  rickets,  psoriasis,  ichthyosis, 
pityriasis,  neurotic  pigmentations,  the  eruptions 
of  secondary  syphilis,  and  those  produced  by 
iodide  of  potassium  and  some  other  medicines  or 
poisons. 

Chronic  rheumatic  arthritis  shows  the  best 
instances  of  symmetrical  changes  coincident 
in  many  different  structures;  for  instance,  in 
the  fibrous  degeneration  and  wasting  of  cartilage, 
the  thickening  and  fringed  growths  of  synovial 
membrane,  the  nodular  formations  on  the  bones. 
In  psoriasis,  whether  syphilitic  or  not,  there  are 
often  good  examples  of  the  coincident  homo- 
logous and  bilateral  symmetries. 

Instances  of  symmetrical  diseases  less  marked 
or  less  constant  than  these  are  seen  in  the  defor- 
mities of  gouty  hands  and  feet,  in  the  thickenings 
and  contractions  of  palmar  fascite,  in  scrofulous 
lymphatics  of  the  neck  or  groin,  in  scrofulous 
hands  and  feet,  in  many  cases  of  eczema,  in  sym- 
metrical gangrene,  and  in  cartilaginous  tumours 
of  the  hands  and  feet. 

Significance. — The  chief  interest  of  the  study 
of  symmetrical  degenerations  and  diseases  is  in 
their  illustration  of  some  principles  of  pathology. 

The  symmetry  of  senile  degeneration  is  an  in- 
dication and  result  of  the  exact  and  perfectly 
maintained  uniformity  of  bilateral  changes  oc- 
curring in  the  natural  life  of  each  symmetrical 
body.  As  the  two  lateral  halves,  from  the  em- 
bryo state  onwards  to  the  state  of  fullest  vigour, 
pass  through  changes  which  are,  in  each  half, 
progressive  at  the  same  rate  and  in  the  same 
method,  so  that  (speaking  generally)  the  two 
halves  are  always  alike  in  size,  structure,  and 
composition,  so  is  it  in  decay  or  degeneration. 
From  beginning  to  end  of  normal  life  the  two 
lateral  halves  keep  time  in  their  similar  and 
equal  changes : the  changes  which  are  symme- 
trical are  as  exactly  synchronous.  Thus,  the 
senile  or  timely  degenerations  of  structures  are 
in  accordance  with  the  laws  of  healthy  life ; and 
their  uniformity  is  the  more  notable  because  they 
indicate,  as  do  some  symmetrical  diseases,  that 
the  two  lateral  halves  of  the  body  are  more  alike 
in  method  of  life  and  probably  in  composition, 
than  they  are  in  size  and  shape.  The  corre- 
sponding limbs  are  very  often  unequal  in  length 
and  circumference.  The  difference  in  the  lower 
limbs  is  often  sufficient  to  give  an  appearance  of 
spinal  curvature.  And  in  faces  exact  symmetry 
is  very  rare : one  eyebrow  is  commonly  higher 
than  the  other;  the  septum  of  the  nose  is  rarely 
median ; the  mouth  often  not  horizontal,  espe- 
cially in  emotional  movements ; or  one  half  of 
the  lower  jaw  is  less  nearly  rectangular  than  the 
other,  and  that  side  of  the  face  is  the  smaller  or 
the  more  oblique.  Yet,  in  parts  thus  unlike  in 
shapo  or  size  degeneration  may  appear  in  perfect 
symmetry.  It  is  in  the  exact  similarity  of  com- 
position and  method  of  life,  thus  shown  to  exist 
in  corresponding  parts  of  the  two  halves  of  the 
body,  that  we  find  the  explanation  of  most  of 
the  symmetrical  diseases. 

In  the  list  of  those  diseases  which  has  been 
given,  and  which  includes  the  best  examples  of 


SYMMETRY  IN  DISEASE, 
the  group,  some  may,  perhaps,  bo  regarded  as 
instances  of  ‘ monstrosity  by  excess,’  deviating 
very  widely  from  the  normal  type.  Sucli  may 
be  the  irregularly  symmetrical  cartilaginous  tu- 
mours of  the  hands  and  feet.  The  rest  may  very 
probably  be  ascribed  to  alterations  in  the  blood 
or  in  the  nervous  force,  or  in  both. 

Among  the  conditions  necessary  to  the  normal 
state  and  life  .of  each  part,  are  the  due  relations 
between  it  and  the  nutritive  materials  supplied 
to  it  in  the  blood.  In  symmetrical  and  exactly 
similar  parts  these  relations  are  exactly  the 
same  ; and  as  the  healthy  blood  equally  supplied 
to  any  two  symmetrical  parts  enables  them  to 
maintain  their  similarity  in  health,  so  an  un- 
healthy blood  may  produce  in  them  an  equal 
similarity  in  disease.  It  may  often  be  impos- 
sible to  find  what  is  really  the  morbid  condition 
of  the  blood  in  symmetrical  disease ; but  the 
existence  of  such  a condition  is  nearly  proved 
in  the  eruptions  produced  by  iodide  of  potassium, 
in  many  cases  of  urticaria,  in  lead-poisoning,  and 
in  cases  of  gouty  and  syphilitic  eruptions. 

Similar  considerations  may  show  that  sym- 
metrical disense  is  due  to  an  altered  state  of 
the  nervous  force.  A certain  healthy  state  of 
this  force  is  a necessary  condition  of  the  healthy 
nutrition  of  every  part ; and  as  the  cerebro- 
spinal nervous  system  and  the  ganglionic  nerves 
associated  with  it  are  arranged  in  a bi-late- 
ral  symmetry,  so  it  may  justly  be  held  that, 
as  a rule,  the  nervous  force  is  in  all  symmetrical 
parts  present  in  exact  likeness.  A general  dis- 
turbance of  the  nervous  force,  or  any  central 
disturbance  transmitted  along  symmetrically 
arranged  nerve-fibres  would,  therefore,  generate 
symmetrical  disease  ; and  this,  whether  we  be- 
lieve that  there  are  special  trophic  nerves  and 
nerve-centres,  or  that  the  trophic  nervous  influ- 
ence is  exercised  through  some  special  condition 
of  the  vaso-motor  or  other  nerve-fibres.  In 
either,  or  in  any  case,  as  a healthy  nerve-force 
in  the  parts  is  a necessary  condition  of  their 
healthy  symmetry,  so  may  or  must  a morbid 
nerve-force  produce  a symmetrical  disease. 

The  instances  of  such  diseases  in  which  the 
disturbance  of  nervous  force  is  most  clear  are 
the  symmetrical  gangrenes  of  fingers,  preceded 
by  intense  neuralgia,  and  the  neurotic  pigment- 
marks  of  the  face  and  forehead.  It  is  not  yet 
possible  to  tell  whether  the  disturbance  is  of 
vaso-motor  or  of  trophic  influence,  or  whether 
(unless  in  a few  instances)  it  is  of  central  origin, 
or  reflected  from  some  previously  existing  peri- 
pheral disease,  or  be  even  due  to  some  affection 
of  peripheral  nerves.  But  the  facts  of  symme- 
trical diseases  are  among  the  chief  of  those  prov- 
ing the  influence  of  the  nervous  system  in  the 
production  and  method  of  organic  disease  ; and 
they  are  mutually  illustrative  with  those  of  uni- 
lateral diseases,  such  as  herpes  zoster,  whose  dis- 
tribution accords  with  that  of  certain  nerves, 
whose  disturbance  is  further  indicated  by  neu- 
ralgia. 

There  thus  appear  to  be  among  the  sym- 
metrical diseases  some  which  may  be  ascribed 
to  morbid  states  of  blood,  and  some  due  to 
morbid  states  of  nerve-force.  But  it  is  probable 
that  in  yet  more,  if  not  in  all,  both  blood  and 
nerve-force  are  at  fault,  the  latter  chiefly  deter- 

99 


SYMPATHETIC  SYSTEM.  1508 
mining  the  localities,  the  former  chiefly  the 
method  and  obvious  characters,  of  each  disease, 
The  phenomena  of  many  of  the  diseases  may  be 
thus  explained  better  than  by  referring  them  to 
only  one  disturbing  force.  There  are,  indeed, 
few  diseases  in  which  the  respective  shares  taken 
by  blood  and  by  nerve-force  in  morbid  processes 
can  be  better  studied ; few,  from  the  study  of 
which  we  may  more  justly  hope  to  attain  the 
means  of  reconciling  the  often  antagonistic  doc- 
trines of  a humoral  and  a neural  pathology. 

Jamks  Paget. 

SYMPATHETIC  (<r vv,  with ; and  irddri, 
feeling). — This  term  implies  that  a part  or  organ 
suffers  in  sympathy  with  some  other  part  or 
organ  which  is  diseased.  Many  disorders  which 
seem,  and  are  popularly  supposed,  to  arise  ir> 
this  way  can  be  traced  to  obvious  pathological 
causes.  Thus,  a morbid  process  may  extend 
directly  along  blood-vessels,  lymphatics,  or  other 
tissues  ; or  a morbific  agent  may  be  convoyed 
by  the  blood  or  lymph  from  one  part  to  another ; 
or  a secondary  lesion  may  be  produced  by  direct 
nervous  influence.  There  are  other  cases,  how- 
ever, in  which  the  connection  is  not  so  evident, 
but  it  is  quite  intelligible  that  organs  which  are 
physiologically  related  may  be  sympathetically 
disturbed  in  pathological  conditions.  The  sym- 
pathetic disturbance  may  bo  indicated  by  mere 
pain  or  other  subjective  sensation  ; by  functional 
derangements,  as  of  secretions  or  actions  ; or  by 
positive  organic  lesions.  The  occurrence  of  such 
phenomena  in  corresponding  parts  on  both  sides 
of  the  body,  when  a disease  has  commenced  on 
one  side,  is  sometimes  very  curious,  especially  as 
regards  organic  lesions.  As  illustrative  of  the 
associations  in  which  the  word  ‘ sympathetic’  is 
employed  may  be  mentioned  sympathetic  'pain, 
sympathetic  headache,  sympathetic  cough,  sympa- 
thetic vomiting , sympathetic  bubo. 

Frederick  T.  Robebts. 

SYMPATHETIC  SYSTEM,  Disorders 

of. — Synon.:  Fr.  Maladies  du  Nerf  sympathique-, 
G-er.  Krankheiten  der  Ncrvtis  sympatkicus. 

Introduction. — This  subject  can  only  be 
treated  in  a brief  and  tentative  manner,  owing 
to  the  fact  that  a wide  basis  of  positive  know- 
ledge does  not  exist.  The  physiology  of  the 
different  departments  of  the  sympathetic  system 
of  nerves  is  now  only  beginning  to  shape  itself, 
whilst  on  the  side  of  pathology  and  morbid 
anatomy  there  is  even  still  less  of  definite  know- 
ledge. Thus  it  happens  that  for  the  most  part 
only  conjectures,  often  very  insecurely  based,  are 
current,  or  can  be  said  to  exist,  in  regard  to 
the  dependence  of  definite  sets  of  symptoms, 
or  distinct  diseases,  upon  disordered  actions  or 
morbid  changes  occurring  in  one  or  other  part 
of  the  sympathetic  system  of  nerves.  These 
problems  are  now,  however,  receiving  the  atten- 
tion of  many  workers,  so  that  before  long  it  is  to 
be  expected  that  our  knowledge  on  this  impor- 
tant subject  will  have  become  both  more  exten- 
sive and  more  definite.  We  shall,  therefore,  in 
the  present  article,  confine  ourselves  to  some 
general  remarks  concerning  the  anatomical  rela- 
tions and  the  functions  of  the  sympathetic  system 
of  nerves  ; to  the  modes  in  which  disorders  of 


SYMPATHETIC  SY'STEM,  DISORDERS  OF. 


1570 

its  several  parts  may  arise ; and  to  little  more 
than  a mere  mention  of  the  various  morbid  con- 
ditions, which  may  be  principally  or  in  part 
occasioned  by  defective  or  otherwise  abnormal 
activity  of  one  or  other  department  of  this  great 
system  of  nerves.  We  shall  thus  be  enabled  to 
indicate  some  of  the  best  established  facts  or 
relations  in  this  direction  which  have  already 
acquired  a clinical  importance,  and  also  to  indi- 
cate the  directions  in  which  further  advances  are 
to  be  looked  for. 

Whilst  the  sympathetic  system  of  nerves,  with 
its  double  ganglionated  cord  and  great  ganglionic 
plexuses,  is  to  a certain  extent  an  independent 
nervous  system,  its  roots  nevertheless  penetrate 
deeply  into  the  cerebro-spinal  axis.  The  two 
nervous  systems  are  connected,  on  each  side  of 
the  spinal  column,  by  means  of  double  sets  of 
filaments,  passing  between  each  of  the  sympa- 
thetic ganglia  and  the  respective  anterior  spinal 
nerves  with  which  they  correspond,  as  well  as 
with  most  of  the  nerves  attached  to  the  medulla 
oblongata.  The  fibres  in  all  these  filaments  of 
communication  are  partly  afferent  and  partly 
efferent.  Thus,  just  as  ingoiug  or  centripetal 
impressions,  instead  of  being  reflected  from  some 
of  the  sympathetic  ganglia,  may  pass  on  to  spinal 
and  medullary  centres,  so  may  motor  or  inhi- 
bitory impressions  pass  outwards  from  these 
cerebro-spinal  centres,  so  as  to  modify  the  sub- 
ordinate motor  or  secretory  influences,  emanating 
from  some  one  or  other  of  the  sympathetic  ganglia 
themselves. 

From  the  ganglionated  cord  on  each  side  of 
the  spinal  column,  numerous  internal  branches 
are  given  off,  which  unite  with  one  another, 
with  those  of  the  opposite  side,  and  often  with 
filaments  of  the  pneumogastrie  nerves,  so  as  to 
form  great  plexuses  with  or  without  well-marked 
ganglia,  with  which  the  various  glandular  organs 
and  hollow  viscera  of  the  body  are  in  connection 
by  means  of  afferent  and  efferent  fibres.  On 
the  course  of  these  visceral  nerves  many  smaller 
ganglia,  constituting  subordinate  centres,  are  to 
be  found. 

The  sympathetic  nerves  are  conducted  to  and 
ccme  from  the  viscera,  principally  upon  and  along 
the  course  of  the  blood-vessels. 

Some  of  the  nerve-fibres  on  the  visceral  blood- 
vessels, and  a much  larger  proportion  of  those 
on  vessels  going  to  other  parts  of  the  body, 
belong  to  a special  set  of  the  sympathetic 
fibres,  which,  from  the  nature  of  their  functions, 
are  known  as  v aso-motnr  nerves.  Some  of  these 
fibres  must  have  ‘afferent’  functions  for  the 
conveyance  of  impressions  to  vaso-motor  centres ; 
while  others  of  them  will  transmit  ‘efferent’ 
impulses ; the  two  sets  together  serving  to  regu- 
late the  calibre  of  the  blood-vessels,  and  conse- 
quently the  amount  of  blood  flowing  through  the 
different  vascular  territories.  These  vaso-motor 
nerves  are  connected  with  small  ganglia  distri- 
buted along  the  length  of  the  blood-vessels, 
from  which,  in  response  to  afferent  impressions, 
motor  stimuli  may  issue  to  such  vessels  and  their 
branches.  Such  peripheral  ganglia  are,  hotvever, 
in  subordinate  relation  with  spinal  vaso-motor 
centres,  situated  along  the  whole  length  of  the 
cord,  and  these  in  their  turn  are  dominated  by 
» still  higher  regulating  centre,  situated  in  the 


medulla  oblongata  (near  the  lower  extremitv  or 
the  fourth  ventricle),  which  appears  to  be  in  re- 
lation with  all  the  vaso-motor  nerves  throughout 
the  body.  Modern  observations  would  seem  to 
show  that  there  is  another  vaso-motor  centre  in 
the  cerebral  cortex ; and  this  is  believed  by 
Benedikt,  Meynert,  and  others  to  be  situated 
in  the  hippocampus-major.  The  nature  of  its 
relations  with  the  medullary  centre  are  as  yet 
uncertain. 

Other  fibres  of  the  sympathetic  system  are 
mixed  up  on  the  vessels  with  those  haviug 
a vaso-motor  function.  These  others  vary 
in  function  and  in  numerical  proportion,  ac- 
cording to  tlie  nature  of  the  organ  to  which 
the  vessels  are  proceeding.  Thus  to  and  from 
the  liver,  the  pancreas,  the  salivary  glands, 
and  other  allied  organs,  would  proceed  nerve- 
fibres,  regulating  the  secretory  and  other  vital 
actions  taking  place  in  the  tissue-elements 
of  the  several  organs  ; also  from  and  to  such 
organs  there  would  proceed  afferent  and  efferent 
fibres  for  rousing  and  regulating  the  activity  of 
the  contractile  tissues  in  their  respective  gland- 
ducts.  Again,  there  would  lie  on  intestinal 
arteries,  in  addition  to  vaso-motor  fibres,  many 
other  sympathetic  fibres  for  the  innervation  of 
the  muscular  layers  of  the  intestine,  and  many 
also  for  the  different  glandular  elements  of  its 
mucous  membrane.  Lastly,  in  such  an  organ  as 
the  bladder,  vaso-motor  nerves,  and  nerves  for 
the  supply  of  its  own  proper  muscular  tissues, 
would  exist  in  abundance,  while  those  in  rela- 
tion with  glandular  elements  would  be  compa- 
ratively scarce. 

Whether  over  and  above  these  different  kinds 
of  sympathetic  fibres,  others  exist  of  the  so- 
called  ‘trophic’  type,  seems  at  present  to  be  ex- 
tremely doubtful. 

If.  therefore,  we  consider  the  functions  of  tho 
sympathetic  system  of  nerves  as  a whole,  we 
find  that  it  has  to  do  with  the  degree  of  contrac- 
tion of  the  pupil ; with  the  calibre  of  the  blood- 
vessels generally;  with  the  activity  of  all  the 
glandular  organs  ; with  the  movements  of  all 
the  hollow  viscera,  and  gland-ducts  ; and  pos- 
sibly in  some  special  manner  with  the  nutrition 
of  all  the  tissues.  And  inasmuch  as  the  nerves 
pertaining  to  this  system,  if  not  both  the  nerves 
and  ganglia,  are  to  be  found  iu  all  parts  of  the 
body,  it  is  to  be  expected  that  its  functions  may 
he  more  or  less  locally  deranged,  or  its  struc- 
ture more  or  less  damaged,  by  almost  every  form 
of  disease,  be  it  local  or  general.  Every  local 
inflammation  must  be  associated  with  a per- 
verted activity  and  deranged  structure  of  sym- 
pathetic nerve-fibres  in  the  inflammatory  focus  ; 
whilst  every  fever  will  entail  widespread  and 
varied  perversions  in  the  functions  of  this  sys- 
tem of  nerves  throughout  the  body.  Owing, 
however,  to  the  fact  of  the  intimate  structural 
relations  existing  between  the  sympathetic  and 
the  cerebro-spinal  nervous  system  (see  Nervous 
System,  Diseases  of),  it  is  more  especially  in 
diseases  of  the  spinal  cord  and  of  the  brain  that 
we  are  accustomed  to  meet  with  definite  sets  ot 
signs  and  symptoms  referable  to  disordered  or 
arrested  action  of  portions  of  the  sympathetic 
system.  In  the  present  article,  therefore,  the 
disorders  of  the  sympathetic  system  will  be  very 


SYMPATHETIC  SYSTEM,  DISORDERS  OF. 


briefly  considered  as  they  occur:  (1)  in  associa- 
tion with  diseases  of  the  spinal  cord  and  brain  ; 
and  (2)  independently  of  affections  of  the  cerebro- 
spinal nervous  system. 

1.  Diseases  of  the  sympathetic  system  in 
connection  with  the  cerebro-spinal  system. 

(a)  The  spinal  cord. — Lesions  of  the  cervical 
region  of  the  spinal  cord  may  be  associated 
with  extreme  contraction  or  extreme  dilatation 
of  the  pupil  on  one  or  both  sides ; with  in- 
creased heat  and  redness,  or  the  reverse,  of  the 
aead  and  neck;  with  perverted  respiration;  with 
perverted  action  of  the  heart ; and  possibly  with 
an  exalted  febrile  heat  of  the  whole  body  {see 
Spixal  Coed,  Diseases  of,  § 9).  Though  we 
regard  these  phenomena  as  signs  of  disease  in 
this  particular  portion  of  the  spinal  cord,  it  is 
none  the  less  true  that  such  phenomena  are  due 
to  altered  activities  in  those  root-portions  of  the 
sympathetic  system  of  nerves  which  take  origin 
in,  or  traverse,  this  region  of  the  cord.  This  is 
shown  by  the  fact  that  similar  sets  of  symptoms 
are  produced  by  injuries,  tumours,  or  other 
morbid  processes  implicating  the  cervical  sym- 
pathetic itself. 

It  will  be  well  to  cite  here  the  phenomena 
commonly  associated  with  irritation  or  paralysis 
of  the  cervical  sympathetic  nerve,  on  account  of 
their  importance  as  diagnostic  indications. 

The  signs  dependent  upon  irritation  of  the 
cervical  sympathetic  in  its  oculo-pupillary  fibres 
are — dilatation  of  the  corresponding  pupil  with 
sluggish  action,  widening  of  the  palpebral  fissure, 
prominence  of  the  eyeball,  feeling  of  tension  in 
the  eye  (as  in  glaucoma),  and  a scanty  secretion  of 
tears  and  mucus ; whilst  in  its  vaso-motor  fibres 
they  are — lowering  of  temperature  of  the  side  of 
the  face  and  head,  diminution  of  sensibility,  an 
absence  of  perspiration,  with  (if  the  irritation 
continue)  a tendency  to  slight  atrophy  of  the 
side  of  the  face.  The  signs  of  paralysis  of  the 
cervical  sympathetic  in  its  two  sets  of  fibres  are 
the  direct  opposites  of  those  above  cited,  so  that 
it  is  not  necessary  to  enumerate  them.  Of  these 
signs,  those  dependent  upon  irritation  or  para- 
lysis of  the  oculo-pupillary  fibres  are  usually 
much  more  constant  and  durable  than  those 
which  depend  upon  irritation  or  paralysis  of  the 
vaso-motor  fibres.  These  latter  signs  are,  for 
reasons  at  present  unknown,  often  transitory 
and  fitful.  Sometimes  there  may  be  signs  of 
paralysis  of  oculo-pupillary  fibres  co-existing 
with  signs  of  irritation  of  the  vaso-motor  fibres, 
or  vice  versa.  It  has  been  definitely  determined 
that  injury  in  the  lower  cervical  region  of  the 
cord,  and  as  far  down  as  the  level  of  the  second 
dorsal  nerve,  may  give  rise  to  the  oculo-pupillary 
signs  of  one  or  other  kind ; and,  on  the  other 
hand,  that  damage  to  the  cord  in  these  same 
parts,  or  as  low  down  as  the  fourth  dorsal  nerve, 
may  give  rise  to  the  above-mentioned  vaso-motor 
signs. 

When  the  dorsal  and  lumbar  regions  of  the 
spinal  cord  are  the  seats  of  disease,  other  groups 
of  phenomena  will  doubtless,  after  a time,  be 
more  fully  recognised  as  results  of  irritation  or 
paralysis  of  those  roots  of  the  sympathetic  sys- 
tem which  have  their  origin  in  or  which  traverse 
these  particular  regions  of  the  spinal  cord.  It  is 
therefore  important  to  bear  in  mind  the  place  of 


1571 

origin  and  the  distribution  of  the  different  inter- 
nal branches  from  the  lateral  sympathetic  cords, 
which  proceed  from  these  regions  to  the  different 
glandular  organs  or  hollow  viscera.  Diarrhoea, 
sickness,  obstinate  constipation,  sexual  defects, 
and  bladder-troubles,  are  among  the  symptoms 
which  have  such  an  origin,  as  well  as  undue  heat 
or  unnatural  coldness  of  the  lower  extremities. 

(5)  The  brain. — In  different  portions  of  the 
brain  some  of  the  signs  and  symptoms  of  disease 
are  also  referable  to  direct  or  indirect  inter- 
ference with  the  functions  of  the  sympathetic 
system  of  nerves ; but  they  constitute  (apart 
from  vaso-motor  derangements,  which  are  very 
common  and  often  well-marked)  far  less  distinc- 
tive aggregates,  owing  to  the  fact  that  the  sym- 
pathetic system  of  nerve6  has  a much  less  exten- 
sive relation  with  the  brain  than  with  the  spinal 
cord.  In  this  direction,  however,  and  in  connec- 
tion especially  with  diseases  of  the  medulla 
oblongata,  we  have  to  bear  in  mind  the  occa- 
sional occurrence  of  diabetes,  polyuria,  or  albu- 
minuria ; also  of  some  cardiac  and  respiratory 
derangements. 

2.  Diseases  of  th.e  sympathetic  system 
proper. — Where  disease  exists  in  the  ganglia  of 
the  sympathetic  system  itself,  or  where  it  in- 
volves them,  we  get  groups  of  symptoms  more 
clearly  referable  to  disordered  activity  of  this 
system  of  nerves  alone. 

These  will  differ  in  particular  cases,  according 
to  the  nature  of  the  morbid  change,  that  is, 
according  as  it  is  destructive  or  merely  irrita- 
tive; and  according  to  the  number  or  particular 
combinations  of  ganglia  and  fibres  affected.  Tho 
ganglia  and  related  plexuses  may  either  be  im- 
plicated by  intrinsic  morbid  processes,  or  may 
be  variously  involved  from  without  by  morbid 
processes  having  their  origin  in  other  adjacent 
tissues. 

a.  Intrinsic  changes. — The  principal  intrinsic 
morbid  processes  which  have  been  hitherto  re- 
cognised post  mortem  in  some  one  or  other  of  tho 
sympathetic  ganglia  are  : — pigmentary  degene- 
ration; cirrhotic  overgrowth  of  their  connective 
tissues,  with  or  without  secondary  atrophy  (the 
ganglia  in  such  cases  being  either  smaller  or 
larger  than  natural) ; a highly  congested  and 
varicose  state  of  their  blood-vessels  ; effusion  of 
blood  into  their  substance  ; new  growths  start- 
ing from  their  substance ; and  fatty  degenera- 
tion, with  more  or  less  marked  atrophy.  It  is 
unnecessary  to  repeat  here  the  statements  re- 
lating to  the  pathology  of  such  changes,  which 
have  been  made  under  Nervous  Ststem,  Diseases 
of. 

b.  Extrinsic  disease. — Different  parts  of  the 
sympathetic  system  may  become  involved  in 
new  growths  or  in  abscesses  ; or  they  may  be 
simply  pressed  upon  by  aneurismal  or  other 
tumours  occurring  in  contiguous  regions  of  the 
body.  _ 

Besides  the  pathological  conditions  already 
enumerated,  it  should  be  borne  in  mind  that  in 
altered  blood-states,  whether  cachectic  or  of  fe- 
brile origin,  we  commonly  have,  and  especially 
in  the  latter  class  of  cases,  a greatly  perverted 
activity  of  the  sympathetic  system  throughout 
tho  body' — as  evidenced  by  the  altered  vascular 
conditions,  increased  tissue-metamorphosis  and 


1572  SYMPATHETIC  SYSTEM, 
body-heat,  together  with  'the  perverted  activity 
of  most  of  the  glands  in  the  body.  See  Fever. 

But  to  what  extent  the  actual  structure  of 
glandular  or  blood-making  organs  may  be  per- 
verted by  primary  or  secondary  morbid  changes 
in  related  portions  of  the  sympathetic  system, 
we  have  yet  to  learn.  Waxy  degeneration  of  the 
liver  or  spleen  may,  for  instance,  be  a result  of 
certain  perversions  of  the  normal  life-processes 
taking  place  in  the  elements  of  these  organs,  pri- 
marily induced  by  changes  in  the  quality  of  the 
blood,  such  as  occu-r  in  many  cachexias.  But 
whether  this  altered  blood  acts  directly  upon 
the  tissue-element,  and  brings  about  the  struc- 
tural change  known  as  waxy  degeneration ; or 
whether  cachectic  states  of  the  system  entail 
upon  the  sympathetic  centres  a perverted  nutri- 
tion, and  a consequent  perverted  influence  upon 
the  tissue-elements  of  related  organs,  whereby 
they,  being  at  the  same  time  fed  only  by  im- 
poverished blood,  lapse  into  those  lower  modes 
of  vitality  which  result  in  the  degenerative 
change  above-mentioned,  are  unsettled  questions, 
well  worthy  of  consideration.  These  remarks, 
with  suitable  modifications,  are  applicable  as 
regards  the  possible  instrumentality  of  related 
portions  of  the  sympathetic  system,  in  causing 
other  varieties  of  morbid  change  in  other  organs 
of  the  body. 

The  principal  disorders  other  than  those  due  to 
structural  diseases  of  the  cord  and  of  the  brain,  in 
which  derangements  of  the  sympathetic  system 
of  nerves  exist,  or  are  believed  to  exist,  and  in 
which  such  derangements  have  either  wholly  or 
in  part  a causal  relationship  to  the  principal  signs 
and  symptoms  of  the  respective  disorders,  are  as 
follows: — epilepsy;  convulsions;  migraine (hemi- 
crania);  exophthalmic  goitre;  unilateral  liyperi- 
drosis  ; progressive  facial  hemiatrophy  ; angina 
pectoris ; asthma ; diabetes  ; Addison’s  disease ; 
gastralgia  ; enteralgia  (colic) ; neuralgia  coeliaca ; 
neuralgia  spermatica ; and  uterine  neuralgia. 
(See  ‘ Phys.  and  Pathol,  of  Sympath.  Syst.  of 
Serves’  by  Eulenberg  and.  Guttmann,  1879.) 
Among  the  affections  more  doubtfully  or  partially 
related  to  disorders  of  the  sympathetic  we  may 
mention  glaucoma;  neuro-retinitis;  progressive 
muscular  atrophy ; pseudo-hypertrophic  paraly- 
sis ; locomotor  ataxy;  diphtheritic  paralysis; 
and  so-called  ‘reflex  paralysis.’  In  the  special 
articles  on  most  of  the  first  group  of  affections, 
the  reader  will  find  references  to  the  dependence 
of  such  conditions  upon  disorders  in  one  or  other 
department  of  the  sympathetic  system.1 

H.  Charlton*  Bastian*. 

SYMPTOM  1 See  Dxsbask 

SYMPTOMATOLOGY  / ’ 

Symptoms  and  Signs  of. 

SYNCOPE  (ffny/coTr?/,  a faint). — Synon*.  : 
Fainting ; Fr.  Syncope ; Ger.  Ohnmacht. 

Definition. — A state  of  suspended  animation, 
due  to  sudden  failure  of  the  action  of  the  heart. 

JEtiolooy. — Syncope  may  be  due  to  any  con- 
dition which  interferes  with  the  action  of  the 
heart,  whether  acting  (<t)  intrinsically ; (6) 
through  the  nervous  system  ; (c)  through  the 
blood-,  (d)  through  more  than  one  of  these  channels. 

* See  also  Long  Fox  on  ‘Tlie  Influence  of  tlie  Sympa- 
thetic on  Disease,’  iled.  Times,  Sept.  2, 1S82. 


SYNCOPE. 

(a)  Syncope  due  to  intrinsic  cardiac  conditions 
is  chiefly  seen  in  organic  diseases  of  the  heart, 
especially  fatty  degeneration.  Amongst  other 
examples  of  this  class  of  causes,  may  be  men- 
tioned. compression  of  the  heart  by  diseased  con- 
ditions, or  by  tight  articles  of  dress ; excessive 
heat,  whether  natural  or  artificial,  as  in  sunstroke 
and  the  warm-bath ; lightning;  and  certain  drugs 
and  poisons,  including  chloroform. 

(b)  The  most  common  nervous  causes  of  faint- 
ing are  of  an  emotional  kind,  such  as  fear,  grief, 
or  joy,  in  nervous  or  hysterical  women.  Sudden 
injury’  of  the  central  nervous  system,  as  in  con- 
cussion of  the  brain,  has  partly  the  same  effect. 
In  a larger  number  of  instances  the  nervous 
causes  of  syncope  act  reflexlv,  and  are  to  be 
found  in  conditions  of  the  stomach  or  intestines 
(corrosive  and  irritant  poisoning,  indigestion, 
worms,  scybala)  ; in  the  liver,  kidneys,  or  uterus 
(injuries,  calculi,  displacements) ; or  in  the  limbs 
or  body  generally  (painful  injuries  of  any  kind). 
Spasm  of  the  arteries,  due  to  reflex  irritation  of 
the  vaso-motor  nerves  (cold  and  certain  poisons), 
may  also  lead  to  syncope. 

(c)  Of  the  causes  of  syncope  connected  with 
the  blood  the  most  frequent  is  haemorrhage. 
Chronic  anaemia,  as  seen  iu  idiopathic  and  per- 
nicious cases,  or  accompanying  chronic  consti 
tutional  diseases,  is  a common  cause  of  serious 
fainting. 

(d)  In  a large  number  of  instances,  however, 
the  causes  of  syncope  are  complex.  Thus  in 
fainting  from  hunger  and  exhaustion  the  heart 
is  depressed  directly*,  as  well  as  through  the 
nervous  system,  and  through  the  blood ; and  in 
severe  injuries,  such  as  railway  accidents,  there 
may  be  a combination  of  depressing  causes, 
including  fear  and  grief,  haemorrhage,  painful 
lesions,  cerebral  concussion,  and  shock.  Faint- 
ing in  a hot,  impure  atmosphere  appears  to  be 
due  partly  to  the  direct  effect  of  heat  upon  the 
circulation ; and  partly  to  the  interference  with 
respiration,  and  indirectly  with  the  heart,  pro- 
duced by  carbonic  acid. 

In  a person  subjected  to  any  of  the  predispos- 
ing causes  of  syncope  already  mentioned,  the 
occurrence  of  fainting  may  be  determined  bv  a 
very  slight  exciting  cause.  It  is  thus  that"  in 
serious  cardiac  disease,  in  hysterical  subjects, 
and  in  persons  suffering  from  anaemia,  the  small- 
est excitement  or  exertion,  unpleasant  sights  or 
smells,  or  exposure  to  an  impure  and  heated 
atmosphere,  may*  cause  faintness,  and  in  some 
instances  even  fatal  syncope. 

Anatomical  Characters. — In  death  by  syn- 
cope the  organs  generally*  are  found  to  be  an- 
aemic; and  if  haemorrhage  hare  occurred,  this 
condition  is  particularly  marked.  The  state  of 
the  heart  varies  with  the  cause  of  its  failure, 
the  ventricles  being  either  dilated  and  full  of 
blood,  or  empty,  as  in  cases  of  fatal  haemorrhage, 
and  possibly  contracted. 

Symptoms. — -A  syncopal  attack  presents  three 
stages,  namely:  (1)  a period  preceding  loss  of 
consciousness;  (2)  a condition  characterised  bv 
insensibility ; and  (3)  a period  of  recovery  from 
the  fainting  state. 

(1)  A person  about  to  faint  is  observed  to  turn 
suddenly  pale ; he  staggers,  or  leans  against 
the  nearest  support ; the  eyes  roll  upwards, 


SYNCOPE. 


whilst  the  eyelids  tremble  or  close ; and  conscious- 
ness and  general  sensibility  are  impaired.  The 
pulse  fails,  generally  becoming  weak,  small,  and 
frequent;  in  other  instances  it  is  infrequent, 
irregular,  or  intermittent.  The  respiration  is 
irregular  and  feeble.  Vomiting  may  possibly 
occur. 

At  the  same  time  the  patient  has  a number  of 
subjective  sensations.  The  most  urgent  of  these 
are  a sense  of  ‘sinking’  in  the  epigastrium, 
a feeling  of  increasing  debility,  ‘ giddiness  ’ in 
the  head,  and  a tendency  to  fall.  Vision  becomes 
indistinct ; the  hearing  is  usually  impaired,  rarely 
more  acute,  or  tinnitus  is  present.  Mentally 
there  is  a rapid  fading  of  sensory  impressions 
and  of  consciousness  ; whilst  in  cases  of  fainting 
from  loss  of  blood  there  may  be  restlessness, 
agitation,  and  delirium. 

(2)  The  phenomena  of  the  first  stage  are  now 
complete.  The  muscles  are  relaxed ; the  patient 
falls  ; and  consciousness  is  completely  lost.  The 
surface  is  pallid,  and  possibly  cold  and  clammy; 
the  eyes  are  closed,  and  the  pupils  dilated ; 
the  pulse  and  the  cardiac  impulse  and  sounds 
are  nearly  or  quite  imperceptible ; respiration  is 
indistinguishable,  or  occurs  as  occasional  weak 
sighs ; and  the  vital  functions  generally  appear 
to  have  ceased.  In  cases  of  syncope  due  to 
severe  haemorrhage  general  convulsions  may 
occur. 

(3)  Recovery  from  syncope  is  marked  by 
signs  of  gradually  returning  consciousness,  in- 
crease of  the  pulse  at  the  wrist,  and  restoration 
of  the  functions  generally.  The  first  obvious 
signs  of  improvement  are  usually  slight  move- 
ments of  the  hands  and  features,  and  deep 
sighing.  Thereupon  the  pulse  becomes  more 
distinct;  the  cardiac  impulse  and  sounds  are 
found  to  be  stronger ; the  senses  of  sight  and 
hearing  can  be  excited ; colour  returns  to  the 
face  and  lips,  and  warmth  to  the  extremities  ; 
and  intelligence  is  gradually  restored.  Very 
shortly  the  patient  may  be  able  to  resume  the 
sitting  posture;  and  the  seizure  is  at  an  end. 

Duration  and  Terminations. — The  duration 
of  the  several  stages  of  syncope  varies  greatly, 
from  a few  seconds  even  to  hours.  In  many 
instances  the  attack  does  not  pass  beyond  the 
first  stage ; in  rarer  cases  insensibility  may  last 
for  an  almost  indefinite  time.  The  most  common 
termination  is  in  recovery ; but  syncope  is  one 
of  the  ordinary  modes  of  death,  especially  in 
haemorrhage  and  organic  disease  of  the  heart. 
In  nervous  subjects  partial  recovery  may  be 
quickly  followed  by  the  return  of  the  fainting 
state,  the  patient  being  said  to  ‘ pass  out  of  one 
faint  into  another.’  Where  referable  to  organic 
disease  or  to  hysteria,  syncope  may  recur  at 
intervals  for  many  years. 

Pathology. — Syncope  consists  essentially  in 
sudden  failure  of  the  action  of  the  heart,  origin- 
ating in  any  of  the  causes  already  mentioned,  and 
leading  to  the  condition  of  acute  general  anaemia. 
Whether  from  some  affection  of  the  heart  itself, 
from  sudden  interference  with  the  nervous  im- 
pulses which  regulate  its  action,  from  failure  in 
the  regularity  of  the  supply  of  blood  within  its 
cavities  and  in  its  substance,  or  from  a combine* 
tion  of  such  causes,  the  systolic  contraction  sud- 
denly becomes  short  and  feeble.  If  there  have 


1673 

been  no  haemorrhage,  the  result  is  distension  of 
the  cardiac  cavities  with  blood,  and  further  em- 
barrassment ; but  if  profuse  haemorrhage  have 
occurred,  the  heart  may  be  deprived  of  blood, 
and  thus  of  the  natural  stimulus  to  contraction. 
In  either  case  fatal  cardiac  paralysis  may  be  the 
result,  unless  the  contractile  power  be  speedily 
■restored. 

The  acute  general  anaemia  which  is  the  result 
specially  affects  the  central  nervous  system.  In 
the  erect  posture  the  circulation  fails  first  within 
the  cerebrum,  producing  rapid  disturbance  and 
then  loss  of  consciousness,  and  depressing  the 
centres  that  regulate  the  heart,  vessels,  respira- 
tion, and  stomach.  The  general  muscular  paralysis 
which  occurs  at  the  same  time  is  also  partly  of 
central  origin.  Similarly,  the  convulsions  which 
may  ensue  in  cases  of  haemorrhage  are  pro- 
bably referable  to  sudden  circulatory  disturbance 
within  the  basal  ganglia  and  cord.  The  senses 
are  further  obscured  by  anaemia  of  their  special 
organs ; the  heart  is  more  depressed  by  failure 
of  the  coronary  circulation  ; the  paralysis  of  the 
muscles  is  increased  by  want  of  blood  within 
them  ; and  the  temperature  falls  from  failure  of 
the  circulation  generally. 

In  non-fatal  cases  recovery  naturally  occurs 
by  restoration  of  the  cerebral  circulation  in  the 
recumbent  position,  and  consequent  stimulation 
of  the  cardiac  centre.  Other  circumstances  fa- 
vour the  recovery  of  the  general  circulation,  such 
as  the  relaxation  of  the  arteries,  and  the  partial 
restoration  of  the  respiratory  and  other  func- 
tions, which  quickly  react  upon  the  heart. 

Diagnosis.— Syncope  has  to  be  diagnosed  from 
other  conditions  in  which  loss  of  consciousness  is 
a prominent  symptom;  and  chiefly  from  epilepsy, 
‘apoplexy’  from  any  cause,  concussion  of  the 
brain,  shock,  and  from  poisoning  of  many  kinds,  in- 
cluding suffocation  by  certain  gases  and  drunken- 
ness. From  such  of  these  conditions  as  com- 
mence in  the  brain,  and  from  poisoning  (unless 
the  poisons  act  as  cardiac  depressants)  syncope 
is  readily  distinguished  by  the  characters  of  the 
pulse.  The  diagnosis  of  shock,  which  usually 
produces  a degree  of  syncope,  is  described  in  the 
article  on  that  subject.  See  Shock. 

Prognosis. — The  prognosis  of  syncope  depends 
upon  its  cause,  and  upon  the  practicability  of 
immediate  treatment.  If  due  to  organic  disease 
of  the  organs  of  circulation,  or  to  serious  injur}’, 
acute  poisoning,  excessive  heat,  or  profuse  hemor- 
rhage, the  case  is  serious,  and  may  prove  fatal 
unless  treatment  be  instantly  applied.  If,  on  the 
other  hand,  the  cause  of  the  faintness  lie  in  an 
excitable  nervous  system,  momentarily  depressed 
by  some  passing  emotional  disturbance,  or  by 
impurity  of  the  atmosphere,  the  attack  may  be 
pronounced  free  from  danger,  although  liable  to 
recur. 

Treatment. — In  the  treatment  of  syncope  two 
indications  are  equally  urgent,  namely,  removal 
of  the  cause  of  faintness,  and  restoration  of  the 
action  of  the  heart.  If  the  patient  should  not 
have  fallen,  he  must  be  immediately  laid  flat  on 
his  back  ; the  atmosphere  should  be  rendered  as 
pure  as  possible  by  throwing  open  the  windows 
and  doors,  by  removal  to  the  open  air,  and  by 
preventing  people  from  crowding  around;  and  tho 
dress  should  be  loosened  about  the  neck,  chest. 


1574  SYNCOI’E. 

and  abdomen.  If  haemorrhage  occur,  means  must 
be  taken  to  stop  it.  Cardiac  stimulants,  direct 
or  indirect,  must  then  he  employed.  The  most 
available  and  powerful  of  these  is  alcohol,  in 
the  form  of  brandy  or  other  spirit;  and  this 
may  be  given  either  pure  or  in  water,  and  in  an 
amount  which  will  vary  with  the  individual  case, 
as  estimated  by  the  immediate  result.  Sal  vola- 
tile, ether,  eau  de  Cologne,  if  available,  are 
equally  valuable  cardiac  stimulants.  Should  the 
patient  be  unable  to  swallow,  these  substances, 
as  well  as  warm  liquids,  must  be  given  at  once 
as  enemata;  or  ether  may  be  injected  under 
the  skin  of  the  praecordium.  Carbonate  of  am- 
monia (‘  smelling  salts  ’)  and  other  strong  smell- 
ing compounds,  including  perfumes,  fanning, 
cold  douches,  and  refrigerant  applications  of  eau 
de  Cologne  or  other  spirit  to  the  temples  and 
hands,  are  other  ready  methods  of  exciting  the 
heart  reflexly  through  the  nervous  centres.  If 
these  measures  fail  after  a fair  trial  the  con- 
dition of  the  patient  is  very  serious.  The  syste- 
matic employment  of  efficient  means  of  resusci- 
tation must  then  be  had  recourse  to,  including 
friction  of  the  limbs  and  trunk,  galvanisation  of 
the  region  of  the  heart,  and  even  transfusion  of 
blood.  See  Resuscitation  (A.). 

In  cases  ending  favourably  the  patient  must 
be  careful  not  to  assume  the  erect  position  too 
hastily,  or  to  undergo  much  exertion,  until  some 
rest  have  been  obtained  or  some  stimulant  or 
nourishment  administered. 

The  occurrence  of  syncope  is  sometimes  the 
first  indication  cf  the  existence  of  serious  or- 
ganic disease  of  the  heart  or  other  organ;  and 
it  should  suggest  a careful  examination  of  the 
patient,  and  the  adoption  of  measures  likely  to 
prevent  the  return  of  such  a dangerous  symptom, 
that  is,  the  avoidance,  as  far  as  they  are  avoid- 
able, of  the  principal  causes  already  mentioned. 

J.  Mitchell  Bruce. 

SYNOCHA  (<rwox<F&>,  I carry  with). — Sy- 
non.  : Febris  coniin.ua. 

SYNOCHTJS  (rrvvexu,  I hold  or  keep  to- 
gether).— Synon.  : Febris  continens. 

Synocha  and  synoclius  are  now  obsolete  terms, 
which  were  used  for  many  centuries  as  epithets  of 
two  distinct  types  of  fever,  hut  in  different  senses 
at  different  periods.  A complete  history  of  their 
varying  meanings  would  occupy  much  space ; a 
few  illustrations  of  it  only  need,  be  given.  Syno- 
cha does  not  occur  in  Galen’s  extant  writings  ; 
and  Synochus  is  by  him  contrasted  with  wupe-rbs 
trwtxvs,  and  defined  to  be  a fever  whose  course 
is  steady  and  uniform  from  its  beginning  to  its 
end.  Under  it,  in  his  Method.  Medend.,  lib.  ix., 
cap.  iii.  he  admits  three  varieties,  namely,  1, 
when  the  temperature  remains  steady ; 2,  when 
it  rises  steadily;  and  3,  when  it  falls  steadily, 
during  the  whole  course  of  the  fully  established 
disease.  The  meaning  of  the  term  has  no  refer- 
ence to  the  duration  of  the  fever.  ir uperbs 
svvex’hs,  on  the  contrary,  is  a fever  with  paro- 
xysms and  remissions.  Galen,  Dejinit.  Med., 
186-7. 

In  the  second  edition  of  Stephen  Blancard’s 
Lexicon,  a.d.  1717,  from  which  the  etymology 
given  above  is  taken,  synocha  is  a continued 
fever,  of  several  days’  duration,  with  paroxysms 


SYPHILIS. 

and  remissions,  attended  by  remarkable  heat, 
and  sometimes  putrid.  It  may  he  either  quo- 
tidian, tertian,  or  quartan.  By  this  he  seems 
to  mean  that  exacerbations  may  take  place  on 
those  days,  hut  the  fever  is  remittent  not  inter- 
mittent. Synochus  is  a continuous  fever  ( febris 
continens),  often  lasting  several  days,  unattended, 
by  serious  symptoms,  and  is  either  simple  or 
putrid,  according  to  its  severity. 

Linnaeus,  in  1763,  and  De  Sauvages,  in  1768, 
both  define  synocha  to  be  a fever  not  lasting 
more  than  a week,  synochus  one  not  lasting 
more  than  two  or  three  weeks. 

Cullen,  in  1785,  dissatisfied,  hesa3's,  with  the 
previous  use  of  the  words,  gives  to  them  a special 
meaning  of  his  own.  In  his  nosology  synocha  is 
a fever  with  very  high  temperature ; a frequent, 
strong,  hard  pulse;  red  urine;  and  very  little 
disturbance  of  the  sensorium.  Synochus  is  a 
contagious  disease,  in  which  the  fever  combines 
the  symptoms  of  synocha  and  of  typhus  ; begin- 
ning as  synocha,  towards  the  end  it  becomes 
typhus. 

With  this  variety  of  meaning  it  is  not  sur- 
prising that  the  same  disease  is  placed  under 
synocha  by  one  author,  under  synochus  by 
another.  As  the  further  uso  of  these  terms, 
apart  from  their  incongruity  with  modern  sys- 
tems of  classification,  can  only  perpetuate  this 
confusion,  they  may  be  allowed  to  become  ohso 
lete.  James  Andrew. 

SYNOVIAL  DISEASES.  See  Joints, 

Diseases  of. 

SYPHILIS  (etymology  uncertain.  Per- 
haps from  avv , with,  or  ervs,  a swine,  and  tpiKia, 
I love;  or  from  cri<p\6s,  crippled,  maimed). — 
iS won. : Vuig.,  Pox;  Fr.  Verole;  Ger.  Lv.st- 
Seuchc. 

Definition. — A specific  contagious  noc-inf<-c- 
tious  disease  ; communicable  by  contact  of  the 
poison  with  a breach  of  surface,  or  by  hereditary 
transmission.  Syphilis  is  characterised  by  a 
period  of  incubation  ; and  (except  in  the  case 
of  inheritance)  by  certain  changes  at  the  seat 
of  contagion,  and  in  the  proximate  lymphatic 
glands.  These  are  followed  by  an  eruption  on 
the  skin  and  mucous  membrane,  and  sometimes 
by  lesions  of  the  deeper  tissues  and  viscera. 

History. — The  origin  of  syphilis  is  unknown. 
In  India  and  China  there  is  little  doubt  that  the 
disease  existed  centuries  ago ; hut  the  time  at 
which  it  first  appeared  in  Europe  has  given  rise 
to  much  discussion,  and  is  still  the  subject  of 
dispute.  Some  writers  maintain  that  syphilis 
was  introduced  by  the  followers  of  Columbus 
from  the  West  Indies,  on  their  return  from  the 
discovery  of  Hayti  in  1493.  Others  again  hold 
that  it  first  broke  out  among  the  French  soldiers 
during  the  siege  of  Naples  in  1494-5.  There 
can  be  no  doubt  that  syphilis  of  a very  severe 
character  was  prevalent  in  Southern  Europe  to- 
wards the  close  of  the  fifteenth  century,  when 
indeed  it  seems  to  have  been  first  clearly  recog- 
nised and  described ; but  it  is  also  probable  that 
the  disease  had  existed  even  in  Europe  long 
before  that  time. 

.Etiology.—  There  is  but  one  cause  of  syphilis, 
namely,  the  absorption  of  the  Yirus  into  the 
blood,  and  its  gradual  diffusion  throughout  the 


SYPHILIS. 


Body.  It  was  formerly  taught — a doctrine  for 
which  John  Hunter  was  largely  responsible — 
that  syphilis,  the  soft  chancre,  and  gonorrhoea 
were  due  to  one  virus.  This  was  more  or  less 
generally  accepted  until  1838,  when  Ricord’s  re- 
searches confirmed  the  conclusions  arrived  at 
long,  before  by  Balfour  (1767),  and  Benjamin 
Bell  (1793),  to  the  effect  that  gonorrhoea  had 
nothing  whatever  to  do  with  the  other  two  dis- 
orders. The  next  step  was  completed  in  1852, 
by  the  publication  of  Bassereau's  evidence,  based 
on  the  comparison  of  a large  number  of  cases  of 
venereal  sore  with  their  source  of  contagion.  The 
results  of  these  observations  tended  to  show  that 
the  ‘ soft  chancre  ’ was  a local  affection,  quite 
distinct  from  the  general  disease  syphilis.  This 
is  the  view  most  generally  held  at  the  present 
day,  and  those  who  hold  it  are  now  called  dualists. 
A smaller  number  of  authors,  however,  still 
maintain  that  syphilis  and  the  soft  sore  are 
products  of  the  same  virus,  and  to  such  the  term 
unicist  is  applied.  The  discussion  of  unity  and 
duality  does  not  come  within  the  scope  of  this 
article.  It  is  sufficient,  therefore,  to  state  that 
it  is  from  the  more  generally  accepted  or  dual- 
ist point  of  view  that  the  present  account  is 
written.  Consequently,  when  the  term  syphilis 
is  used,  the  constitutional  disease  is  always  to 
be  understood.  The  local  suppurating  sore  or 
soft  chancre  is  described  elsewhere.  See  Vene- 
real Sore. 

One  attack  of  syphilis  usually  affords  pro- 
tection against  a second  throughout  the  lifetime 
of  the  individual.  In  the  rare  instances  in 
which  a person  suffers  more  than  once,  the 
second  attack  is,  as  a rule,  modified  by  the 
previous  one. 

Besides  being  capable  of  contaminating  others 
by  direct  contact,  the  subject  of  acquired  syphi- 
lis is  also  liable,  during  a variable  period,  to 
transmit  the  taint  to  his  offspring  ; but  whether 
the  inherited  form  of  disease  be  further  trans- 
missible to  the  next  generation  remains  doubtful. 

It  is  probable  that  many  persons,  though 
exposed  to  contagion,  escape  syphilis  as  they 
escape  other  contagious  diseases,  from  want  of 
susceptibility.  Ou  the  other  hand,  some  persons 
appear  to  be  particularly  susceptible  to  noxious 
influences,  and  suffer  more  than  once  from  the 
same  contagious  disorder.  The  reason  of  such 
peculiarity  is  not  yet  understood. 

Pathology  and  Anatomical  Characters. — 
The  essential  nature  of  the  syphilitic  poison  is 
unknown.  Certain  elements  have  been  reported 
as  found  exclusively  in  the  blood  or  tissues  of 
syphilitic  persons  ; but  not  on  conclusive  evi- 
dence. The  recent  views  on  this  subject  of 
Klebs,  Aufrecht,  and  Birch-Hirschfeld  will  be 
found  in  the  Lancet  for  August  26,  1882,  p.  316. 
Whether  syphilis  is  a special  disease  or  to  be 
classed  among  the  exanthemata,  need  not  be  dis- 
cussed here.  It  will  be  sufficient  to  point 
out  that  while  it  resembles  the  acute  fevers  in 
having  a period  of  incubation,  in  the  develop- 
ment of  an  exanthem,  and  in  the  protection 
commonly  afforded  by  one  attack  against  subse- 
quent ones,  it  yet  differs  from  them  in  its  long 
duration  and  liability  to  relapse,  in  the  non-in- 
fcctious  nature  of  its  poison,  and  in  its  capability 
»f  being  greatly  influenced  by  certain  remedies. 

• 


1575 

When  the  syphilitic  poison  has  been  absorbed, 
it  multiplies  until  the  whole  system  becomes 
pervaded  by  it.  How  soon  this  absorption 
takes  place  is  not  known.  Some  believe  that 
the  virus  remains  localised  at  or  about  the  seat 
of  inoculation  during  the  incubation-period. 
Hence,  of  late  years  excision  of  the  initial  lesion 
has  been  again  extensively  practised  by  Auspitz 
and  others,  with  the  object  of  preventing  further 
development  of  the  disease.  The  results  of  these 
experiments,  however,  have  not,  so  far,  proved 
that  the  removal  or  destruction  of  the  initial 
manifestation  at  any  stage  of  its  development 
can  prevent  general  infection. 

The  changes  which  (syphilis  produces  in  the 
tissues  are  chiefly  of  an  inflammatory  nature. 
The  process,  which  is  essentially  the  same  in  the 
primary  induration  and  in  the  later  manifestations 
of  the  disease,  begins  by  the  production  of  nume- 
rous small  round  cells,  which  are  situated  chiefly 
in  the  outer  portion  of  the  sheath  of  minute 
blood-vessels,  and  imbedded  in  a delicate  stroma 
Thus  the  growth  is  of  the  nature  of  granula- 
tion-tissue, and  does  not  present  any  elements 
peculiar  to  syphilis.  It  is  at  first  a highly 
organised  tissue,  rich  in  blood-vessels  ; but  sub- 
sequently shows  a marked  tendency  to  vasculai 
thrombosis  and  consequent  degeneration. 

The  new  growth  may  develop  in  a diffused 
infiltrating  form,  involving  a greater  or  less  ex- 
tent of  the  invaded  tissues  ; or  in  the  circum- 
scribed masses  known  as  gummata.  Any  of  the 
structures  of  the  body  may  be  attacked,  most 
commonly,  perhaps,  the  subcutaneous  connective 
tissue  ; but  bone,  muscle,  the  blood-vessels,  the 
placenta,  and  the  internal  viscera  are  all  liable 
to  suffer ; and  although  the  morbid  growth  is 
essentially  the  same  wherever  it  is  developed, 
it  of  course  presents  differences  in  appearance, 
according  to  the  particular  tissue  or  organ 
affected. 

It  is,  however,  the  circumscribed  swelling  or 
gumma  that  is  most  characteristic  of  syphilis. 
In  its  typical  form  it  appears  as  a yellowish, 
tough,  somewhat  elastic,  and  sharply  circum- 
scribed mass,  varying  usually  from  the  size  of  a 
marble  to  that  of  a large  chestnut.  It  is  also 
often  caseous  in  the  middle,  and  is  surrounded 
by  a highly  vascular  fibrous  investment.  Gum- 
mata are  frequently  associated  with  the  diffused 
form  of  growth,  which  after  a time  becomes  con- 
verted into  a tough  fibrous  tissue  ; this  finally 
contracts,  and  thus  puckers,  deforms,  and  often 
seriously  affects  the  functions  of  the  organ  in 
which  it  grows.  Fibroid  induration  and  scarring 
are  not  uncommonly  discovered  in  the  organs  of 
syphilitic  subjects,  but  fibroid  disease  is  not 
generally  recognised  as  being  unquestionably 
syphilitic  unless  gummata  be  also  present. 

Besides  the  changes  that  have  just  been  de- 
scribed, lardaccous  disease  is  frequently  caused  by 
syphilis.  Indeed  this  is  probably  the  commonest 
visceral  affection  found  in  the  bodies  of  old 
syphilitic  persons. 

Modes  of  Communication. — Before  consider- 
ing the  different  ways  in  which  syphilis  may  be 
propagated,  it  is  necessary  to  mention  the  vehicles 
of  the  virus.  These  are  : 

1.  The  discharge  of  the  initial  lesion. 

2.  The  secretions  of  all  the  secondary  eruptivs 


<676  SYPHILIS. 


lesions,  especially  of  the  moist  papules  known 
as  mucous  patches  or  tubercles. 

3.  The  blood,  during  the  continuance  of 
secondary  symptoms. 

The  secretions  of  the  later  or  tertiary  affec- 
tions have  not  been  proved  to  be  contagious,  nor 
have  the  physiological  secretions  of  a syphilitic 
person — for  example,  the  saliva,  sweat,  tears, 
semen,  milk — unless  mixed  with  the  secretions 
of  syphilis  or  with  the  blood,  even  though  the 
disease  be  in  an  early  stage.  Further,  the  secre- 
tions of  other  diseases  from  which  a syphilitic 
person  may  be  suffering  are  not  always  con- 
tagious. This  at  least  is  the  case  with  regard 
to  vaccinia;  for  healthy  children  have  been  often 
vaccinated  from  syphilitic  ones  without  con- 
tracting syphilis. 

The  sources  of  contagion  being  so  numerous, 
it  is  easy  to  understand  that  the  modes  of  com- 
munication must  be  so  also.  They  may  be 
described  under  three  heads : — 1.  direct  contact ; 
2.  mediate  communication ; and  3.  hereditary 
transmission. 

1.  Direct  contact. — In  the  great  majority  of 
cases  syphilis  is  imparted  during  sexual  inter- 
course, first,  because  the  genital  organs  are 
the  most  frequent  seat  of  the  contagious  lesions  ; 
secondly,  because  the  delicate  epithelium  of  those 
organs  is  especially  liable  to  abrasion  during 
coitus.  Hence  syphilis  is  usually  described  as 
a venereal  disease,  but  it  should  always  be  re- 
membered that  it  is  not  necessarily  so.  Where- 
ever  the  poison  comes  in  contact  with  a broken 
surface,  it  maybe  absorbed  and  general  infection 
follow.  Instances  of  syphilis  being  conveyed  quite 
independently  of  sexual  relations  are  unfortu- 
nately far  from  rare.  Perhaps  the  most  frequent 
mode  of  extra-genital  contagion  is  the  contamina- 
tion cf  a wet  nurse  by  a syphilitic  child,  or  of  a 
child  by  its  nurse.  The  disease  may  also  be  spread 
by  kissing,  contagious  syphilitic  lesions  being 
very  common  about  the  lips  and  in  the  mouth. 
Again,  medical  men  and  midwives  not  unfre- 
quently  contract  syphilis  by  attending  diseased 
women  in  labour;  and  surgeons  by  examining  or 
operating  upon  syphilitic  persons. 

2.  Mediate  communication. — When  syphilis  is 
communicated  indirectly  the  medium  may  be  of 
almost  endless  variety.  Articles  which  are  used 
in  common  by  different  persons,  such  as  spoons, 
drinking  vessels,  pipes,  &c.,  are  perhaps  the 
commonest  media ; implements  used  in  various 
trades — the  tubes  used  in  glass-blowing,  for  ex- 
ample— have  also  acted  in  the  same  vray.  Again, 
through  the  performance  of  tattooing,  cupping, 
catheterisation  of  the  Eustachian  tube,  &c.,  by 
ignorant  persons  and  quacks,  the  disease  lias 
been  communicated,  and  it  has  also  happened 
during  vaccination  ; but  in  this  country,  where 
that  operation  is  performed  only  by  duly  qualified 
medical  men,  such  an  accident  is  of  extreme 
rarity.  Another  mode  of  mediate  communication, 
where  one  person  conveys  syphilis  to  a third 
through  the  medium  of  a second  who  escapes 
contagion,  has  also  been  described  by  various 
authors. 

3.  Hereditary  transmission. — Our  knowledge 
is  still  imperfect  respecting  the  ways  in  which 
syphilis  may  be  transmitted  from  parent  to  child ; 
and  tho  questions  involved  are  much  too  wide 


for  discussion  in  this  article.  Consequently,  no 
attempt  will  be  made  to  do  more  than  state 
briefly  the  facts  which  are  most  generally  ac- 
cepted, and  the  most  usual  course  of  events  when 
syphilitic  persons  become  parents. 

In  the  first  place  it  must  be  remembered  that 
the  child  does  not  necessarily  become  contami- 
nated, in  whatever  stage  of  syphilis  the  parents 
may  be.  As  a rule,  however,  the  more  recent 
the  infection  of  the  parents  the  more  likely  is 
the  child  to  inherit  the  disease.  The  elder 
children  usually  suffer  most  severely ; but  this 
is  by  no  means  always  the  case.  For  instance, 
treatment  has  great  influence  over  the  transmis- 
sive power,  and  a healthy  child  may  be  bora 
while  the  mother  is  under  the  influence  of 
mercury,  but  a subsequent  one  may  be  tainted, 
if  treatment  have  been  discontinued,  and  tho 
disease  have  again  resumed  activity.  There  are 
also  periods  of  quiescence  in  syphilis  independent 
of  treatment,  during  which  healthy  children  are 
sometimes  bom.  When  the  infection  of  both 
parents  is  recent  the  child  almost  invariably 
suffers,  and  this  is  also  the  case  if  the  mother 
alone  be  diseased.  Under  such  circumstances 
abortion  or  premature  birth  is  common.  When 
the  father  alone  is  syphilitic,  both  mother  and 
child  may  escape.  Some  believe  that  a syphilitic 
father  may  procreate  a diseased  child  while  the 
mother  escapes,  but  this  is  by  no  means  proved. 
Indeed,  it  appears  most  probable  that  the  mother 
of  a syphilitic  child  does  not  really  escape  con- 
tagion, although  she  may  show  no  characteristic 
signs  of  the  disease.  The  most  weighty  evidence 
in  support  of  this  view  is  that  known  as  1 Colles’s 
law’ — namely,  that  the  mother  cf  a syphilitic 
child  never  becomes  infected  by  it  after  birth  ; 
and  further,  seems  proof  against  contagion  in  any 
other  way.  In  the  cases  where  the  mother  does 
not  show  the  ordinary  early  signs  of  syphilis, 
it  is  believed  by  many  that  the  foetus  becomes 
diseased  directly  by  the  father,  and  in  turn 
infects  the  mother  through  the  placental  circula- 
tion {‘choc  cn  retour’).  There  is  much  evidence 
in  favour  of  this  view.  Lastly,  if  the  mother 
acquire  syphilis  during  the  earlier  months  of 
pregnancy  the  child  commonly  suffers ; hut  if  she 
be  infected  after  the  seventh  month  the  child  may 
escape. 

Symptoms. — The  symptoms  of  syphilis  are 
usually  divided  into  three  groups — primary, 
secondary,  and  tertiary.  And  although  such 
division  is  really  artificial,  it  will  be  useful  to 
retain  these  terms  for  the  purpose  of  descrip- 
tion ; but  it  must  be  borne  in  mind  that  the 
patient  during  the  primary  stage  is  just  as 
much  the  subject  of  syphilis  as  during  the  stage 
of  general  symptoms,  and  that  in  certain  cases 
the  signs  proper  to  all  three  periods  may  be 
present  at  the  same  time. 

Primary  syphilis. — A patient  is  said  to  he 
suffering  from  primary  syphilis  as  long  as  the 
initial  manifestation  (hard  chancre),  and  the 
accompanying  glandular  enlargement,  remain  the 
sole  signs  of  the  disease. 

When  the  syphilitic  poison,  unmixed  with  any 
irritating  matter,  has  been  inoculated,  the  abrasion 
quickly  heals,  and  no  further  change  is  observed 
for  three  weeks  or  a month.  This  interval  is 
called  the  period  of  incubation,  and  its  average 


SYPHILIS. 


length,  judging  from  cases  of  experimental  inocula- 
tion, is  about  twenty-four  days ; but  it  may  be  as 
short  as  ten,  or  as  long  as  forty-six  days.  After 
the  lapse  then  usually  of  an  interval  of  three  or 
four  weeks,  a certain  change  occurs  at  the  site  of 
inoculation,  which  is  called  the  initial  manifesta- 
tion or  lesion.  This  may  assume  various  forms, 
and  is  commonly  termed  a hard,  or  indurated,  or 
infecting  chancre.  The  initial  lesion  presonts 
certain  differences  in  appearance,  according  to  its 
position,  and  according  to  whether  it  be  irritated 
or  not.  Its  chief  characteristic  is  the  presence 
of  induration  at  its  base,  and  the  aspect  of  the 
sore  is  much  affected  also  by  the  degree  in  which 
this  hardness  is  developed.  Sometimes  the  lesion 
appears  as  a hard  desquamating  papule  ; some- 
times as  a well-marked  indurated  ulcer,  having 
a hard  well-defined  base  and  thickened  adherent 
margins  (the  so-called  ‘ Hunterian  chancre  ’) ; but 
most  commonly  as  an  erosion  or  shallow  ulcer, 
with  an  amount  of  induration  which  varies  much 
in  different  cases,  and  which  is  not  always  easily 
appreciable  unless  care  be  taken.  Sometimes 
the  induration  develops  in  a thin  layer,  like  a 
pieco  of  parchment  or  even  paper ; hence  the 
term  ‘ parchment  sore  ’ often  applied  to  this  form 
of  the  initial  lesion.  In  rare  instances,  especi- 
ally in  women,  induration  appears  to  be  absent 
altogether.  The  secretion  is  thin,  scanty,  non- 
purulent,  and  not  inoculable  on  the  bearer. 
Hence,  the  syphilitic  primary  sore  is  usually 
single,  contrasting  strongly  in  this  respect  with 
the  local  chancre,  in  which  multiplicity  is  the 
rule.  The  sore  is  indolent  and  often  painless, 
and  tends  to  disappear  spontaneously  after  having 
lasted  several  weeks  or  months. 

The  seat  of  the  initial  lesion  is  most  frequently 
the  genitalorgans,  but,  as  has  already  been  stated, 
absorption  of  the  poison  may  occur  in  any  situa- 
tion where  a breach  of  surface  exists.  Conse- 
quently the  initial  lesion  may  be  found  on  any 
part  of  the  body,  as  about  the  lips  or  mouth  in 
children,  on  the  nipple  in  nurses,  or  on  the  hand 
or  finger  in  the  case  of  doctors  and  midwives. 

If,  as  frequently  happens,  irritating  matter  of 
any  kind  have  been  inoculated  along  with  the 
syphilitic  poison,  the  course  of  events  will  vary 
according  to  circumstances.  Thus,  if  it  be 
mixed  with  ordinary  pus,  irritation  will  begin  at 
once  at  the  site  of  inoculation.  Again,  if  the 
pus  of  the  local  chancre  have  also  been  absorbed 
(a  very  common  occurrence),  the  period  of  incuba- 
lion  will  bo  occupied  by  the  course  of  the  suppura- 
ting sore,  w'hich  may  or  may  not  have  healed  at 
the  time  the  change  peculiar  to  syphilis  occurs. 
If  the  sore  be  still  present,  induration  will  develop, 
and  the  lesion  will  for  a time  assume  the  characters 
of  both  varieties  of  sore  ; but  if  it  have  healed, 
the  cicatrix  will  harden  and  eventually  assume 
more  or  less  closely  the  appearance  of  one  or 
other  of  the  varieties  of  initial  lesion  which  have 
just  been  mentioned. 

The  progress  of  the  initial  lesion  is  usually 
slow.  The  duration  varies  from  two  or  three 
weeks  to  several  months,  according  to  its  size,  and 
the  influence  of  treatment.  It  sometimes  breaks 
out  again  after  cicatrisation  ; induration  may 
also  reappear  without  fresh  contagion.  If  the 
sore,  from  irritation  of  any  kind,  be  made  to  sup- 
purate, the  secretion  may  become  inoculable  on  the 


167T 

bearer.  When  thcchancrous  and  syphilitic  poisons 
have  both  been  inoculated,  tho  resulting  lesion 
has  been  termed  by  Itollet  a 1 mixed  chancre.' 

Glandular  Enlargement. — On  whatever  part  of 
the  body  the  initial  lesion  may  be  situated,  tbs 
nearest  lymphatic  gland  or  glands  become  per- 
ceptibly enlarged  in  from  seven  to  fourteen  days 
after  its  appearance.  The  wholegroup  is  usually 
affected,  blit  the  gland  most  directly  connected 
with  the  point  of  contagion  enlarges  first,  and 
often  attains  a greater  size  than  the  others. 
Each  gland  can  be  felt  as  a separate  distinct 
indolent  swelling,  usually  about  the  size  of  a 
marble,  the  cellular  tissue  aud  skin  remaining 
free.  At  this  time  the  enlargement  commonly 
remains  limited  to  the  nearest  group,  but  later  is 
sometimes  general.  Suppuration  of  the  glands 
probably  never  occurs  unless  there  be  some  source 
of  irritation  in  addition  to  the  syphilitic  poison  ; 
or  the  patient  be  scrofulous,  or  over-exert  or 
injure  himself,  or  be  in  bad  health  from  some 
other  cause.  Even  when  suppuration  does  occur, 
the  abscess  is  always  of  a simple  nature,  and  the 
matter  is  not  inoculable  on  the  bearer  unless  the 
local  chancre  be  present  as  well,  and  direct  ab- 
sorption of  chancrous  pus  take  place  (see  Bubo), 
Besides  the  glands,  the  lymphatic  vessels  leading 
to  them — those  of  the  penis,  for  example — are 
frequently  enlarged  also,  and  can  be  felt  as  hard 
cords,  freely  movable  beneath  the  skin. 

Secondary  Syphilis. — After  the  development 
of  the  initial  manifestation,  with  its  accompanying 
adenopathy,  another  interval  occurs  before  further 
signs  appear.  This  period  is  sometimes  called 
the  ‘ second  incubation,’  to  distinguish  it  from 
that  which  intervenes  between  contagion  and  the 
appearance  of  the  initial  lesion.  This  second 
period  of  quiescence,  counting  from  the  appear- 
ance of  the  initial  lesion  to  the  appearance  of  the 
general  eruption,  is  usually,  unless  prolonged  by 
treatment,  about  six  weeks.  Thus  as  a general 
rule  it  may  be  stated  that  the  exanthem  appears 
from  sixty  to  seventy  days  after  contagion  ; from 
forty  to  fifty  after  the  initial  lesion;  and  from 
thirty  to  forty  after  enlargement  of  the  proximate 
lymphatic  glands. 

During  the  earlier  part  of  this  period  the 
patient  commonly  does  not  feel  ill,  but  towards 
its  close,  and  shortly  before  the  appearance  of 
the  exanthem,  some  patients,  especially  women, 
if  they  be  not  already  under  the  influence  of 
mercury,  develop  certain  symptoms  of  constitu- 
tional derangement  which  have  received  the  name 
of  prodromata.  Thus  the  patient  may  become 
pale  and  anaemic,  and  may  suffer  from  shortness 
of  breath  and  lassitude.  In  addition,  headache, 
loss  of  appetite,  malaise,  pains  in  the  limbs  and 
back,  and  sometimes  rise  of  temperature,  and 
other  symptoms  known  under  the  name  of 
‘ syphilitic  fever  ’ are  present.  During  this  period 
also,  as  was  first  pointed  out  by  Kicord  and 
Grassi,  whose  conclusions  have  since  been  con- 
firmed by  Wilbouchewitch,  Keyes,  and  others,  the 
proportion  of  red  blood-cells  is  diminished.  The 
prodromata  are  usually  mild  in  degree,  but 
occasionally  they  are  intense.  Thus,  headache 
may  be  agonizing,  and  in  rare  instances  the 
amount  of  constitutional  disturbance  is  so  great 
that  the  onset  of  one  of  the  acute  spacific  fevers 
may  be  suspected. 


SYPHILIS. 


1578 

Cutaneous  system. — At  the  end  of  this  second 
.interval  of  quiescence  then,  and  having  been 
preceded  or  not  by  some  of  the  symptoms  just 
mentioned,  the  first  general  eruption  appears. 
This,  in  the  vast  majority  of  cases,  takes  the 
form  of  roseola,  consisting  of  numerous  rosy  red 
spots,  varying  in  size  from  a hemp-seed  to  a 
shilling,  fading  on  pressure  at  first,  but  after- 
wards becoming  dull  red  or  brownish,  and  finally 
disappearing  altogether,  sometimes  with  slight 
desquamation  of  the  cuticle.  The  spots  usually 
appear  first  about  the  flanks,  chest,  and  abdo- 
men. The  extent  and  duration  of  roseola  vary 
much  in  different  persons.  It  may  bo  limited  to 
a few  faint  spots  on  the  anterior  surface  of  the 
trunk,  or  the  whole  body  may  bo  covered  with  the 
rash,  in  which  case  it  often  greatly  resembles  that 
of  measles.  Roseola  may  appear  suddenly  and 
disappear  quickly,  or  it  may  last  for  several  weeks 
and  indeed  occasionally  for  months,  if  untreated. 
It  sometimes  relapses,  but  in  that  case  is  never 
general,  being  usually  limited  to  a few  blotches 
on  the  forehead,  trunk,  or  limbs. 

As  the  macular  eruption  fades,  papules  not 
uncommonly  appear,  so  that  a maeulo-papular 
eruption  is  often  seen  in  early  syphilis.  The 
papules  are  raised,  bright  red  at  first,  but  soon 
changing  to  the  so-called  ‘coppery’  hue,  which, 
however,  is  much  more  like  that  of  raw  ham. 
Finally,  the  cuticle  separates  in  scales,  leaving  a 
characteristic  silvery  border  or  ‘collarette’  round 
the  base  of  the  papule.  The  papules  are  very 
liable  to  relapse,  and  the  oftener  they  re-appeiir 
the  more  scaly  they  become.  When  they  fade 
a brown  stain  is  left,  which  gradually  disappears 
without  leaving  any  scar.  At  this  time  also 
crusts  are  frequently  present  on  the  scalp  among 
the  hair,  which  itself  becomes  dry  and  withered, 
and  at  a later  period  very  often  falls  out  either 
generally  or  in  patches.  Besides  the  scalp  the 
eyebrows,  eyelids,  axill®,  and  indeed  all  the  hairy 
regions  of  the  body,  may  suffer.  The  nails  also 
are  liable  to  be  attacked  in  several  ways.  See 
Nails,  Diseases  of. 

Though  the  macular  and  papular  syphilides 
are  by  far  the  most  frequent  forms  of  early  rash, 
vesicular,  pustular,  and  ulcerating  eruptions 
sometimes  appear  during  the  secondary  stage, 
the  two  latter  being  most  common  in  patients  of 
bad  constitution. 

The  earlier  eruptions  are  usually  superficial, 
and  widely  spread.  The  colour  is  at  first  bright 
red,  but  afterwards  ham-red.  Except  in  the  case 
of  the  earliest  rash,  tire  papule  forms  the  base  of 
the  eruption.  Irritation  and  itching  are  usually 
absent.  The  eruption  has  certain  favourite  seats, 
namely,  the  trunk,  the  border  of  the  hairy  scalp, 
and  the  flexor  surface  of  the  limbs,  including  the 
palms  and  soles.  Several  forms  of  eruption  are 
often  present  at  the  same  time ; most  commonly 
maculce  and  papules,  but  sometimes  papules  and 
vesicles,  or  pustules.  They  all  tend  to  disappear 
spontaneously,  and,  except  the  pustular  form, 
without  leaving  any  scar. 

Mucous  'membranes. — Besides  the  affections  of 
the  skin,  lesions  of  the  mucous  membrane,  parti- 
cularly that  of  the  mouth  and  throat,  are  nearly 
always  present  during  the  secondary  stage.  Ery- 
thema, excoriations,  or  shallow  ulcers  are  very 
common  about  the  fauces  and  tonsils,  as  well  as 


on  the  buccal  surface  and  tongue,  during  the 
ear-ly  portion  of  this  stage ; and  the  nasal  and 
laryngeal  mucous  membrane  is  also  liable  to 
be  similarly  affected.  Equally  common,  though 
usually  somewhat  later,  are  mucous  patches  or 
tubercles  (condylomata).  They  are  merely  the 
papules  of  the  general  eruption  altered  by  mois- 
ture, and  are  most  common  on  the  mucous 
surfaces  and  in  localities  where  skin  and  mu- 
cous membrane  join,  for  instance,  on  the  genital 
organs,  at  the  angles  of  the  mouth,  and  round 
the  anus  ; but  in  dirty  people  they  may  form 
between  the  toes,  about  the  umbilicus,  and  even 
behind  the  ears. 

These  affections  of  the  skin  and  mucous  sur- 
faces are  often  accompanied  by  more  or  less 
deterioration  of  the  general  health,  with  pallor, 
lassitude,  and  considerable  loss  of  weight.  Pains 
iu  the  muscles,  hones,  or  joints  (osteocopic  pains) 
and  sometimes  periosteal  swellings  or  synovial 
effusions  also  occur ; as  well  as  more  or  less 
general  enlargement  of  remote  lymphatic  glands, 
particularly  those  of  the  neck  and  beneath  the 
jaw;  but  the  axillary,  epitrochlear.  and  indeed 
all  the  glands  within  reach,  may  bo  enlarged. 
Iritis  is  also  liable  to  come  on  about  this  time, 
and  later,  choroiditis.  Sometimes,  but  moro 
rarely,  affections  of  the  auditory  apparatus  are 
present. 

The  number,  extent,  and  severity  of  the  secon- 
dary manifestations  vary  greatly  in  different 
persons.  In  some  cases  roseola,  and  slight  red- 
ness and  excoriation  of  the  throat,  are  the  only 
signs  that  appear.  In  other  instances  roseola  is 
succeeded  by  papular  and  scaly  syphilides.  and 
by  obstinately  recurring  lesions  of  the  mouth, 
throat,  genital  organs,  or  other  parts  of  the 
body. 

After  the  lapse  of  a period  which  varies  usually 
from  six  to  eighteen  months,  the  secondary  stage 
comes  to  an  end,  and  in  many  cases  the  disease 
troubles  the  patient  no  longer.  But  supposing 
this  not  to  he  the  case,  there  may  be  an  interr.il 
of  months  or  years  during  which  no  symptoms 
appear.  Sometimes, however,  symptoms  continue 
to  develop  from  time  to  time,  which  partake  of 
the  characters  of  both  the  secondary  and  ter- 
tiary stages,  and  which  gradually  merge  into  the 
latter  without  any  strict  line  of  demarcation  be- 
tween the  two.  Examples  of  these  intermediate 
signs  are  thickened  scaly  patches  on  tho  skin, 
which  often  take  a circular  form,  and  sometimes 
ulcerate  ; obstinate  eruptions  of  the  soles  and 
palms  (the  so-called  plantar  and  palmar  ‘psori- 
asis ’) ; ulcers  of  the  tongue,  gradually  becoming 
deeper,  and  with  thickened  edges;  periosteal 
swellings;  orchitis;  and  affections  of  the  choroid 
and  retina. 

Tertiary  Syphilis. — “While  the  secondary 
stage  of  syphilis  is  mainly  characterised  by  the 
occurrence  of  superficial  lesions,  more  or  less 
widely  spread  over  the  surface,  and  tending  to 
spontaneous  disappearance;  the  main  features  of 
tertiary  affections,  on  the  other  hand,  are  that 
they  usually  attack  only  a limited  area,  that 
they  have  a marked  tendency  to  extend  deeply 
and  to  cause  destruction  of  tissue,  with  consequent 
contraction  and  scarring,  and  that  they  do  toe 
tend  to  spontaneous  recovery. 

The  chief  lesions  usually  classed  as  ceitumf 


SYPHILIS.  1579 


are  severe  forms  of  eruption,  such  as  rupia,  and 
deep  ulcers  of  the  skin  and  mucous  membrane ; 
and  diffused  infiltration  or  gummata  of  the  sub- 
cutaneous and  submucous  cellular  tissue,  muscle, 
bone  and  periosteum,  testes,  brain  and  spinal 
cord,  blood-vessels  and  the  internal  viscera, 
of  which  the  liver  is  most  frequently  attacked. 
The  tertiary  period,  also,  is  often  attended  by 
severe  cachexia,  with  a peculiar  earthy  pallor  of 
the  skin. 

The  syphilitic  new  growth  may  develop  in  a 
diffused  or  in  a circumscribed  form ; but  in  either 
case,  unless  checked  by  treatment,  degeneration 
is  usually  rapid,  leading  to  obstinate  ulceration 
when  the  superficial  structures  are  attacked,  and 
to  the  production  of  toughcontractilefibrous  tissue 
when  the  viscera  are  the  seat  of  the  new  forma- 
tion. 

When  the  gummy  growth  develops  in  the  skin 
or  mucous  membrane  in  a diffused  form,  it  pro- 
duces hard,  flat  plaques  of  varying  extent.  The 
skin  after  a time  becomes  purplish-red  and  ad- 
herent, and  finally  breaks  down  at  several  points ; 
and  an  ulcer  is  left,  which  sometimes  creeps  over 
the  surface  (serpiginous  ulceration),  healing  in 
the  middle  and  extending  at  the  margins,  until  a 
considerable  amount  of  tissue  is  destroyed.  When 
this  diffused  infiltration  occurs  in  the  pharynx, 
larynx,  or  rectum,  the  disease  is  very  obstinate, 
unless  actively  treated  at  an  early  stage,  and 
the  ideeration  and  subsequent  contraction  may 
produce  incurable  and  fatal  stricture  in  any  of 
those  situations. 

When  the  circumscribed  form  develops  in  the 
skin  itself,  it  is  known  as  a syphilitic  tubercle , 
and  when  in  the  cellular  tissue  as  a gumma. 
Gummata  vary  much  in  size.  At  first,  they  are 
small  hard  nodules,  freely  movable  beneath  the 
skin  ; but  after  a time  they  enlarge,  soften,  and 
become  adherent  to  the  discoloured  integument, 
which  finally  gives  way,  exposing  a mass  of 
yellowish-white  material,  which  is  gradually  cast 
off  in  the  form  of  debris,  and  thin  ill-formed  pus. 
The  cavity  then  heals  by  granulation,  leaving  a 
depressed  scar. 

The  syphilitic  affections  of  the  other  tissues, 
and  of  the  various  organs  of  the  body,  with  their 
symptoms,  will  be  found  described  along  with 
the  other  diseases  of  the  several  parts.  See 
Bkain,  Syphilitic  Disease  of ; Bone,  Diseases  of; 
Livek,  Syphilitic  Disease  of;  Testes,  Diseases 
of,  &c. 

Malignant  Syphilis. — It  has  already  been 
mentioned  that  the  division  of  syphilis  into  a 
secondary  and  a tertiary  stage  is  to  a great 
extent  artificial,  and  that  it  is  often  impossible 
to  say  under  which  title  certain  lesions  ought  to 
be  classed.  There  are  again  cases,  fortunately 
not  common,  to  which  the  term  malignant  or 
galloping  syphilis  has  been  applied,  in  which 
the  disease  from  the  first  pursues  a rapid,  de- 
structive, and  sometimes  uncontrollable  course. 
Skin-eruptions,  which  partake  of  the  secondary 
stage  in  their  wide-spread  character,  and  of  the 
tertiary  in  their  tendency  to  ulcerate,  appear 
early,  even  while  the  initial  lesion  is  still  pre- 
sent. Deep  ulcers  form  also  in  the  mucous 
membrane,  and  the  gummy  growth  may  develop 
in  the  internal  organs,  and  cause  death,  or  the 
patient  may  die  worn  out  by  exhaustion. 


Inherited.  Syphilis. — Syphilis  is  a very  fre- 
quent cause  of  abortion,  which  occurs  most  com- 
monly about  the  fifth  or  sixth  month.  If  the 
child  be  carried  the  full  term,  it  may  be  bom 
dead  with  or  without  signs  of  syphilis ; most 
commonly,  however,  if  the  child  be  born  alive  it 
does  not  show  any  signs  of  the  disease  at  birth. 

In  inherited  syphilis  the  initial  manifestation 
is  of  course  absent,  and  the  disease  begins  at 
the  secondary  stage.  With  this  exception  the 
symptoms  of  the  inherited  are  in  their  main 
features  similar  to  those  of  the  acquired  disease, 
allowance  being  made  for  the  difference  between 
the  actively  growing  tissues  of  the  child  and  the 
fully  developed  organs  of  the  adult. 

Supposing,  then,  the  child  to  have  been  born 
alive,  it  usually  shows  no  evidence  of  disease  for 
a period  ranging  between  two  and  six  weeks  after 
birth.  It  then,  as  a rule,  gradually  loses  its 
healthy  appearance,  begins  to  snuffle,  becomes 
fretful,  and  loses  flesh  rapidly.  The  skin  as- 
sumes a dull  dirty  colour,  and  though  loose,  dry, 
and  wrinkled,  is  very  brittle  and  easily  breaks 
round  the  mouth  and.  nose  into  chaps  and  fis- 
sures, the  scars  of  which  often  form  a very  cha- 
racteristic sign  in  after-life  if  the  child  survive. 
Macular,  papular,  vesicular,  or  pustular  rashes, 
resembling  those  seen  in  the  adult,  also  appear, 
and  mucous  patches  are  nearly  always  present 
about  the  orifices  of  the  body.  Pemphigus  is 
seen  only  in  severe  cases  ; it  appears  very  early, 
and  is  frequently  fatal.  The  lesions  of  inherited 
syphilis  are  just  as  contagious  as  those  of  the 
acquired  form  of  the  disease. 

A peculiar  feature  of  inherited  syphilis  con- 
sists in  the  tendency  to  visceral  disease  as  well 
as  to  bone-lesions  at  an  early  period,  even  during 
intra-uterine  life  These  changes  have  been 
particularly  described  by  Wegner,  Parrot,  E.  W. 
Taylor,  Barlow,  Lees,  and  others  of  late  years. 
The  bones  most  liable  to  be  attacked  are  those 
of  the  cranial  vault,  and  the  long  bones  of  the 
extremities,  particularly  the  humerus  and  tibia. 
See  Bone,  Diseases  of. 

In  later  life,  inherited  syphilis  may  manifest 
itself  by  a number  of  symptoms  which  were  for- 
merly ascribed  to  scrofula.  The  forehead  is  pro- 
minent, and  the  bridge  of  the  nose  sunken.  The 
growth  is  checked,  the  individual  being  stunted, 
weakly,  ill-nourished,  and  of  low  vitality.  The 
skin  is  greasy  and  earthy-looking,  and  perhaps 
scarred  by  previous  ulceration.  The  permanent 
teeth,  especially  the  central  upper  incisors,  as 
was  first  pointed  out  by  Mr.  Hutchinson,  are 
conical  or  ‘ pegged  ’ and  sometimes  notched  at  the 
free  border  (see  Teeth,  Diseases  of).  'The  cornea 
is  liable  to  a low  form  of  inflammation  (inter- 
stitial keratitis),  leading  to  opacity  and  more 
or  less  impairment  of  vision  ; the  iris  and  the 
deeper  structures  are  also  liable  to  be  invaded ; 
and  deafness  is  sometimes  present.  The  bones  of 
the  palate  and  nose  may  be  diseased ; and  nodes 
may  appear  in  various  situations.  The  frngers 
and  toes  also,  and,  more  rarely,  the  metacarpal 
and  metatarsal  bones  may  become  enlarged  (dac- 
tylitis). This  affection  is  most  common  in  early 
life  ; but  it  has  been  observed  after  puberty,  as 
well  as  in  connection  with  acquired  syphilis. 
The  soft  palate  and  pharynx  are  often  the  seat 
of  ulceration.  The  deeper  tissues  and  the  vis 


SYPHILIS. 


1580 

cera  are  also  liable  to  be  attacked  by  processes 
similar  to  those  which  occur  in  the  acquired  dis- 
ease, giving  rise  to  a variety  of  symptoms,  and 
sometimes  leading  to  a fatal  issue.  Some  authors, 
Mr.  Hutchinson  for  example,  believe  that  early 
life  may  be  passed  without  symptoms,  and  that 
these  later  affections  may  constitute  the  first 
signs  of  inherited  taint. 

Course,  Duration’,  and  Terminations. — The 
course  of  syphilis  varies  very  much,  according 
to  the  individual,  and  according  to  the  treatment 
adopted.  In  the  majority  of  cases  the  disease 
runs  its  course  in  a year  and  a half  or  two  years ; 
but  in  certain  rare  cases  it  appears  to  end  with 
the  first  exanthem ; sometimes,  perhaps,  even 
earlier  than  this.  When  tertiary  symptoms  en- 
sue, the  commonest  period  for  their  appearance 
is  probably  about  five  years  after  contagion; 
but  they  may  be  delayed  for  ten  or  twenty  years, 
or  even  longer.  On  the  other  hand,  as  has  been 
already  stated,  the  secondary  may  run  on  into 
the  tertiary  stage  without  any  appreciable  in- 
terval. When  tertiary  symptoms  have  once 
appeared,  the  duration  of  the  disease  is  very 
uncertain,  depending  greatly  on  the  habits  and 
constitution  of  the  patient,  and  on  the  effects  of 
treatment.  In  some  cases  the  patient  continues 
to  suffer  throughout  his  life. 

The  most  usual  termination  of  acquired  syphi- 
lis is  recovery,  and  this  in  many  cases  without 
treatment,  if  the  patient  suffer  only  from  the 
more  superficial  forms  of  disease.  In  syphilitic 
disease  of  the  viscera  the  termination  is  fre- 
quently fatal. 

In  inherited  syphilis,  if  the  child  be  bom  with 
signs  of  syphilis,  it  usually  dies ; but  when  it 
remains  healthy  for  some  weeks  after  birth,  the 
disease  not  unfrequently  ends  in  recovery  within 
a year,  provided  proper  treatment  be  carried  out. 
In  later  childhood,  however,  or  in  adolescence, 
further  symptoms  may  develop;  in  which  case 
tho  duration  and  termination  will  depend  greatly 
upon  their  due  recognition  and  appropriate  treat- 
ment. When  the  disease  is  neglected,  death  is  a 
frequent  termination,  especially  among  the  ill- 
fed  children  of  the  poor. 

The  course  and  duration  of  syphilis  are  also 
influenced  by  many  other  causes,  for  example, 
climate,  age,  idiosyncrasy,  pregnancy,  and  the 
hygienic  surroundings  of  the  patient. 

The  greater  or  less  severity  of  the  disease, 
or  the  stage  at  which  it  may  have  arrived 
in  the  person  from  whom  it  is  contracted, 
does  not  appear  to  have  any  appreciable  influ- 
ence on  tho  course  of  acquired  syphilis,  but  the 
children  of  syphilitic  parents  usually  suffer  more 
or  less  severely,  according  as  the  infection  of  the 
parent  is  recent  or  of  long  standing. 

Complications. — PhagecUsna  is  an  occasional 
complication  of  the  initial  lesion,  but  more  fre- 
quently of  the  later  ulcerating  syphilides.  The 
local  chancre  is  a frequent  complication,  giving 
rise  to  what  has  been  termed  the  ‘ mixed  chan- 
cre.’ Erysipelas  sometimes  attacks  syphilitic 
patients,  and  is  said  to  act  beneficially  in  causing 
the  disappearance  of  certain  obstinate  eruptions. 
This  influence,  however,  is  only  seen  in  some 
chronic  cases  when  the  patient  is  otherwise  in 
fair  health.  If  erysipelas  attack  a cachectic 
person,  with  rapidly  spreading  lesions,  the  com- 


plication is  a serious  one  and  not  infrequently 
proves  fatal.  In  scrofulous  patients  syphilis  is 
often  very  obstinate  and  severe,  and  the  skin- 
affections  in  such  persons  are  very  prone  to 
ulcerate.  In  tuberculous  subjects  syphilis  is  apt 
to  rouse  the  constitutional  disease  into  activity. 
The  gouty  diathesis  also  greatly  influences  the 
course  of  syphilis.  The  skin-eruptions  in  such 
cases  often  assume  the  scaly  form,  and  resist 
treatment  obstinately.  Bright's  disease  is  a very 
serious  complication.  Patients  whose  kidneys 
are  diseased  are  very  liable  to  suffer  severely, 
both  as  regards  the  superficial  tissues  and  the 
internal  organs.  Alcoholism  is  detrimental  in 
two  ways : first  by  its  injurious  influence  on  the 
system  generally ; secondly,  by  preventing  the 
proper  action  of  specific  remedies. 

Diagnosis. — In  the  diagnosis  of  syphilis  much 
will  depend  on  the  stage  at  which  the  disease 
has  arrived  when  the  patient  comes  under  ob- 
servation. Before  the  incubation-period  has 
come  to  an  end  the  diagnosis  will  of  course  be 
impossible ; but  when  the  initial  manifestation, 
with  its  accompanying  glandular  enlargement, 
has  appeared,  there  is  usually  no  difficulty,  un- 
less some  local  complication  be  present.  The 
initial  sore  is  distinguished  by  its  indurated 
base,  the  indolent  superficial  character  of  the  ul- 
ceration, the  thin  serous  discharge  which  is  not 
inoculable  on  the  patient  himself,  and  the  indo- 
lent painless  enlargement  of  the  nearest  group 
of  lymphatic  glands.  The  points  of  difference 
between  the  initial  lesion  of  syphilis  and  the 
local  chancre  are  considered  elsewhere.  See 
Venereal  Sore. 

The  diagnosis  of  the  early  exanthem  does  not, 
as  a rule,  present  much  difficulty,  if  the  general 
characters  of  the  eruption  already  mentioned  be 
attended  to.  In  some  cases,  however,  where 
pyrexia  and  general  constitutional  disturbance 
precede  the  outbreak  of  the  eruption,  the  symp- 
toms may,  for  a short  time,  be  mistaken  for 
those  of  some  other  disease.  Syphilitic  roseola 
has  been  mistaken  for  measles,  and  a vesicular 
syphilid  e for  small-pox.  In  doubtful  cases,  care- 
ful attention  to  the  temperature,  and  the  con- 
dition of  the  tongue,  throat,  and  air-passages, 
together  with  the  presence  or  absence  of  other 
signs  of  syphilis,  will  decide  the  question  in  a 
few  days. 

It  is,  however,  at  a later  stage — perhaps  many 
years  after  contagion,  and  long  after  the  disap- 
pearance of  outward  signs  of  the  disease — that 
the  diagnosis  presents  most  difficulty  to  the 
physician.  Bor  example,  a patient  comes  with 
obscure  symptoms,  pointing  to  some  lesion  of 
the  nervous  centres,  lungs,  liver,  or  other  visens. 
In  such  eases  the  skin  and  mucous  membrane, 
particularly  that  of  the  mouth  and  throat,  should 
be  carefully  inspected,  and  the  more  superficial 
bony  surfaces  examined  for  irregularity  or  thick- 
ening. The  eyes  may  afford  important  aid,  by 
the  detection  of  iritic  adhesions  or  changes  in 
the  deeper  structures.  The  presence  of  local 
paralyses,  especially  of  the  ocular  muscles,  is  a 
valuable  diagnostic  sign.  The  absence  of  signs 
or  characters  distinctive  of  other  diseases — cancer 
or  tubercle,  for  example — is  often  also  of  value 
in  doubtful  cases. 

When  no  conclusive  information  can  be  gained 


SYPHILIS. 


from  any  of  tliese  sources,  the  history  becomes 
of  the  greatest  importance.  A venereal  sore 
with  lumps  in  the  groins,  and  followed  by  a rash 
on  the  skin,  sore  throat  or  tongue,  loss  of  hair, 
pains  in  the  bones  worse  at  night,  and  bad  eyes, 
are  some  of  the  points  that  should  be  inquired 
into,  and  in  women  the  occurrence  of  abortion 
or  of  still-births. 

In  investigating  the  history  of  a supposed 
syphilitic  person,  especially  if  the  patient  be  a 
■woman,  it  should  be  borne  in  mind  that  syphilis 
is  not  necessarily  a venereal  disease,  and  that 
the  early  manifestations  in  women  may  be  so 
slight  as  to  escape  observation.  Again,  some 
may  have  forgotten  that  they  have  suffered 
from  earlier  signs,  and  others  vho  do  remember 
obstinately  conceal  the  fact.  However  this  may 
be,  the  practitioner  frequently  fails  to  elicit  any 
history  of  earlier  manifestations  in  those  who 
suffer  from  visceral  syphilis.  Sometimes  also,  for 
various  reasons,  the  history  cannot  be  enquired 
into.  If  neither  the  symptoms  present  at  the 
time,  nor  inspection  of  the  patient’s  body,  nor 
the  method  of  exclusion,  nor  the  history  of  the 
case,  separately  or  combined,  suffice  to  render 
the  diagnosis  clear,  specific  remedies  should  be 
administered,  and  their  effect  awaited  before  a 
positive  opinion  is  given. 

In  the  diagnosis  of  inherited  syphilis  at  an 
early  stage,  the  snuffling  and  coryza,  which  are 
often  present,  are  characteristic.  The  radiat- 
ing cracks  around  the  mouth  and  nostrils  are 
also  valuable  signs.  Mucous  patches  again  are 
nearly  always  present  about  the  mouth,  anus,  or 
genital  organs.  Pemphigus  of  the  palms  or 
soles  is  nearly  always  syphilitic,  but  it  is  com- 
paratively rare.  Enlargement  of  the  spleen  is 
also  a valuable  corroborative  sign.  The  bones  of 
the  skull,  the  humeri,  and  tibiae  should  always 
be  examined  for  osteophytes  or  epiphysial  en- 
largement. It  must  be  remembered  also  that  a 
syphilitic  child  sometimes  retains  a healthy  ap- 
pearance throughout. 

In  later  childhood  the  most  valuable  diag- 
nostic signs  are  the  low  stature  and  puny  de- 
velopment; the  peculiar  condition  of  the  teeth; 
the  dull,  pasty  complexion ; radiating  scars 
about  the  mouth  ; the  sunken  bridge  of  the  nose  ; 
signs  of  present  or  past  mischief  in  the  cornea, 
iris,  or  choroid  ; nodes  on  the  bones ; unhealthy 
ulceration  or  its  sears,  especially  of  the  face  or 
throat.  Here,  again,  if  no  conclusive  signs  be 
present,  the  history  becomes  most  important, 
both  of  the  patient  himself  and  of  his  parents, 
and  here  also  the  diagnosis  has  occasionally  to 
be  postponed  until  anti-syphilitic  remedies  have 
been  administered. 

Prognosis. — This,  in  the  great  majority  of 
cases,  is  favourable,  if  the  patient  be  otherwise 
in  good  health,  of  temperate  habits,  and  espe- 
cially if  his  disease  be  properly  treated  at  an 
early  period.  The  effect  of  other  constitutional 
diseases  has  already  been  indicated  among  the 
complications  of  syphilis.  Probably  nothing 
tends  more  to  prolong  and  aggravate  the  course 
of  syphilis  than  habits  of  drinking.  In  persons 
given  to  alcohol,  therefore,  the  prognosis  should 
always  be  guarded. 

A very  interesting  question,  and  one  on  which 
farther  information  is  much  reeded,  is  whether 


1581 

any  trustworthy  data  as  regards  prognosis  can 
be  gained  from  the  character  of  the  early  mani- 
festations. Neither  the  length  of  incubation, 
nor  the  amount  of  induration  or  ulceration  of 
the  initial  lesion,  has  been  shown  to  afford  any 
reliable  evidence  as  regards  prognosis.  Early 
general  glandular  enlargement  is  often  an  un- 
favourable sign.  Persons  thus  affected  beccmo 
anaemic,  and  consequently  more  liable  to  grave 
affections.  As  regards  the  early  syphilides,  it 
may  be  mentioned  that  the  ordinary  general 
macular  and  papular  eruptions  appear  to  be  less 
common  precursors  of  late  visceral  affections 
than  early  rashes  that  are  ill-marked  and  scanty. 
Obstinate,  frequently  recurring,  but  superficial 
lesions  of  the  skin  and  mucous  membrane  also 
are  rarely  associated  with  visceral  disease.  In 
connection  with  this  may  bo  mentioned  the  fre- 
quent failure  of  the  practitioner  to  elicit  any 
history  of  early  symptoms  in  those  who  suffer  at 
a later  period  from  grave  visceral  affections, 
especially  from  syphilis  of  the  nervous  system. 

In  the  cases  of  malignant  or  galloping  syphilis, 
in  which  ulcerating  and  rapidly  spreading  lesions 
attack  the  skin  and  mucous  membranes,  and  are 
associated  with  a tendency  to  phagedaena  and 
great  prostration  at  an  early  period  after  in- 
fection, the  prognosis  is  grave  ; the  patient  may 
die  worn  out  by  the  pain  and  profuse  discharge 
of  the  superficial  lesions,  or  of  some  acute  affec- 
tion. Again,  if  a patient  be  once  proved  to  have 
visceral  disease  due  to  syphilis,  his  future  is 
usually  a precarious  one,  and  as  a rule  the  dura- 
tion of  life  is  greatly  curtailed. 

Finally,  one  of  the  most  important  points  to 
be  considered  in  prognosis  is  the  way  in  which 
the  patient  has  been  treated.  For,  although  we 
do  not  yet  know  any  certain  sign  which  proves 
that  syphilis  has  come  to  an  end,  it  may  with 
much  confidence  bo  stated  that  if  mercurial 
treatment  have  been  begun  at  an  early  period 
of  the  disease,  and  continued  a sufficient  length 
of  time,  and  if  the  patient  bo  constitutionally 
robust  and  of  temperate  habits,  the  chances  are 
greatly  in  favour  of  complete  subsidence  of  the 
disease  within  two  years  after  contagion. 

There  remains,  however,  a class  of  cases,  for- 
tunately rare,  in  which  anti-syphilitic  remedies 
cannot  be  borne — in  which  indeed  they7  appear  to 
be  harmful.  In  such  persons  the  prognosis  is 
unfavourable,  for  unless  the  disease  run  a mild 
course,  a fatal  result  is  common  within  a few 
years,  either  directly  from  syphilis,  or  indi- 
rectly from  some  intereurrent  affection. 

Much  of  what  has  been  said  as  to  the  pro- 
gnosis of  acquired  syphilis  applies  also  to  the 
inherited  form  of  the  disease.  A child  in  whom 
symptoms  do  not  appear  until  several  weeks 
after  birth,  who  is  well  cared  for,  properly  fed, 
and  who  receives  proper  medical  treatment,  will 
probably  recover ; one  who  is  ill-fed  and  neg- 
lected will  most  probably  die.  Indeed,  among 
the  children  of  the  poor,  syphilis  is  one  of  the 
most  fatal  diseases  of  infantile  life. 

Treatment. — 1.  Preventive  Treatment. — 
The  measures  adopted  by  Government  for  pre- 
venting the  spread  of  venereal  diseases  are  no- 
ticed elsewhere.  See  Public  Health. 

Among  individuals  the  strict  daily  observance 
of  cleanliness,  too  often  neglected  by  both  sexefi 


SYPHILIS. 


1682 

constitutes  the  best  protection  against  disease. 
Certain  mechanical  contrivances  are  sometimes 
effective  in  preventing  contagion,  but  they  are 
untrustworthy.  The  free  use  of  soap  and  water 
immediately  after  intercourse  is  probably  as 
effectual  as  any  other  application. 

Every  person  who  contracts  syphilis  should 
bo  warned  of  the  danger  of  communicating  it  to 
others.  Sexual  intercourse  should  always  be  pro- 
hibited while  the  disease  remains  active.  This 
direction  should  never  be  omitted,  as  many 
patients  are  unaware  that  they  are  liable  to 
communicate  the  disease  after  the  initial  mani- 
festation has  healed. 

The  contagious  nature  of  the  lesions  of  the 
mouth  and  throat  should  also  be  pointed  out, 
and  the  consequent  risk  of  contagion  by  kissing, 
or  by  the  use  of  drinking-vessels,  towels,  er 
other  articles  in  common  with  other  persons. 

The  question  of  marriage  in  relation  to  syphi- 
lis is  one  of  great  importance,  and  it  is  the 
obvious  duty  of  the  physician  to  prevent  the 
contamination  of  a healthy  spouse,  or  the  pro- 
creation of  syphilitic  children,  whenever  it  is  in 
his  power  to  do  so.  No  person  who  shows  ob- 
vious signs  of  syphilis  should  be  permitted  to 
marry,  however  long  a time  may  have  elapsed 
since  contagion  ; for  although  communication  of 
the  disease  is  rare  after  several  years  have  gone 
by , it  may  take  place  after  ten  years,  or  even  longer 
in  neglected  cases.  It  has  already  been  stated 
that  syphilis  usually  ceases  to  be  active  within 
two  years  after  contagion ; but  this  is  not  always 
so.  Hence,  after  the  last  symptoms  have  disap- 
peared, there  should  be  an  interval  of  at  least  a 
year  before  marriage  takes  place.  Consequently, 
the  shortest  period  between  contagion  and  mar- 
riage should  be  three  years.  If  the  treatment 
during  the  early  stages  have  not  been  syste- 
matic and  prolonged,  it  will  be  prudent  to  sub- 
ject the  candidate  for  marriage  to  an  assiduous 
course  of  mercury  for  at  least  three  months, 
and  after  this  he  should  be  kept  under  obser- 
vation for  a year  before  he  is  allowed  to  marry. 
Duringthis  period  a course  of  bathing  in  warm 
sulphur  springs  is  sometimes  useful ; for  if  the 
poison  be  still  active,  the  stimulus  of  the  sul- 
phur may  hasten  the  development  of  the  symp- 
toms. This  test,  however,  is  by  no  means  reliable. 

The  spread  of  syphilis  from  children  to  wet 
nurses,  and  vice  versa,  is  not  so  common  in  this 
country  as  abroad ; but  the  physician  should 
never  allow  a syphil  itic  child  to  be  entrusted  to 
a healthy  wet  nurse,  nor  a syphilitic  nurse  to 
suckle  a healthy  child. 

2.  Therapeutic  Treatment. — The  treatment 
of  syphilis  may  be  divided  into  (a)  general ; (6) 
special ; and  (e)  local  treatment. 

(a)  General  treatment.  — Syphilis  is  essen- 
tially a debilitating  disease,  hence  it  is  most  im- 
portant that  the  general  health  of  the  patient 
should  be  supported  by  nourishing  diet,  good 
air,  warm  clothing,  extreme  moderation  as  re- 
gards alcoholic  liquors,  cleanliness,  cheerful 
society,  and  moderate  exercise  in  the  open  air. 
In  nearly  all  cases  the  patient  should  follow  his 
usual  employment,  in  order  that  his  mind  may 
be  diverted  frem  dwelling  on  the  slow  progress 
of  his  cure.  The  skin  should  be  stimulated 
to  act  freely  by  the  frequent  use  cf  soap  and 


water,  and  an  occasional  Turkish  bath  if  thought 
desirable.  Flannel  should  be  worn  next  the 
skin,  and  sudden  chills  avoided  as  much  as  pos- 
sible. Smoking  in  moderation  may  be  allowed, 
as  long  as  the  mouth  and  throat  remain  free; 
but  when  syphilitic  lesions  are  present,  it  should 
always  be  discontinued.  Regular  action  of  the 
bowels  is  also  important.  Exercise,  short  of 
fatigue,  should  be  taken  daily,  unless  the  weather 
is  very  bad. 

( b ) Special  treatment.  — Besides  attention  to 
the  general  health  of  the  patient  on  ordinary 
principles,  the  administration  of  certain  drugs 
which  are  known  to  have  special  influence  over 
syphilis  should  never  be  omitted,  however  mild 
the  earlier  manifestations  of  the  disease  may  be. 
For  although  syphilis  tends  in  most  cases  to  sub- 
side spontaneously,  it  does  not  do  so  in  all ; and  in 
the  present  state  of  our  knowledge  we  have  no 
certain  means  of  distinguishing  at  the  onset  the 
cases  which  will  get  well,  from  those  in  which 
tertiary  symptoms  will  follow.  There  is  also 
much  evidence  to  show  that  when  proper  and 
sufficient  treatment  has  been  carried  out  in  the 
earlier  period,  the  danger  of  later  manifestations 
is  much  less  than  in  cases  that  have  been  un- 
treated, or  treated  only  by  ordinary  means.  Again, 
in  many  of  the  gravest  cases  of  visceral  syphilis 
there  is  an  absence  of  any  history  of  early  signs, 
showing  that  they  must  hare  been  so  slight  as 
to  have  been  overlooked,  and  consequently  un- 
treated. 

The  two  special  drugs  now  almost  exclusively 
used  in  the  treatment  of  syphilis  are  mercury  and 
iodine.  Of  these  the  former  only  can  be  looked  on 
as  a real  and  permanent  remedy.  Iodine  is  of 
tho  greatest  value  in  dispersing  the  later  mani- 
festations of  syphilis,  and  is  also  useful  in  many 
cases  at  an  earlier  period,  but  its  effects  are 
not  lasting,  and  therefore  the  iodides  cannot  be 
trusted  to  alone. 

Much  of  the  prejudice  against  the  use  of  mer- 
cury has  arisen  from  the  fact  that  in  former 
times  its  administration  was  carried  to  a poison- 
ous extent.  It  is  now  known  that  salivation  is 
hardly  ever  necessary,  and  that  if  the  drug  be 
properly  administered  in  small  doses,  it  acts  as 
a tonic,  syphilitic  patients  rapidly  improving  in 
health  and  gaining  weight  under  its  use. 

As  soon  as  induration  at  the  site  of  contagion, 
and  multiple  indolent  enlargement  of  the  proxi- 
mate lymphatic  glands,  make  the  diagnosis  of 
syphilis  certain,  mercury  should  be  given.  For 
all  the  general  symptoms  of  the  secondary  stage, 
also,  mercury  is  appropriate.  And  in  the  later 
stages  it  should  be  used  in  conjunction  with 
iodine,  or  to  complete  the  cure  after  the  symp- 
toms have  been  dissipated  by  iodine,  or  in  eases 
where  the  iodides  fail  to  relieve.  In  fact,  there 
is  no  stage  of  the  disease  at  which  mercury  may 
not  be  administered  with  advantage  in  many 
cases.  It  may  be  given  to  almost  all  persons 
when  its  use  is  indicated,  but  its  effect  must  be 
carefully  watched  if  the  patient  be  in  very  feeble 
health,  or  the  subject  of  disease  of  the  kid- 
neys. 

Before  a mercurial  course  is  begun  the  mouth 
should,  as  far  as  possible,  be  put  into  a healthy 
condition.  Lmsound  teeth  should  be  stopped  cr 
removed,  and  tartar  got  rid  of.  If  the  gums  are 


SYPHILIS. 


spongy,  an  alum  mouth-wash  should  he  used 
frequently. 

Mercury  should  he  given  more  or  less  con- 
tinuously for  at  least  a year  after  contagion.  If 
symptoms  be  present  at  the  end  of  that  time, 
treatment  should  be  continued  for  at  least  three 
months  after  their  disappearance.  During  this 
period  it  will  of  course  be  necessary  to  omit  the 
mercury  from  time  to  time,  or  to  vary  the  form 
of  the  drug,  according  to  the  peculiar  circum- 
stances of  each  case. 

In  small  doses  mercury  is  a tonic,  and  the 
aim  should  be  to  limit  its  action  as  much  as 
possible  to  the  tonic  effect.  “When  taken  in 
syphilis  the  patient  usually  improves  rapidly  in 
health.  If  a rash  be  present  it  soon  begins  to 
fade,  and  ulcerated  surfaces  begin  to  heal.  All 
tho  useful  effects  of  the  drug  are  usually  attained 
when  only  the  slightest  effect  is  produced  on  the 
gums. 

Mercury  may  be  introduced  into  the  system  in 
various  ways — by  the  stomach,  rectum,  vagina, 
skin,  or  subcutaneous  cellular  tissue,  hut  its 
action  is  essentially  the  same  by  whatever  chan- 
nel it  is  administered. 

In  the  majority  of  cases  mercury  may  be 
most  conveniently  given  internally  in  pills,  or  in 
a mixture  ; but  it  is  sometimes  used  in  the  form 
of  suppository.  This,  however,  frequently  gives 
rise  to  irritation.  In  early  syphilis  blue  pill,  or 
grey  powder,  usually  fulfils  all  the  requirements 
of  the  case.  If  no  urgent  symptoms  be  present, 

1 or  1§  grain  o+'  either  of  these  preparations  may 
he  given,  with  a little  extract  of  gentian,  three  or 
four  times  a day,  at  or  immediately  after  meals. 
Quinine  or  reduced  iron  maybe  added,  if  thought 
desirable.  In  such  small  doses  mercury  rarely 
disagrees,  and  opium  is  unnecessary.  If,  however, 
a rapid  effect  be  desired — in  iritis,  for  example — 

2 or  3 grains  of  blue  pill,  with  £ or  ^ grain 
of  opium,  may  be  given  three  or  four  times  a 
day  until  the  requisite  effect  is  produced,  after 
which  the  drug  may  he  given  less  frequently,  or 
be  reduced  in  quantity.  If  the,  milder  degrees 
of  salivation  he  inadvertently  set  np,  the  mercury 
should  be  discontinued  for  a few  days,  a purge 
administered,  and  the  mouth  washed  out  fre- 
quently with  an  alum  or  chlorate  of  potash  gargle. 
See  Salivation. 

The  green  iodide  of  mercury  is  more  liable  to 
decomposition,  and  to  cause  irritation  than  the 
forms  just  mentioned.  If  preferred,  it  may  be 
given  in  doses  of  £ to  1 grain,  with  a little 
opium,  twice  or  thrice  a day. 

The  perchloride  is  mostly  given  in  the  later 
and  more  chronic  forms  of  syphilis,  when  only 
a mild  action  is  required.  It  may  be  prescribed 
in  doses  of  i to  ^ grain,  either  in  a pill  with 
sugar  of  milk,  or  in  a mixture  with  iodide  of 
potassium  or  with  tincture  of  iron,  according  to 
circumstances. 

AVhen  other  preparations  disagree,  the  bicya- 
nide may  be  given.  The  red  iodide  is  also  often 
useful,  especially  in  cases  of  relapsing  scaly 
syphilides. 

A preparation  of  mercury  with  sarsaparilla 
and  aromatics,  known  as  Z/ittmann's  decoction , is 
sometimes  useful  in  tertiary  syphilis. 

Subcutaneous  injection  of  mercury  is  very  effec- 
tive and  speedy  in  action ; but  it  is  painful,  and 


1583 

requires  daily  medical  attendance.  Hence  it 
is  only  to  be  rocommended  when  other  means 
fail,  or  in  urgent  cases.  The  solution  known  as 
Ragazzoni’s  (containing  the  red  iodide)  is  one  of 
the  most  useful  preparations. 

Inunction  is  also  very  effective,  but  it  is  dirty 
and  troublesome  to  the  patient ; hence  he  often 
neglects  to  carry  it  out  properly.  It  may 
be  employed  whenever  mercury  is  indicated, 
20  to  60  grains  of  mercurial  ointment  being 
rubbed  in  every  night,  or  every  other  night,  as 
required. 

The  mercurial  vapour  bath  is  very  beneficial 
in  certain  cases,  especially  those  of  wide-spread 
rash.  From  20  to  40  grains  of  calomel  is  the 
usual  quantity  for  each  bath. 

The  iodides  are  principally  used  in  the  treat- 
ment of  the  lesions  usually  called  tertiary.  In 
the  later  stage  of  the  secondary  period,  and  in 
cases  where  the  lesions  partake  of  the  characters 
of  both  stages,  the  iodides  may  often  be  advan- 
tageously combined  with  mercury. 

In  all  cases  where  the  symptoms  have  been 
controlled  by  iodine,  mercury  should  be  given  to 
complete  the  cure. 

Iodide  of  potassium  is  the  salt  most  frequently 
used;  but  the  iodides  of  sodium  and  of  ammonium 
are  also  employed,  and  may  be  used  if  the  former 
disagree.  The  action  of  all  is  very  similar,  but 
tho  sodium  appears  to  be  less  depressing  than 
potassium,  while  the  ammonium  salt  is  stimu- 
lating. The  doso  of  the  iodide.s  varies  from 
2 or  3 to  100  grains  or  even  more.  It  is  best 
to  begin  with  3 or  4 grains,  with  a little  am- 
monia, three  times  a day,  and  to  increase  tho 
dose  if  necessary.  In  urgent  cases  of  visceral 
disease,  and  particularly  in  syphilitic  affec- 
tions of  the  nervous  system,  20  grains  may  be 
given  at  first,  and  the  dose  rapidly  increased  to 
an  almost  unlimited  extent  until  some  effect  is 
produced.  In  such  cases,  also,  it  will  often  be 
prudent  to  carry  out  inunction,  or  the  subcuta- 
neous injection  of  mercury,  at  the  same  time. 
Tho  iodides  should  be  given  in  a large  quantity 
of  water  ; and  any  of  the  bitter  infusions,  or 
tartarated  iron,  may  be  added  when  their  use  is 
indicated. 

Iodoform  is  occasionally  given  internally  in 
the  later  stages  of  syphilis;  but  it  frequently 
causes  so  much  gastric  and  intestinal  irritation 
that  it  cannot  be  borne.  The  dose  is  about  a 
grain,  in  the  form  of  pill. 

The  bromides  of  potassium  and  ammonium  are 
serviceable  when  the  patient  has  become  insen- 
sible to  iodine,  and  in  certain  cases  of  affection  of 
the  nervous  system.  They  may  bo  given  alone, 
or  w-ith  iodide  of  potassium. 

Besides  the  foregoing  remedies  many  others, 
especially  tonics  and  sedatives,  may  be  required 
in  the  treatment  of  syphilis.  Iron,  for  example, 
is  frequently  beneficial,  either  in  conjunction 
with  specifics  or  with  quinine,  or  in  the  form  of 
the  iodide.  Cod-liver  oil  also  is  very  valuable 
in  many  cases.  Sarsaparilla  is  sometimes  bene- 
ficial in  enabling  the  patient  to  bear  large  doses 
of  iodide.  It  is  also  often  useful  during  or  after 
a prolonged  course  of  mercury.  Mineral  acids 
and  vegetable  bitters  are  often  of  service  during 
the  intervals  of  specific  treatment.  Opium  is  of 
great  value  in  many  of  the  affections  produced 


SYPHILIS. 


1584 

by  syphilis  — phagedsna  and  periostitis,  for 
example. 

Certain  bathing  resorts  which  possess  sulphur 
springs — -Aix-la  Chapelle,  for  example — have  be- 
come noted  for  the  cure  of  syphilis;  and  there 
can  be  no  doubt  that  great  benefit  is  often  de- 
rived from  the  course  of  treatment  pursued  at 
such  places.  The  good  results,  however,  appear 
to  be  due  more  to  a combination  of  specific 
remedies  and  diaphoresis,  with  strict  attention 
to  diet  and  general  hygiene,  than  to  any  special 
virtues  of  the  waters  themselves. 

When  syphilis  is  complicated  with  scrofula, 
gout,  rheumatism,  &c.,  the  appropriate  remedies 
should  be  given  with  those  proper  for  syphilis, 
or  temporarily  substituted  for  them  according  to 
circumstances. 

(e)  Local  treatment. — The  initial  lesion  usually 
requires  only  cleanliness,  and  the  application  of 
wet  lint.  If  it  be  indolent,  black  wash,  or  a 
lotion  of  sulphate  of  zinc,  or  other  mild  astrin- 
gent, may  be  applied.  If  the  sore  suppurate, 
either  through  neglect  or  from  the  presence  of 
the  virus  of  the  local  chancre  as  well,  the 
surface  should  be  cleaned,  dried,  and  dressed  with 
finely-powdered  iodoform.  Phagedeena  must  be 
treated  by  immersion,  caustics,  or  the  actual 
cautery,  while  the  general  health  receives  atten- 
tion ( see  Venebeal  Soke).  If  tho  lymphatic 
glands  become  tender  or  inflamed,  warm  fomen- 
tations should  be  applied,  and  the  patient  kept 
lying  down.  If  abscess  form,  it  must  be  treated 
according  to  the  directions  given  in  the  article 
on  Bobo. 

The  early  syphilides  rarely  require  local  treat- 
ment. Erosions  or  Jissares  may  be  dressed  with 
an  ointment  of  calomel  and  vaseline,  or  with 
iodoform.  Indolent  or  unhealthy  sores,  especially 
in  weakly  persons,  are  often  benefited  by  a lotion 
of  tartarated  iron.  In  the  scaly  affections  of  the 
palms  and  soles,  an  ointment  of  ammoniated 
mercury,  oxide  of  zinc,  and  vaseline  may  be  well 
rubbed  in  at  bedtime,  and  gloves  worn  during 
the  night.  Mercurial  plaster  also  is  often  a very 
useful  application.  Mucous  patches  should  be 
cleansed  and  dried  several  times  daily',  powdered 
with  calomel  or  oxide  of  zinc,  and  covered  with 
dry  lint.  If  they  become  very  large  and  promi- 
nent, solid  nitrate  of  silver  or  acid  nitrate  of 
mercury  may  be  applied.  Cracks  and  ulcers 
about  the  nails  should  be  dressed  with  mercurial 
plaster,  or  with  red  oxide  of  mercury  ointment. 

Ulcers  or  fissures,  or  mucous  patches  of  the  lips, 
tongue,  mouth,  and  throat  should  be  touched 
every  other  day  with  nitrate  of  silver,  or  sul- 
phate of  copper,  and  an  alum  or  borax  wash 
used  frequently,  especially  after  eating.  For 
the  later  ulcers  soothing  applications  should  be 
used,  but  internal  treatment  is  of  the  greatest 
importance  in  such  cases. 

Ulcers  and  chinks  about  the  nostrils  should  be 
kept  moist  with  red  oxide  of  mercury  and  vaseline 
ointment.  When  necrosis  of  the  nasal  or  palatal 
bones  has  occurred,  a lotion  of  permanganate  of 
potash  or  chlorinated  soda  should  be  used  with 
the  nasal  douche,  and  the  fragments  removed 
as  soon  as  they  become  loose.  The  early  affec- 
tions of  the  larynx  usually  disappear  without 
local  treatment.  In  the  later  affections  tracheo- 
tomy may  he  necessary. 


Ulcers  of  the  anus  require  careful  cleansing 
and  the  application  of  calomel  cr  iodoform  oint- 
ment. For  ulceration  within  the  rectum  iodoform 
suppositories  and  astringent  injections  should 
be  used.  In  stricture  of  the  rectum  careful  dila- 
tation by  means  of  bougies  should  be  tried.  In 
extreme  cases  rectotomy,  or  even  colotomy,  may 
have  to  be  performed. 

As  regards  the  bones,  the  pain  produced  by 
early  nodes  is  relieved  by  painting  with  a solu- 
tion of  iodine,  and  by  blisters.  Nodes  should 
never  he  opened.  If  necrosis  take  place,  the 
dead  bone  should  he  removed  as  soon  as  it 
becomes  loose. 

In  iritis,  besides  the  prompt  administration  of 
mercury,  a solution  of  sulphate  of  atropine  (4 
grains  to  the  ounce)  should  he  dropped  into  the 
eye  every  two  hours  till  the  pupil  is  well  di- 
lated. Afterwards  a weaker  solution  may  bo 
used  to  keep  up  the  effect.  In  interstitial  kera- 
titis also  atropine  should  be  used.  Iridectomy  is 
occasionally  necessary.  In  choroiditis  and  reti- 
nitis repeated  leeching  is  sometimes  useful  when 
there  is  much  pain,  but  constitutional  treatment 
is  most  important. 

In  syphilitic  orchitis  a suspensory  bandage 
should  be  worn,  but  other  local  treatment  is 
usually  unnecessary,  unless  the  gumma  break 
down  and  fungous  protrusion  occur,  in  which 
case  support  should  be  given  by  strapping.  In 
syphilitic  affections  of  the  uterus  frequent  injec- 
tions of  borax  or  sulphate  of  zinc  are  required, 
and  in  case  of  ulceration,  iodoform  or  caustics 
are  sometimes  necessary. 

Treatment  of  Inherited  Syphilis. — Pre- 
ventive treatment. — If  a syphilitic  husband  have 
a relapse  before  his  wife  becomes  pregnant,  he 
ought  at  once  to  desist  from  sexual  inter- 
course— indeed  from  contact  of  every  kind,  and 
undergo  treatment.  The  wife  also  should  be 
watched,  that  treatment  may  be  begun  as  early 
as  possible,  if  she  have  contracted  the  disease. 
If  the  wife  become  pregnant  while  the  husband 
shows  signs  of  syphilis,  both  parents  should  he 
treated  with  mercury. 

Treatment  of  the  child. — Mercurial  treatment 
should  always  be  adopted  as  soon  as  symptoms 
appear.  Grey  powder  may  be  given  in  one-grain 
doses  twice  a day.  But  a strip  of  flannel  smeared 
with  diluted  mercurial  ointment,  and  worn  round 
the  waist,  is  preferable.  The  ointment  should  be 
renewed  every  night,  and  the  skin  cleansed  every 
third  day.  Syrup  of  the  iodide  of  iron  and  cod- 
liver  oil  may  also  he  given.  Treatment  should 
always  be  continued  for  at  least  six  months ; 
and,  if  symptoms  be  then  present,  until  their  dis- 
appearance, and  for  several  months  afterwards. 

Iodide  of  potassium  is  most  valuable  in  the 
later  forms  of  disease.  The  rules  for  its  employ- 
ment are  the  same  as  in  acquired  syphilis,  but 
the  dose  must  of  course  be  smaller. 

The  local  treatment  of  the  syphilitic  affections 
of  children  is  similar  to  that  recommended  for 
adults.  When  the  nostrils  are  obstructed  by 
inspissated  mucus,  they  must  be  carefully  cleansed 
with  a camel's-hair  brush,  and  the  excoriations 
touched  with  red  oxide  of  mercury  ointment. 

The  general  management  and  diet  of  syphilitic 
children  are  most  important.  Whenever  the 
mother  can  suckle  her  child,  she  should  always 


SYPHILIS. 

do  so.  If  this  be  impossible,  a syphilitic  'wet- 
nurse  is  the  best  substitute.  If  neither  be 
available,  ass's,  goat’s,  or  cow’s  milk  must 
be  given.  Extreme  cleanliness  and  fresh  air 
are  essential.  As  the  child  grows  older,  the 
method  of  feeding  must  be  conducted  on  ordi- 
nary principles.  Arthur  Cooper. 

SYRINGOMYELIA  (avpi-y^,  a cavity,  and 
fmeAbs,  the  marrow). — This  is  a name  under 
■which  Ollivier  grouped  numerous  cases  in  which 


TAPE- WORMS.  1585 

cavities  of  different  kinds  were  met  with  within 
the  substance  of  the  spinal  cord.  For  a refer- 
ence to  the  nature  of  these  cases,  see  Spinal 
Cord,  Special  Diseases  of,  No.  21,  Malforma- 
tions. 

SYSTOLIC. — Of  or  belonging  to  the  systole 
or  contraction  of  the  heart,  and  usually  asso- 
ciated with  the  cardiac  impulse  or  sounds,  oi 
with  murmurs.  See  Physical  Examination, 


T 


TABES  (tabes,  a consumption). — A term  for- 
merly employed  to  denote  consumption  or  wast- 
ing of  the  body. 

TABES  DOBSALIS  (tabes,  a consumption, 
and  dorsalis,  spinal). — A name  formerly  applied 
to  a condition  of  debility  caused  by  excessive 
sexual  indulgence,  and  characterised  especially 
by  failure  of  nervous  power.  The  term  is  now 
used  as  synonymous  with  locomotor  ataxy.  See 
Locomotor  Ataxy. 


TABES  MESENTERICA  (tabes,  a con- 
sumption, and  mesenterica,  mesenteric). — A wast- 
ing disease  caused  by  tubercular  or  scrofulous 
affection  of  the  mesenteric  glands.  See  Mesen- 
teric Glands,  Diseases  of. 


TACHE  (French). — A spot  or  patch.  The 
word  is  most  frequently  used  in  connection  with 
morbid  conditions  of  the  skin.  Tache  cerebrale 
has  been  specially  applied  by  Trousseau  to  a 
patch  or  streak  of  hyperaemia,  produced  by  irri- 
tating the  skin  in  certain  cases  of  cerebral  men- 
ingitis. See  Meninges,  Cerebral,  Diseases  of. 


T2ENIA. — Synon.  : Tape-worm. — A genus 
of  cestode  entozoa,  characterised  by  the  posses- 
sion of  a head  furnished 
with  four  sucking  disks; 
also  by  having  repro- 
ductive papillae  either 
uni  serially  or  biserial  ly 
disposed  along  the  la- 
teral margins  of  the 
segments  of  the  body. 
Strictly  speaking,  a 
tapeworm  is  a colony  of 
incomplete  individuals 
(called  zooids  or  pro- 
glottides) arranged  in 
single  fie,  the  upper- 
most zooid  being  trans- 
formed into  an  organ  of 
anchorage,  which  is  po- 
pularly called  the  Tuad 
of  the  parasite.  Several 
species  of  this  genus 
occur  in  man,  the  two 
most  common  forms 
being  the  beef-tape- 
rona  (T.  mediocanellata)  and  the  pork- tape - 


Flo.  89.  Taenia  Echino- 
coccus. Origin 


100 


worm  ( T.  solium).  A third  has  been  indicated  by 
the  writer  as  the  mutton-tapeworm  (T.  tcnella), 


Fig.  90. 

Unarmed  Head  o £ 
Tania,  mediocanellata ; x 
10  diam.  Alter  G.  Fritsch. 


Fig.  91. 

Armed  Head  of  Taenia 
solium ; x 10  diam.  After 
G.  Fritsch. 


Fig.  92. 

Proglottis  of  Tcenia 
mediocanellata-,  x It 
diam.  After  G.  Fritsch. 


Fig.  93. 

Proglottis  of  Taenia 
solium  ; x It  diam. 
After  G.  Fritsch. 


but  at  present  it  is  only  imperfectly  known.  See 
Hydatids  ; and  Tape- worms. 

T.  S.  Cobbold. 


TANGIERS.  See  Morocco. 


TAPE-WORMS.— Synon.  : Fr.  Tcenia-,  Te- 
nia-, Ger.  Bandwurm. — Under  the  heading  Tcenia 
the  zoological  characters  of  these  parasites  are 
given.  Resides  Tcenia  mediocanellata  and  T.  so- 
lium the  human  body  may  be  attacked  by  several 
other  species,  some  of  which,  however,  are  only 
imperfectly  known  (Tcenia  lophosoraa,  T.  tenella 


TAPE-WORMS. 


1586 

T.  elliptica,  T.  flavopuncta,  T.  marginata,  T. 
nana,  Bothriocephalus  latus,  B.  cordatus,  and  B. 
sristatus).  Practically,  in  treating  cases  it  mat- 
ters little  which  form  we  have  to  deal  with, 
except  in  so  far  as  the  complete  'expulsion  of 
the  worm  is  rendered  difficult  or  otherwise. 
This  varying  result  depends  in  a great  measure 
upon  the  character  of  the  species.  Those  tape- 
worms which  are  armed  with  hooks,  in  addi- 
tion to  powerful  suckers,  are  more  difficult  to 
dislodge  from  the  intestines  than  are  those 
species  which  are  unarmed.  The  prognosis  is 
therefore  always  more  favourable  in  cases  of 
the  beef-tapeworm  and  the  ordinary  pit-headed 
worm,  than  in  cases  of  the  pork-tapeworm.  In  so 
far,  however,  as  the  mere  selection  of  drugs  is 
concerned,  the  remedies  that  suffice  to  expel  the 
one  kind  are  equally  suitable,  as  poisons,  for 
the  expulsion  of  the  other.  Unquestionably,  the 
ability  to  recognise  the  various  species  of  tape- 
worm liable  to  be  encountered  in  practice  is  a 
great  help  in  the  general  management  of  cases; 
and  also,  more  particularly,  in  forming  an  opinion 
as  to  the  correct  mode  of  dealing  with  any  parti- 
cular case.  Such  means  of  diagnosis,  however, 
can  only  be  thoroughly  acquired  by  careful  study 


1TG.  94.  Head  (a)  ; and  several  segments  ot  Tcenia  medio- 
canellnta ; reduced  irom  the  natural  size.  After 
Owen. 


of  museum  specimens,  aided  by  the  descriptions 
given  in  standard  works  on  helminthology. 
Whilst  it  is  a comparatively  easy  matter  to  recog- 
nise the  head  of  any  form  of  tape-worm,  and  thus 
to  pronounce  upon  the  nature  of  the  species,  the 
recognition  of  the  true  source  and  character  of 
the  entozoon  is  not  so  readily  made,  by  inspec- 
tion of  fragments  of  the  so-called  body  of  the 
parasite.  All  kinds  of  mistakes  are  continually 
occurring  in  practice  from  a want  of  exact 
knowledge  of  this  sort.  The  writer  has  had 
brought  to  him  many  foreign  bodies  that  were 
erroneously  regarded  as  links  (joints,  segments, 
cucurbitini,  or  proglottides)  of  tape-worms ; 
and  he  has  also  known  instances  where  true 
fragments  of  the  worm  were  mistaken  for  as- 
carides.  The  result  of  such  errors  has  been  that 
the  supposed  victims  had  been  undergoing  treat- 
ment, more  or  less  vigorous  and  prolonged,  when 
there  never  had  been  any  tape-worm  present.  No 
doubt,  partly  from  the  distaste  for  the  subject  of 
parasites  generally,  partly  from  the  circumstance 
that  the  management  of  cases  has  long  been  rele- 
gated to  quacks,  and  other  unqualified  and  igno- 
rant persons,  and  partly  also  because  some  have 
taught  that  the  diagnosis  and  treatment  of  tape- 
worm is  a very  commonplace  and  simple  matter 
— too  simple,  in  fact,  to  need  special  lectures  at 
our  medical  schools — partly,  we  say,  from  these 
and  other  minor  considerations,  the  subject  has 
never  received  that  measure  of  attention  which 
‘it  demands. 


Symptoms. — The  symptoms  occasioned  by  the 
presence  of  tape-worm  aro  extremely  variable, 
both  in  character  and  degree.  The  bearer  may  be 
little  inconvenienced,  or  he  may  suffer  severely. 
He  may  experience  only  feeliDgs  of  weariness  and 
lassitude,  which,  in  some  cases,  are  set  down  to 
other  causes  than  tape-worm.  In  young  persons 
not  even  these  feeble  indications  may  be  present. 
In  grown  persons,  however,  sooner  or  later  a 
general  loss  of  health  commences;  the  processes 
of  digestion  are  interfered  with  ; and  the  patient 
becomes  antemic,  irritable,  and  restless  at  night. 
There  is  headache,  accompanied  by  vertigo.  The 
sight  and  hearing  become  affected ; noises  in  the 
head,  local  irritation  at  the  nose  and  anus,  dys- 
pepsia, and  obscure  pains  about  tkelimbs  and  body, 
present  themselves  in  a greater  or  less  degree. 
The  patient  often  feels  faint,  and  finds  it  necessary 
to  obtain  artificial  support.  In  the  worst  cases 
various  sympathetic  phenomena  make  their  ap- 
pearance, but  in  the  female  they  are  not  so  grave 
as  in  the  male,  commonly  developing  as  hysteria 
and  chorea.  Occasionally,  however,  in  both  sexes, 
there  may  be  paralysis,  with  or  without  epilepti- 
form seizures.  Cases  of  insanity  from  tape-worm 
are  reported  by  Winslow,  W.  Wood,  Ryan,  David 
Ferrus,  Eereol,  and  many  others.  In  one  instance 
mania  of  eight  days’  duration  was  cured  by  ex- 
pulsion of  the  worm.  Cases  of  convulsions,  often 
accompanied  by  peculiar  symptoms,  are  not  in- 
frequent, but  they  usually  do  well.  Affections  of 
the  eye,  such  as  amaurosis  and  squint,  have  also 
yielded  to  appropriate  vermifuges  (Burgiss ; 
Streatfeild).  In  Dr.  Davaine’s  invaluable  trea- 
tise a variety  of  singular  nervous  cases  are  given. 
Amongst  these  we  may  particularise  Leroux’s 
instance  of  spasmodic  phenomena  in  a girl  of 
nineteen  ; Legendre’s  case  of  strange  convulsive 
phenomena  in  a man  twenty-seven  years  of  age; 
Quettier’s  instance  of  periodic  trembling;  and 
especially  Billard’s  case  of  voracity,  accompanied 
by  maniacal  symptoms.  Happily  in  all  these 
severe  cases  the  evacuation  of  the  worm  was 
followed  by  restoration  to  health.  This  is  the 
usual  result ; but  in  those  instances  where  the 
worm  redevelops  itself  the  symptoms  are  apt  to 
return.  It  does  not  necessarily  follow,  however, 
that  the  identical  sympathetic  phenomena  will 
again  make  their  appearance. 

Prognosis. — On  the  whole,  the  prognosis  is 
favourable.  In  a small  percentage  of  cases  tape- 
worm proves  dangerous  to  the  victims.  Some  in- 
fested persons,  rather  than  let  another  know  the 
fact,  will  privately  endure  any  amount  of  incon- 
venience, such  as  daily  arises  from  the  frequent 
passage  of  proglottides.  Such  morbid  sensitive- 
ness is  uncalled  for  and  unwise. 

Treatment. — As  regards  drugs  the  resources 
are  ample.  We  have  turpentine,  kousso,  kamala, 
panna,  pumpkin-seeds,  pomegranate  root-bark, 
areca  nut,  and  last,  not  least,  male  fern  ; not  to 
mention  some  of  the  older  favourite  remedies, 
such  as  calomel,  oxide  of  silver,  tin,  seammony, 
cowage,  jalap,  and  a host  of  drastic  and  injurious 
purgatives.  Speaking  generally,  it  may  be  said 
that  the  right  administration  of  any  of  the  com 
paratively  modern  remedies  is  likely  to  be  at- 
tended with  success,  at  least  as  regards  the 
expulsion  of  the  body  of  the  parasite.  In  the 
writer’s  judgment,  based  upon  a lengthened  ex- 


TAPE-WORMS. 


erience,  no  remedy  is  equal  to  male  fern,  for  he 
as  found  the  ethereal  extract  of  this  root  effec- 
tive in  cases  -where  the  employment  of  nearly  all 
the  other  remedies  had  failed.  On  the  other  hand, 
Dr.  Fock  speaks  of  the  infallible  effects  of  pome- 
granate root  hark  ( Be  Lintworm  en  het  middel 
on  hem  mit  te  drijven,  Utrecht,  1873).  In  the 
country  districts  of  England  the  favourite  re- 
medy is  turpentine,  hut  its  employment  is  gra- 
dually giving  way  to  that  of  male  fern.  Without 
doubt,  the  oil  of  turpentine  is  an  excellent  taenia- 
fuge ; yet  its  nauseous  character  (except  in  cap- 
sules), combined  with  the  well-known  fact  that 
it  not  unfrequently  produces  strangury,  besides 
other  irregular  effects,  should  render  practi- 
tioners cautious  in  its  employment.  To  a certain 
extent  the  use  of  the  male  fern  oil  or  extract  is 
open  to  objection  on  the  score  of  its  nauseous 
taste ; but  this  disadvantage  is  more  than  coun- 
terbalanced by  the  smallness  of  the  quantity 
required  for  a dose.  In  only  one  instance  has  the 
writer  seen  this  drug  persistently  rejected  by  the 
stomach.  To  obviate  this  inconvenience  a variety 
of  extracts  have  been  prepared  by  pharmaceu- 
tists. The  -writer  has  tried  several  of  the  vermi- 
fuge extracts,  such  as  kousso,  kamala,  male  fern, 
but  finds  none  equal  in  power  to  the  oil  of  male 
fern.  M.  Heckel  has  sought  to  ascertain  the 
active  part  of  pumpkin-seeds,  and  he  found  that 
it  resides  in  the  outer  membrane  surrounding  the 
embryo  (Lancet,  1875,  vol.  ii.).  In  two  cases  in 
which  he  administered  this  membrane  the  tape- 
worm was  expelled  entire.  M.  Heckel  believes 
the  active  agent  to  be  a resin,  and  he  thinks  that 
castor  oil,  which  in  the  cases  in  question  was 
given  both  before  and  after  the  remedy,  acts 
favourably,  not  merely  by  its  purgative  proper- 
ties, but  also  in  virtue  of  its  power  of  dissolving 
the  resin. 

Success  in  the  result  depends,  not  so  much  on 
the  choice  of  the  tseniafuge,  as  upon  the  mode  of 
administering  it,  and  of  observing  the  results 
accurately.  In  nine  out  of  ten  cases  it  is  taken 
for  granted  that  all  is  right,  if  the  patient  has 
only  stated  that,  after  taking  the  medicine  pre- 
scribed, he  got  rid  of  several  yards  of  the  worm. 
The  writer  has  heard  of  an  instance  where  the 
patient  alleged  that  he  passed  a single  tape- 
worm which  measured  100  yards.  Of  course  it 
is  quite  conceivable  that  a person  may  be  the 
victim  of  half-a-dozen  or  more  tape-worms  at 
a time.  Twelve  full-grown  tape-worms,  each  25 
feet  in  length,  would  collectively  give  an  ad- 
measurement of  1 00  yards ; but  the  writer  has 
never  yet  found  proof  of  the  occurrence  of  more 
than  four  perfect  taeniae  in  one  and  the  same 
human  bearer.  Such  an  instance  has  been  re- 
corded by  Mr.  Welch  in  his  admirable  memoir 
on  the  anatomy  of  T.  mediocanellata  ( Quarterly 
Journal  of  Microscopic  Science,  1875).  On  several 
occasions  the  writer  has  had  patients  suffering 
from  more  than  one  tape-worm,  and  in  one  in- 
stance, where  there  were  two,  both  heads  were 
expelled  at  one  and  the  same  time.  Kuchen- 
meister  refers  to  numerous  alleged  instances  of 
the  occurrence  of  several  tape-worms  in  ono  host, 
quoting,  amongst  others,  that  by  Madame  Heller, 
who,  it  is  said,  encountered  as  many  as  forty  in 
one  patient.  We  take  upon  ourselves  to  say, 
that  in  most,  if  not  in  all,  of  these  so-called  mul- 


1587 

tiple  tape-worm  cases,  the  various  broken  frag- 
ments of  one  or  two  large  parasites  have  been 
reckoned  as  representing  so  many  different  worms. 
Not  infrequently  foreign  bodies  resembling  seg- 
ments of  tape-worm  are  regarded  as  so  many 
parasites,  and  the  cases  are  treated  accordingly. 
In  the  management  of  genuine  eases  it  is  most 
important  that  the  head  should  be  secured.  This 
minute  structure  is  very  frequently  detached 
separately  from  the  body,  and  it  is  still  more 
frequently  left  adhering  to  the  mucous  membrane 
of  the  small  intestine,  when  the  greater  part  of 
the  body  of  the  worm  has  been  expelled.  It  rarely 
happens  that  either  a nurse  or  a patient  has  any 
notion  as  to  what  the  head  of  a tape-worm  is  like, 
and  we  fear  that  many  practitioners  are  in  the  like 
case.  For  this  want  of  knowledge  there  is  really 
no  excuse;  nevertheless  we  have  heard  it  laid  to 
the  charge  of  our  clinical  teachers  that  they  have 
never  afforded  the  necessary  instructions  on  this 
subject.  Be  that  as  it  may,  the  writer  has  for 
many  years  past  insisted  on  a more  thorough 
examination  of  the  faeces  following  upon  the  ad- 
ministration of  vermifuges.  Only  in  exceptional 
instances  does  the  head  of  the  worm  remain  at- 
tached to  the  unbroken  strobile  or  tape-worm- 
colony.  In  such  cases  a nurse,  or  the  patient 
himself,  may  remove  the  head  and  bring  it  with 
the  body  to  the  practitioner.  In  the  majority  of 
cases  the  body  of  the  worm  breaks  off  at  the 
base  of  the  neck,  but  frequently  also  at  the  upper 
and  narrower  part,  about  an  inch  from  the  head, 
more  or  less.  Occasionally  the  rupture  takes 
place  at  the  base  of  the  head,  leaving  nothing 
but  the  expanded  cephalic  portion  with  its  suckers 
(and  crown  of  hooks,  if  it  be  an  armed  species) 
intact.  The  writer  has  recorded  an  instance  in 
which  only  the  suckers  themselves  were  left  after 
the  expulsion  of  the  entire  body  of  the  worm  had 
been  effected  ( Tape-worms , 3rd  edition,  case  iv. 
p.  55).  In  regard  to  the  employment  of  enemata, 
as  recommended  by  Mosler,  the  writer  is  of 
opinion  that  the  practice  is  altogether  contra- 
indicated. If  it  were  true  that  the  once  detached 
head  were  capable  of  re-anchoring  itself  in  the 
lower  bowel,  as  Mosler  supposes  may  be  the  case, 
then  possibly  such  injections  might  be  employed 
with  advantage.  The  notion  that  a tapeworm 
could  re-develop  in  such  a situation  is  quite  at 
variance  with  all  that  we  know  respecting  the 
growth  and  economy  of  human  cestoids. 

As  regards  prescribing,  all  that  we  deem  it 
necessary  here  to  say  is  that  caution  should  be 
exercised  as  to  the  quality  and  quantity  of  the 
drugs  administered,  and  also  in  respect  of  the 
length  of  time  during  which  the  worm-poisons 
may  be  given.  The  writer  has  witnessed  serious 
results  from  the  persistent  use  of  turpentine  and 
male  fern,  though  the  doses  themselves  were  not 
excessive.  He  has  witnessed  toxic  effects  from 
one-drachm  doses  of  the  male  fern  extract,  when 
given  a few  times  in  succession  to  adults.  In 
young  children  half-drachm  doses  sometimes  pro- 
duce wandering  and  mental  confusion.  These 
unpleasant  symptoms  are  of  brief  duration,  pro- 
vided the  tseniafuges  be  stopped.  In  treating 
young  persons  with  powerful  anthelmintics  the 
patients  should  always  be  carefully  watched, 
and  great  care  be  exercised  lest  the  treatment 
be  injudiciously  prolonged.  So  variable  are  the 


[538  TAPE-WORMS, 

phenomena  and  experiences  encountered,  that  it 
is  not  easy  to  lay  down  any  precise  rules  which 
shall  be  applicable  to  all  cases.  In  every  instance 
the  practitioner  must  be  guided  by  the  actual 
result  of  each  day’s  successive  treatment.  If 
lie  obtain  the  head  of  the  worm  he  need  not 
hesitate  to  pronounce  that  his  patient  is  cured, 
unless  there  be  evidence  that  he  has  to  deal 
with  more  than  one  parasite.  This  very  essen- 
tial point  is  not  so  easy  of  determination  as 
might  be  supposed.  If  the  bodies  of  two  or 
three  distinct  parasites  be  broken  up  by  the 
worm-poison  and  expelled,  it  requires  very  accu- 
rate knowledge  of  the  sexually  mature  and  im- 
mature proglottids  respectively,  in  order  that, 
by  inspection,  the  practitioner  may  determine 
the  point  in  question.  All  the  portions  must  be 
carefully  removed  from  the  stool  and  laid  end  to 
end,  according  to  the  form  in  which  they  would 
present  themselves  during  life.  If  this  be  accu- 
rately done,  then,  and  then  only,  can  it  be  said 
whether  the  patient  has  been  the  victim  of  one, 
two,  three,  or  more  tape-worms.  In  the  correct 
management  of  such  cases  there  is  much  trouble 
and  labour  to  bo  overcome,  to  say  nothing  of  the 
exercise  of  that  scientific  knowledge  which  a care- 
ful study  of  the  structure  and  economy  of  these 
singular  parasites  involves.  No  two  cases  are 
exactly  alike.  In  diagnosis,  as  well  as  in  treat- 
ment, various  questions  present  themselves,  the 
correct  solution  of  any  one  of  which  may  be  of 
importance  to  the  patient.  The  writer  has  wit- 
nessed serious  results  from  false  diagnoses.  In 
one  of  those  maltreated  cases  the  patient,  a lady, 
had  undergone  six  years  of  persistent  drugging 
by  vermifuges,  when  all  this  time  she  was  not 
infested  by  tape-worm,  neither  had  she  at  any 
time  previously  entertained  the  presence  of  any 
cestode  parasite.  See  T^nia. 

T.  S.  CoBBOLD. 

TAPPING. — A popular  synonym  for  para- 
centesis. See  Paeacentesis. 

TARANTISM  ( tarantula , a ground  spider). 
Synon.  : Fr.  Tarentisme ; Choree  epidemique;  Ger. 
Tarantisimts. 

Definition.  — An  epidemic  dancing  mania, 
prevalent  in  Italy  in  the  sixteenth  and  seven- 
teenth centuries,  originating  in  fear  of  the  bite 
of  the  tarantula,  as  a remedy  for  which  the  dance 
was  adopted.  A full  account  of  it  will  be  found 
in  Hecker’s  Epidemics  of  the  Middle  Ages. 

History. — The  Italian  dancing  mania  com- 
menced in  Apulia,  in  the  latter  part  of  the 
fifeenth  century,  contemporaneously  with  the  St. 
Vitus’s  dance  in  Germany.  The  ground  spider 
had  long  been  held  in  dread,  as  causing,  by  its 
bite,  symptoms  of  nervous  and  physical  prostra- 
tion, which  might  end  in  death,  or  lifelong  las- 
situde. At  this  period  the  fear  of  the  frequently 
recurring  epidemics  of  the  Black  Death,  eastern 
plague,  and  other  diseases,  caused  widespread  de- 
pression. The  tarantula  was  dreaded  through- 
out Italy,  and  a bite  from  an  unknown  source 
was  a ready  explanation  of  any  symptoms  of 
nervous  prostration.  The  inspiriting  influence  of 
music  and  rhythmical  motion  was  found  to  dis- 
pel, for  a time,  the  depression,  and  the  theory 
arose  that  by  this  means  the  poison  of  the  spider 


TARTAR  EMETIC,  POISONING  BY. 

W'as  distributed  over  the  body,  and  expelled 
through  the  skin.  The  nervous  excitement  of  the 
remedy  proved,  however,  a greater  evil  than  the 
real  or  supposed  disease.  The  induced  emotion 
outran  control.  The  dancing  became  frantic,  and 
was  continued  until  the  dancersfell  senseless  from 
exhaustion,  with  the  result  of  leaving  them  for  a 
time  free  from  the  depression.  The  dancing  mania 
spread  by  moral  contagion,  and  large  numbers  of 
persons,  young  and  old,  male  and  female,  became 
affected.  The  temporary  relief  gained  by  the 
dance  led  to  the  adoption  of  the  remedy  at  in- 
tervals, which  ultimately  became  yearly;  and 
every  summer  the  sufferers  grew'  depressed  in 
anticipation  of  the  advent  of  the  annual  dance. 
Strange  psychical  conditions  were  induced  by 
the  emotional  disturbance  ; other  sensory  impres- 
sions besides  music  gave  pleasure,  and  certain 
colours,  such  as  red,  or  the  sight  of  the  sea  or 
even  of  clear  water,  exerted  a strange  fascina- 
tion. The  sexual  passion  became  involved  in 
the  tumult  of  emotion,  and  the  mental  excite- 
ment occasionally  ended  in  self-destruction.  Of 
longer  duration  than  the  dancing  epidemics  of 
Northern  Europe,  tarantism  was  at  its  height  in 
the  seventeenth  century,  and  gradually  died  out 
in  the  eighteenth,  leaving  only  a designation  for 
a lively  dance  as  its  harmless  legacy. 

W . R.  Go  WEBS. 

TAEASP,  in  TJnterengadin,  Switzer- 
land.— Alkaline  sulphated  waters.  See  Mineral 
Waters. 

TART.AR  EMETIC,  Po  soning  by. — 

Synon.  ; Fr.  Empoissonement  par  FJntimoine  ; 
Ger.  Antimoniumvergiftung. — Poisoning  by  tar- 
tar emetic,  a soluble  double  tartrate  of  anti- 
mony and  potassium,  is  not  very  common.  The 
emetic  properties  of  the  salt  generally  ensure  its 
speedy  ejection  from  the  stomach.  Poisoning  by 
the  salt  may  be  either  (1)  acute,  from  the  inges- 
tion of  a large  dose  ; or  (2)  chronic,  the  patient 
succumbing  under  the  exhaustion  consequent 
upon  its  prolonged  administration. 

1.  Acute  poisoning. — Shortly  after  taking 
a large  dose  of  tartar  emetic,  the  patient  is 
seized  with  intense  nausea  and  faintness,  accom- 
panied by  depression  of  the  force  of  the  pulse, 
and  increased  perspiration.  Violent  vomiting 
and  retching  follow,  with  a burning  pain  and 
sense  of  constriction  in  the  mouth,  throat,  and 
gullet.  Vomiting  affords  no  relief  to  the  nausea 
and  pain,  and  is  repeated,  the  vomited  matters 
becoming  bilious,  and  ultimately  perhaps  blood- 
tinged.  A metallic  taste  is  felt  in  the  mouth; 
the  abdomen  becomes  painful  and  tender ; and 
profuse  diarrhoea  sets  in,  the  faeces  often  contain- 
ing a considerable  quantity  of  blood.  The  urine 
is  at  first  increased  in  quantity ; but  later  it  may 
be  scanty,  blood-tinged,  or  suppressed.  The  cir- 
culation is  throughout  depressed;  and  the  skin 
cold,  clammy,  and  bathed  in  profuse  perspiration. 
The  muscular  system  is  relaxed;  but  cramps 
of  the  extremities  may  torture  the  patient.  In 
rare  cases  a pustular  rash  appears,  like  that 
produced  by  the  external  medicinal  application 
of  the  drug.  In  some  cases  neither  vomiting 
nor  purging  has  occurred,  the  symptoms  being 
simply  those  of  intense  prostration,  with  embar 


TARTAR  EMETIC,  POISONING  BY. 
rassed  respiration.  In  fatal  cases  death  occurs 
within  a few  hours. 

2.  Chronic  poisoning.— The  administration 
of  repeated  small  doses  of  tartar-emetic  causes 
nausea,  vomiting,  purging,  exhaustion,  and 
debility,  which  not  infrequently  prove  fatal. 
These  symptoms  are  accompanied  by  depressed 
irregular  circulation,  profuse  perspiration,  and 
disturbances  of  respiration. 

Anatomical  Chaeactees. — These  are  somewhat 
variable,  but  on  the  whole  are  those  of  a metallic 
Irritant  poison.  In  most  cases  there  is  inflamma- 
tion of  the  stomach.and  intestinal  tract  generally, 
not  so  patchy  nor  marked  by  such  bright  red- 
ness, as  in  arsenical  poisoning.  Not  infrequently 
the  stomach  and  small  intestines  escape,  and 
the  inflammation  may  be  confined  to  the  large 
bowel;  even  ulceration  of  the  intestines  may 
occur,  accompanied  by  haemorrhagic  extrava- 
sations. Hypostatic  congestion  of  the  lungs  is 
often  prominent. 

Diagnosis. — Poisoning  by  tartar  emetic  may 
be  diagnosed  from  other  irritants,  especially 
arsenic,  by  the  greater  and  earlier  depression, 
the  profuse  perspiration,  greater  irregularity  of 
pulse,  and  the  more  irregular  respiration.  An 
analysis  of  the  ejecta  or  of  the  urine  is  always 
advisable,  and  often  indispensable  to  complete 
the  diagnosis.  In  chronic  cases  an  analysis  of 
the  urine  is  the  only  satisfactory  mode  of  de- 
termining the  nature  of  the  illness,  where  tartar 
emetic  is  not  known  to  have  been  administered 
is  a medicine. 

Peognosis.— This  must  always  be  grave,  so 
loug  as  the  ejecta  contain  considerable  quantities 
of  the  poison.  Inaeute  cases  the  patient  cannot 
be  considered  out  of  danger  till  not  only  the 
vomiting  has  ceased,  but  an  obvious  return  of 
strength  has  set  in  for  some  time. 

Fatal  Dose. — Two  graius  have  proved  fatal  to 
an  adult.  Much  larger  doses  may,  however,  as 
a rule,  be  taken  with  impunity.  The  danger  is 
much  increased  if  the  poison  be  taken  in  con- 
junction with  some  substance,  such  as  opium, 
which  deadens  the  susceptibilities  of  the  stomach. 

Treatment. — The  stomach-pump  is  seldom 
necessary,  vomiting  being  very  profuse.  The 
elimination  of  the  poison  may  be  hastened  by 
free  administration  of  diluents,  and  the  stomach 
protected  by  mucilaginous  drinks.  The  stomach 
should,  however,  be  washed  out  by  means  of 
the  syphon-tube.  The  most  effective  antidote 
is  tannin,  which  forms  an  insoluble  tanuate  of 
antimony.  For  this  purpose  tincture  of  cinchona, 
decoction  of  oak-bark,  or  strong  infusions  of 
tea  or  coffee,  may  be  administered ; or  the 
stomach  may  be  wrnshed  out  with  similar  fluids, 
or  with  a solution  of  half  a drachm  of  tannin. 
Not  till  after  this  has  been  done,  or  the  stomach 
well  and  repeatedly  cleansed  by  free  vomiting, 
should  opium  be  administered.  The  after  treat- 
ment will  depend  upon  the  symptoms.  The 
treatment  of  chronic  cases  consists  in  cessation 
of  the  administration  of  the  poison ; in  the  ex- 
hibition of  ammonia,  stimulants,  and  tonics ; 
and  in  careful  support  of  the  strength.  Nutrient 
and  opiate  enemata  are  of  the  greatest  service. 

Thomas  Stevenson. 

TASMANIA. — A warm,  equable,  sub-tro- 


TASTE,  DISORDERS  OF.  1589 

pical  climate.  Mean  temperature  of  Hobart 
Town,  the  capital,  54°  Fah.  Prevalent  winds, 
N.E.  and  S.W.  Set  Australasia  (in  Appendix)  ; 
and  Climate,  Treatment  of  Disease  by. 

TASTE,  Disorders  of.  — Stnon.  : Fr. 

Troubles  du  Gout ; Ger.  Slbhruvgcn  des  Ge- 
schmackcs. 

Disorders  of  taste  have  to  be  carefully  distin- 
guished from  disturbance  of  olfactory  impressions, 
on  which  all  perception  of  flavour  depends.  They 
have  also  to  be  distinguished  from  disturbed 
appreciation  of  the  sensations  of  taste — in- 
creased or  diminished  enjoyment  of,  or  disgust 
at,  sensations  which  are  themselves  normal. 

1 . Increased  sensitiveness  of  the  nerves 
of  taste. — Stnon.:  Gustatory  byperaesthesia; 
Hypergeusia. — This  condition  is  evidenced  by 
detection  of  a substance  too  minute  in  quantity 
to  be  perceived  by  normal  taste,  or  by  an  abnor- 
mally intense  impression  when  a given  quantity 
of  a substance  is  tasted.  In  excitable  states  of 
the  nervous  system,  as  in  general  malnutrition, 
substances  in  small  quantities  in  the  blood  are 
tasted  with  great  readiness ; the  bitterness  of 
morphia  injected  beneath  the  skin  may  be  at 
once  noticed  (Wernich),  and  for  long  after  a 
bitter  substance  has  been  taken,  whatever  is 
tasted  may  seem  bitter.  Gustatory  hyperaes- 
thesia  is  often  met  with  in  hysterical  persons, 
and  sometimes  in  the  insane.  It  is  not  usually 
a symptom  of  sufficient  prominence  to  demand 
special  treatment. 

2.  Perverted  sense  of  taste. — Stnon.:  Gus- 
tatory parsesthesia ; Parageusia. — This  is  not 
uncommon  in  neurotic  states.  Substances  excite 
a different  taste  from  that  to  which  they  naturally 
give  rise.  A bitter  flavour,  for  instance,  is  de- 
tected in  a simple  saline.  This  condition  is 
commonly  conjoined  with  altered  appreciation  of 
the  taste  which  is  recognised,  so  that  substances 
commonly  considered  pleasant  are  disliked,  and 
those  are  enjoyed  which  commonly  excite  dis- 
gust. It  is  seen  in  a slight  degree  in  some 
toxaemic  conditions,  but  more  frequently  in 
psychical  disturbances.  In  hysteria  it  leads  to 
various  absurdities  in  diet. 

3.  Subjective  sensations  of  taste. — These 
occur  sometimes  from  disorders  of  the  central  ner- 
vous system,  in  hysteria,  insanity,  and  occasion- 
ally in  epileptoid  states.  The  sensation  is  usually 
of  an  unpleasant  description,  and  probably,  from 
its  character,  is  produced  in  the  region  supplied 
by  thejglosso-pharyngeal  nerve. 

Subjective  sensations  of  taste  occur  also,  very 
rarely,  from  irritation  of  the  gustatory  nerves. 
They  have  been  produced  experimentally  by  gal- 
vanising the  chorda  tympani,  when  exposed  by 
disease  of  the  internal  ear,  and  have  occurred  in 
some  cases  of  disease  of  the  petrosal  part  of  the 
facial  nerve.  Irritation  of  the  nerves  ending  in 
the  tongue  by  mechanical  and  electrical  stimuli 
may  also  cause  a sensation  of  taste.  These  sub- 
jective sensations  have  to  be  distinguished  from 
abnormal  sensations  due  to  substances  in  the 
blood  or  to  secretions  of  the  mouth.  The  treat- 
ment of  the  symptom  is  that  of  its  cause. 

4.  Loss  of  the  Sense  of  Taste. — Stnon.. 
Gustatory  anaesthesia ; Ageusia. 

zEtiologt. — Diminished  sense  of  taste  may 


1590  TASTE,  DISORDERS  OF. 


depend  (a)  On  thickening  or  other  changes  in  the 
mucous  membrane  of  the  mouth,  rendering  the 
nerve-endings  less  accessible  to  sapid  solutions. 
(b)  On  local  applications  lessening  the  irrita- 
bility of  the  nerve-endings.  Hot  or  cold  appli- 
cations may  temporarily  destroy  the  sense  of  taste. 
Cool  substances  cannot  be  tasted  so  well  as 
those  which  are  warm,  (c)  On  hysterical  and 
other  functional  nervous  disturbances.  ( d ) On 
disease  of  the  nerves  which  conduct  the  sensa- 
tion. There  is  still  much  uncertainty  as  to  the 
nerves  concerned  in  this  function.  Perception 
of  taste  over  the  posterior,  and  perhaps  also  the 
middle  third  of  the  tongue,  the  soft  palate,  and 
the  anterior  pillars  of  the  fauces,  is  believed  to 
depend  on  the  glosso-pharyngeal  nerve,  and  to 
be  lost  when  that  nerve  is  paralysed.  It  is  pro- 
bable, however,  that  this  is  not  the  case  in  all 
persons.  The  writer  has  met  with  an  instance 
of  complete  unilateral  loss  of  taste  on  tongue 
and  fauces,  in  which  the  fifth  nerve  was  para- 
lysed, and  the  glosso-pharyngeal  was  unaffected. 
Taste  in  the  anterior  third  of  the  tongue  de- 
pends on  the  gustatory  or  lingual  branch  of  the 
fifth,  and  probably  on  the  fibres  it  receives  from 
the  chorda  tympani.  Hence  destruction  of  the 
lingual  (section  for  neuralgia — Inzani),  disease 
of  the  chorda  tympani,  and  disease  of  the  facial 
just  above  the  origin  of  the  chorda  tympani, 
have  all  been  followed  by  loss  of  taste  in  the 
front  of  the  tongue.  It  is  exceedingly  common 
in  facial  paralysis  from  rheumatic  inflammation 
of  the  nerve-trunk,  no  doubt  from  the  mischief 
passing  up  the  bony  canal  as  far  as  the  origin  of 
the  chorda  tympani.  Division  of  the  facial  nerve 
outside  the  skull  has  also  caused  loss  of  taste 
(Stich;  Dotzbeck),  and  hence  it  is  thought  that 
some  fibres  from  the  tongue  must  reach  the 
facial,  by  external  junction.  It  is  much  more 
probable  that  migrating  neuritis  may  have 
passed  up  the  nerve,  and  have  involved  the 
chorda  tympani,  in  these  cases.  But  instances 
are  on  record  in  which  no  loss  of  taste  has 
resulted  from  destruction  of  the  chorda  tympani, 
and  hence  it  is  assumed  that  some  gustatory 
fibres  pass  from  the  lingual  to  the  otic  ganglion, 
and  thence  by  the  small  superficial  petrosal  nerve, 
and  the  nerve  of  Jacobson,  to  the  glosso-pharyn- 
geal. In  these  cases  it  is  possible  that  the  fifth 
nerve  may  supply  the  gustatory  fibres  directly  to 
tire  front  of  the  tongue.  Moreover,  the  glosso- 
pharyngeal fibres  have  been  themselves  traced 
by  Rudinger  to  the  forepart  of  the  tongue,  anas- 
tomosing with  the  twigs  of  the  lingutfl,  and 
Eulenberg  suggests  that  in  some  cases  they  may 
maintain  the  function  of  the  latter.  As  to  the 
path  of  the  gustatory  fibres  which  the  chorda 
tympani  conveys  to  the  facial  nerve,  there  is 
much  difference  of  opinion.  Lussana  believes 
that  they  continue  with  the  facial  and,  as  the 
‘intermediate  part’  of  that  nerve,  pass  to  a 
nucleus  near  that  of  the  glosso-pharyngeal.  But 
since  disease  of  the  facial  nerve  within  the  skull 
does  not,  ns  a rule,  cause  loss  of  taste,  most 
authorities  consider  that  the  fibres  leave  the 
facial  nerve  in  the  large  superficial  petrosal,  and 
thus  reach  the  spheno-palatine  ganglion,  and, 
according  to  Schiff,  pass  to  the  brain  by  the  fifth 
nerve.  This  view  is  supported  by  the  case  just 
mentioned  and  by  one  recorded  by  Hirschberg, 


in  which  disease  ot  the  fifth  within  the  skull 
caused  loss  of  taste  in  the  front  of  the  tongue. 
In  other  cases  of  disease  of  the  fifth  there  is  no 
loss  of  taste  (Lussana,  Renzi,  Althaus);  but  this 
is  not  decisive,  since,  as  just  observed,  the  exten- 
sive distribution  and  connection  of  the  glosso- 
pharyngeal nerve  may  permit  vicarious  action. 
Moreover  the  position  of  the  disease  in  the  fifth 
nerve  was,  in  many  of  the  cases,  uncertain.  In 
some  the  symptoms  may  have  been  due  to  disease 
of  the  nucleus  of  the  nerve,  from  which  the  gusta- 
tory fibres  may  be  separate.  Hermann  suggests 
that  more  fibres  may  pass  from  the  large  and 
small  superficial  petrosal  nerves,  directly  to  the 
glosso-phar3-ngeal,  than  is  commonly  assumed; 
but  the  glosso-pharyngeal  nerve  has  been  para- 
lysed without  loss  of  taste  in  the  anterior  part 
of  the  tongue.  It  is  highly  probable  that  the 
difference  of  opinion  regarding  the  course  of  the 
gustatory  fibres  is  due  to  the  circumstance  that 
this  path  varies  in  different  individuals. 

Symptoms. — Loss  of  taste  involves  the  percep- 
tion of  bitter,  sweet,  and  saline  characters,  to 
which  should,  perhaps,  be  added  the  metallic 
quality.  These  may  be  lost  in  varying  degrees. 
Each  part  of  the  tongue  possesses  the  power 
of  recognising  every  quality,  but  not  in  the 
same  degree ; bitterness  and  sweetness  are  ap- 
preciated chiefly  by  the  glosso-pharyngeal  at  the 
back,  acidity  and  saltness  by  the  lingual  in  the 
fore  part  of  the  tongue,  chiefly  at  the  tip  and 
edges.  The  onset  of  the  defect  may  be  sudden, 
as  in  hysteria ; or  gradual,  as  in  most  forms  of 
nerve-lesion.  In  the  latter  it  is  usually  uni- 
lateral; in  rare  cases  both  sides  are  involved.  It 
is  associated  with  other  symptoms  of  loss  of 
function  of  the  affected  nerves,  as  in  the  case 
mentioned,  in  which  there  was  loss  of  sensibility 
in  the  face,  and  paralysis  of  the  muscles  of  mas- 
tication. 

Diagnosis. — Loss  of  taste  has  always  to  be 
carefully  distinguished  from  loss  of  smell,  since 
all  flavours  are  recognised  by  the  olfaetorv  nerve, 
and  it  is  commonly  assumed  that  when  these 
cease  to  be  perceived,  taste  is  lost.  The  power 
of  tasting  must  be  ascertained  by  powders  or 
colourless  solutions  which  shall  convey  no  infor- 
mation. Citric  acid,  quinine,  sugar,  and  salt,  in 
powder  or  solution,  answer  well.  The  tongue 
must  be  held  out,  and  the  substance  or  solution 
placed  on  the  part  of  the  tongue  it  is  desired  to 
test,  and  after  each  observation  the  mouth  must 
be  rinsed  with  water.  It  must  be  remembered 
also  that  the  anterior  part  of  the  tongue  is 
almost  destitute  of  the  sense  of  taste,  except  on 
the  edges  and  tip.  If  the  loss  is  unilateral,  the 
powder  may  be  rubbed  on  the  side  of  the  pro- 
truded tongue,  near  the  tip,  with  the  finger,  and 
the  patient  should  indicate,  bjr  nodding  or  shak 
ing  the  head,  whether  it  is  tasted,  before  the 
tongue  is  withdrawn  into  the  mouth. 

Prognosis. — This  is  good  in  hysteria,  less 
favourable  in  nerve-affections.  The  loss  due  to 
affection  of  the  facial  nerve  is  frequently  re- 
covered from,  but  may  prevail  even  when  the 
function  of  the  latter  is  recovered.  In  intra- 
cranial disease  of  nerves  the  prognosis  is  very 
unfavourable. 

Treatment.— The  treatment  in  nerve-disease 
is  that  of  the  cause  of  the  symptom.  Stimula 


TASTE,  DISORDERS  OF. 
tion  of  the  nerves  in  the  tongue  may  sometimes 
aid  the  recovery  of  function,  and  for  this  fara- 
disation is  the  most  effectual.  In  hysterical  loss 
of  taste  this  commonly  suffices.  Where  it  de- 
pends on  affection  of  the  mucous  membrane  of 
the  tongue,  local  measures  alone  are  necessary. 

W.  R.  Gowers. 

TEETH,  Diseases  of. — Synon.  : Fr.  Ma- 
ladies des  Denis-,  Ger.  Krankhciten  der  Ztihne. 

Introduction. — The  teeth  aro  peculiar  organs, 
both  anatomically  and  physiologically.  The 
three  hard  tissues  of  the  teeth  are  comparatively 
of  low  organization,  while  they  are  in  connection 
internally  with  a structure,  the  pulp,  mainly 
composed  of  plexuses  of  nerves  and  blood-ves- 
sels, and  their  roots  are  covered  externally  with 
a highly  nervous  and  vascular  periosteum. 

The  functions  of  the  teeth  are  important.  They 
exercise  a large  influence  in  the  production  of 
articulate  sounds.  They  have  a keen  tactile 
faculty,  by  which  they  recognise  the  texture  of 
food,  and  detect  the  presence  of  foreign  bodies. 
But  their  most  important  function  is  mastica- 
tion, by  which  food  is  comminuted  and  at  the 
same  time  insalivated,  two  essential  prelimi- 
naries to  digestion.  The  loss  of  the  teeth  is  with 
many  of  the  lower  animals  the  limit  of  life,  from 
the  cessation  of  these  processes ; and  the  failure 
of  mastication,  through  edentulous  age,  is  a 
frequent  cause  of  intractable  dyspepsia  in  the 
human  subject.  This  fact  cannot  be  too  con- 
stantly remembered  by  the  practitioner.  The 
restoration  of  mastication  by  means  of  artificial 
teeth  is  often  the  immediate  cure  of  imperfect 
digestion,  which  diet  and  drugs  have  failed  to 
influence. 

The  diseases  of  the  teeth  are  for  the  most 
part  of  a surgical  character,  and  need  operative 
interference.  The  pathological  conditions  of  the 
teeth  are,  however,  of  important  interest  to  the 
medical  practitioner,  causing  and  explaining,  as 
they  do,  many  maladies,  especially  of  the  nervous 
system,  and  having  a serious  bearing  on  diges- 
tion and  nutrition  as  dependent  on  efficient  mas- 
tication. 

Again,  the  forms  of  t^ie  teeth,  and  the  characters 
of  their  tissues  are,  in  some  instances,  indicative 
of  former  illness,  and  in  other  instances  are  of 
critical  diagnostic  value  in  establishing  the  exist- 
ence of  a constitutional  taint  which  may  modify 
or  develop  disease.  The  teeth  are  dermal  organs, 
and,  as  such,  are  liable,  especially  during  their 
development,  to  be  affected  by  the  poison  of  the 
eruptive  fevers,  leading  to  disastrous  conse- 
quences to  the  teeth  themselves,  and  to  the 
immediately  contiguous  structures. 

From  tho  peculiar  position  and  surroundings 
of  the  teeth,  they  are  liable  to  mechanical  in- 
juries, and  to  chemical  and  physical  changes  of 
the  most  interesting  nature  in  themselves,  and  in 
relation  to  the  vital  manifestations  to  which  they 
lead. 

In  this  article  the  diseases  of  the  teeth  will  be 
discussed  in  the  following  order: — 1.  Abscess, 
and  blood-stains  ; 2.  Caries  ; 3.  Enamel,  pitted ; 
4.  Eruption  of  wisdom  teeth,  difficult ; 5.  Hae- 
morrhage after  extraction  ; 6.  Loosening;  7.  Ne- 
crosis, after  acute  diseases ; 8.  Nervous  affections 
originating  in  diseases  of  the  teeth;  9.  Odon- 


TEETH,  DISEASES  OF.  1591 

tomes;  10.  Syyphili tic  teeth;  and  11.  Tooth- 
ache. 

1.  Abscess  in  dentine,  and  blood-stains. 
Dentine  is  occasionally  liable  to  abscess  within 
its  substance,  front  suppuration  of  enclosed  fibro- 
vascular  tissue.  It  is  also  not  infrequently  dis- 
coloured by  the  extravasation  of  hematine.  In 
neither  of  these  conditions  do  symptoms  arise  of 
interest  to  the  practitioner. 

2.  Caries. — Caries  of  the  teeth  is  by  a great 
deal  the  most  common  pathological  change  to 
which  the  human  body  is  liable.  It  generally 
affects  some  of  the  temporary  teeth  before  they 
are  shed ; and  there  are  very  few  adults,  indeed,  in 
whose  teeth  caries,  in  some  degree,  is  not  to  be 
found.  Dental  caries  is  a softening  and  disinte- 
gration of  the  tooth's  surface,  gradually  penetra- 
ting towards  its  centre.  It  is  essentially  a super- 
ficial affection,  dependent  on  external  influences. 
These  are  chiefly  chemical,  though  partly  mecha- 
nical, and  it  is  not  improbable  that  the  action 
of  a vegetable  parasite  ( Leptothrix  buccalis)  has 
some  share  in  the  process.  One  of  the  most 
remarkable  circumstances  in  this  pathological 
change  is,  that  though  the  dentine  of  the  tooth 
undergoes,  through  disease,  a radical  change 
in  physical  characters  and  chemical  composi- 
tion, it  long  retains  its  vitality,  and  even  be- 
comes increasedly  sensitive.  The  idea  that  death 
of  the  tissue  antecedes  caries  is  quite  erro- 
neous. The  most  obvious  commencement  of 
caries  takes  place  on  the  surface  of  the  dentine 
immediately  underlying  faulty  enamel,  but  in 
some  instances  it  commences  in  the  enamelitself. 
When  the  enamel  is  attacked,  it  becomes  opaque, 
whitish,  or  grey,  and  then  gradually  stained  of  a 
brownish  colour,  and  this  is  soon  followed  by 
still  more  obvious  changes  in  the  dentine.  The 
latter  tissue  undergoes  more  rapid  alteration 
than  the  enamel ; it  becomes  brown  and  soft, 
and  the  change  penetrates  in  the  direction  of 
the  tubes  towards  the  pulp,  while  it  spreads 
laterally  beneath  the  as  yet  healthy  enamel. 
These  changes  occur  in  endless  variety,  one  form 
passing  into  another.  The  extreme  varieties 
have  been  described  as  distinct  species  of  decay, 
without,  however,  sufficient  justification. 

At  times  the  disease  advances  to  a certain 
stage,  and  then  ceases  ; the  intra-tubular  ma- 
terial becomes  calcified;  and  the  surface  perfectly 
hard  and  dull-brown  or  black.  This  is  called 
‘ arrested,’  ‘ stationary,’  or  ‘carbonised’  decay. 
There  is  a peculiar  and  characteristic  smell  in 
dental  caries,  like  that  of  gangrene  of  the  lung, 
or  like  the  scent  of  the  little  neuropterous 
insect  Chrysopa.  The  softening  of  the  dentine  is 
brought  about  by  the  removal  of  the  phosphate 
of  lime  in  a soluble  acid  form,  and  its  replace- 
ment by  water.  Carious  dentine  has  an  acid 
reaction. 

The  real  causes  of  dental  caries  are  as  yet 
involved  in  much  obscurity,  and  need  not  be  here 
discussed.  The  consequences  are  of  more  prac- 
tical import.  Though  carious  dentine  may  re- 
tain its  vitality  for  a considerable  time,  it  ulti- 
mately dies,  while  part  of  the  same  tooth  may 
be  living,  and  a line  of  demarcation  of  the  live 
and  dead  tissue  indefinable.  The  results  of 
caries  are  many  and  serious.  Tooth-ache,  neu- 
ralgia, periostitis,  suppuration  of  the  pulp,  alveo 


TEETH,  .DISEASES  OF. 


1592 

iar  abscess,  and  occasionally  muscular  paralysis, 
may  all  arise  as  a consequence  of  this  condition ; 
and  it  is  particularly  important  for  the  practi- 
tioner to  bear  this  in  mind,  as  a possible  as- 
sociation. 

Treatment. — The  treatment  of  caries  may  be 
divided  into  'preventive  and  remedial.  The  gene- 
ral conditions  of  health  that  lead  to  caries  are 
not  known  with  sufficient  accuracy  to  allow  of 
such  regulation  of  the  functions  of  nutrition  as 
would  prevent  the  occurrence  of  decay  when 
it  arises  from  such  causes,  but  the  mechanical 
influences  which  occasion  it  are  within  easy  con- 
trol. Every  mechanical  action  which  injures 
the  surface  of  the  teeth  should  be  guarded 
against,  especially  the  crushing  of  the  enamel  by 
the  pressure  of  contiguous  teeth  when  crowded. 
Cleanliness,  by  brushing  with  a dentifrice — 
which  removes  all  decomposing  matter  from 
contact  with  the  teeth — is  of  the  greatest  im- 
portance ; but  tooth-powders  should  be  soft,  and 
free  from  cutting  particles  : vegetable  charcoal 
being  carefully  avoided,  as  it  contains  small 
particles  of  silicates,  which  frequently  remove 
the  enamel.  Remedial  treatment  cannot  be  called 
curative,  as  there  is  no  restoration  of  lost  tissue; 
and  that  which  has  become  decalcified  never 
hardens  again.  But  caries  may  be  arrested,  and 
further  decay  prevented.  The  softened  tissue 
should  be  removed  ; the  hard  subjacent  struc- 
ture polished  and  kept  smooth ; projecting 
edges,  which  might  entangle  food,  levelled  and 
burnished;  and  above  all,  cavities  should  be 
stopped,  and,  if  possible,  with  gold. 

3.  Enamel,  rocky  and  pitted. — It  is  of 
great  importance  to  distinguish  between  syphi- 
litic teeth,  and  other  malformed  teeth  which 
have  no  similar  signification.  When  Mr.  Hutch- 
inson first  described  the  characters  of  teeth  which 
are  often  associated  with  inherited  syphilis, 
much  unnecessary  distress  was  occasioned  by 
confounding  teeth  having  rocky  and  pitted 
enamel  with  those  that  were  truly  syphilitic  in 
their  origin,  and  many  persons  supposed  them- 
selves to  inherit  syphilis,  who  merely  possessed 
teeth  bearing  marks  upon  them  which  registered 
a temporary  illness,  or  a condition  of  depressed 
nutrition  in  childhood  when  the  affected  teeth 
were  forming.  Teeth  with  rocky  and  pitted 
enamel  vary  indefinitely  as  to  the  extent  of  their 
defective  formation,  from  a slight  horizontal 
grooving  in  the  enamel,  to  a condition  in  which 
the  whole  surface  is  rocky  and  rugged,  and 
studded  with  pits  like  a thimble.  In  extreme 
cases  the  enamel  may  be  almost  entirely  want- 
ing ; but  there  is  no  narrowing  of  the  apices  of 
the  crowns  of  the  teeth,  and  no  crescentic  notch 
in  the  superior  incisors,  as  in  syphilis.  The  de- 
fects of  the  enamel  are  nearly  always  horizontal 
in  their  disposition;  and  even  the  pits  have  such 
an  arrangement  in  series.  This  condition  is 
most  frequently  seen  in  the  permanent  teeth, 
though  sometimes  in  the  temporary.  It  is  most 
manifest  in  the  first  molar,  the  incisors,  and  the 
canines.  Barely  it  affects  the  bicuspids,  near  the 
apices  of  the  cusps  ; and  still  more  rarely  the 
whole  bicuspid  crown  suffers.  But  it  will  be 
observed  that  the  malformation  is  symmetrical 
in  the  corresponding  teeth,  and  that  in  the  dif- 
ferent teeth  it  has  occurred  at  a point  in  its 


development  which  each  tooth  had  attained  at 
one  particular  time.  The  writer  believes  that 
the  mildest  and  severest  cases  are  essentially  the 
same  in  their  pathological  meaning,  and  that  the 
difference  is  only  one  of  degree.  It  has  been  sup- 
posed by  Mr.  Hutchinson  that  this  condition  of 
teeth  is  the  result  of  the  constitutional  influence 
of  mercury  given  in  childhood.  The  writer  be- 
lieves it  is  quite  unconnected  with  such  supposed 
cause.  It  is  extremely  rare  for  mercury  to  affect 
the  mouth  in  children.  This  condition  of  teeth 
occurs  where  mercury  has  never  been  given,  and 
equally  among  peoples  not  addicted  to  the  use  of 
that  drug.  It  is  found,  moreover,  among  extinct 
races,  who  lived  before  mercury  was  used  as  a 
medicine.  The  microscopical  structure  of  teeth, 
thus  degenerated,  shows  that  the  condition  is 
essentially  one  of  imperfect  calcification  of  the 
enamel  and  dentine ; and  the  writer  believes  that 
any  influence  or  disease  of  childhood,  suspending 
for  a time  or  depressing  the  nutrition,  may  be  an 
efficient  cause.  As  this  state  of  tooth  is  perma- 
nent, it  remains  a record  through  life  of  an  ill- 
ness in  childhood.  These  defects  in  the  tissues 
of  the  teeth  are  concurrent  with  their  lamina- 
tion. The  tissues  of  the  teeth,  especially  the 
dentine,  exhibit  a series  of  layers  due  to  different 
degrees  of  calcification,  in  which  the  earthy 
impregnation  has  been  greater  and  less  alter- 
nately. This  is  a normal  condition  up  to  a 
certain  degree ; but  when  the  laminae  of  lesser 
calcification  are  extremely  defective  in  earthy 
matter,  histological  defects  arise  which  lead  to 
the  appearances  in  the  teeth  described. 

4.  Eruption  of  wisdom  teeth,  difficult. — 
Insufficient  room  in  the  jaw  for  the  advent  of  the 
wisdom  teeth  is  sometimes  attended  with  very 
painful  and  even  serious  symptoms.  These  are 
confined  to  those  cases  in  which  the  obstruction 
occurs  in  the  lower  jaw.  The  wisdom  tooth  has 
insufficient  room  to  come  through,  and  remains 
impacted  at  the  base  of  the  ascending  ramus 
of  the  jaw,  growing  and  pressing  against  the 
second  molar.  This  gives  rise  to  inflammation, 
and  pain  of  a rheumatic  ehaTacter  wandering 
down  the  neck  and  arm,  the  latter  being  often 
weakened  in  muscular  power.  In  acute  and  neg- 
lected cases,  abscess  forms  at  the  angle  of  the 
jaw,  and  burrows  about  the  cheek.  One  remark- 
able symptom  is  trismus,  which  is  very  usual  in 
these  cases,  and  is  a characteristic  symptom : 
the  masseter  muscle  becoming  contracted  and 
firmly  set,  so  that  the  jaws  can  hardly  be  opened 
a quarter  of  an  inch.  This  locking  of  the  jaw 
sometimes  occasions  very  unnecessary  alarm. 

Well-authenticated  instances  of  epilepsy,  deli- 
rium, and  insanity  have  been  recorded,  having 
been  occasioned  by  the  resisted  eruption  of  the 
lower  wisdom  teeth,  and  cured  by  removal  of 
the  cause  of  irritation. 

Treatment. — The  treatment  depends  much 
on  the  degree  of  obstruction.  Lancing  the  gum 
is  sometimes  sufficient.  Removal  of  the  wisdom 
tooth  is  the  proper  cure.  Where  there  is  trismus 
it  is  necessary  to  wedge  open  the  jaws — slowly 
but  persistently ; and  then  to  extract  the  offend- 
ing tooth,  if  possible.  If  it  cannot  be  reached, 
the  second  molar  should  be  extracted,  when  its 
posterior  fang  will  sometimes  be  found  absorbed. 
When  once  an  abscess  has  formed  in  association 


TEETH,  DISEASES  OF.  1593 


with  an  obstructed  wisdom  tooth,  the  removal  of 
that  tooth  is  unavoidable.  Though  it  may  be 
necessary  to  remove  the  second  molar  first,  the 
third  must  afterwards  follow,  or  the  abscess  will 
remain.  The  trismus  immediately  vanishes  on 
the  extraction  of  the  tooth. 

5.  Haemorrhage  after  tooth-extraction. — 
This  is  an  occasional  manifestation  of  the  hae- 
morrhagic diathesis,  but,  considering  how  many 
teeth  are  extracted,  it  is  rare.  This  form  of 
bleeding  usually  comes  on  some  hours  after  the 
tooth  has  been  taken  out,  and  consists  of  a more 
or  less  rapid  welling  up  of  blood  in  the  recently 
emptied  sockets.  There  is  frequently  a history 
of  inherited  haemorrhagic  diathesis.  It  is,  more- 
over, occasionally  associated  with  menstruation. 

Treatment. — The  treatment  should  be  local 
and  general.  For  the  former  the  writer  would 
recommend  plugging  the  alveolar  cavities  with 
lint  or  cotton-wool,  previously  steeped  in  tinc- 
ture of  matico,  red-gum,  or  turpentine ; for  the 
latter,  the  internal  administration  of  turpentine, 
ergot,  or  tannin.  Tourniquets  have  been  devised 
for  applying  and  sustaining  pressure  on  the 
bleeding  surfaces. 

6.  Loosening  of  Teeth. — Synon.  : Spongy 
gums;  False  scurvy. 

Description. — The  term  ‘ scurvy  of  the  gums  ’ 
has  long  and  generally,  though  very  incorrectly, 
been  applied  by  dentists  to  this  condition  of 
the  gums.  Instead,  however,  of  being  an  en- 
largement of  the  gums  from  extravasation  of 
blood  within  them,  it  mainly  consists  of  a 
general  dilatation  of  the  smaller  vessels  of  the 
papillae  and  periosteum,  and  ultimately  of  those 
of  the  alveolar  bone.  At  first  the  gums  are 
enlarged  and  protrude ; but  afterwards,  while 
the  edges  still  remain  thickened,  they  recede 
from  the  necks  of  the  teeth,  which  consequently 
appear  elongated.  As  the  gums  retire  so  do  the 
alveolar  processes,  which  at  the  same  time  be- 
come large  and  open,  and  like  the  periosteum  are 
soft  and  spongy.  This,  as  a consequence,  loosens 
t he  teeth  ; which,  especially  in  the  front  upper 
jaw,  have  a tendency  to  protrude.  The  disease 
usually  occurs  about  or  after  middle  life.  In  this 
condition  the  gums  are  very  liable  to  bleed 
from  the  slightest  friction  ; tartar  forms  around 
the  necks  of  the  teeth ; considerable  ooze  from 
beneath  the  edge  of  the  gum,  often  of  a purulent 
character,  is  discharged ; and  the  breath  is 
generally  offensive. 

AEtiology. — The  causes  of  this  condition  are 
neither  constant  nor  always  intelligible.  Crowd- 
ing of  the  teeth,  dyspepsia,  frequent  pregnan- 
cies, mercurial  action  at  some  previous  time  of 
life,  and  continued  use  of  iodide  of  potassium, 
have  all  appeared  to  be  causes  of  this  spurious 
scurvy.  But  very  often  no  apparent  reason  can 
be  assigned  for  its  occurrence. 

Treatment. — Restoration  of  th  e general  h eal th 
and  extreme  cleanliness  of  the  mouth  are  essen- 
tial. All  tartar  should  be  removed,  and  the 
bleeding  attending  this  operation  often  has  a 
salutary  effect.  A fairly  stiff  toothbrush  should 
be  used  unsparingly,  and  the  bleeding  of  the 
gums  on  such  occasions  is  beneficial.  This 
should  be  followed  by  an  astringent  mouth- 
wash, such  as  a solution  of  alum  in  a decoction 
of  cinchona. 


7.  Necrosis  of  the  jaw  and  teeth  after 
the  eruptive  fevers. — These  are  among  the 
secondary  maladies  which  are  apt  to  occur  after 
small-pox,  scarlet  fever,  and  measles  in  children. 
The  cases  are  all  singularly  alike;  they  usually 
occur  between  the  third  and  eighth  years,  and 
the  soverity  of  the  previous  attack  of  fever  is 
immaterial.  The  local  symptoms,  which  usually 
appear  from  three  to  six  weeks  after,  consist  in 
a peeling  off  of  the  gum  around  one  or  more  of 
the  temporary  teeth  ; and  this  continues  until 
the  hare  jaw  is  exposed  to  a depth  which  corre- 
sponds, not  only  to  the  fangs  of  the  temporary 
teeth,  but  the  bony  capsules  of  their  immature 
successors.  Transverse  ulceration  then  usually 
follows  ; and  the  temporary  teeth,  their  alveoli, 
the  immature  permanent  teeth,  and  their  bony 
capsules  are  shed.  Frequently  this  occurs  on 
both  sides  of  the  mouth  symmetrically.  Thero 
is  no  swelling  or  formation  of  supplemental 
bone.  In  the  lower  jaw  the  writer  has  never  seen 
the  base  of  the  boDe  involved,  and  the  conse- 
quent disfigurement  is  singularly  slight.  These 
exfoliations  occur  much  more  frequently  after 
scarlet-fever  than  after  measles,  and  they  are 
rare  after  small-pox. 

Treatment. — The  treatment  cf  these  cases 
should  consist  in  as  little  interference  as  pos- 
sible. Little  need  be  done,  beyond  attention  to 
cleanliness  and  deodorisation,  and  the  removal 
of  the  sequestra  when  quite  loose. 

8.  Nervous  system,  affections  of,  de- 
pendent on  diseases  of  the  teeth. — Affec- 
tions of  the  nervous  system  dependent  on  the 
teeth,  but  not  arising  from  the  processes  of  den- 
tition, have  not  been  sufficiently  recognised,  and 
records  of  them  are  so  few  and  partial  that  it  is 
difficult  to  generalise  upon  them.  These  affec- 
tions are  either  reflex,  direct,  or  complex.  In 
the  first  case  some  portion  of  the  nervous  system 
receives  an  exaltation  of  function  from  the  irri- 
tation of  a tooth-nerve ; in  the  second  case  some 
contiguous  nerves  are  involved  by  the  spread  of 
inflammation  from  diseased  teeth,  or  the  pres- 
sure of  the  inflammatory  products  ; and  in  the 
third  case  both  would  be  entailed  in  a mixed  and 
uncertain  proportion. 

Reflex  affections. — As  regards  the  reflex  phe- 
nomena of  disease  dependent  on  the  teeth  wo 
may  enumerate  pain,  muscular  spasm,  muscular 
paralysis,  paralysis  of  some  of  the  nerves  of 
special  sense,  and  perverted  nutrition.  These 
reflex  phenomena  have  been  found  to  be  induced 
by  the  following  diseases : — caries,  with  or  with- 
out exposure  of  the  pulp;  exostosis — hypertrophy 
of  the  crusta  petrosa ; nodular  developments  of 
dentine  in  the  pulp-cavity;  periostitis,  plastic  or 
suppurative;  impaction  of  permanent  teeth  in 
the  maxillary  bones;  and  crowding  of  teeth  from 
insufficient  room. 

Small  excrescences  of  dentine  occurring  within 
the  pulp-cavity,  or  in  the  form  of  small  nodules 
in  the  substance  of  the  pulp,  are  apt  to  produce 
erratic  and  wide-spread  pain  among  the  dental 
nerves  of  one  side  of  the  face.  The  same  condi- 
tion not  infrequently  occurs  where  the  morbid 
change  consists  of  fine  nodular  exostoses  on  the 
fangs  of  the  teeth.  In  these  cases  the  pain  is 
reflected  from  the  spot  of  irritation  over  a larg6 
nervous  area;butthe  tooth  containing  the  offend- 


TEETH,  DISEASES  OF. 


1591 

5ng  growth,  is  usually  perceptible  by  tenderness 
or  elongation,  or  a consciousness  on  the  part  of 
the  patient  that  it  is  the  centre  of  offence.  Where 
it  arises  from  an  exostosis  it  is  apt  to  be  repeated 
with  several  teeth  one  after  another.  These 
cases  are  by  no  moans  uncommon,  and  are  often 
made  the  subjects  of  unavailing  medical  treat- 
ment for  a long  time.  Tooth-extraction  is  the 
only  remedy. 

Wry-neck, epilepsy,  and  tetanus  are  three  forms 
of  muscular  spasm  which  have  been  distinctly 
traced  to  the  irritation  of  disease  of  the  teeth  in 
the  adult. 

Among  the  nerves  of  special  sense  which  have 
been  affected  by  reflex  nervous  action  from  tooth- 
irritation  are  the  auditory  and  the  optic ; cases  of 
deafness  and  of  complete  amaurosis  having  arisen 
from  these  causes. 

There  is  a not  infrequent  form  of  muscular 
and  sentient  paralysis,  affecting  one  or  other  of 
the  arms,  which  has  often  been  wrongly  diagnosed, 
and  led  to  much  needless  suffering  and  alarm. 
It  consists  of  weakness,  some  pain,  and  occasion- 
ally loss  of  feeling  in  the  arm  and  hand  in  ques- 
tion. Pain  frequently  commences  in  the  side  of 
the  neck  or  at  the  point  of  the  shoulder,  and  is 
of  an  aching,  weary  character,  much  increased  by 
any  muscular  effort  of  the  limb,  which  usually 
hangs  in  a powerless,  listless  attitude  by  the 
patient’s  side.  The  hand  is  feeble,  andthe  patient 
has  difficulty  in  grasping  and  shaking  hands  with 
cordial  pressure.  These  symptoms  are  sometimes 
only  induced  by  exertion.  Such  cases  have  been 
several  times  supposed  to  depend  on  central  ner- 
vous disease,  and  have  been  so  treated.  They 
may  depend,  however,  on  some  irritation  of  a 
tooth  of  the  lower  jaw,  usually  a back  molar, 
which  is  transmitted  through  the  cervical  and 
brachial  plexuses  of  nerves.  A carious  or  im- 
pacted wisdom-tooth  is  usually  the  offender. 
Extraction  of  the  tooth  is  followed  by  complete 
relief  within  a few  hours.  There  are  also  on 
record  some  curious  cases  of  perverted  nutrition, 
in  which  the  colour  of  the  iris  has  been  altered, 
and  the  hair  at  certain  spots  has  become  ab- 
ruptly white,  ulcers  have  formed  and  refused  to 
heal,  in  the  neighbourhood  of  the  neck  and 
cheeks,  all  dependent  upon  tooth-irritation. 

Direct  affections. — Direct  affections  of  the  ner- 
vous system,  caused  by  tooth-disease,  are  far 
less  common  and  less  varied  than  those  which 
are  reflex,  and  their  mode  of  production  is  more 
obvious  and  intelligible.  The  portio  dura  of  the 
seventh  nerve,  the  nerves  which  enter  the  orbit, 
and,  very  rarely,  the  dental  nerves  in  their 
tracts  in  the  jaw,  are  those  only  which  suffer  in 
this  way— are  entangled,  that  is,  in  their  course 
by  those  inflammatory  influences  and  products 
which  tooth-diseases  engender. 

The  consequences  of  the  direct  implication  of 
nervous  trunks  by  the  inflammatory  results  of 
tooth-disease  are  so  very  grave,  especially  when 
affecting  the  nerves  of  the  eye  in  their  course  to 
the  orbit,  and  the  ultimate  resultsso permanently 
serious,  when  relief  is  not  speedily  given,  that  it 
is  impossible  to  exaggerate  the  importance  of 
these  cases.  The  writer  would  lay  the  more 
stress  upon  this  subject,  because  he  fears  that 
such  cases  have  been  misunderstood,  and  that 
injuries  have  thus  become  permanent  and  irre- 


mediable, which,  if  correctly  interpreted  and 
properly  treated  at  first,  would  have  been  easily 
removed. 

The  entanglement  of  the  portio  dura  leading 
to  facial  palsy  has  arisen  from  the  plastic  exu- 
dation around  an  upper  back  molar,  and  has 
been  immediately  cured  by  the  extraction  of  the 
tooth.  There  have  been  several  examples  in  which 
the  nerves  passing  into  the  orbit,  and  probably 
within  the  orbit,  have  been  surrounded  with 
plastic  exudation,  leading  to  the  destruction  of 
their  functions,  and  to  temporary  or  perma- 
nent loss  of  sight.  The  author  has  seen  several 
such  cases  ; some  were,  and  all  might  have  been, 
completely  cured  by  the  early  removal  of  the 
offending  teeth.  It  is  very  rare  indeed  for  the 
dental  nerves  in  their  passage  through  the  jaw- 
bones to  be  pressed  upon  and  functionally  dis- 
turbed by  the  inflammatory  products  of  carious 
teeth.  But  such  cases  have  occurred,  producing 
loss  of  sensation  of  the  front  teeth,  lips,  and 
chin. 

Complex  affections. — In  some  instances  the 
nervous  symptoms  are  clearly  of  a mixed  charac- 
ter, partly  reflex  and  partly  direct.  This  is  no 
doubt  the  ease  in  those  remarkable  and  not 
infrequent  examples  of  trismus,  in  which  the 
jaws  are  firmly  closed  by  the  spasmodic  action  of 
the  masseter  muscle,  on  the  side  where  a carious 
or  impacted  lower  molar  tooth  is  keeping  up  irri- 
tation, and  which  is  immediately  cured  by  the 
extraction  of  tho  tooth. 

The  same  may  be  said  of  those  wide-spread 
and  diffused  pains,  attended  with  extreme  tegu- 
mentary  sensibility,  which  so  often  accompany 
ordinary  toothache. 

9.  Odontomes,  or  tooth-tumours.  — The 
teeth  occasionally  develop  tumours  of  their  hard 
tissues  of  an  interesting  and  remarkable  charac- 
ter. They  are  divisible  into  two  distinct  groups 
— those  which  are  congenital-,  and  those  which  are 
developed  in  after-life,  the  secondary  or  induced. 
The  former  consist  of  (a)  ‘warty’  growths  of 
the  crowns  of  the  teeth;  ( b ) ‘hernia’  of  the 
fangs ; and  (e)  nodules  of  enamel  on  the  roots  of 
the  teeth.  But  with  none  of  these  is  the  practi- 
tioner likely  to  be  concerned,  as  they  are  not 
known  to  produce  symptoms  other  than  those 
which  suggest  surgical  interference. 

The  secondary  or  induced  odontomes  are  (a) 
‘exostosis’  on  the  fangs;  and  (6)  ‘ dentine  ex- 
crescence’ within  the  pulp-cavity  of  the  tooth. 
These  forms  of  tooth-tumour,  though  smaller 
and  less  obvious  than  the  others,  are  both  liable 
to  occasion  symptoms,  painful  and  obscure,  which 
it  may  be  difficult  to  diagnose  and  treat. 

Exostosis  of  the  fang  of  a tooth  consists  of  an 
increased  growth  of  the  normal  outer  layer  of  the 
fang — the  tooth-bone.  This  occurs  in  very  vary- 
ing degrees  and  forms,  and,  as  a pathological 
condition  is  not  uncommon.  But  it  is  unusual 
for  these  hypertrophies  to  give  rise  to  symptoms 
of  disease.  They  do  so,  however,  sometimes 
and  with  great  severity,  the  one  symptom  being 
pain,  and  this  is  especially  the  case  when  the 
exostosis  is  small,  nodular,  and  forming  on  one 
side  of  the  fang.  These  exostoses  are  apt  to  at- 
tack the  teeth  in  succession,  and  they  occur  either 
in  early  or  middle  life.  Such  cases  usually  com- 
mence with  pain  in  some  particular  tooth,  whiet 


TEETH,  DISEASES  OF.  1595 


is  apparently  sound ; the  pain  is  inconstant,  of 
a neuralgic  character,  and  wandering  about  the 
tide  of  the  face  and  head.  The  affected  tooth  is 
often  elongated,  tender,  and  very  susceptible  to 
changes  of  temperature.  The  pain  is  not  con- 
stant, but  intermitting;  increasing,  however,  in 
frequency  and  severity  ; and,  though  wandering 
over  a considerable  area,  always  emanating  from 
the  one  affected  tooth.  The  pain  at  length  be- 
comes intolerable,  and  the  apparently  sound 
tooth  is  extracted,  displaying  at  its  fang-end  a 
small  lobuiated  exostosis.  The  loss  of  the  tooth 
is  followed  by  complete  relief,  and  this  may  be 
permanent ; but  not  infrequentl)',  after  an  in- 
terval of  entire  ease,  another  tooth,  generally  an 
immediate  neighbour,  is  attacked  in  the  same 
way,  and  goes  through  the  same  process,  till  it  is 
extracted.  And  this  may  occur  till  all  the  teeth 
are  lost.  No  treatment  short  of  extraction  ap- 
pears to  palliate  the  symptoms. 

Dentine  excrescences  in  the  pulp-cavity  may 
exist  without  causing  any  symptoms ; or  they 
may  be  associated  with  pain,  and  a general  his- 
tory scarcely  to  be  distinguished  from  exostosis. 
In  some  of  the  cases,  however — especially  where 
there  is  a general  intrinsic  calcification  of  the 
pulp,  the  symptoms  have  assumed  the  aspect  of 
the  severest  tic-douloureux.  Extraction  is  the 
only  remedy. 

10.  Syphilitic  teeth. — We  are  indebted  to 
Mr.  Hutchinson  for  the  interesting  discovery  that 
children  who  inherit  syphilis  are  liable  to  cha- 
racteristic deformity  of  certain  teeth,  and  that 
this  is  not  infrequently  associated  with  specific  in- 
terstitial inflammation  of  the  cornea.  Syphilitic 
teeth  are  small,  narrow,  more  or  less  pointed,  and 
usually  of  a dirty  grey  colour.  Both  the  tem- 
porary and  permanent  sets  may  be  affected  ; but 
it  is  the  front  teeth  of  the  latter  that  exhibit  the 
characteristic  and  most  marked  deformity.  The 
lower  incisors  are  peggy  and  pointed ; those  of 
the  upper  jaw  are  narrowed,  instead  of  expanded 
towards  the  cutting  edge ; and  the  centrals  fre- 
quently have  a crescentic  notch.  The  other  ir- 
regularities of  shape  in  the  teeth  may  arise  or  be' 
closely  imitated,  where  there  is  no  specific  taint, 
but  the  crescent  ic  notch  in  the  contracted  cutting 
edge  of  the  superior  permanent  central  incisor  is 
believed  to  be  absolutely  diagnostic  of  inherited 
syphilis.  As  such,  it  is  of  great  value  to  the 
physician  in  deciding  on  the  nature  of  doubt- 
ful symptoms  which  may,  or  may  not,  have  an 
hereditary  syphilitic  origin.  Mr.  Hutchinson 
considers  that  these  malformations  of  teeth  are 
occasioned  by  specific  stomatitis.  But  perverted 
form  and  nutrition  need  not  be  inflammatory; 
and  the  writer  doubts  if  such  action  arises  in 
these  cases.  The  teeth  are  dermal  organs,  and 
upon  the  skin  syphilis  inflicts  some  of  its  chief 
injuries,  which  need  not  be  inflammatory. 

11.  Toothache. — The  term  toothache  can 
scarcely  be  used  with  critical  accuracy,  as  it  is 
popularly  applied  to  any  pain  in  or  immediately 
round  a tooth,  without  distinction  as  to  its  cause 
or  character.  Such  pain  may  be  produced  by 
many  conditions,  the  commonest  of  which  is  den- 
tinal caries,  with  or  without  exposure  of  the 
pulp.  But  other  influences  may  induce  pain, 
scarcely  to  be  distinguished  from  that  of  tooth- 
decay.  Among  these  causes  may  be  enumerated 


impaction  of  the  U'isdom-teeth,  especially  the 
lower;  inflammation  of  the  tooth-pulp  uni  perios- 
teum; rheumatism;  deposit  of  secondary  dentine 
in  the  pulp-chamber  ; and  exostosis. 

Excepting  where  pain  is  very  severe,  and  of 
such  a character  as  to  assert  its  exact  locality,  it 
is  not  infrequently  referred  to  a position,  and 
often  to  a particular  tooth,  other  than  the  one 
affected.  Where  this  is  the  case,  this  pain  is, 
the  writer  believes,  always  anterior  to  the  loca- 
lity of  its  origin;  and  it  is  often  only  by  roughly 
manipulating  or  sharply  tapping  the  teeth  that 
the  actual  offender  is  discovered. 

Toothache  dependent  upon  dental  caries  usu- 
ally arises  when  the  decay  approaches  the  tooth- 
pulp,  and  is  the  result  of  its  inflammation.  The 
tooth-pulp  consists  very  largely  of  nerves,  and 
is  closely  boxed  up  within  unyielding  walls,  so 
that  its  swelling  gives  rise  to  great  internal  pres- 
sure ; hence  the  pain  is  of  a very  severe  and 
distressing  character.  Inflammation  frequently 
yields  to  complete  or  partial  suppuration  of  the 
pulp;  the  escape  of  the  matter  being  attended 
with  marked  relief.  This  may  arise  either  from 
the  breaking  down  of  the  external  carious  wall 
of  the  tooth,  or  from  its  finding  vent  through  the 
orifice  at  the  apex  of  its  fang,  and  so  constitu- 
ting an  alveolar  abscess,  which  ultimately  bursts, 
either  as  a gumboil  within  the  mouth,  or  by  a 
fistulous  opening  upon  the  cheek. 

The  impaetion  of  a wisdom-tooth  produces  a 
form  of  toothache  which  is  usually  of  a dull 
character,  and  gives  a sense  of  tension  and  re- 
straint. It  arises  from  a want  of  room  for  the 
coming  tooth,  whoso  growth  produces  pressure 
on  the  contiguous  structures.  The  pain  often 
wanders  along  the  whole  jaw,  and  may  appear 
to  be  especially  associated  with  any  other  tooth 
on  that  side.  Occasionally  the  second  molar  be- 
comes so  eroded,  through  absorption  of  its  pos- 
terior fang  by  the  pressure  of  the  wisdom-tooth, 
as  to  cause  inflammation  of  its  pulp,  in  which 
case  there  may  be  acute  toothache  and  loosening 
of  the  tooth. 

Inflammation  of  the  tooth-pulp  may  some- 
times occur  spontaneously,  and  thus  give  rise 
to  pain. 

Inflammation  of  the  periosteum  around  any 
particular  tooth,  the  result  of  disease  or  any 
external  violence,  may  have  the  same  effect.  It 
is  said  also  that  the  inflammation  of  the  fibrous 
tissues  round  the  teeth  may  be  of  a rheumatic 
character,  but  of  this  the  writer  has  no  positive 
evidence.  It  may,  however,  arise  from  syphi- 
litic periostitis,  and  from  the  administration  of 
mercury  when  pushed  to  approaching  salivation. 
Iodide  of  potassium  has  sometimes  a like  effect. 

Secondary  dentine  and  exostosis  may  also  be 
associated  with  toothache,  which  is  frequently 
of  a neuralgic  and  wandering  character,  so  that 
it  is  often  difficult  to  fix  upon  the  offending  tooth. 
Whether  the  pain  results  from  the  pressure  of 
the  adventitious  growth,  or  whether  they  are  both 
the  result  of  some  sub-inflammatory  condition,  it 
is  difficult  to  say. 

Treatment. — The  treatment  of  toothache  con- 
sists in  attendance  to  the  general  health;  in  local 
applications ; and  in  extraction  of  the  offending 
organ.  Tonics,  especially  quinine,  are  often  use- 
ful where  the  pains  are  of  an  inconstant  and 


1596  TEETH,  DISEASES  OF. 
neuralgic  character.  Food  and  stimulants,  espe- 
cially wine,  would  also  give  relief  in  such  cases, 
where  the  patient  is  below  par.  When  the  tooth- 
ache arises  from  caries,  great  relief  is  expe- 
rienced in  the  early  stages  by  the  application  of 
creasote,  carbolic  acid,  and  other  hydro-carbons. 
Where  pus  is  pent  up  within  the  pulp-cavity  it 
should  be  evacuated,  either  by  opening  the  pulp- 
cavity  from  above,  or  by  drilling  the  tooth. 

Where  the  pain  arises  from  impaction  of 
wisdom-teeth,  relief  from  pressure  must  be  given 
by  extraction.  If  the  wisdom-tooth  cannot  itself 
-bo  got  at,  the  second  molar  should  he  taken  out. 
In  all  cases  where  the  pain  has  become  exces- 
sive and  intractable,  removal  of  the  tooth  is  the 
only  remedy.  James  Salter. 

TEETH,  Grinding  of. — Automatic  move- 
ments of  the  mouth  are  common  to  many  dis- 
eases, especially  in  young  subjects.  In  cerebral 
disorders  in  children  we  often  notice  a vertical 
movement  of  the  jaw,  as  if  the  patient  were 
chewing.  At  other  times  the  movement  is  a 
lateral  one,  and  the  teeth  are  ground  together, 
so  as  to  give  rise  to  a hard  unpleasant  grating 
60und.  This  symptom  is  not,  however,  neces- 
sarily dependent  upon  disease  of  the  brain,  nor 
is  it  peculiar  to  early  life.  Grinding  of  the 
teeth  may  be  observed  at  all  ages,  and  in  many 
different  complaints.  It  is  frequently  spoken  of 
as  a symptom  of  worms,  and  is,  indeed,  often 
present  when  the  alimentary  canal  is  infested 
with  these  parasites  ; but  the  symptom  is  in  such 
cases  quite  independent  of  the  worms,  and  is  to 
be  ascribed  merely  to  the  intestinal  derangement 
which  is  the  essence  of  the  disease,  the  presence 
of  worms  being  merely  an  accidental  complica- 
tion. Disordered  bowels  are  by  far  the  most 
common  cause  of  grinding  of  the  teeth,  and 
therefore,  with  the  exception  of  cerebral  disease, 
this  symptom  is  almost  confined  to  such  disor- 
ders as  are  accompanied  by  derangements  of  the 
alimentary  canal.  Thus  children  with  tubercu- 
losis often  grate  their  teeth  together  with  painful 
persistency ; but  in  this  disease  an  acid  condition 
of  the  contents  of  the  stomach  and  bowels  is  an 
almost  invariable  complication.  Again,  in  rheu- 
matism and  gout,  where  there  is  the  same  ten- 
dency to  acid  fermentation  of  food,  grinding  of 
the  teeth  is  a common  symptom  in  the  adult. 

The  movement  of  the  jaw  occurs,  as  a rule, 
independently  of  the  will,  and  is  seldom  noticed 
except  during  sleep.  Sometimes,  however,  chil- 
dren will  grind  their  teeth  voluntarily,  and  ap- 
parently with  full  consciousness  of  what  they 
are  doing.  Such  cases  are,  however,  rare. 

The  treatment  of  teeth-grinding  consists  in 
the  correction  or  removal,  if  possible,  of  the 
condition  upon  which  it  depends. 

Eustace  Smith. 

TEETHING,  Disorders  of.  See  Den- 
tition, Disorders  of. 

TEL  AN  GEIECTASIS  (rrj\e,  far,  ayyeiov, 
a blood-vessel,  and  eKraais,  a dilatation). — 
Aneurism  by  anastomosis.  Sec  Aneurism  ; and 
Tumours. 

TEMPERAMENT.— Synon.  : Fr.  Tempe- 
rament ; Ger.  Korpcranlage. — This  term  denotes 
the  correlation  of  grouped  differences  existing 


TEMPERAMENT. 

among  men,  in  respect  of  physical  stmetnro  and 
conformation,  with  differences  of  functional  acti- 
vity, of  mental  endowment  and  disposition,  and 
of  affection  by  external  circumstances. 

The  early  writers  on  medicine,  recognising  the 
facts  that  each  individual  man  is  different  from 
all  other  men  in  physical  appearance;  that,  again, 
in  every  man  are  found  qualities  proper  to  him- 
self, inherent  and  indestructible;  that,  again, 
on  a review  of  many  men  a constant  associa- 
tion of  certain  qualities  with  certain  variations 
in  physical  appearance  may  he  observed,  pro- 
ceeded to  make  generalisations,  tending  to  the 
doctrine  of  temperaments.  This  doctrine,  as 
fully  set  forth  by  Galen,  established  nine  kinds 
of  temperament.  First,  the  balanced  tempera- 
ment (evKpaata,  temperies)  consisting  in  a mix- 
ture of  different  qualities  in  such  due  proportion 
that  none  is  in  excess.  Next,  four  temperaments 
of  simple  excess  or  default — the  hot,  the  cold, 
the  moist,  and  the  dry ; and  then  four  mixtures 
of  these — the  hot  and  dry,  the  hot  and  moist, 
the  cold  and  dry,  the  cold  and  moist.  Subse- 
quently, under  the  influence  of  the  humoral 
pathology,  temperaments  were  classified  as  san- 
guineous, bilious,  phlegmatic,  or  melancholic, 
according  as  the  heart,  the  liver,  the  head,  or 
the  spleen  were  supposed  to  he  predominant  in 
modifying  the  humours  of  the  body.  More  re- 
cent writers  have  again  abridged  the  list,  and 
have  given  its  categories  a new  interpretation. 
They  mostly  acknowledge  but  three  tempera- 
ments— the  sanguine,  the  nervous,  and  the  lym- 
phatic. The  balanced  temperament  is  not  in- 
cluded, because  no  individual  of  such  perfect 
structure  exists.  But  it  is  equally  true  that  the 
descriptions  by  which  the  other  terms  are  defined 
represent  either  individuals  used  as  types,  and 
therefore  correspond  fully  only  to  one  or  very 
few  of  the  units  of  large  genera,  or  are  construc- 
tive types  corresponding  to  no  single  existence. 

Begarding  the  method  of  classification  as 
wholly  artificial,  yet  without  denying  its  useful- 
ness, we  propose  to  preface  the  generally  accepted 
■description  of  the  three  temperaments  above 
mentioned  by  a brief  analysis  of  Galen’s  picture 
of  the  tvKpuros.  The  thoroughly  tempered 
human  being  is  in  his  bodily  constitution  exactly 
midway  between  slimness  and  stoutness,  between 
softness  and  hardness,  between  hot  and  cold.  In 
his  mental  constitution  he  exhibits  the  exact 
mean  between  rashness  and  timidity,  between 
sluggishness  and  precipitancy,  between  the 
sweetness  of  pity  and  the  bitterness  of  hatred. 
Such  an  one  is  brave,  affectionate  at  home,  and 
abroad  discreet.  To  these  essentials  are  added, 
of  necessity,  temperance  in  eating  and  drinking, 
perfect  digestion  and  assimilation  of  food,  phy- 
sical and  psychical  energies  without  a flaw,  the 
best  powers  of  feeling,  the  best  powers  of  move- 
ment, a clear  skin,  a good  breath.  He  is  neither 
too  much  given  to  sleepnor  too  wakeful,  is  midway 
between  baldness  and  hairiness,  between  dark- 
ness and  fairness  of  complexion.  When  a child 
he  has  reddish  rather  than  black  hair,  in  adult 
life  the  reverse.  The  three  modern  categories 
correspond  fairly  to  Galen's  mixed  tempera- 
ments ; the  sanguine  to  the  hot  and  moist,  the 
nervous  to  the  hot  and  dry, the  lymphatic  to  the 
mixtures  of  cold  with  moist  or  dry. 


TEMPERAMENT. 

The  Sanguine  Temperament. — Persons  be- 
longing to  this  group  are  described  as  being  ruddy 
and  bright  of  complexion,  as  having  strong  and 
Balient  muscles,  a relatively  large  chest,  and  a 
relatively  small  head.  The  play  of  their  senses, 
the  determinations  of  their  will,  the  responses 
of  their  muscles  to  impulses,  are  energetic  and 
well-directed.  Arterial  blood  abounds  in  them  ; 
their  veins  are  small.  The  functions  of  their 
bodies  are  rapidly  and  easily  performed.  The 
functions  of  their  minds  show  a similar  vivacity. 
Rapid  thought,  quick  imagination,  brilliant  cour- 
age, are  associated  with  want  of  depth  and  per- 
sistence, with  elastic  forgetfulness  even  of  strong 
impressions.  In  illness  such  people  inflame 
quickly,  develop  diseases  in  a complete  and  re- 
gular way,  and  defervesce  quickly,  often  with 
well-marked  crisis.  They  are  especially  liable 
to  gout,  acute  inflammations,  and  active  haemor- 
rhages. They  are  men  who  dominate  their 
fellows. 

The  Hervous  Temperament. — Herein,  as 
authors  tell  us,  the  skin  is  dark,  dull,  earthy,  or 
sallow,  and  is  hot  and  pungent  to  the  touch,  instead 
of  being  warm  and  moist.  The  cranium  is  large  in 
proportion  to  the  face ; the  muscles  spare  and  not 
well-defined;  the  chest  narrow;  the  circulation 
languid,  with  preponderance  of  the  venous  sys- 
tem. The  face  has  the  lineaments  of  energy  and 
intensity  of  thought  and  feeling;  the  movements 
are  hasty,  abrupt,  often  violent,  in  alternation 
with  languor.  The  affections  are  violent  and 
persistent,  the  sexual  passions  usually  very  strong. 
Sensations  are  intense,  far  in  excess  of  exciting 
causes.  The  mental  powers  are  large  and  capable 
of  persistent  exercise.  The  bodily  organization 
favours  venous  congestion  and  haemorrhage,  neur- 
algia, hepatic  and  intestinal  obstructions,  and  the 
mental  lunacies.  Nevertheless,  these  people  are 
often  found  to  endure  long  fatigue,  privation, 
and  exposure  better  than  the  sanguine.  They 
are  the  people  who  teach  or  lead  their  fellows. 

The  Lymphatic  Temperament. — A heavy 
ill-proportioned  ungainly  form  of  body,  large 
joints,  bulky  head,  large  hands,  broad  flat  feet, 
light  or  reddish  hair,  a sallow  or  pasty  com- 
plexion, accompany  a general  slowness  and  lan- 
guor of  bodily  function.  The  muscles  are  often 
large,  but  their  movements  are  awkward  or  in- 
accurately directed ; the  chest  and  heart  are 
inadequate  in  bulk  to  the  rest  of  the  body.  With 
this,  there  may  often  be  combined  much  mental 
firmness,  solidity,  and  constancy — a good  judg- 
ment if  a poor  energy.  The  power  of  resistance 
to  acute  disease  is  inferior;  the  tendency  to 
chronic  diseases,  particularly  of  strumous  and 
asthenic  kinds,  is  pronounced. 

In  the  sanguine  temperament  a predominance 
of  blood-making  power  and  of  muscular  develop- 
ment is  asserted.  It  may,  perhaps,  be  spoken  of 
as  the  temperament  in  which  the  spinal  system, 
and  the  parts  directly  subordinate  thereto  are 
most  developed.  In  the  nervous  temperament 
the  predominance  of  the  cerebrum  is  clearly  in- 
dicated. In  the  lymphatic  temperament,  languor 
or  slowness  of  both  nervous  and  circulatory  sys- 
tems is  connected  with  slowness  or  default  of  the 
general  nutrition. 

Practically  these  types  comprehend  only  a 
part  of  mankind.  If  we  admit  that  they  can  be 


TEMPERATURE.  1597 

oxtended  in  their  application  by  the  recognition 
of  mixtures  of  them  among  themselves  in  various 
proportions  and  degrees,  we  must  admit  also  that 
there  exist,  outside  of  them  altogether,  numerous 
correlations  of  much  importance  to  tne  physician. 
Moreover,  many  of  the  constituents  of  tempera- 
ments are  capable  of  being  changed  by  age, 
external  circumstances,  and  habit.  New  combi- 
nations may  be  introduced  by  these  agencies,  or 
by  bodily  changes  arising  in  accident  or  disease. 
The  building  anew  of  a man’s  temperament  by 
religious  enthusiasm,  by  suffering,  by  moral  con- 
trol, or  by  indulgence,  is  a spectacle  daily  to  be 
seen  and  studied.  In  that  analysis  of  the  Kpams 
of  the  individual  which  must  furnish  the  inter- 
pretation of  much  of  his  behaviour  in  illness,  the 
accurate  estimation  of  many  combined  influ- 
ences, native  and  accessory,  has  been  called  the 
stumbling-block  of  practice.  It  may  better  be 
called  the  touchstone  of  practical  skill.  That 
physician  does  well  who  carries  with  him  a 
mental  picture  of  some  such  perfect  human 
animal  as  Galen  has  imagined  ; and  who  marks 
on  the  diagram,  with  his  patient  before  him,  the 
lines  of  original  shortcoming,  of  development,  of 
warp,  of  injury,  of  degeneration,  so  as  to  arrive 
at  some  clear  sight  of  the  outcome  or  resultant 
of  all  in  the  present  organisation  and  reactions 
of  that  patient.  William  M.  Oed. 

TEMPERATURE.— Synon.  : Fr.  Tempe- 
rature ; Ger.  Korpcrwdrme  ; Eigenwarme. 

Introduction'. — The  human  body,  like  that 
of  all  warm-blooded  animals,  has  a heat  of  its 
own,  which  is,  to  a great  extent,  independent  of 
the  surrounding  temperature.  As  long  as  the 
body  is  in  a state  of  health,  the  external  cir- 
cumstances must  either  very  materially  change, 
or  a change  of  them  must  operate  for  some 
length  of  time,  before  any  but  a transitory  ele- 
vation or  depression  of  the  blood-heat  will  occur. 
But  the  temperature  becomes  much  more  easily 
altered  when  the  functions  of  the  body  are  ab- 
normally performed,  in  consequence  of  disease. 
A change  of  the  blood-heat  is  often  the  very 
first  symptom  of  a disease,  and  it  may  occur  even 
before  the  slightest  indisposition  is  felt  by  the 
patient.  Rent*;  observations  of  the  temperature 
may  be  extremely  valuable  for  diagnosis,  and 
the  course  of  most  diseases  being  accompanied 
by  corresponding  alterations  of  temperature, 
which  in  many  diseases  are  quite  typical,  the 
great  importance  of  closely  watching  the  course 
of  the  temperature  becomes  evident.  Clinical 
medicine  has  by  the  use  of  thermometry  entered 
on  a new  phase,  having  gained  the  means  of  a 
numerical  expression  for  variations  of  complex 
states  of  the  system  which  the  practitioner, 
from  the  indications  of  the  thermometer,  may 
detect  earlier  and  judge  of  more  correctly  than 
by  any  other  symptom.  For  an  exhaustive 
account  of  the  changes  of  temperature  which 
may  be  observed  in  health,  and  especially  in 
disease,  the  reader  may  be  referred  to  the 
classical  work  of  Wunderlich,  translated  for  tho 
New  Sydenham  Society. 

Sources  and  Regulation  of  the  Body- 
Heat. — The  sources  of  animal  heat  must  be 
chiefly  sought  for  in  chemical  processes,  espe- 
cially oxidation,  which  are  constantly  going  on  in 


TEMPERATURE. 


J598 

the  blood  and  tissues.  To  a minor  degree  various 
processes  of  a purely  physical  nature,  such  as 
friction,  or  the  transformation  into  heat  of  other 
forms  of  energy,  themselves  the  outcome  of 
chemical  processes,  have  also  a share  in  its  pro- 
duction. But  this  generation  of  heat  within  the 
body  does  not  explain  the  fact  of  the  blood-heat 
being  constantly  kept  at  the  same  level.  This  fact 
presupposes  that  the  amount  of  heat  produced  is 
exactly  equalled  by  the  sum-total  of  the  losses 
of  heat  which  are  constantly  going  on — at  the  sur- 
face of  the  body,  by  radiation  and  evaporation, 
from  the  lungs  by  evaporation  and  by  the  warm- 
ing of  the  colder  air  taken  in  at  every  inspiration, 
in  muscles  when  mechanical  work  is  done,  in  the 
intestinal  canal  by  the  warming  of  ingested  cold 
food  or  drink,  and,  lastly,  by  the  dejecta  which 
leave  the  body.  Any  disturbance  of  this  equili- 
brium must  be  followed  either  by  an  increase  or 
by  a lowering  of  the  general  temperature.  But 
there  is  another  factor,  without  which  the  main- 
tenance of  this  equilibrium,  and  an  equal  distri- 
bution of  the  heat  throughout  the  body,  would  be 
impossible,  namely,  the  circulation  of  the  blood. 
By  this  means  a regulation  of  the  loss  of  heat 
may  be  effected  whenever  required,  the  blood- 
supply  to  the  skin  varying  as  the  arteries  dilate 
or  contract  under  the  influence  of  the  vaso-motor 
nerves.  But  not  only  the  losses  of  heat  may  bo 
varied,  but  its  production  also  is  capable  of  being 
modified,  under  the  influence  of  the  nervous  sys- 
tem. Whenever  the  external  temperature  would 
cause  too  considerable  a loss  of  heat,  the  peri- 
pheral arteries  contract,  and  the  circulation  be- 
comes slower ; heat  is  thereby  retained  in  the 
body,  but  at  the  same  time  the  heat-producing 
processes  are  stimulated  to  increased  action,  as 
shown  by  the  quantity  of  carbonic  acid  given  off 
being  increased.  When,  on  the  contrary,  the  loss 
of  heat  on  the  surface  is  prevented,  the  peripheral 
arteries  dilate;  the  heart’s  action  becomes  accele- 
rated ; and  a much  greater  quantity  of  blood 
flows  through  the  skin  and  peripheral  parts,  the 
sweat-glands  pouring  forth  an  increased  quantity 
of  sweat,  which,  by  its  evaporation,  tends  con- 
siderably to  lower  the  temperature.  At  the  same 
time  the  respiration  also  is  accelerated.  Less 
blood  flowing  through  the  internal  organs,  the 
chemical  changes  in  them,  and  therewith  the  heat- 
production,  become  less  active,  and  are  further 
diminished  by  a direct  influence  of  the  nervous 
system  on  these  processes.  Thus  a most  wonder- 
fullyprecise  reflex-mechanism  regulates  the  heat 
of  the  body,  by  altering  the  production  as  well 
as  the  loss  according  to  necessit}’’,  the  mainte- 
nance of  the  proper  heat  being  in  this  way  doubly 
secured. 

Tempebattjre  in  Health. — The  heat  of  the 
blood  is  at  every  moment  of  life  the  result  of 
different  forces  balancing  each  other,  namely  the 
heat-producing  and  the  heat-destroying  processes 
and  influences.  So  also  the  temperature  of  a 
single  part  of  the  body  results  from  the  heat-pro- 
duction going  on  within  it,  and  its  exposure  to 
cooling  influences,  and  is  chiefly  dependent  upon 
its  blood-supply.  The  heat  of  the  body  is,  there- 
fore, most  variable  on  the  surface,  and  is  lowest 
in  its  uncovered  parts,  especially  in  the  most 
projecting  ones  ; almost  uniform,  on  the  contrary, 
in  (he  interior,  where  only  slight  differences, 


amounting  to  a few  tenths  of  a degree,  exist. 
In  the  lower  animals  Claude  Bernard  found  the 
temperature  highest  in  the  hepatic  veins  and  the 
right  auricle.  The  heat  of  an  organ  increases 
when  its  functional  activity  is  heightened,  as, 
for  instance,  when  the  brain,  a muscle,  or  a gland 
is  stimulated  to  increased  function. 

It  is  necessary,  for  practical  purposes,  to  con- 
sider chiefly  the  temperature  in  the  interior,  cf 
the  blood-heat.  The  blood-heat  is  measured,  as 
nearly  as  possible,  by  the  clinical  thermometer. 
See  Thebmometeb,  Clinical. 

In  healthy  men  the  temperature  of  the  body, 
as  measured  in  the  axilla,  is  about  9S'6°  Fahr. 
(37'0°  C.)  Inside  the  mouth,  underneath  the 
tongue,  it  is  almost  the  same;  whereas  in  the  va- 
gina or  rectum  it  is  0'3°  to  0‘6°  higher.  Under 
special  circumstances — for  instance,  when  a con- 
siderable cooling  of  the  surface  takes  place,  or 
when  the  skin  freely  perspires — the  difference 
may  be  somewhat  greater,  and  there  may  be  a 
difference  of  20°  between  the  temperature  of  ex- 
posed parts  of  the  skin  and  the  interior;  on  the 
other  hand,  all  parts  may  be  pretty  equally  warm 
in  the  morning  in  bed,  or  in  a warm  room,  or 
when  the  circulation  has  been  influenced  by 
slight  exercise,  or  by  a good  meal  and  a mode- 
rate amount  of  alcohol.  Of  considerable  influ 
ence  upon  the  temperature  of  the  surface  of  the 
body  is  the  amount  of  fat  in  the  subcutaneous 
tissue.  In  plump  children  and  in  very  obese 
adults  the  surface  may  be  considerably  colder 
than  the  interior,  and  in  the  latter  case  there 
generally  is  yet  another  and  even  more  effec- 
tive cause  for  this  difference,  namely,  weakness 
of  the  heart’s  action. 

The  temperature  of  the  body  is  not  the  same 
all  through  the  day.  Numerous  careful  obser- 
vations, of  which  those  of  Jiirgensen,  Liebermeis- 
ter,  and  Ogle,  may  be  specially  mentioned,  have 
shown  that  even  when  kept  entirely  at  rest  in  bed, 
the  temperature  of  a healthy  person  will  fluc- 
tuate from  about  l-8°  to  2' 3°  Fahr.  in  the  course 
of  the  twenty-four  hours  ; the  mercury  standing 
lowest  between  2 a.m.  and  6 a.sl,  and  then  gra- 
dually rising  until  it  reaches  the  highest  point 
between  5 p.m.  and  8 p.m.  Tbis  rise  is  mostly 
not  continuous,  but  becomes  somewhat  slower, 
or  even  interrupted  by  a slight  decrease,  in  the 
middle  of  the  day,  the  afternoon  hours  showing 
a more  rapid  elevation. 

This  daily  fluctuation  of  the  body-heat  is  a 
fact  of  fundamental  importance,  for  it  not  onlv 
takes  place  in  health,  but  also  when,  in  disease, 
the  whole  range  of  the  temperature  is  either 
depressed  or  abnormally  elevated.  The  causes 
of  this  daily  fluctuation  of  temperature  are  not 
yet  fully  made  out;  but  tbis  much  is  certain,  that 
rest  and  movement,  as  well  as  the  taking  of  food, 
have  some  share  in  producing  it.  Another  cause 
which  must  not  be  overlooked,  and  which  was 
pointed  out  by  Liebermeister,  is  the  force  of 
habit  and  inheritance. 

Race  and  sex  have  no  influence,  to  speak  of, 
upon  the  range  of  the  temperature.  Age,  on  the 
contrary,  has,  by  different  observers,  been  found 
to  influence  the  range  as  well  as  the  daily  flui- 
tuation.  In  the  infant,  immediately  after  its 
birth,  the  temperature  is  slightly  higher  than 
later  on,  its  temperature  in  the  rectum  having 


TEMPERATURE.  1599 


bven  been  found  higher  than  that  of  the  vagina 
of  its  mother.  A higher  range  is  maintained  in 
t!ie  first  weeks  of  life,  and  there  has  also  been 
found  wanting  in  infants  that  steady  course 
of  the  daily  fluctuation  which  is  observed  in 
adults.  In  children,  even  somewhat  more  ad- 
vanced in  age,  the  temperature  is  still  easily 
influenced  by  external  changes,  and  the  range 
of  the  daily  fluctuation  is  greater.  In  old  age 
again,  the  range  is  a little  higher  than  in  adult 
life,  and  here,  also,  a greater  mobility  of  the 
temperature  under  various  external  causes  is 
observed.  No  appreciable  influence  on  the  tem- 
perature in  association  with  menstruation  or 
pregnancy  can  be  observed  in  healthy  women. 
Parturition  slightly  increases  the  temperature, 
evidently  by  the  increased  muscular  action,  an 
increase  which  is  compensated  by  a correspond- 
ing fall  after  the  birth  of  the  child.  If  no  com- 
plications occur,  the  temperature  in  the  puer- 
peral state  generally  does  not  deviate  from  the 
normal. 

Such,  in  fact,  is  the  constancy  of  the  body- 
heat  in  health,  that  the  general  conditions  of 
life,  occupation,  &c.,  hardly  show  any  influence 
upon  it,  and  whenever,  by  muscular  exertion,  or 
by  the  effect  of  external  heat  or  cold — as,  for  in- 
stance, by  baths  of  various  temperatures — a more 
considerable  deviation  from  the  normal  range 
lias  for  a time  been  caused,  there  is  a strong 
tendency  in  the  system  to  compensate  the  in- 
crease or  the  loss  of  heat,  by  a corresponding  fall 
or  rise  afterwards.  This  faculty  is  somewhat 
altered  in  disease ; and  even  in  those  states 
which  are  on  the  borderland  of  disease,  we  fre- 
quently find  a less  perfect  action  of  the  regulation 
of  the  local  or  general  temperature  of  the  body. 

Local  Changes  cf  Te.upeeatuee. — Local 
changes  of  temperature  are  brought  about  by  ex- 
ternal thermic  influences  acting  locally,  or  by 
disease.  Local  stoppage  of  the  blood-supply  or 
local  death  lowers  the  temperature  of  the  part ; 
inflammation,  in  its  first  stage,  raises  it.  Con- 
siderable local  changes  of  temperature  may  arise 
simply  from  vaso-motor  disturbances.  Thus  in 
a paralysed  limb  the  temperature  may  either  be 
lower  or  higher  than  in  the  corresponding  limb 
of  the  other  side ; in  hemiplegia  the  tempe- 
rature of  the  paralysed  side  is  frequently  found 
of  a degree  higher  than  on  the  normal 
side.  Neuralgia  is  sometimes  accompanied  by 
dilatation  of  the  blood-vessels,  and  a considerable 
rise  of  the  local  temperature ; and,  as  a purely 
vaso-motor  disturbance,  local  heat  and  redness  of 
the  skin,  due  to  a passing  dilatation  of  blood- 
vessels, sometimes  occur  in  hysterical  females. 

Changes  of  the  General  Temperatche. — - 
Of  much  greater  practical  importance  than  local 
disturbances  of  the  body-heat  are  changes  of 
t lie  general  temperature,  such  as  occur  in  many 
diseases,  whether  of  the  nature  of  depression  or 
elevation. 

1.  Depression.— Depression  of  the  general 
temperature  is  observed  as  a consequence  of 
considerable  loss  of  blood;  in  starvation  from 
any  cause  ; and  in  the  wasting  of  some  chronic 
diseases,  such  as  cancer  of  various  organs,  or  in 
diseases  of  the  brain  and  spinal  cord.  In  brain- 
disease,  with  the  symptoms  of  melancholia,  ex- 
treme coldness  of  the  surface  and  lowering  of 


the  general  temperature  sometimes  occur.  Vaso- 
motor paralysis  and  dilatation  of  the  blood- 
vessels are  sometimes  the  cause  of  extreme  loss 
of  heat  in  severe  injuries  to  the  upper  part  or 
the  spine.  In  a very  rapid  manner  a consider- 
able fall  of  temperature  may  take  place  in  the 
collapse  sometimes  occurring  in  the  course  of 
typhoid  fever,  but  especially  in  that  of  acute  peri- 
tonitis, and  of  poisoning  by  various  substances. 
In  the  collapse  of  cholera  the  lowering  of  the  tem- 
perature of  the  axilla  may  be  considerable — a 
temperature  as  low  as  89‘6°Fahr.  (32:>  C.)  in  the 
axilla,  and  even  less  under  the  tongue,  having 
been  observed ; but  the  temperature  'of  the  inte- 
rior of  the  body  is  generally  very  high,  reaching 
10i°Fahr.  (10°  C.),  and  sometimes  much  more. 
In  peritonitis  a low  general  temperature  may  be 
present  for  days,  even  if  the  peritonitis  super- 
vene in  the  course  of  typhoid  fever.  With  the 
collapse  caused  by  alcoholic  intoxication  great 
depression  of  the  general  temperature  occurs, 
when  the  patient  is  exposed  to  cold  and  wet; 
and  in  a case  of  carbolic  acid  poisoning,  which 
came  under  the  observation  of  the  writer, 
the  temperature  fell  as  low  as  93'92°  Fahr. 
(3I'4°  C.).  A temperature  of  7 1 '6°  (22°  C.)  has 
been  observed  in  sclerema  neonatorum. 

In  chronic  diseases  of  the  respiratory  organs, 
not  of  an  inflammatory  or  tuberculous  nature,  as 
well  as  in  chronic  heart-disease,  the  temperature 
is  generally  found  somewhat  below  normal;  and 
the  same  is  the  case  in  chronic  nephritis,  more 
especially  in  those  cases  accompanied  by  general 
dropsy.  In  cases  of  the  latter  kind  we  even 
sometimes  see  a febrile  temperature,  caused,  for 
instance,  by  tubercular  disease  of  the  lungs,  be- 
come considerably  abated,  if  not  entirely  re- 
versed, when  chronic  kidney-disease  supervenes; 
as  also  when  intestinal  ulceration  becomes  more 
prominent,  or  leads  to  peritonitis. 

2.  Elevation. — Elevation  of  the  general 
temperature,  as  part  of  the  febrile  process,  is 
the  most  prominent  symptom  in  most  diseases 
of  an  infectious  origin,  as  well  as  in  diseases 
of  an  inflammatory  nature.  In  both  an  in- 
creased production  of  heat,  no  less  than  a dis- 
turbance of  the  regulation  of  the  temperature, 
is  the  effect  of  the  presence  in  the  blood  of 
some  foreign  substance,  acting  injuriously  on 
the  nervous  system,  and  causing  altered  chemical 
processes.  Modern  theories  give  a more  and 
more  prominent  part  in  these  actions  to  organised 
bodies  (fungi,  bacteria),  which,  in  themselves  or, 
possibly,  by  products  of  their  own  life-changes, 
or  by  the  changes  which  they  cause  in  the  fluids 
of  the  body,  are  assumed  to  be  the  cause  of  the 
febrile  process,  and  thus  of  the  increased  tem- 
perature. 

The  proper  balance  of  the  heat-forming  and 
heat-destroying  processes  may  also  be  disturbed 
by  other  influences  acting  upon,  and  by  primary 
diseases  of,  the  nervous  system.  When  the  body 
is  subjected  to  external  cold,  after  it  has  been 
fatigued  by  exercise,  and  already  cooled  by  per 
spiration — if,  for  instance,  a cold  bath  were  taken 
under  such  circumstances,  a rigor,  with  rapid 
rising  of  the  temperature  may  follow ; but,  no 
local  disease  becoming  developed,  the  tempera- 
ture quickly  goes  down  again  amid  protuse 
perspiration,  and  the  whole  attack  may 


TEMPERATURE. 


1600 

over.  Or  a disturbance  of  the  heat-regulating 
functions  of  the  nervous  system  may  be  caused 
by  the  irritation  of  some  nerve-filaments,  as 
by  a gall-stone  passing  the  biliary  duct,  or  a 
stone  passing  the  ureter  or  the  urethra,  and  a 
febrile  attack  'will  follow.  The  rigor,  leading 
to  a high  fever  of  an  evanescent  character, 
which  may  follow  the  introduction  of  a catheter 
(urethral  fever),  sometimes  belongs  to  the  same 
group  of  cases.  But  generally,  in  cases  of  this 
last  kind,  the  nervous  system  is  already  in  an 
abnormal  state  through  the  previous  disease  of 
the  kidneys  or  bladder.  The  functions  of  the 
nervous  system  may  further  be  deranged  by  in- 
jury; and  a rise  of  temperature  has  not  only  been 
observed  in  injuries  to  the  brain,  but,  in  a most 
excessive  degree,  sometimes  after  injury  of  the 
cervical  part  of  the  spinal  cord,  when  temperatures 
of  110°  to  lll°Fahr.  (43‘3°  to  44°C.)  have  been 
observed  (B.Brodie,  H.  Weber,  Teale,  and  others). 
In  tetanus  a very  high  temperature  may  occur, 
rising  still  higher  a little  after  death ; as  much  as 
112-55°  Pahr.  (44’75°  C.)  was  reached  in  a case 
observed  by  Wunderlich.  An  alteration  of  the 
heat-regulating  functions  of  the  nervous  system 
may  be  brought  about  by  a considerable  external 
heat  acting  upon  the  body,  especially  when  com- 
bined with  moisture  of  the  air.  In  cases  of  sun- 
or  heat-stroke,  it  is  quite  common  to  see  the  tem- 
perature of  the  body  rise  to  108°  Fahr.  (42-2°  C.) 
and  more ; and  it  would  seem  probable  that  a 
febrile  elevation  of  temperature,  if  going  on 
unchecked  for  a considerable  time,  by  causing 
exhaustion  of  the  nervous  system,  may  lead  to 
hyperpyrexia.  Thus  it  is  not  very  uncommon  to 
see  the  temperature  rise  excessively  in  infectious 
diseases,  especially  scarlatina,  towards  the  close 
of  life  (proagonic  hyperpyrexia) ; and  the  tempe- 
rature may,  in  such  cases,  even  rise  a little  more 
immediately  after  death.  This  is  due  to  the  losses 
of  heat  being  greatly  reduced  after  the  stoppage 
of  the  circulation,  the  heat- production  going  on 
in  the  interior  for  a time  ; and  the  gradual  failure 
of  the  circulation  probably  also  takes  a great 
share  among  the  causes  of  a proagonic  hyper- 
pyrexia. 

Hyperpyrexia  sometimes  comes  on  m the  con- 
valescence from  acute  rheumatism,  even  after 
the  fever  has  entirely  subsided,  and  when  the 
patient  is  on  the  point  of  being  discharged  from 
the  hospital.  An  excessive  rise  has  occurred  and 
caused  death  in  severe  cases  of  hysteria ; and  in 
hysterical  patients  hyperpyrexia  has  occasionally 
been  observed  without  any  of  the  other  symp- 
toms which  in  other  cases  usually  accompany 
so  grave  a phenomenon.  Cases  of  this  kind  are 
extremely  suspicious,  and  in  some  of  them  it 
was  discovered  how  this  hyperpyrexia  was  simu- 
lated. Thus  the  patient  has  driven  up  the  mer- 
cury by  rubbing  the  bulb  of  the  thermometer 
between  the  folds  of  her  night-dress ; whilst  in 
other  cases  the  high  elevation  of  the  mercury 
has  been  brought  about  by  means  of  poultices,  or 
by  the  patient  having  lowered  the  top  of  the  in- 
strument, so  that  the  column  of  mercury  began 
moving  by  its  own  weight.  This,  however,  is 
not  possible  with  a thermometer  of  the  thin  bore 
which  English  thermometers  now  generally  have. 
A very  high  temperature,  to  which  the  pulse 
and  respiration  and  the  other  symptoms  do  not 


correspond,  must  always  arouse  a suspicion  that 
the  rise  of  the  mercury  has  been  artificially  pro- 
duced, and  the  verification  will  be  easy  if  the 
physician  carefully  watch  the  mercury  as  it  rises, 
or  by  taking  the  temperature  in  the  rectum  or 
vagina. 

The  very  important  part  which  the  nervous 
system  plays  in  regulating  the  blood-heat,  is  also 
seen  in  the  great  liability  of  the  temperature 
easily  to  deviate  from  the  normal  range  during 
convalescence  from  acute  disease,  when  the  weak- 
ness of  the  nervous  system,  brought  on  by  the 
previous  illness,  will  show  itself  in  this  no  less 
than  in  other  alterations  of  function.  This  can 
frequently  be  observed  in  convalescence,  not  only 
from  the  specific  fevers,  but  also  from  pneumonia 
and  other  acute  febrile  diseases,  when  trifling 
external  influences  may  cause  a considerable  rise 
of  the  temperature,  which,  however,  is  generally 
of  short  duration  only,  but  which,  in  the  case  of 
specific  fevers  may  cause  apprehension  lest  a 
relapse  be  comiDg  on.  In  a somewhat  different 
manner,  and  more  lasting,  a slight  sub-febrile 
elevation  of  temperature  may  be  observed  in  the 
convalescence  from  acute  rheumatism,  where 
it  may  persist  for  weeks  without  any  joint-  or 
heart-symptoms  being  present. 

Significance  of  Abnormal  Temperature 
fob  Diagnosis  and  Prognosis. — The  mainte- 
nance of  the  heat  of  the  body  at  a certain  range 
being  so  insured,  any  deviation  of  the  general 
temperature  from  the  normal  standard,  however 
slight  in  degree,  and  unless  of  a very  transient 
nature  or  brought  on  by  evident  external  causes, 
is  to  be  taken  as  a sign  of  disease.  Such  de- 
viation may  be  of  a variable  degree,  along  with 
symptoms  which,  in  part,  are  the  consequence 
of  the  abnormal  temperature,  such  as  an  ab- 
normal rate  of  pulse  and  respiration,  and  ner- 
vous symptoms.  The  whole  range  of  deviation 
within  which  life  can  well  be  maintained  is  com- 
prised between  90°  Fahr.  (32-3°  C.)  and  110° 
Fahr.  (4 3 '4°  C.).  A temperature  approaching 
either  end  of  this  range  indicates  a condition 
of  extreme  danger,  which  is  already  great  with 
a temperature  of  95°  Fahr.  (35°  C.),  or  beyond 
106'5°  Fahr.  (41'5°  C.).  With  reference  to  the 
goneral  condition  of  a patient  who  presents  an 
abnormal  temperature,  a few  distinctions  may 
be  conveniently  tabulated  : — 

1.  Temperature  below  the  normal : — 

a.  Temperature  of  collapse,  below  97°  Fahr. 
(36-2°  C.) 

b.  Subnormal  temperature,  97-98°  Fahr 
(36-2-36-7°  C.) 

2.  Normal  temperature:  98  0-99‘5t’Fahr.(36'7- 
37-5°  C.). 

3.  Temperature  above  the  normal : — 

a.  Subtebrile  temperature,  99-5-100-5°  Fahr. 
(37-5-38  05°  C.). 

b.  Febrile  temperature  of  moderate  degree, 
100-5-102°  Fahr.  (38  05-3S-S80  C.),  morning; 
102-2-103°  Fahr.  (39°-39-44°  C.),  evening. 

c.  Febrile  temperature  of  high  degree,  102  '5° 
Fahr.  (39-2°  C.),  and  more  in  the  morning; 
105-106°  Fahr.  (40-6-411°  C.)  in  the  evening. 

d.  Hyperpyrexia,  105-8-107"5°  Fahr.  (41-42° 
C.)  and  more.  Extremely  dangerous. 

Single  Observations. — Near  the  ends  of  this 
scale  a single  observation  of  the  temperature 


TEMPERATURE. 


of  a patient  may  at  once  decide  the  prognosis. 
Thus  a temperature  below  93°  Eahr.  (33‘88°  C.), 
or  above  1 08°  Eahr.  (42'22°  C.)  is  almost  always 
fatal,  although  cases  have  been  recovered  by 
active  treatment  in  which  the  latter  point  has 
been  exceeded  by  several  de;  rees.  No  less  valu- 
able may  single  observations  be  for  diagnosis, 
chiefly  in  a general  way,  in  showing  that  there 
is  disease  when,  perhaps,  no  other  symptom 
points  to  it,  but  also  for  the  diagnosis  of  a 
special  disease  in  some  instances.  Where  there 
are  other  symptoms  of  disease,  the  discovery  of 
an  abnormally  high  or  a febrile  temperature 
may  at  once  give  quite  a different  aspect  to  a 
case,  as,  for  instance,  when  a patient  who  has 
been  suffering  for  some  time  from  a trouble- 
some cough,  but  in  whom  the  most  careful  ex- 
amination of  the  chest  could  not  detect  any 
lung-disease,  is  found  to  have  pyrexia.  The  sus- 
picion that  there  is  commencing  phthisis  may 
thereby  bo  at  once  confirmed,  or  aroused  for  the 
first  time.  Or,  again,  in  a case  where  the  patient 
simply  complains  of  dyspepsia  and  lassitude,  the 
thermometer  may  give  a degree  of  heat  which 
would  not  have  been  expected  either  from  the 
looks  of  the  patient,  or  from  the  temperature 
of  his  hands  or  chest,  and  the  attention  may 
thereby  at  once  be  directed  to  the  possibility  of 
the  case  being  one  of  typhoid  or  some  other 
specific  fever.  One  reservation  must  be  mado 
with  regard  to  single  observations  in  patients 
who  have  not  been  kept  at  rest  for  some  time 
before,  for  example,  in  patients  who  have  walked 
to  the  physician’s  house,  or  who  had  to  undergo  a 
journey  to  the  hospital.  In  such  cases  the  tem- 
perature may  be  somewhat  altered  by  the  fatigue ; 
and  it  is  quite  common  to  find  the  first  tempe- 
rature in  a patient,  immediately  after  his  admis- 
sion into  the  hospital,  considerably  higher  than 
after  a few  hours’  rest,  or,  if  he  have  been  ex- 
posed to  cold,  much  lower  than  what  would 
otherwise  correspond  to  his  condition. 

Systematic  Series  of  Observations. — But 
of  much  greater  value  than  isolated  observations 
of  temperature  is  the  regular  and  continued 
watching  of  the  course  which  the  temperature 
takes  in  a disease.  Many  diseases  present  a de- 
viation from  the  normal  temperature  showing 
a typical  course  as  regards  the  duration,  as  well 
as  the  daily  fluctuations,  of  the  abnormal  tem- 
perature. Tho  course  of  its  temperature  being 
part  of  the  natural  history  of  a disease,  the 
study  of  this  is  of  great  importance  for  diag- 
nosis. 

Types  of  Pykexia. — First,  it  is  the  mode  of 
rising  of  the  temperature  which  varies,  and  by 
which  some  diseases  may  be  distinguished.  In 
some  diseases  a contraction  of  the  peripheral  arte- 
ries takes  place  at  the  onset,  which,  by  diminish- 
ing the  peripheral  circulation  and  the  giving  off 
of  heat,  leads  to  a rapid  rise  of  the  internal  tem- 
perature, and  is  accompanied  by  a sensation  of  cold. 
In  pneumonia,  therefore,  and  other  diseases  com- 
mencing with  a rigor,  the  temperature  rises  ra- 
pidly and.  continuously  to  a height  of  104°  Eahr. 
(40°  C.)  or  more  ; whereas  diseases  with  a more 
gradual  beginning  show  simply  a slow  elevation 
of  the  normal  range,  both  morning  and  evening 
temperature  becoming  gradually  higher,  and  the 
usual  daily  fluctuation  being  maintained.  Thus,  | 
101 


1601 

in  typhoid  fever  the  temperature  rises  every  day 
about  2°  Eahr. ; but  the  temperature  going  down 
again  in  the  morning,  the  maximum  of  abou! 
10o°Fahr.  is  only  attained  on  the  fifth  or  sixth 
day. 

At  the  height  o f a disease  the  temperature  may 
fluctuate  round  an  average  temperature ’of  about 
103°  Eahr.  (39‘d°  C.)  or  more,  whilst  it  shows 
the  same  daily  course  as  in  health,  that  is,  being 
lowest  in  the  morning  and  highest  in  the  evening. 
The  range  of  this  daily  fluctuation  may,  however, 
differ  considerably  in  different  diseases ; and 
according  to  the  extent  of  the  daily  fluctuation, 
three  types  may  be  distinguished.  When  the 
daily  fluctuation  of  an  elevated  temperature 
shows  only  the  normal  difference,  or  even  a 
smaller  difference,  between  the  morning  and 
evening  temperatures,  we  speak  of  continuous, 
or,  more  correctly,  sub-contmuous  pyrexia ; when 
the  difference  is  greater  than  the  normal,  the 
remission  having  a tendency  to  a low  tempera- 
ture, and  the  exacerbation,  on  the  contrary,  to  a 
considerable  rise,  the  pyrexia  is  called  remittent-, 
and,  thirdly,  when  the  remissions  reach  the 
normal,  or  recede  even  below  it,  we  have  the 
intermittent  type  of  pyrexia. 

A continuous  elevation  of  temperature  is  ob- 
served soon  after  tho  commencement  of  a disease, 
and  during  its  height. 

Considerable  remissions,  or  even  intermissions, 
of  the  febrile  temperature  are  principally  ob- 
served in  the  decline  of  some  acute  diseases, 
and  in  chronic  inflammatory  diseases,  especially 
of  a tubercular  nature,  or  in  chronic  syphilitic 
affections,  the  remissions  generally  becoming 
more  marked  as  the  exhaustion  of  the  patient 
increases. 

Tho  intermittent  type  of  pyrexia  is  most  typi- 
cally shown  in  malarial  diseases,  in  which  the 
elevation  of  temperature  may  follow  a quotidian, 
tertian,  or  quartan  type.  The  same  also  some- 
times occurs  in  chronic  tubercular  disease  of 
the  lungs.  Pyrexia  of  a remittent  type  may 
present  a peculiarity  which  is  worthy  of  note,  as 
being  of  some  diagnostic  value.  Whereas  in  the 
great  majority  of  cases  the  daily  fluctuation  fol- 
lows the  rule  of  health,  the  exacerbation  taking 
place  in  the  evening,  we  sometimes  meet  with 
cases  where  this  order  is  reversed,  the  rise 
taking  place  in  the  morning,  and  the  remission 
occurring  in  the  evening.  This  ‘inverse  type  ’ as 
Traubo  called  it,  of  the  daily  fluctuation  of  a fe- 
brile temperature  has  been  observed  insome  rare 
instances  in  typhoid  fever  ; more  frequently  in 
cases  of  chronic  lung-disease;  whilst  in  doubtful 
cases  of  inflammation  of  the  lungs  it  has  some 
significance  as  to  the  disease  belonging  to  tho 
class  of  phthisis. 

Slight  deviations  in  the  maximum  daily  rise 
of  a febrile  temperature  occur  sometimes  in 
this  way,  that  the  height  is  reached  in  the  mid- 
dle of  the  day,  or  that  the  exacerbation  takes 
place  in  the  night,  or  that  two  or  more  consider- 
able elevations,  instead  of  one  only,  take  place  in 
tho  twenty-four  hours.  Such  occurrences,  which 
have  been  observed  in  typhoid  fever  and  in 
phthisis,  can,  of  course,  only  be  found  out  by  the 
observations  of  the  temperature  being  repeated 
with  sufficient  frequency.  A more  frequent  ap- 
plication of  the  thermometer  will  also  be  neces- 


TEMPERATURE. 


1602 

sary  iri  some  cases  of  ague,  where  the  attacks  are 
not  well-marked,  or  occur  in  the  night,  in  order 
correctly  to  judge  of  the  case. 

The  decline  of  the  elevation  of  temperature,  at 
the  termination  of  a disease,  may  be  gradual,  the 
daily  fluctuation,  however,  taking  place  as  usual; 
or  it  may  be  rapid,  by  a continuous  sinking 
of  the  temperature  to,  or  somewhat  below  the 
normal,  in  the  course  of  from  twelve  to  thirty- 
six  hours,  or  even  in  six  to  eight  hours,  as  in 
relapsing  fever.  The  latter  mode  of  termi- 
nation of  a fever  is  called  crisis,  whereas  the 
former  is  designated  lysis.  A crisis  may  some- 
times be  accompanied  by  symptoms  of  collapse, 
and,  in  some  rare  instances,  by  acute  delirium, 
which,  however,  generally  passes  off  within  a 
day  or  two,  and  is  not  of  bad  omen  provided 
the  general  condition  of  the  patient  remain 
good.  Symptoms  of  this  kind,  as  well  as  a more 
considerable  elevation  of  the  temperature  just 
previously  to  its  fall,  or  a great  irregularity 
in  the  course  of  the  temperature  preceding  it, 
may  be  called  perturbatio  critica.  It  would  ap- 
pear that  diseases  caused  by  the  action  in 
the  system  of  some  foreign  substance — as,  for 
instance,  some  infective  agent,  its  action  being 
of  a limited  duration — have  a tendency  to  a 
critical  defervescence.  Diseases,  on  the  contrary, 
in  or  by  which  an  organ  has  become  materially 
altered,  as  by  an  injury,  or  in  the  course  of  an 
infectious  disease  of  longer  duration,  show  a slow 
decline  of  the  pyrexia,  with  a tendency  to  a re- 
mittent type.  The  repair  of  the  damaged  struc- 
tures taking  some  time,  the  decline  of  the 
pyrexia  is  slow,  and  the  defervescence  by  lysis. 
Examples  of  the  former  mode  of  defervescence 
are  furnished  by  acute  pneumonia,  erysipelas, 
typhus,  relapsing  fever,  and  measles  when  not 
complicated  by  more  serious  inflammation  ; the 
latter  type  is  shown  by  typhoid  fever,  in  which 
the  specific  process  produces  deep  alterations  in 
the  glandular  structures  of  the  intestine,  which 
persist  for  some  time  after  it  has  terminated. 
The  same  is  observed  whenever  an  organ  is 
altered  by  an  inflammatory  process,  be  this  of 
a traumatic  or  of  an  infectious  origin.  The 
ancient  physicians  believed  that  a crisis  took 
place  with  preference  on  certain  days,  as,  for  in- 
stance, the  seventh  day  of  an  illness  ; but  more 
extended  experience,  gained  by  means  of  the 
thermometer,  has  shown  that,  although  a change 
or  a termination  of  a disease  take  place  at  a 
certain  definite  period,  the  latter  is  not  bound 
to  one  particular  day.  See  Crisis. 

Any  irregularity  of  the  course  of  the  tempe- 
rature in  a disease  in  which,  as  a rule,  it  runs  a 
very  regular  and  definite  course,  is  indicative  of 
some  disturbance  or  complication,  and  its  early 
detection  is  therefore  important  for  diagnosis,  no 
less  than  for  prognosis  and  treatment. 

On  the  approach  of  death  the  temperature  in 
many  cases  gradually  sinks;  but  instances  are 
not  of  rare  occurrence  in  which,  on  the  contrary, 
especially  in  diseases  with  high  fever,  a con- 
tinuous rising  takes  place  towards  the  fatal 
termination,  reaching  sometimes  hyperpyrexie 
degrees. 

1 i ctvi  ral  sconce  the  temperature  is  more  easily 
ii  tin  ■noed  by  external  causes,  as  well  as  by  in- 
ternal changes, and  the  approach  of  a relapse  or 


j complication  being  at  once  indicated  by  a rise  of 
temperature,  the  continuance  of  regular  thermo- 
metrical  observations  in  the  first  period  of  con- 
valescence is  of  very  great  importance;  the  more 
so  as  convalescents  are  sometimes  not  sensible  to 
changes,  which  at  first  only  show  themselves  in 
an  alteration  of  the  temperature. 

Treatment. — Abnormal  states  of  temperature 
ought  not,  as  a rule,  to  be  considered  as  objects 
of  treatment  by  themselves,  all  the  concomitant 
symptoms,  in  fact  the  whole  state  of  the  patient, 
having  to  be  taken  into  consideration,  in  order 
properly  to  treat  a case  of  febrile  disease.  Rut 
there  are  exceptional  cases  in  which  the  state  of 
the  temperature  at  once  urgently  requires  a symp- 
tomatic treatment.  Such  are,  for  instance,  cases 
of  hyperpyrexia  in  sun-  or  heat-stroke,  in  which 
the  most  energetic  means  ought  at  once  to  be 
applied  to  reduce  the  temperature.  As  the  expe- 
rience of  American  physicians  has  shown,  life 
may  in  such  cases  sometimes  be  saved  by  con- 
tinually rubbing  the  surface  of  the  body  with 
large  pieces  of  ice,  using  at  the  same  time  stimu- 
lants by  the  rectum  or  subcutaneously.  A rapid 
abstraction  of  heat  by  rubbing  with  ice,  or  cold 
bathing  with  affusions,  may  also  be  the  only 
means  of  saving  a patient  in  whom,  in  the  course 
of  acute  rheumatism,  hyperpyrexia  has  set  in; 
and  a case  published  by  Dr.  Wilson  Fox  in  which 
the  temperature  reached  110°  in  the  rectum,  is 
very  instructive  in  showing  that  external  cooling 
may  be  successful,  when  even  very  large  doses  of 
quinine  (120  grains  had  been  given  in  six  hours), 
had  been  administered  without  effect.  The  same 
plan  must  be  followed  in  hyperpyrexia  occurring 
in  the  course  of  other  diseases.  Complications, 
such  as  pneumonia,  do  not  contraindicate  this 
treatment,  the  success  of  which  is,  however,  de- 
pendent upon  the  possibility  of  rousing  the  ner- 
vous system,  and  upon  the  circulation  remaining 
sufficiently  active. 

An  abnormally  low  temperature  requires  the 
external  application  of  heat,  which  will  be  ma- 
terially assisted  by  warm  stimulating  drinks  or 
injections,  using  eventually  subcutaneous  injec- 
tions of  ether  or  of  tincture  of  musk,  to  stimulate 
the  action  of  the  heart. 

Apart  from  such  exceptional  cases,  the  treat- 
ment of  the  abnormal  suites  of  the  temperature 
must  be  subordinated  lo  the  general  treatment 
of  the  case.  In  many  cases  the  abnormal  tem- 
perature being  dependent  upon  some  local  cause,  • 
the  removal  of  the  latter  will  make  the  abnormal 
temperature  also  disappear,  or  at  least  reduce 
it — an  experience  with  which  surgeons  are  quite 
familiar. 

Rise  of  temperature  being,  however,  the  chief 
and  most  important  symptom  of  pyrexia,  leading 
of  itself  to  serious  consequences,  especially  by 
weakening  the  heart's  action,  it  becomes  neces- 
sary in  many  cases  of  protracted  febrile  disease, 
besides  the  general  or  special  treatment  which 
the  case  requires,  to  treat  the  febrile  temperature 
symptomatically.  It  has  now  been  shown  by  an 
overwhelming  experience  that  the  course  of  the 
specific  fevers,  such  as  typhus,  typhoid,  scarla- 
tina, although  it  cannot  be  cut  short,  can  yet 
materially  be  influenced,  by  keeping  the  febrile 
temperature  artificially  down,  by  means  of  cold 
baths  or  wet  packing,  and  by  antipyretic  medi- 


TEMPERATURE. 

cines.  And  it  is  very  important  not  to  wait  in 
u.  case  with  continuous  high  temperature  until 
symptoms  of  failure  of  the  heart’s  action — a weak 
pulse,  cold  extremities,  cyanosis,  and  congestion 
of  the  lungs,  and  muttering  delirium — show  them- 
selves, but  to  try  to  prevent  these  symptoms  by 
keeping  down  the  temperature.  Patients  treated 
early  on  this  principle  will  be  found  much  less 
frequently  to  pass  into  that  state,  to  sleep  more 
soundly,  and  to  retain  their  appetite  ; bedsores 
and  other  serious  complications  being  of  much 
rarer  occurrence ; and  it  has  been  established 
that  the  mortality  in  specific  fevers  has  by  the 
antipyretic  treatment  been  considerably  dimi- 
nished, and  that  convalescence  also  is  quicker 
than  in  cases  treated  on  the  expectant  plan. 

In  the  symptomatic  treatment  of  pyrexia  in 
acute  disease,  and  especially  in  the  continued 
fevers,  it  is  best  to  follow  the  principle  laid  down 
by  Liebermeister,  than  whom  no  one  has  had 
more  experience  in  these  matters.  Starting  from 
the  fact  that  a febrile  elevation  of  temperature,  of 
a remittent  type,  is  much  better  supported  by 
the  patient  than  a temperature  of  even  a lower 
degree,  but  which  has  a more  continuous  course, 
the  object  he  has  in  view  is,  by  the  anti-pyretic 
treatment,  to  increase  the  remissions  that  nor- 
mally take  place  every  day,  and  to  prolong  them 
as  much  as  possible.  Comparative  experiments 
have  shown  that  external  cooling  by  baths,  and 
other  means,  as  well  as  antipyretic  medicines,  are 
of  greatest  effect  at  those  times  of  the  day  when 
the  temperature  spontaneously  has  a tendency  to 
decline.  In  order  to  attain  the  greatest  anti- 
pyretic effect  with  the  least  frequent  repetition 
of  baths,  the  most  suitable  time  for  the  latter, 
according  to  Liebermeister,  is  the  night;  and  the 
antipyretic  medicines  may  be  given  to  assist  and 
prolong  the  effects  of  the  baths. 

As  regards  external  cooling,  by  far  the  most 
effective  means  are  cold  baths  of  60°  to  70°  Fahr. 
(15°  to  20°  C.),  and  about  ten  minutes’  duration. 
More  agreeable  to  the  patient  are  baths  of  about 
95°  Fahr.  (35°  C.),  gradually  cooled  down  by  the 
addition  of  cold  water  to  70°  Fahr.  (20  C.),  or 
less,  but  their  duration  must  be  longer  to  have 
the  same  effect  as  the  former  ( see  Hydro- 
therapeutics).  Cold  wet-packing  is  less  effec- 
tual, but  may  replace  baths  in  patients  of  small 
volume  (see  Cold,  Therapeutics  of). 

Quinine,  in  order  to  derive  the  greatest  effect 
from  its  use,  ought  to  be  given  in  one  large  dose,  20 
to  40  grains,  in  the  evening,  its  action  being  slow 
and  passing  off  slowly.  Salicylic  acid,  on  the  con- 
trary, and  its  soda-salt,  which  produce  a fall  of  the 
temperature  much  more  quickly,  but  also  much 
less  durably,  are  best  given  in  a dose  of  60  to 
120  grains  in  the  night  or  towards  the  morning. 
Heither  these  medicines  nor  cold  bathing  must, 
however,  be  used  in  a routine  way,  many  things 
having  to  be  taken  into  account  in  their  use  and 
in  judging  of  their  effect,  as  the  time  of  the  day, 
the  severity  of  the  case,  and,  not  least,  the  in- 
dividuality of  the  patient. 

C.  G.  H.  Baumleb. 

TENDERNESS.  — This  word,  in  relation 
to  medical  and  surgical  practice,  usually  implies 
that  pain,  in  various  degrees  and  of  different 
kinds,  is  elicited  by  pressure,  as  distinguished 


TENDERNESS.  1603 

from  the  sensation  which  is  felt  spontaneously 
by  the  patient.  The  term  might  conveniently 
be  made  to  include  all  painful  sensations  elicited 
by  any  physical  disturbance  of  a part,  as,  for 
instance,  the  movement  of  a joint,  or  the  pres- 
sure of  its  structures  against  each  other.  The 
like  observation  applies  to  any  irritation  of  the 
mouth  or  throat,  when  these  parts  are  the  seat 
of  disease  accompanied  by  tenderness  ; as  well 
as  to  other  mucous  surfaces. 

Tenderness  is  a symptom  often  of  great  im- 
portance, and  it  claims  the  careful  attention  of 
the  practitioner.  It  is  often  present  when  there 
is  no  complaint  of  pain  on  the  part  of  the  patient; 
while,  on  the  other  hand,  it  is  by  no  means  a 
necessary  accompaniment  of  spontaneous  pain  ; 
its  very  absence  is  frequently  of  much  conse- 
quence in  diagnosis.  In  an  investigation  for  the 
purpose  of  eliciting  tenderness,  care  is  required, 
especially  in  certain  cases ; and  the  examination 
should  be  made  with  gentleness  and  restraint,  so 
as  not  to  give  the  patient  unnecessary  pain,  or  to 
produce  other  effects,  which  might  prove  serious 
in  some  instances.  It  may  be  that  only  a slight 
touch  can  be  borne,  but  pressure  may  be  gradu- 
ally increased,  if  necessary,  until  tenderness  is 
produced ; it  must  be  noted  what  degree  of 
pressure  is  needed  to  cause  the  sensation.  The 
observer  must  thus  endeavour  to  fix  upon  the 
structure  in  which  the  tenderness  is  located;  ns 
well  as  to  measure  the  intensity  of  the  feeling. 
Its  limitation  in  extent  must  also  be  determined. 
The  patient  can  often  give  useful  information  as 
to  its  exact  character.  Care,  however,  is  neces- 
sary to  guard  against  being  misled  by  malin- 
gerers, hysterical  persons,  or  those  who  have 
imaginary  ailments ; and  also  not  to  mistake 
tenderness  for  mere  hypersesthesia  of  the  skin. 
For  this  purpose  it  is  of  much  help,  among  other 
points,  to  watch  the  patient’s  expression  of  coun- 
tenance whilst  pressure  is  being  made.  Hys- 
terical patients  may  seem  to  suffer  acutely  when 
slight  pressure  is  made ; but  if  this  be  gradually 
increased,  while  their  attention  is  diverted  by 
conversation,  it  is  found  that  the  suffering  is  net 
real.  It  must  also  bo  remembered  that  some 
persons  are  much  more  sensitive  than  others. 

Value  in  Diagnosis. — Without  attempting  to 
treat  the  subject  exhaustively,  a few  hints  may 
be  offered  as  to  the  diagnostic  relations  of  ten- 
derness, and  as  to  the  more  prominent  diseases 
and  conditions  in  which  the  presence  and  degree 
of  this  symptom  are  of  essential  service  in  in- 
dicating their  existence. 

When  pain  is  complained  of,  the  presence  or 
absence  of  tenderness,  and  its  degree,  may  be 
of  signal  value  in  diagnosing  the  kind  of  painful 
sensations  to  which  it  belongs.  For  instance,  it 
may  be  affirmed,  as  ?.  general  rule,  that  the  pain 
of  inflammation  is  accompanied  with  tenderness, 
and  especially  so  if  the  condition  is  superficial, 
has  ended  in  suppuration,  or  involves  nerves. 
On  the  other  hand  a purely  neuralgic  pain  is  on 
the  whole  free  from  tenderness,  and  is  not  un- 
commonly  relieved  by  pressure,  although  there  are 
certain  localised  ‘ tender  points  ’ in  some  forms 
of  this  complaint,  and  these  are  also  of  signifi- 
cance. Hence,  when  pain  is  evidently  seated  in 
a particular  nerve  or  nerves,  pressure  may  de- 
termine whether  they  are  actually  involved  in 


1604  TENDEKNESS. 

some  inflammatory  mischief,  or  merely  function- 
ally disordered.  Again,  the  pain  of  muscular 
rheumatism,  -when  not  inflammatory,  is  often 
relieved  by  pressure  ; while  spasmodic  muscular 
pains  are  usually  thus  greatly  alleviated,  so  that 
pati  ents  of  their  own  accord  press  upon  the  affected 
part.  In  this  way  a very  obvious  and  decided  dis- 
tinction is  frequently  afforded  between  spasmodic 
and  inflammatory  conditions  involving  the  ab- 
dominal structures.  Further,  in  connection  with 
tumours  and  growths,  those  which  are  of  a 
malignant  nature  are  often  accompanied  by  pain 
and  tenderness,  while  those  which  are  benignant 
may  be  said  to  be,  as  a class,  free  from  such 
symptoms.  Marked  tenderness  may  be  an  im- 
portant sign  of  destructive  changes,  such  as 
those  which  occur  in  some  diseases  of  joints, 
or  as  a result  of  the  pressure  of  an  aneurism 
or  other  tumour,  where  there  is  at  the  same  time 
spontaneous  pain.  Very  limited  and  obvious  ten- 
derness may  indicate  the  seat  of  a foreign  body, 
lodged  in  the  soft  parts  or  irritating  them,  es- 
pecially if  it  should  be  pointed,  as,  for  instance,  a 
needle. 

It  must  be  remembered,  in  the  next  place, 
that  tenderness  may  be  a valuable  diagnostic 
sign,  when  there  is  no  complaint  of  pain  on  the 
part  of  the  patient.  For  example,  it  may  reveal 
joint-disease,  not  previously  known  to  exist, 
the  writer  has  found  this  symptom  of  great  as- 
sistance in  recognising  the  presence  and  situation 
of  obscure  limited  disease  in  the  abdomen,  such 
as  cancer,  ulceration,  or  suppuration.  It  may 
also  lead  to  the  discovery  of  undetected  suppu- 
ration. In  the  case  of  children  who  are  too 
young  to  complain,  but  who,  on  account  of  their 
crying,  may  be  supposed  to  be  suffering,  an 
unusual  manifestation  of  pain  during  their  ex- 
amination must  be  carefully  looked  for  and 
attended  to,  as  useful  information  may  thus 
be  obtained.  It  may  be  mentioned  that  general 
tenderness  is  in  some  instances  a striking  symp- 
tom of  commencing  rickets  in  children.  In  the 
case  of  ulcers,  in  order  to  determine  their  con- 
dition for  purposes  of  treatment,  it  is  worth 
while  to  notice  whether  they  exhibit  tenderness, 
as  well  as  its  degree.  Some  ulcers  are  indolent, 
and  scarcely  at  all  sensitive  ; others  are  extremely 
irritable,  and  cannot  be  touched. 

These  illustrations  will  suffice  for  the  general 
diagnosis  of  tenderness,  and  it  now  remains  but 
to  point  out  some  of  the  complaints  in  which 
this  symptom  is  peculiarly  prominent.  Amongst 
these  may  first  be  mentioned  superficial  inflam- 
matory affections,  such  as  acute  erythema  or 
erysipelas,  and  also  any  condition  ending  in  sup- 
puration. Peritonitis  is  usually  attended  with 
remarkable  tenderness,  either  generally  distri- 
buted over  the  abdomen,  or  localized,  according 
to  the  seat  and  extent  of  the  disease.  Here,  how- 
ever, it  is  necessary  to  guard  against  being 
misled  by  certain  hysterical  cases,  in  which  there 
is  intense  hyperesthesia  of  the  skin  covering  the 
abdomen,  but  the  distinctions  already  pointed 
out  should  prevent  any  mistake  in  diagnosis. 
Gout  affecting  the  joints  is  generally’  accom- 
panied by  exquisite  tenderness,  much  more  than 
in  other  forms  of  articular  disease,  although 
affections  of  the  joints  generally  give  rise  to 
tenderness.  Hysterical  patients  are  again  liable 


TENDONS,  DISEASES  OF. 
to  mislead  the  practitioner  in  this  direction,  as 
they  sometimes  seem  to  be  intensely  tender  about 
a joint,  when  there  is  really  nothing  the  matter 
with  it.  There  is  also  a peculiar  complaint  met 
within  these  subjects,  called  ‘ spinal  irritation,’ 
in  which  exquisite  tenderness  is  experienced 
along  the  spine,  or  over  some  of  the  spinous  pro- 
cesses (see  Spinal  Irritation).  Amongst  other 
conditions  which  are  attended  by  peculiar  ten- 
derness may  be  mentioned  corns  and  bunions ; 
neuromata ; certain  stumps  after  amputation  ; 
boils  ; whitlows  ; and  many  affections  involving 
such  sensitive  structures  as  the  eyo,  or  the 
matrix  of  the  nails. 

Treatment. — In  the  first  place',  of  course, 
the  disease  with  which  tenderness  is  associated 
must  be  treated  independently  of  this  particular 
symptom,  although  it  may  afford  useful  indica- 
tions. For  example,  it  may  reveal  suppuration, 
when  an  incision  will  give  vent  to  the  pus,  and 
relieve  the  tenderness.  For  the  nervous  and 
hysterical  conditions  in  which  tenderness  is  a 
prominent  symptom,  general  treatment  directed 
to  the  particular  condition  present  is  essential. 
When  a part  is  really  tender,  all  pressure  must 
be  avoided,  or  even,  in  some  instances,  the  mere 
touch  of  such  articles  as  clothing  or  bed-clothes. 
For  instance,  in  cases  of  acute  inflammation  of 
joints,  or  in  peritonitis,  it  is  of  great  service  in 
treatment  to  raise  the  bed-clothes  by  means  of 
cradles,  so  that  they  do  not  come  into  contact 
with  the  patient.  Hot  and  cold  applications, 
anodynes,  and  allied  agents  may  be  employed 
locally  with  good  effect  in  many  conditions  for 
the  purpose  of  diminishing  undue  sensibility. 
Sec  Hysteria  ; Pain  ; and  Spinal  Irritation. 

Frederick  T.  Koberts. 

TENDON-EEFLEN. — Sec  Spinal  Cord, 
Diseases  of;  page  1458. 

TENDON'S,  Diseases  of. — Svnon.  : Fr. 
Ncdadics  des  Tendons;  Ger.  Krankhciten  dcr 
Schnen. 

Although  simple  in  their  structure,  and  per- 
forming a purely  mechanical  function  of  a passive 
kind,  tendons  and  tendon-sheaths  are  liable  to 
a considerable  variety  of  diseases.  In  some 
instances  these  diseases  are  primary,  and  origi- 
nate in  the  fibrous  and  synovial  structure  of  the 
parts  involved ; whilst  in  other  instances  they 
are  secondary  to  morbid  conditions  of  the  mus- 
cles, joints,  and  fascia;  with  which  the  tendons 
are  connected.  The  primary  injuries  and  diseases 
alone  call  for  notice  here. 

Injuries. — Tendons  are  subject  to  a variety  of 
injuries  as  the  result  of  violence,  such  as  partial 
or  complete  rupture  of  the  tendon  proper  ; rup- 
ture of  the  sheath  ; dislocation  ; incised  wounds; 
and,  most  common  of  all,  sprain  of  its  fibres. 

Inflammation.. — Inflammation  of  a tendon 
and  its  sheath  may  be  traumatic  in  origin,  but  it 
frequently  makes  its  appearance  without  obvious 
cause,  and  then  constitutes  one  form  of  whitlow 
(see  Whitlow).  Certain  effusions  into  the  syno- 
vial sheaths  may  be  regarded  as  of  a chronic 
inflammatory  nature. 

’Rheumatic  affections. — Of  greater  fre- 
quency and  importance  are  the  affections  of  ten- 
dons and  tendon-sheaths,  which  occur  in  aeuts 
and  chronic  rheumatism,  in  rheumatic  arthritis. 


TENDONS,  DISEASES  OF. 
tad  gonorrhoeal  rheumatism.  These  will  be  found 
fully  described  in  the  several  articles  on  those 
subjects.  In  acute  rheumatism,  and  in  the  early 
stage  of  gonorrhoeal  rheumatism,  the  involvement 
of  the  tendon-sheaths  may  give  rise  to  nothing J 
more  serious  than  pain  and  stiffness;  but  in 
protracted  cases  of  the  gonorrhoeal  affection,  and 
in  rheumatic  arthritis,  permanent  changes  may 
result,  including  contractions,  adhesions,  calcifi- 
cation, and  even  complete  destruction. 

Gout. — The  tendons  and  their  synovial  sheaths 
are  by  no  means  an  uncommon  seat  of  gouty 
deposit.  This  condition  is  probably  best  marked 
in  the  extensor  tendons  of  the  hand,  giving  rise 
to  a characteristic  form  of  rigidity,  or  false  an- 
chylosis of  the  finger-joints. 

Ganglion. — This  affection  is  usually  a local 
dilatation  of  a tendon-sheath,  or  a cystic  forma- 
tion in  connection  with  it.  In  the  opinion  of 
the  writer  it  is  especially  common  in  rheumatic 
subjects.  See  Ganglion. 

Deformities. — The  most  obvious  and  the 
most  common  deformities  involving  tendons  are 
of  tho  nature  of  contractions,  such  as  give  rise  to 
club-foot  and  distortions  of  the  fingers.  As  a rule, 
these  are  the  result  of  some  of  the  morbid  con- 
ditions already  referred  to,  but  in  other  instances 
they  are  of  more  obscure  origin.  Thus,  in  the 
so-called  ‘ Dupuytren’s  contraction  of  the  palmar 
fascia,’  a highly  characteristic  deformity  of  the 
fingers  and  palm  of  the  hand  results  from  a 
kind  of  stricture  of  the  sheaths  of  the  flexor 
tendons  of  the  fingers  and  wrist,  due  to  shorten- 
ing of  tho  fibres  connecting  them  with  the  palmar 
fascia.  In  several  cases  of  this  nature  the  writer 
has  found  marked  thickenings  of  the  extensor 
tendons  also,  where  they  are  in  relation  with  the 
inter-phalangeal  joints. 

Hew  growths. — Various  new  growths  of  a 
fibrous,  cartilaginous,  osseous,  or  malignant 
nature  have  been  found  in  connection  with 

tendons. 

SiHPToiis. — The  symptoms  connected  with 
diseases  anl  injuries  of  tendons  are  chiefly  of 
an  objective  and  easily  recognisable  kind.  The 
most  obvious  of  these  is  impairment  of  move- 
ment of  the  tendon  in  its  sheath,  and  of  the  as- 
sociated muscles  and  joints.  In  its  slightest 
degree,  such  impairment  amounts  only  to  stiff- 
ness ; hut  when  it  is  more  marked,  it  may  take 
the  form  of  rigidity,  or  even  complete  loss  of 
lunetion.  Deformities  may  then  very  readily 
arise  in  connexion  with  the  joints,  such  as  un- 
natural flexion  or  extension,  or  actual  disloca- 
tion; whether  referable  to  shortening  of  the 
tendon,  to  constriction  of  its  sheath,  to  pro- 
longed d’suse  of  the  joint,  or  to  wasting  of  the 
associated  muscles  with  over-action  of  their 
opponent  groups.  Similar  results  may  follow 
rupture,  wounds,  or  destructive  ulceration  of 
tendons. 

Traumatic,  rheumatic,  and  goutv  effusions 
into  tendon-sheaths  give  rise  to  swellings  along 
their  course,  which  are  easily  recognised  if  the 
anatomical  relations  of  the  parts  be  remembered, 
but  which  are  probably  often  mistaken  for  intra- 
articular  disease.  Localised  swellings  on  ten- 
dons, such  as  ganglia,  nodules,  and  new  growths, 
present  unmistakeable  characters. 

The  chief  subjective  symptoms  connected  with 


TESTES,  DISEASES  OE.  1605 
the  diseases  of  tendons  are  pain  and  a feeling  of 
stiffness.  Both  of  these  symptoms  vary  greatly 
in  different  instances,  and  neither  is  perhaps 
characteristic  of  affections  of  these  structures, 
apart  from  the  associated  muscles,  bones,  and 
ligaments. 

Treatment. — The  treatment  of  diseases  of 
tendons,  where  it  is  not  of  a strictly  surgical 
nature,  is  fully  described  in  the  several  articles 
in  this  work,  to  which  reference  has  been  made. 

J.  Mitchell  Bruce. 

TENESMUS  (rewu,  I stretch), — Synon.  : 
Er.  Tenesme;  Ger.  StuMzwang. — A certain  group 
of  morbid  sensations  referred  to  the  anus  and  its 
vicinity  have  been  thus  named.  There  is  a feel- 
ing of  fulness  and  weight,  with  frequent  or  con- 
stant inclination  to  go  to  stool,  and  straining 
during  the  act  of  defecation,  little  or  nothing 
being  passed,  and  that  often  of  the  nature  of 
slimy  mucus  or  blood,  while  no  sense  of  relief  is 
experienced  afterwards.  Tenesmus  is  a common 
symptom  in  cases  of  dysentery.  It  may  also  he 
associated  with  local  diseases  about  the  lower 
part  of  the  rectum  or  anus,  such  as  piles,  fistula, 
or  malignant  disease.  Other  sensations  are  often 
present  at  the  same  time. 

Treatment. — Any  local  cause  of  tenesmus 
must  he  removed  or  cured,  if  practicable.  The 
sensations  are  best  relieved  by  local  applications 
of  heat  or  cold,  or  by  the  use  of  small  enemata 
containing  laudanum,  or  of  suppositories  of 
morphia  or  extract  of  belladonna 

Frederick  T.  Roberts. 

TEPLITZ,  in  Bohemia. — Simple  thermal 
waters.  See  Mineral  Waters. 

TERMINATIONS  OF  DISEASE.  See 

Disease,  Terminations  of. 

TERTIAN  ( tertius , the  third). — A term 
applied  to  a form  of  intermittent  fever,  in  which 
the  paroxysms  return  on  the  third  day,  or  at  an 
interval  of  about  forty-eight  hours.  See  Inter- 
mittent Fever. 

TERTIARY  ( tertius , the  third). — This  word 
is  usually  associated  with  the  advanced  forms 
of  syphilitic  disease.  See  Syphilis. 

TESTES,  Diseases  of. — Synon.  : Fr.  Mala- 
dies des  Testicules  ; Ger.  Rrankheiten  der  Roden. 
The  diseases  of  the  testes  will  he  discussed  in 
the  following  order: — 1.  Abnormalities  of  de- 
velopment ; 2.  Hypertrophy ; 3.  Atrophy ; 4. 
Injuries ; 5.  Acute  Inflammation ; 6.  Chronic 
Inflammation ; 7.  Hernia  Testis ; 8.  Cystic 
Disease;  9.  Fibroma ; 10.  Chondroma;  11.  Ma- 
lignant Disease;  12.  Teratoma;  and  13.  Neu- 
ralgia. 

1.  Abnormalities  of  Development.— (a) 
Absence.  There  maybe  complete  absence  of  the 
testicles.  The  subjects  of  this  imperfection,  if 
they  attain  the  age  of  puberty,  present  the  or- 
dinary characteristics  of  eunuchs.  As  the  com- 
plete gland  is  formed  from  two  distinct  parts,  the 
failure  or  arrest  of  development  may  he  limited 
to  either  part,  separately  from  the  other.  Thus 
cases  are  described  where  a well-developed  vesi- 
eula  seminalis  and  vas  deferens  have  been  found, 
without  any  trace  of  a testicle ; and  others, 


1606  TESTES,  DISEASES  OE. 


where  a testicle  existed  with  complete  or  partial 
absence  of  the  tas  deferens. 

( b ) Excess.  — - Supernumerary  testicles  have 
been  described,  and  men  not  unfrequently  believe 
themselves  to  be  so  gifted.  The  mistake  has 
arisen  from  the  presence  of  encysted  hydroceles, 
or  of  fatty  or  fibrous  tumours  of  the  cord,  or  of 
an  old  epiplocele.  There  is  no  well-authenti- 
cated case  recorded  of  the  presence  of  more  than 
two  testicles. 

( c ) Malposition. — The  testicles,  which  are  de- 
veloped in  the  abdomen,  immediately  below  the 
kidneys,  are  at  birth,  or  shortly  after,  lodged 
in  the  scrotum.  This  change  of  position  is  fre- 
quently described  as  ‘descent  of  the  testicle,’  an 
obvious  misuse  of  words,  if  regard  be  paid  to  the 
usual  position  of  the  foetus  in  the  uterus. 

The  testicle  may  be  retained  in  the  abdomen, 
or  in  the  inguinal  canal ; or  may  pass  through 
the  inguinal  canal  into  the  perineum,  and  be 
lodged  between  the  bulb  of  the  urethra  and  the 
anterior  part  of  the  tuber  ischii,  or  over  the  ex- 
ternal pillar  of  the  ring  into  the  subcutaneous 
tissue  of  the  upper  part  of  the  thigh  ; or  may 
pass  through  the  crural  canal  to  the  upper  and 
inner  part  of  the  thigh-,  or,  if  it  has  passed  into 
the  scrotum,  may  be  rotated,  so  that  the  epidi- 
dymis is  in  front  and  the  testicle  behind.  More 
rarely  it  has  the  long  axis  transverse  instead  of 
oblique  ; or  it  may  be  completely  inverted,  so  that 
the  globus  major  is  below,  the  globus  minor 
above. 

Eetention  in  the  abdomen  or  inguinal  canal 
may  be  the  result  of  adhesions  from  intra-uterine 
inflammation,  or  of  disproportion  between  the 
gland  and  the  orifices  through  which  it  has  to 
pass,  or  of  some  constricting  band.  The  passing 
through  the  crural  canal  to  the  thigh,  or  through 
the  inguinal  canal  to  the  perineum  or  thigh, 
must  be  the  result  of  some  unusual  attachment 
of  the  lower  end  of  the  gubernaculum.  Malpo- 
sition in  the  scrotum  must  be  caused  by  some 
abnormality  in  the  development  of  the  cord. 

The  consequences  will  vary  with  the  position. 
If  the  testicle  is  retained  in  the  abdomen,  the 
corresponding  half  of  the  scrotum  remains  un- 
developed, and  the  gland  is  always  much  smaller 
than  normal.  Sometimes  there  is  an  arrest 
of  development,  or  it  undergoes  fatty  or  fibrous 
degeneration,  or  if  otherwise  normal,  does  not 
secrete  a fertilising  fluid.  This  seems  fairly 
established  by  numerous  observations,  both  in 
men  and  the  lower  animals,  where  the  testicle 
has  been  abnormally  retained  in  the  abdomen. 
One  case,  however,  has  been  recorded  by  Hutch- 
inson, where  the  observer,  to  whom  the  retained 
testicle  was  submitted  for  microscopic  examina- 
tion, stated  that  he  found  numerous  sperma- 
tozoa. 

When  the  testicle  lies  at  the  internal  inguinal 
ring,  the  epididymis  is  frequently  found  partly 
in  the  badly-developed  scrotum,  into  which  also 
extends  the  processus  vaginalis.  As  the  com- 
munication between  this  and  the  peritoneal  cavity 
is  usually  maintained  under  such  conditions,  in 
case  of  peritonitis  with  peritoneal  effusion  there 
may  be  distension  of  this  process,  so  as  to  greatly 
simulate  a hernia,  and  render  an  exploratory 
examination  necessary. 

Retention  of  the  testicle  in  the  inguinal  canal 


is  more  liable  to  complications  than  retention 
in  the  abdomen.  It  is  often  accompanied  by 
inguinal  hernia;  is  more  exposed  to  injury;  and 
when  enlarged  at  puberty,  or  by  inflammation, 
may  cause  severe  pain  from  constriction  by  th6 
surrounding  parts. 

Inflammation  of  a testicle  retained  in  the  in- 
guinal canal  has  been  mistaken  for  strangulated 
bubonocele,  or  for  a bubo.  Careful  examination 
of  the  scrotum  should,  therefore,  be  made  in 
doubtful  cases. 

Retraction  can  usually  be  distinguished  from 
retention  of  the  testicle  by  the  state  of  develop- 
ment of  the  corresponding  half  of  the  scrotum. 

The  perineal  or  femoral  position  of  the  gland 
is  not  of  necessity  attended  with  any  bad  re- 
sults. A testicle,  however,  so  situated,  is  usually 
smaller  than  normal  and  is  more  exposed  to  in- 
jury. This  is  especially  the  case  in  the  perineal 
position. 

Treatment. — If  retention  of  the  gland  in 
the  inguinal  canal  be  attended  with  any  incon- 
venience, operative  interference  may  succeed  in 
placing  it  in  the  scrotum.  But  if  this  should 
fail  from  shortness  of  the  cord,  extirpation 
would  be  necessary.  When  in  infants  retention 
of  the  testicle  is  complicated  by  an  inguinal 
hernia,  the  use  of  a truss  is  not  to  be  recom- 
mended, as  it  will  prevent  the  possible  descent 
of  the  testicle,  and  the  hernia  not  infrequently 
spontaneously  subsides.  If  the  retention  of  the 
gland  be  permanent  and  cause  inconvenience,  it 
is  better  to  remove  it  at  once.  If  the  gland  have 
passed  through  the  crural  canal,  nothing  can 
be  done  to  remedy  the  malposition ; but  wheu 
it  has  passed  through  the  inguinal  canal  into 
the  perineum  or  the  thigh,  an  attempt  may  be 
made  to  place  it  in  the  normal  position.  lu 
an  adult,  such  a proceeding  would  be  hopeless, 
from  the  non-development  of  the  scrotum.  In 
infants,  the  attempt  has  been  twice  made  at  the 
London  Hospital,  by  Curling  and  James  Adams. 
Both  cases  died,  and  in  the  second,  in  which 
alone  a post-mortem  examination  was  allowed, 
acute  peritonitis  was  found,  which  had  extended 
from  the  pervious  processus  vaginalis.  With 
antiseptic  precautions,  however,  better  results 
might  be  anticipated. 

Mr.  John  Wood  has  successfully  transplanted 
in  an  infant  a testicle  from  the  perineum  to  the 
scrotum  subcutaneously.  When  a band  of  tissue 
in  the  perineum,  probably  the  gubernaculum, 
had  been  divided  with  a tenotomy  knife,  the 
gland  could  be  pushed  up  to  the  inguinal  canal, 
and  from  thence  into  the  scrotum,  where  it  was 
retained  by  a harelip-pin  passed  above  it  as 
in  acupressure.  This  method,  when  practicable, 
would  be  unattended  with  danger.  Hut  as  some- 
times the  unaided  efforts  of  nature  draw  the 
gland  from  the  perineum  up  to  the  irguinal 
ring,  where  it  is  comparatively  safe  frominjury, 
and  more  favourably  situated  for  any  attempt  at 
removal  to  the  scrotum,  it  is  advisable  always 
in  infants  to  allow  time  for  such  a possible  modi 
fication,  which  might  moreover  be  encouraged  by 
electric  stimulation  of  the  cord. 

Of  malpositions  in  the  scrotum,  that  where 
the  epididymis  is  in  front,  and  the  testicle  proper 
behind,  is  alone  of  any  practical  importance.  In 
any  operation  for  hydrocele  or  haematocele  o! 


TESTES,  DISEASES  OF. 


lh*i  tunica  vaginalis,  the  position  of  the  testicle 
ought  first  to  be  ascertained. 

(d)  Arrest  of  Development. — This  sometimes 
occurs  after  the  testicles  have  passed  into  the 
scrotum, sothat  these  glands  remain  permanently 
in  their  infantile  condition.  No  general  cause  has 
been  discovered  for  this  abnormality. 

2.  Hypertrophy. — When  only  one  testicle 
has  been  retained  in  the  abdomen,  the  other  some- 
times attains  an  unusually  large  size.  Such 
cases  of,  as  it  were,  compensating  development, 
are,  however,  the  exception  and  not  the  rule. 

3.  Atrophy. — Wasting  of  the  testicle  may 
result  from  inflammation,  or  from  lesions  of  the 
spinal  cord  caused  by  injury  or  disease,  or  sub- 
sequently to  injuries  of  the  head.  It  may  also 
be  produced  by  early  and  excessive  venereal  ex- 
citement ; or  by  deficient  blood-supply,  due  to 
aneurism  or  other  causes.  It  is  frequently  found 
associated  with  varicocele. 

4.  Injuries. — These  glands  are  greatly  pro- 
tected from  accidental  violence  by  their  mobility, 
and  the  laxity  of  the  surrounding  structures. 
Immediate  death  has  resulted  from  severe  con- 
tusions of  the  testicle,  probably  from  reflex  in- 
hibition of  the  action  of  the  heart.  Contusion 
and  wounds  require  appropriate  surgical  treat- 
ment. 

5.  Acute  Inflammation.  — When  acute  inflam- 
mation attacks  the  body  of  the  gland  solely  or 
chiefly,  it  is  called  orchitis-,  when  the  epididymis, 
epididymitis.  For  the  comparatively  rare  cases  in 
which  the  vas  deferens,  or  this  duct  along  with  the 
ofher  structures  of  the  spermatic  cord,  is  affected, 
w'thout  the  testicle  being  implicated,  the  bar- 
barous hybrids,  deferenitis  and  funiculitis  have 
been  coined. 

./Etiology. — Acute  inflammation  may  be  caused 
by  direct  violence,  or  by  the  extension  of  inflam- 
matory processes  from  the  mucous  membrane  of 
the  urethra.  It  may  also  occur,  though  rarely, 
as  a sequela  in  small-pox  or  in  pyaemia.  It  is 
not  infrequently  a concomitant  of  parotitis  or 
mumps. 

Of  these  varieties,  the  most  frequent  is  gonor- 
rhoeal epididymitis.  This  was  at  one  time  re- 
garded as  an  instance  of  1 sympathetic  inflamma- 
tion.’ Careful  examination  will,  however,  always 
prove  that  the  vas  deferens  is  also  affected, 
though  sometimes  in  so  slight  a degree  that  its 
participation  in  the  inflammation  might  easily 
escape  notice.  This  form  is,  therefore,  due  to 
direct  extension  of  the  inflammation  of  the  ure- 
thral mucous  membrane.  Orchitis  associated 
with  mumps  has  been  generally  regarded  as  an 
instance  of  ‘ sympathy,’  or  1 metastasis.’  Kocher, 
however,  considers  it  to  be  the  result  of  ure- 
thritis. According  to  this  experienced  observer, 
the  disease  commences  as  stomatitis,  by  which 
the  parotid,  or  sometimes  the  submaxillary  and 
neighbouring  lymphatic  glands  become  infected. 
The  morbid  material  is  carried  by  the  blood 
t.o  the  kidneys,  and  in  its  course  through  the 
urinary  passages  sets  up  cystitis  or  urethritis,  and 
thus  the  orchitis  results.  The  question  cannot, 
however,  be  regarded  as  finally  decided.  Orchitis 
and  epididymitis  sometimes  occur  in  rheumatic 
or  gouty  subjects.  Occasionally  cases  are  met 
with  in  which  no  exciting  cause  can  be  dis- 
covered. 


1007 

Symptoms. — Tho  symptoms  of  orchitis  are 
local  pain  and  swelling,  with,  in  cases  of  or- 
chitis sometimes,  and  in  cases  of  gonorrhoeal  epi- 
didymitis frequently,  redness  and  tension  of  the 
corresponding  part  of  the  scrotum.  Severe  lum- 
bar pain  is  in  some  cases  felt,  especially  by 
labouring  men,  who  apply  for  relief  on  account 
of  some  supposed  sprain  or  injury,  being  either 
ignorant  of,  or  attaching  no  importance  to,  the 
affection  of  the  testicle.  This  is  probably  due  to 
inflammation  of  the  lumbar  lymphatic,  glands, 
with  which  the  lymphatics  of  the  testicle  freely 
communicate ; but  it  may  possibly  be  an  example 
of  ‘ referred  sensation.’ 

Prognosis. — The  prognosis  is  good.  The  in- 
flammation usually  subsides  speedily,  and  leaves 
the  gland  in  a healthy  condition.  Atrophy 
sometimes  results  after  inflammation  associated 
with  mumps,  or  caused  by  severe  contusion. 
Chronic  induration  of  the  epididymis  may  per- 
sist; but  after  some  months  it  usually  disap- 
pears. Stricture  of  the  epididymis,  or  of  the  vas 
deferens,  is  very  rare.  Suppuration  does  not 
occur  except  in  pyaemia,  or  after  small-pox,  or  in 
strumous  and  very  enfeebled  persons. 

Treatment. — Iiest  in  the  recumbent  position, 
with  the  scrotum  supported  by  a crutch-pad,  and 
the  application  of  ico  locally,  are  in  ordinary  cases 
sufficient.  Where  rest  is  impossible,  well  ad- 
justed strapping  of  the  part  affords  considerable 
relief,  and  promotes  absorption  of  the  products 
of  inflammation  so  rapidly  as  not  infrequently  to 
necessitate  the  re-application  of  the  strapping 
within  twenty-four  hours.  Attention  to  diet 
and  avoidance  of  all  violent  exercise  will  be  re- 
quisite. In  moro  protracted  eases,  mercury, 
taken  in  small  doses  internally,  or  applied  locally 
by  inunction,  or  on  strapping,  will  be  found  of 
benefit.  The  practice,  recently  recommended  by 
some  eminent  surgeons,  of  puncture  or  incision 
of  tho  ordinarily  inflamed  gland,  is,  according  to 
the  v-riter's  experience,  never  necessary.  If  sup- 
puration, however,  occur,  a free  incision  should 
be  made  as  early  as  possible. 

6.  Chronic  Inflammation. — Chronic  orchitis 
may  sometimes  be  the  result  of  an  acute  attack, 
but  is  much  more  frequently  induced  by  syphilis, 
struma,  or  gout. 

(a)  Syphilitic  Orchitis. — Description.- — This 
may  occur  in  young  children  who  are  the  subjects 
of  inherited  syphilis,  in  the  form  of  hard  nodules 
in  the  testicle.  In  adults  it  belongs  to  the  tertiary 
stage  of  the  disease,  but  is  very  often  symme- 
trical. It  is  usually  painless,  the  patient  being 
frequently  ignorant  of  its  existence.  The  gland 
is  enlarged,  very  hard,  insensitive  to  pressure, 
and  often  nodular  in  form. 

Treatment. — This  form  of  orchitis  is  usually 
very  amenable  to  treatment,  but  has  a tendency 
to  recur.  Iodide  of  potassium  combined  with 
mercury  in  small  doses  internally,  when  it  can  be 
tolerated,  and  strapping  locally,  will  in  most 
cases  produce  rapid  disappearance  of  the  disease, 
for  a time  at  any  rate.  Atrophy  may  sometimes 
result : and  in  some  cases  suppuration,  with  the 
formation  of  troublesome  sinuses,  may  occur.  In 
one  case  under  the  notice  of  the  writer,  which 
was  complicated  by  an  inguinal  hernia,  the  gland 
had,  after  very  prolonged  and  unsuccessful  treat- 
ment, to  be  removed,  as  the  use  of  a truss  caused 


TESTES,  DISEASES  OF. 


1608 

great  pain,  and  the  non-uso  of  it  led  to  a dan- 
gerous descent  of  the  hernia. 

( b ) Strumous  Orchitis.— In  most  systematic 
works  on  surgery  tubercular  disease  of  the  testicle 
is  given  as  a distinct  affection,  but  the  descriptions 
of  it  are  very  confused,  no  two  being  in  perfect 
agreement.  This  is  partly  because  at  one  time 
the  presence  of  caseous  matter  was  regarded  as 
evidence  of  tubercle,  and  partly  because  in  many 
cases  microscopic  examination  of  the  gland  after 
its  removal  can  alone  determine  the  nature  of 
the  disease.  Tizzoni  and  Gaule  have,  therefore, 
proposed  to  substitute  the  term  ‘phthisis’  for 
‘tuberculosis’  of  the  testis,  since  in  this  organ, 
as  in  the  lungs,  tubercular  and  non-tubercular 
processes,  either  separately  or  concurrently,  run 
the  same  course. 

Symptoms. — -Tubercular  disease  of  the  testis 
is  not  rare  in  young  children,  and  usually  com- 
mences in  the  body  of  the  gland.  It  occurs,  how- 
ever, much  more  frequently  after  puberty,  and 
i hen  commences,  in  the  majority  of  cases,  in  the 
epididymis ; the  body  of  the  gland  and  the  vas 
deferens  becoming  subsequently  infected  in  the 
progress  of  the  disease. 

A nodular  swelling  is  found  either  in  the 
gland  or  in  the  epididymis,  which  is  usually 
only  slightly,  if  at  all  painful,  and  runs  an  indo- 
lent course.  After  a longer  or  shorter  time,  this 
softens  down  into  an  unhealthy  pus ; adhesion 
and  perforation  of  the  superjacent  structures 
ensue ; and  a fistula  is  formed.  This  condition 
may  continue  for  a long  time,  but  usually  the 
disease  extends  to  the  rest  of  the  glandular  appa- 
ratus. Sometimes  the  testicle  is  very  much 
enlarged.  The  vas  deferens,  if  affected,  may7 
either  be  uniformly  thickened,  up  to  the  inguinal 
ring ; or  present  a number  of  distinct  round 
or  spindle-shaped  enlargements.  The  prostatic 
portion  of  the  duct  and  the  vesicula  seminalis 
are  frequently  similarly  affected.  Digital  exami- 
nation of  these  parts,  through  the  rectum,  ought 
therefore  always  to  be  made. 

Treatment. — The  treatment  of  strumous  or- 
chitis consists  in  careful  attention  to  diet  and 
hygienic  conditions  ; in  the  use  of  cod-liver  oil 
and  iodide  of  iron ; and  in  the  protection  of 
the  part  from  accidental  injury  by  a suspen- 
sory bandage.  Abscesses  should  be  opened  as 
early  as  possible,  and  any  fistula  either  laid 
open  by  incision  or  dilated  by  laminaria,  and 
treated  with  stimulating  lotions,  such  as  nitrate 
of  silver,  of  the  strength  of  five  grains  to  the 
ounce.  In  favourable  cases  the  disease  may  be 
arrested,  but  in  many  cases  removal  of  the  gland 
becomes  necessary7.  If  the  epididymis  and  the 
vas  deferens  are  much  involved,  the  gland,  by 
obliteration  of  its  duct,  is  functionally  useless; 
and  as  there  is  always  considerable  risk  of  in- 
fection of  the  system  generally,  early  removal  of 
the  gland  is,  in  such  cases,  to  be  recommended. 
If  the  prostate  and  vesicula  seminalis  have  be- 
come affected,  this  would,  of  course,  he  useless. 

There  is  another  form  of  caseous  orchitis,  not 
of  tubercular  origin,  in  which  the  intertubular 
lymphatic  spaces  of  the  testis  become  filled  with 
a new  growth  of  lymphoid  tissue,  by  which  the 
seminal  tubules  are  ultimately  compressed  and 
destroyed.  This  may  become  transformed  partly 
into  fibrous  tissue,  but  in  the  greater  part 


usually  undergoes  fatty  degeneration,  forming 
caseous  masses,  which  subsequently7  break  down 
into  cr,rd-like  pus.  The  symptoms  are  very 
similar  to  those  of  the  tubercular  disease,  but 
there  is  not  the  same  danger  of  general  infection 
of  the  system. 

(e)  Gouty  Orchitis. — Chronic  orchitis  from  gont 
can  be  diagnosed  by  the  history  of  the  patient, 
and  yields  readily  to  the  ordinary  treatment  for 
gout,  but  is  very  apt  to  recur. 

7.  Hernia  Testis. — This  morbid  condition 
was  formerly  known  as  ‘ benign  fungus  of  the 
testis.’ 

Description. — It  consists  of  a fungous  pro- 
trusion from  the  scrotum,  of  a red  or  yellowish- 
red  colour,  and  varies  from  the  size  of  a pea  to 
that  of  a small  egg.  There  are  two  varieties, 
which  may  be  distinguished  as  superficial  and 
deep.  The  superficial  form  springs  from  the 
visceral  layer  of  the  tunica  vaginalis,  and  is  very 
comparable  to  the  fungous  granulations  occa- 
sionally met  with  in  cases  of  suppuration,  or  in 
wounds  of  the  synovial  sheaths  of  tendons.  In 
this  the  tunica  albuginea  is  intact,  but  probably 
altered  in  structure.  In  the  deep  form  the 
tunica  albuginea  has  been  perforated,  and  the 
protruded  mass  consists  largely  of  seminal 
tubules.  It  cannot  be  regarded  as  an  evidence 
of  any  special  disease  of  the  gland,  as  it  may 
occur,  but  by  no  means  necessarily,  after  any 
form  of  orchitis  in  w7kich  there  has  been  suppu- 
ration. 

Treatment. — The  treatment  consists  in  well- 
adjusted  pressure  upon  the  protrusion  ; with  the 
occasional  application  of  caustics,  such  as  nitrate 
of  silver  or  red  oxide  of  mercury7.  Freeing  the 
margins  of  the  opening  from  adhesions,  and 
bringing  the  thus  liberated  integument  over  the 
protrusion  by  means  of  sutures,  is  usually  very 
successful.  When  the  precedent  inflammation 
has  been  due  to  some  specific  cause,  the  appro- 
priate constitutional  treatment  must  also  be  em- 
ployed. 

S.  Cystic  Disease. — Cysts  are  frequently 
found  in  the  testicle,  either  separately  or  asso- 
ciated with  other  growths. 

Description. — In  true  cystic  disease  or  sim- 
ple cystoma,  the  whole  or  part  of  the  body  of 
the  testicle  is  replaced  by  a closely  aggregated 
mass  of  cysts,  of  very  variable  size.  Some  are 
so  minute  as  only  to  be  visible  on  microscopic 
examination,  while  others  may  attain  to  the 
dimensions  of  a pigeon's  egg.  When  only  part 
of  the  gland  is  so  affected,  healthy  glandular 
substance  is  found  at  the  periphery,  enveloping 
the  cystic  growth.  The  cysts  have  no  proper 
wall,  and  are  lined  witli  shallow  cylindrical  epi- 
thelium, which  is  sometimes  ciliated.  They  are 
filled  with  either  clear  watery,  or  sometimes  very 
viscid,  fluid ; or  with  atheromatous  matter,  re- 
sembling the  contents  of  a sebaceous  cyst.  Very 
frequently  nodules  of  cartilage  are  found  inter- 
posed between  the  cysts.  The  disease  usually 
occurs  in  adults,  but  one  ease  has  been  recorded 
where  the  enlargement  was  first  observed  at  the 
age  of  three  months.  The  structure  seems  to 
indicate  very  clearly  the  origin  of  the  cysts  to 
be  from  retention  within  the  rete  testis. 

There  is.  another  form  of  cystic  disease,  where 
the  cysts  are  separated  by  a considerable  quan- 


TESTES,  DISEASE3  OF.  1 GOO 


tity  of  gelatinous  connective  tissue,  and  often 
contain  polypoid  ingrowths,  which  sometimes 
completely  fill  their  cavities.  The  tumour  is 
often  as  large  as  a child’s  head.  This  form  is 
regarded  as  cystic  adenoma  of  the  gland. 

Cysts  of  the  epididymis  have  been  described 
in  the  article  on  Hydrocele. 

Symptoms. — Cystic  disease  of  the  testicle  is 
usually  attended  with  very  little  pain.  The 
tumour  is  of  an  oval  form,  either  with  a smooth 
surface,  or  with  irregular  elevations  ; and  does 
not  attain  a very  considerable  size,  being  gene- 
rally about  as  large  as  a goose’s  egg.  There  is 
an  indistinct  sense  of  fluctuation,  unequal  at  dif- 
ferent parts. 

Diagnosis. — Cystic  disease  has  sometimes  been 
mistaken  for  hydrocele  or  hsematocele.  The 
form  of  the  tumour,  its  relatively  greater  weight, 
the  absence  of  transparency,  and  the  impossibi- 
lity of  detecting  the  body  of  the  testicle  at  any 
part,  distinguish  it  from  hydrocele.  The  distinc- 
tion from  hsematocele  is  in  some  cases  more 
difficult.  If  exploratory  puncturo  be  considered 
requisite,  a full-sized  instrument  should  be  used, 
as  the  fluid  may  be  so  viscid  as  not  to  flow 
through  a small  cannula. 

Treatment. — Castration  is  the  only  remedy 
for  this  condition. 

9.  Fibroma. — Fibrous  tissue  is  found  in  ab- 
normal quantity  in  atrophy  of  the  testis,  in 
chronic  orchitis,  and  associated  with  new  growths. 
By  fibroma  of  the  testicle,  however,  is  meant  a 
new  formation  of  fibrous  tissue  to  a considerable 
extent,  without  any  other  important  change.  In 
structure  it  resembles  fibrous  tumours  of  the 
uterus.  It  so  rarely  occurs,  however,  as  to  prac- 
tically be  devoid  of  clinical  importance. 

10.  Chondroma. — Cartilage,  usually  of  the 
hyaline,  but  sometimes  of  the  fibrous  variety,  is 
found  in  association  with  many  new  growths  in 
the  testicle.  Pure  chondroma  is  comparatively 
rare. 

Description. — This  form  of  tumour  of  the 
testis  occurs  as  disseminated  nodules,  con- 
nected by  fibrous  tissue ; or  as  elongated  masses 
with  branching  processes.  By  compression  of  the 
seminal  tubules,  it  leads  to  dilatation  of  other 
parts  of  the  tubules ; and  by  invagination  of  the 
walls  of  such  dilatations,  the  growth  often  seems 
to  be  in  the  interior  of  a tubule.  Careful  exami- 
nation, however,  will  always  prove  it  to  be  of 
extra-tubular  origin.  It  similarly  invades  the 
lymphatics,  and  through  them  has  a great  ten- 
dency to  infect  other  parts  of  the  system.  It  is 
ofteD  associated  with  myxoma  ; and  sometimes, 
though  rarely,  it  develops  into  bone.  It  can  only 
be  diagnosed  with  any  certainty  when  the  tumour 
has  attained  a large  size,  and  is  then  characterised 
by  the  hardness  and  slow  growth  of  the  mass. 

Treatment. — Castration  is  the  only  treat- 
ment; and  in  consequence  of  the  tendency  of  this 
disease  to  invade  other  organs,  the  rule  laid 
down  by  Mr.  Curling  is  the  best — ‘ to  recom- 
mend an  operation  without  unnecessary  delay,  in 
all  cases  of  large  sarcocele  w'hich  do  not  give  any 
indication  of  yielding  to  treatment.’ 

11.  Carcinoma  and  Sarcoma. — These  are 
classed  together,  because,  though  histologically 
of  very  different  origin,  the  distinction  between 
them  in  any  individual  case  is  often  impossible, 


except  by  microscopic  examination  of  the  tumour 
after  removal.  Even  then  the  distinction  is 
sometimes  impossible,  if  we  may  judge  from  the 
description  of  recorded  eases  of  mixed  sarcoma 
and  carcinoma. 

The  latter  originates  in  the  epithelial  struc- 
tures of  the  gland,  and  is  almost  invariably  of 
the  encephaloid  variety.  Scirrhus  is  said  by  all 
writers  to  occur  sometimes,  and  so-called  speci- 
mens are  in  many  museums.  According  to 
Butlin,  however,  many  of  these  are  probably 
examples  of  fibrous  sarcoma.  Encephaloid  cancer 
usually  commences  in  the  body  of  the  testis,  by 
the  formation  of  one  or  more  nodules.  Some- 
times the  epididymis  is  first  attacked.  Very 
rarely  is  there  general  infiltration  of  the  gland. 
In  an  early  stage  of  the  disease  the  gland  is  hard, 
from  tension  of  the  tunica  albuginea,  but  when  this 
has  been  destroyed  in  the  progress  of  the  growth, 
the  mass  is  soft,  and  there  is  often  distinct  fluc- 
tuation. This  may  be  unequal  at  different  parts, 
from  the  presence  of  cysts.  The  growth  is  usually 
painless,  but  in  some  cases  there  is  acute  pain, 
either  locally  or  in  the  lumbar  region.  The  chief 
aids  to  diagnosis  at  this  period  are  the  rapidity 
of  the  growth,  the  enlargement  of  the  blood-ves- 
sels of  the  cord,  and  the  age  of  the  patient.  For 
while  encephaloid  cancer  has  been  met  with  in 
young  children  and  old  people,  still  the  vast  ma- 
jority of  recorded  cases  have  occurred  between 
20  and  40  years  of  age. 

If  the  tumour  attain  a very  large  size,  the 
scrotum  may  slough,  and  a bleeding  fungus  pro- 
trude. The  disease  has  a great  tendency  to  in- 
vade other  parts  of  the  system,  and  especially 
at  an  early  period  the  lumbar  lymphatic  glands. 
This  may  lead  to  oedema  of  the  lower  extremities, 
from  pressure  on  the  abdominal  veins.  The 
inguinal  glands  generally  escape  infection,  ex- 
cept in  some  eases  where  the  scrotum  has  been 
involved  in  the  disease.  Secondary  growths 
have  been  found  in  the  mesenteric  glands,  liver, 
spleen,  and  lungs. 

Sarcoma  originates  in  the  connective  tissue 
of  the  testicle,  and  sometimes  develops  in  both 
glands  simultaneously.  With  microscopic  exa- 
mination two  varieties  can  be  distinguished,  the 
round  and  the  spindle-celled.  The  latter  grows 
more  slowly,  and  both  are  often  associated  writh 
cystic  and  cartilaginous  formations.  The  symp- 
toms are  very  similar  to  those  of  cancer. 

Sarcoma  sometimes  commences  in  the  tunica 
vaginalis,  and  is  then  usually  accompanied  with 
extravasation  of  blood  into  the  sac.  The  wwiter 
has  met  with  two  such  eases,  where  the  shape  of 
the  tumour,  the  complete  absence  of  pain,  the 
history  of  gradual  enlargement,  and  the  very 
distinct  fluctuation  were  suggestive  of  hoemato- 
cele.  Exploratory  examination,  however,  proved 
them  to  be  cases  of  sarcoma.  Castration  was 
performed,  and  the  testicles  were  found  to  be 
only  slightly  affected  by  the  disease.  Both  cases 
died  within  a short  period  after  the  operations, 
from  secondary  affection  of  other  organs,  accom- 
panied by  similar  haemorrhages. 

Melanoma  of  the  testis  was  formerly  regarded 
as  a form  of  cancer,  but  is  now  considered  to  be 
sarcomatous.  It  is  extremely  rare,  and  in  the 
few  recorded  cases  of  it,  similar  growths  were 
found  in  many  other  organs  of  the  body. 


1610  TESTES,  DISEASES  OF. 

Diagnosis. — As  a general  rule  it  may  be  stated 
that  sarcoma  occurs  most  frequently  under  ten 
and  after  forty  years  of  age  ; and  that  the  epi- 
didymis is  more  frequently  the  primary  seat  of 
the  disease,  and,  when  secondarily  involved,  is 
attacked  at  an  earlier  period  than  in  cancer. 
The  distinction  in  any  individual  case  must, 
however,  be  very  uncertain,  and  is  of  little  im- 
portance. 

Prognosis  and  Treatment The  prognosis  is 

very  unfavourable  in  both,  as  recurrence  of  the 
growth  in  other  organs  after  the  removal  of  the 
tumour  is  the  rule  to  which  there  are  but  few 
exceptions.  Castration  is  the  only  possible  treat- 
ment for  both  diseases. 

12.  Teratoma. — The  testis,  like  the  ovary, 
may  be  the  seat  of  cysts,  containing  hair,  skin, 
bones,  &c.  The  cysts  are  sometimes  within, 
sometimes  upon  the  gland.  The  more  complex 
cases  may  be  best  explained  as  resulting  from 
the  inclusion  of  a second  fertilised  germ  ; while 
the  simpler  cases  may  be  due  possibly  to  the 
accidental  grafting  of  the  germs  of  such  tissues 
on  the  rudimentary  testicle.  The  history  of  a 
congenital  tumour  will  suffieo  to  direct  atten- 
tion to  any  such  case.  Tlioy  are  very  rarely 
met  with,  and  castration  is  the  only  suitable 
treatment. 

13.  Neuralgia  and  Irritability. — The  tes- 
ticle is  sometimes  the  seat  of  very  acute  per- 
sistent or  periodically  recurring  neuralgia.  This 
must  he  distinguished  from  hypersesthesia  or 
irritability  of  the  gland,  which  is  occasionally 
associated  with  varicocele,  or  may  be  the  result 
of  self-abuse,  excessive  venery,  or  even  of  un- 
satisfied sexual  excitement.  Neuralgia  may  be 
due  to  some  local  cause,  to  varicocele,  or  to  indura- 
tion of  some  part  of  the  glandular  apparatus  from 
precedent  inflammation.  It  may  also  be  sym- 
pathetic, as  in  renal  colic,  or  where  the  digestive 
system  is  disordered.  Occasionally  no  cause  can 
be  discovered,  and  we  have  to  assume  that  it  is 
due  to  some  affection  of  the  central  nervous 
system. 

Treatment. — When  of  local  origin,  the  treat- 
ment of  neuralgia  of  the  testis  must  be  directed 
to  the  removal  of  the  cause  ; and  if  all  other 
methods  fail,  and  the  pain  he  severe  enough  to 
warrant  it,  castration  may  he  required.  When 
due  to  affections  of  other  parts  of  the  body,  the 
treatment  must  be  regulated  accordingly. 

Hyperoesthesia  of  the  gland  usually  yields  in 
time  to  tonics,  and  attention  to  ordinary  hygienic 
conditions.  Jeremiah  McCarthy. 

TETANUS. — Synon.  : Lock-jaw;  Fr.  Te- 
t dnos ; Ger.  Starrkra.mpf. 

Pathology  and  JEtiology. — Our  knowledge 
regarding  the  pathology  of  tetanus  is  very 
limited,  but  the  symptoms  which  characterise 
this  affection  are  undoubtedly  referable  to  an 
abnormal  influence  of  the  nervous  centres  which 
control  the  action  of  the  voluntary  muscles. 
Dr.  C.  Allbutt  and  other  observers  have  described 
the  pathological  changes  in  the  spinal  cord,  after 
death  from  tetanus,  to  consist  of  intense  conges- 
tion of  the  tissues,  with  structureless  exudations, 
especially  in  the  grey  matter  ; it  is  difficult  to 
determine,  however,  whether  these  changes  are 
the  causes,  or  simply  the  effects,  of  the  abnormal 


TETANUS. 

nerve-action  which  characterises  tetanus.  Most 
of  us  have  formed  some  conception  of  the  nature 
of  this  disease,  from  the  analogy  which  exists 
between  the  effects  of  poisonous  doses  of  strych- 
nia and  the  spasms  of  tetanus ; but  we  have  no 
grounds  whatever  for  supposing  that  the  ttvxIus 
operandi  of  nux  vomica  on  the  nervous  system 
is  the  same  as  the  cause,  whatever  it  may  be, 
which  induces  tetanus.  On  the  other  hand, 
there  is  much  in  the  phenomena  presented  by 
some  instances  of  traumatic  tetanus,  to  lead 
us  to  think  that  the  violent  contraction  of  the 
muscles  in  this  disease  is  due  to  irritation  set  up 
in  the  peripheral  distribution  of  a nerve,  and 
that  this  hyper-action  once  established  is  con- 
veyed along  the  nerve  to  the  spinal  cord,  excit- 
ing by'  reflex  action  the  muscles  near  the  injured 
nerve  to  a state  of  spasm.  The  irritation  subse- 
quently extends,  and  so  the  whole  length  of  the 
spinal  cord  becomes  implicated,  a slight  impres- 
sion on  the  skin  producing  general  tetanic  con- 
vulsions. In  support  of  this  theory  as  to  the 
origin  of  the  disease,  a few  cases  have  been  re- 
corded in  which  division  of  the  principal  nerve, 
or  in  other  instances  the  stretching  of  a nerve 
leading  from  a wound,  has  completely  stopped 
an  attack  of  tetanus.  And  in  some  cases  the 
writer  has  certainly  seen  tetanic  spasms  com- 
mence as  if  by  reflex  action  ; for  instance,  after 
tying  a large  bleeding  pile,  the  patient,  within 
thirty-six  hours  of  the  operation,  complained  of 
spasms  of  the  sphincter  ani  muse'e,  and  although 
the  ligature  was  instantly  removed,  nevertheless 
the  disease  ran  a very  rapid  and  fatal  course. 

On  the  other  hand,  the  circumstances  of 
tetanus,  when  considered  in  all  their  bearings, 
point  to  some  influence  at  work  which  is  different 
in  its  nature  from  that  of  ordinary  reflex  action. 
It  is  the  exception  rather  than  the  rule  for  the 
muscles  in  the  neighbourhood  of  the  wounded 
part  to  be  first  involved  in  the  disease,  as  they 
probably  would  be  if  it  arose  from  a purely 
reflex  action;  it  matters  not  where  the  seat  of 
the  injurymay  bo,  in  by  far  the  greater  number 
of  cases  the  muscles  of  the  face  are  affected 
before  those  of  any  other  part  of  the  body.  In 
numerous  instances  of  tetanus  the  writer  has 
noticed,  for  twenty-four  or  forty-eight  hours 
before  spasms  of  the  muscles  have  set  in,  that 
the  patient’s  face  has  presented  a pinched 
appearance,  which  is  very  characteristic  of  the 
disease,  depending  on  rigidity  of  the  muscles  of 
expression.  Various  groups  of  muscles  are  sub- 
sequently involved,  in  the  following  order— those 
of  mastication,  the  neck  and  back,  the  muscles 
of  respiration,  and  lastly,  those  of  the  extremi- 
ties. So  generally  is  this  the  order  in  which  the 
muscles  are  implicated,  that  the  writer  is  dis- 
posed to  think  that,  whatever  the  pathology  of 
the  disease  may  be,  the  morbid  influence  which 
produces  it  commences  in  the  medulla  oblongata, 
and  extends  to  the  spinal  cord.  Lastly,  the 
writer  has  met  with  many  severe  cases  of  teta- 
nus among  persons  in  whom  it  was  impossible 
to  discover  any  wound  or  abrasion  of  the  skin 
or  mucous  membranes  of  the  body,1  and  in  in- 

1 In  the  surgical  wards  of  the  Mayo  Hospital,  Calcutta, 
within  a period  of  five  years,  S3  cases  of  tetanus  were 
treated.  Of  these,  44  cases  were  traumatic,  and  24  di*i. 
Of  the  remaining  39  idiopathic  cases,  10  died. 


TETANUS. 


glances  of  this  description  it  is  difficult  to  account 
for  the  symptoms  of  the  disease  on  the  theory 
that  it  depends  on  reflex  action. 

It  seems  very  certain  that  local  circumstances 
and  meteorological  conditions  greatly  influence 
the  occurrence  of  tetanus.  In  the  tropics,  the 
disease  is  far  more  frequently  met  with  than  in 
other  parts  of  the  world.  It  is  seldom  absent 
from  the  Calcutta  Hospitals,  and  in  some  sea- 
sons appears  to  prevail  as  an  epidemic.  It  is,  in 
fact,  a matter  of  common  observation  in  Bengal, 
that  after  sudden  changes  of  temperature  cases  of 
tetanus  appear  among  surgical  patients ; so  that, 
while  admitting  that  in  many  instances  of  teta- 
nus wounds  are  the  immediate  cause  of  the  dis- 
ease, we  cannot  overlook  the  fact  that  a chill  is 
frequently  an  immediate  antecedent.  The  disease 
attacks  persons  of  all  ages  ; it  occurs  occasionally 
among  infants  immediately  after  birth,  but  more 
commonly  commences  a few  days  after  the  re- 
mains of  the  umbilical  cord  have  separated  from 
the  child’s  body.  Men  are  more  subject  to  te- 
tanus than  women.  In  the  tropics  the  disease 
is  by  no  means  uncommonly  seen  among  horses, 
especially  after  they  have  undergone  the  opera- 
tion of  castration. 

Symptoms. — Tetanus  almost  invariably  com- 
mences, in  man  or  the  lower  animals,  whether  it 
is  of  traumatic  origin  or  otherwise,  in  rigidity  of 
the  muscles  of  expression.  In  the  course  of  a few 
hours  the  muscles  of  mastication  and  of  the 
head,  neck,  and  back  become  involved,  so  that 
the  patient  experiences  difficulty  in  opening  his 
mouth,  or  in  moving  his  head  from  side  to  side  ; 
and  deglutition  is  impeded  by  spasmodic  con- 
traction of  the  pharynx.  The  rigidity  of  one  or 
more  of  the  groups  of  muscles  above  referred  to 
is  constant  throughout  the  whole  course  of  the 
disease ; but  in  addition  to  this,  from  time  to  time 
these  muscles  are  thrown  into  the  most  frightful 
spasms  ; in  this  way  the  patient’s  body  is  some- 
times bent  like  a bow,  the  whole  weight  of 
the  trunk  being  supported  on  the  back  of  his 
head  and  heels.  The  abdominal  and  thoracic 
muscles  are  also  implicated,  and  hence  the 
patient’s  belly  is  tense  and  hard,  and  the  walls 
of  his  chest  expand  imperfectly  in  the  effort  of 
breathing.  The  muscles  of  the  arms  and  legs 
are  often  extremely  rigid,  and  convulsed  in  a 
most  violent  manner ; they  are  the  seat  of  ter- 
rible pain.  The  interval  between  the  paroxysms 
of  spasm  of  the  affected  muscles  is  very  uncer- 
tain ; sometimes  the  cramps  last  only  for  a few 
seconds,  at  other  times  for  five  and  even  ten 
minutes.  The  most  dangerous  cases  of  tetanus 
are  evidently  those  in  which  the  muscles  of 
respiration  are  principally  involved,  for  death  is 
generally  caused  in  this  disease  by  the  inter- 
ference with  the  respiratory  process,  the  chest 
being,  as  it  were,  compressed  in  a vice  (Watson). 
In  consequence  ot  the  condition  of  the  muscles 
of  the  neck  and  thorax,  the  sick  person  is  unable 
to  speak,  but  his  intellect  generally  remains  clear 
up  to  the  last,  nor  are  the  other  functions  of  his 
body  materially  deranged.  The  patient  suffers 
much  from  hunger  and  thirst,  which  he  is  unable 
:o  alleviate;  and,  above  all,  he  longs  for  sleep, 
which  is  frequently  denied  him  in  consequence  of 
the  recurring  spasms.  The  surface  of  the  skin 
is  bedewed  with  perspiration ; and  the  pulse  rises 


1611 

and  falls  with  the  intensity  of  the  spasms,  and 
the  duration  of  the  disease. 

Course  and  Duration. — Tetanus  is  one  of 
those  maladies  which  run  a definite  course,  al- 
though its  duration  is  not  so  precisely  defined 
as  that  of  some  other  diseases ; in  some  cases  it 
may  kill  the  person  affected  in  the  course  of  a 
few  hours,  but  in  the  greater  number  of  in- 
stances patients  die  of  tetanus  from  the  seventh 
to  the  eleventh  day  after  the  commencement  of 
the  disease.  If  they  survive  the  twelfth  day, 
the  malady,  as  a rule,  gradually  subsides ; and 
the  patient  may  usually  be  pronounced  cured  in 
twenty-five  days  from  the  commencement  of  the 
attack ; but  he  often  suffers  for  many  weeks 
subsequently  from  rigidity  of  the  muscles  which 
have  been  involved  in  the  tetanic  spasms. 

Prognosis. — The  writer  has  for  some  time  past 
relied  much  on  the  thermometer,  not  only  as  a 
means  of  forming  a prognosis,  but  as  indicating 
to  some  extent  the  treatment  to  be  followed  in 
tetanus.  Doubtless  in  some  of  the  worst  in- 
stances of  this  disease  the  thermometer  fails  us ; 
for  if  the  muscles  of  respiration  are  very  much 
affected,  as  they  are  in  the  most  severe  cases, 
the  process  of  combustion  within  the  body  is  so 
much  interfered  with  that  its  temperature  is  not 
kept  up  to  the  degree  it  should  be,  in  proportion 
to  the  violence  of  the  muscular  action.  Never- 
theless, as  a general  rule,  in  instances  of  tetanus, 
so  long  as  the  thermometer  indicates  that  the 
temperature  of  the  patient’s  body  is  under  101 3 
Fahr.,  we  may  remain  easy  regarding  the  issue  of 
the  case.  If  the  mercury  rises  in  the  instrument 
beyond  101°,  there  is  impending  danger ; and  if 
it  reaches  103°,  the  case  is  one  to  cause  us  the 
greatest  anxiety.  After  death  from  this  disease 
the  writer  has  found  the  temperature  of  the 
body  to  rise  as  high  as  107°. 

Treatment. — One  of  the  most  remarkable 
facts  connected  with  tetanus  is  the  almost  incre- 
dible amount  of  Indian  hemp  and  opium  which 
persons  suffering  from  it  will  swallow,  without 
producing  their  poisonous  effects  on  the  system. 
The  writer  has  prescribed  these  drugs  in  very 
large  doses,  but  has  failed  to  satisfy  himself  that 
they  influence  for  good  the  progress  of  the  malady. 
He  has  also  given  the  Calabar  bean  a fair  trial 
in  tetanus ; but  unless  it  be  pushed  to  the  extent 
of  rendering  the  patient  collapsed,  the  tempera- 
ture of  his  body  falling  perhaps  to  91°  or  95°, 
and  the  pulse  being  hardly  perceptible  at  the  wrist, 
he  has  found  that  this  medicine  hardly  affects 
the  spasms  of  tetanus  in  severe  cases,  whilst  in  the 
milder  forms  of  the  disease  there  is  no  neces- 
sity for  resorting  to  such  a dangerous  means  of 
cure.  In  fact,  we  know  of  no  system  of  treat- 
ment which  will  cut  short  the  progress  of  a case 
of  tetanus,  and,  therefore,  the  indication  is  to 
employ  all  our  efforts  to  keep  the  sick  person 
alive  during  the  illness  through  which  he  is 
passing.  As  means  to  this  most  desirable 
end,  we  must  feed  him,  and,  if  possible,  secure 
him  at  least  some  eight  hours’  sleep  during  the 
day.  TVith  respect  to  food,  the  patient  must 
be  made  to  swallow  about  four  ounces  of  milk 
every  four  hours  ; one  egg,  or  half  an  ounce  of 
the  juice  of  raw  meat,  being  mixed  with  the 
milk,  morning,  noon,  and  evening.  If  the  pulse 
indicates  great  exhaustion,  beef-tea  and  brandy 


1G12  TETANUS, 

may  be  given  as  an  enema,  in  addition  to  the 
above-mentioned  food.  In  cases  of  tetanus  the 
teeth  are  often  so  firmly  locked  together  that  it 
is  necessary  to  insert  one’s  fingers  between  the 
closed  jaws  and  the  cheeks,  and  pour  the  milk 
into  the  cavity  thus  formed ; the  liquid  will 
trickle  between  andbehindthe  patient’s  teeth,  and 
pass  down  his  throat.  Some  of  it  may  occasion- 
ally run  into  the  trachea,  and  cause  considerable 
spasm,  but  the  writer  has  never  seen  any  more 
serious  result  follow  from  this.  If  the  patient 
can  swallow  with  comparative  ease,  arrowroot 
maybe  mixed  with  the  milk;  a man  can  live 
very  -well  on  a diet  of  this  description  for  some 
twenty-five  days. 

With  reference  to  drugs,  the  writer  knows  of 
no  medicine  which  procures  sleep  so  well  as  the 
hydrate  of  chloral  in  cases  of  tetanus.  It  should 
be  administered  in  40-grain  doses  (to  an  adult)  at 
bedtime  ; and  in  severe  cases  of  the  disease  (the 
temperature  of  the  patient's  body  rising  to  up- 
wards of  101°)  an  additional  30  grains  of  chloral 
should  be  given  at  mid-day.  However  serious 
the  case  may  seem  to  be,  we  should  rigidly 
adhere  to  the  plan  of  treatment  above  described, 
the  urgency  of  the  symptoms  not  causing  ns  to 
deviate  from  our  attempts  to  make  the  patient 
swallow  a sufficiency  of  food,  and  of  the  hydrate 
of  chloral,  to  enable  him  to  struggle  through  the 
malady  from  which  he  is  suffering. 

C.  Macnamaba. 

TETANY. — Synox.  : Tetanilla;  Idiopathic 
muscular  spasm ; Ur.  Tetanos  intermittent. 

Tetany  is  a neurosis  originally  described  by 
Dance  in  1831,  and  more  or  less  fully  described 
since  tinder  many  names,  especially  in  France. 
It  is  probably  much  more  common  in  that 
country  than  in  England,  where  it  is  very  rarely 
met  with.  It  is  mostly  a comparatively  trivial 
and  temporary  malady. 

HStiology. — The  disease  is  associated  with  no 
recognised  organic  changes  in  any  part  of  the 
nervous  system,  and  much  uncertainty  prevails 
in  regard  to  its  causation.  It  occurs  mostly 
between  the  ages  of  15  and  30  years,  though  it 
may  show  itself  in  older  people,  as  well  as  in 
young  children,  and  even  in  infants.  It  occurs 
in  either  sex,  but  is  more  common  among  females. 
Persons  of  a neurotic  temperament,  or  those 
whose  constitutions  have  been  disturbed  or 
Weakened  from  many  causes,  are  specially  liable. 
Teething,  the  establishment  of  menstruation, 
chronic  diarrhoea,  lactation,  the  state  of  conva- 
lescence from  many  acute  diseases,  are  all  con- 
ditions which  predispose  to  this  affection;  whilst 
exposure  to  cold,  and  emotional  disturbance  seem 
to  act  as  the  most  common  exciting  causes. 

Symptoms. — The  morbid  manifestations  con- 
sist, in  the  main,  of  tonic  spasms,  frequently  re- 
curring for  brief  periods  in  one  or  other  part  of 
the  body,  painful  in  character,  and  unaccompanied 
by  less  of  consciousness.  The  attacks  in  different 
individuals  vary  widely,  the  spasms  being  some- 
I imes  quite  local,  and  sometimes  involving  many 
different  regions  of  the  body. 

In  the  slighter  kinds  of  attack,  a numbness 
and  ;ingling  is  felt  in  the  fingers  and  toes,  which 
speedily  become  fixed  in  tonic  spasm.  As  the 
spasms  strengthen,  they  may  extend  to  higher 


TETANY. 

parts  of  the  limb,  and  become  painful.  The 
fingers  are  drawn  together  and  slightly  flexed, 
the  thumb  is  bent  into  the  palm,  and  the  wrist 
slightly  flexed.  The  toes  also  are  drawn  to- 
gether and  towards  the  sole,  the  big  toe  being 
drawn  under  them.  The  dorsum  of  the  foot  is 
arched  and  the  heel  pulled  up,  whilst  the  leg  and 
thigh  are  more  or  less  rigidly  extended.  One 
or  more  of  the  limbs  may  be  affected  in  this 
way,  or  if  all  are  implicated,  it  may  be  simul- 
taneously or  successively.  This  condition  of 
things  lasts  for  a few  minutes,  or  even  for  an 
hour  or  two,  accompanied  often  by  severe  pain 
along  the  nerve-trunks,  and  by  some  diminution 
of  sensibility  in  the  parts  affected.  When  the 
attack  is  about  to  terminate  formication  sets  in, 
as  at  the  commencement  of  the  spasm.  After 
variable  intervals  the  attacks  are  renewed,  it  may 
be  in  an  hour  or  two,  or  only  after  several  daj’s. 
Such  paroxysms  may  be  frequent  during  several 
months  ; and,  according  to  Trousseau,  so  long 
as  a tendency  to  recurrence  of  the  spasms  exists, 
they  may  always  be  excited  anew  by  simply 
‘ compressing  the  affected  parts,  either  in  the 
direction  of  their  principal  nerve-trunks,  or  over 
their  blood-vessels,  so  as  to  impede  the  venous 
or  arterial  circulation.’  On  the  other  hand,  the 
application  of  cold  to  the  parts  affected  fre- 
quently arrests  the  spasms  for  a time. 

In  the  more  severe  forms  of  tetany,  the  attacks 
may  begin  in  the  way  above  indicated  in  the 
upper  extremities,  next  in  the  lower  extremities, 
and  then,  whilst  diminishing  in  the  parts  first 
affected,  they  may  extend  more  or  less  generally 
to  the  trunk  muscles.  The  contractions  are 
invariably  more  or  less  painful.  The  spasms 
may  even  spread  to  the  facial  muscles,  so  that 
the  jaws  may  be  firmly  clenched,  and  speech 
greatly  embarrassed.  If  the  muscles  of  the 
larynx  are  involved,  as  well  as  those  of  the 
chest  and  abdomen,  extreme  dyspnoea  may  be 
induced.  Still  there  is  no  loss  of  consciousness. 
These  attacks  may  be  of  brief  duration ; or  they 
may  be  extreme  in  degree,  long-continued,  and 
frequently  repeated.  In  such  severe  cases  there 
is  slight  elevation  of  temperature,  with  greatly 
quickened  pulse,  and  a furred  tongue.  After 
some  weeks  or  months  the  paroxysms  usually 
become  less  severe,  less  frequent,  and  finally 
cease  altogether. 

Diagnosis. — The  diagnosis  must  be  based  upon 
tile  progressive  character  of  the  at  tacks ; upon  the 
fact  that  they  begin  in  the  upper  and  lower  ex- 
tremities, and  after  a time  completely  intermit; 
upon  the  absence  of  all  loss  of  consciousness 
during  the  attack;  and  upon  the  fact  of  the 
possibility  of  reindneing  the  paroxysms  by  pres- 
sure upon  the  nerves  or  vessels  of  the  parts 
affected.  These  characters  will  suffice  to  distin- 
guish the  affection  from  tetanus,  epilepsy,  and 
hysteria. 

Pbogxosis. — The  prognosis  is  usually  favour- 
able, the  complaint  gradually  subsiding  after  a 
few  months.  Still,  in  very  exceptional  cases,  tho 
patient  may  die  asphyxiated  during  one  of  the 
extremely  severe  attacks. 

Treatment. — The  treatment  of  tetany  should 
in  the  main  be  directed  to  the  improvement  of 
the  patient’s  general  health,  and  the  diminution 
of  all  debilitating  conditions  or  causes  of  irri  - 


TETANY. 

.ation.  At  the  same  time,  we  must  endeavour 
to  lessen  the  general  mobility  of  the  nervous 
system,  by  seeing  that  the  patient  obtains  re- 
gular and  sound  sleep,  as  well  as  by  the  adminis- 
tration of  the  bromides  in  suitable  doses,  in 
combination  with  valerian,  musk,  conium,  or 
other  antispasmodic  remedies. 

H.  Charlton  Bastian. 

TETRASTOMA  EEHALE  (rlrpa,  four- 
fold; ari/ia,  a mouth;  and  ren,  a kidney). — A 
form  of  entozoon  found  on  one  occasion  in  the 
urine  of  a patient  by  Lucarelli,  and  described  by 
Delle  Chiaje.  See  Entozoa , by  Dr.  Cobbold, 
Bond.,  1861. 

TETTER. — Tetter  is  an  old  Saxon  word, 
equivalent  to  the  French  dartre.  Tetter  is  de- 
fined to  be  ‘a  tickling  and  itching  scab,’  and 
may  be  taken  to  signify  a chronic  inflammation 
of  the  skin,  attended  with  desquamation  and 
itching.  In  this  sense  the  term  is  popularly 
applied  to  patches  of  chronic  eczema,  and  espe- 
cially to  those  of  psoriasis  ; but  it  is  altogether 
too  indefinite  in  its  meaning  for  scientific  use. 

Erasmus  Wilson. 

THALAMUS  OPTICUS,  Lesions  of.— 

Svnon.  : Fr.  Maladies  dcs  Ccmchcs  optiques;  Ger. 
Kranklieiten  dcr  Sehhiigel. 

Introduction. — Diseases  of  the  optic  thala- 
mus vary  in  their  symptomatology  according  as 
the  lesion  is  strictly  limited  to  the  ganglion 
itself,  or  implicates  also  neighbouring  structures. 

In  the  former  case  it  is  apparently  well  es- 
tablished, by  numerous  recorded  cases,  that 
lesions,  such  as  apoplectic  cysts,  or  areas  of 
softening,  may  exist  without  producing  any 
discoverable  symptoms,  either  in  the  domain  of 
motility  or  sensibility,  general  or  special.  This 
is  more  particularly  the  case  when  the  lesions 
occupy  the  convexity  or  ventricular  aspect  of  the 
optic  thalamus. 

But  more  frequently  diseases  affecting  the 
optic  thalamus  implicate  also,  directly  or 
indirectly,  the  corpus  striatum,  internal  capsule, 
crus  cerebri,  or  corpora  quadrigemina.  Owing  to 
the  community  of  vascular  supply  between  the 
corpus  striatum  and  optic  thalamus  through 
the  opto-striate  arteries  of  Duret,  embolism  or 
rupture  of  these  vessels  leads  to  conjoint 
destruction,  more  or  less  extensive,  of  both 
ganglia,  as  well  as  rupture,  or  pressure  on  the 
fibres  of  the  internal  capsule.  A haemorrhage  or 
embolism  in  this  region  produces  hemiplegia  of 
the  opposite  side  of  the  body.  But  that  the 
hemiplegia  cannot  be  due  to  the  lesion  of  the 
optic  thalamus  is  clear  from  the  fact  that  such 
lesions  may  exist  without  any  motor  paralysis 
whatever.  It  is,  therefore,  more  logical  to  attri- 
bute motor  paralysis,  when  it  does  occur  in  con- 
nection with  lesions  of  the  optic  thalamus,  to 
implication,  direct  or  indirect,  of  the  corpus 
striatum  or  the  motor  fibres  of  the  internal 
capsule. 

Localizing  Phenomena.  — It  is  a question 
whether,  apart  from  considerations  as  to  causa- 
tion, there  are  any  symptoms  specially  charac- 
teristic of  haemorrhages  in  the  region  of  the 
optic  thalamus. 

Among  other  symptoms  noted  are  clonic  or 


THALAMUS  OPTICUS,  LESIONS  OF.  1613 
tonic  spasms  of  the  paralysed  limbs  in  a con- 
siderable number  of  the  cases.  These,  however, 
though,  according  to  Bastian,  occurring  in  about 
three-fourths  of  the  cases,  cannot  be  regarded  as 
pathognomonic,  for  similar  spasms  may  occur 
from  lesions  elsewhere,  as  in  the  cortex,  centrum 
ovale,  and  pons. 

Nor  is  it  true  that  lesions  of  the  optic 
thalamus  specially  cause  paralysis  of  the  uppei 
extremity,  as  has  been  contended  by  Saacerorte 
and  others.  The  leg  may  suffer  quite  as  much  ; 
and  indeed  when  the  motor  paralysis  is  asso- 
ciated with  anaesthesia,  the  affection  of  the  leg 
is  frequently  much  more  pronounced  than  that 
of  the  arm  or  face. 

The  occurrence  of  anaesthesia  on  the  paralysed 
side  is  more  constant  and  more  enduring  when 
the  lesion  invades  the  optic  thalamus  and  its 
neighbourhood,  than  when  it  is  confined  to  the 
ganglia  of  the  corpus  striatum.  This  is  owing 
to  the  fact  that  the  posterior  fibres  of  the 
internal  capsule  are  directly  injured,  and  not 
merely  pressed  on,  as  in  the  latter  case.  The 
anaesthesia  may  extend  to  the  special  senses  as 
well  as  common  sensibility,  but  more  frequently 
the  tactile  sensibility  only  is  distinctly  im- 
paired. The  reflex  cutaneous  excitability  is 
also  greatly  diminished,  as  has  been  shown  by 
Crichton  Browne  (IFest  Riding  Asylum  Reports, 
vol  v.).  The  paralysed  limbs  are  frequently 
also  affected  with  unsteadiness,  tremors,  or 
choreic-like  spasms,  intensified  on  volitional 
efforts.  This  affection,  termed  post-hcmiplegic 
chorea  (Weir-Mitchell,  Charcot),  is  generally-  if 
not  invariably  associated  with  a greater  or  less 
degree  of  impairment  of  sensibility  in  the  affected 
limbs.  It  is  doubtful  how  much,  if  anything, 
can  be  assigned  to  the  lesion  of  the  optic  tha- 
lamus itself  in  the  causation  of  these  symp- 
toms. But  for  regional  diagnostic  purposes, 
they  may  be  regarded  as  significant  of  lesion 
of  the  optic  thalamus  and  its  immediate  neigh- 
bourhood. When  the  lesion  involves  only  the 
posterior  fibres  of  the  external  capsule,  lying 
external  to  the  optic  thalamus,  the  result  is 
hemiamesthesia,  general  and  special,  of  the  oppo- 
site side  of  the  body.  The  power  of  movement 
ma_v  not  be  apparently  affected.  If  so  the  leg 
is,  in  general,  relatively  more  affected  than  the 
arm.  But,  though  the  motility  is  retained,  the 
muscular  sense  is  lost,  so  that  the  patient  is 
unaware  of  the  state  of  contraction  of  the 
muscles  or  the  position  of  the  limb,  and  requires 
the  aid  of  vision  in  guiding  its  movements. 

Cases  have  been  recorded  by  Hughlings 
Jackson  and  others,  which  render  it  in  the 
highest  degree  probable  that  lesions  of  the 
posterior  aspect  of  the  optic  thalamus,  and 
region  of  the  corpora  geniculata,  cause  hemiopia 
towards  the  side  opposito  the  lesion,  from 
paralysis  of  both  retin®  on  the  corresponding 
side.  A similar  result  ensues  from  direct  lesion 
of  the  optic  tract,  however,  aod  also  from  sever- 
ance of  the  medullary  fibres  of  the  occipito- 
augular  region.  Hence  hemiopia  alone,  with- 
out other  symptoms,  cannot  be  taken  as  abso- 
lutely diagnostic  of  lesion  of  the  posterior  aspect 
of  the  optic  thalamus.  Conjoined  with  affection 
of  the  other  forms  of  sensibility,  however,  it 
points  to  lesion  in  this  region. 


1614  THALAMUS  OPTICUS,  LESIONS  OP. 

Tumours  of  the  optic  thalamus,  in  addition  to 
the  general  symptoms  of  intracranial  growths, 
though  sometimes  these  even  seem  to  have  been 
wanting,  produee  either  no  special  symptoms,  or 
such  a variety  as  to  render  the  regional  diagnosis 
very  uncertain  or  altogether  impossible.  The 
symptoms  may  be  those  indicative  of  lesion  of 
the  internal  capsule,  both  its  motor  and  sensory 
strands  ; or  they  may  be  such  as  have  been 
observed  in  connection  with  lesions  of  the 
corpora  quadrigemina. 

It  will  thus  be  seen  that,  in  respect  to  the 
regional  diagnosis  of  diseases  of  the  optic 
thalamus,  we  are  obliged  to  rely  on  a combina- 
tion of  symptoms,  not  one  of  which  can  be  re- 
garded as  absolutely  depending  on  the  optic 
thalamus  itself,  and  our  localisation  is  at  best 
only  approximate. 

Treatment. — The  treatment  of  diseases  of 
the  optic  thalamus  comes  under  the  head  of 
treatment  of  cerebral  disease  in  general. 

D.  Ferbieb. 

THERAPEUTICS  (depaneva,  I attend. — 
Synon.  : Pr.  Therapeutique ; Ger.  Therapie. 

Definition. — The  science  and  art  of  heal- 
ing. 

Introduction, — Therapeutics  is  the  most  es- 
sential part  of  medicine,  for  although  other  parts 
of  medical  science  are  interesting  to  the  practi- 
tioner, it  is  the  cure  of  disease  which  the  patient 
seeks.  Therapeutics  may  be  divided  into  two 
classes — the  therapeutics  of  fancy,  and  the  thera- 
peutics of  fact.  In  order  to  cure  disease  with 
certainty,  the  practitioner  must  know  what  the 
nature  of  the  disease  is,  and  what  the  action 
of  his  remedies  will  be.  When  these  are  posi- 
tively known,  therapeutics  becomes  a science, 
but  when  either  is  uncertain,  it  is  simply  an 
art.  Its  principles  may  hereafter  become  a 
science,  but  its  practice  must  always  remain 
more  or  less  an  art,  and  be  dependent  for  suc- 
cess upon  the  skill  of  individuals.  For  the 
symptoms  which  ought  to  indicate  to  the  practi- 
tioner the  nature  of  the  disease  may  be  wrongly 
interpreted  by  him,  or,  as  it  is  usually  termed, 
he  may  form  a wrong  diagnosis,  and  thus  be  led 
to  apply  wrong  remedies.  The  idea  in  the  practi- 
tioner’s mind  may  correspond  more  or  less  exactly 
with  the  condition  of  the  patient,  or  may  not 
have  the  slightest  resemblance  to  it ; and  it  is 
only  by  careful  comparison  and  experiment  that 
their  agreement  can  be  ascertained.  An  absurd 
fancy  of  the  practitioner  will  lead  to  absurd 
treatment,  and  the  therapeutic  results  will  not  be 
satisfactory. 

Histoky. — In  all  ages  of  the  world’s  history 
we  have  had  the  therapeutics  of  fancy  and  the 
therapeutics  of  fact  running  side  by  side,  and,  in 
proportion  as  the  latter  has  predominated,  has 
treatment  been  improved.  In  primitive  times 
the  imagination  of  physicians  was  busy  with 
fancies  regarding  the  nature,  the  causes,  and 
the  cure  of  disease.  The  nature  of  the  disease 
was  sometimes  supposed  to  consist  in  the  posses- 
sion of  the  body  by  an  evil  spirit,  which  caused 
the  morbid  symptoms,  and  the  cure  consisted  of 
various  incantations  and  exorcisms.  At  other 
times  the  disease  was  supposed  to  consist  in 
alterations  of  the  fluids  or  of  the  solids  of  the 


THERAPEUTICS. 

body,  cr  of  the  formative  principle  which  per- 
vaded them.  It  was  supposed  that  in  disease 
the  juices  left  their  proper  places  in  the  body, 
or  became  disproportioned  in  quantity,  or  that 
the  atoms  and  pores  of  the  solids  became  altered, 
so  as  no  longer  to  allow  of  free  atomic  motion. 
At  other  times,  again,  morbid  conditions  were 
attributed  to  fermentation,  with  production  of 
alkalies  or  acids  in  the  body;  and  later  on, 
when  the  contractile  power  of  muscular  fibre  was 
recognised,  diseases  were  supposed  to  be  due  to 
spasm  or  atony.  Equally  fanciful  qualities  were 
attributed  to  medicines,  some  being  reckoned 
hot,  some  cold,  some  astringent,  some  opening 
and  some  closing  the  pores,  some  contracting 
and  some  relaxing  the  muscular  fibres,  and  some 
being  supposed  to  cure  disease  because  there  was 
some  external  resemblance  between  them  and 
the  organ  of  the  body  affected. 

Principles. — T he  u n sat i sfactory  results  of  su  cb 
fanciful  therapeutics  have  led  some,  in  all  ages  of 
medicine,  to  a more  or  less  experimental  thera- 
peutics. Physicians  saw  men  suffering  and  dying 
all  around  them,  and  could  not  wait  for  exact 
knowledge.  They  therefore  applied  themselves  to 
tentative  therapeutics,  giving  first  one  thing  and 
then  another  in  the  hope  of  doing  good,  and  col- 
lecting the  results  of  these  experiments  on  their 
patients,  for  the  guidance  of  themselves  and 
others  in  subsequent  cases.  The  results  thus 
obtained,  showing  that  a certain  drug  was  useful 
in  a certain  disease  without  the  reason  of  this 
utility  being  known,  constituted  empirical  thera- 
peutics. In  order  to  obtain  a broader  basis  than 
that  afforded  by  the  observation  of  any  single 
man,  some  have  collected  numbers  of  cases  from 
various  observers,  and  have  analysed  and  tabu- 
lated them.  The  results  of  this  method  con- 
stitute statistical  therapeutics.  But  it  is  liable 
to  great  fallacies,  inasmuch  as  cases  which  are 
very  different  are  tabulated,  for  convenience’ 
sake,  under  the  same  name,  and  the  results  are, 
therefore,  rendered  untrustworthy. 

The  problem  placed  before  the  practitioner  in 
the  treatment  of  any  one  case  is  rendered  ex- 
ceedingly difficult,  not  only  by  reason  of  the 
complexity  of  the  bodily  mechanism  itself,  but 
by  the  manifold  alterations  to  which  it  is  sub- 
ject in  disease,  and  the  variations  produced  in 
the  action  of  a drug  by  alterations  in  dose,  by 
differences  in  the  original  constitution  of  the 
patient,  and  further  differences  superinduced  by 
the  disease.  So  complex,  indeed,  is  the  problem, 
that  it  is  impossible  to  unravel  it  by  any  Dum- 
ber of  observations  in  disease,  and  it  can  only  be 
solved  by  making  ourselves  acquainted  with  a 
few  of  the  conditions  at  a time.  This  can  only 
be  done  by  experiment  upon  animals,  for  human 
life  is  too  valuable  to  allow  of  the  necessary 
sacrifice.  By  experimental  physiology,  the  func- 
tions of  the  various  parts  of  the  body  and  their 
relations  to  each  other  are  being  gradually  ascer- 
tained ; in  experimental  pathology  diseases  are 
induced  artificially,  in  order  that  we  may  dis- 
cover the  alterations  produced  by  them  in  the 
functions;  and  in  experimental  pharmacology, 
drugs  are  administered  in  order  to  determine 
the  part  of  the  body  which  they  affect,  and  the 
nature  of  the  alterations  which  they  produce  in 
its  function.  The  problem  being  thus  simplified, 


THERAPEUTICS. 

tho  practitioner  may  hope  to  recognise,  from 
the  symptoms  of  the  patient,  the  orgar  affected 
by  disease,  the  nature  of  the  disturbance  in  its 
function,  and  to  apply  frith  some  degree  of  suc- 
cess a remedy  which  will  counteract  such  disturb- 
ance. This  constitutes  rational  therapeutics. 
Great  advances  have  of  late  years  been  made  in 
this  direction,  but  it  will  be  a long  time  yet  be- 
fore we  can  hope  to  attain  such  exact  knowledge 
as  we  desire,  and  at  present  our  therapeutics 
must  be  to  a certain  extent  empirical.  When 
directed  towards  the  removal  of  the  cause  of  the 
disease  it  has  been  called  pathogenetic  therapeu- 
tics. When  this  cannot  be  recognised,  or  cannot 
be  removed,  the  treatment  is  directed  to  those 
parts  of  the  organism  on  which  the  cause  of 
disease  acts,  so  as  to  lessen  or  remove  the  symp- 
toms which  it  would  otherwise  produce.  This 
is  symptomatic  therapeutics.  And  when  we  can 
neither  remove  the  cause  nor  relieve  the  symp- 
toms, but  are  forced  to  trust  to  the  vis  medicatrix 
vaturcp,  and  try  to  maintain  the  patient’s  strength 
byfoodand  nursing,  we  have  expectant  treatment. 
This  might  perhaps  also  be  called  expectant  the- 
rapeutics, for  although  in  its  narrowest  sense  we 
generally  understand  by  this  term  cure  by  means 
of  medicines,  in  its  wider  acceptation  it  includes 
nursing,  climate,  and  measures  of  treatment, 
such  as  regulated  exercise,  regulated  gymnastics, 
friction,  massage,  the  application  of  heat,  and 
cold  water.  T.  Lauder  Brunton. 

THERMOMETER,  Clinical  (deppri,  heat, 
and  pirpo v,  a measure). — Synon.  : Fr.  Thermo- 
metre-, Ger.  Thermometer. 

Definition. — An  instrument  for  measuring 
different  degrees  of  heat  or  cold. 

Description  — The  thermometer  was  invented 
by  Galilei,  about  1603,  but  it  was  Sanctorius 
(1561-1636)  who  first  had  the  idea  of  investigat- 
ing the  temperature  of  the  human  body  in  health 
and  disease.  The  substances  made  use  of  in  the 
construction  of  thermometers  are  mercury,  first 
used  by  Fahrenheit ; a coloured  fluid — such  as 
alcohol;  or  air.  Any  of  these  substances,  en- 
closed in  a fine  exhausted  glass  tube,  expanding 
at  one  end  into  a globular  or  cylindrical  bulb, 
represents  a thermometer.  On  applying  heat  or 
cold  to  the  bulb  the  contents  expand  and  rise, 
or  contract  and  descend  in  the  tube.  The  extent 
of  the  rise  or  fall  can  be  expressed  in  a number 
of  a scale,  which  is  engraved  on  the  stem  or  on 
a separate  piece  of  white  glass,  or  on  a strip  of 
paper  fixed  to  the  stem,  and  enclosed  with  it  in 
a wider  glass  tube. 

The  thermometers  used  in  this  country  and  in 
the  United  States  are  graduated  with  Fahrenheit's 
scale,  whereas  on  the  Continent  of  Europe  the 
Centigrade  or  Celsius  scale  is  nowr  everywhere 
used  for  medical  and  scientificpurposes,  the  Reau- 
mur scale  falling  more  and  more  out  of  use.  The 
difference  between  these  three  scales  is  this,  that 
in  the  centigrade  and  Reaumur  scales  the  melt- 
ing-point of  ice  is  marked  zero,  and  the  boiling- 
point  of  water  (or  rather  tho  heat  of  the  steam 
of  water  boiling  at  an  atmospheric  pressure 
equal  to  29-02  inches  of  mercury)  marked  100° 
arid  80°,  respectively;  whilst  Fahrenheit  marked 
the  former  by  32°  and  the  latter  by  212°;  180 
degrees  of  the  Fahrenheit  scale  are,  therefore, 


THERMOMETER,  CLINICAL.  1615 
equal  to  100°  centigrade  and  80°  Reaumur,  and 
the  relation  of  the  three  scales  to  each  other  is, 
therefore,  as 

F.  C.  R. 

9:5  ; 4 

One  degree  of  F.  = § C.  or  |R. ; one  degree 
C.  = |F. 

In  converting  degrees  of  the  Fahrenheit  scale 
into  centigrade  degrees,  it  must,  however,  be 
borne  in  mind  that  zero  of  the  C.  scale  corre- 
sponds to  32  of  the  F.  scale  ; 32  must,  therefore, 
be  deducted  in  converting  a certain  degree  of  the 
F.  scale  into  the  corresponding  degree  of  the  C. 
scale,  and  32  must  be  added  when  C.  degrees  are 
to  be  expressed  by  the  corresponding  degrees  of 
F.  The  formulae  for  these  conversions  are, 
therefore ; — 

x deg.  F.  = (,r-  32)  x § deg.  C. 
x deg.  C.  = (x  x §)  + 32  deg.  F. 


For  instance : 


99'5  F.  = (99  5 — 32)  x § = 67’5  x 5 = 37-5  C. 
39  C.  = (39  x f)  + 32  = 70  2 + 32  = 1 02-2  F. 


It  will  be  convenient,  for  quick  reference,  to 
give  the  corresponding  degrees  of  the  Fahren- 
heit and  centigrade  scales  in  that  range  with 
which  human  physiology  and  pathology  are  con- 
cerned, side  by  side  : — 


Fahr.  Cent. 

95'0  35'0 


Fahr.  Cent. 

104-0  40  0 


960 

35'55 

96-8 

36-0 

97-0 

36-11 

98-0 

36-66 

98-6 

370 

990 

37-22 

9a-5 

375 

1000 

3777 

100-4 

38-0 

1010 

38-33 

101-3 

38-5 

1020 

3888 

102-2 

390 

1030 

39-44 

103-1 

39-5 

104-9 

40-5 

105-0 

40-55 

1058 

41"3 

1060 

41-11 

106-7 

41-5 

107-0 

41-66 

107-6 

42-0 

108-0 

42-22 

108-5 

42-5 

109-0 

42-77 

109-4 

43-0 

110-0 

43-33 

111-2 

44-0 

112-1 

44-5 

113-0 

45-0 

In  thermometers  for  clinical  use  the  degrees 
on  the  scale  ought  to  be  divided  into  fifths. 
Thermometers  ought  to  be  carefully  compared 
from  time  to  time  with  a standard  thermometer, 
as  they  are  liable,  after  a certain  time,  to  give 
abnormally  high  indications,  owing  to  the  bulb 
gradually  contracting  a little.  In  England  they 
may  be  sent  for  comparison  to  the  Kew  Obser- 
vatory. 

Of  great  convenience  for  clinical  use  has  been 
the  introduction  of  self-registering  mercurial 
maximum  thermometers.  It  is  not  without  in- 
terest to  notice  that  a self-registering  thermo- 
meter by  a small  piece  of  iron  being  introduced 
into  the  tube,  had  been  used  by  Currie,  at  the 
end  of  the  last  century  ; but  just  as  Currie  and 
de  Haen’s  work  with  the  thermometer  had  been 
entirely  forgotten  for  half  a century,  so  were 
self-registering  thermometers  only  used  again 
in  medicine  some  time  after  the  ordinarv  ther- 
mometer had  been  re-introduced  into  clinical 
practice  by  Baerensprung,  Traube,  and  Wunder- 


THERMOMETER,  CLINICAL. 


1616 

lich.  Casella  -was  the  first  who  constructed  a 
registering  clinical  thermometer,  by  introducing 
a small  quantity  of  air  into  the  tube,  and  thereby 
separating  a small  part  of  the  mercurial  column 
from  the  rest.  Instruments  are  now  made  in 
which  the  index — that  is,  the  small  separated 
part  of  the  mercurial  column — is  prevented  from 
falling  back  into  the  bulb,  or  in  which  an  index 
is  only  formed  each  time  the  mercury  rises  out 
of  the  bulb.  In  using  an  instrument  of  this  kind, 
the  index,  it  need  hardly  be  said,  must  be  shaken 
down  below  95°  or  90°  before  the  thermometer 
is  applied  to  the  patient. 

Another  principle  has  been  followed  in  the 
construction  of  very  sensitive  instruments  for 
special  researches  on  temperature,  namely,,  that 
of  the  thermo-electric  apparatus.  The  electric 
current,  which  is  produced  in  a circuit  composed 
of  two  different  metals,  when  their  point  of  con- 
tact assumes  a different  temperature  from  that 
of  the  other  ends,  or  again  the  changes  which 
a galvanic  current  shows  when  the  resistance 
of  a part  of  the  circuit  is  altered  by  a change 
of  temperature  acting  on  it,  can  be  measured  by 
a galvanometer  inclosed  in  the  circuit.  Gavarret, 
Ileidenhain,  and  other  physiologists  have  used 
the  thermo-electric  pile  in  physiological  investi- 
gations in  animals.  J.  S.  Lombard  and  Hankel 
have  applied  it  to  observations  in  man.  Quite 
recently  a convenient  form  of  thermo-electric 
apparatus  for  clinical  purposes  has  been  devised 
by  Redard . The  apparatus  constructed,  on  the 
last-mentioned  principle,  by  0.  W.  Siemens,  for 
measuring  deep-sea  temporatures,  might  also 
easily  be  adapted  for  clinical  purposes. 

A self-registering  apparatus  for  continuous 
observations,  on  the  principle  of  an  air-thermo- 
meter. has  been  constructed  by  Marey  ; and  it 
would  seem  as  if  the  desideratum  of  a clinical 
thermograph,  automatically  registering  the 
changes  of  temperature  on  the  surface  of  the 
body  during  a certain  time,  were  near  being 
satisfactorily  realised  in  the  instrument  brought 
out  by  Mr.  W.  D.  Bowkett  ( Lancet , July 
1881). 

For  measuring  surface-temperatures,  mer- 
curial thermometers  of  special  shape,  namely,  a 
long  cylindrical  bulb  coiled  up  in  one  plane  at 
a right  angle  to  the  stem,  have  also  been  con- 
structed. A thermo-electrical  apparatus,  or  Bow- 
kett’s instrument,  is  however  more  sensitive  and 
more  convenient  for  that  purpose. 

Applications  of  the  Thermometer. — The 
object  we  generally  have  in  view  with  clinical 
thermometry  being  to  examine  as  nearly  as  pos- 
sible the  temperature  in  the  interior  of  the  body, 
or  the  blood-heat,  which  is  less  variable  than  that 
of  the  surface  (see  Temperature),  the  localities 
most  suitable  for  applying  the  thermometer 
would  be  the  natural  cavities,  or  the  openings  by 
which  a thermometer  might  be  introduced  to  a 
certain  depth  into  the  interior  of  the  body.  In 
the  rectum,  vagina,  or  bladder,  the  tempera- 
ture is  not  subject  to  the  ordinary  changes  acting 
from  without,  and  the  time  required  for  taking 
an  observation  with  the  thermometer  in  any  of 
these  localities,  would  be  only  such  as  is  ne- 
cessary for  raising  the  temperature  of  the  mer- 
cury to  that  of  the  surrounding  mucous  mem- 
brane. This  time  might  be  materially  shortened 


by  previously  heating  the  thermometer  to  a de- 
gree a little  below  that  to  be  expected  in  the 
body.  "With  this  precaution  an  observation  of 
the  temperature  in  the  rectum  or  vagina  will  not 
take  more  than  half  a minute. 

The  case  is  very  different  if  we  take  the  tem- 
perature in  a cavity  of  the  body  which  is  not 
always  closed,  such  as  the  mouth;  or  in  the  axilla, 
which  can  be  formed  into  a closed  cavity  only  by 
placing  the  arm  closely  against  the  chest.  Here 
the  time  required  for  an  observation  is  much  longer, 
because  the  temperature  of  the  mucous  mem- 
brane of  the  mouth,  or  of  the  skin  of  the  axilla, 
begins  itself  slowly  rising  after  the  closing  of 
these  cavities,  until  it  is  raised  to  that  of  the 
deeper  tissues  which  are  not  exposed  to  the  loss 
of  heat  from  without.  Whereas  nine  to  eleven 
minutes  on  an  average  are  required  for  an  obser- 
vation of  the  temperature  in  the  mouth,  ten  to 
twenty-four  may  be  necessary  for  the  mercury  to 
become  stationary  in  the  axilla.  The  time  varies 
also  according  to  the  state  of  the  general  circu- 
lation. It  will  be  found  much  longer  in  persons 
with  a weak  circulation,  for  instance,  in  a casecf 
heart-disease,  than  in  the  case  of  a vigorous 
patient  with  a good  circulation  and  with  febrile 
heat.  It  is  evident  that,  as  was  first  pointed  out 
by  Liebermeister,  the  time  for  an  observation  in 
the  mouth  or  axilla  can  be  materially  shortened, 
not  so  much  by  previously  heating  the  thermo- 
meter, as  by,  previously  to  the  introduction  of 
the  latter,  keeping  the  mouth  or  axilla  closed  for 
ten  to  fifteen  minutes.  These  cavities  will  then 
have  assumed  a steady  temperature,  and  the  time 
required  for  the  observation  will  only  be  that 
necessary  for  raising  the  temperature  of  the 
mercury  and  the  glass  to  the  temperature  of  the 
surrounding  parts.  It  is,  therefore,  a good  plan 
if  the  patient  had  been  lying  on  one  side  to  turn 
him  over  to  the  other,  or  to  make  him  lie  on  one 
side  for  a time  before  the  thermometer  is  intro- 
duced, and  then  to  put  it  into  that  axilla  which 
had  been  closed  by  the  position  of  the  patient. 
If  the  skin  of  the  axilla  be  very  wet  with  perspi- 
ration, it  ought  to  be  wiped  dry  before  applying 
the  thermometer. 

For  practical  purposes  the  rule  generally  re- 
commended in  observations  being  taken  in  the 
axilla,  to  leave  the  thermometer  until  the  mer- 
cury has  remained  stationary  for  five  minutes — a 
rule  which  naturally  applies  to  self-registering 
no  less  than  to  ordinary  thermometers — secures 
sufficient  accuracy,  and  this  rule  should  be  given 
to  nurses  and  attendants  to  whom  the  observa- 
tions are  left.  Especially  in  obscure  cases,  in 
which  much  depends  upon  the  discovery  of  even 
a trifling  elevation  of  the  temperature  above  the 
normal  standard,  which  may  be  of  great  impor- 
tance for  diagnosis,  this  precaution  ought  never 
to  be  omitted ; and  for  observations  requiring 
scientific  accuracy,  as,  for  instance,  when  the 
effect  of  some  drug  on  the  temperature  of  the 
body  is  being  studied,  the  observations  ought  to 
be  made  by  the  physician  himself. 

For  various  reasons  the  axilla  is  the  locality 
most  suitable,  and,  therefore,  generally  used  f )r 
thermometrical  observations.  In  very  young  or 
restless  children,  however,  as  well  as  in  veiy  ema- 
ciated adults,  axillary  observations  would  become 
untrustworthy.  In  such  cases,  or  where  patieuis 


THERMOMETER,  CLINICAL. 

are  in  an  insensible  state,  or  under  special  cir- 
cumstances— for  instance,  when  a great  diver- 
gence exists  between  the  axillary  and  the  inter- 
nal temperature,  or  when  doubts  arise  as  to  the  cor- 
rectness of  an  axillary  observation — the  rectum, 
or  eventually  the  vagina,  may  be  used  for  apply- 
ing the  thermometer,  and  with  a self-registering 
thermometer  this  can  be  done  without  unneces- 
sarily uncovering  the  patient.  In  using  the  rec- 
tum, great  care  must  be  taken  not  to  let  a small 
instrument  slip  into  it,  and  in  restless  children 
to  prevent  the  instrument  from  being  broken. 
This  is  best  prevented  by  placing  the  patient  on 
his  side,  and  while  the  thermometer  is  kept  in 
situ  with  one  hand,  letting  the  other  one  rest 
on  the  hip  of  the  patient,  in  order  to  be  able  at 
once  to  arrest  any  turning  movement  which  he 
might  happen  to  make.  The  thermometer  ought 
to  be  introduced  about  two  inches  deep  into  the 
rectum ; and  may,  before  being  taken  out,  be 
gently  pushed  forward  a little  more,  in  order  to 
bring  the  mercury  in  contact  with  a fresh  part 
of  the  mucous  membrane,  which  has  not  been 
cooled  by  the  bulb  of  the  thermometer.  When 
large  masses  of  faeces  fill  the  rectum,  the  thermo- 
meter passing  into  them  may  indicate  a somewhat 
lower  temperature  than  when  in  contact  with  the 
mucous  membrane. 

Other  places  of  application,  such  as  the  in- 
guinal fold,  or  the  fold  of  skin  between  the  thumb 
and  the  second  metacarpus,  may  be  used  for 
special,  but  are  quite  unsuitable  for  general, 
clinical  purposes.  For  observations  made  with 
the  thermometer  see  Temperature. 

Thermometrieal  Records. — It  is  extremely 
useful  to  register  the  thermometrieal  observa- 
tions in  a case  of  disease  on  a chart,  and  to  con- 
nect the  marks  bylines;  the  curves  which  are 
thus  formed  being  quite  typical  in  many  dis- 
eases. On  the  same  chart  may  be  entered,  also 
by  marks  and  lines,  or  otherwise,  the  numbers 
of  the  pulse  and  respirations,  as  well  as  remarks 
concerning  other  symptoms,  or  the  treatment. 

The  use  of  the  thermometer  for  estimating  the 
temperature  of  rooms,  and  especially  of  wards, 
is  fully  described  in  other  appropriate  articles. 
See  Nursing  ; and  Personal  Health. 

0.  G.  H.  Baumler. 

THIRD  NERVE,  Diseases  of. — The  third 
nerve  is  purely  motor  in  function  and  supplies 
the  levator  palpebrse  superioris,  the  superior 
inferior  and  internal  recti,  the  inferior  oblique, 
the  ciliary  muscle,  and  the  sphincter  of  the  iris. 
It  arises  from  the  surface  of  the  crus  cerebri  by 
a series  of  fasciculi,  which  pass  to  a nucleus  of 
grey  matter  lying  on  the  posterior  portion  of 
the  floor  of  the  third  ventricle  and  beneath  the 
aqueduct  of  Sylvius.  The  anterior  part  of  the 
nucleus  in  the  floor  of  the  third  ventricle  inner- 
vates the  ciliary  muscle ; the  middle  part,  be- 
neath the  anterior  extremity  of  the  aqueduct  of 
Sylvius,  supplies  the  sphincter  of  the  iris ; and 
the  posterior  part  of  the  nucleus  innervates  the 
extrinsic  muscles  of  the  eyeball  (Hensen  and 
Vcelckers). 

Morbid  states  of  the  third  nerve  show  them- 
selves as  spasm  or  paralysis  in  the  muscles  sup- 
plied by  it,  that  is,  of  the  eyeball,  the  upper 
eyelid,  the  iris,  and  in  the  ciliary  muscle. 

102 


THIRD  NERVE,  DISEASES  OE.  161’ 

1.  Spasm. — Spasm  is  never  met  with  at  the 
same  time  in  all  the  muscles  supplied  by  the 
third  nerve.  It  occurs  in  isolated  ocular  muscles, 
especially  in  the  internal  rectus,  in  conditions  ol 
irritation  of  the  trunk  and  nucleus  of  the  nerve, 
as  in  meningitis,  in  hysteria,  also  in  hyper- 
metropia,  and  in  paralysis  of  the  antagonist 
muscle.  When  extreme  the  eyeball  is  turned  in- 
wards, and  cannot  be  moved  out.  Clonic  spasm 
of  the  muscles  occurs  in  ‘ nystagmus.’  The  eta 
vator  of  the  upper  eyelid  is  occasionally  spas- 
modically contracted,  so  that  the  eye  cannot  be 
shut,  but  remains  widely  or  partly  open  (lag- 
ophthalmos). Slight  contraction  of  this  muscle 
occurs  in  cases  of  long-continued  paralysis  of  the 
orbicularis  palpebrarum.  Spasm  of  the  muscle 
is  chiefly  due  to  reflex  causes,  especially  to  neu- 
ralgia of  the  fifth  nerve. 

Spasm  of  the  sphincter  of  the  iris  produces 
contraction  of  the  pupil,  sometimes  to  very  small 
dimensions  (myosis).  It  may  be  a congenita’ 
condition,  but  also  results  from  irritation  ol 
the  trunk  of  the  third  nerve  ; from  stimulation, 
central  or  reflex,  of  the  nucleus ; or  it  is  se- 
condary to  paralysis  of  the  dilator  fibres  sup 
plied  by  the  sympathetic.  It  may  result  from 
excessive  (associated)  efforts  at  accommodation. 
It  is,  however,  most  frequently  met  with  in  loco- 
motor ataxy,  and  is  associated  with  loss  of  reflex 
action.  The  condition  is  described  more  fully 
in  the  next  section.  Spasm  of  the  ciliary  muscle 
may  result  from  the  other  causes  of  irritation 
of  the  nerve-trunk,  or  from  excessive  efforts  at 
accommodation  in  hypermetropia.  Its  effect  is 
to  produce  a fixed  accommodation  for  near 
objects. 

Treatment. — The  treatment  of  the  central 
causes  of  overaction  of  the  third  nerve  commonly 
resolves  itself  into  that  of  the  primary  condition. 
Where  no  cause  is  obvious,  rest  is  most  impor 
tant,  and  efforts  at  accommodation  should  cease; 
tonics  and  counter-irritation,  and  sometimes  in- 
jections of  morphia,  may  be  employed.  Atropia 
will  overcome  spasm  of  the  sphincter  pupillm 
or  of  the  ciliary  muscle.  The  cold  douche  to  the 
eyeball  is  useful  in  spasmodic  lagophthalmos. 

2.  Paralysis. — ^Etiology. — The  commonest 
cause  of  paralysis  of  the  third  nerve  is  some 
affection  of  its  trunk  in  its  passage  through  the 
membranes  at  the  base  of  the  brain,  the  orbital 
fissure,  or  within  the  orbit ; due  either  to  rheu- 
matic inflammation  of  the  nerve-sheath,  or  to 
syphilitic  inflammation  of  the  nerve  or  mem- 
branes. Less  frequent  causes  are  diseases  of,  or 
adjacent  to,  the  inner  part  of  the  crus  cerebri 
through  which  the  fibres  pass  and  from  which 
they  emerge  (haemorrhage  or  softening  of  the 
crus,  aneurism  or  growth  in  the  interpeduncular 
space),  basilar  meningitis,  and  aneurism  of  the 
termination  of  the  internal  carotid.  It  is  also 
met  with  as  a result  of  diphtheria,  and  in  asso- 
ciation with  disease  of  the  spinal  cord,  especially 
locomotor  ataxy. 

Occasionally  all  the  muscles  supplied  by  the 
third  nerve  become  paralysed,  together  with  the 
other  orbital  muscles — the  ophthalmoplegia  ex- 
terna of  Hutchinson.  In  such  a case  the  writer 
has  found  a degeneration  of  the  nerve-cells  of 
the  nuclei  of  these  nerves. 

Symptoms. — Paralysis  may  affect  some  or  all 


1618  THIRD  NERVE,  DISEASES  OF. 
the  fibres  of  the  third  nerve.  When  complete  the 
upper  eyelid  is  dropped  and  cannot  be  raised, 
and  can  be  moved  only  outwards,  and  a little 
outwards  and  downwards  ; after  a short  time  it 
is  always  turned  outwards.  The  pupil  is  in  a 
mid-state  between  contraction  and  dilatation, 
and  cannot  be  made  to  contract  by  light ; power 
of  accommodation  in  the  eye  is  lost  by  paralysis 
of  the  ciliary  muscle.  Each  part  supplied  by  the 
nerve  may  be  paralysed  separately,  by  affection 
of  the  special  branch  of  the  nerve  after  it  leaves 
the  main  trunk.  When  the  levator  palpebrae 
superioris  is  affected,  ptosis  or  dropping  of  the 
eyelid  alone  results.  An  attempt  is  made  to 
raise  the  eyelid  by  excessive  contraction  of  the 
corresponding  half  of  the  occipito-frontalis. 
Double  ptosis  is  often  seen  in  elderly  persons, 
without  other  evidence  of  nerve-weakness. 

In  paralysis  of  one  of  the  three  straight 
muscles  supplied  by  the  third  nerve,  there  is 
strabismus,  with  defective  movement  in  the  direc- 
tion of  action  of  the  affected  muscle,  and  double 
vision,  the  distance  between  the  two  images  in- 
creasing as  the  object  is  moved  in  the  direction 
of  action  of  the  affected  muscle.  When  the  in- 
ternal rectus  is  paralysed,  slight  power  of  move- 
ment inwards  still  remains  from  the  superior  and 
inferior  recti.  There  is  divergent  strabismus 
and  crossed  diplopia ; when  looking  upwards  and 
inwards  the  images  approach  at  the  top,  when 
looking  downwards  and  inwards  they  approach 
at  the  bottom.  The  patient  carries  his  head 
turned  towards  the  side  of  the  affected  muscle, 
to  avoid  the  double  vision.  When  the  superior 
rectus  alone  is  paralysed,  the  movement  upwards 
of  the  affected  eye  is  diminished,  and  the  eye 
deviates  a little  outwards;  there  is  crossed  dip- 
lopia in  the  upper  half  of  the  visual  field,  the 
image  formed  by  the  affected  eye  being  higher 
than  the  other,  the  two  diverging  above,  the  dif- 
ference in  height  being  greater  in  looking  out- 
wards and  upwards,  while  the  difference  in 
obliquity  is  greater  on  looking  inwards  and  up- 
wards. When  the  inferior  rectus  only  is  affected 
there  is  defective  movement,  with  crossed  dip- 
lopia, on  looking  downwards.  The  second  image 
is  below  that  of  the  healthy  eye,  the  distance 
between  them  being  greatest  on  looking  down- 
wards and  a little  inwards.  The  images  are  not 
parallel,  but  diverge  at  the  bottom,  and  the 
difference  in  obliquity  increases  on  looking  in- 
wards and  downwards.  The  inferior  oblique  is 
very  rarely  affected  alone. 

In  paralysis  of  the  sphincter  pupill*  the 
elasticity  of  the  structure  maintains  the  pupil  at 
middle  size,  and  it  can  be  further  dilated  by 
atropia,  hut  all  power  of  contraction  beyond 
the  middle  size  is  lost.  When  the  ciliarymuscle 
is  paralysed,  the  power  of  accommodation  is 
lost.,  the  far  point  of  vision  remains  the  same, 
but  the  near  point  is  rendered  much  more 
distant. 

The  remarkable  loss  of  reflex  action  of  the 
iris  which  occurs  in  association  with  locomotor 
ataxy  is  usually  accompanied  by  myosis.  Not 
only  does  the  pupil  not  contract  on  exposure  to 
light,  hut,  if  small,  it  does  not  dilate  on  stimu- 
lation of  the  skin  (Erb).  The  associated  con- 
traction on  accommodation  is  usually  preserved 
t(ArgyH-Robertson).  Sometimes  this  is  lost,  and 


THIRST. 

the  ciliarymuscle  is  also  paralysed — the  ophthal- 
moplegia interna  of  Hutchinson.  These  symp- 
toms may  also  occur  in  cases  of  old  syphilis, 
apart  from  spinal  disease.  They  probably  de- 
pend on  localised  degeneration  in  the  nuclei  of 
the  third  nerve. 

Diagnosis. — Paralysis  of  the  third  nerve  is 
generally  obvious ; it  is  only  the  slighter  para- 
lyses of  separate  branches  supplying  the  ocular 
muscles  which  are  sometimes  not  easy  to  recog- 
nise ; and,  for  this  purpose,  a careful  exami- 
nation of  the  double  images  is  often  necessary. 
The  diagnosis  of  the  cause  is  less  easy.  Rheu- 
matic paralysis  succeeds  exposure  to  cold,  and 
is  often  attended  by  much  pain;  in  syphilis 
other  cranial  nerves  are  often  affected  indepen- 
dently ; in  meningeal  and  spinal  disease  there  are 
the  respective  distinctive  symptoms ; in  disease 
| of  the  crus  there  is  hemiplegia  of  the  opposite 
| side,  coincident  in  onset  with  the  affection  of  the 
third  nerve;  in  interpeduncular  disease  the  affec- 
tion of  the  third  nerve  may  precede  the  hemi- 
plegia, and  both  third  nerves  commonly  suffer. 
After  diphtheria  the  ciliary  muscle  is  usually 
alone  affected. 

Prognosis. — When  due  to  cold  or  to  recent 
syphilitic  mischief,  or  after  diphtheria,  the  prog- 
nosis is  good  if  proper  treatment  can  be  secured. 
In  cases  of  organic  cerebral  disease  it  is  less 
favourable,  and  is  subordinated  to  that  of  its 
cause.  In  association  with  spinal  disease  the 
ultimate  prognosis  is  unfavourable,  for,  although 
the  early  attacks  are  usually  recovered  from,  the 
affection  commonly  recurs. 

Treatment. — In  rheumatic  paralysis  from 
cold,  hot  fomentations,  counter-irritation  by 
blisters  to  the  temple,  small  doses  of  iodide  of 
potassium,  and  tonics  are  the  most  useful.  When 
of  syphilitic  origin  large  doses  of  iodide  of  potas- 
sium usually  suffice  to  effect  a cure.  If  associated 
with  spinal  mischief,  strychnia,  iron,  and  arsenic 
are  occasionally  of  some  service.  In  intracranial 
disease — tumour,  aneurism,  or  meningitis — the 
treatment  is  that  of  its  cause.  After  diphtheria 
tonics  are  alone  necessary.  In  paralysis  of 
the  sphincter  pupillse  and  ciliary  muscle,  occa- 
sional instillation  of  a small  quantity  of  Cala- 
bar bean,  by  stimulating  locally  the  paralysed 
fibres,  does  good,  and  has  been  said  to  be  bene- 
ficial in  affections  of  other  branches  of  the  nerve. 
In  the  paralysis  of  the  ocular  muscles  electricity 
is  sometimes  of  use,  applied  through  the  eyelid  to 
the  affected  muscle,  small  electrodes  being  used, 
and  the  eye  so  turned  as  to  bring  the  muscle  as 
much  as  possible  within  reach.  One  electrode  may 
he  placed  on  the  muscle,  the  other  on  some  indif- 
ferent part  or  on  the  temple,  or  both  electrodes 
may  be  placed  over  the  muscle.  The  voltaic 
current  slowly  interrupted  is  the  more  useful; 
the  negative  pole  should  be  placed  on  the  muscle, 
the  positive  on  the  temple.  Faradisation  is  of 
less  service;  the  feeble  strength  which  alone  can 
he  used  is,  so  to  speak,  absorbed  by  the  orbicu- 
laris. The  application  of  the  continuons  current 
in  the  neighbourhood  of  the  orbit  sometimes 
produces  slight  temporary  improvement. 

W.  R.  Gowers. 

THIRST.— Synox.  : Fr.  Soif;  Ger.  Durst.— 
Thirst  is  a sensation  indicating  a neceseifj  on 


THIRST. 

the  part  of  tho  system  for  an  increased  supply  of 
water,  as  appetite  shows  there  is  a need  for  the 
introduction  of  food.  Although  the  sensation  is 
referred  to  the  back  of  the  throat,  it  is  not  a 
purely  local  feeling,  as  is  proved  by  the  fact, 
well-known  to  physiologists,  that  it  cannot  be 
allayed  by  the  swallowing  of  water,  unless  the 
fluid  reach  the  stomach  and  be  absorbed.  It  is 
always  present  in  febrile  disorders,  an  increased 
supply  of  liquid  being  required  both  to  reduce 
the  heat,  by  promoting  the  evaporation  of  mois- 
ture from  the  skin  and  lungs,  and  also  to  wash 
away  the  products  of  the  increased  tissue-changes 
that  accompany  these  complaints.  In  like  man- 
ner it  is  always  present  when  much  fluid  has 
been  abstracted  from  the  system ; thus,  it  shows 
itself  after  all  surgical  operations  attended  by 
haemorrhage.  It  is  a prominent  symptom  in 
cholera  and  diarrhoea,  in  which  diseases  large 
quantities  of  serum  are  rapidly  removed  from 
the  gastro-intestinal  circulation,  and  it  is  equally 
so  in  diabetes,  where  fluid  is  largely  excreted 
along  with  sugar  by  the  urinary  organs.  A crav- 
ing for  cold  and  acid  drinks  presents  itself  in 
acute  gastritis,  the  intensity  of  the  thirst  being 
perhaps  due  to  the  incessant  vomiting,  which 
prevents  fluids  remaining  long  enough  in  the 
stomach  to  be  absorbed.  In  chronic  gastritis 
thirst  is  usually  present,  and  is  chiefly  com- 
plained of  towards  evening.  It  forms  a useful 
diagnostic  sign  where  there  is  a difficulty  in  dis- 
tinguishing between  this  disease  and  mere  atonic 
dyspepsia. 

Treatment. — Thirst  is  relieved  by  the  agents 
usually  recognised  as  refrigerants,  such  as  water, 
barley-water,  toast  and  water,  and  similar  drinks  ; 
sucking  small  pieces  of  ice ; effervescing  drinks ; 
freely  diluted  acid  drinks,  especially  those  made 
with  vegetable  acids  or  phosphoric  acid,  alone 
or  combined  with  a little  aromatic  bitter ; the 
juices  of  fruits,  or  these  made  into  drinks.  Care 
has  often  to  be  exercised  in  the  employment  of 
these  apparently  harmless  agents,  and  their  con- 
sumption has  to  be  checked,  otherwise  patients 
will  take  them  to  excess,  and  may  thus  do  them- 
selves considerable  injury. 

Samuel  Eenwicr. 

THORACENTESIS  (0<$paj,  the  chest,  and 
kcvtIu,  I prick). — A synonym  for  paracentesis 
thoracis,  or  tapping  of  the  chest.  See  Paracen- 
tesis ; and  Pleura,  Diseases  of. 

THORACIC  ANEURISM.- Under  this 
head  are  included  aneurisms  of  (A)  the  intra- 
thoracic  aorta  ; (B)  the  arteria  innominata ; 
(C)  the  pulmonary  artery ; (D)  the  coronary 
arteries ; and  (E)  the  heart.  The  last  two 
forms  have  been  fully  treated  of  under  their  re- 
spective articles,  and  will  not  be  further  referred 
to  here.  See  Coronary  Arteries,  Diseases  of ; 
and  Heart,  Aneurism  of. 

A.  Aneurism  of  the  Intr a- Thoracic  Aorta. 
This  may  be  most  conveniently  discussed  in  its 
clinical  aspects  under  two  heads,  namely,  (1) 
aneurism  of  the  arch , and  (2)  aneurism  of  the 
descending  thoracic  aorta  ; whilst  the  former  may 
be  subdivided  into  aneurism  of  (a)  the  ascending, 

( b ) the  transverse,  and  (c)  the  descending  portion. 

Relative  frequency. — Of  seventy-six  cases 


THORACIC  ANEURISM.  1819 
analysed  by  the  writer,  including  fourteen 
treated  by  himself,  the  seat  of  aneurism,  single 
or  multiple,  stated  in  the  order  of  relative  fre- 
quency, was  as  follows : — Single : ascending  por- 
tion of  arch,  thirty;  transverse  portion,  seventeen ; 
descending  thoracic  aorta,  ten;  ascending  and 
transverse  portions  of  arch,  nine;  transverse  and 
descending  portions,  two ; entire  arch,  two;  de- 
scending portion,  one;  thoracico-abdominal  aorta, 
one.  Multiple : ascending  portion  of  arch  and 
descending  thoracic  aorta,  two;  ascending  por- 
tion of  arch  and  abdominal  aorta,  two. 

(1)  Aneurism  of  the  Arch. — The  different 
parts  of  the  arch  of  the  aorta  must  be  consi- 
dered separately. 

(a)  Ascending  yiorfion.-Aneurisms  arising  from 
one  of  the  sinuses  of  Valsalva,  within  the  range 
of  the  valves,  rarely  attain  a size  larger  than 
that  of  a billiard-ball.  They  are  saccular  and 
not  unfrequently  pedunculated,  communicating 
with  the  aorta  by  a small  orifice.  They  further 
exhibit  a remarkable  tendency  to  descend  in  the 
progress  of  growth,  involving  in  their  course  the 
heart  or  the  root  of  the  pulmonary  artery.  By 
their  position  they  are  sheltered  from  direct  in- 
flux from  the  ventricle,  whilst  they  are  exposed 
to  the  maximum  force  of  reflux  from  the  aorta. 
"When,  however,  the  orifice  is  partially  or  entirely 
above  the  level  of  the  valves,  the  main  pressure 
sustained  by  the  sac  is  that  of  efflux  from  tlm 
ventricle ; hence  the  direction  of  growth  is  up- 
wards. Aneurism  of  the  portion  of  the  vessel 
immediately  above  the  level  of  the  valves  is 
especially  prone  to  advance  towards  the  right 
side,  forming  a tumour  visibly  projecting,  or 
detectable  by  palpation  and  percussion,  in  the 
vicinity  of  the  right  nipple.  It  may  be  fusi- 
form or  saccular,  true  or  false ; it  usually  at- 
tains a large  size  ; and,  when  fusiform,  not  un- 
frequently extends  over  a great  portion,  or  even 
the  whole  of  the  arch.  The  direction  of  growth 
may,  however,  be  backwards  or  to  either  side  ; 
the  aneurism  in  its  progress  implicating  the 
oesophagus,  the  pulmonary  artery  or  one  of  its 
branches,  the  superior  vena  cava,  or  either  auri- 
cle ; it  is  in  such  cases  usually  saccular,  and  of 
comparatively  small  size.  Aneurisms  of  the 
extra-pericardial  portion  of  the  ascending  aorta 
usually  tend  forwards  and  upwards  iu  the  line 
of  main  blood-pressure,  projecting  at  the  right 
margin  of  the  sternum  above  the  fourth  costal 
cartilage,  and  occasionallylikewise  into  the  root  of 
the  neck,  involving  the  arteria  innominata.  They 
may,  however,  grow  backwards  and  to  the  right, 
implicating  the  right  bronchus  or  lung,  or  the 
superior  cava  ; directly  backwards,  pressing  upon 
the  oesophagus  or  the  bifurcation  of  the  trachea; 
or,  projecting  mainly  towards  the  left  side,  they 
may  involve  the  left  branch  of  the  pulmonary 
artery,  and  the  left  bronchus  or  lung. 

Symptoms  and  Signs.  — - Aneurism  of  the 
sinuses  is  rarely  attended  with  very  definite 
symptoms;  indeed  only  when  it  presents  at  the 
anterior  wall  of  the  chest. 

Owing  to  its  position  within  the  pericardium, 
and  its  close  proximity  to  the  heart,  the  symp- 
toms produced  by  aneurism  in  this  situation  mav 
be  readily  confounded  with  structural  or  valvular 
disease  of  the  heart  itself.  The  acoustic  signs  are, 
for  the  purposes  of  diagnosis,  no  less  indefinite  • 


1620  THORACIC 

because,  from  the  position  of  the  aneurism  close 
to  the  orifice  of  the  aorta,  a murmur  produced  by 
it,  whether  of  influx  or  of  efflux,  may  be  easily 
mistaken  for  one  of  the  same  rhythm  caused  by 
obstruction  or  inadequacy  of  the  valves.  The 
difficulty  of  diagnosis  is  further  increased  by  the 
usual  co-existence  of  atheroma  with  dilatation  of 
the  first  portion  of  the  aorta,  relative  incompe- 
tency of  the  valves,  and  dilated  hypertrophy  of 
the  left  ventricle.  The  ordinary  symptoms  are 
those  of  palpitation  and  derangement  of  the 
rhythm  of  the  heart,  from  affection  of  the  car- 
diac plexus.  But  the  diseases  just  mentioned 
may,  in  the  absence  of  aneurism,  give  rise  to 
similar  phenomena.  The  existence  of  venous 
stasis  and  congestion  of  the  upper  half  of  the 
body,  viewed  in  conjunction  with  tumultuous  and 
irregular  action  of  the  heart,  and  in  the  absence 
of  discoverable  cause  of  venous  obstruction  at  a 
higher  point  in  the  chest,  would,  however,  war- 
rant the  presumptive  diagnosis  of  aneurism  at 
the  root  of  the  aorta,  implicating  the  right  auri- 
cle or  the  termination  of  the  superior  cava  ; and 
if  with  these  symptoms  were  associated  systolic 
murmur  at  the  base,  not  transmitted  in  the  course 
of  the  aorta,  or  a double  murmur,  a positive 
diagnosis  to  the  above  effect  might  be  made. 
Were  the  diastolic  murmur  preceded  by  a distinct 
second  sound,  valvular  inadequacy  from  dilata- 
tion of  the  aorta,  without  valvular  disease, 
would  be  thereby  indicated,  and  the  diagnosis  of 
aneurism  pro  tanto  sustained.  Symptoms  of  ob- 
struction of  both  cavae,  namely,  general  venous 
congestion,  and  engorgement  of  the  liver,  would 
in  the  foregoing  connection  justify  the  special 
diagnosis  of  pressure  upon  the  sinus  of  the  right 
auricle.  The  symptoms  of  pressure  upon  the 
other  chambers  of  the  heart  are  those  only  of 
doranged  rhythm  and  circulation,  such  as  may 
be  due  to  various  causes  inherent  in  the  heart. 
Systolic  murmur  in  the  pulmonary  artery  may 
result  from  the  pressure  of  an  aneurism  on  the 
root  of  that  vessel.  Communication  of  an  aneu- 
rism with  one  of  the  chambers  of  the  heart  is 
usually  effected  by  an  aperture  not  more  than  two 
to  three  lines  in  diameter.  It  is  the  result  of 
progressive  absorption,  and  the  symptoms  are 
scarcely  to  be  distinguished  from  those  of  ante- 
cedent pressure.  The  physical  signs  are  more 
characteristic ; they  consist  in  a loud  murmur, 
systolic  or  diastolic,  of  a ‘booming’  or  ‘splashing’ 
character,  accompanied  by  thrill,  traceable  from 
the  root  of  the  aorta  in  the  direction  of  abnormal 
influx,  and  not  transmitted  in  any  of  the  ordi- 
nary lines  of  valvular  murmur.  If  two  murmurs 
exist,  they  are  fused  or  converted  into  a con- 
tinuous rumble.  Sudden  transfer  of  the  seat  of 
greatest  intensity  of  such  a murmur,  from  the 
aortic  area  to  some  other  point  of  the  precordia, 
would  be  conclusive,  not  only  as  to  the  irruption 
of  an  aneurism  into  one  of  the  chambers  of  the 
heart,  but  likewise  as  to  the  date  of  its  occur- 
rence. 

Aneurism  of  the  ascending  aorta,  external  to 
the  pericardium,  is  occasionally  latent,  but  ordi- 
narily it  is  characterised  by  very  definite  symp- 
toms and  signs.  A large  fusiform  aneurism  of 
this  portion  of  the  vessel,  or  engaging  the  en- 
tire arch,  equally  expanded,  not  in  contact  with 
the  anterior  thoracic  wall  or  pressing  inconve- 


ANEURISM. 

niently  upon  any  of  the  adjacent  organs,  may  he 
virtually  latent ; exhibiting  no  symptom  of  aneu- 
rism except  vague  neuralgic  pains  darting  over  the 
chest,  shoulders,  arms,  and  back,  and  no  sign  but 
exaggerated  double  sound.  Pointing  externally, 
or  in  persistent  contact  with  the  chest-wall,  an 
aneurism  may  be  readily  identified  by  the  cir- 
cumstance that  it  presents  a second  centre  of 
pulsation  and  sound.  The  ordinary  pulsation 
is  systolic,  expansile,  and  diffused  (though  not 
always  equally)  over  the  entire  surface  ; but  a 
second  and  minor  impulse  of  diastolic  rhythm 
may  likewise  exist.  The  former  is  in  many  cases 
accompanied  by  tactile  thrill.  The  acoustic  signs 
consist  either  in  two  sharp  accentuated  sounds, 
nearly  alike  in  character,  and  corresponding  in 
rhythm  to  those  of  the  heart ; or  in  a single  or 
double  murmur  of  blowing  or  ‘ booming’  quality. 
There  is  likewise  absolute  dulness,  with  suppres- 
sion of  respiratory  sounds  and  of  vocal  fremitus, 
to  the  extent  of  the  tumour. 

Pressure  upon  the  superior  cava  is  character- 
ised by  venous  congestion,  limited  to  the  upper 
half  of  the  body : whilst  actual  communication 
with  that  vessel  is  evinced  by  cyanosis  to  the  same 
extent ; extreme  engorgement  with  pulsation  of  the 
jugular  veins  ; a buzzing  systolic  murmur,  with 
intense  thrill,  at  the  seat  of  communication  and 
transmitted  into  the  veins  of  the  neck.  Accord- 
ing to  Dr.  Mahomed,  in  cases  of  arterio-venous 
aneurism  inspiration  alters  the  markings  of  the 
sphygmograph,  by  diminishing  the  volume  of 
blood  in  the  artery.  Pressure  upon  the  main 
bronchus  is  indicated  by  diminished  or  suppressed 
respiration,  with  normal  percussion-sound,  in  the 
correspondinglung;and  occasionally  by  ‘whiffing’ 
or  ‘jerking  ’ inspiratory  sound.  Diminished  re- 
spiration throughput  either  lung,  with  inequality 
as  between  its  upper  and  lower  portions,  would 
indicate  pressure,  but  unequal  in  degree,  upon 
the  primary  bronchus  and  its  superior  secondary 
branch ; whilst  partial  or  complete  suppression 
confined  to  the  upper  lobe  would  show  that  the 
superior  lobular  branch  was  alone  implicated. 
Passive  pneumonia,  from  occlusion  of  the  pulmo- 
nary vessels,  is  a frequent  result  of  the  pressure  of 
an  aneurism  upon  the  bronchi.  It  is  worthy  of 
notice  that  consolidation  of  lung-substance  so  pro- 
duced is  especially  characterised  by  the  absence 
of  vocal  fremitus.  Bronchitis  may  likewise  arise 
from  mechanical  irritation ; and  where  present 
may,  in  greater  or  less  degree,  mask  the  physical 
signs  of  aneurism.  The  sudden  irruption  of  an 
aneurism  into  one  of  the  bronchi  is  indicated 
by  copious  discharge  of  florid  blood  from  the 
mouth  and  nostrils,  and  is  instantly  fatal  by 
syncope  or  asphyxia.  An  opening  established 
into  the  pulmonary  substance  is  followed  by 
‘leakage’  of  blood,  or  repeated  but  limited 
haemoptysis.  Pressure  upon  the  pulmonary 
artery  is  necessarily  attended  with  engorgement 
of  the  right  chambers  of  the  heart,  and  general 
venous  congestion  ; and  the  establishment  of  an 
opening  into  that  vessel,  with  sudden  and  urgent 
dyspnoea  without  spasm  or  stridor,  extreme  con- 
gestion of  the  lung,  and  haemoptysis.  Death  is 
rapid  in  such  cases  ; but  should  an  opportunity 
for  physical  exploration  be  afforded,  a 1 buzzing' 
systolic  hum  might  be  detected  in  the  second  and 
third  left  intercostal  spaces,  close  to  the  sternum 


THORACIC  ANEURISM. 


Pressure  upon  the  oesophagus  is  indicated  by  dys- 
phagia, referred  by  the  patient  to  a corresponding 
point  of  the  chest.  Dysphagia  due  to  the  pres- 
sure of  an  aneurism  is  remittent,  and  varies  in 
some  degree  with  posture — traits  by  which  it  is 
distinguished  from  that  produced  by  cancer. 
Dysphagia  from  volvulus  of  the  oesophagus  may, 
ncwever,  exhibit  similar  variations. 

(6)  Transverse  'portion.—  Aneurisms  of  this 
Dortion  of  the  aorta  are  usually  fusiform : they 
involve  mainly  its  anterior  and  superior  wall, 
pushing  forward  the  upper  end  of  the  sternum, 
projecting  into  the  neck,  compressing  the  left 
innominate  vein,  and  modifying,  in  many  eases, 
the  circulation  in  the  primary  arteries  and  their 
branches.  They  likewise  frequently  press  back- 
wards upon  the  oesophagus  and  trachea,  the 
pneumogastric  or  sympathetic  of  either  side,  or 
the  left  recurrent  nerve.  Owing  to  the  back- 
ward courso  of  the  left  extremity  of  the  arch, 
aneurisms  arising  from  this  portion  of  the  vessel 
rarely  appear  in  front.  They  project  above  the 
left  clavicle,  involving  the  innominate  vein,  the 
pneumogastric,  sympathetic,  or  recurrent  nerve 
of  the  left  side,  and  occasionally  all  three ; or 
posteriorly  in  the  left  scapular  region. 

Symptoms  and  Signs. — Pressure  upon  the  left 
innominate  vein  is  accompanied  by  visible  en- 
gorgement of  the  thyroid,  left  jugular,  subcla- 
vian, brachial,  and  superficial  thoracic  veins  and 
their  tributaries,  with  cedema  of  the  left  arm. 
The  circulation  in  the  carotid  or  subclavian  artery 
of  one  side  is  often  diminished  or  suppressed  by 
the  lateral  pressure  of  an  aneurism,  or  by  clot- 
formation  in  the  sac.  Pressure  upon  the  trachea 
is  indicated  by  clanging  or  metallic  cough,  and 
stridor  ‘ from  below,’  that  is,  loudest  at  the  upper 
part  of  the  sternum,  and  distinctly  audible  over 
the  lower  cervical  and  upper  dorsal  vertebrae. 
The  symptoms  of  aneurismal  pressure  upon  the 
sympathetic,  pneumogastric,  and  recurrent  nerves 
are  most  frequently  exhibited  on  the  left  side 
only.  Thosi?  due  to  implication  of  the  sympa- 
thetic or  its  cilio-motor  roots  are  manifested  in 
the  pupil  on  the  affected  side.  They  consist  in 
dilatation  or  contraction  of  the  pupil  according 
to  the  degree  of  pressure ; the  former  from  irri- 
tation, and  the  latter,  which  is  the  more  usual 
phenomenon,  from  paresis  of  the  nerve.  Laryn- 
geal stridor,  huskiness  or  loss  of  voice,  and  harsh 
metallic  cough,  in  the  absence  of  local  disease  of 
the  larynx,  are  eminently  diagnostic  of  pressure 
upon  either  recurrent  nerve.  By  means  of  the 
laryngoscope  the  vocal  cord  on  the  side  of  disease, 
and  in  rare  cases  the  cords  on  both  sides,  are 
seen  to  be  fixed  during  breathing  and  vocalisation, 
from  unilateral  or  bilateral  paralysis  of  the  ab- 
ductor muscles  of  the  larynx.  Dr.  George  John- 
son holds  that  unilateral  paralysis  is  distinguished 
by  slight  huskiness  of  voice,  with  stridor  on  full 
inspiration;  and  bilateral  paralysis,  by  permanent 
dyspnoea  and  stridor.  Paroxysmal  dyspnoea  or 
fatal  asphyxia  may  result  from  collapse  of  the 
arytaenoid  cartilages  in  such  cases.  Pressure  upon 
either  'pneumogastric  is  especially  characterised 
by  paroxysms  of  remittent  spasm  of  the  glottis, 
which  may  be  suddenly  fatal ; but,  where  the 
recurrent  nerve  is  not  likewise  implicated,  persis- 
tent stridulous  breathing,  aphonia,  and  metallic 
eough  are  not  exhibited.  The  writer  has  oeca- 


1021 

sionally  witnessed  urgent  laryngeal  and  bronchial 
spasm  from  the  pressure  of  an  aneurism,  engag- 
ing the  root  of  the  lung,  upon  the  pulmonic 
plexus  exclusively. 

The  physical  signs  are  identical  with  those 
already  described  in  connection  with  aneurism  of 
the  ascending  portion  of  the  vessel. 

(c)  Descending  portion. — Aneurism  of  the  left 
curvature  and  descending  portion  of  the  arch 
involves  the.  left  recurrent  nerve  in  nearly  every 
instance.  In  the  progress  of  growth  it  passes 
into  the  root  of  the  neck ; backwards  towards 
the  left  scapula  ; or  backwards  and  outwards 
into  the  substance  of  the  lung. 

Symptoms  and  Signs. — These  include  symp- 
toms of  pressure  upon  the  recurrent  or  pneumo- 
gastric nerve,  as  well  as  the  subclavian  or  inter- 
nal jugular  vein  ; a pulsating  tumour  in  the  left 
interscapular  space,  which  may  attain  very  large 
proportions  ; and  signs  of  congestion  and  consoli- 
dation of  the  upper  and  back  part  of  the  left 
lung.  In  the  last  case  the  aneurism,  being 
involved  in  the  pulmonary  structure,  may  afford 
no  specific  evidence  of  its  existence. 

The  physical  signs  differ  in  no  respect  from 
those  which  characterise  aneurism  of  the  other 
portions  of  the  arch. 

(2)  Descending  Aorta. — Aneurisms  of  the 
upper  portion  of  this  division  of  the  vessel  rarely 
attain  a large  size.  They  maj'pass  upwards  and 
to  the  right  side,  implicating  the  trachea  and 
oesophagus ; or  directly  to  the  right,  stretching 
the  oesophagus  or  thoracic  duct,  and  ultimately 
opening  into  one  of  them,  or  into  the  right  pleura. 
In  a case  which  came  under  the  writer's  notice, 
the  trachea  and  the  oesophagus  were  simultane- 
ously perforated,  and  death  occurred  by  luemor- 
rhage  into  both.  The  aneurism  may  advance  to 
the  left,  and  ultimately  prove  fatal  by  rupturo 
into  the  left  pleural  cavity ; it  may  erode  the 
vertebrae  and  ribs,  and  point  in  the  left  infra- 
scapular region  ; or  it  may  advance  towards  the 
anterior  wall  of  the  chest,  displacing  the  heart, 
and  involving  itself  in  the  substance  of  the  left 
lung.  Aneurism  of  the  lower  part  of  the  vessel 
usually  extends  into  the  abdomen,  constituting 
the  thoracico-abdominal  form  of  the  disease.  It 
may  displace  the  heart  forwards,  and  the  liver 
downwards;  it  may  likewise  extend  backwards, 
eroding  the  vertebrae,  and  pointing  in  the  lower 
dorsal  or  the  lumbar  region  on  the  left  side. 
Finally,  an  aneurism  in  this  situation  may  prove 
fatal  by  simultaneous  hajmorrhage  into  the  left 
pleural  cavity  and  left  retro-peritoneal  space,  or 
into  the  vertebral  canal. 

Symptoms  and  Signs. — To  what  has  been  al- 
ready stated  on  this  subject  it  is  only  necessary 
to  add,  that  progressive  absorption  of  the  ver- 
tebrae is  indicated  by  fixed  and  boring  pain  re- 
ferred to  a particular  point  of  the  vertebral 
column,  which  is  tender  to  pressure,  and  whence 
not  unfrequently  radiating  or  ‘ nipping  ’ pains 
extend  round  the  chest.  Forward  displacement 
of  the  heart  by  an  aneurism  would  be  charac- 
terized by  violent  impulse,  simulating  that  of 
cardiac  hypertrophy  (the  distinction  would  rest 
upon  the  presence  of  the  special  symptoms  and 
signs  of  aneurism) ; a remarkable  derangement 
of  cardiac  impulse,  constituting  the  ‘double  jog’ 
of  Hope ; with  absence  of  the  positive  signs  of 


1622  THORACIC 

hypertrophy.  Pressure  upon  the  thoracic  duct  is 
very  rare ; it  would  he  indicated  by  the  symp- 
toms of  mat-assimilation,  wasting,  and  inanition, 
— symptoms  which  are  foreign  to  aneurism  under 
its  ordinary  forms. 

The  physical  signs  of  aneurism  of  the  de- 
scending thoracic  aorta  are  ordinarily  limited  to 
a sharp  sound,  single  or  double,  audible  over  the 
dorsal  vertebrae  and  somewhat  to  the  left ; and, 
more  rarely,  perceptible  impulse.  The  existence 
of  murmur  is  exceptional ; when  present,  murmur 
i3  all  but  invariably  single  and  post-systolic, 
and  is  inaudible  in  the  erect  posture. 

Duration-  and  Terminations. — The  duration 
of  aneurism  of  the  intra-thoracic  aorta  may 
vary  from  a few  days  to  several  years.  Death 
is  most  frequently  caused  by  rupture  of  the  sac 
into  various  parts ; or  by  gradual  exhaustion 
from  insomnia  and  inanition.  Of  seventy-one 
cases  of  aneurism  in  this  situation  tabulated  by 
the  writer,  including  twelve  observed  by  him- 
self, twenty-six  were  fatal  by  rupture  of  the  sac ; 
namely,  into  the  pericardium  ten — all  being 
aneurisms  of  the  ascending  aorta;  into  the  left 
lung  or  pleura  five — four  being  of  the  transverse, 
and  one  of  the  descending  thoracic  aorta  ; into 
the  trachea  four — three  of  the  transverse,  and 
one  of  the  ascending  aorta;  into  the  right  lung 
or  pleura  three — two  of  the  ascending,  and  one 
of  the  descending  thoracic  aorta;  into  the  left 
bronchus  or  oesophagus  three — two  of  the  de- 
scending thoracic,  and  one  of  the  transverse 
aorta  (in  one  of  these  an  opening  existed  both 
into. the  left  bronchus  and  the  oesophagus) ; ex- 
ternally one — the  aneurism  having  arisen  from 
the  transverse  aorta.  Death  may  also  result 
from  asphyxia,  intercurrent  inflammation  of  the 
lungs  or  pleura,  or  from  coma. 

B.  Aneurism  of  the  Arteria  Innominata. 
Aneurism  involving  the  innominate  artery  may 
be  mistaken  for  aneurism  of  the  aorta,  at  or 
near  the  first  curve  of  the  arch. 

Symptoms  and  Signs. — Those  which  are  most 
distinctive  of  innominate  aneurism  are  the  early 
appearance  of  pulsating  tumour  above  the  right 
clavicle,  accompanied  by  arterial  obstruction  on 
the  right  side;  displacement  of  the  trachea  and 
larynx  to  the  left ; and  pulsation  with  sound, 
localized  at  the  right  sternoclavicular  joint  and 
immediately  above.  Diminished  circulation  in 
the  right  carotid  and  subclavian  arteries  at  an 
early  period  of  the  disease,  and  the  reduction  or 
arrest  of  pulsation  in  the  sac  by  digital  pressure 
upon  these  vessels,  afford  the  most  constant  and 
least  equivocal  evidence  of  innominate  aneurism. 
The  early  occurrence  of  neuralgic  pains  in  the 
right  side  of  the  neck,  the  right  shoulder  and 
ear,  followed  by  oedema  and  partial  paralysis  of 
the  right  arm,  are  likewise  suggestive  of  inno- 
minate, as  distinguished  from  aortic  aneurism. 
The  symptoms  of  nerve-pressure  on  the  right 
side,  as  exhibited  in  the  larnyx  and  pupil,  are 
usually  well-pronounced  in  this  disease.  Tho 
physical  signs  are  in  no  respect  different  from 
those  of  aneurism  of  the  arch.  Concurrent  im- 
plication of  the  aorta  is  ordinarily  determined 
with  tho  greatest  difficulty,  and  occasionally  a 
positive  diagnosis  in  this  respect  cannot  be 
made.  If  pulsation  and  sound  of  maximum 
intensity  exist  at  the  level  of  the  second  costal 


ANEURISM. 

cartilage,  or  an  inch  auda-half  below  the  sternal 
end  of  the  clavicle,  whilst  the  pulse-tracing  of 
the  right  radial  artery  exhibits  imperfect  aneu- 
rismal  characters,  the  aorta  may  be  considered 
as  involved  in  the  disease. 

C.  Aneurism,  of  the  Pulmonary  Artery. 
Aneurism  of  the  main  trunk  or  primary  branches 
of  the  pulmonary  artery  is  unknown  ; but  aneu- 
rism and  ectasia  of  the  secondary  and  subse- 
quent branches  have  been  repeatedly  found  in 
connection  with  cavities  in  the  lungs,  and  aro 
recognised  as  the  ordinary  source  of  fatal  haemo- 
ptysis in  the  third  stage  of  phthisis.  Cavities 
confined  to  one  lung  with  walls  condensed  by 
fibroid  growth,  and  either  stationary  or  in  pro- 
cess of  secondary  ulceration,  are  those  which  are 
most  favourable  to  the  formation  of  pulmonary 
aneurism  or  ectasia.  In  the  walls  or  trabeculae 
of  such  cavities  the  branches  of  the  pulmonary 
artery  remain  pervious;  their  coats,  already 
thickened  by  chronic  inflammation,  and  weak- 
ened by  degenerative  changes,  expand  under  vas- 
cular pressure,  where  least  supported,  and  form 
an  aneurism,  globular,  fusiform,  or  semi-fusi- 
form, according  to  the  extent  and  degree  of  their 
structural  change  and  denudation,  or  a simple 
ectasia.  These  ultimately  give  way  by  rupture  or 
erosion,  and  severe  haemorrhage  into  the  cavity 
and  connected  bronchia  is  the  immediate  result. 
Active  ulceration  of  an  existing  cavity  is  usually 
attended  with  partial  thrombosis  of  adjacent 
vessels.  Hence,  in  such  cases  haemoptysis  is 
seldom  copious,  and  death  results  from  ex- 
haustion produced  by  repeated  small  haemor- 
rhages. In  the  process  of  primary  and  active 
excavation  of  lung-tissue  the  vessels  are  com- 
pletely blocked,  and  haemoptysis,  even  to  a small 
amount,  is  exceptional.  See  Haemoptysis. 

Symptoms  and  Signs. — Of  a special  kind  there 
are  absolutely  none.  Copious  haemoptysis  iD 
connection  with  cavity  would  be  eminently 
suggestive  of  pulmonary  aneurism.  Of  twelve 
cases  of  fatal  haemoptysis  in  the  third  stage  of 
phthisis,  tabulated  by  Dr.  Douglas  Powell,  a 
ruptured  aneurism  or  ectasia  of  a pulmonary 
branch  was  found  to  be  the  source  of  haemor- 
rhage in  eleven  instances. 

Treatment. — The  treatment  of  aneurism  will 
be  found  described  in  the  articles  Abdomixai 
Aneurism;  and  Aorta,  Diseases  of.  The  cura- 
tive treatment  of  aortic  or  innominate  aneurism 
should  be  directed  to  the  single  object  of  effect- 
ing consolidation  of  the  contents  of  the  sac. 
With  this  object  in  view  three  methods  have 
been  pursued,  either  separately  or  conjointly, 
namely,  the  'postural  and  dietetic ; the  medicinal ; 
and  the  surgical.  As  complemental  of  the  first 
plan  of  treatment  of  thoracic  aneurism,  an  occa- 
sional blood-letting  by  venesection,  to  the  amount 
of  eight  to  ten  ounces,  for  the  purpose  of  reducing 
arterial  tension  or  venous  engorgement,  may  be 
demanded.  With  a view  to  causing  or  promot- 
ing deposition  of  fibrin  in  the  sac  several  agents 
have  been  used,  namely,  acetate  of  lead,  in  doses 
of  four  to  eight  grains;  iodide  of  potassium, 
ten  to  thirty  grains ; and  aconite,  fivo  minims 
of  the  tincture  thrice  daily.  Ergotin  has  been 
used  hypodermically  by  Lungenbeck.  Each  of 
these  agents  has  been  credited  with  success  in 
the  treatment  of  aneurism.  But,  as  spontanecuj 


THORACIC  ANEURISM. 

cure  has  been  occasionally  -witnessed  under 
favourable  circumstances  as  to  diet  and  rest, 
where  no  medicine  had  been  given,  a more  than 
promotive  influence,  by  retarding  the  circulation 
and  reducing  vascular  pressure,  can  scarcely  be 
assigned  to  the  medicine  used,  where  rest  and 
restricted  diet  have  been  observed.  Galvano- 
puncture  of  the  sac  has  been  practised  with 
success.  Deligation  of  the  common  carotid  artery, 
or  of  that  vessel  and  the  subclavian,  may  be 
followed  by  the  most  favourable  result,  in  cases 
where  pressure  upon  these  vessels  has  been 
found  to  control  pulsation  in  the  sac.  For 
details  of  the  surgical  treatment  see  Aneurism:. 

The  'palliative  treatment  of  thoracic  aneurism 
is  discussed  in  the  article  Aorta,  Diseases  of. 
A few  leeches  applied  from  time  to  time  in  the 
vicinity  of  the  sac,  or  a hypodermic  injection  of 
morphia,  will  relieve  the  pain  and  repress  the 
inflammation  caused  by  excentric  pressure. 

Thomas  IIayden. 

THORACIC  DUCT,  Diseases  of. — Synon. 
Fr.  Maladies  du,  Canal  tlioraciqve ; Ger.  Krank- 
lieiten  dcs  Cactus  thoracicus. — The  thoracic  duct 
is  the  main  trunk  belonging  to  the  absorbent 
system,  by  means  of  which  the  chyle  from 
the  lacteals,  and  the  lymph  from  the  lym- 
phatics (except  that  from  the  right  side  of  the 
chest,  neck,  and  head,  and  the  right  arm),  are 
conveyed  into  the  circulatory  system,  so  that 
these  fluids  may  be  mixed  with  the  blood.  It 
starts  from  the  receptaculum  chyli,  deep  in  the 
upper  part  of  the  abdominal  cavity ; passes 
through  the  aortic  opening  of  the  diaphragm, 
on  the  right  of  the  aorta ; accompanies  this 
vessel  along  the  thoracic  cavity  ; passes  beneath 
its  arch  and  the  left  subclavian  artery;  then 
along  the  left  side  of  the  oesophagus ; and,  finally, 
comes  forward  in  the  neck  from  behind  the  left 
carotid  artery,  arching  over  the  subclavian  artery, 
and  crossing  the  phrenic  nerve  and  anterior 
scalenus  muscle,  to  open  usually  into  the  left 
subclavian  vein,  near  its  junction  with  the  in- 
ternal jugular.  It  is  requisite  to  remember  these 
facts  respecting  the  course  and  anatomical  rela- 
tions of  the  thoracic  duct,  in  order  to  understand 
how  its  chief  morbid  conditions  are  produced. 

The  diseases  of  the  thoracic  duct  resemble 
those  of  the  absorbent  vessels  generally  ( see  Lym- 
phatic System,  Diseases  of) ; and  it  will  suffice 
to  indicate  here  the  following  practical  points : — 

1.  The  passage  of  fluid  along  the  duct,  and  its 
escape  into  the  subclavian  vein  may  be  impeded 
by  any  condition  which  interferes  seriously  with 
the  venous  circulation,  and  distends  the  veins 
considerably,  such  as  certain  cardiac  diseases. 

2.  Local  obstruction  of  the  thoracic  duct  may 

arise  at  any  point,  from  direct  pressure  upon  it, 
especially  by  an  aortic  aneurism,  and  it  may  be- 
come thus  permanently  occluded  ; or  from  in- 
trinsic tubercular  disease,  which  is  of  special 
importance  ( see  memoir  by  Stilling,  Virchow’s 
Archiv,  and  Lancet,  vol.  i.,  1882).  3.  As  a result 

of  obstruction,  dilatation  of  the  portion  of  the 
tube  behind  this  point  will  probably  supervene 
in  various  degrees,  and  it  may  become  consider- 
ably enlarged  and  thickened.  The  other  portion 
tends  to  become  contracted  and  atrophied.  4. 
Perforation  of  the  thoracic  duct  occurs  in  excep- 


THREAD-WORM.  1623 

tional  instances,  owing  to  the  destructive  effect 
of  an  aneurism  or  other  morbid  condition,  or  as 
the  result  of  injury. 

It  is,  as  a rule,  quite  impossible  to  determine 
during  life  that  the  thoracic  duct  is  diseased. 
This  might  bo  suspected  if,  along  with  some 
known  cause  which  might  lead  to  obstruction 
of  the  tube,  the  patient  became  extremely  ema- 
ciated, anaemic,  and  weak,  without  other  obvious 
reason  to  account  for  these  symptoms.  No  treat- 
ment directed  immediately  to  the  thoracic  duct 
can  be  practicable  under  any  circumstances. 

Frederick  T.  Roberts. 

THORACIC  TUMOUR. — A tumour  within 
the  chest.  See  Bronchial  Glands,  Diseases  of ; 
Lungs,  Malignant  Disease  of ; Mediastinum. 
Diseases  of;  and  Thoracic  Aneurism. 

THORAX,  Diseases  of.  See  Chest,  Dis- 
eases of;  Chest  Walls,  Diseases  of;  and  De- 
| formities  of  Chest. 

THORAX,  Examination  of.  See  Physi- 
cal Examination. 

THREAD-WORM. — Synon.:  Oxyuris;  Fr. 
Oxyure ; Ger.  Spitzschwanzwurm ; Fadenwurm. 

As  stated  under  the  article  Oxyuris,  thread- 
worms represent  a genus  of  nematoid  worms. 
They  are  commonly  spoken  of  as  Ascarides,  but 
this  is  a misnomer.  The  oxyurides,  or  thread- 
worms, are  also  sometimes  termed  seat-worms. 
By  whatever  name  called,  they  have  acquired 
much  clinical  importance,  since  they  prove  in- 
jurious not  only  to  young  persons,  but  also  to 
people  advanced  in  life.  It  may  be  said,  in- 
deed, that  they  are  more  annoying  to  adults 
than  to  children ; the  prognosis  in  cases  of 
the  former  being  more  unfavourable  than  in 
the  latter.  It  is  usually  stated  in  manuals  that 
these  parasites  reside  in  the  rectum  of  the  human 
bearer;  but  this  is  an  error,  since  their  presence 
in  the  lower  bowel  is  rather  an  accident  than 
otherwise.  No  doubt  they  are  frequently  present, 
both  in  the  rectum  and  sigmoid  flexure  of  the 
colon,  but  their  true  habitat  is  higher  up,  namely, 
in  the  caecum.  Probably  the  tendency  to  migrate 
is  the  chief  cause  of  their  frequent  presence  in 
the  lower  bowel ; at  all  events,  their  passage  by 
the  anus  at  night-time  is  a constant  source  of 
distress  to  young  persons.  Their  wanderings 
thence  into  the  vagina,  and  about  the  neighbour- 
ing parts,  proves  an  additional  source  of  serious 
irritation  and  discomfort,  often  leading  to  the 
involuntary  practice  of  objectionable  habits.  It 
is  of  the  utmost  importance  to  get  rid  of  them, 
especially  at  the  age  of  puberty.  Before  wre 
speak,  however,  of  the  symptoms  and  treatment, 
it  may  be  as  well  to  say  a few  words  respect- 
ing their  modes  of  introduction  into  the  human 
body.  Until  lately  nothing  had  been  dono 
to  clear  up  the  mystery  of  their  origin.  It 
was  generally  supposed — and  this  view  is  still 
held  by  some  unscientific  persons  — that  these 
entozoa  wrere  generated  only  in  individuals  af- 
fected by  a peculiar  cachexia.  The  enfeebled 
condition  produced  by  their  presence  was  pro- 
nounced to  be  the  cause  instead  of  the  effect. 
Many  practitioners  cannot  shake  off  their  old 
notion,  and  some  few  are  impatient  of  correc- 
tion in  this  respect.  A healthy  person  is  just  a? 


1624 


THREAD-WORM. 


I 


\$ 


liable  to  be  attacked  by  nematoid  worms  as  a 
diseased  one,  The  real  question  is,  How  do  the 
germs  gain  access  to  the  human  body  ? Various 
experiments,  in  which  the  writer  has  himself 
taken  part,  have  been  conducted  with  the  view 
of  determining  this  important  point. 

Everyone  is  familiar  with  the  size  and  ap- 
pearance of  the  common  thread- worm  ( Oxyuris 
vermicularis),  at  least  of  the  females,  which  are 
more  numerous  than  the  males. 
If  one  of  the  former,  measuring 
nearly  half  an  inch  in  length, 
be  submitted  to  a magnifying 
power  of  twenty  diameters,  the 
uterine  ducts  will  be  seen  to  con- 
tain a multitude  of  eggs.  Those 
ova  whose  contents  are  in  the 
most  advanced  stage  of  deve- 
lopment already  show  a more 
or  less  perfectly  formed  and  tad- 
pole-shaped embryo.  These  em- 
bryos, after  extrusion  of  the  eggs 
from  the  maternal  body,  soon 
acquire  the  ordinary  vermiform 
character.  As  Yix  and  Leuckart 
have  shown,  ‘ one  needs  only  to 
expose  the  eggs  to  the  action 
of  the  sun’s  rays  in  a moistened 
paper  envelope,  when,  at  the  ex- 
piration of  some  five  or  six  hours, 
the  tadpole-shaped  embryos  will 
have  already  become  slender 
elongated  worms.  At  this  stage 
they  are  not  altogether  unlike 
the  sexually  mature  oxyurides 
in  shape,  exhibiting  rather  lively 
movements  under  the  applica- 
tion of  warmth’  ( Die  Mcnsch. 
Pur.jBd.  II.  s.  130).  Professor 
Heller  has  remarked  to  the  wri- 
ter, that  for  the  artificial  rear- 
ing of  the  vermiform  embryos 
no  plan  is  better  than  that  of 
Fid.  Ob.  Oxyuris  simply  placing  the  eggs  in  a 
vermicularis,  „qasg  tube  filled  with  saliva, 
female.  Highly  s,,  . . , ... 

magnified.  A £-  This  tube  may  be  conveniently 
ter  Leuckart.  carried  in  the  arm-pit,  when  in 
a very  short  space  of  time  the  embryonal  trans- 
formations may  be  followed.  In  this  connection 
it  is  a matter  of  practical  importance  to  know 
whether  or  not  these  and  all  other  embryonal 
changes  which  are  necessary  to  the  sexual  ma- 
turity of  the  parasite,  can  be  accomplished  with- 
in the  human  bowel.  On 
this  point  Leuckart  affirms 
(loc.  cit.  s.  329)  that 
1 elongated  embryos  are  to 
be  found  not  only  in  the 
fteces  but  also  in  the  mu- 
cus of  the  rectum  above 
and  around  the  anus.’  And 
it  appears  that  Vix,  who 
was  the  first  to  discover 
the  filiform  stage,  has  de- 
tected vermiform  embryos, 
along  with  eggs  of  oxyu- 
rides, in  tho  large  intestine.  These  statements, 
taken  by  themselves,  would  seem  to  show  that, 
notwithstanding  all  that  has  been  said  to  the 
contrary,  the  old  view  as  to  the  propagation 


Fig.  93.  Eggs  of  Oxyu- 
ris  vermicularis , in- 
closing tadpole-shaped 
embryos;  x 450 diam. 
(original). 


of  thread-worms  in  the  human  bearer  is  correct. 
All  the  more  recent  evidence,  however,  leads  to 
a contrary  conclusion.  Thus  Leuckart  distinctly 
states  that  ordinarily  the  escape  of  the  embryos 
‘ takes  place  under  the  action  of  the  gastric 
juice,  and  'primarily  also  under  that  condition 
when  by  some  means  or  other  they  have  gained 
access  to  a new  bearer’  (loc.  cit.  s.  329).  Speaking 
also  of  the  subsequent  development  of  oxyuris- 
embryos,  he  says  : ‘ The  development  of  these  em- 
bryos continues  not  merely  in  the  free  state  (when 
the  favourable  conditions  are  thus  afforded)  but 
also — at  least  in  the  human  species — in  the  intes- 
tine of  the  bearer,  presupposing  of  course  that 
the  eggs  remain  there  the  necessary  time.’ 
What  Leuckart  conjectured  to  occur  really  does 
take  place.  According  to  Heller,  who  has  made 
experimental  observations  on  this  subject,  the 
embryos,  after  being  liberated  in  tho  human 
stomach,  escape  into  the  duodenum  and  upper 
bowel.  In  this  situation  the  vermiform  embryos 
undergo  a series  of  moultings,  accompanied  by 
organic  changes,  and  growing  with  great  rapid- 
ity, soon  reach  the  caecum,  where  they  finally 
arrive  at  sexual  maturity.  As  the  question  at 
present  stands,  therefore,  we  conclude  that  oui 
patients  ordinarily  contract  thread-worms  by 
swallowing  the  eggs  of  oxyurides.  This  they 
may  do  by  ingesting  them  with  uncleaned  fruit, 
and  other  kinds  of  food,  to  which  the  eggs  have 
become  adherent;  but,  undoubtedly,  the  most 
common  way  in  which  the  disease  is  prolonged, 
if  not  at  first  contracted,  is  by  swallowing  fresh 
germs  conveyed  directly  to  the  mouth  by  the  hands 
of  the  patient.  The  writer  has  had  a gentleman 
under  his  occasional  care,  who  confessed,  that,  in 
his  rage  with  these  disgusting  parasites,  he  had 
taken  them  alive  between  his  teeth  and  bitten 
them.  In  this  exceptional  way  he  must,  of  course, 
have  liberated  thousands  of  ova  at  a time,  a fact 
which  accounts  for  the  myriads  of  adult  oxyu- 
rides by  which  he  is  infested.  Patients  frequently 
handle  these  parasites,  and  still  more  frequently 
carry  the  ova  under  the  nails.  Children  and  also 
grown  persons  become  infected  by  biting  their 
nails  after  scratching  the  anus.  The  writer  lately 
met  with  an  instance  where,  from  only  the  vestige 
of  a nail  left  upon  a boy’s  thumb,  he  obtained 
some  ova  of  oxyurides.  Thus,  it  is  obvious  that 
without  great  cleanliness,  persons  already  har- 
bouring thread-worms  are  liable  to  increase  the 
number  of  their  parasitic  guests. 

Personal  cleanliness  is  thus  essential,  but 
it  is,  we  think,  going  too  far  to  say,  with  Dr. 
Ransom,  that  ‘probably  any  infected  person  who 
adopted  the  requisite  precautions  against  rein- 
fection from  himself  or  others  would  get  well  in 
a few  weeks  without  treatment  by  drugs.’ 

Symptoms. — The  symptoms  produced  by  thread- 
worms are  very  variable.  Unpleasant  sensations 
show  themselves  generally  in  the  evening  and  at 
night,  consisting  ordinarily  of  heat  and  irritation 
around  the  anus.  These  phenomena  often  become 
excessively  distressing,  especially  when  they  are 
accompanied  by  itching  within  and  about  the 
genito-urinary  passages.  By  the  wandering  of 
the  worms  local  inflammatory  action  is  set  up>. 
Presently,  various  sympathetic  phenomena  are 
superinduced,  such  as  simple  restlessness,  gene- 
ral nervousness  and  irritability,  itchings  at  the 


THREAD-WORM. 

nose,  involuntary  spasms,  chorea,  convulsions, 
and  epileptiform  seizures.  At  early  puberty  the 
local  irritation  sometimes  induces  the  sufferer 
to  seek  relief  by  practices  which  show  a per- 
verted condition  of  the  sexual  functions,  and  in 
young  females  these  phenomena  are  occasionally 
accompanied  by  leueorrheal  discharges,  with 
more  or  less  hysteria.  Cases  exhibiting  varied 
and  anomalous  symptoms  in  connexion  with  the 
presence  of  these  and  other  worms  are  recorded 
by  different  writers,  but  not  many  presenting 
the  severer  phenomena  from  thread-worms  have 
appeared  in  our  English  journals.  In  one  case, 
where  multitudss  of  oxyurides  were  present,  a 
patient  of  the  winter’s  suffered  from  anaemia, 
deafness,  and  extreme  prostration,  the  feebleness 
being  so  marked  that  the  young  lady  could  not 
even  bear  the  exhibition  of  ordinary  vermifuges 
(Worms,  1872,  case  liii.  p.  04). 

Prognosis. — Speaking  generally,  the  prognoses 
in  cases  of  thread-worm  is  favourable  or  other- 
wise, according  to  the  age  of  the  sufferer. 

Treatment. — In  young  persons  small  doses  of 
steel,  followed  by  brisk  saline  purgatives,  some- 
times suffice  to  expel  most,  if  not  all,  of  the 
parasites.  If  the  worms  return,  a repetition 
of  the  remedies  may  be  advised,  increasing  the 
doses.  As  a rule,  the  threadworms  will  return, 
and  if  very  numerous  they  are  apt  to  prove 
obstinate.  In  adults  the  results  of  treatment  are 
far  less  satisfactory.  The  worms  are  expelled 
with  more  difficulty  by  cathartics,  and  even 
copious  enemata  fail  to  reach  those  worms  that 
are  lodged  high  up  in  the  colon  and  caecum. 
Many  patients  object  to  injections  altogether; 
but  if.  containing  turpentine,  they  can  be  em- 
ployed two  or  three  times  weekly,  whilst  active 
salines  are  given  by  the  mouth,  there  is  probably 
no  better  mode  of  obtaining  good  results.  A 
great  variety  of  drugs  have  been  recommended, 
such  as  calomel,  scammony,  jalap,  salt,  san- 
tonin, iron,  aloes,  and  assafcetida  ; one  or  other  of 
these  being  administered  separately  or  together, 
followed  by  medicated  enemata  containing  either 
lime,  tincture  of  steel,  sulphuric  ether,  tansy, 
or  quassia.  It  may  be  said  that  all  of  these 
remedies  prove  more  or  less  useful,  but  the 
writer  has  of  late  years  relied  more  upon  mode- 
rate doses  of  aloes  and  assafcetida,  followed  by 
copious  draughts  of  active  mineral  waters,  such 
as  those  of  Friedrichshall,  Pullna,  and  Hunyadi- 
Janos.  Many  persons  who  object  to  drastic 
cathartics  as  ordinarily  prescribed  will  not  re- 
fuse to  take  the  Friedrichshall  waters  by  them- 
selves, or  the  Hungarian  waters  in  combination 
with  steel  or  other  tonics,  to  any  reasonable 
amount.  In  the  writer’s  experience  these  waters 
are  of  great  value  in  the  treatment  of  certain 
forms  of  entozoal  disease,  especially  of  thread- 
worms. Whatever  drugs  are  given,  it  is  espe- 
cially necessary  that  attention  be  paid  both  to 
diet  and  regimen.  All  green  vegetables  should 
be  avoided,  whether  cooked  or  uncooked.  The 
utmost  cleanliness  must  be  enjoined.  Daily  local 
washings  are,  above  all  things,  to  be  insisted  on, 
especially  after  the  act  of  defaecation,  or  nightly 
at  bed-time,  whether  or  not  enemata  be  em- 
ployed. Simple  cold  water  or  olive  oil  injections 
ire  almost  as  beneficial  as  those  that  are  medi- 
cated. The  nails  must  be  kept  short  and  clean, 


THROAT,  DISEASES  OF.  1625 
and  the  practice  of  biting  them  should  be  de- 
nounced. Under  any  circumstances,  and  in  view 
of  a permanent  cure,  not  only  is  great  perse- 
verance in  the  employment  of  the  remedies 
necessary,  but  also  in  the  matter  of  general 
cleanliness.  See  Ascarides;  Oxyurides;  and 
Seat-worms.  T.  S.  Cobboi/d. 

THROAT,  Diseases  of. — Synon.  : Fr.  Ma- 
ladies de  la  Gorge  ; Ger.  Rachcnkrankheiten. 

The  throat  is  a comprehensive  term,  its  dis- 
eases including  those  of  the  pharynx,  tonsils, 
palate,  and  uvula,  and  in  popular  language  even 
those  of  the  larynx  and  trachea.  The  principal 
affections  of  these  different  structures,  with  the 
exception  of  the  palate,  are  described  in  their 
appropriate  articles,  to  which  the  reader  is 
referred,  and  here  it  will  only  be  necessary  to 
offer  a few  general  remarks  on  throat-diseases, 
and  to  refer  briefly  to  the  affections  of  the 
palate.  In  many  instances  all  the  parts  are  more 
or  less  involved  in  the  morbid  conditions  pre- 
sent, but  in  other  cases  one  structure  is  mainly 
or  exclusively  involved.  Moreover,  the  throat 
may  be  interfered  with  by  neighbouring  dis- 
eases, such  as  retro-pharyngeal  abscess,  and  some 
affections  of  the  neck. 

Summary  of  Diseases.— The  affections  of 
the  throat  may  be  thus  grouped  in  a general 
way:— 1.  There  maybe  no  actual  disease,  but 
the  patient  merely  complains  of  various  sensa- 
tions referred  to  the  throat,  these  being  of  a ner- 
vous character.  2.  The  throat  is  liable  to  in- 
jury by  substances  swallowed.  3.  This  part  is 
obviously  affected  in  certain  general  diseases, 
especially  some  of  the  acute  specifics.  Thus  it  is 
particularly  involved  in  scarlatina  and  diphtheria, 
and  to  a less  degree  in  measles,  rotheln,  influenza, 
and  general  catarrh.  Syphilis  also  implicates 
the  throat  in  its  various  stages.  This  region 
is  sometimes  attacked  by  erysipelas,  small-pox, 
herpes,  or  thrush.  4.  Acute  congestion,  and 
various  forms  of  acute  inflammation,  affecting 
different  structures  of  the  throat,  are  of  common 
occurrence,  resulting  from  causes  acting  either 
locally  or  generally.  The  cases  present  much 
diversity  in  their  severity,  depending  upon  the 
extent,  seat,  and  terminations  of  the  inflamma- 
tion. 5.  Chronic  congestion  and  inflammation 
are  also  not  uncommon,  of  various  degrees,  and 
producing  different  effects  in  different  cases.  6. 
Ulcerations  of  the  throat  are  of  frequent  occur- 
rence, being  usually  dependent  on  some  general 
condition,  such  as  syphilitic,  scarlatinal,  or 
diphtheritic  ulcers,  but  sometimes  local  in  their 
origin.  They  may  become  sloughing  and  gan- 
grenous, causing  much  destruction  of  the  tissues, 
or  even  opening  up  vessels,  and  thus  proving 
fatal  by  haemorrhage.  The  after-effects  of  ulcer- 
ation may  be  evident  in  the  way  of  cicatrices, 
contraction,  adhesions,  and  permanent  loss 
of  parts.  7.  Certain  structures  in  the  throat 
are  very  liable  to  become  relaxed,  and  thus  to 
produce  symptoms,  especially  the  uvula.  8.  The 
throat  may  be  occupied  by  some  enlargement  or 
morbid  growth.  Here  may  be  mentioned  chronic 
enlargement  or  so-called  hypertrophy  of  the 
tonsils,  which,  however,  is  usually  the  result  of 
chronic  inflammation,  congestion,  or  albuminoid 
disease.  Cancer  and  polypi  are  the  forms  of 


1626  THROAT,  DISEASES  OF. 
morbid  growth  usually  met  with,  and  cancer 
may  proceed  to  ulceration.  9.  Malformations 
are  not  uncommonly  of  importance  in  connection 
with  the  throat.  The  size  of  the  pharyngeal 
cavity  varies  much  in  different  persons,  but  its 
unusual  smallness  may  be  of  more  or  less  conse- 
quence. Deformities  of  the  palate  are  of  much 
importance,  being  either  congenital  or  the  result 
of  disease.  1 0.  Sensory  or  motor  paralysis  in- 
volving the  throat  is  sometimes  a serious  affec- 
tion. The  condition  is  especially  met  with  after 
diphtheria,  or  in  cases  of  labio-glosso-laryngeal 
paralysis. 

Clinical  Signs. — The  symptoms  in  throat- 
affections  are  very  variable,  as  regards  their  se- 
verity, exact  nature,  and  combinations,  but  they 
are  more  or  less  of  the  following  nature: — 1. 
Painful  or  other  abnormal  sensations  are  usually 
complained  of.  Pain  may  range  from  mere  ‘ sore- 
throat  ’ to  marked  suffering,  and  in  some  instances 
it  is  attended  with  throbbing,  or  shoots  towards 
the  ear.  Tenderness  is  also  very  common,  when 
anything  passes  over  the  surface,  or  even  when 
the  parts  are  moved  in  the  act  of  swallowing, 
and  the  painful  feeling  may  be  only  experienced 
at  this  time.  Talking  or  coughing  is  sometimes 
painful.  Tenderness  may  also  be  felt  when 
pressure  is  made  over  the  tonsils  from  without. 
Amongst  other  sensations  often  complained  of  are 
a sense  of  dryness,  irritation,  fulness  or  tight- 
ness, heat  or  burning,  and  obstruction.  2.  Hot 
only  may  the  act  of  deglutition  be  painful, 
but  in  throat-disease  it  is  often  attended  with 
difficulty  in  various  ways,  and  may  be  quite  im- 
practicable ( see  Deglutition,  Disorders  of).  3. 
Articulation  is  affected  in  certain  conditions, 
the  voice  being  characteristically  altered,  and 
becoming  of  a thick,  guttural,  or  Dasal  quality. 
In  other  cases  it  is  slightly  rough  or  husky,  and, 
of  course,  is  particularly  liable  to  be  affected  if 
the  larynx  is  involved  in  any  way.  4.  In  some 
forms  of  throat-disease  the  breathing  is  ob- 
structed, owing  to  structures  filling  up  more  or 
less  the  passago  of  the  pharynx.  This  is  espe- 
cially felt  in  the  recumbent  posture  ; and  patients 
suffering  in  this  way  often  breathe  with  the 
mouth  wide  open,  and  snore  loudly.  The  breath 
may  have  an  unpleasant  or  even  foetid  smell,  as 
the  result  of  morbid  states  of  the  throat.  5. 
Throat-affections  frequently  excite  the  acts  of 
hawking  or  coughing,  and  various  materials 
are  thus  expelled  in  many  cases.  It  may  also 
be  mentioned  here  that  some  irritation  in  the 
pharynx  not  uncommonly  causes  reflex  vomiting. 
6.  Morbid  conditions  in  this  p>art  may  give  rise 
to  haemorrhage,  and  this  occasionally  proves  of 
a serious  or  even  fatal  character,  as  the  result  of 
certain  destructive  lesions.  7.  Physical  exami- 
nation of  the  throat  is  of  essential  importance 
in  revealing  its  morbid  conditions.  Inspection 
is  usually  sufficient,  with  the  aid  of  a good  light, 
and  it  is  in  most  cases  necessary  to  depress  the 
tongue  by  means  of  the  finger,  the  handle  of  a 
spoon,  or  a tongue-depressor.  In  some  instances  it 
is  requisite  to  feel  the  parts  in  the  throat  with  the 
finger.  External  examination  should  also  he  made 
beneath  the  angles  of  the  lower  jaw.  The  objec- 
tive conditions  determined  by  physical  examina- 
tion will  depend  on  the  nature  of  the  disease. 

Palate,  Diseases  of. — The  palate  consists 


THROMBOSIS. 

of  two  parts — namely,  the  hard,  and  the  soft 
palate  with  its  arches.  This  structure  takes  an 
important  share  in  the  performance  of  deglu- 
tition, as  well  as  in  articulation.  It  is  liable 
to  be  affected  by  any  of  the  morbid  ccnditiona 
which  are  met  with  in  the  throat,  and  assists  in 
the  production  of  the  symptoms  resulting  there- 
from. When  the  palate  is  inflamed  or  ulcerated, 
marked  soreness  or  pain  is  likely  to  be  felt  when 
anything  passes  over  its  surface  in  the  act  of 
swallowing.  As  a rule  it  can  be  very  readily 
inspected.  The  points  that  demand  special  no- 
tice with  reference  to  the  palate  are,  that  it  is 
not  uncommonly  the  seat  of  more  or  less  exten- 
sive congenital  deficiencies,  as  in  the  different 
forms  of  cleft  palate  ; and  that  it  may  be  de- 
stroyed in  various  degrees  during  the  progress 
of  ulceration,  in  some  instances  a perforation 
remaining,  in  others  the  whole  soft  palate  being 
removed,  or  even  the  hard  palate  involved.  Con- 
sequently the  two  functions  above  referred  to 
are  often  seriously  impaired.  During  the  act 
of  deglutition,  substances  tend  to  pass  back  into 
the  nasal  cavities  through  the  posterior  nares, 
especially  liquids  ; while  speech  is  nasal  or  gut- 
tural and  indistinct,  or  in  some  cases  almost 
unintelligible,  it  being  impossible  for  the  patient 
to  articulate  the  words  properly.  During  the 
act  in  some  cases  the  features  are  more  or  less 
distorted. 

Treatment. — For  the  treatment  of  the  dif- 
ferent throat-affections  the  reader  must  refer  to 
the  articles  in  which  they  are  respectively  dis- 
cussed. The  writer  only  mentions  the  subject 
in  order  to  draw  attention  to  two  points,  namely: 
first,  the  great  importance  of  general  treatment 
in  a large  proportion  of  cases  of  affections  of  the 
throat ; secondly,  the  necessity  of  usiDg  local 
measures  efficiently , when  these  are  required  ; 
while  at  the  same  time  it  is  often  most  desirable 
that  the  parts  affected  should  be  kept  as  much 
at  rest  as  possible.  Should  the  palate  be  con- 
genitally deficient,  or  destroyed  by  disease,  sur- 
gical operations  are  often  of  the  greatest  ser- 
vice ; or  plates  of  different  kinds  may  have  to 
be  worn.  Frederick.  T.  Roberts. 

THROMBOSIS  (Oplfifros,  a clot).—  Stxon.  : 
Fr.  Thrombose;  Ger.  Thrombose. 

Definition. — The  coagulation  of  fibrin  in  the 
heart,  blood-vessels,  or  lymphatics  during  life. 

Description. — Thrombosis  may  take  place  in 
the  heart,  the  arteries,  the  capillaries,  the  veins, 
and  also  in  the  lymphatics.  The  coagulum  con- 
sists of  fibrin,  entangling  in  its  meshes  a larger 
or  smaller  number  of  blood-globules,  which,  in 
rapidly  formed  thrombi,  consist  of  both  red  and 
white  varieties,  and  hence  the  thrombus  is  at 
first  dark-coloured.  In  slowly-formed  thrombi, 
and  in  those  due  to  projections  from  the  coats 
of  the  vessels,  the  red  cells  may  be  absent,  and 
the  thrombus  is  colourless  or  yellowish-white. 
In  most  thrombi  the  white  cells  are  present  in  a 
much  larger  proportion  than  in  normal  blood. 

When  a thrombus  occupies  the  place  where 
coagulation  began,  it  is  called  ft  primitive  throm- 
bus ; when  it  gradually  extends  from  this  point 
along  the  vessel,  an  extension  or  produced 
thrombus.  This  extension  usually  proceeds 
along  the  vessel  to  its  junction  with  a largv 


THROMBOSIS.  1827 


branch,  into  which  the  thrombus  may  often  be 
teen  to  project  with  a rounded  extremity,  and 
this,  by  obstructing  the  blood-current,  may  again 
form  the  starting  point  for  a fresh  extension. 

Structurally,  thrombi  maybe  distinguished  as 
laminated,  and  non- laminated  or  uniform.  The 
former  result  from  a process  of  continuous,  the 
latter  from  one  of  intermitting  coagulation.  In 
laminated  thrombi  there  is  often  a layer  of  white 
blood-cells  between  the  laminae,  due  to  the  ten- 
dency which  these  bodies  have  to  wander  out  of 
the  clot. 

Thrombi  may  further  be  distinguished  into 
■parietal,  or  those  which  adhere  to  some  part  of 
the  wall  of  the  vessel ; and  obliterating,  or  those 
which  complet  ely  fill  the  vessel.  Parietal  thrombi 
are  generally  nearly  colourless,  and  are  due  to 
some  roughness  or  other  change  in  the  lining 
membrane.  Obliterating  thrombi,  which  are 
at  first  coloured,  are  produced  by  the  sudden 
coagulation  of  the  blood;  the  thrombus  thus 
formed  shrinks,  and  leaves  a space  which  again 
fills  with  blood  ; this  again  coagulates,  and  so 
complete  obstruction  of  the  vessel  is  effected. 
A post-mortem  coagulum  never  completely  fills 
the  vessel,  as  after  the  shrinking  process  has 
taken  place,  there  is  no  further  supply  of  blood 
to  coagulate.  Other  points  of  distinction  between 
post-mortem  coagula  and  thrombi  are  these — the 
former  are  never  laminated;  they  are  looser  in 
texture,  and  moister ; they  do  not  adhere  so 
closely  to  the  wall  of  the  vessel ; and  though  they 
may  be  either  coloured  or  colourless,  they  never 
present  the  appearances  due  to  the  subsequent 
changes  which  take  place  in  thrombi. 

Changes  in  Thrombi. — The  first  change  ob- 
served after  the  thrombus  has  shrunken  and 
become  denser  is  decolorisation.  The  colouring 
matter  dissolves  out  of  the  blood-globules,  be- 
comes diffused,  and  is  transformed.  The  throm- 
bus accordingly  changes  from  dark  red  to  tawny, 
and  finally  to  a yellowish-white ; and  at  the  same 
time  it  loses  its  soft  elastic  texture,  and  becomes 
tougher,  denser,  or  even  somewhat  friable. 

The  subsequent  changes  vary.  First,  a process 
of  shrinking  and  drying  up  may  occur,  by  which 
the  thrombus  gets  converted  into  a tough  leathery 
substance,  which  may  even  become  calcified,  and 
in  this  way  are  formed  the  concretions  in  veins 
known  as  phleboliths. 

Secondly,  softening  may  take  place;  this  may 
either  be  due  to  a process  of  molecular  dis- 
integration, or  more  rarely  to  suppuration.  In 
the  former  case  the  thrombus  liquefies  into  a 
milky  fluid,  consisting  of  an  oily  and  granular 
detritus,  the  process  beginning  in  the  centre.  In 
the  heart  this  change  often  occurs  in  the  layers 
of  fibrin  entangled  among  the  trabeculae,  or 
in  the  globular  masses  which  sometimes  project 
from  them  into  the  cavities,  thus  giving  rise 
to  the  formation  of  cysts. 

Suppuration  is  occasionally  seen  in  the 
thrombi  of  veins  surrounded  by,  or  leading 
from,  inflamed  parts  ; a multiplication  of  leuco- 
cytes takes  place  in  the  thrombus,  either  by  pro- 
liferation or  immigration,  and  the  whole  softens 
down  into  a purulent  fluid.  In  these  cases  the 
wall  cf  the  vein  itself  is  always  inflamed. 
These  softened  and  broken-down  thrombi  are  a 
rommon  cause  of  embolisms. 


Lastly,  the  thrombus  may  become  organised. 
Organisation  has  been  chiefly  studied  in  wounds 
and  ligatures  of  arteries  and  veins,  and  the  ap- 
pearances have  been  very  differently  interpreted 
by  different  observers.  According  to  one  opinion 
the  thrombus  itself  becomes  organised  ; the  white 
blood-cells  contained  in  it,  or  immigrant  leuco- 
cytes from  the  vasa  vasorum,  as  proved  by  in- 
cluding a portion  of  vein  between  two  ligatures 
and  impregnating  the  blood  with  vermilion 
(Bubnoff),  become  converted  into  stellate  con- 
nective-tissue corpuscles,  with  interlacing  pro- 
cesses ; new  vessels  permeate  the  clot  along  the 
line  of  the  stellate  processes  from  the  unob- 
structed portion  of  the  artery  or  vein,  and  form 
anastomoses  with  offshoots  from  the  vasa  vaso- 
rum perforating  the  tunica  intima,  which  disap- 
pears; and  thus  a vascular  reticulated  connective 
tissue  is  formed,  in  the  meshes  of  which  lie  the 
remains  of  the  red  blood-globules  and  fibrin  of 
the  clot.  The  progressive  dilatation  of  the  newly 
formed  vessels  gradually  renders  the  thrombus 
cavernous;  and  finally,  by  their  coalescence,  it  en- 
tirely disappears,  and  the  vessel  again  becomes 
pervious.  Cornil  and  Ranvier  dispute  the  cor- 
rectness of  these  observations,  and  assert  that 
the  appearances  are  really  due  to  the  out- 
growth, from  the  tunica  intima,  of  vascular  gra- 
nulations penetrating  the  thrombus,  which  gra- 
dually disappears  without  taking  any  part  in  the 
formation  of  the  reticulated  connective  tissue 
which  is  found  occupying  its  place. 

Pathology. — According  to  the  views  of  coa- 
gulation now  entertained,  the  formation  of  fibrin 
is  due  to  the  interaction  of  two  substances  pre- 
sent in  the  liquor  sanguinis : fibrinogen,  and 
fibrinoplastin  or  paraglobulin,  under  the  influ- 
ence of  a third  substance  which  acts  analogously 
to  a ferment.  The  fibrinoplastin  and  the  fer- 
ment are  contained  in  the  white  blood-cells,  and 
are,  in  all  probability,  derived  from  these  bodies, 
for  in  all  spontaneously  eoagulable  fluids  white 
blood-cells  are  present,  and  where  they  are  ab- 
sent coagulation  does  not  take  place.  Even  in 
the  blood,  when  coagulation  is  retarded,  as  by 
keeping  horse’s  blood  in  a tube  formed  of  the 
excised  jugular  vein,  it  is  found  that  the  upper 
layers,  from  which  the  white  cells  have  subsided, 
coagulate  very  imperfectly,  while  a firm  clot 
forms  in  the  lower  layers,  where  the  corpuscles 
are  numerous.  The  white  blood-cells  also  are 
often  seen  to  form  the  starting  point  from  which 
the  threads  of  fibrin  form. 

The  nature  of  the  process  of  coagulation  is 
still  very  obscure.  It  does  not  appear  to  resemble 
a chemical  precipitate,  and  it  is  very  doubtful 
whether  the  fibrinoplastin  actually  enters  into 
the  formation  of  the  clot ; for  in  artificial  coagu- 
lation, effected  by  adding  fibrinoplastin  to  fibrin- 
ogen, the  weight  of  the  clot  is  always  less  than 
that  of  the  fibrinoplastin  used. 

As  all  the  three  factors  of  coagulation,  fibrin- 
ogen, fibrinoplastin,  and  the  ferment,  are  present 
in  theliquorsanguinis.it  is  evident  that  there 
must  be  some  restraining  influence  which  pre- 
vents coagulation  ; and  the  cause  of  thrombosis 
must  be  looked  for  in  the  removal  or  weakening 
of  this  influence.  According  to  Briicke,  contact 
with  the  healthy  lining  membrane  of  the  vessels 
prevents  the  bloodfrom coagulating;  consequently 


THROMBOSIS. 


1628 

any  structural  change  in  this  membrane  is  liable 
to  cause  thrombosis.  The  presence  of  a foreign 
body  produces  the  same  effect,  and  a thrombus 
itself  acts  as  a foreign  body.  Retardation  or 
arrest  of  the  blood-current  is  also  a common 
cause  of  thrombosis.  Loss  of  motion  in  itself  tends 
to  retard  coagulation,  but  free  circulation  is  ne- 
cessary for  the  maintenance  of  the  nutrition  and 
integrity  both  of  the  vessels  and  the  white  blood- 
cells  ; hence  stagnation  tends  to  cause  thrombosis 
by  removing  the  restraining  influence  of  the 
healthy  vascular  wall,  and  also  by  setting  free 
fibrinoplastin  from  the  white  corpuscles  ; more- 
over, the  motion  of  the  blood  maintains  the 
contact  between  each  particle  and  the  lining 
membrane  of  the  vessels,  and  so  prevents  coagu- 
lation. 

The  principal  causes,  therefore,  of  thrombosis 
are  alterations  in  the  lining  membrane  of  the 
vessels,  and  retardation  or  arrest  of  the  circula- 
tion ; to  these  may  be  added  the  presence  of 
foreign  bodies,  and  probably  also  the  microzymes 
of  septic  processes. 

Hyperinosis,  or  increase  in  the  constituents  of 
the  fibrin,  and  diminished  fluidity,  as  in  cho- 
lera, can  only  be  regarded  as  predisposing  causes 
requiring  retardation  of  the  circulation  to  take 
effect. 

Retardation  of  the  circulation  being  one  of 
the  most  important  causes  of  thrombosis,  we 
find,  as  might  be  expected,  that  its  most  frequent 
seat  is  the  veins,  where  the  circulation  is  natu- 
rally feeble. 

Varieties.—  1.  Venous. — The  principal  causes 
of  venous  thrombosis  are  two.  The  first  of 
these  is  wounds  and  injuries  of  veins,  where 
the  formation  of  thrombi  is  the  natural  way 
of  arresting  haemorrhage.  The  thrombus  may 
extend  along  the  vein  from  its  primitive  seat, 
and  thus  cause  blocking  of  venous  trunks  at 
a distance  from  the  site  of  the  injury.  This 
is  often  seen  after  parturition,  when  throm- 
bosis of  the  uterine  sinuses  may  extend  to  the 
iliac  and  femoral  veins.  Secondly,  inflammation 
of  the  coats  of  the  vein,  by  altering  the  condition 
of  the  lining  membrane,  may  cause  thrombosis  ; 
but  in  many  cases  of  phlebitis  the  thrombosis 
is  the  primary  change,  and  the  inflammation  of 
the  coats  is  set  up  by  it.  Other  causes  of  venous 
thrombosis  are  pressure  on  the  veins,  dilatation, 
and  arrest  of  the  circulation  in  the  capillary  ter- 
ritory of  the  vein,  as  from  embolism  or  inflam- 
matory stasis.  Hence  we  occasionally  find  the 
veins  leading  from  inflamed  organs  thrombosed. 
Lastly,  thrombosis  of  the  veins  is  not  unfre- 
quently  due  to  retardation  of  the  circulation, 
owing  to  failure  of  the  propelling  power  of  the 
heart,  in  cases  of  marasmus  and  exhausting  dis- 
eases. These  thrombi  are  most  frequently  met 
with  in  the  veins  of  the  lower  extremities  and 
pelvis,  next  in  the  sinuses  of  the  dura  mater. 

2.  Arterial. — Apart  from  wounds  and  in- 
juries, thrombosis  of  the  arteries  is  most  fre- 
quently caused  by  degeneration  of  the  lining 
membrane,  giving  rise  to  rough  surfaces  to  which 
the  coagula  attach  themselves,  and  to  aneurisms 
in  which  the  coagulation  is  due  to  stagnation ; 
aneurysmal  thrombi  are  commonly  laminated. 
Arrest  of  the  circulation  from  any  cause,  as 
embolism,  will  also  cause  thrombosis. 


Thrombosis  of  the  larger  arteries,  without 
alteratioh  of  the  lining  membrane,  is  most  pro- 
bably always  the  result  of  embolism,  the  embolus 
being  usually  derived  in  the  systemic  arteries 
from  thrombi  of  the  heart,  the  result  of  asystole. 
Of  this  nature  are  the  cases  of  thrombosis  and 
gangrene  of  the  extremities  which  sometimes 
occur  in  fevers  and  wasting  diseases.  Throm- 
bosis of  the  pulmonary  artery  may  be  produced 
in  a similar  manner,  or  the  embolus  may  be  de- 
rived from  a thrombus  in  the  veins. 

3.  Cardiac. — Thrombosis  of  the  heart  may  be 
caused  by  endocarditis,  the  thrombi  then  usually 
forming  caps  to  the  inflammatory  outgrowths  or 
vegetations.  Large  thrombi  are  most  commonly 
caused  by  imperfect  emptying  of  the  cavities  and 
consequent  stagnation,  due  either  to  stenosis  of 
the  orifices,  or  to  want  of  tone  in  the  muscular 
walls.  Thrombi  may  also  extend  into  the  right 
auricle  from  the  venae  cavae. 

4.  Capillary. — Capillary  thrombosis  may  be 
due  to  extension  from  the  veins  and  arteries,  or 
it  may  be  primary.  In  the  Latter  case  the  con- 
ditions which  cause  it  are  imperfectly  known ; 
aggregations  of  white  blood-globules  will  often 
block  the  capillaries  and  small  vessels  in  the 
manner  of  thrombi,  but  this  condition  is  usually 
transient,  and  not  attended  by  true  coagulation. 
The  inhibitory  influence  of  the  lining  membrane 
of  the  blood-vessels  is  so  powerful  in  the  capil- 
laries that,  as  long  as  their  structure  remains 
intact,  coagulation  rarely  takes  place.  Thus 
inflammatory  stasis,  or  obstruction  of  the  afferent 
artery  by  embolism,  may  exist  for  a considerable 
time  without  the  blood  in  the  capillaries  coagu- 
lating. 

5.  Lymphatic. — Thrombosis  of  the  lymphatics 
has  been  chiefly  observed  in  the  puerperal  condi- 
tion, in  the  lymphatics  of  the  uterus  and  their 
continuations  to  the  lumbar  glands,  and  in  rare 
instances  in  the  thoracic  duct.  It  is  probably 
due  to  alteration  in  the  constitution  of  the  lymph, 
normal  lymph  having  very  slightly  coagulable 
properties. 

Symptoms. — The  symptoms  of  thrombosis  are 
those  of  arrest  of  the  circulation,  and  they  differ 
according  to  the  vessel  affected.  In  the  veins,  if 
a main  trunk  be  obstructed,  so  that  a sufficient 
collateral  circulation  cannot  be  rapidly  estab- 
lished, the  effects  produced  are  passive  hyper- 
eemia,  venous  dilatation,  transudation  of  serum, 
and  sometimes  haemorrhage  in  the  territory  of 
the  blocked  vein,  with  enlargement  of  the  colla- 
teral channels.  In  extreme  cases  moist  gangrene 
may  result.  Thus,  according  to  the  vein  affected, 
we  may  have  anasarca  of  an  extremity,  ascites, 
or  hydrothorax ; haemorrhage  from  the  stomach, 
intestine,  or  kidney ; cedema  and  cyanosis  of  the 
face  and  neck ; and  so  on.  The  symptoms  of 
arterial  dirombosis  are  in  the  main  those  which 
have  already  been  described  as  occurring  when 
the  artery  is  blocked  by  embolism  (see  Em- 
bolism). Coagulation  of  blood  in  the  arteries  of 
the  heart  is  described  in  a separate  article.  See 
Heart,  Thrombosis  of. 

Treatment. — The  treatment  of  thrombosis 
varies  according  to  the  seat  of  the  process.  See 
Aorta,  Diseases  of ; Braxx,  Vessels  of,  Diseases 
of;  Heart, Tkrombosisof;  and  Yeixs,  Diseasesof. 

W.  Cayley. 


THRUSH. 

THRUSH  — Synon.  : Fr.  Aphthe;  Ger. 

Mu  n dscJiwa  mm . 

Definition. — The  popular  name  given  to 
aphthae  in  the  mouth,  and  to  morbid  states 
resembling  them.  It  is  convenient  to  confine  the 
term  aphtha  to  cases  in  which  the  oidium  albi- 
cans is  present ; but  the  term  thrush  must  be 
allowed  a wider  signification,  and  must  be  taken 
to  include  also  many  cases  of  simple  stomatitis. 
See  Aphthie  ; and  Stomatitis. 

Desceiption. — Thrush  is  characterised  by 
small  white  flakes  scattered  over  the  tongue  and 
the  mucosa  of  the  mouth  and  lips.  Occasionally 
the  disease  spreads  down  the  oesophagus.  It  is 
frequently  met  with  in  infancy,  and  in  adults  it 
occurs  in  the  last  stages  of  wasting  complaints. 
The  white  flakes  are  composed  chiefly  of  exuda- 
tion from  a small  spot  of  subjacent  mucosa, 
which  is  acutely  inflamed.  Thus  it  is  that  they 
are  surrounded  by  a red  areola,  and  that,  if  they 
are  picked  off,  they  are  speedily  reproduced.  In 
the  cases  which  are,  strictly  speaking,  aphthous, 
the  white  flakes  may  readily  be  transferred  from 
the  infant’s  mouth  to  the  mother’s  nipple.  The 
minute  spots  of  inflammation  have  a tendency  to 
occur  in  clusters,  and  in  successive  crops,  some 
fading  as  others  appear.  They  are  attended  by 
local  heat  and  tenderness,  so  that  in  a severe 
case  the  infant  can  hardly  take  the  breast ; and 
with  this  there  may  be  feverishness,  drowsiness, 
and  perhaps  diarrhoea.  The  white  flakes  are 
sometimes  so  abundant  as  to  coalesce,  and  form 
large  patches  of  fur.  When  these  flakes  are 
shed,  or  are  removed,  small  ulcers  are  left  be- 
hind, which  are  flat  and  circular  or  oval,  with 
inflamed  bases,  and  a thin  yellowish  or  greyish 
slough.  Their  margins  are  well-defined,  but 
without  thickening  or  elevation.  They  are  always 
attended  by  increased  heat  and  congestion  of  the 
mucosa,  together  with  active  gastric  or  intes- 
tinal disturbance  ; and  there  is  fever  of  a more 
or  less  atonic  kind. 

Treatment. — Thrush  in  infancy  is  usually  due 
either  to  improper  or  insufficient  food,  giving  rise 
to  an  acid  state  of  the  secretions  of  the  mouth; 
and  the  attention  of  the  medical  man  should, 
therefore,  be  directed  particularly  to  this  sub- 
ject. If  the  infant  is  being  nursed  by  its  mother, 
inquiry  should  be  made  as  to  her  health,  for  the 
disease  may  perhaps  arise,  or  be  kept  up,  by  a 
morbid  condition  of  the  milk.  If  there  be  no 
reason  to  suspect  this,  the  child  should  be  con- 
fined entirely  to  the  breast,  and  this  should  be 
given  only  at  stated  intervals.  If  the  infant  is 
being  brought  up  by  hand,  the  most  careful 
attention  should  be  paid,  not  merely  to  the  milk 
or  artificial  food  with  which  it  is  supplied,  but 
also  to  the  cleanliness  of  the  vessels  in  which  it 
is  kept,  and  of  the  bottles  or  spoons  in  which  it 
is  given.  If,  notwithstanding  every  precaution, 
artificial  feeding  does  not  agree  with  the  child,  a 
wet-nurse  must  be  procured.  Attention  to  these 
primary  rules  of  health  sometimes  has  an  almost 
magical  influence  in  removing  the  complaint.  At 
the  same  time  the  child’s  bowels  should  be  regu- 
lated by  a slight  aperient ; while  a little  of  the 
glycerinum  boracis,  or  a powder  composed  of 
borax  and  sugar,  should  be  laid  upon  the  tongue 
every  hour  or  two.  If  ulcers  have  formed,  they 
should  be  dusted  with  powdered  alum,  or  touched 


THYMUS  GLAND,  DISEASES  OF.  1629 
with  a strong  solution  of  nitrate  of  silver  or  of 
sulphate  of  copper,  or  with  the  solid  caustics.  In 
cases  arising  from  weakness  caused  by  insuffi- 
cient nourishment,  two  or  three  drops  of  brandy 
given  in  the  food,  four  or  five  times  a day,  has 
often  a marked  effect  in  checking  the  disease. 
When  the  child  begins  to  amend,  a change  of  air 
will  probably  hasten  its  recovery. 

When  thrush  occurs  in  old  people,  or  as  an 
accompaniment  of  some  wasting  disease,  it  is 
less  easy  to  destroy  the  microscopic  fungus,  and 
to  prevent  its  reproduction.  Still  much  may  be 
done  to  regulate  the  prima  via,  to  support  the 
powers  of  nature,  and  to  arrest  the  spread  of  the 
aphthous  patches.  For  this  purpose,  Sir  William 
Jenner  recommends  a lotion  of  sulphite  of  soda 
(5j  to  the  5]  of  water).  It  should  be  applied 
frequently  with  a camel’s-hair  brush,  or  the 
mouth  should  be  rinsed  with  it.  A weak  solution 
of  carbolic  acid  may  be  used  in  the  same  way; 
or  a solution  of  sulphurous  acid,  in  the  propor- 
tion of  one  part  of  the  acid  to  six  of  water. 

W.  Fairlie  Clarke. 

THYMUS  GLAND,  Diseases  of. — Sy- 
non.: Fr.  Maladies  da  Thymus-,  Ger.  Krank- 
heiten  der  Thymusdriise. 

In  consequence  of  the  atrophy  of  this  organ  in 
early  life,  little  notice  has  been  taken  of  it,  either 
in  its  healthy  state  or  when  affected  by  disease. 

According  to  the  researches  of  Mr.  Simon,  the 
thymus  gland  reaches  maturity  in  the  child  at 
the  age  of  two  years ; it  remains  more  or  less 
perfect  up  to  eight  to  twelve  years ; then  it 
rapidly  decreases  in  size,  the  glandular  sub- 
stance becoming  converted  into  fat ; and  at  the 
age  of  twenty  years  there  is  no  trace  of  the  organ 
left.  At  birth  its  weight  is  in  proportion  to  the 
weight  of  the  child.  Taking  22  grs.  to  the  lb. 
to  be  the  usual  proportion,  100  to  200  grains 
will  be  the  weight  of  the  gland  at  birth.  From 
investigations  made  on  young  and  hybernating 
animals,  it  appears  that  the  greater  the  ratio  of 
respiratory  and  muscular  activity,  the  speedier 
is  the  decline  of  the  gland.  Consequently  Mr. 
Simon  thinks  ‘ the  thymus  fulfils  its  use  as  a 
sinking  fund  of  movement  in  the  service  of 
respiration.’ 

Summary  of  Diseases. — Instances  both  of  ex- 
cessive growth,  and  of  prolonged  existence  of  the 
thymus  have  been  reported.  A list  of  such  cases 
was  published  by  the  late  Mr.  Alexander  Bruce. 
In  a healthy  boy,  aged  fourteen,  killed  by  an 
accident,  the  gland  was  found  to  weigh  620 
grains ; in  a lunatic,  aged  twenty-one  years,  300 
grains;  in  a woman,  aged  twenty-nine  years,  51 
grains  ; in  another  woman,  aged  forty  years, 
30  grains.  Krause  mentions  three  cases,  aged 
twenty-five,  twenty-five,  and  twenty  years, 
wherein  the  glands  weighed  respectively  292, 
380,  and  356  grains. 

The  actual  diseases  of  the  thymus  gland  which 
have  been  recorded  are:— (1)  Inflammation,  fol- 
lowed by  suppuration.  In  one  such  instance  the 
abscess  burst  into  the  trachea.  Syphilis  has  been 
stated  to  be  a cause  of  embryonic  inflammation 
of  the  gland.  (2)  Fatty  degeneration  of  the  gland. 
(3)  Tubercular  deposit  in  the  gland.  (4)  Malig- 
nant disease.  (5)  Enlargement  ot  the  gland  in 
leuc-ccythamia,  and  in  (6)  lymphadenoma.  (7) 


1630  THYMUS  GLAND,  DISEASES  OF. 

Calculi  hare  been  found  imbedded  in  the  gland- 
eubstance. 

Cases  have  been  reported  of  children  dying 
from  suffocation,  with  no  other  cause  assigned 
for  their  death  than  pressure  on  the  trachea 
from  an  enlarged  thymus  gland.  Considering 
the  position  of  the  gland,  between  the  sternum 
and  the  windpipe,  and  the  small  power  of  re- 
sistance possessed  by  the  rings  cf  the  trachea 
during  infantile  life,  an  enlarged  thymus  may  be 
a possible  cause  of  suffocation. 

In  connection  with  an  enlargement  of  the 
gland,  a respiratory  affection  called  ‘ thymic 
asthma’  has  been  recognised.  It  is  also  named 
after  two  physicians,  ‘ Kopp’s,’  or  ‘Millar’s 
asthma’ ; but  the  majority  of  writers  on  diseases 
of  children  deny  the  existence  of  such  a malady. 

Pugin  Thornton. 

THYROID  GLAND,  Diseases  of. 

Synon.  : Fr.  Maladies  de  la  Glande  thyreoide-, 
Ger.  Kranliheiten  der  Schilddriise. 

Goitre  is  the  most  common  affection  of  the 
thyroid ; and  associated  with  it,  but  as  a less 
prevalent  disease,  is  exophthalmic  goitre.  See 
Goitre  ; and  Exophthalmic  Goitre. 

The  diseases  of  the  thyroid  gland  other  than 
goitre  are  rare.  They  comprise : — 1.  Acute  In- 
flammation or  thyroiditis.  2.  Hydatid  cysts. 

3.  Calcareous  deposit  in  the  gland.  4.  Can- 
cer. 5.  Sarcoma.  Patty  degeneration  of  the 
thyroid  is  of  doubtful  occurrence.  Enlargement 
of  the  gland  occasionally  occurs  in  leucoeythae- 
mia,  and  in  lymphadenoma.  The  gland  is  some- 
times absent,  or  an  accessory  lobe  may  be 
present.  It  may  degenerate  in  old  people. 
The  following  affections  alone  require  brief 
notice. 

1.  Acute  Inflammation. — Synon.:  Thyroi- 
ditis.— This  disease  occurs  in  three  forms  : — (a) 
idiopathic  ; ( b ) metastatic ; and  (c)  traumatic. 

(<i)  Idiopathic  thyroiditis  is  the  rarest  of  these 
forms  of  inflammation.  It  chiefly  attacks  young 
people,  and  is  generally  due  to  sudden  changes 
of  temperature. 

(6)  Metastatic  thyroiditis  is  rarely  observed  as 
a complication  of  acute  infectious  diseases,  espe- 
cially typhus,  puerperal  fever,  and  pyaemia.  It 
has  also  been  met  with  in  pneumonia  and  bron- 
chitis ; and  in  connection  with  orchitis. 

( c ) Traumatic  thyroiditis  usually  results  in 
suppuration.  Sphacelus  of  the  gland  is  a pos- 
sible result  of  active  suppuration — a result  not 
necessarily  followed  by  any  further  mischief. 

Symptoms.- — All  three  forms  of  thyroiditis 
commonly  produce,  amongst  other  symptoms, 
dyspnoea  and  dysphagia. 

Treatment. — The  treatment  of  inflammation 
of  the  thyroid  gland  consists  in  applying  leeches 
and  ice,  and  in  using  other  antiphlogistic  reme- 
dies. Deep-seated  suppuration  should  be  re- 
lieved by  an  early  incision,  otherwise  the  pus 
may  find  its  way  into  the  trachea  or  beneath  the 
fascia.  The  best  plan  for  opening  the  abscess  is 
by  means  of  the  trochar  and  cannula. 

2.  Hydatid  cysts. — Echinococci  have,  in  a 
few  cases,  produced  an  enlargement  of  the  thy- 
roid gland.  These  hydatid  cysts  are  difficult  to 
diagnose  from  goitrous  cysts  until  the  fluid  con- 
tents have  been  examined  microscopically. 


TIC-DOULOUREUX. 

3.  Calculi. — These  bodies  have  been  found 
imbedded  in  the  substance  of  the  thyroid.  The 
writer  has  met  with  a specimen  in  which  the  cal- 
culus was  the  size  of  a walnut,  and  almost  en- 
tirely took  the  place  of  the  gland-6ubstance  of 
one  lobe. 

4.  Cancer.— Primary  cancer  of  the  gland  is 
a rare  disease.  It  is  met  with  in  two  forms — 
encephaloidand  scirrhus.  Cancer  is  not,  it  would 
appear,  so  commonly  developed  in  a healthy  gland 
as  in  one  already  affected  by  goitrous  degene- 
ration. Secondary  cancer  of  the  thyroid  may 
also  occur. 

Symptoms  and  Diagnosis. — The  special  symp- 
toms caused  by  malignant  disease  of  the  thyroid 
are  dyspnoea  and  dysphagia.  The  trachea  and 
oesophagus  may  be  involved  in  the  disease.  Very 
commonly  one  or  both  recurrent  laryngeal  nerves 
are  included  in  an  extension  of  the  growth,  and 
sometimes  also  the  large  vessels  and  nerves  of 
the  neck.  Cancerous  disease  of  the  thyroid  is 
probably  present  when  there  is  a rapid  enlarge- 
ment of  the  gland,  followed  in  an  early  stage 
by  duskiness  of  the  skin  over  the  most  prominent 
parts  of  the  swelling.  Superficial  ulceration  at 
a later  date,  often  accompanied  by  haemorrhage, 
and  the  general  condition  of  the  patient,  will 
render  the  diagnosis  clearer. 

Treatment. — The  only  available  treatment  is 
entire  removal  of  the  gland,  and  this,  to  he  of 
service,  must  be  carried  out  at  an  early  stage  of 
the  disease. 

5.  Sarcoma. — Sarcoma  may  be  developed  in 
the  substance  of  a healthy  thyroid  gland,  or  in 
one  already  affected  by  goitrous  disease.  Thyroid 
sarcoma  is,  according  to  Liicke  of  Strasbnrg, 
rapid  in  its  growth,  not  exceeding  a year  in 
duration. 

An  exceedingly  interesting  class  of  cases  has 
been  recognised  within  the  last  few  years,  iu 
which  tumours,  growing  simultaneously  in  vari- 
ous hones,  such  as  the  skull,  vertebrae,  and  femur, 
and  in  the  lungs  and  glands,  have  appeared,  on 
examination,  to  he  secondary  to  a simple  adeno- 
matous enlargement  of  the  thyroid  gland,  and 
have  presented  microscopic  characters  precisely 
similar  to  that  disease. 

Pugin  Thornton. 

TIC  DOULOUREUX  (Fr.).— Synon.  : Fa- 
cial neuralgia ; Prosopalgia. 

Definition. — Neuralgia  of  the  trigeminal,  tri 
facial,  or  fifth  nerve. 

One  alone,  more  often  two,  hut  rarely  all 
three  divisions  of  the  fifth  nerve  of  one  side 
may  be  coincidently  the  seat  of  neuralgia.  It  is 
less  common  for  the  third  division  to  suffer  than 
for  the  first  and  second.  Tic  has  often  been  pre- 
ceded or  followed  by  neuralgia  in  other  districts, 
especially  in  the  occipital  nerve. 

JEtiology. — Trigeminal  neuralgia  is  rare  in 
young  children,  but  may  occasionally  occur  in 
them,  associated  with  decayed  or  irregular  pro- 
trusion of  the  permanent  teeth.  In  these  circum- 
stances, it  is  sometimes  accompanied  by  epileptic 
convulsions.  In  its  migraine  shape,  it  almost 
always  attacks  the  sufferer  at  some  time  during 
the  period  of  bodily  development.  According  to 
the  late  Dr.  Anstie,  the  middle  period  of  life  is  not 
fruitful  in  Jirst  attacks  of  trigeminal  neuralgia. 


TIC-DOULOUREUX. 


but,  given  a declared  neuralgic  tendency,  the 
wear  and  tear  of  this  stage  tends  much  to  recall 
it.  In  women  utero-gestation,  the  exhaustion 
from  haemorrhage  at  parturition,  menorrhagia,  or 
over-suckling,  as  well  as  the  sexual  changes  in 
middle  life,  are  especially  prone  to  reproduce 
facial  neuralgia.  It  is,  however,  in  the  period  of 
degeneration  that  the  worst  and  most  intract- 
able examples  occur. 

The  term  ‘brow  ague’  is  still  frequently  ap- 
plied to  a neuralgia  of  the  first  division  of  the 
trigeminal,  which  cannot  be  referred  to  a ma- 
larious origin.  Formerly,  when  malarious  fevers 
were  rife  in  this  country,  such  an  affection  was, 
doubtless,  of  common  occurrence ; but  at  the 
present  day,  owing  to  drainage  and  cultivation, 
it  is  rare  for  this  cause  to  be  in  operation. 
Cases  do,  however,  occur,  and  these  may  usually 
be  recognised  by  regular  periodicity  in  the  at- 
tacks of  pain,  a semi-algide  condition  of  the 
system,  and  the  rapid  and  effectual  influence 
of  quinine.  Cold  wind,  especially  with  a moist 
atmosphere,  has  an  undoubted  influence  in  start- 
ing neuralgia  of  the  fifth  nerve,  the  unprotected 
condition  of  the  face  explaining  probably  its  pecu- 
liar liability  to  be  so  attacked.  There  appears 
reason  to  think,  however,  that  when  damp  with 
cold  excites  an  attack  of  neuralgia,  there  must  be 
at  the  same  time  a peculiar  condition  of  the  sys- 
tem, or  neuralgia  of  the  fifth  would  be  much  more 
common  in  this  climate  than  it  is.  Such  a con- 
dition is  probably  of  a rheumat  ic  or  gouty  nature, 
and  the  cold  seems  to  start  a subacute  neuritis 
in  the  sheath  of  the  nerve.  As  regards  general 
conditions  predisposing  to  the  affection,  they  are 
those  common  to  neuralgia.  See  Neuralgia. 

Injury  of  the  nerve ; foreign  bodies,  irritating 
either  this  or  some  other  nerve;  morbid  growths  of 
bone,  especially  such  as  cause  contraction  of  bony 
canals  traversed  by  branches  of  the  nerve  ; and 
syphilitic  periostitis,  may  act  as  exciting  causes 
of  tic-douloureux.  Or  the  immediate  cause  may 
be  in  the  floor  of  the  cranium,  in  the  form  of 
tumours  or  disease  of  bone  or  of  membranes, 
aneurism,  or  abscess. 

Symptoms. — Some  obscure  feeling  of  discomfort 
may  precede  the  outburst  of  actual  pain,  or  this 
may  occur  suddenly  and  without  warning  in  some 
part  of  the  district  supplied  by  the  fifth  nerve. 
There  will  be  one  or  more  foci  from  which  the 
pain  will  seem  to  emanate  in  swift  flashes,  a 
dull  aching  remaining  between  whiles,  of  a very 
wearying  character.  Generally  short-lived  at 
first,  the  paroxysms  of  darting,  burning,  boring 
pain  gradually  increase  in  severity  and  dura- 
tion. The  patient  sometimes  cringes  under  the 
violence  of  the  agony.  When  fairly  pronounced 
there  is  a great  tendency  to  the  excitement  of  a 
paroxysm  by  the  influence  of  such  slight  irritants 
as  a current  of  air,  a sudden  noise,  or  the  mus- 
cular movements  concerned  in  speaking,  laughing, 
chewing,  blowing  the  nose,  or  coughing.  The 
attack  of  tic  may  vary  to  any  extent  in  degree 
and  duration,  from  a short-lived  paroxysm  which 
never  returns,  to  a disease  of  the  most  obstinate 
character,  embittering,  with  more  or  less  con- 
stantly repeated  attacks,  the  whole  of  a long  life. 
Iu  such  cases  it  has  a tendency  to  remit  during 
the  course  of  severe  intercurrent  diseases. 

When  the  ophthalmic  division  of  the  nerve  is 


1631 

affected,  it  sometimes  happens  that  the  first 
notice  of  the  attack  is  an  exceeding  soreness  of 
some  spot  on  the  scalp,  recognised  only  on  brush- 
ing the  hair,  and  this  is  followed  some  heurs 
afterwards  by  pains  in  the  branch  of  nerve  distri- 
buted to  this  point.  The  pains  are  most  marked, 
and  tenderness  on  pressure  can  generally  be 
noted  in  one  or  more  of  the  following  places— 
the  supra-orbital  notch,  at  a point  a little  above 
the  parietal  eminence,  in  the  upper  eyelid,  at 
the  junction  of  the  nasal  bone  with  its  cartilage, 
within  the  eyeball,  or  at  the  inner  angle  of  the 
orbit.  There  is  often  lachrymation,  with  redness 
of  the  conjunctiva,  and  sometimes  intolerance  of 
light.  There  is  sometimes  so  much  tenderness 
that  the  patient  cannot  wear  a hat,  or  even  wash 
his  forehead.  Or  he  may  be  unable  to  blow  his 
nose.  If  one  or  two  hairs  be  drawn  over  this 
hypersesthetic  surface,  it  will  be  found  that  the 
tactile  discrimination  is  diminished,  as  compared 
with  the  corresponding  region  of  the  opposite 
side.  The  paiu  is  sometimes  described  as  shoot- 
ingin  the  upper  eyelid,  or  going  between  the  eye- 
ball and  the  cavity  of  the  orbit,  extending  thence 
over  the  brow,  as  though  the  forehead  were  being 
slit  open.  Pressure  upon  the  parietal  point  will 
send  a sort  of  heavy  dull  shock  into  the  eye. 
To  neuralgia  of  this  division,  in  consequence  of 
the  pain  being  limited  to  one-half  of  the  anterior 
aspect  of  the  head,  the  term  hemicrania  has  been 
applied,  whence  the  migraine  of  the  French, 
and.  the  vernacular  ‘ megrim.’  The  neuralgic 
affection  constitutes,  however,  only  a portion  of 
the  complex  group  of  phenomena  to  which 
the  term  migraine  is  properly  applicable,  and 
which  incl  udes,  besides,  subjective  sensations  of 
dazzling  lights  or  colours,  often  ol  a zig-zag 
shape,  transient  hemiopia,  vertigo,  unilateral 
numbness  and  tingling  of  extremities,  impairment 
of  speech,  nausea,  and  vomiting.  See  Migraine. 

When  the  superior  maxillary  division  is  in 
fault,  violent  pain  is  experienced  in  the  cheek- 
bone or  jaw,  or  in  both,  points  of  tenderness 
being  found  at  the  site  of  emergence  of  the 
infra-orbital  nerve,  over  the  malar  bone,  or  on 
the  gum  of  the  upper  jaw.  The  attacks  of  pain 
are  sometimes  accompanied  by  profuse  watery 
secretion  from  the  nasal  and  buccal  mucous 
membranes.  There  may  be  swelling  and  acute 
sensitiveness  of  the  lip  and  nostril,  the  slightest 
contact  with  which  causes  pain  to  shoot  widely 
in  various  directions,  sometimes  appearing  to 
affect  distant  parts  of  the  body.  Acute  pain  may 
also  occur  in  the  parotid  gland,  accompanied  by 
a great  flow  of  saliva,  and  also  in  the  teeth. 

When  the  third  division  is  attacked,  points  of 
intensity  may  be  found  on  the  temple,  a little 
in  front  of  the  ear,  at  the  place  of  exit  of  the 
inferior  dental  nerve,  at  the  side  of  the  tip  of 
the  tongue,  or  more  rarely  in  the  lower  lip.  The 
writer  has  under  his  care  two  ladies  past  middle 
life,  who  are  afflicted  with  neuralgia  of  this  divi- 
sion. In  one  the  pains  attack  both  sides  of  the 
lower  jaw  and  the  under  surface  of  both  bofders 
of  the  tongue.  They  occur  in  plunges  of  agony, 
which  cause  her  to  utter  a kind  of  shrieking 
groan,  and  th3  head  is  jerked  convulsively. 
They  are  brought  on  by  chewing,  swallowing, 
and  even  by  speaking.  Taste  is  not  affected. 
In  the  other  case  the  pain  is  entirely  localised 


1632 


TIC-DOULOUBEUX. 


tn  the  left  side  of  the  tongue-tip,  but  here  at 
times  it  is  so  intense  that  the  patient  rolls  on 
the  floor  in  agony.  There  is  slight  tenderness 
on  pressure,  but  no  painful  dartings  occur  at  the 
point  of  emergence  of  the  inferior  dental  nerve. 
To  cases  of  this  kind  marked  by  lightning-like 
seizures  of  exquisite  character,  and  accompanied 
by  spasmodic  movements  of  the  facial  muscles, 
the  term  epileptiform  neuralgia  is  sometimes 
applied.  Hereditary  tendency  to  insanity  often 
accompanies  this  form.  The  lingual  branch  of  the 
fifth  is  happily  not  so  often  affected  as  the  other 
portions,  for  there  is  probably  no  form  of  neu- 
ralgia involving  more  exquisite  suffering.  When 
the  auriculo-temporal  division  is  affected,  pain  is 
located  in  the  outer  auditory  meatus  and  temple. 
Many  cases  of  so-called  ear-ache  are  doubtless 
examples  of  neuralgia  affecting  this  nerve. 

There  is  a variety  of  trigeminal  neuralgia 
which  is  known  as  claims  hystericus,  and  which 
occurs  chiefly,  but  by  no  means  solely,  in  fe- 
males, and  affects  the  period  of  bodily  develop- 
ment. It  is  characterised  by  intense  pain,  limited 
to  one  or  two  small  points  (the  parietal,  or 
supra-orbital),  and  resembling  the  driving  of  a 
nail  into  the  skull.  It  occurs  most  often  in  the 
anaemic,  and  has  frequently  been  mistaken,  with 
unfortunate  results,  for  some  inflammatoryaffec- 
tion  demanding  depletory  measures. 

In  severe  tic-douloureux  the  facial  muscles, 
those  of  the  tongue,  and  even  sometimes  those  ro- 
tating the  bead,  may  be  spasmodically  contracted 
by  reflex  action  {see  Trifacial  Nerve,  Diseases 
of).  With  supra-orbital  neuralgia  there  may  be 
blepharo-spasm  or  strabismus.  The  writer  has 
lately  seen  a patient  liable  to  neuralgia  of  the 
supra-orbital  division  for  twenty  years  past,  in 
whom,  one  year  ago,  the  attack  began  to  be 
attended  with  complete  ptosis  and  external  stra- 
bismus, from  paralysis  of  the  third  nerve.  A cer- 
tain amount  of  weakness  has  continued  between 
the  attacks,  but  it  is  as  an  immediate  sequel 
of  the  pain  that  the  loss  of  power  is  most 
strongly  marked.  Two  days  after  the  cessation 
of  the  pain  the  eyelid  can  be  raised  fairly  well 
and  the  eyeball  moved,  though  never  quite  freely. 
Some  degree  of  vaso-motor  paralysis  is  shown  by 
the  reddening  and  heightened  temperature  of  the 
face  and  swelling  of  the  veins,  ■which  occur  uni- 
laterally during  the  paroxysms  cf  pain,  as  well 
as  by  the  soreness  of  skin,  indicating  probably 
a temporary  congestion  which  remains  behind. 
To  the  same  cause  must  be  referred  the  extreme 
redness  of  the  conjunctivse  and  mucous  mem- 
brane of  the  nostrils,  with  increased  lachrymation 
and  flow  of  nasal  and  buccal  secretion,  often 
observed  in  this  form  of  neuralgia.  The  hair  is 
very  liable  to  be  changed  in  colour  about  the 
seat  of  pain.  There  may  be  a permanent  blanch- 
ing, as  of  the  greater  part  of  an  eyebrow  or  a 
small  tuft  upon  the  head,  or  the  change  may  be 
a fluctuating  one,  the  colour  returning  during  the 
intermissions  of  the  disease.  Individual  hairs 
in  the  district  of  the  affected  nerve  may  be  hyper- 
trophied, or  the  converse  may  happen ; and  during 
the  persistence  of  attacks  the  hair  may  become 
brittle  and  fall  out,  to  return,  however,  when  the 
neuralgia  subsides.  Anstie  describes  a state  of 
thickening,  the  result  of  subacute  inflammation, 
in  the  periosteum  of  bone  and  in  fibrous  fasciae 


in  the  neighbourhood  of  the  painful  points  of 
neuralgic  nerves.  Pressure  on  these  swellings  may 
not  merely  excite  pains  in  the  affected  branches, 
but  send  a powerful  reflex  influence  through  the 
cord  to  distant  organs,  causing  vomiting,  or  affect- 
ing the  action  of  the  heart.  The  skin  is  apt  to 
grow  coarse,  and  patches  of  pigment  to  occur 
in  the  painful  situations.  In  neuralgia  of  the 
second  and  third  divisions  the  corresponding 
half  of  the  tongue  is  sometimes  seen  to  be  covered 
with  fur  from  overgrowth  of  epithelium,  and 
this  even  when  the  process  of  mastication  has 
taken  place  equally  on  each  side ; or  there  may 
be  salivation  severe  enough  to  cause  a suspicion 
of  mercurial  action,  but  which  may  be  distin- 
guished by  its  being  unilateral.  Acute  inflamma- 
tion of  the  skin,  in  the  form  of  herpes  or  of 
erysipelas,  not  unfrequently  attends  neuralgia  of 
the  fifth,  especially  its  first  division ; and  the 
eyeball  itself  may  become  in  similar  circum- 
stances the  seat  of  serious  inflammatory  action 
in  one  or  other  of  its  tissues.  There  may  be  a 
profuse  and  extensive  eruption  of  herpes,  leaving 
cicatrices  which  suggest  confluent  small-pox.  In 
such  a case  neuralgic  pains  may  cease  during  the 
eruption,  to  recur  with  great  violence  whilst  this 
is  scabbing.  Acute  glaucoma  is  attended  by 
symptoms  whicn  appear  to  refer  it  to  trophic 
changes  consequent  on  neuralgia  of  the  ophthal- 
mic division  of  the  fifth.  There  appears  reason 
to  think  that  recurrent  iritis  may  sometimes  be 
due  to  neuralgia  or  some  kindred  affection  of  the 
same  division.  Common  sensation  is  frequently 
blunted  during  and  after  paroxysms  of  tic,  but 
occasionally  there  will  be  so  much  and  such  per- 
sistent hyperesthesia  of  the  skin,  that  the  pa- 
tient cannot  bear  the  face  to  be  washed.  In  epi- 
leptiform tic  the  sufferer  will  often  be  observed 
to  rub  violently  with  a handkerchief  the  part  of 
the  face  affected  ; but,  on  the  other  hand,  there 
are  cases  in  which  not  even  the  touch  of  a light 
bonnet  can  be  borne,  so  exquisitely  sensitive  is  a 
portion  of  the  scalp.  A touch  with  the  finger 
upon  this  locality  will  sometimes  cause  the 
patient  to  fall  to  the  ground. 

Diagnosis. — The  paroxysmal  character  of  the 
pains,  coupled  with  the  tenderness  on  pressing 
various  points,  sufficiently  indicate  tic-dou- 
loureux.  The  only  condition  with  which  it  is 
at  all  easily  confounded  is  the  painful  ansesthesia 
which  is  apt  to  be  an  early  symptom  of  the  en- 
croachment of  a tumour  upon,  or  some  other 
destructive  lesion  of,  the  trunk  of  the  nerve 
within  the  cranium  ( see  Trifacial  Nerve,  Dis- 
eases of).  The  presence  of  pain  will  distinguish 
the  spasmodic  contractions  of  the  facial  muscles 
secondary  to  the  neuralgia  from  mimetic  spasm 
proper.  There  is  no  doubt  that  neuralgia  about 
the  forehead  is  often  mistaken  for  some  inflam- 
matory intracranial  mischief,  and  this  is  pecu- 
liarly liable  to  happen  where  either  ptosis  or 
strabismus  forms  part  of  the  symptoms.  Careful 
examination,  bearing  in  mind  the  points  of  dia- 
gnosis described,  ought  to  obviate  error.  Stiil 
more  important  is  it  to  avoid  the  error  of  ascrib- 
ing to  this  form  of  neuralgia  the  pain  occa- 
sioned by  the  growth  of  intracranial  tumour  (see 
Brain,  Tumours  of).  It  must  be  remembered, 
too,  that  pus  in  the  antrum  may  occasion  neu- 
ralgic symptoms.  A most  fruitful  source  of  tri- 


TIC-DOULOUREUX. 

geminal  neuralgia  is  caries  of  the  teeth.  The 
first  care  in  a case  should  be  to  have  the  state  of 
the  teeth  accurately  investigated,  and  faulty  teeth 
removed  or  otherwise  treated.  It  may  happen 
that  a tooth  betraying  no  outward  signs  of  deea}r 
is  carious  internally,  and  may  thus  easily  escape 
recognition. 

Prognosis  and  Duration. — Tic-douloureux 
occurring  in  j’outh  and  apparently  as  an  accident 
of  exposure,  or  as  a result  of  faulty  teeth,  may 
never  recur.  It  is  perhaps  more  common,  how- 
ever, for  repetitions  of  the  attack  to  take  place, 
alternating,  it  may  be,  with  neuralgia  in  other 
quarters.  Tic  is  not  unfrequently  liable  to  recur, 
especially  under  circumstances  of  depression, 
through  a whole  lifetime,  but  it  may  never  have 
the  character  of  extreme  severity.  In  certain 
few  cases,  however,  it  is  not  only  obstinate,  but 
of  terrible  violence,  the  patient  being  incapaci- 
tated through  many  years  by  the  constantly 
recurring  affection.  The  pain  has  been  in  some 
cases  violent  enough  to  destroy  life.  As  a rule, 
however,  the  disease,  however  severe  the  agony 
entailed  by  it,  does  not  seem  of  itself  to  shorten 
the  duration  of  the  life  which  it  fills  with  suffer- 
ing. 

Treatment. — As  in  neuralgia  generally,  the 
treatment  is  partly  constitutional  and  partly  local 
and  palliative  of  suffering  [see  Neuralgia).  The 
hypodermic  injection  of  morphia  holds  the  first 
place  as  a means  of  relief.  It  is  well  to  begin 
with  a small  dose,  say  -ith  grain,  and  repeat  it 
in  the  course  of  twelve  hours  if  necessary.  If 
the  doses  employed  can  be  kept  at  a moderate 
amount,  there  will  not  be  much  fear  of  opium- 
hunger  being  created,  and  they  can  be  discon- 
tinued without  difficulty  as  the  disorder  subsides. 
The  injection  is  quite  as  efficacious  when  made 
in  the  arm  as  in  the  face.  Blisters  are  often  of 
great  service.  A small  one  should  be  applied 
over  the  branches  of  the  cervico-occipital  nerve 
at  the  nape  of  the  neck,  and  repeated  if  ne- 
cessary. The  constant  voltaic  current  is  some- 
times useful.  A sufficient  number  of  cells  (from 
four  to  eight  or  ten)  should  be  employed  to 
give  such  a current  as  causes  the  negative  pole 
to  impart  a very  distinct  burning  sensation. 
The  circulation  should  never  be  abruptly  opened 
by  the  removal  of  the  rheophore,  but  on  applying 
and  when  leaving  off  a gradual  heightening  or 
lowering  of  the  strength  should  take  place,  in 
order  to  avoid  a shock.  The  rheophores  should 
be  fitted  with  sponges  well  moistened  with  salt 
and  water,  or  with  carbons  plunged  for  a minute 
or  two  in  hot  water.  The  application  may  be 
continued  for  five  or  ten  minutes  at  a time,  and 
be  repeated  several  times  daily.  In  some  cases 
of  tic  a combination  of  20  or  30  grains  of  chlo- 
ride of  ammonium  with  five  drops  of  nepenthe, 
taken  two  or  three  times  a day,  is  singularly 
efficacious. 

Croton  chloral — 2 to  I grains  in  a pill  taken 
every  two  hours  for  a few  times— may  be  some- 
times employed  with  advantage.  So,  also,  the 
tincture  of  gelsemium  sempervirens,  given  in 
doses  of  15  to  20  minims  every  two  hours,  till 
relief  is  obtained.  The  hydrate  of  chloral  in  a 
dose  of  20  grains  will  sometimes  be  of  great  ser- 
vice, if  the  pain  is  not  very  severe,  in  procuring 
a natural  kind  of  sleep  from  which  the  patient 

103 


TIN,  POISONING-  3Y.  1033 

wakes  relieved.  If,  however,  the  pain  be  severe, 
chloral  is  useless.  It  is  important  not  to  con- 
found the  epithelial  overgrowth  of  the  tongue, 
which  so  commonly  occurs  in  tic,  with  the  ordi- 
nary furring  from  digestive  difficulties  which  is 
supposed  to  indicate  a necessity  for  purgatives. 
It  will  be  observed  that  it  only  affects  a lateral 
half. 

In  two  cases  of  epileptiform  tic  of  from  seven 
to  ten  years’  duration,  which  had  resisted  a.l 
treatment,  and  incapacitated  the  sufferers  from 
earning  their  livelihood,  the  writer  had  two  out 
of  the  three  divisions  of  the  trigeminal  stretched, 
with  most  satisfactory  results.  In  one  case  five 
months,  in  the  other  about  twelve  months  have 
elapsed  since  the  operation,  without  return  of 
pain.  It  appears  to  be  essential  that  not  only 
the  central  end  of  the  nerve  should  be  pulled 
upon  with  considerable  force,  but  also  the  peri- 
pheral portion.  A considerable  amount  of  cuta- 
neous anaesthesia  ought  to  follow  the  operation, 
though  it  usually  does  not  last  more  than  a few 
days.  See  Nerves,  Diseases  of. 

T.  Buzzard. 

TIN,  Poisoning  by. — Synon.  : I’r.  Empoi- 
sonnement  par  I’Etain  ; Ger.  Zinnvergiftung. 

The  importance  of  tin  as  a toxic  agent  has  only 
recently  been  recognised;  for  although  attention 
was  drawn  nearly  a century  ago  to  the  possible 
danger  attending  the  use  of  tinned  vessels  for  culi- 
nary purposes,  the  danger  was  supposed  to  be 
due  simply  to  the  contamination  of  the  metal 
with  arsenic.  Subsequently  alarm  was  excited  in 
consequence  of  the  employment  of  alloys  of  tir. 
for  the  storage  of  tinned  preserved  articles  of 
food,  such  as  meat,  vegetables,  and  fruits ; but 
here  again  the  danger  has  been  assigned  to  the 
lead  with  which  the  tin  is  alloyed,  a lead-tin 
alloy  being  used  for  the  construction  of  the 
capsules  employed.  Very  recently,  however, 
attention  has  been  directed  to  the  tin  with 
which  tinned  foods  are  almost  invariably  con- 
taminated, as  itself  presenting  a source  of  danger 
to  the  consumer.  It  is  known  that  the  soluble 
salts  of  tin,  met  with  in  commerce  as  Dyer's  salt, 
2)inJc  salt,  & c.,  are  poisonous;  and  experiments 
on  animals  show  that  even  the  insoluble  hy- 
drated oxides  of  tin  are  fatally  poisonous,  the 
oxides  being  no  doubt  dissolvedinthe  alimentary 
fluids,  tin  having  been  detected  after  death  in 
such  cases  in  the  liver  and  other  solid  viscera. 
Certain  kinds  of  sugar  recently  brought  into 
commerce  are  prepared  by  a process  which  in- 
troduces tin  to  the  extent  of  from  one-fourth 
to  one-third  of  a grain  per  lb.  of  sugar  into  the 
manufactured  article ; and  it  is  at  present  a 
moot  point  whether  these  sugars  are  innocuous 
or  deleterious. 

Anatomical  Characters. — The  ’post-mortem, 
appearances  in  fatal  poisoning  by  tin  are  those 
of  the  mineral  irritants.  The  cases  observed 
have  been  too  rare  to  be  spoken  of  otherwise 
than  generally.  See  Poisoning. 

Symptoms. — Of  these  but  little  is  known. 
Concentrated  solutions  of  stannous  chloride  and 
of  stannic  chloride — the  lower  and  higher  chlo- 
rides respectively  of  the  metal — are  known  to  act 
as  irritant  poisons.  Neurotic  symptoms  are  also 
manifested,  so  that  tin-salts  do  not  appear  fc 


1634  TIN,  POISONING  BY. 
ict  simply  as  irritants.  In  large  doses  the 
chlorides  produce  fatal  results.  Probably  the 
toxic  results  are  heightened  by  the  free  hydro- 
chloric acid  invariably  present  in  the  commercial 
solutions  of  stannous  and  stannic  chlorides. 

Treatment. — The  treatment  to  be  employed 
is  that  for  mineral  acids.  See  Poisoning. 

Thomas  Stevenson. 

TINEA  ( tinea , a moth-worm). — Synon.  : Fr. 
Teigne;  Ger.  Flechte  ; Tinea. 

Definition. — A class  of  diseases  of  the  skin, 
due  to  the  presence  of  vegetable  parasites  in  the 
integumentary  structures.  The  term  is  also  em- 
ployed as  a generic  name  for  the  organisms 
.hemselves. 

Varieties. — The  varieties  of  tinea  generally 
distinguished  are  Tinea  tonsurans ; Tinea  kerion; 
Tinea  circinata ; Tinea  sycosis ; Tinea  unyium  ; 
Tinea  versicolor ; and  Tinea  favosa.  The  first 
five  are  varieties  caused  by  the  same  fungus,  and 
are  included  under  the  term  Tinea  trichophytina. 
Tinea  favosa  is  described  in  the  article  Favus  ; 
tinea  versicolor  in  the  article  Phytosis  Versi- 
coeor  ; and  tinea  sycosis  is  also  referred  to 
under  the  heading  Sycosis. 

1 . Tinea  tonsurans. — Synon.  : Ringworm 
of  the  hairy  scalp  ; porrigo  scutulata  and  herpes 
tondens  of  old  writers. 

Description. — This  is  a chronic  disease  of  the 
scalp,  resulting  from  an  attack  on  the  epithelial 
tissues  of  a fungus  called  trichophyton  tonsurans. 
The  characteristic  lesion  is  a textural  alteration  of 
the  hairs,  due  to  the  growth  of  the  fungus,  which 
causes  them  to  become  lustreless,  opaque,  dry, 
swollen,  and  brittle,  and  to  break  off  close  to  the 
scalp,  as  though  nibbled  away,  at  the  same  time 
that  they  are  surrounded  and  invaded  by  fungus- 
elements.  This  change  takes  place  over  more 
or  less  circular  areas,  which  are  of  varying  size, 
from  a threepenny-piece  to  that  of  the  palm  of  the 
hand,  and  are  the  seat  of  fine,  white,  meal-like 
desquamation.  The  fungus,  once  implanted  upon 
the  surface,  loads  to  the  changes  detailed  in 
the  article  Epiphytic  Skin-Diseases.  There 
may  be  many  spots  of  disease,  or  only  one. 
Clinically  it  is  important  to  be  aware  that 
the  disease  may  vary  in  appearance  from  the 
typical  characters  above  described.  The  patch 
of  tinea  tonsurans  may  not  he  circular  but 
irregular,  which  may  be  due  to  the  coalescence 
of  two  or  more  patches.  In  strumous  subjects 
a certain  amount  of  pus  may  be  produced  at  the 
seat  of  mischief;  and  this,  together  with  the 
hairs,  may  be  matted  together  into  a semi-crust, 
in  which  the  diseased  hairs  of  ringworm  are  not 
very  recognisable  at  first.  Lastly,  in  elironie 
cases  of  tinea  tonsurans,  there  may  be  only  a 
diseasod  hair  here  and  there  amongst  the  healthy 
ones,  and  these  are  very  liable  to  be  overlooked. 
To  be  made  aware  of  these  variations  in  appear- 
ance is,  however,  to  greatly  facilitate  the  diag- 
nosis. "Whenever  the  growth  of  hairs  seems  to 
he  interfered  with  in  a patchy  form,  and  there 
is  desquamation,  a careful  examination  should 
always  bo  made  for  the  parasite  in  the  hairs. 
Tinea  tonsurans  (of  the  scalp)  often  co-exists 
with  T.  circinata  (of  the  general  surface),  and 
the  latter  may  extend  to  the  scalp  and  there 
become  T.  tonsurans.  Thus  these  two  varieties 


TINEA. 

are  essentially  the  same  in  nature,  the  only  dif- 
ference being,  that  in  the  one  case  the  fungus 
attacks  a hairy  part,  and  causes  a peculiar  change 
in  the  hairs  ; and  in  the  other  it  grows  on  parts 
where  any  implication  cf  hairs  is  a secondary 
feature. 

In  examining  a hair,  it  should  be  soaked  fer 
some  time  in  diluted  liquor  potasses,  placed 
on  the  slide,  and  covered  by  thin  glass  in  the 
usual  way  ; aud  then  a little  pressure  should 
be  made,  so  as  to  flatten  the  piece  of  hair  to 
separate  its  component  fibres,  by  getting  as  it 
were  a thinner  section,  to  bring  the  fungus 
more  readily  into  view.  The  fungus,  the  tri- 
chophyton tonsurans , as  usually  seen,  consists 
almost  entirely  of  conidia,  or  those  reproduc- 
tive bodies  commonly  called  spores.  They  aro 
round,  -003  to  -007  mm.  long,  by  -003  to  '004 
mm.  broad  (equivalent  to  from  to  g^o 
in.)  very  uniform  in  size,  however,  in  any  par- 
ticular case;  nucleated;  sometimes  constricted; 
and  very  abundant  about  the  roots  of  the  hair. 
The  mycelial  filaments,  when  seen,  are  few, 
jointed,  somewhat  undulated,  and  with  interior 
granules.  The  fungus  attacks  both  the  hairs 
and  other  epithelial  structures. 

Diagnosis. — The  diagnosis  of  tinea  tonsurans 
is  at  once  made  Ly  the  presence  of  the  short, 
texturally  altered,  and  broken-off  hairs ; and 
attention  should  he  given  to  this  point,  and  not, 
as  is  too  often  done,  to  the  mere  ‘ eruptive  ’ 
phase  of  the  complaint. 

Treatment. — The  treatment  is  most  disap- 
pointing, and  it  is  difficult  to  enforce  with  any 
great  degree  of  success,  except  in  cases  under  the 
immediate  eye  of  the  medical  attendant.  It  is 
needless  to  enter  here  into  detail  at  length,  and 
tlie  following  is  a summary  of  the  treatment 
of  ringworm,  as  applicable  to  the  majority  of 
cases.  There  are  three  indications.  First,  wo 
must  improve  the  general  nutritive  tone  of  those 
attacked,  for  thereby  the  fungus  finds  a less 
favourable  soil  for  growth.  Secondly,  we  have 
to  get  rid  of  the  fungus ; and  this  is  effected  in 
two  ways,  partly  by  removing  as  far  as  possible 
all  diseased  hairs  by  epilation,  and  partly  by 
bringing  parasit  icides  in  contact  with  the  diseased 
structures.  Aud,  thirdly,  it  is  necessary  to  secure 
an  entirely  new  growth  of  hair,  since,  practically, 
hairs  once  attacked  by  the  fungus  never  return  to 
a healthy  condition  ; and  the  occurrence  of  this 
latter  desideratum  is  favoured  in  proportion  as 
epilation  is  complete,  and  is  accelerated  by  stimu- 
lation after  the  removal  of  the  diseased  hairs. 

The  first  indication  above  stated  is  effected  by 
the  administration  of  good  food ; by  placing  the 
patient  under  the  influence  of  good  hygienic  con- 
ditions ; by  prescribing  cod-liver  oil,  iron,  quinine, 
or  arsenic,  according  as  the  constitutional  state  is 
one  of  a strumous  or  lymphatic  nature,  or  is  at- 
tended by  ansemia,  debility,  or  the  like.  Fatty 
substances  of  all  kinds,  when  they  can  be  di- 
gested, are,  as  a rule,  to  be  taken  by  children 
suffering  from  severe  ringworm. 

As  regards  the  second  indication,  before  epila- 
tion or  parasiticides  are  used,  the  hair  should  be 
cleared  away  from  off"  and  around  the  diseased 
surfaces.  If  there  are  many  places  about  the  scalp, 
it  is  well  to  cut  all  the  hair  off.  It  is  best  removed 
by  the  scissors ; if  the  scalp  be  shaven,  it  is 


TINEA. 


mostly  excoriated  and  made  tender,  so  that  strong 
remedies  cannot  be  so  well  applied.  The  prefer- 
able plan  is  to  cut  the  hair  as  close  as  possible 
to  the  scalp  with  scissors,  and  to  repeat  the  opera- 
tion every  few  days.  When  the  hair  has  been 
removed,  the  diseased  surfaces  appear  as  more 
or  less  well-defined  circular  areas  or  patches, 
which  are  darker  than  the  healthy  scalp,  covered 
by  scales,  and  studded  by  hairs,  which  are 
swollen,  thickened,  lustreless,  and  brittle.  Epila- 
tion is  now  to  be  proceeded  with.  The  nurse, 
mother,  or  medical  man,  whoever  it  may  be, 
(mould  take  a pair  of  ciliary  forceps,  and  clear 
away  the  hairs  as  far  as  practicable,  over  an 
area  of  an  inch  or  more  in  diameter  at  a sitting; 
many  hairs  break  off,  but  some  come  away  whole, 
and  if  they  do  break  away,  more  decided  access 
_s  given  to  the  follicles  for  parasiticides.  All 
patches  should  be  epilated,  the  operation  being 
repeated  over  the  same  areas  from  time  to  time, 
as  the  diseased  hairs  grow  up.  After  epilation, 
two  or  three  courses  may  be  adopted.  The  part 
may  be  blistered,  or  parasiticides  of  anon-vesica- 
ting character — and  their  name  is  legion— may 
be  applied,  or  a plan  combining  the  use  of  both 
means  may  be  adopted.  Repeated  blistering 
with  acetic  acid,  or  acetum  cantharides,  may  be 
resorted  to,  but  perhaps  the  mixed  course  is  the 
best.  It  is  a good  plan  to  blister  occasionally 
or  once  a week,  going  over  tho  same  parts  two  or 
three  or  more  times  after  each  blistering,  allow- 
ing time  to  get  the  scab  off,  then  rubbing  in 
freely  a parasiticide  for  several  days,  and  then 
re-applying  the  blister.  The  best  parasiticides 
are  the  iodine  liniment,  sulphur  compounds,  mer- 
curials, tar,  creasote,  and  carbolic  acid,  which 
may  be  variously  combined  in  strength  accord- 
ing to  the  age  of  the  child.  The  ointment  form 
is  preferable,  and  it  should  be  thoroughly  in- 
uncted  night  and  morning.  Very  small  invete- 
rate patches  may  be  treated  by  croton  oil  lini- 
ment, to  excite  the  formation  of  pustules  round 
each  hair,  or  better  still  artificial  kerion.  The 
hair  is  thus  loosened  and  got  rid  of.  The 
number  of  remedies  for  ringworm  is  legion;  but 
the  particular  remedy  used  is  not  so  important, 
as  that  it  be  used  vigorously,  with  epilation,  till 
every  vestige  of  a diseased  hair  has  disappeared. 
In  fact,  the  entire  absence  of  any  short,  thick, 
brittle  stubs,  which  may  be  broken  off  quite  in  the 
follicles,  and  the  springing  up  of  fine,  downy, 
silky  hairs,  are  the  only  real  proof  that  a scalp 
ringworm  is  cured.  During  this  treatment  the 
head  should  be  well  washed  every  day,  and  light 
linen  or  silk  caps  must  be  worn.  The  individual 
affected  is  to  be  regarded  as  capable  of  spreading 
the  disease  from  person  to  person,  or  of  convey- 
ing ringworm  of  the  surface,  tinea  eircinata,  to 
adults.  Change  of  air  is  always  desirable. 

The  third  indication,  namely,  the  promotion  of 
the  re-growth  of  the  hair,  is  secured  by  the  use  of 
#ome  stimulating  wash.  The  following  is  a good 
one: — Tincture  of  lytta  6 drachms;  distilled 
vinegar,  2 ounces  ; spirit  of  rosemary,  2 ounces ; 
glycerine,  2 drachms ; and  6 ounces  of  rose- 
water ; to  be  well  sponged  into  the  roots  of  the 
uair  night  and  morning. 

2.  Tinea  kerion.  — Description.  — This  is 
not  a common  disease.  It  is  a modification  of 
tinea  tonsurans,  in  which  each  separate  hair- 


1635 

follicle  is  swollen  and  prominent,  and  exudes  a 
puriform  fluid  like  mistletoe  juice.  The  joint 
result  of  the  swelling  of  the  many  hair-follicles 
together  is  the  production  of  a raised  boggy  cir- 
cular swelling,  studded  over  with  minute  orifices, 
discharging  mueiform  fluid.  In  some  cases,  it 
would  seem  as  if  subcutaneous  formation  of  pus 
were  about  to  take  place.  The  hairs  lie  loose  in 
the  follicles,  having  been  detached  from  the  fol- 
licular linings  by  the  exudation  ; and  they  are 
readily  pulled  away,  and  indeed  often  fall  out 
spontaneously.  If  they  remain  in  the  follicle  for 
any  time,  they  are  apt  to  get  vc-ry  brittle.  This 
disease  is  idiopathic  ; or  it  may  be  set  up  by  the 
use  of  irritant  remedies  to  the  scalp,  by  which 
the  follicles  are  inflamed. 

Treatment. — This  disease  cures  itself,  so  to 
speak.  The  hairs,  being  loose  in  the  follicles,  are 
readily  removed  therefrom,  and  with  them  the 
fungus  ; or  so  little  of  it  is  left  behind  that  the 
mildest  parasiticides  alone  are  required.  Epila- 
tion, in  feet,  is  both  easy  and  immediately  suc- 
cessful. The  writer  was  the  first  to  demonstrate 
the  parasitic  nature  of  the  disease,  and  his  ex- 
perience teaches  him  that,  as  a rule,  all  that  is 
needed  is  the  removal  of  the  hairs,  and  tho  use 
of  soothing  remedies,  such  as  liquor  plumbi  oint- 
ment. 

3.  Tinea  eircinata. — Synon.  : Ringworm  of 
the  surface.  — Description. — As  stated  above, 
this  disease  is  produced  by  the  same  fungus  that 
is  present  in  tinea  tonsurans,  but  it  is  an  affec- 
tion of  non-hairy  parts.  It  generally  begins  by  a 
small  scurfy  spot,  or  rarely  a minute  red  patch 
with  a vesicular  edge.  In  either  case  the  fully 
developed  disease  consists  of  one  or  more  well- 
defined  circular  patches,  the  bounding  edge  being 
red,  raised,  and  vesicular;  whilst  the  central  area 
is  much  paler,  aud  is  the  seat  of  branny  desqua- 
mation. If  an  examination  be  made  of  scrapings 
from  the  surface  of  the  patch,  the  fungus  will  be 
detected,  and  in  its  mycelial  form  chiefly.  Tinea 
eircinata  is  common  about  the  forehead,  cheek, 
chin,  and  back  of  the  neck,  but  also  occurs  on 
other  parts  of  the  body.  It  often  co-exists  with 
tinea  tonsurans  ; and  it  can  give  rise  to  the  latter 
by  transmission  to  the  scalp  of  its  fungus-ele- 
ments, or  by  its  extension  from  the  face  or  neck 
to  hairy  parts  of  the  scalp. 

In  some  cases,  especially  in  persons  who  per- 
spire, and  in  hot  weather — that  is  to  say,  under  the 
combined  influence  of  heat  and  moisture,  and 
consequently  in  hot  climates — ringworm  of  the 
surface  may  be  very  severe  and  extensive.  The 
circular  patches  are  very  large,  with  well-defined 
edges,  spreading  over  various  regions  of  the  body. 
The  common  seat  is  the  fork  of  the  thigh,  to 
which  it  may  be  localised,  festooning  down  wards 
some  little  way.  This  is  the  eczema  marginatum 
of  Hebra,  an  eruption  often  seen  in  England.  In 
otljer  cases  there  may  be  rings  or  patches,  still 
with  papular  or  vesicular  edges  and  desquamat- 
ing centres,  scattered  over  the  buttocks,  the  thighs, 
about  the  front  of  the  chest,  the  axill®,  or  the  neck 
and  face ; two,  three,  or  more  places  being  affected 
at  a time.  This  condition  is  common  in  China. 
India,  and  other  hot  climates  and  to  it  the  terms 
‘ Dhobie’s  ’ and  ‘ washerwoman's  itch,’  ‘ Indian 
ringworm,’  and  ‘Chinese  ringworm,’  are  applied 
But  these  locally-named  varieties  are  all  modifi- 


1636  TINEA. 

sations  of  common  tinea  circinata  ; and  the  writer 
has  seen  equally  severe  eases  in  England  in  very 
hot  seasons. 

Diagnosis. — The  diagnosis  is  made  certain  by 
microscopic  examination,  and  the  detection  there- 
by of  the  fungus.  All  circular  well-defined 
patches  of  skin-disease,  with  papular  or  vesi- 
cular edges  and  paler  desquamating  centres, 
should  be  examined  for  a parasitic  cause. 

Treatment. — Tinea  circinata  is  usually  easily 
cured  by  the  inunction  of  any  of  the  parasiti- 
cides already  mentioned;  but  such  treatment  may 
be  preceded  by  the  application  of  some  mild 
vesicant,  as  acetic  acid  or  blistering  fluid,  to 
remove  the  epidermic  layers  in  which  the  fungus 
mostly  flourishes.  In  some  cases  the  disease  is 
very  obstinate,  but  most  will  yield  to  the  free 
application  of  a hyposulphite  of  soda  lotion,  Jss 
to  yij  of  water;  or  to  repeated  applications  of 
gunpowder  or  goa  powder  made  into  a paste 
with  vinegar. 

4.  Tinea  sycosis. — Tinea  sycosis  is  also  pro- 
duced by  the  attack  of  the  trichophyton  tonsu- 
rans upon  the  hairy  parts  of  the  face,  namehr, 
the  whiskers,  or  more  commonly  the  beard.  It 
is  fully  described  under  its  own  heading.  Sec 
Sycosis. 

6.  Tinea  versicolor. — This  disease  is  cha- 
racterised by  the  presence  of  fawn-coloured,  more 
or  less  circular,  patches,  slightly  raised,  itchy, 
and  the  seat  of  branny  desquamation.  THe 
fungus  is  the  Microsporon  furfur,  composed  of 
conidia  of  a round  shape,  '0008  to  '002  mm.  in 
diameter,  collected  together  into  characteristic 
heaps,  connected  by  a network  of  thick  wavy 
and  branched  threads.  In  examining  for  the 
fungus  a very  small  piece  and  a very  thin  layer 
of  scale  must  be  taken,  and  it  must  be  rendered 
very  transparent  by  potash,  and  gently  pressed 
out  between  the  glasses.  For  a description  of 
the  disease  see  Phytosis  Versicolor. 

Onyehomykosis.  — Definition.  — Parasitic 
disease  of  the  nails. 

Description. — Occasionally  the  trichophyton, 
and  very  rarely,  the  achorion,  will  attack  the  nail, 
sending  mycelial  threads  through  the  nail-sub- 
stance, and  rendering  the  nail  opaque,  thickened, 
and  brittle.  Other  causes  produce  thickened, 
opaque,  brittle  nails,  such  as  psoriasis,  syphilis, 
general  debility,  general  eczema,  lichen  ruber ; 
but  in  parasitic  disease  only  a single,  or  perhaps 
two  or  three  nails  are  affected,  the  nails  of  the 
feet  escaping  almost  invariably.  Hence,  in  all 
rases  where  only  one  or  two  nails  are  opaque, 
brittle,  and  thickened,  a careful  examination  of 
the  nail-substance  should  be  made  for  fungus- 
elements.  Onyehomykosis  may  occur  with  tinea 
circinata,  the  latter,  in  fact,  investing  the  nail, 
or  it  may  be  derived  by  contact  with  tinea  ton- 
surans, as  in  the  case  of  those  who  attend  to 
ringworm  cases. 

Treatment. — The  treatment  consists  in  scrap- 
ing away  the  nail-substance  and  soaking  the  parts 
continuously  in  hyposulphite  of  soda,  sulphurous 
acid  lotion,  or  some  approved  parasiticide. 

Tilbury  Fox.1 

TINKLING-,  METALLIC.— A sound  of 
a peculiar  quality,  which  the  name  sufficiently 
' Bevtsed  by  Dr.  T.  Colcott  Fox. 


TOBACCO,  POISONING  BY. 

defines,  occasionally  heard  on  auscultation  ia 
connection  with  cavities  in  the  chest.  See  Physi- 
cal Examination. 

TINNITUS  (Lat.). — Synon.:  Fr.  Bourdonne- 
ment  d’ Oreillcs ; Ger.  Summcn;  Klingen. — This 
term,  which  is  commonly  used  when  speaking  of 
noises  in  the  ears,  is  a frequent  symptom  in  many 
diseases  of  the  external,  middle,  and  inner  ear. 
It  is  usually  present  in  all  those  conditions  where 
there  is  undue  pressure  on  the  labyrinth  ; for 
instance,  when  there  is  pressure  on  the  tympanic 
membrane  from  cerumen,  imperfect  entrance  ol 
air  into  the  tympanum,  due  to  obstruction  of  the 
Eustachian  tube,  or  effusion  within  the  tympanic 
cavity.  It  accompanies  most  inflammatory  dis- 
eases of  the  external  or  middle  ear ; follows  in- 
juries to  the  tympanic  membrane,  and  blows  on 
the  head  or  ear;  may  occur  in  aueurism  at  the 
base  of  the  skull;  and  is  a prominent  symptom  in 
all  nervous  affections  of  the  auditory  apparatus, 
as  well  as  ia  many  states  of  disordered  hearing 
where  the  ear  is  healthy.  So  infinite  are  the 
degrees  and  variations  in  this  symptom  that 
there  is  probably  no  known  sound  to  which  it 
has  not  been  compared  by  patients.  When  tin- 
nitus is  due  to  some  curable  local  cause,  the 
symptom  rapidly  disappears  with  its  removal. 
When,  however,  it  accompanies  deafness  in  ner- 
vous affections,  it  is  often  the  more  troublesome 
symptom  of  the  two,  and  the  less  amenable  to 
treatment.  Strychnia  is  the  most  useful  tonic 
in  ear-affections,  and  quinine  the  least  suitable, 
as  this  drug  exercises  a distinctly  injurious  effect, 
if  taken  in  large  doses.  See  Ear,  Diseases  of; 
Hearing,  Disorders  of ; and  Vertigo. 

W.  B.  Dalbt. 

TITUBATION  ( titubo , I stagger). — A term 
for  staggering  or  stumbling  gait.  See  Cere- 
bellum, Diseases  of ; and  Vertigo. 

TOBACCO,  Poisoning  by.  — Synon.  : Fr. 
Empoissoncmcnt  par  le  Tabac ; Ger.  Tabakver- 
giftung. — The  minor  effects  of  tobacco-poisoning 
— nausea,  depression,  vomiting,  vertigo — are  well 
known  to  the  incipient  smoker.  Fatal  poisoning 
by  tobacco  rarely  occurs,  except  through  its 
ignorant  administration  by  mouth  or  rectum. 
Cases  of  nicotine-poisoning  are  still  more  rare, 
this,  the  volatile  active  alkaloid  of  tobacco,  not 
being  readily  procurable. 

Anatomical  Characters. — .After  death  from 
tobacco-poisoning  the  organs  and  tissues  have 
a tobacco-like  odour,  and  the  odour  of  nicotine 
becomes  more  pronounced  on  treating  them  with 
liquor  potass*.  Turgescence  of  the  brain  has 
been  described;  but,  beyond  the  odour,  there  is 
nothing  diagnostic  in  the  appearances. 

Symptoms. — When  a strong  decoction  of  to- 
bacco or  snuff  is  administered,  either  by  mouth 
or  rectum,  very  speedily — usually  in  about  five 
minutes — the  patient  is  seized  with  vertigo, 
acute  abdominal  pain,  nausea,  and  vomiting. 
The  skin  is  pallid  and  bathed  in  perspiration. 
Stupor  supervenes,  with  partial  or  general  con- 
vulsions, and  stertorous  respiration  ; and  death 
may  result  in  fifteen  cr  twenty  minutes,  pre 
ceded  by  dilatation  and  insensibility  of  the  pupils. 
When  the  alkaloid,  nicotine,  is  swallowed,  insen- 
sibility supervenes  almost  immediately ; the 


TOBACCO,  POISONING  BY. 
pupils  are  ■widely  dilated;  respiration  is  speedily 
suspended;  and  the  patient  dies  in  three  or  four 
minutes. 

Diagnosis.. — -The  odour,  coupled  with  the 
shove-described  symptoms,  would  leave  no  doubt 
83  to  the  nature  of  the  case.  Usually  there  is 
a history  of  administration. 

Prognosis. — The  prognosis  is  in  all  cases 
unfavourable.  Fatal  Dose. — Thirty  grains  of  to- 
bacco are  said  to  have  proved  fatal.  A drop  or 
two  of  nicotine  would  doubtless  prove  fatal. 

Treatment. — The  treatment  of  poisoning  by 
tobacco  consists  in  the  exhibition  of  emetics, 
followed  by  tannin  freely  in  any  form  to  render 
the  alkaloid  insoluble.  Strong  tea,  coffee,  and 
stimulants  should  also  be  administered.  Iodine, 
dissolved  with  iodide  of  potassium,  has  been 
:ecommended ; but  is  probably  of  little  effi- 
cacy, and  is  undoubtedly  irritating  to  the  sto- 
mach. Twenty  to  thirty  minims  of  tincture  of 
nux  vomica  may  be  given,  and  repeated  at  inter- 
vals ; or,  better,  a hypodermic  injection  of 
grain  of  the  nitrate  or  other  soluble  salt  of 
strychnia  may  be  administered. 

Thomas  Stevenson. 

TONE,  "Want  of. — This  expression,  al- 
though commonly  employed  in  a somewhat  loose 
and  unscientific  manner,  is  sufficiently  under- 
stood in  the  main.  To  appreciate  its  meaning,  it 
is  first  necessary  to  enquire  what  tone  is.  In  the 
widest  sense  of  the  term,  a person  may  be  de- 
scribed as  being  in  tone  when  his  several  organs 
individually  discharge  their  functions  in  a per- 
fect manner,  and  act  harmoniously  as  a whole, 
just  as  a violin  is  said  to  be  in  tune  when  me- 
lody can  be  educed  by  striking  its  individual 
strings.  More  correctly,  tone  is  applied  to  a con- 
dition of  the  muscular  system,  as  signifying  that 
state  of  tension  in  which  voluntary  muscular 
efforts  can  be  produced  and  continued  with  a 
healthy  and  pleasurable  feeling;  and  also  to 
muscular  organs,  to  indicate  a certain  degree  or 
power  of  contraction  of  their  walls. 

iETIOLOGY  AND  PATHOLOGY. Various  factors 

combine  to  produce  and  maintain  muscular  tone. 
First,  this  state  is  dependent  on  a proper  supply 
of  nervous  energy ; secondly,  nourishment  and 
oxygen  must  be  furnished  in  abundance ; thirdly, 
the  products  of  waste  must  be  thoroughly  re- 
moved from  the  system ; and  fourthly  the  work 
required  of  the  muscular  tissue  must  not  be 
excessive,  that  is,  a certain  amount  of  rest  must 
be  afforded  to  it. 

Want  of  muscular  tone  results,  then,  from 
failure  of  any  of  these  circumstances. 

1.  Nervous  failure. — Whatever  view  may  be 
taken  of  the  nature  of  nervous  and  muscular 
force,  modern  research  has  shown  that  they  are 
intimately  connected  with  each  other.  If  the 
nerve-supply  be  cut  off,  muscles  waste ; and 
vice  versa,  if  the  muscles  remain  unemployed, 
their  nerve-centres  suffer.  The  effect  of  nervous 
disease  or  disorder  in  producing  loss  of  muscular 
tone  is  illustrated  by  such  neuroses  as  hysteria 
aid  epilepsy,  by  some  forms  of  mental  disease, 
and  by  the  large  but  indefinite  class  of  cases 
known  as  ‘ nervous  debility,’  of  which  mental 
strain,  anxiety,  sexual  excess,  and  alcoholism  are 
frequently  the  exciting  causes.  It  is  in  these 


TONE,  WANT  OF.  1637 

cases  that  we  derive  special  benefit  from  what 
are  called  ‘ nervine  tonics,’  such  as  strychnia, 
the  phosphates,  and  cod-liver  oil. 

2.  Failure  of  nutrition. — Deficiency  of  the 
blood-supply  immediately  lowers  muscular  ac- 
tivity, in  consequence  of  interference  both  with 
the  nutrient  and  the  oxygenating  processes.  It 
is  on  this  account  that  want  of  tone  is  found 
in  anaemia,,  in  convalescence  from  acute  diseases, 
aud  to  a certain  extent  even  in  chronic  dys- 
pepsia. Want  of  oxygen  and  impurity  of  the 
atmosphere  lead  as  distinctly  to  lassitude;  and, 
if  long  continued,  to  lowering  of  muscular  energy 
and  loss  of  tone,  as  amongst  the  inhabitants  of 
large  towns,  and  in  persons  employed  in  close, 
ill-ventilated  rooms. 

3.  Detention  of  waste  products.  — When 
muscles  are  called  into  action  certain  com- 
pounds are  formed  within  them,  which  must  be 
eliminated  by  being  passed  back  into  the  circu- 
lation and  excreted.  The  lungs,  skin,  kidneys, 
liver,  and  bowels  must,  therefore,  discharge  their 
functions  properly  to  keep  the  muscular  system 
in  tone.  We  have  here  the  explanation  of  a 
very  common  class  of  cases  of  want  of  tone. 
Many  persons,  either  from  choice  or  from  neces- 
sity, habitually  take  an  insufficient  amount  of 
active  bodily  exercise  for  the  removal  of  the 
waste  products  from  the  muscular  and  other 
systems.  In  the  former  ease  this  is  the  result 
of  indulgence  in  abundant  rich  food,  combined 
with  lazy  habits,  confinement  to  warm  ‘ relax- 
ing ’ rooms,  and  the  avoidance  of  ‘bracing’ 
exercise.  In  the  latter  ease,  the  metabolic 
inactivity  is  referable  to  enforced  confinement  in 
sedentary  employments,  often  of  an  exhausting 
kind,  carried  on  perhaps  in  an  impure  atmosphere, 
or  throwing  a continuous  strain  upon  one  set  of 
muscles,  such  as  those  involved  in  standing  or 
sitting.  Both  these  classes  of  cases  also  are  met 
with  chiefly  in  large  towns,  and  they  constitute 
a considerable  proportion  of  the  persons  who 
‘ require  tonics.’ 

4.  Muscular  exhaustion. — Excessive  muscular 
exercise  leads  to  loss  of  tone ; first,  by  interfer- 
ing with  nutrition,  which  is  most  active  during 
rest  ; secondly,  by  wear  and  tear ; and  thirdly, 
in  the  case  of  hollow  muscular  organs,  such  as 
the  intestines  (the  muscular  walls  of  which 
have  to  resist  internal  pressure),  by  gradual 
exhaustion  of  muscular  irritability  from  con- 
tinuous excitement,  or  possibly  even  by  over- 
stretching and  dislocation  of  the  fibres.  The 
first  two  forms  of  muscular  atony  are  well 
illustrated  by  certain  instances  of  cardiac  ex- 
haustion; the  third  form  is  met  with  not  only 
in  the  alimentary  canal,  but  in  the  bladder,  in 
the  blood-vessels,  and  indeed  in  all  muscular 
tubes  and  ducts,  when  over-distended  by  solid, 
fluid,  or  gaseous  contents. 

5.  Combined  causes. — In  many  cases  two  or 
more  of  the  causes  mentioned  under  the  pre- 
ceding heads  are  combined,  and  give  rise  to 
want  of  tone  or  atony.  Thus  in  that  large  class 
of  cases  of  debility  with  which  practitioners  in 
large  towns  are  familiar,  and  which  especially 
includes  young  female  subjects  engaged  in  busi- 
ness, over-work,  impure  air,  insufficient  light, 
badly  cooked  or  otherwise  improper  food,  the 
constant  strain  of  the  muscles  of  the  legs  and 


1638  TONE,  WANT  OF. 

tack  without  sufficient  movement,  and  frequently 
many  circumstances  relating  to  the  nervous  sys- 
tem, are  all  combined.  Again,  the  subjects  of 
chronic  nervous  affections,  such  as  epilepsy  and 
hysteria,  are  too  frequently  over-fed,  nursed  in 
warm  rooms,  and  spared  every  form  of  healthy 
exertion,  with  the  result  of  producing  a flabby, 
atonic  state  of  system. 

Symptoms. — Want  of  tone  in  the  muscular 
system  generally  is  characterised  by  a number 
of  symptoms,  which  are  all  more  or  less  ill- 
defined  and  difficult  to  describe,  being  chiefly  of 
a negative  and  subjective  kind.  The  chief  of 
these  are  a peculiar  feeling  of  want  of  muscular 
vigour  ; weakness,  heaviness,  and  even  aching 
of  the  limbs ; languor,  inability  and  unwilling- 
ness to  undertake  or  to  coriffnue  any  kind  of 
physical  or  mental  exertion,  and  a desire  to 
remain  passive  and  undisturbed.  This  reacts 
upon  the  mind,  causing  depression  of  spirits, 
melancholy,  and  other  subjective  symptoms. 

The  symptoms  of  want  of  tone  or  atony  of 
muscular  organs  vary  greatly  with  the  part 
affected.  Thus  atony  of  the  stomach  is  charac- 
terised by  a familiar  form  of  dyspepsia,  which 
is  called  ‘ atonic ; ’ atony  of  the  bowels  is  chiefly 
attended  by  constipation  and  flatulence  ; atony 
of  the  bladder  is  associated  with  retention  of 
urine.  Ulcers  are  said  to  ‘ want  tone  ’ when 
the  healing  process  flags. 

Treatment. — It  will  be  gathered  from  the 
preceding  remarks  that  want  of  tone,  whether 
general  or  local,  is  a condition  which  calls  for 
very  different  kinds  of  treatment,  according  to 
its  cause.  One  of  the  principal  reasons  of  the 
want  of  success  which  frequently  attends  at- 
tempts to  restore  tone  to  the  system  is  failure 
on  the  part  of  the  practitioner  to  appreciate 
this  truth,  and  to  discover  and  remove  tbe  cause 
or  causes  of  the  morbid  state.  Tonic  drugs  sug- 
gest themselves  only  too  readily  as  the  proper 
means  to  be  employed ; and  so  great  is  the 
number  of  remedies  which  go  by  this  name,  and 
so  complex  are  the  combinations  in  which  they 
are  now  presented  by  the  pharmacist,  that  re- 
course is  often  had  to  them  before  an  accurate 
estimate  has  been  made  of  tbe  direction  in  which 
the  system  or  the  affected  organ  is  really  at  fault, 
and  hence  injury,  not  benefit,  results.  These 
remarks  apply  both  to  loss  of  tone  generally, 
and  to  atony  of  special  organs.  Thus  it  hap- 
pens that  the  best  tonic  measure  in  one  case 
may  be  rest,  in  another  case  exercise ; in  a 
third  case  food  and  stimulants  may  be  urgently 
called  for,  in  a fourth  case  lowering  measures  are 
essential  at  the  commencement  of  treatment. 
Time  is  an  equally  important  factor  in  the  pro- 
cess of  restoration  to  tone.  This  is  especially 
true  in  the  instances  where  rest  is  necessary  ; but 
even  in  the  very  opposite  class  of  cases,  where 
exercise  is  demanded,  this  must  be  carried  on 
for  a long  time,  being  commenced  with  caution 
and  slowly  increased. 

The  details  of  tonic  treatment  are  indicated 
in  a special  article  ( see  Tonics).  Here  it  need 
only  be  added  that  when  the  nervous  elements 
are  distinctly  deficient  in  activity,  strychnia,  cin- 
chona, phosphorus,  and  cod-liver  oil  appear  to 
be  specially  indicated,  whilst  galvanism  and  mas- 
sage may  be  useful.  Alcoholic  stimulants  and 


TONGUE. 

iron  are  best  adapted  to  cases  in  which  nourish- 
ment and  oxygenation  have  fallen  below  par. 
Dr.  Weir  Mitchell  has  lately  shown  how  much 
may  be  done  by  systematic  feeding  in  conjunc- 
tion with  the  other  means  just  indicated.  When 
the  activity  of  the  organs  is  diminished  from 
accumulation  of  waste  products,  we  must  have 
recourse  to  moderate  eholagogue  purgation,  to 
such  diuretics  as  digitalis,  to  diaphoretics,  and 
especially  to  change  of  occupation  and  exercise 
of  such  a kind  in  an  open  healthy  atmosphere  as 
shall  bring  all  the  voluntary7  muscles  into  action, 
and  stimulate  if  possible  every  bodily  function. 
In  the  converse  class  of  cases,  where  exhaustion 
is  the  result  of  over-exertion,  we  have,  after 
removing  the  cause,  to  exhibit  antispasmodic  cr 
even  sedative  drugs,  such  as  belladonna  and 
opium,  which  are  especially  useful  in  the  first 
stage  of  atony  of  the  stomach  and  alimentary 
canal,  as  well  as  in  atony  of  the  bladder. 

WlIilAM  Bb.ucr. 

TONGUE,  The. — Synon.  : Fr.  La  Langv.e; 
Ger.  Die  Zunge. — Apart  from  its  own  parti- 
cular diseases,  which  are  described  in  a separate 
article  ( see  Tongue,  Diseases  of),  the  tongue,  as 
is  familiarly  recognised,  gives  important  clinical 
indications  regarding  the  morbid  conditions  of 
the  general  system,  and  of  various  local  diseases, 
which  it  will  be  the  object  of  this  article  to 
endeavour  to  point  out  in  a systematic  manner. 
To  ‘look  at  the  tongue’  is  one  of  the  first  acts 
of  ‘physical  examination’  which  every  tyro  in 
the  medical  profession  performs ; hut  there  is 
much  that  is  indefinite  and  uncertain  in  the 
ideas  as  to  what  this  examination  is  intended  for, 
and  what  information  it  affords. 

Mode  and  Objects  of  Investigation. — In 
general  terms  it  may  be  stated  that  we  examine 
the  tongue,  for  clinical  purposes,  with  reference, 
first,  to  its  subjective  sensations;  secondly,  to 
its  movements ; and,  thirdly,  to  the  objective 
characters  which  it  presents. 

1.  Its  subjective  sensations  chiefly  include  or- 
dinary tactile  sensation  and  the  sense  of  taste. 
In  most  cases  we  rely  for  information  on  these 
points  upon  the  statements  of  patients : but 
under  certain  circumstances  common  sensibility 
may  be  tested  experimentally  by  a suitable  in- 
strument ; and  taste,  by  applying  different  ar- 
ticles to  the  tongue  with  a brush,  or  in  other 
ways  ( sec  Taste,  Disorders  of).  Dr.  Quain  lias 
called  the  attention  of  the  writer  to  a peculiar 
sense  of  heat  or  burning,  sometimes  felt  in  the 
tongue,  which  seems  to  be  associated  with  the 
gouty  diathesis. 

2.  The  movements  of  the  tongue  are  studied 
by  watching  them  directly,  and  by  noticing  any 
abnormal  affection  of  speech  or  deglutition, 
arising  from  defect  or  disorder  of  these  move- 
ments. A peculiar  thickness  of  speech,  or  an 
inability  to  swallow  properly,  may  result  from 
this  cause,  and  finally  articulation  and  degluti- 
tion may  become  impossible.  To  examine  the 
tongue  directly  as  a motor  organ,  it  should  first 
be  looked  at  while  in  the  mouth,  both  at  rest 
and  when  the  patient  moves  it  from  side  to  side, 
or  in  other  directions  ; then  he  should  be  directed 
to  put  it  out,  and  to  perform  similar  movements 
when  the  tongue  is  protruded.  This  mode  oi 


TONGUE. 


investigation  gives,  in  certain  cases,  important 
information. 

3.  The  objective  examination  of  the  tongue  in 
itself  is  of  far  more  frequent  application  than 
the  methods  just  considered,  being  indeed  called 
for  and  ordinarily  practised  in  every  case,  al- 
though it  may  not  necessarily  afford  any  positive 
information.  No  patient  thinks  his  case  properly 
investigated  unless  he  is  told  to  put  out  his 
tongue.  The  examination  is  usually  carried 
out  by  inspection;  but  it  may  also  be  re- 
quisite, and  very  advantageous,  to  feel  the 
tongue  with  the  fingers.  In  looking  at  the 
organ,  an  endeavour  should  be  made  to  inspect 
its  entire  upper  surface,  and  for  this  purpose  the 
patient  should  be  directed  to  open  the  mouth, 
and  protrude  the  tongue  as  far  as  possible,  a 
good  light  being  also  needed  for  observing  it. 
In  some  instances,  as  in  infants  and  rebellious 
children,  as  the  result  of  congenital  malformations 
or  wearing  false  teeth,  in  many  low  febrile  cases, 
and  in  certain  nervous  diseases,  the  tongue 
must  be  examined  while  in  the  mouth,  as  the 
patient  either  cannot  or  will  not  put  it  out 
properly  ; for  this  purpose  it  is  sometimes  neces- 
sary to  open  the  mouth  rather  forcibly,  but  with 
due  care,  and  it  may  be  desirable  to  employ  some 
artificial  light.  For  more  minute  information  in 
certain  cases  it  is  requisite  to  scrape  the  surface 
of  the  organ,  and  to  examine  microscopically  what 
is  thus  removed.  The  points  to  be  noticed  in 
the  objective  examination  of  the  tongue  are:  — 
a.  Its  size  and  shape  as  a whole,  as  well  as  its 
point  and  margins,  b.  Its  condition  as  to  firmness 
or  flabbiness,  c.  The  colour  of  the  mucous  mem- 
brane. d.  Whether  the  surface  is  normal,  un- 
usually smooth  and  glazed,  furrowed,  fissured, 
or  otherwise  altered,  e.  The  condition  of  the 
papillae,  especially  the  fungiform  papillse.  f. 
Whether  the  tongue  is  moist,  sticky,  or  dry. 
g.  The  absence  or  presence  of  any  fur  on 
the  dorsum  of  the  organ  ; and,  if  present,  its 
arrangement,  thickness,  colour,  and  other  general 
characters,  as  well  as  in  some  cases  its  micro- 
scopic characters.  It  may  be  remarked  that  in 
connection  with  this  examination  of  the  tongue, 
it  is  often  advantageous  to  notice  the  condition  of 
the  mouth  generally,  but  especially  of  the  gums 
and  teeth,  and  of  the  lips.  Further,  the  patient 
may  afford  information  with  regard  to  the  objec- 
tive conditions  of  the  tongue,  not  coming  imme- 
diately under  the  notice  of  the  practitioner, 
such  as  whether  it  is  much  furred  on  waking  in 
the  morning,  or  if  it  is  inclined  to  dryness. 

It  is  requisite  to  offer  a few  remarks  respect- 
ing fur  on  the  tongue.  This  varies  much  in  its 
extent,  thickness,  and  appearances.  It  may 
cover  the  whole  surface  of  the  organ  ; or  only 
its  posterior  or  anterior  part,  one  lateral  half,  or 
even  a limited  patch  when  due  to  local  causes. 
The  fur  may  be  a mere  film,  or  of  considerable 
thickness.  Its  chief  colours  are  white,  whitish- 
yellow.  yellow,  yellowish-brown,  brown,  brown- 
ish-black, and  black.  It  is  either  moist  and 
easily  separated;  sticky  and  viscid:  or  dry, 
being  then  often  cracked  and  peeling  off. 
Under  certain  circumstances  fur  appears  and 
disappears  with  great  rapidity.  Microscopically 
it  is  found  to  consist  chiefly  of  epithelium-par- 
ticles, either  formed  in  excess,  or  accumulated 


1G30 

upon  the  surface  of  the  tongue  from  various 
causes.  The  particles  are  held  together  by 
saliva  and  mucus ; and  mixed  with  them  are 
often  the  remains  of  food,  or  bacteroid  growths, 
especially  bacilli  and  micrococci.  Yellow  fur 
is  supposed  to  be  due  to  fatty  degeneration 
of  the  epithelium,  and  then  fatty  particles  ara 
present.  Blood  or  altered  blood,  and  pigments 
are  found  in  the  brown  and  black  furs.  The 
increased  production  of  epithelium,  causing  a 
fur,  is  due  to  liyperoemia  of  the  tongue,  de- 
pendent either  upon  the  general  condition  of 
the  patient,  or  upon  direct  or  reflex  irritation. 
There  are  serious  conditions,  however,  in  which 
the  development  of  epithelium  on  the  tongue  it 
prevented,  and  so  it  is  not  furred,  but  becomes 
red  and  raw. 

Clinical  Indications. — In  the  following  re- 
marks it  is  intended  to  give  a summary  cf  the 
principal  conditions  and  diseases  in  which  the 
tongue  affords  useful  information,  and  to  indicate 
tho  main  characters  which  it  presents.  Allowance 
must  always  be  made  for  individual  peculiarities 
in  the  shapo  or  size,  and  in  the  appearances  pre- 
sented by  this  organ;  for  the  effects  of  certain 
habits,  such  as  excessive  smoking,  or  chewing 
tobacco  and  other  materials;  for  changes  in 
colour  due  to  taking  iron  or  other  medicines ; 
and  for  any  local  irritation.  Moreover,  most 
people,  but  especially  those  who  sleep  with  the 
mouth  open,  have  a more  or  less  furred  tonguo 
in  the  morning,  which  is  of  no  special  import- 
ance, or  it  may  tend  to  dryness;  while  in  some 
individuals  its  surface  presents  constantly  a thick 
fur,  without  evident  disturbance  of  any  organ, 
appetite  being  excellent,  and  the  digestive  func- 
tions performed  in  a most  satisfactory  manner. 
On  the  other  hand,  a perfectly  clean  and  healthy- 
looking  tongue  may  be  associated  with  severe 
dyspeptic  symptoms,  or  even  with  serious  organic 
disease  of  the  alimentary  canal  or  its  related 
organs.  Many  persons  have  the  surface  of  the 
tongue  much  furrowed. 

1.  Nervous  diseases. — In  this  class  of  dis- 
eases the  tongue  often  affords  information  of  much 
value,  and  it  is  here  that  its  sensations  and 
movements  are  mainly  disordered.  In  many 
cases  of  cerebral  lesion  one  half  of  the  tongua 
is  paralysed  in  its  muscles,  so  that  the  organ  is 
unsymmetrieal  in  the  shape  of  its  two  sides  ; and 
deviates,  when  in  the  month  to  the  healthy  side, 
but  when  protruded  towards  the  paralysed  side. 
In  exceptional  cases  the  entire  organ  is  affected, 
so  that  it  cannot  be  protruded  or  even  moved. 
The  way  in  which  a patient  attempts  to  put  out 
the  tongue  when  asked  to  do  so,  may  be  made 
use  of  to  indicate  the  state  of  consciousness  ir. 
various  conditions  affecting  the  brain.  In  many 
cases  of  cerebral  disease  the  tongue  shows  a 
marked  and  speedy  tendency  to  become  thickly 
furred,  and  very  foul.  This  is  well  seen  in 
cases  of  apoplexy  due  to  haemorrhage. 

The  tongue  is  specially  affected  in  certain 
peculiar  nervous  diseases,  especially  labio-glosso- 
laryngeal  paralysis,  many  cases  of  diphtheritic 
paralysis,  general  paralysis  of  the  insane,  and 
extreme  cases  of  wasting  palsy.  Beginning  with 
slight  indications  of  loss  cf  power,  as  tremulous- 
ness, thickness  of  speech,  and  difficulty  in  swal- 
lowing, the  affection  is  liable  to  end  in  complete 


TONGUE. 


1 040 

paralysis  of  the  organ,  which  may  also  involve 
its  sensibility.  These  results  depend  on  disease 
involving  die  roots  of  the  nerves  supplying  the 
tongue.  The  organ  may  also  be  thus  affected 
in  various  degrees,  owing  to  some  morbid  con- 
dition implicating  its  nerves  in  their  course  or 
at  their  origin.  When  completely  paralysed, 
the  tongue  in  time  may  come  to  present  the 
appearance  of  a sodden  mass  lying  in  the  mouth. 
In  cases  of  severe  neuralgia  of  one  side  of  the 
face,  the  tongue  occasionally  presents  peculiar 
appearances,  such  as  unilateral  furring,  thicken- 
ing of  the  mucous  membrane,  or  enlargement  of 
the  papilloe.  The  tremulous  and  foul  tongue  of 
acute  or  chronic  alcoholism  may  also  be  mentioned 
under  this  head.  Signs  of  the  organ  having 
been  bitten  may  be  useful  in  the  diagnosis  of 
obscure  cases  of  epilepsy.  The  jerking  and  irre- 
gular movements  of  the  tongue  are  very  striking 
in  many  cases  of  chorea.  During  attacks  of  mi- 
graine its  surface  usually  becomes  much  furred. 

2.  General  conditions  and  diseases. — The 
tongue  is  usually  markedly  altered  in  the  febrile 
state,  whether  associated  with  specific  fevers,  or 
with  inflammatory  diseases.  It  becomes  covered 
with  more  or  less  fur,  often  of  considerable 
thickness,  and  usually  either  white  or  yellowish- 
white.  In  particular  fevers  the  organ  commonly 
presents  peculiar  characters.  Thus,  in  most  cases 
of  typhoid  fever  it  is  small  and  irritable,  with 
enlarged  papilloe,  and  a thin,  whitish  or  yellowish 
fur;  or  sometimes  it  is  red,  smooth,  and  glazed 
or  shining.  In  this  disease  it  may  be  peculiarly 
tremulous,  and  this  has  been  regarded  as  a bid 
sign,  as  indicating  deep  ulceration  of  the  intes- 
tine. In  scarlatina  the  papillae  tend  to  become 
much  enlarged  and  prominent,  so  that  they  pro- 
ject through  the  fur,  and  the  tongue  in  many 
cases  presents  the  so-called  ‘ strawberry  ’ ap- 
pearance. In  diphtheria  it  may  exhibit  a diph- 
theritic deposit  upon  its  surface.  There  is  gene- 
rally a very  thick,  creamy  fur  in  acute  rheuma- 
tism, as  well  as  preceding  and  during  attacks 
of  gout,  and  in  the  latter  especially  it  often 
becomes  brownish.  In  acute  pneumonia  also 
the  tongue  is  usually  thickly  coated.  In  the 
‘ typhoid  state,’  whatever  this  condition  may- 
be associated  with,  the  tongue  is  dry,  and  usually 
covered  with  a brown  or  even  blackish  crust, 
appearing  as  if  it  were  baked.  It  is  often  very 
red  and  irritable  in  itself,  and  occasionally  the 
typhoid  tongue  has  little  or  nothing  on  its  sur- 
face, but  is  very  dry,  deeply  red,  like  raw  beef, 
and  fissured.  This  is  due  to  the  fact  that  the 
long-continued  pyrexia,  especially  if  high,  pre- 
vents the  formation  of  epithelium.  The  organ 
may  be  in  such  a condition  that  it  can  scarcely 
be  moved  at  all.  At  the  same  time  sordes  are 
present  on  the  teeth  and  gums.  In  malarial 
fevers  the  margins  of  the  tongue  are  said  to  pre- 
sent sometimes  a faint  bluish  tinge. 

It  may  be  remarked  here  that  the  tongue  not 
uncommonly  affords  evidence  of  constitutional 
syphilis,  owing  to  the  past  effects  of  this  disease 
upon  the  organ.  It  also  indicates  the  general 
tone  of  the  system,  being  usually  large  and 
flabby  when  this  is  below  par.  In  some  instances 
of  diseases  attended  with  marked  general  wasting, 
the  tongue  comes  to  present  an  irritable  appear- 
ance. 


3.  Conditions  affecting  the  blood  and 
circulation.  — The  tongue  often  exhibits  ab- 
normal characters,  due  to  the  state  of  the  blood 
or  circulation.  Thus,  in  anaemia  it  is  more  or 
less  pale ; generally  large,  flat,  broad,  and  flabby ; 
and  frequently  marked  at  the  sides  by  the  teeth. 
In  the  plethoric  condition  it  is  also  large,  but  tends 
to  be  of  a deeper  colour  than  normal,  and  may 
present  a venous  tint.  The  anaemic  tongue  is  fre- 
quently quite  clean,  though  this  will  depend  much 
on  its  cause  ; but  the  tongue  of  plethora,  is  gene- 
rally furred,  on  account  of  the  condition  of  the 
alimentary  canal.  A temporarily  congested  con- 
dition of  the  digestive  organs  and  liver  is  sup- 
posed to  produce  a corresponding  plethoric  state 
of  the  tongue.  Any  cause  of  general  obstruc- 
tion to  the  venous  circulation,  or  of  interference 
with  the  due  aeration  of  the  blood,  whether 
seated  in  the  heart  or  lungs,  is  likely  to  give 
rise  to  enlargement  of  the  tongue,  and  to  make  it 
assume  a congested,  or  even  a cyanotic  appear- 
ance in  marked  cases,  such  as  those  of  congenital 
malformation  of  the  heart.  It  occasionally 
happens  that  some  local  obstruction,  affecting  the 
large  veins  in  the  thorax,  as  from  the  pressure 
of  an  aneurism,  produces  a similar  condition  of 
the  tongue. 

4.  Affections  of  the  alimentary  canal 
and.  its  related  organs. — The  tongue  is  of 
peculiar  importance  in  relation  to  these  organs, 
in  most  cases  affording  very  definite  and  valuable 
information  as  to  their  condition.  Indeed,  some 
of  the  deviations  from  the  normal  state  already 
considered  depend  directly  upon  disorder  affect- 
ing the  digestive  apparatus.  Without  attempting 
to  give  a complete  or  detailed  account  of  the 
varieties  of  abnormal  tongue  associated  with 
diseases  of  these  parts,  the  general  indications 
which  it  affords  may  ho  thus  pointed  out. 

a.  The  tongue  is  peculiarly  liable  to  be  altered 
iu  local  affections  of  the  mouth  and  throat.  In 
catarrh  of  these  parts  it  is  more  or  less  furred. 
In  tonsillitis  there  is  usually  a very  thick  fur  ; 
and  it  may  be  most  marked  on  the  side  of  the 
inflamed  tonsil.  Even  a local  irritation,  such 
as  that  caused  by  decayed  teeth,  may  originate 
a fur,  and  it  is  under  such  circumstances  that  it 
is  liable  to  be  localized. 

b.  In  any  acute  disorder  of  the  alimentary 
canal  the  tongue  speedily  becomes  furred,  usually 
either  white  or  yellowish-white,  hut  it  may  be 
more  or  less  brown.  This  is  seen  in  so-called 
acute  dyspepsia,  catarrh  of  the  alimentary  canal, 
and  hepatic  disorders.  The  fur  often  disappears 
very  speedily.  In  severe  acute  gastritis  the 
organ  often  presents  a strikingly  red  and  irri- 
table appearance,  especially  at  the  tip  and  edges, 
with  enlarged  papillae,  and  a tendency  to  dry- 
ness. 

c.  In  chronic  forms  of  dyspepsia  and  gastric 
catarrh,  the  tongue  presents  different  appear- 
ances according  to  circumstances.  In  the  atonic 
variety  it  is  usually  large,  flat,  soft,  and  flabby ; 
frequently  marked  with  the  teeth  : and  more  or 
less  furred,  though  it  may  be  quite  clean.  In 
the  irritative  form  it  tends  to  be  small,  elongated, 
and  pointed;  contracted  and  firm;  red  and 
irritable  ; with  enlarged  papilloe ; and  generally 
only  having  a thin  white  fur,  through  which  these 
papillae  project,  but  it  may  appear  unusually 


TONGUE. 

tleun  and.  raw-looking.  The  organ  may  present 
characters  more  or  less  similar  to  those  just 
described,  in  those  cases  where  the  food  passes 
rapidly  out  of  the  stomach  into  the  duodenum 
m an  undigested  state.  In  the  more  grave 
diseases  of  the  stomach,  namely,  cancer  and 
ulceration,  the  tongue  has  no  special  characters, 
and  indeed  is  often  very  healthy-looking;  its  cha- 
racters will  depend  on  the  state  of  the  gastric 
mucous  membrane  generally. 

d.  The  relation  of  the  tongue  to  affections  of 
the  intestines  is  not  so  evident  as  in  the  case  of 
the  stomach.  When  they  are  implicated  to- 
gether in  the  same  disorder,  the  organ  presents 
the  characters  already  indicated.  The  bowels, 
however,  are  often  much  deranged  or  diseased 
without  any  abnormal  appearances  being  ex- 
hibited by  the  tongue,  provided  the  stomach  is 
unaffected.  It  may  be  said,  however,  that  con- 
stipation, especially  if  habitual,  tends  to  make 
the  tongue  large  and  furred,  particularly  if 
associated  with  portal  congestion  and  deficiency 
of  bile.  In  some  cases  of  chronic  intestinal 
catarrh,  with  diarrhoea,  the  organ  presents  an 
irritable  appearance.  In  chronic  dysentery  it 
often  becomes  red,  glazed,  or  fissured. 

e.  As  regards  the  organs  connected  with  the 
alimentary  canal,  it  is  only  the  liver  which  can 
be  stated  definitely  to  affect  the  tongue.  As 
has  been  already  mentioned,  any  interference 
with  the  portal  circulation  is  liable  to  cause  a 
plethoric  condition  of  the  organ  ; and,  owing  to 
the  effects  produced  on  the  alimentary  canal,  it 
becomes  more  or  less  furred.  Any  deficiency  of 
bile  in  the  intestines  also  leads  to  furring  of  the 
organ;  and  if  this  is  very  marked,  or  if  the  bile 
is  entirely  absent,  the  tongue  tends  to  become 
very  foul.  It  is  much  affected  in  acute  biliary 
disorders  ; and  may  become  coloured  yellow  in 
jaundice. 

5.  Special  diseases.  — In  diabetes  the 
tongue  is  often  peculiarly  irritable,  red,  clean, 
cracked,  and  dry.  In  acute  peritonitis  it  is 
usually  remarkably,  small  and  contracted,  also 
red  and  irritable,  with  but  little  fur.  and  tending 
to  dryness.  In  advanced  cases  of  phthisis,  es- 
pecially with  a high  temperature,  it  frequently 
becomes  red  and  raw,  and  exhibits  enlarged 
papillae  ; the  occurrence  of  thrush  upon  its  sur- 
face may  also  be  a sign  of  approaching  dis- 
solution in  this  disease.  These  illustrations 
will  suffice  to  point  out  the  special  information 
which  the  tongue  may  afford  as  regards  par- 
ticular diseases. 

Conclusion. — By  a consideration  of  the  cha- 
racters of  the  tongue,  it  will  be  seen  from  the 
foregoing  remarks  that  important  and  valuable 
indications  are' often  afforded,  not  only  as  regards 
diagnosis,  but  also  for  prognosis  and  treatment. 
Therefore  it  is  essential  that  its  characters 
should  be  properly  studied  in  every  case,  bearing 
in  mind  the  three  clinical  aspects  which  it 
presents  to  the  practitioner,  namely,  its  sensi- 
bility, movements,  and  objective  characters. 

Frederick.  T.  Roberts. 

TOUGUiE,  Diseases  of. — Synon.  : Fr.  Ma- 
ladies de  la  Langue;  Ger.  Kranlcheiten  dcr 
Ztinge. 

The  principal  morbid  conditions  affecting  the 


TONGUE,  DISEASES  OF.  1641 
tongue  may  be  thus  enumerated  in  alphabetical 
order: — 1.  Adhesions  ; 2.  Atrophy;  3.  Cancer; 
4.  Hypertrophy ; 5.  Inflammation ; 6.  Para- 

sitic affections;  7.  Syphilis;  8.  Tongue-tie;  9. 
Tumours;  10.  Tylosis;  and  11.  Ulceration. 
Aphthae  and  thrush  are  discussed  under  their 
respective  headings  {see  Aphthje;  and  Theush). 
The  simpler  disturbances  of  the  surface  of  the 
tongue,  of  which  the  practitioner  avails  himself 
as  an  aid  to  diagnosis,  are  separately  discussed. 
See  Tongue. 

1.  Adhesions. — Occasionally  the  tongue  is 
attached  more  or  less  extensively  at  its  sides 
and  under  surface  to  the  corresponding  surfaces 
of  the  mouth.  These  adhesions  may  be  con- 
genital, but  more  frequently  they  are  the  result 
of  ulceration  or  sloughing. 

Treatment. — In  congenital  cases  the  mem- 
branous bands  may  either  be  divided  with  blunt- 
pointed  scissors  or  with  a scalpel ; or,  if  they 
are  too  thick  and  extensive  to  be  treated  in  this 
way,  a ligature  may  be  passed  round  them,  and 
drawn  tight,  so  as  to  bring  about  their  division. 
Adhesions  which  have  been  caused  by  ulceration 
or  sloughing  may  be  dealt  with  in  a similar 
manner,  but  the  result  is  much  less  hopeful. 

2.  Atrophy. — Some  degree  of  atrophy  of  the 
muscular  substance  of  the  tongue  usually  accom- 
panies those  forms  of  paralysis  which  affect  its 
nerves.  If  the  paralysis  be  considerable,  the 
muscular  fibres  become  wasted,  but  the  bulk  of 
the  organ  is  often  kept  up  by  the  interstitial 
deposit  of  fat.  Besides  this,  there  are  two  groups 
of  cases  in  which  there  is  well-marked  wasting. 
These  are  ( a ) cases  in  which  there  is  disease  of 
the  medulla  oblongata,  involving  the  hypoglossal 
nucleus ; and  (6)  cases  in  which  the  ninth  nerve 
is  diseased  or  injured  between  the  cerebrum  aDd 
the  muscles  to  which  it  is  distributed.  The  cases 
which  fall  under  the  first  head  may  depend  upon 
softening,  haemorrhage,  syphilitic  disease,  or  other 
causes.  This  class  includes  the  labio-glosso- 
laryngeal  paralysis  of  Duchenne.  Those  which 
come  under  tho  second  head  are  due  to  morbid 
growths  of  different  kinds,  or  to  accidents  or 
injuries.  The  atrophy  may  affect  both  sides 
equally,  or  only  one.  See  Hypoglossal  Nerve, 
Diseases  of. 

Treatment. — Treatment  must  be  directed  to 
the  cause  of  the  complaint. 

3.  Cancer. — ^Etiology. — Cancerof  the  tongue 
is  most  frequently  seen  between  the  ages  of  forty 
and  seventy;  and  it  is  more  than  twice  as  com- 
mon in  men  as  in  women. 

Description. — Cancer  of  the  tongue  commences 
either  as  a small  excrescence,  blister,  or  crack; 
or  as  a hard  lump  in  the  substance  of  the  organ. 
Its  origin  may  often  be  traced  to  some  local  irri- 
tation, or  to  some  previous  lesion.  In  whatever 
way  it  begins,  the  same  symptoms  are  common 
to  all  varieties.  There  is  occasional  darting  pain, 
radiating  towards  the  ear,  temple,  and  vertex. 
The  diseased  portion  is  tender;  eating  is  rendered 
difficult;  speech  is  thiekand  indistinct;  the  base 
of  the  tongue  becomes  infiltrated  ; and  the  organ 
cannot  be  freely  moved  or  protruded  from  the 
mouth.  The  sublingual  and  submaxillary  glands 
as  well  as  those  which  are  connected  with  tho 
lymphatic  system,  become  enlarged  and  painful, 
There  is  an  increased  flow  of  saliva.  The  cireu 


TONGUE,  DISEASES  OF. 


1642 

lation  through,  the  brain  may  be  disturbed,  and 
the  patient  then  complains  of  giddiness  and 
headache.  Bapid  wasting  and  loss  of  strength 
manifest  themselves. 

The  local  disease  gradually  involves  more  and 
more  of  tho  mouth.  Sometimes  large  sloughs 
form,  and  profuse  bleeding  takes  place.  The 
difficulty  of  swallowing  and  even  of  breathing  is 
great,  on  account  of  the  obstruction  which  the 
disease  causes  at  the  pharynx  ; and  this  ob- 
struction is  increased  by  oedema,  the  result  of 
retardation  of  the  venous  current.  Gradually  the 
growth  invades  the  neighbouring  parts ; and  fre- 
quently, before  death  takes  place,  bronchitis  or 
pneumonia  sets  in.  The  most  common  seat  of 
cancer  of  the  tongue  is  on  the  side  of  the  organ, 
at  its  middle  or  back  part.  It  is  almost  always 
of  the  epithelial  variety ; very  rarely  i t i s scirrhou  s 
or  encephaloid.  Its  average  duration  is  fifty- 
seven  weeks ; but  if  the  cases  which  are  sub- 
mitted to  operation  are  taken  by  themselves,  its 
average  duration  is  eighty-six  weeks. 

Diagnosis. — The  earlier  stages  of  cancer  of 
the  tongue  are  sometimes  difficult  to  distinguish 
from  the  simple  affections  of  that  organ,  and 
still  more  frequently  are  they  confounded  with 
its  syphilitic  diseases.  Indeed,  the  diagnosis 
between  cancer  and  syphilis  is  a matter  which 
often  requires  very  nice  discrimination. 

Treatment. — Nothing  effective  can  be  done  by 
medicines  to  induce  the  cure  of  a cancer,  or  to  ar- 
rest its  growth.  It  is  hardly  necessary  to  say  that 
everything  should  be  done  to  rectify  the  patient’s 
general  health,  and  that  ali  sources  of  local  irri- 
tation should  be  removed.  But  our  main  reliance 
must  be  placed  in  operative  treatment.  Opera- 
tions are  either  complete,  when  the  whole  disease 
can  be  removed  ; or  palliative,  when  they  are  un- 
dertaken merely  for  the  relief  of  symptoms.  They 
may  be  performed  either  with  the  knife,  scissors, 
the  galvano-eautery,  the  ecraseur,  or  the  ligature. 
Which  of  these  means  is  used  must  depend  upon 
the  circumstances  of  the  case.  The  knife  is  the 
most  expeditious,  but  then  there  is  sharp  bleed- 
ing, and  for  this  reason  the  patient  cannot  take 
an  anaesthetic.  But  when  the  deraseur  or  the 
galvano-eautery  is  used,  there  is  little  or  no 
luemorrhage,  and  anaesthetics  can  be  given.  The 
ligature  is  seldom  used,  because  it  involves  the 
presence  in  the  mouth  for  some  days  of  a dis- 
agreeable slough.  When  the  ease  admits  only 
of  palliative  treatment,  portions  of  tho  diseased 
tissues  may  be  removed ; or  the  gustatory  nerve 
maybe  divided  to  relieve  pain  and  excessive  sali- 
vation ; or  the  lingual  arteries  may  be  tied  to 
arrest  haemorrhage.  Supposing,  however,  that 
the  case  admits  of  no  operation,  pain  may  be 
blunted  by  conium,  and  sleep  procured  by  opium 
and  its  allies  ; whilst  in  some  instances  the  sub- 
cutaneous injection  of  morphia  is  of  the  utmost 
value.  Sometimes  the  backward  pressure  is  so 
great  that  the  patient  is  unable  to  swallow,  and 
then  it  may  be  necessary  to  feed  him  by  means 
of  the  stomach-pump  or  by  enemata. 

4.  Hypertrophy. — Synon.  : Afacroglossia  ; 
Prolapsus  lingue. — Hypertrophy  consists  in  an 
over-development  of  the  tongue,  and  is  usually 
associated  with  prolapse.  Generally  it  is  congeni- 
tal ; sometimes  it  follows  an  attack  of  inflamma- 
tion. In  tho  congenital  cases  it  is  often  compli- 


cated with  imperfections  in  other  organs,  or  with 
idiocy.  At  first  the  enlarged  tongue  has  a nor- 
mal appearance.  Gradually,  from  exposure  to  the 
air  and  constant  stimulation,  the  mucous  mem- 
brane becomes  dry,  thickened,  and  callous,  or 
covered  with  a slimy  secretion  ; while  the  papillae 
become  larger  and  more  prominent  than  natural. 
After  a time  the  pressure  of  the  teeth  acts  as  a 
line  of  constriction,  and  the  protruding  portion 
of  the  organ  rapidly  enlarges  from  mechanical 
congestion,  ''’he  surface  of  the  tongue  becomes 
bluish  or  brown ; the  mucosa  roughened  and 
cracked ; there  is  a tendency  to  ulceration  and 
haemorrhage ; the  muscles  become  palsied,  and 
are  unable  to  retract  the  organ.  As  time  goes 
on,  the  lower  jaw  is  pressed  down  by  the  superin- 
cumbent weight,  and  occasionally  this  goes  so  far 
as  to  produce  dislocation.  The  teeth  project  for- 
wards, the  lips  are  everted,  and  there  is  a con- 
stant flow  of  saliva  from  the  mouth.  Altogether, 
the  patient’s  appearance  is  most  unsightly,  and 
his  condition  very  distressing ; for  with  such  a 
tongue  mastication  and  deglutition  are  difficult, 
and  speech  is  thick  and  indistinct. 

Tbeatsient. — Bandaging,  with  astringent  lo- 
tions, and  strapping,  should  first  be  tried.  If 
this  fails,  an  operation  for  the  removal  of  the 
redundant  part  must  be  undertaken. 

5.  Inflammation. — Stnon.:  Glossitis. — Occa- 
sionally the  surface  of  the  tongue  is  covered  by 
a crop  of  vesicles — a kind  of  herpetic  eruption— 
and  this  without  affecting  the  deeper  structures. 
At  other  times  the  whole  substance  of  the  organ 
becomes  acutely  inflamed. 

./Etiology. — Fifty  years  ago  by  far  the  most 
common  cause  of  inflammation  of  the  tongue  was 
the  excessive  use  of  mercury;  but  happily  mer- 
curial glossitis  is  now  seldom  seen.  In  some 
cases  acute  glossitis  arises  from  a chill ; the  in- 
flammation, for  some  reason  which  it  is  not  easy 
to  explain,  attacking  tho  tongue,  just  as  in 
other  cases  the  same  exciting  cause  gives  rise  to 
coryza  or  quinsy.  Sometimes  it  is  due  to  the 
contact  of  septic  substances,  or  to  the  eating 
of  particular  articles  of  food,  or  to  taking  corro- 
sive or  acrid  substances  into  the  month  ; or  it 
may  arise  in  the  course  of  fevers  or  eruptive 
diseases,  or  sometimes  without  any  assignable 
cause. 

Symptoms. — The  earliest  symptom  of  glossitis 
is  a red  line  along  the  gums,  at  their  junction 
with  the  teeth.  The  gums  are  tender,  spongy, 
and  apt  to  bleed.  At  the  same  time  the  breath 
acquires  a peculiar  and  offensive  foetor,  known 
as  mercurial,  and  the  patient  has  a disagreeable 
metallic  taste  in  his  mouth.  As  the  case  ad- 
vances, the  gums,  the  tongue,  and  the  inside  of 
the  lips  and  cheeks  become  much  swollen.  The 
tongue  is  sometimes  so  large  as  to  protrude 
constantly  from  the  mouth.  At  its  edges  it  be- 
comes deeply  marked  by  the  teeth,  and  it  is 
very  prone  to  ulceration.  The  flow  of  saliva  is 
incessant.  The  salivary  glands  are  enlarged  and 
painful ; and  the  teeth  ache  and  become  loose, 
though  it  seldom  happens  that  they  drop  out 
Tho  pulse  and  respiration  are  hurried.  There 
is  great  thirst,  but  the  patient  has  difficulty  in 
swallowing ; and  he  is  wholly  unable  to  speak. 
As  a rule  this  state  of  things  subsides  under 
proper  treatment  but  occasionally  matter  forms 


TONGUE,  DISEASES  OF. 


hi  the  substance  of  the  tongue,  or  it  may  be- 
come ulcerated  or  even  gangrenous. 

Treatment.— In  acute  inflammation  of  the 
substance  of  the  tongue,  scarification — in  the 
form  either  of  one  or  two  long  incisions,  or 
of  a number  of  punctures  with  the  point  of  a 
lancet — or  the  application  of  leeches  beneath 
the  jaw  may  be  needed,  if  the  symptoms  are 
urgent,  and  the  patient  plethoric.  But  gene- 
rally milder  measures  will  suffice,  for  instance, 
a saline  purgative,  or  a drop  or  two  of  croton 
oil,  followed,  if  need  be,  by  enemata  from 
day  to  day,  together  with  a mustard  plaster  to 
the  throat,  and  a suitable  mouth-wash.  As 
a wash,  while  the  inflammation  is  at  its  height, 
there  is  nothing  better  than  warm  water  or 
poppy  decoction.  Subsequently  dry  powdered 
alum  may  be  dusted  on  the  tongue ; or  a lotion 
of  alum,  chlorate  of  potash,  or  borax  may  be 
employed.  As  a change,  a wash  containing 
dilute  nitric,  hydrochloric,  or  acetic  acid  may  be 
prescribed  ; but  these  must  not  be  continued  too 
long.  At  the  same  time  ammonia,  iron,  qui- 
nine, or  bark  should  be  given.  If  an  abscess 
form  far  back  in  the  tongue,  and  if  it  can  be 
localised  with  sufficient  accuracy,  an  incision 
should  bo  made  with  a view  to  its  evacuation. 
If  pus  is  set  free,  the  patient  will  experience 
immediate  relief,  and  the  disease  will  soon  be 
cured. 

6.  Parasitic  Affections. — The  most  impor- 
tant parasite  connected  with  the  tongue  is  the 
O'idium  albicans , which  is  present  in  thrush  ( see 
Aphthae  ; and  Thrush),  with  which  the  minute 
beaded  strings  of  Leptothrix  buccalis  are  often 
associated.  Hydatid  cysts  are  occasionally  met 
with;  and  so  is  the  Cysticercus  celluloses.  Among 
the  naematodes  the  Guinea  worm  ( Dracuncvlus 
or  Filaria  medinensis)  and  the  Trichina  spiralis 
have  been  found.  The  draeunculus  may  give 
vise  to  an  abscess,  which  will  require  to  be 
opened ; and  hydatid  cysts  will  have  to  be  ex- 
cised. 

7-  Syphilitic  Affections. — These  form  five- 
ninths  of  all  the  lesions  of  the  tongue  which  come 
under  our  notice.  Primary  sores  are  occasionally 
seen  in  this  situation,  but  their  occurrence  is  so 
rare  that  we  need  only  mention  them.  For  the  sake 
of  clearness  it  is  well  to  arrange  these  syphilitic 
affections  into  four  classes: — (A)  superficial  ul- 
cerations ; (B)  mucous  tubercles  and  vegetations ; 
(C)  gummy  tumours  and  deep  • ulcerations ; and 
(B)  chronic  morbid  states  of  the  mucous  mem- 
brane. 

A.  Superficial  Ulcerations. — Slight  superficial 
ulcerations  of  the  tongue  are  very  common  in 
what  is  called  the  secondary  stage  of  syphilis. 
They  are  usually  situated  on  the  sides,  tip,  and 
under  surface  of  the  free  portion  of  the  organ  ; 
and  are  often  associated  with  similar  ulcerations 
upon  the  inside  of  the  cheeks,  the  lips,  and  the 
angles  of  the  mouth.  They  begin  in  small 
inflamed  spots,  and  spread  into  linear  cracks  and 
fissures  (rhagades).  These  are  exquisitely  sen- 
sitive, and,  as  it  is  very  difficult  to  keep  the 
tongue  at  rest,  are  a source  of  constant  suffering. 
When  these  ulcerations  heal,  whitish  scars  and 
eicatrices  are  left,  which  are  very  persistent. 
When  these  scars  are  extensive,  so  as  to  form 
patches,  their  appearance  somewhat  resembles 


1643 

tylosis,  though  they  are  essentially  different  from 
that  disease. 

B.  Mucous  Tubercles  and  Vegetations. — Mucous 
tubercles,  when  they  occur  on  the  tongue,  are 
generally  met  with  about  the  sides  and  under 
surface  of  the  organ,  or  on  the  fold  of  mucosa 
that  is  reflected  to  the  floor  of  the  mouth  ; and 
they  have  been  noticed  to  coexist  with  mucous 
tubercles  about  the  anus,  the  labia,  and  other 
parts. 

C.  Gummy  Tumours  and  Beep  Ulcerations 

Gummata  are  common  in  the  tongue.  Some- 
times, when  they  first  come  under  notice,  they 
are  not  larger  than  a pea ; at  other  times 
they  are  as  large  as  a marble.  Histologically 
they  consist  of  granulation-tissue,  which  becomes 
very  imperfectly  organized  into  a fibrous  struc- 
ture, and  rapidly  undergoes  degenerative  changes, 
so  that  the  growth  comes  to  be  made  up  of  atro- 
phied and  broken-down  cell-products,  imbedded 
in  an  incompletely  fibrillatcd  matrix.  When 
they  degenerate  they  form  a soft,  semi-fluid 
material,  which  may  either  be  absorbed,  or  make 
its  way  slowly  towards  the  surface.  When  they 
take  the  latter  course,  they  break,  discharge,  and, 
under  appropriate  treatment,  ultimately  heal  up. 
Sometimes,  however,  they  form  the  starting  point 
for  deep  and  intractable  ulceration. 

B.  Chronic  Syphilitic Biscase. — Various  morbid 
conditions  of  the  mucosa  of  the  tongue  are  often 
seen  in  association  with  the  later  stages  of  syphilis. 
Sometimes  circumscribed  patches  of  the  epithe- 
lium become  dead-white,  and  drop  off,  leaving  a 
red,  raw  surface  beneath.  The  epithelium  is 
speedily  restored,  but  another  patch  becomes 
affected  in  a similar  manner,  and  so  the  disease 
continues — one  patch  healing  and  another  des- 
quamating. This  is  the  proper  psoriasis  lingua. 
Again,  there  is  a much  more  extensive  disease, 
to  which  the  name  chronic  superficial  glossitis  has 
been  given.  At  the  commencement  some  por- 
tions of  the  membrane  present  their  natural  ap- 
pearance, while  others  are  of  a deep  red  colour 
and  raw-looking.  These  patches  are  often  oval 
or  oblong.  Their  surface  is  smooth  and  glossy. 
They  are  either  entirely  denuded  of  epithelium, 
or  this  is  reduced  to  an  extremely  thin  layer,  and 
the  papillte  are  obliterated  by  distension.  These 
patches  aro  slightly  elevated  and  hard  to  the 
touch,  in  consequence  of  interstitial  thickening. 
The  tongue  is  swollen.  At  its  edges  it  takes  the 
impression  of  the  teeth,  and  the  lines  thus  pro- 
duced are  prone  to  ulcerate.  Sometimes  the 
whole  organ  has  a bluish,  congested  hue,  as 
if  its  circulation  were  retarded  in  consequence 
of  the  matted  and  thickened  state  of  the  tissues. 
The  mucous  secretion  all  over  the  affected  part 
is  viscid  and  glairy,  giving  the  organ  a peculiar, 
smooth,  glazed  appearance  ; and  sometimes  the 
patient’s  breath  is  so  feetid  that  he  is  offensive  to 
himself  and  to  all  about  him.  He  complains  of 
thirst ; his  mouth  is  parched,  especially  at  night; 
and  when  lie  wakes  in  the  morning,  his  tongue 
feels  dry  and  chipped.  The  disease  is,  in  fact,  a 
chronic  glossitis,  limited  to  the  mucous  mem- 
brane. Supposing  the  more  active  mischief  to  be 
checked,  the  swelling  subsides,  and  the  tongue 
resumes  its  normal  size — indeed  it  may  become 
smaller  than  natural,  and  rather  misshapen  from 
the  irregular  contraction  of  the  diseased  parts. 


TONGUE,  DISEASES  OF. 


1644 

But  the  membrane  never  resumes  its  healthy 
character.  The  patches  that  have  been  affected, 
remain  smooth  and  shining.  The  papillary 
structure  has  been  impaired,  and  what  is  left  is 
in  fact  cicatricial  tissue,  a tissue  which  is  exqui- 
sitely sensitive  to  the  contact  cf  hot,  acid,  or 
pungent  substances,  and  which  is  apt  tc  become 
inflamed  from  very  slight  causes.  At  a later 
date  portions  of  this  cicatricial  membrane  become 
more  completely  fibrous,  presenting  a whitish 
appearance,  and  being  callous  to  the  touch. 

This  condition  is  most  frequently  seen  in  per- 
sons who  have  long  been  affected  with  syphilis  : 
and  the  question  will  sometimes  arise  whether  it 
is  due  to  the  disease,  or  to  the  prolonged  use  of 
the  drugs  by  which  this  has  been  combated.  Sy- 
philis is  so  prone  to  manifest  itself  in  the  tongue, 
that  no  doubt  in  some  eases  the  appearances  de- 
scribed are  entirely  produced  by  it — possibly  by 
svphilis  in  association  with  dyspepsia.  But  in 
other  cases,  particularly  in  those  which  are  at- 
tended by  fcetor  and  an  alteration  in  the  mucous 
secretion,  it  seems  certain  that  they  have  been 
aggravated,  if  not  caused,  by  excessive  medica- 
tion. In  some  instances  this  excessive  medication 
may  be  the  result  of  iodide  of  potassium,  in 
others  of  mercury ; for  both  these  drugs,  as  is 
well  known,  but  especially  the  latter,  are  apt  to 
determine  to  the  mucous  membrane  of  the  mouth. 
But  in  other  cases  the  chronic  superficial  glossitis 
seems  to  be  due  to  severe  and  prolonged  dyspep- 
sia, or  perhaps  to  other  non-specific  causes,  such 
as  gout,  which  impoverish  the  blood,  irritate 
the  stomach,  and  impair  the  nutrition  of  the 
mucosa  of  the  tongue. 

Treatment. — In  the  treatment  of  these  sy- 
philitic affections,  it  is  of  importance  that  the 
tongue  should  have  rest,  and  the  practitioner  should 
satisfy  himself  that  the  patient  is  living  tolerably 
well,  and  is  warmly  clad.  Unless  he  has  a cer- 
tain amount  of  vis  vita,  it  is  impossible  for  him 
to  overcome  the  intensity  of  the  syphilitic  poison. 

If  the  so-called  specific  drugs  have  already 
been  given  to  excess,  we  must  confine  ourselves 
to  local  treatment,  and  to  the  administration  of 
stomachics  and  tonics.  But  if  the  patient  have 
not  already  been  overdosed  with  mercury  or 
iodide  of  potassium,  we  naturally  turn  to  them 
as  our  most  powerful  remedies.  In  the  case  of 
the  superficial  ulcerations  about  the  sides  and 
tip  of  the  tongue,  the  best  plan  is  to  touch  the 
fissures  with  a fine  pencil  of  nitrate  of  silver, 
and  to  prescribe  iodide  of  potassium,  or  perhaps 
a mild  course  of  grey  powder.  In  the  case  of 
gummy  tumours,  if  they  are  seen  early,  their 
absorption  may  be  promoted  by  iodide  of  potas- 
sium or  the  perchloride  of  mercury,  or  by  a course 
of  mercurial  inunction  or  fumigation.  If  they 
have  softened  and  broken,  they  should  be  allowed 
to  discharge,  like  an  abscess ; care  being  taken 
to  keep  up  the  patient’s  general  health,  so  that 
they  may  heal  kindly.  If  they  show  any  ten- 
dency to  ulcerate,  they  should  be  freely  touched 
with  nitrate  of  silver.  The  deeper  and  more  ob- 
stinate ulcerations  may  require  the  application 
of  nitric  acid,  or  of  the  acid  nitrate  of  mercury ; 
and  along  with  such  treatment  a mild  course  of 
mercury  should  be  combined. 

Mucous  tubercles  on  the  tongue  generally 
yield  speedily  to  the  local  application  of  nitrate 


of  silver;  and  a course  of  iodide  of  potassium, 
grey  powder,  or  iodide  of  mercury. 

The  treatment  of  chronic  superficial  glossitis 
is  far  from  satisfactory.  The  first  object  should 
be  to  improve  the  digestion,  and  to  regulate 
the  general  health.  With  this  view  the  vege- 
table bitters  and  the  mineral  acids  should  be 
given  ; or  bismuth  and  hydrocyanic  acid : or 
effervescing  mixtures  containing  an  excess  of 
alkali.  These  and  other  remedies  will  suggest 
themselves  according  to  the  particular  variety  of 
gastric  irritation  from  which  the  patient  is  suffer- 
ing. If  there  be  reason  to  think  that  the  disease  is 
of  syphilitic  origin,  and  that  specific  drugs  have 
not  already  been  given  to  excess,  iodide  of  potas- 
sium or  mercury  may  be  prescribed  in  moderate 
doses,  either  separately  or  in  combination.  With 
either  of  these  lines  of  treatment  it  is  well  to 
order  opium,  especially  Dover's  powder,  hyos- 
cyamus,  conium,  chloral,  or  bromide  of  potassium, 
in  sufficient  doses  to  quiet  the  system  and  pro- 
cure sound  sleep. 

When  there  is  much  superficial  soreness,  a 
mouth-wash  of  borax  and  glycerine,  bismuth 
and  glycerine,  or  chlorate  of  potash,  should  be 
ordered. 

8.  Tongue-tie. — Thetongue  is  said  to  be  ‘tied’ 
when  the  frnenum  is  either  too  short  or  comes 
further  forward  than  it  should,  and  thus  restrains 
the  movements  of  the  anterior  part  of  the  organ. 
The  infant  cannot  put  out  its  tongue,  or  use  it  in 
sucking;  and  if  the  defect  is  allowed  to  remain, 
it  interferes  with  speech. 

Treatment. — The  remedy  is  to  snip  the 
freenum  with  a blunt-pxnnted  pair  of  scissors, 
the  points  being  directed  downwards  so  as  to 
avoid  the  ranine  arteries  and  veins.  Mothers 
often  suppose  that  their  children  are  tongue-tied 
when,  in  truth,  they  are  only  backward  ; so  the 
surgeon  should  be  on  his  guard,  and  not  operate 
unless  he  sees  good  cause. 

9.  Tumours. — The  tongue  may  be  affected 
by  tumours  which  are  neither  parasitic,  cancer- 
ous, nor  syphilitic.  Thus,  the  mucous  mem- 
brane is  occasionally  the  seat  of  a n revue,  of 
simple  warts,  or  of  polypi.  Cysts  are  also  met 
with,  not  merely  beneath  the  tongue,  but  also 
in  its  substance;  and  fatty,  fibrous,  and  fibro- 
cellular  growths  have  from  time  to  time  been 
removed  from  this  situation. 

Treatment. — Warts  should  be  touched  with 
lunar  caustic  or  with  nitric  acid,  or  even  excised, 
Polypi  should  be  ligatured,  or  snipped  off  with 
scissors.  The  other  tumours  mentioned  will  all 
require  operation. 

10.  Tylosis. — SrxoN. : Ichthyosis  lingua. — 
This  is  a peculiar  disease,  which  affects  the 
tongue,  and.  to  a slight  extent,  the  adjacent 
mucous  membrane. 

-Etiology. — The  irritation  which  gives  rise  to 
tylosis  may  be  due  to  excessive  smoking  or  drink- 
ing, superficial  syphilitic  ulceration,  or  to  other 
causes,  such  as  gout.  It  is  almost  entirely  con- 
fined to  men,  and  is  never  seen  before  the  age 
of  puberty. 

Description. — Tylosis  consists  in  an  over- 
growth of  the  papillary  and  epithelial  elements 
of  the  mucosa,  which  become  white  and  sodden 
from  continued  immersion  in  the  fluids  of  the 
mouih.  It  is  the  filiform  p>apillse  which  are 


TONGUE,  DISEASES  OF. 
thiefly  affected,  and  the  disease  never  spreads 
further  back  than  the  line  of  the  circumvallate 
papillae.  Sometimes  the  papilla;,  though  enor- 
mously enlarged,  and  overloaded  with  epithe- 
lium, retain  their  separate  form;  at  other  times 
they  are  welded  together  into  smooth,  hard, 
masses.  The  tylotic  coating  presents  a silvery 
or  snow-white  appearance,  quite  different  from 
any  ordinary  fur.  When  the  disease  has  once 
shown  itself,  it  is  very  persistent.  Its  essential 
nature  appears  to  be  that  of  a chronic  inflam- 
mation. Sometimes  the  patches  are  irregular  in 
form  and  in  situation ; at  other  times  they  have 
a remarkably  symmetrical  arrangement.  The 
disease  appears  to  have  a strong  tendency  to 
become  cancerous,  though  it  may  last  for  twenty 
or  thirty  years  before  it  passes  into  that  stage. 

Treatment. — If  the  patch  be  small,  it  should 
be  excised ; and  when  the  disease  has  reached 
the  epitheliomatous  stage,  it  must  be  dealt  with 
as  a cancer.  But  between  the  early  and  the  late 
stage  the  less  it  is  meddled  with  the  better.  If 
any  local  treatment  be  used,  it  should  be  of  a 
mild  and  soothing  kind.  The  use  of  strong 
caustics,  as  well  as  all  parings  and  scrapings, 
should  be  forbidden.  Mercury,  arsenic,  or  iodide 
of  potassium  may  be  tried,  but  little  dependence 
can  be  placed  on  them.  They  may  produce  some 
amendment,  but  they  cannot  effect  a cure.  Our 
best  hope  is  to  guard  the  tongue  against  all 
sources  of  irritation,  and  to  regulate  and  improve 
the  general  health. 

11.  Ulceration. — Ulcers  of  the  tongue,  as 
already  said,  maybe  syphilitic  or  cancerous,  but 
they  may  also  be  of  simple  origin.  Simple  ulcer- 
ation is  usually  associated  with  dyspepsia.  Dys- 
peptic ulcers  are  apt  to  occur  in  ill-fed  children, 
and  also  in  adults  who  habitually  eat  and  drink 
freely.  Such  ulcers  are  generally  situated  upon 
the  sides  or  upper  surface  near  the  tip  ; but  not 
■•infrequently  they  are  on  the  frEenum.  They 
are  encircled  by  an  inflamed  margin  ; shallow ; 
their  bases  being  flat  and  covered  with  a greyish 
slough.  They  are  very  sensitive  to  the  touch, 
and  painful  when  the  organ  is  moved.  Some- 
times there  is  offensive  discharge,  with  a good 
deal  of  swelling  of  the  sublingual  and  sub- 
maxillary glands. 

Simple  ulceration  is  often  excited  by  external 
causes,  acting  upon  the  tongue  at  a time  when 
its  nutrition  is  impaired  by  faulty  digestion. 
Thus  it  may  be  bitten,  or  scalded,  or  wounded 
with  knives  or  forks,  or  irritated  by  the  sharp 
point  of  a tooth,  or  by  a rough  accumulation  of 
tartar. 

Treatment. — Attention  should  at  once  be 
directed  to  the  digestive  organs ; and,  after  a 
cholagogue  purgative  has  been  given,  a course 
of  alterative  medicine  should  be  ordered,  to  be 
followed  by  stomachics  and  tonics.  Arsenic 
sometimes  acts  like  a charm.  Whatever  dys- 
peptic symptoms  are  present  must  bo  met  by 
their  appropriate  remedies,  for  example,  dilute 
hydrocyanic  acid,  bismuth,  chlorate  cf  potash, 
or  bromide  of  potassium.  As  a local  application, 
there  is  nothing  better  than  nitrate  of  silver. 
In  the  case  of  ulceration  following  injury,  the  sore 
should  be  touched  with  caustic,  and  the  patient’s 
general  health  regulated  and  supported. 

W.  Fatbits  Ct-abke. 


TONICS.  1645 

TONIC  (toros,  tension). — A distinctive  term 
used  in  reference  to  the  nature  of  spasms,  which 
are  usually  divided  into  two  classes,  namely, 
tonic  spasms  and  clonic  spasms-,  the  former  be- 
ing those  in  which  the  muscles  concerned  remain 
in  a state  of  continuous  rather  than  in  one  of 
intermittent  contraction.  See  Spasm. 

TONICS  (rivos,  tension,  tone). — Synon.  : Fr. 
Toniqucs  ; Ger.  Tonische  Mittel. 

Definition. — Therapeutic  agents  which  im- 
part permanent  strength  to  the  body  or  its  parts. 

Enumeration.  — Amongst  the  most  typical 
medicinal  tonics,  which  impart  a feeling  of 
strength,  are  iron,  nux  vomica,  quinine,  and 
vegetable  hitters.  As  the  strength  of  the  body 
generally  depends  on  the  proper  action  of  its 
various  parts,  tonics  have  been  subdivided  into 
those  which  have  an  especial  action  on  the  blood, 
circulation,  digestion,  and  nervous  system. 

1.  Blood  Tonics. — Cod-liver  oil  and  other 
fats,  and  iron  and  its  salts,  are  the  most  impor- 
tant of  this  group  of  tonic  remedies.  Perhaps 
also  phosphate  of  lime,  and  salts  of  potash  and 
soda  should  be  included.  Light,  fresh  air,  good 
food,  bathing,  and  exercise  are  valuable  adjuncts. 

2.  Vascular  Tonics. — The  principal  vascular 
tonics  are  nux  vomica  and  strychnia,  digitalis, 
hellebore,  erythrophleum,  and  squill.  The 
local  application  of  warmth  and  cold,  friction, 
and  massage  increase  the  effect  of  these  medi- 
cines. 

3.  Gastric  Tonies. — Small  doses  of  sulphuric, 
nitric,  and  hydrochloric  acids,  small  doses  of 
arsenic,  small  doses  of  alum,  aloes,  small  doses 
of  bismuth,  bitter  beer,  chamomile,  cinchona, 
casparia,  cascarilla,  small  doses  of  copper,  ca- 
lumba,  hops,  gentian,  orange  and  lemon  peel, 
quassia,  rhubarb,  small  doses  of  silver,  strychnia, 
generally  vegetable  bitters,  and  small  doses  of 
zinc — all  impart  vigour  to  the  gastric  function. 
Valuable  adjuncts  are  pepsin  and  hydrochloric 
acid. 

4.  Intestinal  Tonics. — These  are  chiefly  nux 
vomica,  belladonna,  rhubarb,  the  mineral  acids 
and  metallic  salts  just  mentioned,  and  astrin- 
gents. 

5.  Nervine  Tonics. — Nux  vomica  and  strych- 
nia, cinchona  and  its  alkaloids,  coca,  phospho- 
rus, arsenic  and  its  compounds,  salts  of  iron, 
zinc,  copper,  and  silver,  are  all  included  under 
this  head.  The  tonics  which  act  especially  on 
other  parts  of  the  system  increase  also  the  power 
of  the  nervous  system,  and  act  indirectly  as 
nervous  tonics. 

Action. — The  derivation  of  the  word  * tonics  ’ 
indicates  the  nature  of  their  action.  When  a 
person  feels  limp  and  weak,  and  unfit  for  ex- 
ertion, like  a relaxed  bow-string,  tonics  restore 
the  energy  and  strength,  and  render  him  again 
fit  for  work,  like,  as  it  were,  a re-tightened  bow. 
The  exact  mode  in  which  tonics  act  is  not  yet 
perfectly  ascertained,  but  in  all  probability  they 
increase  the  functions  of  the  different  parts  of 
the  body  by  aiding  tissue-change,  either  by  in- 
creased nutrition,  increased  tissue-metaholism, 
more  rapid  removal  of  waste,  or  possibly  by  all 
three  taken  together. 

Uses. — Tonics  are  employed  in  conditions  of 
debility,  either  of  the  body  generally  or  of  it? 


1G46  TONICS. 

different  parts,  the  selection  of  each  depending 

upon  the  part  of  the  body  affected. 

In  cases  ■where  the  malnutrition  of  the  body 
appears  to  be  dependent  on  tte  want  of  the 
proper  constituents  of  the  blood,  as  in  anaemia, 
struma,  or  general  debility,  without  any  affec- 
tion of  a particular  organ,  blood  tonics,  in- 
cluding iron,  cod-liver  oil,  and  phosphates  are 
employed ; and  these  are  also  useful  where 
impoverishment  of  the  blood  is  due  to  a de- 
finite constitutional  disease,  such  as  phthisis, 
or  Bright’s  disease.  Where  enfeeblement  of  the 
stomach  appears  to  be  present,  as  shown  by  loss 
of  appetite  and  such  signs  of  imperfect  diges- 
tion as  flatulence,  weight,  and  pain  after  eating, 
gastric  tonics  are  used.  Should  its  muscular 
coat  be  feeble  or  inactive,  as  shown  by  tendency 
to  dilatation,  and  splashing  of  the  contents  on 
movement,  strychnia  is  especially  indicated,  and 
galvanism  or  systematic  kneading  may  be  also 
employed.  Where  the  stomach  is  too  debilitated 
to  respond  sufficiently  to  this  form  of  treatment, 
as  after  long-continued  gastric  catarrh,  or  in  old 
age,  its  work  must  be  partly  done  for  it,  and 
then  such  substances  as  hydrochloric  acid  and 
pepsin  are  useful.  When  the  muscular  move- 
ments of  the  intestine  are  sluggish,  as  indicated 
by  constipation,  and  by  a tendency  to  the  dis- 
tension of  the  bowel  with  gas,  nux  vomica  and 
belladonna  may  be  given ; and  when  its  mucous 
membrane  appears  to  be  relaxed  and  flabby,  and 
secreting  too  profusely,  the  mineral  acids,  as- 
tringents, and  metallic  salts  may  be  of  much 
service.  When  the  pulse  is  soft  and  feeble,  and 
there  is  a tendency  to  vascular  dilatation,  either 
general  or  local,  as  shown  by  local  congestion 
and  oedema  of  dependent  parts,  or  by  drowsi- 
ness in  tli9  upright  position  and  sleeplessness 
in  the  recumbent  posture,  vascular  ionics  are 
serviceable.  Nervine  tonics  are  used  where  the 
nervous  functions  are  imperfectly  performed, 
as  shown  by  dulness,  loss  of  memory,  incapacity 
for  work,  languor,  or  tendency  to  spasm,  as  in 
chorea,  and  also  in  paralysis.  As  the  functions 
of  this  system  depend  very  greatly  upon  the 
quality  of  the  blood  with  which  the  nervous 
system  is  supplied,  and  on  the  rapidity  of  the 
circulation,  the  other  tonics  frequently  require 
to  he  given  in  addition  to  nervous  tonics. 

In  administering  tonics,  care  should  always  he 
taken  to  ascertain  that  the  case  is  suitable,  for 
in  very  many  cases  of  apparent  debilily  the  im- 
perfect functional  activity  of  the  body  or  of  its 
parts  does  not  depend  upon  insufficient  nutri- 
tion, but  upon  imperfect  removal  of  the  pro- 
ducts of  waste.  The  proper  treatment  iu  these 
cases  is  not  to  give  tonics,  hut  to  remove  the 
waste  products  by  cholagogues,  purgatives,  and 
diuretics. 

T.  Lauder  Brtjnton. 

TONSILS,  Diseases  of. — Synon.  : Fr. 

Maladies  des  Amygdales;  Ger.  KranJcheitcn  der 
Mandeln. 

These  two  glands,  situated  between  the  ante- 
rior and  posterior  pillars  of  the  fauces,  are 
unusually  liable  to  participate  in  all  affections  of 
the  throat,  both  from  their  peculiar  structure 
and  from  their  position.  An  evident  example  of 
the  truth  of  this  statement  is  to  he  found  in  that 


TONSILS,  DISEASES  OF. 

every-day  affection,  a common  cold,  in  which  the 
tonsils  usually  exhibit  symptoms  of  the  general 
catarrh.  They  are  also  involved  in  diphtheria, 
scarlatina,  and  syphilis  ; they  may  be  the  seat 
of  ulcers,  or  even  gangrene  ; and  they  may  be 
'nvolved  in  malignant  disease.  The  following 
affections  demand  special  notice,  namely,  (1) 
acute  inflammation;  (2)  follicular  catarrh.; 
(3)  hypertrophy  ; and  (4)  tonsillar  calculus. 

1.  Acute  Inflammation. — Synon.  : Tonsil- 
litis; Cynanclic  Tonsillaris-,  Amygdalitis',  Quinsy. 

^Etiology. — This  affection  is  most  commonly 
met  with  in  young  persons,  in  the  damp  weather 
of  spring  and  autumn,  and  one  attack  seems  to 
predispose  to  another.  Exposure  to  damp,  cold, 
and  wet  is  generally  regarded  as  sufficient  to 
excite  this  disorder. 

Symptoms. — These  usually  set  in  with  indica- 
tions of  fever.  The  patient  becomes  restless, 
irritable,  and  hot  (the  temperature  in  very  acute 
cases  rising  to  104°  or  105°);  complains  of  head- 
ache and  general  weariness ; and  may  be  delirious 
at  night,  especially  if  3’oimg.'  The  tongue  is 
covered  with  a thick,  heavy,  yellowish  coating ; 
the  other  symptoms  of  oral  catarrh  are  present ; 
the  breath  is  unpleasant ; and  salivation  is  com- 
plained of.  The  patient  loses  the  power  of  opening 
the  mouth  to  any  extent. ; and  swallowing  is  at- 
tended with  much  pain  and  great  difficulty,  the 
food  not  unfrequently  returning  through  the  nose. 
The  tone  of  the  voice  is  altered,  becoming  thick, 
guttural,  and  nasal.  The  breathing  is  not,  as  a 
rule,  impeded,  but  the  patient  snores  during  sleep ; 
and  W’hen  he  is  awake,  respiration  may  be  noisy. 
Occasionally  he  becomes  deaf.  The  first  indica- 
tion of  uneasiness  in  the  throat  is  a complaint  of 
pricking  and  dryness  in  the  region  of  the  tonsil, 
soon  passing  on  to  actual  soreness,  and  pain  of  a 
dull  character,  which  shoots  up  towards  the  ear 
on  the  affected  side.  Externally,  behind  the 
angle  of  the  lower  jaw,  considerable  swelling  is 
observed,  firm,  and  exceedingly  painful  to  touch. 
On  examination  of  the  parts  internally,  one  ton- 
sil, rarely  both,  will  he  found  to  he  greatly  swol- 
len, of  a bright  red  colour,  perhaps  with  patches 
of  yellowish  secretion  adherent  to  its  surface. 
The  soft  palate  is  also  greatly  swollen,  red, 
cedematous,  and  falling  inwards  to  the  middle  of 
the  mouth.  The  uvula  likewise  partakes  of  the 
general  infiltration,  and  is  usually  found  pushed 
to  the  healthy  side,  and  not  unfrequently  adhe- 
rent to  the  tonsil.  This  state  of  matters  con- 
tinues for  four  or  five  days,  increasing  in  severity, 
and  then  it  may  gradually  begin  to  subside,  the 
inflammation  passing  off ; and  in  ten  days  to  a 
fortnight  the  patient  is  able  to  resume  his  usual 
employment.  Quite  as  frequent  a termination  as 
resolution  is  suppuration  and  formation  of  abscess 
in  the  tonsil.  In  such  a case  the  symptoms  are 
generally  aggravated  before  the  formation  of  the 
pus,  and  more  decided  pain  and  throbbing  are 
complained  of,  extending  upwards  to  the  ear. 
The  abscess  may  burst  spontaneously  and  unex- 
pectedly. After  the  evacuation  of  the  pus,  which 
is  often  fetid,  convalescence  is  speedy. 

Treatment. — If  a case  of  quinsy  is  seen  at 
the  very  outset,  an  attempt  may  be  made  to  abort 
the  disease.  This,  though  seldom  successful,  may 
be  tried  by  giving  an  emetic,  or  by  administer- 
ing tincture  of  aconite  every  hour  in  drop  doses ; 


TONSILS,  DISEASES  OF. 
er  alum  or  nitrate  of  silver  may  be  applied  to  the 
inflamed  throat.  If  not  seen  for  two  days,  or  if 
these  abortive  measures  fail,  the  patient  should 
be  confined  to  bed ; hot  poultices  kept  constantly 
round  the  throat ; steam  inhaled  as  often  as 
practicable  ; and  gargles  of  warm  milk  and  water 
made  use  of  every  hour.  A brisk  saline  purga- 
tive should  be  given.  Ice,  if  found  grateful, 
may  be  allowed  at  discretion.  Such  diet  as  the 
patient  can  be  persuaded  to  swallow  should  be 
ordered,  of  course  in  liquid  or  rather  semi-solid 
form.  Stimulants,  if  called  for,  must  be  ad- 
ministered. Tonics,  such  as  chlorate  of  potash 
and  iron,  or  quinine  and  iron,  will  be  needed 
when  convalescence  sets  in.  If  an  abscess 
should  form,  it  must  be  evacuated  by  means  of 
a well-protected  bistoury  ; and  astringent  gargles 
should  be  made  use  of  for  some  time  after  con- 
valescence is  established. 

2.  Follicular  Catarrh. — The  office  of  the 
tonsils  is  to  secrete  a lubricating  fluid  to  the 
bolus  of  food  as  it  passes  into  the  pharynx,  as 
well  as  to  moisten  the  fauces.  Occasionally  we 
meet  with  cases  where  this  secretion  is  altered 
in  character  or  in  quantity.  And  this  may  be 
the  result  either  of  a simple  catarrh  of  the  ton- 
sils ; or  of  thickening  of  the  interstitial  tissue 
of  the  gland,  compressing  the  follicles,  and  thus 
interfering  with  the  free  outflow  of  the  secretion. 
The  appearance  of  the  tonsil  in  such  a condition 
is  at  times  mistaken  for  a diphtheritic  state,  in 
consequence  of  the  whitish  patches  of  secretion 
deposited  upon  them.  In  this  catarrhal  affection 
it  will  be  observed  that  there  is  no  tendency  to 
the  formation  of  a true  membrane  as  in  diph- 
theria, the  deposit  assuming  a pultaceous  form, 
being  readily  removed,  its  borders  being  well- 
defined,  and  it  is  seen  to  proceed  from  the  fol- 
licles of  the  tonsil.  As  to  the  treatment  of 
this  condition,  all  that  is  wanted  is  a stimulant 
gargle,  probably  some  general  tonic,  and  the 
constant  use  of  chlorate  of  potash — a convenient 
form  of  administering  which  is  found  in  Wyeth's 
lozenges  of  the  compressed  salt. 

3.  Hypertrophy — This  condition  of  the  ton- 
sils is  met  with  both  in  the  young  and  in  the 
adult.  In  the  case  of  the  former,  there  seems 
to  be  a hereditary  tendency  in  some  families, 
the  tonsils  becoming  immensely  large  even  as 
early  as  the  second  year.  In  such  there  is 
usually  some  scrofulous  habit  of  body.  In  the 
adult  this  condition  is  more  frequently  the  result 
of  repeated  angina,  which  induces  a perma- 
nent thickening  of  the  structures  of  the  tonsils, 
whereby  the  secretion,,  no  longer  finding  free 
exit,  distends  the  follicles,  thus  setting  up  a low 
form  of  inflammation,  which  results  in  hyper- 
trophy of  the  gland.  This  condition  is  free  from 
pain.  "When  the  interstitial  tissue  becomes  much 
thickened  and  indurated,  there  occurs  what  is 
sometimes  described  as  ‘ scirrhus  ’ of  the  tonsil. 
The  symptoms  indicative  of  hypertrophy  are 
snoring  during  sleep  ; obstruction  to  the  breath- 
ing, in  consequence  of  which  the  mouth  is  always 
open  night  and  day;  slight  impediment  to  swal- 
lowing, with  a sense  of  something  permanently 
needing  to  he  swallowed;  some  degree  of  deaf- 
ness ; and  thickness  of  voice  or  snuffling.  These 
are  all  greatly  aggravated  when  catarrh  is  super- 
added  ; and  persons  having  enlarged  tonsils  are 


TORSION.  164? 

specially  liable  to  attacks  of  angina,  and  to  severe 
throat-symptoms  when  any  disorder  overtakes 
them,  in  which  the  throat  is  more  than  ordi- 
narily the  point  in  which  the  disease  centres 
itself,  for  example,  scarlatina. 

Treatment. — The  treatment  in  cases  of  scro- 
fulous children  consists  in  the  administration  of 
plentiful  nourishment,  cod-liver  oil,  iodide  of 
iron,  and  other  drugs  of  which  iodine  forms  the 
chief  constituent.  The  bromides  of  ammonium 
and  potassium  also  enjoy  tbe  reputation  of  re- 
ducing enlarged  tonsils.  Locally,  they  should  be 
treated  with  iodine  dissolved  in  glycerine,  or 
with  the  simple  tincture,  every  other  day.  They 
should  not  be  removed  in  children  under  the 
age  of  puberty,  as  frequently  after  that  period 
they  decrease  spontaneously.  In  adults,  if  they 
cause  much  inconvenience,  they  should  be  ex- 
cised, but  not  otherwise. 

4.  Tonsillary  Calculus. — When  two  or  three 
neighbouring  follicles  of  a tonsil,  as  well  as 
the  interstitial  tissue,  are  destroyed,  the  cavity 
thereby  created  pours  out  a greatly  altered  se- 
cretion, the  product  varying  in  consistence  from 
a creamy  pulp  up  to  a calcareous  deposit,  of  a 
white  or  yellow  colour.  This,  on  examination, 
has  been  found  to  consist  of  albumen,  phosphate, 
carbonate,  and  oxalate  of  lime,  with  some  animal 
matter.  Some  authors  regard  these  calculi  as 
the  ‘ resolution  of  tuberculous  deposits  in  the 
tonsils,  which  subsequently  give  rise  to  inflam- 
mation, suppuration,  and  ejection.’ 

Claud  Muirhead. 

TOOTHACHE.— Synon.  : Fr.  Odontalgic; 
Mai  de  Dents ; Ger.  Zaknwek.- — Pain  in  connec- 
tion with  the  teeth.  See  Teeth,  Diseases  of. 

TOOTH-HASH.  See  Dentition,  Disorders 
of. 

TOPHUS  ( tophus , sand). — A term  for  the 
concretions  which  are  met  with  in  gout,  in  con- 
nection with  the  joints  and  other  structures.  It 
is  also  sometimes  applied  to  gravel,  and  to  the 
collection  of  tartar  on  the  teeth.  See  Gout. 

TOPICATi  ( vo7ros , a place).  See  Local. 

TORMINA  (Lat.  griping). — This  word  is 
applied  to  severe  griping  or  colicky  pains  in  the 
abdomen,  due  to  flatus  and  other  causes.  See 
Colic  ; and  Intestines,  Diseases  of. 

TOEPOH  (Lat.  numbness). — Synon.  : Fr. 
Torpeur ; Ger.  1'orpiditat. — A condition  of  in 
activity,  bodily  and  mental,  which  may  be  met 
with  in  certain  brain-diseases  or  febrile  states, 
more  especially  in  aged  persons.  The  cerebral 
condition  associated  with  torpor  is  an  unnatural 
state  of  consciousness,  closely  allied  to  that 
known  as  stupor. 

TORQUAY,  in  South  Devon. — A mild, 
rather  relaxing,  and  sedative  marine  climate. 
Sheltered  from  W.,  N.,  and  E.  winds.  Mean 
winter  temperature  44°  Fahr.  Sec  Climate, 
Treatment  of  Disease  by. 

TORSION  ( iorquco , I twist).— This  word 
signifies  a twisting,  and  is  used  in  the  following 
associations ; — 

1.  In  relation  to  certain  hollow  organs,  it  in 
dieates  a form  of  displacement  in  which  an  organ 


1648  TORSION, 

is  twisted  on  itself,  a condition  especially  noticed 
in  connection  with,  the  intestines.  It  gives  rise 
to  more  or  less  narrowing  of  the  canal,  and 
may  close  it  completely,  so  as  to  cause  absolute 
obstruction.  Torsion  also  interferes  with  the 
circulation,  thus  leading  to  congestion,  inflam- 
mation, or  ultimately  even  to  gangrene.  See 
Intestinal  Obstruction. 

2.  As  a method  of  treatment,  torsion  is  em- 
ployed in  checking  arterial  haemorrhage,  the 
ends  of  the  bleeding  artery  being  seized  by  the 
aid  of  suitable  forceps,  and  twisted.  It  is  chiefly 
used  in  bleeding  from  small  arteries,  but  may 
prove  efficient  even  when  arteries  of  some,  size 
are  the  source  of  the  haemorrhage. 

Frederick  T.  Roberts. 

TORTICOLLIS  ( tortum , twisted,  and  col- 
lum,  the  neck). — A synonym  for  wryneck.  See 
Wryneck. 

TORTJLA. — Description. — Torula  is  a form 
of  microscopic  fungus,  belonging  to  the  order 
Saccharomycetes,  of  the  class  Protophyta , which 
is  the  lowest  division  of  Tkallophyta  (Sachs).  It 
consists  of  round  or  ovoid  cells,  of  an  average 
diameter  of  about  inch,  without  nuclei,  but 
composed  of  masses  of  vacuolated  protoplasm, 
confined  within  a definite  cell-wall.  Occasionally 
they  are  free,  but  they  are  frequently  associated 
into  branching  chains.  See  Microscope  in  Medi- 
cine. 

Sources. — Vinous,  acetous,  and  other  fermen- 
tations are  due  to  the  presence  of  low  or- 
ganisms, of  which  the  ‘ yeast  plant,’  Mycoderma 
or  Torula  ccrivisiee,  is  the  best  known.  Certain 
varieties  of  torula  are  of  constant  occurrence  in 
the  alimentary  canal,  and  would  seem  to  be  nor- 
mally associated  with  intestinal  digestion.  In 
those  cases  of  vomiting  where  the  ejected  matters 
ferment,  torulae  are  always  to  be  found,  together 
with  sarcinm.  These  bodies  are  also  of  frequent 
occurrence  in  diabetic  urine,  if  left  standing  ; but 
they  have  also  been  found  in  non-saccharine 
urine.  The  pathological  significance  of  torula, 
if  any,  is  not  known.  W.  H.  Axechin. 

TOUCH,  Disorders  of. — Synon.  : Fr.  Trou- 
bles du  Tact ; Ger.  Stohrungcn  des  Tastsinncs. — 
The  sense  of  touch  may  be  considered  as  a com- 
pound of  four  distinct  senses,  namely,  those  of 
contact.,  pain,  temperature,  and  muscular  acti- 
vity; and  it  is  not  necessary  that  all  of  these 
should  be  affected  simultaneously  or  in  an  equal 
degree.  Sometimes  but  one  is  the  seat  of  dis- 
order, and  occasionally  only  one  escapes.  The 
lesion  producing  tactile  disorder  may  be  in  any 
part  of  the  sensory  apparatus — in  the  peripheral 
end-organ  in  the  skin  which  receives  impres- 
sions, in  the  trunk  of  the  nerve  which  conveys 
them,  or  in  the  central  ganglion,  the  reaction  in 
which  is  represented  in  consciousness  as  feeling. 
For  the  most  part  disorders  of  touch  must  con- 
sist either  in  a defective  or  in  an  unnaturally 
heightened  reaction  to  impressions  — conditions 
which  are  termed  respectively  ancesthcsia  and 
hyperesthesia.  Rut  there  are  besides  certain 
abnormalities  of  sensation  which  cannot  be  re- 
ferred to  either  of  these  categories,  as,  for 
example,  when  a touch  causes  a sensation  of 
burning,  or  the  electric  current  is  felt  as  some- 


TOUCH,  DISORDERS  OF. 
thing  cold,  and  in  these  circumstances  the  term 
paresthesia  is  used. 

1.  Increased  sensibility. — Description. — 
It  is  doubtfulwhether  the  sense  of  touch  proper, 
the  power  of  tactile  discrimination,  is  ever  mor- 
bidly increased,  except  possibly  in  certain  cases  of 
hysteria  and  mental  disorder.  The  term  hyper- 
esthesia would  be  properly  applied  to  such  a con- 
dition instead  of,  as  it  is  more  commonly  used,  tc 
excess  of  sensibility  to  painful  impressions,  which 
is  perhaps  better  called  hyperalgesia.  In  cuta- 
neous hyperalgesia  even  a light  touch  upon  the 
skin  produces  more  or  less  exquisite  pain.  The 
patient  often  cannot  even  wash  the  skin,  which 
is  described  as  feeling  raw  or  sore  to  the  touch. 
The  symptom  frequently  occurs  in  connection 
with  neuralgia  (especially  of  the  trigeminal 
nerve),  and  in  hysteria,  as  well  as  in  the  various 
forms  of  local  inflammation.  It  may  precede  by 
some  days  the  characteristic  pains  of  neuralgia  ; 
is  often  associated  with  excess  of  sensibility  to 
heat  and  cold  ; and  usually  with  diminution  of 
sensibility  of  the  tactile  sense  proper.  It  is  seen 
in  its  severest  form  in  connection  with  gunshot 
injuries  of  nerves. 

There  may  be  heightened  sensibility  to  tem- 
perature, either  as  regards  heat  or  cold  singly, 
or  in  respect  to  both  at  the  same  time.  This 
symptom  is  observed  in  connection  both  with 
peripheral  and  central  disease,  as  an  accom- 
paniment of  neuritis,  as  well  as  of  degenerative 
changes  in  the  cord  or  cerebral  ganglia.  It  is 
often,  but  not  always,  associated  with  hyper- 
algesia.. 

Heightening  of  the  sense  of  contact  is  rarely 
observed,  and  is  of  but  little  practical  import- 
ance. Perhaps  the  condition  known  as  ‘ fidgets ' 
is  best  explained  as  depending  upon  a heightened 
sense  of  muscular  activity. 

Treatment. — So  far  as  is  practicable,  the 
lesion  which  is  the  cause  of  hyperalgesia,  whether 
peripheral  or  central,  must  be  discovered  and 
become  the  subject  of  treatment.  But  the 
symptom  itself  may  be  mitigated  by  appropriate 
means.  Such  are  the  local  application  of  moist 
heat  by  fomentation  or  poultice ; of  cold,  by 
means  of  ice;  or, of  anodynes,  such  as  veratria 
ointment  somewhat  diluted,  or  atropia  ointment  ; 
or  the  hypodermic  injection  of  morphia  (gr.  to 
gr.  I).  Spongiopiline  may  be  sprinkled  with  a 
liniment  composed  of  chloroform  one  part  and 
belladonna  liniment  three  parts  ; or  equal  pans 
of  ether,  sal  volatile,  laudanum,  and  eau  de 
Cologne  may  be  applied.  A piece  of  lint  soaked  in 
chloroform  may  be  laid  upon  the  painful  portion 
of  skin  and  covered  with  oiled-silk,  or  the  part 
may  be  rubbed  with  camphor-chloral  and  vase- 
line, equal  parts  ; or  painted  with  amyl-colloid. 
The  application  of  one  pole  of  the  continuous 
current  to  the  hyperalgesic  spots,  whilst  the 
other  is  placed  on  an  indifferent  part,  will  often 
be  of  service,  the  power  of  bearing  a gradually 
increased  strength  showing  the  improvement 
produced.  Hysterical  hyperalgesia  can  some- 
times be  successfully  treated  by  the  application 
of  a strong  induced  current,  by  means  of  the 
wire  brush,  the  patient,  if  necessary,  being 
placed  under  the  infiuence  of  ether. 

2.  Defective  sensibility. — Description.— 
Cutaneous  anaesthesia  may  result  from  local  ab 


TOUCH,  DISORDERS  OF. 


Btrsction  of  lieat,  as  from  exposure  to  a very 
low  temperature.  In  such  a case  anaemia  is  pro- 
duced, from  spastic  contraction  of  blood-vessels, 
followed  by  hyperaemia  from  their  secondary 
relaxation.  In  the  anaemic  stage,  whilst  the  other 
tactile  sensations  are  lowered,  that  of  tempera- 
ture is  heightened.  Deficient  sensibility  may  be 
caused  by  irritating  applications,  such  as  soda 
used  by  laundresses,  and  various  chemicals  em- 
ployed in  the  arts.  In  such  cases  there  is  numb- 
ness iu  the  hands  and  forearms,  with  a sensation 
of  ‘ going  to  sleep  ’ in  the  fingers.  It  may  occur 
in  connection  with herpes  zoster , the  skin  between 
the  groups  of  vesicles  being  often  partially  anaes- 
thetic. In  lepra  ancssthetica,  in  which  there  are 
enlargements  of  the  cutaneous  nerves,  the  senses 
of  temperature  and  pain  are  often  abolished,  and 
severe  burns  may  take  place  without  being  re- 
cognised. Anaesthesia  may  be  produced  by  pres- 
sure upon  sensory  or  mixed  nerves,  by  syphilitic 
and  other  growths  in  adjacent  tissues.  Nar- 
cotics, as  chloroform  and  ether,  may  quell  the 
sense  of  pain,  that  of  contact  being,  to  a certain 
extent,  retained.  Wounds  and  lacerations  of  the 
sensory  or  mixed  nerves,  followed  by  inflamma- 
tory processes,  may,  by  irritating,  cause  pain  to 
precede  the  anaesthesia,  arising  from  the  inter- 
ruption of  conductivity  in  the  nerve-fibres.  Sim- 
ple mechanical  pressure  upon  a nerve,  if  long 
continued,  will  often,  especially  if  its  nutrition 
be  impaired  by  constitutional  causes,  excite  a 
low  inflammatory  condition.  In  traumatic  cases, 
as  also  in  lepra  ansesthetica  and  in  cases  of  new 
growths  pressing  on  the  nerve,  motor  and  nu- 
tritive disturbances  are  apt  to  accompany  the 
anaesthesia,  the  nerve-trunks  conveying  not  only 
sensory,  but  also  motor,  vaso-motor.  and  trophic 
fibres.  Severe  trophic  disorder  is  usually  asso- 
ciated with  the  anaesthesia  occasioned  by  lesion 
of  the  fifth  nerve ; and  to  a less  extent  with 
that  accompanying  trigeminal  neuralgia.  See 
Trifacial  Nerve,  Diseases  of. 

Preceding  attacks  of  neuralgia,  the  skin  of  the 
part  about  to  be  affected  is  often  found  to  be 
•dniesthetic,  and  during  attacks  of  sciatica  and 
cervico-brachial  neuralgia  there  is  often  much 
diminution  of  tactile  sensibility,  severally  in  the 
foot  and  lower  part  of  the  leg,  and  in  the  fin- 
gers ; .whilst  the  skin  around  the  eye  may  be 
greatly  deficient  in  tactile  sensibility  during 
severe  supra-orbital  neuralgia.  It  is  important 
to  discriminate  anaesthesia  of  the  skin  caused  by 
disease  of  the  nervous  centres,  from  that  which 
is  of  peripheral  origin. 

Cutaneous  anaesthesia  is  occasionally  an  impor- 
tant symptom  of  an  approaching  cerebral  hsemor- 
rhage.  A sudden  and  increasing  numbness  is 
experienced  in  one  half  of  the  face,  or  in  the 
limbs  on  one  side  of  the  body,  which  maybe  fol- 
lowed shortly  by  coma  and  hemiplegia.  An 
apoplectic  seizure  usually  causes  unilateral  cuta- 
neous ansesthesia,  which  is  at  first  widely  dif- 
fused, owing  probably  to  the  disturbance  of  cir- 
culation in,  and  consequent  disarrangement  of 
the  nervous  molecules,  which  extends  at  first 
far  beyond  the  site  of  the  effusion.  A few  hours 
cr  days  usually  suffice  for  the  clearing  off  of  this 
anaesthesia,  leaving, however,  asubjective  feeling 
of  numbness,  which  may  endure  for  a longer  or 
shorter  period. 


164K 

The  extent  of  antesthesia  bears  no  necessary 
relation  to  the  amount  of  motor  paralysis.  It 
usually  affects  the  paralysed  side  of  the  body, 
but  in  certain  cases  of  haemorrhage  into  or  other 
lesion  of  the  medulla  oblongata  and  pons  varolii, 
it  may  occupy  the  opposite  side.  Complete 
hemi-amesthesia  of  central  origin  may  persist 
long  after  the  paralysis  of  motion  has  disap- 
peared, and  in  such  a case  a lesion  is  likely  to 
be  found  in  the  outside  of  the  optic  thalamus, 
involving  the  internal  capsule.  Occasionally, 
too,  hemi-anoesthesia  may  from  the  first  be  un- 
accompanied by  motor  paralysis.  Much  more 
frequently,  however,  cutaneous  anaesthesia  (ex- 
cept for  the  first  few  hours)  is  of  comparatively 
slight  and  transitory  character,  even  in  cases 
where  there  has  been  extensive  disorganisation 
of  the  brain  from  haemorrhage  or  softening,  and 
where  the  resulting  paralysis  of  the  muscles  is 
complete  and  permanent.  It  may  be  absent 
altogether  from  the  first,  but  this  is  not  common, 
except  in  eases  of  cortical  lesion  of  the  brain. 
Recovery  is  gradual,  and  proceeds  from  the  ner- 
vous centre  downwards,  the  fingers  sometimes 
retaining  slight  anaesthesia  long  after  the  rest  of 
the  arm  has  entirely  recovered.  Cerebral  tu- 
mours may  give  rise  to  cutaneous  amesthesia  by 
pressure  upon  the  Gasserian  ganglion,  or  upon 
the  trunk  or  branches  of  the  fifth  nerve  as  they 
traverse  the  floor  of  the  skull.  lake  the  motor 
paresis  or  paralysis  which  may  be  occasioned  at 
the  same  time,  the  loss  of  sensibility  is  usually, 
but  not  always  gradual,  tending  to  increase 
rather  than  to  diminish  as  time  goes  on.  It  is 
not  usually  a prominent  symptom  in  cerebral 
abscess. 

Lesion  of  the  spinal  cord  or  its  membranes 
may  give  rise  to  cutaneous  anaesthesia,  which  is 
frequently,  in  the  lower  extremities,  extensive 
and  complete;  but  it  maybe  absent,  when — as, 
for  example,  in  very  advanced  sclerosis  of  the 
antero-lateral  columns — there  is  complete  para- 
plegia. A varying  amount  of  cutaneous  anaes- 
thesia, especially  affecting  the  soles  of  the  feet, 
is  apt  to  occur  in  progressive  locomotor  ataxy. 
Anaesthesia  of  spinal  origin  is  usually  bilateral ; 
but  it  affects  that  lower  extremity  alone  which 
is  opposite  to  the  one  paralysed  in  its  motility, 
when  the  causative  lesion  is  limited  to  one  half 
of  the  cord.  Intercurrent  complications  from 
disturbances  of  circulation,  the  temperature  of 
the  limb,  the  extension  or  subsidence  of  inflam- 
mation, and  the  effusion  of  inflammatory  pro- 
ducts about  the  posterior  roots,  as  well  as  the 
spread  of  sclerotic  changes,  may  cause  the  extent 
and  completeness  of  cutaneous  anaesthesia  to 
vary  considerably  in  cases  dependent  upon  spinal 
cord  disease.  "Where  the  lesion  lies  tolerably 
high  up,  tickling  the  soles  of  the  feet,  although 
quite  unfelt  by  the  patient,  is  able  to  excite  the 
motor  nerves,  and  produce  reflex  muscular  con- 
tractions, which  the  loss  of  muscular  sense  pre- 
vents him  from  recognising.  It  is  extremelv 
important  to  remember  that  cutaneous  anaes- 
thesia of  spinal  origin  is  liable  to  be  associated 
with  bed-sores.  In  certain  cases,  where  pro- 
bably trophic  and  vaso-motor  nerves  have  been 
included  in  the  lesion,  this  liability  is  excessive, 
and  may  defy  all  precautions. 

Loss  of  tho  sense  of  muscular  aciihty  may 


104 


1650  TOUCH,  DISORDERS  OF. 
occur  in  an  isolated  form,  the  other  modes  of 
tactile  sensibility  being  unaffected ; or  it  may  be 
associated  with  impairment  of  some  or  all  of 
them.  The  symptom  is  especially  notable  in 
progressive  locomotor  ataxy  {see  Locomotor 
Ataxy).  It  may  also  occur  in  connection  with 
paresis  resulting  from  coarse  disease  of  the  occi- 
pital lobe  of  the  cerebrum.  Loss  of  muscular 
sense  may  accompany  hemiplegia,  attended  with 
strongly  marked  and  prolonged  anaesthesia,  from 
disease  of  the  optic  thalamus.  It  occurs  some- 
times in  hysteria.  There  is  a form  of  anaesthesia 
occasionally  met  with  in  hysteria  which  it  is 
important  to  recognise,  so  as  not  to  confound  it 
with  a somewhat  similar  condition  resulting  from 
disease  of  the  neighbourhood  of  the  optic  thala- 
mus. In  this  the  patient  may  lose  the  power  of 
perceiving  impressions  of  contact,  temperature, 
and  pain  throughout  the  whole  of  one  lateral 
half  of  the  body,  sharply  divided  from  the  sound 
side  by  a line  passing  downwards  from  the  ver- 
tex to  the  os  pubis.  Accompanying  this  hemi- 
aiuesthesia,  as  it  is  called,  there  is  often  ambly- 
opia and  colour-blindness  of  the  corresponding 
eye,  loss  of  taste  and  smell,  together  with  ten- 
derness on  deep  pressure  over  the  region  of  the 
ovary  on  the  same  side.  In  some  cases,  too,  the 
skin  is  unnaturally  pale  and  cold,  and  pricks 
with  a pin  are  said  to  be  not  followed  by  bleed- 
ing, which  readily  takes  place  in  corresponding 
circumstances  on  the  opposite  side  of  the  body. 

Diagnosis. — As  regards  both  hyperaesthesia 
and  anaesthesia  the  most  important  considera- 
tion, after  establishing  the  existence  of  either,  is 
as  to  whether  the  cause  be  central  or  peripheral. 
It  is  impossible  to  do  more  than  indicate  the 
general  principles  upon  which  this  inquiry  is  to 
be  conducted.  The  patient’s  history,  the  condi- 
tion of  viscera  and  circulation,  the  existence  or 
not  of  accompanying  paralysis  or  of  modifications 
of  the  organs  of  special  sense,  will  lend  im- 
portant aid.  As  a rule,  the  anaesthesia  of  central 
origin  is  much  more  widely  diffused,  though  less 
complete,  than  that  dependent  upon  lesion  of 
nerve-trunks,  when  it  is  also  often  accompanied 
with  localised  atrophy  of  muscles  or  other 
trophic  disturbance.  It  is  very  rare  that  hemi- 
ansesthesia  of  central  origin  is  so  complete  as  the 
hysterical,  and  it  is  not  accompanied,  like  the 
latter,  with  tenderness  on  deep  pressure  over  the 
ovarian  region.  There  is  no  doubt  that  hyper- 
aesthesia has  often  been  mistaken  for  localised 
inflammation,  and  treated  accordingly.  The  ab- 
sence of  febrile  movement,  and  the  fact  that  it  is 
mainly  upon  light  surface-touching  that  the  ex- 
quisite tenderness  occurs,  which  fails  to  be  felt 
when  deeper  pressure  is  made,  coupled  with  the 
history,  and  a study  of  the  concomitant  condi- 
tion, ought  to  suffice  to  prevent  all  mistakes. 

Treatment. — Anaesthesia  is  a symptom  of  a 
lesion  either  in  the  central  nervous  system  or  in 
a peripheral  nerve,  and  its  treatment  is  bound  up 
with  that  of  the  disorder  which  gives  rise  to  it. 
But  there  are  many  cases  in  which,  apparently 
as  a result  of  disease,  the  sensory  nerves  fail  to 
convey  impressions  for  a considerable  time  after 
the  lesion  which  interfered  witli  their  function 
has  been  healed.  In  such  circumstances  very 
much  good  can  often  be  done  by  electrical  treat- 
ment. The  skin,  carefully  dried,  should  be 


TRACHEA,  DISEASES  OF. 
brushed  over  for  a few  minutes  every  day  with 
the  wire  brush,  connected  with  an  induction 
machine ; or  the  well-wetted  rheophore  connected 
with  the  negative  pole  of  a constant  current  bat- 
tery may  be  slid  about  over  the  affected  surface, 
well  moistened  with  hot  water.  In  hysterical 
anaesthesia  the  application  of  various  metals 
(gold,  silver,  copper,  tin,  lead,  iron — one  or  other 
of  these),  has  been  found  very  successful  in 
the  hands  of  Drs.  Burq  and  Charcot,  of  Paris, 
and  a trial  of  them  in  appropriate  cases  should 
not  be  omitted.  The  metal  should  be  closely 
applied  to  the  affected  skin  for  ten  minutes  at 
a time. 

Static  electricity  is  a valuable  means  of  com- 
bating anaesthesia  of  this  kind.  The  patient, 
seated  on  an  insulating  chair,  is  connected  by  a 
conducting  chain  with  a. frictional  electrical  ma- 
chine, and  sparks  aro  drawn  from  the  affected 
surface. 

3.  Pareesthesia. — Description. — The  varie- 
ties in  disorder  of  the  different  kinds  of  tactile 
sensibility — touch,  pain,  temperature,  muscular 
activity — are  very  numerous.  Pinches  or  pricks 
with  a needle  may  be  felt  as  touch  only,  whilst 
a very  light  touch  with  the  finger  is  appreciated 
as  touch.  Strong  faradaic  currents  (intolerable 
to  the  healthy)  may  be  felt  as  cold.  Heat  may 
be  felt  as  cold,  but  kept  still  longer  applied  may 
be  recognised  as  heat  or  warmth.  A limb 
plunged  into  hot  or  cold  water  may  get  the  feel- 
ing, not  of  heat  or  cold,  but  of  pain.  To  such 
modifications,  as  well  as  to  feelings  of  burning 
or  cold,  tingling,  creeping  of  ants,  or  actual 
numbness,  the  term  paresthesia  is  often  applied 
A seamstress  may  be  able  to  pick  up  and  thread 
her  needle,  evincing  thereby  considerable  deli- 
cacy of  sense  of  contact,  and  yet  be  scarcely 
able  to  feel  a prick  of  a needle  in  the  finger-tip. 
Or  the  sense  of  contact  may  be  in  abeyance,  as 
well  as  that  of  pain  and  temperature,  and  the 
movements  may  be  then  guided  by  the  sense  of 
muscular  activity,  aided  by  sight. 

T.  Buzzard. 

TOX ffIMIA  (to£i kbv.  a poison,  and  aTua. 
blood). — This  word  literally  signifies  poisoning 
of  the  blood.  It  is  not  employed  with  any  very 
strict  or  definite  meaning,  but  most  commonly 
implies  blood-poisoning  due  to  some  pathological 
condition  within  the  body  itself,  in  contradis- 
tinction to  that  which  results  from  the  introduc- 
tion of  the  ordinary  poisons  from  without.  As 
illustrations  of  toxaemic  states  may  be  men- 
tioned pyaemia  and  septicaemia;  uraemia:  and 
acetona-mia,  upon  which,  according  to  some  autho- 
rities, the  comatose  condition  which  precedes  the 
fatal  issue  in  some  cases  of  diabetes  depends. 
The  accumulation  of  bile  in  the  blood,  in  cases 
of  jaundice,  is  also  a form  of  toxaemia.  The  mor- 
bific agents  which  are  supposed  to  produce  the 
several  infectious  and  malarial  fevers  are  like- 
wise regarded  by  many  as  originating  toxaemic 
conditions ; as  are  also  those  which  originate 
such  affections  as  gout  and  rheumatism.  These 
subjects  will  be  found  discussed  under  their 
several  headings.  Frederick  T.  Roberts 

TRACHEA,  Diseases  of. — Syxox.  : Fr. 
Maladies  de  la  Trachcc ; Ger.  Krankheiien  dm 


TRACHEA,  DISEASES  UF. 


Lh.Jtroh.re. — The  trachea  is  but  little  prone  to 
disease,  except  in  association  with  affections  of 
the  larynx,  bronchi,  and  neighbouring  parts. 
The  diagnosis  and  treatment  of  these  several 
diseases  is  greatly  facilitated  by  the  laryngo- 
scope. With  this  instrument  a skilful  manipu- 
lator can  in  many  cases  examine  the  trachea  in 
its  whole  length,  and  an  accurate  diagnosis  being 
thus  attained,  remedies  may  be  applied,  and  in- 
struments may  be  introduced  for  the  removal 
or  destruction  of  growths,  or  for  other  purposes, 
either  through  the  larynx,  or  by  an  artificial 
opening  made  in  the  trachea.  The  principal 
morbid  affections  of  the  trachea  will  be  discussed 
_n  the  following  order: — 1.  Malformations;  2. 
Inflammation ; 3.  Ulceration  and  Perforation ; 
4,  Syphilis;  5.  Tuberculosis;  6.  Tumours ; 7- 
Stenosis  ; and  8.  Foreign  bodies. 

1.  Malformations. — Defects  in  the  develop- 
ment of  the  trachea  occur  as  rare  causes  of  the 
death  of  newly-born  infants.  The  tube  may  be 
short  and  imperforate  ; or  communication  may 
exist  with  the  oesophagus.  These  conditions  are 
necessarily  fatal.  A fistulous  opening  through  the 
skin  occasionally  occurs,  giving  rise  to  no  serious 
symptoms.  Tracheocele , a hernia  of  the  mucous 
lining  of  the  trachea,  is  a rare  malformation, 
easily  recognised,  which  may  arise  from  a con- 
genital defect,  but  is  more  frequently  acquired. 

2.  Inflammation. — Tracheitis,  simple,  spe- 
cific, or  diphtheritic,  may  result  from  the  exten- 
sion of  inflammation,  either  from  the  larynx  above, 
or  from  the  bronchial  tubes  below;  it  is  rare 
except  in  this  connection.  Some  degree  of  con- 
gestion is  a usual  condition  of  ordinary  catarrh  ; 
and  chronic  tracheitis  is  a frequent  cause  of  the 
cough  of  old  people.  See  Bronchi,  Diseases  of ; 
Diphtheria  ; and  Lartnx,  Diseases  of. 

3.  Ulceration  and  Perforation. — Ulceration 
and  perforation  of  the  walls  of  the  trachea  may 
result  from  the  pressure  of  an  aneurism,  which 
ends  by  bursting  into  the  air-passages,  where  it 
meets  with  least  resistance ; or  from  an  abscess 
which  has  taken  a similar  course. 

4.  Syphilis. — Syphilis,  in  its  secondary  and 
tertiary  stages,  may  affect  the  trachea.  In  the 
tertiary  stage  it  gives  rise  to  ulcers,  which  con- 
tract in  healing,  and  cause  a formidable  condition 
of  stricture,  to  be  presently  considered.  Tracheal 
syphilis,  being  in  its  advanced  form  so  grave  a 
matter,  calls  for  active  constitutional  treatment 
before  this  irremediable  stage  is  reached. 

5.  Tuberculosis. — Tubercle  occurs  in  con- 
nection with  laryngeal  and  pulmonary  phthisis. 
When  the  disease  has  proceeded  to  ulceration, 
it  may  cause  the  rare  complication  of  general 
emphysema,  the  air  being  forced  into  the  cel- 
lular tissue  by  cough  and  other  expiratory  efforts, 
made  when  the  larynx  is  closed.1 

fi.  Tumours. — (a)  Cancer. — Cancer  of  the 
trachea  as  a primary  disease  is  almost  unknown, 
but  the  organ  is  frequently  affected  by  the  ex- 
tension of  the  disease  from  neighbouring  organs. 
The  growth  first  causes  the  symptoms  of  stenosis  ; 
and  then,  as  ulceration  proceeds,  it  gives  rise  to 

1 The  writer  recently  examined  post  mortem,  the  body 
of  a child  (the  patient  of  Dr.  W.  it.  Craig)  which  had 
died  of  acute  tuberculosis,  and  in  which  this  rare  pheno- 
menon had  resulted  from  an  ulcer  of  the  right  bronchus, 
situated  immediately  beyond  the  bronchial  spur. 


1651 

expectoration  and  other  symptoms.  The  diag- 
nosis will  not  be  difficult.  The  only  treatment 
available  for  prolonging  life  is  tracheotomy,  if 
the  seat  of  the  disease  is  high  enough  to  admit 
of  it.  (6)  on-malignant  growths. — Polypi  are 
very  rare.  The  symptoms  are  those  of  obstructed 
breathing,  modified  by  the  size  and  seat  of  the 
growth.  A certain  diagnosis  can  be  attained  only 
by  tracheoscopy.  Without  treatment,  a polypus 
is  almost  certain  to  cause  death  by  suffocation, 
its  rate  of  growth  depending  on  its  pathological 
nature.  Small  growths  situated  high  up  may  be 
treated  by  the  galvano-cautery'  or  by  other  appli- 
cations through  the  larynx  ; larger  tumours  can 
only  be  removed  through  a free  opening  made 
into  the  trachea.  A tumour  may  be  so  situated 
that  tracheotomy,  without  extirpation,  may  en- 
sure the  safety  of  the  patient. 

7.  Stenosis. — The  calibre  of  the  trachea  may 
be  lessened  (a)  by  stricture,  or  by  tumours  grow- 
ing within  it ; or  ( b ) by  pressure  from  without. 

(a)  Stenosis  from  true  stricture,  or  internal 
tumour. — Stricture  is  almost  always  a result  of 
syphilis  ; it  may  be  annular  and  limited,  but 
it  usually  involves  the  tube  for  some  length. 
Tracheal  narrowing,  is  indicated  by  obstructed 
breathing,  with  hissing  inspiratory  dyspnoea,  un- 
accompanied by  the  up-and-down  movement  of 
the  larynx,  and  the  affection  of  the  voice  charac- 
teristic of  laryngeal  dyspnoea,  and  also  without 
the  stethoscopic  signs  of  pressure  on,  or  plugging 
of,  a bronchial  tube.  Under  these  circumstances, 
and  in  the  absence  of  any  tumour  in  the  neck  or 
thorax  pressing  on  the  trachea,  the  stenosis  must 
depend  on  a stricture,  or  on  a tumour  within  th6 
tube.  A syphilitic  history  would  lead  us  to 
diagnose  the  former  ; and  a tracheoscopic  exami- 
nation, if  practicable,  would  make  the  diagnosis 
certain. 

Prognosis. — Stricture  being  usually  cicatri- 
cial, the  prognosis  is  most  unfavourable. 

Treathent.— Treatment  other  than  operative 
is  seldom  available.  If  the  stricture  be  high  up, 
tracheotomy  must  be  performed  below  it ; or,  an 
opening  being  made  above  the  contraction,  a 
long  flexible  tube  maybe  introduced  and  passed 
through  it.  Stricture  of  the  trachea  is  less 
amenable  than  laryngeal  stenosis  to  treatment 
by  mechanical  dilatation  with  hollow  bougies, 
but  this  method  must  be  borne  in  mind  for 
exceptional  cases. 

(&)  Stenosis  from  compression. — The  source 
of  stenosis  caused  by  pressure  from  without  is 
usually  patent,  thoracic  tumours  being  diag- 
nosed by  tbeir  physical  signs  and  concomitant 
symptoms.  The  paroxysmal  dyspnoea  frequently 
caused  by  these  tumours  is  usually  laryngeal, 
depending  on  pressure  on  the  recurrent  nerve  ; 
but  in  some  cases  it  is  a peculiar  result  of  pres- 
sure on  the  trachea.  It  is  not  relieved  by  tracheo- 
tomy, and  is  akin  apparently  to  the  paroxysmal 
dyspnoea  occasionally  seen  as  a result  of  pres- 
sure by  the  tampon-tube  used  after  tracheotomy, 
for  plugging  the  trachea  in  certain  operations. 

8.  Foreign  bodies. — A foreign  body  enter- 
ing the  air-passages  from  the  pharynx,  may 
lodge  in  the  larynx,  either  becoming  impacted 
or  lying  loose.  But,  unless  prevented  by  its 
form  or  bulk,  it  usually  falls  or  is  drawn  through 
the  open  glottis  into  the  trachea.  Here  it  may 


1652  TRACHEA,  DISEASES  OF. 
lodge ; but  it  more  frequently  passes  on  into  one 
of  the  bronchial  tubes — most  frequently  into  the 
right  bronchus,  the  orifice  of  which  is  slightly 
larger  than  that  of  the  left,  and  occupies  more 
of  the  floor  of  the  trachea. 

Symptoms.  — Occlusion  of  the  larynx  by  a 
foreign  body,  which  from  its  bulk  obstructs  the 
passage,  may  cause  instant  death ; and  the  same 
may  be  said  of  the  trachea,  as  when  a person 
vomiting,  in  a state  of  unconsciousness  from  in- 
toxication, or  from  the  action  of  an  anaesthetic, 
draws  in  a quantity  of  food  sufficient  to  choke 
up  the  air-passages.  If  the  body  be  smaller,  it 
causes  dyspnoea,  with  severe  exacerbations  from 
spasm.  A very  small  body,  such  as  a sharp 
piece  of  bone  or  a pin,  may  be  impacted  in  a 
position  in  which  it  causes  only  pain  and  dys- 
phagia without  dyspnoea.  Speaking  generally,  it 
may  be  said  that  when  the  substance  has  passed 
into  the  trachea,  the  symptoms  to  which  it  gives 
rise  depend  on  its  bulk  and  weight.  Rarely,  it 
lies  in  the  air-passages,  giving  rise  to  no  symp- 
toms ; more  frequently,  varying  its  position  with 
the  rush  of  air  in  coughing,  &c.,  it  gives  rise  to 
paroxysmal  dyspnoea,  light  bodies  being  forced 
up  to  the  glottis  and  exciting  spasm.  If  the 
substance  pass  into  the  bronchus,  it  may  become 
impacted  there,  and  will  give  rise  to  charac- 
teristic physical  signs,  usually  exciting  a chronic 
circumscribed  inflammation,  with  symptoms  akin 
to  pneumonic  phthisis. 

Treatment. — From  the  larynx  a foreign  body 
may  be  removed  by  the  finger  or  a suitable 
forceps,  its  presence  having  been  determined 
from  the  symptoms,  aided  by  digital  or  laryn- 
goscopic  examination.  Although  different  forms 
of  long  forceps  are  made  for  passing  through  the 
larynx  into  the  trachea,  it  is  seldom  practicable 
to  remove  per  viasnaturales  a foreign  body  which 
has  once  passed  through  the  rima.  A free  open- 
ing must  be  made  in  the  trachea,  and  its  edges 
held  well  asunder,  to  give  a chance  of  the  body 
being  expelled  by  cough.  If  this  fail,  a forceps 
must  be  introduced  through  the  opening,  and  the 
body,  if  possible,  extracted.  Inversion  of  the 
patient,  so  as  to  allow  a heavy  substance  to  fall 
back  through  the  glottis  into  the  pharynx,  is 
sometimes  successful,  but  not  as  a rule  without 
previous  tracheotomy.  T.  J.  Walkek. 

TRANCE  ( transilus , a going  beyond— of 
the  soul  from  the  body). — Synon.  : Lethargy  ; 
Fr.  Lethargic;  Maladic  du  Sommeit;  Ger.  Schlaf- 
suckt. 

Definition. — A sleep-like  state,  which  comes 
on  spontaneously,  apart  from  any  gross  lesion  of 
the  brain  or  toxic  cause,  and  from  which  the 
sleeper  cannot  be  roused. 

The  term  ‘ trance,’  in  its  derivative  meaning, 
aptly  expresses  the  apparent  reduction  to  a vege- 
tative life,  but  the  popular  use  of  the  word  re- 
fers rather  to  the  separate  activity  of  the  mind 
than  to  the  inactivity  of  the  body.  Hence  many 
writers  prefer  the  term  ‘ lethargy,’  • which  also, 
although  etymologically  exact,  is  currently  em- 
ployed in  a modified  sense.  The  condition  is 
sometimes  included  under  the  generic  term 
‘ catalepsy,’  according  to  its  etymological  mean- 
ing, ‘a  seizing’;  but  this  term  is  usually  re- 
stricted to  those  forms  which  present  a peculiar 


TRANCE 

rigidity.  It  may  be  noted  that  the  terms  trance 
and  catalepsy  are  both  due  to  the  theories  of  a 
mythical  pathology. 

The  ordinary  forms  of  trance  will  be  first 
described,  and  afterwards  the  peculiar  variety 
of  ‘ sleeping-sickness’  which  is  met  with  on  the 
West  Coast  of  Africa. 

/Etiology. — The  influence  of  heredity  in  re- 
lation to  trance  is  to  be  traced  only  in  the 
production  of  a ‘ neuropathic  disposition.’  It 
occurs  chiefly  in  the  female  sex,  between  the 
ages  of  twelve  and  thirty ; very  rarely  in  young 
men  or  children.  The  subjects  are  seldom  in 
perfect  health;  they  usually  present  other  mani- 
festations of  hysteria,  and  are  often  anaemic.  The 
condition  is  rare,  however,  even  in  hysteria. 
Of  a largo  number  of  hysterical  patients  which 
have  come  under  the  writer’s  notice,  only  two 
presented  spontaneous  trance.  The  condition 
has  been  in  some  cases  apparently  due  to  ex- 
hausting diseases,  as  typhoid  fever,  excessive 
brain-work,  insolation,  or  mechanical  obstruction 
to  the  supply  of  blood  to  the  head.  The  imme- 
diate exciting  cause  is  usually  emotional  dis- 
turbance. In  rare  cases,  in  which  trance  has 
followed  traumatic  influences,  the  mechanism  has 
probably  also  been  psychical.  In  several  cases, 
trance  has  succeeded  an  hysterical  convulsion. 
Rarely  no  exciting  cause  may  be  discoverable. 
In  still  more  rare  instances  the  state  has  been 
voluntarily  induced,  as  in  the  well-known  ease 
of  Colonel  Townsend,  who  could  throw  himself 
into  a condition  of  apparent  death,  lasting  several 
hours.  Such  voluntary  induction  is  occasionally 
seen  in  the  East.  Lastly,  minor  degrees  of  trance 
may,  without  difficulty,  be  artificially  produced 
in  most  hysterical  persons,  and  less  readily,  in 
many  others,  by  the  methods  described  in  the 
article  on  Hypnotism.  The  state  now  designated 
hypnotism  is  really  induced  trance,  and  trance 
has  been  accurately  termed  ‘ spontaneous  hypno- 
tism.’ 

Symptoms. — The  onset  of  the  state  of  trance 
is  usually  sudden.  For  instance,  in  a ease  which 
came  under  the  writer’s  notice,  a girl  went  into 
a room  by  herself,  and  was  found,  shortly  after- 
wards, in  a state  of  trance-sleep,  which  lasted 
for  thirty-eight  hours.  In  another  case  (Madden) 
a young  lady  went  into  a room  to  change  her 
dress,  and  was  presently  found  on  the  bed  in  a 
state  of  trance  which  lasted  for  a fortnight.  As 
already  stated,  it  may  succeed  an  hysteroid  con- 
vulsion, and  in  some  other  cases  the  onset  has 
been  attended  with  an  aura,  resembling  the  glo- 
bus hystericus  or  the  sensation  which  precedes 
hysteroid  and  epileptic  fits,  as  of  a ball  rising 
from  the  abdomen  to  the  throat.  In  the  cases 
which  succeeded  typhoid  fever  (Madden)  the  de- 
lirium of  the  fever  passed  gradually  into  coma- 
tose sleep,  which  continued  for  several  weeks. 

During  the  state  of  trance,  the  countenance  is 
usually  extremely  pale.  The  limbs  are  relaxed, 
although  brief  initial  rigidity,  and  sometimes 
occasional  recurrent  cataleptic  rigidity,  or  tran- 
sient convulsive  spasms,  tonic  or  clonic,  have 
been  noted.  In  a few  instances  distinct  hystc- 
roidfits  have  occurred  from  time  to  time  during 
the  course  of  the  trance.  The  eyelids  are  usually 
closed,  and  may  resist  and  quiver  on  attempts  to 
open  them.  The  eyeballs  are  directed  upwards 


TRANCE. 


in  most  cases ; they  often  deviate  from  the 
middle  line,  and  sometimes  diverge  slightly. 
The  pupils  are  usually  moderately  dilated ; rarely 
they  are  moderately  contracted.  The  state  of 
reflex  action  varies  according  to  the  depth  of  the 
trance.  That  from  the  limbs  is  sometimes  ex- 
cessive, so  that  cutaneous  stimulation  produces 
tetanic  rigidity.  Much  more  frequently  reflex 
action  is  lost ; snuff  blown  into  the  nostrils  causes 
no  sneezing,  ovarian  compression  has  no  effect, 
and  pressure  on  hysterogenic  points,  which  may 
have  existed  before,  no  longer  causes  the  usual 
phenomena.  Reflex  action  from  the  conjunctiva, 
and  even  from  the  cornea,  is  commonly  absent. 
The  pupil  may  contract  to  light,  but  in  lessened 
degree,  and  sometimes  do  distinct  action  can  be 
observed. 

The  mental  functions  seem,  in  most  cases,  to 
be  in  complete  abeyance.  No  manifestation  of 
consciousness  can  be  observed,  or  elicited  by 
the  most  powerful  cutaneous  stimulation,  aud 
on  recovery  no  recollection  of  the  state  is  pre- 
served. Rut  in  some  cases  volition  only  is  lost, 
and  the  patient  is  aware  of  all  that  passes,  al- 
though unable  to  give  the  slightest  evidence  of 
consciousness.  The  senses  may  be  even  preter- 
naturally  acute,  as  in  the  analogous  phase  of 
induced  hypnotism ; or  there  may  be  spontaneous 
mental  action,  irrelevant  to  external  impressions, 
and  analogous  to,  probably  identical  with,  the 
state  of  ordinary  dreaming ; it  is  manifested  by 
exclamations,  and  even  by  movements.  Rarely 
the  ‘ obedient  automatism  ’ seen  in  induced  hyp- 
notism may  be  present ; hallucinations  occur, 
and  actions  are  performed,  according  to  sugges- 
tions made  to  the  patient.  The  usual  condition, 
however,  is  that  of  an  entire  absence  of  all  evi- 
dence of  mental  activity. 

The  pallor  of  face  is  the  result  of  a profound 
depression  of  the  vascular  system.  The  pulse 
may  be  less  frequent  or  more  frequent  than 
normal,  but  it  is  invariably  weaker,  and  it  may 
be  imperceptible.  The  cardiac  impulse  may  dis- 
appear, although  the  heart-sounds  are  still  to  be 
heard,  sometimes  much  weakened.  Very  rarely 
they  have  been  inaudible.  In  a case  observed 
by  Weir-Mitchell,  vascular  disturbance  preceded 
the  other  symptoms.  The  breathing  during 
tranco  may  be  tranquil,  slightly  quickened,  or 
slower,  or  may  be  so  feeble  and  deliberate  that 
no  movement  of  the  thoracic  walls  can  be  ob- 
served, uo  respiratory  murmur  can  be  heard  in 
the  lungs,  and  a mirror  held  over  the  mouth  is  un- 
dimmed by  moisture.  Rarely  respiration  presents 
rhythmical  variations.  Temperature,  when  ob- 
served, has  been  normal  in  the  central  parts, 
lowered  at  the  periphery.  The  secretions  go  on ; 
the  urine  may  be  retained  in  the  bladder,  or  passed 
into  the  bed.  The  catamenia  are  usually  absent, 
but  menstruation  has  been  known  to  occur  with- 
out modifying  the  course  of  the  trance-sleep. 
In  the  cases  in  which  the  depression  of  the  vital 
functions  reaches  an  extreme  degree,  the  patient 
appears  dead  to  casual  and  sometimes  to  careful 
observation.  This  condition  has  been  termed 
‘ death-trance  ’ ( Scheintod ),  and  has  furnished  the 
theme  for  many  sensational  stories,  but  the 
most  ghastly  incidents  of  fiction  have  been 
paralleled  by  well-authenticated  facts. 

Duration  and  Course. — The  duration  of 


1653 

trance  has  varied  from  a few  hours  or  days,  to 
several  weeks,  months,  or  even  a year.  When 
of  short  duration,  the  trance-sleep  may  he  un- 
broken, but  when  it  lasts  for  more  than  a few 
days,  there  are  usually  remissions  of  a greater  or 
less  degree,  in  which,  for  instance,  the  patient 
will  half-wake,  take  food  in  an  automatic  man- 
ner, and  then  relapse  into  stupor.  A long 
trance-sleep  may  he  more  profound  at  first  than 
later.  Recovery  may  be  sudden  or  gradual.  Oc- 
casionally it  is  attended  by  some  vaso-motor 
disturbance ; in  a well-authenticated  case  of 
death-tranee  the  intense  mental  excitement  pro- 
duced by  the  preparations  for  fastening  the 
coffin-lid  occasioned  a sweat  to  break  out  over 
the  body.  In  other  cases  haemorrhages  have 
occurred  at  the  time  of  recovery,  and  such  ex- 
travasations in  the  skin  have  been  regarded  as 
legendary  1 stigmata.’  After  the  trance  is  over, 
nervous  prostration,  with  defective  articulation, 
or  mental  dulness,  may  remain  for  a time.  In 
many  cases  repeated  attacks  of  trance  occur,  at 
intervals  of  days,  months,  or  years.  Most  cases 
of  trance-sleep  end  favourably.  The  depression 
of  the  vital  functions  enables  life  to  continue  with 
a very  small  amount  of  nourishment.  Occasion- 
ally death  occurs,  as  in  the  case  of  a deserter 
from  the  German  army,  and  in  one  of  the  cases 
after  typhoid  fever  described  by  Madden. 

Pathology. — The  very  few  post-mortem  ex- 
aminations which  have  been  made  after  death  in 
trance,  throw  no  light  on  its  nature.  The  theo- 
retical pathology  of  the  subject  is  involved  rn 
the  obscurity  which  envelopes  all  the  psychical 
processes  in  health  and  disease,  the  nature  of 
volition,  and  ordinary  sleep.  The  lowered  ac- 
tion of  the  brain  in  sleep,  and  its  lessened 
blood-supply,  have  suggested  the  existence  of 
cerebral  anaemia,  which  the  meagre  results  of 
anatomical  investigation  have  been  supposed  to 
confirm.  It  is  certain  that  the  condition  is 
sometimes  associated  with  defective  cerebral 
nutrition ; but  that  much  more  than  cerebral 
anaemia  is  needed  to  explain  the  state  of  trance, 
is  evident  from  the  facts  that,  on  the  one  hand, 
it  may  occur  when  there  is  no  preceding  sign  of 
defective  blood-supply  to  the  brain,  while,  on 
the  other  hand,  the  occurrence  of  cerebral 
anaemia  without  trance-sleep  is  a matter  of  daily 
observation.  The  phenomena  of  hypnotism  also 
afford  little  support  to  the  theory  of  the  depen- 
dence of  trance-sleep  on  cerebral  anaemia,  but, 
beyond  this,  they  throw  no  light  on  its  patho- 
logy. The  subject  affords  abundant  scope  for 
theories,  which  have  been  freely  supplied,  but 
are,  for  the  most  part,  mere  re-statements  of  the 
observed  phenomena,  in  the  language  of  psy- 
chology. 

Diagnosis. — The  diagnosis  of  trance  rests  on 
the  impossibility  of  rousing  the  sleeper,  com- 
bined with  the  absence  of  any  evidence  of  a 
local  cerebral  lesion  or  a toxic  cause.  Other 
diagnostic  symptoms  are  the  pallor  and  vascular 
depression,  the  occurrence  of  convulsive  phe- 
nomena of  hysteroid  type,  and  the  history  of 
other  manifestations  of  hysteria.  These  symp- 
toms sufficiently  distinguish  trance-sleep  "from 
apoplexy,  for  which,  at  the  onset,  it  is  sometimes 
mistaken.  The  distinction  from  catalepsy  rests 
on  the  absence  of  the  jlexibilitas  ccrea,  but  cata- 


1654  TRANCE. 

lepsy  is  merely  a variety  of  trance.  The  pecu- 
liar tendency  to  "brief  sleep  termed  narcolepsy  is 
distinguished  from  trance  by  the  shortness  of 
the  periods  of  unconsciousness.  Thus  a man 
had  from  youth  fallen  asleep  for  a few  minutes 
under  various  influences,  and  always  did  so  when 
a probe  was  passed  down  a nasal  fistula.  It  is 
to  be  remarked,  however,  that  the  term  narco- 
lepsy has  been  also  applied  in  America  to  cases 
of  true  epilepsy,  in  which  the  attacks  of  petit 
mal  are  characterised  by  sudden  somnolence. 

In  cases  of  ‘ death-trance,’  in  which  no  sign  of 
vitality  can  he  recognised,  the  presence  of  life 
may  be  ascertained  (1)  by  the  absence  of  any 
sign  of  decomposition;  (2)  by  the  normal  ap- 
pearance of  the  fundus  oculi  as  seen  with  the 
ophthalmoscope ; (3)  by  the  persistence  of  the 
excitability  of  the  muscles  by  electricity.  This 
excitability  disappears  in  three  hours  after  ac- 
tual death.  In  a case  observed  by  Rosenthal, 
thirty  hours  after  supposed  death  the  muscles 
were  still  excitable,  and  in  forty-four  hours  the 
patient  awoke.  See  Death,  Signs  of. 

Prognosis. — In  cases  of  hysterical  lethargy 
the  prognosis  is  fairly  good.  The  attack  usually 
passes  off.  In  very  rare  cases  death  has  oc- 
curred. The  slighter  the  degree  of  the  trance, 
the  shorter  is  likely  to  be  its  duration.  The 
prognosis  is  grave  only  when  the  lethargy  has 
been  preceded  by  a state  of  great  physical  de- 
pression, and  is  the  most  serious  when  the  con- 
dition succeeds  an  acute  disease. 

Treatment. — The  treatment  has  to  be  di- 
rected to  two  ends  : the  maintenance  of  life,  and 
the  arrest  of  the  trance.  Advantage  must  bo 
taken  of  any  intervals  of  semi-consciousness  to 
give  nourishment  in  a concentrated  form.  If 
swallowing  is  continuously  impossible,  food  must 
he  given  by  the  nasal  tube,  or  by  enemata. 
Warmth  should  be  applied  to  the  extremities, 
and  care  taken  to  prevent  bed-sores.  In  severe 
eases,  every  attempt  at  arrest  is  often  fruitless. 
Errhines,  as  snuff,  have  usually  no  influence,  and 
it  is  only  in  slight  cases  that  this,  or  stimula- 
tion of  the  skin,  as  by  sinapisms,  is  effective. 
The  most  powerful  cutaneous  excitant  is  strong 
faradisation.  In  a case  under  the  writer’s  notice, 
which  had  lasted  for  thirty-six  hours,  strong 
faradisation  to  the  arm  quickly  roused  the  pa- 
tient. In  another  case,  which  lasted  for  several 
mouths,  this  treatment  had,  for  a long  time,  no 
influence ; afterwards  the  patient  could  be  par- 
tially roused  for  a short  time  by  faradisation, 
and  by  repeating  the  application  at  the  same 
hour  every  day,  a tendency  to  periodical  waking 
was  established,  the  remissions  became  longer 
and  more  complete,  and  the  attack  was  ulti- 
mately brought  to  an  end.  Nervine  stimulants, 
such  as  ether  and  valerian,  may  be  given  by  the 
bowel,  or  sulphuric  ether  may  be  injected  subcu- 
taneously. Alcohol  must  be  given  with  caution 
and  in  small  quantities ; enemata  of  strong  coffee 
are  often  more  useful.  A remedy  which,  from 
its  effect  on  the  vascular  system,  would  cer- 
tainly deserve  trial  in  trance,  is  the  inhalation 
of  nitrite  of  amyl.  Transfusion  of  blood  has 
been  proposed,  and  would  be  justified  in  cases 
following  exhausting  disease.  The  recurrence 
of  attacks  must  be  prevented  by  the  improve- 
ment of  health,  physical  and  moral. 


TRANSFUSION  OF  BLOOD. 

African  Lethargy. — The  ‘sleeping  sickness 
of  the  West  Coast  of  Africa  is  met  with  chiefly 
in  the  Congo  and  Sierra  Leone  regions,  and 
affects  exclusively  negroes.  It  occurs  in  both 
sexes  and  at  all  ages,  but  is  most  frequent  in 
males  between  twelve  and  twenty.  Except  that 
depressing  emotions  seem  to  predispose  to  it,  the 
proximate  causes  are  entirely  unknown.  Euro- 
peans, living  in  the  same  localities,  are  exempt. 
Swelling  of  the  cervical  glands  sometimes  occurs 
at  the  onset,  and  they  are  excised  by  the  native 
doctors  as  a remedial  measure  ; but  the  condition 
is  not  invariable,  and  its  influence  is  doubtful. 
The  general  health  may  be  perfect.  The  symp- 
toms differ  considerably  from  those  of  hysterical 
trance.  There  is  a gradually  increasing  ten- 
dency to  somnolence.  The  patient  will  fall 
asleep  at  his  work  or  over  his  meals.  At  first 
he  can  be  roused,  and  if  treated  by  cutaneous 
stimulation  and  purging,  the  symptoms  may  be 
removed  for  a little  time  ; but  they  soon  recur, 
and  increase  in  spite  of  treatment,  until  at  last 
the  patient  is  always  asleep,  and  refuses  food.  He 
gradually  emaciates,  and  dies  at  the  end  of  three 
or  six  months  from  the  onset  of  the  symptoms. 
Just  before  death  the  disposition  to  sleep  often 
ceases.  The  disease  is  extremely  fatal.  Guerin 
met  with  148  cases,  all  of  which  died.  The  ob- 
servations of  Gore  and  others  place  the  mor- 
tality somewhat  lower — at  about  80  per  cent. 
Post-mortem  examination  has  revealed  only 
hyperaemia  of  the  arachnoid,  slight  signs  of 
chronic  meningitis,  but  no  considerable  excess 
of  fluid  within  the  ventricles  or  outside  the  brain. 
The  cerebral  substance  is  usually  pale.  No 
treatment  appears  to  influence  the  symptoms. 
Only  one  observer  (McCarthy)  has  seen  good 
from  excision  of  the  cervical  glands.  This  mys- 
terious affection  clearly  needs  more  systematic 
investigation  than  it  has  yet  received. 

W.  R.  Gowers. 

TRANSFUSION  OP  BLOOD.—  Syxox.  : 

Fr.  Transfusion  du  Sang ; Ger.  Transfusion  des 
Slides. 

Definition. — The  injection  of  blood  from  the 
human  subject  or  from  one  of  the  lower  animals, 
in  a pure  or  defibrinated  condition,  into  the  veins 
of  a patient. 

Description. — This  operation  was  invented  in 
the  middle  of  the  17th  century,  and  is  now  fully 
established  as  a proceeding  of  great  value ; but 
authorities  are  still  divided  as  to  the  best  mode 
of  performing  it.  Transfusion  is  most  frequently 
undertaken  as  a means  of  saving  life  after  a 
great  loss  of  blood,  and  most  commonly  after 
post-partum  haemorrhage.  It  has  also  been  em- 
ployed in  cases  of  profound  anaemia  from  other 
causes,  as  in  leueocythmmia,  phthisis,  and  1 per- 
nicious anaemia,’  and  its  use  has  been  suggested  in 
the  so-called  blood-diseases,  as  fevers  or  pyaemia, 
but  the  benefit  derived  from  it  in  these  cases 
is  at  most  only  temporary,  and  it  is  probable 
that  the  operation  will  ultimately  be  limited 
to  cases  of  anaemia  from  haemorrhage.  Trans- 
fusion benefits  the  patient,  first,  by  increasing 
the  quantity  of  fluid  entering  the  ventricles,  and 
so  encouraging  their  action ; secondly,  by  in- 
creasing the  number  of  blood-corpuscles  which, 
as  the  carriers  of  oxygen,  are  essential  to  life 


TRANSFUSION  OF  BLOOD. 


thirdly,  l>y  supplying  albumen,  and  so  giving 
nourishment  at  a time  when  it  is  probably  im- 
possible to  do  so  by  any  other  means.  For  none 
of  these  purposes  is  the  fibrin  of  the  blood  es- 
sential, and  consequently  many  operators  prefer 
to  defibrinate  the  blood,  by  which  much  trouble 
in  the  operation  is  saved.  Experiments  on  the 
lower  animals,  and  observations  of  operations 
performed  on  the  human  subject,  seem  at  present 
to  indicate  that  defibrinated  blood  is  in  every 
■way  as  efficient  as  pure  blood.  Yet  when  all 
the  necessary  appliances  are  at  hand,  pure  blood 
is  undoubtedly  the  most  natural  fluid  to  inject. 
When  human  blood  has  not  been  available,  the 
blood  of  a calf,  a sheep,  or  a lamb  has  been  used 
instead,  apparently  with  equally  beneficial  re- 
sults. The  difference  between  the  size  of  the 
corpuscles  in  these  animals  and  in  man  is  of  no 
consequence,  as  those  of  man  are  the  larger. 
The  corpuscles  from  these  animals  probably  break 
up  very  soon,  as  hsematin  has  been  found  in  the 
urine  the  day  after  transfusion  with  lamb’s  blood; 
but  they  no  doubt  serve  as  carriers  of  oxygen  for 
a short  time,  during  which  the  patient  may  rally. 
The  dangers  of  transfusion  are  not  very  great, 
but  as  cases  have  occurred  in  which  the  donor  of 
blood  has  died  in  consequence  of  the  operation, 
it  should  not  be  undertaken  without  a clear 
prospect  of  benefiting  the  recipient.  Care  must 
be  taken  that  air  is  not  injected  with  the  blood. 
The  experiments  of  Ore  ( Etudes  historiques  et 
pliysiologiques  surla  Transfusion  du  Sang,  Paris, 
1 868)  have,  however,  shown  that  this  danger 
has  been  much  exaggerated.  A bubble  of  air 
does  no  harm ; the  quantity  to  cause  death  must 
be  considerable.  Too  great  care  cannot,  how- 
ever, be  taken  to  exclude  air,  as  fatal  cases  have 
occurred  from  this  cause.  The  injection  of  clots 
giving  rise  to  embolism,  and  perhaps  to  pyaemia, 
is  always  considered  one  of  the  dangers  of  the 
operation ; but  evidence  is  wanting  to  show  that 
it  has  been  a frequent  cause  of  death,  or  that  in 
all  the  cases  in  which  pyremia  or  septicaemia  fol- 
lowed the  operation  it  was  due  to  this  cause. 
One  case  is  recorded  by  Jiirgensen  ( Vier  Fdlle 
von  Transfusion  cles  Blutes,  Berlin,  1871)  in 
which  red  maculte  formed  on  the  skin  after  the 
operation,  which  subsequently  suppurated.  These 
were  supposed  to  be  due  to  minute  fragments  of 
fibrin  injected  with  the  defibrinated  blood.  Dr. 
Madge  {Brit.  Med.  Jour.  vol.  ii.  1874 ; and  Obst. 
Jour,  of  Gt.  Brit.,  1874)  has  shown,  however, 
that  with  care  no  such  fragments  need  be  left 
after  whipping  and  straining.  The  wounds  left 
after  transfusion  present  nothing  special,  and 
are  to  be  treated  as  ordinary  venesection  wounds. 
The  difficulties  with  which  the  operator  has  to 
contend  are  not  great  when  defibrinated  blood  is 
used.  When  pure  blood  is  used  by  any  but  the 
immediate  method  of  transfusion  from  artery  to 
artery,  or  vein  to  vein,  there  is  some  necessary 
hurry,  as  the  operation  must  be  finished  before 
coagulation  sets  in.  To  avoid  this.  Dr.  Braxton 
Hicks  recommends  the  addition  of  a solution  of 
phosphate  of  soda  (jj  to  Oj),  in  the  proportion  of 
one  of  the  solution  to  three  of  blood ; and  Dr. 
Richardson  a solution  of  liquor  ammonias  (n\.xx: 
and  distilled  water  yj),  to  be  added  to  a pint  of 
blood.  Both  these  solutions  have  the  power  of 
erresting  coagulation.  There  is  often  some  diffi- 


1655 

culty  in  finding  the  collapsed  and  empty  vein  of 
the  patient.  An  ordinary  venesection  incision  is 
useless  ; the  vein  must  be  cut  down  upon,  picked 
up  with  forceps,  and  then  opened. 

Transfusion  is  either  mediate  or  immediate. 
In  the  mediate  operation  the  blood  may  be  either 
defibrinated  or  pure.  When  pure  blood  is  used, 
the  vein  of  the  patient  must  first  be  exposed  and 
opened,  and  a silver  cannula  introduced.  It  ia 
better  to  use  an  assistant's  fingers  rather  than  s 
ligature  to  retain  the  cannula  in  its  place.  It  is 
well  to  allow  a drop  or  two  of  the  patient's  blood 
to  escape  from  the  cannula,  if  possible,  to  make 
sure  it  contains  no  air,  or  it  may  be  filled  with 
warm  water  or  a solution  of  phosphate  of  soda. 
While  this  is  being  done  the  donor  is  bled  into  a 
clean  vessel.  No  precautions  need  be  taken  to 
keep  the  blood  warm.  Cold  delays  coagulation. 
As  soon  as  sufficient  blood  has  been  obtained,  it 
is  transferred  to  a syringe  which  is  provided 
with  an  india-rubber  tube.  Care  being  taken 
that  the  tube  and  syringe  contain  no  air,  they 
are  now  connected  with  the  cannula,  and  the 
blood  slowly  injected.  Innumerable  instruments 
have  been  invented  for  this  operation,  with  the 
object  of  saving  time,  and  ensuring  against  the 
entrance  of  air.  It  is  impossible  to  describe 
them  here.  The  best  known  are  Hewitt's  {Brit. 
Med.  Jour.  1863,  vol.  ii.),  Hicks’s  {Guy's  Hosp. 
Reports,  1869),  Higginson’s  {Liverpool  Med. 
Chir.  Jour.,  1857).  and  Mathieu’s  {Bull.  Acad, 
dc  Med.  Paris,  1867).  In  this  last  the  blood 
is  received  directly  from  the  donor  into  a fun- 
nel at  the  top  of  the  syringe,  and  great  ra- 
pidity of  operation  is  consequently  attained. 
An  ingenious  instrument,  which  it  is  impossible 
to  describe  without  a drawing,  was  introduced 
into  London  in  1877  by  Dr.  J.  Roussel.  When 
all  its  parts  are  in  good  order  it  doubtless  works 
extremely  well,  but  it  is  somewhat  complicated 
and  uncertain  in  its  action  (Dr.  J.  Roussel  on 
Transfusiori  of  Human  Blood,  with  a preface  by 
Sir  James  Paget.  London,  1877).  When  defi- 
brinated blood  is  used,  complicated  instruments 
are  unnecessary.  The  blood  must  bo  received 
into  a clean  vessel,  and  whipped  with  a clean 
stick  or  a twisted  glass  rod,  till  fibrin  ceases  to 
separate.  The  whipping  must  be  done  gently,  so 
as  not  to  injure  the  blood-corpuscles,  or  to  break 
off  minute  fragments  of  fibrin.  After  whipping, 
the  blood  must  be  carefully  strained  two  or 
three  times  through  some  clean  linen.  It  may 
then  be  injected  as  above  described.  The  opera- 
tion of  immediate  transfusion  has  been  reintro- 
duced by  Dr.  Aveling  ( Obst.  Jour,  of  Gt.  Brit., 
1873).  In  this  operation  two  cannulas  are  re- 
quired, one  for  the  vein  of  the  donor,  and  one  for 
that  of  the  patient.  They  are  connected  with 
each  other  by  an  india-rubber  tube,  with  a small 
ball  in  the  middle  and  a stop-cock  at  each  end. 
The  cannulas  having  been  inserted  are  allowed 
to  fill  with  blood  so  as  to  expel  the  air;  or  that 
in  the  patient’s  vein,  if  no  blood  will  flow  into  it, 
is  filled  with  warm  water.  The  india-rubber 
tube  having  been  previously  filled  with  warm 
water,  is  now  applied  to  the  cannulae,  and  the 
stop-cocks  turned  on.  The  small  ball  is  then 
squeezed,  while  the  tube  is  pinched  on  the  side 
of  the  donor  by  an  assistant.  This  drives  the 
I fluid  in  the  tube  into  the  vein  of  the  patient 


1655  TRANSFUSION  OF  MILK. 

The  tube  is  nest  pinched  on  the  side  of  the 
patient,  and  the  ball  allowed  to  expand  and  then 
emptied  as  before.  Each  squeeze  of  the  ball 
drives  in  three  drachms  of  blood.  Immediate 
transfusion  from  artery  to  vein  has  only  been 
performed  when  an  animal  has  been  the  donor. 
In  this  operation  the  carotid  artery  of  a lamb  or 
calf  is  connected  directly  with  the  vein  of  the 
patient  by  means  of  a simple  india-rubber  tube, 
with  a cannula  at  each  end.  The  force  of  the 
animal’s  circulation  is  quite  sufficient  to  carry 
the  blood  into  the  patient’s  vein.  As  the  result, 
however,  of  a series  of  experiments  carried  out 
at  the  request  of  the  Obstetrical  Society  of 
London,  Professor  Schafer  has  recommended  im- 
mediate transfusion  from  artery  to  artery  as  the 
most  efficacious  method  of  performing  the  opera- 
tion {Trans.  Obst.  Soc.  Lcmd.  1879,  vol.  xxi.). 
The  quantity  injected  in  any  of  the  foregoing 
methods  of  operating  varies  with  the  effect  pro- 
duced. Sometimes  as  much  as  a pint  has  been 
introduced.  Half  that  quantity  is  usually  suf- 
ficient to  produce  a marhed  effect. 

Marcus  Beck. 

TRANSFUSION  OF  MILK.— This  ope- 
ration, or,  as  it  is  more  correctly  termed,  Infu- 
sion or  Intravenous  Injection  of  Milk,  has  been 
recommended  in  America  by  Thomas  (Is.  Y. 
Med.  Journ.  May,  1878),  Howe  (,V.  Y.  Med. 
Hoc.  1878,  p.  413),  and  others,  as  a substitute  for 
transfusion  of  blood.  In  this  country  it  has 
been  practised  and  recommended  chiefly  by  Ur. 
Austin  Meldon,  of  Dublin  {Med.  Press  and  Cir- 
cular, Oct.  22,  1879  ; and  Lancet,  1880,  vol.  i. 
p.  527).  The  subject  has  been  experimentally 
studied  in  F'rance  by  Bechamp  and  Baltus,  La- 
borde,  Culcer,  and  others,  with  the  result  of 
showing  that  a small  amount  of  milk  may  he 
injected  without  any  evil  consequences ; but  if 
the  quantity  be  too  large  and  too  rapidly  in- 
jected, the  animal  dies  asphyxiated  after  severe 
dyspnoea.  The  'post-mortem  examinations  showed 
minute  haemorrhages  and  embolisms,  caused  by 
the  milk-globules  sticking  in  the  capillaries  of 
the  lungs,  kidneys,  brain,  and  other  viscera. 
The  numerous  cases  in  which  the  operation  has 
been  performed  on  the  human  subject  show  that 
it  can  be  safely  undertaken,  provided  that,  in 
addition  to  the  usual  precautions  observed  in 
intravenous  injections,  the  following  points  are 
attended  to.  The  milk  must  be  freshly  di-awn 
from  a cow  or  goat.  A goat  may  be  brought  to 
the  bedside  of  the  patient.  The  milk  must  be 
alkaline  ; and  this  is  best  secured  by  the  addi- 
tion of  a small  quantity  of  carbonate  of  ammonia. 
It  must  be  raised  to  a temperature  somewhere 
near  that  of  the  body.  Under  no  circumstances 
must  more  than  4i  ounces  be  injected  (Meldon). 
If  any  dyspnoea  is 'observed  the  operation  must 
he  at  once  arrested.  The  injection  is  usually 
followed  by  a considerable  rise  of  temperature, 
and  there  may  be  some  disturbance  of  respi- 
ration, which  passes  off  in  a short  time.  The 
operation  is  reported  to  have  been  successfully 
performed  in  cases  of  cholera,  pernicious  anaemia, 
phthisis,  and  loss  of  blood  ; and  it  may  perhaps 
be  recommended  as  a last  resource  in  some  of 
these  conditions  if  no  blood  can  be  obtained  for 
transfusion.  Injection  of  milk  can  only  effect 


TRICHINA. 

two  of  the  purposes  of  transfusion.  It  can  in- 
crease the  amount  of  circulating  fluid;  and  it 
can,  in  an  imperfect  way,  supply  food  at  a timo 
when  it  could  not  otherwise  be  taken;  but  it  can 
do  nothing  to  increase  the  oxygen-carrying  power 
of  the  blood.  Its  inferiority  to  immediate  trans- 
fusion is  self-evident ; and  it  is  more  dangerous 
and  less  efficacious  than  the  transfusion  of 
freshly-defibrinated  blood,  either  of  man  or  ani- 
mals. Marcus  Beck. 

TRANSPOSITION  OF  VISCERA.  See 

Organs,  Displacement  of. 

TRAUMATIC  (rpavpa,  a wound). — That 
which  is  associated  or  connected  with  a wound 
or  injury,  for  example,  traumatic  fever,  traumatic 
gangrene,  and  traumatic  aneurism. 

TREATMENT.  See  Disease,  Treatment  of ; 
and  Therapeutics. 

TREMENS,  DELIRIUM.  See  Delirium 

Tremens  ; and  Alcoholism. 

TREMOR  (Lat.  trembling).- — The  most  deli- 
cate form  of  clonic  spasm,  consisting  of  succes- 
sive movements  of  very  small  amplitude.  Tre- 
mors are  seen  principally  in  the  hands,  the  head, 
the  tongue,  or  the  facial  muscles,  as  a result  of 
disease  or  of  old  age.  They  are  commonly 
spoken  of  as  ‘ coarse  ’ or  1 fine,’  according  to  the 
amount  of  movement  which  they  involve.  For 
some  account  of  the  mode  in  which  tremors  are 
related  to  other  disorders  of  movement  see 
Motility,  Disorders  of. 

TRICHIASIS  {eP\ l,  the  hair).— A morbid 
condition  in  which  the  eyelashes  are  inverted  to- 
wards the  eye.  See  Eye  and  its  Appendages, 
Diseases  of. 

TRICHINA  {rpixivos,  made  of  hair). — Sv- 
non. : Fr.  Trichine',  Ger.  Trichina. — A genus  of 
nematoid  worms,  originally  established  by  Pro- 
fessor Owen  for  the  reception  of  the  minute  spiral 
flesh-worm  ( T.  spiralis).  This  entozoon  was  first 
discovered  in  human  muscle  by  Sir  James  Paget, 
when  a student  at  St.  Bartholomew's  Hospital. 
The  history  of  this  and  other  discoveries  in  con- 
nection with  trichina,  so  much  misunderstood 
abroad,  is  exhaustively  discussed  in  the  writer’s 
work  on  Entozoa'  (Supplement,  1869,  p.  1 etseg.); 
but  it  must,  in  justice  to  continental  observers, 
he  here  at  least  permitted  us  to  remark  that 
whilst  Herbst  was  the  first  to  rear  capsuled 
trichinee  by  experiment,  and  whilst  Virchow  was 
the  first  to  rear  and  recognise  sexually  mature 
intestinal  trichinae  in  a dog,  it  yet  remained 
ffr  Zenker  to  open  up  a new  epoch  in  the 
record  of  trichinal  discovery,  by  a complete  dia- 
gnosis of  the  terrible  disease  which  these  para- 
sites are  capable  of  producing  in  the  human 
frame.  With  Leuekart  rests  the  honour  of  com- 
municating the  fullest  and  most  complete  details 
in  reference  to  the  structure  of  the  worm,  whilst 
at  the  same  time  he  solved  most  of  the  difficult 
problems  relating  to  the  source  and  genetic  re- 
lations of  the  parasite.  In  this  connection  the 
separate  labours  of  Pagenstecher,  Davaine,  and 
Heller  are  also  especially  noteworthy;  the  writer's 
own  experimental  results  at  the  same  time 


TRICHINA. 

Corresponding  very  closely  -with,  those  obtained 
abroad  (Linn.  Soc.  Proceed.,  1865). 

Description.— The  Trichina  spiralis  may  he 
described  as  a minute  helminth,  the  sexually 
mature  male  measuring  the  i of  an  inch,  and 
the  female  | of  an  inch  in  length.  The  tail  of 
the  male  is  distinguished  by 
/ the  presence  of  a bilobed  pro- 

js  minence,  between  the  divisions 

III  4 of  which  the  anal  opening  is 
If  ff  placed,  and  from  which  latter 
a single  spieulum  can  be  pro- 
truded. The  female  is  stouter, 
and  supplied  with  a bluntly 
rounded  caudal  extremity,  the 
reproductive  outlet  being  situ- 


Fig.  97. 

Trichina  spiralis 
magnified  ; male  (a), 
and  female  (i).  After 
Leuckart. 


Fig.  98. 

Portion  of  human  muscle, 
enclosing  a single  capsuled 
Trichina.  Highly  magnified. 
After  Leuckart. 


ated  towards  the  anterior  part  of  the  body.  The 
eggs  measure  only  the  of  an  inch  in  their 
long  diameter,  their  contained  embryos  being  pro- 
duced viviparously.  As  explained  by  Professor 
Leuckart,  the  entire  course  of  development  from 
the  period  of  impregnation  up  to  the  time  of 
sexual  maturity  may,  under  favourable  circum- 
stances, occupy  considerably  less  than  three 
weeks.  The  ingestion  of  trichinous  pork  is  fol- 
lowed by  the  maturation  of  the  muscle-larvae 
in  two  days,  by  the  birth  of  embryos_  in  six 
days,  and  by  the  arrival  of  the  migrating  pro- 
geny within  the  muscles  of  the  human  or  animal 
bearer  in  fourteen  days.  The  formation  of  the 
lemon-shaped  protective  capsules  around  the 
muscle-worms  is  a subsequent  process,  requir- 
ing several  weeks  for  its  accomplishment.  In 
the  perfectly  formed  larva  males  and  females 
are  already  recognisable  as  such. 

The  disorder  produced  by  trichin®  is  almost 
entirely  due  to  the  injury  inflicted  on  the  host  by 
the  act  of  wandering  performed  by  the  embryos. 
The  grave  symptoms  and  results  thus  superin- 
duced are  described  in  the  article  Trichinosis. 

T.  S.  G'obbold. 


TRICHINOSIS  or  TRICHINTASIS.— 
Svnon.  : Pr.  Trichinosc  ; Ger.  TrichinenkranJc- 
keit. 

Definition. — The  name  applied  to  the  vermi- 


TRICHINOSI3  OR  Till CHIN IASIS.  1657 
nous  disorder  called  ‘ flesh- worm  disease,’  or  to 
that  form  of  helminthiasis  which  results  from 
the  wanderings  performed  by  the  larvse  of  Tri- 
china spiralis.  The  discovery  of  this  disease  in 
the  living  human  subjeet  is  due  to  Zenker.  See 
Trichina. 

Historv. — Whilst  the  literature  of  this  direc- 
tion is  of  great  extent,  the  exigencies  of  clinical 
instruction  can  be  sufficiently  met  by  a brief 
record  of  the  principal  phenonema  of  the  disease 
as  ordinarily  presented  by  trichinised  patients. 
Whilst  the  discovery  of  the  worm  itself,  as  a 
nematoid,  rests  with  Sir  James  Paget,  the  earliest 
recognition  of  the  calcified  and  lemon-shaped  cap- 
sules (‘gritty  particles’)  was  made  by  Air.  Hilton 
of  Guy’s  Hospital.  Not  only  so;  Mr.  Hilton 
suggested  the  parasitic  nature  of  the  ‘ specks  ’ 
observed  in  human  muscle,  which  were,  how- 
ever, regarded  by  him  as  ‘ depending  upon  the 
formation  of  very  small  cysticerci.’  The  advo- 
cates of  the  prior  claims  of  Tiedemann  in  this 
connection,  though,  in  the  estimation  of  a few 
persons,  apparently  well-established,  do  not  pre 
tend  to  credit  that  anatomist  with  the  possession 
of  the  faintest  conception  of  the  parasitic  origin 
of  the  specks,  or  ‘ stony  concretions,’  as  he  termed 
them  in  Froriep’s  Notizen  for  1822.  In  1828, 
Mr.  Peacock  observed  similar  little  bodies.  In 
looking  at  the  subject  from  a pathological  stand- 
point, we  see  how  large  a share  our  countrymen 
had  in  first  recognising  the  trichina  capsules  in 
their  calcified  state.  This  degenerated  condition 
may  be  regarded  as  an  invariable  sequela  of  the 
disease,  whenever  the  latter  has  run  its  natural 
course  without  proving  fatal  to  the  bearer.  Mr. 
Richard  Davy  discovered  a number  of  lenticular 
or  oval  bodies,  averaging  the  fourth  of  an  inch  in 
length,  in  the  muscles  of  a dissecting-room  sub- 
ject at  the  "Westminster  Hospital.  To  the  naked 
eye  they  resembled  the  early  condition  of  dege- 
nerating cysticerci;  being  also  firm  in  texture, 
white,  and  of  almost  uniform  size.  The  writer 
examined  one  on  the  1st  of  March,  1876.  It 
consisted  of  a dense  fibrous  capsule,  containing 
caseous  matter  which  effervesced  on  the  applica- 
tion of  strong  acid.  Probably  they  would  have 
become  concretions,  similar  to  those  described 
by  Tiedemann. 

SvjiPTOiis.-The  symptoms  of  tri chinosis,  though 
by  no  means  uniform,  are  tolerably  characteristic. 
Under  ordinary  circumstances,  the  ingestion  of 
badly  trichinised  meat,  insufficiently  cooked,  is 
followed  after  a few  hours  by  symptoms  of  in- 
digestion, such  as  nausea  and  vertigo,  which  may 
be  succeeded  by  actual  sickness  and  marked 
febrile  disturbance.  In  milder  cases  the  pre- 
monitory indications  are  usually  insufficient  to 
excite  attention  ; failure  of  the  appetite,  or  aver- 
sion to  food,  with  more  or  less  malaise,  being  all 
that  is  noticeable.  If  only  a very  small  quantity 
of  diseased  meat  has  been  taken,  the  attack  may 
pass  off  without  particular  observation ; but  in 
bad  cases  diarrhoea  sets  in,  and  may  continue  for 
several  days  in  succession,  the  fever  becoming 
more  and  more  marked.  The  patient  is  now 
prostrate.  The  extremities  become  stiff  and 
painful ; and  thus  the  first  stage  of  the  disorder, 
usually  lasting  for  about  a week,  is  completed. 
The  second  stage  of  the  affection  is  coincident 
with,  and  dependent  upon,  the  active  migration 


TRICHINOSIS  OR  TRICHINIASIS. 


1658 

of  the  progeny  resulting  from  the  maturation  and 
propagation  of  the  capsuled  trichinae  originally 
ingested  by  the  patient.  The  ferer  increases; 
there  is  oedema  of  the  face,  which,  however,  in 
some  cases  is  limited  to  the  eyelids.  Movements  of 
the  eyes  are  accompanied  with  pain,  and  there  is 
intolerance  of  light.  Later  on,  the  muscles  of  the 
limbs  are  swollen  and  rendered  extremely  pain- 
ful to  the  touch,  the  slightest  attempt  at  move- 
ment causing  excruciating  distress.  The  tongue 
is  red  and  slightly  coated.  The  pulse  is  very 
rapid,  rising  to  1 10,  120,  or  more,  per  minute ; 
the  respiratory  movements  and  temperature  like- 
wise generally  increase  in  rapidity  and  height. 
There  is  usually  abundant  perspiration,  whilst 
the  thirst  is  by  no  means  excessive.  In  all 
cases  the  pain  is  apt  to  render  the  patient 
very  ix-ritable,  his  inability  to  sleep  being  one  of 
the  most  distressing  symptoms.  In  grave  cases 
delirium  frequently  sets  in;  the  limbs  become 
flexed  and  paralysed;  and  there  is  also,  generally 
speaking,  excessive  and  continuous  diarrhoea, 
which  rapidly  exhausts  the  patient,  and  places 
him  in  great  danger.  He  lies  on  his  back,  in  a 
state  of  utter  helplessness,  and  frequently  can 
neither  move  a limb,  sneeze,  yawn,  nor  perform 
the  ordinary  acts  of  mastication  and  swallowing, 
in  consequence  of  the  paralysis  of  the  various 
muscles  concerned  in  these  different  functions. 

Course  and  Terminations. — In  about  a month 
or  five  weeks  from  the  commencement  of  the 
attack  the  second  stage  of  the  disorder  is  com- 
pleted ; but  the  lines  of  demarcation  between 
these  various  stages  of  the  malady  are  necessarily 
somewhat  arbitrary.  If  death  take  place,  it  usu- 
ally happens  before  the  completion  of  the  second 
stage,  in  the  third  or  fourth  week ; but  when 
the  patient’s  strength  can  support  the  complete 
immigration  of  all  the  progeny  resulting  from  the 
original  infection,  then  the  marked  cessation  of 
the  febrile  symptoms  indicates  the  commencement 
of  the  third  stage  or  common  period  of  recovery. 
This  third  stage,  however,  is  not  one  of  invari- 
able convalescence.  As  a rule,  the  diminished 
frequency  of  the  pulse,  the  improved  state  of  the 
respiration,  and  the  diminution  of  the  tempera- 
ture go  on  more  or  less  uniformly,  until  the 
patient's  strength  gradually  returns  with  his  re- 
commencing and,  at  first,  very  slowly  increasing 
appetite.  In  bad  cases,  however,  the  diarrhoea 
continues,  and  there  is  a general  collapse  of  all 
the  vital  powers,  resulting  from  all  sorts  of 
sequels  that  had  set  in  during  the  progress  of 
the  affection.  Amongst  these,  affections  of  the 
chest  usually  play  a conspicuous  part,  such  as 
haemoptysis,  pneumonia,  and  hydrothorax.  Dur- 
ing the  period  of  returning  convalescence,  the 
appetite  sometimes  becomes  voracious,  the  body 
rapidly  gains  flesh,  and  there  is  always  more  or 
less  desquamation  of  the  cuticle.  The  periods 
both  of  recovery  and  death,  as  the  case  may  be, 
are  exceedingly  variable  ; in  some  instances  the 
health  not  being  re-established  until  two  or  even 
three  months  have  elapsed. 

Diagnosis. — The  diagnosis  of  this  disease  must 
be  founded  on  a consideration  of  the  symptoms 
described,  taken  in  connexion  with  the  discovery 
of  the  parasite  itself,  first,  in  the  suspected  arti- 
cles of  food  ; secondly,  as  adult  trichinae,  in  the 
slvine  evacuations  during  the  first  six  or  eight 


weeks  of  the  disease  ; and,  thirdly,  as  specimens 
obtained  from  the  muscles  of  the  living  subject 
by  an  instrument  called  the  harpoon,  or  by 
simple  incision,  the  part  being  anaesthetised. 

Treatment. — The  indications  as  to  treatment 
are  obviously  few  and  simple.  To  support  the 
strength  is  essential.  In  our  judgment  no  good 
can  possibly  result  from  the  administration  of 
the  picronitrate  of  potash,  benzoin,  arsenic,  or 
any  other  drug  which  is  given  with  the  view  of 
destroying  the  young  and  migratory  trichinae. 
AVhen  once  the  young  parasites  have  started  on 
their  journe}%  all  hope  of  arresting  their  progress 
is  at  an  end ; when  they  have  become  encapsuled, 
even  a strong  solution  of  chloride  of  zinc  (in- 
jected into  the  body  of  the  deceased  victim  for 
anatomical  purposes)  will  have  no  effect  on  them. 
Far  otherwise,  however,  are  the  results  of  treat- 
ment if  the  disorder  be  attacked  immediately  on 
the  appearance  of  the  premonitory  symptoms.  If 
the  tricliinous  food  has  not  left  the  stomach,  an 
emetic  may  prevent  all  further  mischief.  If 
the  stomachal  contents  have  passed  into  the 
upper  bowel,  a brisk  purgative,  repeated  for 
several  days  in  succession,  may  expel  the  trichinae 
before  they  have  arrived  at  sexual  maturity.  For 
this  purpose,  nothing  seems  to  answer  the 
end  so  well  as  calomel,  which  may  be  given  in 
five-grain  or  larger  doses,  combined  with  jalap, 
scammony,  or  colocynth.  According  to  Rupp- 
recht  (who  enjoyed  large  opportunities  for  testing 
the  value  of  different  drugs  during  theHettstadt 
outbreak),  one-scruple  doses  of  calomel  can  be 
borne,  not  only  with  impunity,  but  with  positive 
advantage.  Castor  oil  and  turpentine,  either 
separately  or  combined,  may  be  given  with 
benefit;  but  the  employment  of  the  ordinary 
vermifuges,  such  as  male  fern  and  santonin,  is 
clearly  contra-indicated.  A good,  active  cathartic, 
such  as  the  compound  senna  mixture,  or  the 
simple  scammony  draught  of  the  British  Phar- 
macopoeia, will  probably  be  fully  as  efficient  as 
any  of  the  drugs  usually  administered  as  ver- 
mifuges. The  measure  of  success  is  clearly  depen- 
dent in  the  main  upon  prompt  catharsis.  In 
cases  where  the  second  stage  of  the  disorder  has 
fairly  set  in,  less  active  purgatives  may  be  given 
at  first,  the  great  obj  ect  being  to  lessen  the  fever, 
and  to  support  the  system  by  judicious  dieting. 
The  disinclination  of  the  patient  to  take  food  of 
any  kind  must  be  overcome  at  all  hazards,  and 
soda-water,  with  meat  extract  very  slightly  di- 
luted, must  be  administered.  AVhen  the  yolk  cf 
an  egg,  or  milk,  or  broth  can  be  given  in  the 
ordinary  way,  as  a meal,  it  should  be  preferred. 
As  remarked  before,  the  strength  must  be  sup- 
ported, if  necessary,  by  small  quantities  of  wine 
or  brandy.  In  this  way  the  patient’s  life  may 
be  upheld  during  the  most  critical  period,  after 
which,  when  convalescence  is  being  re-estab- 
lished, the  employment  of  the  ordinary  vege- 
table tonics  and  steel  may  be  advantageously 
resorted  to.  Natural  chalybeate  waters  are  also 
likely  to  prove  serviceable. 

Prevention. — In  regard  to  the  prevention  of 
trichinosis,  all  that  need  be  remarked  in  this 
place  has  reference  to  the  temperature  to  which 
all  cooked  meat  should  be  raised  in  order  to  kill 
the  parasites.  According  to  most  authorities, 
trichinae  succumb  to  a moist  heat  of  170°  Fair. 


TRICHINOSIS  OR  TRICIIINIASIS. 
whilst  some  assert  that  20  degrees  less  than  this, 
if  prolonged,  is  sufficient  for  the  purpose.  Ac- 
cording to  some  interesting  experiments  by  Dr. 
Lewis,  the  centre  of  a leg  of  mutton  attains  a 
temperature  of  107°  Fahr.  in  about  five  minutes 
after  the  surface  of  the  joint  has  been  exposed 
to  boiling  heat  (212°).  Clearly,  with  the  most 
ordinary  precautions  it  is  easy  to  avoid  infec- 
tion. Recent  experiments  show  that  salting  is 
not  fatal  to  the  capsuled  trichina.  England  is 
singularly  free  from  trichinosis ; but  rather  from 
the  circumstance  that  our  swine  rarely  contain 
trichinae,  than  that  we  are  unaccustomed  to  eat 
underdone  meat.  Only  one  small  outbreak  of 
trichiniasis  has  been  observed  within  our  borders, 
the  original  account  of  which,  by  Dr.  W.  Lindow 
Dickenson,  appeared  in  the  British  Medical  Jour- 
nalist the  year  1871.  Some  outbreaks  supposed 
to  be  those  of  true  trichinosis  have  turned  out 
to  be  spurious.  The  epidemic  on  board  H.M. 
training  ship  ‘ Cornwall ' was  of  this  character. 
An  autopsy  of  one  of  the  boy's  revealed  the 
existence  of  a new  species  of  free  nematoid, 
which  the  writer  called  Ehabditis  Cornwalli,  and 
which  Dr.  Bastian  named  after-wards  Pelodera 
setigera.  A large  number  of  parasites  have  been 
wrongly  described  as  trichinae,  thus  causing  much 
error  of  interpretation  (see  Pelodera).  In  Ger- 
many true  trichina  epidemics  have  been  noto- 
riously frequent,  and  thus  for  our  knowledge 
of  the  phenomena  of  the  disorder  we  have  been 
mainly  dependent  upon  the  writings  of  Rupp- 
reeht,  Zenker,  Virchow,  Leuckart,  Pagenstecker, 
Heller,  and  others.  The  disease  is  not  in- 
frequent in  the  United  States,  where,  however, 
it  is  for  the  most  part  confined  to  the  German  in- 
habitants, who  have  retained  the  habit  of  eating 
‘ smoked  sausages,’  so  common  in  the  Fatherland. 
(For  details,  see  Dr.  Sutton’s  excellent  Report 
cm  Trichinosis,  as  observed  in  Dearborn  eo., 
Indiana,  in  1871:  Transactions  of  the  Indiana 
State  Medical  Society  ior  1875  ; and  also,  espe- 
cially, Dr.  W.  C.  W.  Glazier’s  Report  on  Tri- 
chinae and  Trichinosis,  published  by  order  of 
Congress,  "Washington,  1881.)  For  further  par- 
ticulars on  this  subject  the  reader  is  referred  to 
the  writer’s  book  on  Parasites ; to  Dr.  Althaus’s 
Essay  on  Trichinosis ; and  to  the  still  more  ela- 
borate and  exhaustive  memoir  by  Dr.  Thudi- 
chum,  published  in  the  reports  of  the  Privy 
Council  for  the  year  1864.  See  Trichina. 

T.  S.  ConnoLD. 

TRICHOCEPHALUS  (0f(,  a hair,  and 
Ke<pa?S],  a head). — Synon.  : Fr.  Trichocephale  ; 
Gor.  Haarkopfwurm. — A genus  of  nematode 
worms,  comprising  forms  in  which  the  anterior 
two-thirds  of  the  body  is  filiform,  terminating  in 
a mere  point.  They  are  sometimes  called  whip- 
worms ; the  thickened  body  answering  to  the 
handle  of  the  whip.  The  human  species  (T, 
dispar ) varies  from  an  inch  and  a half  to  two 
inches  in  length,  according  to  sex,  and  it  resides 
principally  in  the  caecum.  The  male  is  smaller 
than  the  female,  and  is  readily  recognised  by  its 
spirally  contorted  tail.  This  parasite  probably 
enjoys  a wide  distribution ; but  little  attention 
has  been  paid  to  it  out  of  Europe.  In  England 
it  is  rare  as  compared  with  France,  where,  ac- 
cording to  the  testimony  of  Davaine  and  Duval, 


TRIFACIAL  NERVE.  1C59 
it  is  extremely  abundant,  the  former  authority 
having  calculated  that  one-half  of  the  Parisians 
were  infested  by  it.  Leidy  says  it  is  frequent 
in  the  United  States.  Clinically,  its  importance 
by  no  means  corresponds  with  its  prevalence ; 
nevertheless,  in  rare  instances  it  has  been  known 
to  occasion  severe  symptoms.  A most  interest- 
ing case  of  this  kind  has  been  placed  on  record 
by  Mr.  D.  Gibson, in  which  ‘paralysis,  with  loss 
of  speech  ’ resulted  from  the  intestinal  irritation 
occasioned  by  the  presence  of  large  numbers 
(Lancet,  August  9,  1862,  p.  139).  In  like 
manner,  Davaine  quotes  a case  by  M.  Felix- 


Pascal,  where  a little  girl,  four  years  of  age,  died 
with  cerebral  symptoms,  the  post-mortem  reveal- 
ing the  presence  of  a ‘ prodigious  quantity  ’ of 
whipworms  in  the  caecum  and  colon.  The  writer 
has  occasionally  expelled  this  parasite  when  em- 
ploying vermifuges  for  other  parasites.  It  is 
worthy  of  remark  that  in  animals  the  presence 
of  a closely  allied  species  (T.  affinis)  Las  been 
knowrn  to  produce  severo  intestinal  irritation. 
See  Whip-worm.  T.  8.  Ccbbold. 

TRICHOMONAS  VAGINALIS  (0plf,  a 

hair,  and  novas,  a monad;  and  vaginalis,  con- 
nected with  the  vagina). — A ciliated  infusorial 
animalcule,  discovered  by  Donne  in  the  vaginal 
mucus,  and  somewhat  resembling  a spermato- 
zoon. See  Rape. 

TRICHOPHYTON  (efe.  a hair,  and  <pv rhv, 
a plant).— A genus  of  parasitic  fungi,  to  the 
presence  of  which  tinea  is  due.  See  Tinea. 

TRICUSPID  VALVES  and  ORIFICE, 

Diseases  of.  Sec  Heart,  Valves  of,  Diseases  of. 

TRIFACIAL  NERVE,  Diseases  of. — 
The  fifth  or  trifacial  nerve  (nervus  trigeminus), 
the  largest  of  the  cranial  nerves,  consists  of  a 
motor  and  sensory  portion,  the  sensory  fibres 
passing  through  the  Gasserian  ganglion  and  be- 
ing distributed  to  the  face  and  a portion  of  the 
head.  The  motor  portion,  much  the  smaller,  is 
physiologically  independent  of  the  ganglion,  and 
supplies  the  pterygoid,  masseter,  buccinator,  and 
temporal  muscles.  The  two  first  divisions— the 
ophthalmic  and  superior  maxillary — are  entirely 
sensory,  and  proceed  from  the  ganglion.  Tho 
third,  or  inferior  maxillary  division,  proceeds 
also  from  the  ganglion,  but  receives  besides  the 
whole  of  the  motor  root.  Lesions  of  this  nerve 
cause  disorders  of  sensation,  motion,  nutrition, 
or  secretion  according  to  the  anatomical  posi- 
tion and  extent  of  the  injury. 

The  affections  of  the  fifth  nerve  may  be  con- 
sidered in  the  following  order: — 

1.  Trifacial  Neuralgia. — Neuralgia  may 
affect  one  or  all  of  the  three  divisions  of  the  nerve. 


IGGO 

tt  is  fully  described  under  the  head  of  tic-dou- 
loureux.  Sea  Tic  Douloureux. 

2.  Trifacial  Anaesthesia. — Ansesthesia  of  the 
trigeminus,  usually  unilateral,  may  be  dependent 
either  upon  (a)  central  lesion ; or  upon  (6) 
peripheral  lesion. 

(a)  Central  lesion. — Hemiplegia  from  apoplexy, 
tumour,  or  other  coarse  disease  of  the  central 
nervous  organs  is  usually  accompanied  by  some 
anaesthesia  in  the  district  supplied  by  the  trige- 
minus, arising  from  interference  with  the  inte- 
grity of  the  fibres  of  origin  of  the  nerve  in  their 
central  course.  The  anaesthesia  usually  occurs 
on  the  same  side  of  the  body  as  the  paralysis 
of  motion,  and  therefore  opposite  to  the  seat  of 
lesion.  This  is  always  the  case  when  the  lesion 
occupies  its  most  frequent  seats  in  the  higher 
ganglionic  centres.  In  disease  of  the  pons  Yarolii, 
however,  the  loss  of  sensibility  may  involve  both 
halves  of  the  face,  although  it  usually  affects  the 
same  side  as  that  upon  which  the  limbs  are 
paralysed,  and  opposite  that  upon  which  the 
portio  dura  and  sixth  nerves  (when  either  or 
both  of  them  are  involved)  are  affected.  In 
cases  of  apoplexy,  the  ansesthesia  is  usually  very 
imperfect,  and  not  sharply  defined.  It  is  short- 
lived, lasting  from  a few  hours  to  days ; but  in 
certain  cases  it  may  continue,  and  even  outlive 
the  motor  paralysis  with  which  it  is  conjoined. 

Intracranial  tumours  may  produce  more  per- 
sistent ansesthesia,  either  by  immediate  destruc- 
tion of  sensory  fibres,  or,  indirectly,  by  the  cere- 
bral enlargement,  due  to  their  growth,  causing 
compression  of  the  fifth  nerve  as  it  traverses  the 
floor  of  the  skull. 

(b)  Peripheral  lesion. — Ansesthesia  dependent 
upon  lesion  of  the  trigeminus  in  its  peripheral 
course  is  a symptom  of  serious  moment,  which 
it  is  important  to  distinguish  from  that  of  cen- 
tral origin,  and  this  may  be  accomplished  by 
noting  the  following  points: — The  degree  of 
peripheral  ansesthesia  far  exceeds  that  which 
obtains  in  cases  owing  their  origin  to  a cen- 
tral cause.  It  is  much  more  complete,  and  in- 
volves, which  the  latter  does  not,  trophic  and 
vaso-motor  complications.  Its  extent  varies  ac- 
cording as  the  trunk  of  the  nerve,  including  the 
Gasserian  ganglion,  is  involved ; or  only  one  or 
two  of  its  branches.  Should  the  main  trunk  be 
affected,  there  is  more  or  less  complete  ansesthe- 
sia of  one  side  of  the  face  and  part  of  the  ear, 
conjunctiva,  cornea,  nostril,  mouth,  half  the 
tongue,  the  gums  on  the  same  side,  and  a part 
of  the  palate.  If  the  conjunctiva  be  touched 
with  the  finger,  there  is  no  reflex  contraction  of 
the  eyelids.  A glass  from  which  the  patient 
drinks  seems  to  him  as  though  it  were  broken, 
for  he  feels  the  material  on  the  sound  side  and 
not  on  the  affected  side.  The  skin  of  the  face  is 
cool,  and  may  be  somewhat  cedematous,  and  pur- 
plish in  tint.  After  a few  days,  if  the  cause 
persists,  the  eye  on  that  side  looks  dry,  glazed, 
and  congested ; the  cornea  becomes  cloudy,  and 
in  time  sloughs  and  perforates,  the  contents  of 
the  eyeball  escaping  to  a varying  extent,  so  that 
the  organ  is  destroyed.  There  is  dryness  of  the 
nostril  on  the  affected  side,  and  irritant  sub- 
stances applied  to  it  fail  to  produce  sneezing. 
Taste  is  lost  on  that  side  of  the  tongue,  except 
at  the  base,  which  is  supplied  by  the  glosso- 


The  salivary  secretion  is  di- 
in time  there  may  be  bleeding  from 
the  gums,  and  ulceration  of  the  mucous  mem- 
brane. Should  the  lesion  exist  upon  one  of  the 
three  divisions  of  the  trigeminus,  the  anaesthesia 
will  be  found  sharply  limited  to  the  district  sup- 
plied by  that  division.  The  nature  of  the  lesion 
must  be  determined  by  the  examination  of  con- 
comitant conditions.  Whatever  be  the  active 
cause  by  which  the  nerve  is  damaged,  the  effects 
will  be  the  same ; pressure  upon,  and  disorgani- 
sation of  the  nerve-fibres  will  result  in  the  dis- 
orders described — sensory,  motor,  trophic,  and 
vaso-motor.  In  such  circumstances,  one  or  more 
of  the  other  cranial  nerves  are  usually  affected 
coincidently.  In  tubercular  meningitis,  the  fifth 
nerve  is  shown  to  be  paralysed  (along  with  others 
traversing  the  floor  of  the  skull)  by  the  conjunc- 
tivitis and  corneitis  so  often  present  in  advanced 
stages  of  the  disease.  Should  the  condition 
accompany  bulbar  paralysis,  the  lesion  must  be 
referred  to  the  nuclei  of  origin  of  the  nerve  in 
the  medulla  oblongata. 

Trextmhn'T. — Syphilitic  gummata  on  the  floor 
of  the  skull,  developed  either  in  the  membranes 
of  the  brain  or  in  the  nerve  itself,  are  so  fre- 
quently the  cause  of  the  disorganisation  of  the 
fifth  nerve  which  gives  rise  to  anaesthesia,  that 
in  all  cases  it  is  right — unless  some  other  cause 
is  evident  beyond  all  doubt — to  bear  in  mind  the 
possibility  of  such  a cause,  and  to  prescribe 
accordingly  without  delay.  Ten-grain  doses  of 
iodide  of  potassium  should  be  administered  every 
four  hours.  Should  there  be  a gumma  pressing 
upon  the  trunk  of  the  nerve,  this  treatment  will 
have  the  effect  of  bringing  about  a rapid  ame- 
lioration, and,  in  many  cases,  supposing  it  has 
been  applied  early  enough,  a complete  cure.  It 
is  evident  that,  as  regards  other  causes,  there 
is  no  particular  indication  for  treatment,  which 
must  be  adapted  to  the  special  circumstances  of 
the  case. 

3.  Trifacial  Hyperalgesia. — Hyperalgesia 
may  accompany  or  precede  neuralgia  of  the  fifth 
nerve.  It  may  also  precede  facial  anaesthesia 
when  this  is  due  to  neuritis.  There  are  varie- 
ties in  tile  degree  of  this  hyperalgesia.  It  is 
sometimes  so  severe  that  the  slightest  touch 
occasions  pain.  The  face  cannot  then  be  washed 
in  the  ordinary  way,  but  the  patient  has  to 
take  a piece  of  sponge  or  wetted  rag  and  cau- 
tiously dab  the  skin  with  it.  Sometimes  it 
is  described  as  a feeling  of  soreness  only  when 
the  hand  is  passed  over  the  face.  In  either 
case  the  condition  is  accompan’ed  by  diminution 
of  the  tactile  discrimination  in  the  part.  In 
mimetic  spasm  of  the  portio  dura,  there  is  often 
hyperalgesia  in  the  region  of  one  or  more  divi- 
sions of  the  fifth,  and  the  lesion  is  then  doubt- 
less connected  with  the  deep  origin  of  the  nerve. 
In  blepharospasm  it  will  often  be  found,  if  the 
face  be  carefully  examined,  that  pressure  with 
the  finger  at  some  point  will  cheek  the  spasm. 

Subcutaneous  division  of  a twig  of  the  filth 
(or  afferent  nerve)  at  this  point,  will  often  bring 
about  a cure  of  the  affection.  The  supra-orbital 
or  subcutaneous  malar,  are  the  nerves  most 
commonly  in  fault. 

Photophobia  is  referable  to  hyperalgesia  ol 
the  branches  distributed  to  the  conjunctiva. 


TRIP  ACT  AL  NERVE,  DISEASES  OP. 

pharyngeal  nerve, 
minished. 


teifaci.il  nerve. 

4.  Motor  Disorders.- — Affections  of  the  motor 
toot  of  the  fifth  nerve  are  either  (a)  of  a spas- 
taodic ; or  ( b ) of  a paralytic  character. 

(a)  Spasm. — Spasm  of  the  muscles  supplied  by 
the  trigeminal  nerve  may  be  tonic  or  clonic.  In 
trismus,  or  ‘locked  jaw,’  the  teeth  are  clenched 
together  by  the  tonic  contraction  of  the  mastica- 
tory muscles,  which  can  he  felt  tense  to  the  touch. 
According  as  the  muscles  are  generally  involved, 
or  only  partially,  the  lower  jaw  will  be  fixed  in 
a symmetrical  position,  or  he  pulled  over  to  one 
side,  or  advanced  or  receded.  Clonic  spasm  of 
the  same  muscles  is  observed  in  various  convulsive 
disorders ; and  slower  movements  of  a horizontal 
character  constitute  the  grinding  of  teeth  some- 
times indicative  of  cerebral  disease. 

Trismus  may  either  be  one  symptom  of  teta- 
nus, or  it  may  occur  by  itself,  and  then  it  either 
arises  from  cold,  or  is  of  reflex  origin,  from  irri- 
tation of  the  sensory  portion  of  the  nerve  by 
decayed  teeth,  dentition,  or  disease  of  the  jaw- 
bone. It  may  be  due  to  the  presence  of  a foreign 
body,  possibly  of  very  small  size,  lodged  in  the 
cicatrix  of  a wound  upon  the  face,  or  even  in 
some  distant  part  of  the  body.  Irritation  from 
worms  is  a possible  cause.  It  is  still  more  com- 
monly hysterical. 

Treatment. — When  arising  from  cold,  the 
constant  current  should  be  applied  to  the  con- 
tracted muscles.  Any  source  of  irritation  must  be 
sought  for,  and,  if  possible,  removed  or  remedied. 

The  removal  of  a foreign  body  will  sometimes 
bring  about  an  immediate  cure.  This  failing, 
the  hypodermic  injection  of  morphia,  in  doses  of 
gr.  may  be  employed,  and  bromide  of  potas- 
sium given  internally  in  doses  of  20  grains.  When 
the  presence  of  worms  is  suspected,  appropriate 
treatment  must  be  employed.  If  the  affection 
be  hysterical,  somewhat  powerful  faradaic  cur- 
rents, directed  to  the  muscles  of  the  jaw,  will 
scarcely  ever  fail  to  open  the  mouth  and  cure 
the  ailment.  Hysterical  trismus  will  not  be  mis- 
taken for  dislocation  of  the  jaw,  if  it  be  remem- 
bered that  in  the  latter  accident  the  jaw  is  fixed 
with  the  mouth  partly  open. 

(b)  Paralysis. — Paralysis  of  the  masticatory 
muscles  is  not  very  common,  but  may  be  observed 
sometimes  incases  of  bulbar  paralysis,  or  it  may 
accompany  anaesthesia  of  the  face,  and  depend 
upon  tumour,  abscess,  aneurism,  or  some  such 
coarse  disease  encroaching  upon  the  trunk  of  the 
nerve  within  the  cranium.  To  test  the  state  of 
the  muscles,  the  patient  should  be  asked  to  move 
his  jaw  to  and  fro  laterally,  as  well  as  in  open- 
ing and  shutting  the  mouth.  Any  irregularity 
of  movement  will  be  evident  to  the  eye,  and 
defective  strength  or  absence  of  contraction  in 
the  affected  muscles  may  be  felt  by  placing  a 
hand  on  each  cheek,  whilst  the  patient  performs 
movements  of  mastication.  When  the  jaw  is 
found  to  fail  in  being  carried  to  one  side  in  a 
munching  movement,  the  fault  of  course  lies 
with  the  pterygoid  muscles  of  the  opposite  side. 
The  affection  is  more  often  unilateral  than  bi- 
lateral. Its  importance  is  bound  up  with  that  of 
the  lesion  which  gives  rise  to  it. 

As  in  peripheral  affections  of  the  sensory 
portion  of  the  nerve,  especial  attention  should 
be  paid  to  the  causation,  and  if  this  probably 
depends  upon  a tumour,  the  possibility  of  its 


TROPICAL  DISEASES.  1661 
syphilitic  character  should  be  borne  in  mind,  and 
iodide  of  potassium  admiuisterea. 

T.  Buzzard. 

TRISMUS  (rplfa,  I gnash.) — Lock-jaw,  oi 
tetanic  closure  of  the  jaws;  a prominent  symp- 
tom in  tetanus.  See  Tetanus. 

TRISMUS  NAS  CENTRUM  (Lat.).  —A 
form  of  tetanus  occurring  in  newly-born  children. 
See  Tetanus. 

TROPHIC  LESIONS.  — Description.  — 
This  name  is  given  to  various  departures  from 
healthy  nutrition,  which  are  caused  (a)  by  the 
cutting  off,  from  certain  tissues  or  parts,  of  some 
customary  nervous  influence,  as  in  the  produc- 
tion of  ‘ secondary  degenerations  ’ in  the  nervous 
system  (see  Spinal  Cord,  Diseases  of,  § 6), 
or  in  the  production  of  rapid  muscular  atrophy, 
consequent  upon  the  severance  of  or  severe  da- 
mage to  motor  nerves  or  their  related  gan- 
glion-cells in  the  anterior  cornua  of  the  cord ; 
and  also  to  lesions  or  morbid  changes  which 
are  caused  ( b ) by  some  irritative  or  perverted 
influences  passing  outwards  along  nerves  to  cer- 
tain tissues  or  parts,  so  as  to  weaken  or  other- 
wise disturb  their  nutrition.  In  this  latter  way, 
the  nutrition  of  the  skin  and  its  appendages 
may  be  variously  affected,  leading  to  eruptions 
of  different  kinds,  to  atrophy,  to  ulceration,  or 
undue  proneness  to  inflammation,  as  well  as  to 
altered  pigmentation  of  the  skin  or  blanching  of 
the  hair.  Or  the  nutrition  of  the  joints  may  be 
affected,  as  in  some  forms  of  hemiplegia,  and  of 
locomotor  ataxy  more  especially.  In  these  va- 
rious cases  there  may  be  disease,  secondary  or 
primary,  of  the  grey  matter  of  the  spinal  cord, 
or  some  irritative  lesions  of  the  sensory  nerve- 
roots  or  trunks. 

Pathology. — Much  dispute  has  taken  place 
during  recent  years  as  to  the  modes  in  which 
such  nutritive  changes  are  brought  about.  Some 
have  endeavoured  to  establish  the  existence  of 
special  ‘ trophic  nerves,’  and  have  taught  that 
the  various  trophic  lesions  referred  to  above,  are 
to  be  explained  by  a cutting  off  or  a perversion 
of  the  influences  usually  operating  upon  the 
tissues  through  such  nerves.  Others  believe  that 
these  nutritive  changes  can  be  accounted  for  by 
altered  states  of  excitation  of  the  vaso-motor 
nerves,  leading  to  spasms  or  dilatations  of  the 
vessels  supplying  the  parts  affected,  and,  as  con- 
sequences, to  the  nutritive  changes  themselves 
(see  Syjipathetic  System,  Disorders  of).  Much 
evidence,  however,  could  be  cited  against  both 
these  modes  of  explanation,  and  it  seems,  on  the 
whole,  more  probable  that  trophic  lesions  are 
due  either  (a)  to  the  cutting  off  of  certain  accus- 
tomed influences  (via  motor  channels),  or  ( b ) to 
the  action  upon  the  tissues  of  perverted  or  un- 
natural influences  (in  a peripheral  direction  via 
sensory  channels). 

On  the  subject  of  these  trophic  lesions  see  also 
Spinal  Cord,  Diseases  of,  § 7 ; Glossy  Skin  ; 
and  Unilateral  Facial  Atrophy. 

H.  Charlton  Bastian. 

TROPICAL  DISEASES.— Diseases  inci- 
dent to  hot  climates.  See  Climate;  Disease, 
Causes  of ; and  the  special  diseases,  such  as 


1062 


TROPICAL  DISEASES. 

Cholera;  Chyluria;  Dysentery;  Fungus  Loot 
of  India  ; Intermittent  Fever  ; Liver,  Dis- 
eases of ; Remittent  Fever  ; and  Sunstroke. 

TUBERCLE  ( tuherculum , a little  swelling). 
Synon.  : Fr.  Tubercule\  Ger.  Tuberkel. — We  have 
not  yet  attained  to  anything  like  unity  of  opinion 
in  respect  of  tubercle.  We  are  not  yet  agreed 
concerning  what  shall  take  the  name  of  tubercle, 
and  this  alone  implies  the  utmost  discord  in 
other  matters.  It  is  a chapter  of  pathology  where- 
in few  assertions  can  be  made  which  will  stand 
the  test  of  a dogma ; that  is  to  say,  a belief  held 
always,  everywhere,  by  all.  But  although  dogma 
has  no  place  here,  it  would  be  wrong  to  fly  to 
the  other  extreme  of  denial.  A method  of 
simple  inquiry  will  be  our  safest  guide  through 
so  perplexed  a topic.  We  will  note  the  diverse 
opinions  in  order  as  they  arose,  being  convinced 
that  most  of  these  opinions  are  true  in  some  par- 
ticular, that  they  commonly  err  by  exclusiveness, 
and  that  the  next  best  thing  to  the  absolute 
truth  will  be  found  in  a comprehension  of  all 
opinions. 

There  havo  been  four  stages  in  the  history  of 
tubercle,  namely,  the  first,  or  etymological  stage  ; 
the  second,  or  stage  of  morbid  anatomy  studied 
by  the  naked  eye ; the  third,  or  stage  of  morbid 
anatomy  studied  by  the  help  of  the  microscope; 
and  the  fourth,  or  stage  of  experimental  pa- 
thology. 

Stage  I. — This  stage  begins  with  the  earliest 
writings  on  medicine.  The  word  tubercle  has 
not  yet  been  wrested  from  its  original  meaning : 
tuherculum,  a little  lump  of  any  kind.  And  this 
primitive  etymological  meaning  survives  even  in 
the  present  day.  We  still  speak  of  tubercles  of 
the  ribs  and  other  bones ; acne  is  a tubercular 
disease  of  the  skin,  and  so  on.  But  down  to  the 
beginning  of  the  nineteenth  century,  tubercle 
meant  a little  lump,  and  nothing  else. 

Stage  II. — At  the  beginning  of  the  present  cen- 
tury tubercle  lost  its  simple  etymological  meaning, 
and  acquired  a pathological  meaning.  Tubercle  is 
no  longer  a matter  of  special  shape,  for  now  it  sig- 
nifies a special  structure.  This  great  change  con- 
curred with  the  rise  of  morbid  anatomy.  And 
thus  it  came  to  pass.  Many  of  the  dead  bodies 
examined  were  necessarily  cases  of  pulmonary  con- 
sumption, and  in  this  form  of  disease  it  was  that 
little  morbid  lumps  or  tubercles  were  discovered 
with  especial  frequency.  Hence  the  tubercles 
found  in  phthisical  lungs  early  showed  a strong 
tendency  to  become  emphatically  the  tubercles 
of  pathology.  We  may  remark  this  tendency  in 
Morton  (a.d.  1689),  and  in  Baillie  (1795).  But 
it  wasBayle  (1803)  who  first  broke  with  the  an- 
cient meaning  altogether,  and  introduced  the 
second  stage  of  opinion.  Debates  concerning  tu- 
bercles are  henceforth  debates  concerning  morbid 
structures. 

Bayle  thus  defines  tubercle  : A homogeneous 
substance;  always  opaque;  in  colour,  white  or 
dirty  white,  sometimes  yellowish,  sometimes 
greyish  ; in  size,  from  a millet  seed  to  a chestnut. 
He  makes  the  criterion  of  tubercle  to  consist  in 
its  opacity.  How  this  opacity  is  most  marked  in 
the  cheesy  products  of  degeneration.  Therefore, 
in  other  words,  the  criterion  of  tubercle  consists 
in  the  clieesy  state.  Cheesy  matter,  wherever 


TUBERCLE. 

found,  in  the  shape  of  a little  lump  or  not,  is  the 
tubercle  of  Bayle.  He  called  that  tubercle  which 
Baillie  had  called  scrofulous  matter. 

Bayle  did  not,  and  could  not,  overlook  the  fact 
that  the  lungs  sometimes  contain  little  nodules 
which  are  translucent.  He  would  not  call  them 
tubercles  because  they  lacked  his  note  of  tubercle, 
opacity ; he  called  them  granulations.  Granula- 
tions are  never  opaque.  And  so,  between  tu- 
bercles and  granulations  he  drew  an  excessively 
strong  distinction. 

It  was  not  long  before  Laennee  (1819)reunited 
what  Bayle  had  put  asunder,  by  showing  that 
granulations  at  length  became  opaque.  And, 
therefore,  he  enlarged  the  definition  of  tubercle, 
so  as  to  make  it  include,  not  only  actual,  but  also 
potential  cheesy  matter.  Thus  Laennec’s  tubercle 
acquired  a most  inclusive  pathological  meaning. 
Moreover,  he  remarked  that  tubercle  sometimes 
involves  large,  irregular  tracts  of  tissue,  a condi- 
tion which  he  distinguished  by  the  name  of  tu- 
berculous infiltration.  Each  of  these  forms,  the 
nodular  and  the  infiltrated,  he  subdivided  into 
three — the  transparent,  the  semi-transparent,  and 
the  opaque  or  cheesy.  Hence  six  forms  of  tubercle 
in  all — three  nodular,  namely,  the  transparent, 
or  Bayle’s  granulations,  the  semi-transparent  or 
miliary,  and  the  opaque  or  crude  yellow  tubercle ; 
three  diffused,  namely,  the  transparent  or  gela- 
tiniform  infiltration,  the  grey  or  semi-transparent 
infiltration,  and  the  yellow  or  opaque.  Laennec's 
descriptions  relate  especially  to  the  lungs  of 
adults.  But  the  structure  of  the  lungs  makes 
the  study  of  tubercle  singularly  difficult  in  them, 
and  it  is  easy  to  note  that  our  debates  concerning 
tubercle  in  general  show  an  unconscious  leaning 
towards  pulmonary  tubercle  in  particular.  The 
writer  does  not  say  that  this  is  wrong  ; we  feel 
that  if  we  could  master  tubercle  in  the  lungs  the 
rest  would  soon  follow. 

Laennec’s  unit  began  to  be  broken  up  when 
men  set  themselves  to  discover  the  seat  of  tu- 
bercle. Carswell  (1S38)  proved,  what  Brons- 
sais  had  guessed,  that  crude  tubercle  was  often 
formed  within  the  cavity  of  the  pulmonary  air- 
sacs.  Thomas  Addison  (1845)  went  much  fur- 
ther. He  began  by  examining  genuine  pneumonia, 
which  he  found  to  have  its  original  and  essential 
seat  in  the  air-cells  of  the  lungs,  and  the  ordinary 
pneumonic  deposits  are  poured  into  these  cells. 
And  when  he,  like  Carswell,  found  this  to  be  the 
chief  seat  of  Laennec's  crude  yellow  tubercle  and 
grey  and  yellow  tubercular  infiltrations,  he  de- 
clared that,  if  called  upon  to  give  an  expressive 
name  to  these  lesions,  he  would  venture  to  desig- 
nate them  scrofulous  pneumonia.  The  case  was 
altered  with  respect  to  the  granulations  ; these 
he  found  to  he  seated  in  the  delicate  filamentous 
tissue  which  forms  the  slight  filmy  parietes  of  the 
air-cells.  Let  it  he  understood  that  Addison’s 
criterion  of  tubercle  lay  in  its  formation  in  the 
septa  of  the  air-sacs  ; he  denied  the  criterion  to 
be  cheesiness,  and  thus,  in  matter  of  fact,  his  use 
of  the  word  tubercle  was  almost  the  exact  con- 
tradictory of  Bayle’s.  Addison  revived  in  some 
degree  Baillie’s  scrofula.  The  other  forms  of 
Laennec's  tubercle,  Addison  conceived  to  be  in- 
flammatory exudation,  mingled  or  not  with  his 
own  true  tubercle.  It  seems  as  if  the  naked  eye 
could  not  carry  ns  much  farther. 


TUBERCLE. 


Stage  III. — About  this  time  the  microscope 
began  to  be  used  for  examining  healthy  and  dis- 
eased tissues.  Cheesy  matter  being  commonly 
deemed  the  most  characteristic  form  of  tubercle, 
men  naturally  supposed  that  the  microscopical 
characters  of  tubercle  would  be  found  in  cheesy 
matter.  Tubercle  being  thought,  moreover,  to 
possess  perfectly  distinct  naked-eye  characters, 
it  was  expected  that  its  minute  structure  must 
likewise  bo  peculiar  and  distinct.  And  thus  it 
came  to  pass  that  Lebert  (1814)  found  certain 
bodies  in  cheesy  matter  which  he  believed  to  be 
characteristic  of  tubercle,  and  which  he  called 
tubercle-corpuscles.  These  corpuscles,  not  being 
found  in  the  transparent  granulation,  some  per- 
sons went  so  far  as  to  deny  its  tubercular  nature, 
and  so  revived  Bayle’s  doctrine,  in  all  its  severity, 
upon  a microscopical  platform.  But  William  Ad- 
dison (1849)  came  to  a very  different  conclusion 
respecting  the  characters  of  pulmonary  tubercle. 
He  repeatedly  examined  with  the  microscope 
the  material  deposited  in  the  air-cells  of  the 
lungs  in  pneumonia,  and  compared  its  characters 
and  appearance  with  that  forming  a tubercle, 
without  being  able  to  detect  any  more  essential 
ar  specific  difference  between  them  than  exists 
between  purulent  matter  recently  excreted  and 
that  of  an  old  chronic  abscess.  This  was  a 
microscopical  confirmation  of  Thomas  Addison’s 
doctrines.  Virchow  (1850)  arrived  at  the  same 
opinion,  namely,  that  there  was  nothing  charac- 
teristic of  tubercle  in  cheesy  degeneration.  For 
instance,  nowhere  is  the  cheesy  degeneration  bet- 
ter seen  than  in  the  enlarged  glands  of  scrofula; 
yet,  examine  these  glands  before  they  become 
cheesy,  and  nothing  more  (so  Virchow  said)  than 
a simplo  hyperplasia  will  be  found,  and  no  new 
formation.  On  the  other  hand,  examine  tubercle 
before  it  becomes  cheesy,  examine  the  transparent 
granulations,  and  it  will  be  found  to  possess  a 
distinct  lymphatic  character.  But  granulations 
are  formed  in  the  connective  tissue;  hence  they 
are  heteroplastic.  So  that  Virchow’s  tubercle 
signifies  a heteroplastic  lymphoma.  The  charac- 
teristic tubercle  is  not  opaque,  but  transparent; 
in  this  respect  Virchow’s  doctrine  was  the  exact 
opposite  of  that  taught  by  the  French  school. 
The  criterion  of  tubercle  with  him  is  not  cheesi- 
ness but  heteroplasia.  Of  late  years  both  parts 
of  Virchow’s  definition  have  been  assailed  : first, 
the  connective  tissues  which  are  infested  by  tu- 
bercle have  been  show'n  to  possess  in  many  places 
a true  lymphatic  character,  so  that  tubercle,  if  a 
lymphatic  growth,  may  be  simply  hyperplastic  as 
well  as  heteroplastic ; next,  the  lymphatic  charac- 
ter of  tubercle  has  been  put  in  question  by  the  in- 
vestigations of  Langhans  and  others.  Thus  Vir- 
chow’s distinction  between  tubercle  and  scrofula 
becomes  untenable ; but  we  will  postpone  further 
discussion  of  these  matters-  for  the  present. 

Stage  IV. — The  results  of  experiment  upon 
living  animals,  or  what  is  commonly  called  thein- 
oculation  of  tubercle,  will  be  narrated  at  the  end 
of  this  article.  Enough  to  say  in  this  place  that 
most  important  changes  in  the  doctrines  of  both 
tubercle  and  scrofula  have  been  largely  due  to  the 
experimental  pathology  of  the  last  fifteen  years. 

Here  ends  the  preliminary  historical  sketch. 
Now  we  will  inquire  into  the  present  state  of 
opinion  concerning  the  characters  of  tubercle. 


1663 

I.  Concerning  the  structure  of  single 
tubercles. — The  formation  of  tubercle  begins 
at  distinct  foci.  The  primitive  tubercle  is  a 
microscopic  body.  W.  Addison  (1849)  taught 
that  it  consists,  in  greater  part,  of  corpuscles, 
like  blood-leucocytes,  or  like  the  corpuscles  of 
lymph  and  of  pus.  Rokitansky  (1855)  showed 
that  giaht  or  myeloid  cells  are  sometimes  found 
in  tubercle.  Virchow  (1863)  taught  that  tu- 
bercle has  a more  histioid  or  tissue-like  struc- 
ture, which,  on  ihe  whole,  resembles  most  the 
tissue  of  a lymphatic  follicle ; so  that,  in  the 
case  of  the  spleen,  tubercle  is  not  always  easily 
distinguished  from  a Malpighian  body.  In  a 
tubercle  there  are  corpuscles  imbedded  in  a re- 
ticulum. The  corpuscles  are  round ; and  most 
of  them  are  like  lymphatic  corpuscles,  smaller 
than  blood-leucocytes ; some,  however,  are  larger, 
it  may  be  twice  or  thrice.  The  corpuscle  is 
colourless,  translucent,  slightly  granular,  and 
easily  broken  up.  In  the  fully  developed  cell 
there  is  a single  nucleus,  small,  tolerably  homo- 
geneous, often  shining.  Tiie  larger  cells  con- 
tain two,  three,  or  even  as  many  as  twelve 
nuclei.  The  reticulum  consists  of  a fine  net- 
work of  connective-tissue  fibres.  When  vessels 
are  present  in  the  tubercle,  they  are  not  new- 
formations,  but  only  remnants  of  the  tissue  in 
which  the  tubercle  has  been  formed.  According 
as  the  cellular  or  the  fibrous  element  of  the 
tubercle  predominates,  it  may  be  called  cellular 
or  fibrous  tubercle,  the  former  being  more 
common.  The  fibrous  element  sometimes  pre- 
dominates so  much  that  the  tubercle  can  be 
distinguished  from  a small  fibroma  only  by  a 
concurrence  of  the  more  common  cellular  form, 
or  by  a tendency  to  undergo  the  further  changes 
of  tubercle,  especially  the  cheesy  change.  In 
the  fibrous  tubercle  there  are  often  found  large, 
roundish,  epithelioid  cells,  with  large  oval  or 
round,  sharply-defined  nuclei.  From  this  de- 
scription it  will  be  seen  that  Virchow  recognised 
lymphoid,  epithelioid,  and  myeloid  or  giant-cells, 
among  the  elements  of  tubercle.  Langhans 
(1868)  was  the  first  to  lay  much  greater  stress 
upon  the  giant-cells ; he  found  them  to  be  an 


Fig.  100.  A tubercle  in  a lymphatic  gland  : in  the  upper 
tbirct,  a large  giant-cell  (with  peripheral  nuclei) ; mar- 
gin of  normal  follicular  tissue  rouud  the  tubercle  ; on 
the  left,  the  capsule  of  the  gland  and  cortical  lymph- 
sinus.  x 60.  ( After  Creighton.) 

almost  constant  element  of  tubercle  in  any 
part.  Ho  believed  that  the  tubercular  giant-cell 
had  characters  proper  to  itself,  namely,  a finely 


TUBEECLE. 


1864 

granular  protoplasm?,,  and  nuclei  of  equal  size, 
peripheral,  and  arranged  in  radiate  fashion.  In 
cellular  tubercle,  the  epithelioid  cells  are  ar- 
ranged around  the  giant-cell.  In  fibrous  tubercle 
a giant-cell  is  always  present  at  the  very  centre. 
Wagner  (1871)  described  tubercle  under  the 
name  of  tubercular  ( tuber /celahnlich ) lymphade- 
noma,  the  structure  being  the  same  as  that  of 
a lymphatic  follicle  (namely,  lymphoid  cor- 
puscles, and  many  nuclei  almost  destitute  of 
surrounding  protoplasma,  imbedded  in  a fibrous 
reticulum)  and  in  the  middle  of  each  tubercle,  a 
giant-cell.  Schuppel  (1871),  who  devoted  him- 
self chiefly  to  tubercle  of  the  lymphatic  glands, 
considered  the  gigantic  cell  to  bo  an  essential 
(though  not  peculiar)  element  of  tubercle.  A 
primitive  tubercle  consists  of  a central  giant- 
corpuscle,  that  is  to  say,  a mass  of  protoplasma 
of  very  varied  form,  spherical,  fiat,  or  elongated  ; 
the  edges  even,  or  provided  with  more  or  fewer 
processes ; more  or  less  granular ; and  contain- 
ing a large  number  of  nuclei,  to  be  reckoned  by 
the  score,  even  as  many  as  two  or  three  hundred. 
Around  this  giant-cell  lies  a zone  of  epithelioid 
cells,  which  make  up  the  greater  part  of  the 
tubercle.  They  are  very  delicate,  easily  broken 
down,  and  the  fact  that  tubercle  has  boen 
supposed  to  consist  chiefly  of  lymphoid  cor- 
puscles is  due  to  the  setting  free  of  the  epitheli- 
oid nuclei,  W'hicli  have  been  mistaken  for  leuco- 
cytes. Lastly,  true  lymphoid  corpuscles  are 
scattered  through  the  tubercle,  filling  up  the 
interstices  between  the  other  cells  as  it  were.  In 
fibrous  tubercle  there  are  no  epithelioid  cells,  a 
fact  which  Schuppel  believes  to  indicate  an  arrest 
in  the  growth  of  the  tubercle  at  an  early  stage. 
Sitpporting  all  these  cells,  there  is  a reticulum 
like  that  of  lymphadenoid  tissue.  These  primi- 
tive tubercles  contain  neither  blood-vessels  nor 
lymphatics.  Friedlander  (1874),  with  especial 
reference  to  these  giant-cells,  very  truly  insists 
that  they  are  by  no  means  peculiar  to  tubercle  ; 
on  the  contrary,  they  are  found  in  a number  of 
other  structures,  both  healthy  and  morbid. 
Moreover  he  maintains  that  there  are  no  dis- 
tinguishing characters  in  the  giant-cells  of  tu- 
bercle. What  has  been  considered  the  reticulum 
of  a tubercle,  Friedlander  asserts  to  be  the  re- 
sult of  the  hardening  processes  employed  in  the 
preparation  of  the  microscopical  specimen ; in 
the  fresh  state  there  is  nothing  but  a small 
quantity  of  amorphous  intercellular  matter. 

II.  Concerning  the  origin  of  tubercle. — 
William  Addison  believed  that  the  lymphoid  cor- 
puscles of  tubercle  were  the  result  of  exudation 
from  the  blood,  through  the  walls  of  the  vessels. 
Virchow  taught  that  tubercle  proceeds  from  a 
proliferation  of  the  fixed  corpuscles  of  suudry 
tissues,  especially  the  connective-tissue  and  its 
allies,  namely,  marrow,  fat,  and  bone.  Hence 
tubercle  is  essentially  heteroplastic,  that  is  to 
say,  lymphatic  tissue  is  formed  in  parts  where 
it  does  not  naturally  exist.  But  is  there,  then, 
no  such  thing  as  tubercle  of  the  lymphatic  struc- 
tures ? This  is  a troublesome  question  for  Vir- 
chow. However,  he  does  not  deny  that  tubercle 
may  be  found  in  lymphatic  glands ; he  supposes 
that  it  is  formed,  not  in  the  follicles  themselves, 
but  in  the  connective-tissue  trabeculae  which 
support  them  ; also,  that  sometimes  an  adventi- 


tious connective-tissue  springs  up  in  the  gland 
in  consequence  of  chronic  inflammation,  and  that 
the  tubercle  grows  in  this  new  tissue.  Yet  Vir- 
chow was  not  without  misgivings  respecting  his 
doctrine  of  the  heterology  of  tubercle,  because 
he  saw  the  close  relationship  which  exists  between 
connective  and  lymphatic  tissues.  He  pointed 
out  (1856)  the  frequency  with  which  tubercle  is 
seated  in  the  outer  coat  of  the  small  blood-vessels, 
and  especially  those  of  the  cerebral  meninges. 
Now  Eobin  (1855)  and  His  (1865)  showed  that 
this  outer  coat,  or  adventitia,  is  a lymphatic 
tissue.  Neumann  (1868)  showed  that  marrow  is 
a lymphatic  tissue.  In  this  way,  fresh  difficul- 
ties arose  with  Virchow’s  heteroplastic  doctrine. 
In  fact,  the  opposite  opinion  gained  ground,  that 
tubercle  is  commonly  hyper-  or  homceoplastic. 
Wilson  Fox  (1868)  and  Sanderson  (1868)  held 
that  it  is  very  often  nothing  but  a hyperplasia  or 
overgrowth  of  pre-existing  lymphadenoid  tissue. 
Lymphadenoid  tissue  has  been  found  to  be  much 
more  extensively  present  in  the  healthy  body 
than  Virchow  thought;  for  instance,  in  the  sub- 
mucous tissue  of  the  whole  alimentary  canal ; in 
the  conjunctiva ; around  the  smaller  bronchia  : 
around  capillary  tufts  beneath  the  epithelium  of 
the  pleura  and  peritoneum  ; around  the  smaller 
arteries  in  many  parts,  such  as  the  pia  mater, 
liver,  spleen  (constituting  the  Malpighian  bodies), 
and  choroid ; besides  the  marrow,  spoken  of 
before.  And  all  these  are  favourite  seats  of 
tubercle.  So  much  for  the  lymphadenoid  tissue 
as  a seat  of  tubercle.  Ivlebs  (1868)  maintained 
that  tubercle  of  the  serous  membranes  arises 
within  the  lymphatic  vessels,  by  a multiplication 
of  their  epithelium.  And  Kindfleisch  (1871) 
describes,  under  the  name  of  lymphangitis  tuber- 
culosa, a kind  of  fibrous  tubercle  often  present 
around  phthisical  cavities.  Each  tubercle  con- 
sists of  a dense  fibrous  capsule,  within  which  lie 
concentric  layers  of  spindle-shaped,  anastomosing 
cells.  The  tubercles  are,  in  fact,  developed  from 
lymphatic  vessels,  by  a metamorphosis  of  the 
endothelium  and  outer  tunic;  the  remnant  of 
the  lumen  of  the  vessel  may  often  he  found  in 
the  middle  of  the  tubercle.  Last  of  all,  a fibrous 
sclerosis  of  the  whole  takes  place.  Aufreeht 
(1869)  supposed  that  tubercle  was  formed  around 
the  lymphatics,  and  was  therefore  a perilymph- 
angitis. But  Sanderson  declares  that  Klebs  and 
Aufreeht  mistook  veins  for  lymphatics,  and  that 
the  perilymphangitis  of  the  latter  is  a hyper- 
plasia of  the  lymphatic  sheath  of  blood-vessels. 
Wagner  (1871)  leaned  to  the  belief  that  tubercle 
(his  lymphadenoma)  is  always  heteroplastic,  even 
when  it  occurs  in  parts  which  naturally  possess 
a certain  quantity  of  lymphadenoid  tissue.  And 
Eindfleisch  (1871)  teaches  that  the  lymphoid 
cells  of  tubercle  do  not  come  directly  from  the 
blood,  but  from  proliferation  of  the  fixed  cells  of 
connective-tissue  ; the  endothelium  of  blood  and 
lymphatic  vessels,  the  epithelium  of  serous 
membranes,  lungs  and  kidneys,  and  even  the 
muscle-cells  of  the  smaller  bronchia  and  vessels, 
undergoing  a tubercular  metamorphosis.  Schiip- 
pel  (1872)  reduces  the  question  to  the  origin  of 
what  he  deemed  to  he  the  most  important  part 
of  tubercle,  namely,  the  giant-cell. ' It  arisc-s. 
he  thinks,  within  a blood-vessel.  Masses  of 
molecular  matter,  very  tenacious  and  adherent 


TUBERCLE. 


grew  up  in  small  blood-vessels  (capillaries  or 
small  veins),  and  become  bigger  and  bigger, 
until  the  vessel  is  quite  choked,  or  even  distended 
at  the  spot.  At  first  there  are  no  nuclei  in 
the  protoplastic  mass,  but  afterwards  they  begin 
to  appear  ; and  their  number  is  proportionate  to 
the  age  of  the  corpuscle.  Where  the  nuclei  come 
from  is  uncertain.  The  epithelioid  cells  next  ap- 
pear around  the  giant-cell,  and  are  most  likely 
derived  from  processes  of  the  giant-cell.  The 
lymphoid  cells  come  from  the  cells  of  the  tissue 
in  which  the  tubercle  is  formed.  The  reticulum, 
in  chief  part,  is  a neoplasm  ; it  grows  with  the 
multiplication  of  the  cells,  and  is  always  con- 
nected with  the  gigantic  corpuscle.  So  soon  as 
the  giant-cell  becomes  surrounded  by  other  cells, 
the  wall  of  the  blood-vessel  disappears.  Other 
authorities  differ  from  Schiippel  with  regard  to 
the  origin  of  the  giant-cell : some  supposing  it  to 
be  formed  from  the  endothelium,  some  from 
blood-leucocytes,  and  some  from  free  protoplasm. 
And  here  the  question  rests  at  present. 

III.  Concerning  the  growth  of  tubercles. 
The  primitive  tubercle  increases  in  size  until  it 
becomes  visible  to  the  naked  eye.  The  enlarge- 
ment is  brought  about  by  the  formation  of  fresh 
tubercular  foci  around  the  original  focus  ; so 
that  when  six  or  more  of  the  primitive  tubercles 
become  agglomerated  into  one  body,  it  becomes 
visible  as  a small  nodule  (tuberculum).  Some- 
times the  agglomeration  does  not  assume  the 
nodular  form,  but  is  diffused  and  of  irregular 
shape ; this  is  called  an  infiltration.  The  dif- 
ference between  nodular  and  infiltrated  tubercle 
is  merely  a naked-eye  difference;  whether  the 
confluent  tubercles  retain  the  nodular  shape  or 
not,  the  primitive  tubercle  is  always  a tubercu- 
lura.  1.  Nodular  tubercle  corresponds  to  most 
of  Bayle’s  granulations,  and  Laennec’s  miliary 
tubercles,  which  were  spoken  of  before.  The 
epithet  miliary  is  much  older  than  Laennec,  and 
has  lost  its  original  etymological  meaning.  Mi- 
liary tubercle  may  or  may  not  be  of  the  size 
of  a millet-seed.  Tubercle  the  size  of  millet-seed 
may  or  may  not  be  miliary.  All  that  is  now 
meant  by  miliary  tubercle  is  a small  nodule, 
roundish,  seldom  larger  than  a hemp-seed,  almost 
colourless  or  greyish,  consistence  almost  equal  to 
that  of  cartilage,  and  either  quite  transparent 
or  opalescent.  Lastly,  miliary  nodules  may  or 
may  not  be  tubercular.  Miliary  tubercle  must 
be  distinguished  from  other  small  nodular  neo- 
plasms; minute  disseminated  carcinoma  and  sar- 
coma, lymphosarcoma,  leuksemic  nodules,  small 
fibromata.  The  diagnosis  depends  upon  the  dis- 
covery of  more  definite  lesions  in  the  same  body, 
and  upon  the  microscopical  structure.  In  the  lungs, 
miliary  semi-transparent  nodules  are  sometimes 
wholly  pneumonic  in  character.  The  peribron- 
chitis of  Virchow  possesses,  according  to  Wagner, 
a lymphadenoid  structure,  and  may  therefore  be 
considered  a tubercular  lesion.  2.  Infiltrated 
tubercle , when  present  in  the  lungs,  corresponds 
with  much  of  Laennec's  gelatiniform  and  grey 
infiltration.  The  gelatiniform  infiltration  may 
often  be  seen  surrounding  nodular  tuborcles,  in 
cases  of  acute  pulmonary  tuberculosis.  In  the 
liver,  tubercular  infiltration  runs  along  the  cap- 
sule of  Glisson  between  the  lobuli.  In  the  cortex 
of  the  kidney,  it  appears  as  streaks  between  the 

105 


1665 

bundles  of  tubuli,  or  as  ill-defined  roundish 
patches.  Tubercle,  not  nodular,  often  may  be 
seen  alongside  the  small  arteries  in  the  cerebral 
meninges.  Wagner  describes  a diffuse  lympha- 
denoma  (tubercle)  of  the  pleura,  which  is  in 
distinguishable  by  the  naked  eye  from  chronic 
pleurisy ; and  even  the  microscope  shows  all 
stages  of  transition  between  lymphadenoid  and 
granulation  tissue,  in  these  cases,  A simila.’ 
diffuse  lesion  occurs  in  the  mucous  membranes. 

IV.  Concerning  the  lesions  which  sur- 
round tubercle. — First,  there  is  the  mechanical 
effect  of  pressure.  Next,  the  lymphatics  and  juice- 
canals  around  are  widened  and  filled  with  chylous 
stuff  containing  a few  corpuscles.  Tubercle  is 
also  commonly  associated  with  surrounding  hy- 
peremia, and  with  inflammatory  exudations  in 
the  neighbourhood.  These  secondary  lesions  are 
well  seen  in  the  serous  and  mucous  membranes. 
Pleurisy,  peritonitis,  pericarditis,  local  or  gene- 
ral, are  sure  to  follow  upon  tuberculosis  of  tha 
respective  membranes.  In  the  mucous  mem- 
branes, hyperemia  and  catarrh  are  the  neces 
sary  results.  But  in  the  tissues  which  are  them- 
selves undergoing  transformation  into  tubercle 
an  obliteration  of  the  blood-vessels  proceeds  verj 
quickly.  Tubercle,  wherever  formed,  is  non- 
vascular ; the  only  approach  to  vascularity  is 
when  tubercle  surrounds  arteries  or  veins  with- 
out closing  them. 

V.  Concerning  the  metamorphosis  of  tu- 
bercle.—Sooner  or  later,  the  tubercles,  which 
have  now  been  described,  undergo  sun  iry  changes. 
These  changes  sometimes  take  place  very  quickly 
certainly  within  twd  or  three  weeks  from  the  for- 
mation of  the  tubercle.  On  the  other  hand,  tuber- 
clo  may  remain  unchanged  for  a long  time,  even 
for  two  or  three  years,  as  Schiippel’s  observa- 
tions upon  one  case  seem  to  prove.  There  are 
two  kinds  of  metamorphosis — the  fibrous  and  the 
caseous,  and  they  correspond  to  the  two  kinds 
of  tubercle  which  Virchow  describes,  the  fibrous 
and  the  cellular.  1st.  The  fibrous  metamor- 
phosis is  by  far  the  less  common.  The  reti- 
culum of  the  tubercle  becomes  greatly  hyper- 
trophied, so  as  to  constitute  a dense  intercellular 
substance,  interspersed  with  a few  small  spindle- 
shaped  nuclei.  The  cells  of  the  tubercle  undergo 
the  caseous  change.  The  result  is  either  a small 
fibroma  with  a cheesy  centre  (which  may  after- 
wards calcify),  or  a simple  fibroma,  the  cheesy 
matter  being  wholly  absorbed.  In  the  writer’s 
opinion,  there  is  reason  to  believe  that  much  larger 
tracts  of  tubercular  infiltration  may  undergo  the 
fibrous  metamorphosis — may  cicatrise,  in  fact. 
Be  this  as  it  may,  the  fibrous  condition,  when  once 
attained,  is  permanent  and  final.  Friedliinder 
(1873)  denies  the  fibrous  metamorphosis  alto- 
gether, and  declares  that  it  proceeds  from  the 
tissue  around  the  tubercle,  and  not  from  the  tu- 
bercle itself,  which  must  caseate.  2nd.  Thechecsy 
metamorphosis  is  very  much  more  common.  All 
parts  of  the  tubercle,  first  the  cells  and  after- 
wards the  reticulum,  become  infiltrated  with  oily 
molecules.  This  change  begins  in  the  very  centre 
of  the  primitive  tubercle.  To  the  naked  eye  mi- 
nute white  specks  appear;  they  become  larger 
and  more  numerous,  and  at  last  coalesce.  The 
oily  change  is  incomplete  : many  of  the  cells 
simply  lose  water,  dry  up,  and  shrivel ; and  in 


TUBERCLE. 


1666 

this  state  they  constitute  the  tubercle-corpuscles 
of  Lebert.  It  is  this  addition  of  partial  desic- 
cation •which  makes  cheesy  degeneration  differ 
from  simple  fatty  degeneration.  But  why  tu- 
bercle should  take  on  the  cheesy  metamorphosis 
cannot  be  explained  : the  deficient  supply  of  nu- 
tritious juices  will  not  alone  meet  (he  case.  The 
cheesy  change  usually  begins  before  the  tubercle 
has  reached  the  size  of  a millet-seed.  But  some- 
times much  more  minute  granulations  degene- 
rate, and  to  this,  the  very  smallest  cheesy  tuber- 
cle, Rilliet  and  Barthez  have  given  the  name  of 
tubercular  dust.  The  change  begins  much  more 
quickly  in  generalised  than  in  local  tubercle. 
Large  nodules,  formed  by  the  aggregation  of 
smaller  cheesy  nodules,  may  reach  the  size  of  a 
peeled  horse-chestnut.  This  caseous  tubercle  is 
the  crude  yellow  tubercle  of  Laennec,  and  the 
tubercle  of  Bayle.  Before  Bayle  it  was  called 
scrofulous  matter,  and  looked  upon  as  wholly  a 
deposition  from  the  blood.  Unlike  the  fibrous 
metamorphosis,  the  cheesy  change  is  not  perma- 
nent: five  further  changes  may  occur.  1.  Sof- 
tening : the  avhole  caseous  mass  breaks  down  into 
a molecular  detritus  of  oily  and  albuminous 
particles.  When  the  supply  of  blood  allows  of 
it,  these  molecules  float  in  a serous  fluid,  which 
to  the  naked  eye  looks  purulent:  curdy  pus,  or 
a tubercular  abscess.  The  abscess,  when  super- 
ficial, bursts,  and  leaves  a tubercular  ttlcer. 
When  all  the  caseous  matter  has  been  cast  off 
the  ulcer  may  heal,  and  so  the  local  disease 
come  to  an  end.  But  usually  the  ulcer  steadily 
enlarges,  by  the  perpetual  production  and  de- 
struction of  tubercles  around  it:  this  is  phthisis, 
in  the  anatomical  sense  of  the  word.  The  cica- 
trix-tissue of  tubercle  has  a tendency  to  con- 
tract strongly.  2.  Capsulation:  sometimes  a 
capsule  of  dense  fibrous  tissue  will  form  around 
the  cheesy  matter,  whether  softened  or  not. 
This  is  the  encysted  tubercle  of  Bayle.  3.  Cal- 
cification : the  oily  particles  become  gradually 
replaced  by  carbonate  and  phosphate  of  lime. 
The  different  degrees  of  calcification  are  denoted 
by  such  words  as  mortary,  chalky,  stony.  In 
itself,  it  is  a permanent  change  ; but  ulceration 
may  occur  around,  and  thus  the  petrified  tubercle 
oe  discharged.  4.  Absorption  no  doubt  occurs 
to  some  degree.  Virchow  believes  that  cheesy 
glands  may  wholly  disappear  in  this  way.  If 
there  be  truth  in  the  current  doctrine  respecting 
the  infectiousness  of  tubercle,  absorption  is,  of 
all  the  terminations,  the  least  to  be  wished.  5. 
Sloughing  in  mass  may  occur.  The  cheesy 
nodule  becomes  a sequestrum,  which  is  gra- 
dually loosened  by  surrounding  suppuration,  until 
it  separates,  and  lies  loose  in  a cavity.  The 
cheesy  metamorphosis  cannot  be  by  any  means 
looked  upon  as  being  peculiar  to  tubercle,  al- 
though no  doubt  most  common  in  tubercle. 
Simple  inflammatory  exudations,  cancer,  syphi- 
litic gummata,  lymphosarcoma,  all  sometimes 
undergo  the  same  change. 

VI.  Concerning  the  tubercular  diathesis 
and  dyscrasia. — It  was  not  possible  that  careful 
examinations  of  dead  bodies  should  he  made, 
without  two  prominent  characters  of  tubercle 
being  noted;  namely,  the  fact  that  certain  tis- 
sues, organs,  or  persons  are  liable  to  tubercle, 
and  certain  others  not  so ; also  the  frequency 


with  which  tubercles  are  disseminated  over  a 
number  of  organs  in  the  same  subject.  Hence 
arose  the  doctrine  of  tubercular  diathesis  and 
dyscrasia. 

1.  Tubercular  diathesis  is  a phrase  first  used 
by  Bayle  (1803),  and  means  a particular  dis- 
position to  the  generation  of  tubercles.  The 
contradictory  word  to  diathesis  is  immunity,  or 
privation  of  diathesis.  The  tubercular  diathesis 
relates  to  tissues,  organs,  or  persons.  ( a ) Tis- 
sues : it  has  been  already  shown  that  tho 
connective  tissues  (and  especially  the  variety 
lymphadenoid  tissue)  are  particularly  predis- 
posed to  tubercle.  The  other  tissues — namely, 
the  epithelial,  and  the  higher,  muscular  and  ner- 
vous tissues,  may  be  said  to  possess  complete 
immunity.  Some  would  deny  this  last  assertion, 
but  their  opinions  have  been  narrated  before, 
and  need  not  be  repeated  here.  Of  late  years  tu- 
bercles have  been  found  in  sundry  morbid  tissues. 
Koster  (1869),  in  cases  of  scrofulous  disease  of 
joints,  found  innumerable  tubercles  imbedded  in 
the  granulations ; not  only  in  those  which  spring 
from  the  synovial  membrane  and  bone,  but  also 
in  those  which  line  abscesses  or  sinuses.  Pried- 
lander  (1873)  declares  that,  under  these  con- 
ditions, tubercles  are  never  absent.  They  are 
visible,  even  to  the  naked  eye,  as  whitish  or 
greyish  specks,  surrounded  by  a ring  of  enlarged 
capillaries.  He  finds  tubercles  in  scrofulous 
ulcers  of  the  skin,  and  in  the  walls  of  scrofulous 
abscesses,  cutaneous  or  connected  with  caries  of 
bone.  Koster  has  seen  tubercles  in  ehancrous 
and  cancerous  ulcers  ; Priedlander  in  the  stroma 
of  a cancer  recurrent,  after  operation.  This  local 
tuberculosis  (if  it  be  tuberculosis)  has  very  little 
disposition  to  become  disseminated;  the  health 
of  the  patients  remains  good;  the  tubercles  often 
remain  for  a long  time  without  becoming  caseous. 
The  microscopical  structure  of  these  tubercles  is 
ident  ical  with  that  which  Schiippel  has  assigned 
to  tubercle  of  the  lymphatic  glands,  and  which 
has  been  already  described,  (hi)  Organs:  tho 
serous  membranes  (pleura,  peritoneum,  pericar- 
dium) are  a very  frequent  seat  of  tubercle.  Endo- 
cardium, very  uncommon.  Dura  mater,  not  very 
common.  Pia  mater,  very  common.  Ependyma, 
uncommon.  Tho  mucous  membranes  (alimentary, 
respiratory,  genito-urinary),  very  common.  Lym- 
phatic glands,  most  common.  Lungs,  liver, 
spleen,  kidneys,  common.  Suprarenals,  not  very 
common.  Testes,  not  uncommon.  Prostate,  not 
common.  Heart,  not  very  common.  Brain 
and  spinal  cord,  tolerably  common.  Salivary 
glands  and  pancreas,  uncommon.  Ovaries,  vo- 
luntary muscle,  and  thyroid,  very  uncommon. 
With  regard  to  the  skin,  tubercles  have  been 
found  around  scrofulous  ulcers ; and  Eriedlander 
(1S72-4)  has  assigned  to  lupus  a microscopical 
character  identical  with  that  of  tubercle.  The 
diathesis  of  organs  can  be  partly  explained  by 
the  diathesis  of  tissues.  Lymphatic  organs  are 
predisposed ; and  hence  we  can  understand  why 
the  spleen  is  prone  to  tubercle  whilst  the  thyroid 
is  not ; also  why  the  intestines  should  bo  more 
liable  than  the  stomach,  because  they  are  much 
richer  in  lymphatic  structures.  But  it  is  not 
easy  to  say  why  the  connective  tissue  of  the 
ovaries,  the  mammary  glands,  and  the  salivary 
glands,  should  be  indisposed  to  tubercle.  Partly, 


TUBERCLE. 


perhaps,  it  is  an  error  of  observation ; partly, 
perhaps,  it  is  explicable  by  the  supply  of  blood 
and  juices,  (c)  Persons : the  tubercular  dia- 
thesis, with  respect  to  persons,  is  met  with  only 
in  the  scrofulous.  No  age  is  exempt  from  the 
possibility  of  tubercles  ; they  are  especially 
common  in  early  life,  and  have  been  found  even 
in  the  feetus. 

2.  Tubercular  dyscrasia.  The  word  dys-crasia 
signifies  a mis-composition,  or  a qualitative  le- 
sion. Strictly  speaking,  there  may  be  a dys- 
crasia  of  any  tissue,  but  the  word  has  come 
to  be  applied  to  qualitative  lesions  of  the  blood 
oulyu  The  dyscrasia,  which  is  believed  to  exist 
in  tuberculosis,  and  to  be  peculiar  to  it,  is 
called  tubercular.  Bayle  was  the  first  to  note  the 
frequency  with  which  tubercle  implicates  a num- 
ber of  organs  in  the  same  subject  and  at  the 
same  time.  Laennec  remarked  that  the  tuber- 
cles often  seem  to  have  been  developed  in  distinct 
crops  : the  age  of  the  tubercles  being  judged  of 
by  the  degree  of  their  degeneration.  So  that  he 
came  to  speak  of  primary  and  secondary  eruptions 
of  tubercle.  He  noted  that  a secondary  eruption 
often  seemed  to  follow  the  softening  of  the  pri- 
mary tubercle.  And  this  he  deemed  to  indicate 
an  actual  and  peculiar  change  in  the  juices  of 
the  part,  a local  dyscrasia : as  if  the  primary 
tubercle  were  the  source  of  an  infection.  It  is 
then  the  multiple  eruption  of  tubercle  which 
suggests  the  notion  of  a dyscrasia.  Eor  the 
matter  stands  thus.  The  multiple  eruption  is 
either  protopathic  or  deuteropathic.  Either 
many  organs  simultaneously  and  spontaneously 
generate  tubercle,  or  they  are  simultaneously 
subjected  to  a common  tuberculising  influence. 
Of  the  two  hypotheses,  the  latter  is  certainly 
the  more  probable.  And  if  so,  it  is  not  asking 
much  to  suppose  that  the  common  cause  exists 
in  the  common  bond  of  all  organs  and  tissues — 
that  is  to  say,  the  blood.  And  granting  this, 
the  further  question  arises  : how  does  the  blood 
acquire  this  tuberculising  property  ? Is  it  pro- 
topathic or  deuteropathic  ? Is  it  a spontaneous 
generation  of  the  blood,  or  is  it  derived  from 
some  other  source  ? Now,  the  prevailing  theory 
of  dyscrasise  asserts  that  every  dyscrasia  is  due 
to  the  constant  afflux  of  morbid  material  de- 
rived from  foci  external  to  the  circulating  blood 
itself:  in  other  words,  dyscrasise  are  always 
secondary  to  a local  lesion.  The  justification  of 
this  doctrine  is  believed  to  be  found  in  certain 
dyscrasise  w'hich  seem  to  be  less  obscure  than 
the  tubercular;  for  instance,  pyaemia  and  mela- 
nsemia.  Admitting  that,  in  the  case  of  the 
tubercular  dyscrasia  also,  there  is  a necessary 
local  antecedent  lesion,  we  have  next  to  inquire 
what  this  lesion  is,  both  in  itself  and  in  its  rela- 
tion to  the  blood. 

First,  concerning  the  nature  of  the  lesion 
which  infects  the  blood.  Dittrich  (1853)  taught 
lhat  detritus,  derived  from  the  breaking-up  of 
tissues  of  any  kind,  and  entering  the  blood, 
would  produce  the  tubercular  dyscrasia.  But 
to  this  doctrine  it  is  justly  objected  that  de- 
tritus, the  result  of  degenerations,  is  often  ab- 
sorbed and  is  not  followed  by  tubercle.  There 
must  be  something  peculiar  to  the  detritus  which 
sets  up  tubercle ; what  we  may  call  a tubercular 
virus.  Buhl  (1857)  held  that  this  virus  pro- 


1667 

ceeded  from  the  sundry  forms  of  Laennec's  tu- 
bercle alone  : that  is  to  say,  from  undegenerated 
tubercle,  and  from  any  kind  of  cheesy  matter. 
He  remarked,  what  is  very  true,  that  it  is  ex- 
ceedingly uncommon  to  fine!  disseminated  miliary 
tubercle,  without  also  finding  cheesy  matter 
somewhere,  especially  in  the  bronchial  and  me- 
senteric glands,  and  in  the  lungs.  And  no  one 
would  deny  that  the  formation  of  the  cheesy 
matter  must  have  preceded,  in  point  of  time, 
the  formation  of  the  miliary  tubercle.  Against 
Buhl’s  theory  there  lie  three  objections,  but 
they  cannot  be  said  to  overthrow  the  theory  by 
any  means.  Cheesy  matter  often  occurs  without 
the  tubercular  dyscrasia ; but  this  proves  nothing 
more  than  that  cheesy  matter  sets  up  the  dys- 
crasia under  certain  conditions  only,  or  that  all 
cheesy  matter  will  not  set  up  the  dyscrasia.  In 
very  rare  cases  of  general  tubercle  no  cheesy 
matter  has  been  found  ; but  it  is  not  denied  that 
recent  undegenerated  tubercle  may  infect.  The 
last  objection  is  this  : the  tubercular  dyscrasia 
implies  the  tubercular  diathesis ; and  it  is  not 
surprising  that  the  signs  of  former  tubercular 
disease,  in  the  form  of  cheesy  matter,  should  be 
found  in  persons  who  have  died  from  a more 
general  tuberculosis  ; but  this  objection  will  lose 
much  of  its  force  when  we  have  discussed  our 
second  topic,  which  we  will  now-  proceed  to  do. 

The  relation  between  the  local  lesion  and  the 
blood,  or  the  mode  in  which  the  tubercular  dys- 
crasia is  developed.  There  are  three  possible  ways 
by  which  the  blood  may  become  contaminated. 
First,  by  a lesion  of  some  part  of  the  sangui- 
ferous system : but  this,  sofar  as  the  writer  knows, 
has  never  been  supposed  the  source  of  tubercle. 
Secondly,  by  an  absorption  of  the  virus  by  the 
blood-vessels  : nothing  can  be  said  for  this  sup- 
position or  against  it.  Thirdly,  by  means  of  the 
lymphatic  system : a source  of  infection  which 
is  highly  probable.  Experience  seems  to  justify 
the  following  theory.  The  local  tuberculising 
lesion  first  of  all  infects  its  immediate  neigh- 
bourhood, through  the  juice  canals.  In  serous 
membranes,  mucous  membranes,  the  lungs,  and 
the  brain,  it  is  very  common  to  see  what  may  be 
called  the  mother  tubercle  surrounded  bya  num- 
ber of  daughter  tubercles.  The  lymphatic  glands 
are  next  infected  ; and  when  they  have  become 
tubercular,  they  pour  tubercular  virus  into  the 
blood.  The  blood  conveys  the  virus  to  all  parts 
of  the  body,  and  thus  disseminates  the  tubercle. 
This  theory  is  satisfactory  on  the  whole,  but  it 
takes  the  primitive  local  lesion  for  granted. 
When  wo  ask  for  the  cause  of  the  specific  local 
lesion  we  are  thrown  back  upon  the  tubercular 
diathesis,  which  we  know  only  in  its  effects,  not 
at  all  in  itself,  and  not  much  more  in  its  ante- 
cedents. 

VH.  Concerning  the  experimental  patho- 
logy of  tubercle. — Passing  over  the  earlier  ex- 
periments of  Cruveilhier,  Lombard,  Erdt,  and 
others,  we  will  come  at  once  to  Villemin  (18651, 
who  was  the  first  to  draw7  general  attention  to  the 
present  topic.  He  inoculated  rabbits  with  fresh 
tubercle,  both  transparent  and  opaque  ; that  is 
to  sav,  he  inserted  small  pieces  of  tubercle  into 
an  incision  made  through  the  skin  of  the  animals. 
When  the  rabbits  were  killed,  about  a month 
afterwards,  an  abundant  crop  of  tubercles  was 


TUBERCLE. 


1668 

found  in  many  of  the  viscera.  On  the  other 
hand,  Villemin  proved  that  rabbits  are  not  sub- 
ject to  spontaneous  formation  of  tubercle.  He 
concluded  that  tubercle  contains  a peculiar  virus, 
which  can  be  reproduced  in  the  body.  Since 
Villemin’s  time  many  pathologists  have  worked 
at  the  artificial  production  of  tubercle.  The  re- 
sults of  their  work  may  be  conveniently  arranged 
under  six  heads. 

1.  Animals  used  in  the  experiments.  In  rab- 
bits, guinea-pigs,  oxen,  sheep,  goats,  and  mon- 
keys, artificial  tubercle  is  easily  generated  ; in 
cats  and  dogs,  not  easily.  Villemin  failed  in  his 
attempts  to  inoculate  a cock  and  a dove. 

2.  Material  inoculated.  Villemin  tised  fresh 
tubercle.  But  soon  afterwards  (1867)  Andrew 
Clark  and  Waldenburg  succeeded  in  rendering 
rabbits  tubercular,  by  inoculating  them  with 
materials  other  than  tubercle.  It  was  next 
found  that  not  only  animal  tissues,  but  even  the 
vegetable,  such  as  a cotton  seton  or  a piece  of 
cork,  could  set  up  tuberculosis.  And,  lastly,  the 
fact  was  discovered  that  a simple  wound,  into 
which  nothing  was  inserted,  would  suffice  to 
generate  tubercle  in  rabbits,  guinea-pigs,  and 
certain  other  animals.  However,  Sanderson 
(1868)  showed  that,  of  all  the  means  for  pro- 
ducing artificial  tubercle  by  inoculation,  none  is 
more  certain  or  more  active  than  the  material 
taken  hot  from  the  diseased  glands  of  a living 
animal  already  infected.  The  dose  required  is 
almost  infinitesimal.  If  a diseased  gland  is 
squeezed  into  a little  distilled  water  in  a capsule, 
and  the  slightly  turbid  liquid  injected,  results 
are  certain.  Both  Sanderson  and  Wilson  Eox 
(1868)  discovered  that  when  non-tubercular 
matters  are  inoculated,  they  become  encapsuled 
by  cheesy  matter  formed  beneath  the  skin  ; so 
that  the  difficulty  of  explaining  the  subsequent 
tuberculosis  is  not  so  great  as  it  seems  at  first. 
The  tubercles  follow,  not  the  material  inocu- 
lated, but  the  inflammatory  products  which  sur- 
round it.  Cohnheim  inferred  that  the  infectious 
matter  was  always  caseous  pus.  But  the  inflam- 
matory products  around  the  wound  of  inoculation 
are  not  always  cheesy,  although  they  are  usually 
so.  Wherefore  we  must  conclude  that  the  infec- 
tious virus,  which  excites  the  general  tuber- 
culosis, is  not  introduced  from  without,  but  is 
generated  by  the  animal  itself ; that  the  animal 
must  possess  a tubercular  diathesis ; and  that, 
given  the  diathesis,  any  kind  of  inflammation, 
set  up  in  any  way,  may  call  forth  tuberculosis. 

3.  Manner  of  introducing  the  exciting  sub- 
stance. Villemin  inoculated  the  tubercle.  He 
also  succeeded  by  injecting  a watery  suspension 
of  tubercle  into  tho  air-tubes.  Feltz  (1867)  in- 
jected cheesy  detritus  into  the  right  side  of  the 
heart,  and  produced,  in  the  lungs,  embolic  nodules 
which  underwent  caseous  degeneration.  Injec- 
tions into  the  left  side  of  the  heart  caused  simi- 
lar changes  in  other  viscera,  especially  the  brain. 
Lebertand  Wyss  obtained  the  same  results  from 
injections  into  the  veins.  Sanderson  injected 
the  serous  cavities.  Chauveau  (1868)  found  that 
infectious  matters  may  be  introduced  into  the 
body  through  the  alimentary  canal : he  rendered 
calves  tubercular  by  feeding  them  with  small 
quantities  of  tubercle,  or  with  muscle,  milk,  or 
sputa  of  a tubercular  animal.  Lastly,  some  have 


suspected  that  infective  particles  may  be  inhaled 
into  the  lungs. 

4.  Lesions  produced.  The  results  of  inocula- 
tion beneath  the  skin  of  guinea-pigs  have  been 
well  described  by  Wilson  Fox.  (a)  The  material 
inserted  becomes  surrounded  by  dry  cheesy  stuff, 
which  is  shown  by  the  microscope  to  consist  of 
dried-up  detritus,  rather  than  true  puriform 
cells.  (6)  Around  tho  cheesy  mass  are  a num- 
ber of  small  round  granulations,  some  transparent 
and  some  opaque,  in  size  from  that  of  a poppy- 
seed to  that  of  a hemp-seed.  These  granulations 
consist  of  many  nuclei,  imbedded  in  a homoge- 
neous substance,  together  with  some  large  epi- 
thelioid cells,  (c)  Indurated  cords  reach,  beneath 
the  skin,  from  the  seat  of  injury  towards — or  to 
— the  nearest  lymphatic  glands.  These  cords 
are  sometimes  cheesy  in  the  centre.  Microscopi- 
cally they  consist  of  strings  or  rows  of  cells  and 
nuclei,  like  those  of  the  granulations,  contained 
in  a limitary  membrane.  These  cords  are  prob- 
ably altered  lymphatics,  (d)  The  next  change  is 
found  in  the  associated  lymphatic  glands.  They 
are  enlarged  to  twice  or  thrice  their  natural  size, 
and  are  also  apparently  much  increased  in  num- 
ber— that  is  to  say,  very  small  glands  become 
visible.  On  section,  they  look  semi-transparent 
and  confused  in  structure:  scattered  through 
them  are  spots  and  streaks  of  cheesy  degenera- 
tion. The  microscope  shows  a great  increase  in 
the  number  of  the  natural  lymphoid  corpuscles, 
and  some  larger  epithelioid  cells,  (c)  The  lungs 
are  next  most  frequently  affected.  They  contain 
scattered  granulations  of  different  sizes,  from  the 
minutest  speck  to  the  size  of  a hemp-seed,  or 
even  larger  ; semi-transparent  and  firm,  with  a 
cheesy  centre,  sometimes  softened.  A distinct 
connection  with  the  air-tubes  and  vessels  can 
often  be  made  out,  the  granulations  being  seated 
in  the  peribronchial  or  perivascular  sheath  ; but 
sometimes  they  have  no  particular  relation  to 
either.  From  these  granulations  proceeds  an 
infiltration  of  the  septa  of  the  air-sacs : and  con- 
currently with  this  change,  the  capillaries  col- 
lapse and  cease  to  be  permeable  by  blood.  The 
bronchial  glands  also  are  affected,  in  the  same 
manner  as  described  above.  (/)  The  next  most 
important  changes  are  in  the  liver.  It  is  much 
increased  both  in  size  and  weight,  in  consequence 
of  a diffuse  infiltration  of  the  capsule  of  Glisson 
and  the  tissue  between  the  acini,  with  small  cor- 
puscles (such  as  before  described)  imbedded  in 
a fibrous  network.  The  new  tissue  looks  semi- 
transparent and  glistering:  scattered  through  it 
are  spots  of  cheesy  change.  Here  and  there  the 
lesion  tends  to  assume  the  nodular  form.  The 
proper  liver-cells  degenerate  and  disappear,  (y) 
The  spleen  is  enlarged.  Kodules,  transparent 
or  cheesy,  and  transparent  diffuse  infiltrations, 
are  scattered  through  it.  (A)  In  the  agminated 
and  solitary  follicles  of  the  intestines  are  some- 
times found  white  or  caseous  nodules,  or  even 
ulcers.  The  stomach  is  unaffected.  The  lym- 
phatic glands  in  the  mesentery  and  in  the  hilum 
of  tho  liver  are  usually  affected,  (i)  Ascites  is 
common,  and  probably  due  to  the  state  of  tlis 
liver,  (j)  In  the  omentum  numerous  granula- 
tions are  often  found,  both  around  the  small 
vessels,  and  also  in  the  tissue  where  there  ar* 
no  vessels. 


TUBERCLE. 

Sanderson  found  that  when  the  serous  cavities 
ire  injected  with  tubercle  the  membranes  be- 
come studded,  in  two  or  three  weeks,  with  granu- 
lations, small,  but  visible  to  the  naked  eye ; and, 
for  the  most  part,  mere  overgrowths  of  lympha- 
denoid  tissue  previously  existing  beneath  the 
epithelium.  The  lungs  undergo  the  change  de- 
scribed by  Wilson  Fox,  and  also  a pneumonic 
change,  consisting  in  a filling  of  the  air-sac 
with  roundish  cells,  liko  those  which  are  always 
found  there  in  small  numbers. 

5.  Nature  of  these  lesions.  The  great  majority 
of  pathologists  are  of  opinion  that  these  lesions, 
thus  artificially  produced  in  the  lower  animals, 
are  the  same  as  those  which  we  call  tubercular 
in  man.  On  the  other  hand,  Friedliinder  holds 
that  these  artificially-produced  nodules  do  not 
possess  the  structure  of  true  tubercles,  to  which 
he  holds  a giant-cell  to  be  essential.  In  his 
opinion,  the  nodules  are  nothing  but  dissemi- 
nated chronic  inflammatory  nodules,  with  a dis- 
position to  caseate.  Ho  declares  that  in  the 
lungs  the  lesion  consists  in  nothing  but  miliary 
pneumonia,  an  assertion  which  is  directly  con- 
trary to  the  experience  of  Wilson  Fox  and  San- 
derson. Friedliinder  refers  to  Sanderson's  views 
upon  the  infective  product  of  inflammation.  But 
Sanderson  does  not  draw  so  excessively  sharp  a 
distinction  between  tubercles  and  chronic  in- 
flammatory nodules  as  Friedliinder  does.  San- 
derson’s doctrines  deserve  the  closest  attention. 
They  may  be  summed  up  as  follows:  An  inflam- 
mation which  is  more  or  less  exactly  limited  in 
duration  and  extent  by  the  original  limits  of 
the  injury  which  has  caused  it,  may,  with  scien- 
tific precision,  be  designated  a simple  or  normal 
inflammation.  An  inflammation  which  spreads 
and  endures  beyond  the  direct  and  primary  ope- 
ration of  its  cause,  which  induces  similar  inflam- 
mations in  other  parts,  and  disorders  the  func- 
tions of  the  whole  body,  has  in  it  something 
beyond  the  effects  of  the  injury,  and  may  pro- 
perly be  called  infecting.  In  the  latter  case, 
material  must  have  been  discharged  from  the 
original  focus,  either  by  the  absorbents  or  the 
veins,  into  the  circulation.  The  remote  effects 
of  this  infecting  inflammation  consist,  partly  in 
the  springing  up  of  new  foci  of  inflammation 
along  the  course  of  the  infected  channels  (the 
anatomical  distribution  of  which  secondary  foci 
always  distinctly  indicates  the  source  from  which 
they  have  originated),  partly  in  the  occurrence 
of  changes  in  the  physical  and  organoleptic  cha- 
racters of  the  blood  itself,  of  such  a nature  as 
to  show  that  it  is  impregnated  with  the  infective 
poison.  When,  in  the  lower  animals,  local  in- 
fective inflammations  are  produced,  either  in  the 
skin  or  peritoneum  by  the  introduction  of  irri- 
tant substances,  two  distinct  sets  of  consequences 
manifest  themselves,  namely,  (1)  a chronic  dis- 
ease, exhibiting  in  all  respects  the  anatomical 
characters  of  tuberculosis,  and  consisting  essen- 
tially in  the  overgrowth  of  certain  tissues  called 
lymphatic  or  adenoid,  and  in  close  relation 
with  the  lymphatic  system  ; and  (2)  pyaemia,  an 
acute  disease,  in  which  abscesses  form.  The 
difference  between  the  rapidly-growing  and 
suppurating  nodule  of  pyaemia,  and  the  slowly- 
formed  caseating  granulation  of  tuberculosis,  is 
one  not  of  origin,  or  even  of  structure,  but  of 


TUBERCULOSIS.  1669 

duration  and  development.  Opinions  such  as 
these  are  held  by  other  eminent  pathologists — 
for  instance,  Chauveau  and  Rindfleisch.  For  a 
further  development  of  the  subject,  in  respect  of 
human  pathology,  the  reader  may  refer  to  the 
article  on  Scrofula. 

6.  Characters  of  the  virus.  Whether  these 
nodules  be  modified  inflammations  or  not,  there 
can  be  no  doubt  of  the  dyscrasia.  But  little  is 
yet  known  concerning  the  virus.  Villemin  sup- 
posed it  to  be  liquid.  Klebs  declares  that  it  is 
soluble  in  water,  but  not  in  alcohol.  Walden- 
burg,  Sanderson,  Chauveau,  and  most  other 
pathologists  deem  it  to  take  the  form  of  minute 
solid  particles. 

Klebs,  Aufrecht,  and  Baumgarten  describe 
the  virus  as  being  of  the  nature  of  a bacillus  ; 
Schuller  and  Toussaint  describe  it  as  being  a 
micrococcus.  More  recently  Koch  has  announced 
the  discovery  by  him  of  a specific  tubercular 
organism  in  tuberculous  structures  and  in  the 
sputa  of  phthisis.  This  organism  is  a slender, 
rod- shaped,  motionless  bacillus,  which  equals  in 
length  from  one  quarter  to  the  whole  of  the 
breadth  of  a red  blood-corpuscle.  This  tubercle 
bacillus  differs  from  all  known  bacilli  in  re- 
maining unaffected  by  the  staining  reagent  ve- 
suvin.  See  Zyme.  S.  J.  Gee. 

TUBERCULAR  ERUPTIONS.  — This 
term  is  applied  to  eruptions  consisting  of  small 
prominences  of  the  skin.  The  use  of  the  ex- 
pression is  somewhat  arbitrary,  inasmuch  as 
a small  tubercle  would  fall  under  the  denomi- 
nation of  ‘ pimple,’  and  a large  tubercle  under 
that  of  ‘ tumour.’  Willan  defines  tubercle  tc 
be  ‘ a small,  hard,  superficial  tumour,  circum 
scribed  and  permanent,  or  suppurating  partially. 
In  this  definition  prominence  and  bulk  alone 
are  regarded ; and,  as  a consequence,  in  his 
group  of  tubercular  eruptions  of  the  skin,  Wil- 
lan brings  together  an  incongruous  assemblage 
of  superficial  growths,  wholly  discordant  in  their 
nature,  some  being  grave  and  some  only  trivial, 
and  of  which  the  greater  part  can  only  be  dealt 
with  under  their  separate  heads.  For  example, 
he  enumerates  as  members  of  this  group : — 
‘phyma,  verruca,  molluscum,  vitiligo,  acne,  sy- 
cosis, lupus,  elephantiasis,  frambsesia ; ’ and 
omits  altogether  that  very  important  group  of 
tubercular  eruptions  which  are  due  to  syphilis. 

Erasmus  Wilson. 

TUBERCULAR  MENINGITIS.  — A 

form  of  meningitis  dependent  on  the  presence  of 
tubercle.  See  Meninges,  Ceuebeal,  ^Diseases  of. 

TUBERCULAR  PHTHISIS.-A  synonym 
for  one  or  more  of  the  forms  of  pulmonary  con- 
sumption associated  with  tubercle.  See  Phthisis; 
Tubercle  ; and  Tuberculosis. 

TUBERCULOSIS. — Synon.  : Fr.  Tuhercu- 
lisation  ; Tuberculose  ; Ger.  'hiberculose  ; Tuber- 
kelbildung. — By  tuberculosis  is  meant  the  pro- 
duction of  tubercle.  The  anatomical  and  setio- 
logical  aspects  of  tuberculosis  are  discussed  in 
the  articles  on  Scrofula  and  Tubercle.  The 
present  article  is  devoted  to  the  semeiotic  aspect 
of  tuberculosis,  that  is  to  say,  to  the  signs 
whereby  we  discover  the  tubercular  process  in 
the  living  man. 


1670  TUBERCULOSIS. 

We  lay  down  two  prime  distinctions  at  the 
outset.  First,  although  tubercle  tend  to  be  dis- 
seminated more  or  less  widely,  yet  it  commonly 
affects  some  one  organ  more  than  the  rest,  so 
that  during  life  this  organ  alone  seems  to  suffer. 
Wherefore  tuberculosis  is  distinguished  according 
to  the  organ  most  affected,  a rule  to  which  there 
is  but  one  exception — namely,  the  form  of  tuber- 
culosis which  does  not  predominate  in  any  part, 
which  is  a disease  of  the  whole  substance,  which 
resembles  typhus  or  enteric  fever,  and  which  will 
bo  described  hereafter.  Secondly,  tuberculosis 
is  acute  or  chronic;  words  which  we  take  in 
their  common  meaning,  without  further  defini- 
tion. 

In  the  article  on  tubercle  will  be  found  a list 
of  the  organs  prone  to  tubercle.  The  signs  of 
the  corresponding  local  forms  of  tuberculosis  are 
described  in  the  appropriate  articles.  We  speak 
of  tubercular  pleurisy,  peritonitis,  pericarditis, 
meningitis ; tubercular  disease  of  the  fauces,  of 
the  intestines,  of  the  larynx;  pulmonary  tuber- 
culosis and  phthisis ; tubercle  of  the  kidneys,  of 
the  genito-urinary  passages  ; of  the  lymphatic 
glands,  of  the  suprarenals,  of  the  testicles,  of  the 
brain,  of  the  skin,  of  the  choroid,  and  of  other 
parts. 

Tuberculosis  tends  to  be  chronic.  But  some 
of  its  forms  are  acute,  specially  tubercular  me- 
ningitis, tubercular  pericarditis,  acute  pulmonary 
tuberculosis,  and  the  typhoid  form  of  the  disease. 

Acute  typhoid,  tuberculosis.— The  signs  of  this 
disease  may  be  summed  up  thus  : Fever,  and 
the  usual  attendants  thereof ; without  signs  of 
local  inflammation,  or  of  typhus  or  enteric  fever. 
Marked  by  the  thermometer,  (he  fever  is  not 
high,  seldom  rising  above  103°.  The  face  de- 
void of  expression,  pale  or  dusky.  The  patient 
heavy,  loth  to  be  disturbed,  but  answering  to  the 
point.  Sleep  disturbed ; much  dreaming.  Pro- 
gressive emaciation.  Skin  dry  and  harsh,  no 
eruption.  Tongue  dry,  sordes  on  teeth,  thirst. 
Belly  not  distended ; spleen  large.  Nausea, 
vomiting;  bowels  costive  and  stools  pale,  or 
temporary  looseness  with  yellow  stools.  Fre- 
quent short  cough  ; no  expectoration ; no  physi- 
cal signs  of  disease  in  chest,  except,  perhaps,  of 
slight  catarrh.  Pulse  frequent  and  weak.  Urine 
high-coloured.  In  a case  such  as  this,  probability 
would  become  certainty  if  tubercles  were  dis- 
covered in  the  choroid  during  life — a lesion  which 
the  writer  has  found  after  death.  Trousseau  says 
that  headache  more  or  less  severe,  and  delirium 
more  or  less  violent,  may  be  present. 

The  onset  is  somewhat  sudden  ; the  duration, 
from  three  to  six  weeks ; and  the  termination, 
death.  We  may  suppose  that  slight  forms  of  the 
disease  end  in  recovery  ; but  proof  is  difficult  or 
well-nigh  impossible. 

Teeatment. — The  treatment  of  acute  tuber- 
culosis is  the  same  as  that  of  any  severe  fever  ; 
for  instance,  typhus.  S.  J . Gee. 

TUBUL  AE. — A peculiar  quality  of  sound,  as 
indicated  by  its  name,  either  elicited  by  percus- 
sion, or  heard  on  auscultation,  in  certain  condi- 
tions. See  Physical  Examination. 

TUMOURS. — Synon.  : Fit  Tumeurs ; Ger. 
Geschwukte. 


TUMOURS. 

Definition. — In  the  broadest  sense  of  the 
word,  a tumour  signifies  a swelling,  and  must 
therefore  include  conditions  so  far  apart  as  a 
phantom-tumour,  a hypertrophied  muscle,  an 
abscess,  a hernia,  or  a cancer;  but  in  its  more 
restricted  sense  its  application  is  confined  to  a 
swelling  caused  by  some  form  of  new  growth. 

Classification.  — The  separation  of  now- 
growths  into  benign  and  malignant,  though  very 
useful  as  an  approximate  clinical  distinction,  is 
not  admissible  in  a scientific  discussion.  Nor 
again  is  one  that  is  founded  upon  the  seat  or 
shape  of  the  tumour  sufficiently  accurate  for  the 
purpose.  This  arrangement  would  involve  such 
antiquated  terms  as  parenchymatous  or  super- 
ficial, nodules,  infiltrations,  fungus-growths,  &c. 
The  true  classification  must  depend  upon  the 
actual  structure,  that  is,  the  microscopical  char- 
acter of  the  growth.  Such  a classification  is  the 
following : — - 

A.  Tumours  composed  of  normal  tissue 
of  the  adult  human  body,  or  of  such  a 
tissue  very  slightly  modified. — 1.  Fibroma, 
hard  and  soft,  including  cheloid;  2.  Lipoma; 
3.  Chondroma;  i.  Osteoma;  5.  Papilloma  (warts 
and  corns) ; 6.  Adenoma  and  glandular  hyper- 
trophies ; 7.  Lymphoma ; 8.  True  Myoma,  in- 
cluding myo-fibroma;  9.  True  Neuroma;  10. 
Angioma;  and  11.  Lymphangioma. 

B.  Tumours  consisting  of  some  modifica- 
tion of  embryonic  connective  tissue,  that 
is,  the  Sarcomas.  1.  Round-celled  sarcoma,  in- 
cluding glioma ; 2.  Oval-celled  sarcoma ; 3.  Spin- 
dle-celled sarcoma,  large  and  small : 1.  Alveolar 
sarcoma ; 5.  Mixed  sarcoma ; 6.  Myeloid  sar- 
coma; 7.  Myxoma  ; 8.  Osteo-sarcoma ; 9.  Chon- 
dro-sarcoma;  10.  Melanotic  sarcoma;  and  11. 
Psammoma. 

C.  Tumours  consisting  of  a modification 
of  epidermic,  epithelial,  and  secreting-gland 
structures. — 1.  Cancers;  and  2.  Rodent  ulcer. 
These  forms  of  new-growth  are  described  in 
special  articles.  See  Cancee  ; and  Rodent  Ulcee. 

D.  Tumours  consisting  of  an  inflamma- 
tory growth.  — 1.  Simple.  — Granulation-tu- 
mours, exostoses,  See.  2.  Specific. — Depending  on 
syphilis,  tubercle,  struma,  leprosy-,  glanders,  and 
other  conditions. 

The  inflammatory  tumours  included  under 
this  class  do  not  come  strictly-  within  the  scope  of 
the  present  discussion ; its  various  sub-divisions 
must  be  sought  under  the  description  of  the 
diseases  which  give  rise  to  them,  in  the  several 
articles  bearing  their  respective  names. 

E.  Cysts. — This  division  is  also  dealt  with  in 
a separate  article.  See  Cysts. 

A.  Tumours  composed  of  a normal  tissue 
of  the  adult  human  body. 

In  this  class  are  included  representatives  of 
each  of  the  primary  tissues  of  the  adult  body. 
The  members  of  it,  therefore,  differ  widely  in 
structure  and  appearance,  hut  they  are  distin- 
guishedfrom  those  of  the  second  and  third  classes 
by  one  important  feature,  namely,  that  though 
often  multiple,  they  show  little  or  no  tendency 
to  return  after  complete  removal — that  is,  they 
are  essentially  benignant.  To  this  may  he  added 
another  less  characteristic  distinction,  namely, 
that  they  have,  consequently’,  but  little  tendency 
to  ulcerate ; and  that,  as  a result,  if  they  interfere 


TUMOURS. 


with  life,  at  all,  it  is  by  pressure  on  important 
organs,  or  in  sueli  an  accidental  -way  as  by  the 
bleeding  which  may  result  from  a uterine  fibroid, 
rather  than  by  the  production  of  direct  constitu- 
tional disturbance. 

1.  Fibromata.  — Definition. — Tumours  con- 
sisting simply  of  fibrous  tissue  or  some  modifica- 
tion of  it. 

Varieties,  Clinical  Characters,  and  Miceo- 
scopical  Appearances. — Fibromata  may  be  di- 
vided into  hard  and  soft  fibromata. 

a.  Soft  fibrous  tumours. — The  soft  fibromata 
are  simple  masses  of  connective  tissue,  occurring 
in  the  submucous  or  subcutaneous  tissues,  and 
generally,  hut  not  always,  more  or  less  pedun- 
culated. In  many  cases  there  are  overgrown 
papillae  on  the  surface  ; and  overgrown  and  dis- 
torted glands  of  the  skin  or  mucous  membrane 
are  often  entangled  amongst  the  meshes  of  the 
tumour.  The  subcutaneous  variety  occurs  in  all 
parts  of  the  body,  hut  is  perhaps  most  common 
in  the  labia  majora  and  the  lower  limbs ; and  to 
it  the  name  of  molluscum  fibrosum  has  been 
applied.  These  tumours  often  contain  a consi- 
derable amount  of  fat,  and  thus  approach  the 
lipomata.  They  often  appear  cedematous ; and 
may  undergo  calcareous  or  other  forms  of  de- 
generation. The  submucous  variety  includes  the 
simple  polypi  of  the  nose  and  ear.  In  these 
the  fibrous  tissue  is  somewhat  modified ; the 
ordinary  connective-tissue  cells,  oval,  oat-shaped, 
or  branched,  being  imbedded  in  a more  or  less 
copious  gelatinous  (?  mucous)  matrix.  Such  tu- 
mours are  nearly  relate!,  on  the  one  hand,  to  the 
myxomata,  and  are  covered  by  a mucous  mem- 
brane corresponding  to  the  region  in  which  they 
occur — ciliated,  for  example,  in  the  nose  (fig. 
102),  and  columnar  in  the  intestine.  On  the 
other  hand,  they  often  contain  in  their  interior 
the  characteristic  glands  of  the  part  they  affect, 
and  thus  approximate  to  the  adenomata.  To  the 
naked  eye  they  have  a gelatinous  appearance. 
The  reader  will  observe  that  the  varieties  of  ele- 
phantiasis, a disease  which  presents  a complex 
structure,  are  not  included  under  this  heading. 

b.  Hard  fibrous  tumours. — These  tumours  are 
made  up  of  pure  fibrous  tissue,  but  it  is  very 
difficult  to  draw  the  line  between  them  and 
some  forms  of  sarcoma.  They  are  firm,  and 
always  encapsuled,  and  often  pedunculated.  To 
the  naked  eye  a section  is  white  or  pinkish,  and 
presents  an  appearance  as  if  its  component  parts 
were  arranged  concentrically  round  a number 
of  points.  This  appearance  is  more  marked  on 
microscopic  examination,  which,  while  it  shows 
this  concentric  arrangement  in  bundles  that  have 
been  cut  across,  exhibits  others  which  have 
been  divided  longitudinally  ( see  fig.  101).  Hard 
fibromata  occur  in  many  situations  : in  the  sub- 
cutaneous tissue,  including  amongst  others  the 
fibrous  tumours  of  the  pinna,  which  are  not 
uncommon  in  idiots,  and  some,  at  least,  of  that 
peculiar  class  of  tumours  called  ‘ the  painful 
subcutaneous  tubercle  ’ ; in  submucous  tissues, 
including  many  of  the  naso-pharyngeal  polypi, 
and  some  of  the  fibrous  tumours  and  polypi  of 
the  uterus ; in  connection  with  the  periosteum, 
including  some  of  the  forms  of  epulis,  the  so- 
called  fibrous  tumours  of  bone,  and  according  to 
some  authorities,  though  this  is  doubtful,  some 


1671 

kinds  of  subungual  exostosis  ; in  nerve-,  including 
the  common  neuromata,  and  bulbous  nerves  in  a 
stump  ; and  in  the  intermuscular  planes.  They 
are  liable  to  various  forms  of  degeneration ; they 
often  calcify;  and  those  in  connection  with  the 
periosteum  may  undergo  ossification.  Some 
fibrous  tumours  cause  serious  danger  to  life  from 
the  position  they  occupy ; it  will  be  enough  to 
cite  the  cases  of  naso-pharyngeal  polypi,  and 
polypi  of  the  uterus. 

Treatment. — Fibromata  can  only  he  treated, 
if  interference  of  any  kind  be  necessary,  by 
complete  removal,  the  nature  of  the  operation 
depending  upon  the  position  of  the  growth.  If 
completely  removed  they  have  no  tendency  to 
recurrence. 

2.  Lipoma. — Definition. — A tumour  com- 
posed of  normal  adipose  tissue. 

Varieties  and  Clinical  Charactees. — Occa- 
sionally more  or  less  local  hypertrophies  of  the 
subcutaneous  fatty  layer  occur,  and  merit  almost 
the  designation  of  a tumour;  hut  the  true  lipoma 
is  a pretty  well-defined  tumour,  made  up  of  a 
larger  or  smaller  number  of  overgrown  fat- 
lobules.  These  are  sometimes  of  enormous 
size,  so  that  only  two  or  three  are  found  in 
a tumour  of  considerable  dimensions.  The  skin 
presents  a very  characteristic  dimpling,  when 
moved  to  and  fro  over  such  a subcutaneous  fatty 
tumour.  The  superficial  parts  of  the  mass  may 
generally  be  easily  separated  from  the  surround- 
ing structures  during  an  operation  for  its  re- 
moval ; but  the  deeper  parts,  often  consisting 
of  smaller  lobules,  and  generally  containing  a 
vessel  of  some  magnitude,  require  more  careful 
enucleation.  Fatty  tumours  are  met  with  in  all 
parts  of  the  body  in  which  adipose  tissue  i? 
normally  developed.  The  writer  once  met  with 
a fatty  tumour  inside  the  spinal  column.  They 
may  occur  congenitally,  but  are  more  common 
in  middle  and  advanced  life.  They  are  often 
multiple,  and  are  apparently  in  some  eases 
developed  as  the  result  of  pressure  ; and  some- 
times they  are  remarkably  symmetrical.  They 
involve  no  danger  to  life,  but  are  often  very 
painful,  as  the  result  of  pressure  upon  cutaneous 
nerves.  Microscopically,  the  structure  is  that  oi 
ordinary  adipose  tissue. 

Treatment. — Though  fatty  tumours  are  said 
to  shift  their  position,  and  sometimes  to  diminish 
in  size  spontaneously,  they  are  not  to  he  dispersed 
hv  internal  remedies  or  external  applications. 
If  necessary,  they  must  be  removed  by  the  knife, 
an  operation  which,  as  was  mentioned  above,  is 
usually  easy.  It  is  a remarkable  fact  that, 
unless  they  be  completely  removed,  recurrence  is 
not  uncommon. 

3.  Chondromata.  — Definition.  — Tumours 
made  up  altogether,  or  in  great  measure,  of  car- 
tilage. 

Varieties,  Course,  and  Clinical  Charac- 
ters.— Cartilage-tumours  may  be  divided  into 
those  which  grow  in  connection  with  a bone-,  and 
those  which  arc  developed  in  the  soft  parts. 

Cartilaginous  tumours  growing  in  connection 
with  bone. — These  may  be  again  subdivided  into 
those  which  grow  from  the  surface  of  the  hone — 
ecchondromata  ; and  those  which  grow  from  the 
interior — cnchondromata.  The  latter  are  the 
simplest  form  of  cartilage-tumours ; they  com 


1672  TUMOURS. 


mene©  usually  during  the  period  of  adolescence, 
and  affect  by  preference  the  fingers  and  toes,  but 
are  occasionally  found  elsewhere ; they  are  almost 
always  multiple,  but  never  show  a malignant 
tendency;  they  may  reach  a very  considerable 
size  ; and  they  are  generally  coated  with  a thin 
layer  of  bony  tissue.  The  ecchondromata,  are 
developed,  as  a rule,  during  a later  period  of 
life;  are  found  in  connection  with  any  of  the 
bones  of  the  body ; and  often  attain  an  enormous 
size.  Some  of  these  tumours,  to  which  Virchow 
has  given  the  name  of  osteoid-chondroma , such 
as  are  occasionally  found  forming  elongated  swell- 
ings in  the  shaft  of  a long  bone,  present  a high 
degree  of  malignancy,  recurring  as  such  in  dis- 
tant parts  of  the  body. 

Cartilaginous  tumours  of  the  soft  farts. — These 
tumours  occur  principally  in  connection  with 
certain  glands,  and  especially  in  the  neighbour- 
hood of  the  parotid,  and  in  the  testicle.  It  has 
been  suggested  that  they  may  originate  from 
some  remains  of  foetal  structures.  Rarer  situa- 
tions for  such  tumours  are  the  submaxillary 
gland,  the  breast,  the  ovary,  the  lachrymal  gland, 
the  kidney,  and,  it  is  said,  the  lung.  These 
tumours  are  comparatively  seldom  pure,  hut  are 
usually  mixed  with  myxomatous,  adenoid,  or  sar- 
comatous structure ; the  degree  of  such  admix- 
ture determining  in  great  part  the  benignness  or 
malignancy  of  the  growth. 

An  account  of  the  so-called  ossifying  chondro- 
mata  is  given  under  the  heading  Osteomata. 

Naked-Eye  Appearances. — Cartilaginous  tu- 
mours vary  very  much  in  density;  the  hardest 
contain  fibrous  tissue,  and  are,  iu  fact,  fibro- 
cartilaginous growths ; the  softest  are  very  soft, 
and  are  very  closely  related  to  the  myxomata ; 
indeed,  it  may  be  held  that  many  myxomata  are 
merely  varieties  of  chondroma.  Some  chondro- 
mata  soften,  either  in  many  parts  or  in  the 
centre,  giving  rise  to  one  -or  more  cysts  in  the 
interior ; the  bursting  of  such  may  lead  to  a 
permanent  sinus.  Other  forms  of  degeneration 
are  not  uncommon,  and  especially  calcification. 
True  ossification  is  not  rare. 

Microscopical  Characters. — Microscopically 
the  structure  often  differs  widely  in  different 
specimens  of  chondroma,  and  in  different  parts 
of  the  same  tumour ; the  matrix  may  be  hyaline 
or  fibrous  ; and  the  cells  round,  irregular,  stel- 
late, or  much-branched  (figs.  105  and  106).  It 
wilL  easily  be  understood  that  with  a soft  hya- 
line matrix  and  much-branched  cells,  the  appear- 
ance of  myxoma  is  very  closely  simulated. 

Treatment. — Bearing  in  mind  the  great 
variety  of  these  tumours,  it  will  he  seen  that  it 
is  impossible  to  sum  up  the  treatment  of  them 
in  a few  words.  The  simple  enehondromata 
of  the  fingers  should  only  be  removed  to  cure 
deformity  or  similar  inconvenience.  As  a rule, 
other  forms  should  be  removed  as  early  as  pos- 
sible; but  many  ehondromata  spring  from  regions 
which  are  altogether  beyond  the  reach  of  the 
surgeon’s  knife. 

4.  Osteomata. — Definition. — Tumours  com- 
posed of  hone. 

Varieties. — If  the  inflammatory  exostoses  he 
excluded,  such  as  those  which  are  found  round  a 
joint  affected  with  chronic  rheumatic  arthritis, 
or  those  which  depend  upon  the  ossification  of  a 


node,  we  may  divide  this  class  of  tumours  as  fol- 
lows:— 

a.  Osteomata  developed  as  such  on  the  exte- 
rior of  a bone,  including  the  ivory  exostosis  — 
periosteal  exostoses. 

b.  Osteomata  developed  as  such  in  the  inte- 
rior of  a bone — enostoses. 

c.  Pedunculalcd  exostoses. 

d.  Osseous  tumours  of  the  soft  parts. 

e.  Osseous  tumours  produced  by  the  ossifica- 
tion of  other  kinds  of  new  growths. 

f.  And  lastly  (though  not  strictly  coming 
under  the  same  category)  the  odontomata. 

a.  Periosteal  exostoses. — These  are  irregular 
boDy  tumours,  appearing  usually  in  adult  life; 
they  are  directly  continuous  with  the  bone  from 
which  they  spring  ; and  are  composed  sometimes 
of  cancellous  structure,  with  a thin  coating  of 
compact  tissue,  but  much  more  frequently  of 
denser  material.  They  most  often  affect  the 
hones  of  the  face,  where  they  produce  horrible 
and  distressing  deformities : but  are  also  found 
on  the  skull,  in  the  meatus  of  the  ear,  or,  more 
rarely,  on  the  long  bones.  From  the  importance 
of  the  neighbouring  structures  it  is,  in  most 
cases,  impossible  to  remove  them.  Some  of  these 
tumours  are  of  extreme  density,  and  have  hence 
been  called  ivory  exostoses;  these,  when  they 
affect  the  upper  jaw,  their  commonest  seat,  must 
be  distinguished  from  the  odontomata,  to  be  pre- 
sently described. 

b.  Enostoses. — Enostoses  need  only  be  men- 
tioned in  order  to  point  out  their  extreme  raritv  ; 
but  it  may  be  remarked  that  many  of  the  last- 
described  series  of  tumours  probably  spring  from 
the  diploe  of  the  cranial  bones,  aud  should  thus, 
perhaps,  more  properly  be  included  under  this 
heading. 

c.  Pedunculated  exostoses. — The  pedunculated 
exostosis,  or  ossifying  chondroma,  is  a subperi- 
osteal chondroma,  with  a tendency  to  ossifica- 
tion, developed  in  young  people,  near  the  junc- 
tion of  an  epiphysis  with  a diaphysis. 

Pedunculated  exostoses  approach  the  spheri- 
cal shape,  hut  are  sometimes  irregular  or  flat- 
tish,  and  often  tuberculated.  The  peduncle 
varies  in  its  relative  size,  the  growth  being  often 
nearly  sessile.  On  section  the  tumour  shows  a 
layer  of  periosteum  superficially ; beneath  this  is 
a layer  of  cartilage,  sometimes  thick,  sometimes 
almost  imperceptible.  The  deeper  part  of  the 
cartilaginous  layer  is  calcified,  and  looks  like 
imperfectly-formed  bone.  The  centre  of  the 
tumour  consists  of  true  hone,  with  Haversian 
systems  complete,  and  is  directly  continuous 
with  the  tissue  of  the  bone  itself. 

The  microscopical  appearance  answers  exactly 
to  the  structure  which  is  apparent  to  the  naked 
eye  (fig.  104). 

Symptoms  and  Treatment. — Those  tumours 
occur  most,  often  near  the  ends  of  the  long  hones, 
but  may  he  found  elsewhere ; in  the  scapula,  for 
example.  They  are  often  multiple  and  symme- 
trical, and  if  multiple  are  often  hereditary.  In 
certain  situations,  as,  for  instance,  on  the  inner 
side  of  the  knees,  they  may  cause  much  incon- 
venience, and  for  this  reason,  or  from  their  size, 
they  may  require  removal.  This  may  be  done 
freely  if  antiseptic  precautions  be  adopted;  other- 
wise the  opening  of  the  cancellous  structure  of 


[To  face  page  1672. 


TUMOURS. 


Drawings  Illustrating  a Series  of  Tumours  of  the  Connective-tissue  Type.  All  drawn  to  the  same 

scale  ( x 87  diameters ). 


Fig.  103.  Mvxoma. 


Fig.  101.  Fibroma  (Neuroma). 


Fig.  102.  Polypus  of  Nose. 


Fig.  104.  Ossifying  Chondroma. 


Fig  106.  Enchondroma  (of  Orbit). 


Fig.  107.  Myeloid  of  Jaw. 


Fig.  109.  Small  Round-celled  Sarcoma. 


Fig.  111.  Lymphoma. 


Fig.  112.  Small  Spindle-celled  Sarcoma. 


Fig.  113.  Alveolar  Sarcoma. 


Fig.  108.  Large  Round-celled  Sarcoma. 


Fig.  110.  Oval-celled  Sarcoma. 


Fig.  114.  Mixed  Sarcoma. 

L 


Fig.  115.  Melanotic  Sarcoma.  Fig.  116.  Large  Spindle-celled  Sarcoma. 


Fig.  105.  Enchondroma  (of  Jaw). 


TUMOURS. 


the  bone,  and  the  danger  of  grounding  the  con- 
tiguous joint,  may  perhaps  involve  greater  risk 
than  the  amount  of  inconvenience  entailed  by 
the  tumour  would  justify.  They  have  sometimes 
been  either  purposely  or  accidentally  separated 
from  their  attachment  by  a blow,  without  inflict- 
ing a wound  on  the  soft  parts  at  all.  Unless  the 
whole  cartilage-layer  be  removed,  recurrence  will 
probably  occur,  as  growth  of  the  tumour  takes 
place  by  increase  of  this  layer  only,  the  process 
of  calcification  and  subsequent  ossification  being 
secondary  and,  so  to  speak,  accidental. 

d.  Osseous  tumours  of  the  soft  parts. — These  os- 
teomata are  also  uncommon.  They  include  such 
conditions  as  the  following: — tumours  springing 
from  the  periosteum,  but  not  actually  united  to 
the  bone  ; ossifying  chondromata  not  connected 
with  the  bone;  detached  exostoses;  ossification 
taking  place  in  muscles  or  tendons,  such  as  that 
which  is  occasionally  met  with  in  the  adductor 
longus  ; and  perhaps  some  other  varieties  of 
greater  rarity. 

e.  Osseous  tumours  produced  by  the  ossification 
of  other  kinds  of  new  growths. — These  are  only 
secondarily,  and  often  only  partially,  worthy  of 
the  name  of  osteomata ; they  are  the  result  of  a 
process  of  ossification  taking  place  in  tumours  of 
a different  nature  originally,  such  as  fibromas  or 
sarcomas.  It  must  be  remembered  that,  while 
calcification  of  new  growths  is  a common  form  of 
degeneration,  the  occurrence  of  true  ossification 
is  very  rare. 

f.  Odontomata.  - — Odontomata  are  tumours 
composed  of  one  or  more  of  the  constituents  of 
the  teeth.  The  simplest  variety  consists  of  a sort 
of  exostosis  from  the  fuDg.  These  are  usually 
of  small  size,  and  may  extend  from  one  tooth  to 
another.  Such  tumours  are  composed  altogether 
of  cement.  The  other  kind  is  more  or  less 
covered  with  enamel,  and  contains  dentine  and 
cement  in  varying  proportions ; these,  the  true 
odontomata,  may  sometimes  attain  a very  con- 
siderable size. 

5.  Papillomata. — DEFiNiTioN.-Papillary  and 
villous  over-growths,  whether  occurring  on  the 
mucous  membrane,  skin,  or  serous  membrane, 
which  do  not  present  malignant  characters. 

Varieties  and  Symptoms. — Mucous  papillo- 
mata are  found  on  the  lips,  tongue,  and  soft 
palate,  and  in  the  larynx ; in  the  intestines,  espe- 
cially at  the  lower  part ; round  the  anus  (condv- 
lomata) ; in  the  bladder  (the  simple  villous  tu- 
mour) ; on  the  conjunctiva ; and  at  the  orifice  of 
the  female  meatus  urinarius.  Epidermic  papillo- 
mata include  the  warts  and  corns,  and  may  occur 
on  any  part  of  the  skin ; those  about  the  exter- 
nal genitals  may  reach  an  enormous  size,  and  are 
frequently  the  result  of  gonorrheea.  The  serous 
and  synovial  papillomata  are  more  rare ; under 
this  class  must  be  named  the  Pacchionian  bodies, 
and  the  enlarged  synovial  fringes  which  areoften 
the  commencements  of  loose  bodies  in  joints. 
Many  papillomata  are  of  syphilitic  origin;  others 
may  be  caused  by  local  irritation,  as,  for  in- 
stance, the  dissecting-room  wart,  in  which  the 
papillary  growth  is  accompanied  by  inflamma- 
tion and  suppuration  beneath  the  skin. 

Naked-Eye  Appearances. — The  naked-eye 
appearances  vary  very  much  with  the  locality  in 
which  the  growth  is  developed  ; but  they  present 


1673 

this  character  in  common,  that  they  are  ob- 
viously composed  of  the  papillae  or  villi  of  the 
part  from  which  they  grow,  thougli  these  are  of 
much  more  than  the  natural  size.  Those  spring- 
ing from  mucous  and  serous  membraues  are  soft, 
and  usually  moist  on  the  surface  ; while  epider- 
mic papillomata  are  dry  and  hard. 

Micboscopicai,  Chakacters. — Microscopically 
papillomata  are  made  up  of  connective  tissue, 
containing  numerous  vessels,  covered  by  the 
characteristic  epithelium  or  epidermis  of  the 
part  (fig.  117,  p.  204).  The  arrangement  of  the 
connective  tissue  and  epithelial  elements  is  a close 
imitation  of  that  of  the  normal  tissues  from 
which  they  grow.  The  microscopical  structure 
of  the  benign  polypus  of  the  intestine  (fig.  120, 
p.  204)  is  hardly  to  be  distinguished  from  that  of 
many  malignant  growths  in  this  situation.  See 
Cancer — Glandular  epithelioma. 

Treatment. — If  affecting  the  larynx  or  bladder 
papillomata  may  give  rise  to  distressing  and  dan- 
gerous symptoms,  and  may  necessitate  severe  ope- 
rations for  their  extirpation.  Those  which  occur 
on  accessible  parts  are  generally  removed  with- 
out any  risk,  except  such  as  arises  from  their 
great  vascularity;  and  show,  as  a rule,  but  little 
tendency  to  recur  after  complete  removal.  The 
common  wart,  however,  often  gives  great  trouble : 
various  caustics  may  be  used,  such  as  the  acid 
nitrate  of  mercury,  fuming  nitric  acid,  caustic 
potash,  acetic  acid,  or  nitrate  of  silver,  but 
while  these  remedies  are  sometimes  efficacious, 
the  warts  will  often  recur  with  the  greatest  pos- 
sible inveteracy.  At  the  same  time  it  must  be 
remembered  that  they  frequently  show  a most 
capricious  tendency  to  spontaneous  cure;  the  sur- 
geon will  sometimes  be  mortified  at  finding  that 
while  his  energies  have  been  devoted  with  but 
partial  success  to  the  cure  of  one  or  two  out  of 
an  extensive  crop  of  these  growths,  the  remainder 
have,  in  the  meantime,  spontaneously  disap- 
peared. The  cadaveric  or  dissecting-room  wart 
is  best  treated  in  the  early  stages  by  soothing 
applications,  and  may  perhaps  be  cured  by  the 
external  use  of  belladonna : should  this,  how- 
ever, prove  unsuccessful,  the  employment  of  a 
caustic  must  be  resorted  to  ( sie  Post-Mortem 
Wounds).  The  best  local  treatment  for  condy- 
lomata  and  gonorrheeal  warts  is  the  application 
of  some  desiccating  powder,  such  as  dried  alum. 
It  is  well  to  remember  that  warts  which  remain 
a long  time  uncured  are  apt  to  take  on  an  epithe- 
liomatous  action  ; and  not  only  so,  but  that  any 
chronic  irritation,  whether  from  the  application 
of  insufficient  methods  of  cure  or  other  causes, 
is  likely  to  lead  to  the  same  result. 

6.  Adenomata. — Definition. — An  ill-defined 
group  of  tumours,  a typical  member  of  which 
is  essentially  non-malignant,  and  is  made  up  of 
tissue  exactly  resembling  that  of  the  gland  from 
which  it  springs;  but  the  departures  from  the 
ordinary  type  are  so  many  and  so  varied,  and,  at 
times,  so  indefinite,  that  it  becomes  impossible 
to  draw  a clear  line  between  the  adenomata  and 
the  carcinomata. 

(a)  Adenoma  of  the  Sweat-glands. — This  class 
is  said  to  include  some  non-ulcerating  cutaneous 
tumours  (the  tubular  epitheliomata  of  some 
authors);  and  some  ulcerating  ones — the  can- 
croids or  rodent  ulcers.  See  Rodent  Ulcer. 


TUMOURS. 


1674 

( b ) Adenoma  of  the  Sebaceous  Glands. — This  is 
a rare  tumour,  growing  on  different  parts  of  the 
tkin  ; the  most  usual  seat  being  the  nose,  when 
it  receives  the  popular  name  of  ‘ grog-blossom.’ 
This  forms  a nodular  purplish  tumour,  growing 
from  the  end  of  the  nose,  and  often  reaching  an 
enorpious  size.  When  cut  into  it  bleeds  freely, 
and  exudes  from  innumerable  cavities  in  its 
interior  an  inspissated  sebaceous  secretion.  Micro- 
scopically it  is  seen  that  the  connective  tissue 
and  the  vessels  are  hypertrophied,  as  well  as 
the  sebaceous  glands.  The  treatment  consists  in 
removal  by  the  knife ; and  cicatrisation  gene- 
rally occurs  with  wonderful  rapidity.  Recur- 
rence is  not  uncommon. 

(c)  Adenoma  of  the  Mucous  Glands. — Under 
this  heading  might  be  included  some  of  the  simple 
polypi  of  the  nose  (see  Fibromata).  The  best 
representation,  however,  is  the  simple  polypus 
of  the  rectum  ; this  is  a sessile  or  pedunculated 
roundish  tumour,  occurring  mostly  in  children 
and  young  subjects.  It  bleeds  freely  from  the 
surface,  and  is  often  the  cause  of  painful  and 
somewhat  troublesome  symptoms,  amongst  which 
prolapsus  ani  is  the  most  common.  Microscopi- 
cally it  consists  of  tissue  closely  resembling  that 
of  the  mucous  membrane  of  the  rectum,  but  the 
hypertrophied  follicles  are  often  imbedded  in  a 
tissue  very  similar  to  that  wltich  forms  the  basis 
of  the  mucous  polypus  of  nose  (fig.  120,  p.  204). 
The  treatment  is  by  removal  either  with  the  knife 
or  ligature,  or  some  form  of  snare  or  ecraseur. 
Recurrence  does  not,  as  a rule,  take  place. 

As  is  stated  in  the  article  Cancer,  and  as  is 
shown  in  figs.  120  and  121,  p.  204,  it  is  often 
almost  impossible  to  distinguish,  by  their  micro- 
scopical appearances,  the  simple  adenomata  of 
the  large  intestine  from  the  malignant  growths 
affecting  the  same  structures.  The  same  observa- 
tion applies  to  many  tumours  of  the  jaws,  such 
as  that  in  fig.  128,  p.  204,  which,  though  classed 
amongst  the  adenoids,  often  exhibit  a high  de- 
gree of  malignancy. 

( d ) Adenoma  of  the  Breast. — The  most  typical 
adenoma  of  the  breast  is  a rounded  tumour  of 
moderate  size,  occurring  often  at  the  margin  of 
the  gland  and  frequently  near  the  axillary  border, 
completely  encapsuled,  and  consisting  of  tissue 
which  hardly  differs  from  ordinary  mammary 
structure  (fig.  130,  p.  204.)  It  occurs  usually  in 
young  women,  often  during  the  child-bearing 
period.  It  shows  no  tendency  to  recur  after  re- 
moval. A large  number  of  adenoids  of  the  breast 
do  not,  however,  agree  with  this  description, 
either  as  regards  position  or  structure.  In  struc- 
ture departure  may  take  place  from  the  normal 
type  in  two  directions  ; by  an  excessive  or  ab- 
normal development  either  of  the  epithelial  or  of 
the  connective-tissue  elements.  In  the  former 
case  the  tumour,  in  proportion  to  its  abnormality, 
approaches  the  cancers  ; in  the  latter  it  assumes 
more  and  more  closely  the  characters  of  the  sar- 
comas. Thus  we  find  some  of  the  softer  adeno- 
mata, as  shown  in  fig.  131,  p.  204,  exhibiting 
a tendency  to  recur  after  removal,  in  the  same 
way  as  a carcinoma,  and  with  an  almost  equal 
degree  of  malignancy  ; while  others,  presenting 
characters  like  those  of  fig.  132,  p.  204,  may 
follow  the  same  course  as  a sarcoma.,  ooth  as 
regards  the  manner  of  involving  surrounding 


tissues,  and  the  way  in  which  they  recur  in  the 
viscera.  These  latter  are  called  adcnosarcomcta, 
and  often  attain  an  enormous  size.  If  the  stroma 
of  one  of  these  tumours  be  in  large  amount, 
and  fibrous  or  myxomatous,  the  names  of  fibro- 
adenoma and  inyxo-adenoma  may  he  applied. 
Adenomata  often  contain  cysts,  and  these  cysts 
not  unfrequently  intraeystic  growths.  They 
must  be  treated  by  removal  of  the  growth. 

The  reader  must  be  content  with  the  fore- 
going approximate  description  of  this  important 
class  of  tumours,  the  varieties  in  the  nomencla- 
ture of  which  are  equal  to  the  number  of  the 
authors  who  have  written  on  the  subject.  The 
writer  believes  that  much  unnecessary  con- 
fusion has  been  caused  by  this  multiplication 
of  names,  for  a detailed  account  of  which  spe- 
cial works  must  be  consulted,  as  their  discussion 
would  lead  far  beyond  the  limits  of  the  present 
article. 

(e)  Other  forms  of  adenoma. — Amongst  other 
rarer  forms  of  adenoma,  hearing  a more  or  less 
close  relationship  to  the  glands  from  which  they 
spring,  may  bo  enumerated  the  following:  ade 
nomata  cf  the  testicle  or  ovary,  of  the  salivary 
and  lachrymal  glands,  of  the  liver,  and  some 
tumours  of  the  thyroid.  Tumours  of  the  thy- 
roid, however,  are  in  most  cases  simply  hyper- 
trophies of  the  gland  itself,  and  should  there- 
fore be  classed  with  simple  hypertrophy  of  the 
breast  and  ordinary  enlarged  prostate,  rather 
than  with  the  tumours  now  under  discussion.  It 
should  be  noted  that  many  of  the  less  typical 
adenomata,  especially  those  of  the  salivary  glands 
and  the  testicle,  frequently  are  found  in  combi- 
nation with  other  heteroplastic  growths,  such  as 
chondroma,  myxoma,  or  some  form  of  sarcoma. 

7 . Lymphom  a. — Under  certai n circumstances, 
for  an  account  of  which  the  reader  is  referred  to 
the  article  Lvmphadenojia,  the  lymphatic  glands 
throughout  tho  body  become  enlarged,  forming 
tumours,  often  of  enormous  size.  Occasionally 
these  growths  assume  a more  malignant  charac- 
ter, involving  the  parts  in  the  neighbourhood 
of  the  glands  from  which  they  spring,  and 
being  followed  by  the  appearance  of  secondary 
growths  in  other  parts  of  the  body.  To  such  a 
condition  as  this  the  term  lymphoma  has  been 
applied.  The  glands  are  soft,  aud  in  the  early 
stages  easily  moveable  amongst,  or  removable 
from,  the  surrounding  tissues ; in  colour  they 
are  a yellowish-white,  as  also  are  the  secondary 
growths.  Microscopically  they  show  the  struc- 
ture of  an  ordinary  lymphatic  gland,  which,  it 
will  be  observed  (fig.  Ill),  differs  from  that  of  a 
small  round-celled  sarcoma  only  in  the  fact  that 
the  stroma  is  much  more  definite  aud  charac- 
teristic. 

8.  Myoma. — Definition. — A tumour  com 
posed  of  muscular  tissue. 

With  certain  very  rare  exceptions,  the  only 
form  of  muscle-tissue  occurring  as  an  integral 
part  of  a tumour,  is  the  unsiriped  variety ; and 
almost  the  only  position  in  which  this  is  found 
is  in  the  so-calied  ‘fibroma’  of  the  uterus.  This 
growth  consists  of  a mixture  of  fibrous  tissue, 
with  plain  muscular  fibres  in  varying  amount, 
usually  exhibiting  the  concentric  arrangement  ol 
its  elements,  which  was  described  as  character- 
istic of  fibromas  generally.  Fibromata  of  th« 


TUMOURS.  1675 


aterus  may  form  pedunculated  tumours  on  the 
external  or  internal  surface  of  the  uterus,  or 
they  may  not  extend  beyond  the  uterine  wall. 
They  give  rise  to  a variety  of  special  symptoms, 
and  require  special  methods  of  treatment,  which 
it  is  beyond  the  scope  of  this  article  to  discuss. 
See  Worn,  Diseases  of. 

Striped  muscular  fibre  has  been  found  in  a few 
cases  of  congenital  tumour  of  the  kidneys,  and 
the  writer  has  also  seen  it  in  a fatty  tumour 
growing  inside  the  spinal  canal. 

9.  Neuromata. — Definition. -Tumours  com- 
posed essentially  of  any  form  of  nerve-tissue. 

The  majority  of  neuromas  are  really  fibromas, 
that  is,  fibrous  tumours  developed  amongst  and 
around  the  fibres  of  the  nerve  from  which  they 
6pring.  The  idiopathic  forms  are  sometimes 
single,  but  generally  multiple,  of  small  size,  very 
hard,  and  affecting  usually  the  branches  of  a 
particular  cutaneous  nerve.  The  amount  of  pain 
and  tenderness  caused  by  these  growths  varies 
very  much,  but  is  sometimes  excessive.  A clinical 
feature  of  some  use  in  diagnosis  is  the  fact  that 
they  usually  move  readily  in  the  lateral,  but  very 
imperfectly  in  the  vertical  direction.  What  may 
bo  called  traumatic  neuromata,  are  fibromas  de- 
veloped at  the  end  of  a divided  nerve  in  a stump. 
These  often  cause  excessive  pain,  and  peculiar 
reflex  phenomena,  and  show  a remarkable  ten- 
dency to  recur  after  removal. 

It  must  not  be  forgotten  that  less  simple  tu- 
mours not  unfrequently  affect  nerves,  such  as  the 
various  forms  of  sarcoma,  or  myxoma.  No 
special  description  of  these  growths  in  this  situa- 
tion is,  however,  required. 

10.  Angioma.— Stnon. : Teleangiectasis. 

Definition.- — A tumour  composed  of  blood- 
vessels. 

Angiomata  divide  themselves  naturally  into 
those  in  which  the  capillary  element  predomi- 
nates ; and  those  which  are  chiefly  made  up  of 
vessels  of  larger  size. 

a.  Capillary  angiomata. — Description. — These 
are  the  navi,  which,  while  they  sometimes  form 
tumours  of  some  magnitude,  often,  as  in  the  case 
of  so-called  ‘claret-cheek,’  involve  no  increase  in 
the  size  of  the  affected  part.  Nsevi  are  nearly 
always  congenital,  hence  the  term  ‘ mother’s 
mark.’  They  may  be  subdivided  into  cutaneous 
and  subcutaneous  nsevi.  The  former  are  of  a 
more  or  less  bright  red  colour,  and  affect  only 
the  cutaneous  structures ; the  latter,  as  seen 
through  the  skin,  in  cases  where  this  remains 
unaffected,  have  a purplish  tint,  and  may  involve 
any  of  the  deeper  structures  of  the  body.  Very 
commonly,  however,  the  subcutaneous  nsevus  in- 
volves the  skin  as  well.  Nsevi  often  grow  with 
extreme  rapidity,  and  though  they  involve  no 
danger  to  life,  may  cause  serious  inconvenience 
and  great  disfigurement.  Sometimes,  however, 
they  exhibit  a tendency  to  spontaneous  disap- 
pearance. and  often  they  remain  permanently 
stationary.  They  are  liable  to  various  forms  of 
degeneration,  notably  the  cystic,  and  the  ulcera- 
tive or  suppurative. 

Microscopically  a nsevus  is  composed  of  large 
capillaries,  amongst  which  are  seen  arterial  and 
venous  trunks  of  larger  size.  Between  the  vessels 
are  found  connective  tissue  or  fat,  and  sometimes 
the  special  constituents  of  the  skin,  such  as  sweat 


or  sebaceous  glands.  It  must  be  remembered 
that  the  naevus-element  enters  rather  largely  into 
the  composition  of  some  other  tumours,  and  nota- 
bly of  congenital  moles  ( benignant  melanoses). 

Treatment. — Inflammation  of  a nsevus  gene- 
rally leads  to  spontaneous  cure ; nature  thus 
suggesting  one  of  the  best  methods  of  treatment 
at  the  disposal  of  the  surgeon,  namely,  the  in- 
jection of  the  tumour  with  some  suitable  irritant, 
such  as  carbolic  acid.  In  adopting  this  line  of 
treatment,  it  must  be  remembered  that  a danger 
exists  of  the  irritating  fluid  entering  a larger 
vessel,  and  by  passing  to  the  heart  and  setting 
up  coagulation  there  causing  instant  death ; this 
may  be  guarded  against  by  the  application  of  a 
temporary  ligature.  Other  recognised  and  use- 
ful plans  of  treatment  are  the  following : — the 
ligature,  pressure,  the  application  of  caustics  — 
and  especially  fuming  nitric  acid,  galvano-punc- 
ture,  puncture  with  the  actual  cautery,  and  com- 
plete excision  of  the  mass. 

b.  Cavernous  angiomata. — Description. — Those 
angiomata  which  are  made  up  of  larger  vessels, 
and  which  are  hence  called  the  cavernous  angio- 
mata, from  their  resemblance  in  structure  to  erec- 
tile tissue,  consist  of  cavernous  spaces,  communi- 
cating by  smaller  or  larger  vessels,  and  separated 
by  trabeculae  of  greater  or  less  thickness  and 
substance.  These  are  the  pulsating  navi,  and 
perhaps  some  of  the  so-called  aneurisms  by 
anastomosis.  They  are  of  a more  dusky  colour 
than  simple  nsevi,  and  often  present  a distinct 
thrill  or  bruit,  which  is  perceptible  both  to  the 
patient  and  .to  the  surgeon.  They  are  sometimes 
encapsuled,  sometimes  diffused ; and  in  the  latter 
case  show  an  almost  malignant  tendency  to  in- 
volve neighbouring  structures.  The  pulsation  is 
often  a most  distressing  symptom  to  the  patient, 
if  the  tumour  be  found  occupying  such  positions 
as  the  pinna  of  the  ear  or  the  fat  of  the  orbit, 
both  of  which  situations  are  not  at  all  uncommon 
for  the  occurrence  of  the  disease.  Microscopically 
a cavernous  angioma  presents  fibrous  trabe- 
culse,  lined  with  the  characteristic  vascular  endo- 
thelium, and  in  parts  perhaps  separated  by 
layers  of  areolar  or  any  other  tissue  which  the 
tumour  may  be  involving. 

Treatment. — The  treatment  must  he  pursued 
on  the  same  lines  as  that  for  the  simple  forms  of 
nsevus. 

11.  Lymphangioma. — Definition. — A rare 
kind  of  tumour,  which  may  briefly  he  described 
as  a cavernous  angioma  made  up  of  lymphatic 
vessels. 

To  this  class  belong,  in  all  probability,  the 
cystic  hygromas  occasionally  met  with  congeni- 
tally, forming  large  masses  'in  the  neck,  beneath 
the  tongue,  on  the  upper  extremities,  or,  rarely, 
in  other  parts  of  the  body.  Our  knowledge  of 
the  pathology  and  treatment  of  these  tumours  is 
at  present  very  imperfect,  and  the  literature  on 
the  subject  is  extremely  meagre.  The  reader  is 
referred,  for  an  account  of  all  forms  of  angio- 
mata, to  the  fourth  volume  of  Virchow’s  Krank- 
haften  Geschwi'dste. 

B.  Sarcomata. — Definition. — It  is  to  be 
regretted  that  the  term  Sarcoma  has  not  been 
allowed  to  slip  out  of  pathological  terminology. 
From  the  days  of  Galen  almost  to  our  own  time 
it  has  served,  in  the  hands  of  different  authors, 


TUMOUES. 


1676 

to  designate  different  classes  of  tumours,  some- 
times of  the  simplest,  sometimes  of  the  most 
malignant  character.  Virchow,  however,  has 
given  a meaning  to  the  word,  which  is  now 
generally  recognised  hy  pathologists.  He  in- 
cludes under  sarcomas  those  new  growths  which, 
while  they  do  not  actually  consist  of  any  of  the 
tissues  of  the  adult  body,  are  evidently  built 
on  the  connective-tissue  type,  and  consist  of  a 
modification  of  the  connective  tissue  of  the  em- 
bryo. They  are  thus  very  closely  related  to  some 
of  the  simple  tumours,  and  indeed  often  include 
portions  of  some  normal  tissue,  such  as  bone, 
cartilage,  or  fibrous  tissue — a fact  which  neces- 
sitates the  employment  of  complicated  and  con- 
fusing names,  including  Ostco-sarcoma , Chondro- 
sarcoma, Fibrosarcoma,  and  such-like. 

Microscopical  Characters.—  Histologically, 
then,  a sarcoma  is  made  up  simply  of  cells  of  the 
connective-tissue  type,  which  may  assume  very 
various  shapes  and  sizes  in  different  tumours, 
and  which  are  surrounded  by  a varying  amount 
of  intercellular  substance. 

Clinical  Characters. — Theoretically  sarco- 
mata should  always  be  developed  in  one  of  the 
connective-tissue  structures,  and  practically  they 
are  not  very  often  seen  to  originate  in  a secret- 
ing gland.  But  a glandular  origin  is  not  by 
any  means  very  uncommon,  as  indeed  might  have 
been  expected  when  it  is  remembered  that  every 
gland  contains  a considerable  amount  of  con- 
nective tissue.  Sarcomas  present  all  degrees  of 
malignancy ; but,  as  a rough  rule,  it  may  be  stated 
that  the  higher  the  degree  of  development  of  the 
tumour  the  less  likely  is  recurrence  to  take 
place  after  removal.  In  connection  with  this 
point  it  is  interesting  to  note  that  each  recur- 
rence cf  a sarcoma  often  shows  a more  rudimen- 
tary structure,  but  at  the  same  time  a greater 
degree  of  malignancy. 

Eeeurrence  does  not  follow  the  same  rule  that 
has  been  observed  in  the  case  of  cancer.  The 
lymphatic  glands  often  escape  altogether,  or  are 
but  slightly  affected;  while  fresh  tumours  spring 
up  in  abundance  in  distant  parts  of  the  body. 

Sarcomas  increase  in  size  in  the  same  way  as 
cancers,  but  in  the  less  malignant  forms  are 
often  surrounded  by  a more  or  less  distinct  cap- 
sule. 

Naked-Eve  Appearances. — The  naked-eye 
appearances  of  sarcomata  are  subject  to  very 
wide  variations.  It  may,  however,  be  observed 
that  they  never  present  the  hollowed  surface  on 
section  which  is  characteristic  of  some  cancers; 
and  thpy  do  not,  except  in  the  case  of  the  softest 
tumours,  exude  a milky  juice  on  scraping.  Sar- 
comata are  well  supplied  with  vessels. 

Varieties. — 1.  Round-celled  Sarcomata. — 
These  are  the  most  rudimentary,  and,  as  a rule,  the 
most  malignant  of  this  class.  They  are  usually 
eoft — sometimes  very  soft,  seldom  encapsuled, 
and  generally  of  a whitish  colour.  Formerly 
they  were  classed  amongst  the  medullary  can- 
cers. They  are  made  up  of  round  cells,  as  the 
name  implies,  and  have  a tendency  to  group 
themselves  into  two  classes,  in  one  of  which  the 
cells  are  small  and  uniform  in  size  (fig.  109), 
closely  resembling  those  of  granulation-tissue ; 
and  in  the  other  large,  and  sometimes  very  large, 
and  often  somewhat  irregular  (fig.  108).  The 


intercellular  substance  may  be  copious  and  homo- 
geneous, in  which  case  the  tumour  approaches 
the  myxomata ; or  smaller  in  amount  and  fibrous, 
when,  if  the  cells  are  small,  it  may  be  difficult  to 
separate  such  a sarcoma  from  the  lymphomata. 

Under  this  head  must  be  placed  the  Gliomata — 
soft  medullary  tumours  connected  usually  with 
nerves,  frequently  with  the  retina,  and  occurring 
commonly  in  children.  They  show  microscopic- 
ally a delicate  stroma. 

2.  Oval-celled  Sarcomata. — This  variety  of  sar- 
coma represents  the  next  stage  in  advance  from 
the  simplest  towards  a more  complex  structure. 
They  differ,  in  fact,  but  slightly  from  the  round- 
celled  growth,  either  in  clinical  or  in  microsco- 
pical characters  (fig.  110),  but  may  be  looked 
upon  as  intermediate  between  these  and  the 
spindle-celled  sarcomas. 

3.  Spindle-celled  Sarcomata. — This  class  must 
be  sub-divided  into  the  small  spindle-celled  and 
the  large  spindle-celled  varieties. 

The  small  spindle-celled  sarcomata  are  firm, 
whitish,  well-defined  tumours,  which  approach 
the  fibromata,  sometimes  very  closely,  and  which 
after  complete  removal  show  a comparatively 
slight  tendency  to  recur.  These  wc-re  the  recur- 
rent fibroids  of  older  writers,  and  are  the  fibro- 
sarcomata of  the  present  day.  Microscopically 
(fig.  112)  they  consist  of  broad  interlacing  bands 
of  elongated  cells,  with  but  little  intercellular 
material — a structure  which  does  not  differ 
widely  from  imperfectly-formed  fibrous  tissue. 

The  large  spindle-celled  sarcomata  (fig.  116)  is 
a softer  growth,  frequently  supplied  with  a 
very  imperfect  capsule,  generally  pinkish  on 
section,  or  stained  in  parts  dark  red  from  extra- 
vasated  blood,  and  often  showing  cysts.  It  may 
occur  in  any  fibrous  structure,  but  is  rather 
common  in  connection  with  the  periosteum.  The 
malignancy  of  these  growths  is  much  greater 
than  that  of  the  small-celled  class.  A/feroseo- 
pically  they  consist  of  very  large  nucleated  cells, 
with  long  tapering  tails,  and  but  little  inter- 
cellular substance.  These  are  the  fibro-plastic 
tumours. 

4.  Alveolar  Sarcomata. — Microscopically  thie 
rare  form  of  tumour  (fig.  113)  bears  a super 
ficial  resemblance  to  tnat  of  a cancer.  Thero 
is,  that  is  to  say,  a coarse  stroma  forming  al- 
veolar spaces,  each  of  which  contains  a variable 
number  of  large,  round,  nucleated  cells  ; eaeh 
space  is,  however,  again  sub-divided  by  a very 
delicate  secondary  intercellular  stroma.  This  is 
only  demonstrable  on  pencilling  out  the  cells, 
which,  unlike  a similar  process  applied  to  a can- 
cer, is  a work  of  considerable  difficulty.  Alveolar 
sarcomas  affect  most  commonly  subcutaueous  tis- 
sues primarily ; they  are  apt  to  recur  in  other 
parts  of  the  body,  and  ultimately  in  internal 
organs,  but  often  rim  a very  chronic  course. 

5.  Mired  Sarcomata. — Tumours  are  often  met 
with  which  present  a mixture  of  the  different 
structures  just  described.  Such  are  conveniently 
called  mixed  sarcomata  ; and  the  term  may  with 
advantage  be  made  to  include  those  growths 
which  contain,  besides  sarcoma-tissue,  bone,  car- 
tilage. gland-tissue,  and  what  not.  The  latter 
growths  will  necessitate  the  employment  of  such 
names  as  osteo-sarcoma,  chondro-sarcoma,  adeno- 
sarcoma,  &c. 


TUMOURS. 

t3.  Myeloid. — Synon.  : Giant-celled  Sarco- 
mata.— These  tumours  are  best  classed  amongst 
the  sarcomata.  Microscopically  (fig.  107)  they 
present  the  following  elements,  one  or  other  of 
which  may  greatly  predominate:  fibroplastic 
or  spmdle-cells,  oval  or  round-cells,  and  very 
large  nucleated  cells,  the  so-called  ‘ myeloid  ’ 
or  ‘ giant  ’ cells.  These  last  are  irregular  or 
rounded  collections  of  granular  protoplasm,  in 
which  occur  numerous  clear  oval  nuclei,  contain- 
ing a well-marked  nucleolus.  The  amount  of 
intercellular  substance  is  small.  In  a fresh 
scraping,  the  clear  oval  nuclei  are  set  free  by 
the  breaking  up  of  the  giant-cells.  To  the 
naked  eye  a section  of  a myeloid  tumour  is  pink 
or  yellowish,  but  almost  always  mottled  with 
darker  spots,  the  result  of  extravasations  of 
blood.  Very  frequently  they  present  points  of 
ossification  or  calcification,  and  not  unfrequently 
cysts.  They  are  very  soft,  and  usually  yield  a 
thick  juice  on  scraping.  They  generally  origi- 
nate in,  or,  more  rarely,  close  to,  the  end  of  one 
of  the  long  bones ; probably  most  often  in  the 
medullary  cavity  or  the  cancellous  structure. 
Another  frequent  seat  is  the  alveolar  border  of 
the  jaws,  where  they  form  the  myeloid  epulis. 
They  occur  most  often  in  young  people,  and  if 
the  bone  involved  be  removed  completely  or  in 
great  part,  have  no  tendency  to  recur  ; but  in 
rare  cases  they  may  exhibit  a high  degree  of 
malignancy,  recurring  not  only  in  other  bones, 
but  in  internal  organs. 

7.  Myxoma. — It  is  not  easy  to  say  whether 
myxomata  should  be  classed  amengst  the  sarco- 
mata or  amongst  the  simple  tumours.  On  the 
one  hand,  the  tissue  of  which  a myxoma  is  com- 
posed finds  no  representative  in  the  adult ; but, 
on  the  other,  they  approach  very  closely  some  of 
the  soft  fibromata,  and  are  nearly  related  to  fatty 
tumours.  At  the  same  time  a large  number  of 
myxomas  appear  to  be  actual  chondromata. 

Microscopically  (fig.  103)  a myxoma  presents 
elongated  or  roundish  much-branched  cells,  the 
prolongations  of  which  intercommunicate  freely. 
These  cells  are  imbedded  in  a copious,  homo- 
geneous, transparent  matrix.  The  structure  thus 
resembles  that  of  fcetal  fat. 

Clinically  these  tumours  are  very  coft  and 
elastic,  strictly  encapsuled,  gelatinous,  semi- 
transparent on  section,  and  exuding  a peculiar 
mucous  juice.  Myxomata  are  not  malignant ; 
and  as  a rule,  if  completely  removed,  do  not 
recur  locally.  They  may  be  found  in  many  parts 
of  the  body,  but  perhaps  most  frequently  in  the 
subcutaneous  tissue,  in  connection  with  some 
gland,  particularly  the  parotid.  Here,  however, 
they  are  often  mixed  with  adenoid  and  cartila- 
ginous material.  Not  unfrequently  myxoma- 
tissue  is  combined  with  that  of  an  undoubted 
sarcoma,  which  necessitates  the  term  myxosar- 
coma. These  tumours  may  occasionally  be  mis- 
taken for  colloid  cancers.  Histologically  some 
of  the  soft  enchondromata  resemble  them  very 
closely. 

8 and  9.  Osteo-Sarcoma ; and  Chondro-Sar- 
conia. — These  forms  of  sarcoma  have  just  been 
referred  to  under  the  head  of  Mixed  Sarcoma. 

10.  Melanotic  Sarcomata. — These  tumours  are, 
in  the  experience  of  the  writer,  usually  of  the 
mixed,  round,  and  spindle-celled  variety.  Some, 


TYLOSIS.  1677 

but  not  all,  of  the  cells  contain  a brown  pig- 
ment, but  in  very  varying  amount  (fig.  116). 
This  gives  the  tumour  a brown  or  blackish  ap- 
pearance. These  tumours,  though  often  com- 
pletely encapsuled,  show  a high  degree  of  ma- 
lignancy ; but  are  often  succeeded  by  a mix- 
ture of  white  and  black  tumours,  or  sometimes 
by  white  tumours  alone.  They  are  not  un- 
common in  connection  with  the  choroid  of  the 
eye,  and  as  affecting  the  papillm  of  the  skin 
(malignant  mole),  but  have  often  been  met  with 
primarily  in  other  parts  of  the  body.  The 
secondary  growths  are  often  found  disseminated 
through  every  tissue  of  the  body,  forming  tu- 
mours in  such  situations  as  the  intestine,  of 
peculiar  and  characteristic  appearance.  It  has 
been  observed  that  in  some  cases  of  melanosis 
the  presence  of  black  pigment,  accompanied  with 
other  morbid  appearances,  has  been  found  in  the 
blood  and  also  in  the  urine. 

11.  Psammoma.  — It  is  only  necessary  to 
mention  this  very  rare  tumour,  which  is  found 
only  in  connection  with  the  membranes  of  the 
brain.  It  is  composed  of  flattened  cells,  and  is 
characterised  by  the  peculiarity  of  containing 
brain-sand  in  its  interior.  It  seldom  or  never 
gives  rise  to  symptoms. 

12.  Teratoma. — Mention  must  be  made,  in 

conclusion,  of  a form  of  growth,  which  does  not 
come  within  the  classification  here  selected. 
This  is  a congenital  tumour  not  unfrequently 
met  with  in  the  region  of  the  sacrum  (congenital 
sacral  tumour ),  but  occasionally  seen  elsewhere  ; 
often  reaching  a size  almost  equal  to  that  of  the 
infant  itself.  In  structure  these  tumours  con- 
sist of  various  imperfectly  developed  fetal  or 
mature  elements  of  the  body  mixed  together  in 
apparently  great  confusion.  Various  theories  as 
to  their  causation  have  been  propounded;  such. 
e.g.,  as  that  they  consist  of  an  imperfect  attached 
fetus,  or  that  they  originate  from  Luschka’s 
gland  ; but  we  have  not  sufficient  data  at  present 
to  express  an  opinion  on  this  point.  Attempts 
at  their  cure  by  removal  are  attended  with  great 
danger.  K.  J.  Godlee. 

TUNBRIDGE  WELLS,  in  Kent. — Iron 
waters.  See  Mineral  Waters. 

TUNNEL  WORM. — A synonym  for  the 
Sclerostoma  duodenale.  See  Sclerostoma. 

TURGESCENCE  ( turgesco , I swell). — A 
term  applied  to  a swollen  condition  of  apart,  gene- 
rally associated  with  fulness  of  the  blood-vesselsi 
as  in  the  mucous  membrane  of  the  conjuctiva, 
the  fauces,  or  the  rectum.  See  Swelling. 

TUSSIS  (Latin). — A synonym  for  cough.  See 
Cough. 

TUSSIVE. — This  word  is  applied  to  certain 
physical  signs  which  are  elicited  by  the  act  of 
coughing,  such  as  tussive  fremitus  and  tussive 
resonance.  See  Physical  Examination. 

TYLOSIS  (t v\6o>,  I make  hard  or  callous.) 
Synon.  : Callosity. 

Definition. — Thickenings  of  the  epidermis, 
occurring  on  parts  of  the  body  that  are  habitually 
subjected  to  pressure  or  friction.  Tylosis  is 
found,  for  example,  on  the  feet,  from  the  wearing 


1078  TYLOSIS, 

of  shoes ; on  the  hands,  from  rowing  or  the 
constant  use  of  some  implement  or  tool ; and  on 
other  parts  of  the  body  unduly  submitted  to 
pressure.  A corn  begins  by  being  a callus  or 
laminated  corn,  and  only  rightfully  acquires  the 
title  of  corn  when  it  has  forced  itself  at  a given 
point  against  the  derma,  and  has  depressed  the 
latter  to  a greater  or  less  extent,  thereby  pro- 
ducing pain  and  suffering.  Callosities  are  in- 
convenient rather  than  painful;  but  occasion- 
ally the  inconvenience  is  so  great  as  to  make  the 
resort  to  treatment  necessary. 

Treatment.  — The  best  remedy  tinder  the 
above  circumstances,  is  the  removal  or  avoidance 
of  the  cause.  Next  to  this,  the  hardened  cuticle 
may  be  softened  by  soaking  in  hot  water,  or  by 
means  of  a water-dressing,  and  afterwards  scraped. 
Or  it  may  be  painted  over  with  the  liniment  of 
iodine  daily,  until  the  excess  of  cuticle  exfoliates 
in  laminae  and  flakes.  In  either  case,  the  skin 
must  be  subsequently  protected,  in  order  to  pre- 
vent it  from  retrograding  into  its  former  state. 

Erasmus  Wilson. 

TYMPANITES  ( tympanum , a drum). — 
Synon. : Fr.  Tympanites  Ger.  Windsucht. — This 
word  is  associated  "with  the  distension  of  the 
abdomen  that  results  from  excessive  accu- 
mulation of  gas  within  its  cavity.  As  a rule, 
the  gas  collects  in  the  interior  of  the  alimentary 
canal,  especially  the  intestines;  but  in  exceptional 
cases  it  occupies  the  peritoneal  cavity. 

./Etiology. — Tympanites  is  chiefly  met  with 
under  the  following  circumstances  : — 1.  In  con- 
nection with  certain  diseases  which,  from  their 
local  effects,  tend  to  paralyse  the  intestines, 
especially  acute  peritonitis,  typhoid  fever,  and 
dysentery.  2.  In  cases  of  intestinal  obstruction 
from  any  cause,  but  particularly  when  this  con- 
dition is  acute.  3.  In  certain  low  febrile  diseases, 
accompanied  with  the  ‘typhoid  state,’  and  tend- 
ing towards  a fatal  issue,  such  as  typhus  fever, 
small-pox,  erysipelas,  and  typhoid  pneumonia. 
4.  As  the  result  of  perforation  of  the  alimentary 
canal.  5.  In  certain  cases  of  chronic  disease  of 
the  spinal  cord,  of  which  the  writer  lias  seen  a 
marked  example.  6.  In  connection  with  hysteria, 
sometimes.  In  all  these  conditions,  except  where 
the  gas  escapes  into  the  peritoneal  cavity,  the 
immediate  cause  of  the  tympanites  is  a paralysed 
state  of  the  walls  of  the  intestines  ; but  there  is 
often,  at  the  same  time,  an  excessive  formation 
of  gas. 

Symptoms. — The  symptoms  of  tympanites  are 
due  to  the  mechanical  effects  of  the  accumulation 
of  air.  The  patient  is  usually  conscious  of  the 
distension  of  the  abdomen,  and  the  sensation 
may  amount  to  extreme  discomfort  or  actual  suf- 
fering and  great  distress,  there  being  a feeling 
as  if  the  abdomen  must  burst  if  the  condition  is 
not  relieved.  The  mental  state  of  the  patient 
may.  however,  be  such  that  he  is  unconscious  of, 
or  indifferent  to,  any  unusual  sensations.  Breath- 
ing is  often  interfered  with  in  various  degrees, 
and  the  act  may  be  very  hurried,  with  a feeling 
of  urgent  dyspnoea.  The  heart  is  also  liable  to 
be  affected,  and  its  action  more  or  less  dis- 
turbed. The  secretion  of  urine  may  be  impeded, 
even  almost  to  actual  suppression. 

Physical  Signs.— Those  are  usually  very  cha- 


TYTHOID  FEVER. 

racteristic.  1.  The  abdomenis  uniformly  enlarged, 
often  to  an  extreme  degree  ; being  of  a rounded 
shape  ; equal  and  symmetrical  in  every  part, 
unless  there  happen  to  be  a portion  of  bowel  un- 
duly distended,  and  without  any  tendency  to  pro- 
jection in  dependent  parts.  The  skin  is  stretched 
more  or  less,  but  there  is  no  protrusion  of  the 
umbilicus.  2.  The  sensations  on  palpation  are 
those  of  perfect  smoothness  and  regularity,  with 
tension  or  a drum-like  feel.  3.  Percussion  gives 
a general  tympanitic  sound  over  the  abdomen, 
and  also  brings  out  the  drum-like  sensation.  It' 
ths  distension  is  extreme,  however,  the  sound 
becomes  more  or  less  muffled  and  dull.  Fre- 
quently the  dulness  of  the  solid  organs  in  the 
abdomen  is  partially  or  entirely  obscured,  or  is 
displaced  upwards.  4.  Change  of  posture  pro  • 
duces  no  alteration  in  the  physical  signs.  5. 
There  may  he  signs  of  displacement  of  the  tho- 
racic organs.  It  must  be  mentioned  that  tym- 
panites may  be  associated  witli  some  fluid  in  the 
peritoneal  cavity,  or  with  other  conditions,  and 
the  physical  signs  will  be  modified  accordingly. 

Treatment. — In  the  first  instance,  any  direct 
cause  of  tympanites  must  be  removed,  if  prac- 
ticable, such  as  intestinal  obstruction.  If  the 
symptom  calls  for  direct  treatment,  relief  may 
be  afforded  in  some  cases  by  applying  heat 
over  the  abdomen  ; and  administering  internally 
such  remedies  as  brandy,  aromatic  spirits  of  am- 
monia, the  various  ethers,  camphor,  musk,  sum- 
bul,  galbanum,  assafoetida  or  other  gum-resins. 
Should  these  fail,  enemata  containing  assafoetida 
or  turpentine  may  sometimes  be  used  with  ad- 
vantage. The  passage  of  a long  tube  through 
the  anus  into  the  bowel,  reaching  as  high  up  as 
possible,  such  as  an  cesophagus-tube,  is  often 
very  serviceable.  In  extreme  cases  it  is  allow- 
able to  puncture  the  large  bowel  in  several  points 
by  me.ans  of  a very  small  trochar,  and  thus  af 
ford  an  exit  for  the  contained  gas. 

Frederick.  T.  Roberts. 

TYMPANITIC  {tympanum,  a drum). — A 
peculiar  drum-like  quality  of  sound  elicited  by 
percussion  ( see  Physical  Examination).  The 
term  is  also  applied  to  the  abdomen,  when  it  is 
distended  with  gas.  See  Tympanites. 

TYMPANUM,  Diseases  of.  See  Ear,  Dis- 
eases of. 

TYPES  OP  DISEASE.  See  Disease, 
Types  and  Varieties  of. 

TYPHLITIS  (■nepAla',  the  caecum). — Inflam- 
mation of  the  caecum.  See  C.ecum,  Diseases  of. 

TYPHOID  FEVER  (tO  <pos,  stupor) — 
Syxon.  : Enteric  Fever;  Pythogenic  Fever; 

Gastric  Fever;  Infantile  Remittent  Fever ; Fr. 
Fievrc  typhoide ; Fievre yastrique;  Dothienentiric ; 
Ger.  Typhus  Abdominalis. 

Definition. — A continued  fever  of  long  dura- 
tion, usually  attended  with  diarrhma,  and  cha- 
racterised by  peculiar  intestinal  lesions,  an  erup- 
tion of  small  rose  spots,  and  enlargement  of  the 
spleen. 

yEnoLOGY. — In  common  with  other  continued 
fevers,  typhoid  fever  is  due  to  the  introduction 
from  without  of  a specific  poison  into  a system 
more  or  less  predisposed  to  the  disease.  The 


1673 


TYPHOID  DETER. 


nature  and  origin  of  the  poison,  and  the  modes 
in  ■which  it  is  propagated,  are  questions  of  ex- 
treme interest  and  importance,  and  they  will  be 
the  first  to  be  considered. 

With  regard  to  the  origin  of  the  poison  two 
distinct  views  have  been  entertained : one  that 
it  is  specific  in  its  nature,  and  derived  only  from 
some  pre-existing  case  of  the  disease  ; the  other 
that,  while  usually  produced  in  a person  suffering 
from  fever,  it  may  also  be  generated  anew  by  the 
decomposition  of  sewage,  and  perhaps  of  other 
forms  of  animal  filth.  The  former  of  these  views 
is  associated  with  the  name  of  the  late  Dr. 
Budd  of  Bristol ; the  latter,  or  pythogenic,  hypo- 
thesis had  its  chief  supporter  in  the  late  Dr. 
Murchison.  Fortunately,  the  practical  issue  of 
both  theories  is  the  same,  namely,  that  the  great 
preventive  measure  is  the  prompt  removal  of 
feecal  matters,  so  thrrt  neither  air  nor  water  may 
be  contaminated  by  them. 

Klebs  claims  to  have  identified  a specific 
typhoid  bacillus,  which  he  has  found  not  only  in 
the  lymphatics  and  blood,  but  in  the  tissues;  and 
it  is  probable  that  this  discovery  will  be  con- 
firmed. 

It  is  accepted  on  all  hands  that  the  typhoid 
poison  is  reproduced  in  the  system  during  the 
fever,  and  that  its  chief,  if  not  exclusive,  out- 
let is  in  the  intestinal  discharges.  There  is  no 
evidence  that  it  is  conveyed  at  all  by  the  breath 
or  perspiration,  or  by  the  urinary  secretion.  While, 
however,  the  contagium  is  present  in  the  feces, 
it  has  not  apparently  at  the  moment  of  their 
passage  its  full  virulence,  but  requires  for  its 
complete  development  a certain  period  of  time, 
and  this  is  forwarded  by  some  conditions,  retarded 
or  prevented  by  others.  Warmth,  stagnation, 
seclusion  from  open  air,  accumulation  and  con- 
centration of  the  infected  discharges  intensify 
the  poison,  and  it  would  seem  that  a small 
amount  of  typhoid  evacuations  may  give  rise  to  a 
large  development  of  the  contagium  in  excretory 
matters  with  which  they  become  mingled,  and 
even  in  milk  to  which  they  may  obtain  access. 
This  increase  by  a sort  of  fermentation  explains 
the  autumnal  prevalence  of  typhoid  fever  ob- 
served in  large  towns,  and  the  association  pointed 
out  by  Dr,  Murchison  between  a hot  and  dry 
summer  and  a high  fever-rate  in  London ; tho 
drains  not  being  flushed  by  abundant  rainfall, 
sewage  accumulates  and  stagnates  in  them,  and 
typhoid  stools  never  being  wanting,  the  specific 
fermentation  goes  on  rapidly  under  the  influence 
of  the  high  temperature,  and  produces  the  poison 
in  quantity  and  intensity.  It  is  possible,  how- 
ever, to  put  another  interpretation  on  facts  of 
this  kind,  and  to  attribute  the  generation  of  cou- 
tagium  to  fermentation  of  fecal  matters,  inde- 
pendently of  any  specific  germ  introduced  in 
typhoid  evacuations.  Such  is,  indeed,  the  basis 
of  the  pythogenic  theory  of  origin  of  typhoid 
fever.  It  is  impossible  to  reproduce  here  the 
discussion  of  the  question  as  to  the  specific  or 
non-specific  character  and  source  of  the  conta- 
gium. There  is  overwhelming  evidence  that  as 
a rule  the  poison  is  derived  from  some  previous 
case,  and  the  only  facts  which  seem  to  require 
the  supposition  of  its  independent  origin  are 
occasional  outbreaks  of  fever  in  villages  orisolated 
buildings  which  cannot  be  traced  to  any  known 


source.  On  similar  grounds,  however,  we  should 
have  to  admit  the  origin  de  novo  of  small-pox 
and  all  other  contagious  affections,  and  it  should 
be  added  that  with  increasing  experience  in  in- 
vestigations of  this  kind  unexplained  outbreaks 
become  more  and  more  rare.  There  are  again 
many  instances  known  in  which  water  largely 
contaminated  by  sewage  has  been  consumed 
for  years  without  giving  rise  to  fever,  until  the 
sewage  has  itself  been  contaminated  by  typhoid 
excreta,  when  an  epidemic  has  at  once  broken 
out.  So  with  regard  to  milk,  impure  water  has 
been  habitually  employed  in  its  adulteration 
without  traceable  bad  effects;  but  when  to  this 
water  typhoid  poison  has  gained  access,  the 
disease  has  immediately  begun  to  be  distributed 
with  the  milk. 

The  modes  in  which  typhoid  fever  is  dissemi- 
nated are  various.  It  is  rarely,  if  ever,  trans 
mitted  directly  from  person  to  person.  Medical 
men,  clergymen,  and  others  visiting  those  who 
are  suffering  are  not  attacked,  nurses  very  rarely 
when  proper  precautions  are  observed.  If,  how-» 
ever,  bed-clothes  or  carpets  soiled  by  the  evacua- 
tions are  not  removed,  and  still  more  where  gross 
neglect  of  cleanliness  and  of  decency  is  permitted, 
attendants  will  contract  the  disease. 

The  most  common  vehicle  of  the  poison  is 
drinking  water,  which  may  be  contaminated  in 
various  ways,  mostly  through  sewage.  The 
water-supply  of  a town  may  be  thus  poisoned  at 
its  source,  such  as  a river  into  which  drains 
empty  themselves,  or  a reservoir  or  well  acci- 
dentally contaminated ; or  the  pipes  of  distribu- 
tion, when  the  supply  is  intermittent,  may  while 
empty  become  charged  with  sewer  gases,  or  may 
even  receive  sewage  ; or  excessive  rainfall  mav, 
in  villages  and  small  towns,  wash  the  contents  of 
cesspools  into  wells.  This  same  rainfall  flush- 
ing the  sewers  of  well-drained  towns,  and  in 
them  preventing  the  disease,  has  often  thus  a 
a contrary  effect  in  town  and  country.  In  some 
places  the  subsoil  water,  permeating  a bed  of 
gravel,  is  at  the  same  time  the  well  water  of  a 
village,  and  a reservoir  of  its  sewage.  An  im- 
ported case  of  fever  will  under  these  conditions 
poison  almost  the  entire  community.  TYith  these 
examples  of  wholesale  dissemination  of  typhoid 
fever  must  be  mentioned  the  so-called  ‘ milk 
epidemics  ’ already  alluded  to.  A case  of  fever 
occurs  at  a farm,  or  among  the  employes  of  a 
dairy ; from  defective  sanitary  arrangements  the 
water  used  at  the  farm  or  dairy  becomes  contami- 
nated by  the  excreta  ; this  is  added  to  the  milk 
as  an  adulteration,  or,  as  is  usually  said,  is 
used  in  washing  out  the  cans,  and  in  this  way 
the  poison  obtains  access  to  the  milk,  where 
apparently  it  must  increase  very  rapidly.  Hun- 
dreds of  cases  have  been  traced  to  a single  dairy. 

More  commonly,  perhaps,  the  occurrence  of 
typhoid  fever  is  traceable  to  the  absence  of 
proper  sanitary  arrangements  in  individual 
houses.  Hot  to  speak  of  cesspools  and  leaking 
drain-pipes  allowing  the  basement  to  be  sodden 
with  sewage,  sinks  or  water-closets  may  be  im- 
perfectly trapped,  and  sewer  gas  diffuses  through 
the  apartments  or  is  drawn  into  the  living-rooms 
by  fires,  or  is  forced  into  the  house  by  pressure  in 
the  main  drains,  when  the  poison  probably  enters 
the  system  through  the  lungs.  Or  the  waste- 


1680  TYPHOID  FEVEK. 


pipe  of  the  cistern  is  in  direct  communication 
with  the  drains,  and  sewer  gases  conveyed  by  it 
are  confined  in  the  space  under  the  cistern-lid, 
and  absorbed  by  the  water  used  for  drinking 
purposes,  which  conveys  the  poison.  In  con- 
nexion with  these  modes  of  dissemination  it 
should  be  borne  in  mind  that  well-made  and 
closefitting  doors  and  windows  may  aid  in  com- 
pelling foul  air  to  enter  from  the  drains  or  sub- 
soil, and  that  houses  in  elevated  situations,  and 
thus  apparently  well  placed  for  drainage,  are  in 
greater  danger  from  pressure  of  gases  in  the 
main  drains. 

It  is  again  possible  that  emanations  from  a 
newly-opened  drain,  or  cesspool,  or  foul  privy, 
may  communicate  the  disease  by  atmospheric 
contagion — though  this  is  comparatively  rare, 
it  being  understood  always  that  typhoid  excreta 
form  part  of  the  contents.  But  a drain  open  to 
the  air  throughout  its  course,  however  offensive, 
is  not  so  likely  to  give  the  disease  as  closed  and 
unventilated  sewers  ; and  sewage-farms,  if  at  all 
well  managed,  are  quite  harmless. 

It  should  he  added  that  while,  in  this  country 
and  in  Europe  generally,  all  the  evidence  tends  in- 
creasingly to  confirm  the  dependence  of  typhoid 
fever  on  pre-existing  cases,  and  the  dissemi- 
nation by  drinking  water  as  its  chief  mode  of 
propagation,  observations  and  investigations  in 
India  appear  to  show  either  that  typhoid  fever 
can  there  arise  independently,  or  at  least  differ- 
ently, or  that  there  is  a disease  not  yet  distin- 
guished from  typhoid  fever  which  has  a different 
method  of  rise  and  spread. 

It  is  unnecessary  here  to  discuss  Petten- 
kofer’s  hypothesis  that  the  varying  prevalence 
of  typhoid  fever  is  connected  with  the  varying 
level  of  the  subsoil  water,  which  as  it  rises  dis- 
places gases  which  have  become  saturated  with 
poison  from  the  soil  into  the  atmosphere.  It 
certainly  does  not  apply  to  the  facts  as  observed 
in  this  country. 

One  word  must  he  said  with  regal’d  to  indi- 
vidual susceptibility  to  the  disease,  and  with 
regard  to  predisposing  causes  acting  on  the 
individual.  It  is  a matter  of  almost  daily 
observation  that  some  persons  never  contract 
typhoid  fever,  however  much  they  may  be  exposed 
to  the  poison,  while  others  take  it  readily;  and  it 
is  almost  equally  obvious  that  certain  families 
are  extremely  susceptible,  and  liable  to  have  the 
disease  in  a severe  form.  It  is  always  a reason 
to  apprehend  a formidable  attack  if  a parent 
have  died  of  the  fever.  Typhoid  fever  may  occur 
at  any  ago,  hut  it  is  very  rare  in  advanced  life. 
It  is  probably  more  common  in  infancy  than  is 
generally  supposed,  as  it  is  easily  overlooked 
or  confounded  with  common  infantile  ailments. 
The  period  of  life  at  which  the  disease  is 
most  common  is  during  adolescence  and  the 
first  decade  of  auult  age.  Among  the  predis- 
posing causes  are  mental  depression  or  shock, 
over-work,  debility,  however  induced.  It  is 
natural  to  suppose  that  unfavourable  hygienic 
conditions  would  generate  a predisposition,  but 
doubt  is  thrown  on  this  by  the  fact  that  typhoid 
fever  does  not  by  any  means  predominantly  affect 
the  poor.  The  influence  of  habitual  consumption 
of  impure  water  again  is  not  very  clear.  In 
some  instances  it  has  appeared  to  make  an  epi- 


demic severe,  but,  on  the  other  hand,  it  would 
almost  seem  that  tho  inhabitants  of  some  towns, 
the  water  of  which  is  eonstautiy  contaminated, 
acquire  an  immunity  from  the  disease. 

Anatomical  Characters  and  Pathology. — 
Special  interest  attaches  to  the  structural  lesions 
which  take  place  in  typhoid  fever,  as  they  are 
closely  associated  with  the  symptoms,  and  are 
accountable  for  many  of  the  complications 
which  occur.  The  primary  change  is  in  the 
blood,  but  in  this  there  is  nothing  characteristic. 
In  fatal  cases  local  congestions  and  inflammations 
are  met  with  in  the  lungs  and  other  organs,  but 
the  special  and  characteristic  lesions  are  those 
taking  place  in  the  intestines  and  mesenteric 
glands.  The  intestinal  mucous  membrane  of  the 
ileum  generally  presents  the  appearances  of 
acute  catarrh ; but  the  chief  seat  of  the  mor- 
bid changes  is  Peyer’s  patches,  and  the  changes 
consist  in  a gradual  infiltration  of  the  glands 
here  crowded  together,  followed  by  ulceration. 
The  process  is  divisible  into  three  stages— of  infil- 
tration, ulceration,  and  separation  or  resolution, 
each  of  which  maybe  said,  speaking  roughly,  to 
occupy  a week.  In  the  first,  that  of  infiltration, 
the  glands  of  Peyer's  patches  are  swollen  and 
distended  by  a corpuscular  exudation.  The  entire 
patch  is  thickened  and  raised  above  the  leyel 
of  the  surrounding  mucous  membrane;  has  a 
reddish,  or  fawn,  or  grey  colour,  according  to  the 
intensity  and  stage  of  the  inflammation ; and  an 
irregular  surface ; is  firm  to  the  touch  ; opaque 
when  the  intestine  is  held  up  to  the  light,  often 
showing  through  the  peritoneal  covering. 

The  patches  are  attacked  successively  from 
below  upwards,  and  as  they  are  largest  and  most 
numerous  at  the  lower  end  of  the  ileum  near  the 
ileo-csecal  valve,  it  is  here  that  the  lesions  are 
most  extensive  and  most  advanced. 

In  about  a week  the  follicles  begin  to  ulcerate, 
or,  as  it  is  sometimes  said,  burst.  This  marks 
the  beginning  of  the  second  stage;  as  it  pro- 
gresses, the  minute  ulcerations  extend  and  coa- 
lesce, the  patch  having  first  a worm-eaten  appear- 
ance, and  later  becoming  one  large  ulcer,  which 
may  he  superficial  or  deep;  in  very  severe  cases 
the  patches  slough  and  fall  off  as  a whole,  a deep 
line  of  demarcation  forming  round  them.  At 
this  period  they  are  stained  with  bile,  or  when 
gangrenous  are  almost  black. 

During  the  third  week  in  mild  cases  a sort  of 
resolution  may  occur,  the  infiltrated  material 
being  broken  down  and  absorbed ; and  this  change 
probably  takes  place  in  patches  high  up  in  the 
ileum  when  in  those  lower  down  there  is  ulcera- 
tive destruction.  For  the  most  part  this  stage  is 
occupied  by  the  separation  by  ulceration  or 
sloughing  of  the  affected  patches,  and  an  ulcer  is 
left  of  corresponding  size  and  shape.  Of  course, 
as  the  patches  run  longitudinally  along  the 
aspect  of  tho  bowel,  away  from  the  mesenteric 
attachment,  the  ulcers  also  have  their  long  dia 
meter  in  the  same  sense.  The  superficial  layer  only 
of  the  mucous  membrane  may  be  ulcerated,  or  its 
entire  thickness  may  be  destroyed,  and  where 
there  has  been  necrosis  of  a patch  as  a whole, 
the  muscular  coat  may  be  implicated,  and  even 
in  some  cases  the  peritoneal  covering.  'When 
the  muscular  fibres  are  laid  bare,  and  especially 
when  they  are  partially  destroyed,  the  base  of 


TYPHOID  FEVER. 


the  ulcer  will  have  a shreddy  appearance.  Large 
vessels  may  be  opened,  giving  rise  to  hemorrhage ; 
or  perforation  of  the  intestine  may  take  place 
from  necrosis  of  the  serous  coat,  near  the  centre 
of  the  ulcer,  and  a perforation  formed  in  this 
way  will  usually  be  large. 

At  the  end  of  the  third  week  the  separation  of 
the  diseased  patches  will  be  completed,  and  the 
ulcerations  left  begin  to  granulate.  There  is  for 
sometime  a liability  to  haemorrhage  from  erosion 
of  vessels,  and  perforation  may  still  occur,  the 
apertures  nefiv,  however,  being  as  a rule  minute. 
Unless  perforation  has  been  preceded  by  adhesion 
to  some  neighbouring  coil  of  intestine,  which  may 
possibly  be  the  case  at  this  period,  the  escape  of 
gas  and  extravasation  of  liquid  faecal  matter 
will  set  up  general  peritonitis,  which  is  almost 
always  fatal.  The  time  required  for  complete 
healing  of  the  ulcers  varies. 

Besides  the  large  ulcers  formed  in  the  patches 
of  Peyer,  it  is  not  uncommon  to  find  small  cir- 
cular ulcerations  scattered  over  the  mucous 
membrane,  and  at  times  minute  disseminated 
ulcers  constitute  the  predominant  lesion,  Peyer's 
patches  being  absent,  or  if  present,  little  affected. 
The  large  intestine  is  usually  healthy  or  nearly 
so,  the  ileo-emcal  valve  forming  a sharp  demar- 
cation between  healthy  and  diseased  mucous 
membrane,  but  in  some  cases  there  are  numerous 
small  ulcerations  in  the  caecum  and  colon. 

The  changes  in  the  mesenteric  glands  are 
secondary  to  those  in  the  intestinal  mucous  mem- 
brane. The  glands  are  enlarged,  firm,  pink  or 
fawn-coloured,  and  present  on  section  a corpus- 
cular infiltration  like  that  affecting  the  agmi- 
nated  glands.  Later,  they  become  paler  and  softer, 
and  may  gradually  return  to  a normal  condition, 
or  may  undergo  caseation. 

The  spleen  is  almost  always  much  enlarged, 
dark  in  colour,  and  soft. 

Granular  degeneration  of  the  gland-cells  of 
the  liver  and  kidneys,  of  the  muscular  fibres  of 
the  heart,  and  of  the  voluntary  muscles  gene- 
rally, is  a constant  morbid  change.  It  is  due  to 
the  prolonged  high  fever,  and  proportionate  to 
its  severity  and  duration  ; when  it  reaches  an 
advanced  stage,  it  may  be  the  cause  of  fatal  syn- 
cope from  failure  of  the  heart. 

Symptoms.  — - The  period  of  incubation  of 
typhoid  fever  is  not  definitely  known.  There  is 
great  difficulty  in  fixing  it,  as  the  date  of  expo- 
sure to  the  poison  can  rarely  be  exactly  ascer- 
tained, and  the  onset  of  the  attack  is  usually 
insidious.  It  is  certain,  however,  that  the  in- 
cubation-period is  long,  probably  in  most  cases 
about  twenty-one  days.  Instances  are  on  record 
in  which  the  disease  appears  to  have  come  on 
immediately  after  exposure  to  powerful  emana- 
tions from  sewers  which  have  burst,  or  have 
been  opened  on  account  of  obstruction,  but 
they  are  quite  exceptional.  The  incubation  is 
not  attended  by  any  marked  symptoms ; some- 
times the  appetite  falls  off,  the  tongue  becomes 
furred,  and  there  is  headache  or  depression,  but, 
as  a rule,  the  patient  is  not  debarred  from  his 
avocation,  and  there  may  be  no  complaint  of  any 
kind. 

Invasion. — The  invasion  is  almost  always 
insidious;  occasionally  severe  headache  sets  in 
suddenly,  with  depression,  muscular  weakness, 

106 


1681 

general  pains,  and  chilliness  almost  amounting 
to  rigor ; but,  as  a rule,  the  patient  at  first  feels 
simply  out  of  sorts,  loses  appetite,  is  indisposed 
for  his  usual  work  or  for  exertion  of  any  kind. 
Epistaxis  is  not  uncommon.  The  headache  in- 
creases; the  prostration  becomes  greater;  sensa- 
tions of  cold  down  the  back,  alternating  with 
heat  and  slight  flushing,  come  on  at  inter- 
vals. At  this  point  medical  advice  is  usually 
sought,  when  the  patient  giving  the  above 
history  will  be  found  to  present  the  usual  indi- 
cations of  the  febrile  state — the  pulse  will  be 
increased  in  frequency,  the  temperature  raised 
and  the  tongue  will  have  a whitish  or  yellow 
coat,  thick  or  thin  in  different  cases.  Thebowels 
may  be  confined  or  relaxed ; the  urine  high 
coloured  and  diminished  in  quantity,  or  so  fai 
apparently  normal. 

In  endeavouring  at  this  early  period  to  decide 
whether  the  case  is  one  of  enterie  fever,  the  first 
thing  to  be  done  is  to  exclude  local  inflammation 
as  a cause  of  the  pyrexia.  Among  the  positive 
indications  the  appearance  of  the  patient  is  often 
a guide ; he  may  look  more  heavy  and  oppressed 
than  is  accounted  for  by  the  temperature  or  the 
duration  of  the  illness,  and  may  be  more  pros- 
trate. The  tongue,  as  a rule,  is  not  thickly 
coated,  and  the  fur  does  not  extend  quite  to  the 
margins  or  tip,  which  even  now  may  be  unduly 
red.  The  abdomen  may  be  tumid,  and  there 
may  be  some  tenderness  over  the  right  iliac  fossa, 
but  the  absence  of  these  symptoms  does  not  ex- 
clude enteric  fever.  The  recurrence  two  or  three 
times  of  slight  epistaxis  during  the  first  few 
days  of  a severer  attack  would  increase  the  pre- 
sumption of  the  disease  being  typhoid.  The 
temperature,  however,  if  it  is  watched  from  the 
first,  affords  the  most  conclusive  early  evidence 
of  the  disease;  it  rises  with  remarkable  regu- 
larity from  day  to  day,  and  is  from  one  to  two 
degrees  higher  in  the  evening  than  in  the  morn- 
ing ; the  appearance  of  the  temperature-chart 
recording  morning  and  evening  observations  is 
highly  characteristic,  and  may,  indeed,  almost  be 
called  diagnostic.  The  opportunity  of  watching 
this  gradual  rise,  however,  is  often  wanting  ; but 
if,  on  the  third  or  fourth  day  of  an  illness,  with- 
out obvious  local  cause  we  find  a temperature  of 
103°  or  101°  Fall.,  and  especially  if  the  evening 
rise  and  morning  fall  are  marked,  the  probabili- 
ties are  that  the  case  is  one  of  enteric  fever, 

As  has  been  stated,  the  fever  is  of  long  dura- 
tion, lasting  from  twenty-one  to  thirty  days  on 
an  average,  and  probably  the  clearest  idea  of  the 
course  and  progress  of  the  disease  will  bo  con- 
veyed by  a brief  description  of  the  condition  of 
the  patient  week  by  week,  during  au  average 
attack. 

At  the  end  of  the  first  week  the  temperature 
will  have  reached  the  level,  whatever  that  maybe, 
which  will  be  maintained  in  the  absence  of  com- 
plications, throughout  the  dominant  stage  of  the 
disease — 103°,  101°,  or  10.5°  Fah.  in  the  evening, 
1°  or  11° Fall,  lower  in  the  morning;  in  mild 
cases  it  may  not  be  more  than  102°  Fah.  when 
highest.  The  fever  is  now  well-established,  and 
all  its  characteristic  features  will  be  more  or  less 
pronounced.  The  initial  headache  will  in  most 
cases  have  disappeared  ; the  patient  lies  on  the 
back  or  on  either  side ; the  face  is  flushed. 


1682  TYPHOID 

often  presenting  a bright  patch  on  the  cheeks, 
rarely  dusky ; the  expression  is  good ; the  eyes 
are  bright  and  observant ; the  skin  is  more  or 
less  hot,  usually  dry,  but  often  moist  at  some 
period  of  the  day.  The  pulse  is  frequent, 
80,  100,  or  120 — short,  large,  and  very  often 
dicrotous.  A short  cough  is  common;  and  a 
scattered  sibilus,  heard  on  auscultating  the 
lungs,  is  so  frequent  as  to  constitute  a feature 
of  the  disease.  The  tongue  will  be  moist,  with 
a white  or  yellowish  fur  thinning  off  towards  the 
edges  and  tip,  where  the  mucous  membrane  is  red, 
and  the  fungiform  papillae  often  conspicuous. 
The  abdomen  will  be  more  or  less  tumid ; and 
on  pressure  tenderness  may  be  elicited  in  the 
right  iliac  fossa,  and  gurgling  of  liquid  and 
gas  mdy  be  felt  in  the  intestine.  It  is  to  be 
understood  that  the  gurgling  is  an  incident 
attendant  on  diarrhoea,  and  is  absent  in  cases 
where  there  is  constipation.  The  spleen  may 
sometimes  be  felt  below  the  ribs,  and  when 
not  reached  from  the  left  hypochondrium  may 
give  an  enlarged  area  of  dulness  on  percus- 
sion, but  it  will  not  yet  have  reached  its  full 
size.  The  characteristic  spots  may  occasionally 
be  found,  but  though  they  have  been  seen  as 
early  as  the  fourth  or  fifth  day,  they  do  not 
usually  come  out  till  after  a week  or  more  of 
fever.  The  bowels  will  mostly  act  loosely,  and 
sometimes  frequently,  so  that  there  is  diarrhcea. 
The  urine  will  be  high-coloured  and  generally 
turbid.  The  motions  will  have  a powerful  and 
offensive  peculiar  odour ; they  will  be  copious, 
liquid,  rather  pale,  yellowish  or  drab  in  colour, 
with  floceuli.  A familiar  descriptive  comparison 
is  to  1 pea-soup.’ 

A week  later,  that  is  on  the  14th  or  15th  da_ , 
he  disease  will  have  told  obviously  upon  the 
patient.  He  will  lie  mostly  on  his  back,  and 
little  on  his  side.  The  face,  still  flushed,  and 
presenting  often  the  red  patches  on  the  cheeks, 
will  begin  to  look  worn  and  thin;  the  eyes, 
still  bright,  will  be  less  observant.  The  hand 
may  be  unsteady  when  held  out,  and  there  may 
be  slight  twitchings  of  the  lips.  There  may  be 
restlessness  or  even  sleeplessness,  and  very  often 
delirium.  It  has  been  stated  that  delirium 
mostly  sets  in  about  the  twelfth  day,  but  the 
time  varies  greatly.  At  first  the  patient  is  con- 
fused on  waking  from  sleep,  does  not  quite  know 
where  he  is,  and  appears  to  have  been  dreaming, 
but  soon  collects  himself ; later  he  fails  to  shake 
off  the  confusion  of  thought,  and  he  may  talk 
incoherently,  may  ramble,  in  fact,  as  it  is  said. 
At  this  period  the  delirium  does  not  go  beyond 
slight  rambling,  and  it  is  rarely  violent  at  any 
Stage. 

The  pulse  will  be  more  frequent,  less  full, 
weaker;  dicrotism  is  rarely  well  marked.  The 
lungs  will  not  have  undergone  much  change; 
the  sibilant  sounds  may  be  more  numerous. 

The  tongue  will  be  more  characteristic ; the  fur 
will  be  represented  by  a thin  yellow  or  brownish 
streak  down  the  centre,  while  the  tip  and  edges 
will  be  red  and  angry.  There  will  be  a ten- 
dency to  dryness,  and  generally  the  entire  tongue 
looks  shrunken  and  pointed. 

The  abdomen  will  be  larger  and  more  tense, 
.and  the  tenderness  and  gurgling  in  the  right 
i iliac  fossa  more  marked;  the  spleen  will  be 


FEVER. 

larger.  Now  the  eruption  may  be  expected  to 
present  itself,  if  at  all,  but  it  must  be  remem- 
bered that  it  is  absent  in  a considerable  propor- 
tion of  cases — a proportion  estimated  by  some 
observers  at  30  per  cent.  The  eruption  consists 
of  small  pink  spots,  about  the  size  of  a pin’s 
head,  slightly  raised  and  pointed,  well-defined, 
and  disappearing  on  pressure,  or  when  the  skin 
is  stretched,  to  re-appear  when  the  pressure  is 
withdrawn.  They  are  usually  few  in  number, 
and  are  distributed  irregularly  over  the  abdomen 
and  chest ; hut  sometimes  they  are  very  profuse, 
the  number  having  no  relation  whatever  to  the 
severity  or  character  of  the  attack.  The  spots 
do  not  all  come  out  at  once,  but  in  successive 
crops,  till  the  end  of  the  fever;  the  duration  of 
individual  spots,  as  observed  by  surrounding  them 
with  a ring  of  ink  and  dating  them,  being  about 
four  days.  It  has  been  Tecommended  that  the 
back  should  be  searched  for  spots,  but  conclu- 
sions from  eruption  found  here  ODly  would  be 
unreliable,  as  the  back  is  seldom  free  from  spots, 
and  there  is  nothing  very  peculiar  in  the  spots  of 
typhoid  fever  to  distinguish  them  from  others. 

If  the  case  is  characterised  by  diarrhoea,  it  is 
usually  at  this  period  that  it  begins  to  be  most 
troublesome ; the  stools  have  the  appearances 
already  described. 

The  temperature  will  be  maintained  at  about 
the  same  height  as  at  the  end  of  the  first  week, 
but  not  uncommonly  there  is  about  this  time  a 
deceptive  remission  of  fever,  and  it  is  perhaps 
worthy'  of  remark  that  the  active  ulceration  is 
now  coming  to  an  end.  The  fever  which  persists 
after  this  period  has  indeed  been  attributed  to 
septic  absorption  from  the  intestinal  ulcers — 
with  doubtful  justice,  however. 

It  is  from  the  later  part  of  the  second  week 
onward  that  complications,  both  local,  such  as 
haemorrhage  or  perforation  from  ulceration  and 
separation  of  sloughs,  and  general,  such  as  pneu- 
monia, are  to  be  apprehended. 

The  end  of  the  third  week  finds  the  sufferer 
at  his  worst.  If  he  is  now  able  to  turn  in  bed 
and  to  lie  on  either  side,  and  if  other  symptoms 
correspond  with  this  indication  of  power,  the 
case  is  favourable.  In  a severe  attack  he  will 
lie  on  his  back,  and  probably  tend  to  slip  down 
in  bed.  The  face  may  be  either  pale  or  dusky; 
its  look  will  be  that  of  prostration.  The  patient 
is  mostly  very  deaf,  often  dull  of  apprehension, 
so  that  he  is  with  difficulty  made  to  put  out  his 
tongue  ; he  may  he  half  unconscious,  or  in  the 
condition  of  coma-vigil,  a stuporous  sleep  with 
the  eyes  half  open  ; or  he  may  be  restless,  with 
muttering  delirium,  picking  at  imaginary  objects 
in  the  air,  or  at  the  bedclothes.  Sometimes  the 
slightest  pressure  on  any  part  of  the  body  ap- 
pears to  givo  pain,  or  the  patient  may  start  in 
great  alarm  when  spoken  to.  The  body  will  be 
emaciated;  the  skin  thin,  pale,  dry,  and  harsh; 
the  muscles  wasted;  the  tendons  starting  up, from 
sudden  irregular  muscular  contractions  (subsul- 
tus  tendinum ) when  the  limbs  are  at  rest,  while 
attempted  movements  are  attended  with  jactita- 
tions and  tremors;  the  lips  tremble  and  the 
tongue  twitches  when  the  patient  speaks  or  puts 
out  the  tongue.  A tap  with  the  end  of  the  finger 
on  the  pectoral  muscle  will  cause  a small  swell- 
ing to  rise  on  the  spot — the  so-called  ‘ nyoidema/ 


T1PH0ID  FEVER.  1683 


due  to  contraction  of  the  degenerated  fibres ; it 
lasts  for  twenty  or  thirty  seconds.  The  tongue 
is  shrivelled,  dry,  brown,  or  eyen  black,  destitute 
of  true  epithelium,  dry  and  shiny,  or  coated  with 
sticky  slime  or  with  black  sordes.  Sometimes 
it  cannot  be  protruded  at  all.  The  roof  of  the 
mouth  will  be  similarly  coated;  and  there  will  be 
sordes  on  the  teeth,  and  perhaps  on  the  lips. 

The  pulse  will  be  small,  soft,  extremely  weak, 
often  very  frequent — 130  or  upwards  per  minute 
in  bad  cases ; the  beats  run  into  each  other,  and 
are  not  distinct,  giving  the  undulatory  sphyg- 
mographic  trace.  The  heart  is  extremely  weak ; 
the  impulse  absent,  or  a mere  tap;  the  first  sound 
short  and  feeble,  or  altogether  extinguished. 
The  lungs  exhibit  evidence  of  hypostatic  con- 
gestion, impairment  of  resonance,  and  imperfect 
entry  of  air  all  over  the  posterior  aspect  of  one 
or  both  sides  of  the  chest. 

The  abdomen  will  usually  be  distended;  spots 
may  be  present  and  continue  to  come  out.  There 
may  or  may  not  be  diarrhoea.  The  stools  may  be 
passed  unconsciously  ; and  there  may  be  reten- 
tion, or  more  frequently  incontinence,  of  urine. 
Bedsores  often  form  rapidly,  unless  the  nursing 
is  both  careful  and  skilful. 

A tendency  to  recovery  is  usually  indicated  by 
improvement  in  the  temperature,  pulse,  tongue, 
and  abdomen.  The  temperature  gradually  falls, 
but  at  first  this  is  shown  chiefly  by  the  increas- 
ingmorning  remissions,  giving  a greater  difference 
between  the  morning  and  evening  temperatures, 
and  showing  on  the  chart  greater  zigzags ; the 
evening  temperature  then  begins  to  fall  day  by 
day.  The  pulse  becomes  less  frequent,  and  more 
full  and  distinct ; the  tongue  gradually  cleans, 
beginning  at  the  margins  ; the  abdomen  subsides, 
the  diarrhoea  ceases;  and  strength  returns  little 
by  little.  In  fatal  cases  the  mode  of  death,  when 
not  due  tosome  complication,  may  be  by  asthenia, 
or  more  frequently  by  coma  and  asthenia  com- 
bined; hyperpyrexia  is  not  uncommon  as  a 
phenomenon  of  the  moribund  condition ; and  as 
the  heart  fails,  hypostatic  congestion  of  the  lungs 
is  usually  very  marked. 

Relapses. — Relapse  is  very  common  in  enteric 
fever.  It  usually  occurs  about  ten  days  after 
the  subsidence  of  the  temperature  in  the  primary 
attack,  and  is  sometimes  attributed  to  prema- 
ture administration  of  solid  food,  but  more 
commonly  has  no  such  cause.  A true  relapse  is 
not  merely  a recurrence  of  pyrexia,  but  a return 
of  all  the  phenomena  of  the  fever.  Fresh  Peyer’s 
patches  are  attacked,  and  there  is  frequently  a 
fresh  outbreak  of  the  spots  at  about  the  same 
period  after  the  initial  symptoms,  or  often 
earlier.  The  relapse,  however,  is  rarely  as  long 
as  the  original  fever ; very  commonly,  indeed, 
the  third  stage,  that  of  so-called  infective  or 
pyaemic  fever,  is  wanting,  and  when  this  is  so, 
it  is  probable  that  there  is  no  ulceration  of 
the  intestinal  glands.  Fortunately,  also,  it  is 
not  so  often  fatal  as  might  be  expected,  seeing 
that  the  patient  is  reduced  by  the  first  attack. 
A second  or  a third  relapse  may  take  place; 
the  writer  has  even  indeed  seen  a fourth,  the 
patient  recovering,  and  surviving  five  distinct 
attacks  of  fever,  each  of  which  was  severe.  No 
satisfactory  explanation  of  the  relapse  of  typhoid 
fever  has  been  given.  It  has  been  said  that 


there  is  a re-infection  cf  the  subject  by  poison 
lodged  in  the  mesenteric  glands,  but  it  is  not  easy 
to  understand  why  he  should  be  susceptible  to 
the  influence  of  the  poison  from  this  source, 
when  for  the  most  part  the  susceptibility  to  the 
disease  is  exhausted  by  an  attack. 

Special  Symptoms  and  Complications. — 
These  are  so  numerous  and  varied  that  it  has 
been  thought  better  to  describe  them  separately, 
rather  than  to  interrupt  the  account  of  the 
fever. 

Hcemorrhage.— This  occurs  in  about  6 or  8 per 
cent,  of  the  cases.  It  may  come  on  as  early  as 
the  tenth  day,  but  more  commonly  it  is  between 
the  fourteenth  and  the  twenty-fourth  days,  and  in 
the  later  rather  than  the  earlier  part  of  this  pe- 
riod ; bleeding  may  be  provoked  by  imprudence 
in  diet,  or  by  exertion  later  still.  The  haemor- 
rhage is  due  to  the  erosion  of  some  vessel  during 
the  ulceration  of  Peyer’s  patches,  without  pro- 
tective plugging  by  fibrin,  or  to  vessels  being 
laid  open  by  the  detachment  of  a slough.  The 
quantity  of  blood  lost,  and  the  rate  at  which  it 
is  poured  out,  vary  greatly.  Sometimes  the 
fact  of  haemorrhage  having  taken  place  is  only 
known  by  the  stools  being  black,  sticky,  and  offen- 
sive. At  other  times  the  blood  is  discharged  in 
large  clots,  or  it  may  be  extravasated  so  rapidly 
that  it  is  liquid  and  red,  not  having  had  time  to 
become  blackened  and  coagulated  by  the  intes- 
tinal contents  or  secretions.  When  the  haemor- 
rhage is  considerable,  the  patient  is  rendered  pale 
and  pulseless.  The  temperature  always  falls, 
and  not  unfrequently  tho  loss  of  blood  can  be 
recognised  before  it  appears  in  the  stools  by 
this  fall  of  temperature,  and  by  the  pulse  and 
general  appearance  of  the  patient.  It  is  said 
that  severe  and  persistent  headache  early  in  the 
attack  is  often  followed  by  haemorrhage  in  a later 
stage. 

This  complication  is  always  attended  with 
anxiety,  and  often  exhausts  the  strength  of  the 
sufferer ; but  it  is  not  by  any  means  necessarily 
fatal.  In  many  cases,  indeed,  the  occurrence  of 
considerable  haemorrhage  marks  the  setting  in 
of  improvement ; the  temperature  which  falls  on 
account  of  the  loss  of  blood  does  not  rise  again; 
the  patient  becomes  clearer  and  less  heavy  and 
oppressed  ; the  tongue  cleans  ; and  all  unfavour- 
able symptoms  gradually  subside. 

Perforation. — -This,  like  haemorrhage,  may 
occur  early  or  later;  when  early  it  is  due  to  the 
entire  thickness  of  the  intestinal  wall  being  im- 
plicated in  the  necrosis  of  the  Peyer's  patch,  and 
the  perforation  may  then  be  large.  Later,  at  the 
end  of  the  third  week  or  afterwards,  the  perfo- 
ration results  from  ulceration,  and  is  often 
very  minute.  Unless  adhesive  inflammation  at 
once  glues  the  affected  point  to  a neighbouring 
coil  of  intestine  or  to  the  abdominal  wall,  there 
is  extravasation  of  intestinal  gases  and  liquid 
into  the  peritoneal  cavity,  producing  general  and 
fetal  peritonitis. 

It  might  bo  expected  that  this  occurrence 
would  give  rise  to  severe  pain,  but  very  often 
there  is  neither  pain  nor  tenderness.  The  ab- 
domen, however,  rapidly  becomes  distended, 
often  to  an  extreme  degree  ; its  walls  are  abso- 
lutely motionless  in  respiration  ; and  on  the  ap- 
plication of  the  hand  and  making  pressure,  there 


TYPHOID  FEVER. 


1631 

is  not  only  tension  but  resistance  of  a peculiar 
kind,  which  is  highly  characteristic.  With  the 
local  symptoms  there  are  evidences  of  shock; 
great  anxiety  of  countenance,  which  may  be 
Hushed  and  beaded  ■with  perspiration,  or  pallid 
and  livid ; extreme  frequency  of  pulse,  often 
140,  160,  or  200,  which  is  small  and  weak;  and 
very  great  frequency  of  respiration.  The  respi- 
ratory distress  is  so  marked  that,  in  some  in- 
stances which  the  writer  has  been  called  to  see, 
the  perforation  had  been  overlooked,  and  the 
condition  attributed  to  some  lung-complication. 

Peritonitis. — Peritonitis,  without  antecedent 
perforation,  is  an  occasional  complication  of 
typhoid  fever.  It  differs  from  the  peritonitis 
caused  by  perforation  in  the  more  gradual  onset, 
and  in  the  less  urgent  character  both  of  local 
signs  and  general  symptoms — of  the  latter  espe- 
cially. 

Tympanites. — Great  distension  of  the  abdomen 
by  hatus  is  not  uncommon  in  the  course  of 
typhoid  fever,  coming  on  independently  of  peri- 
tonitis or  perforation.  Most  frequently  it  gra- 
dually appears  late  in  the  disease,  together  with 
other  symptoms  of  prostration  of  the  nervous 
system,  but  it  may  set  in  abruptly  within  the 
first  week,  and  it  is  then  prognostic  of  an  early 
fatal  issue.  Simple  tympanites  is  distinguished 
from  peritonitic  distension  by  the  difference  in 
the  feel  to  the  hand ; but  chiefly  by  the  fact 
that  the  respiratory  movements  of  the  abdomen 
are  not  suppressed,  though,  of  course,  impeded. 
Absence  of  pain  is  so  common  in  the  peritonitis 
of  typhoid  fever,  that  it  is  no  criterion  by  which 
to  distinguish  inflammation  from  tympanitic 
distension. 

Diarrhoea. — As  has  been  stated,  the  bowels  are 
usually  loose  in  typhoid  fever.  Hot  unfrequently 
this  looseness  becomes  excessive,  and  is  thus  a 
cause  of  exhaustion  and  a source  of  danger. 
Unless  there  is  blood  in  them,  the  stools  are 
more  liquid,  frequent,  and  copious,  but  not  other- 
wise different  from  the  usual  typhoid  motions. 

Albuminuria. — Albuminuria  is  not  uncommon 
as  a complication  of  typhoid,  and  it  may  be 
accompanied  with  convulsions,  though  it  is  by 
no  means  so  dangerous  as  in  typhus.  The 
albuminuria  may  be  the  effect  of  the  poison  or 
of  the  fever-processes  on  the  blood,  or  it  may 
indicate  nephritis.  In  the  former  case,  which  is 
much  more  common,  the  urine  does  not  differ  in 
appearance  from  this  secretion  as  usually  seen 
at  the  stage  of  the  disease  at  which  it  is  pre- 
sent, and  the  albumen  is  only  detected  by 
examination  ; in  the  latter,  the  urine  will  be 
scanty  and  dark-coloured,  as  in  desquamative 
nephritis,  when  it  is  not  a complication  cf 
typhoid  fever. 

Pneumonia. — Inflammation  of  the  lung  may 
come  on  early  or  late  in  the  course  of  typhoid 
fever.  When  early  it  is  usually  a lobar  croupous 
pneumonia,  not  differing  greatly  from  ordinary 
pneumonia ; in  the  later  stages  it  is  often  a 
combination  of  lobular  catarrh  with  hypostatic 
consolidation.  The  symptoms  are  not  marked. 
The  temperature  rises  or  is  more  sustained ; 
there  is  increased  frequency  of  the  pulse  and 
respiration,  and  perhaps  obvious  respiratory 
distress;  the  face  may  be  flushed  or  anxious. 
As  a rule,  there  is  little  or  no  cough  or  expecto- 


ration. Examination,  when  practicable,  reveal* 
the  ordinary  physical  signs. 

Pulmonary  gangrene. — Gangrene  of  the  lung 
may  occur  from  obstruction  of  branches  of  the 
pulmonary  artery  by  fibrinous  coagula  carried 
from  the  heart. 

Pleurisy. — Pleurisy  is  occasionally  met  with 
as  a complication  of  typhoid  fever.  It  does  not 
give  rise  to  much  pain,  and  may  easily  be  over- 
looked, the  condition  of  the  patient  precluding 
careful  examination. 

Thrombosis. — Thrombosis  may  be  either  a 
complication  or  a sequel  of  typhoid  fever.  It 
arises  from  the  languid  state  of  the  circulation, 
and  from  fhe  condition  of  the  blood,  which  is 
liable  to  coagulate.  The  femoral  vein  and  its 
branches  are  the  vessels  most  commonly  ob- 
structed ; there  may  be  deep-seated  pain  and 
tenderness  in  the  calf  or  in  the  gluteal  region 
for  a day  or  two  before  the  large  vein  is  affected. 
Thrombosis  gives  rise  to  pain  and  swelling  of 
the  limb,  with  some  oedema,  and  the  vein  can 
usually  be  felt  as  a solid  cord  ; there  is  a new 
access  of  pyrexia,  especially  if  convalescence  have 
already  set  in. 

Embolism. — Embolism  by  plugs  of  fibrin  de- 
posited in  the  heart,  and  subsequently  launched 
into  the  arteries,  may  occur  in  any  part  of  the 
body.  Hemiplegia  may  occur  from  this  cause  in 
the  course  of  typhoid  fever ; or  occasionally,  but 
very  rarely,  gangrene  of  part  of  a limb. 

Parotitis. — Parotid  abscess  is  less  common  in 
typhoid  than  in  typhus  fever;  but  it  may  occur 
in  very  severe  cases,  and  is  then  an  additional 
source  of  danger. 

Sequel®. — Enteric  fever  always  leaves  the 
patient  weak,  and  the  debility  lasts  long.  Thil 
is  due  not  merely  to  the  waste  of  tissue  by  tho 
protracted  fever,  but  to  the  fact  that  the  intes- 
tinal and  mesenteric  lesions  interfere  with  ab- 
sorption of  nutrient  material.  In  some  cases 
the  patient  never  recovers  strength,  but  gradu- 
ally becomes  emaciated,  and  dies  from  asthenia 
or  from  some  intercurrent  attack.  Occasionally 
the  ulcerations  do  not  heal,  and  they  may  prove 
fatal  after  the  lapse  of  a considerable  time. 
Phthisis  again  may  be  started  by  an  attack  of 
typhoid  fever,  usually,  but  not  invariably,  in  an 
individual  predisposed  to  the  disease.  Insanity 
is  another  occasional  sequel ; the  most  common 
form  of  mental  derangement  is  melancholia,  but 
there  may  be  acute  mania.  It  may  come  on 
almost  immediately,  the  patient  never  appearing 
quite  to  recover  his  faculties  after  the  stupor  of 
a severe  attack  ; or  it  may  develop  itself  at  an 
early  or  late  stage  of  convalescence,  or  not  till  a 
still  later  period. 

Yahieties. — To  complete  the  account  of  ty- 
phoid fever,  some  of  the  principal  deviations  from 
the  ordinary  course  and  type  of  the  disease  must 
be  enumerated,  and  in  the  first  place  it  must  be 
understood  that,  bcth  in  individual  cases  and  in 
entire  epidemics,  typhoid  fever  may  run  its  course 
without  rise  of  temperature,  the  characteristic 
lesions  being  found  after  death.  Again,  there  is 
sometimes  so  little  general  depression  of  strength 
that  the  sufferer  may  walk  about,  and  carry  ou 
his  usual  avocations  up  to  a late  period  of  the 
attack.  The  term  typhus  ambulans,  or  ambula - 
torius,  has  been  applied  to  such  cases.  The 


TYPHOID 

writer  lias  known  several  instances  in  which 
patients  have  walked  into  the  London  Fever 
Hospital  with  perforation. 

Infantile  Eemittent  Fever. — Infantile  re- 
mittent fever  is  so  called  from  the  remissions 
often  observed  in  typhoid  fever  affecting  young 
children.  No  special  description  is  necessary, 
the  disease  pursuing  much  the  same  course  in 
children  as  in  adults,  only  with  greater  fluctua- 
tions. Spots  are  less  frequently  seen. 

Typhoid  Fever  with  Constipation. — This 
really  constitutes  a distinct  variety,  the  consti- 
pation persisting  throughout,  and  not  merely 
lasting  for  a few  days  and  then  giving  place  to 
diarrhoea. 

Bilious  Fever  ( Fievre  bilieuse). — This  is  re- 
cognised as  a special  form  of  typhoid  fever  hy 
French  observers,  and  deservedly  so.  The  charac- 
teristic feature  is  frequent,  sometimes  almost  in- 
cessant, vomiting  of  liquid  containing  bile,  both 
after  food  and  when  no  food  has  been  taken. 
Severe  headache  often  persists  throughout  the 
attack.  The  temperature  does  not,  as  a rule, 
rise  high,  and  it  fluctuates  much ; the  face  is 
pale  and  anxious  ; the  pulse  is  frequent  and  very 
weak ; the  tongue  is  usually  coated,  and  may 
ye  white  or  yellow.  It  is  a very  dangerous  form 
of  the  disease,  and  may  end  fatally  early  by 
simple  asthenia,  without  delirium  or  comatose 
symptoms. 

Typhoid  Fever  with  Meningitis. — True 
meningitis  sometimes,  though  rarely,  occurs  at  an 
early  period  of  typhoid  fever,  and  is  attended  with 
excitement,  which  may  be  maniacal  in  character, 
or  violent  delirium,  and  perhaps  pain  in  the 
head. 

Abortive  Typhoid. — This  is  sometimes  de- 
scribed as  ‘ fourteen-day  fever.’  After  well- 
marked  symptoms  of  the  attack,  the  temperature 
is  not  maintained,  but  gradually  subsides.  Such 
cases  are  mostly  set  down  as  common  continued 
fever,  or  febricula. 

Diagnosis.  — A well-marked  case  of  enteric 
fever  at  the  height  of  the  disease  is  easily  re- 
cognised by  the  aspect  of  tire  patient,  and  by 
the  symptoms  already  described:  the  red  tip 
and  edges  of  the  tongue,  the  tumid  abdomen,  the 
enlarged  spleen,  the  rose  spots,  and  the  character 
of  the  stools.  In  the  early  stage,  however,  it  is 
often  necessary  to  suspend  the  judgment  for  a day 
or  two,  and  there  may  be  difficulty  in  forming  a 
definite  opinion  for  a much  longer  period.  The 
diseases  which  have  most  frequently  been  taken 
for  typhoid  fever  are  tubercular  meningitis,  acute 
pulmonary  tuberculosis,  and  gastro-intestinal  ca- 
tarrh; typhlitis,  catarrhal  pneumonia  and  other 
acute  affections  of  the  lungs,  glanders,  pyaemia, 
and  ulcerative  endocarditis,  have  also  from  time 
to  time  been  confounded  with  it.  On  the  other 
hand,  typhoid  fever  may  possibly  be  taken  for 
one  of  these  affections,  or  may  more  easily  be 
masked  by  some  complication,  such  as  pneumonia 
or  peritonitis.  What  is  most  liable  to  happen  is, 
that  it  may  be  entirely  overlooked. 

The  insidious  onset  of  typhoid  fever  is  very 
characteristic,  and,  as  has  been  said  before,  the 
thermometric  chart  of  the  first  four  days  showing 
a rise  day  by  day  with  the  morning  remissions, 
might  of  itself  suggest  the  diagnosis.  But  occa- 
sionally the  invasion  is  ah  nipt,  or  there  is  some 


FEVER.  1685 

pulmonary  complication  at  the  outset,  which 
raises  the  initial  temperature,  so  that  It  would 
be  unsafe  to  rely  too  implicitly  on  the  tempera- 
ture. The  first  thing  to  be  done  in  establishing 
a diagnosis  of  enteric  fever,  is  to  exclude  local 
inflammation  as  a cause  of  the  febrile  condition, 
which  will  be  effected  by  physical  examination 
and  other  means.  It  must  not  be  forgotten  during 
this  investigation  that  in  pneumonia  the  consoli- 
dation may  not  occur  for  three  or  four  days. 
When  there  is  doubt,  epistaxis  will  be  evidence 
in  favour  of,  herpes  labialis  against  such  a 
diagnosis,  though  herpes  may  break  out  when 
there  has  been  a rigor.  The  presumption  of 
typhoid  fever  arrived  at  by  excluding  local  in- 
flammation and  other  acute  diseases,  will  soon 
be  strengthened  by  the  appearance  of  corrobora- 
tive indications  which  we  need  not  again  specify, 
or  be  overthrown  by  their  continued  absence. 

As  regards  the  particular  diseases  enumerated 
as  those  with  which  it  is  specially  liable  to  be 
confounded — in  tubercular  meningitis  the  tem- 
perature is  not  usually  so  high  as  in  typhoid 
fever,  the  pulse  is  at  first  not  very  frequent,  and 
is  often  hesitating,  while  it  almost  always  pre- 
sents the  condition  of  tension,  thus  contrasting 
with  the  soft  short  pulse  of  fever.  There  are 
usually,  but  not  constantly,  headache  and  vomit- 
ing early  in  the  attack,  the  bowels  are  mostly 
confined,  and  the  abdominal  wall  is  retracted. 
Squint,  inequality  of  the  pupils,  or  double  optic 
neuritis,  would  be  unmistakable  indications  of 
meningitis.  In  acute  pulmonary  tuberculosis 
there  is  more  cough ; and  although  at  first  there 
may  be  only  scattered  sibilant  sounds,  such  as 
are  heard  in  typhoid  fever,  these  soon  become 
more  abundant,  and  other  physical  signs  of  the 
infiltration  of  the  lungs  are  added,  such  as  im- 
pairment of  the  resonanco,  and  imperfect  entry 
of  air.  The  temperature  also  is  usually  more 
sustained.  Gastro-intestinal  catarrh  in  children 
is  sometimes  attended  with  so  much  febrile  dis- 
turbance as  to  give  rise  to  a suspicion,  or  even 
a diagnosis,  of  typhoid  fever,  especially  as  the 
abdomen  is  tumid,  and  there  may  be  diarrhoea ; 
over-feeding  with  milk  may  keep  up  the  appear- 
ance of  fever  for  some  time.  There  are,  how- 
ever, intermissions  and  variations  which,  when 
carefully  noted,  are  found  to  be  inconsistent  with 
continued  fever ; the  tongue  is  more  thickly  and 
coarsely  coated ; and  the  stools,  though  they  may 
be  pale  from  undigested  milk,  have  not  the 
typhoid  character.  In  typhlitis  there  is  more 
local  pain  and  tenderness,  and  a lower  tempera- 
ture ; and  the  symptoms  set  in  more  abruptly, 
vomiting  being  common.  It  is  unnecessary  to 
enter  upon  the  distinction  between  typhoid'  fever 
and  the  other  diseases  mentioned ; for  the  most 
part  a few  days  will  clear  up  any  uncertainty  or 
confusion. 

As  a matter  of  fact,  errors  rarely  arise,  when 
it  is  deliberately  considered  whether  a given 
case  is  or  is  not  one  of  fever.  The  danger  is 
that  the  idea  of  fever  may  not  be  entertained  at 
all,  its  symptoms  being  attributed  to  some  slight 
local  ailment.  Or  there  is  pneumonia  or  peri- 
tonitis as  a complication,  when  the  patient  first 
comes  under  observation,  which  is  not  very  un- 
common among  the  poor  or  in  hospital  practice. 
The  possibility,  therefore,  that  typhoid  fever 


1686  TYPHOID  FEVER. 


may  -underlie  an  acute  local  affection,  should 
always  be  borne  in  mind,  and  when  the  desired 
crisis  does  not  come  on  in  pneumonia,  or  if  in 
peritonitis  the  general  symptoms  are  not  alto- 
gether those  of  inflammation  of  tho  peritoneum, 
indications  of  enteric  fever  should  be  carefully 
looked  for.  When,  again,  a patient  complaining 
only  of  some  functional  derangement,  or  of 
weakness  and  loss  of  appetite,  has  a look  of  ill- 
ness and  prostration  which  is  disproportionate 
to  the  assigned  cause,  enteric  fever  should  be 
suspected. 

There  is  often  great  difficulty  in  distinguish- 
ing infantile  remittent  fever  from  tubercular 
meningitis  on  the  one  hand,  and  from  gastric 
catarrh  on  the  other.  In  gastric  catarrh  the 
tongue  is  more  loaded ; the  temperature  is  less 
sustained  and  more  irregular;  constipation  is 
more  common  than  diarrhcea;  and  the  evacua- 
tions, whether  solid  or  liquid,  have  not  the 
specific  characters,  but  consist  more  of  undi- 
gested food.  In  meningitis  there  will  usually  be 
purposeless  vomiting,  but  not  always;  the  tem- 
perature is  not  so  high  ; the  pulse  is  often  slow 
or  irregular,  and  the  respiration  shallow  and 
sighing ; the  abdomen  is  not  distended,  and  may 
be  retracted ; the  bowels  are  confined.  A squint 
would  at  once  confirm  suspicions  of  meningitis. 

Prognosis. — It  is  never  safe  to  speak  confi- 
dently of  the  recovery  of  a case  of  typhoid  fever, 
in  view  of  the  complications  which  may  arise; 
but  the  prognosis  is  favourable  or  unfavourable, 
according  to  the  antecedent  condition  of  the 
patient,  and  to  the  severity  of  the  attack,  as  esti- 
mated chiefly  by  the  temperature.  The  mor- 
tality varies  from  15  to  25  per  cent.,  but  there 
may  be  epidemics  in  which  it  may  be  throughout 
lower  or  higher  than  the  average  here  stated. 

Children  seldom  die  of  typhoid  fever,  and  in 
the  young  the  attack  is  less  likely  to  be  severe, 
and  there  is  a better  chance  of  recovery  even 
when  it  is.  In  debilitated  subjects,  and  espe- 
cially in  persons  addicted  to  alcohol,  typhoid 
fever  is  always  attended  with  danger  ; even  in  a 
mild  attack  there  may  be  failure  of  the  heart, 
and  pulmonary  complications  or  thrombosis,  which 
may  prove  fatal.  Pregnancy  also  renders  an 
attack  dangerous.  Apart  from  causes  of  anxiety 
in  the  general  condition  of  the  patient,  and  ex- 
ception being  made  of  cases  in  which  the  fever 
assumes  the  bilious  type,  attended  with  frequent 
vomiting  of  bile,  headache,  and  prostration,  and 
of  the  rare  instances  of  meningitis  as  an  early 
complication,  the  prognosis  turns  mainly  on  the 
temperature.  If  this  is  not  more  than  102^°  Pali, 
in  the  evening,  at  the  end  of  the  first  week,  there 
is  very  little  danger ; on  the  other  hand,  if  the 
evening  temperature  reaches  105°  Fall.,  nearly 
half  the  cases  prove  fatal.  When  the  tempe- 
rature ranges  high,  it  is  of  great  importance  to 
ascertain  whether  it  is  so  for  many  consecutive 
hours,  or  only  for  a short  period ; a heat  of 
104°  Fair  sustained  for  a great  part  of  the  day, 
is  a more  serious  matter  than  a brief  rise  to 
105°  Fah.  On  this  account,  and  also  because  the 
maximum  may  be  attained  at  different  periods 
of  the  day,  it  is  desirable  that  the  temperature 
should  be  taken  in  serious  cases  every  two  or 
throe  hours,  or  even  more  frequently.  In  typhoid 
fever  as  in  other  acute  diseases,  a contrast  between 


the  surface  temperature  and  the  temperature  ot 
the  blood,  as  revealed  by  the  thermometer,  is  of 
unfavourable  significance.  If  with  high  tem- 
perature there  are  indications  of  failure,  either 
in  the  nervous  system  or  in  the  heart,  the  pro- 
gnosis becomes  serious ; a tendency  to  stupor, 
or  retention  of  urine  early  in  the  disease,  is  a bad 
sign ; and  acute  tympanites  at  this  period,  in- 
dicating, as  it  does,  paralysis  of  the  muscular 
walls  of  the  intestine,  and  presumably  of  the 
sympathetic  nervous  system,  almost  invariably 
points  to  a speedily  fatal  termination;  the  later 
gradual  distension  of  the  abdomen,  ranks  with 
the  unfavourable  signs,  but  is  often  met  with  in 
cases  which  recover. 

Unusual  frequency  of  the  pulse,  marked  di- 
erotism early,  and  extreme  weakness  of  the 
beat,  and  compressibility  of  the  vessel  later, 
intimate  danger,  as  does  also  an  increasing  fre- 
quency day  by  day  at  the  end  of  the  third  week. 
When  the  beats  run  into  each  other,  and  the  pulse 
is  a mere  flutter,  the  danger  is  immediate  and 
extreme.  The  sounds  of  the  heart  should  be 
noted  throughout  the  disease;  the  first  sound,  as 
heard  at  the  apex,  tends  to  become,  first,  short 
and  sharp,  then  weak,  and  it  may  altogether 
cease  to  be  audible  ; a good  or  bad  first  sound  is 
of  good  or  bad  augury  respectively.  A systolic 
apex-murmur  is  not  uncommon,  and  occasionally 
a distinct  presystolic  murmur  is  heard ; these 
murmurs  have  no  great  significance,  and  usually 
disappear  as  the  patient  recovers. 

Treatment. — The  principles  on  which  the 
treatment  of  typhoid  fever  should  he  conducted 
are  generally  accepted  and  well  understood. 
.Success  depends  greatly  on  their  intelligent  ap- 
plication to  individual  cases,  and  on  careful 
attention  to  details  at  every  stage  of  the  disease. 

The  patient  should,  if  possible,  he  placed 
in  a large,  airy,  and  well -ventilated  room,  the 
windows  and  door  of  which  should  be  more 
or  less  continually  open,  according  to  the 
season  and  weather.  The  bed  should  not  be  too 
wide,  and  it  should  he  approachable  on  both 
sides,  so  that  the  patient  can  be  easily  reached 
from  either  hand ; it  should  be  firm,  but  com- 
fortable. A feather  or  flock  bed  is  very  objec- 
tionable, on  account  of  the  hollow  into  which  the 
patient  sinks  in  it.  When  practicable,  it  is  a 
great  comfort  to  have  two  beds,  one  for  day,  the 
other  for  night.  The  covering  should  be  light, 
but  sufficient  to  protect  the  patient  from  changes 
in  the  external  temperature ; eider-down  quilting, 
or  any  material  impervious  to  the  insensible 
perspiration,  should  be  forbidden ; the  under 
surface  of  such  coverings  will  often  he  found 
quite  damp,  and  exhaling  an  offensive  odour. 
Conscientious,  skilful,  and  efficient  nursing  is  of 
the  utmost  consequence  ; and  that  nothing  may 
be  overlooked,  a record  should  be  kept  of  tho 
condition  of  the  patient,  of  the  food,  stimulants, 
and  medicines  administered,  and  of  the  evacua- 
tions passed. 

The  patient  should  be  sponged  night  and 
morning  with  tepid  water,  to  which  a little 
vinegar  or  permanganate  of  potash  may  or  may 
not  he  added.  The  temperature  of  the  water  may 
vary,  the  feelings  of  the  patient  being  consulted, 
and  the  effects  in  producing  sleep  and  quiet  noted. 
The  hands  and  faco  may  be  washed  or  bathed 


TYPHOID 

frequently,  and  the  general  sponging  may  be 
repeated  at  any  time  'when  it  seems  to  be  re- 
quired by  heat  and  restlessness. 

It  is  useful  to  habituate  the  patient  to  the  use 
of  the  bed-pan  from  the  first.  It  is  true  that 
very  often  the  chair  or  utensil  is  used  through- 
out; but  in  severe  cases,  or  on  the  occurrence 
of  haemorrhage,  the  sitting  posture  is  dangerous, 
and  indeed  impossible,  and  it  may  be  most  dis- 
tressing to  have  to  pass  the  excretions  into  the 
bed-pan  for  the  first  time  under  circumstances 
of  extreme  prostration ; this  may,  indeed,  destroy 
the  patient’s  chance  of  recovery.  A disinfectant 
solution  should  he  placed  in  the  pan  or  other 
vessel  into  which  the  stools  are  received,  and  more 
should  be  added  before  they  are  thrown  away. 

Perhaps  the  most  important  element  in  the 
treatment  of  typhoid  fever  is  the  regulation  of  the 
diet.  This  should  be  exclusively  liquid,  and  the 
staple  constituents  will  be  milk,  and  beef-tea  or 
broths  of  one  kind  or  another.  It  should  be  borne 
in  mind  that  these  liquids  are  food,  and  not  mere 
drinks,  and  they  should  be  given  with  strict 
regularity.  Two  or  three  pints  of  milk,  and  a 
pint  or  pint  and  a-balf  of  beef-tea  or  some  equi- 
valent, will  be  about  the  quantity  required  for 
twenty-four  hours’  consumption  in  the  first  in- 
stance; and  it  should  be  so  divided  that  milk  and 
beef-tea  are  given  alternately  about  every  three 
hours,  judgment  being  exercised  in  waking  up 
the  patient  if  he  is  sleeping  when  food  is  due, 
or  allowing  him  to  sleep  beyond  the  {four.  The 
great  tendency  now,  on  the  part  of  the  public,  is 
to  over-feed  cases  of  fever.  When  the  patient 
asks  for  drink,  milk  is  offered,  and  if  it  is  iced 
or  diluted  with  soda  or  seltzer  water  it  is  suffi- 
ciently grateful  in  quenching  thirst,  to  be  ac- 
cepted in  quantity  altogether  beyond  the  diges- 
tive powers ; it  then  coagulates  in  masses, 
escapes  solution  by  the  gastric  and  pancreatic 
juices,  and  passes  down  the  intestine  in  heavy 
curds,  which  irritate  the  ulcerated  surfaces, 
besides  producing  other  disturbances.  It  is  in 
this  way  that  milk  has  been  discredited  as  an 
article  of  diet.  The  writer’s  experience  is  in  ac- 
cord with  that  of  the  late  Dr.  Parkes,  who  looked 
upon  milk  as  the  typical  diet  for  enteric  fever.  In 
later  stages  of  the  disease  it  may  be  necessary 
to  give  nourishment  'more  frequently,  but  the 
attention  of  the  medical  attendant  will  in  most 
cases  be  required  rather  to  moderate  the  amount 
of  food  given,  than  to  urge  its  administration ; it 
may,  however,  be  found  necessary  to  take  pre- 
cautions against  neglect  in  this  respect  during 
the  night.  In  emergencies  concentrated  meat- 
extracts  may  ha  veto  be  given  in  teaspoonfuls  every 
few  minutes.  The  patient  should,  of  course,  be 
allowed  to  drink  freely  of  cold  water,  toast-water, 
or  any  simple  drink.  The  key  to  the  regulation 
of  the  diet— it  may  almost  be  said  to  the  manage- 
ment of  the  patient — is  to  be  found  in  the  careful 
inspection  of  the  stools ; the  medical  attendant 
ought  to  see  every  evacuation,  or,  at  any  rate, 
one  motion  every  day,  supplementing  his  own 
information  by  the  report  of  a trustworthy  nurse. 
When  curds  appear  in  the  dejections,  either 
too  much  milk  is  taken,  or  too  mnch  at  a time, 
or  its  digestion  is  interfered  with.  If  the 
passage  of  undigested  milk  is  not  remedied, 
there  will  certainly  be  flatulence,  discomfort,  and 


FEVER.  1687 

restlessness,  elevation  of  the  temperature,  and 
in  most  cases  diarrhoea.  When  without  error  in 
the  administration  of  the  milk,  curds  appear  in 
the  stools,  dilution  with  soda  or  seltzer  water, 
or  the  addition  of  lime-water  or  carbonate  of 
soda,  may  prevent  premature  and  unduly  firm 
coagulation ; or  the  admixture  of  arrowroot  or 
of  gelatine  may  cause  the  curds  to  be  subdivided, 
and  thus  ensure  their  digestion.  In  some  cases, 
on  the  other  hand,  beef-tea  excites  diarrhoea, 
and  given  in  excess,  it  will  almost  always  have 
this  effect. 

As  the  fever  subsides,  eggs  beaten  up,  or  lightly 
boiled  or  poached,  may  be  added  to  the  dietary. 
In  all  cases  the  return  to  ordinary  diet  must  be 
made  with  great  caution,  bearing  in  mind  the  fact 
that  there  may  be  intestinal  ulcerations  unhealed, 
and  it  should  be  a rule  that  no  really  solid  food 
be  given  till  the  temperature  has  been  normal 
for  a week  ; even  at  the  end  of  this  time  it  is  not 
uncommon  for  the  temperature  to  rise  one  or 
two  degrees,  after  a moderate  amount  of  fish 
or  meat  with  bread  has  been  taken. 

It  is  an  unfortunate  aggravation  of  the  suffer- 
ings in  typhoid  fever  that  fruit,  which  is  so  grate- 
ful when  the  mouth  is  dry  and  parched,  cannot 
be  given  freely,  on  account  of  its  liability  to 
excite  diarrhoea,  but  a few  grapes  may  be  per- 
mitted, care  being  taken  that  the  skins  and  seeds 
are  not  swallowed,  and  the  effects  being  carefully 
watched. 

The  question  of  stimulants  is  an  important 
one.  Here  again  the  prepossession  in  the  public 
mind  is  in  the  direction  of  almost  indiscrimi- 
nate administration  of  alcohol,  and  the  importu- 
nities of  friends  may  have  to  be  resisted.  The 
amount  of  brandy  or  wine  given  must  there- 
fore be  carefully  checked  and  controlled.  In 
a large  proportion  of  cases  no  alcohol  is  neces- 
sary from  first  to  last;  it  is  scarcely  ever 
required  in  the  early  stages  of  the  disease, 
except  perhaps  in  drunkards ; and  at  no  period 
should  it  be  given  as  a matter  of  routine,  or 
merely  because  the  case  is  one  of  fever,  but  only 
to  meet  certain  definite  indications.  These 
are  mainly  evidences  of  weakness  of  the  heart — 
frequent,  weak,  and  fluttering  pulse,  and 
weakness  or  absence  of  the  first  sound  of  the 
heart.  When,  as  is  usually  the  case,  the  tongue 
is  also  dry,  and  the  teeth  and  lips  are  covered 
and  the  mouth  lined  with  sordes,  the  indications 
for  the  use  of  stimulants  are  unmistakable. 
The  effects  should  be  watched ; when  alcohol 
does  good  the  pulse  becomes  less  frequent,  and 
of  better  strength  and  volume,  and  the  tempera- 
ture is  usually  lowered ; an  important  indica- 
tion also  is  that  the  odour  of  spirit  is  not 
detected  in  the  breath.  When  very  high  tem- 
perature and  other  unfavourable  prognostic 
symptoms  set  in  very  early,  stimulants  may  be 
given  without  waiting  for  the  conditions  above- 
mentioned.  Alcohol  is  again  often  required  as 
an  adjunct  to  the  treatment  of  fever  by  the  cold 
bath.  The  safest  form  of  stimulant  is  brandy 
or  whiskey;  the  quantity  needed  will  vary  greatly 
in  different  cases  ; in  some  2 or  3 ounces  in  the 
twenty-four  hours  will  be  sufficient,  in  others 
10  or  12  ounces  may  bo  required.  It  should 
be  given  in  divided  doses  in,  or  immediately 
after,  the  milk  or  beef-tea. 


TYPHOID  FEVER. 


(688 

It  will  bo  convenient  to  say  here  a -word  on 
the  use  of  opium.  Its  employment  in  certain 
complications — tympanites,  peritonitis  -with  or 
without  perforation,  haemorrhage,  and  excessive 
diarhcea — will  be  described  later ; the  question 
now  is  whether  it  is  well  to  give  it  for  the  relief 
of  sleeplessness  and  restlessness.  In  the  writer’s 
opinion,  when  the  restlessness  is  not  so  far  al- 
layed by  cold  or  tepid  sponging  as  to  permit  of 
sleep,  it  is  of  great  advantage  to  the  patient  to 
give  10  or  15  minims  of  laudanum  at  night,  or  its 
equivalent  in  some  other  form.  The  writer  has 
not  found  it  to  interfere  with  the  digestion. 

It  is  now  almost  universally  recognised  that 
it  is  not  in  the  power  of  medicinal  agencies  to  cut 
short  an  attack  of  fever,  or  indeed  effectually  to 
modify  its  course  ; no  specific  treatment,  there- 
fore, has  to  be  described.  It  is  true  that  the 
hypothesis  of  the  bacteroid  origin  of  typhoid 
fever  has  led  to  the  employment  of  carbolic  acid, 
of  sulpho-carbolates,  and  of  salicylic  acid,  and 
good  results  are  said  to  have  been  obtained,  but 
satisfactory  evidence  is  still  required.  Every  new 
line  of  treatment  is  pronounced  to  be  successful 
for  a time.  In  a large  proportion  of  cases  no 
medicine  need  be  given  from  first  to  last,  but  effer- 
vescing salines  are  usually  grateful ; the  mineral 
acids,  at  one  time  very  largely  employed,  often 
seem  in  small  doses  to  do  good ; and  one  or  two 
grains  of  quinine  may  frequently  be  given  with 
advantage.  It  should  be  understood  that  medi- 
cines are  of  less  importance  than  food,  and  that 
they  are  not  to  be  allowed  to  interfere  with  its 
regular  administration.  A gentle  aperient  at 
the  outset  is  often  useful,  but  it  may  be  blamed 
for  subsequent  diarrhoea.  At  one  time  grey 
powder  (3  or  4 grains)  was  given  two  or  three 
times  a day  during  the  early  part  of  the  attack, 
and  in  watching  cases  so  treated  the  writer’s  im- 
pression has  been  that  the  fever  has  been  mode- 
rated. A single  dose  at  the  outset  has  seemed  to 
him  to  do  good.  In  Germany  the  treatment  is 
often  begun  by  administering  6 or  8 grains  of 
calomel  in  two  doses.  The  main  use  of  pharma- 
ceutical remedies  in  typhoid  fever  is  in  the  treat- 
ment of  certain  emergencies,  and  of  the  various 
complications,  and  this  will  be  for  the  most  part 
described  at  the  same  time  with  the  complications. 
An  important  drug,  however,  has  not  been  men- 
tioned, namely,  digitalis.  This  has  been  employed 
in  considerable  doses  for  the  purpose  of  forcing 
down  the  temperature,  sometimes  alone,  hut  more 
commonly  as  an  adjunct  to  quinine,  and  it  has 
been  said  that  it  is  not  to  be  given  for  the  pur- 
pose of  strengthening  the  failing  heart,  or  of 
reducing  the  frequency  of  the  pulse.  In  the 
writer's  experience  it  is  of  great  value  for  these 
last-named  purposes,  given  with  ammonia  or  other 
stimulant,  or  with  tonics. 

There  still  remains  to  ho  discussed  the  em- 
ployment of  the  cold  or  graduated  bath.  The 
great  source  of  danger  in  typhoid  fever  is  the 
prolonged  high  temperature,  and  it  is  to  this, 
rather  than  to  the  fever  poison  or  process,  that 
are  due  the  prostration  of  the  nervous  system, 
and  the  weakness  of  the  heart  which  are  the 
most  frequent  causes  of  death ; to  keep  down, 
therefore,  the  febrile  heat  of  the  body  is  to 
diminish  very  greatly  the  danger  attending  this 
disease,  and  such  is  the  object  of  the  treatment 


by  bathing.  The  cold-water  treatment  of  fever 
was,  as  is  well  known,  originated  by  Dr.  James 
Currie,  and  practised  with  marked  success  by 
him  and  many  other  distinguished  and  trust- 
worthy physicians.  Notwithstanding  results 
obviously  good,  it  fell  into  disuse,  till  revived 
by  Dr.  Brand,  of  Stettin.  Dr.  Brand’s  method  i3 
to  place  the  patient  in  water  at  a temperature 
of  65°  or  70°  Fah.  whenever  the  temperature  of 
the  body,  as  taken  in  the  rectum,  reaches  102-2°, 
and  to  keep  him  there  for  ten,  fifteen,  or  twenty- 
five  minutes,  until  the  heat  is  reduced  2°,  or 
at  any  rate  until  he  has  been  shivering  for 
some  minutes.  Liebermeister  takes  103°  as  the 
temperature  which  requires  the  bath,  and  this 
he  does  not  make  quite  so  cold,  that  is,  75° 
Fah.,  while  he  recommends  ten  minutes  only 
as  the  period  of  immersion.  The  hath  has  to 
be  repeated  three,  six,  or  eight  times  a day,  as 
often  indeed  as  the  heat  of  the  body  rises  to 
the  point  named ; and  it  must  be  persevered 
with  for  two  or  three  weeks  or  more,  as  may  be 
required.  A little  brandy  is  given  before  or 
during  the  bath;  and  when  the  patient  is  taken 
out  of  the  water,  he  is  placed  in  bed,  dried, 
covered  up,  but  not  too  warmly,  and  kept  at  rest 
( see  Hydrotherapeutics).  In  order  that  the  full 
benefit  may  be  obtained  from  this  treatment,  it 
must  he  begun  early,  in  which  case  the  tempera- 
ture need  never  he  allowed  to  reach  an  injurious 
height,  and  it  is  claimed  that  the  intestinal 
lesions  are  also  held  in  check.  When  thus 
carried  out,  it  must  be  taken  as  established  that 
the  mortality  of  enteric  fever  is  very  greatly 
reduced  by  the  bathing  ; Jiirgensen’s  statistics 
show  a reduction  from  15'4  per  coni.,  to  3'!  : 
Liebermeister’s  from  27'3  to  8-2  (this  observer, 
however,  employing  quinine  largely);  others 
show  a still  larger  fall ; and  it  may  be  safely 
estimated  that  in  France  and  Germany  the  deaths 
have  been  diminished  by  at  least  one-half.  No 
such  results  unfortunately  are  as  yet  forth- 
coming in  England,  but  Dr.  Cayley  has  shown 
that  they  are  to  be  expected,  and  the  writer’s 
own  experience  is  corroborative  of  his  conclu- 
sions. Against  the  advantages  of  cold  bathing 
are  to  he  set  off  the  difficulty  of  carrying  it  out, 
and  the  labour  it  involves ; the  prejudices  of 
the  public,  and  the  dislike  and  dread  of  some 
patients ; the  facts  that  some  cases  may  be  pro- 
tracted (which,  by  the  way,  might  otherwise 
end  fatally) ; and  that  relapse  is  certainly  more 
frequent.  These  are  good  reasons  for  trying 
whether  the  same  end  may  not  be  attained  by- 
other  means ; but  unless  we  are  successful  in  this, 
the  duty  of  the  medical  attendant  is  to  insist  on 
the  uncompromising  employment  of  thecoldbatb. 
The  graduated  bath,  in  which  the  initial  tem- 
perature of  the  water  is  90°  Fah.,  or,  as  the  writer 
has  found  to  answer  the  purpose  equally  well, 
80°,  is  often  more  acceptable  to  patients,  the  water 
being  cooled  down  rapidly  to  70°  or  65°.  If  the 
fever  be  high,  and  the  nervous  prostration  great, 
conditions  in  which  the  shock  of  sudden  cold  is 
of  great  service,  the  cold  water  added  to  bring 
down  the  temperature  may  he  poured  over  the 
patient’s  head.  The  cold  wet  pack  and  Thorn- 
ton’s ice-cap  have  been  tried  as  alternatives 
to  the  bath,  but  without  effects  adequate  to  the 
requirements  of  the  case.  It  has  been  hoped 


TYPHOID 

•gain  to  prolong  the  effects  of  the  bath,  and  so 
render  frequent  repetition  unnecessary,  by  the 
administration  of  large  doses  of  quinine  or  sali- 
cylic acid.  Quinine,  to  keep  down  the  tempera- 
ture for  any  considerable  time,  must  be  given 
in  large  doses,  30  or  40  grains  ; and  even  this 
amount  will,  as  a rule,  produce  no  decided  im- 
pression unless  the  way  has  been  cleared  by  a 
bath.  It  is  to  be  given,  then,  shortly  after  a 
bath  in  two  or  three  equal  portions  within  the 
space  of  about  half-an-hour,  and  a little  lauda- 
num may  be  given  with,  or  just  before  the 
quinine,  to  prevent  vomiting.  Yery  frequently 
the  temperature  remains  depressed  for  twenty- 
four  hours  afterwards,  sometimes  even  for  a 
longer  period.  The  patient  often  suffers  from 
severe  symptoms  of  cinchonism,  but  in  view  of 
the  advantage  obtained  this  need  not  be  seriously 
regarded.  Sometimes,  however,  violent  and  pro- 
tracted vomiting  is  set  up,  which  is  an  absolute 
bar  to  the  further  employment  of  quinine,  ex- 
cept hypodermically.  The  neutral  sulphate  is 
the  most  convenient  form  for  this  purpose,  and 
it  is  sufficiently  soluble  to  be  given  in  adequate 
doses,  that  is,  of  5 or  6 grains.  The  writer’s  awn 
experience  tends  to  the  conclusion  that  the  fre- 
quent bathing  has  advantages  over  the  combina- 
tion of  quinine  with  the  bath,  both  as  regards  the 
safety  and  the  comfort  of  the  patient ; though  he 
lias  ffiso  seen  cases  in  which  the  bath  alone  seemed 
inadequate,  while  with  the  aid  of  quinine  the 
fever  was  kept  down.  He  has  twice  seen  severe 
tetanus  produced  by  the  bath  and  quinine,  both 
cases,  however,  recovering.  Salicylic  acid  and 
the  salicylates  have  appeared  to  him  to  have 
a dangerously  depressing  effect.  Of  digitalis 
employed  in  large  doses  as  an  antipyretic,  he 
has  had  no  experience. 

Without  going  so  far  as  to  say  that  Brand’s 
rule  should  be  obeyed  absolutely,  and  in  all  cases, 
the  writer  is  of  opinion  that  many  lives  would  be 
saved  were  cold-bathing  at  once  put  in  practice, 
whenever  a temperature  of  103-5°  or  104°  Fahr. 
in  the  first  few  days  shows  that  the  attack  is  of 
more  than  average  severity ; and  it  is  of  the 
greatest  importance  that  this  should  be  done 
early,  so  that  the  pyrexia  may  never  get  the 
upper  hand,  and  that  the  intestinal  lesions  may, 
if  such  a thing  is  possible, be  modified.  And  no 
patient  should  be  deprived  of  the  chance  which 
is  afforded  by  the  bath  when,  at  any  stage  of  the 
disease,  life  is  threatened  by  hyperpyrexia  or  by 
consequences  of  high  temperature,  such  as  violent 
excitement,  sleeplessness,  restlessness,  or  nervous 
prostration.  The  only  complications  which  ren- 
der the  bath  inadmissible  are  haemorrhage,  peri- 
tonitis, and  the  advanced  cardiac  weakness  and 
degeneration  sometimes  found  late  in  the  disease. 
Albuminuria  or  pulmonary  affections  do  not  con- 
stitute a bar  to  cold  bathing.  The  writer  has 
known  albumen  to  disappear  from  the  urine  at 
once,  and  pulmonary  congestion  to  clear  up  after 
a single  bath. 

Treatment  of  Complications. — We  will  now 
consider  the  treatment  of  the  chief  symptoms 
and  complications.  The  most  careful  watch 
should  be  kept  for  complications  at  all  stages 
of  the  fever,  but  especially  after  the  end  of 
the  second  week.  A rise  of  temperature  must 
always  be  taken  to  have  some  definite  significance 


FEVER.  1689 

requiring  explanation.  With  increased  frequency 
of  respiration,  it  may  be  the  sole  indication  of 
the  accession  of  pneumonia  or  pleurisy.  A fall 
of  temperature  may  give  warning  of  haemor- 
rhage. Retention  of  urine,  though  uncommon  in 
typhoid  as  compared  with  typhus  fever,  should 
always  be  borne  in  mind  ; and  unusual  restless- 
ness should  at  once  suggest  an  examination  of 
the  hypogastrium.  The  passage  of  a catheter 
has  often  put  an  end  to  sleeplessness  and  ex- 
citement. Bed-sores  ought  never  to  occur,  and 
it  will  conduce  to  their  prevention  for  the 
medical  attendant  to  inspect  the  sacral  region 
and  other  parts  where  they  are  liable  to  be 
produced. 

PLemorrJiage.- — In  the  treatment  of  haemor- 
rhage the  first  thing  to  be  done  is  to  arrest  the 
peristaltic  action  of  the  bowels  by  a fall  dose  of 
opium  ; and  as  an  immediate  effect  is  required, 
one  of  the  liquid  preparations  should  be  given — 
the  tincture  or  liquor,  and  the  dose  may  be  from 
20  minims  to  a drachm.  The  bleeding  vessel 
has  to  be  closed  by  a clot,  and  peristaltic  move- 
ments will  tend  to  disturb  this,  while  it  must 
be  remembered  that  the  blood  poured  out  is  a 
continued  provocative  of  movements  on  the  part 
of  the  intestine.  Direct  astringents  which  de- 
pend on  local  action  are  useless ; before  they 
could  travel  the  whole  length  of  the  small  in- 
testine, and  reach  the  bleeding  point,  they  would 
be  neutralised  by  combining  with  the  intestinal 
contents.  Physiological  haemostatics  may  be  of 
more  service.  Alternate  doses  every  hour  or 
every  two  hours,  of  liquor  ergotse,  5ss  to  yj,  and 
of  turpentine  rux-xv  have  seemed  to  the  writer 
to  have  most  effect.  Acetate  of  lead  and  opium 
or  morphia,  sulphuric  acid  and  decoction  of  log- 
wood, tannic  acid,  and  all  the  known  styptics 
have  been  recommended.  An  important  adjunct 
— probably  more  effectual  than  any  internal 
remedy  except  opium,  is  an  ice-bag  over  the 
region  of  the  caecum  ; this  at  the  same  time 
quiets  peristalsis,  and  contracts  the  vessels. 

Stimulants  must  be  given  if  the  patient  is  in 
danger  of  dying  from  syncope,  but  it  must  be 
borne  in  mind  that  fainting  gives  time  for  the 
vessels  to  close,  and  until  the  bleeding  has 
stopped,  this  condition  must  not  be  too  diligently 
averted.  We  must,  in  fact,  sail  as  close  to  the 
wind  as  is  consistent  with  safety.  The  same 
considerations  apply  to  the  administration  of 
food ; very  little,  if  any,  should  be  given  by  the 
mouth  for  twenty-four  hours,  nourishment  being 
supplied  by  small  nutrient  enemata. 

Perforation. — The  only  treatment  likely  to  be 
of  any  service  is  the  administration  of  large 
doses  (3j  or  more)  of  laudanum  or  liquor  opii 
or  an  equivalent  of  morphia,  either  hypoder- 
mically or  by  the  mouth.  This  has  saved  life 
in  a few  cases  of  undoubted  perforation,  but  in 
the  immense  majority  of  cases  a fatal  termina- 
tion speedily  ensues. 

Peritonitis. — Here,  again,  opium  in  repeated 
moderate  doses  is  the  most  useful  remedy ; with 
poultices  applied  over  the  abdomen. 

Tympanites. — Once  more  the  remedy  is  opium, 
which  should  be  given  in  pill  three  or  four  times 
a day  when  the  distension  is  late  and  gradual : 
in  very  large  doses  of  some  liquid  preparation 
when  it  is  sudden.  Charcoal  lias  been  recom- 


1690  TYPHOID  FEVER. 

mended,  but  in  the  writer’s  experience  it  has 

rarely  been  other  than  hurtful. 

Diarrhoea. — As  long  as  the  stools  do  not  ex- 
ceed three  a day,  or  while  they  do  not  appear  to 
distress  or  exhaust  the  patient,  nothing  special 
need  be  done  to  check  the  diarrhcsa.  It  must 
always  be  borne  in  mind  that  beef-tea  or  other 
strong  flesh-juices  may  excite  diarrhoea;  undi- 
gested curds  of  milk  may  have  the  same  effect. 
As  soon  as  undue  frequency  in  the  action  of  the 
bowels  is  observed,  any  possible  cause  in  the 
diet  should  be  eliminated ; this  failing,  the  best 
remedy  is  an  opiate  enema,  20  or  30  drops  of 
laudanum  in  2 ounces  of  thin  starch.  In  most 
cases  two  or  three  enemata  will  arrest  the  diar- 
rhoea ; should  this  not  happen  astringents  must 
be  given  by  the  mouth — acetate  of  lead  and 
opium  or  morphia,  sulphuric  acid,  laudanum, 
logwood,  or  tannic  acid. 

Constipation. — This,  whether  intereurrent  when 
there  has  been  diarrhoea,  or  present  throughout 
the  fever,  is  a perplexing  symptom.  It  is  best 
relieved  by  enemata  given  every  other  day,  but 
sometimes  these  are  insufficient:  a teaspoonful 
of  castor  oil  may  then  be  given,  care  being  taken 
that  any  accumulation  in  the  rectum  which 
might  give  rise  to  difficulty  is  previously  re- 
moved by  enema. 

Albuminuria. — Nephritis  must  be  treated  by 
poultices  and  dry  cupping  over  the  kidneys. 
Albuminuria  due  to  alteration  of  the  blood  re- 
quires no  special  treatment,  and  it  is  not  a bar 
to  cold  bathing,  but  on  the  contrary  may  be 
among  the  symptoms  calling  for  it.  The  dis- 
appearance of  albumen  from  the  urine,  which  is 
sometimes  observed  when  the  temperature  has 
been  reduced  by  bathing,  seems  to  show  that 
the  blood-change  is  due  to  the  pyrexia,  and  not 
to  the  poison. 

Pneumonia. — When  pneumonia  sets  in,  stimu- 
lants are  generally  required,  and  the  patient  will 
derive  benefit  from  bark  or  quinine,  which  may 
be  given  in  the  form  of  the  ammouiated  tincture. 
Turpentine  in  small  doses,  or  the  stimulant  bal- 
sams, will  often  be  found  useful.  Turpentine 
stupes  are  generally  better  than  poultices. 

Thrombosis. — Elevation  of  the  leg  on  soft 
cushions,  warmth,  and  gentle  support  by  means 
of  a flannel  bandage,  will  be  the  treatment  re- 
quired. W.  H.  Bboadbknt. 

TYPHOID  STATE  (rC<pos.  stupor).— Sy- 
non. : Fr.  Etat  typhoids;  Etat  adynamipue ; Ger. 
Typhose  Ersoheinunaen. 

Definition. — A condition  which  may  arise  in 
the  course  of  any  febrile  disorder,  when  the  ap- 
proach of  death  is  gradual,  and  the  rise  of  tem- 
perature either  excessive  or  long-continued.  The 
typhoid  state  is,  however,  most  frequent  in  typhus, 
enteric,  yellow  fever,  and  pernicious  malarial 
fevers  ; and  in  such  cases  the  tendency  is  often 
evident  from  the  very  beginning  of  the  attack. 

2Etiology. — It  is  unwise  to  attempt  to  attri- 
bute all  these  different  symptoms  to  one  single 
cause.  The  chief  primary  cause  may  be  the 
injurious  influence  of  a high  internal  temperature 
upon  the  central  nervous  organs,  but  this  same 
temperature  acts  directly  also  upon  the  paren- 
chyma of  glandular  organs,  and  upon  the  mus- 
cular fibre,  both  of  the  heart  (Stokes),  and  of  the 


TYPHOID  STATE. 

voluntary  muscles  (Zenker) ; and  the  disorder  of 
the  nervous  centres  must  be  greatly  increased 
by,  if  not  sometimes  directly  due  to,  the  changes 
in  the  composition  of  the  blood,  and  in  the  forces 
of  the  circulation. 

Description. — The  symptoms  of  the  typhoid 
state  relate  chiefly  to  the  nervous  system,  and 
indicate  depression,  not  excitement.  There  is 
low  muttering  delirium,  passing  into  stupor,  with 
little  or  no  true  sleep  ( coma-vigil ) ; with  derange- 
ment of  the  senses,  and  hallucinations  of  sight 
and  hearing  The  urine  and  faeces  are  passed 
unconsciously,  or  there  may  be  retention  of  urine. 
The  sensibility  of  the  skin  is  greatly  impaired: 
flies  may  creep  unnoticed  even  over  the  eye- 
lids. General  muscular  weakness  is  marked, 
the  patient  lying  on  his  back,  sunk  down  in  the 
bed.  The  lips  and  gums  are  covered  with  sordes, 
and  the  tongue  is  dry  and  black.  Subsultus 
tendinum  is  present.  The  pulse  is  frequently 
running,  so  that  it  is  difficult  to  distinguish  and 
count  the  beats  ; small  and  weak  ; sometimes  ir- 
regular and  easily  affected  by  slight  causes,  for 
instance,  failing  distinctly  during  inspiration. 
The  heart’s  impulse  is  greatly  weakened;  the  first 
sound  almost  or  quite  lost  at  the  apex.  The  skin 
is  dry,  if,  as  is  often  the  case,  the  temperature 
is  high,  104-5°  Fahr.  or  upwards;  or  it  is  bathed 
in  clammy  sweats,  which  rarely  prevail  at  one 
time  over  the  entire  surface.  There  is  lividity 
of,  or  even  ecchymoses  on,  the  under  aspect  of 
the  trunk  and  limbs;  and  in  the  exanthematous 
fevers  the  eruption  becomes  petechial.  The 
breathing  is  hurried,  shallow,  and  towards  the 
close  frequently  assumes  the  type  known  as 
Cheyne-Stokes  respiration. 

Prognosis. — The  prognosis  of  the  typhoid 
state  is  always  grave,  but  in  fevers  which  run  a 
definite  course  recovery  may  take  place,  even 
when  the  condition  is  fully  developed,  if  it  be  so 
only  at  or  near  the  crisis. 

Treatment. — The  treatment  consists  in  the 
free  use  of  stimulants.  Of  these  brandy  is  the 
best,  and  may  be  given  in  doses  of  half  an  ounce 
every  half-hour  or  hour  ; but  the  quantity  must 
be  determined,  not  by  measure,  but  by  the 
effects  upon  the  patient.  If  no  improvement 
follows  its  exhibition  by  the  mouth,  frequently 
repeated  rectal  injections  of  brandy  with  egg 
or  strong  beef-tea  ought  to  be  tried.  Musk,  in 
doses  of  one  to  three  grains,  has  been  recom- 
mended, but  the  writer  does  not  attach  any  value 
to  this  drug  in  these  cases.  The  subcutaneous 
injection  of  five  to  fifteen  minims  of  ether  is 
often  so  successful  in  increasing  the  vigour  of 
the  heart’s  action,  that  it  well  deserves  a trial 
here,  too,  if  other  means  prove  ineffectual.  If 
the  temperature  is  excessive,  the  cold  or  tepid 
bath,  or  the  cold  pack,  should  be  used  ; but  im- 
mediately before  or  during  the  application  of 
external  cold,  half  an  ounce  of  brandy  at  least 
should  always  be  given.  The  salutary  effects  of 
cold  are  maintained  and  increased  by  full  doses  of 
quinine,  such  as  five  or  ten  grains  of  the  sulphate 
every  hour,  until  twenty  or  thirty  grains  have 
been  taken.  The  writer  cannot  advise  the  use 
of  salicylic  acid  or  its  salts  in  the  typhoid  state. 
External  stimulating  applications  are  not  without 
value,  for  example,  vesication  by  blistering  fluid, 
or  bj’ strong  liquor  ammonite  to  the  shaven  scalp 


TYPHOID  STATE. 

when  nervous  symptoms  predominate,  or  a flying 
blister  to  the  praecordia  when  the  heart’s  action 
is  seriously  impaired.  Throughout  the  typhoid 
state  th9  patient’s  strength  must  be  husbanded 
as  carefully  as  possible  ; and  the  great  object 
of  the  nursing  should  be  to  save  him  from  the 
necessity  of  any  mental  or  muscular  effort  what- 
ever. James  Andeew. 

TYPHUS  FEVBE  (tvi pos,  stupor). — Sr- 
NON. : Fr.  Typhus ; Ger.  Typhus',  Flecktyphus. 

Definition.— A contagious  febrile  disease, 
marked  by  a peculiar  dark  rash,  with  consider- 
able cerebral  depression,  and  lasting  about  three 
weeks. 

JEtioi.ogy  and  Pathology. — Typhus  is  a 
disease  of  temperate  and  cold  climates,  and  ap- 
pears from  time  to  time  as  an  epidemic  in  our 
towns  and  larger  villages.  Purely  rural  parts  of 
the  country  seem  to  be  in  a great  measure  exempt 
from  it.  Sometimes  it  spreads  as  an  epidemic  over 
a large  part  of  the  country,  either  affecting  many 
towns  simultaneously,  or  breaking  out  in  them  in 
rapid  succession;  but  often  it  attacks  only  a single 
town,  or  a few  towns  at  considerable  distances 
from  each  other,  leaving  others  between  them 
untouched.  AYhen  a serious  epidemic  of  typhus 
occurs  in  a town,  it  usually  lasts  for  a consider- 
able period,  often  for  the  better  part  of  three 
years ; not,  however,  of  the  same  severity 
throughout,  but  increasing  or  diminishing  with 
the  fall  or  rise  of  the  temperature.  Thus  the 
greatest  number  of  cases  occur  during  winter, 
and  the  smallest  number  during  summer ; and 
changes  of  temperature  are  followed  (not  closely, 
but  in  a sort  of  rough  way)  by  changes  in  the 
numbers  attacked  ; whilst  the  ratio  of  mortality 
remains  substantially  the  same  from  the  begin- 
ning to  the  end  of  the  outbreak.  The  larger 
number  of  cases  is  usually  made  up  of  females 
and  young  persons,  and  this  is  particularly 
noticeable  at  the  commencement  of  an  epidemic; 
but  the  heaviest  rate  of  mortality  is  among  the 
adult  males. 

Like  tho  other  exanthems,  typhus  usually  at- 
tacks an  individual  but  once ; although  it  must  be 
admitted  that  this  is  not  invariable,  for  some  per- 
sons seem  liable  to  catch  the  disease  as  often  as 
they  are  exposed  to  contagion.  Such  cases,  how- 
ever, must  be  considered  as  exceptional ; while 
many  cases  of  so-called  second  attacks  are  not  real, 
and  may  be  otherwise  accounted  for.  When  typhus 
enters  a household,  and  sweeps  over  the  members 
of  a family,  it  often  happens  that  one  or  two  of 
them,  instead  of  presenting  the  regular  symptoms 
of  the  disease,  are  affected  merely  by  a slight  feb- 
rile attack,  lasting  for  a short  time.  Such  cases 
are  usually  spoken  of  as  having  had  ‘ the  fever  ’ 
along  with  the  rest  of  the  family  ; and  if  they 
are  at  some  future  period  affected  with  typhus, 
are  set  down  as  having  undergone  a second 
attack.  This  is  obviously  a mistake  ; but,  even 
separating  these  cases,  there  remain  a certain 
number — not  very  large,  it  is  true— where  a 
second  or  even  a third  attack  has  occurred  in 
the  same  individual. 

Although  not  so  extremely  contagions  as  scar- 
latina or  small-pox,  yet  typhus  is  undoubtedly 
propagated  by  contagion.1  The  area  of  conta- 

* Examination  of  cases  where  accurate  data  were 


TYPHUS  FEYEK.  1691 

gion  is,  however,  limited  to  a comparatively 
small  space  around  the  patient.  As  the  breath 
has  a peculiar,  heavy  smell — noticeable,  however, 
only  within  a short  distance  (a  foot  or  two)  of 
the  patient’s  face,  it  is  not  unlikely  that  the 
contagion  is  contained  in  the  exhalations  from 
the  lungs.  Whether  this  be  the  case  or  no,  the 
contagion  is  certainly  propagated  through  the 
air;  it  is  not  capable  of  being  carried  by  the 
clothes  or  by  the  excreta ; and  its  free  dilution 
with  abundance  of  fresh  air  destroys  entirely  its 
noxious  influence.  Hence,  if  the  patient  can  be 
isolated  in  a large,  well-ventilated  apartment, 
there  need  be  no  difficulty  in  preventing  the 
spread  of  the  disease  to  others  of  a family ; and 
the  facility  of  thus  limiting  typhus  is  in  marked 
contrast  with  tho  great  difficulty  of  doing  so  in 
such  diseases  as  scarlatina  or  small-pox.  Unfor- 
tunately, it  is  only  among  the  wealthier  classes 
of  society  that  this  mode  of  checking  the  spread 
of  typhus  can  effectually  be  adopted,  and  hence 
the  rapidity  with  which  it  sweeps  over  the  poorer 
and  working  classes,  when  once  an  epidemic  has 
fairly  broken  out. 

If  we  examine  carefully  the  details  of  any 
epidemic,  we  find  that  it  is  in  the  most  crowded 
parts  of  a town  that  it  always  begins,  and  that 
in  a given  street  it  is  in  the  most  crowded  houses 
that  it  appears  ; that  if  at  the  outset  the  popu- 
lation be  quickly  thinned  by  the  removal  of 
several  of  the  inmates  from  a house  or  group  of 
houses,  the  disease  is  often  checked ; but  that  it 
readily  breaks  out  again  if  the  crowding  be  re- 
newed. Hence  the  primary  cause  of  typhus  is,  in 
all  probability,  to  be  ascribed  to  the  exhalations 
from  a closely  crowded  population,  pent  up  in 
small  rooms,  and  prevented  from  free  access  of 
fresh  air  by  the  obstacle  of  houses  closely  packed 
together.  This  view  of  its  origin  readily  explains 
its  greater  prevalence  in  winter,  and  its  attack- 
ing females  and  young  persons  in  greater  num- 
bers than  adult  males  in  a working  population ; 
for  it  is  in  winter  that  houses  are,  for  the 
sake  of  warmth,  most  crowded  and  most  badly 
ventilated ; and  the  females  and  younger  mem- 
bers of  a family  are  those  most  continuously  ex- 
posed to  any  injurious  influences  which  the  home 
may  possess.  This  also  explains  the  comparative 
immunity  from  the  disease  of  purely  rural  dis- 
tricts, and  the  small  extent  to  which  the  upper 
classes,  and  those  inhabiting  the  open  sparsely- 
built  suburbs  of  our  towns,  are  affected  by  it.  It 
may  be  objected  that,  were  this  the  cause,  the  dis- 
ease ought  to  be  an  endemic  constantly  present 
in  all  our  towns  ; but  if  it  rarely  attacks  an 
individual  more  than  once,  it  must  evidently  die 
out  after  a short  time  from  lack  of  materials, 
and  would  not  reappear  for  some  years,  or  until 
another  generation  has  grown  up  liable  to  its 
attacks.  According  to  this  view  the  bulk  of 
typhus  cases  should  be  comparatively  young; 
and  this  is  found  really  to  hold  good,  the  great 
majority  of  those  attacked  being  between  the 
ages  of  ten  and  thirty. 

It  would  seem  as  if  in  some  epidemics  typhus 
were  connected  with  an  under-fed  or  half-starved 

attainable  shows  the  period  of  incubation  to  be  about  a 
week.  This  may  be  shortened,  or  somewhat  lengthened ; 
but  statements  extending  it  over  several  weeks  are  to 
be  received  with  much  hesitation. 


1692  TYPHUS 

condition  of  the  working  classes ; but  tliis  is  by 
no  means  an  essential  condition.  "When  famine 
exists,  it  will,  for  obvious  reasons,  carry  with  it 
the  condition  of  overcrowding  ; and  it  will  have 
a material  effect  on  the  results  of  an  epidemic, 
inasmuch  as  it  will  render  individuals  less  able 
to  resist  the  disease,  and  so  will  not  only  facili- 
tate its  spread,  but  will  increase  the  ratio  of 
mortality.  But  even  w'hen  the  working  classes 
are  in  full  employment  and  well-fed,  typhus 
from  time  to  time  breaks  out  among  them,  and 
the  only  condition  uniformly  observable  is  that 
of  overcrowding. 

Anatomical  Characters. — Of  the  pathology 
of  typhus  little  is  known.  Post-mortem  exami- 
nation shows  that  the  blood  is  dark-colcured, 
usually  fluid,  or  presenting  soft  and  very  loose 
coagula  in  the  cavities  of  the  heart  and  the  larger 
vessels.  This  appearance,  however,  depending  ap- 
parently  on  a deficiency  in  the  fibrin  of  the  blood, 
is  not  peculiar  to  typhus,  but  is  common  to  it  with 
most  zymotic  diseases.  No  intestinal  affection 
is  seen,  such  as  is  present  in  enteric  fever.  The 
vessels  of  the  brain  are  usually  loaded,  but  there 
is  no  effusion,  and  no  trace  of  any  deposit,  or  of 
anything  approaching  to  inflammatory  change. 
The  only  decided  lesion  to  be  seen  is  in  the  cer- 
vical sympathetic,  the  ganglia  of  w'hich  are  some- 
what enlarged  by  a granular  amorphous  deposit. 
This,  which  extends  more  or  less  to  all  the  cer- 
vical ganglia,  is  best  seen  in  cases  dying  during 
the  second  week;  when  death  occurs  later,  it  is 
much  less  noticeable,  or  may  be  wanting  alto- 
gether. From  this  it  may  be  assumed  that  the 
condition  passes  away  with  the  fading  of  the 
characteristic  symptoms  of  the  disease.  Some- 
times the  deposit  is  limited  to  the  ganglia  of  one 
side,  and  in  this  case  it  may  be  connected  with  a 
symptom  occasionally  observable — a difference 
between  the  temperature  of  the  two  axillae.  If 
this  lesion  be  regarded  as  an  essential  feature  of 
the  disease,  it  would  certainly  afford  an  explana- 
tion of  the  localisation  of  the  symptoms,  of  the 
disturbed  function  of  the  brain,  and  of  the  weak 
action  of  the  heart;  but  even  admitting  this, 
there  is  still  wanting  an  explanation  of  the  nature 
of  the  infection,  and  of  the  reason  why  its  force 
should  be  spent  on  these  organs  alone.  It  has 
been  stated  that  there  occurs  a definite  struc- 
tural change  in  the  heart  itself,  to  which  may  be 
due  the  alteration  in  the  heart’s  sounds;  but 
this  the  writer  has  been  unable  to  verify,  al- 
though he  has  had  the  opportunity  of  looking 
for  it  in  a large  number  of  post-mortem  examina- 
tions. The  texture  of  the  heart  certainly  is  soft 
and  flabby,  with  but  little  cadaveric  rigidity; 
but  the  same  is  observed  in  the  whole  muscular 
system. 

Symptoms. — Typhus  frequently  begins  in  a 
well-marked  way  with  a rigor,  or  with  headache 
and  sickness — more  commonly  the  former ; but 
very  often  nothing  definite  marks  the  exact  time 
of  commencement,  and  then  the  symptoms  come 
on  slowly,  and  gradually  increase  in  intensity. 
The  symptoms  may  be  shortly  summarised  as 
follows : — Heaviness  and  listlessness,  with  a cer- 
tain amount  of  confusion  of  ideas,  and  a diffi- 
culty or  impossibility  of  fixing  the  mind  steadily 
or  continuously  on  any  subject ; dulness  of  all 
the  senses,  with  a heavy  stupid  look  in  the  face; 


FEVER. 

dark-coloured  rash,  in  small  dusky-brownish 
spots,  especially  noticeable  over  the  abdomen, 
and  not  fading  till  convalescence  begins ; heat  of 
skin,  and  rise  of  temperature ; quick,  weak,  fre- 
quent pulse ; white  or  brown  dry  furred  tongue  ; 
thirst ; constipation  ; and  considerable  muscular 
prostration. 

The  disease  runs  its  course  in  three  weeks, 
which  may  be  divided  into  a week  of  onset,  a 
week  of  danger,  and  a week  of  convalescence. 
During  the  first  two  or  three  days  of  the  attack 
the  symptoms  may  not  be  very  urgent;  the 
patient  may  be  going  about,  and  even  at  his 
usual  avocations,  although  he  feels  that  these 
are  performed  with  difficulty,  especially  if  they 
involve  any  mental  exertion.  Towards  the  end 
of  the  first  week  the  symptoms  become  all  well- 
marked;  the  characteristic  rash  makes  its  ap- 
pearance ; and  the  patient  is  now  confined  to  bed. 
During  the  second  week  the  symptoms  increase 
rapidly  in  intensity,  especially  the  muscular 
prostration,  the  rapidity  of  the  pulse,  and  the 
confusion  of  ideas  ; and  these  steadily  progress 
until  the  fourteenth  day,  when  the  disease  ap- 
pears to  have  attained  its  height.  With  the 
third  week  the  tongue  begins  to  clean,  and  the 
pulse  and  temperature  to  fall ; the  rash  quickly 
disappears  ; the  expression  of  the  face  changes  ; 
the  mind  becomes  clear ; and  the  symptoms 
gradually  disappear.  By  the  end  of  the  third 
week  the  attack  may  be  said  to  have  termi- 
nated, but  there  is  often  much  weakness  left, 
and  it  may  be  some  time  before  the  strength  is 
completely  re-established.  Usually  a week  or 
ten  days  will  suffice  for  this  ; but  after  a severe 
attack,  or  in  a patient  previously  debilitated, 
several  weeks  may  be  required. 

The  more  important  symptoms  may  now  be 
described  somewhat  in  detail : — - 

Nervous  System. — The  best-marked  of  the  local 
symptoms  are  those  referring  to  the  brain.  From 
the  very  commencement  there  is  a feeling  of  dul- 
ness and  heaviness,  with  an  indisposition  to  any 
mental  exertion ; a dull  heavy  look  about  the  face ; 
a vacant  expression  in  the  eyes ; a slowness  in 
answering  questions,  and  a partial  confusion  of 
ideas ; the  patient  lying  as  if  in  a half  dreamy 
condition,  and  paying  little  attention  to  anything 
around  him.  As  the  disease  progresses,  these 
symptoms  become  more  and  more  marked.  Even 
in  comparatively  mild  cases  there  is  often  a 
little  muttering,  or  a few  incoherent  words  are 
uttered  from  time  to  time ; but  the  patient  is 
aware  that  he  is  talking  nonsense,  and  readily 
admits  it  though  unable  to  control  it.  In 
severer  cases,  again,  the  delirium  is  very  de 
cided;  the  patient  lies  perfectly  indifferent, 
muttering  incoherently  from  time  to  time;  and 
replies  scarcely',  or  not  at  all,  to  questions,  al- 
though he  is  not  absolutely  unconscious,  as  he 
will  protrude  the  tongue  if  sharply  told  to  do 
so.  Not  unfrequently  patients  afterwards  ask 
whether  in  this  delirium  they  have  not  spoken 
of  things  they  would  wish  concealed,  but  on  this 
point  they  may  be  safely  Teassured ; nothing 
like  a continuous  or  connected  train  of  thought 
passes  through  the  mind — all  is  disjointed  and 
fragmentary;  and  accordingly  the  words  uttered, 
even  if  pieced  together,  are  entirely  meaning- 
less. Along  with  this  confusion  of  ideas  goes  a 


TYPHUS 

dulness  of  all  the  senses ; taste  and  smell  are  en- 
tirely lost ; and  although,  from  the  great  thirst, 
there  is  a craving  for  drinks,  yet  all  are  accepted 
alike,  and  the  feeling  of  relief  which  they  give 
is  unconnected  with  their  taste,  which  is  not 
really  perceived.  Hearing  is  considerably  dulled, 
a certain  amount  of  deafness  being  a very  com- 
mon symptom  ; so  that  it  is  necessary  to  speak 
to  the  patient  in  a distinct  tone  of  voic&,  and 
tolerably  close,  otherwise  hs  will  fail  to  catch 
what  is  said  to  him.  Vision  is  seemingly  also  a 
little  impaired,  although  not  to  so  marked  an 
extent  as  the  other  senses.  Even  ordinary  tactile 
sensation  is  dull,  and  the  impressions  derived  ■ 
from  it  are  often  confused. 

Muscular  System.— Muscular  prostration  is, 
even  from  the  first,  a prominent  symptom.  At  the 
very  onset,  and  while  the  patient  may  still  be 
going  about,  he  complains  of  a feeling  of  weak- 
ness; the  gait  is  often  somewhat  unsteady ; and 
after  he  is  confined  to  bed  this  weakness  becomes 
more  marked.  In  serious  cases  he  lies  supine, 
turning  himself  rarely,  or  in  bad  cases  not  at  all. 
If  turned  on  the  side  he  soon  slides  round  again 
upon  the  back;  the  limbs  are  allowed  to  lie  slack 
in  almost  any  position;  when  the  hand  is  raised 
it  is  tremulous  ; so  also  is  the  tongue  when  pro- 
truded— the  very  protrusion  is  accomplished  with 
difficulty,  and.  the  point  is  pushed  scarcely,  if  at 
all,  beyond  the  lips.  In  bad  cases,  subsultus  is 
occasionally  present.  This  muscular  prostration, 
in  conjunction  with  the  dulness  of  sensation,  is 
doubtless  the  cause  of  the  constipation  so  usually 
present ; and  the  occasional  occurrence  of  reten- 
tion of  urine  is  to  be  explained  in  the  same  way, 
by  inattention  to  the  sensation,  and  by  disinclina- 
tion to  make  even  the  slight  exertion  requisite 
for  emptying  the  bladder. 

Circulatory  System. — The  pulse  is  always  weak, 
and  commonly  frequent.  In  mild  cases  it  does  not 
usually  rise  over  100;  in  more  serious  ones  it 
rises  to  120  ; and  in  bad  cases  to  140,  or  even 
more.  The  character  is,  however,  of  more  im- 
portance than  its  frequency  ; for  while  a very  fre- 
quent pulse  always  indicates  danger,  a compara- 
tively infrequent  pulse,  if  it  be  weak  and  jerking 
in  character,  may  be  equally  serious,  and  hence  it 
occasionally  happens  that  cases  prove  fatal  where 
the  pulse  has  not  risen  above  100.  In  some  cases 
the  pulse  is  markedly  dicrotic  during  the  second 
week,  and  this  especially  happens  if  there  be 
any  pre-existing  lesion  of  the  heart. 

A good  deal  of  stress  has  been  laid  by  some 
observers  upon  the  action  of  the  heart  as  indi- 
cated by  the  stethoscope.  In  all  serious  cases, 
the  heart's  sounds  are  much  fainter  than  usual, 
and  one  or  other,  more  commonly  the  first  sound, 
may  become  so  faint  as  to  be  inaudible.  This 
condition  is  generally  most  readily  made  out  by 
placing  the  stethoscope  over  the  apex  of  the 
heart,  when  the  altered  character  or  absence  of 
the  first  sound  is  at  once  noticeable.  Sometimes 
the  second  sound,  as  heard  ever  the  base  of  the 
heart,  is  lost;  but  this  is  unusual.  The  altera- 
tion or  absence  of  the  first  sound  has  no  neces- 
sary connection  with  the  rapidity  of  the  heart’s 
action,  being  as  often  present  when  the  number 
of  beats  is  under  100,  as  it  is  when  the  number 
is  over  that  figure ; but  the  symptom  marks  the 
Veakness  of  the  heart's  action,  and  is  always  as- 


FEVER.  1693 

sociated  with  a weak  pulse,  and  a considerable 
amount  of  cerebral  disturbance. 

Digestive  System. — With  great  thirst,  there  is 
a dry  tongue,  which  is  first  white  and  finally 
brown.  The  brown  colour  is  at  first  in  the  form 
of  two  broad  bands,  one  on  each  side,  the  centre 
and  edges  remaining  white.  In  bad  cases  the 
whole  tongue  becomes  brown,  often  cracked  and 
bloody;  and  the  same  dry,  cracked,  and  bloody 
appearance  may  extend  to  the  lips,  the  gums  and 
teeth  becoming  crusted  with  sorties.  When  the 
week  of  convalescence  begins,  the  tongue  at  once 
commences  to  clean  at  the  edges ; then  becomes 
moist ; and  finally  the  fur  clears  slowly  off.  It 
generally  requires  the  whole  week  of  conva- 
lescence to  accomplish  this. 

Eruption. — The  rash  in  typhus  fever  is  very 
characteristic,  and  is  almost  invariably  present, 
although  the  amount  varies  much.  In  an  epi- 
demic stray  cases  from  time  to  time  occur  where 
the  rash  is  wanting,  and  the  symptoms  are  other- 
wise mild ; but  it  may  be  doubted  whether  these 
are  cases  of  genuine  typhus  ; at  any  rate  it  is 
amongst  cases  of  this  kind  that  second  attacks 
are  chiefly  found.  The  rash  appears  in  the  form 
of  small,  roundish,  dusky,  or  brown-red  spots  ; 
not  raised  at  all  above  the  surface ; generally 
very  distinct,  but  sometimes  indistinct,  as  if  dimly 
seen  through  a hazy  medium.  It  is  always  most 
marked  about  the  upper,  or  middle  and  tipper 
parts  of  the  abdomen  ; and  it  may  be  limited  to 
a few  spots  there.  If  more  extensive,  it  is  scat- 
tered over  all  the  fore  part  of  the  abdomen,  and 
over  the  lower  and  central  parts  of  the  chest. 
It  sometimes  extends  to  the  limbs,  and  is  then 
found  over  the  fore  part  of  the  thighs  and  arms  ; 
but  this  is  by  no  means  very  common. 

The  rash  shows  itself  during  the  latter  half 
of  the  first  week,  most  commonly  about  the 
fourth  or  fifth  day ; but  sometimes  its  appear- 
ance is  delayed  till  the  early  part  of  the  second 
week.  The  spots,  if  few,  appear  nearly  simul- 
taneously; but  if  numerous  may  come  out  in 
successive  crops,  extending  over  two  or  three 
days.  Once  out  they  undergo  no  further  change, 
except  a gradual  deepening  or  darkening  in 
colour.  They  remain  out  till  the  commencement 
of  the  week  of  convalescence,  and  then  they 
rapidly  disappear.  In  bad  cases  peteehise  may 
also  be  present,  and  passive  haemorrhage  in  any 
situation. 

Complications. — The  only  complication  ot 
common  occurrence  in  typhus  is  a low  form  of 
pneumonia.  This  seems  to  begin  chiefly  by  hypo- 
static congestion ; it  occurs  first  at  the  back  of 
the  lungs,  usually  affecting  both  more  or  less ; 
and  seems  to  be  due  mainly  to  position.  The 
patient,  in  severe  cases,  lies  nearly  continuously 
on  the  back,  and  this  posture,  along  with  the  weak 
and  languid  state  of  the  circulation,  permits  a 
gorging  of  the  posterior  part  of  the  lungs.  Pro- 
bably in  all  severe  cases  this  gorging  is  present 
to  a certain  extent — at  least,  it  is  a very  common 
post-mortem  appearance ; but  in  some  cases  the 
condition  goes  a step  farther,  and  drifts  into 
pneumonia.  The  disease  thus  produced  rarely 
runs  the  course,  or  presents  the  symptoms,  of 
acute  pneumonia;  it  scarcely  goes  beyond  the 
first  stage,  presenting  on  post-mortem  examina- 
tion a very  dark  appearance,  as  if  of  great  venous 


1691  TYPHUS 

congestion,  with  a certain  amount  of  oedema  and 
solidification  ; but  usually  nothing  of  red  or  grey 
hepatisation.  When  it  does  appear,  it  is  com- 
monly towards  the  end  of  the  second  week — the 
period  when  the  causes  above-mentioned  are  in 
operation  to  the  greatest  extent,  and  if  it  inrolve 
much  of  the  lung,  it  proves  fatal  in  a few  days. 
Most  of  the  cases  that  are  fatal  during  the  third 
week  are  cut  off  by  this  complication.  Occasion- 
ally, though  rarely,  the  attack  of  pneumonia  con- 
tinues longer,  and  causes  death  in  the  fourth  week, 
that  is,  after  the  attack  of  typhus  is  over ; but 
in  such  cases  the  symptoms  and  post-mortem 
appearances  approach  more  to  those  of  ordinary 
pneumonia.  The  signs  of  this  complication  are 
cough,  with  little  or  no  sputa ; more  or  less 
oppression  of  the  breathing;  and  small  crepita- 
tion, most  noticeable  always  at  the  back  of  the 
chest.  This  last  is  to  be  accepted  as  the  reliable 
indication,  for  the  patient,  as  a rule,  makes  little 
or  no  complaint ; and,  therefore,  if  cough,  even  to 
a small  extent,  be  present,  the  stethoscope  should 
be  used  to  determine  the  state  of  the  lung.  It 
sometimes  shows  itself  after  the  week  of  con- 
valescence has  begun ; and  if  at  that  time  the 
tongue  becomes  again  dry  after  it  has  begun  to 
clean,  or  if  the  pulse  begins  again  to  rise,  the 
chest  should  be  examined,  even  though  no  cough 
be  spoken  of,  for  the  arrest  of  convalescence  is 
often  due  to  the  commencement  of  this  affection 
of  the  lung. 

Diagnosis. — Typhus  as  above  defined  is  readily 
recognised.  It  is  distinguished  from  typhoid  or 
enteric  fever,  by  the  character  of  the  eruption, 
which  in  typhus  is  in  dusky  brown-red  spots,  re- 
maining out  till  convalescence,  whilst  in  enteric 
it  is  in  bright  rose-red  points  coming  out  and 
fading  in  successive  crops  ; by  the  presence  of 
the  head-symptoms  ; and  by  the  absence  of  sick- 
ness, vomiting,  diarrhoea,  and  abdominal  tender- 
ness. From  meningitis,  or  any  acute  cerebral 
affection,  it  is  distinguished  by  the  absence  of 
excitement  or  of  acute  pain  ; by  the  character  of 
the  delirium  ; by  the  dry-coated,  usually  brown, 
tongue ; by  the  weak  pulse  ; by  the  eruption  ; and 
by  the  muscular  prostration.  From  any  chronic 
cerebral  affection  it  is  distinguished  by  the  pre- 
sence of  fever,  in  addition  to  the  above  charac- 
ters. 

Mortality  and  Prognosis. — The  ratio  of  mor- 
tality from  typhus  varies  somewhat  in  different 
places  and  in  different  epidemics ; but  the  average 
may  be  stated  as  from  10  or  12  to  18  or  20  per 
cent.  This,  however,  applies  only  to  the  total 
mortality  extending  over  a large  number  of 
cases.  If  this  mortality  be  analysed,  it  is  found 
that  it  varies  directly  with  the  age.  In  the 
young  the  mortality  is  small,  in  the  middle-aged 
it  is  considerably  increased,  and  after  middle  life 
it  is  very  high.  This  maybe  expressed  in  figures 
thus : — under  25  years  of  age,  mortality  about 
5 per  cent. ; from  25  to  50  years  of  age,  mortality 
about  25  per  cent. ; over  60  years  of  age,  mor- 
tality about  50  per  cent. 

In  adults  the  rate  of  mortality  is  usually 
higher  in  males  than  in  females,1  a difference, 
however,  which  does  not  hold  good  in  the  case  of 
young  persons  or  children.  This  is  probably  due 

1 In  pregnant  femates  abortion  often  occurs,  and  such 
cases  are  usually  fatal. 


! FEVER. 

to  the  circumstance  that  when  females  or  young 
persons  are  attacked,  they  are  at  once  put  under 
treatment,  or  at  least  allowed  to  rest ; whilst 
adult  males,  especially  heads  of  families,  struggle 
on  for  some  time  after  the  disease  has  begun, 
being  unwilling,  for  the  sake  of  those  dependent 
on  them,  to  give  up  work  until  the  advance  of 
the  disease  compels  them  to  do  so ; and  by  this 
means  the  strength  is  exhausted  early  in  the 
disease,  and  the  chance  of  recovery  materially 
impaired.  In  the  better  classes  of  society,  the 
ratio  of  mortality  is  often  higher  than  among 
the  working  classes. 

The  bulk  of  the  deaths  occur  in  the  second 
week,  and  most  commonly  in  the  latter  half  of 
it— from  the  tenth  to  the  twelfth  day  inclusive 
being  the  most  fatal  period.  Death  very  rarely 
occurs  during  the  first  week,  although  in  bad 
cases  it  may  occur  early  in  the  second  week.  It 
sometimes  happens  that  death  occurs  in  the  third 
week  in  uncomplicated  cases,  as  if  there  had  not 
been  sufficient  strength  left  to  rally  after  the 
brunt  of  the  attack  was  over ; but  this  is  unusual. 
When  death  occurs  in  tho  third  week,  it  is  com- 
monly due  to  pneumonia. 

The  prognosis  in  typhus  depends  on  the 
severity  of  the  symptoms,  especially  of  the 
brain-symptoms,  and  of  the  muscular  prostra- 
tion. If  there  be  much  delirium  or  muttering 
incoherence,  the  prognosis  is  bad,  especially  if, 
as  is  commonly  the  case,  this  be  associated 
with  a quick  pulse  (130  or  over),  such  cases 
being  usually  fatal.  On  the  other  hand,  if  the 
pulse  be  not  .over  100,  if  there  he  little  con- 
tusion of  ideas,  and  if  plenty  of  nourishment  be 
taken,  the  case  is  a mild  one,  and  will  readily 
recover.  The  indications  from  the  rapidity  of  the 
pulse,  and  from  the  cerebral  symptoms,  do  not, 
however,  invariably  coincide  ; and  in  that  case 
the  latter  are  the  more  to  be  regarded.  Thus,  if 
there  be  much  incoherence,  with  indifference  and 
prostration,  and  but  little  nourishment  be  taken, 
even  though  tho  pulse  may  not  be  over  100,  the 
prognosis  is  bad;  whilst, 'if  there  be  little  con- 
fusion, and  plenty  of  nourishment  be  taken,  even 
though  the  pulse  be  120,  the  prognosis,  though 
guarded,  is  not  unfavourable.  The  character'of 
the  pulse,  as  to  weakness  or  otherwise,  is  of  more 
v alue  than  the  mere  rapidity.  If  the  pulse  rise 
much  early  in  the  attack,  it  is  indicative  of  danger. 
The  amount  of  the  rash  seems  to  be  of  little 
momont,  and  is  no  guide  to  the  severity  of  the 
attack.  If  the  tongue,  after  beginning  to  cleat, 
become  again  furred,  or  if  the  pulse  rise  again 
after  having  fallen,  it  is  significant  of  danger, 
and  points  to  the  occurrence  of  some  complica- 
tion, most  commonly  pneumonia. 

The  stethoscopic  character  of  the  cardiac 
sounds  (impairment  or  absence  of  the  first  sound) 
may  be  associated  with  weak  pulse  and  cerebral 
disturbance,  as  a measure  of  the  amount  of  dan- 
ger. It  implies  great  weakness  of  the  heart's 
action,  corresponding  so  far  to  the  muscular 
prostration  elsewhere  noticeable,  only  to  a 
greater  extent ; and,  as  occurring  in  so  important 
an  organ,  indicating  always  the  presence  of 
danger. 

TsEATirENT.-Prciwiffuc.-When  typhus  breaks 
out  in  a family,  the  first  step  to  be  taken  is  to  en- 
deavour to  prevent  its  spread.  For  this  purpose  the 


TYPHUS  FEVEE. 

Dutient  should  be  isolated,  and  placed  in  a large 
well-aired  room,  with  a single  attendant  as  nurse  ; 
and  as  little  communication  as  possible  must  be 
allowed  with  the  rest  of  the  inmates  of  the 
house.  Amongst  the  better  classes  of  society, 
this  is  easily  effected ; but  amongst  the  working 
classes  an  arrangement  of  this  kind  is  usually 
impracticable,  and  then  the  best  course  is  the 
removal  of  the  patient  to  a suitable  hospital.  This 
removal  should  be  effected  at  once,  not  only  be- 
cause the  risk  of  the  disease  spreading  is  lessened 
by  thus  removing  a source  of  infection  ; but  also 
because  removal  late  in  the  disease  is  always  in- 
jurious to  the  patient,  and  often  dangerous.  In 
this  removal  the  patient  should  always  be  car- 
ried, and  not  allowed  to  walk,  oven  should  he 
fancy  himself  able  to  do  so. 

Curative. — Many  attempts  have  been  made,  by 
very  various  means,  to  cut  short  the  disease ; but 
of  these  it  may  be  said  that  all  have  failed.  The 
principle  of  treatment  is  therefore  to  keep  up  and 
economise  the  strength  by  every  means,  until  the 
fortnight  shall  have  passed,  when  convalescence 
will  occur  of  itself.  For  this  purpose  constant 
and  careful  nursing  is  essential.  The  patient 
should  be  kept  absolutely  in  bed,  and  not  allowed 
to  rise,  even  in  the  early  days  of  the  attack, 
when  he  may  fancy  himself  able  to  do  so ; he 
should  be  fed  at  short  intervals  with  liquid 
nourishment,  especially  milk  and  strong  beef- 
tea,  or  strong  soups,  and  these  should  be  given 
to  as  great  an  extent  as  the  patient  can  be  in- 
duced to  take  them.  The  thirst  should  be  relieved 
by  diluents  of  any  kind,  such  as  plain  water,  bar- 
ley water,  effervescing  drinks,  or  diluted  lemon- 
juice.  Taste  being  nearly  gone,  the  patient  will 
take  them  indiscriminately;  but  it  should  be  re- 
membered that  in  serious  cases  he  will  not  trouble 
to  ask  for  them  ; they  should,  therefore,  be  offered 
very  frequently,  and  the  nourishment  should  also 
be  pressed  upon  him.  The  tendency  to  constipa- 
tion is  easily  obviated  by  an  occasional  dose  of 
castor  oil.  Care  should  be  taken  that  the  bladder 
is  regularly  emptied  ; not  that  there  is  any  real 
retention,  for  the  patient  can  readily  empty  it  if 
he  makes  the  effort.  Usually  all  that  is  required 
is  to  tell  him  to  do  so ; but  sometimes,  though 
rarely,  it  may  be  requisite  to  pass  the  catheter. 
Absolute  quiet  should  be  secured ; the  patient 
should  not  be  spoken  to  more  than  is  absolutely 
necessary;  no  conversation  should  be  permitted; 
if  he  talks  in  a rambling  way,  as  is  often  the  case, 
he  should  not  be  answered.  For  sleeplessness  or 
delirium,  the  best  remedies,  besides  quiet,  are 
darkening  the  room,  and  applying  cold  wet  cloths 
steadily  to  the  head.  Cold  applications  frequently 
soothe  the  delirium  and  procure  sleep.  Opium  and 
sedatives  are  ill-borne,  and  should  never  be  had 
recourse  to.  The  use  of  stimulants  has  been  much 
debated ; but  there  can  be  little  doubt  that  their 
judicious  use  in  moderate  quantity  is  often  very 
advantageous.  They  ought  not,  however,  to  be 
nsed  indiscriminately,  nor  should  they  be  em- 


TlUtOSIN.  1605 

ployed  early  in  the  disease,  but  should  be  kept, 
as  it  were,  in  reserve,  to  push  through  an  emer- 
gency. The  best  guides  to  their  employment  are 
the  rapidity,  and  especially  the  strength,  of  the 
pulse  ; the  extent  of  the  muscular  prostration ; 
and  the  quantity  of  nourishment  taken.  If  the 
latter  be  taken  in  fair  quantity,  and  the  weakness 
be  not  very  great,  the  case  will  recover  without 
the  use  of  stimulants,  and  then  they  are  better 
omitted.  Eecourse  should  not  be  had  to  them 
sooner  than  is  absolutely  necessary — certainly  not 
during  the  first  week  if  it  can  at  all  be  avoided ; and 
their  use  need  not  be  prolonged  far  into  the  third 
week,  for  as  soon  as  the  appetite  begins  to  return, 
reliance  should  beplacedupon  feeding,  and  stimu- 
lants should  be  laid  aside.  The  quantity  admi- 
nistered need  not  be  large ; four  to  six  or  eight 
ounces  of  wine,  in  small  quantities  at  a time,  in 
the  twenty-four  hours — a little  more,  with  per- 
haps a small  quantity  of  brandy  added,  in  bad 
cases — will  procure  all  the  advantage  obtainable; 
large  doses  tend  to  increase  the  head-symptoms, 
and  do  harm.  The  best  indication  of  their  doing 
good  is  the  falling  of  the  pulse.  Attention  should 
be  given  to  the  position  of  the  patient,  especially 
in  view  of  the  possible  occurrence  of  pneumonia, 
or  occasionally,  in  spare  or  emaciated  individuals, 
of  bed-sores.  To  avoid  this,  the  supine  position, 
which  the  patient  always  assumes  in  serious 
cases,  should  from  time  to  time  be  altered,  and 
he  should  be  occasionally  turned  on  one  or  other 
side.  He  will  not  lie  long  thus,  but  will  gradually 
slip  round  again  on  to  the  back ; but  the  change 
of  position,  even  fora  short  time,  is  useful.  If 
pneumonia  occur,  ipecacuanha  or  similar  r^jiedies 
in  small  doses  should  be  had  recourse  to,  along 
with  stimulants.  Cold  sponging,  especially  of 
the  face  and  hands,  when  the  skin  feels  hot, 
is  extremely  agreeable  and  soothing  to  tho 
patient. 

E.  Bevebidge. 

TYROSIW. — Tyrosin (C18 H"  NOc)is always 
found  in  conjunction  with  leucin.  It  is  never 
found  in  healthy  livers  (Kiihne),  but  is  perhaps 
present  in  small  quantities  in  the  spleen  and  pan- 
creas. It  is  found  in  the  liver  and  urine  of  acute 
yellow  atrophy,  and  said  to  be  present  in  the 
urine  of  typhoid  fever  and  variola.  The  signi- 
ficance of  tyrosin  in  the  urine  is  uncertain.  Under 
the  microscope  tyrosin  is  seen  as  fine  colourless 
needles,  but  this  appearance  must  never  be 
trusted  without  chemical  tests.  Its  mode  of  pre- 
paration is  the  same  as  that  of  leucin  ; but  the 
residue  of  this,  insoluble  in  boiling  alcohol,  must 
be  dissolved  in  boiling  water,  and  set  aside  to 
cool  and  crystallise.  If  to  a solution  of  tyrosin 
a few  drops  of  nitrate  of  mercury  be  added, 
and  the  whole  boiled,  the  fluid  becomes  a rosy 
red,  and  throws  down  a red  precipitate  (Hoff- 
mann’s test).  See  Leucin  ; Jaundice  ; and  Lives, 
Atrophy  of,  Acute  Yellow. 

J.  Wickham  Lego. 


ITIiCEE  and  ULCEKATTOU  (j\kos,  Ul- 
cus, a sore). — Synon.  : Sore  ; Fr.  Ulcere ; Ger. 
Geschwiir. 

Definition'. — A solution  of  continuity  on  an 
epithelial  or  endothelial  surface,  secreting  pus. 

^Etiology. — A breach  of  surface  may  arise  from 
external  causes,  such  as  a cut  or  laceration,  pres- 
sure, destruction  produced  by  an  escharotic,  a 
burn,  or  a bruise  ; or,  on  the  other  hand,  it  may 
result  from  changes  commencing  -within  the 
tissues  themselves.  These  might  be  acute  inflam- 
mation, giving  rise  to  pus  ; chronic  inflammation, 
giving  rise  to  thickening  of  the  fibrous  tissue, 
with  strangulation  of  the  blood-vessels  passing 
through  it  to  the  surface  ; or  defective  nutrition 
of  the  skin  and  subcutaneous  tissues,  as  seen  in 
senile  subjects. 

Anatomical  Characters. — The  parts  of  a 
healing  ulcer  are — the  surface ; the  thin  blue 
epidermic  pellicle ; the  edges ; the  surroundings  ; 
the  discharge.  When  an  ulcer  departs  from  the 
healing  type,  every  possible  variety  of  appear- 
ance occurs  in  the  surface,  edges,  surroundings, 
discharge,  and  in  the  character  and  intensity  of 
the  accompanying  pain. 

When  a section  of  an  ulcer  is  examined 
microscopically,  the  following  parts  are  made 
out : — a layer  of  pus  on  the  surface  ; project- 
ing up  into  the  pus,  fine  points  consisting  of 
loops  of  blood-vessels,  coated  over  with  living 
white  corpuscles,  constituting  granulations ; be- 
neath this,  a zone  of  thickened  inflammatory 
tissue,  consisting  mainly  of  fine  fibrous  tissues  ; 
and  underneath  this  again,  a zone  of  hyperaemia, 
where  the  blood-capillaries  are  very  numerous, 
and  the  white  blood-corpuscles  are  in  excess, 
lieyond  this  zone  healthy  tissues  are  met  with. 

Should  the  whole  of  the  affected  part  be  seen 
on  a perpendicular  section,  it  would  appear  de- 
pressed in  the  centre,  and  each  zone,  from  the 
surface  downwards,  would  appear  as  an  arc  of  a 
greater  circle  than  the  previous.  Should  the 
ulcer  be  other  than  healthy,  the  same  parts 
would  be  met  with,  but  each  part  would  be  mo- 
dified according  to  the  cause  and  character  of 
the  ulcer. 

The  history  of  the  commencement  of  an  ulcer 
will  evidently  vary,  according  as  it  originates 
(1)  from  external,  or  (2)  from  internal  causes. 

1.  When  a wound  does  not  heal  by  primary 
union,  by  scabbing,  or  by  first  intention,  it  begins 
in  twenty-four  hours  to  show  signs  of  active  hy- 
persemia.  The  surface  exudes  first  serum,  then 
white  blood-corpuscles,  fibrin,  and  albuminous 
matters ; the  surroundings  become  congested  and 
swollen  ; granulations  appear  in  the  bottom  of 
the  wound;  and  an  ulcer  is  thus  established. 

2.  When  the  changes  commence  within  the 
tissues,  they  depend  upon  some  local  irritation, 
causing  a determination  of  blood  to  the  part. 
The  irritation  may  be  a varicose  vein,  a foreign 
body,  a gumma,  a strumous  gland,  or  a scirrhus 


tumour.  The  blood-vessels  at  first  exude  serum, 
which  infiltrates  the  neighbouring  tissues,  caus- 
ing them  to  swell.  White  blood-corpuscles  anl 
fibrin  after  a time  escape  from  the  blood  through 
the  capillary  walls,  and  the  irritated  spot  be- 
comes permeated  by  an  embryonic  connective 
tissue.  The  tissue  thus  formed  passes,  as  the 
result  of  chronic  irritation,  to  a higher  state 
of  development,  becoming  fine  fibrous  tissue,  and 
having  a tendency  to  shrink  or  contract  upon  the 
structures  passing  through  it.  The  consequences 
of  such  a change  as  this  in  any  part  are,  first, 
an  increased  activity  of  its  normal  functions : 
and,  secondly,  a cessation  of  its  functions,  and 
destruction  of  the  tissue  from  the  cutting  off  of 
its  nutrition. 

A section  of  the  part  in  this  condition  would 
show  the  irritating  spot  in  the  centre,  then  a zone 
of  indurated  fibrous  tissue,  and  around  all  a zone 
of  hypersemia.  When  the  skin  becomes  involved 
it  changes  colour,  the  epidermis  is  shed  rapidly, 
serum  oozes  out  through  cracks  and  fissures,  and 
finally  may  collect  on  the  surface  to  form  a scab. 
When  the  scab  falls  off,  a raw  surface,  consisting 
of  the  papillary  layer  of  the  skin,  is  seen,  and 
from  this  a discharge  flows  away,  becoming 
thicker  and  more  purulent.  The  surface  is  now 
an  open  sore,  secreting  matter,  and  exists  as  an 
ulcer. 

Pathology.  — Ulceration . — The  ulcerative 
process  is  so  intimately  associated  with  inflam- 
mation, suppuration,  gangrene,  phagedaena,  granu- 
lation, and  cicatrisation,  that  it  is  impossible  to 
detach  it  from  any  one  of  these,  and  call  it  a sepa- 
rate definite  process.  Few  writers  agree  in  their 
descriptions  of  the  extent  of  the  process,  some 
looking  upon  the  ulcerative  process  as  implying 
destruction  of  the  tissues  only ; others,  as  signi- 
fying both  destruction  and  repair.  In  its  widest 
sense,  the  ulcerative  process  is  the  process 
whereby  ulcers  are  formed,  spread,  arrested, 
maintained,  and  healed.  The  actual  formation 
of  an  ulcer  has  been  discussed  ; and  when  the 
ulcer  is  once  established,  the  ulcerative  process 
is  seen  to  be  a liquefaction  and  dissolution  of 
the  edges,  and  the  formation  of  granulations  and 
discharge.  This  process  goes  on  from  the  begin- 
ning to  the  end  of  the  history  of  an  ulcer,  so  that 
it  is  impossible  to  say  that  it  ends  before  healing 
takes  place. 

In  the  immediate  neighbourhood  of  any  ulcer, 
vascular  changes  take  place,  which  have  to  bo 
followed  closely  before  the  ulcerative  process  can 
be  understood  aright.  In  the  first  place,  tbs 
capillaries  in  the  neighbourhood  of  the  irritated 
spot  are  in  a state  of  tension,  from  increased 
blood-pressure,  and  they  tend  to  relieve  them- 
selves by  the  transudation,  first,  of  serum,  and 
then  of  white  blood-corpuscles  and  fibrin.  These 
products  behave  differently,  according  as  they 
escape  into  the  surrounding  tissues,  or  reach  the 
surface. 


ULCER. 


(a)  When  the  cells  and  fibrin  escape  into  the 
surrounding  tissues,  they  infiltrate  the  immediate 
neighbourhood  of  the  ulcer,  and  produce  swelling 
and  blocking  up  of  the  tissues,  aud  beyond  that 
an  area  of  increased  nutrition,  caused  by  the 
determination  of  blood.  The  pressure  on  the 
blood-vessels  leads  to  interference  with  the  cir- 
culation, and  as  a consequence,  to  a deficiency  of 
the  nutrition  of  the  surrounding  tissues.  The  cel- 
lular elements  of  these  tissues  swell,  undergo 
degeneration,  liquefy  and  are  absorbed,  or  remain 
in  the  tissues.  According  to  the  intensity  of  the 
irritation,  and  the  condition  of  the  patient,  so 
the  area  of  infiltration  and  of  liquefaction  extends, 
and  the  degenerative  process  continues  ; or,  on 
the  other  hand,  along  with  the  infiltration,  in- 
duration occurs,  and  stays  the  processes  of  de- 
struction. The  arrest  of  the  extension  of  infil- 
tration, by  the  formation  of  a barrier  of  firm, 
fibrous,  indurated  tissue,  is  necessary  before 
repair  sufficient  to  heal  the  ulcer  is  induced. 

(b)  The  portion  of  the  transudation  that  reaches 
the  surface  consists  of  two  parts.  The  part  for 
which  sufficient  nutrition  cannot  be  obtained 
flows  away  as  pus,  whilst  the  part  that  is  retained 
in  close  proximity  to  the  blood-vessels  becomes 
formed  into  a layer  of  embryonic  connective 
tissue.  This  layer,  as  the  irritation  declines  in 
intensity,  increases  in  thickness,  becomes  vascu- 
larised,  and  rises  into  small  protuberances  con- 
stituting granulations.  The  vascularisation  of 
the  embryonic  connective  tissue  keeps  pace  with 
the  continued  addition  of  new  cells  on  the  surface, 
and  so  the  reparative  action  is  kept  going.  The 
deeper  layer  of  first-formed  cells  now  become 
spindle-shaped,  with  their  long  axis-parallel  to 
the  blood-vessels.  Along  with  the  blood-vessels, 
lymphatics  and  sympathetic  nerves  find  their 
way  into  the  granulations.  The  spindle-shaped 
cells  now  form  a denser  tissue  and  shrink,  and, 
as  a consequence,  the  granulations  diminish  in 
size  ; the  purulent  secretion  grows  more  scanty ; 
and  by-and-by  the  whole  surface  is  involved  in 
cicatricial  tissue,  and  glossed  over  by  an  epithe- 
lial pellicle  {see  Cicatrization).  The  details  of 
this  process  will  vary  according  as  the  destruc- 
tive or  the  reparative  process  predominates ; the 
predominance  of  the  former  will  cause  ulcers  to 
spread,  forming  inflamed  and  phagedsenic  ulcers ; 
whilst  the  predominance  of  the  latter  will  cause 
ulcers  to  heal,  or  when  in  excess  to  form  ‘ proud 
flesh  ’ or  weak  ulcers. 

That  an  ulcer  heals  by  the  building  up  of  new 
tissue  is  much  to  be  doubted.  The  ulcer  comes 
to  the  same  level  as  the  surroundings,  not  so 
much,  if  at  all,  by  the  growth  of  its  granulations, 
as  by  the  subsidence  of  the  swelling  and  indu- 
ration in  the  edges  and  surroundings  themselves. 
Before  it  can  heal  these  must  be  restored  to  a 
normal  state,  and  it  is  only  when  this  takes 
place,  and  the  same  level  is  reached,  that  the 
epidermis  advances  and  glosses  over  the  fibrous 
tissues  of  the  cicatrix. 

Varieties. — No  better  classification  of  the  va- 
rieties of  ulcers  than  Syme’s  can  bo  given.  All 
writers  on  surgery,  since  his  time,  follow  the 
spirit,  if  not  the  letter,  of  his  classification,  and 
it  is  proposed  to  adopt  this  system  here,  noticing 
in  order  the  following  varieties  of  ulcers: — 1. 
the  healing  or  healthy,  2.  those  which  do  not  heal. 

107 


1 697 

from,  defect  of  action-,  3.  those  which  do  not  heal 
from  excess  of  action  ; and  4.  those  which  do  noi 
heal,  from  peculiarity  of  action. 

1.  The  healing  or  healthy  ulcer. 

The  surface  is  covered  by  granulations,  which 
are  small,  sensitive,  and  bleed  when  smartly 
touched.  There  is  a thin,  blue,  epidermic  pel- 
licle, consisting  of  the  epidermis  advancing  from 
the  edges  and  over  the  surface.  The  edges  are 
on  a level  with  the  surface,  of  a pink  tint,  and 
free  from  induration.  The  surroundings  are  free 
from  induration,  and  normal  in  appearance.  The 
discharge  consists  of  healthy,  laudable  pus. 
The  pain  is  inconsiderable. 

Treatment. — The  treatment  consists  in  help- 
ing the  healing  process  by  local  and  constitutional 
means.  The  local  means  consist,  first,  in  rest, 
by  position,  or  by  splints  or  bandages : and, 
secondly,  in  the  application  of  a piece  of  lint 
dipped  in  water  or  slightly  stimulating  lotion, 
to  absorb  discharge  and  protect  the  surface ; over 
this  a piece  of  oiled  silk  slightly  larger  than  the 
piece  of  lint,  to  prevent  evaporation ; and  then 
a bandage  or  piece  of  strapping  over  all,  to  fix 
the  dressing  aud  support  the  part.  Should  the 
healing  of  the  ulcer  flag,  stimulating  lotions  are 
required  to  restore  the  tone.  If  the  ulcer  has 
involved  a large  amount  of  skin,  the  process  of 
skin-grafting  hastens  the  cure,  and  is  an  effi- 
cient means  of  helping  the  cicatrization.  Tho 
patient’s  general  health  must  be  attended  to,  and 
the  character  of  any  retrograde  change  in  the 
part  will  serve  as  a guide  to  such  treatment. 

2.  Ulcers  that  do  not  heal,  from  defect 
of  action. 

(а)  Weak  ulcer. — The  cause  of  this  form  is 
generally  the  prolonged  use  of  emollient  applica- 
tions. The  characters  are  : — The  granulations 
look  flabby,  watery,  gelatinous  masses,  and  rise 
above  the  level  of  the  surroundings,  constituting 
‘ proud  flesh.’  The  edges  are  normal,  but  over- 
lapped by  the  granulations.  The  surroundings 
are  normal.  The  discharge  is  thin  and  watery. 
There  is  little  or  no  pain. 

Treatment. — It  is  necessary  to  get  rid  of  the 
exuberant  granulations  by  caustics,  such  as  ni- 
trate of  silver  or  sulphate  of  copper  in  substance. 
Afterwards  we  must  employ  firm  bandaging  with 
astringent  lotions,  or  powdered  substances,  such 
as  oxide  of  zinc,  oxide  of  zinc  and  starch,  tannin, 
or  sub-nitrate  of  lead.  When  at  the  same  time 
the  patient’s  health  is  lowered  in  tone,  tonics  and 
bitter  astringents  must  be  given  freely. 

(б)  Indolent,  callous,  or  chronic  ulcer. — This 
sub-variety  occurs  when,  from  chronic  irritation, 
the  fibrous  tissue  induration  is  excessive,  tb9 
blood-vessels  reach  the  surface  of  the  ulcer  in 
too  minute  quantities  to  build  up  healthy  granu- 
lations, and  so  the  ulcer  is  perpetuated. 

The  surface  is  sunk  below  the  level  of  its  sur- 
roundings, is  destitute  of  granulations,  and  looks 
glazed.  The  edges  are  raised,  hard,  and  irre- 
gular. The  surroundings  are  indurated,  raised, 
and  the  veins  in  them  are  frequently  made  vari- 
cose. The  discharge  is  thin,  serous,  and  small 
in  quantity.  The  pain  at  times  is  very  great, 
especially  at  night. 

Treatment. — The  induration  is  got  rid  of  by 
strapping  tightly  and  evenly  with  soap  or  resin, 
or  a mixture  of  soap  and  resin  plaster;  holes  must 


ULCER. 


1698 

be  made  in  the  plaster  to  allow  tne  discharge  to 
escape,  and  the  strapping  should  be  reapplied 
every  forty-eight  hours.  At  each  removal,  the  sur- 
face may  be  touched  with  caustics,  or  washed  with 
a.  strongly  stimulating  lotion,  as  of  carbolic  acid, 
1 to  20,  or  chloride  of  zinc  20  grains  to  the  ounce. 
When  the  induration  is  gone  and  granulations 
appear,  the  ordinary  treatment  for  a healthy 
ulcer  is  all  that  is  required.  Another  method  is 
to  blister  the  surface  of  the  ulcer  with  emplas- 
trum  lyttse,  or  solution  of  cantharides,  to  apply 
a poultice  over  all,  and  to  let  this  remain  for  six 
hours ; and  on  removal  of  this,  to  wash  the  part 
with  carbolic  acid  lotion,  1 to  20,  and  apply  anti- 
septic dressings  {see  Antiseptic  Treatment). 
Still  another  method  of  treatment  is  by  the  elastic 
bandage  ; this  is  used  for  the  lower  extremity 
only.  We  first  wash  the  part  with  carbolic  acid 
1 to  20,  and  then  bandage  the  limb  firmly  and 
evenly  with  Martin’s  elastic  bandage,  from  the 
toes  upwards,  covering  over  the  ulcer.  No  dress- 
ing is  placed  over  the  ulcer.  The  bandage  by 
continued  pressure  causes  softening,  liquefaction, 
and  absorption  of  the  hard  surroundings  ; and 
the  surface  of  the  ulcer  is  bathed  in  the  natural 
secretion  of  the  part.  The  bandage  is  removed 
nightly,  washed  with  carbolic  acid,  hung  up  to 
dry  at  a distance  from  the  fire,  and  reapplied  in 
the  morning. 

3.  Ulcers  that  do  not  heal,  from  excess 
of  action. 

(а)  Irritable  ulcers. — These  are  met  with  on 
the  legs  of  nervous  and  anaemic  women.  The 
surface  is  uneven,  covered  often  with  a grey 
slough.  The  edges  are  irregular.  The  surround- 
ings are  red  and  glazed,  but  not  thickened.  The 
discharge  is  a thin  sanious  pus.  The  pain  is 
excessive,  of  an  aching  kind. 

Treatment. — In  the  treatment  of  irritable 
ulcer  it  is  necessary,  first  of  all,  to  relieve  pain 
by  giving  opium  hypodermically  or  internally, 
and  opiate  or  lead  lotions  externally.  We  must 
then  remove  the  cause  by  restoring  the  patient’s 
health  and  tone.  When  the  pain  has  ceased  we 
treat  the  ulcer  by  any  of  the  above  methods. 

(б)  Inflamed  ulcers. — Any  form  of  ulcer  may 
become  inflamed.  This  sub-variety  usually  arises 
during  the  course  of  an  indolent  ulcer,  from 
derangement  of  the  patient’s  health  and  local 
irritation. 

The  surface  is  covered  with  a greenish-grey 
slough.  The  edges  are  sw’ollen,  everted,  red,  and 
angry.  The  surroundings  are  red,  swollen,  and 
hot.  The  discharge  is  ichorous,  offensive,  often 
bloody,  and  causing  irritation  wherever  it  touches. 
The  pain  is  of  a throbbing  kind. 

Treatment. — The  inflamed  ulcer  should  be 
treated  by  rest,  with  bread-poultices  properly 
applied ; by  three  or  four  leeches,  applied  around 
the  sore  ; or  by  scarification  of  the  edges,  which 
will  allay  the  inflammation.  After  this  the  or- 
dinary treatment  recommended  above  is  to  be 
followed. 

4.  Ulcers  that  do  not  heal,  from  pecu- 
liarity of  action. 

(a)  Phagcdcenic  and  Sloughing  ulcers. — When 
an  inflamed  ulcer  commences  to  spread,  the  edges 
liquefy  and  rapidly  break  down.  This  may  take 
place  with  extraordinary  rapidity,  as  in  chancre, 
'when  it  is  called  phagedaena,  or  as  in  hospital 


gangrene,  when  it  spreads  chiefly  by  sloughing. 
The  patient  in  either  case  is  usually  in  a cachectic 
state ; the  ulcerated  part  is  dusky  red,  angry- 
looking,  hot,  and  painful.  The  surface  is  covered 
by  a grey  or  black  slough,  and  the  edges  are 
sharply  cut  and  underminod.  See  Bcno;  Gan- 
grene; and  Venereal  Sore. 

Treatment. — Rest,  opiates  internally  and 
externally  in  the  form  of  lotions,  and  careful 
dieting  are  necessary,  to  subdue  the  spread  of 
the  inflammatory  action.  Should  this  not  con- 
trol the  action,  the  application  of  strong  nitric 
acid  will  often  succeed.  Fresh  air  and  disinfec- 
tants are  abundantly  required. 

(6)  Varicose  ulcers. — The  points  to  be  observed 
about  a varicose  ulcer  are  that  it  follows  the 
chronic  irritation  of  a varicose  vein;  that  when 
formed  it  may  become  indolent,  inflamed,  irri- 
table, &c.;  and  that  it  frequently  bleeds,  from 
the  ulcerative  actiou  extending  towards  and 
thinning  the  wall  of  a vein.  See  Veins,  Diseases 
of. 

Treatment. — Varicose  ulcer  itself  is  to  be 
treated  by  the  ordinary  methods,  but  the  vari- 
cose vein  must  be  supported  by  an  elastic  stock- 
ing, or,  what  is  better  when  the  ulcer  is  in  a 
healthy  state,  Martin’s  elastic  bandage. 

(c)  Hemorrhagic  ulcers. — Htemorrhagic  ulcers 
occur  in  persons  suffering  from  amenorrhoea, 
scurvy,  chronic  jaundice,  or  hemophilia.  They 
possess  the  characters  of  irritable  ulcers,  but  in 
addition  have  a special  tendency  to  ooze  blood 
from  the  surface.  The  blood  is  of  a capillary- 
venous  character,  and  flows  freely  at  times. 

Treatment. — In  the  haemorrhagic  sub-variety 
we  have  to  attend  to  the  diathesis  with  which 
this  special  form  of  ulceration  is  associated, 
and  treat  the  ulcer  by  any  one  of  the  usual 
methods. 

(d)  Syphilitic,  lupoid,  rodent,  scorbutic,  endo- 
thelial, and  mucous  ulcerations. — These  are  de- 
scribed in  separate  articles. 

One  form  of  ulcer  possesses  so  much  interest 
to  the  practitioner  that  it  calls  for  special  con- 
sideration. 

Bed-sore.  — Stnon  : Fr.  Decubitus ; Ger. 
Decubitus ; Wundliegcn. 

Definition. — A form  of  nicer  caused  by  con- 
tinued pressure,  consequent  cn  the  recumbent 
position. 

-ZEtiology. — Bed-sores  are  dependent  either 
on  a low  condition  of  the  nutrition  of  the  tissues 
of  the  patient,  on  bad  nursing,  or  on  a combina- 
tion of  the  two.  In  patients  suffering  from  frac- 
tured spine,  especially  if  the  spinal  cord  be  tom  ; 
in  those  paralysed  from  other  causes  ; in  cases 
of  fractures  of  the  lower  extremity;  in  angular 
curvature  of  the  spine  ; in  patients  suffering  from 
hip-joint  diseases ; in  the  acute  specific  fevers ; 
and  in  the  aged — in  fact,  in  any  disease  neces- 
sitating long  confinement  to  bed,  and  rest  in  one 
position — bed-sores  may  be  developed.  When 
in  addition  to  the  illness,  the  nursing  is  badly 
conducted,  as  shown  by  urine,  pus,  blood,  or  any 
discharge  whatever  being  allowed  to  remain  on 
the  part  where  the  patient  lies,  a strong  deter- 
mining cause  is  set  up,  which  will  in  all  proba- 
bility end  in  a bed-sore.  Other  strongly  predis- 
posing causes  are  the  use  of  a feather  bed,  and 


ULCER. 


the  presence  of  a blanket  between  the  mattress 
and  the  under  sheet,  into  which  the  perspiration 
from  the  patient’s  body  soaks,  causing  the  blanket 
to  act  like  a poultice.  Hence  it  will  be  seen  that 
paralysis  and  an  enfeebled  state  of  the  circula- 
tion, combined  with  pressure  and  inattention  to 
strict  rules  of  cleanliness,  are  the  main  elements 
present  in  the  production  of  a bed-sore. 

The  various  sites  on  which  bed-sores  form  are 
arranged  here  in  the  order  of  frequency  with 
which  they  are  met : — the  heel,  the  sacrum,  the 
buttocks,  over  the  trochanters,  between  the  shoul- 
ders, on  the  middle  of  the  back  from  the  shoul- 
ders to  the  sacrum,  on  the  malleoli,  on  the 
elbows,  and  on  the  calf  of  the  leg.  On  the  heel 
the  usual  cause  is  the  pressure  of  a splint;  on 
the  elbow  bed-sores  frequently  supervene  in  such 
cases  as  hip-joint  disease,  owing  to  the  tendency 
patients  have  to  support  themselves  on  one  or 
both  elbows. 

Anatomical  Characters.  — This  disease  is 
only  one  of  the  many  forms  of  the  evil  results 
of  pressure.  The  passage  of  blood  through  a 
part  where  pressure  is  great  becomes  mecha- 
nically difficult.  Exudation  from  the  blood- 
vessels takes  place,  causing  the  cuticle  to  be 
Srst  raised,  then  to  peel  off,  and  finally  a moist 
catarrhal  surface  results.  By-and-by  stagnation 
of  the  blood  in  the  blood-vessels  occurs,  and  as 
a consequence  the  part  becomes  practically  dead. 
In  the  surrounding  parts  the  blood-vessels  be- 
come engorged ; and  the  presence  of  the  slough 
acting  as  a foreign  body,  the  irritation  causes 
inflammation,  and  an  exudation  of  inflammatory 
products  occurs  between  the  living  and  dead 
parts.  This  takes  place  all  around  and  beneath 
the  slough,  but  is  first  apparent  as  a furrow  on 
the  skin.  This  furrow  gets  gradually  deeper 
and  deeper,  and  the  process  of  separation  extend- 
ing beneath  the  slough,  it  becomes  detached  and 
finally  thrown  off.  An  ulcerating  surface  now 
results,  the  further  history  of  which  will  vary 
with  the  patient’s  health,  and  according  as  the 
illness,  which  rendered  confinement  to  bed  neces- 
sary, is  of  a curable  or  an  incurable  nature. 

Symptoms.  — The  premonitory  symptoms  of 
bed-sore  may  be  either  subjective  or  objective. 
Subjectively  the  patient  complains  that  the  bed 
feels  hard,  that  there  is  a crease  in  the  sheet, 
that  there  are  crumbs  of  bread  or  salt  in  the 
bed ; along  with  these  generally  imaginary  trou- 
bles, a pricking  numbing  sensation  is  felt  at  the 
point  of  pressure ; but  on  examination  of  the 
part  complained  of,  no  change  may  be  apparent. 
Or,  again,  the  complaints  may  be  nil,  as  in  the 
paralysed,  and  yet  the  effects  of  pressure  may  be 
far  advanced.  The  objective  symptoms,  that  is, 
the  changes  apparent  in  the  part,  may  be,  as  in 
the  paralysed,  the  first  indication  of  the  effects  of 
pressure.  These  are — alteration  in  the  colour  of 
the  skin,  a roughening  of  the  cuticle,  and  a vari- 
able amount  of  pain  on  pressure  with  the  finger. 
Any  of  these  is  sufficient  indication  that  preven- 
tive measures  must  be  immediately  undertaken, 
otherwise  a bed-sore  will  develop.  As  the  symp- 
toms advance,  the  discoloration  becomes  deeper, 
passing  from  red  to  livid  red,  from  purple  to 
black.  The  pain,  except  in  the  paralysed,  be- 
comes for  a time  severe,  and  then  finally  dis- 
appears, as  all  nervous  connexions  are  severed. 


160$ 

The  circulation  through  the  part  being  com- 
pletely stayed,  a dark  slough  is  formed,  and  a 
line  of  demarcation  between  the  living  and  dead 
tissue  is  set  up.  A foul  discharge  runs  from  the 
part ; the  tissues  around  become  red  and  con- 
gested ; the  edges  are  undermined ; and  a feeble 
attempt  is  made  to  throw  off  the  central  slough. 
Should  the  slough  be  thrown  off,  the  muscles, 
fascite,  and  even  the  bone  of  the  damaged  part 
may  be  exposed.  The  general  symptoms  asso- 
ciated with  bed-sores  are  chiefly  those  of  the  dis- 
ease in  the  course  of  which  this  complication  has 
supervened.  In  some  instances  a form  of  pyrexia 
may,  however,  be  induced  by  the  discharging 
ulcer  itself — a condition  which  constitutes  one 
form  of  ‘ bed-fever.’ 

Diagnosis. — The  appearances  described  in  the 
skin,  at  the  point  or  points  of  pressure,  are  un- 
mistakeable  evidence  either  of  the  likelihood  of 
a bed-sore  developing,  or  of  its  actual  presence. 

Progress  and  Prognosis. — Should  the  patient 
recover  from  the  illness  for  which  confinement 
to  bed  had  become  necessary,  the  bed-sore  will 
in  all  probability  heal.  Bed-sores,  however,  can 
scarcely  be  healed  in  those  patients  whose  mala- 
dies do  not  improve,  or  in  whom  recovery  does 
not  take  place.  At  times  pyaemia  supervenes ; or 
the  exhaustion,  consequent  on  a long-continued 
and  profuse  discharge  from  the  sore,  proves  too 
great  a drain  on  the  patient.  The  prognosis  in 
regard  to  bed-sores  developing  in  any  individual 
case,  will  depend  on  the  disease,  the  age  of  the 
patient,  and  the  care  taken  in  nursing.  The 
patients  in  whom  a bad  prognosis  might  be 
given,  in  regard  to  the  appearance  of  a bed-sere, 
would  be  the  old,  and  the  partially  paralysed, 
especially  when  bad  nursing  is  superadded. 

Treatment. — It  is  necessary  to  consider  this 
subject  under  the  heads  of  (1)  the  preventive 
measures  ; (2)  the  treatment  when  abrasions  have 
taken  place ; and  (3)  the  treatment  or  cure  of  the 
sore  when  formed. 

(1)  The  preventive  measures  have,  in  para- 
lysed patients,  and  in  patients  suffering  from 
incontinence  of  urine,  to  be  commenced  at  the 
beginning  of  the  illness,  and  signs  of  changes 
in  the  skin  are  not  to  be  waited  for.  The  part 
must  be  thoroughly  cleaned,  the  circulation 
stimulated,  the  skin  hardened,  and  pressure  re- 
moved from  the  parts  where  it  is  greatest.  The 
best  means  by  which  to  gain  these  ends  are  as 
follows.  First,  we  must  wash  the  part  with  soap 
and  water ; and  then  dry  it  thoroughly.  Se- 
condly, a piece  of  cotton  wool  dipped  in  spirits  of 
wine,  eau-de-Cologne,  or  brandy,  must  be  applied 
to  the  part  with  gentle  rubbing,  until  the  part  has 
become  thoroughly  dry  ; and  this  process  must 
be  repeated  three  or  four  times  at  each  dressing. 
Thirdly,  a draw-sheet  must  be  placed  beneath 
the  patient,  and  oxide  of  zinc  powder  sprinkled 
on  the  part  on  which  the  patient  is  to  lie  ; the 
sheet  must  be  changed  the  moment  it  becomes 
wet,  whether  from  urine,  blood,  pus,  or  sweat. 
Next,  we  must  keep  the  skin  supple.  To  manage 
this,  a very  small  quantity  of  oxide  of  zinc  oint- 
ment or  simple  ointment  must  be  rubbed  into 
the  part,  until  all  greasy  feel  lias  disappeared. 
This  is  to  follow  the  application  of  spirit.  Pres- 
sure must  be  removed  by  frequent  changes  of 
position,  and  by  suitable  pads,  air-cushions, water- 


1700  ULCER, 

pillows,  or  water-beds.  The  part  where  the 
edges  of  the  cushion  press  is  to  be  treated  by 
the  same  preventive  measures,  and  to  be  dressed 
two  or  three  times  a day.  Lastly,  we  must  avoid 
a feather  bed,  and  a blanket  beneath  the  under 
sheet.  In  many  cases  bed-sores  are  caused  by 
careless  nursing,  but  in  others  the  best  nursing 
possible  caunot  prevent  badly  nourished  tissues 
from  falling  into  decay. 

(2)  When  abrasion  or  roughening  of  the  cuticle 
occurs,  the  same  precautions  in  regard  to  pres- 
sure, moisture,  and  the  use  of  the  draw-sheet 
have  to  be  observed ; and,  in  addition,  some 
specific  applications  are  used.  Sometimes  the 
part  is  greased  over  with  zinc  or  simple  oint- 
ment ; this  is  useful  in  certain  cases,  preventing 
urine  or  other  irritating  fluid  from  touching  the 
tender  parts.  Over  an  abraded  portion,  soap 
plaster  spread  on  amadou  or  linen  is  applied ; at 
other  times  collodion  or  flexible  collodion  maybe 
used.  The  best  fluid  applications  are  rectified 
spirit,  or  camphorated  spirit,  with  one-third 
water ; it  is  necessary  to  add  water  owing  to  the 
pain  caused  by  pure  spirit.  The  surface  may 
also  be  touched  with  a solution  of  2 grains  of 
mercuric  chloride  in  one  ounce  of  spirit ; or  with 
one  consisting  of  5 grains  of  nitrate  of  silver  to 
an  ounce  of  water. 

(3)  The  treatment  of  the  bed-sore  itself  con- 
sists in  keeping  the  part  sweet ; in  aiding  the 
removal  of  the  slough  ; in  applying  some  one  of 
the  many  stimulant  and  disinfectant  lotions  in 
use  ; and  in  preventing  the  neighbouring  tissues 
from  breaking  down.  To  clean  the  parts,  and 
hasten  the  removal  of  the  slough,  we  must  apply 
a bread-and-water  poultice.  When  the  discharge 
is  foul,  the  part  should  be  washed  with  Condy’s 
fluid  between  each  application  of  the  poultice  ; 
and,  to  overcome  the  odour  and  sweeten  the  part, 
a poultice  of  half  linseed-meal  and  half  charcoal 
should  then  be  applied,  and  changed  every  three 
hours.  Poulticing  should  not  be  continued  longer 
than  is  necessary  to  clean  the  surface,  as  the 
heat  and  mcisture  tend  to  soften  and  weaken  the 
parts,  and  permit  of  their  rapidly  breaking  down. 

Stimulating  and  disinfectant  dressings  are  em- 
ployed in  one  or  other  of  the  following  methods. 
Cut  a piece  of  lint  the  exact  size  of  the  sore  ; 
soak  it  in  some  stimulant  and  disinfectant  lotion, 
such  as  carbolic  acid,  1 in  40,  or  the  red  lotion, 
or  the  compound  tincture  of  benzoin,  the  balsam 
of  Peru,  or  the  tincture  of  myrrh  or  of  catechu; 
and  apply  it  exactly  within  the  edge  of  the  sore. 
Ovor  this  piece  of  lint  place  a piece  of  oiled  silk 
or  guttapercha  tissue,  a fraction  larger  than  the 
lint  used  ; and  over  this  again  three  or  four  large 
folds  of  lint  or  amadou,  with  a hole  cut  in  the 
centre  corresponding  fo  the  sore. 

In  place  of  the  folds  of  lint  and  amadou,  pads 
or  water-cushions  might  be  used  to  take  the 
pressure  off.  When  the  slough  is  large,  lotions 
and  poultices  should  not  be  applied  to  it,  as  the 
moisture  only  favours  putrefaction.  To  prevent 
this,  we  may  place  a piece  of  oiled  silk  or  gutta- 
percha tissue  exactly  over  the  slough ; and  the 
lint,  dipped  in  one  of  the  above-mentioned  lo- 
tions, when  applied  over  it,  can  only  touch  the 
sore  at  the  ulcerating  furrow  between  the  living 
and  dead  tissue.  All  dressings  should  be  fixed 
by  diachylom  plaster,  and  not  by  a bandage, 


UMBILICAL  REGION, 
owing  to  the  heat  and  moisture  engendered  by 
use  of  the  latter. 

The  neighbouring  tissues  must  be  treated  with 
the  preventive  measures  mentioned  above. 

When  the  slough  has  separated,  an  attempt  is 
to  be  made  to  heal  the  part  by  improving  the 
patient’s  general  health,  provided  the  existing 
malady  permits.  The  usual  precautions  have  to 
be  taken  with  the  surrounding  parts ; and  the 
ulcer  treated  by  one  of  the  methods  recom- 
mended under  the  head  of  ulcers  that  do  not 
heal  from  defect  of  nutrition. 

Jawf.s  Cantlie. 

UMBILICAL  REGION.— This  is  the  cen- 
tral region  of  the  abdomen,  corresponding  to 
the  umbilicus  and  its  vicinity.  The  principal 
structures  which  normally  lie  underneath  it  are 
the  great  omentum,  and  part  of  the  transverse 
colon  and  small  intestines,  with  the  deep  struc- 
tures situated  in  front,  of  the  spine.  The  stomach 
often  reaches  the  umbilical  region  when  distended 
after  a meal. 

Clinical  Investigation. — There  is  nothing 
special  to  say  on  this  point,  the  ordinary  methods 
of  abdominal  examination  being  applicable  in  the 
investigation  of  the  umbilical  region.  The  fol- 
lowing points  may  be  noticed  with  regard  to  the 
abnormal  conditions  met  with  in  this  region. 

1.  When  the  stomach  is  diseased,  it  is  often 
so  distended  as  to  reach  the  umbilical  region. 
The  liver  also,  either  when  enlarged  or  displaced 
downwards,  frequently  extends  to  this  region. 
More  exceptionally  the  spleen  or  kidney  may 
attain  such  a size  as  to  encroach  upon  it.  En- 
larged organs  or  tumours  may  also  ascend  thus 
far  from  below,  as  in  the  case  of  the  uterus  and 
ovaries  ; and  even  a distended  bladder  may  rise 
to  this  height. 

2.  In  general  enlargement  of  the  abdomen 
the  umbilicus  and  its  vicinity  often  give  use- 
ful information  in  determining  its  cause.  Thus, 
when  the  enlargement  is  due  to  fluid  in  the  peri- 
toneum, the  umbilicus  tends  to  become  stretched, 
everted,  obliterated,  or  pouched  out,  which  is  not 
the  case  in  other  forms.  In  some  instances  of 
portal  obstruction  it  not  only  projects,  but  has 
a peculiar  feel,  due  to  the  presence  of  enlarged 
and  thickened  veins.  Moreover,  the  percussion 
sound  in  this  region  remains  tympanitic,  and 
sometimes  even  excessively  so,  when  the  rest  of 
the  abdomen  is  universally  dull.  On  the  other 
hand,  when  the  enlargement  is  due  to  an  organ 
or  tumour,  this  is  not  observed,  and  the  umbili- 
cal region  is  often  dull  when  the  flanks  are  re- 
sonant. An  important  element  in  the  diagnosis 
of  ovarian  tumour  is  often  thus  afforded. 

3.  Should  a very  small  quantity  of  fluid  be 
present  in  the  abdominal  cavity,  this  may  be 
detected  by  placing  the  patient  on  his  hands 
and  knees,  when  the  fluid  gravitates  towards  the 
umbilical  region,  and  can  be  discovered  there  by 
percussion. 

4.  The  umbilicus  itself  may  be  the  seat  of 
disease,  such  as  inflammation,  eczema,  or  gan- 
grene. These  conditions  are  most  important  in 
infants,  and  soon  after  birth  peritonitis  may 
be  set  up  by  the  extension  of  irritation  from  the 
umbilicus  inwards. 

5.  The  umbilical  portion  of  the  abdominal 


UMBILICAL  REGION, 
vail  is  liable  to  be  involved  in  malignant  disease 
affecting  the  underlying  great  omentum,  to  which 
it  then  becomes  fixed,  so  that  it  cannot  be  moved. 

6.  Umbilical  hernia  is  an  important  form  of 
hernia,  of  which  the  writer  has  seen  several 
examples.  It  may  attain  a very  large  size. 
Moreover,  in  connection  with  this  condition, 
much  thickening  and  induration  may  be  met 
with  about  the  umbilicus,  as  the  result  of  a 
chronic  inflammation.  The  writer  has  met  with 
one  ease  presenting  these  changes  in  a marked 
degree.  Frederick  T.  Roberts. 

UNCONSCIOUSNESS.  — Loss  of  consci- 
ousness or  mental  perception.  See  Conscious- 
ness, Disorders  of. 

UNDERCLIFF,  on  the  South  Coast  of 
the  Isle  of  Wight. — Extends  from  Bonchurch 
to  Niton.  A mild,  tonic  climate.  Yentnor  ; 
and  Climate,  Treatment  of  Disease  by. 

UNILATERAL  FACIAL  ATROPHY.— 

Synon.  : Progressive  Facial  Hemiatrophy;  Neu- 
rotic Facial  Atrophy ; Fr.  Aplasie  lamineuse pro- 
gressive ; Ger.  Prosopodysmorphia. 

In  this  affection  the  whole  of  one  side  of  the 
face  becomes  notably  smaller  than  its  fellow, 
owing  to  an  atrophic  condition  of  the  subcuta- 
neous tissaes  and  of  the  skin,  together  with 
atrophy  of  the  muscles,  and  sometimes  even  of 
the  bones  on  the  affected  side  of  the  face.  The 
pathology  of  this  rare  progressive  atrophy  of 
one  side  of  the  face  is  involved  in  considerable 
doubt.  It  has  been  regarded  by  some  as  an 
essential  atrophy ; by  others,  as  a result  of 
disease  in  certain  hypothetical  ‘ trophic  nerves  ’ ; 
by  others  as  a result  of  irritation  acting  upon  the 
fifth  nerve,  and  on  the  portio  dura  of  the  seventh 
cranial  nerve ; and,  finally,  as  an  effect  of  per- 
sistent irritation  acting  upon  the  cervical  sympa- 
thetic, especially  in  its  upper  and  middle  ganglia. 
These  ganglia  have  been  found  distinctly  tender 
on  pressure  being  made  over  them ; and  the  latter 
view  as  to  the  pathology  of  the  affection  would 
seem  to  be  still  further  borne  out  by  the  fact, 
that  marked  amelioration  has  been  produced  in 
6ome  cases  by  the  long-continued  application  of 
a continuous  current,  of  weak  tension,  to  the  cer- 
vical sympathetic  gaDglia. 

H.  Charlton  Bastian. 

UNILATERAL  HYPERIDROSIS.  — 

Synon.  : Hyperidrosis,  or  Ephidrosis  unilate- 
ralis. — Excessive  perspiration  on  one  half  of  the 
body,  occurs  more  or  less  habitually,  or  only 
after  exercise.  It  may  be  limited  to  one  side  of 
the  face  and  head,  or  the  neck  may  be  included; 
or  it  may  implicate  the  whole  of  one  half  of  the 
body.  It  has  sometimes,  and  especially  when 
limited  to  the  face  and  neck,  appeared  as  one  of 
the  symptoms  due  to  paralysis  of  the  cervical 
sympathetic  nerve.  In  other  cases  no  such  re- 
lation has  been  ascertained  to  exist.  See  Sym- 
pathetic System,  Disorders  of. 

Treatment. — In  the  absence  of  definite  in- 
formation as  to  the  pathology  of  this  affection  it 
is  not  possible  to  indicate  any  rational  principles 
ef  treatment.  Empirically  some  of  the  remedies 
used  for  checking  perspiration,  such  as  zinc, 


UR2EMLA.  17  W 

belladonna,  and  quinine,  may  be  tried.  See  Per- 
spiration, Disorders  of. 

H.  Charlton  Bastian. 

URJEMIA  ( oZpov , urine,  and  alfia,  the 
blood). — Synon.  : Fr.  Uremie ; Ger.  Urdmie. 

Definition. — This  term  is  applied  to  a group 
of  nervous  symptoms,  which  occasionally  occur 
in  the  course  of  acute  or  chronic  Bright’s  dis- 
ease, as  well  as  in  other  maladies  which  prevent 
the  secretion  or  the  discharge  of  the  urine. 

.^Etiology  and  Pathology.  — The  circum- 
stances in  which  uraemia  arises  are  pretty  well 
ascertained,  but  the  connection  between  these 
circumstances  and  the  symptoms  is  still  obscure. 
It  occurs  when  there  is  interference  with  the 
secretion  or  the  discharge  of  urine.  It  is  thus 
met  with  in  all  the  forms  of  Bright’s  disease ; in 
cystic,  tubercular,  and  cancerous  disease  of  the 
kidney;  in  suppurative  nephritis  ; and  in  cases 
of  anuria,  either  of  obstructive  or  of  non-obstruc- 
tive origin.  But  some  of  these  conditions  fre- 
quently exist  for  long  periods  without  ursemia 
being  developed,  and  it  is  sometimes  developed 
unexpectedly  without  apparent  alteration  of  the 
patient’s  state.  The  attack  is,  however,  precipi- 
tated frequently  by  pregnancy  and  parturition  ; 
by  indulgence  in  alcohol ; sometimes  by  the 
recurrence  of  the  menstrual  period ; and  pro- 
bably by  intercurrent  disease.  But  the  occur- 
rence of  these  conditions  does  not  in  all  cases 
suffice  to  induce  it,  for  many  women  suffering 
from  Bright’s  disease  pass  through  pregnancy 
and  labour  without  manifesting  uraemic  symp- 
toms, and  so  with  other  inducing  causes. 

Of  the  exact  nature  of  the  uraemic  process  we 
are  unable  to  speak  at  present  with  certainty. 
Two  sets  of  explanations  have  been  suggested — 
namely,  the  mechanical  and  the  chemical.  Dr. 
Owen  Rees,  in  this  country,  and  Prof.  Traube, 
in  Germany,  have  been  among  the  chief  expo- 
nents of  the  mechanical  explanations.  The  for- 
mer dwelt  upon  the  wateriness  of  the  brain  in 
many  cases  of  ursemia ; the  latter  suggested  pro- 
cesses by  which  that  oedema  might  arise.  Sud- 
den increase  of  blood-pressure,  and  sudden  in- 
crease of  the  proportion  of  water  in  the  blood, 
might,  he  thought,  suffice  to  account  for  the 
condition.  Rosenstein  and  others  have  lent  the 
weight  of  their  authority  to  these  views.  Monck 
has  sought  to  demonstrate  by  experiment  that 
cerebral  oedema  from  increased  pressure  may 
produce  the  result ; but  even  if  these  experi- 
ments had  been  correct,  which  is  doubted  by 
many,  it  cannot  be  denied  that  there  are  many 
well-marked  cases  of  ursemia  in  which  there  is 
no  encephalic  oedema.  The  observation  of  Po- 
poff,  which  refers  the  changes  to  accumulation  of 
altered  corpuscles  within  the  cerebral  capillaries, 
may  prove  important,  if  it  should  be  confirmed 
by  other  authorities. 

Among  the  chemical  theories  one  of  the  earliest 
was  that  which  referred  the  process  to  retention 
of  urea,  but  many  difficulties  arise  in  connection 
with  this.  The  very  ingenious  theory  of  Frerichs, 
which  referred  the  process  to  decomposition  of 
retained  urea  by  the  action  of  a ferment,  must 
now  be  held  to  be  disproved,  in  consequence  of 
evidences  discovered,  both  of  a negative  and  of 
a positive  kind.  The  evidence  at  present  before 


UEA2MIA. 


1702 

as  seems  to  point  to  the  probability  of  the  pro- 
cess being  due  to  retention  of  some  excrementi- 
tious  material  or  materials. 

Symptoms.  — All  the  functions  of  the  nervous 
system  are  occasionally  involved  in  uraemia. 
Among  the  disorders  of  the  sensory  function  the 
most  common  are  pain,  especially  in  the  head, 
sometimes  very  intense  and  persistent;  dimness 
of  sight,  or  actual  blindness  of  one  or  both  eyes, 
sometimes  attended  by  no  change  in  the  retinae, 
at  others  by  retinitis  albuminurica ; ringing  in 
the  ears  ; and  sometimes  deafness.  Among  the 
motor  changes  the  most  striking  are  the  general 
convulsions  or  twitching  of  muscles ; the  tendency 
to  vomiting;  and  sometimes  extreme  dyspnoea. 
Among  cerebral  and  mental  derangements,  drow- 
siness, torpor,  coma,  and  delirium  are  the  chief. 

The  forms  of  ursemia  generally  recognised  are 
the  chronic  and  the  acute. 

1.  Chronic  Ursemia. — This  comes  on  gra- 
dually, and  may  at  first  scarcely  attract  atten- 
tion; the  habitual  liStlessness  and  indifference 
of  manner  observable  in  cases  of  Bright's  disease 
becomes  increased.  Movements  are  slow,  and 
speech  is  somewhat  indistinct.  There  is  often 
dimness  of  sight,  ringing  in  the  ears,  uneasiness 
in  the  head,  or  violent  and  persistent  headache. 
The  condition  of  the  patient  varies ; the  symp- 
toms occasionally  pass  away,  but  they  constantly 
recur  and  become  by  degrees  more  intense.  The 
drowsiness  passes  into  torpor.  If  the  patient 
is  roused  to  speak,  his  articulation  is  thick  aDd 
indistinct.  It  soon  becomes  impossible  to  elicit 
any  answer ; lethargy  deepens  into  coma ; the 
breathing  becomes  stertorous,  or  rather  hissing 
in  character,  the  air  being  driven  against  the 
teeth  or  hard  palate;  and  death  supervenes. 
Sometimes,  instead  of  silence,  a rather  noisy 
delirium  comes  on,  in  which  wild  prolonged 
howls  alternate  with  muttering,  and  occasionally 
with  paroxysms  of  excitement.  Sometimes,  again, 
there  is  a low  prolonged  muttering,  with  a repe- 
tition of  the  same  expression  time  after  time. 
Subsultus  tendinum  and  twitching  of  the  facial 
muscles  are  commonly  seen  throughout.  Convul- 
sions, vomiting,  and  diarrhcea  are  frequent  symp- 
toms ; epistaxis  also  occurs,  but  more  rarely. 
This  form  of  uraemia  is  a common  mode  of  fatal 
termination  in  cases  of  chronic  Bright’s  disease. 
It  sometimes  occurs — but  much  more  rarely — in 
the  early  stage  of  the  inflammatory  form. 

2.  Acute  Uraemia. — This  includes  all  the 
varieties  iu  which  the  symptoms  are  suddenly 
developed.  There  are  three  common  forms — the 
comatose,  convulsive,  and  mixed ; and  several  less 
common,  namely,  the  delirious,  dyspncetic,  ocu- 
lar, and  articular.  In  the  acute  comatose  form, 
after  headache,  giddiness,  affection  of  sight,  vo- 
miting, or  delirious  excitement,  coma  is  rapidly 
developed ; or  it  may  supervene  without  such 
premonitory  symptoms.  The  face  is  usually  pale ; 
the  pupils  are  dilated  or  unaltered,  and  react 
slowly  to  light ; or,  on  the  other  hand,  there  may 
be  a red  spot  on  the  cheek,  injected  conjunctive, 
and  contracted  pupils.  There  is  a peculiar  stertor, 
not  the  deep  snoring  of  haemorrhagic  apoplex}-, 
but  a sharper,  more  hissing  sound,  produced  by 
;he  rush  of  expired  air  on  the  hard  palate  or 
teeth.  The  coma  may  rapidly  deepen,  and  death 
ensue  within  a few  hours  ; or,  on  the  other 


hand,  the  patient  may  rally  and  continue  free 
from  the  symptoms  permanently;  or  sooner  or 
later  uraemia  recurs  in  one  or  other  of  its  forms ; 
and  issues  in  death.  Acute  uraemic  coma  occurs 
in  all  of  the  forms  of  Bright’s  disease,  but  is 
most  frequent  iu  the  inflammatory’  and  cirrhotic 
varieties. 

The  second  acute  type  is  the  convulsive,  which 
may  almost  exactly  simulate  epilepsy ; or  be 
unattended  by  loss  of  consciousness ; or  may 
affect  certain  groups  of  muscles,  and  simulate 
tetanus.  The  attack  comes  on  suddenly,  with  or 
without  warning.  The  attacks  may  be  single  and 
solitary ; or  they  may  occur  in  rapid  succession, 
five  or  six,  or  even  more,  in  the  course  of  twelve 
hours.  They  may  be  recovered  from  • or  they 
may  prove  rapidly  fatal,  either  during  the 
paroxysm,  or  in  the  coma  which  succeeds  it. 
They  occur  in  all  the  forms  of  Bright’s  disease, 
but  most  frequently  in  the  cirrhotic  and  in  the 
inflammatory  form.  The  existence  of  cirrhosis 
of  the  kidney  is  not  unfrequently  first  revealed 
by  the  occurrence  of  convulsions. 

The  other  types  of  uraemia,  namely',  the  mixed, 
in  which  sudden  coma  occurs  with  convulsions, 
the  delirious,  in  which  the  ordinary  symptoms 
are  replaced  by  restless  delirium;  the  dyspnce- 
tic, in  which  there  are  sudden  attacks  of  breath- 
lessness, without  corresponding  change  in  the 
physical  signs  of  the  lungs  or  heart;  and  the 
articular,  which  Jaccoud  has  described  as  pre- 
senting many  features  in  common  with  acute 
rheumatism,  are  so  rare  that  they  need  not  be 
described  here. 

Diagnosis. — There  is  little  difficulty  in  dis- 
tinguishing the  chronic  form  of  ursemia  when 
fairly  established.  The  most  important  evi- 
dence is,  of  course,  afforded  by  examination  of 
the  urine.  Uraemia  sometimes  resembles  fever 
or  meningitis ; but  the  history  of  the  illness, 
the  state  of  the  urine,  the  temperature,  and  the 
mode  of  breathing,  suffice  to  distinguish  it  from 
these  conditions. 

The  acute  form  of  coma  may  closely  resemble 
hemiplegia  with  loss  of  consciousness,  but  differs 
iu  the  absence  of  paralysis  of  one  side,  and  also 
in  the  character  of  the  breathing,  while  the  con- 
dition of  the  urine  also  affords  important  indi- 
cations. 

The  convulsive  type  may  resemble  epilepsy, 
but  it  has  rarely  the  initial  cry,  the  corpse-like 
pallor,  the  predominance  of  convulsions  on  one 
side,  the  turning  in  of  the  thumbs  on  the  palms, 
and  the  loss  of  reflex  irritability,  The  chief  re- 
liance is  to  be  placed  on  the  analysis  of  the  urine, 
because,  although  after  true  epilepsy  albumen 
may  be  present,  and  urea  may  perhaps  be  dimi- 
nished for  a time,  the  secretion  soon  returns  to 
its  natural  condition,  while  in  uraemia  it  is  al- 
ways distinctly  albuminous.  From  opium-poi- 
soning it  is  distinguished  by  the  condition  of 
the  pupils,  and  the  examination  of  the  secretion. 
From  belladonna-poisoning  it  is  to  be  distin- 
guished by  the  same  considerations. 

Prognosis. — The  occurrence  of  ursemia  in  a 
case  of  Bright  s disease  is  always  grave ; the 
chronic  form  is  hopeless,  and  when  it  occurs  the 
duration  of  life  cannot  be  long.  The  acute  forms 
are  often  recovered  from ; they  sometimes  sub- 
side spontaneously,  but  when  they  are  due  to 


UR2EMIA. 

thronic  renal  disease,  death  cannot,  as  a rule, 
bs  regarded  as  far  off.  When  they  result  from 
acute  disease,  they  are  not  so  hopeless,  because 
the  conditions  on  which  they  depend  are  fre- 
quently removed  by  treatment.  Puerperal  cases, 
although  involving  great  immediate  danger,  are 
very  frequently  recovered  from,  probably  be- 
cause they  owe  their  origin  to  a combination  of 
circumstances  which  do  not  long  persist. 

Treatment. — The  first  indication  is  to  seek 
to  re-establish  the  suppressed  secretion  of  the 
kidneys.  For  this  purpose,  dry  cupping,  wet  cup- 
ping, leeching,  or  poulticing  over  the  loins,  and 
the  administration  of  digitalis  and  other  non- 
irritating diuretics,  are  indicated.  Frequently 
the  blood  must  be  relieved  more  rapidly  than 
the  action  of  the  diuretics  can  accomplish.  Ve- 
nesection, to  the  amount  of  eight,  ten,  or  more 
ounces,  may  be  of  use,  especially  in  the  puer- 
peral forms,  and  the  acute  inflammatory  cases. 
Purging  with  hydragogue  cathartics,  such  as 
elaterium,  or  compound  powder  of  jalap,  or 
jalap  aDd  scammony ; diaphoretics,  such  as  pilo- 
carpine subcutaneously  or  by  the  mouth;  and 
the  hot  pack — any  of  these  methods  may  often 
relieve  the  system  until  there  is  time  for  the 
diuretics  to  act.  When  the  convulsions  are 
severe,  sedatives,  such  as  bromide  of  potassium 
and  hydrate  of  chloral,  are  useful ; and  although 
some  writers  oppose  its  use,  on  the  ground  that 
it  meets  merely  a symptomatic  indication,  chlo- 
roform is  of  great  value.  It  quiets  the  nervous 
system,  and  checks  the  convulsions  more  rapidly 
than  anything  else,  but  the  tendency  to  coma  in 
the  individual  ease  must  be  carefully  kept  in 
view  while  chloroform  is  being  administered. 
Tonic  remedies,  and  articles  of  diet  such  as 
milk  (which  is  at  once  nourishing  and  power- 
fully diuretic)  should  be  given,  to  ward  off  a 
return  of  the  symptoms  in  cases  in  which  the 
uraemia  has  disappeared.  In  puerperal  cases  an 
obvious  and  important  indication  is  to  complete 
the  labour  with  as  little  delay  as  possible. 

Grainger  Stewart. 

URETERS,  Diseases  of.— Syxon.  : Fr.  Ma- 
ladies dcs  Urelercs;  Ger.  Kranlchcitcn  der  Ham- 
gang e. 

Morbid  conditions  of  the  ureters  are  so  gene- 
rally parts  of,  or  associated  with,  diseases  of 
the  bladder  or  kidney,  and  so  naturally  come 
to  be  described  in  the  articles  treating  of  these 
several  diseases,  that  a separate  account  or  dis- 
tinct classification  of  them  is  perhaps  scarcely 
called  for;  and  a brief  description  of  the  most 
important  will  be  sufficient  for  all  practical  pur- 
poses. 

1.  Congenital  Malformations.— A double 
ureter  is  the  most  frequent  malformation,  the 
division  sometimes  reaching  as  far  as  the  bladder. 
In  very  rare  cases  a triple  ureter  has  been  found. 
Congenital  malformations,  leading  to  more  or  less 
complete  obstruction  of  the  ureter,  are  found  most 
often  near  the  pelvis  of  the  kidney.  If  the 
obstruction  is  complete,  it  gives  rise  to  hydro- 
nephrosis ( see  Hydronephrosis).  If  incomplete, 
a slighter  degree  of  the  same  condition  results, 
the  pelvis  and  calyces  becoming  dilated,  and  the 
kidney-substance  atrophied  and  indurated.  The 
chief  congenital  obstructions  are — 1st.  Total 


URETEES,  DISEASES  OF.  1703 
obliteration  of  the  ureter  as  it  leaves  the  pelvis. 
2nd.  Valvular  opening  from  the  pelvis  into  the 
ureter.  This  becomes  gradually  more  complete 
as  the  dilatation  of  the  pelvis  increases.  3rd.  A 
spiral  arrangement  of  the  ureter.  4th.  An  ab- 
normal renal  artery  pressing  on  the  ureter  as  it 
leaves  the  pelvis.  The  incomplete  obstructions 
frequently  give  way  at  intervals,  when  there  will 
be  a copious  flow  of  urine,  usually  of  low  specific 
gravity  and  pale  colour.  One  instance  has  been 
recorded,  in  which  alternate  contraction  and 
dilatation  existed. 

2.  Acquired.  Obstruction. — Complete  ob- 
structions which  are  not-  congenital  may  arise 
First,  from  impaction  of  a renal  calculus  ; this 
may  take  place  at  any  point,  the  most  frequent 
being  at  the  vesical  orifice.  Secondly,  from  pres- 
sure of  tumours  or  other  conditions,  such  as 
uterine  cancer,  pelvic  tumours,  fibrous  bands, 
enlarged  glands,  or  faecal  accumulations,  in  which 
case  the  condition  would  at  first  be  incomplete. 
Incomplete  obstruction  arises  most  frequently 
from  impediments  to  the  discharge  of  urine,  exist- 
ing in  the  prostate  or  urethra.  In  the  former 
case,  the  bladder  being  in  a state  of  constant  over- 
distension, the  valved  opening  of  the  ureter  is 
closed  with  unnatural  force.  In  the  latter  the  hy- 
pertrophy of  the  bladder  increases  the  length  of 
the  portion  of  ureter  lying  in  the  bladder-walls, 
and  the  bundles  of  muscular  fibres  more  or  less 
constrict  the  orifice.  Any  cause  giving  rise  to 
hypertrophy  of  the  bladder  will  therefore  tend 
to  obstruct  the  orifice  of  the  ureter,  as  is  seen  in 
chronic  cystitis,  stone  in  the  bladder,  and  other 
conditions.  The  opening  is  still  further  narrowed, 
in  many  cases,  by  swelling  of  the  mucous  mem- 
brane, the  result  of  sub-acute  or  chronic  inflam- 
mation. Occasionally  the  orifice  may  be  partially 
obliterated  by  a villous  growth  in  the  bladder. 
Stricture  of  the  ureter  is  found  in  rare  cases,  ap- 
parently the  result  of  previous  inflammation  and 
ulceration.  Slight  obstruction  may  occur  during 
pregnancy,  from  the  pressure  of  the  gravid 
uterus. 

3.  Dilatation. — The  part  of  the  ureter  above 
any  obstruction  is  always  found  more  or  loss 
dilated,  according  to  the  degree  and  the  duration 
of  the  impediment  If  the  condition  be  acuts 
and  complete,  little  or  no  hypertrophy  of  the 
coats  of  the  meter  will  be  found;  but  if  chronic 
and  incomplete,  its  walls  will  be  thickened,  both 
by  fibroid  change,  and  by  hypertrophy  of  tht- 
muscular  coat.  The  dilated  ureter  is  always  tor- 
tuous, being  increased  in  length  as  well  as  in 
diameter,  and  may  even  resemble  a portion  of 
small  gut.  The  mucous  membrane  is  always 
opaque  and  somewhat  thickened,  occasionally  red 
and  injected,  and  frequently  pigmented  from 
previous  attacks  of  inflammation.  A largely 
dilated  ureter  may  sometimes  be  felt  through 
the  abdominal  wall.  There  will  probably  ba 
some  degree  of  pain  or  uneasiness  in  the  course 
of  the  canal,  or  in  the  loin ; and  a tendency  to 
sickness. 

4.  Inflammation. — Simple  inflammation  of 
the  ureter  is  frequently  found,  as  an  extension 
either  from  the  bladder  or  from  the  pelvis  of 
the  kidney.  Septic  inflammation  accompanies 
septic  pyelitis,  due  to  extension  of  decomposi- 
tion from  the  bladder  to  the  pelvis  of  the  k.f.uey 


1704  URETERS,  DISEASES  OF. 
Scrofulous  or  tubercular  inflammation  almost  in- 
variably accompanies  a similar  condition  of  the 
bladder  or  pelvis. 

5.  Malignant  Disease. — Cancer  may  extend 
from  neighbouring  organs  into  the  ureter,  but 
there  is  no  reason  to  believe  it  ever  primarily 
takes  origin  there. 

Neither  the  diagnosis  nor  the  treatment  of  an 
affection  of  the  ureter  can  be  separated  from  that 
of  the  disease  to  which  it  is  secondary. 

Mabcus  Beck. 

URETHRA,  Diseases  of.  — Synon.  : Fr.  Ma- 
ladies de  I'Urethrc;  Ger.  Krankheiten  der  Harn- 
rbhre. — The  affections  of  this  canal  comprise 
urethritis,  with  its  various  consequences,  such  as 
gleet,  warts,  peri-urethral  abscess,  inflamed  fol- 
licles, neuralgia,  and  stricture ; also  syphilis  and 
soft  chancre.  For  descriptions  of  most  of  these 
affections  the  reader  is  referred  to  the  articles 
Gonobbhcea  ; Gleet;  Syphilis;  and  Venereal 
Sobe.  Some  forms  of  urethritis,  neuralgia,  and 
stricture  remain  for  consideration  here  ; whilst 
certain  other  pathological  relations  involving  the 
urethra  will  be  briefly  referred  to. 

1.  Urethritis. — The  origin  of  urethritis  is 
uot  exclusively  due  to  contagion ; inflammation 
of  the  tract,  which  differs  mainly  by  less  accen- 
tuation of  its  features  from  contagious  urethritis, 
is  produced  by  injury,  by  gout,  or  even  by  tuber- 
cular disease;  A very  mild  form  of  urethritis  is 
an  occasional  concomitant  of  early  syphilis.  It 
subsides  spontaneously,  and  is  always  very  limited 
in  amount.  The  distinction  of  these  forms  from 
gonorrhoeal  urethritis  is  not  always  marked.  In 
traumatic  inflammation  the  signs  of  irritation 
follow  immediately  on  the  passage  of  the  foreign 
body,  such  as  a stone  or  a catheter;  soreness 
or  scalding  attends  the  first  subsequent  micturi- 
tion ; and  swelling  and  discharge  follow,  at  most 
twenty-four  hours  later.  In  gouty  urethritis  the 
inflammation  may  be  as  severe  as  in  well-marked 
gonorrhoea,  and  attended  by  the  complications  of 
the  testes,  bladder,  eye,  or  joints  which  are  met 
with  in  cases  of  gonorrhoea.  The  leading  dis- 
tinctions of  gouty  urethritis  are  the  milkiness  of 
the  discharge  ; the  absence  or  small  amount  of 
swelling  of  the  fore  part  of  the  urethra  ; though 
the  scalding  in  the  perinseum  and  irritability  of 
the  bladder  are  severe. 

Asparagus  and  arsenic  are  said  to  have  the 
power  of  producing  urethritis  in  some  persons. 
Tubercular  urethritis  is  always  a very  indolent 
affection,  being  due  to  the  slow  degeneration  and 
ulceration  of  tubercular  deposits  in  the  deeper 
portion  of’  the  canal.  In  such  cases  the  irrita- 
bility and  inflammation  of  the  bladder  are  al- 
ways more  urgent  than  the  urethritis;  while  the 
evidence  of  tubercular  disease  in  other  parts  of 
the  body  is  usually  sufficient  for  diagnosis. 

2.  Urethral  Fever — Sympathetic  Irrita- 
tion.— Besides  inflammation  and  its  complica- 
tions, the  urethra  is  the  source  of  the  conditions 
termed  urethral  fever,  and  sympathetic  irrita- 
tion of  the  nervous  system,  excited  by  certain 
states  of  the  urethra.  Also,  on  the  other  hand, 
the  urethra  is  occasionally  the  seat  of  certain 
symptoms  which  are  caused  by  disease  of  dif- 
ferent organs.  For  example,  the  passage  of  a 
calculus  along  the  ureter  will  determine  pain  in 


URETHRA,  DISEASES  OF. 
the  urethra.  Injury  of  the  other  parts  of  the 
body,  such  as  fracture  of  the  femur,  may  excite 
spasm  of  the  deeper  muscles  of  the  urethra,  and 
thus  produce  retention  of  urine. 

3.  Neuralgia. — The  causes  of  pain  felt  in 
the  urethra,  but  not  necessarily  due  to  disease 
of  that  part,  are  numerous.  Gouty  irritation  is 
frequent ; and  a nervous  condition  produced  by 
prolonged  debauchery  of  various  kinds  is  also 
not  uncommon.  The  gouty  state  is  relieved  by 
treatment  of  the  diathesis ; the  nervous  irritation 
by  suitable  general  treatment,  to  which  may  often 
be  added  local  applications  which  have  the  effect 
of  dulling  the  sensibility  of  the  urethra,  such  as 
the  passage  of  sounds,  and  the  use  of  astringent 
or  (in  obstinate  cases)  of  caustic  injections  to  the 
deeper  portions  of  the  urethra. 

4.  Stricture. — The  average  distensile  capacity 
of  the  urethra  has  a diameter  of  ten,  or  a cir- 
cumference of  thirty,  millimetres.  This  measure 
varies  in  different  portions,  being  widest  at  the 
portion  behind  the  transverse  ligament  (anterior 
layer  of  the  deep  perinseal  fascia),  slightly  less 
in  the  bulbous  portion,  and  least  at  the  meatus. 
This  outlet  is  indeed  frequently  considerably 
narrower,  varying  between  a mere  pinhole  and  a 
diameter  of  fourteen  or  fifteen  millimetres,  the 
most  common  size  being  twenty-five  millimetres. 
The  urethra  in  different  persons  ranges  between 
twenty  and  forty  millimetres  in  its  general  dis- 
tensile capacity. 

Strictures  are  abrupt  abnormal  contractions  of 
the  urethra  at  any  given  point  of  its  course,  and 
may  be  subdivided  into  (a)  spasmodic,  or  those 
due  to  temporary  contraction  of  the  muscular 
fibres  suiTounding  the  canal ; (A)  inflammatory, 
or  those  caused  by  swelling  and  congestion  of  a 
limited  area,  this  condition  being  usually  asso- 
ciated with  more  or  less  muscular  spasm ; and  (c), 
organic,  where  unyielding  fibrous  tissue  replaces 
the  normal  dilatable  structure  of  the  urethral 
walls.  In  the  cases  of  fibrous  thickening,  the 
narrowing  is  often  mucli  increased  by  muscular 
contraction. 

(a)  Spasmodic ; (A)  Inflammatory  Stricture. — 
The  spasmodic  stricture,  which  is  always  a tem- 
porary affection,  is  caused  by  muscular  con- 
traction from  reflex  irritation,  the  existence  of 
inflammatory  swelling  being  one  of  the  most 
frequent,  but  the  passage  of  a calculus  or  a 
catheter  may  also  excite  it.  Again,  the  presence 
of  a fibrous  stricture  near  the  meatus  will  fre- 
quently excite  reflex  spasm  of  the  deep  perinseal 
muscles.  The  inflamjnatory  stricture  is  due  to 
swelling  of  the  deeper  part  of  the  urethra  during 
inflammation.  It  is  a not  unfrequent  compli- 
cation of  acute  gonorrheea.  The  spasmodic  and 
inflammatory  strictures,  being  temporary  ail- 
ments, involve  no  permanent  lesions.  Their 
treatment  is  mainly  general,  consisting  in  the 
removal  of  irritation  and  congestion  by  salines, 
purgatives,  and  warm  baths  ; and  in  the  relief  of 
retention  of  urine,  if  present,  by  passing  a flex- 
ible catheter  (No.  5 or  6 of  the  English  scale). 

(c)  Organic  Stricture. — Organic  stricture  is  pro- 
duced sometimes  by  the  contraction  of  scars,  fol- 
lowing injury;  but  in  the  larger  number  of 
instances  it  is  the  result  of  long-continued  in- 
flammation of  the  sub-mucous  tissue  following 
gonorrhoea. 


URETHRA,  DISEASES  OF.  1705 


Organic  strictures  may  Re  situated  at  any 
part  of  the  urethra  except  the  prostatic,  being 
numerically  most  common  in  the  first  inch  from 
the  meatus.  But  the  thickest  and  toughest  stric- 
tures are  generally  found  near  the  juncture  of 
the  bulbous  and  membranous  portions  of  the  ure- 
thra, that  is,  about  five  inches  from  the  meatus. 
The  membranous  portion  is  only  affected  when 
large  development  of  cicatricial  tissue  reaches 
backwards  from  the  bulb.  This  new  tissue  is 
developed  in  various  forms,  namely,  (<z)  as  a mem- 
branous fold  ( bridle  stricture)  of  which  the  fibres 
cross,  and  occasionally  encircle,  the  axis  of  the 
tube.  Bridles  may  be  either  single  or  several, 
(h)  As  warts  and  superficial  scars  left  by  ulcers, 
which  form  patches  of  tough  tissue,  (c)  As  indu- 
rated areas  or  fibrous  nodules  of  the  submucous 
layers,  which  stand  forward  on  the  surface  of  the 
urethra,  causing  irregular  projections,  as  well 
as  unyielding  contractions.  Thus  they  twist  the 
course  of  the  canal,  and  impede  the  passage  of 
bougies.  Or,  instead  of  being  in  limited  patches, 
the  induration  may  form  evenly  along  the  canal, 
making  it  smooth  and  gristly  for  a large  part 
of  its  length,  with  a narrow  passage  through 
the  centre.  The  depth  of  the  fibrous  contrac- 
tion may  form  only  a single  layer  of  fibres  be- 
neath the  mucous  membrane,  or  may  infiltrate 
the  whole  thickness  of  the  corpus  spongiosum,  or 
it  may  even  spread  through  the  perinaeum  till  it 
converts  that  region  into  a dense  gristly  mass. 

Strictures  vary  in  behaviour  : some  yield  easily 
to  dilatation,  and  slowly  contract ; others  are 
rigid,  and  can  be  dilated  only  to  a small  extent. 
Lastly,  some  expand  quickly,  but  as  quickly 
shrink  back  to  their  previous  narrowness. 

The  mucous  surface  of  a strictured  urethra 
varies  much.  It  is  smooth  and  almost  healthy 
where  the  stricture  is  of  no  great  duration ; but 
in  diseases  of  long  standing  the  lining  membrane 
between  tbe  meatus  and  the  narrowest  contrac- 
tion is  often  puckered  with  fresh  induration,  or 
excoriated,  or  ulcerated ; and  sometimes  just  in 
front  of  the  main  stricture  artificial  perfora- 
tions are  found,  the  results  of  inexpert  instru- 
mentation, leading  backwards  outside  the  stric- 
ture, and  ending  either  as  blind-alleys,  or  opening 
into  the  urethra  or  rectum  behind  the  stricture, 
constituting  ‘false  passages.’  At  the  stricture 
itself  the  surface  is  dull  and  roughened,  while 
behind  it  the  urethra  is  often  dilated,  pouched, 
and  ulcerated,  its  surface  being  beset  with  shreds 
of  thickened  muco-pus.  Occasionally  the  pouches 
have  given  way  into  the  cellular  tissue,  and 
form  abscesses  around  the  urethra ; or,  if  they 
have  pushed  their  way  to  the  surface  of  the 
body,  they  end  as  fistuloe  of  the  perinseum  or 
scrotum.  The  remainder  of  the  urinary  apparatus 
is  often  affected ; the  bladder  has  thickened 
walls,  and  is  the  seat  of  chronic  inflammation  ; 
the  ureters  are  dilated  and  similarly  inflamed. 
The  condition  of  the  kidneys  varies  ; sometimes 
but  slightly  affected,  in  cases  of  long  stand- 
ing they  may  be  greatly  diseased.  If  so,  the 
pelves  and  calyces  are  widely  expanded ; the 
pyramids  are  flattened,  and  partly  destroyed  by 
fibrous  interstitial  degeneration  ; the  cortical 
substance  is  wasted,  and  displays  other  conse- 
quences of  prolonged  chronic  irritation. 

Symptoms. — The  symptoms  of  urethral  stric- 


ture are  the  more  evident  the  narrower  it  is,  and 
the  longer  it  has  existed.  Few  symptoms  attract 
observation  before  the  stricture  is  well  advanced. 
The  most  common  and  earliest  is  a scanty  muco- 
purulent discharge.  This  sign  is  indeed  very 
often  the  indication  of  the  chronic  inflammation 
of  limited  areas  of  the  tract  which  end  in  stricture. 
Those  signs  which  appear  when  the  stricture 
has  developed  are — small  size  of  the  stream ; 
straining  ; frequent  call  to  pass  urine  ; and  pain 
in  passing  it.  Any  or  all  of  these  may  be 
absent,  even  when  the  canal  has  lost  as  much 
as  two-thirds  of  its  distensibility.  Usually  to 
these  troubles  are  added  occasional  attacks  of 
complete  retention  of  urine. 

Treatment. — The  treatment  of  stricture  con- 
sists, first,  in  removing  from  the  habits  and  diet 
of  the  patient  all  causes  of  functional  disorder. 
Temperance  in  alcoholic  drinks,  in  stimulating  or 
highly  nutritious  foods,  in  sexual  indulgence, 
and  in  some  forms  of  exercise,  such  as  horse- 
and  bicycle-riding, must  be  enforced.  Due  atten- 
tion to  the  condition  of  the  skin  and  bowels,  and 
sufficient  bodily  exercise,  are  requisite.  By  these 
means  the  temporary  and  dangerous  aggravation 
of  the  sufferings  caused  by  stricture  will  be 
avoided.  Next  comes  the  local  treatment.  The 
passage  must  be  restored  to,  and  maintained  at, 
such  width  as,  on  the  one  hand,  will  enable  the 
bladder  to  empty  itself  completely  by  each  act 
of  micturition  ; and,  on  the  other,  will  allow 
a sufficient  margin  to  prevent  stoppage  of  the 
flow  of  urine  during  occasions  of  temporary  swell- 
ing or  spasm  of  the  urethra.  Such  an  expan- 
sibility would  seem  for  most  persons  to  be  about 
one  inch  or  three-quarters  of  an  inch  in  circum- 
ference, that  is  about  No.  10  (English  scale), 
though  in  practice  it  is  advisable  to  dilate 
somewhat  further  than  this  to  allow  sufficient 
margin  for  neglect.  In  all  organic  strictures 
there  is  a tendency  to  contract;  hence  when 
sufficient  expansibility  has  been  established,  it 
must  be  maintained  by  the  frequent  passage  of 
a bougie.  In  most  cases  the  patient  should 
learn  to  do  this  for  himself. 

The  methods  employed  for  widening  the 
urethra  at  its  unyielding  parts  are — (a)  gradual 
interrupted  dilatation;  (6)  gradual  continuous 
dilatation  ; (e)  cutting  or  splitting  front  within  ; 
and  (d)  cutting  from,  without.  Other  methods, 
such  as  the  use  of  caustics  or  the  cautery,  have 
dropped  into  desuetude. 

(a)  Gradual  interrupted  dilatation. — This  is 
procured  by  passing  sounds  or  flexible  bougies 
(preferably  the  latter)  through  the  stricture, 
beginning  with  that  size  which  will  just  pass 
through,  and  in  subsequent  sittings  increasing 
the  size  of  the  instrument  without  wounding  the 
urethra,  until  the  requisite  size  (No.  12  or  13 
English)  is  reached. 

( h ) Gradual  continuous  dilatation. — This  me- 
thod consists  in  passing  through  the  stricture  a 
flexible  catheter,  small  enough  to  slip  easily 
through  the  contraction,  and  tying  the  instru- 
ment in  the  passage.  As  the  urethra  widens,  the 
catheter  must  be  replaced  from  time  to  time  by  a 
larger  one,  lest, being  loose,  the  instrument  escape 
from  the  passage.  A week  or  ten  days  usually  suf- 
fices to  bring  the  stricture  to  the  requisite  dimen- 
sion. The  nature  of  the  process  appears  similar 


1706  URETHRA,  DISEASES  OF. 
to  that  of  a seton  in  ordinary  sinuses  or  cellular 
tissue ; the  fibrous  tissue  becomes  loose  and 
succulent,  its  fibres  permeated  by  leucocytes, and 
partial  disintegration  into  pus  takes  place. 

(c)  Splitting  or  cutting  from  within. — In  split- 
ting the  stricture  from  within  (forcible  dilatation, 
divulsion,  ‘immediate  treatment’)  the  unexpand- 
ing fibres  are  rent  asunder  by  an  expanding 
instrument  previously  introduced  in  a contracted 
condition. 

In  cutting,  by  means  of  a sound  or  guide 
passed  through  the  stricture,  a sharp  edge  is 
applied  to  the  narrowed  parts  until  they  are 
divided  sufficiently  to  give  the  urethra  ordinary 
dimensions  at  that  point. 

( d ) Cutting  from  without. — When  attacked 
from  without,  the  urethra  is  reached  from  the 
perinseum  either  with  a guide-staff  passed  to  the 
bladder,  indicating  the  course  of  the  urethra,  or, 
if  that  be  impracticable,  by  a sound  passed  along 
the  urethra  to  the  seat  of  stricture,  which  is 
then  exposed  by  incision.  The  orifice  of  the 
stricture  being  then  visible,  a fine  director  is 
passed  along  it  to  the  bladder,  and  its  fibres 
divided  from  before  backwards. 

Various  instruments  have  been  devised,  and 
are  employed  for  carrying  out  these  several 
principles — some  more  suited  than  others  to 
particular  cases. 

Gradual  interrupted  dilatation  least  interferes 
with  the  patient’s  avocations,  is  least  attended 
by  evil  consequences,  and  is  most  effectual  in 
strictures  of  recent  formation,  situate  near  the 
bulb.  It  is  applicable  in  a larger  number  of 
cases  than  any  other  form  of  treatment.  Ob- 
jections to  this  method  are  the  rapidity  with 
which  recontraction  takes  place  ; and  the  impos- 
sibility in  some  patients  of  dilating  the  stric- 
ture beyond  a certain  calibre  without  exciting 
shivering,  pain,  and  pyrexia,  or  even  local  in- 
flammation and  abscess. 

Gradual  continuous  dilatation  is  easy  and 
rapid,  but  it  is  liable  to  be  followed  by  speedy 
recoutraetion  ; it  excites  in  some  patients  con- 
stitutional fever  and  local  irritation  sufficient  to 
require  its  abandonment.  Hence  gradual  con- 
tinuous dilatation  is  useful  to  obtain  a speedy 
enlargement  of  a very  narrow  stricture  in  cases 
of  advanced  vesical  or  renal  disease,  where  it  is 
requisite  to  give  the  bladder  rest  without  delay, 
yet  the  condition  of  the  kidneys  is  most  un- 
favourable to  any  operation.  Forcible  dilatation 
and  divulsion  have  the  disadvantage  of  putting 
the  patient  to  the  suffering  of  a painful  opera- 
tion, while  not  protecting  him  from  rapid  shrink- 
age of  his  stricture. 

Internal  urethrotomy  is  applicable  with  best 
results  to  young  persons,  in  whom  renal  changes 
have  seldom  advanced  much.  It  is  also  preferable 
for  those  patients  in  whom  gradual  dilatation, 
either  by  interrupted  passage  of  bougies,  or  the 
tying  in  of  catheters,  cannot  be  borne.  The  loca- 
lity of  stricture  has  much  to  do  with  deciding  upon 
the  adoption  of  internal  division.  Serious  disturb- 
ance rarely  follows  incisions  made  in  strictures  be- 
tween the  meatus  and  the  bulb.  Again,  the  shallow 
constrictions,  the  so-called  ‘bridle’  strictures, 
and  the  elastic,  rapidly-yielding,  and  as  rapidly- 
shrinking  strieturos,  are  always  situate  in  this 
portion.  They  are  specially  amenable  to  inci- 


URIC  ACID  DIATHESIS, 
sion,  while  very  little  affected  by  the  passage  of 
bougies.  The  great  thickness  of  certain  stric- 
tures of  the  bulb  renders  their  division  the  only 
mode  of  securing  even  moderate  duration  of 
their  dilatability. 

The  re-contraction  after  treatment  has  esta- 
blished sufficient  distensibility  would  seem  to 
follow  less  speedily  after  division  than  after 
gradual  dilatation. 

External  urethrotomy  is  needed  in  compara- 
tively few  cases.  It  is  advisable  when  the  peri- 
nseum  is  hardened  and  beset  with  fistulse;  or  is 
those  still  more  rare  cases  where  no  instrument 
can  be  introduced  into  the  bladder.  Under  such 
circumstances  it  is  requisite  to  attack  the  stric- 
ture from  the  surface.  Berkeley  Hill. 

URIAGE,  in  France. — Muriated  sulphur 
waters.  Sec  Mineral  Waters. 

URIC  ACID  DIATHESIS:  URIC  ACID 
CALCULUS. — Stnon.  : Lithuria;  Lithiasis; 
Nephrolithiasis;  Fr.  Diathese  urique ; Calcul 
urique. 

.Etiology  and  Pathology. — Uric  acid  is  un- 
doubtedly the  outcome  of  the  proteid  tissues 
of  the  body,  and  it  is  also  derived  from  the 
nitrogenous  elements  of  the  food ; but  where 
and  by  what  agency  this  metabolism  is  effected 
is  unsettled.  By  some  physiologists  it  is  con- 
sidered that  the  liver  is  the  chief  source  of 
uric  acid,  and  this  theory  is  grounded  on  these 
facts — that  urea  is  produced  in  the  liver;  that 
urea  and  uric  acid  are  nearly  allied,  and  often 
replace  each  other ; and  that  in  so-called  liver- 
disorders,  there  is  frequently  a deposit  of  uric 
acid  in  the  urine.  On  the  other  hand,  the 
liver  contains  but  the  merest  trace  of  uric  acid  ; 
the  blood  in  the  hepatic  vein  contains  no  more 
than  that  in  the  portal  vein ; uric  acid  is  found 
in  decided  amount,  and  always,  in  the  spleen; 
and  as  all  the  blood  from  it  passes  through 
the  liver,  so  that  which  escapes  from  the  liver 
may  have  come  to  this  organ  from  the  spleen 
with  the  blood-stream.  In  what  relation  docs 
the  kidney  stand  to  the  formation  of  uric  acid  ? 
On  this  poiut  also  authorities  differ.  Many 
hold  that  the  kidney  merely  filters  it  from  (lie 
blood.  But  there  is  much  evidence  to  sup- 
port the  belief  that  the  function  of  the  kid- 
ney, as  regards  both  urea  and  uric  acid,  is 
more  important  than  mere  excretion  ; that  it 
has  the  power  to  form  and  produce,  as  well  as 
simply  to  eliminate,  these  nitrogenous  constitu- 
ents out  of.  some  antecedents  in  the  blood  ; and 
that  as  the  hepatic  cell  has  the  power  to  form 
bile,  so  the  epithelial  cell  of  the  renal  tubules, 
by  the  metabolic  activity  of  its  protoplasm,  has 
the  power  to  produce  some  of,  if  not  all,  the  urea 
and  uric  acid  found  in  the  urine.  It  is  most 
probable  that  the  water  and  saline  constituents 
of  the  urine  are  simply  eliminated  from  the 
blood  by  osmosis  through  the  blood-vessels  of 
the  glomeruli,  and  are,  therefore,  influenced  as 
to  excess  or  deficiency,  by  greater  or  less  blood- 
pressure,  whilst  the  uric  acid,  urea,  pigments, 
and  other  constituents  are,  in  part  at  least,  the 
result  of  a true  secreting  power  of  the  renal  cells 
in  the  tubules. 

The  quantity  of  uric  acid  excreted  does  no? 


UEIC  ACID  DIATHESIS, 
appear  to  vary  much  whether  vegetable  or 
animal  food  be  exclusively  taken.  Lehmann 
found  this  to  be  the  case  in  his  own  per- 
son, and  it  is  certain  that  excess  and  deposit 
of  uric  acid  is  very  common  amongst  the  poor, 
who  consume  but  little  animal  food.  The 
amount  of  uric  acid  secreted  is  sometimes  very 
considerable  ; it  may  be  roughly  estimated  by 
adding  hydrochloric  acid  to  a definite  quan- 
tity of  urine,  and  washing  and  weighing  that 
which  is  precipitated.  Dr.  Pavy  has  suggested 
a more  ready  and  accurate  method,  namely,  by 
its  reducing  action  on  the  oxide  of  copper  (Med.- 
Chir.  Trans,  vol.  lxiii.  p.  217). 

Characters. — Uric  acid  exists  in  the  urine 
in  combination  with  alkaline  bases.  When  these 
bases  are  deficient,  or  when  the  uric  acid  is  in 
excess,  precipitation  occurs,  and  the  well-known 
rod  particles  are  visible.  Under  the  microscope 
they  appear  in  various  forms  : rhombic  crystals, 
stars,  bundles,  tablets,  and  prisms.  Pure  uric  acid 
is  colourless,  but,  clinically,  it  is  always  tinged 
brown  or  orange-red.  It  is  so  slightly  soluble  in 
water  as  to  require  12,000  to  15,000  parts;  con- 
sequently a very  slight  excess  of  uric  acid  or 
diminution  of  the  water  of  the  urine  leads  to 
deposit.  It  is  insoluble  in  dilute  acids,  but 
readily  dissolves  in  alkalies  and  their  carbonates. 
When  combined  with  potash,  ammonia,  and  soda, 
it  forms  the  thick  brick-dust  sediment  so  com- 
monly seen  in  most  febrile  diseases.  These 
‘ mixed  urates  ’ are  amorphous  ; soluble  by  heat ; 
form  frequently  an  opaque  film  on  the  surface  of 
the  urine ; and  such  is  their  affinity  for  the 
urinary  pigments,  that  they  generally,  but  not 
always,  leave  a reddish  stain  on  the  utensil. 

Calculi  or  concretions  composed  of  pure  uric 
acid  vary  in  size,  from  the  well-known  red 
granules  or  gravel  up  to  masses  of  many  ounces 
in  weight.  They  are  generally  of  a reddish- 
brown  colour;  very  dense  and  hard;  indistinctly 
stratified  ; of  a flattened  oval  shape  ; of  a rough 
tuberous  exterior  when  single,  and  smooth  and 
facetted  when  multiple.  To  this,  however,  some 
exception  should  be  made,  for  it  is  not  uncommon, 
when  only  two  or  three  co-exist  in  the  bladder, 
to  find  them  rough  and  mammillated,  as  if  there 
had  been  no  contact  or  rubbing  between  them. 
When  uric  acid  is  combined  with  ammonia  and 
potash  in  a concretion,  the  colour  is  paler,  the 
lamination  more  distinct,  and  its  texture  more 
friable.  Pure  uric  acid  calculi,  when  broken  by 
the  litliotrite,  form  sharp  angular  fragments;  the 
urate  concretions,  on  the  other  hand,  break  more 
readily  and  assume  the  form  of  flaky  laminae. 

Symptoms. — The  occasional  deposit  of  uric 
acid  and  urates,  even  in  large  quantity,  is  some- 
times observed  without  the  least  disturbance  of 
health;  frequently,  however,  it  is  accompanied 
by  local  irritation  of  the  kidneys  and  bladder,  as 
shown  by  frequent  micturition,  with  heat  and 
even  pai  u during  the  act ; and  by  flatulence,  heart- 
burn, and  other  signs  of  indigestion.  There  is, 
however,  no  habit  of  body,  no  recognised  symp- 
toms of  so  definite  a kind,  which  are  plainly  due 
to,  or  accompanied  by,  an  excess  of  uric  acid,  as 
to  warrant  the  continued  use  of  the  term  ‘ uric 
acid  diathesis.’  Heartburn,  flatulence,  and  other 
signs  of  indigestion  and  liver-disorder  may,  and 
often  do,  exist  without  any  deposit  of  uric  acid  or 


URINARY  ORGANS,  DISEASES  OF.  1707 
urates,  and  when  they  co-exist  there  is  nothing 
to  show  that  the  one  depends  on  the  other ; the 
utmost  that  can  be  said  is  that  the  presence  of 
uric  acid  points  a way  to  successful  treatment. 
Uric  acid  and  its  salts  are  found  in  excess  in 
many  organic  diseases  ; in  maladies  of  the  heart 
and  lungs  in  which  oxidation  of  the  blood  is 
so  frequently  deficient ; in  organic  diseases  of 
the  liver ; in  almost  all  febrile  diseases  ; and 
sometimes  associated  with  diabetes,  chorea,  and 
certain  skin-diseases.  They  are  deficient  or  absent 
in  advanced  diseases  of  the  kidney ; in  some 
cases  of  lead-poisoning ; in  general  anaemia ; and 
in  some  exhausting  non-febrile  diseases.  The 
relation  of  uric  acid  to  gout  is  interesting  and 
important.  In  the  acute  stage  the  daily  secre- 
tion of  uric  acid  is  diminished,  notwithstanding 
that  there  is  frequently  a copious  deposit  of  pink 
urates  ; but  the  normal  quantity  is  restored  or  ex- 
ceeded as  the  attack  passes  off.  In  chronic  gout 
uric  acid  is  markedly  deficient  or  wholly  absent, 
while  the  amount  of  urea  continues  steady  and 
almost  up  to  the  average  in  health.  See  Gout. 

Treatment. — -It  will  be  apparent  that  the 
treatment  of  uric  acid  in  excess  must  be  com- 
prised in  that  of  the  various  diseases  in  connec- 
tion with  which  it  occurs.  For  that  condition  of 
indigestion  and  urinary  irritation  in  which  the 
chief  feature  is  the  copious  deposit  of  uric  acid 
and  urates,  alkaline  remedies,  such  as  the  bicar- 
bonate of  soda,  or  the  carbonate,  citrate,  and 
acetate  of  potash,  in  scruple  or  half-drachm  doses 
dissolved  in  three  or  four  ounces  of  water,  given 
three  or  four  times  a day,  afford  the  best  and 
quickest  relief;  they  produce  an  alkaline  con- 
dition of  the  urine,  and  a complete  solution  of 
the  deposit  for  the  time.  Salts  of  lithia  are  of 
much  value.  Lime-water  and  solution  of  car- 
bonate of  lime  have  the  same  effect,  but  in  part 
this  appears  to  be  due  to  the  diuretic  effect  of 
the  salts  of  lime.  Where  hepatic  congestion  and 
general  sluggishness  of  all  the  secretions  are 
present,  saline  as  well  as  alkaline  remedies  are 
indicated,  and  particularly  those  mineral  waters, 
such  as  Vichy,  Carlsbad,  Wiesbadeh,  &c.,  which 
seem  to  have  the  power  of  exciting  all  the  ali- 
mentary secretory  glands  to  healthy  and  in- 
creased action.  Diaphoretics,  especially  the  warm 
water  or  the  hot  bath,  by  increasing  the  elimina- 
tion of  the  acid  secretion,  are  useful  adjuncts. 
Caution,  however,  is  required  in  the  frequent 
repetition  of  alkaline  remedies,  lest  the  condition 
of  the  blood  itself  be  modified  and  deteriorated. 
A well-chosen,  simple  diet  is  above  all  things 
important,  and  especially  the  avoidance  of  too 
much  animal  food,  of  rich,  sweet,  or  highly  sea- 
soned dishes,  and  of  alcoholic  drinks.  For  th» 
treatment  of  lithic  calculus  in  the  bladder  re- 
ference should  be  made  to  surgical  works.  See 
Gout  ; Gravel  ; and  Benat.  Calculus. 

William  Cadge. 

URINARY  CALCULUS.  A calculus  con- 
nected with  any  part  of  the  urinary  tract.  See 
Calculus  ; and  Renal  Calculus. 

URINARY  ORGANS,  Diseases  of.— Sx- 

non.  : Fr.  Maladies  des  Foies  Urinaircs ; Ger. 
Krankheiten  des  Hamapparats. 

In  accordance  with  the  plan  adopted  in  other 


1 703 


URINARY  ORGANS,  DISEASES  OF. 


corresponding  articles,  it  is  intended  here  merely 
to  discuss  briefly  the  diseases  of  the  urinary 
organs  from  a general  point  of  view.  These 
organs  include: — 1.  The  kidneys,  -with  the  in- 
fundibula and  pelves.  2.  The  ureters.  3.  The 
bladder.  4.  The  urethra.  The  particular  dis- 
eases of  each  part  of  the  urinary  apparatus  will 
be  found  treated  of  under  these  several  headings, 
and  in  certain  special  articles,  to  which  the 
reader  is  referred. 

Summary  of  Diseases. — The  primary  division 
of  diseases  into  functional  and  organic  must 
be  recognised  in  connection  with  the  urinary 
organs. 

I.  Functional. — The  following  disorders  may 
be  included  under  this  group: — 1.  The  excre- 
tory function  of  the  kidneys  is  influenced  and 
often  disturbed  by  various  conditions,  physiolo- 
gical or  pathological,  quite  independent  of  any 
obvious  local  morbid  change.  Hence  the  urine 
is  modified  in  different  ways  and  degrees,  as  re- 
gards its  quantity  or  quality.  This  may  depend, 
for  instance,  upon  some  general  condition,  such 
as  fever  or  gout;  upon  causes  originating  in 
the  nervous  system ; upon  digestive  disorders  ; or 
upon  special  diseases,  such  as  diabetes.  2.  The 
muscular  structures  in  certain  parts  of  the  uri- 
nary apparatus  are  liable  to  be  affected,  and  this 
applies  practically  to  the  bladder  and  urethra. 
The  bladder  is  subject  to  undue  irritability, 
spasm,  or  paralysis,  the  last  being  especially 
important  in  connection  with  disease  of  the 
spinal  cord.  The  urethra  is  not  uncommonly 
the  seat  of  spasm,  giving  rise  to  more  or  less 
spasmodic  stricture,  and  consequent  retention 
of  urine.  3.  It  is  believed  by  some  authorities 
that  the  kidneys  or  bladder  may  be  affected  with 
neuralgic  pains,  without  any  local  mischief  to 
account  for  them. 

II.  Organic. — The  numerous  affections  of  the 
urinary  apparatus  belonging  to  this  division  may 
be  thus  classified: — 

1.  Injuries  of  different  kinds,  under  which 
would  be  included,  not  only  those  of  traumatic 
origin,  but  also  ruptures  or  perforations  due  to 
disease. 

2.  Conditions  affecting  the  circulation,  namely : 
a.  Acute  or  chronic  congestion,  b.  Embolism. 
c.  Haemorrhage.  The  first  two  are  only  met 
with  in  the  kidneys,  but  haemorrhage  may  occur 
from  any  part  of  the  urinary  organs. 

3.  Acute  Inflammatory  Diseases. — These  are  of 
different  kinds,  and  comprise  the  following  sub- 
divisions:— a.  Acute  Bright’s  disease,  involving 
the  kidney-substance,  b.  Suppurative  inflam- 
mation of  the  kidney,  ending  in  renal  abscess. 
v.  Inflammation  of  the  mucous  membrane.  The 
urinary  mucous  tract  may  be  involved  throughout  , 
but  usually  only  a limited  portion  is  affected,  and 
thus  we  have  the  different  complaints  known  as 
pyelitis,  or  inflammation  of  the  pelvis  of  the 
k:  iney ; inflammation  of  the  ureter,  rarely  exist- 
ing alone ; cystitis,  or  inflammation  of  the  blad- 
der ; and  urethritis,  or  inflammation  of  the  urethra, 
the  common  form  of  which  is  gonorrhoea.  This 
mucous  inflammation  often  leads  to  a purulent 
discharge,  and  may  terminate  in  ulceration  or 
gangrene,  d.  Inflammation  around  the  kidney 
— perinephritis ; or  around  the  bladder — peri- 
cystitis. 


4.  Chronic  Inflammatory  Diseases. — These  mav 
remain  after  the  acute  forms,  or  they  are  chronic 
from  the  outset.  Practically  they  include  gene- 
rally certain  forms  only  of  Bright’s  disease,  and 
mucous  inflammations. 

5.  Malpositions  and  Malformations. — These 
abnormal  conditions  may  be  of  considerable  im- 
portance in  connection  with  the  urinary  organs, 
being  either  congenital  or  acquired,  and  varying 
in  their  nature. 

6.  Hypertrophy  and  Atrophy. — The  morbid 
changes  of  this  kind  belong  to  two  main  classes, 
according  as  they  affect  the  kidney-substance,  or 
the  walls  of  the  duct  or  bladder.  Atrophy  of 
the  kidney  is  either  acute  or  chronic,  the  latter 
being  in  almost  all  cases  a form  of  chronic  Bright’s 
disease,  but  it  may  be  congenital  or  due  to  com- 
pression. 

7.  Obstruction,  Dilatation,  and  Accumulations. 
Obstruction  may  be  due  to  different  causes, 
and  localised  at  either  of  the  orifices,  or  at  any 
point  in  the  course  of  the  ureter  or  urethra.  As 
a consequence  of  such  obstruction,  and  occasion- 
ally from  other  causes,  dilatation  occurs,  affect- 
ing either  the  pelvis  and  infundibula  of  the 
kidney,  the  ureter,  the  bladder,  or  the  urethra, 
according  to  its  seat;  the  entire  tract  may  bo 
thus  implicated.  Accumulations  also  follow, 
either  of  urine,  pus,  or  other  materials,  and 
these  may  become  very  serious.  Hydronephrosis 
and  pyonephrosis  are  forms  of  disease  in  which 
urine  or  pus  thus  accumulates  in  the  pelvis  of 
the  kidney.  Retention  of  urine  in  the  bladder 
is  of  common  occurrence,  arising  from  various 
causes.  Cystic  disease  of  the  kidney  may  be 
mentioned  under  this  head,  as  in  some  instances, 
at  any  rate,  it  probably  arises  from  limited  dila- 
tations of  the  renal  tubules. 

8.  New  Growths  and  Degenerations. — Cancer 
may  involve  any  or  every  part  of  the  urinary 
apparatus.  Non-malignant  growths  are  met 
with  in  exceptional  cases.  Tubercular  disease  is 
an  important  and  serious  malady  in  connection 
with  the  urinary  organs.  The  kidneys  are  liable 
to  albuminoid  disease,  and  to  fatty  degenera- 
tion. Syphilitic  growths  may  also  be  found  in 
them. 

9.  Gravel,  Calculi,  and  Foreign  Bodies. — The 
formation  of  calculi  of  different  kinds,  and  the 
morbid  conditions  resulting  therefrom,  are  of 
peculiar  importance  in  relation  to  the  urinary 
organs,  and  a large  proportion  of  cases  in  actual 
practice  belong  to  this  group.  It  may  also  be 
mentioned  here  that  foreign  bodies  are  sometime? 
found  in  the  bladder  and  urethra. 

10.  Parasites. — Certain  parasites  are  particu- 
larly associated  with  the  urinary  organs,  and 
especially  the  Strongylns  gigas  and  the  Bil- 
barzia  hsematobia.  Hydatid  disease  is  met  with 
in  rare  instances. 

zEtioloqy  axd  Pathology. — It  would  be 
quite  out  of  place  here  to  discuss  the  aetiology 
and  pathology  of  some  of  the  morbid  conditions 
that  have  been  mentioned,  such  as  urinary  cal- 
culus, or  cystic  disease  of  the  kidney,  which  are 
fully  considered  in  special  articles.  All  that 
can  be  done  is  to  point  out  in  a general  way 
the  principal  morbific  causes  which  act  upon 
the  urinary  organs,  and  the  modes  of  origin  of 
its  disease.  1.  These  organs  are  much  mow 


URINARY  ORGANS,  DISEASES  OF.  1709 


liable  to  injury  than  most  others.  This  may 
not  only  come  directly  from  without,  but  may 
also  be  inflicted  by  articles  introduced  into  the 
urethra  or  bladder,  by  surgical  operations,  or  by 
calculi.  2.  Certain  morbid  conditions  are  con- 
genital, being  the  result  of  imperfect  develop- 
ment, or  of  intra-uterine  disease.  3.  Exposure 
to  cold  or  vet  undoubtedly  originates  serious 
renal  disease  in  some  cases,  such,  for  instance,  as 
Bright’s  disease  ; and  it  is  also  supposed  to  give 
rise  in  other  instances  to  less  serious  complaints 
in  connection  with  the  urinary  organs,  such  as 
congestion,  or  some  form  of  mucous  inflammation. 
This  cause  probably  acts  by  interfering  with  the 
cutaneous  excretion,  and  inducing  internal  con- 
gestion. It  may  also  be  remarked  that  want  of 
cleanliness  of  the  skin  is  capable  of  assisting  in 
developing  renal  disease.  4.  Affections  of  the 
urinary  organs  are  of  frequent  occurrence  in  con- 
nection with  certain  acute  febrile  diseases,  either 
as  essential  parts  of  these  diseases,  or  as  com- 
plications or  sequelae.  Scarlatina  and  pyaemia 
demand  special  mention  in  this  connection.  5. 
Abnormal  conditions  of  the  urine  when  first  ex- 
creted, or  the  presence  of  certain  materials  in 
the  kidney  which  this  organ  cannot  properly  ex- 
crete, are  prolific  causes  of  urinary  affections. 
These  abnormal  conditions  and  materials  may 
originate  in  a variety  of  remote  causes,  and  they 
are  well  exemplified  by  the  effects  of  certain 
medicines,  alcohol,  excessive  acidity  of  the  urine, 
diabetic  urine,  and  gout.  Such  causes  may  in- 
duce congestion,  inflammation,  chronic  renal 
changes,  or  calculi.  6.  The  urinary  organs  may 
be  implicated  as  part  of  some  general  or  con- 
stitutional disease,  as  in  cancer,  tuberculosis, 
or  albuminoid  disease.  7.  Certain  parasites  spe- 
cially lodge  in  these  organs,  as  has  been  already 
mentioned.  S.  The  urinary  organs  may  be  af- 
fected, owing  to  some  neighbouring  disease.  For 
instance,  a tumour  may  compress  the  ureter  or 
bladder,  or  obstruct  the  renal  vein;  or  the  struc- 
tures may  be  involved  by  extension.  9.  Cardiac 
diseases  which  impede  the  venous  circulation, 
not  only  cause  venous  congestion  of  the  renal 
organs,  but  in  time  give  rise  to  serious  organic 
changes.  10.  The  cause  of  urinary  disease  may 
be  in  the  nervous  system.  Thus  may  arise  a 
form  of  acute  congestion  of  the  kidneys;  and  the 
paralysis  of  the  bladder,  which  spinal  disease  so 
often  produces,  is  liable  to  b6  followed  by  cystitis 
and  its  consequences.  11.  One  specific  disease  is 
associated  with  the  urethra,  namely,  gonorrhoea; 
and  its  effects  often  extend  to  the  bladder,  or 
even  higher  up  along  the  urinary  tract.  12.  It 
is  important  to  notice  that  the  different  parts  of 
the  urinary  apparatus  have  an  intimate  relation 
to  each  other  from  an  setiological  point  of  view. 
For  instance,  it  is  believed  that  one  kidney  may 
become  hypertrophied,  if  the  other  should  be  de- 
stroyed by  disease.  Or  a morbid  condition  may 
extend  directly  from  one  part  of  the  urinary 
organs  to  another.  Again,  urine  which  under- 
goes certain  changes  after  its  formation,  is  liable 
to  cause  mischief.  There  are  other  relations 
which  probably  exist  between  the  different  por- 
tions of  the  urinary  apparatus,  which  are  dis- 
cussed elsewhere.  See  Surgical  Kidney. 

Clinical  Investigation  and  Signs. — With- 
out entering  into  details,  the  symptoms  and  signs 


which  may  be  associated  with  urinary  diseases 
can  be  summarised  in  the  following  way,  and 
this  summary  will  indicate  the  course  to  be 
adopted  in  their  investigation.  1.  Painful  sen- 
sations, with  or  without  tenderness,  may  be 
-eferred  to  the  region  of  the  kidneys,  perhaps  to 
the  ureter,  to  the  bladder,  or  to  the  urethra, 
when  these  are  respectively  the  seat  of  mischief. 
Moreover,  disease  in  one  part  may  be  accom- 
panied with  sympathetic  sensations  in  some 
other  part ; or  in  certain  conditions  there  may  be 
pain  along  the  spermatic  cord  to  the  testis,  with 
retraction  of  this  organ.  Other  sensations  are 
complained  of  in  many  instances,  such  as  itching 
or  tickling  at  the  end  of  the  penis,  heat  or  burn- 
ing along  the  urethra,  heaviness  and  weight 
in  the  lumbar  region,  or  fulness  of  the  bladder. 
These  feelings  are  often  modified  by  various 
causes.  2.  The  sensations  connected  with  mic- 
turition are  of  special  significance,  such  as  a 
frequent  inclination  to  pass  water,  a sudden  and 
urgent  desire,  or  strangury.  3.  The  act  of  mic- 
turition itself  is  often  affected.  It  may  be  too 
frequent  or  infrequent;  difficult,  even  to  com- 
plete retention — dysuria ; or  performed  involun- 
tarily— incontinence.  The  stream  of  urine  is 
altered  in  size  or  shape  in  some  conditions  ( see 
Micturition,  Disorders  of).  4.  The  urine  itself 
affords  signs  of  great  importance  in  relation  to 
diseases  of  the  urinary  apparatus,  in  regard  to 
its  quantity,  physical  characters,  chemical  compo- 
sition, and  microscopic  appearances.  Indeed,  it 
very  often  happens  that  the  urine  alone  affords 
any  evidence  of  urinary  disease.  At  the  same  time 
it  must,  of  course,  be  borne  in  mind  that  this 
excretion  is  modified  by  many  other  conditions, 
the  urinary  organs  being  quite  healthy.  This 
subject  is  fully  treated  of  elsewhere  (see  Urine, 
Morbid  Conditions  of),  o.  Urinary  diseases  often 
produce  important  effects  upon  the  blood  or 
general  system,  as  well  as  upon  other  organs. 
Hence  arise  renal  dropsy;  the  phenomena  of 
uraemia,  septicaemia,  or  the  typhoid  condition  in 
some  forms  of  disease ; collapse  sometimes ; and 
morbid  conditions  affecting  the  heart  and  ves- 
sels, or  certain  structures  in  the  eye.  These 
morbid  changes  may  be  evidenced  by  more  or 
less  marked  symptoms.  Moreover,  enlargement 
of  the  kidney  may  affect  neighbouring  struc- 
tures. 6.  Physical  examination  is  of  essential 
value  in  the  investigation  of  many  urinary  affec- 
tions, and  in  carrying  this  out  the  aid  of  a skil- 
ful surgeon  is  often  of  the  first  consequence. 
The  local  examination  is  directed  to  the  deter- 
mination and  investigation  of  enlargements  or 
tumours  of  the  kidneys;  conditions  of  the  blad- 
der, especially  retention  of  urine,  and  the  pres- 
ence of  calculi  and  growths;  and  morbid  states 
affecting  the  urethra,  such  as  enlarged  prostate, 
stricture,  or  the  lodgment  of  a calculus.  Physi- 
cal examination  also  reveals  the  changes  in  other 
structures  already  alluded  to. 

These  are  the  main  points  which  can  be  use- 
fully discussed  from  a general  point  of  view  with 
reference  to  urinary  diseases.  For  their  dia- 
gnosis, prognosis,  and  treatment,  as  well  as  for 
more  complete  details  on  the  various  matters 
alluded  to,  reference  must  be  made  to  the  dif- 
ferent appropriate  articles,  especially  to  those 
which  deal  with  the  affections  of  the  several 


1710  URINARY  ORGANS,  DISEASES  OF. 
parts  of  the  urinary  apparatus.  See  Bladder, 
Diseases  of ; Bright’s  Disease  ; Kidneys,  Dis- 
eases of ; Renal  Calculus  ; Surgical  Kidney  ; 
Ureter,  Diseases  of,  &c. 

Frederick  T.  Roberts. 

URINE,  Incontinence  of.—  The  involuntary 
discharge  of  urine  from  the  bladder,  the  patient 
being  either  unable  to  retain  it,  or  unaware  of  its 
escape.  See  Micturition,  Disorders  of. 

URINE,  Morbid  Conditions  of. — Synon.  : 
Fr.  Maladies  de  V Urine ; Ger.  Harnkrankheiten. 

Introduction. — The  urine  is  the  excretion  by 
which  the  products  of  nitrogenous  waste  are 
eliminated  from  the  body.  Alterations  in  its 
characters  give  valuable  information  regard- 
ing tissue-change  in  the  body,  and  may  indicate 
the  presence  of  disease  which  would  otherwise 
remain  undetected.  They  therefore  require  de- 
tailed attention.  Before  entering,  however,  upon 
the  discussion  of  the  morbid  conditions  of  the 
urine,  it  will  be  well  to  describe  briefly  its  cha- 
racters and  mode  of  secretion  in  health. 

In  reptiles  and  birds  the  waste  nitrogenous 
products  of  the  body  are  excreted  as  urates  ; and 
the  urine  is  solid.  In  amphibia  and  mammals 
they  are  chiefly  excreted  as  urea,  and  the  urine 
is  liquid. 

Human  urine  is  a clear  liquid,  of  a yellow 
colour,  acid  reaction,  peculiar  odour,  and  saline 
taste.  It  consists  essentially  of  a watery  solu- 
tion of  urea,  extractive  and  colouring  matters, 
and  salts.  Its  average  specific  gravity  is  about 
1,020,  but  this  varies  according  to  the  propor- 
tion of  solids  it  contains. 

Secretion  of  Urine.  — Until  lately,  the 
theory  of  Ludwig  regarding  the  secretion  of 
urine  was  the  prevalent  one.  He  believed  it  to 
be  a process  of  filtration  of  water  and  salts  from 
the  vessels  in  the  glomeruli,  and  that  these  were 
partly  reabsorbed  in  the  tubules  by  the  cells  lin- 
ing them.  But  it  has  been  shown  by  Heidenhain 
that  the  cells  of  the  tubules  also  play  an  active 
part  in  excreting,  inasmuch  as  sulphate  of  in- 
digo injected  into  the  blood  does  not  colour  the 
glomeruli,  but  colours  the  cells  of  the  tubules. 
The  process  of  secretion  of  urine  may  therefore 
be  looked  upon  as  consisting  of  two  parts — first, 
the  filtration  of  water,  and  probably  of  a small 
quantity  of  salts,  which  takes  place  under  pres- 
sure from  the  vessels  of  the  glomeruli ; and 
secondly,  the  excretion  of  urea  and  other  solid 
constituents  by  the  epithelial  lining  of  the  tu- 
bules. The  water  which  exudes  from  the  glo- 
meruli dissolves  and  removes  the  substances  ex- 
creted by  the  tubules,  and  is  very  possibly  also 
to  some  extent  reabsorbed  in  its  passage.  The 
higher  the  tension  of  the  blood  in  the  glomeru- 
lar vessels,  the  more  rapid  is  the  secretion  of 
urine ; or,  to  put  it  more  exactly,  the  greater 
the  difference  is  between  the  tension  of  the  blood 
in  the  blood-vessels  and  the  fluid  in  the  tubules, 
the  more  rapid  is  the  secretion  of  urine.  The 
secretion  may  therefore  be  increased  either  by 
raising  the  pressure  in  the  vessels,  or  by  di- 
minishing that  in  the  tubules;  and,  vice  versa, 
it  may  be  diminished  by  lessening  the.  blood- 
pressure  in  the  glomeruli,  or  by  raising  the 
pressure  of  the  urine  in  the  tubules.  The  blood- 


URINE,  MORBID  CONDITIONS  OF 

pressure  may  be  raised  either  generally  through- 
out the  body,  or  locally  by  dilatation  of  the 
renal  arteries.  These  arteries  have  consider- 
able power  of  contraction,  so  much  so  that 
they  can  lessen  the  pressure  in  the  glomeruli 
even  when  it  is  raised  throughout  the  body 
generally.  The  blood-pressure  may  be  raised 
in  the  body  generally  by  the  contraction  of  the 
arterioles  from  exposure  to  cold,  by  mental 
excitement,  by  the  influence  of  food,  or  by  the 
action  of  certain  drugs,  such  as  digitalis.  It  may 
be  lowered  by  shock,  by  exposure  to  external 
warmth,  or  by  rise  of  the  bodily  temperature,  as 
in  fever.  It  seems  probable,  from  experiments 
made  by  the  writer  and  Mr.  Power,  that  the 
arterial  tension  in  the  glomeruli  may  be  locally 
diminished  even  when  the  general  blood-pres- 
sure is  increased,  by  the  action  of  digitalis, 
which,  while  causing  contraction  of  the  vessels 
generally,  affects  those  of  the  kidney  more  espe- 
cially, and  thus,  by  their  contraction,  lessens 
the  blood-supply  to  these  organs.  The  vessels 
of  the  kidney  are  controlled  by  the  medulla 
oblongata  ; and  when  this  is  stimulated,  either 
directly  by  a galvanic  current  or  by  asphyxial 
blood,  or  reflexly  by  irritation  of  a sensory 
nerve,  the  renal  vessels  contract.  Dr.  Roy  has 
shown  that  they  are  also  very  sensitive  to  slight 
changes  in  the  chemical  constitution  of  the  blood, 
water  or  urea  causing  slight  contraction,  followed 
by  greater  and  longer  dilatation.  Digitalis  does 
so  also;  but  the  contraction  is  much  longer. 
Ccmmcri  salt,  Ditrate  of  soda,  and  acetate  of 
potash  cause  dilatation  without  previous  contrac- 
tion. They  act  upon  the  vessels  even  when  the 
nerves  are  cut,  and  therefore  they  must  affect 
them  either  directly,  or  through  some  local  vaso- 
motor nervous  apparatus. 

By  experiments  on  the  kidneys  of  amphibia, 
which  have  a separate  vascular  supply  to  the 
glomeruli  and  tubules,  Nussbanm  has  found 
that  sugar,  peptones,  and  albumen  are  excreted 
through  the  glomeruli ; but  that  urea  is  passed 
out  through  the  epithelium  of  the  tubules,  and 
in  passing  out  causes  increased  secretion  of 
water  from  them. 

Characters  of  Urine— 1.  Transparency. 
Healthy  urine  is  clear  when  passed,  but  after 
standing  some  time  a light  flocculent  precipitate 
falls.  This  consists  of  mucus  and  epithelial 
cells  from  the  urinary  passages.  A hummocky, 
white,  and  sharply  defined  upper  surface  indicates 
the  presence  of  crystals  of  oxalate  of  lime  in 
the  cloud.  Small  white  flocculi  of  this  size  and 

shape,  looking  somewhat  like  small  

worms,  may  occur  suspended  in  the  -aT 
freshly-passed  urine  of  persons  who  'V 

have  suffered  from  gonorrhoea  or  yy-1 

prostatitis  some  time  previously.  On  FlQ-  lo3- 
microscopic  examination  they  are  found  to  con- 
sist of  aggregations  of  leucocytes.  The  writer 
has  found  the  presence  of  these  flocculi  useful  in 
diagnosing  gonorrhoeal  rheumatism  where  no 
history  of  gonorrhoea  was  given  by  the  patient. 

Urine  which  is  clear  when  passed  may  after- 
wards deposit  sediments  of  urates  or  phosphates. 
These  are  distinguished  from  each  other  by  warm- 
ing the  urine.  The  urates  dissolve  and  the  urine 
becomes  clear  ; but  the  phosphates  are  not  dis- 
solved, and  the  urine  is  rendered  more  turbid  bv 


I 


URINE.  MORBID  CONDITIONS  OF.  1711 


the  heat.  On  the  addition  of  a few  drops  of  acid 
the  phosphates  dissolve  readily,  and  the  urine 
becomes  clear.  When  the  urine  is  concentrated 
and  contains  much  urates,  it  may  become  turbid 
almost  immediately  from  their  deposition,  if  it  is 
passed  into  a cold  vessel. 

Turbidity  of  the  urine  as  it  is  passed  is  gene- 
rally, however,  due  to  earthy  phosphates,  mucus, 
pus,  or  blood.  The  whitish  or  light  colour  of  the 
turbidity  due  to  the  first  three  causes  distin- 
guishes it  from  turbidity  due  to  blood.  The  addi- 
tion of  a few  drops  of  acetic  acid  causes  the  tur- 
bidity due  to  phosphates  to  disappear,  while  it 
does  not  remove  that  due  to  mucus  or  pus.  Tur- 
bidity due  to  pus  is  distinguished  from  that  due 
to  mucus  by  the  presence  of  albumin.  The 
albumin  may  be  recognised  by  adding  a drop  or 
two  of  a clear  solution  of  ferrocyanide  of  potas- 
sium to  the  urine  previously  acidulated  by  acetic 
acid.  If  the  turbidity  is  not  increased  it  is  due 
to  mucus.  If  it  is  increased  it  may  bo  due  to 
pus,  or  to  mucus  in  albuminous  urine.  In  this 
case  let  the  urine  stand  until  the  sediment  has 
deposited,  pour  off  the  supernatant  liquid,  add 
a small  piece  of  caustic  potash  to  the  sediment, 
and  stir  it  for  some  minutes  with  a glass  rod. 
If  it  is  due  to  pus  it  will  become  more  trans- 
parent and  tough,  forming  a thick  mucilaginous 
fluid,  which  flows  with  difficulty  when  the  quan- 
tity of  pus  is  small.  When  there  is  much  pus  it 
will  form  a thick,  glassy  coherent  lump.  If  due 
to  mucus  it  will  not  become  thick  and  coherent. 
If  due  to  blood  the  addition  of  a drop  of  tincture 
of  guaiacum  and  twenty  drops  or  more  of  ozonie 
ether  will  give  a blue  colour. 

2.  Colour. — The  colour  of  urine  varies  from 
an  almost  imperceptible  yellow  to  a dark  brown 
or  almost  a black.  Four  degrees  are  usually 
distinguished — 'pale,  normal,  high-coloured,  and 
dark.  It  is  usually  understood  that  the  descrip- 
tion applies  to  urine  seen  in  a white  chamber- 
pot, from  one-third  to  one-half  filled,  or  more 
exactly,  as  suggested  by  Vogel,  in  a cylindrical 
glass  about  three  and  a half  or  four  inches  in 
diameter.  Vale  urines  are  those  which  under 
such  circumstances  vary  from  an  almost  com- 
plete absence  of  colour,  so  that  they  are  indis- 
tinguishable from  water,  except  when  seen  in 
thick  layers,  up  to  a straw-yellow  colour.  Nor- 
mal urines  are  those  which  have  a golden  yellow 
up  to  an  orange-yellow  colour.  High-coloured 
have  a reddish-yellow  to  a red  colour ; and 
dark  urines  have  a deep  red-brown  or  blackish 
colour. 

These  variations  in  the  colour  of  urine  are  to 
a great  extent  due  to  the  proportion  of  water 
in  which  the  urinary  pigments  are  dissolved. 
Watery  urine  is  pale,  and  concentrated  urine 
is  high-coloured.  It  is  probable  that  they  also 
depend  on  variations  in  the  nature  of  the  pig- 
ments chiefly  present.  Sometimes  they  are  due 
to  an  admixture  of  foreign  colouring  matter, 
such  as  bile  or  blood. 

Clinical  Import. — Pale  urine  occurs  when  se- 
cretion is  rapid,  and  the  urine  is  consequently 
dilute,  as  after  copious  draughts  of  liquid  or 
exposure  to  cold.  It  is  found  also  in  cases  of 
granular  kidney,  anaemia,  chlorosis,  diabetes 
mellitus  and  insipidus,  and  after  hysterical  fits, 
Asthma,  or  other  forms  of  nervous  excitement. 


High-coloured  urine  occurs  when  the  secretion 
is  diminished  by  profuse  perspiration ; and  also 
in  disorders  of  the  liver,  and  febrile  conditions. 
The  colour  of  the  urine  is  generally  deeper  after 
food,  and  the  urine  may  be  high-colcured  after  a 
large  meal  in  healthy  persons. 

Dark  urine  generally  owes  its  colour  to  bile, 
haemoglobin,  or  blood.  Bile  gives  it  various  tints 
of  brown  or  green ; haemoglobin  or  blood  imparts 
a smoky,  blood-red,  or  coffee  colour.  When  blood 
is  mixed  with  much  pus  in  a strongly  alkaline 
urine,  the  colour  may  be  greenish-brown.  Car- 
bolic acid  or  creasote  extensively  used,  either 
externally  or  internally,  renders  the  urine  black- 
ish or  black.  In  cases  of  melanotic  cancer  the 
urine,  although  of  a normal  colour  when  voided, 
may  become  black  after  standing ; and  this 
darkening  is  much  accelerated  by  the  addition 
of  nitric  acid  or  other  oxidising  agents. 

3.  Quantity. — The  quantity  of  urine  passed 
in  twenty-four  hours  varies  very  greatly.  Tho 
average  may  be  roughly  stated  to  be  about  fifty 
ounces,  and  the  ordinary  variation  is  about  one- 
fifth  of  the  quantity  above  or  below  the  normal. 
The  quantity  is  usually  increased  by  anything 
which  raises,  and  lessened  by  anything  which 
diminishes,  the  arterial  tension.  Thus,  cold 
and  nervous  excitement  will  increase  it,  while 
warmth  and  quiet  usually  diminish  it.  The 
quantity  passed  during  the  waking  hours  is 
much  greater  than  during  the  hours  of  sleep ; and 
the  fact  that  the  person  has  to  rise  during  the 
night  one  or  more  times  to  pass  water  awakens 
suspicion  of  renal  disease,  or  of  excessive  se- 
cretion. 

Although  temporary  conditions  may  cause  the 
amount  of  urine  passed  in  one  day  to  differ  much 
from  that  of  another,  yet  in  healthy  people  it 
usually  equalizes  itself  in  two  or  three  days, 
unless  there  be  constant  disturbing  influences, 
such  as  persistent  cold. 

Clinical  Import. — (o)  A persistent  increase  in 
the  quantity  of  urine  may  indicate  diabetes 
mellitus,  polyuria,  waxy  kidney,  or  granular 
kidney.  These  are  diagnosed  by  the  presence  of 
sugar  in  diabetes  ; by  the  entire  absence  of  both 
sugar  and  albumin  in  polyuria  ; by  the  presence 
of  considerable  albumin  in  waxy  kidney ; and  by 
the  presence  of  albumin — though  only  in  small 
quantity,  and  of  high  arterial  tension,  in  granu- 
lar kidney.  The  conditions  in  which  temporary 
increase  in  the  quantity  of  urine  occurs  are 
exposure  to  cold,  nervous  excitement,  hysterical 
fits,  copious  drinking,  the  use  of  diuretic  medi- 
cines or  articles  of  food  containing  tartrates  or 
citrates,  and  the  consumption  of  certain  forms 
of  wine  and  alcohol,  as  hock  and  gin. 

( b ) A quantity  of  urine  below  the  average  may 
be  due  to  habit,  leading  the  individual  to  drink 
little  fluid ; or  to  habitual  exposure  to  heat,  lead- 
ing to  excessive  perspiration.  A diminution  in 
quantity  also  occurs  in  acute  inflammation  of  the 
renal  glomeruli  or  tubules ; in  subacute  exacer- 
bations of  chronic  inflammatory  conditions  ; and 
in  certain  disordered  states  of  the  nervous  sys- 
tem, It  also  occurs  in  cases  of  granular  kidney 
approaching  a fatal  termination,  and  is  then  a 
sign  of  grave  import. 

4.  Specific  Gravity. — This  is  most  easily 
ascertained  by  the  form  of  areometer  which 


1712  URINE,  MORBID 

is  called  a urinomder.  In  using  this  instrument 
care  should  be  taken  that  it  is  clean  and  dry 
before  it  is  put  into  the  urine,  and  that  it 
does  not  touch  the  sides  of  the  vessel.  The 
surface  of  the  fluid  forms  a meniscus,  and 
the  graduation  on  the  stem  of  the  instrument 
should  be  read  off  at  the  lower  edge  of  the 
meniscus  with  the  eye  on  a level  with  it.  When 
there  is  not  sufficient  urine  to  take  the  specific 
gravity,  it  should  be  diluted  with  one,  two,  or 
as  many  times  as  may  be  necessary,  volumes  of 
water,  and  the  specific  gravity  taken.  The  deci- 
mal figures  of  the  specific  gravity  thus  found 
are  then  multiplied  by  the  number  of  times  the 
urine  has  been  diluted,  in  order  to  get  the  true 
specific  gravity.  Thus  if  the  urine  has  been  di- 
luted by  adding  four  times  its  own  volume  of 
water  to  it,  its  bulk  is  increased  to  five  times  that 
of  the  original  urine.  If  the  specific  gravity  of 
the  diluted  urine  is  1002,  the  specific  gravity 
of  the  original  urine  is  TOOO  + (’002  x 5)  = 
1-010.  The  urinometers  give  the  specific  gravity 
at  60°  Fahr.  ; and  at  any  temperatures  above 
this  they  indicate  a lower  specific  gravity,  and 
at  temperatures  below  a higher  specific  gravity, 
than  the  true  one. 

The  specific  gravity  of  the  urine  depends  on 
the  proportion  of  solid  matters  which  it  holds 
in  solution.  The  amount  of  water  in  the  urine 
fluctuates  much  more  than  the  solids,  and  there- 
fore the  specific  gravity  varies  also.  It  is  less 
when  the  urine  is  watery,  and  greater  when  it 
is  concentrated.  The  average  specific  gravity  is 
about  1020,  but  it  may  vary  in  health  between 
1010  and  1025,  or  even  beyond  these  limits.  It 
varies  in  the  same  person  at  different  times  of 
the  day,  and  in  different  portions  of  urine  passed 
at  the  same  time.  As  the  urine  is  secreted  and 
accumulates  gradually  in  the  bladder,  it  becomes 
arranged  in  layers  according  to  its  specific 
gravity,  the  heaviest  layers  being  lowest.  If  the 
person  remains  quiet,  so  as  not  to  mix  the  layers, 
and  passes  the  urine  in  successive  portions  into 
different  glasses,  their  specific  gravity  may  be 
found  to  differ. 

The  specific  gravity  is  diminished  duringfast- 
ing,  but  is  increased  after  meals,  on  account  of 
the  greater  excretion  of  solids  which  then  occurs. 
It  is  diminished  when  the  secretion  is  quick- 
ened, or  rendered  more  abundant  and  watery  by 
drinking  copiously  of  fluids,  by  exposure  to  cold, 
by  mental  excitement,  or  by  the  use  of  diuretics. 
It  is  increased  when  the  urine  is  concentrated  by 
abstinence  from  fluids  ; by  profuse  perspiration, 
which  carries  off  much  water  by  the  skin;  and 
by  long  retention  in  the  bladder,  which  allows 
some  of  the  water  to  be  re-absorbed.  The  varia- 
tions in  specific  gravity  due  to  the  causes  just 
mentioned  are  transitory,  and  are  generally  suc- 
ceeded by  variations  in  an  opposite  direction; 
so  that  the  specific  gravity  of  the  entire  urine 
passed  during  twenty-four  hours  may  be  little 
altered. 

Clinical  Import.— A.  persistently  high  specific 
gravity  generally  indicates  diabetes  mellitus,  or 
azoturia.  It  also  occurs  at  the  beginning  of  acute 
febrile  diseases  ; and  in  acute  nephritis  with  hm- 
maturia. 

The  specific  gravity  is  increased  by  the  pre- 
sence of  albumin  alone,  as  well  as  by  blood.  It  is 


CONDITIONS  OF. 

sometimes  thought  that  the  mere  presence  o! 
albumin  diminishes  the  specific  gravity  of  the 
urine,  but  this  is  an  error.  It  is  quite  true  that 
in  certain  cases  of  albuminuria  the  specific  gra- 
vity is  diminished,  but  this  is  due  to  the  absence 
of  other  ingredients,  and  not  to  the  presence  of 
albumin.  The  writer  has  found  experimentally 
that  the  addition  of  serum-albumin  to  the  urina 
increases  its  specific  gravity. 

An  abnormally  low  specific  gravity  may  indi- 
cate contracted  or  amyloid  kidney,  diabetes  in- 
sipidus, or  hysteria. 

5.  Reaction. — Fresh  normal  urine  is  generally 
acid,  but  when  passed  after  a meal  it  may  be 
neutral  or  even  alkaline,  and  sometimes,  though 
rarely,  the  mixed  urine  of  twenty-four  hours 
may  present  a similar  reaction.  Sometimes  the  re- 
action is  amphoteric  oramphogenous,  that  is,  red 
litmus  paper  is  rendered  blue,  and  blue  litmus 
paper  is  turned  red.  The  acidity  of  the  urine  is 
chiefly  due  to  acid  phosphates,  and  in  part  also 
to  free  organic  acids,  such  as  lactic  and  hippuric. 
The  amphoteric  reaction  is  probably  due  to  the 
presence  of  basic  and  acid  phosphates  together. 
The  acidity  is  less  when  acid  is  being  secreted 
by  the  stomach  or  skin  during  digestion  or  pro- 
fuse perspiration.  It  is  diminished  by  vegetable 
diet,  and  by  alkalies  or  their  salts  with  vegetable 
acids.  It  is  diminished  in  ansemia  and  chlorosis ; 
and  in  melancholia  or  paralysis  the  reaction  may 
be  neutral  or  alkaline  from  potassium  or  sodium 
carbonates.  It  is  increased  by  a flesh  or  a milk 
diet,  by  muscular  exercise,  by  drinking,  and  by 
acids  ; and  also  in  fever  and  diabetes. 

When  urine  is  passed  with  proper  precautions 
into  a vessel  which  has  been  previously  heated, 
so  as  to  destroy  all  germs,  it  may  be  kept 
unchanged  for  years. 

Usually  it  becomes  altered  quickly,  its  reaction 
becoming, first,  more  strongly  acid,  then  less  acid, 
and  finally  alkaline.  These  changes  are  due  to 
fermentation,  which  leads  first  to  the  formation 
of  acid  phosphates,  and  of  lactic  and  acetic 
acids,  from  the  extractive  matters  of  the  urine, 
with  deposition  of  uric  acid.  This  increase  of 
acidity  is  not  constant,  and  deposition  of  uric 
acid  may  occur  simply  from  chemical  reaction 
between  urates  and  acid  phosphates.  After  a 
varying  period  the  urea  becomes  decomposed, 
and  carbonate  of  ammonia  is  formed,  which  gives 
to  the  urine  an  ammoniacal  odour  and  alkaline 
reaction,  and  causes  the  precipitation  of  urate 
of  ammonia,  ammonio-magnesian  phosphate,  cal- 
cium phosphate,  and  calcium  carbonate. 

The  acid  fermentation,  when  present,  is  pro- 
bably due  to  an  organism  similar  to  yeast.  The 
alkaline  fermentation  is  probably  caused  in 
great  measure  by  bacteria,  but  it  may  be  in- 
duced also  by  a non-organised  ferment,  which 
has  been  isolated  from  ammoniacal  urine.  This 
ferment  appears  to  be  generally  produced  by 
bacteria,  but  it  may  be  produced  also,  under 
certain  circumstances,  by  the  mucus-corpuscles 
and  epithelial  cells  in  the  bladder.  Fresh  urine 
inoculated  with  bacteria  from  decomposing  urine 
undergoes  very  rapid  change,  and  the  same  is 
the  case  with  the  urine  inside  the  bladder  when 
it  is  inoculated  by  means  of  dirty  catheters. 
But  similar  changes  may  occur  in  the  bladder  in 
cases  of  cystitis,  even  when  no  instruments  have 


URINE,  MORBID 

been  introduced,  and  the  ferment  in  these  cases 
appears  to  be  formed  by  the  mucus  or  epithelium. 
In  order  to  distinguish  whether  the  alkalinity 
of  the  urine  depends  on  ammonia  or  on  fixed 
alkalies,  the  red  litmus  paper  must  be  dried  after 
being  dipped  in  it.  If  the  alkalinity  is  due 
to  ammonia  the  blueness  of  the  paper  which  it 
produced  will  disappear,  and  the  paper  return  to 
its  original  red  colour  ; but  the  blue  will  remain 
if  the  alkalinity  is  due  to  fixed  alkalies. 

Solid  Constituents. — The  solid  constituents 
of  the  urine  are  the  ashes  of  the  body,  and  their 
quantity  varies  with  the  amount  of  food  con- 
sumed, and  the  amount  of  waste  in  the  tissues 
of  the  body  itself.  Their  quality  depends  on 
the  nature  of  the  nutritive  processes  and  of  the 
tissue-change  going  on  in  the  body:  and  it  thus 
forms  a useful  indication  of  the  healthy  or  dis- 
eased nature  of  the  tissue-change  and  nutritive 
processes.  Some  solids  are  constantly  present, 
although  in  varying  quantities,  in  healthy  urine; 
others  are  only  occasionally  present ; and  others 
again  never  occur  in  health,  so  that  their  pre- 
sence is  a sign  of  disease.  Those  present  in 
health  are  (1)  nitrogenous  substances — urea,  uric 
acid,  allantoin,  oxaluric  acid,  xanthin,  kreatinin, 
sulphoeyanic  acid,  Raumstark’s  body,  and  per- 
haps guanin;  (2 ) ferments — pepsin,  nephrozy- 
moso  or  ptyalin;  (3)  salts — chiefly  chlorides, 
sulphates,  and  phosphates  of  sodium,  potassium, 
ammonium,  calcium,  and  magnesium,  sodium 
chloride  being  the  most  abundant ; (4)  acids — 
oxalic,  lactic,  and  glycero-phosphoric  acids,  pos- 
sibly present  in  combination,  or  partly  free ; 
sulphuric  acid  in  two  forms,  simply  combined 
with  bases  as  sulphates,  or  united  with  other 
substances  so  as  to  form  ether-sulphuric  acids  of 
phenol,  kresol,  brenzcatechin,  indoxyl,  scatoxyl, 
&c. ; and  (5)  pigments,  and  pigment-yielding 
bodies  or  chromogens. 

Abnormal  constituents  include  albumins,  blood, 
haemoglobin,  methaemoglobin,  bile-pigments,  bile- 
acids,  grape  and  milk  sugar,  leucin  and  tyrosin, 
lecithin,  cystin,  fat,  &c. 

The  quantity  of  solid  constituents  is  deter- 
mined exactly  by  weighing  the  dried  residue  of 
a given  quantity  of  urine.  It  may  also  be  ascer- 
tained approximately  by  multiplying  the  last 
two  figures  of  the  specific  gravity  by  2'33. 
This  gives  the  amount  per  thousand,  and  from 
this  the  total  quantity  is  reckoned.  Thus,  if  a 
man  passes  1,560  cub.  cent,  of  urine  daily,  which 
when  mixed  has  a specific  gravity  of  1,022,  then 
22  x 2-33  = 51-26  and  1000  : 1560  ::  51'26  : 
79'96  grammes  of  solids  per  diem. 

The  most  important  constituents  must  now  be 
described. 

1.  Urea  (CON,H,). — This  is  by  far  the  largest 
and  most  important  of  the  organic  constituents 
of  urine,  as  70  or  80  per  cent,  of  the  entire  nitro- 
gen excreted  appears  as  urea.  The  quantity  of 
urea  passed  per  diem  by  a healthy  man  is  on  an 
average  33-18  grammes  or  512-4  grains.  Urea 
may  be  regarded  as  the  ash  of  the  nitrogenous 
substances,  whether  food  or  tissues,  which 
have  undergone  combustion  in  thebody,  and  there- 
fore its  quantity  fluctuates  greatly  according  to 
the  amount  of  nitrogenous  food  consumed,  and 
also  according  to  the  rapidity  of  tissue-change. 
The  variations  due  to  the  food  are  so  great, 
108 


CONDITIONS  OF.  171S 

however,  that  unless  the  amount  of  nitrogen  in 
the  food  consumed  be  kept  rigidly  the  same  from 
day  to  day,  or  food  be  altogether  withheld,  they 
mask  the  variations  due  to  tissue-change.  Hence 
most  of  the  earlier  experiments  on  the  influence 
of  drugs,  exercise,  &e.,  on  tissue-change,  as  de- 
termined from  the  excretion  of  urea,  are  untrust- 
worthy. 

Tlie  quantity  of  urea  varies  with  age,  sex. 
country,  and  other  circumstances ; but  most  of 
these  variations  are  easily  accounted  for  by  the 
proportion  of  nitrogenous  food  taken  by  children 
and  adults,  men  and  women,  English,  French,  or 
Germans  respectively.  Muscular  exercise  up  to 
a certain  point  does  not  increase  it,  but  when 
excessive  it  appears  to  do  so ; the  explanation 
probably  being  that  in  ordinary  exercise  no  de- 
struction of  the  nitrogenous  constituents  of  the 
muscle  occurs,  the  energy  being  supplied  by 
their  non-nitrogenous  elements,  but  that  when 
the  exercise  is  too  severe  and  prolonged,  the 
albuminous  constituents  of  the  muscles  them- 
selves become  partially  destroyed. 

Nitrogenous  food,  such  as  meat  of  all  sorts, 
eggs,  and  gelatin  or  substances  which  yield  it, 
increase  the  excretion  of  urea  in  proportion  to 
the  quantity  of  this  sort  of  food  taken.  There 
seems  to  be  a limit,  however,  beyond  which  the 
excretory  powers  of  the  kidney  will  not  go,  and 
when  this  limit  is  reached,  nature  saves  the 
organism  by  diarrhoea,  which  carries  off  the  ex- 
cess of  nitrogenous  food.  The  addition  of  fat 
alone  to  an  abundant  diet  of  meat  rather  in- 
creases the  excretion  of  urea ; but  when  fari- 
naceous food  is  added  to  such  a diet,  the  urea  is 
rather  diminished.  Farinaceous  food  and  fats 
given  to  an  animal  deprived  altogether  of  nitro- 
genous food,  cause  it  to  excrete  less  urea  than  if 
it  were  totally  deprived  of  food.  The  addition 
of  farinaceous  food  and  fat  therefore  appears  to 
lessen  the  destruction  of  the  nitrogenous  tissues 
themselves. 

When  much  water  is  drunk,  the  absolute 
amount  of  urea  excreted  in  twenty-four  hours  is 
considerably  increased,  although,  the  urine  being 
so  much  more  abundant,  the  percentage  of  urea 
is  lessened.  The  increase  in  urea  is  said  to  be 
greater  when  the  water  is  drunk  during  the 
meal,  than  when  it  is  drunk  after  digestion  has 
taken  placo. 

Table  and  other  salts  increase  the  quantity  or 
urea,  even  when  no  more  water  is  drunk,  and 
also  increase  the  quantity  of  water,  probably  by- 
causing  part  of  the  water  to  be  eliminated  through 
the  kidneys,  which  would  otherwise  have  passed 
off  through  the  lungs  or  skin. 

Moderate  warmth  appears  to  diminish  the 
excretion  of  urea,  probably  by  increasing  the 
secretion  of  sweat;  but  when  an  animal  is  kept 
for  a length  of  time  at  a high  temperature,  a 
condition  of  fever  appears,  and  the  excretion  of 
urea  is  greatly  increased. 

Quantitative  Estimation. — Formerly  urea  was 
usually  estimated  by  Liebig’s  method  of  titra- 
tion with  nitrate  of  mercury ; but  the  mode  now 
usually  adopted,  as  being  at  once  accurate  and 
easy,  is  the  hypobromite  process.  This  method 
is  due  to  Davy,  who  used  hypochlorite  of  soda, 
and  this  was  afterwards  modified  by  Hiifner, 
who  introduced  the  hypobromite  in  place  of 


i/14  URINE,  MORBID 

hypochlorite.  This  method  depends  on  the  fact 
that  urea,  in  contact  with  alkaline  hypobromites 
or  hypochlorites,  is  decomposed,  and  gives  off 
nitrogen,  from  the  amount  of  which  the  quantity 
of  urea  decomposed  can  bo  readily  estimated. 
Various  modifications  in  the  method  of  applying 
the  process  have  been  introduced,  the  one  in 
most  common  use  perhaps  being  that  of  Russell 
and  West. 

The  apparatus  consists  of  a tube  in  which  the 
urine  is  allowed  to  mix  with  a hypobromite  solu- 
tion, and  a pneumatic  trough,  with  a measuring 
tube,  in  which  to  collect  the  evolved  gas.  The 
measuring  tube  is  graduated  to  give  the  percent- 
age of  urea.  Another  apparatus  is  that  of  Dupre, 
in  which  the  urine  and  hypobromite  solution  are 
mixed  in  a bottle  connected  with  the  measuring 
tube  by  an  india-rubber  tube.  Both  of  these 
aro  well  adapted  for  clinical  use.  In  each  of 
them  5 ec.  of  urine  is  mixed  with  four  or  five 
times  its  bulk  of  the  hypobromite  solution. 
This  solution  is  prepared  by  dissolving  100 
parts  of  caustic  soda  in  250  of  water,  and  add- 
ing, when  cold,  25  parts  of  bromine.  The 
solution  does  not  keep,  and  is  best  made  by 
having  the  soda  solution  of  a proper  strength, 
and  adding  the  required  quantity  of  bromine  at 
each  analysis. 

The  readiness  with  which  crystals  of  nitrate 
of  urea  form  on  the  addition  of  nitric  acid  to  a 
solution  containing  it,  affords  a means  of  esti- 
mating roughly  the  quantity  of  urea  present  in 
urine.  These  crystals  do  not  form  in  normal 
urine  on  the  simple  addition  of  nitric  acid,  but 
do  so  in  urine  containing  great  excess  of  urea. 
Thus,  if  equal  parts  of  strong  nitric  acid  and  such 
urine — say,  half  a drachm  of  each — be  mixed 
in  a test-tube,  and  this  be  placed  in  cold  water, 
the  crystals  will  soon  make  their  appearance. 
Another  form  of  test  is  easily  applied  on  an 
object-glass.  One  end  of  a small  piece  of  thread 
is  put  into  a drop  of  urine  on  the  glass  ; the 
drop,  and  the  half  of  the  thread  are  then  pro- 
tected by  a thin  covering- glass ; and  the  other 
end  of  the  thread  is  moistened  with  nitric  acid. 
Tho  whole  is  then  put  under  the  microscope,  and 
hexagonal  plates  of  nitrate  of  urea  are  seen  form- 
ing at  each  side  of  the  thread  when  there  is 
great  excess  of  urea.  If  the  urine  contains  the 
normal,  or  less  than  the  normal,  amount  of  urea, 
it  must  be  more  or  less  evaporated  by  gently 
heating  over  a spirit-lamp  before  the  crystals 
form ; and  from  the  extent  to  which  this  is 
necessary  a rough  estimate  of  the  deficiency  of 
urea  may  be  formed. 

Clinical  Import. — AVhen  the  percentage  of  urea 
is  much  above  2 per  cent,  it  generally  indicates 
that  the  patient  is  either  feverish,  or  has  been  per- 
spiring profusely,  or  that  the  quantity  of  water  he 
drinks  is  too  small  to  ensure  the  ready  elimina- 
tion of  the  products  of  nitrogenous  waste.  In  such 
cases,  if  the  thermometer  does  not  indicate  the 
presence  of  fever,  or  if  the  patient  has  not  been 
perspiring  profusely,  he  should  be  advised  to 
drink  more  water,  in  order  to  prevent  the  pos- 
sible occurrence  of  rheumatic  or  gouty  affections. 
A small  percentage  of  urea  is  of  much  graver 
significance.  It  may  bo  due  to  copious  drinking, 
exposure  to  cold,  or  to  mental  excitement ; but 
when  it  occurs  independently  of  these  causes  in 


CONDITION'S  OF. 

elderly  persons,  it  very  commonly  indicates  the 
presence  of  contracting  kidney. 

The  name  azoturia  has  been  given  to  a con- 
dition in  which  the  excretion  of  urea  is  excessive, 
in  proportion  to  the  weight  of  the  body.  In 
some  persons  excessive  excretion  of  urea  is  asso- 
ciated with  increased  secretion  of  water,  so  that 
the  proportion  of  urea  remains  normal.  In 
others  the  water  is  not  increased,  and  therefore 
the  urea  excreted  is  not  only  increased  in  abso- 
lute quantity  per  diem,  but  its  proportion  in  the 
urine  is  greater  than  normal,  so  that  such  urine 
at  once  gives  crystals  of  nitrate  of  urea  on  the 
addition  of  nitric  acid.  Excessive  excretion  of 
urea,  both  absolute  and  relative  to  the  amount 
of  urine,  may  occur  for  a time  in  perfectly 
healthy  persons,  without  any  abnormal  symp- 
tom whatever.  In  others,  however,  such  an 
excess  of  urea  is  associated  with  gastrointes- 
tinal derangement  and  nervous  symptoms,  tho 
patient  complaining  of  acidity  and  flatulence, 
but  not  of  thirst  or  excessive  appetite.  There 
is  languor,  fatigue  after  slight  exertion,  bodily 
or  mental,  nervousness,  restlessness  at  night, 
dull  pain  in  the  back,  and  sometimes  irritation 
at  the  neck  of  the  bladder,  with  constant  desire 
to  pass  water.  It  is  probable  that  in  some  in- 
dividuals the  nitrogenous  tissue-change  goes  on 
more  rapidly  than  in  others,  and  that  they  con- 
sequently require  a larger  proportion  of  nitro- 
genous constituents  in  their  food,  to  enable  them 
to  do  the  same  amount  of  work ; and  that  when 
indigestion  occurs  in  such  persons,  the  nitro- 
genous products  of  imperfect  digestion  or  tissue- 
waste,  acting  as  nervous  and  muscular  poisons, 
lead  to  the  symptoms  of  which  they  complain. 
In  diabetes  there  is  increased  excretion  of  urea, 
from  the  greater  amount  of  food  taken  by  the 
patients ; and  it  has  been  supposed  by  Prout 
that  cases  of  azoturia  might  pass  into  diabetes. 

The  treatment  consists  in  ordering  nutritious 
diet,  with  a large  proportion  of  farinaceous  con- 
stituents; moderate  exercise;  avoidance  of  fa- 
tigue, mental  or  bodily  ; purgatives  ; alteratives ; 
and  opium. 

2.  Uric  Acid. — (C5H.,N103). — When  pure,  uric 
acid  forms  white  crystals,  very  sparingly  solu- 
ble in  water.  It  does  not  exist  free  in  the 
healthy  urine,  but  is  combined  with  potash,  soda, 
and  ammonia.  From  these  it  may  be  separated 
by  the  addition  of  an  acid,  or  by  acid  fermentation 
in  the  urine  after  it  has  been  passed,  as  already 
desmbed. 

As  deposited  from  the  urine,  uric  acid  is  nearly 
always  coloured.  It  may  be  deposited  in  scat- 
tered brown  specks,  or  as  a dense  deposit  of  red 
sand,  resembling  red  pepper  in  appearance  ; or 
it  may  form  a thin  film  on  the  surface  of  the 
urine.  The  crystalline  character  of  the  deposit 
can  generally,  though  not  always,  be  recognised 
by  the  naked  eye.  On  microscopic  examination 
the  crystals  usually  present  a somewhat  lozenge- 
shaped form.  This  form  is  modified  by  round- 
ing and  by  aggregation.  AVhen  the  angles  are 
rounded  off,  spindle-shaped,  ovoid,  and  barrel- 
shaped forms  are  produced.  Sometimesthey  are 
elongated,  so  as  to  produce  a rod  ; and  the  aggre- 
gation of  the  lozenge,  ovoid,  and  rod-like  forms 
produces  stars  and  spikes,  varying  considerably 
j in  appearance.  Sometimes,  also,  they  appear 


URINE,  MORBID 

like  dumb-bells  ( see  Microscope  in  Medicine). 
The  crystals  of  uric  acid  are  distinguished  by 
their  reddish  or  brown  colour,  as  well  as  by 
their  peculiar  appearance.  They  dissolve  readily 
in  caustic  soda  or  potash,  and  separate  again  on 
the  addition  of  hydrochloric  acid.  The  chemical 
test  for  uric  acid  is  generally  known  by  the 
name  of  the  murexide-test.  It  distinguishes  uric 
acid  and  urates  from  other  urinary  sediments, 
but  it  will  not  distinguish  free  uric  acid  from 
uric  acid  in  combination.  The  mode  of  applying 
it  is  to  warm  the  sediment  in  a porcelain  cap- 
sule, with  a few  drops  of  nitric  acid  and  a little 
water,  and  to  evaporate  it  carefully,  almost  to 
dryness.  It  is  then  moistened  by  a glass  rod 
with  diluted  ammonia,  when  a fine  purple  red 
colour  appears,  which,  on  the  addition  of  a drop 
of  caustic  potash,  passes  into  a purplish  blue. 

Quantitative  Estimation. — Uric  acid  is  esti- 
mated quantitatively  by  mixing  the  urine  with 
ith  of  its  bulk  of  hydrochloric  acid,  and  setting 
it  aside  in  a cool  place  for  twenty-four  hours. 
The  deposit  of  uric  acid  is  then  collected  on  a 
filter,  washed  with  the  least  possible  quantity  of 
water,  dried,  and  weighed ; the  weight  of  the 
filter  alone  having  been  previously  ascertained. 
As  the  weighing  is  troublesome  and  difficult,  the 
quantity  of  uric  acid  may  be  ascertained  by 
carefully  washing  it  off  the  filter,  and  boiling  it 
with  peroxide  of  lead  in  a little  water,  so  as  to 
convert  it  into  carbonic  and  oxalic  acids,  allan- 
toin,  and  urea.  The  amount  of  nitrogen  in  this 
solution  is  then  estimated  by  the  hypobromite 
method  already  described.  Uric  acid  contains 
one-third  of  its  weight  of  nitrogen,  so  that  by 
multiplying  the  weight  of  nitrogen  evolved  by  3, 
one  obtains  the  quantity  of  uric  acid.  Besides 
this  ’0015  gramme  is  to  be  added  for  each  100 
cc.  of  the  urine  employed. 

Another  method  (Cook’s)  is  to  add  3 or  4 
drops  of  caustic  soda  to  300  or  400  c.c.  of  urine, 
and,  after  the  phosphates  have  subsided,  to 
add  to  100  c.c.  of  the  clear  liquid  about  4 c.c.  of 
a solution  (1  in  3)  of  zinc  sulphate,  sufficient  to 
make  the  urine  faintly  acid.  This  precipitates 
the  uric  acid  in  the  form  of  insoluble  zinc  urate. 
The  precipitate  is  washed  on  a filter  with  a 
saturated  solution  of  zinc  urate,  and  then  placed 
with  the  filter  in  the  urea  apparatus,  and  the 
nitrogen  estimated  by  the  hypobromite  method, 
as  already  described.  When  boiled  with  liquor 
potass®  and  cupric  sulphate,  uric  acid  reduces 
the  latter  to  cuprous  oxide.  The  writer  has  seen 
a case  in  which  the  reduction  was  so  great  as 
to  lead  the  patient,  who  was  a medical  man,  to 
think  that  he  was  suffering  from  diabetes,  and  to 
put  himself  on  an  animal  diet,  by  which  his  con- 
dition was  of  course  made  worse. 

5a.  Urates. — Uric  acid  occurs  in  combination 
with  soda,  ammonia,  and  lime;  the  urate  of  soda 
being  the  most  common.  The  urates,  being 
readily  soluble  at  the  temperature  of  the  body, 
are  only  deposited  on  cooling,  so  that  the  urine, 
which  was  clear  when  passed,  becomes  muddy, 
and  a sediment  forms,  which  is  commonly 
coloured  like  brick-dust,  varying  in  shade,  being 
sometimes  almost  white  and  sometimes  red. 
Fale  white  urates  are  readily  distinguished  from 
phosphates  by  quickly  clearing  up  when  the  urine 
is  warmed,  while  the  phosphates  do  not.  Micro- 


CONDITIONS  OF.  1715 

scopieally,  the  urates  of  soda  and  lime  are 
usually  amorphous  ; but  sometimes  the  urate 
of  soda  forms  globules  with  projecting  spikes, 
which  have  caused  them  to  be  compared  to 
hedgehogs.  The  urate  of  ammonia  forms  opaque 
globules,  or  slender  dumb-bells,  which  are  either 
single  or  aggregated,  so  as  to  form  a cross  or 
rosette. 

Clinical  Import. — -Deposit  of  urates  occurs 
readily  after  any  violent  exertion  or  perspira- 
tion, or  after  errors  in  eating  or  drinking.  People 
are  often  frightened  by  such  deposits,  but  they 
are  of  no  importance  unless  they  should  persist 
for  a length  of  time.  Persistent  deposits  occur 
in  febrile  conditions  or  deep-seated  organic  dis- 
ease. In  cirrhosis  the  urine  is  sometimes  heavily 
loaded.  See  Uric  Acid  Diathesis. 

3.  Oxalate  of  Lime.- — - Oxalate  of  lime  is 
recognised  by  the  white,  hummocky  appearance 
of  the  top  of  the  mucous  cloud  in  the  urine.  On 
microscopical  examination,  octahedral  crystals 
are  seen,  presenting  the  appearance  of  a folded 
envelope.  It  also  occurs  in  colourless  dumb- 
bells. It  is  distinguished  from  uric  acid  by 
being  colourless,  and  insoluble  in  alkalies ; and 
from  phosphates  by  being  insoluble  in  acetic 
acid. 

Clinical  Import. — The  occasional  occurrence 
of  oxalates  is  of  slight  importance,  and  is  usu- 
ally connected  with  diet.  In  hospital  practice 
the  writer  has  noticed  that  when  the  patients 
ate  cabbage  for  dinner,  a large  proportion  of 
them  had  oxalates  in  the  urine  next  morning. 
Persistent  presence  of  oxalates  in  the  urine  haa 
been  supposed  to  be  connected  with  a peculiar 
diathesis  (the  oxalic  acid  diathesis),  the  symp- 
toms of  which  are  languor,  depression,  and  me- 
lancholia. It  is  most  probable  that  both  this  and 
the  presenco  of  oxalates  in  the  urine  are  simply 
due  to  imperfect  digestion,  more  especially  as 
they  often  disappear  readily  on  treatment  by 
nitrohydrochloric  acid.  See  Oxaxic  Acid  Dia 
thesis, 

4.  Phosphates. — Two  kinds  of  phosphates 
are  found  in  the  urine — phosphate  of  lime,  and 
ammonio-magnesian  or  triple  phosphate.  They 
are  always  deposited  when  the  urine  becomes 
alkaline  through  fermentation  ; and  when  feebly 
acid  urine  is  heated,  so  that  the  carbonic  acid  is 
driven  off,  phosphates  are  precipitated  in  the 
form  of  a cloud,  which  might  be  mistaken  for 
albumin,  but  clears  up  at  once  on  the  addition  of 
a drop  of  acid.  Under  the  microscope,  phosphate 
of  lime  is  amorphous.  The  ammonio-magnesian 
phosphate  occurs  in  rhombic  prisms,  which  are 
distinguished  from  oxalate  of  lime  by  dissolving 
readily  in  acetic  acid. 

Quantitative  Estimation. — A rough  quantita- 
tive estimation  of  phosphates  is  made  by  ren- 
dering some  urine  alkaline  with  ammonia,  and 
adding  an  ammonio-magnesian  solution  to  it.  A 
precipitate  of  ammonio-magnesian  phosphate  at 
once  occurs  if  the  amount  in  the  urine  be  nor- 
mal, but  is  delayed  when  the  quantity  is  below 
normal. 

Clinical  Import. — In  persons  having  little 
exercise  and  a good  deal  of  brain-work,  the 
urine  may  be  turbid  when  passed,  from  phos- 
phates present  in  it.  This  usually  passes  away 
when  they  get  more  exercise.  It  may  continue 


1716  URINE,  MORBID 

for  months,  and  is  of  importance  only  in  so  far 
as  it  renders  the  patient  liable  to  phosphatic 
calculus.  Such  deposits  do  not  indicate  in- 
creased quantity  of  phosphates  in  the  urine,  but 
are  simply  due  to  diminished  acidity.  The 
writer  has  found  the  actual  quantity  of  phos- 
phates present  in  such  turbid  urines  less  than 
in  specimens  of  clear  urine  from  the  same  in- 
dividual. The  occurrence  of  stellar  crystals  of 
phosphate  of  lime  in  quantity  in  the  urine  is, 
according  to  Roberts,  of  grave  import,  indicating 
serious  disease  of  some  kind  or  other,  although 
a few  such  crystals  may  occur  in  normal  urine. 
The  triple  phosphate  almost  invariably  occurs  in 
ammoniacal  urine,  and  generally  appears  after 
urine,  alkaline  from  any  cause,  has  stood  for 
some  time.  See  Phosphatic  Diathesis. 

The  quantity  of  phosphates  is  increased  in 
febrile  disorders,  and  in  diseases  of  the  nerve- 
centres  and  bones ; it  is  diminished  in  Bright’s 
disease,  and  sometimes  in  dyspepsia,  as  well  as 
after  the  disappearance  of  febrile  conditions. 

5.  Sulphates. — Sulphur  appears  in  the  urine, 
first,  as  sulphuric  acid,  free  or  in  conjunction 
with  organic  radicals ; secondly,  as  oxidisable 
sulphur  compounds,  for  example,  taurine ; and 
thirdly,  as  sulphur  compounds  oxidisable  with 
difficulty.  The  presence  of  sulphuric  acid  in 
simple  combination  with  bases,  or  in  conjunc- 
tion with  radicals,  is  tested  by  adding  barium 
chloride  and  hydrochloric  acid  to  the  urine,  when 
a white  precipitate  takes  place. 

Quantitative  Estimation. — Sulphuric  acid  is 
estimated  quantitatively  by  means  of  strontium, 
but  for  the  details  of  the  process  the  reader  is 
referred  to  text-books.  The  oxidisable  sulphur 
is  estimated  by  boiling  with  nitric  acid  and 
chlorate  of  potash,  and  then  determining  the 
quantity  of  sulphuric  acid  present,  and  deduct- 
ing from  the  amount  thus  found  the  quantity 
obtained  by  the  first  method.  The  sulphur 
oxidisable  with  difficulty  is  determined  by  eva- 
porating a measured  quantity  of  urine  to  dry- 
ness, calcining  with  nitrate  of  potash,  estimating 
the  sulphuric  acid,  and  deducting  from  these  the 
quantity  found  by  the  second  method. 

Clinical  Import. — The  excretion  of  sulphur  in 
the  urine  may  be  used  as  a means  of  diagnosing 
the  condition  of  the  secretion  of  bile.  The  more 
sulphur  is  excreted  in  the  bile,  the  less  appears 
in  the  urine,  and  vice  versd.  In  biliary  colic,  due 
to  impediment  to  the  flow  of  bile  through  the 
ducts,  the  easily  oxidisable  sulphur  has  been 
found  by  Lepine  to  be  diminished,  but  the  diffi- 
cultly oxidisable  to  bo  increased. 

6.  Chlorides. — Chlorine  is  present  in  the  urine 
in  combination  with  ammonia,  fixed  alkalies,  or 
alkaline  earths.  The  quantity  depends  chiefly 
on  the  amount  of  salt  taken  in  the  food.  When 
this  is  constant  the  excretion  is  also  tolerably 
constant ; but  if  a larger  quantity  of  salt  be  then 
regularly  taken,  the  excess  may  not  begin  to  be 
excreted  until  after  about  three  days,  when  it 
will  again  remain  constant ; and  the  excretion 
will  be  in  excess  for  about  three  days  after  the 
quantity  taken  has  been  diminished.  The  body 
has,  therefore,  the  power  of  retaining  a quantity 
of  chlorine.  In  acute  inflammatory  diseases 
the  chlorides  are  retained  completely,  so  as  to 
disappear  from  tho  urine.  The  usual  test  for 


CONDITIONS  OF. 

chloride  is  the  curdy  white  precipitate  given  * 
the  addition  of  nitrate  of  silver  to  urine  acidu- 
lated with  nitric  acid. 

7.  Pigments. — These  have  not  yet  been  fully 
examined,  but  they  appear  to  exist  in  the  urine 
both  in  the  state  of  pigments  and  pigment- 
yielding  substances  or  chromogens.  The  pig- 
ment of  normal  urine  is  urobilin,  which,  ac- 
cording to  McMunn,  is  an  amorphous  yellow- 
brown  pigment.  It  gives  in  solution  a spectro- 
scopic band  at  F,  disappearing  with  excess  of 
ammonia  or  potash,  and  being  again  brought 
into  view  by  acid.  When  febro-urobilin  is 
present,  caustic  soda  or  potash  causes  the  band 
at  F to  disappear,  and  to  be  replaced  by  a band 
nearer  the  red  end  of  the  spectrum. 

Normal  urobilin  appears  to  be  identical  with 
choletelin,  the  body  produced  by  oxidising  acid 
hsematin.  Normal  urine  also  appears  to  con- 
tain two  chromogens,  namely,  the  chromogen  of 
febro-urobilin,  and  indican.  By  the  addition 
of  oxidising  agents  to  the  urine,  or  by  long 
standing,  febro-urobilin  may  be  produced  from 
the  chromogen. 

The  quantity  of  indican  present  in  normal 
urine  is  small.  It  is  tested  by  mixing  the 
urine  with  its  own  bulk  of  hydrochloric  acid, 
and  adding  a drop  or  two  of  saturated  solution 
of  chloride  of  lime.  The  indican  is  thus  split 
up,  yielding  indigo,  which  colours  the  urine  blue, 
and  may  be  removed  by  shaking  with  chloroform 
and  allowing  it  to  settle.  The  supernatant 
liquid  remains  of  a reddish  or  purplish  colour, 
from  the  presence,  probably,  of  indigo-red.  There 
appears  to  be  some  difference  in  the  indigo- 
yielding  substance,  because  occasionally  the 
addition  of  nitric  acid  to  the  urine  has  no  effect, 
although  indican  be  present,  as  shown  by  the  test 
thus  given,  while  on  other  occasions  the  writer 
has  found  the  mere  addition  of  nitric  acid  render 
the  urine  a dark  greenish-blue,  or  almost  black, 
from  the  immediate  separation  of  indigo,  which 
could  be  removed  by  the  treatment  with  chloro- 
form just  described. 

Clinical  Import. — Indican  appears  to  bo  de- 
rived from  indol,  formed  by  pancreatic  digestion. 
Indol  administered  subcutaneously  increases  the 
indigo  in  the  urine.  The  indigo  is  much  in- 
creased by  part  ial  or  complete  obstruction  of  the 
small  intestines.  It  is  less  affected  by  affections 
of  the  large  intestines.  It  has  also  been  found 
increased  in  tabes  mesenterica,  phthisis,  cancer 
of  the  stomach,  lymphatic  growths,  cancer  of  tho 
liver,  Addison’s  disease,  and  cholera.  It  is  pre- 
sent in  large  quantity  in  the  urine  of  persons 
resident  in  the  tropics.  It  appears  to  be  in- 
creased by  turpentine,  oil  of  bitter  almonds,  an  l 
nux  vomica. 

A chromogen,  yielding  a purple  colour  on  the 
addition  of  nitric  acid,  is  often  met  with  in  cases 
of  anaemia  where  the  urine  itself  is  of  a very 
pale  colour,  but  on  the  addition  of  nitric  acid 
becomes  almost  cherry-red. 

S.  Albumin  — The  ordinary  form  of  albumin 
is  serum-albumin.  Besides  this  we  have  para- 
globulin,  fibrinogen,  propeptone,  and  peptone. 
For  the  tests  of  these  substances  see  Ale  mix, 
and  Albuminuria  ; and  for  their  clinical  import 
sec  Bright's  Disease  ; and  Kidxrvs,  Diseases  of. 

Albuminuria  is,  however,  much  more  common 


URINE,  MORBID  CONDITIONS  OF. 
than  is  'usually  supposed,  and  has  been  found  to 
occur  in  eleven  per  cent,  of  apparently  healthy 
persons  presenti  ng  themselves  for  assurance.  Its 
significance  in  such  persons  has  not  been  com- 
pletely ascertained,  hut  it  has  been  found  that 
in  many  such  cases,  when  they  are  kept  under 
observation,  the  health  goes  on  deteriorating. 
Intermittent  albuminuria  is  not  infrequent  in 
persons  who  have  been  exposed  to  malaria; 
and  Dr.  Quath  has  observed  that  intermittent 
albuminuria  in  youth  is  frequently  associated 
with  masturbation.  In  contracting  kidney  the 
albumin  is  usually  small  in  quantity,  and  may 
also  be  completely  intermittent,  traces  of  it 
appearing  only  in  the  urine  passed  after  meals, 
and  being  entirely  absent  from  urine  passed  in 
the  morning.  This,  as  the  writer  has  seen,  may 
occur  even  when  the  patient  is  in  a very  pre- 
carious condition,  and  is  already  suffering  from 
nephritic  asthma.  Dr.  Mahomed  believes  that 
albuminuria  may  be  quite  absent  in  granular 
disease.  Egg-albumin  and  pro-peptones  readily 
pass  through  the  kidneys  ( see  Albuminuria). 
It  has,  however,  been  recently  found  by  Stokvis 
that  if  egg-albumin  is  made  to  pass  through  the 
kidneys  for  a length  of  time,  the  kidneys  them- 
selves undergo  structural  change,  glomerular 
nephritis  being  induced.  These  observations 
confirm  the  idea,  founded  on  clinical  observation 
by  Dr.  G.  Johnson,  that  albuminuria  with  struc- 
nral  kidney-change  may  be  secondary  to  con- 
.inued  indigestion. 

9.  Sugar. — For  the  tests  and  indications  of 
sugar  in  the  urine  see  Diabetes. 

10.  Inosite,  or  Muscle-sugar. — This  occa- 
sionally occurs  in  urine  alternately  with  dex- 
trose. It  has  no  action  on  polarised  light ; it 
does  not  ferment  with  yeast ; and  it  does  not 
reduce  cupric  hydrate,  although  it  causes  it  to 
dissolve.  It  is  detected  by  precipitating  the 
urine  first  with  neutral  lead  acetate,  then  with 
oasic  acetate,  collecting  the  second  precipitate 
on  a filter,  suspending  it  in  a little  water,  and 
decomposing  by  hydric  sulphide,  filtering,  and 
evaporating  to  a small  bulk.  A drop  is  then 
mixed  with  nitric  acid,  and  evaporated  almost  to 
dryness  on  platinum  foil.  A drop  of  ammonia 
and  one  of  calcium  chloride  are  next  added,  and 
the  whole  gently  evaporated  to  dryness.  A rose- 
red  tinge  indicates  the  presence  of  inosite. 

11.  Blood,  Haemoglobin,  Metheemoglobin. 
For  the  tests  and  indications  of  these  see  HAsha- 
turia  ; HvEuatimjbia  ; and  Haemoglobin. 

12.  Bile-acids.  See  Jaundice. 

13.  Leucin,  Tyrosin.  See  Leucin  ; Lives, 
Atrophy  of ; Phosphorus,  Poisoning  by ; and 
Tyrosin. 

14.  Cystin.  See  Calculi. 

15.  Abnormal  Pigments. — The  chief  of  these 
are  uroerythrin,  giving  a red  colour  to  febrile 
urine,  febro-urobilin,  and  urohsematin.  The 
nature  and  relation  both  of  the  normal  and 
abnormal  urinary  pigments  and  chromogens  is 
not  yet  fully  understood.  For  bile-pigments  see 
Jaundice. 

Melanin. — This  black  pigment  has  been  found 
in  the  fresh  urine  of  patients  with  melanotic 
cancer.  It  appears  in  the  fresh  urine  as  a chro- 
mogen, the  urine,  when  freshly  passed,  being 
normal  in  colour ; but  after  standing,  or  after  the 


URINE,  SUPPRESSION  OF.  1717 
addition  of  oxidising  substances,  such  as  nitric 
acid,  the  black  pigment  melanin  is  formed.  This 
must  not  be  confounded  with  the  black  colour 
from  carbolic  acid,  or  with  the  black  colour  due 
to  great  excess  of  indigo  already  described. 

Accidental  Pigments. — Chrysophanic  acid  may 
occur,  from  taking  rhubarb  or  senna.  The  urine 
containing  it  becomes  red  when  it  is  rendered 
alkaline  by  caustic  alkali.  The  colour  disappears 
on  the  addition  of  acid. 

Santonin  colours  acid  urine  yellow  or  greenish. 
It  is  distinguished  from  biliary  pigments  by  be- 
coming cherry-red  and  purple  on  the  addition  of 
caustic  alkali,  this  colour  disappearing  on  the 
addition  of  acid. 

The  pigments  of  bilberries,  logwood,  beet- 
root, indigo,  and  gamboge  also  pass  to  a certain 
extent  into  the  urine,  and  the  Cytisus  alpinus 
gives  it  a grass-green  colour.  After  the  use, 
either  external  and  internal,  of  carbolic  acid, 
creasote,  or  phenol,  the  urine  may  be  greenish- 
brown  or  almost  black.  This  is  due  to  products 
of  the  oxidation  of  these  substances,  chiefly 
hydrochinon.  Sometimes  the  presence  of  iodide 
or  bromide  of  potassium  in  the  urine  may  ren- 
der it  very  dark  after  the  addition  of  nitric  acid, 
on  account  of  the  liberation  of  free  iodine  or 
bromine.  These  are  distinguished  by  their  pene- 
trating odours,  and  may  be  separated  by  treat- 
ing the  urine  with  chloroform  and  then  gently 
evaporating.  T.  Lauder  Bbunton. 

URINE,  Retention  of. — A morbid  condition 
in  which  there  is  difficulty  or  inability  to  expel 
the  urine  from  the  bladder.  See  Micturition, 
Disorders  of. 

URINE,  Suppression  of.  — Synon.  : Fr. 
Suppression  de  la  Urine ; Ger.  Harnverhaltung. 
Suppression  of  the  secretion  of  urine  arises  under 
two  conditions : first,  where  there  is  obstruction 
in  the  line  of  outflow;  secondly,  where  there  is 
some  fault  in  the  action  of  the  kidney  itself. 

1.  Obstructive  Suppression. — This  is  most 
commonly  a result  of  impaction  of  a calculus  in 
the  ureter  of  a patient  who  has  already,  from 
some  cause,  had  one  kidney  permanently  de- 
stroyed ; or  of  the  presence  of  a tumour,  as  of 
the  bladder  or  uterus,  implicating  both  ureters. 
A little  urine  is  commonly  passed  during  the 
progress  of  such  cases.  It  is  generally  pale,  and 
of  low  specific  gravity.  "When  suppression  is 
absolute,  seven  or  eight  days  may  elapse  before 
the  patient  appears  to  suffer  materially,  but  then 
occur  muscular  twitchings,  contraction  of  pupils, 
weakness  of  muscles,  drowsiness,  and  in  rare 
cases  convulsions.  There  is  neither  dropsy  nor 
urinous  odour  of  the  breath.  The  duration  of 
life  appears  to  vary  from  nine  to  eleven  days. 

2.  Non-obstructive  Suppression. — Some- 
times in  the  course  of  acute  inflammatory  Bright’s 
disease,  complete  suppression  of  urine  takes  place. 
It  may  also  occur  in  the  later  stages  particularly 
of  the  inflammatory  and  cirrhoticforms  of  Bright's 
disease;  as  a consequence  of  injuries  and  dis- 
eases of  the  urethra ; and  in  the  cold  stage  of 
cholera.  Doubtless  in  some  of  these  conditions 
suppression  is  due  to  the  nervous  system,  but 
the  way  in  which  it  is  brought  about  is  not  at 
present  understood. 


1718  URINE,  SUPPRESSION  OF. 

Treatment. — Next  to  removal,  if  possible,  of 
the  condition  upon  which  the  suppression  de- 
pends, hot  baths  or  fomentations,  and  the  pa- 
tient avoidance  of  active  interference  with  power- 
ful medicines,  are  among  the  most  important 
indications.  In  cases  of  obstructive  suppression, 
careful  kneading  of  the  abdomen  may  be  tried ; 
and  this  should  be  persevered  with  in  the  most 
advanced  conditions,  as  cases  are  on  record  in 
which  relief  has  been  obtained  when  the  pro- 
spect has  been  utterly  unfavourable.  In  the 
female,  the  introduction  of  a sound  into  the 
ureter  may  be  successfully  practised.  If  relief 
be  not  obtained,  and  death  be  imminent,  sur- 
gical interference  may  perhaps  be  tried. 

T.  Grainger  Stewart. 

URTICARIA  ( urtica , a nettle). — Synon.  : 
Nettle-rash;  Fr.  Urticaire;  Ger.  NcsselausscMag. 

Definition.  — A form  of  erythema,  accom- 
panied by  a sense  of  burning  and  itching,  and  by 
a nodulated  condition  of  the  skin  aseribable  to 
spasm  of  the  muscular  structure  of  the  derma. 

.Etiology  and  Pathology. — Like  other  mor- 
bid states  of  the  system  urticaria  is  sometimes 
excited  through  the  medium  of  the  nervous 
system,  and  by  irritant  substances  taken  into 
the  stomach  ( JJ . ab  ingestis ),  such  as  shell- 
fish and  different  articles  of  diet ; in  the  latter 
case  it  is  influenced  by  idiosyncrasy.  Some 
drugs,  for  instance,  copaiba,  cubebs,  and  tur- 
pentine, produce  eruptions,  scarcely  distinguish- 
able from  urticaria.  The  complex  phenomena 
known  as  dyspepsia  are  a frequent  source  of 
the  eruption;  whilst  in  some  instances  an  irri- 
table or  excitable  condition  of  the  nervous  sys- 
tem itself  may  bo  taken  as  the  cause.  In 
fact,  the  functions  of  the  nerves  are  so  inti- 
mately intermingled  with  the  symptoms  of  urti- 
caria, that  it  has  been  adopted  by  some  authors 
as  a neurotic  disorder.  And  this  view  of  the 
nature  of  the  affection  is  corroborated  by  the 
occasional  concurrence  of  spasmodic  cough  and 
asthma  with  the  development  of  the  rash  at  the 
base  of  the  neck.  Uterine  irritation  from  preg- 
nancy or  other  conditions  is  another  common 
source  of  urticaria ; the  nervous  sensibility  of  the 
integument  is  so  acute  that  wheals  may  be  pro- 
duced by  the  slightest  touch,  and  written  cha- 
racters may  be  developed  at  will  by  the  mere 
act  of  tracing  their  outlines  on  the  skin  with 
the  point  of  a pencil.  Amongst  the  local  or  ex- 
ternal causes  of  urticaria  must  be  mentioned, 
first,  scratching,  or  some  such  mechanical  irri- 
tion,  in  a few  individuals.  This  has  been  called 
factitious  urticaria.  More  often  this  nervous 
sensibility  exists  as  a temporary  condition,  ac- 
companying itching  affections,  such  as  scabies  or 
eczema," or  the  presence  of  pediculi,  and  thus  it 
comes  about  that  the  existence  of  wheals  (urti- 
caria) produced  by  scratching  is  often  the  most 
prominent  symptom  in  scabies.  Other  local 
causes  of  urticaria  are  the  stings  and  bites  of 
insects  and  the  stinging  hairs  of  plants.  See 
Sting  : Stinging  Plants  and  Animals. 

Symptoms  and  Varieties. — Urticaria  varies 
in  the  quantity  and  intensity  of  its  soveral 
symptoms.  Thus,  it  may  be  general  or  partial ; 
or  it  may  be  distinguished  by  excess  of  hyper- 
semia,  of  itching,  or  of  prominence  and  defini- 


TJRTICARIA. 

tion  of  its  nodulated  protuberances.  Its  mot) 
conspicuous  character  is  the  suddenness  of  its 
attack,  and  the  equal  suddenness  of  its  dispersion, 
vanishing  in  a few  hours  or  less  without  leaving 
a trace  of  its  previous  existence  on  the  skin. 
But  whilst  it  thus  disappears  completely  on  one 
part,  it  is  apt  to  show  itself  on  another,  and  in 
this  manner  to  keep  up  the  disease  for  a con- 
siderable time  ; returning,  for  example,  nightly, 
and  interfering  with  the  sleep  of  the  patient  for 
weeks  and  even  months.  Moreover  its  charac- 
teristic tubercles,  which  are  pale  or  white,  and 
show  out  conspicuously  on  a bright  red  ground, 
may  be  isolated  and  dotted  over  the  skin,  or 
accumulated  in  clusters  ; they  may  be  super- 
ficial, or  they  may  be  more  or  less  deep-seated. 
These  several  diversities  of  symptoms  have  sug- 
gested a variety  of  descriptive  appellations  for 
the  affection,  for  example : U.  evanida  or  eva- 
nescent ; U.  perstans  or  persistent ; U.  cor>f>_rta, 
congregated  or  confluent ; U.  subciuanea  or  deep- 
seated  ; and  U.  tuberosa,  in  tuberous  masses  ; all 
of  which  varieties  may  be  simply  expressed  by 
the  terms  ‘ more  or  less  severe,’  or  ‘more  or  less 
transient  or  chronic. 

Urticaria  has  no  constitutional  symptoms  of 
its  own,  but,  being  itself  a symptom,  may  acci- 
dentally be  associated  with  general  derange- 
ment of  the  system,  of  greater  or  less  severity. 
This  fact  is  indicated  by  the  term  U.  febrilis, 
which  ought  rather  to  be  named  urticaria  cum 
febre ; whilst  anothor  designation  relating  to  its 
cause  is  met  with  in  the  term  IT.  ab  ingestis. 
Somoof  its  features  are  found  likewise  in  asso- 
ciation with  other  forms  of  disorder  of  the  skin  ; 
such  as  its  tendency  to  swell  in  erythema  papu- 
losum,  tuberosum,  and  tumescens;  audits  pruritic 
proclivity  in  lichen  urticatus  and  prurigo. 

Diagnosis. — The  pathognomonic  characters  of 
urticaria  are,  first,  white  prominences  of  the  skin, 
sometimes  taking  tho  form  of  round  tubercles, 
at  other  times  occurring  in  stripes  or  wheals  of 
varying  length  and  figure,  which  are  shown  up 
on  a scarlet  or  bright  crimson  ground,  and  are 
accompanied  by  a sense  of  burning  and  prick- 
ling, suggestive  of  the  painful  sensation  caused 
by  the  sting  of  a nettle ; and,  secondly,  the  sudden 
and  complete  evanescence  of  the  local  signs,  as 
well  as  of  the  associated  pruritus,  without  or- 
ganic lesion  of  the  skin. 

Prognosis. — Urticaria  may  be  very  trouble- 
some, but  is  rarely  serious.  As  a symptom  of 
somo  other  form  of  derangement,  the  discovery 
of  the  latter  must  guide  our  opinion  as  to  the 
cause  and  issue  of  the  skin-affection. 

Treatment. — The  evanescent  nature  of  the 
local  affection  points  to  the  consideration  of  a con- 
stitutional treatment  by  which  we  may  strengthen 
digestion,  assist  the  functions  of  the  liver,  and 
maintain  a healthy  operation  of  the  alimentary 
canal.  A tonic-aperient  medicine,  combining  sul- 
phate of  magnesia  with  quinine  and  a bitter  in- 
fusion, will  afford  immediate  relief  where  the 
digestive  organs  are  concerned.  Bilious  and  gouty 
subjects  may  be  assisted  by  a preliminary  blue- 
pill.  The  tone  of  the  stomach  may  be  kept  up 
by  nitro-hydrochloric  acid  combined  with  a 
bitter ; in  other  instances,  alkalies  will  be  found 
serviceable.  In  neurotic  constitutions,  on  the 
other  hand,  we  must  have  recourse  to  quinine  in 


URTICARIA. 

moderate  doses,  to  the  bromides,  and  occasion- 
ally to  sedatives,  to  procure  rest  at  night  and 
induce  sleep.  In  very  chronic  cases  the  liquor 
arsenicalis,  in  doses  of  three  minims  three  times 
a day,  is  of  decided  advantage. 

To  relieve  local  suffering  the  best  remedy  is 
a lotion  of  lime-water  inspissated  with  oxide  of 
zinc,  one  part  of  the  latter  to  eight  of  the  former. 
In  more  severe  eases  the  hot  bath  may  be  found 
serviceable  ; or  heat  applied  by  means  of  flannel 
or  a sponge  wrung  out  of  hot  water. 

Erasmus  Wilson. 

UTERUS,  Diseases  of.  See  Womb,  Dis- 
eases of. 

UVULA,  Diseases  of. — Synon.  : Fr.  Mala- 
dies de  la  Luette ; Ger.  Krankheiten  des  Zapf- 
chens. — Suspended  from  the  middle  of  the  lower 
arid  free  border  of  the  soft  palate,  is  that  small 
conical-shaped  prolongation  termed  the  uvula. 
In  structure  it  is  exactly  the  same  as — indeed 
it  is  a portion  of — the  soft  palate,  which  con- 
sists of  a fold  of  mucous  membrane,  inclosing 
muscles,  aponeuroses,  vessels,  nerves,  and  glands, 
the  latter  being  very  numerous. 

From  its  intimate  relation  with  the  soft  palate, 
the  fauces,  the  tonsils,  and  the  pharynx,  the  uvula 
is  likely  to  become  involved  when  any  of  these 
parts  is  overtaken  by  disease.  This  is  most  evident 
in  cases  of  catarrhal  aDgina.  It  is  extremely  rare 
for  the  uvula  to  be  primarily  and  exclusively 
attacked  with  inflammation,  and  yet  instances 
of  such  an  affection  are  on  record.  On  the  other 
hand,  it  is  by  no  means  uncommon  to  observe 
the  uvula  swollen,  cedematous,  and  elongated, 
as  a consequence  of  prolonged  irritation,  relaxa- 
tion, or  often  repeated  catarrh  of  the  fauces. 
That  form  of  acute  catarrh,  of  which  the  uvula 
partakes  when  the  throat  is  the  subject  of  this 
affection,  disappears  along  with  the  other  symp- 
toms. But  the  condition  known  as  elongated 
uvula  often  proves  very  intractable  to  treat- 
ment for  a long  time,  and  all  the  more  so  that  not 
very  infrequently  this  condition  is  entirely  over- 
looked by  the  nractitionor.  It  ought  to  be  laid 
down  as  a rule,  that,  in  all  affections  of  the 
throat,  the  parts  should  be  inspected.  In  this 
case,  inspection  will  reveal  that  the  uvula  is 
greatly  lengthened,  but  not  of  necessity  always 
thickened  or  cedematous ; so  that  when  the  pa- 


VACCI  NATION.  1718 

tient  reclines,  this  pendulous  body  falls  back- 
wards, sometimes  even  dropping  so  low  as  to 
reach  the  glottis.  The  consequence  is,  that 
the  mucous  membrane  of  the  pharynx  and  la- 
rynx is  kept  in  a continual  state  of  irritation  and 
general  uneasiness.  A peculiarly  annoying  cough 
is  set  up  by  the  constant  tickling  of  the  parts, 
so  that  this  condition  of  the  uvula  may  eveu 
at  times  be  recognised  by  the  quickly  repeated, 
resultless,  brassy  cough.  It  may  be  described 
as  a quick,  ineffectual  hack.  An  inclination 
to  vomit  is  also  induced.  An  irresistible  de- 
sire to  swallow  is  observed,  owing  to  the  sen- 
sation which  the  patient  perceives  in  the  throat, 
as  if  something  were  lodging  there,  and  which 
ought  to  be  got  rid  of  by  swallowing.  If  there 
be  much  thickening  as  well  as  elongation  of  the 
uvula,  then  some  slight  difficulty  may  be  expe- 
rienced when  deglutition  takes  place.  When  the 
elongation  is  very  pronounced,  and  the  uvula 
finds  its  way  into  the  larynx,  the  patient  may  ex- 
perience a sense  of  suffocation,  particularly  if  he 
happen  to  be  asleep,  when  he  suddenly  wakes  up 
in  a state  of  great  alarm  and  breathlessness. 
A more  temporary  condition  of  elongated  uvula 
is  observed  in  that  form  of  relaxed  fauces  which 
public  speakers  and  singers  are  subject  to,  and 
which  comes  on  suddenly,  or  quickly,  after  con- 
tinuous use  of  the  voice  for  an  hour  or  more. 

Treatment. — The  condition  associated  with 
elongated  uvula  must  be  treated  on  general 
principles  (sea  Pharynx,  Diseases  of).  Locally, 
the  elongated  uvula  is  best  treated  by  astringent 
gargles.  One  of  the  best  of  these,  which  is 
perhaps  as  soothing  as  astringent,  is  the  bro- 
mide of  ammonium  gargle,  20  grains  to  the 
ounce  of  water.  Glycerine  of  tannin,  tincture 
of  iodine,  and  other  agents  which  are  quite 
sufficient  for  the  cure  of  the  simply  relaxed 
uvula,  may  prove  insufficient  to  restore  tho 
elongated  uvula,  and  then  a portion  of  it  must  be 
removed,  even  to  the  extent  of  two-thirds. 

Bifld  Uvula  is  a deformity  usually  congenital, 
the  treatment  of  which,  if  necessary,  by  the 
actual  or  galvano-caustic  cautery,  or  other  means, 
falls  within  the  domain  of  surgery. 

Paralysis  of  the  Uvula  is  met  with  as  a 
sequela  of  diphtheria,  when  other  parts  of  the 
throat  are  similarly  affected.  See  Palate, 
Diseases  of;  and  Paralysis.  Diphtheritic. 

Claud  Muirhead. 


XI 

T 


VACCINATION  ( vacca,  a cow).1 — Synon.: 
Fr.  Vaccination ; Ger.  Kuhpockenimpfung. 

Definition. — Inoculation  with  the  material 
of  vaccinia  or  the  cow-pox.  Its  purpose,  as  ap- 
plied to  the  human  subject,  in  which  relation 
alone  we  have  here  to  consider  it,  is  the  protec- 
tion of  the  person  vaccinated  from  an  attack, 

1 This  article,  which  was  written  hy  the  late  Dr. 
Beaton,  has  been  revised  by  Dr.  Collie.  The  passages 
Inserted  by  the  latter  are  marked  [ ]. 


and  especially  from  a severe  or  fatai  attack,  of 
small-pox. 

The  cow-pox,  which  is  a natural,  though  not 
common,  disease  in  the  cow  and  horse,  never 
occurs  spontaneously  in  man.  Nor  is  it  commu- 
nicable to  him  hy  effluvia,  or  in  any  other  way 
than  hy  the  direct  inoculation  of  its  own  spe- 
cific virus.  Such  inoculation  before  the  time 
of  Jenner  was  never  more  than  a matter  of  mere 
accident,  and  occurred  with  comparative  rarity. 


VACCINATION. 


1720 

It  was  matter  of  popular  tradition,  but  was  left 
for  Jenner  to  demonstrate,  that  persons  who  had 
thus  been  accidentally  vaccinated  enjoyed  im- 
munity subsequently  from  small-pox  ; and  it  was 
by  his  great  discovery  that  the  cow-pox,  once 
implanted  in  the  human  subject,  may  be  con- 
tinued by  inoculation  from  individual  to  indi- 
vidual indefinitely,  that  the  practice  of  vaccina- 
tion became  possible. 

Phenomena  of  Vaccination. — The  phenomena 
which  follow  inoculation  with  the  material  of 
cow-pox  vary  according  as  the  person,  in  whom 
the  vaccine  lymph  is  inserted,  may  or  may  not 
have  been  the  subject  of  a previous  successful 
vaccination  [a  previous  inoculation,  or  a pre- 
vious small-pox].  The  description  may  be  divided 
into  (1)  the  course  of  primary  vaccination  ; and 
(2)  the  course  of  secondary  vaccination,  or  re- 
vaccination. 

1.  Course  of  primary  vaccination. — This 
may  be  regtilar,  irregular,  or  complicated. 

(a)  Regular  course. — When  lymph,  taken  from 
a vaccine  vesicle  at  that  period  of  its  course 
when  the  vesiclo  is  fit  for  the  purpose,  is  in- 
serted into  the  skin  by  puncture,  or  is  applied  to 
a small  abraded  surface  of  the  skin  of  an  unpro- 
tected person,  no  particular  effect  is  noticeable 
till  about  the  end  of  the  second  day,  or  early 
on  the  third  day.  By  this  time,  if  the  vaccina- 
tion be  about  to  succeed,  a slight  papular  ele- 
vation becomes  perceptible.  This,  by  the  fifth 
or  sixth  day,  has  become  a distinct  vesicle  of 
a bluish-white  colour,  with  raised  edge  and  cen- 
tral cup-like  depression.  By  the  eighth  day  (the 
day-week  from  that  on  which  the  lymph  was 
inserted)  it  has  attained  its  perfect  growth ; it 
is  then  plump,  round,  more  decidedly  pearl- 
coloured,  and  distended  with  clear  lymph;  its 
margin  is  firm,  and  central  depression  very 
marked.  On  this  day,  or  sometimes  even  by 
the  end  of  the  seventh  day,  a ring  of  inflam- 
mation, called  the  areola,  begins  to  form  about 
its  base ; and  the  vesicle  and  areola  together 
continue  to  spread  for  the  next  two  days.  The 
areola  is  circular,  and  when  fully  developed  has 
a diameter  of  from  one  to  three  inches,  being 
then  often  attended  with  considerable  hardness 
and  swelling  of  the  subjacent  connective  tissue. 
After  the  tenth  day  the  areola  begins  to  fade ; 
and  in  two  or  three  days  more  it  has  usually  dis- 
appeared, with  whatever  of  hardness  or  swelling 
may  have  existed.  With  the  decline  of  the  areola 
the  vesicle  begins  to  dry  in  the  centre;  the 
lymph  remaining  in  it  becomes  opaque  and  gra- 
dually concretes  ; and  by  the  fourteenth  or  fif- 
teenth day  a hard  brown  scab  is  formed,  which 
gradually  contracts,  dries,  and  blackens,  and 
from  the  twentieth  to  the  twenty-fifth  day,  but 
usually  about  the  twenty-first  day,  falls  off. 
There  is  then  left  a cicatrix,  which  is  circular, 
somewhat  depressed,  foveated,  sometimes  radi- 
ated, and,  with  rare  exceptions,  permanent  in 
after-life. 

If  the  lymph  have  been  inserted  by  two,  three, 
or  more  punctures  set  near  together  about  one 
spot,  or  by  abrasion  over  a sufficient  surface, 
two  or  more  vesicles  may  arise  at  the  spot ; and 
in  the  course  of  their  growth,  either  form  a 
largo  vesicle  of  a compound  character,  with  but 
sue  central  depression,  or  a crop  of  vesicles, 


generally  coalescing,  but  eaen  retaining  its  own 
central  depression.  These  compound  vesicles 
and  crops  are  round,  oval,  or  of  irregular  outline, 
according  to  the  manner  in  which  the  cutis  has 
been  penetrated  or  exposed  ; and  the  shape  of 
the  resulting  cicatrices  varies  accordingly.  Vac- 
cination which  has  gone  through  the  course  above 
described  is  held  to  be  protective  against  small 
pox. 

The  constitutional  symptoms  attending  these 
local  phenomena  are  a rise  of  temperature, 
sometimes  detectable  by  thermometer  as  early 
as  the  fourth  day,  more  marked,  but  still  often 
very  slight  from  the  fifth  to  the  seventh  day ; 
more  obvious  feverishness,  with  restlessness, 
and  frequently  derangement  of  the  stomach  and 
bowels,  from  the  eighth  to  the  tenth  day,  that  is, 
during  the  stage  of  areola,  subsiding  as  that  sub- 
sides. The  general  symptoms  are  in  most  cases 
quite  moderate,  and  often  exceedingly  slight. 
Occasionally,  when  the  areola  is  at  its  height, 
swelling  of  the  axillary  glands  may  be  intense; 
and  occasionally  also  at  that  period  in  young 
children  of  full  habit,  especially  in  hot  weather, 
an  eruption  of  roseola  ( vaccine  roseola)  may 
occur,  chiefly  on  the  extremities;  or  a papular 
eruption  ( vaccine  lichen)-,  or  a vesicular  one  — 
the  vesicles,  however,  [differing  from]  vaccine 
vesicles,  in  being  entirely  free  from  central  de- 
pression. The  duration  of  any  of  these  forms  of 
eruption,  when  they  do  occur,  is  very  transitory, 
usually  not  extending  beyond  a week,  and 
very  seldom  indeed  beyond  the  falling  of  the 
scab. 

(6)  Irregular  course. — The  exactitude  with 
which  vaccination  in  the  immense  majority  of 
cases  runs  the  course  above  described  is  very 
remarkable ; but  in  some  cases  an  irregular 
course  is  seen.  The  irregularity  may  be  merely 
in  point  of  time]  the  development  of  the  vesicle 
being  retarded  one  or  two  or  several  days,  or  being 
slightlyr  accelerated,  so  as  to  present,  for  example, 
by  the  eighth  day,  tho  appearances  usually  seen 
on  the  ninth.  If  the  phenomena  are  in  all  other 
respects  regular,  these  mere  variations  in  time  do 
not  [as  far  as  known]  affect  the  protective  power 
of  the  vaccination.  On  the  other  hand,  there 
may  be  irregularity  of  the  character  and  course  of 
the  vesicle,  constituting  spurious  vaccination,  on 
which  no  reliance  can  be  placed  for  protecting 
from  small-pox.  Thus,  papules  or  even  vesicles 
may  arise,  which,  instead  of  undergoing  their 
proper  development,  begin  by  the  fifth  or  sixth 
day  to  die  away,  leaving  a mere  scale  or  slight 
scab  by  the  eighth  day.  More  frequently, 
there  are  vesicles  beginning  early  after  the  in 
sertion  of  the  lymph,  with  itching  and  irritation 
— symptoms  almost  invariably  absent  in  a nor 
mal  primary  vaccination,  assuming  as  they  rise 
an  acuminated  or  conoidal  form,  instead  of  the 
characteristic  flat  form  with  central  depression  ; 
containing  straw-coloured  or  opaque  fluid,  in- 
stead of  clear  lymph  ; and  developing  an  early 
and  irregularly-shaped  areola,  which  is  at  its 
height  by  the  fifth  or  sixth  day,  and  far  on  the 
decline  by  the  day-week.  In  other  cases  the 
vesicles,  rising  apparently  more  regularly  at 
first,  are  found  by  the  eighth  day  to  have  burst; 
and  present  either  an  irregular  scabby  appear- 
ance, or  are  in  the  state  of  open  sores.  Tb» 


VACCINATION. 


chief  causes  of  these  irregularities  will  be  dis- 
cussed further  on. 

(<?)  Complicated  course. — In  spurious  vacci- 
nations, especially  in  the  kind  last  described, 
and  even  in  the  course  of  a regular  vaccination, 
if  the  vesicles  have  been  rubbed  or  otherwise 
injured,  ulcerated  sores  may  succeed,  requiring, 
in  children  who  are  of  scrofulous  or  otherwise 
unhealthy  constitution,  some  time  to  heal.  Oc- 
casionally, also,  in  children  of  such  habit  of 
body,  the  swelling  of  the  axillary  glands,  which 
has  been  mentioned  as  sometimes  attendant  on 
the  areola,  may  result  in  abscess.  But  the  only 
complication  which  can  be  regarded  as  at  all 
formidable  is  erysipelas.  This  disease  may  of 
course  supervene  on  vaccination,  as  it  may  on 
any  other  surgical  operation,  when  the  condi- 
tions which  ordinarily  give  rise  to  it  exist,  and 
especially  where  there  has  been  exposure  to  its 
contagium.  [The  lesson  which  this  teaches  us  is 
not  that  we  should  not  vaccinate,  but  that  we 
should  guard  the  place  of  operation  against  the 
entry  of  dirt  or  decomposing  matter;  alike  at 
the  time  and  during  the  course  of  vaccination. 
If  erysipelas  be  from  any  cause  set  up  during 
vaccination,  it  will  occasionally  be  serious  and 
even  fatal,  just  as  if  it  followed  on  another  kind 
of  wound.]  But  there  have  been  cases,  happily 
rare,  in  which  it  has  manifestly  arisen  from 
the  use  of  improper  lymph,  that  is,  from  lymph 
taken  from  spurious  vesicles,  or  from  regular 
vesicles  at  an  advanced  period  of  their  course, 
or  which  has  been  spoilt  in  keeping. 

2.  Course  of  re-vaccination. — In  some  per- 
sons the  regular  phenomena  of  vaccination  can 
only  be  produced  once  in  the  lifetime.  But  this 
is  not  always  the  case,  and  vesicles  may  be  pro- 
duced by  a second  vaccination,  not  distinguish- 
able in  their  appearance  from  primary  vesicles, 
though  usually  having  a smaller  and  more  tran- 
sitory areola,  and  having  a small  and  poor  cica- 
trix. Much  the  most  frequently  the  result  of 
that  process  is  the  production  of  a spurious 
papule  or  acuminated  vesicle,  with  hard,  irre- 
gular areola,  reaching  its  height  by  the  fifth  or 
sixth  day,  and  having  by  the  eight  day  an  im- 
perfect scab,  which  soon  falls.  There  is  often 
much  itching  and  more  serious  local  irritation ; 
and  the  constitutional  symptoms  are  out  of  all 
proportion  more  frequent  after  re-vaccination 
than  after  primary  vaccination.  In  some  per- 
sons no  specific  local  effect  is  producible  by  re- 
vaccination. 

Performance  of  Vaccination. — (1)  Age. — 
Small-pox  being  a disease  to  which  persons  are 
liable  from  the  moment  of  birth,  and  which  is 
peculiarly  fatal  in  infancy,  it  is  of  great  impor- 
tance that  vaccination  should  be  performed  in 
very  early  life.  In  large  towns,  where  a weekly 
supply  of  lymph  from  arm  to  arm  can  always 
be  maintained,  the  vaccination  of  children 
who  are  plump  and  healthy  should  be  effected 
within  four  or  six  weeks  from  birth.  If  the 
child  be  less  robust,  it  may  properly  be  deferred 
for  three  or  four  weeks  more.  In  small  towns 
and  rural  districts  the  age  at  which  vaccination 
can  be  performed  must  depend  to  some  extent 
on  the  arrangements  for  lymph-supply  in  the 
district;  but  these  are  always  such  as  admit  of  a 
ehild  being  vaccinated  within  a very  few  months 


1721 

from  birth.  It  is  under  ordinary  circumstance* 
a preliminary  condition  of  the  performance  of 
vaccination,  that  the  child  to  be  vaccinated  should 
be  healthy ; and  a careful  examination  to  ascer- 
tain this  is  the  first  duty  of  the  vaccinator.  The 
child  should  not  only  be  free  from  any  acute 
febrile  disease,  but  also  from  diarrhoea  and 
from  cutaneous  diseases,  especially  those  of  the 
vesicular  type.  The  states  of  constitution  asso- 
ciated with  herpes  and  eczema  singularly  inter- 
fere with  the  proper  course  of  vaccination,  and 
seem  to  be  the  most  frequent  causes  of  those 
spurious  results  of  vaccination  just  described. 
They  may  both — especially  intertrigo — without 
care,  be  overlooked ; hence  examination  of  the 
scalp,  and  of  the  folds  of  skin  behind  the  ears, 
in  the  neck,  and  in  the  groins,  is  indispensable. 
Vaccination  should  also  be  postponed  if  ery- 
sipelas be  prevailing  in  the  neighbourhood  in 
which  the  child  is  living,  or  if  it  have  been 
recently  exposed  to  the  infection  of  measles 
or  scarlatina.  There  is,  however,  a state  of 
things  under  which  these  conditions  must  be  dis- 
regarded, namely,  when  there  may  be  immediate 
exposure  to  the  infection  of  small-pox,  as  when 
an  unvaccinated  child  is  in  a house  in  which  the 
infection  exists,  or  has  come  into  direct  contact 
with  an  infected  person.  Under  such  circum- 
stances, it  cannot  be  too  strongly  impressed 
that  no  age  is  too  early  for  vaccination,  and 
no  state  of  health,  except  the  presence  of  acute 
disease  of  a serious  character,  can  be  held  to 
contraindicate  it.  Life  then  may  depend  on 
the  promptitude  with  which  the  vaccination  is 
done. 

(2)  Selection  of  lymph. — The  second  point 
to  attend  to  is  the  selection  of  the  lymph  to  be 
used  in  vaccinating.  [This  may  be  of  two  kinds, 
bovine  or  human.  The  advantages  claimed  for 
the  former  are  immunity  from  human  disease 
and  greater  protection  from  small-pox.  As  the 
risk  of  conveying  human  disease  is  infinitesimal, 
if  the  vaccination  be  done  with  due  care,  much 
weight  need  not  be  attached  to  this  ; and,  more- 
over, if  the  argument  be  sound,  it  applies  a priori 
to  the  bovine  lymph  as  well  as  to  the  human, 
so  that  by  the  adoption  of  bovine  matter  we 
merely  substitute  one  possible  risk  for  another. 
It  is  true  that  the  bovine  lymph  is  recom- 
mended on  the  ground  that  r,o  disease  other 
than  cow-pox  is  capable  of  being  communicated 
to  man  by  inoculation  with  it;  but  this  state- 
ment must  for  the  present  be  open  to  question. 
In  the  selection  of  lymph,  whether  bovine  or 
human,  the  important  point  is  to  select  healthy 
subjects  ; and  it  is  probably  as  easy  to  select  a 
healthy  infant  as  a healthy  calf.  Of  the  greater 
protection  from  small-p'  x,  this  is  not  yet  estab- 
lished on  a sufficiently  wide  induction,  and  years 
must  yet  elapse  before  it  can  be.  If  the  bovine 
lymph  be  preferred  for  general  use,  it  will  still  be 
well  to  choose  humanised  lymph  in  the  case  of 
delicate  children,  because  of  the  severity  of  the 
local  effects  when  bovine  lymph  is  used.  The  pre- 
sent writer  in  the  existing  state  of  knowledge 
prefers  humanised  lymph,  which,  as  employed  by 
his  colleagues  and  himself,  he  has  never  found 
ineffectual ; but,  whilst  of  this  opinion,  he  thinks 
the  propriety  of  more  frequent  recourse  to  the 
calf,  for  the  purpose  of  renewing  our  stock, 


VACCINATION. 


1722 

deserves  consideration.]  Human  lymph  should 
be  taken  from  primary  cases  only,  from  perfectly 
healthy  subjects,  and  from  thoroughly  charac- 
teristic vesicles.  Babies  selected  for  the  purpose 
should  not  only  be  in  good  health  themselves, 
but,  as  far  as  can  be  ascertained,  of  healthy 
parentage.  Those  of  dark  complexion,  not  too 
florid,  with  a thick  smooth,  clear  skin,  generally 
Meld  the  best  and  most  effective  lymph.  Vesicles 
from  which  the  lymph  may  be  taken  must  be 
well  characterised,  uninjured,  and  free  from 
areola.  Lymph  may,  with  perfect  propriety,  be 
taken  so  soon  as  any  can  be  obtained  from  a 
vesicle,  as  at  the  fifth  or  sixth  day  of  its  course  ; 
but  it  is  then  procurable  in  very  small  quantity, 
and  it  is  usually  and  most  conveniently  taken  on 
the  day-week  from  the  vaccination,  when  the 
vesicle  is  perfectly  formed,  but  before  the  stage 
of  areola  has  set  in.  Any  vesicle,  which  at  that 
date  manifests  areola,  must  be  discarded.  This 
was  Jenner’s  ‘golden  rule,’  and  one  which  ought 
to  be  scrupulously  observed.  Good  vaccine 
lymph  is  always  perfectly  limpid,  and  has  be- 
sides a certain  degree  of  viscidity.  A thin, 
serous,  too-readily  flowing  lymph  should  never 
be  used. 

(3)  Method  of  collecting  lymph  : Arm- 
to-arm  vaccination. — The  collection  of  lymph 
from  the  human  subject  for  vaccinating  is  ef- 
fected by  opening  the  vesicle  by  numerous  minute 
punctures  on  its  surface,  the  utmost  care  being 
used  not  to  draw  blood.  Should  any  accident- 
ally be  drawn,  the  vesicle  must  be  discarded 
altogether.  No  lymph  must  be  used  which  does 
not  exude  spontaneously ; there  must  be  no  pres- 
sure or  squeezing  of  the  vesicle.  The  lymph 
which  stands  on  the  surface  of  the  opened  vesi- 
cle, is  taken  on  the  point  of  a lancet  or  other 
instrument  employed,  and  inserted  in  the  arm 
of  the  child  to  be  vaccinated.  This  may  be 
done  in  various  ways,  as  by  puncture,  by  scratch- 
ing, by  scarifications  or  abrasions,  by  tatoo- 
ing.  &c.  It  would  not  be  possible,  within  the 
limits  of  this  article,  to  give  any  description 
of  these  various  modes  of  operating.  Nor  would 
it  be  of  much  use.  They  should  be  learnt  prac- 
tically under  a good  instructor.  All  of  these 
methods  may,  in  careful  and  skilled  hands,  be 
made  equally  successful.  That,  however,  which 
in  the  hands  of  practitioners  generally  the  writer 
has  found  the  most  successful,  has  been  the  plan 
by  scarification  or  tattooing  v.v,  over  surfaces 
oftheexteDt  here  depicted.  Insertions  to  this 
extent  should  be  made  on  at  least  four,  and  pre- 
ferably five,  separate  surfaces.  If  the  vaccina- 
tion be  done  on  both  arms,  the  writer  recom- 
mends three  insertions  of  this  kind  in  each 
arm;  if  it  be  done  on  one  arm  only,  then  there 
should  be  five  on  that  arm.  [While  an  ample 
primary  vaccination  affords  better  protection 
against  small-pox  than  a scanty  primary  vaccina- 
tion (see  p.  1723),  it  has  to  be  admitted  that 
no  number  and  no  quality  of  marks  give  abso- 
lute protection  for  all  time,  nor  even,  in  all 
cases,  for  many  years.  In  well-vaccinated  chil- 
dren under  ten,  for  instance,  re-vaccination  pro- 
duces largo  vesicles  with  well-marked  areolae. 
Some  of  such  children  are  certainly  liable  to  con- 
tract small-pox,  the  certainty  being  proved  by 
the  fact  that  they  have  contracted  it.  For  this 


reason  and  seeing  that  susceptibility  to  re-vac- 
cination may  (for  all  that  is  known  to  the  con- 
trary) be  an  indication  of  susceptibility  to  small- 
pox, there  is  something  to  be  saidfor  a repetition 
of  the  operation,  in  well-vaccinated  persons, 
whether  children  or  adults,  when  small-pox  is 
epidemic.  It  is  certain  that  the  best  vaccination 
will  not  always  protect  up  to  that  very  vague 
period  called  puberty,  a period  reached  at  dif- 
ferent ages  by  different  persons.  Under  what 
circumstances,  and  how  often,  vaccination  should 
be  repeated  is  a subject  for  enquiry ; but  the 
experience  of  small-pox  in  London  during  the 
last  ten  years  proves  that  in  some  cases  re-vac- 
cination cannot  be  delayed  until  puberty,  and  that 
a single  re-vaccination,  when  then  successfully 
performed,  is  not  an  absolute  protection  for  all 
time  against  attack,  or  even  death  from  small- 
pox.] In  vaccination  by  other  modes  of  proce- 
dure, care  should  be  taken  that  local  results  to 
the  full  extent  are  obtained.  An  ordinary  un- 
grooved lancet  is,  in  the  winter’s  opinion,  the 
best  of  all  instruments  for  the  performance  of 
vaccination.  It  is  not  only  readily  cleaned,  but 
it  is  one  concerning  which  we  can  always  be 
sure  that  it  is  clean.  Lancets  used  for  vaccina- 
tion should  be  kept  bright,  and  should  never  be 
used  for  any  other  purpose.  If  used  for  more 
than  one  vaccination  at  a time,  they  should  be 
most  carefully  cleansed  after  each  case. 

(4)  Storage  of  lymph : indirect  vaccina- 
tion.— Vaccination  should  in  all  cases  in  which 
it  is  practicable,  be  done  direct  from  arm  to 
arm.  The  degree  of  success  attending  the  use 
of  conveyed  or  stored  lymph,  in  whatever  way 
the  conveyance  or  storage  be  effected,  does  not 
approach  that  of  lymph  thus  directly  transferred. 
Where  vaccination  from  the  arm  is  impracti- 
cable, lymph  intended  for  immediate  use  may  be 
conveyed  from  case  to  case,  in  the  liquid  form, 
by  means  of  the  vaccine  bottle  and  other  contri- 
vances for  the  purpose  ; but  it  must  be  a quite 
indispensable  condition  of  this  proceeding  that 
the  lymph  be  used  within  a few  hours — six  to 
eight  at  the  outside — of  its  being  taken.  For 
longer  keeping  it  must  be  stored  either  in  her- 
metically-sealed tubes,  or  on  points  thickly 
coated  with  it,  then  carefully  dried,  and  kept 
afterwards  constantly  protected  from  damp  and 
heat.  When  stored  in  the  latter  way,  the  lymph 
needs  revival  before  use  by  dipping  the  point  for 
an  instant  in  water,  and  laying  it  on  the  edge  of 
a book,  so  that  the  lymph  may  become  soft.  In 
the  use  of  stored  lymph  the  process  of  vaccination 
by  scarification  or  abrasion  is  always  to  be  pre- 
ferred. 

(5)  After-treatment. — When  the  vaccination 
has  been  dpne,  the  parent  should  be  cautioned 
against  allowing  the  vesicle  to  get  rubbed  or 
mechanically  injured.  The  case  should  be  seen 
again  by  the  day-week  at  least,  when,  if  the 
vesicle  be  perfectly  formed,  and  pursuing  a 
regular  course,  the  success  of  the  vaccination 
may  fairly  be  pronounced.  But  if  the  case  be 
then  retarded,  it  should  be  seen  again  two  or 
three  days  afterwards ; or  if  there  be  anything 
abnormal  in  the  appearance  of  the  vesicle,  the 
case  should  be  watched  unfailingly  throughout 
its  course. 

Vaccination  as  a Protection  against  Siiai.u- 


VACCINATION. 


1723 


fox. — The  protection  which  vaccination  affords 
against  small-pox  is  manifested  in  two  ways  : 
first,  by  the  immunity  from  that  disease  which, 
as  a rule,  it  confers  ; secondly,  by  the  modifica- 
tion which,  when  immunity  is  not  complete,  it 
induces  in  the  course  and  severity  of  the  disease 
in  the  majority  of  cases.  The  most  precise  of 
the  numerous  facts  which  exist  in  proof  of  this 
are  those  derived  from  the  Small-pox  Hospital 
in  London,  where  it  has  been  found  that  while 
small-pox  in  the  unvaceinated  patients  runs  an 
unmodified  course  in  all  but  2'6  per  cent.,  its 
course  in  vaccinated  patients  is  modified  in  "3 
per  cent. ; and  that  while  the  death-rate  of  natu- 
ral small-pox  is  35'55  per  cent.,  that  of  post- 
vaccinal small-pox  is  but  606  per  cent.  [This 
latter  figure,  obtained  from  cases  admitted  into 
the  Highgate  Small-pox  Hospital  in  the  years 
1836-55  is  lower  than  would  be  given  from  the 
experience  of  the  Asylums  Board  Small-pox 
Hospitals,  during  later  years.  The  difference  is 
due,  in  part,  to  the  circumstance  that  Mr.  Marson 
excluded  what  he  called  ‘ antecedent  or  super- 
added  disease’  ; in  part  probably  to  the  greater 
fatality  of  small-pox  during  more  recent  years,  a 
circumstance  which  has  also  shown  itself  among 
the  unvaccinated ; and  in  part  perhaps  to  the 
cases  admitted  to  the  latter  hospitals  belonging 
to  a more  destitute  class  of  the  community.  In 
the  Asylum  Board  Small-pox  Hospitals,  where  all 
deaths  are  included,  the  post-vaccinal  mortality 
has  amounted  to  8 per  cent.]  The  difference 
between  35  and  6,  however,  gives  but  a feeble 
idea  of  the  protection  which  vaccination  really 
affords,  provided  it  be  thoroughly  done  ; for  in 
nearly  all  the  fatal  cases  the  vaccination  was 
found  to  have  been  of  an  imperfect  character, 
and  had  not  been  done  in  accordance  with  the 
rules  laid  down  above.  The  following  table  pub- 
lished some  years  ago,  based  on  an  examination 
of  5,000  cases,  gives  the  results  of  Mr.  Marson- s 
observations,  extending  over  twenty  years  : — 


Classification  of  Patients  affected 
with  Small-pox 


Number  of  deaths 
per  cent,  in  each 
class  respectively 

1.  Unvaceinated  .....  35 

2.  Stated  to  have  been  vaccinated  hut 

having  no  cicatrix  ....  23'5" 

3.  Vaccinated: — - 

a.  Having  one  vaccine  cicatrix  . 7'73 

b.  Having  two  vaccine  cicatrices  . 4'70 

c.  Having  three  vaccine  cicatrices  . 195 

d.  Having  four  or  more  vaccine 

cicatrices  . . . . 055 

а.  Having  well-marked  cicatrices  . 2-52 

б.  Having  badly-marked  cicatrices  8‘82 

4.  Having  previously  had  small-pox  . 19 

[These  facts  are  confirmed  by  the.experienee  of 

the  Small-pox  Hospitals  of  the  Asylums  Board,  as 
the  following  table,  prepared  by  Dr.  MacCombie 
of  the  Deptford  Small-pox  Hospital,  will  show  : 
Statistics  of  11,724  cases  of  Small-pox  treated 
in  the  Hospitals  of  the  Metropolitan  Asylums 
Board  during  the  years  1871-78  : — 

Homerton  Fever  . . . 1876-77. 


Homerton  Small-pox 
Stockwell  . 
Hampstead . . 

Deptford 

Fulham  . . 


1871-78. 

1871-78. 

1876- 78. 
1878-79. 

1877- 78. 


Cases 

Dcatfcs 

Mort.  p.c. 

Murson's  murt.  p.c, 
corrected  to  include 
antecedent  und  su- 
pcraddtd  disease 

One  f 

Good 

1095 

70 

6-4 

52 

Mark  1 

Indifferent 

2004 

341 

IK  7 

13  8 

Two  j 

Good 

1461 

54 

3-7 

3 G 

Marks  t 

Indifferent 

2476 

279 

11  2 

9 9 

Three  i 

Good 

1095 

41 

3-7 

2 2 

Marks  t 

Indifferent 

1778 

133 

7*4 

4-1 

Four  ( 

Good 

826 

23 

9‘7 

055 

Marks  t 

Indifferent 

949 

46 

4-3 

16 

Total  . . , 

11724 

987 

8-1 

6-6 

1836-55 

Good  marks  : — 4477  eases,  188  deaths.  Mort. 
p.c.  4’1.  Indifferent  marks,  7247  cases,  799 
deaths.  Mort.  p.c.  1 10 

[It  deserves  to  be  noted  that,  if  Mr.  Marson’s 
experience  in  1836-55  were  expressed  in  the 
same  terms  as  the  foregoing  we  should  obtain  : 
Good  marks,  2570  cases,  95  deaths.  Mort.  p.c. 
3'6.  Indifferent  marks,  1956  cases,  206  deaths. 
Mort.  p.c.  10'5.] 

The  apparent  selection  of  years  between  1871 
and  1879  is  due  partly  to  the  fact  that  the  hospi- 
tals were  not  continuously  open  for  small-pox,  and 
partly  to  the  fact  that  the  statistics  were  not  all 
compiled  on  the  same  plan  during  the  period.] 

To  produce  then  at  least  four  perfect  vesicles, 
leaving  four  characteristic  cicatrices,  should  he 
the  aim  of  every  vaccinator. 

Ee-vaccination. — The  necessity  for  re-vacci- 
nation— a term  the  use  of  which  should  always 
be  restricted  to  cases  in  which  vaccination  had 
already  been  performed  with  effect — has  always 
been  recognised  in  certain  cases;  but  it  is  only 
of  late  years  that  its  importance  as  a practice , 
after  a certain  period  of  life,  has  begun  to  be 
understood.  (1)  The  cases  in  which  later  vac- 
cination is  most  obviously  required  are  those 
in  which  the  effect  of  tho  first  ‘ vaccination  ’ lias 
been  of  the  irregular  or  spurious  kind  already 
described,  from  which  no  protection  against 
small-pox  can  be  assured.  Circumstances^nnist 
determine  in  the  case  of  any  particular  child  how 
soon  a completer  vaccination  should  be  performed ; 
but  especial  care  should  be  taken,  before  proceed- 
ing to  vaccinate  again,  to  scrutinise  the  health 
of  the  child,  and  to  correct  anything  in  it  which 
may  be  found  amiss.  The  re-vaccination  should 
be  done  with  every  precaution  against  failure, 
and  therefore,  always,  if  possible  in  cases  of  this 
kind,  direct  from  the  arm.  If  it  totally  fail,  it 
will  need,  of  course,  to  be  repeated  at  intervals 
till  some  result  is  obtained.  This  result  may  be 
a complete  success,  but  more  frequently  it  will 
be  only  a modified  success,  with  which,  however, 
the  practitioner  will  have  to  be  content  for  th6 
present.  He  will  not  fail,  however,  to  impress 
the  necessity  for  a further  re-vaccination  at 
puberty,  or  earlier  if  there  he  any  immediate 
danger  of  small-pox.  (2)  When  primary  vacci- 
nation has  been  successful  to  a certain  extent, 
but  not  to  the  extent  desired,  for  example,  when 
there  have  been  one  or  two  vesicles  only  instead 
of  four  or  more,  but  these  tesicles  quite  genuine, 


1724  VACCINATION, 

re-vaccination  at  puberty  is  of  great  importance, 
but  need  not,  except  under  circumstances  of 
immediate  exposure  to  small-pox,  be  recom- 
mended earlier.  [Considering  that  the  best  pri- 
mary vaccination  doe3  not  confer  complete  pro- 
tection up  to  the  varying  time  of  puberty,  I 
should  be  disposed,  for  my  own  part,  to  advise 
re-vaccination  before  that  period  even  in  the 
case  of  persons  well  vaccinated ; and  probably 
the  age  of  ten  years  would  be  the  most  gene- 
rally suitable.  A.  C.].  (3)  Following  the  fore- 
going rules,  a practitioner,  who  has  to  decide 
the  question  of  re-vaccination  in  cases  in  which 
he  did  not  himself  perform  or  see  the  original 
Vaccination,  and  who  must  therefore  determine 
by  the  marks,  would  recommend  re-vaccination 
as  soon  as  practicable  in  cases  in  which  the 
cicatrices  wanted  the  true  vaccine  character, 
but  would  advise  waiting  when  they  were 
genuine  in  character  and  wanting  only  in 
number.  (4)  The  systematic  performance  of 
re-vaccination  at  puberty  is  a practice,  the  im- 
portance of  which  must  now  bo  regarded  as 
demonstrated.  It  is  of  course  infinitely  more 
important  to  those  whose  vaccination  has  been 
incomplete,  than  to  those  whose  vaccination  has 
been  thorough,  but  even  the  best  vaccinated  de- 
rive additional  security  from  it.  [When  small-pox 
is  of  epidemic  intensity,  even  the  best  vacci- 
nated adults  incur  appreciable  danger  of  attack  ; 
but  with  them  the  disease,  if  it  do  occur,  is  in 
the  majority  of  cases  mild  and  rarely  fatal. 
Amongst  re-vaccinated  adults  attack  is  rarer 
still  and  death  is  almost  unknown.]  The  reason 
why  the  period  of  puberty,  or  thereabouts,  is 
fixed  on  as  the  time  for  the  systematic  perform- 
ance of  re-vaccmation,  is  simply  that  it  is  only 
after  that  period  that  serious  attacks  of  post- 
vaccinal small-pox  are,  as  a rule,  met  with.  The 
post- vaccinal  small-pox,  which  may  occur  in 
childhood,  is  [as  a rule,  to  which  there  are 
exceptions],  unless  when  the  vaccination  has  been 
very  imperfect,  of  little  danger. 

Alleged  Dangers  of  Vaccination. — The  ten- 
dency of  parents  to  refer  to  vaccination  every 
disease,  especially  every  cutaneous  disease,  which 
the  child  may  afterwards  manifest,  is  well  known. 
Most  of  such  allegations  are  without  proof  or 
probability — mere  illustrations  of  post  hoc  prop- 
ter hoc.  It  is  quite  possible,  indeed,  that  in  some 
cases  vaccination  may,  like  teething  or  other 
irritative  cause,  hasten  the  evolution  of  a consti- 
tutional eruption  which  the  child  was  incubating; 
but  even  this  is  not  a common  occurrence,  nor  is 
it  at  all  within  the  meaning  of  the  allegation. 
The  only  real  danger  which  need  be  considered 
here  (the  danger  of  erysipelas  having  been  al- 
ready indicated)  is  that  of  the  introduction  of 
syphilitic  infection  along  with  the  vaccine.  It  is 
by  means  of  the  bicod  that  syphilis  has  been 
introduced.  Such  an  accident,  though  rare,  is  of 
the  most  serious  consequence  when  it  does  occur, 
not  only  on  account  of  the  injury  inflicted  on  in- 
dividuals, hut  from  the  damage  done  by  it  to  the 
reputation  of  vaccination;  and  every  practitioner 
is  bound  to  the  most  scrupulous  observance  of  the 
precautions  whereby  these  evils  may  be  avoided. 
The  precautions  are  (a)  extreme  care  in  the  choice 
of  vaccinifer ; ( b ) brightness  and  cleanliness  of 
lancet,  with  careful  cleansing  after  each  sepa- 


VAGINA,  DISEASES  OF. 

rate  vaccination ; (c)  scrupulous  care  in  opening 
the  vesicles  of  the  vaccinifer  not  to  draw  aDy 
blood,  and  not  to  use  the  lymph  of  any  vesicle 
from  which  blood  may  accidentally  have-  been 
drawn  ; and  (d)  care  also  not  to  take  from  lymph- 
vesicles  in  which  there  is  an  areola,  and  in  which 
therefore  the  normal  contents  of  the  vesicle  will 
have  become  mingled  with  the  products  of  com- 
mon inflammation.  E.  C.  Seaton. 

VAGINA,  Diseases  of.— Stnon.  ; Fr.  Ma- 
ladies da  Vagin-,  Ger.  Krankheiten  der  Schcide. 

The  vagina  frequently  participates  in  the 
morbid  processes  which  affect  the  uterus  and 
other  neighbouring  organs.  The  vaginal  affec- 
tion is  then  a matter  of  minor  importance,  and 
may  net  call  for  special  recognition.  But  this 
organ  is  often  enough  the  seat  of  independent 
diseases,  the  more  important  of  which  will  now  be 
considered. 

1.  Atrosia.-Imperforate  vagina  is  met  with  as 
a congenital  or  acquired  malformation.  Congeni- 
tal atresia  may  occur  alone  : or  it  may  be  com- 
plicated with  absence,  imperfect  development,  or 
closure  of  the  orifice  of  the  uterus.  Occasionally 
the  vagina  is  bifid,  and  the  atresia  affects  only 
one  side,  in  which  the  menstrual  fluid  of  the  cor- 
responding horn  of  the  uterus  may  accumulate, 
producing  the  condi  tion  described  as  heematokolpos 
lateralis.  The  occlusion  may  first  affect  the  organ 
in  its  entire  length ; or,  secondly,  forahalf  or  third 
of  its  length,  most  frequently  towards  the  lower 
extremity ; or,  thirdly,  it  may  be  simply  mem- 
branous, as  from  a too  complete  hymen.  The  con- 
genital atresia  is  usually  complete,  so  that  the 
passage  to  and  from  the  uterus  is  perfectly  oc- 
cluded. Acquired  or  accidental  atresia,  on  the 
other  hand,  may  present  any  degree  of  constric- 
tion, from  a slight  and  partial  narrowing  of  the 
canal  up  to  its  total  obliteration.  We  find  it  re- 
sulting, first,  from  sloughing  after  labour,  when 
it  is  frequently  complicated  with  vesical  or  rectal 
fistulae ; secondly,  from  sloughing  after  fever ; 
thirdly,  from  chronic  inflammations  and  ulcer- 
ations ; fourthly,  from  applications  of  caustics. 

Symptoms  and  Diagnosis. — There  are  three 
stages  at  which  atresia  may  betray  itself  by 
symptoms.  First,  after  puberty  has  set  in,  the 
patient  has  the  usual  indications  that  ovulation 
is  taking  place,  but  she  suffers  from  amcnorrhaea . 
The  uterine  haemorrhage  is  taking  place ; but  the 
extravasated  blood  is  detained  above  the  seal  of 
occlusion,  and  does  not  appear  externally.  Second- 
ly, in  some  women  dgspareunia  (impossibility  of 
copulation)  after  marriage  leads  to  the  examina- 
tion which  discovers  the  obstruction.  Thirdly, 
in  the  acquired  variety  the  difficulty  is  often  only 
discovered  is  consequence  of  the  dystocia  that  re- 
sults from  the  resistance  offered  to  the  advance 
of  the  foetal  head  by  the  constriction  of  the  canal. 
The  physical  examination  may  discover,  first, 
on  abdominal  palpation,  a swelling  in  the  hypo- 
gastric or  inguinal  region,  due  to  the  accumula- 
tion of  menstrual  fluid  in  the  upper  parts  of  the 
sexual  canals.  Secondly,  on  vaginal  exploration 
being  attempted,  either  the  finger  is  soon  arrested 
within  the  labia,  or  a bulging  fluctuating  pouch 
is  felt.  Thirdly,  we  then  examine  per  rectum  or 
per  vesicant  with  sound  or  finger,  or  through  these 
cavities  simultaneously,  combining  the  explors- 


VAGINA,  DISEASES  OF. 


tion  by  means  of  the  fingers  of  one  hand  through 
the  available  openings  in  the  pelvic  floor,  with 
pressure  and  palpation  with  the  other  hand  above 
the  pelvic  brim.  The  exact  seat  and  extent  of 
the  occlusion  can  thus  be  detected,  and  at  the 
samo  time  an  estimate  can  be  formed  of  the 
amount  of  accumulation  that  may  have  taken 
place  above  it. 

Prognosis. — (1)  Where  the  obstructing  mem- 
brane is  thin,  it  may  give  way  at  a menstrual 
period,  or  under  a gangrenous  process.  (2)  The 
sac  formed  by  the  dilated  uterine  or  Fallopian 
cavities  may  burst,  and  pour  its  contents  into  the 
peritoneal  cavity.  (3)  In  a considerable  propor- 
tion of  eases  early  menopause  comes  on,  and  les- 
senstherisk.  (4)  Patients  who  suffer  from  atresia 
vaginae,  even  when  they  have  been  relieved  by 
operative  measures,  show  a tendency  to  die  of 
consumption. 

Treatment. — In  view  of  the  dangers  associated 
with  the  accumulation  of  menstrual  fluid  in  the 
genital  canals,  the  indication  usually  becomes 
very  clear  for  their  evacuation  by  perforating 
the  obstructing  tissues.  But  this  operation  has 
often  been  followed  by  disastrous  results.  Not  to 
speak  of  the  risks  of  wounding  the  bladder  or 
rectum,  or  of  setting  up  pelvic  cellulitis,  in  cases 
where  there  is  total  absence  of  the  vagina,  and  a 
canal  needs  to  be  tunnelled  to  the  uterus,  emptying 
of  a hsmatometra  and  hsematokolpos  has  been 
followed  by  death,  sometimes  from  septicaemia, 
sometimes  from  bursting  of  the  sac  above  when 
pressure  is  made  on  it;  or  dangerous  inflamma- 
tion has  been  set  up  in  the  pelvic  organs.  Care 
must  be  taken  never  to  empty  the  sac  by  pressure 
from  above,  but  by  washing  it  out  with  a warm 
antiseptic  fluid  through  an  opening,  which  may  be 
made  under  antiseptic  precautions.  Where  the 
atresia  has  been  extensive,  there  is  a strong  ten- 
dency to  its  repeated  closure.  This  must  be 
averted  by  making  the  patient  wear  a glass  or 
vulcanite  tube,  filled  with  cotton  wadding  soaked 
in  carbolised  oil,  through  which  the  uterine 
cavity  can  be  occasionally  washed  out  until  it 
has  collapsed.  This  must  be  worn  for  some 
months,  until  the  vaginal  canal  has  fully  cica- 
trized around  it. 

2.  Displacements. — When  the  perinaeum  has 
become  relaxed  or  lacerated,  hernia  of  the  pelvic 
contents  is  apt  to  occur  to  a greater  or  less  extent. 
The  descent  of  the  uterus  in  such  cases  has  com- 
monly been  regarded  as  their  most  important 
feature,  and  they  have  generally  been  described 
as  prolapsus  uteri.  When  the  protrusion  or  her- 
niation, however,  is  complete,  the  walls  of  the 
hernial  sac  are  formed  chiefly  by  the  walls  of  the 
vagina,  and  we  get  the  most  extensive  displace- 
ment, or  inversion,  of  the  vagina.  The  symptoms 
and  treatment  of  this  inversion  belong  to  the  his- 
tory of  uterine  displacements.  But  we  may  have 
displacement  of  one  or  other  of  the  vaginal  walls 
as  an  independent  mischief,  or  as  the  most  pro- 
minent disturbance,  in  a case  where  the  retentive 
power  of  the  pelvic  floor  is  impaired.  If  the  ante- 
rior wall  of  the  vagina  descend,  it  carries  with  it 
the  back  wall  of  the  bladder— cystccele.  If  the 
posterior  vaginal  wall  descend,  it  brings  with  it 
the  anterior  wall  of  the  rectum  —rectoccle. 

The  treatment  of  these  conditions  is  either 
palliative  or  radical.  The  palliative  treatment  is 


1725 

effected  by  the  use  of  astringent  injections,  and 
the  application  of  vaginal  pessaries — such  as 
the  Hodge  pessary  with  cross  bars  towards  its 
lower  end.  The  radical  treatment  implies  a 
plastic  operation  for  repair  of  the  relaxed  or 
ruptured  perimeum,  or  for  producing  a contrac- 
tion in  the  displaced  vaginal  wall. 

3.  Foreign  Bodies. — The  vaginal  canal  is 
sometimes  found  occupied  by  foreign  bodies. 
Every  gynaecologist  has  met  with  arses  where  pes- 
saries have  been  left  in  for  years,  until  by  their 
presence  and  pressure  they  began  to  set  up  ulce- 
rative processes  in  the  vaginal  walls.  Introduced 
at  first  with  a useful  object,  and  producing  for  a 
time  a beneficial  effect,  their  presence  has  some- 
times been  forgotten,  until  the  discharges  they  ex- 
cited has  recalled  attention  to  them.  But  bodies 
of  quite  another  kind  are  sometimes  met  with, 
usually  introduced  by  patients  with  onanistic  pro- 
pensities. Corks,  pieces  cf  wood,  pomade-pots, 
fir-tops,  dram-glasses,  etc.,  have  been  met  with 
in  such  cases.  Portions  of  glass  specula  and  of 
glass  syringes  have  sometimes  broken  off  in  the 
hands  of  practitioners  or  patients.  Ascarides 
and  other  parasites  seem  occasionally  to  make 
their  way  from  the  anus  into  the  vagina. 

Some  of  these  foreign  bodies  are  very  easy  of 
removal.  Others  are  a source  of  great  difficulty 
— those  more  especially  which  have  become  im- 
bedded to  some  extent  in  the  vaginal  walls.  Thus 
it  may  become  necessary  to  anaesthetize  the 
patient,  to  lay  hold  of  the  foreign  body  with  a 
polypus  forceps  or  vulsellum,  and  to  detach  it 
with  the  fingers  or  with  a knife  from  the  tissues 
that  have  granulated  round  it,  before  it  can  be 
withdrawn. 

4.  Inflammation. — Svnon.  : Colpitis;  Vagi- 
nitis.— -Apart  from  gonorrhoeal  inflammation  of 
the  vagina  we  may  have  colpitis  of  a non-spe- 
cific character,  either  as  a primary  disease,  origi- 
nating in  itself,  or  spreading  to  it  from  the 
neighbouring  structures.  The  causes  of  inflam- 
mation commencing  in  the  vagina  are  found  in 
chills  (puerperal  or  menstrual) ; injuries  (as  from 
rude  use  of  obstetric  and  gynaecological  instru- 
ments) ; prolonged  presence  of  pessaries  ; exces- 
sive coition ; irritants  (as  in  cases  where  nitrate 
of  silver  applied  to  the  cervix  has  acted  on  the 
vaginal  mucosa) ; neoplasms ; and  some  of  the 
fevers.  In  elderly  women  we  meet  with  a colpitis 
senilis  or  vetularum  (Buge),  the  cause  of  which 
is  not  easily  traceable,  in  which  the  mucous  mem- 
brane, especially  of  the  upper  part  of  the  vaginal 
tube,  sheds  its  epithelial  covering  in  patches, 
becomes  studded  here  and  there  with  papillary 
granulations,  and  shows  a tendency  to  cicatricial 
contractions.  In  other  women  the  colpitis  in  its 
acute  forms  is  found  as  a catarrh  of  the  mucosa, 
attended  with  swelling,  rapid  desquamation  of 
epithelial  cells,  and  exudation  of  a serous  fluid, 
which  mixed  with  the  granular  cells  produces  a 
milky  discharge.  In  the  chronic  forms  the  dis- 
charge becomes  more  creamy  or  purulent,  as  the 
exudation  is  less  copious,  and  there  is  more  exfo- 
liation of  degenerated  and  often  unripe  epithelial 
cells ; and  then  the  surface  is  often  thickly 
strewn  with  red  papillae,  over  which  the  epithelium 
is  almost  destroyed.  The  symptoms  are  local 
discomfort,  and  leucorrhceal  discharges  of  various 
kinds ; and  the  diagnosis  is  made  by  examination 


1 726  VAGINA,  DISEASES  OF. 
of  the  discharge,  and  exposure  of  the  affected  sur- 
face by  means  of  the  speculum. 

The  treatment  in  the  acute  stage  is  directed 
to  keeping  the  part  at  rest,  and  using  sedative  in- 
jections. In  the  chronic  forms  the  use  of  the  in- 
jection or  douche  must  be  steadily  persevered  in. 
The  canal  must  be  washed  out  with  a stream  of 
hot  water,  in  the  last  pint  of  which  alum  or  some 
other  astringent  has  been  dissolved.  "Where  an 
acute  process  is  likely  to  become  chronic,  or  in 
the  chronic  forms  attended  with  granulations  on 
the  surface,  it  is  well  to  apply  with  a mop  or 
brush  a solution  of  nitrate  of  silver  containing 
half  a drachm  to  the  ounce.  Frequently  the  use 
of  pessaries  of  oxide  of  zinc,  bismuth,  or  iodide 
of  lead,  proves  useful  in  cases  where  patients 
have  difficulty  in  using  the  syringe  or  douche. 
In  the  colpitis  senilis  the  distress  which  the 
patient  feels  from  the  irritating  discharge  is 
best  relieved,  and  the  unhealthy  surface  is  most 
speedily  brought  to  heal,  by  the  application  of 
bismuth  powder,  through  a speculum  or  other 
tube,  to  the  mucous  membrane,  after  washing  or 
wiping  away  the  secretion. 

5.  Injuries.— It  is  principally  in  connexion 
with  labour  that  the  vaginal  walls  are  liable  to  be 
injured.  Not  only  in  operative  cases  where  the 
walls  may  get  bruised  and  torn,  or  in  tedious 
cases  where  the  walls  are  so  long  compressed  that 
they  may  afterwards  slough  and  become  the  seat 
of  fistulse,  but  even  in  ordinary  cases  the  vaginal 
mucous  membrane  is  almost  always  fissured,  or 
torn  more  or  less  deeply,  at  its  lower  extremity. 
These  lacerations  are  mainly  important  because 
of  their  liability  to  become  the  channels  through 
which  septic  matters  are  absorbed  in  the  puer- 
peral patient.  In  every  case  where  there  is  a 
chance  of  infection,  the  canal  should  be  syringed 
with  a solution  of  carbolic  acid  ; and  it  is  a further 
safe  precaution  to  keep  the  raw  surface  dusted 
with  a powder  of  several  grains  of  starch  com- 
bined with  one  grain  of  salicylic  acid,  or  with 
iodoform. 

6.  Neoplasms. — Fibromata  affect  most  fre- 
quently the  anterior  wall  of  the  vagina.  They 
may  be  either  sessile  or  pedunculated.  They  do 
not  give  rise  to  much  distress,  except  from  their 
pressure  on  the  bladder,  or  from  their  protruding 
through  the  vulva.  Extirpation  affords  the  only 
cure,  and  in  carrying  out  the  operation  care  has 
:o  be  taken  to  avoid  injuring  the  bladder  or  ure- 
thra when  they  are  seated  anteriorly,  and  the  rec- 
tum when  they  spring  from  the  posterior  wall. 
Sarcomata , round-celled  or  spindle-celled,  have 
been  in  some  few  cases  found  springing  from  the 
vaginal  walls.  They  have  sometimes  been  de- 
scribed as  growing  from  the  submucous  tissue. 
In  the  only  case  which  the  writer  has  met  with, 
the  growths  arose  from  the  mucous  membrane. 
Early  extirpation  is  indicated.  These  growths 
tend  to  recur.  Carcinoma,  more  markedly-  even 
than  the  other  neoplasms,  is  oftener  a secondary 
than  a primary  affection  in  the  vaginal  walls.  It 
may,  however,  originate  in  the  vagina  itself,  run- 
ning a course  at  least  as  rapid  as  in  the  uterus, 
and  usually  leading  early  to  infiltration  of  the  in- 
guinal glands.  It  only  admits  of  palliative  treat- 
ment. Cystomata , like  the  simple  solid  tumours, 
are  most  frequent  on  tie  anterior  wall.  The 
contents  are  usually  pale,  and  where  they  have 


VALVES,  DISEASES  OF. 

attained  the  size  of  a walnut,  watery.  In  the 
smaller  cysts  the  contents  are  more  viscid.  Some 
seem  to  result  from  cavities  into  which  blood 
has  been  extravasated,  and  then  the  contents  are 
brownish.  They  must  be  freely  evacuated,  and 
iodino  or  nitrate  of  silver  applied  to  their  lining 
membrane ; otherwise  they  are  apt  to  be  re-filled. 

7 Vaginismus. — Under  this  designation  has 
been  described  an  affection  of  the  vaginal  orifice, 
which  is  not  infrequent  among  recently  married 
women,  and  which  utterly  unfits  the  subjects 
of  it  for  enduring  coition.  In  some  of  them  the 
hymen  is  unruptured,  and  there  are  excoriations 
at  its  base,  towards  the  navicular  fossa.  More 
frequently  the  hymen  has  been  infringed,  but 
the  lacerations  resulting  from  the  immissio  penis 
have  not  healed,  or  fissures  have  formed  at  the 
roots  of  the  hymeneal  flaps,  and  a chronic  inflam- 
mation is  set  up  in  the  tissues,  which  renders 
them  exquisitely  sensitive.  In  such  a condition 
any  touch,  even  of  the  finger,  causes  intense  pain, 
and  when  an  attempt  is  made  to  pass  through 
the  orifice,  the  constrictor  vagina  and  the  lower 
fibres  of  the  levator  ani  are  thrown  into  a tenes- 
mic  state,  which  prolongs  the  suffering.  The 
leading  symptom  is  the  distressing  dyspareunia ; 
and  the  diagnosis  is  made  by  the  touch  of  the 
finger,  supplemented  by  inspection.  An  examina- 
tion can  often  be  effected  only  when  the  patient 
is  placed  under  anaesthetics. 

Treatment.— Treatment  of  a palliative  kind 
may  be  attempted,  making  the  patient  use  sitz- 
baths  and  apply  emollients  and  sedatives.  But 
it  is  far  more  satisfactory  to  have  recourse  to 
radical  measures.  The  patient  being  under  the 
influence  of  chloroform,  the  fragments  of  the 
hymen  should  be  pared  or  clipped  off.  An 
incision  should  be  made  on  each  side  of  the 
vaginal  opening  towards  its  posterior  aspect, 
running  in  a direction  outwards  and  backwards, 
and  passing  through  the  whole  thickness  of  the 
mucous  membrane,  and  some  portion  of  the 
thickness  of  the  constrictor  muscle.  The  points 
of  four  fingers  of  the  hand  gathered  together  and 
well  greased,  should  then  be  passed  through  the 
dilated  opening,  so  as  fully  to  distend  it,  and  pro- 
duce complete  relaxation  of  the  sphincter.  With 
due  care  the  bleeding  is  trifling;  the  wound 
heals  kindly;  and  undue  contraction  is  prevented 
by  making  the  patient  wear,  for  half  an  hour  or 
longer  twice  a day,  a thick  vaginal  bougie.  For  a 
time  the  introduction  of  the  bougie  is  resented, 
but  the  pain  passes  off  when  it  is  kept  in  posi- 
tion ; and  after  a few  days  its  passage  ceases  to  be 
painful.  This  operation  can  be  carried  out  with  a 
very  confident  expectation  that  the  dyspareunia 
will  disappear;  and  if  no  other  complication  be 
present,  the  probability- is  that  conception  will 
ensue.  Alexander  Russell  Sixtpsox. 

VALENCIA,  on  the  east  coast  of  Spain. 

A dry,  variable,  mild,  winter  climate.  Mean 
winter  temperature,  Fah.  Prevailing 

■winds  E.  (moist).  W.  and  S.W.  (rough).  See 
Climate,  Treatment  of  Disease  by. 

VALS,  in  France. — Alkaline  waters.  See 
Mineral  Waters. 

VALVES,  Diseases  of.  See  Heart,  Valves 
of,  Diseases  of;  and  Ptlorus,  Diseases  of. 


VARICELLA. 

VARICELLA  (dim.  of  Variola).— A sy- 
nonym for  chicken-pox.  See  Chicken-Pox. 

VARICOCELE  ( varix , a dilated  vein,  and 
icrjAij,  a tumour). — Synon.  : Er.  Varicocele  ; Ger. 
Ki  ampfaderbruck. 

Definition. — A dilated,  elongated,  and  tor- 
tuous condition  of  the  veins  of  the  spermatic 
cord,  due  either  to  increased  pressure  within  the 
vessels,  or  to  diminished  resistance  in  the  walls 
cf  the  vessels  and  the  surrounding  structures. 

Pathology. — The  testicle,  probably  like  other 
glands,  receives  supplies  of  blood  varying  with 
its-  activity;  and  the  veins  are  numerous  and 
tortuous,  freely  anastomose,  are  liable  to  inter- 
mittent compression  in  their  passage  through  the 
inguinal  canal  from  muscular  contraction,  and 
terminate  on  each  side  in  a single  vein,  which, 
like  the  companion  artery,  is  remarkable  for  its 
great  length  and  small  size.  These  conditions 
are  favourable  to  the  production  of  dilatation 
and  varicosity.  Diminished  resistance  in  the  walls 
of  the  vessels  and  surrounding  structures,  is, 
however,  probably  the  chief  cause.  Varicocele  is 
so  much  more  frequent  in  the  left  than  in  the 
right  spermatic  cord,  and  when  present  in  both 
is  so  much  larger  in  the  left,  that  the  inferior 
muscular  development  of  the  left  side  of  the  body 
from  predominant  use  of  the  right  is  very  pos- 
sibly a predisposing  cause.  The  termination  of 
the  left  spermatic  vein  at  right  angles  in  the 
renal  vein,  as  compared  with  the  termination  of 
the  right  vein  at  an  acute  angle  in  the  inferior 
vena  cava,  and  the  relation  of  the  left  vein  to 
the  sigmoid  flexure,  have  been  suggested  as  pos- 
sible exciting  causes ; but  their  influence,  if  any, 
must  be  slight. 

Symptoms. — Varicocele  is  generally  painless, 
but  is  sometimes  associated  with  neuralgia  or 
hyperaesthesia  of  the  testicle.  The  subjects  of  it 
sometimes  complain  of  a feeling  of  weight  or 
uneasiness  in  the  part,  after  standing  or  pro- 
longed exercise ; and  in  extreme  cases,  when  the 
scrotum  is  very  much  relaxed,  labouring  men 
have  found  it  a mechanical  hindrance  in  their 
work.  The  testicle  is  usually  normal,  but  is 
sometimes  soft  and  even  atrophied,  but  these 
conditions  of  the  testicle  are  probably  the  result 
of  other  causes,  and  not  of  the  varicocele.  In 
such  cases  the  patient  is  generally  very  hypo- 
chondriacal. 

Diagnosis. — The  diagnosis  is  easy.  The  veins 
can  be  readily  felt,  and  have  been  aptly  com- 
pared to  a bag  filled  with  worms. 

Treatment. — In  slight  cases  of  varicocele  no 
treatment  is  required.  The  use  of  a light  truss, 
with  pressure  sufficient  to  take  off  the  weight  of 
the  superincumbent  column  of  blood  from  the 
spermatic  veins,  without  interfering  with  the 
current  of  blood  through  the  spermatic  artery, 
has  been  recommended  with  advantage.  A well- 
fitting suspensory  bandage,  cold  bathing,  avoid- 
ance of  constipation,  and  tonics,  will  suffice  for 
most  cases ; and  if  operative  interference  be 
requisite,  the  writer  has  found  excision  of  the 
veins,  with  antiseptic  precautions,  most  satisfac- 
tory. Subcutaneous  ligature  and  division  of  the 
veins  have  been  recommended;  but  the  result  is 
always  uncertain,  and  sometimes  unsuccessful. 

J.  McCarthy. 


VEINS,  DISEASES  OF.  1727 

VARICOSE  VEINS.  See  Veins,  Dis. 
eases  of ; and  Varicocele. 

VARIETIES  OP  DISEASE.  See  Dis- 
ease, Types  and  Varieties  of. 

VARIOLA  ( varius , spotted). — A synonym 
for  small-pox.  See  Small-Pox. 

VARIOLOID  ( variola , small-pox,  and  etSov. 
form). — This  term  has  been  applied  to  a disease 
which  has  the  characters  of  variola  in  a mild 
form,  but  which  is  really  small-pox  modified  by 
previous  vaccination  or  inoculation.  See  Small- 
pox. 

VEGETABLE  PARASITES.  See  Pa- 
rasites. 

VEGETABLE  POISONS.  See  Poison- 
ous Food  ; and  Poisons. 

VEGETATIONS  ( vegco , I grow). — In  mo- 
dern pathology  this  term  is  usually  applied  to 
growths  and  deposits  connected  with  the  valves 
of  the  heart  (see  Heart,  Inflammation  of).  The 
name  is  also  given  to  excessive  granulations  on 
wounds,  and  to  warty  growths. 

VEINS,  Diseases  of. — Synon.  : Fr.  Mala- 
dies des  Veines  ; Ger.  Krankheiten  der  Adern. 

The  diseases  of  veins  will  be  described  in  the 
following  order;— 1.  Inflammation;  2.  Varix; 
3.  Hypertrophy  ; 4.  Atrophy ; 5.  Degenerations  ; 
6.  Phleboliths  ; 7.  Wounds ; 8.  Parasites  ; and 
0.  New  Growths.  Neither  thrombosis  nor  py- 
semia,  except  in  so  far  as  they  affect  the  vessel- 
walls,  will  be  discussed  here.  Until  late  years, 
the  term  phlebitis  included  these  diseases  and 
many  others,  but  they  have  been  gradually 
separated  now  (see  Pyjemia;  and  Thrombosis). 
The  subject  of  the  entrance  of  air  into  veins  is 
also  separately  considered.  See  Veins,  Entrance 
of  Air  into. 

1.  Inflammation.  — Synon.:  Phlebitis;  Fr. 
Pldibite ; Ger.  Venenentziindung. 

Definition. — Inflammation  of  the  coats  of  a 
vein,  associated  with  changes  in  the  blood  pass- 
ing through  the  inflamed  spot. 

Varieties. — Numerous  varieties  of  phlebitis 
exist,  but  no  satisfactory  classification  of  them 
has  yet  been  made.  Indeed,  three  methods  of 
classification  are  suggested,  namely,  1,  according 
to  the  intensity  of  the  inflammation — acute,  sub- 
acute, or  chronic ; 2,  according  to  the  condition 
of  the  thrombus  formed — whether  adhesive  or  sup- 
purative ; and  3,  according  as  the  inflammation 
affects  the  different  parts  of  the  walls— endo-, 
meso-,  exe-,  and  peri-phlebitis.  The  latter  com- 
mends itself  as  the  best,  as  it  is  chiefly  with  the 
walls  of  the  vessels  we  have  to  do.  ’ Practically, 
however,  we  may  discuss  the  subject  under  two 
heads,  namely  endophlebitis  and  periphlebitis. 

HItiology. — The  chief  cause  of  endophlebitis 
is  the  formation  of  a thrombus,  and  whatever 
leads  to  the  one  will  cause  the  other.  It  is 
especially  common  in  the  last  stages  of  exhaust- 
ing diseases,  such  as  phthisis,  and  as  a compli- 
cation or  sequela  of  the  acute  specific  fevers. 
See  Thrombosis. 

Periphlebitis,  being  allied  to  phlegmonous  ery- 
sipelas, is  set  up  by  like  causes.  When  open 
wounds  exist,  whether  old-standing  ulcers,  recent 
wounds,  amputation  flaps,  or  direct  wounds  of 
veins,  and  when  they  are  associated  with  bad 


VEINS,  DISEASES  OF. 


1728 

hygiene,  there  is  a tendency  to  this  form  of  in- 
flammation. Overcrowding  is  a fruitful  source 
of  this  and  allied  diseases  ; and  the  same  must  be 
said  of  chronic  visceral  trouble,  such  as  kidney- 
disease. 

Anatomical  Chabacters  and  Pathology. — 
The  pathology  of  phlebitis  taken  in  the  limited 
sense  referred  to,  as  it  affects  the  vessel-walls, 
is  best  discussed  according  as  the  influences 
which  alter  tho  normal  condition  arise  (a)  in  the 
blood,  or  ( b ) external  to  the  vessel-wall. 

(a)  The  inner  wall  of  a vein  consists  of  an  en- 
dothelial layer,  supported  on  a subendothelial 
basis  of  connective  tissue.  It  is  extravascular, 
but  under  certain  circumstances  is  liable  to  in- 
flammatory and  other  changes. 

From  within  the  vessel  the  only  possible  irri- 
tation must  come  from  the  blood.  That  fluid 
blood,  however  loaded  it  may  be  with  poisonous 
matter,  can  cause  an  appreciable  change  in  the 
coats  of  the  vein,  is  not  known  or  believed. 
Blood,  however,  when  coagulated,  does  cause 
changes  in  the  vessel-wall,  and  the  presence  of 
this  deposited  fibrin,  coagulated  blood,  adhesive 
clot,  or  thrombus,  by  whichever  name  we  prefer 
to  call  it,  is  the  starting-point  of  whatever  en- 
dothelial change  is  derived  from  within.  When 
a thrombus  forms,  contraction  of  the  vessel-wall 
and  staining  of  the  intima  occur;  the  staining 
is  exactly  commensurate  with  the  extent  of  the 
thrombus,  and  is  of  a uniform  reddish  hue.  The 
irritation  set  up  by  the  thrombus  will  cause  a 
determination  of  blood  in  the  vasa  vasorum,  and 
the  sheath  and  the  outer  and  middle  coats  of 
tho  vein  become  injected  and  thickened.  The 
endothelia  now  swell,  the  sub-endothelial  cells 
become  more  numerous,  active,  and  finally  find 
their  way  into  the  thrombus.  There  will  in  this 
way  result  an  adhesion  between  the  vessel-wall 
and  the  thrombus,  especially  at  its  lower  end, 
where  it  occupies  the  whole  calibre  of  the  vessel. 

From  the  contraction  of  the  thrombus  and  the 
paralysis  of  the  muscular  fibres  of  the  middle 
coat,  the  vein  will  be  thrown  into  longitudinal 
folds ; these  effects,  however,  arc  purely  mecha- 
nical, as  by  injecting  the  vein  with  water  the  folds 
readily  disappear.  The  idea  that  a fluid  lymph 
was  effused  on  the  inner  surface  of  the  vein  was 
longbelieved.  Experiments  appeared  toshow  that 
after  irritation  lymph  was  effused  on  the  inner 
surface  of  the  vein.  The  details  of  the  experi- 
ments, however,  were  proved  to  have  been  inaccu- 
rately performed,  as  lymph  was  allowed  to  travel 
through  the  openings  made  in  the  veins,  for  the 
purpose  of  inducing  the  irritation.  When  this 
was  prevented  by  tying  firmly  the  mouth  of  the 
opening  through  which  the  irritating  substance 
(say  a needle)  was  introduced,  not  only  no  lymph 
was  found,  but  the  blood  remained  fluid,  and  no 
change  took  place  in  the  vessel-wall.  The  end 
of  the  relationship  between  the  thrombus  and 
the  vessel  may  then  be  one  or  the  other  of  the 
following : — liquefaction  of  the  thrombus  and 
return  to  the  normal  state  of  the  vessel ; adhesion 
between  thrombus  and  vessel-wall,  growing  more 
and  more  intimate,  the  vessels  of  the  outer  coat 
and  the  thrombus  becoming  continuous;  the  whole 
of  the  vein  and  contents  may  become  a streak  of 
fibrous  tissue ; or  they  may  undergo  calcareous 
infiltration. 


(6)  The  sheath  and  the  outer  coat  are  tne 
parts  of  the  vein  first  liable  to  inflammatory 
or  other  changes  commencing  from  without. 
Around  superficial  veins  especially,  the  tissue  is 
loose  and  areolar,  and  in  it  the  lymphatics 
travel  upwards  to  the  glands.  Pus  finding  its 
way  into  this  loose  tissue  is  readily  conducted 
upwards  or  downwards.  The  old  name  for  peri- 
phlebitis was  ‘ suppurative  ’ or  ‘ diffuse  ’ phle- 
bitis ; it  is  a disease  allied  to  phlegmonous  ery- 
sipelas, the  pus  in  phlebitis  travelling  along  the 
loose  connective  tissue  surrounding  the  veins,  in- 
stead of  being  diffused  in  the  general  connective 
tissue,  as  in  phlegmonous  erysipelas.  The  origin 
of  the  inflammation  may  be  in  an  open  wound, 
an  ulcer,  an  extravasation  of  blood,  an  abscess, 
especially  ischio-rectal ; in  a viscus  such  as  the 
bladder  or  prostate  ; in  the  separation  of  the  pla- 
centa; or  as  a consequence  of  osteomyelitis.  No 
change  need  necessarily  occur  at  the  wound ; the 
surface  may  remain  healthy,  whilst  the  inflam 
mation  extends  along  the  sheath  of  a vein  leading 
from  it.  It  may  be  some  distance  above  the 
wound  that  the  effect  of  the  inflammation  shows 
itself;  if  on  the  leg  the  pus  may  develop  in  the 
region  of  the  popliteal  space,  if  in  the  forearm 
at  the  elbow  or  axilla.  The  spot  is  apparently 
largely  determined  by  the  looseness  of  the 
tissue.  The  inflammation  set  up  ends  in  the  for- 
mation of  pus,  which  may  accumulate  in  suffi- 
cient quantity  to  form  a large  abscess.  Several 
effects  will  follow  these  changes  on  the  sheath. 
First,  the  nutrition  of  the  coats  of  the  vein  will 
be  interfered  with,  through  the  blocking  up  c<f 
the  vasa  vasorum.  Secondly,  there  will  ensue 
paralysis  of  the  muscular  fibres  of  the  middle 
coat.  Thirdly,  the  nutrition  of  the  intima  will 
be  disturbed,  giving  rise  to  cloudy  swelling  rf 
the  cells,  loss  of  smooth  surface,  and  then,  as  a 
consequence  of  the  roughened  wall  presented  to 
the  passing  blood,  coagulation  of  the  fibrin  ami 
the  formation  of  a thrombus.  As  the  change  is 
sudden,  the  blood  coagulates  quickly,  and  a clot 
is  formed  which  is  non-laminated,  and  com- 
mensurate with  the  extent  to  which  the  ves- 
sel-wall is  affected.  Tho  pus  formed  gradually 
finds  its  way  to  the  surface,  points,  and  escapes 
either  by  natural  or  by  artificial  means.  That 
the  pus  found  its  way  inwards  was  long  be- 
lieved, and  the  clot  was  spoken  of  as  a ‘ sup- 
purative’thrombus,  in  the  belief  that  pus  actually 
existed  in  the  thrombus.  At  most  the  thrombus 
presents  only  a puriform  appearance,  and  pus  is 
not  now  believed  to  get  from  without  to  within 
a vein.  The  adhesion  between  the  wall  and  a 
thrombus  so  formed  is  very  loose,  and  easily 
disturbed  ; the  consistence  of  the  thrombus  itself 
is  loose,  its  tissue  friable  and  easily  broken  up ; 
and,  as  a consequence,  particles  may  become 
detached  and  washed  into  the  blood-stream, 
forming  emboli.  See  Embolism  ; and  Throm- 
bosis. 

Symptoms. — {a)  Endophlebi/is.ov  adhesive  phle- 
bitis, being  for  the  most  part  a local  disease,  few 
constitutional  symptoms  are  present.  The  vein 
becomes  hard,  swollen,  and  tender;  opposite  the 
valves  distinct  prominences  occur  where  the 
blood  has  first  become  stagnant;  the  limb  be- 
comes stiff;  and  sharp,  shooting,  darting  pains 
occur  along  the  course  of  the  vessel.  The  train 


VEINS,  DISEASES  OF. 


of  symptoms  ■will  vary  according  as  the  veins 
are  superficial  or  deep.  If  they  are  superficial, 
the  veins  can  be  felt  beneath  the  skin;  the  skin 
over  them  is  of  a livid  red  hue;  and  there  is 
but  little  oedema  of  the  tissues  If,  on  the  other 
hand,  deep  veins  are  affected,  the  results  will 
vary  according  as  the  phlebitis  involves  the  main 
venotis  trunk  or  the  veins  of  secondary  import- 
ance. Should  the  main  venous  trunk  become 
blocked,  as  in  phlegmasia  dolens,  the  whole  limb 
is  swollen,  the  skin  is  pale,  the  superficial  veins 
become  obscured,  and  the  extremity  affected  is 
lease  and  heavy.  Should  it  be  other  than  the 
main  venous  trunk  that  is  affected,  say  the 
filial  instead  of  the  common  femoral,  the  part 
becomes  hard  and  swollen,  the  superficial  veins 
are  full  and  prominent,  but  there  need  be  no  ex- 
tensive superficial  oedema  in  either  case.  The 
constitutional  symptoms  are,  so  long  as  the 
disease  is  localised,  but  slight ; should,  however, 
pus  form,  or  the  clot  break  down,  pyaemia  and 
embolism  may  occur  and  lead  to  a fatal  result. 

( b ) Periphlebitis,  or  suppurative  phlebitis,  oc- 
curs only  when  a person  who  is  the  subject 
of  visceral  disease,  or  who  is  exposed  to  bad 
hygienic  conditions,  suffers  some  local  injury. 
The  inflammatory  condition,  and  it  may  be  the 
pus  formed,  can  be  followed  along  the  course  of 
the  vein,  until  it  develops  in  some  part  where  the 
connective  tissue  is  looser  than  elsewhere.  Here 
au  abscess  rapidly  forms ; the  vessel  is  swollen 
and  hard;  the  tissues  become  oedematous  for 
some  distance  below  the  inflamed  spot  in  the 
vein;  and  the  pain,  at  first  of  a shooting  charac- 
ter, becomes  throbbing  as  pus  forms.  The  consti- 
tutional symptoms  are  of  a typhoid  character:  a 
feeble  fluttering  pulse,  foul  mouth  and  tongue, 
irritable  stomach,  diarrhoea,  fcetid  breath,  with 
muttering  delirium.  The  majority  of  such  cases 
die.  The  disease  is  only  a part  of  pymmia.  See 
Pyemia. 

Gouty  phlebitis  is  a name  assigned  to  a con- 
dition rather  than  to  a disease.  There  is  a 
tendency  in  persons  suffering  from  gout  to  de- 
velop adhesive  phlebitis;  and  when  varicose 
veins  exist  in  a gouty  person,  they  are  espe- 
cially the  seat  of  the  changes  that  go  by  the 
name  of  gouty  phlebitis.  Whether  it  is  the 
vein  itself  or  the  overlying  structures  that  are 
attacked,  it  is  impossible  to  say,  the  symptoms 
in  each  appearing  together.  The  skin  over  the 
vein  becomes  of  a dusky,  or  at  times  of  a livid 
red  hue,  for  some  distance  around  ; the  vein  may 
be  felt  to  be  hard ; the  limb  is  slightly  oedema- 
tous ; the  temperature  of  the  part  is  but  little, 
if  at  all,  raised ; and  the  pain  is  not  troublesome. 
The  disease  is  peculiar,  inasmuch  as  all  the 
symptoms  may  disappear  from  one  part  and  ap- 
pear in  another.  Its  apparent  metastases,  its 
indefinite  symptoms,  and  its  troublesome  recur- 
rences, have  gained  for  this  disease  the  epithet 
‘gouty.’  The  evidence  derived  from  the  treat- 
ment, however,  with  regard  to  the  pathology  of 
this  disease,  rather  negatives  its  gouty  nature, 
and  points  to  a condition  of  loss  of  tone,  asso- 
ciated with  local  erythema. 

Diagnosis. — Inflammation  of  the  veins  has  to 
be  diagnosed  from  inflammation  of  the  lympha- 
tics, and  from  erysipelas.  In  the  case  of  the  lym- 
phatics, the  glands  are  tender  and  enlarged  from 

109 


1729 

an  early  period  of  the  disease,  the  streaks  are 
rosy-red  and  in  large  numbers;  in  erysipelas, 
the  redness  is  a general  blush.  But  it  must  be 
remembered  that  both  of  these  conditions  are 
associated  with  phlebitis,  and  that  all  tend  to- 
wards pyaemia. 

Prognosis. — In  endo-  or  adhesive  phlebitis, 
the  prognosis,  in  regard  to  the  thrombus,  is 
that  it  will  he  gradually  absorbed,  or  that  it 
will  become  incorporated  with  the  wall  of  the 
vein,  and  reduced  to  a cellular  cord.  In  regard 
to  the  walls  of  the  vein,  they  may  return  to  their 
normal  state,  remain  permanently  thickened,  be 
come  adherent  to  the  thrombus  ; or  the  cellular 
cord,  formed  by  the  remains  of  vessel-wall  and 
thrombus,  may  become  perforated,  allowing  blood 
again  to  flow  through  it.  In  peri-  or  suppurative 
phlebitis,  the  prognosis  is  had,  in  regard  both  to 
the  life  of  the  patient,  and  the  recovery  of  the 
vessel. 

Treatment. — In  all  forms  of  phlebitis  we  must 
insure  absolute  rest  by  confining  the  patient  to 
bed,  and  by  fixing  the  whole  limb  between  sand- 
bags, or  by  means  of  splints.  This  is  essential 
to  procure  diminution  of  pain,  and  to  lesson  the 
chance  of  breaking  off  a fragment  of  the  clot, 
whereby  fatal  embolism  might  ho  caused.  Hot 
fomentations  are  by  far  the  most  agreeable  and 
soothing  application.  When  abscesses  form, 
poultices  are  required;  and  to  remove  hardness, 
after  acute  symptoms  are  gone,  salt  and  nitre 
poultices  are  useful.  When  abscesses  form  they 
must  be  opened.  Any  oedema  or  general  thicken- 
ing that  may  remain  must  be  combated  by  Mar- 
tin’s elastic  bandages.  Medicines,  except  those 
given  to  support  the  patient’s  strength,  such  as 
bark  and  ammonia,  and  the  like,  are  not  indi- 
cated. Calomel  and  opium  are  not  administered 
now  as  they  once  were,  as  a specific  to  resolvo 
the  clot  and  restore  the  vein.  Opium  is  given 
only  to  allay  pain,  and  the  less  the  drug  is  used 
for  that  purpose,  so  much  the  better  chance  has 
the  patient  of  recovery.  The  treatment  of  peri-, 
suppurative,  or  diffuse  phlebitis  is  to  be  con- 
ducted at  first  on  the  same  principles,  but  the 
further  treatment  is  discussed  under  pyaemia. 
See  Pyaemia  ; and  Thrombosis. 

2.  Varicose  Veins. — Synon.  : Varix  ; Phle- 
hectasis;  Fr.  Varice;  Ger.  Krampfadcr. 

Definition. — Veins  which  are  increased  in 
length,  diameter,  and  thickness. 

^Etiology. — As  the  current  in  the  veins  is 
dependent  on  a free  and  sufficient  circulation 
through  the  heart,  the  arteries,  the  capillaries, 
and  the  veins  themselves,  whatever  interferes 
with  the  passage  of  blood  through  any  of  these 
will  predispose  to  varicosity.  Hence  feeble  action 
of  the  heart,  obstruction  of  the  current  of  blood 
in  the  arteries,  the  involvement  of  the  capillaries 
in  any  inflamed  or  thickened  mass  of  indurated 
connective  tissue,  will  check  the  free  passage  of 
the  blood,  and  so  withhold  the  vis-a-tergo  ne- 
cessary for  driving  the  blood  along  the  vein.  In 
consequence,  the  blood-current  in  the  veins  will 
he  retarded,  and  the  increased  pressure  on  the 
vessel-wall  will  cause  dilatation.  In  the  veins 
themselves  the  onward  current  may  he  impeded 
by  a tight  garter,  the  pressure  of  a tumour, 
aneurismal  varix,  the  pressure  of  a truss,  a full 
rectum,  a gravid  uterus,  dilatation  of  the  right 


VEINS,  DISEASES  OF. 


1730 

heart,  emphysema,  and  prolonged  standing.  A 
person  engaged  in  any  employment  that  necessi- 
tates much  standing,  and  especially  when  in  ad- 
dition there  is  leaning  forwards,  as  over  a counter 
or  a wash-tub,  throws  most  of  the  strain  on  the 
muscles  of  the  calf.  The  continued  use  of  these 
muscles  will  cause  a determination  of  blood  to 
them,  and  by-and-by  the  full  current  in  the  vein 
will  exhaust  the  resisting  powers  of  its  wall, 
and  allow  of  its  dilatation  ; so  that  from  the  sur- 
faces of  the  soleus  and  gastrocnemius,  several 
enormous  veins  will  be  found  to  emerge. 

Anatomical  Characters.— The  principal  seats 
of  varix  are  the  extremities,  especially  the  lower 
limbs ; the  body,  when  collateral  circulation  is 
set  up  by  blocking  of  the  venous  trunks  ; the 
rectum  (see  Hemorrhoids);  and  the  scrotum. 
See  Varicocele. 

The  morbid  changes  in  the  development  of  a 
varicose  vein  occur  in  the  following  stages : — 

a.  Simple  dilatation  of  a vein  occurs  when 
excess  of  strain  is  thrown  on  its  walls  from  any 
obstruction. 

b.  This  may  he  of  so  long  duration  that  actual 
changes  in  tli9  structure  of  the  wall  ensue. 
These  consist  in  a hypertrophy  of  the  muscle- 
cells  m the  middle  coat,  and  a hyperplasia  of 
the  connective  tissue  in  all  the  coats. 

c.  Should  the  cause  of  the  dilatation  continue, 
the  vessel  becomes  thicker,  increases  in  length, 
and,  as  a consequence,  becomes  tortuous,  wavy 
in  its  outline,  and  irregular  in  its  calibre. 

The  valves,  in  harmony  with  the  vessel-wall, 
become  hypertrophied,  and  for  a time  perform 
their  function ; but  by-and-by  they  are  insuffi- 
cient to  span  the  widening  stream,  and  as  they 
become  useless,  are  reduced  to  fibrous  cords.  Be- 
hind the  valves  the  blood  finds  a quiet  recess, 
where  it  frequently  stagnates,  and  a thrombus 
is  formed,  which  may  remain  as  a partially  ob- 
structing thrombus,  or  by  continual  additions  to 
its  surface,  become  a completely  obstructing 
thrombus.  After  long-continued  dilatation  the 
tissues  around  thicken,  and  the  fibrous  tissue 
formed  will  spread  between  outlying  tissues,  and, 
involving  the  blood-vessels,  will  encroach  on  their 
calibre  and  strangle  them.  In  this  way  it  is  that 
the  vessels  of  the  skin  over  a varicose  vein  are 
destroyed,  and  by  the  removal  of  the  skin  an 
ulcer  is  formed.  See  Ulcer. 

d.  The  vein,  as  it  approaches  the  surface,  may 
by  its  pressure  cause  thinning,  instead  of  thicken- 
ing, of  the  surrounding  tissues ; and  its  walls 
finally  become  thinned  and  ruptured.  In  conse- 
quence an  enormous  quantity  of  blood  may  be 
lost ; and  unless  means  are  employed  to  arrest 
its  flow,  fatal  effects  may  ensue. 

Symptoms. — The  premonitory  symptoms  of 
varicose  veins  in  the  loiver  extremities  are  but 
ill  understood.  Numbness,  cramps,  increased 
heaviness  of  the  limbs,  occasional  swelling  about 
the  ankles  and  feet  precede  the  actual  appear- 
ance; but  these  symptoms  might  be  the  fore- 
runner of  other  troubles,  and  not  of  varicose 
veins  at  all.  It  is  not  until  the  vein  is  seen  to 
be  varicose  that  the  disease  can  be  known  to 
exist.  "When  first  seen,  a small  part  of  a su- 
perficial vein,  usually  about  the  calf  cr  ankle, 
looks  slightly  more  bluish  and  larger  than  usual. 
'This  may  disappear  or  escape  observation  for 


some  time,  only,  however,  to  recur;  and  by-and-by 
the  condition  will  become  permanent,  with  occa- 
sional shooting  pains  in  the  course  of  the  vessel. 
The  superficial  veins  may  become  wholly  in- 
volved, either  from  below  upwards,  or  from  above 
downwards,  according  to  the  seat  of  the  obstruc- 
tion. 

The  superficial  may  be  equally  involved  with 
the  deep  veins.  As  a consequence  the  whole 
limb  is  abnormally  large;  a solid  oedema  p r- 
meates  all  its  parts  ; the  nutrition  of  the  limb  is 
interfered  with  ; and  the  superficial  parts  giving 
way,  profuse  hcemorrhage  or  the  formation  of  a 
varicose  ulcer  may  be  the  result.  The  haemor- 
rhage is  at  times  excessive,  the  blood  pouring 
from  the  upper  instead  of  the  lower  end  of  the 
vessel.  This  anomaly  is  accounted  for  by  the 
destruction  of  all  the  valves  between  the  rup- 
tured spot  and  the  heart;  the  increased  pres- 
sure, in  this  long  column,  relieving  itself  by  the 
aperture  at  its  lower  extremity. 

Diagnosis. — Varicose  veins  are  unmistakable 
in  their  appearance  as  usually  found.  At  times 
a saccular  dilatation  of  the  internal  saphena  vein, 
just  below  Poupart’s  ligameDt,  is  mistaken  for  a 
femoral  hernia ; but  with  ordinary  care  this  is  to 
be  made  out  easily. 

Prognosis. — A dilated  vein  is  dangerous  ac- 
cording as  it  has  a tendency  to  rupture  or  become 
inflamed.  Either  of  these  complications  mav 
prove  fatal.  The  chance  of  an  extensive  group  of 
varicose  veins  becoming  obliterated,  whether  by 
spontaneous  cure  or  by  operation,  is  but  slight. 

Treatment. — The  treatment  in  any  particular 
instance  is  to  find  out  the  cause  of  the  veins 
becoming  varicose,  and  to  remove  it  if  possible. 
The  circulation  in  the  dilated  vessel  must  then 
he  encouraged,  by  obtaining  a good  cardiac  and 
vascular  tone;  by  support  of  the  blood  in  the 
vein  ; and  by  particular  attention  to  dietary  and 
hygienic  rules  for  some  time.  The  vein  is  best 
supported  by  an  elastic  stocking,  or  by  Martin's 
elastic  bandage,  or  by  an  ordinary  roller-bandage 
carefully  applied.  The  position  of  the  limb 
must  be  attended  to.  so  as  to  help  the  venous 
return  ; the  patient  sitting  with  the  feet  raised 
on  all  possible  opportunities,  and  not  neglecting  at 
night  to  sleep  with  the  lower  end  of  the  bed 
slightly  raised.  Pules  of  treatment  such  as 
these  are  no  doubt  beneficial,  but,  unfortunately, 
are  but  seldom  curative.  For  t.he  purpose  of 
cure  by  obliteration  of  the  vessels,  numerous 
plans  are  practised.  The  eases  in  which  it  is 
considered  justifiable  to  operate  are  (1)  when 
the  vein  gives  rise  to  pain  and  inconvenience ; 
(2)  when  hcemorrhage  threatens  or  recurs ; (3) 
when  ulceration  threatens;  (4)  when  oedema  is 
great ; (5)  when  a varicose  ulcer  will  not  heal. 

The  methods  practised  may  be  briefly  noticed. 

a.  At  two  or  three  spots  over  the  varicose  vein, 
the  skin  is  touched  with  caustic  potash,  nitric 
acid,  or  a paste  consisting  of  five  parts  oxide  of 
calcium,  four  parts  caustic  potash,  with  spirits 
of  wine  to  the  proper  consistence. 

b.  Two  or  three  drops  of  perchloride  of  iron 
may  be  injected  into  the  vein.  The  blood  at  the 
part  injected  must  be  rendered  stagnant  by 
compression  above  and  below. 

c.  Needles  may  be  introduced  through  the 
vein,  and  a galvanic  current  passed  along  th  inn 


VEINS,  DISEASES  OF. 

d.  Subcutaneous  division  may  be  practised,  by 
introducing  a narrow  pointed  bistoury  beneath 
the  vein,  and  dividing  it. 

e.  The  varix  may  be  compressed,  by  passing  a 
hare-lip  pin  beneath  the  vein,  opposite  the  high- 
est point  at  which  obliteration  is  wished,  and 
taking  care  not  to  transfix  the  vessel.  A piece 
of  wax  bougie  must  next  be  laid  over  the  pin 
lengthwise  on  the  vein.  The  practitioner  then 
twists  a piece  of  silk  over  the  ends  of  the  pin, 
figure-of-8  manner,  so  as  to  cause  the  bougie  to  be 
pressed  on  the  vein  and  pin.  At  intervals  of  an 
inch  along  the  vessel  the  process  is  repeated  as 
often  as  it  is  necessary,  so  as  to  obliterate  the 
whole  vein.  The  part  must  now  be  kept  abso- 
lutely at  rest,  and  the  pins  left  in  position  for 
eight  days. 

In  all  these  methods,  the  risks  of  phlebitis, 
thrombosis,  and  their  consequences  are  to  be  re- 
membered and  well  weighed,  before  an  operation 
is  undertaken.  The  result  in  regard  to  the  vein 
operated  on  may  be  a permanent  cure,  but  it  is 
almost  certain  that  the  neighbouring  veins  may 
become  varicose  in  a few  months. 

3.  Hypertrophy  of  Walls. — This  takes  place 
when  extra  work  is  thrown  on  the  walls  of  the 
vessel.  See  Varicose  Veins. 

4.  Atrophy. — When  from  any  cause  a vein, 
or  part  of  a vein,  falls  into  disuse,  as  after  an 
amputation,  its  calibre-diminishes,  and  its  coats 
atrophy  until  it  finally  disappears. 

5.  Degeneration.-That  atheroma  of  the  coats 
of  a vein  takes  place  is  not  determined.  The 
calcareous  plates  found 'at  times  in  the  saphena 
veins,  inferior  vena  cava,  and  uterine  veins  are 
probably  a form  of  phlebolithes,  and  do  not  ori- 
ginally proceed  from  the  wall  of  the  vein. 

6.  Phlebolithes. — Phlebolithes,  or  venous 
calculi,  have  a tendency  to  form  in  veins  in  which, 
from  dilatation  of  the  coats,  the  circulation  is  ab- 
normally slow,  as  in  the  veins  of  the  prostate  and 
bladder,  and  in  varicose  veins  anywhere.  They 
commence  no  doubt  as  precipitated  fibrin,  and  to 
this  is  added  the  less  soluble  salts  of  the  blood — 
chiefly  phosphate  of  lime,  and  in  less  quantity  the 
sulphate  of  lime  and  sulphate  of  potash.  Phle- 
bolithes are  harmless,  and  they  require  no  treat- 
ment. 

7.  Wounds,  and  process  of  healing. 
Wounds. — When  a healthy  superficial  vein  is 
wounded,  dark  venous  blood  flows  in  a uni- 
form stream  from  the  distal  end  ; but  in  the  case 
of  a varicose  vein  the  blood  flows  from  both  ends, 
and  chiefly  from  the  cardiac.  At  the  same  time 
a quantity  of  blood  escapes  into  the  subcutaneous 
areolar  tissue,  and  around  the  sheath  of  the  vein. 
When  a deep  vein  is  wounded  with  a breach  of 
surface,  dark,  scarcely  fluid,  blood  oozes  and 
trickles  away.  When  a deep  vein  is  torn  by  a 
broken  bone,  without  breach  of  surface,  the  part 
around  swells,  and  becomes  dark  in  colour;  oedema 
occurs  around  and  below  the  torn  vein  ; and,  ac- 
cording to  the  amount  of  the  extravasation,  and 
the  condition  of  the  patient  and  the  part,  so  will 
there  he  a tendency  to  resolution,  non-union  or  de- 
layed union  of  the  bone,  excess  of  callus,  or  the 
formation  of  pus,  followed  by  osteophlebitis,  py- 
aemia, and  moist  gangrene  associated  with  bullae. 

Healing  process. — When  gentle  pressure  is  ap- 
plied over  the  wound  after  venesection,  and  the 


VEINS,  ENTEANCE  OF  A IE  INTO.  1731 
limb  is  kept  at  rest,  union  takes  place  in  a few 
days,  so  that  no  scar  even  can  be  found  in  the 
injured  vein.  The  coats  of  a vein  contract  and 
retract  only  to  a slight  extent  within  the  sheath, 
but  still  sufficiently  to  help  in  the  arrest  of  the 
haemorrhage  and  the  formation  of  the  clot.  The 
extra vasated  blood  coagulates,  extends  through 
the  opening  in  the  vein,  and  projects  like  a button 
into  the  blood-stream.  The  whole  coagulum  now 
contracts ; the  part  projecting  into  the  vein  be- 
comes organised  ; and  finally  helps  to  close  the 
wound.  No  inflammation  is  necessary,  no  cicatrix 
is  left.,  and  the  vessel  is  not  obstructed.  Instead 
of  this  favourable  ending,  there  may  arise,  from 
excess  of  movement  or  inflammation,  numerous 
troubles,  such  as  complete  obstruction  of  the  vein, 
phlebitis  leading  to  thrombosis  and  the  dispersion 
of  emboli,  local  suppuration,  inflammation  of  the 
lymphatics,  or  pysemia. 

Treatment. — Haemorrhage  from  a superficial 
vein  is  readily  arrested  by  pressure  over  the 
wound,  and  elevation  of  the  limb.  In  the  event 
of  persistent  haemorrhage  occurring  from  a deep 
vein  after  the  employment  of  pressure,  eleva- 
tion,  and  styptics,  the  vessel  must  be  cut  down 
upon  and  ligatured.  When  a large  vein  is  pricked, 
and  the  haemorrhage  cannot  be  checked  by  ordi- 
nary means,  the  margins  of  the  opening  in  the 
vein  may  be  seized  with  a forceps,  and  tied  with 
a catgut  ligature. 

8.  Air  in  Veins.  See  Veins,  Entrance  of 
Air  into. 

0.  Parasites. — The  embryos  of  the  Taenia 
and  the  Bilharzia  haematobia  are  occasionally 
found  in  the  blood  of  the  portal  vein  ; the  latter 
are  also  found  in  the  veins  of  the  bladder.  See 
Bixhaezia. 

10.  Hew  Growths. — Tumours  do  not  ori- 
ginate in  connection  with  veins,  but  the  current 
may  get  checked  or  stopped  by  tumours  in  the 
neighbourhood.  For  venous  naevi  see  Tumours — 
Angiomata.  James  Cantlie. 

VEINS,  Entrance  of  Air  into. — Stnon,  ; 

Er. : Aerkemoctonie ; Ger.  Lvfteintritt  in  die 
Venen. 

The  fact  that  animals  could  be  killed  by  in- 
jection of  air  into  the  veins  had  been  known 
since  the  middle  of  the  seventeenth  century,  but 
the  first  case  of  spontaneous  entry  of  air  in  man 
was  not  recorded  till  1707,  by  Merz.  After  that 
time  numerous  observations  were  made  on  ani- 
mals by  Nysten,  Bichat,  Magendie,  and  others, 
in  order  to  ascertain  the  cause  of  death,  and 
the  conditions  under  which  it  occurred.  In  the 
present  century  the  subject  has  been  investi- 
gated by  Amussat,  Erichsen,  Pirogoff,  Bouillaud. 
Brek,  Panum,  Fischer,  and  many  others. 

Anatomical  Characters. — The  air  is  found 
in  the  right  auricle,  often  greatly  distending  it. 
In  the  whole  right  side  of  the  heart  it  is  usual 
to  find  a frothy  mixture  of  blood  and  air.  Bub- 
bles of  air  are  also  found  in  the  pulmonary 
artery,  even  in  some  cases  in  the  smaller  sub- 
divisions. 

Pathology. — The  result  of  the  investigations 
respecting  the  entrance  of  air  into  veins  may  be 
summed  up  briefly  as  follows 

1.  Amount  of  Air  necessary  to  Cause 
Death. — This  varies  with  the  size  of  the  anima 


1732  VEINS.  ENTRANCE  OF  AIR  INTO. 


experimented  on,  and  tho  mode  of  injection  of 
the  air.  A small  animal  requires  a smaller 
amount  of  air  to  cause  deatli  than  a large  one. 
If  slowly  injected,  enormous  quantities  may  be 
pumped  into  the  veins  with  impunity;  while  a 
quantity  sufficient  to  fill  the  auricle,  injected 
suddenly,  is  certainly  fatal.  Recovery  may  take 
place  after  the  occurrence  of  very  serious  symp- 
toms, and  on  tho  other  hand  death  may  occur 
after  an  interval  of  some  hours  or  even  days. 

2.  Causes  of  the  Spontaneous  Entry  of  Air 
into  a Wounded  Vein. — In  inspiration  the  di- 
minished pressure  within  the  thorax  causes  just 
the  same  tendency  for  the  blood  in  the  large 
veins  at  the  root  of  the  neck  and  the  axilla  to 
rush  into  the  right  auricle,  as  there  is  for  the  air 
to  enter  the  lungs  by  the  trachea.  This  aspira- 
tory  force  does  not  extend  beyond  the  veins 
mentioned,  and  the  region  in  which  they  lie  is 
often  called  ‘ the  dangerous  region.’  If  the  vein 
be  completely  divided,  its  lax  walls  fall  together, 
and  thus  offer  a valve-like  resistance  to  the  en- 
trance of  air  ; but  if  in  any  way  the  opening  be 
kept  patent,  air  will  rush  in  at  each  inspiration. 
The  opening  may  be  kept  patent  by  a diseased 
condition  of  the  walls  of  the  vein,  as  when  it 
passes  through  a tumour,  or  is  imbedded  in  in- 
flammatory products ; or  the  surgeon  may  pull 
open  a half-divided  vein  by  traction  on  the  parts 
he  may  be  removing ; or  the  aperture  may  be  cir- 
cular, as  when  a small  piece  is  cut  out  of  the  wall 
of  the  vein,  or  a branch  is  cut  off  close  to  the  main 
trunk.  The  external  jugular,  if  divided  low  in 
the  neck,  remains  open,  on  account  of  its  connec- 
tion with  the  cervical  fascia.  Gas  formed  in  the 
uterus,  as  the  result  of  decomposition  of  clots 
left  in  its  cavity  after  labour,  is  said  in  some 
rare  cases  to  have  got  up  sufficient  pressure  to 
force  its  way  in  at  the  open  mouths  of  tho  pla- 
cental veins,  and  thus  cause  death. 

Symptoms. — As  the  air  enters  the  opening 
it  gives  rise  to  a noise  variously  described  as 
hissing,  whistling,  or  lapping.  If  the  patient 
be  not  under  tho  influence  of  an  anaesthetic, 
he  cries  out  that  he  is  dying,  or  makes  use 
of  some  expression  indicative  of  great  dis- 
tress. He  becomes  immediately  pale  and  faint. 
There  is  intense  anxiety,  with  the  most  severe 
dyspncea.  The  dyspnoea  is  purely  cardiac  in 
origin,  the  air  entering  the  lungs  freely,  with 
violent  and  hurried  inspirations.  The  sense  of 
want  of  breath  is  due  to  an  interruption  of  the 
flow  of  blood  through  the  lungs.  The  pupils 
are  usually  widely  dilated.  Although  the  pa- 
tient is  pale  and  faint,  the  action  of  the  heart 
may  at  first  be  felt  through  the  chest-walls  to 
be  violent  and  irregular,  and  it  is  said  that  on 
auscultation  a peculiar  churning  sound  may  be 
heard.  The  pulse  rapidly  becomes  weak.  Con- 
vulsions have  occurred  in  some  cases,  of  a tetanic 
character;  and  in  some  violent  coughing  has  also 
been  noted.  If  a large  quantity  of  air  has  entered, 
death  may  be  almost  instantaneous.  If  a small 
quantity  only  has  been  sucked  in,  the  patient 
may  recover,  sometimes  after  some  hours  or 
days  of  distress;  and  occasionally  a fatal  termi- 
nation may  take  place  a considerable  time  after 
the  accident.  Greene  (Amur.  Jour,  of  Med. 
Science,  xciii.  p.  38)  has  collected  68  cases. 
Amongst  these  24  died  almost  immediately ; 


others  died  from  three  hours  to  seven  days  after 
the  accident.  In  the  cases  that  survived  some 
days  bronchitis  supervened,  and  possibly  the 
entrance  of  air  may  not  have  been  the  real  cause 
of  death. 

There  can  be  no  doubt  that  death  results  from 
arrest  of  the  pulmonary  circulation.  It  is  not  from 
paralysis  of  the  heart,  as  some  have  said,  for  the 
cardiac  action  continues  long  after  the  air  has  en- 
tered. The  heart  is  constructed  to  pump  onwards 
a fluid  which,  like  all  other  fluids,  is  incompres- 
sible. If  tiie  right  ventricle  be  filled  with  air 
or  a frothy  mixture  of  air  and  blood,  a consider- 
able part  of  the  force  of  its  contraction  will  be 
wasted  in  merely  compressing  the  air  instead  of 
driving  it  on.  This,  however,  is  but  a small 
factor  in  the  arrest  of  the  circulation  ; the  chief 
cause  being  that  the  air,  or  frothy  mixture  of 
blood  and  air,  fails  to  work  the  valves.  For  the 
pulmonary  valves  to  act  it  is  necessary  that  the 
artery  should  be  filled  and  its  coats  stretched  ; 
but  here  we  have  the  vessel  only  partly  filled, 
and  that  with  an  elastic  gas  instead  of  an  ineom- 
pressiblefluid.  Itseoats  are  but  slightly  stretched, 
and  the  valves  probably  lie  flat  against  them, 
and  are  not  closed  by  the  current  of  air  or  froth 
regurgitating  after  the  ventricular  contraction 
has  ceased.  The  tricuspid  valve  probably  also 
fails  to  act.  The  want  of  blood  in  the  lungs 
causes  the  sense  of  dyspnoea ; and  the  flow  through 
the  lungs  having  ceased,  the  left  side  of  the 
heart  will  become  empty,  and  no  blood  reaching 
the  brain,  faintness,  followed  quickly  by  death, 
naturally  occurs.  Supposing  the  patient  to 
recover,  the  air  which  may  have  got  into  the 
circulation,  is  absorbed  by  the  blood. 

Treatment.— The  accidental  entrance  of  air 
into  the  veins  must  be  prevented  by  careful 
operating.  If  a vein  can  be  seen  to  be  in  danger  it 
is  advisable  to  compress  it  on  the  proximal  side. 
If  it  is  necessary  to  divide  it,  a double  ligature 
must  first  be  applied.  If  the  symptoms  described 
should  appear,  a finger  must  be  at  once  placed 
upon  the  wounded  vein.  The  indications  then  are : 
1.  To  get  the  air  out  of  the  auricle ; 2.  To  fill  the 
auricle  with  blood ; 3.  To  keep  up  a supply  of 
blood  to  the  brain.  To  empty  the  auricle  the  finger 
must  be  kept  on  the  opening  in  the  vein  during 
inspiration,  but  removed  during  expiration,  and 
at  the  same  time  the  chest  should  be  forcibly 
compressed.  By  these  means  frothy  blood  and 
air  may  be  made  to  escape  in  considerable  quan- 
tities from  the  opening.  This  is  recorded  as 
having  occurred  during  the  violent  expiratory 
efforts  of  coughing  that  sometimes  accompany 
this  accident.  To  try  to  suck  out  the  air  by  means 
of  a tube  inserted  (as  has  been  recommended) 
into  the  right  jugular  vein,  would  probably  only 
ensure  the  patient’s  death.  The  auricle  may  be 
filled  with  blood  by  applying  friction  to  the 
limbs  in  an  upward  direction.  In  order  to  ensure 
the  flow  to  the  brain  of  what  little  blood  may  be 
leaving  tho  left  side  of  the  heart,  it  has  been 
recommended  to  compress  the  abdominal  aorta 
and  the  subclavian  arteries.  The  veins  being 
uncompressed  can  empty  themselves  into  the 
auricle,  which  thus  may  be  filled  with  sufficient 
blood  to  work  the  valves,  and  so  restore  the  cir- 
culation. Should  the  respiration  fail,  it  is  advi- 
sable to  try  artificial  respiration ; but  if  the  case 


VEINS,  ENTRANCE  OF  AIR  INTO, 
reaches  that  stage,  there  can  be  but  little  hope  of 
recovery,  as  it  is  not  want  of  air  in  the  lungs 
that  causes  death,  but  want  of  blood  in  the  pul- 
monary vessels.  Those  who  are  interested  in  the 
subject  will  find  references  to  the-  literature  in 
Fischer’s  lecture,  1 Ueber  die  Gefahren  des  Luft- 
eintritts  in  die  Venen  wahrend  einer  Operation,’ 
Velkmanns  Sammlung  Klinisclier  Vortragc,  Series 
v.  No.  113.  Marcus  Beck. 

VENEREAL  DISEASES.  — A common 
term  for  all  forms  of  contagious  disease  usually 
contracted  and  transmitted  by  impure  sexual 
intercourse.  There  are  three  principal  kinds  of 
venereal  disease ; namely,  gonorrhea,  syphilis, 
and  the  local  venereal  sore,  or  chancre.  See 
Gonorrhcea  ; Syphilis  ; and  Venereal  Sore. 

VENEREAL  SORE. — Synon.  : Local,  soft, 
uon-infecting  Chancre  or  Sore;  Fr.  Chancre 
Mou ; Ger.  Schanlcer.  Clerc  employed  the  term 
clancroide,  which,  modified  into  ‘ chancroid,’  has 
been  adopted  by  many  American  authors. 

Definition. — A virulent,  local,  contagious 
lleer,  communicable  only  by  contact  of  its  pus 
vith  a breach  of  surface. 

./Etiology. — The  setiology  of  the  local  chancre 
Is  still  a subject  of  dispute.  Those  who  are  now 
known  as  unicists  maintain  that  it  is  connected 
with  syphilis.  Others  believe  that  it  may  be 
caused  by  the  products  of  simple  inflammation. 
But  the  most  generally  received  opinion,  and 
that  which  is  most  in  accordance  with  the  pre- 
sent state  of  our  knowledge  on  the  subject,  is 
that  the  local  or  soft  chancre  is  due  to  a virus, 
distinct  from  that  of  syphilis ; that  it  never 
gives  rise  to  any  special  constitutional  symp- 
toms ; and  that  its  effects  are  limited  to  the 
neighbourhood  of  the  sore  itself,  and  the  nearest 
lymphatic  glands.  It  is  from  this  so-called 
dualist  point  of  view  that  the  present  article  is 
vritten. 

Contagion. — The  local  chancre,  like  syphilis, 
may  be  communicated  by'  direct  or  by  mediate 
contagion,  but  is  of  course  never  transmitted  by 
inheritance.  Syphilis  is  not  infrequently  con- 
veyed in  various  way’s  independent  of  sexual 
intercourse  {see  Syphilis).  The  local  chancre,  on 
the  other  hand,  is  very  rarely  other  than  a 
venereal  disorder ; chiefly  because,  not  being  part 
of  a general  disease,  it  does  not  give  rise  to  con- 
tagious lesions  on  distant  parts  of  the  body. 

The  disease  may  also  be  conveyed  from  one 
person  to  a third,  through  the  medium  of  one 
whose  cutaneous  or  mucous  surfaco  happens  to 
he  intact,  and  who  thus  escapes  inoculation. 

One  attack  of  the  local  chancre,  unlike 
syphilis,  affords  no  protection  for  the  future  ; 
hence  the  same  person  may  suffer  as  often  as  he 
exposes  himself  to  contagion. 

Description. — When  ebanerous  pus  is  inocu- 
lated artificially,  the  puncture  within  twenty-four 
hours  becomes  surrounded  by  a faint  red  blush  ; 
on  the  second  day  the  redness  extends,  and  the 
site  of  inoculation  becomes  swollen.  On  the  third 
day  a vosicle  appears,  and  rapidly  becomes  a 
pustule.  About  the  fifth  day  the  pustule  bursts, 
leaving  a circular  ulcer  with  well-defined,  sharply 
cut  edges  ; the  surface  of  the  ulcer  is  uneven 
and  spongy,  presenting  a worm-eaten  appear- 


VENEREAL  SORE.  1733 

ance  ; and  tho  base  is  soft  and  surrounded  by  a 
pink  areola. 

Varieties. — In  the  most  characteristic  form  of 
sore  the  ulceration  involves  the  whole  thickness 
of  the  skin  or  mucous  membrane,  and  its  cha- 
racters are  essentially  those  of  the  typical  form 
produced  by  experimental  inoculation.  The  edges 
of  the  sore  are  loose  and  often  undermined.  In 
another  variety  the  characters  are  ill-marked. 
The  sore  is  superficial,  the  edges  are  not  under- 
mined, and  tho  discharge  is  thinner  and  less- 
abundant  than  in  the  typical  sore.  What  has 
been  termed  a third  variety  results  from  exu- 
berant growth.  The  surface  is  raised  above  the 
surrounding  parts  by  the  development  of  promi- 
nent granulations;  hence  the  term  ‘fungating 
sore,’  or  chancre  vegetante  of  French  writers. 

In  all  varieties  of  local  chancre  the  bas9  is 
supple  unless  inflammation  is  present,  in  which 
case  there  is  more  or  less  thickening  of  the  sur- 
rounding parts.  The  discharge  is  readily’  auto- 
inoeulable,  hence  a plurality  of  sores  is  very’ 
common. 

The  seat  of  the  local  chancre  is  nearly  always 
the  genital  organs  or  their  immediate  neighbour- 
hood. A primary  sore  on  the  body  of  the  penis 
is  much  more  likely  to  be  syphilitic  than  local. 

The  form  of  the  local  chancre  varies  in  some 
degree  according  to  its  position.  Thus,  in  the 
furrow  behind  the  glans  penis,  the  sore  i3 
elongated;  about  the  frsenum,  in  the  folds  of 
mucous  membrane  around  the  anus,  and  about 
the  female  genitals  it  is  fissure-like.  Again, 
when  exposed  to  the  air  and  neglected,  it  may 
become  covered  by  a scab.  If  ehancrous  pus 
gain  entrance  to  a follicle  (follicular  chancre) 
the  latter  may  become  distended,  and  tempo- 
rarily simulate  a small  abscess. 

As  regards  sice,  uncomplicated  local  chancres 
do  not  usually  exceed  half  an  inch  in  diameter, 
unless  two  or  more  run  together,  in  which  case 
they  form  a large  irregular  ulcer.  Such  con- 
fluent chancres  are  more  common  in  women. 

Course,  Duration,  and  Terminations. — The 
regular  course  of  the  local  chancre  usually  occu- 
pies from  four  to  eight  weeks ; but  the  super- 
ficial form  may  heal  in  a few  days.  This  course 
is  divided  into  three  stages:  (1)  an  increasing, 
(2)  a stationary,  and  (3)  a healing  stage.  Tho 
length  of  each  is  liable  to  vary  from  many  causes. 
Roughly  speaking,  however,  it  may  bo  said  that 
the  first  period,  during  which  the  sore  sensibly 
increases  in  6ize,  occupies  from  a week  to  a fort- 
night; that  the  second  lasts  about  a fortnight; 
and  that  at  the  end  of  from  three  to  five  weeks, 
the  stage  of  repair  is  reached. 

By  appropriate  treatment  the  duration  can 
generally  be  greatly  shortened.  It  is  also  much 
influenced  by  the  position  of  the  sore.  Thus,  at 
the  orifice  of  the  prepuce  or  urethra,  the  irrita- 
tion of  the  urine  retards  healing,  and  phimosis 
acts  in  a similarmanner.  Chancres  of  the  frgenum, 
again,  often  continue  to  spread  until  they  have 
destroyed  it.  In  fact,  the  more  mobile  and  ex- 
posed to  irritation  is  the  part,  and  the  greater 
the  difficulty  of  keeping  the  dressings  in  place, 
the  longer  will  be  the  duration  of  the  sore. 

If  the  syphilitic  poison  have  been  inoculated 
as  well  as  ehancrous  pus  — a frequent  occurrence 
— the  course  of  events  will  remain  uninfluenced. 


1734  VENEBE 

until  the  incubation-period  of  syphilis  has 
elapsed;  when  if  the  sore  be  still  unhealed,  it  will 
gradually  change  in  appearance  by  the  develop- 
ment of  induration  at  its  base,  until  finally  it 
assumes  the  characters  of  the  initial  manifesta- 
tion ( see  Syphilis).  If,  on  the  other  hand,  the 
local  sore  has  healed  before  the  end  of  the 
period  of  incubation  proper  to  syphilis,  the  scar 
will  become  indurated,  and  erosion  or  ulceration 
will  probably,  though  not  necessarily,  follow. 

Complications. — The  less  serious  complica- 
tions of  the  local  sore  include  inflammation, 
'phimosis,  and  •paraphimosis . 

Bkagedcena.  — This  graver  complication  of 
chancre  may  be  either  acute  or  chronic;  and 
may  attack  the  original  sore,  or  the  consecutive 
bubo,  or  both. 

In  a typical  case  of  acute  sloughing  phagedama 
the  patient  is  usually  much  depressed.  He  soon 
becomes  feverish,  with  a dry,  brown  tongue, 
quick  pulse,  and  other  signs  of  constitutional  dis- 
turbance. The  discharge  from  the  sore  dimi- 
nishes, is  thin,  sanious  and  shreddy,  and  very 
offensive.  The  margins  of  the  ulcer  are  puffy 
and  livid  at  first,  but  soon  become  black  and 
ragged,  presenting  a ‘ gnawed  ’ appearance.  As 
the  process  goes  on  the  dead  tissues  separate  in 
sloughs,  which  vary  in  size  according  to  the 
rapidity  of  the  destruction.  In  the  most  severe 
cases  necrosis  is  very  rapid,  and  attended  by 
excruciating  pain.  The  wholo  of  the  genital 
organs  in  either  sex  may  thus  be  destroyed; 
while,  if  the  groin  be  the  seat  of  phagedsena,  the 
great  vessels  and  nerves  are  quickly  exposed  at 
the  bottom  of  a deep  ragged  cavity.  If  the  pro- 
cess be  not  soon  checked,  death  may  occur  from 
haemorrhage,  from  exhaustion,  or  from  some 
acute  intercurrent  inflammation. 

The  course  which  has  just  been  described  is 
that  of  the  worst  form  of  phagedsena,  which  is 
now  fortunately  rare ; but  less  severe  examples, 
ranging  in  various  degrees  between  that  de- 
scribed and  those  where  a sore  simply  becomes 
larger,  inclined  to  spread,  looks  unhealthy  and 
has  ‘ gnawed  ’ edges,  are  common  enough  in  ve- 
nereal practice. 

In  the  chronic  form  of  phagedsena  (serpiginous 
ulceration)  the  morbid  process  is  much  less  ac- 
tive, and  is  not  usually  attended  by  much  pain  or 
constitutional  disturbance,  at  least  at  first.  The 
sore  spreads  gradually,  but  the  tendency  is  rather 
to  extend  widely  and  superficially  than  deeply. 
The  groin  is  the  most  usual  seat  of  serpiginous 
ulceration,  whence  it  may  extend  upwards  along 
the  abdominal  wall  or  down  the  thigh,  laying 
bare  the  deep  fascia,  and  dissecting  out  the 
superficial  vessels  and  nerves.  It  often  also 
undermines  the  skin  extensively,  before  destroy- 
ing it ; hence  the  loose  and  irregular  margins  of 
the  ulcer  are  detached  from  the  deeper  parts  for 


IAL  SOKE. 

a considerable  distance.  The  duration  of  this 
form  of  ulceration  is  very  variable.  It  often 
lasts  for  months  and  sometimes  for  years;  at 
one  time  appearing  to  be  stationary,  while  at 
others  it  spreads  in  one  direction  and  heals  in 
another.  After  a time  the  patient’s  health  suf- 
fers more  or  less  severely,  and  finally  he  may 
become  exhausted  by  the  constant  and  prolonged 
irritation  and  discharge.  If  he  recover,  he  may 
be  permanently  crippled  by  the  contraction  of 
the  resulting  cicatrices. 

The  causes  of  phagedsena  are  not  yet  fully  un- 
derstood. Some  of  the  worst  cases  no  doubt  occur 
in  persons  whose  constitutions  have  been  broken 
by  debauchery,  syphilis,  starvation,  &c.,  but  in 
other  instances  the  patients  are,  to  all  appear- 
ance, healthy. 

Bubo. — This  complication,  which  is  much  less 
frequent  in  women  than  in  men,  is  said  to  occur 
in  about  one-third  of  the  total  number  of  cases 
of  local  chancre,  but  this  is  probably  too  high 
an  estimate.  It  may  be  either  simple  or  virulent, 
the  former  being  most  common. 

Simple  or  sympathetic  bubo  arises  from  ordi- 
nary irritation,  and  is  similar  to  that  caused  by 
simple  irritation  of  any  other  kind. 

Virulent  ( chancrous ) bubo  is  due  to  the  con- 
veyance of  chancrous  matter  from  the  sore  along 
the  lymphatic  vessels  to  the  gland. 

Bubon  d’emblee. — This  term  has  been  applied 
to  a variety  of  bubo,  believed  by  some  authors  to 
result  from  the  absorption  of  chancrous  pus  and 
its  conveyance  to  a lymphatic  gland  without  the 
production  of  any  lesion  at  the  point  ot  inocu- 
lation. The  existence  of  such  a bubo  is  not  yet 
established  beyond  doubt.  Sec  Bubo. 

Lymphangitis-  This,  like  bubo,  maybe  simple 
or  virulent,  but  is  a less  frequent  complication 
of  the  local  chancre.  Bubo  of  either  kind  may, 
and  frequently  does*  exist  without  any  percep- 
tible change  in  the  lymphatics  leading  to  it ; but 
when  the  vessels  are  affected  the  glands  are  usu- 
ally inflamed  also.  The  thickened  lymphatics 
can  be  felt  as  tender  and  often  irregular  cords, 
and  their  course  is  generally  marked  out  by  red 
streaks  along  the  surface. 

Simple  lymphangitis  may  end  in  resolution,  or 
one  or  more  abscesses  may  form  along  the  course 
of  the  vessel.  The  virulent  form  probably  al- 
ways goes  on  to  suppuration,  and  the  resulting 
sores  become  chancres  in  every  respect  similar 
to  the  original  one. 

Diagnosis. — The  local  chancre  in  its  ordinary 
forms  is  recognised  by  the  characters  which  have 
been  already  mentioned,  and  which  are  recapitu- 
lated in  the  following  table,  where  also  they  are 
contrasted  with  those  of  the  initial  manifestation 
of  syphilis — the  lesion  to  which  by  far  the  most 
importance  attaches  from  a diagnostic  point  o£ 
view. 


VENEREAL  SORE. 


Local  Chancre. 

1.  A local  and  nearly  always  venereal  dis- 
order, produced  only  liy  the  pus  of  a similar 
nicer. 

2.  No  period  of  incubation.  Irritation  begins 
within  a few  hours  after  contagion. 

3.  Begins  as  a pustule  which  soon  bursts, 
leaving  an  excavated  ulcer  with  sharply-cut, 
loose,  often  undermined  edges,  and  an  irregular 
spongy  floor  of  a dirty  yellow  colour. 

4.  Base  supple  unless  inflamed,  in  which  case 
it  becomes  hard  like  that  of  a boil ; the  hard- 
ness is  diffused,  resistent  to  the  touch,  ill-de- 
fined, and  fades  gradually  into  tho  surrounding 
tissues. 


6.  Discharge  abundant,  purulent,  and  freely 
inoculable  on  the  bearer  as  well  as  on  others. 

6.  Inoeulability  on  certain  animals  possible. 

7.  Usually  multiple. 

8.  Very  rarely  seen  far  away  from  the  genital 
organs. 

9.  Course  acute,  and  attended  by  pain. 

1 0.  Duration  greatly  influenced  by  local  treat- 
ment. 

11.  Inflammation  and  phagedaena  not  un- 
common. 

12.  Glands  remain  unaffected  or  become 
acutely  inflamed.  Suppuration  common.  Bubo 
may  be  simple  or  virulent.  Only  one  or  two 
glands  suffer. 

13.  Never  causes  general  infection  of  the 
system. 

14.  Repeated  attacks  common. 


While  the  characters  given  in  the  foregoing 
table  are  amply  sufficient  for  the  diagnosis  of 
the  two  lesions  in  uncomplicated  cases,  it  must 
be  mentioned  that  the  appearance  of  either  sore 
may  be  altered  in  various  ways,  for  example,  by 
neglect  of  cleanliness,  or'  by  the  application  of 
irritants.  Thus  the  local  chancre  may  develop 
an  amount  of  inflammatory  thickening  which 
cannot  for  a time  be  diagnosed  from  that  pro- 
duced by  similar  causes  in  the  syphilitic  initial 
lesion;  for  the  specific  induration  may  become 
masked  by  inflammation.  In  such  cases  a posi- 
tive diagnosis  must  be  postponed  until  the  irri- 
tation has  subsided.  Again,  even  if  a patient 
present  himself  with  a typical  local  chancre,  it  is 
of  course  not  certain  that  the  syphilitic  poison 
has  not  been  imbibed  as  well ; and  the  incuba- 
tion period  of  syphilis  must  be  allowed  to  elapse 
before  the  patient  can  be  assured  that  his  trouble 
is  only  local.  Further,  as  regards  the  two  most 
characteristic  signs  of  primary  syphilis,  namely, 
induration  of  the  base  of  the  sore,  and  indolent 
multiple  enlargement  of  tho  nearest  lymphatic 
glands,  these  are  merely  signs  of  a general  dis- 
ease, and  one  or  other  may  be  ill-marked,  or 
even  absent,  or  at  least  inappreciable.  Then, 
as  regards  number — the  initial  lesion  of  syphilis 
may  be  multiple  if  several  abrasions  happen  to 
be  inoculated  ; and  the  local  chancre  may  be 
single,  especially  in  persons  of  careful  and  cleanly 
habits.  Inflammatory  action  also  may  mask  the 
usually  separate  indolent  glands ; but  apart  from 


1733 

Initial  Manifestation  of  Syphilis. 

1.  The  first  sign  of  a general  and  not  neces- 
sarily venereal  disease:  it  may  be  produced  by 
the  secretion  of  any  syphilitic  lesion  or  by  the 
blood  during  the  earlier  stages  of  the  disease. 

2.  Always  a period  of  incubation,  which  ave- 
rages 24  days. 

3.  Begins  as  a slightly  elevated  papule  or 
erosion.  Ulceration  may  be  absent  throughout. 
Edges  raised,  adherent,  and  rounded.  Surface 
smooth  and  often  of  a ham-red  colour. 

4.  Base  more  or  less  indurated.  The  hardness 
is  sharply  circumscribed,  somewhat  elastic  to  the 
touch,  and  independent  of  acute  inflammatory 
action;  it  varies  much  in  amount,  being  some- 
times superficial  and  scanty,  and  feeling  like  a 
thin  layer  of  parchment  or  paper  ; sometimes 
abundant,  and  feeling  like  a mass  of  cartilage. 

5.  Discharge  scanty,  serous,  and  not  auto- 
inoculable  unless  suppuration  be  produced. 

6.  Inoeulability  on  animals  doubtful. 

7.  Usually  single. 

8.  Not  very  infrequent  on  the  lips  or  fingers, 
and  on  the  breast  in  women. 

9.  Course  chronic.  Rain  frequently  absent. 

10.  Duration  usually'  depends  on  general  spe- 
cific treatment. 

11.  Inflammation  and  phagedama  rare. 

12.  Adenopathy  constant,  indolent,  and  nearly 
always  multiple.  Suppuration  rare.  Bubo  never 
virulent. 

% 

13.  Is  followed  by  constitutional  symptoms. 

14.  A second  attack  rare. 


this,  sometimes  only  one  or  two  glands  can  be 
felt.  This  is  most  often  the  case  when  the 
glands  have  been  spoiled  by  previous  inflamma- 
tion. Absence  of  enlargement  also  appears  to  be 
sometimes  due  to  the  pressure  of  a truss.  In 
very  fat  people  again  the  glands  cannot  always 
be  felt. 

Thus,  in  making  a diagnosis,  not  one  but  allot 
the  signs  that  may  be  present,  together  with  the 
history  of  the  case,  must  be  taken  into  conside- 
ration ; and  if  the  diagnosis  still  remains  doubt- 
ful, the  case  must  be  watched  until  conclusive 
evidence  is  forthcoming. 

Auto-inoculation  is  sometimes  of  service  in 
diagnosis,  but  in  the  present  instance  would 
not  be  of  much  value ; for  even  if  a typical 
local  chancre  were  the  result,  syphilis  could 
not  be  excluded  until  the  incubation  period  had 
elapsed. 

When  an  immediate  diagnosis  is  imperative, 
the  so-called  confrontation , or  comparison  of  the 
patient  with  the  source  of  his  disease,  may  set 
the  question  at  rest ; but  many  precautions  are 
necessary  in  drawing  conclusions  from  such  evi- 
dence. 

Ulcerating  syphilides,  especially  mucous 
patches  of  the  female  genitals,  occasionally  re- 
semble the  local  chancre,  but  the  presence  of 
other  signs  of  syphilis  would  lead  to  a correct 
diagnosis. 

Gummata  about  the  genital  region,  in  both 
sexes,  after  breaking  down,  sometimes  leavo 


VENEREAL  SORE. 


1736 

ulcers  which  have  a remarkably  close  resemblance 
to  local  chancres. 

Besides  syphilitic  affections,  there  are  a few 
others  which  require  to  be  mentioned  in  con- 
nection with  the  diagnosis  of  the  local  chancre. 
Herpes  is  characterised  by  vesicles,  or  small  and 
very  superficial  erosions  grouped  together  on  an 
inflamed  area.  Itching  or  smarting  also  often 
precedes  an  attack  of  herpes,  and  there  is  fre- 
quently a history  of  previous  attacks,  which, 
again,  are  often  independent  of  any  suspicious 
sexual  exposure,  and  are  liable  to  recur  at  regu- 
lar intervals,  or  in  connection  with  digestive  dis- 
turbance. Herpes  also  disappears  in  a few  days 
under  measures  of  simple  cleanliness,  and  the 
discharge  is  not  auto-inoculable. 

Simple  abrasions  are  irregular  in  form,  are 
usually  noticed  by  the  patient  at  the  time  of 
their  production  or  very  soon  afterwards,  and 
heal  readily  in  a few  days  if  they  are  not  irri- 
tated. Both  herpes  and  abrasions,  however, 
as  well  as  the  erosions  due  to  balano-posthitis, 
may,  under  irritation  of  various  kinds,  become 
suppurating  and  inflamed  ulcers,  which  for  a 
time  are  very  difficult  to  distinguish  from  local 
chancres. 

When  phimosis  prevents  exposure  of  the  parts, 
a discharge  from  beneath  the  prepuce  may  be 
ciue  to  several  other  causes  besides  the  local 
chancre,  for  example,  syphilis,  gonorrhoea,  bala- 
nitis, or  warts.  If  the  local  chancre  be  present, 
its  site  is  usually  indicated  by  the  presence  of  a 
tender  spot  in  that  situation,  and  pressure  often 
causes  a slight  oozing  of  blood.  Consecutive 
sores  also  quickly  appear  at  the  margin  of  the 
prepuce.  In  the  case  of  syphilis,  the  presence 
of  induration  and  the  multiple  indolent  enlarge- 
ment of  the  inguinal  glands  will  usually  render 
the  diagnosis  clear.  In  gonorrhoea,  soreness  of 
the  deeper  urethra,  scalding  during  micturition, 
the  presence  of  chordee  and  other  signs  of  ureth- 
ritis, and  the  absence  of  localised  tenderness 
beneath  the  swollen  prepuce,  are  points  that  will 
usually  determine  the  nature  of  the  case.  In 
balanitis  there  will  be  an  absence  of  circum- 
scribed tenderness  and  of  signs  of  urethritis. 
Warts  can  he  felt  through  the  prepuce,  and  a 
portion  of  the  growth  can  usually  be  seen  by 
putting  the  parts  on  the  stretch. 

In  all  these  cases  also,  when  the  source  of  the 
discharge  is  doubtful,  auto-inoculation  may  be 
practised,  though  it  is  rarely  necessary. 

Prognosis. — The  prognosis  of  the  uncompli- 
cated local  chancre  is  always  favourable.  If  any 
complication  arise,  the  prognosis  will  of  course 
depend  upon  the  nature  and  severity  of  the 
complication. 

Treatment. —The  treatment  of  the  local 
chancre  consists  chiefly  in  the  employment  of 
local  remedies;  the  general  treatment  being 
directed,  on  ordinary  principles,  to  the  mainten- 
ance of  the  patient’s  health,  by  tonics,  regulation 
of  the  diet,  moderation  in,  or  abstinence  from, 
alcohol,  and  as  much  rest  as  possible,  in  order  to 
diminish  the  risk  of  complications. 

A local  chancre  of  only  a few  days’  duration 
can  generally  he  destroyed  by  one  thorough 
application  of  heat  or  caustic.  The  advantages 
of  such  a mode  of  procedure  are  that  (a)  con- 
secutive inoculation,  and  consequently  multiplicity 


of  sores,  is  prevented  ; (J)  the  risk  of  bubo  and 
of  other  complications  is  much  diminished;  and 
(c)  the  duration  is  greatly  shortened. 

When  the  surface  is  large,  or  when  the  seres 
are  numerous,  destructive  measures  should  only 
be  employed  when  milder  ones  have  failed. 

The  thermo-cautery  is  the  most  convenient  form 
of  actual  cautery.  For  the  treatment  of  small 
sores,  caustics  are  least  alarming  to  the  patient; 
strong  nitric  acid,  and  the  mixture  of  charcoal 
and  sulphuric  acid  commonly  known  as  ‘Ili cord's 
paste,’  are  the  most  suitable  forms.  Before 
using  either  caustic  or  cautery  the  following 
two  points  should  he  borne  in  mind,  viz. : — 
1.  No  sore  should  over  he  cauterised  unless  the 
whole  of  the  diseased  surface  can  he  acted  on.  2. 
The  surrounding  parts  must  he  cleansed  with 
carbolic  lotion  or  other  disinfectant,  lest  sub- 
sequent re-inoculation  occur  from  any  discharge 
that  may  be  present. 

When  caustics  are  not  used,  the  Lest  applica- 
tion is  iodoform,  of  which  the  powdered  crystals 
may  he  sprinkled  on  the  sore  by  means  of  a 
quill,  or  applied  with  a moistened  camel’s-hair 
brush  twice  or  thrice  daily,  according  to  the 
amount  of  discharge.  The  sore  should  then  be 
covered  with  a piece  of  lint  or  wool,  and  if  the 
dressing  cannot  be  kept  in  place  by  the  natural 
conformation  of  the  parts,  a piece  of  oiled-silk  and 
a narrow  strip  of  bandage  or  plaster  should  he 
applied.  Iodoform  may  also  he  applied  as  an 
ointment  with  vaseline,  or  with  glycerine,  or  an 
ethereal  solution  may  he  painted  on  the  part,  a 
thin  coating  of  iodoform  being  left  after  the  eva- 
poration of  the  ether. 

If  iodoform  is  not  used,  a lotion  of  sulphate  of 
zinc,  lead,  tartarated  iron,  or  nitrate  of  silver 
may  be  applied,  according  to  the  state  of  the 
ulcer.  Whatever  dressing  is  employed,  care 
must  always  be  taken  to  change  it  frequently, 
and  to  arrange  it  so  that  opposed  surfaces  aro 
kept  apart.  Chancres  beneath  a phimosed  pre- 
puce must  he  treated  by  frequent  injections,  with 
a syringe  having  a long  nozzle,  of  carbolic  lotion 
(1  in  40),  or  acetate  of  lead.  Any  of  the  sores 
that  are  within  reach  should  be  dressed  with 
iodoform,  and  a piece  of  absorbent  wool  placed 
within  the  preputial  orifice. 

Treatment  of  Complications.-InfamedL  chancres 
should  be  treated  by  keeping  the  patient  at  rest, 
on  simple  diet ; and  by  the  administration  of  a 
purge,  and  the  application  of  lead  and  opium 
lotion  or  some  other  soothing  dressing.  In 
phimosis,  if  the  swelling  is  so  great  as  to  prevent 
the  use  of  the  syringe,  or  if  sloughing  is  threat- 
ened, the  prepuce  must  be  slit  up  or  removed 
altogether,  and  the  case  treated  according  to  the 
directions  given  for  the  treatment  of  phagedaena. 

If  in  paraphimosis  the  prepuce  be  naturally 
too  narrow,  or  if  strangulation  occur,  reduction 
should  be  effected. 

Phagedena. — On  the  first  appearance  of  signs 
of  acute  phagedaena,  the  affected  part  should  be 
immersed  for  nine  or  ten  hours  a day  in  water, 
kept  as  nearly  as  possible  at  9S°  Fahr.  This 
can  be  easily  accomplished  by  keeping  the  pa- 
tient in  a hip  bath,  and  alternately  adding  and 
removing  small  quantities  of  water,  so  that  the 
requisite  temperature  is  maintained.  Care  must 
of  course  he  taken  to  protect  the  patient  from 


VEfSEREAL  SOEE. 

roid,  by  placing  the  bath  in  a warm  room,  and. 
by  wrapping  the  exposed  parts  of  the  body  in 
blankets.  This  plan  has  succeeded  well  at  the 
Male  Lock  Hospital ; 1 and  if  it  be  adopted  at  an 
early  period  the  sore  often  becomes  healthy  in 
a few  days  ; immersion,  however,  should  always 
be  continued  for  at  least  a day  or  two  after 
this  has  occurred,  to  guard  against  relapse.  The 
patient  may  generaliy  be  allowed  to  go  to  bed 
during  the  night,  iodoform  or  some  other  suit- 
able dressing  being  applied  ; but  if  the  diseased 
action  continue  to  extend,  the  duration  of  the 
bath  must  be  prolonged,  or  even  be  made  con- 
tinuous ; but  in  that  case,  as  well  as  in  those 
where  the  groin  is  the  seat  of  the  disease,  a full- 
sized  bath,  in  which  the  patient  can  lie  down, 
will  be  necessary.  In  all  cases  the  whole  of  the 
diseased  surface  must  be  fully  exposed  and  tho- 
roughly submerged. 

If  milder  measures  fail  to  arrest  the  phage- 
dsenic  action,  the  sore  may  be  cauterised.  If  the 
surface  is  large,  the  actual  cautery  will  be  more 
likely  to  succeed  than  chemical  agents. 

If  cauterisation  fail,  as  it  sometimes  does,  or 
if  it  be  thought  unadvisable  to  have  recourse  to 
it,  a lotion  of  tartarated  iron  (10  to  60  grains  to 
the  ounce)  with  extract  of  opium,  is  often  of  the 
greatest  value. 

Haemorrhage  from  a phagedaenie  sore  should 
always  be  checked  as  soon  as  possible.  If  the 
bleeding  is  slight  the  surface  should  be  cleaned, 
and  pellets  of  cotton  wool,  soaked  in  solution  of 
persulphate  of  iron,  pressed  on  each  bleeding 
spot,  and  retained  in  position  by  a bandage 
applied  as  tightly  as  the  patient  can  bear.  In 
severe  cases  the  actual  cautery  may  be  neces- 
sary, and  in  extreme  instances  ligature  of  the 
larger  arterial  trunks  above  the  seat  of  disease 
may  be  required. 

The  general  treatment  of  phagedaena  consists 
in  the  administration  of  good  food,  tonics,  and 
opium  in  sufficient  quantity  to  relieve  pain, 
though  under  the  immersion  plan  of  treatment 
pain  usually  quickly  ceases,  and  little  or  no 
opium  is  required.  Fresh  air  and  good  ventila- 
tion are  also  powerful  aids  to  recovery. 

The  treatment  of  chronic  phagedtena  or  ser- 
piginous rdceration  is  similar  to  that  of  the 
acute  form,  but  of  course  more  time  is  allowed 
for  the  trial  of  palliative  measures#before  having 
recourse  to  the  cautery. 

The  treatment  of  simple  bubo  will  be  found 
under  Buno. 

The  management  of  the  virulent  bubo,  after 
evacuation  of  the  pus,  differs  in  no  respect 
from  that  of  the  local  chancre,  which  has  just 
been  described ; and  the  treatment  here  recom- 
mended for  phagedsena  applies  equally  to  that 
morbid  process,  as  a complication  of  the  local 
chancre,  of  bubo,  or  of  syphilitic  ulcers, 
whether  primary,  secondary,  or  tertiary  ; but  in 
this  latter  case  the  administration  of  mercury  or 
iodine  or  both,  according  to  circumstances,  forms 
an  important  element  in  the  management.  In 
fact,  in  every  case  of  obstinate  phagedsena, 
especially  of  the  chronic  form,  most  careful 
search  should  bo  made  for  signs  or  a history  of 
syphilis;  for,  if  that  taint  be  present,  it  not 
infrequently  happens  that  all  local  applica- 
* See  Lancet,  ilay  24,  1879. 


VENOM,  EFFECTS  OF.  1737 
tions  fail  until  the  constitutional  malady  is 
attacked.  Arthur  Cooper. 

VENESECTION  {vena,  a vein,  and  secto.  1 
cut). — Synon.  ; Bleeding  ; Blood-letting. — Ab- 
straction of  blood,  by  opening  a vein.  See 
Blood,  Abstraction  of. 

VENOM,  Effects  of:  VENOMOUS 

ANIMALS. — Synon.  : Fr.  Animaux  veneneux; 
Ger.  Gif  tig e Thiere. 

Definition. — Animals  which  possess  the  power 
of  secreting  and  ejecting  a poison,  which,  when 
inoculated  in  man  or  other  animals,  produces 
toxic  or  even  fatal  effects. 

Venomous  animals  are  found  in  many  classes 
of  the  animal  kingdom. 

1.  Heptilia. — Eeptilia  furnish  the  most  nu- 
merous and  important  examples  of  venomous 
animals,  and  these  are  limited  almost  entirely 
to  the  order  Ophidia  or  snakes. 

Description. — The  poison-apparatus  of  a snake 
consists  of  a composite  racemose  gland,  situated 
in  the  temporal  region,  secreting  a clear,  slightly 
viscid  fluid,  which  is  poured  through  a duct  into 
a grooved  fang  situated  on  a movable  maxillary 
bone. 

The  fangs  are  longer,  more  curved,  more 
movable,  and  more  formidable  in  viperino  than 
in  colubrine  snakes. 

Snake-poison  is  a clear,  slightly  viscid  fluid, 
very  deadly  in  its  action,  probably  more  active 
in  some  snakes,  quantity  for  quantity,  than  in 
others,  and  varying  in  activity  in  the  same 
species  or  individual,  according  to  season,  tem- 
perature, and  state  of  health.  It  acts  most 
rapidly  when  injected  into  the  blood;  but  it  can 
be  absorbed  through  mucous  and  serous  mem- 
branes, as  seen  by  its  poisonous  effects  when 
applied  to  the  conjunctiva,  the  stomach,  and 
the  peritoneum.  It  may  neither  be  applied  to 
the  lips  nor  taken  into  the  stomach  with  im- 
punity ; and  sucking  a snake-bite  is  by  no  means 
free  from  danger,  though  if  the  saliva  be  quickly 
ejected  and  the  mouth  washed,  the  danger  is 
probably  small.  It  contains  an  active  principle, 
which  has  been  described  as  echidnine,  viperine, 
and  crotaline.  Analysis  has  shown  the  poison 
to  be  very  nearly  like  albumen  in  composition. 
It  is  most  active  in  its  action  on  warm-blooded 
creatures.  It  appears  that  poisonous  snakes  are 
very  insensible  to  the  venom  of  other  poisonous 
snakes. 

Effects. — The  action  of  the  poison  is  local 
and  general. 

The  local  effects  of  snake-bite  comprise  pain  ; 
partial  paralysis  of  the  bitten  part : ecchymosis  ; 
swelling;  and  if  de>th  does  not  rapidly  follow, 
infiltration  of  other  and  distant,  parts,  cellulitis, 
and  sloughing. 

Associated  with  these  local  effects  are  many 
severe  general  phenomena,  such  as  depression, 
fainting,  nausea,  hurried  respiration,  vomiting, 
exhaustion,  lethargy,  loss  of  co-ordinating  power, 
paralysis,  loss  of  consciousness,  haem  rrhagic  dis- 
charges, relaxation  of  sphincters,  coma,  and  con- 
vulsions. H'  the  quantity  of  poison  injected  be 
small  or  its  nature  feeble,  the  earlier  symptoms 
may  give  way,  and  recovery  take  place. 

Snake-poison  acts  by  paralysing  the  nerva* 


1738  VENOM,  EFFECTS  OF: 

centres — sometimes  the  peripheral  distribution 
of  the  nerves,  and  by  altering  the  constitution  of 
the  blood.  It  takes  effect  through  the  circula- 
tion ; and  if  inserted  into  a large  vessel,  such  as 
the  jugular,  humeral,  or  axillary  veins,  it  ■will 
cause  almost  instant  death,  the  heart’s  action 
stopping  in  systolic  spasm.  The  respiratory 
centres,  the  spinal  Corel,  the  peripheral  nerve- 
distribution,  may  all  be  affected ; in  ordinary 
cases  death  seems  to  take  place  by  arrest  of  the 
respiration,  the  heart’s  action  continuing  for  some 
time  after  apparent  death.  The  muscular  fibre 
itself  would  appear  in  some  cases  to  have  its 
contractility  impaired  or  destroyed.  The  poison 
also  acts  septieally,  producing  at  a later  period 
sloughing  and  haemorrhage. 

There  are  certain  points  of  difference  in  the 
action  of  viperine  and  colubrine  venom.  In  the 
former  there  is  greater  tendency  to  haemorrhage 
than  in  the  latter.  Experiments  on  animals 
show  that,  generally,  after  death  from  cobra- 
poisoning  the  blood  coagulates  firmly,  whilst 
after  death  from  viper-poisoning  the  blood  re- 
mains permanently  fluid.  In  most  eases  of  death 
in  man  the  blood  has  been  found  fluid  even  after 
cobra-poisoning. 

The  convulsion  or  coma  that-  precedes  death 
is  due  to  the  circulation  of  venous  blood  in  poi- 
soning by  colubrine  snakes ; probably  to  the 
direct  action  of  the  poison  on  the  nerve-centres 
in  poisoning  by  viperine  snakes. 

Prognosis. — In  cases  of  moderate  severity 
remedies,  with  careful  nursing  and  tending,  may 
prove  successful ; but  where  the  bite  has  been 
thoroughly  effected  by  the  ophiopkagus,  cohra, 
daboia,  eehis,  rattle-snake,  craspedocephalus,  ce- 
rastes, and  others,  the  prognosis  is  very  un- 
favourable; in  no  case,  however,  should  efforts 
be  relaxed  until  the  last. 

There  is  often  uncertainty  as  to  the  kind  of 
snake,  its  condition,  and  the  extent  to  which  its 
fangs  were  used.  The  great  shock  or  depression 
which  follows  a snake-bite  may  be  in  a measure 
due  to  fright,  and  will,  on  reassurance,  pass 
away.  The  marks  of  two  well-defined  punctures 
attest  the  insertion  of  two  fangs,  and,  if  the 
snake  has  not  boen  seen,  may  enable  one  to  form 
an  opinion  as  to  its  character.  Many  of  the  in- 
nocuous snakes  are  fierce,  and  bite  vigorously, 
but  tlleir  numerous  teeth  leave  different  marks 
from  those  of  the  poison-fangs.  There  are  excep- 
tions to  this  rule,  however ; a few  innocent 
snakes  have  the  anterior  maxillary  teeth  de- 
veloped like  poison-fangs,  but  bites  from  them 
are  not  very  likely  to  occur. 

It  may  be  well  to  note  some  of  the  characters 
that  distinguish  the  venomous  snakes,  asthe  form 
and  arrangement  of  the  teeth  and  an  examina- 
tion of  the  wound  will  reveal  the  true  character 
of  the  bite,  and  serve  to  forma  correctprognosis. 
On  opening  the  mouth  of  a venomous  colubrine 
snake,  such  as  naja  or  bungarus,  two  well-de- 
veloped fangs  will  be  observed,  one  on  either 
side ; and  close  behind  it  there  may  be  seen  one 
or  two  smaller  teeth.  There  is  no  row  of  teeth 
along  the  outer  side  of  the  mouth,  but  a double 
row  will  be  found  on  the  palatine  surface.  In 
the  viperine  and  crotaline  snakes,  a large  fang 
will  be  found  on  either  side,  and  a double  pala- 
tine row.  There  are  no  small  fixed  teeth  behind 


VENOMOUS  ANIMALS, 
the  fangs  as  in  colubrines,  but  in  a fold  ot 
mucous  membrane  at  the  base  of  the  fangs,  both 
in  vipers  and  colubrines,  a set  of  loose  reserve 
fangs  will  be  found.  In  hydropltidxe  the  fangs 
are  arranged  like  those  of  the  cobra,  but  are 
very  minute,  and  no  reliance  can  be  placed  on 
any  mark  made  by  them.  The  circumstances 
under  which  a bite  is  inflicted  will  generally 
help  to  indicate  the  kind  of  snake. 

Harmless  snakes  have  a double  row  of  equal 
or  nearly  equal-sized  teeth  in  the  maxillary  and 
palatine  bones.  But,  as  before  stated,  there  are 
certain  innocent  snakes  that  have  loDg  anterior 
maxillary  teeth,  which  might  cause  doubt  as  to 
the  nature  of  the  bite. 

Treatatent. — There  is  reason  to  believe  that 
the  numerous  agents  that  have  been  recom- 
mended from  the  earliest  times  as  antidotes  of 
snake-poison  are  useless,  and  have  no  such  pro- 
perties as  those  ascribed  to  them. 

The  rational  treatment  of  snake-poisoning  is 
to  endeavour  to  prevent  the  entry  of  the  virus 
into  the  circulation ; to  neutralize  it  in  the 
wound  before  it  is  absorbed ; to  support  the  fail- 
ing nervous  force  if  it  have  entered;  and  to 
favour  its  elimination. 

The  application  of  a ligature  applied  tightly 
between  the  bite  and  the  heart,  and  the  im- 
mediate excision  or  destruction  by  cautery  or 
caustic  of  the  bitten  spot,  are  essential;  and 
other  local  measures  subsequently  may  appear 
necessary.  The  injection  or  the  application  to 
the  puncture  of  some  decomposing  agent,  such  as 
liquor  potassae  or  permanganate  of  potash,  has 
been  especially  recommended  in  Australia,  in 
Brazil,  and  in  India. 

The  constitutional  treatment  requires  that  the 
strength  should  be  supported  by  stimulants,  such 
as  alcohol  and  ammonia.  Next,  if  the  respiration 
be  failing,  artificial  respiration  should  he  resorted 
to.  Elimination  should  be  promoted  by  stimu- 
lating diuretics.  The  patient  should  be  kept 
warm  ; and  must  not  exhaust  himself  by  walk- 
ing about.  Ammonia  has  always  held  a high 
place  among  remedies  in  snake-poisoning;  and 
its  injection  into  the  veins  has  been  warmly 
advocated  in  Australia,  and  seems  to  have  met 
with  success  there  which  it  had  not  in  India. 

The  statement  that  no  lizard  is  poisonous,  is 
not  strictly  correct.  The  heloderm  ( heloderma 
hon'idum),  of  Mexico,  possesses  venomous  pro- 
perties, destructive  to  small  animals,  and  injuri- 
ous to  man  himself. 

2.  Amphibia. — None  of  the  amphibia  are 
known  to  pcssess  a poison-apparatus  like  that 
of  ophidia  ; but  toads  and  salamanders  secrete  a 
fluid  in  glands  along  the  back,  connected  with 
the  integument,  which  yields  an  actively  veno- 
mous principle,  capable  of  causing  local  irrita- 
tion, and  when  injected  into  the  blood,  death, 
preceded  by  symptoms  indicating  action  on  the 
cerebro- spinal  nerve-centres.  Dogs  seizing  the 
toad,  Bufo  vulgaris,  are  known  to  suffer  from 
swelling  of  the  lips  and  salivation ; and  a ease 
of  death  was  related  in  France,  in  1S65,  of  a 
child  in  whom  an  abrasion  of  the  hand  came  in 
contact  with  the  secretion  of  a toad ; death  was 
preceded  by  vertigo,  vomiting,  and  fainting.  V hen 
this  poison  is  injected  into  guinea-pigs,  small 
birds,  and  other  animals,  violent  symptoms  and 


VENOM,  EFFECTS  OF: 

death  soon  follow.  It  is  a viscid,  milky  fluid, 
with  a slight  yellow  tint  and  peculiar  odour;  it 
is  exuded,  and  may  be  pressed,  from  glands  be- 
hind the  orbits.  Zalesky  has  shown  that  the 
land  and  water  salamanders,  S.  maculatus  and 
Triton  cristatus,  and  probably  others,  have  also 
the  power  of  secreting  venom ; and  his  experi- 
ments prove  that  it  contains  a very  active  prin- 
ciple— salamandrine,  and  that  its  action  on  the 
cerebro-spinal  nerve-centres  is  energetic.  It 
appears  that  these  poisons,  like  those  of  ophidia, 
though  effective  on  others,  have  no  action  on 
their  own  species. 

3.  Pisces. — Description. — Several  fishes  are 
provided  with  an  apparatus  consisting  of  a cavity 
at  the  base  of,  or  a sac  and  duct  leading  to,  a 
channelled  spine,  through  which  an  irritating 
secretion  is  ejected.  No  true  poison-gland,  how- 
over,  has  as  yet  been  certainly  made  out.  This 
secretion  is  apparently  connected  with  the  secret- 
ing mucous  system;  and  in  certain  species  it 
produces  marked  symptoms  of  poisoning,  though 
never  to  the  same  extent  as  in  the  case  of  the 
poison  of  venomous  snakes.  Fish  armed  with 
sharp  or  serrated  opercular  or  fin  spines  can 
inflict  severe  and  painful  injuries,  liable  to  cause 
great  pain,  and  to  be  followed  by  the  grave 
symptoms  attributable  to  the  lacerated  or  punc- 
tured nature  of  the  wounds ; and  these  may  bo 
aggravated  by  the  irritating  nature  of  the  mucHS 
with  which  they  are  contaminated.  In  several, 
however,  in  addition  to  the  spine,  there  is  a dis- 
tinct receptacle  in  connection  with  it,  either  in 
the  form  of  a sac  or  duct  such  as  in  the  thalas- 
sophryne,  or  in  a cavity  in  the  spine  itself,  as  in 
the  trachinus  or  weever. 

In  the  case  of  others,  such  as  the  sting-rays, 
which  may  produce  severe  wounds  by  their 
pointed  and  serrated  spines,  there  is  no  distinct 
receptacle  for  the  poisons  in  connection  with 
them.  Whilst  it  is  well  known  that  many  spiny 
fish  are  capable  of  inflicting  wounds  that  are 
dangerous  from  their  lacerated  and  punctured 
character,  it  is  recognised  that  others  increase 
the  danger  by  the  inoculation  of  an  irritating 
fluid,  as  stated  above. 

Effects. — The  effect  of  fish-poison  is  to  pro- 
duce severe  burning  pain  at  and  beyond  the  in- 
jured part,  and  fever.  The  intensity,  no  doubt, 
depends  upon  the  quantity  of  poison  injected, 
and  the  state  of  health  and  constitution  of  the 
person  at  the  time.  The  wound  alone,  even 
without  the  poison,  is  likely  to  be  painful  and 
severe  from  its  punctured  character. 

Treatment. — Ipecacuanha,  alkalies,  alum,  and 
ammonia  have  all  been  recommended  as  useful 
external  applications  to  allay  the  irritating 
action  of  such  poisons.  Poultices  of  onions,  or 
warm  applications  of  opium  or  other 'sedative 
fomentations,  are  likely  to  be  useful ; and 
prompt  surgical  relief,  if  suppuration  or  cellu- 
litis occurs,  is  necessary  to  relieve  tension,  to 
evacuate  pus,  or  give  exit  to  sloughs. 

The  constitutional  treatment  is  such  as  would 
be  indicated  by  the  condition  and  progress  of 
any  other  inflamed  punctured  wound.  In  case 
of  depression  of  the  heart’s  action,  alcohol  or 
ammonia  would  be  indicated.  Pest,  quiet,  and 
due  attention  to  the  state  of  the  bowels  and  of 
elimination  by  the  skin  and  kidneys,  with  careful 


VENOMOUS  ANIMALS.  1730 

regulation  of  the  diet,  should  be  observed.  See 
Post-Mortem  Wounds. 

4.  Mollusca. — -Aphysia  punctata,  the  sea- 
hare,  a gasteropod,  is  said  by  some  to  produce  an 
irritating  secretion  capable  of  causing  urtication 
and  even  severe  inflammation,  and  of  causing  the 
hair  to  fall  off. 

5.  Arthropoda;  Myriapoda,  family  Scolo- 
pendridce. — The  centipedes  possess  mandibles, 
formed  by  a pair  of  dilated  feet,  joined  at  their 
origin,  with  perforated,  hook-like  points  with 
an  aperture  near  the  apex,  through  which  a 
poisonous  fluid,  secreted  in  a poison-gland,  sac, 
and  duct,  is  ejected  when  they  bite,  which  they 
can  severely.  This,  in  the  case  of  the  larger 
tropical  species,  is  sometimes  very  painful,  and 
causes  considerable  local  irritation,  and  even 
constitutional  disturbance,  fever,  and  delirium. 
That  of  the  smaller  kind  generally  causes  only 
local  and  transient  irritation.  Centipedes  are 
found  all  over  the  world  nearly,  in  Europe,  Africa, 
America,  the  East  and  West  Indies  and  Islands, 
aud  in  the  tropics  generally.  Those  of  warm 
climates  are  the  largest  and  most  dangerous. 

6.  Arachnoidea. — ScorpionidcD  or  Pedipalps. 
Description. — Scorpions  have  a segmented  ab- 
domen, the  last  six  joints  of  which  are  na.rrowed 
into  a tail,  terminated  by  a curved  perforated 
spine  or  hook,  with  which  they  strike  and  wound. 
At  its  extremity  are  two  small  orifices,  through 
which  venom  is  injected  from  a gland-receptacle 
and  duct  at  its  base.  Scorpions  run  about  quickly, 
carrying  the  tail  curved  over  the  body.  The}' 
live  in  holes  in  the  ground,  and  under  stones  or 
logs  of  wrood,  in  dark  places.  The  tail  is  used 
as  an  offensive  weapon.  They  seize  small 
creatures  with  their  palpi,  and  then  pierce  them 
with  the  sting.  The  venom  is  so  active  that  it 
quickly  destroys  life.  Those  of  tropical  climates 
are  most  active  and  poisonous.  They  attain  to 
the  length  of  from  two  to  three,  four,  and  six 
inches.  The  European  genera  are  smaller  aud 
less  active. 

Scorpions  exist  in  all  tropical  countries,  but 
extend  also  into  the  warmer  regions  beyond  the 
tropics.  They  are  found  in  the  East  and  West 
Indies,  Ceylon,  and  other  islands,  Australia, 
Africa,  Egypt,  South  of  Europe,  and  America. 
There  are  several  genera,  and  Buthus  afer, 
Androctonus,  and  Buthus  Ccesar,  are  good  ex- 
amples of  the  active  kinds.  Europceus  and  Occi- 
tanus  are  also  venomous,  but  those  of  Europe  are 
less  active  than  the  tropical  forms. 

Effects. — The  effects  of  the  sting  of  the  scor- 
pion and  of  the  bite  of  the  centipede  have  no 
doubt  been  exaggerated ; but  they  may  produce 
very  painful,  and  in  the  case  of  the  larger 
species,  severe  and  serious  symptoms,  in  their 
character  not  unlike,  or  even  more  severe  than, 
those  of  the  sting  of  the  wasp,  namely,  pain, 
swelling,  in  some  cases  numbness,  vertigo,  nausea, 
vomiting,  temporary  loss  of  vision,  swelling  of 
the  tongue,  and  fever.  Death  may  occur  in  deli- 
cate or  sickly  subjects.  The  local  and  constitu- 
tional symptoms  may  be  severe  in  persons  of 
irritable  constitution,  or  otherwise  out  of  health, 
but  generally  in  the  case  of  bites  of  ordinary 
scorpions  or  centipedes  inflicted  on  healthy  sub 
jects,  the  suffering  is  local  and  soon  passes  away. 

Treatment. — A variety  of  remedies  have 


1740  VENOM,  EFFECTS  OF 

been  recommended  for  scorpion-poisoning.  Pro- 
bably the  application  of  a ligature  above  the 
bitten  part,  or  a cupping-glass,  or  suction  of  the 
wound,  as  in  snake-bite,  might  be  useful.  Some 
authorities  recommend  that  the  wound  should 
be  scarified,  volatile  ointment  rubbed  in,  and 
an  emollient  poultice  applied.  Suction  of  the 
wound,  and  the  application  of  salt  water,  vinegar, 
ammonia,  alum,  ipecacuanha,  spirits  of  camphor, 
sau  de  Cologne,  tobacco  water,  turpentine,  tinc- 
ture of  iodine,  alcohol,  the  leaves  of  cruciferous 
plants  made  into  poultices,  solutions  of  opium 
and  lead,  or  other  sedatives,  all  seem  to  lessen 
pain  and  irritation.  The  use  of  diffusible  stimu- 
lants, opiates,  or  other  sedatives  may  be  neces- 
sary, and  such  surgical  interference  as  suppura- 
tion or  cellulitis  may  require. 

7.  Arachnida. — Description. — Some  spiders 
are  venomous,  and  certain  of  the  larger  tropical 
forms  are  capable  of  inflicting  painful  l':tes.  The 
poison-apparatus  of  spiders  consist  of  falces  or 
modified  mandibles  or  jaws,  the  last  joint  of 
which  is  a hard  curved  fang,  with  a fissure  near 
the  point ; there  is  an  elongated  poison-sac  and 
duct  in  which  the  venom  is  elaborated  and  thence 
transmitted  to  the  fang,  by  which  it  is  inocu- 
lated into  the  flesh  of  its  prey. 

Effects. — The  venom  of  spiders  is  a very 
active  principle,  and  apparently  is  capable  of 
rapidly  destroying  the  life  of  the  small  crea- 
tures on  which  the  spider  feeds.  It  also  causes 
symptoms  of  poisoning  in  man  and  the  lower 
animals.  Probably  all  the  species  have  some 
venomous  secretion,  but  it  is  only  the  larger 
kinds  that  are  obnoxious  to  man.  It  may  be 
noted  that  whilst  the  fangs  of  one  section  of 
spiders  move  laterally,  those  of  the  Mygalidse 
move  vertically. 

There  are  several  species.  Those  reputed 
venomous  are  tropical. 

Lycosa  tarantula  is  reputed  to  cause  extra- 
ordinary symptoms.  It  is  poisonous,  but  there  is 
no  reason  to  believe  that  its  effects  exceed  a cer- 
tain amount  of  local  irritation.  See  Tarantism. 

There  are  numerous  families,  genera,  and 
species  of  spiders,  all  probably  possessing  an  irri- 
tating fluid ; but  it  is  only  in  the  larger  kinds 
that  they  do  so  to  any  extent,  and  there  is  no 
very  positive  proof  that  even  in  tropical  climates 
they  inflict  the  grievous  injuries  ascribed  to 
them,  though  the  venom  is  very  fatal  to  the 
creatures  on  which  they  prej’. 

The  popular  notions  that  the  spider  is  very 
poisonous  when  swallowed,  and  that  its  web 
possesses  medicinal  properties,  are  probably  ex- 
aggerated, if  not  altogether  untrue.  One  species 
of  red  spider,  however — perhaps  a mite— called 
coya,  in  Popayan,  is  very  poisonous;  the  juices 
of  its  body  when  crushed,  and  coming  in  contact 
with  the  punctured  skin,  cause  tumours,  or 
even  it  is  said  death.  This  is  no  doubt  ail  ex- 
aggeration, but  it  is  probable  that  the  juices  are 
acrid  and  irritating,  and  it  is  therefore  better  not 
to  crush  them  when  detected  on  the  person,  but 
to  brush  or  blow  them  away. 

In  India,  a streak  of  almost  erysipelatous 
redness  of  the  skin  coming  on  vapidly,  is  often 
attributed  to  a spider.  No  one  has  defined  the 
species;  it  is  possible  that  it  may  be  analogous 
to  that  just  referred  to.  I 


: VENOMOUS  ANIMALS. 

. Treatment. — The  treatment  of  spider-bites  is 
similar  to  that  of  centipedes  aDd  scorpions. 

8.  Acarina. — Description  and  Effects. — 
Some  mites  have  the  power  of  causing  consider- 
able irritation  by  a secretion  ejected  on  the  sur- 
face, or  injected  into  the  wounds  they  make  in 
their  burrowing  operations  with  claws  or  mouth. 

The  Tctranychus  autumnalh,  Leptus  aulum- 
nalis,  or  Harvest  Bug,  is  brick-red  in  colour, 
and  very  minute.  It  is  bred  on  plants,  but 
leaves  them  to  fasten  on  animals,  especially 
man,  when  it  adheres  firmly,  and  causes  swelling, 
great  irritation,  and  severe  itching,  if  in  num- 
bers. The  intense  irritation  causes  fever.  The 
symptoms  are  not  unlike  the  sting  of  a nettle, 
erythema  or  even  blistering  being  caused.  The 
leptus  is  covered  with  hairs,  and  effects  entrance 
into  the  skin  with  its  claws,  and  thus  gives  rise 
to  the  great  irritation,  which  is  probably  aggra- 
vated by  some  acrid  excretion.  These  animals 
are  found  in  Britain,  France,  and  other  parts 
of  Europe ; varieties  of  them  in  the  tropics,  for 
example  in  Brazil,  Honduras,  on  the  Mosquito 
Coast,  and  in  the  IVest  Indies.  The  T.  irritans 
of  the  Mississippi  valleys  causes  great  irritation 
in  the  same  way. 

Treatment. — The  treatment  is  to  extract  the 
bug  with  a needle  or  the  point  of  a knife,  and 
then  apply  some  soothing  lotion. 

Argus  per  sic  us,  a gamosid,  known  also  as  the 
Teigne  de  Miana,  venomous  bug  of  Miana,  is 
common  in  Persia.  It  is  found  in  the  houses, 
and  it  is  said  that  its  puncture  produces  serious 
symptoms,  such  as  convulsions,  delirium,  and 
gangrene,  or  even  death.  This  is  an  exaggera- 
tion, though  probably  it  is  true  that  local  irri- 
tation, and  perhaps  some  constitutional  distur- 
bance, may  be  caused.  It  is  blood-redin  colour, 
spotted  with  white  on  the  back,  the  f6et  yellow. 
Argas  moubata,  a native  of  Angola,  is  said  to 
have  much  the  same  properties. 

The  Argas  talajc  of  Guatemala  produces  great 
irritation.  It  bites  like  an  ordinary  bug,  and 
the  punctures  are  followed  by  great  irritation, 
swelling,  and  pain.  It  lives  in  holes  in  the  bam- 
boo walls,  or  such-like  crevices,  and  issues  at 
night  to  attack  the  sleepers. 

9.  Hemiptera. — Some  of  the  Geocorysts  and 
Hydrocoryscs , or  land  and  water  bugs,  have  irri- 
tating properties,  and  also  an  offensive  odour ; 
they  have  a suctorial  mouth,  armed  with  a 
grooved  instrument  or  rostrum  for  piercing  the 
ski  n. 

Cimex  lectularius,  the  bed  bug,  causes  much 
irritation,  and  in  some  persons  inflammatory  ac- 
tion in  the  bitten  part.  The  effects  are  transient 

Eotonecta  and  Nepa,  common  in  pools  of  water 
in  our  islands,  are  also  capable  of  inflicting  a 
painful  puncture.  Cimex  nemorum  causes  nearly 
as  much  pain  by  its  puncture  as  the  sting  of  a 
wasp.  The  wheel  bug,  Eeduvius  serratus,  of  the 
West  Indies,  gives  an  electric  shock  to  the  per- 
son it  touches.  St.  Pierre  mentions  a species  of 
bug  in  the  Mauritius  whose  bite  is  as  venomous 
as  the  sting  of  a scorpion.  The  Benchucha,  or 
great  black  bug,  of  the  pampas  of  South  America, 
is  more  obnoxious,  it  is  said,  than  the  common 
bed  bug. 

10.  Aphaniptera. — Pulicidm  or  Fleas  com- 
prise several  families.  Pulcx  irritans,  the  com 


VENOM,  EFFECTS  OF: 
mon  flea,  is  universal.  It  varies  much  in  size 
and  colour  ; some  are  almost  black  and  very 
large,  and  are  found  on  the  sandy  shores  of  the 
Mediterranean.  There  are  many  species,  such  as 
P,  cams,  P.  musculus,  P.  vcspertitinus,  and  others. 
Pulex  penetrans  of  the  West  Indies  and  South 
America,  known  also  as  the  jigger  or  chigoe, 
penetrates  the  skin,  and  beneath  the  nails,  gene- 
rally of  the  feet,  causing  great  irritation.  It  will, 
if  not  extracted,  deposit  its  ova,  and  thus  give 
rise  to  sevei'e  irritation.  The  effects  of  the  or- 
dinary flea-bite  are  well  known.  Though  the 
irritation  of  flea-bites  is  chiefly  due  to  the  wound, 
there  is  reason  to  believe  that  this  is  aggravated 
by  the  presence  of  some  irritating  secretion.  No 
special  treatment  need  be  described. 

11.  Diptera. — Description  and  Effects. — 
To  this  order  belong  the  gnats,  mosquitoes,  pip- 
sas,  sand-flies,  and  gad-flies,  all  more  or  less 
dreaded  for  their  bites.  They  have  a proboscis 
composed  of  a grooved  and  flexible  sheath, 
through  which  long,  slender,  sharp  darts  are 
protruded,  that  pierce  the  skin  and  inoculate 
some  venomous  secretion,  though  its  nature  is 
not  known.  They  draw  blood,  raise  white 
lumps  or  swellings  ; some,  such  as  the  pipsa  of 
the  Oossiah  Hills,  India,  leave  a livid  spot  of 
effused  blood,  which  gives  to  the  sufferer  the 
appearance  of  a purpureal  rash.  They  swarm  in 
many  countries,  generally  near  water.  Tho  prin- 
cipal forms  are  the  Culex  pipiens,  C.  reptans,  C. 
mosquito,  C.  laniger , and  the  whame  fly,  C. 
tabanus.  Some  of  these  are  formidable  insects, 
and  are  insatiable  blood-suckers.  The  tsetze  or 
ti'ib,  Glossina  morsitans  of  Africa,  is  one  of  the 
most  remarkable.  The  bite  of  this  poisonous 
insect  is  almost  certain  death  to  the  horse,  ox, 
or  dog;  though  it  appears  not  to  trouble  man 
more  than  by  causing  slight  irritation. 

The  female  Simulium,  or  sand-fly,  is  irritating 
to  man,  the  bite  often  giving  rise  to  painful 
swellings.  The  pipsa  is  probably  a simulium. 
It  appears  from  the  great  irritation  and  the  swell- 
ing that  follows  the  puncture  of  most  of  these 
insects,  that  some  acrid  secretion  is  injected  into 
the  wound.  In  young  full-blooded  persons,  es- 
pecially roceDt  arrivals  in  India  or  the  tropics, 
the  irritation  caused  by  mosquito-bites  is  often 
so  severe  as  to  give  rise  to  violent  inflammatory 
symptoms,  resulting  in  suppuration  or  ulcera- 
tion, and  even  gangrene. 

Treatment. — The  application  of  common  salt, 
solution  of  ammonia,  soda,  potash,  lead,  oil,  ipe- 
cacuanha, or  alum  combined  with  opium,  allays 
irritation  in  the  first  stage.  The  more  violent 
inflammatory  symptoms  are  amenable  to  ordinary 
surgical  treatment.  Camphor,  pulegium,  and 
lime-juice,  applied  to  the  skin,  are  all  regarded 
as  preventives. 

12.  Hymenoptera. — Description  and 
Effects. — A number  of  species  that  secrete 
poison  are  found  among  the  different  families 
of  hymenoptera,  including  bees,  wasps,  and  ants. 
See  also  Sting. 

They  are  distinguished  by  the  presence  of  an 
ovipositor  in  the  female,  which  not  only  is  used 
for  depositing  the  eggs,  but  as  a weapon  for  in- 
jecting venom.  It  consists  of  two  valves  as  a 
sheath,  and  three  bristles  which  form  a grooved 
sting.  Through  this  groove  the  poison  is  in- 


VENOMOUS  ANIMALS.  1741 

jected  into  the  wound,  the  ovipositor  being  con- 
nected with  a poison-gland  at  its  base. 

Formicidce. — Ants  include  Formica  smaragdina 
and  many  others.  The  sting  of  the  ant  causes 
considerable  irritation,  especially  if  many.  It 
has  been  suggested  that  formic  acid  is  the  irri- 
tating principle.  There  are  several  venomous 
species  of  ants,  black  and  red,  of  various  sizes. 
Some  of  the  larger  forms  in  the  tropics  are  ca- 
pable of  inflicting  a very  painful  injury.  Some 
ants  have  no  sting,  hut  eject  a fluid  which  irri- 
tates the  skin. 

Vcspida. — The  females  and  workers  of  the 
wasps  and  hornets  are  provided  with  a poison- 
sac  and  sting.  Vespa ■ vulgaris  is  a type  of  the 
tribe  Crabro.  It  lives  in  communities.  Its  sting 
produces  much  irritation,  pain,  and  swelling, 
especially  when  inflicted  on  the  face,  or  where 
the  cellular  tissue  is  loose. 

Apidre. — True  bees,  and  the  Bombida  or  humble 
bees,  have  similar  properties,  their  sting  pro- 
ducing very  much  the  same  effect  as  that  of  the 
wasp. 

Some  of  the  parasitic  Hymenoptera  inject  a 
poison  into  the  wound  made  by  their  ovipositor. 
The  best  known  instance  is  that  of  the  genus 
Ophion.  The  genus  Paripla  also  injects  a poison 
in  the  same  way,  and  probably  others  of  the 
Ichneumonidre. 

Treatment:— Many  remedies  of  a simple  na- 
ture have  been  recommended  to  allay  the  pain 
and  irritatioii  caused  by  the  sting  of  the  wasp 
and  bee,  such  as  vinegar,  eau  de  Luce,  ammonia, 
solution  of  soda  or  potash,  oil,  indigo,  eau  de  Co- 
logne, alum,  and  all  those  recommended  in  scor- 
pion-stings. In  case  of  venomous  stings,  where 
constitutional  disturbance  is  induced,  stimulants 
or  sedatives  may  be  necessary  ; and  as  the  sting 
is  liable  to  be  left  in  the  wound,  it  ought  to  he 
picked  out.  In  cases  of  wasp  or  bee  stings  in 
the  mouth  or  throat,  which  may  happen  when 
children  bite  a peach  or  other  fruit  that  conceals 
a wasp,  severe  consequences  may  arise  from  the 
oedema  that  supervenes,  and  extends  to  the 
glottis.  An  emetic  is  then  useful.  With  the 
ordinary  treatment  of  oedema,  laryngotomy  may 
become  necessary.  In  other  cases,  should  vio- 
lent symptoms  supervene,  surgical  aid  may  be 
required  to  relieve  tension,  or  give  exit  to  mat- 
ter. Such  untoward  results,  however,  are  happily 
rare. 

Mutilla  coccinea,  a native  of  the  warmer  parts 
of  North  America,  is  said  to  produce  loss  of 
consciousness  within  five  minutes  of  the  inflic- 
tion of  its  sting,  life  being  in  danger  for  sonu 
dajTs  afterwards. 

13.  Lepidoptera. — The  majority  of  insects 
furnished  with  a sting,  as  a means  of  defence, 
belong  to  the  Hymenoptera.  It  is  but  recently 
that  a stinging  Lepidopterous  insect  has  been 
found.  The  species  is  not  mentioned  (F.  Smith). 
The  bee  moth  of  the  Cape  of  Good  Hope  is  said 
to  defend  itself  with  a sting.  Though  the  ma- 
jority of  the  perfect  insects  of  this  tribe  are 
harmless,  some  of  the  caterpillars  appear  to  be 
possessed  of  irritating  properties,  residing  in  the 
fine  hairs  with  which  they  are  cased,  and  which, 
being  sharp  and  brittle,  break  off  and  remain  in 
the  skin,  causing  irritation  mechanically ; hut 
also  probably  from  the  presence  of  some  acrid 


1742  VENOMOUS  ANIMALS, 
substance  concealed  'within  the  hairs.  In  Cey- 
lon, a greenish  hairy  caterpillar,  longitudinally- 
striped,  probably  of  the  genus  Boinbyx,  which 
frequents  the  leaves  of  Hibiscus  populneus,  alight- 
ing on  the  skin,  causes  as  much  irritation  as  the 
sting  of  a nettle.  The  larva  of  Necsra  lepida, 
has  similar  properties.  It  is  short  and  broad, 
cf  a pale  green,  with  fleshy  spines  on  the  upper 
surface,  each  of  which  is  charged  with  venom 
that  occasions  acute  suffering.  The  larvae  of 
Adolia  are  also  armed  with  venomous  hairs. 
Another,  not  uncommon  in  certain  trees  in  the 
terai  of  the  Himalaya,  is  a dark-coloured  hairy 
caterpillar,  which  is  apt  to  fall  on  people  and 
cause  intense  irritation.  It  is  known  as  the 
Komlah,  but  the  moth  that  produces  it  is  not 
known. 

14.  Coleoptera. — Several  beetles  have  acrid 
secretions  capable  of  exciting*great  irritation  and 
inflammation,  raising  blisters,  and  if  absorbed 
causing  painful  strangury  and  great  urinary 
irritation.  Such  are  Mylabris  Cichorii  of  India, 
Cantharis  or  Lytta,  or  Meloe  vesicatoria,  Lytta 
gigas  of  Senegal,  Lytta  vitata  of  America,  and 
Lytta  ruficeps  of  Chili. 

15.  Echinodermata. — The  long  sharp 
pointed  spines  of  some  of  the  echinids  are  capable 
of  inflicting  painful  punetured  wounds,  but  con- 
vey no  true  venom.  Whether,  as  in  the  case  of 
some  spiny  fishes,  there  may  be  an  irritating 
mucous  secretion  inoculated  is  uncertain. 

16.  Coelenterata. — Some  of  the  Medusas  or 
jelly-fish  have  the  powrer  of  stinging.  The 
poison-apparatus  is  placed  in  certain  tubercles 
on  the  surface.  These  contain  a collection  of 
granules,  amongst  which  are  small  vesicles. 
Within  these  corpuscles  or  nematocysts  a spiral 
thread  is  found,  which  bursts  out  on  pressure. 
These  corpuscles  are  found  in  the  mucus  exuded 
by  the  creature,  and  to  them  is  attributed  the 
urticating  power  it  possesses.  There  are  several 
stinging  species,  some  found  on  our  own  coasts, 
others  in  other  seas.  It  is  the  larger  forms  gene- 
rally that  are  venomous,  the  small  ones  having 
no  effect  on  man.  C'yanea  capillata  of  our  seas 
is  a most  formidable  creature,  and  the  terror  of 
bathers.  It  has  a broad  tawny  disk,  and  a long 
train  of  ribbon-like  streamers  floating  after  it ; 
it  makes  its  way  through  the  waters  ; and  what- 
ever comes  in  contact  with  these  trailing  trains 
soon  writhes  in  torture,  the  effect  produced  being 
not  unlike  that  of  the  nettle. 

Physalea  pelagica,  the  Portuguese  man-of-war, 
has  similar  properties.  It  causes  severe  and 
stinging  pain,  extending  up  the  limb,  with  fever- 
ishness, which  has  been  knowm  to  continue  for 
some  hours,  white  wheals  forming  on  the  skin, 
as  in  urticaria.  Several  other  medusae  possess 
these  properties,  and  honed  they  have  received 
the  name  of  Acalephae,  or  sea-nettles.  The  ap- 
plication of  vinegar  or  olive  oil  is  said  to  remove 
tho  unpleasant  symptoms. 

The  Actinia , or  sea-anemones,  and  the  hydroid 
polyps,  appear  to  possess  a similar  power,  and  are 
provided  also  with  thread-cells.  They  cause 
urtication  of  the  human  skin  when  brought  in 
contact  with  their  tentacles.  The  Sagartiadce 
furnish  examples  of  sea-anemones  with  this  pro- 
perty. The  effects,  however,  of  any  of  them  are 
transient.  In  some  parts  of  Europe  the  Acalcphos 


VENTRICLES  OE  THE  BRAIN. 

have  been  used  therapeutically  as  counter-irri- 
tants, by  being  brought  in  contact  with  the 
patient  immersed  in  a salt-water  bath. 

In  the  preceding  description  the  writer  has 
not  attempted  to  treat  exhaustively  the  subject 
of  venomous  animals,  or  to  describe  all  the  forms 
of  animal  life  so  endowed.  His  object  has  been  to 
point  out  the  principal  forms,  and  to  indicate 
generally  the  mode  of  dealing  therapeutically 
witli  the  effects  of  the  venom. 

Joseph  Fayber. 

VEtNT  0X7 S HUM. — A peculiar  murmur 
heard  on  auscultation  of  the  larger  veins,  espe- 
cially  those  of  the  neck  and  chest,  in  ana?mia, 
and  in  cases  of  interference  with  the  flow  of  the 
blood  through  those  vessels.  See  Physical  Exa- 
mination. 

YENTNOE,  in  the  Isle  of  Wight.— A 

mild,  dry,  bracing  climate.  Mean  winter  tem- 
perature for  forty  years,  42'43°  Fahr.  Exposed 
to  S.S.E.  and  S.W.  winds.  See  Climate,  Treat- 
ment of  Disease  by. 

VENTRICLES  OF  THE  BRAIN-,  Dis- 
eases of. — Synon.  : Maladies  des  Vcntricules  du 
Cerveau ; Ger.  Krankheiten  der  Gehirnhohlen. — 
The  chief  morbid  states  of  the  ventricles  of  the 
brain  are  (])  new  growths,  degenerations,  and 
inflammatory  changes  in  the  lining  membrane 
(ependyma)  and  velum  interpositum  ; and  (2) 
accumulations  of  blood,  pus,  and  serum  in  the 
ventricular  cavity. 

1.  Diseases  of  the  lining  membrane  and 
velum. — In  old  age,  and  in  degenerative  brain- 
diseases,  such  as  general  paralysis,  the  ependyma 
of  the  ventricles  becomes  thickened.  The  surface 
is  uniform,  or,  in  some  cases,  covered  by  minute 
warty  granulations.  Some  of  the  latter  may 
attain  the  size  of  a pea,  and  constitute  small 
fibrous  tumours.  Similar  changes  are  sometimes 
found  when  the  brain  has  been  subjected  for  a 
long  time  to  passive  congestion.  In  rare  cases 
the  thickened  membrane  has  been  found  calcified 
in  places.  A few  morbid  growths  have  been  met 
with  in  the  ependyma,  the  most  common  being 
the  granulations  of  tuberculosis,  which  have 
been  found  both  on  tho  lining  membrane  and  the 
choroid  plexus.  The  latter  and  the  velum  inter- 
positum frequently  present  thickening,  and  un- 
due adhesion  to  the  ependyma.  In  rare  cases 
fatty  growth  has  been  met  with,  in  this  situation. 
The  choroid  plexus  may  present  partial  fatty 
degeneration,  and  frequently  contains  corpora 
amylacca.  Aggregations  of  brain-sand  are  com- 
mon in  the  choroid  plexus,  and  occasionally  occur 
in  the  lining  membrane. 

Cystic  degeneration  is  the  most  common  mor- 
bid appearance  in  the  choroid  plexus,  especially 
iu  that  part  which  is  within  the  descending 
cornu.  The  cysts  are  clear,  delicate,  colourless, 
transparent,  from  the  size  of  a pea  downwards. 
They  consist  of  delicate  cells  pressed  together, 
which  are  simply  normal  cellular  elements  of 
the  part  that  have  undergone  a peculiar  degene- 
ration. In  some  of  the  larger  ones  these  cells 
have  become  destroyed  in  the  centre,  so  that  a 
true  fluid-containing  cyst  remains. 

The  adhesions  sometimes  met  with  may  cut 


VENTRICLES  OE  THE  BRAIN, 
off  the  posterior  cornu  from  the  rest  of  the  ven- 
tricle, and  it  may  thus  be  obliterated. 

The  ventricles  may  undergo  passive  congestion 
in  common  with,  the  intracranial  organs,  or  from 
pressure  upon  the  veins  of  Galen,  -which  return 
the  blood  from  the  velum  interpositum.  In  the 
latter  case  considerable  effusion  of  fluid  may 
occur. 

Inflammation  involves  both  the  ependyma 
and  the  velum  interpositum.  It  is  rarely  con- 
fined to  the  ventricles,  still  more  rarely  to  one. 
Commonly  it  is  part  of  a general  meningitis. 
The  ependyma  and  the  velum  are  thickened  and 
pulp}7,  being  infiltrated  -with  cells  of  new  forma- 
tion. The  velum  is  always  injected  ; the  epen- 
dyma may  bo  injected  or  pale.  Occasionally  a 
false  membrane  is  found  upon  its  surface.  The 
tissue  of  the  brain  beneath  the  ependyma  is 
softened,  and  may  be  injected.  The  fluid  in  the 
ventricles  is  increased  in  quantity,  and  is  turbid 
from  pus  and  exudation-cells,  and  even  debris  of 
nerve-fibres.  The  inflammation,  of  which  this  is 
part,  is  usually  fatal ; but  it  may  pass  away,  the 
ependyma  and  velum  remaining  thickened  and 
adherent.  See  Meninges,  Cerebral,  Inflamma- 
tion of,  Tubercular. 

2.  Intraventricular  accumulations. — He- 
morrhage rarely  occurs  directly  into  the  ven- 
tricles, except  by  traumatic  rupture  of  a vein  ; 
but  blood  may  reach  them  from  within  the  cere- 
bral substance,  or  from  the  subarachnoid  space. 
True  pus  may  be  found  in  the  cavities,  from  the 
bursting  into  them  of  a cerebral  abscess  ; and  a 
purulent  fluid  may  result  from  inflammation  of 
the  lining  membrane.  A slight  effusion  of  serum 
results  from  inflammation,  but  is  rarely  con- 
siderable, unless  the  escape  of  that  secreted  by 
the  choroid  plexus  is  prevented  by  the  closure 
of  the  passage  to  the  fourth  ventricle  from  ex- 
ternal pressure,  or  by  the  obliteration  of  the 
foramina  in  the  membrane  closing  in  the  fourth 
ventricle, by  which  its  cavity  communicates  with 
the  subarachnoid  space  (Hilton).  See  Hydro- 
cephalus. In  atrophy  of  the  brain,  the  fluid 
within  the  ventricles  (as  beneath  the  arachnoid) 
undergoes  a considerable  compensatory  increase. 

Lastly,  by  violent  commotions  of  the  brain 
the  septum  lucidum  may  be  ruptured  (Wilks  and 
Moxon). 

Ventricular  hemorrhage  and  hydrocephalus  are 
described  in  other  parts  of  this  work.  See  Brain, 
Haemorrhage  into  ; and  Hydrocephalus. 

The  other  conditions  discussed  are  marked  by 
no  distinctive  symptoms,  and  call  for  no  special 
treatment.  W.  R.  Gowers. 

VENTRICLES  OP  THE  HEART, 

Diseases  of.  See  Heart,  Diseases  of. 

VERDIGRIS,  Poisoning  by.  See  Copper, 
Poisoning  by. 

VERMES  (Lat.  worms).— This  is  a term  of 
variable  import,  according  to  the  practical  or 
scientific  stand-point  from  which  it  happens  to 
be  viewed.  Thus  Gegenbaur  includes  in  this 
group,  not  only  the  helminths  or  entozoa  and 
their  allies,  but  also  a multitude  of  creatures  of 
widely  differing  structure,  as  well  as  the  annu- 
lated  animals  properly  so-called  ( Grundziige  dcr 
Vergleich.  Anatomie,  1870,  s.  1 ooctseq.').  The  late 


VERRUCA.  1713 

Professor  Rolleston,  in  like  manner,  elevates  the 
term  so  as  to  make  it  of  sub-lcingdom  value  in 
zoology.  Practically,  the  term  ‘Vermes’  is  used 
as  the  equivalent  of  Entozoa , which  latter  term, 
as  we  have  explained  elsewhere,  has  a wider 
signification  than  its  simple  literal  meaning  im- 
plies. See  Entozoa;  Helminthes;  Intest inai 
Worms;  Parasites;  and  Worms. 

T.  S.  Cobbold. 

VERMICIDES  ( vermis , a worm,  and  ctsdo, 
I kill).— A group  of  anthelmintics  which  kill 
worms.  See  Anthelmintics. 

VERMIFUGES  ( vermis , a worm,  and  fugo, 
I expel). — A group  of  anthelmintics  which  expel 
worms,  but  do  not  necessarilly  kill  them.  See 
Anthelmintics. 

VERRUCA  (Lat.  A wart.) — Synon.  : Fr. 
Vcrrue ; Ger.  Warze. 

Definition. — A wart  or  papillary  growth  from 
the  skin. 

JEtiology. — -The  wart,  being  an  aberration  of 
growth  of  certain  of  the  constituents  of  the  skin, 
must  necessarily  result  from  a want  of  normal 
power  within  the  integument ; hence  it  is  mostly 
found  in  children  and  elderly  persons,  and  is  less 
frequently  met  with  in  the  adult.  As  children 
become  developed  by  growth,  and  their  tissues 
acquire  strength,  these  partial  exuberant  growths 
disappear.  In  young  persons  of  feeble  organisa- 
tion they  are  sometimes  thrown  out  like  an 
exanthem,  and  yield  to  a constitutional  treat- 
ment directed  towards  the  improved  innervation 
and  nutrition  of  the  tissues.  Their  direct  rela- 
tion with  the  nervous  system  is  often  evinced  by 
their  sudden  disappearance  under  the  influence 
of  mental  emotion,  a circumstance  which  has  led 
to  the  popular  use  of  charms  for  their  cure.  In 
elderly  persons  they  are  often  met  with  on  the 
face,  where  their  presence  must  be  ascribed  to 
debility  of  integument;  and  they  are  frequently 
associated  with  dirt  and  neglect.  Briefly,  warts 
may  he  said  to  he  due  to  aberration  of  nutri- 
tive function  of  the  skin,  consequent  on  defective 
organisation  and  vitality. 

Description. — Pathologically  a wart  is  an 
hypertrophy  or  excessive  growth  of  a small 
group  of  papilla  of  the  skin,  with  excessive  pro- 
duction of  cuticle,  forming  a hard  prominence  of 
the  integument.  "Warts  vary  in  size,  and  aro 
modified  according  to  situation.  They  some- 
times cover  a considerable  extent  of  surface  in 
patches  several  inches  in  diameter,  but  more  com- 
monly appear  as  tubercles,  either  few  in  number 
and  isolated,  or  numerous  and  in  clusters.  One 
kind  is  remarkable  for  the  minimum  of  promi- 
nence, resembling  a flat,  dirty-looking  blotch  on 
the  skin ; whilst  another,  as  on  the  hands,  may 
have  a prominence  of  a quarter  of  an  inch,  or  on 
the  scalp  of  half  an  inch. 

Warts  on  the  hands  afford  the  commonest 
illustration  of  verruca,  as  in  this  situation,  from 
the  greater  nutritive  energy  of  the  skin  and  the 
abundance  of  epidermis,  they  are  most  frequent 
and  most  highly  developed.  When  of  recent 
growth  they  are  convex  and  smooth  on  the  sur- 
face, hut  when  of  longer  standing  the  apex  is 
flat,  from  the  wearing  away  of  the  superficial 
cuticle,  and  the  anatomy  of  the  wart  becomes  dia 


VERRUCA. 


1744 

closed.  Then  it  is  apparent  that  the  wart  is 
composed  of  a bundle  of  fibres,  held  together  in 
a cylindrical  form  by  a boundary  of  thickened 
cuticle.  Each  of  these  fibres  is  a vascular  papilla 
of  the  skin,  enclosed  in  a sheath  of  cuticle,  and 
the  collective  mass  forms  the  body  of  the  growth. 
An  old  wart  'will  frequently  split  up  into  several 
segments — V.  lobosa  or  tabulated  wart,  and  then 
its  construction  of  fibres — V.  fibrosa,  is  strikingly 
conspicuous.  If  a wart  be  cut  through  hori- 
zontally, the  vascular  papillae  will  be  cut  across, 
and  then  the  structure  of  a wart  of  papillae  and 
horny  sheaths  is  still  more  evident.  On  the 
fingers,  aDd  especially  the  knuckles  of  children, 
the  verruca  is  isolated  and  large,  and  not  unfre- 
quently  confluent,  and  on  the  back  of  the  hands 
and  wrists,  as  also  on  the  forehead,  it  is  often 
developed  in  crops,  like  an  eruption ; but  these 
latter  never  attain  the  dimensions  of  the  isolated 
warts  of  the  fingers. 

Verrucae  are  generally  sessile  — V.  scssilis ; but 
on  the  scalp  they  are  frequently  pedunculate, 
and,  from  a peculiarity  of  structure,  have  been 
denominated  digitate — V.  digitata.  The  digitate 
character  of  the  warts  of  the  scalp  is  due  to  the 
lesser  quantity  of  epidermis  occurring  in  .that 
region  ; consequently  the  hypertrophous  papillae 
are  not  held  together  by  a ring  of  thickened 
cuticle  as  elsewhere,  but  being  left  to  themselves 
shoot  out  from  the  centre  like  fingers  ; the  papillae 
likewise  grow  to  a greater  length,  and  their  cylin- 
der is  swollen  so  that  the  bulk  of  the  mass  greatly 
exceeds  that  of  the  base  from  w'hich  thoy  spring. 
.Yevertheless,  the  digitate  verruca  must  be  distin- 
guished from  V.  acrocliordon,  and  the  cauliflower- 
shaped venereal  warts,  both  of  which  are  growths 
of  the  integument,  and  are  not  restricted  to  the 
papillae  cutis  alone;  and  thereby  fall  into  the 
category  of  molluseum,  with  which,  especially 
acrochordon,  they  are  closely  allied  in  patholo- 
gical structure. 

The  normal  colour  of  warts  on  the  hands  is 
a yellowish-grey,  but  from  their  roughness  they 
are  apt  to  retain  dirt  in  their  crevices,  which 
gives  them  a brownish  appearance.  The  flat 
warts  of  the  trunk  of  the  body  and  face  are  ac- 
companied with  the  production  of  pigment,  and 
their  dirty  colour  is  consequently  more  striking. 
A number  of  warts  congregated  on  the  skin  sug- 
gested to  the  fathers  of  medicine  the  idea  of 
ants  crawling  over  the  body,  and  this  appear- 
ance they  designated  myrmceia ; whilst,  another 
resemblance,  which  can  be  frequently  verified, 
brought  to  the  mind  the  blossom  of  the  thyme, 
hence  the  term  Thymion  employed  by  Hippo- 
crates. 

Diagnosis. — As  a simple  epidermic  growth 
enclosing  hypertrophous  papillae,  verruca  is  very 
distinct  from  other  affections  of  the  skin  at- 
tended with  hypertrophous  growth  of  cuticle. 
The  lepra  of  Willan  is  accompanied  with  hvper- 
trophous  papillae  and  cuticle,  but  the  latter  is  a 
morbid  product,  and  is  spread  out  in  the  form  of 
laminated  scales.  Ichthyosis  likewise  is  a com- 
bination of  hypertrophous  papillae,  enclosed  in 
epidermic  sheaths,  with  accumulation  of  cuticle, 
but  is  apt  to  be  associated  with  filiform  and 
branched  processes  of  the  actual  integument. 

True  idiopathic  warts  must  bo  distinguished 
from  other  diseases  which  sometimes  put  on  a 


warty  appearance,  especially  carcinoma  and  - ./- 
philis.  Epithelioma  of  the  skin  is  occasionally 
seen  as  a circumscribed  warty  growth,  but  gene- 
rally with  adherent  scabs  covering  superficial 
ulceration.  These  signs,  together  with  infiltra- 
tion of  adjacent  tissues,  implication  of  neigh- 
bouring glands,  and  pain,  would  arouse  sus- 
picion. It  must  be  remembered,  hove ver,  that 
epithelioma  frequently  attacks  a simple  wart 
which  has  remained  quite  passive  during  a life- 
time; rapid  increase  of  growth  with  the  above- 
mentioned  symptoms  would  suggest  the  super- 
vention of  epithelioma. 

Any  chronic  inflammatory  process  of  the  skin, 
especially  syphilis,  is  liable  to  take  on  a papil- 
lary character.  Without  referring  to  the  papil- 
lary growths  of  early  syphilis  (condylomata), 
which  could  scarcely  lie  confounded  with  simple 
warts,  on  account  of  their  position  and  moisture, 
mention  may  be  made  of  the  dry  warty  charac- 
ter assumed  by  old  syphilitic  lesions,  especially 
such  as  have  been  preceded  by  ulceration.  The 
history  of  the  disease  (previous  ulceration,  &c.). 
together  with  other  concomitant  symptoms  of 
syphilis,  would  assist  the  diagnosis. 

As  of  venereal  origin,  though  never  syphilitic. 
ordinary  ‘ venereal  warts  ’ must  also  be  noted. 
Other  names  by  which  thoy  have  been  described 
suggest  their  characters,  such  as  ‘ pointed  condy- 
loma,’ and  ‘ cauliflower  excrescence.’  They  are 
generally  bright  red  in  colour;  and  the  indivi- 
dual papilla;  are  pointed.  The  rapidity  of  their 
growth,  and  the  situation  where  they  usually 
occur  (the  genitals),  serve  to  distinguish  them 
from  verrueie.  Moreover  they  most  often  accom- 
pany gonorrhoea,  being  caused  by  the  irritating 
discharge. 

Prognosis. — Verruca  is  a blemish  rather  than 
a disease,  and  unimportant  in  its  relations  to  the 
general  health.  By  an  error  of  diagnosis  we 
sometimes  read  of  malignant  warts,  and  warts 
have  been  confounded  with  those  fleshy  growths 
termed  ‘ tegumentary  naevi.’  Moreover  in  elderly 
persons  a warty  state  of  the  skin  is  sometimes 
associated  with  asthenic  ulceration,  and  occa- 
sionally with  rodent  ulcer,  for  which  the  de- 
praved state  of  the  skin,  and  not  the  wart,  is 
responsible. 

Treatment.  — The  best  method  of  treating 
verruca;  is  to  touch  them  with  some  solvent  agent, 
such  as  acetic  acid.  This  acid  dissolves  the  epi- 
dermis, and  reaching  the  vascular  papillae,  de- 
stroys the  whole  structure  of  the  wart  down  to 
its  root.  The  pulpy  mass  then  dries  up  into  a 
scab;  and  when  the  scab  falls  off,  the  growth 
rarely  reappears.  This  little  operation  may 
either  be  completed  at  one  sitting,  or  it  may  be 
repeated  daily  until  its  purpose  is  effected.  "Where 
there  are  numerous  verrucas  to  be  dealt  with, 
the  process  is  tedious,  and  is  generally  left  in 
the  hands  of  the  patient.  The  writer  prefers 
a saturated  solution  of  potassa  fusa,  carefully 
applied  by  means  of  a minute  pencil  of  sponge 
fastened  tc  the  end  of  a stick.  The  alkali  acts 
more  speodily  than  the  acetic  acid,  and  effects  a 
more  thorough  cautery  of  the  vascular  plexus, 
from  which  the  hypertrophous  papillae  derivo 
their  capillary  loops.  The  verrucae  digitatae  of 
the  scalp  are  speedily  and  easily  removed  by 
this  process.  In  the  exanthematous  form  the 


VERRUCA. 

verrueae  are  too  small  and  too  numerous  for  the 
caustic  application.  These  may  he  treated  by 
frictions  of  sulphur  ointment  or  tar  ointment ; 
and  in  this  latter  form  the  rerrucae  are  fre- 
quently entirely  removed  by  a course  of  treat- 
ment with  liquor  arsenicalis,  in  three-  or  four- 
minim  doses,  taken  immediately  after  meals, 
three  times  a day.  Erasmus  Wilson. 

VEBTIGO  ( verto , I turn). — Synon.  : Giddi- 
ness ; Dizziness ; Swimming  of  the  head ; Er. 
Jrertige;  Ger.  Schwindel. 

Definition. — The  consciousness  of  disordered 
equilibration. 

Physiological  Relations. — To  understand 
vertigo  normal  equilibration  must  be  briefly 
considered.  The  equipoise  is  maintained  by  a 
sensori-motor  mechanism.  The  coordinating 
centre  is  the  cerebellum ; the  afferent  or 
sensory  apparatus  consists  of  visual,  tactile, 
and  labyrinthine  impressions ; the  efferent  or 
motor  apparatus  are  the  muscles,  chiefly  those  of 
the  head,  neck,  and  spine.  Derangement  of  any 
part  of  this  mechanism  may  lead  to  vertigo, 
by  interruption  of  its  power  of  adjustment. 
Vertigo  is  often  associated  with  reeling  or  stag- 
gering, and  is  incorrectly  said  to  cause  it. 
Actually  vertigo  is  the  consciousness  of  dis- 
turbed locomotor  coordination — a rudimentary 
disorder  of  coordination  of  locomotive  movements 
(Hughlings  Jackson),  whilst  reeling  is  an  adap- 
tive effort  to  preserve  the  equilibrium.  A fact 
that  supports  the  assertion  that  vertigo  is  a 
rudimentary  disorder  of  coordination,  is  that 
when  in  a person,  who  has  a sensation  as  if  he 
were  moving  or  turning  in  a certain  direction, 
movements  actually  take  place,  they  are  always 
in  the  direction  in  which  he  previously  felt  he 
was  turning  when  no  outward  movements  oc- 
curred. Experimental  researches  and  observa- 
tions in  disease  have  established  the  conclusion 
that  the  semicircular  canals  take  an  important 
share  in  normal  equilibration;  injury  and  disease 
of  these  parts  occasioning  locomotive  incoordina- 
tion, temporary  when  one  side  only  is  deranged, 
permanent  when  both  s'.des  are  involved.  The 
arrangement  of  the  semicircular  canals,  and  the 
physical  principles  involved  in  their  actions,  are 
very  complicated,  but  have  been  carefullystudied 
and  explained  by  Flourens,  Cyon,  Crum-Brown 
and  others  ; and  it  has  been  demonstrated  by 
Elourens  that  injury  of  each  canal  is  followed  by 
definite  locomotive  disturbance,  causing  the  body 
to  tend  to  fall,  or  actually  to  fall,  in  a definite 
and  precise  direction,  forwards,  backwards,  or  to 
one  or  other  side,  according  to  which  of  them  is 
injured.  The  sensory  impressions  originating  in 
the  semicircular  canals  are  caused  by  varying  ten- 
sion of  the  endoiymph, communicated  to  the  vesti- 
bular division  of  the  auditory  nerve  spread  out  on 
the  ampullae  of  the  membranous  canal.  Variations 
in  labyrinthine  tension  may  be  produced  by  alter- 
ations in  the  position  of  the  head,  by  differences 
in  the  vascular  tension  of  the  labyrinthine  blood- 
vessels, and  by  the  varying  pressure  in  the 
middle  chamber  of  the  ear,  induced  by  obstruc- 
tion of  the  Eustachian  tube,  spasm  of  the  tensor 
tympani  muscle,  and  other  causes;  and  it  may 
also  be  due  to  disease  of  the  labyrinth  itself, 
or  communicated  to  the  labyrinth.  Visual  and 
110 


VERTIGO.  1745 

tactile  impressions  are  liable  to  be  deranged  i? 
many  ways,  for  instance,  by  unexpected  or  un- 
usual movements,  as  in  swinging,  being  at  sea, 
&c. ; by  local  disease  of  the  visual  and  tactile 
apparatus;  and  by  disease  in  the  nerve-trunk3 
and  spinal  cord,  interrupting  conduction  from  the 
periphery  to  the  centre.  By  disturbances  in  visual, 
tactile,  or  labyrinthine  impressions  the  equili- 
brising  centre  is  uninformed  or  misinformed, 
and  incoordination  results,  outwardly  shown  by 
reeling  or  falling,  and  inwardly  by  the  sensation 
we  call  vertigo.  Loss  or  perversion  of  visual  or 
tactile  sensations  may  be  compensated  for,  if  tho 
two  remaining  sensory  processes  continue  intact, 
but  nothing  compensates  for  entire  loss  of  laby- 
rinthine impressions  (Ferrier).  The  vestibular 
nerve  which  is  distributed  to  the  semi-circular 
canals  is  a branch  of  the  auditory,  the  nucleus  of 
which  in  the  medulla  is  in  close  relation  with 
that  of  the  vagus ; and  thus  the  fact  is  ex- 
plained that  disturbances  in  the  large  area  of 
distribution  of  the  pneumogastric  are  found 
associated  with  labyrinthine  disease,  by  propa- 
gation of  the  irritation  from  the  nucleus  of  the 
auditory  to  that  of  the  adjacent  vagus ; and 
conversely  the  intimate  association  of  these  two 
nuclei  enables  us  to  understand  how  disease  of 
the  jstomneh  and  other  viscera  occasions  vertigo. 
It  must  further  be  borne  in  mind  that  the  laby- 
rinth receives  its  blood-supply  from  the  vertebral 
artery,  which  at  its  origin  from  the  subclavian 
is  in  near  propinquity  to  the  inferior  cervical 
ganglion  of  the  sympathetic,  from  which  it  re- 
ceives a rich  plexus  of  nervous  filaments.  The 
inferior  cervical  ganglion  also  sends  communi 
eating  branches  to  the  vagus,  and  branches  to 
the  heart.  In  this  double  way,  therefore,  tho 
labyrinth  has  important  nervous  relations  with 
the  stomach,  heart,  and  other  organs. 

Pathology. — Vertigo  may  be  excited  by  va- 
riations in  the  local  or  general  blood-pressure, 
which  cause  variations  in  the  labyrinthine  ten- 
sion, as  in  anaemia,  gout,  and  other  affections. 
Tho  symptom  is  also  produced  by  certain  drugs, 
such  as  quinine,  salicin,  and  the  salicylates, 
which  act  probably7  on  the  labyrinth  through  the 
vascular  system. 

Vertigo  may  be  divided  into  degrees  or  stages, 
namely,  (1)  a feeling  of  confusion  and  instability ; 
(2)  a feeling  as  if  objects  are  moving;  (3)  a 
feeling  as  if  the  individual  himself  is  moving  ; 
and  (4)  actual  movements  of  the  body. 

The  important  forms  of  vertigo  which  occur 
in  practice  will  be  further  considered  under  the 
following  heads:  1.  Ocular;  2.  Auditory; 
3.  Gastric;  4.  Nervous;  5.  Epileptic;  6. 
Migrainous ; 7.  With  organic  brain-dis- 
ease ; and  8.  Gouty. 

1.  Ocular  Vertigo. — Vertigo  is  frequently 
caused  by  ocular  disorders,  and  is  often  mistaken 
for  serious  cerebral  disease.  The  simplest  form 
is  in  paralysis  of  a single  muscle,  as  the  external 
rectus.  The  vertigo  is  not  occasioned  by  the 
diplopia,  but  by  the  incorrect  notion  formed  of 
external  objects  by  the  paralysed  eye,  due  to 
what  is  known  as  ‘ erroneous  projection.’  The 
confusion  thereby  produced  gives  rise  to  vertigo, 
and  often  to  reeling.  One  of  the  most  import- 
ant varieties  of  ocular  vertigo  is  that  occasioned 
by  insufficiency  of  the  internal  recti  muscles — 


VERTIGO. 


1746 

muscular  asthenopia.  This  is  most  commonly  met 
with  in  myopia.  During  reading  these  muscles, 
which  have  long  been  overtaxed  by  exertions 
to  maintain  the  convergence  of  the  eyes  ren- 
dered necessary  when  looking  at  near  objects, 
suddenly  give  way  under  the  strain ; they  relax, 
the  eyeballs  turn  out,  and  the  letters  on  the  page 
become  indistinct,  run  into  each  other  or  overlap, 
and  a sense  of  confusion  and  giddiness  occurs.  It 
is  usually  accompanied  by  aching  at  the  backs 
of  the  eyes,  headache,  and  sometimes  by  nausea. 
Such  cases  are  often  misunderstood  even  by 
medical  men.  Muscular  asthenopia  may  occur 
also  with  hypermetropia ; and  as  a sequel  to 
exhausting  diseases,  such  as  fevers  and  diph- 
theria. For  the  diagnosis  of  the  particular  opti- 
cal defect  and  treatment  the  reader  is  referred  to 
Vision,  Disorders  of. 

2.  Auditory  or  Aural  Vertigo.— Synox.  : 
Vertigo  ah  aure  lesa;  Labyrinthine  vertigo; 
Apoplectiform  vertigo  ; Meniere’s  Disease. 

Auditory  vertigo  is  very  generally  known 
by  the  name  of  Meniere’s  disease,  from  the 
excellent  description  of  the  malady  first  given 
in  1861  by  Meniere.  Under  the  term  Meniere's 
disease  is  grouped  a class  of  cases  in  which 
vertigo  is  caused  by  perversion  or  abeyance  of 
the  labyrinthine  function.  The  labyrinthine  dis- 
turbance may  be  caused  either  (1)  directly  bj?  an 
affection  of  the  labyrinth,  such  as  (a)  hsemor- 
rhage,  (A)  congestion  and  inflammation  ; or  (2) 
indirectly,  by  (a)  disease  of  the  middle  ear  (otitis  . 
media),  (A)  obstruction  of  the  Eustachian  tube, 
(c)  spasm  of  the  tensor  tympani,  or  paralysis  of 
the  stapedius,  or  (d)  irritation  or  obstruction  of 
the  external  auditory  meatus,  and  pressure  on 
the  membrana  tympani,  as  by  cerumen,  foreign 
bodies,  or  by  syringing  the  ears,  especially 
when  the  membrana  tympani  is  perforated. 
Thus  the  labyrinthine  affection  may  be  either 
of  an  irritative  or  of  a destructive  nature,  and 
the  effect  of  the  lesion  will  be  exactly  the  re- 
verse in  the  two  cases  (Ferrier).  That  is  to  say, 
whilst  an  irritative  lesion  would  cause  the 
tendency  to  fall  in  one  direction,  a destruc- 
tive lesion  of  the  same  canal  would  cause  a ten- 
dency to  fall  in  the  opposite  direction.  In 
Meniere’s  disease,  strictly  speaking,  there  is 
always  coincident  affection  of  the  semicircular 
canals  and  cochlea,  as  indicated  by  the  three 
most  important  associated  symptoms  : vertigo, 
tinnitus,  and  deafness.  Accompanying  these  car- 
dinal symptoms  there  are  accessory  phenomena, 
due  to  secondary  visceral  disturbance,  namely, 
pallor,  faintness,  and  nausea  or  vomiting — a con- 
dition of  syncope. 

The  disease  makes  its  appearance,  in  a person 
apparently  quite  well,  or  the  subject  only  of 
some  chronic  auditory  disease,  with  a loud  noise 
in  the  ear,  compared  by  different  persons  to  the 
whistle  of  a steam-engine,  the  firing  of  a gun, 
or  the  roar  of  the  ocean.  When  a person,  as 
•not  infrequently  happens  after  the  first  attack, 
has  an  habitual  noise  in  the  ear,  this  at  the  time 
of  the  attack  is  greatly  exaggerated.  The  noise, 
which  is  wholly  or  principally  in  one  ear,  is  soon 
followed  by  the  feeling  of  giddiness.  This  is 
generally  of  a high  grade,  causing  the  sensation 
of  surrounding  objects  moving  in  some  one  di- 
rection, a feeling  of  translation  of  the  patient's 


body  in  the  same  direction,  or  actual  movement* 
of  the  body.  The  movement,  whether  apparent 
or  real,  is  usually  from  the  side  on  which  the 
ear  is  affected.  In  recurring  attacks  the  move- 
ments, whether  of  objects  or  of  the  individual, 
are  nearly  always  in  the  same  direction.  Usually 
the  sensation  of  movement  is  from  behind  for- 
ward, or  to  one  or  the  other  side,  or  the  patient 
has  a feeling  of  rotation  in  a vertical  axis.  When 
in  bed,  the  room,  bed,  and  occupant  are  felt  as  if 
turning  round  and  round,  or  rising  or  sinking. 
Accompanying  the  vertigo  there  is  reeling,  and 
the  patient  clings  to  surrounding  objects  for 
support.  In  some  cases  the  movement  is  too 
rapid  for  the  patient  to  obtain  security  in  this 
way,  and  he  is  thrown  to  the  ground,  sometimes 
with  such  violence  as  to  occasion  serious  injuries. 
When  falling  takes  place,  it  is  usually  forwards 
or  to  one  side.  It  is,  however,  to  be  especially 
remembered  that,  except  in  rare  cases,  there  is 
no  loss  of  consciousness ; the  patient  being  able 
immediately  after  the  attack  to  describe  the 
sensations  he  experienced,  or  even  to  answer 
questions  in  the  attack  itself.  Following,  in 
more  or  less  rapid  succession,  the  tinnitus  and 
vertigo,  there  occur  nausea  and  in  most  cases 
vomiting,  accompanied  by  pallor  of  the  face; 
the  skin  becomes  cold  and  covered  with  a clammy 
sweat.  In  some  cases  oscillatory  movements  of 
the  eyes  are  observed.  It  is  generally  asserted 
that  objects  appear  to  move  in  a direction 
opposite  to  that  of  the  ocular  movements.  This 
is  not  universally  true ; and  probably,  contrary 
to  the  statements  of  most  writers,  the  apparent 
movements  of  objects  is  in  the  same  direction 
as  the  observed  movements  of  the  eyes.  Gradu- 
ally the  attack  passes  off;  the  noises  in  the  ear 
lessen,  but  deafness  is  left  behind.  The  body 
recovers  its  warmth,  and  the  pallor  subsides, 
but  vertigo  and  vomiting  may  persist  for  some 
hours  or  even  days,  both  being  aggravated  or 
induced  by  rising  from  a horizontal  position. 
Slight  attacks  may  only  last  a few  minutes.  In 
cases  where  there  is  a direct  lesion  of  the  laby- 
rinth, a certain  degree  of  deafness — a limitation 
of  the  field  of  audition,  that  is,  the  loss  of 
certain  sounds  in  the  musical  scale — and  tin- 
nitus remain.  The  patient  is  in  all  other  respects 
well,  except  for  the  dread  of  a recurrence  of  the 
attack.  Occasionally,  however,  a certain  degree 
of  vertigo  and  reeling  persist,  liable  to  be  aggra- 
vated by  gastric  derangement.  A patient  rarely 
escapes  with  one  attack.  Subsequent  attacks 
are  separated  by  distinct  intervals,  but  in  severe 
cases  these  may  become  less  and  less,  until  a 
permanent  vertiginous  state,  of  a most  distress- 
ing character,  may  be  reached,  liable  to  paroxys- 
mal exacerbations.  In  such  very  grave  cases 
spontaneous  cure  may  occur  on  the  establishment 
of  complete  and  permanent  deafness,  or  relief 
may  be  obtained  by  therapeutical  measures. 
When  the  labyrinthine  disturbance  is  secondary 
to  disease  of  some  othor  part  of  the  auditory 
apparatus,  removal  of  the  pirimary  disease,  as 
cerumen  or  tympanic  catarrh,  will,  when  prac- 
ticable, promptly  remove  the  symptoms,  and  the 
attacks  may  not  recur. 

Diagnosis. — Meniere's  disease  has  to  be  dis 
tinguished  from  epilepsy,  apoplexy,  gastric  de- 
rangement, and  other  causes  of  vertigo.  From 


VERTIGO. 


all  of  these  it  is  distinguished,  by  the  invariable 
coexistence  of  tinnitus,  deafness,  and  vertigo, 
■with  in  addition  syncope  and  nausea,  or  vomit- 
ing. The  concurrence  of  the  first  three  symptoms 
shows  that  the  labyrinth  is  involved,  a point 
which  will  be  further  established  by  testing 
audition  with  a tuning-fork  and  watch.  The 
vertigo  is  generally  of  movement  in  a certain 
definite  and  uniform  direction.  There  is  never 
numbness,  tingling,  or  any  sensations  analogous 
to  an  aura ; but  aching  of  the  upper  extremities, 
and  discolouration  of  the  hands  may  occur,  from 
irradiation  of  the  irritation  from  the  inferior 
cervical  ganglion  to  the  brachial  plexus  (Woakes). 
As  to  the  diagnosis  of  the  nature  of  the  labyrinth- 
.ne  affection,  whether  primary  or  secondary,  some 
rules  have  been  laid  down  by  authorities.  If  a per- 
son who  has  formerly  heard  well  becomes  suddenly 
deaf,  or  hard  of  hearing,  with  the  symptoms  of  an 
apoplectic  attack,  and  if  there  is  at  the  same  time 
an  uncertain  and  staggering  gait,  but  no  symp- 
toms of  paralysis  in  the  nerve-tracts,  and  if  the 
examination  shows  a normal  membrana  tympani, 
and  perfectly  permeable  Eustachian  tube,  we  may 
believe  with  great  probability  that  there  is  an 
affection  of  the  labyrinth  (Troltsch).  Deafness 
and  tinnitus  occurring  without  vertigo  indicate  an 
affection  of  the  middle  ear.  Vertigo  and  tinnitus 
without  deafness  may  be  due  to  an  affection  of 
the  middle  ear.  Vertigo,  tinnitus,  and  deafness 
are  certainly  due  to  an  affection  of  the  laby- 
rinth. Careful  otoscopic  examination  should 
be  made,  the  permeability  of  the  Eustachian 
tubes  tested,  and  the  tuning-fork  and  watch 
employed  to  ascertain  the  condition  of  the  con- 
ducting apparatus,  before  an  exact  opinion  can 
be  formed  as  to  the  nature  of  the  labyrinthine 
affection.  Vomiting,  following  the  ingestion  of 
some  rich  or  indigestible  food,  may  be  so  severe 
and  lasting  as  to  monopolise  attention,  and  the 
vertigo  and  tinnitus  may  not  be  complained  of. 
In  such  a case,  a mistake  may  readily  occur  in  a 
first  attack. 

Peognosis. — Where  the  labyrinthine  affection 
is  due  to  some  remediable  defect,  the  disease  will 
subside  on  removal  of  the  cause,  such  as  ceru- 
men, tympanic  catarrh,  &c. ; hence  the  great,  im- 
portance of  an  exact  diagnosis  as  to  the  nature  of 
the  case.  When  the  lesion  is  primarily  of  the 
labyrinth,  a certain  degree  of  deafness  and  tin- 
nitus is  nearly  always  left,  and  recurrence  of  the 
attack  is  to  be  anticipated. 

Teeatment. — In  the  attack,  and  for  a short 
time  following  it,  the  recumbent  position  should 
be  strictly  maintained.  .Bromide  of  potassium 
or  ammonium,  in  ten  to  twenty  grains  for  a dose, 
may  be  administered,  and  small  pieces  of  ice 
swallowed.  Next,  any  gastric  derangement 
should  be  corrected,  for  in  some  cases  gastric 
affection  excites  a paroxysm  in  a person  predis- 
posed to  it  by  some  aural  affection,  insufficient 
alone  to  induce  an  attack.  Alkalies  and  vege- 
table bitters,  with  or  without  bismuth,  will 
generally  be  useful  for  this  purpose.  Any 
abnormal  local  condition  must  be  treated.  Sub- 
sequent to  the  attack  quinine  in  full  doses,  3 to  5 
or  10  grains  three  times  a day, perseveringly used, 
is  sometimes  attended  with  the  best  results 
(Charcot).  Gelsemium  and  salicylate  of  soda 
tsavo  been  fouud  useful  (Gowers).  Counter- 


irritants, including  the  actual  cautery,  applied 
to  the  mastoid  region,  have  proved  serviceable 
in  some  cases,  and  may  be  used  in  addition  to 
other  measures. 

3.  Gastric  Vertigo. — Synon.  : Vertigo  a 
sto macho  Iceso. 

Vertigo,  occasionally  of  a high  grade,  some- 
times accompanies  chronic  gastric  derangement. 
It  is  more  common  with  slight  than  with  grave 
affections  of  the  stomach,  but  has  been  met  with 
in  well-marked  organic  disease  of  this  organ. 
An  explanation  of  its  occurrence  has  been  given 
in  the  introductory  remarks.  It  sometimes 
occurs  soon  after  a meal,  but  more  often  when 
the  stomach  is  empty  (Trousseau).  Associated 
with  it  are  usually  pain  and  a feeling  of  fulness 
in  the  stomach,  increased  by  food  ; heartburn  ; 
eructations;  vomiting;  flatulence; andpain in tho 
left  hypocliondrium  and  chest.  The  bowels  may  be 
torpid,  or  diarrhoea  may  be  present.  The  patient, 
often  suddenly  experiences  a swimming  in  the 
head,  objects  may  appear  to  revolve,  the  patient's 
gait  becomes  tottering,  and  he  may  even  fall. 
Often  there  is  constrictive  headache,  faintness 
and  pallor  with  nausea,  and  sometimes  trouble- 
some vomiting,  but  there  is  no  loss  of  conscious- 
ness. Visual  hallucinations  may  be  present,  and 
buzzing  in  the  ears  experienced,  but  there  is  no 
deafness.  The  vertiginous  symptoms  may  so 
predominate  that  the  gastric  symptoms  may  not 
be  complained  of,  but  treatment  directed  against 
dyspepsia  cures  the  vertigo.  When  predisposing 
gastric  disturbance  is  present,  trivial  causes, 
such  as  looking  at  objects  which  lead  to  con- 
fused visual  impressions,  may  excite  an  attack, 
but  this  may  also  arise  spontaneously.  In  many 
cases  relief  is  obtained  by  the  recumbent  posi- 
tion, but  attacks  may  occur  when  the  patient  is 
lying  down. 

Diagnosis. — This  form  of  vertigo  is  diagnosed 
from  epilepsy  by  absence  of  loss  of  consciousness  ; 
and  from  labyrinthine  vertigo  by  the  absence  of 
deafness,  and  the  physical  signs  of  aural  disease. 
It  cannot  be  concluded  that  the  vertigo  is  essen- 
tially gastric  without  thorough  examination  of 
the  ears,  for,  as  already  stated,  vertigo  may  be 
excited  by  gastric  disturbance  when  there  is  laby- 
rinthine affection  insufficient  alone  to  determine 
an  attack.  It  must  also  be  remembered  that 
signs  of  gastric  and  intestinal  derangement  are 
induced  in  Meniere's  disease,  and  may  be  so 
prominent  as  to  cause  the  aural  affection  to  be 
overlooked. 

4.  Nervous  Vertigo. — Synon.:  Er.  Vertigc 
nerveuse. 

Not  uncommonly  vertigo  is  one  of  the  most 
troublesome  symptoms  of  nervous  exhaustion 
and  depression.  This  occurs  in  persons  unduly 
taxing  their  nervous  powers,  by  severe  in- 
tellectual strain,  especially  when  combined  with 
anxiety,  or  by  sexual  excesses.  It  occurs  also 
from  the  depressing  effects  of  the  immoderate 
use  of  tobacco,  alcohol,  and  tea.  The  vertigo 
rarely  reaches  a high  grade,  manifesting  itself 
by  a sensation  of  confusion,  or  of  objects  re- 
volving, occasionally  only  by  the  feeling  of  a 
tendency  to  fall.  It  may  be  associated  with  a 
slight  reel,  but  more  often  the  patient  feels 
as  if  he  were  walking  unsteadily,  when  there  is 
no  perceptible  peculiarity  of  gait.  As  a rule 


1748  VERTIGO. 

giddiness  is  only  experienced  in  the  upright 
position,  but  in  some  cases  it  occurs  ■when  the 
subject  is  recumbent,  and  the  patient  often  com- 
plains of  sudden  and  violent  startings  when  just 
in  the  act  of  falling  asleep.  It  is  often  intensified 
by  an  elevated  position,  and  in  large  buildings 
and  assemblies.  Hence  it  is  often  experienced 
in  church.  It  is  peculiarly  distressing,  owing  to 
the  sufferer’s  emotional  equilibrium  being  easily 
disturbed,  and  is  frequently  associated  with  a 
dread  of  impending  cerebral  disease — epilepsy, 
apoplexy,  insanity,  etc.  There  often  coexist 
gastric  derangement  and  flatulence,  with  irrita- 
bility of  the  heart,  palpitation,  and  sleeplessness, 
the  former  no  doubt  having  a share  in  its  pro- 
duction. There  may  be  slight  and  temporary 
buzzing  in  the  ears,  but  deafness  is  absent,  and  no 
loss  of  consciousness  occurs.  In  these  respects 
it  is  readily  distinguished  from  Meniere’s  disease 
and  •petit  mal. 

Treatment. — This  is  to  be  treated  by  removal 
of  the  cause — over-work,  excessive  sexual  indul- 
gence, or  the  abuse  of  alcohol,  tobacco,  or  tea  ; 
by  correction  of  any  dyspeptic  symptoms;  and 
by  the  administi'ation  of  nervine  tonics,  such  as 
iron,  quinine,  or  strychnia.  Bromides  should  be 
avoided  if  possible. 

5.  Epileptic  Vertigo. — Vertigo  may  occur  in 
a slight  fit  of  epilepsy,  or  at  the  commence- 
ment of  a severe  attack.  The  symptom  may 
replace  an  epileptic  fit,  or  may  coexist  with  epi- 
lepsy. It  is  more  common  in  epileptic  vertigo 
for  the  patient  to  imagine  that  he  himself  is 
moving  or  turning  round,  than  for  external 
objects  to  appear  in  motion  (Russell-Reynolds). 
Care  must  be  taken  not  to  accept  the  patient's 
mere  statement  of  ‘ giddiness.’  The  term  is 
often  loosely  applied.  It  is  necessary  to  ascertain 
his  exact  sensations,  and  only  to  conclude  there 
is  vertigo  when  actual  feelings  of  movement  are 
experienced.  If  the  vertigo  is  related  to  change 
of  position  of  the  head,  it  is  probably  labyrin- 
thine. The  latter  is  not  usually  accompanied  by 
loss  of  consciousness,  and  is  more  apt  to  be 
followed  by  vomiting  (Gowers). 

6.  Migrainous  Vertigo. — Vertigo  commonly 
constitutes  one  of  the  phenomena  of  migraine, 
occurring  as  a rule  after  the  disorders  of  sight, 
touch,  and  speech,  when  these  form  part  of  the 
seizure,  and  either  attends  or  follows  the  de- 
velopment of  the  headache  (Liveing).  Vertigo 
sometimes  replaces  the  attacks  of  migraine.  It  is 
apt  to  occur  on  change  of  posture,  or  on  suddenly 
turning  the  head.  As  a rule  migrainous  vertigo 
is  slight  in  degree,  but  it  may  be  quite  severe, 
and  accompanied  by  nausea  and  vomiting.  It  is 
unassociated  with  noises  in  the  ear,  or  with 
deafness.  See  Megrim. 

7.  Vertigo  in  connexion  with  organic 
disease  of  the  nervous  system.— Vertigo 
sometimes  accompanies  disease  of  the  cerebrum, 
both  acute,  as  apoplexy,  and  chronic,  as  tumours. 
There  are  reasons  for  believing  that  vertigo  may 
be  excited  by  cortical  lesions,  thus  explaining 
epileptic  and  migrainous  vert  igo.  Disease  of  tho 
cerebellum  and  of  its  middle  crura  are  often 
attended  with  reeling  gait,  and  sometimes  with 
vertigo.  This  symptom  sometimes  accompanies 
the  ataxy  of  tabes  dorsalis ; and  is  a marked 
symptom  of  some  cases  of  insular  sclerosis. 


VIBRATION. 

8.  Gouty  Vertigo. — Vertigo,  labyrinthine  or 
other,  is  occasionally  met  with  in  gouty  persons. 
It  may  disappear  after  an  outburst  of  gouty 
arthritis  ; or  be  removed  by  alkalies,  colchieum, 
and  other  proper  remedies,  and  attention  to  diet. 

Stephen  Mackenzie. 

VESICAL  DISEASES.  See  Bl addeb, 

Dissases  of. 

VESICANTS  ( vesico , I blister). — A class  of 
counter-irritants  which  produce  blisters.  Set 
Counter-Irritants. 

VESICLE  ( vesicula , diminutive  of  vesica,  a 
bladder). — Synon.  : Fr.  Vcsicule ; Ger.  Bldschcn. 

Definition. — An  elevation  of  the  corny  layer 
of  the  epidermis,  caused  by  a minute  circum- 
scribed collection  of  serum  or  sero-pus,  between 
it  and  the  mucous  layer  beneath. 

Description. — Vesicles  may  he  minute  or  of 
considerable  dimensions  ; a vesicle  of  the  size  of 
a millet-seed  gives  the  name  to  the  cutaneous 
affection  miliaria.  The  vesicles  of  eczema  are 
minute  and  frequently  confluent ; those  of  scabies 
are  occasionally  acuminated;  the  vesicles  of  va- 
rioloid are  not  uncommonly  umbilicated  ; tho30 
of  herpes  iris  are  developed  in  rings  ; the  vesiclea 
of  ordinary  herpes  attain  the  bulk  of  a split  pea ; 
and  the  vesicles  of  pemphigus,  on  account  of  their 
large  size,  are  called  ‘ bullae.’  The  contents  of  s 
vesicle  are  apt  to  modify  its  name,  since  a vesicb. 
containing  a purulent  fluid  or  pus  is  termed  t 
‘ pustule.’  The  ordinary  course  of  a vesicle  is  te 
lose  its  fluid  by  evaporation,  absorption,  or  rup- 
ture of  the  distended  cuticle ; to  dry  up  into  a 
thin  scale  ; and  to  terminate  by  desquamation, 
without  further  lesion  of  the  skin. 

Treatment. — The  treatment  of  vesicles  is 
fully  described  under  the  heads  of  the  several 
diseases  of  which  they  are  a symptom.  See 
Chicken-pox  ; Herpes  ; Miliaria  ; and  Pem- 
phigus. Erasmus  Wilson. 

VESICULAR  EMPHYSEMA.— A form 
of  emphysema  of  the  lungs,  in  which  the  alveoli 
are  distended  with  air.  See  Lungs,  Emphysema  of. 

VIABLE  (vie,  life). — Synon.:  Fr.  Viable-, 
Ger.  Lebendig. — An  epithet  applied  to  a newly- 
born  child,  to  indicate  its  capacity  for  maintain- 
ing an  independent  existence.  Viability  has 
chiefly  to  be  determined  by  the  age  of  the  foetus, 
and  by  its  condition  as  regards  formation,  health, 
and  strength  ( see  Fcetus,  Diseases  of).  It  has 
also  been  supposed  to  depend  in  some  measuro 
upon  the  season  of  the  year  in  which  a child  is 
born  (see  Periodicity  in  Disease).  The  question 
of  viability  has  important  medico-legal  bearings, 
for  which  reference  must  be  made  to  works  upon 
forensic  medicine. 

VIBICES  (viler,  a wale). — Synon.  : Fr.  Ver- 
getures  ; Ger.  Striemen. — A term  applied  to 
patches  cf  discolourisation  on  the  surface  of  the 
body,  somewhat  resembling  the  marks  of  stripes 
or  wales,  and  due  to  the  presence  of  altered 
blood  in  the  part.  Vibices  may  arise  either 
during  life,  as  the  result  of  a variety  of  causes 
(see  Extravasation)  ; or  after  death,  as  one 
form  of  cadaveric  liridity  or  hypostasis.  See 
Death,  Signs  of. 

VIBRATION. — This  word  is  sometimes  em- 
ployed as  a synonym  for  fremitus.  See  Fremitus 


VIBRIO. 

"VIBRIO  ( [vibro , I shake). — Synon.  : Fr.  Vi- 
brion ; Ger.  Zitterthierchen.  See  Bacteria. 

VICARIOUS  ( vicarius . in  place  of  another). 
This  word  signifies  substitution,  and  in  physio- 
logy and  pathology  implies  that  some  part  or 
organ  performs  certain  functions,  or  is  morbidly 
affected,  instead  and  in  the  place  of  some  other 
part  or  organ,  thus  becoming  a substitute  for  it. 
The  notion  of  vicariousness  is  chiefly  associated 
•with  a discharge  of  blood,  whether  physiological 
or  morbid.  Thus,  it  is  very  common  to  speak 
about  vicarious  menstruation,  which  is  under- 
stood to  mean  that  the  discharge  of  blood  which 
takes  place  normally  from  the  uterus  at  the 
menstrual  period,  either  does  not  occur  at  all, 
or  only  imperfectly,  and  that  its  place  is  taken  by 
haemorrhage  from  some  other  part,  evidenced 
by  epistaxis,  haemoptysis,  haematemesis,  or  other 
forms  of  bleeding.  The  same  idea  is  extended  to 
morbid  haemorrhages,  such  as  bleeding  from 
piles,  when  this  becomes  habitual  in  an  indivi- 
dual at  frequent  or  regular  intervals.  It  is  sup- 
posed that  bleeding  may  sometimes  take  place 
from  other  parts  as  a vicarious  hsemorrhuge, 
instead  of  from  the  haemorrhoids. 

Again,  discharges,  whether  normal  or  morbid, 
as  of  secretions,  mucus,  pus,  or  other  materials, 
are  believed  by  many  to  exhibit  a vicarious  re- 
lation to  each  other  in  some  instances,  coming 
from  one  part  while  ceasing  or  diminishing  at 
another,  and  so  on.  This  may  be  illustrated  by 
expectoration  and  diarrhoea  in  phthisis,  which 
appear  to  modify  each  other  as  to  their  amount 
in  some  cases  of  this  disease.  Further,  secretions 
and  excretions  are  regarded  as  acting  vicariously 
with  reference  to  each  other.  Thus  some  of  the 
secretions  of  the  alimentary  canal  are  undoubt- 
edly capable  of  acting  mutually  as  substitutes, 
and.  this  may  be  looked  upon  as  an  instance  of 
vicarious  action  ; while  such  a connection  exist- 
ing between  the  perspiration  and  urine  is  gene- 
rally recognised. 

Certain  morbid  conditions  are  also  considered 
as  having  a vicarious  relation.  For  example,  con- 
gestion of  or  hsemorrhage  from  one  part  may  take 
the  place  of  congestion  at  another;  or  inflamma- 
tion in  one  region  may  be  the  substitute  for  in- 
flammation in  another  region. 

There  is  probably  more  or  less  truth  in  these 
notions  of  vicariousness,  as  applied  in  relation 
to  physiology  and  pathology.  In  actual  practice, 
however,  no  case  ought  to  be  regarded  as  belong- 
ing to  this  category,  without  careful  and  thorough 
investigation.  It  has  happened  that  haemor- 
rhages supposed  to  be  vicarious  of  menstruation, 
have  been  important  signs  of  grave  diseases,  such 
as  gastric  ulcer,  or  pulmonary  phthisis.  The 
principle  may  be  of  value  in  certain  conditions 
as  an  indication  for  treatment. 

Frederick  T.  Roberts. 

VICHY,  in  France. — Thermal  alkaline 
waters.  See  Mineral  Waters. 

VIGILIA. — Wakefulness;  a term  formerly 
applied  to  conditions  of  insomnia,  but  now  little 
used  and  almost  obsolete.  See  Sleep,  Disorders 
of ; and  Coma- Vigil. 

VILLOUS  GROWTH  {villus,  hair).— 
Synon.  ; Fr.  Villen  t;  Ger.  Villos;  Zottig. — 


VISION,  DEFECTS  OF.  1749 
A growth  composed  of  hypertrophied  villi.  Set 
Tumours. 

VIRGINIA  SPRINGS,  in  Virginia, 
United  States. — Sulphur  waters.  See  Mineral 
Waters. 

VIRULENT  {virus,  a poison). — Primarily 
this  word  signifies  connected  with  virus  or 
poison.  It  is  generally,  however,  employed  to 
indicate  great  intensity  or  malignancy  of  disease; 
for  example,  virulent  inflammation,  virulent  bubo, 
and  virulent  small-pox. 

VIRUS  (Lat.). — Literally  this  word  signifies 
a poison,  but  in  medical  language  it  is  used  to 
designate  any  kind  of  contagious  material.  See 
Contagion. 

VISION,  Defects  of. — Stnon.  : Fr.  Troubles 
de  la  Vision ; Ger.  Sehenstohrungen. 

Sight  may  be  defective  as  to  perception  of 
form,  of  colour,  or  of  light ; and  the  whole,  or 
only  a part,  of  the  visual  field  may  be  affected. 
Sight  is  also  disordered  whenever  binocular 
single  vision  becomes  difficult  or  impossible  {see 
Strabismus)  ; and  when  visual  endurance  is  im- 
paired. The  terms  ‘ vision  ’ and  ‘ sight,’  as  com- 
monly nsed,  indicate  acuteness  of  vision,  and 
refer  to  the  perception  of  form  at  the  yellow 
spot.  In  this  article  disorders  (A)  of  percep- 
tion. of  light,  (B)  of  perception  of  colour, 
and  (C)  of  the  visual  field,  will  be  shortly 
alluded  to ; hut  attention  will  be  chiefly  given 
to  (D)  disorders  of  acuteness  of  vision  caused 
by  optical  defects  in  the  eyes. 

A.  Disorders  of  Perception  of  Light. — 
Perception  of  light  is  equally  good  in  all  parts  of 
the  retinal  area,  except  the  most  peripheral  zone, 
which  appears  to  be  blind.1  Impaired  perception 
of  light  causes  disproportionate  defect  of  vision 
by  dull  light — ‘ night-blindness  ’ {see  Nycta- 
lopia). It  may  affect  the  whole  field,  or  only 
its  periphery.  It  occurs  chiefly  in  diseases  of  the 
outer  layers  of  the  retina,  especially  syphilitic 
retinitis,  and  retinitis  pigmentosa.  Lowered 
light-sense  over  the  whole  field  occasions  the 
symptoms  in  the  peculiar  disease  known  as  func- 
tional or  endemic  nyctalopia  {torpor  retina).  The 
opposite  condition,  day-blindness  {see  Hemera- 
lopia), with  true  retinal  photophobia,  is  much 
rarer  and  more  obscure.  It  is  usually  congenital, 
and  accompanied  by  nystagmus,  amblyopia,  and 
colour-blindness  ; and  acuteness  of  sight,  which 
is  defective,  is  best  by  dull  light. 

B.  Colour-Blindness. — Synon.:  Dyschroma- 
topsia;  Achromatopsia. — This,  when  congenital,  is 
usually  not  related  to  any  other  defects  of  vision. 
Congenital  colour-blindness  occurs  with  greater 
intensity  and  far  greater  frequency  in  males  than 
in  females  (M.  3 to  5 per  cent. ; E.  "2  per  cent,  or 
less).  It  is  shown  by  more  or  less  want  of  power 
to  distinguish  between  certain  complementary 
colours.  Red  and  green  are  the  two  commonly 
confused,  the  perception  of  blue  and  yellow  being 
but  rarely  affected.  Blindness  for  all  colours  is 
very  rare  except  as  the  result  of  disease.  There 
are  many  degrees  of  colour-blindness.  A red- 
green-blind  person  sees  in  the  spectrum  only 
two  colours,  separated  by  a neutral  stripe,  which 
is  placed  somewhere  in  the  greenish-blue ; all  the 
colours  on  the  side  of  the  red  (‘warm’  colours) 

1 Landolt,  Arch.  d'Oplh.,  i.  203, 18S1. 


VISION,  DEFECTS  OF. 


1750 

are  confused  together,  and  all  on  the  side  of  the 
violet  (‘cold’  colours),  but  the  warm  and  the 
told  are  never  confused  (Donders).1  In  incom- 
plete red-green-blindness,  green,  bluish-green, 
and  often  rose  are  confused  with  grey  of  corre- 
sponding shade,  and  red  is  confused  with  shades 
of  brown  and  greenish-brown.  In  a complete 
case  full  green  and  scarlet  are  confused.  The 
best  test  for  ordinary  use  is  the  one  due  to  Holm- 
gren of  Upsala,  in  which  a skein  of  Berlin  wool, 
of  a particular  colour  and  shade  (green,  rose,  or 
red),  is  given  to  the  patient,  and  he  is  required 
to  match  it  with  all  the  others  which  seem  to 
him  of  the  same  or  a similar  colour,  amongst  a 
large  bundle  of  skeins  of  many  colours.  He  is 
not  usually  allowed  to  name  the  colours,  because 
even  the  colour-blind  often  guess  the  colours  of 
common  objects  correctly.  A very  pale,  pure 
green  is  the  first  test  used,  and  the  colour-blind, 
even  of  slight  degrees,  will  match  with  it  not  only 
other  green  skeins,  but  also  shades  of  pale  grey, 
buff,  and  pink.  • Slight  cases  may  easily  be  over- 
looked, unless  the  wools  are  carefully  selected, 
and  the  examiner  practised.  Stilling's  plates  of 
coloured  let!  ers,  printed  on  a groundwork  of  com- 
plementary colours,  are  also  very  valuable.  Red 
and  green  are  not  well  seen  under  ordinary 
circumstances,  even  by  the  normal  eye,  except 
at  the  central  part  of  the  visual  field  (i.e.  the 
field  for  these  colours  is  smaller  than  for  white  ; 
but  even  at  the  periphery  these  colours  are  re- 
cognised if  very  brightly  lighted  and  of  large  size.2 
Acquired  colour-blindness  often  comes  on  in 
degenerative  or  inflammatory  diseases  which  be- 
gin in  the  optic  nerve.  It  is  much  less  common 
in  diseases  of  the  retina,  and  in  glaucoma.  Like 
the  congenital  form,  it  usually  concerns  only,  or 
chiefly,  red  and  green.  It  may  affect  the  whole 
visual  field  of  these  colours,  or  only  certain 
parts,  a gap,  or  ‘ scotoma,’  being  present,  on 
w'hose  area  the  red  and  green  are  not  perceived 
in  their  true  colours.  When  acquired  colour- 
blindness is  well-marked  in  the  whole  extent  of 
the  field,  in  cases  of  disease  of  the  optic  nerve, 
the  prognosis  for  sight  is  generally  very  bad;  but 
if  it  be  localised  on  a central  scotoma,  even 
though  it  there  reach  a high  degree,  the  prog- 
nosis is  usually  good.  Progressive  atrophy  of 
the  optic  nerve,  however,  occasionally  reaches 
a very  high  degree  without  any  colour-defect. 

C.  Disorders  of  tire  Visual  Field. — The 
visual  field  is  the  whole  surface  visible  to  one 
eye  singly  whilst  at  rest.  It  forms  a con- 
cave surface,  all  the  points  of  which  are  equi- 
distant from,  and  perpendicular  to,  their  corre- 
sponding points  on  the  retina.  In  the  outward 
and  downward  part  it  reaches  to  95°  from  the 
centre;  jnwards,  upwards,  and  downwards  only 
to  about  60°.  Projected  on  a flat  surface  it  thus 
forms  an  oval.  The  centre  of  the  field  (‘  fixation 
point  ’)  corresponds  to  the  yellow  spot,  and  the 
‘blind  spot’  is  about  15°  outwards  from  this 
point.  In  order  to  measure  the  field  roughly, 
the  patient,  placed  with  his  back  to  the  light 
and  covering  one  eye,  looks  steadily  from  a dis- 
tance of  eighteen  inches  at  the  nose  or  eye  of 
the  observer,  who  then  moves  his  hands  about 
in  the  different  parts  of  the  field,  and  notes  any 

1 Donders,  Brit.  Med.  Jour.,  1880,  ii.  767. 

3 Landolt,  Examination  of  the  Eye,  p.213. 


places  whero  the  hand  is  invisible  or  badly  seen. 
This  test,  carefully  applied,  will  detect  any  con- 
siderable loss  of  the  field.  Or  the  patient  may 
gaze  at  a spot  on  a black  board  about  one  foot 
off,  and  a piece  of  white  chalk  be  moved  from 
different  points  at  the  periphery  until  it  just  be- 
comes visible  ; a line  joining  the  various  points 
will  form  the  boundary  of  the  field.  For  accurate 
measurements,  however,  a special  instrument, 
the  Perimeter,  is  necessary. 

D.  Disorders  of  Perception,  of  Form. — 
Perception  of  Form,  Synon.  : Acuteness  of  Vision  ; 
Visus ; V. ; Fr.  Ac  idle  visuelle;  Ger.  Sehschdrfe ; 
S.—  Perception  of  form  is  normal  only  when  the 
image  of  the  object  looked  at  falls  on  the  bacil- 
lary layer  of  the  retina,  at  the  centre  of  the 
yellow  spot,  is  clearly  defined,  sufficiently  bright, 
and  of  a certain  minimum  size. 

Phixciples. — The  size  of  the  image  depends 
(1)  upon  the  size  of  the  ‘visual  angle’  enclosed 
by  the  two  lines  drawn  from  the  extremities  of 
the  object  to  the  ‘nodal  point’  just  behind  the 
crystalline  lens;  and  (2)  on  the  distance  of  the 
nodal  point  from  the  retina,  which  in  the  normal 
eye  is  15  mm.  The  form  of  any  letter  or  cha- 
racter is  distinguished  by  a properly  formed  and 
healthy  eye,  with  average  light,  if  it  subtend  a 
visual  angle  of  five  minutes,  each  of  its  sepa- 
rately distinguishable  parts  subtending  an  angle 
of  ono  minute.  If  the  nodal  point  be  more  than 
fifteen  millimetres  from  the  retina,  the  image  will 
be  larger,  and  acuteness  of  vision  therefore  in- 
creased; this  occurs  in  myopia,  and  also  when  a 
convex  glass  is  held  in  front  of  the  eye.  The 
reverse  is  true  if  the  distance  be  less  than  fifteen 
mm.,  as  in  hypermetropia,  and  when  a concave 
glass  is  held  before  the  eye.  Hence  convex 
lenses  always  increase,  and  concave  lenses  always 
diminish,  the  size  of  the  retinal  images.  Vision 
or  ‘ fixation’  is  called  direct  or  central  when  the 
image  of  the  object  looked  at  falls  on  the  yellow 
spot;  indirect  or  excentric  when,  in  consequenco 
of  impairment  of  function  at  the  yellow  spot,  an 
image  falling  on  some  other  part  is  better  seen. 
The  clearness  of  the  image  depends  (opacities 
of  the  media  apart)  upon  the  retina  being  exactly' 
at  the  focus  of  the  refracting  (dioptric)  media  of 
the  eye  ; it  is  also  influenced  somewhat  by  the 
size  of  the  pupil,  being,  cceteris  paribus,  better 
when  the  pupil  is  small. 

Normal  acuteness  of  vision  is  expressed  as 
unity  (V.  or  S.  = 1);  subnormal  vision  being 
expressed  as  a fraction.  Various  test-types 
are  in  use,  composed  of  letters,  words,  &c.,  of 
such  a size  that  each  subtends  the  minimum 
angle  of  five  minutes  at  a certain  distance.  The 
test-types  of  Dr.  Snellen  are  in  most  general  use, 
and  include  letters  visible  under  the  standard 
angle  at  from  60  metres  to  "5  metre.  If 
No.  CO  be  read  at  60  m.,  then  V.  = §§  or  1 ; if 
No.  60  can  only  be  seen  at  6 m.  V.  = ^ ; &c. 
V.  therefore  is  expressed  by  a fraction  whose  nu- 
merator is  the  greatest  distance  at  which  a given 
type  can  be  read,  and  the  denominator  the  dis- 
tance at  which  it  ought  to  be  seen  ; or  the  frac- 
tion may  be  reduced  (j^  = ^,  &c.).  The  acuteness 
is  said  to  become  progressively  lower  after  the 
age  of  sixty,  without  disease;  so  that  at  eighty 
it  is  only  about  ^ (Donders).1 

1 Anomalies  of  Accommodation  and  Refraction,  p.  19& 


VISION,  DEFECTS  OF. 


1.  Functional  Affections  of  the  Optic 
Nervous  Apparatus. — Amblyopia  without 
ophthalmoscopic  changes  may  be  permanent  or 
temporary,  and  exhibit  many  differences  in  the 
character  of  tho  failure  of  sight.  The  positive  dis- 
use (suppression  of  the  retinal  image)  of  one  eye, 
in  order  to  avoid  diplopia  or  the  confusion  some- 
times caused  by  opacity  of  the  cornea  or  other 
defect,  leads  to  permanent  and  great  defect  of  that 
part  of  the  visual  field  -which  is  common  to  both 
eyes,  ‘amblyopia  ex  anopsia.’  The  defect  is  psy- 
chical, and  the  eye  shows  no  changes.  It  is  most 
easily  acquired  early  in  life,  and  may  be  partly 
remedied  by  separate  use  of  the  eye.  In  cere- 
bral hemiansesthesia  there  may  be  blindness,  or 
high  amblyopia  with  great  contraction  of  the 
field  and  colour-blindness  in  the  eye  opposite 
to  the  lesion,  with  a lower  degree  of  the  same 
condition  in  the  other  eye.  Some  rare  cases  of 
permanent  loss  of  sight  in  one  eye  without 
changes,  in  which  there  is  a history  of  previous 
paralytic  symptoms, probablybelongto  this  group. 
In  hemiopia  (properly  hemianopsia ) there  is 
usually  loss  of  the  corresponding  halves  of  the 
visual  fields,  vision  being  lost  on  the  side 
opposite  to  the  lesion ; when  the  loss  of  field 
extends  quite  up  to  the  fixation-point,  affecting 
central  vision,  the  lesion  is  probably  somewhere 
between  the  chiasma  and  corpora  genieulata ; 
but  when  an  area  of  several  degrees  around  the 
fixation-point  remains  free,  it  is  suggested  that 
the  lesion  is  cerebral.1  Loss  of  both  temporal 
halves  may  indicate  disease  at  the  chiasma ; 
neither  this,  nor  loss  of  both  nasal  halves,  is 
frequent.  In  hemiopia,  even  of  longstanding,  the 
optic  discs  are  seldom  altered.  In  some  cases  of 
‘hemiopia’  only  a quarter  of  each  field  is  lo3t. 
Disease  of  the  optic  nerve  at  a distance  from  the 
rye  causes  blindness  or  defective  sight,  often  at 
first  without  any  ophthalmoscopic  changes ; but  if 
the  defect  remain,  signs  either  of  inflammation 
or  atrophy  appear  in  a few  weeks.  The  oph- 
thalmoscopic changes  may,  however,  be  very 
slight,  as  is  shown  in  the  common  cases  of  central 
amblyopia  usually  caused  by  tobacco-smoking, 
in  which  disease  of  the  optic  nerves  has  now  been 
demonstrated;  with  the  exception  of  this  group, 
casts  of  retro-ocular  disease  of  the  nerve  are  rare. 

Temporary  fogginess  of  sight,  usually  with 
the  appearance  of  coloured  rings  around  a candle, 
occurs  in  the  premonitory  stage  of  glaucoma ; 
these  last  from  half  an  hour  to  a day  or  more ; 
they  do  not  usually  occur  in  both  eyes  at  once  ( see 
Eye  and  its  Appendages,  Diseases  of).  Attacks 
of  megrim  are  often  ushered  in  by  a peculiar, 
transient,  subjective  defect  of  sight;  a small 
cloud,  appearing  near  the  middle  of  the  field, 
quickly  spreads  with  a quivering  movement  and 
zigzag  outline  over  about  half  the  field;  its  bor- 
ders are  often  brilliantly  coloured  ; it  affects  both 
eyes ; is  equally  visible  whether  the  eyes  are 
open  or  shut ; lasts  about  a quarter  of  an  hour ; 
and  is  generally  followed  by  the  other  megrim 
symptoms  to  which  the  patient  is  subject.  But 
some  persons  merely  complain  of  a ‘cloudiness’ 

1 See  Ferrier,  ‘ Cerebral  Amblyopia  and  Hemiopia,’ 
Bruin , January.  1881.  The  subject,  however,  is  far  from 
exhausted  ; see  Robin.  Troubles  Oculaires  darts  les  Mai  de 
V Bnciihale.  p.  390,  1S80,  Haab,  Klin.  Mor.atsbl.f.  Augen- 
‘uilk.  Sic.,  1881,  &c. 


1751 

or  of  ‘ spots  ’ before  their  headaches  (see  Me- 
grim). Brief  attacks  of  blindness  of  one  eye, 
coming  on  quite  suddenly,  and  recurring  in  the 
same  eye,  occasionally  take  place  in  the  sub- 
jects of  heart-disease.  Permanent  blindness, 
with  atrophy  of  disc  or  the  appearances  of  re. 
final  embolism,  has  at  length  supervened  in  a 
few  of  these  cardiac  and  megrim  cases.1 

Persons  who  suffer  from  severe  neuralgic  pain 
in  the  fifth  nerve  sometimes  describe  dimness  of 
the  same  eye  during  an  attack,  but  the  oppor- 
tunity of  verifying  the  statement  seldom  occurs. 
In  connection  with  severe  vertex-headache  in 
hysterical  persons,  sight  is  sometimes  very  bad  ; 
one  eye  may  even  appear  almost  blind.  There 
is  photophobia,  and  there  may  be  symptoms  of 
accommodation-spasm,  and  the  field  is,  or  seems 
to  be,  highly  contracted.  Though  it  may  be 
exceedingly  difficult  to  say  that  there  is  con- 
scious dissimulation,  the  groundless  nature  of 
the  ocular  symptoms  is  sometimes  proved  by  the 
fact  that  acuteness  of  vision,  even  in  the  ‘blind' 
eye,  is  at  once  and  perfectly  restored  by  the 
weakest  possible  lens,  or  by  a piece  of  flat  glass 
mounted  to  resemble  a trial  lens.  Intentionally 
feigned  blindness  of  one  eye  can  nearly  always 
be  detected  by  one  device  or  another ; but  pre- 
tended defect  of  both  eyes  is  more  difficult  to 
expose ; reference  must  be  made  to  works  on 
ophthalmology  for  further  details. 

2.  Abnormalities  of  Refraction. — Synon.  : 
Ametropia. — These  conditions  are  of  importance 
by  preventing  the  formation  of  clear  retinal 
images ; in  addition  they  often  make  the  sus- 
tained use  of  the  eyes  difficult  or  impossible 
(asthenopia).  They  include  (a)  hypennetropia, 
(b)  myopia , and  (c)  astigmatism.  The  varieties 
of  asthenopia  will  receive  a short  separate  ac- 
count after  ‘Disorders  of  Accommodation.’  As 
ametropic  conditions  are  remedied  by  optical 
aids,  it  will  be  convenient  first  to  refer  to  the 
subject  of  spectacles. 

Spectacles. — Varieties  of  Construction  and 
Mode  of  Wearing. — Refracting  spectacles  are 
made  either  of  crown-glass  or  of  rock-crystal. 
The  latter  is  more  expensive  but  harder,  less 
breakable,  and  rather  lighter.  Ordinary  spec- 
tacles are  biconvex  or  biconcave  spherical  lenses. 
Meniscus  lenses  are  sometimes  used,  and  are 
called  ‘periscopic’  because  they  give  a larger 
field.  In  ‘Franklin’  or  ‘pantoscopic’  spectacles 
the  upper  half  is  made  of  a different  focal  length 
from  the  lower ; they  are  sometimes  used  by 
persons  who  need  distance-  and  reading-glasses 
of  different  strengths  in  the  same  frame.  The 
various  non-refracting  protective  glasses  (goggles, 
domed  glasses,  horseshoe-  or  D-protectors,  &c.) 
are  generally  included  under  the  term  ‘ specta- 
cles.’ The  most  important  points  in  the  mount- 
ing of  spectacles  are  that  the  hinges  should  be 
strong,  the  sides  long  enough  to  hold  securely 
without  uncomfortable  pressure,  and  that  the 
bridge  should  fit  the  nose  well.  The  centres  of 
the  lenses  should,  unless  otherwise  ordered,  be 
opposite  the  centres  of  the  pupils  when  the  glasses 
are  in  use.  All  concave  glasses  and  convex  dis- 
tance glasses  should  sit  as  close  to  the  eyes  as 

1 Hutchinson,  Oph.  Eosp.  Reps.  viii.  56  ; Lorinfr,  Amor. 
Jour.  Med.  Bci.,  Apiil  1874  ; the  author,  Brit.  Med.  Jour . 
June  1879  ; Gakzowski,  Gaz.  des  Hop.,  Dec.  1881. 


1752 


VISION,  DEFECTS  OF. 


possible;  convex  reading-glasses  may  be  put 
further  down  the  nose,  and  shaped  to  allow  of 
looking  over  the  top  of  the  frame  in  distant 
vision. 

For  ‘simple’  astigmatism  the  correcting  lens 
is  a segment  of  a cylinder  ; for  ‘ compound  ’ and 
‘ mixed  ’ cases  the  effect  of  a cylindrical  and 
spherical  lens  is  required,  and  may  be  obtained 
either  by  combining  two  suitable  cylindrical 
curvatures  at  right  angles  to  each  other,  or  by 
grinding  the  cylinder  on  the  flat  side  of  a plano- 
convex or  -concave  lens  ; they  require  of  course 
to  be  mounted  with  the  curvature  of  the  cylinder 
exactly  in  the  right  direction.  When  prisms  are 
ordered  they  are  mounted  like  ordinary  spec- 
tacles, and  a lens  may  be  ground  upon  each  sur- 
face of  the  prism  if  necessary;  it  is  not  practi- 
cable to  wear  prisms  of  more  than  about  8°. 
Spherical  lenses  can  be  male  to  act  to  a varying 
degree  as  prisms,  by  putting  them  with  their 
centres  nearer  to  or  further  from  each  other  than 
the  pupils. 

Numbering. — Spectacle  lenses  are  at  present 
numbered  on  two  different  systems,  namely— 
(1)  the  inch  scale;,  and  (2)  the  metrical  scale. 
(1)  In  the  old  system  the  refractive  unit  is  a 
lens  of  1-inch  focal  length,  and  the  inch  may 
be  English,  Parisian,  or  other.  The  lenses  in 
use  being  all  weaker  than  the  unit  are  expressed 
by  fractions  ; thus  the  strongest  in  use  in  the 
trial  case  being  a 2-inch  Ions  is  expressed  as 
£(  + or—,  according  as  it  is  convex  or  con- 
cave) ; a lens  of  10  inches’  focus  is  -jg ; &c.  It 
is  desirable  that  the  series  of  lenses  should 
rise  by  equal  refraction-intervals,  and  here  the 
inch  scale  is  inconvenient  because  it  introduces 
difficult  fractions.  (2)  The  inch  scale  is  rapidly 
giving  place  to  the  metrical  dioptric  scale,  in 
which  the  measure  is  international,  the  refrac- 
tive  unit  is  a weak  instead  of  a strong  lens,  and 
the  refractive  intervals  are  equal.  The  unit  is 
a lens  of  1 metre  (100  cm.)  focal  length,  and  is 
called  one  dioptre  (1  D.)  Stronger  lenses  are 
written  as  whole  numbers;  thus  a lens  four 
times  as  strong  as  the  unit  is  4 D. ; a lens  equal 
to  half  the  unit  is  -5  D.  The  disadvantage  of 
the  system  is  that  the  numbers  do  not,  as  on  the 
inch  system,  express  the  focal  length  of  the 
glasses ; but  the  latter  is  easily  arrived  at  by 
dividing  100  by  the  number  of  the  lens  in  diop- 
tres ; thus  the  focal  length  of  5 D.  = 0 = 20  cm. 

To  convert  a lens  made  by  the  Paris  inch  into 
its  equivalent  in  dioptres,  multiply  its  inch-value 
by  36  (1  m.  = 3G  Paris  inches  nearly);  thus, 
_L  x 36  = 1 D.  To  convert  a metrical  lens  into  its 
equivalent  in  Paris  inches  divide  its  value  in  D. 
by  36;  thus  4 D.  =^j  = i. 

The  following  are  the  most  important  equiva- 
lent numbers : — 


Focal  length 
in 

Dioptres  (D.)  Paris  inches 
•5  72 

(written  ,V  &c.) 


•75 

50 

1- 

36 

1-25 

30 

1-5 

26 

S 

IS 

25 

14 

a 

12 

3 5 

10 

( nearly) 

Focal  length 
in 

Dioptres  (D.)  Paris  inches 

4 

9 

4-5 

8 

5 

7 

6 

6 

7 

5* 

9 

4 

11 

3V 

13 

3‘ 

15 

18 

2 

Several  intermediate  numbers  found  in  the 
trial  cases  have  been  omitted. 

The  several  abnormalities  of  refraction  and 
accommodation  may  now  bo  discussed  in  due 
order. 

a.  Hypermetropia. — In  hypermetropia  the  re- 
tina lies  within,  instead  of  at,  the  principal  focus 
of  the  dioptric  media.  Parallel  rays,  such  as 
come  from  very  distant  objects,  therefore  meet 
the  retina  before  being  focussed ; and  divergent 
rays,  from  near  objects,  meet  it  still  more  in  ad- 
vance of  their  focus.  Hence  the  hypermetropic 
eye,  in  repose,  sees  nothing  clearly.  Distant 
objects  can  be  seen  clearly  if,  by  exerting  accom- 
modation, the  crystalline  lens  be  made  more 
convex;  or  if  the  rays,  before  they  enter  the 
eye,  be  made  sufficiently  convergent  by  passing 
through  a suitable  convex  lens. 

Common  hypermetropia,  due  to  flatness  of  the 
posterior  segment  of  the  eyeball,  called  axial 
hypermetropia,  is  always  congenital ; and  a large 
proportion  of  children  are  hypermetropic  at 
birth— according  to  Ely'  72  percent.  In  sections 
the  circular  fibres  of  the  ciliary  muscle  are,  or 
appear  to  be,  more  abundant  than  in  the  normal 
eye.  The  cornea  is  not  flatter,  but  the  anterior 
chamber  is  rather  shallower,  and  the  pupil  rather 
smaller  than  normal.  In  high  degrees  the  eye- 
ball is  too  small  in  all  directions. 

The  natural  remedy  for  hypermetropia  consists 
in  the  exercise  of  accommodation  for  distant 
sight;  when  in  the  normal  or  emmetropic  eye  it 
is  in  complete  abeyance.  A proportionate  in- 
crease of  accommodation  is  required  by  the  hy- 
permetropic eye  for  near  vision.  The  absolute 
quantity,  amplitude,  or  range  of  accommodation 
is  not  greater  in  hypermetropic  than  in  normal 
eyes  ; hence  in  hypermetropia  it  becomes  sooner 
insufficient  for  the  needs  ; and  the  higher  the 
degree  of  hypermetropia  the  earlier  does  this 
occur. 

Symptoms. — The  symptoms  depend  on  the 
patient’s  age,  occupation,  and  health,  and  on  the 
degree  of  hypermetropia.  The  lower  degrees 
only  exceptionally  cause  symptoms  in  child 
hood.  The  higher  degrees  in  children,  and  the 
lower  degrees  in  young  adults,  cause  difficulty  in 
reading,  writing,  or  sewing,  especially  by  artificial 
light,  and  towards  the  end  of  the  day’s  or  week’s 
work-accommodative  asthenopia.'  The  difficulty* 
is  expressed  in  the  forms  of  mistiness  of  sight, 
weariness  or  aching  of  the  eyes,  headache,  sleepi- 
ness, watering,  chronic  congestion  and  irritation 
of  the  palpebral  conjunctiva.  In  the  highest 
degrees  the  attempt  to  see  clearly  is  often  given 
up.  Such  persons  often  partly  compensate  for 
the  bad  definition  of  the  images  by  holding  the 
book  very  close,  and  so  increasing  their  size, 
and  thus  they  may  seem  to  be  myopic.  All  the 
symptoms  are  worse  when  the  health  is  low. 
As  accommodation  fails  with  age,  a time  arrives 
for  every  hypermetrope  when,  unless  aided  by 
glasses,  no  clear  vision  is  possible  at  any  distance ; 
but  spectacles  are  generally  adopted  before  this 
occurs. 

Concomitant  convergent  squint  often  arises  in 
hypermetropia  (see  Strabismus).  It  isat  firsthand 
may  remain,  periodic,  present  only  during  strong 
accommodation;  but  often  it  becomes  constant. 

1 E!y,  Knapp' t Arch.  d.  Ophlhalm.  ix.  p.  4. 


VISION,  DEFECTS  OF. 


1753 


In  either  case  it  may  alternate  or  may  always 
affect  the  same  eye.  "When  constant  and  fixed 
the  sight  of  the  squinting  eye  becomes  defective, 
as  already  described.  This  occurs  most  easily  in 
squint  acquired  early  in  life.  By  oft-repeated 
separate  practice  of  the  squinting  eye  the  defect 
may  to  a great  extent  be  removed.  The  squint- 
ing eye  can  often  be  proved  to  have  also  had 
some  original  defect,  as  from  corneal  nebula  or 
a higher  degree  of  ametropia,  which  led  to  the 
other  eye  being  used  and  this  one  being  allowed 
to  squint. 

When  the  crystalline  lens  is  absent  (aphakia) 
the  eye  is  very  hypermetropic.  Distant  vision 
is  restored  by  means  of  a convex  lens  of  10 
or  11  D.  (3f  or  3^  inches)  held  about  half  an 
inch  in  frontof  the  cornea  ; objects  at,  say,  25  cm. 
(10  inches)  are  clearly  seen  through  a lens  of 
about  15  D.  (2j  inches).  Accommodation  is 
abolished  in  the  aphakic  eye  ; but  if  the  pupil  be 
round  and  movable,  its  contraction  aids  a little 
in  near  vision,  by  cutting  off  the  peripheral  rays  of 
light. 

From  the  age  of  55  and  onwards  the  normal 
eye  acquires  a low  degree  of  hypermetropia, 
owing  to  a change  in  the  refraction  of  the  crystal- 
line lens. 

Glaucoma  is  commoner  in  hypermetropic  than 
in  normal  or  myopic  eyes.  The  habitual  use  of 
glasses  by  hypermetropic  persons  from  early  life 
may  aid  indirectly  in  preventing  this  disease. 

DiAGNOSis.-The  diagnosis  is  made  subjectively 
by  testing  with  glasses,  or  objectively  by  the 
ophthalmoscope.  The  former  is  the  more  generally 
useful.  Even  distant  objects  are  seen  indistinctly 
by  the  hypermetropic  eye  with  relaxed  accom- 
modation ; but  they  are  made  clear  if  a suitable 
convex  lens  be  held  in  front  of  the  cornea.  1. 
This  test  is  easy  to  apply  when  the  ciliary  muscle 
is  temporarily  paralysed  by  atropia,  or  abolished 
by  natural  senile  changes.  2.  But  when  it  is 
active  the  matter  is  less  simple.  The  old-stand- 
ing habit  of  exerting  accommodation  whenever 
clear  vision,  even  at  a distance,  is  needed,  in 
many  cases  inseparably  connects  the  effort  to 
see,  with  the  action  of  the  ciliary  muscle.  Such 
persons  cannot  relax  thU ir  accommodation  when 
looking  through  a convex  lens  at  a distant  ob- 
ject. The  effect  of  the  lens  is  therefore  added 
to,  instead  of  substituted  for,  that  of  the  accom- 
modation, and  distant  vision  made  worse ; no 
hypermetropia  can  be  found  by  trial  with  glasses, 
it  is  entirely  ‘ latent  ’ ( H.l. ).  3.  Between  these 

extremes  we  find  a large  number  who  can  par- 
tially relax  their  accommodation  for  distance 
in  favour  of  a convex  lens,  but  still  use  a part. 
They  see  well,  or  perfectly,  in  the  distance  with- 
out aid;  they  see  equally  well  or  better  with  con- 
vex lenses  up  to  a certain  strength.  If  now  the 
accommodation  be  suspended  by  means  of  atropia 
we  shall  often  find  a higher  degree  of  hyperme- 
tropia. The  part  that  can  be  detected  when  ac- 
commodation is  active  is  the  ‘ manifest’  (H.m.)  ; 
the  sum  of  the  ‘ manifest  ’ and  the  ‘ latent’  is  the 
* total  ’ (H.). 

In  testing  hypermetropia,  the  patient  being  not 
less  than  ten  feet  from  the  test-types,  we  begin 
with  a very  weak  convex  lens,  and  if  vision  is  not 
made  worse,  try  successively  higher  lenses  until 
we  reach  the  highest  which  allows  the  best  attain- 


able vision.  _ This  lens  represents  the  manifest 
hypermetropia  if  accommodation  be  present,  the 
total  if  it  be  absent.  A stronger  lens  causes  in- 
distinctness by  bringing  the  focus  in  front  of  the 
retina.  In  general  the  younger  the  patient  the 
less  is  the  manifest  in  proportion  to  the  latent 
hypermetropia,  even  though  troublesome  asthen- 
opia be  present. 

Hypermetropia  is  diaguosed  by  the  ophthalmo- 
scope if  an  erect  image  of  the  fundus  is  easily 
seen  when  the  observer  is  at  a distance  of  18 
inches  or  more  from  the  patient.  The  image  is 
seen  equally  well  when  the  observer  comes  as 
close  as  possible  to  the  patient ; and  if  he  pos- 
sess a.  ‘ refraction  ’ ophthalmoscope,  he  can  in  this 
position  measure  the  degree  of  hypermetropia  by 
finding  the  strongest  convex  lens  through  which 
the  details  of  the  fundus  still  look  perfectly 
clear.  In  this  test  the  accommodation  of  both 
persons  must  be  fully  relaxed  ; the  observer  has 
to  learn  to  do  this,  but  the  patient  generally  re- 
laxes his  ciliary  muscle  at  once  in  the  dark  room, 
even  though  he  could  not  do  so  when  tried  with 
glasses  for  the  distant  types. 

Another  test,  Iceratoscopy  or  retinoscopy,  is 
based  on  the  fact  that  when  light  is  thrown  by 
the  ophthalmoscope  into  the  eye  at  a distance  of 
three  or  four  feet,  slight  rotation  of  the  mirror 
causes  a shadow  to  move  across  the  illuminated 
field  ; in  hypermetropia  the  shadow  moves  in  the 
opposite  direction  to  the  rotation  of  the  mirror. 
The  method  is  sometimes  useful  in  young  or  un- 
ruly children,  and  in  skilled  hands  affords  the 
means  of  a tolerably  accurate  determination. 

The  optic  disc  in  hypermetropia,  especially  in 
children,  often  seems,  and  sometimes  is,  hazy, 
and  is  sometimes  too  red ; and  the  retinal  arte- 
ries are  often  too  tortuous. 

Treatment. — Treatment  is  necessary  for 
hypermetropia  whenever  there  is  asthenopia, 
and  when  strabismus  has  arisen.  Convex  spec- 
tacles are  ordered  which,  according  to  circum- 
stances, neutralise  a part  or  all  of  the  hyper- 
metropia, and  are  worn  constantly,  or  only  for 
near  work.  Periodic  squint  may  always  be  cured 
by  the  constant  use  of  fully  correcting  glasses ; 
but  in  most  cases  where  it  has  become  constant, 
an  operation  is  necessary  (see  Strabismus).  In 
children  with  asthenopia  it  is  usually  best  to 
order  glasses  for  constant  use,  which  correct 
almost  the  whole  hypermetropia ; but,  if  the 
symptoms  are  in  connection  with  weak  health 
and  the  hypermetropia  be  slight,  the  temporary 
use  of  glasses  for  near  work  alone  is  enough. 
Young  adults  using  glasses  for  the  first  time 
are  often  satisfied  with  those  which  neutralise 
only  the  manifest  hypermetropia,  using  them  for 
all  near  work ; but  after  some  weeks  or  months 
asthenopic  symptoms  often  recur,  we  find  that 
there  is  more  manifest  hypermetropia  than  be- 
fore, and  are  obliged  to  order  stronger  glasses. 
But  ophthalmoscopic  estimation  will,  as  stated 
above,  generally  tell  us  correctly  almost  the 
total  even  at  the  first  examination  ; and  when 
this  method  makes  it  clear  that  the  total  is  much 
greater  than  the  manifest  hypermetropia,  glasses 
of  nearly  the  full  strength  should  be  ordered  at 
once.  On  theoretical  grounds  it  is  undoubtedly 
best  for  glasses  to  be  worn  constantly  by  hyper- 
metropes,  so  that  the  accommodation  may  always 


(754  VISION,  DEFECTS  OE. 


be  at  rest.  But  a good  deal  of  latitude  must  be 
allowed  to  grown-up  patients  in  regard  to  wear- 
ing them  for  distance,  unless  there  be  constant 
nsthenopia,  and  this  especially  with  elderly 
persons. 

Acuteness  of  sight  is  usually  normal  in  cor- 
rected liypermetropia.  In  many  cases  of  high 
degree,  where  vision  is,  both  with  and  without 
glasses,  subnormal,  some  astigmatism  is  also  pre- 
sent; but  cases  occur  where  the  defect  cannot 
be  thus  accounted  for,  and  it  is  then  assumed  to 
be  due  to  defective  development  of  the  eye.  But 
probably  want  of  education  of  the  retina  in  the 
perception  of  clear  images  in  a great  degree 
accounts  for  the  phenomenon. 

b.  Myopia. — In  myopia  the  retina  lies  beyond 
the  principal  focus  of  the  dioptric  media,  gene- 
rally on  account  of  lengthening  of  the  posterior 
part  of  the  eye— axial  myopia ; it  is  consequently 
at  the  conjugate  focus  of  a point  at  some  definite 
distance  in  front  of  the  eye,  which  indeed  is  the 
‘far  point,’  or  greatest  distance  of  distinct  vision 
of  the  eye  in  question.  The  greater  the  elon- 
gation of  the  eye,  the  nearer  is  the  ‘far  point,’ 
the  ‘ shorter  ’ the  sight,  or  the  higher  the  degree 
of  myopia.  By  using  accommodation  objects  can 
be  seen  at  a still  shorter  distance. 

IEtiology. — Myopia  is  comparatively  seldom 
present  at  birth.  The  elongation  usually  comes 
on  between  about  seven  and  fifteen  years  of  age  ; 
progresses  for  a time  ; and  stops  between  puberty 
and  adult  age.  Myopia  is  often  hereditary,  and 
inheritance  doubtless  accounts  entirely  for  some 
cases  of  very  severo  myopia  whero  none  of  the 
other  causes  have  operated.  But  habitual  use 
of  the  eyes  upon  very  close  work,  especially  in 
a stooping  posture,  aids  very  strongly  in  its  pro- 
duction. Its  onset  is  sometimes  determined  by 
a severo  illness  in  childhood.  It  often  comes 
on  after  severe  keratitis  with  choroiditis  in 
children. 

Myopia  may  also  be  caused  by  increased  cur- 
vature of  the  cornea  after  keratitis,  and  is  an 
invariable  result  of  ‘ conical  cornea.’  Certain 
changes  in  tho  lens  in  the  early  stages  of  senile 
cataract  sometimes  produce  myopia,  even  of  con- 
siderable degree ; and,  as  this  form  of  myopia 
does  not,  like  axial  myopia,  influence  the  pro- 
gnosis, its  possibility  should  always  be  borne  in 
mind  in  a case  of  incipient  cataract. 

Anatomical  Characters.  — The  elongation 
occurs  chiefly  in  the  posterior  part  of  the  eye, 
and  especially  at  the  yellow-spot  region.  The 
sclerotic  and  choroid  are  thinned  in  proportion 
to  the  distension,  and  the  choroid  often  locally 
atrophied.  The  term  ‘ posterior  staphyloma  ’ is 
given  to  the  bulging  region ; in  high  degrees 
the  eye  is  enlarged,  and  its  coats  are  thinned,  in 
all  directions.  The  term  ‘ sclerotico-choroiditis 
posterior’  is  also  used  to  indicate  the  supposed 
nature  of  the  change.  In  high  degrees,  par- 
ticularly late  in  life,  the  vitreous  often  be- 
comes fluid  and  contains  opacities  ; haemorrhages 
may  occur  from  the  choroid ; and  there  is  a strong 
predisposition  to  detachment  of  the  retina  and  to 
cataract.  In  the  ciliary  muscle  of  myopic  eyes 
the  circular  fibres  are  deficient  or  wanting.  The 
Bnterior  chamber  is  often  deeper,  and  the  pupil 
larger  than  usual.  Owing  to  their  large  size 


highly  myopic  eyes  aro  often  prominent  and 
chiefly  from  the  same  cause  their  mobility  is 
somewhat  impaired. 

Symptoms. — A low  degree  of  stationary  myopia 
usually  causes  no  inconvenience.  In  the  higher 
degrees  advice  is  sought,  either  because  distant 
sight  is  bad,  cr  near  work  has  to  be  held  incon- 
veniently close ; or  on  account  of  eyeache,  head- 
ache, watering,  photophobia,  or  dimness ; or 
for  insufficiency  of  tho  internal  recti  (muscular 
asthenopia),  or  actual  divergent  squint.  In  the 
highest  degrees  divergent  squint  is  nearly  always 
present  at  the  natural  distance  of  distinct  vision, 
and  possibly  even  for  distance ; and  in  much 
lower  degrees  there  is  often  difficulty  in  keep- 
ing up  convergence,  and  consequent  pain,  tension, 
and  weariness.  Aching  shows  that  the  myopia 
is  increasing;  it  is  alwaj's  made  worse  by  use 
of  the  eyes,  but  is  often  present,  even  when  at 
rest  in  bed;  it  may  accompany'  the  development 
of  a squint,  or  of  detachment  of  the  retina. 
Myopic  eyes,  even  of  low  grade,  are  often  in- 
tolerant of  bright  light.  Acuteness  of  vision  is 
frequently  sub-normal  in  high  degrees,  especially 
in  old  people ; such  defect  when  not  accounted 
for  by  visible  structural  changes,  is  assigned  to 
irritative  congestion  of  the  choroid. 

Diagnosis. — A myopic  person  with  healthy 
eyes  can  read  the  smallest  print  fluently  at  his 
own  ‘far-point  ’ (see  below),  but  not  further.  He 
gains  perfect  distant  vision  by  looking  through 
a concave  lens,  which  gives  to  rays  of  light  from 
distant  objects  a divergent  direction,  as  if  they 
came  from  his  natural  ‘ far-point.’  Placing  him 
not  less  than  ten  feet  from  the  test  types  wo 
find  experimentally  the  weakest  concave  lens 
that  gives  the  best  attainable  vision.  A stronger 
lens  over-corrects  the  myopia,  producing  hyper- 
metropia,  which,  in  its  turn,  is  corrected  by  the 
exercise  of  accommodation. 

Myopia  is  diagnosed  objectively  as  follows  : — 
(1)  When  by  direct  ophthalmoscopic  examina- 
tion at  a long  distance,  an  image  of  tho  fundus 
is  seen,  which,  on  the  observer  moving  his  head 
from  side  to  side,  seems  to  move  in  the  opposito 
direction.  This  image  disappears  when  tho  ob- 
server comes  near  to  the  eye  examined.  (2) 
When  by  direct  examination  close  to  the  patient, 
a clear  image  (erect)  can  be  obtained  only  by 
placing  a concave  lens  behind  the  mirror;  tho 
weakest  lens  which  gives  a clear  image  being  tho 
measure  of  the  myopia.  (3)  When  in  indirect 
examination  the  size  of  the  ophthalmoscopic 
image  increases  on  withdrawing  the  objective 
lens  from  the  patient's  eye.  (4)  By  keratoseopy, 
the  shadow  moving  in  the  same  direction  as  the 
rotation  of  the  mirror. 

The  ophthalmoscopic  changes  depend  chiefly 
on  the  atrophy  of  the  choroid,  which  so  often 
takes  place  on  some  part  of  the  staphylomatous 
area.  The  commonest  change  is  the  ‘ myopic 
crescent,’  a patch  of  yellowish-white  colour  (ex- 
posed sclerotic),  due  to  atrophy  of  the  choroid 
at  the  true  outer  border  of  the  optic  disc.  It 
is  sometimes  seen  in  eyes  not  myopic.  When 
more  advanced  it  extends  all  round  the  disc 
(annular  staphyloma).  There  may  also  be  sepa- 
rate patches  of  atrophy,  or  a large  area  of  partial 
wasting,  at  the  yellow-spot.  In  high  myopia  with 


VISION,  DEFECTS  OF. 


ftbrupt  bulging  of  tile  tunics,  the  disc  is  often 
tilted  and  then  looks  oral,  and  its  outer  side 
often  becomes  pale. 

CorasE  and  Prognosis. — Axial  myopia  can- 
not diminish.  Though  its  increase  as  a rule 
ceases  about  the  same  time  as  the  cessation  of 
the  bodily  growth,  it  may  continue,  or  may  take 
a fresh  start  later  in  life,  especially  if  the  health 
be  bad,  or  the  eyes  be  excessively  used  for  fine 
work.  But  often  its  course  seems  to  depend 
upon  causes  which  are  not  under  direct  control ; 
for  we  see  myopia  of  high  degree,  leading  to 
disastrous  results,  or  blindness,  in  persons  who 
have  never  learnt  their  alphabet,  or  straiied 
their  eyes  in  any  way;  and,  on  the  other  hand, 
it  is  common  to  meet  with  very  myopic  people, 
of  studious  habits  and  advanced  age,  in  whom  the 
eyes  have  not  changed  since  youth.  In  general 
the  prognosis  is  worse  the  higher  the  degree,  the 
older  the  patient,  and  the  feebler  the  health. 

Teeatment. — Much  may  doubtless  be  gradu- 
ally done  to  prevent  the  acquisition  and  trans- 
mission of  myopia,  by  improvements  in  the  light- 
ing of  school-rooms,  and  construction  of  seats  and 
desks,  and  by  the  choice  of  well-printed  books. 
During  the  progress  of  myopia  the  time  given  to 
school-work  should,  whenever  possible,  be  short- 
ened ; and  if  the  disorder  be  quickly  increasing, 
or  if  there  be  much  aching  or  irritation,  rest  of  the 
eye  should  be  insisted  upon  for  several  months, 
or  longer.  Myopic  children  should  use  their  eyes 
only  as  much  as  is  comfortable,  and  should  be 
forbidden  to  read  fine  print,  to  read  by  bad 
light,  or  to  stoop.  If  there  be  severe  aching  and 
intolerance  of  light,  or  rapid  increase  of  the 
myopia,  especially  with  diminished  acuteness  of 
sight,  prolonged  rest,  subdued  light  (or  smoked 
glasses),  and  the  use  of  the  artificial  leech  at 
intervals  of  a few  days,  with  derivative  treatment, 
are  of  service,  at  least  in  relieving  the  symptoms 
and  improving  vision  fora  time. 

The  corrective  treatment  consists  in  the  use 
of  concave  glasses.  Myopic  children  should  as  a 
rule  wear  glasses  for  distance  merely  on  educa- 
tional grounds.  These  glasses  may  fully  correct 
the  defect,  but  it  is  better  that  they  should  be  a 
little  under  than  over  the  full  strength.  If  there 
be  muscular  asthenopia,  the  glasses  often  cannot 
be  continuously  worn,  unless  treatment  be  also  di- 
rected to  the  internal  recti.  Adults  may  use  their 
own  judgment  as  to  wearing  distance-glasses. 
For  near  work  it  is  seldom  safe,  except  in  low 
degrees,  to  allow  the  fully  correcting  glasses,  be- 
cause their  use  calls  into  powerful  action  the 
function  of  accommodation,  hitherto  but  little 
needed  by  the  myopic  eye,  and  also  deranges  the 
relation  between  this  function  and  convergence 
of  the  visual  lines.  They  also  cause  difficulty 
by  diminishing  the  retinal  images.  If  their  use 
be  persisted  in  for  reading,  &c.,  they  may  act 
indirectly  in  increasing  the  myopia.  “When  the 
natural  far-point  in  myopia  is  not  nearer  than  13 
inches  (33  cm.)  reading  glasses  are  seldom  re- 
quired. But  for  higher  degrees  it  is  often  neces- 
sary to  order  spectacles  which  partly  correct  the 
myopia,  that  is,  make  the  eyes  less  myopic,  and 
thus  remove  the  far  point  further  off  and  allow 
the  patient  to  read,  &c.,  without  stooping.  As  a 
general  rule,  subject  to  the  peculiarities  and 
needs  of  each  case,  about  half  the  full  correction  I 


1755 

may  for  this  purpose  be  safely  and  comfortably 
used.  For  music  or  painting  a rather  stronger 
pair  of  spectacles  are  sometimes  required.  When 
there  is  muscular  asthenopia,  shown  by  the  fact 
that  in  near  vision  one  eye,  if  covered,  deviates 
outwards,  relief  may  often  be  given  by  combining 
prisms  with  their  bases  inwards,  with  the  reading 
glasses;  the  prisms,  by  allowing  the  convergence 
to  be  lessened,  relieve  the  internal  recti. 

c.  Astigmatism. — Astigmatism  may  be  regular 
or  irregular.  Regular  astigmatism  depends  upon 
the  refracting  surfaces  of  the  eye,  chiefly  of  the 
cornea,  not  being  spherical,  but  having  different 
curvatures,  that  is,  focal  lengths,  in  different 
meridians,  the  meridians  of  greatest  and  least 
curvatures  (‘chief’  or‘principal’  meridians) being 
always  at  right  angles  to  each  other,  and  the 
others  having  regularly  intermediate  curvatures. 
The  meridian  of  greatest  curvature  of  the  cornea 
is  generally  vertical  or  nearly  so.  The  astigma- 
tism of  the  lens,  though  less  regular  than  that  of 
the  cornea,  tends  to  correct  the  latter.  In  ‘ simple’ 
astigmatism  one  chief  meridian  is  normal,  the 
other  either  myopic  or  hypermetropic ; when 
‘compound’  both  chief  meridians  are  myopic, 
or  both  hypermetropic,  but  in  different  degrees  ; 
when ‘mixed,’  the  eye  is  hypermetropic  in  one 
chief  meridian,  and  myopic  in  the  other.  When 
the  focal  difference  between  the  chief  meridians, 
or  the  degree  of  astigmatism,  is  not  greater 
than  is  represented  by  a lens  of  72  inches’  focus 
('5  D.)  it  may  generally  be  neglected ; and  much 
higher  degrees  often  cause  no  trouble. 

Astigmatism  is  to  be  suspected  in  all  cases  of 
ametropia  where  spherical  lenses  do  not  raise 
vision  to  the  normal,  no  other  cause  of  the  defect 
being  found.  It  is  detected  subjectively  by  nu- 
merous tests,  most  of  which  consist  essentially  of 
straight  lines  running  in  various  directions,  some 
of  the  lines  being  seen  by  the  astigmatic  eye 
better  than  others.  It  can  also  be  detected  and 
measured  by  the  ophthalmoscope.  It  is  corrected 
by  cylindrical  lenses  which  neutralise  the  differ- 
ence of  refraction  of  the  two  chief  meridians ; but 
in  the  higher  degrees  acuteness  of  vision  often 
remains  even  then  subnormal.  Irregular  astig- 
matism can  seldom  be  remedied. 

3.  Anisometropia. — This  signifies  different 
refraction  in  the  two  eyes,  and  is  a very  com- 
mon condition,  the  difference  sometimes  being 
extreme.  When  one  eye  is  normal  and  the  other 
myopic,  each  may  be,  and  often  is,  used  for.vision 
at  different  distances,  and  each  remains  perfect ; 
but  if  one  be  astigmatic,  or  very  hypermetropic, 
it  is  generally  defective  from  want  of  use. 

When  slight  it  may  be  neutralised  by  corre- 
sponding spectacles,  but  when  the  inequality  is 
great,  fully  correcting  glasses  cause  so  much 
difference  in  the  size  of  the  images  in  the  two 
eyes,  that  equalisation  is  seldom  possible.  But 
it  should  be  attempted  when  there  is  any  ten- 
dency to  divergent  squint,  in  order  to  encourage 
binocular  vision. 

Effect  of  blindness  of  one  eye. — Acuteness  of 
sight  is  always  rather  better  with  both  eyes 
than  with  either  alone ; further,  both  eyes  are 
necessary  for  the  appreciation  of  solidity  and 
distance.  Patients  often  think  that  blindness 
of  one  eye  throws  ‘ double  work  ’ upon  the  other 
and  ‘ weakens  it.’  Nearly  always,  however.  Lb 


1756 


VISION,  DEFECTS  OF. 


inch  a case  some  other  cause  can  he  found  for  at  various  ages,  serves  as  a useful  basis  for  tl  e 
the  asthenopia  of  the  sound  eye.  selection  of  spectacles  for  emmetropic  persons  : — 


4.  Disorders  of  Accommodation. — a.  Pres- 
byopia.— The  ‘ amplitude’  or  ‘range’  of  accom- 
modation is  expressed  by  the  difference  between 
(he  greatest  distance,  ‘far-point,’  (r)  and  the 
least  distance,  ‘near-point,’  ( p ) of  distinct  vision. 
Age  for  age,  it  is  nearly  equal  in  all  eyes,  ■what- 
ever their  refraction.  Its  natural  failure  ■with 
age  causes  presbyopia,  the  onset  of  which  has 
been  arbitrarily  fixed  to  begin,  in  the  emmetropic 
eye,  at  the  age  of  40,  when  the  near  point  is  at 
nine  inches  (22  cm.),  and  the  failure  generally 
progresses  at  a constant  rate.  Presbyopia  is 
corrected  by  the  convex  lens,  which  enables  the 
patient  to  read  at  nine  inches;  the  strength  of 
this  lens  varies  inversely  as  the  amplitude  of 
accommodation,  and  at  the  age  of  65,  the  near 
point  being  removed  to  infinity,  the  correcting 
lens  is  one  of  nine  inches’  focus. 

Symptoms. — Presbyopia  is  first  shown  by  dif- 
ficulty in  reading  or  sewing  by  artificial  light, 
or  in  the  train  or  carriage ; defective  accommo- 
dation prevents  the  work  being  held  close  enough 
to  compensate  for  the  defective  light  or  for  the 
shaking,  and  to  remedy  the  former  the  candle 
is  often  placed  between  the  eyes  and  the  book. 
When  more  advanced  the  patient  becomes  1 long- 
sighted,’ and  has  to  put  his  book  at  arm’s  length 
unless  he  wear  glasses.  If  the  refraction  is  nor- 
mal, distant  sight  is  perfect.  In  hypermetropia, 
presbyopia  begins  at  an  earlier  age,  less  accom- 
modation being  available  for  near  vision  ; and  in 
myopia  it  sets  in  later  because  less  accommo- 
dation is  needed  for  seeing  at  a given  distance. 
Hence  a low  degree  of  myopia  is  an  advantage. 
AVhen  the  far  point  in  myopia  is  at  or  within 
nine  inches  (22  cm.)  presbyopia  does  not  occur. 

Diagnosis. — Presbyopia  is  to  be  distinguished 
from  loss  of  accommodation  due  to  paralysis  of 
the  ciliary  nerves,  and  from  failure  due  to 
feeble  health  or  other  causes,  both  of  which  may 
occur  at  any  age.  True  presbyopia,  however, 
sometimes  progresses  much  more  quickly  than 
usual,  and  especially  in  eyes  which  are  about  to 
suffer  from  glaucoma. 

Treatment. — The  treatment  of  presbyopia 
consists  in  ordering  convex  glasses  which  enable 
the  patient  to  read  at  nine  inches  or  a greater 
distance.  Most  people  prefer  glasses  which  en- 
able them  to  read  easily  at  twelve  or  fifteen 
inches,  arid  with  which  reading  at  the  standard 
nine  inches  is  possible  only  for  a very  short 
time,  if  at  all.  The  smaller  the  quantity  of 
accommodation  remaining,  the  less  is  the  range 
of  clear  vision ; and  if  accommodation  is  abol- 
ished, clear  sight  is  possible  only  when  the  object 
is  at  the  focus  of  the  glasses.  Hence  the  in- 
crease of  strength  of  the  glasses  which  becomes 
necessary  as  age  advances  should  be  made 
gradually,  that  the  patient  may  grow  accustomed 
to  the  loss  of  range,  and  to  the  necessity  for 
keeping  his  book  more  and  more  at  an  unvarying 
distance.  As  the  book  has  to  be  placed  nearer 
by  artificial  than  by  day-light,  it  is  generally  best 
to  have  a rather  stronger  pair  of  glasses  for 
evening  use  than  for  the  daytime.  The  following 
table,  giving  the  strength  of  the  glass  necessary 
to  bring  the  near  point  to  nine  inches  (22  cm.), 


Age 

40 

45 

50 

55 

60 

<55 

70 


Lriass  required  to  bnDg  y ’ to  9 m. 
(22  cm.) 

0 


+ /finch 


1-6J 


+ 1 dioptre. 
2 

3 „ 

4 „ 

4 5 „ 

5'5  „ 


b.  Paralysis  of  Accommodation. — Synon.  : 
Cycloplegia. — Paralysis  of  the  ciliary  muscle 
occurs  in  paralysis  of  the  whole  third  nerve. 
But  it  may  occur  without  affection  of  the  extrin- 
sic muscles  of  the  eyeball ; in  these  cases  it  is 
generally  combined  with  paralysis,  more  or  less 
complete,  of  the  iris  ( ophthalmoplegia  interna) ; 
but  it  maybe  present  as  an  isolated  symptom,  the 
pupils  being  normal,  and  of  this  the  commonest 
example  is  postnliphtheritic  cycloplegia.  The 
failure  of  accommodation  in  glaucoma  mav  be 
accounted  for  in  acute  cases  by  compression  of 
the  ciliary  nerves,  but  in  old  cases  is  doubtless 
due  to  the  atrophy  of  the  ciliary  muscle  which 
always  exists.  Cycloplegia,  usually  with  some 
affection  of  the  iris,  is  a common  result  of  blows 
on  the  eye  ; generally  recoverable,  it  is  however 
occasionally  permanent.  Lowered  endurance  of 
sight,  pain,  and  sudden  temporary  failures  of 
accommodation,  are  amongst  the  most  important 
phenomena  of  sympathetic  irritation. 

c.  Spasm  of  Accommodation.  — Temporary 
spasmodic  action  of  the  ciliary  muscle,  often  ex- 
ceeding the  necessary  amoimt,  frequently  occurs 
in  hypermetropia,  with  every  effort  to  see  clearly . 
it  usually  ceases  at  once  on  going  into  a dark 
room.  In  low  myopia  with  irritative  symptoms, 
the  ciliary  muscle  often  acts  unnecessarily;  and 
such  spasm,  when  persistent,  is  probably  one 
cause  of  further  elongation  of  the  eye.  Spasm 
of  accommodation  also  occurs  in  some  functional 
and  hysterical  affections  of  the  eyes,  with  other 
symptoms  of  ocular  irritation.  The  function  of 
accommodation  is  closely  associated  with  that  of 
convergence,  although  the  two  can  be  exerted 
separately  to  a limited  extent  (‘ relative  accom- 
modation ’).  The  accommodation  of  one  eye 
cannot  be  exercised  without,  and  probably  not 
in  a different  degree  from,  that  of  the  other;  nor 
is  it  proved  that  any  part  of  the  ciliary  muscle 
can  act  independently  of  the  rest. 

d.  Micropsia. — Definition. — Any  condition 
of  sight  in  which  objects  seem  lessened  in  size, 
without  diminution  in  the  size  of  the  retinal 
images.  This  indicates  either  an  extreme  effort 
of  accommodation,  and  maj^  be  thus  complained 
of  when  this  function  is  weakened ; or  disease  of 
the  retina,  especially  syphilitic  retinitis. 

5.  Asthenopia. — Asthenopia  is  any  condi- 
tion in  which  the  eyes  cannot  be  used  for  long 
without  fatigue,  pain,  or  other  symptoms. 

Muscular  asthenopia  is  caused  by  difficulty  in 
maintaining  the  convergence  of  the  visual  lines, 
and  is  commonest  in  myopia,  though  it  is  often 
seen  with  normal  refraction,  especially  in  youths 
and  young  adults.  It  causes,  besides  aching  of 
the  eyes,  ‘dancing’  or  ‘confusion’  of  the  print, 
and  sometimes  double  vision.  In  slight  cases, 
with  myopia,  partially  neutralising  glasses,  which 
enable  the  book  to  be  held  at  a greater  distance. 


VISION,  DEFECTS  OF. 
will  often  give  reliof.  In  many  cases,  with  or 
without  myopia,  spectacles,  consisting  of  prisms 
with  their  bases  inwards,  are  of  great  service, 
by  lessening  the  convergence  necessary  for  vision 
at  a given  distance.  In  high  degrees,  tenotomy  of 
the  external  rectus  is  called  for  (see  Strabismus). 

Asthenopia  from  defective  accommodation  is  also 
shown  by  inability  to  read  for  long,  but  there  is 
no  ‘ moving  ’ or  ‘ dancing  ’ of  the  letters,  nor  any 
diplopia.  The  object  simply  becomes  ‘ misty  ’ or 
‘ the  sight  goes’  for  a time,  returning  when  the 
eyes  are  rested  for  a few  minutes ; or  the  eyes 
feel  tired  and  hot,  and  ache.  Headache  and 
occasionally  even  vomiting  may  follow  neglect  of 
such  symptoms.  It  is  commonest  in  hyperme- 
tropia  (asthenopia  from  excessive  demand  on 
accommodation) ; but  is  also  seen  in  emmetropic, 
and  even  in  slightly  myopic,  eyes,  if  the  tone  of 
the  ciliary  muscle  is  low  (asthenopia  from  weak- 
ness of  accommodation).  Asthenopic  symptoms 
are  not  common  in  presbyopia.  The  above  forms 
of  asthenopia  often  give  rise  to  chronic  conges- 
tion and  irritation  of  the  palpebral  conjunctiva, 
with  watering  and  soreness,  the  symptoms  dis- 
appearing when  glasses  are  worn.  On  the  other 
hand  an  irritable  and  hypersesthetic  state  of  con- 
junctiva and  cornea,  and  perhaps  of  the  retina, 
with  photophobia,  often  causes  irritable  weak- 
ness of  the  ciliary  muscle,  even  when  there  is 
scarcely  any  ametropia  (asthenopia  from  hyper- 
sesthesia) ; these  cases  are  difficult  to  cure. 

Retinal  Asthenopia. — Functional  exhaustion 
of  the  retina  or  optic  nerve  is  sometimes  seen 
in  optic  neuritis,  and  other  diseases  of  the  optic 
nerve ; sight  being  good,  but  becoming  duller 
after  a short  period  of  use.  It  is  not,  on  the 
whole,  a very  important  diagnostic  symptom. 

E.  Nettleship. 

VIS  MEDICATE. IX  ITiTITHAl  (Latin). 
An  expression  formerly  much  used  to  indicate 
the  innate  power  possessed  by  Nature  of  heal- 
ing or  curing  disease.  See  Disease,  Treatment 
of;  and  Therapeutics. 

VITILIGO  (vitulus,  a spotted  calf).-SrNox. : 
Leucopathia ; Leucasmus  ; Leucoderma ; ‘ Pie- 
bald skin’ ; Fr.  and  Ger.  Vitiligo. 

Description. — This  disease  occurs  as  spots, 
which  are  white,  resulting  from  absence  of  pig- 
ment ( achroma ),  of  a circular  figure,  and  various 
in  number  and  dimensions.  The  pigmentless  skin 
is  pale,  but  otherwise  healthy ; and  the  imme- 
diately adjacent  integument  is  more  deeply  co- 
loured near  the  margin  of  the  spots  than  on  the 
rest  of  th6  surface.  At  their  first  appearance 
the  spots  are  small ; they  increase  by  their  cir- 
cumference ; and,  by  continuous  growth,  or  by 
the  blending  of  several  spots,  they  cover  a sur- 
face of  greater  or  less  extent. 

Diagnosis.  — Vitiligo  is  distinguished  from 
other  forms  of  absence  of  pigment  of  the  skin  by 
the  otherwise  healthy  condition  of  the  integument. 
Horphoea  and  scleroma,  the  two  affections  for 
which  it  might  be  mistaken,  both  present  mani- 
fest indications  of  disorganisation  of  the  derma. 
Leucoderma  has  been  confounded  with  the  white 
patches  of  true  leprosy.  In  this  disease,  how- 
ever, the  patches  are  anaesthetic,  and  there  are 
constitutional  symptoms  which  are  never  present 
in  leucoderma. 


VOICE,  DISORDERS  OF.  1751 

Treatment. — Aberration  of  the  pigment-func- 
tion of  the  skin,  and  especially  arrest  of  pigment- 
formation,  imply  feebleness  of  tissue,  and  suggest, 
as  the  indication  for  treatment,  the  strengthening 
of  the  individual,  and  througli  the  individual  the 
strengthening  of  the  faulty  organ.  "We  may 
expect  to  derive  advantage  from  tonic  remedies, 
particularly' from  arsenic;  whilst  externally  we 
must  have  recourse  to  mild  stimulation,  either  by 
friction  or  by  some  stimulant  local  application, 
such  as  tar  or  sulphur,  which  will  induce  hy- 
peraemia,  a more  active  circulation  of  blood,  and 
a more  healthy  nutrition  of  the  skin. 

Erasmus  "Wilson. 

VITILIGOIDEA  (vitulus,  a spotted  calf). 
A term  which  has  been  applied  by  Addison  and 
Sir  William  Gull  to  the  disease  now  known  as 
xanthoma  and  xanthelasma.  See  Xanthoma. 

VOCAL  FREMITUS.- — The  sensation  of 
vibration  conveyed  to  the  hand  when  applied 
over  any  part  of  the  respiratory  organs  during 
vocalisation  both  in  health  and  in  disease.  See 
Physical  Examination. 

VOCAL  RESONANCE. — Thesound heard 
on  auscultation  over  certain  parts  of  the  respi- 
ratory organs,  during  vocalization, both  in  health 
and  in  certain  forms  of  disease.  See  Physical 
Examination. 

VOICE,  Disorders  of.  — Synon.  : Er. 
Troubles  de  la  Voix ; Ger.  Stdkrungen  der 
Stimme, 

Introduction. — Voice  is  the  sound  produced 
in  the  larynx  by  air  driven  from  the  lungs 
tlirough  the  rima  glottidis,  modified  in  accord- 
ance with  acoustic  laws  in  the  upper  air-pae- 
sages.  Vocalization  is  a function  needing  for 
its  perfect  production  a healthy  condition  of  the 
respiratory  muscles,  of  the  lungs,  trachea,  and 
larynx,  of  the  pharyngeal,  oral,  and  nasal  cavi- 
ties, and  of  the  nerves  and  nervous  centres  on 
which  these  parts  depend  for  their  isolated 
or  co-ordinated  muscular  movements  and  their 
normal  sensitiveness.  Eor  the  production  of 
the  simplest  vocal  tone  the  cords  must  he  free  to 
approximate  within  a line  of  one  another,  while 
the  co-ordinated  action  of  about  one  hundred 
muscles  is  required,  to  regulate  their  tension  and 
that  of  the  walls  of  the  air-passages,  to  modify 
the  form  of  the  latter,  and  to  produce  the 
current  of  air. 

Acoustically  the  organ  of  the  voice  must  he 
regarded  as  a combined  reed  and  pipe  ; and  for 
the  production  of  a perfect  note,  it  is  necessary 
that  the  pipe  should  be  in  perfect  unison  with 
the  reed.  This  unison  depends  not  only  on  the 
shape  of  the  various  cavities,  but  on  the  relative 
rigidity  or  flexibility,  and  the  tension  of  their 
walls ; every  variation  in  the  number,  size,  or 
form  of  vibrations  of  the  vocal  cords,  effected  by 
the  intrinsic  laryngeal  muscles,  calling  for  similar 
modifications  of  the  shape,  size,  and  tension  of 
the  consonating  cavities. 

The  word  ‘ voice,’  when  used  alone,  always 
implies  the  presence  of  a musical  tone  (periodic 
vibrations),  hut  sound  sufficient  for  every  pur- 
pose of  speech  and  articulation  may  be  produced 


1758  VOICE.  DISORDERS  OF. 


without  a musical  tone.  This  is  the  whispering 
voice,  caused  by  the  rustling  of  air  through  the 
half-open  rima  and  relaxed  air-passages.  To  this 
condition— absence  of  musical  tone  in  the  voice — 
the  term  aphonia  is  applied,  and  it  must  be  dis- 
tinguished from  the  actual  inability  to  produce 
sound,  which  we  see  after  tracheotomy,  where  in 
the  effort  to  speak,  the  organs  of  articulation 
and  sound  are  seen  to  move,  but  neither  noise 
nor  musical  sound  is  heard. 

Pathological  Relations. — The  morbid  modi- 
fications of  vocalisation  are  necessarily  numerous, 
in  proportion  to  its  complexity  and  the  number 
of  parts  concerned  in  its  production  ; but  it  may 
be  generally  stated  that,  in  consequence  of 
disease  or  perverted  action  in  any  of  these  parts, 
the  voice  may  be  altered  either  (1)  in  loudness 
br  force  (size  of  sound-waves);  (2)  in  pitch,  or 
relative  height  of  its  note  (rate  of  sound- 
waves) ; or  (3)  in  quality  (shape  of  sound-waves). 
And  even  before  there  is  obvious  change  in  any 
of  these  respects,  the  power  of  passing  rapidly 
and  easily  from  one  pitch  to  another,  constitut- 
ing melody,  may  be  seriously  impaired.  The 
morbid  alterations  of  the  voice  in  these  several 
directions  will  now  be  discussed ; and  brief  re- 
ference will  also  be  made  to  (4)  stammering  of 
the  vocal  cords ; (5)  aphonia,  and  (6)  the  vocal 
signs  in  the  chest. 

1.  Changesin  Force.— The  voice  is  weakened 
in  every  disease  which  lowers  the  general  muscu- 
lar tone,  or  depresses  the  nervous  system.  The 
gradual  change  is  well  seen  in  phthisis  without 
laryngeal  affection,  where  at  last  even  the  effort 
to  approximate  the  vocal  cords  is  too  much  for 
the  patient,  and  he  speaks  in  only  a whispering 
voice.  In  the  same  way  painful  affections  of 
any  of  the  parts  enumerated  above,  interfering 
with  muscular  effort,  weaken  the  voice.  Speak- 
ing generally,  mere  diminished  loudness  of  the 
voice  depends  usually  on  general  rather  than  on 
laryngeal  disease. 

2.  Alterations  in  Pitch. — The  note  of  or- 
dinary speech  may  be  habitually  raised  or 
lowered,  and  the  range  of  the  singing  voice  may 
be  seriously  limited.  The  note  of  the  voice 
depends  primarily  on  the  rate  of  vibration  of  the 
vocal  cords  ; and  this  is  the  mean  result  of  the 
tension,  the  length,  the  density,  and  the  thick- 
ness of  the  cords  at  the  time  the  tone  is  produced, 
and  the  force  of  the  current  of  air  sent  through 
the  rima.  Structural  changes,  therefore,  in  any 
one  of  these  respects,  will  alter  the  pitch  of  the 
voice  ; and  change  in  the  ordinary  vocal  note  is 
usually  to  be  referred  either  to  an  affection  of  the 
tensor  muscles  of  the  larynx,  to  structural  change 
in  the  mucous  membrane  covering  the  cords,  or 
in  the  cords  themselves.  Lowering  of  the  pitch  of 
the  speaking  and  the  range  of  the  singing  voice  oc- 
curs with  any  condition  which  relaxes  the  mucous 
membrane,  weakens  the  nervous  and  muscular 
system,  or  makes  the  tense  condition  of  the  vocal 
cords  and  the  eonsonating  cavities  painful. 
Paralysis  of  the  intrinsic  muscles,  which  admit 
of  the  approach  of  the  vocal  cords  but  interfere 
with  their  tension  and  density,  affects  the  pitch 
as  well  as  the  quality,  the  voice  being  rough  and 
deep  in  the  paresis  of  the  tensors  (superior  laryn- 
geal nerve)  and  of  the  abductors  of  the  larynx 
(recurrent  nerve). 


The  imperceptible  transition  from  the  chest 
to  the  falsetto  voice,  in  which,  whilst  tho  con- 
dition of  the  vocal  cords  is  suddenly  altered,  the 
form  of  tho  larynx,  trachea,  and  other  conso- 
nating  cavities  is  simultaneously  changed,  re- 
quires a perfect  control  of  the  vocal  organs,  at- 
tained only  by  accomplished  vocalists.  On  this 
change  of  register  occurring  involuntarilv,  the 
cracked  voice  in  speaking  is  the  result ; and  be- 
ing referable  to  imperfect  co-ordination,  it  is 
common  in  males  about  puberty,  when  the  form 
of  the  larynx  is  changing,  or  may  even  persist 
occasionally  throughout  life.  A curious  affec- 
tion of  the  pitch  of  the  voice,  in  speaking,  when 
two  tones  of  different  pitch  are  simultaneously 
produced  (diplophonia),  appears  to  depend  on 
the  division  of  the  rima  into  an  anterior  and 
posterior  opening,  either  by  small  morbid 
growths,  strings  of  mucus,  or  irregular  action 
of  the  muscles. 

3.  Change  of  Quality. — The  quality  of  the 
voice  is  affected  by  every  alteration  either  in  the 
cords  or  in  the  eonsonating  cavities,  the  purity 
and  character  of  tho  tone  being  liable  to  nu- 
merous modifications,  until,  the  musical  note 
disappearing  entirely,  mere  noise  (aphonia  or 
whispering)  remains. 

Hoarseness.— Hoarseness  and  huskiness,  a com- 
bination of  whispering  and  a badly  sustained 
musical  note,  imply  imperfect  and  irregular 
approximation  of  the  vocal  cords.  Over-exertion 
of  the  voice,  catarrh,  &c.,  produce  it  temporarily, 
giving  rise  to  irregular  tension  of  the  cords,  to 
shreds  of  mucus,  and  to  swellings  of  the  mucous 
lining,  which  interfere  with  their  regular  approxi- 
mation ; while  all  changes  short  of  those  which 
absolutely  prevent  the  closure  of  the  cords, 
maj'  cause  it  as  a persistent  phenomenon.  To 
the  larynx  itself  we  look  therefore  for  the 
source  of  persistent  hoarseness.  Amongst  the 
pathological  conditions  of  which  hoarseness  is  a 
symptom  are  chronic  swelling  of  the  mucous 
membrane,  general  or  local,  interfering  with  the 
closure  of  the  rima  ; exudation  or  ulceration,  and 
therefore  inflammation,  simple,  specific,  or  diph- 
theritic ; neoplasms ; old  cicatricial  contractions ; 
paralysis  of  the  adductors  of  one  cord,  which 
necessitates  the  crossing  of  the  normal  cord 
beyond  the  median  line  to  meet  its  fellow,  as 
well  as  other  forms  of  paralysis  ; fixing  of  one 
vocal  cord  by  anchylosis  of  the  crico-aryttenoid 
joint.  The  paralysis  may  of  course  depend  on 
disease  of  the  nervous  centres,  on  the  nerves 
themselves,  or  on  pressure  by  intra-thoracic  or 
other  tumours  on  the  nerve-trunks.  Hoarse- 
ness, short  of  aphonia,  is  also  a symptom  ot 
general  exhaustion,  as  seen  in  phthisis  and 
cholera. 

The  character  of  the  speaking  voice  is  also 
altered  by  any  change  in  the  resonating  cavities. 
Thus  the  voice  is  said  to  have  a nasal  twang 
when  the  upper  pharyngeal  and  nasal  cavities 
are  not  completely  shut  off  in  vocalisation ; 
while,  on  the  other  hand,  obstruction  in  the 
nares,  preventing  the  passage  of  the  air  through 
them  and  the  formation  of  the  nasal  consonant 
sounds,  is  popularly,  though  wrongly,  called 
‘speaking  through  the  nose.’  If  the  obstruc- 
tion be  situated  in  front  of  the  nares,  the  sounds 
can  be  produced,  but  not  continued  ; if  the  ob- 


VOICE,  DISORDERS  OF, 
struction  be  in  the  upper  pharynx,  or  at  the 
Lack  of  the  nares,  they  cannot  be  produced,  at 
all.  "When  with  obstruction  in  the  nares  there 
is  swelling  of  the  pharynx  and  the  soft  palate, 
the  voice  assumes  the  character  so  familiar  in 
cases  of  quinsy. 

Changes  in  the  walls  of  the  chest  and  the 
pectoral  cavities  also  alter  the  character  of  the 
voice,  the  hollow  voice  of  the  emaciated  phthisi- 
cal patient  illustrating  this.  The  phonation.  on 
inspiration,  of  spasmodic  croup  and  of  child- 
crowing  or  laryngismus  stridulus  must  be  re- 
ferred to  as  the  result  of  spasm  cf  the  vocal 
cords,  though  tills  involuntary  function  hardly 
comes  within  the  definition  of  voice,  which  term 
should  be  limited  to  sound  produced  in  the  vocal 
organs  to  establish  communication  between 
living  beings. 

4.  Stammering  of  the  Vocal  Cords. — - 
Spasm  and  defective  co-ordination  are  the  source 
of  this  peculiar  affection  of  the  voice,  in  which 
there  are  sudden  interruptions  of  the  voice 
without  affection  cf  the  articulation  (Prosser 
James). 

5.  Aphonia. — The  various  modifications  of 
voice  hitherto  considered  only  occur  where  the 
vocal  chords  are  free  to  meet  more  or  less  per- 
fectly. Aphonia  or  complete  loss  of  the  musical 
tone,  occurs  where  the  cords  cannot  meet. 
Amongst  the  conditions  which  will  prevent  the 
approximation  of  the  cords  and  cause  aphonia 
are  paralyis  or  paresis  of  the  adductor  muscles, 
on  whatever  cause  it  may  depend ; fixation  of 
the  cords  by  cicatricial  contractions,  or  by 
anchylosis  of  the  crico-aryttenoid  joints  ; their 
destruction  by  ulceration ; any  painful  affection 
which  makes  the  patient  involuntarily  rest  them; 
or  coating  with  false  membrane.  Rut  by  far 
the  most  frequent  cause  cf  this  aphonia  is  the 
abrogation  or  perversion  of  the  will,  occurring 
in  the  morbid  mental  condition  of  hysteria  or 
other  nervous  disease  ; perfect  power  of  phona- 
tion existing,  but  the  patient,  for  months  or  years, 
declining  to  exercise  the  power,  or  to  make  the 
necessary  effort.  The  intimate  relations  of  the 
voice  to  the  higher  functions  of  the  brain  would 
lead  us  to  expect  that  it  would  be  influenced  by 
the  emotions.  Thus  we  have  a person  hoarse 
with  rage,  speechless  with  terror,  &e.,  and  the 
origin  of  these  cases  of  nervous  aphonia  is 
frequently  some  sudden  emotion,  causing  loss  of 
control  over  the  voice.  Yon  Ziemssen  believes 
that,  even  where  the  vocal  cords  cannot  meet, 
by  a great  effort  the  patient  may  produce  a 
hoarse,  monotonous  tone  by  vicarious  vibrations 
of  the  ventricular  bands. 

Treatment. — The  local  treatment  of  the 
various  diseases  of  the  respiratory  organs  which 
give  rise  to  disorders  of  the  voice,  is  fully  dis- 
cussed in  the  several  articles  on  these  subjects 
{see Larynx, Diseases  of;  Stammering;  Throat 
Diseases  of;  Trachea,  Diseases  of).  The  general 
treatment  will  depend  upon  the  constitutional 
btate.  See  Hysteria  ; and  Phthisis. 

6.  Vocal  Signs  in  Chest. — Some  consider- 
ation must  be  given  to  the  changes  in  the  voice 
which  are  audible  when  the  stethoscope  is  ap- 
plied to  the  chest.  Normally  the  vibrations  of 
the  vocal  cords  are  conveyed  to  the  ear  ap- 
plied to  the  chest  by  propagation  along  the  con- 


POLITION,  DISORDERS  OF.  1759 
tained  air,  the  rigid  portions  of  the  air-chambers, 
and  the  thoracic  walls,  the  voice  being  heard  as 
a feeble,  buzzing,  musical  tone.  This  sound  is 
weakened  when  the  original  tone  is  weakened  by 
laryngeal  disease  ; when  fluid  is  interposed  be- 
tween the  lung  and  the  chest-wall,  pus  and  less 
homogeneous  fluids  forming  a more  complete 
obstacle  than  simple  serum;  and  when  the 
bronchial  tubes  are  obstructed  by  secretions  or 
other  cause,  preventing  the  conveyance  of  the 
vibrations.  The  sound  may,  on  the  contrary, 
be  exaggerated,  giving  rise  to  the  phenomena 
of  bronchophony,  amphoric  voice,  and  agophony. 
Bronchophony  is  simple  increase  in  the  vocal 
resonance,  and  is  heard  under  the  same  con- 
ditions which  give  rise  to  bronchial  breath- 
ing, that  is,  over  lung  consolidated  by 'exuda- 
tion or  condensed  by  compression,  and  over 
cavities  with  solid  walls.  The  terra  pectoriloquy 
is  commonly  applied  to  excessive  bronchophony, 
but  Dr.  Bristowe  would  limit  it  to  the  rare  in- 
stances in  which  not  only  the  laryngeal  tone, 
but  the  articulate  sounds  produced  in  the  mouth, 
are  conveyed  back  to  the  chest,  and  thence 
through  the  chest-wall  to  the  ear.  Amphoric 
voice  ( [amphorophony ) is  the  term  applied  where 
the  vocal  resonance  is  not  only  increased,  but 
acquires  a metallic  ring,  from  the  addition  of 
a consonant  tone  acquired  in  large  cavities  of 
the  lungs.  This  is  sometimes  heard  in  a marked 
degree  in  pneumothorax,  though  in  other  cases 
of  the  same  disease  the  vocal  resonance  may  be 
absent  or  greatly  diminished. 

CEgophony  is  heard  where  there  is  a thin  layer 
of  fluid  between  the  ear  and  the  lung,  as  in  small 
effusions  or  at  the  margin  of  larger  effusions.  It 
is  a bleating,  tremulous  tone,  supposed  by  Bris- 
towe to  result  from  the  interposed  fluid  prevent- 
ing the  fundamental  note-vibrations  from  reach- 
ing the  ear,  while  it  permits  the  finer  and  closer 
vibrations  of  harmonics  to  penetrate.  See 
Phtsicai  Examination. 

Thomas  J.  YTai.ker. 

VOXiITION,  Disorders  of. — Srxox. : Fr. 
Troubles  de  la  Volition;  Ger.  Sldhrungeti  des 
Wollens. 

Various  lesions  of  the  cortex  of  the  hemi- 
spheres may  arrest  or  interfere  with  volition  at 
its  source,  and  that  not  solely  when  the  lesions 
occur  in  the  so-called  ‘motor  regions.’  If  we  as- 
sume that  these  particular  regions  of  the  cortex 
are  the  parts  whence  motor  incitations  pass  off 
on  their  way  to  lower  centres,  it  is  only  necessary 
to  bear  in  mind,  on  the  one  hand,  the  continuity 
of  molecular  actions  through  definite  tracts  of  the 
brain-tissue,  and,  on  the  other  hand,  the  frequency 
with  which  volitions  are  immediately  aroused 
by  some  antecedent  sensorial  processes,  to  under- 
stand that  damages  to  certain  sensorial  centres  or 
intemuncial  fibres  within  the  hemispheres  aro 
almost  as  liable  to  interfere  with  certain  classes 
of  volition  as  are  those  which  occur  in  the  so- 
called  motor  region  itself.  After  all,  volition  is 
only,  and  must  always  be,  a result  of  sense  and 
intellect  in  action.  Its  manifestations  may,  there- 
fore, be  impeded  either  by  disease  at  the  sourceE 
in  which  it  originates,  or  in  one  or  other  portion 
of  tho  tracks  along  which  its  initial  incitations 
are  conducted  on  their  way  to  motor  centres,  and 


1760  VOLITION,  DISORDERS  OF. 
thence  to  the  muscles  whose  activity  is  to  be 
a weened. 

In  other  cases,  with  exalted  activity  of  some 
of  the  centres  in  which  volitional  incitations 
arise,  we  may  have,  especially  in  acute  mania 
and  violent  delirium,  the  birth  of  impulses 
which  are  absolutely  ‘ uncontrollable.’  Where 
these  conditions  are  absent,  however,  and  whether 
the  persons  in  question  have  been  accustomed  or 
not  to  exhibit  evidences  of  a weak  or  defective 
morale,  it  is  most  important  not  to  confound 
‘uncontrolled’  with  ‘uncontrollable’  impulses. 
This  is  the  kind  of  question  which  becomes  all- 
important  in  many  criminal  cases — cases,  that 
is,  in  which  persons  are  under  trial  for  murder, 
manslaughter,  or  theft,  and  in  which  ‘ unsound- 
ness of  mind’  is  pleaded  in  extenuation.  See 
Criminal  Irresponsibility. 

On  the  other  hand,  a dormant  or  sluggish 
volition  is  met  with  in  some  other  forms  of 
insanity,  as  well  as  in  hysteria,  the  subjects  of 
which  cannot  or  do  not  rouse  themselves  to  per- 
form the  most  ordinary  actions.  They  may  from 
this  cause  be  speechless,  or  they  may  experience 
the  most  extreme  difficulty  in  arriving  at  any 
decision  even  in  reference  to  the  most  trivial 
circumstances.  See  Insanity,  Varieties  of. 

Again,  so-called  defects  of  memory  and  defects 
of  volition  are  sometimes  inextricably  involved 
in  many  forms  of  brain-disease  ; so  that  the 
same  disability  may,  from  one  point  of  view,  be 
regarded  as  an  instance  of  defective  memory  of  a 
special  kind,  or  from  another  as  a peculiar  and 
limited  interference  with  volition.  See  Memory, 
Disorders  of. 

In  very  many  cases  of  apparent  loss  of  voli- 
tional power — that  is,  in  multitudes  of  instances 
of  complete  paralysis  of  a part  or  of  a muscle — 
where  the  causal  lesion  is  situated  in  regions 
below  the  cortex  cerebri  (e.g.,  in  lower  motor 
centres,  cerebral  or  spinal,  or  in  motor  nerves), 
there  is  not  an  arrest  of  volition,  but  rather  an 
impediment  to  the  actuation  of  volitions  ( see 
Paralysis,  Motor).  But  whether  volition  itself 
is  nipped  in  the  bud,  or  whether,  though  really 
existent,  it  is  rendered  abortive,  the  patient  is 
practically  reduced  to  the  same  condition — since 
his  power  of  responding  to  sense  or  thought 
through  particular  muscles  may  be  equally 
interfered  with  in  either  case.  See  Speech, 
Disorders  of.  II.  Charlton  Bastian. 

VOLVULUS  ( volvo , I roll). — A synonym 
for  intussusception.  See  Intestinal  Obstruc- 
tion. 

VOMICA  ( vomo , I vomit,  I cast  up). — 
Synon.  : Fr.  Vomique;  Ger.  Lungenqeschwiir. 

Definition. — A term  applicable  to  all  ulcera- 
tive spaces  in  the  lung  in  open  communication 
with  bronchi. 

./Etiology. — The  multifarious  agencies  leading 
to  excavation  may  be  grouped  as  follows : — 

I.  Destructive  processes:  (a)  injury,  (h)  gan- 
grene. 

II.  Suppurative  processes : ( c ) acute  pulmonary 
abscess  ; ( d ) suppuration  around  inhaled  foreign 
bodies ; (e)  suppuration  around  new  formations 
(including  hydatids)  ; (/)  extension  of  abscesses, 
G)  from  the  pleural  cavity;  (2)  from  the  ab- 


VOMICA. 

dominal  cavity,  or  from  the  abdominal  organs ; 
and  (3)  from  the  mediastina. 

III.  Degenerative  processes : (g)  ulceration  of 
cancerous  or  sarcomatous  growths ; ( h ) ulcera- 
tion of  syphilomas  ; (i)  ulceration  of  tubercle ; 
(y)  softening  of  chronic  inflammatory  consolida- 
tions (catarrhal  pneumonia  and  caseous  pneu- 
monia) ; (£)  softening  of  intensely  congested  or 
cedematous  tissues  (a  condition  sometimes  due 
to  pressure  from  aneurisms  or  tumours) ; ( l ) 
liquefaction  of  ancient  deposits — caseous,  pulta- 
ceous  or  haemorrhagic  (haemorrhagic  nodules — 
Dr.  R.  E.  Thompson). 

Phthisis  being  the  cause  of  the  immense 
majority  of  pulmonary  excavations,  the  ensuing 
remarks  will  be  chiefly  devoted  to  phthisical 
vomicae. 

Anatomical  Characters. — Varieties  in  size 
and  in  shape. — Vomicae  may  be  sub-lobular  (then 
aptly  termed  cavernules),  lobular,  lobar,  or  they 
may  involve  the  whole  of  one  lung.  Tubercular 
deposits,  being  usually  smaller  than  catarrhal 
infiltrations,  lead  to  smaller  cavities.  Catarrhal 
inflammation  gives  rise  to  the  lobular,  caseous 
pneumonia  to  the  lobar  excavations,  and  to  the 
wholesale  destruction  of  a lung.  (Edematous 
forms  of  catarrhal  pneumonia  often  undergo 
rapid  and  extensive  softening ; the  interlobular 
septa  escaping  liquefaction,  whilst  the  paren- 
chyma is  carried  away.  This  dissecting  exca 
vation  forms  the  counterpart  of  caseous  pneu- 
monia, where  the  tissues  are  destroyed  en  masse, 
with  the  sole  exception  of  the  larger  branches 
of  the  pulmonary  artery. 

When  strictly  confined  to  a lobule,  the  excava- 
tion is  roughly  spherical.  If  many  lobules  should 
be  simultaneously  involved,  their  coalescence  may 
give  rise  to  irregular  vomicae ; but  the  ultimate 
shape  of  cavities  chiefly  depends  upon  the  pecu- 
liarities of  the  bronchial  distribution  to  the  dis- 
trict affected. 

Vomicae  are  frequently  trabeculated.  Trabe- 
culae (clearly  to  be  distinguished  from  denuded 
branches  of  the  pulmonary  artery)  invariably 
consist  of  blood-vessels  and  of  collapsed  or  in- 
durated alveolar  substance.  They  are  the  re- 
mains of  intervals  of  spongy  tissue,  originally 
separating  distinct  cavities.  Their  ulceration  and 
partial  absorption  often  give  rise  to  a knobbed 
condition  of  the  internal  surface  of  cavities. 

During  the  period  of  formation  and  of  ex- 
tension the  walls  of  cavities  are  rough  and  ul- 
cerous. But  the  completed  cavity  becomes  sur- 
rounded by  a fibro- vascular  zone,  the  outer  surface 
of  which  is  continuous  with  the  pulmonary  tis- 
sue, whilst  its  innermost  stratum  constitutes, 
during  the  active  stages,  a pyogenic  layer,  and 
subsequently  an  exfoliating  false  membrane. 
Vomicie  thus  invested  are  said  to  be  encapsu- 
lated. 

Important  differences  are  noticeable  in  the 
condition  of  tissues  around  cavities.  The  cap- 
sule of  a vomica  may  be  immediately  surrounded 
by  alveolar  substance,  the  expansion  of  which 
may  exert  a favourable  amount  of  pressure  upon 
it ; or  it  may  be  continuous  with  inflamed  and 
thickened  tissue,  or  with  tubercular  infiltrations. 
In  extreme  cases  the  lung  is  to  such  an  extent 
invaded  by  the  fibrous  growth  from  an  adherent 
pleura,  that  the  vomicie  present  the  appearance 


VOMICA. 


of  haring  been  formed  at  the  expense  of  the 
fibrous  tissue  itself  (‘  fibroid  phthisis’). 

Situations. — No  appreciable  difference  exists 
between  the  liability  to  excavation  of  the  right 
and  that  of  the  left  lung.  Primary  excavation 
almost  invariably  attacks  the  upper  part  of  the 
upper  lobe ; its  most  common  seat  is  the  central 
part  of  the  subclavicular  region,  not  the  apex 
proper ; it  may,  however,  extend  to  the  very 
summit  of  the  lung,  or  involve  the  greater  part 
of  the  upper  lobe.  Phthisical  destruction  very 
rarely  has  its  starting-point  in  the  middle  or 
in  the  lower  third  of  the  lung.  The  base  of  the 
lung,  on  the  other  hand,  is  the  most  common  seat 
of  those  cavities  which  are  not  due  to  phthisis 
(for  example,  abscesses  by  extension,  gangrene, 
and  syphilitic  ulceration). 

The  common  form  of  phthisis,  originally  attack- 
ing the  apex,  implicates,  almost  without  excep- 
tion, the  mid-dorsal  region  secondarily  ; this  the 
writer  has  shown  to  be  due  to  the  transmission 
of  irritating  matter  along  the  bronchus  supplying 
that  district.  Similarly  the  base  becomes  affected 
in  the  latest  stages  of  excavating  disease,  if  life 
should  be  sufficiently  prolonged. 

j Bronchi  in  relation  to  vomica. — Cavities  not 
smaller  than  a lobule  inevitably  open  into  a 
bronchus.  The  communication  may  be  tem- 
porarily obliterated,  or  it  may  in  rare  instances 
become  permanently  sealed.  Most  cavities  ex- 
ceeding the  size  of  a single  lobule  intercept  more 
than  one  bronchus  ; and  the  air-tubes  ulcerate 
within  them  at  an  early  period  of  the  softening. 
Thus  two  sets  of  bronchial  orifices  may  be  re- 
cognised in  vomicae,  the  proximal  and  the  distal, 
forming  as  many  small  islands  of  mucous  mem- 
brane on  the  internal  surface  of  cavities. 

Blood-vessels  in  relation  to  vomica. — Trabe- 
culae always  contain  either  patent  or  obliterated 
vascular  branches.  More  resistant  than  all  other 
structures,  these  vessels  may  become  completely 
exposed  and  finally  eroded.  But  aneurism  or 
erosion  more  commonly  has  its  seat  in  those 
branches  of  the  pulmonary  artery  which  ramify 
in  the  thickness  of  the  cavity  wall,  a fact  readily 
explained  by  the  persistence  of  circulation  within 
these  vessels,  by  their  inability  to  retract,  by  the 
uneven  support  which  their  coats  receive  at 
different  points  of  their  circumference,  and  by 
their  diseased  condition.  Fatal  haemorrhage  may 
occur  without  any  warning  from  the  erosions 
or  from  the  aneurisms.  More  habitually  premoni- 
tory bleeding  of  limited  extent  recurs  at  short 
intervals  prior  to  the  fatal  rupture.  Pulmonary 
aneurisms  sometimes  undergo  spontaneous  cure 
when  their  growth  is  limited  by  the  small  size 
of  the  cavity  which  contains  them;  or  the 
pressure  of  the  extra vasated  blood  may  effect  the 
same  result  subsequently  to  their  rupture.  It  is 
almost  the  rule  for  aneurisms  to  occur  simultane- 
ously at  different  parts  of  the  same  lung. 

Extension  of  vomica. — -Cavities  increase  in 
size  by  the  gradual  necrosis  of  their  inner  wall ; 
by  the  fusion  of  adjacent  excavations;  and  by 
their  encroaahment  upon  fresh  bronchial  terri- 
tories, which  become  the  seat  of  similar  ulcera- 
tion. 

Retrocession  of  vomica. — The  contraction  of 
cavities  is  essentially  due  to  the  shrinking  of 
their  capsule.  This  force  is  assisted  in  some 

111 


1761 

cases  by  the  expansion  of  theneighbouring  spongy 
tissue,  or  even  of  the  hypertrophied  healthy 
lung;  in  other  cases  by  the  constricting  pressure 
from  a thick  zone  of  fibrous  tissue ; indirectly 
also  by  the  falling-in  of  the  ribs,  by  the  rise- of 
the  diaphragm,  and  by  the  abundant  growth  of 
new  fibrous  tissue  in  the  thickness  of  the  pleural 
adhesions. 

The  retraction  towards  the  root  of  the  lung, 
which  is  so  commonly  observed  in  chronic  vo- 
micse,  is  partly  due  to  the  inflammatory  thicken- 
ing and  shortening  of  the  bronchus;  it  is  often 
opposed  by  adhesions  of  the  corresponding  pul- 
monary surface  to  the  chest-wall. 

In  their  contracted  state  vomicae  may  remain 
dormant  for  years.  Final  obliteration  is  rarely 
attained,  chiefly  owing  to  their  deficient  granu- 
lating power,  and  to  the  superficial  necrosis  of 
their  opposed  surfaces,  both  these  conditions 
being  the  outcome  of  imperfect  drainage. 

Consequences  of  Excavation. — Amongst  the 
general  consequences  of  pulmonary  excavation 
are  loss  of  breathing  surface  ; exhausting  sup- 
puration, often  leading  to  lardaeeous  degenera- 
tion of  the  organs  ; and  tuberculosis.  The  chief 
local  consequences  are  secondary  deposits  (pneu- 
monic or  tubercular)  in  the  healthy  portions  of 
the  lungs,  as  a result  of  the  inhalation  of  the 
secretion  of  cavities,  and  of  other  products. 
Lastly,  as  the  result  of  the  contraction  of  cavi- 
ties, we  meet  with  local  shrinking  of  the  lung 
and  collateral  emphysema ; various  involutions 
of  the  pulmonary  surface  ; various  deformities 
of  the  thorax,  &c. 

Among  the  fatal  accidents  incidental  to  ex- 
cavation rupture  of  aneurisms  has  already  been 
referred  to.  Perforation  of  the  lung,  leading  to 
pneumothorax,  is  a danger  special  to  the  more 
insidious  varieties,  in  which  the  softening  is 
rapid,  whilst  the  inflammation  is  of  low  type  and 
unaccompanied  with  the  usual  tissue-reaction. 

Diagnosis. — The  ordinary  methods  of  physical 
examination,  by  which  the  presence  of  cavities 
may  he  detected,  are  described  in  other  articles 
(see Phthisis;  andPuysicAi,  Examination).  Afew 
points  only  claim  specially'  to  be  noticed.  Caver- 
nous sounds  are  seldom  given  by  cavities  smaller 
than  an  ordinary  filbert,  probably  owing  to  the 
small  size  of  their  bronchus.  Cavities  even  of 
larger  size  are  not  infrequently  completely  masked 
by  the  interposition  of  spongy  tissue ; this  is 
more  especially  the  case  in  the  tubercular  forms. 
In  the  opposite  condition  of  cirrhosis,  cavernous 
sounds  may  be  absent  or  very  feeble,  in  con- 
sequence of  deficient  inspiratory  movements. 
Lastly,  the  accidental  blocking  of  a bronchus 
may  suspend  for  a time  all  auscultatory  evidence 
of  excavation.  The  distance  of  the  vomica  from 
the  surface  may  be  roughly  estimated  from  the 
intensity  of  the  sounds ; its  degree  of  fulness 
from  their  liquid  character ; the  smoothness  of 
its  walls  from  their  amphoric  nature  ; its  com- 
pressibility by  surrounding  spongy  substance, 
and  its  elastic  resiliency,  from  the  suction-sound 
sometimes  heard  during  the  respiratory  pause 
following  cough,  aptly  termed  by  Dr.  Mitchell 
Bruce  the  indiarubber-ball  sound. 

A determination  of  the  extent  of  the  vomica 
can  generally  be  attained  by  careful  investiga- 
tion. Sometimes,  however,  eavernous  sounds  are 


1762  VOMICA. 

propagated  beyond  the  excavated  region  by  con- 
solidation. Occasionally  they  are  re-echoed  at  a 
symmetrical  point  in  the  sound  lung,  especially 
at  the  base.  Phantom-caverns  of  this  nature 
may  be  suspected  whenever  absolute  identity  in 
the  position  and  in  the  auscultatory  quality  of  the 
sounds  on  either  side  coincides  with  great  disparity 
in  percussion-resonance  and  in  vocal  fremitus. 

Valuable  information  is  derivable  from  the 
sputa.  Abundant  purulent  discharge  always  in- 
dicates an  active  condition ; if  mixed  with  much 
mucus,  it  points  to  a co-existing  bronchial  ca- 
tarrh ; if  shreddy  and  foetid,  to  a cavity  of  some 
magnitude,  imperfectly  drained.  The  intimate 
admixture  of  blood  indicates  a congested  state 
of  the  membrane.  From  the  presence  of  abun- 
dant, well-preserved,  elastic  elements  it  is  pos- 
sible to  diagnose  the  moister  forms  of  necrosis ; 
caseous  lumps  argue  the  existence  of  caseous 
pneumonia  ; the  expectoration  of  calcareous  par- 
ticles shows  that  excavation  is  progressing  at  the 
expense  of  more  or  less  fibrosed  tissue  resulting 
from  former  disease  ; and,  according  to  Koch, 
the  presence  of  bacilli  staining  deeply  with 
methylene-blue  and  not  decolorised  by  vesu- 
vin,  is  a test  for  tubercle.  Lastly  the  cessation 
of  all  secretion  is  indicative  of  a perfect  quies- 
cence of  the  vomica. 

Prognosis.— In  cavities  not  due  to  phthisis, 
the  absence  of  the  constitutional  element  greatly 
favours  recovery  ; and  their  progress  is  mainly 
governed  by  the  nature  of  their  cause,  by  their 
size,  by  their  situation,  and  by  other  influences 
enumerated  below.  Where  healing  is  much 
delayed  in  such  cases,  the  eventual  development 
of  phthisis  is  rendered  probable. 

The  prognosis  of  phthisical  vomicae  is  in- 
timately bound  up  with  the  prognosis  of  phthisis, 
a subject  too  wide  for  discussion  here,  but  fully 
treated  in  the  article  Phthisis,  and  in  Dr.  James 
Pollock's  work  on  The  Elements  of  Prognosis  in 
Consumption.  Most  unfavourable  are  the  vo- 
micse  due  to  a breaking  up  of  tuberculo-pneu- 
monic  deposits.  Vomic®  originating  in  pure 
tubercle,  although  they  may  contract,  seldom 
heal.  Where  haemorrhage  occurring  in  a lung 
previously  quite  free  from  disease,  subsequently 
leads  to  excavation,  the  closure  of  the  cavity  is 
encouraged  by  the  contraction  which  charac- 
terises these  cases.  But  the  pneumonic  class, 
which  comprises  the  most  rapidly  fatal  eases  of 
excavation,  also  supplies  the  most  striking  in- 
stances of  recovery.  There  exists  a large  clini- 
cal group  in  which  the  affection  is  limited  to  a 
small  portion  of  one  lung,  and  in  which  the 
disease  is  rather  local  than  constitutional.  On 
careful  analysis  of  these  favourable  cases,  the 
chief  elements  of  their  fortunate  termination 
will  be  found  to  be  the  following  : — 1st,  unila- 
teral character  of  the  affection ; 2nd,  its  small 
extent ; 3rd,  comparatively  rapid  occurrence  of 
softening ; 4th,  complete  removal  of  the  whole 
consolidation ; 5th,  absence  of  close  adhesions  to 
the  thoracic  parietes ; and  6th,  facilities  afforded 
for  collateral  expansion. 

Treatment. — The  ideal  treatment  of  cavities 
would  have  for  its  objects: — (1)  to  restore 
healthy  action  to  their  surface ; (2)  to  prevent 
a stagnation  of  their  secretions ; and  (3)  to  en- 
courage their  contraction. 


VOMIT,  EXAMINATION  OF. 

For  the  fulfilment  of  these  indications  various 
surgical  measures  have  been  practised: — 1st, 
free  incision  and  injections  (Barry,  1727);  2nd, 
paracentesis  (Ramadge,  1836);  3rd,  free  inci- 
sion and  drainage  (Hastings  and  Storks,  1845); 
4th,  paracentesis  and  injections  (Mosler,  18731; 
and  5th,  needle-injections  of  medicateii  fluids 
(Pepper,  1874). 

Much  may  yet  be  expected  of  modern  surgery 
in  the  treatment  of  excavating  disease.  Hitherto, 
however,  there  exists  but  meagre  evidence  to 
show  that  any  good  has  resulted  from  surgical 
interference,  and  the  range  within  which  such 
interference  is  justifiable  is  very  limited. 

The  ordinary  methods  of  treatment  comprise, 
in  addition  to  the  use  of  constitutional  reme- 
dies : — 

1st.  Treatment  by  inhalation  of  medicated 
spray,  of  medicated  vapours,  of  air  charged  with 
the  natural  exhalations  from  the  sea,  from  pine- 
forests,  &c.  See  Inhalation  ; and  Climate, 
Treatment  of  Disease  by. 

2nd.  Treatment  by  posture,  sometimes  facili- 
tating, as  it  does,  the  drainage  of  cavities. 

3rd.  Treatment  directed  to  the  enlargement 
of  the  thorax  and  to  the  expansion  of  the  luDgs, 
such  as  passive  exercise  of  the  thoracic  muscles, 
inhalation  of  rarefied  air,  and  especially  resid- 
ence at  high  altitudes.  Wm.  Ewart. 

VOMIT  : Examination  of  Vomited 

Matters. — Vomited  matters  may  consist  either 
of  substances  present  in  the  stomach  when  vomit- 
ing begins,  or  of  substances  entering  it  during 
the  process.  Those  present  in  the  stomach  when 
vomiting  begins  include  articles  of  food  and  drink, 
or  other  ingesta,  more  or  less  altered  by  diges- 
tion or  fermentation;  saliva,  epithelium,  mucus, 
pus,  or  blood  from  the  nasal  passages,  mouth, 
pharynx,  or  cesophagus ; fluid  or  mucus  secreted 
by  the  6tomach  itself,  epithelium-cells,  casts  of 
tubules,  or  even  shreds  of  gastric  mucous  mem- 
brane, blood  more  or  less  altered  proceeding  frtim 
the  walls  of  the  stomach,  cells  or  small  pieces  from 
morbid  growths,  and  occasionally,  as  mentioned 
by  Dr.  Quain,  the  whole  of  a pedunculated  morbid 
growth  ; fungi,  as  torul®  and  sarcin®  ; parasitic 
worms  ; bile  ; pancreatic  juice  ; pus  from  abscess 
of  the  stomach  or  liver ; f®culent  matter  from 
the  intestine.  During  vomiting  much  saliva  may 
be  swallowed ; and  bile,  pancreatic  juice,  pus  or 
faces,  not  originally  present  in  the  stomach,  may 
be  pressed  into  it  by  the  straining.  Effusion  of 
blood  into  its  cavity  may  also  be  caused  by  the 
efforts  of  retching. 

Method  of  Examination — In  examining 
the  vomited  matters  it  is  advisable,  first,  to 
separate  the  larger  pieces  of  undigested  food  by 
filtering  the  vomit  through  canvas  or  muslin. 

The  solid  residue  may  be  investigated  by  wash- 
ing the  larger  pieces  and  tearing  them  up,  or 
making  sections  of  them,  so  that  their  nature 
may  be  ascertained.  Partially  digested  curd  is 
sometimes  not  very  easy  to  recognise.  When  a 
large  quantity  of  milk  has  been  drunk  at  one 
time,  the  curd  which  it  forms  in  the  stomach 
may,  when  vomited,  have  the  appearance  of  s 
piece  of  thick  dense  grey  felt. 

The  filtrate  should  be  put  into  a conical  glass 
and  allowed  to  settle.  The  reaction  of  the  fluid 


VOMIT,  EXAMINATION  OF. 

is  to  be  ascertained  by  litmus  paper.  The  pres- 
ence of  free  hydrochloric  acid  may  be  tested  for, 
by  putting  one  drop  into  a watch-glass  contain- 
ing a one  per  cent,  solution  of  tropeolin,  the 
yellow  colour  of  which  is  converted  into  a wine 
red  if  hydrochloric  acid  be  present.  The  total 
acidity  may  be  estimated  by  filtering  and  adding 
a standard  solution  of  caustic  soda  or  potash  to 
a measured  quantity  of  the  filtrate,  until  it  is 
neutralised.  For  the  methods  of  examining 
more  particularly  the  various  acids  — lactic, 
acetic,  butyric,  &c. — and  other  volatile  sub- 
stances, text  books  of  chemistry  must  be  con- 
sulted. 

To  ascertain  the  presence  of  pepsin  in  the 
vomit  we  add  to  it  its  own  bulk  of  dilute  hydro- 
chloric acid  (ten  minims  of  dilute  hydrochloric 
acid,  B.P.,  to  an  ounce  of  water)  and  a flock  of 
fibrin  or  a piece  of  hard-boiled  white  of  egg ; let 
it  stand  for  several  hours  in  a warm  place  ; and 
then  see  whether  or  not  the  fibrin  or  albumen  is 
dissolved. 

To  test  for  trypsin,  wre  proceed  in  the  same 
manner,  but  use  the  vomit  without  the  addition 
of  acid  ; and  if  it  be  already  acid,  neutralize  it 
with  bi-carbonate  of  soda. 

To  test  the  vomit  for  peptone,  we  must  put 
some  of  it  into  a small  dialyzer,  and  let  it  stand 
for  some  hours.  We  then  add  to  tiie  water  in 
which  the  dialyzer  has  stood,  solution  of  corro- 
sive sublimate,  which  gives  a precipitate  -with 
oeptones  ; or  some  liquor  potassse  and  a drop  of 
/ery  dilute  sulphate  of  copper  solution,  which 
gives  a precipitate  dissolving  on  shaking,  and 
forming  a red  solution,  changing  to  purple  when 
more  copper  is  added. 

Bile  is  tested  for  in  the  filtered  liquid  by 
G-melin’s  and  Pettenkofer's  tests. 

For  blood  in  the  vomit  see  Hjemateuesis. 

If  the  vomited  matter  bo  too  thick  to  allow 
the  sediment  to  subside,  a little  of  it  should  be 
mixed  with  some  distilled  water  and  allowed  to 
settle.  A drop  of  the  sediment  is  then  to  be 
examined  microscopically  ; and  the  examination 
is  facilitated  by  adding  to  one  specimen  a drop 
of  iodine  solution,  and  to  another  a drop  of 
aniline  red  or  blue  solution.  The  substances 
most  likely  to  occur  are  partially  digested  fibres 
of  voluntary  or  involuntary  muscle,  elastic 
fibres,  connective-tissue  bundles  from  meat  in 
the  food,  spiral  fibres  and  green  chlorophyll 
granules  from  vegetables,  starch-granules  — 
stained  blue  by  iodine,  torulse  or  sarcinae,  blood- 
corpuscles,  leucocytes,  scaly  epithelium  from 
the  mouth,  cylindrical  epithelium  from  the  sto- 
mach, and  casts  of  the  gastric  follicles— some- 
times fibrinous,  sometimes  composed  of  cells  and 
granules,  which  take  up  the  aniline  colour,  and 
are  thus  rendered  more  easily  visible. 

Clinical  and  Pathological  Indications. — 
If  the  vomited  food  be  unchanged,  or  but  little 
changed,  it  indicates  either  that  the  vomiting 
has  occurred  soon  after  a meal,  or  that  the 
secretion  of  gastric  juice  is  deficient  either  in 
quantity  or  quality.  The  food  is  usually  com- 
paratively little  changed  in  nervous  vomiting,  or 
in  cancer  of  the  cardiac  extremity  of  the  stomach. 
In  vomiting  from  cancer  of  the  pylorus,  or  duo- 
denal ulceration,  the  food  is  much  more  digested, 
as  it  remains  much  longer  in  the  stomach.  If 


VOMITING.  1763 

undigested  food  be  vomited  some  hours  after  a 
meal,  the  vomit  should  be  examined  in  order  to 
ascertain  whether  pepsin  or  acid  is  deficient. 
Complete  absence  of  hydrochloric  acid  has  been 
observed  in  cases  of  amyloid  degeneration  of 
the  stomach,  and  a deficiency  of  acid  has  been 
found  experimentally  in  acute  anaemic  and  febrilo 
conditions.  Abnormal  acidity  from  fermentation 
of  saccharine  or  farinaceous  articles  of  food,  and 
the  consequent  production  of  acetic,  lactic,  and 
butyric  acids,  occurs  in  chronic  catarrhal  con- 
ditions. In  some  cases  of  gastric  catarrh  starch 
appears  to  undergo  a mucous  fermentation,  and 
large  quantities  of  glairy  material  are  formed. 
When  fermentation  has  gone  on  to  a great  extent, 
the  vomit  may  have  a yeasty  look,  and  should 
then  be  examined  for  sareinse  and  torulae.  See 
Sarcin-s:  ; and  Stomach,  Dilatation  of. 

Sometimes  large  quantities  of  a w'atery  fluid 
are  vomited.  This  is  occasionally  alkaline  or 
neutral,  contains  potassium  sulphocyanide,  and 
digests  starch.  It  consists  of  saliva,  which  has 
been  secreted  abundantly  on  account  of  reflex 
irritation  arising  from  the  stomach,  and  swal- 
lowed. At  other  times  it  is  strongly  acid,  and 
appears  to  be  secreted  by  the  stomach.  Some- 
times the  vomit  appears  to  be  a mixture  of 
both  of  these  fluids.  Such  vomiting  may  occur 
from  nervous  disturbance  of  the  stomach,  but 
may  be  symptomatic  also  of  catarrh,  ulcer,  or 
cancer.  Mucus  in  the  vomit  indicates  catarrh  of 
the  gastric  mucous  membrane ; and  the  more  acute 
the  inflammation,  the  more  leucocytes  occur  in 
the  mucus.  Bile  may  he  vomited  pure,  in  the  form 
of  a tasteless  golden-yellow  substance  like  yolk  of 
egg,  from  the  action  of  poisons,  but  this  rarely 
happens.  Vomiting  of  bile,  more  or  less  green 
and  diluted,  or  mixed  with  digestive  secretions 
or  food,  occurs  as  a symptom  in  congestion  of 
the  liver  ; hut  it  may  take  place  in  all  kinds  of 
vomiting,  whatever  its  cause.  Large  quantities 
of  bile,  mixed  with  the  secretions  from  the 
mouth  and  stomach,  and  forming  a grass-green 
liquid  ( vomitus  aniginosvs'),  may  he  vomited  in 
peritonitis  and  cerebral  affections.  The  writer 
has  also  observed  this  character  of  vomit  in 
opium-eaters.  Constant  absence  of  bile  when 
vomiting  is  persistent,  points  to  pyloric  stenosb. 
Pus  may  get  into  vomit  from  the  bursting  of  an 
abscess  in  the  mouth  or  tonsils;  it  sometimes, 
though  rarely,  may  arise  from  au  abscess  in  the 
wails  of  the  stomach ; but  it  is  more  likely  to 
come  from  abscess  of  the  liver.  Blood  vomited 
in  large  quantity,  and  of  a bright  red  colour, 
usually  indicates  ulceration  of  the  stomach  or 
cirrhosis  of  the  liver.  More  or  less  altered,  and 
in  smaller  quantity,  it  occurs  in  the  diseases  just 
mentioned,  and  also  in  cancer  and  yellow  fever 
(see  Black  Vomit;  and  Yellow  Fever).  It  may 
also  be  present  in  hysterical  persons  who  have 
swallowed  blood,  obtained  from  external  sources, 
or  by  sucking  hollow  teeth.  Cancer-cells  in  the 
vomited  matters  are  diagnostic  of  the  presence 
of  that  disease.  T.  Lauder  Brunton. 

VOMITING  (Lat.  vomo ). — Synon.  : Fr.  Vo- 
missement;  Ger.  Erbrechen. 

Definition. — Forcible  expulsion  of  the  con- 
tents of  the  stomach  through  the  oesophagus. 

./Etiology  and  Pathology.— The  contents  -■! 


VOMITING. 


1764 

the  stomach  are  expelled  from  it  by  the  mechanical 
pressure  brought  to  bear  upon  it  by  the  diaphragm 
and  abdominal  parietes,  •which  contract  simulta- 
neously. When  these  muscles  contract,  if  the 
cardiac  orifice  of  the  stomach  remains  closed, 
an  ineffectual  effort  at  vomiting,  or  retching, 
occurs ; but  if  the  cardiac  orifice  dilate,  the 
gastric  contents  are  expelled.  When  the  dia- 
phragm and  abdominal  muscles  are  paralysed, 
vomiting  is  impossible,  though  the  stomach  may 
be  in  active  movement.  The  stomach  is  not 
necessary  to  vomiting,  which  will  occur  when 
that  organ  is  excised,  and  a simple  bladder 
tied  in  its  place ; but  when  the  stomach  is  pre- 
sent, mere  pressure  upon  it  by  the  diaphragm 
and  abdominal  muscles,  as  in  coughing,  does  not 
expel  its  contents.  The  cardiac  orifice  is  re- 
laxed by  means  of  the  longitudinal  fibres,  which 
run  along  the  under  end  of  the  oesophagus  below 
the  diaphragm,  and  then  radiate  completely  over 
the  stomach.  When  they  contract  they  dilate 
the  cardiac  orifice,  and  at  the  same  time  aid  the 
evacuation  of  the  stomach  by  drawing  the  whole 
viscus  towards  the  diaphragm.  In  the  act  of 
vomiting,  then,  the  simultaneous  contraction  of 
three  sets  of  muscles  is  required: — (1)  of  the 
diaphragm,  (2)  of  the  abdominal  wall,  and  (3)  of 
the  muscular  fibres  just  mentioned  in  the  stomach 
itself.  The  movements  of  these  muscles  are  co- 
ordinated by  a nervous  centre,  situated  in  the 
floor  of  the  fourth  ventricle  in  the  medulla 
oblongata.  This  centre  is  closely  associated  with, 
though  of  course  not  identical  with,  the  respi- 
ratory centre.  The  motor  impulses  from  these 
centres  are  sent  to  the  abdominal  muscles,  dia- 
phragm, stomach,  and  oesophagus,  by  the  inter- 
costal, phrenic,  and  pneumogastric  nerves  re- 
spectively. The  reasons  for  supposing  that  the 
nervous  centre  for  vomiting  is  closely  associated 
with  the  respiratory  centre,  are  that  the  move- 
ments of  vomiting  are  modified  respiratory 
movements,  that  emetics  excite  the  respiratory 
centre,  and  that  their  action  is  usually  preceded 
by  increased  respiratory  movement,  while  de- 
pression of  the  activity  of  the  respiratory  centre 
stops  vomiting.  When  the  blood  is  rendered 
very  arterial  by  excessive  respiration,  a condition 
ofapncea,'  in  which  no  need  of  respiration  is  felt, 
and  no  respiratory  movements  are  made,  is  pro- 
duced ; but  if  emetics  are  then  injected  into  the 
veins,  respiration  not  only  becomes  more  fre- 
quent, but  apncea  can  no  longer  be  induced,  unless 
the  activity  of  the  respiratory  centre  be  lowered 
by  narcotics. 

The  vomiting  centre  is  usually  excited  to  action 
by  irritation  of  certain  afferent  nerves.  These  may 
either  act  directly  upon  it,  or  through  the  medium 
of  the  brain.  The  nerves  of  special  sense  act- 
through  the  brain.  The  sight  of  a disgusting 
object,  a disagreeable  stench,  or  an  unpleasant 
taste,  may  excite  vomiting,  and  it  may  also  be 
produced  by  the  simplo  thought  of  such  sub- 
jects. Blows  on  the  head,  or  inflammation  of 
the  brain  or  its  membranes,  also  excite  vomiting. 
According  to  Budge,  the  cerebral  centres  for 
the  movements  of  the  stomach  are  in  the  right 
corpus  striatum,  and  especially  in  the  right  optic 
thalamus.  When  these  parts  are  irritated  the 
stomach  moves.  Irritation  of  the  corresponding 
•arts  on  the  left  side  of  the  brain  ' " "•  "fleet 


the  stomach.  Vomiting  occurs  in  certain  cere- 
bral conditions,  either  affecting  the  brain  itself 
or  its  membranes,  such  as  cancer  or  tubercle 
of  the  brain,  apoplexy,  cerebellar  haemorrhage, 
softening  of  the  cerebral  substance,  sometimes  en- 
cephalitis, poisoning  by  narcotics,  melancholia, 
profuse  haemorrhage,  or  tubercular  meningitis. 
It  is  also  one  of  the  symptoms  of  Meniere’s 
disease  of  the  semi-circular  canals.  It  also 
occurs  in  various  diseases,  in  which,  however, 
it  is  -difficult  to  say  whether  the  vomiting  be 
due  to  direct  affection  of  the  brain  itself,  or  to 
reflex  action  upon  it  from  other  organs.  Such 
diseases  are  typhus,  plague,  yellow  fever,  cholera, 
and  the  cold  stage  of  ague.  Very  painful  im- 
pressions on  sensory  nerves  throughout  the  body 
may  excite  vomiting.  This  is  seen  in  cases  of 
loose  cartilages  in  the  knee,  in  dislocation  of  a 
joint,  or  in  a painful  wound  or  operation.  Here, 
also,  it  is  uncertain  whether  the  vomiting  be 
produced  through  a direct  connection  of  sensory 
nerves  with  the  vomiting  centre,  or  whether  the 
irritation  acts  indirectly  through  the  cerebrum. 

Certain  afferent  nerves  appear  to  have  a more 
direct  connection  with  the  vomiting  centre  than 
others,  and  these  require  special  consideration:— 

(1)  Branches  of  the  glosso-pharyngeal  nerve  to 
the  soft  palate,  the  root  of  the  tongue,  and  the 
pharynx. — These  parts  have  a very  close  connec- 
tion with  the  vomiting  centre,  and  tickling  them 
with  the  finger  or  with  a feather  is  one  of  the 
readiest  means  of  inducing  vomiting. 

We  find  vomiting  occurring  in  inflammation 
of  the  soft  palate  or  tonsils,  and  also  of  the 
pharynx,  especially  in  children. 

(2)  The  nerves  of  the  stomach.— The  sensory 
nerves  of  the  stomach  are  chiefly  branches  of  the 
vagi,  but  they  belong  partly  also  to  the  sympa- 
thetic system.  When  the  vagi  are  cut  vomiting 
becomes  difficult,  but  efforts  at  retching  occur, 
and  vomiting  will  even  take  place  from  the 
action  of  emetics  after  section  of  the  vagi.  It  is 
therefore  evident  that  irritation  of  the  stomach 
produces  vomiting  reflexly  through  other  nerves 
than  the  vagi.  Vomiting  may  occur  from  irritant 
substances  in  the  stomach,  whether  introduced 
into  the  stomach,  or  formed  within  it  ; from 
irritation  within  the  stomach,  from  an  inflamed 
or  irritated  condition  of  its  walls;  or  from  me- 
chanical pressure,  from  without  or  from  within. 
Thus  it  may  occur  from  the  presence  of  undi- 
gested food,  from  irritating  substances  produced 
by  imperfect  digestion,  or  from  irritant  poisons 
within  the  stomach.  It  may  be  due  to  catarrh 
or  congestion  of  the  mucous  membrane  itself,  to 
softening  of  the  mucous  membrane,  or  to  cancer 
in  the  gastric  wall.  It  may  be  produced  by  ex- 
treme distension  of  the  stomach,  by  gas,  liquids, 
or  solids  ; by  compression  of  a part  of  it  within 
the  body,  as  in  hernia  of  the  stomach  ; or  by  the 
pressure  of  a tumour  upon  it.  It  may  be  caused 
by  violent  compression  externally  with  the  hands  ; 
by  the  pressure  of  a too  tightly  laced  corset ; by 
the  pressure  against  the  abdominal  walls  of  hard 
tools  or  benches  in  certain  trades.  It  frequently 
occurs  in  cough,  especially  the  cough  of  phthisis  ; 
but  here  it  is  probable  that  the  vomiting  is  due 
partly  to  the  violent  compression  between  the 
diaphragm  and  abdominal  walls,  aDd  partly  to  the 
congestion  of  the  vessels  which  the  continued 


VOMITING. 


interruption  of  the  circulation  during  the  fit  of 
coughing  brings  on. 

(3)  The  nerves  of  the  liver  and  gall-ducts. — 
These  consist  chiefly  of  branches  of  the  vagus 
and  sympathetic.  From  their  irritation  vomit- 
ing occurs  in  hepatitis,  or  during  the  passage  of 
a biliary  calculus.  It  is  from  irritation  of  these 
branches,  also,  that  vomiting  may  occur  in 
pleurisy  of  the  right  side,  the  congestion  of  the 
pleura  on  the  upper  surface  of  the  diaphragm 
having  led  to  congestive  changes  in  the  liver. 

(4)  Intestinal  nerves. — Ligature  of  the  intes- 
tine in  animals  produces  vomiting,  'which  is  ar- 
rested by  dividing  the  nerves  passing  from  the 
ligatured  parts.  In  man  it  is  the  almost  in- 
variable accompaniment  of  strangulated  hernia 
or  intussusception,  and  it  may  even  occur  in  ob- 
struction of  the  bowel  by  faecal  matters  in  cases 
of  obstinate  constipation.  It  also  takes  place  in 
peritonitis  from  irritation  of  these  nerves. 

(5)  The  renal  turves.- — From  irritation  of  these 
nerves  vomiting  occurs  in  nephritis,  or  by  calculi 
in  the  pelvis  of  the  kidney  or  passing  down  the 
ireter. 

(6)  Vesical  nerves. — In  cystitis  vomiting  oc- 
curs. It  may  possibly  be  due,  however,  not  to 
. rritation  of  the  vesical  nerves,  but  to  extension 
C-f  inflammation  to  neighbouring  parts. 

(7)  Uterine  nerves. — Irritation  of  these  nerves 
is  one  of  the  commonest  causes  of  reflex  vomit- 
ing. It  may  be  produced  in  animals  on  irrita- 
tion of  the  uterine  plexus,  and  occurs  in  the 
human  subject  during  pregnancy  or  in  metritis. 

(S)  Ovarian  nerves. — Vomiting  is  a symptom 
of  inflammation  of  the  ovaries. 

(9)  The  nerves  of  the  testicle. — A blow  on  this 
organ  tends  very  readily  to  produce  nausea  and 
vomiting. 

The  cause  of  vomiting  in  sea-sic/cncss  is  uncer- 
tain, but  it  appears  to  the  writer  to  be  partly  due 
to  the  condition  of  the  nerve-centres,  and  partly 
to  that  of  the  viscera.  See  Sea-Sickness. 

Treatment. — The  treatment  of  vomiting  is  to 
be  directed  to  two  ends  (1)  to  remove  the  cause 
if  possible  ; and  (2)  to  lessen  the  irritability  of  the 
■vomiting  centre.  The  chief  drugs  which  lessen 
the  irritability  of  the  vomiting  centre  are  opium, 
morphia,  bromide  of  potassium,  chloral,  and 
probably  also  hydrocyanic  acid  and  belladonna. 
Strychnia  and  smalldoses  of  ipecacuanha  are  also 
useful  in  vomiting,  and  they  probably  owe  their 
power  to  their  action  on  the  vomiting  centre. 
Most  of  these  drugs  have  a local  sedative  action 
on  the  stomach,  and  therefore  it  is  advantageous 
to  give  them  by  the  mouth  when  possible.  Even 
when  the  stomach  is  very  irritable,  they  may  be 
retained  by  giving  them  in  a concentrated  form. 
When  the  stomach  will  not  retain  them,  they  must 
be  given  by  the  rectum  or  by  subcutaneous  injec- 
tion. In  sea-sickness  the  effect  of  the  position 
of  the  bead  is  sometimes  very  marked,  and  the 
vomiting  may  sometimes  be  arrested  completely 
by  removing  all  pillows  and  putting  the  head  on 
a level  with,  or  rather  lower  than,  the  body. 

In  cases  of  disease  of  the  brain  or  its  mem- 
branes, where  it  is  difficult  or  impossible  to  re- 
move the  cause,  we  must  try  to  lessen  the  conges- 
tion by  means  of  leeches  and  cold  applications  to 
the  head  ; and  also  to  soothe  the  vomiting  centre 
by  hydrocyanic  acid,  or  by  bromide  of  potas- 


1765 

sium.  At  the  same  time,  however,  considerable 
benefit  is  obtained  from  the  use  of  remedies  which 
act  locally  on  the  stomach,  these  seeming  to  have 
some  reflex  effect  upon  the  vomiting  centre.  One 
of  the  most  useful  is  ice,  which  may  be  constantly 
sucked,  and  also  swallowed  in  small  lumps. 
Where  the  vomiting  is  dependent  on  the  action  of 
poisons  circulating  in  the  blood,  as  in  the  later 
stages  of  contracting  kidney,  we  must  endeavour 
to  eliminate  these  by  increasing  the  action  of  the 
kidneys  and  the  skin.  In  vomiting  dependent  on 
inflammation  of  the  mouth  and  fauces,  we  lessen 
the  irritability  by  soothing  or  astringent  gargles, 
confections,  or  glycerines.  A confection  or  gly- 
cerine is  often  better  than  a gargle,  inasmuch  as 
it  remains  longer  attached  to  the  parts,  and  thus 
exercises  a more  prolonged  effect  upon  them. 
When  vomiting  is  due  to  irritant  substances  in 
the  cavity  of  the  stomach,  such  as  indigestible 
food,  and  acrid  fluids  or  poisons,  it  is  best  treated 
by  evacuating  them.  A large  draught  of  luke- 
warm water,  alone  or  mixed  with  a teaspoonful 
of  mustard,  is  one  of  the  best  means.  Large 
draughts  of  warm  water  alone,  even  if  they  are 
not  ejected,  may  give  relief  by  diluting  the  acrid 
substances  in  the  stomach  so  much  as  to  prevent 
their  irritating  the  mucous  membrane.  In  this 
way  they  sometimes  relieve  sick-headaches.  It 
is  of  great  importance  sometimes,  not  only  to 
prevent  the  formation  of  acrid  substances  by  slow 
and  imperfect  digestion,  but  to  prevent  the  me- 
chanical irritation  of  the  mucous  membrane  by 
undigested  food.  For  example,  we  not  unfre- 
quently  notice  that  sickness  and  vomiting  will 
occur  in  susceptible  individuals  after  meals  con- 
taining such  substances  as  are  not  only  slowly  di- 
gested, but  are  swallowed  in  lumps.  Examples 
of  these  are  uncooked  apples  and  cheese,  or  even 
potatoes,  especially  when  imperfectly  boiled  or 
new.  These  articles,  instead  of  being  crushed  to 
a powder  by  the  teeth,  are  swallowed  in  lumps  of 
considerable  size,  and  apparently,  instead  of  pass- 
ing the  pylorus,  are  retained  in  the  stomach,  and, 
partly  by  the  mechanical  irritation,  and  partly 
by  their  giving  rise  to  acrid  products,  cause  sick- 
ness. Milk,  when  swallowed  in  large  draughts, 
or  when  there  is  too  much  acidity  in  the  stomach, 
instead  of  falling  in  fine  flakes  will  coagulate  in 
large  lumps,  which  have  a similar  effect  to  the 
cheese.  To  relieve  this  it  is  advisable  to  mix 
the  milk  with  soda-water  or  lime-water,  or  to  take 
it,  as  in  the  whey  cure,  by  sipping. 

When  vomiting  is  due  to  slow  or  imperfect 
digestion,  which  allows  decomposition  or  fermen- 
tation of  food  to  take  place  in  the  stomach,  it 
may  be  arrested  by  improving  the  digestion. 
Thus  five  grains  of  calomel,  by  acting  on  the 
stomach  through  the  liver,  may  arrest  vomiting  ; 
and  tincture  of  walnut  (the  active  principle  of 
which,  juglandin,  is  an  hepatic  stimulant)  has 
also  been  recommended.  Pepsine  also,  by  facili- 
tating digestion,  may  prevent  vomiting ; and 
bitters,  such  as  calumba,  may  do  so  also,  by  pre- 
venting putrefaction  or  fermentation. 

When  decomposition  or  fermentation  of  food, 
with  formation  of  acrid  or  irritating  products, 
has  once  set  in,  it  may  continue  a long  time, 
as  the  organisms  which  cause  it  remain  con- 
stantly in  the  stomach,  and  renew  the  process  ir, 
every  fresh  supply  of  food.  It  may  bo  stopped 


1760  VOMITING. 

by  antiseptics.  Where  the  vomited,  matters  are 
frothy  and  yeasty-looking,  the  sulphurous  acid  of 
the  Pharmacopoeia,  in  doses  of  one  fluid  drachm, 
diluted  with  half  a wine-glassful  of  water,  often 
arrests  such  vomiting  like  a charm.  Creasote  has 
a similar  action,  but  possibly  has  some  additional 
action  on  the  nervotis  system,  as  it  is  useful  oven 
in  cases  where  the  vomiting  does  not  appear  to 
be  due  to  decomposition  of  food. 

For  the  treatment  of  irritant  poisoning  see 
Poisoning. 

When  the  mucous  membrane  of  the  stomach 
itself  is  inflamed  or  irritated,  we  must  try  to 
lessen  the  irritation.  The  best  drugs  for  this 
purpose  are  ice,  hydrocyanic  acid,  opium,  and 
bismuth.  The  insoluble  salts  of  bismuth,  and 
especially  the  sub-nitrate,  are  to  be  preferred  to 
the  solutions ; and  it  is  advisable  to  combine  them 
with  magnesia,  potash,  soda,  or  carbonate  of  lime, 
according  to  the  condition  of  the  intestines,  pre- 
ferring the  magnesia  when  the  bowels  are  con- 
fined, and  carbonate  of  lime  when  they  are  too 
loose.  Sometimes  the  tendency  to  vomit  is  in- 
creased by  lying  on  the  right  side.  This  is  pro- 
bably partly  due  to  the  drag  of  the  stomach  itself 
upon  the  cardiac  extremity,  and  partly  to  the 
difficulty  with  which  gaseous  eructations  escape 
from  the  stomach  in  this  position.  When  there 
is  a tendency  to  vomit,  therefore,  the  patient 
should  lie  down  on  the  left  side  after  a meal.  In 
tlie  vomiting  of  hepatitis,  in  addition  to  opium 
and  hydrocyanic  acid,  we  may  use  ice-water,  or 
ice  swallowed,  and  leeches  over  the  liver.  In 
biliary  calculus,  wo  may  give,  along  with  opium, 
a full  dose  of  ether  internally,  and  in  addition 
may  employ  ether  or  chloroform  by  inhalation ; 
similar  treatment  maybe  adopted  in  cases  of  renal 
calculus. 

In  intussusception  or  hernia  we  must  remove 
the  cause,  if  possible.  In  peritonitis  full  doses 
of  opium  are  best.  For  the  vomiting  in  cystitis 
and  ovarian  diseases,  we  must  lessen  the  sensi- 
bility of  the  vomiting  centres  by  the  drugs  al- 
ready mentioned,  and  treat  the  local  conditions. 

In  the  vomiting  of  pregnancy  we  trust  partly 
to  the  drugs  already  mentioned  to  act  on  the 
vomiting  centre,  and  partly  to  local  applica- 
tions. It  is  sometimes  arrested  by  the  applica- 
tion of  a 10  per  cent,  solution  of  nitrate  of 
silver  to  the  os  uteri,  or  by  slight  detachment  of 
the  membranes  around  the  margin  of  the  internal 
os.  Where  all  other  methods  fail,  the  induction 
of  premature  labour  must  be  resorted  to.  See 
Pregnancy,  Diseases  and  Disorders  of. 

T.  Lauder  Brunton. 

VULVA,  Diseases  of. — Synon.  Fr.  Maladies 
de  la  Vulvc  ; Ger.  Krankheiten  der  Schamritze. — 
The  vulva  or  external  genitals  of  the  female  com- 
prise all  the  structures  external  to  the  hymen, 
having  the  navicular  fossa  and  perineum  behind, 
the  urethral  orifice,  vestibule,  clitoris,  and  mons 
Veneris  in  front,  and  at  the  two  sides  the  nymphse 
and  labia  majora.  These  organs  may  be  the  seat 
of  many  diseases,  which  will  be  described  in  the 
following  order. 

1.  Atresia  Vulvas. — Closure  of  the  genital 
fissure  is  sometimes  found  as  a congenital  mal- 
formation. This  is  usually  of  itself  of  no  great  im- 
portance, as  it  is  almost  always  associated  with 


VULVA,  DISEASES  OF. 

other  defects  in  development,  as  with  atrosia  ani, 
hermaphroditisms,  extroversion  of  the  bladder, &c. 
Acquired  atresia  results  from  mismanagement  of 
infantile  vulvitis,  from  injuries  of  the  pudenda  in 
childhood,  or  from  cicatrisation  following  upon 
some  ulcerative  process.  It  may  give  rise  to 
trouble  in  micturition  if  the  urethral  orifice  be 
involved.  In  rare  cases  it  is  only  after  puberty 
that  trouble  arises,  from  retention  of  the  menses, 
or  after  marriage,  from  dysparcunia ; or  even 
during  labour,  from  narrowness  of  the  orifice 
delaying  the  escape  of  the  infant.  In  the  slighter 
and  more  recent  cases,  where  the  labia  have  only 
been  agglutinated,  they  may  be  torn  apart  by 
pressure  with  the  thumbs ; or  by  passing  a probe 
or  sound  behind  the  line  of  adhesion,  and  tearing 
it  up  with  the  handle  of  a scalpel,  or  with  the 
nail.  Where  the  union  has  become  organised,  the 
edge  of  the  knife  must  be  employed.  In  any  case 
the  patient  should  be  anaesthetised  ; and  care 
must  be  taken  subsequently  to  prevent  the  re 
production  of  the  adhesions. 

2.  Inflammation — Synon.:  Vulvitis.  — In- 

flammation of  the  vulva  may  be  (a)  general ; 
or  ( b ) localised. 

(a)  General  vulvitis. — This  variety  is  found 
affecting  the  apposed  aspects  of  the  labia,  and 
the  whole  of  the  mucous  surface  they  enclose,  up 
to  the  borders  of  the  hymen.  It  may  be  due  to 
gonorrhoeal  infection,  in  which  case  the  catarrhal 
process  is  apt  to  extend  to  the  urethra  and  the 
vagina.  In  infants  and  young  children  of  stru- 
mous constitution,  it  sometimes  arises  from  ex- 
posure to  cold,  want  of  cleanliness,  or  irritation 
from  ascarides  that  have  passed  out  of  the  anus. 
In  the  adult  it  may  result  from  irijurv,  or  rudo 
coition  ; or  from  the  escape  of  acrid  uterine  or 
vaginal  discharges.  It  shows  itself  with  heat, 
and  tenderness  or  sometimes  itching  in  the  part; 
a discharge  of  viscid  glairy  mucus  bathos  the 
surfaces,  which  sometimes  becomes  purulent,  and 
glues  together  the  labia.  When  the  labia  are 
separated  the  seat  of  the  mischief  is  exposed, 
and  is  seen  to  be  rod,  aud  sometimes  resentful  of 
touch.  Apart  from  the  constitutional  remedies 
that  may  be  indicated  in  individual  cases,  the 
treatment  consists  in  keeping  the  parts  at  rest,  an  1 
carefully  clean ; and  in  bathing  or  douching  the 
surface  with  hot  water,  followed  by  an  astrin- 
gent lotion  or  dusting  powder. 

(A)  Localised  vulvitis. — The  vulvitis  may  be 
localised — (a)  in  the  vestibule  ; (0)  in  the  navi- 
cular fossa  ; or  (7)  in  the  muciparous  follicles  anJ 
glands,  and  especially  in  the  Bartholinia  >1  glands. 
(a)  and  (18)  occur  under  the  same  conditions  as 
the  more  diffused  inflammation,  and  may  be  a 
source  of  considerable  distress  in  walking  or 
when  the  part  is  touched,  without  being  attended 
by  any  leucorrhoeal  discharge.  Such  cased  re- 
quire the  same  treatment  as  cases  of  general 
vulvitis ; only  it  is  important  to  make  the  appli- 
cations directly  to  the  affected  spot,  and  hence  it 
is  usually  best  to  apply  sulphate  of  copper,  in 
the  form  of  a solid  crystal.  (7)  Inflammation 
in  the  Bartholinian  glands  is  the  commonest 
cause  of  labial  abscess.  It  may  attack  females 
at  any  age,  but  is  most  frequently  seen  in  women 
from  twenty  to  thirty,  whether  married  or  un 
married.  It  may  arise  diu-ing  pregnancy,  and 
some  women  are  liable  to  repeated  attacks,  ihe 


VULVA,  DISEASES  OF. 


glands  becoming  swollen  and  cystic  whenever  the 
patient  gets  a chill.  In  some  cases  there  is  pro- 
fuse secretion,  which  escapes  freely.  Far  more 
frequently  the  swelling  in  the  lining  of  the  duct 
leads  to  occlusion.  This  occlusion  is  in  some 
instances  transitory,  and  when  the  swelling  in 
the  duct  and  around  its  orifice  subsides,  the 
secretion  that  had  accumulated  escapes.  In 
other  instances  the  duct  becomes  permanently 
closed.  These  are  the  cases  where  the  patient 
acquires  a swelling  in  the  labium  majus  of  the 
affected  side,  varying  in  size  from  a pigeon’s  to 
a hen’s  egg.  The  accumulated  fluid  may  be 
clear  and  limpid;  but  often  it  is  turbid  and 
distinctly  purulent.  In  all  the  suppurative  cases,  if 
the  cyst  be  evacuated  through  a small  opening, 
the  fluid  is  apt  to  reaccumulate,  and  the  cyst- 
walls  are  now  more  likely  to  be  the  seat  of  a 
mischievous  inflammation.  So  that  the  treat- 
ment consists  first  in  trying  to  reduce  the  in- 
flammation with  hot  fomentations  or  poultices, 
perhaps  aided  by  sedative  lotions  containing  bella- 
donna or  laudanum,  with  the  view  of  getting  the 
orifice  relaxed ; and  where  the  contents  do  not 
escape  through  the  duct,  the  cyst  should  be 
freely  opened,  and  the  cavity  cauterised.  Hu- 
guier's  suggestion,  to  extirpate  the  gland,  is  not 
ordinarily  required,  especially  if  the  evacuation 
be  effected  with  a Paquelin’s  thermo-cautery, 
which  first  makes  a large  and  safe  cut  into  the 
cyst,  and  can  then  be  applied  to  the  interior,  so 
as  to  destroy  the  secreting  surface. 

Specific  inflammations. — The  specific  inflam- 
mations, gonorrhoeal  and  syphilitic,  are  treated  of 
in  their  respective  articles.  Butit  is  to  be  noted 
that  the  vulva  may  be  the  seat  of  erysipelas ; and 
female  children  have  sometimes  suffered  from  a 
gangrenous  vulvitis  or  noma,  of  the  same  nature 
as  the  noma  of  the  mouth  and  cheeks,  which  may 
come  on  after  some  of  the  eruptive  fevers,  such 
as  scarlatina,  and  require  the  same  kind  of 
treatment,  with  chlorate  of  potash  and  tincture 
of  the  muriate  of  iron  and  stimulants,  from  an 
early  stage  of  the  mischief. 

3.  Eruptions.— Various  forms  of  eruption 
may  be  met  with  in  the  vulva,  sometimes  on  the 
nymphpe  or  internal  aspect  of  the  labia  majora, 
sometimes  on  the  external  aspect,  and  extending 
to  tho  mons  Veneris,  or  inside  of  the  thighs.  The 
commonest  are  eczema,  erythema,  herpes,  prurigo, 
and  acne.  They  are  diagnosed  and  treated  in  the 
same  way  as  the  same  affections  in  other  situa- 
tions. It  is  to  be  remembered,  however,  that 
the  tendency  to  chronieity,  which  is  a marked 
feature  of  inflammatory  processes  in  the  sexual 
apparatus  generally,  is  apt  to  show  itself  in  these 
vulvar  eruptions,  and  that  patients,  from  motives 
of  delicacy,  are  apt  to  allow  them  to  remain  un- 
treated for  too  great  a length  of  time.  Further, 
many  of  them  give  rise  to  itching,  which  tempts 
the  patient  to  rub  and  scratch  herself  to  obtain 
relief,  and  may  thus  cause  pruritus. 

4.  Pruritus. — .Etiology. — Itching  of  the 
vulva  is  a not  infrequent  symptom  of  some  of 
the  eruptive  and  inflammatory  affections  of  the 
part,  either  when  these  are  healing  or  have  got 
into  a chronic  stage,  and  it  may  remain  as  a per- 
manent trouble  after  healing  has  taken  place,  if 
the  patient  have  acquired  the  habit  of  relieving 
herself  by  friction.  Sometimes  it  is  reflex,  from 


1767 

oxyuric  irritation  in  the  rectum,  or  when  the 
worms  have  travelled  from  the  anus  to  the  vulva. 
Or  it  may  be  associated  with  disease  of  the  va- 
gina or  uterus,  as  in  cases  of  chronic  colpitis  or 
carcinoma  of  the  cervix,  in  which  the  itching 
may  either  be  due  to  irritation  from  the  nature 
of  the  discharge,  or  be  a reflex  phenomenon. 
In  some  instances  it  can  be  traced  to  circulatory 
disturbance  in  the  labia,  as  when  the  veins  are 
enlarged,  and  in  the  congestion  of  early  preg- 
nancy. In  others  the  renal  ^wretion  is  at  fault ; 
and  it  is  such  a common  phenomenon  in  women 
who  are  the  subjects  of  diabetes,  that  in  every 
patient  who  suffers  from  pruritus  vulvse,  tho 
urine  should  be  tested  for  sugar.  Lastly,  there 
are  some  cases  that  can  only  be  described  as 
idiopathic. 

Symptoms. — The  itching  may  be  localised  on 
the  internal  aspects  of  the  nymph*,  or  of  the 
labia  majora,  or  around  the  clitoris  or  the  peri- 
nseum.  In  most  cases  of  long  standing  it  be- 
comes diffused  all  around  to  the  anus  and  inside 
of  the  thighs.  Sometimes  it  is  temporary,  as 
in  the  pruritus  of  pregnancy,  which  passes  off 
under  careful  management  in  a few  weeks,  or  in 
rarer  cases  during  the  puerperium ; in  other  pa- 
tients it  becomes  chronic,  and  constitutes  one  of 
the  most  distressing  troubles  to  which  the  female 
is  liable.  The  itching  may  come  on  only  occa- 
sionally. For  the  most  part  it  is  likeliest  to 
prove  distressing  when  the  patient  is  warm,  as 
at  bedtime,  or  after  exercise;  but  with  some  the 
feeling  is  never  quite  in  abeyance,  and  the  patieift 
has  the  almost  constant  desire  to  relieve  herself, 
as  for  a time  she  can  do,  by  scratching,  or  rather, 
rubbing  the  parts  with  her  dress  or  a towel, 
until  the  pain  overcomes  the  feeling  of  itch,  or 
sometimes  until  the  collapse  consequent  on  the 
onanistic  orgasm  which  she  has  involuntarily 
produced,  renders  her  for  a time  less  sensitive 
to  her  trouble.  The  result  of  such  friction,  how- 
ever, is  to  keep  up  the  local  irritation  ; so  that 
even  in  cases  where  there  may  not  originally 
have  been  any  local  pathological  change,  but 
where  the.  itching  and  friction  have  persisted  for 
months  or  years,  the  skin  and  mucous  mem- 
brane become  thickened  and  indurated,  and  a 
condition  resembling  that  of  a chronic  eczema 
becomes  induced.  In  two  cases  the  writer  has 
seen  epitheliomatous  nodules  develop  at  the 
sides  of  the  clitoris  and  in  the  vestibule. 

Treatment.  — When  diabetes  is  present  it 
must  be  combated;  and  if  the  patient  is  gouty, 
or  have  her  urine  too  acid  or  alkaline,  these  con- 
ditions must  be  rectified.  Morbid  processes  that 
may  be  present  in  the  vulva  or  other  neighbour- 
ing structures  must  be  treated  according  to  the 
requirements  of  the  case.  A carefully  regulated 
non-stimulating  diet  should  be  enjoined,  and  a 
due  amount  of  exercise.  The  internal  remedies 
that  have  been  found  most  helpful  are  bromide  of 
potassium  and  arsenic.  Then,  for  the  relief  of 
the  itching,  the  patient  must  be  warned  against 
tho  danger  of  rubbing  the  parts,  and  be  taught 
to  soothe  it  by  bathing  with  very  warm  or  some- 
times with  cold  water,  and  drying  the  parts  with 
a soft  towel  or  napkin.  It  can  be  still  better 
allayed  by  mopping  with  a lotion  containing 
infusion  of  tobacco  or  belladonna  or  opium  ; or 
by  applying  afterwards  a piece  of  lint  soaked  in 


1708  VULVA,  DISEASES  OF. 

black  lotion,  or  a lotion  of  acetate  of  lead.  The 
most  effectual  sedatives  are  ointments  containing 
sulphur,  camphor,  tor,  carbolic  acid,  thymol, 
iodide  of  lead,  bichloride  of  mercury,  bismuth, 
prussic  acid,  or  iodoform  (deodorised  -with  ton- 
quin  bean). 

o.  Tumours. — The  following  enlargements 
may  be  found  i n the  vulva : — 

(a)  Hypertrophy.  — The  clitoris  has  some- 
times been  found  of  a size  sufficient  to  cause  dis- 
comfort, and  warrant  its  removal.  Far  more 
frequently  the  nymph®  are  of  unusual  dimen- 
sions, their  margins  projecting  beyond  the  labia, 
and  then  they  are  liable  to  become  the  seat  of 
ulcerative  processes,  and  require  to  be  trimmed, 
which  may  be  done  with  the  knife  or  scissors, 
but  better  with  the  thermo-cautery.  Enlarge- 
ments of  the  labia  majora,  in  the  form  of  elephan- 
tiasis, are  mot  with  among  Hindu  women.  The 
mass  is  sometimes  of  enormous  size,  and  in 
consequence  of  the  calibre  of  the  nutrient  vessels, 
ablation  is  apt  to  be  attended  with  dangerous 
haemorrhage,  so  that  the  application  of  an  elastic 
ligature  is  in  most  cases  the  best  means  of 
effecting  its  removal. 

( b ) Hernia. — Hernial  protrusions  may  occur 
into  the  labia,  and  be  found  among  the  swellings 
of  this  part.  The  detection  and  treatment  are 
to  be  effected  and  conducted  as  in  the  case  of 
other  herni*. 

(c)  Cysts. — Cystic  swellings  are  found  in  the 
upper  part  of  the  labia,  when  the  canal  of  Nuck 
becomes  the  seat  of  an  accumulation  of  fluid, 
which  corresponds  to  hydrocele  of  the  cord  in 
the  male  ; or  lower  down,  when  the  duct  of  a 
Bartholinian  gland  has  become  occluded,  and  the 
secretion  of  the  acini  accumulates  so  as  to  dis- 
tend the  gland  without  its  becoming  inflamed. 
If  a complete  aspiration  in  either  case  is  not 
iollowed  by  perfect  cure,  and  the  fluid  re- 
uccuinulates,  as  it  is  apt  to  do,  the  second  tap- 
ping should  be  accompanied  with  an  injection  of 
iodine;  and  in  the  case  of  the  Bartholinian  cyst, 
the  wall  of  which  is  formed  of  a mucous  rather 
than  of  a serous  membrane,  the  evacuation  may 
require  to  be  effected  through  a larger  opening, 
and  followed  by  the  application  of  a more  powerful 
escharotic. 

( d ) New  growths. — Various  neoplasms  may 


WATER  CANKER. 

have  their  seat  in  the  vulva.  At  the  orifice  of 
the  urethra  not  infrequently  small  red-flesh 
growths,  the  so-called  urethral  caruncles,  make 
their  appearance.  They  are  sometimes  unat- 
tended with  any  symptom  ; more  frequently  they 
cause  intense  suffering  during  micturition,  during 
coitus,  or  when  the  patient  takes  exercise.  The 
pain  is  usually  referred  to  the  urethral  orifice, 
but  it  is  sometimes  reflected  to  distant  parts,  as, 
to  the  heel.  Relief  from  suffering  may  be  tem- 
porarily obtained  by  application  of  sulphate  of 
copper  or  nitrate  of  silver;  but  cure  is  only 
effected  by  removal  of  the  growth.  It  is  impe- 
ratively necessary  to  remove  not  only  the  small 
red  body,  but  the  portion  of  the  urethra  from 
which  it  springs,  and  the  raw  surface  should  be 
freely  cauterised  if  the  ablation  have  not  been 
effected  with  a thermo-cautery.  Specific  swell- 
ings, warty  or  gummatous,  are,  of  course,  fre- 
quently to  be  met  with  on  the  vulva.  Lipomata 
sometimes  grow  under  the  skin  of  the  labia 
pudendi.  More  frequently  fibromata  occur,  which 
may  attain  considerable  size,  and  demand  re- 
moval. Lastly,  the  law  that  carcinomata  have 
a predilection  for  surfaces  where  a transition 
takes  place  from  one  variety  of  epithelium  to 
another,  is  illustrated  by  the  frequency  with 
which  different  forms  of  cancer  affect  the  vulva. 
Their  development,  symptoms,  and  treatment 
present  no  special  features.  Only  it  is  well  to 
remember  that  when  the  mischief  is  met  with  in 
a stage  where  there  is  still  hope  of  its  eradica- 
tion, it  is  best  to  effect  the  removal  of  the  neo- 
plasm by  some  of  the  bloodless  methods  with 
which  modern  surgery  has  become  familiar.  The 
tissues  in  which  the  growth  develops  are  very 
vascular ; and  whilst  in  some  situations — as  at 
and  around  the  clitoris — it  is  comparatively  easy 
to  control  haemorrhage  by  pressure  against  the 
pubic  bones,  in  the  parts  immediately  to  the  side 
and  back  of  the  vaginal  aperture  the  bleeding 
from  a cut  surface  is  apt  to  be  uncontrollable  and 
dangerous.  Hence  commencing  carcinomata 
ought  to  be  extirpated  with  the  £eraseur,  or  better 
still  with  Paquelin’s  thermo-cautery,  which  is 
the  most  serviceable  of  all  instruments  for  the 
removal  of  tho  different  varieties  of  neoplasm 
that  infest  the  vulva. 

Alexander  Russell  Simpson, 


w 


WAKEFULNESS.  Nee  Sleep, Disorders  of. 

WARTS.  See  Verruc.e. 

WASTING. — A synonym  for  atrophy.  See 
Atrophy,  General;  and  Atrophy,  Local. 

WASTING  PALSY. — A synonym  for 
progressive  muscular  atrophy.  See  Progressive 

Muscular  Atrophy. 


WATER,  JEtiological  Relations  of.  See 
Disease,  Causes  of ; and  Public  Health. 

WATER.  Therapeutics  of.  See  Baths, 
Hydrotherapeutics  ; Mineral  Waters  ; and 
Sea  Air,  Sea  Baths,  and  Sea  Voyages. 

WATER  BRASH. — A popular  synonym  for 
1 pyrosis.  See  Pyrosis. 

WATER  CANKER.  — A synonym  f"i 
I cancrum  oris.  See.  Oancrum  Oris. 


WATER  ON  THE  BRAIN. 

WATER  ON  THE  BRAIN— A popular 
synonym  for  hydrocephalus.  See  Hydrocephalus, 
Chronic. 

WATERS,  MINERAL.  See  Mineral 
Waters. 

WAXY  DISEASE. — One  of  the  synonyms 
for  albuminoid  disease.  See  Albuminoid  Dis- 
ease. 

WEAL,  WALE,  or  WHEAL.— This  is 
an  Old-English  word  signifying  the  mark  of  a 
stripe,  that  is,  the  prominent  pale  ridge  caused 
by  the  stroke  of  a lash  upon  the  skin.  The  term 
is  applicable  especially  to  the  prominent  risings 
of  a lengthened  figure  which  are  met  with  in 
urticaria,  in  contradistinction  to  the  button-like 
tubercles  or  protuberances  of  that  affection.  See 
Urticaria. 

WEILBACH,  in  Germany. — Sulphur 
waters.  See  Mineral  Waters. 

WEN. — A popular  term  for  a tumour  of  the 
integument,  without  reference  to  its  pathological 
structure.  Wens  are  commonly  fleshy  or  en- 
cysted ; in  the  latter  case  proceeding  from  disten- 
sion of  the  sac  or  excretory  duct  of  a cutaneous 
gland,  more  especially  a sebiparous  gland. 

WET-PACK.  See  Hydrotherapeutics. 

WHEEZING. — A peculiar  sound,  of  a dry 
piping  or  whistling  character,  which  may  be 
heard  in  connection  with  the  respiratory  organs 
during  the  act  of  breathing,  and  caused  by  cer- 
tain forms  of  obstruction  to  the  passage  of  air. 
See  Asthma  ; Bronchi,  Diseases  of ; and  Physi- 
cal Examination. 

WHIFEING. — A peculiar  quality  of  a mur- 
mur heard  in  connection  with  the  heart  and 
vessels.  See  Heart,  Valves  of,  Diseases  of ; 
and  Physical  Examination. 

WHIP-WORM. — This  term  is  not  unfre- 
quently  applied  to  the  small  human  nematode 
that  is  better  known  to  the  profession  as  the 
Trichcccp  halos  dispar.  Several  of  the  older 
writers,  following  Biittner,  supposed  that  the 
whip-like  portion  of  the  body  formed  the  tail ; 
hence  the  generic  term  Trichuris  under  which 
they  described  the  parasite.  Whip-worms  not 
only  infest  man,  but  also  several  of  our  domesti- 
cated animals,  which  latter,  however,  as  in  the 
case  of  the  human  host,  rarely  suffer  in  conse- 
quence of  the  invasion.  See  Triciiocephalus. 

T.  S.  Cobbold. 

WHISPERING  PECTORILOQUY. — A 

form  of  pectoriloquy  in  which  the  whispered 
voice  is  distinctly  heard.  See  Pectoriloquy  ; and 
Physical  Examination. 

WHITE  GUM. —A  popular  name  for  the 
white  form  of  strophulus,  <S.  albidus.  (See  Stro- 
phulus. 

WHITE  LEG. — A synonym  for  phlegmasia 
dolens.  See  Phlegmasia  Dolens. 

WHITE  SWELLING— A synonym  for 
I'vofulous  disease  of  a joint.  See  Joints, 
Diseases  of. 


• WHITLOW.  1760 

WHITES.— A common  synonym  forleucor- 
rhoea.  See  Leucorrhcea. 

WHITLOW. — Synon.  : Paronychia  ; Fr. 

Panaris  ; Tourniole  ; Ger.  Paronychia. 

Definition. — Whitlow  is  a term  somewhat 
loosely  applied  to  any  acute  inflammation  of  the 
finger  or  thumb,  which  tends  rapidly  to  termi- 
nate in  suppuration,  and  is  not  limited  to  the 
matrix  of  the  nail,  in  which  case  it  would  he 
called  onychia. 

Whitlow  may  he  divided  into  four  chief 
varieties,  hut  these  often  merge  into  one  another. 

1.  Paronychia  ungualis. — Synon.  : Super- 
ficial whitlow  of  Abernethy. — This  form  is  limited 
to  the  ungual  phalanx.  The  skin  only  is  affected, 
and  frequently  at  the  side  of  the  nail.  It  com- 
mences usually  as  the  result  of  some  slight 
injury,  such  as  a bruise  or  puncture,  or  from  the 
inoculation  of  septic  or  other  irritating  matter. 
The  first  signs  are  heat,  tenderness,  and  itching 
in  the  inflamed  part.  The  pain  is  not  severe. 
On  the  third  or  fourth  day  pus  forms,  raising  the 
epithelium  from  the  cutis  vera,  and  as  it  cannot 
point  through  the  dead  cuticle  it  remains  pen: 
up,  and  the  tension  so  caused  increases  the  pain 
and  if  unrelieved  leads  to  ulceration  of  the  true 
skin,  the  pus  then  finding  its  way  into  the 
cellular  tissue  beneath.  The  whitlow  then 
merges  into  the  second  variety.  It  may  also 
spread  to  the  matrix  of  the  nail,  and  so 
become  complicated  with  onychia.  If  relieved 
early,  by  cutting  away  the  cuticle  which  has  been 
raised  by  the  pus,  it  seldom  leads  to  any  un- 
pleasant consequences. 

Treatment. — The  treatment  consists  in  bath- 
ing the  finger  frequently  in  hot  water,  and 
applying  lint  soaked  in  hot  water,  which  is 
cleaner  and  better  than  a poultice.  A com- 
bination of  equal  parts  of  glycerine  and  extract 
of  belladonna  will  be  found  an  invaluable 
application,  frequently  cutting  the  inflammation 
short,  and  always  relieving  the  pain.  As  soon 
as  there  is  any  sign  of  the  cuticle  being  raised 
by  fluid  beneath,  it  should  be  cut  away  with  a 
pair  of  scissors,  or  a razor  or  sharp  knife.  An 
incision  is  never  necessary. 

A form  of  superficial  whitlow  is  sometimes 
seen  occurring  without  any  apparent  cause,  and 
attacking  one  finger  after  another.  The  fluid 
beneath  the  cuticle  is  not  always  purulent — 
sometimes  being  merely  albuminous,  and  mixed 
with  flakes  of  lymph.  It  never  leads  to  any 
deep  suppuration.  It  is  most  common  in 
children  and  females,  and  is  consequent  upon 
general  debility.  It  is  described  by  the  French 
under  the  name  of  Tourniole  or  Panaris  pklyc- 
teno'ide.  It  is  a troublesome  affection,  and 
difficult  to  get  rid  of.  Tonics  and  iron  are  the 
most  important  remedies.  Sometimes  arsenic  is 
of  use. 

2.  Paronychia  eellulosa.  — The  inflamma- 
tion in  this  variety  commences  in  the  cellular 
tissue  of  the  pulp  of  the  ungual  phalanx.  It 
arises  almost  invariably  as  the  result  of  some 
slight  puncture  or  other  injury,  or  as  the  con- 
sequence of  neglecting  the  variety  just  described. 
The  tip  of  the  finger  is  swollen,  tense,  and  ex- 
cessively tender.  There  is  severe  burning, 
throbbing  pain,  and  possibly  red  lines  spread- 


1770  WHITLOW.  * 

ing  from  the  inflamed  part  in  the  course  of  the 
lymphatics.  There  is  more  or  less  fever,  with 
general  constitutional  disturbance.  Pus  forms 
by  the  third  or  fourth  day.  It  tends  to  point 
through  the  shin,  hut  the  thick  cuticle  usually 
resists  its  pressure  for  some  time,  and  if  this 
bo  not  cut  away  early  the  gravest  results  may 
ensue.  The  pus  may  find  its  way  into  the 
sheath  of  the  flexor  tendons  ; or  the  hone  may 
be  exposed,  and  necrosis  may  follow,  the  disease 
then  merging  into  the  two  following  varieties. 
If  an  incision  he  made  about  the  fourth  or  fifth 
day,  a large  slough  will  usually  he  found  be- 
neath the  skin. 

Treatment. — A free  incision  must  be  made 
longitudinally  into  the  pulp  of  the  finger  as  soon 
as  the  condition  is  recognised,  and  by  this  moans 
all  complications  will  be  averted.  If  the  pus 
have  already  found  its  way  through  tho  cutis, 
and  be  pent  up  beneath  the  epidermis,  it  is  often 
sufficient  merely  to  cut  away  the  loosened 
cuticle  with  scissors.  In  other  respects  the 
treatment  is  the  same  as  for  the  first  variety. 

3.  Paronychia  tendinosa. — Synon.  : Thecal 
abscess. — This  is  usually  classed  with  whitlow, 
and  is  often  secondary  to  the  other  varieties.  It 
frequently  begins,  however,  as  a primary  inflam- 
mation of  the  sheath  of  the  flexor  tendons.  It 
is  supposed  by  some  to  be  related  to  erysipelas, 
and  in  many  cases  it  probably  is  so ; but  fre- 
quently its  cause  is  uncertain.  It  may  arise  from 
a wound  opening  the  sheath  of  the  tendon,  but 
then  would  hardly  be  called  a whitlow.  The 
whole  finger  swells,  and  becomes  tense  and  red. 
The  pain  is  most  severe,  usually  shooting  up  the 
hand  and  arm.  Pus  forms  early,  and  if  not 
evacuated  by  incision,  exposes  tho  bones,  destroys 
the  tendons,  burrows  into  the  joints,  and  rapidly 
destroys  the  finger.  If  affecting  the  thumb  or 
little  finger,  the  sheaths  of  which  are  continuous 
with  the  common  sheath  at  the  wrist,  the  sup- 
puration rapidly  extends  to  the  palm  of  the 
hand,  and  to  the  forearm  above  the  annular 
ligament.  The  wrist-joint  may  then  be  opened, 
and  destruction  of  the#  whole  hand  result. 
The  constitutional  disturbance  and  fever  are 
usually  very  marked.  The  disease  is  most 
common  after  middle  life,  and  in  patients  of  a 
broken  constitution.  Tho  affected  finger  or 
hand  seldom  recovers  perfect  utility ; and  death 
is  not  uncommon,  either  from  exhaustion  or  from 
some  secondary  complication. 

Treatment. — Hot  baths  to  the  hand,  fomen- 
tations and  poultices,  and  free  and  early  incisions 
are  required.  Glycerine  and  belladonna  is  a 
most  useful  application,  Stimulants,  good  diet, 
and  tonics  are  always  necessary. 

i.  Paronychia  osseosa. — This  is  a some- 
what rare  variety  of  whitlow,  arising  sometimes 
from  injury,  sometimes  without  apparent  cause. 
It  is  an  acute  inflammation  of  the  periosteum  of 
the  ungual  phalanx.  It  is  characterised  by 
redness  and  swelling,  with  most  intense  aching 
and  tensive  pain,  and  acute  tenderness.  If  an 
incision  be  made  as  soon  as  pus  is  recognised, 
the  bone  will  he  found  to  be  already  bare  and 
necrosed.  This  condition  can  only  be  averted  by 
cutting  down  to  the  bone  before  suppuration  has 
occurred,  and  this  is  rarely  possible. 

Treatment. — This  is  the  same  as  in  the  other 


WHOOPING-COUGH. 

varieties,  namely,  hot  applications  and  free  in- 
cisions. The  necrosed  phalanx  must  be  removed 
as  soon  as  it  is  loose.  If  more  than  one  phalanx 
be  affected,  amputation  may  be  necessary. 

One  or  two  points  common  to  the  treatment  of 
all  varieties  require  further  notice.  All  incisions 
should  he  made  as  far  as  possible  in  the  middle 
line,  so  as  to  avoid  wounding  the  digital  arteries. 
The  sheath  of  the  flexor  tendons  should  on  no 
account  be  opened,  unless  there  is  pus  within  it. 
In  all  doubtful  cases  an  anaesthetic  should  he 
administered,  the  limb  made  bloodless  by  Es- 
march s method,  and  tho  incision  carried  care- 
fully towards  the  flexor  tendons.  In  this  way 
the  exact  situation  of  the  pus  can  with  certainty 
be  ascertained,  and  an  unnecessary  wound  of  the 
sheath  of  the  tendon  avoided.  Incisions  are  fre- 
quently made  into  the  pulp  of  the  ungual  pha- 
lanx of  the  finger  when  the  pus  is  really  on  the 
dorsum.  This  arises  from  the  sense  of  fluctua- 
tion yielded  by  a swollen  finger  covered  by 
somewhat  thick  cuticle.  In  all  cases  the  cuticle 
should  be  cut  away  as  soon  as  it  is  loose,  and 
not  allowed  to  haDg  about  in  shreds  caked  with 
putrid  pus  and  linseed  meal.  The  best  applica- 
tion in  all  cases  is  boraeic  acid  lint,  three  or  four 
layers  thick,  wetted  with  hot  water,  and  covered 
by  oiled-silk  and  cotton  wool.  This  is  perfectly 
clean,  and  in  every  way  as  efficient  as  a poul- 
tice. Soaking  the  hand  frequently  for  an  hour  at 
a time  in  an  arm-bath  usually  gives  great  relief 
in  the  more  severe  forms. 

Marcus  Beck. 

WHOOPING-COUGH.  — Synon.  : Kin- 

cough  ; Hooping-cough ; Pertussis ; Fr.  C'oque 
luche ; Ger.  Kcuchhustcn. 

Definition. — An  infectious  specific  disease, 
chiefly  affeetiug  children,  lasting  six  or  eight 
weeks,  rarely  attacking  the  same  person  twice, 
and  accompanied  by  a peculiar  spasmodic  cough. 
The  cough,  not  characteristic  till  the  second 
week,  comes  on  suddenly  with  some  quick,  short, 
forcible  expirations,  and  flushed  face ; then  a 
long,  shrill  inspiration,  or  whoop,  and  several 
rapid  coughing  efforts  in  repeated  paroxysms 
occur,  ending  in  the  expulsion  of  viscid  mucus, 
or  in  vomiting.  A return  of  cough  is  readily 
excited  for  some  time  after  the  disease  has  sub- 
sided. 

^Etiology. — Infectious  particles  thrown  off 
by  the  cough,  and  carried  to  the  air-passages  of 
the  susceptible,  there  fixing  and  multiplying, 
set  up  the  same  series  of  disturbances  by 
which  they  are  produced,  reproducing  abund- 
antly more  infectious  material.  Whooping-cough 
occurs  in  epidemics,  chiefly  prevalent  in  the 
spring,  extending  over  a large  part  of  any  town 
or  district  associated  by  various  means  of  inter- 
communication, or  by  common  educational  es 
tablishments,  and  spreads  as  long  as  young 
children  who  have  not  had  the  disease  before 
are  brought  within  its  influence.  For  a disease 
of  this  kind,  attacking  the  respirator}-  surfaces, 
and  then  exciting  a specific  secretion,  with 
violent  cough  to  scatter  it,  a more  widely  dif- 
fused air- borne  infection  might  be  imagined  than 
for  other  infectious  diseases.  There  is  no  proof 
that  such  infection  is  ever  carried  across  any  wids 
distances  ; what  the  limit  may  be  for  such  truns. 


WHOOPING-COUGH. 


portation  is  quite  uncertain.  From  the  recep- 
tion of  infection  to  the  evidence  of  its  effects, 
an  interval  for  incubation  always  intervenes. 
When  children  are  said  to  have  been  attacked 
soon  after  exposure  to  keen  air,  this  has  only 
roused  into  activity  a cause  already  in  operation. 
Some  quality  of  the  air  or  season  may  act  as  a 
predisposing  cause.  Certain  bodily  states — the 
condition  of  teething,  and  that  left  after  measles 
and  some  other  diseases — predispose  the  mucous 
surfaces  to  receive  and  foster  the  germs  of 
whooping-cough.  This  infection  is  often  received 
with  that  of  measles,  and  the  characteristic  cough 
of  the  one  disease  is  not  recognised  till  the  rash 
of  the  other  has  passed  away.  Three  weeks  may 
elapse  before  children,  who  have  been  exposed 
to  infection,  show  signs  of  it  by  the  whoop ; 
they,  therefore,  should  not  mix  with  others  who 
are  susceptible  till  this  period  is  safely  over. 
Infection  persists  for  six  or  eight  weeks  after 
the  disease  is  declared ; after  this  there  may  be 
a return  of  cough  or  spasm  without  fresh  danger 
of  infection.  During  the  illness  any  bit  of  mucus 
thrown  off  by  the  cough  may  be  the  medium  of 
infection;  whether  other  secretions  are  infec- 
tious is  a matter  of  doubt ; emanations  from  the 
sufferers  may  be  so  even  after  death.  The  dis- 
ease is  readily  propagated  by, fomites ; it  is  fre- 
quently carried  from  house  to  house  by  the 
clothes  of  visitors ; the  sick  create  an  atmosphere 
around  themselves  into  which  the  susceptible 
cannot  enter  without  danger  of  being  seized ; a 
portion  of  this  atmosphere  is  easily  removed 
and  carried  in  the  folds  of  dress  to  other  houses 
and  rooms.  Some  infectious  particles  cling  to  the 
clothing  of  convalescents  for  a long  time.  Active 
infection  is  given  off  by  thoso  affected  slightly, 
or  only  beginning  to  bo  so,  while  sickening  for 
the  disease ; even  the  insusceptible,  who  are  not 
liable  to  suffer  in  the  same  way  again,  may 
have  slight  cough  or  irritable  throat  after  being 
with  the  sick,  and  so,  ailing  little  or  nothing 
themselves,  be  the  means  of  carrying  infection 
elsewhere. 

Whooping-cough  prevails  so  extensively  in 
early  childhood,  that  it  is  rare  to  find  anyone 
grow  up  without  having  been  exposed  to  it. 
Those  who  escape  infection  in  childhood  mostly 
ascapo  it  altogether.  Adults  are  rarely  seized. 
When  this  happens — and  no  age  is  exempt — the 
disease  goes  through  its  full  course  with  the 
same  symptoms  as  in  infancy,  but  with  none  of 
the  dangers  then  arising,  only  with  the  vexa- 
tions of  a tiresome  and  embarrassing  ailment. 

The  greatest  number  of  cases  occur  in  children 
under  eight  years  of  age.  It  is  one  of  the  three 
diseases  most  fatal  to  young  infants,  and  like  the 
bronchitis  of  cold  weather,  and  the  diarrhcea  of 
summer,  is  most  fatal  to  the  youngest;  it  differs 
from  these  in  not  being  more  fatal  either  in  very 
hotor  in  very  cold  years.  Whooping-cough  comes 
next  to  scarlet-fever  in  the  number  of  deaths 
attributable  to  it  in  this  country,  the  propor- 
tional mortality  from  this  cause  being  five  or  six  per 
ten  thousand  of  population,  and  nearly  2 £ per  cent, 
(one-fortieth)  of  yearly  deaths  from  all  causes. 
Three-fourths  of  all  the  deaths  from  it  are  of 
children  under  two  years  of  age;  yet  more  than 
4-0  per  cent,  of  all  the  mortality  falls  in  the  first 
year,  over  30  in  the  second,  about  15  in  the 


1771 

third,  6 in  the  fourth,  4 in  the  fifth  year, 
and  less  than  4 per  cent  in  the  next  five  years. 
Sex  has  a marked  influence  on  the  fatality  of 
whooping-cough.  Girls  suffer  more  than  hoys. 
While  half  the  attacks  of  boys  are  severe, 
five-sixths  of  the  attacks  among  girls  are  so ; 
the  deaths  of  girls  being  nearly  one-third  more 
than  of  boys.  If  the  proportion  of  deaths  to 
attacks  is  put  at  percent.,  so  great  is  the  dif- 
ference made  by  age,  that  the  range  must  be  frcni 
10  per  cent,  or  more  in  the  first  two  years  to 
a decreasingly  lower  rate  afterwards,  with  a 
smaller  variation  for  sex.  Kace  and  climate 
make  little  or  no  difference  as  to  the  liability  to 
whooping-cough.  Season  has  an  influence  on  its 
epidemic  extension;  this  with  us  is  always  in 
the  spring.  Cold  indirectly  adds  to  the  inten- 
sity of  the  disease ; it  is  increased  by  over- 
crowding, bad  ventilation,  and  the  confinement 
of  the  sick  in  close  apartments.  All  the  hygienic 
defects  which  lead  to  rickets  in  that  way  add 
greatly  to  the  bad  effects  of  whooping-cough. 

The  period  of  incubation  is  well-marked  in 
all  cases,  and  extends  from  four  days  as  the 
shortest  limit,  to  ten  days  or  a fortnight  as  the 
longest;  in  the  latter  instance,  a solitary  one, 
no  catarrhal  symptoms  were  noticed  till  thirteen 
days  after  a single  limited  exposure,  the  whoop 
appearing  ten  days  after  that.  Usually  some 
catarrhal  and  febrile  symptoms,  with  or  with- 
out cough,  appear  from  the  fourth  to  the  seventh 
day  after  exposure  to  infection.  The  invasion,  or 
catarrhal,  stage  lasts  a week.  The  whoop  mostly 
begins  ten  days  from  the  ingress,  unless  acci- 
dentally delayed ; it  has  been  heard  as  early  as 
the  eighth  day,  or  as  late  as  the  twenty-fifth 
and  even  later,  or  not  at  all.  A healthy  infant, 
born  amidst  whooping-cough,  sickened  at  the 
end  of  the  first  week,  and  survived  a fortnight ; 
another,  it  is  said,  was  infected  on  the  second 
day,  and  whooped  on  the  eighth.  A child,  whoso 
mother  had  herself  been  four  weeks  ill  with 
this  disease,  is  stated  to  have  been  born  with 
whooping-cough.  The  complaint  has  not  been 
directly  produced  bj  inoculation. 

Pathology  and  Anatomical  Characters. — 
The  course  and  duration  of  all  the  symptoms  of 
pertussis  are  too  constant  and  definite  for  the 
cough  and  other  results  of  the  disease  to  be  de- 
duced from  the  effects  of  any  kind  of  local  irritant 
on  the  mucous  surfaces  of  the  air-passages.  A 
specific  catarrh  with  hypersesthesia  is  admitted  by 
all.  Is  this  located  chiefly  in  the  bronchi  (Brous- 
sais  and  Guersant);  limited  in  the  first  instance  to 
the  laryngo-pharyngeal  mucous  crypts  (Gendrin); 
or  confined  within  the  larynx  (Beau)  ? The  latter 
view  is  supported  by  the  redness  seen  extending 
from  the  epiglottis  to  the  vocal  cords  ; and  by 
the  tumefaction,  and  viscid  or  puriform  secretion, 
found  in  the  larynx  after  death.  But  the  larnyx 
may  redden  only  when  the  cough  begins,  and 
this  may  be  excited  by  mucus  rising  into  the 
trachea  from  below  as  well  as  by  that  touching 
the  glottis  from  above.  As  neither  laryngitis  nor 
bronchitis  in  children  is  attended  with  persistent 
spasm,  a cause  for  this  has  been  sought  in  the 
swelling  of  the  bronchial  lymphatic  glands  so 
often  associated  with  spasmodic  cough.  This 
source  of  reflex  excitement  of  the  vagus  is  ap- 
plied by  Dr.  Noel  Gueneau  de  Mussy  to  explain 


WHOOPING-COUGH. 


1772 

tlie  recurrence  of  spasm  long  after  the  usual 
t erm,  rather  than  advanced  as  an  explanation  of 
the  character  of  the  cough  throughout  the  dis- 
ease ; he  suggests,  however,  that  the  absence  of 
spasm  from  the  first  stage  of  the  disease,  or  its 
delay,  may  be  from  the  bronchial  glands  not 
being  very  much  enlarged  in  such  cases.  The 
small  lymphatic  glands  in  the  neck  and  along 
the  trachea  and  bronchi  are  affected  early  both  in 
this  disease  and  in  measles  ; their  enlargement  is 
much  less  marked  in  adults  than  in  children,  yet 
adults  have  the  same  spasm  in  the  second  stage 
of  whooping  cough;  and  in  the  serious  pul- 
monary lesions  after  measles  children  have  not 
the  same  kind  of  cough.  The  explanation  is  in 
the  specific  or  contagious  element.  In  ordinary 
catarrh  or  bronchitis  the  spasm  yields  when 
secretion  begins.  Here  the  same  contagious  matter 
that  began  the  irritation  not  only  keeps  it  up  by 
local  increase,  but,  multiplying  vastly  for  a cer- 
tain time,  is  thrown  off  by  the  surfaces  where  it 
proliferates,  or  to  which  it  is  carried,  perhaps 
with  added  virulence  and  activity.  A less  per- 
manent, less  energetic,  or  less  extended  irrita- 
tion of  all  the  sensory  terminations  of  the  pneu- 
mogastric  nerve  would  not  so  excite  and  increase 
the  susceptibility  of  the  nerve,  while  diminish- 
ing and  exhausting  its  power,  thus  modifying 
the  nutrition  and  function  of  its  centre ; the 
change  so  impressed  continuing  long  after  the 
original  exciting  cause  has  ceased.  A special 
influence  may  from  the  first  be  attributed  to 
the  specific  cause.  A certain  degree  of  hyper- 
semia  would  determine  fever,  distend  the  lym- 
phatics, and  excite  cough  by  irritation  of  the 
peripheral  nerves.  But  the  nerve-centres  both 
of  the  respiratory  and  sympathetic  system  are 
disturbed  in  the  earlier  stages,  and  the  vagus 
specially  implicated  before  the  enlarged  bron- 
chial glands  or  other  local  causes  of  excitation 
are  established.  The  impaired  function  of  the 
pneumogastric  is  shown  by  the  rapid  and  weak 
pulse,  epigastric  tenderness,  loss  of  appetite, 
weak  respiration,  and  pulmonary  congestion ; this 
aids  the  impulsion  of  morbid  products  to  the 
bronchial  surface,  hence  a specific  secretion  and 
a further  source  of  reflex  irritation,  hyperaes- 
thesia,  and  the  special  characters  of  the  cough. 
The  element  of  contagion  whatever  it  may  be,  is 
reproduced  abundantly  in  this  catarrhal  secre- 
tion, for  a definite  time,  after  which  it  does  not 
reappear ; the  cough  or  spasm  may  return  for 
months,  but  no  real  relapse  of  the  disease.  One 
attack  is  protective  against  a recurrence.  The 
disease  then  is  zymotic,  and  essentially  neither  a 
neurosis  nor  a bronchitis,  though  both  of  these 
conditions  are  excited  by  it.  Zymosis  may  be 
either  by  a local  proliferation,  or  a general  in- 
fection, or  both ; it  has  been  thought  sufficient 
in  this  case  that  contagia  should  reach  to  the 
surfaces  of  the  air-passages  ; these  acting  locally 
upon  the  mucous  membrane  may  entail  all  the 
consequences  of  the  disease  in  the  former  mode 
only ; and  some  altered  ciliated  cells,  which  could 
not  possibly  enter  the  blood,  have  been  figured  as 
the  infecting  and  infected  bodies.  On  the  other 
hand,  bacteria,  as  seen  by  V.  Potain,  and  micro- 
cocci, described  by  Letzerich  as  in  mucus  only, 
and  seen  by  others,  abound  in  the  secretions,  pe- 
netrate the  cell-structures,  and  are  found  in  the 


leucocytes  of  the  blood  and  tissues.  These  differ 
little,  if  at  all,  from  those  of  ordinary  occur- 
rence, except  in  their  number  and  rapidity  of 
increase.  It  is  unlikely  that  the  common  forms 
could  acquire  special  quality  from  accidental 
inflammation  around  them;  but  these,  derived 
from  a special  source,  may  carry  with  them 
special  qualities  setting  up  the  same  action  in  a 
suitable  medium  as  that  in  the  tissue  from  whence 
they  were  derived ; they  permeate  freely,  and 
the  process  has  ceased  to  be  local  before  the 
signs  cf  disease  are  observed.  The  part  taken  by 
the  white  corpuscles  of  the  blood,  as  agents  of 
absorption  and  infection,  cannot  be  overrated. 

As  in  the  exanthemata  the  rash  shows  im- 
paired vaso-motor  nerve-control,  so  in  whooping- 
cough  the  irritability  of  the  surface  of  the 
pharynx,  glottis,  and  trachea  is  early  evidence  of 
disturbed  innervation.  There  is  no  deep-seated 
congestion  of  the  fauces  ; the  catarrhal  state  is 
more  marked  below  the  glottis  than  above,  the 
trachea  is  often  pale,  the  bronchi  are  always  con- 
gested, and  the  smaller  lymphatic  glands  along 
their  course,  and  besido  the  trachea,  as  well  a3 
the  larger  bronchial  glands,  are  red  and  swollen, 
so  as  to  be  constantly  pathognomonic;  later 
these  or  the  mediastinal  glands  may  show  centric 
softening.  The  bronchial  membrane  is  thickened, 
red,  and  covered  with  sticky  masses  of  secretion, 
in  which  groups  of  micrococci  are  found ; the 
viscid  secretion  in  the  smaller  bronchi  is  an  al- 
most constant  condition,  and  its  liability  to  be 
drawn  into  the  pulmonary  alveoli  a prominent 
character  of  the  disease;  such  blocked  alveoli 
look  like  tubercles  under  the  pleura;  if  punc- 
tured the  contents  will  squeeze  out.  Ecchvmoses 
are  seen  on  the  pleurae,  and  sometimes  in  the 
pericardium.  The  (Esophagus  is  pale,  but  the 
mucous  membrane  of  the  stomach  is  often  swol- 
len and  red,  with  punetiform  injection  or  pete- 
chial spots  ; effused  blood  has  been  found  in  the 
bowels ; a follicular  inflammation  of  the  intestines 
is  associated  with  g;istric  catarrh  ; an!  there 
is  some  enlargement  of  the  mesenteric  and 
retro-peritoneal  glands.  The  liver  is  more  often 
hypersemic  than  the  spleen,  with  some  fatty 
cells;  oris  large,  with  yellowish-grey  fatty  change 
in  the  tuberculous  or  rachitic.  There  is  no 
definite  kidney-lesion.  Cerebral  effusions,  like 
chemosis  or  cedema  of  the  face,  are  the  accidents 
of  cough  and  dyspnoea.  Spasmodic  cough  is  not 
merely  a reflex  from  the  upper  laryngeal  nerve ; 
shallow  respiration  and  insufficient  oxygenation 
excite  respiratory  efforts,  but  if  no  more  air 
gets  to  the  blood,  expiration  is  accentuated,  and 
goes  on  in  a convulsive  repetition,  due  to  the 
stimulation  of  the  medulla  by  the  venous  blood ; 
this  happens  on  any  interference  with  the 
supply  of  oxygenated  blood  to  the  respiratory 
centre,  and  from  these  efforts  exhaustion  results. 
When  the  centre  recovers  its  excitability,  in- 
spiratory effort  follows,  and  on  the  rapid  alter- 
nations of  these  states  much  of  the  frequency, 
force,  and  duration  of  the  paroxysms  depend. 
Repeated  distension  of  the  right  cavities  of  the 
heart  in  the  fit  cause  various  venous  haemorrhages. 
Obstructed  air-cells,  catarrhal  pneumonia,  and 
lobular  collapse  of  lung,  with  surrounding  em- 
physema, also  occur  as  secondary  phenomena. 
These,  with  cerebral  congestion,  result  from 


WHOOPING-COUGH. 


futile  cough.  Impeded  respiration  leads  to  con- 
vulsions in  children ; most,  if  not  all,  of  the 
cerebral  symptoms  during  the  illness  are  indica- 
tive of  some  further  mischief  in  the  lung.  In 
rickety  subjects  these  complications,  together 
with  the  greater  tendency  to  spasm  in  this  dia- 
thesis, produce  bending  in  of  the  ribs  and  con- 
traction of  the  chest,  often  interfering  greatly 
with  healthy  development  in  later  years. 

Symptoms. — The  invasion  of  whooping-cough 
is  insidious,  rarely  with  cnills.  Some  fever  or 
cough  is  first  noticed  at  night ; the  child  is 
better  next  day,  but  loses  appetite,  is  fretful,  or 
looks  pale  and  languid  ; the  pulse  is  quick,  and 
the  respiration  shallow ; there  may  be  sneezing 
or  signs  of  catarrh,  but  these  mostly  appear 
after  another  night  of  fever,  or  of  teasing,  fre- 
quent cough,  which  may  be  croupy  before  seere- 
t ion  begins ; the  glandulae  concatenate  are  per- 
ceptible to  touch  ; instead  of  a freer  secretion 
relieving  the  symptoms,  as  in  ordinary  catarrh, 
it  is  thin,  and  they  increase;  there  may  be  high 
fever,  with  pulmonary  congestion,  or  the  fever 
subsides,  and  bronchial  rales  are  heard  on  deep 
inspiration.  This  is  know’n  as  the  catarrhal 
stage.  It  lasts  eight  or  ten  days,  the  whoop 
being  seldom  heard  till  the  end  of  the  second 
week.  But  the  period  is  not  definite,  for  the 
fever  of  this,  as  of  the  other  two  stages  of 
whooping  cough,  is  marked  by  great  irregula- 
rity, with  intervals  quite  free  from  fever;  in 
this  stage  it  may  be  prolonged  by  various  com- 
plications, or  be  very  little  noticeable.  In  the 
latter  case  the  cough  is  sooner  distinctive ; it 
comes  on  in  fits,  mostly  at  night ; in  the  day 
there  are  intervals  without  cough.  When  the 
cough  is  coming,  the  child’s  face  reddens,  as  if 
trying  to  suppress  it,  till  it  bursts  out  in  a series 
of  short,  quick  forcible  efforts  ; then  the  breath 
is  drawn  in  with  a shrill  whistling  sound,  again 
followed  by  the  boisterous  cough  ; after  a short 
pause  comes  a less  severe  and  shorter  fit,  and 
then  another,  till  a quantity  of  whitish  viscid 
mucus  is  expelled,  some  perhaps  through  the 
nose,  and  some  swallowed,  or  the  child  vomits 
at  the  same  time,  ejecting  the  contents  of  the 
stomach. 

When  the  secretion  is  free  the  catarrhal  stage 
is  over,  and  the  spasmodic  stage  begins.  At  this 
time  laryngoscopic  observation  has  shown  the 
mucous  membrane  pale  to  the  lower  third  of  the 
trachea ; before  the  cough  whitish  mucus  has 
been  seen  to  rise  to  the  bifurcation  of  the  bron- 
chi; then  cough  begins;  some  time  after  it  is 
over  the  vocal  cords  have  been  observed  to  be 
redder  than  before.  Bronchial  catarrh  is  as 
much  a feature  of  this  stage  as  the  spasm. 
When  the  cough  seems  to  have  come  on  without 
cause,  the  secretion  has  risen  to  the  trachea ; 
children  are  often  old  enough  to  describe  a 
tickling  in  the  throat  before  the  cough,  they 
show  dread  of  its  approach,  and  prepare  for  the 
attack,  by  steadying  themselves,  or  clinging  to 
others  for  support;  they  are  glad  when  it  is 
over,  and  seem  afterwards  cheerful  in  the  day,  and 
go  to  sleep  again  at  night.  Not  so  with  younger 
children  ; before  the  attack  the  pulse  quickens, 
the  breathing  is  short  and  insufficient,  rales  are 
heard,  spasm  closes  the  glottis,  the  air  is  forced 
out  in  sudden  jerks,  and  then  enters  with  the 


1773 

loud  long-drawn  whoop  ; this  is  repeated  till  the 
face  becomes  livid  and  swollen,  and  the  child 
exhausted  or  semi-conscious.  Frequent  attacks  of 
this  kind  keep  the  face  puffy  ; may  produce  small 
ulcers  on  the  fraenum  linguse;  and  make  the  eyes 
red  and  watery,  often  with  small  haemorrhages  into 
the  conjunctive.  Or  blood  starts  from  the  nose 
and  mouth  in  the  paroxysm,  and  is  seen  in  the 
matters  vomited,  while  both  urine  and  faeces 
may  be  passed  involuntarily.  In  some  cases 
diarrhoea  and  vomiting  are  serious  symptoms. 
While  the  cough  forces  air  from  the  lung,  the 
percussion  note  is  dulled,  and  becomes  again 
resonant  after  the  sibilant  inspiration  is  heard. 
The  heart’s  action^  is  impeded,  sometimes  inter- 
rupted by  the  passive  congestion  reacting  on  its 
cavities  during  the  cough,  or  from  irritation  of 
the  vagus ; neither  endocardial  nor  pericardial 
lesion  is  found  in  whooping-cough,  and  nothing 
is  found  wrong  with  the  heart  after  the  fit  is 
over. 

Examination  of  the  chest  in  the  intervals  of 
cough  reveals  the  usual  signs  of  whatever  pul- 
monary complication  is  present.  In  most  cases 
mucous  rhonchus  is  heard  over  the  larger  bron- 
chi, and  some  finer  rhonehi  on  deep  inspiration, 
with  weak  respiratory  sounds;  moist  or  dry 
crepitation  replaces  these  in  places  where  the 
finer  bronchioles  or  alveoli  are  affected;  this 
may  occur  without  much  capillary  bronchitis  or 
pneumonia  in  the  following  way: — Violent 
spasm  prevents  air  entering  some  of  the  smallest 
tubes,  the  epithelium  thus  loses  its  cilia,  and, 
mixed  with  muco-purulent  secretion,  blocks  a 
small  lobule  or  fills  an  alveolus  ; this  happens 
when  the  fits  of  cough  are  worst  and  most  fre- 
quent ; with  closed  glottis  the  forcible  expira- 
tory efforts  compress  the  contents  of  the  alveoli, 
and  squeeze  out  the  fluid  parts,  leaving  the 
debris  to  caseate  ; a dry  crackle,  rather  than 
moist  bubbling  rales,  may  be  indicative  of  this. 
Meanwhile  air  in  some  peripheral  lobules, 
compressed  in  the  same  way,  gives  rise  to  vesi- 
cular emphysema  ; this  stato  of  lung  can  recover 
itself  sooner  than  the  other.  A more  extensive 
capillary  bronchitis  or  catarrhal  pneumonia  is 
shown  by  grave  general  symptoms,  restless 
tossing,  rapid  breathing,  dusky  face,  coma,  and 
convulsions. 

Without  these  complications,  the  third  stage , 
of  subsiding  spasm  and  loose  expectoration  with 
returning  health  and  strength,  may  be  reached 
in  from  four  to  six  weeks.  The  mildest  cases 
may  seem  to  be  over  sooner,  with  one  week  for 
the  catarrhal  stage,  and  two  for  the  spasmodic  ; 
but  any  little  want  of  care  will  intensify  the 
symptoms;  and  relapses  are  common  until  six 
weeks  are  accomplished,  even  in  cases  where  the 
second  stage  has  not  been  prolonged  beyond 
four  weeks.  The  disease  often  lasts  two  months, 
and  is  followed  by  a tedious  convalescence.  The 
pulmonary  deposits  may  originate  tuberculosis. 
The  disturbances  of  nutrition  and  innervation 
are  long  in  being  restored;  some  of  the  accidents 
of  rickets  never. 

XhAGNOSis.-Influenza  has  dry,  frequent  cough, 
paroxysmal,  and  worse  at  night,  with  gastric 
and  febrile  symptoms,  hardly  distinguishable 
at  first  from  those  of  the  ingress  of  whoop- 
ing-cough; but  influenza  prevails  as  a widely 


WHOOPING-COUGH. 


1774 

spread  epidemic,  not  limited  to  children  only 
and  to  a particular  neighbourhood,  but  affecting 
persons  of  all  ages ; there  is  more  coryza  ; it  has 
a crisis  in  five  days,  and  is  mostly  over  in  ten 
days,  and  relapses  arc  frequent ; the  same  per- 
sons are  attacked  more  than  once,  sometimes 
even  in  the  same  epidemic.  In  children  if  cough 
persists,  it  is  without  whoop  ; the  conjunctive 
may  be  red,  but  have  no  blood-effusions;  no  small 
ulcers  form  under  the  tongue.  Bronchitis  comes 
on  in  cold  weather  directly  after  exposure  or 
chill;  the  breathing  is  quickened  from  the 
first.  Infantile  laryngitis  also  has  no  stage  of 
incubation.  Laryngeal  diphtheria  has  no  re- 
missions. Both  alter  the  voice  and  cry.  Seme 
catarrhal  attacks  among  children,  coming  on  with 
fever,  often  with  laryngeal  irritation,  and  with  ful- 
ness of  the  small  cervical  glands,  are  less  readily 
recognisable  ; in  these,  if  the  breathing  at  first 
be  less  quickened  than  the  pulse,  this  difference 
ceases  as  soon  as  lung-mischief  begins.  An 
opinion  can  only  be  given  after  some  delay  and 
caution,  unless,  as  is  also  the  case  with  measles, 
the  child  is  known  already  to  have  had  these 
diseases.  A first  question  is,  What  infantile 
ailments  are  over?  the  next,  What  have  been  the 
chances  of  exposure  ? Hay  fever  occurs  in  the 
summer,  mostly  in  adults;  it  attacks  certain 
people  only,  and  these  every  summer;  if  the  first 
attack  were  supposed  to  be  whooping-cough,  the 
mistake  could  not  bo  made  a second  time.  The 
spasmodic  cough  of  hysteria  is  incessant,  and 
without  whoop  ; it  is  only  contagious  by  imita- 
tion. 

Prognosis. — Young  children  under  defective 
hygienic  conditions,  or  the  subjects  of  rickets, 
are  least  likely  to  make  the  favourable  recovery 
generally  expected  in  uncomplicated  whooping- 
cough.  Many  young  infants  die  from  laryngeal 
spasm,  sometimes  in  the  earlier  stages  of  the 
disease,  but  mostly  in  the  second  stage,  when  it 
is  readily  excited  both  by  pulmonary  causes  and 
by  bad  ingesta,  such  as  bits  of  orange-peel  or 
other  irremovable  irritant  in  the  stomach.  With 
good  sanitary  surroundings  and  individual  care 
the  youngest  may  escape,  unless  debilitated  by 
previous  illness,  such  as  measles,  or  a defective 
state  of  nutrition,  at  the  time  of  the  attack.  The 
risks  diminish  with  each  yoar  of  childhood, 
excepting  that  the  impaired  resistance  of  the 
chest-walls  in  rickets  may  place  a child  of  seven 
much  in  the  state  of  another  at  two  or  three 
years  old.  Constitutional  defects,  or  the  acci- 
dents of  nurture  may  lead  to  wasting  diseases 
which  begin  in  the  third  stage,  and  prove  fatal 
some  time  after,  or  at  any  age.  High  fever 
during  invasion  is  a warning  of  severe  compli- 
cations in  tile  subsequent  stages.  Convulsions 
in  any  stage  of  whooping-cough  are  of  the  worst 
significance ; somnolence,  or  a listless  condi- 
tion between  the  attacks,  and  persistent  high 
temperature,  are  bad  signs.  The  danger  of 
the  second  stage  is  in  proportion  to  the  seve- 
rity of  the  spasm.  It  may  be  estimated  by 
noting  the  number  of  attacks  in  the  twenty-four 
hours,  their  intensity,  and  duration ; in  bad 
attacks  the  expulsive  efforts  are  more  rapid, 
and  there  is  a shrill  or  repeated  whoop;  in  mild 
attacks  there  is  less  spasm,  and  the  whoop  is 
imt  always  heard,  or  perhaps  only  ouce.  The 


duration  may  be  from  a few  seconds  to  some 
minutes.  The  number  of  attacks  may  be  raised 
from  twelve  to  twenty  in  the  twenty- four  hours 
without  danger,  if  the  intervals  are  complete 
enough  for  the  child  to  seem  bright  and  take  food 
in  the  day,  and  to  get  sleep  by  night;  as  many 
as  60  to  80,  or  even  140  have  been  counted  ; they 
may  be  so  incessant  as  to  interfere  with  both  food 
and  sleep,  and  are  very  exhausting.  When  the 
nutrition  is  enfeebled,  and  the  tongue  often  pro- 
truded over  the  teeth  in  violent  cough,  small 
ulcers  are  found ; they  are  proofs  of  the  severity 
of  the  spasm,  and  mostly  indicative  of  a danger 
that  is  over.  Capillary  bronchitis  and  pneu- 
monia are  the  complications  most  often  fatal ; 
oedema  of  the  glottis  or  of  the  lung  surely  so, 
but  these  conditions  are  rare.  Chronic  pneu- 
monia is  apt  to  result  in  dilated  bronchi,  or  in 
phthisis.  Emphysema  tends  to  disappear.  Par- 
tial collapse  may  largely  recover  itself  on  air  re- 
gaining admission  to  the  lobule.  Blocked  alveoli 
setup  a circumscribed  pneumonia;  their  contents 
caseate ; and  tuberculosis  results  from  these 
centres,  or  from  degeneration  of  the  enlarged 
bronchial  and  mediastinal  glands.  Tubercular 
meningitis  and  acute  tuberculosis  during  or  after 
the  third  stage  are  rapidly  fatal. 

Treatment.— We  have  no  specific  for  whoop- 
ing cough  ; no  drug  to  check  its  onset  or  stop  its 
progress.  The  disease  is  of  long  duration;  the 
patient  a child.  Hygienic  conditions  must  be 
observed,  and  means  used  to  prevent  distress, 
reserving  the  more  active  remedies  for  special 
occasion.  Rest  and  warmth,  with  much  in- 
dividual care,  and  the  utmost  attention  to  a 
sufficiency  of  pure  air,  are  requisite  from  the 
first,  and  indeed  throughout  the  illness.  It  is 
not  merely  exposure  to  cold,  but  fatigue  and  in- 
judicious food,  that  determine  the  accessions  of 
fever  sofrequent  in  the  course  of  whoopiDg-cough. 
Theso  accessions  have  always  with  them  an  in- 
crease of  the  germs  of  the  disease,  more  as  a result 
than  as  a cause;  they  are  better  lessened  or  pre- 
vented by  whatever  aids  the  resisting  powers  of 
the  child,  than  by  close  cosseting  indoors,  or  the 
use  of  sj  ecial  germicides,  except  as  a means  of 
freshening  the  air  of  the  room  ; an  aggravation 
of  all  the  symptoms  follows  the  confinement  of 
one  or  two  sufferers  to  a single  chamber.  The 
diet  is  to  be  light  and  nutritious,  milk  forming 
an  important  element  in  the  meal,  and  some 
addition  to  the  ordinary  food  has  often  to  be 
sought,  whilst  all  things  hard  of  digestion  or 
irritating  are  to  be  avoided.  Broth  should  be 
made  with  vegetables  and  without  condiments ; 
stewed  fruit,  orange  juice  or  lemon,  and  grapes 
are  grateful ; some  extra  diluent  is  always 
requisite.  Each  child  wants  a good  deal  of  help 
and  ready  assistance;  some  one  should  be  near  to 
calm  from  fright  when  the  cough  begins,  and  to 
raise  and  hold  the  child  till  the  fit  is  over. 

In  the  catarrhal  stage,  if  the  ingress  be  fe- 
brile, a day  in.  bed  may  be  right;  the  child 
is  better  indoors  till  this  stage  is  over;  the 
room  must  be  changed  two  or  three  times  a 
day,  so  that  one  is  thrown  open  and  fresh- 
ened while  the  other  is  occupied,  and  then  closed 
and  warmed,  in  its  turn  to  be  read}-  for  use. 
Seme  simple  saline,  as  acetate  of  ammonia,  may 
be  required,  or  ammonia  in  any  dilute  form.  A sip 


WHOOPING-COUGH. 


of  cold  -water  often  relieves  cough,  but  at  night 
some  ipecacuanha  will  he  needed ; a teaspoonful 
of  the  wine,  mixed  with  an  ounce  or  two  of 
sweetened  water  for  the  night,  can  he  given  by 
spoonfuls  till  the  cough  either  lulls  or  ends  in 
sickness.  The  bromide  of  potassium  or  ammo- 
nium in  repeated  doses,  gr.  iij-v.  to  the  spoon- 
ful of  water,  gives  relief  at  night  in  this  stage, 
though  more  suitable  to  the  next,  when  anti- 
spasmodics,  of  which  chloral  is  the  chief,  are 
most  wanted.  No  form  of  opium  or  of  belladonna 
is  to  be  used  till  the  first  stage  is  over,  and 
secretion  is  free  ; nor  while  there  is  any  local 
congestion  or  other  source  of  irritation  to  be 
removed.  A warm  poultice  of  crushed  linseed 
across  the  back  of  the  chest  is  often  of  the 
greatest  use  when  the  cough  is  teasing,  and 
should  always  be  applied  if  fine  rales  be  heard, 
or  if  there  be  deficient  expansion  over  any  part 
of  the  lung.  The  first  extension  of  bronchitis 
to  the  finer  tubes  excites  bad  spasm,  for  which 
a few  small  closes  of  any  antimonial  may  be 
proper,  if  the  child  be  robust  and  plethoric.  In 
most  cases  ipecacuanha  can  he  continued  in 
small  doses  for  some  time ; the  emetic  dose  at 
night  often  soothes  by  emptying  the  stomach ; 
tin's  relief  must  not  be  sought  too  frequently, 
though  children’s  stomachs  soon  recover  from  this 
effect  of  ipecacuanha  after  a sleep.  The  bro- 
mides of  potassium  or  of  ammonium  can  be  con- 
tinued throughout  all  the  first  and  second  stages 
with  advantage.  A solution  of  carbolic  acid,  2 or 
3 grains  to  the  ounce,  may  he  beneficially  given 
to  children  for  several  days  together  at  the  end 
of  the  catarrhal  stage,  in  doses  of  a teaspoonful 
to  an  infant,  and  a tablespoonful  to  a child 
eight  years  of  age,  every  six  hours.  The  mode 
of  action  of  carbolic  acid  is  probably  very  much 
like  that  of  hydrocyanic  acid,  once  so  much 
recommended  in  this  complaint;  it  not  only 
lessens  spasm,  but  exerts  some  influence  on  the 
white  corpuscles.  Some  of  the  soothing  effect  of 
spraying  this  solution  of  carbolic  acid  with  a 
small  steam  vaporizer  in  a room  may  be  from  a 
part  being  absorbed.  In  very  many  cases  no 
medicinal  treatment  is  needed,  but  there  are 
others  in  which  the  child  is  obviously  ill  with 
more  than  the  usual  fever ; or,  just  when 
amendment  is  expected  and  a freer  secretion 
should  come  on,  there  is  an  increase  of  fever, 
with  no  marked  eomplieatiou.  In  these  cases 
quinine  should  be  given  ; one  grain  'per  diem  in 
powder  for  each  year  of  age,  continued  for  two 
or  three  days  only,  answers  best;  double  this 
quantity  at  a single  dose,  and  that  repeated,  has 
been  given  with  good  effect  during  the  first  four 
or  five  days  of  the  spasmodic  stage.  The  power 
of  quinine  in  opposing  the  pyrogenic  force  of  in- 
fection may  be  exercised  through  the  white  cor- 
puscles, as  explained  by  Binz ; it  has  been  proved 
to  control  reflex  excitability.  Some  priority  in 
the  use  of  quinine  and  of  chloral  may  be  claimed 
by  the  writer,  in  Temperature  Observations  in 
Whooping  Cough,  published  twelve  years  ago. 
Six  grains  of  quinine  given  to  a boy  4 years  old, 
in  the  afternoon  of  March  27,  1869,  reduced 
temperature  3°  in  a few  hours.  A girl,  5 years 
old,  took  thirty  grains  of  chloral  on  April  12, 
1870,  in  three  doses  with  relief  to  spasm.  The 
usual  dose  of  chloral  required  by  children  is 


1775 

one  grain  for  each  year,  given  two,  three,  or 
four  times  in  the  twenty-four  hours,  in  propor- 
tion to  the  frequency  and  severity  of  the  spasm. 
One  great  advantage  in  the  use  of  both  these 
remedies  is  that  they  can  be  given  in  enemata, 
either  nutrient  or  stimulant. 

Eelief  of  spasm  is  the  main  object  of  treat- 
ment in  the  second  or  spasmodic  stage,  the  effi 
cacy  of  the  means  employed  being  measured  by 
the  diminution  in  the  number  of  daily  attacks. 
By  this  test  belladonna  comes  next  to  chloral,  if 
given  in  large  and  continued  doses;  with  a child 
of  three  years  old,  £th  to  Jth  a grain  of  the 
extract,  or  10  to  15  minims  of  the  tincture,  is 
reached  before  the  pupil  is  dilated;  atropine 
divided  into  doses  of  ^th  or  -jA-t h of  a grain 
with  sugar  of  milk,  or  drop  doses  of  the  sulphate 
in  solution,  is  a more  certain  way  of  getting  the 
effect  required,  and  regulating  the  quantity  ne- 
cessary to  produce  it.  Minute  doses  of  morphia, 
ith  of  a grain  given  with  the  atropia,  or  small 
doses  of  any  opiate  with  belladonna,  answer 
better  than  if  given  uncombined ; but  this  addi- 
tion is  only  permissible  when  the  secretions  are 
free,  and  the  means  of  relief  do  not  require 
frequent  repetition;  it  is  specially  useful  near 
meals,  when  food  is  ejected  with  the  cough. 
Oxalate  of  cerium,  2 or  3 grains  for  children,  10 
grains  night  and  morning  for  older  persons,  is  of 
use  here  ; or  strong  coffee  given  after  meals.  The 
liquid  extract  of  ergot,  one  drachm  a day,  given  in 
divided  doses  to  children  for  two  or  three  days, 
is  said  to  control  spasm.  Comum  reduces  spinal 
irritability;  a lozenge  made  with  one  grain  of 
the  extract,  one-sixth  of  a grain  of  ipecacuanha, 
and  one-sixtieth  of  a grain  of  morphia,  mixed 
with  powdered  sugar  or  treacle,  can  be  given 
in  the  earlier  spasmodic  attacks  of  cough  with 
advantage.  A child  of  three  years  old  can  take 
three  or  four  of  these  in  one  day  without  nausea. 
Ten  minims  of  the  succus  conii  are  equal  to  one 
grain  of  the  extract.  The  tincture  is  equally 
active.  Hydrobromate  of  conia,  ~ grain  for  a 
child,  has  been  given.  The  inhalation  of  ether, 
ethyl-bromide,  or  of  chloroform  is  not  suitable 
for  children.  Croton-chloral,  in  doses  half  those 
of  chloral,  one  or  two  grains  in  weak  solution,  or 
disguised  in  powder,  given  to  children  three  or 
four  times  a day,  lessens  the  force  and  frequency 
of  the  spasm.  Bromide  of  ammonium  is  often  all 
that  is  required,  but  nothing  is  so  efficacious  as 
chloral  hydrate.  Most  of  the  remedies  vaunted 
for  cure  of  whooping-cough  owe  their  repute  to 
having  been  administered  in  the  fifth  or  sixth 
week  of  illness,  when  other  agents  are  said  to 
have  failed,  and  the  disease  is  nearly  over. 
Frictions  across  the  back  and  chest  with  an  oily 
liniment,  to  which  oil  of  amber  is  often  added, 
or  with  belladonna  and  opium  liniments  com- 
bined, are  useful.  Spinal  friction,  or  repeated 
use  of  a narrow  poultice  with  a little  mustard 
along  the  spine  every  night  to  cause  temporary 
redness,  has  seemed  to  be  of  service.  All  the 
more  potent  means  of  counter-irritation,  croton 
oil,  blisters,  and  mustard  poultices,  are  to  be 
avoided,  as  well  as  leeches  to  the  head. 

In  the  third  stage  of  whooping-cough  some 
astringents  are  often  of  great  use ; and  re- 
storative means  are  much  wanted.  Alum  is  of 
decided  benefit  when  excessive  secretion  is 


W76  WHOOPING-COUGH. 

troublesome.  So  is  toluorammoniacum.  Tannin, 
and  also  oil  of  turpentine  are  used.  Zinc  in  small 
doses  is  useful.  One  or  two  grains  of  the  oxide 
may  be  given  three  or  four  times  a day  in  powder, 
or  half  a grain  of  the  sulphate  in  solution.  An 
emetic  may  be  required,  to  remove  excess  of  mu- 
cus ; zinc  can  at  this  time  be  added  to  the 
ipecacuanha,  which  alone  is  best  for  the  earlier 
stages,  when  emesis  is  more  often  required. 
Purgatives  are  at  no  time  advisable.  A drop  of 
laudanum  before  food  stays  sickness.  The  mine- 
ral acids  make  an  agreeable  aid  to  digestion. 
Bark  or  iron  may  be  required,  and  cod-liver  oil. 
Minute  doses  of  arsenic  with  meals,  and  iodine 
externally  over  small  spaces  on  alternate  days 
to  back  and  front  on  either  side,  counteract  ob- 
stinate adenopathy.  Change  of  air  has  a remark- 
able effect  in  restoring  appetite,  and  removing 
spasm,  after  the  diseaso  is  quite  over ; it  should 
not  be  sought  before  six  weeks,  and  is  often 
better  deferred  till  two  months  from  the  com- 
mencement of  illness.  If  the  tubercular  diathesis 
have  been  set  up  or  evoked,  the  greatest  care 
in  nursing,  and  the  most  perfect  quietude,  are 
essential.  Great  risks,  without  benefit,  have  been 
run  by  taking  children  to  gasworks  during  the 
course  of  the  complaint.  Attempts  to  cut  short 
the  disease  by  inhalation  or  insufflations  of  ger- 
micides fail.  A weak  spray  of  carbolic  acid  in 
the  room,  or  a solution  of  it,  or  of  peroxide  of 
hydrogen,  on  cloths  cr  near  the  child's  couch,  or 
sprinkled  about,  do  good  by  purifying  the  air. 

W.  Squire. 

WIESBADEN,  in  Germany. — Thermal 
salt  waters.  See  Mineral  Waters. 

WIGHT,  Isle  of.  See  Undercliff  ; Vent- 
nor  ; and  Climate,  Treatment  of  Disease  by. 

WILDBAD,  in  Germany. — Simple  thermal 
waters.  See  Mineral  Waters. 

WILDUN  GEN,  in  Germany.—  Earthy 
waters.  See  Mineral  Waters. 

WINDPIPE,  Diseases  of.  See  Larynx, 
Diseases  of ; and  Trachea,  Diseases  of. 

WINKING,  Involuntary.— Synon.  : Nic- 
titation. See  Facial  Spasm. 

WINTER-COUGH.  — This  expression  is 
associated  with  those  cases  in  which  a patient  is 
subject  to  more  or  less  cough  during  the  winter 
season,  being  free,  or  almost  free,  during  the 
warmer  portiou  of  the  year.  It  may  come  on  at 
any  period  in  the  course  of  the  winter,  and  is 
generally  referable  to  some  obvious  cause,  which 
produces  ‘ a cold.’  The  attacks  tend  as  a rule 
to  become  more  aggravated  and  difficult  to  cure, 
as  well  as  more  easily  excited,  as  time  pro- 
gresses. There  is  no  valid  reason  why  cases  of 
winter-cough  should  receive  any  special  desig- 
nation. At  any  rate  this  should  not  prevent 
them  from  receiving  due  attention,  instead  of 
being  summarily  dismissed  as  mere  cases  of 
‘ winter-cough  ’ ; and  it  is  important  in  every 
instance  that  satisfactory  investigation  should  be 
carried  out,  so  that  the  exact  conditions  which 
produce  the  cough  may  be  determined,  and  the 
proper  treatment  pursued  which  these  conditions 
indicate. 


WOMB,  DISEASES  OF. 

Without  entering  into  details,  it  may  be  stated 
that  cases  of  winter-cough  belong  chiefly  to  the 
following  classes: — 1.  Not  uncommonly  it  is 
merely  due  to  a slight  catarrh,  affecting  the 
throat  and  main  air-passages.  2.  Most  fre- 
quently the  cough  depends  on  bronchial  catarrh 
or  bronchitis  in  various  degrees,  usually  asso- 
ciated with  more  or  less  emphysema.  3.  Win- 
ter-cough may  characterise  some  chronic  phthi- 
sical cases,  this  symptom  subsiding  during  the 
warmer  season.  4.  There  are  certain  forms  of 
cardiac  disease,  of  which  winter-cough  may  be  a 
prominent  phenomenon. 

Treatment. — The  treatment  of  winter-cough 
must  depend  on  the  nature  of  the  cause  which 
gives  rise  to  it,  and  will  be  found  discussed 
in  the  special  articles  descriptive  of  the  several 
conditions.  Frederick  T.  Roberts. 

WOMB,  Diseases  of. — Synon.:  Fr.  Mala- 
dies de  l’ Uterus;  Ger.  Krankheitcn  der  Gebtir- 
mutters. 

There  is  probably  no  department  of  practical 
medicine  in  which  more  progress  has  been  made 
within  the  last  twenty  years,  than  that  compre- 
hended under  this  article  ; and  it  was  only  after 
the  invention  of  exact  methods  of  physical  ex- 
amination, such  as  the  speculum  and  the  uterine 
sound,  that  its  advance  towards  the  prominent 
position  it  now  holds  commenced.  Indeed  until 
these  came  into  use  the  gynaecologist  was  much 
in  the  same  position,  with  regard  to  diseases  of 
the  uterus,  as  the  general  physician  with  regard 
to  diseases  of  the  chest  before  Laennec’s  im- 
mortal discovery.  In  the  one  case,  as  in  the 
other,  the  practitioner  had  of  old  to  trust  to 
general  symptoms  only,  and  these  were  very  apt 
to  mislead.  As  it  is  only  by  an  accurate  ex- 
amination of  the  uterine  organs  that  any  certain 
knowledge  of  their  condition  can  be  acquired, 
the  method  of  making  this  forms  an  essential 
preliminary  to  the  study  of  uterine  disease. 

Methods  of  Physical  Examination.— 
1.  Digital  Examination. — Of  all  methods  of  ex- 
amining the  uterine  organs,  the  most  important 
is  by  the  finger  alone,  nor  is  the  necessar, 
tactus  erudiius  by  any  means  easy  to  acquire 
In  this  country  the  lateral  position  is  general); 
adopted,  and,  except  under  special  circum 
stances,  is  preferable,  as  involving  less  expo 
sure  than  the  dorsal.  The  patient  should  lie  or 
her  left  side,  with  her  hips  as  near  the  edgi 
of  the  bed  as  possible.  The  semi-prone  p(<dtioi. 
is  the  most  convenient,  the  patient  lying  more 
or  less  on  her  face,  her  knees  being  fluxed,  the 
upper  one  more  so  than  the  lower.  A good 
position  much  facilitates  a complete  examination 
of  the  pelvic  cavity,  andattention  1o  these  details 
is  never  superfluous.  The  index  linger  of  the 
right  hand  is  now  carefully  introduced,  at  first 
in  the  axis  of  the  vaginal  outlet,  and  then  in 
that  of  the  pelvic  brim.  The  unimpregnated 
uterus  is  suspended,  as  it  were,  at  the  top 
of  the  vaginal  canal,  with  the  cervix  project 
ing  into  it.  The  latter  is  the  part  of  the 
uterus  which  the  finger  first  reaches.  As  the 
normal  direction  of  the  uterus  corresponds  with 
the  axis  of  the  upper  part  of  the  pelvis,  or, 
roughly  speaking,  with  a line  extending  from 
the  umbilicus  to  the  coccyx,  the  cervix,  in  a 


WOMB,  DIP  BASES  OF. 


healthy  state,  projects  into  the  vagina,  and 
points  backwards  towards  the  sacrum.  Its 
shape  varies  in  women  who  have  had  children, 
and  in  the  unmarried  or  nulliparous.  In  the 
latter  it  is  conical  or  nipple-shaped,  and  the 
opening  of  the  os  uteri  is  felt  at  the  apex 
of  the  cone,  as  a circular  aperture  about  the 
size  of  a pea.  The  anterior  and  posterior 
boundaries  of  the  os  uteri  are  known  as  the  lips 
of  the  cervix,  and  they  are  very  liable  to  alter- 
ations in  size,  becoming  congested  or  enlarged 
under  various  morbid  states,  one  often  to  a 
greater  extent  than  the  other.  In  women  who 
have  borne  children  the  shape  of  tire  ce?vix  is 
altered,  and  it  becomes  shorter  and  less  regu- 
larly conical.  The  os  is  also  changed  from  a 
circular  opening  into  a transverse  fissure,  which 
is  often  more  or  less  nodular  and  irregular  at 
its  edges,  from  lacerations  of  its  tissues  during 
labour;  and  is  sometimes  sufficiently  open  to 
admit  the  tip  of  the  finger.  When  healthy,  the 
mucous  membrane  covering  the  cervix  is  smooth 
and  velvety  to  the  touch;  and  through  the  specu- 
lum it  is  seen  to  be  of  a uniform  rose-pink  colour. 
Under  various  morbid  conditions  it  becomes 
rough,  granular,  stript  of  its  epithelium,  and 
covered  with  hypertrophied  papillae,  and  these 
alterations  are  of  much  importance  from  a diag- 
nostic point  of  view.  Having  ascertained  the 
conditions  of  the  cervix,  paying  particular  atten- 
tion to  its  size,  shape,  density,  sensibility,  and  to 
the  shape  of  the  os  uteri,  we  may  next  proceed 
to  examine  the  body  of  the  uterus,  passing  the 
finger  for  this  purpose  past  the  cervix  into  the 
vaginal  cul-de-sac  behind,  in  front,  and  on  either 
side  of  the  uterus.  In  this  way  we  feel  whether 
the  uterus  is  of  normal  size,  or  hypertrophied,  as 
it  often  is  ; whether  it  is  painful  on  pressure,  or 
not ; whether  the  uterus  is  freely  movable  by  the 
finger,  as  it  ought  to  be  ; or  whether  it  be  fixed 
and  immovable  in  any  part  of  its  contour,  as  is 
often  the  case  from  inflammatory  adhesion  in  its 
vicinity.  Then  again,  in  the  same  examination, 
we  ascertain  if  any  swelling  exists  in  any  of  the 
vaginal  culs-de-sac,  in  front,  behind,  or  at  either 
side  ; and  if  so  we  try  to  determine  its  form, 
density,  mobility,  sensibility,  and  whether  it  is 
attached  to  the  uterus,  or  is  independent  of  it — 
all  points  of  importance  in  arriving  at  an  accu- 
rate diagnosis. 

2.  Palpation. — In  this  part  of  the  examination 
we  may  often  gain  much  assistance  by  combining 
abdominal  palpation  with  vaginal  examination. 
This  method  of  bi-manual  examination  is  always 
of  great  utility,  and  is  sometimes  indispensable 
for  accurate  diagnosis,  and  it  is  not  so  generally 
practised  as  it  ought  to  be.  It  may  be  used  to 
some  extent  while  the  patient  is  still  lying  on 
her  side,  the  left  hand  being  passed  over  her 
right  hip.  But  to  practise  it  thoroughly  we 
must  make  the  patient  turn  over  on  her  back, 
and  then  by  pressing  down  the  abdominal  parietes 
with  the  left  hand,  and  acting  in  concert  with  the 
examining  finger,  we  may  thus  thoroughly  ex- 
plore the  pelvic  cavity,  and  ascertain  much  more 
completely  the  form  and  relations  of  any  tumour 
within  it,  than  by  vaginal  examination  alone. 
In  some  cases  valuable  information  can  be  ob- 
tained by  a rectal  examination,  especially  when 
there  is  a swelling  or  tumour  in  Douglas's  pouch, 
112 


1777 

or  attached  to  the  posterior  part  of  the  uterus, 
which  may  often  be  more  accurately  examined  in 
this  way  than  per  vaginam.  Simple  abdominal 
palpation  is  often  necessary  in  investigating  the 
nature  of  any  tumour  supposed  to  be  uterine.  This 
is  best  used  by  laying  the  patient  on  her  back, 
with  her  knees  elevated,  so  as  to  relax  the  abdo- 
minal parietes.  Percussion  may  often  be  advan- 
tageously combined  with  palpation.  By  using  one 
or  two  fingers  of  the  left  hand  as  a pleximeter, 
and  percussing  with  the  right,  we  get  a dull  or 
tympanitic  sound.  If  the  latter  is  marked 
where  there  is  much  abdominal  distension,  we 
know  that  it  indicates  bowel  distended  with  gas, 
and  that  there  is  probably  no  tumour.  If  there 
be  dulness  we  can  limit  its  area,  and  thus  verify 
the  results  of  palpation  by  mapping  out  abdomi- 
nal swelling  met  with.  By  these  means  also  we 
discover  the  existence  of  fluid,  either  free  in  the 
abdomen,  as  in  ascites,  or  contained  in  an  ovarian 
cyst,  the  presence  of  fluctuation  being  often  very 
readily  determined.  v 

3.  Use  of  the  Speculum. — We  now  proceed  to 
consider  the  means  at  our  disposal  for  ex- 
amining the  lower  segment  of  the  uterus  with 
the  eye;  and  from  the  re-invention  of  the 
speculum  by  Becamier,  in  the  early  part  of  the 
present  century,  we  may  date  the  commence- 
ment of  the  accurate  study  of  uterine  diseases. 
Numerous  varieties  of  specula  have  been  used. 
One  very  generally  employed  is  Cusco's  bi-valve 
speculum  (fig.  134).  This  has  the  advantage  of 


being  easy  to  introduce,  and  of  being  adapted 
for  either  a capacious  or  a narrow  vagina.  It 
exposes  the  cervix  well.  The  objections  to  it 
are  its  expense,  and  the  fact  that  the  metal  is 
apt  to  be  affected  by  various  applications  made 
to  the  cervix.  Personally  the  writer  prefers  the 
tubular  (Fergusson’s)  speculum  (fig.  135)  made 


Fig.  135.  Fergusson’s  speculum. 


of  glass,  and  covered  with  caoutchouc ; and  that 
which  is  bevelled  at  the  end  is  tli6  easiest  to 
introduce,  and  the  best  to  expose  the  cervix.  For 
cleanliness  and  brilliancy  of  illumination  nothing 
can  equal  it.  It  is  unaffected  by  any  remedy 
used  for  local  application,  ar.d  has  the  advan- 
tage, which  is  wanting  in  all  other  specula,  of 
embracing  and  steadying  the  cervix.  In  certain 
cases  requiring  local  medication  this  is  of  great 
value.  The  objection  to  this  form  of  speculum 
is  its  fragility,  and  the  necessity  of  having 
instruments  of  various  sizes,  adapted  to  vaginse 


WOMB,  DISEASES  OF. 


1778 

■jf  different  dimensions.  Practitioners,  therefore, 
at  a distance  from  surgical-instrument  makers, 
will  do  well  to  provide  themselves  with  the 
more  expensive  instrument.  Another  form  of 
speculum  much  used  of  late  years,  and  in  some 
cases  superior  to  all  others,  is  the  ‘duck-bill’ 
speculum  (fig.  136).  This  acts  on  the  principle  of 
drawing  aside  the  perinaeum  and  posterior  vaginal 


wall,  so  as  to  allow  air  to  distend  the  canal,  and 
thus  expose  the  cervix.  For  certain  operations 
it  is  invaluable,  and  is  most  valuable  even  in 
ordinary  examinations  if  the  practitioner  be 
skilled  in  its  use.  Considerable  practice  is  re- 
quired, however,  to  employ  it  satisfactorily,  and 
it  has  the  further  drawback  of  necessitating  the 
assistance  of  a second  person. 

The  passing  of  a speculum,  without  pain,  is  an 
operation  requiring  some  little  practice  to  perform 
skilfully.  In  using  a tubular  glass  speculum  wo 
must  first  choose  one  corresponding  to  the  size 
of  the  vagina.  This  is  a point  of  some  importance  ; 
for  the  attempt  to  pass  a large  speculum  into 
a small  vagina  causes  much  suffering ; and  if,  on 
the  other  hand,  too  small  an  instrument  be  used, 
the  cervix  is  not  properly  exposed.  The  patient 
should  lie  in  the  ordinary  lateral  position.  The 
speculum  should  then  be  taken  in  the  hollow  of 
the  right  hand,  its  bevelled  extremity  resting  on 
the  under  surface  of  the  index  finger,  the  point 
of  which  should  project  a little  over  its  edge,  so 
as  to  guide  it  through  the  ostium  vaginae.  The 
point  of  the  finger  having  been  inserted  into  the 
vagina,  the  mouth  of  the  speculum,  the  centre  of 
which  is  grasped  gently  by  the  other  fingers 
of  the  right  hand,  is  held  by  the  left  hand,  and 
the  instrument,  guided  along  the  under  surface 
of  the  right  index  finger,  is  gently  insinuated 
into  the  vagina,  pressing  back  the  perinteum  as  it 
enters.  When  it  is  fully  introduced,  it  is  turned 
gently  round  until  the  cervix  is  well  exposed. 

By  the  speculum  we  can  speedily  recognise  any 
changes  in  the  cervix  and  os  uteri ; we  can  see  if 
the  mucous  membrane  covering  the  former  be 
pale  or  congested,  smooth  or  abraded,  or  perhaps 
covered  with  granulations  which  bleed  on  being 
touched.  The  character  and  amount  of  discharge 
should  be  noted,  and  it  may  be  wiped  away  with 
cotton  wool  held  in  the  speculum  forceps.  B'  the 
discharge  come  in  great  measure  from  the  interior 
of  the  cervix  and  body  of  the  womb,  it  is  glairy, 
transparent,  and  very  tenacious,  and  it  may  often 
be  seen  oozing  out  of  the  os  uteri  like  white 
of  egg.  This  is  a certain  sign  of  some  morbid 
state  of  the  mucous  lining  of  the  uterus.  If  the 
discharge  come  from  the  surface  of  the  cervix  it 
is  yellow  and  purulent  in  appearance.  We  can 
also  recognise  any  abnormal  growth  that  exists 
about  the  cervix,  as,  for  instance,  small  gelati- 


nous polypi  which  have  evaded  the  sense  ol 
touch. 

4.  Examination  with  the  Sound. — In  certain 
cases  in  which  more  accurate  information  re- 
garding the  state  of  the  uterus  is  required,  other 
accessory  means  of  examination  are  used.  One 
of  these  is  the  uterine  sound  (fig.  137),  by  means 
of  which  we  can  explore  the  interior  of  the  uterus, 
measure  its  length,  ascertain  its  direction,  &c.  The 
instrument  is  a thin  rod  of  flexible  metal,  which 
can  be  bent  into  any  desired  shape,  as  it  is  some- 
times necessary  to  adapt  it  to  the  altered  curve 
of  the  uterine  cavity.  Its  length  is  divided  into 
inches  by  means  of  small  notches  in  the  metal,  and 
at  two  and  a half  inches  from  its  point  is  a small 
knob,  indicating  the  normal  length  of  thehealthy 
uterus.  In  introducing  the  sound,  the  index 
finger  of  the  right  hand  is  passed  into  the  vagina 
until  its  tip  rests  on  the  opening  of  the  os  uteri, 
which  can  be  felt  as  a dimple  or  depression  at 
the  extremity  of  the  cervix.  The  handle  of  the 
sound  being  lightly  held  in  the  left  hand,  its 
point,  previously  warmed  and  oiled,  is  guided 
along  the  palmar  surface  of  the  index  finger  of  the 
right  hand,  until  it  enters  the  os  uteri.  It  is  a 
good  plan  to  pass  the  sound 
through  the  vagina  with  its  con- 
cavity looking  towards  the  peri- 
naeum, and  after  it  has  entered 
the  os,  to  turn  it  gently  round, 
so  that  its  further  progress  may 
he  in  the  ordinary  direction  of 
the  uterine  cavity.  It  is  now 
gently  pushed  on,  no  force  what- 
ever being  used,  until  its  point 
is  arrested  by  the  fundus  uteri. 

The  tip  of  the  riglit  index  finger 
is  now  placed  at  the  os,  and 
withdrawn  in  contact  with  the 
sound,  so  that  the  exact  length 
to  which  it  has  entered  may  be 
ascertained.  Considerable  prac- 
tice is  required  to  pass  the 
sound  easily  and  without  pain. 

Gentleness  is  necessary  above 
all,  and  the  sound  should  be 
coaxed  to  pass,  being  withdrawn 
if  any  resistance  is  met  with,  and 
never  pushed  on  by  force.  Some- 
times the  sound  will  not  pass  in 
the  ordinary  direction,  and  theu 
an  endeavour  must  he  made  to 
adapt  it  to  the  curve  of  the 
uterine  cavity,  by  bending  it,  or 
by  passing  it  with  its  concavity 
backwards,  as  in  the  cases  of 
retroflexion.  The  kind  of  infor- 
mation to  he  derived  from  the 
use  of  the  sound  will  he  best 
appreciated  when  treating  of  the 
separate  diseases  of  the  uterus.  Fig.  137^  The 

5.  Dilatation  of  the  Cervix. — Uterine  Scnnd. 
Another,  mode  of  examination,  sometimes  of  much 
use,  is  the  dilatation  of  the  cervix  by  sponge  or 
laminaria  tents,  so  as  to  admit  of  the  introduc- 
tion of  a finger  and  complete  exploration  of  the 
uterine  cavity.  This  is  of  immense  service  in 
cases  of  profuse  menorrhagia,  when  the  existence 
of  an  intra-utcrine  polypus,  or  portion  of  retained 
placenta,  is  suspected.  The  tent  is  a mass  a' 


WOMB,  DISEASES  OE. 


eompressed  spcmge,  or  a cylinder  of  laminaria 
digitata,  sufficiently  small  to  enter  the  cervix, 
where  it  swells  by  the  imbibition  of  moisture, 
and,  in  doing  so,  expands  the  surrounding  tissues. 
The  best  way  of  effecting  the  desired  object  is  by 
passing  side  by  side  into  the  cervix  a bundle  of 
laminaria  bougies,  sufficiently  long  to  reach  the 
fundus.  These,  if  left  in  situ  for  twenty-four 
hours,  dilate  not  only  the  cervix,  but  the  whole 
uterine  cavity,  and  admit  of  its  being  thoroughly 
explored  under  an  anaesthetic.  In  order  to  effect 
tills  early,  the  cervix  should  be  exposed  by  a 
duck-bill  speculum.  Dilatation  of  the  cervix  is  an 
operation  that  should  not  be  undertaken  without 
due  consideration,  as  it  is  occasionally  followed 
oy  considerable  irritation. 

General  JEtiology  and  Pathology  of 
Uterine  Disease. — Much  as  is  the  attention 
which  has  been  paid  to  uterine  disease  of  late 
years,  the  opinions  of  the  profession  are  as  yet 
far  from  being  decided  on  many  elementary  facts 
connected  with  it.  It  is  beyond  doubt  that  in 
this  class  of  disease  there  are  a series  of  symp- 
toms common  to  all  cases  alike,  such  as  pain  in 
the  lower  part  of  the  abdomen  and  back,  in- 
ability to  walk,  leucorrhceal  discharge,  and 
disordered  menstruation.  If,  however,  modern 
writers  on  gynaecology  are  consulted,  it  will  be 
at  once  seen  how  various  and  irreconeileable  are 
the  explanations  given  of  these  symptoms.  Thus 
we  have  a school  who  teach  that  in  inflammation 
and  congestion,  either  of  the  cervix  alone,  or  of 
the  body  or  lining  membrane  of  the  uterus,  we 
havo  the  key  to  uterine  pathology,  and  that  all 
other  changes  detected  in  the  uterus,  such  as 
displacements  or  flexions,  are  merely  secondary 
results  of  the  primary  affection.  On  the  other 
hand,  there  are  many  influential  gynaecologists 
who  refer  all  uterine  disease  to  mechanical 
causes;  who  consider  displacements  to  be  the 
primary  cause  of  nearly  every  morbid  state  of 
the  uterus,  inflammation  and  congestion  being 
merely  secondary  results ; and  who  naturally 
limit  their  treatment  to  an  endeavour  to  replace 
and  support  the  uterus  in  its  normal  position. 
The  want  of  sufficient  pathological  study  of 
morbid  states  of  the  uterus  accounts  for  these 
varying  opinions,  which  are  much  to  be  regretted ; 
for,  while  one  set  of  theorists  apply  themselves 
to  an  endeavour  to  relieve  the  inflammatory 
symptoms  they  find,  and  which  undoubtedly  gene- 
rally exist,  by  leeches,  rest,  and  suitable  local 
applications,  they  are  apt  to  undervalue  and 
neglect  the  mechanical  means  by  which  the  dis- 
placed organ  may  be  supported  and  steadied,  on 
which  their  opponents  too  exclusively  rely,  but 
the  real  value  of  which  it  is  impossible  to  call 
in  question.  Hence  it  follows  that  these  partial 
and  orih-sided  views  lead  to  neglect  of  really 
important  measures  in  one  direction  or  the  other, 
and  an  amount  of  uncertainty  in  the  mind  of  the 
profession  which  materially  impedes  a due  recog- 
nition of  the  true  importance  of  uterine  disease. 
The  fact,  no  doubt,  is  that  neither  of  these 
opposing  views  is  entirely  right,  but  that  there 
is  a large  measure  of  truth  in  both.  Of  the 
importance  of  inflammatory  conditions  no  one, 
who  impartially  studies  the  clinical  history  of 
eases  coming  under  his  care,  can  entertain  any 
reasonable  doubt.  The  large,  tender,  and  con- 


1779 

gested  uterus,  with  its  thickened  and  hypertro- 
phied walls,  the  inflamed  and  granular  mucous 
membrane  covering  the  cervix,  and  pouring  out 
abundance  of  morbid  secretion,  are  conditions  too 
obvious  to  be  overlooked,  and.  which  are  very 
frequently  indeed  associated  with  displace- 
ments, resulting  from  alterations  in  portions  of 
the  hypertrophied  and  over- weighted  organ.  In 
some  of  these  cases  treatment  directed  to  the 
original  inflammatory  condition  may,  of  itself, 
suffice  to  effect  a cure  ; in  others  this  fails,  un- 
less attention  be  at  the  same  time  paid  to  the 
secondary  displacements.  On  the  other  hand  it 
is  equally  impossible  to  ignore  the  occasional 
remarkable  influence  of  a simple  displacement 
in  producing  disease.  Who,  for  example,  that  has 
witnessed  the  long  chain  of  distressing  symptoms 
following  a traumatig  displacement,  such  as 
retroflexion  from  a fall,  and  the  instantaneous 
relief  sometimes  following  the  introduction  of  a 
suitable  pessary,  can  doubt  this?  In  fact  all 
these  conditions  act  and  re-act  on  each  other,  ami 
too  excessive  attention  to  one  set  of  symptoms, 
based  on  theoretical  dogmas,  is  as  fallacious  in 
uterine  as  in  all  other  forms  of  disease. 

The  causes  of  uterine  disease  are  verynumerous. 
Among  the  most  common  may  be  mentioned  errors 
in  the  mode  of  life  consequent  on  the  habits  of 
modern  society,  such  as  tight-lacing,  want  of 
proper  exercise,  heated  rooms,  imprudence  during 
menstruation,  and  the  like.  By  far  the  most 
prolific  source  of  uterine  disease  is  to  be  found 
in  the  changes  in  the  uterus  consequent  on  par- 
turition. Many  accidental  circumstances  are  apt 
to  check  and  arrest  the  fatty  degeneration  of  the 
hypertrophied  muscles,  which  normally  occurs 
after  delivery.  Hence  the  uterus  remains  large, 
congested,  heavy,  tender,  and  in  the  condition 
known  as  sub-involution,  its  cavity,  as  measured 
by  the  uterine  sound,  being  elongated.  In  such 
cases  the  symptoms  of  uterine  disease  creep  on 
insidiously  after  abortion  or  child-bearing,  and, 
in  a large  proportion  of  eases,  it  will  be  possible 
to  trace  its  origin  to  this  source. 

In  considering  the  diseases  of  the  uterus,  it 
will  economise  space  if  we  divide  them  into  four 
classes,  namely: — 

1.  Inflammatory  aDd  congestive  diseases, 
with  their  results. 

2.  Displacements. 

3.  Malignant  diseases, 

4.  Tumours. 

1.  Inflammatory  and  Congestive  Diseases. 
Under  this  heading  we  may  consider  together 
those  morbid  states  of  the  uterus,  which  are 
variously  described  under  such  terms  as  acute 
and  chronic  metritis,  chronic  parenchymatous 
metritis,  areolar  hyperplasia,  acute  and  chronic 
endo-metritis,  endo- cervicitis,  chronic  uterine 
catarrh,  granular  degeneration  of  the  cervix, 
ulceration  of  the  cervix,  congestion  of  the  uterus, 
and  others. 

This  course  involves  the  disadvantage  of  de- 
scribing together  diseases  which,  whilst  they  are 
very  generally  associated,  and  have  much  that 
is  common  in  their  symptomatology  and  treat- 
ment, may  often,  on  the  other  hand,  repeatedly 
occur,  and  require  important  modifications  in 
their  management,  according  to  the  particular 
parts  of  the  uterus  affected.  It  is  impossible, 


WOMB,  DISEASES  OF. 


17S0 

however,  in  so  short  an  article,  to  discuss  their 
individual  peculiarities,  as  would  naturally  be 
done  in  a systematic  treatise. 

Acute  inflammatory  affections  of  the  uterus, 
whether  of  ils  body  or  of  its  lining  membrane, 
are  of  comparatively  rare  occurrence  when  un- 
connected with  the  puerperal  state,  and  if  a con- 
trary opinion  is  expressed  in  many  of  our  gynae- 
cological works,  it  is  probably  because  various 
other  inflammatory  diseases,  especially  localised 
inflammations  of  the  peritoneum  and  cellular 
tissue  near  the  uterus,  have  been  confounded  with 
inflammations  of  the  uterus  itself.  No  practical 
harm  will  result,  therefore,  if  we  limit  ourselves 
to  the  consideration  of  the  more  chronic  con- 
ditions which  are  of  such  common  occurrence, 
and  produce  such  important  consequences.  One 
of  the  most  common  is  undoubtedly  congestion 
of  the  uterus,  associated  with  enlargement  of  its 
vessels,  and  very  often  leading  secondarily  to 
more  important  and  lasting  disease,  such  as 
inflammation  of  its  lining  membrane,  and  the 
condition  described  as  areolar  hyperplasia  or 
chronic  parenchymatous  metritis. 

^Etiology  and  Anatomical  Characters. — 
The  causes  of  such  congestions  are  very  nume- 
rous, and  indeed  they  occur  normally  in  connec- 
tion with  every  menstrual  period,  andmayreadily 
be  perpetuated.  By  far  the  most  important, 
however,  is  some  interference  with  the  proper 
involution  of  the  uterus  after  delivery  or  abor- 
tion, to  which  a large  proportion -of  such  disease 
may  be  traced.  If  such  congestion  continue  to 
be  repeated,  whatever  be  its  cause,  it  very  often 
leads  to  inflammation  of  the  mucous  membrane 
lining  the  cervix  or  body  of  the  uterus;  and  then 
the  diseases  known  as  endo-mietritis  or  cndo- 
ccrvicitis  are  established,  which  are  of  much  im- 
portance. In  these  the  largely  developed  glan- 
dular structures  of  the  mucous  membrane  are 
the  parts  chiefly  involved.  On  microscopic  ex- 
amination they  are  found  altered  in  character, 
dilated  at  their  mouths,  and  pouring  out  abun- 
dantly the  transparent  spongy  mucus  which  is 
so  characteristic  of  those  affections.  The  villi 
of  the  cervix,  both  those  within  the  canal  and  in 
its  exterior,  become  altered,  stript  of  their  epi- 
thelium, and  eventually  hypertrophied.  These 
enlarged  and  abraded  papillae  on  the  surface 
of  the  cervix,  when  seen  through  the  speculum, 
form  the  characteristic  red,  strawberry-like, 
abrasions  round  the  os,  which,  under  the  name 
of  ulceration,  have  formed  so  fruitful  a subject 
of  controversy  in  uterine  disease.  The  detection 
of  this  condition — which  is  in  no  sense  of  the 
word  an  ulceration,  since  the  epithelium  is  the 
only  structure  destroyed — is  of  much  importance 
from  a diagnostic  point  of  view,  but  chiefly  as 
leading  to  a knowledge  of  the  more  deep-seated 
changes  which  have  produced  it  as  a secondary 
result,  which  are  themselves  beyond  the  sphere 
of  observation,  but  which  are  truly  at  the  root 
of  the  evil.  Hence  the  granular  and  abraded 
state  of  the  cervix  must  be  looked  upon  as  a 
mere  indication  of  disease  elsewhere,  not  as 
being  in  itself  a primary  disease.  Moreover, 
it  is  to  be  noted,  as  specially  pointed  out  of  late 
by  American  gynaecologists,  that  many  apparent 
abrasions  of  the  cervix  are  really  due  to  lacera- 
tion of  its  tissue,  and  eversion  of  its  altered 


lining  membrane,  a condition  which  can  only  be 
satisfactorily  made  out  when  the  duck-bill 
speculum  is  used. 

In  more  advanced  stages  of  these  inflam- 
mations of  the  mucous  membrane  deeper-seated 
alterations  occur.  The  glands  become  obliterated 
or  atrophied,  and  sometimes  undergo  cystic 
degeneration  ; and  the  whole  mucous  membrane 
may  become  adherent,  stript  of  its  epithe- 
lium, covered  with  granulations,  or  finally  con- 
verted into  a layer  of  connective  tissue  covered 
with  polymorphous  cells  (Klebs).  In  no  long 
time,  moreover,  other  morbid  states  of  the 
uterus  are  developed.  The  organ  becomes  en- 
larged, tender  to  touch,  and  very  often  there  is 
more  or  less  forward  or  backward  displacement. 
The  cervix  especially  is  apt  to  be  hypertrophied, 
the  os  patulous,  much  leucorrheal  discharge  is 
present,  and  all  the  distressing  chain  of  symp- 
toms accompanying  confirmed  uterine  disease  is 
established.  Pathologically,  this  enlarged  and 
tender  state  of  the  body  and  cervix  of  the  uterus 
is,  by  most  recent  writers,  believed  to  depend 
on  excessive  growth  of  the  connective  tissue, 
associated  with  vascular  hypersm'a  and  by 
persesthesia  of  the  nerves.  It  should  be  re- 
membered, however,  that  it  is  identical  with  the 
condition  commonly  described  as  chronic  metritis , 
the  essentially  inflammatory  origin  of  which  has 
long  been  an  axiom  in  gynaecology. 

Symptoms.  — The  symptoms  accompanying 
these  morbid  states  of  the  uterus  are,  in  a great 
measure,  those  which  are  common  to  a large  num- 
ber of  uterine  complaints.  Pain  in  the  lower  part 
of  the  abdomen  and  back,  increased  by  exercise  of 
any  kind;  pain  in  defaecation  or  micturition,  and 
in  married  women,  on  sexual  intercourse;  pro- 
fuse glairy,  tenacious,  or  purulent  discharge,  in 
old-standing  cases  very  abundant ; disordered 
menstruation,  either  scanty  or  irregular,  or  more 
often  profuse,  and  frequently  very  painful ; and, 
eventually,  if  the  true  character  of  the  disease  be 
not  recognised,  a long  and  distressing  catalogue 
of  general  symptoms,  such  as  dyspepsia,  hysteria, 
sickness  or  vomiting,  headache,  and  others  tco 
protean  in  their  character  to  be  described,  are 
among  those  which  are  most  commonly  observed. 

The  conditions  met  with  on  physical  ex- 
amination varj'  with  the  duration  and  extent  of 
the  disease,  and  the  tissues  cf  the  uterus  chiefly 
implicated.  In  the  simpler  cases  the  uterus  is 
merely  somewhat  heavy  and  enlarged,  and  tender 
to  the  touch.  When  there  is  endo-metritis  or 
endo-eervicitis  to  any  extent,  the  cervix  is  some- 
what puffy  and  enlarged,  and  the  external  os 
patulous,  so  that  the  sound  passes  easily ; and, 
in  the  same  way,  a dilated  state  of  the  cervical 
canal  and  internal  os  is  recognised.  Very  generally 
also  the  surface  of  the  cervix  is  rough,  granular, 
and  greatly  abraded,  bleeding  on  being  touched, 
while  strings  of  the  characteristic  gelatinous  dis- 
charge are  seen  to  exude  from  the  cervix,  and 
the  cervix  may  be  extensively  fissured.  Lastly, 
on  bi-manual  examination,  in  the  more  chronic 
and  confirmed  cases,  the  whole  uterus  will  be 
found  to  be  distinctly  enlarged,  probably  some- 
what elongated  when  measured  by  the  sound,  and 
very  commonly  the  subject  of  some  of  the  forms 
of  displacement  to  be  presently  described. 

Prognosis. — The  prognosis  of  these  diseases 


WOMB,  DISEASES  OF. 


mast,  of  course,  depend  on  their  extent  and  dura- 
tion. In  their  earlier  stages  they  are  readily 
susceptible  of  improvement  and  cure.  In  old- 
standing  cases,  which  have  lasted  for  years, 
and  produced  all  the  local  and  general  results 
above  described,  the  treatment  is  surrounded 
with  difficulties,  and  the  prospect  is  far  from 
encouraging.  It  is  of  such  states  that  Scanzoni 
speaks  when  he  says  : ‘ Wo  do  not  remember  a 
single  case  in  which  we  have  cured  an  abundant 
zterine  leucorrhoea  of  several  years’  standing  ’—a 
iicvum  which  was  doubtless  true  with  reference 
so  the  methods  of  treatment  generally  employed, 
but  which  fortunately  cannot  be  endorsed  by 
those  who  have  employed  more  radical  means  of 
cure,  applied  directly  to  the  seat  of  the  disease. 

Treatment. — The  treatment  resolves  itself 
into  general  and  local.  With  regard  to  the 
former,  the  indications  are  to  do  all  in  our 
power  to  improve  the  nutrition  and  general 
health  by  ordinary  means  of  treatment,  such  as 
attention  to  diet,  fresh  air,  and  the  adminis- 
tration of  appropriate  remedies,  amongst  which 
such  drugs  as  quinine,  small  doses  of  arsenic 
or  strychnia,  various  ferruginous  preparations, 
end  bromide  of  potassium,  either  alone  or  in 
combination  with  other  remedies,  especially 
when  there  is  much  nervous  irritability,  are 
amongst  the  most  generally  useful.  In  old- 
standing  cases  resort  to  some  of  the  Conti- 
nental watering-places  is  occasionally  of  much 
service.  These  points,  however,  all  depend  on 
general  principles,  and  cannot  be  farther  dwelt 
upon.  Among  the  local  measures  one  of  the 
first  and  most  important  to  attend  to  is  rest.  If 
moving  about  produce  pain,  repose  in  the  recum- 
bent attitude  ought  certainly  to  be  enforced, 
and  in  recent  and  acute  cases,  it  should  be 
absolute.  In  chronic  eases  continuous  rest 
leads  to  the  evils  of  deterioration  of  the  general 
health,  and  the  risk  of  acquiring  habits  of  chronic 
invalidism.  This  must,  then,  be  decided  by  the 
exigencies  of  the  particular  case,  and  the  judg- 
ment of  the  practitioner.  Generally,  some  daily 
gentle  exercise,  short  of  fatigue,  should  be 
advised,  such  as  walking  a little  distance,  driv- 
ing in  an  easy  carriage  or  bath-chair,  or  sitting 
in  the  open  air.  We  may  safely  assume  that 
exercise  which  does  not  produce  or  increase  pain 
is  doing  good. 

In  cases  of  simple  hypersemia,  especially  when 
not  of  old  standing,  and  when  the  uterus  is  tender 
to  the  touch,  the  local  abstraction  of  blood  is 
often  of  marked  benefit.  This  may  be  effected 
either  by  applying  from  two  to  four  leeches  to 
the  cervix  through  a cylindrical  glass  speculum, 
or,  still  better,  by  puncturing  the  cervix  with  a 
scarificator  made  for  the  purpose.  Another 
very  effectual  means  of  relieving  congestion  and 
tenderness  of  the  uterus,  is  the  use  of  pledgets 
of  cotton  wool,  to  which  a string  is  attached, 
thoroughly  soaked  in  glycerine.  If  one  of  these 
is  introduced  into  the  vagina  at  night,  and  re- 
moved by  means  of  the  string  in  the  morning,  it 
will  be  found  to  produce  an  abundant  watery 
discharge  which  saturates  the  linen  of  the 
patient.  Great  relief  is  thus  given,  and  there  is 
hardly  any  form  of  congestive  uterine  disease 
which  is  not  benefited  by  this  treatment,  which 
most  women  can  apply  for  themselves.  The 


1781 

glycerine  pledgets  may  be  used  every  night,  and 
they  do  not  interfere  with  other  modes  of  treat- 
ment. Continuous  irrigations  of  hot  water  at 
110°,  night  and  morning,  are  also  most  service- 
able, but  to  be  of  use  not  less  than  from  one  to 
two  gallons  must  be  used,  with  a suitable  cistern 
syringe.  When  properly  applied  these  give 
immense  relief.  When  the  uterus  is  enlarged 
as  well  as  tender,  much  benefit  may  be  derived 
from  the  application  of  a pledget  of  iodised 
cotton  to  the  cervix  once  a week.  This  should 
be  passed  through  the  speculum,  and  retained  in 
position  by  a large  pledget  soaked  in  glycerine.  It 
rarely  causes  pain  ; if  it  do,  it  should  be  at  once 
removed ; and  it  often  remarkably  reduces  the  size 
of  the  sub-involuted  and  hypertrophied  womb. 

When  there  is  evidence  of  endo-metritis  or 
endo- cervicitis  other  treatment  is  required.  Now 
the  desideratum  is  the  application  of  alterative 
remedies  to  the  diseased  mucous  membrane,  not 
with  the  view  of  destroying  it,  but  of  so  modify- 
ing its  circulation  and  nutrition  as  to  set  up 
healthy  action.  The  want  of  success  so  common 
in  treating  these  cases  may  be  traced  to  the  fact 
that  remedies  have  not  been  applied  directly  to 
the  interior  of  the  cervix  or  uterus,  but  that 
practitioners  have  contented  themselves  with 
treating  the  abraded  or  granular  condition  of 
the  cervix,  thus  leaving  the  real  seat  of  the  dis- 
ease untouched.  Of  late  years  much  advance 
has  been  made,  and  we  need  not  now  talk  of 
these  chronic,  inflammatory  affections  of  the 
lining  membrane  of  the  uterus  in  the  same  hope- 
less strain  as  before.  One  of  the  earliest  modes 
of  intra-uterine  medication  was  the  injection  of 
fluids  into  the  uterine  cavity,  such  as  tincture  of 
iodine,  or  solutions  of  nitrate  of  silver.  It  was 
soon  found  that  such  injections,  when  the  cervix 
had  not  been  previously  dilated,  were  apt  tobefol- 
lowed  by  very  alarming  and  dangerous  symptoms ; 
and  it  is  now  generally  admitted  that  they  are 
inadmissible,  unless  the  cervix  has  been  previously 
dilated  with  sponge  or  laminaria  tents.  This  in 
itself  is  a procedure  not  to  be  lightly  undertaken ; 
and  to  repeat  it  frequently  for  a length  of  time — 
as  would  be  essential  in  the  treatment  of  these 
chronic  cases — would  be  altogether  out  of  the 
question.  Some  other  method  of  attaining  the  de- 
sired object  is,  therefore,  necessary,  and  this  we 
obtain  in  perfection  in  the  local  application  of 
the  desired  alteratives  on  suitable  probes  covered 
with  a thin  layer  of  cotton  wool.  By  this  means 
we  can  reach  the  mucous  membrane  at  any  part 
of  the  uterine  cavity,  and  apply  our  remedies 
to  it,  without  the  necessity  of  any  preliminary 
dilatation.  The  probes  used  by  the  writer  are 
made  of  flexible  metal  (fig.  138),  attached  to  a 
wooden  handle,  and  of  such  a size  that  -when 
tightly  -wrapped  round  with  a thin  film  of  wool, 
they  are  not  thicker  than  an  ordinary  uterine 
sound.  They  are  covered  by  teasing  out  a small 
portion  of  wool,  which  is  flattened  between  the 
palms  of  the  hands.  The  probe  is  then  dipped 
in  water,  to  cause  the  wool  to  adhere,  and  by 
twisting  round  the  handle,  the  wool  being  held 
between  the  forefinger  and  thumb  of  the  left 
hand,  the  wool  is  smoothly  and  firmly  wrapped 
round  it.  A little  practice  enables  us  to  effect 
this  with  great  neatness.  The  cervix  being 
generally  abnormally  patulous,  there  is  no  diffi 


1782 


WOMB,  DISEASES  OF. 


Fro.  138.  Uterine 
Probes. 


culty  in  passing  the  probes  through  the  os,  pre- 
viously exposed  by  the  speculum,  so  as  to  reach 
the  entire  uterine  cavity.  The  writer  is  in  the 
habit  of  using  a mixture  of 
equal  parts  of  crystallised 
carbolic  acid  and  glycerine, 
as  a local  alterative,  than 
which,  he  believes,  there 
is  no  better  application. 
Others,  however,  employ 
tincture  of  iodine,  strong 
solutions  of  nitrate  of  sil- 
ver, or  even,  as  recom- 
mended by  Courty  of  Mont- 
pellier, pass  a solid  piece 
of  nitrate  of  silver  into  the 
uterine  cavity,  leaving  it 
there  to  melt  and  flow  over 
the  mucous  membrane.  The 
writer  first  swabs  out  the 
uterine  cavity  with  one  or 
two  probes  covered  with 
dry  wool,  so  as  to  remove 
the  glutinous  discharge  as 
much  as  possible,  and  then 
passes  in  another  probe, 
covered  with  the  carbolic 
solution,  so  as  to  paint  over 
the  lining  membrane  of  the 
cervix  and  body  of  the 
uterus,  the  external  abrasions  on  the  cervix  being 
subsequently  swabbed  over  with  »the  same  solu- 
tion.  This  rarely  gives  rise  to  any  pain  or  dis- 
comfort, and  may  be  combined  with  the  other 
plans  of  treatment  already  mentioned.  Intra- 
uterine medication  is  most  useful  in  the  week 
immediately  succeeding  menstruation,  when  the 
superficial  layer  of  the  mucous  membrane  has 
been  shed.  If  used  too  near  the  advent  of  the 
next  period  it  may  prove  too  irritating,  and  may 
bring  on  menstruation  prematurely.  As  a rule, 
two  applications,  at  intervals  of  a few  days,  in 
the  early  part  of  the  intra-menstrual  interval 
are  amply  sufficient,  and  it  may  be  necessary  to 
continue  the  treatment  for  many  weeks  or  months, 
Should  laceration  of  the  cervix  and  ectropion 
exist,  Emmett’s  operation  of  tracheloraphe  may 
be  indicated.  In  very  severe  and  obstinate  cases 
of  this  kind  Beeamier  used  to  scrape  the  ute- 
rine mucous  membrane  with  a curette,  so  as  to 
remove  the  granulations,  especially  when  there 
was  much  metrorrhagia,  and  where  there  was 
reason  to  suspect  the  existence  of  a granular 
condition  of  the  intra-uterine  mucous  membrane. 
The  Dublin  physicians  recommend  the  appli- 
cation of  fuming  nitric  acid,  the  cervix  having 
been  first  dilated  with  tents.  This  is  a very 
strong  measure,  which  we  would  not  willingly 
adopt;  but  it  is  only  fair  to  say  that  in  the 
cases  in  which  the  writer  has  used  it,  he  has 
found  it  exceedingly  useful.  Scraping  the  uterine 
cavity  with  the  dull  wire  curette  also  occasion- 
ally has  an  admirable  result  in  such  condi- 
tions, and,  so  far  as  the  writer's  experience 
goes,  this  is  a perfectly  safe  procedure.  Before 
concluding  this  subject,  a word  of  caution  is 
necessary.  Valuable  as  intra-uterine  medication 
certainly  is  in  suitable  cases,  it  should  never  be 
rashly  or  indiscriminately  employed,  and  the 
writer  would  stronglv  insist  that,  before  resort- 


ing to  it,  we  should  satisfy  ourselves  that  the 
uterus  is  likely  to  bear  it  with  impunity.  When- 
ever, therefore,  there  i3  much  tenderness  of  the 
womb  on  being  touched,  even  when  the  case  is 
otherwise  suitable, the  writer  deems  it  advisable 
first  to  remove  the  congested  condition  by  rest, 
the  local  abstraction  of  blood,  the  use  of  gly- 
cerine pledgets,  hot-water  irrigations,  and  other 
appropriate  means;  and,  above  all,  the  slightest 
evidence  of  any  concomitant  mischief  or  irrita- 
tion, recent  or  of  old  standing,  in  the  neighbour- 
hood of  the  uterus,  as  shown  by  tenderness  on 
pressure  in  the  region  of  the  broad  ligaments, 
or  fixity  of  the  uterus,  should  be  an  absolute 
contra-indication. 

2.  Displacements. — Under  this  head  we 
have  to  discuss  a variety  of  diseases  which 
have  furnished  a fruitful  theme  for  controversy 
amoDg  gynaecoolgists.  Practically  physicians 
have  divided  themselves  into  two  great  schools 
with  regard  to  these  affections.  One  of  these 
schools  teaches  that  deviations  of  the  uterus,  in 
whatever  direction  they  occur,  whether  forwards, 
backwards,  or  to  either  side  (for  descent  of  the 
uterus  is  of  a different  character,  and  must  be 
separately  discussed),  form  of  themselves  serious 
maladies  accompanied  by  definite  symptoms ; 
and,  as  a logical  deduction,  have  their  treat- 
ment primarily  in  the  endeavour  to  replace  the 
dislocated  uterus  in  its  normal  position,  and 
maintain  its  position  by  mechanical  contrivance- 
known  as  pessaries.  The  other,  and  perhaps 
larger,  school  holds  that  versions  or  flexions 
are  not  per  se  the  cause  of  the  undoubted  symp- 
toms which  are  met  with  in  the  cases  in  which 
they  are  found  to  be  present ; that  flexions  may, 
and  often  do,  exist  without  giving  rise  to  any 
symptoms  at  all ; that  in  all  cases  the  symp- 
toms may  be  traced  to  the  uterine  engorge- 
ments and  congestions  which  accompany  the  de- 
viations, and  are  their  primary  cause ; and  that, 
therefore,  it  is  unnecessary  to  pay  attention  to 
the  displacement,  which  may  be  left  to  itself, 
while  associated  conditions  are  remedied  by  ap- 
propriate treatment.  As  is  generally  the  ease  in 
all  such  controversies,  it  is  probable  that  neither 
side  is  entirely  in  the  right,  and  that  the  truth 
is  to  be  found  between  the  two.  It  is  certain 
that  in  some  cases,  and  under  certain  peculiari- 
ties of  constitution,  flexions  produce  symptoms 
which  cannot  be  explained  by  the  accompanying 
condition  of  the  uterine  structures,  which  can 
only  be  relieved  by  mechanically  supporting  the 
dislocated  womb,  and  frequently  are  so  relieved 
in  the  most  remarkable  manner.  It  is  unques- 
tionable, however,  that  marked  flexions  often 
exist  without  producing  any  appreciable  symp- 
toms, and  as  these  are  onlyfound  out  accidentally, 
when,  from  some  other  cause,  an  examination  is 
made,  it  is  not  improbable  that  such  cases  aro 
much  more  common  than  is  generally  supposed. 
Upon  the  whole,  the  writer  is  inclined  to  think 
that  displacements  are  rather  the  result  than  the 
cause  of  the  associated  morbid  state  of  the 
uterus,  and  that  one  of  the  chief  elements  of 
treatment  is  to  get  rid  of  ths  congested,  hyper- 
trophied, or  sub-involuted  state  of  the  organ 
which  produces  them.  But  even  if  this  be  ad- 
mitted, it  by  no  means  follows  that  proper  me- 
chanical support,  is  not  needed.  So  far  from  this 


WOMB,  DISEASES  OF. 


being  tlie  case,  the  writer  believes  it  to  be  of  the 
greatest  possible  value  in  supporting  and  steady- 
ing the  overweighted  and  misplaced  organ,  there- 
by facilitating  the  removal  of  its  morbid  states, 
as  well  as  relieving  its  most  urgent  symptoms. 

Properly  speaking,  displacements  of  the  ute- 
rus should  be  divided  into  two  classes,  versions 
and  flexions.  In  the  former  the  body  of  the 
uterus  retains  its  normal  shape,  but  not  its 
sormal  direction,  the  entire  organ  being  displaced 
either  forwards  (ante-version),  backwards  ( retro- 
version),  or  to  one  side  [later o-version).  In  the 
latter  the  shape  of  the  uterus  is  altered,  and  its 
body  is  more  or  less  acutely  bent  over  the  cervix 
in  the  form  of  a retort,  producing  the  analogous 
conditions  of  ante-flexion,  retro-flexion,  or  latero- 
flexion.  But  these  states  are  very  closelyrelated 
to  each  other.  Very  often  they  are  combined, 
they  arise  from  similar  causes,  and  they  produce 
similar  results.  For  the  sake  of  brevity,  there- 
fore, the}’  will  be  discussed  together. 

/Etiology  and  Pathology. — In  order  to  un- 
derstand how  uterine  displacements  are  pro- 
duced, it  is  necessary  to  remember  the  means 
by  which  the  uterus  is  maintained  in  its  natural 
position.  In  the  healthy  state  the  uterus  is 
situated  high  in  the  pelvic  cavity,  its  fundus 
projecting  somewhat  above  the  plane  of  the 
pelvic  brim,  to  the  axis  of  which — that  is,  to  a 
line  drawn  from  the  umbilicus  to  the  coccyx — - 
its  own  axis  corresponds.  It  is  maintained  in 
this  position  partly  by  the  muscular  column  of 
the  vagina  below,  on  which  it  is,  as  it  were, 
poised;  partly  by  the  folds  of  the  peritoneum 
forming  Douglas’s  pouch  behind,  especially  that 
portion  of  them  called  theutero-sacral  ligaments; 
and  partly  by  fibrous  portions  of  pelvic  fascia  in 
front,  attached  to  the  pubes  and  passing  by  the 
side  of  the  bladder.  These  are  fixed  to  the 
uterus  aba  n the  points  of  junction  of  the  internal 
os  with  its  body,  which  is,  therefore,  the  part  of 
the  organ  least  liable  to  change  of  position,  and 
that  at  which  flexions  almost  invariably  take 
place.  The  fundus  and  body  are  much  more 
mobile,  but  their  movements  are  somewhat  con- 
trolled by  the  round  ligaments  in  front,  and  the 
broad  ligaments  at  the  side.  The  shape  of  the 
uterus  is  further  maintained  by  the  well-marked 
inherent  rigidity  of  its  tissue,  and  when  this  is 
altered  by  disease,  or  by  congestion,  sub-involu- 
tion, and  the  like,  displacements  are  much  more 
apt  to  occur.  The  axis  of  the  uterus  is  naturally 
apt  to  alter  its  position  under  various  conditions. 
Thus  it  falls  less  or  more  forwards,  according 
as  the  bladder  is  distended  or  otherwise.  The 
uterus  is  also  so  placed  that  it  ascends  or  de- 
scends with  more  or  less  freedom,  and,  as  it  does 
so,  its  axis  corresponds  with  the  axis  of  the  plane 
of  that  part  of  the  pelvis  in  which  it  lies.  This 
fact  has  been  especially  pointed  out  by  the  late 
Dr.  Squarey,  and  it  goes  far  to  explain  why  simi- 
lar causes  should  at  one  period  produce  a forward, 
and  at  another  a backward,  displacement.  The 
causes  of  displacements  are  chiefly  any  conditions 
which  weaken  the  supports,  or  the  resisting 
power,  of  the  uterus.  They  are,  therefore,  most 
frequently  found  in  association  with  the  results 
of  parturition,  sub-involution,  congestion,  hyper- 
plasia, and  endo-metritis,  which  all  diminish  the 
inherent  tonicity  of  the  uterine  walls,  as  well  as 


17S3 

weaken  its  supports,  and  prevent  its  regaining 
its  natural  shape  when  accidentally  altered.  The 
displacement  itself  may  be  caused  or  favoured  by 
a variety  of  conditions,  such  as  blows,  falls,  tight 
clothing,  fibroid  tumours  developed  in  the  uterine 
walls,  and  many  other  analogous  states.  When 
a flexion  has  been  produced,  the  venous  capil- 
laries at  the  point  of  flexion  are  more  or  less  ob- 
structed, and  the  return  of  blood  through  them 
hindered,  while  the  arteries  continue  to  supply 
blood.  The  fundus,  therefore,  becomes  congested, 
and  subsequent  structural  alterations  are  de- 
veloped. This  point  has  been  insisted  on  by 
Dr.  Graily  Hewitt,  and  there  can  be  no  doubt  of 
its  accuracy.  This  explains  the  fact  that,  ever, 
when  flexions  are  secondary,  it  is  impossible  to 
treat  them  satisfactorily  by  general  means  alone, 
and  that,  in  course  of  time,  a flexion,  original  ly 
secondary  in  its  causation,  may  require  to  be  the 
chief  object  of  treatment. 

Symptoms. — The  symptoms  of  flexion  of  the 
uterus  are  in  no  way  special.  They  are  very 
much  those  which  have  already  been  described 
as  accompanying  the  inflammatory  varieties  of 
uterine  disease,  and  there  are  none  which  would 
enable  the  practitioner  to  foretell  its  existence 
with  certainty.  Amongst  those  most  commonly 
observed  are  pain,  weight,  and  bearing  down, 
often  decidedly  increased  by  exercise  of  any  kind, 
not  unfrequently  rendering  locomotion  an  impos- 
sibility; pain  in  one  orother  ovarianregion ; pain, 
and  sometimes  difficulty,  in  micturition ; and 
various  disorders  of  the  menstrual  function,  more 
especially  dysmenorrlicea  and  menorrhagia.  After 
these  have  lasted  some  time  the  secondary  de- 
rangements of  the  general  health,  so  common  in 
uterine  disease,  become  established,  and  they 
lead  to  very  serious  consequences. 

Diagnosis. — The  diagnosis  of  displacements 
is  not  difficult  on  vaginal  examination.  Sup- 
posing we  have  to  do  with  a flexion,  the  cervix 
is  found  in  its  normal  position  ; but  either  in 
front,  behind,  or,  more  rarely,  at  either  side,  is  a 
rounded  swelling  about  the  size  of  half  an  orange, 
which  can  be  pushed  away  by  the  examining 
finger.  This  might  be  confounded  with  various 
other  conditions,  such  as  small  uterine  fibroids, 
inflammatory  exudation,  lisematocele,  small  ova- 
rian tumours,  &c.  The  diagnosis  can,  however, 
be  readily  cleared  up  by  the  sound,  which  will 
only  pass  in  the  direction  in  which  the  uterus  is 
flexed ; and,  on  turning  it  gently  and  cautiously 
round,  the  flexed  fundus  is  lifted  with  it,  and  can 
no  longer  be  felt  in  its  former  position.  In  ante- 
or  retro-version,  in  addition  to  feeling  the  body  of 
the  uterus  in  its  abnormal  situation,  we  also  find 
that  the  cervix  is  lifted  out  of  its  usual  central 
position,  and  points  either  forwards  or  backwards. 

Treatment. — In  arranging  a plan  of  treat- 
ment for  uterine  displacements,  the  concomitant 
conditions  should  be  carefully  attended  to,  and 
endometritis,  congestion,  and  other  complica- 
tions relieved,  if  they  exist.  Unless  this  is  done, 
the  treatment  may  entirely  fail,  or  may  be  very 
unnecessarily  prolonged.  Here  we  must  limit 
ourselves  to  a very  brief  description  of  the  best 
plans  of  mechanical  treatment,  strongly  insisting, 
however,  that  they  should  not  be  too  exclusively 
relied  on.  In  backward  displacements  w-e  have  a 
very  satisfactory  means  of  supporting  the  mis' 


WOMB,  DISEASES  OF. 


178-1 

placed  organ  in  tlie  well-known  Hodge's  pessary 
numerous  modifications  of  which  exist.  The 
important  point  to  hear  in  mind  is  to  select  an 
instrument  not  too  bulky,  nor  too  long  for  the 
individual  ease ; the  best  material  being  either 
wire  covered  with  soft  india-rubber,  vulcanite,  or 
Britannia-metal.  The  treatment  often  fails  from 
want  of  proper  selection  ; since  a pessary,  to  be 
thoroughly  useful,  should  be  fitted  as  accurately 
as  a 6hoe  to  a foot.  Before  introducing  it  the 
sound  should  be  gently  passed,  and  the  uterus 
replaced  and  held  in  its  proper  direction  for  a 
few  minutes  ; and  this  manoeuvre  should  be  re- 
peated at  intervals  of  about  a week,  until  the 
uterus  does  nut  re-assume  its  abnormal  position. 
Even  then,  however,  tho  pessary  should  be  worn 
continuously  for  several  months,  until  we  feel 
quite  sure  that  tho  misplacement  is  permanently 
relieved.  In  many  cases  relief  is  instantaneous 
and  remarkable ; in  others  the  fundus  is  too 
tender  to  bear  the  pressure  of  the  pessary  at  all. 
When  this  is  the  case  it  should  be  removed,  and 
an  endeavour  should  be  made  to  prepare  the 
uterus  for  tho  use  of  this  support  by  tho  local 
abstraction  of  blood,  hot  irrigations,  the  appli- 
cation of  glycerine  pledgets,  or  sedative  pessaries. 
In  introducing  tho  Hodge’s  pessary,  care  should 
be  taken  to  guide  its  upper  part  into  its  proper 
position  behind  the  cervix,  so  as  to  press  up  the 
fundus;  and,  as  the  case  improves,  a larger  in- 
strument should  bo  introduced,  so  as  to  follow 
up  the  retreatingfundus.  Reposition  of  the  ut  erus 
must,  of  course,  never  be  attempted  if  there  is 
reason  to  think  that  the  fundus  is  bound  down 
by  adhesions,  or  if  the  uterus  is  very  tender.  In 
suitable  cases,  however,  it  materially  facilitates 
the  cure. 

Anterior  displacements  must  be  treated  on 
the  same  principles.  Unfortunately,  wo  do  not 
possess  anything  like  an  equally  good  means  of 
mechanical  support,  and  a thoroughly  efficient 
ante-flexion  pessary  is  still  a desideratum.  After 
trying  a good  many  the  writer  has  come  to  the 
conclusion  that  the  best  is  Dr.  Graily  IlewitUs 
vulcanite  cradle  pessary,  of  a size  suitable  to  the 
case.  It  is,  however,  difficult  to  introduce  and 
remove.  Nor  can  it  always  be  borne.  A well- 
fitting abdominal  belt — and  thebest  is  that  known 
as  the  American  belt— is  often  of  great  assistance, 
by  removing  the  weight  of  the  superincumbent 
intestines.  When  all  other  means  of  restoring  a 
flexed  uterus  fail,  an  intra-uterine  stem  pessary 
may  possibly  succeed.  Great  caution,  however, 
is  necessary,  and  it  should  never  bo  used  unless 
the  patient  is  under  constant  supervision,  so  that 
it  may  be  removed  on  tho  slightest  appearance 
of  undue  irritation.  During  the  treatment  of  all 
flexions,  rest  is  of  paramount  importance,  not 
absolute,  but  as  much  as  possible,  and  exercise 
should  be  very  sparingly  permitted,  and  only  in 
a tentative  manner. 

Prolapsus. — The  only  other  displacement  of 
the  uterus  requiring  special  mention  is  descent 
or  prolapsus,  for  the  corresponding  condition  of 
undue  elevation  is  of  little  practical  importance. 
Descent  of  the  uterus  is  far  from  rare,  and  it 
sometimes  causes  much  discomfort.  In  it  the 
uterus  descends  from  its  normal  position  to  a 
varying  extent,  so  that  the  prolapsus  may  be  only 
partial, or  it  maybe  complete.  When  the  entire 


uterus  lies  without  the  vulva,  along  with  the 
everted  vagina,  the  mass  is  known  as  procidentia 
uteri. 

yEtiology  and  Pathology. — Descent  of  the 
uterus  depends  upon  a variety  of  causes  which 
lead  to  a weakening  of  the  uterine  supports, 
either  from  above  or  below.  These  supports  aro 
chiefly,  above,  the  various  uterine  ligaments,  with 
the  cellular  tissue  of  the  pelvis ; below,  the  mus- 
cular column  of  the  vagina.  When  from  any 
cause,  such  as  imperfect  recovery  after  child- 
birth, senile  absorption  of  adipose  tissue,  or 
rupture  of  the  perinseum  tending  to  prolapse  of 
the  vagina,  they  are  no  longer  able  to  sup- 
port the  uterus  efficiently,  a comparatively  slight 
cause  may  suffice  to  allow  the  womb  to  be 
pushed  or  drawn  out  of  its  place,  as,  for  example, 
straining,  lifting  heavy  weights,  undue  weight 
of  the  organ  itself,  and  many  other  causes.  As 
soon  as  the  organ  is  prolapsed,  to  whatever  de- 
gree this  may  occur,  various  morbid  alterations 
are  pretty  sure  to  follow.  The  uterus  becomes 
irritated,  congested,  and  hypertrophied  ; and  the 
everted  mucous  membrane  of  the  vagina,  which 
then  covers  it,  becomes  greatly  altered,  and 
assumes  almost  the  appearance  of  skin.  The 
most  characteristic  change,  however,  is  generally 
elongation  of  the  cervix,  through  traction  from 
below,  especially  in  cases  in  which  prolapse  fol- 
lows previous  doscentof  the  vaginal  walls.  This 
elongation  is  due  to  yielding  of  the  elastic  tissue 
of  the  cervix,  especially  that  portion  above  the 
roof  of  the  vagina,  which  becomes  greatly  elon- 
gated, so  that  the  sound  introduced  into  the  pro- 
cident  organ  may  pass  for  six  or  seven  inches. 
When  tho  uterus  is  replaced,  the  normal  elasticity 
again  comes  into  play,  and  the  cervix  rapidly 
contracts.  This  is  the  condition  described  by 
Hugier  as  hypertrophic  dovgation  of  the  cervix, 
and  it  is  rarely  absent. 

Symptoms  and  Diagnosis. — The  symptoms  of 
prolapso  of  the  womb  are  mainly  due  to  the 
mechanical  discomfort  attending  it,  such  as 
weight,  difficulty  in  progression,  interference 
with  micturition,  and  much  general  inconveni- 
ence. The  diagnosis  is  a matter  of  no  difficulty. 
In  the  greater  degrees  the  proeident  organ, 
covered  with  the  hardened  and  altered  vaginal 
mucous  membrane,  is  at  once  apparent.  The 
only  condition  it  is  at  all  likely  to  be  confounded 
with,  is  old-standing  inversion  of  the  uterus,  and 
from  this  mistake  the  presence  of  the  os  uteri 
at  the  apex  of  the  tumour  will  at  once  guard 
us.  In  the  slighter  degrees  the  cervix  will  be 
felt  low  in  the  vagina,  or  even  at  its  orifice. 

Treatment. — The  treatment  comprises  two 
principal  indications  -.-First,  rest,  and  consequent 
reduction  of  the  size  and  weight  of  the  proeident 
organ  ; thereby  greatly  facilitating  the  second  in- 
dication, namely,  re-position,  and  maintenance  of 
the  uterus  in  its  normal  position.  The  effect  of 
mere  rest  in  diminishing  the  size  of  a prolapsed 
uterus  is  often  very  remarkable.  A week  or 
ten  days  in  bed  will  often,  of  itself,  reduco  tho 
cervical  elongation  to  a considerable  amount. 
Re-position  is  generally  easily  effected,  and  the 
chief  difficulty  is  in  support.  In  devising  me- 
chanical contrivances  for  keeping  the  uterus  in 
position,  the  chief  thing  to  bear  in  mind  is  that 
we  should  strengthen  the  natural  uterine  sup 


WOMB,  DISEASES  OF.  1785 


ports,  so  that  they  may  regain  their  lost  power 
of  keeping  the  organ  in  its  place.  Hence  the 
old  ring  or  ball  pessaries,  which  greatly  distend 
the  vagina,  are  absolutely  inadmissible.  In  the 
slighter  degrees  an  ordinary  Hodge  may  answer 
every  purpose,  an  endeavour  being,  at  the  same 
time,  made  to  give  better  support  from  below. 
This  is  generally  best  done  by  a perineal  pad, 
and  also  sometimes  by  using  an  astringent  to 
the  vagina,  so  as  to  make  it  a more  efficient 
column  of  support,  such  as  alum  of  oak-bark 
injections.  In  the  greater  degrees  the  best  kind 
of  pessary  is  that  known  as  the  ‘ vaginal  stem,’ 
which  is  in  the  shape  of  the  cup  of  the  ordinary 
toy  known  as  the  cup-and-ball,  on  the  extremity 
of  which  the  cervix  rests,  the  other  end  being 
attached  to  a perineal  band.  If  this  does  not 
answer,  the  pessary  known  as  Swancke's  may 
succeed.  This  has  the  advantage  of  support- 
ing the  uterus  without  unduly  distending  the 
vagina.  Those  measures  are  merely  palliative, 
and  a more  radical  cure  may  be  hoped  for  by 
various  operative  procedures,  into  the  details  of 
which  it  is  impossible  to  enter.  It  may  suffice 
to  say  that  they  consist  of : — First,  tile  removal 
of  a small  portion  of  the  elongated  cervix,  either 
by  the  galvano-caustic  wire  or  the  ecraseur,  in 
the  hope  of  stimulating  the  remainder  to  con- 
tract, a procedure  only  occasionally  required,  but 
sometimes  of  undoubted  utility.  Secondly,  the 
making  of  a new  perinaeum,  incases  in  which  the 
prolapse  seems  secondary  to  undue  descent  of 
the  vagina — a very  valuable  resource.  Thirdly, 
narrowing  of  the  vagina  itself,  for  which  a 
variety  of  operations  are  practised,  which,  like 
romoval  of  a portion  of  the  cervix,  are  rarely 
required. 

3.  Malignant  Disease. — Malignant  diseases 
are  of  common  occurrence  in  the  generative 
organs  of  females,  and  indeed  they  are  more 
often  met  with  in  these  than  in  any  other  part 
of  the  body. 

-ZEtiology. — Malignant  disease  of  the  uterus 
is  most  common  about  the  middle  period  of  life, 
the  largest  number  of  cases  occurring  between 
forty  and  fifty  years  of  age.  Occasionally  we 
meet  with  rapidly  advancing  cases  in  younger 
women  under  thirty  years  of  age,  or  in  old 
women  who  have  long  ceased  to  menstruate. 
Hereditary  predisposition  apparently  plays  some 
part  in  its  production,  but  not  so  much  as  was 
formerly  believed.  Frequent  child-bearing  has 
a decided  influence  in  favouring  its  development, 
since  the  proportion  of  cases  is  larger  in  multi- 
parse. To  this  may  be  added  any  causes  of  con- 
stitutional debility,  since  it  unquestionably  occurs 
more  often  in  weak  and  unhealthy  than  in  strong 
and  robust  women. 

Anatomical  Characters. — All  the  recognised 
forms  of  malignant  disease  occur  in  the  uterus, 
but  some  of  them  are  more  common  than  others. 
Seirrhus  is  that  which  is  least  frequently  ob- 
served, and  the  medullary  caVcinoma  most  often. 
Klebs,  however,  has  pointed  out  that  in  the 
earliest  stages  of  carcinomatous  disease  the 
fibrous  element  preponderates  in  the  affected 
part;  while,  as  the  malady  progresses,  cell-growth 
rapidly  advances,  so  that  in  old-standing  cases, 
and  on  post-mortem  examinations,  the  medullary 
carcinoma  is  that  which  is  found,  although,  at 


first,  the  scirrhous  form  may  probably  have  ex- 
isted. Another  common  variety  of  malignant 
disease  is  the  epithelial  cancer,  which  chiefly 
affects  the  mucous  membrane  of  the  cervix.  The 
so-called  colloid  cancer  is  rarely  met  with.  In 
the  large  majority  of  cases  the  cervix  is  the 
part  first  affected,  although,  in  exceptional  in- 
stances, the  disease  may  originate  in  the  body 
of  the  uterus,  the  cervix  being  at  first  unim- 
plicated. 

At  the  commencement  of  the  more  ordinary 
variety  the  cervix  is  hard,  somewhat  nodular, 
and  hypertrophied.  It  is  comparatively  rare 
for  the  disease  to  be  seen  at  so  early  a stage, 
and,  as  the  uterus  is  then  quite  movable,  it 
is  impossible  to  distinguish  it  from  enlarge- 
ment of  the  cervix  due  to  congestive  forms  of 
disease.  As  the  disease  progresses,  the  carcino- 
matous degeneration  advances  rapidly;  more 
and  more  tissue  is  involved;  and  the  roof  of  the 
vagina  becomes  implicated,  so  that  the  uterus  is 
fixed  in  a mass  of  new  growth.  Before  long  a 
destructive  process  commences  ; portions  of  the 
growth  slough  and  come  away ; haemorrhage  takes 
place  from  theopeningof  vessels;  and,  in  advanced 
stages  of  the  disease,  the  cervix  may  be  entirely 
destroyed,  and  even  the  bladder  or  rectum  opened, 
so  as  to  form  a common  opening  with  the  vagina. 
The  epithelial  variety  of  cancer  commences  on 
the  mucous  surface  of  the  cervix  by  the  growth 
of  its  villi  into  a papillary  tumour,  which,  at 
first,  it  may  be  impossible  to  distinguish  from 
similar  growths  of  a foreign  character.  It  rapidly 
spreads  however,  soon  forming  a fungating  soft 
mass,  not  unlike  the  flower  of  a cauliflower  in 
appearance,  hence  its  popular  name  ‘ the  cauli- 
flower excrescence.’  As  in  medullary  carcinoma, 
destructive  changes  soon  occur  ; ulceration  pro- 
gresses ; and,  as  the  disease  advances,  the  neigh- 
bouring structures  are  implicated.  When  the 
disease  involves  the  more  deeply-seated  tissues, 
post-mortem  examination  shows  that  the  malig- 
nant growth  there  assumes  more  of  the  character 
of  medullary  cancer. 

Symptoms. — The  earliest  sign  that  arouses  sus- 
picion as  to  the  existence  of  malignant  disease  is 
generally  the  occurrence  of  huemorrhage,  at  first 
merely  an  excessive  menstrual  flow,  subsequently 
loss  of  blood,  sometimes  very  great  in  amount, 
at  irregular  intervals.  Sometimes  it  is  brought  on 
by  trivial  causes,  and  a not  unfrequent  complaint 
is  that  it  always  occurs  after  sexual  intercourse. 
Excessive  haemorrhages,  which  are  sometimes 
very  alarming  in  amount,  do  not,  as  a rule,  occur 
until  advanced  stages  of  the  disease,  when  destruc- 
tion of  tissue  is  taking  place.  Another  marked 
symptom  is  profuse  discharge,  often  having  a 
peculiar  and  pathognomonic  feetor,  from  the  ad- 
mixture of  minute  portions  of  sloughing  tissue.  In 
medullary  carcinoma  the  discharge  is  not  usually 
abundant,  but  it  is  sometimes  very  ichorous  in 
character,  producing  excoriations,  intense  pruri- 
tus, or  other  disagreeable  symptoms,  in  conse- 
quence of  its  irritating  property.  In  epithelioma 
it  is  often  very  abundant,  watery  in  character, 
and  tinged  with  blood.  Pain  is  sometimes  ex- 
cessive. The  writer  has  often,  however,  seen 
cases  terminate  fatally  without  any  pain  at 
all.  General  constitutional  disturbance  soon 
results ; the  peculiar  cachexia  of  malignant 


WOMB,  DISEASES  OF. 


17S6 

disease,  is  developed  ; and  the  patient  becomes 
sallow,  emaciated,  and  extremely  debilitated. 

Diagnosis. — In  advanced  cases  vaginal  exami- 
nation at  once  clears  up  the  nature  of  the  case. 
The  cervix  and  roof  of  tile  vagina  are  infiltrated 
with  the  characteristic  hard  growth,  and  the  ute- 
rus is  quite  fixed.  If  ulceration  has  advanced,  the 
ragged  broken  edges  of  the  cervix  are  apparent, 
bleeding  on  being  touched,  and  breaking  down 
under  the  finger.  In  a case  of  this  kirid  mistake 
is  hardly  possible.  In  the  earlier  stages,  before 
fixation  and  ulceration  have  advanced,  error  is 
easy,  and  it  is  far  from  uncommon  to  find  non- 
malignant  alterations  of  the  cervix  which  have 
been  mistaken  for  cancer,  and  even  the  reverse. 
Nothing  but  time  will  clear  up  such  doubtful 
cases,  and  care  should  be  taken  not  to  give  a 
positive  diagnosis,  unless  the  character  of  the 
case  is  marked  and  undoubted.  The  most  diffi- 
cult cases  to  diagnose  are  those  in  which  the  body 
of  the  uterus  is  alone  affected.  Here  haemor- 
rhage, feetid  discharge,  and  recurrent  attacks  of 
spasmodic  pain  (probably  caused  by  the  efforts 
of  the  uterus  to  expel  discharge  collected  in  its 
cavity)  may  arouse  suspicion ; but  nothing  except 
dilatation  of  the  cervix,  and  thorough  explora- 
tion of  the  uterine  cavity,  can  clear  up  the  nature 
of  the  case.  On  account  of  the  friability  of  the 
tissues,  this  must  always  be  done  with  great 
caution.  In  epithelial  cancer  the  soft,  fungating, 
bleeding,  and  easily  broken-down  mass  can  hardly 
be  mistaken  for  anything  else. 

Prognosis. — The  prognosis  is,  of  course,  most 
unfavourable.  There  are,  no  doubt,  a few 
authentic  cases  on  record  in  which  the  patients 
have  recovered  after  amputation  of  the  cervix, 
but  these  are  of  the  utmost  rarity.  In  the  vast 
majority  death  takes  place,  in  a time  varying 
from  a few  months  to  one  or  two  years.  Pro- 
bably the  disease  advances  most  rapidly  in 
younger  patients,  but  few  last  longer  than  two 
years.  Death  takes  place  either  from  exhaustion, 
haemorrhage,  septicaemia,  or  some  other  compli- 
cation. The  writer  has  seen  it  on  one  or-two 
occasions  result  from  uraemia,  the  consequence  of 
occlusion  of  the  ureters  through  extension  of 
the  cancerous  growth. 

Tkeatment. — In  the  large  majority  of  cases 
seen  for  the  first  time  at  an  advanced  stage, 
treatment  must,  of  necessity,  be  palliative  only. 
Here  there  are  two  chief  indications — the  main- 
tenance of  the  general  health;  and  the  relief 
of  pain,  feetor,  or  other  distressing  local  com- 
plications. For  the  former  we  must  rely  mainly 
on  a suitable  diet,  and  the  administration  of 
some  tonic  which  may  be  found  to  agree  with 
the  patient.  The  preparations  of  arsenic,  as  a 
rule,  answer  better  then  either  iron  or  quinine. 
For  the  relief  of  pain  the  use  of  opiates,  either 
in  the  form  of  morphia  suppositories  or  admi- 
nistered subcutaneously,  must  be  our  sheet 
anchor,  and,  when  the  pain  is  severe,  it  may  be 
necessary  to  exhibit  them  in  large  doses.  Feetor 
may  bo  best  arrested  by  the  local  use  of  anti- 
septics. The  plan  which  the  writer  has  found  to 
answer  best  for  the  purpose  is  to  introduce  at 
night  into  the  vagina  a pledget  of  cotton  wool, 
soaked  in  the  glycerine  of  tannin,  to  which  a 
small  quantity  of  the  glycerine  of  carbolic  acid 
has  boen  added,  in  the  proportion  of  about  one 


ounce  of  the  latter  to  eight  ounces  of  the  for- 
mer. This  effectually  destroys  feetor,  while  the 
astringent  property  of  the  tannin  serves  to 
check  unduly  rapid  cell-growth,  and  prevent 
haemorrhage.  In  the  morning  the  vagina  may 
be  syringed  out  with  Condy’s  fluid  and  water. 
Iodoform  pessaries  are  also  extremely  useful  for 
this  purpose.  When  haemorrhage  is  excessive 
local  haemostatics,  such  as  the  diluted  liquor  ferri 
perchloridi,  must  be  used,  and,  if  necessary,  the 
vagina  plugged.  Surgical  treatment  may  be 
adopted,  either  in  the  hope  of  entirely  removing 
the  disease,  or  of  lessening  the  haemorrhage  and 
discharges,  and  so  retarding  its  progress.  Either 
indication  is  most  easily  fulfilled  in  epithelial 
cancer.  AVhen  this  is  limited  to  the  cervix,  when 
there  is  a fair  margin  of  healthy  tissue  between 
the  diseased  portion  of  the  cervix  and  the  body 
of  the  uterus,  amputation  by  the  galvano-caustic 
wire  or  wire  icraseur  should  be  resorted  to,  the 
actual  cautery  being  subsequently  freely  applied 
to  the  stump,  to  destroy,  as  much  as  possible, 
any  infiltrated  cancer-cells.  Even  when  this  fails 
to  prevent  the  recurrence  of  the  disease,  it  will 
certainly  prolong  the  life  of  the  patient,  and 
increase  her  comfort.  In  other  cases  destruction 
of  the  exuberant  growth,  both  in  epithelial  and 
medullary  cancer,  may  be  advantageously  effected 
by  local  caustic  applications,  such  as  strong  solu- 
tions of  chloride  of  zinc,  nitric  acid,  or  bromine. 
Of  late  years  the  same  object  has  been  sought 
by  excising  the  diseased  tissue,  or  by  scraping  it 
away  as  much  as  possible  by  peculiar  scoop-shaped 
curettes  made  for  the  purpose,  after  which  one 
of  the  above-mentioned  caustics,  or  the  actual 
cautery,  may  be  applied.  It  is  in  the  epithelioma- 
tous  form  of  malignant  disease  that  this.proce- 
dure  is  most  valuable,  and  a carefully  performed 
operation  may  prolong  life  for  months  or  years. 
The  more  radical  operations  for  extirpation  of  the 
entire  uterus,  as  practised  by  Freund  andBillroth, 
are  too  little  known  to  justify  discussion  in 
thisplace.  These  procedures,  however  useful  they 
may  be  in  the  earlier  stages  of  the  disease,  are 
clearly  inapplicable  when  it  is  advanced,  and 
when  the  bladder,  rectum,  or  vagina  is  involved 
in  its  spread. 

4.  Tumours.  — (1.)  Fibroid  Tumour. — By  far 
the  most  common  variety  of  uterine  tumours — so 
common  that,  according  to  some  authorities,  it 
is  found  in  60  per  cent,  of  women  who  die  after 
middle  age — is  the  so-called  fibroid  tumour 
(myoma,  fibroma). 

HUtiology. — Fibroid  tumours  are  most  com- 
mon after  twenty  years  of  age,  and  in  certain 
races,  the  African  especially',  they  occur  with 
great  frequency7.  Beyond  this  nothing  is  known 
of  the  causes  which  produce  or  favour  their 
growth. 

Anatomical  Characters. — Fibromata  are 
limited  hypertrophies  of  the  substance  of  the  ute- 
rus, existing  in  the  form  of  more  or  less  globular 
tumours,  contained  loosely  in  a capsule  of  fibro- 
cellular  tissue.  Structurally  they  are  homologous 
with  the  tissue  of  the  uterus  itself,  consisting  of 
connective  tissue,  mixed  with  unstriped  muscular 
fibres.  They  are  found  of  every  size,  varying  from 
dimensions  scarcely  larger  than  a millet-seed,  up 
to  enormous  masses  weighing  as  much  as  fifty 
pounds.  Most  generally7  they  occupy  the  funchit 


WOMB,  DISEASES  OE. 


and  body  of  the  womb,  and  they  are  conveniently 
divided  into  three  classes,  according  to  the  posi- 
tion they  occupy,  namely,  the  sub -peritoneal, 
occupying  chiefly  the  outer  surface  of  the  uterus ; 
the  intra-mural,  chiefly  developed  in  the  sub- 
stance of  the  walls  ; and  the  sub-mucous,  which 
project  into  its  cavity,  and  these  may  be  either 
completely  sessile,  with  a broad  base  of  attach- 
ment, or  they  may  have  become  more  or  less 
pedunculated,  and  then  approach  in  character  to 
the  fibroid  polypi. 

"When  once  formed,  the  future  progress  of 
fibroids  of  the  womb  varies  much.  Generally 
they  are  of  very  slow  growth,  and,  although 
malignant  degeneration  of  their  structure  has 
been  observed  in  rare  instances,  they  most  com- 
monly exist  for  the  rest  of  the  patient’s  life, 
without  giving  rise  to  any  troublesome  effects, 
beyond  those  resulting  from  mechanical  pres- 
sure, provided  they  are  not  accompanied  by 
haemorrhage.  They  are,  however,  subject  to 
certain  occasional  alterations,  such  as  inflam- 
mation and  even  sloughing,  when  mechanically 
injured,  fatty  and  calcareous  degeneration,  and 
even  to  complete  abortion.  The  possibility  of 
their  entire  spontaneous  disappearance  has  been 
strongly  questioned.  The  writer  has  published 
several  instances  coming  under  his  own  obser- 
vation, and  the  fact  is  now  pretty  generally 
admitted,  the  explanation  probably  being  that 
on  account  of  similarity  of  texture  to  that  of 
the  tissues  of  the  uterus,  they  are  subject  to  a 
process  of  involution  like  that  which  the  tissue 
of  the  uterus  undergoes  after  delivery. 

Symptoms.— The  symptoms  of  fibroids  of  the 
womb  depend  to  a great  extent  on  their  position. 
The  sub-peritoneal  and  interstitial  varieties, 
when  not  very  large,  are  often  unaccompanied 
by  any  symptoms  whatever,  and  those  that  exist 
are  chiefly  the  result  of  mechanical  pressure,  such 
as  weight,  difficulty  in  walking,  irritability  of 
the  bladder,  constipation,  and  the  like.  In  the 
sub-mucous  variety,  the  prominent  symptom  is 
haemorrhage,  which  sometimes  occurs  to  a very 
alarming  extent,  and  may  even  put  the  patient’s 
life  in  danger.  The  source  of  the  haemorrhage  is 
probably,  in  the  majority  of  cases,  minute  capil- 
lary vessels  in  the  mucous  membrane  covering 
the  tumour,  which  keeps  up  irritation  and  con- 
gestion in  its  neighbourhood.  It  is  similar  in  its 
origin,  therefore,  to  the  discharge  in  menstru- 
ation, and  is  greatest  in  amount  at  the  menstrual 
period.  The  more  severe  haemorrhages  are  pro- 
bably caused  by  openings  in  various  tissues 
developed  in  the  periphery  of  the  tumour,  where 
the  vessels  are  increased  in  size,  just  as  they  are 
in  pregnancy. 

The  physical  signs  vary  with  the  size  and 
situation  of  the  tumours.  If  large  enough  to 
be  perceptible  on  abdominal  palpation,  they  have 
generally  a more  or  less  rounded  or  lobular  out- 
line, and  a hard,  firm  feel,  without  any  fluctua- 
tion, which  serves  to  distinguish  them  from 
other  varieties  of  abdominal  growth.  Small 
tumours,  however,  growing  from  the  sides  of  the 
uterus,  may  be  easily  confounded  with  other 
conditions,  especially  flexions  of  the  uterus, 
and  deposits  or  exudations  in  its  vicinity,  such 
ns  hsematocele,  or  pelvic  cellulitis  or  peritonitis. 
The  mobility  of  the  uterus,  which  in  the  latter 


1787 

conditions  is  generally  impaired,  and  the  use  of 
the  uterine  sound,  which  shows,  in  tumours,  that 
the  cavity  of  the  uterus  is  considerably  elongated, 
ought  to  enable  us  to  avoid  such  mistakes. 

Treatment. — The  treatment  resolves  itself 
into  medical  and  surgical.  The  former  may  be 
said  to'  be  powerless,  all  the  so-called  absorb- 
ents— iodides,  bromides,  preparations  of  lime, 
Kreuznach  and  other  waters,  being  admitted  to 
be  of  no  reliable  value  whatever.  The  only  plan 
which  merits  further  study  is  the  subcutaneous 
injection  of  ergotine,  in  doses  of  from  gr.  ss.  to 
gr.  j.  daily,  which  is  said  by  Hildebrandt  to  be 
of  great  value,  and  is  favourably  spoken  of  by 
Atthill  and  other  authors.  In  a case  at  present 
under  the  writer’s  care,  in  which  haemorrhage  had 
been  continuous  for  two  years,  and  in  which  a 
mass  of  fibroid  reached  half-way  up  to  the  um- 
bilicus, under  the  continuous  use  of  this  method 
for  several  months,  the  abdominal  tumours  are 
no  longer  to  be  made  out,  although  those  for- 
merly felt  in  the  pelvis  still  exist,  and  the 
haemorrhages  have  entirely  ceased.  In  ODe  or 
two  other  cases  the  writer  has  been  obliged  to 
discontinue  the  treatment,  on  account  of  the 
severe  cutaneous  irritation  the  injections  pro- 
duced. Surgical  methods  of  treatment  are  only 
called  for  when  the  haemorrhages  are  excessive 
and  exhausting.  To  discuss  them  at  length  is 
impossible  in  so  limited  a space,  and  the  writer 
can  do  little  more  than  merely  enumerate  them, 
referring  the  reader  to  any  recent  systematic 
work  for  complete  details. 

a.  Injection  of  styptics  into  the  uterine  cavity, 
such  as  tincture  of  iodine,  or  diluted  tincture 
of  the  perchloride  of  iron,  is  valuable  when  the 
hsemorrhage  is  excessive,  but  a plan  which  should 
not  be  tried  unless  the  cervix  has  been  previously 
dilated. 

b.  Incision  of  the  cervix  is  decidedly  beneficial 
when  the  haemorrhage  is  frequent  and  severe, 
which  is  supposed  to  act  by  allowing  the  uterine 
fibres  to  contract  upon  the  tumour. 

c.  Incision  of  the  capsule  of  the  tumour  itself 
is  useful  in  certain  sessile  tumours  projecting 
into  the  uterine  cavity,  certainly  diminishing 
the  haemorrhage,  and  facilitating  subsequent 
enucleation. 

d.  Removal  of  as  much  as  possible  of  the 
tumour,  with  the  ecraseur  or  galvano-caustic  wire, 
may  be  undertaken,  when  it  is  so  situated  as  to 
be  within  reach. 

e.  Enucleation  is  very  valuable  when  the 
tumour  is  projecting  into  the  uterine  cavity,  and 
is  already  partially  separated  from  its  attach- 
ments. Under  such  circumstances,  it  may  be 
shelled  out  from  its  capsule  en  masse.  The 
operation,  however,  is  difficult  and  severe,  and 
must  be  reserved  for  very  urgent  cases. 

f.  Gastrotomy,  with  the  removal  of  the  mass 
of  the  tumour,  and  even  of  the  entire  uterus— 
is  one  of  the  most  formidable  of  all  operations, 
but  one  which  has  recently  been  occasionally 
successfully  performed,  and  which  is  justifiable 
when  the  patient’s  life  is  seriously  endangered 
from  uncontrollable  haemorrhage. 

g.  The  artificial  production  of  the  menopause 
by  removal  of  the  ovaries  is  an  operation  which 
has  of  late  been  highly  recommended. 

2.  Polypus. — Polypus  of  the  uterus  may  be 


1788  WOMB,  DISEASES  OF. 

considered  in  connection  -with  this  subject,  since 
the  large  majority  of  polypi  are  merely  fibroid 
tumours,  to  a great  extent  enucleated  from  their 
capsules,  and  attached  to  the  uterue  by  a narrow 
pedicle.  There  are,  however,  two  other  varieties 
described,  the  glandular,  and  the  cellular  polypi. 

Anatomical  Characters. — The  glandular 
polypus  is  a localised  hypertrophy  of  connective 
tissue,  rarely  larger  than  an  egg,  and  generally 
attached  to  the  cervix;  the  cellular  is  a hyper- 
trophy of  some  of  the  glandular  structures  of  the 
cervix,  either  of  the  Nabothian  follicles  or  the 
utricular  glands,  and  it  is  generally  of  small  size. 
Fibroid  polypi,  like  fibroid  tumours,  may  be  of 
any  dimensions,  but  they  are  commonly  met  with 
about  the  size  of  a small  pear. 

Symptoms  and  Diagnosis. — Polypi  are  only 
important  because  of  the  haemorrhage  which  so 
frequently  accompanies  them.  When  extruded 
from  the  cervix,  or  growing  from  it,  they  offer 
no  difficulty  in  diagnosis.  Nor  is  there  any 
condition  apt  to  be  mistaken  for  them,  except  a 
chronic  inversion  of  the  womb,  which  can  be 
readily  differentiated  by  tracing  the  pedicle 
through  the  os,  and  finding  that  the  sound  enters 
the  uterus  to  its  usual  depth.  Intra-uterine 
polypi  are  much  more  difficult  to  discover,  and 
here  the  only  plan  is  complete  dilatation  of  the 
cervix,  and  thorough  exploration  of  the  uterine 
cavity.  This  procedure  is  essential  in  all  cases 
of  severe  haemorrhage  resisting  ordinary  hsemo- 
static  treatment. 

Treatment. — When  once  a polypus  has  been 
detected,  the  only  treatment  is  its  removal.  In 
cases  in  which  the  polypus  is  chiefly  in  the 
vagina,  this  is  easy  enough,  the  wire  of  an 
ecraseur  being  passed  round  the  pedicle,  which 
is  separated  in  this  way  from  its  attachment. 
It  is  not  essential  that  the  wire  should  touch  the 
base  of  the  pedicle,  since  the  part  left,  after  the 
bulk  of  the  polypus  is  removed,  always  shrivels 
up  and  disappears.  In  intra-uterine  polypi  it  is 
sometimes  difficult  to  pass  the  wire  round  the 
pedicle,  but  by  thoroughly  anaesthetising  the  pa- 
tient, and  using  a single  wire,  it  can  generally 
be  managed.  No  other  method  of  removing 
polypi  is  so  good.  Excision  may  give  rise  to 
haemorrhage,  and  the  old  method  of  ligature  is 
dangerous  from  the  risk  of  inducing  septicaemia. 

3.  Fibro-cystic  and  Sarcomatous  Tumours. — 
The  only  other  uterine  growths  requiring  mention 
are  the  fibro-cystic  tumours  (cysto-fibroma, 
cysto-sarcoma),  and  the  sarcomatous  tumours. 

The  fibro-cystic  tumour  is  specially  important 
on  account  of  its  great  resemblance  to  cystic  tu- 
mours of  the  ovary,  and  the  extreme  difficulty 
of  differential  diagnosis,  which  is  so  great  that 
probably  there  is  no  ovariotomist  of  any  expe- 
rience who  has  not  mistaken  the  one  for  the 
other.  The  fibro-cystic  tumour  is  afibroid  tumour 
of  the  uterus,  generally  of  the  sub-peritoneal 
variety,  which  has  grown  to  a large  size  from 
the  development  of  cysts  in  its  substance.  This 
is  most  usually  effected  by  degeneration  of  its 
tissue,  which  becomes  liquefied  and  transformed 
into  an  albumino-serous  fluid.  Thus  we  have 
a tumour  partially  solid,  partially  fluctuating — 
although  rarely  so  distinctly  so  as  an  ovarian 
tumour — from  which  fluid  can  be  drawn  by  an 
exploratory  puncture,  and  which  may  obtain  di- 


WOMEN,  DISEASES  OF. 

mensions,  and  produce  constitutional  effects,  net 
less  marked  than  those  of  ovarian  cystic  disease. 
The  differential  diagnosis  may  well  baffle  even 
the  most  expert  gynaecologist.  The  sound  may 
possibly  enable  us  to  ascertain  the  uterine  cha- 
racter of  the  growth,  as  it  enters  for  a consider- 
able length,  and  on  moving  it  the  connection  of 
the  tumour  with  the  uterus  may  he  demonstrated. 
Athill  has  recently  laid  stress  on  the  character 
of  the  fluid  removed  on  puncture  as  diagnostic, 
since,  unlike  ovarian  fluid,  it  coagulates  sponta- 
neously on  standing,  and  on  microscopic  exami- 
nation elongated  fibre-cells,  similar  to  those  of 
the  uterus  itself,  are  found  in  it.  The  prognosis 
of  these  growths  is  unfavourable,  since  they  pro- 
duce all  the  evil  effects  of  ovarian  tumours,  and 
the  risk  attending  their  removal  by  operation, 
which  is  the  only  available  method  of  treatment, 
is  much  greater  than  that  of  ovariotomy. 

Sarcomatous  tumours  of  the  uterus  have  been 
but  little  studied.  They  are  in  many  respects 
like  fibroid  growths,  but  have  a marked  tendency 
to  fungate  and  ulcerate,  and  to  return  after 
removal.  Hence,  they  hold  a place  midway 
between  the  benign  fibroid  and  the  malignant 
cancerous  growths,  and  they  generally  spring 
from  the  uterine  tissue,  like  the  sub-mucous 
fibroids,  but  without  any  distinct  capsule.  The 
symptoms  are  chiefly  those  of  fibroid  in  that 
situation,  namely,  haemorrhage  ; profuse  watery 
discharges,  occasionally  differing  in  character  ; 
and  sometimes  pain,  probably  the  result  of  ute- 
rine contractions.  The  treatment  must  consist 
in  the  removal  of  as  much  as  is  possible  of  the 
tumour  by  the  ecraseur  or  galvano-caustic  wire  ; 
and,  if  the  nature  of  the  tumour  be  ascertained, 
its  attachment  should  be  thoroughly  cauterised 
with  strong  nitric  acid. 

W.  S.  Playfair. 

■WOMEN,  Diseases  of. — Synon, ; Fr.  Ma- 
ladies des  Femmes-,  Ger.  Frauenhrankheiten. 

The  intention  of  this  article  is  to  indicate 
what  is  comprehended  under  its  title  ; to  define 
the  proper  limits  of  the  subject ; toshow  broadly 
the  relations  of  the  subject  to  general  pathology ; 
and  to  set  out  some  connected  points  and  general 
principles  which  could  hardly  be  so  usefully 
stated  in  the  special  articles  into  which  the  sub- 
ject is  necessarily  subdivided. 

It  is  impossible  to  draw  an  arbitrary  line  that 
shall  clearly  separate  what  are  commonly  re- 
garded as  the  special  diseases  of  women  from 
the  domain  of  general  pathology.  The  study  of 
the  diseases  centred  in  the  sexual  system  of 
women  is  no  more  than  the  application  of  gen- 
eral pathology  to  this  particular  system.  Any 
disease  occurring  in  a woman  will  almost  certainly 
involve  some  modifications  in  the  work  of  her 
sexual  system.  On  the  other  hand,  the  ordinary 
or  disturbed  work  of  her  sexual  system  will  in- 
fluence the  course  of  any  disease  which  may  assail 
her,  however  independent  this  disease  may  seem  to 
be  in  its  origin.  Still,  bearing  in  mind  the  fore- 
going fundamental  facts,  it  may  be  stated  broadly 
that  the  diseases  of  women  embrace  more  espe- 
cially those  morbid  processes  and  mechanical 
deviations  of  which  the  principal  seat  is  in  the 
sexual  system,  that  is.  in  the  ovaries,  uterus,  and 
breasts.  Yet  even  this  is  a narrow  and  misleading 


WOMEN,  DISEASES  OF. 


view  to  take.  It  is  do  more  possible  to  imagine 
an  isolated  pathology  of  the  ovaries  or  uterus, 
than  of  the  liver,  kidney,  or  heart.  If  any  one  of 
these  organs  bo  damaged  or  working  imperfectly, 
the  blood,  the  nervous  centres,  the  other  organs, 
the  whole  body  suffer.  No  one  organ  can  with- 
draw itself  from  its  solidarity  with  the  rest.  And 
it  is  often  an  impossible  task  to  analyse  what  ap- 
pears at  first  sight  to  be  a si  mple  case,  say  of  di  s- 
ease  of  the  kidney,  into  its  component  elements, 
and  to  bring  home  to  the  kidney  the  initial  fau.t. 
The  controversy  concerning  arterial  fibrosis, 
heart-disease,  and  Bright’s  disease,  is  a striking, 
but  by  no  means  exceptional,  illustration  of  this 
proposition.  The  same  thing  is  equally  true  of 
many  apparently  special  disorders  of  the  ovaries 
or  uterus.  The  disturbance  in  function  of  these 
organs  may  be  so  obtrusively  prominent  that 
attention  is  concentrated  upon  them  ; and  thus 
we  may  be  led  to  regard  them  as  the  exclusive  or 
principal  seat  of  morbid  action,  and  so  to  expend 
upon  them  our  remedial  care.  The  physician,  in 
search  of  a diagnosis,  is  greatly  guided  by  the 
observation  of  function.  Disturbed  function 
raises  a presumption  that  the  organ  disturbed  is 
itself  at  fault,  and  we  are  instinctively  inclined 
to  help  that  organ  in  its  difficulty.  But  the 
primary  or  efficient  cause  may  be  elsewhere. 
This  is  as  true  of  the  ovaries  and  uterus  as  it  is 
of  the  heart,  kidney,  or  any  other  organ.  One 
illustration  will  suffice.  A woman  suffers  an 
abortion.  There  is  the  uterus  obviously  disturbed 
in  its  function,  acting,  in  fact,  in  an  improper 
manner.  But  we  cannot  in  all  cases  affirm  that 
the  uterus  is  diseased.  The  causes  of  abortion 
are  multitudinous.  An  efficient  cause  may  indeed 
be  found  in  some  mechanical  or  structural  fault 
of  the  uterus  ; but  more  often  it  will  be  found  in 
the  impeded  work  of  some  remote  organ,  or  in  an 
empoisoned  state  of  the  blood.  Nor  is  any  case 
often  simple.  Commonly  several  causes  concur, 
local  conditions  acting  and  reacting  upon  each 
other.  Thus,  when  the  immediate  cause  is  found 
in  some  alteration  of  tissue  in  the  uterus,  we 
may  still  have  to  look  for  the  original  cause  in 
some  antecedent  constitutional  disorder,  for 
example,  struma  or  syphilis,  inherited  or  ac- 
quired, or  perhaps  in  some  long  past  transient 
morbid  process,  whose  action  can  only  be  traced 
back — if  traced  at  all — through  the  fallacious 
records  and  conjectures  of  history.  Nor  even 
then  shall  we  be  justified  in  concluding  that  we 
have  discovered  the  whole  secret  of  the  abortion, 
that  we  are  masters  of  the  situation,  able  to  take 
a right  view  of  its  clinical  significance,  and  com- 
petent to  deal  with  it  on  rational  principles. 
Abortion  is  not  seldom  a conservative  process,  a 
remedy  adopted  by  Nature  to  avert  urgent  dis- 
tress in  the  circulation  or  in  vital  organs.  There 
may  be  no  appreciable  disease  in  the  uterus  or 
embryo  ; but  the  embryo  is  cast  out,  the  uterus 
is  emptied,  in  order  to  relieve  the  system  of  a 
source  of  danger.  Here,  then,  is  proof  of  the 
danger  of  treating  disorders  of  the  sexual  organs 
as  a detached  bit  of  pathology. 

Here  we  may  make  particular  application  of 
a general  law.  The  case  may  be  formulated 
aphoristically.  An  organ  so  made  to  work  against 
obstruction,  in  excess,  or  in  an  unnatural 
manner,  is  prone  to  organic  disease.  This  is 


1789 

remarkably  true  of  the  uterus.  It  may  be  said 
indeed  that  a very  large  proportion  of  the  struc- 
tural abnormalities  of  the  uterus  arise  in  this 
way.  Hence  the  importance  of  looking  at  dis- 
turbed function,  not  necessarily  as  evidence  of 
disease  of  its  correlated  organ,  but  always  as  a 
warning  that  disease  of  that  organ  is  in  course 
of  induction  or  of  aggravation.  This  applies 
most  strongly  to  the  history  of  dysmenorrhma, 
in  which  the  transition  from  physiology  in  diffi- 
culty into  pathology  is  often  conspicuously  ma- 
nifested. 

The  widest  and  perhaps  the  best  definition  of 
the  subject  is  expressed  in  the  word  ‘ Gynaeco- 
logy.’ It  embraces  indeed  far  more  than  is 
expressed  in  the  term  ‘ diseases  of  women.’  In 
its  full  etymological  meaning  it  is  comprehensive 
beyond  the  strict  domain  of  medicine  ; but  expe- 
rience and  thought  will  show  that  it  does  not  go 
beyond  the  philosophical  conception  of  the  care 
of  the  ‘ health  of  women.’  Without  accepting 
the  doctrine  of  Michelet,  that  the  life  of  woman 
is  a history  of  disease,  it  is  undeniable  that  to 
appreciate  justly  the  pathology  of  woman  we 
must  observe  her  in  all  her  social  relations,  study 
minutely  her  moral  and  intellectual  characteris- 
tics— that  we  must,  in  short,  never  fora  moment 
lose  sight  of  those  physical  attributes  which  in- 
delibly stamp  her  as  woman,  which  direct,  con- 
trol, and  limit  the  exercise  of  her  faculties.  This 
collateral  study  is  of  infinitely  more  importance 
in  the  pathological  history  of  woman  than  it  is 
in  that  of  man.  Avery  large,  perhaps  a prepon- 
derating, proportion  of  all  the  diseases  to  which 
vomen  are  subject,  arise  out  of,  or  are  in  inti- 
mate reactive  relation  with  the  play  of  her  sexual 
system.  The  key  to  many  of  the  disorders  of 
woman,  especially  of  the  nervous  system,  will  be 
found  here.  The  essence  of  her  mental  life  is 
responsiveness  ; the  emotional,  the  reflex,  or 
diastaltic  functions  play  an  infinitely  more  active 
part  than  in  man.  It  may  further  be  said  that 
the  reciprocal  action  of  the  brain  and  spinal 
cord  and  ganglionic  nerves  is  quicker  and  more 
intimate  than  in  man,  especially  that  the  brain 
is  more  strictly  subservient  to  the  animal  func- 
tions. Abstraction  from  corporeal  impulse,  initia- 
tion, enterprise  are  masculine  faculties. 

There  is  one  prima-facie  limitation  of  the 
subject.  The  proper  diseases  of  woman  occur 
during  her  sexual  life ; that  is,  during  the  func- 
tional activity  of  the  ovaries,  uterus,  and  breasts. 
Before  this  epoch  sets  in  the  female  is  not  ? 
woman  but  a child;  and  when  this  epoch  is  over, 
those  organs  shrivel  up  and  no  longer  affect 
the  system  as  before.  Practically,  how'ever,  th< 
physical  defects  of  the  sexual  organs  in  course  oi 
development,  as  in  girls,  and  in  course  of  atrophic 
degeneration,  as  in  old  women,  are  so  closely  re- 
lated by  continuity  of  history  with  their  state  in 
the  epoch  of  functional  activity,  that  all  three 
epochs  are  but  linked  chapters  of  the  same  history. 
To  cut  out  arbitrarily  the  consideration  of  the 
child  and  the  old  woman  must  needs  invalidate 
our  knowledge  of  the  physiology  and  pathology 
of  the  woman  proper.  But  for  the  gynecologist 
this  study  need  not  embrace  more  than  the 
development  and  diseases  of  the  sexual  organs. 
In  the  child,  and  up  to  the  advent  of  puberty, 
these  diseases  are  few',  and  may  be  regarded  as 


1700 


WOMEN,  DISEASES  OF. 


accidental.  The  developmental  faults  even  rarely 
acquire  importance  until  the  advent  of  puberty. 
Then  if  the  organs  are  faulty,  and  their  relations 
to  surrounding  organs  are  abnormal,  the  perform- 
ance of  their  functions  may  be  so  hindered  that 
distress  may  ensue  in  the  organs  themselves,  in 
their  immediate  surroundings,  or  in  distant 
organs  ; or  disorders  of  hiematosis,  nutrition,  or 
other  general  processes  may  he  induced.  In  the 
old  -woman  the  sexual  organs,  having  fulfilled 
their  functions,  undergo  what  may  called 
senile  atrophy.  The  ovaries,  the  uterus,  the  va- 
gina often,  and  the  breasts  shririk  : they  are  no 
longer  the  centres  of  active  nervous  and  blood 
distribution;  they  become  inert,  and  henceforth 
exercise  hut  feeble  influence  upon  the  general 
organism.  Unhappily  this  normal  course  is  not 
always  observed.  Towards  the  climacteric  there 
is  too  often  developed  a tendency  to  certain  mor- 
bid processes  in  the  ovaries,  uterus,  vagina,  and 
breasts,  which  compel  the  attention  of  the  gynae- 
cologist. Instead  of  undergoing  what  may  be 
described  as  the  normal  process  of  quiet  extinc- 
tion, their  tissues  exhibit  aberrant  forms  of  nu- 
trition and  degeneration,  as  fibroma  or  cancer, 
and  then  again  the  pelvic  organs  become  active 
foci  of  blood-distribution  and  growth,  entail- 
ing local  distress,  and  general,  it  may  be  life- 
imperilling,  disorder.  And  even  when  no  mor- 
bid tissue-change  occurs,  -when  the  organs  yield  to 
the  process  of  extinction,  various  phenomena 
commonly  show  themselves,  always  more  or  less 
distressing;  and  which  often  assume  pathological 
import.  The  sexual  apparatus  no  longer  domi- 
nating the  system,  tho  balance  of  healthy  action 
and  reaction  being  lost,  the  nervous  force  not 
finding  its  long-aecustom6d  use,  wanders  off  in 
strange  paths,  and  in  its  erratic  play  reveals 
various  nervous  phenomena,  not  seldom  mistaken 
for  special  neuroses — as  neuralgia,  hysteria,  syn- 
copal attacks,  or  vertigo,  or  even  convulsive  at- 
tacks simulating  or  even  merging  into  epilepsy, 
hemiansesthesia,  or  hemiplegia,  single  or  com- 
bined, and  mimicking  apoplexy  or  paralysis;  and 
various  mental  aberrations  more  or  less  rebellious 
to  the  will,  a very  common  phenomenon  being 
enfeebled  memory  and  unsteady  volition.  As- 
sociated or  not  with  some  of  the  foregoing 
phenomena  are  various  subjective  phenomena  of 
sensation.  Illusive  pregnancy — the  pseudocyesis 
of  Mason  Good — is  one  of  the  most  familiar.  Cer- 
tain peripheral  sensations,  as  tingling,  pricking, 
numbness  of  the  limbs,  chilis  and  flushings, 
sometimes  profuse  perspirations,  itching — when 
occurring  in  the  pudenda  assuming  the  character 
of  pruritus — this  in  many  cases  associated  with, 
and  apparently  dependent  upon,  irritating  dis- 
charges from  the  uterus  and  vagina,  the  expres- 
sion often  of  organic  disease,  in  other  cases  with 
glycosuria,  hut  in  all  probably  with  some  pertur- 
bation of  the  glandular  system.  Here  we  see 
proof  of  the  intimate  connection  of  innervation, 
nutrition,  and  glandular  action.  This  origin  of 
glycosuria  is  hut  one  example  of  the  influence  of 
perverted  or  diverted  nerve-force,  in  altering 
the  constitution  of  the  blood,  and  disturbing  the 
work  of  the  glandular  organs.  To  trace  these 
and  their  allied  physiologico- pathological  pro- 
cesses with  any  approach  to  completeness — and 
the  theme  is  tempting — would  lead  us  far  beyond 


the  narrow  scope  necessarily  assigned  to  this 
article.  Here  we  can  only  afford  to  give  them 
a passing  glance.  One  remark  to  emphasize 
the  lesson  the  philosophical  contemplation  of 
them  conveys  is,  that  these  phenomena  taken 
together  are  integral  parts  of  the  play  of  tho 
female  economy,  linking  the  climacteric  and 
senile  epochs  of  woman  with  that  of  her  sexual 
vigour;  that,  occurring  as  they  do  in  subjects 
of  known  sound  organisation,  at  a definite  time 
and  under  conditions  exceptionally  easy  to  trace, 
they  throw  an  independent  and  strong  light 
upon  the  genesis  and  nature  of  like  disorders  in 
the  male,  thus  showing  how  what  is  called  special 
pathology  may  help  to  solve  many  of  the  problems 
of  general  pathology.  If  we  were  to  extend 
this  reasoning  so  as  to  embrace  illustrations 
from  the  processes  of  pregnancy  and  childbed, 
tho  argument  would  he  greatly  strengthened.  We 
should  see  the  strongest  evidence  that  since  sneh 
affections  as  glycosuria  and  albuminuria  may  be- 
gin in  subjects  whose  liver  and  kidneys  are  sound, 
and  disappear  leaving  them  sound,  we  may  cer- 
tainly infer  in  many  cases,  and  so  presumably  in 
more  if  not  in  all,  that  these  and  other  aberrant 
processes  do  not  depend  for  their  origin  upon 
change  in  the  organic  tissue  of  the  organs  which 
appear  to  he  their  immediate  and  necessary  seats. 
These  affections  may  he  defined  as  evidences  of 
disturbance  in  the  work  of  the  system.  To  re- 
gard them  as  disease  is  arbitrary  and  unphilo- 
sophical.  It  may  then  be  safely  affirmed  that  the 
study  of  gynmeology,  pursued  in  a liberal  spirit, 
bears  the  most  instructive  testimony  to  the  law 
which  declares  that  there  is  no  proper  boundary 
between  physiology  and  pathology ; that  patho- 
logy is  but  a chapter  in  the  history  of  physiology ; a 
proposition  which  may  be  otherwise  expressed  by 
the  aphorism;  Pathology  is  simply  physiology  in 
difficulty. 

We  must  hear  in  mind  that  all  the  great 
pathological  processes  may  assail  the  ovaries, 
uterus,  or  breasts;  that  all  the  diatheses  may 
stamp  their  work  upon  these  organs.  And  this 
they  may  do  apparently  primarily  or  with  es- 
pecial activity ; or  secondarily,  in  the  course  of 
the  development  of  the  morbid  process  in  other 
organs,  or  in  the  system  at  large.  Thus  we  are 
familiar  with  cases  of  cancer  starting  to  all  ap- 
pearance in  the  uterus;  the  disease  from  this 
centre  or  focus  invading  the  surrounding  struc- 
tures, and  empoisoning  the  blood.  To  form  a 
just  appreciation  of  these  cases,  it  is  obvious 
that  a clear  knowledge  of  the  general  history  of 
cancer,  as  well  as  of  its  special  local  history,  is 
necessary.  A similar  proposition  may  he  affirmed 
with  regard  to  struma,  although  the  general  and 
local  relations  may  be  more  obscure.  But  the  gynae- 
cologist isfamiliar  with  the  clinical  fact  thaYin  a 
considerable  proportion  of  cases  of  endometritis, 
of  hyperplasia,  and  subinvolution  of  the  uterus, 
and  of  perimetric  inflammations  and  effusions, 
cure  is  extremely  difficult — difficult  beyond  what 
his  experience  of  simple  uncomplicated  cases  of 
nominally  the  same  kind  would  lead  him  to  ex- 
pect. He  may  safely  assume  that  in  a large 
proportion  of  these  cases  there  is  an  underlying 
diathesis,  frequently  the  strumous,  which  stamps 
its  mark  upon  the  tissues,  modifying  the  progress 
of  the  morbid  action,  and  challenging  general 


WOMEN,  DISEASES  OF. 


as  well  as  local  therapeutical  aid.  In  this 
connection  an  incidental  observation  may  be 
made.  Some  of  the  most  obstinate  cases  of  endo- 
metritis and  hyperplasia  the  writer  has  met  with 
were  in  women  who  had  resided  in  the  East,  and 
whose  constitutions  had  been  damaged  by  en- 
demic disease.  These  women  had  in  fact  acquired 
a diathesis  deeply  affecting  the  nutrition  and 
the  tissue-constitution  of  the  body,  which  re- 
vealed its  influence  most  conspicuously  in  the 
uterus,  an  organ  whose  integrity  hadbeen  severely 
tested  by  pregnancy  and  the  ether  conditions  of 
married  life. 

Another  law  is  of  deep  import,  from  a scientific 
as  well  as  from  a clinical  point  of  view.  Almost 
all  the  constituent  elements  of  the  body  are  re- 
presented in  the  uterus,  modified  of  course  in 
arrangement,  and  assuming  certain  peculiar 
characters  in  order  to  subserve  the  particular 
functions  of  the  organ.  But  the  modifications 
so  acquired  do  not  deprive  these  fundamental 
elements  of  their  original  and  essential  proper- 
ties. By  these  fundamental  properties  these 
elements  are  attached  indissolubly  to  general 
pathology ; by  these  specially  adapted  modifica- 
tions these  elements  become  the  seat  of  our  so- 
called  special  pathology.  Thus  the  fibro-muscular 
tissue  of  the  uterus  is  liable  to  all  those  de- 
partures from  the  healthy  type,  as  fibroma, 
myoma,  fibro-myoma,  hyperplasia,  hypertrophy, 
and  the  degenerations,  to  which  like  tissues  else- 
where are  liable.  They  may  indeed  assume 
special  importance  because,  occurring  in  the 
uterus,  they  almost  necessarily  disorder  the 
proper  functions  of  the  organ.  They  belong  to 
the  domain  of  general  pathology  nevertheless. 
But  in  this  special  disturbance  of  function  we  find 
the  special  aspect  of  the  tissue-change.  The 
retention  of  the  essential  properties  of  the  com- 
ponent tissues  of  the  body  is  strikingly  mani- 
fested in  the  vascular,  lymphatic,  mucous,  and 
connective  tissues  of  the  uterus.  They  are  not 
only  subject  to  the  like  physiological  and  patho- 
logical changes  which  the  same  tissues  elsewhere 
are  subject  to  ; they  link  the  pelvic  organs  to  the 
general  system  partly  by  continuity  of  tissue,  as 
especially  in  the  case  of  the  vascular,  lymphatic, 
and  connective  tissues  ; but  they  carry  morbific 
elements  from  the  uterus  into  the  general  system 
by  absorption.  They  thus  are  ‘poison-routes  ’ — 
channels  by  which  poison  or  noxious  matter, 
forming  in,  or  inoculated  in,  them,  enters  the  blood, 
and  thus  empoisons  the  entire  organism.  It  will 
not  escape  attention  that  the  mucous  membrane 
of  the  vagina  and  uterus  is  in  pre-eminent 
degree  exposed  to  contamination  from  external 
sources.  It  is  needless  to  do  more  than  refer 
to  the  direct  infection  from  the  gonorrhoeal  and 
syphilitic  poisons.  The  gonorrhoeal  poison  im- 
planted on  the  mucous  membrane  of  the  vagina 
or  cervix  uteri  sets  up  in  loco  its  specific  inflam- 
mation, and  may  spread  along  the  mucous  tract 
through  the  cavity  of  the  uterus,  and  the  Fallo- 
pian tubes ; and  the  empoisoned  secretion  escaping 
into  the  abdominal  cavity,  may  set  up  a severe 
form  of  pelvic  or  even  general  peritonitis.  The 
syphilitic  poison  in  like  manner,  first  attacking 
the  mucous  membrane,  may  from  this  point  of 
departure  invade  the  general  sytem.  Then  there 
are  the  more  subtle  instances  of  local  and  general 


1791 

syphilisation,  through  an  ovum  impregcatid  by 
the  tainted  male.  The  connective  tissue  again 
is  of  far  more  than  merely  local  importance. 
Like  the  same  tissue  elsewhere,  it  is  a most  active 
poison-route,  mainly  no  doubt  through  its  rela- 
tions with  the  lymphatic  system. 

There  is  a therapeutical  corollary  from  this 
law,  that  deserves  earnest  practical  attention. 
A great  part  of  the  treatment  of  uterine  diseases 
in  which  there  is  change  of  tissue,  as  hyperplasia 
of  the  mucous  membrane  and  muscular  wall,  is 
surgical,  that  is,  it  consists  in  the  topical  applica- 
tion of  caustics,  absorbifacients,  or  antiseptics, 
as  iodine,  carbolic  acid,  bromine,  and  so  forth. 
These  no  doubt  act  in  the  first  place  directly  in 
loco  upon  the  tissues  touched,  modifying  their 
state.  But  what  is  not  so  well  known,  and  is 
rarely  if  ever  designed  or  contemplated,  is  that 
some  remedies  so  applied — notably  iodine — are 
absorbed,  and  thus  may  affect  the  system.  Under 
some  conditions,  as  where  the  mucous  surface 
is  large,  or  when  the  epithelium-investment  is 
lost,  or  where  the  quantity  of  the  agent  is  large, 
and  more  especially  when  the  absorbing  function 
is  in  a state  of  peculiar  activity,  the  general 
intoxication  may  be  excessive,  even  dangerous. 
The  writer  has  seen  the  most  intense  iodism  pro- 
duced in  this  way,  and  cases  are  recorded  of 
poisoning  by  chromic  acid.  But  if  this  law,  and 
the  conditions  under  which  it  acts,  are  borne  in 
mind,  remedies  can  generally  bo  so  applied  as 
to  draw  from  them  both  local  and  constitutional 
benefits  in  the  happiest  manner. 

There  are  two  modes  in  which  iodine,  for 
example,  may  invade  the  system  : first  by  imbi- 
bition or  endosmosis,  the  tissues  becoming  per- 
meated or  soaked  by  the  fluid;  secondly,  by 
absorption  into  the  lymphatics  and  veins.  There 
is  a local  iodism,  and  a general  iodism.  By 
analysis  we  may  resolve  the  complex  action  at 
work  into  the  following  factors ; first,  there  is 
the  direct  mechanical  or  chemical  action  of  the 
iodine  upon  the  surface  touched  by  it ; secondly, 
there  is  the  action  upon  the  submucous  and  mus- 
cular tissues  of  the  uterus,  the  effect  of  their 
permeation ; thirdly,  there  is  the  constitutional 
action  upon  distant  organs,  upon  general  tissue- 
nutrition,  in  which  the  tissues  of  the  uterus 
share,  the  remedy  being  brought  round  again  to 
it  by  the  circulation  ; and  fourthly,  there  is  an 
action  little  thought  of,  from  which  the  most  useful 
effects  have  been  often  unconsciously  drawn — 
namely,  the  antidotal  action  of  the  remedy  topic- 
ally applied  upon  certain  septic  matters  originating 
in  the  uterus,  and  thence  invading  the  system. 
The  same  channel  that  gave  entrance  to  the 
poison  is  made  to  serve  as  a channel  for  the 
antidote.  Thus  the  poison-route  is  in  turn  made 
a remedy-route,  the  antidote  closely  chasing  the 
poison.  The  application  of  this  principle  is 
seen  most  strikingly  in  the  treatment  of  syphilis 
and  cancer,  but  it  may  be  turned  to  useful 
account  in  the  treatment  of  other  morbid  con- 
ditions. 

Pregnancy  and  child-bed  constitute  the  most 
indisputable  part  of  the  territory  assigned  to 
the  gynaecologist.  In  the  careful  study  of  the 
parturient  process,  we  shall  discover  the  secret 
of  many  of  the  disorders  of  menstruation,  and 
arrive  at  a clearer  understanding  of  the  relations 


1792  WOMEN,  DISEASES  OF. 

physiological  and  pathological,  of  the  sexual 
organs  to  the  general  system,  than  could  other- 
wise he  attained.  This  is  to  say,  that  the  study 
of  obstetrics  is  inseparable  from  the  proper  study 
of  the  diseases  of  women.  Parturition  is  the  cul- 
minating point  in  the  functional  work  of  the 
ovaries  and.  uterus,  All  the  other  points  in  this 
work  are  subservient  to  parturition.  It  is  true 
that  in  many  cases  this  ultimate  aim  is  not 
reached.  But  it  is  not  the  less  true  that  this  is 
the  aim  which  Nature  is  always  striving  at. 
She  may  fail  at  any  stage  of  the  journey.  Every 
menstrual  nisus  is  truly  a mimic  or  missed 
pregnancy.  The  points  of  analogy,  or  homology, 
are  striking.  Descending  from  the  observation 
of  parturition  at  term  to  the  observation  of 
premature  delivery  and  abortion,  we  shall  find 
strictly  related  and  similar  phenomena  in  ordi- 
nary menstruation ; and  then  passing  from  the 
ordinary  or  healthy  type  of  parturition  to  the 
so-called  abnormal  types,  again  we  shall  find 
reproduced  homologous  processes  in  the  various 
forms  of  paramenia,  especially  in  dysmenorrhcea. 
And  this  is  so  true  that  the  most  effective  prin- 
ciples of  treatment  flow  from  this  comparative 
study.  Many  cases  of  nervous  disorder,  as 
vomiting,  convulsion,  neuralgia,  such  as  we  see 
in  the  most  definite  relation  to  pregnancy  and 
childbed,  have  their  exact  counterparts  in  seme 
forms  of  dysmenorrhoea ; various  blood-diseases, 
as  ansemia,  septictemia,  thrombosis,  embolism, 
which  we  have  so  many  sad  opportunities  of 
observing  in  childbed,  are  produced  in  the  non- 
pregnant state  from  disturbed  menstruation,  or 
uterine  disease,  notably  from  cancer ; blood- 
poisonings  associated  with  glandular  disorder 
or  disease,  as  glycosuria,  albuminuria,  jaundice, 
simple  and  malignant,  of  which  the  most  striking 
types  occur  in  pregnancy  and  childbed,  find  their 
representation  in  the  non-pregnant  state. 

Making  liberal  allowance  for  the  proverbial 
difficulty  of  framing  definitions  that  shall  be 
proof  against  criticism,  and  against  the  infinite 
complications  of  natural  history,  we  may  cite 
the  following  as  presenting  a minimum  view  of 
the  work  of  the  gynaecologist.  It  embraces  the 
study  and  treatment  of  the  disorders  and  dis- 
eases of  the  female  generative  organs  and  their 
immediate  surroundings — including  pregnancy 
and  parturition,  and  the  disorders  and  lesions, 
general  and  local,  which  result  from  these 
processes. 

We  mny  set  out  some  of  these  heads  more 
particularly,  as  follows  : — 

Scheme  of  the  Diseases  of  Women. 

1.  In  infancy  and  childhood.  Faults  of  de- 
velopment of  the  sexual  organs;  and  the  acci- 
dents from  injury  or  disease  to  which  they  are 
liable. 

2.  At  puberty  and  during  the  virginal  state. 
Some  of  these  are  consequences  of  the  develop- 
mental faults  of  the  first  order;  others  arise 
from  functional  difficulties,  from  diatheses,  &c. 

3.  The  normal  and  abnormal  history  of  preg- 
nancy and  parturition. 

4.  The  injuries  and  diseases  consequent  on 
parturition  and  childbed. 

5.  Mechanical  or  strictly  surgical  affections 
of  the  ovaries,  uterus,  and  vagina,  original  or 
acquired.  These  include  displacements  or  mal- 


WEITEE’S  CEAMP. 

formations  of  the  uterus,  and  diseases  of  the 
ovary  and  broad  ligaments. 

6.  The  disorders  of  senility,  subdivided  into  two 
classes  (a)  Those  of  the  climacteric,  more  im- 
mediately attending  andfollowing  the  menopause. 
(4)  Those  of  senility  proper. 

7.  Those  general  diseases  which  are  strictly 
associated  with  error  of  function  of  the  ovaries 
and  uterus ; and  those  cases  of  general  disease, 
of  which  the  chief  action  is  expended  upon  these 
organs.  The  former  will  include  cases  of  chloro 
ansemia,  &c. ; and  the  latter  cases  of  struma, 
syphilis,  cancer,  &c.,  affecting  the  ovaries,  uterus 
and  vagina. 

8.  The  diseases  of  the  breast,  as  mastitis,  and 
the  conditions  immediately  connected  with  preg- 
nancy, childhood,  and  lactation.  Most  of  tha 
other  diseases  of  this  organ  have  fallen  by  a 
natural  process  of  selection  to  the  surgeon. 

The  special  diseases  of  women  will  be  found 
fully  discussed  in  other  parts  of  this  work 
under  their  respective  headings. 

Robert  Barnes. 

WOODHALL.  in  Lincolnshire. — Commoi 
salt  waters,  containing  iodine  and  bromine.  Set 
Mineral  Waters. 

WOOLSOETEES’  DISEASE.— A form  of 
anthracoid  disease.  See  Pustule,  Malignant. 

WORMS. — This  is  a popular  term,  which  in 
medical  practice  is  applied  in  a restricted  sense, 
as  embracing  only  certain  forms  of  entozoa  oi 
internal  parasites  that  reside  in  the  intestines. 
The  word,  as  thus  employed,  originated  from  an 
entire  misconception  in  regard  to  the  supposed 
affinities  subsisting  between  the  round-worms  or 
lumbricoids  and  common  earth-worms.  Struc- 
turally these  kinds  of  creatures,  though  both 
vermiform,  are  essentially  distinct.  In  a wider 
and  purely  technical  sense,  however,  many  dis- 
tinguished zoologists(Gegenbauer,  Eolleston,&:e.) 
retain  the  term  as  an  expression  of  high  group 
value,  embracing  all  sorts  of  annulose  animals, 
parasitic  and  free.  By  some  practitioners  the 
employment  of  the  term  ‘ worms  ’ merely  signi- 
fies that  a patient  is  suffering  from  ascarides  or 
thread-worms.  See  Entozoa  ; Helminthes  ; and 
Vermes.  T.  S.  Cobbold. 

WRIST-DROP.  — A form  of  paralysis, 
chiefly  affecting  the  extensors  and  supinators  of 
the  wrist,  and  due  almost  exclusively  to  chronic 
lead-poisoning.  See  Lead,  Poisoning  by. 

WRITER  S CRAMP.— Stn-on.  : Scrive- 
ner’s Palsy  ; Fr.  Crampe  dcs  Ecrivains  ; Ger. 
Schrcibckrampf. 

This  disease  may  be  taken  as  the  most  com- 
mon form  and  most  typical  representative  of  a 
class  of  diseases  which  Duchenne  has  called 
‘ functional  impotences.’  In  them  we  find  the 
patient  complaining  of  inability  to  execute  some 
complicated  act,  the  power  to  perform  which 
had  taken  him  perhaps  years  (in  the  case  of 
writing)  to  acquire.  As  a rule  there  is  no 
other  trouble,  and,  as  far  as  the  patient's  ob- 
servation goes,  all  muscular  acts,  however  de- 
licate or  however  complicated,  are  accomplished 
without  difficulty,  with  the  exception  of  one, 
which  unfortunately  is  usually  that  with  which 


W BITER'S  CRAMP. 


ihe  patient  earns  his  living.  Nat  only  have 
cases  of  ‘writer’s  cramp’  been  described,  but 
English  and  foreign  physicians  have  furnished 
accounts  of  ‘ piano-player’s  cramp  ’ in  which  an 
inability  to  strike  chords  with  correctness  is 
present ; of  violinists  who  have  lost  the  power  of 
lidding  the  violin,  and  fingering  with  the  left 
hand  ; of  violoncello-players  who  have  become 
powerless  to  ‘ make  the  nut  ’ with  the  phalan- 
geal joint  of  the  left  thumb  ; of  tailors  who 
can  no  longer  use  the  needle  ; of  dairymen  who 
fail  in  milking  ; of  bricklayers  who  cannot  wield 
the  trowel ; of  smiths  who  cannot  use  the  ham- 
mer; of  compositors  who  cannot  place  the  type  ; 
and  lately  we  have  had  accounts  of  telegraphists 
who  have  become  unable  any  longer  to  work  at 
their  calling.  ‘Writer’s  cramp,’  however,  is  by 
far  the  most  common  of  these  diseases,  and  while 
the  others  which  we  have  mentioned  must  be 
regarded  as  the  rarest  of  medical  curiosities,  the 
one  which  we  have  chosen  to  illustrate  the  class 
is  tolerably  often  met  with. 

Symptoms  and  Course. — The  symptoms  and 
course  in  a typical  case  of  writer’s  cramp  are  as 
follows  : — A clerk,  who  from  his  painstaking  and 
energetic  habits  has  been  tempted  by  his  em- 
ployers to  work  over-time  or  possibly  against 
time,  and  who  perhaps  (as  the  history  of  these 
cases  often  shows)  is  harassed  by  domestic 
troubles,  discovers  that  he  does  not  write  quite 
as  easily  as  he  did,  that  his  hand  possibly  aches 
after  prolonged  writing,  and  he  finds  it  convenient 
to  adopt  some  new  method  of  holding  his  pen. 
At  first  the  trouble  is  hardly  noticeable,  and  then 
he  finds  himself  obliged  to  grasp  his  pen  with 
unusual  tightness  to  prevent  its  becoming  un- 
steady. Then  his  handwriting  begins  to  suffer: 
perhaps  his  forefinger  refuses  to  remain  steadily 
upon  the  penholder,  and  while  he  is  making 
every  effort  to  control  it,  the  pen  somehow  or 
other  eludes  his  grasp  and  falls  from  his  hand. 
If  he  persevere — probably  he  is  one  of  those  who 
would  sooner  die  than  give  in- — his  progress  down- 
hill is  rapid  and  certain.  Every  possible  method 
of  holding  the  pen  is  adopted  by  turns,  such  as 
interlacing  it  between  the  fingers,  grasping  it 
firmly  with  the  whole  hand,  using  only  the  first 
and  second  fingers  without  the  thumb,  or  the 
thumb  and  second  finger  without  the  first,  but 
these  subterfuges  quickly  fail  to  b6  of  service. 
He  cannot  steady  the  pen  by  means  of  them,  and 
he  finds  that  the  arm  rolls  possibly  inwards  or 
outwards,  and  that  he  can  only  form  his  letters 
by  moving  the  whole  arm  from  the  shoulder,  or 
lastly  by  fixing  the  arm  to  the  side  and  swaying 
the  whole  body  to  and  fro.  The  handwriting 
soon  becomes  illegible  ; and  lastly  the  patient  is 
almost  unable,  even  by  the  most  strenuous  efforts, 
to  make  a mark  upon  paper.  To  write  a word 
legibly  in  extreme  cases  is  impossible,  and  there 
are  few  spectacles  more  distressing  than  to  see 
a patient,  whose  handwriting  was  perhaps  his 
means  of  livelihood,  drip  with  perspiration  while 
making  an  ineffectual  effort  to  sign  his  name. 
His  loss  of  writing  power  may  be  his  only 
symptom,  as  was  the  case  with  an  American  suf- 
ferer who  wrote  thus  to  the  writer  : ‘ that  fingers 
which  could  guide  razor  and  needle,  wield  oar  and 
musket,  and,  though  numb  with  cold,  knot  and 
cast  off  reef-points  on  a wet  sail,  should  yet  strike 
113 


1793 

work  when  called  on  for  the  familiar  characters 
of  their  owner’s  name,  seemed  utterly  beyond 
comprehension.’  Patients  should  be  closely 
questioned  as  to  their  ability  to  perform  acts 
other  than  writing.  In  the  writer’s  experience 
it  is  usual  to  find  that  some  other  act  or  acts  is 
affected.  If  the  patient  be  asked  if  he  can  wind 
up  his  watch,  carry  a full  tea-spoon  steadily  to 
his  mouth,  or  perform  some  similar  act  requiring 
a delicate  use  of  the  thumb  and  forefinger,  it 
will  very  commonly  be  found  that  he  has  lost 
his  deftness  in  performing  such  acts,  although 
in  using  a knife  or  wielding  a hammer,  and  in 
performing  functions  requiring  a coarse  use  of 
muscles  other  than  those  used  in  writing,  he 
may  find  no  difficulty  whatever.  Frequently  there 
are  neuralgic  pains,  or  a sense  of  extreme  fatigue 
in  the  hand  and  arm  ; and  in  some  cases  the  effort 
to  write  has  been  followed  by  pain  in  the  back, 
or  severe  headache.  In  some  cases  the  mental 
distress  caused  by  the  loss  of  power  has  pro- 
duced a condition  bordering  on  melancholia. 
Slight  tremor  of  the  hand  is  not  uncommon, 
and  these  tremors  sometimes  occur  independently 
of  writing.  Tenderness  of  the  nerve-trunks 
(median,  ulnar,  or  musculo-spiral)  is  very  often 
present,  and  should  always  be  carefully  looked 
for,  as  indicative  of  congestion  of  the  nerves,  or 
neuritis.  Occasionally  there  is  objective  spasm 
of  some  of  the  muscles  of  the  arm  when  the  effort 
to  write  is  made  ; and  one  case  has  been  reported 
by  the  writer,  in  which  the  symptoms  at  first 
were  those  of  simple  loss  of  writing  power,  but 
which  terminated  in  a general  clonic  spasm  of 
all  the  muscles  of  tho  arm,  apparently  at  hist 
independently  of  any  writing  effort. 

Although  the  above  is  a typical  case  of  ‘ writer’s 
cramp,’  other  cases  are  by  no  means  uncommon, 
in  which  impairment  of  writing  power  supervenes 
quite  independently  of  any  unusual  writing  effort, 
and  even  in  persons  who  have  done  rather  less 
than  an  average  amount  of  writing.  These  latter 
cases  are  not  usually  so  severe  as  the  former, 
since  they  are  not  obliged,  as  is  the  professional 
scrivener,  to  goad  the  unwilling  hand  to  make 
those  efforts  which  are  so  detrimental.  It  has 
been  the  writer’s  experience  too,  that  in  this 
latter  class  of  cases  it  is  more  usual  than  in  the 
former  to  find  that  the  trouble  is  not  very  strictly 
limited  to  the  act  of  writing,  but  that  there  is 
a certain  amount  of  inability  or  clumsiness  in  tho 
performance  of  other  acts  requiring  minuteness 
and  nicety. 

Pathology. — The  morbid  anatomy  of  writer’s 
cramp  is  unknown,  and  consequently  the  pa- 
thology of  the  disease  is  a matter  of  specu- 
lation. Mr.  Solly,  from  the  fact  that  ‘ pain 
ill  the  back  was  a not  unfrequent  concomitant 
symptom,’  was  of  opinion  that  degenerative 
changes  probably  occurred  in  the  spinal  cord, 
which  is  possibly  not  unfrequently  the  case,  the 
failure  of  writing  power  being  merely  the  pre- 
lude to  more  severe  and  more  general  symptoms. 
Dr.  Reynolds  says  : ‘ It  cannot  be  doubted  that 
some  changes  take  place  in  the  nutrition  of  the 
parts  through  which  the  lines  of  nerve-action 
regulating  the  secondarily  automatic  movements 
run.  It  seems  probable  that  the  association  of 
movements  is  effected  by  ganglia  which  are 
common  to  fibres  passing  through  distinct  but 


1794  WRITER’S  CRAMP. 

ro.utiguous  nerve-trunks,  and  that  it  is  owing  to 
Bone  nutritive  ch.mge  in  them,  the  result  of 
persevering  and  foi  ’ed  effort,  tha*'  the  perfection 
of  movement  is  produced  ; associations  at  first 
caused  by  the  will  are  at  length  produced  un- 
consciously. What  happens,  then,  in  such 
maladies  as  writers’  cramp  is  a perverted  nutri- 
tion of  these  parts.’  Duchenne  believes  that  the 
change  is  in  the  nerve-centres  first,  because  local- 
ised faradisation  applied  to  the  hands  has  no 
good  effect  on  the  trouble ; and  he  is  confirmed 
in  this  opinion  because  the  malady  very  quickly 
affects  the  left  hand  if  it  be  usecl  to  supply  the 
place  of  the  right.  The  writer  has  ventured  to 
suggest  that  the  lesion  is,  in  typical  cases  at 
least,  situated  at  the  periphery,  either  in  the 
muscles  themselves,  or  in  the  terminal  motor 
nerves  supplying  these  muscles.  In  real  eases 
of  writer’s  cramp  (the  loss  of  writing  power  oc- 
curring in  an  overworked  scrivener)  it  is  rare  to 
find  any  sign  of  central  change;  neither  wasting 
or  true  paralysis  of  muscle,  nor  fibrillary  tremor, 
cor  general  tremor  of  the  limb,  nor  pain,  nor 
spasm  (except  during,  or  immediately  after,  the 
attempt  to  write).  It  is  generally  observed  that 
the  disease  progresses  from  the  periphery  to- 
wards the  centre  ; that  the  muscles  of  the  fingers 
are  the  first  to  fail,  then  those  of  the  forearm, 
then  those  of  the  arm,  and  lastly,  in  extreme 
cases,  those  of  the  trunk.  It  is  probable  that  the 
muscles  of  pen-prehension,  as  opposed  to  those 
of  pen-movement  (consisting  of  the  adductor 
pollicis,  first  dorsal  interosseous,  &c.)  drift  into 
a condition  of  ‘chronic  fatigue’  owing  to  the 
■prolonged  strain  to  which  they  are  subjected 
when  holding  a pen  for  long  periods  at  a time. 
When  these  normal  muscles  of  pen-prehension 
are  exhausted,  others  are  used  to  supply  their 
place,  such  as  the  superficial  and  deep  flexors  in 
the  forearm,  &c.,  which  in  their'Turn  give  out, 
and  thus  the  trouble  steadily  progresses.  The 
writer  has  had  no  small  experience  of  this  disease, 
and  he  has  never  failed  to  find  that  a careful 
electrical  investigation  of  the  muscles  has  shown 
a certain  diminished  irritability  to  faradisation 
in  the  muscles  of  pen-prehension  on  the  diseased 
side,  when  compared  with  those  of  the  sound  side. 
This  loss  of  irritability  is  due,  in  many  cases,  he 
believes,  to  sheer  over-use  of  the  muscles,  the 
intervals  of  relaxation  between  the  long  periods 
of  contraction  not  being  sufficient  to  allow  of 
their  proper  nutrition.  In  many  cases  of  ‘ writer's 
cramp  ’ no  over-use  of  the  muscles  has  taken 
place,  and  in  such  cases  we  must  suppose  that, 
from  some  condition,  either  constitutional  or 
situated  locally  in  the  nerves,  the  muscles  are  so 
deficient  in  ‘ staying  power  ’ (notwithstanding 
their  ability  to  contract  forcibly  for  a short  time) 
that  they  become  useless,  or  nearly  so,  when 
called  on  for  prolonged  steady  contraction.  It 
is  obvious  that  the  failure  of  one  muscle  (how- 
ever small)  which  had  been  taught,  by  years  of 
laborious  education,  to  act  in  harmony  with  many 
others  for  the  accomplishing  of  a complicated 
and  delicate  act,  such  as  writing,  would  pro  luce 
a true  want  of  co-ordination.  In  other  words 
muscles  which  have  been  induced  to  work  in 
order  together  no  longer  do  so  if  one  of  them  fails, 
:and  the  failure  of  one  must  be  fatal  to  the 
-icccmplishment  of  the  co-ordinated  act. 


WRY-NECK. 

Diagnosis. — Diagnosis  is  of  great  importance, 
since  failure  of  writing  power  is  often  an  early 
symptom  of  disease  the  prognosis  of  which  is 
very  different  from  that  of  ‘ writer’s  cramp.’  Evi- 
dence of  chronic  alcoholism  is  often  afforded  by 
the  handwriting.  So  again  paralysis  agitaDs 
and  disseminated  sclerosis  of  the  spinal  cord 
may  very  early  give  a want  of  steadiness  to  the 
pen.  Dr.  Reynolds  records  a case  of  lead-palsy, 
which  was  sent  to  him  as  a case  of  writer’s 
cramp.  Paralysis  of  any  of  the  nerves  supplying 
the  baud  or  forearm,  such  as  the  ulnar,  median, 
or  musculo-spiral,  will  make  writing  difficult ; and 
the  writer  has  seen  cases  of  progressive  muscular 
atrophy,  in  which  the  shrunken  and  quivering 
interossei  had  made  a firm  grasp  of  the  pen 
impossible. 

Treatment. — The  chief  remedy  is  rest.  'With- 
out it  nothing  can  be  done,  and  if  rest  be  taken 
in  the  earliest  stages  of  the  disease,  complete 
recovery  not  unfrequently  results.  For  such 
writing  as  is  absolutely  necessary,  the  patient 
should  be  advised  to  use  a pencil  or  soft  quill 
pen,  so  that  any  violent  grasp  becomes  impos- 
sible. In  many  cases  the  writer  has  found  the 
rhythmical  exercise  of  those  muscles  whose  irrita- 
bility is  impaired,  together  with  the  employment 
of  a mild  galvanic  current,  of  the  greatest  service, 
and  he  has  recorded  a few  cases  treated  in  this 
way  which  rapidly  improved,  after  having  re- 
sisted every  other  known  method  of  treatment  for 
years.  Injection  of  morphia  is  of  no  use,  but 
in  America  some  good  has  been  said  to  result  from 
the  injection  of  atropine.  If  any  of  the  nerve- 
trunks  be  tender,  these  should  be  blistered. 

G.  V.  Pooek. 

WEY-lfECK.  — Svnon.  : Torticollis;  Fr. 
Torticolis  ; Ger.  Steifcr  Hals. 

Definition. — A twisting  of  the  neck  to  ono 
side. 

Etiology. — Wry-neek  is  a symptom  whieh 
may  be  produced  by  very  different  conditions  ; 
and  it  is  usual  to  distinguish  between  the  va- 
rieties of  this  disease,  which  may  either  be 
congenital  or  acquired. 

The  congenital  wry-ncck  arises  either  from 
fault}'  development  of  the  muscles  on  one  side  of 
the  neck  (in  which  case  there  are  not  unfre- 
quently evidences  of  faulty  development  in  other 
regions  of  the  body,  and  notably  in  the  neigh- 
bouring parts,  such  as  the  face) ; or  from  para- 
lysis of  the  muscles  on  one  side,  often  due  to 
accidental  injury  during  labour.  In  these  cases 
the  head  is  fixed  in  its  abnormal  position.  Ac- 
quired wry-ncck  may  be  a mere  passing  con- 
dition, due  to  ‘ muscular  rheumatism,’  brought 
on  by  exposure  to  cold,  and  under  the  name 
of  ‘ stiff-neck  ’ it  is  familiar  to  everybody  (sec 
Rheumatism,  Muscular).  The  most  formidable 
variety  is  spasmodic  wry-ncck,  which  makes  its 
appearance,  usually  in  persons  otherwise  healthy, 
about  the  middle  period  of  life.  The  mus- 
cles on  one  side  of  the  neck  are  the  seat  of 
spasm,  sometimes  tonic,  but  usually  clonic  in 
character.  The  muscle  chiefly  affected  is  gene- 
rally the  sterno-cleido-mastoid,  and  its  con- 
stantly recurring  contractions  have  the  effect  of 
turning  the  head  away  from  the  sile  which  is 
the  seat  of  spasm  ; drawing  the  occiput  slightlv 


why-: 

downwards,  and  the  chin  slightly  upwards. 
Other  muscles,  such  as  the  scaleni,  splenius,  and 
trapezius,  are  not  unfrequently  affected  also,  and 
then,  in  addition  to  the  rotatory  twisting  of  the 
neck,  we  get  a lateral  downward  bending,  and  an 
deration  of  the  shoulder.  At  the  commencement 
of  the  disease  the  trouble  may  be  slight,  and 
cause  but  a trifling  amount  of  inconvenience,  the 
impressions  produced  on  a bystander  being  that 
the  patient’s  movements  are  caused  by  some  mal- 
arrangement  of  the  dress,  which  he  is  seeking  to 
remedy.  In  its  advanced  form  the  disease  is  a 
very  terrible  one,  and  may  make  life  hardly  sup- 
portable. The  writer  has  seen  one  case  in  which 
the  spasm  was  so  violent,  that  the  constant  for- 
cible impinging  of  the  chin  upon  the  shoulder  of 
the  sound  side  had  produced  a sore  place  as  big 
as  a shilling.  The  spasm  ceases  during  sleep ; 
and  when  the  patient  is  undisturbed,  and  his 
mind  pre-oeeupied,  it  is  not  unusual,  even  in  the 
worst  cases,  for  considerable  remissions  of  the 
symptoms  to  occur.  In  the  presence  of  others, 
especially  strangers,  the  spasm  is  usually  inten- 
sified, and  in  this  it  presents  a striking  simi- 
larity to  stammering  and  writer’s  cramp. 

Pathology. — The  pathology  of  spasmodic  tor- 
ticollis is  very  doubtful.  It  must  be  regarded  in 
almost  all  cases  as  a true  neurosis,  and  must  take 
its  stand  alongside  of  histrionic  spasm  of  the 
face,  writer’s  cramp,  and  stammering.  That  it 
is  due  in  many  cases  to  an  irritable  condition 
of  the  spinal  accessory  nerve  there  can  be  no 
doubt,  but  how  this  condition  of  nerve  is  brought 
about  we  are  unable  to  say.  Want  of  proper 
antagonisation  is  another  factor  which  is  always 
present,  for  without  it  the  symptoms  could  not 
occur.  In  certain  nervous  constitutions  a weak- 
ened action  of  one  sterno-mastoid  would  seem 
of  itself  to  be  almost  sufficient  to  excite  irregular 
contractions  in  its  fellow.  The  writer  has  seen 
one  case  in  which  it  seemed  tolerably  clear  that 
the  sterno-mastoid  and  trapezius  on  one  side 
had  become  weakened  by  overwork,  and  had 
drifted  into  a condition  of  chronic  fatigue,  while 
their  antagonists  were  constantly  in  a state  of 
clonic  spasm,  twisting  the  neck  to  the  weakened 
6ide.  An  electrical  examination  of  the  muscles 
generally  shows  that,  while  those  which  are  the 
seat  of  spasm  have  their  irritability  greatly 
increased,  their  antagonists  are  below  their 
nsrmal  state  as  to  irritability.  Torticollis  is 
usually,  but  not  always,  uncomplicated.  That 
condition  known  as  ‘irritable  spine’  has  been 
observed  in  some  few  female  patients ; histrionic 
spasm,  or  spasm  of  the  limbs,  has  occurred  as  a 
complication,  and  it  is  not  a little  remarkable, 
as  showing  connection  between  the  two  diseases, 
that  Dr.  Eeynolds  has  recorded  three  cases  of 
torticollis  in  which  the  patient  had  suffered  pre- 
viously from  writer’s  cramp.  A difficulty  of 
deglutition  was  observed  in  one  of  Dr.  Beynolds’s 
cases ; and  in  another  there  was  swelling  of  the 
arm,  from  pressure  upon  the  subclavian  vein. 


■NECK.  1795 

Prognosis. — The  prognosis  of  these  cases  is 
bad,  it  being  very  unusual  for  recovery  to  take 
place  after  the  disease  has  become  well  estab- 
lished. 

Diagnosis. — The  diagnosis  of  wry-neck,  as  a 
rule,  is  not  difficult,  but  care  must  be  taken  that 
simple  torticollis  is  not  confounded  with  cases  of 
caries  of  the  cervical  spine,  in  which  there  is 
frequently  a tendency  for  the  head  to  twist  to 
one  side.  It  should  be  borne  in  mind,  also,  that 
in  some  few  eases  of  organic  brain-disease,  in 
which  synergic  movements  of  the  eyeballs  have 
occurred,  a spasmodic  rhythmic  movement  of  the 
neck  has  also  been  observed.  The  other  symp- 
toms of  brain-disease,  however,  would  usually 
prevent  any  such  mistake. 

Theathrnt. — This  necessarily  depends  upon 
the  cause  of  wry-neck.  In  those  cases  in  which 
the  head  is  fixed  by  contraction  or  faulty  de- 
velopment of  the  muscles,  tenotomy  has  been 
of  service,  and  although  it  has  been  practised 
also  in  those  eases  in  which  there  has  been 
definite  clonic  spasm,  and  notwithstanding  that 
temporary  relief  has  in  some  cases  followed,  it  is 
found  that  the  deep-lying  'muscles  are  almost 
certain  to  take  on  a spasmodic  action,  and  that 
in  the  end  the  patient's  discomfort  is  increased 
rather  than  diminished.  Various  mechanical 
contrivances  for  steadying  the  head  have  been 
devised,  but  few  patients  are  able  to  bear  the 
constant  pressure  of  the  apparatus,  and  the 
remedy  has  been  found  in  most  cases  worse  than 
the  disease.  Some  good  has  resulted  from  the 
long-continued  use  of  hypodermic  injections  of 
morphia,  and  Dr.  John  Harley  has  recently  re- 
ported some  cases  which  have  been  greatly 
benefited  by  the  exhibition  of  large  doses 
(yj.  and  over)  of  the  succus  conii.  Electricity 
has  not  been  particularly  serviceable  in  the 
treatment  of  torticollis.  The  galvanic  current 
has  been  used  to  control  the  spasm,  while  the 
weakened  antagonising  muscles  have  been  stimu- 
lated by  faradisation,  and  although  improvement 
has  been  produced  by  these  means,  it  has  gene- 
rally been  of  very  short  duration.  The  writer 
has  lately  had  a very  severe  case  under  his  charge, 
which  was  successfully  treated  by  the  employ- 
ment of  the  continuous  galvanic  current,  com- 
bined with  the  rhythmical  exercise  of  the  affected 
muscles.  The  positive  pole  being  placed  behind 
the  ear,  the  negative  pole  was  applied  over  the 
sterno-mastoid  and  trapezius,  and  at  the  same 
time  the  patient  was  made  to  exercise  these 
muscles  by  shrugging  the  shoulder,  twisting  the 
head,  &c.  The  result  was  very  rapid  and  perma- 
nent improvement.  Another  ease  has  also  been 
no  less  successfully  treated  by  the  writer  by 
faradising  the  antagonist  muscles,  which  were 
somewhat  wasted  and  decidedly  deficient  in  irri- 
tability. This  patient  completely  recovered  ; 
although  tenotomy  of  the  sternomastoid,  which 
was  the  seat  of  spasm,  had  afforded  only  tem- 
porary relief.  G.  V.  Poors. 


X 


^ XANTHELASMA  (Zavdbs,  yellow,  and 
eAcnrga,  a lamina). — A yellow  growth  in  the  su- 
perficial layer  of  the  skin,  assuming  the  form 
of  a lamina  or  plate,  and  more  frequently  met 
with  in  the  eyelids  than  elsewhere.  See  Xan- 
thoma. 

XANTHOMA  (^avObs,  yellow).  — Synon.  : 
Xanthelasma. 

Definition.  — A peculiar  kind  of  yellow 
growth,  originally  observed  in  the  integument, 
but  subsequently  in  the  areolo-fibrous  tissues 
elsewhere, 

/Etiology. — Xanthoma  must  be  referred  to  a 
defect  of  vital  power,  affecting  the  nutrition  and 
growth  of  certain  of  the  tissues  of  the  body — in 
the  present  instance  the  connective  tissue,  and 
especially  that  of  the  surface  membranes  of  the 
body.  A similar  cause  will  serve  to  explain  the 
concentration  of  pigment  which  is  observable  in 
the  integument  of  the  eyelids  in  these  cases.  It 
is  deemed  probable  that  this  affection  may  be 
related  to  a morbid  function,  if  not  to  a morbid 
organic  condition  of  the  liver.  The  latter  organ 
has  frequently  been  found  diseased  in  association 
with  these  cases,  and  in  one  instance  every  organ 
of  the  body  would  seem  to  havo  been  in  a state 
of  disease.  On  the  other  hand,  xanthoma  has 
been  seen  in  persons  apparently  sound  in  every 
other  respect ; therefore  it  would  seem  that 
there  is  nothing  to  prevent  it,  from  affecting  the 
sound  as  well  as  the  diseased.  Some  curious 
cases  have  lately  been  recorded  of  xanthoma  in 
children  in  whom  the  disease  had  been  present 
from  birth  or  early  infancy.  Instances  of  here- 
dity of  the  disease  have  been  noted. 

Anatomical  Characters.  — Pathologically, 
xanthoma  is  a new  growth  of  harmless  character, 
a form  of  degeneration  taking  place  in  the  su- 
perficial integuments — cutaneous,  mucous,  and 
serous,  and  in  some  instances  in  the  subjacent 
areolo-fibrous  tissue.  The  morbid  structure  is 
composed  of  an  areolar  network  of  connective 
tissue,  enclosing  areolce  filled  with  cell-germs, 
and  traversed  by  a scanty  plexus  of  minute  blood- 
vessels. The  process  is  accompanied  by  fatty 
degeneration  of  the  young  cells,  and  the  forma- 
tion of  cholesterine  crystals.  The  papulae  are  not 
due  to  a collection  of  sebum  within  the  follicles, 
as  Hebra  suggested;  neither  is  the  colour  de- 
pendent on  the  absence  of  pigment  in  the  rete 
mucosum,  as  in  vitiligo. 

Description. — Xanthoma  presents  itself  under 
two  forms : first,  as  isolated  nodules,  X.  tuber- 
osum-, and,  secondly,  as  smooth  plates  or  laminae 
of  moderate  dimensions,  X.  planum.  It  is  to 
this  latter  form  that  the  term  ‘ xanthelasma’  was 
intended  to  apply;  and  in  consequence  of  the 
greater  frequency  of  the  disease  in  the  eyelids 
than  elsewhere,  the  term  X.  palpebrarum  was 
inyented  to  distinguish  such  cases  from  those  in 
which  it  occurs  in  both  its  forms,  and  on  other 
parts  besides  the  eyelids,  and  to  which  the  term 
X.  multiplex  has  been  applied. 


On  the  eyelids  xanthoma  may  be  recognised  as 
a yellow  spot,  slightly  elevated,  with  a rounded 
outline,  oblong  and  generally  solitary,  but  some- 
times accompanied  with  several  papulae  of  similar 
colour  scattered  around  the  circumference.  It 
occurs  most  commonly  near  the  inner  angle  of 
the  upper  eyelids,  and  is  usually  symmetrical  on 
both  eyes.  Next  it  is  met  with  at  the  inner 
extremity  of  the  lower  eyelids,  and  in  extreme 
cases  surrounds  the  opening  of  the  eyelids  more 
or  less  completely.  Its  colour  varies  from  that 
of  cream  or  a pale  primrose  to  a deep  orange 
yellow.  On  careful  examination  with  a lens,  the 
patch  may  sometimes  be  seen  to  be  granulated 
(X.  granulosum)  on  the  surface,  many  of  the 
granules  or  nodules  being  punctated  by  the  aper- 
ture of  a follicle;  and  in  the  isolated  papules  this 
structure  is  even  more  distinct.  There  is  some 
slight  variety  in  the  degree  of  prominence;  usu- 
ally there  is  no  redness  or  indication  of  hyperoe- 
mia,  and  the  surrounding  integument  has  a dusky 
or  brownish  tint  of  various  degrees  of  depth. 
There  is  no  pain  of  a spontaneous  character, 
but  instances  are  no  record  where  nodules  about 
the  hands  have  been  so  tender  as  to  prevent  the 
patient  handling  anything. 

Independently  of  its  presence  on  the  eyelids, 
with  which  it  was  formerly  specially  identified, 
the  disease  has  likewise  been  seen,  in  order  of 
frequency,  on  the  palms  and  soles,  knuckles, 
cars,  flexures  of  joints,  nose,  and  cheeks ; in  ad- 
vanced cases  on  the  back  and  abdomen,  as  well 
as  the  face  and  limbs.  It  frequently  attacks  the 
mucous  membrane,  and  has  been  seen  on  the 
lips,  tongue,  and  palate;  also  on  the  trachsea 
and  bile-ducts ; in  the  subcutaneous  areolo- 
fibrous  tissue ; and  in  the  subperitoneal  tissue  of 
the  abdomen  and  of  certain  of  the  abdominal 
viscera. 

Diagnosis. — The  diagnosis  of  xanthoma  is  de- 
termined by  its  colour,  its  situation,  its  material 
structure,  and  its  predominant  forms — always 
circumscribed,  sometimes  occurring  as  rounded 
papules  or  tubercles,  sometimes  as  laminse, 
smooth  on  the  surface  or  granukated  and  nodu- 
lated. 

Prognosis. — Xanthoma  is  essentially  chronic 
in  its  nature,  but  otherwise  harmless, uninfluenced 
by  constitutional  treatment,  but  removable  by 
surgical  operation  when  limited  in  extent.  It 
rarely  gives  rise  to  inconvenience,  and  is  chiefly 
objectionable  from  its  appearance.  A noted 
instance  of  the  spontaneous  disappearance  of 
xanthoma  nodules  has  been  recorded  by  Wick- 
ham Legge. 

Treatment. — Assuming  that  no  local  disease 
can  occur  without  some  constitutional  derange- 
ment, and  having  our  attention  drawn  to  a 
probable  defect  of  function  of  the  liver  and 
possibly  of  the  digestive  organs,  it  is  not  un- 
reasonable to  direct  our  treatment  to  the  regu- 
lation of  those  functions.  Nitro-hydrochloric 
acid  with  a bitter,  and  the  occasional  use  of  blue 
pill,  are  both  indicated.  Subsequent  to  these 


XANTHOMA. 

jemc-dies  we  may  hare  recourse  to  arsenic,  as  a 
nutritive  tonic  possessing  special  properties  of 
peripheral  action.  Locally,  destruction  of  the 
morbid  tissue  by  means  of  caustics  naturally 
occurs  to  the  mind  ; and  where  the  extent  of  the 
disease  is  limited,  it  may  be  effectually  removed 
by  potassa  fusa.  The  case  is  hardly  grave 
enough  for  the  use  of  the  knife,  although  it  is 
sometimes  resorted  to ; and  excision  would  pro- 
bably be  attended  by  the  after-inconvenience  of 
contraction  of  the  integument. 

Erasmus  Wilson; 

XEEODEEMA  ((jjpiiy,  dry,  and  oepua,  the 
skin). — Description. — Xeroderma  is  a state  of 
defective  nutrition  or  atrophy  of  the  integument, 
distinguished  by  dryness,  roughness,  and  gTeyish 


YAWNING.  1797 

discolouration.  The  skin  is  poor  and  starved, 
hard  and  wrinkled ; the  epidermis  is  thickened, 
sometimes  desquamating,  and  sometimes  accu- 
mulated in  crust-like  masses,  corresponding  in 
figure  with  the  area  of  motion  of  the  integument. 
The  disease  is  unaccompanied  by  any  subjective 
sensation.  The  perspiratory  function  is  im- 
paired. Xeroderma  is  congenital  and  sometimes 
hereditary,  and  may  vary  considerably  in  degree, 
entitling  itself  in  its  more  severe  forms  to  be 
considered  as  ichthyosis,  the  latter  disease  being 
always  accompanied  by  xeroderma.  The  term 
has  also  been  applied  by  German  writers  to 
a rare  form  of  atrophy  of  the  skin,  with  dis- 
turbance of  pigment  and  naevoid  changes.  Se* 
Ichthyosis. 

Ebasmus  Wilson. 


Y 


YAWNING  (A.-S.  gdnian).— Synon.  : Fr. 
Baillement ; Ger.  Gahnen. — Yawning  is  one  of 
the  physiological  expressions  of  fatigue.  It  con- 
sists, when  fully  developed^  of  the  following 
phenomena 1.  A deep  inspiration,  with  eleva- 
tion of  the  uvula  and  palate.  2.  A forcible 
spasmodic  depression  of  the  lower  jaw.  3.  A 
flow  of  tears.  4.  A clicking  sound  in  both  ears. 
5.  A tendency  (sometimes  irresistible)  to  stretch 
the  limbs,  especially  the  arms.  6.  An  expira- 
tion, often  accompanied  by  a sound,  the  character 
cf  which  has  probably  given  the  name  to  the 
act. 

^Etiology  and  Pathology. — This  strange  and 
complicated  act  suggests  many  reflections.  Why, 
when  we  are  tired,  should  we  tako  a deep 
breath?  It  may  be  that  the  need  of  oxygen 
experienced  by  the  fatigued  tissues,  laden  with 
waste  products,  prompts  the  instinctive  and  for- 
cible descent  of  the  diaphragm ; but,  on  the 
other  hand,  the  facts  that  yawning  is  common 
when  we  are  merely  ernuye  and  not  genuinely 
fatigued,  and  that  it  is  decidedly  infectious,  are 
both  unaccountable  on  such  a theory.  Why 
should  the  lower  jaw  be  spasmodically  depressed 
when  we  are  fatigued?  The  elevators  of  the 
lower  jaw  are  the  temporal,  masseter,  and  in- 
ternal pterygoid  muscles,  and  it  is  probable  that 
the  external  pterygoid  (whose  main  functions  it 
is  to  move  the  jaw  forward)  has  also  some  share 
in  keeping  the  teeth  in  contact.  These  muscles 
are  constantly  in  action,  having  to  support  the 
jaw  against  the  force  of  gravity;  and  it  is  not 
surprising  that,  as  in  other  cases  of  prolonged 
muscular  action,  they  should  be  prone  to  evince 
fatigue  by  failure  of  function.  Were  it  not  for 
the  fact  that  this  work  of  supporting  the  jaw  is 
divided  amongst  eight  muscles  (four  on  either 
side),  it  is  probable  that  the  jaw  would  fall 
more  often  than  it  does.  When  one  set  of  mus- 
cles is  fatigued,  it  is  quite  in  accordance  with 
experience  that  their  antagonists  should  take  on 
a spasmodic  action,  and  we  may  fairly  look  upon 
the  spasm  of  the  depressors  of  the  jaw,  when 
the  elevators  are  fatigued,  as  the  physiological 


expression  of  an  occasional  pathological  pheno- 
menon. These  considerations  again  do  not  apply 
to  those  instances  of  infectious  (emotional)  yawn- 
ing in  which  we  are  impelled  to  imitate  what  we 
see  in  others. 

A fact  of  considerable  interest  in  connection 
with  yawning  is  the  great  extent  to  which  its 
phenomena  are  limited  to  the  area  of  the  fifth 
nerve.  The  four  muscles  mentioned  above,  as 
concerned  in  the  negative  phase  of  yawning,  aro 
all  supplied  by  the  fifth  ; and  the  anterior  belly 
of  the  digastric  and  the  mylo-hyoid  muscles, 
which  are  connected  with  its  positive  phase,  are 
also  supplied  by  the  fifth.  The  flow  of  tears  and 
the  ‘ click’  in  the  ears,  which  is  probably  due  to 
a contraction  of  the  tensor  tympani,  are  also 
referable  to  the  influence  of  the  same  nerve.  The 
tensor  palati  is  likewise  in  action ; so  that  we 
may  say  that  every  muscle  supplied  by  the  fifth 
is  concerned  in  yawning.  Possibly  yawning  may 
be  regarded  as  a reflex  phenomenon,  of  which 
the  most  ordinary  stimulus  is  the  fatigued  con- 
dition of  the  elevators  of  the  lower  jaw.  The 
reflex  effects  are  largely  manifested  in  the  area 
of  the  fifth  nerve,  but  they  clearly  spread  be- 
yond it,  and  produce  contraction  of  the  dia- 
phragm, palatal  muscles,  depressors  of  the  hyoid 
bone  and  larynx,  and  sometimes  of  the  muscles 
of  the  body  generally,  but  mainly  of  the  exten- 
sors. That  the  contraction  of  the  body  muscles 
at  least  is  a purely  reflex  phenomenon,  may  be 
gathered  from  the  interesting  fact  which  has 
been  often  observed  in  cases  of  hemiplegia, 
namely,  that  when  a hemiplegic  arm  is  entirely 
beyond  the  control  of  the  will,  and  its  flexor 
muscles  are  contracted,  this  contracted  helpless 
hand  will  often  open  during  yawning,  the  stimu- 
lus having  reached  the  extensors  of  the  fingers, 
not  through  the  ordinary  path  of  the  will,  but 
through  the  spinal  cord  by  a reflex  action  travel- 
ling along  some  other  path  of  nervous  energy. 

Treatment. — Yawning  is  generally  oniy  a 
passing  phenomenon,  which  is  removed  by  rest. 
An  undue  tendency  to  yawn  may  indicate  that 
the  body  is  too  easily  fatigued  ; and  then  it  may 


1798  YAWNING, 

bo  necessary  to  inquire  ■whether  the  demands  upon 
it  (mental,  physical,  or  sexual)  are  too  great. 
These  may  have  to  be  removed  or  avoided.  At 
the  same  time  the  bodily  health  should  be  care- 
fully attended  to.  Iron  tonics  may  be  given ; 
the  foul  atmosphere  of  crowded  assemblies  should 
be  forbidden  ; the  diet  should  be  nutritious  and 
digestible  ; and  the  amount  of  alcohol  should  be 
carefully  restricted  to  that  physiological  mini- 
mum which  may  be  necessary  to  aid  digestion. 

G.  V.  Poobe. 

YAWS.  See  Framb.esi,a. 

YELLOW  FEVER— Synon.  : Fr.  Fievre 
jaune  : Ger.  Gelbes  Fieber. 

Definition. — A pestilential  contagious  fever 
of  a continuous  and  special  type ; originally  de- 
veloped in  tropical  and  insular  America ; occur- 
ring only  in  regions  between  45°  N.  and  35°  S. 
lat.  ; and  dependent  for  its  origin  and  spread 
upon  a temperature  not  lower  than  70°  Fahr. 
Yellow  fever  presents  two  well-defined  stages. 
Thefirst  extends  from  36  to  150  hours,  according 
to  the  severity  of  the  disease,  and  is  marked  by 
rapid  circulation,  and  elevated  temperature.  The 
second  is  characterised. by  depression  of  the  ner- 
vous and  muscular  powrers,  and  of  the  circulation, 
with  slow  and  often  intermittent  pulse  ; jaundice  ; 
suppression  of  urine,  albuminuria,  and  desquama- 
tion of  the  renal  epithelium  ; diminution  of  the 
fibrin  of  the  blood,  capillary  congestion,  passive 
haemorrhages  from  the  mucous  surfaces,  and 
black  vomit;  fatty  degeneration  of  the  heart  and 
liver  ; and  convulsions,  delirium,  and  coma.  The 
fever  is  not  dependent  for  its  origin  or  propa- 
gation on  those  causes  and  conditions  which 
gonerate  malarial  paroxysmal  fever,  from  which 
it  differs  essentially  in  symptoms  and  pathology. 
As  a general  rule  it  occurs  but  once  during 
life. 

History. — The  origin  of  the  American  plague, 
or  yellow  fever,  is  involved  in  doubt,  in  conse- 
quence of  the  prevalence  in  regions  in  which  it 
occurs,  both  amongst  natives  and  foreigners,  of 
severe  forms  of  malarial  fever,  often  attended 
with  jaundice,  passive  haemorrhages,  and  black 
vomit.  In  the  eleventh  century,  a disease 
closely  resembling  yellow  fever,  known  as  the 
Matlazahuntl,  made  great  ravages  amongst  the 
Mexicans,  but  it  was  peculiar  to  the  aborigines, 
never  attacking  white  people,  whilst,  on  the 
contrary,  Mexican  Indians  seldom  suffer  from 
yellow  fever.  According  to  authors,  the  first 
trace  of  yellow  fever  was  observed  at  the  end  of 
the  fifteenth  or  beginning  of  the  sixteenth  cen- 
tury, at  San  Domingo  and  Porto  Eieo;  and  Co- 
lumbus, landing  at  the  former  place  in  1493,  lost 
the  greater  number  of  his  men,  within  a year 
after  their  arrival,  from  a disease  described  as 
being  ‘yellow  as  saflfon  or  gold.’  From  1544 
to  1635,  when  it  appeared  at  Guadeloupe,  there 
is  no  record  of  any  outbreak,  but  thenceforward 
it  occurred  at  irregular  intervals.  In  the  seven- 
teenth century  it  spread  along  the  east  coast  of 
America,  as  far  as  8°  S.  lat.  and  42°  N.  lat.,  ap- 
pearing for  the  first  time  in  the  United  States 
at  Boston  in  1693.  In  the  eighteenth  century  it 
appeared  on  the  west  coast  of  South  America, 
and  extended  even  to  Europe  and  Madagascar ; 


YELLOW  FE’VEE. 

the  great  commercial  and  military  actifity  cf 
this  time  doubtless  favouring  its  spread,  and 
increasing  the  frequency  of  the  epidemics, 
eighteen  being  recorded  as  having  occurred  in 
San  Domingo  within  the  century.  Early  in  1700 
it  reached  New  York.  At  the  beginning  of  the 
present  century  it  reached  47°  N.  lat.  in  America, 
and  also  prevailed  in  the  Canary  Islands,  in 
Leghorn,  and  in  the  maritime  cities  of  Spain  and 
Portugal.  In  1853, 1867, 1873,  and  1878  it  spread 
to  a large  number  of  cities,  towns,  and  villages 
ia  the  interior  of  the  American  continent,  being 
transported  by  railroads  and  ships.  During  this 
century  it  appears  to  have  relinquished  its  hold 
upon  the  northern  cities  of  the  Atlantic  coasts, 
and  has  been  concentrated  chiefly  along  the 
southern  borders  of  the  Atlantic  and  Gulf  coasts. 
Yellow  fever  has  prevailed  almost  annually  as 
an  endemic  at  Havana  from  April  to  December ; 
and  from  time  immemorial  it  has  been  endemic 
at  Vera  Cruz. 

Geographical  Distribution.  — At  an  early 
day  it  was  established  that  yellow  fever  is  em- 
phatically the  disease  of  strangers  in  the  warm, 
moist  climates  of  insular  and  tropical  America. 
It  is  endemic  in  the  West  Indies,  and  is  rarely,  if 
ever,  absent,  the  seasons  of  the  year  having  but 
little  influence  in  eradicating  it,  though  the 
disease  is  most  fatal  from  May  to  August.  On 
the  other  hand,  the  history  of  the  settlements 
along  the  shores  of  the  Gulf  of  Mexico  and  At- 
lantic Ocean  has  demonstrated  that  in  the  more 
temperate  regions  it  is  a disease  of  occasional 
occurrence,  and  not  in  the  strict  sense  of  the 
term  endemic.  Since  the  disease  is  dependent 
in  a great  measure  upon  an  elevated  tempera- 
ture, its  occurrence  is  limited  to  tropical  and  sub- 
tropical regions,  or  to  countries  having  a tropical 
climate,  or  a summer  of  sufficient  length  and 
heat.  Within  these  prescribed  limits  the  ex- 
citing cause  seems  to  exist,  but  still  the  fever 
has  seldom,  if  ever,  shown  itself  except  in  mari- 
time regions,  elevated  but  a few  feet  above  the 
sea.  From  Brazil  to  Vera  Cruz  in  one  direction, 
and  from  Barbadoes  to  Tampico  in  another,  the 
exciting  causes  are  in  constant,  though  unequal 
force,  depending  on  differences  of  seasons,  loca- 
lities, and  constitutions.  On  the  Atlantic  coast 
it  has  extended  as  far  north  as  Boston,  Massa- 
chusetts, and  Portland,  Maine,  while  in  the  Mis- 
sissippi valley  it  has  three  times  appeared  as 
high  as  Memphis,  Tennessee,  in  latitude  35°  N. 
In  an  eastern  direction,  but  within  the  same 
parallels,  it  has  extended  to  Cadiz,  Xeres,  Car- 
thagena,  Malaga,  Alieant,  Seville,  Barcelona,  and 
other  cities  on  the  coast  and  in  the  interior  of 
Spain.  It  has  prevailed  several  times  at  Gib- 
raltar, once  at  Eochefort,  twice  at  Lisbon,  and 
once  at  Leghorn.  It  prevailed  at  Monte  Video, 
lat.  34°  54'  S.  in  1S57  and  1872;  in  Buenos 
Ayres  in  1858  and  1S71;  once  at  Panama  and 
Callao,  and  at  Lima  and  Cuzco  in  Peru,  in  1S54 
and  1856.  In  America  it  reaches  from  lat.  36°  S. 
to  45°  N.  on  the  Atlantic  coast,  and  to  35°  N. 
in  the  Mississippi  valley.  On  the  Pacific  coast 
it  extends  from  15°  S.  to  9°  N.  Longitudinal 
Emits  in  the  same  country,  60°  to  07°  W.  In 
the  eastern  hemisphere  it  occurs  within  the 
limits  of  42°  N.  and  8°  S.  It  is  said  not  t» 
appear  in  the  Hist  Indies  or  China. 


YELLOW 

Perpendicular  distribution. — The  older  state- 
ments, that  yellow  fever  never  extended  beyond 
the  height  of  2,500  ft.,  are  shown  to  be  incorrect ; 
for  it  has  prevailed  in  the  elevated  table-lands 
of  Caracas,  3,000  ft.  above  the  sea-level,  on  more 
than  one  occasion;  and  in  1854  and  1856,  it 
committed  fearful  ravages  in  Cuzco  at  an  eleva- 
tion of  11,378  ft.,  and  even  in  other  places  in 
the  Andes  at  14,000  ft.  Great  variety,  however, 
exists  in  this  respect,  for  at  Xalapa,  in  Mexico, 
in  the  same  parallel  with  Yera  Cruz,  4,330  ft. 
above  the  sea,  it  has  never  prevailed  as  an  epi- 
demic; and  the  hills  in  Jamaica  and  San  Domingo 
are  free  from  the  pestilence  which  rages  in  the 
low  lands. 

^Etiology  and  Pathology. — Relation  to  popu- 
lation.— A certain  degree  of  density  of  popula- 
tion appears  to  be  essential  to  the  production  of 
yellow  fever,  which  never  originates  in  country 
districts,  but  is  a disease  of  crowded  cities  on 
the  shores  of  the  ocean  or  large  rivers,  and  of 
ships.  Its  origin  and  spread  are  favoured  by  the 
congregation  of  persons  born  in  a cold  climate  ; 
and  where  developed  in  strangers  who  have  landed 
in  a port  in  which  it  is  not  prevailing,  it  appears 
to  be  referable  to  the  action  of  endemic  causes 
upon  highly  susceptible  individual. 

Relation  to  temperature. — However  violent  the 
disease  may  be  at  any  place,  yellow  fever  is  ar- 
rested from  the  day  on  which  the  earth  is  frozen, 
and  such  localities  may  then  be  visited  with  im- 
punity by  strangers.  The  singular  occurrence  of 
the  disease  at  the  high  elevations  in  the  Andes 
above  mentioned,  appears  to  be  due  to  the  fact 
that,  whilst  in  those  regions  the  night  and  morn- 
ing are  excessively  cold,  intense  heat  prevails  in 
the  afternoon. 

Incubation. — The  period  of  incubation  appears 
to  vary  in  different  epidemics,  and  in  different 
individuals  in  the  same  epidemic,  and  may  extend 
from  twenty-four  hours  to  weeks  or  even  months. 
In  this  respect  yellow  fever  resembles  diseases  of 
malarial  origin,  and  differs  from  the  well-defined 
contagious  maladies.  Whilst  in  some  a few  hours’ 
exposure  to  an  infected  atmosphere  is  sufficient 
to  determine  the  disease,  others  may  remain  un- 
affected until  the  end  of,  or  even  through,  several 
epidemics.  Cases  have  been  known  to  occur  in 
the  winter,  weeks  after  it  is  supposed  that  the 
disease  was  entirely  checked,  the  poison  being 
looked  upon  as  lying  dormant  in  the  system. 
Like  many  other  contagious  diseases,  it  may  be 
communicated  to  the  fetus,  and  this  is  supposed 
to  partially  explain  the  immunity  enjoyed  by  the 
natives  of  localities  in  which  it  is  endemic. 

Essential  cause. — The  various  opinions  on  this 
point  fall  under  three  heads:  1.  That  yellow 
fever  is  a disease  induced  essentially  and  solely 
by  contagion.  2.  That  it  is  essentially  of  endemic 
origin.  3.  That  being  of  endemic  origin,  it 
afterwards  becomes  contagious. 

The  idea  has  been  extensively  entertained  that 
intermittent,  remittent,  and  pernicious  paroxys- 
mal malarial  fevers,  as  well  as  yellow  fever, 
assume  more  or  less,  according  to  circumstances, 
the  type  of  one  another,  and  are  essentially  the 
same,  modified  only  by  the  intensity  of  the  cause, 
and  by  the  prevailing  constitution.  The  marked 
exemption  from  the  disease  of  the  natives  of 
districts  where  yellow  fever  is  endemic,  with  their 


FEVER.  1799 

liability  to  mild  intermittent  and  remittent  at- 
tacks, is  regarded  as  supporting  this  view. 

The  following  facts  have  been  cited  to  sustain 
the  opiniou  that  yellow  fever  arises  from  mias- 
mata. 1.  It  always  appears  simultaneously 
with  bilious  remittent.  2.  A high  range  of 
temperature  is  essential  to  the  generation  of  its 
cause.  3.  Its  first  appearance  is  almost  always 
in  the  lowest  and  most  filthy  parts  of  towns  ; 
and  in  localities  favourable  to  the  production  of 
miasmata.  4.  The  supervention  of  storms,  heavy 
rains,  or  cold  weather  puts  an  immediate  check  to 
its  progress. 

With  some  writers  it  is  still  even  a disputed 
question  whether  certain  fevers  which  have,  er 
are  supposed  to  have,  their  source  in  vegetable 
miasmata,  or  in  effluvia  from  marshes,  or  from 
infusoria  or  fungi,  developed  and  propagateT 
under  certain  combinations  of  heat,  moisture, 
and  putrefying  vegetable  and  animal  matters,  are 
subsequently  spread  by  contagion;  whilst  other 
writers  contend  that  within  the  tropics  yellow 
fever  may  at  any  time,  under  certain  conditions 
of  moisture  and  temperature,  arise  de  novo,  in  the 
impure  atmosphere  of  the  crowded  and  filthy 
ship  or  city.  Others  again  as  strenuously  uphold 
the  doctrine  that  jellowfever  is  a specific,  conta- 
gious, pestilential  disease,  which,  like  small-pox 
or  measles,  may  be  transferred  and  communi- 
cated from  one  ship  or  city  to  others,  thus  fol- 
lowing the  great  avenues  of  commerce.  A third 
class  adopt  and  advocate  a doctrine  which  em- 
braces the  main  features  of  both  propositions. 
Some  who  hold  that  yellow  fever  may  be  engen- 
dered de  novo  in  the  holds  or  atmosphere  of  ships 
navigating  in  the  warm,  moist,  tropical  regions, 
have  coupled  with  this  view  the  doctrine  that  if 
this  poisoned  atmosphere  be  allowed  to  escape 
at  the  wharves  of  cities  situated  beyond  the 
yellew  fever  zone,  those  only  who  come  within 
the  sphere  of  its  influence  will  be  affected,  and 
its  subsequent  spread  will  depend  upon  condi- 
tions of  filth  and  crowding  of  such  localities,  the 
disease  never  spreading  endemically,  but  falling 
harmless  among  the  inhabitants  of  a salubrious 
locality.  According  to  this  view,  the  develop- 
ment of  this  malignant  fever  requires  the  con- 
joint operation  of  both  local  and  general  causes, 
constituting  an  endemico-epidemic  which  is 
unsusceptible  of  propagation  by  specific  conta- 
gion, and  in  the  summer  atmosphere  of  a city 
lying  beyond  the  yellow-fever  zone  there  must 
exist  some  peculiar  combination  of  circumstances, 
or  some  peculiar  agency,  favourable  to  its  deve- 
lopment. In  these  cases  it  is  affirmed  that  there 
is  generally  found  an  infected  district,  which 
slowly  and  regularly  extends  its  boundaries,  ren- 
dering all  who  come  within  its  limits  subject  to 
this  form  of  fever. 

It  has  been  said  that  the  experience  of  several 
centuries  leads  to  the  view  that  the  cause  of  this 
fever  is  perennially  present  in  the  tropical  and 
subtropical  cities  of  America  ; that  it  maintains 
the  same  relation  towards  the  human  system  as 
the  other  malarial  emanations  of  swamps  and  low- 
lands; and  that  it  is  liable  to  be  developed  at  any 
time,  in  different  degrees  of  intensity,  by  the  com- 
binedoperation  ofheatand  otheragents.  Amongst 
the  most  striking  circumstances  in  the  setiology 
of  yellow  fever  are  the  marked  geographical 


YELLOW  LEVEE. 


1800 

boundaries  within  "which  it  is  confined,  and  the  cir- 
cumscribed localities  in  which  it  prevails;  its  more 
frequent  prevalence  in  the  "western  than  in  the 
eastern  hemisphere ; its  almost  universal  limitation 
to  commercial  sea-ports,  elevated  but  a few  feet 
above  the  level  of  the  sea,  although  it  occasionally 
spreads  to  towns  and  cities  in  the  neighbourhood 
of  the  latter,  situated  in  the  interior  of  the  coun- 
try, on  the  banks  of  navigable  rivers ; and  the 
fact  that  i t is  very  frequently  circums  er  ibed  wi  thi  n 
certain  limited  and  well-defined  portions  of  the 
locality  or  city  in  which  it  prevails.  To  these 
may  be  added  the  vastly  greater  susceptibility 
of  strangers  over  the  natives  of  regions  in  which 
the  disease  is  endemic,  although  this  suscepti- 
bility is  liable  to  diminution  by  residence  in  the 
proscribed  regions. 

Anatomicat,  Characters. — In  cases  of  death 
from  yellow  fever  the  features  are  frequently 
bloated ; the  skin  of  the  face  and  upper  part 
of  the  trunk  of  a golden-yellow  colour;  whilst 
dependent  parts  present  a mottled  purple,  and 
a yellow  ecchymosed  appearance.  Considerable 
quantities  of  dark  fluid  blood  escape  on  section 
of  the  muscles,  becoming  bright  scarlet  on  ex- 
posure. Putrefactive  changes  set  in  early,  ap- 
pearing sometimes  to  do  so  before  death. 

The  nervous  system  presents  no  characteristic 
appearances  beyond  general  congestion.  Urea, 
bile,  and  leucin  have  been  obtained,  by  analysis, 
from  the  brain. 

The  heart  is  in  a condition  of  acute  fatty  de- 
generation, of  a pale  yellow  or  brownish-yellow 
colour.  This  degeneration  is  more  extensive 
and  more  rapid  than  in  any  other  disease. 
The  cavities  are  usually  filled  with  dark  fluid 
blood,  which  contains  an  excess  of  urea,  ammo- 
nia, and  extractives,  with  a great  diminution  of 
fibrin.  No  such  appearances  are  found  in  the 
heart  in  malarial  fever. 

The  lungs  present  extreme  congestion  of  de- 
pendent portions,  and  sometimes  circumscribed 
haemorrhages  into  the  pulmonary  tissue. 

The  mucous  membrane  of  the  stomach  is  fre- 
quently intensely  congested,  softened,  and  eroded, 
often  containing  large  quantities  of  black  vomit 
of  an  alkaline  reaction,  from  the  presence  of 
ammonia,  resulting  from  ante-mortem  decompo- 
sition of  the  urea.  Microscopically  the  vomit  is 
seen  to  contain  red  blood-corpuscles,  gastric  epi- 
thelial cells,  dark  masses  of  lisematin.and  some- 
times vibriones  and  other  organisms. 

The  intestines,  as  a general  rule,  are  dark- 
coloured  and  distended  with  gas,  sometimes  con- 
taining large  quantities  of  dark  altered  blood,  of 
an  alkaline  reaction.  Bile  is  always  absent  from 
the  intestinal  contents.  Intussusception  of  the 
bowels  is  by  no  means  unfrequent. 

The  liver  is  yellow  and  bloodless,  and  the 
stroma  and  secreting  cells  are  infiltrated  with 
fat,  though  the  organ  is  firmer  than  is  the  case 
in  ordinary  fatty  degeneration.  None  of  the 
pigment  deposited  in  the  portal  capillary  system 
in  malarial  fevers,  is  found  in  yellow  tVver 
When  yellow  fever  has  been  preceded  by  or  en- 
grafted on  malarial  fever,  the  liver  presents  the 
appearances  of  both  these  diseases,  and  hence 
some  confusion  has  occurred  in  the  recognition 
of  the  normal  pathological  appearances  proper 
Vo  each.  The  golden-yellow  colour  of  the  yellow- 


fever  liver  can  be  extracted  both  by  alcohol  and 
water.  A similar  decoction  of  the  malarial  liver 
is  of  a brownish-yellow  colour  ; in  the  Latter  case 
also  the  organ  is  softer,  contains  more  blood,  and 
is  readily  dissolved  by  liquor  potass®,  forming 
a solution  of  the  appearance  of  venous  blood, 
which  is  not  the  case  in  yellow  fever.  Largs 
quantities  of  urea  and  fat,  as  well  as  glycogen 
and  glucose,  may  be  obtained  from  the  yellow- 
fever  liver,  whilst,  as  a general  rule,  grape-sugar 
is  absent  from  the  malarial  form. 

As  a general  rule  the  gall-bladder  is  con- 
tracted and  flaccid,  and  contains  but  very  little 
bile;  but  sometimes  it  is  distended  with  dark 
grumous  blood,  and  occasionally  an  albuminous 
mucoid  liquid,  without  a trace  of  bile.  In  ma 
larial  fever,  on  the  contrary,  the  gall-bladder  is 
usually  full  of  dark  greenish-black  bile. 

The  spleen  is  but  slightly  enlarged  as  a rule, 
and  is  frequently  normal  in  size  and  appearance, 
internally  as  well  as  outside. 

The  kidneys  are  of  a brownish-yellow  colour, 
and  loaded  with  fat.  The  Malpighian  corpuscles 
and  tubuli  uriniferi  are  filled  with  granular  al- 
buminoid and  fatty  matter,  detached  epithelial 
cells,  and  oil-globules. 

The  urinary  bladder  is  almost  always  empty  ; 
the  little  urine  that  it  may  contain  is  of  a light 
yellow  colour,  free  from  crystalline  deposit,  and 
loaded  with  albumen. 

Symptoms. — Invasion.  — The  symptoms  of 
yellow  fever  at  this  stage  are  uncertain  and  ill- 
defined.  Attacking  a community,  as  this  disease 
does,  without  discrimination  of  age,  sex,  or  state 
of  health,  those  only  being  exempt  who  have 
already  suffered  from  the  malady,  it  of  necessity 
offers  the  greatest  variety  of  manifestations. 
The  onset,  as  occurring  suddenly  in  apparent 
health,  is  marked  by  intense  headache,  rigors, 
pain  in  the  limbs  and  back,  rapid  rise  of  tem- 
perature, eyes  glistening  and  suffused,  congested 
countenance,  intense  thirst,  anorexia,  uneasiness 
at  the  epigastrium,  nausea,  and  vomiting. 

Stage  of  chill,  or  primary  depression. — Here, 
also,  the  symptoms  are  not  uniform.  In  some 
cases,  and  even  in  those  of  the  greatest  violence, 
chills  are  entirely  absent,  or  amount  only  to  a 
sense  of  coldness.  In  others  they  are  deep,  pene- 
trating, and  stupefying,  or  alternate  with  flashes 
of  heat  and  crawling  sensations  ; or  the  constric- 
tion of  peripheral  vessels  may  be  extreme,  caus- 
ing a shrivelled  appearance  of  the  skin.  In  some 
cases,  again,  the  disease  is  ushered  in  by  giddi- 
ness, and  in  others  with  convulsions.  Neither 
the  presence  nor  absence  of  chills,  therefore,  can 
be  regarded  as  characteristic.  The  chills,  when 
they  do  occur,  differ  from  those  occurring  in  true 
malarial  fever,  and  rather  resemble  those  which 
may  take  place  at  the  onset  of  such  diseases  as 
small-pox  or  pneumonia. 

Stage  of  reaction. — The  stage  of  active  febrile 
excitement  follows  the  chills,  or  the  premonitory 
symptoms  of  uneasiness,  prostration,  and  languor, 
with  severe  pain  in  the  head  and  limbs,  in  the 
form  of  a rapid  elevation  of  temperature.  This 
ranges  in  the  first  day  of  the  disease,  according  to 
its  severity,  from  102°  to  110°Fahr.  in  the  axilla; 
and  it  is  probable  that  the  internal  organs  attain 
in  some  cases  a temperature  of  1 1 2°.  As  a general 
rule,  from  the  third  to  the  fifth  day  it  falls  to 


YELLOW 

the  normal  standard,  and  even  below  it ; in  some 
fatal  cases  it  rises  again  towards  the  end,  rarely, 
however,  exceeding  104°  Fahr.,  and  never  attain- 
ing the  high  degree  reached  at  first.  The  super- 
vention of  any  inflammatory  condition,  or  the 
occurrence  of  an  abscess,  will  also  cause  a rise 
of  temperature,  with  slight  evening  exacerba- 
tions ; but  as  a rule  the  secondary  elevation  thus 
caused  never  equals  the  maximum  of  the  stage 
of  active  febrile  excitement.  When  malarial 
paroxysmal  fever  is  engrafted  upon  yellow  fever, 
in  its  later  stages,  or  during  the  period  of  conva- 
lescence, the  temperature  during  the  hot  stage 
may  even  exceed  the  maximum  of  that  of  yellow 
fever,  but  it  will  be  characterised  by  sudden 
periodic  depressions  and  elevations  recurring  at 
definite  intervals.  The  pulse  when  reaction  has 
set  in  is  rapid,  strong,  tense,  and  full,  though 
occasionally  feeble  and  compressible.  The  in- 
crease of  the  frequency  of  the  pulse  does  not 
however,  as  a general  rule,  continue  to  corre- 
spond with  the  elevation  of  the  temperature  ; 
and  in  many  cases  the  remarkable  phenomenon  is 
witnessed  of  the  pulse  progressively  decreasing 
in  frequency,  and  even  descending  below  the 
normal  standard,  while  the  temperature  is  main- 
tained at  an  elevated  degree.  This  singular 
circumstance  is  of  great  diagnostic  value,  as 
serving  to  distinguish  yellow  fever  from  other 
diseases,  and  especially  from  malarial  paroxysmal 
fever,  and  also  as  indicating  the  presence  in 
the  blood  of  a poison  possessing  a specially  de- 
pressing influence  on  the  heart.  On  the  other 
hand,  the  pulse  may  increase  in  frequency,  but 
diminish  in  force,  near  the  fatal  issue,  with  a 
fall  in  temperature,  particularly  if  there  have 
occurred  free  haemorrhage  from  the  stomach. 

The  stage  of  febrile  excitement  is  not  of  fixed 
duration,  and  may  in  some  of  the  gravest  cases 
appear  to  be  comparatively  mild  and  unimpor- 
tant. At  the  same  time  the  pains  may  be  so 
slight  and  there  may  be  such  an  absence  of  de- 
lirium, and  but  small  failure  of  strength,  that 
both  patient  and  physician  may  be  deceived, 
and  yet  the  former  may  die  without  taking  to 
his  bed.  In  most  of  these  so-called  ‘ walking 
cases,’  the  kidneys  have  been  involved  from  the 
inception  of  the  disease,  and  complete  suppres- 
sion of  the  urine  has  supervened  before  death. 
This  latter  symptom  is  almost  invariably  fatal, 
and  is  a chief  cause  of  the  haemorrhages  from 
the  stomach  and  bowels,  and  also  of  the  marked 
blood-changes,  leading  to  severe  nervous  dis- 
turbances, and  frequently  to  sudden  death.  There 
is  no  doubt  but  that  the  fever-poison  directly 
interferes  with  the  nutrition  of  the  gastroin- 
testinal mucous  membrano,  liver,  aDd  kidneys, 
loading  thereby  the  already  vitiated  blood  with 
the  abnormal  products  of  their  disintegration, 
whilst  the  circulation  of  the  impure  blood  neces- 
sarily affects  all  the  tissues  of  the  body,  and 
intensifies  the  morbid  changes  in  those  organs 
primarily  attacked  by  the  specific  poison.  The 
action  of  the  poison  of  yellow  fever,  during  the 
stage  of  acute  febrile  excitement,  is  manifested 
not  only  by  intense  pain  in  the  head  and  back, 
and  the  florid  congestion  of  the  eyes  and  skin,  the 
anorexia  and  nausea,  the  pyrexia  and  increased 
frequency  of  pulse,  but  also  by  the  albuminuria, 
which  is  rarely  entirely  absent  in  severe  cases, 


FEVEK.  1801 

and  may  make  its  appearance  on  the  first  day  of 
the  febrile  state. 

The  congestion,  so  marked  upon  the  conjunc- 
tiva and  skin,  extends  also  to  the  internal  organs, 
and  is  well  seen  in  the  injected  nares,  crimson 
lips,  scarlet  tip  and  edges  of  the  tongue.  As 
a general  rule,  in  the  stage  of  febrile  excitement 
the  tongue  is  pointed,  red  at  the  tip  and  edges, 
and  coated  with  thick  .white  and  yellow  fur  in 
the  centre  and  over  the  Toots.  After  the  febrile 
excitement  has  continued  for  over  three  days,  in 
some  cases  the  tongue  may  present  a corrugated, 
cracked,  and  bloody  appearance.  We  never  ob- 
serve in  specific  yellow  fever  the  broad  tongue 
with  indented  edges,  which  often  characterises 
the  prolonged  action  of  the  malarial  or  paludal 
poison.  The  gums  are  red,  spongy,  and  often 
bleed  upon  pressure,  and  the  fauces  brilliantly 
congested.  The  fact  that  mere  examination  of 
the  throat  and  depression  of  the  tongue  is  suffi- 
cient to  cause  nausea  and  retching,  is  an  impor- 
tant diagnostic  sign. 

Stage  of  depression  and  exhaustion. — In  cases 
which  terminate  favourably,  the  deleterious  sub- 
stances generated  during  the  stage  of  febrile  ex- 
citement are  gradually  eliminated,  and  the  organs 
especially  affected  by  the  poison  resume  their 
healthy  actions.  In  those  cases  which  end  fatally 
at  this  stage,  the  issue  appears  to  be  mainly 
determined  by  heart-failure  from  acute  fatty 
degeneration,  as  well  as  the  profound  blood- 
changes  induced  by  the  specific  poison,  and  the 
retention  of  the  secretions  of  theliver  andkidneys, 
the  functions  of  which  are  arrested.  There 
appear  to  be  no  just  grounds  for  the  subdivision 
of  this  fourth  stage,  in  accordance  with  the  pre- 
sence or  absence  of  haemorrhage,  coma,  jaundice, 
uraemic  poisoning  and  convulsions,  for  these  are 
simply  effects  and  aggravations  of  the  preceding 
symptoms,  and  must  be  regarded  as  the  maximum 
phenomena  of  the  stage.  Neither  is  this  stage 
to  be  regarded  as  similar  to,  or  identical  with,  the 
intermission  or  remission  of  malarial  fever,  or  as 
an  abortive  repetition  of  the  febrile  stage,  in  which 
the  disease  ends  from  adynamic  incompetency  to 
carry  out  the  phenomena. 

The  black  vomit. — The  ejection  of  altered 
blood  from  the  stomach — black  vomit — during 
the  period  of  depression,  although  not  absolutely 
characteristic  of  yellow  fever,  is  still  of  such  fre- 
quent occurrence  as  to  demand  special  consider- 
ation, both  of  its  nature  and  origin.  The  character 
of  the  matters  vomited  varies  in  different  stages  of 
the  disease,  as  also  with  the  degree  of  its  severity. 
Whilst  yellow  fever  is  characterised,  in  common 
with  several  other  diseased  states,  by  an  irritation 
of  the  gastric  mucous  membrane,  the  peculiar  na- 
ture of  the  vomited  matters  does  not  rest  entirely 
upon  this  irritation  and  congestion,  but  is  influ- 
enced to  a greater  or  less  extent  by  the  changes 
in  the  blood,  liver,  kidneys,  and  nervous  system. 
The  vomiting  also  may  be  regarded  as,  to  a cer- 
tain extent,  salutary,  and  as  an  effort  for  the 
elimination  of  excrementitious  materials  from 
the  blood.  For  in  some  cases  distinct  improve- 
ment follows  the  vomiting,  as  seen  in  the  abate- 
ment of  the  pyrexia,  and  the  cleaner  condition 
of  the  tongue ; and  it  would  almost  seem  that, 
were  it  not  for  the  profound  changes  in  the  blood 
and  organs  lying  at  the  back  of  this  almost 


1802  YELLOAV 

universally  fatal  symptom,  recovery  might  start 
from  its  occurrence.  The  first  ejections  generally 
consist  of  the  ordinary  gastric  secretions,  fol- 
lowed by  a mucoid  fluid,  which  is  frequently 
at  first  tinged  with  bile,  sometimes  of  an 
acid,  sometimes  of  an  alkaline  reaction.  The 
acidity  is  not  due  to  tho  presence  of  any  pe- 
culiar acid,  but  to  hydrochloric  or  lactic  acid, 
and  is  mainly  determined  in  intensity  by  the 
nature  of  the  ingesta.  After  the  first  vomiting 
the  stomach  may  remain  tolerably  quiet  until  the 
subsidence  of  the  fever  on  the  third,  fourth,  or 
fifth  day,  when,  without  any  premonitory  symp- 
toms of  nausea,  the  stomach,  on  any  trifling 
provocation,  may  eject  a quantity  of  clear,  pale, 
almost  limpid,  and  slightly  acid,  opalescent  fluid. 
At  this  period  the  disease  may  terminate,  as 
if  this  excretion  were  similar  to  the  perspira- 
tion of  intermittent  fever.  If  the  vomiting 
continue,  it  becomes  first  streaked  with  dark 
flocculi  of  altered  blood,  and  acquires  an  alka- 
line reaction,  due  to  carbonate  of  ammonia, 
arising  from  tho  decomposition  of  the  urea, 
which  is  eliminated  from  tbo  gastric  mucous 
membrane.  The  black  vomit  varies  in  spocific 
gravity  from  near  that  of  distilled  water  to  that 
of  blood;  and  it  consists  of  the  secretion  of  the 
mucous  membrane,  mixed  with  food,  altered  blood, 
epithelial  cells,  and  excrement  itious  products, 
such  as  urea  and  carbonate  of  ammonia. 

The  urine. — The  reaction  of  the  urine  is  in- 
variably acid,  even  in  the  gravest  cases.  As  a 
rule,  the  specific  gravity  ranges  from  1,009  to 
I,02S.  In  those  specimens  of  the  highest  den- 
sity the  increase  appeared  to  bo  due  to  the 
amount  of  albumen.  During  the  early  stages  of 
the  diseaso,  the  urine  is  normal  in  colour,  clear- 
ness, and  quantity ; as  the  disease  proceeds  it 
becomes  of  a deop  yellow  colour,  from  the  ad- 
mixture of  bile  ; and  on  the  fourth  or  fifth  day 
appears  turbid  from  the  presence  of  renal  epi- 
thelial cells,  tube-casts,  and  yellow  granular 
albuminoid  matter.  The  colour  may  deepen  to 
orange-red,  or  even  to  reddish-brown ; and  the 
urine  sometimes  presents  an  oily  appearance.  The 
quantity  may  he  much  diminished,  up  to  com- 
plete suppression.  As  a general  rule,  the  amount 
is  diminished  in  the  active  stages  of  the  fever.  If 
tho  case  advance  favourably  the  urine  is  copious, 
and  the  colour  progressively  increases  in  depth 
even  to  almost  black.  In  grave  cases  it  is  ranch 
less  abundant,  and  at  the  same  time  of  a much 
lighter  colour.  Albumen  is  an  almost  invariable 
constituent,  and  may  appear  as  early  as  the  first 
day  of  the  disease,  but  most  generally  from  the 
second  fb  the  fifth.  When  convalescence  is  pro- 
tracted,the  albuminuria  may  continue  long  after 
all  symptoms  but  debility  have  left  the  patient. 
When  precipitated  by  heat  or  nitric  acid,  the 
albumen  appears  of  a golden  yellow  or  light 
brownish  colour.  As  much  as  one  ounce  of  dried 
albumen  has  been  excreted  in  twenty-four  hours, 
representing  the  albumen  of  nearly  one  pound  of 
blood.  Associated  with  the  albumen  are  renal  epi- 
thelial cells,  and  casts  of  tubules,  but  the  albumi- 
nuria must  not  be  wholly  referred  to  an  acute 
desquamation  of  the  excretory  cells,  nor  to  more 
capillary  congestion,  but  is  equally  duo  to  che- 
mical changes  effected  by  the  poison  of  yellow 
fever  in  the  albumen  and  fibrin  of  the  blood.  The 


FEVER. 

albumen  appears  in  large  amount  in  the  urine, 
in  cases  where  there  is  no  apparent  failure  in  the 
excretory  action  of  the  kidneys,  and  in  which  the 
urine  is  aimed  int,  and  laden  with  urea,  as  well 
as  bile.  The  presence  in  the  urine  of  red  cor- 
puscles and  tho  colouring  matter  of  the  blood  is 
not  so  characteristic  in  this  disease  as  in  the  so- 
called  malarial  hsematuria,  where  renal  casts  and 
epithelium  may  occur  in  considerable  amount, 
but  with  only  sufficient  albumen  to  correspond 
to  the  exuded  blood;  whilst  in  yellow  fever,  when 
blood  does  appear  in  the  urine,  the  amount  of 
albumen  is  much  greator  than  could  thereby  ho 
accounted  for.  In  the  former  disease  also,  the 
urinary  casts  contain  red  corpuscles,  and  are  of  a 
brownish  colour,  in  place  of  the  golden-yellow 
tint  which  these  oil-laden  bodies  present  in  yel- 
low fever. 

Throughout  the  disease,  when  there  is  no  sup- 
pression, tho  amount  of  urea  is  much  increased, 
reaching  as  much  as  a thousand  grains  per  diem. 
There  is  a similar  increase  iu  the  phosphoric  and 
sulphuric  acids,  up  to  as  much  as  fifty  and  sixty 
grains  respectively. 

Pathology. — The  various  manifestations  of 
yellow  fever,  as  the  intense  capillary  congestion, 
cardiac  depression,  delirium,  coma,  and  convul- 
sions, vomiting,  haemorrhage,  urinary  suppres- 
sion, and  jaundice,  may  all  be  referred  to  the 
action  of  the  specific  poison,  and  should  not  he 
erected  into  distinct  types  of  disease,  however 
prominent  any  one  of  these  symptoms  may  Le, 
and  however  much  cases  may  differ  from  one 
another.  The  action  of  tho  yellow-fever  poison 
is  the  same  in  all  cases,  whether  mild  or  severe  ; 
the  progress  and  termination,  and  the  manifesta- 
tion of  the  various  symptoms,  depending  on  the 
degree  of  action  of  the  poison,  the  condition  of 
the  system  at  the  time  of  its  introduction,  the 
peculiarities  of  constitution,  the  various  agencies 
to  which  the  patient  is  subjected  during  the 
course  of  tho  disease,  and  the  supervention  of 
other  maladies. 

Yellow  fever,  according  to  this  view,  partakes 
of  the  nature  of  a continued  pestilential  fever, 
presenting  two  well-defined  stages ; the  first 
characterised  by  active  chemical  change  in  the 
blood  and  organs,  attended  with  elevation  of 
temperature,  which  may  constitute  the  entire 
malady,  and  prove  fatal  in  a manner  similar  to 
other  acute  specific  fevers  ; the  second,  or  stag- 
of  depression,  resulting  from  tho  action  of  the 
poison,  and  the  blood-changes  induced  by  the 
suppressed  functions  of  certain  organs. 

Front  a consideration  of  the  foregoing  symp- 
toms, it  is  manifest  that  the  blood  must  have 
undergone  profound  changes,  which  seem  to  con- 
sist chiefly  of  the  following: — 

1.  Such  an  alteration  of  the  chemico-physieal 
properties  of  the  fibrin  and  albumen,  as  leads  to 
the  transudation  of  the  latter,  through  the  ex- 
cretory structures  of  the  kidney. 

2.  Various  degrees  of  diminution  of  the  fibrin, 
in  some  cases  amounting  to  almost  entire  dis- 
appearance ; and  this  apparently  due  more  to 
the  direct  action  of  the  specific  poison  than  to 
the  retained  urea,  bile-acids,  & c.  As  a result  the 
blood  coagulates  imperfectly  ; and  the  clot  is  soft 
and  bulky,  exuding  but  little  serum,  and  often 
breaking  down  on  standing  into  a grumous  fiu.d. 


YELLOW  FEVER.  1803 


3.  Whilst  the  red  blood-corpuscles  are  not 
specially  diminished,  they  are  much  altered  in 
appearance. 

4.  Increase  of  fatty  and  extractive  matters. 

5.  Accumulation  of  the  biliary  constituents,  as 
shown  by  the  golden-yellow  colour  of  the  serum. 

6.  Accumulation  of  the  urinary  constituents, 
especially  the  urea,  carbonate  of  ammonia,  chlo- 
ride of  sodium,  and  phosphoric  and  sulphuric 
acids.  The  alkaline  reaction  of  the  blood  during 
life  rapidly  changes  after  death  to  acid. 

7.  Rapid  dissolution  of  the  red  blood-cor- 
puscles, with  corresponding  diminution  of  their 
oxygen-carrying  power. 

8.  Rapid  putrefraction,  after  its  abstraction 
from  the  body. 

The  various  causes  of  black  vomit  may  be  thus 
summarised : — 1.  The  irritation  and  structural 
alteration  of  the  gastric  mucous  membrane,  which 
is  a part  of  the  general  tissue-degradation,  con- 
sisting of  granular  and  fatty  degeneration  of  the 
secreting  cells  and  of  the  walls  of  the  smaller 
blood-vessels  and  capillaries,  as  well  as  the  ge- 
neral congestion  of  the  organ.  2.  The  changes 
in  the  blood,  especially  the  marked  diminu- 
tion of  the  fibrin.  3.  The  suppression  of  the 
action  of  the  kidnoys,  and  the  retention  in  the 
blood  of  urea  and  similar  bodies.  It  may  be 
noted  that  black  vomit  rarely  occurs  in  those 
cases  where  the  kidneys  act  continuously  and 
freely.  4.  The  direct  irritation  of  the  urea 
and  its  derivatives,  which  are  eliminated  vica- 
riously from  the  gastro-intestinal  mucous  mem- 
brane. 5.  The  irritant,  nauseating  effects  of  the 
bile  retained  in  the  blood. 

In  yellow  fever,  acute  atrophy  of  the  liver, 
and  acute  phosphorus-poisoning — diseased  states 
which  have  many  symptoms  and  pathological 
lesions  in  common — it  would  seem  that  the  oxi- 
dation of  albuminoids  is  not  so  complete  as  in 
health,  and  besides  the  formation  of  leucin,  ty- 
rosin,  and  other  similar  bodies,  a large  amount  of 
fat  is  produced,  which  may  extensively  infiltrate 
the  tissues.  It  is  clear  that  one  effect  of  suppres- 
sion of  urine  is  to  determine  the  retention  in  the 
blood  of  a large  excess  of  urea.  This  may  in 
part  be  eliminated  by  the  gastro-intestinal  mu- 
cous membrane,  and  the  black  vomit  may  be 
intensely  alkaline  from  carbonate  of  ammonia 
derived  from  this  substance;  and  it  is  further 
evident  that  in  many  cases  of  yellow  fever  the 
fatal  issue  is  determined  chiefly  by  the  retention 
in  the  blood  of  the  constituents  of  the  urine.  To 
the  same  cause  also  must  be  attributed,  to  a great 
extent,  the  nervous  irritation,  delirium,  convul- 
sions, and  coma  which  characterise  the  stage  of 
depression.  Certain  of  the  blood-changes  may  be 
referred  also  to  the  same  cause. 

Duration. — The  several  stages  of  yellow  fever 
whichhavebeen  described  are  not  uniformin  their 
duration,  and  there  may  be  a marked  diversity  in 
the  manifestation  of  the  symptoms  in  individual 
cases,  some  presenting  apparently  but  the  stage 
of  febrile  excitement,  whilst  others,  overwhelmed 
as  it  were  by  the  poison,  at  once  pass  into  a 
condition  of  hopeless  prostration.  In  mild  cases, 
especially  in  children,  the  disease  may  be  so 
slight  as  barely  to  attract  attention,  and  con- 
valescence may  be  established  in  two  or  three 
days.  The  stago  of  febrile  excitement  may 


continuo  from  two  to  six  days,  rarely  beyond 
three  or  four,  and  the  patient  may  pass  almost 
imperceptibly  into  convalescence  during  the 
stage  of  depression.  The  severest  cases  may 
prove  fatal  in  two  or  three  days,  with  an  axillary 
temperature  of  1 1 0°  Fahr. ; or  later  from  haemor- 
rhage, urinary  suppression,  general  prostration, 
or  an  adynamic  state,  accompanied  with  parotid 
abscess,  revival  of  old  complaints,  or  the  super- 
vention of  some  other  disease,  such  as  malarial 
fever.  The  fourth  stage  may  be  of  long  duration, 
extending  over  weeks  and  even  months.  It  is, 
however,  true  that  convalescence  is  usually  com- 
paratively rapid,  and  in  striking  contrast  to  the 
tedious  recovery  from  malarial  fever.  In  some 
cases  vomiting  may  be  the  prominent  symptom  ; 
in  others  haemorrhage  from  the  stomach  and 
bowels,  or  from  the  gums,  eyes,  and  ears ; in 
others,  again,  the  cerebral  symptoms  may  be 
most  marked. 

Terminations  and  Mortality. — In  fatal  cases 
death  may  be  referred  to  a variety  of  causes, 
namely: — 1.  The  direct  action  of  the  fever- 
poison  upon  the  blood  and  nervous  system.  2. 
The  disturbance  or  suppression  of  function  of 
certain  organs,  as  the  kidneys  and  liver.  3. 
Syncope  from  cardiac  degeneration.  4.  Profuse 
haemorrhages  from  the  stomach  and  bowels.  5. 
Blood-poisoning  from  absorption  of  putrid  black 
vomit  in  the  stomach.  6.  The  formation  of 
abscesses  with  sequential  pyaemia. 

The  mortality  occasioned  by  yellow  fever 
appears  to  be  as  great  as  that  caused  by  any 
known  epidemic  or  endemic  disease,  and  varies 
in  different  localities  and  epidemics  from  10  to 
70  per  cent,  of  those  attacked. 

Prognosis. — Continuous  observations  of  the 
temperature  should  be  made,  as  by  that  means 
prognosis  and  treatment  may  best  be  regulated. 
If  the  axilla  temperature  rise  in  the  first  stage 
above  105°,  the  patient  is  in  imminent  danger  ; 
and  if  it  reach  from  109°  to  110°  death  is  al- 
most inevitable.  Cases  however  have  recovered 
in  which  the  temperature  has  reached  the  latter 
point.  When  the  temperature  rapidly  rises  to 
106°  and  upwards,  death  sometimes  occurs  sud- 
denly, and  apparently  solely  from  the  effects  of 
the  high  temperature  upon  the  blood,  heart,  and 
nervous  system,  as  in  sunstroke. 

Treatment. — 1.  Prophylactic.- Experience  has 
established  the  possibility  of  excluding  yellow 
fever  from  localities  in  which  it  has  prevailed  as 
an  epidemic,  subsequent  to  introduction  from 
other  regions,  by  means  of  an  absolutely  strict 
quarantine.  But,  hitherto,  it  has  been  almost 
impossible  to  arrive  at  any  definite  conclusions 
as  to  the  value  of  quarantine  in  those  regions  in 
which  the  disease  is  endemic  and  indigenous. 

Much  difference  of  opinion  has  existed  as  to 
the  value  of  disinfectants,  such  as  chlorine,  car- 
bolic acid,  and  sulphurous  acid.  In  arresting  the 
spread  of  the  fever  it  is  very  doubtful  whether 
much  of  the  benefit  that  has  been  attributed 
to  them  is  not  rather  to  be  ascribed  to  other 
causes ; and,  in  estimating  the  value  of  any 
such  sanitary  measures,  the  following  facts 
in  the  history  of  yellow  fever  should  be  con- 
sidered:— 

(a)  Yellow  fever  may  prevail  in  one  or  more 
cities,  and  at  the  same  time  be  entirely  absent 


YELLOW  FEVER. 


1804 

from  other  cities  in  the  same  zone,  and  subjected 
to  very  nearly  the  same  hygienic  conditions.  Tho 
mere  absence  of  jrnllow  fever  from  a particular 
city,  whilst  it  is  prevailing  elsewhere,  proves 
nothing  as  to  the  mere  sanitary  condition  and 
measures  of  the  city  enjoying  the  immunity. 

( b ) One  of  the  most  essential  elements  for  the 
origin  and  spread  of  yellow  fever  within  and 
immediately  around  its  recognised  geographical 
limits,  is  the  influx  of  strangers  and  immigrants, 
or  an  unacclimatized  population. 

(c)  It  is  not  provable  that  a wide-spread  epi- 
demic would  ever  arise  in  a city  within  the 
recognised  zone,  in  which  the  vast  proportion  of 
the  inhabitants  are  acclimatized,  and  have  been 
subjected  to  the  action  of  the  specific  poison. 

(d ) Yellow  fever  has  been  entirely  absent 
from  many  cities,  where  serious  epidemics  have 
occurred,  during  long  series  of  years;  and  at  other 
times  has  prevailed  to  a very  limited  extent,  and 
with  but  slight  mortality,  when  no  disinfectants 
have  been  used. 

2.  Curative.- — Yellow  fever  is  a ‘self-limited’ 
disease,  and  cannot  be  arrested  by  drugs.  Every 
case  should  be  regarded  as  serious,  however 
slight  the  symptoms  may  appear  ; and  on  account 
of  the  structural  alterations  in  the  blood  and 
organs,  the  closest  medical  attendance  and  most 
careful  nursing  are  required.  Since  so  many  of 
the  symptoms  are  due  to  arrest  of  the  functions 
of  the  skin  and  kidneys,  efforts  should  be  directed 
to  promote  the  activity  of  these  organs  during 
the  progress  of  the  disease.  Stimulant  diuretics 
should,  as  a rule,  be  avoided,  but  benefit  often 
follows  the  free  use  of  hot  mustard  foot-baths, 
vapour  baths,  and  sometimes  warm  baths.  Dia- 
phoresis and  diuresis  may  be  further  promoted 
by  large  draughts  of  lemonade,  decoctions  of 
orange  leaf  and  sage  tea,  and  water  charged 
with  carbonic  acid.  Absolute  rest  in  the  re- 
cumbent posture  must  be  maintained  as  far  as 
possible.  The  necessity  for  this  is  especially 
indicated  by  the  cardiac  weakness,  fatal  results 
having  followed  rising  from  bed  and  walking 
during  the  period  of  calm. 

The  maintenance  of  free  ventilation,  and  the 
avoidance  at  tho  same  time  of  sudden  changes  of 
temperature,  by  proper  coverings,  is  essential. 
Experience  shows  that  many  fatal  cases  from 
urinary  suppression  have  followed  sudden  changes 
and  falls  of  temperature.  Each  case  of  yellow 
fever  should  have  at  least  2,000  cubic  feet  of 
space  ; and  hospitals,  where  practicable,  should 
be  constructed  on  elevated  situations.  All  dis- 
charges should  be  immediately  removed  from  the 
sick-room ; the  bedding  frequently  changed ; and 
the  soiled  clothing  boiled,  or  baked  at  a tem- 
perature of  not  less  than  230°  Fahr. 

The  practice  of  covering  patients  with  heavy 
blankets,  and  at  the  same  time  giving  large 
quantities  of  hot  drinks,  with  the  object  of  in- 
ducing profuse  sweating,  frequently  appears  to 
be  injurious,  not  only  from  the  debilitating  effect, 
but  also  from  the  greater  susceptibility  of  the 
skin,  and  the  increased  tendency  to  renal  conges- 
tion thereby  induced. 

The  diet  should  be  light  and  nutritious.  Beef- 
tea,  chicken-tea,  corn-flour  and  rice  gruel,  barley 
water,  iced  milk,  and  milk  and  lime-water  are 
the  best  forms  of  nourishment,  and  should  be 


continued  at  regular  intervals  throughout  the 
active  stages  of  the  disease.  Solid  food  and 
even  bread  should  be  avoided. 

In  many  cases  the  preceding  measures,  accom- 
panied by  absolute  rest  in  bed,  and  the  careful 
and  continuous  attention  of  an  experienced  nurse, 
will  be  all  that  is  required. 

Alcoholic  stimulants  should  be  used  with 
caution.  They  have  proved  beneficial  in  cases 
attended  with  great  prostration,  champagne  ap- 
pearing to  be  the  best  form. 

The  treatment  for  hyperpyrexia  consists  iu 
the  giving  of  such  cardiac  sedatives  as  aconite, 
veratrum  viride,  or  gelseminum  ; the  injection 
of  large  quantities  of  ice-cold  water  into  the 
rectum  ; sponging  the  surface  with  cold  water, 
or  with  water,  acetic  acid,  and  alcohol ; and 
blood-letting.  It  appears  also  that  an  active 
purgative,  such  as  calomel  or  castor  oil,  followed 
immediately  by  one  or  two  full  doses  of  quinine 
in  the  first  twenty -four  hours  of  the  fever,  may 
reduce  the  temperature. 

Efficient  but  gentle  purgation  in  the  early 
part  of  the  first  stage  may  be  beneficial.  Mer- 
curials should  not  be  given  later  than  the  second 
day  for  an  adult ; eight  to  twelve  grains  of  calo- 
mel or  blue  pill,  or  an  ordinary  dose  of  castor 
oil,  will  be  sufficient.  Purgatives,  as  a general 
rule,  should  not  be  administered  in  the  stage  of 
depression.  An  emetic  maybe  useful  at  the  very 
beginning,  if  the  stomach  be  loaded.  Local  blood- 
letting, whilst  of  occasional  benefit  for  the  relief 
of  congestion  in  the  first  stage,  is  most  injurious 
later.  Dry-cuppings  and  sinapisms  are  usually 
sufficiently  effective. 

The  internal  administration  of  the  mineral 
acids  or  the  tincture  of  the  sesquiehloride  of 
iron,  from  their  supposed  beneficial  effects  upon 
the  jaundice  and  black  vomit  respectively,  is  of 
doubtful  propriety,  and  sometimes  directly  inju- 
rious. 

The  value  of  quinine  in  yellow  fever  is  not 
nearly  so  great  as  in  paroxysmal  malarial  fever  ; 
and  notwithstanding  statements  to  the  contrary, 
the  writer  fails  to  discover  any  facts  or  cases  by 
which  the  power  of  large  doses  of  quinine  to 
abort  this  disease  can  be  fully  and  unequivocally 
established,  though  its  efficacy,  not  only  in 
arresting,  but  in  warding  off  paroxysmal  fever, 
is  undoubted.  It  is  rather  as  an  antidote  to  the 
effects  of  the  poison,  than  to  the  poison  itself, 
that  quinine  is  of  use. 

Opium,  in  whatever  form,  should  be  adminis- 
tered with  great  caution,  from  its  poisonous 
effects  when  the  kidney-action  is  arrested,  but 
may  be  of  advantage  when  sleeplessness  and 
restlessness  are  prominent.  Arrest  of  the  func- 
tion of  the  kidneys,  owing  to  the  grave  alter- 
ations iu  their  structure,  is  beyond  relief  by 
drags.  The  tincture  of  ergot,  which  has  been 
recommended,  has  often  failed;  but  much  good 
has  been  accomplished,  and  the  function  of  the 
kidneys  restored,  by  the  injection  at  regular  in- 
tervals of  a pint  or  more  of  ice-cold  water  into 
the  rectum. 

When  there  is  a threatening  of  black  vomit  ice 
should  be  swallowed,  and  bags  of  the  same  ap- 
plied to  the  epigastrium.  Septic  poisoning  has 
been  known  to  follow  decomposition  of  the  blood 
effused  into  the  gastro-intestinal  tract,  and  to 


YELLOW  EEVER. 

prevent  this,  scruple  doses  of  sulpho-carbolate 
of  soda,  repeated  every  three  or  four  hours,  have 
been  given  with  advantage. 

During  the  period  of  calm,  active  medication, 
beyond  what  has  been  indicated,  should  be  ab- 
•tained  from.  The  diet  should  still  be  of  the 


ZYMOTIC:  ZYME.  1805 

simplest,  most  nutritious,  and  most  digestible 
character.  In  this  stage  there  is  often  a morbid 
craving  for  food,  and  in  some  instances  relaps* 
and  death  have  been  the  result  of  the  unrc 
strained  indulgence  of  the  appetite.1 

Joseph  Joses 


z 


ZINC,  Poisoning  by. — Synon.  : Er.  Em- 
poisonncment  par  le  Zinc,  Ger.  Zinkvergiftung. 

Poisoning  by  compounds  of  zinc  is  rare,  if  we 
except  poisoning  by  the  chloride  (Sir  W.  Burnett’s 
Fluid),  which  acts  as  a corrosive  poison,  like 
the  mineral  acids  {see  Poisons).  Zinc  sulphate 
(white  vitriol)  is  the  only  other  salt  of  zinc  of 
importance  from  a toxicological  point  of  view; 
this  salt  has  proved  fatal  in  a few  instances. 

Anatomical  Characters. — These  are  of  the 
same  nature  as  those  of  the  mineral  irritants — 
gastro-intestinal  inflammation,  ecchymoses,  and 
softening.  Ecchymoses  have  also  been  observed 
in  the  pleura. 

Symptoms. — The  symptoms  of  poisoning  by 
zinc  are  similar  to  those  produced  by  tartar 
emetic.  They  include  an  astringent,  metallic,  and 
burning  taste  in  the  mouth  ; early  and  violent 
vomiting  ; pain  in  the  abdomen  ; purging ; great 
prostration  and  anxiety ; a small  and  feeble 
pulse  ; shallow  respirations  ; cold  perspirations  ; 
and  collapse  and  exhaustion,  ending  in  death. 
The  intellect  is  unaffected. 

Diagnosis. — In  the  absence  of  any  history  of 
the  administration  of  zinc  sulphate,  the  diagnosis 
cannot  be  made  between  this  and  other  forms  of 
irritant  poisoning,  such  as  by  blue  vitriol,  except 
by  the  aid  of  chemical  analysis. 

Prognosis. — The  prognosis  of  zinc-poisoning 
is  generally  favourable. 

Treatment.  — Demulcent  drinks,  sedatives, 
and  alcoholic  stimulants  should  be  immediately 
given.  The  administration  of  a solution  of  the 
common  phosphate  of  soda,  largely  diluted,  is 
advisable.  It  acts  as  an  excellent  precipitant 
of  zinc,  in  the  form  of  an  insoluble  phosphate. 
Opiate  enemata  may  prove  serviceable. 

Thomas  Stevenson. 

ZOJSTA  or  ZOSTER  (<(w«'’J,  a girdle).— 
Synon.  : Shingles  ; Fr.  Zona ; Ger.  Zoster ; Giir- 
tclrose. 

This  term  applies  correctly  only  to  that  form 
of  herpes  which  runs  round  one  half  of  the  trunk 
cf  the  body,  usually  in  the  region  of  the  waist. 
In  other  situations  the  eruption  is  named  in 
accordance  with  the  region ; for  example,  Herpes 
facialis  ; H.  collaris  ; H.  brachialis  ; H.  crumlis  ; 
&e.  Latterly,  however,  the  term  zoster  has  crept 
into  our  dermatological  literature  as  a generic 
appellation,  and  we  read  of  Zoster  facialis, 
brachialis,  &c.,  names  which  philologically  are 
evidently  inaccurate.  See  Herpes. 

Erasmus  Wilson. 

ZYMOTIC:  ZYME  (£  uia>.  I ferment: 


ferment). — Synon.  : Er.  Zymotique : Zymase , 
Ger.  Gdhmngsfahig  : Gdhrstoff.  — The"  terms 
zyme,  zyminc,  zymotic,  and  zymosis  were  intro- 
duced by  Dr.  Parr,  in  a letter  to  the  Registrar- 
General  in  1842,  and  employed  by  him  to  denote, 
in  a general  way,  the  poison  (and  pathological 
processes  excited  by  it)  of  ‘ epidemic,  endemic, 
and  contagious  diseases.’  In  using  the  word 
{vfia,  he  was  careful  to  point  out  that  he  did  not 
consider  the  morbific  process  to  be  absolutely 
identical  with  the  ordinary  phenomena  of  fer- 
mentation, and  that  he  wished  the  terms  zymosis, 
zymotic,  &c.,  to  be  employed  in  English,  ‘ not  in 

1 In  the  epidemic  of  yellow  fever  in  New  Orleans  dur- 
ing 1878,  when,  in  a population  of  210,000  the  deaths 
numbered  4,056,  the  writer  had  an  extensive  experience  of 
the  disease,  himself  treating  256  cases,  of  whom  18  died. 
The  plan  of  treatment  was  based  upon  the  preceding 
principles.  The  alimentary  canal  was  cleared  at  the 
outset  by  an  emetic  of  ipecacuanha,  and  a powder  of  10 
to  20  grains  each  of  calomel  and  quinine,  followed  by  a 
full  dose  of  castor  oil.  The  action  of  tlie  skin  was 
excited  by  hot  mustard  foot-baths  and  mild  diuretics. 
The  function  of  the  kidneys  was  maintained  by  the 
regular  use  of  cold  water,  by  attention  to  the  covering 
of  the  patient,  and  avoiding  cold  currents  of  air.  Abso- 
lute rest,  in  all  cases,  in  a well-ventilated  room,  for  from 
eight  to  fourteen  days,  or  even  longer,  was  strictly 
enforced,  supplemented  with  careful  nursing  night  and 
day,  and  the  most  exact  record  of  the  progressive  state  of 
the  patient.  During  the  period  of  febrile  excitement 
the  patients  were  confined  to  barley  water.  When  the 
initial  temperature  was  high,  2 to  4 drops  of  tinctnra 
veratri  viridis,  or  5 to  10  drops  of  tinctura  gelsemii, 
were  administered  every  two  or  four  hours,  combined 
with  friction  with  a liniment  composed  of  from  1 to  2 
drachms  of  the  sulphate  of  quinine  mixed  with  3 fluid 
ounces  each  of  soap  liniment  and  olive  oil.  Ten  grains 
of  sulpho-carbolate  of  soda  in  orange-leaf  tea  were  given 
every  four  hours.  Where  the  head  was  very  hot  and 
there  was  much  nervous  irritability,  cold  applications 
were  employed.  Gastric  irritation  was  treated  by  sina- 
pisms to  the  epigastrium,  with  carbonate  of  lime  and 
creasote  internally.  Except  in  eases  attended  with  great 
nervous  excitement,  without  urinary  suppression,  opiates 
and  chloral  were  not  given  ; but  in  such  cases  they  were 
apparently  beneficial.  Cupping  over  tbeloins  and  bromide 
of  potassium  were  used  when  the  urine  was  diminished 
in  quantity.  After  the  subsidence  of  the  febrile  excite- 
ment, iced  champagne  and  beef-tea  were  administered 
in  small  quantities,  at  regular  intervals.  In  cases  which 
assumed  the  ‘ typhoid  state,’  attended  with  tympanites, 
ice-cold  enemas,  containing  small  quantities  of  tincture 
of  assafcetida  and  oil  of  turpentine,  were  found  to  be 
beneficial,  by  reducing  the  temperature,  stimulating  the 
bowels  to  expel  the  flatus,  and  promoting  the  action 
of  the  kidneys.  When  secondary  fever  ensued,  and  pre- 
sented an  intermittent  or  remittent  type,  the  sulphate 
and  bromide  of  quinine  were  freely  used.  And  when  the 
stomach  would  tolerate  nourishment  and  stimulants, 
beef-tea,  chicken  tea,  beefsteak,  and  port  wine  or  brandy 
were  administered.  When  convalescence  was  prolonged, 
or  life  endangered  by  abscesses  or  carbuncles,  iron  and 
other  tonics  were  given,  together  with  a nutritious  diet, 
and  the  local  application  of  carbolic  acid,  tincture  of 
iodine,  &c.  Relapses  were  avoided  by  confining  the 
patient  to  bed  until  the  heart  had  regained  its  u»ta! 
vigour. 


1806 


ZYMOTIC:  ZYME. 


the  sense  which  they  have  in  Greek,  but  as  ge- 
neral designations  of  the  morbid  processes  and 
their  exciters.’  With  this  qualification  clearly 
expressed,  the  use  of  the  root-form  ( up. - has  be- 
come general,  not  only  in  scientific  literature, 
but  also  in  the  public  press— almost  invariably, 
however,  in  the  adjectival  form  zymotic. 

Fourteen  years  later  (1856),  in  the  Sixteenth 
Annual  Report  of  the  Registrar-General,  Dr. 
Farr  described  the  diseases  of  the  zymotic  class 
as  conveniently  referable  to  four  groups.  These 
aro : — 1 . The  Miasmatic,  diffusible  through  the 
air  or  water,  attended  by  fevers  of  various  forms ; 
the  matter  by  which  they  are  communicated  is 
derived  from  the  human  body,  as  iD  small-pox, 
or  from  the  earth  (as  in  ague).  These  two  dis- 
eases are  types  of  this  class.  2.  The  Enthetic 
diseases,  which  may  properly  be  called  contagious, 
being  communicated  by  contact,  puncture,  or 
inoculation.  Syphilis  and  glanders  are  types  of 
this  class.  3.  The  Dietic  diseases,  which  arise 
when  the  blood  is  supplied  with  improper  or 
bad  food.  Scurvy  and  ergotism  are  the  types  of 
this  class.  4.  The  Parasitic  diseases,  which  at- 
tack especially  dirty  populations,  and  infest  the 
skin,  the  intestinal  canal,  and  all  the  structures 
of  the  body. 

This  classification  is  open  to  serious  objections. 
It  is  quoted  here  rather  because  it  continues  to 
be  employed  in  official  reports,  than  on  account 
of  its  intrinsic  importance.  Modern  pathology 
will  probably  soon  necessitate  its  revision. 

Recently,  indeed,  the  word  zymotic  has  been 
restricted  to  the  acute  specific  diseases,  included 
under  the  first  group  (miasmatic)  in  the  above 
classification ; and  at  the  present  time  it  is  in 
this  limited  sense  that  it  is  most  commonly  used. 

Another  important  application  of  the  term 
must  now  be  referred  to.  Within  the  last  few 
years  the  root-form  fun-  has  been  introduced 
into  the  terminology  of  normal  physiology  by 
Heidenhain  in  Germany,  to  designate  the  active 
substance  (precursor  of  trypsin,  &c.),  contained 
in  gland-cells  as  zymogen,  which  develops  the 
ferment  by  its  metamorphosis.  Thus,  unfor- 
tunately for  the  purposes  of  exact  description, 
the  same  root-form  is  employed  by  pathologists 
and  physiologists  to  designate  two  apparently 
distinct  processes.  Although  the  intimate  rela- 
tionship of  these  two  processes  was  recognised  as 
early  as  the  seventeenth  century,  by  such  autho- 
rities as  Sydenham  and  Morton,  they  cannot  at 
present  be  considered  identical,  notwithstanding 
the  fact  that  the  similarity  becomes  more  strik- 
ing with  every  fresh  addition  to  experimental 
physiology. 

Corresponding  with  the  adjective  zymotic  is 
the  substantive  zyme.  This  is  a useful  namo, 
by  which  we  refer  to  the  poisonous  cause  of 


zymotic  diseases.  It  is  simpler  than  the  word 
zymine,  originally  proposed  by  Dr.  Farr;  and 
(what  is  much  more  important)  to  speak  of  the 
contagious  poison  as  ‘ a zyme,’  does  not  imply 
the  acceptance  of  any  particular  theory  of  disease, 
while,  on  the  other  hand,  the  use  of  the  word 
‘ germ  ’ distinctly  conveys  the  idea  of  some  orga- 
nised structure,  itself  the  cause  of  the  disease 
by  subsequent  growth  and  multiplication.  See 
Germs  of  Disease. 

The  necessity  for  employing  the  word  zymosis 
does  not  seem  to  be  felt  as  yet ; but  the  same 
reasons  that  lead  us  to  speak  of  the  agent  as  a 
zyme  should  also  guide  us  to  use  zymosis  in  the 
place  of  more  usual  periphrases. 

Analogy  between  Fermentation  and  Infec- 
tive Processes. — Such  being  the  derivation  of 
the  word  zymotic  and  the  terms  related  to  it,  it 
is  natural  to  inquire  how  far  an  analogy  can  be 
traced  between  the  life-history  of  the  diseases 
thus  designated,  and  the  process  of  fermenta- 
tion. This  subject,  which  has  an  important  bear- 
ing upon  the  doctrine  of  contagious  diseases,  is 
discussed  at  length  in  the  article  on  Contagion 
(page  290).1  It  is  there  shown  how  far  the  two 
processes  resemble  each  other,  and  in  what  re- 
spects they  appear  to  be  different,  at  least  in 
some  kinds  of  zymotic  disease.  It  must  not  be 
forgotten  that  fermentation  deals  with  a com- 
paratively simple  substance,  for  instance  dead 
organic  or  inorganic  compounds,  and  the  dis- 
ease-process with  a more  complex  one,  namely, 
the  living  animal  organism,  although  the  ele- 
ments of  action  (the  ferment  on  the  one  hand, 
and  the  zyme  or  zymine  on  the  other)  seem  to 
have  identical  characters.  By  interposing  the 
consideration  of  putrefaction  between  that  of 
fermentation  and  zymosis,  it  is  easy  to  see,  from 
examining  the  products  of  each,  how  similar 
must  bo  the  individual  agencies  ; but,  the  actual 
working  of  the  agent  in  each,  or  indeed  the  real 
nature  of  each,  being  unknown,  the  whole  pro- 
blem remains  unsettled. 

Victor  Horsley. 

1 Although  it  is  four  years  since  the  article  Contagion 
was  written  by  Mr.  Simon,  he  has  thought  it  desirable  to 
leave  that  article  unaltered,  preferring  that  it  should  be 
supplemented,  in  respect  of  the  intervening  years,  by  the 
present  article,  and  others  on  related  objects.  In  discuss- 
ing the  subject  of  the  organic  constitution  of  the  meta- 
bolic contagia,  Mr.  Simon  says: — ‘Though  it  would  be 
at  least  premature  to  say  of  these  diseases’  [erysipelas, 
pyaemia,  tuberculosis,  enteric  fever,  cholera,  diphtheria, 
and  the  smallpox  of  man  and  beast],  ‘ that  they  certainly 
have  as  their  contagia  mycrophyles  respectively  specific  to 
them,  it  seems  at  present  not  too  much  to  say,  that  pro- 
bably such  will  be  found  the  case.  How  far  these  anti- 
cipations have  already  been  realised  may  be  learned  by 
reference  to  the  articles  Bacteria  ; Bacilli  (in  Appen- 
dix) ; Micrococcus  ; Pustule,  Malignant  ; and  on  the 
several  diseases  in  which  the  presence  of  such  organism* 
has  been  recognised.  See  also  Antiseptic  Treatment.— 
Ed.  (September  1882). 


APPENDIX 


ACONITE,  Poisoning  by. — Synon.  : Fr. 
Empoisonnement  par  VAconit;  Ger.  Eisenkut- 
vergiftung. — The  common  garden-plant,  Aconi- 
tum  napellus, known  also  as  ‘ ■wolfsbane’  or  ‘blue- 
rocket,’  as  well  as  other  species  of  aconitum,  are 
poisonous,  and  owe  their  poisonous  properties  to 
the  presence  of  an  alkaloid,  aconitine  or  aconitia, 
or  perhaps  to  a mixture  of  alkaloids  passing 
under  this  name.  A similar  alkaloid,  pseud- 
aconitine,  has  been  obtained  from  the  Indian 
aconite,  A.  ferox ; and  another  alkaloid,  jap- 
aconitine,  from  Japanese  aconite  roots.  All  parts 
of  A.  napellus  are  poisonous.  The  three  alka- 
loids, aconitine,  pseudaconitine,  and  japaconi- 
tine,  are  perhaps  the  most  poisonous  alkaloids 
known.  All  parts  of  the  aconite  plant  when 
chewed,  and  aconitine  when  placed  upon  the 
lips  or  tongue,  produce,  after  a few  minutes,  a 
disagreeable  acrid  burning  sensation,  followed 
by  numbness,  loss  of  sensibility  of  the  part,  sali- 
vation, and  an  after-sensation  of  searedness. 
These  sensations  may  last  for  several  hours. 

The  fresh  root  of  aconite  has  frequently  been 
eaten  in  mistake  for  horse-radish,  to  which  it 
bears  a remote  resemblance.  The  root  of  horse- 
radish is  whitish  on  the  exterior,  is  long  and 
of  fairly  uniform  diameter,  has  a pungent  odour 
when  scraped,  and  the  scraped  surface  retains 
its  white  appearance ; whereas  aconite  root  is 
brown  and  conical,  is  destitute  of  pungent 
odour,  and  speedily  acquires  a pink  colour  when 
scraped  and  exposed  to  the  air.  Mistakes  more 
frequently  occur  from  liniments  containing  aco- 
nite being  swallowed  in  error.  In  two  cases  the 
root  has  been  administered  with  homicidal  in- 
tent; and  in  a recent  case  a young  man  was 
killed  by  the  administration  of,  as  it  is  sup- 
posed, two  grains  of  English  aconitine.  Acci- 
dents have  also  arisen  from  the  administration 
cf  the  potent  English  aconitine  in  mistake  for 
the  impure  inert  exotic  or  German  alkaloid,  or 
mixture  of  alkaloids  passing  under  that  name. 

Anatomical  Characters. — After  poisoning 
by  aconite  there  may  be  gastric  congestion  or 
inflammation  ; but  these  may  be  absent. 

Symptoms. — When  aconite,  or  any  of  its  pre- 
parations, is  taken  by  the  mouth,  the  first  sensa- 
tion, transitory  and  mainly  due  to  the  action  of 
the  solvent,  is  followed  in  about  three  minutes 
by  an  intolerable  burning  and  numbing  pain, 
extending  from  the  place  of  application  to  all 
the  surrounding  parts  of  the  mucous  membrane. 
There  is  salivation  ; and  the  burning  sensation 


extends  down  the  gullet  to  the  stomach.  Occfe- 
sionally,  when  the  poison  has  been  rapidly  swal- 
lowed, no  marked  symptoms  may  supervene  for 
half  an  hour.  The  general  symptoms  are  very 
varied,  but  may  all  be  referred  to  weakening  of 
the  heart’s  action,  disturbances  of  respiration, 
and  paralysis  of  sensation  on  the  surface  of  the 
body.  This  last  may  be  described  as  ‘ numbness  ’ 
or  ‘ drawing  of  the  skin,’  or  by  some  equivalent 
term.  There  is  pain  in  the  epigastrium,  violent 
vomiting,  occasionally  purging ; the  pulse,  at 
first  rapid,  quickly  diminishes  in  frequency  and 
force  till  it  is  imperceptible ; the  skin  is  cold, 
clammy,  and  livid ; respiration  is  laboured.  The 
pupils,  at  first  contracted,  afterwards  dilate; 
and  this  dilatation  sometimes  occurs  suddenly 
and  transitorily,  and  is  accompanied  by  blind- 
ness. Convulsions  are  not  common  ; but  vomit- 
ing is  often  due  to  spasmodic  contraction  of  the 
diaphragm,  causing  frothing  at  the  mouth.  Con- 
sciousness is  retained  till  near  the  end  of  life. 

Diagnosis.  — The  peculiar  sensation  in  the 
mouth— burning,  feeling  of  searedness,  numb- 
ness, &e.— the  great  cardiac  depression,  and  the 
difficulty  of  respiration,  will  generally  serve  to 
determine  the  nature  of  the  case. 

Prognosis. — Death  usually  occurs  within  four 
or  five  hours.  If  the  patient  survive  twelve 
hours,  recovery  is  usually  rapid  and  complete. 

Fatal  dose. — Of  the  root  sixty  grains — pro- 
bably much  less  might  suffice.  Of  the  pharma- 
copceial  tinctura  aconiti  (1  in  S)  two  or  three 
fluid  drachms.  Fleming’s  tincture  is  about  six 
times  as  strong  as  the  officinal  tincture,  and 
twenty-five  minims  have  proved  fatal.  Four 
grains  of  alcoholic  extract  have  proved  a fatal 
dose.  English  aconitine  or  aconitia  (the  alka- 
loid) is  terribly  potent : l-200(Jth  grain  will 
produce  a very  decided  sensation  on  the  tongue, 
and  it  is  probably  as  poisonous  as  the  crystal- 
lised French  aconitine-nitrate,  one-sixteenth  of 
a grain  of  which  has  killed  an  adult  within  five 
hours. 

Treatment. — In  proceeding  to  treat  a case  of 
poisoning  by  aconite  we  must,  first,  wash  out  the 
stomach  by  means  of  the  stomach-pump,  and 
promote  vomiting  by  warm  emetics,  of  which 
carbonate  of  ammonia  is  the  best.  Stimulants 
must  be  freely  administered  ; also  strong  black 
coffee  or  tea.  Brandy  and  ether  may  be  injected 
subcutaneously.  Digitalis  is  a counter-poison, 
and  may  be  administered  with  effect  subcu- 
taneously, in  doses  of  twenty  minims  of  the 


1308  ACONITE,  POISONING  BY. 
tincture,  repeated  in  an  hour  or  so  if  necessary. 
Inhalations  of  nitrite  of  amyl  may  afford  some 
relief.  The  patient  must  be  kept  strictly  in  the 
recumbent  position,  warmth  being  applied  to 
the  surface ; and,  as  a last  resort,  artificial 
respiration  must  be  used. 

Thomas  Stevenson. 

AINHUM  (Nat.,  to  saw).  — This  disease 
was  first  described  by  Dr.  da  Silva  Lima  of 
Bahia  in  1867.  It  is  peculiar  to  the  African 
race,  being  found  not  only  amongst  the  inhabi- 
tants of  the  "West  Coast  of  Africa,  but  also 
amongst  the  Hindoos  of  African  descent,  as 
well  as  amongst  the  slave  population  of  South 
America.  At  its  commencement,  a groove  or  fur- 
row is  seen  at  the  base  of  the  little  toe  (the  part 
almost  invariably  attacked),  situated  on  its  inner 
and  inferior  aspect,  and  corresponding  to  the 
digito-plantar  fold.  The  furrow  soon  extends 
to  the  entire  circumference  of  the  toe,  and  be- 
coming gradually  deeper,  the  latter  is  left  hang- 
ing by  a slender  pedicle,  which  can  only  be 
brought  into  view  by  separating  the  walls  of 
the  furrow.  The  distal  portion  swells  into  an 
ovoid  mass,  about  twice  its  natural  size  ; finally 
some  accident  snaps  the  pedicle,  and  th<3  toe 
drops  off,  in  from  four  to  ten  years  from  the 
commencement  of  the  disease. 

The  furrow  is  caused  by  a constricting  band 
of  hardened  and  contracted  skin — a local  sclero- 
derma— which  leads  to  faulty  nutrition  and  de- 
generative changes  in  the  parts  beyond. 

Ainhum  is  not  a painful  affection  in  itself, 
but  the  extreme  mobility  of  the  little  toe  causes 
trouble  and  inconvenience,  for  which  patients 
often  seek  relief  in  amputation. 

Occasionally  the  sides  and  bottom  of  the 
furrow  ulcerate ; not  unfrequently  both  little 
toes  are  attacked  by  the  disease.  Males  are 
more  subject  to  it  than  females.  /The  micro- 
scope reveals  only  atrophic  and  degenerative 
changes.  The  cause  of  ainhum  is  entirely  ob- 
scure. It  has  been  cured  by  the  early  division 
of  the  constricting  band.  A.  Sangster. 

AMBULANCE  ( amhulo , I walk  about). — 
Definition. — A vehicle  for  the  conveyance  of 
invalid  or  wounded  persons.  The  term  is  gene- 
rally applied  to  such  of  these  vehicles  as  are 
drawn  by  one  or  more  horses.  The  French  use 
it  to  designate  a field  military  hospital. 

The  writer  has  described  the  requirements  of 
an  ambulance  carriage  as  follows: — 1.  Ease  of 
entrance  and  exit ; 2.  Freedom  from  jar  during 
locomotion  ; 3.  Protection  against  weather,  with 
facilities  for  regulating  air  and  light ; 4.  Light- 
ness of  structure,  consistent  with  strength ; 5. 
Facility  of  turning,  and  of  transferring  the 
vehicle  to  or  from  a railway-truck  or  steam- 
ship, without  disturbing  the  patient. 

Military  ambulances  are  adapted  for  carrying 
patients  both  sitting  and  lying,  along  with  an 
attendant ; as  well  as  food,  water,  medicine,  and 
other  appliances.  In  the  ambulance  designed  by 
the  writer,  the  litter,  which  is  slid  noiselessly  on 
india-rubber  rollers,  rests  on  a tramway,  between 
which  and  the  body  of  the  vehicle  are  inter- 
mediate counterpoise  springs,  which  intercept 
shock  and  jar. 


AUSTRALASIA. 

_ Every  ambulance  should  be  provided  with  a 
litter-sheet,  which  can  be  used  without  its 
stretcher  poles,  for  carrying  the  patient  through 
places  too  narrow  or  tortuous  for  other  modes 
of  conveyance.  Benjamin  Howard. 

ANAESTHETICS.  — The  two  following  sub- 
stances have  been  introduced  as  anaesthetics  since 
the  article  on  the  subject  was  written,  and  call 
for  brief  description. 

Bromide  of  Ethyl  (C-.HjBr).— This  substance 
has  been  recommended  and  moderately  used  as 
an  anaesthetic.  Its  merits  are  that  it  exhilarates 
and  produces  rapid  anaesthesia.  Its  effects  pass 
off  quickly,  without  any  tendency  to  depress  the 
action  of  the  heart.  The  objections  to  the  use 
of  bromide  of  ethyl  are  that  it  is  liable  to 
decompose,  leaves  a strong  smell  and  taste  of 
bromine,  and  sometimes  produces  headache  and 
sickness.  Two  deaths  from  it  in  America  have 
been  reported.  Its  use  has  been  abandoned  in 
England. 

Diehloride  of  Ethidene  (C21I.,C12). — This 
substance  is  obtained  by  distilling  aldehyde 
and  pentaehloride  of  phosphorus.  The  effects 
of  this  agent  are  intermediate  between  those 
of  chloroform  and  ether.  Its  odour  is  usually 
preferred  to  that  of  either  of  the  former.  The 
writer  has  used  it  very  extensively;  and  in 
minor  cases,  in  which  the  operation  has  lasted 
only  five  minutes,  the  recovery  is  rarely  attended 
by  sickness  or  excitement.  In  the  more  pro- 
longed cases  it  was  found  to  cause  vomiting,  but 
this  ceased  much  more  rapidly  than  when  chloro- 
form had  been  given.  Its  effect  upon  the  heart 
when  given  in  large  doses  is  depressing,  and 
the  pulse  should  be  carefully  watched  during 
its  administration. 

This  anmsthetic  was  used  by  Dr.  Snow,  but 
abandoned  chiefly  on  account  of  its  expense.  It 
was  reported  upon  favourably  by  the  Glasgow 
Anaesthetic  Committee  of  the  British  Medical 
Association.  They  found  that  the  blood-pressure 
was  diminished  by  it  as  well  as  by  chloroform, 
but  that  it  was  more  regular  in  its  action,  and  less 
potent  also,  so  that  they  found  it  much  easier  to 
keep  a dog  alive  whilst  profoundly  under  its  in- 
fluence than  whilst  under  chloroform. 

Ether. — The  following  point  is  of  importance 
in  connexion  with  the  employment  of  ether  as  an 
anaesthetic.  Under  ether,  bleeding  is  more  rapid 
than  usual ; and  this  may  produce  syncope  when 
the  stimulating  effect  of  the  anaesthetic  is  pass- 
ing off.  To  prevent  this  result,  whenever  haemor- 
rhage is  likely  to  be  great,  temporary  ligatures 
should  be  applied  to  the  arms  and  thighs,  so  as 
to  detain  blood  in  the  veins  until  the  chief  ves- 
sels that  have  been  severed  have  been  tied. 

J.  T.  Cloves. 

ARKANSAS  SPRINGS,  in  Arkansas, 
United  States. — Thermal  waters.  See  Mine- 
ral "Waters. 

AUSTRALASIA. — The  portion  of  Poly- 
nesia lying  between  10°  and  50°  S.  latitude  and 
110°  E.  and  170°  W.  longitude,  which  may  be 
said  to  include  Australia,  Tasmania,  New  Zea- 
land, the  Fiji  Islands,  the  New  Hebrides,  and 
some  less  important  islands. 

Australia.— The  climate  of  the  T.ast  conti- 


AUSTRALASIA. 

nent.  of  Australia,  'which  is  partly  temperate  and 
partly  tropical,  depends,  first,  on  its  latitude, 
*nd,  secondly,  on  its  conformation,  the  mountain 
ranges  being  distributed  along  the  coast  lines, 
especially  on  the  eastern  shores.  In  the  interior, 
which  is  comparatively  flat,  and  for  the  most 
part  a sandy  desert,  there  is  great  heat  and 
little  rain.  The  hot  winds  from  the  east  are 
often  sufficient  in  the  summer  to  raise  the  ther- 
mometer to  127°  Fahr.  There  are  also  sea  winds 
from  the  N.  and  N.  E.  The  southerly  winds, 
prevailing  chiefly  from  November  to  February, 
are  winds  of  great  velocity,  ending  in  heavy 
thunderstorms.  In  the  tropical  part  the  rainfall 
is  from  November  to  April,  and  in  the  tempe- 
rate, which  lies  to  the  east  and  south,  it  prevails 
only  in  the  winter  season. 

The  following  aro  among  the  principal  towns 
or  centres  to  which  invalids  proceed : — 

Adelaide,  the  capital  of  South  Australia,  lat. 
35'  S.,  long.  135^°  E.  It  suffers  from  great  heat 
and  drought.  The  mean  temperature  is  65°, 
the  maximum  115°,  and  the  minimum  34°;  the 
range  being  81°,  and  the  mean  daily  range  20°. 
The  humidity  is  60  per  cent.,  and  the  rainfall  21 
inches.  The  soil  is  sandy. 

Brisbane,  the  chief  town  of  Queensland,  lat. 
27^°  S.,  long.  153°  E.  The  climate  is  almost 
tropical.  The  mean  temperature  is  70°,  the 
maximum  108°,  the , minimum,  34°;  the  range 
74°,  with  a mean  daily  range  of  21°.  The  rain- 
fall is  51  inches,  and  the  mean  humidity  76  per 
v'-ent.  Queensland  is  for  the  most  part  elevated  ; 
and  the  climate  of  the  Darling  Downs  is  consi- 
dered very  fine. 

Melbourne,  the  capital  of  Victoria,  lat.  38°  S., 
long.  145°  E.  It  has  the  roputation  of  being 
a healthy  and  agreeable  residence;  the  climate 
being  dry  and  temperate,  and  far  cooler  in  sum- 
mer than  that  of  Sydney.  Mean  temperature  57°, 
maximum  111°,  minimum  27°,  showing  a range 
of  84°  ; daily  range  18°.  Mean  humidity  72  per 
cent.  Rainfall,  26  inches. 

Berth,  in  Western  Australia,  very  healthy,  but 
as  yet  little  suited  to  the  requirements  of  in- 
valids. The  temperature  is  63°  (mean),  and 
rainfall  30  inches  in  110  days. 

Sydney,  the  capital  of  New  South  Wales,  lat. 
24°  S.  and  long.  151°  E.  The  climate  of  New 
South  Wales  is  clear  and  dry,  the  temperature 
depending  more  on  the  altitude  than  on  the  lati- 
tude. The  plains  in  the  interior,  swept  by  hot 
winds,  are  very  dry,  while  the  coast  districts 
have  abundant  rain.  Mean  temperature  62'5°, 
maximum  107°,  minimum  36°  ; range  71°  ; mean 
daily  range  14°.  Humidity  72  per  cent.,  and 
rainfall  50  inches. 

Tasmania.— Tasmania  lies  150  miles  south  of 
Australia,  between  lat.  40°  40'  and  43°  38',  and 
is  mountainous,  with  a deeply  indented  coast- 
line. The  climate  is  more  temperate  and  equable 
than  that  of  the  south  coast  of  Australia.  In 
winter  the  cold  is  sufficient  to  produce  thin  ice 
in  the  low  lands,  and  snow  showers  in  the 
higher  ranges.  The  mean  temperature  of  Hobart 
Town  on  the  S.E.  coast  is  54°,  the  summer  mean 
being  62°  and  the  winter  47°.  The  rainfall 
varies  greatly,  from  100  inches  at  Macquarie 
Harbour  on  the  W.  coast,  to  24  inches  at  Hobart 
Town,  distributed  over  145  days.  The  prevalent 
114 


BACILLI.  1809 

winds  are  from  the  N.E.  and  S.W.  The  climate 
is  favourable  to  infant  life,  and  the  country  is 
regarded  as  a sanatorium  for  invalids. 

New  Zealand. — New  Zealand  lies  between 
34°  50'  and  47°  50'  S.  lat.,  and  consists  of  a 
North  and  a South  besides  smaller  Islands.  The 
Northern  Island  is  for  the  most  part  volcanic, 
and  abounds  in  hot  springs,  which  promise  to 
become  extensively  useful,  and  active  craters, 
which  impart  an  important  influence  to  its  cli- 
mate. The  Southern  Island  contains  a lofty 
range  of  snowclad  mountains,  whose  lower  slopes 
form  on  the  eastern  shore  a series  of  terraces 
known  as  the  Canterbury  Plains,  and  other  fer 
tile  regions. 

The  climate  is  mild  and  bracing,  but  deci 
dcdly  of  a windy  character,  and  not  suited  for 
all  invalids : at  Auckland  in  1876  no  calm  day 
was  recorded,  the  prevalent  winds  being  W.S.W. 
The  mean  temperature  of  the  North  Island  is 
58°,  of  the  South  54°.  The  maximum  varies 
from  87°  at  Christ  Church  to  75°  at  Hokitika, 
and  the  minimum  from  25°  to  34°  in  the 
Southern  Island.  Cold  is  as  a rule  unknown  in 
the  North  Island,  while  in  the  South  there  are  a 
few  snowy  days  each  year  on  the  coast.  The 
rainfall  varies  from  32  inches  in  135  days  at 
Christ  Church,  to  131  inches  in  186  days  at 
Hokitika. 

Fiji  Islands. — The  Fiji  Islands,  partly  of  vol- 
canic and  partly  of  coraline  origin,  have  a tro- 
pical climate,  moderated  by  the  trade  winds,  so 
that  the  mean  temperature  does  not  exceed  80'* , 
the  minimum  being  given  as  65°.  The  rainfall 
is  chiefly  from  October  to  April — the  hot  season, 
and  varies  from  124  to  215  inches  in  170  days. 
See  Climate,  Treatment  of  Disease  by. 

C.  Theodore  Williams. 


BACILLI  ( bacillus , a little  rod  or  staff). — 
Synon.  : Ft.  Bodies;  Ger . Bacillen. 

Definition.  — Rod-shaped  vegetable  micro- 
organisms, consisting  of  single  cells,  the  length 
of  which  exceeds  twice  the  breadth. 

Description. — The  bacilli,  thus  roughly  de- 
fined, form  a group  of  algse  which,  until  lately, 
wero  classified  under  the  general  terms  of  Bac- 
teria and  Schiiomycetce.  At  present,  in  accord- 
ance with  the  necessities  of  description,  the  word 
bacterium  is  limited  empirically  to  mean  a short 
rod-shaped  organism,  whose  breadth  is  not  less 
than  half  its  length  ; and,  moreover,  as  the  term 
Schizomyeetse  does  not  fully  represent  the  mode 
of  reproduction  in  the  bacilli,  its  value  as  a 
comprehensive  term  is  thereby  lessened.  It 
will,  therefore,  be  well  to  regard  bacilli  as  a 
distinct  order.  From  differences  in  their  habitat 
and  nutritive  requirements,  they  may  be  held 
to  be  specifically  distinct  from  one  another,  al- 
though this  may  not  be  evident  morphologically 
with  our  present  methods  of  research. 

In  common  with  the  rest  of  micro-organisms, 
bacilli  consist  of  a protoplasmic  body,  surrounded 
by  a sheath,  probably  of  the  nature  of  cellulose. 
The  protoplasm  is  albuminous,  granular,  and 
occasionally  shows  brightly  refracting  fat  gran- 
ules within  it ; while  the  sheath  or  envelope  is 
clear,  with  a sharp  outline,  and  capable  of  resist- 
ing very  powerfully  the  action  of  reagents 


1830 


BACILLI. 


The  sides  of  the  rod  are  parallel  straight  lines 
in  the  adult  form,  while  the  extremities  may  be 
either  rounded  or  square.  Notice  has  been  taken 
of  this  fact  in  attempting  to  establish  diagnostic 
points  of  difference  among  the  bacilli;  but  the 
shape  of  the  extremities  varies  in  the  same  kind 
of  bacillus,  so  as  to  suggest  that  the  rounded  end 
is  but  an  advance  on  the  square  surface  left  im- 
mediately after  fission  of  the  parent  organism. 

Although  the  breadth  of  each  bacillus  appears 
to  be  constant  for  the  same  kind,  the  length,  as 
may  be  expected,  varies  considerably,  so  that 
measurements  in  this  direction  are  of  but  re- 
lative value.  The  difference  of  breadth  would 
afford  a means  of  classification,  but  at  present 
the  bacilli  are  named  after  the  diseases  and 
other  conditions  with  which  they  are  found  to 
be  in  relation. 

Development. — Tho  bacilli  multiply  by  two 
distinct  methods,  namely,  simple  transverse 
fission,  and  spore-formation.  The  process  of 
fission,  as  it  occurs  in  the  adult  rod,  appears  to 
consist,  first,  in  a contraction  of  the  proto- 
plasm at  the  centre,  followed  by  an  involution 
of  the  cellulose  envelope,  and  subsequent  sepa- 
ration of  the  two  halves.  The  rod  may  grow  to 
twice  its  length  before  dividing  ; but  when  rapid 
multiplication  is  occurring,  it  is  common  to  find 
rods  of  half  the  adult  length.  The  process  of 
spore-formation  commences  by  steady  growth 
of  the  rod  into  a long  wavy  and  flexible  fila- 
ment, which,  with  others,  may  form  a thick  felt- 
work.  In  the  next  stage  bright  points  appear 
in  the  protoplasm,  which  increase  in  size,  and, 
front  being  first  cylindrical  in  shape,  become 
ovoid,  and  so  form  spores  imbedded  in  the  fila- 
ments. The  protoplasmic  sporo  then  becomes 
covered  with  an  envelope  similar  to  that  cover- 
ing the  adult  rod,  and,  getting  free  from  the 
filament,  develops  into  a rod  by  outgrowth  from 
one  end. 

Adult  Life-History. — The  vital  changes  of 
the  bacilli  are  similar  to  those  of  other  vegetable 
miero-organisms,  that  is,  they  require  a moderate 
temperature  (30°  to  10°  C.),  a nitrogenous  pabu- 
lum, and  the  admission  of  free  oxygen  for  their 
full  development.  The  different  kinds  of  bacilli 
vary  with  regard  to  their  pabulum;  thus  one 
( Bacillus  subtilis)  flourishes  best  in  a hay  in- 
fusion, where  another  ( Bacillus  ant  brads')  finds 
it  hard  to  live.  Diminution  of  the  supply  of 
oxygen  leads  to  abortive  growth.  With  respect 
to  temperature,  they  are  unaffected  (as  regards 
actual  vitality)  by  extreme  cold,  but  probably 
all  varieties  enter  into  heat-rigor  at  60°  C. 

Pathological  Relations  and  Classification. 
The  general  characters  of  the  bacilli  so  far  have 
been  considered  apart  from  their  most  important 
bearing  on  disease,  a preface  to  which  division 
of  the  subject  will  best  be  afforded  by  enumer- 
ating the  kinds  of  bacilli  that  have  ns  yet  been 
described.  They  are  as  follows : — 

Bacillus  subtilis  I not  found  in  living 
ulna  / animal  tissues 
anthracis 
malari* 

septienemite  (experimental) 
leprae 

tuberculosis. 

Of  thsse’kinds  of  bacilli,  the  Bacillus  anthracis, 


found  constantly  in  splenic  fever,  has  been  very 
thoroughly  investigated  (see  Pustule,  Malig- 
nant), and  maybe  accepted  as  an  illustration  of 
the  relation  borne  by  the  different  bacilli  to  the 
diseases  enumerated  in  the  above  list.  The  con- 
ditions under  which  certain  symptoms  appear 
synchronously  with  definite  organisms  is  dis- 
cussed elsewhere,  and  it  only  remains  to  draw 
attention  to  the  nature  of  the  classification,  as 
being  purely  empirical,  and  of  a temporary 
character. 

Diagnosis.— If  it  were  possible,  it  would  be 
desirable  to  show  how  a bacillus,  found  in  con- 
nection with  definite  symptoms,  may  be  identi- 
fied as  peculiar  to  a particular  pathological  pro- 
cess. Morphologically  we  may  arrange  the 
so-called  pathogenetic  bacilli  in  terms  of  their 
breadth,  commencing  with  the  narrowest,  in  tho 
following  order — B.  septiemmiae,  leprie,  tuber- 
culosis, malari®,  and  anthracis  ; whilst,  as  re- 
gards length,  B.  tuberculosis  is  shortest,  arid 
between  this  and  the  remainder  we  may  place 
B.  septic®mi*.  But  the  distinctions  here  given 
are  only  of  very  general  value ; and  as  the 
bacilli  differ  somewhat  in  their  reaction  to 
staining  fluids,  we  have  in  this  another  point  of 
diagnostic  value.  Thus,  B.  tuberculosis  can  only 
be  shown  in  tubercular  fluids  or  tissues  after 
these  have  been  treated  with  a solution  of  an 
aniline  salt,  also  containing  pure  aniline,  anil 
then  washed  in  moderately  strong  nitric  acid,  a 
process  which  would  be  destructive  to  the  oth  r 
forms  of  bacilli.  A complete  means  of  diagnosis 
would  rest  on  their  ph3'siologieal  properties,  but 
in  the  present  state  of  knowledge  this  is  impos- 
sible.1 Victor  Horslf.y. 

1 Note  ou  the  mode  of  demonstrating  bacilli. 

1.  In  fluids , such  as  blood  an>l  sputum. — An  exceed- 
ingly thin  layer  of  the  fluid  is  first  obtained,  by  placing 
a drop  between  two  perfectly  clean  cover  glasses,  which 
are  then  separated  by  a rapid  drawing  movement,  thus 
leaving  a delicate  film  on  each.  The  fluid  is  next  eva- 
porated to  dryness,  by  passing  the  cover  glass  a few 
times  through  the  flame  of  a Bunsen  burner.  The  coagu- 
lation of  the  albumen  thus  effected  is  an  important 
step  in  the  success  of  the  staining  process.  The  dry  film 
may  now  be  stained,  by  pouring  on  it  a concentrated 
solution  of  methyl- violet,  or  by  floating  it  on  a solution 
of  fuchsin,  to  which  some  pure  aniline  has  teen  added. 
This  solution  is  prepared  by  dissolving  the  dye  in  equal 
proportions  of  alcohol  and  water,  10  which  ^th  part  of 
aniline  is  added,  thus  making  the  solution  alkaline.  The 
preparation  is  then  washed  with  a 10  per  cent,  solution 
of  nitric  acid,  until  all  the  colour  has  disappeared. 
Finally,  it  is  washed  with  a concentrated  aqueous  solu- 
tion of  aniline,  to  restore  the  alkaline  reaction  ; or  the 
ground  substance  may  be  stained  with  a fluid  of  the 
same  chemical  reaction,  namely,  vesuvin  or  chrysoidin; 
the  superfluous  reagent  is  washed  off  with  distilled 
water  ; and  the  cover-glass  mounted  (after  drying)  in 
Canada  balsam,  or  in  a mixture  of  glycerine,  glucose  and 
alcohol,  having  an  index  of  refraction  =1*37.  See  Bran, 
Revue  M6dicale  de  la  Suisse  Romande , August  1SS2. 

Bacilli  can  also  be  shown  in  albuminous  fluids  by 
treating  the  dried  film  with  a 1 per  cent,  solution  of 
caustic  potash  in  water.  In  the  case  of  tubercle,  they 
may  be  distinguished  from  the  ordinary  bacilli  of  putre- 
faction by  gently  re-drying  the  potash-treated  film,  ai.d 
then  staining  with  an  aniline  dye.  Under  these  circum- 
stances the  tubercle  bacilli  show  up  distinctly  unstained, 
whilst  the  putrefactive  organisms  are  deeply  coloured 
(Baumgarten,  Centbt./.  d.  med . TTiw.  S.  257,  1882.) 

2.  In  tissues. — The  organs  are  hardened  in  alcohol, 
and  very  thin  sections  from  these  are  stained  by  a 
similar  process  to  that  detailed  above.  In  practice  it  wiil 
be  found  necessary  to  use  a weak  solation  of  acid  for 
the  sections ; and  although  the  section  appears  quite 
white  after  its  removal  from  the  acid  fluid,  its  colour 
partly  returns  on  washing  with  water,  again  to  be  nv 
moved  in  the  subsequent  stages  of  passing  the  section 


CANTHARIDES. 

CAUTHARIDES,  Poisoning  by. — Synon.  : 
Fr.  Empoisonnement  par  la  Cantharide;  Ger. 
Cantharidenvergiftung.  — Cantbarides  or  the 
Spanish  fly  owes  its  poisonous  properties  to  the 
presence  of  cantkaridin,  a non-alkaloidal  body. 
All  the  preparations  of  the  drug  are  highly 
poisonous. 

Symptoms. — Soon  after  taking  a poisonous 
dose  of  cantbarides,  the  patient  is  seized  with 
burning  pain  in  the  pharynx,  and  a sense  of 
constriction  in  the  oesophagus.  The  pain  soon  ex- 
tends to  the  abdomen,  and  vomiting  ensues  ; the 
.abdominal  pain  becomes  aggravated ; and  usually 
purging  sets  in.  The  stools  are  numerous,  often 
scanty',  passed  with  great  pain  and  straining; 
they  are  at  first  mucous,  and  finally  bloody.  .If 
carefully  examined,  little  iridescent  specks — por- 
tions of  the  elytra  of  the  beetle — may7  be  ob- 
served in  the  faeces  and  vomited  matters.  These 
are  of  course  only  observable  when  the  powdered 
insect  has  been  broken ; and  they  frequently  es- 
cape observation.  Up  to  this  period  of  the  case, 
should  portions  of  the  beetle  not  have  been  de- 
tected, there  is  nothing  to  distinguish  the  case 
from  one  of  ordinary  irritant  poisoning;  except, 
perhaps,  that  salivation  and  swelling  of  the  sali- 
vary glands  are  usually  prominent  symptoms. 
The  gastro-intestinal  inflammation  may  be  so  in- 
tensely and  rapidly  developed,  that  death  may 
occur  from  collapse  before  strangury,  the  dia- 
gnostic symptom,  is  developed.  Generally,  how- 
ever, the  course  is  somewhat  different,  genito- 
urinary irritation  and  inflammation  setting  in; 
the  symptoms  of  which  are  aching  pains  in  the 
lumbar  region,  frequent  desire  to  micturate,  with 
violent  tenesmus  of  the  bladder,  till  eventually 
a few  drops  of  albuminous  or  bloody  urine  only 
can  be  passed,  or  none  at  all.  Priapism,  erotic 
excitement,  and  sw'elling  of  the  genitals  are  of 
frequent,  though  not  of  constant,  occurrence. 
Delirium,  tetanic  convulsions,  or  paraplegia, 
may  be  noted  in  some  cases.  Eventually  the 
intolerable  agony  gives  way  to  collapse,  stupor, 
coma,  and  death.  Abortion  not  infrequently  oc- 
curs in  pregnant  women,  the  drug  being  one  in 
common  use  as  an  abortifacient. 

Diagnosis. — The  intense  strangury,  the  swell- 
ing of  the  genitals,  and  the  bloody  stools,  will 
leave  little  or  no  doubt  as  to  the  nature  of  the 
case ; and  the  presence  of  particles  of  the  drug 
in  the  ejecta  will  be  conclusive. 

Fatal  dose. — Less  than  half  a drachm  of  the 
powder,  and  an  ounce  of  the  tincture,  have  alike 
proved  fatal. 

Treatment.— Evacuation  of  the  stomach  by 
the  use  of  the  stomach-pump,  syphon-tube,  or  an 
emetic  is  the  first  indication  in  poisoning  by  can- 
tharides.  It  is  best  to  wash  out  the  stomach  well. 
Mucilaginous  drinks,  white  of  egg  (not  the  yolk), 
and  demulcents,  may  be  freely  given  ; but  oil  in 
any  form  is  to  be  avoided,  as  tending  to  dissolve 
cantharidin.  Opium  by  the  mouth  or  rectum, 
or  the  hypodermic  injection  of  one-third  of  a 
grain  of  morphia,  is  advisable.  Leeches  to  the 

through  alcohol,  oh  of  cloves,  and  mounting  it  in 
balsam. 

Illumination. — For  the  complete  demonstration  of  the 
more  difficult  bacilli,  for  instance,  B.  tuberculosis,  it  is 
advisable  to  employ  oil- immersion  objectives,  and  a dis- 
persive illumination  such  as  that  afforded  by  Abbe’s 
condenser 


CHLORAL  HYDRATE.  1811 

region  of  the  bladder,  warm  fomentations,  and 
warm  sitz-baths  may  afford  relief.  Chloral  should 
also  be  given,  or  the  patient  kept  cautiously 
under  the  influence  of  chloroform.  Collapse  may 
be  met  by  ammonia  and  other  stimulants.  The 
hypodermic  injection  of  a few  drops  of  ether  is 
useful.  There  is  no  known  antidote  for  can- 
tharidin. Thomas  Stfvenson. 

CHLORAL  HYDRATE,  Poisoning 

by. — Synon.  : Fr.  Empoisonnement  par  V Hydrate 
de  Chloral ; Ger.  Ckloralhydratvergiftung. 

Poisoning  by  chloral  hydrate  is  a very  com- 
mon occurrence,  this  medicament  being  fre- 
quently taken  in  fatal  quantity  by  misadven- 
ture. There  is  reason  to  think  that  it  is  also 
largely  used  for  suicidal  purposes.  The  so- 
called  ‘ chloral  habit  ’ is  a growing  evil.  A 
s3’ruP  of  chloral  hydrate,  containing  about 
twenty-two  grains  of  this  substance  per  fluid 
drachm,  is  largely  sold  in  this  country  under  a 
patent-medicine  stamp. 

Anatomical  Characters. — There  may  be  an 
entire  absence  of  any  characteristic  appearances 
after  death  by  hydrate  of  chloral ; and  at  most 
these  consist  in  more  or  less  modified  signs  of 
asphyxia — especially  a dark  colour  of  the  blood, 
and  pulmonary  and  cerebral  hypercemia. 

Symptoms. — The  most  striking  symptom  of 
poisoning  by  chloral  hydrate  is  the  rapid  super- 
vention of  quiet  sleep,  at  first  simulating  natural 
sleep.  In  this  stage  the  patient  can  he  easily 
roused,  but  he  speedily  drops  off  again.  The 
pupils  are  contracted ; the  respirations  are  full , 
deep,  and  regular;  the  pulse  is  not.  much  affected. 
This  condition  rapidly  deepens  into  full  coma. 
The  respirations  slacken ; and  the  pulse  is  either 
weak  and  slow,  or,  more  commonly,  rapid  and 
irregular.  The  temperature  of  the  body  is  re- 
duced ; the  muscular  system  is  totally  relaxed. 
The  pupils  now  dilate  ; and  with  feeble  thready 
pulse,  the  anaesthesia  and  paralysis  gradually 
end  in  death,  preceded  by  lividity  and  collapse. 
Exceptionally,  in  fatal  cases,  burning  pain  in 
the  mouth,  fauces,  and  throat,  and  symptoms  cl 
gastritis  have  been  observed.  In  one  case  of 
recovery  the  patient  became  idiotic. 

Diagnosis. — The  history  of  the  case,  or  the 
finding  of  a vessel  containing  the  medicine, 
coupled  with  the  symptoms,  will  usually  set  all 
doubts  at  rest.  Otherwise  the  case  may  be  mis- 
taken for  poisoning  by  opium  or  other  narcotic, 
for  carbolic  acid  poisoning,  or  for  cerebral  conges- 
tion. The  pupil  is  not  so  contracted  as  in  opium- 
poisoning ; and,  as  the  coma  deepens,  it  dilates 
instead  of  undergoing  further  contraction.  There 
is  an  absence  of  the  olive-green  or  black  urine 
so  commonly  noticed  in  carbolic  acid  poisoning, 
of  the  peculiar  odour  of  the  breath,  and  of 
stains  about  the  mouth  and  lips. 

Prognosis. — This  will  depend  upon  the  state 
in  which  the  patient  is  found,  and  upon  the 
length  of  time  which  has  elapsed  since  the  in- 
gestion of  the  poison. 

Treatment. — Evacuation  of  the  stomach  by 
the  aid  of  the  stomach-pump  is  the  first  step  in 
the  treatment  of  a case  of  poisoning  by  chloral 
hydrate.  Emetics,  unless  given  early,  usually 
fail  to  excite  vomiting.  The  patient  must  he 
roused,  if  possible,  as  in  epium-poisoning  (se> 


1812  CHLORAL  HYDRATE. 

Opium,  Poisoning  by).  The  temperature  of  the 
body  must  be  kept  up  by  -warm  applications. 
Stimulants  may  be  freely  given,  and  hot  coffee 
injected  into  the  rectum.  Strychnia  (5b  gr.) 
has  been  recommended  for  use  as  a counter-poi- 
son, by  subcutaneous  injection ; also  picrotoxine. 
The  former  is  a dangerous  remedy  ; the  latter 
also  would  not  perhaps  be  a safe  antidote,  if 
given  in  full  doses.  Inhalations  of  amyl  nitrite, 
and  artificial  respiration  are  advisable. 

Thomas  Stevenson. 

CHOLESTERINE  bile,  and  crrepbs, 

solid). — Synon.  : Fr.  Cholesterine ; Ger.  Choles- 
tcrin  ; Gallenfett. 

Chemical  and  Physical  Properties, — Cho- 
lesterine is  a monatomic  alcohol,  represented 
by  the  empirical  formula  C26HJ40,  occurring  as 
a normal  constituent  of  the  nervous  tissue  (519 
per  cent,  of  the  solids  of  the  white  matter  and 
186  per  cent,  of  the  solids  of  the  grey  matter 
of  ox-brain) ; and  in  minute  quantities  in  bile 
(•25  per  cent.) ; and  in  blood  (-5  to  2'0  per  1000). 
When  pure  it  occurs  as  white  glittering  scales, 
which  consist  of  needles,  when  crystallised  cut 
from  ethereal  solutions  ; and  of  rhombic  plates, 
often  deficient  at  one  corner,  when  derived  from 
alcoholic  solutions  {see  Microscope  in  Medicine). 
It  is  insoluble  in  water,  alkalies,  and  dilute  acids ; 
but  readily  dissolves  in  ether,  boiling  alcohol, 
benzol,  chloroform, and  solutions  of  the  bile-acids. 
It  melts  at  145°  Fahr.,  and  its  solutions  are  laevo- 
rotatory.  The  crystals,  heated  with  a drop  of 
strong  sulphuric  acid,  give  a carmine-red  colour. 

Sources. — The  exact  physiological  significance 
of  cholesterine  is  not  known,  but  it  is  generally 
regarded  as  a product  of  the  metabolism  of  the 
nervous  tissues  which  should  be  eliminated  by 
tho  liver  in  the  hile.  Since  little  or  none  is 
found  in  the  faeces,  it  is  believed  to  undergo  a 
change  in  the  intestine  into  stercorin  (Flint). 
It  is  also  found  in  the  yolk  of  egg  ; in  some 
vegetables,  such  as  peas  and  maize  ; and  in  olive 
and  almond  oils. 

Pathological  Relations. — The  pathological 
occurrence  of  cholesterine  is  varied.  It  is  in- 
creased in  amount  in  all  acute  febrile  conditions, 
and  especially  in  those  diseases  of  the  liver  lead- 
ing to  the  retention  in  the  blood  of  the  bile-con- 
stituents, producing  in  such  cases  a condition 
known  as  cholcstcrcemia.  The  fluid  of  cysts, 
especially  hydatid  and  ovarian,  seems  to  be  more 
liable  to  contain  it  than  effusions  into  serous 
cavities  ; and  on  this  ground  it  has  been  referred 
to  in  the  differential  diagnosis  of  ascites  from 
ovarian  dropsy.  But  it  sometimes  occurs  in  con- 
siderable quantities  in  hydrocele  fluids,  and  it 
has  been  met  with  in  old  pleural  and  peri- 
toneal effusions. 

Cholesterine  forms  the  greater  bulk  of  most 
gall-stones,  being  formed  into  coherent  masses 
by  inspissated  mucus. 

' In  the  caseous  degeneration  of  pus  and  other 
inflammatory  products,  crystals  of  this  substance 
are  to  be  found. 

In  the  urine  cholesterine  is  never  found  in 
health,  but  it  occasionally  occurs  in  morbid  states, 
and  is  especially  likely  to  be  met  with  when  there 
is  advanced  renal  degeneration. 

W.  H.  Allchin. 


conium,  Poisoning  bi. 

CONIUM,  Poisoning  by. — Synon.  : Fr 

Empoisonnement  par  la  Cigue  ; Ger.  Schierling - 
vergiftung. — All  parts  of  the  hemlock  plant  {Co- 
nium maculatum)  are  poisonous.  Both  the  leaves 
and  fruit  are  used  in  medicine.  Its  toxic  pro- 
perties were  known  in  ancient  times ; the  plant 
was  used  for  the  destruction  of  criminals  by  the 
ancient  Greeks,  and  there  is  no  doubt  that 
Socrates  was  poisoned  by  it.  Death  from  conium 
in  this  country  has  perhaps  always  been  tho 
result  of  misadventure  or  suicide;  but  on  the 
Continent  tho  active  principle  of  the  plant,  conia, 
an  alkaloid,  has  been  administered  for  the  pur- 
pose of  wilful  homicide,  death  resulting  from  a 
dose  of  10  to  15  drops. 

Anatomical  Characters. — The  signs  of  as- 
phyxia, engorgement  of  lungs  and  of  the  right 
heart,  and  a general  venous  condition  of  the 
blood,  appear  to  be  constant  after  death  from  co- 
nium. There  is  nothing  else  specially  noticeable. 

Symptoms. — Preparations  of  conium,  as  well 
as  the  alkaloid,  or  mixture  of  alkaloids,  known 
as  conia,  when  taken  in  toxic  doses,  produco 
excessive  muscular  weakness,  beginning  in  the 
lower  limbs,  and  extending  gradually  upwards, 
with  giddiness  and  disordered  vision.  These 
symptoms  are  in  some  cases  preceded  by  nausea 
and  vomiting,  with  dryness  or  burning  pain  in 
the  mouth  and  fauces.  There  is  a desire  to  re- 
main quiet,  and  a peculiar  heaviness  or  drooping 
of  the  eyelids,  the  patient  lying  with  his  eyes 
shut.  This,  and  the  impairment  of  vision,  appear 
to  be  due  to  paralysis  of  the  ocular  muscles. 
The  pupils  may  be  natural,  but  later  they  be- 
come dilated.  The  pulse  is  slow  till  death  is 
actually  impending.  Tho  paralysis  progresses 
gradually  upwards,  till  eventually  heart  and  re- 
spiration are  affected,  more  especially  the  former. 
Convulsions,  and  impairment  of  the  mental  facul- 
ties— hitherto  intact — now  set  in ; finally  sen- 
sation is  impaired,  and  death  ensues  from  as- 
phyxia. 

Diagnosis.— The  paralysis  of  motion,  pro- 
gressing gradually  upwards,  with  unimpaired 
sensation,  and  the  peculiar  drooping  of  the  eye- 
lids, are  perhaps  diagnostic  of  the  nature  of  the 
poison. 

Prognosis. — As  no  antidote  is  known  which 
counteracts  the  effects  of  conia,  the  prognosis 
must  always  he  a guarded  one,  and  will  depend  en- 
tirely upon  the  general  condition  of  the  patient. 

Treatment. — The  stomach  must  be  emptied 
by  the  stomach-pump  or  syphon-tube,  and  well 
washed  out.  Emetics  may  also  be  used  to  evacuate 
the  stomach.  Tannin  and  astringents  must  be 
freely  administered,  to  precipitate  the  active  alka 
loid,  and  prevent  its  absorption.  Castor  oil,  by 
the  mouth  or  rectum,  may  aid  the  removal  o( 
the  alkaloid  when  it  has  been  rendered  insoluble 
by  tannin.  Strong  coffee,  brandy,  ammonia,  and 
stimulants  generally  are  serviceable,  as  may 
also  be  the  hypodermic  injection  of  ether.  Hypo- 
dermic injections  of  l-40th  grain  of  sulphate  ol 
atropia  are  very  promising,  especially  in  the 
later  stages  ; atropia  acting  as  a respiratory  and 
cardiac  stimulant.  Artificial  respiration,  and  sti- 
mulation of  the  respiratory  and  cardiac  func- 
tions by  the  use  of  electricity,  ought  not  to  be 
neglected  when  these  are  affected. 

Thomas  Stevenson. 


DISTOJAA  RINGERL 

DISTOMA  HINGERI. — Under  tliis  name 
ibere  has  lately  been  described  by  the  writer 
[Medical  Times  and  Gazette,  July  8,  1882),  a 
new  species  of  fluke,  the  mature  form  of  which 
inhabits  the  human  lung,  where  it  was  first 
found  by  Ur.  B.  S.  Binger  in  Formosa,  in  1879. 
The  ova  of  the  parasite  have  frequently  been 
found  by  Prof.  Baely,  of  Tokio,  and  the  writer, 
and  by  them  are  associated  with  a peculiar  form 
of  recurrent  haemoptysis,  to  which  the  term  para- 
sitical hemoptysis  has  been  applied. 

Symptoms  and  Pathology. — The  symptoms 
of  the  disease  associated  with  the  presence  of  the 
distoma  Ringeri  are  slight  cough ; the  expecto- 
ration of  a characteristic  rusty  brown,  viscid 
mucus ; and  at  times  h£emopt}’sis,  either  to  an 
insignificant  or  an  alarming  extent.  The  haemor- 
rhage occurs  at  irregular  intervals  during  many 
years.  The  expectoration  of  rusty  bronchial 
mucus  is  persistent,  and  in  this  the  ova  are 
readily  discovered  with  the  microscope.  These 
(gi0-  in.  x ^ in.)  are  pale  brown  bodies,  oval, 
aouble-outlined,  opereulated  at  the  broad  end, 
iud  contain  protoplasmic  globules  having  very 
active  molecular  movements.  If  the  sputum  is 
occasionally  shaken  up  in  fresh  water,  in  the 
course  of  six  weeks  to  two  months  an  active 
ciliated  embryo  is  developed  in  most  of  the  ova, 
which  in  time  escapes  by  forcing  back  the  oper- 
culum. It  may  be  concluded  from  this  that 
drinking  water,  or  a fresh-water  animal  acting 
as  intermediary  host  is  the,  medium  by  which 
the  disease  passes  from  one  human  subject  to 
another.  See  Distoma. 

This  disease  has  hitherto  been  found  only  in 
Japan  and  Formosa,  but  its  distribution  is  pro- 
bably much  more  extended  than  this. 

The  mature  distoma  measures  if  in.  x A jn. 
x A in.  The  particular  tissue  of  the  lung  it 
inhabits  has  yet  to  be  determined.  It  certainly 
communicates  with  the  bronchi,  as  the  bronchial 
mucus  is  the  medium  by  which  the  ova  are  con- 
veyed to  suitable  incubating  media  ; but  whether 
the  animal  is  free  in  the  bronchi,  or  is  jammed 
into  a branch  of  the  pulmonary  artery,  has  yet 
to  be  ascertained. 

Treatment. — Inhalations  of  sulphurous  acid, 
and  sprays  of  turpentine,  kousso,  quassia,  and 
santonine,  have  been  administered  with  apparent 
benefit.  Patrick  Manson. 


FILARJA  SANGUINIS  -HOMINIS.— 

Whilst  the  article  Filaria  Sanguinis-Hominis 
(p.  512)  contains  a sufficiently  full  account  of  the 
structure  of  this  parasite,  recent  investigations 
enable  us  to  furnish  a more  complete  description 
of  the  life-history  of  the  mature  and  embryo 
worm,  and  of  their  pathological  relations  to  chy- 
luria  and  elephantiasis.  It  is  now  known  that 
the  parent  worm  lives  in  the  lymphatics ; that 
the  embryo  while  in  utcro,  by  dint  of  vigorous 
movements,  stretches  its  oval  chorionat  envelope,  • 
to  form  the  long  tubular  sheath  in  which  it  lies 
extended,  as  we  see  it  in  the  blood  and  lymph  ; 
and  that,  after  this  stretching  of  the  chorion  is 
complete,  the  embryo  is  born  into  the  lymph- 
stream,  which  carries  it  through  the  glands, 
along  the  thoracic  duct,  and  thus  into  the  blood, 
Under  ordinary  circumstances  of  health  and  habit, 


FILARIA  SANGUINIS-HOMINIS.  1813 

the  embryo  cannot  be  found  in  the  blood  during 
the  day,  but  at  evening  it  appears  there,  in  num- 
bers gradually  increasing  up  to  midnight  (when 
in  some  cases  as  many  as  200  may  be  found  in  a 
single  drop)  and  diminishing  towards  morning. 
About  8 or  9 a.m.  it  disappears  for  the  day. 
This  phenomenon  (‘  filarial  periodicity  ’)  is  appa- 
rently an  adaptation  of  the  habits  of  the  para- 
site to  those  of  the  female  of  a particular  species 
of  mosquito,  which  preys  on  the  blood  at  night, 
and  thus  imbibes  the  young  filaria,  to  which  it 
acts  as  intermediary  host.  Having  entered  the 
stomach  of  the  mosquito,  the  filaria  undergoes  a 
metamorphosis,  eventuating  in  its  becoming  pos- 
sessed of  an  alimentary  canal,  rudimentary  or- 
gans of  generation,  increased  size,  great  acti- 
vity, and  a circumoral  crown  of  papillfe.  The 
latter  is  the  boring  apparatus,  which  enables  the 
animal  to  leave  the  body  of  the  mosquito,  when 
this  insect  dies,  after  depositing  her  eggs  on 
water;  and  to  traverse  the  human  tissues,  to 
which  it  gains  access,  probably  by  being  swal- 
lowed in  drinking  water. 

Pathological  Relations. — Chyluria,  naevoid 
elephantiasis  or  lymph- scrotum,  varicose  and 
indurated  groin-glands,  galactoeele,  ascites  with 
milky  fluid,  craw-cravi , and  certain  kinds  of 
abscess,  lymphangitis,  and  lymphatic  fever,  are 
almost  invariably  accompanied  by  the  presence 
of  the  filaria  in  the  blood  or  lymph. 

As  tropical  elephantiasis  is  often  associated 
with,  or  supervenes  on,  some  of  these  affec- 
tions, has  the  same  geographical  distribution, 
attacks  the  same  parts,  and  is  a disease  of  the 
lymphatics,  it  is  therefore — though  the  filaria 
is  not  usually  found  in  developed  elephantiasis 
— believed  to  be  caused  by  this  parasite.  But 
from  the  fact  that  in  many  countries  where 
the  filaria  is  endemic,  quite  10  per  cent,  of  the 
adult  population  harbour  it,  yet  only  a small 
proportion  of  these  have  any  of  the  diseases 
enumerated,  it  is  evident  that  the  parasite  does 
not  necessarily  give  rise  to  disease.  Evidence 
has  been  adduced  which  shows  that,  as  long  as 
the  parent  worm  is  healthy,  it  is  innocuous,  but 
that  if  it  dies,  it  acts  as  a foreign  body,  causing 
abscess ; and  that  the  obstruction  of  the  lym- 
phatics, which  eventuates  in  and  causes  the 
diseases  above  enumerated,  is  brought  about  by 
the  premature  birth  of  the  embryo,  before  the 
chorional  envelope  has  undergone  the  stretching 
process  alluded  to — that  is,  when  ova  (seven  or 
eight  times  the  diameter  of  the  outstretched  em- 
bryo) are  prematurely  launched  into  the  lymph- 
stream.  The  ova  act  as  emboli,  and  being  very 
numerous,  effectually  plug  the  glands  connected, 
directly  or  by  anastomosis,  with  the  lymphatic 
vessel  in  which  the  aborting  parent  lies.  The 
location  of  the  worm,  the  degree  of  embolism, 
and  other  circumstances,  determine  the  site  and 
exact  character  of  the  resulting  disease. 

Treatment. — a.  Curative. — No  means  of  kill- 
ing the  filaria  have  been  discovered.  The 
indications  for  treatment,  when  disease  has  de- 
veloped, are  supplied  by  the  pathology.  Rest, 
elevation  of  the  affected  parts,  elastic  ban- 
daging, and  other  means  to  facilitate  the  flow  of 
lymph  through  the  damaged  lymphatics  are  of 
great  benefit.  See  Chyluria  ; and  Elephan. 
tiakm. 


IS  14  FILAEIA  SANGUINIS-H0MIN1S. 

h.  Preventive. — The  fact  that  the  mosquito 
nets  as  intermediary  host,  indicates  the  di- 
rection that  preventive  measures  should  take. 
Drinking  'water,  in  districts  where  the  filaria  is 
endemic,  ought  to  be  boiled  or  filtered  ; wells, 
cisterns,  and  receptacles  for  drinking  water  ought 
lo  le  covered  by  line  wire  gauze,  to  prevent  the 
access  of  the  mosquito  ; and  persons  known  to 
harbour  the  parasite,  ought  to  sleep  under  pro- 
perly constructed  mosquito-curtains.  By  any 
nr  all  of  these  means,  this  parasite  in  the  course 
of  a single  generation  could  be  exterminated, 
and  the  diseases  it  produces  made  things  of  the 
past.  Patrick  Masson. 

LARYNX,  Diseases  of. — The  chief  neu- 
roses connected  with  the  larynx,  and  the  various 
forms  of  paralysis  affecting  the  organ  of  voice, 
require  more  consideration  than  they  have  re- 
ceived in  the  principal  article,  Larynx,  Diseases 
of. 

1.  Sensory  Neuroses  of  the  Larynx. — 

Hyperesthesia,  of  the  laryngeal  mucous  mem- 
brane is  a usual  accompaniment  of  inflammation, 
acute  and  chronic,  and  is  a not  unfrequent  hys- 
terical symptom.  Anesthesia  occurs  in  cases 
where  the  superior  laryngeal  nerve  or  its  centres 
are  affected,  and  especially  as  a sequel  of  diph- 
theria. It  is  usually  associated  with  paralysis  of 
the  muscles  of  deglutition,  and  of  the  depressors 
of  the  epiglottis,  and  still  further  contributes  to 
the  dysphagia  accompanying  the  lesion,  leading 
to  pulmonary  complications,  owing  to  food  pass- 
ing into  the  larynx  deprived  of  its  reflex  sensi- 
bility. If  necessary,  food  must  bo  administered 
by  the  oesophageal  tube,  while  the  nervous  lesion 
is  suitably  treated. 

2.  Paralysis  of  the  Larynx. — Definition. — 
Loss  of  power  in  the  laryngeal  muscles,  occur- 
ring in  connection  with  disease  or  poisoning  of 
the  nervous  centres,  or  with  pressure  upon  or 
disease  of  the  laryngeal  nerves  or  their  parent 
trunks,  caused  by  aneurism,  enlarged  cervical  or 
bronchial  glands,  or  other  tumours  ; more  rarely 
of  muscular  origin. 

Varieties  and  Symptoms. — Paralysis  of  the 
superior  laryngeal  nerve,  supplying  the  crieo-thy- 
riod  muscle,  in  addition  to  the  symptoms  men- 
tioned under  ansesthesia,  prevents  due  tension  of 
the  vocal  cords,  and  causes  dysplionia.  Com- 
plete paralysis  of  the  muscles  supplied  by  both 
recurrent  laryngeals,  the  motor  nerves  of  the 
larynx,  causes  the  vocal  cords  to  remain  immov- 
able and  semi-closed,  as  in  the  dead  body;  but 
disease  or  pressure  upon  this  nerve  most  com- 
monly paralyses  only  certain  groups  or  indivi- 
dual muscles.  The  most  serious,  and  perhaps 
most  common,  lesion  is  paralysis  of  the  aoductors 
(posterior  crico-arytrenoids,  &c.),  causing  the 
vocal  cords  to  approximate  in  the  middle  line  in 
a relaxed  state.  Even  in  phonation  they  are  not 
tense ; and  during  respiration  only  a narrow 
chink  is  left,  with  relaxed  edges,  causing  very 
stridulous  breathing,  and  possibly  fatal  asphyxia. 
Paralysis  of  the  adductors,  when  one  or  both 
vocal  cords  are  seen  at  all  times  relaxed  and 
drawn  aside,  leading  in  the  latter  case  to  com- 
plete aphonia,  and  in  the  former  to  aphonia 
more  or  less  complete,  is  not  necessarily  attended 


LICHEN. 

with  much  dyspnoea.  "When  these  conditions  are 
of  long  standing,  the  muscles  become  atrophied  ; 
but  many  cases  have  been  reported  where  the 
paresis  of  individual  muscles  has  been  of  true 
muscular  origin. 

Diagnosis. — The  several  varieties  of  paralysis 
of  the  larynx  must  be  recognised  by  the  laryn- 
goscope, the  symptoms  to  which  they  give  rise 
being  common  to  various  diseased  conditions. 
The  dyspnoea  and  stridulous  breathing  of  para- 
lysis of  the  abductors  is  unaccompanied  by  the 
pain  and  other  symptoms  which  attend  them  in 
the  various  inflammatory  affections,  but  may 
without  physical  examination  be  undistinguish- 
able  from  thoso  caused  by  neoplasm  or  by  pas- 
sive oedema. 

Functional  aphonia  has  been  considered  in  the 
body  of  the  work  (see  Larynx,  Diseases  of). 
Organic  aphonia  is  not  only  a frequent  symptom 
of  painful  inflammation,  of  ulcerations,  neo- 
plasms, and  other  affections  of  the  larynx  ; but 
it  may  be  the  only  symptom,  not  only  of  paralysis 
of  the  adductors,  from  disease  of  the  nerves  or 
muscles,  but  of  other  conditions  closely  si  mu 
lating  this,  such  as  anchylosis  of  the  crico- 
arytaenoid  joints  (Dr.  F.  Semon),  contracted  ci 
catrices,  and  other  mechanical  obstacles  to  tho 
approximation  of  the  vocal  cords. 

Treatment. — The  paralysed  condition  usually 
depending  on  serious  disease  outside  the  larynx, 
local  treatment  is  of  little  avail.  Tracheotomy 
may  be  called  for  to  avert  asphyxia.  Cases 
where  the  local  use  of  electricity  is  supposed  to 
have  cured  paralysis  were  probably  cases  of 
simulated  disease.  Sec  Larynx,  Diseases  of;  and 
Pneumogastric  Nerve,  Diseases  of.1 

Thomas  J.  Walker. 

LICHEN. — The  general  pathology  of  lichen 
is  discussed  in  the  body  of  this  work.  Here  it 
is  thought  desirable  to  describe  the  several 
species  of  lichen,  and  to  refer  to  certain  other 
diseases  which  were  formerly  associated  with 
each  other  under  this  generic  name. 

The  somewhat  loose  definition  given  by  the 
older  writers  to  the  word  * papule,’  caused  them 
to  include  under  the  head  of  lichen  diseases,  or 
rather  conditions  of  the  skin,  many  of  which  be- 
long to  other  categories.  Thus  Willan's  list  in- 
cluded seven  species: — 1,  Lichen  simplex,  2.  L. 
pilaris,  3.  L.  circumscriptus,  4.  L.  agrius,  5.  L. 
Hindus,  6.  L.  tropicus,  and  7.  L.  urticatus. 

Lichen  simplex  is  merely  a temporary  lichen- 
ous  condition — in  short,  the  papular  stage  pre- 
ceding the  vesicular  stage  of  eczema.  L.  agruis 
and  L.  tropicus  may  bo  disposed  of  in  like 
manner. 

Lichen  or  Pityriasis  pilaris  is  an  afiection 

1 It  seems  desirable  to  refer  here  to  the  following 
points  which  have  not  been  noticed  in  the  article 
Larynx,  Diseases  of. 

Dilatation  of  contraction  by  bougies  and  plugs  has 
been  frequently  attempted,  and  recently  successfully 
practised  by  Schrotter  and  others. 

Perichondritis,  and  consequent  formation  of  abscess, 
with  consecutive  caries  and  necrosis  of  the  cartilages, 
have  been  alluded  to  as  complicating  tubercular,  syphi- 
litic, and  the  worst  forms  of  non-specific  laryngitis 
(typhns,  kc.) ; rarely  it  occurs  as  a primary  affection, 
giving  rise  to  a limited  suppuration.  Abscess  is  so  rare  a 
complication  of  simple  laryngitis  that  its  eccurrenee 
almost  invariably  indicates  perichondritis,  with  its  for 
midable  results— necrosis,  caries,  Ac. 


LICHEN. 

which  is  differently  classed  by  authors  ; it  is 
essentially  a chronic  condition,  characterised  by 
a heaping  up  of  epidermis  in  horny  masses  round 
the  hair-follicles,  giving  the  part  affected  the 
feel  of  a rasp.  The  outer  surfaces  of  the  ex- 
tremities, the  backs  of  the  hands  and  phalanges, 
are  the  seats  of  election;  its  alliances  are  with 
the  squamous  affections. 

Lichen  circumscriptus  or  circinatus  is  a well- 
defined  affection,  in  which  small  red  papules 
are  seen  t.rranged  in  groups,  and  especially  in 
segments  of  circles.  The  area  enclosed  by  the 
segments  of  circles  is  minutely  scaly,  andof  a buff- 
pink  colour.  The  seats  of  election  are  the  sternal 
region,  between  the  mammse,  and  the  interscapu- 
lar region  ; from  these,  however,  it  may  spread. 
The  affection  is  very  itchy,  and  has  a strongly 
marked  parasitic  appearance,  though  the  existence 
of  fungus  is  extremely  difficult,  if  not  impossible, 
to  demonstrate  byordinary  methods.  Dr.  Crocker 
has,  however,  described  and  figured  a fungus 
which  he  has  found  associated  with  L.  circum- 
scriptus. The  affection  readily  yields  to  a little 
creasote  ointment  (m  vj-x  to  the  ounce  of  lard). 

Lichen  lividus  is  a purpuric  condition,  in  which 
the  purpuric  spots  appear  as  papules  round  hair- 
follicles.  See  Purpura. 

Lichen  urticatus  is  an  affection  which  is  now 
classed  as  a variety  of  urticaria. 

. In  accordance  with  the  teaching  of  Hebra, 
modern  dermatologists  are  disposed  to  restrict 
the  term  lichen  to  papular  affections  in  which 
the  papules  retain  their  character  as  papules, 
and  do  not  undergo  any  further  evolution. 
There  is  another  condition  imposed,  namely, 
that  the  papule  must  be  inflammatory.  The 
group  Lichen  is  thus  narrowed  down  to  one  of 
Willan’s  list,  namely,  Lichen  circumscriptus-,  and 
two  newly-described  diseases,  Lichen  ruber  and 
Lichen  scrofulosorum. 

JLichen  ruber  is  a disease  first  described  by 
Hebra,  in  Vienna,  and  in  this  country  by  Sir 
Erasmus  Wilson,  under  the  name  of  Lichen  pla- 
nus. Although  denied  by  some,  the  essential 
identity  of  the  two  conditions  described  under 
these  names  is  generally  admitted.  The  charac- 
teristic feature  of  L.  planus  or  ruber  is  the  de- 
velopment round  the  hair-follicles  of  lilac-red, 
flat-topped,  somewhat  quadrangular,  shining 
papules;  in  early  stages  a central  depression  or 
umbilication  is  recognisable  in  the  centre  of 
each  papule.  At  first  the  papules  remain  dis- 
crete, but  they  soon  tend  to  group  themselves  in 
patches,  or  run  together  in  lines ; the  patches 
increase  in  size  by  the  development  of  fresh 
papules  in  the  immediate  vicinity  of  the  old 
ones.  In  this  way  whole  are®  may  become  af- 
fected, the  skin  being  then  much  thickened  and 
slightly  scaly.  The  patches  itch  intensely  ; and 
the  clinical  alliances  of  the  disease  are  probably 
with  psoriasis  (Hutchinson).  In  its  severest 
types,  where  the  entire  surface  is  affected,  the 
patient’s  life  may  be  threatened  ; but  in  milder 
forms  it  is  very  manageable  by  the  internal  ad- 
ministration of  arsenic,  combined  with  the  local 
inunction  of  a mild  tar  ointment,  such  as  ft 
Liquoris  Carbonis  detergentis  3'j - Adipis  3'- 
Misce,  et  fiat  unguentum. 

I/ichen  scrofulosorum  is  another  disease,  first 
described  by  Hebra.  It  is  extremely  rare  in  this 


NUCLEUS  OF  CELLS.  1815 
country,  although  itundoubtedly  exists,  especially 
amongst  the  poorer  classes.  It  is  characterised 
by  pale  papules,  approaching  the  colour  of  the 
skin  ; these  tend  to  range  themselves  in  circular 
patches,  not  circles,  generally  on  the  trunk 
rather  than  the  extremities.  Here  and  there  a 
papule  inflames,  and  becomes  acne-like.  Thero 
is  little  itching.  The  disease  is  said  to  occur 
in  young  scrofulous  subjects.  Cod-liver  oil  is 
the  remedy  internally,  and  also  externally  by 
inunction.  Alfred  Sangsteb. 

LUPUS,  Local  Treatment  of. — Volkmann 
has  recently  introduced  a method  of  treating 
lupus  locally,  namely,  by  scraping  or  puncture. 

1.  Scraping  has  for  its  object,  first,  the  re- 
moval of  products  of  secretion,  scabs,  and  crusts ; 
and,  secondly,  the  removal  of  neoplasms  formed 
in  or  on  the  skin.  Forthis  purpose  ‘spoons  ’ or 
‘ scrapers  ’ of  various  sizes  are  made  by  the 
instrument-makers.  It  is  difficult  to  make  any 
impression  on  the  sound  skin  with  such  blunt 
instruments,  and  on  this  fact  the  simplicity  and 
safety  of  scraping  mainly  depend.  It  is  almost 
impossible  to  do  harm,  for  all  that  can  be  made 
to  break  down  (using  moderate  force),  under  the 
scraper  or  spoon,  is  best  removed. 

2.  Multiple  punctiform  scarification  is  the  se- 
cond mechanical  method  employed  by  Volkmann. 
By  this  the  practitioner  seeks,  first,  to  destroy 
newly-formed  vessels ; and,  secondly,  to  favour 
absorption  of  the  neoplasm,  by  traumatic  irrita- 
tion of  the  part.  It  is  practised  by  making 
hundreds  of  punctures  close  together,  about  two 
lines  in  depth.  For  this  purpose  a narrow- 
bladed  bistoury  may  be  used  ; or  the  same  end  is 
gained  in  less  time  by  employing  an  instrument 
composed  of  two  or  more  knives  set  close  to- 
gether. This  method  of  treatment  is  more  appli- 
cable to  non-ulcerated  parts,  where  the  cell- 
infiltration  is  diffuse,  or  where  the  part  is 
swollen  and  vascular.  Such  tissue  might  in  some 
cases  be  made  to  break  down  under  the  spoon, 
but  less  scarring  or  deformity  results  if  the  neo- 
plasm can  be  made  to  disappear  by  the  method 
of  puncture. 

There  is  considerable  bleeding  at  first,  after 
either  scraping  or  puncture.  This,  however,  is 
soon  controlled,  by  the  application  of  sponges 
squeezed  out  in  iced  water.  The  part  may  be 
dressed  after  operation  with  some  simple  dress- 
ing, for  instance,  carbolized  oil  or  lead  lotion. 

It  is  but  rational  to  follow  up  the  scraping  by 
the  application  of  caustics;  for  in  most  eases 
there  must  exist,  deep  in  the  skin,  prolongations 
of  lupus-tissue,  extending  from  the  mass  on  the 
surface  along  the  hair-follicles  and  other  vascular 
structures.  Alfred  Sangster. 


NUCLEUS  OF  CELLS,  The.— Synon. 
Fr.  le  Noyau ; Ger.  der  Kern. 

Definition. — A minute  mass  of  protoplasm 
imbedded  in  the  substance  of  nearly  all  cells. 

The  nucleus  differs  from  the  cell-substance  in 
its  optical  characters,  and  in  its  behaviour  to 
certain  chemical  reagents;  being,  for  example, 
more  readily  stained  by  various  colouring  matters, 
and  presenting,  as  a rule,  greater  resistance  to 
weak  acids  and  alkalies.  Until  recently  it  was 


1816  NUCLEUS  OF  CELLS. 

believed  to  form  an  essential  part  of  all  cells. 
See  Cell. 

Chemical  Characters. — Regarding  the  che- 
mical characters  of  nuclei  but  little  is  known, 
beyond  the  fact  that  they  contain,  in  all  proba- 
bility, an  albuminous  body. 

Microscopical  Characters.— The  intimate 
structure  of  the  nucleus  is  very  complex.  In  many 
animal  cells,  more  especially  gland-,  epithelial, 
and  endothelial  cells,  it  is  made  up  of  a delicate 
network  of  fibres  running  in  all  directions,  in  the 
meshes  of  which  is  a substance  of  more  or  less 
fluid  consistence,  the  whole  being  surrounded 
by  a membranous  envelope  from  which  the 
fibres  spring. 

Physiological  Properties. — It  has  long  been 
believed  that  the  nucleus  plays  a predominating 
role  in  the  process  of  cell-multiplication  ; and 
this  view  has  recently  been  materially  strength- 
ened by  the  discovery  of  the  so-called  indirect 
division  of  the  nuclei  of  epithelial  cells.  Indirect 
division  of  the  nucleus,  or,  as  it  is  called  by 
Flemming,  karyokinesis  ( Kapvov , a nucleus,  and 
mVijarir,  movement)  is  the  name  applied  to  a 
complicated  series  of  structural  changes  accom- 
panying the  division  of  the  nucleus  into  two 
halves  ; and  is  employed  in  contradistinction  to 
the  term  direct  division,  in  which  the  nucleus, 
without  any  accompanying  visible  changes  of 
structure,  divides  into  two  or  more  parts,  called 
‘ daughter-nuclei.’ 

The  changes  in  karyokinesis  consist  chiefly  in 
thickening  of  the  intranuclear  fibrils  above  re- 
ferred to,  and  in  disappearance  of  the  nuclear 
membrane,  accompanied  by  increase  in  the  size 
of  the  nucleus  as  a whole,  this  being  followed  by 
a complicated  series  of  changes  in  the  form  and 
arrangement  of  the  intra-nuclear  fibres,  in  the 
course  of  which  they  often  present  the  most 
regular  stellate,  fan-shaped,  or  wreath- like 
figures,  ending  in  their  dividing  into  two 
bundles  of  fibrils  which  draw  apart  from  one 
another.  This  is  followed  by  separation  into 
two  halves  of  tho  nucleus  as  a whole,  each 
daughter-nucleus  containing  a more  or  less  com- 
plicated bundle  of  fibres  in  its  interior.  The 
division  of  the  nucleus  is  followed  by  that  of  the 
cell,  while  the  fibres  of  the  nucleus  gradually 
diminish  in  thickness,  and  arrange  themselves  in 
the  form  which  they'  present  in  the  ‘ resting  cell.’ 

In  cell-multiplication  by  direct  division  of  the 
nucleus,  no  change  in  the  intimate  structure  of 
the  nucleus  is  to  be  observed;  all  that  is  to  be 
seen  is  that  the  nucleus  becomes  enlarged,  and, 
after  assuming  a dumb-bell  shape,  divides  into 
two  halves,  which  may  themselves  be  again 
divided  into  two. 

Pathological  Relations. — Karyokinesis  is 
of  considerable  pathological  importance,  having 
been  found  to  take  place  in  the  cell-multiplica- 
tion of  certain  forms  of  epithelial  cancer.  On 
the  other  hand,  direct  division  is  the  mode  by 
which  the  nuclei  of  pus-cells  multiply. 


PTOMAINES. 

The  nucleus  is,  as  a rule,  more  resistant  of  re- 
trogressive changes  than  the  rest  of  the  cell, 
often  remaining  apparently  intact  after  the  whole 
of  the  cell-substance  and  of  the  cell-wall  has  dis- 
appeared. In  other  cases  the  destruction  of  the 
nucleus  goes  hand  in  hand  with  that  of  the  rest 
of  the  cell.  Vacuolation  of  the  nucleus  is  by  no 
means  rare,  in  cases  of  commencing  retrogressive 
metamorphosis  of  cells,  and  also  in  cases  of  in- 
flammation, for  instance,  of  the  skin. 

Charles  S.  Roy. 

PTOMAINES  (irrwfia,  a dead  body). — . 
Synon  : Cadaveric  Alkaloids;  Fr.  Ptomaines. — 
Under  this  name  a class  of  bodies  has  been  de- 
scribed, which  are  stated  to  ue  the  basic  products 
of  the  decay  of  animal  matters,  and  to  which 
Selmi  and  others  have  assigned  poisonous  pro- 
perties. It  is  right,  however,  to  state  that 
although  the  existence  of  basic  oralkaloidal  bodies 
among  the  products  of  decay  is  highly  probable, 
the  definite  toxic  properties  of  these  substances 
are  by  no  means  generally  admitted  ; and  their 
preparation,  in  a stato  of  even  approximate 
purity,  has  perhaps  not  hitherto  been  achieved. 

Pauum  first  showed  that  by  the  putrefaction  of 
albuminous  matters  a soluble  ferment  is  pro- 
duced, which  is  poisonous.  Fagge  and  the  writer 
also  showed,  in  1865,  that  the  alcoholic  extracts 
of  many  post-mortem  liquids  taken  from  the 
human  body  are,  even  after  exposure  to  the  tem- 
perature of  the  water-bath,  poisonous  when  in- 
jected beneath  the  skin  of  animals.  Bergmann, 
Schwenninger,  Sonnenschein,  and  Zuelzer  more 
or  less  confirmed  these  observations,  and  added 
to  them.  Selmi  is,  nevertheless,  the  observer 
who  has  chiefly  worked  at  the  cadaveric  alka- 
loids. 

According  to  Selmi  ptomaines  are  alkaloids, 
generated  during  decay,  and  closely  resembling 
tho  vegetable  alkaloids,  not  only  in  their  che- 
mical reactions,  but  also  in  their  physiological 
properties.  Some  ptomaines  appear  to  be  poi- 
sonous ; and  others  to  act  as  counter-poisons  to 
well-known  vegetable  alkaloids.  The  conditions 
under  which  they  are  formed  are  entirely  un- 
known, except  that  they  may  be  found  in  alco- 
holic anatomical  maceration  liquids,  and  that 
exclusion  of  air  possibly  favours  their  formation. 
Some  ptomaines  have  no  marked  physiological 
activity.  Somo  are  formed  even  in  the  living 
body,  during  the  progress  of  such  diseases  as 
peritonitis. 

The  chief  interest  attaching  to  the  ptomaines 
arises  from  their  liability  to  be  confounded  with 
other  and  well-known  natural  alkaloids,  such  as 
morphia,  strychnia,  &c. ; and  hence  to  lead  to 
mistakes  in  medico-legal  practice.  Brouardel 
and  Boutiny  nevertheless  have,  as  they  assert, 
discovered  chemical  reactions  by  which  the 
ptomaines  as  a class  may  be  distinguished  from 
the  natural  alkaloids. 

Thomas  Stevenson 


REASONS  WHY  PHYSICIANS  SHOULD 


SUBSCRIBE  FOR  THE 

I }m  York  BQedical  Journal, 

Edited  by  FRANK  P.  FOSTER,  M.  D. 


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ITH  the  number  for  January,  1889,  this  Journal  enters  upon  the  seventh 


year  of  fits  publication.  The  history  of  the  Journal  has  been  one  of  pro- 
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THE  POPULAR  SCIENCE 
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HERBERT  SPENCER, 

DAVID  A.  WELLS, 

T.  II.  HUXLEY, 

Sib  JOHN  LUBBOCK, 

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THOMAS  HILL, 

N.  S.  SHALER, 

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GRANT  ALLEN, 

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J.  HUGHLINGS  JACKSON,  M.  D. 


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A TEXT-BOOK  ON  THE 

DISEASES  OF  WOMEN. 

By  ALEXANDER  J.  C.  SKENE,  M.  D., 

Professor  of  Gynaecology  in  the  Long  Island  College  Hospital,  Brooklyn,  N.  Y. ; formerly  Professor 
of  Gynaecology  in  the  New  York  Post-graduate  Medical  School  and  Hospital,  etc. 

With  Two  Hundred  and  Fifty-four  Illustrations,  of  which  one  hundred  and 
sixty-five  are  original  and  nine  Chromo-lithographs. 

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This  treatise  is  the  outcome  and  represents  the  experience  of  a 
long  and  active  professional  life,  the  greater  part  of  which  has  been 
spent  in  the  treatment  of  the  diseases  of  women.  It  is  especially- 
adapted  to  meet  the  wants  of  the  general  practitioner  in  recognizing 
this  class  of  diseases  as  he  meets  them  in  every-day  practice  and  in 
treating  them  successfully. 

The  arrangement  of  subjects  is  such  that  they  are  discussed  in 
their  natural  order,  and  thus  more  easily  comprehended  and  remem- 
bered by  the  student. 

Methods  of  operation  have  been  much  simplified  by  the  author  in 
his  practice,  and  it  has  been  his  endeavor  to  so  describe  the  operative 
procedures  adopted  by  him  even  to  their  minutest  details,  as  to  make 
his  treatise  a practical  guide  to  the  gynaecologist. 

Although  all  the  subjects  which  are  discussed  in  the  various  text- 
books on  gynaecology  have  been  treated  by  the  author,  it  has  been  a 
prominent  feature  in  his  plan  to  consider  also  those  which  are  but 
incidentally,  or  not  at  all,  mentioned  in  the  text-books  hitherto  pub- 
lished, and  yet  which  are  constantly  presenting  themselves  to  the  prac- 
titioner for  diagnosis  and  treatment. 

The  illustrations  are  mostly  entirely  new,  and  have  been  specially 
made  for  this  work.  The  drawings  are  from  nature,  or  from  wax 
and  clay  models  from  nature,  and  have  been  reproduced  by  processes 
best  adapted  to  represent  in  the  most  truthful  and  permanent  forms 
the  exact  appearances  of  the  diseased  organs,  methods  of  operation, 
or  instruments  which  they  are  designed  to  illustrate. 

Wherever  it  has  been  possible  to  make  clearer  the  author’s  methods 
of  treatment  by  histories  of  cases  which  have  actually  occurred  in  his 
practice,  this  has  been  done.  A simple,  typical  case,  such  as  is  ordi- 
narily met  with,  is  first  described,  and  then  difficult  and  obscure  cases, 
with  the  various  complications  which  occur.  The  history  of  such  cases 
and  the  methods  of  examination  and  treatment  are  so  minutely  detailed 
as  to  serve  for  guides  in  similar  cases. 


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A Treatise  on  Insanity,  in  its  Medical  Relations.  By  W illiam 
A.  Hammond,  M.  D.,  Surgeon-General  TJ.  S.  Army  (retired  list);  Professor 
of  Diseases  of  the  Mind  and  Nervous  System,  in  the  Nevr  York  Post-Grad- 
uate Medical  School ; President  of  the  American  Neurological  Association, 
etc.  “With  112  Hlustrations.  Eighth  edition,  revised,  corrected,  and  en- 
larged by  the  Addition  of  a New  Section  on  Certain  Obscure  Nervons 
Diseases.  1 voh,  8vo,  945  pages.  Cloth,  $5.00 ; sheep,  $6.00. 

In  this  work  the  author  has  not  only  considered  the  subject  of  Insanity,  hut  has  prefixed  that  division 
of  his  work  with  a general  view  of  the  mind  and  the  several  categories  of  mental  faculties,  and  a full  ac- 
count of  the  various  causes  that  exercise  an  influence  over  mental  derangement,  such  as  habit,  age,  sex, 
hereditary  tendency,  constitution,  temperament,  instinct,  sleep,  dreams,  and  many  other  factors.  Insanity, 
it  is  believed,  is  in  this  volume  brought  before  the  reader  in  an  original  manner,  and  with  a degree  of 
thoroughness  which  can  not  but  lead  to  important  results  in  the  study  of  psychological  medicine. 


The  Applied  Anatomy  of  the  Nervous  System. 

Being  a Study  of  this  Portion  of  the  Human  Body  from  a Standpoint  of 
its  General  Interest  and  Practical  Utility,  designed  for  Use  as  a Text-book 
and  as  a Work  of  Reference.  By  Ambrose  L.  Ranney,  A.  M.,  M.  D.,  Ad- 
junct Professor  of  Anatomy  and  late  Lecturer  on  the  Diseases  of  the  Genito- 
urinary Organs  and  on  Minor  Surgery  in  the  Medical  Department  of  the 
University  of  the  City  of  New  York,  etc.,  etc.  1 vol.,  8vo.  Profusely  illus- 
trated. Cloth,  $4.00;  sheep,  $5.00. 

“Thia  ia  a useful  book,  and  one  of  novel  design.  It  is  especially  valuable  as  bringing  together  facta 
and  inferences  which  aid  greatly  in  forming  correct  diagnoses  in  nervous  diseases.’" — Boston  Medical  and 
Surgical  Journal. 

“There  are  many  books,  to  be  sure,  which  contain  here  and  there  hints  in  this  field  of  great  value  to 
the  physician,  but’it  is  Dr.  Eanney’s  merit  to  have  collected  these  scattered  items  of  interest,  and  to 
have  woven  them  into  an  harmonious  whole,  thereby  producing  a work  of  wide  scope  and  of  correspond- 
ingly wide  usefulness  to  the  practicing  physician.” — Aew  York  Medical  Journal. 


A Treatise  on  Nervous  Diseases:  Their  Symptoms  and 

Treatment.  A Text-book  for  Students  and  Practitioners.  By  S.  G.  Web- 
ber, M.  D.,  Clinical  Instructor  in  Nervous  Diseases,  Harvard  Medical  School: 
Visiting  Physician  for  Diseases  of  the  Nervous  System  at  the  Boston  City 
Hospital,  etc.  1 vol.,  8 vo,  415  pages.  15  Illustrations.  Cloth,  $3.00. 

;*The  book  before  U3  is  especially  adapted  to  tbe  needs  of  the  .general  practitioner  •who,  though  con- 
scious of  his  inability  to  discern  and.trace  the  nervous  element  in  the  cases  under  his  care,  realizes  very 
fully  that  this  inability  is  not  consonant  with  the  best  interests  of  his  patient.  Dr.  Webber  has  not  writ- 
ten for  tbe  specialist,  but  for  the  student  and  general  practitioner,  who  will  find  in  his  hook  what  they 
most  need  for  the  diagnosis  and  treatment  of  the  diseases  as  they  present  themselves  in  general  practice. 
His  style  is  very  readable  and  lucid,  and  is  well  adapted  to  those  who  have  not  specially  prepared  them- 
selves to  understand  the  peculiar  language  of  the  more  advanced  neurologist.  He  covers  very  completely 
the  field  of  nervous  affections,  and  his  book  will  prove  a very  valuable  acquisition  to  the  library  of  the  in- 
telligent physician.’ ‘ — Medical  Agz. 

Paralysis  from  Brain  Disease  in  its  Common 

Forms.  ByH.  Charlton  Bastian,  M.  A.,  M.  D.,  Fellow  of  the  Royal 
College  of  Physicians;  Professor  of  Pathological  Anatomy  in  University 
College,  London.  With  Hlustrations,  1 vol.,  12mo,  340  pages.  Cloth, 
$1.75. 


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SCIENCE  AND  ART  OF  MIDWIFERY. 

By  WILLIAM  THOMPSON  LUSK,  M.  A.,  M.  D., 

Professor  of  Obstetrics  and  Diseases  of  Women  and  Children  in  the  Bellevue  Hospital 
Medical  College  ; Obstetric  Surgeon  to  the  Maternity  and  Emergency 
Hospitals  ; and  Gynaecologist  to  the  Bellevue  Hospital. 

Complete  in  one  volume  8vo,  with  226  Illustrations.  Cloth,  $5.00  ; sheep,  $6.00. 

“ It  contains  one  of  the  best  expositions  of  the  obstetric  science  and  practice  of  the 
day  with  which  we  are  acquainted.  Throughout  the  work  the  author  shows  an  intimate 
acquaintance  with  the  literature  of  obstetrics,  and  gives  evidence  of  large  practical  ex- 
perience, great  discrimination,  and  sound  judgment.  We  heartily  recommend  the  book 
as  a full  and  clear  exposition  of  obstetric  science  and  safe  guide  to  student  and  prac- 
titioner.”— London  Lancet. 

“ Professor  Lusk’s  book  presents  the  art  of  midwifery  with  all  that  modem  science 
or  earlier  learning  has  contributed  to  it.” — Medical  Record , New  York. 

“ This  book  bears  evidence  on  every  page  of  being  the  result  of  patient  and  laborious 
research  and  great  personal  experience,  united  and  harmonized  by  the  true  critical  or 
scientific  spirit,  and  wre  are  convinced  that  the  book  will  raise  the  general  standard  of 
obstetric  knowledge  both  in  his  own  country  and  in  this.  Whether  for  the  student 
obliged  to  learn  the  theoretical  part  of  midwifery,  or  for  the  busy  practitioner  seeking  aid 
in  the  face  of  practical  difficulties,  it  is,  in  our  opinion,  the  best  modem  work  on  mid- 
wifery in  the  English  language.” — Dublin  Journal  of  Medical  Science. 

“ Dr.  Lusk’s  style  is  clear,  generally  concise,  and  he  has  succeeded  in  putting  in  less 
than  seven  hundred  pages  the  best  exposition  in  the  English  language  of  obstetric  science 
and  art.  The  book  will  prove  invaluable  alike  to  the  student  and  the  practitioner.” — 
American  Practitioner. 

“ Dr.  Lusk’s  work  is  so  comprehensive  in  design  and  so  elaborate  in  execution  that  it 
must  be  recognized  as  having  a status  peculiarly  its  own  among  the  text-books  of  mid- 
wifery in  the  English  language.” — New  York  Medical  Journal. 

“ The  work  is,  perhaps,  better  adapted  to  the  wants  of  the  student  as  a text-book, 
and  to  the  practitioner  as  a work  of  reference,  than  any  other  one  publication  on  the 
subject.  It  contains  about  all  that  is  known  of  the  ars  obstetrica , and  must  add  greatly 
to  both  the  fame  and  fortune  of  the  distinguished  author.” — Medical  Herald , Louisville. 

“ Dr.  Lusk’s  book  is  eminently  viable.  It  can  not  fail  to  live  and  obtain  the  honor  of 
a second,  a third,  and  nobody  can  foretell  how  many  editions.  It  is  the  mature  product 
of  great  industry  and  acute  observation.  It  is  by  far  the  most  learned  and  most  com- 
plete exposition  of  the  science  and  art  of  obstetrics  written  in  the  English  language.  It 
is  a book  so  rich  in  scientific  and  practical  information  that  nobody  practicing  obstetrics 
ought  to  deprive  himself  of  the  advantage  he  is  sure  to  gain  from  a frequent  recourse  to 
its  pages.” — American  Journal  of  Obstetrics. 

“ It  is  a pleasure  to  read  such  a book  as  that  which  Dr.  Lusk  has  prepared  ; every- 
thing pertaining  to  the  important  subject  of  obstetrics  is  discussed  in  a masterly  and  cap- 
tivating manner.  We  recommend  the  book  as  an  excellent  one,  and  feel  confident  that 
those  who  read  it  will  be  amply  repaid.” — Obstetric  Gazette , Cincinnati. 

“ To  consider  the  work  in  detail  would  be  merely  to  involve  us  in  a reiteration  of  the 
high  opinion  we  have  already  expressed  of  it.  What  Spiegelberg  has  done  for  Ger- 
many, Lusk,  imitating  him  but  not  copying  him,  has  done  for  English  readers,  and  we 
feel  sure  that  in  this  country,  as  in  America,  the  work  will  meet  with  a very  extensive 
approval.” — Edinburgh  Medical  Journal. 

“ The  whole  range  of  modern  obstetrics  is  gone  over  in  a most  systematic  manner, 
without  indulging  in  the  discussion  of  useless  theories  or  controversies.  The  style  is 
clear,  concise,  compact,  and  pleasing.  The  illustrations  are  abundant,  excellently  exe- 
cuted, remarkably  accurate  in  outline  and  detail,  and,  to  most  of  our  American  readers, 
entirely  fresh.” — Cincinnati  Lancet  and  Clinic. 


New  York : D.  APPLETON  & CO.,  1,  3,  & 5 Bond  Street. 


AN  ILLUSTRATED 


Encyclopaedic  Medical  Dictionary, 

BEING  A DICTIONARY  OF 

THE  TECHNICAL  TERMS  USED  BY  WRITERS  ON  MEDICINE 
AND  THE  COLLATERAL  SCIENCES  IN  THE  LATIN , 
ENGLISH,  FRENCH,  AND  GERMAN 
LANGUAGES. 


By  FRANK  P.  FOSTER,  M.  D., 

Editor  of  "The  New  York  Medical  Journal. 11 


W.  C.  AYRES,  M.  D., 

E.  B.  BRONSON,  M.  D., 

H.  C.  COE,  M.D.,  M.R.C. 
etc. 


WITH  THE  COLLABORATION 

C.  S.  BULL,  M.  D., 

A.  F.  CURRIER,  M.  D., 
I.,  A.  DUANE,  M.  D., 

Prof.  S.  H.  GAGE, 


H.  J.  GARRIGUES,  M.  D., 
C.  B.  KELSEY,  M.  D., 

R.  H.  NEVINS,  M.  D., 
and  B.  G.  WILDER,  M.  D. 


The  distinctive  features  of  Foster's  “Illustrated  Encyclopaedic  Medical  Dic- 
tionary ” are  as  follows : 

It  is  founded  on  independent  reading,  and  is  not  a mere  compilation  from 
other  medical  dictionaries,  consequently  its  definitions  are  more  accurate.  Other 
medical  dictionaries  have,  it  is  true,  been  consulted  constantly  in  its  preparation, 
but  what  has  been  found  in  them  has  not  been  accepted  unless  scrutiny  showed 
it  to  be  correct. 

It  states  the  sources  of  its  information,  thus  enabling  the  critical  reader  to 
provide  himself  with  evidence  by  which  to  judge  of  its  accuracy,  and  also  in 
many  instances  guiding  him  in  any  further  study  of  the  subject  that  he  may 
wish  to  make. 

It  is  the  only  work  of  the  kind  printed  in  the  English  language  in  which  pic- 
torial illustrations  are  used. 

It  tells,  in  regard  to  every  word,  what  part  of  speech  it  is,  and  does  not  de- 
fine nouns  as  if  they  were  adjectives,  and  vice  versa ; and  it  does  not  give  French 
adjectives  as  the  “ analogues  ” of  English  or  Latin  nouns. 

It  contains  more  English  and  Latin  major  headings  than  any  other  medical 
dictionary  printed  in  English  or  Latin,  more  French  ones  than  any  printed  in 
French,  and  more  German  ones  than  any  printed  in  German,  all  arranged  in  a 
continuous  vocabulary. 

The  sub-headings  are  usually  arranged  under  the  fundamental  word,  making 
it  much  more  encyclopedic  in  character  than  if  the  common  custom  had  been 
followed. 

GEiPThis  work  will  be  completed  in  Four  Volumes,  and  is  sold  by  Subscription  only. 

THE  FIRST  VOLUME  NOW  READY. 


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A TEXT-BOOK  ON  SURGERY: 

GENERAL , OPERATIVE,  AND  MECHANICAL. 

By  JOHN  A.  WYETH,  M.  D., 

Professor  of  Surgery  in  the  New  York  Polyclinic  ; Snrgeon  to  Mount  Sinai  Hospital,  etc. 

Price,  Buckram,  uncut  edges,  $7.00 ; Sheep,  $8.00 ; Half  Morocco,  $8.50. 


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This  work,  consisting  of  seven  hundred  and  sixty-nine  pages,  and  containing  seven 
hundred  and  seventy-one  illustrations,  of  which  about  fifty  are  colored,  is  one  of  the  most 
beautiful  and  unique,  and  at  the  same  time  one  of  the  most  complete,  works  on  general 
surgery  ever  published. 

It  is  printed  in  clear,  large  type  on  a superior  quality  of  paper,  and  the  book,  large 
without  being  bulky,  is  in  a shape  to  be  easily  handled.  The  illustrations  are  executed 
with  especial  reference  to  the  accurate  anatomy  of  the  parts  represented ; the  relations  of 
bones,  muscles,  nerves,  and  vessels  to  adjacent  structures  ; and  lines  of  incision  are  indi- 
cated in  operations  about  the  joints  and  articulations,  thus  explaining  and  simplifying 
their  descriptions  in  the  text.  The  colored  illustrations  which  depict  the  more  important 
operations,  especially  with  reference  to  the  large  arteries,  constitute  a novel  and  very  im- 
portant feature  of  the  work. 

The  following  brief  synopsis  will  convey  an  idea  of  the  plan  of  the  work: 

As  a preliminary  to  the  consideration  of  the  various  operations  the  author  thoroughly 
discusses  the  methods  of  preparing  the  different  antiseptic  surgical  dressings,  ligatures, 
sutures,  solutions,  drains  ; the  materials  for  bandaging,  with  illustrated  instructions  as  to 
the  manner  of  applying  bandages  in  the  various  forms  employed  in  different  parts  of  the 
body  ; anaesthesia,  both  local  and  general,  including  the  employment  of  cocaine  as  a local 
anaesthetic;  the  use  and  method  of  administering  ether  and  chloroform;  instruments  and 
their  uses  ; haemostasis  and  the  after-treatment  of  cases. 

Inflammation,  its  causes  and  methods  of  treatment ; wounds  and  the  manner  of  closing 
them;  transfusion,  poisoned  wounds,  burns  and  scalds,  gangrene,  and  the  various  surgical 
lesions  are  thoroughly  considered  and  their  appropriate  treatment  given. 

Amputations,  with  full  and  minute  details  of  the  manner  of  performing  them,  and  the 
different  methods  employed,  constitute  an  important  chapter  in  the  hook.  All  the  prin- 
cipal operations  are  illustrated  by  colored  engravings  made  from  direct  tracings  of  frozen 
sections  on  the  cadaver. 

The  section  devoted  to  the  arteries  and  the  procedures  necessary  in  l'gating  them  is 
one  of  the  most  important  and  most  beautifully  illustrated  portions  of  the  work.  The 
woodcuts  showing  the  relation  of  the  parts  involved  in  tying  the  important  arteries  arc 
colored,  and  their  anatomy  is  depicted  in  a wonderfully  clear  and  accurate  manner. 

Surgical  diseases  and  surgery  of  the  bones ; surgery  of  the  articulations,  regional 
surgery,  including  the  common  operations  on  the  eye,  ear,  and  jaws ; tumors  about  the 
neck,  thyreotomy,  laryngotomy,  tracheotomy,  and  cesophagotomy : the  surgery  of  the 
thorax  and  abdomen ; and  operations  on  the  rectum  and  anus  are  dealt  with  in  the  light 
of  the  most  advanced  surgical  knowledge. 

Genito-urinary  surgery  and  specific  lesions  receive  a due  share  of  attention,  os  do  de- 
formities of  the  spine  and  extremities,  and  malignant  tumors  and  growths. 

This  work,  written  by  an  accomplished  surgeon  of  wide  experience,  and  fully  abreast 
of  the  highest  attainments  in  surgical  knowledge  and  science,  presents  to  the  student  and 
practitioner  a means  of  acquainting  himself  with  modern  surgery  as  it  is  taught  and  prac- 
ticed by  a master  of  the  art,  and  will  enable  him  to  prepare  himself  for  the  intelligent 
performance  of  many  operations,  and  to  treat  many  surgical  lesions  with  which  he  may 
feel  he  is  not  sufficiently  familiar. 

D.  APPLETON  & CO.,  Publishers, 

1.  3.  & 5 BOND  ST.,  NEW  YORK. 


